hospital_name last_updated_on version location_name hospital_address type_2_npi license_number|CA attester_name "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula." general_contract_provisions Monrovia Memorial Hospital 3/1/2026 3.0.0 Monrovia Memorial Hospital "323 S. Heliotrope Avenue, Monrovia CA 91016" 1265601561 930000107 Ron Kupferstein TRUE description code|1 code|1|type code|2 code|2|type modifiers setting drug_unit_of_measurement drug_type_of_measurement standard_charge|gross standard_charge|discounted_cash payer_name plan_name standard_charge|negotiated_dollar standard_charge|negotiated_percentage standard_charge|negotiated_algorithm median_amount 10th_percentile 90th_percentile count standard_charge|methodology standard_charge|min standard_charge|max additional_generic_notes HEMODIALYSIS 600100 CPT outpatient 3000 3000 3000 3000 CATHETER REMOVAL 600122 CPT outpatient 300 300 300 300 BLADE CARBON STEEL SIZE 10 2400100 CPT outpatient 5 5 5 5 BLADE CARBON STEEL SIZE 11 2400101 CPT outpatient 9.79 9.79 9.79 9.79 BLADE CARBON STEEL SIZE 15 2400103 CPT outpatient 5 5 5 5 HYPER/HYPO THERMIA MACHINE 2400107 CPT outpatient 220 220 220 220 SUCTION MACHINE GOMCO 2400108 CPT outpatient 162 162 162 162 IV PRIMARY TUBING 2400110 CPT outpatient 34.38 34.38 34.38 34.38 AMBIENT SUPER MULTVAC 50 2400126 CPT outpatient 370 370 370 370 SCOVILLE BIPOLAR FORCEP 7-3/4 W/12 CORD 2400153 CPT outpatient 244.1 244.1 244.1 244.1 SYRINGE 10 CC LS STERILE LF 2400187 CPT outpatient 5 5 5 5 ACE WRAP 4X5 2400214 CPT outpatient 5 5 5 5 PETROLATUM GAUZE 3 X 9 2400232 CPT outpatient 9.35 9.35 9.35 9.35 AIRWAY GUEDEL SIZE 90MM 2400246 CPT outpatient 5 5 5 5 AIRWAY GUEDEL SIZE 100MM 2400247 CPT outpatient 5 5 5 5 SUTURE SILK 2400249 CPT outpatient 23.79 23.79 23.79 23.79 SUTURE PROLENE 2400254 CPT outpatient 27.2 27.2 27.2 27.2 SUTURE PDS 2400255 CPT outpatient 17.45 17.45 17.45 17.45 SUTURE CHROMIC 2400257 CPT outpatient 21.76 21.76 21.76 21.76 NEEDLE SAFETY 25GX1 LF 2400263 CPT outpatient 8.85 8.85 8.85 8.85 PCA PUMP 2400269 CPT outpatient 113.5 113.5 113.5 113.5 PCA TUBING 2400270 CPT outpatient 23.16 23.16 23.16 23.16 SOL 0.9% NACL IRRIGTION 1000ML 2400271 CPT outpatient 58.65 58.65 58.65 58.65 SOL 0.9% NACL IRRIGATION 500ML 2400272 CPT outpatient 58.65 58.65 58.65 58.65 SOLUTION WATER IRRIGATION 1000ML 2400273 CPT outpatient 31.4 31.4 31.4 31.4 CVC CATH 7F TRAY 2400284 CPT outpatient 265.15 265.15 265.15 265.15 BONE WAX 2400292 CPT outpatient 17.06 17.06 17.06 17.06 SKIN MARKER / MED LABEL 2400293 CPT outpatient 9.4 9.4 9.4 9.4 CONFORMING BANDAGE 4X131 2400295 CPT outpatient 9.9 9.9 9.9 9.9 PACKING STRIP 2X5YD IODOFORM 2400297 CPT outpatient 9.44 9.44 9.44 9.44 PEANUT SPONGES 2400298 CPT outpatient 8.6 8.6 8.6 8.6 THORACIC CATH STRAIGHT (127287) 20 FR 2400305 CPT outpatient 17.13 17.13 17.13 17.13 THORACIC CATH STRAIGHT (127310) 28 FR 2400307 CPT outpatient 17.13 17.13 17.13 17.13 EVACUATION CONTAINER 2000ML 2400310 CPT outpatient 22.5 22.5 22.5 22.5 SURGICAL PREP TRAY 2400314 CPT outpatient 63.44 63.44 63.44 63.44 GAS SAMPLING LINE 2400318 CPT outpatient 6.51 6.51 6.51 6.51 BLADE NONSTICK COATED ELECTRD 2.75 2400321 CPT outpatient 17.58 17.58 17.58 17.58 BLADE NONSTICK COATED ELECTRD 4 2400322 CPT outpatient 12.53 12.53 12.53 12.53 ELECTROSURG DISPERSIVE ELECTRODE 2400323 CPT outpatient 32.38 32.38 32.38 32.38 CAUTERY TIP CLEANER 2400324 CPT outpatient 5 5 5 5 NEEDLE COUNTER 2400325 CPT outpatient 8.28 8.28 8.28 8.28 ESMARK 2400326 CPT outpatient 18.92 18.92 18.92 18.92 GAUZE STERILE 4X4 12 PLY 10'S TRAY 2400328 CPT outpatient 8.47 8.47 8.47 8.47 GAUZE SPONGE 4X4 12PLY XRAY DETECT 2400329 CPT outpatient 8.08 8.08 8.08 8.08 SUPER FLUFFS BANDAGE 2400330 CPT outpatient 10.15 10.15 10.15 10.15 PODIATRY PACK 2400333 CPT outpatient 180.42 180.42 180.42 180.42 BASIC EXTREMITY PACK 2400334 CPT outpatient 104.81 104.81 104.81 104.81 BASIC PACK IV 2400337 CPT outpatient 152.74 152.74 152.74 152.74 SPLIT DRAPE 2400338 CPT outpatient 15.1 15.1 15.1 15.1 O R TABLE COVER 2400340 CPT outpatient 33.45 33.45 33.45 33.45 MAJOR ABDOMINAL DRAPE W/ POUCH 2400342 CPT outpatient 164.8 164.8 164.8 164.8 IMPERVIOUS U DRAPE 2400347 CPT outpatient 54.83 54.83 54.83 54.83 SURGICAL GOWN XXLRG 2400351 CPT outpatient 12.02 12.02 12.02 12.02 SPONGE COUNTER BAG 2400360 CPT outpatient 9.38 9.38 9.38 9.38 LAP SPONGE 2400362 CPT outpatient 5.04 5.04 5.04 5.04 ANESTESIA CIRCUIT 90 2400364 CPT outpatient 11 11 11 11 SPINAL NEEDLE 25G X 4.75 LF 2400367 CPT outpatient 13.34 13.34 13.34 13.34 NEEDLE EPIDURAL 17GX3.5 2400368 CPT outpatient 19.8 19.8 19.8 19.8 TEGADERM 8 X 12 2400369 CPT outpatient 19.14 19.14 19.14 19.14 PREP SKIN DURAPREP 2400371 CPT outpatient 32.95 32.95 32.95 32.95 SPINAL NEEDLE 22GX3.5 2400373 CPT outpatient 12.31 12.31 12.31 12.31 SPINAL NEEDLE 25GX3.5 2400374 CPT outpatient 12.31 12.31 12.31 12.31 EPIDURAL TRAY 1 SHOT 2400375 CPT outpatient 158.06 158.06 158.06 158.06 PEG TRAY PONSKY PULL DELUXE 2400393 CPT outpatient 1235 1235 1235 1235 GASTROSTOMY TUBE ALL SZ 2400395 CPT outpatient 163.71 163.71 163.71 163.71 COUDE FOLEY CATH 14FR 2400414 CPT outpatient 45.89 45.89 45.89 45.89 LEVINE TUBE ALL SIZES 2400416 CPT outpatient 5.48 5.48 5.48 5.48 ANTIEMBOLIC STOCKING ALL SZ 2400425 CPT outpatient 405.09 405.09 405.09 405.09 SCD DAILY 2400428 CPT outpatient 22.5 22.5 22.5 22.5 OXYGEN TUBING 2400439 CPT outpatient 5 5 5 5 DRESSING SURGICEL 2 X 3 2400446 CPT outpatient 75 75 75 75 BLADE: SAW RECIP OSCIL & SAG 2400454 CPT outpatient 109.5 109.5 109.5 109.5 BANDAGE: WEBRIL 2400456 CPT outpatient 40.25 40.25 40.25 40.25 DRSG BIOPATCH 2400465 CPT outpatient 20.46 20.46 20.46 20.46 CURETTE: ARTHOSCOPY 2400469 CPT outpatient 228 228 228 228 EQ-ARTHROSCOPE 2400480 CPT outpatient 175 175 175 175 EQ-BIPOLAR UNIT 2400481 CPT outpatient 1000 1000 1000 1000 EQ-CARDIAC/INV MONITOR 2400483 CPT outpatient 1000 1000 1000 1000 EQ-CO2 ANALYZER 2400484 CPT outpatient 1000 1000 1000 1000 EQ-ELECTRO SURG UNIT 2400485 CPT outpatient 1000 1000 1000 1000 EQ-IRRIGATOR/ASPIRATOR 2400487 CPT outpatient 190 190 190 190 EQ VIDEO CART SYSTEM 2400488 CPT outpatient 1200 1200 1200 1200 EQ VIDEO MONITOR 2400489 CPT outpatient 125 125 125 125 EQ VIDEO PRINTER 2400490 CPT outpatient 125 125 125 125 EQ- MICROSCOPE 2400491 CPT outpatient 2000 2000 2000 2000 EQ-ARTHROSCOPY PUMP 2400492 CPT outpatient 180 180 180 180 EQ- TOURNIQUET 2400493 CPT outpatient 180 180 180 180 IV PUMP DAILY 2400497 CPT outpatient 300 300 300 300 ANESTHESIA GEN 1ST HR 2400520 CPT outpatient 6000 6000 6000 6000 ANESTHESIA GEN EA ADDITIONAL 15 MIN 2400521 CPT outpatient 600 600 600 600 ANESTHESIA LOCAL 1ST HR 2400522 CPT outpatient 300 300 300 300 ANESTHESIA MAC 1ST HOUR 2400524 CPT outpatient 1200 1200 1200 1200 ANESTHESIA MAC EA ADDITIONAL 15 MIN 2400525 CPT outpatient 300 300 300 300 IV SEDATION/MODERATE/CONSCIOUS 2400531 CPT outpatient 400 400 400 400 RECOVERY ROOM 1ST HR 2400536 CPT outpatient 6000 6000 6000 6000 RECOVERY ROOM EA ADDITIONAL 15 MIN 2400537 CPT outpatient 1500 1500 1500 1500 SURGERY MAJOR 1 HOUR 2400538 CPT outpatient 4000 4000 4000 4000 SURGERY MAJOR EA ADDITIONAL 15 MIN 2400539 CPT outpatient 1000 1000 1000 1000 SURGERY MINOR 1 HOUR 2400540 CPT outpatient 3000 3000 3000 3000 SURGERY MINOR EA ADDITIONAL 15 MIN 2400541 CPT outpatient 750 750 750 750 SURGERY SETUP & CANC 2400542 CPT outpatient 600 600 600 600 GOLDTIP BIPOLAR FORCEP 8-1/2 2.0MM 2400564 CPT outpatient 244.1 244.1 244.1 244.1 GOLDTIP BIPOLAR FORCEP 6' 1.5MM 2400565 CPT outpatient 244.1 244.1 244.1 244.1 EQ- INSUFFLATOR 2400573 CPT outpatient 200 200 200 200 EQ- MAJOR INSTRUMENT 2400574 CPT outpatient 360 360 360 360 EQ- MINOR INSTRUMENT 2400575 CPT outpatient 300 300 300 300 EQ- NITROGEN TANK 2400577 CPT outpatient 100 100 100 100 JACKSON TABLE PATIENT PACK KIT 2400578 CPT outpatient 600 600 600 600 ORHTOPEDIC MAJOR 1ST HOUR OF SURGERY 2400587 CPT outpatient 24000 24000 24000 24000 ORTHOPEDIC MAJOR SING ADDITIONAL 15 MIN 2400590 CPT outpatient 4000 4000 4000 4000 ORTHO MINOR SPINE 1ST 2 HOURS SINGLE LEV 2400591 CPT outpatient 32000 32000 32000 32000 ORTHO MINOR SPINE SURGERY EACH ADD15MIN 2400592 CPT outpatient 4000 4000 4000 4000 ORTHO MAJOR SPINE SX 1ST 2 HRS SINGLE 2400593 CPT outpatient 48000 48000 48000 48000 ORTHO MAJOR SPINE SINGLE EA ADDL 15 MINS 2400594 CPT outpatient 4000 4000 4000 4000 OR ROOM 1ST HOUR (PAIN MANAGEMENT) 2400595 CPT outpatient 5000 5000 5000 5000 ORTHO MAJOR SPINE SX 1ST 2 HRS MULTI LEV 2400596 CPT outpatient 58000 58000 58000 58000 ORTHO MAJOR SPINE SX 1ST 2 HRS SCOLIOSIS 2400597 CPT outpatient 68000 68000 68000 68000 ORTHO MINOR SPINE 1ST 2 HOURS MULTI LEVE 2400598 CPT outpatient 38000 38000 38000 38000 ORTHO MAJOR SPINE MULTI EA ADDL 15 MINS 2400599 CPT outpatient 4000 4000 4000 4000 MINOR ADD ON PROCEDURE 2400600 CPT outpatient 8000 8000 8000 8000 MAJOR ADD ON PROCEDURE 2400601 CPT outpatient 8000 8000 8000 8000 LAMINECTOMY TRAY 2400619 CPT outpatient 3500 3500 3500 3500 EQ INTELLISYSTEM AND MONITOR 2400620 CPT outpatient 80 80 80 80 EQ ANES CO2 MONITOR 2400627 CPT outpatient 1000 1000 1000 1000 TRAY TRACHEOSTOMY 2400629 CPT outpatient 1200 1200 1200 1200 NEEDLE SPINAL 18GX3.5 2400639 CPT outpatient 10.26 10.26 10.26 10.26 STAPLER SKIN PROXI PLUS 35W 2400641 CPT outpatient 46.97 46.97 46.97 46.97 SUTURE VICRYL 1-0 36 CTX LF 2400642 CPT outpatient 21.9 21.9 21.9 21.9 DRAPE IOBAN 23 X 17 2400648 CPT outpatient 46.19 46.19 46.19 46.19 BIPOLAR FORCEP 5MM MICRO JAW 2400649 CPT outpatient 244.1 244.1 244.1 244.1 NEEDLE REG BEVEL 25GX1.5 2400650 CPT outpatient 5 5 5 5 MASTISOL ADHESIVE 2400652 CPT outpatient 5 5 5 5 FRAZIER SUCTION TIP 10 FR 2400653 CPT outpatient 24.2 24.2 24.2 24.2 PEG CLEANING BRUSH 2400655 CPT outpatient 211.46 211.46 211.46 211.46 DOUBLE NDLE SET 25GX6 20GX3.5 2400656 CPT outpatient 80.74 80.74 80.74 80.74 UNDERCAST PADDING 4X4YD 2400660 CPT outpatient 20.11 20.11 20.11 20.11 UNDERCAST PADDING 6X4YD 2400661 CPT outpatient 16.01 16.01 16.01 16.01 C-ARMOUR 2400662 CPT outpatient 135 135 135 135 GAUZE XRAY DETECT 16PLY 4X4 2400663 CPT outpatient 7.5 7.5 7.5 7.5 BANDAGE ELASTIC 6 VELCRO 2400664 CPT outpatient 5 5 5 5 DRAPE U 76X120 4X40 SP RNF 2400666 CPT outpatient 18.75 18.75 18.75 18.75 DRAPE FLOUROSCOPE 36X44 2400667 CPT outpatient 7.5 7.5 7.5 7.5 HEMOVAC DRAIN KIT CWV 3 SPRING SUCTION S 2400668 CPT outpatient 28.6 28.6 28.6 28.6 ELECTRODE BLADE 2.5 EZ LF 2400671 CPT outpatient 9.07 9.07 9.07 9.07 ELECTRODE BLADE 6 EXTENSION 2400672 CPT outpatient 19.44 19.44 19.44 19.44 MICROSCOPE DRAPE 2400673 CPT outpatient 22.19 22.19 22.19 22.19 DRAPE INSTRUMENT 7X12 STERILE 2400674 CPT outpatient 5 5 5 5 SUTURE 4-0 MONOCRYL PS2 (Y496G) 2400677 CPT outpatient 17.58 17.58 17.58 17.58 TRAY LAPAROSCOPIC 2400681 CPT outpatient 1200 1200 1200 1200 EQ JACKSON TABLE ORTHO SPINE 2400694 CPT outpatient 3000 3000 3000 3000 SCREW 12MM 2400719 CPT outpatient 90 90 90 90 ARM SLING 2400727 CPT outpatient 30.25 30.25 30.25 30.25 NUERO SPONG3E 1 X 1 2400728 CPT outpatient 12.6 12.6 12.6 12.6 GELFOAM 2400729 CPT outpatient 155.5 155.5 155.5 155.5 FRAZIER SUCTION TIP 8 FR 2400730 CPT outpatient 11.24 11.24 11.24 11.24 THYROID DRAPE 2400732 CPT outpatient 21.27 21.27 21.27 21.27 STERI-DRAPE 17X11 2400733 CPT outpatient 5 5 5 5 OSTOMY BAG 2400748 CPT outpatient 7.32 7.32 7.32 7.32 TRAY-CERVICAL LAMINECTOMY 2400791 CPT outpatient 3500 3500 3500 3500 TRAY-HAND TRAY 2400793 CPT outpatient 1200 1200 1200 1200 EQ - SHOULDER HOLDER 2400795 CPT outpatient 175 175 175 175 SPLINT 2400802 CPT outpatient 206.99 206.99 206.99 206.99 EQ: C - ARM 2400809 CPT outpatient 2000 2000 2000 2000 TOURNIQUET CUFF ALL SIZES 2400810 CPT outpatient 2000 2000 2000 2000 DURAGEN 2400812 CPT outpatient 2600 2600 2600 2600 INSERTION OF PAIN PUMP FOR POST OPERATIV 2400821 CPT outpatient 1200 1200 1200 1200 TRAY-ARTHROSCOPY TRAY 2400859 CPT outpatient 1200 1200 1200 1200 IRRIGATION 3L .9% SODIUM CHLOR 2400861 CPT outpatient 200 200 200 200 ARM SLING XLARGE 2400877 CPT outpatient 30.25 30.25 30.25 30.25 SPLINT 2400879 CPT outpatient 35 35 35 35 TRAY GENERAL ORTHO 2400888 CPT outpatient 1200 1200 1200 1200 TRAY - METRIC SYSTEM 2400890 CPT outpatient 4250 4250 4250 4250 5.0 MM AGRESSIVE PLUS CUTTER 2400891 CPT outpatient 267.35 267.35 267.35 267.35 4.0 MM RESECTOR CUTTER 0375-542-000 2400892 CPT outpatient 274.25 274.25 274.25 274.25 PRESSURIZED CEMENT MIXER 2400893 CPT outpatient 300 300 300 300 SURGICAL SIMPLEX P 2400903 CPT outpatient 454 454 454 454 TRAY CASPAR DISTRACTOR SET 2400904 CPT outpatient 1200 1200 1200 1200 EQ- EMAX ANSPACH DRILL 2400920 CPT outpatient 1200 1200 1200 1200 EQ- LUXTEC LX 300 LIGHT SOURCE 2400921 CPT outpatient 500 500 500 500 STOCKINETTE BIAS CUT 6 2400928 CPT outpatient 12 12 12 12 LARGE TEAR CROSS CUT RASP 2400935 CPT outpatient 195 195 195 195 BIT & BURR DRILL: 4MM COARSE DIAMOND 2400950 CPT outpatient 350 350 350 350 TRAY: BLACK BELT CERVICAL RETRACTOR 2400951 CPT outpatient 1200 1200 1200 1200 14MM SCREW 4.0 2400953 CPT outpatient 1895 1895 1895 1895 HERNIA MESH: 3X3 PROLITE MESH 2400964 CPT outpatient 170 170 170 170 BLADE DUAL CUT SAGITTAL BLADE 25MM X 90 2400974 CPT outpatient 500 500 500 500 TRAY: OSTEOTOIME SET 2400976 CPT outpatient 1500 1500 1500 1500 TRAY: TRACHEOSTOMY TRAY 2400977 CPT outpatient 1200 1200 1200 1200 TRAY-ARTHROSCOPY PUNCHERS AND BITERS SET 2400978 CPT outpatient 1200 1200 1200 1200 EQ-ALVARADO KNEE HOLDER 2400980 CPT outpatient 1000 1000 1000 1000 EQ-STRYKER SYSTEM 5 LARGE DR 2400981 CPT outpatient 1000 1000 1000 1000 EQ-STRYKER SMALL BONE DRIL 2400982 CPT outpatient 1000 1000 1000 1000 EQ: BIPOLAR FORCEP 2400983 CPT outpatient 1000 1000 1000 1000 TRAY-CURVED CURETTE 2400984 CPT outpatient 1200 1200 1200 1200 TRAY-CERVICAL KARLIN CURETTE 2400985 CPT outpatient 1200 1200 1200 1200 TRAY-LUMBAR KARLIN CURETTE 2400986 CPT outpatient 1200 1200 1200 1200 INTERPULSE HAND PIECE W/ SUCTION HIGH FL 2400987 CPT outpatient 199.22 199.22 199.22 199.22 SCD PUMP 2400992 CPT outpatient 100 100 100 100 TRAY-CERVICAL KARLIN CURETTE TRAY 2 2400993 CPT outpatient 1200 1200 1200 1200 DRILL: 3MM DIAMOND BALL LONG ATTACHMENT 2400995 CPT outpatient 350 350 350 350 BIT & BURR DRILL: 3 MM DIAMOND BALL ANGL 2400996 CPT outpatient 207 207 207 207 DRILL: 3MM MATCH STICK FLUTED LONG ATTAC 2400997 CPT outpatient 350 350 350 350 DRILL: 4MM COARSE DIAMOND BALL LONG ATTA 2400998 CPT outpatient 70 70 70 70 BIT & BURR DRILL: 5 MM FLUTED BALL LONG 2401001 CPT outpatient 350 350 350 350 BONE COLLECTOR 2401007 CPT outpatient 325 325 325 325 VAGINAL PACKING ALL SIZES 2401008 CPT outpatient 5.95 5.95 5.95 5.95 SURGICAL GLOVES RADIATION RESISTANT ALL 2401009 CPT outpatient 323 323 323 323 ORTHOPEDIC MINOR 1ST HOUR 2401012 CPT outpatient 16000 16000 16000 16000 ORTHOPEDIC MINOR SURGERY EA 15 MIN ADDIT 2401017 CPT outpatient 2000 2000 2000 2000 DRAPE: DRAPE 1010 SHEET 2401025 CPT outpatient 8.2 8.2 8.2 8.2 INSUFF SYRINGE CUSTOM INFLATION KIT 2401026 CPT outpatient 267 267 267 267 OPTIGUARD 2401029 CPT outpatient 24 24 24 24 LIGACLIP MEDIUM (MCM 20) 2401031 CPT outpatient 65.78 65.78 65.78 65.78 PREP: CHLORAPREP 26ML 2401032 CPT outpatient 64.5 64.5 64.5 64.5 TRANSPAC IV MONITORING KIT 2401033 CPT outpatient 77.19 77.19 77.19 77.19 TRAY - ANTERIOR LUMBAR TRAY 2401034 CPT outpatient 1200 1200 1200 1200 LAPAROTOMY DRAPE WITH POUCHES 2401059 CPT outpatient 37.5 37.5 37.5 37.5 6.5 MM CANNULA 2401063 CPT outpatient 50 50 50 50 TROCAR ENDO 5MM BLADELESS 2401067 CPT outpatient 229.98 229.98 229.98 229.98 TROCAR ENDO 12MM BLADELESS 2401068 CPT outpatient 304.39 304.39 304.39 304.39 LINEAR CUTTER 75MM 2401071 CPT outpatient 735.87 735.87 735.87 735.87 NEEDLE VERESS ULTRA 120 MM LF STRERILE 2401073 CPT outpatient 95.09 95.09 95.09 95.09 ENDOPOUCH RETRIEVER 2401074 CPT outpatient 381.22 381.22 381.22 381.22 UTILITY DRAPE 2401084 CPT outpatient 292.39 292.39 292.39 292.39 LONG TERM HEMODIALYSIS CATH 16FR STRAIGH 2401086 CPT outpatient 1254.5 1254.5 1254.5 1254.5 ULTRASOUND PROBE COVER WITH GEL 2401091 CPT outpatient 58.37 58.37 58.37 58.37 ESOPHAGEAL STETHOSCOPE 2401099 CPT outpatient 21.88 21.88 21.88 21.88 ARTERIAL LINE KIT AK-04510 2401100 CPT outpatient 141.9 141.9 141.9 141.9 STERILE GLOVE ALOE NATURAL ALL SIZES 2401107 CPT outpatient 5 5 5 5 STERILE GLOVE SENSICARE ALL SIZES 2401108 CPT outpatient 12.02 12.02 12.02 12.02 TRANSGASTRIC GASTROJEJUNOSTOMY TUBE 22 F 2401112 CPT outpatient 802.11 802.11 802.11 802.11 INVASIVE PROCEDURE - 1ST HR 2401113 CPT outpatient 351.5 351.5 351.5 351.5 2MM TIGER TAPE 2401117 CPT outpatient 22.5 22.5 22.5 22.5 CANNULATED SCREWS 2401123 CPT outpatient 450 450 450 450 K-WIRE(S) NON-THREADED 2401125 CPT outpatient 30 30 30 30 MAIN PUMP TUBING 2401132 CPT outpatient 153 153 153 153 GLYDESCOPE BLADES 2401135 CPT outpatient 44.4 44.4 44.4 44.4 EQ - GLYDESCOPE 2401136 CPT outpatient 500 500 500 500 TRAY - MICRO DECKER SET 2401137 CPT outpatient 1200 1200 1200 1200 TRAY - CERVICAL RETRACTOR SYSTEM 2401139 CPT outpatient 1200 1200 1200 1200 TRAY - LOBSTER RETRACTOR/OMNI 2401140 CPT outpatient 1200 1200 1200 1200 TRAY - LONG KERRISON SET 2401142 CPT outpatient 1200 1200 1200 1200 TRAY - MCCULLOCH RETRACTOR SET 2401146 CPT outpatient 1200 1200 1200 1200 TRAY - PITUITARY RONGUER SET 2401149 CPT outpatient 1200 1200 1200 1200 EQ - KERRISON SET 2401152 CPT outpatient 1000 1000 1000 1000 ASPIRATING ABLATOR 50* 2401162 CPT outpatient 525 525 525 525 ARTERIAL PRESSURE TUBING 2401169 CPT outpatient 13.48 13.48 13.48 13.48 SUTURE SPECIALTY #3 2401181 CPT outpatient 100 100 100 100 SUTURE SPECIALTY #4 2401182 CPT outpatient 200 200 200 200 SUTURE SPECIALTY #5 2401183 CPT outpatient 300 300 300 300 ETHIBOND 030' CT1 2401184 CPT outpatient 10.08 10.08 10.08 10.08 5.0 MM ANGLED AGRESSIVE PLUS 2401191 CPT outpatient 274.25 274.25 274.25 274.25 5.0 MM ANGLED TOMCAT 2401192 CPT outpatient 274.24 274.24 274.24 274.24 ARMBOARD FOAM / ARM PAD 2401210 CPT outpatient 12.12 12.12 12.12 12.12 COFLEX ALL SIZES 2401212 CPT outpatient 12.85 12.85 12.85 12.85 LONG TERM HEMODIALYSIS CATH 16 FR X 19 C 2401219 CPT outpatient 1254.5 1254.5 1254.5 1254.5 LONG TERM HEMODIALYSIS CATH 16 FR X 24 C 2401220 CPT outpatient 1254.5 1254.5 1254.5 1254.5 STOCKINETTE STERILE ALL SIZES 2401221 CPT outpatient 50 50 50 50 LONG TERM HEMODIALYSIS CATH 16 X 32 CM H 2401222 CPT outpatient 1505.4 1505.4 1505.4 1505.4 BAG DECANTER 2401225 CPT outpatient 11.4 11.4 11.4 11.4 TELFA 3X8 NON-ADHERENT DRESSING 2401228 CPT outpatient 5 5 5 5 GRAFT JACKET 2401229 CPT outpatient 7950 7950 7950 7950 NERVE BLOCK INSULATED NEEDLE 21G X 4 2401230 CPT outpatient 69 69 69 69 NERVE BLOCK INSULATED NEEDLE 22G X 2 2401231 CPT outpatient 69 69 69 69 ELECTRODE NERVE BLOCK CONNECTING CABLE 2401232 CPT outpatient 75 75 75 75 T4 HOOD STERI-SHIELD 2401234 CPT outpatient 257.16 257.16 257.16 257.16 KNEE HOLDER DISP LINER 2401238 CPT outpatient 153.6 153.6 153.6 153.6 ORTHOPEDIC PINS ALL SIZES 2401242 CPT outpatient 45 45 45 45 BLOOD CONSERVATION KIT 2401245 CPT outpatient 365 365 365 365 VENTRAL PATCH HERNIA MESH 2401246 CPT outpatient 5028.99 5028.99 5028.99 5028.99 HEMOSTATIC SEAL-F 10ML 2401251 CPT outpatient 1100 1100 1100 1100 COTTONOID 1/2 X 6 2401253 CPT outpatient 51 51 51 51 COTTONOID 1 X 1 2401254 CPT outpatient 38 38 38 38 SILK 2-0 30 2401256 CPT outpatient 28.8 28.8 28.8 28.8 PROLENE 5-0 24 2401257 CPT outpatient 59.93 59.93 59.93 59.93 PROLENE 3-0 30 2401258 CPT outpatient 48.39 48.39 48.39 48.39 VICRYL 3-0 27 2401259 CPT outpatient 16.48 16.48 16.48 16.48 VICRYL 2.0 18 2401260 CPT outpatient 40.75 40.75 40.75 40.75 MONOCRYL 3-0 18 2401265 CPT outpatient 58.26 58.26 58.26 58.26 PDS II 1 96 2401268 CPT outpatient 52.35 52.35 52.35 52.35 DISP HIGH FLOW INSUFFLATOR TUBE SET 2401761 CPT outpatient 255.63 255.63 255.63 255.63 MINOR PACK 2401771 CPT outpatient 30.35 30.35 30.35 30.35 LUMBAR DISC PREP TRAY 2402276 CPT outpatient 1200 1200 1200 1200 PROTECTIVE DISC W/CHG 2402279 CPT outpatient 20.46 20.46 20.46 20.46 UNIV ELECTR GROUNDING PAD 2402280 CPT outpatient 152.7 152.7 152.7 152.7 NEEDLE-TROCAR TIP 2402281 CPT outpatient 266.4 266.4 266.4 266.4 JAMSHIDI NEEDLE 2402283 CPT outpatient 68.34 68.34 68.34 68.34 FULL COMPONENT TRAY 2402284 CPT outpatient 1275 1275 1275 1275 NEUROMONITORING UP TO 3 HR 2402760 CPT outpatient 1250 1250 1250 1250 NEUROMONITORING EACH ADD HR 2402761 CPT outpatient 150 150 150 150 VICRYL 3-0 18 ' SH 2402766 CPT outpatient 40.65 40.65 40.65 40.65 SURGICAL PATHOLOGY 2408307 CPT outpatient 103.1 103.1 103.1 103.1 HYPER/HYPO THERMIA MACHINEGAYMAR5900 2410107 CPT outpatient 110 110 110 110 BAIR HUGGER WARMING UNIT 2410109 CPT outpatient 53.57 53.57 53.57 53.57 PLUERO-VAC DRAINAGE UNIT 2410281 CPT outpatient 67.8 67.8 67.8 67.8 SKIN MARKER 2410293 CPT outpatient 7.8 7.8 7.8 7.8 ELASTIC BANDAGE 4X5YD 2410296 CPT outpatient 5 5 5 5 EQ-ULTRASOUND 2410496 CPT outpatient 2000 2000 2000 2000 EQ INTELLISYSTEM AND MONITOR 2410620 CPT outpatient 240 240 240 240 EQ ANES C02 MONITOR 2410627 CPT outpatient 200 200 200 200 NUERO SPONGE 1/2X1/2 2410727 CPT outpatient 6.3 6.3 6.3 6.3 GAS LINE SAMPLING 2500001 CPT outpatient 0.1 0.1 0.1 0.1 GUEDEL AIRWAY 90MM 2500002 CPT outpatient 0.1 0.1 0.1 0.1 ENSURE VANILLA 2500007 CPT outpatient 0.42 0.42 0.42 0.42 CHEST DRAIN KIT 2000ML 2500008 CPT outpatient 20.08 20.08 20.08 20.08 22MM ADAPTER 2500009 CPT outpatient 188.65 188.65 188.65 188.65 ET TUBE CHANGERS 2500017 CPT outpatient 238.77 238.77 238.77 238.77 ET TUBE SZ # 6.0 2500020 CPT outpatient 21.25 21.25 21.25 21.25 ET TUBE SZ # 8.0 2500024 CPT outpatient 21.25 21.25 21.25 21.25 MDI VENT ADAPTER 2500030 CPT outpatient 23.94 23.94 23.94 23.94 OP AIRWAYS 100MM 2500033 CPT outpatient 23.62 23.62 23.62 23.62 OP AIRWAYS 120MM 2500034 CPT outpatient 23.62 23.62 23.62 23.62 OP AIRWAYS 90MM 2500035 CPT outpatient 23.62 23.62 23.62 23.62 OP AIRWAYS 110MM 2500036 CPT outpatient 23.62 23.62 23.62 23.62 ABG KITS SUB 2500044 CPT outpatient 188.65 188.65 188.65 188.65 SHILEY TRACH 7 XLTCP 2500049 CPT outpatient 21.22 21.22 21.22 21.22 TRACH COLLAR ADAPTER 22MM 2500055 CPT outpatient 6.71 6.71 6.71 6.71 BLANKET UPPER BODY 2500109 CPT outpatient 56 56 56 56 IV PRIMARY TUBING 2500110 CPT outpatient 26.96 26.96 26.96 26.96 IV SECONDARY TUBING 2500111 CPT outpatient 26.96 26.96 26.96 26.96 CLEANSING LOTION 2500118 CPT outpatient 14.85 14.85 14.85 14.85 COMMODE BARIATRIC 2500126 CPT outpatient 260.22 260.22 260.22 260.22 LIMB HOLDERS (SUB) 2500127 CPT outpatient 32.08 32.08 32.08 32.08 EKG PATCHES 2500132 CPT outpatient 5 5 5 5 HOT PACKS 2500137 CPT outpatient 11.99 11.99 11.99 11.99 HOT PACKS 2500139 CPT outpatient 11.99 11.99 11.99 11.99 GUEDEL AIRWAY 80MM 2500142 CPT outpatient 0.16 0.16 0.16 0.16 ICE PACKS 2500143 CPT outpatient 5.4 5.4 5.4 5.4 MITTENS 2500145 CPT outpatient 61.26 61.26 61.26 61.26 NONSKID FOOTWEAR SMALL 2500148 CPT outpatient 14.85 14.85 14.85 14.85 NONSKID FOOTWEAR MEDIUM 2500149 CPT outpatient 14.85 14.85 14.85 14.85 NONSKID FOOTWEAR LARGE 2500150 CPT outpatient 14.85 14.85 14.85 14.85 NONSKID FOOTWEAR X-LARGE 2500151 CPT outpatient 14.85 14.85 14.85 14.85 NONSKID FOOTWEAR XX-LARGE 2500152 CPT outpatient 14.85 14.85 14.85 14.85 STETHOSCOPE DISPOSABLE 2500158 CPT outpatient 23.83 23.83 23.83 23.83 SKIN REPAIR CREAM 2500164 CPT outpatient 9.37 9.37 9.37 9.37 B/P CUFFS SMALL 2 TUBES 2500175 CPT outpatient 26.96 26.96 26.96 26.96 CALF CUFF 2500176 CPT outpatient 26.96 26.96 26.96 26.96 B/P CUFFS LARGE 2 TUBES 2500177 CPT outpatient 26.96 26.96 26.96 26.96 ANGIO CATH 18GA 2500179 CPT outpatient 41.6 41.6 41.6 41.6 YANKAUER FLANGE TIP 2500180 CPT outpatient 10.38 10.38 10.38 10.38 B/P CUFFS SMALL 1 TUBES 2500181 CPT outpatient 26.96 26.96 26.96 26.96 B/P CUFF MEDIUM 2 TUBES 2500182 CPT outpatient 26.96 26.96 26.96 26.96 GAUZE 4 X4 STERILE 2500207 CPT outpatient 6.1 6.1 6.1 6.1 KERLIX ROLL 2500224 CPT outpatient 7.5 7.5 7.5 7.5 XEROFORM 1X8 2500237 CPT outpatient 31.77 31.77 31.77 31.77 XEROFORM 5X9 2500238 CPT outpatient 31.77 31.77 31.77 31.77 HYPOTHERMIA BLANKET 2500267 CPT outpatient 90 90 90 90 BLANKET LOWER- BODY 2500268 CPT outpatient 56 56 56 56 BLANKET FULL-BODY 2500269 CPT outpatient 56 56 56 56 PORTEX DIC 7.0MM TUBE 2500275 CPT outpatient 250 250 250 250 DIC 7.0MM TUBE 2500276 CPT outpatient 316.25 316.25 316.25 316.25 CANNULA NASAL 7' TUBING 2500289 CPT outpatient 5.23 5.23 5.23 5.23 LMA #4 2500290 CPT outpatient 44.4 44.4 44.4 44.4 ANESTHESIA MASK 2500291 CPT outpatient 9.25 9.25 9.25 9.25 CANNULA NASAL 7' TUBING 2500292 CPT outpatient 6.61 6.61 6.61 6.61 PLEURX KIT 2500308 CPT outpatient 206.06 206.06 206.06 206.06 PLEURX LOCKABLE DRAINAGE LINE KIT 2500309 CPT outpatient 206.06 206.06 206.06 206.06 CULTURE SWABS 2500311 CPT outpatient 10.54 10.54 10.54 10.54 SUCTION CANISTER 2500 2500312 CPT outpatient 20.08 20.08 20.08 20.08 SUTURE REMOVAL TRAY 2500313 CPT outpatient 13.71 13.71 13.71 13.71 SUCTION CANISTER 1500ML 2500314 CPT outpatient 20.08 20.08 20.08 20.08 XEROFORM 4X4 2500331 CPT outpatient 31.77 31.77 31.77 31.77 ISOLATION SUPPLY CHARGES DAILY 2500352 CPT outpatient 150 150 150 150 STAPLE REMOVAL TRAY 2500354 CPT outpatient 23.83 23.83 23.83 23.83 O/R TOWELS 2500363 CPT outpatient 24.6 24.6 24.6 24.6 ORTHO GLOVES SZ 8 2500365 CPT outpatient 19.45 19.45 19.45 19.45 ABG KITS 2500378 CPT outpatient 188.65 188.65 188.65 188.65 CO2 DECTECTOR 2500379 CPT outpatient 55.99 55.99 55.99 55.99 STYLET INTUB 14FR 2500380 CPT outpatient 99.72 99.72 99.72 99.72 SHILEY DIC 6.0 2500389 CPT outpatient 21.22 21.22 21.22 21.22 SHILEY DIC 8.0 2500390 CPT outpatient 21.22 21.22 21.22 21.22 G-TUBE REPLACEMENT 22FR 2500393 CPT outpatient 503.58 503.58 503.58 503.58 G-TUBE REPLACEMENT 18FR 2500394 CPT outpatient 503.58 503.58 503.58 503.58 G-TUBE REPLACEMENT 24FR 2500395 CPT outpatient 503.58 503.58 503.58 503.58 G-TUBE REPLACEMENT 20FR 2500396 CPT outpatient 503.58 503.58 503.58 503.58 AQUAPAK 1070ML 2500399 CPT outpatient 21.03 21.03 21.03 21.03 O2 HUMIDIFER 2500401 CPT outpatient 10.03 10.03 10.03 10.03 TRACH TIES MEDIUM 2500407 CPT outpatient 8.43 8.43 8.43 8.43 TRACH TIES MEDIUM 2500408 CPT outpatient 21 21 21 21 TRACH TIES LARGE 2500409 CPT outpatient 8.43 8.43 8.43 8.43 TRACH TIES LARGE 2500410 CPT outpatient 21 21 21 21 FOLEY SILVER TRAY 16FR 2500413 CPT outpatient 50.02 50.02 50.02 50.02 FOLEY CATH TRAY 14FR 2500414 CPT outpatient 50.02 50.02 50.02 50.02 DRAINAGE BAG ANTI REFLUX 2000ML 2500415 CPT outpatient 50.02 50.02 50.02 50.02 TUBE GASTRIC SUMP 18FR 2500418 CPT outpatient 11.39 11.39 11.39 11.39 NON-REBREATHER MASK 2500435 CPT outpatient 7.44 7.44 7.44 7.44 NON-REBREATHER MASK 2500436 CPT outpatient 9.42 9.42 9.42 9.42 KIT CATHETER SUCTION 14 FR SALINE 2500442 CPT outpatient 6.33 6.33 6.33 6.33 SPECIMEN CONTAINER 2500457 CPT outpatient 5.4 5.4 5.4 5.4 BINDER ABD 9 LG/XL 2500479 CPT outpatient 38.34 38.34 38.34 38.34 BINDER ABD 9 SM/MED 2500480 CPT outpatient 38.34 38.34 38.34 38.34 IV START KIT 2500496 CPT outpatient 25 25 25 25 OXYGEN MASK 2500503 CPT outpatient 6.41 6.41 6.41 6.41 OMNIFLEX CONNECTORS 2500507 CPT outpatient 23.62 23.62 23.62 23.62 CIRCUIT HHN 2500508 CPT outpatient 21.25 21.25 21.25 21.25 HME FILTER 2500510 CPT outpatient 15.82 15.82 15.82 15.82 UTN CUSHION CLEAN CLIP SIDECAR C 2500513 CPT outpatient 70.92 70.92 70.92 70.92 AEROSOL MASK 2500514 CPT outpatient 7.05 7.05 7.05 7.05 O2 VENTURI MASK 2500519 CPT outpatient 6.33 6.33 6.33 6.33 IOBAN 2 23 X 17 2500646 CPT outpatient 17.58 17.58 17.58 17.58 DERMABOND 2500651 CPT outpatient 90.87 90.87 90.87 90.87 SPECIMEN CUP 2500677 CPT outpatient 5 5 5 5 LUER LOCKS 2500681 CPT outpatient 7.23 7.23 7.23 7.23 IRRIGATION SYRINGE 60ML 2500697 CPT outpatient 7.95 7.95 7.95 7.95 PULMOCARE 1.5 CAL 1000ML 2500701 CPT outpatient 23.83 23.83 23.83 23.83 NEPRO 1000ML 2500702 CPT outpatient 41.57 41.57 41.57 41.57 JEVITY 1.2 1500ML (TUBE FEEDING PUMP) 2500703 CPT outpatient 40.32 40.32 40.32 40.32 OSMOLITE 1.2 1000ML 2500704 CPT outpatient 75 75 75 75 NEPRO 2500706 CPT outpatient 41.57 41.57 41.57 41.57 JEVITY 1.2 CAL LIQUID 1000ML 2500707 CPT outpatient 40.32 40.32 40.32 40.32 JEVITY 1.2 2500708 CPT outpatient 40.32 40.32 40.32 40.32 KIT TRACH CLSD 14FR 2500716 CPT outpatient 51.87 51.87 51.87 51.87 BALLARD TRACH (SUB) 2500717 CPT outpatient 51.87 51.87 51.87 51.87 FRAZIER 12FR 2500731 CPT outpatient 11.24 11.24 11.24 11.24 W/V MEDIUM DRESSING 2500732 CPT outpatient 6.06 6.06 6.06 6.06 W/V LARGE DRESSING 2500733 CPT outpatient 6.06 6.06 6.06 6.06 W/V CANISTERS 300ML 2500734 CPT outpatient 6.06 6.06 6.06 6.06 W/V CANISTERS 800ML 2500736 CPT outpatient 6.06 6.06 6.06 6.06 WALKER W/WHEELS 2500749 CPT outpatient 256.4 256.4 256.4 256.4 MASIMO SENSOR PROBES 2500750 CPT outpatient 238.77 238.77 238.77 238.77 DISPOSABLE SPO2 SENSORS 2500751 CPT outpatient 238.77 238.77 238.77 238.77 JEVITY 1.5 2500754 CPT outpatient 40.32 40.32 40.32 40.32 MASIMO RD SET CABLE 8' 2500755 CPT outpatient 238.77 238.77 238.77 238.77 GLUCERNA 1.5 2500756 CPT outpatient 12.72 12.72 12.72 12.72 GLUCERNA 1.2 CAL LIQUID 1000ML 2500757 CPT outpatient 75 75 75 75 GLUCERNA 1.2 2500758 CPT outpatient 12.72 12.72 12.72 12.72 IV OUTLOOK SECONDARY 2500762 CPT outpatient 30.82 30.82 30.82 30.82 PASSY-MUIR VALVE 2500765 CPT outpatient 505.81 505.81 505.81 505.81 QUINTON CATH 12FRX13CM 2500766 CPT outpatient 510.02 510.02 510.02 510.02 QUINTON CATH 12X24CM 2500767 CPT outpatient 510.02 510.02 510.02 510.02 QUINTON CATH 12FR X 16CM 2500768 CPT outpatient 510.02 510.02 510.02 510.02 FLEXISEAL 2500773 CPT outpatient 18.46 18.46 18.46 18.46 BIOFLO PICC 5FDL 2500793 CPT outpatient 417.3 417.3 417.3 417.3 FLEXISEAL SUB 2500794 CPT outpatient 417.3 417.3 417.3 417.3 HIP KIT 2500800 CPT outpatient 76.13 76.13 76.13 76.13 SURGICEL 4 X 8 2500801 CPT outpatient 322.02 322.02 322.02 322.02 VENTED IV SPIKE 2500805 CPT outpatient 3.75 3.75 3.75 3.75 GLIDE SHEETS 2500807 CPT outpatient 159.15 159.15 159.15 159.15 GLIDE UNDERPADS 2500808 CPT outpatient 9.18 9.18 9.18 9.18 TRAY TRACH CARE 2500810 CPT outpatient 6.71 6.71 6.71 6.71 MASK TRACHEOSTOMY ADULT 2500811 CPT outpatient 75.9 75.9 75.9 75.9 OPTIFOAM GENTLE EX 3X3 2500817 CPT outpatient 7.57 7.57 7.57 7.57 BANATROL PLUS POWDER 10.75GM 2500830 CPT outpatient 25 25 25 25 BELT SAFETY-SOFT PATIENT 2500831 CPT outpatient 60.24 60.24 60.24 60.24 MEPILEX HEEL 8.7 X 9.1 2500834 CPT outpatient 25.05 25.05 25.05 25.05 MALE INCONTINENCE WRAP 2500835 CPT outpatient 43.33 43.33 43.33 43.33 CLOTH 2% CHLORHEXIDINE 2500836 CPT outpatient 11.37 11.37 11.37 11.37 MIDLINE TRAY 4FR 2500838 CPT outpatient 416.25 416.25 416.25 416.25 MIDLINE MAX BARRIER 4FR KIT 2500839 CPT outpatient 416.25 416.25 416.25 416.25 SPIKE SET W/ BAG 2500840 CPT outpatient 25.67 25.67 25.67 25.67 LIQUID PROTEIN PROHEAL 2500841 CPT outpatient 153.75 153.75 153.75 153.75 PROHEAL BOTTLE 30ML 2500842 CPT outpatient 25 25 25 25 VITAL 1.2 2500844 CPT outpatient 35.82 35.82 35.82 35.82 BIOFLO MIDLINE 5F DUAL 2500845 CPT outpatient 416.25 416.25 416.25 416.25 BIOFLO MIDLINE 5F (SUB1) 2500847 CPT outpatient 416.25 416.25 416.25 416.25 NT- MIDLINE II TI CAGE 33MMX13MMX8 2500848 CPT outpatient 416.25 416.25 416.25 416.25 COLLAGEN DRESSING PLUS 4 X 4 2500861 CPT outpatient 86.63 86.63 86.63 86.63 DIGNICARE KIT 2500865 CPT outpatient 642.72 642.72 642.72 642.72 DIGNICARE BAGS 2500866 CPT outpatient 11.19 11.19 11.19 11.19 OPTIFOAM GENTLE 6 X6 2500874 CPT outpatient 14.28 14.28 14.28 14.28 VITAL 1.5 2500886 CPT outpatient 44.07 44.07 44.07 44.07 HEEL FOAM PROTECTORS 2500887 CPT outpatient 49.89 49.89 49.89 49.89 HEEL MEDIX 2500888 CPT outpatient 49.89 49.89 49.89 49.89 VAP KITS 2500889 CPT outpatient 67.06 67.06 67.06 67.06 VAP KITS 2500890 CPT outpatient 67.06 67.06 67.06 67.06 EXTENSION SET (SMALLBORE) 2500891 CPT outpatient 12.28 12.28 12.28 12.28 EXTENSION BI-FUSE 2500892 CPT outpatient 20.49 20.49 20.49 20.49 EXTENSION SET (SMALLBORE) 2500893 CPT outpatient 12.28 12.28 12.28 12.28 TPN TUBING (NURSING) 2500895 CPT outpatient 34.58 34.58 34.58 34.58 TPN TUBING LIPID 2500896 CPT outpatient 28.26 28.26 28.26 28.26 BLOOD TUBING 2500897 CPT outpatient 47.32 47.32 47.32 47.32 PUMP BLOOD ADMIN SET 2500898 CPT outpatient 47.32 47.32 47.32 47.32 TPN TUBING (NURSING) 2500900 CPT outpatient 34.58 34.58 34.58 34.58 IN & OUT CATH 15FR 2500903 CPT outpatient 12.42 12.42 12.42 12.42 IN & OUT CATH TRAY 15FR 2500904 CPT outpatient 12.42 12.42 12.42 12.42 DIGITAL B/P MONITOR 2500906 CPT outpatient 52.59 52.59 52.59 52.59 SUCTION CANISTER 3000CC 2500907 CPT outpatient 63.09 63.09 63.09 63.09 AIRVO CIRCUIT W HUMITY CHAMBER 2500909 CPT outpatient 197.76 197.76 197.76 197.76 OPTIFLOW PLUS CANNULA 2500910 CPT outpatient 71.12 71.12 71.12 71.12 STERILE WATER FOR INJECTION 1000ML 2500912 CPT outpatient 7.02 7.02 7.02 7.02 DEVICE ANCHOR FAST 2500914 CPT outpatient 21.2 21.2 21.2 21.2 MASIMO EAR PROBES 2500918 CPT outpatient 238.77 238.77 238.77 238.77 MEPILEX DRESSING 7X7 2500919 CPT outpatient 31.77 31.77 31.77 31.77 PUREWICK FEMALE CATHETER 2500921 CPT outpatient 23.94 23.94 23.94 23.94 OXYMIZER NASAL CANNULA 2500922 CPT outpatient 51.72 51.72 51.72 51.72 FEMALE EXTERNAL CATHETER 2500923 CPT outpatient 23.94 23.94 23.94 23.94 OXYMIZER NASAL CANNULA PENDENT 2500925 CPT outpatient 51.72 51.72 51.72 51.72 SUTURE SILK BLK BR 3-0 18 NONDL 2501179 CPT outpatient 30 30 30 30 SUTURE PROLENE BLU MONO 5-0 30 RB-1 2501180 CPT outpatient 50 50 50 50 DRAINAGE BAG SECUREMENT 2501250 CPT outpatient 50.02 50.02 50.02 50.02 ARM SPLINT 2501509 CPT outpatient 42.88 42.88 42.88 42.88 ADAPTIC 2501768 CPT outpatient 23.94 23.94 23.94 23.94 JEVITY 1.5 CAL LIQUID 1000ML 2501892 CPT outpatient 40.32 40.32 40.32 40.32 LIMB HOLDER 2501925 CPT outpatient 21.15 21.15 21.15 21.15 24HR CONTAINER 2501962 CPT outpatient 23.94 23.94 23.94 23.94 TUBE GASTRIC SUMP 16FR 2502160 CPT outpatient 11.39 11.39 11.39 11.39 OPTIFOAM 6X6 2502190 CPT outpatient 7.23 7.23 7.23 7.23 BENEPROTEIN 2502285 CPT outpatient 12.72 12.72 12.72 12.72 BLANKET 2502584 CPT outpatient 12.72 12.72 12.72 12.72 TEGADERM 4X4 2502633 CPT outpatient 0.1 0.1 0.1 0.1 TEGADERM 6X8 2502634 CPT outpatient 0.1 0.1 0.1 0.1 OPTIFOAM GENTLE EX 4X4 2502647 CPT outpatient 7.57 7.57 7.57 7.57 GLUCERNA VANILLA BOTTLES 2502688 CPT outpatient 12.72 12.72 12.72 12.72 GLUCERNA CHOCOLATE BOTTLE 2502689 CPT outpatient 1.05 1.05 1.05 1.05 GLUCERNA STRAWBERRY BOTTLE 2502690 CPT outpatient 1.05 1.05 1.05 1.05 NEPRO BOTTLE 8OZ 2502696 CPT outpatient 2.94 2.94 2.94 2.94 SPIKE SET W/BAG 2502731 CPT outpatient 42.88 42.88 42.88 42.88 B/P CUFF MEDIUM 1 TUBE 2503214 CPT outpatient 12.72 12.72 12.72 12.72 B/P CUFF SMALL 1 TUBE 2503832 CPT outpatient 12.72 12.72 12.72 12.72 MASIMO RD DISP. SENSOR 2504003 CPT outpatient 238.77 238.77 238.77 238.77 B/P CUFF LARGE 1 TUBE 2504035 CPT outpatient 12.72 12.72 12.72 12.72 ENSURE PUDDING VANILLA 2504234 CPT outpatient 0.81 0.81 0.81 0.81 ETCO2 NASAL CANNULA 2504568 CPT outpatient 21.25 21.25 21.25 21.25 TRAY TRACH CARE 2ND OPT 2504780 CPT outpatient 6.71 6.71 6.71 6.71 ENSURE STRAWBERRY 8OZ. 2504907 CPT outpatient 40.32 40.32 40.32 40.32 ENSURE CHOCOLATE 8OZ. 2504911 CPT outpatient 40.32 40.32 40.32 40.32 SHILEY DIC 8.0 XLT 2504949 CPT outpatient 15.45 15.45 15.45 15.45 SHILEY DIC 6.0 XLT 2504950 CPT outpatient 15.45 15.45 15.45 15.45 6 IN 1 Y CONNECTOR 2505051 CPT outpatient 10.03 10.03 10.03 10.03 SHAMPOO CAPS 2505231 CPT outpatient 42.88 42.88 42.88 42.88 FOLEY CATH 18FR 2 WAY 2505253 CPT outpatient 10.35 10.35 10.35 10.35 BENEPROTEIN PACKET 2505339 CPT outpatient 12.72 12.72 12.72 12.72 FOLEY CATH 20FR 2 WAY 2505351 CPT outpatient 10.35 10.35 10.35 10.35 FOLEY CATH 16FR 2 WAY 2505352 CPT outpatient 10.35 10.35 10.35 10.35 SPINAL ANESTHESIA TRAY 24G X 3 1/2 2505637 CPT outpatient 206.06 206.06 206.06 206.06 OSTOMY POUCHES 2505711 CPT outpatient 6.61 6.61 6.61 6.61 MITTENS 2506159 CPT outpatient 12.72 12.72 12.72 12.72 ENSURE PUDDING CHOCOLATE 2506170 CPT outpatient 0.81 0.81 0.81 0.81 MALE WRAPS 2506224 CPT outpatient 42.88 42.88 42.88 42.88 JUVEN PACKETS UNFLAVORED 2506695 CPT outpatient 12.72 12.72 12.72 12.72 ET TUBE REPLACEMENT 24FR 2507178 CPT outpatient 70.86 70.86 70.86 70.86 ALGINATE 4X4 DRESSING 2507296 CPT outpatient 6.18 6.18 6.18 6.18 ENSURE P/B VANILLA 2507450 CPT outpatient 40.32 40.32 40.32 40.32 ENSURE P/B CHOCOLATE 2507453 CPT outpatient 40.32 40.32 40.32 40.32 SHILEY TRACH SZ 4 2507465 CPT outpatient 127.47 127.47 127.47 127.47 SHILEY TRACH SZ 5 2507466 CPT outpatient 127.47 127.47 127.47 127.47 INNER CANNULA SZ 4 2507467 CPT outpatient 127.47 127.47 127.47 127.47 INNER CANNULA SZ 5 2507468 CPT outpatient 127.47 127.47 127.47 127.47 SHILEY FLEX TRACH TUBE 7.5 2507476 CPT outpatient 127.47 127.47 127.47 127.47 SHILEY FLEX TRACH TUBE 8.5 2507477 CPT outpatient 127.44 127.44 127.44 127.44 SHILEY FLEX TRACH TUBE 8.0 2507478 CPT outpatient 127.44 127.44 127.44 127.44 SHILEY INNER CANNULA 7.5 2507479 CPT outpatient 9.01 9.01 9.01 9.01 SHILEY INNER CANNULA 8.0 2507480 CPT outpatient 9.01 9.01 9.01 9.01 PUREWICK FEMALE CATHETER 2507592 CPT outpatient 7.23 7.23 7.23 7.23 KNEE-HIGH ANTI-EMBOLISM STOCKING MED 2507921 CPT outpatient 9.99 9.99 9.99 9.99 DUODERM 4X4 BORDER 2507971 CPT outpatient 11.37 11.37 11.37 11.37 3N1 BARRIER WIPE 2508322 CPT outpatient 6.71 6.71 6.71 6.71 EXTENSION SET/2 INJECTION SITES 2508612 CPT outpatient 7.57 7.57 7.57 7.57 PURACOL 4.2 X 4.5 DRESSING 2508644 CPT outpatient 31.77 31.77 31.77 31.77 HME TRACHEOLIFE 15FR 2509004 CPT outpatient 127.47 127.47 127.47 127.47 SPIROMETER 2500ML 2509011 CPT outpatient 23.94 23.94 23.94 23.94 PICC LINE DRESSING KIT 2509299 CPT outpatient 7.57 7.57 7.57 7.57 SWAB SUCTION TREATMENT KIT 2509393 CPT outpatient 23.94 23.94 23.94 23.94 BAIR HUGGER WARMING UNIT 2510109 CPT outpatient 53.57 53.57 53.57 53.57 CO2 CANNULA SUPER SOFT ADULT 2545680 CPT outpatient 6.15 6.15 6.15 6.15 PROVIDONE IODINE SOL 4 OZ 2600119 CPT outpatient 5 5 5 5 AMBU BAG 2600139 CPT outpatient 56.73 56.73 56.73 56.73 ACE WRAPS 3X5 2600213 CPT outpatient 5 5 5 5 ACE WRAP 4X5 2600214 CPT outpatient 5 5 5 5 NEEDLE SAFETY 25GX1 LF 2600263 CPT outpatient 8.85 8.85 8.85 8.85 SKIN MARKER 2600293 CPT outpatient 9.4 9.4 9.4 9.4 GAS SAMPLING LINE 2600318 CPT outpatient 6.51 6.51 6.51 6.51 GAUZE STERILE 4X4 12 PLY 10'S TRAY 2600328 CPT outpatient 8.47 8.47 8.47 8.47 ANESTESIA CIRCUIT 90 2600364 CPT outpatient 11 11 11 11 SPINAL NEEDLE 25G X 4.75 LF 2600367 CPT outpatient 13.34 13.34 13.34 13.34 NEEDLE EPIDURAL 17GX3.5 2600368 CPT outpatient 19.8 19.8 19.8 19.8 PREP SKIN DURAPREP 2600371 CPT outpatient 32.95 32.95 32.95 32.95 EPIDURAL TRAY 1 SHOT 2600375 CPT outpatient 158.06 158.06 158.06 158.06 COUDE FOLEY CATH ALL SZ 2600414 CPT outpatient 30.84 30.84 30.84 30.84 LEVINE TUBE ALL SIZES 2600416 CPT outpatient 5.48 5.48 5.48 5.48 OXYGEN TUBING 2600439 CPT outpatient 5 5 5 5 IV PUMP DAILY 2600497 CPT outpatient 300 300 300 300 ANESTHESIA GEN 1ST HR 2600520 CPT outpatient 2400 2400 2400 2400 ANESTHESIA GEN EA ADDITIONAL 15 MIN 2600521 CPT outpatient 300 300 300 300 ANESTHESIA LOCAL 1ST HR 2600522 CPT outpatient 300 300 300 300 ANESTHESIA MAC 1ST HOUR 2600524 CPT outpatient 750 750 750 750 RECOVERY ROOM 1ST HR 2600536 CPT outpatient 900 900 900 900 EQ INTELLISYSTEM AND MONITOR 2600620 CPT outpatient 80 80 80 80 NEEDLE BLUNT FILL 18GX1.5 LF 2600638 CPT outpatient 5 5 5 5 NEEDLE SPINAL 18GX3.5 2600639 CPT outpatient 10.26 10.26 10.26 10.26 SYRINGE 3ML LL 2600644 CPT outpatient 1.09 1.09 1.09 1.09 NEEDLE REG BEVEL 25GX1.5 2600650 CPT outpatient 5 5 5 5 T-CONNECTOR EXTENSION SET 2600655 CPT outpatient 211.46 211.46 211.46 211.46 POINTER PROCEDURAL MARKER 2600779 CPT outpatient 6 6 6 6 OPERATING ROOM SET UP (PAIN MANAGEMENT) 2600780 CPT outpatient 500 500 500 500 O R ROOM 1ST HOUR (PAIN MANAGEMENT) 2600781 CPT outpatient 1800 1800 1800 1800 TOUHY NEEDLE 17G 2600783 CPT outpatient 50 50 50 50 INVASIVE PROCEDURE - 1ST HR 2601113 CPT outpatient 381.5 381.5 381.5 381.5 COFLEX ALL SIZES 2601212 CPT outpatient 12.85 12.85 12.85 12.85 NERVE BLOCK INSULATED NEEDLE 21G X 4 2601230 CPT outpatient 69 69 69 69 ELECTRODE NERVE BLOCK CONNECTING CABLE 2601232 CPT outpatient 75 75 75 75 ANESTHESIA GEN 1ST HR 2610520 CPT outpatient 1200 1200 1200 1200 Anaphylaxis KIT 3000001 CPT outpatient 20 20 20 20 GENTAMICIN PER PHARMACY DOSING 3000005 CPT outpatient 20 20 20 20 GLUCERNA 1.2 CAL LIQUID 1000ML 3000007 CPT outpatient 75 75 75 75 GLUCERNA LIQUID 237ML 3000008 CPT outpatient 25 25 25 25 GLUCERNA 1.5 CAL LIQUID 1000ML 3000009 CPT outpatient 75 75 75 75 ProHeal Critical Care 30ML 3000021 CPT outpatient 35.27 35.27 35.27 35.27 SENSORCAINE/EPI 0.5%-0.0005% VIAL 10ML 3000022 CPT outpatient 179 179 179 179 SODIUM CHLORIDE 0.9% FLUSH SYRINGE 10ML 3000023 CPT outpatient 43.8 43.8 43.8 43.8 VITAL AF 1.2 CAL LIQUID 1000ML 3000030 CPT outpatient 393 393 393 393 WATER FLUSH for IRRIGATION SOLN 1000ML 3000031 CPT outpatient 102.24 102.24 102.24 102.24 MEROPENEM (MERREM) VIAL 500MG 3000110 CPT outpatient 86.4 86.4 86.4 86.4 MICAFUNGIN SODIUM (MYCAMINE) VIAL 50MG 3000115 CPT outpatient 1346.4 1346.4 1346.4 1346.4 A & D VITAMIN OINTMENT 42.5GM 3000138 CPT outpatient 60 60 60 60 SODIUM CHLORIDE 23.4% VIAL 100ML 3000143 CPT outpatient 50.04 50.04 50.04 50.04 MARCAINE W/EPI 0.5%-0.0005% VIAL 10ML 3000151 CPT outpatient 85.16 85.16 85.16 85.16 VANCOMYCIN HCL(VANCOCIN) VIAL 500MG 3000162 CPT outpatient 142.93 142.93 142.93 142.93 AMPICILLIN/SULBACTAM (UNASYN) VIAL 3GM 3000169 CPT outpatient 175.2 175.2 175.2 175.2 LIDOCAINE HCL/PF 2% ABBJ SYRN 100MG/5ML 3000172 CPT outpatient 60 60 60 60 HURRICAINE ONE 20% SPRAY UD 0.5ML 3000176 CPT outpatient 182.75 182.75 182.75 182.75 DENTURE ADHESIVE(FIXODENT) CREAM 3000182 CPT outpatient 58.8 58.8 58.8 58.8 XEROFORM PETROLATUM DRESSING BANDAGE 3000238 CPT outpatient 20 20 20 20 BENEPROTEIN POWDER PACK 7GM 3000699 CPT outpatient 25 25 25 25 PULMOCARE 1.5 CAL LIQUID 1000ML 3000701 CPT outpatient 50.4 50.4 50.4 50.4 NEPRO CARB STEADY LIQUID 1000ML 3000702 CPT outpatient 163.2 163.2 163.2 163.2 JEVITY 1.2 CAL LIQUID 1000ML 3000703 CPT outpatient 80.4 80.4 80.4 80.4 OSMOLITE 1.2 CAL LIQUID 1000ML 3000704 CPT outpatient 125 125 125 125 JEVITY 1 CAL LIQUID 1000ML 3000753 CPT outpatient 69.6 69.6 69.6 69.6 JEVITY 1.5 CAL LIQUID 1000ML 3000754 CPT outpatient 85.2 85.2 85.2 85.2 Z-GUARD PASTE (PHYTOPLEX) 113GM 3000798 CPT outpatient 119.87 119.87 119.87 119.87 CLEAR-AID OINTMENT 71GM 3000803 CPT outpatient 60.9 60.9 60.9 60.9 SODIUM CHLORIDE 0.9% IRRIG SOLN 1000ML 3000823 CPT outpatient 74.2 74.2 74.2 74.2 BANATROL PLUS POWD PACK 10.75GM 3000830 CPT outpatient 25 25 25 25 PSYLLIUM/ASPARTAME(METAMUCIL) POWD PACK 3000840 CPT outpatient 25 25 25 25 Temazepam (RESTORIL) CAPSULE 7.5MG 3000860 CPT outpatient 50.45 50.45 50.45 50.45 NEOMYCIN/POLY/DEXA(MAXITROL) EYE DROPS 3000862 CPT outpatient 223.6 223.6 223.6 223.6 FLUCONAZOLE (DIFLUCAN) TABLET 100MG 3000864 CPT outpatient 37.8 37.8 37.8 37.8 PAMIDRONATE (AREDIA) VIAL 30MG/10ML 3000871 CPT outpatient 369 369 369 369 Labetalol HCl(TRANDATE) VIAL 100MG/20ML 3000874 CPT outpatient 51.26 51.26 51.26 51.26 KETOROLAC (TORADOL) VIAL 30MG/1ML 3000877 CPT outpatient 179 179 179 179 URSODIOL (ACTIGALL) CAPSULE 300MG 3000878 CPT outpatient 98.5 98.5 98.5 98.5 HYDROGEN PEROXIDE 3% SOLN. 4OZ. 3000880 CPT outpatient 185.43 185.43 185.43 185.43 TRIAMCINOLONE (KENALOG) 0.1% CREAM 15GM 3000883 CPT outpatient 93.3 93.3 93.3 93.3 LOSARTAN POTASSIUM (COZAAR) TABLET 50MG 3000885 CPT outpatient 25 25 25 25 OLANZapine (ZyPREXA) 2.5MG TABLET 3000892 CPT outpatient 25 25 25 25 LISINOPRIL (PRINIVIL) TABLET 20MG 3000893 CPT outpatient 25 25 25 25 NIFEdipine (PROCARDIA XL) TAB ER 30MG 3000894 CPT outpatient 25 25 25 25 POTASSIUM PHOSPHATE VIAL 45MMOL/15ML 3000896 CPT outpatient 210.83 210.83 210.83 210.83 PROCAINAMIDE HCl SYRINGE 1GM/10ML 3000897 CPT outpatient 1224 1224 1224 1224 OSMOLITE 1.5 CAL LIQUID 1000ML 3000899 CPT outpatient 78 78 78 78 PHENYTOIN Sod.(DILANTIN) VIAL 100MG/2ML 3000902 CPT outpatient 60 60 60 60 PHENYTOIN(DILANTIN) ORAL SUSP. 100MG/4ML 3000904 CPT outpatient 105.4 105.4 105.4 105.4 NEPHRO-VITE TABLET 0.8MG 3000909 CPT outpatient 25 25 25 25 NA-K PHOSPHATE(PHOS-NAK) POWD PACK 250MG 3000912 CPT outpatient 25 25 25 25 NitroGLYcerin in D5W IV BTL 50MG/250ML 3000916 CPT outpatient 297.6 297.6 297.6 297.6 KETOCONAZOLE (NIZORAL) 2% CREAM 30GM 3000918 CPT outpatient 2084.4 2084.4 2084.4 2084.4 SODIUM CHLORIDE 0.9% IV MNBG+ 100ML 3000920 CPT outpatient 76.44 76.44 76.44 76.44 LISINOPRIL (PRINIVIL) TABLET 5MG 3000924 CPT outpatient 25 25 25 25 SODIUM CHLORIDE 0.9% IV MNBG+ 50ML 3000925 CPT outpatient 76.56 76.56 76.56 76.56 LIDOCAINE (LIDODERM) 5% TD PATCH 3000952 CPT outpatient 128.6 128.6 128.6 128.6 MORPHINE SULF.(DURAMORPH) AMPUL 5MG/10ML 3000954 CPT outpatient 417.01 417.01 417.01 417.01 Cinacalcet HCl (SENSIPAR) TABLET 30MG 3000959 CPT outpatient 371.08 371.08 371.08 371.08 Chlorhexidine (HIBICLENS) LIQUID 118ML 3000965 CPT outpatient 79.15 79.15 79.15 79.15 MEMANTINE HCl (NAMENDA) TABLET 10MG 3000966 CPT outpatient 73.23 73.23 73.23 73.23 TRIAMCINOLONE(KENALOG) 0.5% OINT. 15GM 3000967 CPT outpatient 136 136 136 136 SODIUM CHLORIDE 0.9% ADD-VANTAGE 250ML 3000972 CPT outpatient 98.35 98.35 98.35 98.35 NPH INSULIN (NOVOLIN N) VIAL1000U/10ML 3000982 CPT outpatient 613.4 613.4 613.4 613.4 OFLOXACIN (FLOXIN) 0.3% EAR DROPS 5ML 3000983 CPT outpatient 1851.36 1851.36 1851.36 1851.36 TISSEEL VHSD KIT 10ML **FOR SURGERY** 3000992 CPT outpatient 9337.82 9337.82 9337.82 9337.82 SODIUM PHOSPHATE VIAL 15MMOL/5ML 3000993 CPT outpatient 245.23 245.23 245.23 245.23 ISONIAZID TABLET 300MG 3000995 CPT outpatient 35 35 35 35 HYOSCYAMINE SULF(LEVSIN) TABLET 0.125MG 3000998 CPT outpatient 25 25 25 25 chlordiazePOXIDE (LIBRIUM) CAPSULE 25MG 3000999 CPT outpatient 50 50 50 50 Enalaprilat (VASOTEC) VIAL 1.25MG/1ML 3001002 CPT outpatient 98.71 98.71 98.71 98.71 Tetrahydrozoline HCl 0.05% EYE DROPS15ML 3001005 CPT outpatient 75 75 75 75 PERMETHRIN (ELIMITE) 5% CREAM 60GM 3001006 CPT outpatient 1415.95 1415.95 1415.95 1415.95 Diatrizoate (GASTROGRAFIN) SOLN. 120ML 3001008 CPT outpatient 957.89 957.89 957.89 957.89 DONEPEZIL HCl (ARICEPT) TABLET 10MG 3001009 CPT outpatient 26.63 26.63 26.63 26.63 PROMETHAZINE HCl ORAL SYRUP (473ml) 3001011 CPT outpatient 505 505 505 505 Carvedilol (COREG) TABLET 3.125MG 3001014 CPT outpatient 25 25 25 25 ANASTROZOLE (ARIMIDEX) TABLET 1MG 3001017 CPT outpatient 45.72 45.72 45.72 45.72 MULTIVITAMIN W/ MINERALS(THERA-M) TABLET 3001019 CPT outpatient 25 25 25 25 Enalapril Maleate(VASOTEC) TABLET 10MG 3001025 CPT outpatient 25 25 25 25 buPROPion HCl SR TAB 12H 150MG 3001029 CPT outpatient 25 25 25 25 GLYCOPYROLLATE (ROBINUL) VIAL 0.2MG/1ML 3001038 CPT outpatient 179 179 179 179 Doxazosin Mesylate (CARDURA) TABLET 2MG 3001048 CPT outpatient 25 25 25 25 MARCAINE 0.75% VIAL 30ML 3001052 CPT outpatient 179 179 179 179 Furosemide (LASIX) TABLET 20MG 3001053 CPT outpatient 25.89 25.89 25.89 25.89 levoFLOXacin (LEVAQUIN) TABLET 500MG 3001055 CPT outpatient 20 20 20 20 levoFLOXacin in D5W IVPB 500MG/100ML 3001058 CPT outpatient 75 75 75 75 ESCITALOPRAM OXALATE (LEXAPRO) TAB 10MG 3001060 CPT outpatient 25 25 25 25 Carbidopa/Levodopa(SINEMET) TAB 25/100MG 3001067 CPT outpatient 25 25 25 25 COLLAGENASE (SANTYL) OINTMENT 30GM 3001078 CPT outpatient 3844.6 3844.6 3844.6 3844.6 MARCAINE W/EPI 0.25%-0.0005% VIAL 30ML 3001079 CPT outpatient 179 179 179 179 MONTELUKAST SOD. (SINGULAIR) TABLET 10MG 3001083 CPT outpatient 35 35 35 35 SODIUM ACETATE VIAL 40MEQ/20ML 3001084 CPT outpatient 45.55 45.55 45.55 45.55 Bumetanide (BUMEX) VIAL 1MG/4ML 3001085 CPT outpatient 62.3 62.3 62.3 62.3 SENNA LAX TABLET 8.6MG 3001090 CPT outpatient 25 25 25 25 QUEtiapine fum.(SEROQUEL) TABLET 100MG 3001091 CPT outpatient 35 35 35 35 Clarithromycin (BIAXIN) TABLET 500MG 3001093 CPT outpatient 85.15 85.15 85.15 85.15 Verapamil HCl (CALAN SR) TABLET ER 120MG 3001097 CPT outpatient 25 25 25 25 CALCIUM GLUCONATE VIAL 1GM/10ML 3001101 CPT outpatient 144.29 144.29 144.29 144.29 FLUMAZENIL (ROMAZICON) VIAL 0.5MG/5ML 3001108 CPT outpatient 179 179 179 179 COLCHICINE (COLCRYS) CAPSULE 0.6MG 3001115 CPT outpatient 91.82 91.82 91.82 91.82 busPIRone HCL (BUSPAR) TABLET 5MG 3001124 CPT outpatient 25 25 25 25 BISACODYL (DULCOLAX) TABLET DR 5MG 3001125 CPT outpatient 25 25 25 25 ATROVENT 0.02% SOLN VIAL-NEB 0.5MG/2.5ML 3001134 CPT outpatient 60 60 60 60 Midazolam HCl(VERSED) PF VIAL 2MG/2ML 3001136 CPT outpatient 179 179 179 179 CYANOCOBALAMIN(VIT B12) 1000MCG/ML 3001140 CPT outpatient 99.5 99.5 99.5 99.5 BACLOFEN (LIORESAL) TABLET 10MG 3001142 CPT outpatient 31.22 31.22 31.22 31.22 OxyBUTYnin(DITROPAN) chloride TABLET 5MG 3001145 CPT outpatient 25 25 25 25 Epoetin Alfa (EPOGEN) VIAL 4000U *NF* 3001149 CPT outpatient 795.84 795.84 795.84 795.84 RALOXIFENE HCl (EVISTA) TABLET 60MG 3001154 CPT outpatient 85.52 85.52 85.52 85.52 COMBIVENT RESPIMAT MIST INHAL 20-100mcg 3001157 CPT outpatient 6386.54 6386.54 6386.54 6386.54 PRAZOSIN HCl (MINIPRESS) CAPSULE 1MG 3001158 CPT outpatient 25 25 25 25 TYLENOL #3 TABLET 30MG/300MG 3001162 CPT outpatient 34.14 34.14 34.14 34.14 ACETAMINOPHEN SUPPOSITORY RECTAL 650MG 3001163 CPT outpatient 50 50 50 50 NEOMYCIN/POLYMYXIN B/DEXAMETHA EYE OINT. 3001167 CPT outpatient 223.6 223.6 223.6 223.6 MEGESTROL ACETATE(MEGACE) TABLET 40MG 3001169 CPT outpatient 25 25 25 25 MEGESTROL ACETATE(MEGACE) ORAL SUSP UDC 3001170 CPT outpatient 92.23 92.23 92.23 92.23 FLUoxetine HCl (PROzac) CAPSULE 10mg 3001176 CPT outpatient 25 25 25 25 GLUCOSAMINE CAPSULE 500MG 3001179 CPT outpatient 25 25 25 25 MANNITOL 20% IV SOLN 100GM/500ML 3001181 CPT outpatient 907.92 907.92 907.92 907.92 MethylPREDNISolone (MEDROL) TABLET 4MG 3001183 CPT outpatient 25 25 25 25 predniSONE (DELTASONE) TABLET 5MG 3001186 CPT outpatient 25 25 25 25 ALBUTEROL SULF(PROVENTIL) 0.083%NEB-VIAL 3001188 CPT outpatient 60 60 60 60 COLISTIMETHATE (COLISTIN) VIAL 150MG 3001191 CPT outpatient 403.2 403.2 403.2 403.2 Calcium Carbonate(TUMS) TAB CHEW 500MG 3001196 CPT outpatient 25 25 25 25 diazePAM (VALIUM) SYRINGE 10MG/2ML 3001204 CPT outpatient 354.38 354.38 354.38 354.38 Calcitonin Salmon(MIACALCIN) NASAL SPRAY 3001206 CPT outpatient 1422.48 1422.48 1422.48 1422.48 MINERAL OIL ORAL 473ML 3001207 CPT outpatient 25 25 25 25 Dorzolamide HCl(TRUSOPT)2% EYE DROPS 3001209 CPT outpatient 801 801 801 801 ACETAMINOPHEN (TYLENOL) TABLET 325MG 3001210 CPT outpatient 25.64 25.64 25.64 25.64 ACETAMINOPHEN (TYLENOL) TAB 500MG 3001211 CPT outpatient 25.44 25.44 25.44 25.44 Bethanechol (URECHOLINE) TABLET 25MG 3001213 CPT outpatient 51.69 51.69 51.69 51.69 diazePAM (VALIUM) TABLET 2MG 3001215 CPT outpatient 50 50 50 50 hydrALAZINE HCl (APRESOLINE) TABLET 50MG 3001225 CPT outpatient 26.63 26.63 26.63 26.63 Phytonadione (VIT-K1) AMPUL 10MG/1ML 3001226 CPT outpatient 622.6 622.6 622.6 622.6 Trihexyphenidyl HCl(ARTANE) TABLET 2MG 3001227 CPT outpatient 28.65 28.65 28.65 28.65 ASPIRIN CHEWABLE TABLET 81MG 3001228 CPT outpatient 25.8 25.8 25.8 25.8 ZOLPIDEM TARTARATE (AMBIEN) TABLET 5MG 3001232 CPT outpatient 26.04 26.04 26.04 26.04 AMOXICILLIN CAPSULE 500MG 3001234 CPT outpatient 27.33 27.33 27.33 27.33 ANUCORT-HC SUPPOSITORY RECTAL 25MG 3001240 CPT outpatient 251.46 251.46 251.46 251.46 hydrALAZINE HCl (APRESOLINE) TABLET 25MG 3001241 CPT outpatient 27.53 27.53 27.53 27.53 cloNIDine WEEKLY TD PATCH 0.1MG/24HR 3001252 CPT outpatient 397.47 397.47 397.47 397.47 cloNIDine WEEKLY TD PATCH 0.2MG/24HR 3001253 CPT outpatient 669.18 669.18 669.18 669.18 cloNIDine WEEKLY TD PATCH 0.3MG/24HR 3001254 CPT outpatient 928.32 928.32 928.32 928.32 CATHFLO ACTIVASE VIAL 2MG 3001255 CPT outpatient 2151.2 2151.2 2151.2 2151.2 Celecoxib (CeleBREX) CAPSULE 100MG 3001256 CPT outpatient 55.4 55.4 55.4 55.4 CEPACOL SORE THROAT LOZENGE 15MG 3001263 CPT outpatient 26.83 26.83 26.83 26.83 Triamterene/HCTZ(DYAZIDE) TAB 37.5/25MG 3001264 CPT outpatient 25 25 25 25 MORPHINE SULF. CARPUJECT 10MG/ML 3001271 CPT outpatient 60 60 60 60 IBUPROFEN (MOTRIN) TABLET 600MG 3001272 CPT outpatient 25 25 25 25 ACETYLCYSTEINE (MUCOMYST)20% VIAL INH. 3001276 CPT outpatient 200.84 200.84 200.84 200.84 Ethambutol HCl (MYAMBUTOL) TABLET 400MG 3001278 CPT outpatient 35 35 35 35 CLOTRIMAZOLE (MYCELEX) TROCHE 10MG 3001279 CPT outpatient 25 25 25 25 MAGNESIUM HYDROXIDE (MOM) ORAL SUSP UDC 3001282 CPT outpatient 31.57 31.57 31.57 31.57 TAMSULOSIN HCl (FLOMAX) CAPSULE 0.4MG 3001288 CPT outpatient 25 25 25 25 PRIMIDONE (MYSOLINE) TABLET 250MG 3001295 CPT outpatient 25 25 25 25 NitroGLYcerin(NITRO-BID) 2% OINT. 30GM 3001300 CPT outpatient 511.06 511.06 511.06 511.06 Budesonide(PULMICORT)NEBULIZER 0.5MG/2ML 3001306 CPT outpatient 136.65 136.65 136.65 136.65 IBUPROFEN (MOTRIN) TABLET 200MG 3001308 CPT outpatient 25 25 25 25 MORPHINE SULF.(MS CONTIN) TABLET ER 15MG 3001309 CPT outpatient 60 60 60 60 MVI ADULT (INFUVITE) VIAL 10ML 3001310 CPT outpatient 158.76 158.76 158.76 158.76 NYSTATIN (MYCOSTATIN) POWDER 15GM 3001311 CPT outpatient 409.6 409.6 409.6 409.6 MAG-AL PLUS (MYLANTA) ORAL SUSP UDC 3001312 CPT outpatient 45.5 45.5 45.5 45.5 FLUTICASONE (FLONASE) NASAL SPRAY SUSP. 3001317 CPT outpatient 1023.11 1023.11 1023.11 1023.11 FLUDROCORTISONE ACET.(FLORINEF)TAB 0.1MG 3001318 CPT outpatient 25 25 25 25 HALOPERIDOL LACTATE (HALDOL) VIAL 5MG/ML 3001319 CPT outpatient 86.26 86.26 86.26 86.26 FERROUS SULF. TABLET 325MG 3001320 CPT outpatient 25 25 25 25 ERYTHROMYCIN BASE EYE OINT. 0.5% 3.5GM 3001328 CPT outpatient 228 228 228 228 Sulfamethoxazole/TMP 800mg/160mg TABLET 3001335 CPT outpatient 28.73 28.73 28.73 28.73 diphenhydrAMINE HCL (BENADRYL) CAPS 25MG 3001336 CPT outpatient 25.49 25.49 25.49 25.49 FentaNYL (DURAGESIC) PATCH TD72 75MCG/HR 3001342 CPT outpatient 712.32 712.32 712.32 712.32 Dorzolamide/Timolol (COSOPT) EYE DROPS 3001344 CPT outpatient 699.9 699.9 699.9 699.9 VANCOMYCIN HCL(VANCOCIN) VIAL 1GM 3001345 CPT outpatient 89.82 89.82 89.82 89.82 Thiamine HCl (VIT-B1) VIAL 200MG/2ML 3001352 CPT outpatient 99.65 99.65 99.65 99.65 chlorproMAZINE(THORAZINE) TABLET 25MG 3001353 CPT outpatient 91.69 91.69 91.69 91.69 MUPIROCIN 2% (BACTROBAN) OINTMENT 22GM 3001356 CPT outpatient 137 137 137 137 dicyclomine HCL (BENTYL) CAPSULE 10MG 3001358 CPT outpatient 31.8 31.8 31.8 31.8 ALBUTEROL SULFATE (PROAIR) HFA 90MCG 3001363 CPT outpatient 499.8 499.8 499.8 499.8 Phenazopyridine HCl(PYRIDIUM) TAB 100MG 3001367 CPT outpatient 28.8 28.8 28.8 28.8 Labetalol HCl(TRANDATE) TABLET 100mg 3001368 CPT outpatient 25 25 25 25 Nitroglycerin(NITRO-DUR)PATCH TD24 0.1MG 3001369 CPT outpatient 50 50 50 50 Nitroglycerin(NITRO-DUR)PATCH TD24 0.4MG 3001371 CPT outpatient 50 50 50 50 AUGMENTIN TABLET 500MG/125MG 3001383 CPT outpatient 62.84 62.84 62.84 62.84 PARoxetine HCl (PAXIL) TABLET 10MG 3001410 CPT outpatient 25 25 25 25 HETASTARCH (HESPAN) 6% in NS 500ML 3001415 CPT outpatient 216.6 216.6 216.6 216.6 TOPIRAMATE(TOPAMAX) TABLET 25MG 3001422 CPT outpatient 25.2 25.2 25.2 25.2 TOPIRAMATE(TOPAMAX) TABLET 100MG 3001423 CPT outpatient 25 25 25 25 METOPROLOL SUCC.(TOPROL XL) TAB ER 25MG 3001424 CPT outpatient 25 25 25 25 PENTOXIFYLLINE(TRENtal) TABLET ER 400MG 3001426 CPT outpatient 25 25 25 25 AcetaZOLAMIDE (DIAMOX) sodium VIAL 500MG 3001435 CPT outpatient 572.5 572.5 572.5 572.5 "HEPARIN SOD. MD VIAL 10,000U/10ML" 3001437 CPT outpatient 179 179 179 179 LIDOCAINE HCL / EPI (XYLOCAINE) VL 20ML 3001439 CPT outpatient 179 179 179 179 Metoclopramide HCl(REGLAN) VL 10MG/2ML 3001453 CPT outpatient 179 179 179 179 MIRTAZAPINE (REMERON) TABLET 15MG 3001456 CPT outpatient 25 25 25 25 amLODIPine besylate (NORVASC) TABLET 5MG 3001459 CPT outpatient 25 25 25 25 OYSTER SHELL CALCIUM TABLET 500MG 3001466 CPT outpatient 25 25 25 25 Neostigmine Methylsulfate VIAL 10MG/10ML 3001473 CPT outpatient 256.65 256.65 256.65 256.65 VALPROIC ACID (DEPAKENE) SOLN. 250MG/5ML 3001474 CPT outpatient 25 25 25 25 Sevoflurane (ULTANE) LIQUID*SURGERY* 3001475 CPT outpatient 1958.4 1958.4 1958.4 1958.4 TraZODone HCl (DESYREL) TABLET 50MG 3001478 CPT outpatient 25 25 25 25 Tolterodine Tartrate (DETROL) TABLET 2MG 3001480 CPT outpatient 33.97 33.97 33.97 33.97 FentaNYL (DURAGESIC) PATCH TD72 25MCG/HR 3001486 CPT outpatient 179.2 179.2 179.2 179.2 DIVALPROEX SODIUM TABLET DR 250MG 3001489 CPT outpatient 25 25 25 25 VITAMIN C TABLET 500MG 3001496 CPT outpatient 25.67 25.67 25.67 25.67 buPROPion HCL(WELLBUTRIN) TABLET 100MG 3001498 CPT outpatient 25 25 25 25 LIDOCAINE HCL/PF 1% VIAL 300MG/30ML 3001499 CPT outpatient 60 60 60 60 LACTULOSE (ENULOSE)ORAL SOLN. 20GM/30ML 3001503 CPT outpatient 25 25 25 25 LIOTHYRONINE SODIUM(CYTOMEL)TABLET 25MCG 3001506 CPT outpatient 50 50 50 50 DESMOPRESSIN ACETATE(DDAVP) TABLET 0.1MG 3001510 CPT outpatient 25 25 25 25 DexAMETHasone (DECADRON) VIAL 4MG/ML 3001512 CPT outpatient 25 25 25 25 PHENTOLAMINE mesylate(REGITINE) VIAL 5MG 3001517 CPT outpatient 6045.12 6045.12 6045.12 6045.12 AMMONIA INHALANT AMPUL 3001521 CPT outpatient 129 129 129 129 hydrALAZINE HCl (APRESOLINE)VIAL 20MG/ML 3001525 CPT outpatient 179 179 179 179 GLIMEPIRIDE (AMARYL) TABLET 2MG 3001529 CPT outpatient 33.82 33.82 33.82 33.82 MECLIZINE HCL (ANTIVERT) TABLET 25MG 3001535 CPT outpatient 30.54 30.54 30.54 30.54 hydrALAZINE HCl (APRESOLINE) TABLET 10MG 3001536 CPT outpatient 29.14 29.14 29.14 29.14 Diclofenac Sod.(VOLTAREN)TABLET DR 75MG 3001538 CPT outpatient 25 25 25 25 KCL VIAL 40MEQ/20ML 3001551 CPT outpatient 56 56 56 56 CLOTRIMAZOLE (LOTRIMIN) 1% CREAM 30GM 3001563 CPT outpatient 418.18 418.18 418.18 418.18 MORPHINE SULF. CARPUJECT 2MG/ML 3001571 CPT outpatient 179 179 179 179 SORBITOL 70% SOLUTION 30ML 3001578 CPT outpatient 35.42 35.42 35.42 35.42 PROCHLORPERAZINE (COMPAZINE) TABLET 10MG 3001579 CPT outpatient 25 25 25 25 KETOROLAC (ACULAR) 0.5% EYE DROPS 5ML 3001587 CPT outpatient 1085 1085 1085 1085 DIGOXIN (LANOXIN) 0.125MG 3001589 CPT outpatient 25 25 25 25 FLORANEX TABLET 1MU 3001599 CPT outpatient 25 25 25 25 METOPROLOL TARTARATE VIAL 5MG/5ML 3001601 CPT outpatient 60 60 60 60 buPROPion HCL(WELLBUTRIN) TABLET 75MG 3001626 CPT outpatient 25 25 25 25 ACYCLOVIR (ZOVIRAX) 5% OINTMENT 15GM 3001628 CPT outpatient 4013 4013 4013 4013 PHENobarbital TABLET 100MG 3001636 CPT outpatient 50 50 50 50 POTASSIUM ACETATE VIAL 40MEQ/20ML 3001650 CPT outpatient 82.93 82.93 82.93 82.93 REPAGLINIDE (PRANDIN) TABLET 1MG 3001651 CPT outpatient 43.91 43.91 43.91 43.91 PEPTO-BISMOL ORAL SUSPESNION 236ML 3001655 CPT outpatient 60.6 60.6 60.6 60.6 MARCAINE 0.5% VIAL 30ML 3001662 CPT outpatient 179 179 179 179 AMITRIPTYLINE HCL (ELAVIL) TABLET 25MG 3001663 CPT outpatient 31.36 31.36 31.36 31.36 cloZAPine (CLOZARIL) TABLET 25MG 3001669 CPT outpatient 60 60 60 60 VENLAFAXINE(EFFEXOR XR) CAP 24H 37.5MG 3001671 CPT outpatient 25 25 25 25 Epoetin Alfa (EPOGEN) VIAL 2000U *NF* 3001674 CPT outpatient 397.92 397.92 397.92 397.92 DexAMETHasone (DECADRON) TABLET 4MG 3001675 CPT outpatient 25 25 25 25 AMITRIPTYLINE HCL (ELAVIL) TABLET 10MG 3001684 CPT outpatient 28.18 28.18 28.18 28.18 EPINEPHrine (ADRENALIN) VIAL 30MG/30ML 3001686 CPT outpatient 2376 2376 2376 2376 EPINEPHrine PREFILLED SYRINGE 1MG/10ML 3001687 CPT outpatient 185 185 185 185 FOLIC ACID VIAL 5MG/ML 3001689 CPT outpatient 170.82 170.82 170.82 170.82 PROCHLORPERAZINE (COMPAZINE) SUPP. 25MG 3001692 CPT outpatient 147.1 147.1 147.1 147.1 PROCHLORPERAZINE(COMPAZINE) VL 10MG/2ML 3001693 CPT outpatient 266.4 266.4 266.4 266.4 Carvedilol (COREG) TABLET 12.5MG 3001694 CPT outpatient 25.61 25.61 25.61 25.61 LINEZOLID (ZYVOX) TABLET 600MG 3001703 CPT outpatient 89.14 89.14 89.14 89.14 ADVAIR DISKUS 250-50mcg 3001704 CPT outpatient 4540.8 4540.8 4540.8 4540.8 Latanoprost (XALATAN) 0.005% EYE DROPS 3001707 CPT outpatient 975 975 975 975 ZINC OXIDE 20% OINTMENT 3001710 CPT outpatient 43.27 43.27 43.27 43.27 OLANZapine (ZyPREXA) 10MG TABLET 3001712 CPT outpatient 35 35 35 35 SODIUM HYPOCHLORITE (HYSEPT) 0.25% SOLN. 3001717 CPT outpatient 210 210 210 210 RISACAL-D TABLET 105MG 3001721 CPT outpatient 25 25 25 25 AMMONIUM LACTATE (AMLACTIN) 12% LOTION 3001726 CPT outpatient 63.12 63.12 63.12 63.12 PANTOPRAZOLE (PROTONIX) TABLET DR 40MG 3001730 CPT outpatient 25 25 25 25 risperiDONE (RisperDAL) TABLET 1MG 3001733 CPT outpatient 25 25 25 25 GuaiFENesin/Codeine LIQUID 100-10MG/5ML 3001746 CPT outpatient 50 50 50 50 TOBRAMYCIN SULF. VIAL 80MG/2ML 3001760 CPT outpatient 85 85 85 85 NEOMYCIN SULF. TABLET 500MG 3001761 CPT outpatient 25 25 25 25 MAGNESIUM SULF. in D5W IVPB 1GM/100ML 3001767 CPT outpatient 92.04 92.04 92.04 92.04 OXACILLIN SODIUM VIAL 1GM 3001771 CPT outpatient 162 162 162 162 NAFCILLIN SODIUM VIAL 2GM 3001772 CPT outpatient 195 195 195 195 FAT EMULSION(INTRALIPID) 20% IVPB 250ML 3001789 CPT outpatient 633.9 633.9 633.9 633.9 HYDROXYUREA (HYDREA) CAPSULE 500MG 3001790 CPT outpatient 50 50 50 50 Vitamin B-50 Complex Tab ER 50MG 3001800 CPT outpatient 25 25 25 25 carBAMazepine (TEGretol) TABLET 200MG 3001805 CPT outpatient 25 25 25 25 ATENOLOL (TENORMIN) TABLET 50MG 3001806 CPT outpatient 33.91 33.91 33.91 33.91 Pseudoephedrine HCl(SUDOGEST) TAB. 30MG 3001818 CPT outpatient 25 25 25 25 ZINC SULFATE CAPSULE 220MG 3001819 CPT outpatient 25 25 25 25 ARTIFICIAL TEARS EYE DROPS 15ML 3001825 CPT outpatient 45.4 45.4 45.4 45.4 Solu-CORTEF VIAL 100MG/2ML 3001830 CPT outpatient 222.12 222.12 222.12 222.12 SOLU-Medrol VIAL 125MG/2ML 3001831 CPT outpatient 179 179 179 179 metFORMIN HCl (GLUCOPHAGE) TABLET 850mg 3001839 CPT outpatient 25 25 25 25 HALOPERIDOL (HALDOL) TABLET 1MG 3001842 CPT outpatient 25 25 25 25 LOPERAMIDE HCl(IMODIUM) CAPSULE 2MG 3001844 CPT outpatient 25 25 25 25 glipiZIDE (GLUCOTROL) TABLET 5MG 3001849 CPT outpatient 25 25 25 25 ISOSORBIDE MN (IMDUR) TAB ER 24H 30MG 3001852 CPT outpatient 25 25 25 25 DEXTROSE 5%Water IV SOLN(non PVC) 250ML 3001856 CPT outpatient 76.1 76.1 76.1 76.1 AMPHOTERICIN B (FUNGIZONE) VIAL 50MG 3001861 CPT outpatient 645 645 645 645 GLUCAGON HCL VIAL 1MG 3001862 CPT outpatient 2332.8 2332.8 2332.8 2332.8 AMINOPHYLLINE VIAL 500MG/20ML 3001874 CPT outpatient 162.61 162.61 162.61 162.61 MORPHINE SULF. CARPUJECT 4MG/ML 3001876 CPT outpatient 60 60 60 60 CLOPIDOGREL (PLAVIX) TABLET 75MG 3001892 CPT outpatient 25 25 25 25 prednisoLONE ACETATE 1% EYE DROPS SUSP 3001895 CPT outpatient 663.84 663.84 663.84 663.84 CLINDAMYCIN HCl (CLEOCIN) CAPSULE 150MG 3001908 CPT outpatient 25 25 25 25 MARCAINE 0.25% VIAL 30ML 3001915 CPT outpatient 179 179 179 179 hydrOXYzine HCl (ATARAX) TABLET 10MG 3001921 CPT outpatient 27.85 27.85 27.85 27.85 Bumetanide (BUMEX) TABLET 1MG 3001922 CPT outpatient 25 25 25 25 ROPIVACAINE HCl/PF(NAROPIN) 0.2% VIAL 3001923 CPT outpatient 179 179 179 179 WATER for INJECTION STERILE VIAL 10ML 3001925 CPT outpatient 35 35 35 35 HYDROcodone/APAP (NORCO) TABLET 10/325MG 3001935 CPT outpatient 50 50 50 50 KETAMINE HCL(KETALAR) VIAL 500MG/5ML 3001938 CPT outpatient 119.71 119.71 119.71 119.71 rOPINIRole HCl (REQUIP) TABLET 1MG 3001943 CPT outpatient 25 25 25 25 Metoclopramide HCl(REGLAN) TABLET 5MG 3001947 CPT outpatient 25 25 25 25 ARIPiprazole (ABILIFY) TABLET 5MG 3001965 CPT outpatient 324.26 324.26 324.26 324.26 MINOXIDIL (LONITEN) TABLET 10MG 3001975 CPT outpatient 25.41 25.41 25.41 25.41 Nebivolol HCl (BYSTOLIC) TABLET 5MG 3001982 CPT outpatient 40.32 40.32 40.32 40.32 ARIPiprazole (ABILIFY) TABLET 15MG 3001992 CPT outpatient 345.75 345.75 345.75 345.75 ROPIVACAINE HCl/PF(NAROPIN) 0.5% VIAL 3001996 CPT outpatient 179 179 179 179 ASPIRIN SUPPOSITORY RECTAL 300MG 3001999 CPT outpatient 25 25 25 25 TiZANidine HCl(ZANAFLEX) TABLET 4MG 3002001 CPT outpatient 25 25 25 25 cycloSPORINE (NEORAL) CAPSULE 50MG 3002004 CPT outpatient 32.86 32.86 32.86 32.86 AmBisome VIAL 50MG 3002006 CPT outpatient 3753.5 3753.5 3753.5 3753.5 levOCARNitine (CARNITOR) VIAL 1000MG/5ML 3002007 CPT outpatient 463.04 463.04 463.04 463.04 Cyclobenzaprine (FLEXERIL) TABLET 5MG 3002015 CPT outpatient 25 25 25 25 "VITAMIN D3 CAPSULE 50,000IU (1.25MG)" 3002020 CPT outpatient 25 25 25 25 GLYCOPYROLLATE (ROBINUL) TABLET 1MG 3002024 CPT outpatient 25 25 25 25 MINOXIDIL (LONITEN) TABLET 2.5MG 3002035 CPT outpatient 25 25 25 25 ATOVAQUONE (MEPRON) ORAL SUSP. (210ML) 3002041 CPT outpatient 15792.9 15792.9 15792.9 15792.9 RifAXIMin (XIFAXAN) TABLET 550MG 3002051 CPT outpatient 661.8 661.8 661.8 661.8 "POLYMYXIN B SULFATE VIAL 500,000U" 3002055 CPT outpatient 220 220 220 220 predniSONE (DELTASONE) TABLET 1MG 3002063 CPT outpatient 25 25 25 25 SUMAtriptan succinate(IMITREX) TAB 100MG 3002075 CPT outpatient 276.4 276.4 276.4 276.4 Diclofenac Sod.(VOLTAREN) 1% GEL 100GM 3002081 CPT outpatient 284.7 284.7 284.7 284.7 Lacosamide (VIMPAT) TABLET 200MG 3002083 CPT outpatient 213.25 213.25 213.25 213.25 D5% in LACTATED RINGERS IV SOLN. 1000ML 3002089 CPT outpatient 172 172 172 172 Ceftaroline (TEFLARO) VIAL 600MG 3002091 CPT outpatient 3050.11 3050.11 3050.11 3050.11 SODIUM CHLORIDE 0.65% NASAL SPRAY 44ML 3002095 CPT outpatient 55 55 55 55 FISH OIL CAPSULE 1000MG 3002097 CPT outpatient 25 25 25 25 RIVASTIGMINE TART.(EXELON) CAPSULE 1.5MG 3002098 CPT outpatient 55.94 55.94 55.94 55.94 HYDROMORPHONE HCL(DILAUDID) CARP 1MG/ML 3002099 CPT outpatient 60 60 60 60 AMANTADINE HCL (SYMMETREL) 100MG CAPSULE 3002101 CPT outpatient 33.41 33.41 33.41 33.41 Carbidopa/Levodopa(SINEMET) TAB 10/100MG 3002110 CPT outpatient 25 25 25 25 Oseltamivir Phos.(TAMIFLU) CAPSULE 75MG 3002112 CPT outpatient 218.71 218.71 218.71 218.71 KETOCONAZOLE (NIZORAL) 2% SHAMPOO 120ML 3002114 CPT outpatient 362.88 362.88 362.88 362.88 Rivaroxaban (XARELTO) TABLET 15MG 3002115 CPT outpatient 236.4 236.4 236.4 236.4 NICOTINE(NICODERM) PATCH TD24 7MG/24HR 3002119 CPT outpatient 28.7 28.7 28.7 28.7 DEXTROSE 5%-0.45% NACL IV SOLN. 1000ML 3002120 CPT outpatient 170.8 170.8 170.8 170.8 clonazePAM(KlonoPIN) TABLET (ODT) 0.5MG 3002121 CPT outpatient 50 50 50 50 ZONISAMIDE (ZONEGRAN) CAPSULE 100MG 3002124 CPT outpatient 20.64 20.64 20.64 20.64 ALUMINIUM HYDROXIDE(AMPHOJEL) ORAL SUSP. 3002127 CPT outpatient 103.2 103.2 103.2 103.2 Rivaroxaban (XARELTO) TABLET 10MG 3002128 CPT outpatient 252.83 252.83 252.83 252.83 SEVELAMER CARB.(RENVELA) POWD PACK 0.8GM 3002129 CPT outpatient 207.86 207.86 207.86 207.86 rifAMPin (RIFADIN) VIAL 600MG 3002135 CPT outpatient 2571.26 2571.26 2571.26 2571.26 Theophylline (THEO-DUR) SOLN. 80MG/15ML 3002138 CPT outpatient 1142.5 1142.5 1142.5 1142.5 ETOMIDATE (AMIDATE) VIAL 20MG/10ML 3002146 CPT outpatient 93 93 93 93 DOBUTamine in D5W IVPB 1000MG/250ML 3002148 CPT outpatient 395.71 395.71 395.71 395.71 PHENobarbital TABLET 32.4MG 3002154 CPT outpatient 50 50 50 50 Sugammadex Sodium(BRIDION) VIAL 3002156 CPT outpatient 1580.92 1580.92 1580.92 1580.92 DOPamine in D5W IVPB PREMIX 400MG/250ML 3002163 CPT outpatient 187.5 187.5 187.5 187.5 KETOTIFEN (ALAWAY) 0.025% EYE DROPS 5ML 3002187 CPT outpatient 152.2 152.2 152.2 152.2 Levothyroxine Sod.(SYNTHROID) TAB 125MCG 3002190 CPT outpatient 25 25 25 25 LIDOCAINE HCL / EPI (XYLOCAINE) VL 50ML 3002197 CPT outpatient 124.26 124.26 124.26 124.26 LORazepam (ATIVAN) CARPUJECT 2MG/ML 3002199 CPT outpatient 42.7 42.7 42.7 42.7 MICONAZOLE 2%(MONISTAT 7) VAG CREAM/APPL 3002211 CPT outpatient 72.85 72.85 72.85 72.85 NIFEdipine (PROCARDIA XL) TAB ER 60MG 3002216 CPT outpatient 27.5 27.5 27.5 27.5 Piperacillin-Tazobact (ZOSYN) 3.375GM VL 3002219 CPT outpatient 111 111 111 111 KCL in water(K-RIDER) IVPB 20MEQ/100ML 3002221 CPT outpatient 53.88 53.88 53.88 53.88 VENELEX OINTMENT 60GM 3002225 CPT outpatient 410 410 410 410 PROMETHAZINE HCl (PHENERGAN) TABLET 25MG 3002227 CPT outpatient 25 25 25 25 PROMETHAZINE HCl(PHENERGAN) VIAL 25MG/ML 3002228 CPT outpatient 50 50 50 50 PROPRANOLOL HCl TABLET 10MG 3002229 CPT outpatient 25 25 25 25 PYRAZINAMIDE TABLET 500MG 3002230 CPT outpatient 73.86 73.86 73.86 73.86 rifAMPin (RIFADIN) CAPSULE 300MG 3002234 CPT outpatient 60 60 60 60 SACCHAROMYCES BOULARDII CAPSULE 250MG 3002235 CPT outpatient 35 35 35 35 SERTRALINE HCL (ZOLOFT) TABLET 50MG 3002236 CPT outpatient 25 25 25 25 BICITRA ORAL SOLN. UDC 30ML 3002239 CPT outpatient 77.61 77.61 77.61 77.61 DAKIN'S 0.25% SOLN HALF STRN SOLN. 473ML 3002240 CPT outpatient 128.85 128.85 128.85 128.85 Thiamine (VIT-B1) TABLET 100MG 3002242 CPT outpatient 25 25 25 25 TOBRAMYCIN 0.3% EYE DROPS 5ML 3002244 CPT outpatient 407.76 407.76 407.76 407.76 ALENDRONATE (FOSAMAX) TABLET 70MG 3002249 CPT outpatient 229.87 229.87 229.87 229.87 PROTAMINE SULFATE VIAL 250MG/25ML 3002252 CPT outpatient 420.06 420.06 420.06 420.06 Tigecycline (TYGACIL) VIAL 50MG 3002254 CPT outpatient 1035 1035 1035 1035 NAPHCON-A 0.025%-0.3% EYE DROPS 15ML 3002256 CPT outpatient 112.88 112.88 112.88 112.88 Levothyroxine Sod.(SYNTHROID)VIAL 100MCG 3002257 CPT outpatient 1302 1302 1302 1302 MEPERIDINE HCl(DEMEROL) VIAL 50MG/ML 3002259 CPT outpatient 60 60 60 60 BENADRYL (BANOPHEN) CREAM 28GM 3002264 CPT outpatient 78.5 78.5 78.5 78.5 SILVER SULFADIAZINE 1% CREAM 50GM 3002266 CPT outpatient 181.44 181.44 181.44 181.44 NPH INSULIN/REG INS(NovoLIN) 70-30 VIAL 3002268 CPT outpatient 613.4 613.4 613.4 613.4 Levothyroxine Sod.(SYNTHROID) TAB 25MCG 3002271 CPT outpatient 25 25 25 25 MEROPENEM (MERREM) VIAL 1GM 3002272 CPT outpatient 115.8 115.8 115.8 115.8 DEXTROSE 50% in Water SYRINGE 25GM/50ML 3002273 CPT outpatient 132.48 132.48 132.48 132.48 PHENYTOIN Sod.(DILANTIN) ER CAPS 100MG 3002275 CPT outpatient 25 25 25 25 INSULIN LISPRO(HumaLOG)VIAL 300U/3ML*NF* 3002282 CPT outpatient 1186.7 1186.7 1186.7 1186.7 INSULIN REGULAR (HumuLIN R) VL. 300U/3ML 3002283 CPT outpatient 642.38 642.38 642.38 642.38 NPH INSULIN/REG INS(HumuLIN) 70-30 PEN 3002284 CPT outpatient 642.38 642.38 642.38 642.38 NPH INSULIN(HumuLIN N) PEN 300U/3ML 3002285 CPT outpatient 642.38 642.38 642.38 642.38 SENSORCAINE PF 0.75% VIAL 10ML 3002287 CPT outpatient 70.8 70.8 70.8 70.8 INSULIN ASPART (NovoLOG) PEN 300U/3ML 3002288 CPT outpatient 370.3 370.3 370.3 370.3 INSULIN DETEMIR (LEVEMIR) PEN 300U/3ML 3002290 CPT outpatient 1331.16 1331.16 1331.16 1331.16 "HEPARIN SOD. MD VIAL 5,000U/ML" 3002291 CPT outpatient 59.9 59.9 59.9 59.9 0.45%NACL + KCL 20MEQ IV SOLN 1000ML 3002295 CPT outpatient 286.75 286.75 286.75 286.75 OLANZapine (ZyPREXA) 10MG VIAL 3002296 CPT outpatient 498 498 498 498 MORPHINE SULF. TABLET IR 15MG 3002297 CPT outpatient 50 50 50 50 HALOPERIDOL (HALDOL) TABLET 5MG 3002298 CPT outpatient 25 25 25 25 Levothyroxine Sod.(SYNTHROID) TAB 88MCG 3002303 CPT outpatient 25 25 25 25 DESMOPRESSIN ACETATE(DDAVP) AMP 4MCG/ML 3002304 CPT outpatient 846.62 846.62 846.62 846.62 MAGNESIUM SULF. VIAL 1GM/2ML 3002308 CPT outpatient 55 55 55 55 DAPTOmycin (CUBICIN) VIAL 500MG 3002309 CPT outpatient 268.1 268.1 268.1 268.1 FAMOTIDINE (PEPCID) PF VIAL 20MG/2ML 3002310 CPT outpatient 179 179 179 179 risperiDONE (RisperDAL) TABLET 0.25MG 3002311 CPT outpatient 25 25 25 25 PROPOFOL (DIPRIVAN) VIAL 500MG/50ML 3002318 CPT outpatient 225 225 225 225 DOCUSATE SODIUM (COLACE) CAPSULE 100MG 3002319 CPT outpatient 25 25 25 25 Cefepime HCl(MAXIPIME) VIAL 2GM 3002321 CPT outpatient 448.56 448.56 448.56 448.56 ENOXAPARIN SOD. (LOVENOX) SYRN 60MG 3002322 CPT outpatient 121.69 121.69 121.69 121.69 DANTROLENE SODIUM(DANTRIUM) CAPSULE 25MG 3002323 CPT outpatient 57 57 57 57 CIPROFLOXACIN(CIPRO) in D5W PREMIX IVPB 3002324 CPT outpatient 189 189 189 189 HYDROCORTISONE-ALOE 1% CRM 28GM 3002325 CPT outpatient 50 50 50 50 HYDROCORTISONE 2.5% CREAM 30GM 3002326 CPT outpatient 47.52 47.52 47.52 47.52 METOPROLOL TARTARATE(LOPRESSOR) TAB 25MG 3002329 CPT outpatient 25 25 25 25 Methyl Salicylate/Menthol (BenGay) CREAM 3002331 CPT outpatient 41.82 41.82 41.82 41.82 "EPOEITIN ALFA (PROCRIT) VIAL 10,000U*NF*" 3002334 CPT outpatient 3242 3242 3242 3242 Piperacillin-Tazobact (ZOSYN) 4.5GM VIAL 3002344 CPT outpatient 123 123 123 123 SODIUM CHLORIDE 3% IV SOLN 500ML 3002349 CPT outpatient 118.4 118.4 118.4 118.4 Voriconazole (VFEND) VIAL 200MG 3002350 CPT outpatient 868.32 868.32 868.32 868.32 IMIPENEM/CILASTATIN (PRIMAXIN) VL 500MG 3002351 CPT outpatient 180 180 180 180 THROMBIN (RECOTHROM) VIAL 5MU 3002353 CPT outpatient 1238.4 1238.4 1238.4 1238.4 NOREPINEPHRINE (LEVOPHED) VIAL 4MG/4ML 3002354 CPT outpatient 254.51 254.51 254.51 254.51 Furosemide (LASIX) TABLET 40MG 3002356 CPT outpatient 25 25 25 25 NIACIN (VIT B3) ER TABLET 500MG 3002357 CPT outpatient 25 25 25 25 clonazePAM(KlonoPIN) TABLET (ODT) 1MG 3002361 CPT outpatient 50 50 50 50 AZITHROMYCIN (Z-PAK) TABLET 250MG 3002363 CPT outpatient 39.82 39.82 39.82 39.82 MOXIFLOXACIN HCl (AVELOX) TABLET 400MG 3002369 CPT outpatient 297.25 297.25 297.25 297.25 FAMOTIDINE (PEPCID) TABLET 20MG 3002370 CPT outpatient 25 25 25 25 TRIAMCINOLONE(KENALOG) 0.1% DENTAL PASTE 3002374 CPT outpatient 967.08 967.08 967.08 967.08 SODIUM BICARBONATE 8.4% SYRN 50MEQ/50ML 3002375 CPT outpatient 250.04 250.04 250.04 250.04 SULFAMETHOXAZOLE-TMP 400-80MG/ 5ML VIAL 3002376 CPT outpatient 120.25 120.25 120.25 120.25 MAGNESIUM CITRATE SOLN 296ML 3002379 CPT outpatient 25 25 25 25 SURGIFOAM SG50 SPONGE 3002381 CPT outpatient 351.86 351.86 351.86 351.86 PROPOFOL (DIPRIVAN) VIAL 1000MG/100ML 3002382 CPT outpatient 450 450 450 450 MARCAINE W/EPI 0.5%-0.0005% VIAL 30ML 3002388 CPT outpatient 34.99 34.99 34.99 34.99 DEXTROSE 5% in Water MNBG+ 100ML 3002390 CPT outpatient 104.5 104.5 104.5 104.5 DEXTROSE 5% in Water MNBG+ 50ML 3002391 CPT outpatient 104.6 104.6 104.6 104.6 GABAPENTIN (NEURONTIN) CAPSULE 300MG 3002392 CPT outpatient 25 25 25 25 RASAGILINE MESYLATE(AZILECT) TABLET 1MG 3002395 CPT outpatient 274.83 274.83 274.83 274.83 rifAMPin (RIFADIN) CAPSULE 150MG 3002396 CPT outpatient 35 35 35 35 TRIAZOLAM (HALCION) TABLET 0.25MG 3002398 CPT outpatient 50 50 50 50 MetroNIDAZOLE in NACL IVPB 500MG/100ML 3002399 CPT outpatient 60 60 60 60 CLINIMIX 5/20 IV SOLN. PREMIX 1000ML 3002401 CPT outpatient 738.33 738.33 738.33 738.33 ISOSORBIDE DN (ISORDIL) TABLET 10MG 3002404 CPT outpatient 25 25 25 25 AMPICILLIN SODIUM VIAL 1GM 3002407 CPT outpatient 131.35 131.35 131.35 131.35 Captopril (CAPOTEN) TABLET 12.5MG 3002408 CPT outpatient 25 25 25 25 KCL VIAL 20MEQ/10ML 3002410 CPT outpatient 47.02 47.02 47.02 47.02 ASPIRIN TABLET 325MG 3002411 CPT outpatient 25.18 25.18 25.18 25.18 ROCURONIUM (ZEMURON) VIAL 50MG/5ML 3002413 CPT outpatient 87.56 87.56 87.56 87.56 oxyCODONE/APAP (PERCOCET) TAB 10/325MG 3002417 CPT outpatient 50 50 50 50 PRAMIPEXOLE DI-HCl(MIRAPEX) TAB 1MG 3002422 CPT outpatient 35.4 35.4 35.4 35.4 GALANTAMINE HBr (RAZADYNE) TABLET 8MG 3002424 CPT outpatient 38.2 38.2 38.2 38.2 Fluocinonide (LIDEX) 0.05% CREAM 15GM 3002427 CPT outpatient 546.59 546.59 546.59 546.59 BACITRACIN OINTMENT 28.4GM 3002429 CPT outpatient 106.6 106.6 106.6 106.6 SILDENAFIL CITRATE (REVATIO) TABLET 20MG 3002431 CPT outpatient 35 35 35 35 NAPROXEN TABLET 500MG 3002432 CPT outpatient 25 25 25 25 Pyridoxine HCl(VIT-B6) TABLET 50MG 3002433 CPT outpatient 25 25 25 25 SILODOSIN (RAPAFLO) CAPSULE 8MG 3002434 CPT outpatient 107.68 107.68 107.68 107.68 "HEPARIN SOD. MD VIAL 1,000U/ML" 3002436 CPT outpatient 81.44 81.44 81.44 81.44 LIDOCAINE HCL (XYLOCAINE) 2% MPF VL 2ML 3002437 CPT outpatient 179 179 179 179 MINERAL OIL ENEMA 133ML 3002440 CPT outpatient 36.23 36.23 36.23 36.23 LIDOCAINE HCL 1% VIAL 20MG/2ML 3002441 CPT outpatient 60 60 60 60 CRANBERRY CONCENTRATE CAPSULE 500MG 3002442 CPT outpatient 25 25 25 25 dilTIAZem HCl(CARDIZEM CD)CAP ER 120MG 3002445 CPT outpatient 25 25 25 25 CIPROFLOXACIN(CIPRO) in D5W PREMIX IVPB 3002446 CPT outpatient 110 110 110 110 MIDODRINE HCl (ProAmatine) TABLET 5MG 3002449 CPT outpatient 25 25 25 25 ASPIRIN ENTERIC COATED TABLET DR 81MG 3002452 CPT outpatient 25.2 25.2 25.2 25.2 TRIAMCINOLONE (KENALOG-40) VIAL 40MG/ML 3002454 CPT outpatient 179 179 179 179 ePHEDrine SULF. VIAL 50MG/1ML 3002457 CPT outpatient 219.8 219.8 219.8 219.8 DESFLURANE (SUPRANE) LIQUID 240ML *OR* 3002459 CPT outpatient 2306.88 2306.88 2306.88 2306.88 CALAMINE LOTION 177ML 3002466 CPT outpatient 60 60 60 60 LIDOCAINE HCL (XYLOCAINE) 2% VIAL 10ML 3002467 CPT outpatient 60 60 60 60 AMIKACIN SULF. VIAL 500MG/2ML 3002468 CPT outpatient 71.47 71.47 71.47 71.47 SODIUM BICARBONATE TABLET 650MG 3002469 CPT outpatient 25 25 25 25 LIDOCAINE HCL (XYLOCAINE) 2% VIAL 20ML 3002471 CPT outpatient 179 179 179 179 Octreotide Acetate VIAL 100MCG/1ML 3002474 CPT outpatient 143.14 143.14 143.14 143.14 cloNIDine HCl(CATAPRES) TABLET 0.1MG 3002476 CPT outpatient 25 25 25 25 cefTRIAXone Sodium (ROCEPHIN) VIAL 1GM 3002482 CPT outpatient 60 60 60 60 NitroGLYcerin TAB SUBL 0.4MG 3002484 CPT outpatient 25 25 25 25 SIMETHICONE (MYLICON) TAB CHEW 80MG 3002489 CPT outpatient 25 25 25 25 Labetalol HCl(TRANDATE) SYRINGE 20MG/4ML 3002491 CPT outpatient 192 192 192 192 GENTAMICIN 0.1% OINTMENT 15GM 3002492 CPT outpatient 592.56 592.56 592.56 592.56 NORTRIPTYLINE HCl(PAMELOR) CAPSULE 25MG 3002494 CPT outpatient 25 25 25 25 TIMOLOL MALEATE 0.5% EYE DROPS 5ML 3002496 CPT outpatient 204 204 204 204 RAMIPRIL (ALTACE) CAPSULE 2.5MG 3002497 CPT outpatient 43.06 43.06 43.06 43.06 COSYNTROPIN (CORTROSYN VIAL) VIAL 0.25MG 3002502 CPT outpatient 1313.96 1313.96 1313.96 1313.96 diazePAM (VALIUM) TABLET 5MG 3002503 CPT outpatient 50 50 50 50 NORTRIPTYLINE HCl(PAMELOR) CAPSULE 10MG 3002508 CPT outpatient 25 25 25 25 Levalbuterol(XOPENEX)VIAL-NEB 0.63MG/3ML 3002509 CPT outpatient 55 55 55 55 Levalbuterol(XOPENEX)VIAL-NEB 1.25MG/3ML 3002510 CPT outpatient 55 55 55 55 MAGNESIUM SULF. in Water IVPB 2GM/50ML 3002512 CPT outpatient 181.32 181.32 181.32 181.32 Doxycycline Hyc.(VIBRAMCYIN)CAPS 100MG 3002517 CPT outpatient 25 25 25 25 dilTIAZem HCl(CARDIZEM CD)CAP ER 180MG 3002519 CPT outpatient 25 25 25 25 FOLIC ACID TABLET 1MG 3002526 CPT outpatient 25 25 25 25 hydroCHLOROthiazide(HydroDIURIL)TAB 25MG 3002527 CPT outpatient 25 25 25 25 DULoxetine HCl(CYMBALTA) CAPSULE DR 30MG 3002529 CPT outpatient 94.22 94.22 94.22 94.22 TERAZOSIN HCl(HYTRIN) CAPSULE 5MG 3002534 CPT outpatient 25 25 25 25 NITROFURANTOIN(MACRODANTIN) CAPSULE 50MG 3002535 CPT outpatient 27.26 27.26 27.26 27.26 NIFEdipine (PROCARDIA) CAPSULE 10MG 3002538 CPT outpatient 37.91 37.91 37.91 37.91 METHADONE HCl (DOLOPHINE) TABLET 10MG 3002540 CPT outpatient 50 50 50 50 MORPHINE SULF. VIAL 10MG/ML 3002541 CPT outpatient 60 60 60 60 RACEPINEPHrine HCL VIAL-NEB 2.25% 3002543 CPT outpatient 60 60 60 60 ceFAZolin sodium (ANCEF) VIAL 1GM 3002545 CPT outpatient 179 179 179 179 Piperacillin-Tazobact (ZOSYN) 2.25GM VL 3002548 CPT outpatient 147.7 147.7 147.7 147.7 PREPARATION H SUPPOSITORY. RECTAL 3002550 CPT outpatient 20 20 20 20 cefTRIAXone Sodium (ROCEPHIN) VIAL 2GM 3002556 CPT outpatient 79.72 79.72 79.72 79.72 BENAZEPRIL HCL (LOTENSIN) TABLET 10MG 3002558 CPT outpatient 29.71 29.71 29.71 29.71 PROMETHAZINE/CODEINE SYRUP 6.25-10MG/5ML 3002562 CPT outpatient 50 50 50 50 ERTAPENEM SODIUM (INVanz) VIAL 1GM 3002565 CPT outpatient 515 515 515 515 HYDROMORPHONE HCL(DILAUDID) CARP 2MG/ML 3002571 CPT outpatient 60 60 60 60 oxyCODONE HCl (ROXICODONE) TABLET 10MG 3002573 CPT outpatient 50 50 50 50 GuaiFENesin DM SYRUP 100-10MG/5ML 3002575 CPT outpatient 49.95 49.95 49.95 49.95 dilTIAZem HCl (CARDIZEM) VIAL 125MG/25ML 3002576 CPT outpatient 83.52 83.52 83.52 83.52 DIGOXIN (LANOXIN) AMPUL 0.5MG/2ML 3002579 CPT outpatient 79.2 79.2 79.2 79.2 LORazepam (ATIVAN) TABLET 1MG 3002580 CPT outpatient 33.37 33.37 33.37 33.37 TACROLIMUS (PROGRAF) CAPSULE 0.5MG 3002584 CPT outpatient 35 35 35 35 EPINEPHrine (ADRENALIN) VIAL 1MG/1ML 3002585 CPT outpatient 214.52 214.52 214.52 214.52 DexmedeTOMIDine(PRECEDEX) HCL in NS IVPB 3002591 CPT outpatient 1152 1152 1152 1152 SODIUM ZIRCONIUM(LOKELMA) POWD PACK 10GM 3002592 CPT outpatient 350.22 350.22 350.22 350.22 SIMVASTATIN (ZOCOR) TABLET 40MG 3002594 CPT outpatient 25 25 25 25 MODAFINIL (PROVIGIL) TABLET 100MG 3002596 CPT outpatient 264 264 264 264 Benzonatate (TESSALON) CAPSULE 100MG 3002598 CPT outpatient 25 25 25 25 metFORMIN HCl (GLUCOPHAGE) TABLET 500MG 3002599 CPT outpatient 25 25 25 25 DEXTROSE (GLUTOSE) 15 GEL 40% 37.5GM 3002601 CPT outpatient 64.5 64.5 64.5 64.5 CALCIUM GLUCONATE PREMIX IVPB 1GM/50ML 3002605 CPT outpatient 282 282 282 282 PENICILLIN G (PFIZERPEN) VIAL 5MMUNIT 3002610 CPT outpatient 183.18 183.18 183.18 183.18 NOREPINEPHRINE/D5W PREMIX IVPB 8MG/250ML 3002612 CPT outpatient 445.22 445.22 445.22 445.22 FLUCONAZOLE in NaCL IVPB 400MG/200ML 3002614 CPT outpatient 299.52 299.52 299.52 299.52 lamoTRIgine (LaMICtal) TABLET 100MG 3002616 CPT outpatient 25 25 25 25 methIMAzole (TAPAZOLE) TABLET 5MG 3002617 CPT outpatient 35 35 35 35 valACYclovir HCl(VALTREX) TABLET 500MG 3002618 CPT outpatient 86.69 86.69 86.69 86.69 Cholestyramine LIGHT POWD PACK 4GM 3002622 CPT outpatient 40.21 40.21 40.21 40.21 GuaiFENesin ORAL SOLN. 200MG/10ML 3002623 CPT outpatient 25 25 25 25 MORPHINE SULF. PCA VIAL 30MG/30ML 3002627 CPT outpatient 401.57 401.57 401.57 401.57 LIDOCAINE HCL VISCOUS 2% SOLN UDC 15ML 3002630 CPT outpatient 30 30 30 30 SODIUM CHLORIDE 0.9% ADD-VANTAGE 100ML 3002632 CPT outpatient 71 71 71 71 Fenofibrate (TRICOR) TABLET 54MG 3002634 CPT outpatient 25 25 25 25 TERAZOSIN HCl(HYTRIN) CAPSULE 1MG 3002636 CPT outpatient 25 25 25 25 DUTASTERIDE (AVODART) CAPSULE 0.5MG 3002637 CPT outpatient 85.5 85.5 85.5 85.5 ADVAIR DISKUS 100-50mcg 3002640 CPT outpatient 3664.4 3664.4 3664.4 3664.4 DANTROLENE SODIUM(REVONTO) VIAL 20MG 3002644 CPT outpatient 1008 1008 1008 1008 DOCUSATE (COLACE) ORAL SOLN. 100MG/10ML 3002645 CPT outpatient 25 25 25 25 LANTHANUM Carb.(FOSRENOL) TAB CHEW 500MG 3002646 CPT outpatient 155.44 155.44 155.44 155.44 OXACILLIN SODIUM VIAL 2GM 3002647 CPT outpatient 325.32 325.32 325.32 325.32 BIOTENE ORAL BALANCE GEL 42GM 3002648 CPT outpatient 123.4 123.4 123.4 123.4 FentaNYL (DURAGESIC) PATCH TD72 50MCG/HR 3002650 CPT outpatient 466.58 466.58 466.58 466.58 Ranolazine (RANEXA) TAB ER 500MG 3002651 CPT outpatient 77.08 77.08 77.08 77.08 ARMODAFINIL (NUVIGIL) TABLET 50MG 3002660 CPT outpatient 97.72 97.72 97.72 97.72 ISOSORBIDE DN (ISORDIL) TABLET 20MG 3002662 CPT outpatient 25 25 25 25 CEPHALEXIN (KEFLEX) CAPSULE 500MG 3002663 CPT outpatient 25 25 25 25 PRAVASTATIN SOD.(PRAVACHOL) TABLET 20MG 3002664 CPT outpatient 25 25 25 25 BISACODYL (DULCOLAX) SUPPOSITORY 10MG 3002665 CPT outpatient 28.14 28.14 28.14 28.14 ACARBOSE (PRECOSE) TABLET 50MG 3002668 CPT outpatient 34.68 34.68 34.68 34.68 SODIUM BICARBONATE 8.4% VIAL 50MEQ/50ML 3002673 CPT outpatient 130.54 130.54 130.54 130.54 FentaNYL (DURAGESIC)PATCH TD72 100MCG/HR 3002674 CPT outpatient 944.54 944.54 944.54 944.54 LIOTHYRONINE SODIUM(CYTOMEL) TABLET 5MCG 3002676 CPT outpatient 50 50 50 50 Verapamil HCl (CALAN) TABLET 80MG 3002678 CPT outpatient 25 25 25 25 LIDOCAINE HCl(GLYDO) JELLY 2% PF SYR6ML 3002680 CPT outpatient 85.67 85.67 85.67 85.67 SEVELAMER CARB.(RENVELA) TABLET 800MG 3002681 CPT outpatient 85.95 85.95 85.95 85.95 DIVALPROEX SODIUM SPRINKLE DR CAP 125MG 3002682 CPT outpatient 25 25 25 25 PHENOL (CHLORASEPTIC) 1.4% SPRAY 177ML 3002683 CPT outpatient 53.9 53.9 53.9 53.9 MetroNIDAZOLE (FLAGYL) TABLET 500MG 3002687 CPT outpatient 25 25 25 25 Fenofibrate (TRICOR) TABLET 145MG 3002688 CPT outpatient 68.74 68.74 68.74 68.74 OXYMETAZOLINE HCl 0.05% NASAL SPRAY 3002690 CPT outpatient 112 112 112 112 GABAPENTIN (NEURONTIN) CAPSULE 400MG 3002692 CPT outpatient 25 25 25 25 NYSTATIN/TRAIM(MYCOLOG) 100MU-0.1% CREAM 3002695 CPT outpatient 388 388 388 388 chlorproMAZINE(THORAZINE) TABLET 10MG 3002697 CPT outpatient 50.42 50.42 50.42 50.42 EZETIMIBE (ZETIA) 10MG TABLET 3002698 CPT outpatient 123.4 123.4 123.4 123.4 meTHENAMINE hippurate(HIPREX) TABLET 1GM 3002699 CPT outpatient 25.1 25.1 25.1 25.1 FLUCONAZOLE in NaCL IVPB 200MG/100ML 3002701 CPT outpatient 153 153 153 153 PYRIDOSTIGMINE BR.(MESTINON) TABLET 60MG 3002708 CPT outpatient 25 25 25 25 ETHACRYNIC ACID (EDECRIN) TABLET 25MG 3002710 CPT outpatient 287.4 287.4 287.4 287.4 NALOXONE HCl (NARCAN) VIAL 0.4MG/ML 3002714 CPT outpatient 369.54 369.54 369.54 369.54 GLYCERIN ADULT SUPPOSITORY RECT. 2GM 3002720 CPT outpatient 25 25 25 25 IOHEXOL(OMNIPAQUE) INFUS. BTL**RADIO** 3002722 CPT outpatient 1345.08 1345.08 1345.08 1345.08 ONDANSETRON HCl/PF (ZOFRAN) 4MG/2ML VIAL 3002723 CPT outpatient 179 179 179 179 levoFLOXacin in D5W IVPB 250MG/50ML 3002724 CPT outpatient 86.4 86.4 86.4 86.4 JEVITY 1.2 CAL LIQUID 237ML 3002729 CPT outpatient 20 20 20 20 NEPRO CARB STEADY LIQUID 237ML 3002730 CPT outpatient 42.09 42.09 42.09 42.09 HYDROmorphone(DILAUDID) TABLET 2MG 3002732 CPT outpatient 50 50 50 50 ADENOSINE (ADENOCARD) VIAL 6MG/ML 3002734 CPT outpatient 107 107 107 107 Calcium Acetate(PHOSLO) CAPSULE 667MG 3002735 CPT outpatient 25 25 25 25 VITAMIN D3 (25mcg)TABLET 1000 IU 3002737 CPT outpatient 25 25 25 25 DEXTROSE 5% in Water IV SOLN. 50ML 3002740 CPT outpatient 75 75 75 75 DEXTROSE 5% in Water IV SOLN. 100ML 3002741 CPT outpatient 70.52 70.52 70.52 70.52 DEXTROSE 5% in Water IV SOLN. 250ML 3002742 CPT outpatient 87.2 87.2 87.2 87.2 NitroGLYcerin VIAL 50MG/10ML 3002743 CPT outpatient 205.49 205.49 205.49 205.49 LIDOCAINE HCL in D5W IV SOLN 2GM/500ML 3002745 CPT outpatient 124.4 124.4 124.4 124.4 AMINOCAPROIC ACID (AMICAR) VIAL 5GM/20ML 3002746 CPT outpatient 157.92 157.92 157.92 157.92 SODIUM CHLORIDE 0.9% IV SOLN 1000ML 3002747 CPT outpatient 99.8 99.8 99.8 99.8 SODIUM CHLORIDE 0.45% IV SOLN. 1000ML 3002748 CPT outpatient 135 135 135 135 DEXTROSE 10% in WATER IV SOLN. 1000ML 3002749 CPT outpatient 199.6 199.6 199.6 199.6 DEXTROSE 5%-0.2% NS IV SOLN. 1000ML 3002750 CPT outpatient 180.4 180.4 180.4 180.4 D5%-0.45%NACL+KCL 20MEQ IV SOLN. 1000ML 3002751 CPT outpatient 178 178 178 178 DEXTROSE 5%-0.9% NACL IV SOLN. 1000ML 3002752 CPT outpatient 167.2 167.2 167.2 167.2 DEXTROSE 5% in WATER IV SOLN. 1000ML 3002753 CPT outpatient 166 166 166 166 SODIUM CHLORIDE 0.9% IV MNBG 50ML 3002754 CPT outpatient 65.84 65.84 65.84 65.84 SODIUM CHLORIDE 0.9% IV MNBG 100ML 3002755 CPT outpatient 72.12 72.12 72.12 72.12 SODIUM CHLORIDE 0.9% IV SOLN 250ML 3002756 CPT outpatient 86.9 86.9 86.9 86.9 SODIUM CHLORIDE 0.9% IV SOLN 500ML 3002757 CPT outpatient 90.2 90.2 90.2 90.2 WATER for INJECTION STERILE IV 1000ML 3002758 CPT outpatient 116.4 116.4 116.4 116.4 SPIRONOLACTONE (ALDACTONE) TABLET 25MG 3002759 CPT outpatient 26.87 26.87 26.87 26.87 SODIUM CHLORIDE 5% EYE DROPS 15ML 3002762 CPT outpatient 176.87 176.87 176.87 176.87 hydrOXYzine HCl (ATARAX) TABLET 25MG 3002765 CPT outpatient 30.71 30.71 30.71 30.71 BETADINE 10% SOLUTION 118ML 3002766 CPT outpatient 56.7 56.7 56.7 56.7 dilTIAZem HCl (CARDIZEM) TABLET 60MG 3002768 CPT outpatient 25 25 25 25 Diclofenac Sodium 0.1% EYE DROPS 5ML 3002769 CPT outpatient 200 200 200 200 HYDROCORTISONE (CORTEF) TABLET 10MG 3002770 CPT outpatient 25 25 25 25 DIPHENOXYLATE HCl/ATROPINE(LOMOTIL) TAB 3002773 CPT outpatient 25 25 25 25 levoFLOXacin in D5W IVPB 750MG/150ML 3002775 CPT outpatient 78 78 78 78 KCL (KLOR-CON M20) TAB ER 20MEQ 3002778 CPT outpatient 25 25 25 25 OYSTER SHELL-VIT D3 TABLET 500MG/200IU 3002780 CPT outpatient 25 25 25 25 ACETAMINOPHEN ORAL SOLN. UD 650MG/20.3ML 3002782 CPT outpatient 50.68 50.68 50.68 50.68 MAGNESIUM OXIDE TABLET 400MG 3002785 CPT outpatient 25 25 25 25 TRIPLE ANTIBIOTIC (NEOSPORIN) OINT. 28GM 3002788 CPT outpatient 55.37 55.37 55.37 55.37 MIDODRINE HCl (ProAmatine) TABLET 10MG 3002791 CPT outpatient 25 25 25 25 IVABRADINE HCl (CORLANOR) TABLET 5MG 3002792 CPT outpatient 117.96 117.96 117.96 117.96 AZELASTINE HCl(OPTIVAR) 0.05% EYE DROPS 3002793 CPT outpatient 1065.7 1065.7 1065.7 1065.7 DAPSONE (ACZONE) TABLET 100MG 3002797 CPT outpatient 55.23 55.23 55.23 55.23 HydrOXYzine PAMOATE(VISTARIL) CAPS 25MG 3002798 CPT outpatient 25 25 25 25 IVERMECTIN (STROMECTOL)TABLET 3MG 3002799 CPT outpatient 84.63 84.63 84.63 84.63 Sotalol HCL (BETAPACE) TABLET 80MG 3002800 CPT outpatient 50.62 50.62 50.62 50.62 Tobramycin/Dexa 0.3-0.1% EYE DROPS 2.5ML 3002803 CPT outpatient 546.24 546.24 546.24 546.24 D5%-0.45%NACL+KCL 40MEQ IV SOLN. 1000ML 3002806 CPT outpatient 128.4 128.4 128.4 128.4 D5%-0.225%NACL+KCL 20MEQ IV SOLN. 1000ML 3002807 CPT outpatient 122.4 122.4 122.4 122.4 FLEET DISPOSABLE ENEMA 133ML 3002808 CPT outpatient 25 25 25 25 NAFCILLIN SODIUM VIAL 1GM 3002809 CPT outpatient 190 190 190 190 D5%-0.9%NACL+KCL 20MEQ IV SOLN. 1000ML 3002810 CPT outpatient 327.59 327.59 327.59 327.59 ALENDRONATE (FOSAMAX) TABLET 10MG 3002811 CPT outpatient 54.26 54.26 54.26 54.26 "Epoetin Alfa-Epbx(RETACRIT) VIAL 10,000U" 3002815 CPT outpatient 1358.6 1358.6 1358.6 1358.6 "Epoetin Alfa-Epbx(RETACRIT) VIAL 4,000U" 3002816 CPT outpatient 564.44 564.44 564.44 564.44 "Epoetin Alfa-Epbx(RETACRIT) VIAL 3,000U" 3002817 CPT outpatient 432.08 432.08 432.08 432.08 "Epoetin Alfa-Epbx(RETACRIT) VIAL 2,000U" 3002818 CPT outpatient 299.72 299.72 299.72 299.72 oxyCODONE HCl(OxyCONTIN)TAB ER 12H 10mg 3002819 CPT outpatient 94.8 94.8 94.8 94.8 SIMVASTATIN (ZOCOR) TABLET 10MG 3002820 CPT outpatient 33.47 33.47 33.47 33.47 METOLAZONE (ZAROXOLYN) TABLET 2.5 MG 3002822 CPT outpatient 25 25 25 25 LACTATED RINGERS IV SOLN 1000ML 3002823 CPT outpatient 179 179 179 179 predniSONE (DELTASONE) TABLET 20MG 3002824 CPT outpatient 25 25 25 25 Ziprasidone HCl (GEODON) CAPSULE 20MG 3002825 CPT outpatient 69.48 69.48 69.48 69.48 METOPROLOL TARTARATE(LOPRESSOR) TAB 50MG 3002826 CPT outpatient 25 25 25 25 PHENYLEPHRINE HCl VIAL 10MG/ML 3002827 CPT outpatient 179 179 179 179 KCL in water(K-RIDER) IVPB 40MEQ/100ML 3002828 CPT outpatient 88.4 88.4 88.4 88.4 0.9%NACL + KCL 20 MEQ IV SOLN 1000ML 3002830 CPT outpatient 327.59 327.59 327.59 327.59 PIOGLITAZONE (ACTOS) HCl TABLET 15MG 3002835 CPT outpatient 88.11 88.11 88.11 88.11 AMPICILLIN SODIUM VIAL 2GM 3002836 CPT outpatient 212.53 212.53 212.53 212.53 LORATADINE (CLARITIN) TABLET 10MG 3002838 CPT outpatient 25 25 25 25 GuaiFENesin(MUCINEX ER) TAB ER 12H 600MG 3002839 CPT outpatient 25 25 25 25 Benztropine mesylate(COGENTIN) TAB 1MG 3002840 CPT outpatient 25 25 25 25 Temazepam (RESTORIL) CAPSULE 15MG 3002841 CPT outpatient 50 50 50 50 GEMFIBROZIL (LOPID) TABLET 600MG 3002842 CPT outpatient 25 25 25 25 PALIPERIDONE(INVEGA SUSTENNA) SYR 156MG 3002844 CPT outpatient 9999 9999 9999 9999 PALIPERIDONE(INVEGA SUSTENNA) SYR 234MG 3002845 CPT outpatient 9999 9999 9999 9999 OMEPRAZOLE (PriLOSEC) CAPSULE DR 20MG 3002846 CPT outpatient 25 25 25 25 Doxycycline (DOXY-100) VIAL 100MG 3002849 CPT outpatient 297 297 297 297 WARFARIN SODIUM (JAVOTEN) TABLET 1MG 3002856 CPT outpatient 25 25 25 25 WARFARIN SODIUM (JAVOTEN) TABLET 3MG 3002857 CPT outpatient 25 25 25 25 CIPROFLOXACIN(CILOXAN) 0.3% EYE DROPS 3002859 CPT outpatient 151.2 151.2 151.2 151.2 ALBUTEROL SULFATE TABLET 4MG 3002861 CPT outpatient 83.73 83.73 83.73 83.73 VANCOMYCIN HCL ORAL SOLN RECON 50MG/ML 3002866 CPT outpatient 1275 1275 1275 1275 WARFARIN SODIUM (JAVOTEN) TABLET 2.5MG 3002871 CPT outpatient 25 25 25 25 PRAMIPEXOLE DI-HCl(MIRAPEX) TAB 0.25MG 3002876 CPT outpatient 25 25 25 25 REFRESH LACRI-LUBE EYE OINT. 3.5GM 3002879 CPT outpatient 140.69 140.69 140.69 140.69 fluvoxaMINE maleate CAP ER 24H 100MG 3002882 CPT outpatient 122.2 122.2 122.2 122.2 INSULIN LISPRO(ADMELOG) VIAL 300U/3ML 3002884 CPT outpatient 505.8 505.8 505.8 505.8 EAR WAX REMOVAL 6.5% OTIC DROPS 15ML 3002885 CPT outpatient 25 25 25 25 Methylphenidate HCl (RITALIN) TABLET 5MG 3002888 CPT outpatient 50 50 50 50 Hydroxychloroquine (PLAQUENIL) TAB 200MG 3002890 CPT outpatient 50 50 50 50 Carisoprodol (SOMA) TABLET 350MG 3002892 CPT outpatient 50 50 50 50 oxyCODONE HCl (ROXICODONE) TABLET 5MG 3002895 CPT outpatient 50 50 50 50 cefTAZidime (TAZICEF) VIAL 2GM 3002897 CPT outpatient 144 144 144 144 cefTAZidime (TAZICEF) VIAL 1GM 3002898 CPT outpatient 64.8 64.8 64.8 64.8 Esmolol HCl(BREVIBLOC) VIAL 100MG/10ML 3002900 CPT outpatient 220 220 220 220 ATROPINE SULF. SYRINGE 1MG/10ML 3002902 CPT outpatient 179 179 179 179 HYDROCORTISONE 2.5% CRM RECTAL 28GM 3002903 CPT outpatient 875 875 875 875 TRIAMCINOLONE(KENALOG) 0.1% OINT 15GM 3002904 CPT outpatient 66.83 66.83 66.83 66.83 Clotrimazole/Betamethasone 1%-0.05% CRM 3002907 CPT outpatient 1452.11 1452.11 1452.11 1452.11 Nitroglycerin(NITRO-DUR)PATCH TD24 0.2MG 3002908 CPT outpatient 50 50 50 50 PREGABALIN (LYRICA) CAPSULE 75MG 3002909 CPT outpatient 50 50 50 50 VALSARTAN (DIOVAN) TABLET 80MG 3002910 CPT outpatient 68.47 68.47 68.47 68.47 cloBAZam (ONFI) TABLET 10MG 3002911 CPT outpatient 50 50 50 50 "NYSTATIN(MYCOSTATIN) 100,000 USP CREAM" 3002912 CPT outpatient 210 210 210 210 CILOSTAZOL (PLETAL) TABLET 50MG 3002913 CPT outpatient 25 25 25 25 PANTOPRAZOLE (PROTONIX) GRANPKT DR 40MG 3002914 CPT outpatient 203.86 203.86 203.86 203.86 ALBUMIN HUMAN (FLEXBUMIN) 25% IVPB 100ML 3002915 CPT outpatient 1433.64 1433.64 1433.64 1433.64 LITHIUM CARBONATE CAPSULE 150MG 3002917 CPT outpatient 25 25 25 25 ALPRAZolam (XANAX) TABLET 0.25MG 3002918 CPT outpatient 28.64 28.64 28.64 28.64 Levothyroxine Sod.(SYNTHROID) TAB 112MCG 3002919 CPT outpatient 25 25 25 25 KCL CAPSULE ER 10MEQ 3002920 CPT outpatient 47.99 47.99 47.99 47.99 Nicardipine HCl VIAL 25MG/10ML 3002922 CPT outpatient 367.49 367.49 367.49 367.49 GOLYTELY SOLN RECON. 4000ML 3002924 CPT outpatient 201.6 201.6 201.6 201.6 PHENYLEPHRINE HCl VIAL 50MG/5ML 3002926 CPT outpatient 310 310 310 310 AMPICILLIN/SULBACTAM(UNASYN) VIAL 1.5GM 3002927 CPT outpatient 109.96 109.96 109.96 109.96 OLOPATADINE HCl(PATADAY) 0.2% EYE DROPS 3002930 CPT outpatient 194.9 194.9 194.9 194.9 FERROUS SULF. LIQ. UDC 300MG/5ML 3002933 CPT outpatient 65.72 65.72 65.72 65.72 DAPTOmycin (CUBICIN) VIAL 350MG 3002936 CPT outpatient 825 825 825 825 METHOCARBAMOL (ROBAXIN)TABLET 500MG 3002937 CPT outpatient 25 25 25 25 SODIUM CHLORIDE TABLET 1GM 3002938 CPT outpatient 25 25 25 25 oxyCODONE HCl/APAP(PERCOCET) TAB 5/325MG 3002940 CPT outpatient 50 50 50 50 MESALAMINE (DELZICOL) DR CAPSULES 400MG 3002943 CPT outpatient 50.28 50.28 50.28 50.28 LOPERAMIDE HCl(IMODIUM)LIQUID (120ml) 3002944 CPT outpatient 74.9 74.9 74.9 74.9 "Ergocalciferol (VIT-D2) CAPSULE 50,000U" 3002945 CPT outpatient 25 25 25 25 PREGABALIN (LYRICA) CAPSULE 50MG 3002947 CPT outpatient 50 50 50 50 ACYCLOVIR (ZOVIRAX) TABLET 800MG 3002948 CPT outpatient 67.16 67.16 67.16 67.16 sulfaSALAzine (AZULFIDINE) TABLET 500MG 3002952 CPT outpatient 27.33 27.33 27.33 27.33 TRALEMENT 4 VIAL 1ML 3002954 CPT outpatient 309.6 309.6 309.6 309.6 lamoTRIgine (LaMICtal) TABLET 25MG 3002955 CPT outpatient 25 25 25 25 LUBIPROSTONE (AMITIZA) CAPSULE 24MCG 3002956 CPT outpatient 95.5 95.5 95.5 95.5 glyBURIDE (DIABETA) TABLET 5MG 3002958 CPT outpatient 25 25 25 25 Remdesivir (VEKLURY) VIAL 100MG 3002960 CPT outpatient 7663.2 7663.2 7663.2 7663.2 GADOBENATE(MULTIHANCE) VIAL 5ML **RADIOL 3002962 CPT outpatient 426.9 426.9 426.9 426.9 OYSTER SHELL-VIT D3 TABLET 250MG/125IU 3002964 CPT outpatient 25 25 25 25 DexAMETHasone (DECADRON) PF VIAL 10MG/ML 3002968 CPT outpatient 179 179 179 179 LIDOCAINE 5% OINTMENT 35.44GM 3002969 CPT outpatient 3800.13 3800.13 3800.13 3800.13 PRIMIDONE (MYSOLINE) TABLET 50MG 3002970 CPT outpatient 25 25 25 25 HEPARIN DRIP IN D5W IVPB 25000U/500ML 3002971 CPT outpatient 342.8 342.8 342.8 342.8 SEVELAMER HCl (RENAGEL) TABLET 800MG 3002972 CPT outpatient 107.1 107.1 107.1 107.1 miSOPROStol (CYTOTEC) TABLET 200MCG 3002974 CPT outpatient 52.25 52.25 52.25 52.25 ACYCLOVIR (ZOVIRAX) VIAL 500MG/10ML 3002975 CPT outpatient 205 205 205 205 MICAFUNGIN SODIUM (MYCAMINE) VIAL 100MG 3002976 CPT outpatient 621 621 621 621 Erythromycin Lactobionate ADD-VIAL 500MG 3002980 CPT outpatient 1205.25 1205.25 1205.25 1205.25 CICLOPIROX (PENLAC) 8% NAIL SOLN. 6.6ML 3002982 CPT outpatient 2148 2148 2148 2148 ENTACAPONE (COMTAN) TABLET 200MG 3002984 CPT outpatient 59.3 59.3 59.3 59.3 levETIRAcetam(KEPPRA)ORAL SOLN 500MG/5ML 3002986 CPT outpatient 45.47 45.47 45.47 45.47 Levothyroxine Sod.(SYNTHROID) TAB 100MCG 3002987 CPT outpatient 25 25 25 25 Trihexyphenidyl HCl(ARTANE) TABLET 5MG 3002988 CPT outpatient 32.27 32.27 32.27 32.27 DEPO-Medrol VIAL 80MG/ML 3002989 CPT outpatient 295.8 295.8 295.8 295.8 MAGIC MOUTHWASH BLM SUSPENSION 3002990 CPT outpatient 1525 1525 1525 1525 VENLAFAXINE HCl (EFFEXOR) TABLET 75MG 3002991 CPT outpatient 26.22 26.22 26.22 26.22 aMILoride HCl (MIDAMOR) TABLET 5MG 3002993 CPT outpatient 27.67 27.67 27.67 27.67 ALBUMIN HUMAN (ALBUKED) 5% VIAL 250ML 3002995 CPT outpatient 1125 1125 1125 1125 DEFEROXAMINE (DESFERAL) VIAL 500MG 3002996 CPT outpatient 190.4 190.4 190.4 190.4 MELATONIN TABLET 3MG 3002997 CPT outpatient 25 25 25 25 AMIODARONE HCL(CORDARONE) VIAL 150MG/3ML 3002998 CPT outpatient 60 60 60 60 HEMORRHOIDAL (PREPARATION H) OINT. 57GM 3003003 CPT outpatient 60.23 60.23 60.23 60.23 traMADol HCl (ULTRAM) TABLET 50MG 3003005 CPT outpatient 50 50 50 50 CYANOCOBALAMIN (VIT B12) TABLET 100MCG 3003007 CPT outpatient 25 25 25 25 POTASSIUM PHOSPHATE VIAL 15MMOL/5ML 3003011 CPT outpatient 288 288 288 288 fluvoxaMINE maleate TABLET 50MG 3003021 CPT outpatient 30.84 30.84 30.84 30.84 FEXOFENADINE HCl (ALLEGRA) TABLET 60MG 3003023 CPT outpatient 27.16 27.16 27.16 27.16 Levalbuterol (XOPENEX) HFA AER AD 45MCG 3003025 CPT outpatient 818.87 818.87 818.87 818.87 Verapamil HCl (CALAN) VIAL 5MG/2ML 3003029 CPT outpatient 144 144 144 144 CALCIUM CHLORIDE 10% SYRINGE 3003031 CPT outpatient 129.6 129.6 129.6 129.6 Betamethasone Dipropionate 0.05% CREAM 3003033 CPT outpatient 475 475 475 475 azaTHIOprine (IMURAN) TABLET 50MG 3003037 CPT outpatient 100 100 100 100 VECURONIUM BROMIDE(NORCURON) VIAL 10MG 3003041 CPT outpatient 104.63 104.63 104.63 104.63 Bethanechol (URECHOLINE) TABLET 10MG 3003043 CPT outpatient 45.02 45.02 45.02 45.02 PHENobarbital SODIUM VIAL 65MG/ML 3003045 CPT outpatient 296.84 296.84 296.84 296.84 DAPAGLIFLOZIN (FARXIGA) TABLET 10MG 3003049 CPT outpatient 255.76 255.76 255.76 255.76 ALBUMIN HUMAN (FLEXBUMIN) 25% IVPB 50ML 3003057 CPT outpatient 739.3 739.3 739.3 739.3 LINEZOLID(ZYVOX) PREMIX IVPB 600MG/300ML 3003059 CPT outpatient 224 224 224 224 ENOXAPARIN SOD. (LOVENOX) SYRN 100MG 3003061 CPT outpatient 286.27 286.27 286.27 286.27 ALBUTEROL SULFATE ORAL SYRUP 2MG/5ML 3003063 CPT outpatient 631.3 631.3 631.3 631.3 LIDOCAINE HCL / EPI (XYLOCAINE) VL 20ML 3003065 CPT outpatient 60 60 60 60 NP THYROID TABLET 30MG 3003075 CPT outpatient 25 25 25 25 GABAPENTIN (NEURONTIN) CAPSULE 100MG 3003077 CPT outpatient 25 25 25 25 AMANTADINE(SYMMETREL)ORAL SOLN 50MG/5ML 3003079 CPT outpatient 752.5 752.5 752.5 752.5 PROMETHAZINE DM 6.25-15MG/5ML(118ML) 3003085 CPT outpatient 134.4 134.4 134.4 134.4 SPS ENEMA RECTAL 30GM/120ML 3003089 CPT outpatient 1475 1475 1475 1475 hydrOXYzine HCl VIAL 25MG/1ML 3003091 CPT outpatient 306.14 306.14 306.14 306.14 Terbinafine HCl (LamISIL) 1% CREAM 15GM 3003093 CPT outpatient 115.4 115.4 115.4 115.4 Esomeprazole (NEXIUM) DR SUSP PKT 40MG 3003095 CPT outpatient 139.91 139.91 139.91 139.91 FAMOTIDINE in NaCl PREMIX IVPB 20MG/50ML 3003097 CPT outpatient 73.87 73.87 73.87 73.87 Sucralfate(CARAFATE) ORAL SUSP. 1GM/10ML 3003101 CPT outpatient 103.2 103.2 103.2 103.2 DroNABinol (MARINOL) CAPSULE 2.5MG 3003103 CPT outpatient 68.02 68.02 68.02 68.02 ALENDRONATE (FOSAMAX) ORAL SOLN. 3003107 CPT outpatient 887.42 887.42 887.42 887.42 HYDROmorphone(DILAUDID) PF VIAL 10MG/ML 3003109 CPT outpatient 60 60 60 60 ALPRAZolam (XANAX) TABLET 1MG 3003111 CPT outpatient 36.55 36.55 36.55 36.55 VENLAFAXINE HCl (EFFEXOR) TABLET 50MG 3003117 CPT outpatient 25 25 25 25 Calcitriol (ROCALTROL) CAPSULE 0.25MCG 3003119 CPT outpatient 25 25 25 25 DULoxetine HCl(CYMBALTA) CAPSULE DR 20MG 3003123 CPT outpatient 83.98 83.98 83.98 83.98 VANCOMYCIN in Water Premix IVPB 750MG 3003125 CPT outpatient 172.8 172.8 172.8 172.8 ZINC OXIDE (DESITIN) 40% PASTE 113GM 3003133 CPT outpatient 68.21 68.21 68.21 68.21 LIDOCAINE HCL (XYLOCAINE) 1% MDV 20ML 3003141 CPT outpatient 53.28 53.28 53.28 53.28 LIDOCAINE HCL (XYLOCAINE) 1% PF VL 30ML 3003143 CPT outpatient 220.05 220.05 220.05 220.05 CLINIMIX 5/20 IV SOLN. PREMIX 2000ML 3003145 CPT outpatient 1178.32 1178.32 1178.32 1178.32 URE-NA POWD PACKET 15GM 3003147 CPT outpatient 50.4 50.4 50.4 50.4 FentaNYL citrate/PF VIAL 100MCG/2ML 3003149 CPT outpatient 179 179 179 179 ceFAZolin sodium (ANCEF) VIAL 2GM 3003155 CPT outpatient 118.12 118.12 118.12 118.12 QUEtiapine(SEROQUEL XR) ER TAB 24H 200MG 3003159 CPT outpatient 50 50 50 50 Mycophenolate (CellCept) CAPSULE 250MG 3003165 CPT outpatient 60 60 60 60 CLEOCIN in D5W Premix IVPB 300MG/50ML 3003167 CPT outpatient 178.02 178.02 178.02 178.02 Midazolam HCl(VERSED) 50MG/10ML 3003171 CPT outpatient 173.03 173.03 173.03 173.03 Cefiderocol (FETROJA) VIAL 1GM 3003173 CPT outpatient 2869.03 2869.03 2869.03 2869.03 VASOPRESSIN (VASOSTRICT) VIAL 20U/1ML 3003175 CPT outpatient 381 381 381 381 ESTRADIOL PATCH TD(ONE WEEKLY)0.1MG/24HR 3003179 CPT outpatient 278.49 278.49 278.49 278.49 LIDOCAINE HCL/PF 2% SYRINGE 100MG/5ML 3003181 CPT outpatient 97.2 97.2 97.2 97.2 METHOCARBAMOL (ROBAXIN) VIAL 1000MG 3003183 CPT outpatient 115.2 115.2 115.2 115.2 ACTIVATED CHARCOAL (ACTIDOSE) ORAL SUSP. 3003187 CPT outpatient 192 192 192 192 PAMIDRONATE (AREDIA) VIAL 60MG/10ML 3003189 CPT outpatient 530.1 530.1 530.1 530.1 FentaNYL citrate/PF VIAL 500MCG/10ML 3003193 CPT outpatient 79.83 79.83 79.83 79.83 ACETAMINOPHEN(OFIRMEV) IVPB 1000MG/100ML 3003195 CPT outpatient 179 179 179 179 Octreotide Acetate VIAL 500MCG/1ML 3003199 CPT outpatient 631.28 631.28 631.28 631.28 MILRINONE (PRIMACOR) VIAL 10MG/10ML 3003203 CPT outpatient 57.6 57.6 57.6 57.6 MARCAINE W/EPI 0.25%-0.0005% VIAL 10ML 3003207 CPT outpatient 55.17 55.17 55.17 55.17 PANTOPRAZOLE SODIUM(PROTONIX) VIAL 40MG 3003209 CPT outpatient 70.64 70.64 70.64 70.64 Ipratropium/Albuterol (DUONEB) 3ML NEB 3003211 CPT outpatient 57 57 57 57 SODIUM CHLORIDE 0.9% VIAL 10ML (DILUENT) 3003213 CPT outpatient 35 35 35 35 LinaGLIPtin (TRADJENTA) TABLET 5MG 3003215 CPT outpatient 235.03 235.03 235.03 235.03 WATER BACTERIOSTATIC for INJ. VIAL 30ML 3003221 CPT outpatient 24.8 24.8 24.8 24.8 0.9%NACL + KCL 40 MEQ IV SOLN 1000ML 3003223 CPT outpatient 331.94 331.94 331.94 331.94 AMPICILLIN/SULBACTAM **BULK VIAL** 15GM 3003225 CPT outpatient 570.24 570.24 570.24 570.24 "Epoetin Alfa-Epbx(RETACRIT) VIAL 40,000U" 3003231 CPT outpatient 6353.28 6353.28 6353.28 6353.28 FentaNYL citrate/PF VIAL 250MCG/5ML 3003237 CPT outpatient 43.2 43.2 43.2 43.2 AMINOCAPROIC ACID (AMICAR) TABLET 500MG 3003239 CPT outpatient 249.02 249.02 249.02 249.02 Biotene Dry Mouth 473ml 3003241 CPT outpatient 96.3 96.3 96.3 96.3 Cisatracurium (NIMBEX) VIAL 10MG/5ML 3003243 CPT outpatient 100.8 100.8 100.8 100.8 FLUAD QUAD 65 YRS AND OLDER 2023-24 SYRG 3003247 CPT outpatient 968.17 968.17 968.17 968.17 FLUCELVAX QUAD 2023-2024 SYRINGE 3003249 CPT outpatient 422.64 422.64 422.64 422.64 HEPARIN DRIP 0.45% NS IVPB 25000U/500ML 3003253 CPT outpatient 174.68 174.68 174.68 174.68 FILGRASTIM-AAFI(NIVESTYM) SYRINGE 300MCG 3003259 CPT outpatient 3153.6 3153.6 3153.6 3153.6 CLEOCIN in D5W Premix IVPB 900MG/50ML 3003265 CPT outpatient 20 20 20 20 UMECLIDINIUM Br(INCRUSE ELLIPTA) 62.5MCG 3003267 CPT outpatient 950.6 950.6 950.6 950.6 INSULIN REGULAR(NovoLIN R)PEN 300U/3ML 3003269 CPT outpatient 253.62 253.62 253.62 253.62 SYSTANE 0.3% OPHTHALMIC GEL 10GM 3003271 CPT outpatient 140.98 140.98 140.98 140.98 Vit A/Vit C/Vit E/Zinc/Copper TABLET 3003273 CPT outpatient 25 25 25 25 MEROPENEM (MERREM) VIAL 2GM **NF** 3003275 CPT outpatient 473.76 473.76 473.76 473.76 LIDOCAINE SOL 4%(Laryng-O-Jet)*FOR SURG* 3003277 CPT outpatient 434.88 434.88 434.88 434.88 LIDOCAINE HCL SOLN 4% *FOR SURGERY USE* 3003279 CPT outpatient 775.68 775.68 775.68 775.68 ARGATROBAN VIAL 50MG/50ML 3003281 CPT outpatient 1245 1245 1245 1245 HYALURONIDASE(AMPHADASE) VIAL 150U/1ML 3003283 CPT outpatient 704.6 704.6 704.6 704.6 MARCAINE W/EPI 0.5%-0.0005% VIAL 50ML 3003285 CPT outpatient 235.3 235.3 235.3 235.3 oxyCODONE HCl(OXYCONTIN)TAB ER 12H 30MG 3003287 CPT outpatient 204.31 204.31 204.31 204.31 LIDOCAINE HCL (XYLOCAINE) 2% MPF VL 5ML 3003291 CPT outpatient 179 179 179 179 Filgrastim (RELEUKO) SYR 300MCG/0.5ML 3003293 CPT outpatient 2289.6 2289.6 2289.6 2289.6 SODIUM CHLORIDE 23.4% VIAL 30ML 3003295 CPT outpatient 96.6 96.6 96.6 96.6 ADVAIR DISKUS 500-50mcg 3005497 CPT outpatient 5956.3 5956.3 5956.3 5956.3 ROFLUMILAST (DALIRESP) TABLET 500MCG 3005562 CPT outpatient 148.6 148.6 148.6 148.6 HYDROmorphone PCA VIAL (MMH) 15MG/30ML 3005567 CPT outpatient 200 200 200 200 dilTIAZem HCl (CARDIZEM) VIAL 25MG/5ML 3005572 CPT outpatient 31.39 31.39 31.39 31.39 TIMOLOL MALEATE 0.25% EYE DROPS 5ML 3005578 CPT outpatient 175 175 175 175 leflunomide (ARAVA) TABLET 10MG 3005592 CPT outpatient 189.23 189.23 189.23 189.23 LIDOCAINE HCL VISCOUS 2% SOLN 100ML 3005596 CPT outpatient 157 157 157 157 FOSFOMYCIN tromethamine(MONUROL) PKT 3GM 3005611 CPT outpatient 1029 1029 1029 1029 BENZOCAINE (ORAJEL) 20% GEL 0.42 OZ 3005614 CPT outpatient 105.6 105.6 105.6 105.6 TRANEXAMIC ACID VIAL 1000MG/10ML 3005621 CPT outpatient 179 179 179 179 EXPAREL 1.3% VIAL 133MG/10ML 3005622 CPT outpatient 3414.45 3414.45 3414.45 3414.45 FLOSEAL 10ML (FOR SURGERY ONLY) 3005624 CPT outpatient 4867.86 4867.86 4867.86 4867.86 Lipase/Protease/Amylase(CREON) CAPSULE 3005634 CPT outpatient 74.84 74.84 74.84 74.84 ARIPiprazole (ABILIFY) TABLET 2MG 3005651 CPT outpatient 345.05 345.05 345.05 345.05 Lacosamide (VIMPAT) VIAL 200MG/20ML 3005653 CPT outpatient 942.19 942.19 942.19 942.19 Lacosamide (VIMPAT) TABLET 50MG 3005654 CPT outpatient 48.57 48.57 48.57 48.57 SODIUM CHLORIDE 0.9% IRRIG SOLN (3000ML) 3005655 CPT outpatient 179 179 179 179 Fidaxomicin (DIFICID) TABLET 200MG 3005658 CPT outpatient 3148 3148 3148 3148 FLUTICASONE (FLOVENT) HFA 110MCG 3005660 CPT outpatient 3828.23 3828.23 3828.23 3828.23 DexAMETHasone (DECADRON) TABLET 1MG 3005661 CPT outpatient 25 25 25 25 Chlorhexidine(PERIDEX) 0.12% MOUTHWASH 3005664 CPT outpatient 59.6 59.6 59.6 59.6 Methotrexate Sod. (TREXALL)TABLET 2.5MG 3005666 CPT outpatient 75 75 75 75 Terbinafine HCl (LamISIL)TABLET 250MG 3005669 CPT outpatient 156.9 156.9 156.9 156.9 Febuxostat (ULORIC) TABLET 40MG 3005672 CPT outpatient 36 36 36 36 MINOCYCLINE HCl (MICOCIN) CAPSULE 100MG 3005674 CPT outpatient 25 25 25 25 NATEGLINIDE (STARLIX) TABLET 60MG 3005678 CPT outpatient 25 25 25 25 CITALOPRAM (CeleXA) TABLET 10MG 3005683 CPT outpatient 25 25 25 25 SILVER NITRATE APPLICATOR 75%-25% STICK 3005692 CPT outpatient 60 60 60 60 APIXABAN (ELIQUIS) TABLET 2.5MG 3005700 CPT outpatient 119.79 119.79 119.79 119.79 rOPINIRole HCl (REQUIP) TABLET 0.25MG 3005707 CPT outpatient 25 25 25 25 NUEDEXTA CAPSULE 20MG/10MG 3005723 CPT outpatient 320.4 320.4 320.4 320.4 cefTAZidime/AVIBACTAM(AVYCAZ) VIAL 2.5GM 3005731 CPT outpatient 5029.38 5029.38 5029.38 5029.38 Phytonadione(VIT-K1) ORAL LIQUID*CPD* 3005732 CPT outpatient 698.15 698.15 698.15 698.15 CLEOCIN in D5W Premix IVPB 600MG/50ML 3005741 CPT outpatient 178.02 178.02 178.02 178.02 Theophylline (THEO-24) CAP ER 100MG 3005745 CPT outpatient 71.42 71.42 71.42 71.42 Ceftolozane/Tazobactam(ZERBAXA) VL 1.5GM 3005747 CPT outpatient 1948.8 1948.8 1948.8 1948.8 Oxcarbazepine (TRILEPTAL) TABLET 150MG 3005749 CPT outpatient 25 25 25 25 KCL POWDER PACKET 20MEQ 3005757 CPT outpatient 122.43 122.43 122.43 122.43 Ubidecarenone (CO Q10) CAPSULE 100MG 3005768 CPT outpatient 25 25 25 25 CLINIMIX 4.25/10 IV SOLN. PREMIX 1000ML 3005770 CPT outpatient 667.63 667.63 667.63 667.63 CLINIMIX 4.25/10 IV SOLN. PREMIX 2000ML 3005771 CPT outpatient 1105.3 1105.3 1105.3 1105.3 DOPamine in D5W IVPB PREMIX 800MG/250ML 3005779 CPT outpatient 316.8 316.8 316.8 316.8 FentaNYL (DURAGESIC) PATCH TD72 12MCG/HR 3005790 CPT outpatient 238.02 238.02 238.02 238.02 MetroNIDAZOLE (FLAGYL) 0.75% CREAM 45GM 3005797 CPT outpatient 891.2 891.2 891.2 891.2 Sacubitril/Valsartan(ENTRESTO)TAB24/26MG 3005800 CPT outpatient 139.89 139.89 139.89 139.89 Budesonide/Formoterol HFA 160-4.5mcg 3005801 CPT outpatient 1960.4 1960.4 1960.4 1960.4 D5%-0.45%NACL+KCL 10MEQ IV SOLN. 1000ML 3005806 CPT outpatient 128.4 128.4 128.4 128.4 MULTIVITAMIN PLUS MINERALS ORAL LIQUID 3005808 CPT outpatient 25 25 25 25 PNEUMOVAX 23 SYRINGE 3005824 CPT outpatient 1685.97 1685.97 1685.97 1685.97 SOLU-Medrol VIAL 40MG/1ML 3005827 CPT outpatient 112.62 112.62 112.62 112.62 TESTOSTERONE CYPIONATE VIAL 200MG/ML 3005829 CPT outpatient 337.4 337.4 337.4 337.4 CYANOCOBALAMIN (VIT B12) TABLET 500MCG 3005830 CPT outpatient 25 25 25 25 ENOXAPARIN SOD. (LOVENOX) SYRN 30MG 3005850 CPT outpatient 78.34 78.34 78.34 78.34 ENOXAPARIN SOD. (LOVENOX) SYRN 40MG 3005851 CPT outpatient 79.16 79.16 79.16 79.16 ENOXAPARIN SOD. (LOVENOX) SYRN 80MG 3005853 CPT outpatient 150.63 150.63 150.63 150.63 AcetaZOLAMIDE (DIAMOX) TABLET 250MG 3005861 CPT outpatient 52.59 52.59 52.59 52.59 ALLOPURINOL (ZYLOPRIM) TABLET 100MG 3005867 CPT outpatient 28.96 28.96 28.96 28.96 AMIODARONE HCL(CORDARONE) VIAL 450MG/9ML 3005870 CPT outpatient 127.9 127.9 127.9 127.9 AMIODARONE HCL (CORDARONE) TABLET 200MG 3005872 CPT outpatient 104.44 104.44 104.44 104.44 ATORVASTATIN (LIPITOR) TABLET 10MG 3005879 CPT outpatient 29.99 29.99 29.99 29.99 ATORVASTATIN (LIPITOR) TABLET 40MG 3005880 CPT outpatient 27.91 27.91 27.91 27.91 ATROPINE SULFATE 1% DROPS 3005883 CPT outpatient 503.6 503.6 503.6 503.6 AZITHROMYCIN (ZITHROMAX) VIAL 500MG 3005885 CPT outpatient 80.12 80.12 80.12 80.12 Bicalutamide (CASODEX) TABLET 50MG 3005889 CPT outpatient 210.33 210.33 210.33 210.33 BRIMONIDINE(ALPHAGAN P) 0.2% EYE DROPS 3005890 CPT outpatient 351.5 351.5 351.5 351.5 WATER for INJECTION STERILE VIAL 100ML 3005895 CPT outpatient 96.68 96.68 96.68 96.68 Voriconazole (VFEND) TABLET 200MG 3005901 CPT outpatient 954.2 954.2 954.2 954.2 Cefepime HCl(MAXIPIME) VIAL 1GM 3005907 CPT outpatient 248.34 248.34 248.34 248.34 VITAMIN D3 (125mcg)TABLET 5000 IU 3005918 CPT outpatient 25 25 25 25 DEMECLOCYCLINE (DECLOMYCIN) TABLET 150MG 3005926 CPT outpatient 225.63 225.63 225.63 225.63 DexAMETHasone Sod Phos 1% EYE DROPS 5ML 3005927 CPT outpatient 776.16 776.16 776.16 776.16 DEXTROSE 5% in Water IV SOLN. 500ML 3005929 CPT outpatient 89 89 89 89 dilTIAZem HCl (CARDIZEM) TABLET 30MG 3005931 CPT outpatient 30.24 30.24 30.24 30.24 diphenhydrAMINE HCL(BENADRYL) VL 50mg/mL 3005933 CPT outpatient 179 179 179 179 DOCUSATE SODIUM (COLACE) CAPSULE 250MG 3005935 CPT outpatient 25 25 25 25 Erythromycin E.S. ORAL SUSP. 200MG/5ML 3005947 CPT outpatient 4539 4539 4539 4539 FINASTERIDE (PROSCAR) TABLET 5MG 3005952 CPT outpatient 50 50 50 50 Furosemide (LASIX) VIAL 20MG/2ML 3005958 CPT outpatient 48.77 48.77 48.77 48.77 Furosemide (LASIX) VIAL 40MG/4ML 3005960 CPT outpatient 76.82 76.82 76.82 76.82 Furosemide (LASIX) VIAL 100MG/10ML 3005962 CPT outpatient 59 59 59 59 INSULIN GLARGINE (LANTUS) PEN 300U/3ML 3005971 CPT outpatient 266.32 266.32 266.32 266.32 HYDROcodone/APAP (NORCO) TABLET 5/325MG 3005974 CPT outpatient 50 50 50 50 levETIRAcetam (KEPPRA) VIAL 500MG/5ML 3005982 CPT outpatient 90.43 90.43 90.43 90.43 levETIRAcetam (KEPPRA) TABLET 500MG 3005985 CPT outpatient 25 25 25 25 levOCARNitine (CARNITOR) TABLET 330MG 3005987 CPT outpatient 25 25 25 25 LIDOCAINE HCL (XYLOCAINE) 1% MDV 20ML 3005991 CPT outpatient 60 60 60 60 LIDOCAINE HCL PF 2% VIAL 100MG/5ML 3005993 CPT outpatient 60 60 60 60 Metoclopramide HCl(REGLAN) ORAL SOLN. 3005994 CPT outpatient 73.62 73.62 73.62 73.62 LOSARTAN POTASSIUM (COZAAR) TABLET 25MG 3005995 CPT outpatient 25 25 25 25 HYDROMORPHONE HCL (DILAUDID) SYR 1MG/1ML 3005996 CPT outpatient 60 60 60 60 HYDROmorphone(DILAUDID) PF VIAL 2MG/ML 3005997 CPT outpatient 179 179 179 179 LORazepam (ATIVAN) VIAL 2MG/ML 3005999 CPT outpatient 60 60 60 60 LORazepam (ATIVAN) TABLET 0.5MG 3006001 CPT outpatient 50 50 50 50 MOXIFLOXACIN PREMIX IVPB 400MG/250ML 3006008 CPT outpatient 597 597 597 597 NICOTINE(NICODERM) PATCH TD24 14MG/24HR 3006009 CPT outpatient 56.42 56.42 56.42 56.42 ONDANSETRON (ZOFRAN ODT) TABLET 4MG 3006010 CPT outpatient 277.36 277.36 277.36 277.36 SODIUM PHOSPHATE VIAL 45MMOL/15ML 3006020 CPT outpatient 217.15 217.15 217.15 217.15 TRIAMCINOLONE (KENALOG) 0.1% CREAM 80GM 3006021 CPT outpatient 174.53 174.53 174.53 174.53 VALPROIC ACID (DEPACON) VIAL 500MG/5ML 3006024 CPT outpatient 60 60 60 60 Sodium FERRIC Gluconate VIAL 62.5MG 3006032 CPT outpatient 457.92 457.92 457.92 457.92 AZTREONAM (AZACTAM) VIAL 2GM 3006034 CPT outpatient 700.44 700.44 700.44 700.44 MELOXICAM (MOBIC) TABLET 7.5MG 3006038 CPT outpatient 37.17 37.17 37.17 37.17 Carbidopa/Levodopa(SINEMET) TAB 25/250MG 3006039 CPT outpatient 25 25 25 25 AZTREONAM (AZACTAM) VIAL 1GM 3006041 CPT outpatient 372.72 372.72 372.72 372.72 SUCCINYLCHOLINE CHLORIDE VIAL 200MG/10ML 3006044 CPT outpatient 274.75 274.75 274.75 274.75 Sucralfate (CARAFATE) TABLET 1GM 3006045 CPT outpatient 25 25 25 25 HEPATITIS B VIRUS VACCINE SYRINGE 3006049 CPT outpatient 879.98 879.98 879.98 879.98 CIPROFLOXACIN HCL (CIPRO) TABLET 500MG 3006058 CPT outpatient 67.04 67.04 67.04 67.04 QUEtiapine fum.(SEROQUEL) TABLET 25MG 3006080 CPT outpatient 25 25 25 25 Scopolamine TRANSDERMAL PATCH 1MG/72HR 3006084 CPT outpatient 264.74 264.74 264.74 264.74 D5W + KCL 20MEQ IV SOLN. 1000ML 3006086 CPT outpatient 134.4 134.4 134.4 134.4 GENTAMICIN SULF. VIAL 80MG/2ML 3006091 CPT outpatient 75.98 75.98 75.98 75.98 CALMOSEPTINE OINTMENT 71GM 3006092 CPT outpatient 81 81 81 81 NICOTINE(NICODERM) PATCH TD24 21MG/24HR 3006098 CPT outpatient 25 25 25 25 NYSTATIN(MYCOSTATIN) ORAL SUSP.500KU/5ML 3006100 CPT outpatient 25 25 25 25 PAMIDRONATE (AREDIA) VIAL 90MG/10ML 3006102 CPT outpatient 1167.7 1167.7 1167.7 1167.7 PHENYLEPHRINE HCl VIAL 100MG/10ML 3006103 CPT outpatient 520.8 520.8 520.8 520.8 MIRALAX (PEG 3350) POWD PACK 17GM 3006107 CPT outpatient 25 25 25 25 Bumetanide (BUMEX) VIAL 2.5MG/10ML 3011085 CPT outpatient 74.34 74.34 74.34 74.34 APIXABAN (ELIQUIS) TABLET 5MG 3011240 CPT outpatient 143.89 143.89 143.89 143.89 CYPROHEPTADINE HCl(PERIACTIN) TABLET 4MG 3012529 CPT outpatient 54.96 54.96 54.96 54.96 AMIKACIN/NS INHALATION SOLN: 500MG/3ML 3061105 CPT outpatient 150 150 150 150 SUFentanil Citrate VIAL 50 mcg/mL 3061112 CPT outpatient 1035 1035 1035 1035 METHOCARBAMOL/NS IVPB: 1000MG/100ML 3061122 CPT outpatient 115.2 115.2 115.2 115.2 METHOCARBAMOL/NS IVPB: 500MG/100ML 3061123 CPT outpatient 115.2 115.2 115.2 115.2 Voriconazole(VFEND)/NS IVPB:200MG/100ML 3061124 CPT outpatient 868.32 868.32 868.32 868.32 rifAMPin(RIFADIN)/D5W IVPB: 600MG/100ML 3061125 CPT outpatient 2571.26 2571.26 2571.26 2571.26 COLISTIMETHATE(COLISTIN)/NS INHALAT150MG 3061126 CPT outpatient 403.2 403.2 403.2 403.2 TOBRAMYCIN/D5W IVPB: 80MG/100ML 3061128 CPT outpatient 48.82 48.82 48.82 48.82 TOBRAMYCIN/NS IVPB: 80MG/100ML 3061129 CPT outpatient 48.82 48.82 48.82 48.82 TOBRAMYCIN/NS INHALATION SOLN: 80MG/3ML 3061130 CPT outpatient 48.82 48.82 48.82 48.82 THROMBIN JMI (BOVINE) VIAL 5000 IU 3061131 CPT outpatient 1238.4 1238.4 1238.4 1238.4 MORPHINE SULF. VIAL 4MG/ML 3061132 CPT outpatient 60 60 60 60 FLUCELVAX TRIVALENT 2024-2025 SYRINGE 3061133 CPT outpatient 422.64 422.64 422.64 422.64 FLUAD QUAD 65 YRS AND OLDER 2024-25 SYRG 3061134 CPT outpatient 968.17 968.17 968.17 968.17 ACCU-CHECK 3061139 CPT outpatient 25 25 25 25 Riluzole (RILUTEK) TABLET 50 MG 3061143 CPT outpatient 62 62 62 62 NF-ESTRADIOL TABLET 0.5MG 3061149 CPT outpatient 0.07 0.07 0.07 0.07 Methylene Blue(ProvayBlue) Injection 1% 3061152 CPT outpatient 2535 2535 2535 2535 ValGANciclovir (VALCYTE) TABLET 450MG 3061153 CPT outpatient 668.96 668.96 668.96 668.96 NYSTATIN(MYCOSTATIN) ORAL SUSP 473mL 3061154 CPT outpatient 1184.9 1184.9 1184.9 1184.9 Sulfacetamide (BLEPH)10% EYE DROPS 15ML 3061155 CPT outpatient 635 635 635 635 NF-PROGESTERONE LIQ CAP 100MG 3061156 CPT outpatient 0.04 0.04 0.04 0.04 Durlobactam/Sulbactam(XACDURO) VL 2GM 3061157 CPT outpatient 5988 5988 5988 5988 CHLORHEXIDINE(PERIDEX) 0.12% UDC 3061158 CPT outpatient 25 25 25 25 NF-TRELEGY ELLIPTA 200/62.5/25MCG/INH 3061159 CPT outpatient 1.58 1.58 1.58 1.58 NF-IPRATROPIUM NASAL SPRAY 0.06% 3061160 CPT outpatient 0.77 0.77 0.77 0.77 NF-PREVAGEN ORAL CAP 10MG-50MCG 3061161 CPT outpatient 0.11 0.11 0.11 0.11 MEPERIDINE HCl(DEMEROL) SYR 50MG/ML*OR* 3061162 CPT outpatient 60 60 60 60 MEPERIDINE HCl(DEMEROL) VIAL 25MG/ML 3061166 CPT outpatient 65.43 65.43 65.43 65.43 PREVNAR 20 SYRINGE 3061167 CPT outpatient 3270.6 3270.6 3270.6 3270.6 ALBUMIN HUMAN (ALBUKED) 25% VIAL 100ML 3061168 CPT outpatient 1433.64 1433.64 1433.64 1433.64 ALBUMIN HUMAN (ALBUKED) 25% VIAL 50ML 3061169 CPT outpatient 739.3 739.3 739.3 739.3 NF-IPRATROPIUM BROM NASAL SPRAY 0.03% 3061170 CPT outpatient 0.67 0.67 0.67 0.67 NF-Janumet XR Oral Tab ER 1000MG-100MG 3061172 CPT outpatient 2 2 2 2 PROMETHAZINE DM SYRUP 6.25-15MG/5ML 3061173 CPT outpatient 462.5 462.5 462.5 462.5 SODIUM BICARBONATE 4.2% VIAL 2.5MEQ/5ML 3061174 CPT outpatient 127.93 127.93 127.93 127.93 ENSURE PLUS LIQUID 237ML 3061175 CPT outpatient 25 25 25 25 ENSURE PLANT BASED PROTEIN LIQUID 237ML 3061176 CPT outpatient 35 35 35 35 PROPYLTHIOURACIL (PROPYCIL) TABLET 50MG 3061177 CPT outpatient 58.6 58.6 58.6 58.6 NF-SYNJARDY XR TAB ER 25MG-1000MG 3061178 CPT outpatient 2.93 2.93 2.93 2.93 NF-RYBELSUS ORAL TABLET 7MG 3061179 CPT outpatient 4.65 4.65 4.65 4.65 NF-TROSPIUM CHLORIDE ORAL TABLET 20MG 3061180 CPT outpatient 0.34 0.34 0.34 0.34 NF-CYCLOSPORINE OPHTH EMULSION 0.05% 3061181 CPT outpatient 1.55 1.55 1.55 1.55 NF-TESTOSTERONE GEL 1% 3061182 CPT outpatient 0.29 0.29 0.29 0.29 NF-OPZELURA TOPICAL CREAM 1.5% 3061183 CPT outpatient 4.91 4.91 4.91 4.91 NF-FORTEO SUBCUTANEOUS SOLUTION 250MCG/1 3061184 CPT outpatient 257.39 257.39 257.39 257.39 Tenofovir DF(VIREAD) TABLET 300MG 3061185 CPT outpatient 430.13 430.13 430.13 430.13 NF-OZEMPIC SUBQ SOLN 2MG/3ML 3061186 CPT outpatient 46.49 46.49 46.49 46.49 CLEOCIN in NS Premix IVPB 300MG/50ML 3061187 CPT outpatient 129.95 129.95 129.95 129.95 TACROLIMUS (PROGRAF) CAPSULE 5MG 3061188 CPT outpatient 247.97 247.97 247.97 247.97 DOBUTamine in D5W IVPB 500MG/250ML 3061189 CPT outpatient 524.35 524.35 524.35 524.35 Oseltamivir Phos.(TAMIFLU) CAPSULE 30MG 3061190 CPT outpatient 166.8 166.8 166.8 166.8 GANCICLOVIR (CYTOVENE) VIAL 500MG/10ML 3061191 CPT outpatient 765 765 765 765 NF-OFEV ORAL CAPSULE 100MG 3061192 CPT outpatient 31.19 31.19 31.19 31.19 NF-OFEV CAP 150MG 3061193 CPT outpatient 31.19 31.19 31.19 31.19 NF-ADEMPAS ORAL TABLET 0.5MG 3061194 CPT outpatient 22.13 22.13 22.13 22.13 NF-NEUPRO TD PATCH ER 4MG/24HR 3061195 CPT outpatient 4.05 4.05 4.05 4.05 GuaiFENesin/Codeine LIQUID 200-20MG/10ML 3061198 CPT outpatient 76 76 76 76 NF-Vabomere IV Pwd for Soln 1GM-1GM 3061199 CPT outpatient 23 23 23 23 Meropenem/Vaborbactam(VABOMERE)VIAL 2GM 3061200 CPT outpatient 2770 2770 2770 2770 NF-APTIOM TAB 600MG 3061204 CPT outpatient 6.1 6.1 6.1 6.1 NF-BRIVIACT SOLN 10MG/1ML 3061205 CPT outpatient 0.69 0.69 0.69 0.69 NF-EPIDIOLEX SOLN 100MG/1ML 3061206 CPT outpatient 2.35 2.35 2.35 2.35 NF-CLOBAZAM ORAL SUSPENSION 2.5MG/1ML 3061207 CPT outpatient 1.04 1.04 1.04 1.04 GANCICLOVIR/D5W IVPB: 500MG/100ML 3061208 CPT outpatient 765 765 765 765 HYDROmorphone(DILAUDID) VIAL 50MG/5ML 3061210 CPT outpatient 165.7 165.7 165.7 165.7 SacubitrilValsartan(ENTRESTO)TAB97/103MG 3061212 CPT outpatient 166.04 166.04 166.04 166.04 MEPERIDINE HCl(DEMEROL) SYR 25MG/ML*OR* 3061215 CPT outpatient 179 179 179 179 NF-ANORO ELLIPTA INH PWD 62.5MCG-25MCG/1 3061216 CPT outpatient 1.17 1.17 1.17 1.17 BETAXOLOL(BETOPTIC) 0.5% EYE DROPS 3061217 CPT outpatient 687.7 687.7 687.7 687.7 TRIFLURIDINE(VIROPTIC) 1% EYE DROPS 3061219 CPT outpatient 2475.1 2475.1 2475.1 2475.1 VANCOMYCIN HCL(VANCOCIN) VIAL 750MG 3061220 CPT outpatient 153 153 153 153 NF-ARAVA ORAL TABLET 20MG 3061221 CPT outpatient 2.17 2.17 2.17 2.17 SODIUM CHLORIDE INHALATION SOLN. 7% CPD 3061222 CPT outpatient 150 150 150 150 ROCURONIUM/NS DRIP 200MG/100ML 3061223 CPT outpatient 87.56 87.56 87.56 87.56 NF-CICLOPIROX OLAMINE CREAM 0.77% 3061224 CPT outpatient 546 546 546 546 NF-BREO ELLIPTA INHALATION POWDER 3061225 CPT outpatient 0.98 0.98 0.98 0.98 NF-SECUADO PATCH ER 5.7MG/24HR 3061226 CPT outpatient 7.01 7.01 7.01 7.01 NF-AUGMENTIN TAB 875MG-125MG 3061227 CPT outpatient 1.45 1.45 1.45 1.45 KATE FARMS PLANT 1.0 CAL LIQUID 1000ML 3061228 CPT outpatient 140 140 140 140 NF-ALORA (TWICE-WEEKLY) TD PATCH ER 0.1M 3061229 CPT outpatient 2.12 2.12 2.12 2.12 NF-ALORA (TWICE-WEEKLY) TD PATCH ER 0.1M 3061230 CPT outpatient 2.12 2.12 2.12 2.12 KATE FARMS PLANT 1.0 CAL LIQUID 325ML 3061231 CPT outpatient 140 140 140 140 CLINDAMYCIN (CLEOCIN T) 1% GEL 60GM 3061232 CPT outpatient 1892.1 1892.1 1892.1 1892.1 NF-CEVIMELINE HCL CAP 30MG 3061233 CPT outpatient 0.31 0.31 0.31 0.31 IMIPRAMINE HCL(TOFRANIL) TAB 50MG 3061234 CPT outpatient 50 50 50 50 Terbinafine HCl (LamISIL) 1% CREAM 30GM 3061235 CPT outpatient 145.4 145.4 145.4 145.4 NF-LYRICA CAP 25MG 3061236 CPT outpatient 1.46 1.46 1.46 1.46 NF-KESIMPTA SENSOREADY PEN 20MG/0.4ML 3061237 CPT outpatient 3364.94 3364.94 3364.94 3364.94 NF-VARENICLINE STARTING PACK TAB 0.5MG;1 3061238 CPT outpatient 1.11 1.11 1.11 1.11 NF-MELOXICAM ORAL CAPSULE 5MG 3061239 CPT outpatient 3.73 3.73 3.73 3.73 NF-AZO DUAL PROTECTION CAP 3061240 CPT outpatient 0.13 0.13 0.13 0.13 NEOMYCIN/POLYMYXIN B/HC 1% EAR DROPS 3061241 CPT outpatient 1031.8 1031.8 1031.8 1031.8 NF-RHEUMATE ORAL CAPSULE 1MG-1MG-500MG 3061242 CPT outpatient 24.11 24.11 24.11 24.11 PHENYTOIN ORAL SUSP 125MG/5ML (237ML) 3061244 CPT outpatient 313.4 313.4 313.4 313.4 NF-WEGOVY SUBQ SOLN 0.25MG/0.5ML 3061245 CPT outpatient 97.13 97.13 97.13 97.13 NF-Trelegy Ellipta 200/62.5/25MCG/INH 3061246 CPT outpatient 1 1 1 1 Tenofovir ALAFEN. (VEMLIDY) TABLET 25MG 3061247 CPT outpatient 635.7 635.7 635.7 635.7 MINOCYCLINE (MINOCIN) VIAL 100MG 3061248 CPT outpatient 3147 3147 3147 3147 Rivaroxaban (XARELTO) TABLET 2.5MG 3061250 CPT outpatient 144.61 144.61 144.61 144.61 COPPER GLUCONATE TABLET 2MG 3061251 CPT outpatient 25 25 25 25 NF-PREMARIN ORAL TABLET 0.625MG 3061252 CPT outpatient 0.15 0.15 0.15 0.15 NF-OZEMPIC 1MG DOSES SUBQ SOLN 4MG/3ML 3061253 CPT outpatient 47.88 47.88 47.88 47.88 R.E.C.K(ROP-EPI-CLO-KET) SYRN IN NS 50ML 3061254 CPT outpatient 713.3 713.3 713.3 713.3 FLUCELVAX TRIVALENT 2025-2026 SYRINGE 3061255 CPT outpatient 422.64 422.64 422.64 422.64 FLUAD QUAD 65 YRS AND OLDER 2025-26 SYRG 3061256 CPT outpatient 968.17 968.17 968.17 968.17 NF-BREZTRI AEROSPHERE INH AER LIQ 3061258 CPT outpatient 8.94 8.94 8.94 8.94 NF-ESBRIET ORAL TABLET 801MG 3061259 CPT outpatient 16.72 16.72 16.72 16.72 NF-FELODIPINE ORAL TAB ER 10MG 3061263 CPT outpatient 0.72 0.72 0.72 0.72 NF-TERIPARATIDE SUBQ SOLN 250MCG/1ML 3061264 CPT outpatient 159.11 159.11 159.11 159.11 NF-BUPROPION HCL 24 HR TAB ER 150MG 3061265 CPT outpatient 0.89 0.89 0.89 0.89 NF-BUPROPION HCL 24 HR TAB ER 150MG 3061266 CPT outpatient 0.57 0.57 0.57 0.57 NF-GLUTASOLVE ORAL PACKET 15GM 3061267 CPT outpatient 0.27 0.27 0.27 0.27 NF-MIRABEGRON ORAL TABLET ER 25MG 3061268 CPT outpatient 1.99 1.99 1.99 1.99 MORPHINE SULF. SYRINGE 10MG/ML 3061269 CPT outpatient 75 75 75 75 BUPRENORPHINE/NALOXONE SL FILM 8MG/2MG 3061270 CPT outpatient 60 60 60 60 NF-DOFETILIDE ORAL CAPSULE 125MCG 3061273 CPT outpatient 1.17 1.17 1.17 1.17 MEPERIDINE HCl(DEMEROL) VIAL 1500MG/30ML 3061275 CPT outpatient 1683.9 1683.9 1683.9 1683.9 NF-ENTECAVIR (BARACLUDE) TABLET 0.5MG 3061276 CPT outpatient 469.32 469.32 469.32 469.32 NF-JARDIANCE ORAL TABLET 10MG 3061277 CPT outpatient 3.02 3.02 3.02 3.02 NF-JANUVIA ORAL TABLET 100MG 3061278 CPT outpatient 2.75 2.75 2.75 2.75 PROMETHAZINE HCl (PHENERGAN) AMP 25MG/ML 3061279 CPT outpatient 55.94 55.94 55.94 55.94 NF-VIIBRYD ORAL TABLET 40MG 3061280 CPT outpatient 1.75 1.75 1.75 1.75 NF-NICORETTE ORAL GUM 4MG 3061281 CPT outpatient 0.1 0.1 0.1 0.1 Posaconazole (NOXAFIL) DR TABLET 100MG 3061282 CPT outpatient 765.1 765.1 765.1 765.1 NF-ALBUTEROL SULFATE HFA INH 0.09MG/1ACT 3061283 CPT outpatient 0.81 0.81 0.81 0.81 NF-ALVESCO ORAL AEROSOL LIQUID 80MCG/1AC 3061284 CPT outpatient 6.47 6.47 6.47 6.47 NF-ENTECAVIR ORAL TABLET 0.5MG 3061285 CPT outpatient 5.33 5.33 5.33 5.33 NF-NEUPRO TD PATCH ER 8MG/24HR 3061286 CPT outpatient 345.58 345.58 345.58 345.58 NF-VEOZAH ORAL TABLET 45MG 3061287 CPT outpatient 2.72 2.72 2.72 2.72 MORPHINE SULF. SYRINGE 4MG/ML 3061288 CPT outpatient 69.44 69.44 69.44 69.44 NF-TADALAFIL (CIALIS) ORAL TABLET 20MG 3061289 CPT outpatient 8.65 8.65 8.65 8.65 LACTOBACILLUS ORAL TABLET 0.05MG-0.05MG 3061291 CPT outpatient 25 25 25 25 NF-LINZESS CAP 145MCG 3061292 CPT outpatient 2.73 2.73 2.73 2.73 NF-TAGRISSO ORAL TABLET 80MG 3061293 CPT outpatient 84.63 84.63 84.63 84.63 NF-ALVESCO INH ORAL/NEB LIQ AERO 160MCG/ 3061295 CPT outpatient 6.47 6.47 6.47 6.47 NF-METFORMIN ER ORAL TAB ER 500MG 3061297 CPT outpatient 0.1 0.1 0.1 0.1 NF-Kerendia Oral Tablet 10MG 3061298 CPT outpatient 3 3 3 3 NF-Kerendia Oral Tablet 10MG 3061299 CPT outpatient 3 3 3 3 NF-PROLIA SUBCUTANEOUS SOLUTION 60MG/1ML 3061300 CPT outpatient 270.06 270.06 270.06 270.06 NF-OLMESARTAN MEDOXOMIL ORAL TABLET 40MG 3061301 CPT outpatient 1.1 1.1 1.1 1.1 diphenhydrAMINE HCL (BENADRYL) TABS 25MG 3061302 CPT outpatient 27.62 27.62 27.62 27.62 "NF-1,1,1,3,3PNTFLRPRPN-NRFLRN;BUPI;ISOAL" 3061303 CPT outpatient 83.9 83.9 83.9 83.9 NF-BRINZOLAMIDE OPHTHALMIC SUSP 1% 3061304 CPT outpatient 4.39 4.39 4.39 4.39 cloZAPine (CLOZARIL) TABLET 200MG 3061305 CPT outpatient 49.58 49.58 49.58 49.58 NF-EXELON TD PATCH ER 4.6MG/24HR 3061306 CPT outpatient 3.29 3.29 3.29 3.29 NF-MIRABEGRON ORAL TABLET 50MG 3061307 CPT outpatient 1.99 1.99 1.99 1.99 NF-JUVEN ORAL POWDER FOR SOLUTION 3061308 CPT outpatient 0.01 0.01 0.01 0.01 NF-Brinzolamide Ophthalmic Susp 1% 3061309 CPT outpatient 4 4 4 4 NF-CEFUROXIME AXETIL ORAL TABLET 250MG 3061310 CPT outpatient 25 25 25 25 NF-Trelegy Ellipta 200/62.5/25MCG/INH 3061311 CPT outpatient 1 1 1 1 NF-Ibrance Oral Tablet 100MG 3061312 CPT outpatient 116 116 116 116 NF-Ibrance Oral Capsule 100MG 3061313 CPT outpatient 112 112 112 112 NF-OFLOXACIN OPHTH SOLN 0.3% 3061314 CPT outpatient 1.45 1.45 1.45 1.45 NF-BROMFENAC OPHTHALMIC SOLUTION 0.075% 3061315 CPT outpatient 7 7 7 7 NF-PREDNISOLONE ACETATE OPHTH SUSP 1% 3061316 CPT outpatient 0.27 0.27 0.27 0.27 NF-NURTEC ODT ORAL DIS TABLET 75MG 3061317 CPT outpatient 19.36 19.36 19.36 19.36 NF-ZENPEP CAP DR 10000U-42000U-32000U 3061318 CPT outpatient 0.63 0.63 0.63 0.63 NF-FLECAINIDE ACETATE ORAL TABLET 50MG 3061319 CPT outpatient 0.21 0.21 0.21 0.21 NF-CHLORTHALIDONE AVPAK ORAL TABLET 25MG 3061320 CPT outpatient 0.28 0.28 0.28 0.28 NF-CHLORTHALIDONE ORAL TABLET 25MG 3061321 CPT outpatient 0.14 0.14 0.14 0.14 CKMB 4000012 CPT outpatient 350 350 350 350 ISTAT CHEM8+ 4000013 CPT outpatient 500 500 500 500 ISTAT TCO2 4000014 CPT outpatient 100 100 100 100 LIVER PANEL 4000015 CPT outpatient 400 400 400 400 WHOLE BLOOD GLUCOSE 4000016 CPT outpatient 75 75 75 75 ISTAT HEMATOCRIT 4000017 CPT outpatient 100 100 100 100 MORPHOLOGY EVALUATION (SMEAR) BLOOD 4000018 CPT outpatient 250 250 250 250 TEST ITEM 4000019 CPT outpatient 500 500 500 500 UREA NITROGEN 24-HOUR URINE 4000020 CPT outpatient 2.9 2.9 2.9 2.9 "CHLORIDE, 24 HR URINE" 4000021 CPT outpatient 2.9 2.9 2.9 2.9 COMPLEMENT C2 4000022 CPT outpatient 6.05 6.05 6.05 6.05 CARL MUTATION ANALYSIS 4000070 CPT outpatient 350 350 350 350 COMPLEMENT C3 SERUM 4000071 CPT outpatient 4.27 4.27 4.27 4.27 JAK2 V617F QUANTITATIVE 4000072 CPT outpatient 450 450 450 450 MYCOPLASMA PNEU IGG 4000073 CPT outpatient 13.51 13.51 13.51 13.51 PHLEBOTOMY 4036415 CPT outpatient 90 90 90 90 BLOOD TRANSFUSION SERVICE 4036430 CPT outpatient 250 250 250 250 BASIC METABOLIC PANEL 4080048 CPT outpatient 500 500 500 500 ELECTROLYTE PANEL SERUM 4080051 CPT outpatient 200 200 200 200 COMP METABOLIC PANEL CMP 4080053 CPT outpatient 750 750 750 750 LIPID PANEL 4080061 CPT outpatient 400 400 400 400 RENAL FUNCTION PANEL 4080069 CPT outpatient 400 400 400 400 HEPATIC FUNCTION PANEL 4080076 CPT outpatient 400 400 400 400 ISTAT ELECTROLYTE PANEL 4080151 CPT outpatient 200 200 200 200 VANCOMYCIN TROUGH 4080202 CPT outpatient 150 150 150 150 URINE MICROSCOPY ONLY 4081015 CPT outpatient 40 40 40 40 POTASSIUM SERUM 4081132 CPT outpatient 90 90 90 90 DILANTIN (PHENYTOIN) 4081185 CPT outpatient 250 250 250 250 VANCOMYCIN PEAK 4081200 CPT outpatient 150 150 150 150 VANCOMYCIN RANDOM 4081201 CPT outpatient 150 150 150 150 BILIRUBIM TOTAL 4082247 CPT outpatient 90 90 90 90 BILIRUBIN DIRECT 4082248 CPT outpatient 90 90 90 90 AMYLASE SERUM 4082250 CPT outpatient 110 110 110 110 OCCULT BLOOD SOURCE FECAL 4082270 CPT outpatient 120 120 120 120 CARBON DIOXIDE CO2 4082374 CPT outpatient 90 90 90 90 CREATINE KINASE CK TOTAL 4082551 CPT outpatient 90 90 90 90 CREAT KINASE MB FRACTION CKMB 4082554 CPT outpatient 350 350 350 350 ISTAT BUN/CREATININE 4082565 CPT outpatient 100 100 100 100 CREATININE SERUM 4082566 CPT outpatient 90 90 90 90 ISTAT PH PC02 TC02 HC03 BEECF S02 4082813 CPT outpatient 1070 1070 1070 1070 PH PCO2 TCO2 HCO3 BEECF SO2 4082823 CPT outpatient 1070 1070 1070 1070 GLUCOSE FASTING 4082946 CPT outpatient 90 90 90 90 ISTAT GLUCOSE 4082949 CPT outpatient 100 100 100 100 CHLORIDE 4083435 CPT outpatient 90 90 90 90 CHOLESTEROL 4083465 CPT outpatient 110 110 110 110 HDL HIGH DENSITY LIPOPROTEIN 4083718 CPT outpatient 120 120 120 120 LDL 4083722 CPT outpatient 120 120 120 120 MAGNESIUM 4083735 CPT outpatient 110 110 110 110 PHOSPHORUS 4084100 CPT outpatient 110 110 110 110 ISTAT POTASSIUM 4084132 CPT outpatient 100 100 100 100 ALK PHOSPHATASE 4084175 CPT outpatient 90 90 90 90 PREALBUMIN 4084202 CPT outpatient 200 200 200 200 TOTAL PROTEIN 4084255 CPT outpatient 90 90 90 90 SODIUM SERUM 4084295 CPT outpatient 90 90 90 90 SGOT (AST) 4084450 CPT outpatient 110 110 110 110 SGPT (ALT) 4084460 CPT outpatient 110 110 110 110 TRIGLYCERIDE 4084478 CPT outpatient 110 110 110 110 BUN 4084520 CPT outpatient 90 90 90 90 PREGNANCY TESTING URINE 4084704 CPT outpatient 75 75 75 75 BNP 4084880 CPT outpatient 350 350 350 350 CBC MANUAL DIFF 4085007 CPT outpatient 200 200 200 200 HEMATOCRIT 4085014 CPT outpatient 100 100 100 100 HEMOGLOBIN 4085018 CPT outpatient 100 100 100 100 HEMOGRAM 4085027 CPT outpatient 250 250 250 250 PLATELET COUNT 4085149 CPT outpatient 100 100 100 100 TROPONIN I 4085484 CPT outpatient 300 300 300 300 SED RATE ESR 4085651 CPT outpatient 200 200 200 200 PT INR 4086610 CPT outpatient 250 250 250 250 PROTHROMBIN PT REF 4086611 CPT outpatient 30 30 30 30 PTT 4086730 CPT outpatient 250 250 250 250 ANTIBODY SCREEN 4086853 CPT outpatient 150 150 150 150 AUTOLOGOUS UNIT 4086890 CPT outpatient 400 400 400 400 RH TYPING 4086901 CPT outpatient 72.5 72.5 72.5 72.5 CROSSMATCH AHG 4086920 CPT outpatient 250 250 250 250 THAWING PLASMA 4086921 CPT outpatient 40.89 40.89 40.89 40.89 VRE/MRSA SCREEN 4087081 CPT outpatient 151 151 151 151 LDH 4087082 CPT outpatient 110 110 110 110 MRSA 4087182 CPT outpatient 200 200 200 200 DIGOXIN 4087282 CPT outpatient 250 250 250 250 CLOSTRIDIUM DIFFICILE TOX AND AG 4087324 CPT outpatient 150 150 150 150 DIPSTICK CHARGE 4087382 CPT outpatient 120 120 120 120 COVID AG DIAGNOSTIC TEST 4087426 CPT outpatient 100 100 100 100 CALCIUM 4087482 CPT outpatient 90 90 90 90 GLUCOSE 4087582 CPT outpatient 90 90 90 90 ALBUMIN 4088082 CPT outpatient 90 90 90 90 BB FRESH FROZEN PLASMA 4089017 CPT outpatient 65 65 65 65 HEMOGRAM CHARGE 4089018 CPT outpatient 250 250 250 250 CULTURE GT SITE 4100002 CPT outpatient 16.5 16.5 16.5 16.5 ABDOMINAL FLUID CYTOLOGY 4100019 CPT outpatient 50 50 50 50 ACUTE HEPATITIS PROFILE 4100020 CPT outpatient 19.33 19.33 19.33 19.33 ADENOSINE DEAMINASE 4100021 CPT outpatient 45 45 45 45 AFB ID BY DNA PROBE 4100022 CPT outpatient 109.75 109.75 109.75 109.75 ALBUMIN BODY FLUID 4100023 CPT outpatient 2.9 2.9 2.9 2.9 ALDOSTERONE SERUM 4100024 CPT outpatient 18.69 18.69 18.69 18.69 AMIKACIN RANDOM 4100025 CPT outpatient 13.35 13.35 13.35 13.35 AMIKACIN TROUGH 4100026 CPT outpatient 13.35 13.35 13.35 13.35 ANTIFUNGAL AST 9 DRUGS 4100028 CPT outpatient 1507.28 1507.28 1507.28 1507.28 ASPERGILLUS AG 4100030 CPT outpatient 82.78 82.78 82.78 82.78 REF BASIC METABOLIC PANEL 4100031 CPT outpatient 9.4 9.4 9.4 9.4 CULTURE BODY FLUID 4100032 CPT outpatient 13.75 13.75 13.75 13.75 BRONCHIAL WASHING CULTURE 4100033 CPT outpatient 25.49 25.49 25.49 25.49 CALCIUM RANDOM URINE 4100034 CPT outpatient 2.9 2.9 2.9 2.9 CALCIUM IONIZED 4100035 CPT outpatient 8.01 8.01 8.01 8.01 REF CBC WITH DIFF 4100036 CPT outpatient 3.43 3.43 3.43 3.43 CELL COUNT SEROUS FLUID 4100037 CPT outpatient 33.25 33.25 33.25 33.25 CERULOPLASMIN 4100038 CPT outpatient 5.11 5.11 5.11 5.11 COCCIDIOIDES AG QUANT 4100039 CPT outpatient 107 107 107 107 CRE RECTAL SCREEN 4100040 CPT outpatient 48 48 48 48 CULTURE LOWER RESPIRATORY 4100041 CPT outpatient 9.43 9.43 9.43 9.43 CULTURE TISSUE 4100042 CPT outpatient 63.25 63.25 63.25 63.25 DRUG SCEEN WITH CONFIRMATION 4100044 CPT outpatient 51.9 51.9 51.9 51.9 FUNGITELL BETA-D GLU 4100046 CPT outpatient 30 30 30 30 REF BMP 4100047 CPT outpatient 9.4 9.4 9.4 9.4 MAGNESIUM REF 4100049 CPT outpatient 9.36 9.36 9.36 9.36 MUMPS AB IG 4100050 CPT outpatient 9.51 9.51 9.51 9.51 MYOGLOBIN SERUM 4100051 CPT outpatient 9.79 9.79 9.79 9.79 PANEL ENZYMES REF 4100052 CPT outpatient 100 100 100 100 PLATELET ANTIBODY SCREEN 4100053 CPT outpatient 63.47 63.47 63.47 63.47 PLEURAL FLUID CYTOLOGY 4100054 CPT outpatient 25.49 25.49 25.49 25.49 POTASSIUM 24 HRS URINE 4100055 CPT outpatient 2.9 2.9 2.9 2.9 PTT REF 4100057 CPT outpatient 6.67 6.67 6.67 6.67 SODIUM 24 HRS 4100058 CPT outpatient 2.9 2.9 2.9 2.9 SUS ANTI AERO BACT CULTURE 4100059 CPT outpatient 89.25 89.25 89.25 89.25 THYROID ANTIBODIES 4100061 CPT outpatient 6 6 6 6 TOBRAMYCIN TROUGH 4100064 CPT outpatient 14.58 14.58 14.58 14.58 TRIGLYCERIDES FLUID 4100065 CPT outpatient 2.9 2.9 2.9 2.9 UREA NITROGEN URINE 4100067 CPT outpatient 2.9 2.9 2.9 2.9 VARICELLA-ZOSTER AB 4100068 CPT outpatient 16.02 16.02 16.02 16.02 VORICONAZOLE SERUM 4100069 CPT outpatient 166.46 166.46 166.46 166.46 RETICULOCYTE SEPARATION 4100075 CPT outpatient 75 75 75 75 LDH FLUID 4100156 CPT outpatient 2.9 2.9 2.9 2.9 PHENOBARBITAL 4100184 CPT outpatient 12.81 12.81 12.81 12.81 THEOPHYLLINE 4100198 CPT outpatient 11.66 11.66 11.66 11.66 DECALCIFICATION 4101000 CPT outpatient 23.25 23.25 23.25 23.25 LDH REF 4101115 CPT outpatient 2.9 2.9 2.9 2.9 "COPPER, SERUM OR PLASMA" 4101147 CPT outpatient 16.02 16.02 16.02 16.02 T4-FREE 4101305 CPT outpatient 5.07 5.07 5.07 5.07 HEMOGLOBIN A1C 4101453 CPT outpatient 4 4 4 4 RESPIRATORY PANEL WITH SARS-COV-2 4102020 CPT outpatient 808.75 808.75 808.75 808.75 ACTH PLASMA 4102024 CPT outpatient 23.67 23.67 23.67 23.67 LEVETIRACETAM (KEPPRA) S 4102142 CPT outpatient 19.04 19.04 19.04 19.04 IONIZED CALCIUM 4102330 CPT outpatient 8.01 8.01 8.01 8.01 CEA 4102379 CPT outpatient 7.6 7.6 7.6 7.6 CATECHOLAMINES 4102384 CPT outpatient 26.69 26.69 26.69 26.69 KEPPRA LEVEL 4102542 CPT outpatient 19 19 19 19 ERYTHROPOIETIN SERUM (EPO) 4102688 CPT outpatient 7.41 7.41 7.41 7.41 HEPATITIS PANEL 4102714 CPT outpatient 19.33 19.33 19.33 19.33 FERRITIN 4102729 CPT outpatient 5.35 5.35 5.35 5.35 FOLATE 4102747 CPT outpatient 5.07 5.07 5.07 5.07 IMMUNOGLOBULIN - G 4102784 CPT outpatient 4.67 4.67 4.67 4.67 IMMUNOGLOB-E 4102785 CPT outpatient 6.76 6.76 6.76 6.76 IGM IMMUNOGLOBULIN M QUATITATIVE SERUM 4102786 CPT outpatient 4.67 4.67 4.67 4.67 GGT 4102978 CPT outpatient 2.9 2.9 2.9 2.9 HAPTOGLOBIN 4103010 CPT outpatient 6.9 6.9 6.9 6.9 PROTEIN TOTAL QN 24 HR URINE COLLECTION 4103277 CPT outpatient 3.38 3.38 3.38 3.38 OSMOLALITY URINE 4103443 CPT outpatient 5.57 5.57 5.57 5.57 CREATINE 24 HR URINE COLLECTION 4103475 CPT outpatient 4 4 4 4 MITOCHONDRIAL (M2) ANTIBODY 4103516 CPT outpatient 8.89 8.89 8.89 8.89 ACETYLCHOLENE 4103519 CPT outpatient 138 138 138 138 IRON 4103540 CPT outpatient 2.9 2.9 2.9 2.9 HISTOPLASMA URINE 4103560 CPT outpatient 86.75 86.75 86.75 86.75 LACTIC ACID PLASMA 4103605 CPT outpatient 9.23 9.23 9.23 9.23 LACTATE (LD) (LDH) ENZYME 4103615 CPT outpatient 11.62 11.62 11.62 11.62 LIPASE 4103690 CPT outpatient 3.78 3.78 3.78 3.78 OSMOLALITY SERUM 4103930 CPT outpatient 5.34 5.34 5.34 5.34 PTH-INTACT 4103970 CPT outpatient 5.82 5.82 5.82 5.82 POTASSIUM URINE 4104133 CPT outpatient 2.9 2.9 2.9 2.9 ASSAY OF PROLACTIN 4104146 CPT outpatient 7.6 7.6 7.6 7.6 PROSTATE SPECIFIC ANTIGEN 4104153 CPT outpatient 5.07 5.07 5.07 5.07 SODIUM-URINE 4104302 CPT outpatient 2.9 2.9 2.9 2.9 TESTOSTERONE 4104403 CPT outpatient 6.76 6.76 6.76 6.76 THYROGLOBULIN QUANTITATIVE 4104432 CPT outpatient 6.64 6.64 6.64 6.64 T4-TOTAL 4104436 CPT outpatient 3.72 3.72 3.72 3.72 T3-UPTAKE 4104479 CPT outpatient 3.38 3.38 3.38 3.38 TRIODOTHYRONINE 4104480 CPT outpatient 6.76 6.76 6.76 6.76 T3 FREE SERUM 4104481 CPT outpatient 5.07 5.07 5.07 5.07 RETICULOCYTE COUNT 4105045 CPT outpatient 3.7 3.7 3.7 3.7 RETICULOCYTE COUNT 4105280 CPT outpatient 3.7 3.7 3.7 3.7 PROTIME MIXING STUDY 4105610 CPT outpatient 65.56 65.56 65.56 65.56 CELL CT SYNOVIAL WO 4105996 CPT outpatient 122.25 122.25 122.25 122.25 RA RHEUMATOID ARTHRITIS 4106431 CPT outpatient 4.45 4.45 4.45 4.45 STRONGYLOIDES AB IGG 4106682 CPT outpatient 36.89 36.89 36.89 36.89 HEPATITIS B CORE AB 4106705 CPT outpatient 5.4 5.4 5.4 5.4 HEPATITIS B SURFACE ANTIBODY 4106706 CPT outpatient 3.38 3.38 3.38 3.38 HEPATITIS A ANTIBODY IGM 4106709 CPT outpatient 4.73 4.73 4.73 4.73 SARS-COVZ ANTIBODY IGG/IGM 4106769 CPT outpatient 84.26 84.26 84.26 84.26 SERUM SCREEN X 2 4106852 CPT outpatient 90 90 90 90 BB ABO TYPING / RH 4106900 CPT outpatient 75 75 75 75 RH PHENOTYPE 4106906 CPT outpatient 84 84 84 84 STOOL CULTURE 4107045 CPT outpatient 21.9 21.9 21.9 21.9 CULTURE AEROBIC URINE 4107086 CPT outpatient 12.31 12.31 12.31 12.31 AFB (2 OF 3) SMEAR 4107116 CPT outpatient 30.88 30.88 30.88 30.88 PRIMARY SOURCE SMEAR PROCEDURES 4107178 CPT outpatient 3 3 3 3 MIC 1 DRUG 4107186 CPT outpatient 7.5 7.5 7.5 7.5 HEPATITIS B SURFACE ANTIGEN 4107340 CPT outpatient 3.38 3.38 3.38 3.38 HIV-1 AB (ELISA) 4107389 CPT outpatient 9 9 9 9 HCV RT-PCR QUANTITATIVE 4107522 CPT outpatient 121.75 121.75 121.75 121.75 CAIRETICULIN (CALR)MUTATION ANALYSIS 4108121 CPT outpatient 350 350 350 350 SURGICAL PATH - 1ST SITE 4108305 CPT outpatient 55.26 55.26 55.26 55.26 SURGICAL PATHOLOGY 4108307 CPT outpatient 260.5 260.5 260.5 260.5 SURGICAL PATH - 4TH SITE 4108311 CPT outpatient 80.59 80.59 80.59 80.59 COMPLEMENT C4 SERUM 4108616 CPT outpatient 4.27 4.27 4.27 4.27 STAT-PROCEDURE DELIVERY OR PICK UP 4109199 CPT outpatient 100 100 100 100 PROTEIN BODY FLUID 4109588 CPT outpatient 2.9 2.9 2.9 2.9 HEPATITIS A AB TOTAL 4110047 CPT outpatient 4.73 4.73 4.73 4.73 BCR-ABL1 KDM ANALYSIS (1 OF 5) 4123891 CPT outpatient 16.92 16.92 16.92 16.92 BCR-ABL1 KDM ANALYSIS (2 OF 5) 4123892 CPT outpatient 16.92 16.92 16.92 16.92 BCR-ABL1 KDM ANAL (3 OF 5) INPUT 6 UNITS 4123898 CPT outpatient 70.74 70.74 70.74 70.74 BCR-ABL1 KDM ANAL (4 OF 5) INPUT 4 UNITS 4123902 CPT outpatient 59.91 59.91 59.91 59.91 BCR-ABL1 KDM ANALYSIS (5 OF 5) 4123912 CPT outpatient 16.92 16.92 16.92 16.92 FLOW MARKERS X28 4148912 CPT outpatient 537.53 537.53 537.53 537.53 URINE DRUG SCREEN QUALITATE MULTI 4180100 CPT outpatient 152.5 152.5 152.5 152.5 AMIKACIN PEAK 4180150 CPT outpatient 13.35 13.35 13.35 13.35 CARBAMAZEPINE (TEGRETOL) 4180156 CPT outpatient 12.7 12.7 12.7 12.7 DIGOXIN REF 4180162 CPT outpatient 6.81 6.81 6.81 6.81 VALPROIC ACID (DEPAKOTE) 4180164 CPT outpatient 5.07 5.07 5.07 5.07 GENAMYCIN PEAK 4180171 CPT outpatient 12.68 12.68 12.68 12.68 GENTAMYCIN RANDOM 4180172 CPT outpatient 12.68 12.68 12.68 12.68 GENTAMYCIN TROUGH 4180173 CPT outpatient 27.91 27.91 27.91 27.91 LITHIUM (ESKALITH) SERUM 4180178 CPT outpatient 5.34 5.34 5.34 5.34 DILANTIN (PHENYTOIN) REF 4180185 CPT outpatient 10.7 10.7 10.7 10.7 TOBRAMYCIN RANDOM 4180200 CPT outpatient 14.58 14.58 14.58 14.58 TOPAMAX 4180201 CPT outpatient 29.59 29.59 29.59 29.59 VANCOMYCIN PEAK REF 4180203 CPT outpatient 12.68 12.68 12.68 12.68 VANCOMYCIN RANDOM REF 4180204 CPT outpatient 12.68 12.68 12.68 12.68 VANCOMYCIN TROUGH REF 4180205 CPT outpatient 12.68 12.68 12.68 12.68 VOLUME MEASUREMENT 4181050 CPT outpatient 22.4 22.4 22.4 22.4 JAC 2 MUTATION ANALYSIS 4181270 CPT outpatient 200 200 200 200 T4 FREE 4181305 CPT outpatient 5.07 5.07 5.07 5.07 PLATELET FUNCTION 4181309 CPT outpatient 63.47 63.47 63.47 63.47 HLA B27 4181374 CPT outpatient 22.82 22.82 22.82 22.82 MICROALB/CREAT RATIO RANDM UR 4182043 CPT outpatient 8.03 8.03 8.03 8.03 ETHANOL ETOH 4182055 CPT outpatient 13.58 13.58 13.58 13.58 AFP SERUM 4182105 CPT outpatient 7.41 7.41 7.41 7.41 AMMONIA (NH3) 4182140 CPT outpatient 9.79 9.79 9.79 9.79 AMYLASE URINE 4182150 CPT outpatient 3.78 3.78 3.78 3.78 GASTRIC OCCULT 4182271 CPT outpatient 21.9 21.9 21.9 21.9 VITAMIN D 25 HYDROXY 4182306 CPT outpatient 10.58 10.58 10.58 10.58 IONIZED CALCIUM 4182330 CPT outpatient 8.01 8.01 8.01 8.01 KIDNEY STONE ANALYSIS 4182360 CPT outpatient 14.35 14.35 14.35 14.35 CHLORIDE REF 4182435 CPT outpatient 2.9 2.9 2.9 2.9 CHLORIDE URINE 4182436 CPT outpatient 2.9 2.9 2.9 2.9 CHOLESTEROL PANEL FASTING 4182465 CPT outpatient 4.76 4.76 4.76 4.76 KEPPRA LEVETORACETAM SERUM 4182491 CPT outpatient 22.84 22.84 22.84 22.84 CORTISOL LEVEL 4182533 CPT outpatient 5.51 5.51 5.51 5.51 KEPPRA LEVEL 4182542 CPT outpatient 19 19 19 19 CK-CREATINE KINASE REF 4182550 CPT outpatient 2.9 2.9 2.9 2.9 CK-MB REF 4182553 CPT outpatient 8.46 8.46 8.46 8.46 CREATININE URINE 4182570 CPT outpatient 4 4 4 4 CREATININE CLEARANCE 4182575 CPT outpatient 7.65 7.65 7.65 7.65 VITAMIN B12 4182607 CPT outpatient 5.17 5.17 5.17 5.17 "VIT D 1,25 DIHYDROXY" 4182652 CPT outpatient 19.04 19.04 19.04 19.04 HEPATITIS PANEL 4182714 CPT outpatient 19.33 19.33 19.33 19.33 RBC FOLATE 4182747 CPT outpatient 14.69 14.69 14.69 14.69 OCCULT BLOOD (GASTRIC) 4182772 CPT outpatient 13.98 13.98 13.98 13.98 IGA IMMUNOGLOBULIN A QUANTITATIVE SERUM 4182783 CPT outpatient 4.67 4.67 4.67 4.67 IMMUNOGLOBULIN G 4182784 CPT outpatient 4.67 4.67 4.67 4.67 IMMUNOGLOB E 4182785 CPT outpatient 6.76 6.76 6.76 6.76 IGM IMMUNOGLOBULIN M QUATITATIVE SERUM 4182786 CPT outpatient 4.67 4.67 4.67 4.67 GASTRIN SERUM 4182941 CPT outpatient 9.35 9.35 9.35 9.35 GLUCOSE BODY FLUID 4182945 CPT outpatient 2.9 2.9 2.9 2.9 GLUCOSE FASTING REF 4182947 CPT outpatient 2.9 2.9 2.9 2.9 HEMOSIDERIN URINE 4182948 CPT outpatient 14.8 14.8 14.8 14.8 FRUCTOSAMINE 4182985 CPT outpatient 5.07 5.07 5.07 5.07 FSH 4183001 CPT outpatient 6.76 6.76 6.76 6.76 GROWTH HORMONE SERUM 4183003 CPT outpatient 8.2 8.2 8.2 8.2 HAPTOGLOBIN 4183010 CPT outpatient 6.9 6.9 6.9 6.9 ASSAY OF HEMOSIDERIN QUAL 4183070 CPT outpatient 14.8 14.8 14.8 14.8 ASSAY OF HEMOSIDERIN QUANT 4183071 CPT outpatient 10.03 10.03 10.03 10.03 URINE OSMOLALITY 4183442 CPT outpatient 5.5 5.5 5.5 5.5 ACTIN SMOOTH MUSCLE AB (ASMA) 4183517 CPT outpatient 8.89 8.89 8.89 8.89 IRON 4183540 CPT outpatient 2.9 2.9 2.9 2.9 TOTAL IRON BINDING CAPACITY 4183550 CPT outpatient 7 7 7 7 HISTOPLASMA URINE 4183560 CPT outpatient 86.75 86.75 86.75 86.75 LACTIC ACID PLASMA 4183605 CPT outpatient 9.23 9.23 9.23 9.23 LACTATE DEHYDROGENASE (LDH) ISOENZYME 4183615 CPT outpatient 11.62 11.62 11.62 11.62 LDH ENZYMES 4183625 CPT outpatient 11.62 11.62 11.62 11.62 LDL REF 4183721 CPT outpatient 6.23 6.23 6.23 6.23 URINE MYOGLOBIN 4183874 CPT outpatient 9.79 9.79 9.79 9.79 REF BNP 4183880 CPT outpatient 49.25 49.25 49.25 49.25 N T PROBNP 4183881 CPT outpatient 77.98 77.98 77.98 77.98 FREE KAP & LAMB LIGHT CHAINS +RATIO QUAN 4183883 CPT outpatient 42.32 42.32 42.32 42.32 JAK2 V617F MUT ANAL (1 OF 4) 4183891 CPT outpatient 200 200 200 200 JAK2 V617F MUT ANAL (2 OF 4) 4183900 CPT outpatient 200 200 200 200 JAK2 V617F MUT ANAL (3 OF 4) 4183909 CPT outpatient 200 200 200 200 JAK2 V617F MUT ANAL (4 OF 4) 4183912 CPT outpatient 200 200 200 200 METHYLMALONIC ACID SERUM 4183921 CPT outpatient 21.16 21.16 21.16 21.16 OSMOLALITY SERUM 4183930 CPT outpatient 5.34 5.34 5.34 5.34 PTH INTACT 4183970 CPT outpatient 5.82 5.82 5.82 5.82 PLEURAL FLUID PH STOOL 4183986 CPT outpatient 8.54 8.54 8.54 8.54 ALKALINE PHOSPHATASE ISOENZYMES REF 4184075 CPT outpatient 4.89 4.89 4.89 4.89 POTASSIUM URINE RANDOM 4184133 CPT outpatient 2.9 2.9 2.9 2.9 PREALBUMIN REF 4184134 CPT outpatient 5.9 5.9 5.9 5.9 PROCALCITONIN 4184145 CPT outpatient 90 90 90 90 PROLACTIN 4184146 CPT outpatient 7.6 7.6 7.6 7.6 PROSTATE SPECIFIC ANTIGEN 4184153 CPT outpatient 5.07 5.07 5.07 5.07 PROTEIN ELECTROPHORESIS SERUM REF 4184155 CPT outpatient 4 4 4 4 TOTAL PROTEIN URINE 4184156 CPT outpatient 3.38 3.38 3.38 3.38 BODY FLUID TOTAL PROTEIN 4184157 CPT outpatient 2.9 2.9 2.9 2.9 UPEP PROTEIN ELECTROPHORESIS RANDOM URIN 4184166 CPT outpatient 7.41 7.41 7.41 7.41 ALK PHOSPHATASE REF 4184175 CPT outpatient 4 4 4 4 TOTAL PROTEIN REF 4184255 CPT outpatient 4 4 4 4 SODIUM URINE 4184302 CPT outpatient 2.9 2.9 2.9 2.9 URINE SODIUM 4184303 CPT outpatient 2.9 2.9 2.9 2.9 T4 TOTAL 4184436 CPT outpatient 3.78 3.78 3.78 3.78 TSH THYROID STIMULATING HORMONE 4184443 CPT outpatient 5.5 5.5 5.5 5.5 TRANSFERRIN 4184466 CPT outpatient 6.23 6.23 6.23 6.23 T3 UPTAKE 4184479 CPT outpatient 3.38 3.38 3.38 3.38 TRIIODOTHYRONINE T3 4184480 CPT outpatient 6.76 6.76 6.76 6.76 T3 FREE SERUM 4184481 CPT outpatient 5.07 5.07 5.07 5.07 REF TROPONIN 4184484 CPT outpatient 79.18 79.18 79.18 79.18 URIC ACID 4184550 CPT outpatient 2.9 2.9 2.9 2.9 URIC ACID URINE 4184560 CPT outpatient 2.9 2.9 2.9 2.9 ANTIDIURETIC HORMONE (ADH) 4184588 CPT outpatient 29.65 29.65 29.65 29.65 VOLATILES URINE 4184600 CPT outpatient 13.58 13.58 13.58 13.58 BETA HCG 4184702 CPT outpatient 8.01 8.01 8.01 8.01 PREGNANCY TESTING SERUM 4184705 CPT outpatient 32.28 32.28 32.28 32.28 PLATELET MANUAL 4185032 CPT outpatient 304.5 304.5 304.5 304.5 LEUKOCYTE CELL COUNT 4185048 CPT outpatient 3.06 3.06 3.06 3.06 DIC DISSEMENIATED INTRAVASCULAR COAG 1 4185049 CPT outpatient 3.41 3.41 3.41 3.41 RETICULATED PLATELET ASSAY 4185055 CPT outpatient 38.35 38.35 38.35 38.35 FACTOR 8 ACTIVITY 4185240 CPT outpatient 65.56 65.56 65.56 65.56 FACTOR XII ACTIVITY 4185280 CPT outpatient 250 250 250 250 FDP 4185362 CPT outpatient 13.75 13.75 13.75 13.75 FIBRIN MONOMER 4185366 CPT outpatient 76.17 76.17 76.17 76.17 DIC DISSEMENIATED INTRAVASCULAR COAG 3 4185377 CPT outpatient 14.57 14.57 14.57 14.57 D-DIMER 4185379 CPT outpatient 19.58 19.58 19.58 19.58 FIBRINOGEN 4185384 CPT outpatient 4.86 4.86 4.86 4.86 DIC DISSEMENIATED INTRAVASCULAR COAG 4 4185385 CPT outpatient 12.17 12.17 12.17 12.17 HEPARIN ANTI-XA 4185520 CPT outpatient 50 50 50 50 LAP SCORE 4185540 CPT outpatient 36.96 36.96 36.96 36.96 PT MIXING STUDY REF 4185610 CPT outpatient 30 30 30 30 DIC DISSEMENIATED INTRAVASCULAR COAG 5 4185611 CPT outpatient 5.62 5.62 5.62 5.62 LUPUS ANTI-COAGULANT 1 4185613 CPT outpatient 603.81 603.81 603.81 603.81 REPTILASE TIME 4185635 CPT outpatient 110 110 110 110 THROMBIN TIME 4185670 CPT outpatient 14.21 14.21 14.21 14.21 PTT MIXING STUDY 4185730 CPT outpatient 185.17 185.17 185.17 185.17 DIC DISSEMENIATED INTRAVASCULAR COAG 6 4185731 CPT outpatient 8.6 8.6 8.6 8.6 LUPUS ANTI-COAGULANT 2 4185732 CPT outpatient 603.81 603.81 603.81 603.81 HEPARIN ASSOCIATED AB 4186022 CPT outpatient 55 55 55 55 ANA-ANTINUCLEAR ANTIBODIES 4186038 CPT outpatient 4.23 4.23 4.23 4.23 ANTISTREPTOLYSIN O (ASO) ANTIBODIES 4186060 CPT outpatient 31.38 31.38 31.38 31.38 PT & INR 4186100 CPT outpatient 5.56 5.56 5.56 5.56 C REACTIVE PROTEINE 4186140 CPT outpatient 5.07 5.07 5.07 5.07 ANTICARDIOLIPIN ANTIBODIES (ACA) 4186147 CPT outpatient 10.98 10.98 10.98 10.98 COMPLEMENT C3 SERUM 4186160 CPT outpatient 4.27 4.27 4.27 4.27 ESTERASE INHIBITOR 4186161 CPT outpatient 75.39 75.39 75.39 75.39 COCCI ANTIGEN 4186171 CPT outpatient 107 107 107 107 CCP ANTIBODY 4186200 CPT outpatient 11.64 11.64 11.64 11.64 ANTI-DS DNA (DOUBLE STRANDED) ANTIBODIES 4186225 CPT outpatient 7.41 7.41 7.41 7.41 SJOGRENS ANTI SS-A/SSB 4186235 CPT outpatient 15.7 15.7 15.7 15.7 ANTIPARIETAL CELL ANTIB ANCA 2 PUT 2 UNI 4186256 CPT outpatient 34.1 34.1 34.1 34.1 CA 15-3 4186300 CPT outpatient 18.37 18.37 18.37 18.37 CA 19-9 (CANCER ANTIGEN 19-9) 4186301 CPT outpatient 10.58 10.58 10.58 10.58 CANCER ANTIGEN 125 4186304 CPT outpatient 8.46 8.46 8.46 8.46 CA-27.29 4186316 CPT outpatient 47.61 47.61 47.61 47.61 IMMUNO ELECTROPHORESIS (IEP) 4186320 CPT outpatient 38.28 38.28 38.28 38.28 IMMUNE COMPLEXES CLQ BINDING 4186332 CPT outpatient 30.36 30.36 30.36 30.36 IFE IMMUNOFIXATION URINE 4186335 CPT outpatient 29.62 29.62 29.62 29.62 INTRINSIC FACTOR ANTIBODY-SERUM 4186340 CPT outpatient 10.68 10.68 10.68 10.68 LEUKOCYTE PHAGOCYTOSIS 4186344 CPT outpatient 33.72 33.72 33.72 33.72 CD4 CD8 RATIO PROFILE T CELL ABS COUNT 4186360 CPT outpatient 73.88 73.88 73.88 73.88 ANTIBODY ID PANEL 4186370 CPT outpatient 90 90 90 90 THYROIDPEROXIDASE ANTIBODIES 4186376 CPT outpatient 6 6 6 6 RHEUMATOID ARTHRITIS (RA) FACTOR 4186431 CPT outpatient 24.39 24.39 24.39 24.39 QUANTIFERON TB GOLD 4186480 CPT outpatient 55 55 55 55 RPR 4186592 CPT outpatient 3.16 3.16 3.16 3.16 RAPID PLASMA REAGIN (RPR) 4186593 CPT outpatient 3.16 3.16 3.16 3.16 COCCIDIOIDES ANTIBODY COMPLEMENT FIX CSF 4186635 CPT outpatient 40 40 40 40 H PYLORI IGG 4186677 CPT outpatient 33.37 33.37 33.37 33.37 STRONGYLOIDES AB IGG 4186682 CPT outpatient 36.89 36.89 36.89 36.89 HEPATITIS B CORE AB 4186705 CPT outpatient 5.4 5.4 5.4 5.4 HEPATITIS B SURFACE ANTIBODY 4186706 CPT outpatient 3.38 3.38 3.38 3.38 HEPATITIS A ANTIBODY IGM 4186709 CPT outpatient 4.73 4.73 4.73 4.73 INFLUENZA A & B 4186710 CPT outpatient 230 230 230 230 SARS-COVZ ANTIBODY IGG/IGM 4186769 CPT outpatient 84.26 84.26 84.26 84.26 HCV HEPATITIS C VIRUS ANTIBODY 4186803 CPT outpatient 5.82 5.82 5.82 5.82 HEPATITIS C VIRUS ANTIBODY 4186804 CPT outpatient 6 6 6 6 INDIRECT COOMBS 4186850 CPT outpatient 5.05 5.05 5.05 5.05 SERUM SCREEN X 2 4186852 CPT outpatient 90 90 90 90 ELUTION 4186860 CPT outpatient 84 84 84 84 ANTIBODY ID PANEL X2-X3 4186870 CPT outpatient 90 90 90 90 DAT-ANTI-1GG-POLY X 3 4186880 CPT outpatient 14 14 14 14 DIRECT COOMBS REF 4186881 CPT outpatient 23.1 23.1 23.1 23.1 ANTIBODY TITER 4186886 CPT outpatient 180 180 180 180 ABO TYPING / RH REF 4186900 CPT outpatient 24 24 24 24 ANTIGEN TYPING CLASS 1 4186902 CPT outpatient 195 195 195 195 ANTIGEN TYPING CLASS 2 4186903 CPT outpatient 115 115 115 115 RH TYPING REF 4186904 CPT outpatient 12.81 12.81 12.81 12.81 PHENOTYPE 4186905 CPT outpatient 31 31 31 31 RH PHENOTYPE 4186906 CPT outpatient 84 84 84 84 BLOOD TYPE 4186912 CPT outpatient 72.5 72.5 72.5 72.5 ENZYME TRETMT OF PANE 4186971 CPT outpatient 100 100 100 100 DILUTION SERUM FOR TITRA 4186976 CPT outpatient 36 36 36 36 AFB (1 OF 3) SMEAR 4187015 CPT outpatient 30.88 30.88 30.88 30.88 VRE 4187033 CPT outpatient 35 35 35 35 CULTURE BLOOD 4187040 CPT outpatient 11 11 11 11 CULTURE STOOL 4187045 CPT outpatient 21.9 21.9 21.9 21.9 CULTURE AEROBIC 4187070 CPT outpatient 6 6 6 6 CULTURE THROAT 4187073 CPT outpatient 37.02 37.02 37.02 37.02 CULTURE ANAEROBIC 4187075 CPT outpatient 14 14 14 14 ID ANAEROB 4187076 CPT outpatient 12.81 12.81 12.81 12.81 ID ORGANISM 4187077 CPT outpatient 15.76 15.76 15.76 15.76 CULTURE WOUND SOURCE 4187079 CPT outpatient 15.76 15.76 15.76 15.76 CULTURE URINE 4187086 CPT outpatient 12.31 12.31 12.31 12.31 CULTURE FUNGUS 4187101 CPT outpatient 17.19 17.19 17.19 17.19 CULTURE FUNGAL WITH SMEAR 4187102 CPT outpatient 17.19 17.19 17.19 17.19 CULTURE FUNGAL BLOOD 4187103 CPT outpatient 17.19 17.19 17.19 17.19 FUNGAL ID 4187106 CPT outpatient 12.81 12.81 12.81 12.81 ORGANISM ID 4187176 CPT outpatient 36.01 36.01 36.01 36.01 OVA + PARASITE EXAM 4187177 CPT outpatient 3.9 3.9 3.9 3.9 ANTIBIOTIC MIC ETEST (15) 4187181 CPT outpatient 6.99 6.99 6.99 6.99 MIC 1 DRUG 4187186 CPT outpatient 11.6 11.6 11.6 11.6 SUSCEPTIBILITY 4187187 CPT outpatient 7.5 7.5 7.5 7.5 GRAM STAIN 4187205 CPT outpatient 4.99 4.99 4.99 4.99 AFB (3 OF 3) SMEAR 4187206 CPT outpatient 30.88 30.88 30.88 30.88 CULTURE SPUTUM 4187207 CPT outpatient 9.43 9.43 9.43 9.43 WET MOUNT 4187211 CPT outpatient 18.33 18.33 18.33 18.33 KOH PREP 4187213 CPT outpatient 7.4 7.4 7.4 7.4 SMEAR 4187216 CPT outpatient 4.52 4.52 4.52 4.52 SCABIES WET MOUNT 4187221 CPT outpatient 150 150 150 150 CULTURE VIRAL GEN 4187252 CPT outpatient 39.89 39.89 39.89 39.89 SUSEP ANAER SUS HODGE TEST 4187286 CPT outpatient 20.03 20.03 20.03 20.03 ASPERGILLUS ALLOTOMANNAN ANTIGEN 4187305 CPT outpatient 82.8 82.8 82.8 82.8 HELICO PYLO STOOL 4187338 CPT outpatient 33.37 33.37 33.37 33.37 HEPATITIS B SURFACE ANTIGEN 4187340 CPT outpatient 3.38 3.38 3.38 3.38 HIV-1 AB (ELISA) 4187389 CPT outpatient 9 9 9 9 HIV-1 AG EIA 4187390 CPT outpatient 33.47 33.47 33.47 33.47 FUNGTELL 4187449 CPT outpatient 85 85 85 85 CANDIDA AURIS PCR 4187481 CPT outpatient 150 150 150 150 CHLAMYDIA 4187491 CPT outpatient 17.99 17.99 17.99 17.99 CLOSTRIDIUM DIFICIL DNA PROBE 4187493 CPT outpatient 125 125 125 125 HEPATITIS C VIRUS (HCV) RNA PCR QUAL 4187521 CPT outpatient 121.75 121.75 121.75 121.75 HCV RT-PCR QUANTITATIVE 4187522 CPT outpatient 121.75 121.75 121.75 121.75 HSV TYPES 1/2 DNA PCR 4187529 CPT outpatient 324.98 324.98 324.98 324.98 MTB NAA W OUT AFB CULTURE 4187556 CPT outpatient 109.75 109.75 109.75 109.75 GONOCOCCUS 4187591 CPT outpatient 27.47 27.47 27.47 27.47 COVID PCR 4187635 CPT outpatient 50 50 50 50 CRYPTOCOCCUS ANTIGEN SERUM 4187899 CPT outpatient 9.72 9.72 9.72 9.72 HCV GENOTYPING NON REFLEX 4187902 CPT outpatient 190 190 190 190 SPUTUM CYTOLOGY 4188108 CPT outpatient 54.18 54.18 54.18 54.18 CYTOLOGY DNA PLOIDY REFLEX PROFILE 4188112 CPT outpatient 25.11 25.11 25.11 25.11 FLOW CYTOMETRY FIRST MARKER 4188184 CPT outpatient 289.53 289.53 289.53 289.53 FLOW CYTOMETRY EA ADDL MARKER 4188185 CPT outpatient 172.98 172.98 172.98 172.98 FLOW CYTOMETRY INTERPRET 28 MARKERS 4188187 CPT outpatient 220.2 220.2 220.2 220.2 FLOW CYTOMETRY INTERPRET 915 MARKERS 4188188 CPT outpatient 271.29 271.29 271.29 271.29 FLOW CYTOMETRY INTERP 16 OR MORE MARKERS 4188189 CPT outpatient 340.68 340.68 340.68 340.68 TRILEPTAL 4188254 CPT outpatient 9.85 9.85 9.85 9.85 SURGICAL PATHOLOGY 4188300 CPT outpatient 19.08 19.08 19.08 19.08 SURGICAL PATH - 1ST SITE 4188305 CPT outpatient 55.26 55.26 55.26 55.26 SURGICAL PATH - 3RD SITE 4188310 CPT outpatient 80.59 80.59 80.59 80.59 DECALCIFICATION 1ST 4188311 CPT outpatient 23.25 23.25 23.25 23.25 PCP STAIN 4188312 CPT outpatient 95.53 95.53 95.53 95.53 SURGICAL PATH - 5TH SITE 4188313 CPT outpatient 111 111 111 111 SURGICAL PATH - 6TH SITE 4188314 CPT outpatient 111 111 111 111 SURGICAL PATH - 7TH SITE 4188315 CPT outpatient 111 111 111 111 SURGICAL PATH - 8TH SITE 4188316 CPT outpatient 148 148 148 148 SURGICAL PATH - 4TH SITE 83805 4188321 CPT outpatient 80.59 80.59 80.59 80.59 SURGICAL PATH - 2ND SITE 4188322 CPT outpatient 54.44 54.44 54.44 54.44 SURGICAL PATH - 4TH SITE 83804 4188324 CPT outpatient 54.44 54.44 54.44 54.44 FREE TESTOSTERONE 4188440 CPT outpatient 14.4 14.4 14.4 14.4 CELL COUNT BODY FLUID 4189051 CPT outpatient 33.25 33.25 33.25 33.25 STOOL WBC 4189055 CPT outpatient 7.39 7.39 7.39 7.39 CRYSTAL EXAM 4189060 CPT outpatient 9.74 9.74 9.74 9.74 WBC STOOL 4189155 CPT outpatient 25 25 25 25 RETICULOCYTE SEPARATION 4190075 CPT outpatient 75 75 75 75 STAT PROCEDURE DELIVERY OR PICK UP 4199199 CPT outpatient 100 100 100 100 CANDIDA AURIS PCR 4199200 CPT outpatient 4.73 4.73 4.73 4.73 BB DIRECT COOMBS 4306880 CPT outpatient 150 150 150 150 BB CRYOPRECIPITATE 4309012 CPT outpatient 60 60 60 60 BB RBC LR 4309016 CPT outpatient 275 275 275 275 PLASMA FRESH FZ PROC/STOR 4309017 CPT outpatient 60 60 60 60 BB PLATELET PHERESIS LR 4309035 CPT outpatient 650 650 650 650 XR 1 VIEW CXR 5001010 CPT outpatient 230.5 230.5 230.5 230.5 XR 2 VIEW CXR 5001020 CPT outpatient 315.8 315.8 315.8 315.8 XR CXR WITH DECUBITUS VIEWS 5001035 CPT outpatient 345 345 345 345 XR RIBS UNILATERAL LEFT 5001102 CPT outpatient 194.8 194.8 194.8 194.8 XR 1 VIEW L SPINE 5002022 CPT outpatient 100.4 100.4 100.4 100.4 XR C SPINE LIMITED 5002040 CPT outpatient 350.9 350.9 350.9 350.9 XR L SPINE LIMITED 5002100 CPT outpatient 315.7 315.7 315.7 315.7 XR PELVIS 5002170 CPT outpatient 300.19 300.19 300.19 300.19 XR CLAVICAL RIGHT 5003001 CPT outpatient 490.2 490.2 490.2 490.2 XR SHOULDER 1 VIEW LEFT 5003022 CPT outpatient 246.1 246.1 246.1 246.1 XR SHOULDER COMPLETE RIGHT 5003031 CPT outpatient 556.5 556.5 556.5 556.5 XR SHOULDER COMPLETE LEFT 5003032 CPT outpatient 556.5 556.5 556.5 556.5 XR HUMERUS RIGHT 5003061 CPT outpatient 431.6 431.6 431.6 431.6 XR HUMERUS BILAT 5003063 CPT outpatient 431.6 431.6 431.6 431.6 XR ELBOW 2 VIEW LEFT 5003071 CPT outpatient 300 300 300 300 XR FOREARM RIGHT 5003091 CPT outpatient 400.2 400.2 400.2 400.2 XR WRIST 2 VIEW RIGHT 5003101 CPT outpatient 261.4 261.4 261.4 261.4 XR WRIST 2 VIEW LEFT 5003102 CPT outpatient 261.4 261.4 261.4 261.4 XR HAND 2 VIEW RIGHT 5003121 CPT outpatient 261.4 261.4 261.4 261.4 XR HAND 2 VIEW LEFT 5003122 CPT outpatient 261.4 261.4 261.4 261.4 XR HAND 2 VIEW BILAT 5003123 CPT outpatient 261.4 261.4 261.4 261.4 XR HAND COMPLETE RIGHT 5003131 CPT outpatient 675 675 675 675 XR HAND COMPLETE LEFT 5003132 CPT outpatient 464 464 464 464 XR HIP 1 VIEW RIGHT 5003501 CPT outpatient 261.4 261.4 261.4 261.4 XR HIP 1 VIEW BILAT 5003503 CPT outpatient 263.4 263.4 263.4 263.4 XR HIP 2 VIEW RIGHT 5003511 CPT outpatient 385 385 385 385 XR HIP 2 VIEW LEFT 5003512 CPT outpatient 385 385 385 385 XR KNEE 2 VIEW RIGHT 5003561 CPT outpatient 520 520 520 520 XR KNEE 2 VIEW LEFT 5003563 CPT outpatient 520 520 520 520 XR KNEE 2 VIEW BILAT 5003566 CPT outpatient 520 520 520 520 XR TIBIA FIBULA RIGHT 5003591 CPT outpatient 489.8 489.8 489.8 489.8 XR TIBIA FIBULA LEFT 5003592 CPT outpatient 489.8 489.8 489.8 489.8 XR ANKLE 2 VIEW RIGHT 5003601 CPT outpatient 530 530 530 530 XR FOOT 2 VIEW RIGHT 5003621 CPT outpatient 502.6 502.6 502.6 502.6 XR FOOT 2 VIEW LEFT 5003622 CPT outpatient 502.6 502.6 502.6 502.6 XR FOOT 2 VIEW BILAT 5003623 CPT outpatient 502.6 502.6 502.6 502.6 XR FOOT COMPLETE LEFT 5003632 CPT outpatient 502.6 502.6 502.6 502.6 US CAROTID 5003880 CPT outpatient 1412.28 1412.28 1412.28 1412.28 US ARTERIAL LOWER EXT LEFT 5003928 CPT outpatient 1375 1375 1375 1375 US ARTERIAL LOWER EXT BILAT 5003929 CPT outpatient 1375 1375 1375 1375 US ARTERIAL UPPER EXT BILAT 5003930 CPT outpatient 1375 1375 1375 1375 US ARTERIAL UPPER EXT RIGHT 5003932 CPT outpatient 1375 1375 1375 1375 US VENOUS LOWER EXT BILAT 5003970 CPT outpatient 1375 1375 1375 1375 US VENOUS UPPER EXT RIGHT 5003974 CPT outpatient 725.5 725.5 725.5 725.5 US VENOUS UPPER EXT BILAT 5003976 CPT outpatient 812.1 812.1 812.1 812.1 XR KUB 5004000 CPT outpatient 275.2 275.2 275.2 275.2 XR ABD SERIES 2 VIEW 5004020 CPT outpatient 425.65 425.65 425.65 425.65 XR SBFT 5004250 CPT outpatient 666.14 666.14 666.14 666.14 US PERCUTANEOUS DRAINAGE 5005989 CPT outpatient 825 825 825 825 XR FLUOROSCOPY CARM 5006000 CPT outpatient 630 630 630 630 US SOFT TISSUE THYROID 5006536 CPT outpatient 985 985 985 985 US THORAX RIGHT 5006605 CPT outpatient 985 985 985 985 US THORAX LEFT 5006606 CPT outpatient 985 985 985 985 US THORAX BILAT 5006607 CPT outpatient 985 985 985 985 US ABDOMEN COMPLETE 5006700 CPT outpatient 1325 1325 1325 1325 US ABDOMEN LIMITED 5006705 CPT outpatient 644.6 644.6 644.6 644.6 US RENAL RETROPERITONEAL 5006770 CPT outpatient 1265 1265 1265 1265 US PELVIC COMPLETE 5006851 CPT outpatient 597.1 597.1 597.1 597.1 US PELVIC LIMITED 5006857 CPT outpatient 845 845 845 845 US SCROTAL 5006870 CPT outpatient 1185 1185 1185 1185 US UPPER EXTREMITY LEFT 5006882 CPT outpatient 293.31 293.31 293.31 293.31 US LOWER EXTREMITY RIGHT 5006884 CPT outpatient 378 378 378 378 US LOWER EXTREMITY LEFT 5006885 CPT outpatient 378 378 378 378 US GUIDENCE NEEDLE PLACEMENT 5006942 CPT outpatient 1298.1 1298.1 1298.1 1298.1 XR FLUOROGUIDE CENTRAL LINE 5007001 CPT outpatient 1798.33 1798.33 1798.33 1798.33 XR NEEDLE LOCALIZATION BY XRAY 5007002 CPT outpatient 350 350 350 350 NM HIDA SCAN 5008223 CPT outpatient 2805 2805 2805 2805 NM GI BLOOD LOSS RBC 5008278 CPT outpatient 3720 3720 3720 3720 NM BONE SCAN WHOLE BODY 5008306 CPT outpatient 1860 1860 1860 1860 NM BONE SCAN 3 PHASE 5008315 CPT outpatient 3424 3424 3424 3424 NM LUNG PERFUSION IMAGING 5008580 CPT outpatient 1635 1635 1635 1635 NM LUNG VENTILATION IMAGING 5008593 CPT outpatient 1995 1995 1995 1995 NM LOC INFLAM PRCSS WHL BDY WBC INDIUM 5008806 CPT outpatient 10575 10575 10575 10575 XR LUNG BIOPSY 5032405 CPT outpatient 1898.25 1898.25 1898.25 1898.25 XR ABDOMEN BIOPSY 5049180 CPT outpatient 1898.25 1898.25 1898.25 1898.25 XR LUMBAR PUNCTURE 5062276 CPT outpatient 1875.71 1875.71 1875.71 1875.71 XR ORBITS R/O FOREIGN BODY 5070030 CPT outpatient 134.1 134.1 134.1 134.1 XR MANDIBLE 5070110 CPT outpatient 450.4 450.4 450.4 450.4 XR MASTOIDS 5070130 CPT outpatient 385.4 385.4 385.4 385.4 XR FACIAL BONES 5070150 CPT outpatient 480.75 480.75 480.75 480.75 XR NASAL BONES 5070160 CPT outpatient 330.8 330.8 330.8 330.8 XR ORBITS COMPLETE 5070200 CPT outpatient 450.4 450.4 450.4 450.4 XR SINUS SERIES 5070220 CPT outpatient 460.5 460.5 460.5 460.5 XR SKULL LIMITED 5070250 CPT outpatient 325.5 325.5 325.5 325.5 XR SKULL COMPLETE 5070260 CPT outpatient 530.7 530.7 530.7 530.7 XR TMJ COMPLETE 5070330 CPT outpatient 435.15 435.15 435.15 435.15 XR NECK SOFT TISSUE 5070360 CPT outpatient 305 305 305 305 XR CXR 2 VIEW WITH LORDOTIC 5071021 CPT outpatient 215.25 215.25 215.25 215.25 XR RIBS UNILATERAL RIGHT 5071101 CPT outpatient 385.2 385.2 385.2 385.2 XR RIBS BILATERAL 5071111 CPT outpatient 425 425 425 425 XR STERNUM 5071120 CPT outpatient 385.05 385.05 385.05 385.05 XR STERNOCLAVICULAR JOINTS 5071130 CPT outpatient 285.25 285.25 285.25 285.25 XR 1 VIEW C SPINE 5072021 CPT outpatient 320.7 320.7 320.7 320.7 XR C SPINE COMPLETE 5072050 CPT outpatient 515.6 515.6 515.6 515.6 XR C SPINE COMPLETE WITH FLEX EXT 5072052 CPT outpatient 565.6 565.6 565.6 565.6 XR SCOLIOSIS STUDY 5072069 CPT outpatient 350.43 350.43 350.43 350.43 XR T SPINE COMPLETE 5072072 CPT outpatient 455.4 455.4 455.4 455.4 XR L SPINE COMPLETE 5072110 CPT outpatient 590.1 590.1 590.1 590.1 XR L SPINE COMPLETE WITH BENDING 5072114 CPT outpatient 653.76 653.76 653.76 653.76 XR L SPINE BENDING VIEWS ONLY 5072120 CPT outpatient 325.9 325.9 325.9 325.9 XR S I JOINTS 5072202 CPT outpatient 345.45 345.45 345.45 345.45 XR SACRUM COCCYX 5072220 CPT outpatient 275.4 275.4 275.4 275.4 XR LUMBAR MYELOGRAM 5072265 CPT outpatient 1550.9 1550.9 1550.9 1550.9 XR CLAVICAL LEFT 5073002 CPT outpatient 490.2 490.2 490.2 490.2 XR CLAVICAL BILAT 5073003 CPT outpatient 490.2 490.2 490.2 490.2 XR SCAPULA RIGHT 5073011 CPT outpatient 354 354 354 354 XR SCAPULA LEFT 5073012 CPT outpatient 354 354 354 354 XR SCAPULA BILAT 5073013 CPT outpatient 354 354 354 354 XR SHOULDER 1 VIEW RIGHT 5073020 CPT outpatient 255.5 255.5 255.5 255.5 XR SHOULDER 1 VIEW BILAT 5073023 CPT outpatient 246.1 246.1 246.1 246.1 XR SHOULDER COMPLETE BILAT 5073033 CPT outpatient 556.5 556.5 556.5 556.5 XR ACROMIO CLAVICULAR JOINTS 5073050 CPT outpatient 332.85 332.85 332.85 332.85 XR HUMERUS LEFT 5073062 CPT outpatient 431.6 431.6 431.6 431.6 XR ELBOW 2 VIEW BILAT 5073070 CPT outpatient 300 300 300 300 XR ELBOW 2 VIEW RIGHT 5073072 CPT outpatient 300 300 300 300 XR ELBOW COMPLETE RIGHT 5073081 CPT outpatient 492 492 492 492 XR ELBOW COMPLETE LEFT 5073082 CPT outpatient 492 492 492 492 XR ELBOW COMPLETE BILAT 5073083 CPT outpatient 492 492 492 492 XR FOREARM LEFT 5073092 CPT outpatient 400.2 400.2 400.2 400.2 XR FOREARM BILAT 5073093 CPT outpatient 475 475 475 475 XR INFANT UPPER EXT RIGHT 5073094 CPT outpatient 134.1 134.1 134.1 134.1 XR INFANT UPPER EXT LEFT 5073095 CPT outpatient 134.1 134.1 134.1 134.1 XR INFANT UPPER EXT BILAT 5073096 CPT outpatient 134.1 134.1 134.1 134.1 XR WRIST 2 VIEW BILAT 5073103 CPT outpatient 261.4 261.4 261.4 261.4 XR WRIST COMPLETE RIGHT 5073111 CPT outpatient 538.7 538.7 538.7 538.7 XR WRIST COMPLETE LEFT 5073112 CPT outpatient 538.7 538.7 538.7 538.7 XR WRIST COMPLETE BILAT 5073113 CPT outpatient 675 675 675 675 XR HAND COMPLETE BILAT 5073133 CPT outpatient 464 464 464 464 XR FINGER THUMB RIGHT 5073141 CPT outpatient 230.05 230.05 230.05 230.05 XR FINGER 2ND RIGHT 5073142 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER 3RD RIGHT 5073143 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER 4TH RIGHT 5073144 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER 5TH RIGHT 5073145 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER THUMB LEFT 5073146 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER 2ND LEFT 5073147 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER 3RD LEFT 5073148 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER 4TH LEFT 5073149 CPT outpatient 193.7 193.7 193.7 193.7 XR FINGER 5TH LEFT 5073150 CPT outpatient 193.7 193.7 193.7 193.7 XR HIP 1 VIEW LEFT 5073502 CPT outpatient 262.4 262.4 262.4 262.4 XR HIP 2 VIEW BILAT 5073513 CPT outpatient 385 385 385 385 XR PELVIS W BILAT HIPS 5073520 CPT outpatient 585.22 585.22 585.22 585.22 XR FEMUR RIGHT 5073551 CPT outpatient 532.2 532.2 532.2 532.2 XR FEMUR LEFT 5073552 CPT outpatient 532.2 532.2 532.2 532.2 XR FEMUR BILAT 5073553 CPT outpatient 532.2 532.2 532.2 532.2 XR KNEE 4 VIEW RIGHT 5073561 CPT outpatient 436.6 436.6 436.6 436.6 XR KNEE 3 VIEW RIGHT 5073562 CPT outpatient 520 520 520 520 XR KNEE 4 VIEW BILAT 5073563 CPT outpatient 873.2 873.2 873.2 873.2 XR WT BEARING KNEE RIGHT 5073564 CPT outpatient 258.94 258.94 258.94 258.94 XR WT BEARING KNEE LEFT 5073565 CPT outpatient 258.94 258.94 258.94 258.94 XR WT BEARING KNEE BILAT 5073566 CPT outpatient 571.88 571.88 571.88 571.88 XR KNEE 3 VIEW LEFT 5073567 CPT outpatient 520 520 520 520 XR KNEE 3 VIEW BILAT 5073568 CPT outpatient 520 520 520 520 XR INFANT LOWER EXT LEFT 5073592 CPT outpatient 134.1 134.1 134.1 134.1 XR TIBIA FIBULA BILAT 5073593 CPT outpatient 489.8 489.8 489.8 489.8 XR INFANT LOWER EXT RIGHT 5073594 CPT outpatient 134.1 134.1 134.1 134.1 XR INFANT LOWER EXT BILAT 5073596 CPT outpatient 134.1 134.1 134.1 134.1 XR ANKLE 2 VIEW LEFT 5073602 CPT outpatient 530 530 530 530 XR ANKLE 2 VIEW BILAT 5073604 CPT outpatient 530 530 530 530 XR ANKLE COMPLETE RIGHT 5073611 CPT outpatient 530 530 530 530 XR ANKLE COMPLETE LEFT 5073612 CPT outpatient 530 530 530 530 XR ANKLE COMPLETE BILAT 5073613 CPT outpatient 675 675 675 675 XR FOOT COMPLETE RIGHT 5073631 CPT outpatient 502.6 502.6 502.6 502.6 XR FOOT COMPLETE BILAT 5073633 CPT outpatient 675 675 675 675 XR CALCANEOUS RIGHT 5073651 CPT outpatient 530 530 530 530 XR CALCANEOUS LEFT 5073652 CPT outpatient 530 530 530 530 XR CALCANEOUS BILAT 5073653 CPT outpatient 530 530 530 530 XR TOE GREAT TOE RIGHT 5073661 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 2ND RIGHT 5073662 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 3RD RIGHT 5073663 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 4TH RIGHT 5073664 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 5TH RIGHT 5073665 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE GREAT TOE LEFT 5073666 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 2ND LEFT 5073667 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 3RD LEFT 5073668 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 4TH LEFT 5073669 CPT outpatient 94.4 94.4 94.4 94.4 XR TOE 5TH LEFT 5073670 CPT outpatient 94.4 94.4 94.4 94.4 XR ABD SERIES W CXR 5074022 CPT outpatient 510.35 510.35 510.35 510.35 XR ESOPHAGRAM 5074220 CPT outpatient 475.4 475.4 475.4 475.4 XR CINE ESOPHAGRAM 5074230 CPT outpatient 526.3 526.3 526.3 526.3 XR UGI W AIR 5074247 CPT outpatient 785.25 785.25 785.25 785.25 XR UGI W SBFT 5074249 CPT outpatient 1035.8 1035.8 1035.8 1035.8 XR BARIUM ENEMA 5074270 CPT outpatient 2499 2499 2499 2499 XR BARIUM ENEMA W AIR 5074280 CPT outpatient 935.9 935.9 935.9 935.9 XR CHOLANGIOGRAM IN OR 5074300 CPT outpatient 565.75 565.75 565.75 565.75 XR T TUBE CHOLANGIOGRAM 5074305 CPT outpatient 593.85 593.85 593.85 593.85 XR ERCP 5074330 CPT outpatient 1384.6 1384.6 1384.6 1384.6 XR IVP 5074400 CPT outpatient 1325 1325 1325 1325 XR RETROGRADE PYELOGRAM IN OR 5074420 CPT outpatient 575.94 575.94 575.94 575.94 XR CYTOGRAM 5074450 CPT outpatient 522 522 522 522 XR VCUG 5074455 CPT outpatient 725.43 725.43 725.43 725.43 XR VENOGRAM RIGHT 5075821 CPT outpatient 1089 1089 1089 1089 XR VENOGRAM BILAT 5075822 CPT outpatient 2218 2218 2218 2218 XR VENOGRAM LEFT 5075823 CPT outpatient 1089 1089 1089 1089 XR IVC FILTER PLACEMENT 5075940 CPT outpatient 720 720 720 720 XR FLUOROSCOPY C ARM 1 HR+ 5076001 CPT outpatient 630 630 630 630 XR FLOURI GUIDENCE NEEDLE PLACEMENT 5076003 CPT outpatient 365.75 365.75 365.75 365.75 XR NOSE TO RECTUM R/O FB ON CHILD 5076010 CPT outpatient 315.5 315.5 315.5 315.5 XR BONE AGE 5076020 CPT outpatient 370 370 370 370 XR BONE SURVEY METZ 5076062 CPT outpatient 430.16 430.16 430.16 430.16 XR BONE SURVEY INFANT 5076065 CPT outpatient 472.6 472.6 472.6 472.6 XR FISTULA SINUS TRACT STUDY 5076080 CPT outpatient 561.75 561.75 561.75 561.75 XR NEONATAL HEAD 5076506 CPT outpatient 187.5 187.5 187.5 187.5 US BREAST LEFT 5076646 CPT outpatient 558.5 558.5 558.5 558.5 US BREAST RIGHT 5076647 CPT outpatient 558.5 558.5 558.5 558.5 US BREAST BILAT 5076648 CPT outpatient 558.5 558.5 558.5 558.5 US SPINE SPINAL CANAL 5076800 CPT outpatient 865.75 865.75 865.75 865.75 US OB COMPLETE 5076811 CPT outpatient 745.2 745.2 745.2 745.2 US OB GROWTH EFW 5076816 CPT outpatient 475 475 475 475 US OB TRANSVAGINAL 5076817 CPT outpatient 428 428 428 428 US TRANSVAGINAL 5076830 CPT outpatient 945 945 945 945 US PROSTATE 5076856 CPT outpatient 730.93 730.93 730.93 730.93 US TRANSRECTAL 5076872 CPT outpatient 633.4 633.4 633.4 633.4 US UPPER EXTREMITY RIGHT 5076881 CPT outpatient 293.31 293.31 293.31 293.31 US UPPER EXTREMITY BILAT 5076883 CPT outpatient 438 438 438 438 US INFANT HIPS 5076887 CPT outpatient 187.5 187.5 187.5 187.5 US LOWER EXTREMITY BILAT 5076888 CPT outpatient 438 438 438 438 NM THYROID UPTAKE SINGLE DETERMINATION 5078000 CPT outpatient 856 856 856 856 NM THYROID IMAGING WITH UPTAKE 5078006 CPT outpatient 1551.5 1551.5 1551.5 1551.5 NM TYROID IMAGING ONLY 5078010 CPT outpatient 444 444 444 444 NM PARATHYROID IMAGING 5078070 CPT outpatient 637.7 637.7 637.7 637.7 NM LIVER SPLEEN IMAGING 5078215 CPT outpatient 1829.7 1829.7 1829.7 1829.7 NM GASTRIC EMPTYING 5078264 CPT outpatient 1241.5 1241.5 1241.5 1241.5 NM INTESTING IMAGING MECKELS 5078290 CPT outpatient 1337.5 1337.5 1337.5 1337.5 NM BONE SCAN LIMITED 5078300 CPT outpatient 1860 1860 1860 1860 NM MYOCARDIAL STRESS OR REST THALLIUM 5078460 CPT outpatient 2025 2025 2025 2025 NM MYOCARDIAL IMAGING QUALITY OR QUANTIT 5078466 CPT outpatient 2025 2025 2025 2025 NM MUGA SCAN W WALL MTN AND EJCT FRCTN 5078472 CPT outpatient 2445 2445 2445 2445 NM BRAIN IMAGING COMPLETE 5078605 CPT outpatient 1410 1410 1410 1410 NM CISTERNOGRAM 5078630 CPT outpatient 2514.5 2514.5 2514.5 2514.5 NM RENOGRAM IMAGING 5078704 CPT outpatient 1582.62 1582.62 1582.62 1582.62 NM RENOGRAM IMAGING WO LASIX 5078707 CPT outpatient 986.97 986.97 986.97 986.97 NM RENOGRAM IMAGING WO AND W LASIX 5078709 CPT outpatient 3690 3690 3690 3690 NM TESTICULAR IMAGING WITH VASCULAR FLOW 5078761 CPT outpatient 1206.96 1206.96 1206.96 1206.96 NM LOCALIZE TUMOR SINGLE DAY GALLIUM 5078802 CPT outpatient 2865 2865 2865 2865 NM LOC TUMOR MULTI DAY IMAGING GALLIUM 5078804 CPT outpatient 5415 5415 5415 5415 NM RAI INDIUM 111 OXINE 5078807 CPT outpatient 833.3 833.3 833.3 833.3 XR KNEE 4 VIEW LEFT 5083562 CPT outpatient 436.6 436.6 436.6 436.6 2D ECHO COMPLETE 5093307 CPT outpatient 1060 1060 1060 1060 US ECHO COLOR FLOW DOPPLER 5093325 CPT outpatient 540 540 540 540 US ARTERIAL LOWER EXT RIGHT 5093927 CPT outpatient 1375 1375 1375 1375 US ARTERIAL UPPER EXT LEFT 5093933 CPT outpatient 725.5 725.5 725.5 725.5 US VENOUS UPPER EXT LEFT 5093971 CPT outpatient 725.5 725.5 725.5 725.5 US VENOUS LOWER EXT RIGHT 5093972 CPT outpatient 725.5 725.5 725.5 725.5 US VENOUS LOWER EXT LEFT 5093973 CPT outpatient 725.5 725.5 725.5 725.5 US RETRO DUPLEX ABD PELVIC 5093975 CPT outpatient 1425 1425 1425 1425 US VENOUS MAPPING AND MEASURE 5093977 CPT outpatient 812.1 812.1 812.1 812.1 US DUPLEX HEMODIALYSIS ACCESS 5093990 CPT outpatient 725 725 725 725 CT BRAIN WO 5200450 CPT outpatient 4614 4614 4614 4614 CT BRAIN WO AND W 5200470 CPT outpatient 2460 2460 2460 2460 CT FACIAL BONES 5200488 CPT outpatient 1110 1110 1110 1110 CT SOFT TISSUE NECK WO 5200490 CPT outpatient 5377 5377 5377 5377 CT SOFT TISSUE NECK W 5200491 CPT outpatient 5673.33 5673.33 5673.33 5673.33 CT CHEST WO 5201250 CPT outpatient 5500.33 5500.33 5500.33 5500.33 CT CHEST W 5201260 CPT outpatient 5807.33 5807.33 5807.33 5807.33 CT CHEST RO PE 5201275 CPT outpatient 5660.67 5660.67 5660.67 5660.67 CT C SPINE 5202125 CPT outpatient 5244.67 5244.67 5244.67 5244.67 CT L SPINE 5202131 CPT outpatient 1110 1110 1110 1110 CT PELVIS WO DYE 5202192 CPT outpatient 5360 5360 5360 5360 CT PELVIS W 5202193 CPT outpatient 5458.67 5458.67 5458.67 5458.67 CT UPPER EXTREMITY LEFT 5203201 CPT outpatient 1110 1110 1110 1110 CT LOWER EXTREMITY RIGHT 5203701 CPT outpatient 5103.33 5103.33 5103.33 5103.33 CT LOWER EXTREMITY LEFT 5203702 CPT outpatient 5103.33 5103.33 5103.33 5103.33 CT ABDOMEN WO 5204150 CPT outpatient 5348.67 5348.67 5348.67 5348.67 CT ABDOMEN W 5204160 CPT outpatient 5620.33 5620.33 5620.33 5620.33 LIVER BIOPSY 5247000 CPT outpatient 1898.25 1898.25 1898.25 1898.25 CT BRAIN WO CONTRAST 5270450 CPT outpatient 750 750 750 750 CT ORBITS 5270480 CPT outpatient 1110 1110 1110 1110 CT INTERNAL AUDITORY CANALS W 5270481 CPT outpatient 1350 1350 1350 1350 CT IACS WO AND W 5270482 CPT outpatient 2460 2460 2460 2460 CT SINUS WO DYE 5270486 CPT outpatient 1110 1110 1110 1110 CT SOFT TISSUE NECK WO AND W 5270492 CPT outpatient 2460 2460 2460 2460 CT CHEST WO AND W 5271270 CPT outpatient 2460 2460 2460 2460 CT T SPINE 5272128 CPT outpatient 1110 1110 1110 1110 CT LUMBAR SPINT W DYE 5272132 CPT outpatient 2090.79 2090.79 2090.79 2090.79 CT PELVIS WO AND W 5272194 CPT outpatient 2460 2460 2460 2460 CT UPPER EXTREMITY RIGHT 5273200 CPT outpatient 1110 1110 1110 1110 CT ABDOMEN WO AND W 5274170 CPT outpatient 2460 2460 2460 2460 BIOPSY 5275970 CPT outpatient 1763.8 1763.8 1763.8 1763.8 CT GUIDED DRAINAGE 5275989 CPT outpatient 465.93 465.93 465.93 465.93 CT GUIDED NEEDLE PLACEMENT 5276360 CPT outpatient 1133.79 1133.79 1133.79 1133.79 CT GUIDED BIOPSY 5276362 CPT outpatient 1133.79 1133.79 1133.79 1133.79 CT L SPINE 5276375 CPT outpatient 481.17 481.17 481.17 481.17 CT SCAN FOR NEEDLE BIOPSY 5277012 CPT outpatient 1298.1 1298.1 1298.1 1298.1 MRI BRAIN WO 5300551 CPT outpatient 1830 1830 1830 1830 MRI BRAIN WO AND W 5300553 CPT outpatient 4733.1 4733.1 4733.1 4733.1 MRI C SPINE WO 5302141 CPT outpatient 3588.17 3588.17 3588.17 3588.17 MRI L SPINE WO 5302148 CPT outpatient 3588.17 3588.17 3588.17 3588.17 MRI T SPINE WO AND W 5302157 CPT outpatient 8017 8017 8017 8017 MRI L SPINE WO AND W 5302158 CPT outpatient 4733.1 4733.1 4733.1 4733.1 MRI PELVIS WO 5302195 CPT outpatient 3588.17 3588.17 3588.17 3588.17 MRI LOWER EXTREMITY WO RIGHT 5303724 CPT outpatient 3360 3360 3360 3360 MRA ABDOMEN WO OR W 5308902 CPT outpatient 1616.1 1616.1 1616.1 1616.1 MRA HEAD WO DYE 5370544 CPT outpatient 1479.6 1479.6 1479.6 1479.6 MRA HEAD W DYE 5370545 CPT outpatient 2250 2250 2250 2250 MRA HEAD W AND WO DYE 5370546 CPT outpatient 2260.5 2260.5 2260.5 2260.5 MRA NECK WO DYE 5370547 CPT outpatient 1479.6 1479.6 1479.6 1479.6 MRA NECK W DYE 5370548 CPT outpatient 2250 2250 2250 2250 MRA NECK W AND WO DYE 5370549 CPT outpatient 2500 2500 2500 2500 MRI T SPINE WO 5372146 CPT outpatient 3588.17 3588.17 3588.17 3588.17 MRI C SPINE WO W 5372156 CPT outpatient 4733.1 4733.1 4733.1 4733.1 MRI UPPER EXTREMITY WO LEFT 5373218 CPT outpatient 1044.18 1044.18 1044.18 1044.18 MRI UPPER EXTREMITY WO RIGHT 5373219 CPT outpatient 3897.6 3897.6 3897.6 3897.6 MRI UPPER EXTREMITY W LEFT 5373221 CPT outpatient 3897.6 3897.6 3897.6 3897.6 MRI UPPER EXTREMITY W RIGHT 5373222 CPT outpatient 3897.6 3897.6 3897.6 3897.6 MRI LOWER EXTREMITY WO LEFT 5373721 CPT outpatient 3360 3360 3360 3360 MRI LOWER EXTREMITY W LEFT 5373722 CPT outpatient 3322.36 3322.36 3322.36 3322.36 MRI LOWER EXTREMITY W RIGHT 5373723 CPT outpatient 3360 3360 3360 3360 MRI ABDOMEN WO 5374181 CPT outpatient 3150 3150 3150 3150 MRI ABDOMEN W 5374182 CPT outpatient 3721.04 3721.04 3721.04 3721.04 MRI ABDOMEN WO AND W 5374183 CPT outpatient 1616.1 1616.1 1616.1 1616.1 PT INITIAL EVAL 6100100 CPT outpatient 323.12 323.12 323.12 323.12 PT EVAL MOD COMPLEXITY 6100101 CPT outpatient 323.12 323.12 323.12 323.12 PT EVAL HIGH COMPLEXITY 6100102 CPT outpatient 323.12 323.12 323.12 323.12 PT RE-EVAL 6100103 CPT outpatient 127.68 127.68 127.68 127.68 PT EVAL LOW COMPLEXITY 6100113 CPT outpatient 323.12 323.12 323.12 323.12 OT EVALUATION 6100200 CPT outpatient 348.76 348.76 348.76 348.76 OT TREATMENT 6100201 CPT outpatient 95.34 95.34 95.34 95.34 PT ADL/SELF/FUNC 6100202 CPT outpatient 142.54 142.54 142.54 142.54 OT EXER ACTIVITY UE 6100203 CPT outpatient 131.57 131.57 131.57 131.57 OT PT/CAREGIVER TRAINING 6100204 CPT outpatient 123.95 123.95 123.95 123.95 OT THERAPY EXERCISE 15 MIN 6100205 CPT outpatient 131.57 131.57 131.57 131.57 OT FUNCT ACTIVITIES 15 MIN 6100206 CPT outpatient 124.16 124.16 124.16 124.16 OT RANGE OF MOTION EX 6100207 CPT outpatient 95.34 95.34 95.34 95.34 OT RANGE OF MOTION HAND 6100208 CPT outpatient 95.34 95.34 95.34 95.34 OT NEUROMUSCULAR 6100209 CPT outpatient 99.3 99.3 99.3 99.3 OT ELECT MUSCLE STIM 6100210 CPT outpatient 55.56 55.56 55.56 55.56 OT E S ELCTRODE 6100211 CPT outpatient 55.56 55.56 55.56 55.56 OT ULTRASOUND 6100212 CPT outpatient 39.12 39.12 39.12 39.12 OT HOT/COLD THERAPY 6100213 CPT outpatient 96.8 96.8 96.8 96.8 OT MASSAGE 6100214 CPT outpatient 77.43 77.43 77.43 77.43 OT WHIRLPOOL SM EXT 6100215 CPT outpatient 63.78 63.78 63.78 63.78 OT DIATHERMY 6100216 CPT outpatient 19.56 19.56 19.56 19.56 OT MANUAL THERAPY 6100217 CPT outpatient 89.1 89.1 89.1 89.1 OT PARAFFIN WAX BATH 6100218 CPT outpatient 28.86 28.86 28.86 28.86 OT SELF HOME CARE MGMT 6100219 CPT outpatient 103.29 103.29 103.29 103.29 OT ADL/SELF/FUNC TRAINING 6100220 CPT outpatient 142.54 142.54 142.54 142.54 ST TREATMENT 6100301 CPT outpatient 308.3 308.3 308.3 308.3 PT SWALLOW EVAL 6100302 CPT outpatient 535.68 535.68 535.68 535.68 ST SWALLOW VIDEO 6100303 CPT outpatient 388.17 388.17 388.17 388.17 ST PMV EVALUATION 6100304 CPT outpatient 545.88 545.88 545.88 545.88 PT SWALLOW TX (ORAL FUNCTION) 6100305 CPT outpatient 465.17 465.17 465.17 465.17 ST EVAL 6100312 CPT outpatient 655.06 655.06 655.06 655.06 ST SWALLOW EVAL 6100323 CPT outpatient 535.68 535.68 535.68 535.68 ST SWALLOW TX ORAL FUNCTION 6100325 CPT outpatient 465.17 465.17 465.17 465.17 PT THERAPY EXERCISE 15 MIN 6100400 CPT outpatient 131.57 131.57 131.57 131.57 PT FUNC ACTIVITIES 15 MIN 6100401 CPT outpatient 142.79 142.79 142.79 142.79 PT RANGE OF MOTION EX 6100402 CPT outpatient 131.57 131.57 131.57 131.57 PT RANGE OF MOTION (HAND) 6100403 CPT outpatient 114.41 114.41 114.41 114.41 PT NEUROMUSCULAR RE-ED 6100404 CPT outpatient 137.04 137.04 137.04 137.04 PT GAIT TRAINING 6100405 CPT outpatient 116.46 116.46 116.46 116.46 PT GAIT TRAINING EXT 6100406 CPT outpatient 101.27 101.27 101.27 101.27 PT CRUTCH TRAINING 6100407 CPT outpatient 103.29 103.29 103.29 103.29 PT CRUTCH FIT/ADJ/GAIT 6100408 CPT outpatient 103.29 103.29 103.29 103.29 PT ELECT MUSCLE STIM 6100500 CPT outpatient 55.56 55.56 55.56 55.56 PT E S ELCTRODE 6100501 CPT outpatient 55.56 55.56 55.56 55.56 PT TENS/EMS CHECK 6100502 CPT outpatient 120 120 120 120 PT ULTRASOUND 6100503 CPT outpatient 39.12 39.12 39.12 39.12 PT HOT COLD THERAPY 6100504 CPT outpatient 96.8 96.8 96.8 96.8 PT MASSAGE 6100505 CPT outpatient 77.43 77.43 77.43 77.43 PT PHONOPHORESIS 6100506 CPT outpatient 50 50 50 50 PT WHIRLPOOL SM EXT 6100507 CPT outpatient 63.78 63.78 63.78 63.78 PT IONTOPHORESIS 6100508 CPT outpatient 59.02 59.02 59.02 59.02 PT DIATHERMY 6100509 CPT outpatient 19.56 19.56 19.56 19.56 PT MANUAL THERAPY 6100510 CPT outpatient 89.1 89.1 89.1 89.1 PT PARAFFIN WAX BATH 6100511 CPT outpatient 28.86 28.86 28.86 28.86 PT CPM SET UP 6100512 CPT outpatient 82.8 82.8 82.8 82.8 PT TRACTION MECHANICAL 6100514 CPT outpatient 82.8 82.8 82.8 82.8 PT SELF HOME CARE MGMT 6100608 CPT outpatient 103.29 103.29 103.29 103.29 PT MEPERIDINE HCL PF VIAL 50MG/ML 6102259 CPT outpatient 15.75 15.75 15.75 15.75 YANKAUER 6400177 CPT outpatient 13.13 13.13 13.13 13.13 TRACH TUBE 6400275 CPT outpatient 316.25 316.25 316.25 316.25 NASAL CANNULA 6400289 CPT outpatient 6.61 6.61 6.61 6.61 STYLET 6400380 CPT outpatient 126.15 126.15 126.15 126.15 O2 TUBING 6400382 CPT outpatient 6.33 6.33 6.33 6.33 ADAPTER MDI 6400386 CPT outpatient 5.75 5.75 5.75 5.75 VENTI-COMP BAG 6400387 CPT outpatient 5 5 5 5 ET-TUBE (ALL SIZES) 6400406 CPT outpatient 32.52 32.52 32.52 32.52 BIOPSY FORCEP 6400427 CPT outpatient 142.12 142.12 142.12 142.12 NONREBREATHER MASK 6400435 CPT outpatient 9.42 9.42 9.42 9.42 NASAL TRUMPHET 6400436 CPT outpatient 18.52 18.52 18.52 18.52 O2 ADAPTER 6400440 CPT outpatient 6.33 6.33 6.33 6.33 CYTOLOGY BRUSH 6400475 CPT outpatient 166.98 166.98 166.98 166.98 SIMPLE MASK 6400503 CPT outpatient 6.41 6.41 6.41 6.41 ORO-AIRWAY 6400506 CPT outpatient 21.25 21.25 21.25 21.25 INCENTIVE SPIROMETER ASSIST 6400881 CPT outpatient 75.9 75.9 75.9 75.9 AIRVO TRACHOSTOMY INTERFACE 6400911 CPT outpatient 140.17 140.17 140.17 140.17 INTUBATION OR ASSIST 6401500 CPT outpatient 548.25 548.25 548.25 548.25 TRACH CHANGE 6401502 CPT outpatient 548.25 548.25 548.25 548.25 BRONCHOSCOPY 6401622 CPT outpatient 2783 2783 2783 2783 PASSY MUIR ASSIST 6402507 CPT outpatient 310.87 310.87 310.87 310.87 ARTERIAL BLOOD GAS 6402803 CPT outpatient 681.94 681.94 681.94 681.94 CPR 30 MINUTES 6402950 CPT outpatient 1391.5 1391.5 1391.5 1391.5 EKG 6403005 CPT outpatient 294.31 294.31 294.31 294.31 ECHO COMPLETE 6403307 CPT outpatient 1474.99 1474.99 1474.99 1474.99 ECHO DOPPLER ONLY 6403320 CPT outpatient 922.57 922.57 922.57 922.57 ECHO TRANSTHORACIC STRESS TEST 6403350 CPT outpatient 2723.23 2723.23 2723.23 2723.23 VENTILATOR INITIAL 6404002 CPT outpatient 15654.4 15654.4 15654.4 15654.4 VENTILATOR SUBSEQUENT 6404003 CPT outpatient 12523.5 12523.5 12523.5 12523.5 HHN/MDI/IPPB TX INITIAL 6404640 CPT outpatient 308.09 308.09 308.09 308.09 HHN/MDI/IPPB TX SUBSEQUENT 6404641 CPT outpatient 308.09 308.09 308.09 308.09 HHN/MDI/IPPB TX TERTIARY 6404642 CPT outpatient 308.09 308.09 308.09 308.09 HHN/MDI/IPPB TX QUATERNARY 6404643 CPT outpatient 308.09 308.09 308.09 308.09 BIPAP DAILY INITIAL 6404662 CPT outpatient 5426.85 5426.85 5426.85 5426.85 BIPAP DAILY SUBSEQUENT 6404663 CPT outpatient 5426.85 5426.85 5426.85 5426.85 CPT INITIAL 6404667 CPT outpatient 173.94 173.94 173.94 173.94 CPT SUBSEQUENT 6404668 CPT outpatient 97.14 97.14 97.14 97.14 OXIMETRY SINGLE 6404760 CPT outpatient 157.25 157.25 157.25 157.25 OXIMETRY CONTINOUS 6404762 CPT outpatient 2504.7 2504.7 2504.7 2504.7 RT ASSIST 15 MIN 6404795 CPT outpatient 139.15 139.15 139.15 139.15 OXYGEN PER DAY 6404798 CPT outpatient 2504.7 2504.7 2504.7 2504.7 RESP ASSESSMENT / RE-ASSESS 6404799 CPT outpatient 542.12 542.12 542.12 542.12 EEG MONITOR 1 HR 6405812 CPT outpatient 1182.56 1182.56 1182.56 1182.56 EEG AWAKE / SLEEP 6405819 CPT outpatient 1306.37 1306.37 1306.37 1306.37 ARTERIAL PUNCTURE 6406600 CPT outpatient 264.39 264.39 264.39 264.39 SPUTUM COLLECTION 6409220 CPT outpatient 101.94 101.94 101.94 101.94 ECHO LIMITED FOLLOW UP 6493308 CPT outpatient 1170.13 1170.13 1170.13 1170.13 ECHO COLOR FLOW 6493325 CPT outpatient 543.38 543.38 543.38 543.38 EEG MONITOR ADD HR 6495813 CPT outpatient 1406.01 1406.01 1406.01 1406.01 EEG AWAKE/DROWSY 6495816 CPT outpatient 1083.06 1083.06 1083.06 1083.06 SUCTION MACHINE GOMCO 6600108 CPT outpatient 81 81 81 81 PROVIDONE IODINE SOL 4 OZ 6600119 CPT outpatient 5 5 5 5 AMBU BAG 6600139 CPT outpatient 56.73 56.73 56.73 56.73 TEGADERM SURESITE 2X3 6600194 CPT outpatient 5 5 5 5 TEGADERM SURESITE 4X5 6600195 CPT outpatient 5 5 5 5 TEGADERM SURESITE 6X8 6600196 CPT outpatient 10.86 10.86 10.86 10.86 ACE WRAPS 3X5 6600213 CPT outpatient 5 5 5 5 ACE WRAP 4X5 6600214 CPT outpatient 5 5 5 5 NEEDLE SAFETY 25GX1 LF 6600263 CPT outpatient 8.85 8.85 8.85 8.85 SKIN MARKER 6600293 CPT outpatient 9.4 9.4 9.4 9.4 GAUZE STERILE 4X4 12 PLY 10'S TRAY 6600328 CPT outpatient 8.47 8.47 8.47 8.47 ANESTESIA CIRCUIT 90 6600364 CPT outpatient 11 11 11 11 PEG TRAY PONSKY PULL DELUXE 6600393 CPT outpatient 577.8 577.8 577.8 577.8 GASTROSTOMY TUBE ALL SZ 6600395 CPT outpatient 163.71 163.71 163.71 163.71 COUDE FOLEY CATH ALL SZ 6600414 CPT outpatient 30.84 30.84 30.84 30.84 LEVINE TUBE ALL SIZES 6600416 CPT outpatient 5.48 5.48 5.48 5.48 OXYGEN TUBING 6600439 CPT outpatient 5 5 5 5 POLYPECTOMY SNARE 6600470 CPT outpatient 113.4 113.4 113.4 113.4 BIOPSY FRCP RADIAL JAW 6600471 CPT outpatient 300 300 300 300 BITE BLOCK SCOPE 6600473 CPT outpatient 97.5 97.5 97.5 97.5 EQ-CARDIAC/INV MONITOR 6600483 CPT outpatient 175 175 175 175 EQ-IRRIGATOR/ASPIRATOR 6600487 CPT outpatient 190 190 190 190 EQ VIDEO CART SYSTEM 6600488 CPT outpatient 1200 1200 1200 1200 EQ VIDEO MONITOR 6600489 CPT outpatient 125 125 125 125 EQ VIDEO PRINTER 6600490 CPT outpatient 125 125 125 125 IV PUMP DAILY 6600497 CPT outpatient 300 300 300 300 ANESTHESIA GEN 1ST HR 6600520 CPT outpatient 1200 1200 1200 1200 GI LAB 1ST HR 6600528 CPT outpatient 2000 2000 2000 2000 IV SEDATION/MODERATE/CONSCIOUS 6600531 CPT outpatient 400 400 400 400 RECOVERY ROOM 1ST HR 6600536 CPT outpatient 2000 2000 2000 2000 NEEDLE BLUNT FILL 18GX1.5 LF 6600638 CPT outpatient 5 5 5 5 SYRINGE 3ML LL 6600644 CPT outpatient 1.09 1.09 1.09 1.09 NEEDLE REG BEVEL 25GX1.5 6600650 CPT outpatient 5 5 5 5 ACCUSNARE POLYPECTOMY SNARE 6600651 CPT outpatient 302.4 302.4 302.4 302.4 PEG CLEANING BRUSH 6600655 CPT outpatient 94.54 94.54 94.54 94.54 TRI FUNNEL G TUBE 22FR REPLACEMENT GT 6600656 CPT outpatient 274 274 274 274 ELECTRODE NERVE BLOCK CONNECTING CABLE 6601232 CPT outpatient 75 75 75 75 CONSULTATION NUTRITION PER SESSION 7000500 CPT outpatient 54 54 54 54 DIET CONSULT REASSESS 15MIN 7000506 CPT outpatient 29 29 29 29 DIETARY WORK UP 15MIN 7000526 CPT outpatient 208 208 208 208 INITL DIET CONSULT 15MIN 7000529 CPT outpatient 29 29 29 29 NUTRITIONAL FOLLOW-UP VISIT 15MIN 7000533 CPT outpatient 113 113 113 113 HAIR BRUSH 8008899 CPT outpatient 5 5 5 5 ECG RECORDING PAPER 8009579 CPT outpatient 5.42 5.42 5.42 5.42 SMALL 3.75G 9000037 CPT outpatient 6.71 6.71 6.71 6.71 LMA #5 9000288 CPT outpatient 44.4 44.4 44.4 44.4 THREADED TEMPORARY FIXATION PIN 9000805 CPT outpatient 51.87 51.87 51.87 51.87 STANDARD PLATE 1 LEVEL 17MM 9001117 CPT outpatient 221.64 221.64 221.64 221.64 STANDARD PLATE 2 LEVEL 34MM 9001234 CPT outpatient 26.5 26.5 26.5 26.5 CERVICAL LORDOTIC 14X16X9 9001609 CPT outpatient 26.5 26.5 26.5 26.5 CERVICAL 16X18 LORDOTIC 9001807 CPT outpatient 51.87 51.87 51.87 51.87 ANGIO CATH 14GA X 3.25 9002268 CPT outpatient 11.74 11.74 11.74 11.74 CANCELATION AFTER ARRIVAL 9002525 CPT outpatient 7.91 7.91 7.91 7.91 VARIABLE SCREW 4.0X 14MM 9003284 CPT outpatient 135 135 135 135 FIXED SCREW 4.0 X 14MM 9004014 CPT outpatient 135 135 135 135 BONE MILL BLADE 5MM 9009217 CPT outpatient 11.39 11.39 11.39 11.39 THERAPY MATTRESS 9009417 CPT outpatient 7.5 7.5 7.5 7.5 PORCINE GEL HEMOSTAT KIT 9009497 CPT outpatient 48.33 48.33 48.33 48.33 FLEXTIP EPIDURAL CATH 19TH 9009571 CPT outpatient 11.39 11.39 11.39 11.39 7 HOLE PLATE 9009573 CPT outpatient 100 100 100 100 LOCKING SCREW 18MM 9009574 CPT outpatient 100 100 100 100 CORTICAL SCREW 14MM 9009575 CPT outpatient 100 100 100 100 CORTICAL SCREW 20MM 9009576 CPT outpatient 100 100 100 100 TWIST DRILL 9009577 CPT outpatient 100 100 100 100 APOLLO RF 50 9009815 CPT outpatient 6.26 6.26 6.26 6.26 SCD PUMP 24000428 CPT outpatient 100 100 100 100 SHROUD KIT 25000161 CPT outpatient 23.94 23.94 23.94 23.94 ELASTIC BANDAGE 2 X 5YD 25007002 CPT outpatient 14.85 14.85 14.85 14.85 ELASTIC BANDAGE 3 X 5YD 25007003 CPT outpatient 14.85 14.85 14.85 14.85 ELASTIC BANDAGE 4 X 5YD 25007004 CPT outpatient 14.85 14.85 14.85 14.85 ELASTIC BANDAGE 6 X 5YD 25007006 CPT outpatient 14.85 14.85 14.85 14.85 OPTIVIEW CLEAR 7 X7 25007777 CPT outpatient 11.37 11.37 11.37 11.37 FOLEY COUDE 2 WAY 14FR 25011214 CPT outpatient 14.85 14.85 14.85 14.85 FOLEY COUDE 2 WAY 16FR 25011216 CPT outpatient 14.85 14.85 14.85 14.85 URETHRAL CATH 10FR 25013510 CPT outpatient 14.85 14.85 14.85 14.85 URETHRAL CATH 16FR 25013516 CPT outpatient 14.85 14.85 14.85 14.85 URETHRAL CATH 18FR 25013518 CPT outpatient 14.85 14.85 14.85 14.85 URETHRAL CATH 20FR 25013520 CPT outpatient 14.85 14.85 14.85 14.85 OPTIFOAM 4X4 NON-ADHESIVE 80000010 CPT outpatient 62.51 62.51 62.51 62.51 "ELASTIC NET,SZ 1" 80000101 CPT outpatient 5 5 5 5 SYRINGE 3ML LL 80000116 CPT outpatient 6.8 6.8 6.8 6.8 SYRINGE 3ML LL 80000117 CPT outpatient 6.8 6.8 6.8 6.8 EKG PATCHES 80000132 CPT outpatient 5 5 5 5 SYRINGE 5CC LL 80000185 CPT outpatient 5 5 5 5 SYRINGE 10ML 80000187 CPT outpatient 5 5 5 5 SYRINGE 50ML LL 80000188 CPT outpatient 5 5 5 5 5CC SYRINGE 80000189 CPT outpatient 5 5 5 5 "ELASTIC NET,SZ 2" 80000202 CPT outpatient 5 5 5 5 HYPODERMIC NEEDLES 20GA X 1 80000205 CPT outpatient 5 5 5 5 ABD PADS 80000208 CPT outpatient 6.26 6.26 6.26 6.26 3M TRANSPORE TAPE 1 80000210 CPT outpatient 7.91 7.91 7.91 7.91 UTN CUSHION CLEAN CLIP SIDECAR B 80000212 CPT outpatient 70.92 70.92 70.92 70.92 3M TRANSPORE TAPE 1 80000213 CPT outpatient 1.86 1.86 1.86 1.86 BANDAID 1 X3 80000215 CPT outpatient 6.26 6.26 6.26 6.26 STAT STRIP GLUCOSE 80000236 CPT outpatient 10.57 10.57 10.57 10.57 T/B SYRINGE (SUB) 80000261 CPT outpatient 5 5 5 5 SYRINGE T/B 80000262 CPT outpatient 5 5 5 5 DRAIN SPONGE 80000294 CPT outpatient 5.42 5.42 5.42 5.42 "ELASTIC NET,SZ 3" 80000303 CPT outpatient 5 5 5 5 GOWN NON-REINFORCED LARGE 80000349 CPT outpatient 12.35 12.35 12.35 12.35 X-LARGE GOWNS 80000350 CPT outpatient 12.68 12.68 12.68 12.68 O/R TOWELS 80000363 CPT outpatient 24.6 24.6 24.6 24.6 POST OP SHOE MEDIUM 80000400 CPT outpatient 5 5 5 5 POST OP SHOE SMALL 80000401 CPT outpatient 5 5 5 5 "ELASTIC NET,SZ 4" 80000404 CPT outpatient 5 5 5 5 "ELASTIC NET,SZ 5" 80000505 CPT outpatient 5 5 5 5 SYRINGE 20ML LL 80000637 CPT outpatient 5 5 5 5 SYRINGE 20ML LL 80000638 CPT outpatient 5 5 5 5 PHYTOPLEX CLEAR / ZINC 80000833 CPT outpatient 14.1 14.1 14.1 14.1 DYNA HEX 4% CHG BOTTLES 80000915 CPT outpatient 21.09 21.09 21.09 21.09 UTN CUSHION SIZE A 80000980 CPT outpatient 70.92 70.92 70.92 70.92 CIRCUIT CONNECTOR 15MM 80001035 CPT outpatient 5.42 5.42 5.42 5.42 ETT HOLDER VELCRO 80001060 CPT outpatient 5 5 5 5 OXY 2 PRO MASKS 80001108 CPT outpatient 21.09 21.09 21.09 21.09 O2 CONNECTOR TUBING 80001115 CPT outpatient 5 5 5 5 HHN KIT 80001210 CPT outpatient 62.51 62.51 62.51 62.51 CANNULA CLEANERS 1/4 X12 80001472 CPT outpatient 5 5 5 5 SYRINGE INSULIN 1/2ML 80001773 CPT outpatient 1 1 1 1 "MANUAL 2-WAY BALL VALVE NPT,BRASS" 80001840 CPT outpatient 1.86 1.86 1.86 1.86 PALM CUP PERCUSSOR MEDIUM 80002263 CPT outpatient 21.09 21.09 21.09 21.09 COMB 9 80002303 CPT outpatient 5 5 5 5 BATTERIES AA 80002548 CPT outpatient 6.26 6.26 6.26 6.26 BATTERIES AAA 80002549 CPT outpatient 6.26 6.26 6.26 6.26 BATTERIES 9 VOLT 80002550 CPT outpatient 6.26 6.26 6.26 6.26 BATTERIES C 80002551 CPT outpatient 6.26 6.26 6.26 6.26 BATTERIES D 80002552 CPT outpatient 6.26 6.26 6.26 6.26 HP 37A TONER 80002807 CPT outpatient 62.51 62.51 62.51 62.51 SYRINGE 20ML SLIP TIP 80002831 CPT outpatient 5 5 5 5 BITE BLOCK ADULT ORANGE 80003111 CPT outpatient 5 5 5 5 RED VAC TUBES 80005218 CPT outpatient 10.57 10.57 10.57 10.57 3M DURAPORE 3 TAPE 80005383 CPT outpatient 1.86 1.86 1.86 1.86 LEXMARK PRINTER STAND 80005498 CPT outpatient 6.26 6.26 6.26 6.26 MONARCH 1131 LABELER 80005735 CPT outpatient 62.51 62.51 62.51 62.51 "PRIMER, WATER, ACRYLIC 5 GAL. WHITE" 80006031 CPT outpatient 1.86 1.86 1.86 1.86 0.9% SODIUM CHLORIDE IRR 3000ML 80007278 CPT outpatient 157.72 157.72 157.72 157.72 MINDRAY 5 LEAD ECG LEADWIRER 36 80007374 CPT outpatient 60 60 60 60 LEXMARK MX721ADE PRINTER 80007628 CPT outpatient 6.26 6.26 6.26 6.26 LEXMARK BLACK TONER 80007674 CPT outpatient 6.26 6.26 6.26 6.26 BRONCHIAL SUCTIONING CATHETER 14FR 80007814 CPT outpatient 5 5 5 5 VENT CIRCUIT 80008087 CPT outpatient 62.51 62.51 62.51 62.51 RECYCLE BIN 7 GALLON 80008215 CPT outpatient 62.51 62.51 62.51 62.51 URINE TEST STRIPS 80008888 CPT outpatient 10.57 10.57 10.57 10.57 NITRILE GLOVES MEDIUM 80008892 CPT outpatient 65 65 65 65 HYDRODERMIC NEEDLE 18G X 1 80009249 CPT outpatient 5 5 5 5 WEITLANER GUARD SMALL 80009517 CPT outpatient 51.16 51.16 51.16 51.16 WEITLANER GUARD MEDIUM 80009518 CPT outpatient 51.16 51.16 51.16 51.16 GELPI GUARD SMALL 80009519 CPT outpatient 51.16 51.16 51.16 51.16 GELPI GUARD MEDIUM 80009520 CPT outpatient 51.16 51.16 51.16 51.16 GELPI GUARD 38MM 80009559 CPT outpatient 51.16 51.16 51.16 51.16 GELPI GUARD 38MM 80009560 CPT outpatient 51.16 51.16 51.16 51.16 T-WILSON FRAME 90000003 CPT outpatient 48.33 48.33 48.33 48.33 PORTEX DCT 6.0 90000004 CPT outpatient 314.16 314.16 314.16 314.16 T-STRYKER SYSTEM 7 BATTERIES & STATION 90000007 CPT outpatient 314.16 314.16 314.16 314.16 T-TOTAL KNEE REPLACEMENT POSTIONER (TKR) 90000008 CPT outpatient 314.16 314.16 314.16 314.16 CANE STANDARD 90000012 CPT outpatient 260.22 260.22 260.22 260.22 DIC 9.0MM TUBE 90000014 CPT outpatient 250 250 250 250 DIC 6.0MM TUBE 90000015 CPT outpatient 250 250 250 250 PORTEX DIC 9.0 90000016 CPT outpatient 314.16 314.16 314.16 314.16 GUIDEWIRE 2.5X220MM 90000017 CPT outpatient 221.64 221.64 221.64 221.64 20MM CROSS CONNECTOR 90000028 CPT outpatient 316.25 316.25 316.25 316.25 TOTAL KNEE 90000029 CPT outpatient 49.42 49.42 49.42 49.42 NASOPHARYNGEAL AIRWAY 32FR 90000032 CPT outpatient 32.52 32.52 32.52 32.52 35MM CONNECTOR 90000035 CPT outpatient 316.25 316.25 316.25 316.25 40MM CONNECTOR 90000040 CPT outpatient 316.25 316.25 316.25 316.25 48MM CROSS CONNECTOR 90000048 CPT outpatient 316.25 316.25 316.25 316.25 ETHICON 3-0 30 PERMA-HAND SILK 90000084 CPT outpatient 9 9 9 9 REV PERIPSCREW 5.0 X 30MM N/S 90000091 CPT outpatient 221.64 221.64 221.64 221.64 SET SCREW 90000100 CPT outpatient 316.25 316.25 316.25 316.25 UPPER BODY BLANKET 90000109 CPT outpatient 100 100 100 100 SAFETY NEEDLES 25GA X 5/8 90000116 CPT outpatient 6.8 6.8 6.8 6.8 SAFETY NEEDLES 25GA X 1 90000117 CPT outpatient 6.8 6.8 6.8 6.8 KINEMATX IMPACTION STAND 90000120 CPT outpatient 6.06 6.06 6.06 6.06 JACKSON TABLE KIT 90000125 CPT outpatient 26.5 26.5 26.5 26.5 COMMODE 3-IN-1 STEEL 90000126 CPT outpatient 260.22 260.22 260.22 260.22 LIMB HOLDERS (SUB) 90000127 CPT outpatient 32.08 32.08 32.08 32.08 REV CTRSCREW 6.5X30MM N/S 90000130 CPT outpatient 221.64 221.64 221.64 221.64 INSPACE US MEDIUM 90000131 CPT outpatient 9.26 9.26 9.26 9.26 TOURNIQUET 24 X4 SINGLE BLADDER 90000135 CPT outpatient 12 12 12 12 IODINE SWABSTICK 90000141 CPT outpatient 5 5 5 5 ICE PACKS 6X9 90000143 CPT outpatient 5.4 5.4 5.4 5.4 MITTENS 90000145 CPT outpatient 61.26 61.26 61.26 61.26 INTEGRA MONITOR ICP EXTERNAL DRAINAGE BA 90000150 CPT outpatient 44.18 44.18 44.18 44.18 DISPOSABLE STETHOSCOPE 90000158 CPT outpatient 11.07 11.07 11.07 11.07 REPAIR CREAM 90000164 CPT outpatient 9.37 9.37 9.37 9.37 B/P CUFFS MEDIUM 1 TUBE 90000175 CPT outpatient 26.96 26.96 26.96 26.96 B/P CUFF MEDIUM 2 TUBES 90000176 CPT outpatient 26.96 26.96 26.96 26.96 YANKAUER BULB TIP 90000177 CPT outpatient 10.38 10.38 10.38 10.38 ANGIO CATH 20GA 90000180 CPT outpatient 41.6 41.6 41.6 41.6 IV CATH 22G 90000181 CPT outpatient 41.6 41.6 41.6 41.6 IV CATH 24G 90000182 CPT outpatient 41.6 41.6 41.6 41.6 SYRINGE 50ML LL 90000188 CPT outpatient 5 5 5 5 TRANSPARENT TAPE 1 90000210 CPT outpatient 7.91 7.91 7.91 7.91 MICROFOAM 4 TAPE 90000211 CPT outpatient 14.14 14.14 14.14 14.14 FEMORAL COMPONENT S3+L CEMENTED 90000212 CPT outpatient 49.42 49.42 49.42 49.42 TRANSPARENT TAPE 1 90000213 CPT outpatient 1.86 1.86 1.86 1.86 BANDAGE ADHESIVE FABRIC 1 X3 STRL LF 90000215 CPT outpatient 0.66 0.66 0.66 0.66 PLATE 30MM 90000223 CPT outpatient 221.64 221.64 221.64 221.64 KERLIX ROLL 90000224 CPT outpatient 7.5 7.5 7.5 7.5 THREADED PHATION PINS 90000233 CPT outpatient 221.64 221.64 221.64 221.64 TOURNIQUET 30 X4 SINGLE BLADDER 90000235 CPT outpatient 12 12 12 12 XEROFORM 1 X8 90000237 CPT outpatient 8.82 8.82 8.82 8.82 SURGILUBE 4.25OZ 90000241 CPT outpatient 9.26 9.26 9.26 9.26 T-UNIVERSAL CERVICAL REMOVAL SYSTEM #1 90000251 CPT outpatient 7.91 7.91 7.91 7.91 PEEK CAGE ANTERIOR 30MM X 11MM X 12 90000265 CPT outpatient 221.64 221.64 221.64 221.64 ETHICON 2-0 27 COATED VICRYL 90000266 CPT outpatient 22.68 22.68 22.68 22.68 COVIDIEN 2-0 30 MONSOF BLK 90000267 CPT outpatient 22.68 22.68 22.68 22.68 LOWER BODY BLANKET 90000268 CPT outpatient 56 56 56 56 BLANKET FULL-BODY 90000269 CPT outpatient 56 56 56 56 TRACH TUBE CUFFED 90000275 CPT outpatient 250 250 250 250 TRACH TUBE CUFFED 90000276 CPT outpatient 316.25 316.25 316.25 316.25 DIC 8.0MM TUBE 90000277 CPT outpatient 250 250 250 250 CIRCUIT VENT LONG NOVATION 90000280 CPT outpatient 49.42 49.42 49.42 49.42 THORA-PARA CATH DRAINAGE TRAY 90000282 CPT outpatient 101.87 101.87 101.87 101.87 TUBING CIRCUIT/6' F/CPAP/BIPAP DISP 90000283 CPT outpatient 49.42 49.42 49.42 49.42 TUBING CIRCUIT/6' F/CPAP/BIPAP DISP 90000284 CPT outpatient 62.51 62.51 62.51 62.51 CIRCUIT VENT LONG NOVATION 90000285 CPT outpatient 62.51 62.51 62.51 62.51 LMA #3 90000286 CPT outpatient 44.4 44.4 44.4 44.4 DIC 8.0MM TUBE 90000288 CPT outpatient 316.25 316.25 316.25 316.25 LMA #4 90000290 CPT outpatient 44.4 44.4 44.4 44.4 ANESTHESIA MASK 90000291 CPT outpatient 9.25 9.25 9.25 9.25 HEAD TO HEAD CAP SCREW 90000300 CPT outpatient 25.7 25.7 25.7 25.7 MAYO STAND COVER 90000301 CPT outpatient 14.95 14.95 14.95 14.95 ETHICON 2-0 30 PERMA-HAND SILK 90000305 CPT outpatient 9 9 9 9 INSTRUMENT TIP COVERS 90000307 CPT outpatient 250 250 250 250 TIBIAL INSERT E-CROSS FLEX3 - 10MM 90000310 CPT outpatient 49.42 49.42 49.42 49.42 SUCTION CANISTER 1500ML 90000312 CPT outpatient 20.08 20.08 20.08 20.08 SUTURE REMOVAL TRAY 90000313 CPT outpatient 13.71 13.71 13.71 13.71 VARIABLE SCREW 3.70 X 14MM 90000314 CPT outpatient 221.64 221.64 221.64 221.64 SUCTION TUBING 1/4 X12' 90000316 CPT outpatient 6.43 6.43 6.43 6.43 SUCTION TUBING 1/4 X6' 90000317 CPT outpatient 6.43 6.43 6.43 6.43 CAUTERY PENCIL 90000320 CPT outpatient 44.18 44.18 44.18 44.18 REV PERIPSCREW 5.0 X 30MMM N/S 90000322 CPT outpatient 221.64 221.64 221.64 221.64 GAUZE SPONGE 4 X4 12PLY STRL LF 10/TRAY 90000327 CPT outpatient 6.9 6.9 6.9 6.9 SURE SET BASIN 90000335 CPT outpatient 112.52 112.52 112.52 112.52 REV PERIPSCREW 5.0 X 38MM N/S 90000338 CPT outpatient 221.64 221.64 221.64 221.64 SHEET DRAPE 53X77 STERILE 90000339 CPT outpatient 7.26 7.26 7.26 7.26 RUHOF FOAMING AUTOCLAVE CLEANER 90000345 CPT outpatient 51.87 51.87 51.87 51.87 GOWN SLEEVE 90000349 CPT outpatient 12.35 12.35 12.35 12.35 X-LARGE GOWNS 90000350 CPT outpatient 12.68 12.68 12.68 12.68 JACKSON ARM FOAM 90000351 CPT outpatient 12.68 12.68 12.68 12.68 ARM BOARD STRAP 90000352 CPT outpatient 12.68 12.68 12.68 12.68 LIGHT HANDLE COVERS 90000353 CPT outpatient 7.06 7.06 7.06 7.06 CENTRAL LINE DRESSING KIT 90000355 CPT outpatient 55.13 55.13 55.13 55.13 BIOGEL PF 8.5 90000356 CPT outpatient 5 5 5 5 CLIPPER BLADES 90000359 CPT outpatient 7.5 7.5 7.5 7.5 O/R TOWELS 90000363 CPT outpatient 24.6 24.6 24.6 24.6 TEGADERM 4 X4.75 90000370 CPT outpatient 8.15 8.15 8.15 8.15 GLIDERITE RIGID STYLETTE 90000380 CPT outpatient 99.72 99.72 99.72 99.72 ADAPTER 15MM X 22MM 90000384 CPT outpatient 6.33 6.33 6.33 6.33 T-VALVE ADAPTER 90000385 CPT outpatient 11.74 11.74 11.74 11.74 HUMERAL STEM SZ 3 90000388 CPT outpatient 221.64 221.64 221.64 221.64 INNER CANNULA 90000389 CPT outpatient 21.22 21.22 21.22 21.22 CANNULA DISPOSABLE SZ8 INNER 90000390 CPT outpatient 21.22 21.22 21.22 21.22 G-TUBE REPLACEMENT 22FR 90000395 CPT outpatient 503.58 503.58 503.58 503.58 AEROSOL AQUAPAK SET-UP 90000399 CPT outpatient 21.03 21.03 21.03 21.03 SUPRAPUBIC CATH KIT 12FR 90000404 CPT outpatient 44.18 44.18 44.18 44.18 DURAFLEX GRAFT 4CM X 5CM 90000405 CPT outpatient 528 528 528 528 ET TUBE #7 90000406 CPT outpatient 25.7 25.7 25.7 25.7 ET TUBE #8 90000407 CPT outpatient 32.52 32.52 32.52 32.52 ET TUBE 6.5MM 90000408 CPT outpatient 25.7 25.7 25.7 25.7 ET TUBE 7.5MM 90000409 CPT outpatient 32.52 32.52 32.52 32.52 TRACH TIE 90000410 CPT outpatient 8.43 8.43 8.43 8.43 EMERGENCY RESPONSE 90000411 CPT outpatient 21 21 21 21 OPTIFOAM BASIC 90000413 CPT outpatient 21 21 21 21 URINARY DRAINAGE BAG 90000415 CPT outpatient 10.98 10.98 10.98 10.98 ETHICON 3-0 27 MONOCRYL PLUS 90000416 CPT outpatient 9 9 9 9 TUBE GASTRIC SUMP 18FR 90000418 CPT outpatient 11.39 11.39 11.39 11.39 ETHICON 3-0 27 MONOCRYL 19MM 90000427 CPT outpatient 9 9 9 9 TUBING CORRUGATED CORR-A-FLEX 100FT RL 90000434 CPT outpatient 10.15 10.15 10.15 10.15 SUCTION CATH KIT W/H2O 90000442 CPT outpatient 6.33 6.33 6.33 6.33 COVIDIEN ENDO GIA STAPLER 12MM 90000449 CPT outpatient 22.68 22.68 22.68 22.68 BINDER ABD 9 SM/MD 90000479 CPT outpatient 38.34 38.34 38.34 38.34 IV START KIT 90000496 CPT outpatient 25 25 25 25 STRYKER 5.0MM FLUTED BURR 90000500 CPT outpatient 22.68 22.68 22.68 22.68 REV FULLWEDGE BP 15 DEG.25MM 90000505 CPT outpatient 221.64 221.64 221.64 221.64 PLATE 2 HOLE 7MM 90000507 CPT outpatient 316.25 316.25 316.25 316.25 PLATE 2 HOLE 8MM 90000508 CPT outpatient 316.25 316.25 316.25 316.25 HME SUB 90000510 CPT outpatient 15.82 15.82 15.82 15.82 PERFORMAX SMALL 90000516 CPT outpatient 314.16 314.16 314.16 314.16 PERFORMAX LARGE 90000517 CPT outpatient 314.16 314.16 314.16 314.16 FILTER BACTERIA HOSE BARB TO THREAD 90000518 CPT outpatient 24.74 24.74 24.74 24.74 CAMEL ABSORBENT MAT 90000531 CPT outpatient 26.5 26.5 26.5 26.5 CRUTCHES TALL 90000534 CPT outpatient 25.7 25.7 25.7 25.7 CRUTCHES MEDIUM 90000535 CPT outpatient 12.68 12.68 12.68 12.68 CRUTCHES YOUTH 90000536 CPT outpatient 12.68 12.68 12.68 12.68 T-STRYKER SYSTEM 7 DRILL W/BATTERIES 90000550 CPT outpatient 25.7 25.7 25.7 25.7 FACE MASK 90000559 CPT outpatient 5 5 5 5 ETHICON ENDO-SURGERY 5MM 90000589 CPT outpatient 22.68 22.68 22.68 22.68 ETHICON 2-0 18 ETHILON 90000593 CPT outpatient 9 9 9 9 HEAD POSITIONER (LARGE) 90000599 CPT outpatient 26.5 26.5 26.5 26.5 DUO VENTED INSTRUMENT GUARD ORANGE 90000607 CPT outpatient 250 250 250 250 DURAFLEX GRAFT 6CM C 8CM 90000608 CPT outpatient 528 528 528 528 C-ARM COVER 90000662 CPT outpatient 14.95 14.95 14.95 14.95 EXTREMITY DRAPE 90000692 CPT outpatient 26.5 26.5 26.5 26.5 U IMPERVIOS DRAPE 90000693 CPT outpatient 26.5 26.5 26.5 26.5 IRRIGATION SYRINGE 60ML 90000697 CPT outpatient 7.95 7.95 7.95 7.95 BENEPROTEIN POWDER PACK 7GM 90000699 CPT outpatient 25 25 25 25 NEPRO 90000702 CPT outpatient 41.57 41.57 41.57 41.57 OSTEOTOMY SAW BLADE HUB STYLE S 90000704 CPT outpatient 6.06 6.06 6.06 6.06 T-PIECE TRACH CARE 14FR 90000716 CPT outpatient 51.87 51.87 51.87 51.87 INLINE SX CATH TRACH 90000717 CPT outpatient 51.87 51.87 51.87 51.87 SHILEY TRACH 6 UNCUFF/FEN 90000718 CPT outpatient 51.87 51.87 51.87 51.87 AMBU BAGS 90000746 CPT outpatient 56.25 56.25 56.25 56.25 WALKER W/WHEELS 90000749 CPT outpatient 256.4 256.4 256.4 256.4 JEVITY 1.5 CAL LIQUID 1000ML 90000754 CPT outpatient 42.48 42.48 42.48 42.48 WALKER W/WHEELS YOUTH 90000758 CPT outpatient 256.4 256.4 256.4 256.4 ETHICON 2-0 18 COATED VICRYL 90000762 CPT outpatient 44.18 44.18 44.18 44.18 QUINTON CATH 12FRX20CM 90000768 CPT outpatient 510.02 510.02 510.02 510.02 ORAL SWAB KITS 90000794 CPT outpatient 5.29 5.29 5.29 5.29 COURIER FEE 90000801 CPT outpatient 6.06 6.06 6.06 6.06 CLEAR AID ZINC 90000803 CPT outpatient 151.25 151.25 151.25 151.25 TRACH CARE KIT 90000810 CPT outpatient 6.71 6.71 6.71 6.71 ETHICON 3-0 30 PERMA-AND SILK 90000832 CPT outpatient 9 9 9 9 MALE INCONTINENCE WRAP 90000835 CPT outpatient 43.33 43.33 43.33 43.33 SPIKE SET W/ BAG 90000840 CPT outpatient 25.67 25.67 25.67 25.67 DIGNICARE BAGS 90000866 CPT outpatient 11.19 11.19 11.19 11.19 OPTIFOAM GENTLE 4 X 4 90000873 CPT outpatient 10.09 10.09 10.09 10.09 OPTIFOAM GENTLE 6 X6 90000874 CPT outpatient 14.28 14.28 14.28 14.28 IV LINE ARMBOARD 90000903 CPT outpatient 51.87 51.87 51.87 51.87 TPN TUBING (NURSING) 90000906 CPT outpatient 34.58 34.58 34.58 34.58 ORAL CARE KIT 90000913 CPT outpatient 67.06 67.06 67.06 67.06 ETHILON 1 60 BLACK 90000924 CPT outpatient 11.74 11.74 11.74 11.74 ETHICON 3-0 36 COATED VICRYL 90000944 CPT outpatient 22.68 22.68 22.68 22.68 PRE-SUTURED TENDON QUAD STRAND 90000966 CPT outpatient 314.16 314.16 314.16 314.16 ETHICON 2-0 18 ETHILON 90000979 CPT outpatient 9 9 9 9 SARS COVID API 90000987 CPT outpatient 32.52 32.52 32.52 32.52 ETHICON 0 60 PDS II 90000990 CPT outpatient 9 9 9 9 ENDOTRACHEAL STYLET SLICK 10FR 90001000 CPT outpatient 25.7 25.7 25.7 25.7 HYDRO BACTERIAL FILTER 90001003 CPT outpatient 21 21 21 21 ROD CURVE 5.5 X 45MM 90001005 CPT outpatient 25.7 25.7 25.7 25.7 1.6MM GUIDEWIRE 90001006 CPT outpatient 6.06 6.06 6.06 6.06 G-TUBE CONNECTOR 90001010 CPT outpatient 25.7 25.7 25.7 25.7 CAVICIDE DISINFECTANT 24oz 90001024 CPT outpatient 51.87 51.87 51.87 51.87 INTEGRA MONITOR ICP EXTERNAL DRAINAGE BA 90001033 CPT outpatient 44.18 44.18 44.18 44.18 LOVE-GRUENWALD IVD 3X10MM 7 STR 90001053 CPT outpatient 44.18 44.18 44.18 44.18 10.5 X 60MM SCREW 90001060 CPT outpatient 316.25 316.25 316.25 316.25 SHOULDER POUCH FLUID 90001067 CPT outpatient 250 250 250 250 MAYFIELD POSITIONER W/PINS 90001072 CPT outpatient 44.18 44.18 44.18 44.18 KINEMATX RADIAL STEM SZ 1 STERILE PACKED 90001100 CPT outpatient 6.06 6.06 6.06 6.06 PEEK CAGE ANTERIOR LUMBAR 30MM X 11MM 8 90001108 CPT outpatient 221.64 221.64 221.64 221.64 SURGICAL BLADES # 11 90001111 CPT outpatient 25.7 25.7 25.7 25.7 SURGICAL BLADES # 15 90001115 CPT outpatient 25.7 25.7 25.7 25.7 PLATE 1 LEVEL 20MM 90001120 CPT outpatient 51.87 51.87 51.87 51.87 PLATE 1 LEVEL 22MM 90001122 CPT outpatient 51.87 51.87 51.87 51.87 REV PHERIPHERAL SCREW DRILL BIT 3.2MM ST 90001126 CPT outpatient 221.64 221.64 221.64 221.64 FOAM HEAD POSTIONER 90001147 CPT outpatient 12.68 12.68 12.68 12.68 KINEMATX BOX CHISEL 90001150 CPT outpatient 6.06 6.06 6.06 6.06 8.0 / 9.5 X-POST REAMER 90001180 CPT outpatient 6.06 6.06 6.06 6.06 PERFORM STEM RSA-PERF REV LAT 90001197 CPT outpatient 6.33 6.33 6.33 6.33 FEMORAL COMPONENT CEMENTED 90001202 CPT outpatient 49.42 49.42 49.42 49.42 TIBIAL TRAY CEMENTED LEFT S2 90001203 CPT outpatient 49.42 49.42 49.42 49.42 TIBIAL TRAY CEMENTED RT S4 90001204 CPT outpatient 49.42 49.42 49.42 49.42 TIBIAL CEMENTED 90001205 CPT outpatient 49.42 49.42 49.42 49.42 FERORAL COMPONENT CEMENTED 90001206 CPT outpatient 49.42 49.42 49.42 49.42 TIBIAL INSERT E-CROSS 90001210 CPT outpatient 49.42 49.42 49.42 49.42 FEMORAL COMPONENT S4+R CEMENTED 90001214 CPT outpatient 49.42 49.42 49.42 49.42 TIBIAL INSERT E-CROSS 10MM 90001220 CPT outpatient 49.42 49.42 49.42 49.42 MAJOR PACK 90001233 CPT outpatient 221.64 221.64 221.64 221.64 PLATE 2 LEVEL 38MM 90001238 CPT outpatient 316.25 316.25 316.25 316.25 VICRYL 3-0 18 PS-2 90001240 CPT outpatient 168.64 168.64 168.64 168.64 TIBIAL COMPONENT CEMENTED 90001243 CPT outpatient 49.42 49.42 49.42 49.42 STRUXXURE STANDARD PLATE 2 LEVEL 48MM 90001248 CPT outpatient 5.38 5.38 5.38 5.38 STERILIZATION RECORD ENVELOPES 90001254 CPT outpatient 51.87 51.87 51.87 51.87 ELAN 4 1-RING DISP. OSEN BURR D4.0 90001265 CPT outpatient 51.87 51.87 51.87 51.87 STERILIZATION RECORD LABELS 90001269 CPT outpatient 51.87 51.87 51.87 51.87 "INDICATOR,STEAM STERILIZER,RAPID READ" 90001291 CPT outpatient 51.87 51.87 51.87 51.87 ROUND DRAIN 7FR W/O TROCAR 90001320 CPT outpatient 25.7 25.7 25.7 25.7 EAGLE UNIT PAPER 90001328 CPT outpatient 12.35 12.35 12.35 12.35 AESEPTICLAVE UNIT PAPER 90001329 CPT outpatient 12.35 12.35 12.35 12.35 ULNAR NERVE ARM POSITIONER 90001340 CPT outpatient 44.18 44.18 44.18 44.18 KINEMATX RADIAL CARTILAGE REMOVAL TOOL - 90001370 CPT outpatient 6.06 6.06 6.06 6.06 KINEMATX RADIAL BROACH SX 1 90001371 CPT outpatient 6.06 6.06 6.06 6.06 KINEMATX RADIAL BODY-LEFT PLUS 2 STERILE 90001373 CPT outpatient 6.06 6.06 6.06 6.06 KINEMATX 4.75MM LOCKING SCREW X 45MM 90001374 CPT outpatient 6.06 6.06 6.06 6.06 KINEKINEMATX STANDARD BASEPLATE 15MM STE 90001375 CPT outpatient 6.06 6.06 6.06 6.06 ETHICON 1 18 STRATAFIX SYMMETRIC 90001404 CPT outpatient 22.68 22.68 22.68 22.68 2-0 12 STRATAFIX PDS 36MM 90001410 CPT outpatient 22.68 22.68 22.68 22.68 2-0 6 STRATAFIX CT-2 26MM 90001413 CPT outpatient 22.68 22.68 22.68 22.68 CERVICAL PARELLEL 14D X 16W X 6H 90001416 CPT outpatient 51.87 51.87 51.87 51.87 ETHICON 2-0 18 STRATAFIX 90001417 CPT outpatient 22.68 22.68 22.68 22.68 3-0 15CM STRATAFIX SPIRAL PDS 26MM 90001420 CPT outpatient 22.68 22.68 22.68 22.68 STRATRAFIX SYMMETRIC PDS VIOLET CT-1 90001435 CPT outpatient 22.68 22.68 22.68 22.68 OLIVE WIRE 1.6MM SMOOTH SHORT 90001446 CPT outpatient 6.06 6.06 6.06 6.06 ARM SLING MEDIUM 90001506 CPT outpatient 100 100 100 100 ARM SLING LARGE 90001507 CPT outpatient 100 100 100 100 STERI-STRIPS 2/3CC 90001544 CPT outpatient 7.26 7.26 7.26 7.26 STERI STRIP 1/2 90001547 CPT outpatient 51.87 51.87 51.87 51.87 CERVICAL 14X16X7 90001607 CPT outpatient 51.87 51.87 51.87 51.87 CERVICAL 16X18 LORDOTIC 90001608 CPT outpatient 51.87 51.87 51.87 51.87 CERVICAL 16X18X6 LORDOTIC 90001618 CPT outpatient 51.87 51.87 51.87 51.87 FOAM POSITIONER KIT SCHLEIN 90001647 CPT outpatient 51.87 51.87 51.87 51.87 VICRYL 4-0 18 PS-2 90001649 CPT outpatient 12.87 12.87 12.87 12.87 VICRYL 0 18 CT-2 90001653 CPT outpatient 36.99 36.99 36.99 36.99 ETHICON 2-0 30 ETHILON 90001674 CPT outpatient 16.59 16.59 16.59 16.59 ETHICON 3-0 18 PERMA-HAND SILK 90001679 CPT outpatient 9 9 9 9 PLASTER SPLINT 3 X 15 90001700 CPT outpatient 51.87 51.87 51.87 51.87 FACE SHIELD DISPOSABLE 90001800 CPT outpatient 25.7 25.7 25.7 25.7 CERVICAL 16X18X7 90001807 CPT outpatient 51.87 51.87 51.87 51.87 CERVICAL PARALLEL 16X18X10 90001810 CPT outpatient 5.38 5.38 5.38 5.38 CERVICAL 16X18 LORDTIC 6 90001818 CPT outpatient 5.38 5.38 5.38 5.38 LIGASURE BLUNT TIP 5MM-23CM 90001823 CPT outpatient 911.55 911.55 911.55 911.55 LIGASURE BLUNT TIP 5MM-37CM 90001837 CPT outpatient 911.55 911.55 911.55 911.55 3 UNIVESAL COLLAR 90001900 CPT outpatient 100 100 100 100 STRUXXURE SCREW FIXED 4.0 X 14MM 90001907 CPT outpatient 51.87 51.87 51.87 51.87 STRUXXURE PLATE 2 LEVEL 36MM 90001908 CPT outpatient 51.87 51.87 51.87 51.87 LIGASURE MARYLAND JAW OPEN SEALER 90001923 CPT outpatient 911.55 911.55 911.55 911.55 STRATRAFIX SYMMETRY0 CT-1 90001935 CPT outpatient 22.68 22.68 22.68 22.68 SUTURE STRATAFIX 45CM 18 90001936 CPT outpatient 22.68 22.68 22.68 22.68 LIGASURE MARYLAND JAW LAPAROSCOPIC SEALE 90001937 CPT outpatient 911.55 911.55 911.55 911.55 NON-BILLABLE ITEM SURGICAL SYSTEM TRAY 90002005 CPT outpatient 6.06 6.06 6.06 6.06 TREE TRIMMING 90002025 CPT outpatient 10.15 10.15 10.15 10.15 CANNULATED DRILL - 3.OMM 90002030 CPT outpatient 6.06 6.06 6.06 6.06 PEANUT SPONGE SMALL 90002038 CPT outpatient 5 5 5 5 LOCKING COVER 7MM 90002107 CPT outpatient 316.25 316.25 316.25 316.25 LOCKING COVER 8MM 90002108 CPT outpatient 316.25 316.25 316.25 316.25 PLATE ONE LEVEL 14MM 90002114 CPT outpatient 221.64 221.64 221.64 221.64 FEMORAL COMP CEMENTED 90002121 CPT outpatient 49.42 49.42 49.42 49.42 TIBIAL INSERT E-CROSS 10MM 90002124 CPT outpatient 49.42 49.42 49.42 49.42 PAPER SELF SEAL POUCH 8 X 16 90002168 CPT outpatient 51.87 51.87 51.87 51.87 NT-22 X 10MM 6 STRAIGHT TI CAGE 90002210 CPT outpatient 316.25 316.25 316.25 316.25 LUMBAR INTERBODY 22X11MM 90002211 CPT outpatient 316.25 316.25 316.25 316.25 REDUCTION SCREW 7.5 X 30MM 90002212 CPT outpatient 316.25 316.25 316.25 316.25 PAPER SELF-SEAL 3 1/2 X 9 7/8 90002309 CPT outpatient 51.87 51.87 51.87 51.87 ACUFEX/DYONICS LEG HOLDER 90002310 CPT outpatient 5 5 5 5 MEDTRONIC AQUAMANTYS 2.3 BIPOLAR SEALER 90002311 CPT outpatient 22.68 22.68 22.68 22.68 MEDTRONIC EPIDURAL VEIN SEALER 90002312 CPT outpatient 22.68 22.68 22.68 22.68 FIXED SCREW 3.75 X 14MM 90002314 CPT outpatient 221.64 221.64 221.64 221.64 PAPER SELF SEAL POUCH 5 1/2 X 10 90002318 CPT outpatient 51.87 51.87 51.87 51.87 SELF SEAL POUCH 3 1/2 X 22 90002322 CPT outpatient 51.87 51.87 51.87 51.87 "TENSILE STRENGHT SZ 1, SZ 2 24CM" 90002402 CPT outpatient 22.68 22.68 22.68 22.68 STRAIGHT INTERBODY 24X9X6 90002409 CPT outpatient 316.25 316.25 316.25 316.25 TIBIA INSERT E-CROSS 10MM 90002410 CPT outpatient 49.42 49.42 49.42 49.42 STRAIGHT INTERBODY 24X11X8 90002411 CPT outpatient 49.42 49.42 49.42 49.42 STRAIGHT INTERBODY 24X14X6 90002414 CPT outpatient 316.25 316.25 316.25 316.25 TEMPORAL SCANNER 90002427 CPT outpatient 250 250 250 250 STOCKINETTE 8X48 90002430 CPT outpatient 25.7 25.7 25.7 25.7 PAPER SELF SEAL POUCH 5 1/2 X 10 90002510 CPT outpatient 51.87 51.87 51.87 51.87 STERILE STOCKINETTE 6X30 90002520 CPT outpatient 25.7 25.7 25.7 25.7 LUMBAR INTERBODY 26X10MM 6 90002610 CPT outpatient 316.25 316.25 316.25 316.25 TIBIAL INSERT 11MM FLEX 6R 90002621 CPT outpatient 49.42 49.42 49.42 49.42 STOCKINETTE 4X4 90002640 CPT outpatient 25.7 25.7 25.7 25.7 STOCKINETTE 6X4 90002660 CPT outpatient 25.7 25.7 25.7 25.7 PAPER SELF SEAL POUCH 7 1/2 X 13 90002713 CPT outpatient 51.87 51.87 51.87 51.87 STERILE GUIDE PIN 90002908 CPT outpatient 6.33 6.33 6.33 6.33 SYNTHES 0.8MM KIESCHNER WIRE 70MM 90002920 CPT outpatient 22.68 22.68 22.68 22.68 SUPRAPUBIC CATH KIT 14FR 90003004 CPT outpatient 44.18 44.18 44.18 44.18 SUPRAPUBIC CATH KIT 16FR 90003040 CPT outpatient 44.18 44.18 44.18 44.18 ET TUBE 6.0MM 90003060 CPT outpatient 25.7 25.7 25.7 25.7 ET TUBE 8.5MM 90003085 CPT outpatient 32.52 32.52 32.52 32.52 INTERBODY 14X13XX8MM 90003087 CPT outpatient 316.25 316.25 316.25 316.25 SHORT-NARROW BLADE 15MM X 7MM 90003103 CPT outpatient 51.87 51.87 51.87 51.87 PLATE 2 LEVEL 40MM 90003124 CPT outpatient 51.87 51.87 51.87 51.87 AC PLATE 3 LEVEL 57MM 90003157 CPT outpatient 5.38 5.38 5.38 5.38 VARIABLE SELF DRILL 3.5X14MM SCREW 90003214 CPT outpatient 316.25 316.25 316.25 316.25 NT-THR VARIABLE SCREW 4.0 X 14MM 90003264 CPT outpatient 316.25 316.25 316.25 316.25 NT-THR FIXEDSCREW 4.0 X 14MM 90003274 CPT outpatient 316.25 316.25 316.25 316.25 SCREW 3.5 X 18MM 90003518 CPT outpatient 25.7 25.7 25.7 25.7 SCREW 3.5 X 20MM 90003520 CPT outpatient 25.7 25.7 25.7 25.7 PLASTER BANDAGE 5 X30 90003677 CPT outpatient 12.68 12.68 12.68 12.68 ETHICON 1 36' PDS 90003717 CPT outpatient 22.68 22.68 22.68 22.68 KINEMATX CARPAL CAP STERILE PACK 90003731 CPT outpatient 6.06 6.06 6.06 6.06 SCREW 5.5 X 30MM 90003950 CPT outpatient 25.7 25.7 25.7 25.7 PEDICLE SCREW 7.5 X 45MM 90003975 CPT outpatient 316.25 316.25 316.25 316.25 NT-REFORM 8.5 X 40MM POLY PEDICLE SCREW 90003985 CPT outpatient 316.25 316.25 316.25 316.25 REFORM 9.5 X 70MM POLY PEDICLE SCREW 90003986 CPT outpatient 316.25 316.25 316.25 316.25 4.0 X 14MM VARIABLE SCREW 90004014 CPT outpatient 51.87 51.87 51.87 51.87 VARIABLE SCREW 4.0 X 4016 90004016 CPT outpatient 316.25 316.25 316.25 316.25 SCREW 4.0 X 18MM 90004018 CPT outpatient 25.7 25.7 25.7 25.7 SCREW 4.5 X 20MM 90004020 CPT outpatient 25.7 25.7 25.7 25.7 ART GUIDEWIRE .25 90004025 CPT outpatient 100 100 100 100 VARIABLE SCREW 4.35 X 16MM 90004036 CPT outpatient 316.25 316.25 316.25 316.25 INTERBODY 16X14X7MM 90004077 CPT outpatient 316.25 316.25 316.25 316.25 STEAM INTERGRATOR RECORD CARD 90004171 CPT outpatient 51.87 51.87 51.87 51.87 ETHICON 2-0 27 COATED VICRYL PLUS ANTIB 90004200 CPT outpatient 44.18 44.18 44.18 44.18 TOURNIQUET 34 X4 SINGLE BLADDER 90004235 CPT outpatient 12 12 12 12 RAD 97 PULSE OX CABLE 5' 90004256 CPT outpatient 250 250 250 250 RAD 97 PULSE OX CABLE 12' 90004257 CPT outpatient 250 250 250 250 4.35 X 16MM FIXED SCREW 90004314 CPT outpatient 51.87 51.87 51.87 51.87 4.35 X 16MM FIXED TAPPING SCREW 90004316 CPT outpatient 316.25 316.25 316.25 316.25 VARIABLE SCREW 4.0 X 18MM 90004318 CPT outpatient 316.25 316.25 316.25 316.25 REV INSERT SZ 3/4 36MM +3 RET 90004363 CPT outpatient 221.64 221.64 221.64 221.64 FIXED SCREW 4.0 X 18MM 90004418 CPT outpatient 316.25 316.25 316.25 316.25 NASAL CANNULA W/EAR CUSHION 90004514 CPT outpatient 11.74 11.74 11.74 11.74 SCREW 4.0 X 20MM 90004520 CPT outpatient 25.7 25.7 25.7 25.7 SCREW 4.5 X 25MM 90004525 CPT outpatient 25.7 25.7 25.7 25.7 SCREW 4.5 X 30MM 90004530 CPT outpatient 25.7 25.7 25.7 25.7 REDUCTION SCREW 8.5MM X 45MM 90004538 CPT outpatient 250 250 250 250 POLYAXIAL SCREW 8.5X45MM 90004539 CPT outpatient 250 250 250 250 COVIDIEN ENDO GIA 45MM 90004545 CPT outpatient 22.68 22.68 22.68 22.68 COVIDIEN ENDO GIA 60MM 90004560 CPT outpatient 22.68 22.68 22.68 22.68 KINEMATX 4.75MM LOCKING SCREW X 15MM 90004751 CPT outpatient 6.06 6.06 6.06 6.06 5 LEAD WIRE GRABBER 36 90004786 CPT outpatient 51.87 51.87 51.87 51.87 5 LEAD WIRE GRABBER 36 DISPOSABLE 90004787 CPT outpatient 51.87 51.87 51.87 51.87 WRAP 48 X 48 SUB 90004848 CPT outpatient 256.4 256.4 256.4 256.4 EPIDURAL SYRINGE 7ML 90004900 CPT outpatient 256.4 256.4 256.4 256.4 CAVICIDE 1 SURFACE 1 GALLON 90005000 CPT outpatient 51.87 51.87 51.87 51.87 INTEGRA HERMETRCLUMETR LUMBER CLOSED TIP 90005005 CPT outpatient 44.18 44.18 44.18 44.18 WITTACRE INTRODUCER 24X3.5 90005010 CPT outpatient 12.68 12.68 12.68 12.68 CERVICAL 12X14X6 90005012 CPT outpatient 316.25 316.25 316.25 316.25 MATRIXX CERVICAL 14X16X7 90005014 CPT outpatient 5.38 5.38 5.38 5.38 MATRIXX CERVICAL 14X16X8 90005016 CPT outpatient 5.38 5.38 5.38 5.38 CERVICAL PARALLEL 16X18X7 90005018 CPT outpatient 316.25 316.25 316.25 316.25 ETHICON EVARREST FIBRIN PATCH 2 X4 90005024 CPT outpatient 22.68 22.68 22.68 22.68 40MM ROD 90005040 CPT outpatient 316.25 316.25 316.25 316.25 STRAIGHT ROD 3.5 X 50MM 90005050 CPT outpatient 25.7 25.7 25.7 25.7 WITTACRE SPINAL NEEDLE 22G X 3.5 90005051 CPT outpatient 12.68 12.68 12.68 12.68 STRAIGHT ROD 3.5 X 70MM TITANIUM 90005070 CPT outpatient 25.7 25.7 25.7 25.7 LORDOTIC TI ROD 5.5 X 75MM 90005075 CPT outpatient 316.25 316.25 316.25 316.25 LORDOTIC TI ROD 5.5 X 70MM 90005076 CPT outpatient 316.25 316.25 316.25 316.25 LORDOTIC TI ROD 5.5 X 75MM 90005077 CPT outpatient 316.25 316.25 316.25 316.25 ROD 5.5 X 80MM 90005080 CPT outpatient 316.25 316.25 316.25 316.25 ROD 5.5 X 70MM 90005090 CPT outpatient 316.25 316.25 316.25 316.25 TI ROD 5.50 X 100MM 90005100 CPT outpatient 316.25 316.25 316.25 316.25 TRIPLE LUMEN CATH 13FRX12.5CM CUR 90005120 CPT outpatient 510.02 510.02 510.02 510.02 TRIPLE LUMEN CATH 13FRX15CM CUR 90005150 CPT outpatient 510.02 510.02 510.02 510.02 TRIPLE LUMEN CATH 13FRX20CM CUR 90005200 CPT outpatient 510.02 510.02 510.02 510.02 T-LEICA SURGICAL MICROSCOPE 90005254 CPT outpatient 14.95 14.95 14.95 14.95 ROD HEX END 5.5 X 300MM 90005300 CPT outpatient 316.25 316.25 316.25 316.25 400MM ROD 90005400 CPT outpatient 316.25 316.25 316.25 316.25 STANDARD CUP SCREW 90005501 CPT outpatient 25.7 25.7 25.7 25.7 TRANSITION ROD 3.5 - 5.5 X 250MM 90005502 CPT outpatient 25.7 25.7 25.7 25.7 ENDOTRACHEAL STYLET SLICK 10FR 90005530 CPT outpatient 25.7 25.7 25.7 25.7 5.5 X 40M SCREW 90005540 CPT outpatient 316.25 316.25 316.25 316.25 4-0 NEUROLON 90005544 CPT outpatient 96 96 96 96 ROD 5.5 X 50 90005550 CPT outpatient 316.25 316.25 316.25 316.25 ROD 5.5 X 55 90005555 CPT outpatient 316.25 316.25 316.25 316.25 5.0MM ROUND FLUTED BUR 90005820 CPT outpatient 22.68 22.68 22.68 22.68 PRP KIT 90005877 CPT outpatient 316.25 316.25 316.25 316.25 MIDLINE ABO SCREW 6.0 X 25MM 90006025 CPT outpatient 221.64 221.64 221.64 221.64 MIDLINE ABO SCREW 6.0 X 30MM 90006030 CPT outpatient 221.64 221.64 221.64 221.64 MIDLINE ABO REVISION SCREW 6.0 X 30MM 90006031 CPT outpatient 221.64 221.64 221.64 221.64 MULTI LUMEN TRAY 90006117 CPT outpatient 100 100 100 100 B/P ADAPTER WELCH ALLYN 90006224 CPT outpatient 9.26 9.26 9.26 9.26 BARI WALKER W/WHEELS 90006410 CPT outpatient 256.4 256.4 256.4 256.4 6.5 X 30MM SCREW 90006530 CPT outpatient 316.25 316.25 316.25 316.25 6.5 X 40MM SCREW 90006531 CPT outpatient 316.25 316.25 316.25 316.25 6.5 X 35MM SCREW 90006532 CPT outpatient 316.25 316.25 316.25 316.25 7.5 X 35MM SCREW 90006533 CPT outpatient 316.25 316.25 316.25 316.25 PARALLEL DOMINO CLOSED OPEN NARROW 90006534 CPT outpatient 316.25 316.25 316.25 316.25 REDUCTION SCREW 6.5 X 35MM 90006535 CPT outpatient 25.7 25.7 25.7 25.7 DOMINO WIDE PARALLEL 90006536 CPT outpatient 316.25 316.25 316.25 316.25 6.5 X 40MM SCREW 90006539 CPT outpatient 316.25 316.25 316.25 316.25 POLYAXIALSCREW 6.5X40MM 90006540 CPT outpatient 250 250 250 250 65 X 45MM SCREW 90006545 CPT outpatient 250 250 250 250 PASSPORT BUTTON CANNULA 90006592 CPT outpatient 314.16 314.16 314.16 314.16 3M BAIR HUGGER HOSE 90006752 CPT outpatient 44.18 44.18 44.18 44.18 DRAIN CHEST PLEURAVAC 90007000 CPT outpatient 537.4 537.4 537.4 537.4 STRYKER NEURO (HEAD MATCH) 3.0MM 90007030 CPT outpatient 22.68 22.68 22.68 22.68 K-WIRE DOUBLE END TROCAR 0.03 X 9 90007111 CPT outpatient 12.68 12.68 12.68 12.68 K-WIRE DOUBLE END TROCAR 0.045 X 9 90007112 CPT outpatient 12.68 12.68 12.68 12.68 TEAR CROSS-CUT RASP SMALL 90007113 CPT outpatient 51.87 51.87 51.87 51.87 TEAR CROSS-CUT RASP LARGE 90007114 CPT outpatient 51.87 51.87 51.87 51.87 "FIBERWIRE, BRAIDED SUTURES" 90007201 CPT outpatient 250 250 250 250 "FIBERLINK 2, BRAIDED SUTURE" 90007202 CPT outpatient 250 250 250 250 FIBERTAPE BLU W/NDLS 17 TAPE 90007217 CPT outpatient 250 250 250 250 NT-22 X 12MM 6 STRAIGHT TI CAGE 90007222 CPT outpatient 316.25 316.25 316.25 316.25 FIBERTAPE 90007237 CPT outpatient 314.16 314.16 314.16 314.16 PLASTER ROLL SPLINT 4 90007334 CPT outpatient 51.87 51.87 51.87 51.87 PLASTER ROLL SPLINT 5 90007335 CPT outpatient 51.87 51.87 51.87 51.87 WELCH ALLYN VITAL MACHINES 90007373 CPT outpatient 7.06 7.06 7.06 7.06 WELCH ALLYN MOBILE STAND 90007374 CPT outpatient 7.06 7.06 7.06 7.06 UPGRADE REBATE 90007375 CPT outpatient 7.06 7.06 7.06 7.06 NEEDLE TOUHY DISP 17G X 3.5 90007399 CPT outpatient 22.68 22.68 22.68 22.68 STRAIGHT INTERBODY 24X10X60 90007424 CPT outpatient 316.25 316.25 316.25 316.25 TI CAGE 26 X 11 X 6 90007425 CPT outpatient 316.25 316.25 316.25 316.25 "TUBING,WARMING SET,FLUID" 90007477 CPT outpatient 250 250 250 250 NEURO DRILL 3MM X 3.8MM PRECISION 90007530 CPT outpatient 51.87 51.87 51.87 51.87 POLYAXIALSCREW 7.5X40MM 90007540 CPT outpatient 250 250 250 250 REDUCTION SCREW 7.5 X 40MM 90007541 CPT outpatient 25.7 25.7 25.7 25.7 POLYAXIAL SCREW 7.5X45MM 90007545 CPT outpatient 250 250 250 250 PEDICLE SCREW 7.5 X 50MM 90007550 CPT outpatient 250 250 250 250 ETHICON 2-0 27 VICRYL 90007602 CPT outpatient 22.68 22.68 22.68 22.68 CHEST TUBE TRAY 90007603 CPT outpatient 101.87 101.87 101.87 101.87 K-WIRE DOUBLE END TROCAR 0.062 X 9 90007713 CPT outpatient 12.68 12.68 12.68 12.68 REDUCTION SCREW 6.5 X 35MM 90007739 CPT outpatient 316.25 316.25 316.25 316.25 REDUCTION SCREW 7.5 X 40MM 90007740 CPT outpatient 316.25 316.25 316.25 316.25 SUTURE PROLENE BLU MONO 2-0 30 SH 90007818 CPT outpatient 48.33 48.33 48.33 48.33 SUTURE PROLENE BLU MONO 0 30 SH 90007819 CPT outpatient 24.3 24.3 24.3 24.3 SUTURE ETHBND GRN BR 0 30 CT-1 B424H 90007820 CPT outpatient 10.08 10.08 10.08 10.08 SUTURE ETHLON BLK MONO 0 48 CT 90007824 CPT outpatient 18.87 18.87 18.87 18.87 SUTURE SOFSILK O BLK 18 90007825 CPT outpatient 21.15 21.15 21.15 21.15 SUTURE ETHBND GRN BR 1 30 CT-1 B4254H 90007826 CPT outpatient 9.33 9.33 9.33 9.33 SUTURE MONCRYL UD 3-0 18 PS-2 90007828 CPT outpatient 31.11 31.11 31.11 31.11 BONE WAX 90007835 CPT outpatient 29.16 29.16 29.16 29.16 SUTURE PROLENE BLU MONO 3-0 30 SH 90007837 CPT outpatient 18.03 18.03 18.03 18.03 DISTRACTION SCREWS 12MM 90007854 CPT outpatient 87.78 87.78 87.78 87.78 DURAFLEX GRAFT 2CM X 7CM 90007866 CPT outpatient 528 528 528 528 EVOLUTION: UNIVERSAL LUMBAR REMOVAL 90007887 CPT outpatient 100 100 100 100 CHROMIC GUT SUTURES 90007927 CPT outpatient 39.36 39.36 39.36 39.36 ARMOR RX - COVER UP 90007928 CPT outpatient 42.18 42.18 42.18 42.18 SPEED GRAFT 8.5 X 245 90008001 CPT outpatient 11.74 11.74 11.74 11.74 STEEL RACK FOR D E CYLINDERS 90008070 CPT outpatient 12.68 12.68 12.68 12.68 HUMERAL GUIDE PIN 3.0 X 100MM 90008100 CPT outpatient 221.64 221.64 221.64 221.64 MONOCRYL 4-0 27 90008109 CPT outpatient 22.68 22.68 22.68 22.68 MONOCRYL 4-0 PS-2 90008178 CPT outpatient 62.76 62.76 62.76 62.76 PLASTER SPLINT 5 X 30 90008190 CPT outpatient 51.87 51.87 51.87 51.87 ETHICON 0 - 36 VICRYL 90008232 CPT outpatient 9 9 9 9 SUTURE 3-0 NYLON PS-2 90008283 CPT outpatient 9.57 9.57 9.57 9.57 JEJUNAL FEDING TUBE 8.5FR 90008330 CPT outpatient 408.9 408.9 408.9 408.9 J-TUBE 14FR 90008331 CPT outpatient 618.81 618.81 618.81 618.81 PEG KIT 20FR 90008376 CPT outpatient 150 150 150 150 ETHICON 3-0 18 COATED VICRYL 90008384 CPT outpatient 31.5 31.5 31.5 31.5 ARTERIAL LINE KITS 90008500 CPT outpatient 148.56 148.56 148.56 148.56 8.5 X 45MM SCREW 90008545 CPT outpatient 316.25 316.25 316.25 316.25 REDUCTION SCREW 85 X 45MM SCREW 90008546 CPT outpatient 250 250 250 250 8.5 X 50MM SCREW 90008550 CPT outpatient 316.25 316.25 316.25 316.25 I-STAT CG4+ CARTRIDGE 90008551 CPT outpatient 25.7 25.7 25.7 25.7 SUTURE VICRYL UD BR CT 2-0 2 7 CT1 90008676 CPT outpatient 24.66 24.66 24.66 24.66 SUTURE VICRYL UD BR CT 2-0 2 7 CT2 90008677 CPT outpatient 26.31 26.31 26.31 26.31 TWINFIX 5.5MM SUTURE ANCHOR 90008678 CPT outpatient 522 522 522 522 SUTURE MONOSOF 2/0 18 BLK C15 90008680 CPT outpatient 30.06 30.06 30.06 30.06 VICRYL UD BR CT 0 36 CTX 90008681 CPT outpatient 27.42 27.42 27.42 27.42 VICRYL 0 CT-1 TAPER 18 90008683 CPT outpatient 135.09 135.09 135.09 135.09 MONOSOF BLACK 3/0 18 P-12 90008684 CPT outpatient 87.15 87.15 87.15 87.15 ETHICON 6-0 30 PROLENE 90008709 CPT outpatient 22.68 22.68 22.68 22.68 VICRYL 3-0 COATED 27 90008716 CPT outpatient 27.99 27.99 27.99 27.99 VICRYL PLUS 2-0 18 90008755 CPT outpatient 38.76 38.76 38.76 38.76 SE-METRX MIS FULL SYSTEM #1 90008801 CPT outpatient 100 100 100 100 SE-MAYFIELD-01 90008802 CPT outpatient 100 100 100 100 ZIMMER DERMATOME BLADES 90008810 CPT outpatient 12 12 12 12 ETHICON 2-0 18 PERMA-HAND SILK 90008851 CPT outpatient 22.68 22.68 22.68 22.68 4-0 MONOCRYL 90008855 CPT outpatient 16.59 16.59 16.59 16.59 3-0 VICRYL 18 90008879 CPT outpatient 28.5 28.5 28.5 28.5 3-0 VICRYL 36 SUTURE 90008880 CPT outpatient 9.57 9.57 9.57 9.57 0 VICRYL 18 SUTURE 90008882 CPT outpatient 31.5 31.5 31.5 31.5 3-0 MONOCRYL 27 SUTURE 90008884 CPT outpatient 8.01 8.01 8.01 8.01 LARGE 15G 90008905 CPT outpatient 135 135 135 135 BIOGEL UNDERGLOVES SZ 8 90008980 CPT outpatient 7.26 7.26 7.26 7.26 ETHICON 2-0 30 PROLENE 90009130 CPT outpatient 12 12 12 12 ETHICON 6-0 24 PROLENE 90009132 CPT outpatient 30.33 30.33 30.33 30.33 FINGERNAIL CLEANER 90009204 CPT outpatient 260.22 260.22 260.22 260.22 MILL DISPOSABLE - FINE 90009218 CPT outpatient 11.39 11.39 11.39 11.39 BANDED BAG 36X28 90009249 CPT outpatient 5 5 5 5 SCREW 7.5 X 45MM 90009545 CPT outpatient 316.25 316.25 316.25 316.25 PEDICLE SCREW 9.5 X 50MM 90009550 CPT outpatient 316.25 316.25 316.25 316.25 REDUCTION SCREW 9.5 X 60MM 90009560 CPT outpatient 316.25 316.25 316.25 316.25 SCREW 7.5 X 50MM 90009755 CPT outpatient 316.25 316.25 316.25 316.25 REDUCTION SCREW 8.5 X 50MM 90009855 CPT outpatient 316.25 316.25 316.25 316.25 TIBIALIS TENDON POSTERIOR 90009897 CPT outpatient 48.33 48.33 48.33 48.33 CERVICAL 14X16X7 90041607 CPT outpatient 51.87 51.87 51.87 51.87 CERVICAL 16X18X8 90061818 CPT outpatient 51.87 51.87 51.87 51.87 4.0 X 16MM FIXED SCREW SELF TAPPING 90094016 CPT outpatient 316.25 316.25 316.25 316.25 FLEXITIP SING EPIDURAL CATH 19TH 90099571 CPT outpatient 11.39 11.39 11.39 11.39 TWINFIX ULTRA SUTURE ANCHOR 6.5 90102605 CPT outpatient 94.5 94.5 94.5 94.5