Flint River Hospital Effective as of 01 01 2026 Hospital License # 094-693 Georgia State License Department Department Description Billing Code Charge Number Description CPT Code, HCPCS, DRG UB04 Rev Code Inpatient and Outpatient Price Cash Discounted Price De-Identified Minimum De-Identified Maximum Georgia DCH TraditionalMedicaid Payment Amount Medicare Traditional Payment Amount Anthem Blue Cross Wellcare Medicare Advantage Plan Amerigroup Medicaid Advantage Plan Peach State Ambetter CareSource United Healthcare Aetna Kaiser Tri-Care Humana United Healthcare EON Healthcare / Clear Spring Health Provider Network of America N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A Medicaid State of Georgia Plan Medicare Federal Plan PPO Plans, POS Plans Medicare PPO Medicare PPO Medicaid CMO Plan Commercial Insuarance Plan Medicaid CMO Plan Medicare Advantage Plan Medicare Advantage Plan, PPO Kaiser Group Plan, Medicare Champus, Champ VA Medicare CMO POS, HMO, PPO, Medicare Advantage Medicare Advantage Plan Medicare Plan N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A MS-DRG = I/P, % Charges O/P, Case Rate MS-DRG = I/P, % Charges O/P, Case Rate Per Diem, % Charges, Case Rate MS-DRG = I/P % Charges O/P MS DRG = I/P % Charges O/P MS DRG = I/P % Charges O/P MS DRG = I/P % Charges O/P MS DRG = I/P % Charges O/P MS DRG = I/P % Charges O/P Case Rates MS DRG = I/P % Charges O/P Case Rates MS DRG = I/P % Charges O/P MS DRG = I/P % Charges O/P Case Rates MS DRG = I/P, % Charges O/P MS DRG = I/P, Percent Charges = O/P MS DRG = I/P, Percent Charges = O/P MS DRG = I/P, Percent Charges = O/P 3200 Hos Outpatient Treatment Facility Fee 3246 BONE MARROW NEEDLE BX (CHIP) 38221 761 124 86.8 26.96 124 63.17 26.96 93 26.96 63.17 63.17 63.17 63.17 26.96 29.656000000000002 26.96 26.96 26.96 26.96 27.499200000000002 26.96 3200 Hos Outpatient Treatment Facility Fee 3247 BONE MARROW ASPIRATION 38220 761 846 592.1999999999999 183.92 846 430.95 183.92 634.5 183.92 430.95 430.95 430.95 430.95 183.92 202.312 183.92 183.92 183.92 183.92 187.5984 183.92 3200 Hos Outpatient Treatment Facility Fee 3248 BONE MARROW ASPIRATION & BX G0364 761 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 3200 Hos Outpatient Treatment Facility Fee 3249 THERA. INFUSION EA ADD HR 96366 260 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 3200 Hos Outpatient Treatment Facility Fee 3251 BLADDER IRRIGATION 51700 761 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 3200 Hos Outpatient Treatment Facility Fee 3252 STRAIGHT CATH - TEMPORARY 51701 761 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 3200 Hos Outpatient Treatment Facility Fee 3253 FOLEY CATH INSERTION DIFFICULT 51703 761 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 3200 Hos Outpatient Treatment Facility Fee 3254 VENIPUNCTURE (PORT/VAD) 36591 761 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 3200 Hos Outpatient Treatment Facility Fee 3255 INITIAL IV ACCESS 36000 260 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 3200 Hos Outpatient Treatment Facility Fee 3256 VENIPUNTURE (CVL/PICC) 36592 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 3200 Hos Outpatient Treatment Facility Fee 3257 VENIPUNTURE (PERIPHERAL VENUS) 36415 761 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 3200 Hos Outpatient Treatment Facility Fee 3258 COLLECT BLOOD FROM IMPLANT/VAD 36591 300 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 3200 Hos Outpatient Treatment Facility Fee 3259 ADD SEQUEN. IV PUSH NEW DRUG 96375 260 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 3200 Hos Outpatient Treatment Facility Fee 3260 ADD. SEQUEN. INFUSION NEW DRUG 96367 260 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 3200 Hos Outpatient Treatment Facility Fee 3261 IV HYDRATION INITIAL 31-60MIN 96360 260 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 3200 Hos Outpatient Treatment Facility Fee 3262 HYDRATION INFUS EA HR UP TO 8H 96361 260 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 3200 Hos Outpatient Treatment Facility Fee 3263 FOLEY CATH INSERTION 51702 761 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 3200 Hos Outpatient Treatment Facility Fee 3264 ADD SEQUEN. IV PUSH SAME DRUG 96376 260 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 3200 Hos Outpatient Treatment Facility Fee 3265 IRRIGATION OF IMPLANTED VENOUS 96523 260 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 3200 Hos Outpatient Treatment Facility Fee 3266 ARTHROCENTESIS MAJOR JOINT 20610 360 374 261.8 81.31 374 190.52 81.31 280.5 81.31 190.52 190.52 190.52 190.52 81.31 89.44100000000002 81.31 81.31 81.31 81.31 82.9362 81.31 3200 Hos Outpatient Treatment Facility Fee 3268 Simple repair 2.5cm or < 12001 761 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 3200 Hos Outpatient Treatment Facility Fee 5047 CONCURRENT INFUSION 96368 260 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 3200 Hos Outpatient Treatment Facility Fee 3065689 CARIMUNE 500MG INJ J1566 636 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 3200 Hos Outpatient Treatment Facility Fee 3065690 IMMUNE GLOBULIN 500MG INJ J1566 636 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 3200 Hos Outpatient Treatment Facility Fee 3101367 TX ROOM WITHOUT PROCEDURE G0463 761 172 120.39999999999999 37.39 172 87.62 37.39 129 37.39 87.62 87.62 87.62 87.62 37.39 41.129000000000005 37.39 37.39 37.39 37.39 38.1378 37.39 3200 Hos Outpatient Treatment Facility Fee 3200003 REPEAT SQ OR IM INJECTION 96372 260 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 3200 Hos Outpatient Treatment Facility Fee 3200011 CHANGE G-TUBE 43760 761 531 371.7 115.44 531 270.49 115.44 398.25 115.44 270.49 270.49 270.49 270.49 115.44 126.98400000000001 115.44 115.44 115.44 115.44 117.7488 115.44 3200 Hos Outpatient Treatment Facility Fee 3200029 IV THERAPY INFUSION UP TO 1 HR 9636 260 301 210.7 65.44 301 153.33 65.44 225.75 65.44 153.33 153.33 153.33 153.33 65.44 71.98400000000001 65.44 65.44 65.44 65.44 66.7488 65.44 3200 Hos Outpatient Treatment Facility Fee 3200037 SQ OR IM INJ 96372 260 113 79.1 24.57 113 57.56 24.57 84.75 24.57 57.56 57.56 57.56 57.56 24.57 27.027 24.57 24.57 24.57 24.57 25.0614 24.57 3200 Hos Outpatient Treatment Facility Fee 3200052 OTHER DIAG. INJECTION 96374 761 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 3200 Hos Outpatient Treatment Facility Fee 3200292 REPEAT IM INJECT ANTIBIOTIC 96379 761 113 79.1 24.57 113 57.56 24.57 84.75 24.57 57.56 57.56 57.56 57.56 24.57 27.027 24.57 24.57 24.57 24.57 25.0614 24.57 3200 Hos Outpatient Treatment Facility Fee 3200904 CENTRAL LINE INSERTION >AGE 5 36556 760 2568 1797.6 558.28 2568 1308.14 558.28 1458 558.28 1308.14 1308.14 1308.14 1308.14 558.28 614.1080000000001 558.28 558.28 558.28 558.28 569.4456 558.28 3200 Hos Outpatient Treatment Facility Fee 3203007 LEGAL BLOOD DRAW 36415 300 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 3200 Hos Outpatient Treatment Facility Fee 3203759 LUMB PUNC DX (SPINAL TAP) 62270 761 878 614.5999999999999 190.88 878 447.25 190.88 658.5 190.88 447.25 447.25 447.25 447.25 190.88 209.96800000000002 190.88 190.88 190.88 190.88 194.6976 190.88 3200 Hos Outpatient Treatment Facility Fee 3220092 LUMBAR CATH INSERT & INJECT 62319 761 389 272.29999999999995 84.57 389 198.16 84.57 291.75 84.57 198.16 198.16 198.16 198.16 84.57 93.027 84.57 84.57 84.57 84.57 86.2614 84.57 4010 Hos Surgery Facility Fee 5027754 ADD 15 MIN O.R. L-1 N/A 360 342 239.39999999999998 74.35 342 174.21 74.35 256.5 74.35 174.21 174.21 174.21 174.21 74.35 81.785 74.35 74.35 74.35 74.35 75.83699999999999 74.35 4010 Hos Surgery Facility Fee 5027755 ADD 15 MIN O.R. L-2 N/A 360 427 298.9 92.83 427 217.51 92.83 320.25 92.83 217.51 217.51 217.51 217.51 92.83 102.113 92.83 92.83 92.83 92.83 94.6866 92.83 4010 Hos Surgery Facility Fee 5027756 ADD 15 MIN O.R. L-3 N/A 360 512 358.4 111.31 512 260.81 111.31 384 111.31 260.81 260.81 260.81 260.81 111.31 122.44100000000002 111.31 111.31 111.31 111.31 113.53620000000001 111.31 4010 Hos Surgery Facility Fee 5027758 ADD 15 MIN O.R. L-5 N/A 360 683 478.09999999999997 148.48 683 347.92 148.48 512.25 148.48 347.92 347.92 347.92 347.92 148.48 163.328 148.48 148.48 148.48 148.48 151.4496 148.48 4010 Hos Surgery Facility Fee 5027759 ADD 15 MIN O.R. L-6 N/A 360 768 537.5999999999999 166.96 768 391.22 166.96 576 166.96 391.22 391.22 391.22 391.22 166.96 183.65600000000003 166.96 166.96 166.96 166.96 170.2992 166.96 4010 Hos Surgery Facility Fee 5027757 ADD MIN O.R. L-4 N/A 360 597 417.9 129.79 597 304.11 129.79 447.75 129.79 304.11 304.11 304.11 304.11 129.79 142.769 129.79 129.79 129.79 129.79 132.3858 129.79 4010 Hos Surgery Facility Fee 6093 ALMALGAM-ONE SURFACE PERMANENT D2140 360 133 93.1 28.91 133 67.75 28.91 99.75 28.91 67.75 67.75 67.75 67.75 28.91 31.801000000000002 28.91 28.91 28.91 28.91 29.4882 28.91 4010 Hos Surgery Facility Fee 6092 ALMALGAM-ONE SURFACE PRIMARY D2140 360 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4010 Hos Surgery Facility Fee 6096 AMALGAM TWO SURFACES PERMANENT D2150 401 170 118.99999999999999 36.96 170 86.6 36.96 127.5 36.96 86.6 86.6 86.6 86.6 36.96 40.656000000000006 36.96 36.96 36.96 36.96 37.699200000000005 36.96 4010 Hos Surgery Facility Fee 6095 AMALGAM TWO SURFACES PRIMARY D2150 360 152 106.39999999999999 33.04 152 77.43 33.04 114 33.04 77.43 77.43 77.43 77.43 33.04 36.344 33.04 33.04 33.04 33.04 33.7008 33.04 4010 Hos Surgery Facility Fee 6088 BITEWING SINGLE FILM D0210 360 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4010 Hos Surgery Facility Fee 6071 BITEWING, TWO FILMS D0210 360 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4010 Hos Surgery Facility Fee 6086 CHANGE OF GASTRONOMY TUBE 43763 360 531 371.7 115.44 531 270.49 115.44 398.25 115.44 270.49 270.49 270.49 270.49 115.44 126.98400000000001 115.44 115.44 115.44 115.44 117.7488 115.44 4010 Hos Surgery Facility Fee 5027748 CPR 92950 360 1063 744.0999999999999 231.1 1063 541.49 231.1 797.25 231.1 541.49 541.49 541.49 541.49 231.1 254.21 231.1 231.1 231.1 231.1 235.722 231.1 4010 Hos Surgery Facility Fee 6084 CROWN, FULL, BASE METAL D2750 360 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4010 Hos Surgery Facility Fee 6094 CYSTOURETHROSCOPY W/CALIBRATIO 52281 360 580 406 126.09 580 295.45 126.09 435 126.09 295.45 295.45 295.45 295.45 126.09 138.699 126.09 126.09 126.09 126.09 128.61180000000002 126.09 4010 Hos Surgery Facility Fee 6085 DEBRIDE SKIN & SUBQ. TISSUE 11042 360 230 161 50 230 117.16 50 172.5 50 117.16 117.16 117.16 117.16 50 55.00000000000001 50 50 50 50 51 50 4010 Hos Surgery Facility Fee 512566 DENTAL PROCEDURE, UNLISTED 41899 360 256 179.2 55.65 256 130.41 55.65 192 55.65 130.41 130.41 130.41 130.41 55.65 61.215 55.65 55.65 55.65 55.65 56.763 55.65 4010 Hos Surgery Facility Fee 6091 EPIGASTRIC HERNIA REPAIR 49570 360 909 636.3 197.62 909 463.04 197.62 681.75 197.62 463.04 463.04 463.04 463.04 197.62 217.38200000000003 197.62 197.62 197.62 197.62 201.57240000000002 197.62 4010 Hos Surgery Facility Fee 5015409 ESWL WITH STENT 50590 790 15460 10822 3361.01 15460 7875.32 3361.01 1458 3361.01 7875.32 7875.32 7875.32 7875.32 3361.01 3697.1110000000003 3361.01 3361.01 3361.01 3361.01 3428.2302000000004 3361.01 4010 Hos Surgery Facility Fee 6077 EXTRACTION EA ADDTL TOOTH D7140 360 135 94.5 29.35 135 68.77 29.35 101.25 29.35 68.77 68.77 68.77 68.77 29.35 32.285000000000004 29.35 29.35 29.35 29.35 29.937 29.35 4010 Hos Surgery Facility Fee 6076 EXTRACTION ERUPTED TOOTH OR D7140 360 141 98.69999999999999 30.65 141 71.83 30.65 105.75 30.65 71.83 71.83 71.83 71.83 30.65 33.715 30.65 30.65 30.65 30.65 31.262999999999998 30.65 4010 Hos Surgery Facility Fee 6087 HEMORRHOIDECTOMY, INT. & EXT. 46260 360 766 536.1999999999999 166.53 766 390.2 166.53 574.5 166.53 390.2 390.2 390.2 390.2 166.53 183.18300000000002 166.53 166.53 166.53 166.53 169.8606 166.53 4010 Hos Surgery Facility Fee 6090 HERNIA REP. INIT/INCIS OR VENT 49560 360 1602 1121.3999999999999 348.28 1602 816.06 348.28 1201.5 348.28 816.06 816.06 816.06 816.06 348.28 383.108 348.28 348.28 348.28 348.28 355.24559999999997 348.28 4010 Hos Surgery Facility Fee 5021369 HOLMIUM LASER 52214 360 1687 1180.8999999999999 366.75 1687 859.36 366.75 1265.25 366.75 859.36 859.36 859.36 859.36 366.75 403.425 366.75 366.75 366.75 366.75 374.085 366.75 4010 Hos Surgery Facility Fee 6073 INTRAORAL PERIAPICAL EA ADDTL D0230 360 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4010 Hos Surgery Facility Fee 6072 INTRAORAL-PERIAPICAL 1ST FILM D0220 360 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4010 Hos Surgery Facility Fee 6007 PREFABRICATED SS CROWN PRIMARY D2930 360 316 221.2 68.7 316 160.97 68.7 237 68.7 160.97 160.97 160.97 160.97 68.7 75.57000000000001 68.7 68.7 68.7 68.7 70.074 68.7 4010 Hos Surgery Facility Fee 6070 PROPHYLAXIS-CHILD D1120 360 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4010 Hos Surgery Facility Fee 6075 RESIN BASED COMP-ONE SURFACE D2391 360 195 136.5 42.39 195 99.33 42.39 146.25 42.39 99.33 99.33 99.33 99.33 42.39 46.629000000000005 42.39 42.39 42.39 42.39 43.2378 42.39 4010 Hos Surgery Facility Fee 6080 RESIN BASED COMP-ONE SURFACE D2391 360 195 136.5 42.39 195 99.33 42.39 146.25 42.39 99.33 99.33 99.33 99.33 42.39 46.629000000000005 42.39 42.39 42.39 42.39 43.2378 42.39 4010 Hos Surgery Facility Fee 6081 RESIN BASED COMP-TWO SURFACE D2392 360 200 140 43.48 200 101.88 43.48 150 43.48 101.88 101.88 101.88 101.88 43.48 47.828 43.48 43.48 43.48 43.48 44.349599999999995 43.48 4010 Hos Surgery Facility Fee 6082 RESIN COMPOS CROWN ANTERIOR D2390 360 274 191.79999999999998 59.57 274 139.58 59.57 205.5 59.57 139.58 139.58 139.58 139.58 59.57 65.527 59.57 59.57 59.57 59.57 60.7614 59.57 4010 Hos Surgery Facility Fee 6008 RESIN-BASED COMP TWO SURFACE D2392 360 252 176.39999999999998 54.78 252 128.37 54.78 189 54.78 128.37 128.37 128.37 128.37 54.78 60.258 54.78 54.78 54.78 54.78 55.8756 54.78 4010 Hos Surgery Facility Fee 6009 RESIN-BASED COMP-TWO SURFACE D2392 360 302 211.39999999999998 65.65 302 153.84 65.65 226.5 65.65 153.84 153.84 153.84 153.84 65.65 72.21500000000002 65.65 65.65 65.65 65.65 66.96300000000001 65.65 4010 Hos Surgery Facility Fee 6000 RESIN-BASED COMPOSITE-ONE SURF D2391 360 156 109.19999999999999 33.91 156 79.47 33.91 117 33.91 79.47 79.47 79.47 79.47 33.91 37.301 33.91 33.91 33.91 33.91 34.5882 33.91 4010 Hos Surgery Facility Fee 6005 RESIN-BASED COMPOSITE-TWO SURF D2392 360 208 145.6 45.22 208 105.96 45.22 156 45.22 105.96 105.96 105.96 105.96 45.22 49.742000000000004 45.22 45.22 45.22 45.22 46.1244 45.22 4010 Hos Surgery Facility Fee 6006 RESIN-BASED COMPOSITE-TWO SURF D2392 360 243 170.1 52.83 243 123.78 52.83 182.25 52.83 123.78 123.78 123.78 123.78 52.83 58.113 52.83 52.83 52.83 52.83 53.8866 52.83 4010 Hos Surgery Facility Fee 6078 SPACE MAINTAINER-FIXED UNILAT. D1510 360 395 276.5 85.87 395 201.21 85.87 296.25 85.87 201.21 201.21 201.21 201.21 85.87 94.45700000000001 85.87 85.87 85.87 85.87 87.5874 85.87 4010 Hos Surgery Facility Fee 5061 SURGICAL PROCEDURE LEVEL 1 N/A 360 5111 3577.7 1111.13 5111 2603.54 1111.13 3833.25 1111.13 2603.54 2603.54 2603.54 2603.54 1111.13 1222.2430000000002 1111.13 1111.13 1111.13 1111.13 1133.3526000000002 1111.13 4010 Hos Surgery Facility Fee 5027749 SURGICAL PROCEDURE LEVEL 2 N/A 360 5963 4174.099999999999 1296.36 5963 3037.55 1296.36 4472.25 1296.36 3037.55 3037.55 3037.55 3037.55 1296.36 1425.996 1296.36 1296.36 1296.36 1296.36 1322.2872 1296.36 4010 Hos Surgery Facility Fee 5027750 SURGICAL PROCEDURE LEVEL 3 N/A 360 7666 5366.2 1666.59 7666 3905.06 1666.59 5749.5 1666.59 3905.06 3905.06 3905.06 3905.06 1666.59 1833.249 1666.59 1666.59 1666.59 1666.59 1699.9217999999998 1666.59 4010 Hos Surgery Facility Fee 5027751 SURGICAL PROCEDURE LEVEL 4 N/A 360 9540 6678 2074 9540 4859.68 2074 7155 2074 4859.68 4859.68 4859.68 4859.68 2074 2281.4 2074 2074 2074 2074 2115.48 2074 4010 Hos Surgery Facility Fee 5027752 SURGICAL PROCEDURE LEVEL 5 N/A 360 11073 7751.099999999999 2407.28 11073 5640.59 2407.28 8304.75 2407.28 5640.59 5640.59 5640.59 5640.59 2407.28 2648.0080000000003 2407.28 2407.28 2407.28 2407.28 2455.4256 2407.28 4010 Hos Surgery Facility Fee 5027753 SURGICAL PROCEDURE LEVEL 6 N/A 360 12777 8943.9 2777.73 12777 6508.6 2777.73 9582.75 2777.73 6508.6 6508.6 6508.6 6508.6 2777.73 3055.503 2777.73 2777.73 2777.73 2777.73 2833.2846 2777.73 4010 Hos Surgery Facility Fee 6079 THERAPEUTIC PULPOTOMY D3220 360 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4010 Hos Surgery Facility Fee 6083 TOPICAL APPLICATION /FLUORIDE D1201 360 59 41.3 12.83 59 30.05 12.83 44.25 12.83 30.05 30.05 30.05 30.05 12.83 14.113000000000001 12.83 12.83 12.83 12.83 13.0866 12.83 4010 Hos Surgery Facility Fee 6074 TOPICAL FLOURIDE VARNISH D1206 360 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4010 Hos Surgery Facility Fee 6089 UPPER GASTROINTESTINAL ENDOS. 43246 360 553 387.09999999999997 120.22 553 281.7 120.22 414.75 120.22 281.7 281.7 281.7 281.7 120.22 132.24200000000002 120.22 120.22 120.22 120.22 122.6244 120.22 4010 Hos Surgery Facility Fee 5029319 CHANGE GASTROSTOMY TUBE 43763 360 470 329 102.18 470 239.42 102.18 352.5 102.18 239.42 239.42 239.42 239.42 102.18 112.39800000000001 102.18 102.18 102.18 102.18 104.2236 102.18 4010 Hos Surgery Facility Fee 5029320 ENDOSCOPY LEVEL 1 43235 360 2130 1491 463.06 2130 1085.02 463.06 1597.5 463.06 1085.02 1085.02 1085.02 1085.02 463.06 509.36600000000004 463.06 463.06 463.06 463.06 472.32120000000003 463.06 4010 Hos Surgery Facility Fee 5029321 ENDOSCOPY LEVEL 2 43247 360 2840 1987.9999999999998 617.42 2840 1446.7 617.42 2130 617.42 1446.7 1446.7 1446.7 1446.7 617.42 679.162 617.42 617.42 617.42 617.42 629.7683999999999 617.42 4010 Hos Surgery Facility Fee 5029322 ENDOSCOPY LEVEL 3 43206 360 4543 3180.1 987.65 4543 2314.2 987.65 3407.25 987.65 2314.2 2314.2 2314.2 2314.2 987.65 1086.415 987.65 987.65 987.65 987.65 1007.403 987.65 4010 Hos Surgery Facility Fee 5017355 NASOPHARYNGOSCOPY 92511 360 1592 1114.3999999999999 346.1 1592 810.96 346.1 1194 346.1 810.96 810.96 810.96 810.96 346.1 380.71000000000004 346.1 346.1 346.1 346.1 353.02200000000005 346.1 4060 Hos Anesthesiology Facility Fee 1419712 A-P RESECTION 00800 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419852 ACCESS TO CENTRAL VEN. CIRC C9780 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419241 ACHILLES TENDON W or W/O GRAFT 01472 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419399 AMPUTATION, ABOVE KNEE 01482 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419266 ANKLE ARTHROSCOPY 01464 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419621 ANORECTAL 00812 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418663 AXILLARY NERVE BLOCK 00812 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418938 BKA 01120 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418953 BONE MARROW ILIAC CREST 01112 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418888 BONY PELVIS PROCEDURES 01112 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419886 BREAST WITH DISSECTION 00400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419894 BREAST;RAD, MOD,RAD. 00400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418912 BURN DEBRIDEMENT 4-9% 01951 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418920 BURN DEBRIDEMENT < 4% 01951 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418904 BURN DEBRIDEMENT EA ADDT'L 9% 01951 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419282 CAST, KNEE 01420 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1415025 CERTIFIED RN ANES PER UNIT N/A 964 137 95.89999999999999 29.78 137 69.79 29.78 102.75 29.78 69.79 69.79 69.79 69.79 29.78 32.758 29.78 29.78 29.78 29.78 30.375600000000002 29.78 4060 Hos Anesthesiology Facility Fee 1419480 CERVICAL CERCL. 00948 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419878 CLAVICLE,SCAPULA NOS 00450 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419506 COLPO. 00942 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419472 CULDOSCOPY 00950 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419027 CVL > 5YR OLD 36558 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419654 CYSTO LITHOTOMY 00142 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419035 DAILY EPID. DRUG ADMIN. 01996 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418961 DX or THER LUMBAR PUNCTURE 62328 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419977 EAR;INC. BX 00120 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418722 ELBOW, OPEN 01730 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419001 EMERGENCY INTUBATION 31500 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418862 IRIDECTOMY 00812 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418714 EPIDURAL DOSE W/O CATH 01967 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419043 EPIDURAL INSERTION 01967 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419910 ESOPH,THYR,LARY TRACH N.O.S. 00731 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419860 ESOPHAGUS 00731 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419647 ESWL W/O WATER BATH 00873 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419696 EXTRAPERITONEAL,LOW ABD,NOS 00862 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419969 EYE;N.O.S. 00142 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419415 FEMUR,CLOSED UPPER 2/3 01220 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419340 FEMUR,OPEN LOWER 1/3 01230 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419407 FEMUR,OPEN UPPER 2/3 01230 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419084 FOREARM TISSUE 01230 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419076 FOREARM, CLOSED 01820 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419068 FOREARM, OPEN 01820 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418821 FOREARM,WRIST,HAND,CAST 01820 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419928 HEAD,NECK,POST TRUNK N.O.S. 00300 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418813 HERNIA LOWER ABD. < 1YR 00830 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419746 HERNIA REPAIR LOWER ABD. NOS 00832 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419829 HERNIA,UPPER ABD,NOS 00832 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419456 HIP CLOSED 01214 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419449 HIP OPEN, NOS 01214 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419092 HUMERUS CYST/TUMOR 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419118 HUMERUS OSTEOTOMY 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418730 HUMERUS, ELBOW CLOSED 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419464 HYSTEROSCOPY 01967 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 24196464 HYTEROSCOPY 01967 964 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4060 Hos Anesthesiology Facility Fee 1419936 INTRAORAL;INCL. BX 00170 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 29.78 29.78 30.375600000000002 29.78 4060 Hos Anesthesiology Facility Fee 1419324 KNEE ARTHROSCOPY 01400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418763 KNEE ARTHROSCOPY W/PROCED. 01400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419332 KNEE CLOSED 01400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419290 KNEE OPEN/ARTHRO W/ PROCEDURE 01400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419365 KNEE TISSUE 01400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419316 KNEE,UPPER TIB-FIB, CLOSED 01400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419308 KNEE,UPPER TIB-FIB,OPEN 01400 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419720 LAPAROSCOPY LOW ABD 00840 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419795 LAPAROSCOPY UPPER ABD. 00840 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419951 LENS SURGERY 00142 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419787 LOWER ANT. ABD. WALL 00802 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419761 LOWER INTEST. ENDOSCOPY 00811 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419233 LOWER LEG BONE, OPEN 01480 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419217 LOWER LEG CAST 01480 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419258 LOWER LEG TISSUE, NOS 01480 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 2419258 LOWER LEG, TISSUE 01480 964 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4060 Hos Anesthesiology Facility Fee 1419274 LOWER LEG,CLOSED 01480 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419753 LOWER POST. ABD. WALL 00840 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419548 MALE EXT. GENIT., NOS 00100 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 2415025 MODERATE SEDATION 01999 370 137 95.89999999999999 29.78 137 69.79 29.78 102.75 29.78 69.79 69.79 69.79 69.79 29.78 32.758 29.78 29.78 29.78 29.78 30.375600000000002 29.78 4060 Hos Anesthesiology Facility Fee 1419050 NONINVAS RADIOLOGY 01922 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419944 NOSE,ACCESS SINUS,N.O.S. 00160 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419522 ORCHIPEXY 54640 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419225 OSTEOTOMY, TIB-FIB 00840 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419779 PANNICULECTOMY 00100 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418847 PERCUT. LIVER BX 00813 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419605 PERINEAL PROSTATE 01936 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418655 PICC LINE INSERTION 01936 964 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418789 PNEUMOCENTESIS 01924 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419563 POST-TUR BLEEDING 00834 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419704 RADICAL HYSTERECTOMY 00862 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418854 RADICAL ORCHIETOMY, INGUINAL 00811 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419662 RADICAL PROSTATE 01936 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419985 RECONSTRUCTIVE EYELID 00142 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419555 REMOVAL URETERAL CALCULI 00918 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419688 RENAL UPPER 1/3 URETER 00918 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418946 REVISION TOTAL HIP 01214 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419175 SHOULDER OPEN 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419159 SHOULDER SPICA 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419183 SHOULDER, ARTHROSCOPY 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419209 SHOULDER, AXILLA TISSUE 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419191 SHOULDER,CLOSED 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418947 SIMPLE LIGATION (ANES FOR MAJ 01967 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419902 SKIN,THORAX, NOS 00406 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419670 TOTAL CYSTECTOMY 00840 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419423 TOTAL HIP REPLACEMENT 01214 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418706 TOTAL KNEE ARTHROPLASTY 01402 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418681 TOTAL SHOULDER REPLACEMENT 01630 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 2418681 TOTAL SHOULDER REPLACEMENT 01630 964 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4060 Hos Anesthesiology Facility Fee 1419803 TRANSABD. DIAPHRAG. HERNIA 00942 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419597 TRANSURETH., NOS 00910 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418755 TUBAL LIGATION/TRANSECTION 00851 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419589 TURBT 00910 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419571 TURP 00910 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419530 UNDESCEND TESTIS 00924 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418987 UNLISTED ANESTHSIA PROCEDURE 01999 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419845 UPPER ANT. ABD. WALL NOS 00700 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419142 UPPER ARM TISSUE 01710 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419837 UPPER ENDOSCOPIC 00731 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 2419837 UPPER ENDOSCOPY 00732 964 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4060 Hos Anesthesiology Facility Fee 1419381 UPPER LEG TISSUE 01234 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419373 UPPER LEG VEINS 01234 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419498 VAGINAL HYST. 00942 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419514 VAGINAL,NOS 00942 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 2418698 VASCULAR SHUNT OR REV. 01844 964 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4060 Hos Anesthesiology Facility Fee 1418797 VASCULAR SHUNT/SHUNT REVI. 01844 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418805 VASECTOMY, UNI/BILAT. 00921 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1418839 VEINS LOWER LEG 01522 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419738 VENT. INCIS. HERNIA LOW ABD 00529 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419811 VENTRAL HERNIA,WOUND DEHISC. 00832 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4060 Hos Anesthesiology Facility Fee 1419613 VULVECTOMY 00812 370 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4120 Hos Pharmacy Facility Fee 3099994 ABILIFY 10MG TAB J8499 637 250 175 54.35 250 127.35 54.35 187.5 54.35 127.35 127.35 127.35 127.35 54.35 59.785000000000004 54.35 54.35 54.35 54.35 55.437000000000005 54.35 4120 Hos Pharmacy Facility Fee 3099995 ABILIFY 15MG TAB J8499 637 250 175 54.35 250 127.35 54.35 187.5 54.35 127.35 127.35 127.35 127.35 54.35 59.785000000000004 54.35 54.35 54.35 54.35 55.437000000000005 54.35 4120 Hos Pharmacy Facility Fee 3100029 ABILIFY 5MG TB J8499 637 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4120 Hos Pharmacy Facility Fee 3047859 ACETAMINOPHEN W/CODEINE 30/300 J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3100007 CHARCOAL W/SORBITOL 25 GM / 120 ML J8499 637 343 240.1 74.57 343 174.72 74.57 257.25 74.57 174.72 174.72 174.72 174.72 74.57 82.027 74.57 74.57 74.57 74.57 76.06139999999999 74.57 4120 Hos Pharmacy Facility Fee 3063310 ACTOS 15MG TAB J8499 637 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4120 Hos Pharmacy Facility Fee 3100033 ACYCLOVIR 400MG TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3039666 ADALAT 10MG CAPSULE J8499 637 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3010303 ADENOSINE INJ 6 MG / 1 EA J8499 636 865 605.5 188.05 865 440.63 188.05 648.75 188.05 440.63 440.63 440.63 440.63 188.05 206.85500000000002 188.05 188.05 188.05 188.05 191.811 188.05 4120 Hos Pharmacy Facility Fee 3010279 EPINEPHRINE 1:1000 INJ 1 EA J8499 250 170 118.99999999999999 36.96 170 86.6 36.96 127.5 36.96 86.6 86.6 86.6 86.6 36.96 40.656000000000006 36.96 36.96 36.96 36.96 37.699200000000005 36.96 4120 Hos Pharmacy Facility Fee 3064128 FLUTICASONE/SALMETEROL 100/50MG 1 EA J8499 637 798 558.5999999999999 173.49 798 406.5 173.49 598.5 173.49 406.5 406.5 406.5 406.5 173.49 190.83900000000003 173.49 173.49 173.49 173.49 176.9598 173.49 4120 Hos Pharmacy Facility Fee 3064136 ADVAIR INH 250/50 J8499 637 991 693.6999999999999 215.44 991 504.82 215.44 743.25 215.44 504.82 504.82 504.82 504.82 215.44 236.984 215.44 215.44 215.44 215.44 219.7488 215.44 4120 Hos Pharmacy Facility Fee 3064144 FLUTICASONE/SALMETEROL 500/50MG 1 EA J8499 637 1375 962.4999999999999 298.93 1375 700.43 298.93 1031.25 298.93 700.43 700.43 700.43 700.43 298.93 328.82300000000004 298.93 298.93 298.93 298.93 304.90860000000004 298.93 4120 Hos Pharmacy Facility Fee 3010352 OXYMETAZOLINE NASAL SPRAY 15 ML J8499 637 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4120 Hos Pharmacy Facility Fee 3010402 OXYMETAZOLINE NOSE DROPS 20 ML J8499 259 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3010659 ALDACTONE UNIT-DOSE 25 MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3062957 BRIMONIDINE OPHTH SOLN 5 ML J8499 637 425 297.5 92.4 425 216.5 92.4 318.75 92.4 216.5 216.5 216.5 216.5 92.4 101.64000000000001 92.4 92.4 92.4 92.4 94.248 92.4 4120 Hos Pharmacy Facility Fee 3060126 ALTACE 2.5MG CAP J8499 637 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4120 Hos Pharmacy Facility Fee 3100001 AMARYL 2MG TAB J8499 637 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4120 Hos Pharmacy Facility Fee 3062510 GLIMEPIRIDE 4 MG / 1 TAB J8499 637 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4120 Hos Pharmacy Facility Fee 3060373 AMBIEN 5MG J8499 637 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4120 Hos Pharmacy Facility Fee 3064666 AMIODARONE 0.6ML INJ 30 MG / 0.6 ML J8499 250 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4120 Hos Pharmacy Facility Fee 3023504 AMITRIPTYLINE 10 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3023405 AMITRIPTYLINE HCL 25MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3023454 AMITRIPTYLINE 100 MG / 1 TAB J8499 637 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4120 Hos Pharmacy Facility Fee 3060423 AMOXICILLIN 500MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3011707 ANUSOL HC SUPP. J8499 637 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4120 Hos Pharmacy Facility Fee 3011806 APLISOL 0.1CC J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3100050 ARICEPT 5MG TAB J8499 637 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4120 Hos Pharmacy Facility Fee 3062627 ARTANE 2MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3012598 ASCORBIC ACID 500MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3012788 ASPIRIN 325MG TAB J8499 637 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3052248 ASPIRIN 81MG TAB J8499 637 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3064433 ASPRIN 81MG CHEW TAB J8499 637 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3064680 ATENOLOL 25 MG TAB J8499 637 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4120 Hos Pharmacy Facility Fee 3045440 ATENOLOL 50MG TAB J8499 637 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4120 Hos Pharmacy Facility Fee 3013158 ATIVAN 0.5MG TAB J8499 637 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3013257 ATIVAN 1 MG TAB J8499 637 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4120 Hos Pharmacy Facility Fee 3051372 ATIVAN 2MG/ML INJ J8499 250 358 250.6 77.83 358 182.37 77.83 268.5 77.83 182.37 182.37 182.37 182.37 77.83 85.613 77.83 77.83 77.83 77.83 79.3866 77.83 4120 Hos Pharmacy Facility Fee 3100051 ATROPINE INJ 1MG J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3013455 AUGMENTIN 500MG TABS J8499 637 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4120 Hos Pharmacy Facility Fee 3064342 AUGMENTIN 875 TAB J8499 637 124 86.8 26.96 124 63.17 26.96 93 26.96 63.17 63.17 63.17 63.17 26.96 29.656000000000002 26.96 26.96 26.96 26.96 27.499200000000002 26.96 4120 Hos Pharmacy Facility Fee 3064657 DUTASTERIDE 0.5 MG / 1 CAP J8499 637 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4120 Hos Pharmacy Facility Fee 3099916 AZITHROMYCIN 500 MG INJ J8499 250 631 441.7 137.18 631 321.43 137.18 473.25 137.18 321.43 321.43 321.43 321.43 137.18 150.89800000000002 137.18 137.18 137.18 137.18 139.92360000000002 137.18 4120 Hos Pharmacy Facility Fee 3013513 SULFASALAZINE 500 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064177 BACITRACIN OINT 0.9GM PACKET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061561 BACITRACIN OINT 15 GM J8499 637 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4120 Hos Pharmacy Facility Fee 3051281 BACLOFEN 10MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3013604 BACTRIM DS 800-160MG J8499 259 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4120 Hos Pharmacy Facility Fee 3060050 BACTROBAN OINT 2% J8499 637 431 301.7 93.7 431 219.55 93.7 323.25 93.7 219.55 219.55 219.55 219.55 93.7 103.07000000000001 93.7 93.7 93.7 93.7 95.574 93.7 4120 Hos Pharmacy Facility Fee 3100054 BENZTROPINE 0.5MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3017910 BENZTROPINE MESYLATE 1MG TAB J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3100017 BICILLIN LA 1.2MU J8499 250 686 480.2 149.14 686 349.45 149.14 514.5 149.14 349.45 349.45 349.45 349.45 149.14 164.054 149.14 149.14 149.14 149.14 152.12279999999998 149.14 4120 Hos Pharmacy Facility Fee 3022902 BISACODYL 10MG SUPPOS. J8499 637 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3014909 BISACODYL 5MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3100064 BLEPH-10 OPTH LIQUIFILM 5ML J8499 637 230 161 50 230 117.16 50 172.5 50 117.16 117.16 117.16 117.16 50 55.00000000000001 50 50 50 50 51 50 4120 Hos Pharmacy Facility Fee 3064169 SULFACETAMIDE PREDNIZONE OPHTH SOLN 5 ML J8499 637 496 347.2 107.83 496 252.66 107.83 372 107.83 252.66 252.66 252.66 252.66 107.83 118.61300000000001 107.83 107.83 107.83 107.83 109.9866 107.83 4120 Hos Pharmacy Facility Fee 3015518 BUMETANIDE 1 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063740 BUPROPION 100mg TAB J8499 637 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4120 Hos Pharmacy Facility Fee 3060563 BUSPAR 5MG TAB J8499 259 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4120 Hos Pharmacy Facility Fee 3063039 VERAPAMIL HCL 120 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3015757 VERAPAMIL HCL INJ 2.5 MG / 1 EA J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3060670 CALAN SR 120MG TAB J8499 637 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4120 Hos Pharmacy Facility Fee 3060555 VERAPAMIL ER HCL 180 MG / 1 TAB J8499 637 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4120 Hos Pharmacy Facility Fee 3052487 CALAN SR 240MG TAB J8499 637 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4120 Hos Pharmacy Facility Fee 3015856 CALCIUM CHLORIDE VIAL 1 GM / 10 ML J8499 637 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3015906 CALCIUM GLUCONATE INJ 1 GM / 10 ML J8499 250 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4120 Hos Pharmacy Facility Fee 3016052 CAPTOPRIL 25 MG / 1 TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3016003 CAPTOPRIL 12.5MG TAB J8499 637 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3016110 CARAFATE TABLETS J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3020401 CARBAMIDE PEROXIDE 6.5% 15ML J8499 637 135 94.5 29.35 135 68.77 29.35 101.25 29.35 68.77 68.77 68.77 68.77 29.35 32.285000000000004 29.35 29.35 29.35 29.35 29.937 29.35 4120 Hos Pharmacy Facility Fee 3016144 CARDIZEM 30MG UD TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060274 CARDIZEM CD 120MG CAP J8499 637 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3052529 CARDIZEM CD 180MG CAP J8499 637 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4120 Hos Pharmacy Facility Fee 3060159 CARDURA 4MG TAB J8499 637 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3051711 CLONIDINE PATCH 0.1 MG / 1 EA J8499 637 234 163.79999999999998 50.87 234 119.2 50.87 175.5 50.87 119.2 119.2 119.2 119.2 50.87 55.957 50.87 50.87 50.87 50.87 51.8874 50.87 4120 Hos Pharmacy Facility Fee 3016268 CATAPRES 0.3MG TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3052446 CLONIDINE-TTS PATCH 0.2 MG / 1 EA J8499 637 348 243.6 75.66 348 177.27 75.66 261 75.66 177.27 177.27 177.27 177.27 75.66 83.226 75.66 75.66 75.66 75.66 77.1732 75.66 4120 Hos Pharmacy Facility Fee 3052453 CLONIDINE-TTS PATCH 0.3 MG / 1 EA J8499 637 482 337.4 104.79 482 245.53 104.79 361.5 104.79 245.53 245.53 245.53 245.53 104.79 115.26900000000002 104.79 104.79 104.79 104.79 106.8858 104.79 4120 Hos Pharmacy Facility Fee 3016201 CATAPRESS 0.1MG TAB J8499 637 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4120 Hos Pharmacy Facility Fee 3016250 CATAPRESS 0.2 MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3016474 CEFTIN 250MG TABLET J8499 637 140 98 30.44 140 71.32 30.44 105 30.44 71.32 71.32 71.32 71.32 30.44 33.484 30.44 30.44 30.44 30.44 31.048800000000004 30.44 4120 Hos Pharmacy Facility Fee 3041357 CEFTRIAXONE INJ 250 MG / 1 EA J8499 250 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4120 Hos Pharmacy Facility Fee 3063922 CELEXA 20mg Tab J8499 637 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4120 Hos Pharmacy Facility Fee 3016672 ACTIVATED CHARCOAL SUSP 25 GM J8499 637 263 184.1 57.18 263 133.97 57.18 197.25 57.18 133.97 133.97 133.97 133.97 57.18 62.898 57.18 57.18 57.18 57.18 58.3236 57.18 4120 Hos Pharmacy Facility Fee 3017068 CHLORASEPTIC LOZENGE 1 EA J8499 637 15 10.5 3.26 15 7.64 3.26 11.25 3.26 7.64 7.64 7.64 7.64 3.26 3.586 3.26 3.26 3.26 3.26 3.3251999999999997 3.26 4120 Hos Pharmacy Facility Fee 3017050 CHLORASEPTIC MENTHOL SPRAY J8499 637 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4120 Hos Pharmacy Facility Fee 3017100 CHLORDIAZEPOXIDE HCL 25MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3046018 CHLORPROMAZINE (THORAZINE)25MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3046042 CHLORPROMAZINE HCL 25MG INJ J8499 636 170 118.99999999999999 36.96 170 86.6 36.96 127.5 36.96 86.6 86.6 86.6 86.6 36.96 40.656000000000006 36.96 36.96 36.96 36.96 37.699200000000005 36.96 4120 Hos Pharmacy Facility Fee 3100072 CHLORPROMAZINE HCL 25MG/ML INJ J8499 636 278 194.6 60.44 278 141.61 60.44 208.5 60.44 141.61 141.61 141.61 141.61 60.44 66.48400000000001 60.44 60.44 60.44 60.44 61.6488 60.44 4120 Hos Pharmacy Facility Fee 3027331 CHLORTHALIDONE 50 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3100015 CIPROFLOXIN 2MG/ML INJ 200ML J8499 636 328 229.6 71.31 328 167.08 71.31 246 71.31 167.08 167.08 167.08 167.08 71.31 78.441 71.31 71.31 71.31 71.31 72.7362 71.31 4120 Hos Pharmacy Facility Fee 3100013 CIPROFLOXIN 500MG TABLET J8499 637 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4120 Hos Pharmacy Facility Fee 3061116 CLARITIN 10MG TAB J8499 637 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4120 Hos Pharmacy Facility Fee 3051299 CLEOCIN 150MG CAPSULE J8499 637 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4120 Hos Pharmacy Facility Fee 3064683 COGENTIN 1MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060167 COL-BENEMID TAB J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3017951 COLACE 100MG CAP UNIT DOSE J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3062387 CORDARONE 200MG TAB. J8499 637 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4120 Hos Pharmacy Facility Fee 3062411 COREG 12.5mg TAB J8499 637 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4120 Hos Pharmacy Facility Fee 3064276 COREG 6.25 TAB J8499 637 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4120 Hos Pharmacy Facility Fee 3099973 HYDROCORTISONE 20 MG / 1 TAB J8499 637 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4120 Hos Pharmacy Facility Fee 3018959 CORTISPORIN OTIC SUSP. J8499 637 527 368.9 114.57 527 268.45 114.57 395.25 114.57 268.45 268.45 268.45 268.45 114.57 126.027 114.57 114.57 114.57 114.57 116.86139999999999 114.57 4120 Hos Pharmacy Facility Fee 3063948 COSOPT OPHTH SOLN. 5ml J1720 637 534 373.79999999999995 116.09 534 272.02 116.09 400.5 116.09 272.02 272.02 272.02 272.02 116.09 127.69900000000001 116.09 116.09 116.09 116.09 118.4118 116.09 4120 Hos Pharmacy Facility Fee 3062171 WARFARIN 1 MG / 1 TAB J1720 637 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4120 Hos Pharmacy Facility Fee 3061660 COZAAR 25MG TABLET J8499 637 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4120 Hos Pharmacy Facility Fee 3099953 CRESTOR 10 MG TAB J8499 637 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4120 Hos Pharmacy Facility Fee 3019304 CYANOCOBALAMINE 1MG INJ 1000MC J8499 250 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4120 Hos Pharmacy Facility Fee 3099929 CYMBALTA 30 MG CAP J8499 637 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4120 Hos Pharmacy Facility Fee 3099930 CYMBALTA 60 MG CAB J8499 637 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4120 Hos Pharmacy Facility Fee 3064235 CYPROHEPTADINE 4MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3020757 DECADRON INJ. 4MG/ML 5CC VIAL J8499 250 12 8.399999999999999 2.61 12 6.11 2.61 9 2.61 6.11 6.11 6.11 6.11 2.61 2.871 2.61 2.61 2.61 2.61 2.6622 2.61 4120 Hos Pharmacy Facility Fee 3039369 DELTASONE 5MG TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3039377 DELTASONE UNIT-DOSE 10MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3039385 DELTASONE UNIT-DOSE 20MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3099984 DEMADEX 10 MG TAB J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3062791 TORSEMIDE 20 MG / 1 TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3099934 VALPROATE SODIUM INJ 500 MG / 5 ML J8499 250 341 238.7 74.13 341 173.71 74.13 255.75 74.13 173.71 173.71 173.71 173.71 74.13 81.543 74.13 74.13 74.13 74.13 75.6126 74.13 4120 Hos Pharmacy Facility Fee 3064648 DEPAKENE 250 MG/5ML SOLTN 5ML J8499 637 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4120 Hos Pharmacy Facility Fee 3061744 DEPAKOTE 250MG TAB J8499 637 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4120 Hos Pharmacy Facility Fee 3064642 DEPAKOTE 500 MG TABLET J8499 637 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4120 Hos Pharmacy Facility Fee 3021631 DESYREL 50MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063773 DETROL LA 4mg CAP J8499 637 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4120 Hos Pharmacy Facility Fee 3100016 DEXAMETHASONE 1MG INH J8499 250 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4120 Hos Pharmacy Facility Fee 3021649 DEXTROSE 50% 50CC J8499 250 270 189 58.7 270 137.54 58.7 202.5 58.7 137.54 137.54 137.54 137.54 58.7 64.57000000000001 58.7 58.7 58.7 58.7 59.874 58.7 4120 Hos Pharmacy Facility Fee 3021656 DEXTROSE 50% INJECTION J8499 250 590 413 128.27 590 300.55 128.27 442.5 128.27 300.55 300.55 300.55 300.55 128.27 141.09700000000004 128.27 128.27 128.27 128.27 130.83540000000002 128.27 4120 Hos Pharmacy Facility Fee 3061587 GLYBURIDE 2.5 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3021706 DIABETA 5MG TAB J8499 637 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4120 Hos Pharmacy Facility Fee 3065681 ACETAZOLAMIDE 250 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3048659 DIAZEPAM 5MG TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3048501 DIAZEPAM INJ 5 MG / 1 EA J8499 250 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4120 Hos Pharmacy Facility Fee 3065683 DICYCLOMINE INJ 20 MG / 1 EA J8499 250 791 553.6999999999999 171.96 791 402.94 171.96 593.25 171.96 402.94 402.94 402.94 402.94 171.96 189.15600000000003 171.96 171.96 171.96 171.96 175.3992 171.96 4120 Hos Pharmacy Facility Fee 3014305 DICYCLOMINE 10MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3014206 DICYCLOMINE 20MG J8499 637 486 340.2 105.66 486 247.57 105.66 364.5 105.66 247.57 247.57 247.57 247.57 105.66 116.226 105.66 105.66 105.66 105.66 107.7732 105.66 4120 Hos Pharmacy Facility Fee 3060779 DIFLUCAN 100MG TAB J8499 637 12 8.399999999999999 2.61 12 6.11 2.61 9 2.61 6.11 6.11 6.11 6.11 2.61 2.871 2.61 2.61 2.61 2.61 2.6622 2.61 4120 Hos Pharmacy Facility Fee 3063138 FLUCONAZOLE 150 MG / 1 TAB J8499 637 278 194.6 60.44 278 141.61 60.44 208.5 60.44 141.61 141.61 141.61 141.61 60.44 66.48400000000001 60.44 60.44 60.44 60.44 61.6488 60.44 4120 Hos Pharmacy Facility Fee 3051661 DIGOXIN INJ 0.5 MG / 1 EA J8499 250 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4120 Hos Pharmacy Facility Fee 3100035 DIPHENHYDRAMINE 25MG CAP J8499 637 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3042553 DOXEPIN HCL 25MG J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3049251 DOXYCYCLINE=VIBRAMY 100MG CAP J8499 637 102 71.39999999999999 22.17 102 51.96 22.17 76.5 22.17 51.96 51.96 51.96 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 4120 Hos Pharmacy Facility Fee 3052222 DURAGESIC 25MCG J8499 637 306 214.2 66.52 306 155.88 66.52 229.5 66.52 155.88 155.88 155.88 155.88 66.52 73.172 66.52 66.52 66.52 66.52 67.8504 66.52 4120 Hos Pharmacy Facility Fee 3052230 DURAGESIC 50MCG J8499 637 475 332.5 103.27 475 241.97 103.27 356.25 103.27 241.97 241.97 241.97 241.97 103.27 113.59700000000001 103.27 103.27 103.27 103.27 105.33539999999999 103.27 4120 Hos Pharmacy Facility Fee 3063146 DURAGESIC 75MCG/HR PATCH J8499 637 721 504.7 156.75 721 367.28 156.75 540.75 156.75 367.28 367.28 367.28 367.28 156.75 172.425 156.75 156.75 156.75 156.75 159.885 156.75 4120 Hos Pharmacy Facility Fee 3062205 EFFEXOR 37.5MG TAB J8499 637 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3062916 EFFEXOR 37.5MG XR CAP. J8499 637 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4120 Hos Pharmacy Facility Fee 3064664 EFFEXOR XR 150MG CAPS J8499 637 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4120 Hos Pharmacy Facility Fee 3063609 MOMETASONE FUROATE 0.1% CR 45 GM J8499 637 468 327.59999999999997 101.74 468 238.4 101.74 351 101.74 238.4 238.4 238.4 238.4 101.74 111.914 101.74 101.74 101.74 101.74 103.7748 101.74 4120 Hos Pharmacy Facility Fee 3063625 ENALAPRIL MALEATE 2.5mg Tab J8499 637 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4120 Hos Pharmacy Facility Fee 3061280 ENTERIC COATED ASPIRIN 325MG J8499 637 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3024205 EPINEPHRINE 0.1ML/ML INJ J8499 250 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4120 Hos Pharmacy Facility Fee 3027158 Hydrochlorothiazide 25MG TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064573 ESTRADIOL 1 MG TAB J8499 637 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4120 Hos Pharmacy Facility Fee 3063096 RIVASTIGMINE TARTRATE 1.5 MG / 1 CAP J8499 637 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4120 Hos Pharmacy Facility Fee 3100041 EXELON 4.6 MG/24H PATCH J8499 637 140 98 30.44 140 71.32 30.44 105 30.44 71.32 71.32 71.32 71.32 30.44 33.484 30.44 30.44 30.44 30.44 31.048800000000004 30.44 4120 Hos Pharmacy Facility Fee 3099992 EXELON 6MG CAP J8499 637 74 51.8 16.09 74 37.7 16.09 55.5 16.09 37.7 37.7 37.7 37.7 16.09 17.699 16.09 16.09 16.09 16.09 16.4118 16.09 4120 Hos Pharmacy Facility Fee 3100042 EXELON 9.5MG/24H PATCH J8499 637 140 98 30.44 140 71.32 30.44 105 30.44 71.32 71.32 71.32 71.32 30.44 33.484 30.44 30.44 30.44 30.44 31.048800000000004 30.44 4120 Hos Pharmacy Facility Fee 3024957 FERROUS SULFATE 325MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060712 FIORICET TAB J8499 259 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4120 Hos Pharmacy Facility Fee 3100039 FISH OIL 1000MG CAPS J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3025103 FLAGYL UNIT-DOSE TABLET 250MG J8499 637 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4120 Hos Pharmacy Facility Fee 3025152 FLEXERIL UNIT-DOSE TABLET 10MG J8499 637 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3062809 FLOMAX 0.4MG CAP J8499 637 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3062312 FLONASE NASAL INHALER J8499 637 629 440.29999999999995 136.74 629 320.41 136.74 471.75 136.74 320.41 320.41 320.41 320.41 136.74 150.41400000000002 136.74 136.74 136.74 136.74 139.47480000000002 136.74 4120 Hos Pharmacy Facility Fee 3051224 FLORINEF 0.1MG TABLET J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3025202 FLUORESCEIN STRIP 1 EA J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3062189 FLUMADINE 100 MG / 1 TAB J8499 637 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4120 Hos Pharmacy Facility Fee 3025400 FOLIC ACID 1 MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063831 FOLIC ACID INJ 5 MG / 1 ML J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3030756 FUROSEMIDE 20 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3030707 FUROSEMIDE (LASIX) 40MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3030657 FUROSEMIDE 40MG/4ML INJ. J8499 250 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3063336 GABAPENTIN 100Mg Cap J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3025756 GENOPTIC 5MG/ML SOLN J8499 637 303 212.1 65.87 303 154.35 65.87 227.25 65.87 154.35 154.35 154.35 154.35 65.87 72.45700000000001 65.87 65.87 65.87 65.87 67.18740000000001 65.87 4120 Hos Pharmacy Facility Fee 3025806 GENTACIDIN 3MG/GM OINTMENT PC J8499 637 319 223.29999999999998 69.35 319 162.5 69.35 239.25 69.35 162.5 162.5 162.5 162.5 69.35 76.285 69.35 69.35 69.35 69.35 70.737 69.35 4120 Hos Pharmacy Facility Fee 3099981 GEODON 20MG CAP J8499 637 140 98 30.44 140 71.32 30.44 105 30.44 71.32 71.32 71.32 71.32 30.44 33.484 30.44 30.44 30.44 30.44 31.048800000000004 30.44 4120 Hos Pharmacy Facility Fee 3100002 GEODON 20MG INJ. J8499 250 268 187.6 58.26 268 136.52 58.26 201 58.26 136.52 136.52 136.52 136.52 58.26 64.086 58.26 58.26 58.26 58.26 59.4252 58.26 4120 Hos Pharmacy Facility Fee 3099933 GEODON 40MG CAP J8499 637 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4120 Hos Pharmacy Facility Fee 3025947 GLUCAGON INJ 1 MG / 1 EA J8499 636 1429 1000.3 310.67 1429 727.93 310.67 1071.75 310.67 727.93 727.93 727.93 727.93 310.67 341.737 310.67 310.67 310.67 310.67 316.8834 310.67 4120 Hos Pharmacy Facility Fee 3061645 GLUCOPHAGE 500MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063906 GLUCOPHAGE XR 500mg tab J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3025939 GLUCOTROL 5MG UD TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3041100 GUAIFENESIN (ROBITUSSIN) 30CC J8499 637 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3041159 GUAIFENESIN (ROBITUSSIN) 5CC J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063542 GUAIFENESIN 100mg/CODEINE 10mg J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061090 GUAIFENESIN 600MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3041258 GUAIFENESIN DM (ROB. DM) 30CC J8499 637 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3041308 GUAIFENESIN DM (ROB. DM) 5CC J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3026150 CLOTRIMAZOLE-7 1% CR 1 EA J8499 259 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4120 Hos Pharmacy Facility Fee 3026309 HALOPERIDOL 2 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3026218 HALDOL 10 MG UD TAB J8499 637 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4120 Hos Pharmacy Facility Fee 3026358 HALDOL UNIT DOSE TABLET 1 MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3026259 HALDOL UNIT DOSE TABLET 5MG J8499 637 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4120 Hos Pharmacy Facility Fee 3026200 HALOPERIDOL 5MG INJ J8499 250 222 155.39999999999998 48.26 222 113.09 48.26 166.5 48.26 113.09 113.09 113.09 113.09 48.26 53.086000000000006 48.26 48.26 48.26 48.26 49.2252 48.26 4120 Hos Pharmacy Facility Fee 3064011 HALOPERIDOL DECANOATE 50MG/0.5 J8499 250 431 301.7 93.7 431 219.55 93.7 323.25 93.7 219.55 219.55 219.55 219.55 93.7 103.07000000000001 93.7 93.7 93.7 93.7 95.574 93.7 4120 Hos Pharmacy Facility Fee 3026507 HEPARIN 10 UNITS J8499 636 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4120 Hos Pharmacy Facility Fee 3060183 HEPARIN 100U/ML INJ. 30ML J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3061298 HEPARIN 10OO UNITS J8499 636 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4120 Hos Pharmacy Facility Fee 3100037 HEPARIN FLUSH 10 UNITS/ML 5ML J8499 636 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3026606 HEPARIN SODIUM INJ 10000 UN / 1 ML J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3064490 INSULIN LISPRO 50/50 INJ 5 UN / 1 EA J8499 250 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3063641 INSULIN LISPRO 75/25 INJ 5 UN / 1 EA J8499 259 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3011954 HYDRALAZINE 10 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3012101 HYDRALAZINE 25MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3012002 HYDRALAZINE INJ 20 MG / 1 EA J8499 250 317 221.89999999999998 68.92 317 161.48 68.92 237.75 68.92 161.48 161.48 161.48 161.48 68.92 75.81200000000001 68.92 68.92 68.92 68.92 70.2984 68.92 4120 Hos Pharmacy Facility Fee 3099921 HYDREA 500 MG CAPS J8499 637 30 21 6.52 30 15.28 6.52 22.5 6.52 15.28 15.28 15.28 15.28 6.52 7.172 6.52 6.52 6.52 6.52 6.650399999999999 6.52 4120 Hos Pharmacy Facility Fee 3064638 HYDROCHLOROTHIAZIDE 12.5 MG CP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3062031 HYDROCORTISONE 2.5% CR 30 GM J8499 637 166 116.19999999999999 36.09 166 84.56 36.09 124.5 36.09 84.56 84.56 84.56 84.56 36.09 39.699000000000005 36.09 36.09 36.09 36.09 36.811800000000005 36.09 4120 Hos Pharmacy Facility Fee 3026952 HYDROCORTISONE 1% OINT 1 EA J8499 637 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4120 Hos Pharmacy Facility Fee 3018850 HYDROCORTIZONE 1% CREAM J8499 637 239 167.29999999999998 51.96 239 121.75 51.96 179.25 51.96 121.75 121.75 121.75 121.75 51.96 57.156000000000006 51.96 51.96 51.96 51.96 52.9992 51.96 4120 Hos Pharmacy Facility Fee 3022209 HYDROMORPHONE 2MG/ML INJ J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3013109 HYDROXYZINE HCL 25MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3049558 HYDROXYZINE HCL INTRA 100MG/2M J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3049756 HYDROXYZINE PAMOATE 25MG J8499 637 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4120 Hos Pharmacy Facility Fee 3051588 HYDROXYZINE PAMOATE 50MG CAP J8499 637 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4120 Hos Pharmacy Facility Fee 3051786 TERAZOSIN 1 MG / 1 TAB J8499 637 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4120 Hos Pharmacy Facility Fee 3063369 IMDUR 30MG TAB J8499 637 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4120 Hos Pharmacy Facility Fee 3062874 IMIPRAMINE 25MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064599 IMITREX 50 MG TAB J8499 637 371 259.7 80.66 371 188.99 80.66 278.25 80.66 188.99 188.99 188.99 188.99 80.66 88.726 80.66 80.66 80.66 80.66 82.2732 80.66 4120 Hos Pharmacy Facility Fee 3027802 IMODIUM CAPSULE 2MG J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3027901 INDERAL UNIT-DOSE TAB 10MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3028057 INDERAL UNIT-DOSE TAB 20MG J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3028008 PROPRANOLOL HCL 40 MG / 1 TAB J8499 637 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3028206 INDOMETHACIN 25MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3028255 INDOMETHACIN 50MG J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3025350 INFLUENZA VIRUS VAC,AGE 3+ J8499 259 291 203.7 63.26 291 148.24 63.26 218.25 63.26 148.24 148.24 148.24 148.24 63.26 69.586 63.26 63.26 63.26 63.26 64.5252 63.26 4120 Hos Pharmacy Facility Fee 3100018 INSULIN LISPRO INJ 5 UNITS J8499 250 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3061108 INTAL INHALER J8499 637 707 494.9 153.7 707 360.15 153.7 530.25 153.7 360.15 360.15 360.15 360.15 153.7 169.07 153.7 153.7 153.7 153.7 156.774 153.7 4120 Hos Pharmacy Facility Fee 3064383 IPRATROPIUM BROMIDE 1MG INH J8499 250 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4120 Hos Pharmacy Facility Fee 3060811 ISMO 20MG TABLET J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3028958 ISORDIL TITRA CLINPK TAB 20MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3029006 ISORDIL TITRA CLINPK TAB 5MG J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3028909 ISORDIL TITRAE CLINPK TAB 10MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3029162 ISOPROTERENOL 1:5000 INJ ML J8499 250 522 365.4 113.48 522 265.91 113.48 391.5 113.48 265.91 265.91 265.91 265.91 113.48 124.82800000000002 113.48 113.48 113.48 113.48 115.7496 113.48 4120 Hos Pharmacy Facility Fee 3100009 JANUVIA 50MG TABLET J8499 637 139 97.3 30.22 139 70.81 30.22 104.25 30.22 70.81 70.81 70.81 70.81 30.22 33.242000000000004 30.22 30.22 30.22 30.22 30.8244 30.22 4120 Hos Pharmacy Facility Fee 3060092 K-DUR 20MEQ TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3099985 SODIUM POLYSTYRENE SULFONATE 15 GM / 60 ML J8499 637 127 88.89999999999999 27.61 127 64.69 27.61 95.25 27.61 64.69 64.69 64.69 64.69 27.61 30.371000000000002 27.61 27.61 27.61 27.61 28.1622 27.61 4120 Hos Pharmacy Facility Fee 3029550 SODIUM POLYSTYRENE SULFONATE 30 GM / 120 ML J8499 637 369 258.3 80.22 369 187.97 80.22 276.75 80.22 187.97 187.97 187.97 187.97 80.22 88.242 80.22 80.22 80.22 80.22 81.8244 80.22 4120 Hos Pharmacy Facility Fee 3029808 KELFEX PULVULE CAPSULE 500MG J8499 637 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4120 Hos Pharmacy Facility Fee 3030053 TRIAMCINOLONE INJ 40 MG / 1 EA J8499 636 155 108.5 33.7 155 78.96 33.7 116.25 33.7 78.96 78.96 78.96 78.96 33.7 37.07000000000001 33.7 33.7 33.7 33.7 34.374 33.7 4120 Hos Pharmacy Facility Fee 3099999 LEVETIRACETAM SOLN 100 MG / 5 ML J8499 637 67 46.9 14.57 67 34.13 14.57 50.25 14.57 34.13 34.13 34.13 34.13 14.57 16.027 14.57 14.57 14.57 14.57 14.8614 14.57 4120 Hos Pharmacy Facility Fee 3064659 KEPPRA 500MG TAB J8499 637 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4120 Hos Pharmacy Facility Fee 3051562 KETORALAC 15MG INJ J8499 250 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4120 Hos Pharmacy Facility Fee 3060613 KLONOPIN 0.5MG TAB J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3062015 LACTOBACILLUS 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3099977 LACTULOSE 10 GM/15ML UD J8499 637 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3030459 LANOXIN .25MG TABLET J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3030509 LANOXIN UNIT DOSE TAB 0.125MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063963 LANTUS J8499 259 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4120 Hos Pharmacy Facility Fee 3061157 NOREPINEPHRINE INJ 4 ML / 1 EA J8499 636 426 298.2 92.61 426 217 92.61 319.5 92.61 217 217 217 217 92.61 101.87100000000001 92.61 92.61 92.61 92.61 94.4622 92.61 4120 Hos Pharmacy Facility Fee 3061918 LEVOTHYROXINE 0.05MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063393 LEVOTHYROXINE 0.075MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061926 LEVOTHYROXINE 0.088MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061934 LEVOTHYROXINE 0.112 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061942 LEVOTHYROXINE 0.125MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061959 LEVOTHYROXINE 0.15 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3030954 LEVSIN .125MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3030905 HYOSCYAMINE SULFATE LIQ 30 ML J8499 637 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4120 Hos Pharmacy Facility Fee 3064466 LEXAPRO 10 MG TAB J8499 637 49 34.3 10.65 49 24.96 10.65 36.75 10.65 24.96 24.96 24.96 24.96 10.65 11.715000000000002 10.65 10.65 10.65 10.65 10.863000000000001 10.65 4120 Hos Pharmacy Facility Fee 3099903 LIDOCAINE W/D5W DRIP 1 GM / 250 ML J8499 250 672 470.4 146.09 672 342.32 146.09 504 146.09 342.32 342.32 342.32 342.32 146.09 160.699 146.09 146.09 146.09 146.09 149.0118 146.09 4120 Hos Pharmacy Facility Fee 3062841 LIPITOR 10MG TAB J8499 637 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4120 Hos Pharmacy Facility Fee 3064639 LIPITOR 40 MG TABLET J8499 637 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4120 Hos Pharmacy Facility Fee 3031275 LITHONATE UD 300MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3051679 LOPID 600MG TAB J8499 637 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4120 Hos Pharmacy Facility Fee 3031366 LOPRESSOR UNIT-DOSE 50MG J8499 637 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4120 Hos Pharmacy Facility Fee 3052081 LORTAB-5 J8499 637 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4120 Hos Pharmacy Facility Fee 3052099 LORTAB-7.5 MG J8499 637 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4120 Hos Pharmacy Facility Fee 3061199 LOTENSIN 10MG TAB J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3031507 CLOTRIMAZOLE 1% CR 15 GM J8499 637 296 207.2 64.35 296 150.78 64.35 222 64.35 150.78 150.78 150.78 150.78 64.35 70.785 64.35 64.35 64.35 64.35 65.637 64.35 4120 Hos Pharmacy Facility Fee 3031515 LOTRISONE CREAM J8499 637 456 319.2 99.13 456 232.29 99.13 342 99.13 232.29 232.29 232.29 232.29 99.13 109.043 99.13 99.13 99.13 99.13 101.1126 99.13 4120 Hos Pharmacy Facility Fee 3063559 LOVENOX 100mg J8499 636 176 123.19999999999999 38.26 176 89.65 38.26 132 38.26 89.65 89.65 89.65 89.65 38.26 42.086 38.26 38.26 38.26 38.26 39.0252 38.26 4120 Hos Pharmacy Facility Fee 3061637 LOVENOX 30MG J8499 636 176 123.19999999999999 38.26 176 89.65 38.26 132 38.26 89.65 89.65 89.65 89.65 38.26 42.086 38.26 38.26 38.26 38.26 39.0252 38.26 4120 Hos Pharmacy Facility Fee 3063716 LOVENOX 40mg J8499 636 176 123.19999999999999 38.26 176 89.65 38.26 132 38.26 89.65 89.65 89.65 89.65 38.26 42.086 38.26 38.26 38.26 38.26 39.0252 38.26 4120 Hos Pharmacy Facility Fee 3064029 LOVENOX 60MG J8499 636 176 123.19999999999999 38.26 176 89.65 38.26 132 38.26 89.65 89.65 89.65 89.65 38.26 42.086 38.26 38.26 38.26 38.26 39.0252 38.26 4120 Hos Pharmacy Facility Fee 3099922 BIMATOPROST 0.03% OPHTH 2.5 ML J8499 637 698 488.59999999999997 151.75 698 355.56 151.75 523.5 151.75 355.56 355.56 355.56 355.56 151.75 166.925 151.75 151.75 151.75 151.75 154.785 151.75 4120 Hos Pharmacy Facility Fee 3099914 LYRICA 50MG CAP J8499 637 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4120 Hos Pharmacy Facility Fee 3099915 LYRICA 75MG CAP J8499 637 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4120 Hos Pharmacy Facility Fee 3064607 MAALOX PLUS 30 ML UD J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064667 MACROBID 100 MG CAP J8499 637 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4120 Hos Pharmacy Facility Fee 3062866 MAG-OX 400 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3062114 MAGNESIUM CHLORIDE 200MG/ML IN J8499 250 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4120 Hos Pharmacy Facility Fee 3031853 MAGNESIUM SULFATE INJ 500 MG / 1 EA J8499 250 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4120 Hos Pharmacy Facility Fee 3011558 MECLIZINE 25MG TAB J8499 637 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4120 Hos Pharmacy Facility Fee 3100031 MEDROL DOSE PACK 4MG J8499 637 210 147 45.65 210 106.97 45.65 157.5 45.65 106.97 106.97 106.97 106.97 45.65 50.215 45.65 45.65 45.65 45.65 46.563 45.65 4120 Hos Pharmacy Facility Fee 3063328 MEDROXYPROGESTERONE 2.5 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3099926 MEGACE 40MG/ML SUSP 5ML J8499 637 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4120 Hos Pharmacy Facility Fee 3032604 METAMUCIL INSTANT MIX J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064086 METFORMIN 1000 MG TABLET J8499 637 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4120 Hos Pharmacy Facility Fee 3043205 METHYLPREDNISOLONE 125MG INJ J8499 250 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4120 Hos Pharmacy Facility Fee 3032307 METHYLPREDNISOLONE 4MG TAB J8499 637 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4120 Hos Pharmacy Facility Fee 3040607 METOCLOPRAMIDE 10 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064652 METOPROLOL 25MG TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060654 METOPROLOL 5MG/5ML INJ. J8499 250 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4120 Hos Pharmacy Facility Fee 3032760 MEVACOR 20MG TABLET J8499 637 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 4120 Hos Pharmacy Facility Fee 3061579 MEXILETINE 150MG CAP J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3063930 MICONAZOLE NITRATE VAG CR 45 GM J8499 637 199 139.29999999999998 43.26 199 101.37 43.26 149.25 43.26 101.37 101.37 101.37 101.37 43.26 47.586 43.26 43.26 43.26 43.26 44.1252 43.26 4120 Hos Pharmacy Facility Fee 3051596 MIDAZOLAM 1MG INJ J8499 250 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4120 Hos Pharmacy Facility Fee 3032901 MILK OF MAGNESIA 30ML CUP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3032976 MINIPRES 1MG UD CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064631 MIRALAX PACKET J8499 637 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4120 Hos Pharmacy Facility Fee 3100004 MIRAPEX 0.25MG TABLET J8499 637 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4120 Hos Pharmacy Facility Fee 3100028 MOBIC 15MG TAB J8499 637 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4120 Hos Pharmacy Facility Fee 3100027 MOBIC 7.5MG TAB J8499 637 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4120 Hos Pharmacy Facility Fee 3063443 MOEXIPRIL 15Mg TAB J8499 637 30 21 6.52 30 15.28 6.52 22.5 6.52 15.28 15.28 15.28 15.28 6.52 7.172 6.52 6.52 6.52 6.52 6.650399999999999 6.52 4120 Hos Pharmacy Facility Fee 3060241 MORPHINE 2MG INJ. J8499 636 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4120 Hos Pharmacy Facility Fee 3099917 MORPHINE 2MG/ML INJ J8499 250 69 48.3 15 69 35.15 15 51.75 15 35.15 35.15 35.15 35.15 15 16.5 15 15 15 15 15.3 15 4120 Hos Pharmacy Facility Fee 3099918 MORPHINE 4MG/ML INJECTION J8499 250 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4120 Hos Pharmacy Facility Fee 3033602 MOTRIN UD 400MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3033701 ACETYLCYSTEINE 20% 30 ML J8499 637 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4120 Hos Pharmacy Facility Fee 3060662 MULTIVITAMIN WITH IRON TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064682 MUPIROCIN 2% OINT 22 GM J8499 637 520 364 113.05 520 264.89 113.05 390 113.05 264.89 264.89 264.89 264.89 113.05 124.355 113.05 113.05 113.05 113.05 115.31099999999999 113.05 4120 Hos Pharmacy Facility Fee 3100046 MYCOGEN CREAM 30MG J8499 637 636 445.2 138.27 636 323.98 138.27 477 138.27 323.98 323.98 323.98 323.98 138.27 152.09700000000004 138.27 138.27 138.27 138.27 141.0354 138.27 4120 Hos Pharmacy Facility Fee 3034204 MYLICON-80 UNIT-DOSE 80MG J8499 637 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4120 Hos Pharmacy Facility Fee 3099997 NAMENDA 10MG TAB J8499 637 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4120 Hos Pharmacy Facility Fee 3034501 NAPROSYN UD 250MG TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3034741 NAVANE 1MG UD CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3034709 NAVANE UNITDOSE 5MG CAP J8499 637 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4120 Hos Pharmacy Facility Fee 3035151 NEOMYCIN/POLYMYXIN/BACITRACIN 15 GM J8499 637 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4120 Hos Pharmacy Facility Fee 3035144 NEOMYCIN/POLYMYXIN/GRAMICIDIN OINT 0.9 GM J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061496 NEOMYCIN/POLYMYXIN OPHTH SOLN 10 ML J8499 259 241 168.7 52.39 241 122.77 52.39 180.75 52.39 122.77 122.77 122.77 122.77 52.39 57.629000000000005 52.39 52.39 52.39 52.39 53.4378 52.39 4120 Hos Pharmacy Facility Fee 3035250 NEOMYCIN/POLYMYXIN/GRAMICIDIN OPHTH OINT 1 EA J8499 637 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4120 Hos Pharmacy Facility Fee 3035300 NEOSPORIN OPTHODROPS USE J8499 637 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4120 Hos Pharmacy Facility Fee 3035052 PHENYLEPHRINE 0.25% SPRAY 15 ML J8499 637 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4120 Hos Pharmacy Facility Fee 3065686 NEURONTIN 100 MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3062544 NEURONTIN 300MG CAP J8499 637 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4120 Hos Pharmacy Facility Fee 3035409 NIACIN 100MG_TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3099996 NIACIN 250 MG / 1 TAB J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060647 NICODERM 21MG PATCH J8499 637 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4120 Hos Pharmacy Facility Fee 3063898 NICOTINE PATCH 14mg/day J8499 637 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4120 Hos Pharmacy Facility Fee 3033909 NILSTAT 100MU SUSP 5 ML J8499 259 444 310.79999999999995 96.53 444 226.17 96.53 333 96.53 226.17 226.17 226.17 226.17 96.53 106.183 96.53 96.53 96.53 96.53 98.4606 96.53 4120 Hos Pharmacy Facility Fee 3046711 NITROGLYCERIN PATCH 15 MG / 1 EA J8499 637 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4120 Hos Pharmacy Facility Fee 3046646 NITRO-DUR II 10MG ADH PATCH J8499 637 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4120 Hos Pharmacy Facility Fee 3046703 NITROGLYCERIN PATCH 2.5 MG / 1 EA J8499 637 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 4120 Hos Pharmacy Facility Fee 3046638 NITRO-DURII 5MG ADH PATCH J8499 637 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 4120 Hos Pharmacy Facility Fee 3035607 NITROGLYCERINE 0.4MG TAB (EA) J8499 637 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4120 Hos Pharmacy Facility Fee 3035557 NITROSTAT 4X25 PER 25 0.4GM J8499 637 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4120 Hos Pharmacy Facility Fee 3064643 KETOCONAZOLE 2% SHAMPOO 1 EA J8499 637 348 243.6 75.66 348 177.27 75.66 261 75.66 177.27 177.27 177.27 177.27 75.66 83.226 75.66 75.66 75.66 75.66 77.1732 75.66 4120 Hos Pharmacy Facility Fee 3060845 KETOCONAZOLE CR 15 GM J8499 637 430 301 93.48 430 219.04 93.48 322.5 93.48 219.04 219.04 219.04 219.04 93.48 102.82800000000002 93.48 93.48 93.48 93.48 95.34960000000001 93.48 4120 Hos Pharmacy Facility Fee 3063088 NORCO 10MG TAB J8499 637 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3100005 NORCO 5MG/325MG TAB J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3060852 NORFLEX 100MG TAB J8499 637 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4120 Hos Pharmacy Facility Fee 3035839 NORMODYNE 200MG TABLET J8499 637 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4120 Hos Pharmacy Facility Fee 3035821 LABETALOL INJ 5 MG / 20 ML J8499 250 871 609.6999999999999 189.36 871 443.69 189.36 653.25 189.36 443.69 443.69 443.69 443.69 189.36 208.29600000000002 189.36 189.36 189.36 189.36 193.14720000000003 189.36 4120 Hos Pharmacy Facility Fee 3035854 NORPACE 150MG CAPSULE J8499 259 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4120 Hos Pharmacy Facility Fee 3035953 NORPRAMIN 25MG TAB J8499 637 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3060381 NORVASC 5MG TAB J8499 637 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4120 Hos Pharmacy Facility Fee 3051778 NOVOLIN 70/30 5 UNITS J8499 250 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3026515 INSULIN HUMAN-N 5 UNITS J8499 250 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3026556 NOVOLIN R J8499 250 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3063633 NOVOLOG J8499 259 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4120 Hos Pharmacy Facility Fee 3064482 NOVOLOG 70/30 INJ J8499 250 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3099904 NITROGLYCERIN/D5W DRIP 25 MG / 250 ML J8499 250 515 360.5 111.96 515 262.34 111.96 386.25 111.96 262.34 262.34 262.34 262.34 111.96 123.156 111.96 111.96 111.96 111.96 114.19919999999999 111.96 4120 Hos Pharmacy Facility Fee 3064647 NYSTATIN 100 MU/ML 5ML SUSP J8499 637 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4120 Hos Pharmacy Facility Fee 3100048 NYSTATIN 100MU/GM 15GM J8499 637 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4120 Hos Pharmacy Facility Fee 3064632 ONDANSETRON HCL 1MG INJ J8499 250 914 639.8 198.7 914 465.59 198.7 685.5 198.7 465.59 465.59 465.59 465.59 198.7 218.57 198.7 198.7 198.7 198.7 202.67399999999998 198.7 4120 Hos Pharmacy Facility Fee 3035805 ORPHENADRINE 60MG/2ML INJ J8499 636 474 331.79999999999995 103.05 474 241.46 103.05 355.5 103.05 241.46 241.46 241.46 241.46 103.05 113.355 103.05 103.05 103.05 103.05 105.111 103.05 4120 Hos Pharmacy Facility Fee 3022357 OXYBUTYNIN 5MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064645 OXYCODONE 5 MG TABLET J8499 259 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4120 Hos Pharmacy Facility Fee 3052131 PAMELOR 10MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3051844 PAMELOR 25MG CAPSULE J8499 637 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4120 Hos Pharmacy Facility Fee 3061991 PAXIL 20MG TAB J8499 637 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 4120 Hos Pharmacy Facility Fee 3037363 PEPCID 40MG TABLET J8499 259 89 62.3 19.35 89 45.34 19.35 66.75 19.35 45.34 45.34 45.34 45.34 19.35 21.285000000000004 19.35 19.35 19.35 19.35 19.737000000000002 19.35 4120 Hos Pharmacy Facility Fee 3061710 PEPCID INJ. 20MG/2ML J8499 250 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4120 Hos Pharmacy Facility Fee 3099990 PERCOCET 10MG/325MG TAB J8499 637 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4120 Hos Pharmacy Facility Fee 3047909 PERCOCET TAB (TYLOX) J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3040102 PHENAOPYRIDINE 200MG TAB J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3060233 PHENERGAN 50MG INJ. J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3060787 PHENOBARBITAL 1 GRAIN TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3038254 PHENOBARBITAL 32MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064661 PHENYLEPHRINE 10% OPHTH 5 ML J8499 637 139 97.3 30.22 139 70.81 30.22 104.25 30.22 70.81 70.81 70.81 70.81 30.22 33.242000000000004 30.22 30.22 30.22 30.22 30.8244 30.22 4120 Hos Pharmacy Facility Fee 3061405 PHENYLEPHRINE INJ 10 MG / 1 ML J8499 250 89 62.3 19.35 89 45.34 19.35 66.75 19.35 45.34 45.34 45.34 45.34 19.35 21.285000000000004 19.35 19.35 19.35 19.35 19.737000000000002 19.35 4120 Hos Pharmacy Facility Fee 3035375 PHENYLEPHRINE 1OMG/ML INJ J8499 636 216 151.2 46.96 216 110.03 46.96 162 46.96 110.03 110.03 110.03 110.03 46.96 51.656000000000006 46.96 46.96 46.96 46.96 47.8992 46.96 4120 Hos Pharmacy Facility Fee 3061074 PHENYLEPHRINE 2.5% OPHTH SOLN 1 EA J8499 637 134 93.8 29.13 134 68.26 29.13 100.5 29.13 68.26 68.26 68.26 68.26 29.13 32.043 29.13 29.13 29.13 29.13 29.7126 29.13 4120 Hos Pharmacy Facility Fee 3022100 PHENYTOIN SODIUM 100MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3021953 PHENYTOIN SODIUM 50MG INJ J8499 250 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4120 Hos Pharmacy Facility Fee 3011459 PHYSOSTIGMINE SALICYLATE INJ 1 MG / 1 EA J8499 250 264 184.79999999999998 57.39 264 134.48 57.39 198 57.39 134.48 134.48 134.48 134.48 57.39 63.129000000000005 57.39 57.39 57.39 57.39 58.537800000000004 57.39 4120 Hos Pharmacy Facility Fee 3012143 PHYTONADIONE 1MG INJ J8499 250 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4120 Hos Pharmacy Facility Fee 3064644 PLAQUENIL 200 MG TABLETS J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3062858 PLAVIX 75MG TAB J8499 637 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4120 Hos Pharmacy Facility Fee 3063203 FELODIPINE 5 MG / 1 TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3099913 CILOSTAZOL 100 MG / 1 TAB J8499 637 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4120 Hos Pharmacy Facility Fee 3038676 PNEUMONIA VACCINE J8499 636 924 646.8 200.88 924 470.69 200.88 693 200.88 470.69 470.69 470.69 470.69 200.88 220.96800000000002 200.88 200.88 200.88 200.88 204.8976 200.88 4120 Hos Pharmacy Facility Fee 3039351 POTASSIUM CHLORIDE 10% LIQUID J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3039302 POTASSIUM CHLORIDE 20% LIQUID J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3039153 POTASSIUM CHLORIDE 40 INJ. MEQ J8499 250 156 109.19999999999999 33.91 156 79.47 33.91 117 33.91 79.47 79.47 79.47 79.47 33.91 37.301 33.91 33.91 33.91 33.91 34.5882 33.91 4120 Hos Pharmacy Facility Fee 3039252 POTASSIUM CHLORIDE 40MEQ INJ J8499 636 11 7.699999999999999 2.39 11 5.6 2.39 8.25 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 4120 Hos Pharmacy Facility Fee 3029352 POTASSIUM CHLORIDE 750MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063617 PRAVACHOL 20mg Tab J8499 637 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4120 Hos Pharmacy Facility Fee 3061967 PRECOSE 50MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060969 PREDNISOLONE ACETATE 1% OPHTH SOLN 5 ML J8499 637 296 207.2 64.35 296 150.78 64.35 222 64.35 150.78 150.78 150.78 150.78 64.35 70.785 64.35 64.35 64.35 64.35 65.637 64.35 4120 Hos Pharmacy Facility Fee 3062999 PREMARIN 0.3mg TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3061132 CONJUGATED ESTROGENS 0.625 MG / 1 TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3039450 PREMARIN UNIT-DOSE 1.25 MG J8499 259 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4120 Hos Pharmacy Facility Fee 3099908 PROAIR HFA 90 MCG INHALER J8499 637 415 290.5 90.22 415 211.4 90.22 311.25 90.22 211.4 211.4 211.4 211.4 90.22 99.242 90.22 90.22 90.22 90.22 92.0244 90.22 4120 Hos Pharmacy Facility Fee 3052198 PROCARDIA XL 30MG J8499 259 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4120 Hos Pharmacy Facility Fee 3037900 PROMETHAZINE 25MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060225 PROMETHAZINE HCL 25MG/1ML INJ J8499 636 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4120 Hos Pharmacy Facility Fee 3027851 PROPRANOLOL 1MG INJ J8499 250 225 157.5 48.92 225 114.62 48.92 168.75 48.92 114.62 114.62 114.62 114.62 48.92 53.812000000000005 48.92 48.92 48.92 48.92 49.8984 48.92 4120 Hos Pharmacy Facility Fee 3039856 PROPYLTHIOURACIL 50MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060704 FINASTERIDE 5 MG / 1 TAB J8499 637 59 41.3 12.83 59 30.05 12.83 44.25 12.83 30.05 30.05 30.05 30.05 12.83 14.113000000000001 12.83 12.83 12.83 12.83 13.0866 12.83 4120 Hos Pharmacy Facility Fee 3051539 PROTAMINE SULFATE INJ 10 MG / 1 EA J8499 250 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4120 Hos Pharmacy Facility Fee 3063237 PROTONIX 40MG EC TAB J8499 637 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4120 Hos Pharmacy Facility Fee 3064318 PROTONIX 40MG IV J8499 250 565 395.5 122.83 565 287.81 122.83 423.75 122.83 287.81 287.81 287.81 287.81 122.83 135.113 122.83 122.83 122.83 122.83 125.2866 122.83 4120 Hos Pharmacy Facility Fee 3065682 PROVENTIL INHALER 17GM J8499 637 415 290.5 90.22 415 211.4 90.22 311.25 90.22 211.4 211.4 211.4 211.4 90.22 99.242 90.22 90.22 90.22 90.22 92.0244 90.22 4120 Hos Pharmacy Facility Fee 3040060 PROVERA 10MG TABS J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3063351 PROZAC 10MG TAB J8499 637 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 4120 Hos Pharmacy Facility Fee 3051448 PROZAC 20MG J8499 637 69 48.3 15 69 35.15 15 51.75 15 35.15 35.15 35.15 35.15 15 16.5 15 15 15 15 15.3 15 4120 Hos Pharmacy Facility Fee 3040177 PYRIDOXINE 50MG TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063245 RANITIDINE 150MG TAB J8499 637 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4120 Hos Pharmacy Facility Fee 3060738 REGLAN 5MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063401 REMERON 15MG TAB J8499 637 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4120 Hos Pharmacy Facility Fee 3099954 REQUIP 1 MG TAB J8499 637 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4120 Hos Pharmacy Facility Fee 3063286 RESPERIDAL 2MG TAB J8499 637 104 72.8 22.61 104 52.98 22.61 78 22.61 52.98 52.98 52.98 52.98 22.61 24.871000000000002 22.61 22.61 22.61 22.61 23.0622 22.61 4120 Hos Pharmacy Facility Fee 3040805 RESTORIL CONTROLPAK 15MG CAP J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3040854 RIFAMPIN 300 MG / 1 CAP J8499 637 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4120 Hos Pharmacy Facility Fee 3061264 RISPERDAL 1MG TAB J8499 637 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4120 Hos Pharmacy Facility Fee 3040920 METHYLPHENIDATE HCL 5 MG / 1 TAB J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064658 METHOCARBAMOL 500 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3040946 ROBAXIN 750MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3065687 ROBITUSSIN AC 5ML J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3041373 ROCEPHIN 1GM J8499 636 185 129.5 40.22 185 94.24 40.22 138.75 40.22 94.24 94.24 94.24 94.24 40.22 44.242000000000004 40.22 40.22 40.22 40.22 41.0244 40.22 4120 Hos Pharmacy Facility Fee 3099998 CEFTRIAXONE INJ 2 GM / 1 EA J8499 636 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4120 Hos Pharmacy Facility Fee 3041365 CEFTRIAXONE INJ 500 MG / 1 EA J8499 636 202 141.39999999999998 43.91 202 102.9 43.91 151.5 43.91 102.9 102.9 102.9 102.9 43.91 48.301 43.91 43.91 43.91 43.91 44.788199999999996 43.91 4120 Hos Pharmacy Facility Fee 3060589 ROMAZICON INJ. 0.1MG/ML 5ML J8499 250 825 577.5 179.36 825 420.26 179.36 618.75 179.36 420.26 420.26 420.26 420.26 179.36 197.29600000000002 179.36 179.36 179.36 179.36 182.9472 179.36 4120 Hos Pharmacy Facility Fee 3061819 PROPAFENONE HCL 150 MG / 1 TAB J8499 637 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3062460 SALINE NASAL SPRAY 45ML J8499 637 67 46.9 14.57 67 34.13 14.57 50.25 14.57 34.13 34.13 34.13 34.13 14.57 16.027 14.57 14.57 14.57 14.57 14.8614 14.57 4120 Hos Pharmacy Facility Fee 3100030 SAPHRIS 5MG TAB J8499 637 146 102.19999999999999 31.74 146 74.37 31.74 109.5 31.74 74.37 74.37 74.37 74.37 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 4120 Hos Pharmacy Facility Fee 3064641 SEROQUEL 100 MG TABLET J8499 637 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4120 Hos Pharmacy Facility Fee 3064367 SEROQUEL 200MG TAB J8499 637 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4120 Hos Pharmacy Facility Fee 3063666 SEROQUEL 25mg Tab J8499 637 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4120 Hos Pharmacy Facility Fee 3042405 SILVER SULFADIAZINE 1% CR 400 GM J8499 637 618 432.59999999999997 134.35 618 314.81 134.35 463.5 134.35 314.81 314.81 314.81 314.81 134.35 147.785 134.35 134.35 134.35 134.35 137.037 134.35 4120 Hos Pharmacy Facility Fee 3042454 SILVADENE CREAM 1% 50GM J8499 637 147 102.89999999999999 31.96 147 74.88 31.96 110.25 31.96 74.88 74.88 74.88 74.88 31.96 35.156000000000006 31.96 31.96 31.96 31.96 32.5992 31.96 4120 Hos Pharmacy Facility Fee 3064243 SIMVASTATIN 40MG TAB J8499 637 102 71.39999999999999 22.17 102 51.96 22.17 76.5 22.17 51.96 51.96 51.96 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 4120 Hos Pharmacy Facility Fee 3042504 CARBIDOPA/LEVODOPA 10/100MG 1 TAB J8499 637 22 15.399999999999999 4.78 22 11.21 4.78 16.5 4.78 11.21 11.21 11.21 11.21 4.78 5.258000000000001 4.78 4.78 4.78 4.78 4.8756 4.78 4120 Hos Pharmacy Facility Fee 3062395 SINEMET 25/100 TAB J8499 637 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4120 Hos Pharmacy Facility Fee 3042512 SINEMET 25/250 TAB J8499 637 30 21 6.52 30 15.28 6.52 22.5 6.52 15.28 15.28 15.28 15.28 6.52 7.172 6.52 6.52 6.52 6.52 6.650399999999999 6.52 4120 Hos Pharmacy Facility Fee 3042546 SINEQUAN 10MG U.D. J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3065684 SINEQUAN 25 MG CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063708 SINGULAIR 10mg Tab J8499 637 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4120 Hos Pharmacy Facility Fee 3045804 THEOPHYLLINE 200 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3042702 SODIUM BICARBONATE 8.4% INJ 1 EA J8499 250 622 435.4 135.22 622 316.85 135.22 466.5 135.22 316.85 316.85 316.85 316.85 135.22 148.74200000000002 135.22 135.22 135.22 135.22 137.9244 135.22 4120 Hos Pharmacy Facility Fee 3042652 SODIUM BICARBONATE 325 MG / 1 TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061611 SODIUM CHLORIDE 1GRAM TAB J8499 259 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3043452 SOMA-350 UNIT-DOSE 350MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3064250 SOTOLOL 80 MG / 1 TAB J8499 637 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4120 Hos Pharmacy Facility Fee 3064375 NATEGLINIDE 120 MG / 1 TAB J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3060928 SUMATRIPTAN INJ 6 MG / 1 EA J8499 636 1136 795.1999999999999 246.97 1136 578.68 246.97 852 246.97 578.68 578.68 578.68 578.68 246.97 271.66700000000003 246.97 246.97 246.97 246.97 251.9094 246.97 4120 Hos Pharmacy Facility Fee 3044708 SYMMETREL 100MG J8499 637 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4120 Hos Pharmacy Facility Fee 3044807 SYNTHROID 0.1MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063674 SYNTHROID(LEVOTHROID) 25mg TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3099971 TAMIFLU 75 MG CAP J8499 637 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4120 Hos Pharmacy Facility Fee 3099931 METHIMAZOLE 5 MG J8499 250 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3100038 TDAP VACCINE >7YRS OLD/OLDER J8499 636 848 593.5999999999999 184.36 848 431.97 184.36 636 184.36 431.97 431.97 431.97 431.97 184.36 202.79600000000002 184.36 184.36 184.36 184.36 188.0472 184.36 4120 Hos Pharmacy Facility Fee 3045259 TEARISOL OPHTH DROPS 1 EA J8499 637 192 134.39999999999998 41.74 192 97.8 41.74 144 41.74 97.8 97.8 97.8 97.8 41.74 45.91400000000001 41.74 41.74 41.74 41.74 42.5748 41.74 4120 Hos Pharmacy Facility Fee 3051265 TEGRETOL 200MG TABLET J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3061629 TENORMIN INJ 5MG/10ML J8499 250 194 135.79999999999998 42.18 194 98.82 42.18 145.5 42.18 98.82 98.82 98.82 98.82 42.18 46.398 42.18 42.18 42.18 42.18 43.0236 42.18 4120 Hos Pharmacy Facility Fee 3061173 TERCONAZOLE-7 VAG CR 1 EA J8499 637 660 461.99999999999994 143.48 660 336.2 143.48 495 143.48 336.2 336.2 336.2 336.2 143.48 157.828 143.48 143.48 143.48 143.48 146.34959999999998 143.48 4120 Hos Pharmacy Facility Fee 3051984 TESSALON PERLES J8499 637 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3099906 TETANUS/DIPTHERIA TOXOID 0.5ML J8499 250 496 347.2 107.83 496 252.66 107.83 372 107.83 252.66 252.66 252.66 252.66 107.83 118.61300000000001 107.83 107.83 107.83 107.83 109.9866 107.83 4120 Hos Pharmacy Facility Fee 3061033 TETRACAINE HCL 0.5% OPHTH SOLN 1 EA J8499 637 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 4120 Hos Pharmacy Facility Fee 3045903 THIAMINE HCL 100MG INJ J8499 636 132 92.39999999999999 28.7 132 67.24 28.7 99 28.7 67.24 67.24 67.24 67.24 28.7 31.57 28.7 28.7 28.7 28.7 29.274 28.7 4120 Hos Pharmacy Facility Fee 3045952 THIAMINE HCL U-D 100MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063179 TIMOLOL MALEATE 0.25% OPHTH SOLN 5 ML J8499 637 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4120 Hos Pharmacy Facility Fee 3046372 TIMOPTIC 0.5% 5CC J8499 637 502 351.4 109.14 502 255.72 109.14 376.5 109.14 255.72 255.72 255.72 255.72 109.14 120.05400000000002 109.14 109.14 109.14 109.14 111.3228 109.14 4120 Hos Pharmacy Facility Fee 3064292 TIZANIDINE 4MG TAB J8499 637 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4120 Hos Pharmacy Facility Fee 3060951 TOBRAMYCIN/DEXAMETHASONE OPHTH OINT 3.5 GM J8499 637 543 380.09999999999997 118.05 543 276.6 118.05 407.25 118.05 276.6 276.6 276.6 276.6 118.05 129.85500000000002 118.05 118.05 118.05 118.05 120.411 118.05 4120 Hos Pharmacy Facility Fee 3064110 TOBRAMYCIN 0.3% OPHTH OINT 1 EA J8499 637 633 443.09999999999997 137.61 633 322.45 137.61 474.75 137.61 322.45 322.45 322.45 322.45 137.61 151.37100000000004 137.61 137.61 137.61 137.61 140.36220000000003 137.61 4120 Hos Pharmacy Facility Fee 3060506 TOBRAMYCIN O.S. 2.5 ML J8499 637 301 210.7 65.44 301 153.33 65.44 225.75 65.44 153.33 153.33 153.33 153.33 65.44 71.98400000000001 65.44 65.44 65.44 65.44 66.7488 65.44 4120 Hos Pharmacy Facility Fee 3060498 TOBREX O.S. 5ML J8499 637 511 357.7 111.09 511 260.3 111.09 383.25 111.09 260.3 260.3 260.3 260.3 111.09 122.19900000000001 111.09 111.09 111.09 111.09 113.3118 111.09 4120 Hos Pharmacy Facility Fee 3099963 TOPAMAX 100 MG TAB J8499 637 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4120 Hos Pharmacy Facility Fee 3100006 TOPAMAX 25MG TABLET J8499 637 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4120 Hos Pharmacy Facility Fee 3064102 TOPROL XL 25MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3060076 TOPROL XL 50MG TAB J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3052404 TORADOL 10MG TAB J8499 637 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4120 Hos Pharmacy Facility Fee 3051554 TORADOL 30MG INJECTION J8499 250 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4120 Hos Pharmacy Facility Fee 3051943 TORADOL 60MG/ML INJ J8499 250 201 140.7 43.7 201 102.39 43.7 150.75 43.7 102.39 102.39 102.39 102.39 43.7 48.07000000000001 43.7 43.7 43.7 43.7 44.574000000000005 43.7 4120 Hos Pharmacy Facility Fee 3100024 TRAMADOL (ULTRAM) 50MG J8499 637 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4120 Hos Pharmacy Facility Fee 3012408 TRIAMCINOLONE 0.1% CRM 15GM J8499 637 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4120 Hos Pharmacy Facility Fee 3030004 TRIAMCINOLONE INJ 40 MG / 1 EA J8499 250 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4120 Hos Pharmacy Facility Fee 3022977 TRIAMTERENE W/HCTZ 25/50 CAP J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3032216 TRIAMTERENE/HCTZ 37.5/25MG 1 CAP J8499 637 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4120 Hos Pharmacy Facility Fee 3046802 PERPHENAZINE AMITRIPT 2-25MG 1 TAB J8499 637 30 21 6.52 30 15.28 6.52 22.5 6.52 15.28 15.28 15.28 15.28 6.52 7.172 6.52 6.52 6.52 6.52 6.650399999999999 6.52 4120 Hos Pharmacy Facility Fee 3064669 TRICOR 145 MG TAB J8499 637 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3100034 TRICOR 48MG TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3061975 TUMS CHEWABLE J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3047701 TYLENOL 325MG TAB J8499 637 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3051976 TYLENOL EXTRA STRENGTH 500MG J8499 637 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4120 Hos Pharmacy Facility Fee 3047800 TYLENOL W/CODEINE 5CC J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3062262 UROKINASE 5000units INJ. J8499 250 1683 1178.1 365.89 1683 857.32 365.89 1262.25 365.89 857.32 857.32 857.32 857.32 365.89 402.47900000000004 365.89 365.89 365.89 365.89 373.2078 365.89 4120 Hos Pharmacy Facility Fee 3062759 VALPROIC ACID SYRUP 250 MG / 5 ML J8499 637 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4120 Hos Pharmacy Facility Fee 3063047 VALTREX 1000MG TAB J8499 637 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4120 Hos Pharmacy Facility Fee 3061215 ENALIPRIL MALEATE IV VIAL 1.25 MG / 2 ML J8499 250 758 530.6 164.79 758 386.13 164.79 568.5 164.79 386.13 386.13 386.13 386.13 164.79 181.269 164.79 164.79 164.79 164.79 168.0858 164.79 4120 Hos Pharmacy Facility Fee 3048972 VASOTEC 10MG TABLET J8499 637 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3048964 VASOTEC 5MG TABLET J8499 637 30 21 6.52 30 15.28 6.52 22.5 6.52 15.28 15.28 15.28 15.28 6.52 7.172 6.52 6.52 6.52 6.52 6.650399999999999 6.52 4120 Hos Pharmacy Facility Fee 3052149 VENTOLIN INHALER 6.8 grams J8499 637 221 154.7 48.05 221 112.58 48.05 165.75 48.05 112.58 112.58 112.58 112.58 48.05 52.855000000000004 48.05 48.05 48.05 48.05 49.010999999999996 48.05 4120 Hos Pharmacy Facility Fee 3100066 VERAPAMIL 2.5MG/ML SDV 2ML J8499 250 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4120 Hos Pharmacy Facility Fee 3049806 VITAMIN A & D OINT 1 EA J8499 637 541 378.7 117.61 541 275.59 117.61 405.75 117.61 275.59 275.59 275.59 275.59 117.61 129.371 117.61 117.61 117.61 117.61 119.9622 117.61 4120 Hos Pharmacy Facility Fee 3100040 VITAMIN D3 2000 UNITS CAPS J8499 637 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4120 Hos Pharmacy Facility Fee 3062247 VITAMIN E 400IU CAP J8499 637 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4120 Hos Pharmacy Facility Fee 3052305 VOLTAREN 75MG TAB J8499 637 517 361.9 112.4 517 263.36 112.4 387.75 112.4 263.36 263.36 263.36 263.36 112.4 123.64000000000001 112.4 112.4 112.4 112.4 114.64800000000001 112.4 4120 Hos Pharmacy Facility Fee 3019155 WARFARIN 2.5MG TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3019205 WARFARIN 2MG TAB J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3019106 WARFARIN 5MG TAB J8499 637 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4120 Hos Pharmacy Facility Fee 3019213 WARFARIN 7.5 MG / 1 TAB J8499 637 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4120 Hos Pharmacy Facility Fee 3060985 WELBUTRIN 75MG TAB J8499 637 30 21 6.52 30 15.28 6.52 22.5 6.52 15.28 15.28 15.28 15.28 6.52 7.172 6.52 6.52 6.52 6.52 6.650399999999999 6.52 4120 Hos Pharmacy Facility Fee 3062478 WELLBUTRIN SR 150MG J8499 637 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4120 Hos Pharmacy Facility Fee 3064668 WELLBUTRIN XL 150MG TAB J8499 637 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3062940 LATANOPROST OPHTH SOLN 2.5ML 2.5 ML J8499 637 718 502.59999999999997 156.09 718 365.75 156.09 538.5 156.09 365.75 365.75 365.75 365.75 156.09 171.699 156.09 156.09 156.09 156.09 159.2118 156.09 4120 Hos Pharmacy Facility Fee 3050317 XANAX 0.25MG UD J8499 637 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4120 Hos Pharmacy Facility Fee 3050333 XANAX 1.0MG UD J8499 259 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4120 Hos Pharmacy Facility Fee 3050655 LIDOCAINE INJ 100 MG / 1 EA J8499 636 368 257.59999999999997 80 368 187.46 80 276 80 187.46 187.46 187.46 187.46 80 88 80 80 80 80 81.6 80 4120 Hos Pharmacy Facility Fee 3050457 XYLOCAINE 1PC J8499 636 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3050507 LIDOCAINE 2% INJ 1 EA J8499 636 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3050754 XYLOCAINE VISCOUS 2% J8499 637 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4120 Hos Pharmacy Facility Fee 3050853 LIDOCAINE 2% W/EPI:1-100000 1 EA J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3050804 LIDOCAINE 2% W/EPI:1-100000 1 EA J8499 250 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4120 Hos Pharmacy Facility Fee 3063302 ZAROXOLYN 2.5MG TAB J8499 637 638 446.59999999999997 138.7 638 325 138.7 478.5 138.7 325 325 325 325 138.7 152.57 138.7 138.7 138.7 138.7 141.474 138.7 4120 Hos Pharmacy Facility Fee 3050911 ZAROXOLYN 5MG U.D. J8499 637 721 504.7 156.75 721 367.28 156.75 540.75 156.75 367.28 367.28 367.28 367.28 156.75 172.425 156.75 156.75 156.75 156.75 159.885 156.75 4120 Hos Pharmacy Facility Fee 3039591 ZESTRIL 10MG TABLET J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3064637 ZESTRIL 20MG TABLET J8499 637 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4120 Hos Pharmacy Facility Fee 3062973 ZESTRIL 5MG TAB J8499 637 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3064640 ZETIA 10MG TABLET J8499 637 721 504.7 156.75 721 367.28 156.75 540.75 156.75 367.28 367.28 367.28 367.28 156.75 172.425 156.75 156.75 156.75 156.75 159.885 156.75 4120 Hos Pharmacy Facility Fee 3062635 ZIAC 2.5MG J8499 637 374 261.8 81.31 374 190.52 81.31 280.5 81.31 190.52 190.52 190.52 190.52 81.31 89.44100000000002 81.31 81.31 81.31 81.31 82.9362 81.31 4120 Hos Pharmacy Facility Fee 3062643 BISOPROLOL/HCTZ 5 MG / 1 TAB J8499 637 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3060480 ZITHROMAX 250MG TAB J8499 637 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4120 Hos Pharmacy Facility Fee 3060696 ZOCOR 10MG J8499 637 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4120 Hos Pharmacy Facility Fee 3100026 ZOFRAN ODT 4MG TAB J8499 637 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3060357 ZOLOFT 50MG TAB J8499 637 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4120 Hos Pharmacy Facility Fee 3051059 ZYLOPRIM UNIT-DOSE 100MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3051109 ZYLOPRIM UNIT-DOSE 300MG J8499 637 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3063419 ZYPREXA 5MG TAB J8499 637 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4120 Hos Pharmacy Facility Fee 3100043 ZYPREXA ZYDIS 5MG TAB J8499 637 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4120 Hos Pharmacy Facility Fee 3100076 RDARONE 200 MG TAB J8499 637 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4120 Hos Pharmacy Facility Fee 3100079 MBALTA 30 MG CAP J8499 637 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4120 Hos Pharmacy Facility Fee 3100080 MBALTA 60 MG CAP J8499 637 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4120 Hos Pharmacy Facility Fee 3100083 PO-ESTRADIOL 5 MG/ML J8499 636 118 82.6 25.65 118 60.11 25.65 88.5 25.65 60.11 60.11 60.11 60.11 25.65 28.215 25.65 25.65 25.65 25.65 26.163 25.65 4120 Hos Pharmacy Facility Fee 3100085 SFERAL MESYLATE J8499 636 309 216.29999999999998 67.18 309 157.4 67.18 231.75 67.18 157.4 157.4 157.4 157.4 67.18 73.89800000000001 67.18 67.18 67.18 67.18 68.5236 67.18 4120 Hos Pharmacy Facility Fee 3100087 ROPINE 0.01MG INJ J8499 636 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4120 Hos Pharmacy Facility Fee 3033800 NYSTATIN TRIAMCINOLONE CR 1 EA J8499 250 1615 1130.5 351.1 1615 822.68 351.1 1211.25 351.1 822.68 822.68 822.68 822.68 351.1 386.21000000000004 351.1 351.1 351.1 351.1 358.122 351.1 4120 Hos Pharmacy Facility Fee 3033859 NILSTAT 100MU TOPICAL CR 15 GM J8499 250 304 212.79999999999998 66.09 304 154.86 66.09 228 66.09 154.86 154.86 154.86 154.86 66.09 72.69900000000001 66.09 66.09 66.09 66.09 67.4118 66.09 4120 Hos Pharmacy Facility Fee 3062429 DONEPEZIL 5 MG / 1 TAB J8499 250 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4120 Hos Pharmacy Facility Fee 3410123 D51/2NS 1000ML 1000 ML J8499 250 330 230.99999999999997 71.74 330 168.1 71.74 247.5 71.74 168.1 168.1 168.1 168.1 71.74 78.914 71.74 71.74 71.74 71.74 73.17479999999999 71.74 4120 Hos Pharmacy Facility Fee 3410073 D5W 1000ML 1000 ML J8499 250 125 87.5 87.5 125 63.67424242424242 27.174242424242422 93.75 27.174242424242422 93.75 93.75 93.75 93.75 27.174242424242422 29.891666666666666 27.174242424242422 27.174242424242422 27.174242424242422 27.174242424242422 27.71772727272727 27.174242424242422 4120 Hos Pharmacy Facility Fee 3410651 NS 250ML 250 ML J8499 250 85 59.49999999999999 59.5 85 43.29848484848485 18.478484848484847 63.75 18.478484848484847 63.75 63.75 63.75 63.75 18.478484848484847 20.326333333333334 18.478484848484847 18.478484848484847 18.478484848484847 18.478484848484847 18.848054545454545 18.478484848484847 4120 Hos Pharmacy Facility Fee 3410800 NS 100ML MINIBAG 100 ML J8499 636 25 17.5 17.5 25 12.734848484848484 5.434848484848484 18.75 5.434848484848484 18.75 18.75 18.75 18.75 5.434848484848484 5.978333333333333 5.434848484848484 5.434848484848484 5.434848484848484 5.434848484848484 5.543545454545454 5.434848484848484 4120 Hos Pharmacy Facility Fee 3410801 KCL 20MEQ/100ML STERILE WATER 20 MEQ / 100 ML J8499 250 35 24.5 24.5 35 17.828787878787878 7.6087878787878775 26.25 7.6087878787878775 26.25 26.25 26.25 26.25 7.6087878787878775 8.369666666666665 7.6087878787878775 7.6087878787878775 7.6087878787878775 7.6087878787878775 7.760963636363635 7.6087878787878775 4120 Hos Pharmacy Facility Fee 3410693 HEPARIN DRIP 25000 UN / 250 ML J8499 250 125 87.5 87.5 125 63.67424242424242 27.17424242424242 93.75 27.17424242424242 93.75 93.75 93.75 93.75 27.17424242424242 29.891666666666662 27.17424242424242 27.17424242424242 27.17424242424242 27.17424242424242 27.717727272727267 27.17424242424242 4120 Hos Pharmacy Facility Fee 3100109 ALBUTEROL SULFATE VIAL-NEB 2.5 MG / 3 ML J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3100108 ALBUTEROL SULFATE INHALER 90 MCG / 1 PUFF J8499 250 67 46.9 14.57 67 34.13 14.57 50.25 14.57 34.13 34.13 34.13 34.13 14.57 16.027 14.57 14.57 14.57 14.57 14.8614 14.57 4120 Hos Pharmacy Facility Fee 3100111 IPRATROPIUM BROMIDE NEB FOR INH 0.5 MG / 2.5 ML J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3100113 LURASIDONE HCL TABLET 40 MG J8499 250 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4120 Hos Pharmacy Facility Fee 3410806 Oxcarhazepine 300 mg J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3100102 Diphenhydramine 50mg/ml INJ J8499 250 160 112 34.78 160 81.5 34.78 120 34.78 81.5 81.5 81.5 81.5 34.78 38.258 34.78 34.78 34.78 34.78 35.4756 34.78 4120 Hos Pharmacy Facility Fee 3410807 Risperdal 3mg J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410808 Seroquel 300mg J8499 250 370 259 80.44 370 188.48 80.44 277.5 80.44 188.48 188.48 188.48 188.48 80.44 88.48400000000001 80.44 80.44 80.44 80.44 82.0488 80.44 4120 Hos Pharmacy Facility Fee 3410810 Perphenazine 8 mg tablet J8499 250 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4120 Hos Pharmacy Facility Fee 3410811 Valacyclovir 1 gm tablet J8499 250 293 205.1 63.7 293 149.25 63.7 219.75 63.7 149.25 149.25 149.25 149.25 63.7 70.07000000000001 63.7 63.7 63.7 63.7 64.974 63.7 4120 Hos Pharmacy Facility Fee 3410812 Chlorthalidone 25 mg tablet J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410813 Olanzapine J8499 250 485 339.5 105.44 485 247.06 105.44 363.75 105.44 247.06 247.06 247.06 247.06 105.44 115.98400000000001 105.44 105.44 105.44 105.44 107.5488 105.44 4120 Hos Pharmacy Facility Fee 3410815 Suboxone 4mg/mg J8499 636 199 139.29999999999998 43.26 199 101.37 43.26 149.25 43.26 101.37 101.37 101.37 101.37 43.26 47.586 43.26 43.26 43.26 43.26 44.1252 43.26 4120 Hos Pharmacy Facility Fee 3410816 Suboxone 8 mg/1mg tablet J8499 250 199 139.29999999999998 43.26 199 101.37 43.26 149.25 43.26 101.37 101.37 101.37 101.37 43.26 47.586 43.26 43.26 43.26 43.26 44.1252 43.26 4120 Hos Pharmacy Facility Fee 3410817 Wellbutrin 75mg J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410818 Lamictal 25 mg J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410819 Lamictal 100mg J8499 250 59 41.3 12.83 59 30.05 12.83 44.25 12.83 30.05 30.05 30.05 30.05 12.83 14.113000000000001 12.83 12.83 12.83 12.83 13.0866 12.83 4120 Hos Pharmacy Facility Fee 3410820 Prolixin 5mg tablet J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410821 Prolixin 10mg tablet J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410822 Prolixin Decanoate 25mg injection J8499 250 220 154 47.83 220 112.07 47.83 165 47.83 112.07 112.07 112.07 112.07 47.83 52.613 47.83 47.83 47.83 47.83 48.7866 47.83 4120 Hos Pharmacy Facility Fee 3410823 Depakote ER 500mg Tablet J8499 250 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4120 Hos Pharmacy Facility Fee 3410824 Invega 1.5mg tablet J8499 250 N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C #VALUE! N/C N/C N/C N/C N/C N/C 4120 Hos Pharmacy Facility Fee 3410825 Invega 3.0mg tablet J8499 250 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.87 8.7 4120 Hos Pharmacy Facility Fee 3410826 Invega 6mg tablet J8499 250 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4120 Hos Pharmacy Facility Fee 3410827 Invega 9mg tablet J8499 250 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4120 Hos Pharmacy Facility Fee 3410828 Invega Sustenna 156mg J8499 250 0.01 0.006999999999999999 0 0.01 0.01 0 0.01 0 0.01 0.01 0.01 0.01 0 0 0 0 8.7 8.7 8.87 8.7 4120 Hos Pharmacy Facility Fee 3410829 Invega Sustenna 234mg J8499 250 0.01 0.006999999999999999 0 0.01 0.01 0 0.01 0 0.01 0.01 0.01 0.01 0 0 0 0 0.01 0.01 0.01 0.01 4120 Hos Pharmacy Facility Fee 3410830 Artane 5mg tablet J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410831 Navane 5 mg Capsule J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410832 Lexapro 20mg tablet J8499 250 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4120 Hos Pharmacy Facility Fee 3410833 Oxycodone 30 mg UD J8499 250 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4120 Hos Pharmacy Facility Fee 3410834 Klonopin 1mg J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410835 Prolixin HCL 2.5mg/ml injection J8499 250 1610 1127 350.01 1610 820.13 350.01 1207.5 350.01 820.13 820.13 820.13 820.13 350.01 385.011 350.01 350.01 350.01 350.01 357.0102 350.01 4120 Hos Pharmacy Facility Fee 3410836 Depakote ER 500mg Tablet J8499 250 39 27.299999999999997 8.48 39 19.87 8.48 29.25 8.48 19.87 19.87 19.87 19.87 8.48 9.328000000000001 8.48 8.48 8.48 8.48 8.649600000000001 8.48 4120 Hos Pharmacy Facility Fee 3410838 Loxapine 5mg capsule J8499 250 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4120 Hos Pharmacy Facility Fee 3410839 Fiorcet Capsule J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410840 Chlorpromazine 100 mg Tablet J8499 250 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4120 Hos Pharmacy Facility Fee 3410841 Gabapentin 400 mg Capsule J8499 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4120 Hos Pharmacy Facility Fee 3410842 Luvox 100 mg tablet J8499 250 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4120 Hos Pharmacy Facility Fee 3410843 Thorazine 50 mg Tablet J8499 250 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4120 Hos Pharmacy Facility Fee 3410844 Lithium Carbonate 450 mg J8499 250 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4120 Hos Pharmacy Facility Fee 3410845 Trifluoperazine 5mg tablet J8499 250 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4120 Hos Pharmacy Facility Fee 3410846 Effexor 75mg XR capsule J8499 250 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4120 Hos Pharmacy Facility Fee 3410847 Trazodone 100mg tablet J8499 250 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4120 Hos Pharmacy Facility Fee 3410850 Risperdal Consta 37.5mg J8499 250 1508 1055.6 327.84 1508 768.18 327.84 1131 327.84 768.18 768.18 768.18 768.18 327.84 360.624 327.84 327.84 327.84 327.84 334.3968 327.84 4120 Hos Pharmacy Facility Fee 3410851 Risperdal Consta 50mg J8499 250 2011 1407.6999999999998 437.19 2011 1024.4 437.19 1458 437.19 1024.4 1024.4 1024.4 1024.4 437.19 480.90900000000005 437.19 437.19 437.19 437.19 445.9338 437.19 4120 Hos Pharmacy Facility Fee 3410852 Anafranil 25mg J8499 250 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4120 Hos Pharmacy Facility Fee 3410854 Risperdal Consta 25ng Kit J8499 250 861 602.6999999999999 187.18 861 438.59 187.18 645.75 187.18 438.59 438.59 438.59 438.59 187.18 205.89800000000002 187.18 187.18 187.18 187.18 190.92360000000002 187.18 4120 Hos Pharmacy Facility Fee 3410855 Loxapine 50 mg capsule J8499 250 13 9.1 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 4120 Hos Pharmacy Facility Fee 3410857 Melatonin 10 mg J8499 250 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4120 Hos Pharmacy Facility Fee 3410858 Permethrin 5% cream 60 grams J8499 250 208 145.6 45.22 208 105.96 45.22 156 45.22 105.96 105.96 105.96 105.96 45.22 49.742000000000004 45.22 45.22 45.22 45.22 46.1244 45.22 4120 Hos Pharmacy Facility Fee 3410859 Lovenox 80mg J8499 636 176 123.19999999999999 38.26 176 89.65 38.26 132 38.26 89.65 89.65 89.65 89.65 38.26 42.086 38.26 38.26 38.26 38.26 39.0252 38.26 4120 Hos Pharmacy Facility Fee 3410860 Viibryd 10 mg tablet J8499 250 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3410861 Viibryd 40 mg tablet J8499 250 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4120 Hos Pharmacy Facility Fee 3410862 Propranolol injection 1mg/ml J8499 250 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4120 Hos Pharmacy Facility Fee 3410864 Aripiprazole 675mg J8499 250 0.01 0.006999999999999999 0 0.01 0.01 0 0.01 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 4120 Hos Pharmacy Facility Fee 3410865 Aripiprazole 882mg J8499 250 0.01 0.006999999999999999 0 0.01 0.01 0 0.01 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 4120 Hos Pharmacy Facility Fee 3410866 Aripiprazole 1064mg J8499 250 0.01 0.006999999999999999 0 0.01 0.01 0 0.01 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 4120 Hos Pharmacy Facility Fee 3410867 Vitamin D3 1000IU J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410868 Eliquis 5mg tablet J8499 250 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4120 Hos Pharmacy Facility Fee 3410869 Atorvastatin 10mg J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410870 Fluvoxamine 100mg J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410871 Aristada 662mg J8499 250 0.01 0.006999999999999999 0 0.01 0.01 0 0.01 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 4120 Hos Pharmacy Facility Fee 3410872 Melatonin 5mg J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410873 Naltrexone 50 mg tablet J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410874 Valsartan 80mg J8499 637 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4120 Hos Pharmacy Facility Fee 3410875 Suboxone 2-0.5mg J8499 250 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4120 Hos Pharmacy Facility Fee 3410876 Olanzapine 10mg injection J8499 250 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4120 Hos Pharmacy Facility Fee 3410877 Olanzapine 15 mg J8499 250 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4120 Hos Pharmacy Facility Fee 3410878 Oxcarbazepine J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410879 Famotidine 20mg J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410880 Losarten 50 mg Tablet J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410881 Atorvastatin 40 mg Tablet J8499 250 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4120 Hos Pharmacy Facility Fee 3410882 Olanzapine 20 mg ODT tablet J8499 637 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4120 Hos Pharmacy Facility Fee 3410883 Guanfacine J8499 250 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4120 Hos Pharmacy Facility Fee 3410884 Norvasc 10mg J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3410885 Buspar 10mg J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4120 Hos Pharmacy Facility Fee 3100103 Diphenhydramine 50mg Tab J8499 250 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4160 Hos Iv Therapy Facility Fee 3410453 0.45% NACL 1000CC J7030 258 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4160 Hos Iv Therapy Facility Fee 3410628 0.45% SALINE 500CC 0.45PC J7030 258 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4160 Hos Iv Therapy Facility Fee 3410412 3-WAY STOPCOCK EXT 36-SL G05609 270 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4160 Hos Iv Therapy Facility Fee 3410537 40MM SCREWCAP SET B4036 270 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 4160 Hos Iv Therapy Facility Fee 3410305 60 MICROBORE EXTENSION SET S1015 270 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4160 Hos Iv Therapy Facility Fee 3410776 ALCOHOL 5% IN DEXTROSE 5% 1000 B4185 258 161 112.69999999999999 35 161 82.01 35 120.75 35 82.01 82.01 82.01 82.01 35 38.5 35 35 35 35 35.7 35 4160 Hos Iv Therapy Facility Fee 3410586 AMINOSYN 3.5% M 1000CC B4168 258 537 375.9 116.74 537 273.55 116.74 402.75 116.74 273.55 273.55 273.55 273.55 116.74 128.41400000000002 116.74 116.74 116.74 116.74 119.0748 116.74 4160 Hos Iv Therapy Facility Fee 3410321 AMINOSYN 8.5PC W/TPN KIT B4176 258 824 576.8 179.14 824 419.75 179.14 618 179.14 419.75 419.75 419.75 419.75 179.14 197.054 179.14 179.14 179.14 179.14 182.72279999999998 179.14 4160 Hos Iv Therapy Facility Fee 3410032 ANESTHESIA VENOSET W/CAIR CLAM A4223 270 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4160 Hos Iv Therapy Facility Fee 3410602 BARD SYRINGE PUMP FEE E0780 270 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4160 Hos Iv Therapy Facility Fee 3410743 BLOOD COMPONENT SET 81406 270 132 92.39999999999999 28.7 132 67.24 28.7 99 28.7 67.24 67.24 67.24 67.24 28.7 31.57 28.7 28.7 28.7 28.7 29.274 28.7 4160 Hos Iv Therapy Facility Fee 3410370 BLOOD Y-TYPE SET 78 P9099 270 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4160 Hos Iv Therapy Facility Fee 3410040 BUTTERFLY 19X7/8, 12 TUBING A4222 272 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4160 Hos Iv Therapy Facility Fee 3410057 BUTTERFLY 21X3/4, 12 TUBING 36415 272 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4160 Hos Iv Therapy Facility Fee 3410297 BUTTERFLY 25X3/4, 12 TUBING 36415 272 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4160 Hos Iv Therapy Facility Fee 3410065 BUTTERLY 23X3/4, 12 TUBING 36415 272 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4160 Hos Iv Therapy Facility Fee 3410804 CLINIMIX 4.25/25 1000ML B4189 258 380 266 82.61 380 193.57 82.61 285 82.61 193.57 193.57 193.57 193.57 82.61 90.87100000000001 82.61 82.61 82.61 82.61 84.2622 82.61 4160 Hos Iv Therapy Facility Fee 3410805 CLINIMIX 4.25/5 1000ML B4189 258 395 276.5 85.87 395 201.21 85.87 296.25 85.87 201.21 201.21 201.21 201.21 85.87 94.45700000000001 85.87 85.87 85.87 85.87 87.5874 85.87 4160 Hos Iv Therapy Facility Fee 3099969 CLINIMIX E 4.25/25 1000 ML B4189 258 446 312.2 96.96 446 227.19 96.96 334.5 96.96 227.19 227.19 227.19 227.19 96.96 106.656 96.96 96.96 96.96 96.96 98.8992 96.96 4160 Hos Iv Therapy Facility Fee 3410529 CYSTOSCOPY/IRRIGATION SET A4355 270 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4160 Hos Iv Therapy Facility Fee 3410123 D51/2NS 1000ML 96360 258 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4160 Hos Iv Therapy Facility Fee 3410115 D51/2NS 500ML 96360 258 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4160 Hos Iv Therapy Facility Fee 3410107 D51/3NS 1000ML 96360 258 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4160 Hos Iv Therapy Facility Fee 3410420 D51/3NS 500ML 96360 258 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4160 Hos Iv Therapy Facility Fee 3410644 D51/4NS 1000CC 96360 258 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4160 Hos Iv Therapy Facility Fee 3410636 D51/4NS 500CC 96360 258 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4160 Hos Iv Therapy Facility Fee 3410164 D5LR 1000ML 96360 258 104 72.8 22.61 104 52.98 22.61 78 22.61 52.98 52.98 52.98 52.98 22.61 24.871000000000002 22.61 22.61 22.61 22.61 23.0622 22.61 4160 Hos Iv Therapy Facility Fee 3410156 D5LR 500ML 96360 258 87 60.9 18.91 87 44.32 18.91 65.25 18.91 44.32 44.32 44.32 44.32 18.91 20.801000000000002 18.91 18.91 18.91 18.91 19.2882 18.91 4160 Hos Iv Therapy Facility Fee 3410149 D5NS 1000ML 96360 258 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4160 Hos Iv Therapy Facility Fee 3410799 D5NS W/40 MEQ KCL /1000ML 96360 258 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4160 Hos Iv Therapy Facility Fee 3410795 D5NS/20MEQ KCL / 1000 ML 96360 258 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4160 Hos Iv Therapy Facility Fee 3410803 D5W 0.45% NACLW/30MEQKCL/1000M 96360 258 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4160 Hos Iv Therapy Facility Fee 3410793 D5W/0.45%NACLW/20MEQKCL 1000ML 96360 258 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4160 Hos Iv Therapy Facility Fee 3410794 D5W/0.45%NACLW40MEQKCL/1000ML 96360 258 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4160 Hos Iv Therapy Facility Fee 3410578 DEXTROSE 10% 1000CC J7030 258 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4160 Hos Iv Therapy Facility Fee 3410792 DEXTROSE 20% IV 500ML J7030 250 104 72.8 22.61 104 52.98 22.61 78 22.61 52.98 52.98 52.98 52.98 22.61 24.871000000000002 22.61 22.61 22.61 22.61 23.0622 22.61 4160 Hos Iv Therapy Facility Fee 3410099 DEXTROSE 250CC J7030 258 74 51.8 16.09 74 37.7 16.09 55.5 16.09 37.7 37.7 37.7 37.7 16.09 17.699 16.09 16.09 16.09 16.09 16.4118 16.09 4160 Hos Iv Therapy Facility Fee 3410073 DEXTROSE 5% 1000ML J7030 258 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4160 Hos Iv Therapy Facility Fee 3410081 DEXTROSE 5% 500ML J7030 258 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4160 Hos Iv Therapy Facility Fee 3410131 DEXTROSE 5%/NORMAL SALINE500ML J7030 258 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4160 Hos Iv Therapy Facility Fee 3410677 DEXTROSE 50% 500ML J7030 258 280 196 60.87 280 142.63 60.87 210 60.87 142.63 142.63 142.63 142.63 60.87 66.95700000000001 60.87 60.87 60.87 60.87 62.087399999999995 60.87 4160 Hos Iv Therapy Facility Fee 3410172 DEXTROSE IN WATER 5% 100ML J7030 258 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4160 Hos Iv Therapy Facility Fee 3410008 DIAL-A-FLOW A4206 272 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4160 Hos Iv Therapy Facility Fee 3410396 DILUENT 10ml A4216 258 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4160 Hos Iv Therapy Facility Fee 3410784 DILUENT 20 ml A4216 258 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4160 Hos Iv Therapy Facility Fee 3410719 EVACUATED CONTAINER 1000ML A4206 270 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4160 Hos Iv Therapy Facility Fee 3410198 EXTENSION SET 30, STERILE PAK A4206 272 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4160 Hos Iv Therapy Facility Fee 3410669 FLUCONAZOLE 200MG INJ J1450 250 204 142.79999999999998 44.35 204 103.92 44.35 153 44.35 103.92 103.92 103.92 103.92 44.35 48.785000000000004 44.35 44.35 44.35 44.35 45.237 44.35 4160 Hos Iv Therapy Facility Fee 3410487 GLYCINE FOR IRRIGATION 1.5PC J7040 258 167 116.89999999999999 36.31 167 85.07 36.31 125.25 36.31 85.07 85.07 85.07 85.07 36.31 39.941 36.31 36.31 36.31 36.31 37.0362 36.31 4160 Hos Iv Therapy Facility Fee 3410693 HEPARIN DRIP 25000U IN 250ML J1642 258 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4160 Hos Iv Therapy Facility Fee 3052073 IV FILTER SET A4206 272 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4160 Hos Iv Therapy Facility Fee 3410768 IV PUMP SET NITROGLYCERIN A4206 272 174 121.8 37.83 174 88.64 37.83 130.5 37.83 88.64 88.64 88.64 88.64 37.83 41.613 37.83 37.83 37.83 37.83 38.5866 37.83 4160 Hos Iv Therapy Facility Fee 3410206 JELCO IV RADIOPAQUE 16GX2.25IN J4054 272 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4160 Hos Iv Therapy Facility Fee 3410214 JELCO IV RADIOPAQUE 18GX1.75IN J4054 272 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4160 Hos Iv Therapy Facility Fee 3410222 JELCO IV RADIOPAQUE 20GX1.25IN J4054 272 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4160 Hos Iv Therapy Facility Fee 3410230 JELCO IV RADIOPAQUE 22GX1 IN J4054 272 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4160 Hos Iv Therapy Facility Fee 3410248 JELCO IV RADIOPAQUE 24GX.75 IN J4054 272 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4160 Hos Iv Therapy Facility Fee 3410255 LACTATED RINGERS 1000ML J7120 258 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4160 Hos Iv Therapy Facility Fee 3410263 LACTATED RINGERS 500CC J7120 258 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4160 Hos Iv Therapy Facility Fee 3410552 LIPOSYN 10% 500CC B4224 258 308 215.6 66.96 308 156.9 66.96 231 66.96 156.9 156.9 156.9 156.9 66.96 73.656 66.96 66.96 66.96 66.96 68.2992 66.96 4160 Hos Iv Therapy Facility Fee 3410560 LIPOSYN 20% 500CC B4224 258 461 322.7 100.22 461 234.83 100.22 345.75 100.22 234.83 234.83 234.83 234.83 100.22 110.242 100.22 100.22 100.22 100.22 102.2244 100.22 4160 Hos Iv Therapy Facility Fee 3410271 MALE ADAPTER PLUG W/INJ SITE A4364 272 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4160 Hos Iv Therapy Facility Fee 3410701 METRISET MEASURED VOL IV SET A4206 272 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4160 Hos Iv Therapy Facility Fee 3410798 NACL 0.45% / 20KCL / 1000 ML J7030 258 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4160 Hos Iv Therapy Facility Fee 3410800 NS 100 ML MINI BAG J7030 636 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4160 Hos Iv Therapy Facility Fee 3410347 NS 1000ML 0.9% J7030 636 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4160 Hos Iv Therapy Facility Fee 3410797 NS W/ 40MEQ KCL / 1000 ML J7030 258 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4160 Hos Iv Therapy Facility Fee 3410796 NS W/20MEQ KCL /1000 ML J7030 258 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4160 Hos Iv Therapy Facility Fee 3052271 PCA SET A4206 272 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4160 Hos Iv Therapy Facility Fee 3410801 POTASSIUM CL 20 MEQ /50ML H20 J3480 258 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4160 Hos Iv Therapy Facility Fee 3410802 POTASSIUM CL 40MEQ/1000ML H20 J3480 258 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4160 Hos Iv Therapy Facility Fee 3410404 SECONDARY IV SET PIGGYBACK A4206 270 49 34.3 10.65 49 24.96 10.65 36.75 10.65 24.96 24.96 24.96 24.96 10.65 11.715000000000002 10.65 10.65 10.65 10.65 10.863000000000001 10.65 4160 Hos Iv Therapy Facility Fee 3410354 SOD. CHLORIDE 50ML IN 100ML J4390 258 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4160 Hos Iv Therapy Facility Fee 3410362 SOD. CHLORIDE PART-FILL 100ML J4390 258 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4160 Hos Iv Therapy Facility Fee 3410651 SODIUM CHLORIDE 0.9% 250ML J4390 258 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4160 Hos Iv Therapy Facility Fee 3410461 SODIUM CHLORIDE 0.9% 500ML J4390 258 59 41.3 12.83 59 30.05 12.83 44.25 12.83 30.05 30.05 30.05 30.05 12.83 14.113000000000001 12.83 12.83 12.83 12.83 13.0866 12.83 4160 Hos Iv Therapy Facility Fee 3410610 SODIUM CHLORIDE 3000CC IRRIGAT J4390 258 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4160 Hos Iv Therapy Facility Fee 3410511 STERILE WATER FOR INJ A4216 258 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4160 Hos Iv Therapy Facility Fee 3410503 TUR EXTENSION SET A4206 270 89 62.3 19.35 89 45.34 19.35 66.75 19.35 45.34 45.34 45.34 45.34 19.35 21.285000000000004 19.35 19.35 19.35 19.35 19.737000000000002 19.35 4160 Hos Iv Therapy Facility Fee 3410495 TUR SYST W/FLOW POUCH 2000 A4413 270 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4160 Hos Iv Therapy Facility Fee 3410685 UNIVERSAL ADAPTER PIN A4206 272 69 48.3 15 69 35.15 15 51.75 15 35.15 35.15 35.15 35.15 15 16.5 15 15 15 15 15.3 15 4160 Hos Iv Therapy Facility Fee 3410388 VENOSET 78 W/ CLAIR CLAMP A4206 270 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4160 Hos Iv Therapy Facility Fee 3410313 VENOSET MICRODRIP SET A4206 270 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4160 Hos Iv Therapy Facility Fee 3410438 VENTED I V PUMP SET A4206 270 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4200 Radiology Facility Fee 2066 PEDIATRIC CRANIAL ULTRASOUND 76506 402 427 298.9 92.83 427 217.51 92.83 320.25 92.83 217.51 217.51 217.51 217.51 92.83 102.113 92.83 92.83 92.83 92.83 94.6866 92.83 4200 Radiology Facility Fee 2067 PEDIATRIC B/L HIP ULTRASOUND 76885 402 711 497.7 154.57 711 362.18 154.57 533.25 154.57 362.18 362.18 362.18 362.18 154.57 170.02700000000002 154.57 154.57 154.57 154.57 157.6614 154.57 4200 Radiology Facility Fee 2601 OB PELVIC 1ST TRIM 1 BABY 76506 402 761 532.6999999999999 165.44 761 387.65 165.44 570.75 165.44 387.65 387.65 387.65 387.65 165.44 181.984 165.44 165.44 165.44 165.44 168.7488 165.44 4200 Radiology Facility Fee 2602 OB PELVIC 1ST TRIM @ ADDT BABY 76885 402 382 267.4 83.05 382 194.59 83.05 286.5 83.05 194.59 194.59 194.59 194.59 83.05 91.355 83.05 83.05 83.05 83.05 84.711 83.05 4200 Radiology Facility Fee 2603 PENILE VENOUS & ARTERIAL FLOW 93980 402 898 628.5999999999999 195.23 898 457.44 195.23 673.5 195.23 457.44 457.44 457.44 457.44 195.23 214.75300000000001 195.23 195.23 195.23 195.23 199.1346 195.23 4200 Radiology Facility Fee 2604 TRANSVAGINAL B-SCAN/REAL TIME 76856 402 912 638.4 198.27 912 464.57 198.27 684 198.27 464.57 464.57 464.57 464.57 198.27 218.09700000000004 198.27 198.27 198.27 198.27 202.23540000000003 198.27 4200 Radiology Facility Fee 2605 TRANSVAGINAL OB 76817 402 849 594.3 184.57 849 432.48 184.57 636.75 184.57 432.48 432.48 432.48 432.48 184.57 203.02700000000002 184.57 184.57 184.57 184.57 188.2614 184.57 4200 Radiology Facility Fee 2800 CT SINUSES W & W/O 70488 351 2509 1756.3 545.46 2509 1278.08 545.46 1458 545.46 1278.08 1278.08 1278.08 1278.08 545.46 600.0060000000001 545.46 545.46 545.46 545.46 556.3692000000001 545.46 4200 Radiology Professional Fee 12401 THYROID IMAGE/UPTAKE - SINGLE 78006 341 330 230.99999999999997 71.74 330 168.1 71.74 247.5 71.74 168.1 168.1 168.1 168.1 71.74 78.914 71.74 71.74 71.74 71.74 73.17479999999999 71.74 4200 Radiology Professional Fee 12408 MECKEL'S SCAN 78261 340 301 210.7 65.44 301 153.33 65.44 225.75 65.44 153.33 153.33 153.33 153.33 65.44 71.98400000000001 65.44 65.44 65.44 65.44 66.7488 65.44 4200 Radiology Professional Fee 12601 OB PELVIC FIRST TRIMESTER 76801 972 523 366.09999999999997 113.7 523 266.42 113.7 392.25 113.7 266.42 266.42 266.42 266.42 113.7 125.07000000000001 113.7 113.7 113.7 113.7 115.974 113.7 4200 Radiology Professional Fee 12603 PENILE VENOUS & ARTERIAL FLOW 93980 972 243 170.1 52.83 243 123.78 52.83 182.25 52.83 123.78 123.78 123.78 123.78 52.83 58.113 52.83 52.83 52.83 52.83 53.8866 52.83 4200 Radiology Professional Fee 12800 CT SINUSES W & W/O 70488 972 419 293.29999999999995 91.09 419 213.44 91.09 314.25 91.09 213.44 213.44 213.44 213.44 91.09 100.19900000000001 91.09 91.09 91.09 91.09 92.9118 91.09 4200 Radiology Facility Fee 2210003 ANKLE COMPLETE, MIN 3 VIEW LT 73610 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210037 CHEST ONE FRONTAL VIEW 71045 324 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4200 Radiology Facility Fee 2210045 CHEST PA & LAT 71046 324 308 215.6 66.96 308 156.9 66.96 231 66.96 156.9 156.9 156.9 156.9 66.96 73.656 66.96 66.96 66.96 66.96 68.2992 66.96 4200 Radiology Facility Fee 2210052 RIBS COMPLETE RT W/PA CHEST 71101 320 371 259.7 80.66 371 188.99 80.66 278.25 80.66 188.99 188.99 188.99 188.99 80.66 88.726 80.66 80.66 80.66 80.66 82.2732 80.66 4200 Radiology Facility Fee 2210078 STERNUM MIN 2 VIEWS 71120 320 238 166.6 51.74 238 121.24 51.74 178.5 51.74 121.24 121.24 121.24 121.24 51.74 56.91400000000001 51.74 51.74 51.74 51.74 52.774800000000006 51.74 4200 Radiology Facility Fee 2210094 KUB 74018 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2210102 ABD SERIES 74022 320 392 274.4 85.22 392 199.68 85.22 294 85.22 199.68 199.68 199.68 199.68 85.22 93.742 85.22 85.22 85.22 85.22 86.9244 85.22 4200 Radiology Facility Fee 2210110 C-SPINE MIN 4 VIEWS 72050 320 409 286.29999999999995 88.92 409 208.34 88.92 306.75 88.92 208.34 208.34 208.34 208.34 88.92 97.81200000000001 88.92 88.92 88.92 88.92 90.6984 88.92 4200 Radiology Facility Fee 2210128 T-SPINE 3VIEWS 72072 320 354 247.79999999999998 76.96 354 180.33 76.96 265.5 76.96 180.33 180.33 180.33 180.33 76.96 84.656 76.96 76.96 76.96 76.96 78.4992 76.96 4200 Radiology Facility Fee 2210136 L-SPINE MIN. 4 VIEWS 72110 320 499 349.29999999999995 108.48 499 254.19 108.48 374.25 108.48 254.19 254.19 254.19 254.19 108.48 119.32800000000002 108.48 108.48 108.48 108.48 110.6496 108.48 4200 Radiology Facility Fee 2210151 COCCYX AND SACRUM MIN 2 VW 72220 320 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4200 Radiology Facility Fee 2210177 HIP MIN 2VIEWS RT 73502 320 279 195.29999999999998 60.65 279 142.12 60.65 209.25 60.65 142.12 142.12 142.12 142.12 60.65 66.715 60.65 60.65 60.65 60.65 61.863 60.65 4200 Radiology Facility Fee 2210185 FEMUR RT 2 VIEWS ONLY 73552 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210193 KNEE 4 OR > VIEWS RT 73564 320 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4200 Radiology Facility Fee 2210201 TIB/FIB 2 VIEW ONLY RT 73590 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210219 ANKLE COMPLETE, MIN 3 VIEWS RT 73610 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210227 OSCALIS (HEEL) MIN 2 VIEWS RT 73650 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2210235 FOOT MIN 3-VIEWS RT 73630 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210243 TOES MIN 2 VIEWS BI 73660 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2210250 CLAVICLE COMPLETE RT 73000 320 222 155.39999999999998 48.26 222 113.09 48.26 166.5 48.26 113.09 113.09 113.09 113.09 48.26 53.086000000000006 48.26 48.26 48.26 48.26 49.2252 48.26 4200 Radiology Facility Fee 2210268 SHOULDER COMP. MIN 2VW RT 73030 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210276 HUMERUS MIN 2-VIEW RT 73060 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210284 ELBOW COMPLETE RT MIN 3 VIEWS 73080 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210292 FOREARM RT 2 VIEWS ONLY 73090 320 216 151.2 46.96 216 110.03 46.96 162 46.96 110.03 110.03 110.03 110.03 46.96 51.656000000000006 46.96 46.96 46.96 46.96 47.8992 46.96 4200 Radiology Facility Fee 2210300 WRIST COMP. MIN 3VW RT 73110 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210318 HAND MIN 3-VIEWS RT 73130 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210326 FINGER(S) LT MIN 2 VIEWS 73140 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2210334 SKULL COMPLETE MIN 4 VIEWS 70260 320 409 286.29999999999995 88.92 409 208.34 88.92 306.75 88.92 208.34 208.34 208.34 208.34 88.92 97.81200000000001 88.92 88.92 88.92 88.92 90.6984 88.92 4200 Radiology Facility Fee 2210342 ORBITS COMPLETE MIN 4 VIEWS 70200 320 409 286.29999999999995 88.92 409 208.34 88.92 306.75 88.92 208.34 208.34 208.34 208.34 88.92 97.81200000000001 88.92 88.92 88.92 88.92 90.6984 88.92 4200 Radiology Facility Fee 2210359 FACIAL BONES, MIN 3 VIEWS 70150 320 375 262.5 81.53 375 191.03 81.53 281.25 81.53 191.03 191.03 191.03 191.03 81.53 89.683 81.53 81.53 81.53 81.53 83.1606 81.53 4200 Radiology Facility Fee 2210367 MANDIBLE MIN 4 VW 70110 320 375 262.5 81.53 375 191.03 81.53 281.25 81.53 191.03 191.03 191.03 191.03 81.53 89.683 81.53 81.53 81.53 81.53 83.1606 81.53 4200 Radiology Facility Fee 2210383 NASAL BONES MIN 3 VIEWS 70160 320 276 193.2 60 276 140.59 60 207 60 140.59 140.59 140.59 140.59 60 66 60 60 60 60 61.2 60 4200 Radiology Facility Fee 2210391 SINUSES - 3 VIEW MINIMUM 70220 320 397 277.9 86.31 397 202.23 86.31 297.75 86.31 202.23 202.23 202.23 202.23 86.31 94.94100000000002 86.31 86.31 86.31 86.31 88.03620000000001 86.31 4200 Radiology Facility Fee 2210409 SOFT TISSUE NECK 70360 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2210607 FLOUROTIME (O/R) MORE THAN 1HR 76001 320 832 582.4 180.88 832 423.82 180.88 624 180.88 423.82 423.82 423.82 423.82 180.88 198.96800000000002 180.88 180.88 180.88 180.88 184.4976 180.88 4200 Radiology Facility Fee 2210615 FLOURO TIME UP TO 1 HR RADIOLO 76000 320 383 268.09999999999997 83.26 383 195.1 83.26 287.25 83.26 195.1 195.1 195.1 195.1 83.26 91.58600000000001 83.26 83.26 83.26 83.26 84.9252 83.26 4200 Radiology Facility Fee 2210631 CHEST W/APIC LORDOTIC 71046 324 375 262.5 81.53 375 191.03 81.53 281.25 81.53 191.03 191.03 191.03 191.03 81.53 89.683 81.53 81.53 81.53 81.53 83.1606 81.53 4200 Radiology Facility Fee 2210649 CHEST SPECIAL VIEWS 71035 324 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2210656 CHEST PA & LAT W/OBLIQUES 71046 324 375 262.5 81.53 375 191.03 81.53 281.25 81.53 191.03 191.03 191.03 191.03 81.53 89.683 81.53 81.53 81.53 81.53 83.1606 81.53 4200 Radiology Facility Fee 2210664 C SPINE 2 OR 3 VIEWS 72040 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2210672 L-SPINE 2 OR 3 VIEWS 72100 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2210698 SKULL < 4 VIEWS 70250 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2210706 MASTOIDS MIN 3 VWS PER SIDE 70130 320 423 296.09999999999997 91.96 423 215.48 91.96 317.25 91.96 215.48 215.48 215.48 215.48 91.96 101.156 91.96 91.96 91.96 91.96 93.7992 91.96 4200 Radiology Facility Fee 2210714 TMJ RIGHT OPEN AND CLOSED 70328 320 248 173.6 53.92 248 126.33 53.92 186 53.92 126.33 126.33 126.33 126.33 53.92 59.312000000000005 53.92 53.92 53.92 53.92 54.998400000000004 53.92 4200 Radiology Facility Fee 2210730 AC JTS BLT W OR W/O WTS. 2VIEW 73050 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2210763 ELBOW 2-VIEWS RT 73070 320 219 153.29999999999998 47.61 219 111.56 47.61 164.25 47.61 111.56 111.56 111.56 111.56 47.61 52.371 47.61 47.61 47.61 47.61 48.5622 47.61 4200 Radiology Facility Fee 2210797 S I JOINTS < 3 VIEWS 72200 320 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4200 Radiology Facility Fee 2210805 SCAPULA COMPLETE RT 73010 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2211803 ELBOW 2 VIEW LT 73070 320 219 153.29999999999998 47.61 219 111.56 47.61 164.25 47.61 111.56 111.56 111.56 111.56 47.61 52.371 47.61 47.61 47.61 47.61 48.5622 47.61 4200 Radiology Facility Fee 2213809 FOREARM BLT 2 VIEWS ONLY 73090 320 430 301 93.48 430 219.04 93.48 322.5 93.48 219.04 219.04 219.04 219.04 93.48 102.82800000000002 93.48 93.48 93.48 93.48 95.34960000000001 93.48 4200 Radiology Facility Fee 2217412 SOUTHWEST GA. TB 71010 324 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4200 Radiology Facility Fee 2220002 RIBS, BILAT 3 VIEWS 71110 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2220010 RIBS, UNILATERAL 2 VIEWS RT 71100 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2220028 RIBS, UNILATERAL 2 VIEWS LT 71100 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221018 ANKLE COMPLETE, MIN 3 VIEW BLT 73610 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221034 ANKLE 2 VIEWS RT 73600 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221042 ANKLE 2 VIEWT LT 73600 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221059 ANKLE 2 VIEWS BI 73600 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2221067 TMJ LT OPEN AND CLOSED 70328 320 248 173.6 53.92 248 126.33 53.92 186 53.92 126.33 126.33 126.33 126.33 53.92 59.312000000000005 53.92 53.92 53.92 53.92 54.998400000000004 53.92 4200 Radiology Facility Fee 2221075 RIBS COMPLETE LT W/PA CHEST 71101 320 371 259.7 80.66 371 188.99 80.66 278.25 80.66 188.99 188.99 188.99 188.99 80.66 88.726 80.66 80.66 80.66 80.66 82.2732 80.66 4200 Radiology Facility Fee 2221125 SPINE ONE VIEW 72020 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221133 CLAVICLE COMPLETE LT 73000 320 222 155.39999999999998 48.26 222 113.09 48.26 166.5 48.26 113.09 113.09 113.09 113.09 48.26 53.086000000000006 48.26 48.26 48.26 48.26 49.2252 48.26 4200 Radiology Facility Fee 2221141 CLAVICLE COMPLETE BLT 73000 320 441 308.7 95.87 441 224.65 95.87 330.75 95.87 224.65 224.65 224.65 224.65 95.87 105.45700000000001 95.87 95.87 95.87 95.87 97.7874 95.87 4200 Radiology Facility Fee 2221158 ELBOW COMPLETE LT MIN 3 VIEWS 73080 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221166 ELBOW COMPLETE, BLT MIN 3 VIEW 73080 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221190 ELBOW 2 VIEW BLT 73070 320 436 305.2 94.79 436 222.1 94.79 327 94.79 222.1 222.1 222.1 222.1 94.79 104.26900000000002 94.79 94.79 94.79 94.79 96.68580000000001 94.79 4200 Radiology Facility Fee 2221208 FACIAL BONES 1-3 VIEWS 70140 320 266 186.2 57.83 266 135.5 57.83 199.5 57.83 135.5 135.5 135.5 135.5 57.83 63.61300000000001 57.83 57.83 57.83 57.83 58.9866 57.83 4200 Radiology Facility Fee 2221216 FEMUR LT 2 VIEWS ONLY 73552 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221224 FEMUR BLT 2 VIEWS ONLY 73550 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221323 FOOT MIN 3 VIEWS LT 73630 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221331 FOOT MIN 3 VIEWS BLT 73630 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221349 FOOT 2 VIEWS RT 73620 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221356 FOOT 2 VIEWS LT 73620 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221362 MANDIBLE-PARTIAL LESS 4 VIEW 70100 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2221364 FOOT 2 VIEWS BI 73620 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2221365 HIP LT 1 VIEW 73501 320 175 122.49999999999999 38.05 175 89.15 38.05 131.25 38.05 89.15 89.15 89.15 89.15 38.05 41.855 38.05 38.05 38.05 38.05 38.811 38.05 4200 Radiology Facility Fee 2221368 HIP RT 1 VIEW 73501 320 175 122.49999999999999 38.05 175 89.15 38.05 131.25 38.05 89.15 89.15 89.15 89.15 38.05 41.855 38.05 38.05 38.05 38.05 38.811 38.05 4200 Radiology Facility Fee 2221372 FOREARM LT 2 VIEWS ONLY 73090 320 216 151.2 46.96 216 110.03 46.96 162 46.96 110.03 110.03 110.03 110.03 46.96 51.656000000000006 46.96 46.96 46.96 46.96 47.8992 46.96 4200 Radiology Facility Fee 2221378 ORBIT - FOREIGN BODY 70030 320 256 179.2 55.65 256 130.41 55.65 192 55.65 130.41 130.41 130.41 130.41 55.65 61.215 55.65 55.65 55.65 55.65 56.763 55.65 4200 Radiology Facility Fee 2221380 INFANT-MIN 2VW UPPER EXT. 73092 320 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4200 Radiology Facility Fee 2221385 INFANT-MIN 2VW PELVIS/HIPS 73502 320 221 154.7 48.05 221 112.58 48.05 165.75 48.05 112.58 112.58 112.58 112.58 48.05 52.855000000000004 48.05 48.05 48.05 48.05 49.010999999999996 48.05 4200 Radiology Facility Fee 2221392 BONE SURVEY(METS) LIMITED 77074 320 575 402.5 125.01 575 292.91 125.01 431.25 125.01 292.91 292.91 292.91 292.91 125.01 137.51100000000002 125.01 125.01 125.01 125.01 127.51020000000001 125.01 4200 Radiology Facility Fee 2221398 HAND MIN 3 VIEWS LT 73130 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221406 HAND MIN 3 VIEWS BLT 73130 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221414 HAND 2 VIEWS RT 73120 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221422 HAND 2 VIEW LT 73120 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221430 HAND 2 VIEW BLT 73120 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2221448 HIP MIN 2VIEWS LT 73502 320 279 195.29999999999998 60.65 279 142.12 60.65 209.25 60.65 142.12 142.12 142.12 142.12 60.65 66.715 60.65 60.65 60.65 60.65 61.863 60.65 4200 Radiology Facility Fee 2221455 HIP BLT MIN 2 VW EA W/AP PELVI 73523 320 557 389.9 121.09 557 283.74 121.09 417.75 121.09 283.74 283.74 283.74 283.74 121.09 133.199 121.09 121.09 121.09 121.09 123.51180000000001 121.09 4200 Radiology Facility Fee 2221463 HUMERUS MIN 2 VIEWS LT 73060 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221471 HUMERUS MIN 2 VIEWS BLT 73060 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221489 KNEE 4 OR > VIEWS BLT 73564 320 578 404.59999999999997 125.66 578 294.43 125.66 433.5 125.66 294.43 294.43 294.43 294.43 125.66 138.226 125.66 125.66 125.66 125.66 128.1732 125.66 4200 Radiology Facility Fee 2221497 KNEE 1 OR 2 VIEWS RIGHT 73560 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221505 KNEE 1 OR 2 VIEW LEFT 73560 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221513 KNEE 1 OR 2 VIEW BLT 73560 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2221521 TIB/FIB 2 VIEW ONLY LT 73590 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221539 TIB/FIB 2 VIEW ONLY BLT 73590 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221554 OSCALIS (HEEL) MIN 2 VIEWS LT 73650 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221562 OSCALIS (HEEL) MIN 2 VIEWS BLT 73650 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2221570 PELVIS 1 OR 2 VIEW 72170 320 280 196 60.87 280 142.63 60.87 210 60.87 142.63 142.63 142.63 142.63 60.87 66.95700000000001 60.87 60.87 60.87 60.87 62.087399999999995 60.87 4200 Radiology Facility Fee 2221588 SCAPULA COMPLETE LT 73010 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221596 SCAPULA COMPLETE BLT 73010 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2221604 SHOULDER COMP. MIN 2VW LT 73030 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221612 SHOULDER COMP. MIN 2VW BLT 73030 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221729 WRIST COMP. MIN 3VW LT 73110 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2221737 WRIST COMP. MIN 3VW BLT 73110 320 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Facility Fee 2221752 WRIST 2 VIEW RT 73100 320 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4200 Radiology Facility Fee 2221760 WRIST 2 VIEW LT 73100 320 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4200 Radiology Facility Fee 2221778 WRIST 2 VIEW BLT 73100 320 358 250.6 77.83 358 182.37 77.83 268.5 77.83 182.37 182.37 182.37 182.37 77.83 85.613 77.83 77.83 77.83 77.83 79.3866 77.83 4200 Radiology Facility Fee 2221869 TOES MIN 2 VIEWS RT 73660 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221893 TOES MIN 2 VIEWS LT 73660 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221919 FINGER(S) RT MIN 2 VIEWS 73140 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2221927 FINGER(S) BLT MIN 2 VIEWS 73140 320 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Facility Fee 2222222 KNEES BLT AP AND STANDING 1VW 73565 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2225001 ABD 2-3 VWS-KUB/DEC +/OR ERECT 74021 320 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4200 Radiology Facility Fee 2227411 CHEST TB-WEST CENTRAL 71045 324 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4200 Radiology Facility Fee 2227412 CHEST-DISTRICT CLINIC 71045 324 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4200 Radiology Facility Fee 2270015 SINUSES - (LESS THAN 3 VIEWS) 70210 320 300 210 65.22 300 152.82 65.22 225 65.22 152.82 152.82 152.82 152.82 65.22 71.742 65.22 65.22 65.22 65.22 66.5244 65.22 4200 Radiology Facility Fee 2270106 TMJ BILAT OPEN AND CLOSED 70330 320 353 247.1 76.74 353 179.82 76.74 264.75 76.74 179.82 179.82 179.82 179.82 76.74 84.414 76.74 76.74 76.74 76.74 78.2748 76.74 4200 Radiology Facility Fee 2270205 RIBS BLT COMP W/PA MIN 4VW 71111 320 389 272.29999999999995 84.57 389 198.16 84.57 291.75 84.57 198.16 198.16 198.16 198.16 84.57 93.027 84.57 84.57 84.57 84.57 86.2614 84.57 4200 Radiology Facility Fee 2270304 C-SPINE W/OBL/FLEX AND/OR EXTE 72052 320 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Facility Fee 2270403 T-SPINE AP/LAT 72070 320 252 176.39999999999998 54.78 252 128.37 54.78 189 54.78 128.37 128.37 128.37 128.37 54.78 60.258 54.78 54.78 54.78 54.78 55.8756 54.78 4200 Radiology Facility Fee 2270411 L-SPINE W/BEND VIEW MIN 6 VIEW 72114 320 578 404.59999999999997 125.66 578 294.43 125.66 433.5 125.66 294.43 294.43 294.43 294.43 125.66 138.226 125.66 125.66 125.66 125.66 128.1732 125.66 4200 Radiology Facility Fee 2272011 KNEE 4 OR > VWS LT 73564 320 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4200 Radiology Facility Fee 2273019 BONE AGE STUDIES 77072 320 378 264.59999999999997 82.18 378 192.55 82.18 283.5 82.18 192.55 192.55 192.55 192.55 82.18 90.39800000000001 82.18 82.18 82.18 82.18 83.82360000000001 82.18 4200 Radiology Facility Fee 2274009 G-TUBE PLACEMENT/FLURO/FILMS 74340 320 848 593.5999999999999 184.36 848 431.97 184.36 636 184.36 431.97 431.97 431.97 431.97 184.36 202.79600000000002 184.36 184.36 184.36 184.36 188.0472 184.36 4200 Radiology Facility Fee 2280006 LEG LENGTH STUDY 77073 320 316 221.2 68.7 316 160.97 68.7 237 68.7 160.97 160.97 160.97 160.97 68.7 75.57000000000001 68.7 68.7 68.7 68.7 70.074 68.7 4200 Radiology Facility Fee 2280055 BONE-METABOLIC (AX/APPEN/SKEL) 77075 320 751 525.6999999999999 163.27 751 382.56 163.27 563.25 163.27 382.56 382.56 382.56 382.56 163.27 179.59700000000004 163.27 163.27 163.27 163.27 166.5354 163.27 4200 Radiology Facility Fee 2280057 SPINE SURVEY AP & LATERAL 72010 320 405 283.5 88.05 405 206.31 88.05 303.75 88.05 206.31 206.31 206.31 206.31 88.05 96.855 88.05 88.05 88.05 88.05 89.81099999999999 88.05 4200 Radiology Facility Fee 2280058 ISOVUE 300 PER CC Q9967 636 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4200 Radiology Facility Fee 2280067 ABDOMEN SERIES WITH DECUBITUS 74022 320 392 274.4 85.22 392 199.68 85.22 294 85.22 199.68 199.68 199.68 199.68 85.22 93.742 85.22 85.22 85.22 85.22 86.9244 85.22 4200 Radiology Facility Fee 2280068 BABYGRAM 71045 320 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4200 Radiology Facility Fee 2280069 BONE AGE < 2 YEARS 77072 320 378 264.59999999999997 82.18 378 192.55 82.18 283.5 82.18 192.55 192.55 192.55 192.55 82.18 90.39800000000001 82.18 82.18 82.18 82.18 83.82360000000001 82.18 4200 Radiology Facility Fee 2280070 BONE AGE > 2 YEARS 77072 320 378 264.59999999999997 82.18 378 192.55 82.18 283.5 82.18 192.55 192.55 192.55 192.55 82.18 90.39800000000001 82.18 82.18 82.18 82.18 83.82360000000001 82.18 4200 Radiology Facility Fee 2280071 CERVICAL SPINE 1V CROSS-TABLE 72020 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280072 CERVICAL SPINE 2V 72040 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2280073 CERVICAL SPINE 3V 72040 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2280074 CERVICAL SPINE 3V FLEXION EXT 72052 320 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Facility Fee 2280075 CERVICAL SPINE 4V FLEX_EXT 72050 320 409 286.29999999999995 88.92 409 208.34 88.92 306.75 88.92 208.34 208.34 208.34 208.34 88.92 97.81200000000001 88.92 88.92 88.92 88.92 90.6984 88.92 4200 Radiology Facility Fee 2280076 CERVICAL SPINE 4V OBLIQUES 72050 320 409 286.29999999999995 88.92 409 208.34 88.92 306.75 88.92 208.34 208.34 208.34 208.34 88.92 97.81200000000001 88.92 88.92 88.92 88.92 90.6984 88.92 4200 Radiology Facility Fee 2280077 CHEST 1V AP 71045 320 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4200 Radiology Facility Fee 2280078 CHEST 1V DECUBITUS LEFT 71048 320 308 215.6 66.96 308 156.9 66.96 231 66.96 156.9 156.9 156.9 156.9 66.96 73.656 66.96 66.96 66.96 66.96 68.2992 66.96 4200 Radiology Facility Fee 2280079 CHEST 1V DECUBITUS RIGHT 71048 320 308 215.6 66.96 308 156.9 66.96 231 66.96 156.9 156.9 156.9 156.9 66.96 73.656 66.96 66.96 66.96 66.96 68.2992 66.96 4200 Radiology Facility Fee 2280080 CHEST 1V PA 71045 320 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4200 Radiology Facility Fee 2280081 EXT LOWER 2V LEFT INFANT 73592 320 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4200 Radiology Facility Fee 2280082 EXT LOWER 2V RIGHT INFANT 73592 320 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4200 Radiology Facility Fee 2280083 EXT UPPER 2V LEFT INFANT 73092 320 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4200 Radiology Facility Fee 2280084 EXT UPPER 2V RIGHT INFANT 73092 320 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4200 Radiology Facility Fee 2280086 HIP 2V LEFT WITH PELVIS 73502 320 279 195.29999999999998 60.65 279 142.12 60.65 209.25 60.65 142.12 142.12 142.12 142.12 60.65 66.715 60.65 60.65 60.65 60.65 61.863 60.65 4200 Radiology Facility Fee 2280087 HIP 2V RIGHT WITH PELVIS 73502 320 279 195.29999999999998 60.65 279 142.12 60.65 209.25 60.65 142.12 142.12 142.12 142.12 60.65 66.715 60.65 60.65 60.65 60.65 61.863 60.65 4200 Radiology Facility Fee 2280088 HIPS 2V BILATERAL WO PELVIS 73510 320 279 195.29999999999998 60.65 279 142.12 60.65 209.25 60.65 142.12 142.12 142.12 142.12 60.65 66.715 60.65 60.65 60.65 60.65 61.863 60.65 4200 Radiology Facility Fee 2280089 KNEE 1V LEFT 73560 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280090 KNEE 1V RIGHT 73560 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280091 KNEE 2V LEFT 73560 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280092 KNEE 2V RIGHT 73560 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280093 KNEE 3V W OBLIQUE LEFT 73562 320 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4200 Radiology Facility Fee 2280094 KNEE 3V W OBLIQUE RIGHT 73562 320 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4200 Radiology Facility Fee 2280095 KNEE 3V W PATELLA LEFT 73562 320 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4200 Radiology Facility Fee 2280096 KNEE 3V W PATELLA RIGHT 73562 320 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4200 Radiology Facility Fee 2280097 LUMBAR SPINE 1V 72020 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280098 LUMBAR SPINE 1V X_TABLE LATERA 72020 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280099 LUMBAR SPINE 2V 72100 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2280100 LUMBER SPINE 3V 72100 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2280101 LUMBAR SPINE 4V OBLIQUES 72110 320 499 349.29999999999995 108.48 499 254.19 108.48 374.25 108.48 254.19 254.19 254.19 254.19 108.48 119.32800000000002 108.48 108.48 108.48 108.48 110.6496 108.48 4200 Radiology Facility Fee 2280102 LUMBAR SPINE 4V W FLEX & EXT 72110 320 499 349.29999999999995 108.48 499 254.19 108.48 374.25 108.48 254.19 254.19 254.19 254.19 108.48 119.32800000000002 108.48 108.48 108.48 108.48 110.6496 108.48 4200 Radiology Facility Fee 2280103 LUMBAR SPINE 5V FLEX_EXT 72110 320 499 349.29999999999995 108.48 499 254.19 108.48 374.25 108.48 254.19 254.19 254.19 254.19 108.48 119.32800000000002 108.48 108.48 108.48 108.48 110.6496 108.48 4200 Radiology Facility Fee 2280104 LUMBAR SPINE FLEX_EXT 72100 320 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4200 Radiology Facility Fee 2280105 SHOULDER 1V LEFT 73020 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2280106 SHOULDER 1V RIGHT 73020 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2280107 SHOULDER 2V LEFT 73030 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2280108 SHOULDER 2V RIGHT 73030 320 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4200 Radiology Facility Fee 2280109 SKELETAL SURVEY FOR METASTATIC 77075 320 751 525.6999999999999 163.27 751 382.56 163.27 563.25 163.27 382.56 382.56 382.56 382.56 163.27 179.59700000000004 163.27 163.27 163.27 163.27 166.5354 163.27 4200 Radiology Facility Fee 2280110 SKULL 2V LIMITED 70250 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280111 SKULL 3V LIMITED 70250 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2280113 THORACIC SPINE CROSS-TABLE 72020 320 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Facility Fee 2610020 LIMITED SINGLE ORGAN (eg. GB) 76705 402 564 394.79999999999995 122.61 564 287.3 122.61 423 122.61 287.3 287.3 287.3 287.3 122.61 134.871 122.61 122.61 122.61 122.61 125.0622 122.61 4200 Radiology Facility Fee 2610061 RETROPERITONEAL U/S 76770 402 720 503.99999999999994 156.53 720 366.77 156.53 540 156.53 366.77 366.77 366.77 366.77 156.53 172.18300000000002 156.53 156.53 156.53 156.53 159.66060000000002 156.53 4200 Radiology Facility Fee 2610079 ABDOM AORTA, DUPLEX COMPLETE 93978 921 1047 732.9 227.62 1047 533.34 227.62 785.25 227.62 533.34 533.34 533.34 533.34 227.62 250.38200000000003 227.62 227.62 227.62 227.62 232.1724 227.62 4200 Radiology Facility Fee 2610111 ABDOMINAL U/S COMPLETE 76700 402 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2610145 FETAL FOLLOW-UP 1 FETUS 76816 402 576 403.2 125.22 576 293.41 125.22 432 125.22 293.41 293.41 293.41 293.41 125.22 137.74200000000002 125.22 125.22 125.22 125.22 127.7244 125.22 4200 Radiology Facility Fee 2610152 PELVIC U/S 76856 402 485 339.5 105.44 485 247.06 105.44 363.75 105.44 247.06 247.06 247.06 247.06 105.44 115.98400000000001 105.44 105.44 105.44 105.44 107.5488 105.44 4200 Radiology Facility Fee 2610160 COMPL FETAL STDY P 1ST TRIMEST 76805 402 761 532.6999999999999 165.44 761 387.65 165.44 570.75 165.44 387.65 387.65 387.65 387.65 165.44 181.984 165.44 165.44 165.44 165.44 168.7488 165.44 4200 Radiology Facility Fee 2610178 MULTIPLE FETUS P 1ST TRIMESTER 76810 402 1338 936.5999999999999 290.88 1338 681.58 290.88 1003.5 290.88 681.58 681.58 681.58 681.58 290.88 319.968 290.88 290.88 290.88 290.88 296.6976 290.88 4200 Radiology Facility Fee 2610194 THYROID U/S 76536 402 456 319.2 99.13 456 232.29 99.13 342 99.13 232.29 232.29 232.29 232.29 99.13 109.043 99.13 99.13 99.13 99.13 101.1126 99.13 4200 Radiology Facility Fee 2610202 SCROTUM AND CONTENTS U/S 76870 402 660 461.99999999999994 143.48 660 336.2 143.48 495 143.48 336.2 336.2 336.2 336.2 143.48 157.828 143.48 143.48 143.48 143.48 146.34959999999998 143.48 4200 Radiology Facility Fee 2610301 BREAST U/S BILAT OR UNILAT 76641 402 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2610400 VENOUS DOPPLER EXT RT 73971 921 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2610418 VENOUS DOPPLER EXT LT 93971 921 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2610426 LOWER ARTERIAL EXT RT 93926 921 760 532 165.22 760 387.14 165.22 570 165.22 387.14 387.14 387.14 387.14 165.22 181.74200000000002 165.22 165.22 165.22 165.22 168.5244 165.22 4200 Radiology Facility Fee 2610434 LOWER ARTERIAL EXTREM. LT 93926 921 760 532 165.22 760 387.14 165.22 570 165.22 387.14 387.14 387.14 387.14 165.22 181.74200000000002 165.22 165.22 165.22 165.22 168.5244 165.22 4200 Radiology Facility Fee 2610442 UPPER ARTERIAL EXTREM. RT 93931 921 760 532 165.22 760 387.14 165.22 570 165.22 387.14 387.14 387.14 387.14 165.22 181.74200000000002 165.22 165.22 165.22 165.22 168.5244 165.22 4200 Radiology Facility Fee 2610459 UPPER ARTERIAL EXT LT 93391 921 760 532 165.22 760 387.14 165.22 570 165.22 387.14 387.14 387.14 387.14 165.22 181.74200000000002 165.22 165.22 165.22 165.22 168.5244 165.22 4200 Radiology Facility Fee 2610475 NON VASCULAR EXT BLT 76881 402 972 680.4 211.31 972 495.14 211.31 729 211.31 495.14 495.14 495.14 495.14 211.31 232.44100000000003 211.31 211.31 211.31 211.31 215.5362 211.31 4200 Radiology Facility Fee 2610566 NON VASCULAR EXT LT 76881 402 456 319.2 99.13 456 232.29 99.13 342 99.13 232.29 232.29 232.29 232.29 99.13 109.043 99.13 99.13 99.13 99.13 101.1126 99.13 4200 Radiology Facility Fee 2610608 CAROTIDS BI-LATERAL DUPLEX 93880 921 975 682.5 211.97 975 496.67 211.97 731.25 211.97 496.67 496.67 496.67 496.67 211.97 233.16700000000003 211.97 211.97 211.97 211.97 216.20940000000002 211.97 4200 Radiology Facility Fee 2610905 DOPPLER COLOR FLOW MAPPING T.C 93325 480 1228 859.5999999999999 266.97 1228 625.54 266.97 921 266.97 625.54 625.54 625.54 625.54 266.97 293.66700000000003 266.97 266.97 266.97 266.97 272.30940000000004 266.97 4200 Radiology Facility Fee 2611507 TRANSVAGINAL U/S 76830 402 840 588 182.62 840 427.9 182.62 630 182.62 427.9 427.9 427.9 427.9 182.62 200.88200000000003 182.62 182.62 182.62 182.62 186.2724 182.62 4200 Radiology Facility Fee 2614105 NEEDLE BIOPSY W/ U S GUIDANCE 76942 402 620 434 134.79 620 315.83 134.79 465 134.79 315.83 315.83 315.83 315.83 134.79 148.269 134.79 134.79 134.79 134.79 137.48579999999998 134.79 4200 Radiology Facility Fee 2615003 LOWER ARTERIAL EXTR BILATERAL 93925 921 925 647.5 201.1 925 471.2 201.1 693.75 201.1 471.2 471.2 471.2 471.2 201.1 221.21 201.1 201.1 201.1 201.1 205.12199999999999 201.1 4200 Radiology Facility Fee 2615011 UPPER ARTERIAL EXTR BLT 93930 921 949 664.3 206.31 949 483.42 206.31 711.75 206.31 483.42 483.42 483.42 483.42 206.31 226.94100000000003 206.31 206.31 206.31 206.31 210.4362 206.31 4200 Radiology Facility Fee 2615052 VENOUS DOPPLER EXT BILAT 93970 921 1024 716.8 222.62 1024 521.63 222.62 768 222.62 521.63 521.63 521.63 521.63 222.62 244.88200000000003 222.62 222.62 222.62 222.62 227.07240000000002 222.62 4200 Radiology Facility Fee 2616076 NON VASCULAR EXT RT 76881 402 456 319.2 99.13 456 232.29 99.13 342 99.13 232.29 232.29 232.29 232.29 99.13 109.043 99.13 99.13 99.13 99.13 101.1126 99.13 4200 Radiology Facility Fee 2621602 BREAST T ULTRASOUND 76641 402 141 98.69999999999999 30.65 141 71.83 30.65 105.75 30.65 71.83 71.83 71.83 71.83 30.65 33.715 30.65 30.65 30.65 30.65 31.262999999999998 30.65 4200 Radiology Facility Fee 2621603 FETAL F/U EACH ADDT'L FETUS 76816 402 411 287.7 89.35 411 209.36 89.35 308.25 89.35 209.36 209.36 209.36 209.36 89.35 98.285 89.35 89.35 89.35 89.35 91.137 89.35 4200 Radiology Facility Fee 2621604 ECHO 93306 483 2079 1455.3 451.98 2079 1059.04 451.98 1458 451.98 1059.04 1059.04 1059.04 1059.04 451.98 497.17800000000005 451.98 451.98 451.98 451.98 461.0196 451.98 4200 Radiology Facility Fee 2621605 US ABDOMEN LIMITED 76705 402 564 394.79999999999995 122.61 564 287.3 122.61 423 122.61 287.3 287.3 287.3 287.3 122.61 134.871 122.61 122.61 122.61 122.61 125.0622 122.61 4200 Radiology Facility Fee 2621606 US ABDOMEN LIMITED LIVER 76705 402 564 394.79999999999995 122.61 564 287.3 122.61 423 122.61 287.3 287.3 287.3 287.3 122.61 134.871 122.61 122.61 122.61 122.61 125.0622 122.61 4200 Radiology Facility Fee 2621607 US BLADDER 76857 402 720 503.99999999999994 156.53 720 366.77 156.53 540 156.53 366.77 366.77 366.77 366.77 156.53 172.18300000000002 156.53 156.53 156.53 156.53 159.66060000000002 156.53 4200 Radiology Facility Fee 2621608 US BREAST LEFT 76641 402 564 394.79999999999995 122.61 564 287.3 122.61 423 122.61 287.3 287.3 287.3 287.3 122.61 134.871 122.61 122.61 122.61 122.61 125.0622 122.61 4200 Radiology Facility Fee 2621609 US BREAST RIGHT 76641 402 564 394.79999999999995 122.61 564 287.3 122.61 423 122.61 287.3 287.3 287.3 287.3 122.61 134.871 122.61 122.61 122.61 122.61 125.0622 122.61 4200 Radiology Facility Fee 2621610 US EXT LOWER VENOUS DUPLEX 93970 921 1024 716.8 222.62 1024 521.63 222.62 768 222.62 521.63 521.63 521.63 521.63 222.62 244.88200000000003 222.62 222.62 222.62 222.62 227.07240000000002 222.62 4200 Radiology Facility Fee 2621611 US EXT LOWER VENOUS DUPLEX 93971 921 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2621612 US EXT LOWER VENOUS DUPLEX 93971 921 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2621613 US EXT NONVASCULAR COMPLETE 76881 402 972 680.4 211.31 972 495.14 211.31 729 211.31 495.14 495.14 495.14 495.14 211.31 232.44100000000003 211.31 211.31 211.31 211.31 215.5362 211.31 4200 Radiology Facility Fee 2621614 US EXT NONVASCULAR LIMITED 76882 402 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2621615 US EXT UPPER VENOUS DUPLEX 93970 921 1024 716.8 222.62 1024 521.63 222.62 768 222.62 521.63 521.63 521.63 521.63 222.62 244.88200000000003 222.62 222.62 222.62 222.62 227.07240000000002 222.62 4200 Radiology Facility Fee 2621616 US EXT UPPER VENOUS DUPLPEX 93971 921 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2621617 US EXT UPPER VENOUS DUPLEX 93971 921 753 527.1 163.7 753 383.58 163.7 564.75 163.7 383.58 383.58 383.58 383.58 163.7 180.07 163.7 163.7 163.7 163.7 166.974 163.7 4200 Radiology Facility Fee 2621618 US SOFT TISSUE of Head and Neck 76536 402 456 319.2 99.13 456 232.29 99.13 342 99.13 232.29 232.29 232.29 232.29 99.13 109.043 99.13 99.13 99.13 99.13 101.1126 99.13 4200 Radiology Facility Fee 2810000 CT ABD W & W/O CONTRAST 74170 352 2865 2005.4999999999998 622.85 2865 1459.43 622.85 1458 622.85 1459.43 1459.43 1459.43 1459.43 622.85 685.1350000000001 622.85 622.85 622.85 622.85 635.307 622.85 4200 Radiology Facility Fee 2810505 CT CHEST W & W/O CONTRAST 71270 352 2865 2005.4999999999998 622.85 2865 1459.43 622.85 1458 622.85 1459.43 1459.43 1459.43 1459.43 622.85 685.1350000000001 622.85 622.85 622.85 622.85 635.307 622.85 4200 Radiology Facility Fee 2811008 CT BRAIN W & W/O CONTRAST 70470 351 2458 1720.6 534.37 2458 1252.11 534.37 1458 534.37 1252.11 1252.11 1252.11 1252.11 534.37 587.807 534.37 534.37 534.37 534.37 545.0574 534.37 4200 Radiology Facility Fee 2811016 CT-LOWER EXTREM W/O CONTR LT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2811024 CT LOWER EXT W&W/O CONTRAST LT 73702 352 2864 2004.8 622.64 2864 1458.92 622.64 1458 622.64 1458.92 1458.92 1458.92 1458.92 622.64 684.904 622.64 622.64 622.64 622.64 635.0928 622.64 4200 Radiology Facility Fee 2811032 CT LOWER EXT W.CONTRAST BIL 73701 352 3898 2728.6 847.43 3898 1985.64 847.43 1458 847.43 1985.64 1985.64 1985.64 1985.64 847.43 932.173 847.43 847.43 847.43 847.43 864.3786 847.43 4200 Radiology Facility Fee 2811040 CT-LOWER EXTREM W/O CONTR BLT 73700 352 2952 2066.4 641.77 2952 1503.75 641.77 1458 641.77 1503.75 1503.75 1503.75 1503.75 641.77 705.947 641.77 641.77 641.77 641.77 654.6054 641.77 4200 Radiology Facility Fee 2811065 CT UPPER EXT W/CONTRAST LT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2811073 CT-UPPER EXTREM W/O CONTR LT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2811081 CT UPPER EXT W&W/O CONTRAST LT 73202 352 2864 2004.8 622.64 2864 1458.92 622.64 1458 622.64 1458.92 1458.92 1458.92 1458.92 622.64 684.904 622.64 622.64 622.64 622.64 635.0928 622.64 4200 Radiology Facility Fee 2811099 CT UPPER EXT W/CONTRAST BIL 73201 352 3898 2728.6 847.43 3898 1985.64 847.43 1458 847.43 1985.64 1985.64 1985.64 1985.64 847.43 932.173 847.43 847.43 847.43 847.43 864.3786 847.43 4200 Radiology Facility Fee 2811107 CT-UPPER EXTREM W/O CONTR BLT 73200 352 2952 2066.4 641.77 2952 1503.75 641.77 1458 641.77 1503.75 1503.75 1503.75 1503.75 641.77 705.947 641.77 641.77 641.77 641.77 654.6054 641.77 4200 Radiology Facility Fee 2811115 CT UPPER EXT W&W/O CONTR BIL 73202 352 5074 3551.7999999999997 1103.09 5074 2584.7 1103.09 1458 1103.09 2584.7 2584.7 2584.7 2584.7 1103.09 1213.3990000000001 1103.09 1103.09 1103.09 1103.09 1125.1517999999999 1103.09 4200 Radiology Facility Fee 2811123 CT L SPINE W/CONTRAST 72132 352 2439 1707.3 530.24 2439 1242.43 530.24 1458 530.24 1242.43 1242.43 1242.43 1242.43 530.24 583.264 530.24 530.24 530.24 530.24 540.8448 530.24 4200 Radiology Facility Fee 2811131 CT L SPINE W&W/O CONTRAST 72133 352 2812 1968.3999999999999 611.33 2812 1432.43 611.33 1458 611.33 1432.43 1432.43 1432.43 1432.43 611.33 672.4630000000001 611.33 611.33 611.33 611.33 623.5566 611.33 4200 Radiology Facility Fee 2811149 CT C-SPINE W/CONTRAST 72126 352 2439 1707.3 530.24 2439 1242.43 530.24 1458 530.24 1242.43 1242.43 1242.43 1242.43 530.24 583.264 530.24 530.24 530.24 530.24 540.8448 530.24 4200 Radiology Facility Fee 2811503 CT C-SPINE W/O CONTRAST 72125 352 1539 1077.3 334.58 1539 783.97 334.58 1154.25 334.58 783.97 783.97 783.97 783.97 334.58 368.038 334.58 334.58 334.58 334.58 341.2716 334.58 4200 Radiology Facility Fee 2811507 CT LOWER EXT W & W/O CONTR BIL 73702 352 5074 3551.7999999999997 1103.09 5074 2584.7 1103.09 1458 1103.09 2584.7 2584.7 2584.7 2584.7 1103.09 1213.3990000000001 1103.09 1103.09 1103.09 1103.09 1125.1517999999999 1103.09 4200 Radiology Facility Fee 2811511 CT PELVIS W & W/O CONTRAST 72194 352 2864 2004.8 622.64 2864 1458.92 622.64 1458 622.64 1458.92 1458.92 1458.92 1458.92 622.64 684.904 622.64 622.64 622.64 622.64 635.0928 622.64 4200 Radiology Facility Fee 2811529 CT ABDOMEN W/O CONTRAST 74150 352 1572 1100.3999999999999 341.75 1572 800.78 341.75 1179 341.75 800.78 800.78 800.78 800.78 341.75 375.925 341.75 341.75 341.75 341.75 348.585 341.75 4200 Radiology Facility Fee 2811537 CT ABDOMEN W/CONTRAST 74160 352 2409 1686.3 523.72 2409 1227.14 523.72 1458 523.72 1227.14 1227.14 1227.14 1227.14 523.72 576.0920000000001 523.72 523.72 523.72 523.72 534.1944000000001 523.72 4200 Radiology Facility Fee 2811545 CT CHEST W/O CONTRAST 71250 352 1539 1077.3 334.58 1539 783.97 334.58 1154.25 334.58 783.97 783.97 783.97 783.97 334.58 368.038 334.58 334.58 334.58 334.58 341.2716 334.58 4200 Radiology Facility Fee 2811552 CT CHEST W/CONTRAST 71260 352 2447 1712.8999999999999 531.98 2447 1246.5 531.98 1458 531.98 1246.5 1246.5 1246.5 1246.5 531.98 585.1780000000001 531.98 531.98 531.98 531.98 542.6196 531.98 4200 Radiology Facility Fee 2811560 CT BRAIN W/O CONTRAST 70450 351 1477 1033.8999999999999 321.1 1477 752.38 321.1 1458 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2811578 CT BRAIN W/CONTRAST 70460 351 2275 1592.5 494.59 2275 1158.89 494.59 1458 494.59 1158.89 1158.89 1158.89 1158.89 494.59 544.049 494.59 494.59 494.59 494.59 504.48179999999996 494.59 4200 Radiology Facility Fee 2811602 CT PELVIS W/O CONTRAST 72192 352 1517 1061.8999999999999 329.8 1517 772.76 329.8 1137.75 329.8 772.76 772.76 772.76 772.76 329.8 362.78000000000003 329.8 329.8 329.8 329.8 336.396 329.8 4200 Radiology Facility Fee 2811610 CT PELVIS W/CONTRAST 72193 352 2376 1663.1999999999998 516.54 2376 1210.33 516.54 1458 516.54 1210.33 1210.33 1210.33 1210.33 516.54 568.194 516.54 516.54 516.54 516.54 526.8707999999999 516.54 4200 Radiology Facility Fee 2811628 CT THORACIC SPINE W/O CONTRAST 72128 352 1841 1288.6999999999998 400.23 1841 937.81 400.23 1380.75 400.23 937.81 937.81 937.81 937.81 400.23 440.25300000000004 400.23 400.23 400.23 400.23 408.2346 400.23 4200 Radiology Facility Fee 2811636 CT L-SPINE W/O CONTRAST 72131 352 1539 1077.3 334.58 1539 783.97 334.58 1154.25 334.58 783.97 783.97 783.97 783.97 334.58 368.038 334.58 334.58 334.58 334.58 341.2716 334.58 4200 Radiology Facility Fee 2811651 CT SINUSES W/O CONTRAST 70486 351 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2811655 CT SINUSES W/CONTRAST 70487 351 1947 1362.8999999999999 423.28 1947 991.8 423.28 1458 423.28 991.8 991.8 991.8 991.8 423.28 465.608 423.28 423.28 423.28 423.28 431.74559999999997 423.28 4200 Radiology Facility Fee 2811701 CT NECK W/CONTRAST 70491 351 2202 1541.3999999999999 478.72 2202 1121.7 478.72 1458 478.72 1121.7 1121.7 1121.7 1121.7 478.72 526.5920000000001 478.72 478.72 478.72 478.72 488.29440000000005 478.72 4200 Radiology Facility Fee 2811719 CT NECK - W/O CONTRAST 70490 351 1335 934.4999999999999 290.23 1335 680.05 290.23 1001.25 290.23 680.05 680.05 680.05 680.05 290.23 319.25300000000004 290.23 290.23 290.23 290.23 296.0346 290.23 4200 Radiology Facility Fee 2811727 CT NECK W & W/O CONTRAST 70492 351 2509 1756.3 545.46 2509 1278.08 545.46 1458 545.46 1278.08 1278.08 1278.08 1278.08 545.46 600.0060000000001 545.46 545.46 545.46 545.46 556.3692000000001 545.46 4200 Radiology Facility Fee 2815017 CT FACIAL BONES W/O CONTRAST 70480 351 1634 1143.8 355.23 1634 832.36 355.23 1225.5 355.23 832.36 832.36 832.36 832.36 355.23 390.75300000000004 355.23 355.23 355.23 355.23 362.3346 355.23 4200 Radiology Facility Fee 2815025 CT FACIAL BONES W/ CONTRAST 70481 351 2397 1677.8999999999999 521.11 2397 1221.03 521.11 1458 521.11 1221.03 1221.03 1221.03 1221.03 521.11 573.2210000000001 521.11 521.11 521.11 521.11 531.5322 521.11 4200 Radiology Facility Fee 2815033 CT FACIAL BONES W&W/O CONTRAST 70482 351 2509 1756.3 545.46 2509 1278.08 545.46 1458 545.46 1278.08 1278.08 1278.08 1278.08 545.46 600.0060000000001 545.46 545.46 545.46 545.46 556.3692000000001 545.46 4200 Radiology Facility Fee 2815116 CT-LOWER EXT W/O CONTR RT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2815124 CT LOWER EXT W/CONTRAST RT 73701 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2815132 CT LOWER EXT W & W/O CONTR RT 73702 352 2864 2004.8 622.64 2864 1458.92 622.64 1458 622.64 1458.92 1458.92 1458.92 1458.92 622.64 684.904 622.64 622.64 622.64 622.64 635.0928 622.64 4200 Radiology Facility Fee 2816015 CT-UPPER EXTR W/O CONTR RT 73200 359 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2816023 CT UPPER EXT W/CONTRAST RT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2816031 CT UPPER EXT W&W/O CONTRAST RT 73202 352 2864 2004.8 622.64 2864 1458.92 622.64 1458 622.64 1458.92 1458.92 1458.92 1458.92 622.64 684.904 622.64 622.64 622.64 622.64 635.0928 622.64 4200 Radiology Facility Fee 2816503 CT ABD AND PELVIS W/O CONTRAST 74176 352 2301 1610.6999999999998 500.24 2301 1172.13 500.24 1458 500.24 1172.13 1172.13 1172.13 1172.13 500.24 550.264 500.24 500.24 500.24 500.24 510.2448 500.24 4200 Radiology Facility Fee 2816504 CT ABD AND PELVIS W/CONTRAST 74177 352 3997 2797.8999999999996 868.95 3997 2036.07 868.95 1458 868.95 2036.07 2036.07 2036.07 2036.07 868.95 955.8450000000001 868.95 868.95 868.95 868.95 886.3290000000001 868.95 4200 Radiology Facility Fee 2816505 CT ABD AND PELVIS W/&W/O CONTR 74178 352 4939 3457.2999999999997 1073.74 4939 2515.93 1073.74 1458 1073.74 2515.93 2515.93 2515.93 2515.93 1073.74 1181.114 1073.74 1073.74 1073.74 1073.74 1095.2148 1073.74 4200 Radiology Facility Fee 2819506 CT C SPINE W & W/O CONTRAST 72127 352 2812 1968.3999999999999 611.33 2812 1432.43 611.33 1458 611.33 1432.43 1432.43 1432.43 1432.43 611.33 672.4630000000001 611.33 611.33 611.33 611.33 623.5566 611.33 4200 Radiology Facility Fee 2819514 CT LOWER EXT W/CONTRAST LT 73701 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2821501 CT GUIDANCE FOR NEEDLE BIOPSY 77012 350 1497 1047.8999999999999 325.45 1497 762.57 325.45 1122.75 325.45 762.57 762.57 762.57 762.57 325.45 357.995 325.45 325.45 325.45 325.45 331.959 325.45 4200 Radiology Facility Fee 2850148 ISOVUE 250 Q9661 636 200 140 43.48 200 101.88 43.48 150 43.48 101.88 101.88 101.88 101.88 43.48 47.828 43.48 43.48 43.48 43.48 44.349599999999995 43.48 4200 Radiology Facility Fee 2850149 ISOVUE 300 Q9967 636 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4200 Radiology Facility Fee 2850151 CT EXT ANKLE WO CONTRAST LEFT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850152 CT EXT ANKLE WO CONTRAST RT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850153 CT EXT ELBOW W CONTRAST LEFT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850154 CT EXT ELBOW W CONTRAST RT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850155 CT EXT ELBOW WO CONTRAST LEFT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850156 CT EXT ELBOW WO CONTRAST RT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850157 CT EXT FOOT WO CONTRAST LEFT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850158 CT EXT FOOT WO CONTRAST RT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850159 CT EXT HAND WITH CONTRAST LT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1713 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850160 CT EXT HAND WITH CONTRAST RT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1713 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850161 CT EXT HAND WO CONTRAST LT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850162 CT EXT HAND WO CONTRAST RT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850163 CT EXT SHOULDER W CONTRAST LT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850164 CT EXT SHOULDER W CONTRAST RT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850165 CT EXT SHOULDER WO CONTRAST LT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850166 CT EXT SHOULDER WO CONTRAST RT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850167 CT EXT THIGH W CONTRAST LEFT 73701 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850168 CT EXT THIGH W CONTRAST RT 73701 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850169 CT EXT THIGH WO CONTRAST LEFT 73700, 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850170 CT EXT THIGH WO CONTRAST RT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850171 CT EXT THIGH WO/W CONTRAST RT 73702 352 2864 2004.8 622.64 2864 1458.92 622.64 1458 622.64 1458.92 1458.92 1458.92 1458.92 622.64 684.904 622.64 622.64 622.64 622.64 635.0928 622.64 4200 Radiology Facility Fee 2850172 CT EXT THIGH WO/W CONTRAST LT 73702 352 2864 2004.8 622.64 2864 1458.92 622.64 1458 622.64 1458.92 1458.92 1458.92 1458.92 622.64 684.904 622.64 622.64 622.64 622.64 635.0928 622.64 4200 Radiology Facility Fee 2850173 CT EXT WRIST W CONTRAST LEFT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850174 CT EXT WRIST W CONTRAST RT 73201 352 2284 1598.8 496.54 2284 1163.47 496.54 1458 496.54 1163.47 1163.47 1163.47 1163.47 496.54 546.1940000000001 496.54 496.54 496.54 496.54 506.47080000000005 496.54 4200 Radiology Facility Fee 2850175 CT EXT WRIST WO CONTRAST LEFT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850176 CT EXT WRIST WO CONTRAST RT 73200 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850177 CT HIP WO CONTRAST LEFT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850178 CT HIP WO CONTRAST RIGHT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850179 CT KNEE WO CONTRAST LEFT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850180 CT KNEE WO CONTRAST RIGHT 73700 352 1477 1033.8999999999999 321.1 1477 752.38 321.1 1107.75 321.1 752.38 752.38 752.38 752.38 321.1 353.21000000000004 321.1 321.1 321.1 321.1 327.52200000000005 321.1 4200 Radiology Facility Fee 2850181 CT SPINE THORACIC W CONTRAST 72129 352 2447 1712.8999999999999 531.98 2447 1246.5 531.98 1458 531.98 1246.5 1246.5 1246.5 1246.5 531.98 585.1780000000001 531.98 531.98 531.98 531.98 542.6196 531.98 4200 Radiology Facility Fee 2850182 CT SPINE THORACIC WO/W CONTRAS 72130 352 2865 2005.4999999999998 622.85 2865 1459.43 622.85 1458 622.85 1459.43 1459.43 1459.43 1459.43 622.85 685.1350000000001 622.85 622.85 622.85 622.85 635.307 622.85 4200 Radiology Facility Fee 2900017 MRI ABDOMEN W/O CONTRAST 74181 610 2742 1919.3999999999999 596.11 2742 1396.77 596.11 1458 596.11 1396.77 1396.77 1396.77 1396.77 596.11 655.7210000000001 596.11 596.11 596.11 596.11 608.0322 596.11 4200 Radiology Facility Fee 2900025 MRI LOWER EXTR JT W/O CONTR RT 73721 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900058 MRI CHEST WITH 71551 610 2742 1919.3999999999999 596.11 2742 1396.77 596.11 1458 596.11 1396.77 1396.77 1396.77 1396.77 596.11 655.7210000000001 596.11 596.11 596.11 596.11 608.0322 596.11 4200 Radiology Facility Fee 2900066 MRI UPPER EXTR JT W/O CONTR RT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2900074 MRI UPPER EXT WITHOUT RT 73218 610 2146 1502.1999999999998 466.54 2146 1093.17 466.54 1458 466.54 1093.17 1093.17 1093.17 1093.17 466.54 513.1940000000001 466.54 466.54 466.54 466.54 475.87080000000003 466.54 4200 Radiology Facility Fee 2900082 MRI LOWER EXTR W/O CONTR RT 73718 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900090 MRI LOWER EXTR W/O CONTR LT 73718 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900108 MRI UPPER EXT WITHOUT LT 73218 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900116 MRI LOWER EXT JT W/O BILAT 73721 610 5414 3789.7999999999997 1177.01 5414 2757.89 1177.01 1458 1177.01 2757.89 2757.89 2757.89 2757.89 1177.01 1294.711 1177.01 1177.01 1177.01 1177.01 1200.5502 1177.01 4200 Radiology Facility Fee 2900124 MRI LOWER EXT JT W/O CONT LT 73721 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900140 MRI ORBIT/FACE/NECK WITHOUT 70540 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900173 MRI PELVIS WITHOUT 72195 610 2701 1890.6999999999998 587.2 2701 1375.89 587.2 1458 587.2 1375.89 1375.89 1375.89 1375.89 587.2 645.9200000000001 587.2 587.2 587.2 587.2 598.9440000000001 587.2 4200 Radiology Facility Fee 2900207 MRI UPPER EXTR JT W/O CONTR LT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2900223 MRI TMJ'S 70336 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2900231 MRI UPPER EXTR JT W/O CONT BLT 73221 610 5296 3707.2 1151.35 5296 2697.78 1151.35 1458 1151.35 2697.78 2697.78 2697.78 2697.78 1151.35 1266.485 1151.35 1151.35 1151.35 1151.35 1174.377 1151.35 4200 Radiology Facility Fee 2900249 MRI BRAIN W/O CONTRAST 70551 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900256 MRI BRAIN W/CONTRAST 70552 610 3248 2273.6 706.12 3248 1654.53 706.12 1458 706.12 1654.53 1654.53 1654.53 1654.53 706.12 776.7320000000001 706.12 706.12 706.12 706.12 720.2424 706.12 4200 Radiology Facility Fee 2900264 MRI BRAIN W/O & W/CONTRAST 70553 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2900272 MRI CERVICAL W/O CONTRAST 72141 610 2742 1919.3999999999999 596.11 2742 1396.77 596.11 1458 596.11 1396.77 1396.77 1396.77 1396.77 596.11 655.7210000000001 596.11 596.11 596.11 596.11 608.0322 596.11 4200 Radiology Facility Fee 2900280 MRI CERVICAL W/CONTRAST 72142 610 3289 2302.2999999999997 715.03 3289 1675.42 715.03 1458 715.03 1675.42 1675.42 1675.42 1675.42 715.03 786.533 715.03 715.03 715.03 715.03 729.3306 715.03 4200 Radiology Facility Fee 2900298 MRI CERVICAL W/O & W/CONTRAST 72156 610 5798 4058.6 1260.49 5798 2953.5 1260.49 1458 1260.49 2953.5 2953.5 2953.5 2953.5 1260.49 1386.5390000000002 1260.49 1260.49 1260.49 1260.49 1285.6998 1260.49 4200 Radiology Facility Fee 2900306 MRI THORACIC W/O CONTRAST 72146 610 2992 2094.4 650.46 2992 1524.12 650.46 1458 650.46 1524.12 1524.12 1524.12 1524.12 650.46 715.5060000000001 650.46 650.46 650.46 650.46 663.4692 650.46 4200 Radiology Facility Fee 2900314 MRI THORACIC W/CONTRAST 72147 610 3289 2302.2999999999997 715.03 3289 1675.42 715.03 1458 715.03 1675.42 1675.42 1675.42 1675.42 715.03 786.533 715.03 715.03 715.03 715.03 729.3306 715.03 4200 Radiology Facility Fee 2900322 MRI THORACIC W/O & W/CONTRAST 72157 610 5798 4058.6 1260.49 5798 2953.5 1260.49 1458 1260.49 2953.5 2953.5 2953.5 2953.5 1260.49 1386.5390000000002 1260.49 1260.49 1260.49 1260.49 1285.6998 1260.49 4200 Radiology Facility Fee 2900330 MRI LUMBAR W/O CONTRAST 72148 610 2956 2069.2 642.64 2956 1505.79 642.64 1458 642.64 1505.79 1505.79 1505.79 1505.79 642.64 706.904 642.64 642.64 642.64 642.64 655.4928 642.64 4200 Radiology Facility Fee 2900348 MRI LUMBAR W/CONTRAST 72149 610 3248 2273.6 706.12 3248 1654.53 706.12 1458 706.12 1654.53 1654.53 1654.53 1654.53 706.12 776.7320000000001 706.12 706.12 706.12 706.12 720.2424 706.12 4200 Radiology Facility Fee 2900355 MRI LUMBAR W/O & W/CONTRAST 72158 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2900389 MRI UPPER EXT WITHOUT BILAT 73218 610 5414 3789.7999999999997 1177.01 5414 2757.89 1177.01 1458 1177.01 2757.89 2757.89 2757.89 2757.89 1177.01 1294.711 1177.01 1177.01 1177.01 1177.01 1200.5502 1177.01 4200 Radiology Facility Fee 2900397 MRA UPPER EXT WITH OR W/O RT 73225 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2900413 MRA UPPER EXT WITH OR W/O BILA 73225 610 5534 3873.7999999999997 1203.09 5534 2819.02 1203.09 1458 1203.09 2819.02 2819.02 2819.02 2819.02 1203.09 1323.3990000000001 1203.09 1203.09 1203.09 1203.09 1227.1517999999999 1203.09 4200 Radiology Facility Fee 2900454 MRA LOWER EXT W OR W/O RT 73725 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2900462 MRA LOWER EXT W OR W/O LT 73725 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2900470 MRA LOWER EXT W OR W/O BLT 73725 610 5534 3873.7999999999997 1203.09 5534 2819.02 1203.09 1458 1203.09 2819.02 2819.02 2819.02 2819.02 1203.09 1323.3990000000001 1203.09 1203.09 1203.09 1203.09 1227.1517999999999 1203.09 4200 Radiology Facility Fee 2900538 MRA SPINE W OR W/O 72159 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2900546 MRA HEAD W/O 70544 610 2700 1889.9999999999998 586.98 2700 1375.38 586.98 1458 586.98 1375.38 1375.38 1375.38 1375.38 586.98 645.6780000000001 586.98 586.98 586.98 586.98 598.7196 586.98 4200 Radiology Facility Fee 2900561 MRA NECK WITHOUT 70547 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2900579 MRA PELVIS W OR W/O 72198 610 2904 2032.8 631.33 2904 1479.3 631.33 1458 631.33 1479.3 1479.3 1479.3 1479.3 631.33 694.4630000000001 631.33 631.33 631.33 631.33 643.9566000000001 631.33 4200 Radiology Facility Fee 2900645 MRA UPPER EXT WITH OR W/O LT 73225 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2905495 MRI CHEST WITHOUT 71550 610 2673 1871.1 581.11 2673 1361.63 581.11 1458 581.11 1361.63 1361.63 1361.63 1361.63 581.11 639.2210000000001 581.11 581.11 581.11 581.11 592.7322 581.11 4200 Radiology Facility Fee 2905990 MRI CHEST WITH AND W/O 71552 610 3289 2302.2999999999997 715.03 3289 1675.42 715.03 1458 715.03 1675.42 1675.42 1675.42 1675.42 715.03 786.533 715.03 715.03 715.03 715.03 729.3306 715.03 4200 Radiology Facility Fee 2906402 MRI LOWER EXT W/O CONTR BLT 73718 610 5414 3789.7999999999997 1177.01 5414 2757.89 1177.01 1458 1177.01 2757.89 2757.89 2757.89 2757.89 1177.01 1294.711 1177.01 1177.01 1177.01 1177.01 1200.5502 1177.01 4200 Radiology Facility Fee 2906477 MRI LOWER EXT JT WITH&W/O BILA 73723 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2906485 MRI LOWER EXT JT WITH & W/O LT 73723 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2906493 MRI LOWER EXT JT WITH & W/O RT 73723 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2906899 MRI ABDOMEN WITH & WITHOUT 74183 610 3289 2302.2999999999997 715.03 3289 1675.42 715.03 1458 715.03 1675.42 1675.42 1675.42 1675.42 715.03 786.533 715.03 715.03 715.03 715.03 729.3306 715.03 4200 Radiology Facility Fee 2908051 MRA NECK WITH 70548 610 3248 2273.6 706.12 3248 1654.53 706.12 1458 706.12 1654.53 1654.53 1654.53 1654.53 706.12 776.7320000000001 706.12 706.12 706.12 706.12 720.2424 706.12 4200 Radiology Facility Fee 2908069 MRA NECK WITH & W/O 70549 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2909117 MRI UPPER EXT JT W & W/O RT 73223 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2909323 MRI UPPER EXT WITH & W/O LT 73220 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2909331 MRI UPPER EXT JT W & W/O BILAT 73223 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2909505 MRI LOWER EXT W & W/O BILAT 73720 610 5399 3779.2999999999997 1173.75 5399 2750.25 1173.75 1458 1173.75 2750.25 2750.25 2750.25 2750.25 1173.75 1291.125 1173.75 1173.75 1173.75 1173.75 1197.225 1173.75 4200 Radiology Facility Fee 2909513 MRI LOWER EXT WITH & W/O LEFT 73720 610 2700 1889.9999999999998 586.98 2700 1375.38 586.98 1458 586.98 1375.38 1375.38 1375.38 1375.38 586.98 645.6780000000001 586.98 586.98 586.98 586.98 598.7196 586.98 4200 Radiology Facility Fee 2909521 MRI LOWER EXT WITH & W/O RIGHT 73720 610 2700 1889.9999999999998 586.98 2700 1375.38 586.98 1458 586.98 1375.38 1375.38 1375.38 1375.38 586.98 645.6780000000001 586.98 586.98 586.98 586.98 598.7196 586.98 4200 Radiology Facility Fee 2909588 MRI UPPER EXT WITH & W/O BILAT 73220 610 5414 3789.7999999999997 1177.01 5414 2757.89 1177.01 1458 1177.01 2757.89 2757.89 2757.89 2757.89 1177.01 1294.711 1177.01 1177.01 1177.01 1177.01 1200.5502 1177.01 4200 Radiology Facility Fee 2909653 MRI ORBIT/FACE/NECK WITH & W/O 70543 610 3038 2126.6 660.46 3038 1547.56 660.46 1458 660.46 1547.56 1547.56 1547.56 1547.56 660.46 726.5060000000001 660.46 660.46 660.46 660.46 673.6692 660.46 4200 Radiology Facility Fee 2909703 MRI PELVIS WITH AND W/O 72197 610 3150 2205 684.81 3150 1604.61 684.81 1458 684.81 1604.61 1604.61 1604.61 1604.61 684.81 753.291 684.81 684.81 684.81 684.81 698.5061999999999 684.81 4200 Radiology Facility Fee 2909711 MRI UPPER EXT JT W & W/O LT 73223 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2909794 MRI UPPER EXT WITH & W/O RT 73220 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2910008 MRA ABD. W OR W/O 74185 610 3374 2361.7999999999997 733.51 3374 1718.72 733.51 1458 733.51 1718.72 1718.72 1718.72 1718.72 733.51 806.8610000000001 733.51 733.51 733.51 733.51 748.1802 733.51 4200 Radiology Facility Fee 2910099 MRA CHEST WITHOUT CONTRAST 71555 610 2261 1582.6999999999998 491.54 2261 1151.75 491.54 1458 491.54 1151.75 1151.75 1151.75 1151.75 491.54 540.6940000000001 491.54 491.54 491.54 491.54 501.37080000000003 491.54 4200 Radiology Facility Fee 2911543 MRI PELVIS W/CONTRAST 72196 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2912343 MRI JT UPPR EXT W/CONTRAST BIL 73222 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2914406 MRI JT LOWER EXT WITH BILAT 73722 610 5534 3873.7999999999997 1203.09 5534 2819.02 1203.09 1458 1203.09 2819.02 2819.02 2819.02 2819.02 1203.09 1323.3990000000001 1203.09 1203.09 1203.09 1203.09 1227.1517999999999 1203.09 4200 Radiology Facility Fee 2914455 MRI ABDOMEN W/CONTRAST 74182 610 3038 2126.6 660.46 3038 1547.56 660.46 1458 660.46 1547.56 1547.56 1547.56 1547.56 660.46 726.5060000000001 660.46 660.46 660.46 660.46 673.6692 660.46 4200 Radiology Facility Fee 2915502 MRA CHEST W OR W/O 71555 610 3374 2361.7999999999997 733.51 3374 1718.72 733.51 1458 733.51 1718.72 1718.72 1718.72 1718.72 733.51 806.8610000000001 733.51 733.51 733.51 733.51 748.1802 733.51 4200 Radiology Facility Fee 2915544 MRI JT UPPER EXT W/CONTRAST RT 73222 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2915643 MRI UPPER EXT WO/CONTRAST RT 73219 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2915650 MRI UPPER EXT W/CONTRAST BIL 73219 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2916609 MRI JT LOWER EXT WITH LT 73722 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2916625 MRI JT UPPER EXT W/CONTRAST LT 73722 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2917581 MRA HEAD WITH CONTRAST 70545 610 3150 2205 684.81 3150 1604.61 684.81 1458 684.81 1604.61 1604.61 1604.61 1604.61 684.81 753.291 684.81 684.81 684.81 684.81 698.5061999999999 684.81 4200 Radiology Facility Fee 2917706 MRI JT LOWER EXT WITH RT 73722 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2918530 MRI UPPER EXT W/CONTRAST LT 73219 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2918795 MRA HEAD WITH & WITHOUT 70546 610 3374 2361.7999999999997 733.51 3374 1718.72 733.51 1458 733.51 1718.72 1718.72 1718.72 1718.72 733.51 806.8610000000001 733.51 733.51 733.51 733.51 748.1802 733.51 4200 Radiology Facility Fee 2918796 MRI ANKLE W CONTRAST LEFT 73722 610 5534 3873.7999999999997 1203.09 5534 2819.02 1203.09 1458 1203.09 2819.02 2819.02 2819.02 2819.02 1203.09 1323.3990000000001 1203.09 1203.09 1203.09 1203.09 1227.1517999999999 1203.09 4200 Radiology Facility Fee 2918797 MRI ANKLE W CONTRAST RIGHT 73722 610 5534 3873.7999999999997 1203.09 5534 2819.02 1203.09 1458 1203.09 2819.02 2819.02 2819.02 2819.02 1203.09 1323.3990000000001 1203.09 1203.09 1203.09 1203.09 1227.1517999999999 1203.09 4200 Radiology Facility Fee 2918798 MRI ANKLE WO CONTRAST LEFT 73721 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918799 MRI ANKLE WO CONTRAST RIGHT 73721 610 2711 1897.6999999999998 589.37 2711 1380.98 589.37 1458 589.37 1380.98 1380.98 1380.98 1380.98 589.37 648.307 589.37 589.37 589.37 589.37 601.1574 589.37 4200 Radiology Facility Fee 2918800 MRI ANKLE WO/W CONTRAST LEFT 73723 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918801 MRI ANKLE WO/W CONTRAST RIGHT 73723 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918802 MRI ELBOW W CONTRAST LEFT 73222 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2918803 MRI ELBOW W CONTRAST RIGHT 73222 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2918804 MRI ELBOW WO CONTRAST LEFT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918805 MR ELBOW WO CONTRAST RIGHT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918806 MRI ELBOW WO/W CONTRAST LEFT 73223 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918807 MRI ELBOW WO/W CONTRAST RIGHT 73223 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918808 MRI EXT LOWER OTHER THAN JT 73719 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918809 MRI EXT LOWER OTHER THAN JT 73719 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918810 MRI EXT LOWER OTHER THAN JT 73718 610 2146 1502.1999999999998 466.54 2146 1093.17 466.54 1458 466.54 1093.17 1093.17 1093.17 1093.17 466.54 513.1940000000001 466.54 466.54 466.54 466.54 475.87080000000003 466.54 4200 Radiology Facility Fee 2918811 MRI EXT LOWER OTHER THAN JT 73718 610 2146 1502.1999999999998 466.54 2146 1093.17 466.54 1458 466.54 1093.17 1093.17 1093.17 1093.17 466.54 513.1940000000001 466.54 466.54 466.54 466.54 475.87080000000003 466.54 4200 Radiology Facility Fee 2918812 MRI EXT LOWER OTHER THAN JT 73720 610 5399 3779.2999999999997 1173.75 5399 2750.25 1173.75 1458 1173.75 2750.25 2750.25 2750.25 2750.25 1173.75 1291.125 1173.75 1173.75 1173.75 1173.75 1197.225 1173.75 4200 Radiology Facility Fee 2918813 MRI EXT LOWER OTHER THAN JT 73720 610 5399 3779.2999999999997 1173.75 5399 2750.25 1173.75 1458 1173.75 2750.25 2750.25 2750.25 2750.25 1173.75 1291.125 1173.75 1173.75 1173.75 1173.75 1197.225 1173.75 4200 Radiology Facility Fee 2918814 MRI EXT UPPER OTHJER THAN JT 73219 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2918815 MRI EXT UPPER OTHER THAN JT 73219 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2918816 MRI EXT UPPER OTHER THAN JT 73218 610 2146 1502.1999999999998 466.54 2146 1093.17 466.54 1458 466.54 1093.17 1093.17 1093.17 1093.17 466.54 513.1940000000001 466.54 466.54 466.54 466.54 475.87080000000003 466.54 4200 Radiology Facility Fee 2918817 MRI EXT UPPER OTHER THAN JT 73218 610 2146 1502.1999999999998 466.54 2146 1093.17 466.54 1458 466.54 1093.17 1093.17 1093.17 1093.17 466.54 513.1940000000001 466.54 466.54 466.54 466.54 475.87080000000003 466.54 4200 Radiology Facility Fee 2918818 MRI EXT UPPER OTHER THAN JT 73220 610 5414 3789.7999999999997 1177.01 5414 2757.89 1177.01 1458 1177.01 2757.89 2757.89 2757.89 2757.89 1177.01 1294.711 1177.01 1177.01 1177.01 1177.01 1200.5502 1177.01 4200 Radiology Facility Fee 2918819 MRI EXT UPPER OTHER THAN JT 73220 610 5414 3789.7999999999997 1177.01 5414 2757.89 1177.01 1458 1177.01 2757.89 2757.89 2757.89 2757.89 1177.01 1294.711 1177.01 1177.01 1177.01 1177.01 1200.5502 1177.01 4200 Radiology Facility Fee 2918820 MRI FOOT W CONTRAST LEFT 73719 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918821 MRI FOOT W CONTRAST RIGHT 73719 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918822 MRO FOOT WO CONTRAST LEFT 73718 610 2146 1502.1999999999998 466.54 2146 1093.17 466.54 1458 466.54 1093.17 1093.17 1093.17 1093.17 466.54 513.1940000000001 466.54 466.54 466.54 466.54 475.87080000000003 466.54 4200 Radiology Facility Fee 2918823 MRI FOOT WO CONTRAST RIGHT 73718 610 2146 1502.1999999999998 466.54 2146 1093.17 466.54 1458 466.54 1093.17 1093.17 1093.17 1093.17 466.54 513.1940000000001 466.54 466.54 466.54 466.54 475.87080000000003 466.54 4200 Radiology Facility Fee 2918824 MRI FOOT WO/W CONTRAST LEFT 73720 610 5399 3779.2999999999997 1173.75 5399 2750.25 1173.75 1458 1173.75 2750.25 2750.25 2750.25 2750.25 1173.75 1291.125 1173.75 1173.75 1173.75 1173.75 1197.225 1173.75 4200 Radiology Facility Fee 2918825 MRI FOOT WO/W CONTRAST RIGHT 73720 610 5399 3779.2999999999997 1173.75 5399 2750.25 1173.75 1458 1173.75 2750.25 2750.25 2750.25 2750.25 1173.75 1291.125 1173.75 1173.75 1173.75 1173.75 1197.225 1173.75 4200 Radiology Facility Fee 2918826 MRI HAND WO CONTRAST LEFT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918827 MRI HAND WO CONTRAST RIGHT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918828 MRI HIP W CONTRAST LEFT 73722 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2918829 MRI HIP W CONTRAST RIGHT 73722 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2918830 MRI HIP WO CONTRAST - BILAT 73721 610 5414 3789.7999999999997 1177.01 5414 2757.89 1177.01 1458 1177.01 2757.89 2757.89 2757.89 2757.89 1177.01 1294.711 1177.01 1177.01 1177.01 1177.01 1200.5502 1177.01 4200 Radiology Facility Fee 2918831 MRI HIP WO CONTRAST LEFT 73721 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918832 MRI HIP WO CONTRAST RIGHT 73721 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918833 MRI HIP WO/W CONTRAST LEFT 73723 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2918834 MRI HIP WO/W CONTRAST RIGHT 73723 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2918835 MRI KNEE W CONTRAST LEFT 73722 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2918836 MRI KNEE W CONTRAST RIGHT 73722 610 2768 1937.6 601.76 2768 1410.02 601.76 1458 601.76 1410.02 1410.02 1410.02 1410.02 601.76 661.936 601.76 601.76 601.76 601.76 613.7952 601.76 4200 Radiology Facility Fee 2918837 MRI KNEE WO CONTRAST LEFT 73721 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918838 MRI KNEE WO CONTRAST RIGHT 73721 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918839 MRI KNEE WO/W CONTRAST LEFT 73723 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2918840 MRI KNEE WO/W CONTRAST RIGHT 73723 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2918841 MRI LUMBAR SPINE W CONTRAST 72149 610 3248 2273.6 706.12 3248 1654.53 706.12 1458 706.12 1654.53 1654.53 1654.53 1654.53 706.12 776.7320000000001 706.12 706.12 706.12 706.12 720.2424 706.12 4200 Radiology Facility Fee 2918842 MRI LUMBAR SPINE WO CONTRAST 72148 610 2956 2069.2 642.64 2956 1505.79 642.64 1458 642.64 1505.79 1505.79 1505.79 1505.79 642.64 706.904 642.64 642.64 642.64 642.64 655.4928 642.64 4200 Radiology Facility Fee 2918843 MRI LUMBAR SPINE WO/W CONTRAST 72158 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918844 MRI NECK W CONTRAST 70542 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2918845 MRI NECK WO CONTRAST 70540 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918846 MRI NECK WO/W CONTRAST 70543 610 3038 2126.6 660.46 3038 1547.56 660.46 1458 660.46 1547.56 1547.56 1547.56 1547.56 660.46 726.5060000000001 660.46 660.46 660.46 660.46 673.6692 660.46 4200 Radiology Facility Fee 2918847 MRI ORBITS W CONTRAST 70542 610 2871 2009.6999999999998 624.16 2871 1462.49 624.16 1458 624.16 1462.49 1462.49 1462.49 1462.49 624.16 686.576 624.16 624.16 624.16 624.16 636.6432 624.16 4200 Radiology Facility Fee 2918848 MRI ORBITS WO CONTRAST 70540 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918849 MRI ORBITS WO/W CONTRAST 70543 610 3038 2126.6 660.46 3038 1547.56 660.46 1458 660.46 1547.56 1547.56 1547.56 1547.56 660.46 726.5060000000001 660.46 660.46 660.46 660.46 673.6692 660.46 4200 Radiology Facility Fee 2918850 MRI PELVIS W CONTRAST 72196 610 2925 2047.4999999999998 635.9 2925 1490 635.9 1458 635.9 1490 1490 1490 1490 635.9 699.49 635.9 635.9 635.9 635.9 648.6179999999999 635.9 4200 Radiology Facility Fee 2918851 MRI PITUITARY WO CONTRAST 70551 610 2789 1952.3 606.33 2789 1420.72 606.33 1458 606.33 1420.72 1420.72 1420.72 1420.72 606.33 666.9630000000001 606.33 606.33 606.33 606.33 618.4566000000001 606.33 4200 Radiology Facility Fee 2918852 MRI PITUITARY WO/W CONTRAST 70553 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918853 MRI SHOULDER W CONTRAST LEFT 73222 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2918854 MRI SHOULDER W CONTRAST RIGHT 73222 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2918855 MRI SHOULDER WO CONTRAST LEFT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918856 MRI SHOULDER WO CONTRAST RIGHT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918857 MRI SHOULDER WO/W CONTRAST LT 73223 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918858 MRI SHOULDER WO/W CONTRAST RT 73223 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918859 MRI WRIST W CONTRAST LEFT 73222 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2918860 MRI WRIST W CONTRAST RIGHT 73222 610 5848 4093.6 1271.36 5848 2978.97 1271.36 1458 1271.36 2978.97 2978.97 2978.97 2978.97 1271.36 1398.496 1271.36 1271.36 1271.36 1271.36 1296.7872 1271.36 4200 Radiology Facility Fee 2918861 MRI WRIST WO CONTRAST LEFT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918862 MRI WRIST WO CONTRAST RIGHT 73221 610 2649 1854.3 575.89 2649 1349.4 575.89 1458 575.89 1349.4 1349.4 1349.4 1349.4 575.89 633.479 575.89 575.89 575.89 575.89 587.4078 575.89 4200 Radiology Facility Fee 2918863 MRI WRIST WO/W CONTRAST LEFT 73223 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918864 MRI WRIST WO/W CONTRAST RIGHT 73223 610 5740 4017.9999999999995 1247.88 5740 2923.96 1247.88 1458 1247.88 2923.96 2923.96 2923.96 2923.96 1247.88 1372.6680000000001 1247.88 1247.88 1247.88 1247.88 1272.8376 1247.88 4200 Radiology Facility Fee 2918865 MRA ABDOMEN W CONTRAST 74185 610 3038 2126.6 660.46 3038 1547.56 660.46 1458 660.46 1547.56 1547.56 1547.56 1547.56 660.46 726.5060000000001 660.46 660.46 660.46 660.46 673.6692 660.46 4200 Radiology Facility Fee 2918866 MRA ABDOMEN WO CONTRAST 74185 610 2261 1582.6999999999998 491.54 2261 1151.75 491.54 1458 491.54 1151.75 1151.75 1151.75 1151.75 491.54 540.6940000000001 491.54 491.54 491.54 491.54 501.37080000000003 491.54 4200 Radiology Facility Fee 2918867 MRA CHEST W CONTRAST 71555 610 2904 2032.8 631.33 2904 1479.3 631.33 1458 631.33 1479.3 1479.3 1479.3 1479.3 631.33 694.4630000000001 631.33 631.33 631.33 631.33 643.9566000000001 631.33 4200 Radiology Facility Fee 2918868 Ultrasound Soft tissue Back/Chest 76604 402 333 233.1 72.39 333 169.63 72.39 249.75 72.39 169.63 169.63 169.63 169.63 72.39 79.629 72.39 72.39 72.39 72.39 73.8378 72.39 4200 Radiology Facility Fee 2918869 Scoliosis Evaluation 72082 320 405 283.5 88.05 405 206.31 88.05 303.75 88.05 206.31 206.31 206.31 206.31 88.05 96.855 88.05 88.05 88.05 88.05 89.81099999999999 88.05 4200 Radiology Facility Fee 2918870 OB Pelvic U/S >14wks 76805 402 761 532.6999999999999 165.44 761 387.65 165.44 570.75 165.44 387.65 387.65 387.65 387.65 165.44 181.984 165.44 165.44 165.44 165.44 168.7488 165.44 4200 Radiology Professional Fee 12210003 ANKLE COMPLETE, MIN 3 VIEW LT 73610 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12210037 CHEST ONE FRONTAL VIEW 71045 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12210045 CHEST PA & LAT 71046 972 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4200 Radiology Professional Fee 12210052 RIBS COMPLETE RT W/PA CHEST 71101 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12210078 STERNUM MIN 2 VIEWS 71120 972 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4200 Radiology Professional Fee 12210094 ABD 1 VW-FLAT OR ERRECT 74018 972 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4200 Radiology Professional Fee 12210102 ABD SERIES 3-4VWS PA/KUB/ER 74022 972 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4200 Radiology Professional Fee 12210110 C SPINE MIN 4 VIEWS 72050 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12210128 T-SPINE W/SWIMMERS 3 VIEW 72072 972 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4200 Radiology Professional Fee 12210136 L SPINE MIN 4 VIEWS 72110 972 103 72.1 22.39 103 52.47 22.39 77.25 22.39 52.47 52.47 52.47 52.47 22.39 24.629 22.39 22.39 22.39 22.39 22.8378 22.39 4200 Radiology Professional Fee 12210151 COCCYX AND SACRUM MIN 2 VIEW 72220 972 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4200 Radiology Professional Fee 12210177 HIP RT MIN 2 VIEWS W/O PELVIS 73510 972 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4200 Radiology Professional Fee 12210185 FEMUR RT 2 VIEWS ONLY 73550 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12210193 KNEE 4 OR MORE VIEWS RT 73564 972 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4200 Radiology Professional Fee 12210201 TIB/FIB 2 VIEWS ONLY RT 73590 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12210219 ANKLE COMPLETE, MIN 3 VIEW 73218 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12210227 OSCALIS(HEEL) MIN 2 VIEWS RT 73650 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12210235 FOOT MIN 3 VIEWS RT 73630 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12210243 TOES MIN 2 VIEWS BI 73660 972 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4200 Radiology Professional Fee 12210250 CLAVICLE COMPLETE RT 73000 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12210268 SHOULDER COMP MIN 2 VIEWS RT 73030 972 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4200 Radiology Professional Fee 12210276 HUMERUS MIN 2 VIEWS RT 73060 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12210284 ELBOW COMPLETE RT MIN 3 VIEWS 73080 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12210292 FOREARM RT 2 VIEWS ONLY 73090 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12210300 WRIST COMP. MIN 3 VIEWS RT 73110 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12210318 HAND MIN 3 VIEWS RT 73130 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12210326 FINGER(S) LT MIN 2 VIEWS 73140 972 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4200 Radiology Professional Fee 12210334 SKULL COMPLETE MIN 4 VIEWS 70260 972 102 71.39999999999999 22.17 102 51.96 22.17 76.5 22.17 51.96 51.96 51.96 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 4200 Radiology Professional Fee 12210342 ORBITS COMPLETE MIN 4 VIEWS 70200 972 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4200 Radiology Professional Fee 12210359 FACIAL BONES, MIN 3 VIEWS 70150 972 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4200 Radiology Professional Fee 12210367 MANDIBLE MIN 4 VIEWS 70110 972 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4200 Radiology Professional Fee 12210383 NASAL BONES MIN 3 VIEWS 70160 972 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4200 Radiology Professional Fee 12210391 SINUSES 3 VIEW MINIMUM 70220 972 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4200 Radiology Professional Fee 12210409 SOFT TISSUE NECK 70360 972 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4200 Radiology Professional Fee 12210417 BARIUM SWALLOW FUNC. (VIDEO) 74230 972 158 110.6 34.35 158 80.49 34.35 118.5 34.35 80.49 80.49 80.49 80.49 34.35 37.785000000000004 34.35 34.35 34.35 34.35 35.037 34.35 4200 Radiology Professional Fee 12210425 UGI W/AIR-BAR-FIZ-KUB+W OR W/O 74247 972 237 165.89999999999998 51.52 237 120.73 51.52 177.75 51.52 120.73 120.73 120.73 120.73 51.52 56.67200000000001 51.52 51.52 51.52 51.52 52.5504 51.52 4200 Radiology Professional Fee 12210433 SM BOWEL W/FILMS 74250 972 139 97.3 30.22 139 70.81 30.22 104.25 30.22 70.81 70.81 70.81 70.81 30.22 33.242000000000004 30.22 30.22 30.22 30.22 30.8244 30.22 4200 Radiology Professional Fee 12210441 BE W/AIR W/O KUB OR W/O GLUC 74280 972 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4200 Radiology Professional Fee 12210458 BE W OR W/O KUB 74270 972 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4200 Radiology Professional Fee 12210474 CHOLANG. T-TUBE POST-OPER. 74305 972 130 91 28.26 130 66.22 28.26 97.5 28.26 66.22 66.22 66.22 66.22 28.26 31.086000000000006 28.26 28.26 28.26 28.26 28.825200000000002 28.26 4200 Radiology Professional Fee 12210482 IVP W OR W/O KUB W OR W/O 74400 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12210508 CYSTOGRAM MIN. 3 VIEWS 74430 972 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4200 Radiology Professional Fee 12210516 CYSTOGRAM - VOIDING 74455 972 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4200 Radiology Professional Fee 12210524 RETROG PYLEGRAM W OR W/O KUB 74420 972 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4200 Radiology Professional Fee 12210607 FLOUROTIME 1 HOUR (O/R) 76001 972 222 155.39999999999998 48.26 222 113.09 48.26 166.5 48.26 113.09 113.09 113.09 113.09 48.26 53.086000000000006 48.26 48.26 48.26 48.26 49.2252 48.26 4200 Radiology Professional Fee 12210615 FLOURO TIME UP TO 1 HR 76000 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12210631 CHEST W/APIC LORDOTIC 71046 972 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4200 Radiology Professional Fee 12210649 CHEST LAT OR DEC OR BUCKY STUD 71035 972 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4200 Radiology Professional Fee 12210656 CHEST PA & LAT W/OBLIQUES 71022 972 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4200 Radiology Professional Fee 12210664 C SPINE 2 OR 3 VIEWS 72040 972 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4200 Radiology Professional Fee 12210672 L SPINE 2 OR 3 VIEWS 72100 972 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4200 Radiology Professional Fee 12210698 SKULL LESS THAN 4 VIEWS 70250 972 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4200 Radiology Professional Fee 12210706 MASTOIDS MIN 3 VIES PER SIDE 70130 972 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4200 Radiology Professional Fee 12210714 TMJ RIGHT OPEN AND CLOSED 70328 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12210730 AC JTS BLT W OR W/O WTS 2 VIEW 73050 972 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4200 Radiology Professional Fee 12210763 ELBOW 2 VIEWS RT 73070 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12210789 KNEE AP & LAT 73560 972 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4200 Radiology Professional Fee 12210797 S I JOINTS < 3 VIEWS 72200 972 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4200 Radiology Professional Fee 12210805 SCAPULA COMPLETE RT 73010 972 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4200 Radiology Professional Fee 12210854 CHOLANGIOGRAM INTRAOPERATIVE 74300 972 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4200 Radiology Professional Fee 12210862 CHOLANGIOGRAM NON-OPERATIVE 74320 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12210953 SM BOWEL VIA ENTEOCLYSIS TUBE 74251 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12210987 BARIUM SWALLOW SPEECH THERAPY 70371 972 246 172.2 53.48 246 125.31 53.48 184.5 53.48 125.31 125.31 125.31 125.31 53.48 58.828 53.48 53.48 53.48 53.48 54.5496 53.48 4200 Radiology Professional Fee 12211803 ELBOW 2 VIEW LT 70370 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12213015 UGI W/KUB, W OR W/O DEL. FILMS 74241 972 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4200 Radiology Professional Fee 12213809 FOREARM BLT 2 VIEWS ONLY 73090 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12213908 CHOLECYSTOGRAM ORAL 74290 972 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4200 Radiology Professional Fee 12214154 SCREENING MAMMOGRAM 77057 972 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4200 Radiology Professional Fee 12214155 DIAG MAMMOGRAM BILAT 77056 972 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4200 Radiology Professional Fee 12214156 DIAG MAMMOGRAM LT 77055 972 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4200 Radiology Professional Fee 12214157 DIAG MAMMOGRAM RT 77055 972 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4200 Radiology Professional Fee 12214203 BREAST LOCAL/MAMMO GUIDE RT 77032 972 190 133 41.31 190 96.79 41.31 142.5 41.31 96.79 96.79 96.79 96.79 41.31 45.44100000000001 41.31 41.31 41.31 41.31 42.1362 41.31 4200 Radiology Professional Fee 12220002 RIBS BILAT 3 VIEWS 71110 972 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4200 Radiology Professional Fee 12220010 RIBS UNILATERAL 2 VIEWS RT 71100 972 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4200 Radiology Professional Fee 12220028 RIBS UNILATERAL 2 VIEWS LT 71100 972 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4200 Radiology Professional Fee 12220507 LOOPOGRAM 74425 972 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4200 Radiology Professional Fee 12220804 IVP WITH TOMO'S 74415 972 171 119.69999999999999 37.18 171 87.11 37.18 128.25 37.18 87.11 87.11 87.11 87.11 37.18 40.898 37.18 37.18 37.18 37.18 37.9236 37.18 4200 Radiology Professional Fee 12221018 ANKLE COMPLETE, MIN 3 VIEW BLT 73610 972 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4200 Radiology Professional Fee 12221026 TOMOGRAPHY 76100 972 182 127.39999999999999 39.57 182 92.71 39.57 136.5 39.57 92.71 92.71 92.71 92.71 39.57 43.527 39.57 39.57 39.57 39.57 40.3614 39.57 4200 Radiology Professional Fee 12221034 ANKLE 2 VIEWS RT 73600 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221042 ANKLE 2 VIEWS LT 73600 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221059 ANKLE 2 VIEWS BI 73600 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12221067 TMJ LT OPEN AND CLOSED 70328 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12221075 RIBS COMPLETE LT W/PA CHEST 71101 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12221083 BREAST LOCAL/MAMMO GUIDE LT 77032 972 190 133 41.31 190 96.79 41.31 142.5 41.31 96.79 96.79 96.79 96.79 41.31 45.44100000000001 41.31 41.31 41.31 41.31 42.1362 41.31 4200 Radiology Professional Fee 12221091 BREAST LOCAL/MAMMO GUIDE BILAT 77032 972 379 265.3 82.39 379 193.06 82.39 284.25 82.39 193.06 193.06 193.06 193.06 82.39 90.629 82.39 82.39 82.39 82.39 84.0378 82.39 4200 Radiology Professional Fee 12221109 BREAST SPECIMEN LT 76098 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12221117 BREAST SPECIMENT BILAT 76098 972 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4200 Radiology Professional Fee 12221125 SPINE ONE VIEW 72020 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221133 CLAVICLE COMPLETE LT 73000 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12221141 CLAVICLE COMPLETE BLT 73000 972 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4200 Radiology Professional Fee 12221158 ELBOW COMPLETE LT MIN 3 VIEWS 73080 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12221166 ELBOW COMPLETE, BLT MIN 3 VIEW 73080 972 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4200 Radiology Professional Fee 12221190 ELBOW 2 VIEW BLT 73070 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12221208 FACIAL BONES 1-3 VIEWS 70140 972 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4200 Radiology Professional Fee 12221216 FEMUR LT 2 VIEWS ONLY 73550 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12221224 FEMUR BLT 2 VIEWS ONLY 73550 972 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4200 Radiology Professional Fee 12221311 UGI W/AIR, SMALL BOWEL+FILMS 74249 972 268 187.6 58.26 268 136.52 58.26 201 58.26 136.52 136.52 136.52 136.52 58.26 64.086 58.26 58.26 58.26 58.26 59.4252 58.26 4200 Radiology Professional Fee 12221323 FOOT MIN 3 VIEWS LT 73630 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12221331 FOOT MIN 3 VIEWS BLT 73630 972 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4200 Radiology Professional Fee 12221349 FOOT 2 VIEWS RT 73620 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221356 FOOT 2 VIEWS LT 73620 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221358 BARIUM SWALLOW 74220 972 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 4200 Radiology Professional Fee 12221362 MANDIBLE PARTIAL LESS 4 VIEWS 70100 972 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4200 Radiology Professional Fee 12221364 FOOT 2 VIEWS BI 73620 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12221365 HIP LT 1 VIEW 73500 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12221368 HIP RT 1 VIEW 73500 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12221372 FOREARM LT 2 VIEWS ONLY 73090 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221378 ORBIT FOREIGN BODY 70030 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12221380 INFANT MIN 2 VIEWS UPPER EXT. 73092 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221385 INFANT MIN 2 VIEWS PELVIS/HIPS 73540 972 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4200 Radiology Professional Fee 12221387 UGI W/KUB & SM BOWEL W/FILMS 74245 972 268 187.6 58.26 268 136.52 58.26 201 58.26 136.52 136.52 136.52 136.52 58.26 64.086 58.26 58.26 58.26 58.26 59.4252 58.26 4200 Radiology Professional Fee 12221392 BONE SURVEY(METS) LIMITED 77074 972 150 105 32.61 150 76.41 32.61 112.5 32.61 76.41 76.41 76.41 76.41 32.61 35.871 32.61 32.61 32.61 32.61 33.2622 32.61 4200 Radiology Professional Fee 12221398 HAND MIN 3 VIEWS LT 73130 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12221406 HAND MIN 3 VIEWS BLT 73130 972 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4200 Radiology Professional Fee 12221414 HAND 2 VIEWS RT 73120 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221422 HAND 2 VIEWS LT 73120 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221430 HAND 2 VIEWS BLT 73120 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12221448 HIP LT MIN 2 VIEWS 73510 972 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4200 Radiology Professional Fee 12221455 HIP BLT MIN 2 VIEWS EACH 73520 972 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4200 Radiology Professional Fee 12221463 HUMERUS MIN 2 VIEWS LT 73060 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12221471 HUMERUS MIN 2 VIEWS BLT 73060 972 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4200 Radiology Professional Fee 12221489 KNEE 4 OR MORE VIEWS BLT 73564 972 152 106.39999999999999 33.04 152 77.43 33.04 114 33.04 77.43 77.43 77.43 77.43 33.04 36.344 33.04 33.04 33.04 33.04 33.7008 33.04 4200 Radiology Professional Fee 12221497 KNEE 1 OR 2 VIEWS RT 73560 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12221505 KNEE 1 OR 2 VIEWS LT 73560 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12221513 KNEE 1 OR 2 VIEWS BLT 73560 972 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4200 Radiology Professional Fee 12221521 TIB/FIB 2 VIEWS ONLY LT 73590 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12221539 TIB/FIB 2 VIEWS ONLY BLT 73590 972 127 88.89999999999999 27.61 127 64.69 27.61 95.25 27.61 64.69 64.69 64.69 64.69 27.61 30.371000000000002 27.61 27.61 27.61 27.61 28.1622 27.61 4200 Radiology Professional Fee 12221554 OSCALIS(HEEL) MIN 2 VIEWS LT 73650 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12221562 OSCALIS(HEEL) MIN 2 VIEWS BLT 73650 972 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4200 Radiology Professional Fee 12221570 PELVIS 1 OR 2 VIEW 72170 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12221588 SCAPULA COMPLETE LT 73010 972 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4200 Radiology Professional Fee 12221596 SCAPULA COMPLETE BLT 73010 972 127 88.89999999999999 27.61 127 64.69 27.61 95.25 27.61 64.69 64.69 64.69 64.69 27.61 30.371000000000002 27.61 27.61 27.61 27.61 28.1622 27.61 4200 Radiology Professional Fee 12221604 SHOULDER COMP MIN 2 VIEWS LT 73030 972 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4200 Radiology Professional Fee 12221612 SHOULDER COMP MIN 2 VIEWS BLT 73030 972 124 86.8 26.96 124 63.17 26.96 93 26.96 63.17 63.17 63.17 63.17 26.96 29.656000000000002 26.96 26.96 26.96 26.96 27.499200000000002 26.96 4200 Radiology Professional Fee 12221729 WRIST COMP. MIN 3 VIEWS LT 73110 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12221737 WRIST COMP. MIN 3 VIEWS BLT 73110 972 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4200 Radiology Professional Fee 12221752 WRIST 2 VIEWS RT 73100 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221760 WRIST 2 VIEWS LT 73100 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12221778 WRIST 2 VIEWS BLT 73100 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12221869 TOES MIN 2 VIEWS RT 73660 972 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4200 Radiology Professional Fee 12221893 TOES MIN 2 VIEWS LT 73660 972 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4200 Radiology Professional Fee 12221919 FINGER(S) RT MIN 2 VIEWS 73140 972 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4200 Radiology Professional Fee 12221927 FINGERS(S) BLT MIN 2 VIEWS 73140 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12222222 KNEES BLT AP AND STANDING 1 VW 73565 972 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4200 Radiology Professional Fee 12223659 BE/LOW RISK SCREENING G0106 972 583 408.09999999999997 126.74 583 296.98 126.74 437.25 126.74 296.98 296.98 296.98 296.98 126.74 139.41400000000002 126.74 126.74 126.74 126.74 129.2748 126.74 4200 Radiology Professional Fee 12224111 BE/HIGH RISK SCREENING G0120 972 583 408.09999999999997 126.74 583 296.98 126.74 437.25 126.74 296.98 296.98 296.98 296.98 126.74 139.41400000000002 126.74 126.74 126.74 126.74 129.2748 126.74 4200 Radiology Professional Fee 12225001 ABD 2-3 VWS-KUB/DEC=/OR ERRECT 74021 972 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4200 Radiology Professional Fee 12227411 WEST CENTRAL TB 71010 972 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4200 Radiology Professional Fee 12270015 SINUSES (LESS THAN 3 VIEWS) 70210 972 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4200 Radiology Professional Fee 12270106 TMJ BILAT OPEN AND CLOSED 70330 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12270205 RIBS BLT COMP W/PA MIN 4 VIEWS 71111 972 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4200 Radiology Professional Fee 12270304 C SPINE W/OBL/FLEX AND/OR EXTE 72052 972 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4200 Radiology Professional Fee 12270403 T-SPINE AP/LAT 72070 972 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4200 Radiology Professional Fee 12270411 L SPINE W/BEND VIEW MIN 6 VIEW 72114 972 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4200 Radiology Professional Fee 12272011 KNEE 4 OR MORE VIEWS LT 73564 972 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4200 Radiology Professional Fee 12273019 BONE AGE STUDIES 77072 972 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4200 Radiology Professional Fee 12274009 GT TUBE PLACEMENT 74340 972 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4200 Radiology Professional Fee 12275105 BREAST SPECIMEN RT 76098 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12280006 LEG LENGHT STUDY 77073 972 74 51.8 16.09 74 37.7 16.09 55.5 16.09 37.7 37.7 37.7 37.7 16.09 17.699 16.09 16.09 16.09 16.09 16.4118 16.09 4200 Radiology Professional Fee 12280057 SPINE SURVEY AP AND LATERAL 72010 972 103 72.1 22.39 103 52.47 22.39 77.25 22.39 52.47 52.47 52.47 52.47 22.39 24.629 22.39 22.39 22.39 22.39 22.8378 22.39 4200 Radiology Professional Fee 12280059 UTROGRADE URETHROGRAM 74450 972 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4200 Radiology Professional Fee 12280060 NEPHROSTOGRAM 74425 972 169 118.3 36.74 169 86.09 36.74 126.75 36.74 86.09 86.09 86.09 86.09 36.74 40.41400000000001 36.74 36.74 36.74 36.74 37.4748 36.74 4200 Radiology Professional Fee 12280061 RT HIP ARTHROGRAM 73525 972 103 72.1 22.39 103 52.47 22.39 77.25 22.39 52.47 52.47 52.47 52.47 22.39 24.629 22.39 22.39 22.39 22.39 22.8378 22.39 4200 Radiology Professional Fee 12280063 KNEE ARTHROGRAM 73580 972 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4200 Radiology Professional Fee 12280066 FISTULAGRAM 76080 972 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4200 Radiology Professional Fee 12300002 ABDOMEN ONE VIEW AP 74018 972 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4200 Radiology Professional Fee 12300010 ANKLE COMPLETE RT MIN 3 VIEW 73610 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12300036 CHEST 2 VIEW PA\\AP & LAT 71046 972 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4200 Radiology Professional Fee 12300044 CHEST ONE VIEW 71010 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12300051 CHEST DECUBITUS 71035 972 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4200 Radiology Professional Fee 12300069 ELBOW 2 VIEW RT 73070 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300085 FEMUR 2 VIEW RT 73550 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12300093 FINGER(S) RT 73140 972 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4200 Radiology Professional Fee 12300101 FOOT RT 73620 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300143 FOREARM RT 73090 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300168 HAND 73120 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300184 HIP RT 73510 972 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4200 Radiology Professional Fee 12300200 HUMERUS RT 73060 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12300226 KNEE RT 73560 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12300259 LOWER LEG (TIBIA & FIBULA) RT 73590 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12300275 PELVIS 72170 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12300283 RIBS RT 71101 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12300291 SHOULDER MIN 2 VIEWS RT 73030 972 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4200 Radiology Professional Fee 12300358 SKULL ( AP & LAT) 70250 972 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4200 Radiology Professional Fee 12300366 TOE(S) RT 73660 972 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4200 Radiology Professional Fee 12300382 WRIST RT 73100 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300614 ANKLE COMPLETE LT MIN 3 VIEW 73610 972 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4200 Radiology Professional Fee 12300622 ANKLE COMPLETE BILAT 73610 972 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4200 Radiology Professional Fee 12300630 ANKLE 2 VIEW RT 73600 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300648 ANKLE 2 VIEW LT 73600 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300655 ANKEL 2 VIEW BILAT 73600 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12300663 ELBOW 2 VIEW LT 73070 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300671 ELBOW 2 VIEW BILAT 73070 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12300689 FEMUR 2 VIEW LT 73550 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12300697 FEMUR 2 VIEW BLT 73550 972 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4200 Radiology Professional Fee 12300788 FINGER(S) LT 73140 972 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4200 Radiology Professional Fee 12300796 FOOT LT 73620 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300804 FOOT BLT 73620 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12300812 FOREARM LT 73090 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300820 FOREARM BILAT 73090 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12300838 HAND LT 73120 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12300846 HAND BILAT 73120 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12300853 HIP LT 73510 972 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4200 Radiology Professional Fee 12300861 HIP BILAT 73510 972 140 98 30.44 140 71.32 30.44 105 30.44 71.32 71.32 71.32 71.32 30.44 33.484 30.44 30.44 30.44 30.44 31.048800000000004 30.44 4200 Radiology Professional Fee 12300879 HUMERUS LT 73060 972 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4200 Radiology Professional Fee 12300887 HUMERUS BILAT 73060 972 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4200 Radiology Professional Fee 12300895 KNEE LT 73560 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12300903 KNEE BILAT 73560 972 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4200 Radiology Professional Fee 12300911 LOWER LEG (TIBIA & FIBULA) LT 73590 972 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4200 Radiology Professional Fee 12300929 LOWER LEG (TIB/FIB) BILAT 73590 972 127 88.89999999999999 27.61 127 64.69 27.61 95.25 27.61 64.69 64.69 64.69 64.69 27.61 30.371000000000002 27.61 27.61 27.61 27.61 28.1622 27.61 4200 Radiology Professional Fee 12300937 RIBS LT 71101 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12300945 RIBS BILAT 71101 972 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4200 Radiology Professional Fee 12300952 SHOULDER MIN 2 VIEWS LT 73030 972 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4200 Radiology Professional Fee 12300960 SHOULDER MIN 2 VIEWS EACH BLT 73030 972 124 86.8 26.96 124 63.17 26.96 93 26.96 63.17 63.17 63.17 63.17 26.96 29.656000000000002 26.96 26.96 26.96 26.96 27.499200000000002 26.96 4200 Radiology Professional Fee 12300978 C-SPINE 72040 972 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4200 Radiology Professional Fee 12300986 L-SPINE 72100 972 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4200 Radiology Professional Fee 12300994 T-SPINE 72070 972 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4200 Radiology Professional Fee 12301117 WRIST LT 73100 972 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4200 Radiology Professional Fee 12301158 FINGER(S) BILAT 73140 972 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4200 Radiology Professional Fee 12301166 TOE(S) LT 73660 972 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4200 Radiology Professional Fee 12301174 TOE(S) BILAT 73660 972 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4200 Radiology Professional Fee 12301257 WRIST BILAT 73100 972 109 76.3 23.7 109 55.52 23.7 81.75 23.7 55.52 55.52 55.52 55.52 23.7 26.07 23.7 23.7 23.7 23.7 24.174 23.7 4200 Radiology Professional Fee 12410025 BONE SCAN ( MULTIPLE AREAS) 73805 972 276 193.2 60 276 140.59 60 207 60 140.59 140.59 140.59 140.59 60 66 60 60 60 60 61.2 60 4200 Radiology Professional Fee 12410033 BONE SCAN LIMITED 78300 972 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4200 Radiology Professional Fee 12410041 LIVER/SPLEEN 78215 972 222 155.39999999999998 48.26 222 113.09 48.26 166.5 48.26 113.09 113.09 113.09 113.09 48.26 53.086000000000006 48.26 48.26 48.26 48.26 49.2252 48.26 4200 Radiology Professional Fee 12410058 HIDA SCAN 78226 972 269 188.29999999999998 58.48 269 137.03 58.48 201.75 58.48 137.03 137.03 137.03 137.03 58.48 64.328 58.48 58.48 58.48 58.48 59.6496 58.48 4200 Radiology Professional Fee 12410066 RENAL SCAN/FLOW 78707 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12410074 BOWEL IMAGING (EG. MECKELS) 78290 972 227 158.89999999999998 49.35 227 115.63 49.35 170.25 49.35 115.63 115.63 115.63 115.63 49.35 54.285000000000004 49.35 49.35 49.35 49.35 50.337 49.35 4200 Radiology Professional Fee 12410082 GI BLEED SCAN 78278 972 292 204.39999999999998 63.48 292 148.74 63.48 219 63.48 148.74 148.74 148.74 148.74 63.48 69.828 63.48 63.48 63.48 63.48 64.7496 63.48 4200 Radiology Professional Fee 12410090 PERFUSION LUNG SCAN 78580 972 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Professional Fee 12410173 THYROID SCAN 78010 972 127 88.89999999999999 27.61 127 64.69 27.61 95.25 27.61 64.69 64.69 64.69 64.69 27.61 30.371000000000002 27.61 27.61 27.61 27.61 28.1622 27.61 4200 Radiology Professional Fee 12410181 MYOCARDIAL INFARCT AVID 78466 972 206 144.2 44.78 206 104.94 44.78 154.5 44.78 104.94 104.94 104.94 104.94 44.78 49.258 44.78 44.78 44.78 44.78 45.6756 44.78 4200 Radiology Professional Fee 12410199 MYOCARDIAL SPECT STRESS/REST 78465 972 457 319.9 99.35 457 232.8 99.35 342.75 99.35 232.8 232.8 232.8 232.8 99.35 109.285 99.35 99.35 99.35 99.35 101.33699999999999 99.35 4200 Radiology Professional Fee 12410215 MUGA 78472 972 269 188.29999999999998 58.48 269 137.03 58.48 201.75 58.48 137.03 137.03 137.03 137.03 58.48 64.328 58.48 58.48 58.48 58.48 59.6496 58.48 4200 Radiology Professional Fee 12410231 MYOCARDIAL SPECT REST OR STRES 78464 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12410306 BONE SCAN WHOLEBODY 78306 972 276 193.2 60 276 140.59 60 207 60 140.59 140.59 140.59 140.59 60 66 60 60 60 60 61.2 60 4200 Radiology Professional Fee 12410355 BONE SCAN 3 PHASE 78315 972 316 221.2 68.7 316 160.97 68.7 237 68.7 160.97 160.97 160.97 160.97 68.7 75.57000000000001 68.7 68.7 68.7 68.7 70.074 68.7 4200 Radiology Professional Fee 12410405 BONE SPECT 78320 972 347 242.89999999999998 75.44 347 176.76 75.44 260.25 75.44 176.76 176.76 176.76 176.76 75.44 82.98400000000001 75.44 75.44 75.44 75.44 76.9488 75.44 4200 Radiology Professional Fee 12410454 BRAIN SCAN WITH FLOW 78606 972 206 144.2 44.78 206 104.94 44.78 154.5 44.78 104.94 104.94 104.94 104.94 44.78 49.258 44.78 44.78 44.78 44.78 45.6756 44.78 4200 Radiology Professional Fee 12410504 BRAIN SCAN/SPECT 78607 972 410 287 89.13 410 208.85 89.13 307.5 89.13 208.85 208.85 208.85 208.85 89.13 98.043 89.13 89.13 89.13 89.13 90.9126 89.13 4200 Radiology Professional Fee 12410553 RENAL SCAN W/PHARMACY 78709 972 363 254.1 78.92 363 184.91 78.92 272.25 78.92 184.91 184.91 184.91 184.91 78.92 86.81200000000001 78.92 78.92 78.92 78.92 80.4984 78.92 4200 Radiology Professional Fee 12410603 TESTICULAR SCAN/FLOW 78761 972 229 160.29999999999998 49.78 229 116.65 49.78 171.75 49.78 116.65 116.65 116.65 116.65 49.78 54.758 49.78 49.78 49.78 49.78 50.775600000000004 49.78 4200 Radiology Professional Fee 12410652 GALLIUM SCAN/TUMOR 78802 972 316 221.2 68.7 316 160.97 68.7 237 68.7 160.97 160.97 160.97 160.97 68.7 75.57000000000001 68.7 68.7 68.7 68.7 70.074 68.7 4200 Radiology Professional Fee 12410702 HMPAO/LABEL WHITE CELL SCAN 78806 972 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4200 Radiology Professional Fee 12410751 THYROID SCAN/UPTAKE 78007 972 175 122.49999999999999 38.05 175 89.15 38.05 131.25 38.05 89.15 89.15 89.15 89.15 38.05 41.855 38.05 38.05 38.05 38.05 38.811 38.05 4200 Radiology Professional Fee 12410801 PARATHYROID SCAN 78070 972 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4200 Radiology Professional Fee 12411209 THYROID SCAN/I131 (1-6MCI) 78007 972 175 122.49999999999999 38.05 175 89.15 38.05 131.25 38.05 89.15 89.15 89.15 89.15 38.05 41.855 38.05 38.05 38.05 38.05 38.811 38.05 4200 Radiology Professional Fee 12411212 THYROID SCAN - I123 CAP 78007 972 175 122.49999999999999 38.05 175 89.15 38.05 131.25 38.05 89.15 89.15 89.15 89.15 38.05 41.855 38.05 38.05 38.05 38.05 38.811 38.05 4200 Radiology Professional Fee 12411214 THYROID SCAN-I131 2SUCI-1MCI) 78007 972 175 122.49999999999999 38.05 175 89.15 38.05 131.25 38.05 89.15 89.15 89.15 89.15 38.05 41.855 38.05 38.05 38.05 38.05 38.811 38.05 4200 Radiology Professional Fee 12411216 RENAL SCAN MAG3 78709 972 363 254.1 78.92 363 184.91 78.92 272.25 78.92 184.91 184.91 184.91 184.91 78.92 86.81200000000001 78.92 78.92 78.92 78.92 80.4984 78.92 4200 Radiology Professional Fee 12411684 VENTILATION SCAN 78579 972 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4200 Radiology Professional Fee 12411809 SCINTIMAMMOGRAPHY 78800 972 174 121.8 37.83 174 88.64 37.83 130.5 37.83 88.64 88.64 88.64 88.64 37.83 41.613 37.83 37.83 37.83 37.83 38.5866 37.83 4200 Radiology Professional Fee 12412005 THYROID UPTAKE 78001 972 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4200 Radiology Professional Fee 12415495 MUGA FIRST PASS 78496 972 170 118.99999999999999 36.96 170 86.6 36.96 127.5 36.96 86.6 86.6 86.6 86.6 36.96 40.656000000000006 36.96 36.96 36.96 36.96 37.699200000000005 36.96 4200 Radiology Professional Fee 12418507 MYOCARDIAL WALL MOTION 78478 972 207 144.89999999999998 45 207 105.45 45 155.25 45 105.45 105.45 105.45 105.45 45 49.50000000000001 45 45 45 45 45.9 45 4200 Radiology Professional Fee 12419000 MYOCARDIAL EJECTION FRACTION 78480 972 207 144.89999999999998 45 207 105.45 45 155.25 45 105.45 105.45 105.45 105.45 45 49.50000000000001 45 45 45 45 45.9 45 4200 Radiology Professional Fee 12419001 GASTRIC EMPTYING 78264 972 237 165.89999999999998 51.52 237 120.73 51.52 177.75 51.52 120.73 120.73 120.73 120.73 51.52 56.67200000000001 51.52 51.52 51.52 51.52 52.5504 51.52 4200 Radiology Professional Fee 12610020 LIMITED SINGLE ORGAN (EG. GB) 76705 972 173 121.1 37.61 173 88.13 37.61 129.75 37.61 88.13 88.13 88.13 88.13 37.61 41.371 37.61 37.61 37.61 37.61 38.3622 37.61 4200 Radiology Professional Fee 12610061 RETROPERITONEAL (EG. RENAL 76770 972 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4200 Radiology Professional Fee 12610079 ABDOM AORTA, DUPLEX COMPLETE 93978 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12610111 UPPER ABD(GB,LVR,PANCR,CBD) 76700 972 237 165.89999999999998 51.52 237 120.73 51.52 177.75 51.52 120.73 120.73 120.73 120.73 51.52 56.67200000000001 51.52 51.52 51.52 51.52 52.5504 51.52 4200 Radiology Professional Fee 12610145 FETAL FOLLOW-UP 76816 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12610152 PELVIC 76856 972 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4200 Radiology Professional Fee 12610160 COMPLETE FETAL STUDY 76805 972 294 205.79999999999998 63.92 294 149.76 63.92 220.5 63.92 149.76 149.76 149.76 149.76 63.92 70.31200000000001 63.92 63.92 63.92 63.92 65.1984 63.92 4200 Radiology Professional Fee 12610178 MULTIPLE FETUS > 1ST TRIMESTER 76810 972 450 315 97.83 450 229.23 97.83 337.5 97.83 229.23 229.23 229.23 229.23 97.83 107.61300000000001 97.83 97.83 97.83 97.83 99.7866 97.83 4200 Radiology Professional Fee 12610186 BIOPHYSICAL PROFILE/FETAL 76818 972 229 160.29999999999998 49.78 229 116.65 49.78 171.75 49.78 116.65 116.65 116.65 116.65 49.78 54.758 49.78 49.78 49.78 49.78 50.775600000000004 49.78 4200 Radiology Professional Fee 12610194 SOFT TISSUE OF HEAD AND NECK 76536 972 188 131.6 40.87 188 95.77 40.87 141 40.87 95.77 95.77 95.77 95.77 40.87 44.957 40.87 40.87 40.87 40.87 41.6874 40.87 4200 Radiology Professional Fee 12610202 SCROTUM AND CONTENTS 76870 972 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4200 Radiology Professional Fee 12610301 BREAST, BILAT OR UNILAT 76645 972 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4200 Radiology Professional Fee 12610400 VENOUS EXT RT 93791 972 229 160.29999999999998 49.78 229 116.65 49.78 171.75 49.78 116.65 116.65 116.65 116.65 49.78 54.758 49.78 49.78 49.78 49.78 50.775600000000004 49.78 4200 Radiology Professional Fee 12610418 VENOUS EXT LT 93970 972 229 160.29999999999998 49.78 229 116.65 49.78 171.75 49.78 116.65 116.65 116.65 116.65 49.78 54.758 49.78 49.78 49.78 49.78 50.775600000000004 49.78 4200 Radiology Professional Fee 12610426 LOWER ARTERIAL EXT RT 93926 972 140 98 30.44 140 71.32 30.44 105 30.44 71.32 71.32 71.32 71.32 30.44 33.484 30.44 30.44 30.44 30.44 31.048800000000004 30.44 4200 Radiology Professional Fee 12610434 LOWER ARTERIAL EXT LT 93926 972 140 98 30.44 140 71.32 30.44 105 30.44 71.32 71.32 71.32 71.32 30.44 33.484 30.44 30.44 30.44 30.44 31.048800000000004 30.44 4200 Radiology Professional Fee 12610442 UPPER ARTERIAL EXT RT 93931 972 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4200 Radiology Professional Fee 12610459 UPPER ARTERIAL EXT LT 93931 972 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4200 Radiology Professional Fee 12610475 NON VASCULAR EXT BILAT 76881 972 385 269.5 83.7 385 196.12 83.7 288.75 83.7 196.12 196.12 196.12 196.12 83.7 92.07000000000001 83.7 83.7 83.7 83.7 85.37400000000001 83.7 4200 Radiology Professional Fee 12610509 ECHO 2D, COMPLETE 93307 972 173 121.1 37.61 173 88.13 37.61 129.75 37.61 88.13 88.13 88.13 88.13 37.61 41.371 37.61 37.61 37.61 37.61 38.3622 37.61 4200 Radiology Professional Fee 12610566 NON VASCULAR EXT LT 76880 972 193 135.1 41.96 193 98.31 41.96 144.75 41.96 98.31 98.31 98.31 98.31 41.96 46.156000000000006 41.96 41.96 41.96 41.96 42.7992 41.96 4200 Radiology Professional Fee 12610608 CAROTIDS BI-LATERAL DUPLEX 93880 972 260 182 56.52 260 132.44 56.52 195 56.52 132.44 132.44 132.44 132.44 56.52 62.17200000000001 56.52 56.52 56.52 56.52 57.650400000000005 56.52 4200 Radiology Professional Fee 12610806 DOPPLER ECHO-PULSED/CONT WAVE 93320 972 173 121.1 37.61 173 88.13 37.61 129.75 37.61 88.13 88.13 88.13 88.13 37.61 41.371 37.61 37.61 37.61 37.61 38.3622 37.61 4200 Radiology Professional Fee 12610905 DOPPLER COLOR FLOW MAPPING 93325 972 225 157.5 48.92 225 114.62 48.92 168.75 48.92 114.62 114.62 114.62 114.62 48.92 53.812000000000005 48.92 48.92 48.92 48.92 49.8984 48.92 4200 Radiology Professional Fee 12611507 TRANSVAGINAL SONOGRAM 76830 972 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4200 Radiology Professional Fee 12611622 CHEST B SCAN 76604 972 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4200 Radiology Professional Fee 12614105 NEEDLE BIOPSY W/ US GUIDANCE 76942 972 200 140 43.48 200 101.88 43.48 150 43.48 101.88 101.88 101.88 101.88 43.48 47.828 43.48 43.48 43.48 43.48 44.349599999999995 43.48 4200 Radiology Professional Fee 12615003 LOWER ARTERIAL EXT BILATERAL 93925 972 278 194.6 60.44 278 141.61 60.44 208.5 60.44 141.61 141.61 141.61 141.61 60.44 66.48400000000001 60.44 60.44 60.44 60.44 61.6488 60.44 4200 Radiology Professional Fee 12615011 UPPER ARTERIAL EXT BILAT 93930 972 200 140 43.48 200 101.88 43.48 150 43.48 101.88 101.88 101.88 101.88 43.48 47.828 43.48 43.48 43.48 43.48 44.349599999999995 43.48 4200 Radiology Professional Fee 12615052 VENOUS EXT BILAT 93970 972 457 319.9 99.35 457 232.8 99.35 342.75 99.35 232.8 232.8 232.8 232.8 99.35 109.285 99.35 99.35 99.35 99.35 101.33699999999999 99.35 4200 Radiology Professional Fee 12616001 ULTRA SOUND GUIDENCE OF 76999 972 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4200 Radiology Professional Fee 12616076 NON VASCULAR EXT RT 76880 972 193 135.1 41.96 193 98.31 41.96 144.75 41.96 98.31 98.31 98.31 98.31 41.96 46.156000000000006 41.96 41.96 41.96 41.96 42.7992 41.96 4200 Radiology Professional Fee 12810000 CT ABDOMEN W & W/O 74170 972 450 315 97.83 450 229.23 97.83 337.5 97.83 229.23 229.23 229.23 229.23 97.83 107.61300000000001 97.83 97.83 97.83 97.83 99.7866 97.83 4200 Radiology Professional Fee 12810505 CT CHEST W & W/O 71270 972 419 293.29999999999995 91.09 419 213.44 91.09 314.25 91.09 213.44 213.44 213.44 213.44 91.09 100.19900000000001 91.09 91.09 91.09 91.09 92.9118 91.09 4200 Radiology Professional Fee 12811008 CT BRAIN W & W/O 70470 972 419 293.29999999999995 91.09 419 213.44 91.09 314.25 91.09 213.44 213.44 213.44 213.44 91.09 100.19900000000001 91.09 91.09 91.09 91.09 92.9118 91.09 4200 Radiology Professional Fee 12811016 CT LOWER EXT W/O CONTRAST LT 73700 972 347 242.89999999999998 75.44 347 176.76 75.44 260.25 75.44 176.76 176.76 176.76 176.76 75.44 82.98400000000001 75.44 75.44 75.44 75.44 76.9488 75.44 4200 Radiology Professional Fee 12811024 CT LOWER EXT W & W/O LEFT 73702 972 398 278.59999999999997 86.53 398 202.74 86.53 298.5 86.53 202.74 202.74 202.74 202.74 86.53 95.183 86.53 86.53 86.53 86.53 88.2606 86.53 4200 Radiology Professional Fee 12811032 CT LOWER EXT BILAT /WITH 73701 972 662 463.4 143.92 662 337.22 143.92 496.5 143.92 337.22 337.22 337.22 337.22 143.92 158.312 143.92 143.92 143.92 143.92 146.7984 143.92 4200 Radiology Professional Fee 12811040 CT LOWER EXT W/O CONTRAST BLT 73700 972 693 485.09999999999997 150.66 693 353.01 150.66 519.75 150.66 353.01 353.01 353.01 353.01 150.66 165.726 150.66 150.66 150.66 150.66 153.6732 150.66 4200 Radiology Professional Fee 12811065 CT UPPER EXT LEFT / WITH 73201 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12811073 CT UPPER EXT W/O CONTRAST LT 73200 972 347 242.89999999999998 75.44 347 176.76 75.44 260.25 75.44 176.76 176.76 176.76 176.76 75.44 82.98400000000001 75.44 75.44 75.44 75.44 76.9488 75.44 4200 Radiology Professional Fee 12811081 CT UPPER EXT W & W/O LEFT 73202 972 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4200 Radiology Professional Fee 12811099 CT UPPER EXT BILAT / WITH 73201 972 662 463.4 143.92 662 337.22 143.92 496.5 143.92 337.22 337.22 337.22 337.22 143.92 158.312 143.92 143.92 143.92 143.92 146.7984 143.92 4200 Radiology Professional Fee 12811107 CT UPPER EXT W/O CONTRAST BLT 73200 972 693 485.09999999999997 150.66 693 353.01 150.66 519.75 150.66 353.01 353.01 353.01 353.01 150.66 165.726 150.66 150.66 150.66 150.66 153.6732 150.66 4200 Radiology Professional Fee 12811115 CT UPPER EXT BILAT W & W/O 73202 972 772 540.4 167.83 772 393.26 167.83 579 167.83 393.26 393.26 393.26 393.26 167.83 184.61300000000003 167.83 167.83 167.83 167.83 171.18660000000003 167.83 4200 Radiology Professional Fee 12811123 CT LUMBAR / WITH 72132 972 371 259.7 80.66 371 188.99 80.66 278.25 80.66 188.99 188.99 188.99 188.99 80.66 88.726 80.66 80.66 80.66 80.66 82.2732 80.66 4200 Radiology Professional Fee 12811131 CT LUMBAR W & W/O 72133 972 410 287 89.13 410 208.85 89.13 307.5 89.13 208.85 208.85 208.85 208.85 89.13 98.043 89.13 89.13 89.13 89.13 90.9126 89.13 4200 Radiology Professional Fee 12811149 CT CERVICAL / WITH 72126 972 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4200 Radiology Professional Fee 12811503 CT C-SPINE W/O CONTRAST 72125 972 347 242.89999999999998 75.44 347 176.76 75.44 260.25 75.44 176.76 176.76 176.76 176.76 75.44 82.98400000000001 75.44 75.44 75.44 75.44 76.9488 75.44 4200 Radiology Professional Fee 12811507 CT LOWER EXT BILAT W & W/O 73702 972 794 555.8 172.62 794 404.46 172.62 595.5 172.62 404.46 404.46 404.46 404.46 172.62 189.88200000000003 172.62 172.62 172.62 172.62 176.07240000000002 172.62 4200 Radiology Professional Fee 12811511 CT PELVIS W & W/O 72194 972 363 254.1 78.92 363 184.91 78.92 272.25 78.92 184.91 184.91 184.91 184.91 78.92 86.81200000000001 78.92 78.92 78.92 78.92 80.4984 78.92 4200 Radiology Professional Fee 12811529 ABDOMEN CT - W/O CONTRAST 74150 972 363 254.1 78.92 363 184.91 78.92 272.25 78.92 184.91 184.91 184.91 184.91 78.92 86.81200000000001 78.92 78.92 78.92 78.92 80.4984 78.92 4200 Radiology Professional Fee 12811537 CT ABDOMEN WITH 74160 972 394 275.79999999999995 85.66 394 200.7 85.66 295.5 85.66 200.7 200.7 200.7 200.7 85.66 94.226 85.66 85.66 85.66 85.66 87.3732 85.66 4200 Radiology Professional Fee 12811545 CT CHEST W/O CONTRAST 71250 972 347 242.89999999999998 75.44 347 176.76 75.44 260.25 75.44 176.76 176.76 176.76 176.76 75.44 82.98400000000001 75.44 75.44 75.44 75.44 76.9488 75.44 4200 Radiology Professional Fee 12811552 CT CHEST / WITH 71260 972 363 254.1 78.92 363 184.91 78.92 272.25 78.92 184.91 184.91 184.91 184.91 78.92 86.81200000000001 78.92 78.92 78.92 78.92 80.4984 78.92 4200 Radiology Professional Fee 12811560 CT HEAD W/O CONTRAST 70450 972 316 221.2 68.7 316 160.97 68.7 237 68.7 160.97 160.97 160.97 160.97 68.7 75.57000000000001 68.7 68.7 68.7 68.7 70.074 68.7 4200 Radiology Professional Fee 12811578 CT BRAIN / WITH 70460 972 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4200 Radiology Professional Fee 12811602 CT PELVIS W/O CONTRAST 72192 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12811610 CT PELVIS / WITH 72193 972 338 236.6 73.48 338 172.18 73.48 253.5 73.48 172.18 172.18 172.18 172.18 73.48 80.82800000000002 73.48 73.48 73.48 73.48 74.9496 73.48 4200 Radiology Professional Fee 12811628 CT THORACIC SPINE W/O CONTRAST 72128 972 363 254.1 78.92 363 184.91 78.92 272.25 78.92 184.91 184.91 184.91 184.91 78.92 86.81200000000001 78.92 78.92 78.92 78.92 80.4984 78.92 4200 Radiology Professional Fee 12811636 CT L-SPINE W/O CONTRAST 72131 972 363 254.1 78.92 363 184.91 78.92 272.25 78.92 184.91 184.91 184.91 184.91 78.92 86.81200000000001 78.92 78.92 78.92 78.92 80.4984 78.92 4200 Radiology Professional Fee 12811651 CT W/O SINUSES/FACIAL 70486 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12811655 CT W SINUSES/FACIAL 70487 972 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4200 Radiology Professional Fee 12811659 CT W & W/O SINUSES/FACIAL 70488 972 419 293.29999999999995 91.09 419 213.44 91.09 314.25 91.09 213.44 213.44 213.44 213.44 91.09 100.19900000000001 91.09 91.09 91.09 91.09 92.9118 91.09 4200 Radiology Professional Fee 12811701 CT NECK / WITH 70491 972 419 293.29999999999995 91.09 419 213.44 91.09 314.25 91.09 213.44 213.44 213.44 213.44 91.09 100.19900000000001 91.09 91.09 91.09 91.09 92.9118 91.09 4200 Radiology Professional Fee 12811719 CT NECK - W/O CONTRAST 70490 972 372 260.4 80.87 372 189.5 80.87 279 80.87 189.5 189.5 189.5 189.5 80.87 88.95700000000001 80.87 80.87 80.87 80.87 82.48740000000001 80.87 4200 Radiology Professional Fee 12811727 CT NECK W & W/O 70492 972 457 319.9 99.35 457 232.8 99.35 342.75 99.35 232.8 232.8 232.8 232.8 99.35 109.285 99.35 99.35 99.35 99.35 101.33699999999999 99.35 4200 Radiology Professional Fee 12815017 CT ORBITS/SELLA/DOST FOSSA/IAC 70480 972 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4200 Radiology Professional Fee 12815025 CT ORBITS/IAC/SELLA WITH 70481 972 419 293.29999999999995 91.09 419 213.44 91.09 314.25 91.09 213.44 213.44 213.44 213.44 91.09 100.19900000000001 91.09 91.09 91.09 91.09 92.9118 91.09 4200 Radiology Professional Fee 12815033 CT ORBITS/IAC/SELLA W & W/O 70482 972 450 315 97.83 450 229.23 97.83 337.5 97.83 229.23 229.23 229.23 229.23 97.83 107.61300000000001 97.83 97.83 97.83 97.83 99.7866 97.83 4200 Radiology Professional Fee 12815116 CT LOWER EXT W/O CONTRAST RT 73700 972 347 242.89999999999998 75.44 347 176.76 75.44 260.25 75.44 176.76 176.76 176.76 176.76 75.44 82.98400000000001 75.44 75.44 75.44 75.44 76.9488 75.44 4200 Radiology Professional Fee 12815124 CT RT LOWER EXT / WITH 73701 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12815132 CT LOWER EXT RT W & W/O 73702 972 398 278.59999999999997 86.53 398 202.74 86.53 298.5 86.53 202.74 202.74 202.74 202.74 86.53 95.183 86.53 86.53 86.53 86.53 88.2606 86.53 4200 Radiology Professional Fee 12816015 CT UPPER EXT W/O CONTRAST RT 73200 972 347 242.89999999999998 75.44 347 176.76 75.44 260.25 75.44 176.76 176.76 176.76 176.76 75.44 82.98400000000001 75.44 75.44 75.44 75.44 76.9488 75.44 4200 Radiology Professional Fee 12816023 CT RT UPPER EXT /WITH 73201 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12816031 CT UPPER EXT RT W & W/O 73202 972 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4200 Radiology Professional Fee 12816510 CTA CHEST 71275 972 621 434.7 135.01 621 316.34 135.01 465.75 135.01 316.34 316.34 316.34 316.34 135.01 148.511 135.01 135.01 135.01 135.01 137.7102 135.01 4200 Radiology Professional Fee 12819506 CT CERVICAL W & W/O 72127 972 418 292.59999999999997 90.87 418 212.93 90.87 313.5 90.87 212.93 212.93 212.93 212.93 90.87 99.95700000000001 90.87 90.87 90.87 90.87 92.68740000000001 90.87 4200 Radiology Professional Fee 12819514 CT LT LOWER EXT / WITH 73701 972 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4200 Radiology Professional Fee 12821501 CT GUIDANCE FOR NEEDLE BIOPSY 77012 972 336 235.2 73.05 336 171.16 73.05 252 73.05 171.16 171.16 171.16 171.16 73.05 80.355 73.05 73.05 73.05 73.05 74.511 73.05 4200 Radiology Professional Fee 12850014 CTA UPPER EXT LEFT 73206 972 588 411.59999999999997 127.83 588 299.53 127.83 441 127.83 299.53 299.53 299.53 299.53 127.83 140.613 127.83 127.83 127.83 127.83 130.3866 127.83 4200 Radiology Professional Fee 12850022 CTA UPPER EXT RT 73206 972 588 411.59999999999997 127.83 588 299.53 127.83 441 127.83 299.53 299.53 299.53 299.53 127.83 140.613 127.83 127.83 127.83 127.83 130.3866 127.83 4200 Radiology Professional Fee 12850030 CTA - BILAT UPPER EXT 73206 972 1175 822.5 255.45 1175 598.55 255.45 881.25 255.45 598.55 598.55 598.55 598.55 255.45 280.995 255.45 255.45 255.45 255.45 260.55899999999997 255.45 4200 Radiology Professional Fee 12850048 CTA LOWER EXT LEFT 73706 972 617 431.9 134.14 617 314.3 134.14 462.75 134.14 314.3 314.3 314.3 314.3 134.14 147.554 134.14 134.14 134.14 134.14 136.8228 134.14 4200 Radiology Professional Fee 12850055 CTA LOWER EXT RT 73706 972 617 431.9 134.14 617 314.3 134.14 462.75 134.14 314.3 314.3 314.3 314.3 134.14 147.554 134.14 134.14 134.14 134.14 136.8228 134.14 4200 Radiology Professional Fee 12850063 CTA - BILAT LOWER EXT 73706 972 1232 862.4 267.84 1232 627.58 267.84 924 267.84 627.58 627.58 627.58 627.58 267.84 294.624 267.84 267.84 267.84 267.84 273.1968 267.84 4200 Radiology Professional Fee 12850071 CTA ABDOMEN 74175 972 617 431.9 134.14 617 314.3 134.14 462.75 134.14 314.3 314.3 314.3 314.3 134.14 147.554 134.14 134.14 134.14 134.14 136.8228 134.14 4200 Radiology Professional Fee 12850089 INTRO OF CATH FOR DRAINAGE $ O 74475 972 159 111.3 34.57 159 80.99 34.57 119.25 34.57 80.99 80.99 80.99 80.99 34.57 38.027 34.57 34.57 34.57 34.57 35.2614 34.57 4200 Radiology Professional Fee 12850097 URETERAL CATH FOR DRAINAGE &/O 74480 972 168 117.6 36.52 168 85.58 36.52 126 36.52 85.58 85.58 85.58 85.58 36.52 40.172000000000004 36.52 36.52 36.52 36.52 37.250400000000006 36.52 4200 Radiology Professional Fee 12850105 CTA BRAIN 70496 972 571 399.7 124.14 571 290.87 124.14 428.25 124.14 290.87 290.87 290.87 290.87 124.14 136.554 124.14 124.14 124.14 124.14 126.6228 124.14 4200 Radiology Professional Fee 12850113 CTA NECK 70498 972 571 399.7 124.14 571 290.87 124.14 428.25 124.14 290.87 290.87 290.87 290.87 124.14 136.554 124.14 124.14 124.14 124.14 126.6228 124.14 4200 Radiology Professional Fee 12850139 CTA PELVIS 72191 972 588 411.59999999999997 127.83 588 299.53 127.83 441 127.83 299.53 299.53 299.53 299.53 127.83 140.613 127.83 127.83 127.83 127.83 130.3866 127.83 4200 Radiology Professional Fee 12850147 CTA AORTO-ILIO RUNNOFF 75635 972 782 547.4 170.01 782 398.35 170.01 586.5 170.01 398.35 398.35 398.35 398.35 170.01 187.011 170.01 170.01 170.01 170.01 173.4102 170.01 4200 Radiology Professional Fee 12900017 MRI ABDOMEN W/O CONTRAST 74181 972 489 342.29999999999995 106.31 489 249.1 106.31 366.75 106.31 249.1 249.1 249.1 249.1 106.31 116.94100000000002 106.31 106.31 106.31 106.31 108.4362 106.31 4200 Radiology Professional Fee 12900025 MRI LOWER EXT JT RT W/O 73721 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12900058 MRI CHEST WITH 71551 972 536 375.2 116.53 536 273.04 116.53 402 116.53 273.04 273.04 273.04 273.04 116.53 128.18300000000002 116.53 116.53 116.53 116.53 118.8606 116.53 4200 Radiology Professional Fee 12900066 MRI UPPER EXT JOINT W/O 73221 972 450 315 97.83 450 229.23 97.83 337.5 97.83 229.23 229.23 229.23 229.23 97.83 107.61300000000001 97.83 97.83 97.83 97.83 99.7866 97.83 4200 Radiology Professional Fee 12900074 MRI UPPER EXT W/O RT 73218 972 461 322.7 100.22 461 234.83 100.22 345.75 100.22 234.83 234.83 234.83 234.83 100.22 110.242 100.22 100.22 100.22 100.22 102.2244 100.22 4200 Radiology Professional Fee 12900082 MRI LOWER EXT W/O CONTRAST RT 73718 972 463 324.09999999999997 100.66 463 235.85 100.66 347.25 100.66 235.85 235.85 235.85 235.85 100.66 110.726 100.66 100.66 100.66 100.66 102.6732 100.66 4200 Radiology Professional Fee 12900090 MRI LOWER EXT W/O CONTRAST LT 73718 972 463 324.09999999999997 100.66 463 235.85 100.66 347.25 100.66 235.85 235.85 235.85 235.85 100.66 110.726 100.66 100.66 100.66 100.66 102.6732 100.66 4200 Radiology Professional Fee 12900108 MRI UPPER EXT W/O LEFT 73128 972 461 322.7 100.22 461 234.83 100.22 345.75 100.22 234.83 234.83 234.83 234.83 100.22 110.242 100.22 100.22 100.22 100.22 102.2244 100.22 4200 Radiology Professional Fee 12900116 MRI LOWER EXT JOINT 73721 972 945 661.5 205.44 945 481.38 205.44 708.75 205.44 481.38 481.38 481.38 481.38 205.44 225.984 205.44 205.44 205.44 205.44 209.5488 205.44 4200 Radiology Professional Fee 12900124 MRI LOWER EXT JOINT W/O 73721 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12900140 MRI ORBIT/FACE/NECK W/O 70540 972 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4200 Radiology Professional Fee 12900173 MRI PELVIS WITHOUT 72195 972 490 343 106.53 490 249.61 106.53 367.5 106.53 249.61 249.61 249.61 249.61 106.53 117.183 106.53 106.53 106.53 106.53 108.6606 106.53 4200 Radiology Professional Fee 12900207 MRI UPPER EXT JOINT W/O 73221 972 450 315 97.83 450 229.23 97.83 337.5 97.83 229.23 229.23 229.23 229.23 97.83 107.61300000000001 97.83 97.83 97.83 97.83 99.7866 97.83 4200 Radiology Professional Fee 12900223 MRI TMJ'S 70336 972 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4200 Radiology Professional Fee 12900231 MRI UPPER EXT JOINT W/O 70336 972 898 628.5999999999999 195.23 898 457.44 195.23 673.5 195.23 457.44 457.44 457.44 457.44 195.23 214.75300000000001 195.23 195.23 195.23 195.23 199.1346 195.23 4200 Radiology Professional Fee 12900249 MRI BRAIN W/O CONTRAST 70551 972 432 302.4 93.92 432 220.06 93.92 324 93.92 220.06 220.06 220.06 220.06 93.92 103.31200000000001 93.92 93.92 93.92 93.92 95.7984 93.92 4200 Radiology Professional Fee 12900256 MRI BRAIN W/CONTRAST 70552 972 552 386.4 120.01 552 281.19 120.01 414 120.01 281.19 281.19 281.19 281.19 120.01 132.01100000000002 120.01 120.01 120.01 120.01 122.4102 120.01 4200 Radiology Professional Fee 12900264 MRI BRAIN W & W/O CONTRAST 70553 972 687 480.9 149.35 687 349.96 149.35 515.25 149.35 349.96 349.96 349.96 349.96 149.35 164.285 149.35 149.35 149.35 149.35 152.337 149.35 4200 Radiology Professional Fee 12900272 MRI CERVICAL W/O CONTRAST 72141 972 464 324.79999999999995 100.87 464 236.36 100.87 348 100.87 236.36 236.36 236.36 236.36 100.87 110.95700000000001 100.87 100.87 100.87 100.87 102.8874 100.87 4200 Radiology Professional Fee 12900280 MRI CERVICAL W/CONTRAST 72142 972 590 413 128.27 590 300.55 128.27 442.5 128.27 300.55 300.55 300.55 300.55 128.27 141.09700000000004 128.27 128.27 128.27 128.27 130.83540000000002 128.27 4200 Radiology Professional Fee 12900298 MRI CERVICAL W & W/O CONTRAST 72156 972 757 529.9 164.57 757 385.62 164.57 567.75 164.57 385.62 385.62 385.62 385.62 164.57 181.02700000000002 164.57 164.57 164.57 164.57 167.8614 164.57 4200 Radiology Professional Fee 12900306 MRI THORACIC W/O CONTRAST 72146 972 489 342.29999999999995 106.31 489 249.1 106.31 366.75 106.31 249.1 249.1 249.1 249.1 106.31 116.94100000000002 106.31 106.31 106.31 106.31 108.4362 106.31 4200 Radiology Professional Fee 12900314 MRI THIORACIC W/ CONTRAST 72147 972 560 392 121.74 560 285.26 121.74 420 121.74 285.26 285.26 285.26 285.26 121.74 133.91400000000002 121.74 121.74 121.74 121.74 124.17479999999999 121.74 4200 Radiology Professional Fee 12900322 MRI THORACIC W & W/O CONTRAST 72157 972 757 529.9 164.57 757 385.62 164.57 567.75 164.57 385.62 385.62 385.62 385.62 164.57 181.02700000000002 164.57 164.57 164.57 164.57 167.8614 164.57 4200 Radiology Professional Fee 12900330 MRI LUMBAR W/O CONTRAST 72148 972 505 353.5 109.79 505 257.25 109.79 378.75 109.79 257.25 257.25 257.25 257.25 109.79 120.76900000000002 109.79 109.79 109.79 109.79 111.98580000000001 109.79 4200 Radiology Professional Fee 12900348 MRI LUMBAR W/ CONTRAST 72149 972 567 396.9 123.27 567 288.83 123.27 425.25 123.27 288.83 288.83 288.83 288.83 123.27 135.597 123.27 123.27 123.27 123.27 125.7354 123.27 4200 Radiology Professional Fee 12900355 MRI LUMBAR W & W/O CONTRAST 72158 972 709 496.29999999999995 154.14 709 361.16 154.14 531.75 154.14 361.16 361.16 361.16 361.16 154.14 169.554 154.14 154.14 154.14 154.14 157.22279999999998 154.14 4200 Radiology Professional Fee 12900389 MRI UPPER EXT W/O BILAT 73218 972 921 644.6999999999999 200.23 921 469.16 200.23 690.75 200.23 469.16 469.16 469.16 469.16 200.23 220.25300000000001 200.23 200.23 200.23 200.23 204.2346 200.23 4200 Radiology Professional Fee 12900397 MRA UPPER EXT W OR W/O RT 73225 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12900413 MRA UPPER EXT W OR W/O BILAT 73225 972 945 661.5 205.44 945 481.38 205.44 708.75 205.44 481.38 481.38 481.38 481.38 205.44 225.984 205.44 205.44 205.44 205.44 209.5488 205.44 4200 Radiology Professional Fee 12900454 MRA LOWER EXT RIGHT W OR W/O 73725 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12900462 MRA LOWER EXT LEFT W OR W/O 73725 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12900470 MRA LOWER EXT BILAT W OR W/O 73725 972 945 661.5 205.44 945 481.38 205.44 708.75 205.44 481.38 481.38 481.38 481.38 205.44 225.984 205.44 205.44 205.44 205.44 209.5488 205.44 4200 Radiology Professional Fee 12900538 MRA SPINE W OR W/O 72159 972 615 430.5 133.7 615 313.28 133.7 461.25 133.7 313.28 313.28 313.28 313.28 133.7 147.07 133.7 133.7 133.7 133.7 136.374 133.7 4200 Radiology Professional Fee 12900546 MRA HEAD W/O 70544 972 433 303.09999999999997 94.13 433 220.57 94.13 324.75 94.13 220.57 220.57 220.57 220.57 94.13 103.543 94.13 94.13 94.13 94.13 96.01259999999999 94.13 4200 Radiology Professional Fee 12900561 MRA NECK WITHOUT 70547 972 590 413 128.27 590 300.55 128.27 442.5 128.27 300.55 300.55 300.55 300.55 128.27 141.09700000000004 128.27 128.27 128.27 128.27 130.83540000000002 128.27 4200 Radiology Professional Fee 12900579 MRA PELVIS W OR W/O 72198 972 550 385 119.57 550 280.17 119.57 412.5 119.57 280.17 280.17 280.17 280.17 119.57 131.52700000000002 119.57 119.57 119.57 119.57 121.9614 119.57 4200 Radiology Professional Fee 12900645 MRA UPPER EXT W OR W/O LT 73225 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12905495 MRI CHEST W/O 71550 972 489 342.29999999999995 106.31 489 249.1 106.31 366.75 106.31 249.1 249.1 249.1 249.1 106.31 116.94100000000002 106.31 106.31 106.31 106.31 108.4362 106.31 4200 Radiology Professional Fee 12905990 MRI CHEST W & W/O 71552 972 615 430.5 133.7 615 313.28 133.7 461.25 133.7 313.28 313.28 313.28 313.28 133.7 147.07 133.7 133.7 133.7 133.7 136.374 133.7 4200 Radiology Professional Fee 12906402 MRI LOWER EXT W/O CONTRAST BLT 73718 972 923 646.0999999999999 200.66 923 470.18 200.66 692.25 200.66 470.18 470.18 470.18 470.18 200.66 220.72600000000003 200.66 200.66 200.66 200.66 204.6732 200.66 4200 Radiology Professional Fee 12906477 MRI LOWER EXT JOINT WITH AND 73723 972 1215 850.5 264.14 1215 618.92 264.14 911.25 264.14 618.92 618.92 618.92 618.92 264.14 290.55400000000003 264.14 264.14 264.14 264.14 269.4228 264.14 4200 Radiology Professional Fee 12906485 MRI LOWER EXT JOINT WITH AND 73723 972 608 425.59999999999997 132.18 608 309.72 132.18 456 132.18 309.72 309.72 309.72 309.72 132.18 145.39800000000002 132.18 132.18 132.18 132.18 134.8236 132.18 4200 Radiology Professional Fee 12906493 MRI LOWER EXT JOINT WITH AND 73723 972 608 425.59999999999997 132.18 608 309.72 132.18 456 132.18 309.72 309.72 309.72 309.72 132.18 145.39800000000002 132.18 132.18 132.18 132.18 134.8236 132.18 4200 Radiology Professional Fee 12906899 MRI ABDOMEN W & W/O 74183 972 636 445.2 138.27 636 323.98 138.27 477 138.27 323.98 323.98 323.98 323.98 138.27 152.09700000000004 138.27 138.27 138.27 138.27 141.0354 138.27 4200 Radiology Professional Fee 12908051 MRA NECK WITH 70548 972 590 413 128.27 590 300.55 128.27 442.5 128.27 300.55 300.55 300.55 300.55 128.27 141.09700000000004 128.27 128.27 128.27 128.27 130.83540000000002 128.27 4200 Radiology Professional Fee 12908069 MRA NECK W AND W/O 70549 972 615 430.5 133.7 615 313.28 133.7 461.25 133.7 313.28 313.28 313.28 313.28 133.7 147.07 133.7 133.7 133.7 133.7 136.374 133.7 4200 Radiology Professional Fee 12909117 MRI UPPER EXT JOINT W & 73223 972 589 412.29999999999995 128.05 589 300.04 128.05 441.75 128.05 300.04 300.04 300.04 300.04 128.05 140.85500000000002 128.05 128.05 128.05 128.05 130.61100000000002 128.05 4200 Radiology Professional Fee 12909323 MRI UPPER EXT W & W/O LEFT 73220 972 567 396.9 123.27 567 288.83 123.27 425.25 123.27 288.83 288.83 288.83 288.83 123.27 135.597 123.27 123.27 123.27 123.27 125.7354 123.27 4200 Radiology Professional Fee 12909331 MRI UPPER EXT JOINT W & W/O 73223 972 1178 824.5999999999999 256.1 1178 600.07 256.1 883.5 256.1 600.07 600.07 600.07 600.07 256.1 281.71000000000004 256.1 256.1 256.1 256.1 261.22200000000004 256.1 4200 Radiology Professional Fee 12909505 MRI LOWER EXT W & W/O BILAT 73720 972 1212 848.4 263.49 1212 617.39 263.49 909 263.49 617.39 617.39 617.39 617.39 263.49 289.83900000000006 263.49 263.49 263.49 263.49 268.75980000000004 263.49 4200 Radiology Professional Fee 12909513 MRI LOWER EXT WITH & W/O LEFT 73720 972 607 424.9 131.96 607 309.21 131.96 455.25 131.96 309.21 309.21 309.21 309.21 131.96 145.15600000000003 131.96 131.96 131.96 131.96 134.59920000000002 131.96 4200 Radiology Professional Fee 12909521 MRI LOWER EXT W & W/O RIGHT 73720 972 607 424.9 131.96 607 309.21 131.96 455.25 131.96 309.21 309.21 309.21 309.21 131.96 145.15600000000003 131.96 131.96 131.96 131.96 134.59920000000002 131.96 4200 Radiology Professional Fee 12909588 MRI UPPER EXT WITH & W/O BILAT 73220 972 1133 793.0999999999999 246.31 1133 577.15 246.31 849.75 246.31 577.15 577.15 577.15 577.15 246.31 270.94100000000003 246.31 246.31 246.31 246.31 251.2362 246.31 4200 Radiology Professional Fee 12909653 MRI ORBIT/FACE/NECK W & W/O 70543 972 607 424.9 131.96 607 309.21 131.96 455.25 131.96 309.21 309.21 309.21 309.21 131.96 145.15600000000003 131.96 131.96 131.96 131.96 134.59920000000002 131.96 4200 Radiology Professional Fee 12909703 MRI PELVIS W & W/O 72197 972 646 452.2 140.44 646 329.07 140.44 484.5 140.44 329.07 329.07 329.07 329.07 140.44 154.484 140.44 140.44 140.44 140.44 143.2488 140.44 4200 Radiology Professional Fee 12909711 MRI UPPER EXT JOINT W & 73223 972 589 412.29999999999995 128.05 589 300.04 128.05 441.75 128.05 300.04 300.04 300.04 300.04 128.05 140.85500000000002 128.05 128.05 128.05 128.05 130.61100000000002 128.05 4200 Radiology Professional Fee 12909794 MRI UPPER EXT W & W/O RT 73220 972 567 396.9 123.27 567 288.83 123.27 425.25 123.27 288.83 288.83 288.83 288.83 123.27 135.597 123.27 123.27 123.27 123.27 125.7354 123.27 4200 Radiology Professional Fee 12910008 MRA ABDOMEN W OR W/O 74185 972 520 364 113.05 520 264.89 113.05 390 113.05 264.89 264.89 264.89 264.89 113.05 124.355 113.05 113.05 113.05 113.05 115.31099999999999 113.05 4200 Radiology Professional Fee 12911543 MRI PELVIS WITH DYE 72196 972 505 353.5 109.79 505 257.25 109.79 378.75 109.79 257.25 257.25 257.25 257.25 109.79 120.76900000000002 109.79 109.79 109.79 109.79 111.98580000000001 109.79 4200 Radiology Professional Fee 12912343 MRI JOINT UPPER EXT WITH 73222 972 945 661.5 205.44 945 481.38 205.44 708.75 205.44 481.38 481.38 481.38 481.38 205.44 225.984 205.44 205.44 205.44 205.44 209.5488 205.44 4200 Radiology Professional Fee 12914406 MRI JOINT LOWER EXT W/ BILAT 73722 972 1055 738.5 229.36 1055 537.42 229.36 791.25 229.36 537.42 537.42 537.42 537.42 229.36 252.29600000000005 229.36 229.36 229.36 229.36 233.9472 229.36 4200 Radiology Professional Fee 12914455 MRI ABDOMEN WITH DYE 74182 972 561 392.7 121.96 561 285.77 121.96 420.75 121.96 285.77 285.77 285.77 285.77 121.96 134.156 121.96 121.96 121.96 121.96 124.3992 121.96 4200 Radiology Professional Fee 12915502 MRA CHEST W OR W/O 71555 972 535 374.5 116.31 535 272.53 116.31 401.25 116.31 272.53 272.53 272.53 272.53 116.31 127.94100000000002 116.31 116.31 116.31 116.31 118.6362 116.31 4200 Radiology Professional Fee 12915544 MRI JOINT UPPER EXT WITH 73222 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12915643 MRI UPPER EXT WITH DYE RT 73219 972 528 369.59999999999997 114.79 528 268.96 114.79 396 114.79 268.96 268.96 268.96 268.96 114.79 126.26900000000002 114.79 114.79 114.79 114.79 117.0858 114.79 4200 Radiology Professional Fee 12915650 MRI UPPER EXT WITH DYE BILAT 73219 972 1053 737.0999999999999 228.92 1053 536.4 228.92 789.75 228.92 536.4 536.4 536.4 536.4 228.92 251.812 228.92 228.92 228.92 228.92 233.4984 228.92 4200 Radiology Professional Fee 12916609 MRI JOINT LOWER EXT WITH LEFT 73722 972 529 370.29999999999995 115 529 269.47 115 396.75 115 269.47 269.47 269.47 269.47 115 126.50000000000001 115 115 115 115 117.3 115 4200 Radiology Professional Fee 12916625 MRI JOINT UPPER EXT WITH 73222 972 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4200 Radiology Professional Fee 12917581 MRA HEAD WITH CONTRAST 70545 972 583 408.09999999999997 126.74 583 296.98 126.74 437.25 126.74 296.98 296.98 296.98 296.98 126.74 139.41400000000002 126.74 126.74 126.74 126.74 129.2748 126.74 4200 Radiology Professional Fee 12917706 MRI JOINT LOWER EXT WITH RT 73722 972 529 370.29999999999995 115 529 269.47 115 396.75 115 269.47 269.47 269.47 269.47 115 126.50000000000001 115 115 115 115 117.3 115 4200 Radiology Professional Fee 12918530 MRI UPPER EXT WITH DYE LT 73219 972 528 369.59999999999997 114.79 528 268.96 114.79 396 114.79 268.96 268.96 268.96 268.96 114.79 126.26900000000002 114.79 114.79 114.79 114.79 117.0858 114.79 4200 Radiology Professional Fee 12918795 MRA HEAD WITH & WITHOUT 70546 972 665 465.49999999999994 144.57 665 338.75 144.57 498.75 144.57 338.75 338.75 338.75 338.75 144.57 159.02700000000002 144.57 144.57 144.57 144.57 147.4614 144.57 4200 Radiology Professional Fee 12918796 PEDIATRIC CRANIAL ULTRASOUND 76506 972 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4200 Radiology Professional Fee 12918797 PEDIATRIC B/L HIP ULTRASOUND 76885 972 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4200 Radiology Professional Fee 12918799 OCTOBER CASH MAMMOGRAMS 74290 972 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4350 Hos Laboratory Facilty Fee 411 ACETYLCHOL REC MODOK AB 83591 302 245 171.5 53.26 245 124.8 53.26 183.75 53.26 124.8 124.8 124.8 124.8 53.26 58.586000000000006 53.26 53.26 53.26 53.26 54.3252 53.26 4350 Hos Laboratory Facilty Fee 4000 MOLECULAR EXTRACTION 83891 302 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4350 Hos Laboratory Facilty Fee 4001 MOLECULAR ENZ. DIGEST. 83892 302 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4350 Hos Laboratory Facilty Fee 4002 MOLECULAR SEPARATION 83894 302 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4350 Hos Laboratory Facilty Fee 4003 MOLECULAR AMPLIF. PCR 83898 302 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4350 Hos Laboratory Facilty Fee 4004 MOLECULAR INTERPRET. 83912 302 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4350 Hos Laboratory Facilty Fee 4005 PARVOVIRUS PANEL 86747 302 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4006 XYLOSE LEVEL 84620 301 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4008 ETHYLENE GLYCOL 82693 301 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4350 Hos Laboratory Facilty Fee 4009 C1-INHIBITOR 83520 301 137 95.89999999999999 29.78 137 69.79 29.78 102.75 29.78 69.79 69.79 69.79 69.79 29.78 32.758 29.78 29.78 29.78 29.78 30.375600000000002 29.78 4350 Hos Laboratory Facilty Fee 4010 VIP(VASOACTIVE INTEST POLYPEP) 84586 301 193 135.1 41.96 193 98.31 41.96 144.75 41.96 98.31 98.31 98.31 98.31 41.96 46.156000000000006 41.96 41.96 41.96 41.96 42.7992 41.96 4350 Hos Laboratory Facilty Fee 4011 MICROALBUMIN 82043 301 102 71.39999999999999 22.17 102 51.96 22.17 76.5 22.17 51.96 51.96 51.96 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 4350 Hos Laboratory Facilty Fee 4012 PHENOLPHTHALEIN,FECES 80299 300 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4013 DHEA 82626 301 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4014 METH MALONIC OR OTHER ORG. ACD 83921 301 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4015 REPEAT SALICYLATE 80196 300 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4016 REPEAT MANUAL DIFF 85007 305 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4017 FATTY ACID PROF. 82725 301 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4350 Hos Laboratory Facilty Fee 4018 METHADONE 83480 301 170 118.99999999999999 36.96 170 86.6 36.96 127.5 36.96 86.6 86.6 86.6 86.6 36.96 40.656000000000006 36.96 36.96 36.96 36.96 37.699200000000005 36.96 4350 Hos Laboratory Facilty Fee 4019 DILAUDID 82649 301 188 131.6 40.87 188 95.77 40.87 141 40.87 95.77 95.77 95.77 95.77 40.87 44.957 40.87 40.87 40.87 40.87 41.6874 40.87 4350 Hos Laboratory Facilty Fee 4020 T-3 (REVERSE) 84482 301 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4021 DIFFERENTIAL AUTOMATED 85004 305 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4350 Hos Laboratory Facilty Fee 4022 REPEAT DIFF. AUTO 85004 305 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4350 Hos Laboratory Facilty Fee 4023 CENTROMERE ABS 86038 302 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4350 Hos Laboratory Facilty Fee 4024 SULFATE, URINE 84392 301 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4350 Hos Laboratory Facilty Fee 4025 EHRLICHIA CHAF. AB 86666 302 314 219.79999999999998 68.26 314 159.95 68.26 235.5 68.26 159.95 159.95 159.95 159.95 68.26 75.08600000000001 68.26 68.26 68.26 68.26 69.6252 68.26 4350 Hos Laboratory Facilty Fee 4026 INS. LIKE GROWTH FACTOR I 84305 301 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4350 Hos Laboratory Facilty Fee 4027 STRIATED/SKELETAL MUSC. AB 86255 302 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4028 MISC. AB TITER 86256 302 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4029 RBC AUTOMATED 85041 305 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4030 HANDLING FEE - DNA TEST 99000 300 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4031 VAP TM CHOLEST 83701 301 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4032 CRP HI SENSITIV 86141 302 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4350 Hos Laboratory Facilty Fee 4034 IGG SUBCLASSES EACH 82787 301 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4350 Hos Laboratory Facilty Fee 4035 DOT DRUG SCREEN 80101 300 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4036 IDP 5 80100 300 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4350 Hos Laboratory Facilty Fee 4037 BENZODIAZEPINE 80154 300 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4039 TOBRAMYCIN PEAK 80200 300 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4040 PROTEIN TOTAL URINE 84156 301 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4041 PROTEIN TOTAL - BODY FLUID 84157 301 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4042 AMIKACIN - PEAK 80150 300 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4043 OCCULT BLOOD OTHER SOURCES 82271 301 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4044 CULTURE, RTN EACH ADDTL SITE 87070 306 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4045 SENS EA ADDT'L ISOLATION 87186 306 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4046 SENS, URINE EA ADDTL ISOLATION 87186 306 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4047 URINE ALCOHOL CHAIN OF CUSTODY 82055 301 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4048 IDP 5 INDUSTRIAL 80100 300 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4350 Hos Laboratory Facilty Fee 4049 NICOTINE 83887 301 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4050 BNP NATRIURETIC PEPTIDE 83880 301 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4350 Hos Laboratory Facilty Fee 4051 HEMOCULT, SCREENING 82270 301 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4350 Hos Laboratory Facilty Fee 4052 MAGNESIUM RBC 83735 301 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4053 AMITRIPTYLINE 80152 300 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4350 Hos Laboratory Facilty Fee 4054 CHLORIDE (NOT BLOOD OR URINE) 82438 301 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4055 SODIUM (NOT BLOOD OR URINE) 84302 301 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4056 UNLISTED CHEM PROCEDURE 84999 301 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4057 POTASSIUM (STOOL) 84999 301 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4058 OSMOLALITY (STOOL) 84999 301 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4059 TOPIRAMATE (TOPOMAX) 80201 300 103 72.1 22.39 103 52.47 22.39 77.25 22.39 52.47 52.47 52.47 52.47 22.39 24.629 22.39 22.39 22.39 22.39 22.8378 22.39 4350 Hos Laboratory Facilty Fee 4060 ELECROPHORESIS URINE/MISC FLD 84166 301 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4350 Hos Laboratory Facilty Fee 4061 IMMUNOFIXATION URINE 86335 302 168 117.6 36.52 168 85.58 36.52 126 36.52 85.58 85.58 85.58 85.58 36.52 40.172000000000004 36.52 36.52 36.52 36.52 37.250400000000006 36.52 4350 Hos Laboratory Facilty Fee 4062 COMPLEMENT LEVEL 4 86160 302 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4063 ASPERGILLUS FUMIGATUS 86606 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4065 BLASTOMYCES 86612 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4066 COCCIDIOIDES 86635 302 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4067 AMINO ACID, EACH, QUANT 82131 301 171 119.69999999999999 37.18 171 87.11 37.18 128.25 37.18 87.11 87.11 87.11 87.11 37.18 40.898 37.18 37.18 37.18 37.18 37.9236 37.18 4350 Hos Laboratory Facilty Fee 4068 INFLUENZA B SWAB WASH 87400 302 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4069 CRYPTOSPORIDIUM AG. 87272 306 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4070 CONCENTRATION OF STOOL 87015 306 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4350 Hos Laboratory Facilty Fee 4071 MUMPS IGM 86735 302 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4072 PCP (PHENCYCLIDINE) 83992 301 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4073 HERPES SIMPLEX VIRUS IGM 86694 302 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4074 LEVETIRACETAM (KEPRA) 80299 300 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4350 Hos Laboratory Facilty Fee 4075 VITAMIN B-1 84425 301 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4350 Hos Laboratory Facilty Fee 4076 BORDETELLA PER. IGG IGA OR IGM 86615 302 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4350 Hos Laboratory Facilty Fee 4077 TETANUS TITER POST 86774 302 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4078 PNEUMOCOCCAL AB TITER X6 86609 302 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4079 REPEAT BUN 84520 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4080 REPEAT CREATININE 82565 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4081 PSA FREE 84154 301 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4082 D-DIMER QUANT. 85379 305 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4083 PROTEIN C ANTIGEN 85302 305 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4084 PROTEIN S ANTIGEN 85305 305 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4085 NUCLEIC ACID ISOL/EXTRACT 83890 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4086 NUCLEIC ACID PROBE 83896 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4087 NUCLEIC ACID AMPLIF. MULTIPLEX 83901 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4088 NUCLEIC ACID MUTATION INTERP 83912 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4089 NUCLEIC ACID AMPLIF EACH SEQ 83898 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4090 REPEAT ALBUMIN 82040 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4091 REPEAT BLEEDING TIME 85002 305 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4092 REPEAT CALCIUM 82310 301 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4093 DEFINITIVE PATHOGEN ID 87077 306 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4094 GEL ELECTROPH. SEPAR EACH 83894 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4095 CLOTTING FACTOR IX 85250 305 169 118.3 36.74 169 86.09 36.74 126.75 36.74 86.09 86.09 86.09 86.09 36.74 40.41400000000001 36.74 36.74 36.74 36.74 37.4748 36.74 4350 Hos Laboratory Facilty Fee 4096 CLOTTING FACTOR XI 85270 305 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4097 CLOTTING FACTOR XII 85280 305 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4098 BETA 2 BLY PROT AB IGG, M A EC 86146 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4099 PHOSPHATIDYLSER. AB IGG IGM EA 86148 302 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4100 PROTHROMBIN ABS IGG, IGM EA 83520 301 193 135.1 41.96 193 98.31 41.96 144.75 41.96 98.31 98.31 98.31 98.31 41.96 46.156000000000006 41.96 41.96 41.96 41.96 42.7992 41.96 4350 Hos Laboratory Facilty Fee 4101 CHROMOSOME STUDY INTERP 88291 309 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4102 SMEAR FOR PARASITES 87207 306 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4103 CADMIUM 82300 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4104 COBALT 83018 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4105 THALLIUM 83018 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4106 REPEAT BNP 83880 301 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4350 Hos Laboratory Facilty Fee 4107 HYDROXYCARBAZ (TRILEPTAL) 80299 300 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4108 LSD SCREEN G0431 300 153 107.1 33.26 153 77.94 33.26 114.75 33.26 77.94 77.94 77.94 77.94 33.26 36.586 33.26 33.26 33.26 33.26 33.9252 33.26 4350 Hos Laboratory Facilty Fee 4109 FRUCTOSAMINE 82985 301 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4110 Antimusk antibody, quantitative by radioimmunoassay 83519 300 245 171.5 53.26 245 124.8 53.26 183.75 53.26 124.8 124.8 124.8 124.8 53.26 58.586000000000006 53.26 53.26 53.26 53.26 54.3252 53.26 4350 Hos Laboratory Facilty Fee 4112 OCCULT BLOOD FECES SINGLE SPEC 82272 301 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4114 NUCLEIC ACID AMPLIF 1ST 2 SEQ 83900 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4115 NUCLEIC ACID EXTRACT LYSIS 83907 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4116 R A QUANT 86431 302 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4117 OVA & PARASITE DIRECT SMEAR 87207 306 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4118 REPEAT CPK ISOENZYMES 82552 301 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4119 INHIBIN A 86336 302 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4350 Hos Laboratory Facilty Fee 4120 COMPLEMENT COMP C1Q 86160 302 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4121 GLUTAMIC ACD DECARBOX AB 83519 301 153 107.1 33.26 153 77.94 33.26 114.75 33.26 77.94 77.94 77.94 77.94 33.26 36.586 33.26 33.26 33.26 33.26 33.9252 33.26 4350 Hos Laboratory Facilty Fee 4122 BLOOD ALCOHOL LEGAL 82055 301 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4123 CHROMIUM, Urine or Plasma 82495 301 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4124 RAPAMYCIN/SIROLIMUS 80299 300 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4350 Hos Laboratory Facilty Fee 4125 LIPOPROTEIN A 83695 301 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4126 ACYLCARNITINE 82017 301 273 191.1 59.35 273 139.07 59.35 204.75 59.35 139.07 139.07 139.07 139.07 59.35 65.28500000000001 59.35 59.35 59.35 59.35 60.537 59.35 4350 Hos Laboratory Facilty Fee 4127 CARNITINE FRACT. 82379 301 289 202.29999999999998 62.83 289 147.22 62.83 216.75 62.83 147.22 147.22 147.22 147.22 62.83 69.113 62.83 62.83 62.83 62.83 64.0866 62.83 4350 Hos Laboratory Facilty Fee 4128 MUTATION ID SINGLE SEG 83914 301 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4350 Hos Laboratory Facilty Fee 4129 ADENOVIRUS, DIRECT IF 87260 306 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4130 CYCLIC CITRUL PEPTIDE 86200 302 179 125.3 38.91 179 91.18 38.91 134.25 38.91 91.18 91.18 91.18 91.18 38.91 42.801 38.91 38.91 38.91 38.91 39.688199999999995 38.91 4350 Hos Laboratory Facilty Fee 4131 HIV SCREEN: PCR 87535 306 248 173.6 53.92 248 126.33 53.92 186 53.92 126.33 126.33 126.33 126.33 53.92 59.312000000000005 53.92 53.92 53.92 53.92 54.998400000000004 53.92 4350 Hos Laboratory Facilty Fee 4132 MYCOPLASMA IGM 86738 302 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4133 ESTROGENS FRACTIONATED 82671 301 297 207.89999999999998 64.57 297 151.29 64.57 222.75 64.57 151.29 151.29 151.29 151.29 64.57 71.027 64.57 64.57 64.57 64.57 65.86139999999999 64.57 4350 Hos Laboratory Facilty Fee 4134 N-TELOPEPTIDE (NTX) 82523 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4135 JO-1 AB 86235 302 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4137 IGF BP3 83519 301 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4350 Hos Laboratory Facilty Fee 4138 IDP-7 80100 300 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4350 Hos Laboratory Facilty Fee 4139 CLOZAPINE/NORCLOZPINE 83789 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4140 WEST NILE AB (IGG) 86789 302 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4350 Hos Laboratory Facilty Fee 4141 WEST NILE AB (IGM) 86788 302 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4350 Hos Laboratory Facilty Fee 4142 VET CBC 85027 305 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4350 Hos Laboratory Facilty Fee 4143 VET CMP 80053 300 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4350 Hos Laboratory Facilty Fee 4144 VET AMY 82150 301 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4350 Hos Laboratory Facilty Fee 4145 VET BASIC 80048 300 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4350 Hos Laboratory Facilty Fee 4146 MOL EP HIGH RESOT TECH 83909 301 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4147 NOREPINEPHRINE 82383 301 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4148 INTRINSIC FACTOR BLK AB 86340 302 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4149 PARIETAL CELL AB 83516 301 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4150 PARIETAL CELL AB REFLX TITER 86255 302 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4151 AFB OR FLUROESCENT 87206 306 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4152 RICKETTSIA 86757 302 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4153 TYPHUS IGM RICKETTSIA 86757 302 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4154 BABESIA IGG 86753 302 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4155 BABESIA IGM 86753 302 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4156 RETICULIN AB 86255 302 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4157 BARTONELLA HENSLAE X2 86611 302 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4350 Hos Laboratory Facilty Fee 4159 PLATELET AB 86022 302 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4160 ACID FAST STAIN 87206 306 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4301 X-MATCH IMMED. SPIN 86920 305 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4302 SEX HORMONE BINDING GLOB 84270 301 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4303 VET PROTIME 85610 300 13 9.1 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 4350 Hos Laboratory Facilty Fee 4304 VET APTT 85730 300 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4350 Hos Laboratory Facilty Fee 4307 NOCARDIA RAST 86744 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4308 GEL DIFFUSION EA. AG. 86331 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4309 AMPHETAMINES (SER) 82145 301 196 137.2 42.61 196 99.84 42.61 147 42.61 99.84 99.84 99.84 99.84 42.61 46.871 42.61 42.61 42.61 42.61 43.4622 42.61 4350 Hos Laboratory Facilty Fee 4310 HYDROCODONE (SER) 82646 301 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4350 Hos Laboratory Facilty Fee 4311 REPEAT ALCOHOL (ETOH) 82055 301 123 86.1 26.74 123 62.66 26.74 92.25 26.74 62.66 62.66 62.66 62.66 26.74 29.414 26.74 26.74 26.74 26.74 27.2748 26.74 4350 Hos Laboratory Facilty Fee 4312 CANNABINOIDS, SERUM 82542 301 251 175.7 54.57 251 127.86 54.57 188.25 54.57 127.86 127.86 127.86 127.86 54.57 60.02700000000001 54.57 54.57 54.57 54.57 55.6614 54.57 4350 Hos Laboratory Facilty Fee 4313 FELBAMATE (FELBATOL) 80299 300 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4314 GLOMER. BASEMENT MEMB AB 83520 301 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4350 Hos Laboratory Facilty Fee 4316 FLOW CYTOM.FIRST MARKER 88184 300 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4350 Hos Laboratory Facilty Fee 4317 FLOW CYTOM. EACH ADDTL MARKER 88185 300 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4350 Hos Laboratory Facilty Fee 4318 FLOW CYTOM. INTERPRET 88187 300 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4350 Hos Laboratory Facilty Fee 4319 H.PYLORI 86677 306 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4350 Hos Laboratory Facilty Fee 4320 V. WILLEBR. AG.MULTI-MERIC ANA 85247 305 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4350 Hos Laboratory Facilty Fee 4321 BLASTOMYCES 86612 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4322 HEP BE AB 86707 302 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 4350 Hos Laboratory Facilty Fee 4323 HEP BE AG 87350 306 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 4350 Hos Laboratory Facilty Fee 4324 CHIP PANEL 84999 301 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4350 Hos Laboratory Facilty Fee 4325 DIPTHERIA AB 86648 302 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4350 Hos Laboratory Facilty Fee 4326 TRILEPTAL/OXCARBAZEPINE 83789 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4327 REPEAT GRAM STAIN 87205 306 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4328 DRUG SCREEN-INHOUSE RPT X9 G0431 300 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4350 Hos Laboratory Facilty Fee 4329 PRIMIDONE 80188 300 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4333 TRYPSIN, FECES, (QUANT.) 84490 301 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4334 CARISOPRODOL LEVEL 82492 301 113 79.1 24.57 113 57.56 24.57 84.75 24.57 57.56 57.56 57.56 57.56 24.57 27.027 24.57 24.57 24.57 24.57 25.0614 24.57 4350 Hos Laboratory Facilty Fee 4335 REPEAT PHENOBARB 80184 301 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4350 Hos Laboratory Facilty Fee 4336 XANAX (ALPRAZOLAM) 80154 301 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4350 Hos Laboratory Facilty Fee 4337 D-TEST (CLINDAMY INDUCT) 87184 306 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4350 Hos Laboratory Facilty Fee 4339 H. INFLU B AG 86403 302 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4340 H. INFLU B AB 86684 302 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4350 Hos Laboratory Facilty Fee 4341 VET LIPASE 83690 300 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4350 Hos Laboratory Facilty Fee 4342 PHOSPHOLIPID 86147 302 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4350 Hos Laboratory Facilty Fee 4343 REPEAT DRUG SCREEN G0431 300 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4350 Hos Laboratory Facilty Fee 4344 CHRONIC URTICARIAL AB 86343 302 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4350 Hos Laboratory Facilty Fee 4345 ROCKY MT IGM 86757 302 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4346 VARICELLA IGM 86787 302 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4347 EPST BARR VCA IGM 86665 302 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4348 ROCKY MT IGG 86757 302 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4349 VARICELLA IGG 86787 302 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4350 EPST BARR VCA IGG 86665 302 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4351 EPSTEIN-BARR EA (NCT IN PROF) 86663 302 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4352 EPSTEIN-BARR NA 86664 302 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4353 REPEAT VALPROIC 80164 300 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4350 Hos Laboratory Facilty Fee 4354 REPEAT D-DIMER 85378 305 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4350 Hos Laboratory Facilty Fee 4355 IMIPRAMINE 80174 300 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4350 Hos Laboratory Facilty Fee 4356 PERTUSSIS DNA PROBE 87798 306 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4350 Hos Laboratory Facilty Fee 4357 ISLET CELL AB 86341 302 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4358 NEPHELOMETRY EACH 83883 301 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4359 EPST BARR QUAL PCR 87798 306 407 284.9 88.48 407 207.33 88.48 305.25 88.48 207.33 207.33 207.33 207.33 88.48 97.32800000000002 88.48 88.48 88.48 88.48 90.2496 88.48 4350 Hos Laboratory Facilty Fee 4360 CATECHOLAMINES UR FRACT 82384 301 104 72.8 22.61 104 52.98 22.61 78 22.61 52.98 52.98 52.98 52.98 22.61 24.871000000000002 22.61 22.61 22.61 22.61 23.0622 22.61 4350 Hos Laboratory Facilty Fee 4361 MUTAT. ID/ENZ LIGAT. SINGLE SE 83914 302 11 7.699999999999999 2.39 11 5.6 2.39 8.25 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 4350 Hos Laboratory Facilty Fee 4362 ISOL/EXTR NUCL ACD EACH 83891 302 11 7.699999999999999 2.39 11 5.6 2.39 8.25 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 4350 Hos Laboratory Facilty Fee 4365 PREGNENOLONE 84140 301 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4350 Hos Laboratory Facilty Fee 4366 METANEPHRINES PLASMA 83835 301 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4350 Hos Laboratory Facilty Fee 4367 FLOW CYTOM MONON AG QUANT 86356 302 259 181.29999999999998 56.31 259 131.93 56.31 194.25 56.31 131.93 131.93 131.93 131.93 56.31 61.94100000000001 56.31 56.31 56.31 56.31 57.43620000000001 56.31 4350 Hos Laboratory Facilty Fee 4368 NATURAL KILLER CELLS TOTAL 86357 302 259 181.29999999999998 56.31 259 131.93 56.31 194.25 56.31 131.93 131.93 131.93 131.93 56.31 61.94100000000001 56.31 56.31 56.31 56.31 57.43620000000001 56.31 4350 Hos Laboratory Facilty Fee 4369 DRUG SCREEN-IN HOUSE G0431 300 174 121.8 37.83 174 88.64 37.83 130.5 37.83 88.64 88.64 88.64 88.64 37.83 41.613 37.83 37.83 37.83 37.83 38.5866 37.83 4350 Hos Laboratory Facilty Fee 4370 REPEAT DRUG SCREEN-IN HOUSE G0431 300 174 121.8 37.83 174 88.64 37.83 130.5 37.83 88.64 88.64 88.64 88.64 37.83 41.613 37.83 37.83 37.83 37.83 38.5866 37.83 4350 Hos Laboratory Facilty Fee 4371 PSA DIAGNOSTIC 84153 301 147 102.89999999999999 31.96 147 74.88 31.96 110.25 31.96 74.88 74.88 74.88 74.88 31.96 35.156000000000006 31.96 31.96 31.96 31.96 32.5992 31.96 4350 Hos Laboratory Facilty Fee 4372 BORDETELLA DNA/PCR 87798 302 296 207.2 64.35 296 150.78 64.35 222 64.35 150.78 150.78 150.78 150.78 64.35 70.785 64.35 64.35 64.35 64.35 65.637 64.35 4350 Hos Laboratory Facilty Fee 4373 PNEUMOCYSTIS CARIN STAIN 87281 306 113 79.1 24.57 113 57.56 24.57 84.75 24.57 57.56 57.56 57.56 57.56 24.57 27.027 24.57 24.57 24.57 24.57 25.0614 24.57 4350 Hos Laboratory Facilty Fee 4374 LIPOPAOT-ASSOC PHOSLIPASE 83700 301 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4350 Hos Laboratory Facilty Fee 4375 H. PYLORI STOOL 87338 302 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4350 Hos Laboratory Facilty Fee 4376 E COLI 0157 SHIGA TOX 87427 306 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4350 Hos Laboratory Facilty Fee 4377 THYROTROP RECEPT AB 83520 302 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4350 Hos Laboratory Facilty Fee 4378 MRSA SCREEN 87081 306 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4350 Hos Laboratory Facilty Fee 4379 REPEAT DRUG SCREEN IN HOUSE G0431 300 433 303.09999999999997 94.13 433 220.57 94.13 324.75 94.13 220.57 220.57 220.57 220.57 94.13 103.543 94.13 94.13 94.13 94.13 96.01259999999999 94.13 4350 Hos Laboratory Facilty Fee 4380 ALBUMIN OTHER FLUID 82042 301 141 98.69999999999999 30.65 141 71.83 30.65 105.75 30.65 71.83 71.83 71.83 71.83 30.65 33.715 30.65 30.65 30.65 30.65 31.262999999999998 30.65 4350 Hos Laboratory Facilty Fee 4381 LP-PLA2 83698 301 232 162.39999999999998 50.44 232 118.18 50.44 174 50.44 118.18 118.18 118.18 118.18 50.44 55.484 50.44 50.44 50.44 50.44 51.4488 50.44 4350 Hos Laboratory Facilty Fee 4382 CHLAM AB IGG 86631 302 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4350 Hos Laboratory Facilty Fee 4383 CHLAM AB IGM 86632 302 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4350 Hos Laboratory Facilty Fee 4384 GLUCOSE 2HR POST PRANDIAL 82947 301 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4385 LASA (SCIALIC ACID) 84275 301 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4350 Hos Laboratory Facilty Fee 4386 LIPO PROT PARTICLE STUDY 83704 301 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4350 Hos Laboratory Facilty Fee 4387 DOT/SLOT BLOT PROD/NVC ACID 83893 302 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4350 Hos Laboratory Facilty Fee 4388 LEUKOCYTE HISTAMINE RELEASE 86343 302 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4389 MYCOPHENOLIC ACID 82542 301 123 86.1 26.74 123 62.66 26.74 92.25 26.74 62.66 62.66 62.66 62.66 26.74 29.414 26.74 26.74 26.74 26.74 27.2748 26.74 4350 Hos Laboratory Facilty Fee 4391 SPUTUM CULTURE 87070 306 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4350 Hos Laboratory Facilty Fee 4394 WEST NILE VIRUS 86789 302 155 108.5 33.7 155 78.96 33.7 116.25 33.7 78.96 78.96 78.96 78.96 33.7 37.07000000000001 33.7 33.7 33.7 33.7 34.374 33.7 4350 Hos Laboratory Facilty Fee 4405 NEISSERIA PROBE 87591 306 185 129.5 40.22 185 94.24 40.22 138.75 40.22 94.24 94.24 94.24 94.24 40.22 44.242000000000004 40.22 40.22 40.22 40.22 41.0244 40.22 4350 Hos Laboratory Facilty Fee 4406 CLAM. TRACH PROBE 87491 306 185 129.5 40.22 185 94.24 40.22 138.75 40.22 94.24 94.24 94.24 94.24 40.22 44.242000000000004 40.22 40.22 40.22 40.22 41.0244 40.22 4350 Hos Laboratory Facilty Fee 4407 INTERLEUKIN 6 83520 302 450 315 97.83 450 229.23 97.83 337.5 97.83 229.23 229.23 229.23 229.23 97.83 107.61300000000001 97.83 97.83 97.83 97.83 99.7866 97.83 4350 Hos Laboratory Facilty Fee 4409 FECAL FAT QUANT 82710 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4410 VISCOSITY 85810 301 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4350 Hos Laboratory Facilty Fee 4411 LAB CORP VENIPUNTURE 36415 300 12 8.399999999999999 2.61 12 6.11 2.61 9 2.61 6.11 6.11 6.11 6.11 2.61 2.871 2.61 2.61 2.61 2.61 2.6622 2.61 4350 Hos Laboratory Facilty Fee 4412 Insulin Free 83527 301 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4418 ovysion, Bladder Cancer Fish 88120 301 1472 1030.3999999999999 320.01 1472 749.84 320.01 1104 320.01 749.84 749.84 749.84 749.84 320.01 352.011 320.01 320.01 320.01 320.01 326.4102 320.01 4350 Hos Laboratory Facilty Fee 4421 HBV PCR Quant 87517 301 367 256.9 79.79 367 186.95 79.79 275.25 79.79 186.95 186.95 186.95 186.95 79.79 87.76900000000002 79.79 79.79 79.79 79.79 81.3858 79.79 4350 Hos Laboratory Facilty Fee 4422 HBV PCR Super Quant 87517 301 367 256.9 79.79 367 186.95 79.79 275.25 79.79 186.95 186.95 186.95 186.95 79.79 87.76900000000002 79.79 79.79 79.79 79.79 81.3858 79.79 4350 Hos Laboratory Facilty Fee 40654 ASPERGILLUS FLAVUS 86606 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 2017358 HEMOCULT 82272 300 17 11.899999999999999 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 4350 Hos Laboratory Facilty Fee 4000030 RPR or VDRL 86592 300 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4350 Hos Laboratory Facilty Fee 4000048 MONO TEST 86403 300 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4350 Hos Laboratory Facilty Fee 4000055 PROTIME 85610 300 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4350 Hos Laboratory Facilty Fee 4000063 PTT 85730 300 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4000071 CK-MB 82553 300 155 108.5 33.7 155 78.96 33.7 116.25 33.7 78.96 78.96 78.96 78.96 33.7 37.07000000000001 33.7 33.7 33.7 33.7 34.374 33.7 4350 Hos Laboratory Facilty Fee 4000089 CREAT. CLEARANCE 82575 300 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4350 Hos Laboratory Facilty Fee 4000105 OCCULT BLOOD FECES 1-3 SPEC 82270 300 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4000121 ACID PHOSPHATASE, PROSTATIC 84066 301 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4000139 AFB CULTURE 87116 306 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4000147 ALCOHOL (ETHANOL) 82055 301 123 86.1 26.74 123 62.66 26.74 92.25 26.74 62.66 62.66 62.66 62.66 26.74 29.414 26.74 26.74 26.74 26.74 27.2748 26.74 4350 Hos Laboratory Facilty Fee 4000154 ANA-ANTINUCLEAR ANTIBODIES 86038 301 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4000170 ASO TITER 86060 302 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4000188 HEP. B SURF. AG. 87340 300 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4000196 VITAMIN B-12 CYANOCOBAL 82607 301 127 88.89999999999999 27.61 127 64.69 27.61 95.25 27.61 64.69 64.69 64.69 64.69 27.61 30.371000000000002 27.61 27.61 27.61 27.61 28.1622 27.61 4350 Hos Laboratory Facilty Fee 4000212 PREGNANCY TEST (SERUM) 81025 300 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4000246 COMPLEMENT LEVEL 3 86160 302 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4000261 KIDNEY STONE ANALYSIS 82365 301 103 72.1 22.39 103 52.47 22.39 77.25 22.39 52.47 52.47 52.47 52.47 22.39 24.629 22.39 22.39 22.39 22.39 22.8378 22.39 4350 Hos Laboratory Facilty Fee 4000279 CATECHOLAMINES (URINE) 82382 301 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4350 Hos Laboratory Facilty Fee 4000287 CEA 82378 301 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4350 Hos Laboratory Facilty Fee 4000295 COLD AGGLUTININ 86156 302 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4000329 CORTISOL AM 82533 301 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4000337 CRP INFLAM 86140 302 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4000360 DIGOXIN 80162 300 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4000378 DILANTIN 80185 300 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4000394 DRUG SCREEN COMP URINE X9 G0431 300 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4350 Hos Laboratory Facilty Fee 4000402 ELECTROPHORESIS (HGB) 83020 301 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4000410 ELECTROPHORESIS SERUM/PROTEIN 84165 301 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4350 Hos Laboratory Facilty Fee 4000428 ELECTROPHORESIS LIPID 83700 301 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4000436 FERRITIN 82728 301 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4000444 FOLATE SERUM 82746 301 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4350 Hos Laboratory Facilty Fee 4000451 TREPONEMA PALL, FTA ABS 86780 301 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4000469 GASTRIN 86780 300 171 119.69999999999999 37.18 171 87.11 37.18 128.25 37.18 87.11 87.11 87.11 87.11 37.18 40.898 37.18 37.18 37.18 37.18 37.9236 37.18 4350 Hos Laboratory Facilty Fee 4000477 HYDROXYINDOLACETIC ACID 5 83497 301 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4000485 HEPATITIS PANEL 80074 300 338 236.6 73.48 338 172.18 73.48 253.5 73.48 172.18 172.18 172.18 172.18 73.48 80.82800000000002 73.48 73.48 73.48 73.48 74.9496 73.48 4350 Hos Laboratory Facilty Fee 4000501 ARTHRITIS PANEL 80072 300 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4000527 LDH ISOENZ 83625 301 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4000535 LITHIUM 80178 300 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4000543 MAGNESIUM 83735 301 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4000550 METANEPHRINES URINE 83835 301 158 110.6 34.35 158 80.49 34.35 118.5 34.35 80.49 80.49 80.49 80.49 34.35 37.785000000000004 34.35 34.35 34.35 34.35 35.037 34.35 4350 Hos Laboratory Facilty Fee 4000568 OVA AND PARASITE 87177 306 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4000584 PROLACTIN 84146 301 163 114.1 35.44 163 83.03 35.44 122.25 35.44 83.03 83.03 83.03 83.03 35.44 38.984 35.44 35.44 35.44 35.44 36.1488 35.44 4350 Hos Laboratory Facilty Fee 4000592 RUBELLA TITER 86762 302 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4000600 SALICYLATE (ASPRIN) 80196 300 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4000618 SICKLE CELL 85660 305 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4000642 T-3 84480 301 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4000659 T-4 84436 301 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4000667 TSH 84443 301 134 93.8 29.13 134 68.26 29.13 100.5 29.13 68.26 68.26 68.26 68.26 29.13 32.043 29.13 29.13 29.13 29.13 29.7126 29.13 4350 Hos Laboratory Facilty Fee 4000675 T-3 FREE 84481 301 147 102.89999999999999 31.96 147 74.88 31.96 110.25 31.96 74.88 74.88 74.88 74.88 31.96 35.156000000000006 31.96 31.96 31.96 31.96 32.5992 31.96 4350 Hos Laboratory Facilty Fee 4000683 THEOPHYLLINE 80198 300 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4000709 URIC ACID CRYSTAL EXAM 89060 300 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4000717 VMA 84585 301 167 116.89999999999999 36.31 167 85.07 36.31 125.25 36.31 85.07 85.07 85.07 85.07 36.31 39.941 36.31 36.31 36.31 36.31 37.0362 36.31 4350 Hos Laboratory Facilty Fee 4000741 BODY FLUID: CELL CT and DIFF 89051 300 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4000758 BODY FLUID: GLUCOSE 82945 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4000824 AMYLASE (URINE) 82150 301 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4000857 HYDROXYCORTICOSTEROIDS, 17 83491 301 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4000865 KETOSTEROIDS, 17 TOTAL 83586 301 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4000873 LIPID PANEL 80061 300 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4350 Hos Laboratory Facilty Fee 4000899 TEGRETOL / CARBAMAZEPINE 80156 300 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4350 Hos Laboratory Facilty Fee 4000907 ACETAMINOPHEN (TYLENOL)325mg 82003 301 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4350 Hos Laboratory Facilty Fee 4000915 AMMONIA 82140 301 136 95.19999999999999 29.57 136 69.28 29.57 102 29.57 69.28 69.28 69.28 69.28 29.57 32.527 29.57 29.57 29.57 29.57 30.1614 29.57 4350 Hos Laboratory Facilty Fee 4000931 CREATININE (URINE) 82570 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4000949 FEBRILE AGGLUT X6 86000 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4000956 HEMOGLOBIN A1C 83036 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4000980 LEUKOCYTE, ALK. PHOS. 85540 305 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4001004 QUINIDINE 80194 300 123 86.1 26.74 123 62.66 26.74 92.25 26.74 62.66 62.66 62.66 62.66 26.74 29.414 26.74 26.74 26.74 26.74 27.2748 26.74 4350 Hos Laboratory Facilty Fee 4001012 RA LATEX 86430 302 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4350 Hos Laboratory Facilty Fee 4001020 TOBRAMYCIN - TROUGH OR RANDOM 80200 300 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4001038 TRANSFERRIN 84466 301 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4350 Hos Laboratory Facilty Fee 4001046 PHENOBARB 80184 300 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4350 Hos Laboratory Facilty Fee 4001053 CATECHOLAMINE PLASMA 82383 301 324 226.79999999999998 70.44 324 165.05 70.44 243 70.44 165.05 165.05 165.05 165.05 70.44 77.48400000000001 70.44 70.44 70.44 70.44 71.8488 70.44 4350 Hos Laboratory Facilty Fee 4001061 COMPLEMENT TOTAL (CH50) 86162 302 171 119.69999999999999 37.18 171 87.11 37.18 128.25 37.18 87.11 87.11 87.11 87.11 37.18 40.898 37.18 37.18 37.18 37.18 37.9236 37.18 4350 Hos Laboratory Facilty Fee 4001079 ADRENOCORTICOTROPH (ACTH) 82024 301 296 207.2 64.35 296 150.78 64.35 222 64.35 150.78 150.78 150.78 150.78 64.35 70.785 64.35 64.35 64.35 64.35 65.637 64.35 4350 Hos Laboratory Facilty Fee 4001087 LIPASE 83690 301 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4350 Hos Laboratory Facilty Fee 4001095 URINE NA 84300 301 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4001103 KOH PREP 87220 306 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4350 Hos Laboratory Facilty Fee 4001129 UREA (URINE) 84540 301 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4001137 C PEPTIDE 84681 301 145 101.5 31.52 145 73.86 31.52 108.75 31.52 73.86 73.86 73.86 73.86 31.52 34.672000000000004 31.52 31.52 31.52 31.52 32.1504 31.52 4350 Hos Laboratory Facilty Fee 4001145 IGE 82785 301 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4350 Hos Laboratory Facilty Fee 4001152 CMV 86644 302 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4001160 ANTI INSULIN ANTIBODY 86337 302 251 175.7 54.57 251 127.86 54.57 188.25 54.57 127.86 127.86 127.86 127.86 54.57 60.02700000000001 54.57 54.57 54.57 54.57 55.6614 54.57 4350 Hos Laboratory Facilty Fee 4001178 NUCLEOTIDASE 5 83915 301 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4001186 ALDOLASE 82085 301 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4001194 ALPHA (FETOPROTEIN) 82105 301 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4001202 GROWTH HORMONE 83003 301 158 110.6 34.35 158 80.49 34.35 118.5 34.35 80.49 80.49 80.49 80.49 34.35 37.785000000000004 34.35 34.35 34.35 34.35 35.037 34.35 4350 Hos Laboratory Facilty Fee 4001210 PTH 83970 301 319 223.29999999999998 69.35 319 162.5 69.35 239.25 69.35 162.5 162.5 162.5 162.5 69.35 76.285 69.35 69.35 69.35 69.35 70.737 69.35 4350 Hos Laboratory Facilty Fee 4001228 TESTOSTERONE TOTAL 84403 301 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4001236 RENIN 84244 301 199 139.29999999999998 43.26 199 101.37 43.26 149.25 43.26 101.37 101.37 101.37 101.37 43.26 47.586 43.26 43.26 43.26 43.26 44.1252 43.26 4350 Hos Laboratory Facilty Fee 4001244 OSMOLALITY (BLOOD) 83930 301 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4001251 GENTAMYCIN - TROUGH OR RANDOM 80170 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4001293 RAST ALLERGY EVAL-EACH ALLERGY 86003 302 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4350 Hos Laboratory Facilty Fee 4001327 MORE THAN 1-TRIP (NON-PATIENT) P9604 301 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4350 Hos Laboratory Facilty Fee 4001343 ALPHA 1 ANTITRYPSIN 82103 301 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4350 Hos Laboratory Facilty Fee 4001350 MYSOLINE 80188 300 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4350 Hos Laboratory Facilty Fee 4001400 MYCOPLASMA IGG 86738 302 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4001426 LUTEINIZING HORMONE 83002 301 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4001459 FSH 83001 301 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4350 Hos Laboratory Facilty Fee 4001467 HIV-1 AB. SCREEN 86703 302 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4001475 HIV-1 AB. CONFIRM WSTRN BLOT 86689 302 303 212.1 65.87 303 154.35 65.87 227.25 65.87 154.35 154.35 154.35 154.35 65.87 72.45700000000001 65.87 65.87 65.87 65.87 67.18740000000001 65.87 4350 Hos Laboratory Facilty Fee 4001525 IRON 83540 301 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4350 Hos Laboratory Facilty Fee 4001541 ALK PHOS ISOENZYMES 84080 301 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4350 Hos Laboratory Facilty Fee 4001574 Immunoglobulin A,D,G OR M EACH, Quantitative 82784 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4001582 ACETONE (KETONE) SERUM 82010 301 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4001608 FIBRINOGEN 85384 301 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4001632 PROCAINAMIDE 80190 300 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4350 Hos Laboratory Facilty Fee 4001640 SEMEN ANALYSIS 89331 300 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4001657 TRANSFUSION REACT. WORK-UP 86078 302 194 135.79999999999998 42.18 194 98.82 42.18 145.5 42.18 98.82 98.82 98.82 98.82 42.18 46.398 42.18 42.18 42.18 42.18 43.0236 42.18 4350 Hos Laboratory Facilty Fee 4001665 HCG QUANTITATIVE 84702 301 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4001673 UROBILINOGEN URINE 84578 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4001699 THERAPEUTIC PHLEBOTOMY 99195 301 163 114.1 35.44 163 83.03 35.44 122.25 35.44 83.03 83.03 83.03 83.03 35.44 38.984 35.44 35.44 35.44 35.44 36.1488 35.44 4350 Hos Laboratory Facilty Fee 4001707 VALPROIC ACID (DEPAKENE) 80164 300 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4350 Hos Laboratory Facilty Fee 4001715 ESTROGEN RECEPTOR 84233 301 457 319.9 99.35 457 232.8 99.35 342.75 99.35 232.8 232.8 232.8 232.8 99.35 109.285 99.35 99.35 99.35 99.35 101.33699999999999 99.35 4350 Hos Laboratory Facilty Fee 4001723 VASOPRESSIN 84588 301 378 264.59999999999997 82.18 378 192.55 82.18 283.5 82.18 192.55 192.55 192.55 192.55 82.18 90.39800000000001 82.18 82.18 82.18 82.18 83.82360000000001 82.18 4350 Hos Laboratory Facilty Fee 4001731 ALDOSTERONE (SERUM) 82088 301 203 142.1 44.13 203 103.41 44.13 152.25 44.13 103.41 103.41 103.41 103.41 44.13 48.543000000000006 44.13 44.13 44.13 44.13 45.012600000000006 44.13 4350 Hos Laboratory Facilty Fee 4001749 HDL 83718 301 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4001764 DRUG SCREEN COMP SERIM X6 G0431 300 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4350 Hos Laboratory Facilty Fee 4001772 HEP. A IGM VIRAL AB 86709 302 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4001780 HEP A VIRAL AB 86708 302 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4001798 HEP B CORE AB 86704 302 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4001806 HEP B SURFACE AB 86706 302 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4001814 MEASURE URINE VOLUME 81050 300 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4350 Hos Laboratory Facilty Fee 4001822 IDP 6 80100 300 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4001830 IDP 10 80100 300 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4350 Hos Laboratory Facilty Fee 4001848 IDP 10 w/ALCOHOL (EMS) 80100 300 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4350 Hos Laboratory Facilty Fee 4001913 LEAD 83655 301 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4001939 VITAMIN D (25-HYDROXY) 82036 301 269 188.29999999999998 58.48 269 137.03 58.48 201.75 58.48 137.03 137.03 137.03 137.03 58.48 64.328 58.48 58.48 58.48 58.48 59.6496 58.48 4350 Hos Laboratory Facilty Fee 4001947 VITAMIN D 25 HYDROXY 82306 300 230 161 50 230 117.16 50 172.5 50 117.16 117.16 117.16 117.16 50 55.00000000000001 50 50 50 50 51 50 4350 Hos Laboratory Facilty Fee 4001970 PSA TOTAL 84153 301 147 102.89999999999999 31.96 147 74.88 31.96 110.25 31.96 74.88 74.88 74.88 74.88 31.96 35.156000000000006 31.96 31.96 31.96 31.96 32.5992 31.96 4350 Hos Laboratory Facilty Fee 4001988 ATIVAN LEVEL 80299 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4001996 ERYTHROPOIETIN 82668 301 188 131.6 40.87 188 95.77 40.87 141 40.87 95.77 95.77 95.77 95.77 40.87 44.957 40.87 40.87 40.87 40.87 41.6874 40.87 4350 Hos Laboratory Facilty Fee 4002002 VENIPUNCTURE MC 36415 300 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4350 Hos Laboratory Facilty Fee 4002010 ESTRADIOL 82670 301 146 102.19999999999999 31.74 146 74.37 31.74 109.5 31.74 74.37 74.37 74.37 74.37 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 4350 Hos Laboratory Facilty Fee 4002028 DEOXYORTISOL II (COMPS) 82634 301 188 131.6 40.87 188 95.77 40.87 141 40.87 95.77 95.77 95.77 95.77 40.87 44.957 40.87 40.87 40.87 40.87 41.6874 40.87 4350 Hos Laboratory Facilty Fee 4002036 ROTAVIRUS 86759 302 123 86.1 26.74 123 62.66 26.74 92.25 26.74 62.66 62.66 62.66 62.66 26.74 29.414 26.74 26.74 26.74 26.74 27.2748 26.74 4350 Hos Laboratory Facilty Fee 4002044 TRICHINELLA TITER 86784 302 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4350 Hos Laboratory Facilty Fee 4002051 CLOSTRIDIUM TOXIN 87230 306 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4002069 HERPES CULTURE 87274 306 146 102.19999999999999 31.74 146 74.37 31.74 109.5 31.74 74.37 74.37 74.37 74.37 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 4350 Hos Laboratory Facilty Fee 4002085 LYME DISEASE 86618 302 151 105.69999999999999 32.83 151 76.92 32.83 113.25 32.83 76.92 76.92 76.92 76.92 32.83 36.113 32.83 32.83 32.83 32.83 33.486599999999996 32.83 4350 Hos Laboratory Facilty Fee 4002093 HERPES SIMPLEX I IGG 86695 302 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4350 Hos Laboratory Facilty Fee 4002127 BLEEDING TIME 85002 305 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4002135 THYROGLOBULIN AB 86800 302 151 105.69999999999999 32.83 151 76.92 32.83 113.25 32.83 76.92 76.92 76.92 76.92 32.83 36.113 32.83 32.83 32.83 32.83 33.486599999999996 32.83 4350 Hos Laboratory Facilty Fee 4002143 PROGESTERONE 84144 301 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4350 Hos Laboratory Facilty Fee 4002150 PCHE 82480 301 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4002168 INSULIN LEVEL 83525 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4002176 ZINC (SERUM) 84630 301 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4002184 URINE K+ 84133 301 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4350 Hos Laboratory Facilty Fee 4002192 T-4 FREE 84439 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4002200 EOSINOPHIL COUNT 85048 301 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4350 Hos Laboratory Facilty Fee 4002218 T-3 UPTAKE 84479 301 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4350 Hos Laboratory Facilty Fee 4002234 ESTROGEN 82672 301 147 102.89999999999999 31.96 147 74.88 31.96 110.25 31.96 74.88 74.88 74.88 74.88 31.96 35.156000000000006 31.96 31.96 31.96 31.96 32.5992 31.96 4350 Hos Laboratory Facilty Fee 4002242 LEGIONELLA TITER 86731 302 169 118.3 36.74 169 86.09 36.74 126.75 36.74 86.09 86.09 86.09 86.09 36.74 40.41400000000001 36.74 36.74 36.74 36.74 37.4748 36.74 4350 Hos Laboratory Facilty Fee 4002259 INFLUENZA A SWAB/WASH 87400 306 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4002267 URIC ACID OTHER SOURCE 84560 301 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4350 Hos Laboratory Facilty Fee 4002275 HELICOBACTER TITER (H PYLORI) 86677 301 173 121.1 37.61 173 88.13 37.61 129.75 37.61 88.13 88.13 88.13 88.13 37.61 41.371 37.61 37.61 37.61 37.61 38.3622 37.61 4350 Hos Laboratory Facilty Fee 4002283 HAPTOGLOBIN SERUM 83010 301 87 60.9 18.91 87 44.32 18.91 65.25 18.91 44.32 44.32 44.32 44.32 18.91 20.801000000000002 18.91 18.91 18.91 18.91 19.2882 18.91 4350 Hos Laboratory Facilty Fee 4002309 VANCOMYCIN - TROUGH OR RANDOM 80202 300 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4350 Hos Laboratory Facilty Fee 4002317 FIBRIN SPLIT PRODUCTS 85362 301 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4350 Hos Laboratory Facilty Fee 4002325 MEDICAL PROFESSIONAL PANEL 2 80100 300 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4350 Hos Laboratory Facilty Fee 4002333 CALCIUM (URINE) 82340 301 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4002341 PHOSPHORUS (URINE) 84105 300 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4002366 OXALATE (URINE) 83945 301 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4002382 PH FLUID 83986 301 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4350 Hos Laboratory Facilty Fee 4002408 BACTERIAL ANTIGEN PANEL X 5 86403 302 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4350 Hos Laboratory Facilty Fee 4002416 OSMOLALITY (URINE) 83935 301 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4350 Hos Laboratory Facilty Fee 4002465 IRON BINDING CAP. (TIBC) 83550 301 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4002507 ESTRIOL 82677 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4002515 CD4 and CD8 86360 302 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4350 Hos Laboratory Facilty Fee 4002572 ANTIBODY AGGLUT (EACH) 86403 302 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4350 Hos Laboratory Facilty Fee 4002598 VIRAL AB MISC IGG OR IGM EACH 86790 302 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4350 Hos Laboratory Facilty Fee 4002614 VITAMIN D 1.25 DIHYDROXY 82652 300 230 161 50 230 117.16 50 172.5 50 117.16 117.16 117.16 117.16 50 55.00000000000001 50 50 50 50 51 50 4350 Hos Laboratory Facilty Fee 4002630 FLOW CYTOM.CELL CYCLE/DNA ANAL 88182 311 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4350 Hos Laboratory Facilty Fee 4002648 CYCLOSPORINE 80158 300 189 132.29999999999998 41.09 189 96.28 41.09 141.75 41.09 96.28 96.28 96.28 96.28 41.09 45.199000000000005 41.09 41.09 41.09 41.09 41.91180000000001 41.09 4350 Hos Laboratory Facilty Fee 4002663 D-DIMER 85379 305 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4350 Hos Laboratory Facilty Fee 4002671 URINE CL 82436 311 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4350 Hos Laboratory Facilty Fee 4002689 TROPONIN 84484 301 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4350 Hos Laboratory Facilty Fee 4002705 THIAMINE (VITAMIN B1) 84425 301 199 139.29999999999998 43.26 199 101.37 43.26 149.25 43.26 101.37 101.37 101.37 101.37 43.26 47.586 43.26 43.26 43.26 43.26 44.1252 43.26 4350 Hos Laboratory Facilty Fee 4002721 AMIKACIN - TROUGH OR RANDOM 80150 300 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4002739 DRUG SCREEN-INHOUSE X9 G0431 300 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4350 Hos Laboratory Facilty Fee 4002747 LACTIC ACID (LACTATE) 83605 301 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4002754 HEP C AB 86803 301 185 129.5 40.22 185 94.24 40.22 138.75 40.22 94.24 94.24 94.24 94.24 40.22 44.242000000000004 40.22 40.22 40.22 40.22 41.0244 40.22 4350 Hos Laboratory Facilty Fee 4002796 IMMUNOFIXATION SERUM 86334 302 168 117.6 36.52 168 85.58 36.52 126 36.52 85.58 85.58 85.58 85.58 36.52 40.172000000000004 36.52 36.52 36.52 36.52 37.250400000000006 36.52 4350 Hos Laboratory Facilty Fee 4002804 HERPES SIMPLEX II IGG 86696 302 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4350 Hos Laboratory Facilty Fee 4002838 TSH RECEPTOR AB 84235 301 207 144.89999999999998 45 207 105.45 45 155.25 45 105.45 105.45 105.45 105.45 45 49.50000000000001 45 45 45 45 45.9 45 4350 Hos Laboratory Facilty Fee 4002846 DHEAS 82627 301 150 105 32.61 150 76.41 32.61 112.5 32.61 76.41 76.41 76.41 76.41 32.61 35.871 32.61 32.61 32.61 32.61 33.2622 32.61 4350 Hos Laboratory Facilty Fee 4002853 HYDROXYPROLINE 83505 301 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4002861 PROTEINASE-3 AB (C-ANCA, P-ANC 86021 302 182 127.39999999999999 39.57 182 92.71 39.57 136.5 39.57 92.71 92.71 92.71 92.71 39.57 43.527 39.57 39.57 39.57 39.57 40.3614 39.57 4350 Hos Laboratory Facilty Fee 4002887 DNA AB NATIVE/DOUBLE STRAND 86725 302 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4350 Hos Laboratory Facilty Fee 4002903 CALCIUM IONIZED 82330 301 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4002911 VITAMIN A 84590 301 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4002937 ACETYLCHOL.REC. BIND. AB 83519 301 245 171.5 53.26 245 124.8 53.26 183.75 53.26 124.8 124.8 124.8 124.8 53.26 58.586000000000006 53.26 53.26 53.26 53.26 54.3252 53.26 4350 Hos Laboratory Facilty Fee 4002945 GIARDIA AG, EIA 87329 306 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4002952 PTH RELATED PROTEIN 83519 301 398 278.59999999999997 86.53 398 202.74 86.53 298.5 86.53 202.74 202.74 202.74 202.74 86.53 95.183 86.53 86.53 86.53 86.53 88.2606 86.53 4350 Hos Laboratory Facilty Fee 4002960 HIV VIRAL LOAD 87536 306 646 452.2 140.44 646 329.07 140.44 484.5 140.44 329.07 329.07 329.07 329.07 140.44 154.484 140.44 140.44 140.44 140.44 143.2488 140.44 4350 Hos Laboratory Facilty Fee 4002978 BENZENE 82491 301 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4002986 AMINO ACID QUANT (UR) 83918 301 608 425.59999999999997 132.18 608 309.72 132.18 456 132.18 309.72 309.72 309.72 309.72 132.18 145.39800000000002 132.18 132.18 132.18 132.18 134.8236 132.18 4350 Hos Laboratory Facilty Fee 4003018 CD4 ABSOLUTE 86361 302 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4350 Hos Laboratory Facilty Fee 4003026 RBC;FOLATE 82747 301 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4003042 ANGIOTENSIN I, CONV ENZ, ACE 82164 301 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4003083 THYROXINE BINDING GLOB 84442 301 136 95.19999999999999 29.57 136 69.28 29.57 102 29.57 69.28 69.28 69.28 69.28 29.57 32.527 29.57 29.57 29.57 29.57 30.1614 29.57 4350 Hos Laboratory Facilty Fee 4003109 HYDROX-PROGEST-17 83498 301 187 130.9 40.65 187 95.26 40.65 140.25 40.65 95.26 95.26 95.26 95.26 40.65 44.715 40.65 40.65 40.65 40.65 41.463 40.65 4350 Hos Laboratory Facilty Fee 4003117 PROGRAPH-TACROLIMUS 80197 300 355 248.49999999999997 77.18 355 180.84 77.18 266.25 77.18 180.84 180.84 180.84 180.84 77.18 84.89800000000001 77.18 77.18 77.18 77.18 78.7236 77.18 4350 Hos Laboratory Facilty Fee 4003125 GABAPENTIN-NEURONTIN 80299 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4003141 MUMPS IGG 86735 302 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4003158 LAMOTRIGINE (LAMICTAL) 80299 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4003166 TOPIRAMATE 80201 300 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4003174 CA15-3 (27.29) 86300 302 168 117.6 36.52 168 85.58 36.52 126 36.52 85.58 85.58 85.58 85.58 36.52 40.172000000000004 36.52 36.52 36.52 36.52 37.250400000000006 36.52 4350 Hos Laboratory Facilty Fee 4003182 LEUCINE AMINOPEPTIBASE 83670 301 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4350 Hos Laboratory Facilty Fee 4003190 HOMOCYSTINE 83090 301 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4003216 APOLIPOPROTEIN (EACH) 82172 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4003224 IGF - 1 (SOMATOMEDIN) 84305 301 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4350 Hos Laboratory Facilty Fee 4003232 CRYOGLOBULIN 82595 301 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4350 Hos Laboratory Facilty Fee 4003240 GASTROCCULT 82271 301 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4350 Hos Laboratory Facilty Fee 4003257 CALCITONIN 82308 301 146 102.19999999999999 31.74 146 74.37 31.74 109.5 31.74 74.37 74.37 74.37 74.37 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 4350 Hos Laboratory Facilty Fee 4003265 THYROGLOBULIN 84432 301 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4003299 PROTEIN C ACTIVITY 85303 305 281 196.7 61.09 281 143.14 61.09 210.75 61.09 143.14 143.14 143.14 143.14 61.09 67.19900000000001 61.09 61.09 61.09 61.09 62.311800000000005 61.09 4350 Hos Laboratory Facilty Fee 4003307 PROTEIN S ACTIVITY 85306 300 281 196.7 61.09 281 143.14 61.09 210.75 61.09 143.14 143.14 143.14 143.14 61.09 67.19900000000001 61.09 61.09 61.09 61.09 62.311800000000005 61.09 4350 Hos Laboratory Facilty Fee 4003315 ANTI-THROMB III 85300 305 331 231.7 71.96 331 168.61 71.96 248.25 71.96 168.61 168.61 168.61 168.61 71.96 79.156 71.96 71.96 71.96 71.96 73.3992 71.96 4350 Hos Laboratory Facilty Fee 4003323 NORPACE 80299 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4003331 TESTOSTERONE FREE 84402 301 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4003349 CA-125 86304 302 168 117.6 36.52 168 85.58 36.52 126 36.52 85.58 85.58 85.58 85.58 36.52 40.172000000000004 36.52 36.52 36.52 36.52 37.250400000000006 36.52 4350 Hos Laboratory Facilty Fee 4003356 SERENTIL (PHENOTHIAZINE) 84022 301 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4003372 SJOGREN SSA 86235 302 182 127.39999999999999 39.57 182 92.71 39.57 136.5 39.57 92.71 92.71 92.71 92.71 39.57 43.527 39.57 39.57 39.57 39.57 40.3614 39.57 4350 Hos Laboratory Facilty Fee 4003380 SJOGRAN SSB 86235 302 228 159.6 49.57 228 116.14 49.57 171 49.57 116.14 116.14 116.14 116.14 49.57 54.52700000000001 49.57 49.57 49.57 49.57 50.5614 49.57 4350 Hos Laboratory Facilty Fee 4003398 SM ANTIBODY 86235 302 228 159.6 49.57 228 116.14 49.57 171 49.57 116.14 116.14 116.14 116.14 49.57 54.52700000000001 49.57 49.57 49.57 49.57 50.5614 49.57 4350 Hos Laboratory Facilty Fee 4003406 RNP OR OTHER EXTRACT NUC AG 86235 302 228 159.6 49.57 228 116.14 49.57 171 49.57 116.14 116.14 116.14 116.14 49.57 54.52700000000001 49.57 49.57 49.57 49.57 50.5614 49.57 4350 Hos Laboratory Facilty Fee 4003414 SMOOTH MUSCLE AB 86255 302 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4003422 SCLERODERMA AB SCL-70 86235 302 228 159.6 49.57 228 116.14 49.57 171 49.57 116.14 116.14 116.14 116.14 49.57 54.52700000000001 49.57 49.57 49.57 49.57 50.5614 49.57 4350 Hos Laboratory Facilty Fee 4003430 CERULOPLASMIN 82390 301 74 51.8 16.09 74 37.7 16.09 55.5 16.09 37.7 37.7 37.7 37.7 16.09 17.699 16.09 16.09 16.09 16.09 16.4118 16.09 4350 Hos Laboratory Facilty Fee 4003448 COPPER 82525 301 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4003455 ENCEPH CALIF 86651 302 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4003463 ENCEPH EAST EQ 86652 302 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4003471 ENCEPH ST. LOUIS 86653 302 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4003489 ENCEPH WEST EQ 86654 302 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4003497 VIRAL CULTURE 87252 306 380 266 82.61 380 193.57 82.61 285 82.61 193.57 193.57 193.57 193.57 82.61 90.87100000000001 82.61 82.61 82.61 82.61 84.2622 82.61 4350 Hos Laboratory Facilty Fee 4003505 IDP 10 WITH ALCOHOL 80100 300 188 131.6 40.87 188 95.77 40.87 141 40.87 95.77 95.77 95.77 95.77 40.87 44.957 40.87 40.87 40.87 40.87 41.6874 40.87 4350 Hos Laboratory Facilty Fee 4003539 CANDIDA ABS x2 86628 302 74 51.8 16.09 74 37.7 16.09 55.5 16.09 37.7 37.7 37.7 37.7 16.09 17.699 16.09 16.09 16.09 16.09 16.4118 16.09 4350 Hos Laboratory Facilty Fee 4003554 HLA B27 86812 302 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4350 Hos Laboratory Facilty Fee 4003562 ASPERGILLUS NIGER 86606 302 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4003588 CPK ISOENZYMES 82552 301 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4003612 PREALBUMIN 84134 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4003638 CARBOXYHEMOGLOBIN 82375 301 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4350 Hos Laboratory Facilty Fee 4003646 HEP DELTA VIRUS 86692 302 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4350 Hos Laboratory Facilty Fee 4003653 PORPHYRIN QUANT 84120 301 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4003661 PSA SCREENING/YRLY G0103 301 147 102.89999999999999 31.96 147 74.88 31.96 110.25 31.96 74.88 74.88 74.88 74.88 31.96 35.156000000000006 31.96 31.96 31.96 31.96 32.5992 31.96 4350 Hos Laboratory Facilty Fee 4003679 AMIODARONE 80299 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4003695 REPEAT CBC AUTO DIFF. 85025 305 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4350 Hos Laboratory Facilty Fee 4003703 REPEAT HEMATOCRIT 85014 305 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4350 Hos Laboratory Facilty Fee 4003711 REPEAT HEMOGLOBIN 85018 305 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4350 Hos Laboratory Facilty Fee 4003729 REPEAT WHITE BLOOD COUNT 85048 305 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4003737 REPEAT SODIUM 84295 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4003745 REPEAT POTASSIUM 84132 301 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4350 Hos Laboratory Facilty Fee 4003752 REPEAT GLUCOSE 82947 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4003778 REPEAT BASIC METABOLIC PANEL 80048 300 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4350 Hos Laboratory Facilty Fee 4003786 REPEAT VANCOMYCIN LEVEL 80202 300 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4350 Hos Laboratory Facilty Fee 4003794 REPEAT TROPONIN 84484 301 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4350 Hos Laboratory Facilty Fee 4003802 REPEAT STOOL FOR BLOOD 82270 301 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4350 Hos Laboratory Facilty Fee 4003810 REPEAT PTT 85730 305 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4003828 REPEAT PROTIME 85610 305 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4350 Hos Laboratory Facilty Fee 4003836 GENTAMYCIN - PEAK 80170 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4003851 REPEAT AMMONIA 82140 301 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4350 Hos Laboratory Facilty Fee 4003869 REPEAT ACETAMINOPHEN 82033 301 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4350 Hos Laboratory Facilty Fee 4003877 REPEAT BLOOD CULTURE 87040 306 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4350 Hos Laboratory Facilty Fee 4003885 REPEAT ROUTINE CULTURE 87070 306 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4003893 REPEAT SENS & ID 87186 306 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4003901 REPEAT URINALYSIS 81000 307 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4350 Hos Laboratory Facilty Fee 4003919 ETHOSUXIMIDE 80168 300 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4003927 ANTI-GLIADIN AB.X2 83516 301 146 102.19999999999999 31.74 146 74.37 31.74 109.5 31.74 74.37 74.37 74.37 74.37 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 4350 Hos Laboratory Facilty Fee 4003943 ALPHA-1 GLYCO (OROSOMUCOIB) 82985 301 163 114.1 35.44 163 83.03 35.44 122.25 35.44 83.03 83.03 83.03 83.03 35.44 38.984 35.44 35.44 35.44 35.44 36.1488 35.44 4350 Hos Laboratory Facilty Fee 4003950 REPEAT CBC/MANUAL DIFF 85027 305 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4350 Hos Laboratory Facilty Fee 4003968 REPEAT CK MB 82553 301 155 108.5 33.7 155 78.96 33.7 116.25 33.7 78.96 78.96 78.96 78.96 33.7 37.07000000000001 33.7 33.7 33.7 33.7 34.374 33.7 4350 Hos Laboratory Facilty Fee 4003976 REPEAT CPK 82550 301 113 79.1 24.57 113 57.56 24.57 84.75 24.57 57.56 57.56 57.56 57.56 24.57 27.027 24.57 24.57 24.57 24.57 25.0614 24.57 4350 Hos Laboratory Facilty Fee 4003984 MYOGLOBIN 83874 301 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4003992 STREP PNEUM AB 86403 302 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4350 Hos Laboratory Facilty Fee 4004032 CHLAMYDIA AB 86632 302 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4350 Hos Laboratory Facilty Fee 4004057 BETA-2 MICROGIOB 82232 301 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4350 Hos Laboratory Facilty Fee 4004065 HISTOPLASMA AB SER/CSF 86698 302 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4004073 HISTOPLASMA ANTIGEN UR 87385 306 239 167.29999999999998 51.96 239 121.75 51.96 179.25 51.96 121.75 121.75 121.75 121.75 51.96 57.156000000000006 51.96 51.96 51.96 51.96 52.9992 51.96 4350 Hos Laboratory Facilty Fee 4004081 RUBEOLA TITER 86765 302 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4004099 THYROID STIMUL. IMMUN 84445 301 520 364 113.05 520 264.89 113.05 390 113.05 264.89 264.89 264.89 264.89 113.05 124.355 113.05 113.05 113.05 113.05 115.31099999999999 113.05 4350 Hos Laboratory Facilty Fee 4004107 CORTISOL FREE-URINE 82530 301 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4350 Hos Laboratory Facilty Fee 4004115 DRUG SCREEN COLLECT FEE 99001 300 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4350 Hos Laboratory Facilty Fee 4004123 SEMEN EXAM POST VASECTOMY 89321 300 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4350 Hos Laboratory Facilty Fee 4004131 SULFONYLUREA HYPOGLY. 80299 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4004149 REPEAT CMP 80053 300 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4004164 REPEAT AMYLASE 82150 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4004172 RESP.SYN. VIRUS AB 86756 302 69 48.3 15 69 35.15 15 51.75 15 35.15 35.15 35.15 35.15 15 16.5 15 15 15 15 15.3 15 4350 Hos Laboratory Facilty Fee 4004180 CITRATE (CITRIC ACID) 82507 301 376 263.2 81.74 376 191.53 81.74 282 81.74 191.53 191.53 191.53 191.53 81.74 89.914 81.74 81.74 81.74 81.74 83.3748 81.74 4350 Hos Laboratory Facilty Fee 4004198 SEX HORMONE BIND, GIOB 84270 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4004206 HEP C PCR Quantitative 87522 306 564 394.79999999999995 122.61 564 287.3 122.61 423 122.61 287.3 287.3 287.3 287.3 122.61 134.871 122.61 122.61 122.61 122.61 125.0622 122.61 4350 Hos Laboratory Facilty Fee 4004214 INFLUENZA SWAB A&B 87804 306 139 97.3 30.22 139 70.81 30.22 104.25 30.22 70.81 70.81 70.81 70.81 30.22 33.242000000000004 30.22 30.22 30.22 30.22 30.8244 30.22 4350 Hos Laboratory Facilty Fee 4004222 CHROMOSOME STUDY TISSUE 88237 310 652 456.4 141.75 652 332.13 141.75 489 141.75 332.13 332.13 332.13 332.13 141.75 155.925 141.75 141.75 141.75 141.75 144.585 141.75 4350 Hos Laboratory Facilty Fee 4004230 CHROMOSOME STUDY CELL COUNT 88262 310 652 456.4 141.75 652 332.13 141.75 489 141.75 332.13 332.13 332.13 332.13 141.75 155.925 141.75 141.75 141.75 141.75 144.585 141.75 4350 Hos Laboratory Facilty Fee 4004248 THYROID PEROX AB (MICROSOMAL) 86376 302 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4350 Hos Laboratory Facilty Fee 4004255 ARSENIC 82175 301 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4004263 MERCURY 83825 301 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4350 Hos Laboratory Facilty Fee 4004271 HLA-DR,DQ PHENOTYPE 86817 302 441 308.7 95.87 441 224.65 95.87 330.75 95.87 224.65 224.65 224.65 224.65 95.87 105.45700000000001 95.87 95.87 95.87 95.87 97.7874 95.87 4350 Hos Laboratory Facilty Fee 4004289 HALOPERIDOL (HALDOL) 80173 300 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4350 Hos Laboratory Facilty Fee 4004297 CYSTINE,URINE QNT 82131 301 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4350 Hos Laboratory Facilty Fee 4004305 VANCOMYCIN - PEAK 80202 300 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4350 Hos Laboratory Facilty Fee 4004321 HISTONE AB. 83516 302 168 117.6 36.52 168 85.58 36.52 126 36.52 85.58 85.58 85.58 85.58 36.52 40.172000000000004 36.52 36.52 36.52 36.52 37.250400000000006 36.52 4350 Hos Laboratory Facilty Fee 4004339 COXSACKIE A VIR AB x4 86658 302 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4350 Hos Laboratory Facilty Fee 4004347 CMV IGM 86645 302 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4004354 COXSACKIE B VIR AB x6 86658 302 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4350 Hos Laboratory Facilty Fee 4004362 REPEAT MAGNESIUM 83735 301 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4004370 REPEAT PHOSPHOROUS 84100 301 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4004388 REPEAT LIPASE 83690 301 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4350 Hos Laboratory Facilty Fee 4004396 REPEAT CO2 82374 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4004404 REPEAT ACETONE (SERUM) 82010 301 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4004412 CORTISOL PM 82533 301 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4004420 REPEAT DIGOXIN 80162 300 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4004438 REPEAT DILANTIN 80185 300 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4004453 REPEAT OCCULT BLOOD 82270 301 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4350 Hos Laboratory Facilty Fee 4004461 REPEAT DIFF. MANUAL 85007 301 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4004479 REPEAT THEOPHYLINE 80198 300 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4004503 TRYPSIN, FECES, (QUAL.) 84488 301 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4004511 HEP C IMMUNOBLOT (RIBA) 86804 302 161 112.69999999999999 35 161 82.01 35 120.75 35 82.01 82.01 82.01 82.01 35 38.5 35 35 35 35 35.7 35 4350 Hos Laboratory Facilty Fee 4004529 CRYPTOCOCCUS AG. 87899 306 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4350 Hos Laboratory Facilty Fee 4004537 HLA PANEL A,B,C 86813 302 194 135.79999999999998 42.18 194 98.82 42.18 145.5 42.18 98.82 98.82 98.82 98.82 42.18 46.398 42.18 42.18 42.18 42.18 43.0236 42.18 4350 Hos Laboratory Facilty Fee 4004545 LYSOZYME 85549 305 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4350 Hos Laboratory Facilty Fee 4004552 LEGIONELLA DFA 87299 306 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4350 Hos Laboratory Facilty Fee 4004560 VIRAL GENO GEL SEP 83894 301 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4350 Hos Laboratory Facilty Fee 4004578 VIRAL GENO REV TRANS 83902 301 300 210 65.22 300 152.82 65.22 225 65.22 152.82 152.82 152.82 152.82 65.22 71.742 65.22 65.22 65.22 65.22 66.5244 65.22 4350 Hos Laboratory Facilty Fee 4004586 VIRAL GENO NUC ACD-AMP EA NUC 83898 301 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4350 Hos Laboratory Facilty Fee 4004594 VIRAL GENO ENZ DIGEST 83892 301 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4350 Hos Laboratory Facilty Fee 4004602 VIRAL GENO INTERPRET 83912 301 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4350 Hos Laboratory Facilty Fee 4004610 COGENTIN (BENZTROPINE) 80299 300 161 112.69999999999999 35 161 82.01 35 120.75 35 82.01 82.01 82.01 82.01 35 38.5 35 35 35 35 35.7 35 4350 Hos Laboratory Facilty Fee 4004628 C-REACT. PROT.(HIGH SENS) 86141 301 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4004636 HEPATITIS C VIRUS GENOTYPing, Nonreflex 87902 306 529 370.29999999999995 115 529 269.47 115 396.75 115 269.47 269.47 269.47 269.47 115 126.50000000000001 115 115 115 115 117.3 115 4350 Hos Laboratory Facilty Fee 4004644 LDL CHOLESTEROL 83721 301 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4004651 CA-19.9 86301 302 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4004669 ESTRONE 82679 301 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4350 Hos Laboratory Facilty Fee 4004677 PLATELET NEUTRALIZATION 85597 305 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4004685 RUSSELL VIPER VEN. TIME 85612 305 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4004693 PTT PLASMA SUBST. 85732 305 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4004701 TOXOPLASMA ABS 86778 302 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4004768 CARDIOLIPIN AB (A,G,or M) 86147 302 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4004982 OXYCODONE/HYDROCODONE 82646 301 168 117.6 36.52 168 85.58 36.52 126 36.52 85.58 85.58 85.58 85.58 36.52 40.172000000000004 36.52 36.52 36.52 36.52 37.250400000000006 36.52 4350 Hos Laboratory Facilty Fee 4004990 OXYCONTIN 80102 300 69 48.3 15 69 35.15 15 51.75 15 35.15 35.15 35.15 35.15 15 16.5 15 15 15 15 15.3 15 4350 Hos Laboratory Facilty Fee 4005005 CLOTTING FACTOR VIII 85240 305 193 135.1 41.96 193 98.31 41.96 144.75 41.96 98.31 98.31 98.31 98.31 41.96 46.156000000000006 41.96 41.96 41.96 41.96 42.7992 41.96 4350 Hos Laboratory Facilty Fee 4005013 RISTOCETIN COFACTOR 85245 305 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4350 Hos Laboratory Facilty Fee 4005021 VON WILLEBRAND FACTOR AG. 85246 305 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4350 Hos Laboratory Facilty Fee 4005039 ANDROSTENEDIONE 85157 301 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4005047 TISSUE TRANSGLUTAMINASE AB. 83516 301 207 144.89999999999998 45 207 105.45 45 155.25 45 105.45 105.45 105.45 105.45 45 49.50000000000001 45 45 45 45 45.9 45 4350 Hos Laboratory Facilty Fee 4005054 NORTRIPTYLINE 80182 300 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4005062 MITOCHONDRIAL AB 86255 302 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4005070 ENDOMYSIAL AB (TIS. GLUTAMNASE 86255 302 182 127.39999999999999 39.57 182 92.71 39.57 136.5 39.57 92.71 92.71 92.71 92.71 39.57 43.527 39.57 39.57 39.57 39.57 40.3614 39.57 4350 Hos Laboratory Facilty Fee 4005088 AMINO ACID SCREEN (PL) 82128 301 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4005096 AMINO ACID SCREEN (UR) 82128 301 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4005104 AMINO ACID QUANT (PL) 82139 301 608 425.59999999999997 132.18 608 309.72 132.18 456 132.18 309.72 309.72 309.72 309.72 132.18 145.39800000000002 132.18 132.18 132.18 132.18 134.8236 132.18 4350 Hos Laboratory Facilty Fee 4005112 OSMOTIC FRAGILITY 85557 305 256 179.2 55.65 256 130.41 55.65 192 55.65 130.41 130.41 130.41 130.41 55.65 61.215 55.65 55.65 55.65 55.65 56.763 55.65 4350 Hos Laboratory Facilty Fee 4005120 THYR. REL. HORM 83519 301 398 278.59999999999997 86.53 398 202.74 86.53 298.5 86.53 202.74 202.74 202.74 202.74 86.53 95.183 86.53 86.53 86.53 86.53 88.2606 86.53 4350 Hos Laboratory Facilty Fee 4005138 PORPHOBILINOGEN QN 84110 301 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4005146 CLOTTING FACTOR V 85220 305 193 135.1 41.96 193 98.31 41.96 144.75 41.96 98.31 98.31 98.31 98.31 41.96 46.156000000000006 41.96 41.96 41.96 41.96 42.7992 41.96 4350 Hos Laboratory Facilty Fee 4005153 REPEAT ELECTROLYTES 80051 300 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4005161 REPEAT BLEEDING TIME 85002 305 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4005179 PYRUVATE KINASE 84999 301 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4005187 REPEAT MYOGLOBIN 83874 301 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4005195 VIT.E (TOCOPHEROL) 84446 301 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4350 Hos Laboratory Facilty Fee 4005203 CYANIDE LEVEL 82600 301 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4350 Hos Laboratory Facilty Fee 4005211 VITAMIN B-6 84207 301 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4005229 REPEAT HEPATIC FUNCT. PANEL 80076 300 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4005237 BRAIN NATRIURETIC PEPTIDE 83880 301 290 203 63.05 290 147.73 63.05 217.5 63.05 147.73 147.73 147.73 147.73 63.05 69.355 63.05 63.05 63.05 63.05 64.31099999999999 63.05 4350 Hos Laboratory Facilty Fee 4005245 DEOXYPYRIDINOLKINE (COLLAGEN) 82523 301 161 112.69999999999999 35 161 82.01 35 120.75 35 82.01 82.01 82.01 82.01 35 38.5 35 35 35 35 35.7 35 4350 Hos Laboratory Facilty Fee 4005500 BRUCELLA AB. 86622 302 161 112.69999999999999 35 161 82.01 35 120.75 35 82.01 82.01 82.01 82.01 35 38.5 35 35 35 35 35.7 35 4350 Hos Laboratory Facilty Fee 4005518 RIFAMPIN LEVEL 80299 300 353 247.1 76.74 353 179.82 76.74 264.75 76.74 179.82 179.82 179.82 179.82 76.74 84.414 76.74 76.74 76.74 76.74 78.2748 76.74 4350 Hos Laboratory Facilty Fee 4005526 THROMBIN TIME 85670 305 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4005534 PLASMINOGEN 85420 305 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4350 Hos Laboratory Facilty Fee 4005559 Q FEVER X4 86638 302 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4005575 VENIPUNCTURE INS. 36415 300 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4350 Hos Laboratory Facilty Fee 4032736 G6PD 82955 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4098000 FAT STAIN 82705 301 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4098018 SUGARS; SINGLE QUALITATIVE; EA 84376 301 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4098026 REDUCING SUBST. URINE 81005 300 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4350 Hos Laboratory Facilty Fee 4300018 COMPATIBILITY SCR. USE PT 86904 390 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4300026 AB ID (RBC) EACH PANEL 86870 305 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4350 Hos Laboratory Facilty Fee 4300042 AB SCREEN (RBC) EACH TECHNIQUE 86850 305 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4300059 PACKED RED BLOOD CELLS P9016 390 720 503.99999999999994 156.53 720 366.77 156.53 540 156.53 366.77 366.77 366.77 366.77 156.53 172.18300000000002 156.53 156.53 156.53 156.53 159.66060000000002 156.53 4350 Hos Laboratory Facilty Fee 4300109 WHOLE BLOOD P9010 390 519 363.29999999999995 112.83 519 264.38 112.83 389.25 112.83 264.38 264.38 264.38 264.38 112.83 124.11300000000001 112.83 112.83 112.83 112.83 115.0866 112.83 4350 Hos Laboratory Facilty Fee 4300117 X-MATCH (AHG) 86922 305 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4300208 FRESH FROZEN PLASMA P9017 390 223 156.1 48.48 223 113.6 48.48 167.25 48.48 113.6 113.6 113.6 113.6 48.48 53.328 48.48 48.48 48.48 48.48 49.4496 48.48 4350 Hos Laboratory Facilty Fee 4300307 FRESH FROZEN PLASMA LAB PREP 86927 302 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4350 Hos Laboratory Facilty Fee 4300505 BLOOD TYPE RH 86901 302 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4300513 BLOOD TYPE ABO 86900 302 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4300521 DIRECT ANTI GLOB. TEST 86880 302 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4300802 NORM SER ALBUMIN P9047 636 371 259.7 80.66 371 188.99 80.66 278.25 80.66 188.99 188.99 188.99 188.99 80.66 88.726 80.66 80.66 80.66 80.66 82.2732 80.66 4350 Hos Laboratory Facilty Fee 4300927 PLATELET PHERESIS P9034 390 1692 1184.3999999999999 367.84 1692 861.9 367.84 1269 367.84 861.9 861.9 861.9 861.9 367.84 404.624 367.84 367.84 367.84 367.84 375.1968 367.84 4350 Hos Laboratory Facilty Fee 4303004 ANTIBODY ELUTION (RBC) EACH 86860 302 97 67.89999999999999 21.09 97 49.41 21.09 72.75 21.09 49.41 49.41 49.41 49.41 21.09 23.199 21.09 21.09 21.09 21.09 21.5118 21.09 4350 Hos Laboratory Facilty Fee 4303012 RBC AG. (NOT ABO OR D) EACH 86905 302 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4303020 INCUBATION OF X-MATCH (EACH) 86921 302 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4303038 PRETREAT. OF RBC WITH CHEMICAL 86970 302 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4303046 RH PHENOTYPE, COMPLETE 86906 302 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4350 Hos Laboratory Facilty Fee 4399903 BLOOD ADMIN 36430 391 864 604.8 187.83 864 440.12 187.83 648 187.83 440.12 440.12 440.12 440.12 187.83 206.61300000000003 187.83 187.83 187.83 187.83 191.5866 187.83 4350 Hos Laboratory Facilty Fee 4400057 GLUCOSE 82947 301 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4350 Hos Laboratory Facilty Fee 4400065 BUN-BLOOD UREA NITROGEN 84250 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4400073 CREATININE 82565 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4400081 SODIUM 84295 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4400099 POTASSIUM 84132 301 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4350 Hos Laboratory Facilty Fee 4400107 CHLORIDE 82435 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4400115 CARBON DIOXIDE 82374 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4400123 CALCIUM 82310 301 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4400131 PHOSPHOROUS 84100 301 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4400149 URIC ACID 84550 301 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4350 Hos Laboratory Facilty Fee 4400156 CHOLESTEROL 82465 301 43 30.099999999999998 9.35 43 21.9 9.35 32.25 9.35 21.9 21.9 21.9 21.9 9.35 10.285 9.35 9.35 9.35 9.35 9.536999999999999 9.35 4350 Hos Laboratory Facilty Fee 4400164 TRIGLYCERIDE 84478 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4400172 PROTEIN TOTAL SERUM 84155 301 55 38.5 11.96 55 28.02 11.96 41.25 11.96 28.02 28.02 28.02 28.02 11.96 13.156000000000002 11.96 11.96 11.96 11.96 12.199200000000001 11.96 4350 Hos Laboratory Facilty Fee 4400180 ALBUMIN 82040 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4400214 BILIRUBIN, TOTAL 82247 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4400222 ALK. PHOS. 84075 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4400230 LDH 83615 301 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4350 Hos Laboratory Facilty Fee 4400248 AST 84450 301 57 39.9 12.39 57 29.04 12.39 42.75 12.39 29.04 29.04 29.04 29.04 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 4350 Hos Laboratory Facilty Fee 4400255 ALT 84460 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4400263 GAMMA GLUTAM TRANS PEP 82977 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4400271 CPK 82550 301 113 79.1 24.57 113 57.56 24.57 84.75 24.57 57.56 57.56 57.56 57.56 24.57 27.027 24.57 24.57 24.57 24.57 25.0614 24.57 4350 Hos Laboratory Facilty Fee 4400305 AMYLASE SERUM 82150 301 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4350 Hos Laboratory Facilty Fee 4400347 GTT. 3 SPECIMENS 82951 301 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4350 Hos Laboratory Facilty Fee 4400354 GLU TOL. EACH ADDT'L SPEC. 82952 301 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4400362 OBSTETRIC PANEL 80055 300 204 142.79999999999998 44.35 204 103.92 44.35 153 44.35 103.92 103.92 103.92 103.92 44.35 48.785000000000004 44.35 44.35 44.35 44.35 45.237 44.35 4350 Hos Laboratory Facilty Fee 4400388 RENAL FUNCTION PANEL 80069 300 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4400701 HEPATIC FUNCTION PANEL 80076 300 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4350 Hos Laboratory Facilty Fee 4400750 BASIC METABOLIC PANEL 80048 300 119 83.3 25.87 119 60.62 25.87 89.25 25.87 60.62 60.62 60.62 60.62 25.87 28.457000000000004 25.87 25.87 25.87 25.87 26.387400000000003 25.87 4350 Hos Laboratory Facilty Fee 4400792 ELECTROLYTES PANEL 80051 300 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4400842 COMPREHENSIVE METABOLIC PANEL 80053 300 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4401006 BILIRUBIN DIRECT 82248 301 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4350 Hos Laboratory Facilty Fee 4401501 GENERAL HEALTH PANEL 80050 300 273 191.1 59.35 273 139.07 59.35 204.75 59.35 139.07 139.07 139.07 139.07 59.35 65.28500000000001 59.35 59.35 59.35 59.35 60.537 59.35 4350 Hos Laboratory Facilty Fee 4401519 GLUCOSE (POC) 82948 301 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4350 Hos Laboratory Facilty Fee 4401527 GLUCOSE (POC) REPEAT 82948 301 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4350 Hos Laboratory Facilty Fee 4413142 CANDIDA TITER 86628 302 139 97.3 30.22 139 70.81 30.22 104.25 30.22 70.81 70.81 70.81 70.81 30.22 33.242000000000004 30.22 30.22 30.22 30.22 30.8244 30.22 4350 Hos Laboratory Facilty Fee 4500005 DIFFERENTIAL MANUAL 85009 305 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4500013 SED RATE 85651 305 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4350 Hos Laboratory Facilty Fee 4500021 RETIC COUNT 85045 305 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4500039 CBC/AUTO DIFF 85025 305 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4350 Hos Laboratory Facilty Fee 4500047 WBC- WHITE BLOOD COUNT 85048 305 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4500054 HEMOGLOBIN 85018 305 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4350 Hos Laboratory Facilty Fee 4500062 HEMATOCRIT 85014 305 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4350 Hos Laboratory Facilty Fee 4500070 PLATELET COUNT AUTO 85049 305 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4500211 CBC (NEEDS MANUAL DIFF) 85027 305 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4350 Hos Laboratory Facilty Fee 4600003 CULTURE, ROUTINE 82070 306 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4350 Hos Laboratory Facilty Fee 4600011 GRAM STAIN 87205 306 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4600045 YEAST IDENTIFICATION 87106 306 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4350 Hos Laboratory Facilty Fee 4600052 FUNGAL DRUG SENSITIVITY 87186 306 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4600060 RAPID STREP SCREEN 87880 302 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4350 Hos Laboratory Facilty Fee 4600078 BAC T SEROLOGY 87147 306 61 42.699999999999996 13.26 61 31.07 13.26 45.75 13.26 31.07 31.07 31.07 31.07 13.26 14.586 13.26 13.26 13.26 13.26 13.5252 13.26 4350 Hos Laboratory Facilty Fee 4600086 E COLI 0157 AGGLUTINATION 87147 306 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4350 Hos Laboratory Facilty Fee 4600102 LEUKOCYTES, FECAL 89055 306 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4350 Hos Laboratory Facilty Fee 4600110 E COLI 157 CULTURE 87046 306 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4600136 CULTURE, ANAEROBIC 87073 306 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4350 Hos Laboratory Facilty Fee 4600144 INFLUENZA TITER A OR B SERUM 86710 302 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4350 Hos Laboratory Facilty Fee 4600151 RESP. SYNCYT. VIRUS (EIA) WASH 87420 306 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4600169 STOOL FOR CAMPY 87046 306 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4600177 FUNGAL CULTURE (SKIN, HAIR) 87101 306 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4350 Hos Laboratory Facilty Fee 4600185 FUNGAL CULTURE, OTHER 87102 306 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4350 Hos Laboratory Facilty Fee 4600193 ACID FAST BACILLI CULTURE 87116 306 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4350 Hos Laboratory Facilty Fee 4600201 CHLAMYDIA CULTURE 87110 306 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4350 Hos Laboratory Facilty Fee 4600235 AEROBIC ISOLATE ID 87077 306 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4350 Hos Laboratory Facilty Fee 4600250 SENS, MISC FIRST ISOLATION 87186 306 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4610002 SENS, URINE FIRST ISOLATION 87186 306 60 42 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 4350 Hos Laboratory Facilty Fee 4610010 CULTURE, BLOOD 87040 306 112 78.39999999999999 24.35 112 57.05 24.35 84 24.35 57.05 57.05 57.05 57.05 24.35 26.785000000000004 24.35 24.35 24.35 24.35 24.837000000000003 24.35 4350 Hos Laboratory Facilty Fee 4610028 STOOL CULTURE (SS) 87045 306 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4610036 CULTURE, URINE 87086 306 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4350 Hos Laboratory Facilty Fee 4610051 Gonorrhea Urine Culture 87081 306 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4350 Hos Laboratory Facilty Fee 4700001 PREGNANCY TEST (URINE) 81025 300 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4350 Hos Laboratory Facilty Fee 4700019 VAGINAL WET PREP 87210 306 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4700027 UA - DIP ONLY 81002 307 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4700035 URINALYSIS 81000 307 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4350 Hos Laboratory Facilty Fee 4700043 SPECIFIC GRAVITY 81002 307 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4350 Hos Laboratory Facilty Fee 4700044 Antimitochondrial Antibodies 83516 301 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4350 Hos Laboratory Facilty Fee 4700045 Synovial Fluid Analysis, Joint Fluid 83872 306 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4350 Hos Laboratory Facilty Fee 4700046 Histamine 83088 305 150 105 32.61 150 76.41 32.61 112.5 32.61 76.41 76.41 76.41 76.41 32.61 35.871 32.61 32.61 32.61 32.61 33.2622 32.61 4350 Hos Laboratory Facilty Fee 4700047 Absolute Basophil Count 85025 305 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4700048 Selenium, Whole Blood 84255 305 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4350 Hos Laboratory Facilty Fee 4700049 Fecal Calprotectin 83993 302 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4350 Hos Laboratory Facilty Fee 4700050 Nova Bio 82947 301 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4350 Hos Laboratory Facilty Fee 4700051 Quantiferon TB Gold Tuberculosis Test 86480 302 210 147 45.65 210 106.97 45.65 157.5 45.65 106.97 106.97 106.97 106.97 45.65 50.215 45.65 45.65 45.65 45.65 46.563 45.65 4350 Hos Laboratory Facilty Fee 4700052 T-Spot TB test 86481 302 252 176.39999999999998 54.78 252 128.37 54.78 189 54.78 128.37 128.37 128.37 128.37 54.78 60.258 54.78 54.78 54.78 54.78 55.8756 54.78 4350 Hos Laboratory Facilty Fee 4700052 T-Spot Tb test 86481 302 252 176.39999999999998 54.78 252 128.37 54.78 189 54.78 128.37 128.37 128.37 128.37 54.78 60.258 54.78 54.78 54.78 54.78 55.8756 54.78 4350 Hos Laboratory Facilty Fee 4700053 Pasp Screening, Image guided (rescreen or review) 88175 311 91 63.699999999999996 19.78 91 46.36 19.78 68.25 19.78 46.36 46.36 46.36 46.36 19.78 21.758000000000003 19.78 19.78 19.78 19.78 20.175600000000003 19.78 4350 Hos Laboratory Facilty Fee 4700054 Pap Screening Test 88142 311 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4350 Hos Laboratory Facilty Fee 4700055 10 panel blood drug screen G0431 300 87 60.9 18.91 87 44.32 18.91 65.25 18.91 44.32 44.32 44.32 44.32 18.91 20.801000000000002 18.91 18.91 18.91 18.91 19.2882 18.91 4350 Hos Laboratory Facilty Fee 4700056 Toxoplasma 86777 302 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4350 Hos Laboratory Facilty Fee 4700057 HIV 1/2 Antigen and Antibodies Fourth Generation 87389 302 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4700058 HIV 1 Antibody 86701 302 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4350 Hos Laboratory Facilty Fee 4700059 HIV 2 Antibody 86702 302 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4350 Hos Laboratory Facilty Fee 4700060 Polyomavirus BK Virus Quantitaion, Urine Real time PCR 87799 307 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4350 Hos Laboratory Facilty Fee 4700061 Viral Culture Rapid Respiratory Influenza A & B (H1N1) 87254 306 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4350 Hos Laboratory Facilty Fee 4700062 Vitamin C 82180 301 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4350 Hos Laboratory Facilty Fee 4700063 Vitamin B2, Whole Blood 84252 301 91 63.699999999999996 19.78 91 46.36 19.78 68.25 19.78 46.36 46.36 46.36 46.36 19.78 21.758000000000003 19.78 19.78 19.78 19.78 20.175600000000003 19.78 4350 Hos Laboratory Facilty Fee 4700064 Vitamin B3 (niacin & metabolite) 84591 301 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4350 Hos Laboratory Facilty Fee 4700065 Fungus Antibody 86671 301 56 39.199999999999996 12.17 56 28.53 12.17 42 12.17 28.53 28.53 28.53 28.53 12.17 13.387 12.17 12.17 12.17 12.17 12.4134 12.17 4350 Hos Laboratory Facilty Fee 4700066 Creatine 24 hr urine 82540 301 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4350 Hos Laboratory Facilty Fee 4700067 Drug Screen, Whole Blood (10 classes) T 80307 300 181 126.69999999999999 39.35 181 92.2 39.35 135.75 39.35 92.2 92.2 92.2 92.2 39.35 43.285000000000004 39.35 39.35 39.35 39.35 40.137 39.35 4350 Hos Laboratory Facilty Fee 4700068 Drug Screen, Serum Whole Blood, Alcohols 80320 301 229.5 160.64999999999998 49.89 229.5 116.91 49.89 172.13 49.89 116.91 116.91 116.91 116.91 49.89 54.879000000000005 49.89 49.89 49.89 49.89 50.8878 49.89 4350 Hos Laboratory Facilty Fee 4700069 Urinalysis (Fee schedule) 81001 307 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4350 Hos Laboratory Facilty Fee 4700070 Covid 19 Test U0002 300 153 107.1 33.26 153 77.94 33.26 114.75 33.26 77.94 77.94 77.94 77.94 33.26 36.586 33.26 33.26 33.26 33.26 33.9252 33.26 4350 Hos Laboratory Facilty Fee 4700071 COVID 19 Collection Fee C9803 300 30 21 6.52 30 15.28 6.52 22.5 6.52 15.28 15.28 15.28 15.28 6.52 7.172 6.52 6.52 6.52 6.52 6.650399999999999 6.52 4350 Hos Laboratory Facilty Fee 4700072 Antibody, COVID 19 86769 300 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4350 Hos Laboratory Facilty Fee 4700073 Anti NMDA Receptor IGG antibodies 86255 301 446 312.2 96.96 446 227.19 96.96 334.5 96.96 227.19 227.19 227.19 227.19 96.96 106.656 96.96 96.96 96.96 96.96 98.8992 96.96 4350 Hos Laboratory Facilty Fee 4700075 Rapid Screen Covid/Flu/Strep 87428 300 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4350 Hos Laboratory Facilty Fee 4700076 Urine Drug Screen 80307 307 65 45.5 14.13 65 33.11 14.13 48.75 14.13 33.11 33.11 33.11 33.11 14.13 15.543000000000003 14.13 14.13 14.13 14.13 14.412600000000001 14.13 4360 Hos Pathology Profee Facilty Fee 8002 BLOOD SMEAR, PERIPHERAL W/ 85060 305 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4360 Hos Pathology Profee Facilty Fee 8004 CYTOPATHOLOGY W/INTERPRETATION 88112 311 171 119.69999999999999 37.18 171 87.11 37.18 128.25 37.18 87.11 87.11 87.11 87.11 37.18 40.898 37.18 37.18 37.18 37.18 37.9236 37.18 4360 Hos Pathology Profee Facilty Fee 8008 DECALCIFICATION PROCEDURE 88311 302 110 77 23.91 110 56.03 23.91 82.5 23.91 56.03 56.03 56.03 56.03 23.91 26.301000000000002 23.91 23.91 23.91 23.91 24.3882 23.91 4360 Hos Pathology Profee Facilty Fee 8001 GROUP II ALL OTHER 88313 309 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4360 Hos Pathology Profee Facilty Fee 8005 IMMUNOHISTOCHEMISTRY 88342 309 124 86.8 26.96 124 63.17 26.96 93 26.96 63.17 63.17 63.17 63.17 26.96 29.656000000000002 26.96 26.96 26.96 26.96 27.499200000000002 26.96 4360 Hos Pathology Profee Facilty Fee 8006 LEVEL III- SURGICAL PATHOLOGY 88304 310 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4360 Hos Pathology Profee Facilty Fee 8000 LEVEL IV SURGICAL PATHOLOGY 88305 310 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4360 Hos Pathology Profee Facilty Fee 8003 LEVEL V- SURGICAL PATHOLOGY 88307 310 239 167.29999999999998 51.96 239 121.75 51.96 179.25 51.96 121.75 121.75 121.75 121.75 51.96 57.156000000000006 51.96 51.96 51.96 51.96 52.9992 51.96 4360 Hos Pathology Profee Facilty Fee 8007 SPECIAL STAIN W-INTER & REPORT 88312 310 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4480 E.K.G. Facilty Fee 6610018 EKG 93005 730 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4480 E.K.G. Facilty Fee 6610042 EKG STRESS TEST 93017 482 532 372.4 115.66 532 271 115.66 399 115.66 271 271 271 271 115.66 127.22600000000001 115.66 115.66 115.66 115.66 117.9732 115.66 4480 E.K.G. Facilty Fee 6600019 REPEAT EKG 93005 730 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4480 E.K.G. Facilty Fee 1203 BI-LEVEL VENTILATION 95811 920 4600 3220 1000.04 4600 2343.24 1000.04 3450 1000.04 2343.24 2343.24 2343.24 2343.24 1000.04 1100.044 1000.04 1000.04 1000.04 1000.04 1020.0408 1000.04 4480 E.K.G. Facilty Fee 1209 CPAP TITR. SLEEP STUDY MORE 95811 920 4600 3220 1000.04 4600 2343.24 1000.04 3450 1000.04 2343.24 2343.24 2343.24 2343.24 1000.04 1100.044 1000.04 1000.04 1000.04 1000.04 1020.0408 1000.04 4480 E.K.G. Facilty Fee 1204 EMERGENCY SPLIT SLEEP STUDY 95811 920 4600 3220 1000.04 4600 2343.24 1000.04 3450 1000.04 2343.24 2343.24 2343.24 2343.24 1000.04 1100.044 1000.04 1000.04 1000.04 1000.04 1020.0408 1000.04 4480 E.K.G. Facilty Fee 1208 INITIAL SLEEP STUDY MORE THAN 95810 920 3834 2683.7999999999997 833.51 3834 1953.04 833.51 2875.5 833.51 1953.04 1953.04 1953.04 1953.04 833.51 916.8610000000001 833.51 833.51 833.51 833.51 850.1802 833.51 4480 E.K.G. Facilty Fee 1200 MULTIPLE SLEEP LATENCY TEST 95805 920 3834 2683.7999999999997 833.51 3834 1953.04 833.51 2875.5 833.51 1953.04 1953.04 1953.04 1953.04 833.51 916.8610000000001 833.51 833.51 833.51 833.51 850.1802 833.51 4480 E.K.G. Facilty Fee 1210 MUTIPLE SLEEP LATENCY TEST 95805 920 3222 2255.3999999999996 700.46 3222 1641.29 700.46 2416.5 700.46 1641.29 1641.29 1641.29 1641.29 700.46 770.5060000000001 700.46 700.46 700.46 700.46 714.4692 700.46 4480 E.K.G. Facilty Fee 1207 ORDERED SPLIT SLEEP STUDY 95811 920 4600 3220 1000.04 4600 2343.24 1000.04 3450 1000.04 2343.24 2343.24 2343.24 2343.24 1000.04 1100.044 1000.04 1000.04 1000.04 1000.04 1020.0408 1000.04 4480 E.K.G. Facilty Fee 1202 POLYSOMNOGRAPHY (CPAP) 95811 920 4600 3220 1000.04 4600 2343.24 1000.04 3450 1000.04 2343.24 2343.24 2343.24 2343.24 1000.04 1100.044 1000.04 1000.04 1000.04 1000.04 1020.0408 1000.04 4480 E.K.G. Facilty Fee 1201 POLYSOMNOGRAPHY- INITIAL STUDY 95810 920 3834 2683.7999999999997 833.51 3834 1953.04 833.51 2875.5 833.51 1953.04 1953.04 1953.04 1953.04 833.51 916.8610000000001 833.51 833.51 833.51 833.51 850.1802 833.51 4480 E.K.G. Facilty Fee 1206 REPEAT CPAP TITRATION SLEEP 95811 920 4600 3220 1000.04 4600 2343.24 1000.04 3450 1000.04 2343.24 2343.24 2343.24 2343.24 1000.04 1100.044 1000.04 1000.04 1000.04 1000.04 1020.0408 1000.04 4480 E.K.G. Facilty Fee 1205 REPEAT INITIAL SLEEP STUDY 95810 920 3834 2683.7999999999997 833.51 3834 1953.04 833.51 2875.5 833.51 1953.04 1953.04 1953.04 1953.04 833.51 916.8610000000001 833.51 833.51 833.51 833.51 850.1802 833.51 4480 E.K.G. Facilty Fee 6010177 VENTILATOR 1ST DAY 94002 410 657 459.9 142.83 657 334.68 142.83 492.75 142.83 334.68 334.68 334.68 334.68 142.83 157.11300000000003 142.83 142.83 142.83 142.83 145.68660000000003 142.83 4480 E.K.G. Facilty Fee 6010300 02/HR. E0431 270 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4480 E.K.G. Facilty Fee 6010136 A.B.G. 82803 301 184 128.79999999999998 40 184 93.73 40 138 40 93.73 93.73 93.73 93.73 40 44 40 40 40 40 40.8 40 4480 E.K.G. Facilty Fee 60371 AEROSOL TEATMENT SUBSEQUENT 94640 410 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4480 E.K.G. Facilty Fee 6010433 ARTERIAL PUNCTURE/DAY 36600 410 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 4480 E.K.G. Facilty Fee 6010235 CARDIAC MON./R.R.-E.R. 93041 730 133 93.1 28.91 133 67.75 28.91 99.75 28.91 67.75 67.75 67.75 67.75 28.91 31.801000000000002 28.91 28.91 28.91 28.91 29.4882 28.91 4480 E.K.G. Facilty Fee 6010706 CODE BLUE (CPR) 92950 480 946 662.1999999999999 205.66 946 481.89 205.66 709.5 205.66 481.89 481.89 481.89 481.89 205.66 226.22600000000003 205.66 205.66 205.66 205.66 209.7732 205.66 4480 E.K.G. Facilty Fee 60391 CONT INHALATION TRTMNT SUBSQ 94645 410 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4480 E.K.G. Facilty Fee 60381 CONTINOUS INHALATION TREATMENT 94644 410 392 274.4 85.22 392 199.68 85.22 294 85.22 199.68 199.68 199.68 199.68 85.22 93.742 85.22 85.22 85.22 85.22 86.9244 85.22 4480 E.K.G. Facilty Fee 6210120 CPAP/BIPAP SUBSEQUENT 94660 410 362 253.39999999999998 78.7 362 184.4 78.7 271.5 78.7 184.4 184.4 184.4 184.4 78.7 86.57000000000001 78.7 78.7 78.7 78.7 80.274 78.7 4480 E.K.G. Facilty Fee 6010102 CPT & DRAINAGE 1st DAY 94667 410 108 75.6 23.48 108 55.02 23.48 81 23.48 55.02 55.02 55.02 55.02 23.48 25.828000000000003 23.48 23.48 23.48 23.48 23.9496 23.48 4480 E.K.G. Facilty Fee 6011522 CPT & DRAINAGE SUBSEQUENT DAYS 94668 410 108 75.6 23.48 108 55.02 23.48 81 23.48 55.02 55.02 55.02 55.02 23.48 25.828000000000003 23.48 23.48 23.48 23.48 23.9496 23.48 4480 E.K.G. Facilty Fee 6011702 DEMON & EVAL NEBULIZER TX 94664 410 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4480 E.K.G. Facilty Fee 6010225 EVENT MONITOR 93270 730 218 152.6 47.39 218 111.05 47.39 163.5 47.39 111.05 111.05 111.05 111.05 47.39 52.129000000000005 47.39 47.39 47.39 47.39 48.3378 47.39 4480 E.K.G. Facilty Fee 6033 HFN - NEB,INHALER - DEM/EVAL 94664 410 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4480 E.K.G. Facilty Fee 6010037 HFN TX 94664 410 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4480 E.K.G. Facilty Fee 6010222 HOLTER MONITOR 93225 731 218 152.6 47.39 218 111.05 47.39 163.5 47.39 111.05 111.05 111.05 111.05 47.39 52.129000000000005 47.39 47.39 47.39 47.39 48.3378 47.39 4480 E.K.G. Facilty Fee 6012991 INHALATION TX FOR AC.AIRWAY OB 94640 410 76 53.199999999999996 16.52 76 38.71 16.52 57 16.52 38.71 38.71 38.71 38.71 16.52 18.172 16.52 16.52 16.52 16.52 16.8504 16.52 4480 E.K.G. Facilty Fee 60361 INITIAL AEROSOL INHALATIONS 94640 410 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 4480 E.K.G. Facilty Fee 6010201 INTUBATION 31500 410 544 380.79999999999995 118.27 544 277.11 118.27 408 118.27 277.11 277.11 277.11 277.11 118.27 130.097 118.27 118.27 118.27 118.27 120.6354 118.27 4480 E.K.G. Facilty Fee 6010441 NASO-TRACHIAL SUCTION 31720 419 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4480 E.K.G. Facilty Fee 6010904 PEAK FLOW 94150 270 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4480 E.K.G. Facilty Fee 6210017 PFT 94010 460 196 137.2 42.61 196 99.84 42.61 147 42.61 99.84 99.84 99.84 99.84 42.61 46.871 42.61 42.61 42.61 42.61 43.4622 42.61 4480 E.K.G. Facilty Fee 6010516 PULSE OXIMETER CONT MONITORING 94762 460 146 102.19999999999999 31.74 146 74.37 31.74 109.5 31.74 74.37 74.37 74.37 74.37 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 4480 E.K.G. Facilty Fee 6010458 PULSE OXIMETRY - ER 94760 450 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4480 E.K.G. Facilty Fee 6011998 PULSE OXIMETRY - OUTPT 94760 760 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4480 E.K.G. Facilty Fee 6010873 PULSE OXIMETRY - RESPIRATORY 94760 410 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4480 E.K.G. Facilty Fee 6011605 REPEAT ABG ANALYSIS 82803 301 184 128.79999999999998 40 184 93.73 40 138 40 93.73 93.73 93.73 93.73 40 44 40 40 40 40 40.8 40 4480 E.K.G. Facilty Fee 6034 REPEAT ABG ANALYSIS 82803 410 184 128.79999999999998 40 184 93.73 40 138 40 93.73 93.73 93.73 93.73 40 44 40 40 40 40 40.8 40 4480 E.K.G. Facilty Fee 6011621 REPEAT ARTERIAL PUNCTURE 36600 410 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 4480 E.K.G. Facilty Fee 6035 SMOKING CESSATION EDUCATION 98960 942 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4480 E.K.G. Facilty Fee 6010078 SPUTUM COLLECTION 89220 300 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4480 E.K.G. Facilty Fee 6010193 VENTILATOR SUGSEQUENT DAYS 94003 410 657 459.9 142.83 657 334.68 142.83 492.75 142.83 334.68 334.68 334.68 334.68 142.83 157.11300000000003 142.83 142.83 142.83 142.83 145.68660000000003 142.83 4480 E.K.G. Facilty Fee 1211 Polysomnorgaphy, Unattended (Sleep Study) 95800 920 2184 1528.8 474.8 2184 1112.53 474.8 1638 474.8 1112.53 1112.53 1112.53 1112.53 474.8 522.2800000000001 474.8 474.8 474.8 474.8 484.296 474.8 4480 E.K.G. Facilty Fee 1212 HST (Home Sleep Study) 95806 920 2184 1528.8 474.8 2184 1112.53 474.8 1638 474.8 1112.53 1112.53 1112.53 1112.53 474.8 522.2800000000001 474.8 474.8 474.8 474.8 484.296 474.8 4480 E.K.G. Facilty Fee 1213 Home Sleep test with type iii portable monitor, unattended G0399 999 2184 1528.8 474.8 2184 1112.53 474.8 1638 474.8 1112.53 1112.53 1112.53 1112.53 474.8 522.2800000000001 474.8 474.8 474.8 474.8 484.296 474.8 4510 Bho Profee Facilty Fee 9070 INPATIENT CONSULTATION 99254 961 437 305.9 95 437 222.61 95 327.75 95 222.61 222.61 222.61 222.61 95 104.50000000000001 95 95 95 95 96.9 95 4510 Bho Profee Facilty Fee 9102 INTERACTIVE COMPLEXITY 90785 961 13 9.1 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 4510 Bho Profee Facilty Fee 9084 LEVEL 1 (10 MIN) NEW PATIENT 99201 961 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4510 Bho Profee Facilty Fee 9103 LEVEL 1 (20MIN) INPT CONSULT 99251 961 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4510 Bho Profee Facilty Fee 9090 LEVEL 1 (5 MIN) ESTAB. PATIENT 99211 961 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4510 Bho Profee Facilty Fee 9091 LEVEL 2 (10MIN) ESTAB. PATIENT 99212 961 68 47.599999999999994 14.78 68 34.64 14.78 51 14.78 34.64 34.64 34.64 34.64 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 4510 Bho Profee Facilty Fee 9085 LEVEL 2 (20 MIN) NEW PATIENT 99202 961 136 95.19999999999999 29.57 136 69.28 29.57 102 29.57 69.28 69.28 69.28 69.28 29.57 32.527 29.57 29.57 29.57 29.57 30.1614 29.57 4510 Bho Profee Facilty Fee 9104 LEVEL 2 (40MIN) INPT CONSULT 99252 961 216 151.2 46.96 216 110.03 46.96 162 46.96 110.03 110.03 110.03 110.03 46.96 51.656000000000006 46.96 46.96 46.96 46.96 47.8992 46.96 4510 Bho Profee Facilty Fee 9092 LEVEL 3 (15MIN) ESTAB. PATIENT 99213 961 137 95.89999999999999 29.78 137 69.79 29.78 102.75 29.78 69.79 69.79 69.79 69.79 29.78 32.758 29.78 29.78 29.78 29.78 30.375600000000002 29.78 4510 Bho Profee Facilty Fee 9086 LEVEL 3 (30 MIN) NEW PATIENT 99203 961 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4510 Bho Profee Facilty Fee 9072 DISCHARGE - 30MIN OR LESS 99238 961 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4510 Bho Profee Facilty Fee 9105 LEVEL 3 (55MIN) INPT CONSULT 99253 961 289 202.29999999999998 62.83 289 147.22 62.83 216.75 62.83 147.22 147.22 147.22 147.22 62.83 69.113 62.83 62.83 62.83 62.83 64.0866 62.83 4510 Bho Profee Facilty Fee 9093 LEVEL 4 (25MIN) ESTAB. PATIENT 99214 961 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4510 Bho Profee Facilty Fee 9087 LEVEL 4 (45 MIN) NEW PATIENT 99204 961 357 249.89999999999998 77.61 357 181.86 77.61 267.75 77.61 181.86 181.86 181.86 181.86 77.61 85.37100000000001 77.61 77.61 77.61 77.61 79.1622 77.61 4510 Bho Profee Facilty Fee 9106 LEVEL 5 (110MIN) INPT CONSULT 99255 961 551 385.7 119.79 551 280.68 119.79 413.25 119.79 280.68 280.68 280.68 280.68 119.79 131.769 119.79 119.79 119.79 119.79 122.18580000000001 119.79 4510 Bho Profee Facilty Fee 9094 LEVEL 5 (40MIN) ESTAB. PATIENT 99215 961 296 207.2 64.35 296 150.78 64.35 222 64.35 150.78 150.78 150.78 150.78 64.35 70.785 64.35 64.35 64.35 64.35 65.637 64.35 4510 Bho Profee Facilty Fee 9089 LEVEL 5 (60 MIN) NEW PATIENT 99205 961 456 319.2 99.13 456 232.29 99.13 342 99.13 232.29 232.29 232.29 232.29 99.13 109.043 99.13 99.13 99.13 99.13 101.1126 99.13 4510 Bho Profee Facilty Fee 9095 PSYCHIATRIC DIAG. EVAL 90801 961 315 220.5 68.48 315 160.46 68.48 236.25 68.48 160.46 160.46 160.46 160.46 68.48 75.32800000000002 68.48 68.48 68.48 68.48 69.84960000000001 68.48 4510 Bho Profee Facilty Fee 9096 PSYCHIATRIC DIAG. EVAL. 90801 961 324 226.79999999999998 70.44 324 165.05 70.44 243 70.44 165.05 165.05 165.05 165.05 70.44 77.48400000000001 70.44 70.44 70.44 70.44 71.8488 70.44 4510 Bho Profee Facilty Fee 9076 PSYCHIATRIC DIAG. INTERVIEW 90801 961 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4510 Bho Profee Facilty Fee 9100 PSYCHOTHERAPY FOR CRISIS 90840 961 322 225.39999999999998 70 322 164.03 70 241.5 70 164.03 164.03 164.03 164.03 70 77 70 70 70 70 71.4 70 4510 Bho Profee Facilty Fee 9071 DISCHARGE- MORE THAN 30 MIN 99239 961 310 217 67.39 310 157.91 67.39 232.5 67.39 157.91 157.91 157.91 157.91 67.39 74.129 67.39 67.39 67.39 67.39 68.73780000000001 67.39 4510 Bho Profee Facilty Fee 9101 PSYCHOTHERAPY FOR CRISIS 90840 961 255 178.5 55.44 255 129.9 55.44 191.25 55.44 129.9 129.9 129.9 129.9 55.44 60.984 55.44 55.44 55.44 55.44 56.5488 55.44 4510 Bho Profee Facilty Fee 9098 PSYCHOTHERAPY-45MIN 90834 961 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4510 Bho Profee Facilty Fee 9099 PSYCHOTHERAPY-60MIN 90837 961 298 208.6 64.79 298 151.8 64.79 223.5 64.79 151.8 151.8 151.8 151.8 64.79 71.26900000000002 64.79 64.79 64.79 64.79 66.0858 64.79 4510 Bho Profee Facilty Fee 9097 PSYCHOTHEREAPY-30MIN 90832 961 133 93.1 28.91 133 67.75 28.91 99.75 28.91 67.75 67.75 67.75 67.75 28.91 31.801000000000002 28.91 28.91 28.91 28.91 29.4882 28.91 4510 Bho Profee Facilty Fee 9073 SUBSEQUENT CARE- BRIEF 99231 961 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4510 Bho Profee Facilty Fee 9074 SUBSEQUENT CARE- DETAILED 99232 961 212 148.39999999999998 46.09 212 107.99 46.09 159 46.09 107.99 107.99 107.99 107.99 46.09 50.699000000000005 46.09 46.09 46.09 46.09 47.0118 46.09 4510 Bho Profee Facilty Fee 9075 SUBSEQUENT CARE- EXTENDED 99233 961 303 212.1 65.87 303 154.35 65.87 227.25 65.87 154.35 154.35 154.35 154.35 65.87 72.45700000000001 65.87 65.87 65.87 65.87 67.18740000000001 65.87 4510 Bho Profee Facilty Fee 9082 FAMILY PSYCHOTHERAPY 90847 961 132 92.39999999999999 28.7 132 67.24 28.7 99 28.7 67.24 67.24 67.24 67.24 28.7 31.57 28.7 28.7 28.7 28.7 29.274 28.7 4510 Bho Profee Facilty Fee 9065 FAMILY PSYCHOTHERAPY 90847 961 286 200.2 62.18 286 145.69 62.18 214.5 62.18 145.69 145.69 145.69 145.69 62.18 68.39800000000001 62.18 62.18 62.18 62.18 63.4236 62.18 4510 Bho Profee Facilty Fee 9066 GROUP PSYCHOTHERAPY 90853 961 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4510 Bho Profee Facilty Fee 90671 LEVEL 1 (10MIN) NEW PATIENT 99201 961 177 123.89999999999999 38.48 177 90.16 38.48 132.75 38.48 90.16 90.16 90.16 90.16 38.48 42.328 38.48 38.48 38.48 38.48 39.2496 38.48 4510 Bho Profee Facilty Fee 9083 GROUP PSYCHOTHERAPY 90853 961 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4510 Bho Profee Facilty Fee 9069 INITIAL INPT EVAL - HIGH 99223 961 589 412.29999999999995 128.05 589 300.04 128.05 441.75 128.05 300.04 300.04 300.04 300.04 128.05 140.85500000000002 128.05 128.05 128.05 128.05 130.61100000000002 128.05 4510 Bho Profee Facilty Fee 9016 Initial Inpatient 30 min G0425 988 297 207.89999999999998 64.57 297 151.29 64.57 222.75 64.57 151.29 151.29 151.29 151.29 64.57 71.027 64.57 64.57 64.57 64.57 65.86139999999999 64.57 4510 Bho Profee Facilty Fee 9017 Initial Inpatient 50 min G0426 988 402 281.4 87.4 402 204.78 87.4 301.5 87.4 204.78 204.78 204.78 204.78 87.4 96.14000000000001 87.4 87.4 87.4 87.4 89.14800000000001 87.4 4510 Bho Profee Facilty Fee 9019 Follow Up Inaptient, Limited 15min G0406 987 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4510 Bho Profee Facilty Fee 9020 Follow Up Inpatient, Intermediate 25 min G0407 987 212 148.39999999999998 46.09 212 107.99 46.09 159 46.09 107.99 107.99 107.99 107.99 46.09 50.699000000000005 46.09 46.09 46.09 46.09 47.0118 46.09 4510 Bho Profee Facilty Fee 9021 Follow Up Inpatient , Complex 35 min 99233 987 303 212.1 65.87 303 154.35 65.87 227.25 65.87 154.35 154.35 154.35 154.35 65.87 72.45700000000001 65.87 65.87 65.87 65.87 67.18740000000001 65.87 4510 Bho Profee Facilty Fee 9109 Psychotherapy 30 min, add-on code for 16-37min (Pt & Family) 90836 961 199 139.29999999999998 43.26 199 101.37 43.26 149.25 43.26 101.37 101.37 101.37 101.37 43.26 47.586 43.26 43.26 43.26 43.26 44.1252 43.26 4510 Bho Profee Facilty Fee 9110 Psychotherapy 45min, Add-on code for 38-52min (Pt & Family) 99253 961 255 178.5 55.44 255 129.9 55.44 191.25 55.44 129.9 129.9 129.9 129.9 55.44 60.984 55.44 55.44 55.44 55.44 56.5488 55.44 4510 Bho Profee Facilty Fee 9111 Psychiatric diagnostic evaluation 90791 961 410 287 89.13 410 208.85 89.13 307.5 89.13 208.85 208.85 208.85 208.85 89.13 98.043 89.13 89.13 89.13 89.13 90.9126 89.13 4510 Bho Profee Facilty Fee 9112 Psychiatric diagnostic Eval w/Medical services 90792 961 430 301 93.48 430 219.04 93.48 322.5 93.48 219.04 219.04 219.04 219.04 93.48 102.82800000000002 93.48 93.48 93.48 93.48 95.34960000000001 93.48 4510 Bho Profee Facilty Fee 9113 Psychotherapy 60min, add-on for +53min,( Pt & Family) 90838 961 337 235.89999999999998 73.26 337 171.67 73.26 252.75 73.26 171.67 171.67 171.67 171.67 73.26 80.58600000000001 73.26 73.26 73.26 73.26 74.7252 73.26 4510 Bho Profee Facilty Fee 9114 Interactive Complexity 90785 961 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4510 Bho Profee Facilty Fee 9115 Psychotherapy for crisis, first 60 min 90839 961 409 286.29999999999995 88.92 409 208.34 88.92 306.75 88.92 208.34 208.34 208.34 208.34 88.92 97.81200000000001 88.92 88.92 88.92 88.92 90.6984 88.92 4510 Bho Profee Facilty Fee 9116 Psychotherapy for crisis, each additional 30 min Add-on code 90840 961 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4510 Bho Profee Facilty Fee 9108 Telehealth Facility Fee Q3014 780 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4510 Bho Profee Facilty Fee 9117 TeleHealth Inpatient Pharmacologic Management G0459 961 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4510 Bho Profee Facilty Fee 9068 INITIAL INPT EVAL- MODERATE 99222 961 402 281.4 87.4 402 204.78 87.4 301.5 87.4 204.78 204.78 204.78 204.78 87.4 96.14000000000001 87.4 87.4 87.4 87.4 89.14800000000001 87.4 4510 Bho Profee Facilty Fee 9067 INITIAL INPT EVAL-LOW SEVERITY 99221 961 297 207.89999999999998 64.57 297 151.29 64.57 222.75 64.57 151.29 151.29 151.29 151.29 64.57 71.027 64.57 64.57 64.57 64.57 65.86139999999999 64.57 4510 Bho Profee Facilty Fee 9107 INJECTION FEE 96372 961 87 60.9 18.91 87 44.32 18.91 65.25 18.91 44.32 44.32 44.32 44.32 18.91 20.801000000000002 18.91 18.91 18.91 18.91 19.2882 18.91 4630 E.M.G. Facilty Fee 6807085 DISPOSABLE NEEDLE ELECTRODES A4555 270 13 9.1 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 4630 E.M.G. Facilty Fee 6810477 EMG 1 EXTREMITY GP PER VISIT 95860 922 355 248.49999999999997 77.18 355 180.84 77.18 266.25 77.18 180.84 180.84 180.84 180.84 77.18 84.89800000000001 77.18 77.18 77.18 77.18 78.7236 77.18 4630 E.M.G. Facilty Fee 6810188 CONTRAST BATH PER 15MIN 97034 420 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4630 E.M.G. Facilty Fee 6810295 CRUTCH FIT/TRAIN GP PER 15MIN 97116 420 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4630 E.M.G. Facilty Fee 6810287 CRUTCH FITTING/TRAIN PER 15MIN 97116 420 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4630 E.M.G. Facilty Fee 6810147 EVALUATION INITIAL 97001 424 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4630 E.M.G. Facilty Fee 6810154 EVALUATION INITIAL 97001 424 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4630 E.M.G. Facilty Fee 6810402 FUNCTIONAL ACTIV GP PER 15MIN 97530 420 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4630 E.M.G. Facilty Fee 6810394 FUNCTIONAL ACTIVITIES PER 15MI 97530 420 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4630 E.M.G. Facilty Fee 6810451 FUNCTIONAL CAP GP PER 15MIN 97750 420 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4630 E.M.G. Facilty Fee 6810279 GAIT TRAINING GP PER 15MIN 97116 420 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4630 E.M.G. Facilty Fee 6810261 GAIT TRAINING PER 15MIN 97116 420 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4630 E.M.G. Facilty Fee 6810733 IONTOPHORESIS ELECTRODE E1399 270 22 15.399999999999999 4.78 22 11.21 4.78 16.5 4.78 11.21 11.21 11.21 11.21 4.78 5.258000000000001 4.78 4.78 4.78 4.78 4.8756 4.78 4630 E.M.G. Facilty Fee 6810469 IONTOPHORESIS GP PER 15MIN 97033 420 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4630 E.M.G. Facilty Fee 6810337 JOINT MOBILIZATION GP PER 15MI 97140 420 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4630 E.M.G. Facilty Fee 6810329 JOINT MOBILIZATION PER 15MIN 97140 420 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4630 E.M.G. Facilty Fee 6810311 MASSAGE GP PER 15MIN 97124 420 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4630 E.M.G. Facilty Fee 6810303 MASSAGE PER 15MIN 97124 420 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4630 E.M.G. Facilty Fee 6803 MOBILITY CURRENT STATUS G8978 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6805 MOBILITY D/C STATUS G8980 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6804 MOBILITY GOAL STATUS G8979 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6800270 MUSCLE TEST-MANUAL FULL BODY 95834 420 174 121.8 37.83 174 88.64 37.83 130.5 37.83 88.64 88.64 88.64 88.64 37.83 41.613 37.83 37.83 37.83 37.83 38.5866 37.83 4630 E.M.G. Facilty Fee 6800288 MUSCLE TEST-MANUAL ONE EXTREMI 95831 420 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4630 E.M.G. Facilty Fee 6810253 NEUROMUSCULAR RE-EDUC GP 15MIN 97112 420 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4630 E.M.G. Facilty Fee 6810246 NEUROMUSCULAR REEDUCATION 15MI 97112 420 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4630 E.M.G. Facilty Fee 6810360 ORTHOTICS FIT/TRAIN GP PER 15M 97760 420 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4630 E.M.G. Facilty Fee 6810352 ORTHOTICS FIT/TRAIN PER 15MIN 97760 420 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4630 E.M.G. Facilty Fee 6815 OTHER PT/OT CURRENT STATUS G8990 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6817 OTHER PT/OT D/C STATUS G8992 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6816 OTHER PT/OT GOAL STATUS G8991 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6810121 PARAFIN BATH SUPERVISED GP 97018 421 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4630 E.M.G. Facilty Fee 6810378 PROSTHATIC TRAINING PER 15MIN 97761 420 118 82.6 25.65 118 60.11 25.65 88.5 25.65 60.11 60.11 60.11 60.11 25.65 28.215 25.65 25.65 25.65 25.65 26.163 25.65 4630 E.M.G. Facilty Fee 6810386 PROSTHETIC TRAIN GP PER 15MIN 97761 420 118 82.6 25.65 118 60.11 25.65 88.5 25.65 60.11 60.11 60.11 60.11 25.65 28.215 25.65 25.65 25.65 25.65 26.163 25.65 4630 E.M.G. Facilty Fee 6810162 RE-EVALUATION 97002 424 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4630 E.M.G. Facilty Fee 6810170 RE-EVALUATION GP 97002 424 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4630 E.M.G. Facilty Fee 6812 SELF CARE CURRENT STATUS G8987 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6814 SELF CARE D/C STATUS G8989 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6813 SELF CARE GOAL STATUS G8988 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6810113 STIM ELEC UNATTENDED PER VIS G0283 761 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4630 E.M.G. Facilty Fee 6818 SUB. PT/OT CURRENT STATUS 97161 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6819 SUB. PT/OT GOAL STATUS 97164 420 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4630 E.M.G. Facilty Fee 6810576 TENS CONSULTATION GP PER 15MIN 97032 420 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4630 E.M.G. Facilty Fee 6810568 TENS TREATMENT GP PER 15MIN 97032 420 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4630 E.M.G. Facilty Fee 6810238 THERAP EXCERSISE GP PER 15MIN 97110 420 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4630 E.M.G. Facilty Fee 6810220 THERAPEUTIC EXERCISE PER 15MIN 97110 420 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4630 E.M.G. Facilty Fee 6836779 TRACTION HALTER E0942 274 111 77.69999999999999 24.13 111 56.54 24.13 83.25 24.13 56.54 56.54 56.54 56.54 24.13 26.543000000000003 24.13 24.13 24.13 24.13 24.6126 24.13 4630 E.M.G. Facilty Fee 6810345 TRACTION MANUAL GP PER 15MIN 97140 420 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4630 E.M.G. Facilty Fee 6810105 TRACTION, MECH PER VISIT 97012 421 111 77.69999999999999 24.13 111 56.54 24.13 83.25 24.13 56.54 56.54 56.54 56.54 24.13 26.543000000000003 24.13 24.13 24.13 24.13 24.6126 24.13 4630 E.M.G. Facilty Fee 6810212 ULTRASOUND GP PER 15MIN 97035 420 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4630 E.M.G. Facilty Fee 6810204 ULTRASOUND PER 15MIN 97035 420 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4630 E.M.G. Facilty Fee 6802 UNNA BOOT 29580 420 136 95.19999999999999 29.57 136 69.28 29.57 102 29.57 69.28 69.28 69.28 69.28 29.57 32.527 29.57 29.57 29.57 29.57 30.1614 29.57 4630 E.M.G. Facilty Fee 6810139 WHIRLPOO., EXTREMITY GP 97022 421 118 82.6 25.65 118 60.11 25.65 88.5 25.65 60.11 60.11 60.11 60.11 25.65 28.215 25.65 25.65 25.65 25.65 26.163 25.65 4630 E.M.G. Facilty Fee 6806004 WHIRLPOOL - BODY 97036 420 125 87.5 27.18 125 63.68 27.18 93.75 27.18 63.68 63.68 63.68 63.68 27.18 29.898000000000003 27.18 27.18 27.18 27.18 27.7236 27.18 4630 E.M.G. Facilty Fee 6810444 WORK HARDEN/COND GP ADD 1HR 97546 420 162 113.39999999999999 35.22 162 82.52 35.22 121.5 35.22 82.52 82.52 82.52 82.52 35.22 38.742000000000004 35.22 35.22 35.22 35.22 35.9244 35.22 4630 E.M.G. Facilty Fee 6810436 WORK HARDEN/COND GP INIT 2HR 97545 420 323 226.1 70.22 323 164.54 70.22 242.25 70.22 164.54 164.54 164.54 164.54 70.22 77.242 70.22 70.22 70.22 70.22 71.6244 70.22 4630 E.M.G. Facilty Fee 6807440 WOUND NON-SELECTIVE 97602 420 247 172.89999999999998 53.7 247 125.82 53.7 185.25 53.7 125.82 125.82 125.82 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4630 E.M.G. Facilty Fee 6807424 WOUND SELEC. DEBRIDE 97597 420 340 237.99999999999997 73.92 340 173.2 73.92 255 73.92 173.2 173.2 173.2 173.2 73.92 81.31200000000001 73.92 73.92 73.92 73.92 75.39840000000001 73.92 4640 Hos Speech Therapy Facilty Fee 6906 EVAL SWALLOWING FUNCTION 92610 440 236 165.2 51.31 236 120.22 51.31 177 51.31 120.22 120.22 120.22 120.22 51.31 56.44100000000001 51.31 51.31 51.31 51.31 52.336200000000005 51.31 4640 Hos Speech Therapy Facilty Fee 6902 EVALUATE SWALLOWING FUNCTION 92610 440 236 165.2 51.31 236 120.22 51.31 177 51.31 120.22 120.22 120.22 120.22 51.31 56.44100000000001 51.31 51.31 51.31 51.31 52.336200000000005 51.31 4640 Hos Speech Therapy Facilty Fee 6904 SPEECH EVALUATION 92506 440 264 184.79999999999998 57.39 264 134.48 57.39 198 57.39 134.48 134.48 134.48 134.48 57.39 63.129000000000005 57.39 57.39 57.39 57.39 58.537800000000004 57.39 4640 Hos Speech Therapy Facilty Fee 6900 SPEECH EVALUATION OR RE-EVAL 92506 440 264 184.79999999999998 57.39 264 134.48 57.39 198 57.39 134.48 134.48 134.48 134.48 57.39 63.129000000000005 57.39 57.39 57.39 57.39 58.537800000000004 57.39 4640 Hos Speech Therapy Facilty Fee 6901 SPEECH TREATMENT 92507 440 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4640 Hos Speech Therapy Facilty Fee 6905 SPEECH TREATMENT 92507 440 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4640 Hos Speech Therapy Facilty Fee 6903 TREAT SWALLOWING/DYSFUNCTION 92526 440 200 140 43.48 200 101.88 43.48 150 43.48 101.88 101.88 101.88 101.88 43.48 47.828 43.48 43.48 43.48 43.48 44.349599999999995 43.48 4640 Hos Speech Therapy Facilty Fee 6907 TRTMNT SWALLOWING DYSFUNCTIOON 92526 440 200 140 43.48 200 101.88 43.48 150 43.48 101.88 101.88 101.88 101.88 43.48 47.828 43.48 43.48 43.48 43.48 44.349599999999995 43.48 4650 Hos Occupational Therapy Facilty Fee 46505 ADL 97535 430 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4650 Hos Occupational Therapy Facilty Fee 46512 ADL 97535 430 80 56 17.39 80 40.75 17.39 60 17.39 40.75 40.75 40.75 40.75 17.39 19.129 17.39 17.39 17.39 17.39 17.7378 17.39 4650 Hos Occupational Therapy Facilty Fee 46508 FUNCTIONAL ACTIVITIES 97530 430 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4650 Hos Occupational Therapy Facilty Fee 46515 FUNCTIONAL ACTIVITIES 97530 430 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4650 Hos Occupational Therapy Facilty Fee 46507 MANUAL THERAPY 97140 430 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4650 Hos Occupational Therapy Facilty Fee 46514 MANUAL THERAPY 97140 430 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4650 Hos Occupational Therapy Facilty Fee 46509 NEUROMUSC RE-ED 97112 430 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4650 Hos Occupational Therapy Facilty Fee 46516 NEUROMUSC RE-ED 97112 430 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4650 Hos Occupational Therapy Facilty Fee 46501 O T EVALUATION 97165 434 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4650 Hos Occupational Therapy Facilty Fee 46502 O T EVALUATION 97165 434 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4650 Hos Occupational Therapy Facilty Fee 46503 O T RE-EVALUATION 97165 434 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4650 Hos Occupational Therapy Facilty Fee 46504 O T RE-EVALUATION 97165 434 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4650 Hos Occupational Therapy Facilty Fee 46511 ORTHOTIC FITTING 97760 430 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4650 Hos Occupational Therapy Facilty Fee 46518 ORTHOTIC FITTING 97760 430 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4650 Hos Occupational Therapy Facilty Fee 46510 PARAFFIN 97018 430 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4650 Hos Occupational Therapy Facilty Fee 46517 PARAFFIN 97018 430 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4650 Hos Occupational Therapy Facilty Fee 46513 THERAPUETIC EXCERCISE 97110 430 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4650 Hos Occupational Therapy Facilty Fee 46506 THERAPY 97110 430 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4730 Frc Rural Health Clinic Facilty Fee 9508 ALLERGY INJECTION:SINGLE 95115 521 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9512 PEDIARIX DTAP,HEP B AND IPV 90723 771 11 7.699999999999999 2.39 11 5.6 2.39 8.25 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 4730 Frc Rural Health Clinic Facilty Fee 9525 DECADRON 1MG 95115 636 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9526 DECADRON LA 1MG 90723 636 5 3.5 1.09 5 2.55 1.09 3.75 1.09 2.55 2.55 2.55 2.55 1.09 1.1990000000000003 1.09 1.09 1.09 1.09 1.1118000000000001 1.09 4730 Frc Rural Health Clinic Facilty Fee 9528 INSULIN 5 UNITS J1100 636 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4730 Frc Rural Health Clinic Facilty Fee 9546 VARICELLA VACCINE J1094 771 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4730 Frc Rural Health Clinic Facilty Fee 9547 BICILLIN LA 1.2 MMU J1815 636 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4730 Frc Rural Health Clinic Facilty Fee 9548 COBAN 90716 270 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9551 ROUT CULT EA ADDTL SITE J0570 306 62 43.4 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 4730 Frc Rural Health Clinic Facilty Fee 9553 INFLUENZA SWAB A&B 87400 302 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4730 Frc Rural Health Clinic Facilty Fee 9569 FUNGAL CULTURE SKIN HAIR NAIL 87070 306 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4730 Frc Rural Health Clinic Facilty Fee 9570 FUNGAL CULTURE OTHER 87804 306 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4730 Frc Rural Health Clinic Facilty Fee 9573 VIRAL CULTURE 87101 521 249 174.29999999999998 54.13 249 126.84 54.13 186.75 54.13 126.84 126.84 126.84 126.84 54.13 59.543000000000006 54.13 54.13 54.13 54.13 55.2126 54.13 4730 Frc Rural Health Clinic Facilty Fee 9575 FUNGAL CULT (HAIR, SKIN) 87102 521 82 57.4 17.83 82 41.77 17.83 61.5 17.83 41.77 41.77 41.77 41.77 17.83 19.613 17.83 17.83 17.83 17.83 18.1866 17.83 4730 Frc Rural Health Clinic Facilty Fee 9576 AFT OR FLUORESCENT STAIN 87252 521 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4730 Frc Rural Health Clinic Facilty Fee 9577 TYPHUS IGG 87102 521 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4730 Frc Rural Health Clinic Facilty Fee 9578 TYPHUS IGM 87206 521 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4730 Frc Rural Health Clinic Facilty Fee 9584 HPV IMMUNIZATION GARDASIL 86757 771 184 128.79999999999998 40 184 93.73 40 138 40 93.73 93.73 93.73 93.73 40 44 40 40 40 40 40.8 40 4730 Frc Rural Health Clinic Facilty Fee 9585 HEPA ADULT DOSE 86757 771 245 171.5 53.26 245 124.8 53.26 183.75 53.26 124.8 124.8 124.8 124.8 53.26 58.586000000000006 53.26 53.26 53.26 53.26 54.3252 53.26 4730 Frc Rural Health Clinic Facilty Fee 9589 DTAP < 7 YRS 90469 771 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4730 Frc Rural Health Clinic Facilty Fee 9590 WT PROGRAM W/BCOMPLEX INJECT. 90632 942 53 37.099999999999994 11.52 53 27 11.52 39.75 11.52 27 27 27 27 11.52 12.672 11.52 11.52 11.52 11.52 11.750399999999999 11.52 4730 Frc Rural Health Clinic Facilty Fee 9591 WT PROGRAM W/O BCOMPLEX INJECT 90700 942 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4730 Frc Rural Health Clinic Facilty Fee 9592 HEPATITIS A VACCINE SINGLE DOS 90632 250 53 37.099999999999994 11.52 53 27 11.52 39.75 11.52 27 27 27 27 11.52 12.672 11.52 11.52 11.52 11.52 11.750399999999999 11.52 4730 Frc Rural Health Clinic Facilty Fee 9594 CASH HEPATITIS B VACCINE 90746 771 32 22.4 6.96 32 16.3 6.96 24 6.96 16.3 16.3 16.3 16.3 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 4730 Frc Rural Health Clinic Facilty Fee 9595 TDAP VACCINE 90633 771 69 48.3 15 69 35.15 15 51.75 15 35.15 35.15 35.15 35.15 15 16.5 15 15 15 15 15.3 15 4730 Frc Rural Health Clinic Facilty Fee 9596 CASH TDAP VACCINE 90744 771 53 37.099999999999994 11.52 53 27 11.52 39.75 11.52 27 27 27 27 11.52 12.672 11.52 11.52 11.52 11.52 11.750399999999999 11.52 4730 Frc Rural Health Clinic Facilty Fee 9597 CASH VARICELLA VACCINE 90715 771 105 73.5 22.83 105 53.49 22.83 78.75 22.83 53.49 53.49 53.49 53.49 22.83 25.113 22.83 22.83 22.83 22.83 23.2866 22.83 4730 Frc Rural Health Clinic Facilty Fee 9598 MENINGITIS VACCINE 90715 771 300 210 65.22 300 152.82 65.22 225 65.22 152.82 152.82 152.82 152.82 65.22 71.742 65.22 65.22 65.22 65.22 66.5244 65.22 4730 Frc Rural Health Clinic Facilty Fee 9599 CASH MENINGITIS VACCINE 90716 771 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4730 Frc Rural Health Clinic Facilty Fee 9600 CASH HPV 90734 771 158 110.6 34.35 158 80.49 34.35 118.5 34.35 80.49 80.49 80.49 80.49 34.35 37.785000000000004 34.35 34.35 34.35 34.35 35.037 34.35 4730 Frc Rural Health Clinic Facilty Fee 9601 MARCAINE / XYLOCAINE 90734 250 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9602 PNEUMOVAX 90649 771 31 21.7 6.74 31 15.79 6.74 23.25 6.74 15.79 15.79 15.79 15.79 6.74 7.414000000000001 6.74 6.74 6.74 6.74 6.8748000000000005 6.74 4730 Frc Rural Health Clinic Facilty Fee 9603 H1N1 ADMINISTRATION S0020 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9605 PPD 90470 302 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4730 Frc Rural Health Clinic Facilty Fee 9606 SHAVING OF EPID. OR DER.LESION 90663 521 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4730 Frc Rural Health Clinic Facilty Fee 9607 BIOPSY OF SKIN, SINGLE LESION 86580 521 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4730 Frc Rural Health Clinic Facilty Fee 9608 BIOPSY OF SKIN, EA. SEP/ADD 11031 521 49 34.3 10.65 49 24.96 10.65 36.75 10.65 24.96 24.96 24.96 24.96 10.65 11.715000000000002 10.65 10.65 10.65 10.65 10.863000000000001 10.65 4730 Frc Rural Health Clinic Facilty Fee 9609 EKG W/INTERPRETATION 11100 730 132 92.39999999999999 28.7 132 67.24 28.7 99 28.7 67.24 67.24 67.24 67.24 28.7 31.57 28.7 28.7 28.7 28.7 29.274 28.7 4730 Frc Rural Health Clinic Facilty Fee 9610 LIPOTONIX PLUS 11101 250 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4730 Frc Rural Health Clinic Facilty Fee 9611 LAB CORP VENIPUNCTURE 93010 300 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4730 Frc Rural Health Clinic 9612 ANNUAL WELLNESS VISIT, INITIAL G0439 521 129 90.3 28.04 129 65.71 28.04 96.75 28.04 65.71 65.71 65.71 65.71 28.04 30.844 28.04 28.04 28.04 28.04 28.6008 28.04 4730 Frc Rural Health Clinic 9613 ANNUAL WELLNESS VISIT SUBSQT 99000 521 108 75.6 23.48 108 55.02 23.48 81 23.48 55.02 55.02 55.02 55.02 23.48 25.828000000000003 23.48 23.48 23.48 23.48 23.9496 23.48 4730 Frc Rural Health Clinic Facilty Fee 9614 LAB CORP VENIPUNCTURE G0438 300 11 7.699999999999999 2.39 11 5.6 2.39 8.25 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 4730 Frc Rural Health Clinic Facilty Fee 9615 Cash Flu Shot G0439 250 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4730 Frc Rural Health Clinic Facilty Fee 9616 No Charge Follow-up Visit 36415 521 0.01 0.006999999999999999 0.01 0.01 0.01 0.01 0.01 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.0102 0.01 4730 Frc Rural Health Clinic Facilty Fee 9617 Removal of toenail plate 11730 521 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4730 Frc Rural Health Clinic Facilty Fee 9618 Initial IV access 99211 260 91 63.699999999999996 19.78 91 46.36 19.78 68.25 19.78 46.36 46.36 46.36 46.36 19.78 21.758000000000003 19.78 19.78 19.78 19.78 20.175600000000003 19.78 4730 Frc Rural Health Clinic Facilty Fee 9819 Needle 20G X 1.5 Sterile A4215 270 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4730 Frc Rural Health Clinic Facilty Fee 9820 Nerve Block - Other peripheral nerve or branch 36000 521 135 94.5 29.35 135 68.77 29.35 101.25 29.35 68.77 68.77 68.77 68.77 29.35 32.285000000000004 29.35 29.35 29.35 29.35 29.937 29.35 4730 Frc Rural Health Clinic Facilty Fee 9821 Closed treatment of joint dislocation single w/o anesthesia N/A 521 786 550.1999999999999 170.88 786 400.39 170.88 589.5 170.88 400.39 400.39 400.39 400.39 170.88 187.96800000000002 170.88 170.88 170.88 170.88 174.2976 170.88 4730 Frc Rural Health Clinic Facilty Fee 9822 Zofran 4mg tablet 64450 250 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4730 Frc Rural Health Clinic Facilty Fee 9823 Demerol 50mg 26770 636 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9824 Atrovent, Ipratropium Bromide N/A 250 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4730 Frc Rural Health Clinic Facilty Fee 9825 Lovenox 80mg J2175 636 169 118.3 36.74 169 86.09 36.74 126.75 36.74 86.09 86.09 86.09 86.09 36.74 40.41400000000001 36.74 36.74 36.74 36.74 37.4748 36.74 4730 Frc Rural Health Clinic Facilty Fee 9826 Novolog N/A 259 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4730 Frc Rural Health Clinic Facilty Fee 9827 Toradol 10mg J1650 250 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4730 Frc Rural Health Clinic Facilty Fee 9828 Aspirin 325mg Tab G8598 250 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9829 Hydrochlorathiazide 25mg J3490 637 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9830 Valsartan 80mg J8499 637 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9831 Olanzapine 15mg 99422 250 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4730 Frc Rural Health Clinic Facilty Fee 9832 Online Digital E&M Service 5-10minutes for up to 7 days 99423 521 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4730 Frc Rural Health Clinic Facilty Fee 9833 Online digital E&M for established patient for up to 7 days 11-20 minutes 99421 521 137 95.89999999999999 29.78 137 69.79 29.78 102.75 29.78 69.79 69.79 69.79 69.79 29.78 32.758 29.78 29.78 29.78 29.78 30.375600000000002 29.78 4730 Frc Rural Health Clinic Facilty Fee 9834 Online digital E&M for established patient for up to 7 days 21 or more minutes 99421 521 218 152.6 47.39 218 111.05 47.39 163.5 47.39 111.05 111.05 111.05 111.05 47.39 52.129000000000005 47.39 47.39 47.39 47.39 48.3378 47.39 4730 Frc Rural Health Clinic Facilty Fee 9835 Covid 19 test 99422 300 102 71.39999999999999 22.17 102 51.96 22.17 76.5 22.17 51.96 51.96 51.96 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 4730 Frc Rural Health Clinic Facilty Fee 9836 Orphenadine 60mg/2ml injection 99423 636 15 10.5 3.26 15 7.64 3.26 11.25 3.26 7.64 7.64 7.64 7.64 3.26 3.586 3.26 3.26 3.26 3.26 3.3251999999999997 3.26 4730 Frc Rural Health Clinic Facilty Fee 9840 Rapid Screening Covid/Flu U0002 521 90 62.99999999999999 19.57 90 45.85 19.57 67.5 19.57 45.85 45.85 45.85 45.85 19.57 21.527 19.57 19.57 19.57 19.57 19.9614 19.57 4730 Frc Rural Health Clinic Professional Fees 9500000 NEW PT LEVEL 2 J2360 521 178 124.6 38.7 178 87.29 38.7 133.5 38.7 87.29 87.29 87.29 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4730 Frc Rural Health Clinic Professional Fees 9500018 NEW PT LEVEL 1 87428 521 166 116.19999999999999 36.09 166 87.29 36.09 124.5 36.09 87.29 87.29 87.29 84.56 36.09 39.699000000000005 36.09 36.09 36.09 36.09 36.811800000000005 36.09 4730 Frc Rural Health Clinic Professional Fees 9500059 NEW PT LEVEL 3 99213 521 192 134.39999999999998 41.74 192 87.29 41.74 144 41.74 87.29 87.29 87.29 97.8 41.74 45.91400000000001 41.74 41.74 41.74 41.74 42.5748 41.74 4730 Frc Rural Health Clinic Professional Fees 9500109 NEW PT LEVEL 4 99202 521 231 161.7 50.22 231 87.29 50.22 173.25 50.22 87.29 87.29 87.29 117.67 50.22 55.242000000000004 50.22 50.22 50.22 50.22 51.2244 50.22 4730 Frc Rural Health Clinic Professional Fees 9500117 NEW PT LEVEL 5 99201 521 310 217 67.39 310 87.29 67.39 232.5 67.39 87.29 87.29 87.29 157.91 67.39 74.129 67.39 67.39 67.39 67.39 68.73780000000001 67.39 4730 Frc Rural Health Clinic Professional Fees 9500158 ESTAB PATIENT LEVEL 1 99203 521 137 95.89999999999999 29.78 137 87.29 29.78 102.75 29.78 87.29 87.29 87.29 69.79 29.78 32.758 29.78 29.78 29.78 29.78 30.375600000000002 29.78 4730 Frc Rural Health Clinic Professional Fees 9500208 ESTAB PATIENT LEVEL 2 99204 521 152 106.39999999999999 33.04 152 87.29 33.04 114 33.04 87.29 87.29 87.29 77.43 33.04 36.344 33.04 33.04 33.04 33.04 33.7008 33.04 4730 Frc Rural Health Clinic Professional Fees 9500257 ESTAB PATIENT LEVEL 3 99205 521 175 122.49999999999999 38.05 175 87.29 38.05 131.25 38.05 87.29 87.29 87.29 89.15 38.05 41.855 38.05 38.05 38.05 38.05 38.811 38.05 4730 Frc Rural Health Clinic Professional Fees 9500307 ESTAB PATIENT LEVEL 4 99211 521 180 125.99999999999999 39.13 180 87.29 39.13 135 39.13 87.29 87.29 87.29 91.69 39.13 43.043000000000006 39.13 39.13 39.13 39.13 39.912600000000005 39.13 4730 Frc Rural Health Clinic Professional Fees 9500356 ESTAB PATIENT LEVEL 5 99212 521 231 161.7 50.22 231 87.29 50.22 173.25 50.22 87.29 87.29 87.29 117.67 50.22 55.242000000000004 50.22 50.22 50.22 50.22 51.2244 50.22 4730 Frc Rural Health Clinic Professional Fees 9500406 CONSULTATION-MINIMAL 99213 521 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4730 Frc Rural Health Clinic Professional Fees 9500455 CONSULTATION-MODERATE 99214 521 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4730 Frc Rural Health Clinic Professional Fees 9500505 CONSULTATION-ADVANCED 99215 521 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4730 Frc Rural Health Clinic Facilty Fee 9501008 URINE DIP 99241 521 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4730 Frc Rural Health Clinic Facilty Fee 9502378 HEMOGLOBIN 99243 305 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9502402 ROUTINE VENIPUNCTURE 81002 300 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4730 Frc Rural Health Clinic Facilty Fee 9502709 PSA - (SCREENING) 81002 300 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4730 Frc Rural Health Clinic Facilty Fee 9502964 THROAT CULTURE RAPID STREP 85018 302 50 35 10.87 50 25.47 10.87 37.5 10.87 25.47 25.47 25.47 25.47 10.87 11.957 10.87 10.87 10.87 10.87 11.087399999999999 10.87 4730 Frc Rural Health Clinic Facilty Fee 9503087 URINALYSIS 36415 307 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4730 Frc Rural Health Clinic Facilty Fee 9503103 URINE CULTURE 87086 306 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4730 Frc Rural Health Clinic Facilty Fee 9503186 SIMPLE REPAIR T/E 2.5cm 81000 521 161 112.69999999999999 35 161 82.01 35 120.75 35 82.01 82.01 82.01 82.01 35 38.5 35 35 35 35 35.7 35 4730 Frc Rural Health Clinic Facilty Fee 9503202 SIMPLE REPAIR T/E 2.6-7.5cm 87086 521 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4730 Frc Rural Health Clinic Facilty Fee 9503210 SIMPLE REPAIR T/E 7.6-12.5cm 87086 521 258 180.6 56.09 258 131.43 56.09 193.5 56.09 131.43 131.43 131.43 131.43 56.09 61.69900000000001 56.09 56.09 56.09 56.09 57.211800000000004 56.09 4730 Frc Rural Health Clinic Facilty Fee 9503228 SIMPLE REPAIR T/E 12.6-20.0cm 12001 521 368 257.59999999999997 80 368 187.46 80 276 80 187.46 187.46 187.46 187.46 80 88 80 80 80 80 81.6 80 4730 Frc Rural Health Clinic Facilty Fee 9503301 SIMPLE FACE/HEAD 2.5cm or < 12002 521 212 148.39999999999998 46.09 212 107.99 46.09 159 46.09 107.99 107.99 107.99 107.99 46.09 50.699000000000005 46.09 46.09 46.09 46.09 47.0118 46.09 4730 Frc Rural Health Clinic Facilty Fee 9503319 SIMPLE FACE/HEAD 2.6-5.0cm 12004 521 260 182 56.52 260 132.44 56.52 195 56.52 132.44 132.44 132.44 132.44 56.52 62.17200000000001 56.52 56.52 56.52 56.52 57.650400000000005 56.52 4730 Frc Rural Health Clinic Facilty Fee 9503327 SIMPLE FACE/HEAD 5.1-7.5cm 12005 521 322 225.39999999999998 70 322 164.03 70 241.5 70 164.03 164.03 164.03 164.03 70 77 70 70 70 70 71.4 70 4730 Frc Rural Health Clinic Facilty Fee 9503335 SIMPLE FACE/HEAD 7.6-12.5cm 12011 521 399 279.29999999999995 86.74 399 203.25 86.74 299.25 86.74 203.25 203.25 203.25 203.25 86.74 95.414 86.74 86.74 86.74 86.74 88.4748 86.74 4730 Frc Rural Health Clinic Facilty Fee 9503343 SIMPLE FACE/HEAD 12.6-20.0cm 12013 521 508 355.59999999999997 110.44 508 258.78 110.44 381 110.44 258.78 258.78 258.78 258.78 110.44 121.48400000000001 110.44 110.44 110.44 110.44 112.6488 110.44 4730 Frc Rural Health Clinic Facilty Fee 9503376 LAYER CLSR S/T/E 2.5cm 12014 521 230 161 50 230 117.16 50 172.5 50 117.16 117.16 117.16 117.16 50 55.00000000000001 50 50 50 50 51 50 4730 Frc Rural Health Clinic Facilty Fee 9503384 LAYER CLSR S/T/E 2.6-7.5cm 122015 521 328 229.6 71.31 328 167.08 71.31 246 71.31 167.08 167.08 167.08 167.08 71.31 78.441 71.31 71.31 71.31 71.31 72.7362 71.31 4730 Frc Rural Health Clinic Facilty Fee 9503392 LAYER CLSR S/T/E 7.6-12.5cm 12016 521 382 267.4 83.05 382 194.59 83.05 286.5 83.05 194.59 194.59 194.59 194.59 83.05 91.355 83.05 83.05 83.05 83.05 84.711 83.05 4730 Frc Rural Health Clinic Facilty Fee 9503400 LAYER CLSR S/T/E 12.6-20.0cm 12031 521 467 326.9 101.53 467 237.89 101.53 350.25 101.53 237.89 237.89 237.89 237.89 101.53 111.683 101.53 101.53 101.53 101.53 103.56060000000001 101.53 4730 Frc Rural Health Clinic Facilty Fee 9503426 PREGNANCY TEST,URINE 12032 300 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4730 Frc Rural Health Clinic Facilty Fee 9503509 LAYER CLSR FACE 2.5cm 12034 521 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4730 Frc Rural Health Clinic Facilty Fee 9503517 LAYER CLSR FACE 2.6-5.0cm 12035 521 404 282.79999999999995 87.83 404 205.8 87.83 303 87.83 205.8 205.8 205.8 205.8 87.83 96.613 87.83 87.83 87.83 87.83 89.5866 87.83 4730 Frc Rural Health Clinic Facilty Fee 9503525 LAYER CLSR FACE 5.1-7.5cm 81025 521 462 323.4 100.44 462 235.34 100.44 346.5 100.44 235.34 235.34 235.34 235.34 100.44 110.48400000000001 100.44 100.44 100.44 100.44 102.4488 100.44 4730 Frc Rural Health Clinic Facilty Fee 9503533 LAYER CLSR FACE 7.6-12.5cm 12051 521 572 400.4 124.35 572 291.38 124.35 429 124.35 291.38 291.38 291.38 291.38 124.35 136.785 124.35 124.35 124.35 124.35 126.837 124.35 4730 Frc Rural Health Clinic Facilty Fee 9503608 REMOVAL FOREIGN BODY,SIMPLE 12052 521 593 415.09999999999997 128.92 593 302.07 128.92 444.75 128.92 302.07 302.07 302.07 302.07 128.92 141.812 128.92 128.92 128.92 128.92 131.4984 128.92 4730 Frc Rural Health Clinic Facilty Fee 9503616 REMOVAL FOREIGN BODY,COMPLICAT 12053 521 393 275.09999999999997 85.44 393 200.19 85.44 294.75 85.44 200.19 200.19 200.19 200.19 85.44 93.98400000000001 85.44 85.44 85.44 85.44 87.1488 85.44 4730 Frc Rural Health Clinic Facilty Fee 9503624 REMOVE FB,FOOT SQ 12054 521 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4730 Frc Rural Health Clinic Facilty Fee 9503707 EXC.BENIGN LESION,EXT3.1-4.0cm 10120 521 400 280 86.96 400 87.29 86.96 300 86.96 87.29 87.29 87.29 203.76 86.96 95.656 86.96 86.96 86.96 86.96 88.69919999999999 86.96 4730 Frc Rural Health Clinic Facilty Fee 9503715 EXC.BENIGN LESION,EXT > 4.0cm 10121 521 554 387.79999999999995 120.44 554 87.29 120.44 415.5 120.44 87.29 87.29 87.29 282.21 120.44 132.484 120.44 120.44 120.44 120.44 122.8488 120.44 4730 Frc Rural Health Clinic Facilty Fee 9503723 REMOVAL OF SKIN TAGS Up To 15 28190 521 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4730 Frc Rural Health Clinic Facilty Fee 9503731 REMOVAL OF EA ADDTL 10 LESIONS 11404 521 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4730 Frc Rural Health Clinic Facilty Fee 9503749 REMOVE FB EAR 11406 521 129 90.3 28.04 129 65.71 28.04 96.75 28.04 65.71 65.71 65.71 65.71 28.04 30.844 28.04 28.04 28.04 28.04 28.6008 28.04 4730 Frc Rural Health Clinic Facilty Fee 9503871 PREGNANCY TEST,SERUM 11200 301 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4730 Frc Rural Health Clinic Facilty Fee 9504002 RPR TRUNK COMPLEX 1.1-2.5cm 11201 521 360 251.99999999999997 78.26 360 183.38 78.26 270 78.26 183.38 183.38 183.38 183.38 78.26 86.08600000000001 78.26 78.26 78.26 78.26 79.82520000000001 78.26 4730 Frc Rural Health Clinic Facilty Fee 9504010 RPR TRUNK COMPLEX 2.6-7.5cm 69200 521 487 340.9 105.87 487 248.08 105.87 365.25 105.87 248.08 248.08 248.08 248.08 105.87 116.45700000000001 105.87 105.87 105.87 105.87 107.98740000000001 105.87 4730 Frc Rural Health Clinic Facilty Fee 9504374 IRON 84703 301 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4730 Frc Rural Health Clinic Facilty Fee 9504697 PAP SMEAR (BRST & PELVIC EXAM) 13100 521 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4730 Frc Rural Health Clinic Facilty Fee 9504739 CHLAYMDIA CULTURE 13101 306 71 49.699999999999996 15.44 71 36.17 15.44 53.25 15.44 36.17 36.17 36.17 36.17 15.44 16.984 15.44 15.44 15.44 15.44 15.7488 15.44 4730 Frc Rural Health Clinic Facilty Fee 9504754 WET MOUNT 83540 306 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4730 Frc Rural Health Clinic Facilty Fee 9505009 CULTURE, ROUTINE G0101 306 45 31.499999999999996 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 4730 Frc Rural Health Clinic Facilty Fee 9505082 GC/STREP PLATE 87110 306 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4730 Frc Rural Health Clinic Facilty Fee 9505157 HEMOCCULT:BLOOD 87210 521 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9505454 DRUG SCREEN 87070 301 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4730 Frc Rural Health Clinic Facilty Fee 9505595 PARIETAL CELL ANTIBODIES 87081 300 67 46.9 14.57 67 34.13 14.57 50.25 14.57 34.13 34.13 34.13 34.13 14.57 16.027 14.57 14.57 14.57 14.57 14.8614 14.57 4730 Frc Rural Health Clinic Facilty Fee 9505793 LEAD 82270 300 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4730 Frc Rural Health Clinic Facilty Fee 9506015 URINE CULT. QUANT. COL. CT. 80100 306 46 32.199999999999996 10 46 23.43 10 34.5 10 23.43 23.43 23.43 23.43 10 11 10 10 10 10 10.2 10 4730 Frc Rural Health Clinic Facilty Fee 9506486 KOH PREP 86255 306 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9506684 LAB HANDLING FEE 99070 300 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9506783 VAGINAL CULTURE & SENS 87086 306 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4730 Frc Rural Health Clinic Facilty Fee 9506841 TB TINE TEST 7220 302 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9506866 PSA,DIAGNOSTIC 99000 301 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4730 Frc Rural Health Clinic Facilty Fee 9506908 ALLERGY INJ (MULTIPLE) 88142 250 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9506924 DEBRIDEMENT OF SKIN SQ TISSUE 86580 521 315 220.5 68.48 315 160.46 68.48 236.25 68.48 160.46 160.46 160.46 160.46 68.48 75.32800000000002 68.48 68.48 68.48 68.48 69.84960000000001 68.48 4730 Frc Rural Health Clinic Facilty Fee 9506940 LESION PARING(CORN,CALLUS)ONE 84153 521 79 55.3 17.17 79 40.24 17.17 59.25 17.17 40.24 40.24 40.24 40.24 17.17 18.887000000000004 17.17 17.17 17.17 17.17 17.5134 17.17 4730 Frc Rural Health Clinic Facilty Fee 9506957 LESION PARING 2-4(CORN,CALLUS) 95117 521 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4730 Frc Rural Health Clinic Facilty Fee 9506965 LINCOCIN 1cc 11042 636 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9506973 NAIL REMOVAL,AVULSION 11055 521 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4730 Frc Rural Health Clinic Facilty Fee 9506981 NAIL REVISION,INGROWN 11056 521 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4730 Frc Rural Health Clinic Facilty Fee 9507021 ORAL POLIO VACCINE 11730 771 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9507039 PFT WITH BRONCHODILATOR 11730 460 163 114.1 35.44 163 83.03 35.44 122.25 35.44 83.03 83.03 83.03 83.03 35.44 38.984 35.44 35.44 35.44 35.44 36.1488 35.44 4730 Frc Rural Health Clinic Professional Fees 9507047 PHYS NP AGE 1-4 11765 521 107 74.89999999999999 23.26 107 87.29 23.26 80.25 23.26 87.29 87.29 87.29 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4730 Frc Rural Health Clinic Professional Fees 9507054 PHYS NP AGE 5-11 90712 521 121 84.69999999999999 26.31 121 87.29 26.31 90.75 26.31 87.29 87.29 87.29 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4730 Frc Rural Health Clinic Professional Fees 9507062 PHYS NP AGE 12-17 94060 521 131 91.69999999999999 28.48 131 87.29 28.48 98.25 28.48 87.29 87.29 87.29 66.73 28.48 31.328000000000003 28.48 28.48 28.48 28.48 29.0496 28.48 4730 Frc Rural Health Clinic Professional Fees 9507070 PHYS NP AGE 18-39 99382 521 148 103.6 32.18 148 87.29 32.18 111 32.18 87.29 87.29 87.29 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4730 Frc Rural Health Clinic Professional Fees 9507088 PHYS NP AGE 40-64 99383 521 153 107.1 33.26 153 87.29 33.26 114.75 33.26 87.29 87.29 87.29 77.94 33.26 36.586 33.26 33.26 33.26 33.26 33.9252 33.26 4730 Frc Rural Health Clinic Professional Fees 9507096 PHYS NP AGE 65 AND OLDER 99384 521 173 121.1 37.61 173 87.29 37.61 129.75 37.61 87.29 87.29 87.29 88.13 37.61 41.371 37.61 37.61 37.61 37.61 38.3622 37.61 4730 Frc Rural Health Clinic Professional Fees 9507104 PHYS EST PT AGE 0-1 99385 521 75 52.5 16.31 75 87.29 16.31 56.25 16.31 87.29 87.29 87.29 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4730 Frc Rural Health Clinic Professional Fees 9507112 PHYS NP PT AGE 0-1 99386 521 102 71.39999999999999 22.17 102 87.29 22.17 76.5 22.17 87.29 87.29 87.29 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 4730 Frc Rural Health Clinic Professional Fees 9507120 PHYS EST PT 1-4 99387 521 85 59.49999999999999 18.48 85 87.29 18.48 63.75 18.48 87.29 87.29 87.29 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4730 Frc Rural Health Clinic Professional Fees 9507138 PHYS EST PT AGE 5-11 99391 521 95 66.5 20.65 95 87.29 20.65 71.25 20.65 87.29 87.29 87.29 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4730 Frc Rural Health Clinic Professional Fees 9507146 PHYS EST PT AGE 12-17 99381 521 106 74.19999999999999 23.04 106 87.29 23.04 79.5 23.04 87.29 87.29 87.29 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4730 Frc Rural Health Clinic Professional Fees 9507153 PHYS EST PT AGE 18-39 99392 521 115 80.5 25 115 87.29 25 86.25 25 87.29 87.29 87.29 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4730 Frc Rural Health Clinic Professional Fees 9507161 Health Screening PHYS EST PT AGE 40-64 99393 521 129 90.3 28.04 129 87.29 28.04 96.75 28.04 87.29 87.29 87.29 65.71 28.04 30.844 28.04 28.04 28.04 28.04 28.6008 28.04 4730 Frc Rural Health Clinic Professional Fees 9507179 PHYS EST PT AGE 65 AND OLDER 99394 521 144 100.8 31.31 144 87.29 31.31 108 31.31 87.29 87.29 87.29 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4730 Frc Rural Health Clinic Facilty Fee 9507187 PROCARDIA 10MG SL 99395 636 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9507195 PUNCTURE ASP OF ABSCESS 99396 521 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4730 Frc Rural Health Clinic Facilty Fee 9507211 REMOVE IMBEDDED FB EYELID 99397 521 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4730 Frc Rural Health Clinic Facilty Fee 9507229 RPR FACE COMPLEX 2.6-7.5cm J3490 521 1265 885.5 275.01 1265 644.39 275.01 948.75 275.01 644.39 644.39 644.39 644.39 275.01 302.511 275.01 275.01 275.01 275.01 280.5102 275.01 4730 Frc Rural Health Clinic Facilty Fee 9507237 REPORTS, INS FORMS, ETC 10160 521 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9507286 SPLINT,COCKUP 67938 270 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4730 Frc Rural Health Clinic Facilty Fee 9507294 SPLINT,FINGER 13512 270 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9507302 SPLINT,WRIST 99080 270 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4730 Frc Rural Health Clinic Facilty Fee 9507310 TUBE REMOVAL, EAR A4570 521 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4730 Frc Rural Health Clinic Facilty Fee 9507336 VISCOUS LIDOCAINE A4570 259 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9507393 DIGITAL RECTAL EXAM A4570 305 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4730 Frc Rural Health Clinic Facilty Fee 9507419 ADMIN OF VACCINE TOXOID 1st 69424 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9507427 ADMIN OF HEPATITIS B VACCINE G0102 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9507435 ADMIN OF VACCINE/TOXOIDS EA.AD G0102 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9507450 WEIGHT PROGRAM,FOLLOW UP 90471 521 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9508842 CULTURE ANAEROBIC 90471 306 74 51.8 16.09 74 37.7 16.09 55.5 16.09 37.7 37.7 37.7 37.7 16.09 17.699 16.09 16.09 16.09 16.09 16.4118 16.09 4730 Frc Rural Health Clinic Facilty Fee 9510116 EYE TRAY 90472 272 23 16.099999999999998 5 23 11.72 5 17.25 5 11.72 11.72 11.72 11.72 5 5.5 5 5 5 5 5.1 5 4730 Frc Rural Health Clinic Facilty Fee 9510140 SPLINT,ANKLE 99211 270 58 40.599999999999994 12.61 58 29.55 12.61 43.5 12.61 29.55 29.55 29.55 29.55 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 4730 Frc Rural Health Clinic Facilty Fee 9510215 INJECTION FEE 87075 521 83 58.099999999999994 18.04 83 42.28 18.04 62.25 18.04 42.28 42.28 42.28 42.28 18.04 19.844 18.04 18.04 18.04 18.04 18.4008 18.04 4730 Frc Rural Health Clinic Facilty Fee 9510235 AEROBIC ISOLATE ID 99070 306 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9510603 FINGERSTICK, GLUCOSE A4570 521 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9520008 EKG 96372 730 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4730 Frc Rural Health Clinic Facilty Fee 9520107 HIGH FLOW NEBULIZER 87077 521 91 63.699999999999996 19.78 91 46.36 19.78 68.25 19.78 46.36 46.36 46.36 46.36 19.78 21.758000000000003 19.78 19.78 19.78 19.78 20.175600000000003 19.78 4730 Frc Rural Health Clinic Facilty Fee 9520115 DRUG SCREEN COLLECT FEE 82962 521 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4730 Frc Rural Health Clinic Facilty Fee 9520156 EAR IRRIGATION,IMPACTED CER. 93005 521 146 102.19999999999999 31.74 146 74.37 31.74 109.5 31.74 74.37 74.37 74.37 74.37 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 4730 Frc Rural Health Clinic Facilty Fee 9520198 AEROCHAMBER 94664 270 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9520206 TRIGGER POINT 99001 521 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4730 Frc Rural Health Clinic Facilty Fee 9520404 I&D ABSCESS 69210 521 324 226.79999999999998 70.44 324 165.05 70.44 243 70.44 165.05 165.05 165.05 165.05 70.44 77.48400000000001 70.44 70.44 70.44 70.44 71.8488 70.44 4730 Frc Rural Health Clinic Facilty Fee 9520503 FLOW VOLUME LOOP TEST 99070 460 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4730 Frc Rural Health Clinic Facilty Fee 9520586 ALBUTEROL INHALATION SOLUTION 20550 250 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9526138 MAG CITRATE 10060 259 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4730 Frc Rural Health Clinic Facilty Fee 9529009 WATKINS - PFT 94375 460 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4730 Frc Rural Health Clinic Facilty Fee 9530007 B12 1000mcg J7613 636 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9530056 DEPO-TESTADIOL 1cc J1060 636 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9530072 BENTYL 94010 636 11 7.699999999999999 2.39 11 5.6 2.39 8.25 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 4730 Frc Rural Health Clinic Facilty Fee 9530098 COLCHICINE, UP TO 2mg J3420 636 53 37.099999999999994 11.52 53 27 11.52 39.75 11.52 27 27 27 27 11.52 12.672 11.52 11.52 11.52 11.52 11.750399999999999 11.52 4730 Frc Rural Health Clinic Facilty Fee 9530106 DECADRON 4mg J1060 636 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9530254 TORADOL 30mg J0500 636 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9530304 TORADOL 60mg J0760 636 25 17.5 5.44 25 12.74 5.44 18.75 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 4730 Frc Rural Health Clinic Facilty Fee 9530312 DEPOPROVERA 50mg J1100 636 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9530338 DEPOTEST UP TO 100mg J1885 636 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4730 Frc Rural Health Clinic Facilty Fee 9530353 ROCEPHIN 250mg J1885 636 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9530437 IMITREX INJECTION 6mg J1051 636 89 62.3 19.35 89 45.34 19.35 66.75 19.35 45.34 45.34 45.34 45.34 19.35 21.285000000000004 19.35 19.35 19.35 19.35 19.737000000000002 19.35 4730 Frc Rural Health Clinic Facilty Fee 9530478 INFLUENZA VACCINE J1070 771 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9530650 PHENERGAN Up To 50mg J0696 636 13 9.1 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 4730 Frc Rural Health Clinic Facilty Fee 9530700 THEELIN INJECTION J3070 636 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9530759 KENALOG/TRILOG 1cc 90658 636 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9530809 OFFICE VISIT ALLERGY J2550 521 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9531070 MAG SULFATE INJECT PER 500mg J1435 636 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9531112 TESTOSTERONE INJECT,1cc,200mg J3301 636 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9531138 HYPERTET 95115 636 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4730 Frc Rural Health Clinic Facilty Fee 9531153 UNASYN 1.5mg J3475 636 27 18.9 5.87 27 13.75 5.87 20.25 5.87 13.75 13.75 13.75 13.75 5.87 6.457000000000001 5.87 5.87 5.87 5.87 5.9874 5.87 4730 Frc Rural Health Clinic Facilty Fee 9531195 VISTARIL 25mg J1071 636 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9531211 WYCILLIN 600,000 units J1670 636 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9531237 ZOLADEX 3.6mg J0295 636 405 283.5 88.05 405 206.31 88.05 303.75 88.05 206.31 206.31 206.31 206.31 88.05 96.855 88.05 88.05 88.05 88.05 89.81099999999999 88.05 4730 Frc Rural Health Clinic Facilty Fee 9531476 CLAFORAN 1GRAM J3410 636 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4730 Frc Rural Health Clinic Facilty Fee 9531559 TRIPLE OINTMENT J2540 259 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9531617 PEROXIDE J9202 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9531633 SILVER NITRATE APPLICATORS J0698 259 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9531658 BENZOUL PEROXIDE GEL 10% N/A 259 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9531690 NEOSPORIN 99070 259 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4730 Frc Rural Health Clinic Facilty Fee 9531732 LASIX 40mg N/A 636 13 9.1 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 4730 Frc Rural Health Clinic Facilty Fee 9531757 VISTARIL 50mg N/A 636 18 12.6 3.91 18 9.17 3.91 13.5 3.91 9.17 9.17 9.17 9.17 3.91 4.301 3.91 3.91 3.91 3.91 3.9882000000000004 3.91 4730 Frc Rural Health Clinic Facilty Fee 9531856 DEPO-ESTRADIOL 1cc N/A 636 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9531906 NITROGLYCERINE TAB 0.4mg J1940 259 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9531963 VITAMIN B COMPLEX J3410 636 15 10.5 3.26 15 7.64 3.26 11.25 3.26 7.64 7.64 7.64 7.64 3.26 3.586 3.26 3.26 3.26 3.26 3.3251999999999997 3.26 4730 Frc Rural Health Clinic Facilty Fee 9532045 HEPATITIS B VACCINE J0970 771 42 29.4 9.13 42 21.39 9.13 31.5 9.13 21.39 21.39 21.39 21.39 9.13 10.043000000000001 9.13 9.13 9.13 9.13 9.312600000000002 9.13 4730 Frc Rural Health Clinic Facilty Fee 9532060 TETANUS AND DIPTHERIA N/A 771 77 53.9 16.74 77 39.22 16.74 57.75 16.74 39.22 39.22 39.22 39.22 16.74 18.414 16.74 16.74 16.74 16.74 17.0748 16.74 4730 Frc Rural Health Clinic Facilty Fee 9532102 COMPAZINE 5mg/cc J3490 636 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9532128 SOLU-CORTEF Up To 100mg 90633 636 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9532177 NIFEDIPINE(PROCARDIA)30mg 90714 636 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9532193 NORFLEX 60mg J0780 636 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 4730 Frc Rural Health Clinic Facilty Fee 9532219 CLONIDINE 2mg J1720 636 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9532276 SODIUM CHLORIDE PARTIAL FILL J3490 258 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9532334 MAALOX 30cc J2360 636 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9532359 TYLENOL SUPPOSITORY J0735 259 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9532375 VITAMIN K PER 1MG N/A 636 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9532391 DONNATAL ELIXIR J3490 259 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9532433 SOLU-MEDROL 125mg 99070 636 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9532474 PROVENTIL UNIT DOSE J3430 636 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9532524 MUCOMYST ( ACETYLCYSTEINE) J3490 636 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9540006 KLING WRAP 2 J2930 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9540022 KLING WRAP 3 J7613 270 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9540055 KLING WRAP 4 J7608 270 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9540105 MEDIUM BANDAGE 99070 270 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9540121 DRAPE,STERILE 99070 272 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4730 Frc Rural Health Clinic Facilty Fee 9540154 GLOVES STERILE 99070 272 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9540188 ACE BANDAGE 2 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9540204 ACE BANDAGE 3 99070 270 5 3.5 1.09 5 2.55 1.09 3.75 1.09 2.55 2.55 2.55 2.55 1.09 1.1990000000000003 1.09 1.09 1.09 1.09 1.1118000000000001 1.09 4730 Frc Rural Health Clinic Facilty Fee 9540220 ACE BANDAGE 4 99070 270 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9540246 ACE BANDAGE 6 99070 270 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4730 Frc Rural Health Clinic Facilty Fee 9540501 GEL WRAP 4 99070 270 11 7.699999999999999 2.39 11 5.6 2.39 8.25 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 4730 Frc Rural Health Clinic Facilty Fee 9540543 STERILE SET UP 99070 272 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4730 Frc Rural Health Clinic Facilty Fee 9540576 GEL WRAP 6 99070 270 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9540618 SUTURES 99070 272 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9540659 ADAPTIC,SMALL 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9540675 ADAPTIC LARGE 99070 270 8 5.6 1.74 8 4.08 1.74 6 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 4730 Frc Rural Health Clinic Facilty Fee 9540725 TELFA,SMALL 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9540741 TELFA,LARGE 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9540774 VASELINE GAUZE 99070 270 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9540808 COMBINE DRESSING,SMALL 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9540824 COMBINE DRESSING,LARGE 99070 270 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9540857 GAUZE,4x4 99070 270 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4730 Frc Rural Health Clinic Facilty Fee 9540907 STERI STRIPS 99070 270 5 3.5 1.09 5 2.55 1.09 3.75 1.09 2.55 2.55 2.55 2.55 1.09 1.1990000000000003 1.09 1.09 1.09 1.09 1.1118000000000001 1.09 4730 Frc Rural Health Clinic Facilty Fee 9540956 SPLINT,THUMB 99070 270 27 18.9 5.87 27 13.75 5.87 20.25 5.87 13.75 13.75 13.75 13.75 5.87 6.457000000000001 5.87 5.87 5.87 5.87 5.9874 5.87 4730 Frc Rural Health Clinic Facilty Fee 9541004 SPLINT,AIR 99070 270 66 46.199999999999996 14.35 66 33.62 14.35 49.5 14.35 33.62 33.62 33.62 33.62 14.35 15.785 14.35 14.35 14.35 14.35 14.637 14.35 4730 Frc Rural Health Clinic Facilty Fee 9541046 SKIN STAPLES 99070 270 27 18.9 5.87 27 13.75 5.87 20.25 5.87 13.75 13.75 13.75 13.75 5.87 6.457000000000001 5.87 5.87 5.87 5.87 5.9874 5.87 4730 Frc Rural Health Clinic Facilty Fee 9541103 BLADE, DISPOSABLE A4570 270 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4730 Frc Rural Health Clinic Facilty Fee 9541152 COLD PACK A4570 270 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9541202 ELASTIC BANDAGE 12 99070 270 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9541228 TEGADERM 15x20 99070 270 16 11.2 3.48 16 8.15 3.48 12 3.48 8.15 8.15 8.15 8.15 3.48 3.8280000000000003 3.48 3.48 3.48 3.48 3.5496 3.48 4730 Frc Rural Health Clinic Facilty Fee 9541251 SHOE, POST-OP 99070 270 26 18.2 5.65 26 13.24 5.65 19.5 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 4730 Frc Rural Health Clinic Facilty Fee 9541277 TEGADERM 6x7 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9541301 PENROSE DRAIN 99070 272 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9541335 ARM SLING 99070 270 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9541368 EYE PAD 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9541384 0.9% NORMAL SALINE 1000cc 99070 258 20 14 4.35 20 10.19 4.35 15 4.35 10.19 10.19 10.19 10.19 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 4730 Frc Rural Health Clinic Facilty Fee 9541442 MALE ADAPTER 99070 270 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9541483 SUTURE REMOVAL TRAY 99070 272 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9541509 SUTURE TRAY J7030 272 27 18.9 5.87 27 13.75 5.87 20.25 5.87 13.75 13.75 13.75 13.75 5.87 6.457000000000001 5.87 5.87 5.87 5.87 5.9874 5.87 4730 Frc Rural Health Clinic Facilty Fee 9541525 HIBICLENS 99070 270 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4730 Frc Rural Health Clinic Facilty Fee 9541541 WRIST/FOREARM SUPPORT 99070 270 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9541608 SPLINT,ELBOW A4550 270 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4730 Frc Rural Health Clinic Facilty Fee 9541624 UNNA BOOT-APPLICATION 99070 270 243 170.1 52.83 243 123.78 52.83 182.25 52.83 123.78 123.78 123.78 123.78 52.83 58.113 52.83 52.83 52.83 52.83 53.8866 52.83 4730 Frc Rural Health Clinic Facilty Fee 9541640 URETHRAL TRAY 99070 272 19 13.299999999999999 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 4730 Frc Rural Health Clinic Facilty Fee 9541665 OXYGEN TUBING A4570 270 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4730 Frc Rural Health Clinic Facilty Fee 9541681 NASAL CANULA 29580 270 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4730 Frc Rural Health Clinic Facilty Fee 9541707 CERVICAL COLLAR 99070 270 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4730 Frc Rural Health Clinic Facilty Fee 9541723 URINAL 99070 990 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9541749 EMESIS BASIN 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9541756 HUBER NEEDLE L0120 270 49 34.3 10.65 49 24.96 10.65 36.75 10.65 24.96 24.96 24.96 24.96 10.65 11.715000000000002 10.65 10.65 10.65 10.65 10.863000000000001 10.65 4730 Frc Rural Health Clinic Facilty Fee 9541772 CATHETER TRAY 99070 272 51 35.699999999999996 11.09 51 25.98 11.09 38.25 11.09 25.98 25.98 25.98 25.98 11.09 12.199000000000002 11.09 11.09 11.09 11.09 11.3118 11.09 4730 Frc Rural Health Clinic Facilty Fee 9541798 LEG BAG 99070 270 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4730 Frc Rural Health Clinic Facilty Fee 9541855 HFN CIRCUIT 99070 270 27 18.9 5.87 27 13.75 5.87 20.25 5.87 13.75 13.75 13.75 13.75 5.87 6.457000000000001 5.87 5.87 5.87 5.87 5.9874 5.87 4730 Frc Rural Health Clinic Facilty Fee 9541871 COUDE CATHETER #14 99070 272 91 63.699999999999996 19.78 91 46.36 19.78 68.25 19.78 46.36 46.36 46.36 46.36 19.78 21.758000000000003 19.78 19.78 19.78 19.78 20.175600000000003 19.78 4730 Frc Rural Health Clinic Facilty Fee 9541897 SURGICAL SUPPLIES 99070 272 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4730 Frc Rural Health Clinic Facilty Fee 9541939 ABD PAD 99070 270 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9559006 DESTR.BEN.LESION 1>15 MOLES 99070 521 462 323.4 100.44 462 235.34 100.44 346.5 100.44 235.34 235.34 235.34 235.34 100.44 110.48400000000001 100.44 100.44 100.44 100.44 102.4488 100.44 4730 Frc Rural Health Clinic Facilty Fee 9559071 NEISS.GONORR.DNA PROBE A4550 306 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4730 Frc Rural Health Clinic Facilty Fee 9560004 HOT OR COLD PACKS 97010 521 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4730 Frc Rural Health Clinic Facilty Fee 9560053 ELEC. MUSCLE STIMULATION 17004 521 41 28.7 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 4730 Frc Rural Health Clinic Facilty Fee 9560202 HYDROTHERAPY 87590 521 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4730 Frc Rural Health Clinic Facilty Fee 9560228 ARTHROCENTESIS:MAJOR JOINT 97010 521 579 405.29999999999995 125.87 579 294.94 125.87 434.25 125.87 294.94 294.94 294.94 294.94 125.87 138.45700000000002 125.87 125.87 125.87 125.87 128.3874 125.87 4730 Frc Rural Health Clinic Facilty Fee 9565219 CRYOTHERAPY For ACNE 97014 521 78 54.599999999999994 16.96 78 39.73 16.96 58.5 16.96 39.73 39.73 39.73 39.73 16.96 18.656000000000002 16.96 16.96 16.96 16.96 17.299200000000003 16.96 4730 Frc Rural Health Clinic Facilty Fee 9570037 DEBRIDE INFEC SKIN,Up TO10%BSA 97022 521 99 69.3 21.52 99 50.43 21.52 74.25 21.52 50.43 50.43 50.43 50.43 21.52 23.672 21.52 21.52 21.52 21.52 21.9504 21.52 4730 Frc Rural Health Clinic Facilty Fee 9570052 INJECT PERIPH NERVE or BRANCH 20610 521 180 125.99999999999999 39.13 180 91.69 39.13 135 39.13 91.69 91.69 91.69 91.69 39.13 43.043000000000006 39.13 39.13 39.13 39.13 39.912600000000005 39.13 4730 Frc Rural Health Clinic Facilty Fee 9570086 ARTHROCENTESIS; INTERM JOINT 17340 521 580 406 126.09 580 295.45 126.09 435 126.09 295.45 295.45 295.45 295.45 126.09 138.699 126.09 126.09 126.09 126.09 128.61180000000002 126.09 4730 Frc Rural Health Clinic Facilty Fee 9570136 NAIL REMOVAL,PART/COMPLETE 11000 521 1105 773.5 240.23 1105 562.89 240.23 828.75 240.23 562.89 562.89 562.89 562.89 240.23 264.253 240.23 240.23 240.23 240.23 245.03459999999998 240.23 4730 Frc Rural Health Clinic Facilty Fee 9570151 LES DESTRUCT,BENIGN 1st LESION 64450 521 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4730 Frc Rural Health Clinic Facilty Fee 9570177 EXCISE LESION,EXTREM < = 0.5cm 20605 521 150 105 32.61 150 87.29 32.61 112.5 32.61 87.29 87.29 87.29 76.41 32.61 35.871 32.61 32.61 32.61 32.61 33.2622 32.61 4730 Frc Rural Health Clinic Facilty Fee 9570193 EXC.BEN.LES,HAND/FOOT1.1-2.0cm 11750 521 262 183.39999999999998 56.96 262 87.29 56.96 196.5 56.96 87.29 87.29 87.29 133.46 56.96 62.656000000000006 56.96 56.96 56.96 56.96 58.0992 56.96 4730 Frc Rural Health Clinic Facilty Fee 9570219 EXC.BEN LES,HAND/FOOT0.5cm or< 17000 521 167 116.89999999999999 36.31 167 87.29 36.31 125.25 36.31 87.29 87.29 87.29 85.07 36.31 39.941 36.31 36.31 36.31 36.31 37.0362 36.31 4730 Frc Rural Health Clinic Facilty Fee 9570235 SHAVE LESION,FACE 0.6-1.0cm 11400 521 189 132.29999999999998 41.09 189 96.28 41.09 141.75 41.09 96.28 96.28 96.28 96.28 41.09 45.199000000000005 41.09 41.09 41.09 41.09 41.91180000000001 41.09 4730 Frc Rural Health Clinic Facilty Fee 9570250 EXCIS LESION; 0.5cm or less 11422 521 202 141.39999999999998 43.91 202 87.29 43.91 151.5 43.91 87.29 87.29 87.29 102.9 43.91 48.301 43.91 43.91 43.91 43.91 44.788199999999996 43.91 4730 Frc Rural Health Clinic Facilty Fee 9570276 EXC.BENIGN LESION,EXT0.6-1.0cm 11420 521 190 133 41.31 190 87.29 41.31 142.5 41.31 87.29 87.29 87.29 96.79 41.31 45.44100000000001 41.31 41.31 41.31 41.31 42.1362 41.31 4730 Frc Rural Health Clinic Facilty Fee 9570300 ARTHROCENTESIS; SM JOINT 11311 521 580 406 126.09 580 295.45 126.09 435 126.09 295.45 295.45 295.45 295.45 126.09 138.699 126.09 126.09 126.09 126.09 128.61180000000002 126.09 4730 Frc Rural Health Clinic Facilty Fee 9570367 LES DESTRUCT,BENIGN EA ADDTL 11440 521 35 24.5 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 4730 Frc Rural Health Clinic Facilty Fee 9570383 SHAVE LESION,EXTREM 0.5cm or < 11401 521 199 139.29999999999998 43.26 199 101.37 43.26 149.25 43.26 101.37 101.37 101.37 101.37 43.26 47.586 43.26 43.26 43.26 43.26 44.1252 43.26 4730 Frc Rural Health Clinic Facilty Fee 9570433 ADMINISTRATION OF FLU VACCINE 20600 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9570474 ADMIN OF PNEUMONIA VACCINE 17003 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4730 Frc Rural Health Clinic Facilty Fee 9570516 SHAVE LESION,EXTREM OVER 2cm 11300 521 253 177.1 55 253 128.88 55 189.75 55 128.88 128.88 128.88 128.88 55 60.50000000000001 55 55 55 55 56.1 55 4730 Frc Rural Health Clinic Facilty Fee 9570532 WART REMOVAL Up To 14 G0008 521 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4730 Frc Rural Health Clinic Facilty Fee 9570573 SHAVE LESION,SCLP/NECK 1.1-2cm G0009 521 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4730 Frc Rural Health Clinic Facilty Fee 9570599 SHAVE LESION 1.1 - 2cm 11303 521 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4730 Frc Rural Health Clinic Facilty Fee 9570615 CRYOSURGERY 17110 521 227 158.89999999999998 49.35 227 115.63 49.35 170.25 49.35 115.63 115.63 115.63 115.63 49.35 54.285000000000004 49.35 49.35 49.35 49.35 50.337 49.35 4730 Frc Rural Health Clinic Facilty Fee 9570631 SHAVE LESION,FACE 0.5cm or < 11307 521 147 102.89999999999999 31.96 147 74.88 31.96 110.25 31.96 74.88 74.88 74.88 74.88 31.96 35.156000000000006 31.96 31.96 31.96 31.96 32.5992 31.96 4730 Frc Rural Health Clinic Facilty Fee 9570656 INJECT LUMBAR JOINT,SINGLE LEV 11312 521 314 219.79999999999998 68.26 314 159.95 68.26 235.5 68.26 159.95 159.95 159.95 159.95 68.26 75.08600000000001 68.26 68.26 68.26 68.26 69.6252 68.26 4730 Frc Rural Health Clinic Facilty Fee 9570672 BIOPSY SHOULDER AREA 46916 521 265 185.5 57.61 265 134.99 57.61 198.75 57.61 134.99 134.99 134.99 134.99 57.61 63.371 57.61 57.61 57.61 57.61 58.7622 57.61 4730 Frc Rural Health Clinic Facilty Fee 9570698 EXC.BENIGN LESION,EXT1.1-2.0cm 11310 521 247 172.89999999999998 53.7 247 87.29 53.7 185.25 53.7 87.29 87.29 87.29 125.82 53.7 59.07000000000001 53.7 53.7 53.7 53.7 54.774 53.7 4730 Frc Rural Health Clinic Facilty Fee 9570714 SHAVE LESION,FACE > 2cm DIAM 64475 521 308 215.6 66.96 308 156.9 66.96 231 66.96 156.9 156.9 156.9 156.9 66.96 73.656 66.96 66.96 66.96 66.96 68.2992 66.96 4730 Frc Rural Health Clinic Facilty Fee 9570730 DEBRIDE NAIL(S) 1-5 23065 521 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4730 Frc Rural Health Clinic Facilty Fee 9570755 DEBRIDE SKIN,PARTIAL THICKNESS 11402 521 96 67.19999999999999 20.87 96 48.9 20.87 72 20.87 48.9 48.9 48.9 48.9 20.87 22.957000000000004 20.87 20.87 20.87 20.87 21.2874 20.87 4730 Frc Rural Health Clinic Facilty Fee 9570771 EXC.LES.MALIG.FACE 0.5cm or > 11313 521 337 235.89999999999998 73.26 337 87.29 73.26 252.75 73.26 87.29 87.29 87.29 171.67 73.26 80.58600000000001 73.26 73.26 73.26 73.26 74.7252 73.26 4730 Frc Rural Health Clinic Facilty Fee 9570797 DEBRIDE NAILS 6 or MORE 11720 521 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4730 Frc Rural Health Clinic Facilty Fee 9570813 LES DESTRUCT,BENIGN 15 or MORE 11040 521 617 431.9 134.14 617 314.3 134.14 462.75 134.14 314.3 314.3 314.3 314.3 134.14 147.554 134.14 134.14 134.14 134.14 136.8228 134.14 4730 Frc Rural Health Clinic Facilty Fee 9570839 EXC.LES.MALIG.FACE 0.5cm or < 11640 521 278 194.6 60.44 278 87.29 60.44 208.5 60.44 87.29 87.29 87.29 141.61 60.44 66.48400000000001 60.44 60.44 60.44 60.44 61.6488 60.44 4730 Frc Rural Health Clinic Facilty Fee 9570870 SHAVE LESION,SCLP/NECK < 0.5cm 1721 521 142 99.39999999999999 30.87 142 72.33 30.87 106.5 30.87 72.33 72.33 72.33 72.33 30.87 33.957 30.87 30.87 30.87 30.87 31.4874 30.87 4730 Frc Rural Health Clinic Facilty Fee 9570896 DISABILITY PHYS (NP) LEVEL 5 17004 521 227 158.89999999999998 49.35 227 115.63 49.35 170.25 49.35 115.63 115.63 115.63 115.63 49.35 54.285000000000004 49.35 49.35 49.35 49.35 50.337 49.35 4730 Frc Rural Health Clinic Facilty Fee 9571126 DILATION URETHRAL MALE 11620 521 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 4730 Frc Rural Health Clinic Professional Fees 9571159 HOSPITAL ADMIT LEVEL 1 11305 521 234 163.79999999999998 50.87 234 119.2 50.87 175.5 50.87 119.2 119.2 119.2 119.2 50.87 55.957 50.87 50.87 50.87 50.87 51.8874 50.87 4730 Frc Rural Health Clinic Professional Fees 9571175 HOSPITAL LEVEL 2 99205 521 320 224 69.57 320 163.01 69.57 240 69.57 163.01 163.01 163.01 163.01 69.57 76.527 69.57 69.57 69.57 69.57 70.9614 69.57 4730 Frc Rural Health Clinic Professional Fees 9571191 HOSPITAL ADMIT LEVEL 3 53600 521 386 270.2 83.92 386 196.63 83.92 289.5 83.92 196.63 196.63 196.63 196.63 83.92 92.31200000000001 83.92 83.92 83.92 83.92 85.5984 83.92 4730 Frc Rural Health Clinic Facilty Fee 9571217 REMOVE FB,FOOT DEEP 99234 521 572 400.4 124.35 572 291.38 124.35 429 124.35 291.38 291.38 291.38 291.38 124.35 136.785 124.35 124.35 124.35 124.35 126.837 124.35 4730 Frc Rural Health Clinic Professional Fees 9571233 PHYSICAL (AGE UNDER 1 Yr) NPT 99235 521 108 75.6 23.48 108 87.29 23.48 81 23.48 87.29 87.29 87.29 55.02 23.48 25.828000000000003 23.48 23.48 23.48 23.48 23.9496 23.48 4730 Frc Rural Health Clinic Professional Fees 9571258 PHYSICALL (AGE 1thru4 yrs) NPT 99236 521 143 100.1 31.09 143 87.29 31.09 107.25 31.09 87.29 87.29 87.29 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 4730 Frc Rural Health Clinic Professional Fees 9571332 SCHOOL/SPORTS PHYSICAL 28192 521 21 14.7 4.57 21 10.7 4.57 15.75 4.57 10.7 10.7 10.7 10.7 4.57 5.027000000000001 4.57 4.57 4.57 4.57 4.6614 4.57 4730 Frc Rural Health Clinic Professional Fees 9571357 EPT SCHOOL/SPORTS PHYS (12-17) 99381 521 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4730 Frc Rural Health Clinic Professional Fees 9571373 EPT SCHOOL/SPORTS PHYS(18-39) 99382 521 24 16.799999999999997 5.22 24 12.23 5.22 18 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 5.22 5.22 5.3244 5.22 4730 Frc Rural Health Clinic Facilty Fee 9571399 TOE NAIL TRIMMING 99393 521 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4730 Frc Rural Health Clinic Facilty Fee 9571415 EYE IRRIGATION 99394 521 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4730 Frc Rural Health Clinic Facilty Fee 9571431 DISABILITY PHYS (EST PT) 99395 521 186 130.2 40.44 186 94.75 40.44 139.5 40.44 94.75 94.75 94.75 94.75 40.44 44.484 40.44 40.44 40.44 40.44 41.248799999999996 40.44 4730 Frc Rural Health Clinic Facilty Fee 9571464 HEARING TEST (AUDIO) 11719 521 48 33.599999999999994 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 4730 Frc Rural Health Clinic Facilty Fee 9571506 REMOVE FB,FOOT,COMPLICATED 65205 521 798 558.5999999999999 173.49 798 406.5 173.49 598.5 173.49 406.5 406.5 406.5 406.5 173.49 190.83900000000003 173.49 173.49 173.49 173.49 176.9598 173.49 4730 Frc Rural Health Clinic Facilty Fee 9571514 DOT PHYSICAL 99215 521 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4730 Frc Rural Health Clinic Facilty Fee 9579509 IHCC EMPLOYEE PHYSICAL 92551 521 36 25.2 7.83 36 18.34 7.83 27 7.83 18.34 18.34 18.34 18.34 7.83 8.613000000000001 7.83 7.83 7.83 7.83 7.9866 7.83 4730 Frc Rural Health Clinic Facilty Fee 9579525 SDF EMPLOYEE PHYSICAL 28193 521 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4730 Frc Rural Health Clinic Facilty Fee 9579541 CONCRETE CO. EMP. PHYS. 97750 521 79 55.3 17.17 79 40.24 17.17 59.25 17.17 40.24 40.24 40.24 40.24 17.17 18.887000000000004 17.17 17.17 17.17 17.17 17.5134 17.17 4730 Frc Rural Health Clinic Facilty Fee 9579566 URS EMPLOYEE PHYSICAL 99214 521 79 55.3 17.17 79 40.24 17.17 59.25 17.17 40.24 40.24 40.24 40.24 17.17 18.887000000000004 17.17 17.17 17.17 17.17 17.5134 17.17 4730 Frc Rural Health Clinic Facilty Fee 9580507 INITIAL TREATMENT 1st DEG BURN 99214 521 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4730 Frc Rural Health Clinic Facilty Fee 9581505 I&D COMPLICATED OR MULT 99214 521 251 175.7 54.57 251 127.86 54.57 188.25 54.57 127.86 127.86 127.86 127.86 54.57 60.02700000000001 54.57 54.57 54.57 54.57 55.6614 54.57 4730 Frc Rural Health Clinic Facilty Fee 9581513 I&D HEMATOMA/SEROMA 99214 521 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4730 Frc Rural Health Clinic Facilty Fee 9581521 BIOPSY OF SKIN LESION 16000 521 326 228.2 70.87 326 166.06 70.87 244.5 70.87 166.06 166.06 166.06 166.06 70.87 77.95700000000001 70.87 70.87 70.87 70.87 72.2874 70.87 4730 Frc Rural Health Clinic Facilty Fee 9581539 EXC BENIGN LES EXT 2.1-3.0cm 10061 521 310 217 67.39 310 87.29 67.39 232.5 67.39 87.29 87.29 87.29 157.91 67.39 74.129 67.39 67.39 67.39 67.39 68.73780000000001 67.39 4730 Frc Rural Health Clinic Facilty Fee 9581547 EXC BENIGN LES HAND/FT2.1-3.0c 10140 521 353 247.1 76.74 353 87.29 76.74 264.75 76.74 87.29 87.29 87.29 179.82 76.74 84.414 76.74 76.74 76.74 76.74 78.2748 76.74 4730 Frc Rural Health Clinic Facilty Fee 9581554 EXC BENIGN LES HND/FT 3.1-4.0c 11102 521 441 308.7 95.87 441 87.29 95.87 330.75 95.87 87.29 87.29 87.29 224.65 95.87 105.45700000000001 95.87 95.87 95.87 95.87 97.7874 95.87 4730 Frc Rural Health Clinic Facilty Fee 9581562 EXC BENIGN LES HND/FT > 4.0cm 11403 521 64 44.8 13.91 64 87.29 13.91 48 13.91 87.29 87.29 87.29 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4730 Frc Rural Health Clinic Facilty Fee 9581570 SUBUNGAL HEMATOMA EVACUATION 11423 521 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4730 Frc Rural Health Clinic Facilty Fee 9581588 LYR CLSR EXT 7.6-12.5cm 11424 521 331 231.7 71.96 331 168.61 71.96 248.25 71.96 168.61 168.61 168.61 168.61 71.96 79.156 71.96 71.96 71.96 71.96 73.3992 71.96 4730 Frc Rural Health Clinic Facilty Fee 9581596 DESTRUCT MALIG LES 0.5 or LESS 11426 521 189 132.29999999999998 41.09 189 96.28 41.09 141.75 41.09 96.28 96.28 96.28 96.28 41.09 45.199000000000005 41.09 41.09 41.09 41.09 41.91180000000001 41.09 4730 Frc Rural Health Clinic Facilty Fee 9581604 DESTRUCT MALIG LES 1.1-2.0cm 11740 521 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4730 Frc Rural Health Clinic Facilty Fee 9581612 PELVIC (ONLY) EXAM 12042 521 81 56.699999999999996 17.61 81 41.26 17.61 60.75 17.61 41.26 41.26 41.26 41.26 17.61 19.371000000000002 17.61 17.61 17.61 17.61 17.9622 17.61 4730 Frc Rural Health Clinic Facilty Fee 9582073 GI COCKTAIL 17260 259 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9582735 REMOVE CENTRAL VENOUS CATHETER 17262 521 29 20.299999999999997 6.3 29 14.77 6.3 21.75 6.3 14.77 14.77 14.77 14.77 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 4730 Frc Rural Health Clinic Facilty Fee 9583220 PULSE OXIMETER Q0091 460 38 26.599999999999998 8.26 38 19.36 8.26 28.5 8.26 19.36 19.36 19.36 19.36 8.26 9.086 8.26 8.26 8.26 8.26 8.4252 8.26 4730 Frc Rural Health Clinic Facilty Fee 9584400 FB REMOVAL INTRANASAL 30300 521 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4730 Frc Rural Health Clinic Facilty Fee 9585506 BENADRYL Up To 50mg INJECTION 99381 636 13 9.1 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 4730 Frc Rural Health Clinic Facilty Fee 9585688 PELVIC EXAM,SCREENING 94760 521 52 36.4 11.3 52 26.49 11.3 39 11.3 26.49 26.49 26.49 26.49 11.3 12.430000000000001 11.3 11.3 11.3 11.3 11.526000000000002 11.3 4730 Frc Rural Health Clinic Facilty Fee 9586009 ALPUPENT INHALATION SOLUTION 30300 259 40 28 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 4730 Frc Rural Health Clinic Facilty Fee 9586421 ANUSOL SUPPOSITORY J1200 250 6 4.199999999999999 1.3 6 3.06 1.3 4.5 1.3 3.06 3.06 3.06 3.06 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 4730 Frc Rural Health Clinic Facilty Fee 9586991 CATAPRES 0.1mg PO G0101 636 3 2.0999999999999996 0.65 3 1.53 0.65 2.25 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 4730 Frc Rural Health Clinic Facilty Fee 9587312 CATAPRES 0.2mg PO G0101 636 4 2.8 0.87 4 2.04 0.87 3 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 4730 Frc Rural Health Clinic Facilty Fee 9587585 MOTRIN 200MG 259 2 1.4 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 4730 Frc Rural Health Clinic Facilty Fee 9588013 CHLAMYDIA PROBE J8999 300 33 23.099999999999998 7.17 33 16.81 7.17 24.75 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 4730 Frc Rural Health Clinic Facilty Fee 9588542 COMPLEX RPR FACE 1.1-2.5cm J0735 521 86 60.199999999999996 18.7 86 43.81 18.7 64.5 18.7 43.81 43.81 43.81 43.81 18.7 20.57 18.7 18.7 18.7 18.7 19.073999999999998 18.7 4730 Frc Rural Health Clinic Facilty Fee 9588583 FOLEY CATHETER INSERTION 51702 521 47 32.9 10.22 47 23.94 10.22 35.25 10.22 23.94 23.94 23.94 23.94 10.22 11.242 10.22 10.22 10.22 10.22 10.4244 10.22 4730 Frc Rural Health Clinic Facilty Fee 9589891 ICPM Established Patient Level Ages 5-11 87490 521 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4730 Frc Rural Health Clinic Facilty Fee 9589892 ICPM Established Patient Level 11131 521 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589821 10-12 YEARS ABNORMAL 51702 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589813 10-12 YEARS NORMAL 99393 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589847 12-14 YEARS ABNORMAL 99394 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589862 14-16 YEARS ABNORMAL 99394 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589854 14-16 YEARS NORMAL 99394 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589888 16-18 YEARS ABNORMAL G0439 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589870 16-18 YEARS NORMAL G0439 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589748 4-5 YEARS ABNORMAL G0439 983 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589730 4-5 YEARS NORMAL G0439 983 64 44.8 13.91 64 32.6 13.91 48 13.91 32.6 32.6 32.6 32.6 13.91 15.301000000000002 13.91 13.91 13.91 13.91 14.1882 13.91 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589805 8-10 YEARS ABNORMAL G0439 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589797 8-10 YEARS NORMAL G0439 983 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589078 ABNORMAL HEARING SCREEN G0439 521 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589052 ABNORMAL VISION SCREEN G0439 521 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588161 DTAP (0-7 YEARS) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589902 DTAP, HEP B-IPV(PEDIARIX) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588153 FLU VAC (3 YRS AND ABOVE) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588138 FLU VAC (3-35 MONTH)IM G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589900 FLU VAC (NASAL) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589942 H1N1 ADMINISTRATION G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588179 HC/DPT ADMINISTRATION G0439 771 12 8.399999999999999 2.61 12 6.11 2.61 9 2.61 6.11 6.11 6.11 6.11 2.61 2.871 2.61 2.61 2.61 2.61 2.6622 2.61 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9584475 HC/DTP & HIB COMBO ADMIN G0439 771 12 8.399999999999999 2.61 12 6.11 2.61 9 2.61 6.11 6.11 6.11 6.11 2.61 2.871 2.61 2.61 2.61 2.61 2.6622 2.61 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588195 HC/MR ADMINISTRATION G0439 771 12 8.399999999999999 2.61 12 6.11 2.61 9 2.61 6.11 6.11 6.11 6.11 2.61 2.871 2.61 2.61 2.61 2.61 2.6622 2.61 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9585134 HC/TB SKIN TEST G0439 250 10 7 2.17 10 5.09 2.17 7.5 2.17 5.09 5.09 5.09 5.09 2.17 2.387 2.17 2.17 2.17 2.17 2.2134 2.17 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588120 HEMOPHILUS INF B VACCINE G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589905 HEP A 2-DOSE G0439 521 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9584970 HEP B, HIB (COMBIVAX) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9532003 HEPATITIS B G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589906 HPV (9-18 YRS) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589889 ICPM EST PT (AGES 1-4) G0439 521 85 59.49999999999999 18.48 85 43.3 18.48 63.75 18.48 43.3 43.3 43.3 43.3 18.48 20.328000000000003 18.48 18.48 18.48 18.48 18.849600000000002 18.48 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589892 ICPM EST PT (AGES 12-17) G0439 521 106 74.19999999999999 23.04 106 54 23.04 79.5 23.04 54 54 54 54 23.04 25.344 23.04 23.04 23.04 23.04 23.500799999999998 23.04 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589893 ICPM EST PT (AGES 18-21) G0439 521 115 80.5 25 115 58.58 25 86.25 25 58.58 58.58 58.58 58.58 25 27.500000000000004 25 25 25 25 25.5 25 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589891 ICPM EST PT (AGES 5-11) G0439 521 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589890 ICPM EST PT (UNDER 1) G0439 521 75 52.5 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588146 IPV - POLIO G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589907 MENINGOCOCAL (MV4) G0439 521 300 210 65.22 300 152.82 65.22 225 65.22 152.82 152.82 152.82 152.82 65.22 71.742 65.22 65.22 65.22 65.22 66.5244 65.22 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588187 MMR G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589904 MMR V (MEASLES, MUMPS, VARIC.) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589894 NEW PT ICPM (AGES 1-4) G0439 521 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589896 NEW PT ICPM (AGES 12-17) G0439 521 131 91.69999999999999 28.48 131 66.73 28.48 98.25 28.48 66.73 66.73 66.73 66.73 28.48 31.328000000000003 28.48 28.48 28.48 28.48 29.0496 28.48 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589897 NEW PT ICPM (AGES 18-21) G0439 521 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589895 NEW PT ICPM (AGES 5-11) G0439 521 121 84.69999999999999 26.31 121 61.64 26.31 90.75 26.31 61.64 61.64 61.64 61.64 26.31 28.941000000000003 26.31 26.31 26.31 26.31 26.836199999999998 26.31 4780 Frc Peachcare Clinic (Wellness Professional Fees 9589898 NEW PT ICPM (UNDER 1) G0439 521 102 71.39999999999999 22.17 102 51.96 22.17 76.5 22.17 51.96 51.96 51.96 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589060 NORMAL HEARING SCREEN G0439 521 103 72.1 22.39 103 52.47 22.39 77.25 22.39 52.47 52.47 52.47 52.47 22.39 24.629 22.39 22.39 22.39 22.39 22.8378 22.39 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589045 NORMAL VISION SCREEN G0439 521 7 4.8999999999999995 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9531260 PNEUMOVAX G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589903 PREVNAR G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9589901 TDAP G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9584483 TETANUS, DIPTHERIA (0-7) G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4780 Frc Peachcare Clinic (Wellness Facilty Fee 9588203 VARICELLA G0439 771 9 6.3 1.96 9 4.58 1.96 6.75 1.96 4.58 4.58 4.58 4.58 1.96 2.156 1.96 1.96 1.96 1.96 1.9992 1.96 4900 Hos Emergency Services Facilty Fee 5001 CLSD TX RADIAL HEAD 25605 450 358 250.6 77.83 358 182.37 77.83 268.5 77.83 182.37 182.37 182.37 182.37 77.83 85.613 77.83 77.83 77.83 77.83 79.3866 77.83 4900 Hos Emergency Services Facilty Fee 5002 SMPL RPR FACE/HEAD OVER 30CM 12011 450 749 524.3 162.83 749 381.54 162.83 561.75 162.83 381.54 381.54 381.54 381.54 162.83 179.11300000000003 162.83 162.83 162.83 162.83 166.0866 162.83 4900 Hos Emergency Services Facilty Fee 5003 ARTHROCENTESIS,ASPIRATION AND 24640 450 603 422.09999999999997 131.09 603 307.17 131.09 452.25 131.09 307.17 307.17 307.17 307.17 131.09 144.199 131.09 131.09 131.09 131.09 133.7118 131.09 4900 Hos Emergency Services Facilty Fee 5006 AVULSION OF NAIL PLATE, PARTIA 12018 450 206 144.2 44.78 206 104.94 44.78 154.5 44.78 104.94 104.94 104.94 104.94 44.78 49.258 44.78 44.78 44.78 44.78 45.6756 44.78 4900 Hos Emergency Services Facilty Fee 5010 REMOVAL FB EYELID 20600 450 126 88.19999999999999 27.39 126 64.18 27.39 94.5 27.39 64.18 64.18 64.18 64.18 27.39 30.129 27.39 27.39 27.39 27.39 27.9378 27.39 4900 Hos Emergency Services Facilty Fee 5011 REPLACE TRACH TUBE 11730 450 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4900 Hos Emergency Services Facilty Fee 5012 MANIPULATION OF PATELLA 67928 450 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4900 Hos Emergency Services Facilty Fee 5013 I & D OF ABSCESS, COMPLICATED 31502 450 237 165.89999999999998 51.52 237 120.73 51.52 177.75 51.52 120.73 120.73 120.73 120.73 51.52 56.67200000000001 51.52 51.52 51.52 51.52 52.5504 51.52 4900 Hos Emergency Services Facilty Fee 5014 DELIVERY OF PLACENTA 27560 450 710 496.99999999999994 154.35 710 361.67 154.35 532.5 154.35 361.67 361.67 361.67 361.67 154.35 169.785 154.35 154.35 154.35 154.35 157.43699999999998 154.35 4900 Hos Emergency Services Facilty Fee 5015 I & D SCROTAL ABSCESS 10061 450 1177 823.9 255.88 1177 599.56 255.88 882.75 255.88 599.56 599.56 599.56 599.56 255.88 281.468 255.88 255.88 255.88 255.88 260.9976 255.88 4900 Hos Emergency Services Facilty Fee 5016 FB REMOVAL FROM SCROTUM 59414 450 252 176.39999999999998 54.78 252 128.37 54.78 189 54.78 128.37 128.37 128.37 128.37 54.78 60.258 54.78 54.78 54.78 54.78 55.8756 54.78 4900 Hos Emergency Services Facilty Fee 5017 REPAIR OF NAILBED 55100 450 132 92.39999999999999 28.7 132 67.24 28.7 99 28.7 67.24 67.24 67.24 67.24 28.7 31.57 28.7 28.7 28.7 28.7 29.274 28.7 4900 Hos Emergency Services Facilty Fee 5020 UNLISTED UROLOGY SURGERY PROC 55899 450 94 65.8 20.44 94 47.88 20.44 70.5 20.44 47.88 47.88 47.88 47.88 20.44 22.484 20.44 20.44 20.44 20.44 20.8488 20.44 4900 Hos Emergency Services Facilty Fee 5021 COMPLEX REPAIR EA ADD 5 CM 11760 450 130 91 28.26 130 66.22 28.26 97.5 28.26 66.22 66.22 66.22 66.22 28.26 31.086000000000006 28.26 28.26 28.26 28.26 28.825200000000002 28.26 4900 Hos Emergency Services Facilty Fee 5022 AMP FINGER/THUMB PRIM SEC 53899 450 241 168.7 52.39 241 122.77 52.39 180.75 52.39 122.77 122.77 122.77 122.77 52.39 57.629000000000005 52.39 52.39 52.39 52.39 53.4378 52.39 4900 Hos Emergency Services Facilty Fee 5023 REMOVAL FB CORNEA 13122 450 114 79.8 24.78 114 58.07 24.78 85.5 24.78 58.07 58.07 58.07 58.07 24.78 27.258000000000003 24.78 24.78 24.78 24.78 25.2756 24.78 4900 Hos Emergency Services Facilty Fee 5024 CHANGE NEPHROSTOMY TUBE 26951 450 671 469.7 145.88 671 341.81 145.88 503.25 145.88 341.81 341.81 341.81 341.81 145.88 160.46800000000002 145.88 145.88 145.88 145.88 148.7976 145.88 4900 Hos Emergency Services Facilty Fee 5025 APP FINGER SPLINT/DYNAMIC 65220 450 254 177.79999999999998 55.22 254 129.39 55.22 190.5 55.22 129.39 129.39 129.39 129.39 55.22 60.742000000000004 55.22 55.22 55.22 55.22 56.3244 55.22 4900 Hos Emergency Services Facilty Fee 5026 APP FOREARM SPLINT/DYNAMIC 50398 450 254 177.79999999999998 55.22 254 129.39 55.22 190.5 55.22 129.39 129.39 129.39 129.39 55.22 60.742000000000004 55.22 55.22 55.22 55.22 56.3244 55.22 4900 Hos Emergency Services Facilty Fee 5027 U/L PROCEDURE LEG/ANKLE 29131 450 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4900 Hos Emergency Services Facilty Fee 5028 TX OF FIBULA FRACTURE 29126 450 101 70.69999999999999 21.96 101 51.45 21.96 75.75 21.96 51.45 51.45 51.45 51.45 21.96 24.156000000000002 21.96 21.96 21.96 21.96 22.3992 21.96 4900 Hos Emergency Services Facilty Fee 5029 ARTHROTOMY OF METATAIS 27899 450 1045 731.5 227.18 1045 532.32 227.18 783.75 227.18 532.32 532.32 532.32 532.32 227.18 249.89800000000002 227.18 227.18 227.18 227.18 231.7236 227.18 4900 Hos Emergency Services Facilty Fee 5030 CRITICAL CARE EA ADDTL 30 MIN 27780 450 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4900 Hos Emergency Services Facilty Fee 5031 REPLACEMENT OF CATHETER 28022 450 312 218.39999999999998 67.83 312 158.93 67.83 234 67.83 158.93 158.93 158.93 158.93 67.83 74.613 67.83 67.83 67.83 67.83 69.1866 67.83 4900 Hos Emergency Services Facilty Fee 5032 IV THERAPY INFUS EACH ADD. HR 99292 450 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4900 Hos Emergency Services Facilty Fee 5033 LAYER CLOSURE 7.6CM-12.5CM 36578 450 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4900 Hos Emergency Services Facilty Fee 5034 IRRIGATION OF CORPORA CAVERNOS 96366 450 460 322 100 460 234.32 100 345 100 234.32 234.32 234.32 234.32 100 110.00000000000001 100 100 100 100 102 100 4900 Hos Emergency Services Facilty Fee 5035 TX SF WD DEH W/ PACKING 12044 450 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4900 Hos Emergency Services Facilty Fee 5036 OSTEOPATHIC MANIPULATION 54220 450 59 41.3 12.83 59 30.05 12.83 44.25 12.83 30.05 30.05 30.05 30.05 12.83 14.113000000000001 12.83 12.83 12.83 12.83 13.0866 12.83 4900 Hos Emergency Services Facilty Fee 5037 INJ ANESTHETIC OF FACIAL NERVE 12021 450 177 123.89999999999999 38.48 177 90.16 38.48 132.75 38.48 90.16 90.16 90.16 90.16 38.48 42.328 38.48 38.48 38.48 38.48 39.2496 38.48 4900 Hos Emergency Services Facilty Fee 5038 DESTR MAL LESION 1.1 - 2 CM 98295 450 141 98.69999999999999 30.65 141 71.83 30.65 105.75 30.65 71.83 71.83 71.83 71.83 30.65 33.715 30.65 30.65 30.65 30.65 31.262999999999998 30.65 4900 Hos Emergency Services Facilty Fee 5039 REMOVAL FB FRM UPPR ARM, SUBCU 64402 450 338 236.6 73.48 338 172.18 73.48 253.5 73.48 172.18 172.18 172.18 172.18 73.48 80.82800000000002 73.48 73.48 73.48 73.48 74.9496 73.48 4900 Hos Emergency Services Facilty Fee 5040 OMT 3-4 AREAS 17262 450 59 41.3 12.83 59 30.05 12.83 44.25 12.83 30.05 30.05 30.05 30.05 12.83 14.113000000000001 12.83 12.83 12.83 12.83 13.0866 12.83 4900 Hos Emergency Services Facilty Fee 5041 CARDIOVERSION 24200 450 1219 853.3 265.01 1219 620.96 265.01 914.25 265.01 620.96 620.96 620.96 620.96 265.01 291.511 265.01 265.01 265.01 265.01 270.3102 265.01 4900 Hos Emergency Services Facilty Fee 5043 I&D ABSCESS DENTOALVEOLAR 98926 450 158 110.6 34.35 158 80.49 34.35 118.5 34.35 80.49 80.49 80.49 80.49 34.35 37.785000000000004 34.35 34.35 34.35 34.35 35.037 34.35 4900 Hos Emergency Services Facilty Fee 5044 FOLEY CATH INSERTION 92960 450 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4900 Hos Emergency Services Facilty Fee 5045 HYDRATION INFUSION 31-60MIN 41800 450 249 174.29999999999998 54.13 249 126.84 54.13 186.75 54.13 126.84 126.84 126.84 126.84 54.13 59.543000000000006 54.13 54.13 54.13 54.13 55.2126 54.13 4900 Hos Emergency Services Facilty Fee 5048 BIOPSY SKIN LESION 51702 450 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4900 Hos Emergency Services Facilty Fee 5049 I&D PERIRECTAL ABCESS 96360 450 427 298.9 92.83 427 217.51 92.83 320.25 92.83 217.51 217.51 217.51 217.51 92.83 102.113 92.83 92.83 92.83 92.83 94.6866 92.83 4900 Hos Emergency Services Facilty Fee 5050 INJ EPIDURAL BLOOD PATCH 11100 450 473 331.09999999999997 102.83 473 240.95 102.83 354.75 102.83 240.95 240.95 240.95 240.95 102.83 113.11300000000001 102.83 102.83 102.83 102.83 104.8866 102.83 4900 Hos Emergency Services Facilty Fee 5051 WEDGE EXCISION NAIL BED 46040 450 139 97.3 30.22 139 70.81 30.22 104.25 30.22 70.81 70.81 70.81 70.81 30.22 33.242000000000004 30.22 30.22 30.22 30.22 30.8244 30.22 4900 Hos Emergency Services Facilty Fee 5052 UL PRO STOMACH/REINSERTION NGT 62273 450 204 142.79999999999998 44.35 204 103.92 44.35 153 44.35 103.92 103.92 103.92 103.92 44.35 48.785000000000004 44.35 44.35 44.35 44.35 45.237 44.35 4900 Hos Emergency Services Facilty Fee 5053 I&D ABCESS EXT EAR CANAL 11765 450 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4900 Hos Emergency Services Facilty Fee 5054 VAGINAL DELIVERY NORMAL 43999 450 1747 1222.8999999999999 379.8 1747 889.92 379.8 1310.25 379.8 889.92 889.92 889.92 889.92 379.8 417.78000000000003 379.8 379.8 379.8 379.8 387.396 379.8 4900 Hos Emergency Services Facilty Fee 5055 TREATMENT FX RADIUS/ULNA 6900 450 1253 877.0999999999999 272.4 1253 638.28 272.4 939.75 272.4 638.28 638.28 638.28 638.28 272.4 299.64 272.4 272.4 272.4 272.4 277.84799999999996 272.4 4900 Hos Emergency Services Facilty Fee 5057 U/L PULMONARY SERVICE OR PROC 59409 450 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4900 Hos Emergency Services Facilty Fee 5058 CLSD TX OF WRIST FX W/MANIP 25605 450 219 153.29999999999998 47.61 219 111.56 47.61 164.25 47.61 111.56 111.56 111.56 111.56 47.61 52.371 47.61 47.61 47.61 47.61 48.5622 47.61 4900 Hos Emergency Services Facilty Fee 5059 CLSD TX OF CLAVICLE FX 94799 450 219 153.29999999999998 47.61 219 111.56 47.61 164.25 47.61 111.56 111.56 111.56 111.56 47.61 52.371 47.61 47.61 47.61 47.61 48.5622 47.61 4900 Hos Emergency Services Facilty Fee 5060 SIMPLE REPAIR OF SF WOUNDS 25635 450 198 138.6 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 4900 Hos Emergency Services Facilty Fee 5061 FOLEY CATH IRRIGATION 23505 450 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4900 Hos Emergency Services Facilty Fee 5062 STRAIGHT CATH - TEMPORARY 12106 450 63 44.099999999999994 13.7 63 32.09 13.7 47.25 13.7 32.09 32.09 32.09 32.09 13.7 15.07 13.7 13.7 13.7 13.7 13.974 13.7 4900 Hos Emergency Services Facilty Fee 5063 FOLEY CATH INSERTION DIFFICULT 51700 450 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4900 Hos Emergency Services Facilty Fee 5064 ESCHAROTOMY - INITIAL 51701 450 640 448 139.14 640 326.02 139.14 480 139.14 326.02 326.02 326.02 326.02 139.14 153.054 139.14 139.14 139.14 139.14 141.9228 139.14 4900 Hos Emergency Services Facilty Fee 5065 ESCHAROTOMY - SUBSEQUENT 51703 450 462 323.4 100.44 462 235.34 100.44 346.5 100.44 235.34 235.34 235.34 235.34 100.44 110.48400000000001 100.44 100.44 100.44 100.44 102.4488 100.44 4900 Hos Emergency Services Facilty Fee 5066 CLOSED FX BIMALLEOLAR ANKLE 16035 450 924 646.8 200.88 924 470.69 200.88 693 200.88 470.69 470.69 470.69 470.69 200.88 220.96800000000002 200.88 200.88 200.88 200.88 204.8976 200.88 4900 Hos Emergency Services Facilty Fee 5067 CRICOTHYROID-ASST W/I.CARE &O2 16036 450 356 249.2 77.39 356 181.35 77.39 267 77.39 181.35 181.35 181.35 181.35 77.39 85.129 77.39 77.39 77.39 77.39 78.9378 77.39 4900 Hos Emergency Services Facilty Fee 5068 CRICOTHYROID, MEMBRANE INSERT. 27810 981 704 492.79999999999995 153.05 704 358.62 153.05 528 153.05 358.62 358.62 358.62 358.62 153.05 168.35500000000002 153.05 153.05 153.05 153.05 156.11100000000002 153.05 4900 Hos Emergency Services Facilty Fee 5069 CLOSED REDUCTION W/MAN.TIB/FIB 31605 450 100 70 21.74 100 50.94 21.74 75 21.74 50.94 50.94 50.94 50.94 21.74 23.914 21.74 21.74 21.74 21.74 22.174799999999998 21.74 4900 Hos Emergency Services Facilty Fee 5070 CLOSED REDUCT. W/MAN. TIB/FIB 31605 981 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 4900 Hos Emergency Services Facilty Fee 5071 CLSD TX SHLDR DISLOC W/ANESTH 27752 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 5072 CLSD TX SHLDR DISLOC W/ANESTHE 27752 981 143 100.1 31.09 143 72.84 31.09 107.25 31.09 72.84 72.84 72.84 72.84 31.09 34.199000000000005 31.09 31.09 31.09 31.09 31.7118 31.09 4900 Hos Emergency Services Facilty Fee 5073 INJ. SINGLE OR MULTI 1OR2 MUSC 23655 450 604 422.79999999999995 131.31 604 307.68 131.31 453 131.31 307.68 307.68 307.68 307.68 131.31 144.441 131.31 131.31 131.31 131.31 133.9362 131.31 4900 Hos Emergency Services Facilty Fee 5074 INJ. SINGLE OR MULTI. 1OR2MUSC 23655 981 108 75.6 23.48 108 55.02 23.48 81 23.48 55.02 55.02 55.02 55.02 23.48 25.828000000000003 23.48 23.48 23.48 23.48 23.9496 23.48 4900 Hos Emergency Services Facilty Fee 5075 INJ;ANESTH;INTERCOS. NER.MULTI 20552 450 214 149.79999999999998 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 4900 Hos Emergency Services Facilty Fee 5078 ADD SEQUEN. IV PUSH NEW DRUG 64421 450 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4900 Hos Emergency Services Facilty Fee 5079 ADD SEQUEN. IV PUSH SAME DRUG 27810 450 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4900 Hos Emergency Services Facilty Fee 5082 IV HYDRATION; EACH ADD HR 96375 450 87 60.9 18.91 87 44.32 18.91 65.25 18.91 44.32 44.32 44.32 44.32 18.91 20.801000000000002 18.91 18.91 18.91 18.91 19.2882 18.91 4900 Hos Emergency Services Facilty Fee 5083 ADD. SEQUEN. INFUSION NEW DRUG 96376 450 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4900 Hos Emergency Services Facilty Fee 5084 CONCURRENT INFUSION 96361 450 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 4900 Hos Emergency Services Facilty Fee 5085 CLSD TX WRIST DISLOC W/MANIP 96367 450 947 662.9 205.88 947 482.4 205.88 710.25 205.88 482.4 482.4 482.4 482.4 205.88 226.46800000000002 205.88 205.88 205.88 205.88 209.9976 205.88 4900 Hos Emergency Services Facilty Fee 5086 TX LOWER LEG FX 96368 450 1217 851.9 264.58 1217 619.94 264.58 912.75 264.58 619.94 619.94 619.94 619.94 264.58 291.038 264.58 264.58 264.58 264.58 269.8716 264.58 4900 Hos Emergency Services Facilty Fee 5087 VENIPUNCTURE (PORT/VAD) 25660 450 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4900 Hos Emergency Services Facilty Fee 5088 INITIAL IV ACCESS 27825 450 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4900 Hos Emergency Services Facilty Fee 5089 VENIPUNTURE (CVL/PICC) 36591 450 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4900 Hos Emergency Services Facilty Fee 5090 VENIPUNTURE (PERIPHERAL VENUS) 36000 450 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 4900 Hos Emergency Services Facilty Fee 5091 TRIAGE, MEDICAL SCREEN ONLY 36592 450 170 118.99999999999999 36.96 170 86.6 36.96 127.5 36.96 86.6 86.6 86.6 86.6 36.96 40.656000000000006 36.96 36.96 36.96 36.96 37.699200000000005 36.96 4900 Hos Emergency Services Facilty Fee 5096 CRITICAL CARE 1ST 30 TO 74 MIN 36415 450 1520 1064 330.45 1520 774.29 330.45 1140 330.45 774.29 774.29 774.29 774.29 330.45 363.495 330.45 330.45 330.45 330.45 337.05899999999997 330.45 4900 Hos Emergency Services Facilty Fee 5098 COLLECT BLOOD FROM IMPLAN. VAD 99281 450 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4900 Hos Emergency Services Facilty Fee 5099 COLLECT BLOOD SPEC FR CVL/PICC 99291 450 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4900 Hos Emergency Services Facilty Fee 5101 TEMPORARY EXTERNAL PACING 36591 450 34 23.799999999999997 7.39 34 17.32 7.39 25.5 7.39 17.32 17.32 17.32 17.32 7.39 8.129 7.39 7.39 7.39 7.39 7.5378 7.39 4900 Hos Emergency Services Facilty Fee 5102 LEVEL 1 - ER PROC. SIMPLE 36592 450 191 133.7 41.52 191 97.3 41.52 143.25 41.52 97.3 97.3 97.3 97.3 41.52 45.672000000000004 41.52 41.52 41.52 41.52 42.3504 41.52 4900 Hos Emergency Services Facilty Fee 5103 LEVEL 2 - ER PROC. INTERMEDIAL 92953 450 284 198.79999999999998 61.74 284 144.67 61.74 213 61.74 144.67 144.67 144.67 144.67 61.74 67.914 61.74 61.74 61.74 61.74 62.9748 61.74 4900 Hos Emergency Services Facilty Fee 5104 LEVEL 3 - ER PROC. COMPLEX 99281 450 379 265.3 82.39 379 193.06 82.39 284.25 82.39 193.06 193.06 193.06 193.06 82.39 90.629 82.39 82.39 82.39 82.39 84.0378 82.39 4900 Hos Emergency Services Facilty Fee 5105 ER LEVEL 1 99282 450 349 244.29999999999998 75.87 349 177.78 75.87 261.75 75.87 177.78 177.78 177.78 177.78 75.87 83.45700000000001 75.87 75.87 75.87 75.87 77.3874 75.87 4900 Hos Emergency Services Facilty Fee 5106 ER LEVEL 2 99283 450 442 309.4 96.09 442 225.15 96.09 331.5 96.09 225.15 225.15 225.15 225.15 96.09 105.69900000000001 96.09 96.09 96.09 96.09 98.01180000000001 96.09 4900 Hos Emergency Services Facilty Fee 5107 ER LEVEL 3 99281 450 648 453.59999999999997 140.88 648 330.09 140.88 486 140.88 330.09 330.09 330.09 330.09 140.88 154.96800000000002 140.88 140.88 140.88 140.88 143.6976 140.88 4900 Hos Emergency Services Facilty Fee 5108 ER LEVEL 4 99282 450 933 653.0999999999999 202.83 933 475.27 202.83 699.75 202.83 475.27 475.27 475.27 475.27 202.83 223.11300000000003 202.83 202.83 202.83 202.83 206.88660000000002 202.83 4900 Hos Emergency Services Facilty Fee 5109 SUTURE REMOVAL - No Charge , Note to patients for service performed 99283 450 N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C N/C 4900 Hos Emergency Services Facilty Fee 5110 EXCISION BENIGN LESION 99284 450 463 324.09999999999997 100.66 463 235.85 100.66 347.25 100.66 235.85 235.85 235.85 235.85 100.66 110.726 100.66 100.66 100.66 100.66 102.6732 100.66 4900 Hos Emergency Services Facilty Fee 5111 CLSD TX HIP DISLOC, W/OUT ANES 27252 450 702 491.4 152.62 702 357.6 152.62 526.5 152.62 357.6 357.6 357.6 357.6 152.62 167.882 152.62 152.62 152.62 152.62 155.6724 152.62 4900 Hos Emergency Services Facilty Fee 5112 INJECTION OF HEMORRHOIDS 11402 450 484 338.79999999999995 105.22 484 246.55 105.22 363 105.22 246.55 246.55 246.55 246.55 105.22 115.742 105.22 105.22 105.22 105.22 107.3244 105.22 4900 Hos Emergency Services Facilty Fee 5113 MSE ONLY 27250 450 171 119.69999999999999 37.18 171 87.11 37.18 128.25 37.18 87.11 87.11 87.11 87.11 37.18 40.898 37.18 37.18 37.18 37.18 37.9236 37.18 4900 Hos Emergency Services Facilty Fee 5117 LEVEL 5 ER 46500 450 1504 1052.8 326.97 1504 766.14 326.97 1128 326.97 766.14 766.14 766.14 766.14 326.97 359.6670000000001 326.97 326.97 326.97 326.97 333.5094 326.97 4900 Hos Emergency Services Facilty Fee 5118 TX KNUCKLE DISLOCATION 26770 450 359 251.29999999999998 78.05 359 182.87 78.05 269.25 78.05 182.87 182.87 182.87 182.87 78.05 85.855 78.05 78.05 78.05 78.05 79.611 78.05 4900 Hos Emergency Services Facilty Fee 5119 COMPLEX REPAIR OF LACERATION 12001 450 1163 814.0999999999999 252.84 1163 592.43 252.84 872.25 252.84 592.43 592.43 592.43 592.43 252.84 278.124 252.84 252.84 252.84 252.84 257.8968 252.84 4900 Hos Emergency Services Facilty Fee 5120 REPAIR COMPLEX E ADDTIL 12001 450 714 499.79999999999995 155.22 714 363.71 155.22 535.5 155.22 363.71 363.71 363.71 363.71 155.22 170.74200000000002 155.22 155.22 155.22 155.22 158.3244 155.22 4900 Hos Emergency Services Facilty Fee 5121 CLSD TX SHLDR DISLOC. W/FX OF 23665 450 1244 870.8 270.45 1244 633.69 270.45 933 270.45 633.69 633.69 633.69 633.69 270.45 297.495 270.45 270.45 270.45 270.45 275.859 270.45 4900 Hos Emergency Services Facilty Fee 5122 REPAIR LAC. 2.5CM/< FLOOR OF 41250 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 5123 ADMINISTRATION OF HEPATITIS B G0010 450 28 19.599999999999998 6.09 28 14.26 6.09 21 6.09 14.26 14.26 14.26 14.26 6.09 6.699000000000001 6.09 6.09 6.09 6.09 6.2118 6.09 4900 Hos Emergency Services Facilty Fee 5124 G-TUBE IRRIGATION 51040 450 244 170.79999999999998 53.05 244 124.29 53.05 183 53.05 124.29 124.29 124.29 124.29 53.05 58.355000000000004 53.05 53.05 53.05 53.05 54.111 53.05 4900 Hos Emergency Services Facilty Fee 5125 CYSTOSTOMY, W/DRAINAGE 29075 450 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4900 Hos Emergency Services Facilty Fee 5126 SHORT ARM, CAST APPLICATION 29065 270 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4900 Hos Emergency Services Facilty Fee 5127 LONG ARM, CAST APPLICATION 30300 270 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4900 Hos Emergency Services Facilty Fee 5128 REMOVAL FOREIGN BDY INTRANASAL 99144 450 256 179.2 55.65 256 130.41 55.65 192 55.65 130.41 130.41 130.41 130.41 55.65 61.215 55.65 55.65 55.65 55.65 56.763 55.65 4900 Hos Emergency Services Facilty Fee 5129 MODERATE CONSCIOUS SEDATION 40804 450 84 58.8 18.26 84 42.79 18.26 63 18.26 42.79 42.79 42.79 42.79 18.26 20.086000000000002 18.26 18.26 18.26 18.26 18.625200000000003 18.26 4900 Hos Emergency Services Facilty Fee 5130 REMOVAL OF FOREIGN BODY-MOUTH G0008 450 480 336 104.35 480 244.51 104.35 360 104.35 244.51 244.51 244.51 244.51 104.35 114.785 104.35 104.35 104.35 104.35 106.437 104.35 4900 Hos Emergency Services Facilty Fee 5131 ADMINISTRATION OF FLU VACCINE 90715 771 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4900 Hos Emergency Services Facilty Fee 5132 TDAP VACCINE 7YRS AND OLDER G0009 450 242 169.39999999999998 52.61 242 123.27 52.61 181.5 52.61 123.27 123.27 123.27 123.27 52.61 57.871 52.61 52.61 52.61 52.61 53.6622 52.61 4900 Hos Emergency Services Facilty Fee 5133 ADMINISTRATION OF PNEUMOCOCCAL 4640 771 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4900 Hos Emergency Services Facilty Fee 6001 CLSD TX RADIAL HEAD SUBLUX W/ 12018 981 377 263.9 81.96 377 192.04 81.96 282.75 81.96 192.04 192.04 192.04 192.04 81.96 90.156 81.96 81.96 81.96 81.96 83.5992 81.96 4900 Hos Emergency Services Facilty Fee 6002 SIMP CLOS FACE/EARS/EYELIDS/ 20600 981 277 193.89999999999998 60.22 277 141.1 60.22 207.75 60.22 141.1 141.1 141.1 141.1 60.22 66.242 60.22 60.22 60.22 60.22 61.4244 60.22 4900 Hos Emergency Services Facilty Fee 6003 ARTHROCENTESIS;FINGERS,TOES 11730 981 103 72.1 22.39 103 52.47 22.39 77.25 22.39 52.47 52.47 52.47 52.47 22.39 24.629 22.39 22.39 22.39 22.39 22.8378 22.39 4900 Hos Emergency Services Facilty Fee 6004 AVULSION OF NAIL PLATE,PARTIAL 67938 981 152 106.39999999999999 33.04 152 77.43 33.04 114 33.04 77.43 77.43 77.43 77.43 33.04 36.344 33.04 33.04 33.04 33.04 33.7008 33.04 4900 Hos Emergency Services Facilty Fee 6010 REMOVAL FB EYELID 31502 981 246 172.2 53.48 246 125.31 53.48 184.5 53.48 125.31 125.31 125.31 125.31 53.48 58.828 53.48 53.48 53.48 53.48 54.5496 53.48 4900 Hos Emergency Services Facilty Fee 6011 REPLACE TRACH TUBE 27560 981 272 190.39999999999998 59.13 272 138.56 59.13 204 59.13 138.56 138.56 138.56 138.56 59.13 65.043 59.13 59.13 59.13 59.13 60.3126 59.13 4900 Hos Emergency Services Facilty Fee 6012 CLOSED TX PATELLA DISLOCATION 10061 981 839 587.3 182.4 839 427.39 182.4 629.25 182.4 427.39 427.39 427.39 427.39 182.4 200.64000000000001 182.4 182.4 182.4 182.4 186.048 182.4 4900 Hos Emergency Services Facilty Fee 6013 I & D ABSCESS, COMPLICATED 59414 981 425 297.5 92.4 425 216.5 92.4 318.75 92.4 216.5 216.5 216.5 216.5 92.4 101.64000000000001 92.4 92.4 92.4 92.4 94.248 92.4 4900 Hos Emergency Services Facilty Fee 6014 DELIVERY OF PLACENTA 55100 981 808 565.5999999999999 175.66 808 411.6 175.66 606 175.66 411.6 411.6 411.6 411.6 175.66 193.226 175.66 175.66 175.66 175.66 179.1732 175.66 4900 Hos Emergency Services Facilty Fee 6015 I & D SCROTAL WALL ABSCESS 11760 981 457 319.9 99.35 457 232.8 99.35 342.75 99.35 232.8 232.8 232.8 232.8 99.35 109.285 99.35 99.35 99.35 99.35 101.33699999999999 99.35 4900 Hos Emergency Services Facilty Fee 6017 REPAIR OF NAILBED 13122 981 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4900 Hos Emergency Services Facilty Fee 6020 COMP REPAIR SCALP,ARMS,&/OR 26951 981 197 137.89999999999998 42.83 197 100.35 42.83 147.75 42.83 100.35 100.35 100.35 100.35 42.83 47.113 42.83 42.83 42.83 42.83 43.6866 42.83 4900 Hos Emergency Services Facilty Fee 6021 AMP FINGER,PRIM/SEC, ANY PHAL 12004 981 361 252.7 78.48 361 183.89 78.48 270.75 78.48 183.89 183.89 183.89 183.89 78.48 86.32800000000002 78.48 78.48 78.48 78.48 80.04960000000001 78.48 4900 Hos Emergency Services Facilty Fee 6022 SIMP CLOS SCALP/NECK/AXILL/ 65220 981 351 245.7 76.31 351 178.8 76.31 263.25 76.31 178.8 178.8 178.8 178.8 76.31 83.941 76.31 76.31 76.31 76.31 77.8362 76.31 4900 Hos Emergency Services Facilty Fee 6023 REMOVAL FB EXTERNAL EYE/CORNEA 50398 981 170 118.99999999999999 36.96 170 86.6 36.96 127.5 36.96 86.6 86.6 86.6 86.6 36.96 40.656000000000006 36.96 36.96 36.96 36.96 37.699200000000005 36.96 4900 Hos Emergency Services Facilty Fee 6024 CHANGE NEPHROSTOMY TUBE 29131 981 1006 704.1999999999999 218.7 1006 512.46 218.7 754.5 218.7 512.46 512.46 512.46 512.46 218.7 240.57 218.7 218.7 218.7 218.7 223.07399999999998 218.7 4900 Hos Emergency Services Facilty Fee 6025 APP FINGER SPLINT/DYNAMIC 29126 981 104 72.8 22.61 104 52.98 22.61 78 22.61 52.98 52.98 52.98 52.98 22.61 24.871000000000002 22.61 22.61 22.61 22.61 23.0622 22.61 4900 Hos Emergency Services Facilty Fee 6026 APP SHORT ARM SPLINT; DYNAMIC 27780 981 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4900 Hos Emergency Services Facilty Fee 6028 CLOSED TX PROX FIB/SHAFT FX 28022 981 151 105.69999999999999 32.83 151 76.92 32.83 113.25 32.83 76.92 76.92 76.92 76.92 32.83 36.113 32.83 32.83 32.83 32.83 33.486599999999996 32.83 4900 Hos Emergency Services Facilty Fee 6029 ARTHROTOMY/EXP/DRAIN/REMOVE FB 36578 981 1566 1096.1999999999998 340.45 1566 797.72 340.45 1174.5 340.45 797.72 797.72 797.72 797.72 340.45 374.495 340.45 340.45 340.45 340.45 347.259 340.45 4900 Hos Emergency Services Facilty Fee 6030 REPLACEMENT OF CVP LINE 12044 981 468 327.59999999999997 101.74 468 238.4 101.74 351 101.74 238.4 238.4 238.4 238.4 101.74 111.914 101.74 101.74 101.74 101.74 103.7748 101.74 4900 Hos Emergency Services Facilty Fee 6031 LAYER CLOS NECK/HANDS/FEET/ 54220 981 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4900 Hos Emergency Services Facilty Fee 6032 IRRIGATION OF COPORA CAVERNOSA 12021 981 302 211.39999999999998 65.65 302 153.84 65.65 226.5 65.65 153.84 153.84 153.84 153.84 65.65 72.21500000000002 65.65 65.65 65.65 65.65 66.96300000000001 65.65 4900 Hos Emergency Services Facilty Fee 6035 TX SF. WD. DEH. W/ PACKING 98925 981 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4900 Hos Emergency Services Facilty Fee 6036 OSTEOPATHIC MANIPUTLATION 64402 981 87 60.9 18.91 87 44.32 18.91 65.25 18.91 44.32 44.32 44.32 44.32 18.91 20.801000000000002 18.91 18.91 18.91 18.91 19.2882 18.91 4900 Hos Emergency Services Facilty Fee 6037 INJ ANESTHETIC OF FACIAL NERVE 17262 981 266 186.2 57.83 266 135.5 57.83 199.5 57.83 135.5 135.5 135.5 135.5 57.83 63.61300000000001 57.83 57.83 57.83 57.83 58.9866 57.83 4900 Hos Emergency Services Facilty Fee 6038 DESTR MAL LESION 1.1-2 CM 24200 981 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4900 Hos Emergency Services Facilty Fee 6039 REMOVAL FB FRM UPPR ARM, SUBCU 98296 981 507 354.9 110.22 507 258.27 110.22 380.25 110.22 258.27 258.27 258.27 258.27 110.22 121.242 110.22 110.22 110.22 110.22 112.4244 110.22 4900 Hos Emergency Services Facilty Fee 6040 OMT 3 - 4 AREAS 92960 981 87 60.9 18.91 87 44.32 18.91 65.25 18.91 44.32 44.32 44.32 44.32 18.91 20.801000000000002 18.91 18.91 18.91 18.91 19.2882 18.91 4900 Hos Emergency Services Facilty Fee 6041 CARDIOVERSION ELEC MIX 20550 981 681 476.7 148.05 681 346.9 148.05 510.75 148.05 346.9 346.9 346.9 346.9 148.05 162.85500000000002 148.05 148.05 148.05 148.05 151.01100000000002 148.05 4900 Hos Emergency Services Facilty Fee 6042 INJECT TENDON SHEATH/LIQ 41800 981 187 130.9 40.65 187 95.26 40.65 140.25 40.65 95.26 95.26 95.26 95.26 40.65 44.715 40.65 40.65 40.65 40.65 41.463 40.65 4900 Hos Emergency Services Facilty Fee 6043 I&D ABSCESS DENTOALVEOLAR STRU 11100 981 236 165.2 51.31 236 120.22 51.31 177 51.31 120.22 120.22 120.22 120.22 51.31 56.44100000000001 51.31 51.31 51.31 51.31 52.336200000000005 51.31 4900 Hos Emergency Services Facilty Fee 6044 BIOPSY SKIN LESION 46040 981 108 75.6 23.48 108 55.02 23.48 81 23.48 55.02 55.02 55.02 55.02 23.48 25.828000000000003 23.48 23.48 23.48 23.48 23.9496 23.48 4900 Hos Emergency Services Facilty Fee 6045 I&D PERIRECTAL ABCESS 62273 981 490 343 106.53 490 249.61 106.53 367.5 106.53 249.61 249.61 249.61 249.61 106.53 117.183 106.53 106.53 106.53 106.53 108.6606 106.53 4900 Hos Emergency Services Facilty Fee 6046 INJ EPIDURAL BLOOD PATCH 11765 981 543 380.09999999999997 118.05 543 276.6 118.05 407.25 118.05 276.6 276.6 276.6 276.6 118.05 129.85500000000002 118.05 118.05 118.05 118.05 120.411 118.05 4900 Hos Emergency Services Facilty Fee 6047 WEDGE EXCISION NAILBED 69020 981 208 145.6 45.22 208 105.96 45.22 156 45.22 105.96 105.96 105.96 105.96 45.22 49.742000000000004 45.22 45.22 45.22 45.22 46.1244 45.22 4900 Hos Emergency Services Facilty Fee 6049 I&D ABCESS EXT EAR CANAL 59409 981 192 134.39999999999998 41.74 192 97.8 41.74 144 41.74 97.8 97.8 97.8 97.8 41.74 45.91400000000001 41.74 41.74 41.74 41.74 42.5748 41.74 4900 Hos Emergency Services Facilty Fee 6050 VAGINAL DELIVERY, NORMAL 25605 981 2619 1833.3 569.37 2619 1334.12 569.37 1964.25 569.37 1334.12 1334.12 1334.12 1334.12 569.37 626.307 569.37 569.37 569.37 569.37 580.7574 569.37 4900 Hos Emergency Services Facilty Fee 6051 TREATMENT FX RADIUS/ULNA 25635 981 219 153.29999999999998 47.61 219 111.56 47.61 164.25 47.61 111.56 111.56 111.56 111.56 47.61 52.371 47.61 47.61 47.61 47.61 48.5622 47.61 4900 Hos Emergency Services Facilty Fee 6054 CLSD TX OF WRIST FX W/MANIP 23505 981 328 229.6 71.31 328 167.08 71.31 246 71.31 167.08 167.08 167.08 167.08 71.31 78.441 71.31 71.31 71.31 71.31 72.7362 71.31 4900 Hos Emergency Services Facilty Fee 6055 CLSD TX OF CLAVICLE FX 12016 981 328 229.6 71.31 328 167.08 71.31 246 71.31 167.08 167.08 167.08 167.08 71.31 78.441 71.31 71.31 71.31 71.31 72.7362 71.31 4900 Hos Emergency Services Facilty Fee 6056 SIMPLE REPAIR SF WOUNDS SCALP 12055 981 296 207.2 64.35 296 150.78 64.35 222 64.35 150.78 150.78 150.78 150.78 64.35 70.785 64.35 64.35 64.35 64.35 65.637 64.35 4900 Hos Emergency Services Facilty Fee 6057 LYR CLSR FC/HD 12.6 - 20.0 CM 16035 981 828 579.5999999999999 180.01 828 421.78 180.01 621 180.01 421.78 421.78 421.78 421.78 180.01 198.011 180.01 180.01 180.01 180.01 183.6102 180.01 4900 Hos Emergency Services Facilty Fee 6058 ESCHAROTOMY - INITIAL 16036 981 711 497.7 154.57 711 362.18 154.57 533.25 154.57 362.18 362.18 362.18 362.18 154.57 170.02700000000002 154.57 154.57 154.57 154.57 157.6614 154.57 4900 Hos Emergency Services Facilty Fee 6059 ESCHAROTOMY EA. ADD INCISION 64421 981 533 373.09999999999997 115.87 533 271.51 115.87 399.75 115.87 271.51 271.51 271.51 271.51 115.87 127.45700000000002 115.87 115.87 115.87 115.87 118.18740000000001 115.87 4900 Hos Emergency Services Facilty Fee 6060 INJ;ANESTHETIC;INTERCOSTAL NER 25660 981 249 174.29999999999998 54.13 249 126.84 54.13 186.75 54.13 126.84 126.84 126.84 126.84 54.13 59.543000000000006 54.13 54.13 54.13 54.13 55.2126 54.13 4900 Hos Emergency Services Facilty Fee 6061 CLSD TX WRIST DISLOC W/MANIP 27825 981 947 662.9 205.88 947 482.4 205.88 710.25 205.88 482.4 482.4 482.4 482.4 205.88 226.46800000000002 205.88 205.88 205.88 205.88 209.9976 205.88 4900 Hos Emergency Services Facilty Fee 6062 TX LOWER LEG FX 11402 981 1217 851.9 264.58 1217 619.94 264.58 912.75 264.58 619.94 619.94 619.94 619.94 264.58 291.038 264.58 264.58 264.58 264.58 269.8716 264.58 4900 Hos Emergency Services Facilty Fee 6063 EXCISION BENIGN LESION 27250 981 332 232.39999999999998 72.18 332 169.12 72.18 249 72.18 169.12 169.12 169.12 169.12 72.18 79.39800000000001 72.18 72.18 72.18 72.18 73.62360000000001 72.18 4900 Hos Emergency Services Facilty Fee 6064 CLSD TX HIP DISLOC, W/OUT ANES 46500 981 668 467.59999999999997 145.22 668 340.28 145.22 501 145.22 340.28 340.28 340.28 340.28 145.22 159.74200000000002 145.22 145.22 145.22 145.22 148.1244 145.22 4900 Hos Emergency Services Facilty Fee 6065 INJECTION OF HEMORRHOIDS 12035 981 296 207.2 64.35 296 150.78 64.35 222 64.35 150.78 150.78 150.78 150.78 64.35 70.785 64.35 64.35 64.35 64.35 65.637 64.35 4900 Hos Emergency Services Facilty Fee 501007 LAYER CLOS. WOUND 12.6-20CM 99281 450 320 224 69.57 320 163.01 69.57 240 69.57 163.01 163.01 163.01 163.01 69.57 76.527 69.57 69.57 69.57 69.57 70.9614 69.57 4900 Hos Emergency Services Facilty Fee 510107 EMERGENCY RM - TRIAGE 32002 450 108 75.6 23.48 108 55.02 23.48 81 23.48 55.02 55.02 55.02 55.02 23.48 25.828000000000003 23.48 23.48 23.48 23.48 23.9496 23.48 4900 Hos Emergency Services Facilty Fee 510321 CAST APPLICATION/REMOVAL 96372 700 70 49 15.22 70 35.66 15.22 52.5 15.22 35.66 35.66 35.66 35.66 15.22 16.742 15.22 15.22 15.22 15.22 15.524400000000002 15.22 4900 Hos Emergency Services Facilty Fee 510347 SPINAL BOARD 96373 270 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4900 Hos Emergency Services Facilty Fee 510354 RN TRANSPORT ASSISTANCE 96374 450 120 84 26.09 120 61.13 26.09 90 26.09 61.13 61.13 61.13 61.13 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 4900 Hos Emergency Services Facilty Fee 511212 THORACENTESIS W/INSERT TUBE 96379 450 480 336 104.35 480 244.51 104.35 360 104.35 244.51 244.51 244.51 244.51 104.35 114.785 104.35 104.35 104.35 104.35 106.437 104.35 4900 Hos Emergency Services Facilty Fee 511501 SUBQ OR IM INJECTION 10060 450 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4900 Hos Emergency Services Facilty Fee 511519 INTRA-ARTERIAL INJECTION 10080 450 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4900 Hos Emergency Services Facilty Fee 511527 INTRAVENOUS INJECTION -INITIAL 10120 450 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4900 Hos Emergency Services Facilty Fee 511543 UNLISTED THERAP/PROPH/DIAG INJ 10140 450 107 74.89999999999999 23.26 107 54.51 23.26 80.25 23.26 54.51 54.51 54.51 54.51 23.26 25.586000000000002 23.26 23.26 23.26 23.26 23.7252 23.26 4900 Hos Emergency Services Facilty Fee 511568 I&D ABCESS SIMPLE 10160 450 337 235.89999999999998 73.26 337 171.67 73.26 252.75 73.26 171.67 171.67 171.67 171.67 73.26 80.58600000000001 73.26 73.26 73.26 73.26 74.7252 73.26 4900 Hos Emergency Services Facilty Fee 511576 I&D PILONIDAL CYST SIMPLE 11042 450 337 235.89999999999998 73.26 337 171.67 73.26 252.75 73.26 171.67 171.67 171.67 171.67 73.26 80.58600000000001 73.26 73.26 73.26 73.26 74.7252 73.26 4900 Hos Emergency Services Facilty Fee 511584 I&D FOREING BODY SUBQ SIMPLE 11400 450 264 184.79999999999998 57.39 264 134.48 57.39 198 57.39 134.48 134.48 134.48 134.48 57.39 63.129000000000005 57.39 57.39 57.39 57.39 58.537800000000004 57.39 4900 Hos Emergency Services Facilty Fee 511600 I&D HEMATOMA, SEROMA, FLUID 11420 450 485 339.5 105.44 485 247.06 105.44 363.75 105.44 247.06 247.06 247.06 247.06 105.44 115.98400000000001 105.44 105.44 105.44 105.44 107.5488 105.44 4900 Hos Emergency Services Facilty Fee 511618 PUNCTURE ASPIRATION ABCESS 11740 450 264 184.79999999999998 57.39 264 134.48 57.39 198 57.39 134.48 134.48 134.48 134.48 57.39 63.129000000000005 57.39 57.39 57.39 57.39 58.537800000000004 57.39 4900 Hos Emergency Services Facilty Fee 511634 DEBRIDE SKIN & SUBQ TISSUE 11750 450 230 161 50 230 117.16 50 172.5 50 117.16 117.16 117.16 117.16 50 55.00000000000001 50 50 50 50 51 50 4900 Hos Emergency Services Facilty Fee 511642 EX LES TRK,ARMS,LEGS 5CM OR < 12001 450 527 368.9 114.57 527 268.45 114.57 395.25 114.57 268.45 268.45 268.45 268.45 114.57 126.027 114.57 114.57 114.57 114.57 116.86139999999999 114.57 4900 Hos Emergency Services Facilty Fee 511659 EX LES SCALP,NECK,HANDS 5CM < 12002 450 481 336.7 104.57 481 245.02 104.57 360.75 104.57 245.02 245.02 245.02 245.02 104.57 115.027 104.57 104.57 104.57 104.57 106.6614 104.57 4900 Hos Emergency Services Facilty Fee 511667 EVAC SUBUNGUAL HEMATOMAS 12011 450 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4900 Hos Emergency Services Facilty Fee 511675 EXC NAIL/NAIL MATRIX (INGROWN) 12013 450 1148 803.5999999999999 249.58 1148 584.79 249.58 861 249.58 584.79 584.79 584.79 584.79 249.58 274.538 249.58 249.58 249.58 249.58 254.57160000000002 249.58 4900 Hos Emergency Services Facilty Fee 511683 SIMPLE REPAIR T/E 2.5CM OR < 12014 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511691 SIMPLE REPAIR T/E 2.6-7.5CM 12015 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511709 SIMP REP FACE/HEAD 2.5CM OR < 12031 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511717 SIMP REP FACE/HEAD 2.6-5.0CM 12032 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511725 SIMP REP FACE/HEAD 5.1-7.5CM 12041 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511733 SIMP REP FACE/HEAD 7.6-12.5CM 12042 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511741 LAYER CLSR S/T/E 2.5CM OR < 12051 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511758 LAYER CLSR S/T/E 2.6-7.5CM 12052 450 714 499.79999999999995 155.22 714 363.71 155.22 535.5 155.22 363.71 363.71 363.71 363.71 155.22 170.74200000000002 155.22 155.22 155.22 155.22 158.3244 155.22 4900 Hos Emergency Services Facilty Fee 511766 LAYER CLSR NECK/EXT 2.5CM OR < 11720 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511774 LAYER CLSR NECK/EXT 2.6-7.5CM 16000 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511782 LAYER CLSR FACE/HEAD 2.5CM < 16020 450 714 499.79999999999995 155.22 714 363.71 155.22 535.5 155.22 363.71 363.71 363.71 363.71 155.22 170.74200000000002 155.22 155.22 155.22 155.22 158.3244 155.22 4900 Hos Emergency Services Facilty Fee 511790 LAYER CLSR FACE/HEAD 2.6-5.0CM 17110 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511808 DEBRID NAILS ANY METHOD 20550 450 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4900 Hos Emergency Services Facilty Fee 511816 INITIAL TREAT 1ST BURN 20610 450 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4900 Hos Emergency Services Facilty Fee 511824 DRESS AND/OR DEBRID BURN SMALL 21480 450 233 163.1 50.65 233 118.69 50.65 174.75 50.65 118.69 118.69 118.69 118.69 50.65 55.715 50.65 50.65 50.65 50.65 51.663 50.65 4900 Hos Emergency Services Facilty Fee 511832 WART REMOVAL 12004 450 73 51.099999999999994 15.87 73 37.19 15.87 54.75 15.87 37.19 37.19 37.19 37.19 15.87 17.457 15.87 15.87 15.87 15.87 16.1874 15.87 4900 Hos Emergency Services Facilty Fee 511840 INJ TENDON,TRIGG PTS GANGLION 12005 450 278 194.6 60.44 278 141.61 60.44 208.5 60.44 141.61 141.61 141.61 141.61 60.44 66.48400000000001 60.44 60.44 60.44 60.44 61.6488 60.44 4900 Hos Emergency Services Facilty Fee 511857 ARTHROCENTESIS MAJOR JOINT 12006 450 603 422.09999999999997 131.09 603 307.17 131.09 452.25 131.09 307.17 307.17 307.17 307.17 131.09 144.199 131.09 131.09 131.09 131.09 133.7118 131.09 4900 Hos Emergency Services Facilty Fee 511865 CLSD RED TEMPOROMANDIBULAR 12007 450 222 155.39999999999998 48.26 222 113.09 48.26 166.5 48.26 113.09 113.09 113.09 113.09 48.26 53.086000000000006 48.26 48.26 48.26 48.26 49.2252 48.26 4900 Hos Emergency Services Facilty Fee 511873 SIMPLE REPAIR T/E 7.6CM-12.5CM 12020 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511881 SIMPLE REPAIR T/E 12.6-20.0CM 96365 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511899 SIMPLE REPAIR T/E 20.1CM-30CM 62319 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511907 SIMPLE REPAIR T/E OVER 30.0CM 23650 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511915 CLOSURE WOUND DEHISCENCE 23930 450 321 224.7 69.79 321 163.52 69.79 240.75 69.79 163.52 163.52 163.52 163.52 69.79 76.76900000000002 69.79 69.79 69.79 69.79 71.18580000000001 69.79 4900 Hos Emergency Services Facilty Fee 511923 THEAPEUTIC INF UP TO 1 HOUR 25260 450 421 294.7 91.53 421 214.46 91.53 315.75 91.53 214.46 214.46 214.46 214.46 91.53 100.683 91.53 91.53 91.53 91.53 93.3606 91.53 4900 Hos Emergency Services Facilty Fee 511931 INJECTION LUMBAR W/CATH 26750 450 437 305.9 95 437 222.61 95 327.75 95 222.61 222.61 222.61 222.61 95 104.50000000000001 95 95 95 95 96.9 95 4900 Hos Emergency Services Facilty Fee 511949 CLOSED SHOULDER MANIP. 26770 450 357 249.89999999999998 77.61 357 181.86 77.61 267.75 77.61 181.86 181.86 181.86 181.86 77.61 85.37100000000001 77.61 77.61 77.61 77.61 79.1622 77.61 4900 Hos Emergency Services Facilty Fee 511956 I&D UPPER ARM ELBOW 31500 450 810 567 176.09 810 412.61 176.09 607.5 176.09 412.61 412.61 412.61 412.61 176.09 193.699 176.09 176.09 176.09 176.09 179.61180000000002 176.09 4900 Hos Emergency Services Facilty Fee 511964 REP. TEND/MUSC UPPER EXT. 32420 450 1854 1297.8 403.06 1854 944.43 403.06 1390.5 403.06 944.43 944.43 944.43 944.43 403.06 443.36600000000004 403.06 403.06 403.06 403.06 411.1212 403.06 4900 Hos Emergency Services Facilty Fee 511972 CLSD TX FINGER/THUMB W/O MANIP 35206 450 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4900 Hos Emergency Services Facilty Fee 511980 CLSD TX JOINT DISLOC W/MANIP 36556 450 357 249.89999999999998 77.61 357 181.86 77.61 267.75 77.61 181.86 181.86 181.86 181.86 77.61 85.37100000000001 77.61 77.61 77.61 77.61 79.1622 77.61 4900 Hos Emergency Services Facilty Fee 511998 INTUBATION ENDOTRACH. EMER. 43760 450 594 415.79999999999995 129.14 594 302.58 129.14 445.5 129.14 302.58 302.58 302.58 302.58 129.14 142.054 129.14 129.14 129.14 129.14 131.72279999999998 129.14 4900 Hos Emergency Services Facilty Fee 512012 PNEUMOCENTESIS, LUNG ASPIR. 56420 450 480 336 104.35 480 244.51 104.35 360 104.35 244.51 244.51 244.51 244.51 104.35 114.785 104.35 104.35 104.35 104.35 106.437 104.35 4900 Hos Emergency Services Facilty Fee 512038 REPAIR BLOOD VESSEL HAND/FING 65205 450 2546 1782.1999999999998 553.5 2546 1296.93 553.5 1909.5 553.5 1296.93 1296.93 1296.93 1296.93 553.5 608.85 553.5 553.5 553.5 553.5 564.57 553.5 4900 Hos Emergency Services Facilty Fee 512046 PLACEMENT CENTRAL VEN. CATH 69200 450 2564 1794.8 557.42 2564 1306.1 557.42 1923 557.42 1306.1 1306.1 1306.1 1306.1 557.42 613.162 557.42 557.42 557.42 557.42 568.5684 557.42 4900 Hos Emergency Services Facilty Fee 512053 CHANGE GASTROSTOMY TUBE 69210 450 532 372.4 115.66 532 271 115.66 399 115.66 271 271 271 271 115.66 127.22600000000001 115.66 115.66 115.66 115.66 117.9732 115.66 4900 Hos Emergency Services Facilty Fee 512061 I&D BARTHOLIN ABSCESS 80597 450 314 219.79999999999998 68.26 314 159.95 68.26 235.5 68.26 159.95 159.95 159.95 159.95 68.26 75.08600000000001 68.26 68.26 68.26 68.26 69.6252 68.26 4900 Hos Emergency Services Facilty Fee 512079 REMOVE FB EYE SUPERFICIAL 38221 450 348 243.6 75.66 348 177.27 75.66 261 75.66 177.27 177.27 177.27 177.27 75.66 83.226 75.66 75.66 75.66 75.66 77.1732 75.66 4900 Hos Emergency Services Facilty Fee 512087 REMOVE FB AUDITORY CANAL 17999 450 152 106.39999999999999 33.04 152 77.43 33.04 114 33.04 77.43 77.43 77.43 77.43 33.04 36.344 33.04 33.04 33.04 33.04 33.7008 33.04 4900 Hos Emergency Services Facilty Fee 512095 REMOVE IMPACT EAR CERUMEN 32551 450 152 106.39999999999999 33.04 152 77.43 33.04 114 33.04 77.43 77.43 77.43 77.43 33.04 36.344 33.04 33.04 33.04 33.04 33.7008 33.04 4900 Hos Emergency Services Facilty Fee 512103 BONE MARROW BIOPSY ASPIRATION 27550 450 129 90.3 28.04 129 65.71 28.04 96.75 28.04 65.71 65.71 65.71 65.71 28.04 30.844 28.04 28.04 28.04 28.04 28.6008 28.04 4900 Hos Emergency Services Facilty Fee 512111 BONE MARROW BIOPSY NEEDLE 27899 450 129 90.3 28.04 129 65.71 28.04 96.75 28.04 65.71 65.71 65.71 65.71 28.04 30.844 28.04 28.04 28.04 28.04 28.6008 28.04 4900 Hos Emergency Services Facilty Fee 512509 UP SKIN/MUCOUS MEM/SUBQ TISSUE 28660 450 243 170.1 52.83 243 123.78 52.83 182.25 52.83 123.78 123.78 123.78 123.78 52.83 58.113 52.83 52.83 52.83 52.83 53.8866 52.83 4900 Hos Emergency Services Facilty Fee 512517 TUBE THORACOSTOMY W/WO H20SEAL 26989 450 1256 879.1999999999999 273.06 1256 639.81 273.06 942 273.06 639.81 639.81 639.81 639.81 273.06 300.36600000000004 273.06 273.06 273.06 273.06 278.5212 273.06 4900 Hos Emergency Services Facilty Fee 512525 MANIPULATION OF KNEE DISLOCATN 26010 450 286 200.2 62.18 286 145.69 62.18 214.5 62.18 145.69 145.69 145.69 145.69 62.18 68.39800000000001 62.18 62.18 62.18 62.18 63.4236 62.18 4900 Hos Emergency Services Facilty Fee 512533 REMOVAL FB LEG/ANKLE 30999 450 286 200.2 62.18 286 145.69 62.18 214.5 62.18 145.69 145.69 145.69 145.69 62.18 68.39800000000001 62.18 62.18 62.18 62.18 63.4236 62.18 4900 Hos Emergency Services Facilty Fee 512541 CLOSED TX JT DISLOCTN W/O ANES 12053 450 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4900 Hos Emergency Services Facilty Fee 512558 OTHER PROCEDURE HAND/FINGER 62770 450 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4900 Hos Emergency Services Facilty Fee 514505 I & D FINGER ABSCESS/SIMPLE 43752 450 338 236.6 73.48 338 172.18 73.48 253.5 73.48 172.18 172.18 172.18 172.18 73.48 80.82800000000002 73.48 73.48 73.48 73.48 74.9496 73.48 4900 Hos Emergency Services Facilty Fee 514661 REMOVAL FB NOSE 23991 450 256 179.2 55.65 256 130.41 55.65 192 55.65 130.41 130.41 130.41 130.41 55.65 61.215 55.65 55.65 55.65 55.65 56.763 55.65 4900 Hos Emergency Services Facilty Fee 514893 LAYER CLSR 5.1cm-7.5cm FACE 28190 450 310 217 67.39 310 157.91 67.39 232.5 67.39 157.91 157.91 157.91 157.91 67.39 74.129 67.39 67.39 67.39 67.39 68.73780000000001 67.39 4900 Hos Emergency Services Facilty Fee 514927 LUMBAR PUNCTURE DIAGNOSTIC 69000 450 393 275.09999999999997 85.44 393 200.19 85.44 294.75 85.44 200.19 200.19 200.19 200.19 85.44 93.98400000000001 85.44 85.44 85.44 85.44 87.1488 85.44 4900 Hos Emergency Services Facilty Fee 515775 INSERT NASOGASTRIC TUBE 46050 450 302 211.39999999999998 65.65 302 153.84 65.65 226.5 65.65 153.84 153.84 153.84 153.84 65.65 72.21500000000002 65.65 65.65 65.65 65.65 66.96300000000001 65.65 4900 Hos Emergency Services Facilty Fee 515973 I & D UPPER ARM/ELBOW/BURSA 96365 450 607 424.9 131.96 607 309.21 131.96 455.25 131.96 309.21 309.21 309.21 309.21 131.96 145.15600000000003 131.96 131.96 131.96 131.96 134.59920000000002 131.96 4900 Hos Emergency Services Facilty Fee 516237 REMOVE FB FOOT SUBCUTANEOUS 99211 450 1916 1341.1999999999998 416.54 1916 976.01 416.54 1437 416.54 976.01 976.01 976.01 976.01 416.54 458.1940000000001 416.54 416.54 416.54 416.54 424.87080000000003 416.54 4900 Hos Emergency Services Facilty Fee 516658 I&D OF EXTERNAL EAR, SIMPLE 41599 450 256 179.2 55.65 256 130.41 55.65 192 55.65 130.41 130.41 130.41 130.41 55.65 61.215 55.65 55.65 55.65 55.65 56.763 55.65 4900 Hos Emergency Services Facilty Fee 516732 I&D PERIANAL ABSCESS 12034 450 3636 2545.2 790.47 3636 1852.18 790.47 2727 790.47 1852.18 1852.18 1852.18 1852.18 790.47 869.517 790.47 790.47 790.47 790.47 806.2794 790.47 4900 Hos Emergency Services Facilty Fee 517557 IV THERAPY INFUSION UP TO 1HR 30901 260 301 210.7 65.44 301 153.33 65.44 225.75 65.44 153.33 153.33 153.33 153.33 65.44 71.98400000000001 65.44 65.44 65.44 65.44 66.7488 65.44 4900 Hos Emergency Services Facilty Fee 517581 MCAID NON EMERGENCY TREATMENT 25999 761 133 93.1 28.91 133 67.75 28.91 99.75 28.91 67.75 67.75 67.75 67.75 28.91 31.801000000000002 28.91 28.91 28.91 28.91 29.4882 28.91 4900 Hos Emergency Services Facilty Fee 517763 UNLISTED PROCEDURE MOUTH 90471 450 216 151.2 46.96 216 110.03 46.96 162 46.96 110.03 110.03 110.03 110.03 46.96 51.656000000000006 46.96 46.96 46.96 46.96 47.8992 46.96 4900 Hos Emergency Services Facilty Fee 517797 LAYER CLSR SCP/AX/TRK7.6-12.5c 93041 450 311 217.7 67.61 311 158.42 67.61 233.25 67.61 158.42 158.42 158.42 158.42 67.61 74.37100000000001 67.61 67.61 67.61 67.61 68.9622 67.61 4900 Hos Emergency Services Facilty Fee 517938 CONTROL NOSEBLEED ANTERIOR 92950 450 283 198.1 61.52 283 144.16 61.52 212.25 61.52 144.16 144.16 144.16 144.16 61.52 67.67200000000001 61.52 61.52 61.52 61.52 62.750400000000006 61.52 4900 Hos Emergency Services Facilty Fee 518068 REMOVAL FB FOREARM/WRIST 24600 450 278 194.6 60.44 278 141.61 60.44 208.5 60.44 141.61 141.61 141.61 141.61 60.44 66.48400000000001 60.44 60.44 60.44 60.44 61.6488 60.44 4900 Hos Emergency Services Facilty Fee 518316 ADMINISTRATION OF TOXOID 20605 771 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4900 Hos Emergency Services Facilty Fee 518332 CARDIAC MONITOR ER 29105 450 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4900 Hos Emergency Services Facilty Fee 518555 CPR ER 29125 450 886 620.1999999999999 192.62 886 451.33 192.62 664.5 192.62 451.33 451.33 451.33 451.33 192.62 211.88200000000003 192.62 192.62 192.62 192.62 196.47240000000002 192.62 4900 Hos Emergency Services Facilty Fee 518837 CLOSED TX ELBOW DISLOCATION 29130 450 278 194.6 60.44 278 141.61 60.44 208.5 60.44 141.61 141.61 141.61 141.61 60.44 66.48400000000001 60.44 60.44 60.44 60.44 61.6488 60.44 4900 Hos Emergency Services Facilty Fee 518878 ARTHROCENTESIS INTERM JOINT 29200 450 265 185.5 57.61 265 134.99 57.61 198.75 57.61 134.99 134.99 134.99 134.99 57.61 63.371 57.61 57.61 57.61 57.61 58.7622 57.61 4900 Hos Emergency Services Facilty Fee 519009 APPLICATION OF LONG ARM SPLINT 29240 450 245 171.5 53.26 245 124.8 53.26 183.75 53.26 124.8 124.8 124.8 124.8 53.26 58.586000000000006 53.26 53.26 53.26 53.26 54.3252 53.26 4900 Hos Emergency Services Facilty Fee 519017 STATIC SPLINT 29260 450 128 89.6 27.83 128 65.2 27.83 96 27.83 65.2 65.2 65.2 65.2 27.83 30.613 27.83 27.83 27.83 27.83 28.386599999999998 27.83 4900 Hos Emergency Services Facilty Fee 519025 APPLICATION OF FINGER SPLINT 29280 450 91 63.699999999999996 19.78 91 46.36 19.78 68.25 19.78 46.36 46.36 46.36 46.36 19.78 21.758000000000003 19.78 19.78 19.78 19.78 20.175600000000003 19.78 4900 Hos Emergency Services Facilty Fee 519033 STRAPPING THORAX 29345 450 227 158.89999999999998 49.35 227 115.63 49.35 170.25 49.35 115.63 115.63 115.63 115.63 49.35 54.285000000000004 49.35 49.35 49.35 49.35 50.337 49.35 4900 Hos Emergency Services Facilty Fee 519058 STRAPPING SHOULDER 29405 450 254 177.79999999999998 55.22 254 129.39 55.22 190.5 55.22 129.39 129.39 129.39 129.39 55.22 60.742000000000004 55.22 55.22 55.22 55.22 56.3244 55.22 4900 Hos Emergency Services Facilty Fee 519066 STRAPPING ELBOW or WRIST 29505 450 227 158.89999999999998 49.35 227 115.63 49.35 170.25 49.35 115.63 115.63 115.63 115.63 49.35 54.285000000000004 49.35 49.35 49.35 49.35 50.337 49.35 4900 Hos Emergency Services Facilty Fee 519074 STRAPPING HAND or FINGER 29515 450 227 158.89999999999998 49.35 227 115.63 49.35 170.25 49.35 115.63 115.63 115.63 115.63 49.35 54.285000000000004 49.35 49.35 49.35 49.35 50.337 49.35 4900 Hos Emergency Services Facilty Fee 519082 APP. OF LONG LEG CAST 29530 450 245 171.5 53.26 245 124.8 53.26 183.75 53.26 124.8 124.8 124.8 124.8 53.26 58.586000000000006 53.26 53.26 53.26 53.26 54.3252 53.26 4900 Hos Emergency Services Facilty Fee 519090 APP. OF SHORT LEG CAST 29540 450 227 158.89999999999998 49.35 227 115.63 49.35 170.25 49.35 115.63 115.63 115.63 115.63 49.35 54.285000000000004 49.35 49.35 49.35 49.35 50.337 49.35 4900 Hos Emergency Services Facilty Fee 519108 APP. OF LONG LEG SPLINT 29550 450 155 108.5 33.7 155 78.96 33.7 116.25 33.7 78.96 78.96 78.96 78.96 33.7 37.07000000000001 33.7 33.7 33.7 33.7 34.374 33.7 4900 Hos Emergency Services Facilty Fee 519116 APP. OF SHORT LEG SPLINT 29705 450 254 177.79999999999998 55.22 254 129.39 55.22 190.5 55.22 129.39 129.39 129.39 129.39 55.22 60.742000000000004 55.22 55.22 55.22 55.22 56.3244 55.22 4900 Hos Emergency Services Facilty Fee 519124 STRAPPING OF KNEE 29730 450 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4900 Hos Emergency Services Facilty Fee 519132 STRAPPING OF ANKLE 28510 450 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4900 Hos Emergency Services Facilty Fee 519140 STRAPPING OF TOES 28495 450 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4900 Hos Emergency Services Facilty Fee 519157 REMOVAL OF ARM or LEG CAST 29540 450 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4900 Hos Emergency Services Facilty Fee 519173 WINDOWING OF CAST 20999 450 155 108.5 33.7 155 78.96 33.7 116.25 33.7 78.96 78.96 78.96 78.96 33.7 37.07000000000001 33.7 33.7 33.7 33.7 34.374 33.7 4900 Hos Emergency Services Facilty Fee 519181 CLSD TX FX PHALANX EXC GRT W/O 26725 450 543 380.09999999999997 118.05 543 276.6 118.05 407.25 118.05 276.6 276.6 276.6 276.6 118.05 129.85500000000002 118.05 118.05 118.05 118.05 120.411 118.05 4900 Hos Emergency Services Facilty Fee 519199 CLSD TX OF FX TREAT TOE W/O MA 42809 450 212 148.39999999999998 46.09 212 107.99 46.09 159 46.09 107.99 107.99 107.99 107.99 46.09 50.699000000000005 46.09 46.09 46.09 46.09 47.0118 46.09 4900 Hos Emergency Services Facilty Fee 519207 STRAPPING ANKLE/OUTPATIENT 30905 761 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4900 Hos Emergency Services Facilty Fee 519355 APPL OF CERVICAL COLLAR BY ER 46083 450 133 93.1 28.91 133 67.75 28.91 99.75 28.91 67.75 67.75 67.75 67.75 28.91 31.801000000000002 28.91 28.91 28.91 28.91 29.4882 28.91 4900 Hos Emergency Services Facilty Fee 519454 CLSD TX PHAL SHFT FX W/MANIP 12054 450 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4900 Hos Emergency Services Facilty Fee 519462 REMOVAL FOREIGN BODY PHARYNX 53600 450 216 151.2 46.96 216 110.03 46.96 162 46.96 110.03 110.03 110.03 110.03 46.96 51.656000000000006 46.96 46.96 46.96 46.96 47.8992 46.96 4900 Hos Emergency Services Facilty Fee 519512 CONTROL NOSEBLEED POSTERIOR 29799 450 291 203.7 63.26 291 148.24 63.26 218.25 63.26 148.24 148.24 148.24 148.24 63.26 69.586 63.26 63.26 63.26 63.26 64.5252 63.26 4900 Hos Emergency Services Facilty Fee 520014 INCIS THROMBOSSED HEMORROID,EX 11306 450 300 210 65.22 300 152.82 65.22 225 65.22 152.82 152.82 152.82 152.82 65.22 71.742 65.22 65.22 65.22 65.22 66.5244 65.22 4900 Hos Emergency Services Facilty Fee 520304 LAYER CLS FACE/HEAD 7.6-12.5cm 20103 450 322 225.39999999999998 70 322 164.03 70 241.5 70 164.03 164.03 164.03 164.03 70 77 70 70 70 70 71.4 70 4900 Hos Emergency Services Facilty Fee 523118 DILATION OF URETHRA 31730 450 329 230.29999999999998 71.52 329 167.59 71.52 246.75 71.52 167.59 167.59 167.59 167.59 71.52 78.672 71.52 71.52 71.52 71.52 72.9504 71.52 4900 Hos Emergency Services Facilty Fee 526004 UNLISTED CASTING or STRAPPING 49999 450 133 93.1 28.91 133 67.75 28.91 99.75 28.91 67.75 67.75 67.75 67.75 28.91 31.801000000000002 28.91 28.91 28.91 28.91 29.4882 28.91 4900 Hos Emergency Services Facilty Fee 526020 SHAVE SKIN LESION 0.6-1.0cm 26755 450 117 81.89999999999999 25.44 117 59.6 25.44 87.75 25.44 59.6 59.6 59.6 59.6 25.44 27.984000000000005 25.44 25.44 25.44 25.44 25.948800000000002 25.44 4900 Hos Emergency Services Facilty Fee 527366 EXPLORATION PENETRAT WND,EXTRE 13121 450 344 240.79999999999998 74.79 344 175.23 74.79 258 74.79 175.23 175.23 175.23 175.23 74.79 82.26900000000002 74.79 74.79 74.79 74.79 76.28580000000001 74.79 4900 Hos Emergency Services Facilty Fee 527368 TRNSTRACH TUBE FOR O2 TX 28515 450 524 366.79999999999995 113.92 524 266.93 113.92 393 113.92 266.93 266.93 266.93 266.93 113.92 125.31200000000001 113.92 113.92 113.92 113.92 116.1984 113.92 4900 Hos Emergency Services Facilty Fee 528075 UNLISTED PROCEDURE ABD,PERITON 122036 450 302 211.39999999999998 65.65 302 153.84 65.65 226.5 65.65 153.84 153.84 153.84 153.84 65.65 72.21500000000002 65.65 65.65 65.65 65.65 66.96300000000001 65.65 4900 Hos Emergency Services Facilty Fee 528380 CLSD TX DIS PHAL FX W/MANIP 92981 450 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4900 Hos Emergency Services Facilty Fee 528430 COMPLEX RPR,SCLP/ARM/LEG2.6-7. 99282 450 479 335.29999999999995 104.13 479 244 104.13 359.25 104.13 244 244 244 244 104.13 114.543 104.13 104.13 104.13 104.13 106.2126 104.13 4900 Hos Emergency Services Facilty Fee 528794 CLSD TX FX PHALANX EXC GRT W M 99283 450 543 380.09999999999997 118.05 543 276.6 118.05 407.25 118.05 276.6 276.6 276.6 276.6 118.05 129.85500000000002 118.05 118.05 118.05 118.05 120.411 118.05 4900 Hos Emergency Services Facilty Fee 534685 LAYER CLSR S/T/E 20.1-30.0cm 99284 450 311 217.7 67.61 311 158.42 67.61 233.25 67.61 158.42 158.42 158.42 158.42 67.61 74.37100000000001 67.61 67.61 67.61 67.61 68.9622 67.61 4900 Hos Emergency Services Professional Fees 610105 ER PHYSICIAN-LEVEL I 99291 981 279 195.29999999999998 60.65 279 142.12 60.65 209.25 60.65 142.12 142.12 142.12 142.12 60.65 66.715 60.65 60.65 0 0 0 0 4900 Hos Emergency Services Professional Fees 610113 ER PHYSICIAN-LEVEL II 12054 981 351 245.7 76.31 351 178.8 76.31 263.25 76.31 178.8 178.8 178.8 178.8 76.31 83.941 76.31 76.31 76.31 76.31 77.8362 76.31 4900 Hos Emergency Services Professional Fees 610204 ER PHYSICIAN-LEVEL III 46050 981 465 325.5 101.09 465 236.87 101.09 348.75 101.09 236.87 236.87 236.87 236.87 101.09 111.19900000000001 101.09 101.09 101.09 101.09 103.1118 101.09 4900 Hos Emergency Services Professional Fees 610303 ER PHYSICIAN-LEVEL IV 24600 981 620 434 134.79 620 315.83 134.79 465 134.79 315.83 315.83 315.83 315.83 134.79 148.269 134.79 134.79 134.79 134.79 137.48579999999998 134.79 4900 Hos Emergency Services Professional Fees 610402 ER PHYSICIAN-LEVEL V 10060 981 834 583.8 181.31 834 424.84 181.31 625.5 181.31 424.84 424.84 424.84 424.84 181.31 199.44100000000003 181.31 181.31 181.31 181.31 184.9362 181.31 4900 Hos Emergency Services Professional Fees 611004 ER PHYSICIAN - CRITICAL CARE 10080 981 622 435.4 135.22 622 316.85 135.22 466.5 135.22 316.85 316.85 316.85 316.85 135.22 148.74200000000002 135.22 135.22 135.22 135.22 137.9244 135.22 4900 Hos Emergency Services Facilty Fee 615021 LAYERCLOSFACE/EARS/EYELIDS/NOS 10120 981 766 536.1999999999999 166.53 766 390.2 166.53 574.5 166.53 390.2 390.2 390.2 390.2 166.53 183.18300000000002 166.53 166.53 166.53 166.53 169.8606 166.53 4900 Hos Emergency Services Facilty Fee 616250 I&D PERIANAL ABSCESS;SUPERFICI 10140 981 451 315.7 98.05 451 229.74 98.05 338.25 98.05 229.74 229.74 229.74 229.74 98.05 107.855 98.05 98.05 98.05 98.05 100.011 98.05 4900 Hos Emergency Services Facilty Fee 618793 CLOSED TX ELBOW DISLOCATION 10160 981 457 319.9 99.35 457 232.8 99.35 342.75 99.35 232.8 232.8 232.8 232.8 99.35 109.285 99.35 99.35 99.35 99.35 101.33699999999999 99.35 4900 Hos Emergency Services Facilty Fee 620005 I & D ABSCESS, SIMPLE 11042 981 189 132.29999999999998 41.09 189 96.28 41.09 141.75 41.09 96.28 96.28 96.28 96.28 41.09 45.199000000000005 41.09 41.09 41.09 41.09 41.91180000000001 41.09 4900 Hos Emergency Services Facilty Fee 620021 I & D PILONIDAL CYST; SIMPLE 11400 981 275 192.5 59.79 275 140.09 59.79 206.25 59.79 140.09 140.09 140.09 140.09 59.79 65.769 59.79 59.79 59.79 59.79 60.9858 59.79 4900 Hos Emergency Services Facilty Fee 620054 INCISION & REMOVAL FB SUBQ; 11420 981 196 137.2 42.61 196 99.84 42.61 147 42.61 99.84 99.84 99.84 99.84 42.61 46.871 42.61 42.61 42.61 42.61 43.4622 42.61 4900 Hos Emergency Services Facilty Fee 620088 I & D HEMATOMA, SEROMA OR FLUI 11622 981 222 155.39999999999998 48.26 222 113.09 48.26 166.5 48.26 113.09 113.09 113.09 113.09 48.26 53.086000000000006 48.26 48.26 48.26 48.26 49.2252 48.26 4900 Hos Emergency Services Facilty Fee 620104 PUNC ASP OF ABSCESS/HEMATOMA/ 11720 981 167 116.89999999999999 36.31 167 85.07 36.31 125.25 36.31 85.07 85.07 85.07 85.07 36.31 39.941 36.31 36.31 36.31 36.31 37.0362 36.31 4900 Hos Emergency Services Facilty Fee 620153 DEBRID;SKIN & SUB Q TISSUE 11740 981 345 241.49999999999997 75 345 175.74 75 258.75 75 175.74 175.74 175.74 175.74 75 82.5 75 75 75 75 76.5 75 4900 Hos Emergency Services Facilty Fee 620187 EXCIS LESION TRUNK,ARMS,LEGS 11750 981 220 154 47.83 220 112.07 47.83 165 47.83 112.07 112.07 112.07 112.07 47.83 52.613 47.83 47.83 47.83 47.83 48.7866 47.83 4900 Hos Emergency Services Facilty Fee 620203 EXCIS LESION,SCALP,NECK,HANDS 12001 981 302 211.39999999999998 65.65 302 153.84 65.65 226.5 65.65 153.84 153.84 153.84 153.84 65.65 72.21500000000002 65.65 65.65 65.65 65.65 66.96300000000001 65.65 4900 Hos Emergency Services Facilty Fee 620229 EXC. MALIG LESION SCALP, ETC. 12002 981 714 499.79999999999995 155.22 714 363.71 155.22 535.5 155.22 363.71 363.71 363.71 363.71 155.22 170.74200000000002 155.22 155.22 155.22 155.22 158.3244 155.22 4900 Hos Emergency Services Facilty Fee 620245 NAIL DEBRIDEMENT 1-5 12011 981 132 92.39999999999999 28.7 132 67.24 28.7 99 28.7 67.24 67.24 67.24 67.24 28.7 31.57 28.7 28.7 28.7 28.7 29.274 28.7 4900 Hos Emergency Services Facilty Fee 620260 EVAC OF SUBUNGUAL HEMATOMA 12013 981 123 86.1 26.74 123 62.66 26.74 92.25 26.74 62.66 62.66 62.66 62.66 26.74 29.414 26.74 26.74 26.74 26.74 27.2748 26.74 4900 Hos Emergency Services Facilty Fee 620286 EXC NAIL & MATRIX,PARTIAL/COMP 12014 981 787 550.9 171.09 787 400.9 171.09 590.25 171.09 400.9 400.9 400.9 400.9 171.09 188.199 171.09 171.09 171.09 171.09 174.5118 171.09 4900 Hos Emergency Services Facilty Fee 620302 SIMPCLOSSCALP/NECK/AXILL/GENT 12015 981 245 171.5 53.26 245 124.8 53.26 183.75 53.26 124.8 124.8 124.8 124.8 53.26 58.586000000000006 53.26 53.26 53.26 53.26 54.3252 53.26 4900 Hos Emergency Services Facilty Fee 620328 SIMP CLOS SCALP/NECK/AXILL/ 12031 981 298 208.6 64.79 298 151.8 64.79 223.5 64.79 151.8 151.8 151.8 151.8 64.79 71.26900000000002 64.79 64.79 64.79 64.79 66.0858 64.79 4900 Hos Emergency Services Facilty Fee 620344 SIMP REP FACE/EARS/EYELIDS/ 12032 981 330 230.99999999999997 71.74 330 168.1 71.74 247.5 71.74 168.1 168.1 168.1 168.1 71.74 78.914 71.74 71.74 71.74 71.74 73.17479999999999 71.74 4900 Hos Emergency Services Facilty Fee 620369 SIMP CLOS FACE/EARS/EYELIDS/ 12041 981 424 296.79999999999995 92.18 424 215.99 92.18 318 92.18 215.99 215.99 215.99 215.99 92.18 101.39800000000001 92.18 92.18 92.18 92.18 94.0236 92.18 4900 Hos Emergency Services Facilty Fee 620385 SIMP CLOS FACE/EARS/EYELIDS/ 12042 981 528 369.59999999999997 114.79 528 268.96 114.79 396 114.79 268.96 268.96 268.96 268.96 114.79 126.26900000000002 114.79 114.79 114.79 114.79 117.0858 114.79 4900 Hos Emergency Services Facilty Fee 620401 SIMP CLOS FACE/EARS/EYELIDS/ 12051 981 772 540.4 167.83 772 393.26 167.83 579 167.83 393.26 393.26 393.26 393.26 167.83 184.61300000000003 167.83 167.83 167.83 167.83 171.18660000000003 167.83 4900 Hos Emergency Services Facilty Fee 620427 LAYER CLOS SCALP/AXILL/TRUNK/ 12052 981 348 243.6 75.66 348 177.27 75.66 261 75.66 177.27 177.27 177.27 177.27 75.66 83.226 75.66 75.66 75.66 75.66 77.1732 75.66 4900 Hos Emergency Services Facilty Fee 620443 LAYER CLOS SCALP/AXILL/TRUNK/ 16000 981 507 354.9 110.22 507 258.27 110.22 380.25 110.22 258.27 258.27 258.27 258.27 110.22 121.242 110.22 110.22 110.22 110.22 112.4244 110.22 4900 Hos Emergency Services Facilty Fee 620468 LAYER CLSR NECK/HANDS/FEET/ 16020 981 357 249.89999999999998 77.61 357 181.86 77.61 267.75 77.61 181.86 181.86 181.86 181.86 77.61 85.37100000000001 77.61 77.61 77.61 77.61 79.1622 77.61 4900 Hos Emergency Services Facilty Fee 620484 LAYER CLOS NECK/HANDS/FEET/ 17110 981 539 377.29999999999995 117.18 539 274.57 117.18 404.25 117.18 274.57 274.57 274.57 274.57 117.18 128.89800000000002 117.18 117.18 117.18 117.18 119.52360000000002 117.18 4900 Hos Emergency Services Facilty Fee 620500 LAYER CLOS FACE/EARS/EYELIDS/ 20610 981 436 305.2 94.79 436 222.1 94.79 327 94.79 222.1 222.1 222.1 222.1 94.79 104.26900000000002 94.79 94.79 94.79 94.79 96.68580000000001 94.79 4900 Hos Emergency Services Facilty Fee 620526 LAYER CLOS FACE/EARS/EYELIDS/ 21480 981 673 471.09999999999997 146.31 673 342.83 146.31 504.75 146.31 342.83 342.83 342.83 342.83 146.31 160.941 146.31 146.31 146.31 146.31 149.2362 146.31 4900 Hos Emergency Services Facilty Fee 620542 INIT TREAT FIRST DEGREE BURN 23650 981 134 93.8 29.13 134 68.26 29.13 100.5 29.13 68.26 68.26 68.26 68.26 29.13 32.043 29.13 29.13 29.13 29.13 29.7126 29.13 4900 Hos Emergency Services Facilty Fee 620567 DRESS &/OR DEBRID BURN;SMALL 23930 981 217 151.89999999999998 47.18 217 110.54 47.18 162.75 47.18 110.54 110.54 110.54 110.54 47.18 51.898 47.18 47.18 47.18 47.18 48.1236 47.18 4900 Hos Emergency Services Facilty Fee 620583 WART REMOVAL 25260 981 154 107.8 33.48 154 78.45 33.48 115.5 33.48 78.45 78.45 78.45 78.45 33.48 36.828 33.48 33.48 33.48 33.48 34.1496 33.48 4900 Hos Emergency Services Facilty Fee 620625 ARTHROCENTESIS;SHOULDER,KNEE, 26750 981 166 116.19999999999999 36.09 166 84.56 36.09 124.5 36.09 84.56 84.56 84.56 84.56 36.09 39.699000000000005 36.09 36.09 36.09 36.09 36.811800000000005 36.09 4900 Hos Emergency Services Facilty Fee 620641 CLSD REDUCT TEMPOROMAN DISLOCA 26770 981 366 256.2 79.57 366 186.44 79.57 274.5 79.57 186.44 186.44 186.44 186.44 79.57 87.527 79.57 79.57 79.57 79.57 81.1614 79.57 4900 Hos Emergency Services Facilty Fee 620674 CLOSED TX SHOULDER DISLOC W/ 31500 981 760 532 165.22 760 387.14 165.22 570 165.22 387.14 387.14 387.14 387.14 165.22 181.74200000000002 165.22 165.22 165.22 165.22 168.5244 165.22 4900 Hos Emergency Services Facilty Fee 620690 I&D UP ARM/ELBOW;DEEP ABSCESS 32420 981 728 509.59999999999997 158.27 728 370.84 158.27 546 158.27 370.84 370.84 370.84 370.84 158.27 174.09700000000004 158.27 158.27 158.27 158.27 161.43540000000002 158.27 4900 Hos Emergency Services Facilty Fee 620716 REPAIR EA TEND/MUSC, FLEXOR 33210 981 1930 1351 419.58 1930 983.14 419.58 1447.5 419.58 983.14 983.14 983.14 983.14 419.58 461.538 419.58 419.58 419.58 419.58 427.97159999999997 419.58 4900 Hos Emergency Services Facilty Fee 620732 CLOSED TX OF EA DISTAL PHAL FX 35206 981 284 198.79999999999998 61.74 284 144.67 61.74 213 61.74 144.67 144.67 144.67 144.67 61.74 67.914 61.74 61.74 61.74 61.74 62.9748 61.74 4900 Hos Emergency Services Facilty Fee 620757 CLOSED TX OF SINGLE INTERPHALA 35207 981 366 256.2 79.57 366 186.44 79.57 274.5 79.57 186.44 186.44 186.44 186.44 79.57 87.527 79.57 79.57 79.57 79.57 81.1614 79.57 4900 Hos Emergency Services Facilty Fee 620773 INTUBATION, ENDOTRACH -EMERGEN 36556 981 481 336.7 104.57 481 245.02 104.57 360.75 104.57 245.02 245.02 245.02 245.02 104.57 115.027 104.57 104.57 104.57 104.57 106.6614 104.57 4900 Hos Emergency Services Facilty Fee 620815 PNEUMONCENTHESIS, LUNG ASPIRAT 43760 981 504 352.79999999999995 109.57 504 256.74 109.57 378 109.57 256.74 256.74 256.74 256.74 109.57 120.527 109.57 109.57 109.57 109.57 111.7614 109.57 4900 Hos Emergency Services Facilty Fee 620831 INSRT/REPLACE TEMP PACEMAKER 56420 981 1416 991.1999999999999 307.84 1416 721.31 307.84 1062 307.84 721.31 721.31 721.31 721.31 307.84 338.624 307.84 307.84 307.84 307.84 313.9968 307.84 4900 Hos Emergency Services Facilty Fee 620856 REPAIR BLOOD VESSEL,ARM 65205 981 5523 3866.1 1200.7 5523 2813.42 1200.7 4142.25 1200.7 2813.42 2813.42 2813.42 2813.42 1200.7 1320.7700000000002 1200.7 1200.7 1200.7 1200.7 1224.7140000000002 1200.7 4900 Hos Emergency Services Facilty Fee 620872 REPAIR BLOOD VESSEL, HAND/FING 69200 981 5599 3919.2999999999997 1217.23 5599 2852.13 1217.23 4199.25 1217.23 2852.13 2852.13 2852.13 2852.13 1217.23 1338.9530000000002 1217.23 1217.23 1217.23 1217.23 1241.5746000000001 1217.23 4900 Hos Emergency Services Facilty Fee 620898 PLACEMENT CENT VEN CATH >AGE 2 69210 981 570 399 123.92 570 290.36 123.92 427.5 123.92 290.36 290.36 290.36 290.36 123.92 136.312 123.92 123.92 123.92 123.92 126.39840000000001 123.92 4900 Hos Emergency Services Facilty Fee 620914 CHANGE GASTROSTOMY TUBE 38220 981 297 207.89999999999998 64.57 297 151.29 64.57 222.75 64.57 151.29 151.29 151.29 151.29 64.57 71.027 64.57 64.57 64.57 64.57 65.86139999999999 64.57 4900 Hos Emergency Services Facilty Fee 620930 I&D BARTHOLIN'S GLAND ABSCESS 43752 981 295 206.5 64.13 295 150.27 64.13 221.25 64.13 150.27 150.27 150.27 150.27 64.13 70.543 64.13 64.13 64.13 64.13 65.4126 64.13 4900 Hos Emergency Services Facilty Fee 620955 REMOVE FB EXTERNAL EYE; 38221 981 130 91 28.26 130 66.22 28.26 97.5 28.26 66.22 66.22 66.22 66.22 28.26 31.086000000000006 28.26 28.26 28.26 28.26 28.825200000000002 28.26 4900 Hos Emergency Services Facilty Fee 620971 REMOV F.B. EXT AUDITORY CANAL 99288 981 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4900 Hos Emergency Services Facilty Fee 620997 REMOV INPACT CERUMEN 1 OR BOTH 99292 981 98 68.6 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 4900 Hos Emergency Services Facilty Fee 621003 BONE MARROW BIOPSY 92950 981 226 158.2 49.13 226 115.12 49.13 169.5 49.13 115.12 115.12 115.12 115.12 49.13 54.043000000000006 49.13 49.13 49.13 49.13 50.1126 49.13 4900 Hos Emergency Services Facilty Fee 621029 INSERT NG TUBE REQ PHYSICIAN & 11306 981 269 188.29999999999998 58.48 269 137.03 58.48 201.75 58.48 137.03 137.03 137.03 137.03 58.48 64.328 58.48 58.48 58.48 58.48 59.6496 58.48 4900 Hos Emergency Services Facilty Fee 621037 BONE MARROW BIOPSY, NEEDLE 32551 981 325 227.49999999999997 70.66 325 165.56 70.66 243.75 70.66 165.56 165.56 165.56 165.56 70.66 77.726 70.66 70.66 70.66 70.66 72.0732 70.66 4900 Hos Emergency Services Facilty Fee 621052 PHYS DIRECTION EMERG SYSTEMS 27550 981 295 206.5 64.13 295 150.27 64.13 221.25 64.13 150.27 150.27 150.27 150.27 64.13 70.543 64.13 64.13 64.13 64.13 65.4126 64.13 4900 Hos Emergency Services Facilty Fee 621094 PHYS CRITICAL CARE ADD'L 30MIN 28660 981 307 214.89999999999998 66.74 307 156.39 66.74 230.25 66.74 156.39 156.39 156.39 156.39 66.74 73.414 66.74 66.74 66.74 66.74 68.0748 66.74 4900 Hos Emergency Services Facilty Fee 621102 CPR 26725 981 886 620.1999999999999 192.62 886 451.33 192.62 664.5 192.62 451.33 451.33 451.33 451.33 192.62 211.88200000000003 192.62 192.62 192.62 192.62 196.47240000000002 192.62 4900 Hos Emergency Services Facilty Fee 626028 SHAVE SKIN LESION 0.6-1.0cm 69000 981 187 130.9 40.65 187 95.26 40.65 140.25 40.65 95.26 95.26 95.26 95.26 40.65 44.715 40.65 40.65 40.65 40.65 41.463 40.65 4900 Hos Emergency Services Facilty Fee 626036 TUBE THORACOSTOMY W/WO H2HSEAL 42809 981 284 198.79999999999998 61.74 284 144.67 61.74 213 61.74 144.67 144.67 144.67 144.67 61.74 67.914 61.74 61.74 61.74 61.74 62.9748 61.74 4900 Hos Emergency Services Facilty Fee 626069 CLOSED TX KNEE DISLOCATION W/O 12034 981 255 178.5 55.44 255 129.9 55.44 191.25 55.44 129.9 129.9 129.9 129.9 55.44 60.984 55.44 55.44 55.44 55.44 56.5488 55.44 4900 Hos Emergency Services Facilty Fee 626101 CLOSED TX OF INTERPHALANGEAL 12035 981 193 135.1 41.96 193 98.31 41.96 144.75 41.96 98.31 98.31 98.31 98.31 41.96 46.156000000000006 41.96 41.96 41.96 41.96 42.7992 41.96 4900 Hos Emergency Services Facilty Fee 626309 CLSD TX EA PHAL FX, PROX/MID 26755 981 374 261.8 81.31 374 190.52 81.31 280.5 81.31 190.52 190.52 190.52 190.52 81.31 89.44100000000002 81.31 81.31 81.31 81.31 82.9362 81.31 4900 Hos Emergency Services Facilty Fee 626374 I&D OF EXTERNAL EAR, SIMPLE 12020 981 413 289.09999999999997 89.79 413 210.38 89.79 309.75 89.79 210.38 210.38 210.38 210.38 89.79 98.76900000000002 89.79 89.79 89.79 89.79 91.5858 89.79 4900 Hos Emergency Services Facilty Fee 626408 REMOVAL FOREIGN BODY PHARYNX 28515 981 280 196 60.87 280 142.63 60.87 210 60.87 142.63 142.63 142.63 142.63 60.87 66.95700000000001 60.87 60.87 60.87 60.87 62.087399999999995 60.87 4900 Hos Emergency Services Facilty Fee 627802 LAYER CLOS SCALP/AXILL/TRUNK/ 13121 981 352 246.39999999999998 76.53 352 179.31 76.53 264 76.53 179.31 179.31 179.31 179.31 76.53 84.183 76.53 76.53 76.53 76.53 78.06060000000001 76.53 4900 Hos Emergency Services Facilty Fee 627885 LAYER CLOS SCALP/AXILL/TRUNK/ 20103 981 392 274.4 85.22 392 199.68 85.22 294 85.22 199.68 199.68 199.68 199.68 85.22 93.742 85.22 85.22 85.22 85.22 86.9244 85.22 4900 Hos Emergency Services Facilty Fee 628859 CLSD TX EA DIS PHALANGEAL FX 31730 981 304 212.79999999999998 66.09 304 154.86 66.09 228 66.09 154.86 154.86 154.86 154.86 66.09 72.69900000000001 66.09 66.09 66.09 66.09 67.4118 66.09 4900 Hos Emergency Services Facilty Fee 628875 SIMPLE CLSR WOUND DEHISCENCE 46083 981 133 93.1 28.91 133 67.75 28.91 99.75 28.91 67.75 67.75 67.75 67.75 28.91 31.801000000000002 28.91 28.91 28.91 28.91 29.4882 28.91 4900 Hos Emergency Services Facilty Fee 628909 CLOSED TX EA PHALANX FX (NOT 53600 981 582 407.4 126.53 582 296.47 126.53 436.5 126.53 296.47 296.47 296.47 296.47 126.53 139.18300000000002 126.53 126.53 126.53 126.53 129.0606 126.53 4900 Hos Emergency Services Facilty Fee 628982 COMP REPAIR SCALP,ARMS,&/OR 281930 981 508 355.59999999999997 110.44 508 258.78 110.44 381 110.44 258.78 258.78 258.78 258.78 110.44 121.48400000000001 110.44 110.44 110.44 110.44 112.6488 110.44 4900 Hos Emergency Services Facilty Fee 629469 EXP OF PENETRATING WOUND; 12036 981 618 432.59999999999997 134.35 618 314.81 134.35 463.5 134.35 314.81 314.81 314.81 314.81 134.35 147.785 134.35 134.35 134.35 134.35 137.037 134.35 4900 Hos Emergency Services Facilty Fee 629470 TRANSTRACH TUBE FOR O2 TX 206605 981 704 492.79999999999995 153.05 704 358.62 153.05 528 153.05 358.62 358.62 358.62 358.62 153.05 168.35500000000002 153.05 153.05 153.05 153.05 156.11100000000002 153.05 4900 Hos Emergency Services Facilty Fee 630012 INCIS THROMBOSSED HEMORROID,EX 23931 981 240 168 52.18 240 122.26 52.18 180 52.18 122.26 122.26 122.26 122.26 52.18 57.398 52.18 52.18 52.18 52.18 53.2236 52.18 4900 Hos Emergency Services Facilty Fee 630087 DILATION OF URETHRA STRICTURE; 30905 981 136 95.19999999999999 29.57 136 69.28 29.57 102 29.57 69.28 69.28 69.28 69.28 29.57 32.527 29.57 29.57 29.57 29.57 30.1614 29.57 4900 Hos Emergency Services Facilty Fee 630103 REMOVE FB FOOT SUBCUTANEOUS 12053 981 579 405.29999999999995 125.87 579 294.94 125.87 434.25 125.87 294.94 294.94 294.94 294.94 125.87 138.45700000000002 125.87 125.87 125.87 125.87 128.3874 125.87 4900 Hos Emergency Services Facilty Fee 631655 LAYER CLOS SCALP/AXILL/TRUNK/ 30901 981 466 326.2 101.31 466 237.38 101.31 349.5 101.31 237.38 237.38 237.38 237.38 101.31 111.44100000000002 101.31 101.31 101.31 101.31 103.3362 101.31 4900 Hos Emergency Services Facilty Fee 635961 ARTHROCENTESIS;WRIST,ELBOW, 29540 981 274 191.79999999999998 59.57 274 139.58 59.57 205.5 59.57 139.58 139.58 139.58 139.58 59.57 65.527 59.57 59.57 59.57 59.57 60.7614 59.57 4900 Hos Emergency Services Facilty Fee 640508 I & D UPPER ARM/ELBOW/BURSA 29530 981 196 137.2 42.61 196 99.84 42.61 147 42.61 99.84 99.84 99.84 99.84 42.61 46.871 42.61 42.61 42.61 42.61 43.4622 42.61 4900 Hos Emergency Services Facilty Fee 645507 CONTROL NOSEBLEED POSTERIOR W 29550 981 392 274.4 85.22 392 199.68 85.22 294 85.22 199.68 199.68 199.68 199.68 85.22 93.742 85.22 85.22 85.22 85.22 86.9244 85.22 4900 Hos Emergency Services Facilty Fee 648337 LAYER CLOS FACE/EARS/EYELIDS/ 29730 981 704 492.79999999999995 153.05 704 358.62 153.05 528 153.05 358.62 358.62 358.62 358.62 153.05 168.35500000000002 153.05 153.05 153.05 153.05 156.11100000000002 153.05 4900 Hos Emergency Services Facilty Fee 650507 CONTROL NOSEBLEED ANTERIOR 28495 981 314 219.79999999999998 68.26 314 159.95 68.26 235.5 68.26 159.95 159.95 159.95 159.95 68.26 75.08600000000001 68.26 68.26 68.26 68.26 69.6252 68.26 4900 Hos Emergency Services Facilty Fee 651026 STRAPPING OF ANKLE &/OR FOOT 28510 981 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4900 Hos Emergency Services Facilty Fee 651125 STRAPPING OF KNEE 29705 981 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4900 Hos Emergency Services Facilty Fee 651133 STRAPPING OF TOES 51703 981 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4900 Hos Emergency Services Facilty Fee 651174 WINDOWING OF CAST 29345 981 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4900 Hos Emergency Services Facilty Fee 651182 CLSD TX FX GR TOE,PHALANX/ 29280 981 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4900 Hos Emergency Services Facilty Fee 651190 CLSD TX EA PHALANX FX (NOT GR 26010 981 371 259.7 80.66 371 188.99 80.66 278.25 80.66 188.99 188.99 188.99 188.99 80.66 88.726 80.66 80.66 80.66 80.66 82.2732 80.66 4900 Hos Emergency Services Facilty Fee 652123 REMOVAL OF ARM or LEG CAST 29260 981 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4900 Hos Emergency Services Facilty Fee 652727 FOLEY CATH INSRTION,DIFFICULT 29200 981 337 235.89999999999998 73.26 337 171.67 73.26 252.75 73.26 171.67 171.67 171.67 171.67 73.26 80.58600000000001 73.26 73.26 73.26 73.26 74.7252 73.26 4900 Hos Emergency Services Facilty Fee 653030 APP. Of LONG LEG CAST 29405 981 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4900 Hos Emergency Services Facilty Fee 653139 STRAPPING HAND OR FINGER 29505 981 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4900 Hos Emergency Services Facilty Fee 653238 INC & DRAIN FINGER ABSCESS: 29420 981 195 136.5 42.39 195 99.33 42.39 146.25 42.39 99.33 99.33 99.33 99.33 42.39 46.629000000000005 42.39 42.39 42.39 42.39 43.2378 42.39 4900 Hos Emergency Services Facilty Fee 653246 STRAPPING ELBOW or WRIST 29515 981 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4900 Hos Emergency Services Facilty Fee 653345 STRAPPING THORAX 29130 981 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4900 Hos Emergency Services Facilty Fee 654046 APP. Of SHORT LEG CAST 29105 981 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4900 Hos Emergency Services Facilty Fee 654111 APP. Of LONG LEG SPLINT 29125 981 180 125.99999999999999 39.13 180 91.69 39.13 135 39.13 91.69 91.69 91.69 91.69 39.13 43.043000000000006 39.13 39.13 39.13 39.13 39.912600000000005 39.13 4900 Hos Emergency Services Facilty Fee 654145 STRAPPING LOW BACK 12006 981 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4900 Hos Emergency Services Facilty Fee 654152 STRAPPING SHOULDER 41250 981 267 186.89999999999998 58.05 267 136.01 58.05 200.25 58.05 136.01 136.01 136.01 136.01 58.05 63.855000000000004 58.05 58.05 58.05 58.05 59.211 58.05 4900 Hos Emergency Services Facilty Fee 654210 APP. OF SHORT LEG SPLINT 62270 981 165 115.49999999999999 35.87 165 84.05 35.87 123.75 35.87 84.05 84.05 84.05 84.05 35.87 39.457 35.87 35.87 35.87 35.87 36.587399999999995 35.87 4900 Hos Emergency Services Facilty Fee 654434 APP OF FINGER SPLINT; STATIC 12005 981 104 72.8 22.61 104 52.98 22.61 78 22.61 52.98 52.98 52.98 52.98 22.61 24.871000000000002 22.61 22.61 22.61 22.61 23.0622 22.61 4900 Hos Emergency Services Facilty Fee 657221 APP OF LONG ARM SPLINT 12007 981 282 197.39999999999998 61.31 282 143.65 61.31 211.5 61.31 143.65 143.65 143.65 143.65 61.31 67.441 61.31 61.31 61.31 61.31 62.5362 61.31 4900 Hos Emergency Services Facilty Fee 657239 STATIC SPLINT SHORT ARM 93041 981 138 96.6 30 138 70.3 30 103.5 30 70.3 70.3 70.3 70.3 30 33 30 30 30 30 30.6 30 4900 Hos Emergency Services Facilty Fee 657270 SIMP CLOS SCALP/NECK/AXILL/ 56405 981 532 372.4 115.66 532 271 115.66 399 115.66 271 271 271 271 115.66 127.22600000000001 115.66 115.66 115.66 115.66 117.9732 115.66 4900 Hos Emergency Services Facilty Fee 657437 REPAIR ANT 2/3 TONGUE LAC/ 41252 981 314 219.79999999999998 68.26 314 159.95 68.26 235.5 68.26 159.95 159.95 159.95 159.95 68.26 75.08600000000001 68.26 68.26 68.26 68.26 69.6252 68.26 4900 Hos Emergency Services Facilty Fee 675322 LUMBAR PUNCTURE DIAGNOSTIC 56405 981 349 244.29999999999998 75.87 349 177.78 75.87 261.75 75.87 177.78 177.78 177.78 177.78 75.87 83.45700000000001 75.87 75.87 75.87 75.87 77.3874 75.87 4900 Hos Emergency Services Facilty Fee 698977 SIMP CLOS SCALP/NECK/AXILL/ 41252 981 379 265.3 82.39 379 193.06 82.39 284.25 82.39 193.06 193.06 193.06 193.06 82.39 90.629 82.39 82.39 82.39 82.39 84.0378 82.39 4900 Hos Emergency Services Facilty Fee 698985 SIMP CLOS SCALP/NECK/AXILL/ 12001 981 379 265.3 82.39 379 193.06 82.39 284.25 82.39 193.06 193.06 193.06 193.06 82.39 90.629 82.39 82.39 82.39 82.39 84.0378 82.39 4900 Hos Emergency Services Facilty Fee 3207701 CARDIAC MONITORING OBSERVATION 93229 760 54 37.8 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 4900 Hos Emergency Services Facilty Fee 5224369 I & D VULVA/PERINEAL ABCESS 56405 450 370 259 80.44 370 188.48 80.44 277.5 80.44 188.48 188.48 188.48 188.48 80.44 88.48400000000001 80.44 80.44 80.44 80.44 82.0488 80.44 4900 Hos Emergency Services Facilty Fee 5224470 REPAIR TONGUE LACERATION,CMPLX 41252 450 1515 1060.5 329.36 1515 771.74 329.36 1136.25 329.36 771.74 771.74 771.74 771.74 329.36 362.29600000000005 329.36 329.36 329.36 329.36 335.9472 329.36 4900 Hos Emergency Services Facilty Fee 6224369 I & D VULVA/PERINEAL ABCESS 56405 981 292 204.39999999999998 63.48 292 148.74 63.48 219 63.48 148.74 148.74 148.74 148.74 63.48 69.828 63.48 63.48 63.48 63.48 64.7496 63.48 4900 Hos Emergency Services Facilty Fee 6224470 REPAIR TONGUE LAC/MOUTH FLOOR 41252 981 711 497.7 154.57 711 362.18 154.57 533.25 154.57 362.18 362.18 362.18 362.18 154.57 170.02700000000002 154.57 154.57 154.57 154.57 157.6614 154.57 4920 Medical Profees Professional Fee 9000 Initial Care - Comprhensive H&P Low Complexity - 30 min 99221 960 297 207.89999999999998 64.57 297 151.29 64.57 222.75 64.57 151.29 151.29 151.29 151.29 64.57 71.027 64.57 64.57 64.57 64.57 65.86139999999999 64.57 4920 Medical Profees Professional Fee 9001 Initial Care - Comprehensive H&P, Moderate Complexity - 50min 99222 960 402 281.4 87.4 402 204.78 87.4 301.5 87.4 204.78 204.78 204.78 204.78 87.4 96.14000000000001 87.4 87.4 87.4 87.4 89.14800000000001 87.4 4920 Medical Profees Professional Fee 9002 Initial Care - Comprehensive H&P, High Complexity - 70min 99223 960 589 412.29999999999995 128.05 589 300.04 128.05 441.75 128.05 300.04 300.04 300.04 300.04 128.05 140.85500000000002 128.05 128.05 128.05 128.05 130.61100000000002 128.05 4920 Medical Profees Professional Fee 9003 Subsequent Care - Problem Focused H&P, Low Complexity - 15min 99231 960 116 81.19999999999999 25.22 116 59.09 25.22 87 25.22 59.09 59.09 59.09 59.09 25.22 27.742 25.22 25.22 25.22 25.22 25.7244 25.22 4920 Medical Profees Professional Fee 9004 Subsequent Care - Expanded H&P Focused, Moderate Complexity - 25min 99232 960 212 148.39999999999998 46.09 212 107.99 46.09 159 46.09 107.99 107.99 107.99 107.99 46.09 50.699000000000005 46.09 46.09 46.09 46.09 47.0118 46.09 4920 Medical Profees Professional Fee 9005 Subsequent Care - Detailed H&P, High Complexity - 35min 99233 960 303 212.1 65.87 303 154.35 65.87 227.25 65.87 154.35 154.35 154.35 154.35 65.87 72.45700000000001 65.87 65.87 65.87 65.87 67.18740000000001 65.87 4920 Medical Profees Professional Fee 9006 Discharge - 30 minutes or less 99238 960 211 147.7 45.87 211 107.48 45.87 158.25 45.87 107.48 107.48 107.48 107.48 45.87 50.457 45.87 45.87 45.87 45.87 46.7874 45.87 4920 Medical Profees Professional Fee 9007 Discharge - More than 30 minutes 99239 960 310 217 67.39 310 157.91 67.39 232.5 67.39 157.91 157.91 157.91 157.91 67.39 74.129 67.39 67.39 67.39 67.39 68.73780000000001 67.39 4920 Medical Profees Professional Fee 9008 Initial Obeservation - Comprhensive H&P, Low Complexity - 30 min 99221 960 292 204.39999999999998 63.48 292 148.74 63.48 219 63.48 148.74 148.74 148.74 148.74 63.48 69.828 63.48 63.48 63.48 63.48 64.7496 63.48 4920 Medical Profees Professional Fee 9009 Initial Observation Care - Comprehensive H&P, Moderate Complexity - 50 min 99222 960 398 278.59999999999997 86.53 398 202.74 86.53 298.5 86.53 202.74 202.74 202.74 202.74 86.53 95.183 86.53 86.53 86.53 86.53 88.2606 86.53 4920 Medical Profees Professional Fee 9010 Initial Observation Care - Comprehensive H&P, High Complexity - 70 min 99223 960 545 381.5 118.48 545 277.62 118.48 408.75 118.48 277.62 277.62 277.62 277.62 118.48 130.328 118.48 118.48 118.48 118.48 120.84960000000001 118.48 4920 Medical Profees Professional Fee 9011 Hospital Middle Days - Moderate to High - 40 min 99221 960 424 296.79999999999995 92.18 424 215.99 92.18 318 92.18 215.99 215.99 215.99 215.99 92.18 101.39800000000001 92.18 92.18 92.18 92.18 94.0236 92.18 4920 Medical Profees Professional Fee 9012 Observation Discharge Day 99221 960 213 149.1 46.31 213 108.5 46.31 159.75 46.31 108.5 108.5 108.5 108.5 46.31 50.94100000000001 46.31 46.31 46.31 46.31 47.236200000000004 46.31 4920 Medical Profees Professional Fee 9013 Level 1: Observation Care - Admit & Discharge Same Day Low Severity - 40 min 99222 960 397 277.9 86.31 397 202.23 86.31 297.75 86.31 202.23 202.23 202.23 202.23 86.31 94.94100000000002 86.31 86.31 86.31 86.31 88.03620000000001 86.31 4920 Medical Profees Professional Fee 9014 Level 2: Observation Care - Admit & Discharge Same Day Moderate Severity - 50 min 99223 960 496 347.2 107.83 496 252.66 107.83 372 107.83 252.66 252.66 252.66 252.66 107.83 118.61300000000001 107.83 107.83 107.83 107.83 109.9866 107.83 4920 Medical Profees Professional Fee 9015 Level 3: Observation Care - Admit & Discharge Same Day High Severity - 55 min 99224 960 641 448.7 139.35 641 326.53 139.35 480.75 139.35 326.53 326.53 326.53 326.53 139.35 153.285 139.35 139.35 139.35 139.35 142.137 139.35 4980 Hos Observation Facility Fee 3120 ADD SEQ INFUSION NEW DRUG 96360 260 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4980 Hos Observation Facility Fee 3114 ADD SEQUEN. IV PUSH NEW DRUG 96360 760 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4980 Hos Observation Facility Fee 3115 ADD SEQUEN. IV PUSH SAME DRUG 96360 260 37 25.9 8.04 37 18.85 8.04 27.75 8.04 18.85 18.85 18.85 18.85 8.04 8.844 8.04 8.04 8.04 8.04 8.2008 8.04 4980 Hos Observation Facility Fee 3121 CONCURRENT INFUSION 96360 260 44 30.799999999999997 9.57 44 22.41 9.57 33 9.57 22.41 22.41 22.41 22.41 9.57 10.527000000000001 9.57 9.57 9.57 9.57 9.7614 9.57 4980 Hos Observation Professional Fee 3110 DAILY EPIDURAL ADMINISTRATION 96360 762 93 65.1 20.22 93 47.37 20.22 69.75 20.22 47.37 47.37 47.37 47.37 20.22 22.242 20.22 20.22 20.22 20.22 20.624399999999998 20.22 4980 Hos Observation Professional Fee 3109261 DIRECT ADMIT TO OPO 99234 762 192 134.39999999999998 41.74 192 97.8 41.74 144 41.74 97.8 97.8 97.8 97.8 41.74 45.91400000000001 41.74 41.74 41.74 41.74 42.5748 41.74 4980 Hos Observation Professional Fee 3109 FOLEY CATH INSERTION 51702 762 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4980 Hos Observation Professional Fee 3113 FOLEY CATH INSERTION DIFFICULT 51702 762 148 103.6 32.18 148 75.39 32.18 111 32.18 75.39 75.39 75.39 75.39 32.18 35.398 32.18 32.18 32.18 32.18 32.8236 32.18 4980 Hos Observation Professional Fee 3111 FOLEY CATH IRRIGATION 96523 762 460 322 100 460 234.32 100 345 100 234.32 234.32 234.32 234.32 100 110.00000000000001 100 100 100 100 102 100 4980 Hos Observation Facility Fee 3108 HYDRATION INF EA HR UP TO 8 96360 260 72 50.4 15.65 72 36.68 15.65 54 15.65 36.68 36.68 36.68 36.68 15.65 17.215000000000003 15.65 15.65 15.65 15.65 15.963000000000001 15.65 4980 Hos Observation Facility Fee 3107 HYDRATION INFUSION UP TO 1 HR 96360 260 301 210.7 65.44 301 153.33 65.44 225.75 65.44 153.33 153.33 153.33 153.33 65.44 71.98400000000001 65.44 65.44 65.44 65.44 66.7488 65.44 4980 Hos Observation Facility Fee 3123 INITIAL IV ACCESS 96360 762 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4980 Hos Observation Facility Fee 3118 IV HYDRATION, INITIAL 31-60MIN 96360 260 178 124.6 38.7 178 90.67 38.7 133.5 38.7 90.67 90.67 90.67 90.67 38.7 42.57000000000001 38.7 38.7 38.7 38.7 39.474000000000004 38.7 4980 Hos Observation Facility Fee 3103 IV PUSH;SINGLE/INITIAL DRUG 96360 760 122 85.39999999999999 26.52 122 62.15 26.52 91.5 26.52 62.15 62.15 62.15 62.15 26.52 29.172 26.52 26.52 26.52 26.52 27.0504 26.52 4980 Hos Observation Facility Fee 3127 OBSERVATION EACH ADDIT. HOUR N/A 762 15 10.5 3.26 15 7.64 3.26 11.25 3.26 7.64 7.64 7.64 7.64 3.26 3.586 3.26 3.26 $- $- #VALUE! $- 4980 Hos Observation Facility Fee 3126 OBSERVATION FIRST HOUR N/A 762 219 153.29999999999998 47.61 219 111.56 47.61 164.25 47.61 111.56 111.56 111.56 111.56 47.61 52.371 47.61 47.61 47.61 47.61 48.5622 47.61 4980 Hos Observation Facility Fee 3112 STRAIGHT CATH - TEMPORARY 51702 762 152 106.39999999999999 33.04 152 77.43 33.04 114 33.04 77.43 77.43 77.43 77.43 33.04 36.344 33.04 33.04 33.04 33.04 33.7008 33.04 4980 Hos Observation Facility Fee 3105 SUBQ/IM INJECTION 51702 760 95 66.5 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 4980 Hos Observation Facility Fee 3100 THER INFUSION EA ADD HR 96360 260 88 61.599999999999994 19.13 88 44.83 19.13 66 19.13 44.83 44.83 44.83 44.83 19.13 21.043 19.13 19.13 19.13 19.13 19.5126 19.13 4980 Hos Observation Facility Fee 3101 THERAPEUTIC INFUSION UP TO 1HR 963606 260 421 294.7 91.53 421 214.46 91.53 315.75 91.53 214.46 214.46 214.46 214.46 91.53 100.683 91.53 91.53 91.53 91.53 93.3606 91.53 4980 Hos Observation Facility Fee 3122 VENIPUNCTURE (PORT/VAD) 36415 762 144 100.8 31.31 144 73.35 31.31 108 31.31 73.35 73.35 73.35 73.35 31.31 34.441 31.31 31.31 31.31 31.31 31.9362 31.31 4980 Hos Observation Facility Fee 3124 VENIPUNTURE (CVL/PICC) 36415 300 92 64.39999999999999 20 92 46.86 20 69 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 4980 Hos Observation Facility Fee 3125 VENIPUNTURE (PERIPHERAL VENUS) 36415 762 14 9.799999999999999 3.04 14 7.13 3.04 10.5 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 8600 Hos Central Supply Facility Fee 50129 ##-RXL PROBE CLEANER A9270 270 10.23 7.161 0.16 0.72 0.37 0.16 0.54 0.16 0.37 0.37 0.37 0.37 0.16 0.17600000000000002 0.16 0.16 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 50130 ##-RXL SAMPLE PROBE CLEANER A9270 270 13.59 9.513 0.17 0.79 0.4 0.17 0.59 0.17 0.4 0.4 0.4 0.4 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 50131 #-ABS/ABSORBANCE A9270 270 20.09 14.062999999999999 111.68 513.7 261.68 111.68 385.28 111.68 261.68 261.68 261.68 261.68 111.68 122.84800000000001 111.68 111.68 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 50132 #-CREATININE REV A9270 270 0.29 0.20299999999999999 19.76 90.88 46.29 19.76 68.16 19.76 46.29 46.29 46.29 46.29 19.76 21.736000000000004 19.76 19.76 19.76 19.76 20.1552 19.76 8600 Hos Central Supply Facility Fee 50133 #-CREATININE REV A9270 270 24.96 17.471999999999998 19.76 90.88 46.29 19.76 68.16 19.76 46.29 46.29 46.29 46.29 19.76 21.736000000000004 19.76 19.76 19.76 19.76 20.1552 19.76 8600 Hos Central Supply Facility Fee 50134 #-GENT A/GENT AMICIN A9270 270 103.68 72.576 0.7 3.2 1.63 0.7 2.4 0.7 1.63 1.63 1.63 1.63 0.7 0.77 0.7 0.7 0.7 0.7 0.714 0.7 8600 Hos Central Supply Facility Fee 50278 #M TROUBLESHOOTER N/A 270 40.55 28.384999999999994 0.56 2.58 1.31 0.56 1.94 0.56 1.31 1.31 1.31 1.31 0.56 0.6160000000000001 0.56 0.56 0.56 0.56 0.5712 0.56 8600 Hos Central Supply Facility Fee 50135 #-SAL/SALICYATE A9270 270 155.52 108.864 0.69 3.19 1.62 0.69 2.39 0.69 1.62 1.62 1.62 1.62 0.69 0.759 0.69 0.69 0.69 0.69 0.7038 0.69 8600 Hos Central Supply Facility Fee 50136 #-TP/TOTAL PROTEIN A9270 270 0.29 0.20299999999999999 0.07 0.32 0.16 0.07 0.24 0.07 0.16 0.16 0.16 0.16 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 50137 %TROPI-CAL/DRYICE/SHIP AIR ONLY T8688 270 40 28 0.79 3.64 1.85 0.79 2.73 0.79 1.85 1.85 1.85 1.85 0.79 0.8690000000000001 0.79 0.79 0.79 0.79 0.8058000000000001 0.79 8600 Hos Central Supply Facility Fee 50734 15.0 WATTS SCREW-IN BULB N/A 270 2.93 2.051 5.45 25.08 12.78 5.45 18.81 5.45 12.78 12.78 12.78 12.78 5.45 5.995000000000001 5.45 5.45 0.8 0.8 0.8160000000000001 0.8 8600 Hos Central Supply Facility Fee 50594 18 X 18 X 2 PLEATED AIR FILTERS MERV 7 N/A 270 4.11 2.8770000000000002 0.33 1.52 0.77 0.33 1.14 0.33 0.77 0.77 0.77 0.77 0.33 0.36300000000000004 0.33 0.33 0.33 0.33 0.3366 0.33 8600 Hos Central Supply Facility Fee 1576 20ML LEUR LOK SYRINGE A4467 270 37.09 25.963 2.62 12.04 6.13 2.62 9.03 2.62 6.13 6.13 6.13 6.13 2.62 2.8820000000000006 2.62 2.62 1.21 1.21 1.2342 1.21 8600 Hos Central Supply Facility Fee 50736 21 GAL GALVANIZED STEEL RED FOOT OPERATED SELF CLOSING WASTE CAN N/A 270 163.19 114.23299999999999 0.94 4.33 2.21 0.94 3.25 0.94 2.21 2.21 2.21 2.21 0.94 1.034 0.94 0.94 0.94 0.94 0.9588 0.94 8600 Hos Central Supply Facility Fee 1457 3 X 5 STICKIE PADS N/A 270 0.31 0.217 0.03 0.15 0.08 0.03 0.11 0.03 0.08 0.08 0.08 0.08 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 50623 35 W U-SHAPPED LAMP N/A 270 8.05 5.635 0.03 0.15 0.08 0.03 0.11 0.03 0.08 0.08 0.08 0.08 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 1190 3V LITHUM HOME MEDICAL BATTERY A4467 270 0.94 0.6579999999999999 0.56 2.59 1.32 0.56 1.94 0.56 1.32 1.32 1.32 1.32 0.56 0.6160000000000001 0.56 0.56 0.32 0.32 0.3264 0.32 8600 Hos Central Supply Facility Fee 1820 6FR STYLET ET TUBE A4467 270 28.4 19.88 386.42 1777.47 905.44 386.42 1333.1 386.42 905.44 905.44 905.44 905.44 386.42 425.06200000000007 386.42 386.42 1.1 1.1 1.122 1.1 8600 Hos Central Supply Facility Fee 1714 A & D OINTMENT 5G FOIL PK 144/BX A4467 270 8.18 5.725999999999999 1.21 5.57 2.84 1.21 4.18 1.21 2.84 2.84 2.84 2.84 1.21 1.331 1.21 1.21 131.37 131.37 133.9974 131.37 8600 Hos Central Supply Facility Fee 50077 A TAXO DISCS A4467 270 25.81 18.066999999999997 224.68 1033.48 526.45 224.68 775.11 224.68 526.45 526.45 526.45 526.45 224.68 247.14800000000002 224.68 224.68 224.68 224.68 229.17360000000002 224.68 8600 Hos Central Supply Facility Fee 864 ABD PADS A4467 270 0.14 0.098 8.1 37.24 18.97 8.1 27.93 8.1 18.97 18.97 18.97 18.97 8.1 8.91 8.1 8.1 8.1 8.1 8.262 8.1 8600 Hos Central Supply Facility Fee 50138 ACA CFP-C & DIM CFP/UP-C A9270 270 26.03 18.221 37.6 172.93 88.09 37.6 129.7 37.6 88.09 88.09 88.09 88.09 37.6 41.36000000000001 37.6 37.6 37.6 37.6 38.352000000000004 37.6 8600 Hos Central Supply Facility Fee 50139 ACA/DIM ALCOHOL CALIBRATOR C8633 270 20.87 14.609 0.37 1.7 0.87 0.37 1.28 0.37 0.87 0.87 0.87 0.87 0.37 0.40700000000000003 0.37 0.37 0.37 0.37 0.3774 0.37 8600 Hos Central Supply Facility Fee 50140 ACA/DIM SAL CALIBRATOR C8677 270 25.06 17.541999999999998 1.11 5.09 2.59 1.11 3.82 1.11 2.59 2.59 2.59 2.59 1.11 1.2210000000000003 1.11 1.11 1.11 1.11 1.1322 1.11 8600 Hos Central Supply Facility Fee 50141 ACA/DIM TP/ALB CALIB 792031901 A4467 270 28.66 20.061999999999998 0.61 2.79 1.42 0.61 2.09 0.61 1.42 1.42 1.42 1.42 0.61 0.671 0.61 0.61 0.61 0.61 0.6222 0.61 8600 Hos Central Supply Facility Fee 755 ACCO RECYCLED PAPER CLIPS SILVER FINISH JUMBO A4467 270 0.01 0.006999999999999999 0.92 4.23 2.15 0.92 3.17 0.92 2.15 2.15 2.15 2.15 0.92 1.0120000000000002 0.92 0.92 0.92 0.92 0.9384 0.92 8600 Hos Central Supply Facility Fee 1121 ACCUCHEK AVIVA PLUS TEST STRIPS A4467 270 97.86 68.502 73.31 337.21 171.77 73.31 252.91 73.31 171.77 171.77 171.77 171.77 73.31 80.641 73.31 73.31 73.31 73.31 74.7762 73.31 8600 Hos Central Supply Facility Fee 964 ACCU-CHEK BATTERY A4239 270 0.95 0.6649999999999999 1.12 5.13 2.61 1.12 3.85 1.12 2.61 2.61 2.61 2.61 1.12 1.2320000000000002 1.12 1.12 1.12 1.12 1.1424 1.12 8600 Hos Central Supply Facility Fee 1185 ACCU-CHEK INFORM II 2 LEVEL CONTROLS A4256 270 13.76 9.632 0.68 3.11 1.58 0.68 2.33 0.68 1.58 1.58 1.58 1.58 0.68 0.7480000000000001 0.68 0.68 0.68 0.68 0.6936000000000001 0.68 8600 Hos Central Supply Facility Fee 1089 ACCU-CHEK PERFORMA METER C8666 270 31.33 21.930999999999997 0.97 4.44 2.26 0.97 3.33 0.97 2.26 2.26 2.26 2.26 0.97 1.067 0.97 0.97 0.97 0.97 0.9894 0.97 8600 Hos Central Supply Facility Fee 1088 ACCU-CHEK PERFORMA TEST STRIPS A4253 270 49.69 34.782999999999994 0.99 4.55 2.32 0.99 3.41 0.99 2.32 2.32 2.32 2.32 0.99 1.089 0.99 0.99 0.99 0.99 1.0098 0.99 8600 Hos Central Supply Facility Fee 1386 ACORN CLOTHES HOOK PANEL WITH 1 HOOK SS A4467 270 75 52.5 0.13 0.58 0.3 0.13 0.44 0.13 0.3 0.3 0.3 0.3 0.13 0.14300000000000002 0.13 0.13 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 50034 ACT 5 DIFF CALIBRATOR. 2 X 2 ML A4467 270 144.19 100.93299999999999 0.02 0.1 0.05 0.02 0.08 0.02 0.05 0.05 0.05 0.05 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 50039 ACT 5 DIFF DILUENT, 20 L A4467 270 64.16 44.91199999999999 0.42 1.95 0.99 0.42 1.46 0.42 0.99 0.99 0.99 0.99 0.42 0.462 0.42 0.42 0.42 0.42 0.4284 0.42 8600 Hos Central Supply Facility Fee 50036 ACT 5 DIFF FIX, 1 L A4467 270 116.28 81.396 5.7 26.24 13.37 5.7 19.68 5.7 13.37 13.37 13.37 13.37 5.7 6.2700000000000005 5.7 5.7 5.7 5.7 5.814 5.7 8600 Hos Central Supply Facility Fee 50038 ACT 5 DIFF HGB LYSE. 400ML A4467 270 89.82 62.87399999999999 18.49 85.05 43.32 18.49 63.79 18.49 43.32 43.32 43.32 43.32 18.49 20.339 18.49 18.49 18.49 18.49 18.8598 18.49 8600 Hos Central Supply Facility Fee 50035 ACT 5 DIFF RINSE, 1 L A4467 270 25.67 17.969 0.2 0.91 0.46 0.2 0.68 0.2 0.46 0.46 0.46 0.46 0.2 0.22000000000000003 0.2 0.2 0.2 0.2 0.20400000000000001 0.2 8600 Hos Central Supply Facility Fee 50037 ACT 5 DIFF WBC LYSE, 1L A4467 270 116.28 81.396 3.2 14.74 7.51 3.2 11.06 3.2 7.51 7.51 7.51 7.51 3.2 3.5200000000000005 3.2 3.2 3.2 3.2 3.2640000000000002 3.2 8600 Hos Central Supply Facility Fee 50142 ACTIN FSL 10X2ML A9270 270 11.64 8.148 10.43 47.99 24.45 10.43 35.99 10.43 24.45 24.45 24.45 24.45 10.43 11.473 10.43 10.43 10.43 10.43 10.6386 10.43 8600 Hos Central Supply Facility Fee 50453 ACUITY LITHONIA EXTERIOR LIGHT FIXTURE HIGH ABUSE N/A 270 82.31 57.617 5.22 24.01 12.23 5.22 18.01 5.22 12.23 12.23 12.23 12.23 5.22 5.742 5.22 5.22 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 500 ADAPTER TRACH DISPOSABLE A4467 270 0.14 0.098 0.29 1.32 0.67 0.29 0.99 0.29 0.67 0.67 0.67 0.67 0.29 0.319 0.29 0.29 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 50071 ADAPTER VALVE T 22MM OD ID A4467 270 1.6 1.1199999999999999 0.6 2.77 1.41 0.6 2.08 0.6 1.41 1.41 1.41 1.41 0.6 0.66 0.6 0.6 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 1132 ADHESIVE DENTURE SPARKLE FRESH A4467 270 3.96 2.772 0.55 2.52 1.28 0.55 1.89 0.55 1.28 1.28 1.28 1.28 0.55 0.6050000000000001 0.55 0.55 0.95 0.95 0.969 0.95 8600 Hos Central Supply Facility Fee 50714 ADR 4550 LEVER LAATCH FOR MS LOCK N/A 270 350 244.99999999999997 48.54 223.26 113.73 48.54 167.45 48.54 113.73 113.73 113.73 113.73 48.54 53.394000000000005 48.54 48.54 48.54 48.54 49.5108 48.54 8600 Hos Central Supply Facility Fee 841 ADULT LUMBAR PUNCTURE TRAY A4467 270 7.82 5.474 29.17 134.17 68.35 29.17 100.63 29.17 68.35 68.35 68.35 68.35 29.17 32.087 29.17 29.17 29.17 29.17 29.753400000000003 29.17 8600 Hos Central Supply Facility Fee 43 AIRWAY BERMAN MEDIUM ADULT A4206 270 0.18 0.126 0.76 3.51 1.79 0.76 2.63 0.76 1.79 1.79 1.79 1.79 0.76 0.8360000000000001 0.76 0.76 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 308 AIRWAY DISP NASOPHARYNGE 8.0 MM R5206 270 10.03 7.020999999999999 0.02 0.08 0.04 0.02 0.06 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 292 AIRWAY NASAL 9.0 L8699 270 1.74 1.218 1.16 5.32 2.71 1.16 3.99 1.16 2.71 2.71 2.71 2.71 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 1821 AIRWAY NASOPHARYNGEAL 14FR I8644 270 57.59 40.313 2.08 9.55 4.86 2.08 7.16 2.08 4.86 4.86 4.86 4.86 2.08 2.2880000000000003 2.08 2.08 2.08 2.08 2.1216 2.08 8600 Hos Central Supply Facility Fee 1822 AIRWAY NASOPHARYNGEAL 16FR I8644 270 57.59 40.313 2.08 9.55 4.86 2.08 7.16 2.08 4.86 4.86 4.86 4.86 2.08 2.2880000000000003 2.08 2.08 2.08 2.08 2.1216 2.08 8600 Hos Central Supply Facility Fee 289 AIRWAY NASOPHARYNGEAL PVC 26FR 8MM L8699 270 1.74 1.218 2.08 9.55 4.86 2.08 7.16 2.08 4.86 4.86 4.86 4.86 2.08 2.2880000000000003 2.08 2.08 2.08 2.08 2.1216 2.08 8600 Hos Central Supply Facility Fee 290 AIRWAY NASOPHARYNGEAL PVC 30 FR L8699 270 1.74 1.218 0.55 2.53 1.29 0.55 1.9 0.55 1.29 1.29 1.29 1.29 0.55 0.6050000000000001 0.55 0.55 0.55 0.55 0.561 0.55 8600 Hos Central Supply Facility Fee 291 AIRWAY NASOPHARYNGEAL PVC 34 FR 8.5MM L8699 270 1.7 1.19 1 4.58 2.33 1 3.44 1 2.33 2.33 2.33 2.33 1 1.1 1 1 1 1 1.02 1 8600 Hos Central Supply Facility Fee 50143 ALB/ALBUMIN A4467 270 0.29 0.20299999999999999 0.23 1.05 0.53 0.23 0.79 0.23 0.53 0.53 0.53 0.53 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 50144 ALB/ALBUMIN A4467 270 24.96 17.471999999999998 4.46 20.5 10.44 4.46 15.38 4.46 10.44 10.44 10.44 10.44 4.46 4.906000000000001 4.46 4.46 4.46 4.46 4.5492 4.46 8600 Hos Central Supply Facility Fee 50253 ALBUMMIN A4467 270 0 0 7.09 32.62 16.62 7.09 24.47 7.09 16.62 16.62 16.62 16.62 7.09 7.799 7.09 7.09 7.09 7.09 7.2318 7.09 8600 Hos Central Supply Facility Fee 50145 ALC/ALCOHOL A4467 270 111.48 78.036 7.15 32.89 16.75 7.15 24.67 7.15 16.75 16.75 16.75 16.75 7.15 7.865000000000001 7.15 7.15 7.15 7.15 7.293 7.15 8600 Hos Central Supply Facility Fee 50007 ALCOHOL A4467 270 236.55 165.585 0.06 0.27 0.14 0.06 0.2 0.06 0.14 0.14 0.14 0.14 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 870 ALCOHOL PREP PAD A4245 270 1.56 1.0919999999999999 3.26 15 7.64 3.26 11.25 3.26 7.64 7.64 7.64 7.64 3.26 3.586 3.26 3.26 3.26 3.26 3.3251999999999997 3.26 8600 Hos Central Supply Facility Fee 50146 ALP/ALKALINE PHOS A4467 270 0.29 0.20299999999999999 0.57 2.63 1.34 0.57 1.97 0.57 1.34 1.34 1.34 1.34 0.57 0.627 0.57 0.57 5.49 5.49 5.5998 5.49 8600 Hos Central Supply Facility Fee 50147 ALP/ALKALINE PHOS A4467 270 18.72 13.104 0.49 2.25 1.15 0.49 1.69 0.49 1.15 1.15 1.15 1.15 0.49 0.539 0.49 0.49 0.49 0.49 0.4998 0.49 8600 Hos Central Supply Facility Fee 50008 AMMONIA A4467 270 141.1 98.77 4.09 18.8 9.58 4.09 14.1 4.09 9.58 9.58 9.58 9.58 4.09 4.4990000000000006 4.09 4.09 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 50148 AMON CALIBRATOR A4467 270 20.78 14.546 5.72 26.3 13.4 5.72 19.73 5.72 13.4 13.4 13.4 13.4 5.72 6.292 5.72 5.72 5.72 5.72 5.8344 5.72 8600 Hos Central Supply Facility Fee 1713 AMSCAN STICKY TACK 5.3 OZ 5/PACK A4467 270 25.91 18.137 29.35 135 68.77 29.35 101.25 29.35 68.77 68.77 68.77 68.77 29.35 32.285000000000004 29.35 29.35 29.35 29.35 29.937 29.35 8600 Hos Central Supply Facility Fee 588 ANEROID,HAND HELD,ADULT A4467 270 8.32 5.824 34.78 160 81.5 34.78 120 34.78 81.5 81.5 81.5 81.5 34.78 38.258 34.78 34.78 34.78 34.78 35.4756 34.78 8600 Hos Central Supply Facility Fee 589 ANEROID,HAND HELD,CHILD A4467 270 8.99 6.293 39.13 180 91.69 39.13 135 39.13 91.69 91.69 91.69 91.69 39.13 43.043000000000006 39.13 39.13 39.13 39.13 39.912600000000005 39.13 8600 Hos Central Supply Facility Fee 590 ANEROID,HAND HELD,LRG ADULT A4467 270 8.59 6.013 9.67 44.46 22.65 9.67 33.35 9.67 22.65 22.65 22.65 22.65 9.67 10.637 9.67 9.67 9.67 9.67 9.8634 9.67 8600 Hos Central Supply Facility Fee 1243 ANGED BROOM 11 1/2 WIDE N/A 270 13.23 9.261 1.1 5.05 2.57 1.1 3.79 1.1 2.57 2.57 2.57 2.57 1.1 1.2100000000000002 1.1 1.1 1.1 1.1 1.122 1.1 8600 Hos Central Supply Facility Fee 583 ANTIPER/DEODORANT,ROLL-ON, 1.5 OZ A6542 270 0.25 0.175 0.96 4.41 2.25 0.96 3.31 0.96 2.25 2.25 2.25 2.25 0.96 1.056 0.96 0.96 0.96 0.96 0.9792 0.96 8600 Hos Central Supply Facility Fee 117 ANTISEPTIC AVAGARD HAND WITH MOISTURIZERS 500ML DSPN BOTTLEETHANOL SO T0206 270 31.52 22.064 0.84 3.85 1.96 0.84 2.89 0.84 1.96 1.96 1.96 1.96 0.84 0.924 0.84 0.84 0.84 0.84 0.8568 0.84 8600 Hos Central Supply Facility Fee 144 APPLICATOR 3 ML 2 PERCENT CHLORHEXIDINE P3206 270 1.05 0.735 0.84 3.85 1.96 0.84 2.89 0.84 1.96 1.96 1.96 1.96 0.84 0.924 0.84 0.84 0.84 0.84 0.8568 0.84 8600 Hos Central Supply Facility Fee 1441 APPLICATOR CHLORAPREP ONE STEP 10.5ML LF A4467 270 0 0 3.08 14.15 7.21 3.08 10.61 3.08 7.21 7.21 7.21 7.21 3.08 3.3880000000000003 3.08 3.08 3.08 3.08 3.1416 3.08 8600 Hos Central Supply Facility Fee 380 APPLICATOR CHLORAPREP ONE STEP 10.5ML LF 2% CHLRHXDN GLUCONATE 70% ISPRPYL ALCHL P7206 270 4.68 3.276 3.08 14.15 7.21 3.08 10.61 3.08 7.21 7.21 7.21 7.21 3.08 3.3880000000000003 3.08 3.08 3.08 3.08 3.1416 3.08 8600 Hos Central Supply Facility Fee 1442 APPLICATOR CHOLORAPREP ONE STEP 10.5ML LF A4467 270 4.33 3.0309999999999997 3.08 14.15 7.21 3.08 10.61 3.08 7.21 7.21 7.21 7.21 3.08 3.3880000000000003 3.08 3.08 3.08 3.08 3.1416 3.08 8600 Hos Central Supply Facility Fee 50700 ARCH FLAS WARNING LABE; 3 1/2 H PACK OF 5 N/A 270 14.87 10.408999999999999 1.05 4.83 2.46 1.05 3.62 1.05 2.46 2.46 2.46 2.46 1.05 1.1550000000000002 1.05 1.05 3.08 3.08 3.1416 3.08 8600 Hos Central Supply Facility Fee 1493 ARM SLING 11 SM A4565 270 2.92 2.044 1.05 4.83 2.46 1.05 3.62 1.05 2.46 2.46 2.46 2.46 1.05 1.1550000000000002 1.05 1.05 1.05 1.05 1.0710000000000002 1.05 8600 Hos Central Supply Facility Fee 1496 ARM SLING 11 XL A4565 270 2.92 2.044 1.05 4.83 2.46 1.05 3.62 1.05 2.46 2.46 2.46 2.46 1.05 1.1550000000000002 1.05 1.05 1.05 1.05 1.0710000000000002 1.05 8600 Hos Central Supply Facility Fee 1495 ARM SLING11 LG A4565 270 2.92 2.044 0.53 2.42 1.23 0.53 1.82 0.53 1.23 1.23 1.23 1.23 0.53 0.5830000000000001 0.53 0.53 0.53 0.53 0.5406000000000001 0.53 8600 Hos Central Supply Facility Fee 1494 ARM SLING11 MED A4565 270 2.92 2.044 0.53 2.42 1.23 0.53 1.82 0.53 1.23 1.23 1.23 1.23 0.53 0.5830000000000001 0.53 0.53 0.53 0.53 0.5406000000000001 0.53 8600 Hos Central Supply Facility Fee 50254 AST A4467 270 0 0 0.53 2.42 1.23 0.53 1.82 0.53 1.23 1.23 1.23 1.23 0.53 0.5830000000000001 0.53 0.53 0.53 0.53 0.5406000000000001 0.53 8600 Hos Central Supply Facility Fee 993 AVIVA ACCU-CHEK METER V8688 270 29.01 20.307 0.07 0.31 0.16 0.07 0.23 0.07 0.16 0.16 0.16 0.16 0.07 0.07700000000000001 0.07 0.07 1.11 1.11 1.1322 1.11 8600 Hos Central Supply Facility Fee 992 AVIVA ACCU-CHEK TEST STRIP A4253 270 98 68.6 0.18 0.83 0.42 0.18 0.62 0.18 0.42 0.42 0.42 0.42 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 50481 B & G CIRCULATOR PUMP 1/4HP, 1IN. N/A 270 2196.66 1537.6619999999998 0.46 2.13 1.09 0.46 1.6 0.46 1.09 1.09 1.09 1.09 0.46 0.5060000000000001 0.46 0.46 0.46 0.46 0.4692 0.46 8600 Hos Central Supply Facility Fee 1329 B & S CRAYOLA WASHABLE CLASSPACK MARKERS N/A 270 99.27 69.48899999999999 0.4 1.85 0.94 0.4 1.39 0.4 0.94 0.94 0.94 0.94 0.4 0.44000000000000006 0.4 0.4 0.4 0.4 0.40800000000000003 0.4 8600 Hos Central Supply Facility Fee 50149 B4264-12 WASTE BOTTLE B4264 270 318.26 222.78199999999998 0.01 0.06 0.03 0.01 0.05 0.01 0.03 0.03 0.03 0.03 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 50050 BAG LLD 30 X 36 20-30GL .70 ML CLEAR A4467 270 0.62 0.434 0.46 2.11 1.07 0.46 1.58 0.46 1.07 1.07 1.07 1.07 0.46 0.5060000000000001 0.46 0.46 0.46 0.46 0.4692 0.46 8600 Hos Central Supply Facility Fee 50049 BAG LLD 30X36 20-30GL .50ML CLEAR A4467 270 0.03 0.020999999999999998 0.73 3.37 1.72 0.73 2.53 0.73 1.72 1.72 1.72 1.72 0.73 0.803 0.73 0.73 0.73 0.73 0.7446 0.73 8600 Hos Central Supply Facility Fee 50052 BAG LLD PRINT 30 X 36 20 TO 30 GL 1.3 ML RED A4467 270 0.1 0.06999999999999999 0.81 3.72 1.89 0.81 2.79 0.81 1.89 1.89 1.89 1.89 0.81 0.8910000000000001 0.81 0.81 0.81 0.81 0.8262 0.81 8600 Hos Central Supply Facility Fee 50051 BAG LLD PRINT 30X36 20 TO 30GL 1.3ML RED A4467 270 0.12 0.08399999999999999 0.45 2.07 1.05 0.45 1.55 0.45 1.05 1.05 1.05 1.05 0.45 0.49500000000000005 0.45 0.45 0.45 0.45 0.459 0.45 8600 Hos Central Supply Facility Fee 1858 BAG PATIENT BELONG A8666 270 35.06 24.542 0.42 1.95 0.99 0.42 1.46 0.42 0.99 0.99 0.99 0.99 0.42 0.462 0.42 0.42 0.42 0.42 0.4284 0.42 8600 Hos Central Supply Facility Fee 1062 BAG PATIENT BELONGING CLEAR A4467 270 0.16 0.11199999999999999 0.81 3.73 1.9 0.81 2.8 0.81 1.9 1.9 1.9 1.9 0.81 0.8910000000000001 0.81 0.81 0.81 0.81 0.8262 0.81 8600 Hos Central Supply Facility Fee 999 BAG PATIENT BELONING WHT DRAWSTRING N/A 270 27.52 19.264 1.77 8.15 4.15 1.77 6.11 1.77 4.15 4.15 4.15 4.15 1.77 1.9470000000000003 1.77 1.77 1.77 1.77 1.8054000000000001 1.77 8600 Hos Central Supply Facility Fee 50053 BAG REPRO 38X58 60GL 1.5ML BLACK A4467 270 0.24 0.16799999999999998 0.01 0.04 0.02 0.01 0.03 0.01 0.02 0.02 0.02 0.02 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1828 BAG SPECIMEN BIOHAZARD ZIP 8 X 8 POCKET A4467 270 59.9 41.93 1.77 8.16 4.16 1.77 6.12 1.77 4.16 4.16 4.16 4.16 1.77 1.9470000000000003 1.77 1.77 1.77 1.77 1.8054000000000001 1.77 8600 Hos Central Supply Facility Fee 560 BAG,EMESIS,SICKNESS CLEAN-UP,CLEAN SACK A9270 270 2.72 1.904 0.01 0.04 0.02 0.01 0.03 0.01 0.02 0.02 0.02 0.02 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 559 BAG,PATIENT BELONGING,RGD HDL,WHT,PRNT A9270 270 0.15 0.105 1.64 7.55 3.85 1.64 5.66 1.64 3.85 3.85 3.85 3.85 1.64 1.804 1.64 1.64 1.64 1.64 1.6727999999999998 1.64 8600 Hos Central Supply Facility Fee 963 BANDAGE CURAD 3/4X2.5 A6445 270 1.69 1.1829999999999998 15.13 69.6 35.45 15.13 52.2 15.13 35.45 35.45 35.45 35.45 15.13 16.643 15.13 15.13 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1416 BANDAGE GAUZE SOF-FORM 2 A6443 270 0.11 0.077 7.88 36.26 18.47 7.88 27.2 7.88 18.47 18.47 18.47 18.47 7.88 8.668000000000001 7.88 7.88 7.88 7.88 8.0376 7.88 8600 Hos Central Supply Facility Fee 1353 BANDAGE GAUZE STRL 6 A4467 270 0.34 0.238 0.02 0.08 0.04 0.02 0.06 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 1609 BANDAGE SPOT A4467 270 3.53 2.4709999999999996 0.06 0.28 0.14 0.06 0.21 0.06 0.14 0.14 0.14 0.14 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 1291 BANDAGE SPOT PLASTIC 7/8 A4467 270 1.38 0.9659999999999999 4.93 22.69 11.56 4.93 17.02 4.93 11.56 11.56 11.56 11.56 4.93 5.423 4.93 4.93 4.93 4.93 5.0286 4.93 8600 Hos Central Supply Facility Fee 599 BANDAGE,ADHESIVE,PLASTIC,3/4X3,STRL,LF A4467 270 1.19 0.833 0.21 0.95 0.48 0.21 0.71 0.21 0.48 0.48 0.48 0.48 0.21 0.231 0.21 0.21 0.21 0.21 0.2142 0.21 8600 Hos Central Supply Facility Fee 597 BANDAGE,ELASTIC,SWIFT-WRAP,4X5YD,VELCRO A4206 270 0.48 0.33599999999999997 0.56 2.56 1.3 0.56 1.92 0.56 1.3 1.3 1.3 1.3 0.56 0.6160000000000001 0.56 0.56 0.56 0.56 0.5712 0.56 8600 Hos Central Supply Facility Fee 598 BANDAGE,ELASTIC,SWIFT-WRAP,6X5YD,VELCRO A4206 270 0.74 0.518 0.14 0.63 0.32 0.14 0.47 0.14 0.32 0.32 0.32 0.32 0.14 0.15400000000000003 0.14 0.14 0.14 0.14 0.1428 0.14 8600 Hos Central Supply Facility Fee 594 BANDAGE,GAUZE,SOF-FORM,2X75,STRL,LF A4206 270 0.13 0.091 1.78 8.2 4.18 1.78 6.15 1.78 4.18 4.18 4.18 4.18 1.78 1.9580000000000002 1.78 1.78 1.78 1.78 1.8156 1.78 8600 Hos Central Supply Facility Fee 591 BANDAGE,GAUZE,SOF-FORM,3X75,NS,LF A4206 270 0.18 0.126 2.39 10.99 5.6 2.39 8.24 2.39 5.6 5.6 5.6 5.6 2.39 2.6290000000000004 2.39 2.39 2.39 2.39 2.4378 2.39 8600 Hos Central Supply Facility Fee 592 BANDAGE,GAUZE,SOF-FORM,4X75,NS,LF A4206 270 0.12 0.08399999999999999 2.23 10.24 5.22 2.23 7.68 2.23 5.22 5.22 5.22 5.22 2.23 2.4530000000000003 2.23 2.23 2.23 2.23 2.2746 2.23 8600 Hos Central Supply Facility Fee 595 BANDAGE,GAUZE,SOF-FORM,4X75,STRL,LF A4206 270 0.19 0.13299999999999998 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 593 BANDAGE,GAUZE,SOF-FORM,6X80,NS,LF A4206 270 0.4 0.27999999999999997 0.13 0.58 0.3 0.13 0.44 0.13 0.3 0.3 0.3 0.3 0.13 0.14300000000000002 0.13 0.13 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 230 BASIC PACK, TIBURION S2206 270 8.02 5.613999999999999 1.52 6.97 3.55 1.52 5.23 1.52 3.55 3.55 3.55 3.55 1.52 1.6720000000000002 1.52 1.52 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 1335 BATTALION DISC TUMBLER CAM LOCK A4467 270 7.84 5.4879999999999995 1.59 7.3 3.72 1.59 5.48 1.59 3.72 3.72 3.72 3.72 1.59 1.7490000000000003 1.59 1.59 1.11 1.11 1.1322 1.11 8600 Hos Central Supply Facility Fee 1399 BATTALION FLOOR DOOR STOP A4467 270 9.67 6.768999999999999 0.16 0.73 0.37 0.16 0.55 0.16 0.37 0.37 0.37 0.37 0.16 0.17600000000000002 0.16 0.16 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 239 BATTERY ACCU-CHEK CR2450N T9206 270 0.95 0.6649999999999999 0.47 2.14 1.09 0.47 1.61 0.47 1.09 1.09 1.09 1.09 0.47 0.517 0.47 0.47 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 1119 BATTERY ENERGIZER AA A9270 270 10.82 7.574 0.47 2.14 1.09 0.47 1.61 0.47 1.09 1.09 1.09 1.09 0.47 0.517 0.47 0.47 0.47 0.47 0.4794 0.47 8600 Hos Central Supply Facility Fee 409 BATTERY ENERGIZER ALK 9V T0206 270 0.65 0.45499999999999996 0.33 1.5 0.76 0.33 1.13 0.33 0.76 0.76 0.76 0.76 0.33 0.36300000000000004 0.33 0.33 0.33 0.33 0.3366 0.33 8600 Hos Central Supply Facility Fee 256 BATTERY ENERGIZER ALK AA Q0498 270 0.19 0.13299999999999998 0.3 1.39 0.71 0.3 1.04 0.3 0.71 0.71 0.71 0.71 0.3 0.33 0.3 0.3 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 258 BATTERY ENERGIZER ALK C Q0498 270 0.08 0.055999999999999994 0.4 1.84 0.94 0.4 1.38 0.4 0.94 0.94 0.94 0.94 0.4 0.44000000000000006 0.4 0.4 0.4 0.4 0.40800000000000003 0.4 8600 Hos Central Supply Facility Fee 259 BATTERY ENERGIZER ALK D Q0498 270 0.11 0.077 0.39 1.8 0.92 0.39 1.35 0.39 0.92 0.92 0.92 0.92 0.39 0.42900000000000005 0.39 0.39 0.39 0.39 0.39780000000000004 0.39 8600 Hos Central Supply Facility Fee 1120 BATTERY LITHIUM COIN L7367 270 0.81 0.567 0.73 3.34 1.7 0.73 2.51 0.73 1.7 1.7 1.7 1.7 0.73 0.803 0.73 0.73 0.73 0.73 0.7446 0.73 8600 Hos Central Supply Facility Fee 255 BATTERY LITHIUM COIN 3 V Q0498 270 0.73 0.511 0.3 1.39 0.71 0.3 1.04 0.3 0.71 0.71 0.71 0.71 0.3 0.33 0.3 0.3 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 164 BATTERY RECHARGABLE 2.5V T9206 270 44.46 31.122 0.19 0.89 0.45 0.19 0.67 0.19 0.45 0.45 0.45 0.45 0.19 0.20900000000000002 0.19 0.19 0.19 0.19 0.1938 0.19 8600 Hos Central Supply Facility Fee 304 BATTERY RECHARGEABLE 3.5V T0206 270 32.09 22.463 0.65 2.98 1.52 0.65 2.24 0.65 1.52 1.52 1.52 1.52 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 8600 Hos Central Supply Facility Fee 606 BEDPAN,FRACTURE,GRAPHITE,24 EA A4467 270 0.55 0.385 0.69 3.17 1.61 0.69 2.38 0.69 1.61 1.61 1.61 1.61 0.69 0.759 0.69 0.69 0.69 0.69 0.7038 0.69 8600 Hos Central Supply Facility Fee 247 BLADE B-P SURGICAL CARB STER SZ 11 A9206 270 0.29 0.20299999999999999 0.02 0.11 0.06 0.02 0.08 0.02 0.06 0.06 0.06 0.06 0.02 0.022000000000000002 0.02 0.02 0.72 0.72 0.7343999999999999 0.72 8600 Hos Central Supply Facility Fee 112 BLADE B-P SURGICAL SZ15 CARB S STER A9206 270 0.29 0.20299999999999999 2.03 9.35 4.76 2.03 7.01 2.03 4.76 4.76 4.76 4.76 2.03 2.233 2.03 2.03 2.03 2.03 2.0705999999999998 2.03 8600 Hos Central Supply Facility Fee 368 BLADE DERMATONE STERILE L8699 270 30.01 21.007 2.53 11.66 5.94 2.53 8.75 2.53 5.94 5.94 5.94 5.94 2.53 2.783 2.53 2.53 2.53 2.53 2.5806 2.53 8600 Hos Central Supply Facility Fee 119 BLADE FOR 3M SURGICAL CLIPPER DISPOSABLE A9206 270 2.52 1.7639999999999998 1.22 5.62 2.86 1.22 4.22 1.22 2.86 2.86 2.86 2.86 1.22 1.342 1.22 1.22 1.22 1.22 1.2444 1.22 8600 Hos Central Supply Facility Fee 1672 BLADE MACINTOSH NO2 100MM-21MM F/O CHILD A4467 270 11.36 7.951999999999999 3.15 14.5 7.39 3.15 10.88 3.15 7.39 7.39 7.39 7.39 3.15 3.4650000000000003 3.15 3.15 3.15 3.15 3.213 3.15 8600 Hos Central Supply Facility Fee 382 BLADE SAFETYLOCK RIB-BACK SZ 15 CARB A4206 270 0.32 0.22399999999999998 0.56 2.59 1.32 0.56 1.94 0.56 1.32 1.32 1.32 1.32 0.56 0.6160000000000001 0.56 0.56 0.56 0.56 0.5712 0.56 8600 Hos Central Supply Facility Fee 104 BLADE SAW GIGLI 510MM LENGTH A4206 270 26.24 18.368 0.51 2.36 1.2 0.51 1.77 0.51 1.2 1.2 1.2 1.2 0.51 0.561 0.51 0.51 0.51 0.51 0.5202 0.51 8600 Hos Central Supply Facility Fee 1440 BLADE SHAVE BIOPSY FLEX DERMABLADE A4467 270 1.1 0.77 6.98 32.09 16.35 6.98 24.07 6.98 16.35 16.35 16.35 16.35 6.98 7.678000000000001 6.98 6.98 6.98 6.98 7.1196 6.98 8600 Hos Central Supply Facility Fee 621 BLADE,TONGUE,6,STERILE A4467 270 2.04 1.428 9.97 45.86 23.36 9.97 34.4 9.97 23.36 23.36 23.36 23.36 9.97 10.967000000000002 9.97 9.97 9.97 9.97 10.169400000000001 9.97 8600 Hos Central Supply Facility Fee 50009 BLOOD BANK A4467 270 315.4 220.77999999999997 2.18 10.03 5.11 2.18 7.52 2.18 5.11 5.11 5.11 5.11 2.18 2.3980000000000006 2.18 2.18 2.95 2.95 3.0090000000000003 2.95 8600 Hos Central Supply Facility Fee 50078 BLOOD BNK SALINE A9270 270 10.87 7.608999999999999 7.22 33.22 16.92 7.22 24.92 7.22 16.92 16.92 16.92 16.92 7.22 7.942 7.22 7.22 7.22 7.22 7.3644 7.22 8600 Hos Central Supply Facility Fee 50010 BLOOD CELL ID (SECONDARY) A4467 270 37.35 26.145 0.02 0.08 0.04 0.02 0.06 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 50004 BLOOD GAS A4467 270 323.7 226.58999999999997 0.17 0.8 0.41 0.17 0.6 0.17 0.41 0.41 0.41 0.41 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 355 BONE MAR BIOP/ASP NDL 13X2 1/2 N2206 270 18.85 13.195 21.34 98.15 50 21.34 73.61 21.34 50 50 50 50 21.34 23.474 21.34 21.34 7.82 7.82 7.976400000000001 7.82 8600 Hos Central Supply Facility Fee 1040 BP CUFF 1 TUBE ADULT L3730 270 10.4 7.279999999999999 0.31 1.43 0.73 0.31 1.07 0.31 0.73 0.73 0.73 0.73 0.31 0.341 0.31 0.31 22.62 22.62 23.072400000000002 22.62 8600 Hos Central Supply Facility Fee 1041 BP CUFF LF ADULT LARGE L3730 270 14.26 9.982 2.89 13.31 6.78 2.89 9.98 2.89 6.78 6.78 6.78 6.78 2.89 3.1790000000000003 2.89 2.89 2.89 2.89 2.9478 2.89 8600 Hos Central Supply Facility Fee 1434 BP CUFF THIGH P8688 270 39.23 27.460999999999995 0.76 3.5 1.78 0.76 2.63 0.76 1.78 1.78 1.78 1.78 0.76 0.8360000000000001 0.76 0.76 0.76 0.76 0.7752 0.76 8600 Hos Central Supply Facility Fee 282 BRACE ANKLE STANDARD LARGE RIGHT A5206 270 23.73 16.611 20.96 96.39 49.1 20.96 72.29 20.96 49.1 49.1 49.1 49.1 20.96 23.056000000000004 20.96 20.96 20.96 20.96 21.3792 20.96 8600 Hos Central Supply Facility Fee 281 BRACE ANKLE STANDARD LEFT A5206 270 23.73 16.611 0.59 2.71 1.38 0.59 2.03 0.59 1.38 1.38 1.38 1.38 0.59 0.649 0.59 0.59 0.59 0.59 0.6018 0.59 8600 Hos Central Supply Facility Fee 169 BRACE ANKLE STIRRUP PNEUMATIC A4206 270 14.15 9.905 1.89 8.7 4.43 1.89 6.53 1.89 4.43 4.43 4.43 4.43 1.89 2.079 1.89 1.89 1.89 1.89 1.9278 1.89 8600 Hos Central Supply Facility Fee 170 BRACE ANKLE STIRRUP PNEUMATIC A4206 270 14.15 9.905 0.23 1.07 0.55 0.23 0.8 0.23 0.55 0.55 0.55 0.55 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 171 BRACE ANKLE STIRRUP PNEUMATIC A4206 270 14.15 9.905 0.31 1.41 0.72 0.31 1.06 0.31 0.72 0.72 0.72 0.72 0.31 0.341 0.31 0.31 0.31 0.31 0.3162 0.31 8600 Hos Central Supply Facility Fee 172 BRACE ANKLE STIRRUP PNEUMATIC A4206 270 14.15 9.905 0.32 1.46 0.74 0.32 1.1 0.32 0.74 0.74 0.74 0.74 0.32 0.35200000000000004 0.32 0.32 0.32 0.32 0.3264 0.32 8600 Hos Central Supply Facility Fee 1506 BRACE KNEE SZ XX-LGE l1810 270 23.55 16.485 0.3 1.4 0.71 0.3 1.05 0.3 0.71 0.71 0.71 0.71 0.3 0.33 0.3 0.3 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 50458 BRACKET MASK FACE R8677 270 21.74 15.217999999999998 0.31 1.44 0.73 0.31 1.08 0.31 0.73 0.73 0.73 0.73 0.31 0.341 0.31 0.31 0.31 0.31 0.3162 0.31 8600 Hos Central Supply Facility Fee 50518 BRADY TEXT AND SYMBOL ONE WAY N/A 270 37.23 26.060999999999996 0.6 2.74 1.4 0.6 2.06 0.6 1.4 1.4 1.4 1.4 0.6 0.66 0.6 0.6 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 50519 BRADY TEXT AND SYMBOL ONE WAY N/A 270 39.85 27.895 11.6 53.34 27.17 11.6 40.01 11.6 27.17 27.17 27.17 27.17 11.6 12.76 11.6 11.6 11.6 11.6 11.831999999999999 11.6 8600 Hos Central Supply Facility Fee 1060 BRIEF 2XL A4467 270 2.04 1.428 1.81 8.34 4.25 1.81 6.26 1.81 4.25 4.25 4.25 4.25 1.81 1.9910000000000003 1.81 1.81 13.92 13.92 14.1984 13.92 8600 Hos Central Supply Facility Fee 1453 BRIEF CLOTHLIKE SMALL T4521 270 7.71 5.396999999999999 1.76 8.08 4.12 1.76 6.06 1.76 4.12 4.12 4.12 4.12 1.76 1.9360000000000002 1.76 1.76 1.76 1.76 1.7952000000000001 1.76 8600 Hos Central Supply Facility Fee 1095 BRIEF CLOTHLIKE XXL T4543 270 11.03 7.720999999999999 0.67 3.06 1.56 0.67 2.3 0.67 1.56 1.56 1.56 1.56 0.67 0.7370000000000001 0.67 0.67 0.67 0.67 0.6834 0.67 8600 Hos Central Supply Facility Fee 1002 BRIEF FITULTRA LG T4523 270 7.22 5.053999999999999 0.67 3.06 1.56 0.67 2.3 0.67 1.56 1.56 1.56 1.56 0.67 0.7370000000000001 0.67 0.67 0.67 0.67 0.6834 0.67 8600 Hos Central Supply Facility Fee 1003 BRIEF FITULTRA RG T4522 270 6.99 4.893 1.16 5.33 2.72 1.16 4 1.16 2.72 2.72 2.72 2.72 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 1004 BRIEF FITULTRA XLG T4524 270 9.94 6.957999999999999 1.16 5.33 2.72 1.16 4 1.16 2.72 2.72 2.72 2.72 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 1058 BRIEF MD/LG A4467 270 1.89 1.323 1.16 5.33 2.72 1.16 4 1.16 2.72 2.72 2.72 2.72 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 1059 BRIEF XL A4467 270 1.96 1.3719999999999999 1.16 5.33 2.72 1.16 4 1.16 2.72 2.72 2.72 2.72 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 584 BRIEF,ULTRASOFT,CLOTHLIKE,LG,48-58 A8689 270 8.46 5.922000000000001 1.16 5.33 2.72 1.16 4 1.16 2.72 2.72 2.72 2.72 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 1057 BRIEFS MD/LG A4467 270 0 0 1.16 5.33 2.72 1.16 4 1.16 2.72 2.72 2.72 2.72 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 965 BRIEFS STRETCH SM/MS T4529 270 1.39 0.9729999999999999 0.97 4.46 2.27 0.97 3.35 0.97 2.27 2.27 2.27 2.27 0.97 1.067 0.97 0.97 0.97 0.97 0.9894 0.97 8600 Hos Central Supply Facility Fee 50255 BUN A4467 270 0 0 0.39 1.78 0.91 0.39 1.34 0.39 0.91 0.91 0.91 0.91 0.39 0.42900000000000005 0.39 0.39 0.97 0.97 0.9894 0.97 8600 Hos Central Supply Facility Fee 50150 BUN/UREA NITROGEN A4467 270 0.29 0.20299999999999999 0.18 0.82 0.42 0.18 0.62 0.18 0.42 0.42 0.42 0.42 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 50151 BUN/UREA NITROGEN A4467 270 24.96 17.471999999999998 3.41 15.7 8 3.41 11.78 3.41 8 8 8 8 3.41 3.7510000000000003 3.41 3.41 3.41 3.41 3.4782 3.41 8600 Hos Central Supply Facility Fee 50012 C. DIFFICILE TOXIN OR ANTIGEN- 2 SAMPLES A56643 270 112.05 78.43499999999999 0.03 0.12 0.06 0.03 0.09 0.03 0.06 0.06 0.06 0.06 0.03 0.033 0.03 0.03 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 50264 CA CLEAN A4467 270 24.56 17.191999999999997 0.13 0.58 0.3 0.13 0.44 0.13 0.3 0.3 0.3 0.3 0.13 0.14300000000000002 0.13 0.13 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 50152 CA CLEAN I 50ML SOLUTION A4467 270 24.56 17.191999999999997 0.03 0.15 0.08 0.03 0.11 0.03 0.08 0.08 0.08 0.08 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 50153 CA/CALCIUM REVISED A4467 270 0.29 0.20299999999999999 0.01 0.06 0.03 0.01 0.05 0.01 0.03 0.03 0.03 0.03 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 50154 CA/CALCIUM REVISED A4467 270 24.96 17.471999999999998 0.22 1.01 0.51 0.22 0.76 0.22 0.51 0.51 0.51 0.51 0.22 0.24200000000000002 0.22 0.22 0.22 0.22 0.22440000000000002 0.22 8600 Hos Central Supply Facility Fee 50256 CALCIUM A4467 270 0.32 0.22399999999999998 0.07 0.32 0.16 0.07 0.24 0.07 0.16 0.16 0.16 0.16 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 50155 CALCIUM CHLORIDE SOLUTION 0.02 A4467 270 13.73 9.610999999999999 0.77 3.55 1.81 0.77 2.66 0.77 1.81 1.81 1.81 1.81 0.77 0.8470000000000001 0.77 0.77 0.77 0.77 0.7854 0.77 8600 Hos Central Supply Facility Fee 50552 CALIBRATION OF THERMCO THERMOMETERS N/A 270 41 28.7 4.93 22.69 11.56 4.93 17.02 4.93 11.56 11.56 11.56 11.56 4.93 5.423 4.93 4.93 12.35 12.35 12.597 12.35 8600 Hos Central Supply Facility Fee 50473 CAM FOR BERKEL SLICER N/A 270 21.59 15.113 5.26 24.18 12.32 5.26 18.14 5.26 12.32 12.32 12.32 12.32 5.26 5.7860000000000005 5.26 5.26 5.26 5.26 5.3652 5.26 8600 Hos Central Supply Facility Fee 50079 CAMPYLOBACTER BLOOD AGAR A9270 270 0.38 0.26599999999999996 0.02 0.08 0.04 0.02 0.06 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 330 CANISTER 1200CC GUARDIAN W/LOCKING LID N3206 270 1.07 0.749 1.49 6.86 3.49 1.49 5.15 1.49 3.49 3.49 3.49 3.49 1.49 1.639 1.49 1.49 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 50070 CANISTER GUARDIAN 2000CC W/ LOCKING LID A4467 270 1.22 0.854 0.12 0.55 0.28 0.12 0.41 0.12 0.28 0.28 0.28 0.28 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 332 CANISTER GUARDIAN 3000CC N4206 270 1.41 0.9869999999999999 0.05 0.21 0.11 0.05 0.16 0.05 0.11 0.11 0.11 0.11 0.05 0.05500000000000001 0.05 0.05 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 1839 CANNULA ADULT SOFT TOUCH 7' TUBE A4467 270 26.16 18.311999999999998 0.62 2.85 1.45 0.62 2.14 0.62 1.45 1.45 1.45 1.45 0.62 0.682 0.62 0.62 0.62 0.62 0.6324 0.62 8600 Hos Central Supply Facility Fee 50041 CANNULA CUSHION ADULT W/14 FT TBG A4467 270 0.77 0.5389999999999999 0.23 1.05 0.53 0.23 0.79 0.23 0.53 0.53 0.53 0.53 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 50042 CANNULA CUSHION PED W/ 7 FT TUBE A4467 270 0.82 0.574 0.82 3.79 1.93 0.82 2.84 0.82 1.93 1.93 1.93 1.93 0.82 0.902 0.82 0.82 0.82 0.82 0.8363999999999999 0.82 8600 Hos Central Supply Facility Fee 101 CAP BOUFFANT SBP CELEBRATION P8206 270 0.58 0.40599999999999997 0.82 3.75 1.91 0.82 2.81 0.82 1.91 1.91 1.91 1.91 0.82 0.902 0.82 0.82 0.41 0.41 0.41819999999999996 0.41 8600 Hos Central Supply Facility Fee 157 CAP BOUFFANT SPUNBONDED BLUE P1206 270 0.04 0.027999999999999997 2.05 9.42 4.8 2.05 7.07 2.05 4.8 4.8 4.8 4.8 2.05 2.255 2.05 2.05 2.05 2.05 2.0909999999999997 2.05 8600 Hos Central Supply Facility Fee 235 CAP SURGICAL UNIVERSAL POLYSPUN P2206 270 0.08 0.055999999999999994 0.56 2.58 1.31 0.56 1.94 0.56 1.31 1.31 1.31 1.31 0.56 0.6160000000000001 0.56 0.56 0.56 0.56 0.5712 0.56 8600 Hos Central Supply Facility Fee 50156 CARBAMAZEPINE A4467 270 103.68 72.576 0.02 0.07 0.04 0.02 0.05 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 50013 CARDIAC MARKERS- 5 SAMPLES A56643 270 199.2 139.43999999999997 0.34 1.55 0.79 0.34 1.16 0.34 0.79 0.79 0.79 0.79 0.34 0.37400000000000005 0.34 0.34 6.54 6.54 6.6708 6.54 8600 Hos Central Supply Facility Fee 50450 CARLISLE PORTABLE SNEEZE GUARD N/A 270 325 227.49999999999997 0.29 1.33 0.68 0.29 1 0.29 0.68 0.68 0.68 0.68 0.29 0.319 0.29 0.29 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 1673 CARRIERS BREAKAWAY A4467 270 1.41 0.9869999999999999 0.28 1.3 0.66 0.28 0.98 0.28 0.66 0.66 0.66 0.66 0.28 0.30800000000000005 0.28 0.28 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 50157 CARTON ASSY, DM HB1C A4467 270 4.92 3.444 0.31 1.41 0.72 0.31 1.06 0.31 0.72 0.72 0.72 0.72 0.31 0.341 0.31 0.31 0.31 0.31 0.3162 0.31 8600 Hos Central Supply Facility Fee 50158 CARTON ASSY, DM HB1C A4467 270 291.6 204.12 0.28 1.3 0.66 0.28 0.98 0.28 0.66 0.66 0.66 0.66 0.28 0.30800000000000005 0.28 0.28 0.28 0.28 0.2856 0.28 8600 Hos Central Supply Facility Fee 98 CAST PADDING STRL 3 S7206 270 3.11 2.1769999999999996 0.65 2.97 1.51 0.65 2.23 0.65 1.51 1.51 1.51 1.51 0.65 0.7150000000000001 0.65 0.65 0.4 0.4 0.40800000000000003 0.4 8600 Hos Central Supply Facility Fee 371 CATH TROCAR 24FR 16L T3206 270 15.7 10.989999999999998 0.3 1.4 0.71 0.3 1.05 0.3 0.71 0.71 0.71 0.71 0.3 0.33 0.3 0.3 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 402 CATHETER ALL PURPOSE 10FR 16IN T0206 270 0.34 0.238 2.98 13.73 6.99 2.98 10.3 2.98 6.99 6.99 6.99 6.99 2.98 3.278 2.98 2.98 2.98 2.98 3.0396 2.98 8600 Hos Central Supply Facility Fee 1421 CATHETER FEMALE KIT 8FR GLOVE/WIIPES A4467 270 1.8 1.26 2.11 9.72 4.95 2.11 7.29 2.11 4.95 4.95 4.95 4.95 2.11 2.321 2.11 2.11 2.11 2.11 2.1522 2.11 8600 Hos Central Supply Facility Fee 245 CATHETER FOLEY HYDRPHLC COUDE 5 CC 14 FR A4344 270 10.99 7.693 0.45 2.06 1.05 0.45 1.55 0.45 1.05 1.05 1.05 1.05 0.45 0.49500000000000005 0.45 0.45 0.45 0.45 0.459 0.45 8600 Hos Central Supply Facility Fee 134 CATHETER FOLEY SILK COAT 16 FR 5 CC T2206 270 3.27 2.2889999999999997 0.01 0.06 0.03 0.01 0.05 0.01 0.03 0.03 0.03 0.03 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1380 CATHETER INTROCAN SAFETY 16G X 1.25 A4467 270 97.35 68.145 0.38 1.76 0.9 0.38 1.32 0.38 0.9 0.9 0.9 0.9 0.38 0.41800000000000004 0.38 0.38 0.38 0.38 0.3876 0.38 8600 Hos Central Supply Facility Fee 318 CATHETER IV INTROCAN SAFETY 18G 1.3X32MM TEFLON A4344 270 104.05 72.835 0.68 3.14 1.6 0.68 2.36 0.68 1.6 1.6 1.6 1.6 0.68 0.7480000000000001 0.68 0.68 0.68 0.68 0.6936000000000001 0.68 8600 Hos Central Supply Facility Fee 317 CATHETER IV INTROCAN SAFETY 20G 1.1X32MM TEFLON A4344 270 98.15 68.705 0.01 0.04 0.02 0.01 0.03 0.01 0.02 0.02 0.02 0.02 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1535 CATHETER IV INTROCAN SAFETY 20G X 1.25 A4467 270 97.21 68.047 0.21 0.95 0.48 0.21 0.71 0.21 0.48 0.48 0.48 0.48 0.21 0.231 0.21 0.21 0.21 0.21 0.2142 0.21 8600 Hos Central Supply Facility Fee 316 CATHETER IV INTROCAN SAFETY 22G 0.9X25MM TEFLON A4344 270 97.5 68.25 0.27 1.26 0.64 0.27 0.95 0.27 0.64 0.64 0.64 0.64 0.27 0.29700000000000004 0.27 0.27 0.27 0.27 0.27540000000000003 0.27 8600 Hos Central Supply Facility Fee 1817 CATHETER IV INTROCAN SAFETY 24G A4467 270 102.25 71.57499999999999 0.35 1.63 0.83 0.35 1.22 0.35 0.83 0.83 0.83 0.83 0.35 0.385 0.35 0.35 0.35 0.35 0.357 0.35 8600 Hos Central Supply Facility Fee 315 CATHETER IV INTROCAN SFTY 24G 0.55IN FEP STRAIGHT A4344 270 89.83 62.88099999999999 0.05 0.21 0.11 0.05 0.16 0.05 0.11 0.11 0.11 0.11 0.05 0.05500000000000001 0.05 0.05 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 937 CATHETER SELF 14FR A8633 270 34.81 24.367 0.16 0.72 0.37 0.16 0.54 0.16 0.37 0.37 0.37 0.37 0.16 0.17600000000000002 0.16 0.16 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 1744 CATHETER SPEDICATH MALE 14FR A4467 270 58.96 41.272 0.26 1.18 0.6 0.26 0.89 0.26 0.6 0.6 0.6 0.6 0.26 0.28600000000000003 0.26 0.26 0.26 0.26 0.2652 0.26 8600 Hos Central Supply Facility Fee 960 CATHETER WORD A4467 270 154.67 108.26899999999999 0.3 1.36 0.69 0.3 1.02 0.3 0.69 0.69 0.69 0.69 0.3 0.33 0.3 0.3 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 325 CATHETER WORD BARTHOLIN 10F LATEX STERILE T8206 270 13.31 9.317 0.28 1.3 0.66 0.28 0.98 0.28 0.66 0.66 0.66 0.66 0.28 0.30800000000000005 0.28 0.28 0.28 0.28 0.2856 0.28 8600 Hos Central Supply Facility Fee 843 CAUTERY HIGH TEMP A9270 270 8.7 6.089999999999999 1.12 5.15 2.62 1.12 3.86 1.12 2.62 2.62 2.62 2.62 1.12 1.2320000000000002 1.12 1.12 1.12 1.12 1.1424 1.12 8600 Hos Central Supply Facility Fee 1692 CAUTERY HIGH TEMP A8655 270 114.54 80.178 0.19 0.87 0.44 0.19 0.65 0.19 0.44 0.44 0.44 0.44 0.19 0.20900000000000002 0.19 0.19 0.19 0.19 0.1938 0.19 8600 Hos Central Supply Facility Fee 329 CAUTERY HIGH TEMP LOOP TIP U3206 270 8.7 6.089999999999999 0.19 0.87 0.44 0.19 0.65 0.19 0.44 0.44 0.44 0.44 0.19 0.20900000000000002 0.19 0.19 0.19 0.19 0.1938 0.19 8600 Hos Central Supply Facility Fee 293 CHART EYE TEST UNIVERSAL A5206 270 14.18 9.925999999999998 10.09 46.41 23.64 10.09 34.81 10.09 23.64 23.64 23.64 23.64 10.09 11.099 10.09 10.09 0.38 0.38 0.3876 0.38 8600 Hos Central Supply Facility Fee 50116 CHECK CELL 1 X 10 A4467 270 53.69 37.583 1.21 5.57 2.84 1.21 4.18 1.21 2.84 2.84 2.84 2.84 1.21 1.331 1.21 1.21 1.21 1.21 1.2342 1.21 8600 Hos Central Supply Facility Fee 50159 CHEM II CALIBRATOR H8600 270 32.58 22.805999999999997 11.39 52.39 26.69 11.39 39.29 11.39 26.69 26.69 26.69 26.69 11.39 12.529000000000002 11.39 11.39 11.39 11.39 11.6178 11.39 8600 Hos Central Supply Facility Fee 50005 CHEMISTRY 3 A4467 270 323.7 226.58999999999997 0.36 1.67 0.85 0.36 1.25 0.36 0.85 0.85 0.85 0.85 0.36 0.396 0.36 0.36 0.36 0.36 0.36719999999999997 0.36 8600 Hos Central Supply Facility Fee 831 CHEST DRAINAGE VALVE H8644 270 30.51 21.357 0.04 0.17 0.09 0.04 0.13 0.04 0.09 0.09 0.09 0.09 0.04 0.044000000000000004 0.04 0.04 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 1573 CHILDRENS STICKERS N/A 270 7.23 5.061 5.16 23.74 12.09 5.16 17.81 5.16 12.09 12.09 12.09 12.09 5.16 5.676000000000001 5.16 5.16 5.16 5.16 5.2632 5.16 8600 Hos Central Supply Facility Fee 50080 CHOC 2 AGAR A9270 270 0.2 0.13999999999999999 0.59 2.7 1.38 0.59 2.03 0.59 1.38 1.38 1.38 1.38 0.59 0.649 0.59 0.59 0.59 0.59 0.6018 0.59 8600 Hos Central Supply Facility Fee 50160 CHOL CALIBRATOR A4467 270 20.78 14.546 1.21 5.55 2.83 1.21 4.16 1.21 2.83 2.83 2.83 2.83 1.21 1.331 1.21 1.21 1.21 1.21 1.2342 1.21 8600 Hos Central Supply Facility Fee 50161 CHOL/CHOLESTEROL A4467 270 0.29 0.20299999999999999 7.33 33.71 17.17 7.33 25.28 7.33 17.17 17.17 17.17 17.17 7.33 8.063 7.33 7.33 7.33 7.33 7.4766 7.33 8600 Hos Central Supply Facility Fee 105 CHOLANGIOGRAPHY SET WITH BALLOON CATHETE O7206 270 85.05 59.535 0.63 2.89 1.47 0.63 2.17 0.63 1.47 1.47 1.47 1.47 0.63 0.6930000000000001 0.63 0.63 0.63 0.63 0.6426000000000001 0.63 8600 Hos Central Supply Facility Fee 113 CIDEX OPA SOLUTION GALLON D4206 270 24.01 16.807 0.32 1.49 0.76 0.32 1.12 0.32 0.76 0.76 0.76 0.76 0.32 0.35200000000000004 0.32 0.32 0.32 0.32 0.3264 0.32 8600 Hos Central Supply Facility Fee 114 CIDEX OPA TEST STRIPS D1206 270 1.32 0.9239999999999999 0.47 2.15 1.1 0.47 1.61 0.47 1.1 1.1 1.1 1.1 0.47 0.517 0.47 0.47 0.47 0.47 0.4794 0.47 8600 Hos Central Supply Facility Fee 103 CIRCUIT 40 INCH ELBOW FXY 3LITER BAG SAMPLE R1206 270 1.95 1.365 0.34 1.56 0.79 0.34 1.17 0.34 0.79 0.79 0.79 0.79 0.34 0.37400000000000005 0.34 0.34 0.34 0.34 0.34680000000000005 0.34 8600 Hos Central Supply Facility Fee 86 CIRCUIT ANES O2 ADAPTER 22 MM ID X 6 MM OD R4206 270 0.78 0.5459999999999999 0.83 3.8 1.94 0.83 2.85 0.83 1.94 1.94 1.94 1.94 0.83 0.913 0.83 0.83 0.83 0.83 0.8466 0.83 8600 Hos Central Supply Facility Fee 50048 CIRCUIT RESP PV 8FT ADULT A4467 270 6.88 4.816 0.81 3.71 1.89 0.81 2.78 0.81 1.89 1.89 1.89 1.89 0.81 0.8910000000000001 0.81 0.81 0.81 0.81 0.8262 0.81 8600 Hos Central Supply Facility Fee 50162 CITROL 1/20X 1ML I8688 270 23.51 16.457 2.99 13.75 7 2.99 10.31 2.99 7 7 7 7 2.99 3.2890000000000006 2.99 2.99 2.99 2.99 3.0498000000000003 2.99 8600 Hos Central Supply Facility Fee 50163 CITROL 3/20X 1ML I8688 270 23.51 16.457 54.8 252.05 128.39 54.8 189.04 54.8 128.39 128.39 128.39 128.39 54.8 60.28 54.8 54.8 54.8 54.8 55.896 54.8 8600 Hos Central Supply Facility Fee 50426 CLAMP METER 600A A4356 270 197.96 138.572 0.4 1.83 0.93 0.4 1.37 0.4 0.93 0.93 0.93 0.93 0.4 0.44000000000000006 0.4 0.4 0.4 0.4 0.40800000000000003 0.4 8600 Hos Central Supply Facility Fee 248 CLEANER STRL ELECT SURGICAL CAUTERY TIP E8206 270 0.58 0.40599999999999997 0.47 2.14 1.09 0.47 1.61 0.47 1.09 1.09 1.09 1.09 0.47 0.517 0.47 0.47 0.2 0.2 0.20400000000000001 0.2 8600 Hos Central Supply Facility Fee 829 CLEANSING ENEMA SET A4467 270 0.79 0.5529999999999999 0.06 0.26 0.13 0.06 0.2 0.06 0.13 0.13 0.13 0.13 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 1519 CLEAR VUE D RING BINDER A4467 270 5.07 3.549 0.43 1.96 1 0.43 1.47 0.43 1 1 1 1 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 8600 Hos Central Supply Facility Fee 50081 CLINDAMYCIN 1 CART 2 MCG A4467 270 21.06 14.741999999999997 3.25 14.97 7.63 3.25 11.23 3.25 7.63 7.63 7.63 7.63 3.25 3.575 3.25 3.25 3.25 3.25 3.315 3.25 8600 Hos Central Supply Facility Fee 91 CLIP APPLIER PREMIUM SURGICLIP L-13.0 IN I3206 270 172.93 121.051 0.05 0.25 0.13 0.05 0.19 0.05 0.13 0.13 0.13 0.13 0.05 0.05500000000000001 0.05 0.05 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 45 CLIP ENDO 5MM APPLIER SINGLE USE 44799 270 513.7 359.59000000000003 0.49 2.27 1.16 0.49 1.7 0.49 1.16 1.16 1.16 1.16 0.49 0.539 0.49 0.49 0.49 0.49 0.4998 0.49 8600 Hos Central Supply Facility Fee 96 CLIP ENDO II ML 10 MM PISTOL A9270 270 337.21 236.04699999999997 0.03 0.15 0.08 0.03 0.11 0.03 0.08 0.08 0.08 0.08 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 1318 CLIPPER NAIL FINGER NO FILE A4649 270 9.73 6.811 0.59 2.72 1.39 0.59 2.04 0.59 1.39 1.39 1.39 1.39 0.59 0.649 0.59 0.59 0.59 0.59 0.6018 0.59 8600 Hos Central Supply Facility Fee 1317 CLIPPER NAIL STRAIGHT JAW 2 SPRING SS 5 A4649 270 24.43 17.101 0.6 2.74 1.4 0.6 2.06 0.6 1.4 1.4 1.4 1.4 0.6 0.66 0.6 0.6 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 1319 CLIPPER NAIL TOE NO FILE LARGE A4649 270 12.79 8.953 0.03 0.13 0.07 0.03 0.1 0.03 0.07 0.07 0.07 0.07 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 118 CLIPPER SURGICAL DISPOSABLE SINGLE USE SINGLE USE I2206 270 2.31 1.617 0.18 0.85 0.43 0.18 0.64 0.18 0.43 0.43 0.43 0.43 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 452 CLOSURE SKIN STERI-STRIP 1/4X4 REINFORCED A4450 270 1.09 0.763 0.06 0.28 0.14 0.06 0.21 0.06 0.14 0.14 0.14 0.14 0.06 0.066 0.06 0.06 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 451 CLOSURE SKIN STERI-STRIP 1/8X3 REINFORCED A4450 270 0.55 0.385 0.11 0.49 0.25 0.11 0.37 0.11 0.25 0.25 0.25 0.25 0.11 0.12100000000000001 0.11 0.11 0.11 0.11 0.11220000000000001 0.11 8600 Hos Central Supply Facility Fee 448 CLOSURE SKIN STERI-STRIP ANTIMICROBIAL IDOPHOR 1/2X4 12001 270 0.87 0.609 0.17 0.8 0.41 0.17 0.6 0.17 0.41 0.41 0.41 0.41 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 447 CLOSURE SKIN STERI-STRIP ANTIMICROBIAL IDOPHOR 1/4X4 12001 270 0.87 0.609 0.19 0.86 0.44 0.19 0.65 0.19 0.44 0.44 0.44 0.44 0.19 0.20900000000000002 0.19 0.19 0.19 0.19 0.1938 0.19 8600 Hos Central Supply Facility Fee 449 CLOSURE SKIN STERI-STRIP ANTIMICROBIAL IDOPHOR 1X5 12001 270 1.74 1.218 0.04 0.17 0.09 0.04 0.13 0.04 0.09 0.09 0.09 0.09 0.04 0.044000000000000004 0.04 0.04 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 1161 COBAN LF WRAP O8699 270 46.3 32.41 0.08 0.37 0.19 0.08 0.28 0.08 0.19 0.19 0.19 0.19 0.08 0.08800000000000001 0.08 0.08 0.08 0.08 0.0816 0.08 8600 Hos Central Supply Facility Fee 173 COLLAR CALIFORNIA 4.25 IN LRG L9206 270 9.22 6.454 0.62 2.83 1.44 0.62 2.12 0.62 1.44 1.44 1.44 1.44 0.62 0.682 0.62 0.62 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 176 COLLAR CERVICAL LOW CONTOUR LRG L1206 270 4.83 3.381 0.05 0.25 0.13 0.05 0.19 0.05 0.13 0.13 0.13 0.13 0.05 0.05500000000000001 0.05 0.05 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 175 COLLAR CERVICAL LOW CONTOUR MED L1206 270 4.83 3.381 1.84 8.46 4.31 1.84 6.35 1.84 4.31 4.31 4.31 4.31 1.84 2.0240000000000005 1.84 1.84 1.84 1.84 1.8768 1.84 8600 Hos Central Supply Facility Fee 174 COLLAR CERVICAL LOW CONTOUR SM L1206 270 4.83 3.381 0.08 0.37 0.19 0.08 0.28 0.08 0.19 0.19 0.19 0.19 0.08 0.08800000000000001 0.08 0.08 0.08 0.08 0.0816 0.08 8600 Hos Central Supply Facility Fee 346 COLLAR FORM FIT CERVICAL MEDIUM C1776 270 3.06 2.142 0.08 0.38 0.19 0.08 0.29 0.08 0.19 0.19 0.19 0.19 0.08 0.08800000000000001 0.08 0.08 0.08 0.08 0.0816 0.08 8600 Hos Central Supply Facility Fee 345 COLLAR FORM FIT CERVICAL SMALL C1776 270 3.06 2.142 0.12 0.56 0.29 0.12 0.42 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 1825 COLLECTION, BLOOD NEEDLE TUBE HOLDER A4467 270 12.3 8.61 1.81 8.32 4.24 1.81 6.24 1.81 4.24 4.24 4.24 4.24 1.81 1.9910000000000003 1.81 1.81 1.81 1.81 1.8462 1.81 8600 Hos Central Supply Facility Fee 1810 COLLECTOR URINE PEDIATRIC O8644 270 28.94 20.258 1.95 8.99 4.58 1.95 6.74 1.95 4.58 4.58 4.58 4.58 1.95 2.145 1.95 1.95 1.95 1.95 1.9889999999999999 1.95 8600 Hos Central Supply Facility Fee 931 COMB LARGE HANDLE BLACK A4467 270 0.13 0.091 0.04 0.18 0.09 0.04 0.14 0.04 0.09 0.09 0.09 0.09 0.04 0.044000000000000004 0.04 0.04 1.87 1.87 1.9074000000000002 1.87 8600 Hos Central Supply Facility Fee 582 COMB,BLACK,5 A4467 270 2.83 1.9809999999999999 0.03 0.12 0.06 0.03 0.09 0.03 0.06 0.06 0.06 0.06 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 1398 COMPAT REPLACEMENT BALLON GASTROSOTOMY 20FR A4467 270 37 25.9 0.09 0.4 0.2 0.09 0.3 0.09 0.2 0.2 0.2 0.2 0.09 0.099 0.09 0.09 0.09 0.09 0.09179999999999999 0.09 8600 Hos Central Supply Facility Fee 1465 COMPOSITIION BOOK N/A 270 0.75 0.5249999999999999 0.03 0.13 0.07 0.03 0.1 0.03 0.07 0.07 0.07 0.07 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 1838 CONNECTOR ALUMINUM FEMALE LEUR A4467 270 0.56 0.392 0.04 0.19 0.1 0.04 0.14 0.04 0.1 0.1 0.1 0.1 0.04 0.044000000000000004 0.04 0.04 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 502 CONNECTOR CF 22 MM ID BOTH ENDS N0206 270 0.33 0.23099999999999998 0.01 0.05 0.03 0.01 0.04 0.01 0.03 0.03 0.03 0.03 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 501 CONNECTOR OXYGEN TUBING F/2 N2206 270 0.08 0.055999999999999994 0.1 0.48 0.24 0.1 0.36 0.1 0.24 0.24 0.24 0.24 0.1 0.11000000000000001 0.1 0.1 0.1 0.1 0.10200000000000001 0.1 8600 Hos Central Supply Facility Fee 224 CONNECTOR TUBING FEMALE LUER ADAPTER N9206 270 0.62 0.434 0.16 0.74 0.38 0.16 0.56 0.16 0.38 0.38 0.38 0.38 0.16 0.17600000000000002 0.16 0.16 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 50362 CONTAINER 1 QT SHARPS N/A 270 174.34 122.038 0.26 1.19 0.61 0.26 0.89 0.26 0.61 0.61 0.61 0.61 0.26 0.28600000000000003 0.26 0.26 0.26 0.26 0.2652 0.26 8600 Hos Central Supply Facility Fee 1710 CONTAINER SHARPS 1 QT RED PHLEB A4467 270 117.77 82.439 0.79 3.62 1.84 0.79 2.72 0.79 1.84 1.84 1.84 1.84 0.79 0.8690000000000001 0.79 0.79 0.79 0.79 0.8058000000000001 0.79 8600 Hos Central Supply Facility Fee 50592 CONTAINER SHARPS 18 GAL RED, PORT PG11 N/A 270 152.77 106.93900000000001 0.76 3.51 1.79 0.76 2.63 0.76 1.79 1.79 1.79 1.79 0.76 0.8360000000000001 0.76 0.76 0.76 0.76 0.7752 0.76 8600 Hos Central Supply Facility Fee 50060 CONTAINER SHARPS 5 QT RED A4467 270 2.79 1.9529999999999998 0.55 2.52 1.28 0.55 1.89 0.55 1.28 1.28 1.28 1.28 0.55 0.6050000000000001 0.55 0.55 0.55 0.55 0.561 0.55 8600 Hos Central Supply Facility Fee 50061 CONTAINER SHARPS RED SLIDE LID DISP 18 GL A4467 270 17.03 11.921 4.59 21.13 10.76 4.59 15.85 4.59 10.76 10.76 10.76 10.76 4.59 5.049 4.59 4.59 4.59 4.59 4.6818 4.59 8600 Hos Central Supply Facility Fee 1083 CONTROL SOLUTION 1 STATSTRIP A4467 270 5.25 3.675 4.24 19.51 9.94 4.24 14.63 4.24 9.94 9.94 9.94 9.94 4.24 4.664000000000001 4.24 4.24 4.24 4.24 4.324800000000001 4.24 8600 Hos Central Supply Facility Fee 1084 CONTROL SOLUTION 3, STATSTRIP A4467 270 5.25 3.675 0.07 0.31 0.16 0.07 0.23 0.07 0.16 0.16 0.16 0.16 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 596 COTTON BALL,MEDIUM,1,NS,200/BG,4000/CS A4467 270 0.05 0.034999999999999996 5.19 23.89 12.17 5.19 17.92 5.19 12.17 12.17 12.17 12.17 5.19 5.7090000000000005 5.19 5.19 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 50281 COTTON METERED AIR FRESHNER A4467 270 4.81 3.3669999999999995 0.85 3.9 1.99 0.85 2.93 0.85 1.99 1.99 1.99 1.99 0.85 0.935 0.85 0.85 0.85 0.85 0.867 0.85 8600 Hos Central Supply Facility Fee 50688 COVER LINEN CART N/A 270 65.51 45.857 1.21 5.58 2.84 1.21 4.19 1.21 2.84 2.84 2.84 2.84 1.21 1.331 1.21 1.21 1.21 1.21 1.2342 1.21 8600 Hos Central Supply Facility Fee 1389 COVER PROBE ENDOCAVITY O8622 270 155.32 108.72399999999999 0.44 2.04 1.04 0.44 1.53 0.44 1.04 1.04 1.04 1.04 0.44 0.48400000000000004 0.44 0.44 0.44 0.44 0.44880000000000003 0.44 8600 Hos Central Supply Facility Fee 486 COVER SEAT 1/2 FOLD SAFE T GUARD WHITE V7206 270 1.83 1.281 0.07 0.34 0.17 0.07 0.26 0.07 0.17 0.17 0.17 0.17 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 50661 COVER SHOENONSKID BLUE REG/LG N/A 270 15.16 10.612 1.26 5.79 2.95 1.26 4.34 1.26 2.95 2.95 2.95 2.95 1.26 1.3860000000000001 1.26 1.26 1.26 1.26 1.2852000000000001 1.26 8600 Hos Central Supply Facility Fee 1857 COVER, PROBE FASTEMP O8611 270 29.27 20.488999999999997 6.68 30.73 15.65 6.68 23.05 6.68 15.65 15.65 15.65 15.65 6.68 7.348 6.68 6.68 6.68 6.68 6.8136 6.68 8600 Hos Central Supply Facility Fee 50011 C-REACTIVE PROTEIN-QUANTITATIVE A4467 270 120.35 84.24499999999999 0.65 2.99 1.52 0.65 2.24 0.65 1.52 1.52 1.52 1.52 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 8600 Hos Central Supply Facility Fee 50165 CRP/C-REACTIVE PROTEIN A9270 270 29.8 20.86 0.33 1.53 0.78 0.33 1.15 0.33 0.78 0.78 0.78 0.78 0.33 0.36300000000000004 0.33 0.33 0.33 0.33 0.3366 0.33 8600 Hos Central Supply Facility Fee 50015 CSF & BODY FLUID ANAYSIS A4467 270 232.4 162.68 0.07 0.33 0.17 0.07 0.25 0.07 0.17 0.17 0.17 0.17 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 50728 CUBE TRUCK 20.0 CU FT N/A 270 285.03 199.52099999999996 0.63 2.89 1.47 0.63 2.17 0.63 1.47 1.47 1.47 1.47 0.63 0.6930000000000001 0.63 0.63 0.63 0.63 0.6426000000000001 0.63 8600 Hos Central Supply Facility Fee 50316 CUBICLE TRACK N/A 270 356.2 249.33999999999997 6.76 31.08 15.83 6.76 23.31 6.76 15.83 15.83 15.83 15.83 6.76 7.436 6.76 6.76 6.76 6.76 6.8952 6.76 8600 Hos Central Supply Facility Fee 1650 CUFF ADULT 1 TUBE A4467 270 0.8 0.5599999999999999 0.17 0.8 0.41 0.17 0.6 0.17 0.41 0.41 0.41 0.41 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 1651 CUFF ADULT 1 TUBE A4467 270 26.82 18.773999999999997 0.12 0.57 0.29 0.12 0.43 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 1636 CUFF BLADDER ADLT. 1 TUBE A4467 270 24.08 16.855999999999998 1.01 4.65 2.37 1.01 3.49 1.01 2.37 2.37 2.37 2.37 1.01 1.1110000000000002 1.01 1.01 1.01 1.01 1.0302 1.01 8600 Hos Central Supply Facility Fee 1638 CUFF BLADDER SM/ADLT 1 TUBE A4467 270 24.08 16.855999999999998 1.01 4.65 2.37 1.01 3.49 1.01 2.37 2.37 2.37 2.37 1.01 1.1110000000000002 1.01 1.01 1.01 1.01 1.0302 1.01 8600 Hos Central Supply Facility Fee 1642 CUFF BLADDER SM/ADLT 1 TUBE A4467 270 20.95 14.665 0.1 0.47 0.24 0.1 0.35 0.1 0.24 0.24 0.24 0.24 0.1 0.11000000000000001 0.1 0.1 0.1 0.1 0.10200000000000001 0.1 8600 Hos Central Supply Facility Fee 1042 CUFF BP THIGH L3730 270 21.41 14.986999999999998 0 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1648 CUFF LARGE ADULT 1 TUBE A4467 270 40.33 28.230999999999998 0.24 1.09 0.56 0.24 0.82 0.24 0.56 0.56 0.56 0.56 0.24 0.264 0.24 0.24 0.24 0.24 0.2448 0.24 8600 Hos Central Supply Facility Fee 1640 CUFF OMNI XL/ADLT 1 TUBE A4467 270 30.1 21.07 0.07 0.33 0.17 0.07 0.25 0.07 0.17 0.17 0.17 0.17 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 1649 CUFF THIGH 1 TUBE A4467 270 38.41 26.886999999999997 0.01 0.04 0.02 0.01 0.03 0.01 0.02 0.02 0.02 0.02 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1619 CUFF TWICE AS TOUGH ANKLE Q/R STRAPS A4467 270 23.08 16.156 0.21 0.96 0.49 0.21 0.72 0.21 0.49 0.49 0.49 0.49 0.21 0.231 0.21 0.21 0.21 0.21 0.2142 0.21 8600 Hos Central Supply Facility Fee 1620 CUFF TWICE AS TOUGH WRIST Q/R STRAPS A4467 270 22.78 15.946 6.83 31.42 16.01 6.83 23.57 6.83 16.01 16.01 16.01 16.01 6.83 7.513000000000001 6.83 6.83 6.83 6.83 6.966600000000001 6.83 8600 Hos Central Supply Facility Fee 1385 CUFF W/NEOPRENE ER GURNEY A4467 270 42.13 29.491 0.88 4.03 2.05 0.88 3.02 0.88 2.05 2.05 2.05 2.05 0.88 0.9680000000000001 0.88 0.88 0.88 0.88 0.8976000000000001 0.88 8600 Hos Central Supply Facility Fee 1639 CUFF, OMNI LG/ADLT 1 TUBE A4467 270 41.9 29.33 0.84 3.86 1.97 0.84 2.9 0.84 1.97 1.97 1.97 1.97 0.84 0.924 0.84 0.84 0.84 0.84 0.8568 0.84 8600 Hos Central Supply Facility Fee 1420 CUFFS WRIST TWICE AS TOUGH A4467 270 23.05 16.134999999999998 3.69 16.99 8.65 3.69 12.74 3.69 8.65 8.65 8.65 8.65 3.69 4.059 3.69 3.69 3.69 3.69 3.7638 3.69 8600 Hos Central Supply Facility Fee 50082 CULT TUBE DISP 12 X 75 75 MM A4467 270 0.08 0.055999999999999994 3.25 14.97 7.63 3.25 11.23 3.25 7.63 7.63 7.63 7.63 3.25 3.575 3.25 3.25 3.25 3.25 3.315 3.25 8600 Hos Central Supply Facility Fee 861 CURAD BANDAIDS 2 X 4 A4467 270 2.63 1.8409999999999997 0.36 1.66 0.85 0.36 1.25 0.36 0.85 0.85 0.85 0.85 0.36 0.396 0.36 0.36 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 1575 CURETTE WHITE FLEXLOOP EAR A4467 270 41.32 28.924 3.41 15.67 7.98 3.41 11.75 3.41 7.98 7.98 7.98 7.98 3.41 3.7510000000000003 3.41 3.41 3.41 3.41 3.4782 3.41 8600 Hos Central Supply Facility Fee 50168 CUVETTE CARTRDIGE (1 X 12000/PK) A4467 270 135.35 94.74499999999999 0.03 0.15 0.08 0.03 0.11 0.03 0.08 0.08 0.08 0.08 0.03 0.033 0.03 0.03 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 50084 CUVETTES HB 201 A4467 270 1.7 1.19 3.41 15.67 7.98 3.41 11.75 3.41 7.98 7.98 7.98 7.98 3.41 3.7510000000000003 3.41 3.41 3.41 3.41 3.4782 3.41 8600 Hos Central Supply Facility Fee 66 CYSTO PACK, TIBURION A4649 270 4.74 3.318 5.44 25.01 12.74 5.44 18.76 5.44 12.74 12.74 12.74 12.74 5.44 5.984000000000001 5.44 5.44 5.44 5.44 5.548800000000001 5.44 8600 Hos Central Supply Facility Fee 100 CYSTO SET CYSTO TWR S3206 270 4.55 3.1849999999999996 12.08 55.58 28.31 12.08 41.69 12.08 28.31 28.31 28.31 28.31 12.08 13.288000000000002 12.08 12.08 12.08 12.08 12.3216 12.08 8600 Hos Central Supply Facility Fee 50250 DBI A4467 270 3.01 2.1069999999999998 0.65 3.01 1.53 0.65 2.26 0.65 1.53 1.53 1.53 1.53 0.65 0.7150000000000001 0.65 0.65 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 642 DBIL/DIRECT BILIRUBIN A4467 270 0.29 0.20299999999999999 1.07 4.93 2.51 1.07 3.7 1.07 2.51 2.51 2.51 2.51 1.07 1.1770000000000003 1.07 1.07 1.07 1.07 1.0914000000000001 1.07 8600 Hos Central Supply Facility Fee 50169 DBIL/DIRECT BILIRUBIN A4467 270 30.72 21.503999999999998 0.76 3.49 1.78 0.76 2.62 0.76 1.78 1.78 1.78 1.78 0.76 0.8360000000000001 0.76 0.76 0.76 0.76 0.7752 0.76 8600 Hos Central Supply Facility Fee 50016 D-DIMER- QUANTITATIVE A4467 270 124.5 87.14999999999999 0.17 0.78 0.4 0.17 0.59 0.17 0.4 0.4 0.4 0.4 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 50085 DEIONIZED WATER LABCRAFT 5 GAL A4467 270 25.46 17.822 0.47 2.16 1.1 0.47 1.62 0.47 1.1 1.1 1.1 1.1 0.47 0.517 0.47 0.47 0.47 0.47 0.4794 0.47 8600 Hos Central Supply Facility Fee 865 DENTURE CUPS A4467 270 0.36 0.252 0.02 0.08 0.04 0.02 0.06 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 404 DERMABOND ADV. ADHESIVE E8666 270 33.09 23.163 0.01 0.05 0.03 0.01 0.04 0.01 0.03 0.03 0.03 0.03 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1017 DERMABOND MINI ADHESIVE G0168 270 19 13.299999999999999 0.52 2.38 1.21 0.52 1.79 0.52 1.21 1.21 1.21 1.21 0.52 0.5720000000000001 0.52 0.52 0.52 0.52 0.5304 0.52 8600 Hos Central Supply Facility Fee 1009 DEVELOPER HEMOCCULT SENSA E8666 270 57.05 39.934999999999995 0.08 0.39 0.2 0.08 0.29 0.08 0.2 0.2 0.2 0.2 0.08 0.08800000000000001 0.08 0.08 4.68 4.68 4.7736 4.68 8600 Hos Central Supply Facility Fee 816 DIAL A FLOW IV SET A4467 270 3.01 2.1069999999999998 0.2 0.92 0.47 0.2 0.69 0.2 0.47 0.47 0.47 0.47 0.2 0.22000000000000003 0.2 0.2 0.2 0.2 0.20400000000000001 0.2 8600 Hos Central Supply Facility Fee 50384 DIGESTER ENZYME RTU N/A 270 29.14 20.398 0.84 3.88 1.98 0.84 2.91 0.84 1.98 1.98 1.98 1.98 0.84 0.924 0.84 0.84 0.84 0.84 0.8568 0.84 8600 Hos Central Supply Facility Fee 50386 DIGITAL CAMERA VIVITAR F128 N/A 270 39.99 27.993 0.39 1.81 0.92 0.39 1.36 0.39 0.92 0.92 0.92 0.92 0.39 0.42900000000000005 0.39 0.39 0.39 0.39 0.39780000000000004 0.39 8600 Hos Central Supply Facility Fee 50170 DIM IBCT FLEX REAGENT A4467 270 87.52 61.263999999999996 4.12 18.94 9.65 4.12 14.21 4.12 9.65 9.65 9.65 9.65 4.12 4.532000000000001 4.12 4.12 4.12 4.12 4.2024 4.12 8600 Hos Central Supply Facility Fee 50171 DIM PHNO FLEX I8611 270 103.68 72.576 3.39 15.59 7.94 3.39 11.69 3.39 7.94 7.94 7.94 7.94 3.39 3.7290000000000005 3.39 3.39 3.39 3.39 3.4578 3.39 8600 Hos Central Supply Facility Fee 50172 DIMENSION ALT (GPT) A9270 270 0.29 0.20299999999999999 5.16 23.74 12.09 5.16 17.81 5.16 12.09 12.09 12.09 12.09 5.16 5.676000000000001 5.16 5.16 5.16 5.16 5.2632 5.16 8600 Hos Central Supply Facility Fee 50179 DIMENSION ALT (GPT) A9270 270 12.48 8.735999999999999 1.42 6.53 3.33 1.42 4.9 1.42 3.33 3.33 3.33 3.33 1.42 1.562 1.42 1.42 1.42 1.42 1.4484 1.42 8600 Hos Central Supply Facility Fee 50173 DIMENSION AST (GOT) A9270 270 0.29 0.20299999999999999 1.7 7.82 3.98 1.7 5.87 1.7 3.98 3.98 3.98 3.98 1.7 1.87 1.7 1.7 1.7 1.7 1.734 1.7 8600 Hos Central Supply Facility Fee 50180 DIMENSION AST (GOT) A9270 270 18.72 13.104 0.11 0.5 0.25 0.11 0.38 0.11 0.25 0.25 0.25 0.25 0.11 0.12100000000000001 0.11 0.11 0.11 0.11 0.11220000000000001 0.11 8600 Hos Central Supply Facility Fee 50174 DIMENSION CL CPRR BILLING A4467 270 0.13 0.091 1.89 8.7 4.43 1.89 6.53 1.89 4.43 4.43 4.43 4.43 1.89 2.079 1.89 1.89 1.89 1.89 1.9278 1.89 8600 Hos Central Supply Facility Fee 50178 DIMENSION ENZYME CALIBRATOR I8644 270 49.36 34.552 1.35 6.19 3.15 1.35 4.64 1.35 3.15 3.15 3.15 3.15 1.35 1.4850000000000003 1.35 1.35 1.35 1.35 1.3770000000000002 1.35 8600 Hos Central Supply Facility Fee 50175 DIMENSION K CPRR BILLING A4467 270 0.13 0.091 0.48 2.22 1.13 0.48 1.67 0.48 1.13 1.13 1.13 1.13 0.48 0.528 0.48 0.48 0.48 0.48 0.4896 0.48 8600 Hos Central Supply Facility Fee 50177 DIMENSION LDH IFCC I8677 270 50.4 35.279999999999994 0.48 2.22 1.13 0.48 1.67 0.48 1.13 1.13 1.13 1.13 0.48 0.528 0.48 0.48 0.48 0.48 0.4896 0.48 8600 Hos Central Supply Facility Fee 50176 DIMENSION NA CPRR BILLING A4467 270 0.13 0.091 0.48 2.22 1.13 0.48 1.67 0.48 1.13 1.13 1.13 1.13 0.48 0.528 0.48 0.48 0.48 0.48 0.4896 0.48 8600 Hos Central Supply Facility Fee 50086 DISC ERYTHROMYCIN A4467 270 0.29 0.20299999999999999 0.48 2.19 1.12 0.48 1.64 0.48 1.12 1.12 1.12 1.12 0.48 0.528 0.48 0.48 0.1 0.1 0.10200000000000001 0.1 8600 Hos Central Supply Facility Fee 73 DISCS SODASORB-WR GRACE S7206 270 5.96 4.172 0.1 0.45 0.23 0.1 0.34 0.1 0.23 0.23 0.23 0.23 0.1 0.11000000000000001 0.1 0.1 0.77 0.77 0.7854 0.77 8600 Hos Central Supply Facility Fee 50069 DISP PEEP VALVE 0-20 CM 22 MM W/22 MM ADPT A4467 270 3.5 2.4499999999999997 8.85 40.72 20.74 8.85 30.54 8.85 20.74 20.74 20.74 20.74 8.85 9.735000000000001 8.85 8.85 8.85 8.85 9.027 8.85 8600 Hos Central Supply Facility Fee 50181 DM AHDL CAL M8699 270 20.78 14.546 70.37 323.7 164.89 70.37 242.78 70.37 164.89 164.89 164.89 164.89 70.37 77.40700000000001 70.37 70.37 6.41 6.41 6.538200000000001 6.41 8600 Hos Central Supply Facility Fee 50182 DM AHDL FLEX REAGENT A4467 270 2.2 1.54 46.92 215.8 109.93 46.92 161.85 46.92 109.93 109.93 109.93 109.93 46.92 51.61200000000001 46.92 46.92 46.92 46.92 47.8584 46.92 8600 Hos Central Supply Facility Fee 50183 DM AHDL FLEX REAGENT A4467 270 83.04 58.128 51.43 236.55 120.5 51.43 177.41 51.43 120.5 120.5 120.5 120.5 51.43 56.57300000000001 51.43 51.43 51.43 51.43 52.458600000000004 51.43 8600 Hos Central Supply Facility Fee 50184 DM CKI FLEX REAGENT A4467 270 0.29 0.20299999999999999 30.68 141.1 71.88 30.68 105.83 30.68 71.88 71.88 71.88 71.88 30.68 33.748000000000005 30.68 30.68 30.68 30.68 31.2936 30.68 8600 Hos Central Supply Facility Fee 50185 DM DRUG CALIBRATOR M8600 270 120.93 84.651 68.57 315.4 160.66 68.57 236.55 68.57 160.66 160.66 160.66 160.66 68.57 75.42699999999999 68.57 68.57 68.57 68.57 69.94139999999999 68.57 8600 Hos Central Supply Facility Fee 50186 DM IBCT CALIB 2 SETS/3 LEVELS/1 ML A4467 270 24.18 16.926 8.12 37.35 19.03 8.12 28.01 8.12 19.03 19.03 19.03 19.03 8.12 8.932 8.12 8.12 8.12 8.12 8.282399999999999 8.12 8600 Hos Central Supply Facility Fee 50187 DM IRON REVISED IRON A4467 270 59.59 41.713 26.16 120.35 61.31 26.16 90.26 26.16 61.31 61.31 61.31 61.31 26.16 28.776000000000003 26.16 26.16 26.16 26.16 26.6832 26.16 8600 Hos Central Supply Facility Fee 50188 DM LIPL CALS 2 LEVELS A4467 270 37 25.9 24.36 112.05 57.08 24.36 84.04 24.36 57.08 57.08 57.08 57.08 24.36 26.796000000000003 24.36 24.36 24.36 24.36 24.8472 24.36 8600 Hos Central Supply Facility Fee 50189 DM LIPL FLEX REAGENT A4467 270 2.2 1.54 43.31 199.2 101.47 43.31 149.4 43.31 101.47 101.47 101.47 101.47 43.31 47.641000000000005 43.31 43.31 43.31 43.31 44.1762 43.31 8600 Hos Central Supply Facility Fee 50190 DM LIPL FLEX REAGENT A4467 270 43.76 30.631999999999998 29.77 136.95 69.76 29.77 102.71 29.77 69.76 69.76 69.76 69.76 29.77 32.747 29.77 29.77 29.77 29.77 30.3654 29.77 8600 Hos Central Supply Facility Fee 50191 DM REVISED GLUCOSE GLUC FLEX 1400 A4467 270 0.29 0.20299999999999999 50.52 232.4 118.38 50.52 174.3 50.52 118.38 118.38 118.38 118.38 50.52 55.57200000000001 50.52 50.52 50.52 50.52 51.53040000000001 50.52 8600 Hos Central Supply Facility Fee 50192 DM REVISED GLUCOSE GLUC FLEX 1400 A4467 270 74.88 52.416 27.07 124.5 63.42 27.07 93.38 27.07 63.42 63.42 63.42 63.42 27.07 29.777 27.07 27.07 27.07 27.07 27.6114 27.07 8600 Hos Central Supply Facility Fee 50193 DM REVISED IRON CALIBRATOR A4467 270 20.09 14.062999999999999 31.58 145.25 73.99 31.58 108.94 31.58 73.99 73.99 73.99 73.99 31.58 34.738 31.58 31.58 31.58 31.58 32.2116 31.58 8600 Hos Central Supply Facility Fee 460 DRAINAGE CHEST PLEUR-EVAC NDLSS 6EA/CS VALVE SAHARA AND WATER S-1150-08LF A0609 270 52.39 36.672999999999995 27.07 124.5 63.42 27.07 93.38 27.07 63.42 63.42 63.42 63.42 27.07 29.777 27.07 27.07 27.07 27.07 27.6114 27.07 8600 Hos Central Supply Facility Fee 1435 DRAPE SHEET A4467 270 20.43 14.300999999999998 15.34 70.55 35.94 15.34 52.91 15.34 35.94 35.94 35.94 35.94 15.34 16.874000000000002 15.34 15.34 15.34 15.34 15.6468 15.34 8600 Hos Central Supply Facility Fee 48 DRESSING AQUACEL 4IN X 4IN HYDROFIBER A6324 270 3.2 2.2399999999999998 19.85 91.3 46.51 19.85 68.48 19.85 46.51 46.51 46.51 46.51 19.85 21.835000000000004 19.85 19.85 19.85 19.85 20.247000000000003 19.85 8600 Hos Central Supply Facility Fee 49 DRESSING DUODERM 4IN X 4IN A6324 270 2.58 1.8059999999999998 39.7 182.6 93.02 39.7 136.95 39.7 93.02 93.02 93.02 93.02 39.7 43.67000000000001 39.7 39.7 39.7 39.7 40.49400000000001 39.7 8600 Hos Central Supply Facility Fee 1716 DRESSING GAUZE PETROLATUM CURAD 3 X 9 A4467 270 19.69 13.783 48.72 224.1 114.16 48.72 168.08 48.72 114.16 114.16 114.16 114.16 48.72 53.592000000000006 48.72 48.72 48.72 48.72 49.6944 48.72 8600 Hos Central Supply Facility Fee 1717 DRESSING GAUZE XEROFORM 5 X 9 A4467 270 27.44 19.208 26.16 120.35 61.31 26.16 90.26 26.16 61.31 61.31 61.31 61.31 26.16 28.776000000000003 26.16 26.16 26.16 26.16 26.6832 26.16 8600 Hos Central Supply Facility Fee 148 DRESSING LITE 4 X 4IN 10 X 10 CM MEPILEX E8206 270 0.27 0.189 31.35 144.19 73.45 31.35 108.14 31.35 73.45 73.45 73.45 73.45 31.35 34.48500000000001 31.35 31.35 31.35 31.35 31.977 31.35 8600 Hos Central Supply Facility Fee 986 DRESSING MAXORB 4 X 4 A4649 270 28.47 19.929 5.58 25.67 13.08 5.58 19.25 5.58 13.08 13.08 13.08 13.08 5.58 6.138000000000001 5.58 5.58 5.58 5.58 5.6916 5.58 8600 Hos Central Supply Facility Fee 987 DRESSING MAXORB 4 X 8 A4649 270 24.14 16.898 25.28 116.28 59.23 25.28 87.21 25.28 59.23 59.23 59.23 59.23 25.28 27.808000000000003 25.28 25.28 25.28 25.28 25.785600000000002 25.28 8600 Hos Central Supply Facility Fee 988 DRESSING OPTIFOAM 4 X 4 A4649 270 22.44 15.708 25.28 116.28 59.23 25.28 87.21 25.28 59.23 59.23 59.23 59.23 25.28 27.808000000000003 25.28 25.28 25.28 25.28 25.785600000000002 25.28 8600 Hos Central Supply Facility Fee 989 DRESSING OPTIFOAM 6 X 6 A4649 270 37.57 26.299 19.53 89.82 45.75 19.53 67.37 19.53 45.75 45.75 45.75 45.75 19.53 21.483000000000004 19.53 19.53 19.53 19.53 19.9206 19.53 8600 Hos Central Supply Facility Fee 442 DRESSING TEGADERM LATEX FREE TRANSPARENT ORG FRAME 4X4-3/4 IN A4649 270 0.72 0.504 13.95 64.16 32.68 13.95 48.12 13.95 32.68 32.68 32.68 32.68 13.95 15.345 13.95 13.95 13.95 13.95 14.229 13.95 8600 Hos Central Supply Facility Fee 441 DRESSING TEGADERM LATEX FREE TRANSPRNT PICTURE FRAME 6X7CM E6206 270 0.21 0.147 1.74 8.01 4.08 1.74 6.01 1.74 4.08 4.08 4.08 4.08 1.74 1.9140000000000001 1.74 1.74 1.74 1.74 1.7748 1.74 8600 Hos Central Supply Facility Fee 443 DRESSING TEGADERM TRAN 10X25CM E7206 270 1.18 0.826 0.17 0.77 0.39 0.17 0.58 0.17 0.39 0.39 0.39 0.39 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 444 DRESSING TEGADERM TRANSP 15X20 E2206 270 1.36 0.952 0.18 0.82 0.42 0.18 0.62 0.18 0.42 0.42 0.42 0.42 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 1735 DRESSING TEGADERM TRANSPARENT R8600 270 24.54 17.177999999999997 0.1 0.46 0.23 0.1 0.35 0.1 0.23 0.23 0.23 0.23 0.1 0.11000000000000001 0.1 0.1 0.1 0.1 0.10200000000000001 0.1 8600 Hos Central Supply Facility Fee 400 DRESSING WOUND COVADERM 4X14IN OVERALL PAD 2''''X11 E6206 270 2.12 1.484 0.12 0.57 0.29 0.12 0.43 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 615 DRESSING,EXUDERM,ODORSHIELD,4 X 4 A4206 270 1.77 1.2389999999999999 0.14 0.63 0.32 0.14 0.47 0.14 0.32 0.32 0.32 0.32 0.14 0.15400000000000003 0.14 0.14 0.14 0.14 0.1428 0.14 8600 Hos Central Supply Facility Fee 617 DRESSING,FLAT ROPE,MAXORB EXTRA AG,1X12 A4467 270 23.89 16.723 0.13 0.62 0.32 0.13 0.47 0.13 0.32 0.32 0.32 0.32 0.13 0.14300000000000002 0.13 0.13 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 614 DRESSING,OPTIFOAM,NON-ADHESIVE,4X4 A4206 270 22.95 16.064999999999998 0.12 0.53 0.27 0.12 0.4 0.12 0.27 0.27 0.27 0.27 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 50480 DWYER INSTRUMENTS PRESSURE GAUGE N/A 270 116.81 81.767 0.08 0.38 0.19 0.08 0.29 0.08 0.19 0.19 0.19 0.19 0.08 0.08800000000000001 0.08 0.08 1.5 1.5 1.53 1.5 8600 Hos Central Supply Facility Fee 50484 DWYER INSTRUMENTS PRESSURE GUAGE, 0 TO 2 IN H2O N/A 270 112.58 78.806 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 1755 DYMO LERTA TAG PLUS HAND-HELD LABEL MAKER N/A 270 25.2 17.639999999999997 0.76 3.5 1.78 0.76 2.63 0.76 1.78 1.78 1.78 1.78 0.76 0.8360000000000001 0.76 0.76 0.76 0.76 0.7752 0.76 8600 Hos Central Supply Facility Fee 1754 DYMO LETRA TAG LABEL TAPE N/A 270 12.48 8.735999999999999 0.27 1.22 0.62 0.27 0.92 0.27 0.62 0.62 0.62 0.62 0.27 0.29700000000000004 0.27 0.27 0.27 0.27 0.27540000000000003 0.27 8600 Hos Central Supply Facility Fee 407 EASY CAP II CO2 DETECTOR S7206 270 9.46 6.622 0.35 1.6 0.82 0.35 1.2 0.35 0.82 0.82 0.82 0.82 0.35 0.385 0.35 0.35 0.35 0.35 0.357 0.35 8600 Hos Central Supply Facility Fee 67 ELARGED ORTHO SPLIT SHEET, TIBURION L3260 270 5.09 3.5629999999999997 0.59 2.72 1.39 0.59 2.04 0.59 1.39 1.39 1.39 1.39 0.59 0.649 0.59 0.59 1.44 1.44 1.4687999999999999 1.44 8600 Hos Central Supply Facility Fee 240 ELECTRODE ADULT RESTING ECG RECTANGLE E0206 270 2.56 1.7919999999999998 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 241 ELECTRODE ADULT TAPE GEL SQUARE E9206 270 0.63 0.44099999999999995 5.61 25.81 13.15 5.61 19.36 5.61 13.15 13.15 13.15 13.15 5.61 6.171000000000001 5.61 5.61 5.61 5.61 5.722200000000001 5.61 8600 Hos Central Supply Facility Fee 395 ELECTRODE ADULT TAPE GEL SQUARE E6206 270 0.21 0.147 2.36 10.87 5.54 2.36 8.15 2.36 5.54 5.54 5.54 5.54 2.36 2.596 2.36 2.36 2.36 2.36 2.4072 2.36 8600 Hos Central Supply Facility Fee 1402 ELECTRODE ECG CLEAR TAPE SOLID GEL 5 A4467 270 5.94 4.158 0.08 0.38 0.19 0.08 0.29 0.08 0.19 0.19 0.19 0.19 0.08 0.08800000000000001 0.08 0.08 0.08 0.08 0.0816 0.08 8600 Hos Central Supply Facility Fee 1379 ELECTRODE ECG CLEAR TAPE SOLID GEL 50PK A4467 270 4.96 3.472 0.04 0.2 0.1 0.04 0.15 0.04 0.1 0.1 0.1 0.1 0.04 0.044000000000000004 0.04 0.04 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 1211 ELECTRODE ECG MONITORING SS SNAP TAP A4649 270 64.81 45.367 4.58 21.06 10.73 4.58 15.8 4.58 10.73 10.73 10.73 10.73 4.58 5.038 4.58 4.58 4.58 4.58 4.6716 4.58 8600 Hos Central Supply Facility Fee 252 ELECTRODE EDGE COATED NEEDLE 2.84 IN E9206 270 6.97 4.879 0.02 0.08 0.04 0.02 0.06 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 1333 ELECTRODE EDGE QUICK COMBO ADULT A4467 270 27.87 19.509 0.03 0.14 0.07 0.03 0.11 0.03 0.07 0.07 0.07 0.07 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 254 ELECTRODE INFANT REM POLYHESIVE II E9206 270 7.3 5.109999999999999 0.37 1.7 0.87 0.37 1.28 0.37 0.87 0.87 0.87 0.87 0.37 0.40700000000000003 0.37 0.37 0.37 0.37 0.3774 0.37 8600 Hos Central Supply Facility Fee 410 ELECTRODE NEEDLE MODIFIED EXTENDED E7206 270 3.75 2.625 5.54 25.46 12.97 5.54 19.1 5.54 12.97 12.97 12.97 12.97 5.54 6.094 5.54 5.54 5.54 5.54 5.6508 5.54 8600 Hos Central Supply Facility Fee 155 ELECTRODE Q-TRACE ECL 5400 E2206 270 2.63 1.8409999999999997 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 150 ELECTRODE QUICK COMBO E4206 270 25.27 17.689 1.89 8.69 4.43 1.89 6.52 1.89 4.43 4.43 4.43 4.43 1.89 2.079 1.89 1.89 1.89 1.89 1.9278 1.89 8600 Hos Central Supply Facility Fee 625 ELECTRODE QUICK COMBO ECG A4467 270 30.73 21.511 0.35 1.59 0.81 0.35 1.19 0.35 0.81 0.81 0.81 0.81 0.35 0.385 0.35 0.35 0.35 0.35 0.357 0.35 8600 Hos Central Supply Facility Fee 1334 ELECTRODE UICK COMBO ECG A4467 270 34.55 24.184999999999995 4.46 20.5 10.44 4.46 15.38 4.46 10.44 10.44 10.44 10.44 4.46 4.906000000000001 4.46 4.46 4.46 4.46 4.5492 4.46 8600 Hos Central Supply Facility Fee 1815 ELECTRODES ECG TAB 10/CARD 500/BOX A4467 270 171.21 119.847 4.46 20.5 10.44 4.46 15.38 4.46 10.44 10.44 10.44 10.44 4.46 4.906000000000001 4.46 4.46 4.46 4.46 4.5492 4.46 8600 Hos Central Supply Facility Fee 1720 ELECTRONIC BATTERY A23 12V A4467 270 1.35 0.945 7.31 33.64 17.14 7.31 25.23 7.31 17.14 17.14 17.14 17.14 7.31 8.041 7.31 7.31 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 321 ENDOTROL WITH CONTROL 9MM 36FR ENDO TUBE D3206 270 7.1 4.97 0.05 0.24 0.12 0.05 0.18 0.05 0.12 0.12 0.12 0.12 0.05 0.05500000000000001 0.05 0.05 7.31 7.31 7.4562 7.31 8600 Hos Central Supply Facility Fee 1163 ENEMA SALINE A4467 270 0.74 0.518 0.06 0.26 0.13 0.06 0.2 0.06 0.13 0.13 0.13 0.13 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 50196 ENZYMATIC CARBONATE CALIBRATOR N8666 270 24.65 17.255 0.12 0.56 0.29 0.12 0.42 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 2.58 2.58 2.6316 2.58 8600 Hos Central Supply Facility Fee 50195 ENZYMATIC CARBONATE FLEXR REA. CAR A4467 270 0.29 0.20299999999999999 0.03 0.14 0.07 0.03 0.11 0.03 0.07 0.07 0.07 0.07 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 50197 ENZYMATIC CARBONATE FLEXR REA. CAR A4467 270 18.72 13.104 0.1 0.45 0.23 0.1 0.34 0.1 0.23 0.23 0.23 0.23 0.1 0.11000000000000001 0.1 0.1 0.1 0.1 0.10200000000000001 0.1 8600 Hos Central Supply Facility Fee 50198 ENZYME VERIFER A4467 270 49.36 34.552 3.27 15.03 7.66 3.27 11.27 3.27 7.66 7.66 7.66 7.66 3.27 3.5970000000000004 3.27 3.27 3.27 3.27 3.3354 3.27 8600 Hos Central Supply Facility Fee 50260 ENZYME VERIFIER A4467 270 0.27 0.189 0.06 0.27 0.14 0.06 0.2 0.06 0.14 0.14 0.14 0.14 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 238 EPIDURAL TRAY CONT WE17G 3.5 C19 1T2673 I3206 270 22.69 15.883 11.67 53.69 27.35 11.67 40.27 11.67 27.35 27.35 27.35 27.35 11.67 12.837000000000002 11.67 11.67 11.67 11.67 11.9034 11.67 8600 Hos Central Supply Facility Fee 867 ER TELEMETRY PAPER A9270 270 2.03 1.4209999999999998 0.99 4.56 2.32 0.99 3.42 0.99 2.32 2.32 2.32 2.32 0.99 1.089 0.99 0.99 2.83 2.83 2.8866 2.83 8600 Hos Central Supply Facility Fee 50555 ESCUTCHEON 2 PIECE STEEL N/A 270 3.48 2.436 0.58 2.69 1.37 0.58 2.02 0.58 1.37 1.37 1.37 1.37 0.58 0.638 0.58 0.58 0.58 0.58 0.5916 0.58 8600 Hos Central Supply Facility Fee 219 ESTEEM STRETCHY NITRILE I BLUE L A4467 270 0.04 0.027999999999999997 0.64 2.96 1.51 0.64 2.22 0.64 1.51 1.51 1.51 1.51 0.64 0.7040000000000001 0.64 0.64 0.64 0.64 0.6528 0.64 8600 Hos Central Supply Facility Fee 217 ESTEEM STRETCHY NITRILE I BLUE M A4467 270 0.04 0.027999999999999997 0.46 2.13 1.09 0.46 1.6 0.46 1.09 1.09 1.09 1.09 0.46 0.5060000000000001 0.46 0.46 0.46 0.46 0.4692 0.46 8600 Hos Central Supply Facility Fee 215 ESTEEM STRETCHY NITRILE I BLUE S A4467 270 0.04 0.027999999999999997 0.52 2.41 1.23 0.52 1.81 0.52 1.23 1.23 1.23 1.23 0.52 0.5720000000000001 0.52 0.52 0.52 0.52 0.5304 0.52 8600 Hos Central Supply Facility Fee 221 ESTEEM STRETCHY NITRILE I BLUE XL A4467 270 0.05 0.034999999999999996 2.22 10.23 5.21 2.22 7.67 2.22 5.21 5.21 5.21 5.21 2.22 2.4420000000000006 2.22 2.22 2.22 2.22 2.2644 2.22 8600 Hos Central Supply Facility Fee 1830 ESWAB MRSA ONE FLOCK SWAB A4467 270 140.38 98.26599999999999 2.95 13.59 6.92 2.95 10.19 2.95 6.92 6.92 6.92 6.92 2.95 3.2450000000000006 2.95 2.95 2.95 2.95 3.0090000000000003 2.95 8600 Hos Central Supply Facility Fee 459 ET AGT NASAL CUFFED 3.5MM A7521 270 5.57 3.899 4.37 20.09 10.23 4.37 15.07 4.37 10.23 10.23 10.23 10.23 4.37 4.807 4.37 4.37 4.37 4.37 4.4574 4.37 8600 Hos Central Supply Facility Fee 50252 ETOH A4467 270 166.8 116.76 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 1130 EXIDINE 4% CHG SCRUB SOLUTION A4467 270 149.9 104.92999999999999 33.81 155.52 79.22 33.81 116.64 33.81 79.22 79.22 79.22 79.22 33.81 37.191 33.81 33.81 5.43 5.43 5.5386 5.43 8600 Hos Central Supply Facility Fee 821 EXTENSION SET A4467 270 2.72 1.904 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 1613 EXTENSION SET 7 X8622 270 154.34 108.038 5.66 26.03 13.26 5.66 19.52 5.66 13.26 13.26 13.26 13.26 5.66 6.226000000000001 5.66 5.66 5.66 5.66 5.7732 5.66 8600 Hos Central Supply Facility Fee 1786 EYE WASH/SHOWER INSPECTION TAG A4467 270 9.16 6.412 4.54 20.87 10.63 4.54 15.65 4.54 10.63 10.63 10.63 10.63 4.54 4.994000000000001 4.54 4.54 4.54 4.54 4.6308 4.54 8600 Hos Central Supply Facility Fee 50087 EZ 40NM ANAEROBIC A4467 270 8.69 6.082999999999999 5.45 25.06 12.77 5.45 18.8 5.45 12.77 12.77 12.77 12.77 5.45 5.995000000000001 5.45 5.45 5.45 5.45 5.559 5.45 8600 Hos Central Supply Facility Fee 50057 FACE MASK FULL LARGE DISPOSABLE A4467 270 21.23 14.860999999999999 6.23 28.66 14.6 6.23 21.5 6.23 14.6 14.6 14.6 14.6 6.23 6.853000000000001 6.23 6.23 6.23 6.23 6.3546000000000005 6.23 8600 Hos Central Supply Facility Fee 50058 FACE MASK FULL MEDIUM DISPOSABLE A4467 270 21.23 14.860999999999999 2.53 11.64 5.93 2.53 8.73 2.53 5.93 5.93 5.93 5.93 2.53 2.783 2.53 2.53 2.53 2.53 2.5806 2.53 8600 Hos Central Supply Facility Fee 126 FACE MASK FULL SMALL DISPOSABLE C7206 270 21.23 14.860999999999999 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 50088 FB BB TRANS PPT NS 5 ML A4467 270 0.02 0.013999999999999999 24.24 111.48 56.79 24.24 83.61 24.24 56.79 56.79 56.79 56.79 24.24 26.664 24.24 24.24 5.43 5.43 5.5386 5.43 8600 Hos Central Supply Facility Fee 50460 FELLOWS COSMIC @ LAMINATOR 9 1/2 ENTRY WIDTH A4467 270 93.6 65.52 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 833 FEMALE CATHETER KIT A4467 270 0.39 0.27299999999999996 4.07 18.72 9.54 4.07 14.04 4.07 9.54 9.54 9.54 9.54 4.07 4.477 4.07 4.07 4.07 4.07 4.151400000000001 4.07 8600 Hos Central Supply Facility Fee 1188 FIGER SPLINT W/FOAM LARGE A4467 270 1.6 1.1199999999999999 4.52 20.78 10.59 4.52 15.59 4.52 10.59 10.59 10.59 10.59 4.52 4.9719999999999995 4.52 4.52 4.52 4.52 4.610399999999999 4.52 8600 Hos Central Supply Facility Fee 294 FILTER UROLOGICAL DISPOSABLE L3206 270 0.11 0.077 63.39 291.6 148.54 63.39 218.7 63.39 148.54 148.54 148.54 148.54 63.39 69.729 63.39 63.39 69.19 69.19 70.5738 69.19 8600 Hos Central Supply Facility Fee 1187 FINGER SPLINR W/FOAM MEDIUM A4467 270 1.6 1.1199999999999999 7.08 32.58 16.6 7.08 24.44 7.08 16.6 16.6 16.6 16.6 7.08 7.788000000000001 7.08 7.08 7.08 7.08 7.2216000000000005 7.08 8600 Hos Central Supply Facility Fee 1186 FINGER SPLINT 4 PRONG W/FOAM SMALL A4467 270 1.6 1.1199999999999999 4.52 20.78 10.59 4.52 15.59 4.52 10.59 10.59 10.59 10.59 4.52 4.9719999999999995 4.52 4.52 4.52 4.52 4.610399999999999 4.52 8600 Hos Central Supply Facility Fee 1189 FINGER SPLINT STACK STARTER KIT A4467 270 128.9 90.23 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 398 FLANGE W/WAFER ROUND FLANGE-2 3/4IN TAPE COLLAR FLEX EXTENDED WEAR STOMA CUT TO A4409 270 3.79 2.653 5.64 25.95 13.22 5.64 19.46 5.64 13.22 13.22 13.22 13.22 5.64 6.204 5.64 5.64 5.11 5.11 5.2122 5.11 8600 Hos Central Supply Facility Fee 1681 FLEX FLNG 5 X 5 2 3/4 SUR-FIT NATURA A4409 270 67.6 47.31999999999999 19.03 87.52 44.58 19.03 65.64 19.03 44.58 44.58 44.58 44.58 19.03 20.933000000000003 19.03 19.03 29.43 29.43 30.0186 29.43 8600 Hos Central Supply Facility Fee 1245 FLORENCE DOCUMENT FRAME WITH MAT 11 X 14 N/A 270 21.48 15.036 0.03 0.13 0.07 0.03 0.1 0.03 0.07 0.07 0.07 0.07 0.03 0.033 0.03 0.03 22.54 22.54 22.9908 22.54 8600 Hos Central Supply Facility Fee 1853 FLU SWABS A & B A4467 270 286.25 200.375 0.03 0.13 0.07 0.03 0.1 0.03 0.07 0.07 0.07 0.07 0.03 0.033 0.03 0.03 0.03 0.03 0.0306 0.03 8600 Hos Central Supply Facility Fee 1855 FLU SWABS A & B A4467 270 334.79 234.353 10.96 50.4 25.67 10.96 37.8 10.96 25.67 25.67 25.67 25.67 10.96 12.056000000000003 10.96 10.96 10.96 10.96 11.179200000000002 10.96 8600 Hos Central Supply Facility Fee 50533 FLUKE TONE AND PROBE KIT N/A 270 225.94 158.158 10.73 49.36 25.14 10.73 37.02 10.73 25.14 25.14 25.14 25.14 10.73 11.803 10.73 10.73 10.73 10.73 10.944600000000001 10.73 8600 Hos Central Supply Facility Fee 203 FOAM TRACH TIES 13-24 IN LG ADULT A6206 270 0.83 0.581 2.71 12.48 6.36 2.71 9.36 2.71 6.36 6.36 6.36 6.36 2.71 2.9810000000000003 2.71 2.71 2.71 2.71 2.7642 2.71 8600 Hos Central Supply Facility Fee 251 GARMENT CALF STANDARD UP TO 17 INCHES R0206 270 13.7 9.589999999999998 3.57 16.4 8.35 3.57 12.3 3.57 8.35 8.35 8.35 8.35 3.57 3.927 3.57 3.57 4.07 4.07 4.151400000000001 4.07 8600 Hos Central Supply Facility Fee 50018 GASTRIC OCCULT BLOOD A8622 270 124.5 87.14999999999999 1.03 4.73 2.41 1.03 3.55 1.03 2.41 2.41 2.41 2.41 1.03 1.1330000000000002 1.03 1.03 14.35 14.35 14.637 14.35 8600 Hos Central Supply Facility Fee 50089 GASTROCULT SLIDES A4467 270 1.59 1.113 27.72 127.52 64.96 27.72 95.64 27.72 64.96 64.96 64.96 64.96 27.72 30.492 27.72 27.72 27.72 27.72 28.2744 27.72 8600 Hos Central Supply Facility Fee 359 GAUZE PETROLATUM XEROFORM 2X2IN PATCH PEELABLE FOIL PACK STERILE A4649 270 0.74 0.518 0.22 0.99 0.5 0.22 0.74 0.22 0.5 0.5 0.5 0.5 0.22 0.24200000000000002 0.22 0.22 0.22 0.22 0.22440000000000002 0.22 8600 Hos Central Supply Facility Fee 360 GAUZE PETROLATUM XEROFORM 4X4IN PATCH PEELABLE FOIL PACK STERILE A4649 270 1.05 0.735 6.48 29.8 15.18 6.48 22.35 6.48 15.18 15.18 15.18 15.18 6.48 7.128000000000001 6.48 6.48 6.48 6.48 6.6096 6.48 8600 Hos Central Supply Facility Fee 361 GAUZE PETROLATUM XEROFORM 5X9IN STRIP PEELABLE FOIL PACK STERILE A4649 270 0.92 0.644 0.74 3.39 1.73 0.74 2.54 0.74 1.73 1.73 1.73 1.73 0.74 0.8140000000000001 0.74 0.74 0.74 0.74 0.7548 0.74 8600 Hos Central Supply Facility Fee 1298 GAUZE SPONGE 4 X 4 12 PLY NS, LF A4467 270 3.34 2.3379999999999996 33.5 154.08 78.49 33.5 115.56 33.5 78.49 78.49 78.49 78.49 33.5 36.85 33.5 33.5 33.5 33.5 34.17 33.5 8600 Hos Central Supply Facility Fee 1297 GAUZE SPONGE 4 X 4 12PLY NS LF A4467 270 3.08 2.1559999999999997 8.7 40 20.38 8.7 30 8.7 20.38 20.38 20.38 20.38 8.7 9.57 8.7 8.7 8.7 8.7 8.873999999999999 8.7 8600 Hos Central Supply Facility Fee 1454 GAUZE SPONGE 4 X 4 8 PLYNS LF 4000/CS A4467 270 1.87 1.309 51.13 235.2 119.81 51.13 176.4 51.13 119.81 119.81 119.81 119.81 51.13 56.24300000000001 51.13 51.13 51.13 51.13 52.15260000000001 51.13 8600 Hos Central Supply Facility Fee 1172 GAUZE SPONGE 4 X 4 STERILE A4467 270 1.66 1.162 51.13 235.2 119.81 51.13 176.4 51.13 119.81 119.81 119.81 119.81 51.13 56.24300000000001 51.13 51.13 51.13 51.13 52.15260000000001 51.13 8600 Hos Central Supply Facility Fee 603 GAUZE,PACKING STRIP,PLAIN,1/2X5YD,STRL A4467 270 21.13 14.790999999999999 11.91 54.8 27.92 11.91 41.1 11.91 27.92 27.92 27.92 27.92 11.91 13.101 11.91 11.91 11.91 11.91 12.148200000000001 11.91 8600 Hos Central Supply Facility Fee 604 GAUZE,PACKING STRIP,PLAIN,1/4X5YD,STRL A4467 270 19.51 13.657 0.87 4.01 2.04 0.87 3.01 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 0.87 0.87 0.8874 0.87 8600 Hos Central Supply Facility Fee 601 GAUZE,PACKING STRIP,PLAIN,1X5YD,STRL,LF A4467 270 3.51 2.457 31.56 145.15 73.94 31.56 108.86 31.56 73.94 73.94 73.94 73.94 31.56 34.716 31.56 31.56 31.56 31.56 32.1912 31.56 8600 Hos Central Supply Facility Fee 600 GAUZE,SPONGE,4X4,16PLY,NS,LF,2000/CS A4467 270 3.62 2.534 21.05 96.82 49.32 21.05 72.62 21.05 49.32 49.32 49.32 49.32 21.05 23.155 21.05 21.05 21.05 21.05 21.471 21.05 8600 Hos Central Supply Facility Fee 605 GAUZE,SPONGE,4X4,8PLY,STRL,LF,10/TRAY A4467 270 0.31 0.217 22 101.21 51.56 22 75.91 22 51.56 51.56 51.56 51.56 22 24.200000000000003 22 22 22 22 22.44 22 8600 Hos Central Supply Facility Fee 1413 GEL ADQUASONIC 100 5L A4467 270 21.64 15.148 0.87 4.01 2.04 0.87 3.01 0.87 2.04 2.04 2.04 2.04 0.87 0.9570000000000001 0.87 0.87 1.25 1.25 1.275 1.25 8600 Hos Central Supply Facility Fee 1709 GEL AQUASONIC 100 5L SONICPAC A4467 270 20.26 14.182 17 78.21 39.84 17 58.66 17 39.84 39.84 39.84 39.84 17 18.700000000000003 17 17 17 17 17.34 17 8600 Hos Central Supply Facility Fee 50124 GEL HAND ANTISEPTIC SOFT N SURE A4467 270 4.56 3.1919999999999997 0.22 0.99 0.5 0.22 0.74 0.22 0.5 0.5 0.5 0.5 0.22 0.24200000000000002 0.22 0.22 0.22 0.22 0.22440000000000002 0.22 8600 Hos Central Supply Facility Fee 50608 GEL HAND SANITIZER SOFT N SURE N/A 270 53.11 37.177 12.95 59.59 30.36 12.95 44.69 12.95 30.36 30.36 30.36 30.36 12.95 14.245000000000001 12.95 12.95 12.95 12.95 13.209 12.95 8600 Hos Central Supply Facility Fee 1021 GEL SILVER ANTIMICROB SILVASORB 3 OZ A4467 270 30.06 21.041999999999998 4.54 20.87 10.63 4.54 15.65 4.54 10.63 10.63 10.63 10.63 4.54 4.994000000000001 4.54 4.54 4.54 4.54 4.6308 4.54 8600 Hos Central Supply Facility Fee 417 GLASSMAN VISCERA RETAINER LG STRL A5206 270 30.08 21.055999999999997 10.24 47.1 23.99 10.24 35.33 10.24 23.99 23.99 23.99 23.99 10.24 11.264000000000001 10.24 10.24 10.24 10.24 10.4448 10.24 8600 Hos Central Supply Facility Fee 1513 GLOBAL AIRFLOW EXECUTIVE CHAIR A4467 270 140.75 98.52499999999999 21.05 96.82 49.32 21.05 72.62 21.05 49.32 49.32 49.32 49.32 21.05 23.155 21.05 21.05 21.05 21.05 21.471 21.05 8600 Hos Central Supply Facility Fee 218 GLOVE NITRILE EXAM LG A4467 270 8.16 5.712 21.05 96.82 49.32 21.05 72.62 21.05 49.32 49.32 49.32 49.32 21.05 23.155 21.05 21.05 21.05 21.05 21.471 21.05 8600 Hos Central Supply Facility Fee 216 GLOVE NITRILE EXAM MEDIUM A4467 270 8.16 5.712 10.76 49.49 25.21 10.76 37.12 10.76 25.21 25.21 25.21 25.21 10.76 11.836 10.76 10.76 10.76 10.76 10.9752 10.76 8600 Hos Central Supply Facility Fee 1140 GLOVE EXAM PF NITRILE SMALL A4467 270 10.21 7.147 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 1171 GLOVE EXAM PF NITRILE XLARGE A4467 270 10.6 7.419999999999999 5.43 24.96 12.71 5.43 18.72 5.43 12.71 12.71 12.71 12.71 5.43 5.973 5.43 5.43 5.43 5.43 5.5386 5.43 8600 Hos Central Supply Facility Fee 1223 GLOVE EXAN NITRILE XL A4467 270 8.53 5.970999999999999 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 220 GLOVE NITRILE EXAM XLG A4467 270 7.55 5.284999999999999 10.02 46.08 23.47 10.02 34.56 10.02 23.47 23.47 23.47 23.47 10.02 11.022 10.02 10.02 10.02 10.02 10.2204 10.02 8600 Hos Central Supply Facility Fee 214 GLOVE NITRILE EXAM SMALL A4467 270 8.15 5.705 11.01 50.64 25.8 11.01 37.98 11.01 25.8 25.8 25.8 25.8 11.01 12.111 11.01 11.01 11.01 11.01 11.2302 11.01 8600 Hos Central Supply Facility Fee 1850 GLOVE SURG LF,PF8.0 A4467 270 67.58 47.306 60.23 277.04 141.12 60.23 207.78 60.23 141.12 141.12 141.12 141.12 60.23 66.253 60.23 60.23 60.23 60.23 61.434599999999996 60.23 8600 Hos Central Supply Facility Fee 1849 GLOVE SURG LFPF 6.0 A4467 270 67.58 47.306 0.01 0.03 0.02 0.01 0.02 0.01 0.02 0.02 0.02 0.02 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 137 GLOVE SURGICAL SIZE 8 1/2 STER PERRY WHT A4467 270 0.08 0.055999999999999994 0.13 0.58 0.3 0.13 0.44 0.13 0.3 0.3 0.3 0.3 0.13 0.14300000000000002 0.13 0.13 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 563 GLOVE,SURG,ALOETOUCH GREEN,LTX,PF,7 A4467 270 0.85 0.595 0.01 0.05 0.03 0.01 0.04 0.01 0.03 0.03 0.03 0.03 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 564 GLOVE,SURG,ALOETOUCH GREEN,LTX,PF,8 A4467 270 0.77 0.5389999999999999 0.02 0.11 0.06 0.02 0.08 0.02 0.06 0.06 0.06 0.06 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 565 GLOVE,SURG,ALOETOUCH GREEN,LTX,PF,8.5 A4467 270 0.85 0.595 0.01 0.03 0.02 0.01 0.02 0.01 0.02 0.02 0.02 0.02 0.01 0.011000000000000001 0.01 0.01 0.01 0.01 0.0102 0.01 8600 Hos Central Supply Facility Fee 1133 GLOVES EXAM PF NITRILE MEDIUM A4467 270 10.21 7.147 3.56 16.36 8.33 3.56 12.27 3.56 8.33 8.33 8.33 8.33 3.56 3.9160000000000004 3.56 3.56 3.56 3.56 3.6312 3.56 8600 Hos Central Supply Facility Fee 1141 GLOVEW EXAM NITRILE PF LARGE A4467 270 10.39 7.273 0.04 0.2 0.1 0.04 0.15 0.04 0.1 0.1 0.1 0.1 0.04 0.044000000000000004 0.04 0.04 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 50090 GLU/HGB DUAL CONTROL HIGH 3 VIALS 1.5 M A4467 270 20.5 14.35 1.57 7.22 3.68 1.57 5.42 1.57 3.68 3.68 3.68 3.68 1.57 1.7270000000000003 1.57 1.57 1.57 1.57 1.6014000000000002 1.57 8600 Hos Central Supply Facility Fee 50091 GLU/HGB DUAL CONTROL LOW 3 VIALS 1.5 ML A4467 270 20.5 14.35 2.2 10.11 5.15 2.2 7.58 2.2 5.15 5.15 5.15 5.15 2.2 2.4200000000000004 2.2 2.2 2.2 2.2 2.244 2.2 8600 Hos Central Supply Facility Fee 50019 GLYCOHEMOGLOBIN A4467 270 153.55 107.485 2.83 13 6.62 2.83 9.75 2.83 6.62 6.62 6.62 6.62 2.83 3.1130000000000004 2.83 2.83 2.83 2.83 2.8866 2.83 8600 Hos Central Supply Facility Fee 413 GOWN EXAM ECONO 30 X 44 BLUE W6206 270 0.85 0.595 0.6 0.85 0.4328461538461539 0.18503846153846154 0.6375 0.18503846153846154 0.4328461538461539 0.4328461538461539 0.4328461538461539 0.4328461538461539 0.18503846153846154 0.20354230769230772 0.18503846153846154 0.18503846153846154 0.18503846153846154 0.18503846153846154 0.18873923076923077 0.18503846153846154 8600 Hos Central Supply Facility Fee 1091 GOWN PATIENT A4467 270 21.57 15.098999999999998 15.1 21.57 10.984107692307694 4.695623076923077 16.177500000000002 4.695623076923077 10.984107692307694 10.984107692307694 10.984107692307694 10.984107692307694 4.695623076923077 5.165185384615385 4.695623076923077 4.695623076923077 4.695623076923077 4.695623076923077 4.789535538461538 4.695623076923077 8600 Hos Central Supply Facility Fee 1743 GOWN PATIENT 3 ARM HOLE REG/LG A4467 270 48.87 34.208999999999996 34.21 48.87 24.886107692307693 10.638623076923077 36.652499999999996 10.638623076923077 24.886107692307693 24.886107692307693 24.886107692307693 24.886107692307693 10.638623076923077 11.702485384615386 10.638623076923077 10.638623076923077 10.638623076923077 10.638623076923077 10.851395538461539 10.638623076923077 8600 Hos Central Supply Facility Fee 50682 GOWN PATIENT TIESIDE 3XL A4467 270 3.93 2.751 36.26 166.8 84.97 36.26 2.9475000000000002 36.26 84.97 84.97 84.97 84.97 36.26 39.886 36.26 36.26 36.26 36.26 36.9852 36.26 8600 Hos Central Supply Facility Fee 466 GOWN POLY WITH THUMBHOOKS XL SOFT BLUE W4206 270 5.55 3.885 3.89 5.55 2.8272392086330935 1.2064928057553956 4.1625 1.2064928057553956 2.8272392086330935 2.8272392086330935 2.8272392086330935 2.8272392086330935 1.2064928057553956 1.3271420863309353 $- $- 1.2064928057553956 1.2064928057553956 1.2306226618705036 1.2064928057553956 8600 Hos Central Supply Facility Fee 586 GOWN,ISO,POLY,THUMBS UP,XL,BLUE A4467 270 0.38 0.26599999999999996 0.27 0.38 0.1935767386091127 0.08260671462829736 0.28500000000000003 0.08260671462829736 0.1935767386091127 0.1935767386091127 0.1935767386091127 0.1935767386091127 0.08260671462829736 0.0908673860911271 $- $- 0.08260671462829736 0.08260671462829736 0.0842588489208633 0.08260671462829736 8600 Hos Central Supply Facility Fee 557 GOWN,PATIENT,DELUXE,T/P/T,WHITE,30X42 W7206 270 0.25 0.175 0.27 0.175 0.1273531175059952 0.0380425659472422 0.1875 0.0380425659472422 0.1273531175059952 0.1273531175059952 0.1273531175059952 0.1273531175059952 0.0380425659472422 0.04184682254196642 $- $- 0.0380425659472422 0.0380425659472422 0.038803417266187044 0.0380425659472422 8600 Hos Central Supply Facility Fee 1766 GRAM STAIN REAGENT SAFRANIN, 8OZ 4/CS A4467 270 55.05 38.535 0.34 1.56 0.79 0.34 1.17 0.34 0.79 0.79 0.79 0.79 0.34 0.37400000000000005 0.34 0.34 0.34 0.34 0.34 0.34 8600 Hos Central Supply Facility Fee 1846 GRIP CANE 4 R8611 270 24.37 17.059 14.56 66.99 34.12 14.56 50.24 14.56 34.12 34.12 34.12 34.12 14.56 16.016000000000002 14.56 14.56 1.42 1.42 1.4484 1.42 8600 Hos Central Supply Facility Fee 50607 H21 PIM 12 LEAD FOR PHILIPS PAGEWRITER A4467 270 770.82 539.574 5.82 26.76 13.63 5.82 20.07 5.82 13.63 13.63 13.63 13.63 5.82 6.402000000000001 5.82 5.82 11.13 11.13 11.3526 11.13 8600 Hos Central Supply Facility Fee 1562 HB201 BASIC COMBO HEMOCUE A4467 270 602.78 421.94599999999997 21.42 98.54 50.2 21.42 73.91 21.42 50.2 50.2 50.2 50.2 21.42 23.562000000000005 21.42 21.42 7.17 7.17 7.3134 7.17 8600 Hos Central Supply Facility Fee 1020 HB201 HEMMOCUE A4467 270 490.64 343.448 4.34 19.95 10.16 4.34 14.96 4.34 10.16 10.16 10.16 10.16 4.34 4.774 4.34 4.34 4.34 4.34 4.4268 4.34 8600 Hos Central Supply Facility Fee 1146 HCG COMBO TEST ONE STEP QUICKVUE A4467 270 91.31 63.916999999999994 2.92 13.41 6.83 2.92 10.06 2.92 6.83 6.83 6.83 6.83 2.92 3.212 2.92 2.92 2.92 2.92 2.9784 2.92 8600 Hos Central Supply Facility Fee 50092 HEKTOEN ENTERIC AGAR A4467 270 0.26 0.182 3.38 15.57 7.93 3.38 11.68 3.38 7.93 7.93 7.93 7.93 3.38 3.718 3.38 3.38 8.04 8.04 8.2008 8.04 8600 Hos Central Supply Facility Fee 932 HELMET SOFT SHELL LARGE A4467 270 228.27 159.789 4.95 22.78 11.6 4.95 17.09 4.95 11.6 11.6 11.6 11.6 4.95 5.445 4.95 4.95 4.95 4.95 5.049 4.95 8600 Hos Central Supply Facility Fee 1466 HELMET SOFT SHELL LARGE ROYAL BLUE A4467 270 116.9 81.83 0.17 0.79 0.4 0.17 0.59 0.17 0.4 0.4 0.4 0.4 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 1486 HELMET SOFT SHELL TAN A4467 270 267.65 187.35499999999996 2.18 10.04 5.11 2.18 7.53 2.18 5.11 5.11 5.11 5.11 2.18 2.3980000000000006 2.18 2.18 2.18 2.18 2.2236000000000002 2.18 8600 Hos Central Supply Facility Fee 396 HEMACYTOMETER NEUBAUER IMPROVED DISPOSABLE M9206 270 2.85 1.9949999999999999 2.35 10.81 5.51 2.35 8.11 2.35 5.51 5.51 5.51 5.51 2.35 2.5850000000000004 2.35 2.35 2.35 2.35 2.3970000000000002 2.35 8600 Hos Central Supply Facility Fee 50021 HEMATOLOGY- 5A A4467 270 249 174.29999999999998 4.27 19.62 9.99 4.27 14.72 4.27 9.99 9.99 9.99 9.99 4.27 4.697 4.27 4.27 4.27 4.27 4.3553999999999995 4.27 8600 Hos Central Supply Facility Fee 1286 HEMOCCULT SENSA 1 SLIDE A4467 270 42.21 29.546999999999997 1.29 5.94 3.03 1.29 4.46 1.29 3.03 3.03 3.03 3.03 1.29 1.4190000000000003 1.29 1.29 1.29 1.29 1.3158 1.29 8600 Hos Central Supply Facility Fee 1014 HEMOCCULT SLIDE A4467 270 34.91 24.436999999999998 0.12 0.57 0.29 0.12 0.43 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 1641 HEMOCCULT SLIDE SINGLE E8655 270 82.94 58.05799999999999 8.9 40.94 20.85 8.9 30.71 8.9 20.85 20.85 20.85 20.85 8.9 9.790000000000001 8.9 8.9 8.9 8.9 9.078000000000001 8.9 8600 Hos Central Supply Facility Fee 50022 HEMOCUE- 5 SAMPLES A4467 270 203.35 142.345 10.51 48.33 24.62 10.51 36.25 10.51 24.62 24.62 24.62 24.62 10.51 11.561 10.51 10.51 10.51 10.51 10.7202 10.51 8600 Hos Central Supply Facility Fee 1255 HEMOCUE HB 201 MICROCUVETTES A4467 270 145.98 102.18599999999999 4.12 18.94 9.65 4.12 14.21 4.12 9.65 9.65 9.65 9.65 4.12 4.532000000000001 4.12 4.12 4.12 4.12 4.2024 4.12 8600 Hos Central Supply Facility Fee 50376 HINGE SPRING LOADED N/A 270 88.06 61.641999999999996 8.04 36.97 18.83 8.04 27.73 8.04 18.83 18.83 18.83 18.83 8.04 8.844 8.04 8.04 6.71 6.71 6.8442 6.71 8600 Hos Central Supply Facility Fee 50729 HINGED CUBE TRUCK LID N/A 270 183.19 128.233 0.23 1.06 0.54 0.23 0.8 0.23 0.54 0.54 0.54 0.54 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 1406 HISTOFREEZE CRYOKIT 60-120 A9270 270 611.49 428.043 0.75 3.44 1.75 0.75 2.58 0.75 1.75 1.75 1.75 1.75 0.75 0.8250000000000001 0.75 0.75 0.75 0.75 0.765 0.75 8600 Hos Central Supply Facility Fee 50270 HISTOFREEZER A4467 270 380.77 266.539 1.68 7.74 3.94 1.68 5.81 1.68 3.94 3.94 3.94 3.94 1.68 1.848 1.68 1.68 1.68 1.68 1.7136 1.68 8600 Hos Central Supply Facility Fee 50199 HM REACTION VESSELS M8633 270 24.01 16.807 1.25 5.76 2.93 1.25 4.32 1.25 2.93 2.93 2.93 2.93 1.25 1.375 1.25 1.25 1.25 1.25 1.275 1.25 8600 Hos Central Supply Facility Fee 1582 HME TRACHEOSTOMY A4467 270 78.36 54.852 1.13 5.22 2.66 1.13 3.92 1.13 2.66 2.66 2.66 2.66 1.13 1.2429999999999999 1.13 1.13 1.13 1.13 1.1525999999999998 1.13 8600 Hos Central Supply Facility Fee 143 HOLDER DISP LIMB WRIST L3206 270 4.58 3.206 0.92 4.23 2.15 0.92 3.17 0.92 2.15 2.15 2.15 2.15 0.92 1.0120000000000002 0.92 0.92 0.92 0.92 0.9384 0.92 8600 Hos Central Supply Facility Fee 156 HOLDER ET TUBE 320-264-040 L0206 270 2.25 1.575 0.26 1.19 0.61 0.26 0.89 0.26 0.61 0.61 0.61 0.61 0.26 0.28600000000000003 0.26 0.26 0.26 0.26 0.2652 0.26 8600 Hos Central Supply Facility Fee 307 HOLDER ET TUBE 320-264-040 L0206 270 2.25 1.575 0.22 1.02 0.52 0.22 0.77 0.22 0.52 0.52 0.52 0.52 0.22 0.24200000000000002 0.22 0.22 0.22 0.22 0.22440000000000002 0.22 8600 Hos Central Supply Facility Fee 297 HOLDER LIMB QUICK RELEASE QUILTED L6206 270 5.62 3.9339999999999997 4.1 18.87 9.61 4.1 14.15 4.1 9.61 9.61 9.61 9.61 4.1 4.51 4.1 4.1 4.1 4.1 4.1819999999999995 4.1 8600 Hos Central Supply Facility Fee 142 HOLDER LIMB THICK FOAM L9206 270 2.53 1.7709999999999997 0.4 1.83 0.93 0.4 1.37 0.4 0.93 0.93 0.93 0.93 0.4 0.44000000000000006 0.4 0.4 0.4 0.4 0.40800000000000003 0.4 8600 Hos Central Supply Facility Fee 1388 HOLDER TUBE SINGLE USE A4467 270 22.14 15.498 1.28 5.87 2.99 1.28 4.4 1.28 2.99 2.99 2.99 2.99 1.28 1.4080000000000001 1.28 1.28 1.28 1.28 1.3056 1.28 8600 Hos Central Supply Facility Fee 260 HW1916HRF WHIN 19 G 11206 270 2.6 1.8199999999999998 4.37 20.09 10.23 4.37 15.07 4.37 10.23 10.23 10.23 10.23 4.37 4.807 4.37 4.37 4.58 4.58 4.6716 4.58 8600 Hos Central Supply Facility Fee 261 HW1976HRF WHIN19 G 17206 270 2.14 1.498 6.55 30.11 15.34 6.55 22.58 6.55 15.34 15.34 15.34 15.34 6.55 7.205 6.55 6.55 6.55 6.55 6.681 6.55 8600 Hos Central Supply Facility Fee 262 HW2016HRF WHIN 20 G 27206 270 2.14 1.498 63.12 290.33 147.89 63.12 217.75 63.12 147.89 147.89 147.89 147.89 63.12 69.432 63.12 63.12 63.12 63.12 64.3824 63.12 8600 Hos Central Supply Facility Fee 263 HW2076HRF WHIN 20 G 27206 270 2.14 1.498 9.06 41.66 21.22 9.06 31.25 9.06 21.22 21.22 21.22 21.22 9.06 9.966000000000001 9.06 9.06 9.06 9.06 9.241200000000001 9.06 8600 Hos Central Supply Facility Fee 264 HW2216HRF 27206 270 2.14 1.498 0.45 2.05 1.04 0.45 1.54 0.45 1.04 1.04 1.04 1.04 0.45 0.49500000000000005 0.45 0.45 0.45 0.45 0.459 0.45 8600 Hos Central Supply Facility Fee 623 HYDROGEN PEROXIDE,USP 3%,16OZ A4244 270 5.79 4.053 5.64 25.94 13.21 5.64 19.46 5.64 13.21 13.21 13.21 13.21 5.64 6.204 5.64 5.64 5.64 5.64 5.7528 5.64 8600 Hos Central Supply Facility Fee 287 ICE BAG-LG/ELASTIC 6X 14' E1206 270 6.42 4.494 0.46 2.11 1.07 0.46 1.58 0.46 1.07 1.07 1.07 1.07 0.46 0.5060000000000001 0.46 0.46 8.59 8.59 8.7618 8.59 8600 Hos Central Supply Facility Fee 50200 IML 1000 PSA 100 TEST A4467 270 182.5 127.74999999999999 8.37 38.52 19.62 8.37 28.89 8.37 19.62 19.62 19.62 19.62 8.37 9.207 8.37 8.37 0.11 0.11 0.11220000000000001 0.11 8600 Hos Central Supply Facility Fee 50201 IML. CALPROIC ACID TEST A4467 270 135.5 94.85 0.08 0.36 0.18 0.08 0.27 0.08 0.18 0.18 0.18 0.18 0.08 0.08800000000000001 0.08 0.08 0.08 0.08 0.0816 0.08 8600 Hos Central Supply Facility Fee 50202 IMMULITE PROBE CLEANING A9270 270 8.4 5.88 3.15 14.5 7.39 3.15 10.88 3.15 7.39 7.39 7.39 7.39 3.15 3.4650000000000003 3.15 3.15 3.15 3.15 3.213 3.15 8600 Hos Central Supply Facility Fee 50204 IMMULITE SAMPLE CUPS (1000) A4467 270 16.4 11.479999999999999 5.64 25.92 13.2 5.64 19.44 5.64 13.2 13.2 13.2 13.2 5.64 6.204 5.64 5.64 5.64 5.64 5.7528 5.64 8600 Hos Central Supply Facility Fee 50203 IMMULITE SUBSTRATE MODULE A9270 270 283.5 198.45 33.63 154.67 78.79 33.63 116 33.63 78.79 78.79 78.79 78.79 33.63 36.99300000000001 33.63 33.63 33.63 33.63 34.302600000000005 33.63 8600 Hos Central Supply Facility Fee 50205 IMMULITE TOTAL T4 KIT A4467 270 66 46.199999999999996 8.03 36.94 18.82 8.03 27.71 8.03 18.82 18.82 18.82 18.82 8.03 8.833 8.03 8.03 8.03 8.03 8.1906 8.03 8600 Hos Central Supply Facility Fee 50023 IMMUNOASSAY A4467 270 182.6 127.82 0.4 1.85 0.94 0.4 1.39 0.4 0.94 0.94 0.94 0.94 0.4 0.44000000000000006 0.4 0.4 0.4 0.4 0.40800000000000003 0.4 8600 Hos Central Supply Facility Fee 1401 INCIPIO CAPTURE COVER FOR TABLET A4467 270 43 30.099999999999998 0.37 1.69 0.86 0.37 1.27 0.37 0.86 0.86 0.86 0.86 0.37 0.40700000000000003 0.37 0.37 0.37 0.37 0.3774 0.37 8600 Hos Central Supply Facility Fee 1400 INCIPIO CAPTURE PROTECTIVE COVER FOR TABLET A4467 270 43 30.099999999999998 0.21 0.95 0.48 0.21 0.71 0.21 0.48 0.48 0.48 0.48 0.21 0.231 0.21 0.21 0.21 0.21 0.2142 0.21 8600 Hos Central Supply Facility Fee 123 INDICATOR BIOLOGICAL STEAM PLUS TEST DIS D7206 270 4.69 3.283 34.27 157.64 80.3 34.27 118.23 34.27 80.3 80.3 80.3 80.3 34.27 37.69700000000001 34.27 34.27 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 42 INDICATOR TEMP FOREHEAD A4206 270 0.79 0.5529999999999999 73.48 337.99 172.17 73.48 253.49 73.48 172.17 172.17 172.17 172.17 73.48 80.82800000000002 73.48 73.48 73.48 73.48 74.9496 73.48 8600 Hos Central Supply Facility Fee 50024 INFECTIOUS MONONUCLEOSIS & RHEUMTOID FACTOR A4467 270 190.9 133.63 3.75 17.27 8.8 3.75 12.95 3.75 8.8 8.8 8.8 8.8 3.75 4.125 3.75 3.75 1.11 1.11 1.1322 1.11 8600 Hos Central Supply Facility Fee 971 INK TONER60 COLOR N8655 270 38.57 26.999 0.02 0.07 0.04 0.02 0.05 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 50206 INNOVIN 10XF.10ML A4467 270 42.63 29.841 8.39 38.57 19.65 8.39 28.93 8.39 19.65 19.65 19.65 19.65 8.39 9.229000000000001 8.39 8.39 8.39 8.39 8.5578 8.39 8600 Hos Central Supply Facility Fee 50207 INOCS, DRIED, US (240) A4467 270 0 0 1.92 8.83 4.5 1.92 6.62 1.92 4.5 4.5 4.5 4.5 1.92 2.112 1.92 1.92 1.92 1.92 1.9584 1.92 8600 Hos Central Supply Facility Fee 152 INSTAPAD 32 IN X 36 IN NON STERILE S6206 270 4.98 3.486 8.69 39.99 20.37 8.69 29.99 8.69 20.37 20.37 20.37 20.37 8.69 9.559000000000001 8.69 8.69 8.69 8.69 8.8638 8.69 8600 Hos Central Supply Facility Fee 107 INSUFF,10' 0.1 MIC,CPC FX LUER 10FT .1 MIC FILT CPC FX LUER S3206 270 14.74 10.318 0.17 0.77 0.39 0.17 0.58 0.17 0.39 0.39 0.39 0.39 0.17 0.18700000000000003 0.17 0.17 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 90 INTEGRATOR COMPLY STEAM STERIL T7206 270 37.24 26.068 4.3 19.77 10.07 4.3 14.83 4.3 10.07 10.07 10.07 10.07 4.3 4.73 4.3 4.3 0.17 0.17 0.17340000000000003 0.17 8600 Hos Central Supply Facility Fee 824 INTROCAN 16 G SAFETY IV NEEDLE A4467 270 1.6 1.1199999999999999 4 18.4 9.37 4 13.8 4 9.37 9.37 9.37 9.37 4 4.4 4 4 4 4 4.08 4 8600 Hos Central Supply Facility Fee 50093 IST LVL1 AQUS CTL 10 X 1.7 ML A4467 270 33.64 23.548 0.7 3.22 1.64 0.7 2.42 0.7 1.64 1.64 1.64 1.64 0.7 0.77 0.7 0.7 0.7 0.7 0.714 0.7 8600 Hos Central Supply Facility Fee 50094 IST LVL2 AQUS CTL 10X1.7ML A4467 270 33.64 23.548 0.12 0.57 0.29 0.12 0.43 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 50095 IST LVL3 AQUS CTL 10X1.7ML A4467 270 336.4 235.47999999999996 0.07 0.3 0.15 0.07 0.23 0.07 0.15 0.15 0.15 0.15 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 753 ITOYA ETONA HEAVY DUTY CASSETTE STAPLES 5/16 LEG LENGTH YELLOW A4467 270 0.01 0.006999999999999999 1.24 5.72 2.91 1.24 4.29 1.24 2.91 2.91 2.91 2.91 1.24 1.364 1.24 1.24 1.24 1.24 1.2648 1.24 8600 Hos Central Supply Facility Fee 752 ITOYA HEAVY DUTY CASSETTE STAPLES 5/16 YELLOW A4467 270 0.01 0.006999999999999999 7.36 33.85 17.24 7.36 25.39 7.36 17.24 17.24 17.24 17.24 7.36 8.096000000000002 7.36 7.36 7.36 7.36 7.5072 7.36 8600 Hos Central Supply Facility Fee 859 IV ARM BOARDS A9270 270 0.37 0.259 6.19 28.47 14.5 6.19 21.35 6.19 14.5 14.5 14.5 14.5 6.19 6.809000000000001 6.19 6.19 6.19 6.19 6.3138000000000005 6.19 8600 Hos Central Supply Facility Fee 872 IV SET SECONDARY V8677 270 29 20.299999999999997 5.25 24.14 12.3 5.25 18.11 5.25 12.3 12.3 12.3 12.3 5.25 5.775 5.25 5.25 5.25 5.25 5.355 5.25 8600 Hos Central Supply Facility Fee 566 IV START KIT A4467 270 5.5 3.8499999999999996 4.88 22.44 11.43 4.88 16.83 4.88 11.43 11.43 11.43 11.43 4.88 5.368 4.88 4.88 4.88 4.88 4.9776 4.88 8600 Hos Central Supply Facility Fee 953 IV START KIT V8655 270 95.11 66.577 8.17 37.57 19.14 8.17 28.18 8.17 19.14 19.14 19.14 19.14 8.17 8.987 8.17 8.17 8.17 8.17 8.3334 8.17 8600 Hos Central Supply Facility Fee 1807 IV START KIT A4649 270 1.04 0.728 14.57 67.03 34.15 14.57 50.27 14.57 34.15 34.15 34.15 34.15 14.57 16.027 14.57 14.57 14.57 14.57 14.8614 14.57 8600 Hos Central Supply Facility Fee 1166 IVES ELBOW CABINET CATCH A4467 270 2.84 1.9879999999999998 2.98 13.7 6.98 2.98 10.28 2.98 6.98 6.98 6.98 6.98 2.98 3.278 2.98 2.98 2.98 2.98 3.0396 2.98 8600 Hos Central Supply Facility Fee 50364 JACKET LAB N/A 270 30.1 21.07 21.31 98 49.92 21.31 73.5 21.31 49.92 49.92 49.92 49.92 21.31 23.441 21.31 21.31 21.31 21.31 21.7362 21.31 8600 Hos Central Supply Facility Fee 1767 JACKET LAB BLU XL A4467 270 33.29 23.302999999999997 6.31 29.01 14.78 6.31 21.76 6.31 14.78 14.78 14.78 14.78 6.31 6.941 6.31 6.31 6.31 6.31 6.4361999999999995 6.31 8600 Hos Central Supply Facility Fee 50125 JACKET LAB HIP LEGH RASP LARGE DISP A4467 270 2.69 1.8829999999999998 8.61 39.61 20.18 8.61 29.71 8.61 20.18 20.18 20.18 20.18 8.61 9.471 8.61 8.61 8.61 8.61 8.7822 8.61 8600 Hos Central Supply Facility Fee 50126 JACKET LAB HIP LEGH TEAL MEDIUM DISP A4467 270 2.96 2.072 1 4.61 2.35 1 3.46 1 2.35 2.35 2.35 2.35 1 1.1 1 1 1 1 1.02 1 8600 Hos Central Supply Facility Fee 403 JAMSHIDI NEEDLE BONE MARROW 11GX4 ASP ASPIRATION M3206 270 1.38 0.9659999999999999 4.3 19.8 10.09 4.3 14.85 4.3 10.09 10.09 10.09 10.09 4.3 4.73 4.3 4.3 1.3 1.3 1.326 1.3 8600 Hos Central Supply Facility Fee 837 JASMSHIDI BONE MARROW TRAY A4467 270 18.94 13.258000000000001 8.49 39.05 19.89 8.49 29.29 8.49 19.89 19.89 19.89 19.89 8.49 9.339 8.49 8.49 8.49 8.49 8.6598 8.49 8600 Hos Central Supply Facility Fee 1436 JELLY LUBE FOIL PACK 2.7GM A4467 270 0.07 0.049 5.98 27.52 14.02 5.98 20.64 5.98 14.02 14.02 14.02 14.02 5.98 6.578000000000001 5.98 5.98 5.98 5.98 6.099600000000001 5.98 8600 Hos Central Supply Facility Fee 972 JELLY LUBE FOIL PACK 5GRAM A4467 270 8.83 6.181 0.14 0.64 0.33 0.14 0.48 0.14 0.33 0.33 0.33 0.33 0.14 0.15400000000000003 0.14 0.14 0.14 0.14 0.1428 0.14 8600 Hos Central Supply Facility Fee 138 JELLY LUBRICATING 5.0GM L7206 270 5.32 3.7239999999999998 0.07 0.33 0.17 0.07 0.25 0.07 0.17 0.17 0.17 0.17 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 397 JELLY LUBRICATING E-Z 4OZ STERILE A4402 270 1.05 0.735 1.57 7.22 3.68 1.57 5.42 1.57 3.68 3.68 3.68 3.68 1.57 1.7270000000000003 1.57 1.57 1.57 1.57 1.6014000000000002 1.57 8600 Hos Central Supply Facility Fee 620 JELLY,LUBE,STRL,FLIP TOP,TUBE,4 OZ A4402 270 5.58 3.9059999999999997 1.52 6.99 3.56 1.52 5.24 1.52 3.56 3.56 3.56 3.56 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 8600 Hos Central Supply Facility Fee 132 JP 19FR SILICONE DRAIN C1729 270 13.44 9.408 2.16 9.94 5.06 2.16 7.46 2.16 5.06 5.06 5.06 5.06 2.16 2.3760000000000003 2.16 2.16 2.16 2.16 2.2032000000000003 2.16 8600 Hos Central Supply Facility Fee 50096 KETO-DIASTIX A4467 270 29.98 20.986 12.4 57.05 29.06 12.4 42.79 12.4 29.06 29.06 29.06 29.06 12.4 13.640000000000002 12.4 12.4 13.52 13.52 13.7904 13.52 8600 Hos Central Supply Facility Fee 1167 KEY RING WRIST COIL A4467 270 0.32 0.22399999999999998 1.26 5.79 2.95 1.26 4.34 1.26 2.95 2.95 2.95 2.95 1.26 1.3860000000000001 1.26 1.26 5.44 5.44 5.548800000000001 5.44 8600 Hos Central Supply Facility Fee 1847 KEY RING WRIST COIL BLACK 5/PK47 A4467 270 2.8 1.9599999999999997 7.59 34.91 17.78 7.59 26.18 7.59 17.78 17.78 17.78 17.78 7.59 8.349 7.59 7.59 7.59 7.59 7.7418 7.59 8600 Hos Central Supply Facility Fee 50388 KINDEST CARE BODY & HAND WASH A4467 270 46.36 32.452 4.13 19 9.68 4.13 14.25 4.13 9.68 9.68 9.68 9.68 4.13 4.543 4.13 4.13 21.34 21.34 21.7668 21.34 8600 Hos Central Supply Facility Fee 50063 KINDEST KARE ANTIBACT BODY WASH AND SHMP A4467 270 3.88 2.7159999999999997 0.04 0.18 0.09 0.04 0.14 0.04 0.09 0.09 0.09 0.09 0.04 0.044000000000000004 0.04 0.04 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 50062 KINDEST KARE BODY AND HAND WASH SHAMPOO A4467 270 11.75 8.225 43.13 198.39 101.06 43.13 148.79 43.13 101.06 101.06 101.06 101.06 43.13 47.443000000000005 43.13 43.13 43.13 43.13 43.9926 43.13 8600 Hos Central Supply Facility Fee 50059 KIT BLOOD GAS 3CC 23GX1 A4467 270 1.17 0.819 6.54 30.06 15.31 6.54 22.55 6.54 15.31 15.31 15.31 15.31 6.54 7.194000000000001 6.54 6.54 106.67 106.67 108.80340000000001 106.67 8600 Hos Central Supply Facility Fee 1016 KIT IV START I8633 270 99 69.3 9.48 43.62 22.22 9.48 32.72 9.48 22.22 22.22 22.22 22.22 9.48 10.428 9.48 9.48 9.48 9.48 9.6696 9.48 8600 Hos Central Supply Facility Fee 50002 KIT, CTRL LVL 1, TOTAL 5 ALERE A4467 270 6.4 4.4799999999999995 1.17 5.4 2.75 1.17 4.05 1.17 2.75 2.75 2.75 2.75 1.17 1.287 1.17 1.17 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 50003 KIT, CTRL LVL 2, TOTAL 5 ALERE A4467 270 2.75 1.9249999999999998 0.6 2.75 1.4 0.6 2.06 0.6 1.4 1.4 1.4 1.4 0.6 0.66 0.6 0.6 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 1637 KIT, SLIDE HEMOCCULT SINGLE A4467 270 91.68 64.176 19.93 91.68 46.7 19.93 68.76 19.93 46.7 46.7 46.7 46.7 19.93 21.923000000000002 19.93 19.93 19.93 19.93 20.3286 19.93 8600 Hos Central Supply Facility Fee 1635 KIT, SLIDE HEMOCCULT SLIDE A4467 270 29.45 20.615 6.4 29.45 15 6.4 22.09 6.4 15 15 15 15 6.4 7.040000000000001 6.4 6.4 6.4 6.4 6.5280000000000005 6.4 8600 Hos Central Supply Facility Fee 50001 KIT, TIRAGE BNP-XR TEST A9270 270 13.99 9.793 3.04 13.99 7.13 3.04 10.49 3.04 7.13 7.13 7.13 7.13 3.04 3.3440000000000003 3.04 3.04 3.04 3.04 3.1008 3.04 8600 Hos Central Supply Facility Fee 50000 KIT, TRIAGE D-DIMER TEST A9270 270 14.4 10.08 3.13 14.4 7.34 3.13 10.8 3.13 7.34 7.34 7.34 7.34 3.13 3.443 3.13 3.13 3.13 3.13 3.1926 3.13 8600 Hos Central Supply Facility Fee 1578 KLEENEX CUBE BOX A9270 270 6.59 4.6129999999999995 2.25 10.33 5.26 2.25 7.75 2.25 5.26 5.26 5.26 5.26 2.25 2.475 2.25 2.25 2.25 2.25 2.295 2.25 8600 Hos Central Supply Facility Fee 1509 KNEE IMMOB. X-LGE L1830 270 14.98 10.485999999999999 0.41 1.89 0.96 0.41 1.42 0.41 0.96 0.96 0.96 0.96 0.41 0.451 0.41 0.41 0.41 0.41 0.41819999999999996 0.41 8600 Hos Central Supply Facility Fee 136 LAMP SURGICAL 2.5V HALOGEN M0206 270 3.51 2.457 6.69 30.76 15.67 6.69 23.07 6.69 15.67 15.67 15.67 15.67 6.69 7.359000000000001 6.69 6.69 3.5 3.5 3.5700000000000003 3.5 8600 Hos Central Supply Facility Fee 306 LAMP SURGICAL 3.5V HALOGEN M6206 270 13.57 9.498999999999999 12.46 57.33 29.2 12.46 43 12.46 29.2 29.2 29.2 29.2 12.46 13.706000000000001 12.46 12.46 12.46 12.46 12.709200000000001 12.46 8600 Hos Central Supply Facility Fee 309 LANCET ACCU-CHEK SAFETY PRO PLUS N4206 270 33.22 23.253999999999998 7.92 36.41 18.55 7.92 27.31 7.92 18.55 18.55 18.55 18.55 7.92 8.712 7.92 7.92 7.92 7.92 8.0784 7.92 8600 Hos Central Supply Facility Fee 1599 LANCET SAFETY 21G 1.8MM PUSH BUTTON A4467 270 25.55 17.884999999999998 8.77 40.35 20.55 8.77 30.26 8.77 20.55 20.55 20.55 20.55 8.77 9.647 8.77 8.77 8.77 8.77 8.9454 8.77 8600 Hos Central Supply Facility Fee 463 LANCET STATLET SFTY AUTO CMFRT 21G 1.8MM N5206 270 0.17 0.119 2.43 11.16 5.68 2.43 8.37 2.43 5.68 5.68 5.68 5.68 2.43 2.6730000000000005 2.43 2.43 2.43 2.43 2.4786 2.43 8600 Hos Central Supply Facility Fee 50586 LANTERN 6V N/A 270 7.84 5.4879999999999995 1.7 7.8 3.97 1.7 5.85 1.7 3.97 3.97 3.97 3.97 1.7 1.87 1.7 1.7 1.7 1.7 1.734 1.7 8600 Hos Central Supply Facility Fee 64 LAP PACK TIBURON A4648 270 11.78 8.245999999999999 0.02 0.07 0.04 0.02 0.05 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 305 LARYNGOSSCOPE HANDLE LIGHT WEIGHT R4206 270 45.86 32.102 5.63 25.91 13.2 5.63 19.43 5.63 13.2 13.2 13.2 13.2 5.63 6.1930000000000005 5.63 5.63 5.63 5.63 5.7426 5.63 8600 Hos Central Supply Facility Fee 793 LEE SORTWIK HYGENIC FINGERTIP MOISTENER 1.75 OZ A4467 270 1.66 1.162 16.94 77.92 39.69 16.94 58.44 16.94 39.69 39.69 39.69 39.69 16.94 18.634000000000004 16.94 16.94 19.56 19.56 19.9512 19.56 8600 Hos Central Supply Facility Fee 50097 LEVINE EMB AGAR A4467 270 0.22 0.154 8.72 40.13 20.44 8.72 30.1 8.72 20.44 20.44 20.44 20.44 8.72 9.592000000000002 8.72 8.72 16.98 16.98 17.3196 16.98 8600 Hos Central Supply Facility Fee 80 LIGACLIP TITANIUM 6/CTG L G8206 270 5.04 3.5279999999999996 2.4 11.03 5.62 2.4 8.27 2.4 5.62 5.62 5.62 5.62 2.4 2.64 2.4 2.4 4.32 4.32 4.4064000000000005 4.32 8600 Hos Central Supply Facility Fee 79 LIGACLIP TITANIUM 6/CTG M G1206 270 2.59 1.8129999999999997 3.28 15.09 7.69 3.28 11.32 3.28 7.69 7.69 7.69 7.69 3.28 3.608 3.28 3.28 3.28 3.28 3.3455999999999997 3.28 8600 Hos Central Supply Facility Fee 906 LIMB HOLDER A4467 270 27.55 19.285 2.7 12.44 6.34 2.7 9.33 2.7 6.34 6.34 6.34 6.34 2.7 2.9700000000000006 2.7 2.7 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 1173 LIMB HOLDER ANKLE FIXED POSITION A4467 270 47.19 33.032999999999994 5.84 26.88 13.69 5.84 20.16 5.84 13.69 13.69 13.69 13.69 5.84 6.424 5.84 5.84 5.84 5.84 5.9568 5.84 8600 Hos Central Supply Facility Fee 1174 LIMB HOLDER WRIST FIXED POSITION A4467 270 47.19 33.032999999999994 0.11 0.5 0.25 0.11 0.38 0.11 0.25 0.25 0.25 0.25 0.11 0.12100000000000001 0.11 0.11 0.11 0.11 0.11220000000000001 0.11 8600 Hos Central Supply Facility Fee 512 LINE GAS SAMPLE A9270 270 1.96 1.3719999999999999 2.18 10.03 5.11 2.18 7.52 2.18 5.11 5.11 5.11 5.11 2.18 2.3980000000000006 2.18 2.18 2.18 2.18 2.2236000000000002 2.18 8600 Hos Central Supply Facility Fee 1479 LINER KEEPER A4467 270 77.8 54.459999999999994 2.6 11.95 6.09 2.6 8.96 2.6 6.09 6.09 6.09 6.09 2.6 2.8600000000000003 2.6 2.6 2.6 2.6 2.652 2.6 8600 Hos Central Supply Facility Fee 50075 LINER WAXED WASTE CAN A4467 270 0.02 0.013999999999999999 7.45 34.28 17.46 7.45 25.71 7.45 17.46 17.46 17.46 17.46 7.45 8.195 7.45 7.45 7.45 7.45 7.599 7.45 8600 Hos Central Supply Facility Fee 1478 LINERS SURFACEGUARD BLUE I8611 270 101.7 71.19 5.62 25.83 13.16 5.62 19.37 5.62 13.16 13.16 13.16 13.16 5.62 6.182 5.62 5.62 5.62 5.62 5.7324 5.62 8600 Hos Central Supply Facility Fee 1534 LIQUICHEK URINALYSIS BILEVEL 12X 12ML A4467 270 192.04 134.428 12.61 58.02 29.56 12.61 43.52 12.61 29.56 29.56 29.56 29.56 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 8600 Hos Central Supply Facility Fee 1007 LIQUICHEK URINALYSIS LEVEL 1 A4467 270 194.31 136.017 2.91 13.37 6.81 2.91 10.03 2.91 6.81 6.81 6.81 6.81 2.91 3.2010000000000005 2.91 2.91 2.91 2.91 2.9682000000000004 2.91 8600 Hos Central Supply Facility Fee 1008 LIQUICHEK URINALYSIS LEVEL 2 A4467 270 194.31 136.017 0.63 2.89 1.47 0.63 2.17 0.63 1.47 1.47 1.47 1.47 0.63 0.6930000000000001 0.63 0.63 0.63 0.63 0.6426000000000001 0.63 8600 Hos Central Supply Facility Fee 68 LITHOTOMY DRAPE W/POUCH, ASTOUND A4206 270 12.04 8.427999999999999 45.65 210 106.97 45.65 157.5 45.65 106.97 106.97 106.97 106.97 45.65 50.215 45.65 45.65 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 74 LOADING UNIT GIA 60-3.8 SINGLE USE A2206 270 172.63 120.841 1.52 7 3.57 1.52 5.25 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 16.32 16.32 16.6464 16.32 8600 Hos Central Supply Facility Fee 83 LOADING UNIT MULTIFIRE ENDO GIA 30-2.5 A9270 270 1777.47 1244.229 34.84 160.26 81.64 34.84 120.2 34.84 81.64 81.64 81.64 81.64 34.84 38.324000000000005 34.84 34.84 34.84 34.84 35.53680000000001 34.84 8600 Hos Central Supply Facility Fee 1232 LOTION 2OZ WITH DISPENSING CAP A4467 270 0.35 0.24499999999999997 0.29 1.33 0.68 0.29 1 0.29 0.68 0.68 0.68 0.68 0.29 0.319 0.29 0.29 2.35 2.35 2.3970000000000002 2.35 8600 Hos Central Supply Facility Fee 1252 LOTION W/DISP. CAP 2OZ A4467 270 0.29 0.20299999999999999 1.63 7.5 3.82 1.63 5.63 1.63 3.82 3.82 3.82 3.82 1.63 1.793 1.63 1.63 1.63 1.63 1.6625999999999999 1.63 8600 Hos Central Supply Facility Fee 576 LOTION,SOOTHE & COOL,4 OZ A4467 270 0.01 0.006999999999999999 7.04 32.39 16.5 7.04 24.29 7.04 16.5 16.5 16.5 16.5 7.04 7.744000000000001 7.04 7.04 7.04 7.04 7.1808000000000005 7.04 8600 Hos Central Supply Facility Fee 145 LUBRICANT BACTERIOSTATIC 2 OZ TUBE STER B4206 270 20.5 14.35 1.21 5.58 2.84 1.21 4.19 1.21 2.84 2.84 2.84 2.84 1.21 1.331 1.21 1.21 1.21 1.21 1.2342 1.21 8600 Hos Central Supply Facility Fee 146 LUBRICANT BACTERIOSTATIC 4.25 OZ TBE STER B2206 270 32.62 22.833999999999996 11.49 52.84 26.92 11.49 39.63 11.49 26.92 26.92 26.92 26.92 11.49 12.639000000000001 11.49 11.49 11.49 11.49 11.719800000000001 11.49 8600 Hos Central Supply Facility Fee 147 LUBRICANT BCTRSTTC 4.25 OZ FLIPCAP STER B3206 270 32.89 23.023 32.59 149.9 76.36 32.59 112.43 32.59 76.36 76.36 76.36 76.36 32.59 35.849000000000004 32.59 32.59 32.59 32.59 33.241800000000005 32.59 8600 Hos Central Supply Facility Fee 200 LUBRICATH FOLEY TRAY 16 FR HYDROGEL STER B1206 270 9.29 6.502999999999999 63.62 292.63 149.07 63.62 219.47 63.62 149.07 149.07 149.07 149.07 63.62 69.982 63.62 63.62 63.62 63.62 64.8924 63.62 8600 Hos Central Supply Facility Fee 201 LUBRICATH FOLEY TRAY 18 FR HYDROGEL STER B1206 270 9.29 6.502999999999999 0.86 3.96 2.02 0.86 2.97 0.86 2.02 2.02 2.02 2.02 0.86 0.9460000000000001 0.86 0.86 0.86 0.86 0.8772 0.86 8600 Hos Central Supply Facility Fee 1837 LUER CONNECTOR METAL BP CUFF A4467 270 1.77 1.2389999999999999 2.22 10.21 5.2 2.22 7.66 2.22 5.2 5.2 5.2 5.2 2.22 2.4420000000000006 2.22 2.22 2.22 2.22 2.2644 2.22 8600 Hos Central Supply Facility Fee 50099 MACCONKEY AGAR II A4467 270 0.19 0.13299999999999998 4.2 19.32 9.84 4.2 14.49 4.2 9.84 9.84 9.84 9.84 4.2 4.620000000000001 4.2 4.2 9.36 9.36 9.5472 9.36 8600 Hos Central Supply Facility Fee 813 MACRO EXTENSION SET A4467 270 2.72 1.904 0.54 2.47 1.26 0.54 1.85 0.54 1.26 1.26 1.26 1.26 0.54 0.5940000000000001 0.54 0.54 0.54 0.54 0.5508000000000001 0.54 8600 Hos Central Supply Facility Fee 50208 MALB MICRO ALBUMIN A9270 270 4.73 3.311 19.85 91.31 46.51 19.85 68.48 19.85 46.51 46.51 46.51 46.51 19.85 21.835000000000004 19.85 19.85 2.22 2.22 2.2644 2.22 8600 Hos Central Supply Facility Fee 50209 MALB MICRO ALBUMIN A8666 270 127.52 89.264 12.26 56.38 28.72 12.26 42.29 12.26 28.72 28.72 28.72 28.72 12.26 13.486 12.26 12.26 12.26 12.26 12.5052 12.26 8600 Hos Central Supply Facility Fee 819 MALE ADAPTER A4467 270 0.78 0.5459999999999999 12.26 56.38 28.72 12.26 42.29 12.26 28.72 28.72 28.72 28.72 12.26 13.486 12.26 12.26 12.26 12.26 12.5052 12.26 8600 Hos Central Supply Facility Fee 496 MASK NON-REBREATHER ADULT W/SAFETY VENT A7031 270 0.99 0.693 20.09 92.42 47.08 20.09 69.32 20.09 47.08 47.08 47.08 47.08 20.09 22.099 20.09 20.09 13.34 13.34 13.6068 13.34 8600 Hos Central Supply Facility Fee 499 MASK AEROSOL PED UNDER CHIN S1206 270 0.37 0.259 1.78 8.17 4.16 1.78 6.13 1.78 4.16 4.16 4.16 4.16 1.78 1.9580000000000002 1.78 1.78 1.78 1.78 1.8156 1.78 8600 Hos Central Supply Facility Fee 50068 MASK AEROSOL UNDER CHIN ADULT A4467 270 0.29 0.20299999999999999 1.15 5.28 2.69 1.15 3.96 1.15 2.69 2.69 2.69 2.69 1.15 1.265 1.15 1.15 1.15 1.15 1.1729999999999998 1.15 8600 Hos Central Supply Facility Fee 1608 MASK CHILD PROCEDURE A8633 270 20.47 14.328999999999999 3.68 16.95 8.63 3.68 12.71 3.68 8.63 8.63 8.63 8.63 3.68 4.048000000000001 3.68 3.68 3.68 3.68 3.7536 3.68 8600 Hos Central Supply Facility Fee 465 MASK FACE EARLOOP TRONEX UNISIZE BLUE S4206 270 2.7 1.89 10.07 46.3 23.59 10.07 34.73 10.07 23.59 23.59 23.59 23.59 10.07 11.077000000000002 10.07 10.07 10.07 10.07 10.2714 10.07 8600 Hos Central Supply Facility Fee 102 MASK FACE SURGICAL FOG FREE BLUE S3206 270 0.1 0.06999999999999999 8.23 37.87 19.29 8.23 28.4 8.23 19.29 19.29 19.29 19.29 8.23 9.053 8.23 8.23 8.23 8.23 8.3946 8.23 8600 Hos Central Supply Facility Fee 497 MASK FACE TENT A7031 270 1.01 0.707 0.16 0.74 0.38 0.16 0.56 0.16 0.38 0.38 0.38 0.38 0.16 0.17600000000000002 0.16 0.16 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 60 MASK LARGE ADULT SIZE 6 A7030 270 1.52 1.0639999999999998 6.96 32.02 16.31 6.96 24.02 6.96 16.31 16.31 16.31 16.31 6.96 7.656000000000001 6.96 6.96 6.96 6.96 7.0992 6.96 8600 Hos Central Supply Facility Fee 50044 MASK OXYGEN UNDERCHIN PED A4467 270 0.57 0.39899999999999997 38.49 177.05 90.19 38.49 132.79 38.49 90.19 90.19 90.19 90.19 38.49 42.339000000000006 38.49 38.49 38.49 38.49 39.259800000000006 38.49 8600 Hos Central Supply Facility Fee 50043 MASK OXYGEN W/TUBING A4467 270 0.46 0.322 0.62 2.84 1.45 0.62 2.13 0.62 1.45 1.45 1.45 1.45 0.62 0.682 0.62 0.62 0.62 0.62 0.6324 0.62 8600 Hos Central Supply Facility Fee 149 MASK RESUS AD MAN W/TUBE 40 S1206 270 15 10.5 0.07 0.32 0.16 0.07 0.24 0.07 0.16 0.16 0.16 0.16 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 78 MASK TODDLER SIZE 3 S4206 270 33.29 23.302999999999997 26.09 119.99 61.12 26.09 89.99 26.09 61.12 61.12 61.12 61.12 26.09 28.699 26.09 26.09 26.09 26.09 26.6118 26.09 8600 Hos Central Supply Facility Fee 561 MASK,FACE,ISOLATION,EARLOOPS,YELLOW,L S6206 270 2.74 1.918 0.71 3.25 1.66 0.71 2.44 0.71 1.66 1.66 1.66 1.66 0.71 0.781 0.71 0.71 0.71 0.71 0.7242 0.71 8600 Hos Central Supply Facility Fee 866 MATERN1TY PADS A4467 270 0.08 0.055999999999999994 2.3 10.6 5.4 2.3 7.95 2.3 5.4 5.4 5.4 5.4 2.3 2.53 2.3 2.3 0.98 0.98 0.9996 0.98 8600 Hos Central Supply Facility Fee 868 MED-SURG TELEMETRY PAPER A9270 270 4.54 3.178 0.24 1.09 0.56 0.24 0.82 0.24 0.56 0.56 0.56 0.56 0.24 0.264 0.24 0.24 0.36 0.36 0.36719999999999997 0.36 8600 Hos Central Supply Facility Fee 121 MESH POLYPROPYLENE 6X6IN NON-ABS S1206 270 134.17 93.91899999999998 1.24 5.69 2.9 1.24 4.27 1.24 2.9 2.9 2.9 2.9 1.24 1.364 1.24 1.24 0.26 0.26 0.2652 0.26 8600 Hos Central Supply Facility Fee 233 METER IBKY ACCU-CHEK ADVANTAGE T8206 270 69.6 48.71999999999999 0.24 1.1 0.56 0.24 0.83 0.24 0.56 0.56 0.56 0.56 0.24 0.264 0.24 0.24 0.24 0.24 0.2448 0.24 8600 Hos Central Supply Facility Fee 135 METER URINE DOUBLE SIDE ENTRY T1206 270 6.41 4.487 6.45 29.69 15.12 6.45 22.27 6.45 15.12 15.12 15.12 15.12 6.45 7.095000000000001 6.45 6.45 6.45 6.45 6.579000000000001 6.45 8600 Hos Central Supply Facility Fee 50447 METERED AEROSOL ASSORTED N/A 270 61.6 43.12 2.99 13.76 7.01 2.99 10.32 2.99 7.01 7.01 7.01 7.01 2.99 3.2890000000000006 2.99 2.99 2.99 2.99 3.0498000000000003 2.99 8600 Hos Central Supply Facility Fee 50303 METERED AIR FRESHNER GOJO COTTON N/A 270 4.81 3.3669999999999995 0.35 1.6 0.82 0.35 1.2 0.35 0.82 0.82 0.82 0.82 0.35 0.385 0.35 0.35 0.35 0.35 0.357 0.35 8600 Hos Central Supply Facility Fee 1617 MEXICAN POTTERY CLAY E8611 270 21.81 15.266999999999998 0.35 1.6 0.82 0.35 1.2 0.35 0.82 0.82 0.82 0.82 0.35 0.385 0.35 0.35 0.35 0.35 0.357 0.35 8600 Hos Central Supply Facility Fee 50210 MG/MAGNESIUM A4467 270 0.99 0.693 0.35 1.6 0.82 0.35 1.2 0.35 0.82 0.82 0.82 0.82 0.35 0.385 0.35 0.35 0.35 0.35 0.357 0.35 8600 Hos Central Supply Facility Fee 50211 MG/MAGNESIUM A4467 270 29.8 20.86 28.02 128.9 65.66 28.02 96.68 28.02 65.66 65.66 65.66 65.66 28.02 30.822000000000003 28.02 28.02 28.02 28.02 28.5804 28.02 8600 Hos Central Supply Facility Fee 50100 MICROT PLAS SEP LITH HEP A4467 270 0.35 0.24499999999999997 1.25 5.76 2.93 1.25 4.32 1.25 2.93 2.93 2.93 2.93 1.25 1.375 1.25 1.25 0.2 0.2 0.20400000000000001 0.2 8600 Hos Central Supply Facility Fee 50101 MICROTAINER TUBE W/EDTA A4467 270 0.34 0.238 0.14 0.64 0.33 0.14 0.48 0.14 0.33 0.33 0.33 0.33 0.14 0.15400000000000003 0.14 0.14 0.14 0.14 0.1428 0.14 8600 Hos Central Supply Facility Fee 858 MID STREAM URINE COLLECTOR A4467 270 0.6 0.42 0.13 0.61 0.31 0.13 0.46 0.13 0.31 0.31 0.31 0.31 0.13 0.14300000000000002 0.13 0.13 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 250 MITTEN FINGER CONTROL ADT T8206 270 23.18 16.226 0.2 0.93 0.47 0.2 0.7 0.2 0.47 0.47 0.47 0.47 0.2 0.22000000000000003 0.2 0.2 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 507 MM10 SVN NEB ONLY 18206 270 0.26 0.182 0.23 1.06 0.54 0.23 0.8 0.23 0.54 0.54 0.54 0.54 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 1224 MM10 SVN W/TEE FLEX 7FT TBG 50/CS A4467 270 34.01 23.807 0.18 0.81 0.41 0.18 0.61 0.18 0.41 0.41 0.41 0.41 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 50045 MM10 SVN W/TEE M/P FLEX 7 FT TBG A4467 270 0.63 0.44099999999999995 0.15 0.69 0.35 0.15 0.52 0.15 0.35 0.35 0.35 0.35 0.15 0.165 0.15 0.15 0.15 0.15 0.153 0.15 8600 Hos Central Supply Facility Fee 50261 MMB CAL A4467 270 0.63 0.44099999999999995 0.14 0.63 0.32 0.14 0.47 0.14 0.32 0.32 0.32 0.32 0.14 0.15400000000000003 0.14 0.14 0.14 0.14 0.1428 0.14 8600 Hos Central Supply Facility Fee 50212 MMB, MASS CKMB A9270 270 0.6 0.42 0.13 0.6 0.31 0.13 0.45 0.13 0.31 0.31 0.31 0.31 0.13 0.14300000000000002 0.13 0.13 0.13 0.13 0.1326 0.13 8600 Hos Central Supply Facility Fee 50213 MMB, MASS CKMB M8699 270 154.08 107.85600000000001 0.2 0.91 0.46 0.2 0.68 0.2 0.46 0.46 0.46 0.46 0.2 0.22000000000000003 0.2 0.2 0.2 0.2 0.20400000000000001 0.2 8600 Hos Central Supply Facility Fee 50214 MMB/M-CKMB CALIBRATOR RXL M8688 270 40 28 0.23 1.04 0.53 0.23 0.78 0.23 0.53 0.53 0.53 0.53 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 50102 MOD THAYER MARTIN MTM AG A4467 270 0.24 0.16799999999999998 14.09 64.81 33.01 14.09 48.61 14.09 33.01 33.01 33.01 33.01 14.09 15.499 14.09 14.09 6.06 6.06 6.1812 6.06 8600 Hos Central Supply Facility Fee 1257 MOISTURIZER REMEDY PHYTOPLEX 2 OZ TUBE A4467 270 1.09 0.763 4.07 18.74 9.55 4.07 14.06 4.07 9.55 9.55 9.55 9.55 4.07 4.477 4.07 4.07 4.07 4.07 4.151400000000001 4.07 8600 Hos Central Supply Facility Fee 1550 MONITOR BP AUTO DIGITAL LG ADULT A4467 270 33.44 23.407999999999998 0.7 3.2 1.63 0.7 2.4 0.7 1.63 1.63 1.63 1.63 0.7 0.77 0.7 0.7 43.2 43.2 44.06400000000001 43.2 8600 Hos Central Supply Facility Fee 1854 MONOJECT NEEDLE 22G 1 1/2 A4467 270 8.38 5.8660000000000005 14.5 66.72 33.99 14.5 50.04 14.5 33.99 33.99 33.99 33.99 14.5 15.950000000000001 14.5 14.5 27.04 27.04 27.5808 27.04 8600 Hos Central Supply Facility Fee 579 MOUTHWASH,ALCOHOL FREE,4 OZ A9270 270 0.22 0.154 0.23 1.04 0.53 0.23 0.78 0.23 0.53 0.53 0.53 0.53 0.23 0.25300000000000006 0.23 0.23 0.14 0.14 0.1428 0.14 8600 Hos Central Supply Facility Fee 50103 MUELLER HINTON AGAR A4467 270 0.26 0.182 0.56 2.59 1.32 0.56 1.94 0.56 1.32 1.32 1.32 1.32 0.56 0.6160000000000001 0.56 0.56 1.03 1.03 1.0506 1.03 8600 Hos Central Supply Facility Fee 1165 MULE KICK ENZYME 25 POUND A4467 270 177.05 123.935 0.04 0.19 0.1 0.04 0.14 0.04 0.1 0.1 0.1 0.1 0.04 0.044000000000000004 0.04 0.04 0.04 0.04 0.0408 0.04 8600 Hos Central Supply Facility Fee 1473 N95 FIT TEST KIT A4467 270 140.21 98.147 9.34 42.94 21.87 9.34 32.21 9.34 21.87 21.87 21.87 21.87 9.34 10.274000000000001 9.34 9.34 9.34 9.34 9.5268 9.34 8600 Hos Central Supply Facility Fee 1748 N95 RESP. CONE REG SIZE MASK A4467 270 7.58 5.306 4.21 19.38 9.87 4.21 14.54 4.21 9.87 9.87 9.87 9.87 4.21 4.631 4.21 4.21 4.21 4.21 4.2942 4.21 8600 Hos Central Supply Facility Fee 1626 NAPSACK SANITARY DISPOSAL BAGS A4467 270 50.32 35.224 5.65 25.99 13.24 5.65 19.49 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 8600 Hos Central Supply Facility Fee 1612 NASAL M TYPE LARGE PACKING A4467 270 135.22 94.654 0.08 0.35 0.18 0.08 0.26 0.08 0.18 0.18 0.18 0.18 0.08 0.08800000000000001 0.08 0.08 0.08 0.08 0.0816 0.08 8600 Hos Central Supply Facility Fee 324 NEBULIZER JET 28% 350ML 28-98% FIO2 B4206 270 1.43 1.001 16.94 77.92 39.69 16.94 58.44 16.94 39.69 39.69 39.69 39.69 16.94 18.634000000000004 16.94 16.94 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 1731 NEBULIZER T UP DRAT WITH MOUTHPIECE A4467 270 46.7 32.69 16.99 78.15 39.81 16.99 58.61 16.99 39.81 39.81 39.81 39.81 16.99 18.689 16.99 16.99 16.99 16.99 17.3298 16.99 8600 Hos Central Supply Facility Fee 1565 NEEDLE 21G1 1/2 A4215 270 7.79 5.452999999999999 14.77 67.95 34.61 14.77 50.96 14.77 34.61 34.61 34.61 34.61 14.77 16.247 14.77 14.77 14.77 14.77 15.0654 14.77 8600 Hos Central Supply Facility Fee 1043 NEEDLE 27G1 A4467 270 11.55 8.085 35.85 164.91 84.01 35.85 123.68 35.85 84.01 84.01 84.01 84.01 35.85 39.435 35.85 35.85 35.85 35.85 36.567 35.85 8600 Hos Central Supply Facility Fee 1090 NEEDLE BD 22G 1 1/2 A4467 270 4.05 2.8349999999999995 7.6 34.94 17.8 7.6 26.21 7.6 17.8 17.8 17.8 17.8 7.6 8.36 7.6 7.6 7.6 7.6 7.752 7.6 8600 Hos Central Supply Facility Fee 1407 NEEDLE BD ECLIPSE 22G X 1 1/2 A4467 270 22.54 15.777999999999999 0.43 2 1.02 0.43 1.5 0.43 1.02 1.02 1.02 1.02 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 8600 Hos Central Supply Facility Fee 51 NEEDLE BD YALE DISP RG 19G X 1 STERILE A4208 270 0.32 0.22399999999999998 0.95 4.35 2.22 0.95 3.26 0.95 2.22 2.22 2.22 2.22 0.95 1.045 0.95 0.95 0.95 0.95 0.969 0.95 8600 Hos Central Supply Facility Fee 52 NEEDLE BD YALE DISP RG 20GX1.5 STERILE A4208 270 3.64 2.548 0.15 0.69 0.35 0.15 0.52 0.15 0.35 0.35 0.35 0.35 0.15 0.165 0.15 0.15 0.15 0.15 0.153 0.15 8600 Hos Central Supply Facility Fee 1451 NEEDLE BLUNT FILL 18G X 1 1/2 A4467 270 8.48 5.936 2.88 13.23 6.74 2.88 9.92 2.88 6.74 6.74 6.74 6.74 2.88 3.168 2.88 2.88 2.88 2.88 2.9375999999999998 2.88 8600 Hos Central Supply Facility Fee 414 NEEDLE MULTI-SAMPLE 22 X 1 A4206 270 0.07 0.049 3.01 13.85 7.06 3.01 10.39 3.01 7.06 7.06 7.06 7.06 3.01 3.311 3.01 3.01 3.01 3.01 3.0702 3.01 8600 Hos Central Supply Facility Fee 50 NEEDLE REG BEVEL 18GX11/2 STERILE A4208 270 3.19 2.2329999999999997 4.67 21.48 10.94 4.67 16.11 4.67 10.94 10.94 10.94 10.94 4.67 5.1370000000000005 4.67 4.67 4.67 4.67 4.7634 4.67 8600 Hos Central Supply Facility Fee 1293 NEEDLE REG BEVEL 22G 1 1/2IN A4467 270 12.68 8.876 4.26 19.61 9.99 4.26 14.71 4.26 9.99 9.99 9.99 9.99 4.26 4.686 4.26 4.26 4.26 4.26 4.3452 4.26 8600 Hos Central Supply Facility Fee 383 NEEDLE REG BEVEL 22GX1 STERILE E1206 270 3.55 2.485 18.92 87.03 44.33 18.92 65.27 18.92 44.33 44.33 44.33 44.33 18.92 20.812000000000005 18.92 18.92 18.92 18.92 19.2984 18.92 8600 Hos Central Supply Facility Fee 53 NEEDLE REG BEVEL 23GX1 STERILE A4208 270 3.69 2.5829999999999997 0.15 0.67 0.34 0.15 0.5 0.15 0.34 0.34 0.34 0.34 0.15 0.165 0.15 0.15 0.15 0.15 0.153 0.15 8600 Hos Central Supply Facility Fee 56 NEEDLE REG BEVEL 25G X 1 1/2 A4208 270 3.62 2.534 0.19 0.86 0.44 0.19 0.65 0.19 0.44 0.44 0.44 0.44 0.19 0.20900000000000002 0.19 0.19 0.19 0.19 0.1938 0.19 8600 Hos Central Supply Facility Fee 55 NEEDLE REG BEVEL 25GX1 A4208 270 4.05 2.8349999999999995 24.89 114.47 58.31 24.89 85.85 24.89 58.31 58.31 58.31 58.31 24.89 27.379 24.89 24.89 24.89 24.89 25.387800000000002 24.89 8600 Hos Central Supply Facility Fee 54 NEEDLE REG BEVEL 25X5/8 STERILE A4208 270 3.72 2.604 2.1 9.65 4.92 2.1 7.24 2.1 4.92 4.92 4.92 4.92 2.1 2.3100000000000005 2.1 2.1 2.1 2.1 2.1420000000000003 2.1 8600 Hos Central Supply Facility Fee 1033 NEEDLE SAFETYGLIDE 22GX1.5 A4215 270 16.08 11.255999999999998 0.06 0.29 0.15 0.06 0.22 0.06 0.15 0.15 0.15 0.15 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 386 NEEDLE SAFETYLOK 3ML 23GX1IN H1N1 A4206 270 22.69 15.883 0.59 2.72 1.39 0.59 2.04 0.59 1.39 1.39 1.39 1.39 0.59 0.649 0.59 0.59 0.59 0.59 0.6018 0.59 8600 Hos Central Supply Facility Fee 237 NEEDLE SPINAL S/SU 22 G 3-1/2 IN QUINCKE E8206 270 0.28 0.196 0.05 0.21 0.11 0.05 0.16 0.05 0.11 0.11 0.11 0.11 0.05 0.05500000000000001 0.05 0.05 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 109 NEEDLE VENIPUNCTURE PRO DEVICE 40 E3206 270 0.12 0.08399999999999999 31.74 145.98 74.36 31.74 109.49 31.74 74.36 74.36 74.36 74.36 31.74 34.914 31.74 31.74 31.74 31.74 32.3748 31.74 8600 Hos Central Supply Facility Fee 1712 NEEDLE, SPINAL 22G 3 -1/2IN A4215 270 30.78 21.546 3.55 16.33 8.32 3.55 12.25 3.55 8.32 8.32 8.32 8.32 3.55 3.9050000000000002 3.55 3.55 3.55 3.55 3.621 3.55 8600 Hos Central Supply Facility Fee 50215 NEG URINE COMBO 51 A4467 270 235.2 164.64 0.24 1.09 0.56 0.24 0.82 0.24 0.56 0.56 0.56 0.56 0.24 0.264 0.24 0.24 0.24 0.24 0.2448 0.24 8600 Hos Central Supply Facility Fee 458 NEW FORMULA BIOFREEZE GEL - 32 OZ. PUMP A9270 270 46.41 32.486999999999995 2.46 11.33 5.77 2.46 8.5 2.46 5.77 5.77 5.77 5.77 2.46 2.706 2.46 2.46 0.45 0.45 0.459 0.45 8600 Hos Central Supply Facility Fee 820 NITRO SETS A4467 270 4.22 2.9539999999999997 0.61 2.79 1.42 0.61 2.09 0.61 1.42 1.42 1.42 1.42 0.61 0.671 0.61 0.61 1.35 1.35 1.3770000000000002 1.35 8600 Hos Central Supply Facility Fee 966 ORTHO GLASS SPLINT SYSTEM A4467 270 157.64 110.34799999999998 40.5 186.29 94.9 40.5 139.72 40.5 94.9 94.9 94.9 94.9 40.5 44.550000000000004 40.5 40.5 8.59 8.59 8.7618 8.59 8600 Hos Central Supply Facility Fee 160 PACK HEAT 10 IN X 18 IN SPINAL HOTPACS HYDRO C6206 270 26.3 18.41 8.59 39.49 20.12 8.59 29.62 8.59 20.12 20.12 20.12 20.12 8.59 9.449 8.59 8.59 0.64 0.64 0.6528 0.64 8600 Hos Central Supply Facility Fee 159 PACK HEAT 24 IN NECK CONTOUR PK HOTPACS C0206 270 18.8 13.16 0.27 1.25 0.64 0.27 0.94 0.27 0.64 0.64 0.64 0.64 0.27 0.29700000000000004 0.27 0.27 0.27 0.27 0.27540000000000003 0.27 8600 Hos Central Supply Facility Fee 622 PACK,COLD,INSTANT,HEAVY-WEIGHT,6X10 A6669 270 0.34 0.238 1.95 8.97 4.57 1.95 6.73 1.95 4.57 4.57 4.57 4.57 1.95 2.145 1.95 1.95 1.95 1.95 1.9889999999999999 1.95 8600 Hos Central Supply Facility Fee 272 PACKING CURITY F1/4 IN X 5 YD STRIP PLAIN C3206 270 2.98 2.086 0.11 0.51 0.26 0.11 0.38 0.11 0.26 0.26 0.26 0.26 0.11 0.12100000000000001 0.11 0.11 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 1178 PAD ALCHO; PREP MEDIUM A4467 270 1.09 0.763 0.08 0.39 0.2 0.08 0.29 0.08 0.2 0.2 0.2 0.2 0.08 0.08800000000000001 0.08 0.08 2.76 2.76 2.8152 2.76 8600 Hos Central Supply Facility Fee 1179 PAD ALCOHOL PREP MEDIUM A4467 270 1.18 0.826 0.23 1.04 0.53 0.23 0.78 0.23 0.53 0.53 0.53 0.53 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 1176 PAD ALCOHOL PREP PAD MEDIUM A4467 270 1.09 0.763 0.67 3.08 1.57 0.67 2.31 0.67 1.57 1.57 1.57 1.57 0.67 0.7370000000000001 0.67 0.67 0.67 0.67 0.6834 0.67 8600 Hos Central Supply Facility Fee 165 PAD BOVIE ADULT D8206 270 5.05 3.5349999999999997 0.73 3.34 1.7 0.73 2.51 0.73 1.7 1.7 1.7 1.7 0.73 0.803 0.73 0.73 0.73 0.73 0.7446 0.73 8600 Hos Central Supply Facility Fee 1061 PAD SANITARY IND. BOX A4467 270 0.14 0.098 1.59 7.33 3.73 1.59 5.5 1.59 3.73 3.73 3.73 3.73 1.59 1.7490000000000003 1.59 1.59 17.17 17.17 17.5134 17.17 8600 Hos Central Supply Facility Fee 1022 PAD SANITARY WITH ADHESIVE A4467 270 43.62 30.533999999999995 1.16 5.33 2.72 1.16 4 1.16 2.72 2.72 2.72 2.72 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 1610 PADDING CAST 4 L2132 270 7.5 5.25 1.58 7.25 3.69 1.58 5.44 1.58 3.69 3.69 3.69 3.69 1.58 1.7380000000000002 1.58 1.58 14.59 14.59 14.8818 14.59 8600 Hos Central Supply Facility Fee 1611 PADDING CAST 6 L2132 270 5.21 3.647 1.58 7.25 3.69 1.58 5.44 1.58 3.69 3.69 3.69 3.69 1.58 1.7380000000000002 1.58 1.58 1.58 1.58 1.6116000000000001 1.58 8600 Hos Central Supply Facility Fee 618 PAN,SPECIMEN,URINE/STOOL,GRADUATED A4467 270 163.5 114.44999999999999 35.54 163.5 83.29 35.54 122.63 35.54 83.29 83.29 83.29 83.29 35.54 39.094 35.54 35.54 5.33 5.33 5.4366 5.33 8600 Hos Central Supply Facility Fee 50216 PANEL, POS BP COMBO 20 A4467 270 235.2 164.64 7.86 36.14 18.41 7.86 27.11 7.86 18.41 18.41 18.41 18.41 7.86 8.646 7.86 7.86 5.32 5.32 5.4264 5.32 8600 Hos Central Supply Facility Fee 50118 PANOSCREEN 2 X 10 A4467 270 13 9.1 5.31 24.43 12.44 5.31 18.32 5.31 12.44 12.44 12.44 12.44 5.31 5.841 5.31 5.31 5.31 5.31 5.4162 5.31 8600 Hos Central Supply Facility Fee 1687 PANT SCRUB BLUE LG DISP A4467 270 27.2 19.04 2.12 9.73 4.96 2.12 7.3 2.12 4.96 4.96 4.96 4.96 2.12 2.3320000000000003 2.12 2.12 2.12 2.12 2.1624000000000003 2.12 8600 Hos Central Supply Facility Fee 1209 PANT SCRUB DISP 3XL A6539 270 1.04 0.728 2.78 12.79 6.52 2.78 9.59 2.78 6.52 6.52 6.52 6.52 2.78 3.058 2.78 2.78 2.78 2.78 2.8356 2.78 8600 Hos Central Supply Facility Fee 1208 PANT SCRUB DISP BLUE LG A6539 270 0.91 0.637 1.97 9.05 4.61 1.97 6.79 1.97 4.61 4.61 4.61 4.61 1.97 2.1670000000000003 1.97 1.97 1.97 1.97 2.0094 1.97 8600 Hos Central Supply Facility Fee 1203 PANT SCRUB DISPOSABLE ELASTIC WAIST BLUE 2XL A6539 270 1.06 0.742 0.16 0.73 0.37 0.16 0.55 0.16 0.37 0.37 0.37 0.37 0.16 0.17600000000000002 0.16 0.16 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 1200 PANT SCRUB DISPOSABLE ELASTIC WAIST BLUE MD A6539 270 0.95 0.6649999999999999 20.96 96.43 49.12 20.96 72.32 20.96 49.12 49.12 49.12 49.12 20.96 23.056000000000004 20.96 20.96 20.96 20.96 21.3792 20.96 8600 Hos Central Supply Facility Fee 1201 PANT SCRUB DISPOSABLE ELASTIC WAIST BLUE SM A6539 270 0.95 0.6649999999999999 10.44 48 24.45 10.44 36 10.44 24.45 24.45 24.45 24.45 10.44 11.484 10.44 10.44 10.44 10.44 10.6488 10.44 8600 Hos Central Supply Facility Fee 1202 PANT SCRUB DISPOSABLE ELASTIC WAIST BLUE XL A6539 270 0.93 0.651 18.77 86.35 43.99 18.77 64.76 18.77 43.99 43.99 43.99 43.99 18.77 20.647000000000002 18.77 18.77 18.77 18.77 19.1454 18.77 8600 Hos Central Supply Facility Fee 1204 PANT SCRUB DISPOSABLE ELASTIC WAIST BLUE XXXL A6539 270 0.81 0.567 4.14 19.06 9.71 4.14 14.3 4.14 9.71 9.71 9.71 9.71 4.14 4.554 4.14 4.14 4.14 4.14 4.222799999999999 4.14 8600 Hos Central Supply Facility Fee 945 PANTY DISPOSABLE A4467 270 290.33 203.23099999999997 3.24 14.89 7.58 3.24 11.17 3.24 7.58 7.58 7.58 7.58 3.24 3.5640000000000005 3.24 3.24 3.24 3.24 3.3048 3.24 8600 Hos Central Supply Facility Fee 921 PAPER EXAM TABLE 21 A4467 270 3.03 2.1209999999999996 70.48 324.18 165.14 70.48 243.14 70.48 165.14 165.14 165.14 165.14 70.48 77.528 70.48 70.48 4.14 4.14 4.222799999999999 4.14 8600 Hos Central Supply Facility Fee 1101 PAPER ROLLS THERMAL A8699 270 26.88 18.816 2.13 9.81 5 2.13 7.36 2.13 5 5 5 5 2.13 2.343 2.13 2.13 2.13 2.13 2.1726 2.13 8600 Hos Central Supply Facility Fee 1831 PAPER THERMAL ASSURANCE ECLIPSE 850 A4467 270 264.35 185.04500000000002 2.2 10.12 5.16 2.2 7.59 2.2 5.16 5.16 5.16 5.16 2.2 2.4200000000000004 2.2 2.2 2.2 2.2 2.244 2.2 8600 Hos Central Supply Facility Fee 1832 PAPER THERMAL ASSURANCE ECLIPSE 850 A4467 270 338.71 237.09699999999998 2.81 12.91 6.58 2.81 9.68 2.81 6.58 6.58 6.58 6.58 2.81 3.091 2.81 2.81 2.81 2.81 2.8662 2.81 8600 Hos Central Supply Facility Fee 1336 PAPER TISSUE FACIAL PREM A4467 270 1.2 0.84 3.56 16.38 8.34 3.56 12.29 3.56 8.34 8.34 8.34 8.34 3.56 3.9160000000000004 3.56 3.56 3.56 3.56 3.6312 3.56 8600 Hos Central Supply Facility Fee 50217 PAPER XL/RXL/IND/STAR A4467 270 54.8 38.35999999999999 2.13 9.81 5 2.13 7.36 2.13 5 5 5 5 2.13 2.343 2.13 2.13 2.13 2.13 2.1726 2.13 8600 Hos Central Supply Facility Fee 558 PAPER,EXAM TABLE,STND,CREPE,21X125' P1206 270 2.27 1.589 2.09 9.61 4.9 2.09 7.21 2.09 4.9 4.9 4.9 4.9 2.09 2.299 2.09 2.09 2.09 2.09 2.1317999999999997 2.09 8600 Hos Central Supply Facility Fee 759 PAPERMATE COMFORTABLE BALLPOINT PENS MEDIUM POINT 1.0 MM RED INK RED BARREL A4467 270 0.33 0.23099999999999998 9.02 41.5 21.14 9.02 31.13 9.02 21.14 21.14 21.14 21.14 9.02 9.922 9.02 9.02 9.02 9.02 9.2004 9.02 8600 Hos Central Supply Facility Fee 839 PARACENTESIS/THORACENTESIS TRAY A4467 270 23.74 16.618 9.7 44.63 22.73 9.7 33.47 9.7 22.73 22.73 22.73 22.73 9.7 10.67 9.7 9.7 9.7 9.7 9.894 9.7 8600 Hos Central Supply Facility Fee 130 PATCH SURGIPRO MESH HERNIA LARGE T3206 270 172.95 121.06499999999998 16.38 75.36 38.39 16.38 56.52 16.38 38.39 38.39 38.39 38.39 16.38 18.018 16.38 16.38 19.01 19.01 19.390200000000004 19.01 8600 Hos Central Supply Facility Fee 822 PCA SET A4467 270 2.16 1.512 13.48 62 31.58 13.48 46.5 13.48 31.58 31.58 31.58 31.58 13.48 14.828000000000001 13.48 13.48 13.48 13.48 13.749600000000001 13.48 8600 Hos Central Supply Facility Fee 1225 PCB ASSEMBLY A4467 270 180.07 126.04899999999999 4.74 21.81 11.11 4.74 16.36 4.74 11.11 11.11 11.11 11.11 4.74 5.214 4.74 4.74 4.74 4.74 4.8348 4.74 8600 Hos Central Supply Facility Fee 50468 PDI SANI CLOTH PLUS WIPES N/A 270 11.93 8.350999999999999 22.66 104.23 53.09 22.66 78.17 22.66 53.09 53.09 53.09 53.09 22.66 24.926000000000002 22.66 22.66 22.66 22.66 23.1132 22.66 8600 Hos Central Supply Facility Fee 69 PEDIATRIC DRAPE, TIBURION A4206 270 4.33 3.0309999999999997 0.07 0.34 0.17 0.07 0.26 0.07 0.17 0.17 0.17 0.17 0.07 0.07700000000000001 0.07 0.07 0.07 0.07 0.0714 0.07 8600 Hos Central Supply Facility Fee 840 PEDIATRIC LUMBAR PUNCTURE TRAY A4467 270 6.53 4.571 1.29 5.93 3.02 1.29 4.45 1.29 3.02 3.02 3.02 3.02 1.29 1.4190000000000003 1.29 1.29 1.29 1.29 1.3158 1.29 8600 Hos Central Supply Facility Fee 253 PENCIL BUTTON SWITCH HOLSTER STERILE N0206 270 5.12 3.5839999999999996 2.71 12.48 6.36 2.71 9.36 2.71 6.36 6.36 6.36 6.36 2.71 2.9810000000000003 2.71 2.71 0.59 0.59 0.6018 0.59 8600 Hos Central Supply Facility Fee 303 PENROSE DRAIN 18 X 12 067 N4206 270 2.36 1.652 0.66 3.04 1.55 0.66 2.28 0.66 1.55 1.55 1.55 1.55 0.66 0.7260000000000001 0.66 0.66 0.66 0.66 0.6732 0.66 8600 Hos Central Supply Facility Fee 912 PENS ZEBRA, BLUE GEL A4467 270 5.22 3.6539999999999995 16.87 77.61 39.53 16.87 58.21 16.87 39.53 39.53 39.53 39.53 16.87 18.557000000000002 16.87 16.87 16.87 16.87 17.2074 16.87 8600 Hos Central Supply Facility Fee 1738 PENTEL DELUX LIQUID GEL-INK PENS A9270 270 14.28 9.995999999999999 3.39 15.6 7.95 3.39 11.7 3.39 7.95 7.95 7.95 7.95 3.39 3.7290000000000005 3.39 3.39 1.63 1.63 1.6625999999999999 1.63 8600 Hos Central Supply Facility Fee 65 PERI/GYN PACK, TIBURION A4648 270 7.26 5.082 5.58 25.67 13.08 5.58 19.25 5.58 13.08 13.08 13.08 13.08 5.58 6.138000000000001 5.58 5.58 5.58 5.58 5.6916 5.58 8600 Hos Central Supply Facility Fee 983 PERMANENT MARKERS CHISEL TIP BLACK A4467 270 0.3 0.21 2.7 12.43 6.33 2.7 9.32 2.7 6.33 6.33 6.33 6.33 2.7 2.9700000000000006 2.7 2.7 2.7 2.7 2.7540000000000004 2.7 8600 Hos Central Supply Facility Fee 1778 PETROLATUM WHITE 5 GR FOIL PACK A4467 270 14.31 10.017 0.32 1.49 0.76 0.32 1.12 0.32 0.76 0.76 0.76 0.76 0.32 0.35200000000000004 0.32 0.32 0.3 0.3 0.306 0.3 8600 Hos Central Supply Facility Fee 616 PETROLEUM JEL 5G FOIL PK A4467 270 7.32 5.124 0.32 1.49 0.76 0.32 1.12 0.32 0.76 0.76 0.76 0.76 0.32 0.35200000000000004 0.32 0.32 0.32 0.32 0.3264 0.32 8600 Hos Central Supply Facility Fee 50218 PHENYTOIN FLEX A4467 270 4.01 2.8069999999999995 1.15 5.31 2.7 1.15 3.98 1.15 2.7 2.7 2.7 2.7 1.15 1.265 1.15 1.15 1.15 1.15 1.1729999999999998 1.15 8600 Hos Central Supply Facility Fee 50219 PHENYTOIN FLEX A4467 270 145.15 101.605 0.18 0.83 0.42 0.18 0.62 0.18 0.42 0.42 0.42 0.42 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 830 PHOSPATE SALINE ENEMA A4467 270 0.64 0.44799999999999995 22.56 103.78 52.87 22.56 77.84 22.56 52.87 52.87 52.87 52.87 22.56 24.816 22.56 22.56 22.56 22.56 23.0112 22.56 8600 Hos Central Supply Facility Fee 1452 PILL SPLITTER A4467 270 1.63 1.1409999999999998 3.05 14.03 7.15 3.05 10.52 3.05 7.15 7.15 7.15 7.15 3.05 3.355 3.05 3.05 3.05 3.05 3.1109999999999998 3.05 8600 Hos Central Supply Facility Fee 50308 PILLOW DISPOSABLE 11OZ I8633 270 23.61 16.526999999999997 0.28 1.27 0.65 0.28 0.95 0.28 0.65 0.65 0.65 0.65 0.28 0.30800000000000005 0.28 0.28 0.28 0.28 0.2856 0.28 8600 Hos Central Supply Facility Fee 50404 PILLOW OVATION WHITE 20 X 26 A4467 270 2.66 1.8619999999999999 11.55 53.11 27.05 11.55 39.83 11.55 27.05 27.05 27.05 27.05 11.55 12.705000000000002 11.55 11.55 11.55 11.55 11.781 11.55 8600 Hos Central Supply Facility Fee 50120 PILLOW,DISPOSABLE,21X27,HEAVY WT,12/CS A4467 270 1.94 1.3579999999999999 2.64 12.15 6.19 2.64 9.11 2.64 6.19 6.19 6.19 6.19 2.64 2.9040000000000004 2.64 2.64 2.64 2.64 2.6928 2.64 8600 Hos Central Supply Facility Fee 50356 PILLOWS OVATION BLUE RESUEABLE A4467 270 3.06 2.142 0.6 2.74 1.4 0.6 2.06 0.6 1.4 1.4 1.4 1.4 0.6 0.66 0.6 0.6 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 1739 PILOT ACROBALL PENS MED. POINT BLUE INK A4467 270 1.75 1.2249999999999999 5 22.99 11.71 5 17.24 5 11.71 11.71 11.71 11.71 5 5.5 5 5 5 5 5.1 5 8600 Hos Central Supply Facility Fee 394 PIN SAFETY MED STERILE 2EA/PK N7206 270 0.55 0.385 9.16 42.13 21.46 9.16 31.6 9.16 21.46 21.46 21.46 21.46 9.16 10.076 9.16 9.16 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 888 PLASTIC BINDING COMBS A9270 270 8.4 5.88 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 8600 Hos Central Supply Facility Fee 44 POUCH SPECIMEN 10MM ENDO CATCH GOLD A4413 270 197.1 137.97 43.27 199.04 101.39 43.27 149.28 43.27 101.39 101.39 101.39 101.39 43.27 47.59700000000001 43.27 43.27 6.27 6.27 6.3953999999999995 6.27 8600 Hos Central Supply Facility Fee 122 POUCH STER L16INXW8IN SLF S PP10546 HPG A4413 270 0.12 0.08399999999999999 132.94 611.49 311.49 132.94 458.62 132.94 311.49 311.49 311.49 311.49 132.94 146.234 132.94 132.94 132.94 132.94 135.5988 132.94 8600 Hos Central Supply Facility Fee 1438 POUCH SUR-FIT NATURAL DRAINABLE A4413 270 0.75 0.5249999999999999 4.9 22.54 11.48 4.9 16.91 4.9 11.48 11.48 11.48 11.48 4.9 5.390000000000001 4.9 4.9 4.9 4.9 4.998 4.9 8600 Hos Central Supply Facility Fee 399 POUCH TRANSPORT BLUE STANDARD 11IN STOMA SIZE UP TO 2IN A4413 270 1.89 1.323 17.48 80.4 40.96 17.48 60.3 17.48 40.96 40.96 40.96 40.96 17.48 19.228 17.48 17.48 17.48 17.48 17.8296 17.48 8600 Hos Central Supply Facility Fee 1664 POUCH-SUR-FIT 12IN OPAQUE 2 3/4IN A4413 270 38.59 27.013 7.91 36.38 18.53 7.91 27.29 7.91 18.53 18.53 18.53 18.53 7.91 8.701 7.91 7.91 7.91 7.91 8.068200000000001 7.91 8600 Hos Central Supply Facility Fee 1404 POWDER BABY TALC 2OZ A4467 270 0.38 0.26599999999999996 1.4 6.42 3.27 1.4 4.82 1.4 3.27 3.27 3.27 3.27 1.4 1.54 1.4 1.4 1.4 1.4 1.428 1.4 8600 Hos Central Supply Facility Fee 577 POWDER,BABY,TALC,4 OZ A4467 270 0.37 0.259 0.06 0.27 0.14 0.06 0.2 0.06 0.14 0.14 0.14 0.14 0.06 0.066 0.06 0.06 0.06 0.06 0.0612 0.06 8600 Hos Central Supply Facility Fee 962 PREP ALCOHOL A4467 270 1.85 1.295 0.27 1.22 0.62 0.27 0.92 0.27 0.62 0.62 0.62 0.62 0.27 0.29700000000000004 0.27 0.27 107.62 107.62 109.7724 107.62 8600 Hos Central Supply Facility Fee 433 PREP ALCOHOL LARGE 2-PLY WEBCOL STERILE A4245 270 2.06 1.442 0.29 1.32 0.67 0.29 0.99 0.29 0.67 0.67 0.67 0.67 0.29 0.319 0.29 0.29 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 818 PRIMARY IV PLUM SET A4467 270 3.49 2.443 2.33 10.73 5.47 2.33 8.05 2.33 5.47 5.47 5.47 5.47 2.33 2.563 2.33 2.33 2.33 2.33 2.3766000000000003 2.33 8600 Hos Central Supply Facility Fee 815 PRIMARY IV SET A4467 270 3.09 2.163 5.01 23.05 11.74 5.01 17.29 5.01 11.74 11.74 11.74 11.74 5.01 5.511 5.01 5.01 5.01 5.01 5.1102 5.01 8600 Hos Central Supply Facility Fee 1019 PRIMARY PLUMSET CLAVE Y-SITE S1015 270 198.39 138.873 0.39 1.8 0.92 0.39 1.35 0.39 0.92 0.92 0.92 0.92 0.39 0.42900000000000005 0.39 0.39 0.39 0.39 0.39780000000000004 0.39 8600 Hos Central Supply Facility Fee 41 PROBE COVER DISP FOR SURETEMP A4206 270 0.72 0.504 4.13 18.98 9.67 4.13 14.24 4.13 9.67 9.67 9.67 9.67 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 8600 Hos Central Supply Facility Fee 871 PROBE COVER SURETEMP A4649 270 6.52 4.563999999999999 1.58 7.28 3.71 1.58 5.46 1.58 3.71 3.71 3.71 3.71 1.58 1.7380000000000002 1.58 1.58 1.58 1.58 1.6116000000000001 1.58 8600 Hos Central Supply Facility Fee 313 PROBE FOGARTY BILIARY BALLOON 5F 23 CM O3206 270 35.98 25.185999999999996 6.2 28.53 14.53 6.2 21.4 6.2 14.53 14.53 14.53 14.53 6.2 6.820000000000001 6.2 6.2 6.2 6.2 6.324000000000001 6.2 8600 Hos Central Supply Facility Fee 1690 PROBE WELL KIT 9FT ORAL A4467 270 53.69 37.583 0.12 0.57 0.29 0.12 0.43 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 1250 PROBE WELL KIT ORAL A4467 270 114.47 80.12899999999999 2.1 9.67 4.93 2.1 7.25 2.1 4.93 4.93 4.93 4.93 2.1 2.3100000000000005 2.1 2.1 2.1 2.1 2.1420000000000003 2.1 8600 Hos Central Supply Facility Fee 50220 PROMPT INOCULATION SYSTEM-D (60) A9270 270 18.69 13.083 4.06 18.69 9.52 4.06 14.02 4.06 9.52 9.52 9.52 9.52 4.06 4.466 4.06 4.06 4.06 4.06 4.1411999999999995 4.06 8600 Hos Central Supply Facility Fee 50412 PRO-STRIP ULTRA DIVERSY N/A 270 68.98 48.286 0.95 4.39 2.24 0.95 3.29 0.95 2.24 2.24 2.24 2.24 0.95 1.045 0.95 0.95 0.95 0.95 0.969 0.95 8600 Hos Central Supply Facility Fee 954 PROTECTANT, SKIN REMEDY R8633 270 33.23 23.260999999999996 0.18 0.84 0.43 0.18 0.63 0.18 0.43 0.43 0.43 0.43 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 168 PROTECTOR MESH HEEL/ELBOW REPAIR O1206 270 3.85 2.695 1.34 6.15 3.13 1.34 4.61 1.34 3.13 3.13 3.13 3.13 1.34 1.4740000000000002 1.34 1.34 1.34 1.34 1.3668 1.34 8600 Hos Central Supply Facility Fee 50280 PUMIE SCOURING STICK U8699 270 25.31 17.717 8.53 39.23 19.98 8.53 29.42 8.53 19.98 19.98 19.98 19.98 8.53 9.383000000000001 8.53 8.53 1.34 1.34 1.3668 1.34 8600 Hos Central Supply Facility Fee 1803 PUNCH BIOPSY 2MM U8622 270 42.64 29.848 4.44 20.43 10.41 4.44 15.32 4.44 10.41 10.41 10.41 10.41 4.44 4.884000000000001 4.44 4.44 4.44 4.44 4.5288 4.44 8600 Hos Central Supply Facility Fee 794 PURCHASE ORDER BOOK CARBONLESS 3 PARTS 8 1/2 X 11 A4467 270 15.67 10.969 0.02 0.07 0.04 0.02 0.05 0.02 0.04 0.04 0.04 0.04 0.02 0.022000000000000002 0.02 0.02 0.02 0.02 0.0204 0.02 8600 Hos Central Supply Facility Fee 797 PURCHASE ORDER BOOK CARBONLESS 3 PARTS 8 1/2 X 11 A4467 270 15.67 10.969 3.42 15.75 8.02 3.42 11.81 3.42 8.02 8.02 8.02 8.02 3.42 3.762 3.42 3.42 3.42 3.42 3.4884 3.42 8600 Hos Central Supply Facility Fee 1667 PURELL ADV HAND SANITIZER 36/1OZ A4467 270 86.76 60.732 0.16 0.75 0.38 0.16 0.56 0.16 0.38 0.38 0.38 0.38 0.16 0.17600000000000002 0.16 0.16 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 1314 PURELL ADV. GREEN INSTANT HAND SANITIZER 1200 ML 2/PK A4467 270 24.47 17.128999999999998 0.18 0.81 0.41 0.18 0.61 0.18 0.41 0.41 0.41 0.41 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 1381 PURELL INSTANT HAND SANITIZER A4467 270 45.13 31.591 8.3 38.16 19.44 8.3 28.62 8.3 19.44 19.44 19.44 19.44 8.3 9.13 8.3 8.3 0.24 0.24 0.2448 0.24 8600 Hos Central Supply Facility Fee 82 PURSTRING 65 INSTRUMENT SINGLE USE R9206 270 193.98 135.78599999999997 1.48 6.8 3.46 1.48 5.1 1.48 3.46 3.46 3.46 3.46 1.48 1.6280000000000001 1.48 1.48 5.87 5.87 5.9874 5.87 8600 Hos Central Supply Facility Fee 50598 PWCBL COMPLETE LEAD SET AAMI N/A 270 146.73 102.71099999999998 4.55 20.92 10.66 4.55 15.69 4.55 10.66 10.66 10.66 10.66 4.55 5.005 4.55 4.55 4.55 4.55 4.641 4.55 8600 Hos Central Supply Facility Fee 1123 QUICK VIEW INFLUENZA SWABS A4467 270 741.29 518.9029999999999 0.32 1.46 0.74 0.32 1.1 0.32 0.74 0.74 0.74 0.74 0.32 0.35200000000000004 0.32 0.32 0.32 0.32 0.3264 0.32 8600 Hos Central Supply Facility Fee 50104 QUICKVUE INFLUENZA A + B A4467 270 11.88 8.316 14.7 67.61 34.44 14.7 50.71 14.7 34.44 34.44 34.44 34.44 14.7 16.17 14.7 14.7 14.7 14.7 14.994 14.7 8600 Hos Central Supply Facility Fee 1006 QUICKVUE INFLUENZA A/B 25T A4467 270 278.75 195.125 5.89 27.1 13.8 5.89 20.33 5.89 13.8 13.8 13.8 13.8 5.89 6.479 5.89 5.89 5.89 5.89 6.0078 5.89 8600 Hos Central Supply Facility Fee 1131 QUICKVUE INFLUENZA TEST 87804 270 292.63 204.84099999999998 1.84 8.48 4.32 1.84 6.36 1.84 4.32 4.32 4.32 4.32 1.84 2.0240000000000005 1.84 1.84 1.84 1.84 1.8768 1.84 8600 Hos Central Supply Facility Fee 1455 QUICKVUE PLUS ONE-STEP HCG COMBO 81025 270 52.23 36.56099999999999 0.35 1.63 0.83 0.35 1.22 0.35 0.83 0.83 0.83 0.83 0.35 0.385 0.35 0.35 0.35 0.35 0.357 0.35 8600 Hos Central Supply Facility Fee 50221 QUIKLYTE FLUSH SOL. 3 X 1000 ML A4467 270 96.82 67.77399999999999 1.68 7.71 3.93 1.68 5.78 1.68 3.93 3.93 3.93 3.93 1.68 1.848 1.68 1.68 1.68 1.68 1.7136 1.68 8600 Hos Central Supply Facility Fee 50222 QUIKLYTE NA/K/CL INDIRECT DENS A4467 270 101.21 70.847 0.41 1.87 0.95 0.41 1.4 0.41 0.95 0.95 0.95 0.95 0.41 0.451 0.41 0.41 0.41 0.41 0.41819999999999996 0.41 8600 Hos Central Supply Facility Fee 1559 RAPID CARTRIDGE STAPLES (YELLOW) A4467 270 16.14 11.298 2.47 11.34 5.78 2.47 8.51 2.47 5.78 5.78 5.78 5.78 2.47 2.7170000000000005 2.47 2.47 11.35 11.35 11.577 11.35 8600 Hos Central Supply Facility Fee 1723 RAYOVAC LED LANTERN BLACK A4467 270 40.11 28.076999999999998 0.73 3.38 1.72 0.73 2.54 0.73 1.72 1.72 1.72 1.72 0.73 0.803 0.73 0.73 0.73 0.73 0.7446 0.73 8600 Hos Central Supply Facility Fee 832 RAZORS PATIENT A4467 270 0.13 0.091 26.98 124.11 63.22 26.98 93.08 26.98 63.22 63.22 63.22 63.22 26.98 29.678000000000004 26.98 26.98 26.98 26.98 27.5196 26.98 8600 Hos Central Supply Facility Fee 50223 R-CTNI TROPONIN FLEX A9270 270 5.74 4.018 0.72 3.31 1.69 0.72 2.48 0.72 1.69 1.69 1.69 1.69 0.72 0.792 0.72 0.72 0.16 0.16 0.1632 0.16 8600 Hos Central Supply Facility Fee 50224 R-CTNI TROPONIN FLEX A9270 270 211.68 148.176 2.45 11.25 5.73 2.45 8.44 2.45 5.73 5.73 5.73 5.73 2.45 2.6950000000000003 2.45 2.45 2.45 2.45 2.499 2.45 8600 Hos Central Supply Facility Fee 50225 REACTION TUBE SYSMEX CA 3 X 1000 EA/P A4467 270 210 147 11.04 50.79 25.87 11.04 38.09 11.04 25.87 25.87 25.87 25.87 11.04 12.144 11.04 11.04 11.04 11.04 11.2608 11.04 8600 Hos Central Supply Facility Fee 578 READYBATH, SELECT, AB, FRAG FREE, 8/PK A4467 270 0.85 0.595 5.27 24.25 12.35 5.27 18.19 5.27 12.35 12.35 12.35 12.35 5.27 5.797 5.27 5.27 5.27 5.27 5.3754 5.27 8600 Hos Central Supply Facility Fee 834 RECTAL TUBE A4467 270 0.92 0.644 23.14 106.44 54.22 23.14 79.83 23.14 54.22 54.22 54.22 54.22 23.14 25.454000000000004 23.14 23.14 9.13 9.13 9.312600000000002 9.13 8600 Hos Central Supply Facility Fee 1001 REMEDY SHAMPOO AND BODY WASH 4 OZ A4467 270 0.33 0.23099999999999998 13.64 62.76 31.97 13.64 47.07 13.64 31.97 31.97 31.97 31.97 13.64 15.004000000000001 13.64 13.64 30.48 30.48 31.0896 30.48 8600 Hos Central Supply Facility Fee 997 REMEDY SHOWER AND BODY WASH A4467 270 19.8 13.86 1.94 8.94 4.55 1.94 6.71 1.94 4.55 4.55 4.55 4.55 1.94 2.134 1.94 1.94 1.94 1.94 1.9788 1.94 8600 Hos Central Supply Facility Fee 270 REMOVER STAPLE M3206 270 1.39 0.9729999999999999 2.89 13.3 6.78 2.89 9.98 2.89 6.78 6.78 6.78 6.78 2.89 3.1790000000000003 2.89 2.89 2.89 2.89 2.9478 2.89 8600 Hos Central Supply Facility Fee 904 RESTRAIANT VEST M E8622 270 40.29 28.202999999999996 4.04 18.6 9.47 4.04 13.95 4.04 9.47 9.47 9.47 9.47 4.04 4.444000000000001 4.04 4.04 1.32 1.32 1.3464 1.32 8600 Hos Central Supply Facility Fee 903 RESTRAINT VEST SM E8622 270 40.29 28.202999999999996 2.31 10.62 5.41 2.31 7.97 2.31 5.41 5.41 5.41 5.41 2.31 2.5410000000000004 2.31 2.31 2.31 2.31 2.3562000000000003 2.31 8600 Hos Central Supply Facility Fee 50055 RESUS BAG ADULT W/PEEP A4467 270 18.59 13.013 4.78 21.99 11.2 4.78 16.49 4.78 11.2 11.2 11.2 11.2 4.78 5.258000000000001 4.78 4.78 4.78 4.78 4.8756 4.78 8600 Hos Central Supply Facility Fee 50056 RESUS BAG PEDIATRIC MANUAL A4467 270 18.09 12.662999999999998 0.72 3.32 1.69 0.72 2.49 0.72 1.69 1.69 1.69 1.69 0.72 0.792 0.72 0.72 0.72 0.72 0.7343999999999999 0.72 8600 Hos Central Supply Facility Fee 50105 RETIC-CHEX LVLS 1 2 3 DPR VIAL A4467 270 124.12 86.884 2.4 11.02 5.61 2.4 8.27 2.4 5.61 5.61 5.61 5.61 2.4 2.64 2.4 2.4 2.4 2.4 2.448 2.4 8600 Hos Central Supply Facility Fee 50026 RETICULOCYTE COUNT A4467 270 186.75 130.725 2.4 11.02 5.61 2.4 8.27 2.4 5.61 5.61 5.61 5.61 2.4 2.64 2.4 2.4 2.4 2.4 2.448 2.4 8600 Hos Central Supply Facility Fee 50226 REV DIGOXIN FLEX-DIG A9270 270 4.01 2.8069999999999995 0.63 2.92 1.49 0.63 2.19 0.63 1.49 1.49 1.49 1.49 0.63 0.6930000000000001 0.63 0.63 0.63 0.63 0.6426000000000001 0.63 8600 Hos Central Supply Facility Fee 50227 REV DIGOXIN FLEX-DIG E8644 270 78.21 54.74699999999999 0.63 2.92 1.49 0.63 2.19 0.63 1.49 1.49 1.49 1.49 0.63 0.6930000000000001 0.63 0.63 0.63 0.63 0.6426000000000001 0.63 8600 Hos Central Supply Facility Fee 50228 REV DIM AMYLASE FLEX A4467 270 0.99 0.693 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 50229 REV DIM AMYLASE FLEX A4467 270 59.59 41.713 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 50230 REVISED CHEM I CALIBRATOR A4467 270 20.87 14.609 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 50231 REVISED TRIGLYCERIDE FLEX A9270 270 0.29 0.20299999999999999 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 288 RHINO ROCKET I2206 270 10.57 7.399 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 1405 RHINO ROCKET STARTER PACK 8/BOX A4467 270 199.04 139.32799999999997 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 552 RIBBON CASSETTE/MESSAGE CENTER A9270 270 14.97 10.479 1.93 8.9 4.53 1.93 6.68 1.93 4.53 4.53 4.53 4.53 1.93 2.123 1.93 1.93 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 50232 ROCKER TUBE FOR GENTLE MIXING A4467 270 348 243.6 3.26 14.98 7.63 3.26 11.24 3.26 7.63 7.63 7.63 7.63 3.26 3.586 3.26 3.26 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 81 ROTICULATOR 55-3.5 SINGLE USE STAPLER BLU A9270 270 636.33 445.431 0.53 2.45 1.25 0.53 1.84 0.53 1.25 1.25 1.25 1.25 0.53 0.5830000000000001 0.53 0.53 3.26 3.26 3.3251999999999997 3.26 8600 Hos Central Supply Facility Fee 50233 RXL CHEMISTRY WASH A9270 270 17.7 12.389999999999999 0.5 2.29 1.17 0.5 1.72 0.5 1.17 1.17 1.17 1.17 0.5 0.55 0.5 0.5 0.05 0.05 0.051000000000000004 0.05 8600 Hos Central Supply Facility Fee 1694 SAFCO WOOD LITERATURE ORGANIZER A4467 270 118.23 82.761 17.56 80.79 41.15 17.56 60.59 17.56 41.15 41.15 41.15 41.15 17.56 19.316 17.56 17.56 17.56 17.56 17.911199999999997 17.56 8600 Hos Central Supply Facility Fee 862 SAFETY PENS NONSTERILE A9270 270 0.02 0.013999999999999999 0.26 1.2 0.61 0.26 0.9 0.26 0.61 0.61 0.61 0.61 0.26 0.28600000000000003 0.26 0.26 0.26 0.26 0.2652 0.26 8600 Hos Central Supply Facility Fee 828 SALEM SUMP TUBE 10FR A4467 270 21.54 15.077999999999998 0.07 0.34 0.17 0.07 0.26 0.07 0.17 0.17 0.17 0.17 0.07 0.07700000000000001 0.07 0.07 2.51 2.51 2.5602 2.51 8600 Hos Central Supply Facility Fee 50263 SALT BRIDGE A4467 270 71.71 50.196999999999996 15.59 71.71 36.53 15.59 53.78 15.59 36.53 36.53 36.53 36.53 15.59 17.149 15.59 15.59 15.59 15.59 15.9018 15.59 8600 Hos Central Supply Facility Fee 50234 SALT BRIDGE SOLUTION A8622 270 25.96 18.172 10.99 50.56 25.76 10.99 37.92 10.99 25.76 25.76 25.76 25.76 10.99 12.089 10.99 10.99 10.99 10.99 11.2098 10.99 8600 Hos Central Supply Facility Fee 807 SANFORD SHARPIE PERMANENT MARKERS FINE TIP SILVER METALLIC INK A4467 270 0.83 0.581 10.53 48.43 24.67 10.53 36.32 10.53 24.67 24.67 24.67 24.67 10.53 11.583 10.53 10.53 0.09 0.09 0.09179999999999999 0.09 8600 Hos Central Supply Facility Fee 50243 SANI-CLOTH PLUS WIPE A8600 270 50.64 35.448 1.67 7.66 3.9 1.67 5.75 1.67 3.9 3.9 3.9 3.9 1.67 1.837 1.67 1.67 1.67 1.67 1.7034 1.67 8600 Hos Central Supply Facility Fee 1634 SANITARY NAPKIN RECEPTICALE A8655 270 46.63 32.641 10.54 48.49 24.7 10.54 36.37 10.54 24.7 24.7 24.7 24.7 10.54 11.594 10.54 10.54 10.54 10.54 10.7508 10.54 8600 Hos Central Supply Facility Fee 1273 SANITIZER GEL HAND EPI-CLENZ 1.5OZ A9286 270 0.82 0.574 41.75 192.04 97.83 41.75 144.03 41.75 97.83 97.83 97.83 97.83 41.75 45.925000000000004 41.75 41.75 41.75 41.75 42.585 41.75 8600 Hos Central Supply Facility Fee 1031 SCALPEI DISP. #15 99070 270 10.33 7.231 1.15 5.28 2.69 1.15 3.96 1.15 2.69 2.69 2.69 2.69 1.15 1.265 1.15 1.15 21.13 21.13 21.552599999999998 21.13 8600 Hos Central Supply Facility Fee 1029 SCALPEL DISP. #10 99070 270 13.99 9.793 34.55 158.92 80.95 34.55 119.19 34.55 80.95 80.95 80.95 80.95 34.55 38.005 34.55 34.55 34.55 34.55 35.241 34.55 8600 Hos Central Supply Facility Fee 1030 SCALPEL DISP. #11 99070 270 14.4 10.08 19.34 88.95 45.31 19.34 66.71 19.34 45.31 45.31 45.31 45.31 19.34 21.274 19.34 19.34 19.34 19.34 19.7268 19.34 8600 Hos Central Supply Facility Fee 1158 SCALPEL SS #11 DISP. A4467 270 8.17 5.718999999999999 32.74 150.59 76.71 32.74 112.94 32.74 76.71 76.71 76.71 76.71 32.74 36.014 32.74 32.74 32.74 32.74 33.394800000000004 32.74 8600 Hos Central Supply Facility Fee 70 SCAPEL SAFETY STERILE DISPOSABLE #10 A4206 270 0.15 0.105 0.22 1.03 0.52 0.22 0.77 0.22 0.52 0.52 0.52 0.52 0.22 0.24200000000000002 0.22 0.22 0.22 0.22 0.22440000000000002 0.22 8600 Hos Central Supply Facility Fee 71 SCAPEL SAFETY STERILE DISPOSABLE #11 A4206 270 0.15 0.105 0.5 2.31 1.18 0.5 1.73 0.5 1.18 1.18 1.18 1.18 0.5 0.55 0.5 0.5 0.5 0.5 0.51 0.5 8600 Hos Central Supply Facility Fee 72 SCAPEL SAFETY STERILE DISPOSABLE #15 A4206 270 1.48 1.036 27.64 127.14 64.77 27.64 95.36 27.64 64.77 64.77 64.77 64.77 27.64 30.404000000000003 27.64 27.64 27.64 27.64 28.192800000000002 27.64 8600 Hos Central Supply Facility Fee 1511 SCISSORS BLUE 8 A9270 270 2.45 1.715 41.46 190.73 97.16 41.46 143.05 41.46 97.16 97.16 97.16 97.16 41.46 45.606 41.46 41.46 41.46 41.46 42.2892 41.46 8600 Hos Central Supply Facility Fee 778 SCOTCH MAGIC GREENER TAPE REFILL VALUE PACK 3/4 X 900 1' CORE N/A 270 2.77 1.9389999999999998 1.26 5.79 2.95 1.26 4.34 1.26 2.95 2.95 2.95 2.95 1.26 1.3860000000000001 1.26 1.26 1.26 1.26 1.2852000000000001 1.26 8600 Hos Central Supply Facility Fee 1199 SCRUB PANTS DISPOSABLE ELASTIC WAIST BLUE LARGE A6539 270 0.88 0.616 0.43 1.99 1.01 0.43 1.49 0.43 1.01 1.01 1.01 1.01 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 8600 Hos Central Supply Facility Fee 1070 SCRUB POVIDONE IODINE 4OZ A4467 270 31.99 22.392999999999997 91.57 421.19 214.55 91.57 315.89 91.57 214.55 214.55 214.55 214.55 91.57 100.727 91.57 91.57 91.57 91.57 93.4014 91.57 8600 Hos Central Supply Facility Fee 1198 SCRUB SHIRT DISPOSABLE BLUE ROUND NECK 3XL A6539 270 0.85 0.595 7.27 33.44 17.03 7.27 25.08 7.27 17.03 17.03 17.03 17.03 7.27 7.997 7.27 7.27 7.27 7.27 7.4154 7.27 8600 Hos Central Supply Facility Fee 1205 SCRUB SHIRT DISPOSABLE BLUE VNECK 2XL A6539 270 0.69 0.48299999999999993 0.65 2.99 1.52 0.65 2.24 0.65 1.52 1.52 1.52 1.52 0.65 0.7150000000000001 0.65 0.65 0.65 0.65 0.663 0.65 8600 Hos Central Supply Facility Fee 814 SECONDARY IV SET A4467 270 0.75 0.5249999999999999 3.02 13.88 7.07 3.02 10.41 3.02 7.07 7.07 7.07 7.07 3.02 3.3220000000000005 3.02 3.02 12.48 12.48 12.729600000000001 12.48 8600 Hos Central Supply Facility Fee 929 SECURE PEN REPLACEMENT A9270 270 0.81 0.567 3.08 14.17 7.22 3.08 10.63 3.08 7.22 7.22 7.22 7.22 3.08 3.3880000000000003 3.08 3.08 3.08 3.08 3.1416 3.08 8600 Hos Central Supply Facility Fee 50106 SECURLINE BLOOD BAND/RED A4467 270 22.7 15.889999999999999 3.29 15.12 7.7 3.29 11.34 3.29 7.7 7.7 7.7 7.7 3.29 3.619 3.29 3.29 0.63 0.63 0.6426000000000001 0.63 8600 Hos Central Supply Facility Fee 50027 SEDIMENTATION RATE- A E8622 270 124.5 87.14999999999999 4.87 22.4 11.41 4.87 16.8 4.87 11.41 11.41 11.41 11.41 4.87 5.357 4.87 4.87 4.87 4.87 4.9674000000000005 4.87 8600 Hos Central Supply Facility Fee 151 SENSOR OXIMETRY FINGER N3206 270 125.31 87.717 1.69 7.79 3.97 1.69 5.84 1.69 3.97 3.97 3.97 3.97 1.69 1.859 1.69 1.69 131.04 131.04 133.6608 131.04 8600 Hos Central Supply Facility Fee 50028 SERUM HCG A4467 270 124.5 87.14999999999999 1.48 6.79 3.46 1.48 5.09 1.48 3.46 3.46 3.46 3.46 1.48 1.6280000000000001 1.48 1.48 1.48 1.48 1.5096 1.48 8600 Hos Central Supply Facility Fee 1675 SET BLOOD COLLECTION 25G A4467 270 29.9 20.929999999999996 27.7 127.41 64.9 27.7 95.56 27.7 64.9 64.9 64.9 64.9 27.7 30.470000000000002 27.7 27.7 27.7 27.7 28.254 27.7 8600 Hos Central Supply Facility Fee 379 SET BLOOD COLLECTION SAFELK 21G W/ADP 12 IN TUBING W/SAMPLE LUER ADAPT T0206 270 44.57 31.198999999999998 3.22 14.82 7.55 3.22 11.12 3.22 7.55 7.55 7.55 7.55 3.22 3.5420000000000007 3.22 3.22 3.22 3.22 3.2844 3.22 8600 Hos Central Supply Facility Fee 378 SET BLOOD COLLECTION SAFELK 23G ADPT 23 GAUGE 12 IN TUBING T1206 270 1.01 0.707 0.29 1.33 0.68 0.29 1 0.29 0.68 0.68 0.68 0.68 0.29 0.319 0.29 0.29 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 1806 SET BP CUFF LARGE ADULT 1 TUBE A4467 270 15.91 11.136999999999999 0.43 1.98 1.01 0.43 1.49 0.43 1.01 1.01 1.01 1.01 0.43 0.47300000000000003 0.43 0.43 0.43 0.43 0.4386 0.43 8600 Hos Central Supply Facility Fee 1818 SET CLAVE PRT LS MALE A4467 270 146.69 102.68299999999999 0.31 1.44 0.73 0.31 1.08 0.31 0.73 0.73 0.73 0.73 0.31 0.341 0.31 0.31 0.31 0.31 0.3162 0.31 8600 Hos Central Supply Facility Fee 1219 SHAMPOO BODY WASH J4390 270 1.96 1.3719999999999999 0.29 1.33 0.68 0.29 1 0.29 0.68 0.68 0.68 0.68 0.29 0.319 0.29 0.29 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 1222 SHAMPOO BODY WASH ALOE VESTA 4OZ J4390 270 0.48 0.33599999999999997 1.57 7.23 3.68 1.57 5.42 1.57 3.68 3.68 3.68 3.68 1.57 1.7270000000000003 1.57 1.57 1.57 1.57 1.6014000000000002 1.57 8600 Hos Central Supply Facility Fee 1000 SHAMPOO BODY WASH PHYTOPLEX 2 OZ A4467 270 0.64 0.44799999999999995 2.59 11.9 6.06 2.59 8.93 2.59 6.06 6.06 6.06 6.06 2.59 2.849 2.59 2.59 2.59 2.59 2.6418 2.59 8600 Hos Central Supply Facility Fee 1220 SHAMPOO BODY WASH REMEDY PHYTOPLEX J4390 270 1.04 0.728 8.98 41.32 21.05 8.98 30.99 8.98 21.05 21.05 21.05 21.05 8.98 9.878000000000002 8.98 8.98 8.98 8.98 9.159600000000001 8.98 8600 Hos Central Supply Facility Fee 1160 SHEET DRAPE ECONOMY 40 X 70 A4467 270 16.95 11.864999999999998 17.04 78.36 39.92 17.04 58.77 17.04 39.92 39.92 39.92 39.92 17.04 18.744 17.04 17.04 8.06 8.06 8.221200000000001 8.06 8600 Hos Central Supply Facility Fee 1015 SHIELD FACE FULL H8600 270 98.16 68.71199999999999 30.53 140.44 71.54 30.53 105.33 30.53 71.54 71.54 71.54 71.54 30.53 33.583000000000006 30.53 30.53 18.21 18.21 18.5742 18.21 8600 Hos Central Supply Facility Fee 1207 SHIRT SCRUB DISP BLUE VNECK XL A6539 270 0.6 0.42 1.32 6.07 3.09 1.32 4.55 1.32 3.09 3.09 3.09 3.09 1.32 1.4520000000000002 1.32 1.32 1.32 1.32 1.3464 1.32 8600 Hos Central Supply Facility Fee 1206 SHIRT SCRUB DISPOSABLE BLUE VNECK S A6539 270 0.63 0.44099999999999995 14.12 64.96 33.09 14.12 48.72 14.12 33.09 33.09 33.09 33.09 14.12 15.532 14.12 14.12 14.12 14.12 14.4024 14.12 8600 Hos Central Supply Facility Fee 1197 SHIRT SCRUB DISPOSABLE BLUE VNECK SMALL A6539 270 0.59 0.413 1.73 7.98 4.07 1.73 5.99 1.73 4.07 4.07 4.07 4.07 1.73 1.903 1.73 1.73 1.73 1.73 1.7646 1.73 8600 Hos Central Supply Facility Fee 1195 SHIRT SCRUB DISPOSABLE VNECK BLUE LARGE A6539 270 0.64 0.44799999999999995 0.18 0.82 0.42 0.18 0.62 0.18 0.42 0.42 0.42 0.42 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 1196 SHIRT SCRUB DISPOSABLE VNECK BLUE MED A6539 270 0.61 0.427 0.23 1.06 0.54 0.23 0.8 0.23 0.54 0.54 0.54 0.54 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 1705 SHIRT SCRUB V NECK BLUE SMALL DISPOSABLE A4467 270 18.41 12.886999999999999 2.7 12.41 6.32 2.7 9.31 2.7 6.32 6.32 6.32 6.32 2.7 2.9700000000000006 2.7 2.7 2.7 2.7 2.7540000000000004 2.7 8600 Hos Central Supply Facility Fee 197 SHOE POST OP FEMALE VELCRO LRG O0206 270 4.46 3.122 2.7 12.41 6.32 2.7 9.31 2.7 6.32 6.32 6.32 6.32 2.7 2.9700000000000006 2.7 2.7 2.7 2.7 2.7540000000000004 2.7 8600 Hos Central Supply Facility Fee 196 SHOE POST OP FEMALE VELCRO MED O0206 270 4.46 3.122 5.28 24.29 12.37 5.28 18.22 5.28 12.37 12.37 12.37 12.37 5.28 5.808000000000001 5.28 5.28 5.28 5.28 5.3856 5.28 8600 Hos Central Supply Facility Fee 194 SHOE POST OP MALE VELCRO LRG O0206 270 4.46 3.122 9 41.42 21.1 9 31.07 9 21.1 21.1 21.1 21.1 9 9.9 9 9 9 9 9.18 9 8600 Hos Central Supply Facility Fee 193 SHOE POST OP MALE VELCRO MED O0206 270 4.46 3.122 5.81 26.73 13.62 5.81 20.05 5.81 13.62 13.62 13.62 13.62 5.81 6.391 5.81 5.81 5.81 5.81 5.9262 5.81 8600 Hos Central Supply Facility Fee 195 SHOE POST OP MALE VELCRO XL O1206 270 4.49 3.143 0.86 3.97 2.02 0.86 2.98 0.86 2.02 2.02 2.02 2.02 0.86 0.9460000000000001 0.86 0.86 0.86 0.86 0.8772 0.86 8600 Hos Central Supply Facility Fee 192 SHOE POST OP MALE VELCRO XSMALL O1206 270 4.49 3.143 5.55 25.55 13.02 5.55 19.16 5.55 13.02 13.02 13.02 13.02 5.55 6.105 5.55 5.55 5.55 5.55 5.661 5.55 8600 Hos Central Supply Facility Fee 354 SHOE POST-OP FEMALE VELCRO SM O0206 270 4.46 3.122 0.85 3.92 2 0.85 2.94 0.85 2 2 2 2 0.85 0.935 0.85 0.85 0.85 0.85 0.867 0.85 8600 Hos Central Supply Facility Fee 353 SHOE POST-OP MALE VELCRO SM O0206 270 4.46 3.122 1.4 6.44 3.28 1.4 4.83 1.4 3.28 3.28 3.28 3.28 1.4 1.54 1.4 1.4 1.4 1.4 1.428 1.4 8600 Hos Central Supply Facility Fee 1758 SHOE SHOWER FLEXIBLE LARGE/EX BEIGE A4467 270 93.7 65.59 0.53 2.44 1.24 0.53 1.83 0.53 1.24 1.24 1.24 1.24 0.53 0.5830000000000001 0.53 0.53 0.53 0.53 0.5406000000000001 0.53 8600 Hos Central Supply Facility Fee 1757 SHOE SHOWER FLEXIBLE MEDIUM/LARGE BLUE A4467 270 101.2 70.84 0.64 2.93 1.49 0.64 2.2 0.64 1.49 1.49 1.49 1.49 0.64 0.7040000000000001 0.64 0.64 0.64 0.64 0.6528 0.64 8600 Hos Central Supply Facility Fee 1756 SHOE SHOWER FLEXIBLE SMALL YELLOW A4467 270 101.2 70.84 54.06 248.66 126.67 54.06 186.5 54.06 126.67 126.67 126.67 126.67 54.06 59.46600000000001 54.06 54.06 54.06 54.06 55.141200000000005 54.06 8600 Hos Central Supply Facility Fee 1760 SHOE SHOWER FLEXIBLE XL/2XL GREEN A4467 270 101.2 70.84 12.47 57.36 29.22 12.47 43.02 12.47 29.22 29.22 29.22 29.22 12.47 13.717000000000002 12.47 12.47 12.47 12.47 12.7194 12.47 8600 Hos Central Supply Facility Fee 1759 SHOE SHOWER FLEXIBLELARGE/XL BEIGE A4467 270 101.2 70.84 3.09 14.23 7.25 3.09 10.67 3.09 7.25 7.25 7.25 7.25 3.09 3.399 3.09 3.09 3.09 3.09 3.1517999999999997 3.09 8600 Hos Central Supply Facility Fee 1542 SKIN AFFIX SURG ADHESIVE 12/BOX A4467 270 150.59 105.413 2.55 11.71 5.97 2.55 8.78 2.55 5.97 5.97 5.97 5.97 2.55 2.805 2.55 2.55 0.31 0.31 0.3162 0.31 8600 Hos Central Supply Facility Fee 179 SLING ARM DELUX WITH PAD LRG I6206 270 2.42 1.694 2.44 11.23 5.72 2.44 8.42 2.44 5.72 5.72 5.72 5.72 2.44 2.684 2.44 2.44 2.44 2.44 2.4888 2.44 8600 Hos Central Supply Facility Fee 178 SLING ARM DELUXE WITH PAD MED I6206 270 2.42 1.694 2.82 12.99 6.62 2.82 9.74 2.82 6.62 6.62 6.62 6.62 2.82 3.102 2.82 2.82 2.82 2.82 2.8764 2.82 8600 Hos Central Supply Facility Fee 177 SLING ARM DELUXE WITH PAD SM I6206 270 2.42 1.694 10.94 50.32 25.63 10.94 37.74 10.94 25.63 25.63 25.63 25.63 10.94 12.034 10.94 10.94 10.94 10.94 11.1588 10.94 8600 Hos Central Supply Facility Fee 180 SLING ARM DELUXE WITH PAD XL I6206 270 2.42 1.694 1.2 5.51 2.81 1.2 4.13 1.2 2.81 2.81 2.81 2.81 1.2 1.32 1.2 1.2 1.2 1.2 1.224 1.2 8600 Hos Central Supply Facility Fee 990 SLIPPER BARIATRIC BLUE L8655 270 67.03 46.921 14.78 67.97 34.62 14.78 50.98 14.78 34.62 34.62 34.62 34.62 14.78 16.258 14.78 14.78 14.78 14.78 15.0756 14.78 8600 Hos Central Supply Facility Fee 994 SLIPPER DOUBLE TREAD AT RISK RED LARGE A4467 270 39.61 27.726999999999997 14.55 66.92 34.09 14.55 50.19 14.55 34.09 34.09 34.09 34.09 14.55 16.005000000000003 14.55 14.55 14.55 14.55 14.841000000000001 14.55 8600 Hos Central Supply Facility Fee 1369 SLIPPER DOUBLE TREAD GRAY XXLARGE A4467 270 0.83 0.581 5.27 24.24 12.35 5.27 18.18 5.27 12.35 12.35 12.35 12.35 5.27 5.797 5.27 5.27 5.27 5.27 5.3754 5.27 8600 Hos Central Supply Facility Fee 1657 SLIPPER DOUBLE TREAD GRAY XXLARGE A4467 270 39.89 27.923 4.97 22.84 11.63 4.97 17.13 4.97 11.63 11.63 11.63 11.63 4.97 5.4670000000000005 4.97 4.97 4.97 4.97 5.0694 4.97 8600 Hos Central Supply Facility Fee 974 SLIPPER DOUBLE TREAD RED XLARGE A4467 270 0.77 0.5389999999999999 1.45 6.66 3.39 1.45 5 1.45 3.39 3.39 3.39 3.39 1.45 1.595 1.45 1.45 1.45 1.45 1.4789999999999999 1.45 8600 Hos Central Supply Facility Fee 975 SLIPPER DOUBLE TREAD YELLOW UNIVERSAL A4467 270 0.77 0.5389999999999999 3.59 16.53 8.42 3.59 12.4 3.59 8.42 8.42 8.42 8.42 3.59 3.9490000000000003 3.59 3.59 3.59 3.59 3.6618 3.59 8600 Hos Central Supply Facility Fee 131 SLIPPER DOUBLE TREAD YELLOW UNIVERSAL AVAILABLE TO HPG AND GOVERN ONLY I4206 270 0.77 0.5389999999999999 10.14 46.63 23.75 10.14 34.97 10.14 23.75 23.75 23.75 23.75 10.14 11.154000000000002 10.14 10.14 10.14 10.14 10.3428 10.14 8600 Hos Central Supply Facility Fee 897 SLIPPER FALL PREV. RED A4467 270 40.94 28.657999999999998 16.17 74.37 37.88 16.17 55.78 16.17 37.88 37.88 37.88 37.88 16.17 17.787000000000003 16.17 16.17 16.17 16.17 16.4934 16.17 8600 Hos Central Supply Facility Fee 898 SLIPPER FALL PREV. YELLOW A4467 270 48.33 33.830999999999996 5.24 24.08 12.27 5.24 18.06 5.24 12.27 12.27 12.27 12.27 5.24 5.764000000000001 5.24 5.24 5.24 5.24 5.3448 5.24 8600 Hos Central Supply Facility Fee 915 SLIPPER FALL PREV. YELLOW A4467 270 1.02 0.714 16.17 74.37 37.88 16.17 55.78 16.17 37.88 37.88 37.88 37.88 16.17 17.787000000000003 16.17 16.17 16.17 16.17 16.4934 16.17 8600 Hos Central Supply Facility Fee 573 SLIPPER,DOUBLE TREAD,BEIGE,X-LARGE A4467 270 0.86 0.602 5.24 24.08 12.27 5.24 18.06 5.24 12.27 12.27 12.27 12.27 5.24 5.764000000000001 5.24 5.24 5.24 5.24 5.3448 5.24 8600 Hos Central Supply Facility Fee 572 SLIPPER,DOUBLE TREAD,BLUE,LARGE A4467 270 0.8 0.5599999999999999 9.11 41.9 21.34 9.11 31.43 9.11 21.34 21.34 21.34 21.34 9.11 10.021 9.11 9.11 9.11 9.11 9.2922 9.11 8600 Hos Central Supply Facility Fee 914 SLIPPERS NON-SLIP XL A9270 270 1.19 0.833 6.54 30.1 15.33 6.54 22.58 6.54 15.33 15.33 15.33 15.33 6.54 7.194000000000001 6.54 6.54 6.54 6.54 6.6708 6.54 8600 Hos Central Supply Facility Fee 228 SMART SLEEVE, LARGE A4206 270 2.69 1.8829999999999998 18.03 82.94 42.25 18.03 62.21 18.03 42.25 42.25 42.25 42.25 18.03 19.833000000000002 18.03 18.03 18.03 18.03 18.390600000000003 18.03 8600 Hos Central Supply Facility Fee 229 SMART SLEEVE, XX-LARGE A0206 270 3.83 2.681 4.55 20.95 10.67 4.55 15.71 4.55 10.67 10.67 10.67 10.67 4.55 5.005 4.55 4.55 4.55 4.55 4.641 4.55 8600 Hos Central Supply Facility Fee 50515 SNAP ON COLLAR N/A 270 10.59 7.412999999999999 8.77 40.33 20.54 8.77 30.25 8.77 20.54 20.54 20.54 20.54 8.77 9.647 8.77 8.77 8.69 8.69 8.8638 8.69 8600 Hos Central Supply Facility Fee 50516 SNAP PIPE REDUCER N/A 270 24.83 17.380999999999997 8.35 38.41 19.57 8.35 28.81 8.35 19.57 19.57 19.57 19.57 8.35 9.185 8.35 8.35 8.35 8.35 8.517 8.35 8600 Hos Central Supply Facility Fee 50615 SOAP ANTIMICROBIAL 1 L N/A 270 47.34 33.138 5.83 26.82 13.66 5.83 20.12 5.83 13.66 13.66 13.66 13.66 5.83 6.413 5.83 5.83 5.83 5.83 5.9466 5.83 8600 Hos Central Supply Facility Fee 998 SOAP BAR 1.5OZ O8699 270 39.05 27.334999999999997 7.17 32.99 16.81 7.17 24.74 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 8600 Hos Central Supply Facility Fee 1069 SOAP BAR DEODORANT O8622 270 36.36 25.451999999999998 9.37 43.1 21.96 9.37 32.33 9.37 21.96 21.96 21.96 21.96 9.37 10.307 9.37 9.37 9.37 9.37 9.5574 9.37 8600 Hos Central Supply Facility Fee 1604 SOFT SHELL HELMET, LARGE A4467 270 248.66 174.06199999999998 4.19 19.27 9.82 4.19 14.45 4.19 9.82 9.82 9.82 9.82 4.19 4.609000000000001 4.19 4.19 4.33 4.33 4.4166 4.33 8600 Hos Central Supply Facility Fee 812 SOLUCTION SCRUB CHG 4% 32 OZ A4467 270 8.21 5.747 30.31 139.4 71.01 30.31 104.55 30.31 71.01 71.01 71.01 71.01 30.31 33.341 30.31 30.31 30.27 30.27 30.8754 30.27 8600 Hos Central Supply Facility Fee 244 SOLUTION ANTI-FOG W/ FOAM PAD L7206 270 8.2 5.739999999999999 30.32 139.46 71.04 30.32 104.6 30.32 71.04 71.04 71.04 71.04 30.32 33.352000000000004 30.32 30.32 30.32 30.32 30.9264 30.32 8600 Hos Central Supply Facility Fee 1282 SOLUTION CIDEX ACTIVATED DIALDEHYDE 4.7L A4467 270 51.39 35.973 20.81 95.74 48.77 20.81 71.81 20.81 48.77 48.77 48.77 48.77 20.81 22.891000000000002 20.81 20.81 20.81 20.81 21.2262 20.81 8600 Hos Central Supply Facility Fee 1491 SOLUTION CNTRL LVL 1 GLUCOSE STATSTRIP A4467 270 11.02 7.7139999999999995 8.39 38.59 19.66 8.39 28.94 8.39 19.66 19.66 19.66 19.66 8.39 9.229000000000001 8.39 8.39 8.39 8.39 8.5578 8.39 8600 Hos Central Supply Facility Fee 1574 SOLUTION CNTRL LVL 1 GLUCOSE STATSTRIP A4467 270 11.9 8.33 10.91 50.18 25.56 10.91 37.64 10.91 25.56 25.56 25.56 25.56 10.91 12.001000000000001 10.91 10.91 10.91 10.91 11.1282 10.91 8600 Hos Central Supply Facility Fee 1492 SOLUTION CNTRL LVL 3 GLUCOSE STATSTRIP A4467 270 11.02 7.7139999999999995 8.3 38.18 19.45 8.3 28.64 8.3 19.45 19.45 19.45 19.45 8.3 9.13 8.3 8.3 8.3 8.3 8.466000000000001 8.3 8600 Hos Central Supply Facility Fee 381 SOLUTION LINEARITY ACCU-CHK COMFORTCURVE A4206 270 31.5 22.049999999999997 18.86 86.76 44.2 18.86 65.07 18.86 44.2 44.2 44.2 44.2 18.86 20.746000000000002 18.86 18.86 18.86 18.86 19.2372 18.86 8600 Hos Central Supply Facility Fee 1597 SOLUTION SCRUB POVIDONE IODINE 8 OZ A4467 270 26.73 18.711 3.58 16.45 8.38 3.58 12.34 3.58 8.38 8.38 8.38 8.38 3.58 3.9380000000000006 3.58 3.58 3.58 3.58 3.6516 3.58 8600 Hos Central Supply Facility Fee 1824 SOLUTION SENSITIVITY, BITTER/SWEET 6 BOTTLES A4467 270 112.51 78.757 1.62 7.44 3.79 1.62 5.58 1.62 3.79 3.79 3.79 3.79 1.62 1.7820000000000003 1.62 1.62 1.62 1.62 1.6524 1.62 8600 Hos Central Supply Facility Fee 116 SOLUTION SURGICAL DURAPREP 26ML APPLICTR SKIN PREPPINGRESIN SOLUTION L7206 270 4.39 3.0729999999999995 0.23 1.07 0.55 0.23 0.8 0.23 0.55 0.55 0.55 0.55 0.23 0.25300000000000006 0.23 0.23 0.23 0.23 0.2346 0.23 8600 Hos Central Supply Facility Fee 587 SOLUTION,PREP,POVIDONE IODINE,4 OZ BTL A4467 270 0.56 0.392 5.59 25.69 13.09 5.59 19.27 5.59 13.09 13.09 13.09 13.09 5.59 6.149 5.59 5.59 5.59 5.59 5.7017999999999995 5.59 8600 Hos Central Supply Facility Fee 362 SPECIMEN TRAP STERILE 40CC E5206 270 1.46 1.022 0.44 2.04 1.04 0.44 1.53 0.44 1.04 1.04 1.04 1.04 0.44 0.48400000000000004 0.44 0.44 2.47 2.47 2.5194 2.47 8600 Hos Central Supply Facility Fee 1048 SPEC-PAN E0275 270 30.76 21.532 6.5 29.9 15.23 6.5 22.43 6.5 15.23 15.23 15.23 15.23 6.5 7.15 6.5 6.5 6.5 6.5 6.63 6.5 8600 Hos Central Supply Facility Fee 1155 SPECULA OTOSCOPE 2.75MM P8688 270 26.07 18.249 9 41.4 21.09 9 31.05 9 21.09 21.09 21.09 21.09 9 9.9 9 9 9 9 9.18 9 8600 Hos Central Supply Facility Fee 1092 SPECULA OTOSCOPE 5MM 92504 270 47.74 33.418 1.65 7.61 3.88 1.65 5.71 1.65 3.88 3.88 3.88 3.88 1.65 1.815 1.65 1.65 1.65 1.65 1.6829999999999998 1.65 8600 Hos Central Supply Facility Fee 153 SPECULA OTOSCOPE DISP 4.25 MM 92504 270 7.61 5.327 1.65 7.61 3.88 1.65 5.71 1.65 3.88 3.88 3.88 3.88 1.65 1.815 1.65 1.65 1.65 1.65 1.6829999999999998 1.65 8600 Hos Central Supply Facility Fee 1346 SPECULA VAG MED P8644 270 41.5 29.049999999999997 1.65 7.61 3.88 1.65 5.71 1.65 3.88 3.88 3.88 3.88 1.65 1.815 1.65 1.65 1.65 1.65 1.6829999999999998 1.65 8600 Hos Central Supply Facility Fee 1347 SPECULA VAG SM P8633 270 44.63 31.241 31.18 143.42 73.06 31.18 107.57 31.18 73.06 73.06 73.06 73.06 31.18 34.298 31.18 31.18 31.18 31.18 31.8036 31.18 8600 Hos Central Supply Facility Fee 469 SPECULA VAGINA KLEENSPEC PREM 590 SRS SM E6206 270 1.49 1.043 14.7 67.6 34.44 14.7 50.7 14.7 34.44 34.44 34.44 34.44 14.7 16.17 14.7 14.7 14.7 14.7 14.994 14.7 8600 Hos Central Supply Facility Fee 312 SPECULA VAGINAL DISP SML E5206 270 0.8 0.5599999999999999 33.68 154.9 78.91 33.68 116.18 33.68 78.91 78.91 78.91 78.91 33.68 37.048 33.68 33.68 33.68 33.68 34.3536 33.68 8600 Hos Central Supply Facility Fee 468 SPECULA VAGINAL KLEENSPEC PRMIUM MED 580 WITH SHEATH E0206 270 2.89 2.023 4.12 18.96 9.66 4.12 14.22 4.12 9.66 9.66 9.66 9.66 4.12 4.532000000000001 4.12 4.12 4.12 4.12 4.2024 4.12 8600 Hos Central Supply Facility Fee 1134 SPECULA VAGINAL W/SHEATH MED A4467 270 43.07 30.148999999999997 6.64 30.55 15.56 6.64 22.91 6.64 15.56 15.56 15.56 15.56 6.64 7.304 6.64 6.64 6.64 6.64 6.7728 6.64 8600 Hos Central Supply Facility Fee 1135 SPECULA VAGINAL W/SHEATH SMALL A4467 270 43.07 30.148999999999997 14.94 68.72 35.01 14.94 51.54 14.94 35.01 35.01 35.01 35.01 14.94 16.434 14.94 14.94 14.94 14.94 15.2388 14.94 8600 Hos Central Supply Facility Fee 326 SPECULA VAGINAL WITH SHEATH LRG INTEGRATED LIGHT E0206 270 3.5 2.4499999999999997 0.09 0.41 0.21 0.09 0.31 0.09 0.21 0.21 0.21 0.21 0.09 0.099 0.09 0.09 0.09 0.09 0.09179999999999999 0.09 8600 Hos Central Supply Facility Fee 948 SPECULUA OTOSCOPE 4.25MM P8611 270 25.94 18.158 5.91 27.2 13.86 5.91 20.4 5.91 13.86 13.86 13.86 13.86 5.91 6.501 5.91 5.91 5.91 5.91 6.0282 5.91 8600 Hos Central Supply Facility Fee 1647 SPHYGMTR ANEROID THIGH P8611 270 42.61 29.826999999999998 3.86 17.76 9.05 3.86 13.32 3.86 9.05 9.05 9.05 9.05 3.86 4.246 3.86 3.86 1.29 1.29 1.3158 1.29 8600 Hos Central Supply Facility Fee 505 SPIROMETER VOL INCENT 4000 ML W/1 WAY VALVE A4467 270 2.14 1.498 11.67 53.69 27.35 11.67 40.27 11.67 27.35 27.35 27.35 27.35 11.67 12.837000000000002 11.67 11.67 11.67 11.67 11.9034 11.67 8600 Hos Central Supply Facility Fee 349 SPLINT CLAVICLE ADJ BUCKLE SM A4649 270 5.33 3.731 5.7 26.24 13.37 5.7 19.68 5.7 13.37 13.37 13.37 13.37 5.7 6.2700000000000005 5.7 5.7 5.7 5.7 5.814 5.7 8600 Hos Central Supply Facility Fee 351 SPLINT CLAVICLE ADJ BUCKLE LRG A4649 270 5.33 3.731 24.9 114.54 58.35 24.9 85.91 24.9 58.35 58.35 58.35 58.35 24.9 27.39 24.9 24.9 24.9 24.9 25.398 24.9 8600 Hos Central Supply Facility Fee 350 SPLINT CLAVICLE ADJ BUCKLE MED A4649 270 5.33 3.731 2.33 10.7 5.45 2.33 8.03 2.33 5.45 5.45 5.45 5.45 2.33 2.563 2.33 2.33 2.33 2.33 2.3766000000000003 2.33 8600 Hos Central Supply Facility Fee 347 SPLINT CLAVICLE ADJ BUCKLE PED XXS A4649 270 5.33 3.731 25.7 118.23 60.23 25.7 88.67 25.7 60.23 60.23 60.23 60.23 25.7 28.270000000000003 25.7 25.7 25.7 25.7 26.214 25.7 8600 Hos Central Supply Facility Fee 352 SPLINT CLAVICLE ADJ BUCKLE XL A4649 270 5.33 3.731 47.29 217.52 110.8 47.29 163.14 47.29 110.8 110.8 110.8 110.8 47.29 52.019000000000005 47.29 47.29 47.29 47.29 48.2358 47.29 8600 Hos Central Supply Facility Fee 348 SPLINT CLAVICLE ADJ BUCKLE XS A4649 270 5.33 3.731 4.58 21.06 10.73 4.58 15.8 4.58 10.73 10.73 10.73 10.73 4.58 5.038 4.58 4.58 4.58 4.58 4.6716 4.58 8600 Hos Central Supply Facility Fee 167 SPLINT FOREARM PADDED A/R RT LRG L1206 270 3.85 2.695 14.95 68.76 35.03 14.95 51.57 14.95 35.03 35.03 35.03 35.03 14.95 16.445 14.95 14.95 14.95 14.95 15.248999999999999 14.95 8600 Hos Central Supply Facility Fee 166 SPLINT FOREARM PADDED Y/L LT MED L8206 270 4.41 3.0869999999999997 5.69 26.19 13.34 5.69 19.64 5.69 13.34 13.34 13.34 13.34 5.69 6.259000000000001 5.69 5.69 5.69 5.69 5.803800000000001 5.69 8600 Hos Central Supply Facility Fee 344 SPLINT KNEE SUPER 20 IN 2XL A4649 270 8.08 5.656 1 4.59 2.34 1 3.44 1 2.34 2.34 2.34 2.34 1 1.1 1 1 1 1 1.02 1 8600 Hos Central Supply Facility Fee 342 SPLINT KNEE SUPER 20 IN LRG A4649 270 8.34 5.837999999999999 7.87 36.19 18.44 7.87 27.14 7.87 18.44 18.44 18.44 18.44 7.87 8.657 7.87 7.87 7.87 7.87 8.0274 7.87 8600 Hos Central Supply Facility Fee 341 SPLINT KNEE SUPER 20 IN MED A4649 270 8.34 5.837999999999999 46.47 213.76 108.89 46.47 160.32 46.47 108.89 108.89 108.89 108.89 46.47 51.117000000000004 46.47 46.47 46.47 46.47 47.3994 46.47 8600 Hos Central Supply Facility Fee 340 SPLINT KNEE SUPER 20 IN SM A4649 270 8.34 5.837999999999999 2.65 12.18 6.2 2.65 9.14 2.65 6.2 6.2 6.2 6.2 2.65 2.915 2.65 2.65 2.65 2.65 2.703 2.65 8600 Hos Central Supply Facility Fee 343 SPLINT KNEE SUPER 20 IN XL A4649 270 8.34 5.837999999999999 9.56 43.98 22.4 9.56 32.99 9.56 22.4 22.4 22.4 22.4 9.56 10.516000000000002 9.56 9.56 9.56 9.56 9.7512 9.56 8600 Hos Central Supply Facility Fee 190 SPLINT LOOP-LOCK COCKUP 8 IN LEFT LG L0206 270 5.1 3.5699999999999994 7.47 34.34 17.49 7.47 25.76 7.47 17.49 17.49 17.49 17.49 7.47 8.217 7.47 7.47 7.47 7.47 7.6194 7.47 8600 Hos Central Supply Facility Fee 189 SPLINT LOOP-LOCK COCKUP 8 IN LEFT MED L0206 270 5.1 3.5699999999999994 4 18.41 9.38 4 13.81 4 9.38 9.38 9.38 9.38 4 4.4 4 4 4 4 4.08 4 8600 Hos Central Supply Facility Fee 188 SPLINT LOOP-LOCK COCKUP 8 IN LEFT SM L0206 270 5.1 3.5699999999999994 1.26 5.8 2.95 1.26 4.35 1.26 2.95 2.95 2.95 2.95 1.26 1.3860000000000001 1.26 1.26 1.26 1.26 1.2852000000000001 1.26 8600 Hos Central Supply Facility Fee 191 SPLINT LOOP-LOCK COCKUP 8 IN LEFT XL L0206 270 5.1 3.5699999999999994 0.53 2.43 1.24 0.53 1.82 0.53 1.24 1.24 1.24 1.24 0.53 0.5830000000000001 0.53 0.53 0.53 0.53 0.5406000000000001 0.53 8600 Hos Central Supply Facility Fee 185 SPLINT LOOP-LOCK COCKUP 8 IN LEFT XS A4649 270 5.1 3.5699999999999994 11.93 54.87 27.95 11.93 41.15 11.93 27.95 27.95 27.95 27.95 11.93 13.123000000000001 11.93 11.93 11.93 11.93 12.1686 11.93 8600 Hos Central Supply Facility Fee 183 SPLINT LOOP-LOCK COCKUP 8 IN RIGHT LRG A4649 270 5.1 3.5699999999999994 4.4 20.26 10.32 4.4 15.2 4.4 10.32 10.32 10.32 10.32 4.4 4.840000000000001 4.4 4.4 4.4 4.4 4.488 4.4 8600 Hos Central Supply Facility Fee 182 SPLINT LOOP-LOCK COCKUP 8 IN RIGHT MED A4649 270 5.1 3.5699999999999994 25.6 117.77 59.99 25.6 88.33 25.6 59.99 59.99 59.99 59.99 25.6 28.160000000000004 25.6 25.6 25.6 25.6 26.112000000000002 25.6 8600 Hos Central Supply Facility Fee 181 SPLINT LOOP-LOCK COCKUP 8 IN RIGHT SM A4649 270 5.1 3.5699999999999994 6.31 29.04 14.79 6.31 21.78 6.31 14.79 14.79 14.79 14.79 6.31 6.941 6.31 6.31 6.31 6.31 6.4361999999999995 6.31 8600 Hos Central Supply Facility Fee 184 SPLINT LOOP-LOCK COCKUP 8 IN RIGHT XL A4649 270 5.1 3.5699999999999994 6.69 30.78 15.68 6.69 23.09 6.69 15.68 15.68 15.68 15.68 6.69 7.359000000000001 6.69 6.69 6.69 6.69 6.8238 6.69 8600 Hos Central Supply Facility Fee 1545 SPLINT ORTHO GLASS 4 A4467 270 127.14 88.99799999999999 5.63 25.91 13.2 5.63 19.43 5.63 13.2 13.2 13.2 13.2 5.63 6.1930000000000005 5.63 5.63 5.63 5.63 5.7426 5.63 8600 Hos Central Supply Facility Fee 1540 SPLINT ORTHO GLASS 5 A4467 270 158.92 111.24399999999999 1.78 8.18 4.17 1.78 6.14 1.78 4.17 4.17 4.17 4.17 1.78 1.9580000000000002 1.78 1.78 1.78 1.78 1.8156 1.78 8600 Hos Central Supply Facility Fee 1546 SPLINT ORTHO GLASS 6 A4467 270 190.73 133.511 14.44 66.4 33.82 14.44 49.8 14.44 33.82 33.82 33.82 33.82 14.44 15.884 14.44 14.44 14.44 14.44 14.7288 14.44 8600 Hos Central Supply Facility Fee 1443 SPLINT ORTHO GLASS SYSTEM A4467 270 38.16 26.711999999999996 4.28 19.69 10.03 4.28 14.77 4.28 10.03 10.03 10.03 10.03 4.28 4.708000000000001 4.28 4.28 4.28 4.28 4.365600000000001 4.28 8600 Hos Central Supply Facility Fee 339 SPLINT ORTHO GLASS SYSTEM 10CMX4.6M A4649 270 64.01 44.807 5.97 27.44 13.98 5.97 20.58 5.97 13.98 13.98 13.98 13.98 5.97 6.567 5.97 5.97 5.97 5.97 6.0893999999999995 5.97 8600 Hos Central Supply Facility Fee 338 SPLINT ORTHO GLASS SYSTEM 7.5CMX4.6M a4649 270 53.34 37.338 1 4.6 2.34 1 3.45 1 2.34 2.34 2.34 2.34 1 1.1 1 1 1 1 1.02 1 8600 Hos Central Supply Facility Fee 1544 SPONGE GAUZE AVANT 4 X 4 STRL A4467 270 2.31 1.617 3.54 16.28 8.29 3.54 12.21 3.54 8.29 8.29 8.29 8.29 3.54 3.8940000000000006 3.54 3.54 3.54 3.54 3.6108000000000002 3.54 8600 Hos Central Supply Facility Fee 106 SPONGE PEANUT SMALL 3/8IN NON STRUNG 5EA IN HOLDER TAIL X-RAY DETECTABLE O8206 270 0.91 0.637 0.29 1.35 0.69 0.29 1.01 0.29 0.69 0.69 0.69 0.69 0.29 0.319 0.29 0.29 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 271 SPONGE X-RAY DETEC 4 X 4 IN O7206 270 0.89 0.623 3.8 17.49 8.91 3.8 13.12 3.8 8.91 8.91 8.91 8.91 3.8 4.18 3.8 3.8 3.8 3.8 3.876 3.8 8600 Hos Central Supply Facility Fee 50122 STAIN RETICULOCYTE 125ML/EA T8699 270 52.4 36.68 1.84 8.47 4.31 1.84 6.35 1.84 4.31 4.31 4.31 4.31 1.84 2.0240000000000005 1.84 1.84 0.7 0.7 0.714 0.7 8600 Hos Central Supply Facility Fee 75 STAPLER GIA 60-3.8 SINGLE USE RELOADABLE A9270 270 324.31 227.017 2.81 12.94 6.59 2.81 9.71 2.81 6.59 6.59 6.59 6.59 2.81 3.091 2.81 2.81 1.93 1.93 1.9686 1.93 8600 Hos Central Supply Facility Fee 84 STAPLER MULTIFIRE ENDO GIA 30-2.5 12 MM A9270 270 604.28 422.996 0.74 3.41 1.74 0.74 2.56 0.74 1.74 1.74 1.74 1.74 0.74 0.8140000000000001 0.74 0.74 0.74 0.74 0.7548 0.74 8600 Hos Central Supply Facility Fee 475 STAPLER MULTIFIRE VERSATACK BLACK A2206 270 252.05 176.435 1.52 7.01 3.57 1.52 5.26 1.52 3.57 3.57 3.57 3.57 1.52 1.6720000000000002 1.52 1.52 1.52 1.52 1.5504 1.52 8600 Hos Central Supply Facility Fee 85 STAPLER POWERED LDS 15W DISP A9270 270 395.94 277.15799999999996 12.82 58.96 30.03 12.82 44.22 12.82 30.03 30.03 30.03 30.03 12.82 14.102000000000002 12.82 12.82 10.62 10.62 10.8324 10.62 8600 Hos Central Supply Facility Fee 89 STAPLER PREMIUM PLUS CEEA 31 SINGLE USE A9270 270 1033.48 723.4359999999999 5.81 26.73 13.62 5.81 20.05 5.81 13.62 13.62 13.62 13.62 5.81 6.391 5.81 5.81 5.81 5.81 5.9262 5.81 8600 Hos Central Supply Facility Fee 133 STAPLER SINGLE USE LOADING UNIT A1206 270 146.92 102.84399999999998 2.36 10.85 5.53 2.36 8.14 2.36 5.53 5.53 5.53 5.53 2.36 2.596 2.36 2.36 2.36 2.36 2.4072 2.36 8600 Hos Central Supply Facility Fee 474 STAPLER SKIN MULTIFIRE PREMIUM 35W A2206 270 13.75 9.625 10.56 48.59 24.75 10.56 36.44 10.56 24.75 24.75 24.75 24.75 10.56 11.616000000000001 10.56 10.56 10.56 10.56 10.7712 10.56 8600 Hos Central Supply Facility Fee 450 STAPLER SKIN PRECISE SYSTEM A9206 270 3.48 2.436 1.65 7.58 3.86 1.65 5.69 1.65 3.86 3.86 3.86 3.86 1.65 1.815 1.65 1.65 1.65 1.65 1.6829999999999998 1.65 8600 Hos Central Supply Facility Fee 783 STAPLES CD-R KSPINDLE 700MB 80-MINUTE CLEAR A4467 270 0.16 0.11199999999999999 15.02 69.11 35.2 15.02 51.83 15.02 35.2 35.2 35.2 35.2 15.02 16.522000000000002 15.02 15.02 0.59 0.59 0.6018 0.59 8600 Hos Central Supply Facility Fee 1080 STATSTRIP GLUCOSE METER 2D A4467 270 187.09 130.963 40.67 187.09 95.3 40.67 140.32 40.67 95.3 95.3 95.3 95.3 40.67 44.73700000000001 40.67 40.67 3.28 3.28 3.3455999999999997 3.28 8600 Hos Central Supply Facility Fee 1082 STATSTRIP GLUCOSE STRIPS A4253 270 803.45 562.415 2.55 11.74 5.98 2.55 8.81 2.55 5.98 5.98 5.98 5.98 2.55 2.805 2.55 2.55 2.55 2.55 2.601 2.55 8600 Hos Central Supply Facility Fee 1085 STATSTRIP LINEARITY KIT(5 LEVELS 1 OF EACH) A4467 270 83.21 58.24699999999999 6.59 30.33 15.45 6.59 22.75 6.59 15.45 15.45 15.45 15.45 6.59 7.2490000000000006 6.59 6.59 6.59 6.59 6.7218 6.59 8600 Hos Central Supply Facility Fee 50262 STD A A4467 270 8.42 5.893999999999999 1.83 8.42 4.29 1.83 6.32 1.83 4.29 4.29 4.29 4.29 1.83 2.0130000000000003 1.83 1.83 1.83 1.83 1.8666 1.83 8600 Hos Central Supply Facility Fee 1845 STERILANT NON-GLUT CIDEX OPA GALLON A9270 270 31.88 22.316 37.22 171.21 87.21 37.22 128.41 37.22 87.21 87.21 87.21 87.21 37.22 40.942 37.22 37.22 37.22 37.22 37.9644 37.22 8600 Hos Central Supply Facility Fee 323 STERILE SKIN PREP TRAY W/TWO NON-STERILE NO LONGER MADE REPLACEMENT 4468 E0206 270 4.8 3.36 2.66 12.25 6.24 2.66 9.19 2.66 6.24 6.24 6.24 6.24 2.66 2.9260000000000006 2.66 2.66 2.66 2.66 2.7132 2.66 8600 Hos Central Supply Facility Fee 1798 STERI-STRIP 1/2 X 2 R1549 270 45.39 31.773 22.23 102.25 52.09 22.23 76.69 22.23 52.09 52.09 52.09 52.09 22.23 24.453000000000003 22.23 22.23 22.23 22.23 22.6746 22.23 8600 Hos Central Supply Facility Fee 1129 STERI-STRIP 1/4 X 4 R1549 270 52.84 36.988 31.89 146.69 74.72 31.89 110.02 31.89 74.72 74.72 74.72 74.72 31.89 35.079 31.89 31.89 31.89 31.89 32.5278 31.89 8600 Hos Central Supply Facility Fee 1323 STETHOSCOPE ACCUCARE SS BURGUNDY A4467 270 48 33.599999999999994 6.11 28.09 14.31 6.11 21.07 6.11 14.31 14.31 14.31 14.31 6.11 6.721000000000001 6.11 6.11 6.11 6.11 6.232200000000001 6.11 8600 Hos Central Supply Facility Fee 1516 STETHOSCOPE CARDIOLOGY ACCUCARE SS BLACK A4467 270 56.16 39.312 6.17 28.4 14.47 6.17 21.3 6.17 14.47 14.47 14.47 14.47 6.17 6.787000000000001 6.17 6.17 6.17 6.17 6.2934 6.17 8600 Hos Central Supply Facility Fee 1734 STETHOSCOPE CARDIOLOGY IV NAVY BLUE 27IN A4467 270 277.81 194.46699999999998 12.52 57.59 29.34 12.52 43.19 12.52 29.34 29.34 29.34 29.34 12.52 13.772 12.52 12.52 12.52 12.52 12.7704 12.52 8600 Hos Central Supply Facility Fee 1221 STETHOSCOPE DUAL HEAD A4467 270 4.75 3.3249999999999997 12.52 57.59 29.34 12.52 43.19 12.52 29.34 29.34 29.34 29.34 12.52 13.772 12.52 12.52 12.52 12.52 12.7704 12.52 8600 Hos Central Supply Facility Fee 1403 STETHOSCOPE DUAL HEAD HUNTER GREEN A4467 270 4.84 3.388 12 55.22 28.13 12 41.42 12 28.13 28.13 28.13 28.13 12 13.200000000000001 12 12 12 12 12.24 12 8600 Hos Central Supply Facility Fee 1337 STETHOSCOPE MASTER-CLASSIC 11 NAVY A9270 270 324.18 226.926 24.46 112.51 57.31 24.46 84.38 24.46 57.31 57.31 57.31 57.31 24.46 26.906000000000002 24.46 24.46 24.46 24.46 24.9492 24.46 8600 Hos Central Supply Facility Fee 619 STETHOSCOPE,SINGLE-HEAD,BLACK A4660 270 3.9 2.73 2.67 12.3 6.27 2.67 9.23 2.67 6.27 6.27 6.27 6.27 2.67 2.9370000000000003 2.67 2.67 2.67 2.67 2.7234 2.67 8600 Hos Central Supply Facility Fee 141 STOCKING ANTI-EMB KNEE-LENGTH LG/REG O0206 270 9.55 6.6850000000000005 13.02 59.9 30.51 13.02 44.93 13.02 30.51 30.51 30.51 30.51 13.02 14.322000000000001 13.02 13.02 3.21 3.21 3.2742 3.21 8600 Hos Central Supply Facility Fee 432 STOCKING ANTI-EMB LARGE-REG TEMP UNAVAILABLE MBO POSS SUB 3728LFTHIG A6532 270 9.72 6.804 0.52 2.41 1.23 0.52 1.81 0.52 1.23 1.23 1.23 1.23 0.52 0.5720000000000001 0.52 0.52 0.52 0.52 0.5304 0.52 8600 Hos Central Supply Facility Fee 269 STOCKING ANTI-EMB MED-REG O4206 270 3.34 2.3379999999999996 30.52 140.38 71.51 30.52 105.29 30.52 71.51 71.51 71.51 71.51 30.52 33.572 30.52 30.52 30.52 30.52 31.1304 30.52 8600 Hos Central Supply Facility Fee 140 STOCKING KNEE LENGTH MEDIUM REGULAR O0206 270 9.55 6.6850000000000005 57.47 264.35 134.66 57.47 198.26 57.47 134.66 134.66 134.66 134.66 57.47 63.217000000000006 57.47 57.47 57.47 57.47 58.6194 57.47 8600 Hos Central Supply Facility Fee 139 STOCKING KNEE LENGTH SMALL REGULAR O0206 270 9.55 6.6850000000000005 73.64 338.71 172.54 73.64 254.03 73.64 172.54 172.54 172.54 172.54 73.64 81.004 73.64 73.64 73.64 73.64 75.11280000000001 73.64 8600 Hos Central Supply Facility Fee 154 STOCKING T.E.D. THIGH SMALL REG O4206 270 4.9 3.43 19.07 87.73 44.69 19.07 65.8 19.07 44.69 44.69 44.69 44.69 19.07 20.977 19.07 19.07 19.07 19.07 19.4514 19.07 8600 Hos Central Supply Facility Fee 302 STRAP STRETCHER OR 60 IN R1206 270 2.59 1.8129999999999997 3.46 15.92 8.11 3.46 11.94 3.46 8.11 8.11 8.11 8.11 3.46 3.806 3.46 3.46 10.35 10.35 10.557 10.35 8600 Hos Central Supply Facility Fee 1145 STREP A RAPID PLUS TEST A4467 270 53.91 37.736999999999995 3.38 15.55 7.92 3.38 11.66 3.38 7.92 7.92 7.92 7.92 3.38 3.718 3.38 3.38 0.38 0.38 0.3876 0.38 8600 Hos Central Supply Facility Fee 232 STRIP ACCU-CHEK COMFORT CURVE H TEST R0206 270 98.7 69.09 3.32 15.27 7.78 3.32 11.45 3.32 7.78 7.78 7.78 7.78 3.32 3.652 3.32 3.32 3.32 3.32 3.3864 3.32 8600 Hos Central Supply Facility Fee 467 STRIP CHEMSTRIP 10 WITH SG URINALYSIS T R5206 270 33.71 23.596999999999998 4.61 21.22 10.81 4.61 15.92 4.61 10.81 10.81 10.81 10.81 4.61 5.071000000000001 4.61 4.61 4.61 4.61 4.7022 4.61 8600 Hos Central Supply Facility Fee 1408 STRIP CHEMSTRIP 10SG URINALYSIS A4467 270 80.4 56.28 4.6 21.18 10.79 4.6 15.89 4.6 10.79 10.79 10.79 10.79 4.6 5.06 4.6 4.6 4.6 4.6 4.691999999999999 4.6 8600 Hos Central Supply Facility Fee 1281 STRIP CIDEX SOLUTION TEST A4467 270 95.18 66.626 3.75 17.23 8.78 3.75 12.92 3.75 8.78 8.78 8.78 8.78 3.75 4.125 3.75 3.75 3.75 3.75 3.825 3.75 8600 Hos Central Supply Facility Fee 1283 STRIP CIDEX SOLUTION TEST 14 DAY 60/EA A4467 270 102.9 72.03 6.93 31.88 16.24 6.93 23.91 6.93 16.24 16.24 16.24 16.24 6.93 7.623 6.93 6.93 6.93 6.93 7.0686 6.93 8600 Hos Central Supply Facility Fee 274 STRIP IODOFORM PAC 1/2 X 5 YD R4206 270 3.31 2.3169999999999997 5.3 24.37 12.41 5.3 18.28 5.3 12.41 12.41 12.41 12.41 5.3 5.83 5.3 5.3 5.3 5.3 5.406 5.3 8600 Hos Central Supply Facility Fee 273 STRIP IODOFORM PAC 1/4 X 5 YD R9206 270 3.17 2.219 0.61 2.8 1.43 0.61 2.1 0.61 1.43 1.43 1.43 1.43 0.61 0.671 0.61 0.61 0.61 0.61 0.6222 0.61 8600 Hos Central Supply Facility Fee 1162 STRIP MULTISTIX 10SG T8699 270 37.87 26.508999999999997 2.1 9.68 4.93 2.1 7.26 2.1 4.93 4.93 4.93 4.93 2.1 2.3100000000000005 2.1 2.1 2.1 2.1 2.1420000000000003 2.1 8600 Hos Central Supply Facility Fee 231 STRIP TEST BLOOD GLUCOSE CONTOUR R5206 270 3.66 2.562 14.69 67.58 34.43 14.69 50.69 14.69 34.43 34.43 34.43 34.43 14.69 16.159000000000002 14.69 14.69 14.69 14.69 14.9838 14.69 8600 Hos Central Supply Facility Fee 1533 STRL INCISION & DRAINAGE TRAY A4467 270 48.49 33.943 7.62 35.06 17.86 7.62 26.3 7.62 17.86 17.86 17.86 17.86 7.62 8.382000000000001 7.62 7.62 14.69 14.69 14.9838 14.69 8600 Hos Central Supply Facility Fee 850 STYLET 14FR A4467 270 3.52 2.464 3.36 15.45 7.87 3.36 11.59 3.36 7.87 7.87 7.87 7.87 3.36 3.696 3.36 3.36 3.36 3.36 3.4272 3.36 8600 Hos Central Supply Facility Fee 849 STYLET 6FR A4467 270 2.19 1.533 6.01 27.65 14.08 6.01 20.74 6.01 14.08 14.08 14.08 14.08 6.01 6.611000000000001 6.01 6.01 6.01 6.01 6.1302 6.01 8600 Hos Central Supply Facility Fee 1669 STYLET PEDIATRIC TUBE ENDOTRACHEAL GUIDE A4467 270 7.44 5.208 22.17 102 51.96 22.17 76.5 22.17 51.96 51.96 51.96 51.96 22.17 24.387000000000004 22.17 22.17 22.17 22.17 22.613400000000002 22.17 8600 Hos Central Supply Facility Fee 50259 SUBSTRATE A4467 270 283.5 198.45 195.66 899.99 458.45 195.66 674.99 195.66 458.45 458.45 458.45 458.45 195.66 215.22600000000003 195.66 195.66 195.66 195.66 199.5732 195.66 8600 Hos Central Supply Facility Fee 851 SUCTION CATHETER 6FR A4624 270 0.45 0.315 82.78 380.77 193.96 82.78 285.58 82.78 193.96 193.96 193.96 193.96 82.78 91.058 82.78 82.78 82.78 82.78 84.43560000000001 82.78 8600 Hos Central Supply Facility Fee 845 SUCTION CATHETER TRAY 10FR A4467 270 2.22 1.554 30.43 139.95 71.29 30.43 104.96 30.43 71.29 71.29 71.29 71.29 30.43 33.473 30.43 30.43 30.43 30.43 31.0386 30.43 8600 Hos Central Supply Facility Fee 846 SUCTION CATHETER TRAY 12FR A4467 270 2.22 1.554 30.43 139.95 71.29 30.43 104.96 30.43 71.29 71.29 71.29 71.29 30.43 33.473 30.43 30.43 30.43 30.43 31.0386 30.43 8600 Hos Central Supply Facility Fee 847 SUCTION CATHETER TRAY 14FR A4467 270 2.22 1.554 15.79 72.63 37 15.79 54.47 15.79 37 37 37 37 15.79 17.369 15.79 15.79 15.79 15.79 16.1058 15.79 8600 Hos Central Supply Facility Fee 848 SUCTION CATHETER TRAY 18FR A4467 270 0.46 0.322 6.43 29.59 15.07 6.43 22.19 6.43 15.07 15.07 15.07 15.07 6.43 7.073 6.43 6.43 6.43 6.43 6.5586 6.43 8600 Hos Central Supply Facility Fee 899 SUGAR PACKETS 3000 CS A4467 270 18.94 13.258000000000001 5.39 24.79 12.63 5.39 18.59 5.39 12.63 12.63 12.63 12.63 5.39 5.929 5.39 5.39 5.39 5.39 5.4978 5.39 8600 Hos Central Supply Facility Fee 1103 SUGAR PACKETS DIXIE CRYSTAL A4467 270 10.03 7.020999999999999 44.36 204.06 103.95 44.36 153.05 44.36 103.95 103.95 103.95 103.95 44.36 48.79600000000001 44.36 44.36 44.36 44.36 45.2472 44.36 8600 Hos Central Supply Facility Fee 50107 SURE-VUE RF 100 A4467 270 1.71 1.1969999999999998 5.5 25.31 12.89 5.5 18.98 5.5 12.89 12.89 12.89 12.89 5.5 6.050000000000001 5.5 5.5 8.82 8.82 8.996400000000001 8.82 8600 Hos Central Supply Facility Fee 1122 SURE-VUE STREP A SWABS 87081 270 164.84 115.38799999999999 1.05 4.81 2.45 1.05 3.61 1.05 2.45 2.45 2.45 2.45 1.05 1.1550000000000002 1.05 1.05 1.05 1.05 1.0710000000000002 1.05 8600 Hos Central Supply Facility Fee 1437 SURGISEAL SKIN ADHESIVE G0168 270 15.75 11.024999999999999 1.22 5.6 2.85 1.22 4.2 1.22 2.85 2.85 2.85 2.85 1.22 1.342 1.22 1.22 1.22 1.22 1.2444 1.22 8600 Hos Central Supply Facility Fee 50121 SUSCEPTIBILITY TEST MICROBIOLOGY 2M 40ML VERSATREK REDOX EZDRAW A4467 270 9.27 6.488999999999999 3.13 14.41 7.34 3.13 10.81 3.13 7.34 7.34 7.34 7.34 3.13 3.443 3.13 3.13 3.13 3.13 3.1926 3.13 8600 Hos Central Supply Facility Fee 785 SUSTAINABLE EARTH BY STAPLES GUMMED RECYCLED #10 BUSINESS ENEVELOPES 4 1/8 X 9 1 A4467 270 0.03 0.020999999999999998 27.16 124.95 63.65 27.16 93.71 27.16 63.65 63.65 63.65 63.65 27.16 29.876 27.16 27.16 27.16 27.16 27.7032 27.16 8600 Hos Central Supply Facility Fee 1270 SUTUE REMOVAL KIT S0630 270 0.78 0.5459999999999999 1.44 6.63 3.38 1.44 4.97 1.44 3.38 3.38 3.38 3.38 1.44 1.584 1.44 1.44 1.44 1.44 1.4687999999999999 1.44 8600 Hos Central Supply Facility Fee 1802 SUTURE 3/0 J219H U8600 270 59.28 41.495999999999995 65.22 299.99 152.81 65.22 224.99 65.22 152.81 152.81 152.81 152.81 65.22 71.742 65.22 65.22 65.22 65.22 66.5244 65.22 8600 Hos Central Supply Facility Fee 1800 SUTURE 4/0 1864G U8644 270 44.25 30.974999999999998 15.92 73.25 37.31 15.92 54.94 15.92 37.31 37.31 37.31 37.31 15.92 17.512 15.92 15.92 15.92 15.92 16.2384 15.92 8600 Hos Central Supply Facility Fee 328 SUTURE CHROMIC GUT 2/0 27IN FS-1 C-14 FS-1/C-14/CE-6/C7/DS24 70CM T5206 270 2.71 1.8969999999999998 22.88 105.24 53.61 22.88 78.93 22.88 53.61 53.61 53.61 53.61 22.88 25.168 22.88 22.88 22.88 22.88 23.3376 22.88 8600 Hos Central Supply Facility Fee 412 SUTURE CHROMIC GUT 3/0 27IN SH V-20 SH/V-20/T-5/HR26/T/VF-20/C-2/HR26 70CM A7679 270 2.58 1.8059999999999998 4.13 18.99 9.67 4.13 14.24 4.13 9.67 9.67 9.67 9.67 4.13 4.543 4.13 4.13 4.13 4.13 4.2126 4.13 8600 Hos Central Supply Facility Fee 93 SUTURE CHROMIC GUT 4/0 18 IN P-3 P-13 T9206 270 5.09 3.5629999999999997 53.13 244.39 124.49 53.13 183.29 53.13 124.49 124.49 124.49 124.49 53.13 58.443000000000005 53.13 53.13 53.13 53.13 54.192600000000006 53.13 8600 Hos Central Supply Facility Fee 97 SUTURE CHROMIC GUT 6/0 18 IN PS-6 P-22 T1206 270 5.13 3.5909999999999997 21.46 98.69 50.27 21.46 74.02 21.46 50.27 50.27 50.27 50.27 21.46 23.606 21.46 21.46 21.46 21.46 21.889200000000002 21.46 8600 Hos Central Supply Facility Fee 411 SUTURE CTD VICRYL 3/0 8X18IN VIOLET SH A7679 270 9.42 6.593999999999999 14.85 68.31 34.8 14.85 51.23 14.85 34.8 34.8 34.8 34.8 14.85 16.335 14.85 14.85 14.85 14.85 15.147 14.85 8600 Hos Central Supply Facility Fee 470 SUTURE ETHIBOND 1 30IN GREEN OS-6 HOS-11 75CM A7679 270 2.15 1.505 6.54 30.06 15.31 6.54 22.55 6.54 15.31 15.31 15.31 15.31 6.54 7.194000000000001 6.54 6.54 6.54 6.54 6.6708 6.54 8600 Hos Central Supply Facility Fee 204 SUTURE ETHILON 1 60 IN BLACK TP1 XLH GS26 T6206 270 2.13 1.4909999999999999 849.44 3907.26 1990.36 849.44 2930.45 849.44 1990.36 1990.36 1990.36 1990.36 849.44 934.3840000000001 849.44 849.44 849.44 849.44 866.4288 849.44 8600 Hos Central Supply Facility Fee 95 SUTURE ETHILON 2/0 30 IN BLACK FSLX C-17 T2206 270 4.23 2.9610000000000003 22.4 103.03 52.48 22.4 77.27 22.4 52.48 52.48 52.48 52.48 22.4 24.64 22.4 22.4 22.4 22.4 22.848 22.4 8600 Hos Central Supply Facility Fee 94 SUTURE ETHILON 3/0 18 IN BLACK PS-1 P-14 T7206 270 2.79 1.9529999999999998 22.56 103.78 52.87 22.56 77.84 22.56 52.87 52.87 52.87 52.87 22.56 24.816 22.56 22.56 22.56 22.56 23.0112 22.56 8600 Hos Central Supply Facility Fee 334 SUTURE ETHILON 4/0 18IN BLACK FS-2 C-13 FS-2/C-13/CE-4/C6/DS18 45CM A4649 270 1.4 0.9799999999999999 29.91 137.56 70.07 29.91 103.17 29.91 70.07 70.07 70.07 70.07 29.91 32.901 29.91 29.91 29.91 29.91 30.508200000000002 29.91 8600 Hos Central Supply Facility Fee 337 SUTURE ETHILON 4/0 18IN BLACK P-3 P-13 P-3/P-13/PRE-2/SBE-2/DSM13/DGL13 45CM A4649 270 2.74 1.918 1.05 4.81 2.45 1.05 3.61 1.05 2.45 2.45 2.45 2.45 1.05 1.1550000000000002 1.05 1.05 1.05 1.05 1.0710000000000002 1.05 8600 Hos Central Supply Facility Fee 1799 SUTURE ETHILON 5/0 1855G A4467 270 44.61 31.226999999999997 1.05 4.81 2.45 1.05 3.61 1.05 2.45 2.45 2.45 2.45 1.05 1.1550000000000002 1.05 1.05 1.05 1.05 1.0710000000000002 1.05 8600 Hos Central Supply Facility Fee 336 SUTURE ETHILON 5/0 18IN 45CM P-3 NEEDLE BLACK P-1/P-10/PRE-1/SBE-1/DGL11/DSM11 A4649 270 2.74 1.918 1.27 5.82 2.96 1.27 4.37 1.27 2.96 2.96 2.96 2.96 1.27 1.3970000000000002 1.27 1.27 1.27 1.27 1.2954 1.27 8600 Hos Central Supply Facility Fee 333 SUTURE ETHILON 5/0 18IN BLACK FS-2 C-13 FS-2/C-13/CE-4/C6/DS18 45CM A4649 270 1.46 1.022 19.85 91.3 46.51 19.85 68.48 19.85 46.51 46.51 46.51 46.51 19.85 21.835000000000004 19.85 19.85 19.85 19.85 20.247000000000003 19.85 8600 Hos Central Supply Facility Fee 335 SUTURE ETHILON 6/0 18IN BLACK C-2 C-1 C-2/C-1/CE-21/C17/DS12 45CM A4649 270 1.44 1.008 4.29 19.75 10.06 4.29 14.81 4.29 10.06 10.06 10.06 10.06 4.29 4.719 4.29 4.29 4.29 4.29 4.3758 4.29 8600 Hos Central Supply Facility Fee 472 SUTURE MONOCRYL 4/0 18IN UNDYED P-3 P-13 P-3/P-13/PRE-2/SBE-2/DSM13/DGL13 45CM A4649 270 3.8 2.6599999999999997 1.05 4.81 2.45 1.05 3.61 1.05 2.45 2.45 2.45 2.45 1.05 1.1550000000000002 1.05 1.05 1.05 1.05 1.0710000000000002 1.05 8600 Hos Central Supply Facility Fee 471 SUTURE MONOCRYL 4/0 27IN UNDYED SH V-20 SH/V-20/T-5/HR26/T/VF-20/C-2 70CM A7679 270 1.56 1.0919999999999999 4.29 19.75 10.06 4.29 14.81 4.29 10.06 10.06 10.06 10.06 4.29 4.719 4.29 4.29 4.29 4.29 4.3758 4.29 8600 Hos Central Supply Facility Fee 473 SUTURE PDS II 1 27IN VIOLET XLH HR76 70CM T6206 270 3.71 2.597 5.43 24.99 12.73 5.43 18.74 5.43 12.73 12.73 12.73 12.73 5.43 5.973 5.43 5.43 5.43 5.43 5.5386 5.43 8600 Hos Central Supply Facility Fee 358 SUTURE PROLENE 0 30IN BLUE CT-1 GS-21 CT-1/GS-21/T-12 75CM L8699 270 1.84 1.288 18.74 86.22 43.92 18.74 64.67 18.74 43.92 43.92 43.92 43.92 18.74 20.614 18.74 18.74 18.74 18.74 19.1148 18.74 8600 Hos Central Supply Facility Fee 205 SUTURE PROLENE 2/0 30 IN BLUE CT-2 GS-22 T8206 270 1.85 1.295 5.61 25.82 13.15 5.61 19.37 5.61 13.15 13.15 13.15 13.15 5.61 6.171000000000001 5.61 5.61 5.61 5.61 5.722200000000001 5.61 8600 Hos Central Supply Facility Fee 1585 SUTURE PROLENE 3/0 U8666 270 57.63 40.341 5.13 23.61 12.03 5.13 17.71 5.13 12.03 12.03 12.03 12.03 5.13 5.643000000000001 5.13 5.13 5.13 5.13 5.2326 5.13 8600 Hos Central Supply Facility Fee 212 SUTURE PROLENE 3/0 18 IN BLUE FS-1 C-14 A4649 270 1.95 1.365 10.86 49.95 25.44 10.86 37.46 10.86 25.44 25.44 25.44 25.44 10.86 11.946 10.86 10.86 10.86 10.86 11.0772 10.86 8600 Hos Central Supply Facility Fee 209 SUTURE PROLENE 3/0 18 IN BLUE PS-1 P-14 A4649 270 3.37 2.359 3.61 16.62 8.47 3.61 12.47 3.61 8.47 8.47 8.47 8.47 3.61 3.971 3.61 3.61 3.61 3.61 3.6822 3.61 8600 Hos Central Supply Facility Fee 357 SUTURE PROLENE 3/0 30IN BLUE CT-2 GS-22 CT-2/GS-22/T-19 75CM L8699 270 1.87 1.309 22.43 103.19 52.56 22.43 77.39 22.43 52.56 52.56 52.56 52.56 22.43 24.673000000000002 22.43 22.43 22.43 22.43 22.8786 22.43 8600 Hos Central Supply Facility Fee 1583 SUTURE PROLENE 4/0 U8666 270 83.75 58.62499999999999 25.19 115.88 59.03 25.19 86.91 25.19 59.03 59.03 59.03 59.03 25.19 27.709000000000003 25.19 25.19 25.19 25.19 25.693800000000003 25.19 8600 Hos Central Supply Facility Fee 211 SUTURE PROLENE 4/0 18 IN BLUE FS-2 C-13 A4649 270 2.07 1.4489999999999998 10.58 48.68 24.8 10.58 36.51 10.58 24.8 24.8 24.8 24.8 10.58 11.638000000000002 10.58 10.58 10.58 10.58 10.7916 10.58 8600 Hos Central Supply Facility Fee 367 SUTURE PROLENE 4/0 18IN BLUE P-3 P-13 P-3/P-13/PRE-2/SBE-2/DSM13/DGL13 45CM A4649 270 3.46 2.4219999999999997 10.92 50.22 25.58 10.92 37.67 10.92 25.58 25.58 25.58 25.58 10.92 12.012 10.92 10.92 10.92 10.92 11.1384 10.92 8600 Hos Central Supply Facility Fee 365 SUTURE PROLENE 4/0 18IN BLUE PS-2 P-14 PS-2/P-14/PRE-6/PC33/DSM24 45CM A4649 270 3.37 2.359 8.78 40.4 20.58 8.78 30.3 8.78 20.58 20.58 20.58 20.58 8.78 9.658 8.78 8.78 8.78 8.78 8.955599999999999 8.78 8600 Hos Central Supply Facility Fee 1584 SUTURE PROLENE 5/0 U8688 270 58.66 41.062 77.44 356.2 181.45 77.44 267.15 77.44 181.45 181.45 181.45 181.45 77.44 85.184 77.44 77.44 77.44 77.44 78.9888 77.44 8600 Hos Central Supply Facility Fee 1586 SUTURE PROLENE 5/0 U8688 270 68.47 47.928999999999995 46.52 214 109.01 46.52 160.5 46.52 109.01 109.01 109.01 109.01 46.52 51.172000000000004 46.52 46.52 46.52 46.52 47.4504 46.52 8600 Hos Central Supply Facility Fee 208 SUTURE PROLENE 5/0 18 IN BLUE FS-3 C-12 A4649 270 2.11 1.4769999999999999 238.97 1099.23 559.95 238.97 824.42 238.97 559.95 559.95 559.95 559.95 238.97 262.867 238.97 238.97 238.97 238.97 243.7494 238.97 8600 Hos Central Supply Facility Fee 366 SUTURE PROLENE 5/0 18IN BLUE P-3 P-13 P-3/P-13/PRE-2/SBE-2/DSM13/DGL13 45CM A4649 270 3.67 2.569 21.54 99.08 50.47 21.54 74.31 21.54 50.47 50.47 50.47 50.47 21.54 23.694000000000003 21.54 21.54 21.54 21.54 21.9708 21.54 8600 Hos Central Supply Facility Fee 364 SUTURE PROLENE 5/0 18IN BLUE PS-3 P-11 PS-3/P-11/PRE-3/SBE-3/DSM16 45CM A4649 270 3.69 2.5829999999999997 15.67 72.06 36.71 15.67 54.05 15.67 36.71 36.71 36.71 36.71 15.67 17.237000000000002 15.67 15.67 15.67 15.67 15.9834 15.67 8600 Hos Central Supply Facility Fee 213 SUTURE PROLENE 6/0 18 IN BLUE PP-3 P-13 A4649 270 3.73 2.6109999999999998 2 9.22 4.7 2 6.92 2 4.7 4.7 4.7 4.7 2 2.2 2 2 2 2 2.04 2 8600 Hos Central Supply Facility Fee 210 SUTURE PROLENE 6/0 18 IN BLUE PS-3 P-11 A4649 270 3.72 2.604 58.7 269.99 137.53 58.7 202.49 58.7 137.53 137.53 137.53 137.53 58.7 64.57000000000001 58.7 58.7 58.7 58.7 59.874 58.7 8600 Hos Central Supply Facility Fee 842 SUTURE REMOVAL TRAY A4550 270 0.5 0.35 26.76 123.09 62.7 26.76 92.32 26.76 62.7 62.7 62.7 62.7 26.76 29.436000000000003 26.76 26.76 26.76 26.76 27.2952 26.76 8600 Hos Central Supply Facility Fee 393 SUTURE SILK 2/0 8X18IN BLACK SH V-20 SH/V-20/T-5/HR26/T/VF-20/C-2 45CM DETACH A7679 270 6.86 4.802 9.51 43.73 22.28 9.51 32.8 9.51 22.28 22.28 22.28 22.28 9.51 10.461 9.51 9.51 9.51 9.51 9.7002 9.51 8600 Hos Central Supply Facility Fee 462 SUTURE SILK 3/0 17X18IN BLACK TIES 45CM T2206 270 1.67 1.1689999999999998 1.39 6.39 3.26 1.39 4.79 1.39 3.26 3.26 3.26 3.26 1.39 1.529 1.39 1.39 1.39 1.39 1.4178 1.39 8600 Hos Central Supply Facility Fee 392 SUTURE SILK 3/0 18IN BLACK SH-1 CV-25 SH-1/CV-25/T-16/HR22/T4 45CM DETACH A7679 270 6.94 4.858 2.6 11.95 6.09 2.6 8.96 2.6 6.09 6.09 6.09 6.09 2.6 2.8600000000000003 2.6 2.6 2.6 2.6 2.652 2.6 8600 Hos Central Supply Facility Fee 408 SUTURE VICRYL 0 18IN VIOLET ENDOLOOP 45CM T3206 270 36.2 25.34 4.36 20.05 10.21 4.36 15.04 4.36 10.21 10.21 10.21 10.21 4.36 4.796000000000001 4.36 4.36 4.36 4.36 4.4472000000000005 4.36 8600 Hos Central Supply Facility Fee 428 SUTURE VICRYL 0 27IN UNDYED CPX GS-13 CPX/GS-13/C-12/HS48 70CM ORTHO A7679 270 1.46 1.022 18.34 84.34 42.96 18.34 63.26 18.34 42.96 42.96 42.96 42.96 18.34 20.174000000000003 18.34 18.34 18.34 18.34 18.7068 18.34 8600 Hos Central Supply Facility Fee 266 SUTURE VICRYL 0 36 IN VIOLET CT-1 GS-21 T3206 270 1.39 0.9729999999999999 26.08 119.94 61.1 26.08 89.96 26.08 61.1 61.1 61.1 61.1 26.08 28.688 26.08 26.08 26.08 26.08 26.601599999999998 26.08 8600 Hos Central Supply Facility Fee 427 SUTURE VICRYL 2/0 27IN UNDYED OS-6 HOS11 OS-6/HOS-11/HS37SS 70CM ORTHO A7679 270 2.08 1.456 30.99 142.56 72.62 30.99 106.92 30.99 72.62 72.62 72.62 72.62 30.99 34.089 30.99 30.99 30.99 30.99 31.6098 30.99 8600 Hos Central Supply Facility Fee 423 SUTURE VICRYL 2/0 27IN UNDYED SH V-20 A7679 270 1.3 0.9099999999999999 14.37 66.11 33.68 14.37 49.58 14.37 33.68 33.68 33.68 33.68 14.37 15.807 14.37 14.37 14.37 14.37 14.657399999999999 14.37 8600 Hos Central Supply Facility Fee 429 SUTURE VICRYL 2/0 27IN VIOLET XLH HR76 70CM A7679 270 2.97 2.079 13.04 60 30.56 13.04 45 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 8600 Hos Central Supply Facility Fee 421 SUTURE VICRYL 2/0 37IN VIOLET CT-1 GS-21 CT-1/GS-21/T-12/HR37 70CM A7679 270 1.3 0.9099999999999999 4.84 22.25 11.33 4.84 16.69 4.84 11.33 11.33 11.33 11.33 4.84 5.324 4.84 4.84 4.84 4.84 4.9368 4.84 8600 Hos Central Supply Facility Fee 265 SUTURE VICRYL 3/0 27 IN UNDYED SH-1 CV-25 T7206 270 1.5 1.0499999999999998 4.84 22.25 11.33 4.84 16.69 4.84 11.33 11.33 11.33 11.33 4.84 5.324 4.84 4.84 4.84 4.84 4.9368 4.84 8600 Hos Central Supply Facility Fee 430 SUTURE VICRYL 3/0 36IN UNDYED CT-1 GS-21 CT-1/GS-21/T-12/HR37 90CM A7679 270 1.4 0.9799999999999999 4.84 22.25 11.33 4.84 16.69 4.84 11.33 11.33 11.33 11.33 4.84 5.324 4.84 4.84 4.84 4.84 4.9368 4.84 8600 Hos Central Supply Facility Fee 422 SUTURE VICRYL 3/0 36IN VIOLET CT-1 GS-21 CT-1/GS-21/T-12/HR37 90CM A7679 270 1.41 0.9869999999999999 7.37 33.91 17.27 7.37 25.43 7.37 17.27 17.27 17.27 17.27 7.37 8.107000000000001 7.37 7.37 7.37 7.37 7.5174 7.37 8600 Hos Central Supply Facility Fee 418 SUTURE VICRYL 3/0 54IN VIOLET REEL TIES 135CM LIGAPAK A7679 270 1.55 1.085 6.37 29.31 14.93 6.37 21.98 6.37 14.93 14.93 14.93 14.93 6.37 7.007000000000001 6.37 6.37 6.37 6.37 6.4974 6.37 8600 Hos Central Supply Facility Fee 426 SUTURE VICRYL 4/0 18IN UNDYED P-3 P-13 P-3/P-13/PRE-2/SBE-2/DSM13/DGL13 45CM A4649 270 3 2.0999999999999996 18.49 85.04 43.32 18.49 63.78 18.49 43.32 43.32 43.32 43.32 18.49 20.339 18.49 18.49 18.49 18.49 18.8598 18.49 8600 Hos Central Supply Facility Fee 268 SUTURE VICRYL 4/0 27 IN UNDYED FS-2 C-13 T6206 270 1.8 1.26 86.3 396.96 202.21 86.3 297.72 86.3 202.21 202.21 202.21 202.21 86.3 94.93 86.3 86.3 86.3 86.3 88.026 86.3 8600 Hos Central Supply Facility Fee 424 SUTURE VICRYL 4/0 27IN UNDYED FS-1 C-14 FS-1/C-14/CE-6/C7/DS24 70CM A7679 270 1.83 1.281 2.7 12.44 6.34 2.7 9.33 2.7 6.34 6.34 6.34 6.34 2.7 2.9700000000000006 2.7 2.7 2.7 2.7 2.7540000000000004 2.7 8600 Hos Central Supply Facility Fee 419 SUTURE VICRYL 4/0 27IN UNDYED SH-1 CV-25 SH-1/CV-25/T-16/HR22/T4 70CM A7679 270 1.33 0.9309999999999999 0.6517 1.33 0.6778295819935692 0.2886655948553055 43.4925 0.29 0.6778295819935692 0.6778295819935692 0.6778295819935692 0.6778295819935692 0.29 0.29 0.29 0.29 0.29 0.29 0.2958 0.29 8600 Hos Central Supply Facility Fee 420 SUTURE VICRYL 4/0 27IN VIOLET CT-1 GS-21 CT-1/GS-21/T-12/HR37 70CM A7679 270 1.33 0.9309999999999999 12.61 57.99 29.54 12.61 43.49 12.61 29.54 29.54 29.54 29.54 12.61 13.871 12.61 12.61 12.61 12.61 12.8622 12.61 8600 Hos Central Supply Facility Fee 267 SUTURE VICRYL 5/0 27 IN UNDYED FS-2 C-13 T7206 270 1.84 1.288 9.56 43.99 22.41 9.56 32.99 9.56 22.41 22.41 22.41 22.41 9.56 10.516000000000002 9.56 9.56 9.56 9.56 9.7512 9.56 8600 Hos Central Supply Facility Fee 425 SUTURE VICRYL 6/0 18IN UNDYED P-3 P-13 P-3/P-13/PRE-2/SBE-2/DSM13/DGL13 45CM A4649 270 3.09 2.163 6.91 31.8 16.2 6.91 23.85 6.91 16.2 16.2 16.2 16.2 6.91 7.601000000000001 6.91 6.91 6.91 6.91 7.0482000000000005 6.91 8600 Hos Central Supply Facility Fee 1801 SUTURE3/0 A4467 270 38.38 26.866 12.39 56.99 29.03 12.39 42.74 12.39 29.03 29.03 29.03 29.03 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 8600 Hos Central Supply Facility Fee 50108 SWAB LIQ STUARTS DBL FB A4467 270 0.49 0.34299999999999997 8.32 38.25 19.48 8.32 28.69 8.32 19.48 19.48 19.48 19.48 8.32 9.152000000000001 8.32 8.32 8.32 8.32 8.4864 8.32 8600 Hos Central Supply Facility Fee 613 SWAB,ORAL,DENTIPS,UNTREAT,INDV WRP,BLUE A4467 270 0.09 0.063 9.78 45 22.92 9.78 33.75 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 8600 Hos Central Supply Facility Fee 356 SYRINGE 1/2 CC INSULIN SAFETY 30X5/16 SUB: ED053005IN R2206 270 0.4 0.27999999999999997 164.55 756.9 385.56 164.55 567.68 164.55 385.56 385.56 385.56 385.56 164.55 181.00500000000002 164.55 164.55 46.08 46.08 47.001599999999996 46.08 8600 Hos Central Supply Facility Fee 973 SYRINGE 1/2 CC SAFETY INSULIN A4467 270 39.99 27.993 260.42 1197.9 610.21 260.42 898.43 260.42 610.21 610.21 610.21 610.21 260.42 286.46200000000005 260.42 260.42 260.42 260.42 265.6284 260.42 8600 Hos Central Supply Facility Fee 1763 SYRINGE 10CC LUER TIP A4467 270 15.1 10.569999999999999 345.73 1590.3 810.1 345.73 1192.73 345.73 810.1 810.1 810.1 810.1 345.73 380.30300000000005 345.73 345.73 345.73 345.73 352.6446 345.73 8600 Hos Central Supply Facility Fee 388 SYRINGE 10CC LUER-LOK TIP STERILE DISPOSABLE A4206 270 0.08 0.055999999999999994 38.45 176.85 90.09 38.45 132.64 38.45 90.09 90.09 90.09 90.09 38.45 42.29500000000001 38.45 38.45 38.45 38.45 39.219 38.45 8600 Hos Central Supply Facility Fee 1789 SYRINGE 10ML LL Y8677 270 21.53 15.071 0.67 3.06 1.56 0.67 2.3 0.67 1.56 1.56 1.56 1.56 0.67 0.7370000000000001 0.67 0.67 0.67 0.67 0.6834 0.67 8600 Hos Central Supply Facility Fee 1050 SYRINGE 10ML SALINE Y8655 270 36.41 25.486999999999995 3.7 17 8.66 3.7 12.75 3.7 8.66 8.66 8.66 8.66 3.7 4.07 3.7 3.7 3.7 3.7 3.7740000000000005 3.7 8600 Hos Central Supply Facility Fee 1320 SYRINGE 1CC SUB-Q 26 G A2629 270 9.05 6.335 7.06 32.46 16.54 7.06 24.35 7.06 16.54 16.54 16.54 16.54 7.06 7.766 7.06 7.06 7.06 7.06 7.2012 7.06 8600 Hos Central Supply Facility Fee 1691 SYRINGE 20CC W/O NEEDLE A4467 270 26.24 18.368 3.43 15.77 8.03 3.43 11.83 3.43 8.03 8.03 8.03 8.03 3.43 3.7730000000000006 3.43 3.43 3.43 3.43 3.4986 3.43 8600 Hos Central Supply Facility Fee 1844 SYRINGE 23G 1IN A4657 270 17.23 12.061 17.47 80.36 40.94 17.47 60.27 17.47 40.94 40.94 40.94 40.94 17.47 19.217 17.47 17.47 17.47 17.47 17.819399999999998 17.47 8600 Hos Central Supply Facility Fee 1108 SYRINGE 30CC A4467 270 13.37 9.358999999999998 12.21 56.18 28.62 12.21 42.14 12.21 28.62 28.62 28.62 28.62 12.21 13.431000000000003 12.21 12.21 12.21 12.21 12.454200000000002 12.21 8600 Hos Central Supply Facility Fee 389 SYRINGE 30ML LUER-LOK TIP NO LONGER MADE REPLACEMENT BF302832 A4206 270 0.19 0.13299999999999998 37.9 174.34 88.81 37.9 130.76 37.9 88.81 88.81 88.81 88.81 37.9 41.690000000000005 37.9 37.9 37.9 37.9 38.658 37.9 8600 Hos Central Supply Facility Fee 1262 SYRINGE 3CC 10ML 29GX1/2 A4467 270 39.52 27.664 22.68 104.34 53.15 22.68 78.26 22.68 53.15 53.15 53.15 53.15 22.68 24.948 22.68 22.68 22.68 22.68 23.1336 22.68 8600 Hos Central Supply Facility Fee 1841 SYRINGE 3CC21G 1 1/2 A4467 270 15.27 10.688999999999998 6.54 30.1 15.33 6.54 22.58 6.54 15.33 15.33 15.33 15.33 6.54 7.194000000000001 6.54 6.54 6.54 6.54 6.6708 6.54 8600 Hos Central Supply Facility Fee 1840 SYRINGE 3ML 22G1 1/2 A4467 270 15.55 10.885 0.93 4.28 2.18 0.93 3.21 0.93 2.18 2.18 2.18 2.18 0.93 1.0230000000000001 0.93 0.93 0.93 0.93 0.9486000000000001 0.93 8600 Hos Central Supply Facility Fee 1051 SYRINGE 5CC LL Y8655 270 40.35 28.244999999999997 4.31 19.83 10.1 4.31 14.87 4.31 10.1 10.1 10.1 10.1 4.31 4.741 4.31 4.31 4.31 4.31 4.396199999999999 4.31 8600 Hos Central Supply Facility Fee 1111 SYRINGE 5CC LUER LOK A4467 270 210 147 5.62 25.86 13.17 5.62 19.4 5.62 13.17 13.17 13.17 13.17 5.62 6.182 5.62 5.62 5.62 5.62 5.7324 5.62 8600 Hos Central Supply Facility Fee 363 SYRINGE 60CC CATHETER TIP SOFTPACK R5206 270 0.49 0.34299999999999997 6.97 32.06 16.33 6.97 24.05 6.97 16.33 16.33 16.33 16.33 6.97 7.667000000000001 6.97 6.97 6.97 6.97 7.1094 6.97 8600 Hos Central Supply Facility Fee 1425 SYRINGE 60ML CATH TIP R5206 270 0.57 0.39899999999999997 7.17 32.99 16.81 7.17 24.74 7.17 16.81 16.81 16.81 16.81 7.17 7.8870000000000005 7.17 7.17 7.17 7.17 7.3134 7.17 8600 Hos Central Supply Facility Fee 390 SYRINGE BD 60ML LUER-LOK TIP GRADUATION A4206 270 0.29 0.20299999999999999 3.65 16.79 8.55 3.65 12.59 3.65 8.55 8.55 8.55 8.55 3.65 4.015000000000001 3.65 3.65 3.65 3.65 3.723 3.65 8600 Hos Central Supply Facility Fee 1514 SYRINGE CONTROL 10CC A4657 270 19.51 13.657 8.65 39.78 20.26 8.65 29.84 8.65 20.26 20.26 20.26 20.26 8.65 9.515 8.65 8.65 8.65 8.65 8.823 8.65 8600 Hos Central Supply Facility Fee 1106 SYRINGE FLUSH 10 ML A4467 270 25.83 18.080999999999996 22.35 102.81 52.37 22.35 77.11 22.35 52.37 52.37 52.37 52.37 22.35 24.585000000000004 22.35 22.35 22.35 22.35 22.797 22.35 8600 Hos Central Supply Facility Fee 944 SYRINGE INSULIN 1CC A4206 270 30.11 21.076999999999998 5.47 25.15 12.81 5.47 18.86 5.47 12.81 12.81 12.81 12.81 5.47 6.017 5.47 5.47 5.47 5.47 5.5794 5.47 8600 Hos Central Supply Facility Fee 1294 SYRINGE INSULIN 1CC 28G X 1/2 A4206 270 9.29 6.502999999999999 36.74 169 86.09 36.74 126.75 36.74 86.09 86.09 86.09 86.09 36.74 40.41400000000001 36.74 36.74 36.74 36.74 37.4748 36.74 8600 Hos Central Supply Facility Fee 1531 SYRINGE INSULIN 1ML 29G X 1/2IN SAFETY A4206 270 48.43 33.900999999999996 12.39 56.99 29.03 12.39 42.74 12.39 29.03 29.03 29.03 29.03 12.39 13.629000000000001 12.39 12.39 12.39 12.39 12.6378 12.39 8600 Hos Central Supply Facility Fee 1528 SYRINGE INSULIN SAFETY 29G 1/2 A4206 270 50.56 35.391999999999996 19.14 88.06 44.86 19.14 66.05 19.14 44.86 44.86 44.86 44.86 19.14 21.054000000000002 19.14 19.14 19.14 19.14 19.5228 19.14 8600 Hos Central Supply Facility Fee 1010 SYRINGE NEEDLE PRO 100 INSULIN A4467 270 25.01 17.507 7.16 32.94 16.78 7.16 24.71 7.16 16.78 16.78 16.78 16.78 7.16 7.876000000000001 7.16 7.16 7.16 7.16 7.3032 7.16 8600 Hos Central Supply Facility Fee 387 SYRINGE SAF-LOK 3CC 21G X 1 1/2 A4206 270 24.18 16.926 17.75 81.66 41.6 17.75 61.25 17.75 41.6 41.6 41.6 41.6 17.75 19.525000000000002 17.75 17.75 17.75 17.75 18.105 17.75 8600 Hos Central Supply Facility Fee 385 SYRINGE SAF-LOK 3CC 22GX11/2 A1619 270 32.64 22.848 54.18 249.22 126.95 54.18 186.92 54.18 126.95 126.95 126.95 126.95 54.18 59.598000000000006 54.18 54.18 54.18 54.18 55.263600000000004 54.18 8600 Hos Central Supply Facility Fee 384 SYRINGE TB 1CC 25GX5/8 SAFETY-LOK A4206 270 56.8 39.76 1.62 7.44 3.79 1.62 5.58 1.62 3.79 3.79 3.79 3.79 1.62 1.7820000000000003 1.62 1.62 1.62 1.62 1.6524 1.62 8600 Hos Central Supply Facility Fee 401 SYSTEM IRRIGATOR SUCTION SIMPULSE 1.75IN STERILE SPLASH SHIELD S8206 270 34.67 24.269 3.03 13.93 7.1 3.03 10.45 3.03 7.1 7.1 7.1 7.1 3.03 3.333 3.03 3.03 3.03 3.03 3.0906 3.03 8600 Hos Central Supply Facility Fee 961 TABLE PAPER CREPE A8622 270 36.94 25.857999999999997 0.6 2.75 1.4 0.6 2.06 0.6 1.4 1.4 1.4 1.4 0.6 0.66 0.6 0.6 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 1856 TAPE DISPENSER PACKING TAPE A4467 270 9.76 6.832 108.69 499.95 254.67 108.69 374.96 108.69 254.67 254.67 254.67 254.67 108.69 119.55900000000001 108.69 108.69 1.97 1.97 2.0094 1.97 8600 Hos Central Supply Facility Fee 57 TAPE HYTAPE 1/4IN X 5 YD BULK PACKAGE A4452 270 1.42 0.9939999999999999 10.08 46.36 23.62 10.08 34.77 10.08 23.62 23.62 23.62 23.62 10.08 11.088000000000001 10.08 10.08 10.08 10.08 10.281600000000001 10.08 8600 Hos Central Supply Facility Fee 1301 TAPE LABELING ORANGE 2 A4467 270 8.77 6.138999999999999 0.61 2.81 1.43 0.61 2.11 0.61 1.43 1.43 1.43 1.43 0.61 0.671 0.61 0.61 0.61 0.61 0.6222 0.61 8600 Hos Central Supply Facility Fee 446 TAPE MEDIPORE SOFT CLOTH 3 INCHX10 YARDS A4450 270 5.15 3.605 20.69 95.19 48.49 20.69 71.39 20.69 48.49 48.49 48.49 48.49 20.69 22.759000000000004 20.69 20.69 20.69 20.69 21.103800000000003 20.69 8600 Hos Central Supply Facility Fee 438 TAPE SURG DURAPORE 1IN X 10YD ROLL STD ROLL A4450 270 0.95 0.6649999999999999 164.55 756.9 385.56 164.55 567.68 164.55 385.56 385.56 385.56 385.56 164.55 181.00500000000002 164.55 164.55 3.78 3.78 3.8556 3.78 8600 Hos Central Supply Facility Fee 439 TAPE SURG DURAPORE 2IN X 10YD ROLL STD ROLL A4450 270 1.26 0.8819999999999999 345.73 1590.3 810.1 345.73 1192.73 345.73 810.1 810.1 810.1 810.1 345.73 380.30300000000005 345.73 345.73 345.73 345.73 352.6446 345.73 8600 Hos Central Supply Facility Fee 440 TAPE SURG DURAPORE 3IN X 10YD ROLL STD ROLL A4450 270 1.63 1.1409999999999998 20 91.99 46.86 20 68.99 20 46.86 46.86 46.86 46.86 20 22 20 20 20 20 20.4 20 8600 Hos Central Supply Facility Fee 436 TAPE SURG MICROFOAM 3INX5-1/2Y ROLL A4450 270 3.14 2.198 10.78 49.59 25.26 10.78 37.19 10.78 25.26 25.26 25.26 25.26 10.78 11.858 10.78 10.78 10.78 10.78 10.9956 10.78 8600 Hos Central Supply Facility Fee 437 TAPE SURG MICROPORE 1INX10YD ROLL STD ROLL A4450 270 0.04 0.027999999999999997 20.65 95 48.39 20.65 71.25 20.65 48.39 48.39 48.39 48.39 20.65 22.715 20.65 20.65 20.65 20.65 21.063 20.65 8600 Hos Central Supply Facility Fee 434 TAPE SURG TRANSPORE 1IN X 10YD A4450 270 0.06 0.041999999999999996 176.09 810 412.61 176.09 607.5 176.09 412.61 412.61 412.61 412.61 176.09 193.699 176.09 176.09 176.09 176.09 179.61180000000002 176.09 8600 Hos Central Supply Facility Fee 435 TAPE SURG TRANSPORE 3IN X 10YD ROLL STD ROLL A4450 270 1.76 1.232 6924.39 31850.85 16224.82 6924.39 23888.14 6924.39 16224.82 16224.82 16224.82 16224.82 6924.39 7616.829000000001 6924.39 6924.39 6924.39 6924.39 7062.8778 6924.39 8600 Hos Central Supply Facility Fee 202 TB, BC LAV 13 X 75 2.5 ML EDTA-L A4467 270 0.31 0.217 10.51 48.36 24.63 10.51 36.27 10.51 24.63 24.63 24.63 24.63 10.51 11.561 10.51 10.51 4.19 4.19 4.2738000000000005 4.19 8600 Hos Central Supply Facility Fee 1696 T-BASE FOOT CONNECTOR l2114 270 21.06 14.741999999999997 0.12 0.56 0.29 0.12 0.42 0.12 0.29 0.29 0.29 0.29 0.12 0.132 0.12 0.12 0.12 0.12 0.1224 0.12 8600 Hos Central Supply Facility Fee 50238 TBIL/DBIL CALIBRATOR A4467 270 49.49 34.643 0.58 2.66 1.36 0.58 2 0.58 1.36 1.36 1.36 1.36 0.58 0.638 0.58 0.58 0.58 0.58 0.5916 0.58 8600 Hos Central Supply Facility Fee 50239 TBIL/TOTAL BILIRUBIN A4467 270 0.29 0.20299999999999999 0.69 3.18 1.62 0.69 2.39 0.69 1.62 1.62 1.62 1.62 0.69 0.759 0.69 0.69 0.69 0.69 0.7038 0.69 8600 Hos Central Supply Facility Fee 50240 TBIL/TOTAL BILIRUBIN A4467 270 24.96 17.471999999999998 0.73 3.36 1.71 0.73 2.52 0.73 1.71 1.71 1.71 1.71 0.73 0.803 0.73 0.73 0.73 0.73 0.7446 0.73 8600 Hos Central Supply Facility Fee 493 TELEMETRY POUCH, FOAM A5051 270 0.94 0.6579999999999999 0.76 3.5 1.78 0.76 2.63 0.76 1.78 1.78 1.78 1.78 0.76 0.8360000000000001 0.76 0.76 0.62 0.62 0.6324 0.62 8600 Hos Central Supply Facility Fee 825 TELFA PAD 2 X 3 A4467 270 3.38 2.3659999999999997 0.73 3.38 1.72 0.73 2.54 0.73 1.72 1.72 1.72 1.72 0.73 0.803 0.73 0.73 0.73 0.73 0.7446 0.73 8600 Hos Central Supply Facility Fee 826 TELFA PAD 3 X 4 A4467 270 0.05 0.034999999999999996 0.82 3.75 1.91 0.82 2.81 0.82 1.91 1.91 1.91 1.91 0.82 0.902 0.82 0.82 0.82 0.82 0.8363999999999999 0.82 8600 Hos Central Supply Facility Fee 823 TELFA PADS 3X8 A4467 270 0.08 0.055999999999999994 15 68.98 35.14 15 51.74 15 35.14 35.14 35.14 35.14 15 16.5 15 15 15 15 15.3 15 8600 Hos Central Supply Facility Fee 127 TENDER GRIP SKIN FIXATION SYST ADT N2206 270 1.35 0.945 107.52 494.56 251.93 107.52 370.92 107.52 251.93 251.93 251.93 251.93 107.52 118.272 107.52 107.52 107.52 107.52 109.6704 107.52 8600 Hos Central Supply Facility Fee 115 TEST BOWIE DICK PLUS COMPLY LEAD FREE S7206 270 2.77 1.9389999999999998 23.15 106.49 54.25 23.15 79.87 23.15 54.25 54.25 54.25 54.25 23.15 25.465 23.15 23.15 23.15 23.15 23.613 23.15 8600 Hos Central Supply Facility Fee 1783 TEST STATUS FLU A & B 22/BX A4467 270 285.77 200.039 3.61 16.62 8.47 3.61 12.47 3.61 8.47 8.47 8.47 8.47 3.61 3.971 3.61 3.61 3.61 3.61 3.6822 3.61 8600 Hos Central Supply Facility Fee 161 THERABAND , THIN, YELLOW E4206 270 135 94.5 185.88 855 435.54 185.88 641.25 185.88 435.54 435.54 435.54 435.54 185.88 204.46800000000002 185.88 185.88 185.88 185.88 189.5976 185.88 8600 Hos Central Supply Facility Fee 327 THERABAND GREEN HEAVY 50YD E2206 270 96.39 67.473 6.45 29.66 15.11 6.45 22.25 6.45 15.11 15.11 15.11 15.11 6.45 7.095000000000001 6.45 6.45 6.45 6.45 6.579000000000001 6.45 8600 Hos Central Supply Facility Fee 163 THERABAND, HEAVY, GREEN E5206 270 180 125.99999999999999 18.31 84.24 42.91 18.31 63.18 18.31 42.91 42.91 42.91 42.91 18.31 20.141000000000002 18.31 18.31 18.31 18.31 18.676199999999998 18.31 8600 Hos Central Supply Facility Fee 162 THERABAND, MEDIUM, RED E2206 270 160 112 7.67 35.29 17.98 7.67 26.47 7.67 17.98 17.98 17.98 17.98 7.67 8.437000000000001 7.67 7.67 7.67 7.67 7.8234 7.67 8600 Hos Central Supply Facility Fee 1665 THERMOMETER DGTL TRPL DISPLAY/ALARM A4467 270 50.18 35.126 7.67 35.29 17.98 7.67 26.47 7.67 17.98 17.98 17.98 17.98 7.67 8.437000000000001 7.67 7.67 34.26 34.26 34.9452 34.26 8600 Hos Central Supply Facility Fee 1762 THERMOMETER DIGITAL FREEZER H8600 270 69.11 48.376999999999995 4.79 22.05 11.23 4.79 16.54 4.79 11.23 11.23 11.23 11.23 4.79 5.269 4.79 4.79 4.79 4.79 4.8858 4.79 8600 Hos Central Supply Facility Fee 1761 THERMOMETER DIGITAL REFRIG H8677 270 61.18 42.826 17.31 79.63 40.56 17.31 59.72 17.31 40.56 40.56 40.56 40.56 17.31 19.041 17.31 17.31 17.31 17.31 17.6562 17.31 8600 Hos Central Supply Facility Fee 1481 THERMOMETER DIGITAL WATERPROOF (XRAY) A4467 270 62.76 43.931999999999995 1.42 6.54 3.33 1.42 4.91 1.42 3.33 3.33 3.33 3.33 1.42 1.562 1.42 1.42 781.37 781.37 796.9974 781.37 8600 Hos Central Supply Facility Fee 464 THORACENTESIS/PARACENTESIS TRAY CATH 8FR 4.75IN OVER 18GX8IN INTRO NEEDL O6206 270 23.74 16.618 610.03 2806 1429.38 610.03 2104.5 610.03 1429.38 1429.38 1429.38 1429.38 610.03 671.033 610.03 610.03 43.04 43.04 43.9008 43.04 8600 Hos Central Supply Facility Fee 838 THORACOSTOMY PROCEDURE TRAY A4467 270 15.59 10.912999999999998 1398.97 6435 3277.99 1398.97 4826.25 1398.97 3277.99 3277.99 3277.99 3277.99 1398.97 1538.8670000000002 1398.97 1398.97 1398.97 1398.97 1426.9494 1398.97 8600 Hos Central Supply Facility Fee 99 TIBURON CYSTOSCOPY PACK B9206 270 4.44 3.108 461.98 2125 1082.48 461.98 1593.75 461.98 1082.48 1082.48 1082.48 1082.48 461.98 508.17800000000005 461.98 461.98 461.98 461.98 471.2196 461.98 8600 Hos Central Supply Facility Fee 50109 TIP MLA 1000UL STCK RK A4467 270 0.03 0.020999999999999998 11.93 54.87 27.95 11.93 41.15 11.93 27.95 27.95 27.95 27.95 11.93 13.123000000000001 11.93 11.93 201.1 201.1 205.12199999999999 201.1 8600 Hos Central Supply Facility Fee 580 TOOTHBRUSH,INDIVDUALLY WRAPPED,30 TUFT A9286 270 0.03 0.020999999999999998 8.38 38.55 19.64 8.38 28.91 8.38 19.64 19.64 19.64 19.64 8.38 9.218000000000002 8.38 8.38 1.89 1.89 1.9278 1.89 8600 Hos Central Supply Facility Fee 905 TOOTHPASE 1.5OZ A4467 270 0.6 0.42 1.09 5 2.55 1.09 3.75 1.09 2.55 2.55 2.55 2.55 1.09 1.1990000000000003 1.09 1.09 1.09 1.09 1.1118000000000001 1.09 8600 Hos Central Supply Facility Fee 581 TOOTHPASTE,SPARKLE FRESH,FLUORIDE,.85OZ A4467 270 0.26 0.182 8.5 39.11 19.92 8.5 29.33 8.5 19.92 19.92 19.92 19.92 8.5 9.350000000000001 8.5 8.5 8.5 8.5 8.67 8.5 8600 Hos Central Supply Facility Fee 1555 TOURNIQUET A4467 270 13.88 9.716 1.41 6.47 3.3 1.41 4.85 1.41 3.3 3.3 3.3 3.3 1.41 1.551 1.41 1.41 4.73 4.73 4.8246 4.73 8600 Hos Central Supply Facility Fee 50268 TOWEL ENMOTION WHITE O8666 270 102 71.39999999999999 8.38 38.55 19.64 8.38 28.91 8.38 19.64 19.64 19.64 19.64 8.38 9.218000000000002 8.38 8.38 8.38 8.38 8.547600000000001 8.38 8600 Hos Central Supply Facility Fee 50072 TOWEL ENMOTION WHITE 10 IN X 800 FT A4467 270 6.61 4.627 565.04 2599.08 1323.97 565.04 1949.31 565.04 1323.97 1323.97 1323.97 1323.97 565.04 621.544 565.04 565.04 565.04 565.04 576.3408 565.04 8600 Hos Central Supply Facility Fee 1804 TOWELETTE, OBGYN A4467 270 4.25 2.9749999999999996 39.13 179.99 91.69 39.13 134.99 39.13 91.69 91.69 91.69 91.69 39.13 43.043000000000006 39.13 39.13 290.49 290.49 296.2998 290.49 8600 Hos Central Supply Facility Fee 857 TRACH TUBE 10.0 R8688 270 26.47 18.528999999999996 39.13 179.99 91.69 39.13 134.99 39.13 91.69 91.69 91.69 91.69 39.13 43.043000000000006 39.13 39.13 39.13 39.13 39.912600000000005 39.13 8600 Hos Central Supply Facility Fee 853 TRACH TUBE 6.0 R8611 270 29.47 20.628999999999998 127.49 586.41 298.72 127.49 439.81 127.49 298.72 298.72 298.72 298.72 127.49 140.239 127.49 127.49 127.49 127.49 130.03979999999999 127.49 8600 Hos Central Supply Facility Fee 854 TRACH TUBE 7.0 R8611 270 29.47 20.628999999999998 4.69 21.59 11 4.69 16.19 4.69 11 11 11 11 4.69 5.159000000000001 4.69 4.69 4.69 4.69 4.7838 4.69 8600 Hos Central Supply Facility Fee 855 TRACH TUBE 8.0 R8611 270 29.47 20.628999999999998 195.07 897.3 457.08 195.07 672.98 195.07 457.08 457.08 457.08 457.08 195.07 214.577 195.07 195.07 195.07 195.07 198.9714 195.07 8600 Hos Central Supply Facility Fee 856 TRACH TUBE 9.0 R8611 270 29.47 20.628999999999998 22.3 102.56 52.24 22.3 76.92 22.3 52.24 52.24 52.24 52.24 22.3 24.53 22.3 22.3 22.3 22.3 22.746000000000002 22.3 8600 Hos Central Supply Facility Fee 852 TRACH TUBE PED 8.3 A4467 270 40.72 28.503999999999998 0.54 2.49 1.27 0.54 1.87 0.54 1.27 1.27 1.27 1.27 0.54 0.5940000000000001 0.54 0.54 0.54 0.54 0.5508000000000001 0.54 8600 Hos Central Supply Facility Fee 405 TRANSDUCER ADLT OXYGEN A9270 270 546.39 382.47299999999996 5.42 24.95 12.71 5.42 18.71 5.42 12.71 12.71 12.71 12.71 5.42 5.962000000000001 5.42 5.42 5.42 5.42 5.5284 5.42 8600 Hos Central Supply Facility Fee 1467 TRAP STERILE MUCUS SPECIMEN 40CC A4467 270 3.31 2.3169999999999997 1.49 6.86 3.49 1.49 5.15 1.49 3.49 3.49 3.49 3.49 1.49 1.639 1.49 1.49 1.49 1.49 1.5198 1.49 8600 Hos Central Supply Facility Fee 1812 TRAY FOLEY 18FR A4310 270 11.74 8.218 24.47 112.58 57.35 24.47 84.44 24.47 57.35 57.35 57.35 57.35 24.47 26.917 24.47 24.47 25.39 25.39 25.8978 25.39 8600 Hos Central Supply Facility Fee 322 TRAY SKIN PREP PVP-1 SCRUB CARE A0206 270 4.8 3.36 0.68 3.14 1.6 0.68 2.36 0.68 1.6 1.6 1.6 1.6 0.68 0.7480000000000001 0.68 0.68 0.68 0.68 0.6936000000000001 0.68 8600 Hos Central Supply Facility Fee 1653 TRAY SUTURE REMOVAL R8666 270 43.1 30.169999999999998 0.57 2.64 1.34 0.57 1.98 0.57 1.34 1.34 1.34 1.34 0.57 0.627 0.57 0.57 0.57 0.57 0.5813999999999999 0.57 8600 Hos Central Supply Facility Fee 562 TRAY,CATHETER,URETHRAL,RED-RUBBER,15FR A1619 270 0.13 0.091 0.6 2.75 1.4 0.6 2.06 0.6 1.4 1.4 1.4 1.4 0.6 0.66 0.6 0.6 0.6 0.6 0.612 0.6 8600 Hos Central Supply Facility Fee 567 TRAY,DRESSING CHANGE A4467 270 2.66 1.8619999999999999 162.83 749 381.54 162.83 561.75 162.83 381.54 381.54 381.54 381.54 162.83 179.11300000000003 162.83 162.83 162.83 162.83 166.0866 162.83 8600 Hos Central Supply Facility Fee 568 TRAY,IRRIGATION,PISTON SYRINGE,60ML,STRL A4467 270 0.04 0.027999999999999997 6.3 28.98 14.76 6.3 21.74 6.3 14.76 14.76 14.76 14.76 6.3 6.930000000000001 6.3 6.3 6.3 6.3 6.426 6.3 8600 Hos Central Supply Facility Fee 569 TRAY,LACERATION,LIDDED TRAY,STERILE A4467 270 4.2 2.94 3.32 15.27 7.78 3.32 11.45 3.32 7.78 7.78 7.78 7.78 3.32 3.652 3.32 3.32 3.32 3.32 3.3864 3.32 8600 Hos Central Supply Facility Fee 234 TROCAR ENDPTH XCEL BLDLS CANN 100 MM 5 DIA O3206 270 36.26 25.381999999999998 2.63 12.11 6.17 2.63 9.08 2.63 6.17 6.17 6.17 6.17 2.63 2.8930000000000002 2.63 2.63 3.65 3.65 3.723 3.65 8600 Hos Central Supply Facility Fee 108 TROCAR ENDPTH XCEL BLDLS STBLTY 100MM 12 O0206 270 47.99 33.592999999999996 18.58 85.46 43.53 18.58 64.1 18.58 43.53 43.53 43.53 43.53 18.58 20.438 18.58 18.58 18.58 18.58 18.9516 18.58 8600 Hos Central Supply Facility Fee 120 TROCAR SPACEMAKER BLUNT TIP 12MM O1206 270 223.26 156.28199999999998 25.74 118.41 60.32 25.74 88.81 25.74 60.32 60.32 60.32 60.32 25.74 28.314 25.74 25.74 25.74 25.74 26.2548 25.74 8600 Hos Central Supply Facility Fee 301 TRU-CUT NEEDLE BIOPSY SOFT TISS 14 G X 4.5 U5206 270 14.5 10.149999999999999 40.51 186.32 94.91 40.51 139.74 40.51 94.91 94.91 94.91 94.91 40.51 44.561 40.51 40.51 40.51 40.51 41.3202 40.51 8600 Hos Central Supply Facility Fee 50110 TRYPT SOY AGR W/5% BLOOD A4467 270 0.19 0.13299999999999998 1.29 5.95 3.03 1.29 4.46 1.29 3.03 3.03 3.03 3.03 1.29 1.4190000000000003 1.29 1.29 1.29 1.29 1.3158 1.29 8600 Hos Central Supply Facility Fee 50258 TSH A4467 270 331 231.7 1.29 5.95 3.03 1.29 4.46 1.29 3.03 3.03 3.03 3.03 1.29 1.4190000000000003 1.29 1.29 1.29 1.29 1.3158 1.29 8600 Hos Central Supply Facility Fee 741 TUBBING INSUFFLATION HI FLO A4467 270 21.28 14.895999999999999 16.01 73.63 37.51 16.01 55.22 16.01 37.51 37.51 37.51 37.51 16.01 17.611000000000004 16.01 16.01 16.01 16.01 16.3302 16.01 8600 Hos Central Supply Facility Fee 61 TUBE AGT ENDOTRACH 3.5-8.0 MMID A4629 270 5.57 3.899 1.37 6.31 3.21 1.37 4.73 1.37 3.21 3.21 3.21 3.21 1.37 1.5070000000000003 1.37 1.37 1.37 1.37 1.3974000000000002 1.37 8600 Hos Central Supply Facility Fee 62 TUBE AGT ENDOTRACH 4.0MM A4629 270 5.57 3.899 1.88 8.63 4.4 1.88 6.47 1.88 4.4 4.4 4.4 4.4 1.88 2.068 1.88 1.88 1.88 1.88 1.9176 1.88 8600 Hos Central Supply Facility Fee 88 TUBE AGT ENDOTRACH 4.5MM B5206 270 5.57 3.899 5.27 24.23 12.34 5.27 18.17 5.27 12.34 12.34 12.34 12.34 5.27 5.797 5.27 5.27 5.27 5.27 5.3754 5.27 8600 Hos Central Supply Facility Fee 63 TUBE AGT ENDOTRACH 5.0 MM A4629 270 5.57 3.899 42.71 196.46 100.08 42.71 147.35 42.71 100.08 100.08 100.08 100.08 42.71 46.981 42.71 42.71 42.71 42.71 43.5642 42.71 8600 Hos Central Supply Facility Fee 377 TUBE BLOOD BANK ACD SOL A YLW 8.5ML DRAW B1206 270 1.01 0.707 5.08 23.36 11.9 5.08 17.52 5.08 11.9 11.9 11.9 11.9 5.08 5.588000000000001 5.08 5.08 5.08 5.08 5.1816 5.08 8600 Hos Central Supply Facility Fee 370 TUBE CONN 5MMX3.1M NON-CONDUCT W/SURE-GRIP MOLD CONN B5206 270 0.82 0.574 150.22 690.99 351.99 150.22 518.24 150.22 351.99 351.99 351.99 351.99 150.22 165.24200000000002 150.22 150.22 150.22 150.22 153.2244 150.22 8600 Hos Central Supply Facility Fee 226 TUBE CONN 6 MM X 3.1 M NON-CONDUCT B1206 270 1 0.7 33.69 154.99 78.95 33.69 116.24 33.69 78.95 78.95 78.95 78.95 33.69 37.059 33.69 33.69 33.69 33.69 34.3638 33.69 8600 Hos Central Supply Facility Fee 1671 TUBE ENDO 5.5MM LF A4467 270 25.69 17.983 5.65 25.99 13.24 5.65 19.49 5.65 13.24 13.24 13.24 13.24 5.65 6.215000000000001 5.65 5.65 5.65 5.65 5.763000000000001 5.65 8600 Hos Central Supply Facility Fee 1623 TUBE ENDOTRACH 7.5MM A7521 270 11.71 8.197000000000001 231.14 1063.19 541.59 231.14 797.39 231.14 541.59 541.59 541.59 541.59 231.14 254.25400000000002 231.14 231.14 231.14 231.14 235.7628 231.14 8600 Hos Central Supply Facility Fee 1624 TUBE ENDOTRACH 8.0MM A7521 270 11.23 7.861 163.05 750 382.05 163.05 562.5 163.05 382.05 382.05 382.05 382.05 163.05 179.35500000000002 163.05 163.05 163.05 163.05 166.311 163.05 8600 Hos Central Supply Facility Fee 1625 TUBE ENDOTRACH 8.5MM A7521 270 12.99 9.093 16.31 75 38.21 16.31 56.25 16.31 38.21 38.21 38.21 38.21 16.31 17.941 16.31 16.31 16.31 16.31 16.6362 16.31 8600 Hos Central Supply Facility Fee 1622 TUBE ENDOTRACH CUFF 7.0MM A4467 270 12.04 8.427999999999999 7.61 35 17.83 7.61 26.25 7.61 17.83 17.83 17.83 17.83 7.61 8.371 7.61 7.61 7.61 7.61 7.762200000000001 7.61 8600 Hos Central Supply Facility Fee 1811 TUBE FCBS 5ML 15.3X92MM PP SC PRINT GWB A4467 270 187.09 130.963 9.99 45.96 23.41 9.99 34.47 9.99 23.41 23.41 23.41 23.41 9.99 10.989 9.99 9.99 9.99 9.99 10.1898 9.99 8600 Hos Central Supply Facility Fee 50296 TUBE GASTR 14FR U8677 270 103.78 72.646 35.79 164.61 83.85 35.79 123.46 35.79 83.85 83.85 83.85 83.85 35.79 39.369 35.79 35.79 35.79 35.79 36.5058 35.79 8600 Hos Central Supply Facility Fee 276 TUBE GASTROSTOMY 14 FR 3.5 SHAFT LENGTH B4087 270 90.88 63.61599999999999 14.83 68.22 34.75 14.83 51.17 14.83 34.75 34.75 34.75 34.75 14.83 16.313000000000002 14.83 14.83 14.83 14.83 15.1266 14.83 8600 Hos Central Supply Facility Fee 453 TUBE GASTROSTOMY 14FR REPLACEMENT 5CC BALLOONPROTECT FROM FREEZING B9206 270 19.06 13.341999999999999 2.3 10.59 5.39 2.3 7.94 2.3 5.39 5.39 5.39 5.39 2.3 2.53 2.3 2.3 2.3 2.3 2.3459999999999996 2.3 8600 Hos Central Supply Facility Fee 277 TUBE GASTROSTOMY 16 FR 2.3 SHAFT LENGTH B4087 270 90.88 63.61599999999999 5.4 24.83 12.65 5.4 18.62 5.4 12.65 12.65 12.65 12.65 5.4 5.940000000000001 5.4 5.4 5.4 5.4 5.508000000000001 5.4 8600 Hos Central Supply Facility Fee 454 TUBE GASTROSTOMY 16FR REPLACEMENT 15CC BALLOONPROTECT FROM FREEZING B9206 270 19.06 13.341999999999999 16.32 75.08 38.25 16.32 56.31 16.32 38.25 38.25 38.25 38.25 16.32 17.952 16.32 16.32 16.32 16.32 16.6464 16.32 8600 Hos Central Supply Facility Fee 278 TUBE GASTROSTOMY 18 FR 2.3 SHAFT LENGTH B4087 270 90.88 63.61599999999999 8.09 37.23 18.96 8.09 27.92 8.09 18.96 18.96 18.96 18.96 8.09 8.899000000000001 8.09 8.09 8.09 8.09 8.2518 8.09 8600 Hos Central Supply Facility Fee 455 TUBE GASTROSTOMY 18FR REPLACEMENT 15CC BALLOONPROTECT FROM FREEZING B9206 270 19.06 13.341999999999999 8.66 39.85 20.3 8.66 29.89 8.66 20.3 20.3 20.3 20.3 8.66 9.526000000000002 8.66 8.66 8.66 8.66 8.8332 8.66 8600 Hos Central Supply Facility Fee 46 TUBE GASTROSTOMY 20 FR 2.5 SHAFT LENGTH B4087 270 90.88 63.61599999999999 9 41.41 21.09 9 31.06 9 21.09 21.09 21.09 21.09 9 9.9 9 9 9 9 9.18 9 8600 Hos Central Supply Facility Fee 279 TUBE GASTROSTOMY 20 FR 2.5 SHAFT LENGTH B4087 270 90.88 63.61599999999999 38.43 176.78 90.05 38.43 132.59 38.43 90.05 90.05 90.05 90.05 38.43 42.273 38.43 38.43 38.43 38.43 39.1986 38.43 8600 Hos Central Supply Facility Fee 456 TUBE GASTROSTOMY 20FR REPLACEMENT 15CC BALLOONDO NOT FREEZE B9206 270 19.06 13.341999999999999 9.05 41.63 21.21 9.05 31.22 9.05 21.21 21.21 21.21 21.21 9.05 9.955000000000002 9.05 9.05 9.05 9.05 9.231000000000002 9.05 8600 Hos Central Supply Facility Fee 280 TUBE GASTROSTOMY 24 FR 2.3 SHAFT LENGTH B4087 270 90.88 63.61599999999999 4.78 21.99 11.2 4.78 16.49 4.78 11.2 11.2 11.2 11.2 4.78 5.258000000000001 4.78 4.78 4.78 4.78 4.8756 4.78 8600 Hos Central Supply Facility Fee 47 TUBE GASTROSTOMY 24 FR 2.5 SHAFT LENGTH B4087 270 90.88 63.61599999999999 4.78 21.99 11.2 4.78 16.49 4.78 11.2 11.2 11.2 11.2 4.78 5.258000000000001 4.78 4.78 4.78 4.78 4.8756 4.78 8600 Hos Central Supply Facility Fee 457 TUBE GASTROSTOMY 24FR REPLACEMENT 15CC BALLOONDO NOT FREEZE B9206 270 19.06 13.341999999999999 1548.24 7121.58 3627.73 1548.24 5341.19 1548.24 3627.73 3627.73 3627.73 3627.73 1548.24 1703.064 1548.24 1548.24 1548.24 1548.24 1579.2048 1548.24 8600 Hos Central Supply Facility Fee 1777 TUBE HOLDER BLOOD COLLECTION A4467 270 41.97 29.378999999999998 3.2 14.73 7.5 3.2 11.05 3.2 7.5 7.5 7.5 7.5 3.2 3.5200000000000005 3.2 3.2 3.2 3.2 3.2640000000000002 3.2 8600 Hos Central Supply Facility Fee 1676 TUBE HOLDERBLOOD COLLECTION U8699 270 41.4 28.979999999999997 59.01 271.43 138.27 59.01 203.57 59.01 138.27 138.27 138.27 138.27 59.01 64.911 59.01 59.01 59.01 59.01 60.1902 59.01 8600 Hos Central Supply Facility Fee 1563 TUBE LARYNGECTOMY 8FR U8666 270 45.26 31.681999999999995 3.44 15.83 8.06 3.44 11.87 3.44 8.06 8.06 8.06 8.06 3.44 3.7840000000000003 3.44 3.44 3.44 3.44 3.5088 3.44 8600 Hos Central Supply Facility Fee 1564 TUBE MIC 18FR U8666 270 35.26 24.682 1.63 7.49 3.82 1.63 5.62 1.63 3.82 3.82 3.82 3.82 1.63 1.793 1.63 1.63 1.63 1.63 1.6625999999999999 1.63 8600 Hos Central Supply Facility Fee 369 TUBE SALEM SUMP SENT 16FR 48'' W/ SENTINEL LINE B5206 270 1.78 1.246 18.34 84.36 42.97 18.34 63.27 18.34 42.97 42.97 42.97 42.97 18.34 20.174000000000003 18.34 18.34 18.34 18.34 18.7068 18.34 8600 Hos Central Supply Facility Fee 1370 TUBE SKIN LEVEL GASTR 14FR 1.2 SHAFT A4467 270 103.78 72.646 1.3 5.97 3.04 1.3 4.48 1.3 3.04 3.04 3.04 3.04 1.3 1.4300000000000002 1.3 1.3 1.3 1.3 1.326 1.3 8600 Hos Central Supply Facility Fee 1670 TUBE STOMACH 14FR 48IN LONG A4467 270 1.07 0.749 6.2 28.53 14.53 6.2 21.4 6.2 14.53 14.53 14.53 14.53 6.2 6.820000000000001 6.2 6.2 6.2 6.2 6.324000000000001 6.2 8600 Hos Central Supply Facility Fee 319 TUBE TRACH ENDOTROL 7.0 28FR ENDO TUBE B3206 270 7.1 4.97 49.12 225.94 115.09 49.12 169.46 49.12 115.09 115.09 115.09 115.09 49.12 54.032000000000004 49.12 49.12 49.12 49.12 50.102399999999996 49.12 8600 Hos Central Supply Facility Fee 320 TUBE TRACH ENDOTROL 8.0 32FR ENDO TUBE B3206 270 7.1 4.97 11.86 54.57 27.8 11.86 40.93 11.86 27.8 27.8 27.8 27.8 11.86 13.046000000000001 11.86 11.86 11.86 11.86 12.097199999999999 11.86 8600 Hos Central Supply Facility Fee 1482 TUBE TRANSPORT A4467 270 8.94 6.257999999999999 8.85 40.71 20.74 8.85 30.53 8.85 20.74 20.74 20.74 20.74 8.85 9.735000000000001 8.85 8.85 8.85 8.85 9.027 8.85 8600 Hos Central Supply Facility Fee 1483 TUBE VACUTAINER A4467 270 13.3 9.31 56.58 260.27 132.58 56.58 195.2 56.58 132.58 132.58 132.58 132.58 56.58 62.23800000000001 56.58 56.58 56.58 56.58 57.7116 56.58 8600 Hos Central Supply Facility Fee 1484 TUBE VACUTAINER A4467 270 6.07 4.249 16.09 73.99 37.69 16.09 55.49 16.09 37.69 37.69 37.69 37.69 16.09 17.699 16.09 16.09 16.09 16.09 16.4118 16.09 8600 Hos Central Supply Facility Fee 1485 TUBE VACUTAINER A4467 270 8.54 5.977999999999999 1.37 6.32 3.22 1.37 4.74 1.37 3.22 3.22 3.22 3.22 1.37 1.5070000000000003 1.37 1.37 1.37 1.37 1.3974000000000002 1.37 8600 Hos Central Supply Facility Fee 1487 TUBE VACUTAINER A4467 270 18.6 13.02 0.63 2.92 1.49 0.63 2.19 0.63 1.49 1.49 1.49 1.49 0.63 0.6930000000000001 0.63 0.63 0.63 0.63 0.6426000000000001 0.63 8600 Hos Central Supply Facility Fee 374 TUBE VACUTAINER 13X100 HEMOGARD RED 6ML 13 X 100 W/HEMOGARD CLOSURE RED B8206 270 0.58 0.40599999999999997 2.55 11.71 5.97 2.55 8.78 2.55 5.97 5.97 5.97 5.97 2.55 2.805 2.55 2.55 2.55 2.55 2.601 2.55 8600 Hos Central Supply Facility Fee 1587 TUBE VACUTAINER 8.5ML GEL 16X100 A4467 270 140.44 98.30799999999999 17.52 80.6 41.06 17.52 60.45 17.52 41.06 41.06 41.06 41.06 17.52 19.272000000000002 17.52 17.52 17.52 17.52 17.8704 17.52 8600 Hos Central Supply Facility Fee 311 TUBE VACUTAINER PLSTC CTRATE .109 M 1.8 ML B2206 270 0.08 0.055999999999999994 116.52 535.95 273.01 116.52 401.96 116.52 273.01 273.01 273.01 273.01 116.52 128.172 116.52 116.52 116.52 116.52 118.8504 116.52 8600 Hos Central Supply Facility Fee 376 TUBE VACUTAINER PLUS 13X75 2ML DRAW K2EDTA W/HEMOGARD CLOSURE LAVENDER B1206 270 0.06 0.041999999999999996 127.67 587.25 299.15 127.67 440.44 127.67 299.15 299.15 299.15 299.15 127.67 140.437 127.67 127.67 127.67 127.67 130.2234 127.67 8600 Hos Central Supply Facility Fee 375 TUBE VACUTAINER PLUS PST 13X100 W/HEMOGARD CLOSURE L GREEN 4.5ML PAPER B4206 270 0.15 0.105 27.88 128.25 65.33 27.88 96.19 27.88 65.33 65.33 65.33 65.33 27.88 30.668000000000003 27.88 27.88 27.88 27.88 28.4376 27.88 8600 Hos Central Supply Facility Fee 1476 TUBE VACUTAINER PLUS SERIUM A4467 270 72.53 50.771 174.14 801.02 408.04 174.14 600.77 174.14 408.04 408.04 408.04 408.04 174.14 191.554 174.14 174.14 174.14 174.14 177.62279999999998 174.14 8600 Hos Central Supply Facility Fee 1464 TUBE VACUTAINER PLUS SST A4467 270 124.11 86.877 538.21 2475.66 1261.1 538.21 1856.75 538.21 1261.1 1261.1 1261.1 1261.1 538.21 592.0310000000001 538.21 538.21 538.21 538.21 548.9742 538.21 8600 Hos Central Supply Facility Fee 373 TUBE VACUTAINER SST PLUS PLASTIC 5ML 13X100MM PAPER LABELGOLD CLOSURE B3206 270 124.11 86.877 538.21 2475.66 1261.1 538.21 1856.75 538.21 1261.1 1261.1 1261.1 1261.1 538.21 592.0310000000001 538.21 538.21 538.21 538.21 548.9742 538.21 8600 Hos Central Supply Facility Fee 372 TUBING 12IN SAF T WING 23GX3/4IN B3206 270 0.75 0.5249999999999999 199.52 917.73 467.49 199.52 688.3 199.52 467.49 467.49 467.49 467.49 199.52 219.47200000000004 199.52 199.52 199.52 199.52 203.5104 199.52 8600 Hos Central Supply Facility Fee 223 TUBING CONNECTOR B2206 270 0.4 0.27999999999999997 4.38 20.16 10.27 4.38 15.12 4.38 10.27 10.27 10.27 10.27 4.38 4.8180000000000005 4.38 4.38 4.38 4.38 4.4676 4.38 8600 Hos Central Supply Facility Fee 50046 TUBING CORR 6 FT EVA SEGMENTED DISP A4467 270 0.62 0.434 5.26 24.19 12.32 5.26 18.14 5.26 12.32 12.32 12.32 12.32 5.26 5.7860000000000005 5.26 5.26 5.26 5.26 5.3652 5.26 8600 Hos Central Supply Facility Fee 50047 TUBING OXYGEN 14 FT W/CRUSH RESIST LUMEN A4467 270 0.53 0.371 0.86 3.94 2.01 0.86 2.96 0.86 2.01 2.01 2.01 2.01 0.86 0.9460000000000001 0.86 0.86 0.86 0.86 0.8772 0.86 8600 Hos Central Supply Facility Fee 811 TUBING SURGICAL SUCT DEVICE DISP TIP A4467 270 135.68 94.976 8.91 41 20.89 8.91 30.75 8.91 20.89 20.89 20.89 20.89 8.91 9.801 8.91 8.91 8.91 8.91 9.0882 8.91 8600 Hos Central Supply Facility Fee 225 TUBING UNIV BUBBLE 6 MM X 30.5 MM B3206 270 0.1 0.06999999999999999 0.79 3.62 1.84 0.79 2.72 0.79 1.84 1.84 1.84 1.84 0.79 0.8690000000000001 0.79 0.79 0.79 0.79 0.8058000000000001 0.79 8600 Hos Central Supply Facility Fee 571 TUBING,SUCTION,CONNECTING,3/16X10',STR A4467 270 0.49 0.34299999999999997 9.78 44.99 22.92 9.78 33.74 9.78 22.92 22.92 22.92 22.92 9.78 10.758000000000001 9.78 9.78 9.78 9.78 9.9756 9.78 8600 Hos Central Supply Facility Fee 50585 TYPE 1 BARRICADE N/A 270 66.91 46.836999999999996 0.76 3.48 1.77 0.76 2.61 0.76 1.77 1.77 1.77 1.77 0.76 0.8360000000000001 0.76 0.76 0.76 0.76 0.7752 0.76 8600 Hos Central Supply Facility Fee 50295 UB04-ONE PART LASER B8688 270 103.03 72.121 9.58 44.06 22.44 9.58 33.05 9.58 22.44 22.44 22.44 22.44 9.58 10.538 9.58 9.58 9.58 9.58 9.7716 9.58 8600 Hos Central Supply Facility Fee 295 ULTRA FOREHEAD TEMPERTURE T3206 270 9.35 6.544999999999999 2.68 12.31 6.27 2.68 9.23 2.68 6.27 6.27 6.27 6.27 2.68 2.9480000000000004 2.68 2.68 2.68 2.68 2.7336 2.68 8600 Hos Central Supply Facility Fee 50619 ULTRA SOUND PROBE LOANER N/A 270 250 175 43.05 198 100.86 43.05 148.5 43.05 100.86 100.86 100.86 100.86 43.05 47.355000000000004 43.05 43.05 43.05 43.05 43.911 43.05 8600 Hos Central Supply Facility Fee 985 ULTRAPLUSLG A4467 270 33.85 23.695 7.87 36.21 18.45 7.87 27.16 7.87 18.45 18.45 18.45 18.45 7.87 8.657 7.87 7.87 7.87 7.87 8.0274 7.87 8600 Hos Central Supply Facility Fee 585 UNDERPAD,POLYMER,DLUX,PROT PLUS,36X36 A4467 270 0.37 0.259 2.8 12.89 6.57 2.8 9.67 2.8 6.57 6.57 6.57 6.57 2.8 3.08 2.8 2.8 2.8 2.8 2.856 2.8 8600 Hos Central Supply Facility Fee 1615 UNDERWARE PROTECTIVE SUPER LG 40-56 T4527 270 8.33 5.8309999999999995 9.97 45.84 23.35 9.97 34.38 9.97 23.35 23.35 23.35 23.35 9.97 10.967000000000002 9.97 9.97 9.97 9.97 10.169400000000001 9.97 8600 Hos Central Supply Facility Fee 1614 UNDERWARE PROTECTIVE SUPER MD 28-40 T4526 270 7.53 5.271 15.18 69.81 35.56 15.18 52.36 15.18 35.56 35.56 35.56 35.56 15.18 16.698 15.18 15.18 15.18 15.18 15.4836 15.18 8600 Hos Central Supply Facility Fee 1616 UNDERWARE PROTECTIVE SUPER XL 56-68 T4528 270 10.74 7.518 5.49 25.23 12.85 5.49 18.92 5.49 12.85 12.85 12.85 12.85 5.49 6.039000000000001 5.49 5.49 5.49 5.49 5.5998 5.49 8600 Hos Central Supply Facility Fee 50241 URCA/URIC ACID A4467 270 0.29 0.20299999999999999 16.97 78.07 39.77 16.97 58.55 16.97 39.77 39.77 39.77 39.77 16.97 18.667 16.97 16.97 0.24 0.24 0.2448 0.24 8600 Hos Central Supply Facility Fee 50242 URCA/URIC ACID A4467 270 46.08 32.256 7.79 35.84 18.26 7.79 26.88 7.79 18.26 18.26 18.26 18.26 7.79 8.569 7.79 7.79 7.79 7.79 7.9458 7.79 8600 Hos Central Supply Facility Fee 1296 URINAL MALE A4467 270 1.04 0.728 3.13 14.4 7.34 3.13 10.8 3.13 7.34 7.34 7.34 7.34 3.13 3.443 3.13 3.13 3.13 3.13 3.1926 3.13 8600 Hos Central Supply Facility Fee 610 URINAL,MALE,SUPREME A4467 270 0.26 0.182 2.02 9.29 4.73 2.02 6.97 2.02 4.73 4.73 4.73 4.73 2.02 2.2220000000000004 2.02 2.02 2.02 2.02 2.0604 2.02 8600 Hos Central Supply Facility Fee 50030 URINALYSIS, HCG & FECAL OCCULT BLOOD A4467 270 91.3 63.91 6.87 31.61 16.1 6.87 23.71 6.87 16.1 16.1 16.1 16.1 6.87 7.557 6.87 6.87 6.87 6.87 7.0074000000000005 6.87 8600 Hos Central Supply Facility Fee 835 URINARY DRAINAGE BAG A4467 270 3.88 2.7159999999999997 1.75 8.07 4.11 1.75 6.05 1.75 4.11 4.11 4.11 4.11 1.75 1.9250000000000003 1.75 1.75 1.75 1.75 1.7850000000000001 1.75 8600 Hos Central Supply Facility Fee 836 URINARY LEG BAG A4467 270 1.81 1.267 1.77 8.12 4.14 1.77 6.09 1.77 4.14 4.14 4.14 4.14 1.77 1.9470000000000003 1.77 1.77 1.77 1.77 1.8054000000000001 1.77 8600 Hos Central Supply Facility Fee 50032 URINE CHEMISTRY A4467 270 224.1 156.86999999999998 1.77 8.12 4.14 1.77 6.09 1.77 4.14 4.14 4.14 4.14 1.77 1.9470000000000003 1.77 1.77 1.77 1.77 1.8054000000000001 1.77 8600 Hos Central Supply Facility Fee 50031 URINE DRUG SCREEN R8622 270 182.6 127.82 1.1 5.06 2.58 1.1 3.8 1.1 2.58 2.58 2.58 2.58 1.1 1.2100000000000002 1.1 1.1 1.1 1.1 1.122 1.1 8600 Hos Central Supply Facility Fee 50111 URISYSTEM SLIDE 10 TEST A4467 270 0.56 0.392 0.18 0.82 0.42 0.18 0.62 0.18 0.42 0.42 0.42 0.42 0.18 0.198 0.18 0.18 0.18 0.18 0.18359999999999999 0.18 8600 Hos Central Supply Facility Fee 50112 URISYSTEM TUBES A4467 270 0.14 0.098 0.99 4.57 2.33 0.99 3.43 0.99 2.33 2.33 2.33 2.33 0.99 1.089 0.99 0.99 0.99 0.99 1.0098 0.99 8600 Hos Central Supply Facility Fee 50113 VACT TB K2EDTA 13 X 100 6 ML C/PK A4467 270 0.45 0.315 2.61 11.99 6.11 2.61 8.99 2.61 6.11 6.11 6.11 6.11 2.61 2.871 2.61 2.61 17.6 17.6 17.952 17.6 8600 Hos Central Supply Facility Fee 827 VAGINAL IRRIGATOR SET A4467 270 2.38 1.666 20.24 93.11 47.43 20.24 69.83 20.24 47.43 47.43 47.43 47.43 20.24 22.264 20.24 20.24 20.24 20.24 20.6448 20.24 8600 Hos Central Supply Facility Fee 1724 VALUE BRIGHT LANTERN KRYPTON BULB 6V A4467 270 8.47 5.929 17.6 80.96 41.24 17.6 60.72 17.6 41.24 41.24 41.24 41.24 17.6 19.360000000000003 17.6 17.6 17.6 17.6 17.952 17.6 8600 Hos Central Supply Facility Fee 222 VALVE F/SALEM SUMP ANTI-REFLUX L8206 270 6.01 4.207 12.1 55.67 28.36 12.1 41.75 12.1 28.36 28.36 28.36 28.36 12.1 13.31 12.1 12.1 12.1 12.1 12.342 12.1 8600 Hos Central Supply Facility Fee 111 VALVE HEIMLICH CHEST DRAIN STRL L8206 270 30.51 21.357 0.54 2.47 1.26 0.54 1.85 0.54 1.26 1.26 1.26 1.26 0.54 0.5940000000000001 0.54 0.54 0.54 0.54 0.5508000000000001 0.54 8600 Hos Central Supply Facility Fee 1590 VANNA'S PALETTE BONBONS YARN, HAPPY A4467 270 7.98 5.586 3.27 15.06 7.67 3.27 11.3 3.27 7.67 7.67 7.67 7.67 3.27 3.5970000000000004 3.27 3.27 3.27 3.27 3.3354 3.27 8600 Hos Central Supply Facility Fee 206 VASELINE 5 GM PACKET WHITE PETROLEUM S1206 270 0.06 0.041999999999999996 14.55 66.91 34.08 14.55 50.18 14.55 34.08 34.08 34.08 34.08 14.55 16.005000000000003 14.55 14.55 14.55 14.55 14.841000000000001 14.55 8600 Hos Central Supply Facility Fee 1392 VASELINE 5GM PACKET WHITE PETROLEUM A4467 270 42.69 29.882999999999996 1.7 7.84 3.99 1.7 5.88 1.7 3.99 3.99 3.99 3.99 1.7 1.87 1.7 1.7 1.7 1.7 1.734 1.7 8600 Hos Central Supply Facility Fee 955 VASELINE 5GM PACKS A8666 270 42.52 29.764 1.78 8.2 4.18 1.78 6.15 1.78 4.18 4.18 4.18 4.18 1.78 1.9580000000000002 1.78 1.78 1.78 1.78 1.8156 1.78 8600 Hos Central Supply Facility Fee 158 VEST CRISSCROSS COTTON WITH TIE S9206 270 12.72 8.904 33.21 152.77 77.82 33.21 114.58 33.21 77.82 77.82 77.82 77.82 33.21 36.531000000000006 33.21 33.21 4.3 4.3 4.386 4.3 8600 Hos Central Supply Facility Fee 296 VEST CRISSCROSS WITH TIES MEDIUM S6206 270 11.66 8.161999999999999 3.58 16.49 8.4 3.58 12.37 3.58 8.4 8.4 8.4 8.4 3.58 3.9380000000000006 3.58 3.58 3.58 3.58 3.6516 3.58 8600 Hos Central Supply Facility Fee 198 VEST RESTRAINT MED S8206 270 11.71 8.197000000000001 0.89 4.11 2.09 0.89 3.08 0.89 2.09 2.09 2.09 2.09 0.89 0.9790000000000001 0.89 0.89 0.89 0.89 0.9078 0.89 8600 Hos Central Supply Facility Fee 50033 VIROLOGY PACKAGE- WAIVED I8611 270 120.35 84.24499999999999 1.15 5.27 2.68 1.15 3.95 1.15 2.68 2.68 2.68 2.68 1.15 1.265 1.15 1.15 1.15 1.15 1.1729999999999998 1.15 8600 Hos Central Supply Facility Fee 50114 VRSA TRK REDOX 40 ML A4467 270 15.03 10.520999999999999 35.24 162.09 82.57 35.24 121.57 35.24 82.57 82.57 82.57 82.57 35.24 38.764 35.24 35.24 35.24 35.24 35.9448 35.24 8600 Hos Central Supply Facility Fee 1552 WAFER STOMAHESIVE FLX 70MM A4467 270 57.42 40.193999999999996 7.99 36.75 18.72 7.99 27.56 7.99 18.72 18.72 18.72 18.72 7.99 8.789000000000001 7.99 7.99 1.5 1.5 1.53 1.5 8600 Hos Central Supply Facility Fee 1439 WAFER SURFIT NATURAL STOMAHESIVE A4467 270 0.81 0.567 13.04 59.99 30.56 13.04 44.99 13.04 30.56 30.56 30.56 30.56 13.04 14.344 13.04 13.04 13.04 13.04 13.300799999999999 13.04 8600 Hos Central Supply Facility Fee 1099 WALKER A4467 270 30.82 21.573999999999998 11.95 54.99 28.01 11.95 41.24 11.95 28.01 28.01 28.01 28.01 11.95 13.145 11.95 11.95 11.95 11.95 12.189 11.95 8600 Hos Central Supply Facility Fee 1181 WASHBASIN GRAPHITE 8QT A9270 270 0.42 0.294 1.46 6.7 3.41 1.46 5.03 1.46 3.41 3.41 3.41 3.41 1.46 1.606 1.46 1.46 11.95 11.95 12.189 11.95 8600 Hos Central Supply Facility Fee 612 WASHBASIN,RECTANGULAR,GRAPHITE,6 QT A4467 270 0.31 0.217 11.22 51.59 26.28 11.22 38.69 11.22 26.28 26.28 26.28 26.28 11.22 12.342000000000002 11.22 11.22 11.22 11.22 11.444400000000002 11.22 8600 Hos Central Supply Facility Fee 50512 WHEEL POLYURETHANE FLAT FREE N/A 270 45.96 32.172 0.2 0.93 0.47 0.2 0.7 0.2 0.47 0.47 0.47 0.47 0.2 0.22000000000000003 0.2 0.2 0.2 0.2 0.2 0.2 8600 Hos Central Supply Facility Fee 50006 WHOLE BLOOD GLUCOSE- 5 SAMPLES A4253 270 215.8 151.06 54.35 250 127.35 54.35 187.5 54.35 127.35 127.35 127.35 127.35 54.35 59.785000000000004 54.35 54.35 54.35 54.35 54.35 54.35 8600 Hos Central Supply Facility Fee 922 WINDOW ENVELOPE #10 SECURITY A4467 270 54.94 38.458 3.88 17.87 9.1 3.88 13.4 3.88 9.1 9.1 9.1 9.1 3.88 4.268 3.88 3.88 3.88 3.88 3.9576 3.88 8600 Hos Central Supply Facility Fee 50076 WIPER BRAWNY WHITE INDUSTRIAL HEF A4467 270 8.9 6.2299999999999995 1.16 5.35 2.73 1.16 4.01 1.16 2.73 2.73 2.73 2.73 1.16 1.276 1.16 1.16 1.16 1.16 1.1832 1.16 8600 Hos Central Supply Facility Fee 246 WIRE POLYPECTOMY SNARE SOFT LOOP LARGE R1206 270 10.24 7.167999999999999 14.82 68.19 34.74 14.82 51.14 14.82 34.74 34.74 34.74 34.74 14.82 16.302000000000003 14.82 14.82 14.82 14.82 15.1164 14.82 8600 Hos Central Supply Facility Fee 445 WRAP SELF-ADHERENT COBAN LF 3 IN X 5 YD NON-STERILE A53287 270 1.3 0.9099999999999999 4.35 19.99 10.18 4.35 14.99 4.35 10.18 10.18 10.18 10.18 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 8600 Hos Central Supply Facility Fee 76 WRAP STERILIZATION 24 IN X 24 IN KIMGUARD A8206 270 0.27 0.189 3.72 17.11 8.72 3.72 12.83 3.72 8.72 8.72 8.72 8.72 3.72 4.0920000000000005 3.72 3.72 3.72 3.72 3.7944000000000004 3.72 8600 Hos Central Supply Facility Fee 77 WRAP STERILIZATION 45 IN X 45 IN HEAVY DUTY A5206 270 0.82 0.574 3.92 18.03 9.18 3.92 13.52 3.92 9.18 9.18 9.18 9.18 3.92 4.312 3.92 3.92 3.92 3.92 3.9984 3.92 8600 Hos Central Supply Facility Fee 860 WRIST IV ARM BOARD A4467 270 0.32 0.22399999999999998 11.74 54 27.51 11.74 40.5 11.74 27.51 27.51 27.51 27.51 11.74 12.914000000000001 11.74 11.74 11.74 11.74 11.9748 11.74 8600 Hos Central Supply Facility Fee 1746 WRIST SPLINT BLUE RH/MED A4467 270 10.85 7.594999999999999 96.4 443.42 225.88 96.4 332.57 96.4 225.88 225.88 225.88 225.88 96.4 106.04000000000002 96.4 96.4 96.4 96.4 98.328 96.4 8600 Hos Central Supply Facility Fee 1344 WRIST SPLINT LH LARGE L3908 270 9.81 6.867 4.35 19.99 10.18 4.35 14.99 4.35 10.18 10.18 10.18 10.18 4.35 4.785 4.35 4.35 4.35 4.35 4.436999999999999 4.35 8600 Hos Central Supply Facility Fee 1343 WRIST SPLINT LH MED L3908 270 16.38 11.466 2.98 13.7 6.98 2.98 10.28 2.98 6.98 6.98 6.98 6.98 2.98 3.278 2.98 2.98 2.98 2.98 3.0396 2.98 8600 Hos Central Supply Facility Fee 1345 WRIST SPLINT LH XL L3908 270 9.61 6.726999999999999 17.52 80.61 41.06 17.52 60.46 17.52 41.06 41.06 41.06 41.06 17.52 19.272000000000002 17.52 17.52 17.52 17.52 17.8704 17.52 8600 Hos Central Supply Facility Fee 1504 WRIST SPLINT LH/LGE L3908 270 8.9 6.2299999999999995 85.01 391.05 199.2 85.01 293.29 85.01 199.2 199.2 199.2 199.2 85.01 93.51100000000001 85.01 85.01 85.01 85.01 86.7102 85.01 8600 Hos Central Supply Facility Fee 1503 WRIST SPLINT LH/MED L3908 270 8.9 6.2299999999999995 11.08 50.95 25.95 11.08 38.21 11.08 25.95 25.95 25.95 25.95 11.08 12.188 11.08 11.08 11.08 11.08 11.3016 11.08 8600 Hos Central Supply Facility Fee 1502 WRIST SPLINT LH/SML L3908 270 8.9 6.2299999999999995 54.54 250.86 127.79 54.54 188.15 54.54 127.79 127.79 127.79 127.79 54.54 59.99400000000001 54.54 54.54 54.54 54.54 55.6308 54.54 8600 Hos Central Supply Facility Fee 1505 WRIST SPLINT LH/XL L3908 270 8.9 6.2299999999999995 59.89 275.49 140.33 59.89 206.62 59.89 140.33 140.33 140.33 140.33 59.89 65.879 59.89 59.89 59.89 59.89 61.0878 59.89 8600 Hos Central Supply Facility Fee 1339 WRIST SPLINT MED L3908 270 9.81 6.867 14.25 65.57 33.4 14.25 49.18 14.25 33.4 33.4 33.4 33.4 14.25 15.675 14.25 14.25 14.25 14.25 14.535 14.25 8600 Hos Central Supply Facility Fee 1340 WRIST SPLINT RH LARGE L3908 270 9.81 6.867 15.61 71.81 36.58 15.61 53.86 15.61 36.58 36.58 36.58 36.58 15.61 17.171 15.61 15.61 15.61 15.61 15.9222 15.61 8600 Hos Central Supply Facility Fee 1338 WRIST SPLINT RH SMALL L3908 270 9.81 6.867 31.71 145.85 74.3 31.71 109.39 31.71 74.3 74.3 74.3 74.3 31.71 34.881 31.71 31.71 31.71 31.71 32.3442 31.71 8600 Hos Central Supply Facility Fee 1341 WRIST SPLINT RH XL L3908 270 10.12 7.083999999999999 13.6 62.58 31.88 13.6 46.94 13.6 31.88 31.88 31.88 31.88 13.6 14.96 13.6 13.6 13.6 13.6 13.872 13.6 8600 Hos Central Supply Facility Fee 1500 WRIST SPLINT RH/LG L3908 270 8.9 6.2299999999999995 13.6 62.58 31.88 13.6 46.94 13.6 31.88 31.88 31.88 31.88 13.6 14.96 13.6 13.6 13.6 13.6 13.872 13.6 8600 Hos Central Supply Facility Fee 1498 WRIST SPLINT RH/MED L3908 270 8.9 6.2299999999999995 10.67 49.06 24.99 10.67 36.8 10.67 24.99 24.99 24.99 24.99 10.67 11.737 10.67 10.67 10.67 10.67 10.8834 10.67 8600 Hos Central Supply Facility Fee 1499 WRIST SPLINT RH/MED L3908 270 8.9 6.2299999999999995 5.33 24.52 12.49 5.33 18.39 5.33 12.49 12.49 12.49 12.49 5.33 5.863 5.33 5.33 5.33 5.33 5.4366 5.33 8600 Hos Central Supply Facility Fee 1497 WRIST SPLINT RH/SML L3908 270 8.9 6.2299999999999995 2.67 12.27 6.25 2.67 9.2 2.67 6.25 6.25 6.25 6.25 2.67 2.9370000000000003 2.67 2.67 2.67 2.67 2.7234 2.67 8600 Hos Central Supply Facility Fee 1501 WRIST SPLINT RH/XLG L3908 270 8.9 6.2299999999999995 27.7 127.43 64.91 27.7 95.57 27.7 64.91 64.91 64.91 64.91 27.7 30.470000000000002 27.7 27.7 27.7 27.7 28.254 27.7 8600 Hos Central Supply Facility Fee 1342 WRIST SPLIT LH SM L3908 270 12.91 9.036999999999999 130.11 598.5 304.88 130.11 448.88 130.11 304.88 304.88 304.88 304.88 130.11 143.12100000000004 130.11 130.11 130.11 130.11 132.71220000000002 130.11 8600 Hos Central Supply Facility Fee 50115 XLD AGAR OPTILUX PLATE A4467 270 0.27 0.189 76.32 351.05 178.82 76.32 263.29 76.32 178.82 178.82 178.82 178.82 76.32 83.952 76.32 76.32 41.19 41.19 42.013799999999996 41.19 8600 Hos Central Supply Facility Fee 817 Y BLOOD SET A4467 270 4.93 3.4509999999999996 11.45 52.67 26.83 11.45 39.5 11.45 26.83 26.83 26.83 26.83 11.45 12.595 11.45 11.45 11.45 11.45 11.679 11.45 8600 Hos Central Supply Facility Fee 570 YANKAUER,BULB TIP,VENT A4467 270 0.28 0.196 0.71 3.25 1.66 0.71 2.44 0.71 1.66 1.66 1.66 1.66 0.71 0.781 0.71 0.71 0.71 0.71 0.7242 0.71 8600 Hos Central Supply Facility Fee 1350 ZOLL BATTERY PACK 4410 A4467 270 62 43.4 210.69 969.15 493.69 210.69 726.86 210.69 493.69 493.69 493.69 493.69 210.69 231.75900000000001 210.69 210.69 11.74 11.74 11.9748 11.74 Room Charges are included in negotiated rates with all insurance companies. 0 21.11 21.11 21.5322 21.11 ROOM Room Charges Facility Fee 1001 ICU Room Charge N/A 200 1050 735 228.27 1050 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1002 Behavioral Health Private Room N/A 114 800 560 173.92 800 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1003 Behavioral Health Semi-Private Room N/A 124 700 489.99999999999994 152.18 700 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1004 Isolation Room N/A 110 1050 735 228.27 1050 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1005 Inpatient Private Room N/A 111 800 560 173.92 800 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1006 Swing Bed Private N/A 119 0 0 $- 0 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1007 Swing Bed Semi Private N/A 129 650 454.99999999999994 141.31 650 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1008 Inpatient Semi Private Room N/A 121 700 489.99999999999994 152.18 700 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1009 Surgery Private Room N/A 110 2080 1456 452.19 2080 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1010 Surgery Semi Private Room N/A 120 700 489.99999999999994 152.18 700 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1011 Hospice Private Room N/A 115 2080 1456 452.19 2080 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1012 Hospice Semi Private Room N/A 125 2000 1400 434.8 2000 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1015 Detox Semi Private N/A 126 700 489.99999999999994 152.18 700 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A ROOM Room Charges Facility Fee 1016 Detox Private N/A 116 800 560 173.92 800 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A DRG Hospital Inpatient Facility Fee DRG HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC MS-DRG 001 N/A 846592.03 592614.421 3078 846592.03 184819.9850238 253821.53 369595.25 253821.53 184819.9850238 184819.9850238 184819.9850238 5377 253821.53 279203.683 253821.53 251205.104535 253821.53 253821.53 253821.53 253821.53 DRG Hospital Inpatient Facility Fee DRG HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC MS-DRG 002 N/A 752886.92 527020.844 4050 752886.92 89194.9980486 121500.41 303368.99 121500.41 89194.9980486 89194.9980486 89194.9980486 5377 121500.41 133650.451 121500.41 121232.770395 121500.41 121500.41 123930.4182 121500.41 DRG Hospital Inpatient Facility Fee DRG ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES MS-DRG 003 N/A 645099.41 451569.587 3078 645099.41 156357.69659459998 182498.16 304003.19 182498.16 156357.69659459998 156357.69659459998 156357.69659459998 5377 182498.16 200747.97600000002 182498.16 212519.503845 182498.16 182498.16 186148.1232 182498.16 DRG Hospital Inpatient Facility Fee DRG TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES MS-DRG 004 N/A 949211.27 664447.889 3078 949211.27 96803.51012879999 123832.47 386734.86 123832.47 96803.51012879999 96803.51012879999 96803.51012879999 5377 123832.47 136215.717 123832.47 131574.16866 123832.47 123832.47 126309.11940000001 123832.47 DRG Hospital Inpatient Facility Fee DRG LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT MS-DRG 005 N/A 473562.45 331493.71499999997 4050 473562.45 73925.4890514 102868.32 181673.03 102868.32 73925.4890514 73925.4890514 73925.4890514 5377 102868.32 113155.15200000002 102868.32 100478.637105 102868.32 102868.32 104925.6864 102868.32 DRG Hospital Inpatient Facility Fee DRG LIVER TRANSPLANT WITHOUT MCC MS-DRG 006 N/A 613006.45 429104.51499999996 4050 613006.45 37947.133425 43370.26 228564.12 43370.26 37947.133425 37947.133425 37947.133425 5377 43370.26 47707.28600000001 43370.26 51577.288125 43370.26 43370.26 44237.6652 43370.26 DRG Hospital Inpatient Facility Fee DRG LUNG TRANSPLANT MS-DRG 007 N/A 2162847.2 1513993.04 4050 2162847.2 80815.31671859999 110085.43 896410.74 110085.43 80815.31671859999 80815.31671859999 80815.31671859999 5377 110085.43 121093.973 110085.43 109843.208145 110085.43 110085.43 112287.13859999999 110085.43 DRG Hospital Inpatient Facility Fee DRG SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT MS-DRG 008 N/A 591940.4 414358.27999999997 4050 591940.4 37014.3347346 50420.54 221089.69 50420.54 37014.3347346 37014.3347346 37014.3347346 5377 50420.54 55462.594000000005 50420.54 50309.439345 50420.54 50420.54 51428.9508 50420.54 DRG Hospital Inpatient Facility Fee DRG Bone marrow transplant MS-DRG 009 N/A 10881.9 7617.329999999999 3078 96789.44 36623.680551599995 5440.95 62571.65 5440.95 0 0 0 5377 5440.95 5985.045 5440.95 5440.95 5440.95 5549.769 5440.95 DRG Hospital Inpatient Facility Fee DRG PANCREAS TRANSPLANT MS-DRG 010 N/A 363908.35 254735.84499999997 4050 363908.35 27452.551739399998 37395.84 122181.22 37395.84 27452.551739399998 27452.551739399998 27452.551739399998 5377 37395.84 41135.424 37395.84 37313.178705 37395.84 37395.84 38143.756799999996 37395.84 DRG Hospital Inpatient Facility Fee DRG TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC MS-DRG 011 N/A 225144.85 157601.395 3078 225144.85 26642.6152806 46579.77 65440.1 46579.77 26642.6152806 26642.6152806 26642.6152806 5377 46579.77 51237.747 46579.77 36212.322795 46579.77 46579.77 47511.365399999995 46579.77 DRG Hospital Inpatient Facility Fee DRG TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC MS-DRG 012 N/A 170114.57 119080.199 3078 170114.57 28025.710013999997 35255.87 39922.55 35255.87 28025.710013999997 28025.710013999997 28025.710013999997 5377 35255.87 38781.45700000001 35255.87 38092.208549999996 35255.87 35255.87 35960.987400000005 35255.87 DRG Hospital Inpatient Facility Fee DRG TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC MS-DRG 013 N/A 129151.39 90405.973 3078 129151.39 17541.863863199997 25505.61 28027.58 25505.61 17541.863863199997 17541.863863199997 17541.863863199997 5377 25505.61 28056.171000000002 25505.61 23842.69074 25505.61 25505.61 26015.7222 25505.61 DRG Hospital Inpatient Facility Fee DRG ALLOGENEIC BONE MARROW TRANSPLANT MS-DRG 014 N/A 38882.04 27217.428 4050 163722.53 107833.6757172 100938.47 105836.31 100938.47 107833.6757172 107833.6757172 107833.6757172 5377 100938.47 111032.31700000001 100938.47 146566.23729000002 100938.47 100938.47 102957.2394 100938.47 DRG Hospital Inpatient Facility Fee DRG AUTOLOGOUS BONE MARROW TRANSPLANT MS-DRG 015 N/A 42014.91 29410.437 3078 88277.2 82980.568 21007.46 57069.44 21007.46 0 0 0 5377 21007.46 23108.206000000002 21007.46 21007.46 21007.46 21427.6092 21007.46 DRG Hospital Inpatient Facility Fee DRG AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC MS-DRG 016 N/A 176947 123862.9 4023.29 176947 36623.680551599995 54869.12 58315.93 54869.12 36623.680551599995 36623.680551599995 36623.680551599995 5377 54869.12 60356.03200000001 54869.12 49778.46687 54869.12 54869.12 55966.502400000005 54869.12 DRG Hospital Inpatient Facility Fee DRG AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC MS-DRG 017 N/A 18898.13 13228.691 4050 65535.39 28931.073448799994 39409.56 42369.44 39409.56 28931.073448799994 28931.073448799994 28931.073448799994 5377 39409.56 43350.516 39409.56 39322.76766 39409.56 39409.56 40197.7512 39409.56 DRG Hospital Inpatient Facility Fee DRG CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES MS-DRG 018 N/A 2860061 2002042.7 3078 2860061 141221.78536379998 325957.41 1234296.42 325957.41 141221.78536379998 141221.78536379998 141221.78536379998 5377 325957.41 358553.151 325957.41 191946.955035 325957.41 325957.41 332476.55819999997 325957.41 DRG Hospital Inpatient Facility Fee DRG SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS MS-DRG 019 N/A 16368.9 11458.23 3078 105318.83 47232.7746084 64339.82 68084.94 64339.82 47232.7746084 47232.7746084 47232.7746084 5377 64339.82 70773.80200000001 64339.82 64198.22013 64339.82 64339.82 65626.6164 64339.82 DRG Hospital Inpatient Facility Fee DRG INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC MS-DRG 020 N/A 387183.73 271028.611 3078 387183.73 52022.612385 83897.16 141378.14 83897.16 52022.612385 52022.612385 52022.612385 5377 83897.16 92286.87600000002 83897.16 70708.510125 83897.16 83897.16 85575.10320000001 83897.16 DRG Hospital Inpatient Facility Fee DRG INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC MS-DRG 021 N/A 369444.8 258611.36 3078 369444.8 47570.9439546 61225.01 129320.04 61225.01 47570.9439546 47570.9439546 47570.9439546 5377 61225.01 67347.51100000001 61225.01 64657.855845 61225.01 61225.01 62449.510200000004 61225.01 DRG Hospital Inpatient Facility Fee DRG INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC MS-DRG 022 N/A 357603.65 250322.555 3078 357603.65 28854.1354494 39304.95 119903.75 39304.95 28854.1354494 28854.1354494 28854.1354494 5377 39304.95 43235.445 39304.95 39218.194455000004 39304.95 39304.95 40091.049 39304.95 DRG Hospital Inpatient Facility Fee DRG CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR MS-DRG 023 N/A 286913.55 200839.485 3078 286913.55 41354.472886799995 51685.77 92550.06 51685.77 41354.472886799995 41354.472886799995 41354.472886799995 5377 51685.77 56854.347 51685.77 56208.50300999999 51685.77 51685.77 52719.4854 51685.77 DRG Hospital Inpatient Facility Fee DRG CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC MS-DRG 024 N/A 85954.55 60168.185 3078 85954.55 24290.9367408 35610.28 38450.52 35610.28 24290.9367408 24290.9367408 24290.9367408 5377 35610.28 39171.308000000005 35610.28 33015.94956 35610.28 35610.28 36322.4856 35610.28 DRG Hospital Inpatient Facility Fee DRG CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC MS-DRG 025 N/A 91615.14 64130.598 3078 91615.14 24834.274085399997 40946.23 43954.54 40946.23 24834.274085399997 24834.274085399997 24834.274085399997 5377 40946.23 45040.85300000001 40946.23 33754.447155 40946.23 40946.23 41765.1546 40946.23 DRG Hospital Inpatient Facility Fee DRG CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC MS-DRG 026 N/A 70359.96 49251.972 3078 70359.96 18377.4463218 27265.92 29843.32 27265.92 18377.4463218 18377.4463218 18377.4463218 5377 27265.92 29992.512 27265.92 24978.404385 27265.92 27265.92 27811.2384 27265.92 DRG Hospital Inpatient Facility Fee DRG CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC MS-DRG 027 N/A 58167.18 40717.026 3078 58167.18 16102.1093628 22503.52 24930.93 22503.52 16102.1093628 16102.1093628 16102.1093628 5377 22503.52 24753.872000000003 22503.52 21885.79371 22503.52 22503.52 22953.5904 22503.52 DRG Hospital Inpatient Facility Fee DRG SPINAL PROCEDURES WITH MCC MS-DRG 028 N/A 76934.47 53854.129 3078 87228.14 23118.9741918 53003.3 56391.35 53003.3 23118.9741918 23118.9741918 23118.9741918 5377 53003.3 58303.630000000005 53003.3 31423.032135 53003.3 53003.3 54063.366 53003.3 DRG Hospital Inpatient Facility Fee DRG SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS MS-DRG 029 N/A 59319.28 41523.496 3078 59319.28 16267.913733599999 30819.92 33509.26 30819.92 16267.913733599999 16267.913733599999 16267.913733599999 5377 30819.92 33901.912000000004 30819.92 22111.153019999998 30819.92 30819.92 31436.3184 30819.92 DRG Hospital Inpatient Facility Fee DRG SPINAL PROCEDURES WITHOUT CC/MCC MS-DRG 030 N/A 61352.4 42946.68 3078 61352.4 11558.592467999999 21112.94 23496.55 21112.94 11558.592467999999 11558.592467999999 11558.592467999999 5377 21112.94 23224.234 21112.94 15710.300099999999 21112.94 21112.94 21535.1988 21112.94 DRG Hospital Inpatient Facility Fee DRG VENTRICULAR SHUNT PROCEDURES WITH MCC MS-DRG 031 N/A 123249.83 86274.881 3078 123249.83 13554.805522199998 37163.18 40052.33 37163.18 13554.805522199998 13554.805522199998 13554.805522199998 5377 37163.18 40879.49800000001 37163.18 18423.528915 37163.18 37163.18 37906.4436 37163.18 DRG Hospital Inpatient Facility Fee DRG VENTRICULAR SHUNT PROCEDURES WITH CC MS-DRG 032 N/A 73551.1 51485.770000000004 3078 73551.1 11963.5606974 18527.48 20829.67 18527.48 11963.5606974 11963.5606974 11963.5606974 5377 18527.48 20380.228000000003 18527.48 16260.728055 18527.48 18527.48 18898.0296 18527.48 DRG Hospital Inpatient Facility Fee DRG VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC MS-DRG 033 N/A 38492.19 26944.533 3078 38492.19 9837.924807 15317.07 17518.14 15317.07 9837.924807 9837.924807 9837.924807 5377 15317.07 16848.777000000002 15317.07 13371.589275 15317.07 15317.07 15623.4114 15317.07 DRG Hospital Inpatient Facility Fee DRG CAROTID ARTERY STENT PROCEDURES WITH MCC MS-DRG 034 N/A 94876.96 66413.872 3078 94876.96 26476.8109098 36066.59 38921.17 36066.59 26476.8109098 26476.8109098 26476.8109098 5377 36066.59 39673.248999999996 36066.59 35986.963485 36066.59 36066.59 36787.9218 36066.59 DRG Hospital Inpatient Facility Fee DRG CAROTID ARTERY STENT PROCEDURES WITH CC MS-DRG 035 N/A 54593.36 38215.352 3078 54593.36 12263.5592532 20595.31 22962.6 20595.31 12263.5592532 12263.5592532 12263.5592532 5377 20595.31 22654.841000000004 20595.31 16668.48249 20595.31 20595.31 21007.216200000003 20595.31 DRG Hospital Inpatient Facility Fee DRG CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC MS-DRG 036 N/A 69162.71 48413.897000000004 3078 69162.71 10034.146526399998 16960.15 19212.99 16960.15 10034.146526399998 10034.146526399998 10034.146526399998 5377 16960.15 18656.165000000005 16960.15 13638.291479999998 16960.15 16960.15 17299.353000000003 16960.15 DRG Hospital Inpatient Facility Fee DRG EXTRACRANIAL PROCEDURES WITH MCC MS-DRG 037 N/A 54638.26 38246.782 3078 54638.26 18945.236828999998 30417.71 33094.37 30417.71 18945.236828999998 18945.236828999998 18945.236828999998 5377 30417.71 33459.481 30417.71 25750.138424999997 30417.71 30417.71 31026.0642 30417.71 DRG Hospital Inpatient Facility Fee DRG EXTRACRANIAL PROCEDURES WITH CC MS-DRG 038 N/A 81949.86 57364.901999999995 3078 81949.86 9591.6039252 14748.94 16932.11 14748.94 9591.6039252 9591.6039252 9591.6039252 5377 14748.94 16223.834000000003 14748.94 13036.79289 14748.94 14748.94 15043.918800000001 14748.94 DRG Hospital Inpatient Facility Fee DRG EXTRACRANIAL PROCEDURES WITHOUT CC/MCC MS-DRG 039 N/A 31964.84 22375.388 3078 31964.84 9872.5170858 10395.05 12441.1 10395.05 9872.5170858 9872.5170858 9872.5170858 5377 10395.05 11434.555 10395.05 13418.606684999999 10395.05 10395.05 10602.951 10395.05 DRG Hospital Inpatient Facility Fee DRG PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC MS-DRG 040 N/A 208935.75 146255.025 3078 208935.75 18827.1459462 34163.79 56094.38 34163.79 18827.1459462 18827.1459462 18827.1459462 5377 34163.79 37580.169 34163.79 25589.630715 34163.79 34163.79 34847.065800000004 34163.79 DRG Hospital Inpatient Facility Fee DRG PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR MS-DRG 041 N/A 65394.38 45776.066 3078 65394.38 14611.062862800001 21084.99 23467.73 21084.99 14611.062862800001 14611.062862800001 14611.062862800001 5377 21084.99 23193.489000000005 21084.99 19859.181210000002 21084.99 21084.99 21506.689800000004 21084.99 DRG Hospital Inpatient Facility Fee DRG PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC MS-DRG 042 N/A 103213.63 72249.541 3078 103213.63 9803.332528199999 16680.59 18924.61 16680.59 9803.332528199999 9803.332528199999 9803.332528199999 5377 16680.59 18348.649 16680.59 13324.571865 16680.59 16680.59 17014.2018 16680.59 DRG Hospital Inpatient Facility Fee DRG NEUROLOGICAL EYE DISORDERS MS-DRG 045 N/A 79098.57 55368.999 72.18 79098.57 74352.65580000001 39549.28 72.18 39549.28 0 0 0 5377 39549.28 43504.208 39549.28 39549.28 39549.28 40340.2656 39549.28 DRG Hospital Inpatient Facility Fee DRG SPINAL DISORDERS AND INJURIES WITH CC/MCC MS-DRG 052 N/A 102606.2 71824.34 592.55 102606.2 12313.658415599999 16054.75 18279.04 16054.75 12313.658415599999 12313.658415599999 12313.658415599999 5377 16054.75 17660.225000000002 16054.75 16736.57667 16054.75 16054.75 16375.845000000001 16054.75 DRG Hospital Inpatient Facility Fee DRG SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC MS-DRG 053 N/A 13107.04 9174.928 3078 17365 6085.8553944 9223.61 11232.74 9223.61 6085.8553944 6085.8553944 6085.8553944 5377 9223.61 10145.971000000001 9223.61 8271.82158 9223.61 9223.61 9408.0822 9223.61 DRG Hospital Inpatient Facility Fee DRG NERVOUS SYSTEM NEOPLASMS WITH MCC MS-DRG 054 N/A 26598.96 18619.271999999997 3078 26598.96 7527.399150599999 12507.97 14620.57 12507.97 7527.399150599999 7527.399150599999 7527.399150599999 5377 12507.97 13758.767 12507.97 10231.150545 12507.97 12507.97 12758.1294 12507.97 DRG Hospital Inpatient Facility Fee DRG NERVOUS SYSTEM NEOPLASMS WITHOUT MCC MS-DRG 055 N/A 17451.57 12216.098999999998 3078 17451.57 5428.0056786 9092.85 11097.87 9092.85 5428.0056786 5428.0056786 5428.0056786 5377 9092.85 10002.135000000002 9092.85 7377.680145 9092.85 9092.85 9274.707 9092.85 DRG Hospital Inpatient Facility Fee DRG DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC MS-DRG 056 N/A 53540.96 37478.672 2872.94 53540.96 13870.3109616 20117.35 22469.62 20117.35 13870.3109616 13870.3109616 13870.3109616 5377 20117.35 22129.085 20117.35 18852.36012 20117.35 20117.35 20519.697 20117.35 DRG Hospital Inpatient Facility Fee DRG DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC MS-DRG 057 N/A 75826.2 53078.34 1783.18 75826.2 8556.8176542 11736.93 13825.23 11736.93 8556.8176542 8556.8176542 8556.8176542 5377 11736.93 12910.623000000001 11736.93 11630.323815 11736.93 11736.93 11971.6686 11736.93 DRG Hospital Inpatient Facility Fee DRG MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC MS-DRG 058 N/A 24161.54 16913.078 3078 27474.57 12623.199668999998 15558.76 17767.44 15558.76 12623.199668999998 12623.199668999998 12623.199668999998 5377 15558.76 17114.636000000002 15558.76 17157.301424999998 15558.76 15558.76 15869.9352 15558.76 DRG Hospital Inpatient Facility Fee DRG MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC MS-DRG 059 N/A 26848.2 18793.739999999998 3078 26848.2 6149.672184599999 10312.08 12355.51 10312.08 6149.672184599999 6149.672184599999 6149.672184599999 5377 10312.08 11343.288 10312.08 8358.560594999999 10312.08 10312.08 10518.3216 10312.08 DRG Hospital Inpatient Facility Fee DRG MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC MS-DRG 060 N/A 27025.65 18917.954999999998 3078 27025.65 6357.2258574 8173.01 10149.07 8173.01 6357.2258574 6357.2258574 6357.2258574 5377 8173.01 8990.311000000002 8173.01 8640.665055 8173.01 8173.01 8336.4702 8173.01 DRG Hospital Inpatient Facility Fee DRG ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC MS-DRG 061 N/A 80017.81 56012.467 3078 80017.81 17897.9257674 26446.19 28997.76 26446.19 17897.9257674 17897.9257674 17897.9257674 5377 26446.19 29090.809 26446.19 24326.645805 26446.19 26446.19 26975.1138 26446.19 DRG Hospital Inpatient Facility Fee DRG ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC MS-DRG 062 N/A 55957.97 39170.579 3078 55957.97 11621.216421 17289.31 19552.49 17289.31 11621.216421 11621.216421 11621.216421 5377 17289.31 19018.241 17289.31 15795.417824999999 17289.31 17289.31 17635.0962 17289.31 DRG Hospital Inpatient Facility Fee DRG ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC MS-DRG 063 N/A 46419.23 32493.461 3078 46419.23 10278.0817338 14257.46 16425.17 14257.46 10278.0817338 10278.0817338 10278.0817338 5377 14257.46 15683.206 14257.46 13969.845285 14257.46 14257.46 14542.609199999999 14257.46 DRG Hospital Inpatient Facility Fee DRG INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC MS-DRG 064 N/A 24842.34 17389.638 3078 31024.75 13137.3125022 17783.5 20062.23 17783.5 13137.3125022 13137.3125022 13137.3125022 5377 17783.5 19561.850000000002 17783.5 17856.077415 17783.5 17783.5 18139.170000000002 17783.5 DRG Hospital Inpatient Facility Fee DRG INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS MS-DRG 065 N/A 30689.16 21482.412 3078 30689.16 7153.4446884 9165.9 11173.2 9165.9 7153.4446884 7153.4446884 7153.4446884 5377 9165.9 10082.49 9165.9 9722.87613 9165.9 9165.9 9349.217999999999 9165.9 DRG Hospital Inpatient Facility Fee DRG INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC MS-DRG 066 N/A 16066.8 11246.759999999998 3078 16066.8 6151.4614404 6299.07 8216.11 6299.07 6151.4614404 6151.4614404 6151.4614404 5377 6299.07 6928.977 6299.07 8360.992530000001 6299.07 6299.07 6425.051399999999 6299.07 DRG Hospital Inpatient Facility Fee DRG NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC MS-DRG 067 N/A 61151.51 42806.057 3078 61151.51 9361.9827642 12752.35 14872.64 12752.35 9361.9827642 9361.9827642 9361.9827642 5377 12752.35 14027.585000000001 12752.35 12724.694565 12752.35 12752.35 13007.397 12752.35 DRG Hospital Inpatient Facility Fee DRG NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC MS-DRG 068 N/A 21884.28 15318.995999999997 3078 21884.28 4845.901124999999 8149.57 10124.87 8149.57 4845.901124999999 4845.901124999999 4845.901124999999 5377 8149.57 8964.527 8149.57 6586.490624999999 8149.57 8149.57 8312.5614 8149.57 DRG Hospital Inpatient Facility Fee DRG TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC MS-DRG 069 N/A 27911.98 19538.386 3078 27911.98 4321.6491756 7195.46 9140.75 7195.46 4321.6491756 4321.6491756 4321.6491756 5377 7195.46 7915.006 7195.46 5873.93367 7195.46 7195.46 7339.3692 7195.46 DRG Hospital Inpatient Facility Fee DRG NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC MS-DRG 070 N/A 173317.67 121322.369 3078 173317.67 11630.162699999999 15548.83 37304.45 15548.83 11630.162699999999 11630.162699999999 11630.162699999999 5377 15548.83 17103.713 15548.83 15807.5775 15548.83 15548.83 15859.8066 15548.83 DRG Hospital Inpatient Facility Fee DRG NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC MS-DRG 071 N/A 69189.56 48432.691999999995 2391.58 69189.56 6121.6405104 9640.24 11662.51 9640.24 6121.6405104 6121.6405104 6121.6405104 5377 9640.24 10604.264000000001 9640.24 8320.46028 9640.24 9640.24 9833.0448 9640.24 DRG Hospital Inpatient Facility Fee DRG NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC MS-DRG 072 N/A 11605.67 8123.968999999999 3078 13755.78 4461.211128 6961.9 8899.8 6961.9 4461.211128 4461.211128 4461.211128 5377 6961.9 7658.09 6961.9 6063.6246 6961.9 6961.9 7101.138 6961.9 DRG Hospital Inpatient Facility Fee DRG CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC MS-DRG 073 N/A 12658.25 8860.775 3078 24222.24 12775.286412 13520.69 15665.17 13520.69 12775.286412 12775.286412 12775.286412 5377 13520.69 14872.759000000002 13520.69 17364.0159 13520.69 13520.69 13791.1038 13520.69 DRG Hospital Inpatient Facility Fee DRG CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC MS-DRG 074 N/A 33328.71 23330.096999999998 3078 33328.71 6169.950416999999 9230.82 11240.19 9230.82 6169.950416999999 6169.950416999999 6169.950416999999 5377 9230.82 10153.902 9230.82 8386.122524999999 9230.82 9230.82 9415.4364 9230.82 DRG Hospital Inpatient Facility Fee DRG VIRAL MENINGITIS WITH CC/MCC MS-DRG 075 N/A 69590.66 48713.462 3078 69590.66 6756.2299008 16457.85 18694.84 16457.85 6756.2299008 6756.2299008 6756.2299008 5377 16457.85 18103.635 16457.85 9182.98656 16457.85 16457.85 16787.006999999998 16457.85 DRG Hospital Inpatient Facility Fee DRG VIRAL MENINGITIS WITHOUT CC/MCC MS-DRG 076 N/A 31172.63 21820.841 2934.25 31172.63 4113.4990842 8903.47 10902.54 8903.47 4113.4990842 4113.4990842 4113.4990842 5377 8903.47 9793.817000000001 8903.47 5591.018564999999 8903.47 8903.47 9081.5394 8903.47 DRG Hospital Inpatient Facility Fee DRG HYPERTENSIVE ENCEPHALOPATHY WITH MCC MS-DRG 077 N/A 31234.9 21864.43 3078 31234.9 10355.616151799999 14105.96 16268.88 14105.96 10355.616151799999 10355.616151799999 10355.616151799999 5377 14105.96 15516.556 14105.96 14075.229135 14105.96 14105.96 14388.0792 14105.96 DRG Hospital Inpatient Facility Fee DRG HYPERTENSIVE ENCEPHALOPATHY WITH CC MS-DRG 078 N/A 13864.07 9704.848999999998 3078 16933.3 6572.532972 8953.07 10953.69 8953.07 6572.532972 6572.532972 6572.532972 5377 8953.07 9848.377 8953.07 8933.3079 8953.07 8953.07 9132.1314 8953.07 DRG Hospital Inpatient Facility Fee DRG HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC MS-DRG 079 N/A 13560.7 9492.49 3078 15164.3 4858.4259156 6618.31 9814 6618.31 4858.4259156 4858.4259156 4858.4259156 5377 6618.31 7280.141000000001 6618.31 6603.5141699999995 6618.31 6618.31 6750.676200000001 6618.31 DRG Hospital Inpatient Facility Fee DRG NONTRAUMATIC STUPOR AND COMA WITH MCC MS-DRG 080 N/A 28957.85 20270.495 3078 37439.17 13143.2766882 18394.92 24218.86 18394.92 13143.2766882 13143.2766882 13143.2766882 5377 18394.92 20234.412 18394.92 17864.183865 18394.92 18394.92 18762.8184 18394.92 DRG Hospital Inpatient Facility Fee DRG NONTRAUMATIC STUPOR AND COMA WITHOUT MCC MS-DRG 081 N/A 41858.54 29300.978 3078 41858.54 4184.4728976 8102.67 10076.51 8102.67 4184.4728976 4184.4728976 4184.4728976 5377 8102.67 8912.937 8102.67 5687.48532 8102.67 8102.67 8264.7234 8102.67 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC MS-DRG 082 N/A 114305.04 80013.52799999999 3078 114305.04 13402.1223606 20428.48 22790.53 20428.48 13402.1223606 13402.1223606 13402.1223606 5377 20428.48 22471.328 20428.48 18216.003795 20428.48 20428.48 20837.0496 20428.48 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC MS-DRG 083 N/A 42419.97 29693.979 3078 42419.97 9828.3821094 12158.07 14259.63 12158.07 9828.3821094 9828.3821094 9828.3821094 5377 12158.07 13373.877 12158.07 13358.618955 12158.07 12158.07 12401.2314 12158.07 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC MS-DRG 084 N/A 45680.28 31976.195999999996 3078 45680.28 4578.1091736 8265 10243.94 8265 4578.1091736 4578.1091736 4578.1091736 5377 8265 9091.5 8265 6222.511019999999 8265 8265 8430.3 8265 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC MS-DRG 085 N/A 78235.03 54764.52099999999 3078 78235.03 12635.128041 21063.34 23445.42 21063.34 12635.128041 12635.128041 12635.128041 5377 21063.34 23169.674000000003 21063.34 17173.514325 21063.34 21063.34 21484.6068 21063.34 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC MS-DRG 086 N/A 17344.28 12140.996 3078 21349.82 8426.2019808 11720.69 13808.48 11720.69 8426.2019808 8426.2019808 8426.2019808 5377 11720.69 12892.759000000002 11720.69 11452.79256 11720.69 11720.69 11955.1038 11720.69 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC MS-DRG 087 N/A 9449.72 6614.803999999999 3078 15200.62 4434.372291 7867.3 9833.72 7867.3 4434.372291 4434.372291 4434.372291 5377 7867.3 8654.03 7867.3 6027.1455750000005 7867.3 7867.3 8024.646000000001 7867.3 DRG Hospital Inpatient Facility Fee DRG CONCUSSION WITH MCC MS-DRG 088 N/A 23268.73 16288.110999999999 3078 25330.34 10435.5362442 14215.07 16381.44 14215.07 10435.5362442 10435.5362442 10435.5362442 5377 14215.07 15636.577000000001 14215.07 14183.855565 14215.07 14215.07 14499.3714 14215.07 DRG Hospital Inpatient Facility Fee DRG CONCUSSION WITH CC MS-DRG 089 N/A 10637.67 7446.369 3078 19450.24 8305.7254236 10530.32 12580.62 10530.32 8305.7254236 8305.7254236 8305.7254236 5377 10530.32 11583.352 10530.32 11289.04227 10530.32 10530.32 10740.9264 10530.32 DRG Hospital Inpatient Facility Fee DRG CONCUSSION WITHOUT CC/MCC MS-DRG 090 N/A 18552.78 12986.945999999998 3078 18552.78 6131.1832079999995 7422.72 9375.14 7422.72 6131.1832079999995 6131.1832079999995 6131.1832079999995 5377 7422.72 8164.992000000001 7422.72 8333.4306 7422.72 7422.72 7571.174400000001 7422.72 DRG Hospital Inpatient Facility Fee DRG OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC MS-DRG 091 N/A 42379.15 29665.405 3078 42379.15 9540.9083442 15577.69 20772.9 15577.69 9540.9083442 9540.9083442 9540.9083442 5377 15577.69 17135.459000000003 15577.69 12967.888065 15577.69 15577.69 15889.2438 15577.69 DRG Hospital Inpatient Facility Fee DRG OTHER DISORDERS OF NERVOUS SYSTEM WITH CC MS-DRG 092 N/A 69961.81 48973.26699999999 2582.21 69961.81 6391.8181362000005 8966.6 10967.67 8966.6 6391.8181362000005 6391.8181362000005 6391.8181362000005 5377 8966.6 9863.260000000002 8966.6 8687.682465 8966.6 8966.6 9145.932 8966.6 DRG Hospital Inpatient Facility Fee DRG OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC MS-DRG 093 N/A 11645.16 8151.611999999999 3078 13652.17 4932.9782405999995 6896.97 8832.82 6896.97 4932.9782405999995 4932.9782405999995 4932.9782405999995 5377 6896.97 7586.667000000001 6896.97 6704.844794999999 6896.97 6896.97 7034.9094000000005 6896.97 DRG Hospital Inpatient Facility Fee DRG BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC MS-DRG 094 N/A 104786.07 73350.249 3078 104786.07 22652.574846599997 32225.82 34959.47 32225.82 22652.574846599997 22652.574846599997 22652.574846599997 5377 32225.82 35448.402 32225.82 30789.107744999998 32225.82 32225.82 32870.3364 32225.82 DRG Hospital Inpatient Facility Fee DRG BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC MS-DRG 095 N/A 67142.65 46999.854999999996 3078 67142.65 22490.945406 23057.22 25502.1 23057.22 22490.945406 22490.945406 22490.945406 5377 23057.22 25362.942000000003 23057.22 30569.42295 23057.22 23057.22 23518.364400000002 23057.22 DRG Hospital Inpatient Facility Fee DRG BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC MS-DRG 096 N/A 25580.4 17906.28 3078 35519.06 13052.621060999998 20599.82 22967.29 20599.82 13052.621060999998 13052.621060999998 13052.621060999998 5377 20599.82 22659.802000000003 20599.82 17740.965825 20599.82 20599.82 21011.8164 20599.82 DRG Hospital Inpatient Facility Fee DRG NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC MS-DRG 097 N/A 72623.85 50836.695 3078 72623.85 19897.1209146 35063.79 37886.8 35063.79 19897.1209146 19897.1209146 19897.1209146 5377 35063.79 38570.169 35063.79 27043.927845 35063.79 35063.79 35765.065800000004 35063.79 DRG Hospital Inpatient Facility Fee DRG NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC MS-DRG 098 N/A 16932.56 11852.792 3078 32639.45 12716.240970599998 18795.32 21105.95 18795.32 12716.240970599998 12716.240970599998 12716.240970599998 5377 18795.32 20674.852000000003 18795.32 17283.762045 18795.32 18795.32 19171.2264 18795.32 DRG Hospital Inpatient Facility Fee DRG NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC MS-DRG 099 N/A 108969 76278.29999999999 3078 108969 6752.6513892 12611.67 14727.53 12611.67 6752.6513892 6752.6513892 6752.6513892 5377 12611.67 13872.837000000001 12611.67 9178.12269 12611.67 12611.67 12863.903400000001 12611.67 DRG Hospital Inpatient Facility Fee DRG SEIZURES WITH MCC MS-DRG 100 N/A 27400.51 19180.356999999996 3078 30290.85 10827.979683 17323.58 19587.84 17323.58 10827.979683 10827.979683 10827.979683 5377 17323.58 19055.938000000002 17323.58 14717.259974999999 17323.58 17323.58 17670.051600000003 17323.58 DRG Hospital Inpatient Facility Fee DRG SEIZURES WITHOUT MCC MS-DRG 101 N/A 18120.55 12684.384999999998 3078 18120.55 4269.164338799999 8129.73 10104.43 8129.73 4269.164338799999 4269.164338799999 4269.164338799999 5377 8129.73 8942.703 8129.73 5802.59691 8129.73 8129.73 8292.3246 8129.73 DRG Hospital Inpatient Facility Fee DRG HEADACHES WITH MCC MS-DRG 102 N/A 65519.75 45863.825 3078 65519.75 7370.5410587999995 10369.8 12415.03 10369.8 7370.5410587999995 7370.5410587999995 7370.5410587999995 5377 10369.8 11406.78 10369.8 10017.95091 10369.8 10369.8 10577.196 10369.8 DRG Hospital Inpatient Facility Fee DRG HEADACHES WITHOUT MCC MS-DRG 103 N/A 9608.16 6725.7119999999995 3078 14626.44 5153.6531226 7507.49 9462.58 7507.49 5153.6531226 5153.6531226 5153.6531226 5377 7507.49 8258.239 7507.49 7004.783445 7507.49 7507.49 7657.6398 7507.49 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W CARD CATH MS-DRG 104 N/A 599559.59 419691.71299999993 72.18 599559.59 16969.3020072 299779.79 72.18 299779.79 16969.3020072 16969.3020072 16969.3020072 5377 299779.79 329757.76900000003 299779.79 23064.471540000002 299779.79 299779.79 305775.3858 299779.79 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE & OTH MAJOR CARDIOTHORACIC PROC W/O CARD CATH MS-DRG 105 N/A 372415.27 260690.68899999998 72.18 372415.27 2763.8037923999996 186207.64 72.18 186207.64 2763.8037923999996 2763.8037923999996 2763.8037923999996 5377 186207.64 204828.40400000004 186207.64 3756.52893 186207.64 186207.64 189931.79280000002 186207.64 DRG Hospital Inpatient Facility Fee DRG NO LONGER VALID MS-DRG 107 N/A 131788.55 92251.98499999999 72.18 131788.55 3118.6728594 65894.27 72.18 65894.27 3118.6728594 3118.6728594 3118.6728594 5377 65894.27 72483.69700000001 65894.27 4238.8627050000005 65894.27 65894.27 67212.1554 65894.27 DRG Hospital Inpatient Facility Fee DRG MAJOR CARDIOVASCULAR PROCEDURES W CC MS-DRG 110 N/A 85727.51 60009.25699999999 72.18 85727.51 80583.85939999999 42863.75 72.18 42863.75 0 0 0 5377 42863.75 47150.12500000001 42863.75 42863.75 42863.75 43721.025 42863.75 DRG Hospital Inpatient Facility Fee DRG NO LONGER VALID MS-DRG 112 N/A 137461.4 96222.98 72.18 137461.4 1932.396264 68730.7 72.18 68730.7 1932.396264 1932.396264 1932.396264 5377 68730.7 75603.77 68730.7 2626.4898 68730.7 68730.7 70105.314 68730.7 DRG Hospital Inpatient Facility Fee DRG ORBITAL PROCEDURES WITH CC/MCC MS-DRG 113 N/A 61669.39 43168.573 3078 61669.39 13506.4956156 20248.12 22604.48 20248.12 13506.4956156 13506.4956156 13506.4956156 5377 20248.12 22272.932 20248.12 18357.86667 20248.12 20248.12 20653.0824 20248.12 DRG Hospital Inpatient Facility Fee DRG ORBITAL PROCEDURES WITHOUT CC/MCC MS-DRG 114 N/A 135936.86 95155.80199999998 3078 135936.86 9617.8463436 11748.65 20755.09 11748.65 9617.8463436 9617.8463436 9617.8463436 5377 11748.65 12923.515000000001 11748.65 13072.46127 11748.65 11748.65 11983.623 11748.65 DRG Hospital Inpatient Facility Fee DRG EXTRAOCULAR PROCEDURES EXCEPT ORBIT MS-DRG 115 N/A 43891.64 30724.147999999997 3078 43891.64 10056.810433199998 13699.24 15849.35 13699.24 10056.810433199998 10056.810433199998 10056.810433199998 5377 13699.24 15069.164 13699.24 13669.09599 13699.24 13699.24 13973.2248 13699.24 DRG Hospital Inpatient Facility Fee DRG INTRAOCULAR PROCEDURES WITH CC/MCC MS-DRG 116 N/A 90656.69 63459.683 3078 90656.69 12489.005484 17012.46 19266.91 17012.46 12489.005484 12489.005484 12489.005484 5377 17012.46 18713.706000000002 17012.46 16974.9063 17012.46 17012.46 17352.7092 17012.46 DRG Hospital Inpatient Facility Fee DRG INTRAOCULAR PROCEDURES WITHOUT CC/MCC MS-DRG 117 N/A 15879.7 11115.789999999999 3078 16933.3 6572.532972 8953.07 10953.69 8953.07 6572.532972 6572.532972 6572.532972 5377 8953.07 9848.377 8953.07 8933.3079 8953.07 8953.07 9132.1314 8953.07 DRG Hospital Inpatient Facility Fee DRG OTHER CIRCULATORY SYSTEM O.R. PROCEDURES MS-DRG 120 N/A 122985.83 86090.08099999999 72.18 122985.83 4166.5803396 61492.92 72.18 61492.92 4166.5803396 4166.5803396 4166.5803396 5377 61492.92 67642.212 61492.92 5663.16597 61492.92 61492.92 62722.7784 61492.92 DRG Hospital Inpatient Facility Fee DRG ACUTE MAJOR EYE INFECTIONS WITH CC/MCC MS-DRG 121 N/A 12191 8533.699999999999 3078 20279.14 3447.2995079999996 11049.76 13116.4 11049.76 3447.2995079999996 3447.2995079999996 3447.2995079999996 5377 11049.76 12154.736 11049.76 4685.5280999999995 11049.76 11049.76 11270.7552 11049.76 DRG Hospital Inpatient Facility Fee DRG ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC MS-DRG 122 N/A 18895.27 13226.689 2457.8 18895.27 2200.1882154 6229.63 8144.48 6229.63 2200.1882154 2200.1882154 2200.1882154 5377 6229.63 6852.593000000001 6229.63 2990.469405 6229.63 6229.63 6354.2226 6229.63 DRG Hospital Inpatient Facility Fee DRG NEUROLOGICAL EYE DISORDERS MS-DRG 123 N/A 14805.58 10363.905999999999 3078 14805.58 5958.8182326 7158.49 9102.6 7158.49 5958.8182326 5958.8182326 5958.8182326 5377 7158.49 7874.339 7158.49 8099.154195 7158.49 7158.49 7301.659799999999 7158.49 DRG Hospital Inpatient Facility Fee DRG OTHER DISORDERS OF THE EYE WITH MCC MS-DRG 124 N/A 59999.06 41999.342 3078 59999.06 9273.116392799999 12631.51 14747.99 12631.51 9273.116392799999 9273.116392799999 9273.116392799999 5377 12631.51 13894.661000000002 12631.51 12603.908459999999 12631.51 12631.51 12884.1402 12631.51 DRG Hospital Inpatient Facility Fee DRG OTHER DISORDERS OF THE EYE WITHOUT MCC MS-DRG 125 N/A 10109.8 7076.859999999999 3078 15052.41 3663.2030411999995 7774.42 9737.92 7774.42 3663.2030411999995 3663.2030411999995 3663.2030411999995 5377 7774.42 8551.862000000001 7774.42 4978.981589999999 7774.42 7774.42 7929.9084 7774.42 DRG Hospital Inpatient Facility Fee DRG HEART FAILURE & SHOCK MS-DRG 127 N/A 23516.66 16461.662 72.18 23516.66 22105.660399999997 11758.33 72.18 11758.33 0 0 0 5377 11758.33 12934.163 11758.33 11758.33 11758.33 11993.4966 11758.33 DRG Hospital Inpatient Facility Fee DRG MAJOR HEAD & NECK PROCEDURES W CC/MCC OR MAJOR DEVICE MS-DRG 129 N/A 309506.05 216654.235 3078 309506.05 290935.687 154753.02 95835.4 154753.02 0 0 0 5377 154753.02 170228.32200000001 154753.02 154753.02 154753.02 157848.0804 154753.02 DRG Hospital Inpatient Facility Fee DRG MAJOR HEAD & NECK PROCEDURES W/O CC/MCC MS-DRG 130 N/A 87855.05 61498.534999999996 3078 87855.05 82583.747 43927.53 15165.65 43927.53 0 0 0 5377 43927.53 48320.283 43927.53 43927.53 43927.53 44806.0806 43927.53 DRG Hospital Inpatient Facility Fee DRG CRANIAL/FACIAL PROCEDURES W CC/MCC MS-DRG 131 N/A 134149.4 93904.57999999999 3078 134149.4 126100.43599999999 67074.7 26734.61 67074.7 0 0 0 5377 67074.7 73782.17 67074.7 67074.7 67074.7 68416.194 67074.7 DRG Hospital Inpatient Facility Fee DRG CRANIAL/FACIAL PROCEDURES W/O CC/MCC MS-DRG 132 N/A 40796.5 28557.55 3078 40796.5 38348.71 20398.25 16504.22 20398.25 0 0 0 5377 20398.25 22438.075 20398.25 20398.25 20398.25 20806.215 20398.25 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W CC/MCC MS-DRG 133 N/A 102274.35 71592.045 3078 102274.35 96137.889 51137.18 21689.17 51137.18 0 0 0 5377 51137.18 56250.89800000001 51137.18 51137.18 51137.18 52159.9236 51137.18 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH & THROAT O.R. PROCEDURES W/O CC/MCC MS-DRG 134 N/A 103520.1 72464.06999999999 3078 103520.1 97308.894 51760.05 12965.73 51760.05 0 0 0 5377 51760.05 56936.05500000001 51760.05 51760.05 51760.05 52795.251000000004 51760.05 DRG Hospital Inpatient Facility Fee DRG SINUS AND MASTOID PROCEDURES WITH CC/MCC MS-DRG 135 N/A 51204.11 35842.877 3078 51204.11 16224.375175799998 22100.41 24515.12 22100.41 16224.375175799998 16224.375175799998 16224.375175799998 5377 22100.41 24310.451 22100.41 22051.975935 22100.41 22100.41 22542.4182 22100.41 DRG Hospital Inpatient Facility Fee DRG SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC MS-DRG 136 N/A 67030.05 46921.034999999996 3078 67030.05 7681.2751493999995 10463.59 12511.8 10463.59 7681.2751493999995 7681.2751493999995 7681.2751493999995 5377 10463.59 11509.949 10463.59 10440.296955 10463.59 10463.59 10672.8618 10463.59 DRG Hospital Inpatient Facility Fee DRG MOUTH PROCEDURES WITH CC/MCC MS-DRG 137 N/A 27006.4 18904.48 3078 27006.4 7519.645708799999 13523.39 15667.97 13523.39 7519.645708799999 7519.645708799999 7519.645708799999 5377 13523.39 14875.729000000001 13523.39 10220.612159999999 13523.39 13523.39 13793.8578 13523.39 DRG Hospital Inpatient Facility Fee DRG MOUTH PROCEDURES WITHOUT CC/MCC MS-DRG 138 N/A 13103.7 9172.59 3078 15371.89 5854.4449776 7974.62 9944.42 7974.62 5854.4449776 5854.4449776 5854.4449776 5377 7974.62 8772.082 7974.62 7957.29132 7974.62 7974.62 8134.1124 7974.62 DRG Hospital Inpatient Facility Fee DRG SALIVARY GLAND PROCEDURES MS-DRG 139 N/A 30706.94 21494.857999999997 3078 30706.94 8324.810818799999 11340.14 13415.94 11340.14 8324.810818799999 8324.810818799999 8324.810818799999 5377 11340.14 12474.154 11340.14 11314.982909999999 11340.14 11340.14 11566.942799999999 11340.14 DRG Hospital Inpatient Facility Fee DRG MAJOR HEAD AND NECK PROCEDURES WITH MCC MS-DRG 140 N/A 184620.42 129234.294 3078 184620.42 3543.3229025999995 37481.51 46495.96 37481.51 3543.3229025999995 3543.3229025999995 3543.3229025999995 5377 37481.51 41229.66100000001 37481.51 4816.041945 37481.51 37481.51 38231.1402 37481.51 DRG Hospital Inpatient Facility Fee DRG MAJOR HEAD AND NECK PROCEDURES WITH CC MS-DRG 141 N/A 70160.27 49112.189 2793.42 70160.27 2494.8190038 20133.59 22486.39 20133.59 2494.8190038 2494.8190038 2494.8190038 5377 20133.59 22146.949 20133.59 3390.928035 20133.59 20133.59 20536.2618 20133.59 DRG Hospital Inpatient Facility Fee DRG MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC MS-DRG 142 N/A 55594.76 38916.332 1403.93 55594.76 11106.5071692 15345.93 17547.9 15345.93 11106.5071692 11106.5071692 11106.5071692 5377 15345.93 16880.523 15345.93 15095.83119 15345.93 15345.93 15652.848600000001 15345.93 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC MS-DRG 143 N/A 121135.93 84795.15099999998 3078 121135.93 9645.8780178 28610.51 31230.29 28610.51 9645.8780178 9645.8780178 9645.8780178 5377 28610.51 31471.561 28610.51 13110.561585 28610.51 28610.51 29182.7202 28610.51 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC MS-DRG 144 N/A 41631.4 29141.98 3078 41631.4 5638.5414444 16316.27 18548.81 16316.27 5638.5414444 5638.5414444 5638.5414444 5377 16316.27 17947.897 16316.27 7663.83783 16316.27 16316.27 16642.595400000002 16316.27 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 145 N/A 73916.87 51741.808999999994 2597.36 73916.87 2685.0765371999996 10891.94 12953.62 10891.94 2685.0765371999996 2685.0765371999996 2685.0765371999996 5377 10891.94 11981.134000000002 10891.94 3649.5237899999997 10891.94 10891.94 11109.7788 10891.94 DRG Hospital Inpatient Facility Fee DRG EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC MS-DRG 146 N/A 19339.55 13537.685 3078 31632.1 9158.007603 18164.06 20454.81 18164.06 9158.007603 9158.007603 9158.007603 5377 18164.06 19980.466000000004 18164.06 12447.453975 18164.06 18164.06 18527.341200000003 18164.06 DRG Hospital Inpatient Facility Fee DRG EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC MS-DRG 147 N/A 31769.64 22238.748 3078 31769.64 7204.1402694 10921.7 12984.35 10921.7 7204.1402694 7204.1402694 7204.1402694 5377 10921.7 12013.870000000003 10921.7 9791.780955 10921.7 10921.7 11140.134000000002 10921.7 DRG Hospital Inpatient Facility Fee DRG EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC MS-DRG 148 N/A 71835.45 50284.814999999995 3078 71835.45 5412.4987949999995 7373.12 9323.97 7373.12 5412.4987949999995 5412.4987949999995 5412.4987949999995 5377 7373.12 8110.432000000001 7373.12 7356.603375 7373.12 7373.12 7520.5824 7373.12 DRG Hospital Inpatient Facility Fee DRG DYSEQUILIBRIUM MS-DRG 149 N/A 18663.21 13064.247 3078 18663.21 4463.000383799999 6808.59 8741.67 6808.59 4463.000383799999 4463.000383799999 4463.000383799999 5377 6808.59 7489.4490000000005 6808.59 6066.056535 6808.59 6808.59 6944.7618 6808.59 DRG Hospital Inpatient Facility Fee DRG EPISTAXIS WITH MCC MS-DRG 150 N/A 33684.89 23579.423 3078 33684.89 9131.168765999999 12438.53 14548.94 12438.53 9131.168765999999 9131.168765999999 9131.168765999999 5377 12438.53 13682.383000000002 12438.53 12410.97495 12438.53 12438.53 12687.3006 12438.53 DRG Hospital Inpatient Facility Fee DRG EPISTAXIS WITHOUT MCC MS-DRG 151 N/A 11733.5 8213.449999999999 3063.87 13741.42 2960.0255118 6952.88 8890.51 6952.88 2960.0255118 2960.0255118 2960.0255118 5377 6952.88 7648.168000000001 6952.88 4023.231135 6952.88 6952.88 7091.9376 6952.88 DRG Hospital Inpatient Facility Fee DRG OTITIS MEDIA AND URI WITH MCC MS-DRG 152 N/A 15687.05 10980.935 3078 19881.97 4729.0030794 10800.86 12859.68 10800.86 4729.0030794 4729.0030794 4729.0030794 5377 10800.86 11880.946000000002 10800.86 6427.604205000001 10800.86 10800.86 11016.8772 10800.86 DRG Hospital Inpatient Facility Fee DRG OTITIS MEDIA AND URI WITHOUT MCC MS-DRG 153 N/A 9385.36 6569.752 3078 12582.97 2938.5544422 6226.93 8141.7 6226.93 2938.5544422 2938.5544422 2938.5544422 5377 6226.93 6849.6230000000005 6226.93 3994.047915 6226.93 6226.93 6351.4686 6226.93 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC MS-DRG 154 N/A 57331.51 40132.057 3078 57331.51 8436.341097 13553.15 15698.66 13553.15 8436.341097 8436.341097 8436.341097 5377 13553.15 14908.465 13553.15 11466.573525 13553.15 13553.15 13824.213 13553.15 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC MS-DRG 155 N/A 4914.15 3439.9049999999997 2237.67 15875.57 4226.2221996 8290.25 10270 8290.25 4226.2221996 4226.2221996 4226.2221996 5377 8290.25 9119.275000000001 8290.25 5744.2304699999995 8290.25 8290.25 8456.055 8290.25 DRG Hospital Inpatient Facility Fee DRG OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC MS-DRG 156 N/A 21886.08 15320.256 3078 21886.08 4030.5968987999995 6147.57 8059.82 6147.57 4030.5968987999995 4030.5968987999995 4030.5968987999995 5377 6147.57 6762.327 6147.57 5478.3389099999995 6147.57 6147.57 6270.5214 6147.57 DRG Hospital Inpatient Facility Fee DRG DENTAL AND ORAL DISEASES WITH MCC MS-DRG 157 N/A 21898 15328.599999999999 3078 26704.64 8992.2032322 15076.29 17269.77 15076.29 8992.2032322 8992.2032322 8992.2032322 5377 15076.29 16583.919 15076.29 12222.094665 15076.29 15076.29 15377.8158 15076.29 DRG Hospital Inpatient Facility Fee DRG DENTAL AND ORAL DISEASES WITH CC MS-DRG 158 N/A 9377.61 6564.327 2922.76 16016.6 3436.5639732 8378.62 10361.16 8378.62 3436.5639732 3436.5639732 3436.5639732 5377 8378.62 9216.482000000002 8378.62 4670.93649 8378.62 8378.62 8546.192400000002 8378.62 DRG Hospital Inpatient Facility Fee DRG DENTAL AND ORAL DISEASES WITHOUT CC/MCC MS-DRG 159 N/A 20242.3 14169.609999999999 3078 20242.3 3762.2085288 6762.6 8694.23 6762.6 3762.2085288 3762.2085288 3762.2085288 5377 6762.6 7438.860000000001 6762.6 5113.54866 6762.6 6762.6 6897.852000000001 6762.6 DRG Hospital Inpatient Facility Fee DRG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W CC MS-DRG 161 N/A 36517.42 25562.193999999996 72.18 36517.42 12279.0661368 18258.71 72.18 18258.71 12279.0661368 12279.0661368 12279.0661368 5377 18258.71 20084.581000000002 18258.71 16689.55926 18258.71 18258.71 18623.8842 18258.71 DRG Hospital Inpatient Facility Fee DRG INGUINAL & FEMORAL HERNIA PROCEDURES AGE >17 W/O CC MS-DRG 162 N/A 36511.34 25557.937999999995 72.18 36511.34 6982.2725502 18255.67 72.18 18255.67 6982.2725502 6982.2725502 6982.2725502 5377 18255.67 20081.237 18255.67 9490.221015000001 18255.67 18255.67 18620.7834 18255.67 DRG Hospital Inpatient Facility Fee DRG MAJOR CHEST PROCEDURES WITH MCC MS-DRG 163 N/A 460004.33 322003.031 3078 460004.33 27178.199183399996 43680.49 165655.47 43680.49 27178.199183399996 27178.199183399996 27178.199183399996 5377 43680.49 48048.539000000004 43680.49 36940.282004999994 43680.49 43680.49 44554.099799999996 43680.49 DRG Hospital Inpatient Facility Fee DRG MAJOR CHEST PROCEDURES WITH CC MS-DRG 164 N/A 53600.38 37520.265999999996 3078 53600.38 14996.349278400001 23290.79 25742.99 23290.79 14996.349278400001 14996.349278400001 14996.349278400001 5377 23290.79 25619.869000000002 23290.79 20382.85788 23290.79 23290.79 23756.6058 23290.79 DRG Hospital Inpatient Facility Fee DRG MAJOR CHEST PROCEDURES WITHOUT CC/MCC MS-DRG 165 N/A 27968.09 19577.663 3078 30375.76 10832.1546132 17376.78 19642.72 17376.78 10832.1546132 10832.1546132 10832.1546132 5377 17376.78 19114.458 17376.78 14722.93449 17376.78 17376.78 17724.315599999998 17376.78 DRG Hospital Inpatient Facility Fee DRG OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC MS-DRG 166 N/A 74854.15 52397.90499999999 3078 74854.15 23351.577445799998 33058.18 35818.06 33058.18 23351.577445799998 23351.577445799998 23351.577445799998 5377 33058.18 36363.99800000001 33058.18 31739.183684999996 33058.18 33058.18 33719.3436 33058.18 DRG Hospital Inpatient Facility Fee DRG OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC MS-DRG 167 N/A 40671.01 28469.707 3078 40671.01 14908.0793256 17144.12 19402.74 17144.12 14908.0793256 14908.0793256 14908.0793256 5377 17144.12 18858.532 17144.12 20262.882419999998 17144.12 17144.12 17487.002399999998 17144.12 DRG Hospital Inpatient Facility Fee DRG OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 168 N/A 26178.11 18324.677 3078 26178.11 10088.420618999999 12783.92 14905.21 12783.92 10088.420618999999 10088.420618999999 10088.420618999999 5377 12783.92 14062.312000000002 12783.92 13712.060175 12783.92 12783.92 13039.5984 12783.92 DRG Hospital Inpatient Facility Fee DRG MOUTH PROCEDURES W/O CC MS-DRG 169 N/A 47121.23 32984.861 72.18 47121.23 2792.4318851999997 23560.61 72.18 23560.61 2792.4318851999997 2792.4318851999997 2792.4318851999997 5377 23560.61 25916.671000000002 23560.61 3795.43989 23560.61 23560.61 24031.822200000002 23560.61 DRG Hospital Inpatient Facility Fee DRG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W CC MS-DRG 170 N/A 67376.1 47163.270000000004 72.18 67376.1 2647.5021653999997 33688.05 72.18 33688.05 2647.5021653999997 2647.5021653999997 2647.5021653999997 5377 33688.05 37056.855 33688.05 3598.453155 33688.05 33688.05 34361.811 33688.05 DRG Hospital Inpatient Facility Fee DRG DIGESTIVE MALIGNANCY W CC MS-DRG 172 N/A 65890.94 46123.657999999996 72.18 65890.94 2996.4070463999997 32945.47 72.18 32945.47 2996.4070463999997 2996.4070463999997 2996.4070463999997 5377 32945.47 36240.01700000001 32945.47 4072.6804799999995 32945.47 32945.47 33604.379400000005 32945.47 DRG Hospital Inpatient Facility Fee DRG G.I. HEMORRHAGE W CC MS-DRG 174 N/A 64468 45127.6 72.18 64468 2266.9870985999996 32234 72.18 32234 2266.9870985999996 2266.9870985999996 2266.9870985999996 5377 32234 35457.4 32234 3081.261645 32234 32234 32878.68 32234 DRG Hospital Inpatient Facility Fee DRG PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE MS-DRG 175 N/A 70940.07 49658.049 3078 70940.07 5976.710790599999 12596.34 14711.73 12596.34 5976.710790599999 5976.710790599999 5976.710790599999 5377 12596.34 13855.974000000002 12596.34 8123.473545 12596.34 12596.34 12848.266800000001 12596.34 DRG Hospital Inpatient Facility Fee DRG PULMONARY EMBOLISM WITHOUT MCC MS-DRG 176 N/A 23951.21 16765.846999999998 3078 23951.21 3817.07904 7373.12 9323.97 7373.12 3817.07904 3817.07904 3817.07904 5377 7373.12 8110.432000000001 7373.12 5188.128 7373.12 7373.12 7520.5824 7373.12 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC MS-DRG 177 N/A 101892.05 71324.435 3078 101892.05 7888.2324036 16051.14 40254.28 16051.14 7888.2324036 7888.2324036 7888.2324036 5377 16051.14 17656.254 16051.14 10721.590769999999 16051.14 16051.14 16372.1628 16051.14 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC MS-DRG 178 N/A 92444.06 64710.842 3078 92444.06 4508.3281974 9802.57 13708.91 9802.57 4508.3281974 4508.3281974 4508.3281974 5377 9802.57 10782.827000000001 9802.57 6127.665555 9802.57 9802.57 9998.6214 9802.57 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC MS-DRG 179 N/A 17529.5 12270.65 3078 17529.5 3673.9385759999996 7082.74 10382.07 7082.74 3673.9385759999996 3673.9385759999996 3673.9385759999996 5377 7082.74 7791.014 7082.74 4993.5732 7082.74 7082.74 7224.3948 7082.74 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY NEOPLASMS WITH MCC MS-DRG 180 N/A 24259.53 16981.671 3078 27022.68 8581.8672354 15275.59 17475.34 15275.59 8581.8672354 8581.8672354 8581.8672354 5377 15275.59 16803.149 15275.59 11664.370905 15275.59 15275.59 15581.1018 15275.59 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY NEOPLASMS WITH CC MS-DRG 181 N/A 32331.16 22631.811999999998 3078 32331.16 6736.548086999999 10223.71 12264.35 10223.71 6736.548086999999 6736.548086999999 6736.548086999999 5377 10223.71 11246.081 10223.71 9156.235275 10223.71 10223.71 10428.1842 10223.71 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY NEOPLASMS WITHOUT CC/MCC MS-DRG 182 N/A 32556.95 22789.864999999998 3078 32556.95 5875.319628599999 8003.47 9974.2 8003.47 5875.319628599999 5875.319628599999 5875.319628599999 5377 8003.47 8803.817000000001 8003.47 7985.663895 8003.47 8003.47 8163.539400000001 8003.47 DRG Hospital Inpatient Facility Fee DRG MAJOR CHEST TRAUMA WITH MCC MS-DRG 183 N/A 24075.55 16852.885 3078 24263.98 7557.220080599999 13546.84 15692.15 13546.84 7557.220080599999 7557.220080599999 7557.220080599999 5377 13546.84 14901.524000000001 13546.84 10271.682794999999 13546.84 13546.84 13817.7768 13546.84 DRG Hospital Inpatient Facility Fee DRG MAJOR CHEST TRAUMA WITH CC MS-DRG 184 N/A 9036.76 6325.732 3078 17687.36 5983.2713952 9425.61 11441.12 9425.61 5983.2713952 5983.2713952 5983.2713952 5377 9425.61 10368.171000000002 9425.61 8132.3906400000005 9425.61 9425.61 9614.122200000002 9425.61 DRG Hospital Inpatient Facility Fee DRG MAJOR CHEST TRAUMA WITHOUT CC/MCC MS-DRG 185 N/A 8862.05 6203.4349999999995 3078 13511.14 4717.0747074 6808.59 8741.67 6808.59 4717.0747074 4717.0747074 4717.0747074 5377 6808.59 7489.4490000000005 6808.59 6411.391305 6808.59 6808.59 6944.7618 6808.59 DRG Hospital Inpatient Facility Fee DRG PLEURAL EFFUSION WITH MCC MS-DRG 186 N/A 11978.95 8385.265 3078 24617.99 9839.7140628 13768.68 15920.98 13768.68 9839.7140628 9839.7140628 9839.7140628 5377 13768.68 15145.548 13768.68 13374.021209999999 13768.68 13768.68 14044.053600000001 13768.68 DRG Hospital Inpatient Facility Fee DRG PLEURAL EFFUSION WITH CC MS-DRG 187 N/A 14085.28 9859.696 3078 17697.42 5526.4147476 9431.93 11447.61 9431.93 5526.4147476 5526.4147476 5526.4147476 5377 9431.93 10375.123000000001 9431.93 7511.43657 9431.93 9431.93 9620.5686 9431.93 DRG Hospital Inpatient Facility Fee DRG PLEURAL EFFUSION WITHOUT CC/MCC MS-DRG 188 N/A 24224.73 16957.310999999998 2187.45 24224.73 4055.0500613999993 6529.03 8453.31 6529.03 4055.0500613999993 4055.0500613999993 4055.0500613999993 5377 6529.03 7181.933 6529.03 5511.575354999999 6529.03 6529.03 6659.6106 6529.03 DRG Hospital Inpatient Facility Fee DRG PULMONARY EDEMA AND RESPIRATORY FAILURE MS-DRG 189 N/A 57631.06 40341.742 3078 57631.06 5015.880426 10884.73 12946.2 10884.73 5015.880426 5015.880426 5015.880426 5377 10884.73 11973.203000000001 10884.73 6817.52445 10884.73 10884.73 11102.4246 10884.73 DRG Hospital Inpatient Facility Fee DRG CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC MS-DRG 190 N/A 55747.55 39023.284999999996 3078 55747.55 5234.7660522 9789.04 11816.01 9789.04 5234.7660522 5234.7660522 5234.7660522 5377 9789.04 10767.944000000001 9789.04 7115.031165 9789.04 9789.04 9984.820800000001 9789.04 DRG Hospital Inpatient Facility Fee DRG CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC MS-DRG 191 N/A 16260.22 11382.153999999999 3078 16260.22 4814.8873578 7793.36 9757.45 7793.36 4814.8873578 4814.8873578 4814.8873578 5377 7793.36 8572.696 7793.36 6544.337085 7793.36 7793.36 7949.227199999999 7793.36 DRG Hospital Inpatient Facility Fee DRG CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC MS-DRG 192 N/A 7549.4 5284.579999999999 2702.07 12030.32 3703.759506 5880.64 7784.49 5880.64 3703.759506 3703.759506 3703.759506 5377 5880.64 6468.704000000001 5880.64 5034.10545 5880.64 5880.64 5998.2528 5880.64 DRG Hospital Inpatient Facility Fee DRG SIMPLE PNEUMONIA AND PLEURISY WITH MCC MS-DRG 193 N/A 13356.75 9349.724999999999 3078 21335.47 6602.353902 11711.68 13799.21 11711.68 6602.353902 6602.353902 6602.353902 5377 11711.68 12882.848000000002 11711.68 8973.84015 11711.68 11711.68 11945.9136 11711.68 DRG Hospital Inpatient Facility Fee DRG SIMPLE PNEUMONIA AND PLEURISY WITH CC MS-DRG 194 N/A 15774.01 11041.806999999999 3078 15774.01 4523.835080999999 7576.92 9534.21 7576.92 4523.835080999999 4523.835080999999 4523.835080999999 5377 7576.92 8334.612000000001 7576.92 6148.742324999999 7576.92 7576.92 7728.4584 7576.92 DRG Hospital Inpatient Facility Fee DRG SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC MS-DRG 195 N/A 16003.7 11202.59 3057.45 16003.7 3396.6039269999997 5787.75 7688.68 5787.75 3396.6039269999997 3396.6039269999997 3396.6039269999997 5377 5787.75 6366.525000000001 5787.75 4616.623275 5787.75 5787.75 5903.505 5787.75 DRG Hospital Inpatient Facility Fee DRG INTERSTITIAL LUNG DISEASE WITH MCC MS-DRG 196 N/A 37074 25951.8 3078 37074 14723.7859782 15670.58 17882.8 15670.58 14723.7859782 14723.7859782 14723.7859782 5377 15670.58 17237.638000000003 15670.58 20012.393115 15670.58 15670.58 15983.9916 15670.58 DRG Hospital Inpatient Facility Fee DRG INTERSTITIAL LUNG DISEASE WITH CC MS-DRG 197 N/A 296166.91 207316.83699999997 3078 296166.91 5074.925867399999 8870.11 87830.69 8870.11 5074.925867399999 5074.925867399999 5074.925867399999 5377 8870.11 9757.121000000001 8870.11 6897.778305 8870.11 8870.11 9047.512200000001 8870.11 DRG Hospital Inpatient Facility Fee DRG INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC MS-DRG 198 N/A 148872 104210.4 3078 148872 4817.8694508 6410.9 25141.38 6410.9 4817.8694508 4817.8694508 4817.8694508 5377 6410.9 7051.99 6410.9 6548.39031 6410.9 6410.9 6539.1179999999995 6410.9 DRG Hospital Inpatient Facility Fee DRG PNEUMOTHORAX WITH MCC MS-DRG 199 N/A 105155.52 73608.864 2835.98 105155.52 7077.6995262 15859.05 18077.19 15859.05 7077.6995262 7077.6995262 7077.6995262 5377 15859.05 17444.955 15859.05 9619.924215000001 15859.05 15859.05 16176.231 15859.05 DRG Hospital Inpatient Facility Fee DRG PNEUMOTHORAX WITH CC MS-DRG 200 N/A 34351.7 24046.189999999995 3078 34351.7 4942.520938199999 9667.3 11690.42 9667.3 4942.520938199999 4942.520938199999 4942.520938199999 5377 9667.3 10634.03 9667.3 6717.815114999999 9667.3 9667.3 9860.645999999999 9667.3 DRG Hospital Inpatient Facility Fee DRG PNEUMOTHORAX WITHOUT CC/MCC MS-DRG 201 N/A 72758.3 50930.81 2033.48 72758.3 3074.5378829999995 6564.2 8489.58 6564.2 3074.5378829999995 3074.5378829999995 3074.5378829999995 5377 6564.2 7220.620000000001 6564.2 4178.874975 6564.2 6564.2 6695.484 6564.2 DRG Hospital Inpatient Facility Fee DRG BRONCHITIS AND ASTHMA WITH CC/MCC MS-DRG 202 N/A 16607.12 11624.983999999999 3078 16607.12 4293.6175014 8348.86 10330.47 8348.86 4293.6175014 4293.6175014 4293.6175014 5377 8348.86 9183.746000000001 8348.86 5835.833355 8348.86 8348.86 8515.8372 8348.86 DRG Hospital Inpatient Facility Fee DRG BRONCHITIS AND ASTHMA WITHOUT CC/MCC MS-DRG 203 N/A 15625.5 10937.849999999999 2805.38 15625.5 2951.0792327999998 6015.91 7924.02 6015.91 2951.0792327999998 2951.0792327999998 2951.0792327999998 5377 6015.91 6617.501 6015.91 4011.07146 6015.91 6015.91 6136.2282 6015.91 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY SIGNS AND SYMPTOMS MS-DRG 204 N/A 9717.38 6802.165999999999 3078 14294 2501.3796084 7299.17 9247.7 7299.17 2501.3796084 2501.3796084 2501.3796084 5377 7299.17 8029.087 7299.17 3399.8451299999997 7299.17 7299.17 7445.1534 7299.17 DRG Hospital Inpatient Facility Fee DRG OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC MS-DRG 205 N/A 75362.47 52753.729 3078 75362.47 8943.296907 16061.06 18285.56 16061.06 8943.296907 8943.296907 8943.296907 5377 16061.06 17667.166 16061.06 12155.621775 16061.06 16061.06 16382.2812 16061.06 DRG Hospital Inpatient Facility Fee DRG OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC MS-DRG 206 N/A 27310.39 19117.272999999997 3078 27310.39 3221.8532772 8056.68 10029.06 8056.68 3221.8532772 3221.8532772 3221.8532772 5377 8056.68 8862.348000000002 8056.68 4379.10429 8056.68 8056.68 8217.813600000001 8056.68 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS MS-DRG 207 N/A 557980.25 390586.175 3078 557980.25 48080.285439 59211.28 237770.51 59211.28 48080.285439 48080.285439 48080.285439 5377 59211.28 65132.408 59211.28 65350.146675 59211.28 59211.28 60395.5056 59211.28 DRG Hospital Inpatient Facility Fee DRG RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS MS-DRG 208 N/A 68978.3 48284.81 3078 68978.3 17170.891494 23447.7 25904.87 23447.7 17170.891494 17170.891494 17170.891494 5377 23447.7 25792.47 23447.7 23338.469549999998 23447.7 23447.7 23916.654000000002 23447.7 DRG Hospital Inpatient Facility Fee DRG NO LONGER VALID MS-DRG 209 N/A 64271.35 44989.945 72.18 64271.35 1977.127659 32135.67 72.18 32135.67 1977.127659 1977.127659 1977.127659 5377 32135.67 35349.237 32135.67 2687.288175 32135.67 32135.67 32778.3834 32135.67 DRG Hospital Inpatient Facility Fee DRG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC MS-DRG 210 N/A 45267.84 31687.487999999994 72.18 45267.84 4166.5803396 22633.92 72.18 22633.92 4166.5803396 4166.5803396 4166.5803396 5377 22633.92 24897.312 22633.92 5663.16597 22633.92 22633.92 23086.5984 22633.92 DRG Hospital Inpatient Facility Fee DRG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/O CC MS-DRG 211 N/A 48910.1 34237.07 72.18 48910.1 3917.2773648 24455.05 72.18 24455.05 3917.2773648 3917.2773648 3917.2773648 5377 24455.05 26900.555 24455.05 5324.316360000001 24455.05 24455.05 24944.150999999998 24455.05 DRG Hospital Inpatient Facility Fee DRG HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT AGE 0-17 MS-DRG 212 N/A 148868.05 104207.63499999998 72.18 148868.05 4620.4548942 74434.02 72.18 74434.02 4620.4548942 4620.4548942 4620.4548942 5377 74434.02 81877.422 74434.02 6280.066815 74434.02 74434.02 75922.7004 74434.02 DRG Hospital Inpatient Facility Fee DRG AMPUTATION FOR MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS MS-DRG 213 N/A 382425.6 267697.92 72.18 382425.6 7701.5533817999985 191212.8 72.18 191212.8 7701.5533817999985 7701.5533817999985 7701.5533817999985 5377 191212.8 210334.08000000002 191212.8 10467.858885 191212.8 191212.8 195037.05599999998 191212.8 DRG Hospital Inpatient Facility Fee DRG NO LONGER VALID MS-DRG 214 N/A 68145.15 47701.604999999996 72.18 68145.15 3599.386251 34072.57 72.18 34072.57 3599.386251 3599.386251 3599.386251 5377 34072.57 37479.827000000005 34072.57 4892.242575 34072.57 34072.57 34754.0214 34072.57 DRG Hospital Inpatient Facility Fee DRG OTHER HEART ASSIST SYSTEM IMPLANT MS-DRG 215 N/A 335128.6 234590.01999999996 3078 335128.6 52713.861542399995 92914.26 121215.17 92914.26 52713.861542399995 52713.861542399995 52713.861542399995 5377 92914.26 102205.686 92914.26 71648.04768 92914.26 92914.26 94772.5452 92914.26 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC MS-DRG 216 N/A 303808.65 212666.055 3078 303808.65 75065.8414146 87852.45 106970.79 87852.45 75065.8414146 75065.8414146 75065.8414146 5377 87852.45 96637.695 87852.45 102028.590345 87852.45 87852.45 89609.499 87852.45 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC MS-DRG 217 N/A 162028.05 113419.63499999998 3078 162028.05 39830.0269452 57253.48 60775.38 57253.48 39830.0269452 39830.0269452 39830.0269452 5377 57253.48 62978.82800000001 57253.48 54136.49439 57253.48 57253.48 58398.549600000006 57253.48 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC MS-DRG 218 N/A 52475.89 36733.123 3078 88108.83 39315.914112 53555.2 56960.62 53555.2 39315.914112 39315.914112 39315.914112 5377 53555.2 58910.72 53555.2 53437.7184 53555.2 53555.2 54626.304 53555.2 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC MS-DRG 219 N/A 302432.06 211702.44199999998 3078 302432.06 42153.6738108 73301.01 103457.67 73301.01 42153.6738108 42153.6738108 42153.6738108 5377 73301.01 80631.111 73301.01 57294.76731 73301.01 73301.01 74767.0302 73301.01 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC MS-DRG 220 N/A 111085.61 77759.927 3078 111085.61 30847.3664106 49013.73 52276.12 49013.73 30847.3664106 30847.3664106 30847.3664106 5377 49013.73 53915.10300000001 49013.73 41927.370045 49013.73 49013.73 49994.00460000001 49013.73 DRG Hospital Inpatient Facility Fee DRG CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC MS-DRG 221 N/A 129859.38 90901.56599999999 3078 129859.38 27627.3023892 42669.57 45732.13 42669.57 27627.3023892 27627.3023892 27627.3023892 5377 42669.57 46936.527 42669.57 37550.69769 42669.57 42669.57 43522.9614 42669.57 DRG Hospital Inpatient Facility Fee DRG CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI, HF OR SHOCK WITH MCC MS-DRG 222 N/A 159375.1 111562.56999999999 3078 159375.1 44203.564539 69047.22 72940.58 69047.22 44203.564539 44203.564539 44203.564539 5377 69047.22 75951.94200000001 69047.22 60080.954175 69047.22 69047.22 70428.16440000001 69047.22 DRG Hospital Inpatient Facility Fee DRG CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI, HF OR SHOCK WITHOUT MCC MS-DRG 223 N/A 290106.23 203074.36099999998 3078 290106.23 34549.3366608 47062.23 92966.6 47062.23 34549.3366608 34549.3366608 34549.3366608 5377 47062.23 51768.45300000001 47062.23 46959.04356 47062.23 47062.23 48003.4746 47062.23 DRG Hospital Inpatient Facility Fee DRG CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI, HF OR SHOCK WITH MCC MS-DRG 224 N/A 35291.23 24703.861 3078 104665.5 42324.2495304 63930.41 67662.63 63930.41 42324.2495304 42324.2495304 42324.2495304 5377 63930.41 70323.45100000002 63930.41 57526.61178 63930.41 63930.41 65209.018200000006 63930.41 DRG Hospital Inpatient Facility Fee DRG CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI, HF OR SHOCK WITHOUT MCC MS-DRG 225 N/A 165498.01 115848.607 3078 165498.01 27441.219785999998 45610.33 48765.54 45610.33 27441.219785999998 27441.219785999998 27441.219785999998 5377 45610.33 50171.363000000005 45610.33 37297.77645 45610.33 45610.33 46522.5366 45610.33 DRG Hospital Inpatient Facility Fee DRG CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC MS-DRG 226 N/A 197034.5 137924.15 3078 197034.5 33500.832762 57723.32 61260.02 57723.32 33500.832762 33500.832762 33500.832762 5377 57723.32 63495.652 57723.32 45533.92965 57723.32 57723.32 58877.7864 57723.32 DRG Hospital Inpatient Facility Fee DRG CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC MS-DRG 227 N/A 125713.88 87999.716 3078 125713.88 24819.960039 45276.67 48421.36 45276.67 24819.960039 24819.960039 24819.960039 5377 45276.67 49804.337 45276.67 33734.991675 45276.67 45276.67 46182.2034 45276.67 DRG Hospital Inpatient Facility Fee DRG OTHER CARDIOTHORACIC PROCEDURES WITH MCC MS-DRG 228 N/A 99958.54 69970.97799999999 3078 99958.54 37267.81263959999 44443.41 47561.86 44443.41 37267.81263959999 37267.81263959999 37267.81263959999 5377 44443.41 48887.75100000001 44443.41 50653.963469999995 44443.41 44443.41 45332.27820000001 44443.41 DRG Hospital Inpatient Facility Fee DRG OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC MS-DRG 229 N/A 91193.2 63835.23999999999 3078 91193.2 24357.735623999997 29767.52 32423.72 29767.52 24357.735623999997 24357.735623999997 24357.735623999997 5377 29767.52 32744.272000000004 29767.52 33106.741799999996 29767.52 29767.52 30362.8704 29767.52 DRG Hospital Inpatient Facility Fee DRG OTHER CARDIOTHORACIC PROCEDURES W/O CC/MCC MS-DRG 230 N/A 288760.15 202132.105 3078 288760.15 271434.541 144380.08 90732.26 144380.08 0 0 0 5377 144380.08 158818.088 144380.08 144380.08 144380.08 147267.68159999998 144380.08 DRG Hospital Inpatient Facility Fee DRG CORONARY BYPASS WITH PTCA WITH MCC MS-DRG 231 N/A 312560.3 218792.21 3078 312560.3 62575.046674799996 75689.88 108215.53 75689.88 62575.046674799996 62575.046674799996 62575.046674799996 5377 75689.88 83258.86800000002 75689.88 85051.25211 75689.88 75689.88 77203.67760000001 75689.88 DRG Hospital Inpatient Facility Fee DRG CORONARY BYPASS WITH PTCA WITHOUT MCC MS-DRG 232 N/A 194247.61 135973.327 3078 194247.61 38780.3302092 52825.64 56208.09 52825.64 38780.3302092 38780.3302092 38780.3302092 5377 52825.64 58108.204000000005 52825.64 52709.75919 52825.64 52825.64 53882.1528 52825.64 DRG Hospital Inpatient Facility Fee DRG CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC MS-DRG 233 N/A 215419.13 150793.391 3078 215419.13 46545.7003812 69843.51 73761.98 69843.51 46545.7003812 46545.7003812 46545.7003812 5377 69843.51 76827.861 69843.51 63264.35709 69843.51 69843.51 71240.3802 69843.51 DRG Hospital Inpatient Facility Fee DRG CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC MS-DRG 234 N/A 151346.44 105942.508 3078 151346.44 36536.0070174 46770.05 49961.8 46770.05 36536.0070174 36536.0070174 36536.0070174 5377 46770.05 51447.05500000001 46770.05 49659.30205499999 46770.05 46770.05 47705.451 46770.05 DRG Hospital Inpatient Facility Fee DRG CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC MS-DRG 235 N/A 120412.94 84289.05799999999 3078 120412.94 37159.2644544 54017.82 57437.82 54017.82 37159.2644544 37159.2644544 37159.2644544 5377 54017.82 59419.602000000006 54017.82 50506.426080000005 54017.82 54017.82 55098.176400000004 54017.82 DRG Hospital Inpatient Facility Fee DRG CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC MS-DRG 236 N/A 99681.47 69777.029 3078 99681.47 30330.271484399997 36779.01 39656.06 36779.01 30330.271484399997 30330.271484399997 30330.271484399997 5377 36779.01 40456.91100000001 36779.01 41224.54083 36779.01 36779.01 37514.590200000006 36779.01 DRG Hospital Inpatient Facility Fee DRG MAJOR CARDIOVASC PROCEDURES W MCC MS-DRG 237 N/A 715523.45 500866.4149999999 3078 715523.45 672592.043 357761.72 272350.56 357761.72 0 0 0 5377 357761.72 393537.892 357761.72 357761.72 357761.72 364916.9544 357761.72 DRG Hospital Inpatient Facility Fee DRG MAJOR CARDIOVASC PROCEDURES W/O MCC MS-DRG 238 N/A 300874.7 210612.29 3078 300874.7 282822.218 150437.35 94252.78 150437.35 0 0 0 5377 150437.35 165481.08500000002 150437.35 150437.35 150437.35 153446.097 150437.35 DRG Hospital Inpatient Facility Fee DRG AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC MS-DRG 239 N/A 195923 137146.1 3078 195923 24174.6351138 41934.6 52165.54 41934.6 24174.6351138 24174.6351138 24174.6351138 5377 41934.6 46128.060000000005 41934.6 32857.873785 41934.6 41934.6 42773.292 41934.6 DRG Hospital Inpatient Facility Fee DRG AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC MS-DRG 240 N/A 51095.05 35766.534999999996 3078 51095.05 17597.330792999997 24476.66 26966.21 24476.66 17597.330792999997 17597.330792999997 17597.330792999997 5377 24476.66 26924.326 24476.66 23918.080725 24476.66 24476.66 24966.1932 24476.66 DRG Hospital Inpatient Facility Fee DRG AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC MS-DRG 241 N/A 68296.07 47807.249 3078 68296.07 10254.2249898 13967.98 16126.57 13967.98 10254.2249898 10254.2249898 10254.2249898 5377 13967.98 15364.778 13967.98 13937.419485 13967.98 13967.98 14247.3396 13967.98 DRG Hospital Inpatient Facility Fee DRG PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC MS-DRG 242 N/A 165390.68 115773.47599999998 3078 165390.68 16318.609314599998 31324.03 37135.75 31324.03 16318.609314599998 16318.609314599998 16318.609314599998 5377 31324.03 34456.433000000005 31324.03 22180.057845 31324.03 31324.03 31950.510599999998 31324.03 DRG Hospital Inpatient Facility Fee DRG PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC MS-DRG 243 N/A 59612.99 41729.09299999999 3078 59612.99 15700.1232264 21138.19 23522.6 21138.19 15700.1232264 15700.1232264 15700.1232264 5377 21138.19 23252.009000000002 21138.19 21339.41898 21138.19 21138.19 21560.9538 21138.19 DRG Hospital Inpatient Facility Fee DRG PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC MS-DRG 244 N/A 69413.85 48589.695 3078 69413.85 14977.2638832 17144.12 19402.74 17144.12 14977.2638832 14977.2638832 14977.2638832 5377 17144.12 18858.532 17144.12 20356.91724 17144.12 17144.12 17487.002399999998 17144.12 DRG Hospital Inpatient Facility Fee DRG AICD GENERATOR PROCEDURES MS-DRG 245 N/A 97360.51 68152.35699999999 3078 97360.51 32280.5603064 43971.77 47075.36 43971.77 32280.5603064 32280.5603064 32280.5603064 5377 43971.77 48368.947 43971.77 43875.34998 43971.77 43971.77 44851.2054 43971.77 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS MS-DRG 246 N/A 251843.09 176290.163 3078 251843.09 19365.711941999998 27012.52 72770.72 27012.52 19365.711941999998 19365.711941999998 19365.711941999998 5377 27012.52 29713.772000000004 27012.52 26321.64315 27012.52 27012.52 27552.7704 27012.52 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC MS-DRG 247 N/A 71973.82 50381.674 3078 71973.82 14713.050443399998 17219.87 19480.87 17219.87 14713.050443399998 14713.050443399998 14713.050443399998 5377 17219.87 18941.857 17219.87 19997.801505 17219.87 17219.87 17564.2674 17219.87 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS MS-DRG 248 N/A 99454.8 69618.36 3078 99454.8 19925.749007399998 27142.38 29715.89 27142.38 19925.749007399998 19925.749007399998 19925.749007399998 5377 27142.38 29856.618000000002 27142.38 27082.838805 27142.38 27142.38 27685.227600000002 27142.38 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC MS-DRG 249 N/A 120263.5 84184.45 3078 120263.5 17194.748238 16383 18617.64 16383 17194.748238 17194.748238 17194.748238 5377 16383 18021.300000000003 16383 23370.89535 16383 16383 16710.66 16383 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC MS-DRG 250 N/A 124284.85 86999.395 3078 124284.85 14865.1371864 21820.85 28409.4 21820.85 14865.1371864 14865.1371864 14865.1371864 5377 21820.85 24002.935 21820.85 20204.51598 21820.85 21820.85 22257.267 21820.85 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITHOUT MCC MS-DRG 251 N/A 92078.6 64455.02 3078 92078.6 13789.7944506 14656.96 16837.25 14656.96 13789.7944506 13789.7944506 13789.7944506 5377 14656.96 16122.656 14656.96 18742.923045 14656.96 14656.96 14950.099199999999 14656.96 DRG Hospital Inpatient Facility Fee DRG OTHER VASCULAR PROCEDURES WITH MCC MS-DRG 252 N/A 123233.8 86263.66 3078 123233.8 24827.713480799997 30149.88 32818.14 30149.88 24827.713480799997 24827.713480799997 24827.713480799997 5377 30149.88 33164.868 30149.88 33745.53006 30149.88 30149.88 30752.8776 30149.88 DRG Hospital Inpatient Facility Fee DRG OTHER VASCULAR PROCEDURES WITH CC MS-DRG 253 N/A 118251.75 82776.22499999999 3078 118251.75 16468.9068018 24114.13 26592.28 24114.13 16468.9068018 16468.9068018 16468.9068018 5377 24114.13 26525.543 24114.13 22384.340385 24114.13 24114.13 24596.4126 24114.13 DRG Hospital Inpatient Facility Fee DRG OTHER VASCULAR PROCEDURES WITHOUT CC/MCC MS-DRG 254 N/A 49571.69 34700.183 3078 49571.69 12120.418789199999 16489.41 18727.42 16489.41 12120.418789199999 12120.418789199999 12120.418789199999 5377 16489.41 18138.351000000002 16489.41 16473.92769 16489.41 16489.41 16819.1982 16489.41 DRG Hospital Inpatient Facility Fee DRG UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC MS-DRG 255 N/A 37721.69 26405.183 3078 39567.19 16984.8088908 23136.58 25583.95 23136.58 16984.8088908 16984.8088908 16984.8088908 5377 23136.58 25450.238000000005 23136.58 23085.54831 23136.58 23136.58 23599.3116 23136.58 DRG Hospital Inpatient Facility Fee DRG UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC MS-DRG 256 N/A 41018.55 28712.985 3078 41018.55 10805.3157762 14719.18 16901.43 14719.18 10805.3157762 10805.3157762 10805.3157762 5377 14719.18 16191.098000000002 14719.18 14686.455465000001 14719.18 14719.18 15013.563600000001 14719.18 DRG Hospital Inpatient Facility Fee DRG UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC MS-DRG 257 N/A 36216.63 25351.640999999996 3078 36216.63 6942.908922599999 9457.18 11473.7 9457.18 6942.908922599999 6942.908922599999 6942.908922599999 5377 9457.18 10402.898000000001 9457.18 9436.718444999999 9457.18 9457.18 9646.3236 9457.18 DRG Hospital Inpatient Facility Fee DRG CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC MS-DRG 258 N/A 66366.35 46456.445 3078 66366.35 18876.052271399996 25713.02 33170.2 25713.02 18876.052271399996 18876.052271399996 18876.052271399996 5377 25713.02 28284.322000000004 25713.02 25656.103604999997 25713.02 25713.02 26227.2804 25713.02 DRG Hospital Inpatient Facility Fee DRG CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC MS-DRG 259 N/A 58252.65 40776.854999999996 3078 58252.65 13201.725710999997 17982.79 20267.82 17982.79 13201.725710999997 13201.725710999997 13201.725710999997 5377 17982.79 19781.069000000003 17982.79 17943.627074999997 17982.79 17982.79 18342.4458 17982.79 DRG Hospital Inpatient Facility Fee DRG CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC MS-DRG 260 N/A 112219.86 78553.902 3078 112219.86 24147.7962768 31550.37 34262.74 31550.37 24147.7962768 24147.7962768 24147.7962768 5377 31550.37 34705.407 31550.37 32821.394759999996 31550.37 31550.37 32181.3774 31550.37 DRG Hospital Inpatient Facility Fee DRG CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC MS-DRG 261 N/A 50271.86 35190.301999999996 3078 50271.86 8826.398861399999 17231.59 19492.98 17231.59 8826.398861399999 8826.398861399999 8826.398861399999 5377 17231.59 18954.749000000003 17231.59 11996.735354999999 17231.59 17231.59 17576.2218 17231.59 DRG Hospital Inpatient Facility Fee DRG CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC MS-DRG 262 N/A 65578.62 45905.03399999999 3078 65578.62 11179.2702384 15121.38 17316.29 15121.38 11179.2702384 11179.2702384 11179.2702384 5377 15121.38 16633.518 15121.38 15194.72988 15121.38 15121.38 15423.8076 15121.38 DRG Hospital Inpatient Facility Fee DRG VEIN LIGATION AND STRIPPING MS-DRG 263 N/A 114668.35 80267.845 3078 114668.35 18444.245205 25124.15 27634.11 25124.15 18444.245205 18444.245205 18444.245205 5377 25124.15 27636.565000000002 25124.15 25069.196624999997 25124.15 25124.15 25626.633 25124.15 DRG Hospital Inpatient Facility Fee DRG OTHER CIRCULATORY SYSTEM O.R. PROCEDURES MS-DRG 264 N/A 49580.14 34706.098 3078 50275.37 20417.7943524 29846.87 32505.57 29846.87 20417.7943524 20417.7943524 20417.7943524 5377 29846.87 32831.557 29846.87 27751.62093 29846.87 29846.87 30443.807399999998 29846.87 DRG Hospital Inpatient Facility Fee DRG AICD LEAD PROCEDURES MS-DRG 265 N/A 97365.4 68155.78 3078 97365.4 22390.1506626 30499.78 33179.06 30499.78 22390.1506626 22390.1506626 22390.1506626 5377 30499.78 33549.758 30499.78 30432.423945000002 30499.78 30499.78 31109.7756 30499.78 DRG Hospital Inpatient Facility Fee DRG ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC MS-DRG 266 N/A 187383.61 131168.52699999997 3078 187383.61 39902.193595799996 59525.11 63118.58 59525.11 39902.193595799996 39902.193595799996 39902.193595799996 5377 59525.11 65477.62100000001 59525.11 54234.582435 59525.11 59525.11 60715.6122 59525.11 DRG Hospital Inpatient Facility Fee DRG ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC MS-DRG 267 N/A 166713.8 116699.65999999999 3078 166713.8 2670.7624908 46538.29 49722.73 46538.29 2670.7624908 2670.7624908 2670.7624908 5377 46538.29 51192.119000000006 46538.29 3630.0683099999997 46538.29 46538.29 47469.0558 46538.29 DRG Hospital Inpatient Facility Fee DRG AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC MS-DRG 268 N/A 540754.16 378527.912 3078 540754.16 10771.319916 62411.77 201892.82 62411.77 10771.319916 10771.319916 10771.319916 5377 62411.77 68652.947 62411.77 14640.2487 62411.77 62411.77 63660.005399999995 62411.77 DRG Hospital Inpatient Facility Fee DRG AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC MS-DRG 269 N/A 209018.27 146312.789 2691.02 209018.27 4427.215267799999 38563.67 57015.71 38563.67 4427.215267799999 4427.215267799999 4427.215267799999 5377 38563.67 42420.037000000004 38563.67 6017.417834999999 38563.67 38563.67 39334.9434 38563.67 DRG Hospital Inpatient Facility Fee DRG OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC MS-DRG 270 N/A 97783.91 68448.737 1716.55 97783.91 1414.7049192 46105.43 49276.22 46105.43 1414.7049192 1414.7049192 1414.7049192 5377 46105.43 50715.973000000005 46105.43 1922.8499399999998 46105.43 46105.43 47027.5386 46105.43 DRG Hospital Inpatient Facility Fee DRG OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC MS-DRG 271 N/A 129608.65 90726.055 3078 129608.65 2995.8106277999996 31416.91 34125.05 31416.91 2995.8106277999996 2995.8106277999996 2995.8106277999996 5377 31416.91 34558.601 31416.91 4071.8698349999995 31416.91 31416.91 32045.2482 31416.91 DRG Hospital Inpatient Facility Fee DRG OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC MS-DRG 272 N/A 99807.25 69865.075 2872.07 99807.25 93818.81499999999 23414.34 25870.43 23414.34 0 0 0 5377 23414.34 25755.774 23414.34 23414.34 23414.34 23882.626800000002 23414.34 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC MS-DRG 273 N/A 117267.4 82087.18 3078 117267.4 28932.862704599997 36189.23 39047.69 36189.23 28932.862704599997 28932.862704599997 28932.862704599997 5377 36189.23 39808.153000000006 36189.23 39325.199595 36189.23 36189.23 36913.0146 36189.23 DRG Hospital Inpatient Facility Fee DRG PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC MS-DRG 274 N/A 73360.01 51352.00699999999 3078 73360.01 21100.6936494 30295.97 32968.83 30295.97 21100.6936494 21100.6936494 21100.6936494 5377 30295.97 33325.567 30295.97 28679.809455 30295.97 30295.97 30901.8894 30295.97 DRG Hospital Inpatient Facility Fee DRG NON-MALIGANT BREAST DISORDERS MS-DRG 276 N/A 70317.29 49222.102999999996 72.18 70317.29 23369.470003799997 35158.65 72.18 35158.65 23369.470003799997 23369.470003799997 23369.470003799997 5377 35158.65 38674.51500000001 35158.65 31763.503034999998 35158.65 35158.65 35861.823000000004 35158.65 DRG Hospital Inpatient Facility Fee DRG CELLULITIS AGE >17 W CC MS-DRG 277 N/A 232912 163038.4 72.18 232912 34343.5722438 116456 72.18 116456 34343.5722438 34343.5722438 34343.5722438 5377 116456 128101.6 116456 46679.371035000004 116456 116456 118785.12 116456 DRG Hospital Inpatient Facility Fee DRG CELLULITIS AGE >17 W/O CC MS-DRG 278 N/A 14430.94 10101.658 72.18 14430.94 20961.7281156 7215.47 72.18 7215.47 20961.7281156 20961.7281156 20961.7281156 5377 7215.47 7937.017000000001 7215.47 28490.92917 7215.47 7215.47 7359.7794 7215.47 DRG Hospital Inpatient Facility Fee DRG CELLULITIS AGE 0-17 MS-DRG 279 N/A 21133.95 14793.765 72.18 21133.95 18118.6006494 10566.98 72.18 10566.98 18118.6006494 18118.6006494 18118.6006494 5377 10566.98 11623.678 10566.98 24626.584455 10566.98 10566.98 10778.319599999999 10566.98 DRG Hospital Inpatient Facility Fee DRG ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC MS-DRG 280 N/A 36022.5 25215.75 3078 36022.5 9246.2775558 14486.52 16661.44 14486.52 9246.2775558 9246.2775558 9246.2775558 5377 14486.52 15935.172000000002 14486.52 12567.429435 14486.52 14486.52 14776.2504 14486.52 DRG Hospital Inpatient Facility Fee DRG ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC MS-DRG 281 N/A 38670.76 27069.532 3078 38670.76 6353.647345799999 8283.93 10263.49 8283.93 6353.647345799999 6353.647345799999 6353.647345799999 5377 8283.93 9112.323 8283.93 8635.801184999998 8283.93 8283.93 8449.6086 8283.93 DRG Hospital Inpatient Facility Fee DRG ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC MS-DRG 282 N/A 16815.1 11770.569999999998 3078 16815.1 5645.698467599999 6463.2 8385.41 6463.2 5645.698467599999 5645.698467599999 5645.698467599999 5377 6463.2 7109.52 6463.2 7673.56557 6463.2 6463.2 6592.464 6463.2 DRG Hospital Inpatient Facility Fee DRG ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC MS-DRG 283 N/A 42013.14 29409.197999999997 3078 42013.14 14580.0490956 17301.93 19565.53 17301.93 14580.0490956 14580.0490956 14580.0490956 5377 17301.93 19032.123000000003 17301.93 19817.02767 17301.93 17301.93 17647.9686 17301.93 DRG Hospital Inpatient Facility Fee DRG ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC MS-DRG 284 N/A 27554.45 19288.114999999998 3078 27554.45 4868.5650318 6631.84 8559.36 6631.84 4868.5650318 4868.5650318 4868.5650318 5377 6631.84 7295.024 6631.84 6617.295135 6631.84 6631.84 6764.4768 6631.84 DRG Hospital Inpatient Facility Fee DRG ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC MS-DRG 285 N/A 5503.15 3852.2049999999995 2505.87 10443.04 3586.8614604 4885.95 6758.48 4885.95 3586.8614604 3586.8614604 3586.8614604 5377 4885.95 5374.545 4885.95 4875.21903 4885.95 4885.95 4983.669 4885.95 DRG Hospital Inpatient Facility Fee DRG CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC MS-DRG 286 N/A 87979.51 61585.65699999999 3078 87979.51 13244.6678502 19127.18 21448.28 19127.18 13244.6678502 13244.6678502 13244.6678502 5377 19127.18 21039.898 19127.18 18001.993515 19127.18 19127.18 19509.7236 19127.18 DRG Hospital Inpatient Facility Fee DRG CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC MS-DRG 287 N/A 37312.2 26118.539999999997 3078 37312.2 7347.877151999999 9921.6 11952.75 9921.6 7347.877151999999 7347.877151999999 7347.877151999999 5377 9921.6 10913.760000000002 9921.6 9987.1464 9921.6 9921.6 10120.032000000001 9921.6 DRG Hospital Inpatient Facility Fee DRG ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC MS-DRG 288 N/A 187723.59 131406.51299999998 3078 187723.59 17851.4051166 24317.04 45153.83 24317.04 17851.4051166 17851.4051166 17851.4051166 5377 24317.04 26748.744000000002 24317.04 24263.415495 24317.04 24317.04 24803.380800000003 24317.04 DRG Hospital Inpatient Facility Fee DRG ACUTE AND SUBACUTE ENDOCARDITIS WITH CC MS-DRG 289 N/A 66467.35 46527.145000000004 3078 66467.35 10639.5114054 14492.83 16667.93 14492.83 10639.5114054 10639.5114054 10639.5114054 5377 14492.83 15942.113000000001 14492.83 14461.096155 14492.83 14492.83 14782.6866 14492.83 DRG Hospital Inpatient Facility Fee DRG ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC MS-DRG 290 N/A 25901.01 18130.707 3078 25901.01 7981.870123799999 10873 12934.08 10873 7981.870123799999 7981.870123799999 7981.870123799999 5377 10873 11960.300000000001 10873 10848.862035 10873 10873 11090.460000000001 10873 DRG Hospital Inpatient Facility Fee DRG HEART FAILURE AND SHOCK WITH MCC MS-DRG 291 N/A 34429.05 24100.335 2940.01 34429.05 6162.793393800001 11541.24 13623.37 11541.24 6162.793393800001 6162.793393800001 6162.793393800001 5377 11541.24 12695.364000000001 11541.24 8376.394785 11541.24 11541.24 11772.0648 11541.24 DRG Hospital Inpatient Facility Fee DRG HEART FAILURE AND SHOCK WITH CC MS-DRG 292 N/A 42397.47 29678.229 3078 42397.47 5283.0759588 7780.73 9744.43 7780.73 5283.0759588 5283.0759588 5283.0759588 5377 7780.73 8558.803 7780.73 7180.69341 7780.73 7780.73 7936.344599999999 7780.73 DRG Hospital Inpatient Facility Fee DRG HEART FAILURE AND SHOCK WITHOUT CC/MCC MS-DRG 293 N/A 38586 27010.199999999997 3078 38586 3121.0585337999996 5052.79 6930.57 5052.79 3121.0585337999996 3121.0585337999996 3121.0585337999996 5377 5052.79 5558.069 5052.79 4242.105285 5052.79 5052.79 5153.8458 5052.79 DRG Hospital Inpatient Facility Fee DRG DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC MS-DRG 294 N/A 17979.8 12585.859999999999 3078 19260.29 7643.104359 10411.28 12457.84 10411.28 7643.104359 7643.104359 7643.104359 5377 10411.28 11452.408000000001 10411.28 10388.415675 10411.28 10411.28 10619.5056 10411.28 DRG Hospital Inpatient Facility Fee DRG DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC MS-DRG 295 N/A 9867.9 6907.53 3078 15392.05 5863.3912566 7987.24 9957.45 7987.24 5863.3912566 5863.3912566 5863.3912566 5377 7987.24 8785.964 7987.24 7969.450994999999 7987.24 7987.24 8146.9848 7987.24 DRG Hospital Inpatient Facility Fee DRG CARDIAC ARREST, UNEXPLAINED WITH MCC MS-DRG 296 N/A 55614.63 38930.240999999995 3078 55614.63 12425.7851124 14774.19 16958.14 14774.19 12425.7851124 12425.7851124 12425.7851124 5377 14774.19 16251.609000000002 14774.19 16888.97793 14774.19 14774.19 15069.6738 14774.19 DRG Hospital Inpatient Facility Fee DRG CARDIAC ARREST, UNEXPLAINED WITH CC MS-DRG 297 N/A 43220.87 30254.609 2905.96 43220.87 4212.5045718 5738.15 7637.51 5738.15 4212.5045718 4212.5045718 4212.5045718 5377 5738.15 6311.965 5738.15 5725.585635 5738.15 5738.15 5852.913 5738.15 DRG Hospital Inpatient Facility Fee DRG CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC MS-DRG 298 N/A 76073.39 53251.373 2905.96 76073.39 3233.7816491999997 4405.29 7107.1 4405.29 3233.7816491999997 3233.7816491999997 3233.7816491999997 5377 4405.29 4845.819 4405.29 4395.31719 4405.29 4405.29 4493.3958 4405.29 DRG Hospital Inpatient Facility Fee DRG PERIPHERAL VASCULAR DISORDERS WITH MCC MS-DRG 299 N/A 33825.06 23677.541999999998 3078 33825.06 6595.7932974000005 13869.68 16025.17 13869.68 6595.7932974000005 6595.7932974000005 6595.7932974000005 5377 13869.68 15256.648000000001 13869.68 8964.923055000001 13869.68 13869.68 14147.0736 13869.68 DRG Hospital Inpatient Facility Fee DRG PERIPHERAL VASCULAR DISORDERS WITH CC MS-DRG 300 N/A 27068.61 18948.027 3078 27068.61 5601.5634912 9298.46 11309.98 9298.46 5601.5634912 5601.5634912 5601.5634912 5377 9298.46 10228.306 9298.46 7613.57784 9298.46 9298.46 9484.429199999999 9298.46 DRG Hospital Inpatient Facility Fee DRG PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC MS-DRG 301 N/A 7547.9 5283.53 3078 12952.8 4731.3887538 6458.69 8380.76 6458.69 4731.3887538 4731.3887538 4731.3887538 5377 6458.69 7104.559 6458.69 6430.846785 6458.69 6458.69 6587.8638 6458.69 DRG Hospital Inpatient Facility Fee DRG ATHEROSCLEROSIS WITH MCC MS-DRG 302 N/A 20997.25 14698.074999999999 3078 20997.25 3125.8298826 10873.9 12935.03 10873.9 3125.8298826 3125.8298826 3125.8298826 5377 10873.9 11961.29 10873.9 4248.590445 10873.9 10873.9 11091.378 10873.9 DRG Hospital Inpatient Facility Fee DRG ATHEROSCLEROSIS WITHOUT MCC MS-DRG 303 N/A 84215.49 58950.843 3078 84215.49 3869.5638768 6097.07 8007.74 6097.07 3869.5638768 3869.5638768 3869.5638768 5377 6097.07 6706.777 6097.07 5259.46476 6097.07 6097.07 6219.011399999999 6097.07 DRG Hospital Inpatient Facility Fee DRG HYPERTENSION WITH MCC MS-DRG 304 N/A 22917.54 16042.278 3078 22917.54 6345.2974854 9907.17 11937.85 9907.17 6345.2974854 6345.2974854 6345.2974854 5377 9907.17 10897.887 9907.17 8624.452155 9907.17 9907.17 10105.313400000001 9907.17 DRG Hospital Inpatient Facility Fee DRG HYPERTENSION WITHOUT MCC MS-DRG 305 N/A 23822.82 16675.974 3078 23822.82 4267.9715016 6723.82 8654.22 6723.82 4267.9715016 4267.9715016 4267.9715016 5377 6723.82 7396.202 6723.82 5800.97562 6723.82 6723.82 6858.2964 6723.82 DRG Hospital Inpatient Facility Fee DRG CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC MS-DRG 306 N/A 28684.87 20079.409 3078 28684.87 9769.933086599998 13308.76 15446.57 13308.76 9769.933086599998 9769.933086599998 9769.933086599998 5377 13308.76 14639.636000000002 13308.76 13279.175744999999 13308.76 13308.76 13574.9352 13308.76 DRG Hospital Inpatient Facility Fee DRG CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC MS-DRG 307 N/A 27261.84 19083.288 3078 27261.84 5309.914795799999 8219.01 10196.52 8219.01 5309.914795799999 5309.914795799999 5309.914795799999 5377 8219.01 9040.911000000002 8219.01 7217.1724349999995 8219.01 8219.01 8383.3902 8219.01 DRG Hospital Inpatient Facility Fee DRG CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC MS-DRG 308 N/A 9909.75 6936.825 3078 19520.75 5685.6585138 10574.51 12626.19 10574.51 5685.6585138 5685.6585138 5685.6585138 5377 10574.51 11631.961000000001 10574.51 7727.878785 10574.51 10574.51 10786.0002 10574.51 DRG Hospital Inpatient Facility Fee DRG CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC MS-DRG 309 N/A 16576.65 11603.655 3009.6 16576.65 3499.1879261999998 6651.68 8579.8 6651.68 3499.1879261999998 3499.1879261999998 3499.1879261999998 5377 6651.68 7316.848000000001 6651.68 4756.054215 6651.68 6651.68 6784.7136 6651.68 DRG Hospital Inpatient Facility Fee DRG CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC MS-DRG 310 N/A 4792.95 3355.0649999999996 2182.48 10578.33 2739.3506297999998 4970.72 6845.93 4970.72 2739.3506297999998 2739.3506297999998 2739.3506297999998 5377 4970.72 5467.792 4970.72 3723.292485 4970.72 4970.72 5070.1344 4970.72 DRG Hospital Inpatient Facility Fee DRG ANGINA PECTORIS MS-DRG 311 N/A 23256.37 16279.458999999999 3078 23256.37 3980.4977363999997 6024.93 7933.32 6024.93 3980.4977363999997 3980.4977363999997 3980.4977363999997 5377 6024.93 6627.423000000001 6024.93 5410.244729999999 6024.93 6024.93 6145.4286 6024.93 DRG Hospital Inpatient Facility Fee DRG SYNCOPE AND COLLAPSE MS-DRG 312 N/A 18194.95 12736.465 3078 18194.95 4298.9852688 7689.65 9650.46 7689.65 4298.9852688 4298.9852688 4298.9852688 5377 7689.65 8458.615 7689.65 5843.1291599999995 7689.65 7689.65 7843.443 7689.65 DRG Hospital Inpatient Facility Fee DRG CHEST PAIN MS-DRG 313 N/A 12530.81 8771.567 3078 13056.43 4028.2112244 6523.62 8447.75 6523.62 4028.2112244 4028.2112244 4028.2112244 5377 6523.62 7175.982000000001 6523.62 5475.09633 6523.62 6523.62 6654.0924 6523.62 DRG Hospital Inpatient Facility Fee DRG OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC MS-DRG 314 N/A 195514.55 136860.185 3078 195514.55 10650.2469402 18780.89 47328.06 18780.89 10650.2469402 10650.2469402 10650.2469402 5377 18780.89 20658.979 18780.89 14475.687765 18780.89 18780.89 19156.5078 18780.89 DRG Hospital Inpatient Facility Fee DRG OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC MS-DRG 315 N/A 9036.4 6325.48 3078 16583.6 5370.153074399999 8733.93 10727.66 8733.93 5370.153074399999 5370.153074399999 5370.153074399999 5377 8733.93 9607.323 8733.93 7299.0475799999995 8733.93 8733.93 8908.6086 8733.93 DRG Hospital Inpatient Facility Fee DRG OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC MS-DRG 316 N/A 25627.04 17938.928 3078 25627.04 3770.5583891999995 6150.28 8062.61 6150.28 3770.5583891999995 3770.5583891999995 3770.5583891999995 5377 6150.28 6765.308 6150.28 5124.89769 6150.28 6150.28 6273.2856 6150.28 DRG Hospital Inpatient Facility Fee DRG OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC MS-DRG 319 N/A 124093.3 86865.31 3078 124093.3 42998.798967 38836.92 41778.78 38836.92 42998.798967 42998.798967 42998.798967 5377 38836.92 42720.612 38836.92 58443.451275 38836.92 38836.92 39613.6584 38836.92 DRG Hospital Inpatient Facility Fee DRG OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC MS-DRG 320 N/A 74171.41 51919.987 3078 74171.41 22972.2552162 22287.09 24707.67 22287.09 22972.2552162 22972.2552162 22972.2552162 5377 22287.09 24515.799000000003 22287.09 31223.613465 22287.09 22287.09 22732.8318 22287.09 DRG Hospital Inpatient Facility Fee DRG KIDNEY & URINARY TRACT INFECTIONS AGE >17 W/O CC MS-DRG 321 N/A 39010.92 27307.643999999997 72.18 39010.92 38862.635976 19505.46 72.18 19505.46 38862.635976 38862.635976 38862.635976 5377 19505.46 21456.006 19505.46 52821.6282 19505.46 19505.46 19895.569199999998 19505.46 DRG Hospital Inpatient Facility Fee DRG KIDNEY & URINARY TRACT INFECTIONS AGE 0-17 MS-DRG 322 N/A 17584.43 12309.100999999999 72.18 17584.43 16361.551453799999 8792.22 72.18 8792.22 16361.551453799999 16361.551453799999 16361.551453799999 5377 8792.22 9671.442000000001 8792.22 22238.424285 8792.22 8792.22 8968.0644 8792.22 DRG Hospital Inpatient Facility Fee DRG URINARY STONES W CC, &/OR ESW LITHOTRIPSY MS-DRG 323 N/A 53161.41 37212.987 72.18 53161.41 53161.41 26580.71 72.18 26580.71 0 0 0 5377 26580.71 29238.781000000003 26580.71 26580.71 26580.71 27112.3242 26580.71 DRG Hospital Inpatient Facility Fee DRG URINARY STONES W/O CC MS-DRG 324 N/A 21060.87 14742.608999999999 72.18 21060.87 21060.87 10530.44 72.18 10530.44 0 0 0 5377 10530.44 11583.484000000002 10530.44 10530.44 10530.44 10741.0488 10530.44 DRG Hospital Inpatient Facility Fee DRG STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC MS-DRG 326 N/A 381082.36 266757.652 3078 381082.36 381082.36 46161.34 131198.84 46161.34 0 0 0 5377 46161.34 50777.474 46161.34 46161.34 46161.34 47084.5668 46161.34 DRG Hospital Inpatient Facility Fee DRG STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC MS-DRG 327 N/A 215405.31 150783.71699999998 3078 215405.31 215405.31 23097.8 56596.49 23097.8 0 0 0 5377 23097.8 25407.58 23097.8 23097.8 23097.8 23559.756 23097.8 DRG Hospital Inpatient Facility Fee DRG STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC MS-DRG 328 N/A 31579.22 22105.453999999998 3078 31579.22 24957.732735599995 14949.14 17138.61 14949.14 24957.732735599995 24957.732735599995 24957.732735599995 5377 14949.14 16444.054 14949.14 33922.250669999994 14949.14 14949.14 15248.1228 14949.14 DRG Hospital Inpatient Facility Fee DRG MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC MS-DRG 329 N/A 162067.99 113447.593 3078 162067.99 15263.5448112 41692.92 44724.75 41692.92 15263.5448112 15263.5448112 15263.5448112 5377 41692.92 45862.212 41692.92 20746.026840000002 41692.92 41692.92 42526.778399999996 41692.92 DRG Hospital Inpatient Facility Fee DRG MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC MS-DRG 330 N/A 71058.74 49741.118 3078 71058.74 11722.011164399999 22142.8 24558.87 22142.8 11722.011164399999 11722.011164399999 11722.011164399999 5377 22142.8 24357.08 22142.8 15932.41683 22142.8 22142.8 22585.656 22142.8 DRG Hospital Inpatient Facility Fee DRG MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC MS-DRG 331 N/A 49813.41 34869.387 3078 49813.41 26821.5408606 15409.96 17613.96 15409.96 26821.5408606 26821.5408606 26821.5408606 5377 15409.96 16950.956000000002 15409.96 36455.516294999994 15409.96 15409.96 15718.1592 15409.96 DRG Hospital Inpatient Facility Fee DRG RECTAL RESECTION WITH MCC MS-DRG 332 N/A 98833.25 69183.275 3078 98833.25 14453.608352399999 36615.79 39487.67 36615.79 14453.608352399999 14453.608352399999 14453.608352399999 5377 36615.79 40277.369000000006 36615.79 19645.17093 36615.79 36615.79 37348.105800000005 36615.79 DRG Hospital Inpatient Facility Fee DRG RECTAL RESECTION WITH CC MS-DRG 333 N/A 216636.1 151645.27 3078 216636.1 11806.7026056 20138.1 56519.86 20138.1 11806.7026056 11806.7026056 11806.7026056 5377 20138.1 22151.91 20138.1 16047.52842 20138.1 20138.1 20540.861999999997 20138.1 DRG Hospital Inpatient Facility Fee DRG RECTAL RESECTION WITHOUT CC/MCC MS-DRG 334 N/A 25943.58 18160.506 3078 27319.14 26879.989883399998 15461.36 17666.97 15461.36 26879.989883399998 26879.989883399998 26879.989883399998 5377 15461.36 17007.496000000003 15461.36 36534.959505 15461.36 15461.36 15770.587200000002 15461.36 DRG Hospital Inpatient Facility Fee DRG PERITONEAL ADHESIOLYSIS WITH MCC MS-DRG 335 N/A 91601.21 64120.847 2852.34 91601.21 18308.2617642 33220.51 35985.48 33220.51 18308.2617642 18308.2617642 18308.2617642 5377 33220.51 36542.56100000001 33220.51 24884.369565 33220.51 33220.51 33884.9202 33220.51 DRG Hospital Inpatient Facility Fee DRG PERITONEAL ADHESIOLYSIS WITH CC MS-DRG 336 N/A 87233.66 61063.562 3078 87233.66 14594.363142 19181.29 21504.07 19181.29 14594.363142 14594.363142 14594.363142 5377 19181.29 21099.419 19181.29 19836.48315 19181.29 19181.29 19564.915800000002 19181.29 DRG Hospital Inpatient Facility Fee DRG PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC MS-DRG 337 N/A 28868.58 20208.006 3078 28868.58 18824.1638532 14207.86 16373.99 14207.86 18824.1638532 18824.1638532 18824.1638532 5377 14207.86 15628.646000000002 14207.86 25585.57749 14207.86 14207.86 14492.0172 14207.86 DRG Hospital Inpatient Facility Fee DRG APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC MS-DRG 338 N/A 65561.97 45893.379 3078 65561.97 12752.622505199999 23956.32 26429.49 23956.32 12752.622505199999 12752.622505199999 12752.622505199999 5377 23956.32 26351.952 23956.32 17333.21139 23956.32 23956.32 24435.4464 23956.32 DRG Hospital Inpatient Facility Fee DRG APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC MS-DRG 339 N/A 90229.98 63160.98599999999 3078 90229.98 8992.7996508 14684.91 16866.09 14684.91 8992.7996508 8992.7996508 8992.7996508 5377 14684.91 16153.401000000002 14684.91 12222.90531 14684.91 14684.91 14978.6082 14684.91 DRG Hospital Inpatient Facility Fee DRG APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC MS-DRG 340 N/A 27249.77 19074.839 3078 27249.77 11354.617306799999 10820.7 12880.15 10820.7 11354.617306799999 11354.617306799999 11354.617306799999 5377 10820.7 11902.770000000002 10820.7 15433.05951 10820.7 10820.7 11037.114000000001 10820.7 DRG Hospital Inpatient Facility Fee DRG APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC MS-DRG 341 N/A 25517.51 17862.256999999998 3078 35154.94 9425.7995544 20371.66 22731.92 20371.66 9425.7995544 9425.7995544 9425.7995544 5377 20371.66 22408.826 20371.66 12811.43358 20371.66 20371.66 20779.0932 20371.66 DRG Hospital Inpatient Facility Fee DRG APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC MS-DRG 342 N/A 20155.6 14108.919999999998 3078 23558.83 7004.340038400001 13104.96 15236.35 13104.96 7004.340038400001 7004.340038400001 7004.340038400001 5377 13104.96 14415.456 13104.96 9520.214880000001 13104.96 13104.96 13367.0592 13104.96 DRG Hospital Inpatient Facility Fee DRG APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC MS-DRG 343 N/A 27192.06 19034.442 3078 27192.06 8195.9844012 9853.97 11882.99 9853.97 8195.9844012 8195.9844012 8195.9844012 5377 9853.97 10839.367 9853.97 11139.883590000001 9853.97 9853.97 10051.0494 9853.97 DRG Hospital Inpatient Facility Fee DRG MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC MS-DRG 344 N/A 87865.51 61505.85699999999 3078 87865.51 8210.8948662 23739.88 26206.23 23739.88 8210.8948662 8210.8948662 8210.8948662 5377 23739.88 26113.868000000002 23739.88 11160.149715 23739.88 23739.88 24214.677600000003 23739.88 DRG Hospital Inpatient Facility Fee DRG MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC MS-DRG 345 N/A 59524.56 41667.191999999995 3078 59524.56 6888.0384114 13991.43 16150.75 13991.43 6888.0384114 6888.0384114 6888.0384114 5377 13991.43 15390.573000000002 13991.43 9362.139105 13991.43 13991.43 14271.258600000001 13991.43 DRG Hospital Inpatient Facility Fee DRG MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC MS-DRG 346 N/A 63351.65 44346.155 3078 63351.65 15220.602671999999 11278.81 13352.69 11278.81 15220.602671999999 15220.602671999999 15220.602671999999 5377 11278.81 12406.691 11278.81 20687.6604 11278.81 11278.81 11504.386199999999 11278.81 DRG Hospital Inpatient Facility Fee DRG ANAL AND STOMAL PROCEDURES WITH MCC MS-DRG 347 N/A 294993.23 206495.26099999997 3078 294993.23 7112.8882236 22889.48 90159.76 22889.48 7112.8882236 7112.8882236 7112.8882236 5377 22889.48 25178.428 22889.48 9667.75227 22889.48 22889.48 23347.2696 22889.48 DRG Hospital Inpatient Facility Fee DRG ANAL AND STOMAL PROCEDURES WITH CC MS-DRG 348 N/A 4397.9 3078.5299999999997 2002.59 22519.8 7188.6333858 12453.86 14564.74 12453.86 7188.6333858 7188.6333858 7188.6333858 5377 12453.86 13699.246000000001 12453.86 9770.704185 12453.86 12453.86 12702.9372 12453.86 DRG Hospital Inpatient Facility Fee DRG ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC MS-DRG 349 N/A 24450.29 17115.203 3078 24450.29 16803.4976364 8992.75 10994.63 8992.75 16803.4976364 16803.4976364 16803.4976364 5377 8992.75 9892.025000000001 8992.75 22839.11223 8992.75 8992.75 9172.605 8992.75 DRG Hospital Inpatient Facility Fee DRG INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC MS-DRG 350 N/A 18403.82 12882.673999999999 3078 36565.24 7029.3896196000005 21255.43 23643.53 21255.43 7029.3896196000005 7029.3896196000005 7029.3896196000005 5377 21255.43 23380.973 21255.43 9554.261970000001 21255.43 21255.43 21680.5386 21255.43 DRG Hospital Inpatient Facility Fee DRG INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC MS-DRG 351 N/A 55245.34 38671.738 3078 55245.34 5416.0773066 13258.26 15394.48 13258.26 5416.0773066 5416.0773066 5416.0773066 5377 13258.26 14584.086000000001 13258.26 7361.467245 13258.26 13258.26 13523.4252 13258.26 DRG Hospital Inpatient Facility Fee DRG INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC MS-DRG 352 N/A 24699.99 17289.993 3078 24699.99 15604.099831799998 9938.74 11970.4 9938.74 15604.099831799998 15604.099831799998 15604.099831799998 5377 9938.74 10932.614000000001 9938.74 21208.905134999997 9938.74 9938.74 10137.5148 9938.74 DRG Hospital Inpatient Facility Fee DRG HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC MS-DRG 353 N/A 67045.62 46931.933999999994 3078 67045.62 10177.883408999998 25861.82 28395.01 25861.82 10177.883408999998 10177.883408999998 10177.883408999998 5377 25861.82 28448.002 25861.82 13833.656925 25861.82 25861.82 26379.0564 25861.82 DRG Hospital Inpatient Facility Fee DRG HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC MS-DRG 354 N/A 30591.67 21414.168999999998 3078 30591.67 9008.306534399999 15799.54 18015.81 15799.54 9008.306534399999 9008.306534399999 9008.306534399999 5377 15799.54 17379.494000000002 15799.54 12243.98208 15799.54 15799.54 16115.5308 15799.54 DRG Hospital Inpatient Facility Fee DRG HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC MS-DRG 355 N/A 48102.13 33671.490999999995 3078 48102.13 15907.676899199998 12375.4 14483.82 12375.4 15907.676899199998 15907.676899199998 15907.676899199998 5377 12375.4 13612.94 12375.4 21621.523439999997 12375.4 12375.4 12622.908 12375.4 DRG Hospital Inpatient Facility Fee DRG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC MS-DRG 356 N/A 330339.55 231237.68499999997 3078 330339.55 11949.8430696 38078.51 108144.68 38078.51 11949.8430696 11949.8430696 11949.8430696 5377 38078.51 41886.361000000004 38078.51 16242.08322 38078.51 38078.51 38840.080200000004 38078.51 DRG Hospital Inpatient Facility Fee DRG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC MS-DRG 357 N/A 102592.92 71815.044 3078 102592.92 7076.506689000001 20256.23 22612.88 20256.23 7076.506689000001 7076.506689000001 7076.506689000001 5377 20256.23 22281.853000000003 20256.23 9618.302925 20256.23 20256.23 20661.3546 20256.23 DRG Hospital Inpatient Facility Fee DRG OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 358 N/A 58367.19 40857.032999999996 3078 58367.19 34230.2527098 12509.77 14622.42 12509.77 34230.2527098 34230.2527098 34230.2527098 5377 12509.77 13760.747000000001 12509.77 46525.348485 12509.77 12509.77 12759.965400000001 12509.77 DRG Hospital Inpatient Facility Fee DRG UTERINE & ADNEXA PROC FOR NON-MALIGNANCY W/O CC MS-DRG 359 N/A 52440.04 36708.028 72.18 52440.04 13083.6348282 26220.02 72.18 26220.02 13083.6348282 13083.6348282 13083.6348282 5377 26220.02 28842.022000000004 26220.02 17783.119365000002 26220.02 26220.02 26744.420400000003 26220.02 DRG Hospital Inpatient Facility Fee DRG VAGINA, CERVIX & VULVA PROCEDURES MS-DRG 360 N/A 99949.81 69964.867 72.18 99949.81 7751.0561256 49974.91 72.18 49974.91 7751.0561256 7751.0561256 7751.0561256 5377 49974.91 54972.401000000005 49974.91 10535.14242 49974.91 49974.91 50974.408200000005 49974.91 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM W CC MS-DRG 366 N/A 12008.85 8406.195 72.18 12008.85 11288.319 6004.43 72.18 6004.43 0 0 0 5377 6004.43 6604.8730000000005 6004.43 6004.43 6004.43 6124.5186 6004.43 DRG Hospital Inpatient Facility Fee DRG MAJOR ESOPHAGEAL DISORDERS WITH MCC MS-DRG 368 N/A 39681.81 27777.266999999996 3078 39681.81 37300.901399999995 15819.38 18036.27 15819.38 0 0 0 5377 15819.38 17401.318 15819.38 15819.38 15819.38 16135.7676 15819.38 DRG Hospital Inpatient Facility Fee DRG MAJOR ESOPHAGEAL DISORDERS WITH CC MS-DRG 369 N/A 38078.85 26655.194999999996 3078 38078.85 35794.119 9217.3 11226.26 9217.3 0 0 0 5377 9217.3 10139.03 9217.3 9217.3 9217.3 9401.645999999999 9217.3 DRG Hospital Inpatient Facility Fee DRG MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC MS-DRG 370 N/A 23048.45 16133.914999999999 3078 23048.45 9780.072202799998 6751.78 8683.05 6751.78 9780.072202799998 9780.072202799998 9780.072202799998 5377 6751.78 7426.9580000000005 6751.78 13292.956709999999 6751.78 6751.78 6886.8156 6751.78 DRG Hospital Inpatient Facility Fee DRG MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC MS-DRG 371 N/A 27555.51 19288.856999999996 2891.9 27555.51 4845.901124999999 15256.65 17455.83 15256.65 4845.901124999999 4845.901124999999 4845.901124999999 5377 15256.65 16782.315000000002 15256.65 6586.490624999999 15256.65 15256.65 15561.783 15256.65 DRG Hospital Inpatient Facility Fee DRG MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC MS-DRG 372 N/A 20047.91 14033.536999999998 2583.17 20047.91 4262.6037342 9180.32 11188.1 9180.32 4262.6037342 4262.6037342 4262.6037342 5377 9180.32 10098.352 9180.32 5793.6798149999995 9180.32 9180.32 9363.9264 9180.32 DRG Hospital Inpatient Facility Fee DRG MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC MS-DRG 373 N/A 9254.8 6478.359999999999 2697.37 13093.81 8559.2033286 6547.07 8471.9 6547.07 8559.2033286 8559.2033286 8559.2033286 5377 6547.07 7201.777 6547.07 11633.566395 6547.07 6547.07 6678.011399999999 6547.07 DRG Hospital Inpatient Facility Fee DRG DIGESTIVE MALIGNANCY WITH MCC MS-DRG 374 N/A 8564.8 5995.359999999999 3078 31331.32 4722.442474799999 17975.58 20260.39 17975.58 4722.442474799999 4722.442474799999 4722.442474799999 5377 17975.58 19773.138000000003 17975.58 6418.68711 17975.58 17975.58 18335.091600000003 17975.58 DRG Hospital Inpatient Facility Fee DRG DIGESTIVE MALIGNANCY WITH CC MS-DRG 375 N/A 18009.91 12606.937 3078 19981.26 3092.4304409999995 10863.08 12923.86 10863.08 3092.4304409999995 3092.4304409999995 3092.4304409999995 5377 10863.08 11949.388 10863.08 4203.1943249999995 10863.08 10863.08 11080.3416 10863.08 DRG Hospital Inpatient Facility Fee DRG DIGESTIVE MALIGNANCY WITHOUT CC/MCC MS-DRG 376 N/A 28696.77 20087.738999999998 3078 28696.77 10208.3007576 7916 9883.98 7916 10208.3007576 10208.3007576 10208.3007576 5377 7916 8707.6 7916 13874.999819999999 7916 7916 8074.32 7916 DRG Hospital Inpatient Facility Fee DRG GASTROINTESTINAL HEMORRHAGE WITH MCC MS-DRG 377 N/A 27397.14 19177.998 3078 28232.98 6267.166648799999 16034 18257.66 16034 6267.166648799999 6267.166648799999 6267.166648799999 5377 16034 17637.4 16034 8518.25766 16034 16034 16354.68 16034 DRG Hospital Inpatient Facility Fee DRG GASTROINTESTINAL HEMORRHAGE WITH CC MS-DRG 378 N/A 15963.42 11174.394 3078 16821.02 5811.5028384 8882.73 10881.12 8882.73 5811.5028384 5811.5028384 5811.5028384 5377 8882.73 9771.003 8882.73 7898.9248800000005 8882.73 8882.73 9060.3846 8882.73 DRG Hospital Inpatient Facility Fee DRG GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC MS-DRG 379 N/A 24961.51 17473.056999999997 3078 24961.51 9225.9993234 5715.61 7614.27 5715.61 9225.9993234 9225.9993234 9225.9993234 5377 5715.61 6287.171 5715.61 12539.867504999998 5715.61 5715.61 5829.9222 5715.61 DRG Hospital Inpatient Facility Fee DRG COMPLICATED PEPTIC ULCER WITH MCC MS-DRG 380 N/A 20647.45 14453.215 3078 30047.65 5133.9713088 17171.17 19430.64 17171.17 5133.9713088 5133.9713088 5133.9713088 5377 17171.17 18888.287 17171.17 6978.03216 17171.17 17171.17 17514.593399999998 17171.17 DRG Hospital Inpatient Facility Fee DRG COMPLICATED PEPTIC ULCER WITH CC MS-DRG 381 N/A 24357.36 17050.152 3078 24357.36 3583.2829487999998 9518.5 11536.93 9518.5 3583.2829487999998 3583.2829487999998 3583.2829487999998 5377 9518.5 10470.35 9518.5 4870.35516 9518.5 9518.5 9708.87 9518.5 DRG Hospital Inpatient Facility Fee DRG COMPLICATED PEPTIC ULCER WITHOUT CC/MCC MS-DRG 382 N/A 18981.25 13286.875 3078 18981.25 8203.141424399999 6942.06 8879.36 6942.06 8203.141424399999 8203.141424399999 8203.141424399999 5377 6942.06 7636.266000000001 6942.06 11149.61133 6942.06 6942.06 7080.9012 6942.06 DRG Hospital Inpatient Facility Fee DRG UNCOMPLICATED PEPTIC ULCER WITH MCC MS-DRG 383 N/A 69496.3 48647.409999999996 3078 69496.3 5457.826608599999 12264.48 14369.41 12264.48 5457.826608599999 5457.826608599999 5457.826608599999 5377 12264.48 13490.928 12264.48 7418.2123950000005 12264.48 12264.48 12509.7696 12264.48 DRG Hospital Inpatient Facility Fee DRG UNCOMPLICATED PEPTIC ULCER WITHOUT MCC MS-DRG 384 N/A 32205.27 22543.689 3078 32205.27 5060.0154024 8130.63 10105.35 8130.63 5060.0154024 5060.0154024 5060.0154024 5377 8130.63 8943.693000000001 8130.63 6877.512180000001 8130.63 8130.63 8293.2426 8130.63 DRG Hospital Inpatient Facility Fee DRG INFLAMMATORY BOWEL DISEASE WITH MCC MS-DRG 385 N/A 130707.5 91495.25 2937.51 130707.5 9003.5351856 14687.62 19139.19 14687.62 9003.5351856 9003.5351856 9003.5351856 5377 14687.62 16156.382000000001 14687.62 12237.49692 14687.62 14687.62 14981.3724 14687.62 DRG Hospital Inpatient Facility Fee DRG INFLAMMATORY BOWEL DISEASE WITH CC MS-DRG 386 N/A 54282.82 37997.973999999995 2884.17 54282.82 5546.69298 8926.02 10925.79 8926.02 5546.69298 5546.69298 5546.69298 5377 8926.02 9818.622000000001 8926.02 7538.998500000001 8926.02 8926.02 9104.5404 8926.02 DRG Hospital Inpatient Facility Fee DRG INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC MS-DRG 387 N/A 22343.51 15640.456999999999 2986.78 22343.51 7054.4392008 6236.85 8151.93 6236.85 7054.4392008 7054.4392008 7054.4392008 5377 6236.85 6860.535000000001 6236.85 9588.30906 6236.85 6236.85 6361.587 6236.85 DRG Hospital Inpatient Facility Fee DRG GASTROINTESTINAL OBSTRUCTION WITH MCC MS-DRG 388 N/A 28530.52 19971.363999999998 3078 28530.52 5206.734378 13233.01 15368.44 13233.01 5206.734378 5206.734378 5206.734378 5377 13233.01 14556.311000000002 13233.01 7076.93085 13233.01 13233.01 13497.6702 13233.01 DRG Hospital Inpatient Facility Fee DRG GASTROINTESTINAL OBSTRUCTION WITH CC MS-DRG 389 N/A 35840.22 25088.154 2655.25 35840.22 4057.4357357999997 7278.43 9226.33 7278.43 4057.4357357999997 4057.4357357999997 4057.4357357999997 5377 7278.43 8006.273000000001 7278.43 5514.817935 7278.43 7278.43 7423.998600000001 7278.43 DRG Hospital Inpatient Facility Fee DRG GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC MS-DRG 390 N/A 14384.14 10068.898 2620.62 14384.14 5986.8499068 5099.68 6978.95 5099.68 5986.8499068 5986.8499068 5986.8499068 5377 5099.68 5609.648000000001 5099.68 8137.25451 5099.68 5099.68 5201.6736 5099.68 DRG Hospital Inpatient Facility Fee DRG ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC MS-DRG 391 N/A 10844.95 7591.465 3078 21123.88 3998.986713 11579.11 13662.43 11579.11 3998.986713 3998.986713 3998.986713 5377 11579.11 12737.021000000002 11579.11 5435.374725 11579.11 11579.11 11810.692200000001 11579.11 DRG Hospital Inpatient Facility Fee DRG ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC MS-DRG 392 N/A 29380.11 20566.076999999997 3078 29380.11 2667.7803977999997 7102.58 9044.93 7102.58 2667.7803977999997 2667.7803977999997 2667.7803977999997 5377 7102.58 7812.838000000001 7102.58 3626.0150849999995 7102.58 7102.58 7244.6316 7102.58 DRG Hospital Inpatient Facility Fee DRG OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC MS-DRG 393 N/A 43350.74 30345.517999999996 3078 43350.74 6356.0330202000005 14530.7 16707.01 14530.7 6356.0330202000005 6356.0330202000005 6356.0330202000005 5377 14530.7 15983.770000000002 14530.7 8639.043765 14530.7 14530.7 14821.314 14530.7 DRG Hospital Inpatient Facility Fee DRG OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC MS-DRG 394 N/A 61789.2 43252.439999999995 3078 61789.2 4019.2649454 8503.97 10490.45 8503.97 4019.2649454 4019.2649454 4019.2649454 5377 8503.97 9354.367 8503.97 5462.936655 8503.97 8503.97 8674.0494 8503.97 DRG Hospital Inpatient Facility Fee DRG OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC MS-DRG 395 N/A 19630.86 13741.601999999999 3078 19630.86 8006.919704999999 5815.71 7717.51 5815.71 8006.919704999999 8006.919704999999 8006.919704999999 5377 5815.71 6397.281000000001 5815.71 10882.909125 5815.71 5815.71 5932.0242 5815.71 DRG Hospital Inpatient Facility Fee DRG RED BLOOD CELL DISORDERS AGE 0-17 MS-DRG 396 N/A 20385.16 14269.612 72.18 20385.16 4657.4328474 10192.58 72.18 10192.58 4657.4328474 4657.4328474 4657.4328474 5377 10192.58 11211.838000000002 10192.58 6330.326805000001 10192.58 10192.58 10396.4316 10192.58 DRG Hospital Inpatient Facility Fee DRG COAGULATION DISORDERS MS-DRG 397 N/A 58178.43 40724.901 72.18 58178.43 3582.6865302 29089.22 72.18 29089.22 3582.6865302 3582.6865302 3582.6865302 5377 29089.22 31998.142000000003 29089.22 4869.544515 29089.22 29089.22 29671.0044 29089.22 DRG Hospital Inpatient Facility Fee DRG RETICULOENDOTHELIAL & IMMUNITY DISORDERS W CC MS-DRG 398 N/A 82456.32 57719.424 72.18 82456.32 26943.806673599996 41228.16 72.18 41228.16 26943.806673599996 26943.806673599996 26943.806673599996 5377 41228.16 45350.97600000001 41228.16 36621.69852 41228.16 41228.16 42052.72320000001 41228.16 DRG Hospital Inpatient Facility Fee DRG RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC MS-DRG 399 N/A 180382.64 126267.848 72.18 180382.64 13537.509382799999 90191.32 72.18 90191.32 13537.509382799999 13537.509382799999 13537.509382799999 5377 90191.32 99210.45200000002 90191.32 18400.02021 90191.32 90191.32 91995.14640000001 90191.32 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA & NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC MS-DRG 402 N/A 253839.77 177687.83899999998 72.18 253839.77 6328.001345999999 126919.89 72.18 126919.89 6328.001345999999 6328.001345999999 6328.001345999999 5377 126919.89 139611.87900000002 126919.89 8600.943449999999 126919.89 126919.89 129458.2878 126919.89 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA & NON-ACUTE LEUKEMIA W CC MS-DRG 403 N/A 54238 37966.6 72.18 54238 9517.051600199999 27119 72.18 27119 9517.051600199999 9517.051600199999 9517.051600199999 5377 27119 29830.9 27119 12935.462264999998 27119 27119 27661.38 27119 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA & NON-ACUTE LEUKEMIA W/O CC MS-DRG 404 N/A 57239.86 40067.901999999995 72.18 57239.86 7589.426684999999 28619.93 72.18 28619.93 7589.426684999999 7589.426684999999 7589.426684999999 5377 28619.93 31481.923000000003 28619.93 10315.457625 28619.93 28619.93 29192.3286 28619.93 DRG Hospital Inpatient Facility Fee DRG PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC MS-DRG 405 N/A 157405.59 110183.91299999999 3078 157405.59 147961.2546 49976.85 53269.59 49976.85 0 0 0 5377 49976.85 54974.535 49976.85 49976.85 49976.85 50976.387 49976.85 DRG Hospital Inpatient Facility Fee DRG PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC MS-DRG 406 N/A 130087.47 91061.22899999999 3078 130087.47 122282.2218 26420.03 28970.8 26420.03 0 0 0 5377 26420.03 29062.033 26420.03 26420.03 26420.03 26948.4306 26420.03 DRG Hospital Inpatient Facility Fee DRG PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC MS-DRG 407 N/A 99426.11 69598.277 3078 99426.11 32242.389515999996 20071.36 22422.19 20071.36 32242.389515999996 32242.389515999996 32242.389515999996 5377 20071.36 22078.496000000003 20071.36 43823.4687 20071.36 20071.36 20472.787200000002 20071.36 DRG Hospital Inpatient Facility Fee DRG BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC MS-DRG 408 N/A 51389.25 35972.475 3078 55453.18 20377.8343062 33091.55 35852.44 33091.55 20377.8343062 20377.8343062 20377.8343062 5377 33091.55 36400.70500000001 33091.55 27697.307715 33091.55 33091.55 33753.381 33091.55 DRG Hospital Inpatient Facility Fee DRG BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC MS-DRG 409 N/A 52702.77 36891.939 3078 52702.77 15966.722340599998 19220.97 21544.99 19220.97 15966.722340599998 15966.722340599998 15966.722340599998 5377 19220.97 21143.067000000003 19220.97 21701.777294999996 19220.97 19220.97 19605.3894 19220.97 DRG Hospital Inpatient Facility Fee DRG BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC MS-DRG 410 N/A 27090.29 18963.202999999998 3078 27090.29 19138.4764554 15309.86 17510.68 15309.86 19138.4764554 19138.4764554 19138.4764554 5377 15309.86 16840.846 15309.86 26012.787405 15309.86 15309.86 15616.057200000001 15309.86 DRG Hospital Inpatient Facility Fee DRG CHOLECYSTECTOMY WITH C.D.E. WITH MCC MS-DRG 411 N/A 71316.29 49921.40299999999 3078 71316.29 19244.6389662 30464.61 33142.76 30464.61 19244.6389662 19244.6389662 19244.6389662 5377 30464.61 33511.071 30464.61 26157.082215000002 30464.61 30464.61 31073.9022 30464.61 DRG Hospital Inpatient Facility Fee DRG CHOLECYSTECTOMY WITH C.D.E. WITH CC MS-DRG 412 N/A 91649.8 64154.86 3078 91649.8 9811.6823886 20702.62 23073.33 20702.62 9811.6823886 9811.6823886 9811.6823886 5377 20702.62 22772.882 20702.62 13335.920895 20702.62 20702.62 21116.6724 20702.62 DRG Hospital Inpatient Facility Fee DRG CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC MS-DRG 413 N/A 75430.55 52801.385 3078 75430.55 22364.5046628 14612.77 16791.65 14612.77 22364.5046628 22364.5046628 22364.5046628 5377 14612.77 16074.047000000002 14612.77 30397.56621 14612.77 14612.77 14905.0254 14612.77 DRG Hospital Inpatient Facility Fee DRG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC MS-DRG 414 N/A 61982.45 43387.715 3078 61982.45 15197.938765199999 31875.92 34598.55 31875.92 15197.938765199999 15197.938765199999 15197.938765199999 5377 31875.92 35063.512 31875.92 20656.85589 31875.92 31875.92 32513.4384 31875.92 DRG Hospital Inpatient Facility Fee DRG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC MS-DRG 415 N/A 34375.9 24063.13 3078 34375.9 10727.1849396 18036 20322.69 18036 10727.1849396 10727.1849396 10727.1849396 5377 18036 19839.600000000002 18036 14580.26097 18036 18036 18396.72 18036 DRG Hospital Inpatient Facility Fee DRG CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC MS-DRG 416 N/A 99392.05 69574.435 3078 99392.05 23400.483771 12412.38 14521.97 12412.38 23400.483771 23400.483771 23400.483771 5377 12412.38 13653.618 12412.38 31805.656575 12412.38 12412.38 12660.6276 12412.38 DRG Hospital Inpatient Facility Fee DRG LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC MS-DRG 417 N/A 34070.91 23849.637000000002 3078 36863.15 10456.4108952 21442.1 23836.09 21442.1 10456.4108952 10456.4108952 10456.4108952 5377 21442.1 23586.31 21442.1 14212.228140000001 21442.1 21442.1 21870.942 21442.1 DRG Hospital Inpatient Facility Fee DRG LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC MS-DRG 418 N/A 42789.37 29952.559 3078 42789.37 9307.7086716 14978.9 17169.3 14978.9 9307.7086716 9307.7086716 9307.7086716 5377 14978.9 16476.79 14978.9 12650.92587 14978.9 14978.9 15278.478 14978.9 DRG Hospital Inpatient Facility Fee DRG LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC MS-DRG 419 N/A 21367.94 14957.557999999997 3078 21426.12 12087.0193476 11768.49 13857.8 11768.49 12087.0193476 12087.0193476 12087.0193476 5377 11768.49 12945.339 11768.49 16428.531570000003 11768.49 11768.49 12003.8598 11768.49 DRG Hospital Inpatient Facility Fee DRG HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC MS-DRG 420 N/A 21833.19 15283.232999999998 3078 49577.42 11203.723401 29409.5 32054.42 29409.5 11203.723401 11203.723401 11203.723401 5377 29409.5 32350.450000000004 29409.5 15227.966325 29409.5 29409.5 29997.690000000002 29409.5 DRG Hospital Inpatient Facility Fee DRG HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC MS-DRG 421 N/A 86822.16 60775.511999999995 3078 86822.16 8775.106861799999 16337.01 18570.18 16337.01 8775.106861799999 8775.106861799999 8775.106861799999 5377 16337.01 17970.711000000003 16337.01 11927.019885 16337.01 16337.01 16663.750200000002 16337.01 DRG Hospital Inpatient Facility Fee DRG HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC MS-DRG 422 N/A 41265.17 28885.618999999995 3078 41265.17 19458.7532436 12495.34 14607.54 12495.34 19458.7532436 19458.7532436 19458.7532436 5377 12495.34 13744.874000000002 12495.34 26448.103769999998 12495.34 12495.34 12745.2468 12495.34 DRG Hospital Inpatient Facility Fee DRG OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC MS-DRG 423 N/A 129419.5 90593.65 3078 129419.5 11993.381627399998 35457.87 38293.31 35457.87 11993.381627399998 11993.381627399998 11993.381627399998 5377 35457.87 39003.65700000001 35457.87 16301.260305 35457.87 35457.87 36167.027400000006 35457.87 DRG Hospital Inpatient Facility Fee DRG OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC MS-DRG 424 N/A 131285.99 91900.19299999998 3078 131285.99 9172.918067999999 21360.03 23751.44 21360.03 9172.918067999999 9172.918067999999 9172.918067999999 5377 21360.03 23496.033 21360.03 12467.7201 21360.03 21360.03 21787.2306 21360.03 DRG Hospital Inpatient Facility Fee DRG OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 425 N/A 56248 39373.6 3078 56248 23509.0319562 12901.15 15026.13 12901.15 23509.0319562 23509.0319562 23509.0319562 5377 12901.15 14191.265000000001 12901.15 31953.193965 12901.15 12901.15 13159.173 12901.15 DRG Hospital Inpatient Facility Fee DRG DEPRESSIVE NEUROSES MS-DRG 426 N/A 31834.62 22284.233999999997 72.18 31834.62 11603.323863 15917.31 72.18 15917.31 11603.323863 11603.323863 11603.323863 5377 15917.31 17509.041 15917.31 15771.098474999999 15917.31 15917.31 16235.6562 15917.31 DRG Hospital Inpatient Facility Fee DRG NEUROSES EXCEPT DEPRESSIVE MS-DRG 427 N/A 38989.51 27292.657 72.18 38989.51 9471.127368 19494.75 72.18 19494.75 9471.127368 9471.127368 9471.127368 5377 19494.75 21444.225000000002 19494.75 12873.0426 19494.75 19494.75 19884.645 19494.75 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF PERSONALITY & IMPULSE CONTROL MS-DRG 428 N/A 8290.87 5803.609 72.18 8290.87 7793.4178 4145.44 72.18 4145.44 0 0 0 5377 4145.44 4559.984 4145.44 4145.44 4145.44 4228.3488 4145.44 DRG Hospital Inpatient Facility Fee DRG ORGANIC DISTURBANCES & MENTAL RETARDATION MS-DRG 429 N/A 40999.38 28699.565999999995 72.18 40999.38 38539.417199999996 20499.69 72.18 20499.69 0 0 0 5377 20499.69 22549.659 20499.69 20499.69 20499.69 20909.6838 20499.69 DRG Hospital Inpatient Facility Fee DRG PSYCHOSES MS-DRG 430 N/A 6239.65 4367.754999999999 72.18 6239.65 5865.271 3119.82 72.18 3119.82 0 0 0 5377 3119.82 3431.8020000000006 3119.82 3119.82 3119.82 3182.2164000000002 3119.82 DRG Hospital Inpatient Facility Fee DRG CHILDHOOD MENTAL DISORDERS MS-DRG 431 N/A 40019.54 28013.678 72.18 40019.54 37618.3676 20009.77 72.18 20009.77 0 0 0 5377 20009.77 22010.747000000003 20009.77 20009.77 20009.77 20409.9654 20009.77 DRG Hospital Inpatient Facility Fee DRG CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC MS-DRG 432 N/A 239740.52 167818.36399999997 3078 239740.52 225356.08879999997 17027.78 65648.81 17027.78 0 0 0 5377 17027.78 18730.558 17027.78 17027.78 17027.78 17368.3356 17027.78 DRG Hospital Inpatient Facility Fee DRG CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC MS-DRG 433 N/A 39526.67 27668.668999999998 590 39526.67 37155.0698 9376.92 11390.9 9376.92 0 0 0 5377 9376.92 10314.612000000001 9376.92 9376.92 9376.92 9564.4584 9376.92 DRG Hospital Inpatient Facility Fee DRG CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC MS-DRG 434 N/A 15193.29 10635.303 590 15193.29 11184.6380058 5660.6 7557.53 5660.6 11184.6380058 11184.6380058 11184.6380058 5377 5660.6 6226.660000000001 5660.6 15202.025684999999 5660.6 5660.6 5773.812000000001 5660.6 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC MS-DRG 435 N/A 21604.03 15122.820999999998 590 27804.1 6043.5096738 15765.27 17980.45 15765.27 6043.5096738 6043.5096738 6043.5096738 5377 15765.27 17341.797000000002 15765.27 8214.265785000001 15765.27 15765.27 16080.575400000002 15765.27 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC MS-DRG 436 N/A 51738.15 36216.705 590 51738.15 2177.5243085999996 9923.41 11954.6 9923.41 2177.5243085999996 2177.5243085999996 2177.5243085999996 5377 9923.41 10915.751 9923.41 2959.664895 9923.41 9923.41 10121.8782 9923.41 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC MS-DRG 437 N/A 20677.34 14474.137999999999 590 20677.34 9426.395972999999 7628.33 9587.21 7628.33 9426.395972999999 9426.395972999999 9426.395972999999 5377 7628.33 8391.163 7628.33 12812.244225 7628.33 7628.33 7780.8966 7628.33 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC MS-DRG 438 N/A 71239.58 49867.706 590 71239.58 6920.8414344 14946.43 17135.81 14946.43 6920.8414344 6920.8414344 6920.8414344 5377 14946.43 16441.073 14946.43 9406.72458 14946.43 14946.43 15245.358600000001 14946.43 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC MS-DRG 439 N/A 15051.16 10535.812 2727.31 15163.25 5599.774235399999 7843.86 9809.56 7843.86 5599.774235399999 5599.774235399999 5599.774235399999 5377 7843.86 8628.246000000001 7843.86 7611.145904999999 7843.86 7843.86 8000.7372 7843.86 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC MS-DRG 440 N/A 14921.15 10444.804999999998 2786.5 14921.15 10219.632711 5468.52 7359.36 5468.52 10219.632711 10219.632711 10219.632711 5377 5468.52 6015.372000000001 5468.52 13890.402075 5468.52 5468.52 5577.8904 5468.52 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC MS-DRG 441 N/A 31896.9 22327.829999999998 3078 31896.9 4783.8735906 17087.31 19344.12 17087.31 4783.8735906 4783.8735906 4783.8735906 5377 17087.31 18796.041000000005 17087.31 6502.183545 17087.31 17087.31 17429.056200000003 17087.31 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC MS-DRG 442 N/A 12393.05 8675.134999999998 3078 16259.81 3632.189274 8531.03 10518.36 8531.03 3632.189274 3632.189274 3632.189274 5377 8531.03 9384.133000000002 8531.03 4936.82805 8531.03 8531.03 8701.6506 8531.03 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC MS-DRG 443 N/A 19819.15 13873.405 3078 19819.15 12335.725903799997 5878.83 7782.64 5878.83 12335.725903799997 12335.725903799997 12335.725903799997 5377 5878.83 6466.713000000001 5878.83 16766.570535 5878.83 5878.83 5996.4066 5878.83 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF THE BILIARY TRACT WITH MCC MS-DRG 444 N/A 100238.96 70167.272 3078 100238.96 5790.6281874 15012.26 17203.74 15012.26 5790.6281874 5790.6281874 5790.6281874 5377 15012.26 16513.486 15012.26 7870.552304999999 15012.26 15012.26 15312.5052 15012.26 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF THE BILIARY TRACT WITH CC MS-DRG 445 N/A 17420.78 12194.545999999998 3078 18470.23 4157.037641999999 9916.19 11947.15 9916.19 4157.037641999999 4157.037641999999 4157.037641999999 5377 9916.19 10907.809000000001 9916.19 5650.19565 9916.19 9916.19 10114.5138 9916.19 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC MS-DRG 446 N/A 12465.01 8725.507 3078 14327.1 9601.743041400001 7319.91 9269.09 7319.91 9601.743041400001 9601.743041400001 9601.743041400001 5377 7319.91 8051.901000000001 7319.91 13050.573855 7319.91 7319.91 7466.3082 7319.91 DRG Hospital Inpatient Facility Fee DRG ALLERGIC REACTIONS AGE >17 MS-DRG 447 N/A 10297.37 7208.159 72.18 10297.37 6273.1308348 5148.68 72.18 5148.68 6273.1308348 6273.1308348 6273.1308348 5377 5148.68 5663.548000000001 5148.68 8526.36411 5148.68 5148.68 5251.653600000001 5148.68 DRG Hospital Inpatient Facility Fee DRG POISONING & TOXIC EFFECTS OF DRUGS AGE >17 W CC MS-DRG 449 N/A 15815.97 11071.178999999998 72.18 15815.97 14867.011799999998 7907.99 72.18 7907.99 0 0 0 5377 7907.99 8698.789 7907.99 7907.99 7907.99 8066.1498 7907.99 DRG Hospital Inpatient Facility Fee DRG POISONING & TOXIC EFFECTS OF DRUGS AGE 0-17 MS-DRG 451 N/A 78978.04 55284.62799999999 72.18 78978.04 74239.35759999999 39489.02 72.18 39489.02 0 0 0 5377 39489.02 43437.922 39489.02 39489.02 39489.02 40278.8004 39489.02 DRG Hospital Inpatient Facility Fee DRG COMPLICATIONS OF TREATMENT W CC MS-DRG 452 N/A 47352.19 33146.533 72.18 47352.19 44511.0586 23676.09 72.18 23676.09 0 0 0 5377 23676.09 26043.699 23676.09 23676.09 23676.09 24149.6118 23676.09 DRG Hospital Inpatient Facility Fee DRG COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC MS-DRG 453 N/A 273655.62 191558.93399999998 3078 273655.62 257236.2828 82557.99 93172.21 82557.99 0 0 0 5377 82557.99 90813.78900000002 82557.99 82557.99 82557.99 84209.14980000001 82557.99 DRG Hospital Inpatient Facility Fee DRG COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC MS-DRG 454 N/A 89596.6 62717.62 3078 90299.14 84881.19159999999 54927.74 58376.4 54927.74 0 0 0 5377 54927.74 60420.514 54927.74 54927.74 54927.74 56026.294799999996 54927.74 DRG Hospital Inpatient Facility Fee DRG COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC MS-DRG 455 N/A 146158.35 102310.845 3078 146158.35 56928.7517886 43178.18 46256.79 43178.18 56928.7517886 56928.7517886 56928.7517886 5377 43178.18 47495.99800000001 43178.18 77376.87589499999 43178.18 43178.18 44041.7436 43178.18 DRG Hospital Inpatient Facility Fee DRG SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC MS-DRG 456 N/A 325502.69 227851.883 3078 325502.69 37094.851245599995 76194.89 113782.07 76194.89 37094.851245599995 37094.851245599995 37094.851245599995 5377 76194.89 83814.379 76194.89 50418.87642 76194.89 76194.89 77718.7878 76194.89 DRG Hospital Inpatient Facility Fee DRG SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC MS-DRG 457 N/A 73807.86 51665.502 3078 89520.59 25678.206404399996 54439.86 57873.17 54439.86 25678.206404399996 25678.206404399996 25678.206404399996 5377 54439.86 59883.846000000005 54439.86 34901.509829999995 54439.86 54439.86 55528.6572 54439.86 DRG Hospital Inpatient Facility Fee DRG SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC MS-DRG 458 N/A 107178.61 75025.027 3078 107178.61 39971.3781534 43404.54 46490.26 43404.54 39971.3781534 39971.3781534 39971.3781534 5377 43404.54 47744.994000000006 43404.54 54328.617255 43404.54 43404.54 44272.6308 43404.54 DRG Hospital Inpatient Facility Fee DRG SPINAL FUSION EXCEPT CERVICAL WITH MCC MS-DRG 459 N/A 176973.88 123881.716 3078 176973.88 32563.8591414 59816.4 63419.04 59816.4 32563.8591414 32563.8591414 32563.8591414 5377 59816.4 65798.04000000001 59816.4 44260.406355 59816.4 59816.4 61012.728 59816.4 DRG Hospital Inpatient Facility Fee DRG SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC MS-DRG 460 N/A 79728.89 55810.223 3078 79728.89 35118.9164238 33961.79 36750.09 33961.79 35118.9164238 35118.9164238 35118.9164238 5377 33961.79 37357.969000000005 33961.79 47733.209535 33961.79 33961.79 34641.0258 33961.79 DRG Hospital Inpatient Facility Fee DRG BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC MS-DRG 461 N/A 373981.41 261786.98699999996 3078 373981.41 45912.9002466 57852.27 130556.06 57852.27 45912.9002466 45912.9002466 45912.9002466 5377 57852.27 63637.497 57852.27 62404.262745 57852.27 57852.27 59009.3154 57852.27 DRG Hospital Inpatient Facility Fee DRG BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC MS-DRG 462 N/A 76509.89 53556.922999999995 3078 76509.89 22118.183781 26924.14 29490.8 26924.14 22118.183781 22118.183781 22118.183781 5377 26924.14 29616.554 26924.14 30062.769825 26924.14 26924.14 27462.6228 26924.14 DRG Hospital Inpatient Facility Fee DRG WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC MS-DRG 463 N/A 126655.08 88658.556 3078 126655.08 42470.3720874 47268.75 50476.2 47268.75 42470.3720874 42470.3720874 42470.3720874 5377 47268.75 51995.62500000001 47268.75 57725.21980499999 47268.75 47268.75 48214.125 47268.75 DRG Hospital Inpatient Facility Fee DRG WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC MS-DRG 464 N/A 44462.9 31124.03 3078 45634.34 17747.0318616 26938.57 29505.67 26938.57 17747.0318616 17747.0318616 17747.0318616 5377 26938.57 29632.427000000003 26938.57 24121.55262 26938.57 26938.57 27477.3414 26938.57 DRG Hospital Inpatient Facility Fee DRG WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC MS-DRG 465 N/A 27625.55 19337.885 3078 31322.68 43668.57705479999 17970.17 20254.8 17970.17 43668.57705479999 43668.57705479999 43668.57705479999 5377 17970.17 19767.186999999998 17970.17 59353.805609999996 17970.17 17970.17 18329.573399999997 17970.17 DRG Hospital Inpatient Facility Fee DRG REVISION OF HIP OR KNEE REPLACEMENT WITH MCC MS-DRG 466 N/A 70708.36 49495.852 3078 78127.36 21271.8657876 47300.31 50508.72 47300.31 21271.8657876 21271.8657876 21271.8657876 5377 47300.31 52030.341 47300.31 28912.46457 47300.31 47300.31 48246.3162 47300.31 DRG Hospital Inpatient Facility Fee DRG REVISION OF HIP OR KNEE REPLACEMENT WITH CC MS-DRG 467 N/A 64303.7 45012.59 3078 64303.7 15765.7292724 32698.37 35446.89 32698.37 15765.7292724 15765.7292724 15765.7292724 5377 32698.37 35968.207 32698.37 21428.589930000002 32698.37 32698.37 33352.3374 32698.37 DRG Hospital Inpatient Facility Fee DRG REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC MS-DRG 468 N/A 115598.48 80918.93599999999 3078 115598.48 31758.694031400002 25153.91 27664.79 25153.91 31758.694031400002 31758.694031400002 31758.694031400002 5377 25153.91 27669.301000000003 25153.91 43166.035605000005 25153.91 25153.91 25656.9882 25153.91 DRG Hospital Inpatient Facility Fee DRG MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT MS-DRG 469 N/A 88757.58 62130.306 3078 88757.58 19787.9763108 29140.77 31777.22 29140.77 19787.9763108 19787.9763108 19787.9763108 5377 29140.77 32054.847 29140.77 26895.57981 29140.77 29140.77 29723.5854 29140.77 DRG Hospital Inpatient Facility Fee DRG MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC MS-DRG 470 N/A 27601.38 19320.966 3078 30159.9 17123.178006 17241.51 19503.2 17241.51 17123.178006 17123.178006 17123.178006 5377 17241.51 18965.661 17241.51 23273.61795 17241.51 17241.51 17586.3402 17241.51 DRG Hospital Inpatient Facility Fee DRG CERVICAL SPINAL FUSION WITH MCC MS-DRG 471 N/A 389336.94 272535.858 3078 389336.94 21709.63704 45423.66 134535.63 45423.66 21709.63704 21709.63704 21709.63704 5377 45423.66 49966.026000000005 45423.66 29507.478 45423.66 45423.66 46332.133200000004 45423.66 DRG Hospital Inpatient Facility Fee DRG CERVICAL SPINAL FUSION WITH CC MS-DRG 472 N/A 70030.12 49021.083999999995 3078 70030.12 11842.4877216 27694.28 30285.17 27694.28 11842.4877216 11842.4877216 11842.4877216 5377 27694.28 30463.708000000002 27694.28 16096.16712 27694.28 27694.28 28248.1656 27694.28 DRG Hospital Inpatient Facility Fee DRG CERVICAL SPINAL FUSION WITHOUT CC/MCC MS-DRG 473 N/A 34258.62 23981.034 3078 39128.26 25959.119564999997 22861.53 25300.24 22861.53 25959.119564999997 25959.119564999997 25959.119564999997 5377 22861.53 25147.683 22861.53 35283.323625 22861.53 22861.53 23318.760599999998 22861.53 DRG Hospital Inpatient Facility Fee DRG AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC MS-DRG 474 N/A 67395.91 47177.137 3078 67395.91 17744.6461872 36945.84 39828.15 36945.84 17744.6461872 17744.6461872 17744.6461872 5377 36945.84 40640.424 36945.84 24118.31004 36945.84 36945.84 37684.756799999996 36945.84 DRG Hospital Inpatient Facility Fee DRG AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC MS-DRG 475 N/A 72229.3 50560.51 3078 72229.3 14210.865982199999 20030.78 22380.33 20030.78 14210.865982199999 14210.865982199999 14210.865982199999 5377 20030.78 22033.858 20030.78 19315.238415 20030.78 20030.78 20431.3956 20030.78 DRG Hospital Inpatient Facility Fee DRG AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC MS-DRG 476 N/A 76416.87 53491.808999999994 3078 76416.87 13373.4942678 11069.6 13136.88 11069.6 13373.4942678 13373.4942678 13373.4942678 5377 11069.6 12176.560000000001 11069.6 18177.092835 11069.6 11069.6 11290.992 11069.6 DRG Hospital Inpatient Facility Fee DRG BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC MS-DRG 477 N/A 89449.11 62614.37699999999 3078 89449.11 16649.621637599997 30686.45 33371.59 30686.45 16649.621637599997 16649.621637599997 16649.621637599997 5377 30686.45 33755.095 30686.45 22629.965819999998 30686.45 30686.45 31300.179 30686.45 DRG Hospital Inpatient Facility Fee DRG BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC MS-DRG 478 N/A 35593.66 24915.562 3078 36448.67 7726.0065444 21182.38 23568.18 21182.38 7726.0065444 7726.0065444 7726.0065444 5377 21182.38 23300.618000000002 21182.38 10501.09533 21182.38 21182.38 21606.0276 21182.38 DRG Hospital Inpatient Facility Fee DRG BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC MS-DRG 479 N/A 83074.35 58152.045 3078 83074.35 22527.3269406 15947.43 18168.36 15947.43 22527.3269406 22527.3269406 22527.3269406 5377 15947.43 17542.173000000003 15947.43 30618.872294999997 15947.43 15947.43 16266.3786 15947.43 DRG Hospital Inpatient Facility Fee DRG HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC MS-DRG 480 N/A 72083.34 50458.337999999996 3078 72083.34 10800.544427399998 26747.39 34435.42 26747.39 10800.544427399998 10800.544427399998 10800.544427399998 5377 26747.39 29422.129 26747.39 14679.970304999999 26747.39 26747.39 27282.3378 26747.39 DRG Hospital Inpatient Facility Fee DRG HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC MS-DRG 481 N/A 85845.69 60091.983 3078 85845.69 8315.2681212 19049.62 21368.24 19049.62 8315.2681212 8315.2681212 8315.2681212 5377 19049.62 20954.582000000002 19049.62 11302.01259 19049.62 19049.62 19430.612399999998 19049.62 DRG Hospital Inpatient Facility Fee DRG HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC MS-DRG 482 N/A 37525.16 26267.612 3078 37525.16 20318.1924462 14844.53 17030.72 14844.53 20318.1924462 20318.1924462 20318.1924462 5377 14844.53 16328.983000000002 14844.53 27616.243215 14844.53 14844.53 15141.420600000001 14844.53 DRG Hospital Inpatient Facility Fee DRG MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES MS-DRG 483 N/A 67916.65 47541.65499999999 3078 67916.65 16295.945407799998 21260.84 23649.12 21260.84 16295.945407799998 16295.945407799998 16295.945407799998 5377 21260.84 23386.924000000003 21260.84 22149.253334999998 21260.84 21260.84 21686.056800000002 21260.84 DRG Hospital Inpatient Facility Fee DRG MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W/O CC/MCC MS-DRG 484 N/A 52588.54 36811.977999999996 3078 52588.54 12598.150087799999 26294.27 22460.31 26294.27 12598.150087799999 12598.150087799999 12598.150087799999 5377 26294.27 28923.697000000004 26294.27 17123.254334999998 26294.27 26294.27 26820.1554 26294.27 DRG Hospital Inpatient Facility Fee DRG KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC MS-DRG 485 N/A 233889.68 163722.77599999998 3078 233889.68 13836.3151014 29317.52 65654.51 29317.52 13836.3151014 13836.3151014 13836.3151014 5377 29317.52 32249.272000000004 29317.52 18806.153355 29317.52 29317.52 29903.8704 29317.52 DRG Hospital Inpatient Facility Fee DRG KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC MS-DRG 486 N/A 70710.76 49497.53199999999 3078 70710.76 66468.11439999999 18811.55 21122.66 18811.55 0 0 0 5377 18811.55 20692.705 18811.55 18811.55 18811.55 19187.781 18811.55 DRG Hospital Inpatient Facility Fee DRG KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC MS-DRG 487 N/A 34833.67 24383.568999999996 3078 34833.67 21522.3615996 14464.87 16639.09 14464.87 21522.3615996 21522.3615996 21522.3615996 5377 14464.87 15911.357000000002 14464.87 29252.93547 14464.87 14464.87 14754.1674 14464.87 DRG Hospital Inpatient Facility Fee DRG KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC MS-DRG 488 N/A 61441.57 43009.098999999995 3078 61441.57 11971.910557799998 20463.65 22826.81 20463.65 11971.910557799998 11971.910557799998 11971.910557799998 5377 20463.65 22510.015000000003 20463.65 16272.077084999999 20463.65 20463.65 20872.923000000003 20463.65 DRG Hospital Inpatient Facility Fee DRG KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC MS-DRG 489 N/A 43380 30365.999999999996 3078 43380 8101.1538438 11989.43 14085.7 11989.43 8101.1538438 8101.1538438 8101.1538438 5377 11989.43 13188.373000000001 11989.43 11010.991035000001 11989.43 11989.43 12229.2186 11989.43 DRG Hospital Inpatient Facility Fee DRG BACK & NECK PROC EXC SPINAL FUSION W CC/MCC OR DISC DEVICE/NEUROSTIM MS-DRG 490 N/A 158640.2 111048.14 3078 158640.2 20367.098771399997 79320.1 31398.27 79320.1 20367.098771399997 20367.098771399997 20367.098771399997 5377 79320.1 87252.11000000002 79320.1 27682.716105 79320.1 79320.1 80906.50200000001 79320.1 DRG Hospital Inpatient Facility Fee DRG BACK & NECK PROC EXC SPINAL FUSION W/O CC/MCC MS-DRG 491 N/A 37716.55 26401.585 3078 37716.55 13229.1609666 18858.28 11851.35 18858.28 13229.1609666 13229.1609666 13229.1609666 5377 18858.28 20744.108 18858.28 17980.916745000002 18858.28 18858.28 19235.4456 18858.28 DRG Hospital Inpatient Facility Fee DRG LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC MS-DRG 492 N/A 67420.69 47194.483 3078 67420.69 63375.448599999996 31435.85 34144.61 31435.85 0 0 0 5377 31435.85 34579.435 31435.85 31435.85 31435.85 32064.567 31435.85 DRG Hospital Inpatient Facility Fee DRG LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC MS-DRG 493 N/A 27615.92 19331.143999999997 3078 36835.81 34625.6614 21424.96 23818.42 21424.96 0 0 0 5377 21424.96 23567.456000000002 21424.96 21424.96 21424.96 21853.4592 21424.96 DRG Hospital Inpatient Facility Fee DRG LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC MS-DRG 494 N/A 42400.19 29680.132999999998 3078 42400.19 19716.4060788 17033.2 19288.31 17033.2 19716.4060788 19716.4060788 19716.4060788 5377 17033.2 18736.520000000004 17033.2 26798.30241 17033.2 17033.2 17373.864 17033.2 DRG Hospital Inpatient Facility Fee DRG LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC MS-DRG 495 N/A 127136.41 88995.487 3078 127136.41 18570.6859482 33496.46 36270.1 33496.46 18570.6859482 18570.6859482 18570.6859482 5377 33496.46 36846.106 33496.46 25241.053365 33496.46 33496.46 34166.3892 33496.46 DRG Hospital Inpatient Facility Fee DRG LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC MS-DRG 496 N/A 92723.42 64906.39399999999 3078 92723.42 12500.933856 18935.09 21250.12 18935.09 12500.933856 12500.933856 12500.933856 5377 18935.09 20828.599000000002 18935.09 16991.1192 18935.09 18935.09 19313.7918 18935.09 DRG Hospital Inpatient Facility Fee DRG LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC MS-DRG 497 N/A 21754.39 15228.072999999999 3078 24544.62 24590.338878 13722.69 15873.56 13722.69 24590.338878 24590.338878 24590.338878 5377 13722.69 15094.959000000003 13722.69 33422.89335 13722.69 13722.69 13997.143800000002 13722.69 DRG Hospital Inpatient Facility Fee DRG LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC MS-DRG 498 N/A 27946.82 19562.773999999998 3078 39531.17 11591.9919096 23114.04 25560.66 23114.04 11591.9919096 11591.9919096 11591.9919096 5377 23114.04 25425.444000000003 23114.04 15755.69622 23114.04 23114.04 23576.3208 23114.04 DRG Hospital Inpatient Facility Fee DRG LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC MS-DRG 499 N/A 130921.62 91645.13399999999 3078 130921.62 9394.189368599998 11892.04 18666.35 11892.04 9394.189368599998 9394.189368599998 9394.189368599998 5377 11892.04 13081.244000000002 11892.04 12768.469395 11892.04 11892.04 12129.8808 11892.04 DRG Hospital Inpatient Facility Fee DRG SOFT TISSUE PROCEDURES WITH MCC MS-DRG 500 N/A 176939.48 123857.636 3078 176939.48 11664.1585602 28898.19 41523.35 28898.19 11664.1585602 11664.1585602 11664.1585602 5377 28898.19 31788.009000000002 28898.19 15853.784265 28898.19 28898.19 29476.1538 28898.19 DRG Hospital Inpatient Facility Fee DRG SOFT TISSUE PROCEDURES WITH CC MS-DRG 501 N/A 62985.41 44089.787 3078 62985.41 11624.7949326 15851.84 18069.75 15851.84 11624.7949326 11624.7949326 11624.7949326 5377 15851.84 17437.024 15851.84 15800.281695 15851.84 15851.84 16168.8768 15851.84 DRG Hospital Inpatient Facility Fee DRG SOFT TISSUE PROCEDURES WITHOUT CC/MCC MS-DRG 502 N/A 51141.78 35799.246 3078 51141.78 14701.71849 12395.24 14504.29 12395.24 14701.71849 14701.71849 14701.71849 5377 12395.24 13634.764000000001 12395.24 19982.39925 12395.24 12395.24 12643.1448 12395.24 DRG Hospital Inpatient Facility Fee DRG FOOT PROCEDURES WITH MCC MS-DRG 503 N/A 204187.44 142931.20799999998 3078 204187.44 11414.855585399999 22845.3 51808.98 22845.3 11414.855585399999 11414.855585399999 11414.855585399999 5377 22845.3 25129.83 22845.3 15514.934655 22845.3 22845.3 23302.206 22845.3 DRG Hospital Inpatient Facility Fee DRG FOOT PROCEDURES WITH CC MS-DRG 504 N/A 68072.88 47651.016 3078 68072.88 10788.0196368 16005.15 18227.9 16005.15 10788.0196368 10788.0196368 10788.0196368 5377 16005.15 17605.665 16005.15 14662.946759999999 16005.15 16005.15 16325.253 16005.15 DRG Hospital Inpatient Facility Fee DRG FOOT PROCEDURES WITHOUT CC/MCC MS-DRG 505 N/A 52428.48 36699.936 3078 52428.48 16771.291031999997 15933 18153.49 15933 16771.291031999997 16771.291031999997 16771.291031999997 5377 15933 17526.300000000003 15933 22795.337399999997 15933 15933 16251.66 15933 DRG Hospital Inpatient Facility Fee DRG MAJOR THUMB OR JOINT PROCEDURES MS-DRG 506 N/A 38743.03 27120.121 3078 38743.03 13399.1402676 12713.58 14832.63 12713.58 13399.1402676 13399.1402676 13399.1402676 5377 12713.58 13984.938000000002 12713.58 18211.950569999997 12713.58 12713.58 12967.8516 12713.58 DRG Hospital Inpatient Facility Fee DRG MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC MS-DRG 507 N/A 63525.09 44467.562999999995 3078 63525.09 13997.944542 16726.59 18972.05 16726.59 13997.944542 13997.944542 13997.944542 5377 16726.59 18399.249000000003 16726.59 19025.83815 16726.59 16726.59 17061.1218 16726.59 DRG Hospital Inpatient Facility Fee DRG MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC MS-DRG 508 N/A 31317.65 21922.355 3078 31317.65 9333.354671399999 13059.87 15189.86 13059.87 9333.354671399999 9333.354671399999 9333.354671399999 5377 13059.87 14365.857000000002 13059.87 12685.783604999999 13059.87 13059.87 13321.067400000002 13059.87 DRG Hospital Inpatient Facility Fee DRG ARTHROSCOPY MS-DRG 509 N/A 136252.68 95376.87599999999 3078 136252.68 12279.0661368 13688.42 21279.27 13688.42 12279.0661368 12279.0661368 12279.0661368 5377 13688.42 15057.262 13688.42 16689.55926 13688.42 13688.42 13962.188400000001 13688.42 DRG Hospital Inpatient Facility Fee DRG SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC MS-DRG 510 N/A 61412.99 42989.09299999999 3078 61412.99 9587.428994999998 26044.89 28583.85 26044.89 9587.428994999998 9587.428994999998 9587.428994999998 5377 26044.89 28649.379 26044.89 13031.118375 26044.89 26044.89 26565.7878 26044.89 DRG Hospital Inpatient Facility Fee DRG SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC MS-DRG 511 N/A 43788.19 30651.733 3078 43788.19 10049.0569914 17846.62 20127.38 17846.62 10049.0569914 10049.0569914 10049.0569914 5377 17846.62 19631.282 17846.62 13658.557605 17846.62 17846.62 18203.5524 17846.62 DRG Hospital Inpatient Facility Fee DRG SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC MS-DRG 512 N/A 43239.4 30267.579999999998 3078 43239.4 19119.987478799998 14487.42 16662.36 14487.42 19119.987478799998 19119.987478799998 19119.987478799998 5377 14487.42 15936.162000000002 14487.42 25987.65741 14487.42 14487.42 14777.1684 14487.42 DRG Hospital Inpatient Facility Fee DRG HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC MS-DRG 513 N/A 26265.22 18385.654 3078 26265.22 14930.146813799998 14374.69 16546.08 14374.69 14930.146813799998 14930.146813799998 14930.146813799998 5377 14374.69 15812.159000000001 14374.69 20292.876285 14374.69 14374.69 14662.1838 14374.69 DRG Hospital Inpatient Facility Fee DRG HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC MS-DRG 514 N/A 33195.87 23237.109 3078 33195.87 11520.4216776 9312.89 11324.85 9312.89 11520.4216776 11520.4216776 11520.4216776 5377 9312.89 10244.179 9312.89 15658.418819999999 9312.89 9312.89 9499.147799999999 9312.89 DRG Hospital Inpatient Facility Fee DRG OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC MS-DRG 515 N/A 58121.58 40685.106 3078 58121.58 9320.2334622 28116.32 30720.52 28116.32 9320.2334622 9320.2334622 9320.2334622 5377 28116.32 30927.952 28116.32 12667.949415 28116.32 28116.32 28678.6464 28116.32 DRG Hospital Inpatient Facility Fee DRG OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC MS-DRG 516 N/A 40642.75 28449.925 3078 40642.75 6335.1583691999995 18340.81 20637.12 18340.81 6335.1583691999995 6335.1583691999995 6335.1583691999995 5377 18340.81 20174.891000000003 18340.81 8610.671190000001 18340.81 18340.81 18707.626200000002 18340.81 DRG Hospital Inpatient Facility Fee DRG OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 517 N/A 34106.68 23874.676 3078 34106.68 22952.573402399998 13616.28 15763.77 13616.28 22952.573402399998 22952.573402399998 22952.573402399998 5377 13616.28 14977.908000000001 13616.28 31196.862179999996 13616.28 13616.28 13888.6056 13616.28 DRG Hospital Inpatient Facility Fee DRG BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR MS-DRG 518 N/A 97896.3 68527.41 3078 97896.3 14130.349471200001 33616.4 36393.84 33616.4 14130.349471200001 14130.349471200001 14130.349471200001 5377 33616.4 36978.04000000001 33616.4 19205.80134 33616.4 33616.4 34288.728 33616.4 DRG Hospital Inpatient Facility Fee DRG BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC MS-DRG 519 N/A 48442 33909.4 3078 48442 11606.902374599998 18029.69 20316.19 18029.69 11606.902374599998 11606.902374599998 11606.902374599998 5377 18029.69 19832.659 18029.69 15775.962345 18029.69 18029.69 18390.283799999997 18029.69 DRG Hospital Inpatient Facility Fee DRG BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC MS-DRG 520 N/A 39307.68 27515.376 3078 39307.68 21802.6783416 13344.84 15483.79 13344.84 21802.6783416 21802.6783416 21802.6783416 5377 13344.84 14679.324 13344.84 29633.93862 13344.84 13344.84 13611.7368 13344.84 DRG Hospital Inpatient Facility Fee DRG HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC MS-DRG 521 N/A 57374.18 40161.926 590 57374.18 12842.6817138 27227.15 29803.32 27227.15 12842.6817138 12842.6817138 12842.6817138 5377 27227.15 29949.865000000005 27227.15 17455.618785000002 27227.15 27227.15 27771.693000000003 27227.15 DRG Hospital Inpatient Facility Fee DRG HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC MS-DRG 522 N/A 78575.38 55002.766 590 78575.38 10907.3033568 19595.21 21931.02 19595.21 10907.3033568 10907.3033568 10907.3033568 5377 19595.21 21554.731 19595.21 14825.07576 19595.21 19595.21 19987.1142 19595.21 DRG Hospital Inpatient Facility Fee DRG ALC/DRUG ABUSE OR DEPEND W/O REHABILITATION THERAPY W/O CC MS-DRG 523 N/A 13879.32 9715.524 72.18 13879.32 19987.7765418 6939.66 72.18 6939.66 19987.7765418 19987.7765418 19987.7765418 5377 6939.66 7633.626 6939.66 27167.145885 6939.66 6939.66 7078.4532 6939.66 DRG Hospital Inpatient Facility Fee DRG TRANSIENT ISCHEMIA MS-DRG 524 N/A 26575.49 18602.843 72.18 26575.49 13683.0355212 13287.75 72.18 13287.75 13683.0355212 13683.0355212 13683.0355212 5377 13287.75 14616.525000000001 13287.75 18597.81759 13287.75 13287.75 13553.505000000001 13287.75 DRG Hospital Inpatient Facility Fee DRG SPINAL PROCEDURES W CC MS-DRG 531 N/A 152879.4 107015.57999999999 72.18 152879.4 143706.636 76439.7 72.18 76439.7 0 0 0 5377 76439.7 84083.67 76439.7 76439.7 76439.7 77968.49399999999 76439.7 DRG Hospital Inpatient Facility Fee DRG SPINAL PROCEDURES W/O CC MS-DRG 532 N/A 63324.8 44327.36 72.18 63324.8 59525.312 31662.4 72.18 31662.4 0 0 0 5377 31662.4 34828.64000000001 31662.4 31662.4 31662.4 32295.648 31662.4 DRG Hospital Inpatient Facility Fee DRG FRACTURES OF FEMUR WITH MCC MS-DRG 533 N/A 39680.04 27776.028 3078 39680.04 37299.2376 12862.37 14986.13 12862.37 0 0 0 5377 12862.37 14148.607000000002 12862.37 12862.37 12862.37 13119.617400000001 12862.37 DRG Hospital Inpatient Facility Fee DRG FRACTURES OF FEMUR WITHOUT MCC MS-DRG 534 N/A 14318.46 10022.921999999999 2878.94 14318.46 13459.352399999998 7177.43 9122.12 7177.43 0 0 0 5377 7177.43 7895.173000000001 7177.43 7177.43 7177.43 7320.9786 7177.43 DRG Hospital Inpatient Facility Fee DRG FRACTURES OF HIP AND PELVIS WITH MCC MS-DRG 535 N/A 29592.09 20714.463 3078 29592.09 9442.4992752 11628.71 13713.6 11628.71 9442.4992752 9442.4992752 9442.4992752 5377 11628.71 12791.581 11628.71 12834.13164 11628.71 11628.71 11861.2842 11628.71 DRG Hospital Inpatient Facility Fee DRG FRACTURES OF HIP AND PELVIS WITHOUT MCC MS-DRG 536 N/A 12027.7 8419.39 3078 13829.2 3242.7279281999995 7007.89 8947.24 7007.89 3242.7279281999995 3242.7279281999995 3242.7279281999995 5377 7007.89 7708.679000000001 7007.89 4407.476865 7007.89 7007.89 7148.0478 7007.89 DRG Hospital Inpatient Facility Fee DRG SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC MS-DRG 537 N/A 30271.38 21189.966 3078 30271.38 8536.5394218 8958.48 10959.27 8958.48 8536.5394218 8536.5394218 8536.5394218 5377 8958.48 9854.328 8958.48 11602.761885 8958.48 8958.48 9137.649599999999 8958.48 DRG Hospital Inpatient Facility Fee DRG SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC MS-DRG 538 N/A 27988.28 19591.796 3078 27988.28 4811.3088462 6278.33 8194.71 6278.33 4811.3088462 4811.3088462 4811.3088462 5377 6278.33 6906.1630000000005 6278.33 6539.473215 6278.33 6278.33 6403.8966 6278.33 DRG Hospital Inpatient Facility Fee DRG OSTEOMYELITIS WITH MCC MS-DRG 539 N/A 4927.45 3449.2149999999997 2243.72 31368.71 6576.7079022 17999.03 20284.55 17999.03 6576.7079022 6576.7079022 6576.7079022 5377 17999.03 19798.933 17999.03 8938.982415 17999.03 17999.03 18359.010599999998 17999.03 DRG Hospital Inpatient Facility Fee DRG OSTEOMYELITIS WITH CC MS-DRG 540 N/A 17946.29 12562.403 2080.55 22024.75 4609.1229408 12143.64 14244.74 12143.64 4609.1229408 4609.1229408 4609.1229408 5377 12143.64 13358.004 12143.64 6264.66456 12143.64 12143.64 12386.5128 12143.64 DRG Hospital Inpatient Facility Fee DRG OSTEOMYELITIS WITHOUT CC/MCC MS-DRG 541 N/A 47911 33537.7 3078 47911 9649.456529399999 7376.72 9327.71 7376.72 9649.456529399999 9649.456529399999 9649.456529399999 5377 7376.72 8114.392000000001 7376.72 13115.425454999999 7376.72 7376.72 7524.254400000001 7376.72 DRG Hospital Inpatient Facility Fee DRG PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC MS-DRG 542 N/A 31573.4 22101.38 3078 31573.4 7080.6816192 16484.9 18722.74 16484.9 7080.6816192 7080.6816192 7080.6816192 5377 16484.9 18133.390000000003 16484.9 9623.97744 16484.9 16484.9 16814.598 16484.9 DRG Hospital Inpatient Facility Fee DRG PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC MS-DRG 543 N/A 22892.29 16024.603 3078 22892.29 5340.9285629999995 9820.6 11848.55 9820.6 5340.9285629999995 5340.9285629999995 5340.9285629999995 5377 9820.6 10802.660000000002 9820.6 7259.325975 9820.6 9820.6 10017.012 9820.6 DRG Hospital Inpatient Facility Fee DRG PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC MS-DRG 544 N/A 14717.25 10302.074999999999 3078 14717.25 10069.931642399999 7016.91 8956.54 7016.91 10069.931642399999 10069.931642399999 10069.931642399999 5377 7016.91 7718.601000000001 7016.91 13686.93018 7016.91 7016.91 7157.2482 7016.91 DRG Hospital Inpatient Facility Fee DRG CONNECTIVE TISSUE DISORDERS WITH MCC MS-DRG 545 N/A 12536.7 8775.69 3078 38746.91 8333.1606792 22622.55 25053.72 22622.55 8333.1606792 8333.1606792 8333.1606792 5377 22622.55 24884.805 22622.55 11326.33194 22622.55 22622.55 23075.001 22622.55 DRG Hospital Inpatient Facility Fee DRG CONNECTIVE TISSUE DISORDERS WITH CC MS-DRG 546 N/A 44913.39 31439.372999999996 3078 44913.39 4479.1036859999995 10872.1 12933.17 10872.1 4479.1036859999995 4479.1036859999995 4479.1036859999995 5377 10872.1 11959.310000000001 10872.1 6087.94395 10872.1 10872.1 11089.542000000001 10872.1 DRG Hospital Inpatient Facility Fee DRG CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC MS-DRG 547 N/A 18778.51 13144.956999999999 3078 18778.51 18417.406368 8249.67 10228.13 8249.67 18417.406368 18417.406368 18417.406368 5377 8249.67 9074.637 8249.67 25032.7176 8249.67 8249.67 8414.6634 8249.67 DRG Hospital Inpatient Facility Fee DRG SEPTIC ARTHRITIS WITH MCC MS-DRG 548 N/A 32771.75 22940.225 3078 32771.75 8476.8975618 17494.02 19763.64 17494.02 8476.8975618 8476.8975618 8476.8975618 5377 17494.02 19243.422000000002 17494.02 11521.697385 17494.02 17494.02 17843.900400000002 17494.02 DRG Hospital Inpatient Facility Fee DRG SEPTIC ARTHRITIS WITH CC MS-DRG 549 N/A 14036.2 9825.34 3078 20083.41 5572.3389798 10927.11 12989.9 10927.11 5572.3389798 5572.3389798 5572.3389798 5377 10927.11 12019.821000000002 10927.11 7573.856235 10927.11 10927.11 11145.6522 10927.11 DRG Hospital Inpatient Facility Fee DRG SEPTIC ARTHRITIS WITHOUT CC/MCC MS-DRG 550 N/A 6275.35 4392.745 2857.49 17731.98 12842.6817138 9453.57 11469.96 9453.57 12842.6817138 12842.6817138 12842.6817138 5377 9453.57 10398.927 9453.57 17455.618785000002 9453.57 9453.57 9642.6414 9453.57 DRG Hospital Inpatient Facility Fee DRG MEDICAL BACK PROBLEMS WITH MCC MS-DRG 551 N/A 8515.08 5960.556 3078 26727.7 8193.002308199999 15090.72 17284.68 15090.72 8193.002308199999 8193.002308199999 8193.002308199999 5377 15090.72 16599.792 15090.72 11135.830365 15090.72 15090.72 15392.5344 15090.72 DRG Hospital Inpatient Facility Fee DRG MEDICAL BACK PROBLEMS WITHOUT MCC MS-DRG 552 N/A 19879.32 13915.524 3078 19879.32 6279.0950207999995 8661.79 10653.24 8661.79 6279.0950207999995 6279.0950207999995 6279.0950207999995 5377 8661.79 9527.969000000001 8661.79 8534.47056 8661.79 8661.79 8835.025800000001 8661.79 DRG Hospital Inpatient Facility Fee DRG BONE DISEASES AND ARTHROPATHIES WITH MCC MS-DRG 553 N/A 18942.62 13259.833999999999 3078 21726.9 7337.738035799999 11956.97 14052.22 11956.97 7337.738035799999 7337.738035799999 7337.738035799999 5377 11956.97 13152.667 11956.97 9973.365435 11956.97 11956.97 12196.1094 11956.97 DRG Hospital Inpatient Facility Fee DRG BONE DISEASES AND ARTHROPATHIES WITHOUT MCC MS-DRG 554 N/A 11257.1 7879.969999999999 2671.11 14449.43 4677.1146612 7396.56 9348.16 7396.56 4677.1146612 4677.1146612 4677.1146612 5377 7396.56 8136.216000000001 7396.56 6357.07809 7396.56 7396.56 7544.4912 7396.56 DRG Hospital Inpatient Facility Fee DRG SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC MS-DRG 555 N/A 76861.44 53803.008 3078 76861.44 8777.4925362 12004.76 14101.51 12004.76 8777.4925362 8777.4925362 8777.4925362 5377 12004.76 13205.236 12004.76 11930.262465 12004.76 12004.76 12244.8552 12004.76 DRG Hospital Inpatient Facility Fee DRG SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC MS-DRG 556 N/A 21056.7 14739.689999999999 3058.8 21056.7 3696.0060642 7286.54 9234.68 7286.54 3696.0060642 3696.0060642 3696.0060642 5377 7286.54 8015.194 7286.54 5023.567065 7286.54 7286.54 7432.2708 7286.54 DRG Hospital Inpatient Facility Fee DRG TENDONITIS, MYOSITIS AND BURSITIS WITH MCC MS-DRG 557 N/A 43706.81 30594.766999999996 2498.75 43706.81 8499.561468599999 12912.87 15038.21 12912.87 8499.561468599999 8499.561468599999 8499.561468599999 5377 12912.87 14204.157000000003 12912.87 11552.501895 12912.87 12912.87 13171.127400000001 12912.87 DRG Hospital Inpatient Facility Fee DRG TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC MS-DRG 558 N/A 10134.19 7093.933 2132.54 15151.72 4887.650427 7836.64 9802.11 7836.64 4887.650427 4887.650427 4887.650427 5377 7836.64 8620.304000000002 7836.64 6643.235775 7836.64 7836.64 7993.3728 7836.64 DRG Hospital Inpatient Facility Fee DRG AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC MS-DRG 559 N/A 79503.05 55652.135 1750.35 79503.05 5640.927118799999 16097.13 18322.78 16097.13 5640.927118799999 5640.927118799999 5640.927118799999 5377 16097.13 17706.843 16097.13 7667.08041 16097.13 16097.13 16419.0726 16097.13 DRG Hospital Inpatient Facility Fee DRG AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC MS-DRG 560 N/A 55806.65 39064.655 1893.57 55806.65 3235.5709049999996 9880.12 11909.96 9880.12 3235.5709049999996 3235.5709049999996 3235.5709049999996 5377 9880.12 10868.132000000001 9880.12 4397.749124999999 9880.12 9880.12 10077.7224 9880.12 DRG Hospital Inpatient Facility Fee DRG AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC MS-DRG 561 N/A 22377.5 15664.249999999998 1963.75 22377.5 10644.2827542 7126.02 9069.1 7126.02 10644.2827542 10644.2827542 10644.2827542 5377 7126.02 7838.622000000001 7126.02 14467.581315 7126.02 7126.02 7268.540400000001 7126.02 DRG Hospital Inpatient Facility Fee DRG FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC MS-DRG 562 N/A 12082.46 8457.722 3078 23696.98 8346.281888399999 13191.53 15325.66 13191.53 8346.281888399999 8346.281888399999 8346.281888399999 5377 13191.53 14510.683000000003 13191.53 11344.16613 13191.53 13191.53 13455.360600000002 13191.53 DRG Hospital Inpatient Facility Fee DRG FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC MS-DRG 563 N/A 20896.21 14627.346999999998 3078 20896.21 4371.151919399999 7766.3 9729.55 7766.3 4371.151919399999 4371.151919399999 4371.151919399999 5377 7766.3 8542.93 7766.3 5941.217205 7766.3 7766.3 7921.626 7766.3 DRG Hospital Inpatient Facility Fee DRG OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC MS-DRG 564 N/A 36873.68 25811.575999999997 3078 36873.68 9171.7252308 14007.66 16167.49 14007.66 9171.7252308 9171.7252308 9171.7252308 5377 14007.66 15408.426000000001 14007.66 12466.09881 14007.66 14007.66 14287.8132 14007.66 DRG Hospital Inpatient Facility Fee DRG OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC MS-DRG 565 N/A 62513.51 43759.457 3078 62513.51 4870.3542876 8904.37 10903.45 8904.37 4870.3542876 4870.3542876 4870.3542876 5377 8904.37 9794.807000000003 8904.37 6619.72707 8904.37 8904.37 9082.457400000001 8904.37 DRG Hospital Inpatient Facility Fee DRG OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC MS-DRG 566 N/A 2473.45 1731.4149999999997 1126.29 13334.15 11118.4355412 6697.67 8627.26 6697.67 11118.4355412 11118.4355412 11118.4355412 5377 6697.67 7367.437000000001 6697.67 15112.04409 6697.67 6697.67 6831.6234 6697.67 DRG Hospital Inpatient Facility Fee DRG STOMACH, ESOPHAGEAL & DUODENAL PROC AGE > 17 W CC W MAJOR GI DX MS-DRG 567 N/A 92298.76 64609.13199999999 72.18 92298.76 4958.6242403999995 46149.38 72.18 46149.38 4958.6242403999995 4958.6242403999995 4958.6242403999995 5377 46149.38 50764.318 46149.38 6739.7025300000005 46149.38 46149.38 47072.3676 46149.38 DRG Hospital Inpatient Facility Fee DRG MAJOR SMALL & LARGE BOWEL PROCEDURES W CC W MAJOR GI DX MS-DRG 569 N/A 61152.62 42806.834 72.18 61152.62 57483.4628 30576.31 72.18 30576.31 0 0 0 5377 30576.31 33633.941000000006 30576.31 30576.31 30576.31 31187.8362 30576.31 DRG Hospital Inpatient Facility Fee DRG SKIN DEBRIDEMENT WITH MCC MS-DRG 570 N/A 561768.89 393238.223 3078 561768.89 528062.7566 26306.41 203491.52 26306.41 0 0 0 5377 26306.41 28937.051000000003 26306.41 26306.41 26306.41 26832.5382 26306.41 DRG Hospital Inpatient Facility Fee DRG SKIN DEBRIDEMENT WITH CC MS-DRG 571 N/A 58000.61 40600.426999999996 3078 58000.61 54520.573399999994 14867.07 17053.97 14867.07 0 0 0 5377 14867.07 16353.777000000002 14867.07 14867.07 14867.07 15164.4114 14867.07 DRG Hospital Inpatient Facility Fee DRG SKIN DEBRIDEMENT WITHOUT CC/MCC MS-DRG 572 N/A 24179.22 16925.454 3078 24179.22 17283.6146094 10854.06 12914.55 10854.06 17283.6146094 17283.6146094 17283.6146094 5377 10854.06 11939.466 10854.06 23491.681454999998 10854.06 10854.06 11071.1412 10854.06 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC MS-DRG 573 N/A 59670.53 41769.371 3078 87127.38 8750.6536992 52940.17 56326.22 52940.17 8750.6536992 8750.6536992 8750.6536992 5377 52940.17 58234.187000000005 52940.17 11893.783440000001 52940.17 52940.17 53998.9734 52940.17 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC MS-DRG 574 N/A 64056.51 44839.557 3078 64056.51 7491.614034599999 32506.28 35248.75 32506.28 7491.614034599999 7491.614034599999 7491.614034599999 5377 32506.28 35756.908 32506.28 10182.511844999999 32506.28 32506.28 33156.4056 32506.28 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC MS-DRG 575 N/A 66346 46442.2 3078 66346 38864.4252318 18483.29 20784.09 18483.29 38864.4252318 38864.4252318 38864.4252318 5377 18483.29 20331.619000000002 18483.29 52824.060135 18483.29 18483.29 18852.9558 18483.29 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC MS-DRG 576 N/A 12730.44 8911.307999999999 3078 83939.85 23863.304604599998 50942.68 54265.84 50942.68 23863.304604599998 23863.304604599998 23863.304604599998 5377 50942.68 56036.948000000004 50942.68 32434.717095 50942.68 50942.68 51961.5336 50942.68 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC MS-DRG 577 N/A 41098.3 28768.81 3078 41098.3 13569.1195686 23615.44 26077.88 23615.44 13569.1195686 13569.1195686 13569.1195686 5377 23615.44 25976.984 23615.44 18442.984395 23615.44 23615.44 24087.748799999998 23615.44 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC MS-DRG 578 N/A 79712.1 55798.47 3078 79712.1 37397.8318944 15443.32 17648.35 15443.32 37397.8318944 37397.8318944 37397.8318944 5377 15443.32 16987.652000000002 15443.32 50830.68408 15443.32 15443.32 15752.1864 15443.32 DRG Hospital Inpatient Facility Fee DRG OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC MS-DRG 579 N/A 66730.18 46711.12599999999 3078 66730.18 17336.6958648 28422.03 31035.87 28422.03 17336.6958648 17336.6958648 17336.6958648 5377 28422.03 31264.233 28422.03 23563.82886 28422.03 28422.03 28990.4706 28422.03 DRG Hospital Inpatient Facility Fee DRG OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC MS-DRG 580 N/A 18014.15 12609.905 3078 27631.42 12357.196973399998 15657.05 17868.83 15657.05 12357.196973399998 12357.196973399998 12357.196973399998 5377 15657.05 17222.755 15657.05 16795.753754999998 15657.05 15657.05 15970.190999999999 15657.05 DRG Hospital Inpatient Facility Fee DRG OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC MS-DRG 581 N/A 76405.64 53483.948 3078 76405.64 19277.4419892 12728.91 14848.45 12728.91 19277.4419892 19277.4419892 19277.4419892 5377 12728.91 14001.801000000001 12728.91 26201.667690000002 12728.91 12728.91 12983.4882 12728.91 DRG Hospital Inpatient Facility Fee DRG MASTECTOMY FOR MALIGNANCY WITH CC/MCC MS-DRG 582 N/A 47963.77 33574.638999999996 3078 47963.77 13394.965337399997 17448.03 19716.22 17448.03 13394.965337399997 13394.965337399997 13394.965337399997 5377 17448.03 19192.833 17448.03 18206.276055 17448.03 17448.03 17796.990599999997 17448.03 DRG Hospital Inpatient Facility Fee DRG MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC MS-DRG 583 N/A 25052.88 17537.016 3078 25052.88 11838.3127914 13624.39 15772.17 13624.39 11838.3127914 11838.3127914 11838.3127914 5377 13624.39 14986.829 13624.39 16090.492605000001 13624.39 13624.39 13896.8778 13624.39 DRG Hospital Inpatient Facility Fee DRG BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC MS-DRG 584 N/A 67318.6 47123.020000000004 3078 67318.6 12808.6858536 19260.64 21585.91 19260.64 12808.6858536 12808.6858536 12808.6858536 5377 19260.64 21186.704 19260.64 17409.41202 19260.64 19260.64 19645.8528 19260.64 DRG Hospital Inpatient Facility Fee DRG BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC MS-DRG 585 N/A 38958.21 27270.747 3078 38958.21 18494.3443674 16603.04 18844.58 16603.04 18494.3443674 18494.3443674 18494.3443674 5377 16603.04 18263.344 16603.04 25137.290805 16603.04 16603.04 16935.1008 16603.04 DRG Hospital Inpatient Facility Fee DRG SKIN ULCERS WITH MCC MS-DRG 592 N/A 23877.38 16714.166 3078 28319.31 26620.1514 16088.11 18313.47 16088.11 0 0 0 5377 16088.11 17696.921000000002 16088.11 16088.11 16088.11 16409.8722 16088.11 DRG Hospital Inpatient Facility Fee DRG SKIN ULCERS WITH CC MS-DRG 593 N/A 12032.2 8422.54 2236.17 19222.85 18069.479 10387.83 12433.63 10387.83 0 0 0 5377 10387.83 11426.613000000001 10387.83 10387.83 10387.83 10595.5866 10387.83 DRG Hospital Inpatient Facility Fee DRG SKIN ULCERS WITHOUT CC/MCC MS-DRG 594 N/A 51935 36354.5 2951.8 51935 11810.281117199998 6979.03 8917.49 6979.03 11810.281117199998 11810.281117199998 11810.281117199998 5377 6979.03 7676.933 6979.03 16052.39229 6979.03 6979.03 7118.6106 6979.03 DRG Hospital Inpatient Facility Fee DRG MAJOR SKIN DISORDERS WITH MCC MS-DRG 595 N/A 56655 39658.5 3078 56655 9600.550204199999 19311.15 21638 19311.15 9600.550204199999 9600.550204199999 9600.550204199999 5377 19311.15 21242.265000000003 19311.15 13048.952565 19311.15 19311.15 19697.373000000003 19311.15 DRG Hospital Inpatient Facility Fee DRG MAJOR SKIN DISORDERS WITHOUT MCC MS-DRG 596 N/A 8436.85 5905.795 2114.15 18357.97 5123.235774 9845.85 11874.59 9845.85 5123.235774 5123.235774 5123.235774 5377 9845.85 10830.435000000001 9845.85 6963.440549999999 9845.85 9845.85 10042.767 9845.85 DRG Hospital Inpatient Facility Fee DRG MALIGNANT BREAST DISORDERS WITH MCC MS-DRG 597 N/A 19881.41 13916.987 3078 26880.23 9048.266580599999 15186.31 17383.26 15186.31 9048.266580599999 9048.266580599999 9048.266580599999 5377 15186.31 16704.941000000003 15186.31 12298.295294999998 15186.31 15186.31 15490.0362 15186.31 DRG Hospital Inpatient Facility Fee DRG MALIGNANT BREAST DISORDERS WITH CC MS-DRG 598 N/A 181097 126767.9 3078 181097 2713.70463 9632.13 39397.09 9632.13 2713.70463 2713.70463 2713.70463 5377 9632.13 10595.343 9632.13 3688.43475 9632.13 9632.13 9824.7726 9632.13 DRG Hospital Inpatient Facility Fee DRG MALIGNANT BREAST DISORDERS WITHOUT CC/MCC MS-DRG 599 N/A 110652.26 77456.582 3035.96 110652.26 6205.1391144 6741.86 9070.16 6741.86 6205.1391144 6205.1391144 6205.1391144 5377 6741.86 7416.046 6741.86 8433.95058 6741.86 6741.86 6876.6972 6741.86 DRG Hospital Inpatient Facility Fee DRG NON-MALIGNANT BREAST DISORDERS WITH CC/MCC MS-DRG 600 N/A 24740.28 17318.195999999996 2574.43 24740.28 7376.505244799999 9388.64 11402.98 9388.64 7376.505244799999 7376.505244799999 7376.505244799999 5377 9388.64 10327.504 9388.64 10026.057359999999 9388.64 9388.64 9576.4128 9388.64 DRG Hospital Inpatient Facility Fee DRG NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC MS-DRG 601 N/A 19465 13625.5 2670.26 19465 4949.0815428 6347.77 8266.32 6347.77 4949.0815428 4949.0815428 4949.0815428 5377 6347.77 6982.547000000001 6347.77 6726.73221 6347.77 6347.77 6474.7254 6347.77 DRG Hospital Inpatient Facility Fee DRG CELLULITIS WITH MCC MS-DRG 602 N/A 37078.36 25954.852 3078 37078.36 4525.0279182 12996.74 15124.73 12996.74 4525.0279182 4525.0279182 4525.0279182 5377 12996.74 14296.414 12996.74 6150.363615 12996.74 12996.74 13256.6748 12996.74 DRG Hospital Inpatient Facility Fee DRG CELLULITIS WITHOUT MCC MS-DRG 603 N/A 29892.65 20924.855 2633.52 29892.65 1473.7503605999998 7952.07 9921.17 7952.07 1473.7503605999998 1473.7503605999998 1473.7503605999998 5377 7952.07 8747.277 7952.07 2003.1037949999998 7952.07 7952.07 8111.1114 7952.07 DRG Hospital Inpatient Facility Fee DRG TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC MS-DRG 604 N/A 31437.15 22006.005 3078 31437.15 8534.1537474 13609.97 15757.28 13609.97 8534.1537474 8534.1537474 8534.1537474 5377 13609.97 14970.967 13609.97 11599.519305 13609.97 13609.97 13882.169399999999 13609.97 DRG Hospital Inpatient Facility Fee DRG TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC MS-DRG 605 N/A 65545.76 45882.03199999999 3078 65545.76 3768.7691334 8209.99 10187.24 8209.99 3768.7691334 3768.7691334 3768.7691334 5377 8209.99 9030.989000000001 8209.99 5122.465755 8209.99 8209.99 8374.1898 8209.99 DRG Hospital Inpatient Facility Fee DRG MINOR SKIN DISORDERS WITH MCC MS-DRG 606 N/A 25787.91 18051.537 3009.31 25787.91 5664.7838628 13841.73 15996.34 13841.73 5664.7838628 5664.7838628 5664.7838628 5377 13841.73 15225.903 13841.73 7699.50621 13841.73 13841.73 14118.5646 13841.73 DRG Hospital Inpatient Facility Fee DRG MINOR SKIN DISORDERS WITHOUT MCC MS-DRG 607 N/A 7411.7 5188.19 2838.58 14852.36 4841.7261948 7649.07 9608.62 7649.07 4841.7261948 4841.7261948 4841.7261948 5377 7649.07 8413.977 7649.07 6580.81611 7649.07 7649.07 7802.0514 7649.07 DRG Hospital Inpatient Facility Fee DRG ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC MS-DRG 614 N/A 72650.04 50855.02799999999 3078 72650.04 229844.81797499998 21191.4 23577.47 21191.4 229844.81797499998 229844.81797499998 229844.81797499998 5377 21191.4 23310.540000000005 21191.4 312402.316875 21191.4 21191.4 21615.228000000003 21191.4 DRG Hospital Inpatient Facility Fee DRG ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC MS-DRG 615 N/A 28783.68 20148.575999999997 3078 28783.68 46694.8050312 13308.76 15446.57 13308.76 46694.8050312 46694.8050312 46694.8050312 5377 13308.76 14639.636000000002 13308.76 63467.01834 13308.76 13308.76 13574.9352 13308.76 DRG Hospital Inpatient Facility Fee DRG AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC MS-DRG 616 N/A 128738.6 90117.02 3078 128738.6 15034.520068799999 33948.26 36736.15 33948.26 15034.520068799999 15034.520068799999 15034.520068799999 5377 33948.26 37343.086 33948.26 20434.739159999997 33948.26 33948.26 34627.2252 33948.26 DRG Hospital Inpatient Facility Fee DRG AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC MS-DRG 617 N/A 41529.67 29070.768999999997 3078 41529.67 11327.7784698 17530.99 19801.78 17530.99 11327.7784698 11327.7784698 11327.7784698 5377 17530.99 19284.089000000004 17530.99 15396.580485 17530.99 17530.99 17881.609800000002 17530.99 DRG Hospital Inpatient Facility Fee DRG AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC MS-DRG 618 N/A 121878.25 85314.775 3078 121878.25 16203.5005248 10577.21 14582.97 10577.21 16203.5005248 16203.5005248 16203.5005248 5377 10577.21 11634.931 10577.21 22023.60336 10577.21 10577.21 10788.7542 10577.21 DRG Hospital Inpatient Facility Fee DRG O.R. PROCEDURES FOR OBESITY WITH MCC MS-DRG 619 N/A 33781.57 23647.099 3078 44260.02 10399.1547096 26077.35 28617.33 26077.35 10399.1547096 10399.1547096 10399.1547096 5377 26077.35 28685.085 26077.35 14134.40622 26077.35 26077.35 26598.896999999997 26077.35 DRG Hospital Inpatient Facility Fee DRG O.R. PROCEDURES FOR OBESITY WITH CC MS-DRG 620 N/A 81373.57 56961.499 3078 81373.57 7764.7737534 15200.74 17398.15 15200.74 7764.7737534 7764.7737534 7764.7737534 5377 15200.74 16720.814000000002 15200.74 10553.787255000001 15200.74 15200.74 15504.7548 15200.74 DRG Hospital Inpatient Facility Fee DRG O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC MS-DRG 621 N/A 34546.91 24182.837 3078 34546.91 15858.770573999998 14022.99 16183.31 14022.99 15858.770573999998 15858.770573999998 15858.770573999998 5377 14022.99 15425.289 14022.99 21555.050549999996 14022.99 14022.99 14303.4498 14022.99 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC MS-DRG 622 N/A 51124.11 35786.877 3078 54756.7 11181.655912799999 32655.08 35402.24 32655.08 11181.655912799999 11181.655912799999 11181.655912799999 5377 32655.08 35920.588 32655.08 15197.972459999999 32655.08 32655.08 33308.1816 32655.08 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC MS-DRG 623 N/A 36502.44 25551.708 3078 36502.44 10424.8007094 16995.32 19249.25 16995.32 10424.8007094 10424.8007094 10424.8007094 5377 16995.32 18694.852000000003 16995.32 14169.263955 16995.32 16995.32 17335.2264 16995.32 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC MS-DRG 624 N/A 112264.28 78584.996 3078 112264.28 21013.6165338 8918.8 10918.34 8918.8 21013.6165338 21013.6165338 21013.6165338 5377 8918.8 9810.68 8918.8 28561.455285 8918.8 8918.8 9097.176 8918.8 DRG Hospital Inpatient Facility Fee DRG THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC MS-DRG 625 N/A 71098.16 49768.712 3078 71098.16 10010.2897824 25946.59 28482.45 25946.59 10010.2897824 10010.2897824 10010.2897824 5377 25946.59 28541.249000000003 25946.59 13605.865679999999 25946.59 25946.59 26465.521800000002 25946.59 DRG Hospital Inpatient Facility Fee DRG THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC MS-DRG 626 N/A 41061.46 28743.021999999997 3078 41061.46 6547.4833908 14601.95 16780.47 14601.95 6547.4833908 6547.4833908 6547.4833908 5377 14601.95 16062.145000000002 14601.95 8899.260810000002 14601.95 14601.95 14893.989000000001 14601.95 DRG Hospital Inpatient Facility Fee DRG THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC MS-DRG 627 N/A 48536.61 33975.627 3078 48536.61 19047.8208282 11506.07 13587.08 11506.07 19047.8208282 19047.8208282 19047.8208282 5377 11506.07 12656.677000000001 11506.07 25889.569365 11506.07 11506.07 11736.1914 11506.07 DRG Hospital Inpatient Facility Fee DRG OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC MS-DRG 628 N/A 54815.89 38371.123 3078 55097.75 10055.0211774 32868.81 35622.69 32868.81 10055.0211774 10055.0211774 10055.0211774 5377 32868.81 36155.691 32868.81 13666.664055 32868.81 32868.81 33526.1862 32868.81 DRG Hospital Inpatient Facility Fee DRG OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC MS-DRG 629 N/A 39761.51 27833.057 3078 39761.51 8193.002308199999 20234.59 22590.54 20234.59 8193.002308199999 8193.002308199999 8193.002308199999 5377 20234.59 22258.049000000003 20234.59 11135.830365 20234.59 20234.59 20639.2818 20234.59 DRG Hospital Inpatient Facility Fee DRG OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 630 N/A 148101.7 103671.19 3078 148101.7 26680.786070999995 12663.08 26075.82 12663.08 26680.786070999995 26680.786070999995 26680.786070999995 5377 12663.08 13929.388 12663.08 36264.204074999994 12663.08 12663.08 12916.3416 12663.08 DRG Hospital Inpatient Facility Fee DRG DIABETES WITH MCC MS-DRG 637 N/A 33970.71 23779.497 3078 33970.71 41464.8103278 12586.42 14701.48 12586.42 41464.8103278 41464.8103278 41464.8103278 5377 12586.42 13845.062000000002 12586.42 56358.472335 12586.42 12586.42 12838.1484 12586.42 DRG Hospital Inpatient Facility Fee DRG DIABETES WITH CC MS-DRG 638 N/A 39582 27707.399999999998 3078 39582 138306.491247 7899.77 9867.21 7899.77 138306.491247 138306.491247 138306.491247 5377 7899.77 8689.747000000001 7899.77 187984.522275 7899.77 7899.77 8057.7654 7899.77 DRG Hospital Inpatient Facility Fee DRG DIABETES WITHOUT CC/MCC MS-DRG 639 N/A 11204.61 7843.227 3067.81 11292.08 6479.4916704 5418.01 7307.28 5418.01 6479.4916704 6479.4916704 6479.4916704 5377 5418.01 5959.811000000001 5418.01 8806.84728 5418.01 5418.01 5526.3702 5418.01 DRG Hospital Inpatient Facility Fee DRG MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC MS-DRG 640 N/A 8048.4 5633.879999999999 3078 24228.47 3731.1947616 11410.48 15675.68 11410.48 3731.1947616 3731.1947616 3731.1947616 5377 11410.48 12551.528 11410.48 5071.39512 11410.48 11410.48 11638.6896 11410.48 DRG Hospital Inpatient Facility Fee DRG MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC MS-DRG 641 N/A 31964.09 22374.862999999998 2931.64 31964.09 2772.1536527999997 6945.66 8883.05 6945.66 2772.1536527999997 2772.1536527999997 2772.1536527999997 5377 6945.66 7640.226000000001 6945.66 3767.87796 6945.66 6945.66 7084.5732 6945.66 DRG Hospital Inpatient Facility Fee DRG INBORN AND OTHER DISORDERS OF METABOLISM MS-DRG 642 N/A 4436.15 3105.3049999999994 2020.01 22840.76 6882.670643999999 12654.96 14772.21 12654.96 6882.670643999999 6882.670643999999 6882.670643999999 5377 12654.96 13920.456 12654.96 9354.843299999999 12654.96 12654.96 12908.0592 12654.96 DRG Hospital Inpatient Facility Fee DRG ENDOCRINE DISORDERS WITH MCC MS-DRG 643 N/A 36759.88 25731.915999999997 3078 36759.88 3901.1740626 14822.89 17008.39 14822.89 3901.1740626 3901.1740626 3901.1740626 5377 14822.89 16305.179 14822.89 5302.428945 14822.89 14822.89 15119.3478 14822.89 DRG Hospital Inpatient Facility Fee DRG ENDOCRINE DISORDERS WITH CC MS-DRG 644 N/A 40553.23 28387.261000000002 3078 40553.23 7660.400498399999 9190.24 11198.34 9190.24 7660.400498399999 7660.400498399999 7660.400498399999 5377 9190.24 10109.264000000001 9190.24 10411.92438 9190.24 9190.24 9374.0448 9190.24 DRG Hospital Inpatient Facility Fee DRG ENDOCRINE DISORDERS WITHOUT CC/MCC MS-DRG 645 N/A 30670.48 21469.336 3078 30670.48 10795.17666 6696.77 8626.33 6696.77 10795.17666 10795.17666 10795.17666 5377 6696.77 7366.447000000001 6696.77 14672.674500000001 6696.77 6696.77 6830.705400000001 6696.77 DRG Hospital Inpatient Facility Fee DRG KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC MS-DRG 650 N/A 236647.5 165653.25 3078 236647.5 31888.116867599994 41878.69 69349.79 41878.69 31888.116867599994 31888.116867599994 31888.116867599994 5377 41878.69 46066.55900000001 41878.69 43341.945569999996 41878.69 41878.69 42716.2638 41878.69 DRG Hospital Inpatient Facility Fee DRG KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC MS-DRG 651 N/A 219147.25 153403.07499999998 3078 219147.25 19495.7311968 31979.63 59966.01 31979.63 19495.7311968 19495.7311968 19495.7311968 5377 31979.63 35177.593 31979.63 26498.36376 31979.63 31979.63 32619.2226 31979.63 DRG Hospital Inpatient Facility Fee DRG KIDNEY TRANSPLANT MS-DRG 652 N/A 177139.02 123997.31399999998 4050 177139.02 14425.5766782 27821.43 41390.66 27821.43 14425.5766782 14425.5766782 14425.5766782 5377 27821.43 30603.573000000004 27821.43 19607.070614999997 27821.43 27821.43 28377.8586 27821.43 DRG Hospital Inpatient Facility Fee DRG MAJOR BLADDER PROCEDURES WITH MCC MS-DRG 653 N/A 432627.77 302839.439 3078 432627.77 83589.8560458 50110.32 153759.04 50110.32 83589.8560458 83589.8560458 83589.8560458 5377 50110.32 55121.352000000006 50110.32 113614.328685 50110.32 50110.32 51112.5264 50110.32 DRG Hospital Inpatient Facility Fee DRG MAJOR BLADDER PROCEDURES WITH CC MS-DRG 654 N/A 81612.18 57128.52599999999 3078 81612.18 18998.318084399998 25633.66 28159.68 25633.66 18998.318084399998 18998.318084399998 18998.318084399998 5377 25633.66 28197.026 25633.66 25822.28583 25633.66 25633.66 26146.3332 25633.66 DRG Hospital Inpatient Facility Fee DRG MAJOR BLADDER PROCEDURES WITHOUT CC/MCC MS-DRG 655 N/A 73376.32 51363.424 3078 73376.32 22240.449593999998 19467.16 21798.93 19467.16 22240.449593999998 22240.449593999998 22240.449593999998 5377 19467.16 21413.876 19467.16 30228.95205 19467.16 19467.16 19856.5032 19467.16 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC MS-DRG 656 N/A 131651.34 92155.938 3078 131651.34 17965.3210692 29807.2 32464.65 29807.2 17965.3210692 17965.3210692 17965.3210692 5377 29807.2 32787.920000000006 29807.2 24418.24869 29807.2 29807.2 30403.344 29807.2 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC MS-DRG 657 N/A 62219.43 43553.600999999995 3078 62219.43 12742.483388999999 16935.8 19187.86 16935.8 12742.483388999999 12742.483388999999 12742.483388999999 5377 16935.8 18629.38 16935.8 17319.430425 16935.8 16935.8 17274.516 16935.8 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC MS-DRG 658 N/A 76102.07 53271.449 3078 76102.07 21299.3010432 14239.42 16406.54 14239.42 21299.3010432 21299.3010432 21299.3010432 5377 14239.42 15663.362000000001 14239.42 28949.754240000002 14239.42 14239.42 14524.2084 14239.42 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC MS-DRG 659 N/A 38402.27 26881.588999999996 3078 39729.78 12570.118413600001 23238.48 25689.04 23238.48 12570.118413600001 12570.118413600001 12570.118413600001 5377 23238.48 25562.328 23238.48 17085.15402 23238.48 23238.48 23703.2496 23238.48 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC MS-DRG 660 N/A 23177.07 16223.948999999999 3078 23177.07 10819.033404 12726.2 14845.67 12726.2 10819.033404 10819.033404 10819.033404 5377 12726.2 13998.820000000002 12726.2 14705.1003 12726.2 12726.2 12980.724 12726.2 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC MS-DRG 661 N/A 30018.68 21013.075999999997 3078 30018.68 12581.450367 9720.5 11745.3 9720.5 12581.450367 12581.450367 12581.450367 5377 9720.5 10692.550000000001 9720.5 17100.556275000003 9720.5 9720.5 9914.91 9720.5 DRG Hospital Inpatient Facility Fee DRG MINOR BLADDER PROCEDURES WITH MCC MS-DRG 662 N/A 33134.19 23193.933 3078 46375.45 8088.6290532 27403 29984.72 27403 8088.6290532 8088.6290532 8088.6290532 5377 27403 30143.300000000003 27403 10993.96749 27403 27403 27951.06 27403 DRG Hospital Inpatient Facility Fee DRG MINOR BLADDER PROCEDURES WITH CC MS-DRG 663 N/A 27971.6 19580.12 3078 27971.6 7397.3798958 13752.45 15904.25 13752.45 7397.3798958 7397.3798958 7397.3798958 5377 13752.45 15127.695000000002 13752.45 10054.429935 13752.45 13752.45 14027.499000000002 13752.45 DRG Hospital Inpatient Facility Fee DRG MINOR BLADDER PROCEDURES WITHOUT CC/MCC MS-DRG 664 N/A 89991.79 62994.25299999999 3078 89991.79 20117.199378 10160.58 12199.25 10160.58 20117.199378 20117.199378 20117.199378 5377 10160.58 11176.638 10160.58 27343.05585 10160.58 10160.58 10363.7916 10160.58 DRG Hospital Inpatient Facility Fee DRG PROSTATECTOMY WITH MCC MS-DRG 665 N/A 117010.21 81907.147 3078 117010.21 10096.1740608 27597.79 30185.68 27597.79 10096.1740608 10096.1740608 10096.1740608 5377 27597.79 30357.569000000003 27597.79 13722.59856 27597.79 27597.79 28149.7458 27597.79 DRG Hospital Inpatient Facility Fee DRG PROSTATECTOMY WITH CC MS-DRG 666 N/A 29579.09 20705.362999999998 3078 29579.09 7458.811011599999 15528.09 17735.8 15528.09 7458.811011599999 7458.811011599999 7458.811011599999 5377 15528.09 17080.899 15528.09 10137.92637 15528.09 15528.09 15838.6518 15528.09 DRG Hospital Inpatient Facility Fee DRG PROSTATECTOMY WITHOUT CC/MCC MS-DRG 667 N/A 19815.41 13870.786999999998 3078 19815.41 20259.7434234 8872.81 10870.9 8872.81 20259.7434234 20259.7434234 20259.7434234 5377 8872.81 9760.091 8872.81 27536.800005 8872.81 8872.81 9050.2662 8872.81 DRG Hospital Inpatient Facility Fee DRG TRANSURETHRAL PROCEDURES WITH MCC MS-DRG 668 N/A 127396.42 89177.49399999999 3078 127396.42 11399.3487018 25456.91 27977.36 25456.91 11399.3487018 11399.3487018 11399.3487018 5377 25456.91 28002.601000000002 25456.91 15493.857885 25456.91 25456.91 25966.0482 25456.91 DRG Hospital Inpatient Facility Fee DRG TRANSURETHRAL PROCEDURES WITH CC MS-DRG 669 N/A 69198.75 48439.125 3078 69198.75 6513.4875306 14196.14 16361.91 14196.14 6513.4875306 6513.4875306 6513.4875306 5377 14196.14 15615.754 14196.14 8853.054045 14196.14 14196.14 14480.0628 14196.14 DRG Hospital Inpatient Facility Fee DRG TRANSURETHRAL PROCEDURES WITHOUT CC/MCC MS-DRG 670 N/A 15250.74 10675.518 3078 16857.04 18688.180412399997 8905.27 10904.41 8905.27 18688.180412399997 18688.180412399997 18688.180412399997 5377 8905.27 9795.797 8905.27 25400.75043 8905.27 8905.27 9083.3754 8905.27 DRG Hospital Inpatient Facility Fee DRG URETHRAL PROCEDURES WITH CC/MCC MS-DRG 671 N/A 53785.46 37649.822 3078 53785.46 10421.8186164 16516.47 18755.33 16516.47 10421.8186164 10421.8186164 10421.8186164 5377 16516.47 18168.117000000002 16516.47 14165.21073 16516.47 16516.47 16846.7994 16516.47 DRG Hospital Inpatient Facility Fee DRG URETHRAL PROCEDURES WITHOUT CC/MCC MS-DRG 672 N/A 83728.82 58610.174 3078 83728.82 6537.3442746 9394.05 11408.55 9394.05 6537.3442746 6537.3442746 6537.3442746 5377 9394.05 10333.455 9394.05 8885.479845 9394.05 9394.05 9581.930999999999 9394.05 DRG Hospital Inpatient Facility Fee DRG OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC MS-DRG 673 N/A 174696.12 122287.28399999999 3078 174696.12 12125.190137999998 31508.89 41102.12 31508.89 12125.190137999998 12125.190137999998 12125.190137999998 5377 31508.89 34659.779 31508.89 16480.41285 31508.89 31508.89 32139.0678 31508.89 DRG Hospital Inpatient Facility Fee DRG OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC MS-DRG 674 N/A 53552.56 37486.791999999994 3078 53552.56 6896.3882718 21377.17 23769.1 21377.17 6896.3882718 6896.3882718 6896.3882718 5377 21377.17 23514.887 21377.17 9373.488135000001 21377.17 21377.17 21804.713399999997 21377.17 DRG Hospital Inpatient Facility Fee DRG OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC MS-DRG 675 N/A 136275.2 95392.64 3078 136275.2 19869.089240399997 15207.96 21594.94 15207.96 19869.089240399997 19869.089240399997 19869.089240399997 5377 15207.96 16728.756 15207.96 27005.82753 15207.96 15207.96 15512.1192 15207.96 DRG Hospital Inpatient Facility Fee DRG RENAL FAILURE WITH MCC MS-DRG 682 N/A 111871.45 78310.015 3078 111871.45 5391.624143999999 13406.16 15547.04 13406.16 5391.624143999999 5391.624143999999 5391.624143999999 5377 13406.16 14746.776000000002 13406.16 7328.2308 13406.16 13406.16 13674.2832 13406.16 DRG Hospital Inpatient Facility Fee DRG RENAL FAILURE WITH CC MS-DRG 683 N/A 30636.01 21445.207 3033.92 30636.01 72217.94259959999 8070.21 10043.02 8070.21 72217.94259959999 72217.94259959999 72217.94259959999 5377 8070.21 8877.231000000002 8070.21 98157.76047 8070.21 8070.21 8231.6142 8070.21 DRG Hospital Inpatient Facility Fee DRG RENAL FAILURE WITHOUT CC/MCC MS-DRG 684 N/A 18080.88 12656.616 2853.38 18080.88 7392.0121284 5454.09 7344.51 5454.09 7392.0121284 7392.0121284 7392.0121284 5377 5454.09 5999.499000000001 5454.09 10047.13413 5454.09 5454.09 5563.1718 5454.09 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC MS-DRG 686 N/A 15221.7 10655.19 3078 27078.82 4285.267641 15310.76 17511.63 15310.76 4285.267641 4285.267641 4285.267641 5377 15310.76 16841.836000000003 15310.76 5824.484325 15310.76 15310.76 15616.9752 15310.76 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URINARY TRACT NEOPLASMS WITH CC MS-DRG 687 N/A 34693.76 24285.632 3078 34693.76 2923.6439772 9376.92 11390.9 9376.92 2923.6439772 2923.6439772 2923.6439772 5377 9376.92 10314.612000000001 9376.92 3973.78179 9376.92 9376.92 9564.4584 9376.92 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC MS-DRG 688 N/A 86132.5 60292.74999999999 3078 86132.5 80964.54999999999 7813.2 9777.92 7813.2 0 0 0 5377 7813.2 8594.52 7813.2 7813.2 7813.2 7969.464 7813.2 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URINARY TRACT INFECTIONS WITH MCC MS-DRG 689 N/A 19446.16 13612.312 3020.13 19446.16 9042.8988132 10344.55 12389 10344.55 9042.8988132 9042.8988132 9042.8988132 5377 10344.55 11379.005000000001 10344.55 12290.99949 10344.55 10344.55 10551.440999999999 10344.55 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC MS-DRG 690 N/A 12849.77 8994.839 2912.14 14095.42 5143.5140064 7174.72 9119.33 7174.72 5143.5140064 5143.5140064 5143.5140064 5377 7174.72 7892.192000000001 7174.72 6991.00248 7174.72 7174.72 7318.214400000001 7174.72 DRG Hospital Inpatient Facility Fee DRG URINARY STONES W ESW LITHOTRIPSY W CC/MCC MS-DRG 691 N/A 57074.79 39952.352999999996 3078 57074.79 5735.7576762 28537.4 16827.02 28537.4 5735.7576762 5735.7576762 5735.7576762 5377 28537.4 31391.140000000003 28537.4 7795.972965 28537.4 28537.4 29108.148 28537.4 DRG Hospital Inpatient Facility Fee DRG URINARY STONES WITH MCC MS-DRG 693 N/A 28633.78 20043.645999999997 3078 28633.78 3735.9661103999997 12902.95 15027.99 12902.95 3735.9661103999997 3735.9661103999997 3735.9661103999997 5377 12902.95 14193.245000000003 12902.95 5077.880279999999 12902.95 12902.95 13161.009000000002 12902.95 DRG Hospital Inpatient Facility Fee DRG URINARY STONES WITHOUT MCC MS-DRG 694 N/A 11695.31 8186.716999999999 3078 14117.02 32641.989977999998 7188.25 9133.29 7188.25 32641.989977999998 32641.989977999998 32641.989977999998 5377 7188.25 7907.075000000001 7188.25 44366.600849999995 7188.25 7188.25 7332.015 7188.25 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC MS-DRG 695 N/A 5896 4127.2 2684.75 19171.08 21339.2610894 10355.37 12400.17 10355.37 21339.2610894 21339.2610894 21339.2610894 5377 10355.37 11390.907000000001 10355.37 29004.067455 10355.37 10355.37 10562.477400000002 10355.37 DRG Hospital Inpatient Facility Fee DRG KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC MS-DRG 696 N/A 4657.3 3260.11 2120.71 12618.92 8247.8728194 6249.47 8164.94 6249.47 8247.8728194 8247.8728194 8247.8728194 5377 6249.47 6874.417000000001 6249.47 11210.409705 6249.47 6249.47 6374.459400000001 6249.47 DRG Hospital Inpatient Facility Fee DRG URETHRAL STRICTURE MS-DRG 697 N/A 19857.1 13899.969999999998 3078 19857.1 3722.2484825999995 8949.46 10949.98 8949.46 3722.2484825999995 3722.2484825999995 3722.2484825999995 5377 8949.46 9844.405999999999 8949.46 5059.235444999999 8949.46 8949.46 9128.4492 8949.46 DRG Hospital Inpatient Facility Fee DRG OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC MS-DRG 698 N/A 56416.22 39491.354 3078 56416.22 7601.951475599999 14451.35 16625.16 14451.35 7601.951475599999 7601.951475599999 7601.951475599999 5377 14451.35 15896.485000000002 14451.35 10332.48117 14451.35 14451.35 14740.377 14451.35 DRG Hospital Inpatient Facility Fee DRG OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC MS-DRG 699 N/A 26881.21 18816.846999999998 3078 26881.21 3066.1880226 9127.12 11133.24 9127.12 3066.1880226 3066.1880226 3066.1880226 5377 9127.12 10039.832000000002 9127.12 4167.525945 9127.12 9127.12 9309.662400000001 9127.12 DRG Hospital Inpatient Facility Fee DRG OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC MS-DRG 700 N/A 6715.25 4700.674999999999 3057.8 13306.81 6570.1472976 6680.53 8609.59 6680.53 6570.1472976 6570.1472976 6570.1472976 5377 6680.53 7348.5830000000005 6680.53 8930.06532 6680.53 6680.53 6814.1406 6680.53 DRG Hospital Inpatient Facility Fee DRG MAJOR MALE PELVIC PROCEDURES WITH CC/MCC MS-DRG 707 N/A 66963.06 46874.14199999999 3078 66963.06 62945.276399999995 17993.62 20278.97 17993.62 0 0 0 5377 17993.62 19792.982 17993.62 17993.62 17993.62 18353.4924 17993.62 DRG Hospital Inpatient Facility Fee DRG MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC MS-DRG 708 N/A 46824.58 32777.206 3078 46824.58 44015.1052 13389.02 15529.37 13389.02 0 0 0 5377 13389.02 14727.922000000002 13389.02 13389.02 13389.02 13656.8004 13389.02 DRG Hospital Inpatient Facility Fee DRG PENIS PROCEDURES WITH CC/MCC MS-DRG 709 N/A 69382.55 48567.784999999996 3078 69382.55 65219.597 21751.42 24155.15 21751.42 0 0 0 5377 21751.42 23926.562 21751.42 21751.42 21751.42 22186.448399999997 21751.42 DRG Hospital Inpatient Facility Fee DRG PENIS PROCEDURES WITHOUT CC/MCC MS-DRG 710 N/A 22683.62 15878.533999999998 3078 23389.02 14191.1841684 12998.55 15126.59 12998.55 14191.1841684 14191.1841684 14191.1841684 5377 12998.55 14298.405 12998.55 19288.487129999998 12998.55 12998.55 13258.520999999999 12998.55 DRG Hospital Inpatient Facility Fee DRG TESTES PROCEDURES WITH CC/MCC MS-DRG 711 N/A 34652.46 24256.721999999998 3078 34652.46 11821.016651999998 18427.38 20726.41 18427.38 11821.016651999998 11821.016651999998 11821.016651999998 5377 18427.38 20270.118000000002 18427.38 16066.9839 18427.38 18427.38 18795.927600000003 18427.38 DRG Hospital Inpatient Facility Fee DRG TESTES PROCEDURES WITHOUT CC/MCC MS-DRG 712 N/A 29206.86 20444.802 3078 29206.86 15967.915177799998 11196.75 13268.03 11196.75 15967.915177799998 15967.915177799998 15967.915177799998 5377 11196.75 12316.425000000001 11196.75 21703.398585 11196.75 11196.75 11420.685 11196.75 DRG Hospital Inpatient Facility Fee DRG TRANSURETHRAL PROSTATECTOMY WITH CC/MCC MS-DRG 713 N/A 32318.06 22622.642 3078 32318.06 5960.607488399999 13363.77 15503.34 13363.77 5960.607488399999 5960.607488399999 5960.607488399999 5377 13363.77 14700.147 13363.77 8101.58613 13363.77 13363.77 13631.0454 13363.77 DRG Hospital Inpatient Facility Fee DRG TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC MS-DRG 714 N/A 20973.3 14681.309999999998 3078 20973.3 13527.966685200001 8641.05 10631.85 8641.05 13527.966685200001 13527.966685200001 13527.966685200001 5377 8641.05 9505.155 8641.05 18387.049890000002 8641.05 8641.05 8813.871 8641.05 DRG Hospital Inpatient Facility Fee DRG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC MS-DRG 715 N/A 19972.65 13980.855 3078 34783.65 5328.4037724 20139 22491.93 20139 5328.4037724 5328.4037724 5328.4037724 5377 20139 22152.9 20139 7242.30243 20139 20139 20541.78 20139 DRG Hospital Inpatient Facility Fee DRG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC MS-DRG 716 N/A 50778.62 35545.034 3078 50778.62 6939.926829599999 11852.36 13944.3 11852.36 6939.926829599999 6939.926829599999 6939.926829599999 5377 11852.36 13037.596000000001 11852.36 9432.665219999999 11852.36 11852.36 12089.407200000001 11852.36 DRG Hospital Inpatient Facility Fee DRG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC MS-DRG 717 N/A 38317.77 26822.438999999995 3078 38317.77 6343.5082296 15964.57 18186.02 15964.57 6343.5082296 6343.5082296 6343.5082296 5377 15964.57 17561.027000000002 15964.57 8622.02022 15964.57 15964.57 16283.8614 15964.57 DRG Hospital Inpatient Facility Fee DRG OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC MS-DRG 718 N/A 43045.97 30132.179 3078 43045.97 14784.620675399998 11443.84 13522.93 11443.84 14784.620675399998 14784.620675399998 14784.620675399998 5377 11443.84 12588.224000000002 11443.84 20095.078905 11443.84 11443.84 11672.7168 11443.84 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC MS-DRG 722 N/A 87193.43 61035.40099999999 3078 87193.43 81961.82419999999 15309.86 17510.68 15309.86 0 0 0 5377 15309.86 16840.846 15309.86 15309.86 15309.86 15616.057200000001 15309.86 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC MS-DRG 723 N/A 21475.26 15032.681999999997 3078 21475.26 20186.744399999996 10392.34 12438.31 10392.34 0 0 0 5377 10392.34 11431.574 10392.34 10392.34 10392.34 10600.1868 10392.34 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC MS-DRG 724 N/A 79043.35 55330.345 3078 79043.35 74300.749 6899.67 8835.62 6899.67 0 0 0 5377 6899.67 7589.637000000001 6899.67 6899.67 6899.67 7037.6634 6899.67 DRG Hospital Inpatient Facility Fee DRG BENIGN PROSTATIC HYPERTROPHY WITH MCC MS-DRG 725 N/A 22255.4 15578.78 3078 22255.4 11238.9120984 11266.19 13339.66 11266.19 11238.9120984 11238.9120984 11238.9120984 5377 11266.19 12392.809000000001 11266.19 15275.79438 11266.19 11266.19 11491.5138 11266.19 DRG Hospital Inpatient Facility Fee DRG BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC MS-DRG 726 N/A 27734.19 19413.932999999997 3078 27734.19 7629.386731199999 6958.29 8896.09 6958.29 7629.386731199999 7629.386731199999 7629.386731199999 5377 6958.29 7654.119000000001 6958.29 10369.77084 6958.29 6958.29 7097.4558 6958.29 DRG Hospital Inpatient Facility Fee DRG INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC MS-DRG 727 N/A 27913.6 19539.519999999997 3078 27913.6 5065.3831698 12957.06 17567.42 12957.06 5065.3831698 5065.3831698 5065.3831698 5377 12957.06 14252.766000000001 12957.06 6884.807985 12957.06 12957.06 13216.2012 12957.06 DRG Hospital Inpatient Facility Fee DRG INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC MS-DRG 728 N/A 14870.3 10409.21 2954.02 14870.3 8270.5367262 7410.09 9362.1 7410.09 8270.5367262 8270.5367262 8270.5367262 5377 7410.09 8151.099000000001 7410.09 11241.214215 7410.09 7410.09 7558.2918 7410.09 DRG Hospital Inpatient Facility Fee DRG OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC MS-DRG 729 N/A 12327.96 8629.571999999998 3078 18156.51 3589.2471348 9719.6 11744.37 9719.6 3589.2471348 3589.2471348 3589.2471348 5377 9719.6 10691.560000000001 9719.6 4878.46161 9719.6 9719.6 9913.992 9719.6 DRG Hospital Inpatient Facility Fee DRG OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC MS-DRG 730 N/A 22931.08 16051.756 3078 22931.08 9511.6838328 5914 7818.91 5914 9511.6838328 9511.6838328 9511.6838328 5377 5914 6505.400000000001 5914 12928.16646 5914 5914 6032.28 5914 DRG Hospital Inpatient Facility Fee DRG PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC MS-DRG 734 N/A 46160.61 32312.427 3078 46160.61 43390.973399999995 19706.13 22045.46 19706.13 0 0 0 5377 19706.13 21676.743000000002 19706.13 19706.13 19706.13 20100.2526 19706.13 DRG Hospital Inpatient Facility Fee DRG PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC MS-DRG 735 N/A 41241.3 28868.91 3078 41241.3 38766.822 11472.7 13552.68 11472.7 0 0 0 5377 11472.7 12619.970000000001 11472.7 11472.7 11472.7 11702.154 11472.7 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC MS-DRG 736 N/A 137231.03 96061.72099999999 3078 137231.03 128997.16819999999 38463.57 41393.68 38463.57 0 0 0 5377 38463.57 42309.927 38463.57 38463.57 38463.57 39232.8414 38463.57 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC MS-DRG 737 N/A 58068.15 40647.705 3078 58068.15 16029.3462936 18247.92 20541.31 18247.92 16029.3462936 16029.3462936 16029.3462936 5377 18247.92 20072.712 18247.92 21786.89502 18247.92 18247.92 18612.878399999998 18247.92 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC MS-DRG 738 N/A 52712.18 36898.526 3078 52712.18 8422.0270506 12659.47 14776.81 12659.47 8422.0270506 8422.0270506 8422.0270506 5377 12659.47 13925.417000000001 12659.47 11447.118045 12659.47 12659.47 12912.6594 12659.47 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC MS-DRG 739 N/A 104791.2 73353.84 3078 104791.2 17565.1241886 35190.94 38017.96 35190.94 17565.1241886 17565.1241886 17565.1241886 5377 35190.94 38710.03400000001 35190.94 23874.305895 35190.94 35190.94 35894.7588 35190.94 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC MS-DRG 740 N/A 86206.51 60344.55699999999 3078 86206.51 10576.8874524 16254.04 18484.63 16254.04 10576.8874524 10576.8874524 10576.8874524 5377 16254.04 17879.444000000003 16254.04 14375.978430000001 16254.04 16254.04 16579.1208 16254.04 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC MS-DRG 741 N/A 146177.2 102324.04000000001 3078 146177.2 8410.0986786 11839.73 25097.33 11839.73 8410.0986786 8410.0986786 8410.0986786 5377 11839.73 13023.703000000001 11839.73 11430.905144999999 11839.73 11839.73 12076.5246 11839.73 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC MS-DRG 742 N/A 35288.83 24702.181 3078 35288.83 25834.4680776 16251.34 18481.84 16251.34 25834.4680776 25834.4680776 25834.4680776 5377 16251.34 17876.474000000002 16251.34 35113.898819999995 16251.34 16251.34 16576.3668 16251.34 DRG Hospital Inpatient Facility Fee DRG UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC MS-DRG 743 N/A 51987.52 36391.263999999996 3078 51987.52 11946.264558 10556.47 12607.61 10556.47 11946.264558 11946.264558 11946.264558 5377 10556.47 11612.117 10556.47 16237.219350000001 10556.47 10556.47 10767.5994 10556.47 DRG Hospital Inpatient Facility Fee DRG D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC MS-DRG 744 N/A 69973.75 48981.625 3078 69973.75 8261.5904472 17118.87 19376.7 17118.87 8261.5904472 8261.5904472 8261.5904472 5377 17118.87 18830.757 17118.87 11229.05454 17118.87 17118.87 17461.2474 17118.87 DRG Hospital Inpatient Facility Fee DRG D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC MS-DRG 745 N/A 243234.3 170264.00999999998 3078 243234.3 9996.572154599999 10377.91 65784.18 10377.91 9996.572154599999 9996.572154599999 9996.572154599999 5377 10377.91 11415.701000000001 10377.91 13587.220845 10377.91 10377.91 10585.4682 10377.91 DRG Hospital Inpatient Facility Fee DRG VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC MS-DRG 746 N/A 35953.68 25167.575999999997 3078 35953.68 7336.5451986 14098.74 16261.44 14098.74 7336.5451986 7336.5451986 7336.5451986 5377 14098.74 15508.614000000001 14098.74 9971.744144999999 14098.74 14098.74 14380.7148 14098.74 DRG Hospital Inpatient Facility Fee DRG VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC MS-DRG 747 N/A 26761.36 18732.951999999997 3078 26761.36 6879.688550999999 8825.01 10821.6 8825.01 6879.688550999999 6879.688550999999 6879.688550999999 5377 8825.01 9707.511 8825.01 9350.790074999999 8825.01 8825.01 9001.5102 8825.01 DRG Hospital Inpatient Facility Fee DRG FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES MS-DRG 748 N/A 15033.89 10523.722999999998 3078 23040.74 7081.8744564 12780.31 14901.47 12780.31 7081.8744564 7081.8744564 7081.8744564 5377 12780.31 14058.341 12780.31 9625.59873 12780.31 12780.31 13035.9162 12780.31 DRG Hospital Inpatient Facility Fee DRG OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC MS-DRG 749 N/A 59606.65 41724.655 3078 59606.65 7978.8880308 22781.27 25217.44 22781.27 7978.8880308 7978.8880308 7978.8880308 5377 22781.27 25059.397 22781.27 10844.80881 22781.27 22781.27 23236.8954 22781.27 DRG Hospital Inpatient Facility Fee DRG OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 750 N/A 65013 45509.1 3078 65013 8417.852120399999 12868.69 14992.64 12868.69 8417.852120399999 8417.852120399999 8417.852120399999 5377 12868.69 14155.559000000001 12868.69 11441.44353 12868.69 12868.69 13126.0638 12868.69 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC MS-DRG 754 N/A 74666.65 52266.65499999999 3078 74666.65 70186.65099999998 15663.36 17875.34 15663.36 0 0 0 5377 15663.36 17229.696000000004 15663.36 15663.36 15663.36 15976.6272 15663.36 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC MS-DRG 755 N/A 26254.25 18377.975 3078 26254.25 24678.995 9749.36 11775.07 9749.36 0 0 0 5377 9749.36 10724.296000000002 9749.36 9749.36 9749.36 9944.3472 9749.36 DRG Hospital Inpatient Facility Fee DRG MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC MS-DRG 756 N/A 6250.35 4375.245 2846.11 16990.88 15971.4272 8989.14 10990.92 8989.14 0 0 0 5377 8989.14 9888.054 8989.14 8989.14 8989.14 9168.9228 8989.14 DRG Hospital Inpatient Facility Fee DRG INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC MS-DRG 757 N/A 75493.27 52845.289 3078 75493.27 11148.256471199998 12374.5 14482.9 12374.5 11148.256471199998 11148.256471199998 11148.256471199998 5377 12374.5 13611.95 12374.5 15152.57634 12374.5 12374.5 12621.99 12374.5 DRG Hospital Inpatient Facility Fee DRG INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC MS-DRG 758 N/A 21037.87 14726.508999999998 2902.82 21037.87 5442.319724999999 8616.7 10606.75 8616.7 5442.319724999999 5442.319724999999 5442.319724999999 5377 8616.7 9478.37 8616.7 7397.135625 8616.7 8616.7 8789.034000000001 8616.7 DRG Hospital Inpatient Facility Fee DRG INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC MS-DRG 759 N/A 11862.7 8303.89 2675.84 11862.7 6598.7753904 5594.77 7489.62 5594.77 6598.7753904 6598.7753904 6598.7753904 5377 5594.77 6154.247000000001 5594.77 8968.97628 5594.77 5594.77 5706.665400000001 5594.77 DRG Hospital Inpatient Facility Fee DRG MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC MS-DRG 760 N/A 12988.31 9091.817 3078 16556.26 9084.0516966 8716.8 10709.98 8716.8 9084.0516966 9084.0516966 9084.0516966 5377 8716.8 9588.48 8716.8 12346.933995 8716.8 8716.8 8891.135999999999 8716.8 DRG Hospital Inpatient Facility Fee DRG MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC MS-DRG 761 N/A 50357.6 35250.32 3078 50357.6 3803.9578308 5101.48 6980.8 5101.48 3803.9578308 3803.9578308 3803.9578308 5377 5101.48 5611.628 5101.48 5170.29381 5101.48 5101.48 5203.509599999999 5101.48 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION W CC/MCC MS-DRG 765 N/A 16068.64 11248.047999999999 1400 19584.09 6775.9117146 8034.32 12667.14 8034.32 6775.9117146 6775.9117146 6775.9117146 5377 8034.32 8837.752 8034.32 9209.737845000001 8034.32 8034.32 8195.0064 8034.32 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION W/O CC/MCC MS-DRG 766 N/A 16232.71 11362.896999999999 1400 16232.71 4775.5237302 8116.35 9505.35 8116.35 4775.5237302 4775.5237302 4775.5237302 5377 8116.35 8927.985 8116.35 6490.834515 8116.35 8116.35 8278.677 8116.35 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY W STERILIZATION &/OR D&C MS-DRG 767 N/A 34433.3 24103.31 3078 34433.3 3966.7801086 17216.65 10379.76 17216.65 3966.7801086 3966.7801086 3966.7801086 5377 17216.65 18938.315000000002 17216.65 5391.599895 17216.65 17216.65 17560.983 17216.65 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C MS-DRG 768 N/A 29206 20444.199999999997 2866.68 29206 27453.64 7908.33 12386.2 7908.33 0 0 0 7528 7908.33 8699.163 7908.33 7908.33 7908.33 8066.4966 7908.33 DRG Hospital Inpatient Facility Fee DRG POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES MS-DRG 769 N/A 92796.51 64957.55699999999 3078 92796.51 87228.71939999999 14981.6 17172.12 14981.6 0 0 0 5377 14981.6 16479.760000000002 14981.6 14981.6 14981.6 15281.232 14981.6 DRG Hospital Inpatient Facility Fee DRG ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY MS-DRG 770 N/A 26537.43 18576.200999999997 3078 26537.43 24945.1842 7807.78 9772.33 7807.78 0 0 0 5377 7807.78 8588.558 7807.78 7807.78 7807.78 7963.9356 7807.78 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY W COMPLICATING DIAGNOSES MS-DRG 774 N/A 6935.15 4854.605 2572.93 14596.22 6512.2946934 3467.57 9443.04 3467.57 6512.2946934 6512.2946934 6512.2946934 5377 3467.57 3814.3270000000007 3467.57 8851.432755 3467.57 3467.57 3536.9214 3467.57 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES MS-DRG 775 N/A 20386.25 14270.375 2628.74 20386.25 5245.501587 10193.13 7722.17 10193.13 5245.501587 5245.501587 5245.501587 5377 10193.13 11212.443 10193.13 7129.622775 10193.13 10193.13 10396.9926 10193.13 DRG Hospital Inpatient Facility Fee DRG POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES MS-DRG 776 N/A 12164.5 8515.15 2423.39 12677.94 4469.5609884 6286.45 8203.09 6286.45 4469.5609884 4469.5609884 4469.5609884 5377 6286.45 6915.095 6286.45 6074.9736299999995 6286.45 6286.45 6412.179 6286.45 DRG Hospital Inpatient Facility Fee DRG ECTOPIC PREGNANCY MS-DRG 777 N/A 55971.39 39179.973 3078 55971.39 52613.1066 27985.69 9886.75 27985.69 0 0 0 5377 27985.69 30784.259000000002 27985.69 27985.69 27985.69 28545.4038 27985.69 DRG Hospital Inpatient Facility Fee DRG THREATENED ABORTION MS-DRG 778 N/A 27160.82 19012.573999999997 1835.5 27160.82 25531.1708 13580.41 7379.84 13580.41 0 0 0 5377 13580.41 14938.451000000001 13580.41 13580.41 13580.41 13852.0182 13580.41 DRG Hospital Inpatient Facility Fee DRG ABORTION WITHOUT D&C MS-DRG 779 N/A 16384.21 11468.946999999998 3078 17304.59 2585.474631 9185.73 11193.7 9185.73 2585.474631 2585.474631 2585.474631 5377 9185.73 10104.303 9185.73 3514.146075 9185.73 9185.73 9369.444599999999 9185.73 DRG Hospital Inpatient Facility Fee DRG FALSE LABOR MS-DRG 780 N/A 16921.78 11845.246 1665.23 16921.78 15906.473199999999 8460.89 6257.28 8460.89 0 0 0 5377 8460.89 9306.979 8460.89 8460.89 8460.89 8630.1078 8460.89 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS MS-DRG 781 N/A 5278.3 3694.81 2259.42 15043.79 14141.1626 2639.15 9732.35 2639.15 0 0 0 5377 2639.15 2903.0650000000005 2639.15 2639.15 2639.15 2691.933 2639.15 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS MS-DRG 782 N/A 15934 11153.8 2021.44 15934 2596.2101658 7967 7406.84 7967 2596.2101658 2596.2101658 2596.2101658 5377 7967 8763.7 7967 3528.737685 7967 7967 8126.34 7967 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION WITH STERILIZATION WITH MCC MS-DRG 783 N/A 186295.25 130406.67499999999 1400 186295.25 175117.535 13307.21 43157.49 13307.21 0 0 0 7528 13307.21 14637.931 13307.21 13307.21 13307.21 13573.3542 13307.21 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION WITH STERILIZATION WITH CC MS-DRG 784 N/A 32327.37 22629.159 1400 32327.37 30387.727799999997 7199.42 11429.96 7199.42 0 0 0 7528 7199.42 7919.362000000001 7199.42 7199.42 7199.42 7343.4084 7199.42 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC MS-DRG 785 N/A 21662.06 15163.442 1400 21662.06 20362.3364 6289.84 10203.03 6289.84 0 0 0 7528 6289.84 6918.8240000000005 6289.84 6289.84 6289.84 6415.6368 6289.84 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION WITHOUT STERILIZATION WITH MCC MS-DRG 786 N/A 122634.78 85844.34599999999 1400 122634.78 6648.8745528 11137.04 16741.42 11137.04 6648.8745528 6648.8745528 6648.8745528 7528 11137.04 12250.744000000002 11137.04 9037.070459999999 11137.04 11137.04 11359.7808 11137.04 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION WITHOUT STERILIZATION WITH CC MS-DRG 787 N/A 26905.87 18834.108999999997 1400 26905.87 5238.9409823999995 7346.31 11628.07 7346.31 5238.9409823999995 5238.9409823999995 5238.9409823999995 7528 7346.31 8080.941000000001 7346.31 7120.705679999999 7346.31 7346.31 7493.2362 7346.31 DRG Hospital Inpatient Facility Fee DRG CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC MS-DRG 788 N/A 21977.06 15383.942 1400 21977.06 4460.0182908 6016.07 9833.72 6016.07 4460.0182908 4460.0182908 4460.0182908 7528 6016.07 6617.677000000001 6016.07 6062.00331 6016.07 6016.07 6136.3913999999995 6016.07 DRG Hospital Inpatient Facility Fee DRG NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY MS-DRG 789 N/A 2353.7 1647.5899999999997 880 28920.85 27185.599 12590.72 18702.29 12590.72 0 0 0 5377 12590.72 13849.792000000001 12590.72 12590.72 12590.72 12842.5344 12590.72 DRG Hospital Inpatient Facility Fee DRG EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE MS-DRG 790 N/A 5125.05 3587.535 1040 89294.67 7039.528735799999 41521.51 57727.13 41521.51 7039.528735799999 7039.528735799999 7039.528735799999 5377 41521.51 45673.66100000001 41521.51 9568.042935 41521.51 41521.51 42351.940200000005 41521.51 DRG Hospital Inpatient Facility Fee DRG PREMATURITY WITH MAJOR PROBLEMS MS-DRG 791 N/A 8398.75 5879.125 960 61822.57 5395.202655599999 28357.04 39969.53 28357.04 5395.202655599999 5395.202655599999 5395.202655599999 5377 28357.04 31192.744000000002 28357.04 7333.0946699999995 28357.04 28357.04 28924.180800000002 28357.04 DRG Hospital Inpatient Facility Fee DRG PREMATURITY WITHOUT MAJOR PROBLEMS MS-DRG 792 N/A 12743.6 8920.52 880 38352.58 13227.3717108 17110.36 24798.84 17110.36 13227.3717108 13227.3717108 13227.3717108 5377 17110.36 18821.396 17110.36 17978.484809999998 17110.36 17110.36 17452.5672 17110.36 DRG Hospital Inpatient Facility Fee DRG FULL TERM NEONATE WITH MAJOR PROBLEMS MS-DRG 793 N/A 8538.2 5976.74 960 63432.92 4164.7910838 29128.7 41010.43 29128.7 4164.7910838 4164.7910838 4164.7910838 5377 29128.7 32041.570000000003 29128.7 5660.734035 29128.7 29128.7 29711.274 29128.7 DRG Hospital Inpatient Facility Fee DRG NEONATE WITH OTHER SIGNIFICANT PROBLEMS MS-DRG 794 N/A 5530.6 3871.42 880 24161.83 1591.2448247999998 10310.21 15626.12 10310.21 1591.2448247999998 1591.2448247999998 1591.2448247999998 5377 10310.21 11341.231 10310.21 2162.80086 10310.21 10310.21 10516.4142 10310.21 DRG Hospital Inpatient Facility Fee DRG NORMAL NEWBORN MS-DRG 795 N/A 8131.1 5691.7699999999995 320 8131.1 1214.3082696 1395.75 3601.37 1395.75 1214.3082696 1214.3082696 1214.3082696 5377 1395.75 1535.325 1395.75 1650.47322 1395.75 1395.75 1423.665 1395.75 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC MS-DRG 796 N/A 38130.37 26691.259000000002 2718.16 38130.37 27963.6824796 9054.45 13932.19 9054.45 27963.6824796 27963.6824796 27963.6824796 7528 9054.45 9959.895000000002 9054.45 38007.90147 9054.45 9054.45 9235.539 9054.45 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC MS-DRG 797 N/A 26607.11 18624.977 3078 26607.11 25111.608734399997 8367.8 10349.99 8367.8 25111.608734399997 25111.608734399997 25111.608734399997 7528 8367.8 9204.58 8367.8 34131.397079999995 8367.8 8367.8 8535.155999999999 8367.8 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC MS-DRG 798 N/A 23319.68 16323.776 3078 23319.68 735.9805524 6398.8 10349.99 6398.8 735.9805524 735.9805524 735.9805524 7528 6398.8 7038.680000000001 6398.8 1000.33593 6398.8 6398.8 6526.776000000001 6398.8 DRG Hospital Inpatient Facility Fee DRG SPLENECTOMY WITH MCC MS-DRG 799 N/A 101529.57 71070.699 3078 101529.57 8692.2046764 46963.04 50160.83 46963.04 8692.2046764 8692.2046764 8692.2046764 5377 46963.04 51659.344000000005 46963.04 11814.34023 46963.04 46963.04 47902.300800000005 46963.04 DRG Hospital Inpatient Facility Fee DRG SPLENECTOMY WITH CC MS-DRG 800 N/A 143242.9 100270.02999999998 3078 143242.9 6143.11158 23974.35 26448.1 23974.35 6143.11158 6143.11158 6143.11158 5377 23974.35 26371.785 23974.35 8349.6435 23974.35 23974.35 24453.837 23974.35 DRG Hospital Inpatient Facility Fee DRG SPLENECTOMY WITHOUT CC/MCC MS-DRG 801 N/A 31853.62 22297.534 3078 31853.62 29942.402799999996 16196.33 18425.09 16196.33 0 0 0 5377 16196.33 17815.963 16196.33 16196.33 16196.33 16520.2566 16196.33 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC MS-DRG 802 N/A 230149.08 161104.35599999997 3078 230149.08 26140.4308194 34376.62 65094.38 34376.62 26140.4308194 26140.4308194 26140.4308194 5377 34376.62 37814.28200000001 34376.62 35529.759705000004 34376.62 34376.62 35064.152400000006 34376.62 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC MS-DRG 803 N/A 41460.8 29022.56 3078 41460.8 17599.716467399998 18516.66 20818.5 18516.66 17599.716467399998 17599.716467399998 17599.716467399998 5377 18516.66 20368.326 18516.66 23921.323304999998 18516.66 18516.66 18886.9932 18516.66 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC MS-DRG 804 N/A 19543.65 13680.555 3078 20804.45 11890.2012096 11378.91 13455.96 11378.91 11890.2012096 11890.2012096 11890.2012096 5377 11378.91 12516.801000000001 11378.91 16161.01872 11378.91 11378.91 11606.4882 11378.91 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC MS-DRG 805 N/A 41013.95 28709.764999999996 2547.24 41013.95 25236.2602218 6934.62 11072.75 6934.62 25236.2602218 25236.2602218 25236.2602218 7528 6934.62 7628.082 6934.62 34300.821885 6934.62 6934.62 7073.3124 6934.62 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC MS-DRG 806 N/A 14977.1 10483.97 2755.51 14977.1 12837.910364999998 4812.03 8209.6 4812.03 12837.910364999998 12837.910364999998 12837.910364999998 7528 4812.03 5293.233 4812.03 17449.133625 4812.03 4812.03 4908.2706 4812.03 DRG Hospital Inpatient Facility Fee DRG VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC MS-DRG 807 N/A 21055.65 14738.955 2786.9 21055.65 7486.2462672 4354.13 7591.94 4354.13 7486.2462672 7486.2462672 7486.2462672 7528 4354.13 4789.543000000001 4354.13 10175.216040000001 4354.13 4354.13 4441.2126 4354.13 DRG Hospital Inpatient Facility Fee DRG MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC MS-DRG 808 N/A 17457.15 12220.005000000001 3078 33456.85 3149.6866265999997 19307.54 21634.29 19307.54 3149.6866265999997 3149.6866265999997 3149.6866265999997 5377 19307.54 21238.294 19307.54 4281.016245 19307.54 19307.54 19693.6908 19307.54 DRG Hospital Inpatient Facility Fee DRG MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC MS-DRG 809 N/A 142873.1 100011.17 3078 142873.1 2806.7459316 10963.18 23525.61 10963.18 2806.7459316 2806.7459316 2806.7459316 5377 10963.18 12059.498000000001 10963.18 3814.89537 10963.18 10963.18 11182.4436 10963.18 DRG Hospital Inpatient Facility Fee DRG MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC MS-DRG 810 N/A 30392.95 21275.065 3078 30392.95 2501.9760269999997 8466.1 10451.39 8466.1 2501.9760269999997 2501.9760269999997 2501.9760269999997 5377 8466.1 9312.710000000001 8466.1 3400.6557749999997 8466.1 8466.1 8635.422 8466.1 DRG Hospital Inpatient Facility Fee DRG RED BLOOD CELL DISORDERS WITH MCC MS-DRG 811 N/A 55261.4 38682.979999999996 3078 55261.4 13037.710595999999 12537.73 14651.25 12537.73 13037.710595999999 13037.710595999999 13037.710595999999 5377 12537.73 13791.503 12537.73 17720.699699999997 12537.73 12537.73 12788.4846 12537.73 DRG Hospital Inpatient Facility Fee DRG RED BLOOD CELL DISORDERS WITHOUT MCC MS-DRG 812 N/A 17408.5 12185.949999999999 3078 17408.5 6020.2493484 8098.16 10071.85 8098.16 6020.2493484 6020.2493484 6020.2493484 5377 8098.16 8907.976 8098.16 8182.65063 8098.16 8098.16 8260.1232 8098.16 DRG Hospital Inpatient Facility Fee DRG COAGULATION DISORDERS MS-DRG 813 N/A 38244.46 26771.122 3078 38244.46 4372.9411752 14114.07 16277.25 14114.07 4372.9411752 4372.9411752 4372.9411752 5377 14114.07 15525.477 14114.07 5943.6491399999995 14114.07 14114.07 14396.3514 14114.07 DRG Hospital Inpatient Facility Fee DRG RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC MS-DRG 814 N/A 34088.78 23862.145999999997 3078 34088.78 8535.3465846 16945.72 19198.1 16945.72 8535.3465846 8535.3465846 8535.3465846 5377 16945.72 18640.292 16945.72 11601.140595 16945.72 16945.72 17284.634400000003 16945.72 DRG Hospital Inpatient Facility Fee DRG RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC MS-DRG 815 N/A 22628.76 15840.131999999998 3078 22628.76 4048.4894567999995 9298.46 11309.98 9298.46 4048.4894567999995 4048.4894567999995 4048.4894567999995 5377 9298.46 10228.306 9298.46 5502.658259999999 9298.46 9298.46 9484.429199999999 9298.46 DRG Hospital Inpatient Facility Fee DRG RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC MS-DRG 816 N/A 9544.86 6681.402 3036.13 13136.99 7705.1318934 6574.12 8499.82 6574.12 7705.1318934 7705.1318934 7705.1318934 5377 6574.12 7231.532 6574.12 10472.722755 6574.12 6574.12 6705.6024 6574.12 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC MS-DRG 817 N/A 50451.51 35316.057 3078 50451.51 11268.7330284 28224.54 30832.14 28224.54 11268.7330284 11268.7330284 11268.7330284 5377 28224.54 31046.994000000002 28224.54 15316.32663 28224.54 28224.54 28789.0308 28224.54 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC MS-DRG 818 N/A 25611.96 17928.372 3078 25611.96 5533.571770799999 14339.52 16509.8 14339.52 5533.571770799999 5533.571770799999 5533.571770799999 5377 14339.52 15773.472000000002 14339.52 7521.164309999999 14339.52 14339.52 14626.3104 14339.52 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 819 N/A 20508.89 14356.222999999998 3078 20508.89 2884.8767682 8012.49 9983.49 8012.49 2884.8767682 2884.8767682 2884.8767682 5377 8012.49 8813.739 8012.49 3921.089865 8012.49 8012.49 8172.7398 8012.49 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC MS-DRG 820 N/A 159643.33 111750.33099999999 3078 159643.33 8704.1330484 47954.12 60374.97 47954.12 8704.1330484 8704.1330484 8704.1330484 5377 47954.12 52749.53200000001 47954.12 11830.55313 47954.12 47954.12 48913.2024 47954.12 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC MS-DRG 821 N/A 66408.94 46486.258 3078 66408.94 8091.6111462 19500.52 21833.36 19500.52 8091.6111462 8091.6111462 8091.6111462 5377 19500.52 21450.572000000004 19500.52 10998.020715 19500.52 19500.52 19890.5304 19500.52 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 822 N/A 47891.35 33523.945 3078 47891.35 5634.962932799999 10866.69 12927.58 10866.69 5634.962932799999 5634.962932799999 5634.962932799999 5377 10866.69 11953.359000000002 10866.69 7658.973959999999 10866.69 10866.69 11084.0238 10866.69 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC MS-DRG 823 N/A 170430.3 119301.20999999998 3078 170430.3 55236.1158018 39015.47 41962.95 39015.47 55236.1158018 55236.1158018 55236.1158018 5377 39015.47 42917.01700000001 39015.47 75076.265385 39015.47 39015.47 39795.7794 39015.47 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC MS-DRG 824 N/A 39700.17 27790.119 3078 39700.17 19874.4570078 20653.93 23023.09 20653.93 19874.4570078 19874.4570078 19874.4570078 5377 20653.93 22719.323000000004 20653.93 27013.123335 20653.93 20653.93 21067.0086 20653.93 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC MS-DRG 825 N/A 30788.35 21551.844999999998 3078 30788.35 8114.275052999999 11873.1 13965.7 11873.1 8114.275052999999 8114.275052999999 8114.275052999999 5377 11873.1 13060.410000000002 11873.1 11028.825225 11873.1 11873.1 12110.562 11873.1 DRG Hospital Inpatient Facility Fee DRG MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC MS-DRG 826 N/A 149954.58 104968.20599999999 3078 149954.58 49280.2796622 46369.65 49548.77 46369.65 49280.2796622 49280.2796622 49280.2796622 5377 46369.65 51006.615000000005 46369.65 66981.164415 46369.65 46369.65 47297.043000000005 46369.65 DRG Hospital Inpatient Facility Fee DRG MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC MS-DRG 827 N/A 81700.5 57190.35 3078 81700.5 16808.8654038 21956.12 24366.3 21956.12 16808.8654038 16808.8654038 16808.8654038 5377 21956.12 24151.732 21956.12 22846.408034999997 21956.12 21956.12 22395.2424 21956.12 DRG Hospital Inpatient Facility Fee DRG MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 828 N/A 38301.2 26810.839999999997 3078 38301.2 10172.515641599999 15683.2 17895.82 15683.2 10172.515641599999 10172.515641599999 10172.515641599999 5377 15683.2 17251.52 15683.2 13826.36112 15683.2 15683.2 15996.864000000001 15683.2 DRG Hospital Inpatient Facility Fee DRG MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC MS-DRG 829 N/A 46628.89 32640.222999999998 3078 48188.72 30197.2701366 28539.26 31156.79 28539.26 30197.2701366 30197.2701366 30197.2701366 5377 28539.26 31393.186 28539.26 41043.766995000005 28539.26 28539.26 29110.0452 28539.26 DRG Hospital Inpatient Facility Fee DRG MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC MS-DRG 830 N/A 113309 79316.29999999999 3078 113309 14199.534028799999 13260.97 15397.28 13260.97 14199.534028799999 14199.534028799999 14199.534028799999 5377 13260.97 14587.067000000001 13260.97 19299.83616 13260.97 13260.97 13526.1894 13260.97 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC MS-DRG 831 N/A 30753.3 21527.309999999998 3059.51 30753.3 13683.0355212 10774.71 15429.91 10774.71 13683.0355212 13683.0355212 13683.0355212 5377 10774.71 11852.181 10774.71 18597.81759 10774.71 10774.71 10990.2042 10774.71 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC MS-DRG 832 N/A 17148.9 12004.23 2077.52 17148.9 17014.629820799997 6317.11 8234.7 6317.11 17014.629820799997 17014.629820799997 17014.629820799997 5377 6317.11 6948.821 6317.11 23126.08056 6317.11 6317.11 6443.4522 6317.11 DRG Hospital Inpatient Facility Fee DRG OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 833 N/A 4370.2 3059.14 2097.35 9899.06 9735.3408078 4545.07 6406.86 4545.07 9735.3408078 9735.3408078 9735.3408078 5377 4545.07 4999.577 4545.07 13232.158335 4545.07 4545.07 4635.971399999999 4545.07 DRG Hospital Inpatient Facility Fee DRG ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC MS-DRG 834 N/A 39815.6 27870.92 3078 82227.31 4638.9438708 49869.54 53158.88 49869.54 4638.9438708 4638.9438708 4638.9438708 5377 49869.54 54856.494000000006 49869.54 6305.19681 49869.54 49869.54 50866.9308 49869.54 DRG Hospital Inpatient Facility Fee DRG ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC MS-DRG 835 N/A 53175.15 37222.604999999996 3078 53175.15 2646.3093282 18911.65 21225.93 18911.65 2646.3093282 2646.3093282 2646.3093282 5377 18911.65 20802.815000000002 18911.65 3596.8318649999997 18911.65 18911.65 19289.883 18911.65 DRG Hospital Inpatient Facility Fee DRG ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 836 N/A 12338.53 8636.971 3078 25222.41 1797.6056603999998 14147.44 16311.68 14147.44 1797.6056603999998 1797.6056603999998 1797.6056603999998 5377 14147.44 15562.184000000001 14147.44 2443.28403 14147.44 14147.44 14430.3888 14147.44 DRG Hospital Inpatient Facility Fee DRG CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC MS-DRG 837 N/A 468312.38 327818.66599999997 3078 468312.38 39309.949926 48536.68 197359.51 48536.68 39309.949926 39309.949926 39309.949926 5377 48536.68 53390.348000000005 48536.68 53429.61195 48536.68 48536.68 49507.4136 48536.68 DRG Hospital Inpatient Facility Fee DRG CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT MS-DRG 838 N/A 42671.4 29869.98 3078 42671.4 16109.266386 20056.93 22407.3 20056.93 16109.266386 16109.266386 16109.266386 5377 20056.93 22062.623000000003 20056.93 21895.52145 20056.93 20056.93 20458.068600000002 20056.93 DRG Hospital Inpatient Facility Fee DRG CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC MS-DRG 839 N/A 32216.5 22551.55 3078 32216.5 9171.1288122 12397.04 14506.12 12397.04 9171.1288122 9171.1288122 9171.1288122 5377 12397.04 13636.744000000002 12397.04 12465.288165 12397.04 12397.04 12644.980800000001 12397.04 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC MS-DRG 840 N/A 33758.23 23630.761000000002 3078 47358.34 21360.732159 28018.93 30620.04 28018.93 21360.732159 21360.732159 21360.732159 5377 28018.93 30820.823000000004 28018.93 29033.250675 28018.93 28018.93 28579.3086 28018.93 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC MS-DRG 841 N/A 198513.05 138959.13499999998 3078 198513.05 7149.2697582 14381.9 47707.82 14381.9 7149.2697582 7149.2697582 7149.2697582 5377 14381.9 15820.09 14381.9 9717.201615 14381.9 14381.9 14669.538 14381.9 DRG Hospital Inpatient Facility Fee DRG LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC MS-DRG 842 N/A 11821.95 8275.365 3078 18529.25 6678.695482799999 9953.17 11985.3 9953.17 6678.695482799999 6678.695482799999 6678.695482799999 5377 9953.17 10948.487000000001 9953.17 9077.60271 9953.17 9953.17 10152.233400000001 9953.17 DRG Hospital Inpatient Facility Fee DRG OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC MS-DRG 843 N/A 60153.46 42107.422 3078 60153.46 20311.6318416 17471.47 19740.4 17471.47 20311.6318416 20311.6318416 20311.6318416 5377 17471.47 19218.617000000002 17471.47 27607.32612 17471.47 17471.47 17820.899400000002 17471.47 DRG Hospital Inpatient Facility Fee DRG OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC MS-DRG 844 N/A 2159.2 1511.4399999999998 983.2 19060.25 10663.3681494 10285.93 12328.52 10285.93 10663.3681494 10663.3681494 10663.3681494 5377 10285.93 11314.523000000001 10285.93 14493.521955 10285.93 10285.93 10491.6486 10285.93 DRG Hospital Inpatient Facility Fee DRG OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC MS-DRG 845 N/A 32557.64 22790.347999999998 3078 32557.64 8216.8590522 7624.72 9583.49 7624.72 8216.8590522 8216.8590522 8216.8590522 5377 7624.72 8387.192000000001 7624.72 11168.256164999999 7624.72 7624.72 7777.214400000001 7624.72 DRG Hospital Inpatient Facility Fee DRG CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC MS-DRG 846 N/A 11534.15 8073.904999999999 3078 37313.55 11742.2893968 21724.36 24127.22 21724.36 11742.2893968 11742.2893968 11742.2893968 5377 21724.36 23896.796000000002 21724.36 15959.97876 21724.36 21724.36 22158.8472 21724.36 DRG Hospital Inpatient Facility Fee DRG CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC MS-DRG 847 N/A 11203.5 7842.45 3078 20175.53 7106.9240376 10984.83 13049.42 10984.83 7106.9240376 7106.9240376 7106.9240376 5377 10984.83 12083.313 10984.83 9659.64582 10984.83 10984.83 11204.5266 10984.83 DRG Hospital Inpatient Facility Fee DRG CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC MS-DRG 848 N/A 5057.25 3540.075 2302.83 16016.6 5597.388561 8378.62 10361.16 8378.62 5597.388561 5597.388561 5597.388561 5377 8378.62 9216.482000000002 8378.62 7607.903325 8378.62 8378.62 8546.192400000002 8378.62 DRG Hospital Inpatient Facility Fee DRG RADIOTHERAPY MS-DRG 849 N/A 266108 186275.59999999998 3078 266108 14828.1592332 21092.2 77601.13 21092.2 14828.1592332 14828.1592332 14828.1592332 5377 21092.2 23201.420000000002 21092.2 20154.25599 21092.2 21092.2 21514.044 21092.2 DRG Hospital Inpatient Facility Fee DRG INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC MS-DRG 853 N/A 84615.14 59230.598 3078 86242.97 81068.3918 44197.22 55779.65 44197.22 0 0 0 5377 44197.22 48616.942 44197.22 44197.22 44197.22 45081.1644 44197.22 DRG Hospital Inpatient Facility Fee DRG INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC MS-DRG 854 N/A 53028.07 37119.649 3078 53028.07 49846.3858 18537.4 20839.88 18537.4 0 0 0 5377 18537.4 20391.140000000003 18537.4 18537.4 18537.4 18908.148 18537.4 DRG Hospital Inpatient Facility Fee DRG INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 855 N/A 23089.45 16162.615 3078 24630.95 23153.093 13776.8 15929.36 13776.8 0 0 0 5377 13776.8 15154.48 13776.8 13776.8 13776.8 14052.336 13776.8 DRG Hospital Inpatient Facility Fee DRG POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC MS-DRG 856 N/A 66578.88 46605.216 3078 66578.88 31757.5011942 39793.73 42765.74 39793.73 31757.5011942 31757.5011942 31757.5011942 5377 39793.73 43773.10300000001 39793.73 43164.414315 39793.73 39793.73 40589.604600000006 39793.73 DRG Hospital Inpatient Facility Fee DRG POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC MS-DRG 857 N/A 17677.03 12373.920999999998 3078 32996.34 10081.2635958 19018.96 21336.64 19018.96 10081.2635958 10081.2635958 10081.2635958 5377 19018.96 20920.856 19018.96 13702.332434999998 19018.96 19018.96 19399.3392 19018.96 DRG Hospital Inpatient Facility Fee DRG POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC MS-DRG 858 N/A 30941.88 21659.316 3078 30941.88 9863.570806799999 12756.86 14877.29 12756.86 9863.570806799999 9863.570806799999 9863.570806799999 5377 12756.86 14032.546000000002 12756.86 13406.44701 12756.86 12756.86 13011.997200000002 12756.86 DRG Hospital Inpatient Facility Fee DRG POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC MS-DRG 862 N/A 29575.5 20702.85 3078 29575.5 27800.969999999998 16494.82 18732.99 16494.82 0 0 0 5377 16494.82 18144.302 16494.82 16494.82 16494.82 16824.7164 16494.82 DRG Hospital Inpatient Facility Fee DRG POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC MS-DRG 863 N/A 13743.8 9620.659999999998 2923.12 17121.8 16094.491999999998 9071.21 11075.55 9071.21 0 0 0 5377 9071.21 9978.331 9071.21 9071.21 9071.21 9252.634199999999 9071.21 DRG Hospital Inpatient Facility Fee DRG FEVER AND INFLAMMATORY CONDITIONS MS-DRG 864 N/A 21115.6 14780.919999999998 3078 21115.6 19848.663999999997 7649.07 9608.62 7649.07 0 0 0 5377 7649.07 8413.977 7649.07 7649.07 7649.07 7802.0514 7649.07 DRG Hospital Inpatient Facility Fee DRG VIRAL ILLNESS WITH MCC MS-DRG 865 N/A 62805.68 43963.975999999995 3078 62805.68 7314.4777103999995 15085.31 17279.06 15085.31 7314.4777103999995 7314.4777103999995 7314.4777103999995 5377 15085.31 16593.841 15085.31 9941.750279999998 15085.31 15085.31 15387.0162 15085.31 DRG Hospital Inpatient Facility Fee DRG VIRAL ILLNESS WITHOUT MCC MS-DRG 866 N/A 9776.5 6843.549999999999 2748.72 15593.51 4387.2552216 8113.49 10087.68 8113.49 4387.2552216 4387.2552216 4387.2552216 5377 8113.49 8924.839 8113.49 5963.10462 8113.49 8113.49 8275.7598 8113.49 DRG Hospital Inpatient Facility Fee DRG OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC MS-DRG 867 N/A 164328.63 115030.041 3078 164328.63 4247.0968506 19058.64 34216.08 19058.64 4247.0968506 4247.0968506 4247.0968506 5377 19058.64 20964.504 19058.64 5772.603045 19058.64 19058.64 19439.8128 19058.64 DRG Hospital Inpatient Facility Fee DRG OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC MS-DRG 868 N/A 21753.27 15227.288999999999 2472.94 21753.27 27167.4636486 9520.3 11538.78 9520.3 27167.4636486 27167.4636486 27167.4636486 5377 9520.3 10472.33 9520.3 36925.690395000005 9520.3 9520.3 9710.706 9520.3 DRG Hospital Inpatient Facility Fee DRG OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC MS-DRG 869 N/A 12086.42 8460.493999999999 3078 13306.82 4039.5431777999997 6680.53 8609.59 6680.53 4039.5431777999997 4039.5431777999997 4039.5431777999997 5377 6680.53 7348.5830000000005 6680.53 5490.498585 6680.53 6680.53 6814.1406 6680.53 DRG Hospital Inpatient Facility Fee DRG SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS MS-DRG 870 N/A 205349.01 143744.307 3078 205349.01 10859.5898688 61240.33 64887.81 61240.33 10859.5898688 10859.5898688 10859.5898688 5377 61240.33 67364.36300000001 61240.33 14760.22416 61240.33 61240.33 62465.136600000005 61240.33 DRG Hospital Inpatient Facility Fee DRG SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC MS-DRG 871 N/A 62888.2 44021.74 3078 62888.2 4566.7772202 17650.03 19924.57 17650.03 4566.7772202 4566.7772202 4566.7772202 5377 17650.03 19415.033 17650.03 6207.108765 17650.03 17650.03 18003.0306 17650.03 DRG Hospital Inpatient Facility Fee DRG SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC MS-DRG 872 N/A 22890.72 16023.503999999999 3078 22890.72 3481.8917868 9270.5 11281.14 9270.5 3481.8917868 3481.8917868 3481.8917868 5377 9270.5 10197.550000000001 9270.5 4732.54551 9270.5 9270.5 9455.91 9270.5 DRG Hospital Inpatient Facility Fee DRG O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS MS-DRG 876 N/A 86300.43 60410.30099999999 2596.69 86300.43 81122.40419999999 28824.23 31450.73 28824.23 0 0 0 5377 28824.23 31706.653000000002 28824.23 28824.23 28824.23 29400.7146 28824.23 DRG Hospital Inpatient Facility Fee DRG ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION MS-DRG 880 N/A 5685 3979.4999999999995 857 61941.75 3569.565321 8172.11 10148.15 8172.11 3569.565321 3569.565321 3569.565321 5377 8172.11 8989.321 8172.11 8172.11 8172.11 8335.5522 8172.11 DRG Hospital Inpatient Facility Fee DRG DEPRESSIVE NEUROSES MS-DRG 881 N/A 6215 4350.5 857 61403.45 2592.0352356 7714.9 9676.53 7714.9 2592.0352356 2592.0352356 2592.0352356 5377 7714.9 8486.39 7714.9 7714.9 7714.9 7869.197999999999 7714.9 DRG Hospital Inpatient Facility Fee DRG NEUROSES EXCEPT DEPRESSIVE MS-DRG 882 N/A 4716.3 3301.41 857 15216.46 8416.659283199999 7877.22 9843.96 7877.22 8416.659283199999 8416.659283199999 8416.659283199999 5377 7877.22 8664.942000000001 7877.22 7877.22 7877.22 8034.7644 7877.22 DRG Hospital Inpatient Facility Fee DRG DISORDERS OF PERSONALITY AND IMPULSE CONTROL MS-DRG 883 N/A 9857.35 6900.1449999999995 857 25880.08 6554.6404139999995 14559.56 16736.79 14559.56 6554.6404139999995 6554.6404139999995 6554.6404139999995 5377 14559.56 16015.516000000001 14559.56 4851.710325 14559.56 14559.56 14850.7512 14559.56 DRG Hospital Inpatient Facility Fee DRG ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY MS-DRG 884 N/A 31045.1 21731.569999999996 857 31045.1 11251.436889 14158.26 16322.82 14158.26 11251.436889 11251.436889 11251.436889 5377 14158.26 15574.086000000001 14158.26 3523.06317 14158.26 14158.26 14441.4252 14158.26 DRG Hospital Inpatient Facility Fee DRG PSYCHOSES MS-DRG 885 N/A 27225.8 19058.059999999998 857 27225.8 4519.6601508 11682.82 13769.43 11682.82 4519.6601508 4519.6601508 4519.6601508 5377 11682.82 12851.102 11682.82 11439.82224 11682.82 11682.82 11916.4764 11682.82 DRG Hospital Inpatient Facility Fee DRG BEHAVIORAL AND DEVELOPMENTAL DISORDERS MS-DRG 886 N/A 82868.35 58007.845 857 82868.35 5255.6407032 12309.57 14415.89 12309.57 5255.6407032 5255.6407032 5255.6407032 5377 12309.57 13540.527 12309.57 8908.98855 12309.57 12309.57 12555.7614 12309.57 DRG Hospital Inpatient Facility Fee DRG OTHER MENTAL DISORDER DIAGNOSES MS-DRG 887 N/A 14824.89 10377.422999999999 857 21303.79 7138.5342234 11691.84 13778.73 11691.84 7138.5342234 7138.5342234 7138.5342234 5377 11691.84 12861.024000000001 11691.84 15292.817925 11691.84 11691.84 11925.676800000001 11691.84 DRG Hospital Inpatient Facility Fee DRG ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA MS-DRG 894 N/A 14902.12 10431.484 857 14902.12 2645.7129096 5156.49 7037.54 5156.49 2645.7129096 2645.7129096 2645.7129096 5377 5156.49 5672.139 5156.49 5156.49 5156.49 5259.6197999999995 5156.49 DRG Hospital Inpatient Facility Fee DRG ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY MS-DRG 895 N/A 245827.15 172079.00499999998 857 245827.15 9679.2774594 14056.36 67620.14 14056.36 9679.2774594 9679.2774594 9679.2774594 5377 14056.36 15461.996000000001 14056.36 14056.36 14056.36 14337.487200000001 14056.36 DRG Hospital Inpatient Facility Fee DRG ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC MS-DRG 896 N/A 175848.6 123094.01999999999 857 175848.6 8272.325982 15832 38430.14 15832 8272.325982 8272.325982 8272.325982 5377 15832 17415.2 15832 15832 15832 16148.64 15832 DRG Hospital Inpatient Facility Fee DRG ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC MS-DRG 897 N/A 56201.6 39341.119999999995 3078 56201.6 52829.50399999999 7677.02 9637.47 7677.02 0 0 0 5377 7677.02 8444.722000000002 7677.02 3596.02122 7677.02 7677.02 7830.5604 7677.02 DRG Hospital Inpatient Facility Fee DRG WOUND DEBRIDEMENTS FOR INJURIES WITH MCC MS-DRG 901 N/A 89423.75 62596.62499999999 3078 89423.75 36939.185991 39666.57 42634.56 39666.57 36939.185991 36939.185991 36939.185991 5377 39666.57 43633.227000000006 39666.57 5828.53755 39666.57 39666.57 40459.9014 39666.57 DRG Hospital Inpatient Facility Fee DRG WOUND DEBRIDEMENTS FOR INJURIES WITH CC MS-DRG 902 N/A 44389.15 31072.405 3078 44389.15 11665.3513974 17871.87 20153.42 17871.87 11665.3513974 11665.3513974 11665.3513974 5377 17871.87 19659.057 17871.87 6616.48449 17871.87 17871.87 18229.307399999998 17871.87 DRG Hospital Inpatient Facility Fee DRG WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC MS-DRG 903 N/A 39598.86 27719.201999999997 3078 39598.86 6254.6418582 10962.28 13026.18 10962.28 6254.6418582 6254.6418582 6254.6418582 5377 10962.28 12058.508000000002 10962.28 10962.28 10962.28 11181.5256 10962.28 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFTS FOR INJURIES WITH CC/MCC MS-DRG 904 N/A 128193.2 89735.23999999999 3078 128193.2 26312.1993762 32031.03 34758.52 32031.03 26312.1993762 26312.1993762 26312.1993762 5377 32031.03 35234.133 32031.03 50207.298075 32031.03 32031.03 32671.6506 32031.03 DRG Hospital Inpatient Facility Fee DRG SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC MS-DRG 905 N/A 120097.86 84068.502 3078 120097.86 10326.988059 14067.18 16228.88 14067.18 10326.988059 10326.988059 10326.988059 5377 14067.18 15473.898000000001 14067.18 15855.405555 14067.18 14067.18 14348.5236 14067.18 DRG Hospital Inpatient Facility Fee DRG HAND PROCEDURES FOR INJURIES MS-DRG 906 N/A 29851.6 20896.12 3078 29851.6 10026.3930846 16122.38 18348.8 16122.38 10026.3930846 10026.3930846 10026.3930846 5377 16122.38 17734.618000000002 16122.38 8501.234115 16122.38 16122.38 16444.8276 16122.38 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES FOR INJURIES WITH MCC MS-DRG 907 N/A 76056.11 53239.276999999995 3078 76056.11 21682.2017844 34860.88 37677.51 34860.88 21682.2017844 21682.2017844 21682.2017844 5377 34860.88 38346.968 34860.88 35763.225464999996 34860.88 34860.88 35558.0976 34860.88 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES FOR INJURIES WITH CC MS-DRG 908 N/A 199020.3 139314.21 3078 199020.3 11272.907958599999 18545.51 48760.9 18545.51 11272.907958599999 11272.907958599999 11272.907958599999 5377 18545.51 20400.061 18545.51 14036.318175 18545.51 18545.51 18916.4202 18545.51 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC MS-DRG 909 N/A 42556.16 29789.312 3078 42556.16 8621.230862999999 12306.86 14413.12 12306.86 8621.230862999999 8621.230862999999 8621.230862999999 5377 12306.86 13537.546000000002 12306.86 13627.753095 12306.86 12306.86 12552.997200000002 12306.86 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC INJURY WITH MCC MS-DRG 913 N/A 58403.01 40882.106999999996 3078 58403.01 10024.0074102 13654.15 15802.86 13654.15 10024.0074102 10024.0074102 10024.0074102 5377 13654.15 15019.565 13654.15 13654.15 13654.15 13927.233 13654.15 DRG Hospital Inpatient Facility Fee DRG TRAUMATIC INJURY WITHOUT MCC MS-DRG 914 N/A 11519.85 8063.8949999999995 3078 15440.96 3925.6272252 8017.9 9989.07 8017.9 3925.6272252 3925.6272252 3925.6272252 5377 8017.9 8819.69 8017.9 8017.9 8017.9 8178.258 8017.9 DRG Hospital Inpatient Facility Fee DRG ALLERGIC REACTIONS WITH MCC MS-DRG 915 N/A 94290.68 66003.476 3078 94290.68 9839.7140628 16413.66 18649.28 16413.66 9839.7140628 9839.7140628 9839.7140628 5377 16413.66 18055.026 16413.66 16413.66 16413.66 16741.9332 16413.66 DRG Hospital Inpatient Facility Fee DRG ALLERGIC REACTIONS WITHOUT MCC MS-DRG 916 N/A 6382.15 4467.504999999999 2882.06 12204.45 3183.0860681999998 5989.76 7897.03 5989.76 3183.0860681999998 3183.0860681999998 3183.0860681999998 5377 5989.76 6588.736000000001 5989.76 13624.510515 5989.76 5989.76 6109.555200000001 5989.76 DRG Hospital Inpatient Facility Fee DRG POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC MS-DRG 917 N/A 61938.87 43357.209 3078 61938.87 7358.0162682 13729.9 15880.99 13729.9 7358.0162682 7358.0162682 7358.0162682 5377 13729.9 15102.890000000001 13729.9 5335.66539 13729.9 13729.9 14004.498 13729.9 DRG Hospital Inpatient Facility Fee DRG POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC MS-DRG 918 N/A 6775.15 4742.605 3078 14413.46 3596.404158 7374.02 9324.91 7374.02 3596.404158 3596.404158 3596.404158 5377 7374.02 8111.422000000001 7374.02 13374.021209999999 7374.02 7374.02 7521.500400000001 7374.02 DRG Hospital Inpatient Facility Fee DRG COMPLICATIONS OF TREATMENT WITH MCC MS-DRG 919 N/A 23186.81 16230.767 3078 28457.46 10131.3627582 16174.68 18402.76 16174.68 10131.3627582 10131.3627582 10131.3627582 5377 16174.68 17792.148 16174.68 4326.412364999999 16174.68 16174.68 16498.173600000002 16174.68 DRG Hospital Inpatient Facility Fee DRG COMPLICATIONS OF TREATMENT WITH CC MS-DRG 920 N/A 7725.4 5407.78 3078 17350.65 4851.865311 9214.59 11223.47 9214.59 4851.865311 4851.865311 4851.865311 5377 9214.59 10136.049 9214.59 10000.927365 9214.59 9214.59 9398.881800000001 9214.59 DRG Hospital Inpatient Facility Fee DRG COMPLICATIONS OF TREATMENT WITHOUT CC/MCC MS-DRG 921 N/A 5149.5 3604.6499999999996 2344.83 13121.17 2772.1536527999997 6564.2 8489.58 6564.2 2772.1536527999997 2772.1536527999997 2772.1536527999997 5377 6564.2 7220.620000000001 6564.2 4888.18935 6564.2 6564.2 6695.484 6564.2 DRG Hospital Inpatient Facility Fee DRG OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC MS-DRG 922 N/A 21410.96 14987.671999999999 3078 25035.35 10003.1327592 14030.2 16190.76 14030.2 10003.1327592 10003.1327592 10003.1327592 5377 14030.2 15433.220000000001 14030.2 13770.426615 14030.2 14030.2 14310.804 14030.2 DRG Hospital Inpatient Facility Fee DRG OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC MS-DRG 923 N/A 3158.51 2210.957 1438.23 16219.51 3660.8173668 8505.78 10492.31 8505.78 3660.8173668 3660.8173668 3660.8173668 5377 8505.78 9356.358000000002 8505.78 6594.597075 8505.78 8505.78 8675.895600000002 8505.78 DRG Hospital Inpatient Facility Fee DRG EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT MS-DRG 927 N/A 465667.5 325967.25 3078 465667.5 195049.1604324 171181.48 193829.72 171181.48 195049.1604324 195049.1604324 195049.1604324 5377 171181.48 188299.62800000003 171181.48 171181.48 171181.48 174605.10960000003 171181.48 DRG Hospital Inpatient Facility Fee DRG FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC MS-DRG 928 N/A 58306.05 40814.235 3078 91743.97 39500.20745939999 55833.14 59310.32 55833.14 39500.20745939999 39500.20745939999 39500.20745939999 5377 55833.14 61416.454000000005 55833.14 55833.14 55833.14 56949.8028 55833.14 DRG Hospital Inpatient Facility Fee DRG FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC MS-DRG 929 N/A 162010.38 113407.266 3078 162010.38 11445.272934 26502.1 35447.11 26502.1 11445.272934 11445.272934 11445.272934 5377 26502.1 29152.31 26502.1 26502.1 26502.1 27032.142 26502.1 DRG Hospital Inpatient Facility Fee DRG EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT MS-DRG 933 N/A 138107.65 96675.355 3078 138107.65 20079.028587599998 27351.59 29931.7 27351.59 20079.028587599998 20079.028587599998 20079.028587599998 5377 27351.59 30086.749000000003 27351.59 27351.59 27351.59 27898.6218 27351.59 DRG Hospital Inpatient Facility Fee DRG FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY MS-DRG 934 N/A 30471.01 21329.707 3078 30471.01 5996.3926044 16917.77 19169.26 16917.77 5996.3926044 5996.3926044 5996.3926044 5377 16917.77 18609.547000000002 16917.77 16917.77 16917.77 17256.1254 16917.77 DRG Hospital Inpatient Facility Fee DRG NON-EXTENSIVE BURNS MS-DRG 935 N/A 17332.7 12132.89 3078 31774.55 6790.8221796 18253.33 20546.89 18253.33 6790.8221796 6790.8221796 6790.8221796 5377 18253.33 20078.663000000004 18253.33 18253.33 18253.33 18618.396600000004 18253.33 DRG Hospital Inpatient Facility Fee DRG O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC MS-DRG 939 N/A 138795.87 97157.109 3078 138795.87 16574.472894 27929.65 30527.96 27929.65 16574.472894 16574.472894 16574.472894 5377 27929.65 30722.615000000005 27929.65 27929.65 27929.65 28488.243000000002 27929.65 DRG Hospital Inpatient Facility Fee DRG O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC MS-DRG 940 N/A 37231.85 26062.295 3078 37231.85 10847.0650782 19869.36 22213.81 19869.36 10847.0650782 10847.0650782 10847.0650782 5377 19869.36 21856.296000000002 19869.36 19869.36 19869.36 20266.7472 19869.36 DRG Hospital Inpatient Facility Fee DRG O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC MS-DRG 941 N/A 41481.7 29037.189999999995 3078 41481.7 15601.1177388 17020.57 19275.28 17020.57 15601.1177388 15601.1177388 15601.1177388 5377 17020.57 18722.627 17020.57 17020.57 17020.57 17360.9814 17020.57 DRG Hospital Inpatient Facility Fee DRG REHABILITATION WITH CC/MCC MS-DRG 945 N/A 73807 51664.899999999994 3078 73807 9964.9619688 13573.89 15720.08 13573.89 9964.9619688 9964.9619688 9964.9619688 5377 13573.89 14931.279 13573.89 13573.89 13573.89 13845.3678 13573.89 DRG Hospital Inpatient Facility Fee DRG REHABILITATION WITHOUT CC/MCC MS-DRG 946 N/A 44072.25 30850.574999999997 3078 44072.25 7431.9721746 10123.61 12161.11 10123.61 7431.9721746 7431.9721746 7431.9721746 5377 10123.61 11135.971000000001 10123.61 10123.61 10123.61 10326.0822 10123.61 DRG Hospital Inpatient Facility Fee DRG SIGNS AND SYMPTOMS WITH MCC MS-DRG 947 N/A 29600.95 20720.665 2854.43 29600.95 8220.4375638 10962.28 13026.18 10962.28 8220.4375638 8220.4375638 8220.4375638 5377 10962.28 12058.508000000002 10962.28 10962.28 10962.28 11181.5256 10962.28 DRG Hospital Inpatient Facility Fee DRG SIGNS AND SYMPTOMS WITHOUT MCC MS-DRG 948 N/A 39405.87 27584.109 2597.97 39405.87 4238.1505716 7012.4 8951.89 7012.4 4238.1505716 4238.1505716 4238.1505716 5377 7012.4 7713.64 7012.4 13544.256660000001 7012.4 7012.4 7152.648 7012.4 DRG Hospital Inpatient Facility Fee DRG AFTERCARE WITH CC/MCC MS-DRG 949 N/A 9142.3 6399.609999999999 1786.89 19799.95 8311.093191 10749.46 12806.66 10749.46 8311.093191 8311.093191 8311.093191 5377 10749.46 11824.406 10749.46 10101.447345 10749.46 10749.46 10964.4492 10749.46 DRG Hospital Inpatient Facility Fee DRG AFTERCARE WITHOUT CC/MCC MS-DRG 950 N/A 108263 75784.09999999999 2143.34 108263 5816.8706058 6398.27 8318.42 6398.27 5816.8706058 5816.8706058 5816.8706058 5377 6398.27 7038.097000000001 6398.27 11173.120035 6398.27 6398.27 6526.2354000000005 6398.27 DRG Hospital Inpatient Facility Fee DRG OTHER FACTORS INFLUENCING HEALTH STATUS MS-DRG 951 N/A 6934.55 4854.1849999999995 1780.22 10837.33 2988.6536045999997 5133.05 7013.34 5133.05 2988.6536045999997 2988.6536045999997 2988.6536045999997 5377 5133.05 5646.3550000000005 5133.05 5760.44337 5133.05 5133.05 5235.711 5133.05 DRG Hospital Inpatient Facility Fee DRG CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA MS-DRG 955 N/A 203377.17 142364.019 3078 203377.17 51207.9045774 60745.25 64377.15 60745.25 51207.9045774 51207.9045774 51207.9045774 5377 60745.25 66819.77500000001 60745.25 60745.25 60745.25 61960.155 60745.25 DRG Hospital Inpatient Facility Fee DRG LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MS-DRG 956 N/A 103543.21 72480.247 3078 103543.21 47162.3972136 34306.28 43681.27 34306.28 47162.3972136 47162.3972136 47162.3972136 5377 34306.28 37736.908 34306.28 34306.28 34306.28 34992.4056 34306.28 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC MS-DRG 957 N/A 179465.74 125626.01799999998 3078 179465.74 49106.12543099999 66827.89 70651.37 66827.89 49106.12543099999 49106.12543099999 49106.12543099999 5377 66827.89 73510.679 66827.89 66827.89 66827.89 68164.4478 66827.89 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC MS-DRG 958 N/A 73140.24 51198.168 3078 73140.24 30553.332040799996 37609.57 40512.76 37609.57 30553.332040799996 30553.332040799996 30553.332040799996 5377 37609.57 41370.527 37609.57 69601.169055 37609.57 37609.57 38361.7614 37609.57 DRG Hospital Inpatient Facility Fee DRG OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC MS-DRG 959 N/A 197083.71 137958.59699999998 3078 197083.71 21369.678438 23164.54 48873.83 23164.54 21369.678438 21369.678438 21369.678438 5377 23164.54 25480.994000000002 23164.54 64102.564020000005 23164.54 23164.54 23627.8308 23164.54 DRG Hospital Inpatient Facility Fee DRG OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC MS-DRG 963 N/A 125866.54 88106.578 3078 125866.54 20582.405886 25008.72 27515.05 25008.72 20582.405886 20582.405886 20582.405886 5377 25008.72 27509.592000000004 25008.72 25008.72 25008.72 25508.8944 25008.72 DRG Hospital Inpatient Facility Fee DRG OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC MS-DRG 964 N/A 22813.09 15969.162999999999 3078 23721.43 9532.5584838 13206.86 15341.46 13206.86 9532.5584838 9532.5584838 9532.5584838 5377 13206.86 14527.546000000002 13206.86 13206.86 13206.86 13470.997200000002 13206.86 DRG Hospital Inpatient Facility Fee DRG OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC MS-DRG 965 N/A 36821.18 25774.825999999997 3078 36821.18 6990.025991999999 8205.48 10182.56 8205.48 6990.025991999999 6990.025991999999 6990.025991999999 5377 8205.48 9026.028 8205.48 8205.48 8205.48 8369.5896 8205.48 DRG Hospital Inpatient Facility Fee DRG HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC MS-DRG 969 N/A 740885.64 518619.948 3078 740885.64 47980.6835328 65358.86 286990.14 65358.86 47980.6835328 47980.6835328 47980.6835328 5377 65358.86 71894.746 65358.86 65358.86 65358.86 66666.0372 65358.86 DRG Hospital Inpatient Facility Fee DRG HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC MS-DRG 970 N/A 290321.1 203224.76999999996 3078 290321.1 20445.8260266 27851.2 89186.66 27851.2 20445.8260266 20445.8260266 20445.8260266 5377 27851.2 30636.320000000003 27851.2 27851.2 27851.2 28408.224000000002 27851.2 DRG Hospital Inpatient Facility Fee DRG HIV WITH MAJOR RELATED CONDITION WITH MCC MS-DRG 974 N/A 37394.6 26176.219999999998 3078 43990.92 15139.489742400001 25908.71 28443.39 25908.71 15139.489742400001 15139.489742400001 15139.489742400001 5377 25908.71 28499.581000000002 25908.71 25908.71 25908.71 26426.8842 25908.71 DRG Hospital Inpatient Facility Fee DRG HIV WITH MAJOR RELATED CONDITION WITH CC MS-DRG 975 N/A 14280.15 9996.105 3078 22443.53 9107.312021999998 12406.06 14515.43 12406.06 9107.312021999998 9107.312021999998 9107.312021999998 5377 12406.06 13646.666000000001 12406.06 12406.06 12406.06 12654.181199999999 12406.06 DRG Hospital Inpatient Facility Fee DRG HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC MS-DRG 976 N/A 89110 62376.99999999999 3078 89110 6109.115719799999 8321.81 10302.55 8321.81 6109.115719799999 6109.115719799999 6109.115719799999 5377 8321.81 9153.991 8321.81 8321.81 8321.81 8488.2462 8321.81 DRG Hospital Inpatient Facility Fee DRG HIV WITH OR WITHOUT OTHER RELATED CONDITION MS-DRG 977 N/A 16416.4 11491.48 3078 21352.72 8605.7239794 11722.5 13810.35 11722.5 8605.7239794 8605.7239794 8605.7239794 5377 11722.5 12894.750000000002 11722.5 20577.41268 11722.5 11722.5 11956.95 11722.5 DRG Hospital Inpatient Facility Fee DRG EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC MS-DRG 981 N/A 88334.89 61834.422999999995 3078 88334.89 33747.1536438 41306.05 44325.68 41306.05 33747.1536438 33747.1536438 33747.1536438 5377 41306.05 45436.655000000006 41306.05 41306.05 41306.05 42132.171 41306.05 DRG Hospital Inpatient Facility Fee DRG EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC MS-DRG 982 N/A 114607.23 80225.06099999999 3078 114607.23 15426.367089 22618.95 25049.99 22618.95 15426.367089 15426.367089 15426.367089 5377 22618.95 24880.845 22618.95 22618.95 22618.95 23071.329 22618.95 DRG Hospital Inpatient Facility Fee DRG EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC MS-DRG 983 N/A 81808.06 57265.64199999999 3078 81808.06 9525.997879199998 15061.86 17254.88 15061.86 9525.997879199998 9525.997879199998 9525.997879199998 5377 15061.86 16568.046000000002 15061.86 15061.86 15061.86 15363.0972 15061.86 DRG Hospital Inpatient Facility Fee DRG PROSTATIC O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W/O CC/MCC MS-DRG 986 N/A 120116.6 84081.62 3078 120116.6 112909.60399999999 60058.3 13729.94 60058.3 0 0 0 5377 60058.3 66064.13 60058.3 12947.621939999999 60058.3 60058.3 61259.46600000001 60058.3 DRG Hospital Inpatient Facility Fee DRG NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC MS-DRG 987 N/A 19484.65 13639.255000000001 3078 50400.56 20730.9141174 29925.33 32586.49 29925.33 20730.9141174 20730.9141174 20730.9141174 5377 29925.33 32917.863000000005 29925.33 28177.209555 29925.33 29925.33 30523.836600000002 29925.33 DRG Hospital Inpatient Facility Fee DRG NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC MS-DRG 988 N/A 19735.35 13814.744999999999 3078 27058.68 10164.1657812 15298.14 17498.61 15298.14 10164.1657812 10164.1657812 10164.1657812 5377 15298.14 16827.954 15298.14 13815.012089999998 15298.14 15298.14 15604.1028 15298.14 DRG Hospital Inpatient Facility Fee DRG NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC MS-DRG 989 N/A 17411.3 12187.909999999998 3078 18510.5 7171.3372463999995 9941.44 11973.19 9941.44 7171.3372463999995 7171.3372463999995 7171.3372463999995 5377 9941.44 10935.584 9941.44 9747.195479999998 9941.44 9941.44 10140.2688 9941.44 DRG Hospital Inpatient Facility Fee DRG PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS MS-DRG 998 N/A 11377.95 7964.565 72.18 11377.95 10695.273 5688.98 72.18 5688.98 0 0 0 5377 5688.98 6257.878 5688.98 5688.98 5688.98 5802.759599999999 5688.98 DRG Hospital Inpatient Facility Fee DRG UNGROUPABLE MS-DRG 999 N/A 21765.36 15235.751999999999 72.18 21765.36 20459.4384 10882.68 72.18 10882.68 0 0 0 5377 10882.68 11970.948000000002 10882.68 10882.68 10882.68 11100.3336 10882.68