Overview

CDM Standard Charge File
Aetna
Aetna MCR ADV
Armor Health
Blue Cross Health Options
Blue Cross MCR ADV HMO PPO
Blue Cross NWB
Blue Cross PPC
Blue Cross Traditional
FL Medicaid
Freedom Health HMO PPO MCR ADV
Freedom Health MCD ADV
Humana Choice Care
Humana MCR ADV HMO PPO
Integral HP MCD ADV
Medicare
Molina MCD ADV
Multiplan PHCS
Self Insured Plans LLC
Seminole Tribe MCR ADV
Simply Health MCD ADV
Staywell Healthy Kids MCD ADV
Sunshine Ambetter
Sunshine State HP MCD ADV
Tricare Florida
Tricare Humana
UHC
UHC MCR ADV HMO PPO
UPMC MCR ADV
VA Community Care Network
Vivida MCD ADV
Wellcare MCD ADV


Sheet 1: CDM Standard Charge File

Naples Community Hospital

























File Updated: 04/15/2022




















































Charge Code Bill Item Description CPT® Alternate CPT® HCPCS Alternate HCPCS CPT® Modifier Revenue Code NDC Code Service Location Gross Charge/Unit Cash Price Minimum Allowable Maximum Allowable Aetna International - Inpatient Aetna International - Outpatient Beech Street - Inpatient/Outpatient Cigna - Inpatient/Outpatient Cigna Connect - Inpatient Cigna Connect - Outpatient Consortium - Inpatient/Outpatient First Health - Outpatient Freedom Health PPO - Inpatient/Outpatient Mail Handlers - Inpatient/Outpatient Multiplan PHCS - Outpatient Seminole Tribe Employee PPO - Inpatient/Outpatient
30106 7195886 ROOM/BED: Private CVRU




110
IP $4,994.00 $1,997.60 $2,586.89 $4,494.60 $3,995.20 N/A $4,494.60 $3,395.92 $2,586.89 N/A $2,846.58 N/A $2,996.40 $3,495.80 N/A $4,244.90
30106 7195886 ROOM/BED: Private Post Angio




110
IP $3,087.00 $1,234.80 $1,599.07 $2,778.30 $2,469.60 N/A $2,778.30 $2,099.16 $1,599.07 N/A $1,759.59 N/A $1,852.20 $2,160.90 N/A $2,623.95
30106 7195886 ROOM/BED: Private 2N Angio




110
IP $3,087.00 $1,234.80 $1,599.07 $2,778.30 $2,469.60 N/A $2,778.30 $2,099.16 $1,599.07 N/A $1,759.59 N/A $1,852.20 $2,160.90 N/A $2,623.95
30106 7195886 ROOM/BED: Private 6N GVS




110
IP $2,614.00 $1,045.60 $1,354.05 $2,352.60 $2,091.20 N/A $2,352.60 $1,777.52 $1,354.05 N/A $1,489.98 N/A $1,568.40 $1,829.80 N/A $2,221.90
30106 7195886 ROOM/BED: Private Psych




110
IP $2,593.00 $1,037.20 $1,343.17 $2,333.70 $2,074.40 N/A $2,333.70 $1,763.24 $1,343.17 N/A $1,478.01 N/A $1,555.80 $1,815.10 N/A $2,204.05
30106 7195886 ROOM/BED: Private L&D




110
IP $2,258.00 $903.20 $1,169.64 $2,032.20 $1,806.40 N/A $2,032.20 $1,535.44 $1,169.64 N/A $1,287.06 N/A $1,354.80 $1,580.60 N/A $1,919.30
31906 7204287 PRIVATE WOMEN & CHILDREN




110
IP $2,240.00 $896.00 $1,160.32 $2,016.00 $1,792.00 N/A $2,016.00 $1,523.20 $1,160.32 N/A $1,276.80 N/A $1,344.00 $1,568.00 N/A $1,904.00
30106 7195886 ROOM/BED: Private SICU




110
IP $2,164.00 $865.60 $1,120.95 $1,947.60 $1,731.20 N/A $1,947.60 $1,471.52 $1,120.95 N/A $1,233.48 N/A $1,298.40 $1,514.80 N/A $1,839.40
30106 7195886 ROOM/BED: Private




110
IP $2,164.00 $865.60 $1,120.95 $1,947.60 $1,731.20 N/A $1,947.60 $1,471.52 $1,120.95 N/A $1,233.48 N/A $1,298.40 $1,514.80 N/A $1,839.40
50104 7195887 ROOM/BED: Semi Private Post Angio




120
IP $2,812.00 $1,124.80 $1,456.62 $2,530.80 $2,249.60 N/A $2,530.80 $1,912.16 $1,456.62 N/A $1,602.84 N/A $1,687.20 $1,968.40 N/A $2,390.20
50104 7195887 ROOM/BED: Semi Private 2N Angio




120
IP $2,812.00 $1,124.80 $1,456.62 $2,530.80 $2,249.60 N/A $2,530.80 $1,912.16 $1,456.62 N/A $1,602.84 N/A $1,687.20 $1,968.40 N/A $2,390.20
50104 7195887 ROOM/BED: Semi Private SICU




120
IP $2,318.00 $927.20 $1,200.72 $2,086.20 $1,854.40 N/A $2,086.20 $1,576.24 $1,200.72 N/A $1,321.26 N/A $1,390.80 $1,622.60 N/A $1,970.30
50104 7195887 ROOM/BED: Semi Private L&D




120
IP $1,983.00 $793.20 $1,027.19 $1,784.70 $1,586.40 N/A $1,784.70 $1,348.44 $1,027.19 N/A $1,130.31 N/A $1,189.80 $1,388.10 N/A $1,685.55
51904 7204288 SEMI PRIVATE L&D-MED/SURG




120
IP $1,951.00 $780.40 $1,010.62 $1,755.90 $1,560.80 N/A $1,755.90 $1,326.68 $1,010.62 N/A $1,112.07 N/A $1,170.60 $1,365.70 N/A $1,658.35
50104 7195887 ROOM/BED: Semi Private




120
IP $1,889.00 $755.60 $978.50 $1,700.10 $1,511.20 N/A $1,700.10 $1,284.52 $978.50 N/A $1,076.73 N/A $1,133.40 $1,322.30 N/A $1,605.65
7739954 7739954 Room/Bed Hospice




120
IP $1,248.00 $499.20 $646.46 $1,123.20 $998.40 N/A $1,123.20 $848.64 $646.46 N/A $711.36 N/A $748.80 $873.60 N/A $1,060.80
7195880 7195880 Suite - Women and Children L&D




140
IP $2,505.00 $1,002.00 $1,297.59 $2,254.50 $2,004.00 N/A $2,254.50 $1,703.40 $1,297.59 N/A $1,427.85 N/A $1,503.00 $1,753.50 N/A $2,129.25
7195880 7195880 Suite - Women and Children




140
IP $2,505.00 $1,002.00 $1,297.59 $2,254.50 $2,004.00 N/A $2,254.50 $1,703.40 $1,297.59 N/A $1,427.85 N/A $1,503.00 $1,753.50 N/A $2,129.25
61903 7195882 ROOM/BED: Nursery




170
IP $1,255.00 $502.00 $650.09 $1,129.50 $1,004.00 N/A $1,129.50 $853.40 $650.09 N/A $715.35 N/A $753.00 $878.50 N/A $1,066.75
61903 7204289 NORMAL NEWBORN CARE




170
IP $1,255.00 $502.00 $650.09 $1,129.50 $1,004.00 N/A $1,129.50 $853.40 $650.09 N/A $715.35 N/A $753.00 $878.50 N/A $1,066.75
81901 7195881 ROOM/BED NICU




174
IP $3,238.00 $1,295.20 $1,677.28 $2,914.20 $2,590.40 N/A $2,914.20 $2,201.84 $1,677.28 N/A $1,845.66 N/A $1,942.80 $2,266.60 N/A $2,752.30
81901 7195881 ROOM/BED NICU ACN/CCN




174
IP $2,243.00 $897.20 $1,161.87 $2,018.70 $1,794.40 N/A $2,018.70 $1,525.24 $1,161.87 N/A $1,278.51 N/A $1,345.80 $1,570.10 N/A $1,906.55
81208 7195879 ROOM/BED:ICU SICU




200
IP $3,961.00 $1,584.40 $2,051.80 $3,564.90 $3,168.80 N/A $3,564.90 $2,693.48 $2,051.80 N/A $2,257.77 N/A $2,376.60 $2,772.70 N/A $3,366.85
81208 7195879 ROOM/BED:ICU




200
IP $3,961.00 $1,584.40 $2,051.80 $3,564.90 $3,168.80 N/A $3,564.90 $2,693.48 $2,051.80 N/A $2,257.77 N/A $2,376.60 $2,772.70 N/A $3,366.85
81208 7195879 ROOM/BED:ICU CVRU




200
IP $3,722.00 $1,488.80 $1,928.00 $3,349.80 $2,977.60 N/A $3,349.80 $2,530.96 $1,928.00 N/A $2,121.54 N/A $2,233.20 $2,605.40 N/A $3,163.70
81307 7195885 ROOM/BED: PICU




203
IP $3,697.00 $1,478.80 $1,915.05 $3,327.30 $2,957.60 N/A $3,327.30 $2,513.96 $1,915.05 N/A $2,107.29 N/A $2,218.20 $2,587.90 N/A $3,142.45
20701 7195884 ROOM/BED:PCU




206
IP $3,211.00 $1,284.40 $1,663.30 $2,889.90 $2,568.80 N/A $2,889.90 $2,183.48 $1,663.30 N/A $1,830.27 N/A $1,926.60 $2,247.70 N/A $2,729.35
21907 7204286 PRIVATE W&C PROGRESSIVE CARE




206
IP $3,211.00 $1,284.40 $1,663.30 $2,889.90 $2,568.80 N/A $2,889.90 $2,183.48 $1,663.30 N/A $1,830.27 N/A $1,926.60 $2,247.70 N/A $2,729.35
7000615 7225123 XANAX 0.25MG TAB 7000615




250 63739-0644-10 IP/OP $0.07 $0.03 $0.02 $0.06 $0.06 $0.06 $0.06 $0.05 $0.04 $0.02 $0.04 $0.06 $0.04 $0.05 $0.06 $0.06
7009764 7225130 LASIX 40MG TAB 7009764




250 00378-0216-10 IP/OP $0.16 $0.06 $0.06 $0.14 $0.13 $0.14 $0.14 $0.11 $0.08 $0.06 $0.09 $0.14 $0.10 $0.11 $0.14 $0.14
7001100 7225139 AMOXIL 250MG CAP 7001100




250 00781-2020-01 IP/OP $0.25 $0.10 $0.09 $0.22 $0.20 $0.21 $0.22 $0.17 $0.13 $0.09 $0.14 $0.21 $0.15 $0.17 $0.21 $0.21
7004724 7225121 CATAPRES 0.1MG TAB 7004724




250 63739-0060-10 IP/OP $0.32 $0.13 $0.11 $0.29 $0.25 $0.27 $0.29 $0.22 $0.16 $0.11 $0.18 $0.27 $0.19 $0.22 $0.27 $0.27
7000466 7225116 PROVENTIL 120ML SYR 7000466




250 00093-0661-16 IP/OP $0.33 $0.13 $0.11 $0.29 $0.26 $0.28 $0.29 $0.22 $0.17 $0.11 $0.19 $0.28 $0.20 $0.23 $0.28 $0.28
7006521 7225122 BENTYL 20MG TAB 7006521




250 00378-1620-01 IP/OP $0.36 $0.14 $0.12 $0.32 $0.28 $0.30 $0.32 $0.24 $0.18 $0.12 $0.20 $0.30 $0.21 $0.25 $0.30 $0.30
7011455 7225150 MOTRIN 400MG TAB 7011455




250 53746-0464-01 IP/OP $0.39 $0.16 $0.14 $0.35 $0.31 $0.33 $0.35 $0.27 $0.20 $0.14 $0.22 $0.33 $0.24 $0.27 $0.33 $0.33
7000136 7225138 TYLENOL-CODEINE SYR UD 7000136




250 00121-0504-05 IP/OP $0.58 $0.23 $0.20 $0.52 $0.46 $0.49 $0.52 $0.39 $0.30 $0.20 $0.33 $0.49 $0.35 $0.41 $0.49 $0.49
7021231 7225151 SEPTRA/BACTRIM TAB 7021231




250 53746-0271-01 IP/OP $0.66 $0.27 $0.23 $0.60 $0.53 $0.56 $0.60 $0.45 $0.34 $0.23 $0.38 $0.56 $0.40 $0.47 $0.56 $0.56
7000037 7225132 TYLENOL 120MG SUP 7000037




250 51672-2115-02 IP/OP $0.80 $0.32 $0.28 $0.72 $0.64 $0.68 $0.72 $0.55 $0.42 $0.28 $0.46 $0.68 $0.48 $0.56 $0.68 $0.68
7008691 7225118 PEPCID 20MG/2ML INJ 7008691




250 63323-0739-12 IP/OP $1.13 $0.45 $0.40 $1.02 $0.90 $0.96 $1.02 $0.77 $0.59 $0.40 $0.64 $0.96 $0.68 $0.79 $0.96 $0.96
7005317 7225128 FLEXERIL 10MG TAB 7005317




250 00603-3079-21 IP/OP $1.16 $0.46 $0.41 $1.04 $0.93 $0.98 $1.04 $0.79 $0.60 $0.41 $0.66 $0.98 $0.69 $0.81 $0.98 $0.98
7003858 7225117 KEFLEX 500MG CAP 7003858




250 00093-3147-05 IP/OP $1.35 $0.54 $0.47 $1.21 $1.08 $1.15 $1.21 $0.92 $0.70 $0.47 $0.77 $1.15 $0.81 $0.94 $1.15 $1.15
7000219 7225115 PERCOCET 5/325MG TAB 7000219




250 68084-0355-01 IP/OP $1.38 $0.55 $0.48 $1.24 $1.10 $1.17 $1.24 $0.94 $0.71 $0.48 $0.79 $1.17 $0.83 $0.97 $1.17 $1.17
7024821 7225145 MOTRIN SUS 100 MG/5 ML 7024821




250 68094-0503-61 IP/OP $1.45 $0.58 $0.51 $1.31 $1.16 $1.23 $1.31 $0.99 $0.75 $0.51 $0.83 $1.23 $0.87 $1.02 $1.23 $1.23
7241100 7352862 ALBUTEROL 0.63MG




250 00378-6991-52 IP/OP $1.66 $0.66 $0.58 $1.49 $1.33 $1.41 $1.49 $1.13 $0.86 $0.58 $0.95 $1.41 $1.00 $1.16 $1.41 $1.41
7241100 7352875 ALBUTEROL 0.63MG




250 00378-6991-52 IP/OP $1.66 $0.66 $0.58 $1.49 $1.33 $1.41 $1.49 $1.13 $0.86 $0.58 $0.95 $1.41 $1.00 $1.16 $1.41 $1.41
7006786 7225135 CARDIZEM 25MG/5ML INJ 7006786




250 00641-6013-10 IP/OP $2.62 $1.05 $0.92 $2.35 $2.09 $2.22 $2.35 $1.78 $1.36 $0.92 $1.49 $2.22 $1.57 $1.83 $2.22 $2.22
7002660 7225147 MARCAINE 0.5% 30ML INJ 7002660




250 00409-1162-02 IP/OP $2.64 $1.05 $0.92 $2.37 $2.11 $2.24 $2.37 $1.79 $1.37 $0.92 $1.50 $2.24 $1.58 $1.84 $2.24 $2.24
7005184 7225140 MAALOX 30ML SUS 7005184




250 00121-1761-30 IP/OP $2.78 $1.11 $0.97 $2.51 $2.23 $2.37 $2.51 $1.89 $1.44 $0.97 $1.59 $2.37 $1.67 $1.95 $2.37 $2.37
7004336 7225113 CIPRO 500MG TAB 7004336




250 62135-0309-01 IP/OP $5.19 $2.08 $1.82 $4.67 $4.15 $4.41 $4.67 $3.53 $2.69 $1.82 $2.96 $4.41 $3.12 $3.63 $4.41 $4.41
7001225 7225125 AUGMENTIN 250MG TAB 7001225




250 16714-0295-01 IP/OP $5.92 $2.37 $2.07 $5.33 $4.73 $5.03 $5.33 $4.02 $3.07 $2.07 $3.37 $5.03 $3.55 $4.14 $5.03 $5.03
7003312 7225120 DEBROX OTIC 15ML SOL 7003312




250 00904-6627-35 IP/OP $6.00 $2.40 $2.10 $5.40 $4.80 $5.10 $5.40 $4.08 $3.11 $2.10 $3.42 $5.10 $3.60 $4.20 $5.10 $5.10
7006802 7225154 CARDIZEM 125MG/25ML INJ 7006802




250 00641-6015-10 IP/OP $6.96 $2.78 $2.44 $6.26 $5.57 $5.92 $6.26 $4.73 $3.61 $2.44 $3.97 $5.92 $4.18 $4.87 $5.92 $5.92
7004799 7225148 PLAVIX 75MG TAB 7004799




250 16729-0218-16 IP/OP $6.96 $2.78 $2.44 $6.26 $5.57 $5.92 $6.26 $4.73 $3.61 $2.44 $3.97 $5.92 $4.18 $4.87 $5.92 $5.92
7002033 7225134 ZITHROMAX 500MG TAB 7002033




250 00093-7169-56 IP/OP $15.57 $6.23 $5.45 $14.01 $12.45 $13.23 $14.01 $10.59 $8.06 $5.45 $8.87 $13.23 $9.34 $10.90 $13.23 $13.23
7007370 7225142 DONNATAL 10ML ELI 7007370




250 66689-0063-10 IP/OP $41.86 $16.74 $14.65 $37.67 $33.49 $35.58 $37.67 $28.46 $21.68 $14.65 $23.86 $35.58 $25.12 $29.30 $35.58 $35.58
7005218 7225141 CORTISPORIN 7.5ML OPH SUS 7005218




250 61314-0641-75 IP/OP $170.25 $68.10 $59.59 $153.23 $136.20 $144.71 $153.23 $115.77 $88.19 $59.59 $97.04 $144.71 $102.15 $119.18 $144.71 $144.71
7430357 7430357 99997-0323-78 - niCARdipine 5 mg/d5w 50 mL IV Drip




250 99997-0323-78 IP/OP $407.31 $162.92 $142.56 $366.58 $325.85 $346.21 $366.58 $276.97 $210.99 $142.56 $232.17 $346.21 $244.39 $285.12 $346.21 $346.21
7903982 3152876 HEART PERFUSION SET




250
IP/OP $2,250.00 $900.00 $787.50 $2,025.00 $1,800.00 $1,912.50 $2,025.00 $1,530.00 $1,165.50 $787.50 $1,282.50 $1,912.50 $1,350.00 $1,575.00 $1,912.50 $1,912.50
6301394 7076270 INTEGRA FLOWABLE WOUND MATRIX 1CC

Q4114

250
IP/OP $1,733.00 $693.20 $606.55 $1,559.70 $1,386.40 $1,473.05 $1,559.70 $1,178.44 $897.69 $606.55 $987.81 $1,473.05 $1,039.80 $1,213.10 $1,473.05 $1,473.05
7903958 3152859 ANESTHESIA MEDICATION SET




250
IP/OP $1,500.00 $600.00 $525.00 $1,350.00 $1,200.00 $1,275.00 $1,350.00 $1,020.00 $777.00 $525.00 $855.00 $1,275.00 $900.00 $1,050.00 $1,275.00 $1,275.00
7903958 3416883 ANESTHESIA MEDICATION SET




250
IP/OP $1,500.00 $600.00 $525.00 $1,350.00 $1,200.00 $1,275.00 $1,350.00 $1,020.00 $777.00 $525.00 $855.00 $1,275.00 $900.00 $1,050.00 $1,275.00 $1,275.00
8134156 8134156 TEE Anesth Medication set




250
IP/OP $1,500.00 $600.00 $525.00 $1,350.00 $1,200.00 $1,275.00 $1,350.00 $1,020.00 $777.00 $525.00 $855.00 $1,275.00 $900.00 $1,050.00 $1,275.00 $1,275.00
8189084 8189084 TEE Anesth Medication set




250
IP/OP $1,500.00 $600.00 $525.00 $1,350.00 $1,200.00 $1,275.00 $1,350.00 $1,020.00 $777.00 $525.00 $855.00 $1,275.00 $900.00 $1,050.00 $1,275.00 $1,275.00
8241201 8241201 TEE ANESTHESIA MEDICATION SET - SH




250
IP/OP $1,500.00 $600.00 $525.00 $1,350.00 $1,200.00 $1,275.00 $1,350.00 $1,020.00 $777.00 $525.00 $855.00 $1,275.00 $900.00 $1,050.00 $1,275.00 $1,275.00
7589976 7589976 EVICEL FIBRIN SEALANT (HUMAN) 10ML 3905




250
IP/OP $1,024.00 $409.60 $358.40 $921.60 $819.20 $870.40 $921.60 $696.32 $530.43 $358.40 $583.68 $870.40 $614.40 $716.80 $870.40 $870.40
8210942 8210942 VISTASEAL FIBRIN SEALANT (HUMAN) 10ML VST10




250
IP/OP $997.00 $398.80 $348.95 $897.30 $797.60 $847.45 $897.30 $677.96 $516.45 $348.95 $568.29 $847.45 $598.20 $697.90 $847.45 $847.45
8070424 8070424 10122-0313-10- niCARdipine 40 mg IV PREMIX




250
IP/OP $771.46 $308.58 $270.01 $694.31 $617.17 $655.74 $694.31 $524.59 $399.62 $270.01 $439.73 $655.74 $462.88 $540.02 $655.74 $655.74
7596066 7596066 EVICEL FIBRIN SEALANT (HUMAN) 4ML 3902




250
IP/OP $668.00 $267.20 $233.80 $601.20 $534.40 $567.80 $601.20 $454.24 $346.02 $233.80 $380.76 $567.80 $400.80 $467.60 $567.80 $567.80
7903966 3152875 KIT CONSCIOUS SEDATION MEDS




250
IP/OP $625.00 $250.00 $218.75 $562.50 $500.00 $531.25 $562.50 $425.00 $323.75 $218.75 $356.25 $531.25 $375.00 $437.50 $531.25 $531.25
7903966 3416881 CONSCIOUS SEDATION MEDS




250
IP/OP $625.00 $250.00 $218.75 $562.50 $500.00 $531.25 $562.50 $425.00 $323.75 $218.75 $356.25 $531.25 $375.00 $437.50 $531.25 $531.25
7452730 7452730 MONITORED ANESTHESIA CASE




250
IP/OP $625.00 $250.00 $218.75 $562.50 $500.00 $531.25 $562.50 $425.00 $323.75 $218.75 $356.25 $531.25 $375.00 $437.50 $531.25 $531.25
3161452 36649 OPTISON PER ML

Q9956

250
IP/OP $592.00 $236.80 $207.20 $532.80 $473.60 $503.20 $532.80 $402.56 $306.66 $207.20 $337.44 $503.20 $355.20 $414.40 $503.20 $503.20
6641773 7204290 SEALANT FLOSEAL




250
IP/OP $540.00 $216.00 $189.00 $486.00 $432.00 $459.00 $486.00 $367.20 $279.72 $189.00 $307.80 $459.00 $324.00 $378.00 $459.00 $459.00
7452732 7452732 Bill Only Cath Lab Interventional Medication Kit




250
IP/OP $506.00 $202.40 $177.10 $455.40 $404.80 $430.10 $455.40 $344.08 $262.11 $177.10 $288.42 $430.10 $303.60 $354.20 $430.10 $430.10
6802789 3282878 FLOSEAL HEMOSTATIC MATRIX 5ML ADS201844




250
IP/OP $412.00 $164.80 $144.20 $370.80 $329.60 $350.20 $370.80 $280.16 $213.42 $144.20 $234.84 $350.20 $247.20 $288.40 $350.20 $350.20
6802789 7558509 Floseal Hemostatic Matrix 5ml




250
IP/OP $412.00 $164.80 $144.20 $370.80 $329.60 $350.20 $370.80 $280.16 $213.42 $144.20 $234.84 $350.20 $247.20 $288.40 $350.20 $350.20
6099501 6047082 0469-6501-89 LEXISCAN INJECTION

J2785

250
IP/OP $402.00 $160.80 $140.70 $361.80 $321.60 $341.70 $361.80 $273.36 $208.24 $140.70 $229.14 $341.70 $241.20 $281.40 $341.70 $341.70
7131709 2944999 PULMOZYME 2.5MG/2.5ML




250
IP/OP $303.00 $121.20 $106.05 $272.70 $242.40 $257.55 $272.70 $206.04 $156.95 $106.05 $172.71 $257.55 $181.80 $212.10 $257.55 $257.55
3892544 7197565 CONTRAST MEDIA 200-299MG 100ML 3892544

Q9966

250
IP/OP $285.00 $114.00 $99.75 $256.50 $228.00 $242.25 $256.50 $193.80 $147.63 $99.75 $162.45 $242.25 $171.00 $199.50 $242.25 $242.25
7135288 3814919 PULMOZYME 2.5MG/2.5ML NEB




250
IP/OP $272.00 $108.80 $95.20 $244.80 $217.60 $231.20 $244.80 $184.96 $140.90 $95.20 $155.04 $231.20 $163.20 $190.40 $231.20 $231.20
7135288 4286906 PULMOZYME 2.5MG/2.5ML NEB




250
IP/OP $272.00 $108.80 $95.20 $244.80 $217.60 $231.20 $244.80 $184.96 $140.90 $95.20 $155.04 $231.20 $163.20 $190.40 $231.20 $231.20
3992476 7197274 CONTRAST MEDIA 300-399MG 100ML 3992476

Q9967

250
IP/OP $257.00 $102.80 $89.95 $231.30 $205.60 $218.45 $231.30 $174.76 $133.13 $89.95 $146.49 $218.45 $154.20 $179.90 $218.45 $218.45
3992542 7197280 CONTRAST MEDIA 200-299MG 100ML 3992542

Q9966

250
IP/OP $257.00 $102.80 $89.95 $231.30 $205.60 $218.45 $231.30 $174.76 $133.13 $89.95 $146.49 $218.45 $154.20 $179.90 $218.45 $218.45
3140019 36637 PERFLUTREN LIPID MICROSPHERE PER ML

Q9957

250
IP/OP $252.00 $100.80 $88.20 $226.80 $201.60 $214.20 $226.80 $171.36 $130.54 $88.20 $143.64 $214.20 $151.20 $176.40 $214.20 $214.20
6751101 3073418 AVITENE FLOUR 0.5 GRAM 1010010




250
IP/OP $226.00 $90.40 $79.10 $203.40 $180.80 $192.10 $203.40 $153.68 $117.07 $79.10 $128.82 $192.10 $135.60 $158.20 $192.10 $192.10
4490777 3081633 GADOLINIUM 20 ML

A9579

250
IP/OP $226.00 $90.40 $79.10 $203.40 $180.80 $192.10 $203.40 $153.68 $117.07 $79.10 $128.82 $192.10 $135.60 $158.20 $192.10 $192.10
6751002 3252951 THROMBIN




250
IP/OP $176.00 $70.40 $61.60 $158.40 $140.80 $149.60 $158.40 $119.68 $91.17 $61.60 $100.32 $149.60 $105.60 $123.20 $149.60 $149.60
7135312 3814915 TOBRAMYCIN 160MG/4ML NEB




250
IP/OP $166.00 $66.40 $58.10 $149.40 $132.80 $141.10 $149.40 $112.88 $85.99 $58.10 $94.62 $141.10 $99.60 $116.20 $141.10 $141.10
7135312 4286903 TOBRAMYCIN 160MG/4ML NEB




250
IP/OP $166.00 $66.40 $58.10 $149.40 $132.80 $141.10 $149.40 $112.88 $85.99 $58.10 $94.62 $141.10 $99.60 $116.20 $141.10 $141.10
3992468 7197273 CONTRAST MEDIA 300-399MG 50ML 3992468

Q9967

250
IP/OP $142.00 $56.80 $49.70 $127.80 $113.60 $120.70 $127.80 $96.56 $73.56 $49.70 $80.94 $120.70 $85.20 $99.40 $120.70 $120.70
3892460 7197561 CONTRAST MEDIA 300-399MG 50ML 3892460

Q9967

250
IP/OP $142.00 $56.80 $49.70 $127.80 $113.60 $120.70 $127.80 $96.56 $73.56 $49.70 $80.94 $120.70 $85.20 $99.40 $120.70 $120.70
3892536 7197564 CONTRAST MEDIA 200-299MG 50ML 3892536

Q9966

250
IP/OP $142.00 $56.80 $49.70 $127.80 $113.60 $120.70 $127.80 $96.56 $73.56 $49.70 $80.94 $120.70 $85.20 $99.40 $120.70 $120.70
3992534 7197279 CONTRAST MEDIA 200-299MG 50ML 3992534

Q9966

250
IP/OP $128.00 $51.20 $44.80 $115.20 $102.40 $108.80 $115.20 $87.04 $66.30 $44.80 $72.96 $108.80 $76.80 $89.60 $108.80 $108.80
7130420 39397 PENTAM 300 MG




250
IP/OP $118.00 $47.20 $41.30 $106.20 $94.40 $100.30 $106.20 $80.24 $61.12 $41.30 $67.26 $100.30 $70.80 $82.60 $100.30 $100.30
7492270 7492270 CLOSURE PATCH QUIK CLOT




250
IP/OP $100.00 $40.00 $35.00 $90.00 $80.00 $85.00 $90.00 $68.00 $51.80 $35.00 $57.00 $85.00 $60.00 $70.00 $85.00 $85.00
2967642 2967642 00338-1049-02 - nitroglycerin 50 mg/250 mL d5w Premix




250
IP/OP $98.86 $39.54 $34.60 $88.97 $79.09 $84.03 $88.97 $67.22 $51.21 $34.60 $56.35 $84.03 $59.32 $69.20 $84.03 $84.03
7452731 7452731 Bill Only Cath Lab Diagnostic Medication Kit




250
IP/OP $87.80 $35.12 $30.73 $79.02 $70.24 $74.63 $79.02 $59.70 $45.48 $30.73 $50.05 $74.63 $52.68 $61.46 $74.63 $74.63
7135320 3814916 TOBRAMYCIN 80MG/2ML NEB




250
IP/OP $75.00 $30.00 $26.25 $67.50 $60.00 $63.75 $67.50 $51.00 $38.85 $26.25 $42.75 $63.75 $45.00 $52.50 $63.75 $63.75
7135320 4286902 TOBRAMYCIN 80MG/2ML NEB




250
IP/OP $75.00 $30.00 $26.25 $67.50 $60.00 $63.75 $67.50 $51.00 $38.85 $26.25 $42.75 $63.75 $45.00 $52.50 $63.75 $63.75
3992450 7197272 CONTRAST MEDIA 300-399MG 20ML 3992450

Q9967

250
IP/OP $57.00 $22.80 $19.95 $51.30 $45.60 $48.45 $51.30 $38.76 $29.53 $19.95 $32.49 $48.45 $34.20 $39.90 $48.45 $48.45
3892452 7197560 CONTRAST MEDIA 300-399MG 20ML 3892452

Q9967

250
IP/OP $57.00 $22.80 $19.95 $51.30 $45.60 $48.45 $51.30 $38.76 $29.53 $19.95 $32.49 $48.45 $34.20 $39.90 $48.45 $48.45
3892528 7197563 CONTRAST MEDIA 200-299MG 20ML 3892528

Q9966

250
IP/OP $57.00 $22.80 $19.95 $51.30 $45.60 $48.45 $51.30 $38.76 $29.53 $19.95 $32.49 $48.45 $34.20 $39.90 $48.45 $48.45
3992526 7197278 CONTRAST MEDIA 200-299MG 20ML 3992526

Q9966

250
IP/OP $51.00 $20.40 $17.85 $45.90 $40.80 $43.35 $45.90 $34.68 $26.42 $17.85 $29.07 $43.35 $30.60 $35.70 $43.35 $43.35
7130933 31241 TOBRAMYCIN 40MG/ML




250
IP/OP $41.00 $16.40 $14.35 $36.90 $32.80 $34.85 $36.90 $27.88 $21.24 $14.35 $23.37 $34.85 $24.60 $28.70 $34.85 $34.85
7130933 37813 TOBRAMYCIN 40MG/ML




250
IP/OP $41.00 $16.40 $14.35 $36.90 $32.80 $34.85 $36.90 $27.88 $21.24 $14.35 $23.37 $34.85 $24.60 $28.70 $34.85 $34.85
7130933 39420 TOBRAMYCIN 40MG/ML




250
IP/OP $41.00 $16.40 $14.35 $36.90 $32.80 $34.85 $36.90 $27.88 $21.24 $14.35 $23.37 $34.85 $24.60 $28.70 $34.85 $34.85
7135403 4971068 TOBRAMYCIN 200MG




250
IP/OP $41.00 $16.40 $14.35 $36.90 $32.80 $34.85 $36.90 $27.88 $21.24 $14.35 $23.37 $34.85 $24.60 $28.70 $34.85 $34.85
7135403 4982886 TOBRAMYCIN 200MG




250
IP/OP $41.00 $16.40 $14.35 $36.90 $32.80 $34.85 $36.90 $27.88 $21.24 $14.35 $23.37 $34.85 $24.60 $28.70 $34.85 $34.85
7011430 7225131 MOTRIN 20MG/ML 120ML SUS 7011430




250
IP/OP $38.00 $15.20 $13.30 $34.20 $30.40 $32.30 $34.20 $25.84 $19.68 $13.30 $21.66 $32.30 $22.80 $26.60 $32.30 $32.30
7135353 3814913 XOPENEX 0.63MG/3ML NEB




250
IP/OP $36.00 $14.40 $12.60 $32.40 $28.80 $30.60 $32.40 $24.48 $18.65 $12.60 $20.52 $30.60 $21.60 $25.20 $30.60 $30.60
7135254 3814922 MUCOMYST 20% 4ML NEB




250
IP/OP $36.00 $14.40 $12.60 $32.40 $28.80 $30.60 $32.40 $24.48 $18.65 $12.60 $20.52 $30.60 $21.60 $25.20 $30.60 $30.60
7135254 4286909 MUCOMYST 20% 4ML NEB




250
IP/OP $36.00 $14.40 $12.60 $32.40 $28.80 $30.60 $32.40 $24.48 $18.65 $12.60 $20.52 $30.60 $21.60 $25.20 $30.60 $30.60
7135353 4288911 XOPENEX 0.63MG/3ML NEB




250
IP/OP $36.00 $14.40 $12.60 $32.40 $28.80 $30.60 $32.40 $24.48 $18.65 $12.60 $20.52 $30.60 $21.60 $25.20 $30.60 $30.60
7135353 4288914 XOPENEX 0.63MG/3ML NEB




250
IP/OP $36.00 $14.40 $12.60 $32.40 $28.80 $30.60 $32.40 $24.48 $18.65 $12.60 $20.52 $30.60 $21.60 $25.20 $30.60 $30.60
7130941 31240 GENTAMICIN 40MG/ML NEB




250
IP/OP $34.00 $13.60 $11.90 $30.60 $27.20 $28.90 $30.60 $23.12 $17.61 $11.90 $19.38 $28.90 $20.40 $23.80 $28.90 $28.90
7130941 37812 GENTAMICIN 40MG/ML NEB




250
IP/OP $34.00 $13.60 $11.90 $30.60 $27.20 $28.90 $30.60 $23.12 $17.61 $11.90 $19.38 $28.90 $20.40 $23.80 $28.90 $28.90
7130941 39421 GENTAMICIN 40MG/ML NEB




250
IP/OP $34.00 $13.60 $11.90 $30.60 $27.20 $28.90 $30.60 $23.12 $17.61 $11.90 $19.38 $28.90 $20.40 $23.80 $28.90 $28.90
7130966 30640 MUCOMYST 10% NEB




250
IP/OP $33.00 $13.20 $11.55 $29.70 $26.40 $28.05 $29.70 $22.44 $17.09 $11.55 $18.81 $28.05 $19.80 $23.10 $28.05 $28.05
7130966 37807 MUCOMYST 10% NEB




250
IP/OP $33.00 $13.20 $11.55 $29.70 $26.40 $28.05 $29.70 $22.44 $17.09 $11.55 $18.81 $28.05 $19.80 $23.10 $28.05 $28.05
7130966 38190 MUCOMYST 10% NEB




250
IP/OP $33.00 $13.20 $11.55 $29.70 $26.40 $28.05 $29.70 $22.44 $17.09 $11.55 $18.81 $28.05 $19.80 $23.10 $28.05 $28.05
4491130 6060577 MULTIHANCE PER ML

A9577

250
IP/OP $32.00 $12.80 $11.20 $28.80 $25.60 $27.20 $28.80 $21.76 $16.58 $11.20 $18.24 $27.20 $19.20 $22.40 $27.20 $27.20
7135213 3814926 GENTAMICIN 160MG/4ML NEB




250
IP/OP $31.00 $12.40 $10.85 $27.90 $24.80 $26.35 $27.90 $21.08 $16.06 $10.85 $17.67 $26.35 $18.60 $21.70 $26.35 $26.35
7135213 4286913 GENTAMICIN 160MG/4ML NEB




250
IP/OP $31.00 $12.40 $10.85 $27.90 $24.80 $26.35 $27.90 $21.08 $16.06 $10.85 $17.67 $26.35 $18.60 $21.70 $26.35 $26.35
7135270 3814920 PULMICORT 0.5MG/2ML NEB




250
IP/OP $30.00 $12.00 $10.50 $27.00 $24.00 $25.50 $27.00 $20.40 $15.54 $10.50 $17.10 $25.50 $18.00 $21.00 $25.50 $25.50
7135270 4286907 PULMICORT 0.5MG/2ML NEB




250
IP/OP $30.00 $12.00 $10.50 $27.00 $24.00 $25.50 $27.00 $20.40 $15.54 $10.50 $17.10 $25.50 $18.00 $21.00 $25.50 $25.50
7130974 30641 MUCOMYST 20% NEB




250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
7130974 31236 MUCOMYST 20% NEB




250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
7130974 37808 MUCOMYST 20% NEB




250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
7135247 3814923 MUCOMYST 10% 4ML NEB




250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
7135247 4286910 MUCOMYST 10% 4ML NEB




250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
4491114 6050730 PROHANCE PER ML INJ

A9579

250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
7643919 7075843 PASTE BOUDREAUX'S BUTT




250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
3992443 7197271 CONTRAST MEDIA 300-399MG 10ML 3992443

Q9967

250
IP/OP $29.00 $11.60 $10.15 $26.10 $23.20 $24.65 $26.10 $19.72 $15.02 $10.15 $16.53 $24.65 $17.40 $20.30 $24.65 $24.65
7135262 3814921 PULMICORT 0.25MG/2ML NEB




250
IP/OP $28.00 $11.20 $9.80 $25.20 $22.40 $23.80 $25.20 $19.04 $14.50 $9.80 $15.96 $23.80 $16.80 $19.60 $23.80 $23.80
7135262 4286908 PULMICORT 0.25MG/2ML NEB




250
IP/OP $28.00 $11.20 $9.80 $25.20 $22.40 $23.80 $25.20 $19.04 $14.50 $9.80 $15.96 $23.80 $16.80 $19.60 $23.80 $23.80
7131303 37805 XOPENEX 0.63MG INHAL SOL




250
IP/OP $27.00 $10.80 $9.45 $24.30 $21.60 $22.95 $24.30 $18.36 $13.99 $9.45 $15.39 $22.95 $16.20 $18.90 $22.95 $22.95
6099360 3081975 63323-0280-02 - LASIX 20 mg INJ

J1940

250
IP/OP $27.00 $10.80 $9.45 $24.30 $21.60 $22.95 $24.30 $18.36 $13.99 $9.45 $15.39 $22.95 $16.20 $18.90 $22.95 $22.95
7131303 4310911 XOPENEX 0.63MG INHAL SOL




250
IP/OP $27.00 $10.80 $9.45 $24.30 $21.60 $22.95 $24.30 $18.36 $13.99 $9.45 $15.39 $22.95 $16.20 $18.90 $22.95 $22.95
3992518 7197277 CONTRAST MEDIA 200-299MG 10ML 3992518

Q9966

250
IP/OP $26.00 $10.40 $9.10 $23.40 $20.80 $22.10 $23.40 $17.68 $13.47 $9.10 $14.82 $22.10 $15.60 $18.20 $22.10 $22.10
7484199 7484148 Metoprolol Tartrate (5mg/each)




250
IP/OP $25.00 $10.00 $8.75 $22.50 $20.00 $21.25 $22.50 $17.00 $12.95 $8.75 $14.25 $21.25 $15.00 $17.50 $21.25 $21.25
7135429 6109297 BROVANA 15 MCG/2ML NEB




250
IP/OP $24.00 $9.60 $8.40 $21.60 $19.20 $20.40 $21.60 $16.32 $12.43 $8.40 $13.68 $20.40 $14.40 $16.80 $20.40 $20.40
7131519 31238 PULMOCORT RESPULES .25MG/.5MG




250
IP/OP $23.00 $9.20 $8.05 $20.70 $18.40 $19.55 $20.70 $15.64 $11.91 $8.05 $13.11 $19.55 $13.80 $16.10 $19.55 $19.55
7131519 37810 PULMOCORT RESPULES .25MG/.5MG




250
IP/OP $23.00 $9.20 $8.05 $20.70 $18.40 $19.55 $20.70 $15.64 $11.91 $8.05 $13.11 $19.55 $13.80 $16.10 $19.55 $19.55
7131519 38186 PULMOCORT RESPULES .25MG/.5MG




250
IP/OP $23.00 $9.20 $8.05 $20.70 $18.40 $19.55 $20.70 $15.64 $11.91 $8.05 $13.11 $19.55 $13.80 $16.10 $19.55 $19.55
7130891 37804 ATROVENT .02%




250
IP/OP $18.00 $7.20 $6.30 $16.20 $14.40 $15.30 $16.20 $12.24 $9.32 $6.30 $10.26 $15.30 $10.80 $12.60 $15.30 $15.30
7130891 4310909 ATROVENT .02%




250
IP/OP $18.00 $7.20 $6.30 $16.20 $14.40 $15.30 $16.20 $12.24 $9.32 $6.30 $10.26 $15.30 $10.80 $12.60 $15.30 $15.30
7135221 3814925 GENTAMICIN 80MG/2ML NEB




250
IP/OP $16.00 $6.40 $5.60 $14.40 $12.80 $13.60 $14.40 $10.88 $8.29 $5.60 $9.12 $13.60 $9.60 $11.20 $13.60 $13.60
7135221 4286912 GENTAMICIN 80MG/2ML NEB




250
IP/OP $16.00 $6.40 $5.60 $14.40 $12.80 $13.60 $14.40 $10.88 $8.29 $5.60 $9.12 $13.60 $9.60 $11.20 $13.60 $13.60
7130982 31239 REACEMIC EPINEPHRINE 2.25% NEB




250
IP/OP $15.00 $6.00 $5.25 $13.50 $12.00 $12.75 $13.50 $10.20 $7.77 $5.25 $8.55 $12.75 $9.00 $10.50 $12.75 $12.75
7130982 37811 REACEMIC EPINEPHRINE 2.25% NEB




250
IP/OP $15.00 $6.00 $5.25 $13.50 $12.00 $12.75 $13.50 $10.20 $7.77 $5.25 $8.55 $12.75 $9.00 $10.50 $12.75 $12.75
7130982 38192 REACEMIC EPINEPHRINE 2.25% NEB




250
IP/OP $15.00 $6.00 $5.25 $13.50 $12.00 $12.75 $13.50 $10.20 $7.77 $5.25 $8.55 $12.75 $9.00 $10.50 $12.75 $12.75
7135395 4342885 LIDOCAINE 1% 20ML NEB




250
IP/OP $15.00 $6.00 $5.25 $13.50 $12.00 $12.75 $13.50 $10.20 $7.77 $5.25 $8.55 $12.75 $9.00 $10.50 $12.75 $12.75
7135395 4342886 LIDOCAINE 1% 20ML NEB




250
IP/OP $15.00 $6.00 $5.25 $13.50 $12.00 $12.75 $13.50 $10.20 $7.77 $5.25 $8.55 $12.75 $9.00 $10.50 $12.75 $12.75
7135411 4992889 LIDOCAINE 2% 20ML INJ




250
IP/OP $15.00 $6.00 $5.25 $13.50 $12.00 $12.75 $13.50 $10.20 $7.77 $5.25 $8.55 $12.75 $9.00 $10.50 $12.75 $12.75
3992435 7197270 CONTRAST MEDIA 300-399MG 5ML 3992435

Q9967

250
IP/OP $14.00 $5.60 $4.90 $12.60 $11.20 $11.90 $12.60 $9.52 $7.25 $4.90 $7.98 $11.90 $8.40 $9.80 $11.90 $11.90
7484198 7484147 Nitroglycerin lingual spray




250
IP/OP $14.00 $5.60 $4.90 $12.60 $11.20 $11.90 $12.60 $9.52 $7.25 $4.90 $7.98 $11.90 $8.40 $9.80 $11.90 $11.90
3992500 7197276 CONTRAST MEDIA 200-299MG 5ML 3992500

Q9966

250
IP/OP $13.00 $5.20 $4.55 $11.70 $10.40 $11.05 $11.70 $8.84 $6.73 $4.55 $7.41 $11.05 $7.80 $9.10 $11.05 $11.05
4043857 5350903 MAGNEVIST PER ML (SP)

A9579

250
IP/OP $12.00 $4.80 $4.20 $10.80 $9.60 $10.20 $10.80 $8.16 $6.22 $4.20 $6.84 $10.20 $7.20 $8.40 $10.20 $10.20
7130917 31237 ALUPENT .6%




250
IP/OP $11.00 $4.40 $3.85 $9.90 $8.80 $9.35 $9.90 $7.48 $5.70 $3.85 $6.27 $9.35 $6.60 $7.70 $9.35 $9.35
7130917 37809 ALUPENT .6%




250
IP/OP $11.00 $4.40 $3.85 $9.90 $8.80 $9.35 $9.90 $7.48 $5.70 $3.85 $6.27 $9.35 $6.60 $7.70 $9.35 $9.35
7130917 39418 ALUPENT .6%




250
IP/OP $11.00 $4.40 $3.85 $9.90 $8.80 $9.35 $9.90 $7.48 $5.70 $3.85 $6.27 $9.35 $6.60 $7.70 $9.35 $9.35
7135197 3814928 ATROVENT 0.02% 2.5ML NEB




250
IP/OP $11.00 $4.40 $3.85 $9.90 $8.80 $9.35 $9.90 $7.48 $5.70 $3.85 $6.27 $9.35 $6.60 $7.70 $9.35 $9.35
7135197 4286915 ATROVENT 0.02% 2.5ML NEB




250
IP/OP $11.00 $4.40 $3.85 $9.90 $8.80 $9.35 $9.90 $7.48 $5.70 $3.85 $6.27 $9.35 $6.60 $7.70 $9.35 $9.35
7135197 4286921 ATROVENT 0.02% 2.5ML NEB




250
IP/OP $11.00 $4.40 $3.85 $9.90 $8.80 $9.35 $9.90 $7.48 $5.70 $3.85 $6.27 $9.35 $6.60 $7.70 $9.35 $9.35
4491122 6058376 MAGNEVIST PER ML

A9579

250
IP/OP $11.00 $4.40 $3.85 $9.90 $8.80 $9.35 $9.90 $7.48 $5.70 $3.85 $6.27 $9.35 $6.60 $7.70 $9.35 $9.35
7007594 7225143 VIBRAMYCIN 100MG TAB 7007594




250
IP/OP $10.00 $4.00 $3.50 $9.00 $8.00 $8.50 $9.00 $6.80 $5.18 $3.50 $5.70 $8.50 $6.00 $7.00 $8.50 $8.50
7130990 31243 B% HYPERTONIC SALINE




250
IP/OP $9.00 $3.60 $3.15 $8.10 $7.20 $7.65 $8.10 $6.12 $4.66 $3.15 $5.13 $7.65 $5.40 $6.30 $7.65 $7.65
7135155 3814932 ALBUTEROL 1.25MG/3ML NEB




250
IP/OP $9.00 $3.60 $3.15 $8.10 $7.20 $7.65 $8.10 $6.12 $4.66 $3.15 $5.13 $7.65 $5.40 $6.30 $7.65 $7.65
7135155 4286919 ALBUTEROL 1.25MG/3ML NEB




250
IP/OP $9.00 $3.60 $3.15 $8.10 $7.20 $7.65 $8.10 $6.12 $4.66 $3.15 $5.13 $7.65 $5.40 $6.30 $7.65 $7.65
7135155 4286924 ALBUTEROL 1.25MG/3ML NEB




250
IP/OP $9.00 $3.60 $3.15 $8.10 $7.20 $7.65 $8.10 $6.12 $4.66 $3.15 $5.13 $7.65 $5.40 $6.30 $7.65 $7.65
7130883 37803 ALBUTEROL .083%




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7130883 39416 ALBUTEROL .083%




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7130909 39417 ALUPENT .4%




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7135205 3814927 EPINEPHRINE 2.25% 0.5ML NEB




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7135189 3814929 ALUPENT 0.4% 2.5ML NEB




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7135171 3814930 ALBUTEROL 2.5MG/3ML NEB




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7135205 4286914 EPINEPHRINE 2.25% 0.5ML NEB




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7135189 4286916 ALUPENT 0.4% 2.5ML NEB




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7135171 4286917 ALBUTEROL 2.5MG/3ML NEB




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7135171 4286922 ALBUTEROL 2.5MG/3ML NEB




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7237104 7352863 ALB 2.5MG/ATR 0.5MG DUO




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
7237104 7352876 ALB 2.5MG/ATR 0.5MG DUO




250
IP/OP $7.00 $2.80 $2.45 $6.30 $5.60 $5.95 $6.30 $4.76 $3.63 $2.45 $3.99 $5.95 $4.20 $4.90 $5.95 $5.95
6099352 3081967 AMINOPHYLLIN ^250MG INJ

J0280

250
IP/OP $5.00 $2.00 $1.75 $4.50 $4.00 $4.25 $4.50 $3.40 $2.59 $1.75 $2.85 $4.25 $3.00 $3.50 $4.25 $4.25
7135163 3814931 ALBUTEROL 2.5MG/0.5ML NEB




250
IP/OP $5.00 $2.00 $1.75 $4.50 $4.00 $4.25 $4.50 $3.40 $2.59 $1.75 $2.85 $4.25 $3.00 $3.50 $4.25 $4.25
7135163 4286918 ALBUTEROL 2.5MG/0.5ML NEB




250
IP/OP $5.00 $2.00 $1.75 $4.50 $4.00 $4.25 $4.50 $3.40 $2.59 $1.75 $2.85 $4.25 $3.00 $3.50 $4.25 $4.25
7135163 4286923 ALBUTEROL 2.5MG/0.5ML NEB




250
IP/OP $5.00 $2.00 $1.75 $4.50 $4.00 $4.25 $4.50 $3.40 $2.59 $1.75 $2.85 $4.25 $3.00 $3.50 $4.25 $4.25
7130875 31244 ATROPINE SULF 1MG NEB




250
IP/OP $4.00 $1.60 $1.40 $3.60 $3.20 $3.40 $3.60 $2.72 $2.07 $1.40 $2.28 $3.40 $2.40 $2.80 $3.40 $3.40
7130875 37816 ATROPINE SULF 1MG NEB




250
IP/OP $4.00 $1.60 $1.40 $3.60 $3.20 $3.40 $3.60 $2.72 $2.07 $1.40 $2.28 $3.40 $2.40 $2.80 $3.40 $3.40
7130875 39415 ATROPINE SULF 1MG NEB




250
IP/OP $4.00 $1.60 $1.40 $3.60 $3.20 $3.40 $3.60 $2.72 $2.07 $1.40 $2.28 $3.40 $2.40 $2.80 $3.40 $3.40
7135304 3814917 SOD CHLOR 3% 15ML NEB




250
IP/OP $4.00 $1.60 $1.40 $3.60 $3.20 $3.40 $3.60 $2.72 $2.07 $1.40 $2.28 $3.40 $2.40 $2.80 $3.40 $3.40
7135304 4286904 SOD CHLOR 3% 15ML NEB




250
IP/OP $4.00 $1.60 $1.40 $3.60 $3.20 $3.40 $3.60 $2.72 $2.07 $1.40 $2.28 $3.40 $2.40 $2.80 $3.40 $3.40
7000185 7225114 LORTAB 5/500MG TAB 7000185




250
IP/OP $4.00 $1.60 $1.40 $3.60 $3.20 $3.40 $3.60 $2.72 $2.07 $1.40 $2.28 $3.40 $2.40 $2.80 $3.40 $3.40
7135346 4286920 Xopenex 0.31mg/3mL




250
IP/OP $3.00 $1.20 $1.05 $2.70 $2.40 $2.55 $2.70 $2.04 $1.55 $1.05 $1.71 $2.55 $1.80 $2.10 $2.55 $2.55
7001456 7225133 AURALGAN 10ML OTIC SOL 7001456




250
IP/OP $3.00 $1.20 $1.05 $2.70 $2.40 $2.55 $2.70 $2.04 $1.55 $1.05 $1.71 $2.55 $1.80 $2.10 $2.55 $2.55
7135296 3814918 SOD CHLOR 0.9% 3ML NEB




250
IP/OP $1.00 $0.40 $0.35 $0.90 $0.80 $0.85 $0.90 $0.68 $0.52 $0.35 $0.57 $0.85 $0.60 $0.70 $0.85 $0.85
7135296 4286905 SOD CHLOR 0.9% 3ML NEB




250
IP/OP $1.00 $0.40 $0.35 $0.90 $0.80 $0.85 $0.90 $0.68 $0.52 $0.35 $0.57 $0.85 $0.60 $0.70 $0.85 $0.85
7009285 7225119 FLUOR-I-STRIP 9MG STRIP 7009285




250
IP/OP $1.00 $0.40 $0.35 $0.90 $0.80 $0.85 $0.90 $0.68 $0.52 $0.35 $0.57 $0.85 $0.60 $0.70 $0.85 $0.85
7099914 7474810 Silvadene 50gram tub




253
IP/OP $246.00 $98.40 $86.10 $221.40 $196.80 $209.10 $221.40 $167.28 $127.43 $86.10 $140.22 $209.10 $147.60 $172.20 $209.10 $209.10
3161460 15393 Contrast Echo Add On




255
IP/OP $195.00 $78.00 $68.25 $175.50 $156.00 $165.75 $175.50 $132.60 $101.01 $68.25 $111.15 $165.75 $117.00 $136.50 $165.75 $165.75
4490769 3081643 GADOLINIUM 15 ML

A9579

255
IP/OP $182.00 $72.80 $63.70 $163.80 $145.60 $154.70 $163.80 $123.76 $94.28 $63.70 $103.74 $154.70 $109.20 $127.40 $154.70 $154.70
4490751 3081645 GADOLINIUM 10 ML

A9579

255
IP/OP $125.00 $50.00 $43.75 $112.50 $100.00 $106.25 $112.50 $85.00 $64.75 $43.75 $71.25 $106.25 $75.00 $87.50 $106.25 $106.25
6802813 3152897 METHYLENE BLUE




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
6802813 3153281 DYE RADIOLOGIC




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
6802813 3252916 DYE RADIOLOGIC




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
6802813 3282891 DYE RADIOLOGIC OPTIRAY




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
6802813 3772883 DYE VISIPAQUE (IODIXANOL)




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
6802813 4580959 DYE RADIOLOGIC




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
6802813 7476172 OMNIPAQUE DYE 300MG/ML




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
6802813 7739940 OMNIPAQUE DYE 180MG/ML




255
IP/OP $65.00 $26.00 $22.75 $58.50 $52.00 $55.25 $58.50 $44.20 $33.67 $22.75 $37.05 $55.25 $39.00 $45.50 $55.25 $55.25
4948887 4948887 Gadolinium per ml




255
IP/OP $25.00 $10.00 $8.75 $22.50 $20.00 $21.25 $22.50 $17.00 $12.95 $8.75 $14.25 $21.25 $15.00 $17.50 $21.25 $21.25
5500418 7075394 D1OW ELEC 48 1A3079




258
IP/OP $114.00 $45.60 $39.90 $102.60 $91.20 $96.90 $102.60 $77.52 $59.05 $39.90 $64.98 $96.90 $68.40 $79.80 $96.90 $96.90
5504667 7432400 OPIS NS/D5W w/20 KCL 1000 ml




258
IP/OP $114.00 $45.60 $39.90 $102.60 $91.20 $96.90 $102.60 $77.52 $59.05 $39.90 $64.98 $96.90 $68.40 $79.80 $96.90 $96.90
5502604 3252987 NACL 250ML 2B1322




258
IP/OP $113.00 $45.20 $39.55 $101.70 $90.40 $96.05 $101.70 $76.84 $58.53 $39.55 $64.41 $96.05 $67.80 $79.10 $96.05 $96.05
5500806 7075395 D5W .255NACL 2B1094




258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
5501507 7075396 D5W .9NACL 2B1064

J7042

258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
5500558 7075397 D5W 250ML 2B0062




258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
5500608 7075398 D5W 500ML 2B0063




258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7432394 7432394 00338-0049-02 - OPIS NS250 mL

J7050

258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7432395 7432395 OPIS NS 500 ml

J7040

258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7432396 7432396 OPIS NS 1000 ml

J7030

258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7432397 7432397 OPIS D5W 500 ml

J7060

258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7432398 7432398 OPIS D5 1/2 NS 1000 ml




258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7432399 7432399 OPIS D5 NS 1000 ml

J7042

258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7432401 7432401 00264-7800-20 - OPIS NS 250 ml Blood Transfusion

J7050

258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7450272 7450272 SOL Lactated Ringers




258
IP/OP $108.00 $43.20 $37.80 $97.20 $86.40 $91.80 $97.20 $73.44 $55.94 $37.80 $61.56 $91.80 $64.80 $75.60 $91.80 $91.80
7892672 7075877 SOLUTION 0.9 SODIUM CHLORIDE 500ML

J7040

258
IP/OP $100.00 $40.00 $35.00 $90.00 $80.00 $85.00 $90.00 $68.00 $51.80 $35.00 $57.00 $85.00 $60.00 $70.00 $85.00 $85.00
5502307 7075399 LACTATED RINGERS 2B2324




258
IP/OP $95.00 $38.00 $33.25 $85.50 $76.00 $80.75 $85.50 $64.60 $49.21 $33.25 $54.15 $80.75 $57.00 $66.50 $80.75 $80.75
5503404 7075401 NACL 1000ML 2B1324




258
IP/OP $95.00 $38.00 $33.25 $85.50 $76.00 $80.75 $85.50 $64.60 $49.21 $33.25 $54.15 $80.75 $57.00 $66.50 $80.75 $80.75
5503305 7075402 NACL 500ML 2B1323




258
IP/OP $95.00 $38.00 $33.25 $85.50 $76.00 $80.75 $85.50 $64.60 $49.21 $33.25 $54.15 $80.75 $57.00 $66.50 $80.75 $80.75
5500400 7075393 D10W 1000ML 2B0164




258
IP/OP $85.00 $34.00 $29.75 $76.50 $68.00 $72.25 $76.50 $57.80 $44.03 $29.75 $48.45 $72.25 $51.00 $59.50 $72.25 $72.25
7400146 7225222 VISTARIL CAP PER 25 MG 7400146

Q0177

259 00185-0615-01 IP/OP $0.24 $0.10 $0.09 $0.22 $0.20 $0.21 $0.22 $0.17 $0.13 $0.09 $0.14 $0.21 $0.15 $0.17 $0.21 $0.21
7017122 7225186 ZOFRAN ODT 4 MG TAB 7017122

Q0162

259 68462-0157-13 IP/OP $23.11 $9.25 $8.09 $20.80 $18.49 $19.65 $20.80 $15.72 $11.97 $8.09 $13.17 $19.65 $13.87 $16.18 $19.65 $19.65
7400351 7225223 ZOFRAN ODT 8 MG TAB 7400351




259 68462-0158-13 IP/OP $38.50 $15.40 $13.47 $34.65 $30.80 $32.72 $34.65 $26.18 $19.94 $13.47 $21.94 $32.72 $23.10 $26.95 $32.72 $32.72
5902218 3875191 INF THERAPY 16-90 MIN 96365



260
IP/OP $923.00 $369.20 $323.05 $830.70 $738.40 $784.55 $830.70 $627.64 $478.11 $323.05 $526.11 $784.55 $553.80 $646.10 $784.55 $784.55
6650048 7204295 INF THERAPY 16-90 MIN 96365



260
IP/OP $923.00 $369.20 $323.05 $830.70 $738.40 $784.55 $830.70 $627.64 $478.11 $323.05 $526.11 $784.55 $553.80 $646.10 $784.55 $784.55
5796511 7222207 INF THERAPY 16-90 MIN 5796511 96365



260
IP/OP $923.00 $369.20 $323.05 $830.70 $738.40 $784.55 $830.70 $627.64 $478.11 $323.05 $526.11 $784.55 $553.80 $646.10 $784.55 $784.55
7384229 7384229 INF THERAPY 16-90 MIN. 96365



260
IP/OP $923.00 $369.20 $323.05 $830.70 $738.40 $784.55 $830.70 $627.64 $478.11 $323.05 $526.11 $784.55 $553.80 $646.10 $784.55 $784.55
5796511 7432378 OPIS Non-Chemo Infusion up to 1 hour 96365



260
IP/OP $923.00 $369.20 $323.05 $830.70 $738.40 $784.55 $830.70 $627.64 $478.11 $323.05 $526.11 $784.55 $553.80 $646.10 $784.55 $784.55
5796511 8014048 Non Chemo Infusion 1st Hour 96365



260
IP/OP $923.00 $369.20 $323.05 $830.70 $738.40 $784.55 $830.70 $627.64 $478.11 $323.05 $526.11 $784.55 $553.80 $646.10 $784.55 $784.55
8279183 8279183 96365 INF THERAPY 16-60 MIN - OB ED 96365



260
IP/OP $923.00 $369.20 $323.05 $830.70 $738.40 $784.55 $830.70 $627.64 $478.11 $323.05 $526.11 $784.55 $553.80 $646.10 $784.55 $784.55
5902259 3875198 INF HYDRAT 31-90 MIN 96360



260
IP/OP $665.00 $266.00 $232.75 $598.50 $532.00 $565.25 $598.50 $452.20 $344.47 $232.75 $379.05 $565.25 $399.00 $465.50 $565.25 $565.25
6650006 7204291 INF HYDRAT 31-90 MIN 6650006 96360



260
IP/OP $665.00 $266.00 $232.75 $598.50 $532.00 $565.25 $598.50 $452.20 $344.47 $232.75 $379.05 $565.25 $399.00 $465.50 $565.25 $565.25
5796701 7204335 INF HYDRAT 31-90 MIN 5796701 96360



260
IP/OP $665.00 $266.00 $232.75 $598.50 $532.00 $565.25 $598.50 $452.20 $344.47 $232.75 $379.05 $565.25 $399.00 $465.50 $565.25 $565.25
5796701 7432416 OPIS Hydration only up to 1 hr 96360



260
IP/OP $665.00 $266.00 $232.75 $598.50 $532.00 $565.25 $598.50 $452.20 $344.47 $232.75 $379.05 $565.25 $399.00 $465.50 $565.25 $565.25
5796701 8014049 Hydration 1st Hour 96360



260
IP/OP $665.00 $266.00 $232.75 $598.50 $532.00 $565.25 $598.50 $452.20 $344.47 $232.75 $379.05 $565.25 $399.00 $465.50 $565.25 $565.25
8279181 8279181 96360 INF HYDRAT 31-90 MIN - OB ED 96360



260
IP/OP $665.00 $266.00 $232.75 $598.50 $532.00 $565.25 $598.50 $452.20 $344.47 $232.75 $379.05 $565.25 $399.00 $465.50 $565.25 $565.25
6650063 7204297 INF ADDL SEQ 16-90 MIN 6650063 96367



260
IP/OP $547.00 $218.80 $191.45 $492.30 $437.60 $464.95 $492.30 $371.96 $283.35 $191.45 $311.79 $464.95 $328.20 $382.90 $464.95 $464.95
5902309 7204313 INF ADDL SEQ 16-90 MIN 5902309 96367



260
IP/OP $547.00 $218.80 $191.45 $492.30 $437.60 $464.95 $492.30 $371.96 $283.35 $191.45 $311.79 $464.95 $328.20 $382.90 $464.95 $464.95
8279191 8279191 96367 INF ADDL SEQUENTIAL 16-90 MIN - OB ED 96367



260
IP/OP $547.00 $218.80 $191.45 $492.30 $437.60 $464.95 $492.30 $371.96 $283.35 $191.45 $311.79 $464.95 $328.20 $382.90 $464.95 $464.95
6650089 7204299 IV PUSH ADDL SEQ NEW DRUG 6650089 96375



260
IP/OP $495.00 $198.00 $173.25 $445.50 $396.00 $420.75 $445.50 $336.60 $256.41 $173.25 $282.15 $420.75 $297.00 $346.50 $420.75 $420.75
5902325 7204315 IV PUSH ADDL SEQ NEW DRUG 5902325 96375



260
IP/OP $495.00 $198.00 $173.25 $445.50 $396.00 $420.75 $445.50 $336.60 $256.41 $173.25 $282.15 $420.75 $297.00 $346.50 $420.75 $420.75
5701107 7204332 IV PUSH ADDL SEQ NEW DRUG 5701107 96375



260
IP/OP $495.00 $198.00 $173.25 $445.50 $396.00 $420.75 $445.50 $336.60 $256.41 $173.25 $282.15 $420.75 $297.00 $346.50 $420.75 $420.75
5701107 7432423 OPIS Non-Chemo IVP inject. Addtl Drugs 96375



260
IP/OP $495.00 $198.00 $173.25 $445.50 $396.00 $420.75 $445.50 $336.60 $256.41 $173.25 $282.15 $420.75 $297.00 $346.50 $420.75 $420.75
5701107 8014043 OP Non-Chemo IVP inject addtl Seq New Drug 96375



260
IP/OP $495.00 $198.00 $173.25 $445.50 $396.00 $420.75 $445.50 $336.60 $256.41 $173.25 $282.15 $420.75 $297.00 $346.50 $420.75 $420.75
8279195 8279195 96375 IV PUSH ADDL SEQ NEW DRUG - OB ED 96375



260
IP/OP $495.00 $198.00 $173.25 $445.50 $396.00 $420.75 $445.50 $336.60 $256.41 $173.25 $282.15 $420.75 $297.00 $346.50 $420.75 $420.75
5797006 7204352 INF ADDL SEQ 16-90 MIN 5797006 96367



260
IP/OP $488.00 $195.20 $170.80 $439.20 $390.40 $414.80 $439.20 $331.84 $252.78 $170.80 $278.16 $414.80 $292.80 $341.60 $414.80 $414.80
5797006 7432415 OPIS Non-Chemo Inf Addtl Sequential 96367



260
IP/OP $488.00 $195.20 $170.80 $439.20 $390.40 $414.80 $439.20 $331.84 $252.78 $170.80 $278.16 $414.80 $292.80 $341.60 $414.80 $414.80
5797006 8014041 OP Non-chemo Inf Addtl Sequential 96367



260
IP/OP $488.00 $195.20 $170.80 $439.20 $390.40 $414.80 $439.20 $331.84 $252.78 $170.80 $278.16 $414.80 $292.80 $341.60 $414.80 $414.80
5796735 7432426 OPIS Port Blood Draw 36591



260
IP/OP $431.00 $172.40 $150.85 $387.90 $344.80 $366.35 $387.90 $293.08 $223.26 $150.85 $245.67 $366.35 $258.60 $301.70 $366.35 $366.35
6650071 7204298 INF CONCURRENT 6650071 96368



260
IP/OP $407.00 $162.80 $142.45 $366.30 $325.60 $345.95 $366.30 $276.76 $210.83 $142.45 $231.99 $345.95 $244.20 $284.90 $345.95 $345.95
5902317 7204314 INF CONCURRENT 5902317 96368



260
IP/OP $407.00 $162.80 $142.45 $366.30 $325.60 $345.95 $366.30 $276.76 $210.83 $142.45 $231.99 $345.95 $244.20 $284.90 $345.95 $345.95
8279192 8279192 96368 INF CONCURRENT - OB ED 96368



260
IP/OP $407.00 $162.80 $142.45 $366.30 $325.60 $345.95 $366.30 $276.76 $210.83 $142.45 $231.99 $345.95 $244.20 $284.90 $345.95 $345.95
3162013 36083 INJECTION IVP INIT DRUG 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
3162013 36555 INJECTION IVP INIT DRUG 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
1890755 3153207 INJECTION IV PUSH 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
5902267 3875190 INJECTION IVP INIT DRUG 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
6650022 7204293 INJECTION IVP INIT DRUG 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
5701016 7222202 INJECTION IVP INIT DRUG 5701016 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
3162013 7352278 Diagnostic Injection Of Contrast 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
5701016 7432381 OPIS Non-Chemo Injection IVP 1st Drug 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
5701016 8014047 Non-Chemo IV Push 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
8279194 8279194 96374 INJECTION IV PUSH - OB ED 96374



260
IP/OP $384.00 $153.60 $134.40 $345.60 $307.20 $326.40 $345.60 $261.12 $198.91 $134.40 $218.88 $326.40 $230.40 $268.80 $326.40 $326.40
5902226 3875192 INF THER ADDL 60 MIN 96366



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
6650055 7204296 INF THER ADDL 60 MIN 6650055 96366



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
5797014 7204353 INF CONCURRENT 5797014 96368



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
5796529 7222208 INF THER ADDL 60 MIN 5796529 96366



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
7384230 7384230 INF THERAPY Addtl 60 MIN. 96366



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
5796529 7432379 OPIS Non-Chemo Inf each additional hour 96366



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
5797014 7432414 OPIS Non-Chemo Infusion Concurrent 96368



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
5797014 8014039 OP Non-chemo Infusion Concurrent 96368



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
5796529 8014040 OP Non-Chemo Inf each addtional hour 96366



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
8279190 8279190 96366 INF THERAPY ADDL 60 MIN - OB ED 96366



260
IP/OP $369.00 $147.60 $129.15 $332.10 $295.20 $313.65 $332.10 $250.92 $191.14 $129.15 $210.33 $313.65 $221.40 $258.30 $313.65 $313.65
5902242 3875199 INF HYDR ADDL 60 MIN 96361



260
IP/OP $334.00 $133.60 $116.90 $300.60 $267.20 $283.90 $300.60 $227.12 $173.01 $116.90 $190.38 $283.90 $200.40 $233.80 $283.90 $283.90
6650030 7204294 INF HYDR ADDL 60 MIN 6650030 96361



260
IP/OP $334.00 $133.60 $116.90 $300.60 $267.20 $283.90 $300.60 $227.12 $173.01 $116.90 $190.38 $283.90 $200.40 $233.80 $283.90 $283.90
5796719 7204336 INF HYDR ADDL 60 MIN 5796719 96361



260
IP/OP $334.00 $133.60 $116.90 $300.60 $267.20 $283.90 $300.60 $227.12 $173.01 $116.90 $190.38 $283.90 $200.40 $233.80 $283.90 $283.90
5796719 7432417 OPIS Hydration only each addtl hr 96361



260
IP/OP $334.00 $133.60 $116.90 $300.60 $267.20 $283.90 $300.60 $227.12 $173.01 $116.90 $190.38 $283.90 $200.40 $233.80 $283.90 $283.90
5796719 8014045 OP Hydration only each addtl hr 96361



260
IP/OP $334.00 $133.60 $116.90 $300.60 $267.20 $283.90 $300.60 $227.12 $173.01 $116.90 $190.38 $283.90 $200.40 $233.80 $283.90 $283.90
8279182 8279182 96361 INF HYDRAT ADDL 60 MIN - OB ED 96361



260
IP/OP $334.00 $133.60 $116.90 $300.60 $267.20 $283.90 $300.60 $227.12 $173.01 $116.90 $190.38 $283.90 $200.40 $233.80 $283.90 $283.90
8279193 8279193 96372 INJ IM SQ - OB ED 96372



260
IP/OP $297.00 $118.80 $103.95 $267.30 $237.60 $252.45 $267.30 $201.96 $153.85 $103.95 $169.29 $252.45 $178.20 $207.90 $252.45 $252.45
6650097 7204300 IV PUSH ADDL SEQ SAME DRUG 6650097 96376



260
IP/OP $296.00 $118.40 $103.60 $266.40 $236.80 $251.60 $266.40 $201.28 $153.33 $103.60 $168.72 $251.60 $177.60 $207.20 $251.60 $251.60
5902333 7204316 IV PUSH ADDL SEQ SAME DRUG 5902333 96376



260
IP/OP $296.00 $118.40 $103.60 $266.40 $236.80 $251.60 $266.40 $201.28 $153.33 $103.60 $168.72 $251.60 $177.60 $207.20 $251.60 $251.60
5797022 7204354 IV PUSH ADDL SEQ SAME DRUG 5797022 96376



260
IP/OP $296.00 $118.40 $103.60 $266.40 $236.80 $251.60 $266.40 $201.28 $153.33 $103.60 $168.72 $251.60 $177.60 $207.20 $251.60 $251.60
5797022 7432424 OPIS Non-Chemo IVP addtl Sequential 96376



260
IP/OP $296.00 $118.40 $103.60 $266.40 $236.80 $251.60 $266.40 $201.28 $153.33 $103.60 $168.72 $251.60 $177.60 $207.20 $251.60 $251.60
5797022 8014042 OP Non-Chemo IVP addtl Sequential same drug 96376



260
IP/OP $296.00 $118.40 $103.60 $266.40 $236.80 $251.60 $266.40 $201.28 $153.33 $103.60 $168.72 $251.60 $177.60 $207.20 $251.60 $251.60
8279196 8279196 96376 IV PUSH ADDL SEQ SAME DRUG - OB ED 96376



260
IP/OP $296.00 $118.40 $103.60 $266.40 $236.80 $251.60 $266.40 $201.28 $153.33 $103.60 $168.72 $251.60 $177.60 $207.20 $251.60 $251.60
7573837 7583444 OPIS AIM Pump Initial Non-Chemo
99999 C8957 C8957
261
IP/OP $1,832.00 $732.80 $641.20 $1,648.80 $1,465.60 $1,557.20 $1,648.80 $1,245.76 $948.98 $641.20 $1,044.24 $1,557.20 $1,099.20 $1,282.40 $1,557.20 $1,557.20
7597205 7597205 OPIS AIM PUMP INITIAL NON-CHEMO
99999 C8957 C8957
261
IP/OP $1,832.00 $732.80 $641.20 $1,648.80 $1,465.60 $1,557.20 $1,648.80 $1,245.76 $948.98 $641.20 $1,044.24 $1,557.20 $1,099.20 $1,282.40 $1,557.20 $1,557.20
8086526 8086526 STEALTH STATION EM ENT SYSTEM SERVICEH5-SS2




270
IP/OP $6,300.00 $2,520.00 $2,205.00 $5,670.00 $5,040.00 $5,355.00 $5,670.00 $4,284.00 $3,263.40 $2,205.00 $3,591.00 $5,355.00 $3,780.00 $4,410.00 $5,355.00 $5,355.00
1600444 3153294 RENTAL:LASER TMR




270
IP/OP $3,168.00 $1,267.20 $1,108.80 $2,851.20 $2,534.40 $2,692.80 $2,851.20 $2,154.24 $1,641.02 $1,108.80 $1,805.76 $2,692.80 $1,900.80 $2,217.60 $2,692.80 $2,692.80
8027226 8027226 RECHARGER FOR NEUROSTIMULATOR 97755




270
IP/OP $2,814.00 $1,125.60 $984.90 $2,532.60 $2,251.20 $2,391.90 $2,532.60 $1,913.52 $1,457.65 $984.90 $1,603.98 $2,391.90 $1,688.40 $1,969.80 $2,391.90 $2,391.90
6987861 3153300 RENTAL:STEALTH SYSTEM




270
IP/OP $2,625.00 $1,050.00 $918.75 $2,362.50 $2,100.00 $2,231.25 $2,362.50 $1,785.00 $1,359.75 $918.75 $1,496.25 $2,231.25 $1,575.00 $1,837.50 $2,231.25 $2,231.25
6778112 3253059 RENTAL:DAVINCI ROBOT




270
IP/OP $2,550.00 $1,020.00 $892.50 $2,295.00 $2,040.00 $2,167.50 $2,295.00 $1,734.00 $1,320.90 $892.50 $1,453.50 $2,167.50 $1,530.00 $1,785.00 $2,167.50 $2,167.50
8195657 8195657 JADA System Vacuum-Induced Hemorrhage control




270
IP/OP $2,151.00 $860.40 $752.85 $1,935.90 $1,720.80 $1,828.35 $1,935.90 $1,462.68 $1,114.22 $752.85 $1,226.07 $1,828.35 $1,290.60 $1,505.70 $1,828.35 $1,828.35
9999999 6310468 ARGON BEAM COAGULATOR




270
IP/OP $1,990.00 $796.00 $696.50 $1,791.00 $1,592.00 $1,691.50 $1,791.00 $1,353.20 $1,030.82 $696.50 $1,134.30 $1,691.50 $1,194.00 $1,393.00 $1,691.50 $1,691.50
4085262 3081228 PULSE SPRAY

C1751

270
IP/OP $1,010.00 $404.00 $353.50 $909.00 $808.00 $858.50 $909.00 $686.80 $523.18 $353.50 $575.70 $858.50 $606.00 $707.00 $858.50 $858.50
7790181 7075628 BACK SUPPORT TLSO 15D LG




270
IP/OP $862.00 $344.80 $301.70 $775.80 $689.60 $732.70 $775.80 $586.16 $446.52 $301.70 $491.34 $732.70 $517.20 $603.40 $732.70 $732.70
7790173 7075629 BACK SUPPORT TLSO 15D MED




270
IP/OP $862.00 $344.80 $301.70 $775.80 $689.60 $732.70 $775.80 $586.16 $446.52 $301.70 $491.34 $732.70 $517.20 $603.40 $732.70 $732.70
7790199 7075631 BACK SUPPORT TLSO 15D XL




270
IP/OP $862.00 $344.80 $301.70 $775.80 $689.60 $732.70 $775.80 $586.16 $446.52 $301.70 $491.34 $732.70 $517.20 $603.40 $732.70 $732.70
7790207 7075632 BACK SUPPORT TLSO 15D XXL




270
IP/OP $862.00 $344.80 $301.70 $775.80 $689.60 $732.70 $775.80 $586.16 $446.52 $301.70 $491.34 $732.70 $517.20 $603.40 $732.70 $732.70
7790132 7075623 BACK SUPPORT LSO 15D LG




270
IP/OP $787.00 $314.80 $275.45 $708.30 $629.60 $668.95 $708.30 $535.16 $407.67 $275.45 $448.59 $668.95 $472.20 $550.90 $668.95 $668.95
7790124 7075624 BACK SUPPORT LSO 15D MED




270
IP/OP $787.00 $314.80 $275.45 $708.30 $629.60 $668.95 $708.30 $535.16 $407.67 $275.45 $448.59 $668.95 $472.20 $550.90 $668.95 $668.95
7790116 7075625 BACK SUPPORT LSO 15D SM




270
IP/OP $787.00 $314.80 $275.45 $708.30 $629.60 $668.95 $708.30 $535.16 $407.67 $275.45 $448.59 $668.95 $472.20 $550.90 $668.95 $668.95
7790140 7075626 BACK SUPPORT LSO 15D XL




270
IP/OP $787.00 $314.80 $275.45 $708.30 $629.60 $668.95 $708.30 $535.16 $407.67 $275.45 $448.59 $668.95 $472.20 $550.90 $668.95 $668.95
7790157 7075627 BACK SUPPORT LSO 15D XXL




270
IP/OP $787.00 $314.80 $275.45 $708.30 $629.60 $668.95 $708.30 $535.16 $407.67 $275.45 $448.59 $668.95 $472.20 $550.90 $668.95 $668.95
8107699 8107699 SPY-PHI SINGLE PROCEDURE KIT HH9006




270
IP/OP $667.00 $266.80 $233.45 $600.30 $533.60 $566.95 $600.30 $453.56 $345.51 $233.45 $380.19 $566.95 $400.20 $466.90 $566.95 $566.95
6134019 2962325 CRASH CART




270
IP/OP $605.00 $242.00 $211.75 $544.50 $484.00 $514.25 $544.50 $411.40 $313.39 $211.75 $344.85 $514.25 $363.00 $423.50 $514.25 $514.25
6749006 3153283 RENTAL:ANSPACH MOTOR 6749006




270
IP/OP $557.00 $222.80 $194.95 $501.30 $445.60 $473.45 $501.30 $378.76 $288.53 $194.95 $317.49 $473.45 $334.20 $389.90 $473.45 $473.45
7735376 3153051 CATH GOLD PROBE BIPOLAR 2.8MM / 300CM M00560070




270
IP/OP $480.00 $192.00 $168.00 $432.00 $384.00 $408.00 $432.00 $326.40 $248.64 $168.00 $273.60 $408.00 $288.00 $336.00 $408.00 $408.00
7875683 7875683 FastCastOLS 50" Cast Kit & LG Boot




270
IP/OP $380.00 $152.00 $133.00 $342.00 $304.00 $323.00 $342.00 $258.40 $196.84 $133.00 $216.60 $323.00 $228.00 $266.00 $323.00 $323.00
7875685 7875685 FastCastOLS 56" Cast Kit & LG Boot




270
IP/OP $380.00 $152.00 $133.00 $342.00 $304.00 $323.00 $342.00 $258.40 $196.84 $133.00 $216.60 $323.00 $228.00 $266.00 $323.00 $323.00
7912654 7912654 FastCastOLS 50 Cast Kit & LG Boot




270
IP/OP $380.00 $152.00 $133.00 $342.00 $304.00 $323.00 $342.00 $258.40 $196.84 $133.00 $216.60 $323.00 $228.00 $266.00 $323.00 $323.00
7912656 7912656 FastCastOLS 56 Cast Kit & LG Boot




270
IP/OP $380.00 $152.00 $133.00 $342.00 $304.00 $323.00 $342.00 $258.40 $196.84 $133.00 $216.60 $323.00 $228.00 $266.00 $323.00 $323.00
7875684 7875684 FastCastOLS 56" Cast Kit




270
IP/OP $363.00 $145.20 $127.05 $326.70 $290.40 $308.55 $326.70 $246.84 $188.03 $127.05 $206.91 $308.55 $217.80 $254.10 $308.55 $308.55
7912655 7912655 FastCastOLS 56 Cast Kit




270
IP/OP $363.00 $145.20 $127.05 $326.70 $290.40 $308.55 $326.70 $246.84 $188.03 $127.05 $206.91 $308.55 $217.80 $254.10 $308.55 $308.55
6745004 3153296 RENTAL:MICROSCOPE 6745004




270
IP/OP $350.00 $140.00 $122.50 $315.00 $280.00 $297.50 $315.00 $238.00 $181.30 $122.50 $199.50 $297.50 $210.00 $245.00 $297.50 $297.50
7875682 7875682 FastCastOLS 50" Cast Kit




270
IP/OP $339.00 $135.60 $118.65 $305.10 $271.20 $288.15 $305.10 $230.52 $175.60 $118.65 $193.23 $288.15 $203.40 $237.30 $288.15 $288.15
7912653 7912653 FastCastOLS 50 Cast Kit




270
IP/OP $339.00 $135.60 $118.65 $305.10 $271.20 $288.15 $305.10 $230.52 $175.60 $118.65 $193.23 $288.15 $203.40 $237.30 $288.15 $288.15
6641765 11400 OB C/S PACK




270
IP/OP $315.00 $126.00 $110.25 $283.50 $252.00 $267.75 $283.50 $214.20 $163.17 $110.25 $179.55 $267.75 $189.00 $220.50 $267.75 $267.75
7622665 2961732 MATTRESS AND PLATFORM BARI 48 ""




270
IP/OP $270.00 $108.00 $94.50 $243.00 $216.00 $229.50 $243.00 $183.60 $139.86 $94.50 $153.90 $229.50 $162.00 $189.00 $229.50 $229.50
7760010 7075648 BOOT ROOKE




270
IP/OP $269.00 $107.60 $94.15 $242.10 $215.20 $228.65 $242.10 $182.92 $139.34 $94.15 $153.33 $228.65 $161.40 $188.30 $228.65 $228.65
6990337 3075256 KIT ANESTHESIA SUPPLY




270
IP/OP $245.00 $98.00 $85.75 $220.50 $196.00 $208.25 $220.50 $166.60 $126.91 $85.75 $139.65 $208.25 $147.00 $171.50 $208.25 $208.25
6990337 3416879 KIT ANESTHESIA SUPPLY




270
IP/OP $245.00 $98.00 $85.75 $220.50 $196.00 $208.25 $220.50 $166.60 $126.91 $85.75 $139.65 $208.25 $147.00 $171.50 $208.25 $208.25
7622673 2961731 MATTRESS AND PLATFORM BARI 39 ""




270
IP/OP $240.00 $96.00 $84.00 $216.00 $192.00 $204.00 $216.00 $163.20 $124.32 $84.00 $136.80 $204.00 $144.00 $168.00 $204.00 $204.00
7130495 30812 RESUS BAG/MASK-INFANT




270
IP/OP $229.00 $91.60 $80.15 $206.10 $183.20 $194.65 $206.10 $155.72 $118.62 $80.15 $130.53 $194.65 $137.40 $160.30 $194.65 $194.65
7130495 39401 RESUS BAG/MASK-INFANT




270
IP/OP $229.00 $91.60 $80.15 $206.10 $183.20 $194.65 $206.10 $155.72 $118.62 $80.15 $130.53 $194.65 $137.40 $160.30 $194.65 $194.65
1600337 3075807 OH WARMING BLANKET RENTAL




270
IP/OP $214.00 $85.60 $74.90 $192.60 $171.20 $181.90 $192.60 $145.52 $110.85 $74.90 $121.98 $181.90 $128.40 $149.80 $181.90 $181.90
7875686 7875686 FastCastOLS LG CAM Boot