Utility version: 2.4 Run started: 5/20/2021  4:33 PM Location: VAN WERT HEALTH Payer: Self pay Ref Date: 5/20/2021
Procedure|Code Type|Code|NDC|Rev Code|Procedure Description|Quantity|Payer|Contract|Plan(s)|IP Price|IP Pricing Detail|IP Expected Reimbursement|IP XR Detail|OP Price|OP Pricing Detail|OP Expected Reimbursement|OP XR Detail
MS521|DRG|MS-DRG V38 (FY 2021) 521|||Hip Replacement With Principal Diagnosis Of Hip Fracture With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|41,008.32|Repriced: HLB.310398505; Cases: 2|22,554.58|||||
MS522|DRG|MS-DRG V38 (FY 2021) 522|||Hip Replacement With Principal Diagnosis Of Hip Fracture Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|36,014.80|Repriced: HLB.288885101; Cases: 6|19,808.14|||||
MS783|DRG|MS-DRG V38 (FY 2021) 783|||Cesarean Section With Sterilization With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|26,776.88|Repriced: HLB.242685221; Cases: 1|14,727.28|||||
MS784|DRG|MS-DRG V38 (FY 2021) 784|||Cesarean Section With Sterilization With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|14,572.22|Repriced: HLB.273167874; Cases: 1|8,014.72|||||
MS785|DRG|MS-DRG V38 (FY 2021) 785|||Cesarean Section With Sterilization Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|13,762.66|Repriced: HLB.286926314; Cases: 14|7,569.46|||||
MS786|DRG|MS-DRG V38 (FY 2021) 786|||Cesarean Section Without Sterilization With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|18,918.54|Repriced: HLB.238853821; Cases: 3|10,405.20|||||
MS787|DRG|MS-DRG V38 (FY 2021) 787|||Cesarean Section Without Sterilization With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|19,091.98|Repriced: HLB.276507018; Cases: 5|10,500.59|||||
MS788|DRG|MS-DRG V38 (FY 2021) 788|||Cesarean Section Without Sterilization Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|13,221.74|Repriced: HLB.284126687; Cases: 29|7,271.96|||||
MS805|DRG|MS-DRG V38 (FY 2021) 805|||Vaginal Delivery Without Sterilization Or D&C With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|9,435.07|Repriced: HLB.280053472; Cases: 3|5,189.29|||||
MS806|DRG|MS-DRG V38 (FY 2021) 806|||Vaginal Delivery Without Sterilization Or D&C With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|9,722.57|Repriced: HLB.305367054; Cases: 12|5,347.41|||||
MS807|DRG|MS-DRG V38 (FY 2021) 807|||Vaginal Delivery Without Sterilization Or D&C Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|9,517.63|Repriced: HLB.217146680; Cases: 106|5,234.70|||||
MS818|DRG|MS-DRG V38 (FY 2021) 818|||Other Antepartum Diagnoses With O.R. Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|17,871.40|Repriced: HLB.311261005; Cases: 1|9,829.27|||||
MS819|DRG|MS-DRG V38 (FY 2021) 819|||Other Antepartum Diagnoses With O.R. Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|21,227.32|Repriced: HLB.263642062; Cases: 1|11,675.03|||||
MS831|DRG|MS-DRG V38 (FY 2021) 831|||Other Antepartum Diagnoses Without O.R. Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|25,350.55|Repriced: HLB.246038705; Cases: 1|13,942.80|||||
MS832|DRG|MS-DRG V38 (FY 2021) 832|||Other Antepartum Diagnoses Without O.R. Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|3,868.99|Repriced: HLB.265768478; Cases: 2|2,127.94|||||
MS833|DRG|MS-DRG V38 (FY 2021) 833|||Other Antepartum Diagnoses Without O.R. Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|3,385.00|Repriced: HLB.258224402; Cases: 1|1,861.75|||||
MS004|DRG|MS-DRG V38 (FY 2021) 004|||Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R. Procedures|1|<Self-pay>|<Self-pay>|<Self-pay>|324,288.48|Repriced: HLB.272238747; Cases: 1|178,358.66|||||
MS037|DRG|MS-DRG V38 (FY 2021) 037|||Extracranial Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|20,236.72|Repriced: HLB.276380862; Cases: 1|11,130.20|||||
MS039|DRG|MS-DRG V38 (FY 2021) 039|||Extracranial Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|17,442.57|Repriced: HLB.299591074; Cases: 1|9,593.41|||||
MS057|DRG|MS-DRG V38 (FY 2021) 057|||Degenerative Nervous System Disorders Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|33,252.04|Repriced: HLB.234014932; Cases: 1|18,288.62|||||
MS064|DRG|MS-DRG V38 (FY 2021) 064|||Intracranial Hemorrhage Or Cerebral Infarction With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|46,973.44|Repriced: HLB.311229359; Cases: 1|25,835.39|||||
MS065|DRG|MS-DRG V38 (FY 2021) 065|||Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|23,638.61|Repriced: HLB.246039342; Cases: 1|13,001.24|||||
MS066|DRG|MS-DRG V38 (FY 2021) 066|||Intracranial Hemorrhage Or Cerebral Infarction Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|20,727.34|Repriced: HLB.247987841; Cases: 3|11,400.04|||||
MS068|DRG|MS-DRG V38 (FY 2021) 068|||Nonspecific Cva And Precerebral Occlusion Without Infarction Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|24,417.14|Repriced: HLB.268474172; Cases: 1|13,429.43|||||
MS069|DRG|MS-DRG V38 (FY 2021) 069|||Transient Ischemia Without Thrombolytic|1|<Self-pay>|<Self-pay>|<Self-pay>|9,677.55|Repriced: HLB.292075795; Cases: 2|5,322.65|||||
MS070|DRG|MS-DRG V38 (FY 2021) 070|||Nonspecific Cerebrovascular Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|14,723.84|Repriced: HLB.323650112; Cases: 1|8,098.11|||||
MS071|DRG|MS-DRG V38 (FY 2021) 071|||Nonspecific Cerebrovascular Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|32,821.27|Repriced: HLB.273310962; Cases: 1|18,051.70|||||
MS075|DRG|MS-DRG V38 (FY 2021) 075|||Viral Meningitis With Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|26,354.31|Repriced: HLB.291877199; Cases: 1|14,494.87|||||
MS079|DRG|MS-DRG V38 (FY 2021) 079|||Hypertensive Encephalopathy Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|8,019.93|Repriced: HLB.274707833; Cases: 1|4,410.96|||||
MS091|DRG|MS-DRG V38 (FY 2021) 091|||Other Disorders Of Nervous System With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|9,392.69|Repriced: HLB.322240856; Cases: 1|5,165.98|||||
MS092|DRG|MS-DRG V38 (FY 2021) 092|||Other Disorders Of Nervous System With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|12,739.81|Repriced: HLB.286386207; Cases: 2|7,006.90|||||
MS100|DRG|MS-DRG V38 (FY 2021) 100|||Seizures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|29,092.56|Repriced: HLB.232332597; Cases: 1|16,000.91|||||
MS103|DRG|MS-DRG V38 (FY 2021) 103|||Headaches Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|33,859.36|Repriced: HLB.228449780; Cases: 1|18,622.65|||||
MS149|DRG|MS-DRG V38 (FY 2021) 149|||Dysequilibrium|1|<Self-pay>|<Self-pay>|<Self-pay>|19,468.81|Repriced: HLB.282103505; Cases: 1|10,707.85|||||
MS153|DRG|MS-DRG V38 (FY 2021) 153|||Otitis Media And Uri Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|5,291.46|Repriced: HLB.259864054; Cases: 1|2,910.30|||||
MS158|DRG|MS-DRG V38 (FY 2021) 158|||Dental And Oral Diseases With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|27,362.03|Repriced: HLB.238992990; Cases: 1|15,049.12|||||
MS165|DRG|MS-DRG V38 (FY 2021) 165|||Major Chest Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|42,008.12|Repriced: HLB.255950353; Cases: 1|23,104.47|||||
MS167|DRG|MS-DRG V38 (FY 2021) 167|||Other Respiratory System O.R. Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|56,672.47|Repriced: HLB.231749479; Cases: 1|31,169.86|||||
MS175|DRG|MS-DRG V38 (FY 2021) 175|||Pulmonary Embolism With McC Or Acute Cor Pulmonale|1|<Self-pay>|<Self-pay>|<Self-pay>|24,990.84|Repriced: HLB.306992997; Cases: 1|13,744.96|||||
MS176|DRG|MS-DRG V38 (FY 2021) 176|||Pulmonary Embolism Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|16,007.92|Repriced: HLB.247059233; Cases: 1|8,804.36|||||
MS177|DRG|MS-DRG V38 (FY 2021) 177|||Respiratory Infections And Inflammations With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|34,321.99|Repriced: HLB.287650297; Cases: 55|18,877.09|||||
MS178|DRG|MS-DRG V38 (FY 2021) 178|||Respiratory Infections And Inflammations With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|19,569.21|Repriced: HLB.308318446; Cases: 8|10,763.07|||||
MS179|DRG|MS-DRG V38 (FY 2021) 179|||Respiratory Infections And Inflammations Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|8,906.80|Repriced: HLB.287356001; Cases: 1|4,898.74|||||
MS180|DRG|MS-DRG V38 (FY 2021) 180|||Respiratory Neoplasms With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|28,902.66|Repriced: HLB.314840501; Cases: 1|15,896.46|||||
MS183|DRG|MS-DRG V38 (FY 2021) 183|||Major Chest Trauma With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|26,148.62|Repriced: HLB.260596251; Cases: 1|14,381.74|||||
MS187|DRG|MS-DRG V38 (FY 2021) 187|||Pleural Effusion With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|9,547.97|Repriced: HLB.255617286; Cases: 1|5,251.38|||||
MS189|DRG|MS-DRG V38 (FY 2021) 189|||Pulmonary Edema And Respiratory Failure|1|<Self-pay>|<Self-pay>|<Self-pay>|28,318.42|Repriced: HLB.304538513; Cases: 9|15,575.13|||||
MS190|DRG|MS-DRG V38 (FY 2021) 190|||Chronic Obstructive Pulmonary Disease With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|24,964.90|Repriced: HLB.293390710; Cases: 6|13,730.69|||||
MS191|DRG|MS-DRG V38 (FY 2021) 191|||Chronic Obstructive Pulmonary Disease With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|14,511.89|Repriced: HLB.285363813; Cases: 2|7,981.54|||||
MS192|DRG|MS-DRG V38 (FY 2021) 192|||Chronic Obstructive Pulmonary Disease Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|10,759.23|Repriced: HLB.277806419; Cases: 1|5,917.58|||||
MS193|DRG|MS-DRG V38 (FY 2021) 193|||Simple Pneumonia And Pleurisy With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|22,615.87|Repriced: HLB.298501631; Cases: 17|12,438.73|||||
MS194|DRG|MS-DRG V38 (FY 2021) 194|||Simple Pneumonia And Pleurisy With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|14,924.00|Repriced: HLB.259450131; Cases: 8|8,208.20|||||
MS197|DRG|MS-DRG V38 (FY 2021) 197|||Interstitial Lung Disease With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|10,889.51|Repriced: HLB.264036972; Cases: 1|5,989.23|||||
MS199|DRG|MS-DRG V38 (FY 2021) 199|||Pneumothorax With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|29,542.48|Repriced: HLB.231608076; Cases: 1|16,248.36|||||
MS200|DRG|MS-DRG V38 (FY 2021) 200|||Pneumothorax With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|12,859.92|Repriced: HLB.212147422; Cases: 2|7,072.96|||||
MS202|DRG|MS-DRG V38 (FY 2021) 202|||Bronchitis And Asthma With Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|16,407.52|Repriced: HLB.255975061; Cases: 1|9,024.14|||||
MS203|DRG|MS-DRG V38 (FY 2021) 203|||Bronchitis And Asthma Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|6,953.80|Repriced: HLB.248698137; Cases: 1|3,824.59|||||
MS207|DRG|MS-DRG V38 (FY 2021) 207|||Respiratory System Diagnosis With Ventilator Support >96 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|86,779.55|Repriced: HLB.319388111; Cases: 1|47,728.75|||||
MS208|DRG|MS-DRG V38 (FY 2021) 208|||Respiratory System Diagnosis With Ventilator Support <=96 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|82,375.50|Repriced: HLB.298320665; Cases: 3|45,306.52|||||
MS240|DRG|MS-DRG V38 (FY 2021) 240|||Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|29,711.52|Repriced: HLB.252507642; Cases: 1|16,341.34|||||
MS256|DRG|MS-DRG V38 (FY 2021) 256|||Upper Limb And Toe Amputation For Circulatory System Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|12,263.98|Repriced: HLB.236754897; Cases: 1|6,745.19|||||
MS280|DRG|MS-DRG V38 (FY 2021) 280|||Acute Myocardial Infarction, Discharged Alive With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|14,960.78|Repriced: HLB.290150508; Cases: 12|8,228.43|||||
MS281|DRG|MS-DRG V38 (FY 2021) 281|||Acute Myocardial Infarction, Discharged Alive With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|6,927.23|Repriced: HLB.254887729; Cases: 2|3,809.98|||||
MS282|DRG|MS-DRG V38 (FY 2021) 282|||Acute Myocardial Infarction, Discharged Alive Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|7,210.89|Repriced: HLB.254868423; Cases: 2|3,965.99|||||
MS291|DRG|MS-DRG V38 (FY 2021) 291|||Heart Failure And Shock With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|21,639.74|Repriced: HLB.267018012; Cases: 21|11,901.86|||||
MS292|DRG|MS-DRG V38 (FY 2021) 292|||Heart Failure And Shock With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|20,279.80|Repriced: HLB.269218910; Cases: 9|11,153.89|||||
MS299|DRG|MS-DRG V38 (FY 2021) 299|||Peripheral Vascular Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|22,285.88|Repriced: HLB.273026931; Cases: 1|12,257.23|||||
MS304|DRG|MS-DRG V38 (FY 2021) 304|||Hypertension With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|31,878.49|Repriced: HLB.218444424; Cases: 1|17,533.17|||||
MS305|DRG|MS-DRG V38 (FY 2021) 305|||Hypertension Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,623.55|Repriced: HLB.275399034; Cases: 1|6,392.95|||||
MS308|DRG|MS-DRG V38 (FY 2021) 308|||Cardiac Arrhythmia And Conduction Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|13,901.73|Repriced: HLB.292558786; Cases: 5|7,645.95|||||
MS309|DRG|MS-DRG V38 (FY 2021) 309|||Cardiac Arrhythmia And Conduction Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|13,913.87|Repriced: HLB.264151758; Cases: 4|7,652.63|||||
MS310|DRG|MS-DRG V38 (FY 2021) 310|||Cardiac Arrhythmia And Conduction Disorders Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|23,801.41|Repriced: HLB.234318720; Cases: 2|13,090.78|||||
MS311|DRG|MS-DRG V38 (FY 2021) 311|||Angina Pectoris|1|<Self-pay>|<Self-pay>|<Self-pay>|9,452.56|Repriced: HLB.301857375; Cases: 1|5,198.91|||||
MS312|DRG|MS-DRG V38 (FY 2021) 312|||Syncope And Collapse|1|<Self-pay>|<Self-pay>|<Self-pay>|9,532.06|Repriced: HLB.199389375; Cases: 2|5,242.63|||||
MS314|DRG|MS-DRG V38 (FY 2021) 314|||Other Circulatory System Diagnoses With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|33,431.93|Repriced: HLB.326133205; Cases: 1|18,387.56|||||
MS315|DRG|MS-DRG V38 (FY 2021) 315|||Other Circulatory System Diagnoses With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|17,359.63|Repriced: HLB.281966549; Cases: 1|9,547.80|||||
MS326|DRG|MS-DRG V38 (FY 2021) 326|||Stomach, Esophageal And Duodenal Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|48,605.74|Repriced: HLB.301878246; Cases: 4|26,733.16|||||
MS327|DRG|MS-DRG V38 (FY 2021) 327|||Stomach, Esophageal And Duodenal Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|30,973.17|Repriced: HLB.277919438; Cases: 1|17,035.24|||||
MS328|DRG|MS-DRG V38 (FY 2021) 328|||Stomach, Esophageal And Duodenal Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|34,458.14|Repriced: HLB.266154840; Cases: 1|18,951.98|||||
MS329|DRG|MS-DRG V38 (FY 2021) 329|||Major Small And Large Bowel Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|77,316.61|Repriced: HLB.316283036; Cases: 9|42,524.14|||||
MS330|DRG|MS-DRG V38 (FY 2021) 330|||Major Small And Large Bowel Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|34,948.36|Repriced: HLB.288630653; Cases: 10|19,221.60|||||
MS331|DRG|MS-DRG V38 (FY 2021) 331|||Major Small And Large Bowel Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|21,916.32|Repriced: HLB.306074307; Cases: 2|12,053.98|||||
MS335|DRG|MS-DRG V38 (FY 2021) 335|||Peritoneal Adhesiolysis With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|32,493.20|Repriced: HLB.264338704; Cases: 1|17,871.26|||||
MS336|DRG|MS-DRG V38 (FY 2021) 336|||Peritoneal Adhesiolysis With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|81,908.30|Repriced: HLB.232344824; Cases: 3|45,049.56|||||
MS337|DRG|MS-DRG V38 (FY 2021) 337|||Peritoneal Adhesiolysis Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|24,720.67|Repriced: HLB.232423569; Cases: 1|13,596.37|||||
MS339|DRG|MS-DRG V38 (FY 2021) 339|||Appendectomy With Complicated Principal Diagnosis With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|27,846.93|Repriced: HLB.267801930; Cases: 2|15,315.81|||||
MS340|DRG|MS-DRG V38 (FY 2021) 340|||Appendectomy With Complicated Principal Diagnosis Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|20,969.28|Repriced: HLB.315852625; Cases: 3|11,533.10|||||
MS343|DRG|MS-DRG V38 (FY 2021) 343|||Appendectomy Without Complicated Principal Diagnosis Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|17,114.03|Repriced: HLB.271240364; Cases: 2|9,412.72|||||
MS345|DRG|MS-DRG V38 (FY 2021) 345|||Minor Small And Large Bowel Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|12,550.59|Repriced: HLB.231190950; Cases: 2|6,902.82|||||
MS348|DRG|MS-DRG V38 (FY 2021) 348|||Anal And Stomal Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|16,820.48|Repriced: HLB.266079896; Cases: 2|9,251.26|||||
MS351|DRG|MS-DRG V38 (FY 2021) 351|||Inguinal And Femoral Hernia Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|24,342.08|Repriced: HLB.308421969; Cases: 1|13,388.14|||||
MS353|DRG|MS-DRG V38 (FY 2021) 353|||Hernia Procedures Except Inguinal And Femoral With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|54,118.57|Repriced: HLB.243749340; Cases: 2|29,765.21|||||
MS354|DRG|MS-DRG V38 (FY 2021) 354|||Hernia Procedures Except Inguinal And Femoral With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|18,292.21|Repriced: HLB.291111868; Cases: 1|10,060.72|||||
MS355|DRG|MS-DRG V38 (FY 2021) 355|||Hernia Procedures Except Inguinal And Femoral Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|32,528.43|Repriced: HLB.302865076; Cases: 2|17,890.64|||||
MS357|DRG|MS-DRG V38 (FY 2021) 357|||Other Digestive System O.R. Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|25,884.88|Repriced: HLB.316686467; Cases: 2|14,236.68|||||
MS358|DRG|MS-DRG V38 (FY 2021) 358|||Other Digestive System O.R. Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|27,197.66|Repriced: HLB.267039723; Cases: 1|14,958.71|||||
MS369|DRG|MS-DRG V38 (FY 2021) 369|||Major Esophageal Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|10,087.46|Repriced: HLB.297167437; Cases: 1|5,548.10|||||
MS372|DRG|MS-DRG V38 (FY 2021) 372|||Major Gastrointestinal Disorders And Peritoneal Infections With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|41,507.85|Repriced: HLB.241008004; Cases: 1|22,829.32|||||
MS373|DRG|MS-DRG V38 (FY 2021) 373|||Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|14,520.18|Repriced: HLB.276505602; Cases: 1|7,986.10|||||
MS374|DRG|MS-DRG V38 (FY 2021) 374|||Digestive Malignancy With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|40,580.87|Repriced: HLB.286789640; Cases: 1|22,319.48|||||
MS375|DRG|MS-DRG V38 (FY 2021) 375|||Digestive Malignancy With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|19,972.54|Repriced: HLB.325780903; Cases: 2|10,984.90|||||
MS377|DRG|MS-DRG V38 (FY 2021) 377|||Gastrointestinal Hemorrhage With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|30,572.53|Repriced: HLB.311155669; Cases: 12|16,814.89|||||
MS378|DRG|MS-DRG V38 (FY 2021) 378|||Gastrointestinal Hemorrhage With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|15,336.49|Repriced: HLB.261115203; Cases: 18|8,435.07|||||
MS379|DRG|MS-DRG V38 (FY 2021) 379|||Gastrointestinal Hemorrhage Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,385.65|Repriced: HLB.266086933; Cases: 1|6,262.11|||||
MS381|DRG|MS-DRG V38 (FY 2021) 381|||Complicated Peptic Ulcer With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|15,051.23|Repriced: HLB.298961295; Cases: 1|8,278.18|||||
MS382|DRG|MS-DRG V38 (FY 2021) 382|||Complicated Peptic Ulcer Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|15,254.06|Repriced: HLB.280914878; Cases: 1|8,389.73|||||
MS386|DRG|MS-DRG V38 (FY 2021) 386|||Inflammatory Bowel Disease With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|26,510.24|Repriced: HLB.309827736; Cases: 1|14,580.63|||||
MS387|DRG|MS-DRG V38 (FY 2021) 387|||Inflammatory Bowel Disease Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|25,078.13|Repriced: HLB.245323729; Cases: 1|13,792.97|||||
MS389|DRG|MS-DRG V38 (FY 2021) 389|||Gastrointestinal Obstruction With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|16,145.41|Repriced: HLB.294411790; Cases: 8|8,879.98|||||
MS390|DRG|MS-DRG V38 (FY 2021) 390|||Gastrointestinal Obstruction Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,100.27|Repriced: HLB.277421065; Cases: 5|6,105.15|||||
MS391|DRG|MS-DRG V38 (FY 2021) 391|||Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|54,291.71|Repriced: HLB.301861064; Cases: 1|29,860.44|||||
MS392|DRG|MS-DRG V38 (FY 2021) 392|||Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|17,378.43|Repriced: HLB.303764652; Cases: 11|9,558.14|||||
MS393|DRG|MS-DRG V38 (FY 2021) 393|||Other Digestive System Diagnoses With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|21,256.52|Repriced: HLB.235804166; Cases: 1|11,691.09|||||
MS394|DRG|MS-DRG V38 (FY 2021) 394|||Other Digestive System Diagnoses With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|20,270.06|Repriced: HLB.276445333; Cases: 3|11,148.53|||||
MS412|DRG|MS-DRG V38 (FY 2021) 412|||Cholecystectomy With C.D.E. With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|61,526.59|Repriced: HLB.219768081; Cases: 1|33,839.62|||||
MS415|DRG|MS-DRG V38 (FY 2021) 415|||Cholecystectomy Except By Laparoscope Without C.D.E. With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|42,298.04|Repriced: HLB.271251181; Cases: 1|23,263.92|||||
MS417|DRG|MS-DRG V38 (FY 2021) 417|||Laparoscopic Cholecystectomy Without C.D.E. With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|36,736.14|Repriced: HLB.257175119; Cases: 5|20,204.88|||||
MS418|DRG|MS-DRG V38 (FY 2021) 418|||Laparoscopic Cholecystectomy Without C.D.E. With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|28,134.75|Repriced: HLB.325842920; Cases: 7|15,474.11|||||
MS419|DRG|MS-DRG V38 (FY 2021) 419|||Laparoscopic Cholecystectomy Without C.D.E. Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|26,753.41|Repriced: HLB.245247415; Cases: 2|14,714.38|||||
MS432|DRG|MS-DRG V38 (FY 2021) 432|||Cirrhosis And Alcoholic Hepatitis With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|9,447.53|Repriced: HLB.273654086; Cases: 1|5,196.14|||||
MS438|DRG|MS-DRG V38 (FY 2021) 438|||Disorders Of Pancreas Except Malignancy With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|34,548.32|Repriced: HLB.243352755; Cases: 1|19,001.58|||||
MS439|DRG|MS-DRG V38 (FY 2021) 439|||Disorders Of Pancreas Except Malignancy With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|21,276.26|Repriced: HLB.283743323; Cases: 9|11,701.94|||||
MS440|DRG|MS-DRG V38 (FY 2021) 440|||Disorders Of Pancreas Except Malignancy Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|18,440.27|Repriced: HLB.282716240; Cases: 1|10,142.15|||||
MS441|DRG|MS-DRG V38 (FY 2021) 441|||Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|15,100.12|Repriced: HLB.245945234; Cases: 2|8,305.07|||||
MS442|DRG|MS-DRG V38 (FY 2021) 442|||Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|18,463.92|Repriced: HLB.262943200; Cases: 1|10,155.16|||||
MS444|DRG|MS-DRG V38 (FY 2021) 444|||Disorders Of The Biliary Tract With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|22,337.82|Repriced: HLB.266578829; Cases: 1|12,285.80|||||
MS445|DRG|MS-DRG V38 (FY 2021) 445|||Disorders Of The Biliary Tract With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|13,586.86|Repriced: HLB.284143795; Cases: 1|7,472.77|||||
MS463|DRG|MS-DRG V38 (FY 2021) 463|||Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|160,738.23|Repriced: HLB.242874881; Cases: 1|88,406.03|||||
MS464|DRG|MS-DRG V38 (FY 2021) 464|||Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|21,100.67|Repriced: HLB.267193343; Cases: 2|11,605.37|||||
MS465|DRG|MS-DRG V38 (FY 2021) 465|||Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|27,404.90|Repriced: HLB.268036185; Cases: 1|15,072.69|||||
MS467|DRG|MS-DRG V38 (FY 2021) 467|||Revision Of Hip Or Knee Replacement With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|68,980.08|Repriced: HLB.295648978; Cases: 1|37,939.04|||||
MS468|DRG|MS-DRG V38 (FY 2021) 468|||Revision Of Hip Or Knee Replacement Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|50,470.92|Repriced: HLB.314078149; Cases: 1|27,759.01|||||
MS469|DRG|MS-DRG V38 (FY 2021) 469|||Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With McC Or Total Ankle Replacement|1|<Self-pay>|<Self-pay>|<Self-pay>|36,446.21|Repriced: HLB.304089423; Cases: 2|20,045.42|||||
MS470|DRG|MS-DRG V38 (FY 2021) 470|||Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|29,384.46|Repriced: HLB.256250918; Cases: 57|16,161.45|||||
MS475|DRG|MS-DRG V38 (FY 2021) 475|||Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|13,509.90|Repriced: HLB.317687663; Cases: 1|7,430.44|||||
MS480|DRG|MS-DRG V38 (FY 2021) 480|||Hip And Femur Procedures Except Major Joint With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|35,412.50|Repriced: HLB.277616298; Cases: 4|19,476.87|||||
MS481|DRG|MS-DRG V38 (FY 2021) 481|||Hip And Femur Procedures Except Major Joint With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|36,709.33|Repriced: HLB.311193826; Cases: 26|20,190.13|||||
MS482|DRG|MS-DRG V38 (FY 2021) 482|||Hip And Femur Procedures Except Major Joint Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|33,172.34|Repriced: HLB.247293148; Cases: 3|18,244.79|||||
MS483|DRG|MS-DRG V38 (FY 2021) 483|||Major Joint Or Limb Reattachment Procedures Of Upper Extremities|1|<Self-pay>|<Self-pay>|<Self-pay>|46,921.22|Repriced: HLB.275897125; Cases: 1|25,806.67|||||
MS487|DRG|MS-DRG V38 (FY 2021) 487|||Knee Procedures With Principal Diagnosis Of Infection Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,857.93|Repriced: HLB.259226950; Cases: 1|6,521.86|||||
MS489|DRG|MS-DRG V38 (FY 2021) 489|||Knee Procedures Without Principal Diagnosis Of Infection Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,556.07|Repriced: HLB.251062267; Cases: 1|6,355.84|||||
MS492|DRG|MS-DRG V38 (FY 2021) 492|||Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|37,235.06|Repriced: HLB.260915068; Cases: 2|20,479.28|||||
MS493|DRG|MS-DRG V38 (FY 2021) 493|||Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|41,291.58|Repriced: HLB.266658510; Cases: 3|22,710.37|||||
MS494|DRG|MS-DRG V38 (FY 2021) 494|||Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|34,242.13|Repriced: HLB.253454718; Cases: 3|18,833.17|||||
MS498|DRG|MS-DRG V38 (FY 2021) 498|||Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|31,885.57|Repriced: HLB.280673146; Cases: 1|17,537.06|||||
MS501|DRG|MS-DRG V38 (FY 2021) 501|||Soft Tissue Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|25,564.80|Repriced: HLB.301087312; Cases: 3|14,060.64|||||
MS504|DRG|MS-DRG V38 (FY 2021) 504|||Foot Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|14,602.54|Repriced: HLB.326490751; Cases: 1|8,031.40|||||
MS533|DRG|MS-DRG V38 (FY 2021) 533|||Fractures Of Femur With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,594.71|Repriced: HLB.272788494; Cases: 1|6,377.09|||||
MS534|DRG|MS-DRG V38 (FY 2021) 534|||Fractures Of Femur Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,044.73|Repriced: HLB.241946415; Cases: 1|6,074.60|||||
MS535|DRG|MS-DRG V38 (FY 2021) 535|||Fractures Of Hip And Pelvis With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|19,536.49|Repriced: HLB.266586029; Cases: 1|10,745.07|||||
MS536|DRG|MS-DRG V38 (FY 2021) 536|||Fractures Of Hip And Pelvis Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|7,222.82|Repriced: HLB.257066656; Cases: 2|3,972.55|||||
MS547|DRG|MS-DRG V38 (FY 2021) 547|||Connective Tissue Disorders Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|14,590.72|Repriced: HLB.271756079; Cases: 1|8,024.90|||||
MS548|DRG|MS-DRG V38 (FY 2021) 548|||Septic Arthritis With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|17,302.27|Repriced: HLB.218467180; Cases: 1|9,516.25|||||
MS551|DRG|MS-DRG V38 (FY 2021) 551|||Medical Back Problems With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|15,125.80|Repriced: HLB.266094695; Cases: 1|8,319.19|||||
MS552|DRG|MS-DRG V38 (FY 2021) 552|||Medical Back Problems Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|12,900.48|Repriced: HLB.240468010; Cases: 1|7,095.26|||||
MS560|DRG|MS-DRG V38 (FY 2021) 560|||Aftercare, Musculoskeletal System And Connective Tissue With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|7,168.00|Repriced: HLB.275351223; Cases: 1|3,942.40|||||
MS563|DRG|MS-DRG V38 (FY 2021) 563|||Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,765.37|Repriced: HLB.281960039; Cases: 1|6,470.95|||||
MS564|DRG|MS-DRG V38 (FY 2021) 564|||Other Musculoskeletal System And Connective Tissue Diagnoses With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|26,559.42|Repriced: HLB.315720625; Cases: 1|14,607.68|||||
MS565|DRG|MS-DRG V38 (FY 2021) 565|||Other Musculoskeletal System And Connective Tissue Diagnoses With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|13,579.21|Repriced: HLB.280618002; Cases: 1|7,468.57|||||
MS579|DRG|MS-DRG V38 (FY 2021) 579|||Other Skin, Subcutaneous Tissue And Breast Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|41,235.25|Repriced: HLB.317007824; Cases: 1|22,679.39|||||
MS580|DRG|MS-DRG V38 (FY 2021) 580|||Other Skin, Subcutaneous Tissue And Breast Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|19,138.22|Repriced: HLB.277012795; Cases: 6|10,526.02|||||
MS581|DRG|MS-DRG V38 (FY 2021) 581|||Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|18,244.70|Repriced: HLB.264887176; Cases: 1|10,034.58|||||
MS596|DRG|MS-DRG V38 (FY 2021) 596|||Major Skin Disorders Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|12,909.14|Repriced: HLB.293142056; Cases: 1|7,100.03|||||
MS603|DRG|MS-DRG V38 (FY 2021) 603|||Cellulitis Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|15,015.26|Repriced: HLB.275637588; Cases: 8|8,258.39|||||
MS605|DRG|MS-DRG V38 (FY 2021) 605|||Trauma To The Skin, Subcutaneous Tissue And Breast Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|12,041.32|Repriced: HLB.304899251; Cases: 1|6,622.73|||||
MS607|DRG|MS-DRG V38 (FY 2021) 607|||Minor Skin Disorders Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|7,454.44|Repriced: HLB.315842676; Cases: 1|4,099.94|||||
MS616|DRG|MS-DRG V38 (FY 2021) 616|||Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|23,118.20|Repriced: HLB.300740227; Cases: 1|12,715.01|||||
MS617|DRG|MS-DRG V38 (FY 2021) 617|||Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|24,194.35|Repriced: HLB.293198793; Cases: 5|13,306.89|||||
MS623|DRG|MS-DRG V38 (FY 2021) 623|||Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|10,894.44|Repriced: HLB.277062708; Cases: 2|5,991.94|||||
MS637|DRG|MS-DRG V38 (FY 2021) 637|||Diabetes With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|15,693.14|Repriced: HLB.292496755; Cases: 5|8,631.23|||||
MS638|DRG|MS-DRG V38 (FY 2021) 638|||Diabetes With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|12,568.80|Repriced: HLB.244574772; Cases: 9|6,912.84|||||
MS640|DRG|MS-DRG V38 (FY 2021) 640|||Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|17,135.77|Repriced: HLB.225192219; Cases: 2|9,424.67|||||
MS641|DRG|MS-DRG V38 (FY 2021) 641|||Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|14,395.95|Repriced: HLB.253696360; Cases: 7|7,917.77|||||
MS643|DRG|MS-DRG V38 (FY 2021) 643|||Endocrine Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,145.76|Repriced: HLB.274054659; Cases: 1|6,130.17|||||
MS644|DRG|MS-DRG V38 (FY 2021) 644|||Endocrine Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|42,847.02|Repriced: HLB.246047160; Cases: 1|23,565.86|||||
MS656|DRG|MS-DRG V38 (FY 2021) 656|||Kidney And Ureter Procedures For Neoplasm With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|31,968.58|Repriced: HLB.302144688; Cases: 1|17,582.72|||||
MS660|DRG|MS-DRG V38 (FY 2021) 660|||Kidney And Ureter Procedures For Non-Neoplasm With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|22,412.58|Repriced: HLB.281780031; Cases: 3|12,326.92|||||
MS673|DRG|MS-DRG V38 (FY 2021) 673|||Other Kidney And Urinary Tract Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|33,273.70|Repriced: HLB.236398446; Cases: 1|18,300.53|||||
MS682|DRG|MS-DRG V38 (FY 2021) 682|||Renal Failure With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|21,396.28|Repriced: HLB.249951471; Cases: 1|11,767.95|||||
MS683|DRG|MS-DRG V38 (FY 2021) 683|||Renal Failure With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|9,466.01|Repriced: HLB.280932528; Cases: 6|5,206.31|||||
MS689|DRG|MS-DRG V38 (FY 2021) 689|||Kidney And Urinary Tract Infections With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|12,867.62|Repriced: HLB.274150448; Cases: 8|7,077.19|||||
MS690|DRG|MS-DRG V38 (FY 2021) 690|||Kidney And Urinary Tract Infections Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,223.29|Repriced: HLB.284036900; Cases: 10|6,172.81|||||
MS698|DRG|MS-DRG V38 (FY 2021) 698|||Other Kidney And Urinary Tract Diagnoses With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|17,176.03|Repriced: HLB.263023993; Cases: 10|9,446.82|||||
MS708|DRG|MS-DRG V38 (FY 2021) 708|||Major Male Pelvic Procedures Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|21,364.17|Repriced: HLB.308232772; Cases: 1|11,750.29|||||
MS717|DRG|MS-DRG V38 (FY 2021) 717|||Other Male Reproductive System O.R. Procedures Except Malignancy With Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|26,121.29|Repriced: HLB.276470593; Cases: 1|14,366.71|||||
MS741|DRG|MS-DRG V38 (FY 2021) 741|||Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|17,323.84|Repriced: HLB.284830373; Cases: 2|9,528.11|||||
MS742|DRG|MS-DRG V38 (FY 2021) 742|||Uterine And Adnexa Procedures For Non-Malignancy With Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|20,589.47|Repriced: HLB.271019645; Cases: 3|11,324.21|||||
MS743|DRG|MS-DRG V38 (FY 2021) 743|||Uterine And Adnexa Procedures For Non-Malignancy Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|15,139.78|Repriced: HLB.256237769; Cases: 8|8,326.88|||||
MS759|DRG|MS-DRG V38 (FY 2021) 759|||Infections, Female Reproductive System Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|11,751.83|Repriced: HLB.205111671; Cases: 1|6,463.51|||||
MS760|DRG|MS-DRG V38 (FY 2021) 760|||Menstrual And Other Female Reproductive System Disorders With Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|16,606.03|Repriced: HLB.281761898; Cases: 1|9,133.32|||||
MS768|DRG|MS-DRG V38 (FY 2021) 768|||Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C|1|<Self-pay>|<Self-pay>|<Self-pay>|13,297.63|Repriced: HLB.299109541; Cases: 5|7,313.70|||||
MS776|DRG|MS-DRG V38 (FY 2021) 776|||Postpartum And Post Abortion Diagnoses Without O.R. Procedures|1|<Self-pay>|<Self-pay>|<Self-pay>|2,569.35|Repriced: HLB.310122130; Cases: 1|1,413.14|||||
MS779|DRG|MS-DRG V38 (FY 2021) 779|||Abortion Without D&C|1|<Self-pay>|<Self-pay>|<Self-pay>|3,989.85|Repriced: HLB.287592054; Cases: 1|2,194.42|||||
MS789|DRG|MS-DRG V38 (FY 2021) 789|||Neonates, Died Or Transferred To Another Acute Care Facility|1|<Self-pay>|<Self-pay>|<Self-pay>|2,799.94|Repriced: HLB.246873658; Cases: 4|1,539.97|||||
MS792|DRG|MS-DRG V38 (FY 2021) 792|||Prematurity Without Major Problems|1|<Self-pay>|<Self-pay>|<Self-pay>|4,803.30|Repriced: HLB.295396414; Cases: 6|2,641.81|||||
MS793|DRG|MS-DRG V38 (FY 2021) 793|||Full Term Neonate With Major Problems|1|<Self-pay>|<Self-pay>|<Self-pay>|7,757.35|Repriced: HLB.299621388; Cases: 4|4,266.54|||||
MS794|DRG|MS-DRG V38 (FY 2021) 794|||Neonate With Other Significant Problems|1|<Self-pay>|<Self-pay>|<Self-pay>|4,856.00|Repriced: HLB.324278276; Cases: 24|2,670.80|||||
MS795|DRG|MS-DRG V38 (FY 2021) 795|||Normal Newborn|1|<Self-pay>|<Self-pay>|<Self-pay>|4,822.90|Repriced: HLB.282212269; Cases: 153|2,652.59|||||
MS808|DRG|MS-DRG V38 (FY 2021) 808|||Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|32,051.79|Repriced: HLB.235501153; Cases: 1|17,628.48|||||
MS809|DRG|MS-DRG V38 (FY 2021) 809|||Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|22,171.88|Repriced: HLB.305441073; Cases: 3|12,194.53|||||
MS811|DRG|MS-DRG V38 (FY 2021) 811|||Red Blood Cell Disorders With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|25,671.25|Repriced: HLB.289145341; Cases: 2|14,119.19|||||
MS812|DRG|MS-DRG V38 (FY 2021) 812|||Red Blood Cell Disorders Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|18,812.98|Repriced: HLB.281651516; Cases: 2|10,347.14|||||
MS813|DRG|MS-DRG V38 (FY 2021) 813|||Coagulation Disorders|1|<Self-pay>|<Self-pay>|<Self-pay>|20,110.82|Repriced: HLB.264434666; Cases: 4|11,060.95|||||
MS821|DRG|MS-DRG V38 (FY 2021) 821|||Lymphoma And Leukemia With Major O.R. Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|17,104.82|Repriced: HLB.280464954; Cases: 1|9,407.65|||||
MS853|DRG|MS-DRG V38 (FY 2021) 853|||Infectious And Parasitic Diseases With O.R. Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|59,344.08|Repriced: HLB.222445801; Cases: 10|32,639.24|||||
MS854|DRG|MS-DRG V38 (FY 2021) 854|||Infectious And Parasitic Diseases With O.R. Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|37,032.18|Repriced: HLB.278549986; Cases: 3|20,367.70|||||
MS856|DRG|MS-DRG V38 (FY 2021) 856|||Postoperative Or Post-Traumatic Infections With O.R. Procedures With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|35,548.91|Repriced: HLB.290099635; Cases: 1|19,551.90|||||
MS857|DRG|MS-DRG V38 (FY 2021) 857|||Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|16,890.54|Repriced: HLB.290121139; Cases: 2|9,289.80|||||
MS863|DRG|MS-DRG V38 (FY 2021) 863|||Postoperative And Post-Traumatic Infections Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|9,814.15|Repriced: HLB.254992081; Cases: 1|5,397.78|||||
MS866|DRG|MS-DRG V38 (FY 2021) 866|||Viral Illness Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|15,707.26|Repriced: HLB.193584733; Cases: 1|8,638.99|||||
MS870|DRG|MS-DRG V38 (FY 2021) 870|||Septicemia Or Severe Sepsis With Mv >96 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|236,712.07|Repriced: HLB.299810769; Cases: 1|130,191.64|||||
MS871|DRG|MS-DRG V38 (FY 2021) 871|||Septicemia Or Severe Sepsis Without Mv >96 Hours With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|24,096.86|Repriced: HLB.268331188; Cases: 74|13,253.27|||||
MS872|DRG|MS-DRG V38 (FY 2021) 872|||Septicemia Or Severe Sepsis Without Mv >96 Hours Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|16,263.55|Repriced: HLB.268876711; Cases: 18|8,944.95|||||
MS884|DRG|MS-DRG V38 (FY 2021) 884|||Organic Disturbances And Intellectual Disability|1|<Self-pay>|<Self-pay>|<Self-pay>|25,961.18|Repriced: HLB.325831085; Cases: 1|14,278.65|||||
MS885|DRG|MS-DRG V38 (FY 2021) 885|||Psychoses|1|<Self-pay>|<Self-pay>|<Self-pay>|11,765.71|Repriced: HLB.313186223; Cases: 1|6,471.14|||||
MS896|DRG|MS-DRG V38 (FY 2021) 896|||Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|16,190.92|Repriced: HLB.242018330; Cases: 2|8,905.01|||||
MS902|DRG|MS-DRG V38 (FY 2021) 902|||Wound Debridements For Injuries With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|36,232.93|Repriced: HLB.231437966; Cases: 1|19,928.11|||||
MS904|DRG|MS-DRG V38 (FY 2021) 904|||Skin Grafts For Injuries With Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|77,610.95|Repriced: HLB.234677661; Cases: 1|42,686.02|||||
MS907|DRG|MS-DRG V38 (FY 2021) 907|||Other O.R. Procedures For Injuries With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|28,366.66|Repriced: HLB.274211415; Cases: 4|15,601.66|||||
MS908|DRG|MS-DRG V38 (FY 2021) 908|||Other O.R. Procedures For Injuries With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|41,447.77|Repriced: HLB.257414712; Cases: 1|22,796.27|||||
MS909|DRG|MS-DRG V38 (FY 2021) 909|||Other O.R. Procedures For Injuries Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|27,206.21|Repriced: HLB.252722782; Cases: 1|14,963.42|||||
MS914|DRG|MS-DRG V38 (FY 2021) 914|||Traumatic Injury Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|12,427.88|Repriced: HLB.269534250; Cases: 1|6,835.33|||||
MS915|DRG|MS-DRG V38 (FY 2021) 915|||Allergic Reactions With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|32,122.64|Repriced: HLB.276183529; Cases: 1|17,667.45|||||
MS917|DRG|MS-DRG V38 (FY 2021) 917|||Poisoning And Toxic Effects Of Drugs With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|20,040.78|Repriced: HLB.263945799; Cases: 3|11,022.43|||||
MS918|DRG|MS-DRG V38 (FY 2021) 918|||Poisoning And Toxic Effects Of Drugs Without McC|1|<Self-pay>|<Self-pay>|<Self-pay>|9,259.74|Repriced: HLB.288101521; Cases: 2|5,092.86|||||
MS920|DRG|MS-DRG V38 (FY 2021) 920|||Complications Of Treatment With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|15,690.17|Repriced: HLB.265929404; Cases: 1|8,629.59|||||
MS957|DRG|MS-DRG V38 (FY 2021) 957|||Other O.R. Procedures For Multiple Significant Trauma With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|12,828.34|Repriced: HLB.324645568; Cases: 2|7,055.59|||||
MS975|DRG|MS-DRG V38 (FY 2021) 975|||Hiv With Major Related Condition With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|44,802.90|Repriced: HLB.235817149; Cases: 1|24,641.59|||||
MS982|DRG|MS-DRG V38 (FY 2021) 982|||Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|21,924.40|Repriced: HLB.261199833; Cases: 4|12,058.42|||||
MS988|DRG|MS-DRG V38 (FY 2021) 988|||Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|21,506.44|Repriced: HLB.312603608; Cases: 2|11,828.54|||||
MS570|DRG|MS-DRG V38 (FY 2021) 570|||Skin Debridement With McC|1|<Self-pay>|<Self-pay>|<Self-pay>|22,453.88|Repriced: HLB.279554943; Cases: 2|12,349.63|||||
MS571|DRG|MS-DRG V38 (FY 2021) 571|||Skin Debridement With Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|17,714.10|Repriced: HLB.312907503; Cases: 2|9,742.75|||||
MS572|DRG|MS-DRG V38 (FY 2021) 572|||Skin Debridement Without Cc/McC|1|<Self-pay>|<Self-pay>|<Self-pay>|19,661.98|Repriced: HLB.282451497; Cases: 1|10,814.09|||||
25605|EAP|CPT® 25605|||Pr Closed Rx Dist Rad/ulna Fx,manipul|1|<Self-pay>|<Self-pay>|<Self-pay>|799.00|FSC: 46100; BFG: 52|||799.00|FSC: 46100; BFG: 52|439.45|
26010|EAP|CPT® 26010||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Drain Finger Abscess,simple|1|<Self-pay>|<Self-pay>|<Self-pay>|595.00|FSC: 46100; BFG: 52|||595.00|FSC: 46100; BFG: 52|327.25|
26055|EAP|CPT® 26055|||Pr Incise Finger Tendon Sheath|1|<Self-pay>|<Self-pay>|<Self-pay>|807.00|FSC: 46100; BFG: 52|||807.00|FSC: 46100; BFG: 52|443.85|
26160|EAP|CPT® 26160|||Pr Excis Tendon Sheath Lesion, Hand/finger|1|<Self-pay>|<Self-pay>|<Self-pay>|835.00|FSC: 46100; BFG: 52|||835.00|FSC: 46100; BFG: 52|459.25|
26418|EAP|CPT® 26418|||Pr Repair Exten Tendon,dorsum Fingr,ea|1|<Self-pay>|<Self-pay>|<Self-pay>|831.00|FSC: 46100; BFG: 52|||831.00|FSC: 46100; BFG: 52|457.05|
32551|EAP|CPT® 32551|||TUBE THORACOSTOMY INCLUDES WATER SEAL|1|<Self-pay>|<Self-pay>|<Self-pay>|285.00|FSC: 46100; BFG: 52|||285.00|FSC: 46100; BFG: 52|156.75|
99406|EAP|CPT® 99406|||PR SMOKE/TOBACCO COUNSELING|1|<Self-pay>|<Self-pay>|<Self-pay>|25.00|FSC: 46100; BFG: 52|||25.00|FSC: 46100; BFG: 52|13.75|
99441|EAP|CPT® 99441||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|PHYS/QHP TELEPHONE EVALUATION|1|<Self-pay>|<Self-pay>|<Self-pay>|34.00|FSC: 46100; BFG: 52|||34.00|FSC: 46100; BFG: 52|18.70|
99442|EAP|CPT® 99442||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|PHYS/QHP TELEPHONE EVALUATION|1|<Self-pay>|<Self-pay>|<Self-pay>|68.00|FSC: 46100; BFG: 52|||68.00|FSC: 46100; BFG: 52|37.40|
99443|EAP|CPT® 99443||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|PHYS/QHP TELEPHONE EVALUATION|1|<Self-pay>|<Self-pay>|<Self-pay>|102.00|FSC: 46100; BFG: 52|||102.00|FSC: 46100; BFG: 52|56.10|
NCNC|EAP|Custom NCNC0|||No Charge|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 46100|||0.00|FSC: 46100|0.00|
S2083|EAP|HCPCS S2083|||Pr Adjustment Gastric Band|1|<Self-pay>|<Self-pay>|<Self-pay>|215.00|FSC: 46100; BFG: 52|||215.00|FSC: 46100; BFG: 52|118.25|
45000001|EAP|CPT® 99281||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Emergency Room Level 1|1|<Self-pay>|<Self-pay>|<Self-pay>|199.50|FSC: 400601; BFG: 52|||199.50|FSC: 400601; BFG: 52|109.72|
45000002|EAP|CPT® 99282||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Emergency Room Level 2|1|<Self-pay>|<Self-pay>|<Self-pay>|279.30|FSC: 400601; BFG: 52|||279.30|FSC: 400601; BFG: 52|153.61|
45000003|EAP|CPT® 99283||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Emergency Room Level 3|1|<Self-pay>|<Self-pay>|<Self-pay>|837.90|FSC: 400601; BFG: 52|||837.90|FSC: 400601; BFG: 52|460.84|
45000004|EAP|CPT® 99284||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Emergency Room Level 4|1|<Self-pay>|<Self-pay>|<Self-pay>|1,421.70|FSC: 400601; BFG: 52|||1,421.70|FSC: 400601; BFG: 52|781.93|
45000005|EAP|CPT® 99285||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Emergency Room Level 5|1|<Self-pay>|<Self-pay>|<Self-pay>|1,575.00|FSC: 400601; BFG: 52|||1,575.00|FSC: 400601; BFG: 52|866.25|
45000006|EAP|CPT® 99291||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Emergency Room Critical Care|1|<Self-pay>|<Self-pay>|<Self-pay>|2,431.80|FSC: 400601; BFG: 52|||2,431.80|FSC: 400601; BFG: 52|1,337.49|
26000002|EAP|CPT® 96361||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Hydration Each Additional Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|121.80|FSC: 400601; BFG: 52|||121.80|FSC: 400601; BFG: 52|66.99|
26000001|EAP|CPT® 96360||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Hydration Initial Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|420.00|FSC: 400601; BFG: 52|||420.00|FSC: 400601; BFG: 52|231.00|
26000004|EAP|CPT® 96366||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Iv Infusion Non-chemo Each Additional Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|123.90|FSC: 400601; BFG: 52|||123.90|FSC: 400601; BFG: 52|68.14|
26000003|EAP|CPT® 96365||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Iv Infusion Non-chemo Initial Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|420.00|FSC: 400601; BFG: 52|||420.00|FSC: 400601; BFG: 52|231.00|
26000005|EAP|CPT® 96367||0260 - IV THERAPY - GENERAL CLASSIFICATION|HC IV INFUSION NON-CHEMO SEQUENTIAL|1|<Self-pay>|<Self-pay>|<Self-pay>|331.80|FSC: 400601; BFG: 52|||331.80|FSC: 400601; BFG: 52|182.49|
26000007|EAP|CPT® 96374||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Iv Push Non-chemo Initial|1|<Self-pay>|<Self-pay>|<Self-pay>|531.30|FSC: 400601; BFG: 52|||531.30|FSC: 400601; BFG: 52|292.21|
26000008|EAP|CPT® 96375||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Iv Push Non-chemo Sequential Different Drug|1|<Self-pay>|<Self-pay>|<Self-pay>|128.10|FSC: 400601; BFG: 52|||128.10|FSC: 400601; BFG: 52|70.45|
26000009|EAP|CPT® 96376||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Iv Push Non-chemo Sequential Same Drug|1|<Self-pay>|<Self-pay>|<Self-pay>|107.10|FSC: 400601; BFG: 52|||107.10|FSC: 400601; BFG: 52|58.90|
32000195|EAP|CPT® 76377||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc 3d Rendering Postprocessing W/ Independent Workstation Diag Rad|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
32000194|EAP|CPT® 76376||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc 3d Rendering Postprocessing W/o Independent Workstation Diag Rad|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
32000092|EAP|CPT® 73615||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Arthrography Ankle|1|<Self-pay>|<Self-pay>|<Self-pay>|1,222.20|FSC: 400601; BFG: 52|||1,222.20|FSC: 400601; BFG: 52|672.21|
32000070|EAP|CPT® 73085||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Arthrography Elbow|1|<Self-pay>|<Self-pay>|<Self-pay>|1,222.20|FSC: 400601; BFG: 52|||1,222.20|FSC: 400601; BFG: 52|672.21|
32000081|EAP|CPT® 73525||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Arthrography Hip|1|<Self-pay>|<Self-pay>|<Self-pay>|1,222.20|FSC: 400601; BFG: 52|||1,222.20|FSC: 400601; BFG: 52|672.21|
32000088|EAP|CPT® 73580||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Arthrography Knee|1|<Self-pay>|<Self-pay>|<Self-pay>|1,222.20|FSC: 400601; BFG: 52|||1,222.20|FSC: 400601; BFG: 52|672.21|
32000065|EAP|CPT® 73040||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Arthrography Shoulder|1|<Self-pay>|<Self-pay>|<Self-pay>|1,222.20|FSC: 400601; BFG: 52|||1,222.20|FSC: 400601; BFG: 52|672.21|
32000074|EAP|CPT® 73115||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Arthrography Wrist|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000113|EAP|CPT® 74300||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Cholangiography Pancreatography Intraoperative|1|<Self-pay>|<Self-pay>|<Self-pay>|285.60|FSC: 400601; BFG: 52|||285.60|FSC: 400601; BFG: 52|157.08|
32000114|EAP|CPT® 74301||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Cholangiography Pancreatography Intraoperative Additional Set|1|<Self-pay>|<Self-pay>|<Self-pay>|130.20|FSC: 400601; BFG: 52|||130.20|FSC: 400601; BFG: 52|71.61|
32000058|EAP|CPT® 72285||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Discography Cervical Thoracic|1|<Self-pay>|<Self-pay>|<Self-pay>|4,312.35|FSC: 400601; BFG: 52|||4,312.35|FSC: 400601; BFG: 52|2,371.79|
32000060|EAP|CPT® 72295||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Discography Lumbar|1|<Self-pay>|<Self-pay>|<Self-pay>|4,312.35|FSC: 400601; BFG: 52|||4,312.35|FSC: 400601; BFG: 52|2,371.79|
32000183|EAP|CPT® 75989||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Placement Percutaneous Drainage Catheter Fluoro|1|<Self-pay>|<Self-pay>|<Self-pay>|985.95|FSC: 400601; BFG: 52|||985.95|FSC: 400601; BFG: 52|542.27|
32000191|EAP|CPT® 76080||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Abscess Fistula Sinus Tract Study|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32000204|EAP|CPT® 77072||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Bone Age Study|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000210|EAP|CPT® 77081||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Bone Density Study Appendicular|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000209|EAP|CPT® 77080||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Bone Density Study Axial|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000205|EAP|CPT® 77073||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Bone Length Studies|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000182|EAP|CPT® 75984||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Change Percutaneous Drainage Catheter|1|<Self-pay>|<Self-pay>|<Self-pay>|687.75|FSC: 400601; BFG: 52|||687.75|FSC: 400601; BFG: 52|378.26|
32000130|EAP|CPT® 74430||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Cystography Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|1,013.25|FSC: 400601; BFG: 52|||1,013.25|FSC: 400601; BFG: 52|557.29|
32000097|EAP|CPT® 74018||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Abdomen Single View|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000066|EAP|CPT® 73050||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Acromioclavicular Joints Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000090|EAP|CPT® 73600||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Ankle 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000091|EAP|CPT® 73610||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Ankle Complete- Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000095|EAP|CPT® 73650||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Calcaneus Min 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000036|EAP|CPT® 72040||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Cervical Spine 2 Or 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000037|EAP|CPT® 72050||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|HC RADIOLOGY EXAM CERVICAL SPINE MIN 4 VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000038|EAP|CPT® 72052||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|HC RADIOLOGY EXAM CERVICAL SPINE, COMPLETE, OBLIQUE, FLEXION, OR EXTENSION|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000061|EAP|CPT® 73000||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Clavicle- Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000111|EAP|CPT® 74280||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Colon Incl Scout Abdominal W/double-contrast (barium)|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000110|EAP|CPT® 74270||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Colon Incl Scout Abdominal W/single-contrast (barium)|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000099|EAP|CPT® 74022||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Acute Abdomen Series Complete 2 Or More Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000068|EAP|CPT® 73070||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Elbow 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000069|EAP|CPT® 73080||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Elbow Complete- Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000101|EAP|CPT® 74220||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Esophagus Incl Scout Neck W/single-contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000002|EAP|CPT® 70030||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Eye For Fb Detection|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000008|EAP|CPT® 70140||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Facial Bones < 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000009|EAP|CPT® 70150||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Facial Bones Complete- Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000077|EAP|CPT® 73140||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Finger(s) Min 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000093|EAP|CPT® 73620||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Foot 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000094|EAP|CPT® 73630||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Foot Complete- Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000071|EAP|CPT® 73090||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Forearm 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000075|EAP|CPT® 73120||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Hand 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000076|EAP|CPT® 73130||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Hand Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000067|EAP|CPT® 73060||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Humerus Min 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000084|EAP|CPT® 73560||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Knee 1 Or 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000085|EAP|CPT® 73562||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Knee 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000086|EAP|CPT® 73564||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Knee Complete- 4 Or More Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000087|EAP|CPT® 73565||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Knees Bilateral Standing Ap|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000048|EAP|CPT® 72120||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Lumbosacral Bending Only 2 Or 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000045|EAP|CPT® 72100||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Lumbosacral Spine 2 Or 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000046|EAP|CPT® 72110||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Lumbosacral Spine Min 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000047|EAP|CPT® 72114||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|HC RADIOLOGY EXAM LUMBOSACRAL SPINE, COMPLETE, INCLUDING BENDING VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000004|EAP|CPT® 70110||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Mandible Complete- Min 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000003|EAP|CPT® 70100||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Mandible Partial < 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000006|EAP|CPT® 70130||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Mastoids Complete- Min 3 Views Per Side|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000010|EAP|CPT® 70160||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Nasal Bones Complete-min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000024|EAP|CPT® 70360||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Neck Soft Tissue|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000012|EAP|CPT® 70200||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Orbits Complete- Min 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000013|EAP|CPT® 70210||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Paranasal Sinuses < 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000014|EAP|CPT® 70220||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Paranasal Sinuses Complete- Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000049|EAP|CPT® 72170||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Pelvis 1 Or 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000050|EAP|CPT® 72190||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Pelvis Complete- Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000100|EAP|CPT® 74210||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Pharynx Cervical Esophagus Incl Scout Neck W/contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000030|EAP|CPT® 71110||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Ribs Bilateral 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000031|EAP|CPT® 71111||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Ribs Bilateral W/ Pa Chest Min 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000028|EAP|CPT® 71100||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Ribs Unilateral 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000029|EAP|CPT® 71101||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Ribs Unilateral W/ Pa Chest Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000052|EAP|CPT® 72202||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Sacroiliac Joint 3 Or More Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000053|EAP|CPT® 72220||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Sacrum & Coccyx Min 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000025|EAP|CPT® 70380||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Salivary Gland Calculus|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000062|EAP|CPT® 73010||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Scapula- Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000015|EAP|CPT® 70240||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Sella Turcica|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000063|EAP|CPT® 73020||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Shoulder 1 View|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000064|EAP|CPT® 73030||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Shoulder Complete- Min 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000016|EAP|CPT® 70250||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Skull < 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000017|EAP|CPT® 70260||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Skull Complete- Min 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000107|EAP|CPT® 74250||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Small Intestine Incl Scout Abdominal W/single-contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000108|EAP|CPT® 74251||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Small Int Via Entercolysis Tube Incl Scout Abd Dbl-contst|1|<Self-pay>|<Self-pay>|<Self-pay>|605.85|FSC: 400601; BFG: 52|||605.85|FSC: 400601; BFG: 52|333.22|
32000035|EAP|CPT® 72020||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Spine Single View- Specify Level|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000033|EAP|CPT® 71130||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Sternoclavicular Joint Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000032|EAP|CPT® 71120||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Sternum Min 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000040|EAP|CPT® 72070||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Thoracic Spine 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000041|EAP|CPT® 72072||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Thoracic Spine 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000042|EAP|CPT® 72074||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Thoracic Spine Min 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000043|EAP|CPT® 72080||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Thoracolumbar Spine 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000089|EAP|CPT® 73590||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Tibia Fibula 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000021|EAP|CPT® 70330||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Tmj Open & Closed Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000096|EAP|CPT® 73660||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Toe(s) Min 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000106|EAP|CPT® 74249||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Upper Gi W/ Air Contrast W/ Small Bowel Follow-through|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000105|EAP|CPT® 74246||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Upper Gi Incl Scout Abdominal W/double-contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000104|EAP|CPT® 74245||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Upper Gi W/ Small Intestine|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32000103|EAP|CPT® 74240||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Upper Gi Incl Scout Abdominal W/single-contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000072|EAP|CPT® 73100||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Wrist 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000073|EAP|CPT® 73110||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Wrist Complete- Min 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000197|EAP|CPT® 77001||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Fluoroscopic Guidance For Central Venous Access Device|1|<Self-pay>|<Self-pay>|<Self-pay>|386.40|FSC: 400601; BFG: 52|||386.40|FSC: 400601; BFG: 52|212.52|
32000198|EAP|CPT® 77002||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Fluoroscopic Guidance For Needle Placement Bx Or Fna|1|<Self-pay>|<Self-pay>|<Self-pay>|348.60|FSC: 400601; BFG: 52|||348.60|FSC: 400601; BFG: 52|191.73|
32000199|EAP|CPT® 77003||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Fluoroscopic Guidance For Spinal Injection|1|<Self-pay>|<Self-pay>|<Self-pay>|413.70|FSC: 400601; BFG: 52|||413.70|FSC: 400601; BFG: 52|227.53|
32000189|EAP|CPT® 76000||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Fluoroscopy Up To 1 Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32000136|EAP|CPT® 74740||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Hysterosalpingography|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32000123|EAP|CPT® 74360||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Intraluminal Dilation Stricture Obstruction|1|<Self-pay>|<Self-pay>|<Self-pay>|408.45|FSC: 400601; BFG: 52|||408.45|FSC: 400601; BFG: 52|224.65|
32000121|EAP|CPT® 74340||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Introduction Of Long Gi Tube|1|<Self-pay>|<Self-pay>|<Self-pay>|337.05|FSC: 400601; BFG: 52|||337.05|FSC: 400601; BFG: 52|185.38|
32000202|EAP|CPT® 77053||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Mammary Ductogram|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32000207|EAP|CPT® 77075||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Osseous Survey- Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000206|EAP|CPT® 77074||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Osseous Survey- Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000124|EAP|CPT® 74363||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Percutaneous Transhepatic Dilation Biliary Duct|1|<Self-pay>|<Self-pay>|<Self-pay>|788.55|FSC: 400601; BFG: 52|||788.55|FSC: 400601; BFG: 52|433.70|
32000131|EAP|CPT® 74450||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Retrograde Urethrocystography|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32000128|EAP|CPT® 74420||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Retrograde Urography|1|<Self-pay>|<Self-pay>|<Self-pay>|1,222.20|FSC: 400601; BFG: 52|||1,222.20|FSC: 400601; BFG: 52|672.21|
32000193|EAP|CPT® 76100||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Single Plane Body Section|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000208|EAP|CPT® 77077||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Single View Joint Survey 2+ Joints|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000192|EAP|CPT® 76098||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Surgical Specimen|1|<Self-pay>|<Self-pay>|<Self-pay>|1,303.05|FSC: 400601; BFG: 52|||1,303.05|FSC: 400601; BFG: 52|716.68|
32000127|EAP|CPT® 74415||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Urography Infusion W/ Tomography|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000125|EAP|CPT® 74400||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Urography Intravenous|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000140|EAP|CPT® 75822||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Venography Extremity Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|2,632.35|FSC: 400601; BFG: 52|||2,632.35|FSC: 400601; BFG: 52|1,447.79|
32000139|EAP|CPT® 75820||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Venography Extremity Unilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|1,640.10|FSC: 400601; BFG: 52|||1,640.10|FSC: 400601; BFG: 52|902.05|
32000102|EAP|CPT® 74230||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Swalowing Function Incl Scout Neck W/contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000132|EAP|CPT® 74455||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Voiding Urethrocystography|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32000026|EAP|CPT® 70390||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Sialography|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
32400002|EAP|CPT® 71046||0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY|Hc Radiology X-ray Chest 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32400004|EAP|CPT® 71048||0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY|Hc Radiology X-ray Chest Min 4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32400001|EAP|CPT® 71045||0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY|Hc Radiology X-ray Chest Single View|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
61000020|EAP|CPT® 76377||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc 3d Rendering Postprocessing W/ Independent Workstation Mri|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
61000019|EAP|CPT® 76376||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc 3d Rendering Postprocessing W/o Independent Workstation Mri|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
61000013|EAP|CPT® 74181||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Abdomen W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,547.70|FSC: 400601; BFG: 52|||1,547.70|FSC: 400601; BFG: 52|851.23|
61000022|EAP|CPT® 77084||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Bone Marrow|1|<Self-pay>|<Self-pay>|<Self-pay>|1,795.50|FSC: 400601; BFG: 52|||1,795.50|FSC: 400601; BFG: 52|987.52|
61000025|EAP|HCPCS C8908||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Breast W & W/o Contrast Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|1,795.50|FSC: 400601; BFG: 52|||1,795.50|FSC: 400601; BFG: 52|987.52|
61000024|EAP|HCPCS C8905||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Breast W & W/o Contrast Unilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|1,078.35|FSC: 400601; BFG: 52|||1,078.35|FSC: 400601; BFG: 52|593.09|
61000016|EAP|CPT® 75561||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Cardiac Morphology & Function W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,078.35|FSC: 400601; BFG: 52|||1,078.35|FSC: 400601; BFG: 52|593.09|
61000017|EAP|CPT® 75563||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Cardiac Morphology & Function W/ & W/o Contrast W/ Stress|1|<Self-pay>|<Self-pay>|<Self-pay>|1,607.55|FSC: 400601; BFG: 52|||1,607.55|FSC: 400601; BFG: 52|884.15|
61000014|EAP|CPT® 75557||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Cardiac Morphology & Function W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,795.50|FSC: 400601; BFG: 52|||1,795.50|FSC: 400601; BFG: 52|987.52|
61000015|EAP|CPT® 75559||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Cardiac Morphology & Function W/o Contrast W/ Stress|1|<Self-pay>|<Self-pay>|<Self-pay>|1,795.50|FSC: 400601; BFG: 52|||1,795.50|FSC: 400601; BFG: 52|987.52|
61000018|EAP|CPT® 75565||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Cardiac Velocity Flow Mapping|1|<Self-pay>|<Self-pay>|<Self-pay>|850.50|FSC: 400601; BFG: 52|||850.50|FSC: 400601; BFG: 52|467.77|
61000005|EAP|CPT® 71550||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Chest W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,941.45|FSC: 400601; BFG: 52|||1,941.45|FSC: 400601; BFG: 52|1,067.80|
61000012|EAP|CPT® 73721||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Lower Extremity Joint W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,883.70|FSC: 400601; BFG: 52|||1,883.70|FSC: 400601; BFG: 52|1,036.03|
61000011|EAP|CPT® 73720||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Lower Extremity Other Than Joint W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,698.50|FSC: 400601; BFG: 52|||2,698.50|FSC: 400601; BFG: 52|1,484.17|
61000004|EAP|CPT® 70543||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Orbit Face Neck W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,698.50|FSC: 400601; BFG: 52|||2,698.50|FSC: 400601; BFG: 52|1,484.17|
61000002|EAP|CPT® 70540||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Orbit Face Neck W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,972.95|FSC: 400601; BFG: 52|||1,972.95|FSC: 400601; BFG: 52|1,085.12|
61000008|EAP|CPT® 72197||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Pelvis W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,311.05|FSC: 400601; BFG: 52|||2,311.05|FSC: 400601; BFG: 52|1,271.08|
61000006|EAP|CPT® 72195||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Pelvis W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,588.65|FSC: 400601; BFG: 52|||1,588.65|FSC: 400601; BFG: 52|873.76|
61000001|EAP|CPT® 70336||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Tempromandibular Joint|1|<Self-pay>|<Self-pay>|<Self-pay>|2,356.20|FSC: 400601; BFG: 52|||2,356.20|FSC: 400601; BFG: 52|1,295.91|
61000010|EAP|CPT® 73221||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Upper Extremity Joint W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,713.60|FSC: 400601; BFG: 52|||1,713.60|FSC: 400601; BFG: 52|942.48|
61000009|EAP|CPT® 73220||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Upper Extremity Other Than Joint W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,698.50|FSC: 400601; BFG: 52|||2,698.50|FSC: 400601; BFG: 52|1,484.17|
61100003|EAP|CPT® 70553||0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN (INCLUDING BRAINSTEM)|Hc Mri Brain W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,798.25|FSC: 400601; BFG: 52|||2,798.25|FSC: 400601; BFG: 52|1,539.04|
61100002|EAP|CPT® 70552||0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN (INCLUDING BRAINSTEM)|Hc Mri Brain W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,107.35|FSC: 400601; BFG: 52|||2,107.35|FSC: 400601; BFG: 52|1,159.04|
61100001|EAP|CPT® 70551||0611 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - BRAIN (INCLUDING BRAINSTEM)|Hc Mri Brain W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,615.95|FSC: 400601; BFG: 52|||1,615.95|FSC: 400601; BFG: 52|888.77|
61200007|EAP|CPT® 72156||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/ & W/o Contrast Cervical|1|<Self-pay>|<Self-pay>|<Self-pay>|2,702.70|FSC: 400601; BFG: 52|||2,702.70|FSC: 400601; BFG: 52|1,486.48|
61200009|EAP|CPT® 72158||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/ & W/o Contrast Lumbar|1|<Self-pay>|<Self-pay>|<Self-pay>|2,731.05|FSC: 400601; BFG: 52|||2,731.05|FSC: 400601; BFG: 52|1,502.08|
61200008|EAP|CPT® 72157||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/ & W/o Contrast Thoracic|1|<Self-pay>|<Self-pay>|<Self-pay>|2,702.70|FSC: 400601; BFG: 52|||2,702.70|FSC: 400601; BFG: 52|1,486.48|
61200002|EAP|CPT® 72142||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/ Contrast Cervical|1|<Self-pay>|<Self-pay>|<Self-pay>|1,846.95|FSC: 400601; BFG: 52|||1,846.95|FSC: 400601; BFG: 52|1,015.82|
61200006|EAP|CPT® 72149||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/ Contrast Lumbar|1|<Self-pay>|<Self-pay>|<Self-pay>|1,918.35|FSC: 400601; BFG: 52|||1,918.35|FSC: 400601; BFG: 52|1,055.09|
61200004|EAP|CPT® 72147||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/ Contrast Thoracic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,078.35|FSC: 400601; BFG: 52|||1,078.35|FSC: 400601; BFG: 52|593.09|
61200001|EAP|CPT® 72141||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/o Contrast Cervical|1|<Self-pay>|<Self-pay>|<Self-pay>|1,825.95|FSC: 400601; BFG: 52|||1,825.95|FSC: 400601; BFG: 52|1,004.27|
61200005|EAP|CPT® 72148||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/o Contrast Lumbar|1|<Self-pay>|<Self-pay>|<Self-pay>|1,560.30|FSC: 400601; BFG: 52|||1,560.30|FSC: 400601; BFG: 52|858.16|
61200003|EAP|CPT® 72146||0612 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - SPINAL CORD (INCLUDING SPINE)|Hc Mri Spine W/o Contrast Thoracic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,560.30|FSC: 400601; BFG: 52|||1,560.30|FSC: 400601; BFG: 52|858.16|
61400003|EAP|CPT® 71552||0614 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRI - OTHER|Hc Mri Chest W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,681.70|FSC: 400601; BFG: 52|||2,681.70|FSC: 400601; BFG: 52|1,474.93|
61500003|EAP|CPT® 70546||0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK|Hc Mra Head W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,969.80|FSC: 400601; BFG: 52|||1,969.80|FSC: 400601; BFG: 52|1,083.39|
61500002|EAP|CPT® 70545||0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK|Hc Mra Head W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,179.80|FSC: 400601; BFG: 52|||2,179.80|FSC: 400601; BFG: 52|1,198.89|
61500001|EAP|CPT® 70544||0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK|Hc Mra Head W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,549.80|FSC: 400601; BFG: 52|||1,549.80|FSC: 400601; BFG: 52|852.39|
61500006|EAP|CPT® 70549||0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK|Hc Mra Neck W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,179.80|FSC: 400601; BFG: 52|||2,179.80|FSC: 400601; BFG: 52|1,198.89|
61500005|EAP|CPT® 70548||0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK|Hc Mra Neck W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,284.80|FSC: 400601; BFG: 52|||2,284.80|FSC: 400601; BFG: 52|1,256.64|
61500004|EAP|CPT® 70547||0615 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - HEAD AND NECK|Hc Mra Neck W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,549.80|FSC: 400601; BFG: 52|||1,549.80|FSC: 400601; BFG: 52|852.39|
61600003|EAP|HCPCS C8914||0616 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - LOWER EXTREMITIES|Hc Mra Lower Extremity W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,284.80|FSC: 400601; BFG: 52|||2,284.80|FSC: 400601; BFG: 52|1,256.64|
61600001|EAP|HCPCS C8912||0616 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - LOWER EXTREMITIES|Hc Mra Lower Extremity W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,179.80|FSC: 400601; BFG: 52|||2,179.80|FSC: 400601; BFG: 52|1,198.89|
61600002|EAP|HCPCS C8913||0616 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - LOWER EXTREMITIES|Hc Mra Lower Extremity W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,549.80|FSC: 400601; BFG: 52|||1,549.80|FSC: 400601; BFG: 52|852.39|
61800005|EAP|HCPCS C8902||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Abdomen W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,284.80|FSC: 400601; BFG: 52|||2,284.80|FSC: 400601; BFG: 52|1,256.64|
61800003|EAP|HCPCS C8900||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Abdomen W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,599.80|FSC: 400601; BFG: 52|||2,599.80|FSC: 400601; BFG: 52|1,429.89|
61800004|EAP|HCPCS C8901||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Abdomen W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,549.80|FSC: 400601; BFG: 52|||1,549.80|FSC: 400601; BFG: 52|852.39|
61800008|EAP|HCPCS C8911||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Chest W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,284.80|FSC: 400601; BFG: 52|||2,284.80|FSC: 400601; BFG: 52|1,256.64|
61800006|EAP|HCPCS C8909||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Chest W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,284.80|FSC: 400601; BFG: 52|||2,284.80|FSC: 400601; BFG: 52|1,256.64|
61800007|EAP|HCPCS C8910||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Chest W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,549.80|FSC: 400601; BFG: 52|||1,549.80|FSC: 400601; BFG: 52|852.39|
61800011|EAP|HCPCS C8920||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Pelvis W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,284.80|FSC: 400601; BFG: 52|||2,284.80|FSC: 400601; BFG: 52|1,256.64|
61800009|EAP|HCPCS C8918||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Pelvis W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,284.80|FSC: 400601; BFG: 52|||2,284.80|FSC: 400601; BFG: 52|1,256.64|
61800010|EAP|HCPCS C8919||0618 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - MRA - OTHER|Hc Mra Pelvis W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,549.80|FSC: 400601; BFG: 52|||1,549.80|FSC: 400601; BFG: 52|852.39|
75000076|EAP|CPT® 45378||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,900.50|FSC: 400601; BFG: 52|||1,900.50|FSC: 400601; BFG: 52|1,045.27|
75000081|EAP|CPT® 45388||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Ablation Tumor Polyp Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000078|EAP|CPT® 45380||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000080|EAP|CPT® 45382||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Control Of Bleeding|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000077|EAP|CPT® 45379||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Removal Fb|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000082|EAP|CPT® 45384||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Removal Tumor Polyp Lesion By Hot Bx Forcep|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000083|EAP|CPT® 45385||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Removal Tumor Polyp Lesion By Snare|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000079|EAP|CPT® 45381||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Submucosal Injection|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000103|EAP|HCPCS G0121||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Screening|1|<Self-pay>|<Self-pay>|<Self-pay>|1,900.50|FSC: 400601; BFG: 52|||1,900.50|FSC: 400601; BFG: 52|1,045.27|
75000102|EAP|HCPCS G0105||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Screening High Risk|1|<Self-pay>|<Self-pay>|<Self-pay>|1,900.50|FSC: 400601; BFG: 52|||1,900.50|FSC: 400601; BFG: 52|1,045.27|
75000058|EAP|CPT® 44388||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Through Stoma Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,919.40|FSC: 400601; BFG: 52|||1,919.40|FSC: 400601; BFG: 52|1,055.67|
75000060|EAP|CPT® 44401||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Through Stoma W/ Ablation Tumor Polyp Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
75000059|EAP|CPT® 44389||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Through Stoma W/ Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
75000039|EAP|CPT® 43450||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Dilation Esophagus Unguided Sound Or Bougie|1|<Self-pay>|<Self-pay>|<Self-pay>|2,009.70|FSC: 400601; BFG: 52|||2,009.70|FSC: 400601; BFG: 52|1,105.33|
75000008|EAP|CPT® 43235||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|2,009.70|FSC: 400601; BFG: 52|||2,009.70|FSC: 400601; BFG: 52|1,105.33|
75000012|EAP|CPT® 43239||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|2,009.70|FSC: 400601; BFG: 52|||2,009.70|FSC: 400601; BFG: 52|1,105.33|
75000025|EAP|CPT® 43255||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Control Bleeding|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000021|EAP|CPT® 43248||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Dilation Esophagus Over Guide Wire|1|<Self-pay>|<Self-pay>|<Self-pay>|2,009.70|FSC: 400601; BFG: 52|||2,009.70|FSC: 400601; BFG: 52|1,105.33|
75000018|EAP|CPT® 43245||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Dilation Gastric Outlet Obstruction|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000019|EAP|CPT® 43246||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Placement Percutaneous G-tube|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000014|EAP|CPT® 43241||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Placement Tube/cath|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000020|EAP|CPT® 43247||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Removal Fb|1|<Self-pay>|<Self-pay>|<Self-pay>|2,009.70|FSC: 400601; BFG: 52|||2,009.70|FSC: 400601; BFG: 52|1,105.33|
75000023|EAP|CPT® 43250||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Removal Tumor Polyp Lesion By Hot Bx Forcep|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000024|EAP|CPT® 43251||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Removal Tumor Polyp Lesion By Snare|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000009|EAP|CPT® 43236||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Submucosal Injection|1|<Self-pay>|<Self-pay>|<Self-pay>|2,009.70|FSC: 400601; BFG: 52|||2,009.70|FSC: 400601; BFG: 52|1,105.33|
75000043|EAP|CPT® 44360||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine No Ileum Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000048|EAP|CPT® 44369||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine No Ileum W/ Ablation Tumor Polyp Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000044|EAP|CPT® 44361||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine No Ileum W/ Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000047|EAP|CPT® 44366||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine No Ileum W/ Control Bleeding|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000049|EAP|CPT® 44372||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine No Ileum W/ Placement Percutaneous J-tube|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000045|EAP|CPT® 44363||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine No Ileum W/ Removal Fb|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000046|EAP|CPT® 44364||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine No Ileum W/ Removal Tumor Polyp Lesion By Snare|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000051|EAP|CPT® 44376||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine W/ Ileum Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000052|EAP|CPT® 44377||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine W/ Ileum W/ Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000053|EAP|CPT® 44378||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Endo Small Intestine W/ Ileum W/ Control Bleeding|1|<Self-pay>|<Self-pay>|<Self-pay>|3,859.80|FSC: 400601; BFG: 52|||3,859.80|FSC: 400601; BFG: 52|2,122.89|
75000097|EAP|CPT® 43753||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Gastric Intubation|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
75000042|EAP|CPT® 43761||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc G-tube Repositioning For Enteric Nutrition|1|<Self-pay>|<Self-pay>|<Self-pay>|620.55|FSC: 400601; BFG: 52|||620.55|FSC: 400601; BFG: 52|341.30|
75000064|EAP|CPT® 45330||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,919.40|FSC: 400601; BFG: 52|||1,919.40|FSC: 400601; BFG: 52|1,055.67|
75000101|EAP|HCPCS G0104||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible Screening|1|<Self-pay>|<Self-pay>|<Self-pay>|1,900.50|FSC: 400601; BFG: 52|||1,900.50|FSC: 400601; BFG: 52|1,045.27|
75000072|EAP|CPT® 45346||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Ablation Tumor Polyp Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
75000065|EAP|CPT® 45331||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|1,919.40|FSC: 400601; BFG: 52|||1,919.40|FSC: 400601; BFG: 52|1,055.67|
75000068|EAP|CPT® 45334||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Control Bleeding|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
75000070|EAP|CPT® 45337||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Decompression|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
75000066|EAP|CPT® 45332||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Removal Fb|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
75000067|EAP|CPT® 45333||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Removal Tumor Polyp Lesion By Hot Bx Forcep|1|<Self-pay>|<Self-pay>|<Self-pay>|1,919.40|FSC: 400601; BFG: 52|||1,919.40|FSC: 400601; BFG: 52|1,055.67|
75000071|EAP|CPT® 45338||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Removal Tumor Polyp Lesion By Snare|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
75000069|EAP|CPT® 45335||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Submucosal Injection|1|<Self-pay>|<Self-pay>|<Self-pay>|1,919.40|FSC: 400601; BFG: 52|||1,919.40|FSC: 400601; BFG: 52|1,055.67|
75000062|EAP|CPT® 45300||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Rigid Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,919.40|FSC: 400601; BFG: 52|||1,919.40|FSC: 400601; BFG: 52|1,055.67|
75000063|EAP|CPT® 45305||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Rigid W/ Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|2,531.55|FSC: 400601; BFG: 52|||2,531.55|FSC: 400601; BFG: 52|1,392.35|
47100003|EAP|CPT® 92587||0471 - AUDIOLOGY - DIAGNOSTIC|Hc Evoked Otoacoustic Emissions Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
48000002|EAP|CPT® 92960||0480 - CARDIOLOGY - GENERAL CLASSIFICATION|Hc Cardioversion Elective|1|<Self-pay>|<Self-pay>|<Self-pay>|1,372.35|FSC: 400601; BFG: 52|||1,372.35|FSC: 400601; BFG: 52|754.79|
48000001|EAP|CPT® 92950||0480 - CARDIOLOGY - GENERAL CLASSIFICATION|Hc Cpr|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
48300014|EAP|CPT® 93325||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Doppler Color Flow Velocity Mapping|1|<Self-pay>|<Self-pay>|<Self-pay>|366.45|FSC: 400601; BFG: 52|||366.45|FSC: 400601; BFG: 52|201.55|
48300015|EAP|CPT® 93320||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Doppler Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|330.75|FSC: 400601; BFG: 52|||330.75|FSC: 400601; BFG: 52|181.91|
48300016|EAP|CPT® 93321||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Doppler Limited Or Follow-up|1|<Self-pay>|<Self-pay>|<Self-pay>|220.50|FSC: 400601; BFG: 52|||220.50|FSC: 400601; BFG: 52|121.27|
48000057|EAP|HCPCS C8923||0480 - CARDIOLOGY - GENERAL CLASSIFICATION|Hc Echo M-mode Complete W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,821.75|FSC: 400601; BFG: 52|||1,821.75|FSC: 400601; BFG: 52|1,001.96|
48300017|EAP|CPT® 93307||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo M-mode Complete W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,303.05|FSC: 400601; BFG: 52|||1,303.05|FSC: 400601; BFG: 52|716.68|
48300018|EAP|CPT® 93308||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo M-mode Follow-up Or Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
48300019|EAP|CPT® 93350||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Stress|1|<Self-pay>|<Self-pay>|<Self-pay>|1,303.05|FSC: 400601; BFG: 52|||1,303.05|FSC: 400601; BFG: 52|716.68|
48300020|EAP|CPT® 93312||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Tee Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|1,303.05|FSC: 400601; BFG: 52|||1,303.05|FSC: 400601; BFG: 52|716.68|
48200001|EAP|CPT® 93017||0482 - CARDIOLOGY - STRESS TEST|Hc Stress Test W/ Continuous Ekg Monitoring|1|<Self-pay>|<Self-pay>|<Self-pay>|880.95|FSC: 400601; BFG: 52|||880.95|FSC: 400601; BFG: 52|484.52|
48300001|EAP|CPT® 93303||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Complete Congenital Anomalies W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,149.75|FSC: 400601; BFG: 52|||1,149.75|FSC: 400601; BFG: 52|632.36|
48300004|EAP|CPT® 93306||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Complete W/ Bubble Study|1|<Self-pay>|<Self-pay>|<Self-pay>|2,025.45|FSC: 400601; BFG: 52|||2,025.45|FSC: 400601; BFG: 52|1,114.00|
48300013|EAP|HCPCS C8929||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Complete W/ Doppler W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,607.55|FSC: 400601; BFG: 52|||1,607.55|FSC: 400601; BFG: 52|884.15|
48300003|EAP|CPT® 93306||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Complete W/ Doppler W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,025.45|FSC: 400601; BFG: 52|||2,025.45|FSC: 400601; BFG: 52|1,114.00|
48300010|EAP|HCPCS C8924||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo F/u Or Ltd W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,078.35|FSC: 400601; BFG: 52|||1,078.35|FSC: 400601; BFG: 52|593.09|
33100005|EAP|CPT® 96409||0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED|Hc Chemo Admin Initial Iv Push|1|<Self-pay>|<Self-pay>|<Self-pay>|527.10|FSC: 400601; BFG: 52|||527.10|FSC: 400601; BFG: 52|289.90|
33100002|EAP|CPT® 96402||0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED|Hc Chemo Admin Sq/im Hormonal|1|<Self-pay>|<Self-pay>|<Self-pay>|164.85|FSC: 400601; BFG: 52|||164.85|FSC: 400601; BFG: 52|90.67|
33100001|EAP|CPT® 96401||0331 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - INJECTED|Hc Chemo Admin Sq/im Non-hormonal|1|<Self-pay>|<Self-pay>|<Self-pay>|160.65|FSC: 400601; BFG: 52|||160.65|FSC: 400601; BFG: 52|88.36|
33500002|EAP|CPT® 96415||0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV|Hc Chemo Admin Iv Each Additional Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|160.65|FSC: 400601; BFG: 52|||160.65|FSC: 400601; BFG: 52|88.36|
33500001|EAP|CPT® 96413||0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV|Hc Chemo Admin Iv Initial Up To 1 Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|820.05|FSC: 400601; BFG: 52|||820.05|FSC: 400601; BFG: 52|451.03|
33500003|EAP|CPT® 96416||0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV|Hc Chemo Admin Iv Prolonged Infusion W/ Implantable Pump|1|<Self-pay>|<Self-pay>|<Self-pay>|820.05|FSC: 400601; BFG: 52|||820.05|FSC: 400601; BFG: 52|451.03|
33500004|EAP|CPT® 96417||0335 - RADIOLOGY - THERAPEUTIC AND/OR CHEMOTHERAPY ADMINISTRATION - CHEMOTHERAPY ADMINISTRATION - IV|Hc Chemo Admin Iv Sequential Up To 1 Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|160.65|FSC: 400601; BFG: 52|||160.65|FSC: 400601; BFG: 52|88.36|
34000002|EAP|CPT® 78102||0340 - NUCLEAR MEDICINE - GENERAL CLASSIFICATION|Hc Nuc Med Bone Marrow Imaging Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100026|EAP|CPT® 78278||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Acute Gi Blood Loss Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100031|EAP|CPT® 78306||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Bone Joint Imaging Whole Body|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100032|EAP|CPT® 78315||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Bone Imaging 3 Phase Study|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100029|EAP|CPT® 78300||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Bone Joint Imaging- Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100030|EAP|CPT® 78305||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Bone Joint Imaging- Multiple|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100052|EAP|CPT® 78605||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Brain Imaging Static|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
34100044|EAP|CPT® 78472||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Cardiac Blood Pool Single Wall Motion + Ef|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100056|EAP|CPT® 78630||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Csf Flow Cisternography|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
34100025|EAP|CPT® 78264||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Gastric Emptying Study|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100027|EAP|CPT® 78290||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Intestine Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100062|EAP|CPT® 78709||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Kidney Imaging W/ Vascular Flow And Function Multiple|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
34100061|EAP|CPT® 78707||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Kidney Imaging W/ Vascular Flow And Function Single|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
34100018|EAP|CPT® 78215||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Liver And Spleen Imaging Static|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100015|EAP|CPT® 78201||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Liver Imaging Static|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
34100016|EAP|CPT® 78202||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Liver Imaging W/ Vascular Flow|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
34100014|EAP|CPT® 78195||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Lymphatic And Lymph Node Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
34100037|EAP|CPT® 78452||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Myocardial Perfusion Spect Multiple Rest Or Stress|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
34100036|EAP|CPT® 78451||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Myocardial Perfusion Spect Single Rest Or Stress|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
34100008|EAP|CPT® 78070||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|HC NUC MED PARATHYROID IMAGING|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100048|EAP|CPT® 78580||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Pulmonary Perfusion Imaging Particulate|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100012|EAP|CPT® 78185||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Spleen Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100066|EAP|CPT® 78761||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Testicular Imaging W/ Vascular Flow|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100067|EAP|CPT® 78800||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Tumor Loc/inflammatory Process W/ Radiopharm Single Area /day|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100068|EAP|CPT® 78801||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Tumor Loc/inflammatory Process W/ Radiopharm 2 Or More Area/days|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100070|EAP|CPT® 78803||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Tumor Loc/inflamatory Process W/ Radiopharm Singl Area/day Spect|1|<Self-pay>|<Self-pay>|<Self-pay>|3,156.30|FSC: 400601; BFG: 52|||3,156.30|FSC: 400601; BFG: 52|1,735.96|
34100069|EAP|CPT® 78802||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Tumor Loc/inflamatory Process W/ Radiopharm Whole Body Singl Day|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
34100065|EAP|CPT® 78740||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Ureteral Reflux Study|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
40100004|EAP|CPT® 77066||0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY|Hc Mammogram Diagnostic  Bilateral Including Cad|1|<Self-pay>|<Self-pay>|<Self-pay>|415.80|FSC: 400601; BFG: 52|||415.80|FSC: 400601; BFG: 52|228.69|
40100005|EAP|CPT® 77065||0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY|Hc Mammogram Diagnostic  Unilateral Including Cad|1|<Self-pay>|<Self-pay>|<Self-pay>|337.05|FSC: 400601; BFG: 52|||337.05|FSC: 400601; BFG: 52|185.38|
40200003|EAP|CPT® 76377||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc 3d Rendering Postprocessing W/ Independent Workstation Us|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
40200002|EAP|CPT® 76376||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc 3d Rendering Postprocessing W/o Independent Workstation Us|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
40200032|EAP|CPT® 76936||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Guidance For Compression Repair Arterial Aneurysm Or Av Fistuale|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
40200033|EAP|CPT® 76937||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Guidance For Vascular Access|1|<Self-pay>|<Self-pay>|<Self-pay>|317.10|FSC: 400601; BFG: 52|||317.10|FSC: 400601; BFG: 52|174.40|
40200015|EAP|CPT® 76801||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us 1st Trimester Transabdominal Single/first Gestation|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
40200016|EAP|CPT® 76802||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us 1st Trimester Transabdominal Each Additional Fetus|1|<Self-pay>|<Self-pay>|<Self-pay>|216.30|FSC: 400601; BFG: 52|||216.30|FSC: 400601; BFG: 52|118.96|
40200043|EAP|HCPCS 76706||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Aaa Screening|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200010|EAP|CPT® 76700||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Abdominal Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|526.05|FSC: 400601; BFG: 52|||526.05|FSC: 400601; BFG: 52|289.33|
40200011|EAP|CPT® 76705||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Abdominal Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|384.30|FSC: 400601; BFG: 52|||384.30|FSC: 400601; BFG: 52|211.36|
40200026|EAP|CPT® 76818||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Bpp W/ Non-stress Test|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
40200027|EAP|CPT® 76819||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Bpp W/o Non-stress Test|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200008|EAP|CPT® 76604||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Chest|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200004|EAP|CPT® 76506||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Echoencephalography|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200037|EAP|CPT® 76870||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Scrotum|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200035|EAP|CPT® 76856||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Pelvic Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|413.70|FSC: 400601; BFG: 52|||413.70|FSC: 400601; BFG: 52|227.53|
40200036|EAP|CPT® 76857||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Pelvic Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200034|EAP|CPT® 76830||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Transvaginal|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
40200007|EAP|CPT® 76536||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Head And Neck|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200017|EAP|CPT® 76805||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Ob After 1st Trimester Transabdominal Single/first Gestation|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
40200018|EAP|CPT® 76810||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Ob After 1st Trimester Transabdominal Each Additional Fetus|1|<Self-pay>|<Self-pay>|<Self-pay>|249.90|FSC: 400601; BFG: 52|||249.90|FSC: 400601; BFG: 52|137.44|
40200024|EAP|CPT® 76816||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Ob Follow-up Transabdominal Per Fetus|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
40200023|EAP|CPT® 76815||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Ob Limited 1 Or More Fetuses|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
40200019|EAP|CPT® 76811||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Ob Transabdominal W/ Detailed Fetal Exam|1|<Self-pay>|<Self-pay>|<Self-pay>|602.70|FSC: 400601; BFG: 52|||602.70|FSC: 400601; BFG: 52|331.48|
40200025|EAP|CPT® 76817||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Ob Transvaginal|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
40200012|EAP|CPT® 76770||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Retroperitoneal Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200013|EAP|CPT® 76775||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Retroperitoneal Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200014|EAP|CPT® 76776||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Transplanted Kidney W/ Doppler|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200028|EAP|CPT® 76820||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Umbilical Artery Doppler|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40300003|EAP|CPT® 77067||0403 - OTHER IMAGING SERVICES - SCREENING MAMMOGRAPHY|Hc Mammogram Screening Bilateral Including Cad|1|<Self-pay>|<Self-pay>|<Self-pay>|346.50|FSC: 400601; BFG: 52|||346.50|FSC: 400601; BFG: 52|190.57|
40400003|EAP|CPT® 78608||0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY|Hc Pet Brain Metabolic Eval|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
40400004|EAP|CPT® 78814||0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY|Hc Pet Ct Limited Area|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
40400005|EAP|CPT® 78815||0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY|Hc Pet Ct Skull Base To Mid-thigh|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
40400006|EAP|CPT® 78816||0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY|Hc Pet Ct Whole Body|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
40400001|EAP|CPT® 78459||0404 - OTHER IMAGING SERVICES - POSITRON EMISSION TOMOGRAPHY|Hc Pet Myocardial Metabolic Eval Single Study|1|<Self-pay>|<Self-pay>|<Self-pay>|3,220.35|FSC: 400601; BFG: 52|||3,220.35|FSC: 400601; BFG: 52|1,771.19|
35000022|EAP|CPT® 76377||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc 3d Rendering Postprocessing W/ Independent Workstation Ct|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
35000021|EAP|CPT® 76376||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc 3d Rendering Postprocessing W/o Independent Workstation Ct|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
35000006|EAP|CPT® 72127||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Cervical Spine W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,493.10|FSC: 400601; BFG: 52|||1,493.10|FSC: 400601; BFG: 52|821.20|
35000005|EAP|CPT® 72126||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Cervical Spine W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,493.10|FSC: 400601; BFG: 52|||1,493.10|FSC: 400601; BFG: 52|821.20|
35000004|EAP|CPT® 72125||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Cervical Spine W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,383.90|FSC: 400601; BFG: 52|||1,383.90|FSC: 400601; BFG: 52|761.14|
35000010|EAP|CPT® 72133||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Lumbar Spine W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,531.95|FSC: 400601; BFG: 52|||1,531.95|FSC: 400601; BFG: 52|842.57|
35000009|EAP|CPT® 72132||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Lumbar Spine W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,463.70|FSC: 400601; BFG: 52|||1,463.70|FSC: 400601; BFG: 52|805.03|
35000008|EAP|CPT® 72130||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Thoracic Spine W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,493.10|FSC: 400601; BFG: 52|||1,493.10|FSC: 400601; BFG: 52|821.20|
35000007|EAP|CPT® 72129||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Thoracic Spine W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,493.10|FSC: 400601; BFG: 52|||1,493.10|FSC: 400601; BFG: 52|821.20|
35000014|EAP|CPT® 74175||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Abdomen W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|1,711.50|FSC: 400601; BFG: 52|||1,711.50|FSC: 400601; BFG: 52|941.32|
35000019|EAP|CPT® 75635||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Abdominal Aorta W/ Bilateral Iliofemoral Run-off & Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|1,711.50|FSC: 400601; BFG: 52|||1,711.50|FSC: 400601; BFG: 52|941.32|
35000003|EAP|CPT® 71275||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Chest (non-coronary) W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|1,875.30|FSC: 400601; BFG: 52|||1,875.30|FSC: 400601; BFG: 52|1,031.41|
35000001|EAP|CPT® 70496||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Head W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|871.50|FSC: 400601; BFG: 52|||871.50|FSC: 400601; BFG: 52|479.32|
35000013|EAP|CPT® 73706||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Lower Extremity W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|1,493.10|FSC: 400601; BFG: 52|||1,493.10|FSC: 400601; BFG: 52|821.20|
35000002|EAP|CPT® 70498||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Neck W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|1,373.40|FSC: 400601; BFG: 52|||1,373.40|FSC: 400601; BFG: 52|755.37|
35000011|EAP|CPT® 72191||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Pelvis W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|2,085.30|FSC: 400601; BFG: 52|||2,085.30|FSC: 400601; BFG: 52|1,146.91|
35000012|EAP|CPT® 73206||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Upper Extremity W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|1,362.90|FSC: 400601; BFG: 52|||1,362.90|FSC: 400601; BFG: 52|749.59|
35000024|EAP|CPT® 77012||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Ct Guided Needle Placement|1|<Self-pay>|<Self-pay>|<Self-pay>|1,380.75|FSC: 400601; BFG: 52|||1,380.75|FSC: 400601; BFG: 52|759.41|
35100004|EAP|CPT® 70470||0351 - CT SCAN - HEAD SCAN|Hc Ct Head/brain W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|756.00|FSC: 400601; BFG: 52|||756.00|FSC: 400601; BFG: 52|415.80|
35100003|EAP|CPT® 70460||0351 - CT SCAN - HEAD SCAN|Hc Ct Head/brain W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|744.45|FSC: 400601; BFG: 52|||744.45|FSC: 400601; BFG: 52|409.45|
35100002|EAP|CPT® 70450||0351 - CT SCAN - HEAD SCAN|Hc Ct Head/brain W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|696.15|FSC: 400601; BFG: 52|||696.15|FSC: 400601; BFG: 52|382.88|
35100010|EAP|CPT® 70488||0351 - CT SCAN - HEAD SCAN|Hc Ct Maxillofacial W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,402.80|FSC: 400601; BFG: 52|||1,402.80|FSC: 400601; BFG: 52|771.54|
35100009|EAP|CPT® 70487||0351 - CT SCAN - HEAD SCAN|Hc Ct Maxillofacial W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,402.80|FSC: 400601; BFG: 52|||1,402.80|FSC: 400601; BFG: 52|771.54|
35100008|EAP|CPT® 70486||0351 - CT SCAN - HEAD SCAN|Hc Ct Maxillofacial W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,293.60|FSC: 400601; BFG: 52|||1,293.60|FSC: 400601; BFG: 52|711.48|
35100013|EAP|CPT® 70492||0351 - CT SCAN - HEAD SCAN|Hc Ct Neck W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
35100012|EAP|CPT® 70491||0351 - CT SCAN - HEAD SCAN|Hc Ct Neck W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
35100011|EAP|CPT® 70490||0351 - CT SCAN - HEAD SCAN|Hc Ct Neck W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|826.35|FSC: 400601; BFG: 52|||826.35|FSC: 400601; BFG: 52|454.49|
35100007|EAP|CPT® 70482||0351 - CT SCAN - HEAD SCAN|Hc Ct Orbit Sella Posterior Fossa Ear W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,402.80|FSC: 400601; BFG: 52|||1,402.80|FSC: 400601; BFG: 52|771.54|
35100006|EAP|CPT® 70481||0351 - CT SCAN - HEAD SCAN|Hc Ct Orbit Sella Posterior Fossa Ear W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,402.80|FSC: 400601; BFG: 52|||1,402.80|FSC: 400601; BFG: 52|771.54|
35100005|EAP|CPT® 70480||0351 - CT SCAN - HEAD SCAN|Hc Ct Orbit Sella Posterior Fossa Ear W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,293.60|FSC: 400601; BFG: 52|||1,293.60|FSC: 400601; BFG: 52|711.48|
35200017|EAP|CPT® 74170||0352 - CT SCAN - BODY SCAN|Hc Ct Abdomen W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,056.30|FSC: 400601; BFG: 52|||1,056.30|FSC: 400601; BFG: 52|580.96|
35200016|EAP|CPT® 74160||0352 - CT SCAN - BODY SCAN|Hc Ct Abdomen W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,017.45|FSC: 400601; BFG: 52|||1,017.45|FSC: 400601; BFG: 52|559.60|
35200015|EAP|CPT® 74150||0352 - CT SCAN - BODY SCAN|Hc Ct Abdomen W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|858.90|FSC: 400601; BFG: 52|||858.90|FSC: 400601; BFG: 52|472.39|
35200014|EAP|CPT® 73702||0352 - CT SCAN - BODY SCAN|Hc Ct Lower Extremity W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,411.20|FSC: 400601; BFG: 52|||1,411.20|FSC: 400601; BFG: 52|776.16|
35200013|EAP|CPT® 73701||0352 - CT SCAN - BODY SCAN|Hc Ct Lower Extremity W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,411.20|FSC: 400601; BFG: 52|||1,411.20|FSC: 400601; BFG: 52|776.16|
35200012|EAP|CPT® 73700||0352 - CT SCAN - BODY SCAN|Hc Ct Lower Extremity W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,192.80|FSC: 400601; BFG: 52|||1,192.80|FSC: 400601; BFG: 52|656.04|
35200005|EAP|CPT® 72131||0352 - CT SCAN - BODY SCAN|Hc Ct Lumbar Spine W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,473.15|FSC: 400601; BFG: 52|||1,473.15|FSC: 400601; BFG: 52|810.23|
35200008|EAP|CPT® 72194||0352 - CT SCAN - BODY SCAN|Hc Ct Pelvis W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,206.45|FSC: 400601; BFG: 52|||1,206.45|FSC: 400601; BFG: 52|663.55|
35200007|EAP|CPT® 72193||0352 - CT SCAN - BODY SCAN|Hc Ct Pelvis W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,205.40|FSC: 400601; BFG: 52|||1,205.40|FSC: 400601; BFG: 52|662.97|
35200006|EAP|CPT® 72192||0352 - CT SCAN - BODY SCAN|Hc Ct Pelvis W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,118.25|FSC: 400601; BFG: 52|||1,118.25|FSC: 400601; BFG: 52|615.04|
35200004|EAP|CPT® 72128||0352 - CT SCAN - BODY SCAN|Hc Ct Thoracic Spine W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|717.15|FSC: 400601; BFG: 52|||717.15|FSC: 400601; BFG: 52|394.43|
35200003|EAP|CPT® 71270||0352 - CT SCAN - BODY SCAN|Hc Ct Thorax W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
35200002|EAP|CPT® 71260||0352 - CT SCAN - BODY SCAN|Hc Ct Thorax W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
35200001|EAP|CPT® 71250||0352 - CT SCAN - BODY SCAN|Hc Ct Thorax W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|826.35|FSC: 400601; BFG: 52|||826.35|FSC: 400601; BFG: 52|454.49|
35200011|EAP|CPT® 73202||0352 - CT SCAN - BODY SCAN|Hc Ct Upper Extremity W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,411.20|FSC: 400601; BFG: 52|||1,411.20|FSC: 400601; BFG: 52|776.16|
35200010|EAP|CPT® 73201||0352 - CT SCAN - BODY SCAN|Hc Ct Upper Extremity W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,411.20|FSC: 400601; BFG: 52|||1,411.20|FSC: 400601; BFG: 52|776.16|
35200009|EAP|CPT® 73200||0352 - CT SCAN - BODY SCAN|Hc Ct Upper Extremity W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,192.80|FSC: 400601; BFG: 52|||1,192.80|FSC: 400601; BFG: 52|656.04|
73000001|EAP|CPT® 93005||0730 - EKG/ECG (ELECTROCARDIOGRAM) - GENERAL CLASSIFICATION|Hc Ekg 12-lead|1|<Self-pay>|<Self-pay>|<Self-pay>|212.10|FSC: 400601; BFG: 52|||212.10|FSC: 400601; BFG: 52|116.65|
73100003|EAP|CPT® 93270||0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR|Hc Event Recorder Patient Activated Per 30 Days|1|<Self-pay>|<Self-pay>|<Self-pay>|100.80|FSC: 400601; BFG: 52|||100.80|FSC: 400601; BFG: 52|55.44|
73100001|EAP|CPT® 93225||0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR|Hc Holter Monitor Hook-up Up To 48 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|484.05|FSC: 400601; BFG: 52|||484.05|FSC: 400601; BFG: 52|266.23|
73100002|EAP|CPT® 93226||0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR|Hc Holter Monitor Scan Up To 48 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
64490|EAP|CPT® 64490|||Pr Inj Dx/ther Agnt Paravert Facet Joint, Cerv/thorac, 1st Level|1|<Self-pay>|<Self-pay>|<Self-pay>|274.00|FSC: 46100; BFG: 52|||274.00|FSC: 46100; BFG: 52|150.70|
64491|EAP|CPT® 64491|||Pr Inj Dx/ther Agnt Paravert Facet Joint, Cerv/thorac, 2nd Level|1|<Self-pay>|<Self-pay>|<Self-pay>|136.00|FSC: 46100; BFG: 52|||136.00|FSC: 46100; BFG: 52|74.80|
64492|EAP|CPT® 64492|||Pr Inj Dx/ther Agnt Paravert Facet Joint, Cerv/thorac, Add Level|1|<Self-pay>|<Self-pay>|<Self-pay>|137.00|FSC: 46100; BFG: 52|||137.00|FSC: 46100; BFG: 52|75.35|
64493|EAP|CPT® 64493|||Pr Inj Dx/ther Agnt Paravert Facet Joint, Lumbar/sac, 1st Level|1|<Self-pay>|<Self-pay>|<Self-pay>|248.00|FSC: 46100; BFG: 52|||248.00|FSC: 46100; BFG: 52|136.40|
64494|EAP|CPT® 64494|||Pr Inj Dx/ther Agnt Paravert Facet Joint, Lumbar/sac, 2nd Level|1|<Self-pay>|<Self-pay>|<Self-pay>|126.00|FSC: 46100; BFG: 52|||126.00|FSC: 46100; BFG: 52|69.30|
64495|EAP|CPT® 64495|||Pr Inj Dx/ther Agnt Paravert Facet Joint, Lumbar/sac, Add Level|1|<Self-pay>|<Self-pay>|<Self-pay>|126.00|FSC: 46100; BFG: 52|||126.00|FSC: 46100; BFG: 52|69.30|
30200197|EAP|CPT® 86612||0302 - LABORATORY - IMMUNOLOGY|Hc So Blastomyces Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|61.95|FSC: 400601; BFG: 52|||61.95|FSC: 400601; BFG: 52|34.07|
30200198|EAP|CPT® 86635||0302 - LABORATORY - IMMUNOLOGY|Hc So Coccidioides Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|74.55|FSC: 400601; BFG: 52|||74.55|FSC: 400601; BFG: 52|41.00|
30100488|EAP|CPT® 83615||0301 - LABORATORY - CHEMISTRY|Hc So Lactate Dehydrogenase (ld) (ldh)|1|<Self-pay>|<Self-pay>|<Self-pay>|19.95|FSC: 400601; BFG: 52|||19.95|FSC: 400601; BFG: 52|10.97|
30100489|EAP|CPT® 83625||0301 - LABORATORY - CHEMISTRY|Hc So Ldh Isoenzymes|1|<Self-pay>|<Self-pay>|<Self-pay>|163.80|FSC: 400601; BFG: 52|||163.80|FSC: 400601; BFG: 52|90.09|
30100490|EAP|CPT® 84488||0301 - LABORATORY - CHEMISTRY|Hc So Trypsin Feces Qual|1|<Self-pay>|<Self-pay>|<Self-pay>|78.75|FSC: 400601; BFG: 52|||78.75|FSC: 400601; BFG: 52|43.31|
30200199|EAP|CPT® 86023||0302 - LABORATORY - IMMUNOLOGY|Hc So Platelet Associated Ig Assay|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|FSC: 400601; BFG: 52|||59.85|FSC: 400601; BFG: 52|32.92|
30200200|EAP|CPT® 86757||0302 - LABORATORY - IMMUNOLOGY|Hc So Richettisiae Antibody - A|1|<Self-pay>|<Self-pay>|<Self-pay>|93.45|FSC: 400601; BFG: 52|||93.45|FSC: 400601; BFG: 52|51.40|
30200201|EAP|CPT® 86713||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Legionella|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
30500065|EAP|CPT® 85598||0305 - LABORATORY - HEMATOLOGY|Hc So Phospholipid- Hexagonal|1|<Self-pay>|<Self-pay>|<Self-pay>|132.50|FSC: 400601; BFG: 52|||132.50|FSC: 400601; BFG: 52|72.87|
27000099|EAP|Custom 27000099||0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION|Hc Cch Broncho Brush|1|<Self-pay>|<Self-pay>|<Self-pay>|91.35|FSC: 400601; BFG: 52|||91.35|FSC: 400601; BFG: 52|50.24|
27204243|EAP|Custom 27204243||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Arterial Blood Gas Kit|1|<Self-pay>|<Self-pay>|<Self-pay>|140.25|FSC: 400601; BFG: 52|||140.25|FSC: 400601; BFG: 52|77.14|
94800001|EAP|HCPCS G0424||0948 - OTHER THERAPEUTIC SERVICES-PULMONARY REHAB|Hc Pulmonary Rehab Exercise Per Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
30200202|EAP|CPT® 86674||0302 - LABORATORY - IMMUNOLOGY|Hc So Giardia Lamblia Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|71.40|FSC: 400601; BFG: 52|||71.40|FSC: 400601; BFG: 52|39.27|
27100011|EAP|Custom 27100011||0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - NON STERILE SUPPLY|Hc Cch Aerosol Nebulizer|1|<Self-pay>|<Self-pay>|<Self-pay>|27.30|FSC: 400601; BFG: 52|||27.30|FSC: 400601; BFG: 52|15.01|
27204279|EAP|Custom 27204279||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sterile Urinary Leg Bag|1|<Self-pay>|<Self-pay>|<Self-pay>|14.50|FSC: 400601; BFG: 52|||14.50|FSC: 400601; BFG: 52|7.97|
26000011|EAP|CPT® 96368||0260 - IV THERAPY - GENERAL CLASSIFICATION|Hc Iv Infusion Concurrent|1|<Self-pay>|<Self-pay>|<Self-pay>|134.40|FSC: 400601; BFG: 52|||134.40|FSC: 400601; BFG: 52|73.92|
75000158|EAP|CPT® 45350||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Sigmoidoscopy Flexible W/ Band Ligation|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
27000136|EAP|Custom 27000136||0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION|Hc Cch Pulse Ox|1|<Self-pay>|<Self-pay>|<Self-pay>|114.45|FSC: 400601; BFG: 52|||114.45|FSC: 400601; BFG: 52|62.95|
30100498|EAP|CPT® 83993||0301 - LABORATORY - CHEMISTRY|Hc So Calprotectin Fecal|1|<Self-pay>|<Self-pay>|<Self-pay>|65.10|FSC: 400601; BFG: 52|||65.10|FSC: 400601; BFG: 52|35.80|
30100499|EAP|CPT® 82664||0301 - LABORATORY - CHEMISTRY|Hc So Electrophoresis Nes|1|<Self-pay>|<Self-pay>|<Self-pay>|153.30|FSC: 400601; BFG: 52|||153.30|FSC: 400601; BFG: 52|84.31|
30100500|EAP|CPT® 83013||0301 - LABORATORY - CHEMISTRY|Hc So H Pylori (c-13) Breath Test|1|<Self-pay>|<Self-pay>|<Self-pay>|218.40|FSC: 400601; BFG: 52|||218.40|FSC: 400601; BFG: 52|120.12|
27204313|EAP|Custom 27204313||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Warming Blanket|1|<Self-pay>|<Self-pay>|<Self-pay>|98.65|FSC: 400601; BFG: 52|||98.65|FSC: 400601; BFG: 52|54.26|
30200204|EAP|CPT® 86305||0302 - LABORATORY - IMMUNOLOGY|Hc So Human Epididymis Protein 4|1|<Self-pay>|<Self-pay>|<Self-pay>|180.00|FSC: 400601; BFG: 52|||180.00|FSC: 400601; BFG: 52|99.00|
30200205|EAP|CPT® 86800||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Thyroglobulin|1|<Self-pay>|<Self-pay>|<Self-pay>|52.50|FSC: 400601; BFG: 52|||52.50|FSC: 400601; BFG: 52|28.87|
30600157|EAP|CPT® 87486||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Chlamydia P Amplif Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|151.20|FSC: 400601; BFG: 52|||151.20|FSC: 400601; BFG: 52|83.16|
30100502|EAP|CPT® 84140||0301 - LABORATORY - CHEMISTRY|Hc So Pregnenolone|1|<Self-pay>|<Self-pay>|<Self-pay>|86.10|FSC: 400601; BFG: 52|||86.10|FSC: 400601; BFG: 52|47.35|
77100006|EAP|HCPCS G0010||0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION|Hc Hepatitis B Vaccine Administration|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|FSC: 400601; BFG: 52|||98.70|FSC: 400601; BFG: 52|54.28|
49000838|EAP|CPT® 64510||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Stellate Ganglion (cervical Sympathetic) For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000839|EAP|CPT® 64517||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Superior Hypogastric Plexus For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000840|EAP|CPT® 64520||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Lumbar Or Thoracic (paravertebral Sympathetic) For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000843|EAP|CPT® 64479||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Inj Anesthetic/steroid Epidural W/ Img Guid Cervical Or Thoracic Single Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000844|EAP|CPT® 64480||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Inj Anesthetic/steroid Epidural W/ Img Guid Cervical Or Thoracic Ea Add Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|836.85|FSC: 400601; BFG: 52|||836.85|FSC: 400601; BFG: 52|460.27|
49000845|EAP|CPT® 64490||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Paravertebral Facet Joint W/ Img Guid Cervical Or Thoracic Single Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000846|EAP|CPT® 64491||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Paravertebral Facet Joint W/ Img Guid Cervical Or Thoracic Second Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|523.95|FSC: 400601; BFG: 52|||523.95|FSC: 400601; BFG: 52|288.17|
49000847|EAP|CPT® 64492||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Paravertebral Facet Joint W/ Img Guid Cervical Or Thoracic Third + Levels For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|523.95|FSC: 400601; BFG: 52|||523.95|FSC: 400601; BFG: 52|288.17|
30100551|EAP|CPT® 84305||0301 - LABORATORY - CHEMISTRY|Hc So Somatomedin|1|<Self-pay>|<Self-pay>|<Self-pay>|70.35|FSC: 400601; BFG: 52|||70.35|FSC: 400601; BFG: 52|38.69|
49000848|EAP|CPT® 64493||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Paravertebral Facet Joint W/ Img Guid Lumbar Or Sacral Single Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|2,228.10|FSC: 400601; BFG: 52|||2,228.10|FSC: 400601; BFG: 52|1,225.45|
49000849|EAP|CPT® 64494||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Paravertebral Facet Joint W/ Img Guid Lumbar Or Sacral Second Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,380.75|FSC: 400601; BFG: 52|||1,380.75|FSC: 400601; BFG: 52|759.41|
49000850|EAP|CPT® 64495||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Paravertebral Facet Joint W/ Img Guid Lumbar Or Sacral Third + Levels For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|523.95|FSC: 400601; BFG: 52|||523.95|FSC: 400601; BFG: 52|288.17|
51000605|EAP|CPT® 20526||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Injection Therapeutic Carpal Tunnel|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
27204405|EAP|Custom 27204405||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cannula Trach 6 Moore Inner|1|<Self-pay>|<Self-pay>|<Self-pay>|19.50|FSC: 400601; BFG: 52|||19.50|FSC: 400601; BFG: 52|10.72|
27204406|EAP|Custom 27204406||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cannula Trach 8 Moore Inner|1|<Self-pay>|<Self-pay>|<Self-pay>|19.50|FSC: 400601; BFG: 52|||19.50|FSC: 400601; BFG: 52|10.72|
30100552|EAP|CPT® 84112||0301 - LABORATORY - CHEMISTRY|Hc Cch Placenta Alpha Micro Ig C/v|1|<Self-pay>|<Self-pay>|<Self-pay>|257.25|FSC: 400601; BFG: 52|||257.25|FSC: 400601; BFG: 52|141.49|
92900001|EAP|Custom 92900001||0929 - OTHER DIAGNOSTIC SERVICES - OTHER DIAGNOSTIC SERVICE|Hc Sane Collection|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
92900002|EAP|Custom 92900002||0929 - OTHER DIAGNOSTIC SERVICES - OTHER DIAGNOSTIC SERVICE|Hc Sane Supply|1|<Self-pay>|<Self-pay>|<Self-pay>|92.40|FSC: 400601; BFG: 52|||92.40|FSC: 400601; BFG: 52|50.82|
27207667|EAP|Custom 27207667||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bag Resuscitation Adult Manual|1|<Self-pay>|<Self-pay>|<Self-pay>|82.65|FSC: 400601; BFG: 52|||82.65|FSC: 400601; BFG: 52|45.46|
27207681|EAP|Custom 27207681||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cannula Disposable Inner Any Size|1|<Self-pay>|<Self-pay>|<Self-pay>|34.20|FSC: 400601; BFG: 52|||34.20|FSC: 400601; BFG: 52|18.81|
27207693|EAP|Custom 27207693||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Circuit Ventilator Bipap|1|<Self-pay>|<Self-pay>|<Self-pay>|30.95|FSC: 400601; BFG: 52|||30.95|FSC: 400601; BFG: 52|17.02|
27204424|EAP|Custom 27204424||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Circuit W/ Vent|1|<Self-pay>|<Self-pay>|<Self-pay>|52.20|FSC: 400601; BFG: 52|||52.20|FSC: 400601; BFG: 52|28.71|
27204427|EAP|Custom 27204427||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sling & Swathe Sm|1|<Self-pay>|<Self-pay>|<Self-pay>|45.45|FSC: 400601; BFG: 52|||45.45|FSC: 400601; BFG: 52|25.00|
32555|EAP|CPT® 32555|||THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING|1|<Self-pay>|<Self-pay>|<Self-pay>|825.00|FSC: 46100; BFG: 52|||825.00|FSC: 46100; BFG: 52|453.75|
27207699|EAP|Custom 27207699||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Container 1000ml Empty Evacuated Glass|1|<Self-pay>|<Self-pay>|<Self-pay>|23.95|FSC: 400601; BFG: 52|||23.95|FSC: 400601; BFG: 52|13.17|
49000688|EAP|CPT® 63650||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Implant Neurostimulator Electrodes Percutaneous Epidural|1|<Self-pay>|<Self-pay>|<Self-pay>|16,214.10|FSC: 400601; BFG: 52|||16,214.10|FSC: 400601; BFG: 52|8,917.75|
27207716|EAP|Custom 27207716||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Optifoam Dressing 4x4|1|<Self-pay>|<Self-pay>|<Self-pay>|14.55|FSC: 400601; BFG: 52|||14.55|FSC: 400601; BFG: 52|8.00|
27207720|EAP|Custom 27207720||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Holder Tube Endotracheal|1|<Self-pay>|<Self-pay>|<Self-pay>|28.40|FSC: 400601; BFG: 52|||28.40|FSC: 400601; BFG: 52|15.62|
30000074|EAP|CPT® 86906||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Cch Bld Typing Serologic Rh Phnt|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
27207728|EAP|Custom 27207728||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle 19ga X 1in Powerloc W/y-site|1|<Self-pay>|<Self-pay>|<Self-pay>|41.15|FSC: 400601; BFG: 52|||41.15|FSC: 400601; BFG: 52|22.63|
30100811|EAP|CPT® 82943||0301 - LABORATORY - CHEMISTRY|Hc So Glucagon|1|<Self-pay>|<Self-pay>|<Self-pay>|113.40|FSC: 400601; BFG: 52|||113.40|FSC: 400601; BFG: 52|62.37|
30100812|EAP|CPT® 84586||0301 - LABORATORY - CHEMISTRY|Hc So Vip Vasoactive Intestinal Peptide|1|<Self-pay>|<Self-pay>|<Self-pay>|261.45|FSC: 400601; BFG: 52|||261.45|FSC: 400601; BFG: 52|143.80|
27205814|EAP|Custom 27205814||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Corrugated Comfort Flo Circuit|1|<Self-pay>|<Self-pay>|<Self-pay>|114.00|FSC: 400601; BFG: 52|||114.00|FSC: 400601; BFG: 52|62.70|
27205815|EAP|Custom 27205815||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Comfort Flo Plus Cannula W/ Chin Strap Large|1|<Self-pay>|<Self-pay>|<Self-pay>|53.58|FSC: 400601; BFG: 52|||53.58|FSC: 400601; BFG: 52|29.47|
27205816|EAP|Custom 27205816||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Comfort Flo Plus Cannula W/ Chin Strap Medium|1|<Self-pay>|<Self-pay>|<Self-pay>|53.58|FSC: 400601; BFG: 52|||53.58|FSC: 400601; BFG: 52|29.47|
27207738|EAP|Custom 27207738||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Bipap Performa W/ Headgear Med|1|<Self-pay>|<Self-pay>|<Self-pay>|194.45|FSC: 400601; BFG: 52|||194.45|FSC: 400601; BFG: 52|106.95|
27207739|EAP|Custom 27207739||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Bipap Performa W/ Headgear Lg|1|<Self-pay>|<Self-pay>|<Self-pay>|194.45|FSC: 400601; BFG: 52|||194.45|FSC: 400601; BFG: 52|106.95|
27204699|EAP|Custom 27204699||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Airway Laryngeal Mask Sz 1|1|<Self-pay>|<Self-pay>|<Self-pay>|79.30|FSC: 400601; BFG: 52|||79.30|FSC: 400601; BFG: 52|43.61|
27204707|EAP|Custom 27204707||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Knee Brace Medium|1|<Self-pay>|<Self-pay>|<Self-pay>|177.20|FSC: 400601; BFG: 52|||177.20|FSC: 400601; BFG: 52|97.46|
27204708|EAP|Custom 27204708||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Knee Brace Large|1|<Self-pay>|<Self-pay>|<Self-pay>|203.85|FSC: 400601; BFG: 52|||203.85|FSC: 400601; BFG: 52|112.12|
49000690|EAP|CPT® 41010||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Incision Of Lingual Frenum (frenotomy)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,408.05|FSC: 400601; BFG: 52|||1,408.05|FSC: 400601; BFG: 52|774.43|
49000691|EAP|CPT® 40806||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Incision Of Labial Frenum (frenotomy)|1|<Self-pay>|<Self-pay>|<Self-pay>|686.70|FSC: 400601; BFG: 52|||686.70|FSC: 400601; BFG: 52|377.68|
27207752|EAP|Custom 27207752||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Set Y-type Tur-bladder Irrigation|1|<Self-pay>|<Self-pay>|<Self-pay>|22.15|FSC: 400601; BFG: 52|||22.15|FSC: 400601; BFG: 52|12.18|
27207754|EAP|Custom 27207754||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Optifoam Dressing 6x6|1|<Self-pay>|<Self-pay>|<Self-pay>|24.45|FSC: 400601; BFG: 52|||24.45|FSC: 400601; BFG: 52|13.45|
30100565|EAP|CPT® 82610||0301 - LABORATORY - CHEMISTRY|Hc So Cystatin C|1|<Self-pay>|<Self-pay>|<Self-pay>|67.50|FSC: 400601; BFG: 52|||67.50|FSC: 400601; BFG: 52|37.12|
73502|EAP|CPT® 73502|||RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|115.00|FSC: 46100; BFG: 52|||115.00|FSC: 46100; BFG: 52|63.25|
73522|EAP|CPT® 73522|||RADEX HIPS BILATERAL WITH PELVIS 3-4 VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|69.78|FSC: 46100; BFG: 52|||69.78|FSC: 46100; BFG: 52|38.38|
30200219|EAP|CPT® 86005||0302 - LABORATORY - IMMUNOLOGY|Hc So Allergen Specific Ige|1|<Self-pay>|<Self-pay>|<Self-pay>|36.75|FSC: 400601; BFG: 52|||36.75|FSC: 400601; BFG: 52|20.21|
27206067|EAP|Custom 27206067||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Acticoat 7|1|<Self-pay>|<Self-pay>|<Self-pay>|120.60|FSC: 400601; BFG: 52|||120.60|FSC: 400601; BFG: 52|66.33|
27206068|EAP|Custom 27206068||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Acticoat Absorb|1|<Self-pay>|<Self-pay>|<Self-pay>|56.50|FSC: 400601; BFG: 52|||56.50|FSC: 400601; BFG: 52|31.07|
27206076|EAP|Custom 27206076||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Aero Chamber|1|<Self-pay>|<Self-pay>|<Self-pay>|42.45|FSC: 400601; BFG: 52|||42.45|FSC: 400601; BFG: 52|23.35|
49000692|EAP|CPT® 64400||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Trigeminal Each Branch For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
49000694|EAP|CPT® 64405||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Greater Occipital For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
49000697|EAP|CPT® 64416||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Brachial Plexus Cont Infusion By Cath For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,918.26|FSC: 400601; BFG: 52|||1,918.26|FSC: 400601; BFG: 52|1,055.04|
49000698|EAP|CPT® 64418||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Suprascapular For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
49000699|EAP|CPT® 64420||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Intercostal Single Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
49000700|EAP|CPT® 64421||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Intercostal Ea Addtl Level For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000702|EAP|CPT® 64449||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Lumbar Plexus Posterior Approach Cont Infusion By Cath For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,918.26|FSC: 400601; BFG: 52|||1,918.26|FSC: 400601; BFG: 52|1,055.04|
27206085|EAP|Custom 27206085||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Amnihook|1|<Self-pay>|<Self-pay>|<Self-pay>|13.60|FSC: 400601; BFG: 52|||13.60|FSC: 400601; BFG: 52|7.48|
49000704|EAP|CPT® 64448||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Femoral Cont Infusion By Cath For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,918.26|FSC: 400601; BFG: 52|||1,918.26|FSC: 400601; BFG: 52|1,055.04|
30200220|EAP|CPT® 86039||0302 - LABORATORY - IMMUNOLOGY|Hc So Antinuclear Ab (ana) Titer|1|<Self-pay>|<Self-pay>|<Self-pay>|36.75|FSC: 400601; BFG: 52|||36.75|FSC: 400601; BFG: 52|20.21|
75000126|EAP|CPT® 44391||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Through Stoma W/ Control Of Bleeding|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
19083|EAP|CPT® 19083|||BX BREAST W DEVICE 1ST LESION ULTRASOUND GUIDE|1|<Self-pay>|<Self-pay>|<Self-pay>|959.00|FSC: 46100; BFG: 52|||959.00|FSC: 46100; BFG: 52|527.45|
64647|EAP|CPT® 64647|||CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES|1|<Self-pay>|<Self-pay>|<Self-pay>|264.00|FSC: 46100; BFG: 52|||264.00|FSC: 46100; BFG: 52|145.20|
27206107|EAP|Custom 27206107||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Athletic Supporter|1|<Self-pay>|<Self-pay>|<Self-pay>|30.15|FSC: 400601; BFG: 52|||30.15|FSC: 400601; BFG: 52|16.58|
27206112|EAP|Custom 27206112||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Back Brace-industria|1|<Self-pay>|<Self-pay>|<Self-pay>|196.80|FSC: 400601; BFG: 52|||196.80|FSC: 400601; BFG: 52|108.24|
49000658|EAP|CPT® 32554||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Thoracentesis W/o Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,640.10|FSC: 400601; BFG: 52|||1,640.10|FSC: 400601; BFG: 52|902.05|
49000659|EAP|CPT® 32555||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Thoracentesis W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,640.10|FSC: 400601; BFG: 52|||1,640.10|FSC: 400601; BFG: 52|902.05|
34100084|EAP|CPT® 78012||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Thyroid Uptake Single Or Multiple W/quantitative Measurements|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100085|EAP|CPT® 78013||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Thyroid Imaging W/ Or W/o Vascular Flow|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100086|EAP|CPT® 78014||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Thyroid Uptake Single Or Multiple W/quantitative Measurements W Or W/o Vascular Flow|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100087|EAP|CPT® 78071||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Parathyroid Planar W/ Or W/o Subtraction W/ Spect|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
30200206|EAP|CPT® 86711||0302 - LABORATORY - IMMUNOLOGY|Hc So Antibody John Cunningham Virus|1|<Self-pay>|<Self-pay>|<Self-pay>|45.00|FSC: 400601; BFG: 52|||45.00|FSC: 400601; BFG: 52|24.75|
30200210|EAP|CPT® 86831||0302 - LABORATORY - IMMUNOLOGY|Hc Hla Class Ii Phenotype Qual|1|<Self-pay>|<Self-pay>|<Self-pay>|204.70|FSC: 400601; BFG: 52|||204.70|FSC: 400601; BFG: 52|112.58|
30600158|EAP|CPT® 87631||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Resp Virus 3-5 Targets|1|<Self-pay>|<Self-pay>|<Self-pay>|254.10|FSC: 400601; BFG: 52|||254.10|FSC: 400601; BFG: 52|139.75|
49000674|EAP|CPT® 32557||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Insertion Indwelling Catheter Percutaneous For Pleural Drainage W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|2,632.35|FSC: 400601; BFG: 52|||2,632.35|FSC: 400601; BFG: 52|1,447.79|
27206152|EAP|Custom 27206152||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Blood Collection Set|1|<Self-pay>|<Self-pay>|<Self-pay>|15.45|FSC: 400601; BFG: 52|||15.45|FSC: 400601; BFG: 52|8.50|
75000173|EAP|CPT® 45393||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonsocopy Flexible W Decompression Inc Placement Of Decompression Tube When Performed|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
27206168|EAP|Custom 27206168||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Breast Pump|1|<Self-pay>|<Self-pay>|<Self-pay>|178.35|FSC: 400601; BFG: 52|||178.35|FSC: 400601; BFG: 52|98.09|
27206171|EAP|Custom 27206171||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Breast Shields|1|<Self-pay>|<Self-pay>|<Self-pay>|26.35|FSC: 400601; BFG: 52|||26.35|FSC: 400601; BFG: 52|14.49|
27206194|EAP|Custom 27206194||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cast Shoe|1|<Self-pay>|<Self-pay>|<Self-pay>|31.95|FSC: 400601; BFG: 52|||31.95|FSC: 400601; BFG: 52|17.57|
27206200|EAP|Custom 27206200||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cath Coude Tip 16fr|1|<Self-pay>|<Self-pay>|<Self-pay>|62.05|FSC: 400601; BFG: 52|||62.05|FSC: 400601; BFG: 52|34.13|
27206201|EAP|Custom 27206201||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cath Coude Tip 18fr|1|<Self-pay>|<Self-pay>|<Self-pay>|58.75|FSC: 400601; BFG: 52|||58.75|FSC: 400601; BFG: 52|32.31|
27206211|EAP|Custom 27206211||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Thoracic|1|<Self-pay>|<Self-pay>|<Self-pay>|26.25|FSC: 400601; BFG: 52|||26.25|FSC: 400601; BFG: 52|14.44|
27206212|EAP|Custom 27206212||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Tray Foley|1|<Self-pay>|<Self-pay>|<Self-pay>|98.75|FSC: 400601; BFG: 52|||98.75|FSC: 400601; BFG: 52|54.31|
27206217|EAP|Custom 27206217||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Silicone|1|<Self-pay>|<Self-pay>|<Self-pay>|21.40|FSC: 400601; BFG: 52|||21.40|FSC: 400601; BFG: 52|11.77|
27206231|EAP|Custom 27206231||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Clipper Blade Disp.|1|<Self-pay>|<Self-pay>|<Self-pay>|94.00|FSC: 400601; BFG: 52|||94.00|FSC: 400601; BFG: 52|51.70|
27206236|EAP|Custom 27206236||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Coban 4"|1|<Self-pay>|<Self-pay>|<Self-pay>|13.30|FSC: 400601; BFG: 52|||13.30|FSC: 400601; BFG: 52|7.31|
27206298|EAP|Custom 27206298||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Disposable Vent Circuit|1|<Self-pay>|<Self-pay>|<Self-pay>|91.10|FSC: 400601; BFG: 52|||91.10|FSC: 400601; BFG: 52|50.10|
27206317|EAP|Custom 27206317||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Dressing Promogran|1|<Self-pay>|<Self-pay>|<Self-pay>|36.30|FSC: 400601; BFG: 52|||36.30|FSC: 400601; BFG: 52|19.96|
27206338|EAP|Custom 27206338||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Elastoplast Roll 2"|1|<Self-pay>|<Self-pay>|<Self-pay>|20.05|FSC: 400601; BFG: 52|||20.05|FSC: 400601; BFG: 52|11.03|
27206339|EAP|Custom 27206339||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Elastoplast Roll 4"|1|<Self-pay>|<Self-pay>|<Self-pay>|24.90|FSC: 400601; BFG: 52|||24.90|FSC: 400601; BFG: 52|13.69|
27206386|EAP|Custom 27206386||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Cath 6 Fr|1|<Self-pay>|<Self-pay>|<Self-pay>|32.90|FSC: 400601; BFG: 52|||32.90|FSC: 400601; BFG: 52|18.09|
27206392|EAP|Custom 27206392||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Gait Belt 60"|1|<Self-pay>|<Self-pay>|<Self-pay>|32.35|FSC: 400601; BFG: 52|||32.35|FSC: 400601; BFG: 52|17.79|
49000675|EAP|CPT® 64415||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Brachial Plexus For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000676|EAP|CPT® 64447||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Femoral For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
49000677|EAP|CPT® 64445||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Sciatic For Pain Mgmt|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
51000495|EAP|CPT® 10030||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Catheter Drainage Soft Tissue Percutaneous W/ Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000717|EAP|CPT® 19285||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Pre-op Placement Breast Localization Device First Lesion W/ Us Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
75000142|EAP|CPT® 43254||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Endoscopic Mucosal Resection|1|<Self-pay>|<Self-pay>|<Self-pay>|3,822.00|FSC: 400601; BFG: 52|||3,822.00|FSC: 400601; BFG: 52|2,102.10|
49000729|EAP|CPT® 49405||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Drainage Catheter Visceral Percutaneous W/ Image Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
49000730|EAP|CPT® 49406||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Drainage Catheter Percutaneous Peritoneal/retroperitoneal|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
27206443|EAP|Custom 27206443||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Intraosseous Needle|1|<Self-pay>|<Self-pay>|<Self-pay>|651.70|FSC: 400601; BFG: 52|||651.70|FSC: 400601; BFG: 52|358.43|
51000496|EAP|CPT® 64616||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Chemodenervation Muscle Neck Excl Larynx Unilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
51000498|EAP|CPT® 64642||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Chemodenervation Extremity 1-4 Muscles|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
51000502|EAP|CPT® 64646||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Chemodenervation Trunk 1-5 Muscles|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
30100568|EAP|CPT® 80159||0301 - LABORATORY - CHEMISTRY|Hc So Drug Screen Quant Clozapine|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
30100571|EAP|CPT® 80169||0301 - LABORATORY - CHEMISTRY|Hc So Drug Screen Quant Everolimus|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100572|EAP|CPT® 80171||0301 - LABORATORY - CHEMISTRY|Hc So Gabapentin Whole Blood/serum/plasma|1|<Self-pay>|<Self-pay>|<Self-pay>|138.60|FSC: 400601; BFG: 52|||138.60|FSC: 400601; BFG: 52|76.23|
30100574|EAP|CPT® 80175||0301 - LABORATORY - CHEMISTRY|Hc So Drug Screen Quan Lamotrigine|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30100576|EAP|CPT® 80177||0301 - LABORATORY - CHEMISTRY|Hc So Drug Scrn Quan Levetiracetam - A|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30100580|EAP|CPT® 80183||0301 - LABORATORY - CHEMISTRY|Hc So Drug Scrn Quant Oxcarbazepin|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30100584|EAP|CPT® 80203||0301 - LABORATORY - CHEMISTRY|Hc So Drug Screen Quant Zonisamide|1|<Self-pay>|<Self-pay>|<Self-pay>|58.00|FSC: 400601; BFG: 52|||58.00|FSC: 400601; BFG: 52|31.90|
30600177|EAP|CPT® 87661||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Trichomonas Vaginalis Amplif - A|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
44400011|EAP|CPT® 92521||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Speech Evaluation Fluency|1|<Self-pay>|<Self-pay>|<Self-pay>|138.60|FSC: 400601; BFG: 52|||138.60|FSC: 400601; BFG: 52|76.23|
44400012|EAP|CPT® 92522||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Speech Evaluation Sound Production|1|<Self-pay>|<Self-pay>|<Self-pay>|113.40|FSC: 400601; BFG: 52|||113.40|FSC: 400601; BFG: 52|62.37|
44400014|EAP|CPT® 92524||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Behavioral And Qualitative Analysis Of Voice And Resonance|1|<Self-pay>|<Self-pay>|<Self-pay>|117.60|FSC: 400601; BFG: 52|||117.60|FSC: 400601; BFG: 52|64.68|
27206455|EAP|Custom 27206455||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Irrigiation Solution Water 3000|1|<Self-pay>|<Self-pay>|<Self-pay>|31.70|FSC: 400601; BFG: 52|||31.70|FSC: 400601; BFG: 52|17.43|
27206457|EAP|Custom 27206457||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Irrigiation Saline 3000cc|1|<Self-pay>|<Self-pay>|<Self-pay>|30.50|FSC: 400601; BFG: 52|||30.50|FSC: 400601; BFG: 52|16.77|
49000734|EAP|CPT® 62324||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Placement Epidural Cervical/thoracic For Cont Infusion For Pain Mgmt W/o Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000707|EAP|CPT® 19081||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|HC BREAST BX W/ LOC DEVICE & IMG OF SPEC FIRST LESION W/ STEREOTACTIC GUIDE|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
49000708|EAP|CPT® 19082||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Breast Bx W/ Localization Device & Imaging Of Specimen Ea Addl Lesion W/ Stereotactic Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,666.35|FSC: 400601; BFG: 52|||1,666.35|FSC: 400601; BFG: 52|916.49|
49000709|EAP|CPT® 19083||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Breast Bx W/ Localization Device & Imaging Of Specimen First Lesion W/ Us Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
49000710|EAP|CPT® 19084||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Breast Bx W/ Localization Device & Imaging Of Specimen Ea Addl Lesion W/ Us Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,338.75|FSC: 400601; BFG: 52|||1,338.75|FSC: 400601; BFG: 52|736.31|
49000713|EAP|CPT® 19281||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Pre-op Placement Breast Localization Device First Lesion W/ Mammographic Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000714|EAP|CPT® 19282||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Pre-op Placement Breast Localization Device Ea Addl Lesion W/ Mammographic Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|397.95|FSC: 400601; BFG: 52|||397.95|FSC: 400601; BFG: 52|218.87|
49000715|EAP|CPT® 19283||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Pre-op Placement Breast Localization Device First Lesion W/ Stereostatic Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000716|EAP|CPT® 19284||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Pre-op Placement Breast Localization Device Ea Addl Lesion W/ Stereotactic Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|550.20|FSC: 400601; BFG: 52|||550.20|FSC: 400601; BFG: 52|302.61|
49000718|EAP|CPT® 19286||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Pre-op Placement Breast Localization Device Ea Addl Lesion W/ Us Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|439.95|FSC: 400601; BFG: 52|||439.95|FSC: 400601; BFG: 52|241.97|
27206469|EAP|Custom 27206469||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Isolation Thermometer|1|<Self-pay>|<Self-pay>|<Self-pay>|24.75|FSC: 400601; BFG: 52|||24.75|FSC: 400601; BFG: 52|13.61|
49000731|EAP|CPT® 49407||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Drainage Catheter Peritoneal/retroperitoneal W/ Transvaginal/transrectal Image Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
44400013|EAP|CPT® 92523||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Speech Evaluation Sound Production W/ Language Comprehension And Expression|1|<Self-pay>|<Self-pay>|<Self-pay>|234.15|FSC: 400601; BFG: 52|||234.15|FSC: 400601; BFG: 52|128.78|
27206480|EAP|Custom 27206480||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kaltostat 2gm|1|<Self-pay>|<Self-pay>|<Self-pay>|13.55|FSC: 400601; BFG: 52|||13.55|FSC: 400601; BFG: 52|7.45|
27206498|EAP|Custom 27206498||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Knee Brace Neo Hinge|1|<Self-pay>|<Self-pay>|<Self-pay>|394.25|FSC: 400601; BFG: 52|||394.25|FSC: 400601; BFG: 52|216.84|
27206512|EAP|Custom 27206512||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Limb Restraint Disp|1|<Self-pay>|<Self-pay>|<Self-pay>|19.55|FSC: 400601; BFG: 52|||19.55|FSC: 400601; BFG: 52|10.75|
27206517|EAP|Custom 27206517||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Lumbar Brace Warm&fr|1|<Self-pay>|<Self-pay>|<Self-pay>|101.60|FSC: 400601; BFG: 52|||101.60|FSC: 400601; BFG: 52|55.88|
27000092|EAP|Custom 27000092||0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION|Hc Cch Mouth Care System|1|<Self-pay>|<Self-pay>|<Self-pay>|103.95|FSC: 400601; BFG: 52|||103.95|FSC: 400601; BFG: 52|57.17|
27400276|EAP|Custom 27400276||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Cch Shoe Post Op|1|<Self-pay>|<Self-pay>|<Self-pay>|87.15|FSC: 400601; BFG: 52|||87.15|FSC: 400601; BFG: 52|47.93|
27204219|EAP|Custom 27204219||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Stapler Skin|1|<Self-pay>|<Self-pay>|<Self-pay>|59.95|FSC: 400601; BFG: 52|||59.95|FSC: 400601; BFG: 52|32.97|
76100122|EAP|CPT® 54160||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Cch Circumcision Neonate <= 28 Days|1|<Self-pay>|<Self-pay>|<Self-pay>|1,285.20|FSC: 400601; BFG: 52|||1,285.20|FSC: 400601; BFG: 52|706.86|
30100538|EAP|CPT® 83550||0301 - LABORATORY - CHEMISTRY|Hc Cch Iron Binding Capacity|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
34100089|EAP|CPT® 78708||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Cch Nuc Med Kidney Image Morphology W/ Vasc Flow Function & Pharmocologic Intervention Sgl Study|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
32000226|EAP|CPT® 76010||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Cch Radiology Exam Nose To Rectum For Fb Single View Child|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000227|EAP|CPT® 77076||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Cch Radiology Exam Osseous Survey Infant|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000225|EAP|CPT® 74247||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Cch Radiology Exam Upper Gi W/ Air Contrast W/ Kub|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000224|EAP|CPT® 74241||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Cch Radiology Exam Upper Gi W/ Kub|1|<Self-pay>|<Self-pay>|<Self-pay>|676.20|FSC: 400601; BFG: 52|||676.20|FSC: 400601; BFG: 52|371.91|
32000220|EAP|CPT® 73092||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology X-ray Arm Infant 2+ Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
30600167|EAP|CPT® 87880||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Strep A Assay W/ Optic|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30600281|EAP|CPT® 0100U||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Respiratory Pathogens 20 Targets|1|<Self-pay>|<Self-pay>|<Self-pay>|847.35|FSC: 400601; BFG: 52|||847.35|FSC: 400601; BFG: 52|466.04|
30600282|EAP|CPT® 87507||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Gi Pathogen 22 Targets|1|<Self-pay>|<Self-pay>|<Self-pay>|994.35|FSC: 400601; BFG: 52|||994.35|FSC: 400601; BFG: 52|546.89|
27206569|EAP|Custom 27206569||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Nebulizer Set Up Continous|1|<Self-pay>|<Self-pay>|<Self-pay>|86.30|FSC: 400601; BFG: 52|||86.30|FSC: 400601; BFG: 52|47.46|
27206594|EAP|Custom 27206594||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Oxygen Humidifier Disp|1|<Self-pay>|<Self-pay>|<Self-pay>|19.45|FSC: 400601; BFG: 52|||19.45|FSC: 400601; BFG: 52|10.70|
30600170|EAP|CPT® 87493||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So C Diff Amplified Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
27802778|EAP|HCPCS C1751||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|Hc Cath Umbilical 5.0fr Dual|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
27802779|EAP|HCPCS C1751||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|Hc Cath Umbilical 3.5fr Dual|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
27206605|EAP|Custom 27206605||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Ointment Lanolin|1|<Self-pay>|<Self-pay>|<Self-pay>|22.70|FSC: 400601; BFG: 52|||22.70|FSC: 400601; BFG: 52|12.48|
27204224|EAP|Custom 27204224||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Mattress Infant Transwarmer|1|<Self-pay>|<Self-pay>|<Self-pay>|132.45|FSC: 400601; BFG: 52|||132.45|FSC: 400601; BFG: 52|72.85|
27204227|EAP|Custom 27204227||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Transducer Trifurcated W Vamp|1|<Self-pay>|<Self-pay>|<Self-pay>|110.70|FSC: 400601; BFG: 52|||110.70|FSC: 400601; BFG: 52|60.88|
27206614|EAP|Custom 27206614||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Ostomy Skin Br-4"|1|<Self-pay>|<Self-pay>|<Self-pay>|24.75|FSC: 400601; BFG: 52|||24.75|FSC: 400601; BFG: 52|13.61|
49000679|EAP|CPT® 41115||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Excision Of Lingual Frenum (frenectomy)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,723.05|FSC: 400601; BFG: 52|||1,723.05|FSC: 400601; BFG: 52|947.68|
49000678|EAP|CPT® 40819||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Excision Of Frenum Labial Or Buccal|1|<Self-pay>|<Self-pay>|<Self-pay>|2,060.10|FSC: 400601; BFG: 52|||2,060.10|FSC: 400601; BFG: 52|1,133.05|
27206636|EAP|Custom 27206636||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Paste Stomahes 2 Oz|1|<Self-pay>|<Self-pay>|<Self-pay>|51.90|FSC: 400601; BFG: 52|||51.90|FSC: 400601; BFG: 52|28.54|
27206638|EAP|Custom 27206638||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Peak Flow Meter|1|<Self-pay>|<Self-pay>|<Self-pay>|59.20|FSC: 400601; BFG: 52|||59.20|FSC: 400601; BFG: 52|32.56|
27206642|EAP|Custom 27206642||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Perc.suprapubic Cath|1|<Self-pay>|<Self-pay>|<Self-pay>|434.30|FSC: 400601; BFG: 52|||434.30|FSC: 400601; BFG: 52|238.86|
27206653|EAP|Custom 27206653||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Pneumothorax Kit-dis|1|<Self-pay>|<Self-pay>|<Self-pay>|952.40|FSC: 400601; BFG: 52|||952.40|FSC: 400601; BFG: 52|523.82|
27206663|EAP|Custom 27206663||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Pouch Ostomy Drain|1|<Self-pay>|<Self-pay>|<Self-pay>|59.70|FSC: 400601; BFG: 52|||59.70|FSC: 400601; BFG: 52|32.83|
27206673|EAP|Custom 27206673||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Prisma Dressing|1|<Self-pay>|<Self-pay>|<Self-pay>|99.85|FSC: 400601; BFG: 52|||99.85|FSC: 400601; BFG: 52|54.92|
27206686|EAP|Custom 27206686||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Radial Artery Cath|1|<Self-pay>|<Self-pay>|<Self-pay>|53.40|FSC: 400601; BFG: 52|||53.40|FSC: 400601; BFG: 52|29.37|
27206721|EAP|Custom 27206721||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sitz Bath Disposable|1|<Self-pay>|<Self-pay>|<Self-pay>|112.10|FSC: 400601; BFG: 52|||112.10|FSC: 400601; BFG: 52|61.65|
27206726|EAP|Custom 27206726||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sling Arm|1|<Self-pay>|<Self-pay>|<Self-pay>|16.75|FSC: 400601; BFG: 52|||16.75|FSC: 400601; BFG: 52|9.21|
27206736|EAP|Custom 27206736||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Spandage/foot|1|<Self-pay>|<Self-pay>|<Self-pay>|13.60|FSC: 400601; BFG: 52|||13.60|FSC: 400601; BFG: 52|7.48|
27206738|EAP|Custom 27206738||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Spirometer Disposable|1|<Self-pay>|<Self-pay>|<Self-pay>|23.60|FSC: 400601; BFG: 52|||23.60|FSC: 400601; BFG: 52|12.98|
30600179|EAP|CPT® 87205||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Smear - Gram Or Giemsa|1|<Self-pay>|<Self-pay>|<Self-pay>|13.65|FSC: 400601; BFG: 52|||13.65|FSC: 400601; BFG: 52|7.51|
44000037|EAP|CPT® 96125||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Cognitive Test Per Hour By St|1|<Self-pay>|<Self-pay>|<Self-pay>|102.90|FSC: 400601; BFG: 52|||102.90|FSC: 400601; BFG: 52|56.59|
27206783|EAP|Custom 27206783||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Surgicel 4x8|1|<Self-pay>|<Self-pay>|<Self-pay>|286.25|FSC: 400601; BFG: 52|||286.25|FSC: 400601; BFG: 52|157.44|
49000784|EAP|CPT® 47531||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Cholangiography Percutaneous Incl Imaging Guidance Existing Access|1|<Self-pay>|<Self-pay>|<Self-pay>|6,189.75|FSC: 400601; BFG: 52|||6,189.75|FSC: 400601; BFG: 52|3,404.36|
49000800|EAP|CPT® 50431||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Antegrade Nephrostogram/ureterogram W/ Image Guidance Existing Access|1|<Self-pay>|<Self-pay>|<Self-pay>|1,514.10|FSC: 400601; BFG: 52|||1,514.10|FSC: 400601; BFG: 52|832.75|
49000801|EAP|CPT® 50432||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Placement Nephrostomy Catheter Percutaneous W/ Image Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|4,540.20|FSC: 400601; BFG: 52|||4,540.20|FSC: 400601; BFG: 52|2,497.11|
27206799|EAP|Custom 27206799||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tape Elastoplast 3in|1|<Self-pay>|<Self-pay>|<Self-pay>|19.10|FSC: 400601; BFG: 52|||19.10|FSC: 400601; BFG: 52|10.50|
49000804|EAP|CPT® 50435||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Exchange Nephrostomy Catheter Percutaneous W/ Image Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|4,540.20|FSC: 400601; BFG: 52|||4,540.20|FSC: 400601; BFG: 52|2,497.11|
49000806|EAP|CPT® 50693||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Placement Ureteral Stent Percutaneous W/ Image Guidance Via Pre-existing Nephrostomy Tract|1|<Self-pay>|<Self-pay>|<Self-pay>|3,653.48|FSC: 400601; BFG: 52|||3,653.48|FSC: 400601; BFG: 52|2,009.41|
32000232|EAP|CPT® 72081||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Spine Entire Thoracic And Lumbar 1 View|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000233|EAP|CPT® 72082||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Spine Entire Thoracic And Lumbar 2 Or 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000234|EAP|CPT® 72083||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Spine Entire Thoracic And Lumbar 4 Or 5 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000236|EAP|CPT® 73501||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Hip W/ Pelvis When Performed Unilateral 1 View|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000237|EAP|CPT® 73502||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Hip W/ Pelvis When Performed Unilateral 2 -3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000240|EAP|CPT® 73522||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Hip W/ Pelvis When Performed Bilateral 3-4 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000241|EAP|CPT® 73523||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Hip W/ Pelvis When Performed Bilateral Minimum 5 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000242|EAP|CPT® 73551||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Femur 1 View|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
32000243|EAP|CPT® 73552||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Femur Minimum 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
27206824|EAP|Custom 27206824||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Towels Sterile Nodis|1|<Self-pay>|<Self-pay>|<Self-pay>|15.45|FSC: 400601; BFG: 52|||15.45|FSC: 400601; BFG: 52|8.50|
27206829|EAP|Custom 27206829||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tracheostomy Tube|1|<Self-pay>|<Self-pay>|<Self-pay>|240.85|FSC: 400601; BFG: 52|||240.85|FSC: 400601; BFG: 52|132.47|
42000087|EAP|CPT® 97139||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Pt Visit/procedure|1|<Self-pay>|<Self-pay>|<Self-pay>|63.00|FSC: 400601; BFG: 52|||63.00|FSC: 400601; BFG: 52|34.65|
43000084|EAP|CPT® 97139||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Ot Visit/procedure|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
27206852|EAP|Custom 27206852||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Unna Boot|1|<Self-pay>|<Self-pay>|<Self-pay>|47.55|FSC: 400601; BFG: 52|||47.55|FSC: 400601; BFG: 52|26.15|
27206863|EAP|Custom 27206863||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Urine Drainage Bag|1|<Self-pay>|<Self-pay>|<Self-pay>|23.30|FSC: 400601; BFG: 52|||23.30|FSC: 400601; BFG: 52|12.81|
27206876|EAP|Custom 27206876||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Vacuum Delivery Kit|1|<Self-pay>|<Self-pay>|<Self-pay>|196.30|FSC: 400601; BFG: 52|||196.30|FSC: 400601; BFG: 52|107.96|
27206880|EAP|Custom 27206880||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Valve Reflex Salem|1|<Self-pay>|<Self-pay>|<Self-pay>|113.85|FSC: 400601; BFG: 52|||113.85|FSC: 400601; BFG: 52|62.62|
27206900|EAP|Custom 27206900||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Water Drainage Seal|1|<Self-pay>|<Self-pay>|<Self-pay>|171.80|FSC: 400601; BFG: 52|||171.80|FSC: 400601; BFG: 52|94.49|
30600283|EAP|CPT® 87541||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Legionella Pneumphilia Amplified Probe Technique|1|<Self-pay>|<Self-pay>|<Self-pay>|205.80|FSC: 400601; BFG: 52|||205.80|FSC: 400601; BFG: 52|113.19|
30100752|EAP|CPT® 83986||0301 - LABORATORY - CHEMISTRY|Hc So Assay Ph Body Fluid|1|<Self-pay>|<Self-pay>|<Self-pay>|19.95|FSC: 400601; BFG: 52|||19.95|FSC: 400601; BFG: 52|10.97|
30100756|EAP|CPT® 84560||0301 - LABORATORY - CHEMISTRY|Hc So Uric Acid|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
62100002|EAP|Custom 62100002||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Barium Thick|1|<Self-pay>|<Self-pay>|<Self-pay>|22.05|FSC: 400601; BFG: 52|||22.05|FSC: 400601; BFG: 52|12.13|
62100004|EAP|Custom 62100004||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Barium Readi Cat|1|<Self-pay>|<Self-pay>|<Self-pay>|26.25|FSC: 400601; BFG: 52|||26.25|FSC: 400601; BFG: 52|14.44|
62100006|EAP|Custom 62100006||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Biopsy Gun|1|<Self-pay>|<Self-pay>|<Self-pay>|271.95|FSC: 400601; BFG: 52|||271.95|FSC: 400601; BFG: 52|149.57|
31000044|EAP|CPT® 81219||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Calr Gene Com Variants|1|<Self-pay>|<Self-pay>|<Self-pay>|273.67|FSC: 400601; BFG: 52|||273.67|FSC: 400601; BFG: 52|150.52|
62100016|EAP|Custom 62100016||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Chiba Needle|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
62100018|EAP|Custom 62100018||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Connecting Tube|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
62100024|EAP|Custom 62100024||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Ez A.c. Barium|1|<Self-pay>|<Self-pay>|<Self-pay>|139.65|FSC: 400601; BFG: 52|||139.65|FSC: 400601; BFG: 52|76.81|
62100026|EAP|Custom 62100026||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Ez Gas|1|<Self-pay>|<Self-pay>|<Self-pay>|18.90|FSC: 400601; BFG: 52|||18.90|FSC: 400601; BFG: 52|10.39|
31200029|EAP|CPT® 88307||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Surg Path Level V|1|<Self-pay>|<Self-pay>|<Self-pay>|576.45|FSC: 400601; BFG: 52|||576.45|FSC: 400601; BFG: 52|317.05|
27204911|EAP|Custom 27204911||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Valve Chest Drain Pneumostat|1|<Self-pay>|<Self-pay>|<Self-pay>|196.30|FSC: 400601; BFG: 52|||196.30|FSC: 400601; BFG: 52|107.96|
27204915|EAP|Custom 27204915||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Lens Morgan|1|<Self-pay>|<Self-pay>|<Self-pay>|29.15|FSC: 400601; BFG: 52|||29.15|FSC: 400601; BFG: 52|16.03|
30500070|EAP|CPT® 85420||0305 - LABORATORY - HEMATOLOGY|Hc So Functional Plasminogen|1|<Self-pay>|<Self-pay>|<Self-pay>|120.75|FSC: 400601; BFG: 52|||120.75|FSC: 400601; BFG: 52|66.41|
94200026|EAP|CPT® 97802||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Medical Nutrition Therapy Individual Initial Assessment & Intervention Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|54.60|FSC: 400601; BFG: 52|||54.60|FSC: 400601; BFG: 52|30.03|
94200027|EAP|CPT® 97803||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Medical Nutrition Therapy Individual Re-assessment & Intervention Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|54.60|FSC: 400601; BFG: 52|||54.60|FSC: 400601; BFG: 52|30.03|
94200028|EAP|CPT® 97804||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Medical Nutrition Therapy Group >2 Individuals Each 30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|23.10|FSC: 400601; BFG: 52|||23.10|FSC: 400601; BFG: 52|12.70|
30000072|EAP|CPT® 86885||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc So Coombs Test Indirect Qual|1|<Self-pay>|<Self-pay>|<Self-pay>|345.45|FSC: 400601; BFG: 52|||345.45|FSC: 400601; BFG: 52|190.00|
35200025|EAP|CPT® 71271||0352 - CT SCAN - BODY SCAN|HC LOW DOSE CT LLUNG SCREENING|1|<Self-pay>|<Self-pay>|<Self-pay>|163.80|FSC: 400601; BFG: 52|||163.80|FSC: 400601; BFG: 52|90.09|
77000004|EAP|HCPCS G0296||0770 - PREVENTIVE CARE SERVICES - GENERAL CLASSIFICATION|Hc Visit For Determination Low Dose Ct Scan Elig|1|<Self-pay>|<Self-pay>|<Self-pay>|166.95|FSC: 400601; BFG: 52|||166.95|FSC: 400601; BFG: 52|91.82|
62100057|EAP|Custom 62100057||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Thoracentesis Set|1|<Self-pay>|<Self-pay>|<Self-pay>|19.95|FSC: 400601; BFG: 52|||19.95|FSC: 400601; BFG: 52|10.97|
51400001|EAP|CPT® 59000||0514 - CLINIC - OB-GYN CLINIC|Hc Amniocentesis Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,541.40|FSC: 400601; BFG: 52|||1,541.40|FSC: 400601; BFG: 52|847.77|
39100001|EAP|CPT® 36430||0391 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - ADMINISTRATION (EG, TRANSFUSIONS)|Hc Transfusion Blood Or Blood Components|1|<Self-pay>|<Self-pay>|<Self-pay>|682.50|FSC: 400601; BFG: 52|||682.50|FSC: 400601; BFG: 52|375.37|
44400004|EAP|CPT® 92610||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Swallowing Evaluation|1|<Self-pay>|<Self-pay>|<Self-pay>|232.05|FSC: 400601; BFG: 52|||232.05|FSC: 400601; BFG: 52|127.63|
44400005|EAP|CPT® 92611||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Motion Fluoroscopic Swallowing Evaluation|1|<Self-pay>|<Self-pay>|<Self-pay>|278.25|FSC: 400601; BFG: 52|||278.25|FSC: 400601; BFG: 52|153.04|
44400006|EAP|CPT® 96105||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Aphasia Assessment Per Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|238.35|FSC: 400601; BFG: 52|||238.35|FSC: 400601; BFG: 52|131.09|
77100001|EAP|CPT® 90471||0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION|Hc Vaccine Administration Initial|1|<Self-pay>|<Self-pay>|<Self-pay>|155.40|FSC: 400601; BFG: 52|||155.40|FSC: 400601; BFG: 52|85.47|
77100002|EAP|CPT® 90472||0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION|Hc Vaccine Administration Each Additional|1|<Self-pay>|<Self-pay>|<Self-pay>|27.30|FSC: 400601; BFG: 52|||27.30|FSC: 400601; BFG: 52|15.01|
77100003|EAP|HCPCS G0008||0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION|Hc Influenza Vaccine Administration|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|FSC: 400601; BFG: 52|||98.70|FSC: 400601; BFG: 52|54.28|
77100004|EAP|HCPCS G0009||0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION|Hc Pneumococcal Vaccine Administration|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|FSC: 400601; BFG: 52|||98.70|FSC: 400601; BFG: 52|54.28|
92100001|EAP|CPT® 93880||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Extracranial Arteries Complete Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|835.80|FSC: 400601; BFG: 52|||835.80|FSC: 400601; BFG: 52|459.69|
92100002|EAP|CPT® 93882||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Extracranial Arteries Unilateral Or Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|605.85|FSC: 400601; BFG: 52|||605.85|FSC: 400601; BFG: 52|333.22|
92100005|EAP|CPT® 93924||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Complete Le Study At Rest And Stress Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|365.40|FSC: 400601; BFG: 52|||365.40|FSC: 400601; BFG: 52|200.97|
92100006|EAP|CPT® 93925||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Le Arteries Or Bypass Grafts Complete Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
92100007|EAP|CPT® 93926||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Le Arteries Or Bypass Grafts Unilateral Or Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|605.85|FSC: 400601; BFG: 52|||605.85|FSC: 400601; BFG: 52|333.22|
92100008|EAP|CPT® 93930||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Ue Arteries Or Bypass Grafts Complete Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
92100009|EAP|CPT® 93931||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Ue Arteries Or Bypass Grafts Unilateral Or Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|605.85|FSC: 400601; BFG: 52|||605.85|FSC: 400601; BFG: 52|333.22|
92100010|EAP|CPT® 93970||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Extremity Veins Compression Complete Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
92100011|EAP|CPT® 93971||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Extremity Veins Compression Unilateral Or Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|605.85|FSC: 400601; BFG: 52|||605.85|FSC: 400601; BFG: 52|333.22|
92100012|EAP|CPT® 93975||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Abdomen Pelvis Retroperitoneal Or Scrotum Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|1,043.70|FSC: 400601; BFG: 52|||1,043.70|FSC: 400601; BFG: 52|574.03|
92100013|EAP|CPT® 93976||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Duplex Abdomen Pelvis Retroperitoneal Or Scrotum Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|1,043.70|FSC: 400601; BFG: 52|||1,043.70|FSC: 400601; BFG: 52|574.03|
62100062|EAP|Custom 62100062||0621 - MEDICAL/SURGICAL SUPPLIES - SUPPLIES INCIDENT TO RADIOLOGY|Hc Cch Vessel Dilator|1|<Self-pay>|<Self-pay>|<Self-pay>|46.20|FSC: 400601; BFG: 52|||46.20|FSC: 400601; BFG: 52|25.41|
94000024|EAP|CPT® 99195||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Phlebotomy Therapeutic|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
49000006|EAP|CPT® 10160||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Puncture Aspiration Abscess Hematoma Or Cyst|1|<Self-pay>|<Self-pay>|<Self-pay>|832.65|FSC: 400601; BFG: 52|||832.65|FSC: 400601; BFG: 52|457.96|
30500075|EAP|CPT® 85810||0305 - LABORATORY - HEMATOLOGY|Hc So Viscosity|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
49000028|EAP|CPT® 19000||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Puncture Aspiration Breast Cyst|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000036|EAP|CPT® 20206||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Muscle Percutaneous Needle|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
49000037|EAP|CPT® 20220||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Bone Trocar/needle Superficial|1|<Self-pay>|<Self-pay>|<Self-pay>|1,657.95|FSC: 400601; BFG: 52|||1,657.95|FSC: 400601; BFG: 52|911.87|
49000039|EAP|CPT® 20501||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Sinus Tract Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|241.50|FSC: 400601; BFG: 52|||241.50|FSC: 400601; BFG: 52|132.82|
49000051|EAP|CPT® 23350||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Shoulder Arthrography|1|<Self-pay>|<Self-pay>|<Self-pay>|177.45|FSC: 400601; BFG: 52|||177.45|FSC: 400601; BFG: 52|97.60|
49000052|EAP|CPT® 24220||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Elbow Arthrography|1|<Self-pay>|<Self-pay>|<Self-pay>|233.10|FSC: 400601; BFG: 52|||233.10|FSC: 400601; BFG: 52|128.20|
49000053|EAP|CPT® 25246||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Wrist Arthrography|1|<Self-pay>|<Self-pay>|<Self-pay>|256.20|FSC: 400601; BFG: 52|||256.20|FSC: 400601; BFG: 52|140.91|
49000055|EAP|CPT® 27093||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Hip Arthrography|1|<Self-pay>|<Self-pay>|<Self-pay>|264.60|FSC: 400601; BFG: 52|||264.60|FSC: 400601; BFG: 52|145.53|
49000056|EAP|CPT® 27369||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Knee Arthrography|1|<Self-pay>|<Self-pay>|<Self-pay>|172.20|FSC: 400601; BFG: 52|||172.20|FSC: 400601; BFG: 52|94.71|
49000057|EAP|CPT® 27648||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Ankle Arthrography|1|<Self-pay>|<Self-pay>|<Self-pay>|172.20|FSC: 400601; BFG: 52|||172.20|FSC: 400601; BFG: 52|94.71|
49000060|EAP|CPT® 31622||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|3,543.75|FSC: 400601; BFG: 52|||3,543.75|FSC: 400601; BFG: 52|1,949.06|
49000061|EAP|CPT® 31623||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy W/ Brushings|1|<Self-pay>|<Self-pay>|<Self-pay>|3,543.75|FSC: 400601; BFG: 52|||3,543.75|FSC: 400601; BFG: 52|1,949.06|
49000062|EAP|CPT® 31624||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy W/ Bal|1|<Self-pay>|<Self-pay>|<Self-pay>|3,543.75|FSC: 400601; BFG: 52|||3,543.75|FSC: 400601; BFG: 52|1,949.06|
49000063|EAP|CPT® 31625||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy W/ Bronch Or Endobronchial Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|3,543.75|FSC: 400601; BFG: 52|||3,543.75|FSC: 400601; BFG: 52|1,949.06|
49000064|EAP|CPT® 31628||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy W/ Transbronch Lung Bx Single Lobe|1|<Self-pay>|<Self-pay>|<Self-pay>|5,755.05|FSC: 400601; BFG: 52|||5,755.05|FSC: 400601; BFG: 52|3,165.28|
49000065|EAP|CPT® 31629||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy Needle Bx Trachea Main Stem And Bronch|1|<Self-pay>|<Self-pay>|<Self-pay>|7,197.75|FSC: 400601; BFG: 52|||7,197.75|FSC: 400601; BFG: 52|3,958.76|
49000068|EAP|CPT® 31632||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy W/ Transbronch Lung Bx Each Addl Lobe|1|<Self-pay>|<Self-pay>|<Self-pay>|2,356.20|FSC: 400601; BFG: 52|||2,356.20|FSC: 400601; BFG: 52|1,295.91|
49000070|EAP|CPT® 31635||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy W/ Removal Fb|1|<Self-pay>|<Self-pay>|<Self-pay>|3,543.75|FSC: 400601; BFG: 52|||3,543.75|FSC: 400601; BFG: 52|1,949.06|
49000076|EAP|CPT® 31645||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bronchoscopy W/ Asp Tracheobronchial Tree Initial|1|<Self-pay>|<Self-pay>|<Self-pay>|3,666.60|FSC: 400601; BFG: 52|||3,666.60|FSC: 400601; BFG: 52|2,016.63|
49000080|EAP|CPT® 32408||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|HC BX LUNG MEDIASTINUM PERCUTANEOUS NEEDLE|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
49000084|EAP|CPT® 32560||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Treat Pleurodesis With Agent|1|<Self-pay>|<Self-pay>|<Self-pay>|1,640.10|FSC: 400601; BFG: 52|||1,640.10|FSC: 400601; BFG: 52|902.05|
99900104|EAP|Custom 99900104||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Cch Edema Glove|1|<Self-pay>|<Self-pay>|<Self-pay>|21.00|FSC: 400601; BFG: 52|||21.00|FSC: 400601; BFG: 52|11.55|
49000153|EAP|CPT® 36005||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Extremity Venography|1|<Self-pay>|<Self-pay>|<Self-pay>|168.00|FSC: 400601; BFG: 52|||168.00|FSC: 400601; BFG: 52|92.40|
49000154|EAP|CPT® 36010||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Introduction Cath Inferior Or Superior Vena Cava|1|<Self-pay>|<Self-pay>|<Self-pay>|434.70|FSC: 400601; BFG: 52|||434.70|FSC: 400601; BFG: 52|239.08|
49000155|EAP|CPT® 36011||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cath Placement Venous 1st Order|1|<Self-pay>|<Self-pay>|<Self-pay>|558.60|FSC: 400601; BFG: 52|||558.60|FSC: 400601; BFG: 52|307.23|
49000156|EAP|CPT® 36012||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cath Placement Venous 2nd Order Or More Selective Branch|1|<Self-pay>|<Self-pay>|<Self-pay>|620.55|FSC: 400601; BFG: 52|||620.55|FSC: 400601; BFG: 52|341.30|
49000164|EAP|CPT® 36200||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Introduction Needle Or Intracatheter Aorta|1|<Self-pay>|<Self-pay>|<Self-pay>|537.60|FSC: 400601; BFG: 52|||537.60|FSC: 400601; BFG: 52|295.68|
49000176|EAP|CPT® 36500||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Venous Cath For Selective Organ Blood Sampling|1|<Self-pay>|<Self-pay>|<Self-pay>|642.60|FSC: 400601; BFG: 52|||642.60|FSC: 400601; BFG: 52|353.43|
27205089|EAP|Custom 27205089||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Wound Vac Cannister 300cc|1|<Self-pay>|<Self-pay>|<Self-pay>|234.15|FSC: 400601; BFG: 52|||234.15|FSC: 400601; BFG: 52|128.78|
76100020|EAP|CPT® 32552||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Removal Pleural Cath|1|<Self-pay>|<Self-pay>|<Self-pay>|1,640.10|FSC: 400601; BFG: 52|||1,640.10|FSC: 400601; BFG: 52|902.05|
76100094|EAP|CPT® 97605||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Negative Pressure Wound Tx W/ Dme <= 50 Sq Cm|1|<Self-pay>|<Self-pay>|<Self-pay>|452.55|FSC: 400601; BFG: 52|||452.55|FSC: 400601; BFG: 52|248.90|
76100095|EAP|CPT® 97606||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Negative Pressure Wound Tx W/ Dme > 50 Sq Cm|1|<Self-pay>|<Self-pay>|<Self-pay>|832.65|FSC: 400601; BFG: 52|||832.65|FSC: 400601; BFG: 52|457.96|
94000019|EAP|CPT® 96372||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Injection Im Or Sq|1|<Self-pay>|<Self-pay>|<Self-pay>|134.40|FSC: 400601; BFG: 52|||134.40|FSC: 400601; BFG: 52|73.92|
49000180|EAP|CPT® 36556||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Insertion Non-tunneled Cvc >5 Years Old|1|<Self-pay>|<Self-pay>|<Self-pay>|3,669.64|FSC: 400601; BFG: 52|||3,669.64|FSC: 400601; BFG: 52|2,018.30|
49000186|EAP|CPT® 36569||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Insertion Picc W/o Pump/port W/o Imaging > 5 Years Old|1|<Self-pay>|<Self-pay>|<Self-pay>|2,632.35|FSC: 400601; BFG: 52|||2,632.35|FSC: 400601; BFG: 52|1,447.79|
49000200|EAP|CPT® 36597||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Repositioning Cvc Under Fluoro|1|<Self-pay>|<Self-pay>|<Self-pay>|2,632.35|FSC: 400601; BFG: 52|||2,632.35|FSC: 400601; BFG: 52|1,447.79|
49000201|EAP|CPT® 36598||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Contrast For Eval Of Central Vad W/ Fluoro|1|<Self-pay>|<Self-pay>|<Self-pay>|511.35|FSC: 400601; BFG: 52|||511.35|FSC: 400601; BFG: 52|281.24|
27205102|EAP|Custom 27205102||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Lens Morgan Mt200|1|<Self-pay>|<Self-pay>|<Self-pay>|110.60|FSC: 400601; BFG: 52|||110.60|FSC: 400601; BFG: 52|60.83|
51000514|EAP|CPT® 64615||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Chemodenervation Muscles Facial/trigem/cerv Sp/access Nerves Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
49000238|EAP|CPT® 38505||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Lymph Node Needle Superficial|1|<Self-pay>|<Self-pay>|<Self-pay>|1,657.95|FSC: 400601; BFG: 52|||1,657.95|FSC: 400601; BFG: 52|911.87|
92000007|EAP|CPT® 59020||0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION|Hc Fetal Contraction Stress Test|1|<Self-pay>|<Self-pay>|<Self-pay>|430.50|FSC: 400601; BFG: 52|||430.50|FSC: 400601; BFG: 52|236.77|
92000008|EAP|CPT® 59025||0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION|Hc Fetal Non-stress Test|1|<Self-pay>|<Self-pay>|<Self-pay>|430.50|FSC: 400601; BFG: 52|||430.50|FSC: 400601; BFG: 52|236.77|
51000515|EAP|CPT® 20551||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Injection Tendon Origin/insertion Single|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
94000034|EAP|Custom 94000034||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Dry Needling Of Trigger Point By Pt Per 15 Min|1|<Self-pay>|<Self-pay>|<Self-pay>|70.01|FSC: 400601; BFG: 52|||70.01|FSC: 400601; BFG: 52|38.51|
49000243|EAP|CPT® 42400||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Salivary Gland Needle|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000248|EAP|CPT® 44500||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Introduction Long Gi Tube|1|<Self-pay>|<Self-pay>|<Self-pay>|2,063.25|FSC: 400601; BFG: 52|||2,063.25|FSC: 400601; BFG: 52|1,134.79|
49000252|EAP|CPT® 47000||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Liver Needle Percutaneous|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
49000271|EAP|CPT® 48102||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Pancreas Percutaneous|1|<Self-pay>|<Self-pay>|<Self-pay>|2,888.55|FSC: 400601; BFG: 52|||2,888.55|FSC: 400601; BFG: 52|1,588.70|
49000281|EAP|CPT® 49180||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Abdominal/retroperitonela Mass Percutaneous|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
49000283|EAP|CPT® 49423||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Exchange Abscess Or Cyst Drainage Cath|1|<Self-pay>|<Self-pay>|<Self-pay>|1,743.00|FSC: 400601; BFG: 52|||1,743.00|FSC: 400601; BFG: 52|958.65|
49000284|EAP|CPT® 49424||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Contrast Via Cath/tube For Eval Abscess Or Cyst|1|<Self-pay>|<Self-pay>|<Self-pay>|689.85|FSC: 400601; BFG: 52|||689.85|FSC: 400601; BFG: 52|379.42|
49000294|EAP|CPT® 49465||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Contrast Percutaneous For Eval Gi Tube|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
49000299|EAP|CPT® 50200||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Renal Percutaneous|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
30100793|EAP|CPT® 83986||0301 - LABORATORY - CHEMISTRY|Hc Assay Ph Body Fluid Nos|1|<Self-pay>|<Self-pay>|<Self-pay>|11.55|FSC: 400601; BFG: 52|||11.55|FSC: 400601; BFG: 52|6.35|
49000302|EAP|CPT® 50390||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Aspiration/injection Renal Cyst/pelvis Percutaneous|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000316|EAP|CPT® 50690||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Visualization Ileal Conduit/ureteropyelography|1|<Self-pay>|<Self-pay>|<Self-pay>|203.70|FSC: 400601; BFG: 52|||203.70|FSC: 400601; BFG: 52|112.03|
49000319|EAP|CPT® 51102||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bladder Aspiration W/ Insertion Suprapubic Cath|1|<Self-pay>|<Self-pay>|<Self-pay>|4,540.20|FSC: 400601; BFG: 52|||4,540.20|FSC: 400601; BFG: 52|2,497.11|
27206921|EAP|Custom 27206921||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bair Hugger Blanket|1|<Self-pay>|<Self-pay>|<Self-pay>|44.80|FSC: 400601; BFG: 52|||44.80|FSC: 400601; BFG: 52|24.64|
49000320|EAP|CPT® 51600||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Cystography/voiding Urethrocystography|1|<Self-pay>|<Self-pay>|<Self-pay>|407.40|FSC: 400601; BFG: 52|||407.40|FSC: 400601; BFG: 52|224.07|
49000321|EAP|CPT® 51610||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Retrograde Urethrocystography|1|<Self-pay>|<Self-pay>|<Self-pay>|349.65|FSC: 400601; BFG: 52|||349.65|FSC: 400601; BFG: 52|192.31|
27206926|EAP|Custom 27206926||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Elbow-band It|1|<Self-pay>|<Self-pay>|<Self-pay>|177.55|FSC: 400601; BFG: 52|||177.55|FSC: 400601; BFG: 52|97.65|
49000358|EAP|CPT® 58340||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Hysterosalpingography Or Saline Infusion Sonohysterograophy|1|<Self-pay>|<Self-pay>|<Self-pay>|208.95|FSC: 400601; BFG: 52|||208.95|FSC: 400601; BFG: 52|114.92|
27206931|EAP|Custom 27206931||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Nasopharyngl Airway|1|<Self-pay>|<Self-pay>|<Self-pay>|24.70|FSC: 400601; BFG: 52|||24.70|FSC: 400601; BFG: 52|13.58|
49000366|EAP|CPT® 60100||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Thyroid Percutaneous Needle Core|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000367|EAP|CPT® 60300||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Aspiration Thyroid Cyst|1|<Self-pay>|<Self-pay>|<Self-pay>|1,534.05|FSC: 400601; BFG: 52|||1,534.05|FSC: 400601; BFG: 52|843.73|
49000375|EAP|CPT® 62270||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|HC LUMBAR PUNCTURE DIAGNOSTIC W/O GUIDANCE|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
49000376|EAP|CPT® 62273||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|HC INJECTION/EPICURAL BLOOD/CLOT PATCH|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
49000377|EAP|CPT® 62284||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Myelography And/or Ct Lumbar|1|<Self-pay>|<Self-pay>|<Self-pay>|380.10|FSC: 400601; BFG: 52|||380.10|FSC: 400601; BFG: 52|209.05|
49000378|EAP|CPT® 62290||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Discography Lumbar Each Level|1|<Self-pay>|<Self-pay>|<Self-pay>|505.05|FSC: 400601; BFG: 52|||505.05|FSC: 400601; BFG: 52|277.78|
49000389|EAP|CPT® 64640||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction Neurolytic Agent Other Peripheral Nerve|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000390|EAP|HCPCS G0260||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Sacroiliac Joint W/ Arthrography & Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
51000046|EAP|CPT® 10140||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc I&d Hematoma Seroma Or Fluid|1|<Self-pay>|<Self-pay>|<Self-pay>|3,683.40|FSC: 400601; BFG: 52|||3,683.40|FSC: 400601; BFG: 52|2,025.87|
27206950|EAP|Custom 27206950||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Splint Traction|1|<Self-pay>|<Self-pay>|<Self-pay>|96.45|FSC: 400601; BFG: 52|||96.45|FSC: 400601; BFG: 52|53.05|
12000001|EAP|Custom 12000001||0120 - ROOM & BOARD - SEMI-PRIVATE TWO BED (MEDICAL OR GENERAL) - GENERAL CLASSIFICATION|Hc Med/surg|1|<Self-pay>|<Self-pay>|<Self-pay>|909.30|FSC: 400601; BFG: 52|||909.30|FSC: 400601; BFG: 52|500.11|
12000002|EAP|Custom 12000002||0120 - ROOM & BOARD - SEMI-PRIVATE TWO BED (MEDICAL OR GENERAL) - GENERAL CLASSIFICATION|Hc Med/surg|1|<Self-pay>|<Self-pay>|<Self-pay>|1,338.75|FSC: 400601; BFG: 52|||1,338.75|FSC: 400601; BFG: 52|736.31|
17000001|EAP|Custom 17000001||0170 - NURSERY - GENERAL CLASSIFICATION|Hc Nursery|1|<Self-pay>|<Self-pay>|<Self-pay>|1,499.40|FSC: 400601; BFG: 52|||1,499.40|FSC: 400601; BFG: 52|824.67|
20000001|EAP|Custom 20000001||0200 - INTENSIVE CARE - GENERAL CLASSIFICATION|Hc Icu|1|<Self-pay>|<Self-pay>|<Self-pay>|2,356.20|FSC: 400601; BFG: 52|||2,356.20|FSC: 400601; BFG: 52|1,295.91|
20600001|EAP|Custom 20600001||0206 - INTENSIVE CARE - INTERMEDIATE ICU|Hc Intermediate Care|1|<Self-pay>|<Self-pay>|<Self-pay>|1,606.50|FSC: 400601; BFG: 52|||1,606.50|FSC: 400601; BFG: 52|883.57|
37000010|EAP|Custom 37000010||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Regional Anesthesia|1|<Self-pay>|<Self-pay>|<Self-pay>|294.00|FSC: 400601; BFG: 52|||294.00|FSC: 400601; BFG: 52|161.70|
41000001|EAP|CPT® 94002||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Ventilator Initial Day|1|<Self-pay>|<Self-pay>|<Self-pay>|1,233.75|FSC: 400601; BFG: 52|||1,233.75|FSC: 400601; BFG: 52|678.56|
41000002|EAP|CPT® 94003||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Ventilator Each Subsequent Day|1|<Self-pay>|<Self-pay>|<Self-pay>|1,233.75|FSC: 400601; BFG: 52|||1,233.75|FSC: 400601; BFG: 52|678.56|
41000016|EAP|CPT® 94644||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Continuous Inhalation Tx 1st Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
41000017|EAP|CPT® 94645||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Continuous Inhalation Tx Each Addl Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
41000028|EAP|CPT® 94667||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Manual Chest Wall Manipulation (pep) Initial|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
41000029|EAP|CPT® 94668||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Manual Chest Wall Manipulation (pep) Subsequent|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
41000033|EAP|HCPCS G0239||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Pulmonary Exercise Session Group|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
42000011|EAP|CPT® 97012||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Traction Mechanical|1|<Self-pay>|<Self-pay>|<Self-pay>|57.75|FSC: 400601; BFG: 52|||57.75|FSC: 400601; BFG: 52|31.76|
42000013|EAP|CPT® 97018||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Paraffin Bath|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
42000014|EAP|CPT® 97022||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Whirlpool|1|<Self-pay>|<Self-pay>|<Self-pay>|99.75|FSC: 400601; BFG: 52|||99.75|FSC: 400601; BFG: 52|54.86|
42000016|EAP|CPT® 97032||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Electrical Stimulation Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|68.25|FSC: 400601; BFG: 52|||68.25|FSC: 400601; BFG: 52|37.54|
42000017|EAP|CPT® 97033||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Iontophoresis Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|159.60|FSC: 400601; BFG: 52|||159.60|FSC: 400601; BFG: 52|87.78|
42000018|EAP|CPT® 97034||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Contrast Baths Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
42000019|EAP|CPT® 97035||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Ultrasound Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
42000021|EAP|CPT® 97110||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Therapeutic Exercises Rom & Flexibility Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|99.75|FSC: 400601; BFG: 52|||99.75|FSC: 400601; BFG: 52|54.86|
42000022|EAP|CPT® 97112||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Neuromuscular Reeducation Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
42000023|EAP|CPT® 97113||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Aquatic Therapy Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|111.30|FSC: 400601; BFG: 52|||111.30|FSC: 400601; BFG: 52|61.21|
42000024|EAP|CPT® 97116||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Gait Training Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
42000025|EAP|CPT® 97124||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Massage Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|74.55|FSC: 400601; BFG: 52|||74.55|FSC: 400601; BFG: 52|41.00|
42000026|EAP|CPT® 97140||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Manual Therapy Techniques Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|117.60|FSC: 400601; BFG: 52|||117.60|FSC: 400601; BFG: 52|64.68|
42000030|EAP|CPT® 97533||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Sensory Integrative Techniques Direct Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|87.15|FSC: 400601; BFG: 52|||87.15|FSC: 400601; BFG: 52|47.93|
42000034|EAP|CPT® 97545||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Work Hardening/conditioning Initial 2 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|241.50|FSC: 400601; BFG: 52|||241.50|FSC: 400601; BFG: 52|132.82|
42000035|EAP|CPT® 97546||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Work Hardening/conditioning Each Addl Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|122.85|FSC: 400601; BFG: 52|||122.85|FSC: 400601; BFG: 52|67.57|
42000045|EAP|CPT® 97750||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Physical Performance Test W/ Report Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
42000040|EAP|CPT® 97760||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Orthotic Mgmt & Training Initial Each 15 Min|1|<Self-pay>|<Self-pay>|<Self-pay>|103.95|FSC: 400601; BFG: 52|||103.95|FSC: 400601; BFG: 52|57.17|
42000041|EAP|CPT® 97761||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Prosthetic Training Upper/lower Extremity Initial Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|94.50|FSC: 400601; BFG: 52|||94.50|FSC: 400601; BFG: 52|51.97|
42000043|EAP|HCPCS G0283||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Electrical Stimulation Non-wound Care|1|<Self-pay>|<Self-pay>|<Self-pay>|63.00|FSC: 400601; BFG: 52|||63.00|FSC: 400601; BFG: 52|34.65|
41000045|EAP|CPT® 31500||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Intubation Endotracheal Emergent|1|<Self-pay>|<Self-pay>|<Self-pay>|477.75|FSC: 400601; BFG: 52|||477.75|FSC: 400601; BFG: 52|262.76|
36000006|EAP|CPT® 32551||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|HC INSERTION CHEST TUBE|1|<Self-pay>|<Self-pay>|<Self-pay>|2,632.35|FSC: 400601; BFG: 52|||2,632.35|FSC: 400601; BFG: 52|1,447.79|
36000027|EAP|Custom 36000027||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level I 0-30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|1,905.75|FSC: 400601; BFG: 52|||1,905.75|FSC: 400601; BFG: 52|1,048.16|
36000028|EAP|Custom 36000028||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level I Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|328.65|FSC: 400601; BFG: 52|||328.65|FSC: 400601; BFG: 52|180.76|
36000029|EAP|Custom 36000029||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level Ii 0-30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|1,926.75|FSC: 400601; BFG: 52|||1,926.75|FSC: 400601; BFG: 52|1,059.71|
36000030|EAP|Custom 36000030||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level Ii Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|369.60|FSC: 400601; BFG: 52|||369.60|FSC: 400601; BFG: 52|203.28|
36000031|EAP|Custom 36000031||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level Iii 0-30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|2,102.10|FSC: 400601; BFG: 52|||2,102.10|FSC: 400601; BFG: 52|1,156.15|
36000032|EAP|Custom 36000032||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level Iii Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|410.55|FSC: 400601; BFG: 52|||410.55|FSC: 400601; BFG: 52|225.80|
36000033|EAP|Custom 36000033||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level Iv 0-30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|2,452.80|FSC: 400601; BFG: 52|||2,452.80|FSC: 400601; BFG: 52|1,349.04|
36000034|EAP|Custom 36000034||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level Iv Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|452.55|FSC: 400601; BFG: 52|||452.55|FSC: 400601; BFG: 52|248.90|
36000035|EAP|Custom 36000035||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level V 0-30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|2,803.50|FSC: 400601; BFG: 52|||2,803.50|FSC: 400601; BFG: 52|1,541.92|
36000036|EAP|Custom 36000036||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Or Level V Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|487.20|FSC: 400601; BFG: 52|||487.20|FSC: 400601; BFG: 52|267.96|
63600218|EAP|HCPCS J2790||0636 - PHARMACY - DRUGS REQUIRING DETAILED CODING|Hc Rho D Immune Globulin Full Dose|1|<Self-pay>|<Self-pay>|<Self-pay>|178.50|FSC: 400601; BFG: 52|||178.50|FSC: 400601; BFG: 52|98.17|
27206959|EAP|Custom 27206959||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Nasal Cannula|1|<Self-pay>|<Self-pay>|<Self-pay>|17.40|FSC: 400601; BFG: 52|||17.40|FSC: 400601; BFG: 52|9.57|
44000001|EAP|CPT® 92507||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Speech Therapy Individual|1|<Self-pay>|<Self-pay>|<Self-pay>|240.45|FSC: 400601; BFG: 52|||240.45|FSC: 400601; BFG: 52|132.25|
44000002|EAP|CPT® 92508||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Speech Therapy Group|1|<Self-pay>|<Self-pay>|<Self-pay>|28.35|FSC: 400601; BFG: 52|||28.35|FSC: 400601; BFG: 52|15.59|
44000003|EAP|CPT® 92526||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Swallowing Dysfunction Treatment|1|<Self-pay>|<Self-pay>|<Self-pay>|171.15|FSC: 400601; BFG: 52|||171.15|FSC: 400601; BFG: 52|94.13|
44400007|EAP|CPT® 92597||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Evaluation For Use/fit Of Voice Prosthetic Device|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
44400008|EAP|CPT® 92607||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Evaluation Rx For Speech Device First Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|158.55|FSC: 400601; BFG: 52|||158.55|FSC: 400601; BFG: 52|87.20|
44400009|EAP|CPT® 92608||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Evaluation Rx For Speech Device Each Addl 30 Minutes|1|<Self-pay>|<Self-pay>|<Self-pay>|170.10|FSC: 400601; BFG: 52|||170.10|FSC: 400601; BFG: 52|93.55|
44000008|EAP|CPT® 92609||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Therapeutic Services For Speech Devices|1|<Self-pay>|<Self-pay>|<Self-pay>|164.85|FSC: 400601; BFG: 52|||164.85|FSC: 400601; BFG: 52|90.67|
27400393|EAP|HCPCS L1906||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Cch Ankle Brace|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|FSC: 400601; BFG: 52|||98.70|FSC: 400601; BFG: 52|54.28|
30102042|EAP|CPT® 81247||0301 - LABORATORY - CHEMISTRY|Hc Cch So Glucose-6-phosphate Dehydrogenase (g6pd) 2 Mutations|1|<Self-pay>|<Self-pay>|<Self-pay>|412.99|FSC: 400601; BFG: 52|||412.99|FSC: 400601; BFG: 52|227.14|
46000001|EAP|CPT® 94010||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Spirometry Vital Capacity W/ Or W/o Maximal Voluntary Ventilation|1|<Self-pay>|<Self-pay>|<Self-pay>|365.40|FSC: 400601; BFG: 52|||365.40|FSC: 400601; BFG: 52|200.97|
46000002|EAP|CPT® 94060||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Bronchodilation Response Pre & Post Bronchodilator Admin|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
46000003|EAP|CPT® 94070||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Bronchospasm Provocation Eval|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
46000021|EAP|CPT® 94760||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Pulse Oximetry For O2 Sat Single|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
46000022|EAP|CPT® 94761||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Pulse Oximetry For O2 Sat Multiple|1|<Self-pay>|<Self-pay>|<Self-pay>|63.00|FSC: 400601; BFG: 52|||63.00|FSC: 400601; BFG: 52|34.65|
46000023|EAP|CPT® 94762||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Pulse Oximetry For O2 Sat Continuous|1|<Self-pay>|<Self-pay>|<Self-pay>|365.40|FSC: 400601; BFG: 52|||365.40|FSC: 400601; BFG: 52|200.97|
42400002|EAP|CPT® 97164||0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Pt Re-evaluation|1|<Self-pay>|<Self-pay>|<Self-pay>|109.20|FSC: 400601; BFG: 52|||109.20|FSC: 400601; BFG: 52|60.06|
27400408|EAP|HCPCS A4565||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Cch Immobilizer Shoulder|1|<Self-pay>|<Self-pay>|<Self-pay>|56.70|FSC: 400601; BFG: 52|||56.70|FSC: 400601; BFG: 52|31.18|
43000004|EAP|CPT® 95852||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Rom Testing Hand|1|<Self-pay>|<Self-pay>|<Self-pay>|112.35|FSC: 400601; BFG: 52|||112.35|FSC: 400601; BFG: 52|61.79|
30100814|EAP|CPT® 83018||0301 - LABORATORY - CHEMISTRY|Hc So Heavy Metal Quan - A|1|<Self-pay>|<Self-pay>|<Self-pay>|54.90|FSC: 400601; BFG: 52|||54.90|FSC: 400601; BFG: 52|30.19|
30100815|EAP|CPT® 80201||0301 - LABORATORY - CHEMISTRY|Hc So Topiramate|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200231|EAP|CPT® 86671||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Fungus Nes|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30200234|EAP|CPT® 86793||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Yersinia|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
40100006|EAP|HCPCS G0279||0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY|Hc Diagnostic Mammo Tomo Unilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|337.05|FSC: 400601; BFG: 52|||337.05|FSC: 400601; BFG: 52|185.38|
30100816|EAP|CPT® 80074||0301 - LABORATORY - CHEMISTRY|Hc Cch So Acute Hepatitis Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|157.50|FSC: 400601; BFG: 52|||157.50|FSC: 400601; BFG: 52|86.62|
30100817|EAP|CPT® 80178||0301 - LABORATORY - CHEMISTRY|Hc Cch So Lithium|1|<Self-pay>|<Self-pay>|<Self-pay>|22.05|FSC: 400601; BFG: 52|||22.05|FSC: 400601; BFG: 52|12.13|
30100819|EAP|CPT® 80186||0301 - LABORATORY - CHEMISTRY|Hc Cch So Phenytoin Free|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100820|EAP|CPT® 80197||0301 - LABORATORY - CHEMISTRY|Hc Cch So Tacrolimus|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30200228|EAP|CPT® 86708||0302 - LABORATORY - IMMUNOLOGY|Hc So Hepatitis A Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30200229|EAP|CPT® 86709||0302 - LABORATORY - IMMUNOLOGY|Hc So Hepatitis A Igm Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|36.75|FSC: 400601; BFG: 52|||36.75|FSC: 400601; BFG: 52|20.21|
30100822|EAP|CPT® 82024||0301 - LABORATORY - CHEMISTRY|Hc Cch So Acth|1|<Self-pay>|<Self-pay>|<Self-pay>|128.10|FSC: 400601; BFG: 52|||128.10|FSC: 400601; BFG: 52|70.45|
30100823|EAP|CPT® 82308||0301 - LABORATORY - CHEMISTRY|Hc So Calcitonin|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
30100825|EAP|CPT® 82378||0301 - LABORATORY - CHEMISTRY|Hc Cch So Carcinoembryonic Antigen (cea)|1|<Self-pay>|<Self-pay>|<Self-pay>|63.00|FSC: 400601; BFG: 52|||63.00|FSC: 400601; BFG: 52|34.65|
30100828|EAP|CPT® 82542||0301 - LABORATORY - CHEMISTRY|Hc Cch So Hplc 6-mtgn|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
30100830|EAP|CPT® 82607||0301 - LABORATORY - CHEMISTRY|Hc Cch So Vitamin B-12 Level|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30100831|EAP|CPT® 82627||0301 - LABORATORY - CHEMISTRY|Hc Cch So Dhea-s|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|FSC: 400601; BFG: 52|||73.50|FSC: 400601; BFG: 52|40.42|
30100832|EAP|CPT® 82705||0301 - LABORATORY - CHEMISTRY|Hc Cch So Fat Or Lipids Feces Qual|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100833|EAP|CPT® 82728||0301 - LABORATORY - CHEMISTRY|Hc Cch So Ferritin|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
51000100|EAP|CPT® 29580||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Unna Boot Strapping|1|<Self-pay>|<Self-pay>|<Self-pay>|362.25|FSC: 400601; BFG: 52|||362.25|FSC: 400601; BFG: 52|199.24|
51000101|EAP|CPT® 29581||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Application Multi-layer Wound Compression Below Knee|1|<Self-pay>|<Self-pay>|<Self-pay>|362.25|FSC: 400601; BFG: 52|||362.25|FSC: 400601; BFG: 52|199.24|
30100834|EAP|CPT® 82746||0301 - LABORATORY - CHEMISTRY|Hc Cch So Folic Acid Serum|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30100835|EAP|CPT® 82747||0301 - LABORATORY - CHEMISTRY|Hc Cch So Folic Acid Rbc|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30100836|EAP|CPT® 82941||0301 - LABORATORY - CHEMISTRY|Hc Cch So Gastrin|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
51000110|EAP|CPT® 31575||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Laryngoscopy Flexible Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|444.15|FSC: 400601; BFG: 52|||444.15|FSC: 400601; BFG: 52|244.28|
51000111|EAP|CPT® 31579||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Laryngoscopy W/ Stroboscopy|1|<Self-pay>|<Self-pay>|<Self-pay>|1,004.85|FSC: 400601; BFG: 52|||1,004.85|FSC: 400601; BFG: 52|552.67|
30100837|EAP|CPT® 83001||0301 - LABORATORY - CHEMISTRY|Hc Cch So Gonadotropin Fsh|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
30100838|EAP|CPT® 83002||0301 - LABORATORY - CHEMISTRY|Hc Cch So Gonadotropin Luteinizing Hormone|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
30100839|EAP|CPT® 83070||0301 - LABORATORY - CHEMISTRY|Hc Cch So Hemosiderin Qualitative|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
51000143|EAP|CPT® 64450||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|HC INJECTION PERIPHERAL NERVE OR BRANCH|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
51000144|EAP|CPT® 64483||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Injection(s) Transforaminal Lumbar Sacral Single Level|1|<Self-pay>|<Self-pay>|<Self-pay>|2,047.50|FSC: 400601; BFG: 52|||2,047.50|FSC: 400601; BFG: 52|1,126.12|
51000145|EAP|CPT® 64484||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Injection(s) Transforaminal Lumbar Sacral Each Addl Level|1|<Self-pay>|<Self-pay>|<Self-pay>|836.85|FSC: 400601; BFG: 52|||836.85|FSC: 400601; BFG: 52|460.27|
30100843|EAP|CPT® 83586||0301 - LABORATORY - CHEMISTRY|Hc Cch So Ketosteroids 17 Total|1|<Self-pay>|<Self-pay>|<Self-pay>|151.20|FSC: 400601; BFG: 52|||151.20|FSC: 400601; BFG: 52|83.16|
51000152|EAP|CPT® 92520||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Laryngeal Function Studies|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
51000002|EAP|CPT® 99202||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit New Pt Level 2|1|<Self-pay>|<Self-pay>|<Self-pay>|221.55|FSC: 400601; BFG: 52|||221.55|FSC: 400601; BFG: 52|121.85|
51000003|EAP|CPT® 99203||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit New Pt Level 3|1|<Self-pay>|<Self-pay>|<Self-pay>|279.30|FSC: 400601; BFG: 52|||279.30|FSC: 400601; BFG: 52|153.61|
51000004|EAP|CPT® 99204||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit New Pt Level 4|1|<Self-pay>|<Self-pay>|<Self-pay>|318.15|FSC: 400601; BFG: 52|||318.15|FSC: 400601; BFG: 52|174.98|
51000005|EAP|CPT® 99205||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit New Pt Level 5|1|<Self-pay>|<Self-pay>|<Self-pay>|341.25|FSC: 400601; BFG: 52|||341.25|FSC: 400601; BFG: 52|187.69|
51000006|EAP|CPT® 99211||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit Established Pt Level 1|1|<Self-pay>|<Self-pay>|<Self-pay>|87.15|FSC: 400601; BFG: 52|||87.15|FSC: 400601; BFG: 52|47.93|
30100846|EAP|CPT® 83918||0301 - LABORATORY - CHEMISTRY|Hc Cch So Organic Acids Total Quantitative Each Specimen|1|<Self-pay>|<Self-pay>|<Self-pay>|112.35|FSC: 400601; BFG: 52|||112.35|FSC: 400601; BFG: 52|61.79|
51000007|EAP|CPT® 99212||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit Established Pt Level 2|1|<Self-pay>|<Self-pay>|<Self-pay>|178.50|FSC: 400601; BFG: 52|||178.50|FSC: 400601; BFG: 52|98.17|
51000008|EAP|CPT® 99213||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit Established Pt Level 3|1|<Self-pay>|<Self-pay>|<Self-pay>|203.70|FSC: 400601; BFG: 52|||203.70|FSC: 400601; BFG: 52|112.03|
30100847|EAP|CPT® 83930||0301 - LABORATORY - CHEMISTRY|Hc Cch So Blood Osmolality|1|<Self-pay>|<Self-pay>|<Self-pay>|22.05|FSC: 400601; BFG: 52|||22.05|FSC: 400601; BFG: 52|12.13|
51000009|EAP|CPT® 99214||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit Established Pt Level 4|1|<Self-pay>|<Self-pay>|<Self-pay>|252.00|FSC: 400601; BFG: 52|||252.00|FSC: 400601; BFG: 52|138.60|
51000010|EAP|CPT® 99215||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Clinic Visit Established Pt Level 5|1|<Self-pay>|<Self-pay>|<Self-pay>|275.10|FSC: 400601; BFG: 52|||275.10|FSC: 400601; BFG: 52|151.30|
30100848|EAP|CPT® 83935||0301 - LABORATORY - CHEMISTRY|Hc Cch So Osmolality Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|22.05|FSC: 400601; BFG: 52|||22.05|FSC: 400601; BFG: 52|12.13|
30100850|EAP|CPT® 84134||0301 - LABORATORY - CHEMISTRY|Hc Cch So Prealbumin|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30100851|EAP|CPT® 84144||0301 - LABORATORY - CHEMISTRY|Hc Cch So Progesterone|1|<Self-pay>|<Self-pay>|<Self-pay>|69.30|FSC: 400601; BFG: 52|||69.30|FSC: 400601; BFG: 52|38.11|
30100852|EAP|CPT® 84146||0301 - LABORATORY - CHEMISTRY|Hc Cch So Prolactin Assay|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
30100856|EAP|CPT® 84165||0301 - LABORATORY - CHEMISTRY|Hc Cch So Protein Ep Fract & Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|35.70|FSC: 400601; BFG: 52|||35.70|FSC: 400601; BFG: 52|19.63|
30100860|EAP|CPT® 84466||0301 - LABORATORY - CHEMISTRY|Hc Cch So Transferrin|1|<Self-pay>|<Self-pay>|<Self-pay>|42.00|FSC: 400601; BFG: 52|||42.00|FSC: 400601; BFG: 52|23.10|
30100861|EAP|CPT® 84479||0301 - LABORATORY - CHEMISTRY|Hc Cch So T3 Or T4 Or Thyroid Hormone|1|<Self-pay>|<Self-pay>|<Self-pay>|57.75|FSC: 400601; BFG: 52|||57.75|FSC: 400601; BFG: 52|31.76|
30100862|EAP|CPT® 84681||0301 - LABORATORY - CHEMISTRY|Hc Cch So C-peptide|1|<Self-pay>|<Self-pay>|<Self-pay>|69.30|FSC: 400601; BFG: 52|||69.30|FSC: 400601; BFG: 52|38.11|
30200240|EAP|CPT® 86157||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Cold Agglutinin Titer|1|<Self-pay>|<Self-pay>|<Self-pay>|80.85|FSC: 400601; BFG: 52|||80.85|FSC: 400601; BFG: 52|44.47|
30200241|EAP|CPT® 86200||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Ccp Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30200242|EAP|CPT® 86304||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Ia-quant Ca 125|1|<Self-pay>|<Self-pay>|<Self-pay>|69.30|FSC: 400601; BFG: 52|||69.30|FSC: 400601; BFG: 52|38.11|
30200245|EAP|CPT® 86361||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So T Cells Absolute Cd4 Count|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
30200246|EAP|CPT® 86376||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Microsomal Ab Each|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
94300002|EAP|CPT® 93798||0943 - OTHER THERAPEUTIC SERVICES - CARDIAC REHABILITATION|Hc Cardiac Rehab W/ Ekg Per Session|1|<Self-pay>|<Self-pay>|<Self-pay>|210.00|FSC: 400601; BFG: 52|||210.00|FSC: 400601; BFG: 52|115.50|
30200250|EAP|CPT® 86707||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Ab Hbeab|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
30500077|EAP|CPT® 85004||0305 - LABORATORY - HEMATOLOGY|Hc Auto Diff Wbc Count|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
30500082|EAP|CPT® 85097||0305 - LABORATORY - HEMATOLOGY|Hc Cch Bone Marrow Smear|1|<Self-pay>|<Self-pay>|<Self-pay>|1,648.50|FSC: 400601; BFG: 52|||1,648.50|FSC: 400601; BFG: 52|906.67|
30500085|EAP|CPT® 85245||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Clotting Factor Viii Ristocetin Cofact|1|<Self-pay>|<Self-pay>|<Self-pay>|75.60|FSC: 400601; BFG: 52|||75.60|FSC: 400601; BFG: 52|41.58|
30500086|EAP|CPT® 85260||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Clotting Factor X|1|<Self-pay>|<Self-pay>|<Self-pay>|58.80|FSC: 400601; BFG: 52|||58.80|FSC: 400601; BFG: 52|32.34|
30500087|EAP|CPT® 85300||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Clotting Inhib/anticoag|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
30500089|EAP|CPT® 85460||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Fetal Screen Rbc|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|FSC: 400601; BFG: 52|||25.20|FSC: 400601; BFG: 52|13.86|
30500091|EAP|CPT® 85613||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Russell Viper Venom Time Diluted|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
30500092|EAP|CPT® 85730||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Ptt Plasma Or Whole Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30600207|EAP|CPT® 87102||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Fungus Culture Not Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|27.30|FSC: 400601; BFG: 52|||27.30|FSC: 400601; BFG: 52|15.01|
30600209|EAP|CPT® 87116||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Culture Acid-fast Bacilli Isol & Id|1|<Self-pay>|<Self-pay>|<Self-pay>|35.70|FSC: 400601; BFG: 52|||35.70|FSC: 400601; BFG: 52|19.63|
30600211|EAP|CPT® 87206||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Smear Fluorescent Or Afb Stain|1|<Self-pay>|<Self-pay>|<Self-pay>|17.85|FSC: 400601; BFG: 52|||17.85|FSC: 400601; BFG: 52|9.82|
30600212|EAP|CPT® 87220||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Koh For Fungi/parasites/mites|1|<Self-pay>|<Self-pay>|<Self-pay>|13.65|FSC: 400601; BFG: 52|||13.65|FSC: 400601; BFG: 52|7.51|
30600215|EAP|CPT® 87337||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Entamoeb Hist Group Ag Ia|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30600216|EAP|CPT® 87350||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Hepatitis Be Ag Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
30600217|EAP|CPT® 87389||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Hiv-1 Ag W/hiv-1 & Hiv-2 Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|79.80|FSC: 400601; BFG: 52|||79.80|FSC: 400601; BFG: 52|43.89|
30600218|EAP|CPT® 87400||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Influenza A Or B Antigen|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30600223|EAP|CPT® 87480||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Candida Na Direct Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
30600225|EAP|CPT® 87510||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Gardnerella Dir Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
30600228|EAP|CPT® 87641||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Mr-staph Dna Amp Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
30600229|EAP|CPT® 87660||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Trichomonas Vagin Dir Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
30900010|EAP|CPT® 89055||0309 - LABORATORY - OTHER LABORATORY|Hc Cch Leukocyte Assessment Fecal Qualitative/semiquantitative|1|<Self-pay>|<Self-pay>|<Self-pay>|13.65|FSC: 400601; BFG: 52|||13.65|FSC: 400601; BFG: 52|7.51|
30900011|EAP|CPT® 89160||0309 - LABORATORY - OTHER LABORATORY|Hc Cch So Meat Fibers Feces|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30900012|EAP|CPT® 89190||0309 - LABORATORY - OTHER LABORATORY|Hc Cch Nasal Smear For Eosinophils|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|FSC: 400601; BFG: 52|||25.20|FSC: 400601; BFG: 52|13.86|
31000071|EAP|CPT® 81256||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Mer Hemochromatosis Muta|1|<Self-pay>|<Self-pay>|<Self-pay>|216.30|FSC: 400601; BFG: 52|||216.30|FSC: 400601; BFG: 52|118.96|
31000078|EAP|CPT® 81402||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch Mer Jak Rfx 2|1|<Self-pay>|<Self-pay>|<Self-pay>|667.00|FSC: 400601; BFG: 52|||667.00|FSC: 400601; BFG: 52|366.85|
31100040|EAP|CPT® 88142||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Cp Cerv/vag Atl Manual Scrn (diagnostic)|1|<Self-pay>|<Self-pay>|<Self-pay>|95.55|FSC: 400601; BFG: 52|||95.55|FSC: 400601; BFG: 52|52.55|
31100041|EAP|HCPCS G0123||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Cp Cerv/vag Atl Manual Scrn|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
31100043|EAP|CPT® 88175||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Cytopath C/v Auto Fluid Redo (diagnostic)|1|<Self-pay>|<Self-pay>|<Self-pay>|87.15|FSC: 400601; BFG: 52|||87.15|FSC: 400601; BFG: 52|47.93|
30000076|EAP|CPT® 86901||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Blood Typing Rh D|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
30000078|EAP|CPT® 86965||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Pool Platelets Or Bld Product|1|<Self-pay>|<Self-pay>|<Self-pay>|122.85|FSC: 400601; BFG: 52|||122.85|FSC: 400601; BFG: 52|67.57|
30000079|EAP|CPT® 86970||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Pretreat Rbc Chem Or Drugs|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
30200252|EAP|CPT® 86146||0302 - LABORATORY - IMMUNOLOGY|Hc Beta 2 Glycoprotein I Ab- Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30900001|EAP|CPT® 89060||0309 - LABORATORY - OTHER LABORATORY|Hc Exam Synovial Fluid Crystals|1|<Self-pay>|<Self-pay>|<Self-pay>|24.15|FSC: 400601; BFG: 52|||24.15|FSC: 400601; BFG: 52|13.28|
30900004|EAP|CPT® 89051||0309 - LABORATORY - OTHER LABORATORY|Hc Cell Count W/ Diff Fluid|1|<Self-pay>|<Self-pay>|<Self-pay>|17.85|FSC: 400601; BFG: 52|||17.85|FSC: 400601; BFG: 52|9.82|
30000095|EAP|CPT® 86920||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Compatibilty Test Spin|1|<Self-pay>|<Self-pay>|<Self-pay>|345.45|FSC: 400601; BFG: 52|||345.45|FSC: 400601; BFG: 52|190.00|
30000001|EAP|CPT® 36415||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Venipuncture|1|<Self-pay>|<Self-pay>|<Self-pay>|21.00|FSC: 400601; BFG: 52|||21.00|FSC: 400601; BFG: 52|11.55|
30000002|EAP|CPT® 36591||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Collect Blood From Implantable Venous Device|1|<Self-pay>|<Self-pay>|<Self-pay>|275.73|FSC: 400601; BFG: 52|||275.73|FSC: 400601; BFG: 52|151.65|
30000003|EAP|CPT® 36592||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Collect Blood From Cvc/picc/midline|1|<Self-pay>|<Self-pay>|<Self-pay>|275.73|FSC: 400601; BFG: 52|||275.73|FSC: 400601; BFG: 52|151.65|
27207865|EAP|Custom 27207865||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Picc Line Statlock Stabilization Device Foam|1|<Self-pay>|<Self-pay>|<Self-pay>|36.15|FSC: 400601; BFG: 52|||36.15|FSC: 400601; BFG: 52|19.88|
30000014|EAP|CPT® 86850||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Rbc Ab Scrn Ea Techiq|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
30000036|EAP|CPT® 86880||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Direct Coombs|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
30000021|EAP|CPT® 86927||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Cch Ffp Thawing- Ea Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|46.20|FSC: 400601; BFG: 52|||46.20|FSC: 400601; BFG: 52|25.41|
30000022|EAP|CPT® 86945||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Debit Irradiate Bld Product Ea Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
30100001|EAP|CPT® 80061||0301 - LABORATORY - CHEMISTRY|Hc Lipid Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|145.95|FSC: 400601; BFG: 52|||145.95|FSC: 400601; BFG: 52|80.27|
30100005|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO AMITRIPTYLINE 1 OR 2|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30100006|EAP|CPT® 80156||0301 - LABORATORY - CHEMISTRY|Hc Carbamazepine Total|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30100008|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO DESIPRAMINE 1 OR 2|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30100009|EAP|CPT® 80162||0301 - LABORATORY - CHEMISTRY|Hc Digoxin Total|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30100010|EAP|CPT® 80164||0301 - LABORATORY - CHEMISTRY|Hc Valproic Acid (dipropylacetic Acid) Total|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100011|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO DOXEPIN 1 OR 2|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30100216|EAP|CPT® 80168||0301 - LABORATORY - CHEMISTRY|Hc So Ethosuximide|1|<Self-pay>|<Self-pay>|<Self-pay>|95.55|FSC: 400601; BFG: 52|||95.55|FSC: 400601; BFG: 52|52.55|
30100013|EAP|CPT® 80170||0301 - LABORATORY - CHEMISTRY|Hc Gentamicin|1|<Self-pay>|<Self-pay>|<Self-pay>|54.60|FSC: 400601; BFG: 52|||54.60|FSC: 400601; BFG: 52|30.03|
30100016|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO IMIPRAMINE 1 OR 2|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30100019|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO NORTRIPTYLINE 1 OR 2|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
30100020|EAP|CPT® 80184||0301 - LABORATORY - CHEMISTRY|Hc Phenobarbital|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30100021|EAP|CPT® 80185||0301 - LABORATORY - CHEMISTRY|Hc Phenytoin Total|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30100023|EAP|CPT® 80188||0301 - LABORATORY - CHEMISTRY|Hc So Primidone|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
30100024|EAP|CPT® 80192||0301 - LABORATORY - CHEMISTRY|Hc So Procainamide W Metabolites|1|<Self-pay>|<Self-pay>|<Self-pay>|106.05|FSC: 400601; BFG: 52|||106.05|FSC: 400601; BFG: 52|58.33|
30100025|EAP|CPT® 80194||0301 - LABORATORY - CHEMISTRY|Hc So Quinidine|1|<Self-pay>|<Self-pay>|<Self-pay>|86.10|FSC: 400601; BFG: 52|||86.10|FSC: 400601; BFG: 52|47.35|
30100026|EAP|CPT® 80195||0301 - LABORATORY - CHEMISTRY|Hc So Sirolimus|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100029|EAP|CPT® 80198||0301 - LABORATORY - CHEMISTRY|Hc Theophylline|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30100031|EAP|CPT® 80202||0301 - LABORATORY - CHEMISTRY|Hc Vancomycin|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100166|EAP|CPT® 80299||0301 - LABORATORY - CHEMISTRY|Hc So Drug Quant Nes - A|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
30100034|EAP|CPT® 82009||0301 - LABORATORY - CHEMISTRY|Hc Qual Serum Acetone/ketones|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
30100040|EAP|CPT® 82040||0301 - LABORATORY - CHEMISTRY|Hc Assay Of Serum Albumin|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100042|EAP|CPT® 82043||0301 - LABORATORY - CHEMISTRY|Hc Microalbumin Urine Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|18.90|FSC: 400601; BFG: 52|||18.90|FSC: 400601; BFG: 52|10.39|
30100044|EAP|CPT® 82085||0301 - LABORATORY - CHEMISTRY|Hc So Aldolase|1|<Self-pay>|<Self-pay>|<Self-pay>|32.55|FSC: 400601; BFG: 52|||32.55|FSC: 400601; BFG: 52|17.90|
30100296|EAP|CPT® 82088||0301 - LABORATORY - CHEMISTRY|Hc So Aldosterone|1|<Self-pay>|<Self-pay>|<Self-pay>|134.40|FSC: 400601; BFG: 52|||134.40|FSC: 400601; BFG: 52|73.92|
30100301|EAP|CPT® 82103||0301 - LABORATORY - CHEMISTRY|Hc So Alpha-1-antitrypsin Total|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30100051|EAP|CPT® 82108||0301 - LABORATORY - CHEMISTRY|Hc So Aluminum Assay|1|<Self-pay>|<Self-pay>|<Self-pay>|123.90|FSC: 400601; BFG: 52|||123.90|FSC: 400601; BFG: 52|68.14|
30100052|EAP|CPT® 82131||0301 - LABORATORY - CHEMISTRY|Hc So Amino Acids Sgl Quan Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|91.35|FSC: 400601; BFG: 52|||91.35|FSC: 400601; BFG: 52|50.24|
30100053|EAP|CPT® 82135||0301 - LABORATORY - CHEMISTRY|Hc So Delta Ala|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|FSC: 400601; BFG: 52|||73.50|FSC: 400601; BFG: 52|40.42|
30100055|EAP|CPT® 82139||0301 - LABORATORY - CHEMISTRY|Hc So Amino Acids 6/> Quan Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|381.15|FSC: 400601; BFG: 52|||381.15|FSC: 400601; BFG: 52|209.63|
30100056|EAP|CPT® 82140||0301 - LABORATORY - CHEMISTRY|Hc Ammonia|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30100297|EAP|CPT® 82150||0301 - LABORATORY - CHEMISTRY|Hc Amylase|1|<Self-pay>|<Self-pay>|<Self-pay>|21.00|FSC: 400601; BFG: 52|||21.00|FSC: 400601; BFG: 52|11.55|
30100298|EAP|CPT® 82150||0301 - LABORATORY - CHEMISTRY|Hc So Amylase|1|<Self-pay>|<Self-pay>|<Self-pay>|21.00|FSC: 400601; BFG: 52|||21.00|FSC: 400601; BFG: 52|11.55|
30100058|EAP|CPT® 82157||0301 - LABORATORY - CHEMISTRY|Hc So Androstenedione|1|<Self-pay>|<Self-pay>|<Self-pay>|141.75|FSC: 400601; BFG: 52|||141.75|FSC: 400601; BFG: 52|77.96|
30100059|EAP|CPT® 82164||0301 - LABORATORY - CHEMISTRY|Hc So Angiotensin I Convering Enzyme|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30100294|EAP|CPT® 82175||0301 - LABORATORY - CHEMISTRY|Hc So Arsenic|1|<Self-pay>|<Self-pay>|<Self-pay>|63.00|FSC: 400601; BFG: 52|||63.00|FSC: 400601; BFG: 52|34.65|
30100061|EAP|CPT® 82180||0301 - LABORATORY - CHEMISTRY|Hc So Ascorbic Acid- Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|86.10|FSC: 400601; BFG: 52|||86.10|FSC: 400601; BFG: 52|47.35|
63600222|EAP|CPT® 90662||0636 - PHARMACY - DRUGS REQUIRING DETAILED CODING|Hc Influenza Vaccine Quadrivalent Split Virus Prsrv Free High Dose Im|1|<Self-pay>|<Self-pay>|<Self-pay>|86.00|FSC: 400601; BFG: 52|||86.00|FSC: 400601; BFG: 52|47.30|
30100302|EAP|CPT® 82232||0301 - LABORATORY - CHEMISTRY|Hc So Beta-2 Microglobulin|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
30100289|EAP|CPT® 82239||0301 - LABORATORY - CHEMISTRY|Hc So Bile Acids Total|1|<Self-pay>|<Self-pay>|<Self-pay>|56.70|FSC: 400601; BFG: 52|||56.70|FSC: 400601; BFG: 52|31.18|
30100064|EAP|CPT® 82247||0301 - LABORATORY - CHEMISTRY|Hc Bilirubin Total|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100065|EAP|CPT® 82248||0301 - LABORATORY - CHEMISTRY|Hc Bilirubin Direct|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100319|EAP|CPT® 82270||0301 - LABORATORY - CHEMISTRY|Hc Occult Blood Feces|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100067|EAP|CPT® 82271||0301 - LABORATORY - CHEMISTRY|Hc Occult Blood Other Sources|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
30100068|EAP|CPT® 82272||0301 - LABORATORY - CHEMISTRY|Hc Occult Blood 1-3 Tests|1|<Self-pay>|<Self-pay>|<Self-pay>|11.55|FSC: 400601; BFG: 52|||11.55|FSC: 400601; BFG: 52|6.35|
30100321|EAP|CPT® 82306||0301 - LABORATORY - CHEMISTRY|Hc So Vitamin D 25 Hydroxy|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
30100071|EAP|CPT® 82310||0301 - LABORATORY - CHEMISTRY|Hc Calcium Total|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100072|EAP|CPT® 82330||0301 - LABORATORY - CHEMISTRY|Hc Calcium Ionized|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100073|EAP|CPT® 82340||0301 - LABORATORY - CHEMISTRY|Hc Calcium Urine Quan Timed|1|<Self-pay>|<Self-pay>|<Self-pay>|19.95|FSC: 400601; BFG: 52|||19.95|FSC: 400601; BFG: 52|10.97|
30100074|EAP|CPT® 82365||0301 - LABORATORY - CHEMISTRY|Hc So Stone Infrared Spectroscopy|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30100076|EAP|CPT® 82374||0301 - LABORATORY - CHEMISTRY|Hc Carbon Dioxide (co2)|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
30100077|EAP|CPT® 82375||0301 - LABORATORY - CHEMISTRY|Hc Assay Carboxyhb Quant|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30100079|EAP|CPT® 82379||0301 - LABORATORY - CHEMISTRY|Hc So Carnitine Quan Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|64.62|FSC: 400601; BFG: 52|||64.62|FSC: 400601; BFG: 52|35.54|
30100080|EAP|CPT® 82380||0301 - LABORATORY - CHEMISTRY|Hc So Carotene|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
30100295|EAP|CPT® 82384||0301 - LABORATORY - CHEMISTRY|Hc So Catecholamines Fractionated|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30100299|EAP|CPT® 82397||0301 - LABORATORY - CHEMISTRY|Hc So Chemiluminescent Assay|1|<Self-pay>|<Self-pay>|<Self-pay>|183.75|FSC: 400601; BFG: 52|||183.75|FSC: 400601; BFG: 52|101.06|
30100082|EAP|CPT® 82435||0301 - LABORATORY - CHEMISTRY|Hc Chloride Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
30100085|EAP|CPT® 82441||0301 - LABORATORY - CHEMISTRY|Hc So Chlorinated Hc Screen|1|<Self-pay>|<Self-pay>|<Self-pay>|130.20|FSC: 400601; BFG: 52|||130.20|FSC: 400601; BFG: 52|71.61|
30100086|EAP|CPT® 82465||0301 - LABORATORY - CHEMISTRY|Hc Serum/wb Tot Cholest|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
30100322|EAP|CPT® 82465||0301 - LABORATORY - CHEMISTRY|Hc So Serum/wb Tot Cholest|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
12000003|EAP|Custom 12000003||0120 - ROOM & BOARD - SEMI-PRIVATE TWO BED (MEDICAL OR GENERAL) - GENERAL CLASSIFICATION|Hc Cch Ob|1|<Self-pay>|<Self-pay>|<Self-pay>|1,499.40|FSC: 400601; BFG: 52|||1,499.40|FSC: 400601; BFG: 52|824.67|
30100091|EAP|CPT® 82495||0301 - LABORATORY - CHEMISTRY|Hc So Chromium|1|<Self-pay>|<Self-pay>|<Self-pay>|50.70|FSC: 400601; BFG: 52|||50.70|FSC: 400601; BFG: 52|27.88|
30100092|EAP|CPT® 82507||0301 - LABORATORY - CHEMISTRY|Hc So Citrate|1|<Self-pay>|<Self-pay>|<Self-pay>|134.40|FSC: 400601; BFG: 52|||134.40|FSC: 400601; BFG: 52|73.92|
30100093|EAP|CPT® 82523||0301 - LABORATORY - CHEMISTRY|Hc So Collagen Cross Links - A|1|<Self-pay>|<Self-pay>|<Self-pay>|82.95|FSC: 400601; BFG: 52|||82.95|FSC: 400601; BFG: 52|45.62|
30100094|EAP|CPT® 82525||0301 - LABORATORY - CHEMISTRY|Hc So Copper|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30100095|EAP|CPT® 82530||0301 - LABORATORY - CHEMISTRY|Hc So Cortisol Free|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30100099|EAP|CPT® 82550||0301 - LABORATORY - CHEMISTRY|Hc Cpk Total|1|<Self-pay>|<Self-pay>|<Self-pay>|22.05|FSC: 400601; BFG: 52|||22.05|FSC: 400601; BFG: 52|12.13|
30100100|EAP|CPT® 82552||0301 - LABORATORY - CHEMISTRY|Hc So Cpk Isoenzymes|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30100864|EAP|CPT® 88720||0301 - LABORATORY - CHEMISTRY|Hc Cch Bilirubin Total Transcutaneous|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100102|EAP|CPT® 82565||0301 - LABORATORY - CHEMISTRY|Hc Creatinine Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30100305|EAP|CPT® 82570||0301 - LABORATORY - CHEMISTRY|Hc Creatinine Not Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
32000247|EAP|CPT® 77054||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Cch Radiology Mammary Ductogram Or Galactogram Multiple|1|<Self-pay>|<Self-pay>|<Self-pay>|621.60|FSC: 400601; BFG: 52|||621.60|FSC: 400601; BFG: 52|341.88|
30100103|EAP|CPT® 82575||0301 - LABORATORY - CHEMISTRY|Hc Creatinine Clearance|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
30100316|EAP|CPT® 82595||0301 - LABORATORY - CHEMISTRY|Hc So Cryoglobulin - Qual/semi Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|21.00|FSC: 400601; BFG: 52|||21.00|FSC: 400601; BFG: 52|11.55|
30100106|EAP|CPT® 82600||0301 - LABORATORY - CHEMISTRY|Hc So Cyanide|1|<Self-pay>|<Self-pay>|<Self-pay>|92.40|FSC: 400601; BFG: 52|||92.40|FSC: 400601; BFG: 52|50.82|
30100109|EAP|CPT® 82626||0301 - LABORATORY - CHEMISTRY|Hc So Dhea|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30100114|EAP|CPT® 82652||0301 - LABORATORY - CHEMISTRY|Hc So Vit D 1- 25-dihydroxy|1|<Self-pay>|<Self-pay>|<Self-pay>|127.05|FSC: 400601; BFG: 52|||127.05|FSC: 400601; BFG: 52|69.88|
30100308|EAP|CPT® 82657||0301 - LABORATORY - CHEMISTRY|Hc So Enzyme Activity Bc Not Ra - A|1|<Self-pay>|<Self-pay>|<Self-pay>|100.00|FSC: 400601; BFG: 52|||100.00|FSC: 400601; BFG: 52|55.00|
40200066|EAP|CPT® 76999||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Cch Ultrasound Unlisted|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
30100310|EAP|CPT® 82672||0301 - LABORATORY - CHEMISTRY|Hc So Estrogens Total|1|<Self-pay>|<Self-pay>|<Self-pay>|71.40|FSC: 400601; BFG: 52|||71.40|FSC: 400601; BFG: 52|39.27|
30100311|EAP|CPT® 82677||0301 - LABORATORY - CHEMISTRY|Hc So Estriol|1|<Self-pay>|<Self-pay>|<Self-pay>|123.90|FSC: 400601; BFG: 52|||123.90|FSC: 400601; BFG: 52|68.14|
30100118|EAP|CPT® 82679||0301 - LABORATORY - CHEMISTRY|Hc So Estrone|1|<Self-pay>|<Self-pay>|<Self-pay>|120.75|FSC: 400601; BFG: 52|||120.75|FSC: 400601; BFG: 52|66.41|
41000048|EAP|CPT® 31720||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Cch Nasotracheal Catheter Aspiration|1|<Self-pay>|<Self-pay>|<Self-pay>|498.75|FSC: 400601; BFG: 52|||498.75|FSC: 400601; BFG: 52|274.31|
30100312|EAP|CPT® 82710||0301 - LABORATORY - CHEMISTRY|Hc So Fat/lipids- Feces Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
30100318|EAP|CPT® 82784||0301 - LABORATORY - CHEMISTRY|Hc So Assay Iga/igd/igm Each|1|<Self-pay>|<Self-pay>|<Self-pay>|30.45|FSC: 400601; BFG: 52|||30.45|FSC: 400601; BFG: 52|16.75|
30100129|EAP|CPT® 82787||0301 - LABORATORY - CHEMISTRY|Hc So Igg 1/2/3/or 4 Each|1|<Self-pay>|<Self-pay>|<Self-pay>|26.25|FSC: 400601; BFG: 52|||26.25|FSC: 400601; BFG: 52|14.44|
30100130|EAP|CPT® 82800||0301 - LABORATORY - CHEMISTRY|Hc Blood Gas Ph Only|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
30100131|EAP|CPT® 82803||0301 - LABORATORY - CHEMISTRY|Hc Blood Gas Mixed Wo O2 Sat|1|<Self-pay>|<Self-pay>|<Self-pay>|69.30|FSC: 400601; BFG: 52|||69.30|FSC: 400601; BFG: 52|38.11|
42000073|EAP|CPT® 97597||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Debridement Wound Selective 1st 20 Sq Cm By Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|470.40|FSC: 400601; BFG: 52|||470.40|FSC: 400601; BFG: 52|258.72|
42000074|EAP|CPT® 97602||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Debridement Wound Nonselective By Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|470.40|FSC: 400601; BFG: 52|||470.40|FSC: 400601; BFG: 52|258.72|
30100138|EAP|CPT® 82945||0301 - LABORATORY - CHEMISTRY|Hc Glucose Body Fluid Other Than Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|12.60|FSC: 400601; BFG: 52|||12.60|FSC: 400601; BFG: 52|6.93|
30100314|EAP|CPT® 82947||0301 - LABORATORY - CHEMISTRY|Hc Glucose Quan Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30100139|EAP|CPT® 82948||0301 - LABORATORY - CHEMISTRY|Hc Glucose Blood Reagent Strip|1|<Self-pay>|<Self-pay>|<Self-pay>|11.55|FSC: 400601; BFG: 52|||11.55|FSC: 400601; BFG: 52|6.35|
30100140|EAP|CPT® 82950||0301 - LABORATORY - CHEMISTRY|Hc Glucose Post Glucose Dose|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
30100141|EAP|CPT® 82951||0301 - LABORATORY - CHEMISTRY|Hc Glucose Tolerance Test Incl 3 Specimens|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30100142|EAP|CPT® 82952||0301 - LABORATORY - CHEMISTRY|Hc Glucose Tolerance Test Ea Add'l Specimen|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30100143|EAP|CPT® 82955||0301 - LABORATORY - CHEMISTRY|Hc So G6pd Quantitative|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 400601; BFG: 52|||35.00|FSC: 400601; BFG: 52|19.25|
30100145|EAP|CPT® 82977||0301 - LABORATORY - CHEMISTRY|Hc Glutamyltransferase Gamma|1|<Self-pay>|<Self-pay>|<Self-pay>|24.15|FSC: 400601; BFG: 52|||24.15|FSC: 400601; BFG: 52|13.28|
30100146|EAP|CPT® 82985||0301 - LABORATORY - CHEMISTRY|Hc So Glycated Protein - A|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30100152|EAP|CPT® 83033||0301 - LABORATORY - CHEMISTRY|Hc So Hgb Fetal Qual|1|<Self-pay>|<Self-pay>|<Self-pay>|34.65|FSC: 400601; BFG: 52|||34.65|FSC: 400601; BFG: 52|19.06|
30100331|EAP|CPT® 83036||0301 - LABORATORY - CHEMISTRY|Hc So Hgb Glycosylated (a1c)|1|<Self-pay>|<Self-pay>|<Self-pay>|101.85|FSC: 400601; BFG: 52|||101.85|FSC: 400601; BFG: 52|56.02|
30100329|EAP|CPT® 83088||0301 - LABORATORY - CHEMISTRY|Hc So Histamine|1|<Self-pay>|<Self-pay>|<Self-pay>|492.45|FSC: 400601; BFG: 52|||492.45|FSC: 400601; BFG: 52|270.85|
30100335|EAP|CPT® 83090||0301 - LABORATORY - CHEMISTRY|Hc So Assay Of Homocystine|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30100159|EAP|CPT® 83491||0301 - LABORATORY - CHEMISTRY|Hc So 17-ohcs|1|<Self-pay>|<Self-pay>|<Self-pay>|138.60|FSC: 400601; BFG: 52|||138.60|FSC: 400601; BFG: 52|76.23|
30100160|EAP|CPT® 83497||0301 - LABORATORY - CHEMISTRY|Hc So 5-hiaa|1|<Self-pay>|<Self-pay>|<Self-pay>|91.35|FSC: 400601; BFG: 52|||91.35|FSC: 400601; BFG: 52|50.24|
43000070|EAP|CPT® 97597||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Debridement Wound Selective 1st 20 Sq Cm By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|470.40|FSC: 400601; BFG: 52|||470.40|FSC: 400601; BFG: 52|258.72|
30100161|EAP|CPT® 83498||0301 - LABORATORY - CHEMISTRY|Hc So Hydroxyprogesterone 17-d|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
30100162|EAP|CPT® 83500||0301 - LABORATORY - CHEMISTRY|Hc So Hydroxyproline Free|1|<Self-pay>|<Self-pay>|<Self-pay>|136.50|FSC: 400601; BFG: 52|||136.50|FSC: 400601; BFG: 52|75.07|
43000071|EAP|CPT® 97602||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Debridement Wound Nonselective By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|470.40|FSC: 400601; BFG: 52|||470.40|FSC: 400601; BFG: 52|258.72|
30100163|EAP|CPT® 83505||0301 - LABORATORY - CHEMISTRY|Hc So Hydroxyproline Total|1|<Self-pay>|<Self-pay>|<Self-pay>|116.55|FSC: 400601; BFG: 52|||116.55|FSC: 400601; BFG: 52|64.10|
30100337|EAP|CPT® 83516||0301 - LABORATORY - CHEMISTRY|Hc So Immunoassay- Nonantibody - A|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
30100333|EAP|CPT® 83519||0301 - LABORATORY - CHEMISTRY|Hc So Ria Nonantibody - A|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30100334|EAP|CPT® 83520||0301 - LABORATORY - CHEMISTRY|Hc So Immunoassay Quant Nos Nonab - A|1|<Self-pay>|<Self-pay>|<Self-pay>|46.20|FSC: 400601; BFG: 52|||46.20|FSC: 400601; BFG: 52|25.41|
30100338|EAP|CPT® 83525||0301 - LABORATORY - CHEMISTRY|Hc So Insulin Total|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
30100165|EAP|CPT® 83540||0301 - LABORATORY - CHEMISTRY|Hc Iron|1|<Self-pay>|<Self-pay>|<Self-pay>|21.00|FSC: 400601; BFG: 52|||21.00|FSC: 400601; BFG: 52|11.55|
30100167|EAP|CPT® 83593||0301 - LABORATORY - CHEMISTRY|Hc So Ketosteroids 17 Fractionation|1|<Self-pay>|<Self-pay>|<Self-pay>|151.20|FSC: 400601; BFG: 52|||151.20|FSC: 400601; BFG: 52|83.16|
30100168|EAP|CPT® 83605||0301 - LABORATORY - CHEMISTRY|Hc Lactate (lactic Acid)|1|<Self-pay>|<Self-pay>|<Self-pay>|123.90|FSC: 400601; BFG: 52|||123.90|FSC: 400601; BFG: 52|68.14|
30100169|EAP|CPT® 83615||0301 - LABORATORY - CHEMISTRY|Hc Lactate Dehydrogenase (ld) (ldh)|1|<Self-pay>|<Self-pay>|<Self-pay>|19.95|FSC: 400601; BFG: 52|||19.95|FSC: 400601; BFG: 52|10.97|
30100341|EAP|CPT® 83655||0301 - LABORATORY - CHEMISTRY|Hc So Lead - A|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30100174|EAP|CPT® 83690||0301 - LABORATORY - CHEMISTRY|Hc Lipase|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
30100175|EAP|CPT® 83695||0301 - LABORATORY - CHEMISTRY|Hc So Assay Of Lipoprotein (a)|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
30100342|EAP|CPT® 83701||0301 - LABORATORY - CHEMISTRY|Hc So Lipoprotein Bld- Hr Fraction|1|<Self-pay>|<Self-pay>|<Self-pay>|156.45|FSC: 400601; BFG: 52|||156.45|FSC: 400601; BFG: 52|86.05|
30100177|EAP|CPT® 83704||0301 - LABORATORY - CHEMISTRY|Hc So Lipoprotein Bld By Nmr|1|<Self-pay>|<Self-pay>|<Self-pay>|76.93|FSC: 400601; BFG: 52|||76.93|FSC: 400601; BFG: 52|42.31|
30100178|EAP|CPT® 83718||0301 - LABORATORY - CHEMISTRY|Hc Lipoprotein Hdl|1|<Self-pay>|<Self-pay>|<Self-pay>|27.30|FSC: 400601; BFG: 52|||27.30|FSC: 400601; BFG: 52|15.01|
30100400|EAP|CPT® 83721||0301 - LABORATORY - CHEMISTRY|Hc So Assay Of Blood Lipoprotein|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
30100180|EAP|CPT® 83735||0301 - LABORATORY - CHEMISTRY|Hc Magnesium|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
44400015|EAP|CPT® 92626||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Cch Eval Of Auditory Func For Candidacy Or Postop Status First Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|365.40|FSC: 400601; BFG: 52|||365.40|FSC: 400601; BFG: 52|200.97|
30100345|EAP|CPT® 83789||0301 - LABORATORY - CHEMISTRY|Hc So Quan Mass Spect  Ea Specimen - A|1|<Self-pay>|<Self-pay>|<Self-pay>|280.35|FSC: 400601; BFG: 52|||280.35|FSC: 400601; BFG: 52|154.19|
30100346|EAP|CPT® 83825||0301 - LABORATORY - CHEMISTRY|Hc So Mercury Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
44400016|EAP|CPT® 92627||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Cch Eval Of Auditory Func For Candidacy Or Postop Status Ea Addtl 15 Min|1|<Self-pay>|<Self-pay>|<Self-pay>|102.90|FSC: 400601; BFG: 52|||102.90|FSC: 400601; BFG: 52|56.59|
30100181|EAP|CPT® 83835||0301 - LABORATORY - CHEMISTRY|Hc So Metanephrines|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30100183|EAP|CPT® 83873||0301 - LABORATORY - CHEMISTRY|Hc So Myelin Basic Protein- Csf|1|<Self-pay>|<Self-pay>|<Self-pay>|56.70|FSC: 400601; BFG: 52|||56.70|FSC: 400601; BFG: 52|31.18|
45000011|EAP|CPT® 92977||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Cch Iv Infusion Coronary Thrombolysis|1|<Self-pay>|<Self-pay>|<Self-pay>|390.60|FSC: 400601; BFG: 52|||390.60|FSC: 400601; BFG: 52|214.83|
30100347|EAP|CPT® 83874||0301 - LABORATORY - CHEMISTRY|Hc So Myoglobin|1|<Self-pay>|<Self-pay>|<Self-pay>|114.45|FSC: 400601; BFG: 52|||114.45|FSC: 400601; BFG: 52|62.95|
30100186|EAP|CPT® 83880||0301 - LABORATORY - CHEMISTRY|Hc Natriueretic Peptide|1|<Self-pay>|<Self-pay>|<Self-pay>|298.20|FSC: 400601; BFG: 52|||298.20|FSC: 400601; BFG: 52|164.01|
30100348|EAP|CPT® 83880||0301 - LABORATORY - CHEMISTRY|Hc So Natriueretic Peptide|1|<Self-pay>|<Self-pay>|<Self-pay>|298.20|FSC: 400601; BFG: 52|||298.20|FSC: 400601; BFG: 52|164.01|
30100402|EAP|CPT® 83883||0301 - LABORATORY - CHEMISTRY|Hc So Nephelometry Ea Analyte Nes|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
45000014|EAP|Custom 45000014||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Cch Emergency Room Procedure Level 1|1|<Self-pay>|<Self-pay>|<Self-pay>|120.75|FSC: 400601; BFG: 52|||120.75|FSC: 400601; BFG: 52|66.41|
30100187|EAP|CPT® 83885||0301 - LABORATORY - CHEMISTRY|Hc So Nickel|1|<Self-pay>|<Self-pay>|<Self-pay>|55.15|FSC: 400601; BFG: 52|||55.15|FSC: 400601; BFG: 52|30.33|
30100403|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO NICOTINE|1|<Self-pay>|<Self-pay>|<Self-pay>|300.30|FSC: 400601; BFG: 52|||300.30|FSC: 400601; BFG: 52|165.16|
45000015|EAP|Custom 45000015||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Cch Emergency Room Procedure Level 2|1|<Self-pay>|<Self-pay>|<Self-pay>|225.75|FSC: 400601; BFG: 52|||225.75|FSC: 400601; BFG: 52|124.16|
45000016|EAP|Custom 45000016||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Cch Emergency Room Procedure Level 3|1|<Self-pay>|<Self-pay>|<Self-pay>|630.00|FSC: 400601; BFG: 52|||630.00|FSC: 400601; BFG: 52|346.50|
45000017|EAP|Custom 45000017||0450 - EMERGENCY ROOM - GENERAL CLASSIFICATION|Hc Cch Emergency Room Procedure Level 4|1|<Self-pay>|<Self-pay>|<Self-pay>|882.00|FSC: 400601; BFG: 52|||882.00|FSC: 400601; BFG: 52|485.10|
49000852|EAP|CPT® 19030||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Mammary Ductogram Or Galactogram|1|<Self-pay>|<Self-pay>|<Self-pay>|268.80|FSC: 400601; BFG: 52|||268.80|FSC: 400601; BFG: 52|147.84|
49000857|EAP|CPT® 64417||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Axillary Nerve|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000858|EAP|CPT® 64505||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Anesthetic Agent Sphenopalatine Ganglion|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
30100203|EAP|CPT® 83915||0301 - LABORATORY - CHEMISTRY|Hc So Assay Of Nucleotidase|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
30100206|EAP|CPT® 83921||0301 - LABORATORY - CHEMISTRY|Hc So Organic Acid- Single  Quant|1|<Self-pay>|<Self-pay>|<Self-pay>|56.70|FSC: 400601; BFG: 52|||56.70|FSC: 400601; BFG: 52|31.18|
30100210|EAP|CPT® 83937||0301 - LABORATORY - CHEMISTRY|Hc So Osteocalcin|1|<Self-pay>|<Self-pay>|<Self-pay>|144.90|FSC: 400601; BFG: 52|||144.90|FSC: 400601; BFG: 52|79.69|
30100211|EAP|CPT® 83945||0301 - LABORATORY - CHEMISTRY|Hc So Oxalate - A|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30100213|EAP|CPT® 84060||0301 - LABORATORY - CHEMISTRY|Hc So Total Acid Phosphatase|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
30100214|EAP|CPT® 84066||0301 - LABORATORY - CHEMISTRY|Hc So Prostatic Acid  Phosphatase|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|FSC: 400601; BFG: 52|||73.50|FSC: 400601; BFG: 52|40.42|
30100215|EAP|CPT® 84075||0301 - LABORATORY - CHEMISTRY|Hc Alkaline Phosphatase|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100373|EAP|CPT® 84080||0301 - LABORATORY - CHEMISTRY|Hc So Alkaline Phosphatase Isoenzym|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30100217|EAP|CPT® 84100||0301 - LABORATORY - CHEMISTRY|Hc Phosphate Inorganic|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
30100218|EAP|CPT® 84105||0301 - LABORATORY - CHEMISTRY|Hc Urine Phosphate|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
30100220|EAP|CPT® 84110||0301 - LABORATORY - CHEMISTRY|Hc So Porphobilinogen- Urine Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30100221|EAP|CPT® 84120||0301 - LABORATORY - CHEMISTRY|Hc So Quan Urine Porphyrins|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
30100222|EAP|CPT® 84126||0301 - LABORATORY - CHEMISTRY|Hc So Quan Fecal Porphyrins|1|<Self-pay>|<Self-pay>|<Self-pay>|316.05|FSC: 400601; BFG: 52|||316.05|FSC: 400601; BFG: 52|173.83|
30100223|EAP|CPT® 84132||0301 - LABORATORY - CHEMISTRY|Hc Assay Of Serum Potassium|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
30100224|EAP|CPT® 84133||0301 - LABORATORY - CHEMISTRY|Hc Potassium Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
73100005|EAP|CPT® 93271||0731 - EKG/ECG (ELECTROCARDIOGRAM) - HOLTER MONITOR|Hc Cch Event Monitoring And Analysis|1|<Self-pay>|<Self-pay>|<Self-pay>|308.70|FSC: 400601; BFG: 52|||308.70|FSC: 400601; BFG: 52|169.78|
30100226|EAP|CPT® 84143||0301 - LABORATORY - CHEMISTRY|Hc So 17-hydroxypregnenolone|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
30100392|EAP|CPT® 84153||0301 - LABORATORY - CHEMISTRY|Hc So Psa Total|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
92000042|EAP|HCPCS G0399||0920 - OTHER DIAGNOSTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Home Sleep Test|1|<Self-pay>|<Self-pay>|<Self-pay>|365.40|FSC: 400601; BFG: 52|||365.40|FSC: 400601; BFG: 52|200.97|
30100230|EAP|CPT® 84154||0301 - LABORATORY - CHEMISTRY|Hc So Psa Free|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
30100231|EAP|CPT® 84155||0301 - LABORATORY - CHEMISTRY|Hc Assay Of Protein Serum|1|<Self-pay>|<Self-pay>|<Self-pay>|12.60|FSC: 400601; BFG: 52|||12.60|FSC: 400601; BFG: 52|6.93|
94000036|EAP|CPT® 92953||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Temporary Transcutaneous Pacing|1|<Self-pay>|<Self-pay>|<Self-pay>|1,372.35|FSC: 400601; BFG: 52|||1,372.35|FSC: 400601; BFG: 52|754.79|
30100233|EAP|CPT® 84156||0301 - LABORATORY - CHEMISTRY|Hc Urine Total Protein|1|<Self-pay>|<Self-pay>|<Self-pay>|12.60|FSC: 400601; BFG: 52|||12.60|FSC: 400601; BFG: 52|6.93|
30100234|EAP|CPT® 84157||0301 - LABORATORY - CHEMISTRY|Hc Total Protein Other Specimen|1|<Self-pay>|<Self-pay>|<Self-pay>|12.60|FSC: 400601; BFG: 52|||12.60|FSC: 400601; BFG: 52|6.93|
94200029|EAP|HCPCS G0270||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Medical Nutrition Therapy Reevaluation Ind Per 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30100237|EAP|CPT® 84182||0301 - LABORATORY - CHEMISTRY|Hc So Protein Western Blot Im Id For Bands - A|1|<Self-pay>|<Self-pay>|<Self-pay>|73.03|FSC: 400601; BFG: 52|||73.03|FSC: 400601; BFG: 52|40.17|
30100238|EAP|CPT® 84202||0301 - LABORATORY - CHEMISTRY|Hc So Protoporphyrin- Rbc Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|69.30|FSC: 400601; BFG: 52|||69.30|FSC: 400601; BFG: 52|38.11|
94200030|EAP|HCPCS G0271||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Medical Nutrition Therapy Reevaluation Group Per 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|FSC: 400601; BFG: 52|||25.20|FSC: 400601; BFG: 52|13.86|
30100240|EAP|CPT® 84207||0301 - LABORATORY - CHEMISTRY|Hc So Vitamin B6|1|<Self-pay>|<Self-pay>|<Self-pay>|92.40|FSC: 400601; BFG: 52|||92.40|FSC: 400601; BFG: 52|50.82|
30100242|EAP|CPT® 84220||0301 - LABORATORY - CHEMISTRY|Hc So Pyruvate Kinase|1|<Self-pay>|<Self-pay>|<Self-pay>|130.20|FSC: 400601; BFG: 52|||130.20|FSC: 400601; BFG: 52|71.61|
30100375|EAP|CPT® 84238||0301 - LABORATORY - CHEMISTRY|Hc So Assay- Nonendocrine Receptor - A|1|<Self-pay>|<Self-pay>|<Self-pay>|120.75|FSC: 400601; BFG: 52|||120.75|FSC: 400601; BFG: 52|66.41|
30100393|EAP|CPT® 84244||0301 - LABORATORY - CHEMISTRY|Hc So Renin|1|<Self-pay>|<Self-pay>|<Self-pay>|72.45|FSC: 400601; BFG: 52|||72.45|FSC: 400601; BFG: 52|39.85|
30100244|EAP|CPT® 84252||0301 - LABORATORY - CHEMISTRY|Hc So Riboflavin|1|<Self-pay>|<Self-pay>|<Self-pay>|67.20|FSC: 400601; BFG: 52|||67.20|FSC: 400601; BFG: 52|36.96|
30100245|EAP|CPT® 84255||0301 - LABORATORY - CHEMISTRY|Hc So Selenium|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30100247|EAP|CPT® 84270||0301 - LABORATORY - CHEMISTRY|Hc So Sex Hormone Binding Globulin|1|<Self-pay>|<Self-pay>|<Self-pay>|110.25|FSC: 400601; BFG: 52|||110.25|FSC: 400601; BFG: 52|60.64|
30100249|EAP|CPT® 84295||0301 - LABORATORY - CHEMISTRY|Hc Assay Of Serum Sodium|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
30100250|EAP|CPT® 84300||0301 - LABORATORY - CHEMISTRY|Hc Sodium Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
30100377|EAP|CPT® 84311||0301 - LABORATORY - CHEMISTRY|Hc So Spectrophotometry- Analyte Nes - A|1|<Self-pay>|<Self-pay>|<Self-pay>|351.75|FSC: 400601; BFG: 52|||351.75|FSC: 400601; BFG: 52|193.46|
30100253|EAP|CPT® 84315||0301 - LABORATORY - CHEMISTRY|Hc Non-urine Specific Gravity|1|<Self-pay>|<Self-pay>|<Self-pay>|8.40|FSC: 400601; BFG: 52|||8.40|FSC: 400601; BFG: 52|4.62|
30100254|EAP|CPT® 84376||0301 - LABORATORY - CHEMISTRY|Hc So Sugars Single Qual- Ea Specimen|1|<Self-pay>|<Self-pay>|<Self-pay>|17.85|FSC: 400601; BFG: 52|||17.85|FSC: 400601; BFG: 52|9.82|
30100394|EAP|CPT® 84402||0301 - LABORATORY - CHEMISTRY|Hc So Testosterone Free|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30100378|EAP|CPT® 84403||0301 - LABORATORY - CHEMISTRY|Hc So Testosterone Total|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
30100379|EAP|CPT® 84425||0301 - LABORATORY - CHEMISTRY|Hc So Thiamine (vitamin B-1)|1|<Self-pay>|<Self-pay>|<Self-pay>|70.35|FSC: 400601; BFG: 52|||70.35|FSC: 400601; BFG: 52|38.69|
30100381|EAP|CPT® 84432||0301 - LABORATORY - CHEMISTRY|Hc So Thyroglobulin|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
30100395|EAP|CPT® 84436||0301 - LABORATORY - CHEMISTRY|Hc So Thyroxine Total|1|<Self-pay>|<Self-pay>|<Self-pay>|23.10|FSC: 400601; BFG: 52|||23.10|FSC: 400601; BFG: 52|12.70|
30100262|EAP|CPT® 84439||0301 - LABORATORY - CHEMISTRY|Hc Free Thyroxine|1|<Self-pay>|<Self-pay>|<Self-pay>|87.15|FSC: 400601; BFG: 52|||87.15|FSC: 400601; BFG: 52|47.93|
30100263|EAP|CPT® 84442||0301 - LABORATORY - CHEMISTRY|Hc So Thyroxine Binding Globulin|1|<Self-pay>|<Self-pay>|<Self-pay>|156.45|FSC: 400601; BFG: 52|||156.45|FSC: 400601; BFG: 52|86.05|
30100264|EAP|CPT® 84443||0301 - LABORATORY - CHEMISTRY|Hc Thyroid Stimulating Hormone|1|<Self-pay>|<Self-pay>|<Self-pay>|142.80|FSC: 400601; BFG: 52|||142.80|FSC: 400601; BFG: 52|78.54|
30100265|EAP|CPT® 84445||0301 - LABORATORY - CHEMISTRY|Hc So Thyroid Stimulating Immunoglobulins|1|<Self-pay>|<Self-pay>|<Self-pay>|168.00|FSC: 400601; BFG: 52|||168.00|FSC: 400601; BFG: 52|92.40|
30100266|EAP|CPT® 84446||0301 - LABORATORY - CHEMISTRY|Hc So Tocopherol Alpha (vit E)|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30100267|EAP|CPT® 84450||0301 - LABORATORY - CHEMISTRY|Hc Ast Or Sgot|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100268|EAP|CPT® 84460||0301 - LABORATORY - CHEMISTRY|Hc Transferase Alanine Amino|1|<Self-pay>|<Self-pay>|<Self-pay>|17.85|FSC: 400601; BFG: 52|||17.85|FSC: 400601; BFG: 52|9.82|
30100270|EAP|CPT® 84478||0301 - LABORATORY - CHEMISTRY|Hc Triglycerides|1|<Self-pay>|<Self-pay>|<Self-pay>|18.90|FSC: 400601; BFG: 52|||18.90|FSC: 400601; BFG: 52|10.39|
30100382|EAP|CPT® 84478||0301 - LABORATORY - CHEMISTRY|Hc So Tryiglycerides|1|<Self-pay>|<Self-pay>|<Self-pay>|18.90|FSC: 400601; BFG: 52|||18.90|FSC: 400601; BFG: 52|10.39|
30100398|EAP|CPT® 84481||0301 - LABORATORY - CHEMISTRY|Hc So T3 Free|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30100274|EAP|CPT® 84482||0301 - LABORATORY - CHEMISTRY|Hc So T3 Reverse|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
30100275|EAP|CPT® 84484||0301 - LABORATORY - CHEMISTRY|Hc Troponin Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
30100276|EAP|CPT® 84520||0301 - LABORATORY - CHEMISTRY|Hc Urea Nitrogen Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|27.30|FSC: 400601; BFG: 52|||27.30|FSC: 400601; BFG: 52|15.01|
30100277|EAP|CPT® 84540||0301 - LABORATORY - CHEMISTRY|Hc Urea Nitrogen Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|32.55|FSC: 400601; BFG: 52|||32.55|FSC: 400601; BFG: 52|17.90|
30100278|EAP|CPT® 84550||0301 - LABORATORY - CHEMISTRY|Hc Uric Acid Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
30100279|EAP|CPT® 84560||0301 - LABORATORY - CHEMISTRY|Hc Uric Acid Not Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
30100281|EAP|CPT® 84585||0301 - LABORATORY - CHEMISTRY|Hc So Vma- Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|51.45|FSC: 400601; BFG: 52|||51.45|FSC: 400601; BFG: 52|28.30|
30100282|EAP|CPT® 84588||0301 - LABORATORY - CHEMISTRY|Hc So Vasopressin|1|<Self-pay>|<Self-pay>|<Self-pay>|164.85|FSC: 400601; BFG: 52|||164.85|FSC: 400601; BFG: 52|90.67|
30100283|EAP|CPT® 84590||0301 - LABORATORY - CHEMISTRY|Hc So Vitamin A|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
30100384|EAP|CPT® 84591||0301 - LABORATORY - CHEMISTRY|Hc So Vitamin Nos - A|1|<Self-pay>|<Self-pay>|<Self-pay>|46.20|FSC: 400601; BFG: 52|||46.20|FSC: 400601; BFG: 52|25.41|
30100284|EAP|CPT® 84597||0301 - LABORATORY - CHEMISTRY|Hc So Vitamin K|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100285|EAP|CPT® 84620||0301 - LABORATORY - CHEMISTRY|Hc So Xylose Absorption- Blood &/or Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30100286|EAP|CPT® 84630||0301 - LABORATORY - CHEMISTRY|Hc So Zinc|1|<Self-pay>|<Self-pay>|<Self-pay>|37.80|FSC: 400601; BFG: 52|||37.80|FSC: 400601; BFG: 52|20.79|
30100386|EAP|CPT® 84702||0301 - LABORATORY - CHEMISTRY|Hc Hcg Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30100387|EAP|CPT® 84703||0301 - LABORATORY - CHEMISTRY|Hc Hcg Qual|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|FSC: 400601; BFG: 52|||25.20|FSC: 400601; BFG: 52|13.86|
30100389|EAP|CPT® 84999||0301 - LABORATORY - CHEMISTRY|Hc So Unlisted Chemistry Test - A|1|<Self-pay>|<Self-pay>|<Self-pay>|250.95|FSC: 400601; BFG: 52|||250.95|FSC: 400601; BFG: 52|138.02|
30200001|EAP|CPT® 86000||0302 - LABORATORY - IMMUNOLOGY|Hc So Agglutinins- Febrile|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30200108|EAP|CPT® 86003||0302 - LABORATORY - IMMUNOLOGY|Hc So Allergen Specific Ige- Ea - A|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30200109|EAP|CPT® 86021||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Id Leukocyte Ab - A|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|FSC: 400601; BFG: 52|||73.50|FSC: 400601; BFG: 52|40.42|
30200111|EAP|CPT® 86022||0302 - LABORATORY - IMMUNOLOGY|Hc So Hep Plt Aggregating Factor|1|<Self-pay>|<Self-pay>|<Self-pay>|191.10|FSC: 400601; BFG: 52|||191.10|FSC: 400601; BFG: 52|105.10|
30200005|EAP|CPT® 86060||0302 - LABORATORY - IMMUNOLOGY|Hc So Aso Titer|1|<Self-pay>|<Self-pay>|<Self-pay>|24.15|FSC: 400601; BFG: 52|||24.15|FSC: 400601; BFG: 52|13.28|
30200007|EAP|CPT® 86140||0302 - LABORATORY - IMMUNOLOGY|Hc C-reactive Protein|1|<Self-pay>|<Self-pay>|<Self-pay>|140.70|FSC: 400601; BFG: 52|||140.70|FSC: 400601; BFG: 52|77.38|
30200008|EAP|CPT® 86141||0302 - LABORATORY - IMMUNOLOGY|Hc So C-reactive Protein Hs|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30200168|EAP|CPT® 86147||0302 - LABORATORY - IMMUNOLOGY|Hc So Cardiolipin Ab- Ea Ig Class|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30200011|EAP|CPT® 86148||0302 - LABORATORY - IMMUNOLOGY|Hc So Anti-phosphatidylserine Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|77.70|FSC: 400601; BFG: 52|||77.70|FSC: 400601; BFG: 52|42.73|
30200012|EAP|CPT® 86156||0302 - LABORATORY - IMMUNOLOGY|Hc Cold Agglutinin Screen|1|<Self-pay>|<Self-pay>|<Self-pay>|20.18|FSC: 400601; BFG: 52|||20.18|FSC: 400601; BFG: 52|11.10|
30200113|EAP|CPT® 86160||0302 - LABORATORY - IMMUNOLOGY|Hc So Complement- Each|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200114|EAP|CPT® 86161||0302 - LABORATORY - IMMUNOLOGY|Hc So Complement Fcn Activity- Ea - A|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200019|EAP|CPT® 86226||0302 - LABORATORY - IMMUNOLOGY|Hc So Dna Ab Ss|1|<Self-pay>|<Self-pay>|<Self-pay>|126.00|FSC: 400601; BFG: 52|||126.00|FSC: 400601; BFG: 52|69.30|
30200026|EAP|CPT® 86235||0302 - LABORATORY - IMMUNOLOGY|Hc So Ena- Any Method - A|1|<Self-pay>|<Self-pay>|<Self-pay>|58.80|FSC: 400601; BFG: 52|||58.80|FSC: 400601; BFG: 52|32.34|
30200116|EAP|CPT® 86255||0302 - LABORATORY - IMMUNOLOGY|Hc So Fluorescent Noninf Agent Ab- Ea - A|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200169|EAP|CPT® 86256||0302 - LABORATORY - IMMUNOLOGY|Hc So Fluorescent Ab Titer- Ea Ab - A|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200118|EAP|CPT® 86300||0302 - LABORATORY - IMMUNOLOGY|Hc So Ca 15-3 (27.29)|1|<Self-pay>|<Self-pay>|<Self-pay>|69.30|FSC: 400601; BFG: 52|||69.30|FSC: 400601; BFG: 52|38.11|
30200023|EAP|CPT® 86308||0302 - LABORATORY - IMMUNOLOGY|Hc Qual Heterophile Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30200119|EAP|CPT® 86316||0302 - LABORATORY - IMMUNOLOGY|Hc So Tumor Marker- Immunoassay|1|<Self-pay>|<Self-pay>|<Self-pay>|69.30|FSC: 400601; BFG: 52|||69.30|FSC: 400601; BFG: 52|38.11|
30200120|EAP|CPT® 86317||0302 - LABORATORY - IMMUNOLOGY|Hc So Immunoassay Infectious Agent|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30200122|EAP|CPT® 86331||0302 - LABORATORY - IMMUNOLOGY|Hc So Gel- Diffusion/qual/nos|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200123|EAP|CPT® 86332||0302 - LABORATORY - IMMUNOLOGY|Hc So Immune Complex Assay|1|<Self-pay>|<Self-pay>|<Self-pay>|80.85|FSC: 400601; BFG: 52|||80.85|FSC: 400601; BFG: 52|44.47|
30200125|EAP|CPT® 86335||0302 - LABORATORY - IMMUNOLOGY|Hc So Immunofixation- Fluid|1|<Self-pay>|<Self-pay>|<Self-pay>|96.60|FSC: 400601; BFG: 52|||96.60|FSC: 400601; BFG: 52|53.13|
30200126|EAP|CPT® 86336||0302 - LABORATORY - IMMUNOLOGY|Hc So Inhibin A|1|<Self-pay>|<Self-pay>|<Self-pay>|51.45|FSC: 400601; BFG: 52|||51.45|FSC: 400601; BFG: 52|28.30|
30200029|EAP|CPT® 86337||0302 - LABORATORY - IMMUNOLOGY|Hc So Insulin Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|103.95|FSC: 400601; BFG: 52|||103.95|FSC: 400601; BFG: 52|57.17|
30200030|EAP|CPT® 86340||0302 - LABORATORY - IMMUNOLOGY|Hc So Intrinsic Factor Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
30200127|EAP|CPT® 86341||0302 - LABORATORY - IMMUNOLOGY|Hc So Islet Cell Antibody - A|1|<Self-pay>|<Self-pay>|<Self-pay>|65.10|FSC: 400601; BFG: 52|||65.10|FSC: 400601; BFG: 52|35.80|
30200031|EAP|CPT® 86353||0302 - LABORATORY - IMMUNOLOGY|Hc So Lymph Transform- Mitogen|1|<Self-pay>|<Self-pay>|<Self-pay>|233.10|FSC: 400601; BFG: 52|||233.10|FSC: 400601; BFG: 52|128.20|
30200129|EAP|CPT® 86480||0302 - LABORATORY - IMMUNOLOGY|Hc So Tb Test- Cell Immun Measure|1|<Self-pay>|<Self-pay>|<Self-pay>|200.55|FSC: 400601; BFG: 52|||200.55|FSC: 400601; BFG: 52|110.30|
30200132|EAP|CPT® 86592||0302 - LABORATORY - IMMUNOLOGY|Hc So Syphilis Test|1|<Self-pay>|<Self-pay>|<Self-pay>|13.65|FSC: 400601; BFG: 52|||13.65|FSC: 400601; BFG: 52|7.51|
30200045|EAP|CPT® 86603||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Adenovirus|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|FSC: 400601; BFG: 52|||98.70|FSC: 400601; BFG: 52|54.28|
30200134|EAP|CPT® 86606||0302 - LABORATORY - IMMUNOLOGY|Hc So Aspergillus Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30200047|EAP|CPT® 86611||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Bartonella|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30200048|EAP|CPT® 86615||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Bordetella|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30200049|EAP|CPT® 86617||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Lyme's (wb) Confirm - A|1|<Self-pay>|<Self-pay>|<Self-pay>|140.70|FSC: 400601; BFG: 52|||140.70|FSC: 400601; BFG: 52|77.38|
30200171|EAP|CPT® 86618||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Lyme's Disease|1|<Self-pay>|<Self-pay>|<Self-pay>|56.70|FSC: 400601; BFG: 52|||56.70|FSC: 400601; BFG: 52|31.18|
30200051|EAP|CPT® 86622||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Brucella|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30200053|EAP|CPT® 86628||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Candida|1|<Self-pay>|<Self-pay>|<Self-pay>|95.55|FSC: 400601; BFG: 52|||95.55|FSC: 400601; BFG: 52|52.55|
30200136|EAP|CPT® 86631||0302 - LABORATORY - IMMUNOLOGY|Hc So Chlamydia Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
30200055|EAP|CPT® 86638||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Coxiella Brunetii|1|<Self-pay>|<Self-pay>|<Self-pay>|60.00|FSC: 400601; BFG: 52|||60.00|FSC: 400601; BFG: 52|33.00|
30200138|EAP|CPT® 86644||0302 - LABORATORY - IMMUNOLOGY|Hc So Cytomegalovirus Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30200139|EAP|CPT® 86645||0302 - LABORATORY - IMMUNOLOGY|Hc So Cytomegalovirus Igm Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30200060|EAP|CPT® 86651||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Encephalitis- Calif|1|<Self-pay>|<Self-pay>|<Self-pay>|74.55|FSC: 400601; BFG: 52|||74.55|FSC: 400601; BFG: 52|41.00|
30200061|EAP|CPT® 86652||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Encephalitis- E Equine|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
30200062|EAP|CPT® 86653||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Encephalitis- St. Louis|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
30200063|EAP|CPT® 86654||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Encephalitis- W/ Equine|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
30200140|EAP|CPT® 86658||0302 - LABORATORY - IMMUNOLOGY|Hc So Enterovirus|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30200064|EAP|CPT® 86663||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Eb- Early Ag Virus|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30200065|EAP|CPT® 86664||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Ebna|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
30200067|EAP|CPT® 86668||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Francisella Tularensis|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
30200068|EAP|CPT® 86677||0302 - LABORATORY - IMMUNOLOGY|Hc Ab Helicobacter Pylori|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30200142|EAP|CPT® 86677||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Helicobacter Pylori|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30200069|EAP|CPT® 86684||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Hemophilus Influenza|1|<Self-pay>|<Self-pay>|<Self-pay>|76.65|FSC: 400601; BFG: 52|||76.65|FSC: 400601; BFG: 52|42.16|
30200147|EAP|CPT® 86689||0302 - LABORATORY - IMMUNOLOGY|Hc So Western Blot|1|<Self-pay>|<Self-pay>|<Self-pay>|155.40|FSC: 400601; BFG: 52|||155.40|FSC: 400601; BFG: 52|85.47|
30200071|EAP|CPT® 86692||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Hepatitis D|1|<Self-pay>|<Self-pay>|<Self-pay>|186.90|FSC: 400601; BFG: 52|||186.90|FSC: 400601; BFG: 52|102.79|
30200072|EAP|CPT® 86694||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Hsv- Non-specific|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30200149|EAP|CPT® 86695||0302 - LABORATORY - IMMUNOLOGY|Hc So Herpes Simplex- Type I|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30200172|EAP|CPT® 86696||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Hsv Ii|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
30200151|EAP|CPT® 86698||0302 - LABORATORY - IMMUNOLOGY|Hc So Histoplasma Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|76.65|FSC: 400601; BFG: 52|||76.65|FSC: 400601; BFG: 52|42.16|
30200152|EAP|CPT® 86703||0302 - LABORATORY - IMMUNOLOGY|Hc So Anti Hiv 1\hiv 2|1|<Self-pay>|<Self-pay>|<Self-pay>|118.65|FSC: 400601; BFG: 52|||118.65|FSC: 400601; BFG: 52|65.26|
30200153|EAP|CPT® 86704||0302 - LABORATORY - IMMUNOLOGY|Hc So Hepatitis B Core Ab- Total|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200154|EAP|CPT® 86706||0302 - LABORATORY - IMMUNOLOGY|Hc So Hepatitis B Surf Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|35.70|FSC: 400601; BFG: 52|||35.70|FSC: 400601; BFG: 52|19.63|
30200155|EAP|CPT® 86710||0302 - LABORATORY - IMMUNOLOGY|Hc So Influenza Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|70.35|FSC: 400601; BFG: 52|||70.35|FSC: 400601; BFG: 52|38.69|
30200084|EAP|CPT® 86720||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Leptospira|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
30200156|EAP|CPT® 86735||0302 - LABORATORY - IMMUNOLOGY|Hc So Mumps Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30200173|EAP|CPT® 86738||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Mycoplasma|1|<Self-pay>|<Self-pay>|<Self-pay>|82.95|FSC: 400601; BFG: 52|||82.95|FSC: 400601; BFG: 52|45.62|
30200088|EAP|CPT® 86747||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Parvovirus|1|<Self-pay>|<Self-pay>|<Self-pay>|72.45|FSC: 400601; BFG: 52|||72.45|FSC: 400601; BFG: 52|39.85|
30200090|EAP|CPT® 86756||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Rsv|1|<Self-pay>|<Self-pay>|<Self-pay>|80.85|FSC: 400601; BFG: 52|||80.85|FSC: 400601; BFG: 52|44.47|
30200160|EAP|CPT® 86762||0302 - LABORATORY - IMMUNOLOGY|Hc So Rubella Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30200174|EAP|CPT® 86765||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Rubeola|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30200092|EAP|CPT® 86768||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Salmonella|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
30200096|EAP|CPT® 86780||0302 - LABORATORY - IMMUNOLOGY|Hc So Treponema Pallidum|1|<Self-pay>|<Self-pay>|<Self-pay>|44.10|FSC: 400601; BFG: 52|||44.10|FSC: 400601; BFG: 52|24.25|
30200161|EAP|CPT® 86787||0302 - LABORATORY - IMMUNOLOGY|Hc So Varicella Zoster Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30200162|EAP|CPT® 86790||0302 - LABORATORY - IMMUNOLOGY|Hc So Viral Antibody Nos - A|1|<Self-pay>|<Self-pay>|<Self-pay>|131.25|FSC: 400601; BFG: 52|||131.25|FSC: 400601; BFG: 52|72.19|
30200163|EAP|CPT® 86803||0302 - LABORATORY - IMMUNOLOGY|Hc So Hepatitis C Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30200101|EAP|CPT® 86804||0302 - LABORATORY - IMMUNOLOGY|Hc So Hepatitis C Confirmation|1|<Self-pay>|<Self-pay>|<Self-pay>|205.80|FSC: 400601; BFG: 52|||205.80|FSC: 400601; BFG: 52|113.19|
30200165|EAP|CPT® 86812||0302 - LABORATORY - IMMUNOLOGY|Hc So Hla Typing- Ea Antigen|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
30200166|EAP|CPT® 86813||0302 - LABORATORY - IMMUNOLOGY|Hc So Hla Type A/ B/ C/ Multi Ag|1|<Self-pay>|<Self-pay>|<Self-pay>|276.15|FSC: 400601; BFG: 52|||276.15|FSC: 400601; BFG: 52|151.88|
30500001|EAP|CPT® 85007||0305 - LABORATORY - HEMATOLOGY|Hc Bl Smear W/ Diff Wbc Count|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30500002|EAP|CPT® 85014||0305 - LABORATORY - HEMATOLOGY|Hc Hematocrit|1|<Self-pay>|<Self-pay>|<Self-pay>|7.35|FSC: 400601; BFG: 52|||7.35|FSC: 400601; BFG: 52|4.04|
30500003|EAP|CPT® 85018||0305 - LABORATORY - HEMATOLOGY|Hc Hemoglobin|1|<Self-pay>|<Self-pay>|<Self-pay>|27.30|FSC: 400601; BFG: 52|||27.30|FSC: 400601; BFG: 52|15.01|
30500004|EAP|CPT® 85025||0305 - LABORATORY - HEMATOLOGY|Hc Cbc Ediff & Platelet|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
30500051|EAP|CPT® 85027||0305 - LABORATORY - HEMATOLOGY|Hc Cbc & Platelet|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30500052|EAP|CPT® 85048||0305 - LABORATORY - HEMATOLOGY|Hc Wbc Count|1|<Self-pay>|<Self-pay>|<Self-pay>|8.40|FSC: 400601; BFG: 52|||8.40|FSC: 400601; BFG: 52|4.62|
30500006|EAP|CPT® 85049||0305 - LABORATORY - HEMATOLOGY|Hc Platelet Count|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|FSC: 400601; BFG: 52|||14.70|FSC: 400601; BFG: 52|8.08|
30500011|EAP|CPT® 85240||0305 - LABORATORY - HEMATOLOGY|Hc Clotting Factor Viii|1|<Self-pay>|<Self-pay>|<Self-pay>|44.75|FSC: 400601; BFG: 52|||44.75|FSC: 400601; BFG: 52|24.61|
30500013|EAP|CPT® 85246||0305 - LABORATORY - HEMATOLOGY|Hc So Clotting: Factor Viii- Vw Factor Ag|1|<Self-pay>|<Self-pay>|<Self-pay>|75.60|FSC: 400601; BFG: 52|||75.60|FSC: 400601; BFG: 52|41.58|
30500018|EAP|CPT® 85280||0305 - LABORATORY - HEMATOLOGY|Hc So Clotting Factor Xii|1|<Self-pay>|<Self-pay>|<Self-pay>|213.15|FSC: 400601; BFG: 52|||213.15|FSC: 400601; BFG: 52|117.23|
30500022|EAP|CPT® 85302||0305 - LABORATORY - HEMATOLOGY|Hc So Clotting Inhibitor Protein C Ag|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30500023|EAP|CPT® 85303||0305 - LABORATORY - HEMATOLOGY|Hc Clotting Inhibitor Protein C Activity|1|<Self-pay>|<Self-pay>|<Self-pay>|34.60|FSC: 400601; BFG: 52|||34.60|FSC: 400601; BFG: 52|19.03|
30500024|EAP|CPT® 85305||0305 - LABORATORY - HEMATOLOGY|Hc So Clotting Inhibitor Protein S- Total|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
30500025|EAP|CPT® 85306||0305 - LABORATORY - HEMATOLOGY|Hc So Protein S- Free|1|<Self-pay>|<Self-pay>|<Self-pay>|60.00|FSC: 400601; BFG: 52|||60.00|FSC: 400601; BFG: 52|33.00|
30500026|EAP|CPT® 85307||0305 - LABORATORY - HEMATOLOGY|Hc So Activated Protein C Resistance|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
30500029|EAP|CPT® 85379||0305 - LABORATORY - HEMATOLOGY|Hc D-dimer - Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30500030|EAP|CPT® 85384||0305 - LABORATORY - HEMATOLOGY|Hc Fibrinogen Activity|1|<Self-pay>|<Self-pay>|<Self-pay>|28.35|FSC: 400601; BFG: 52|||28.35|FSC: 400601; BFG: 52|15.59|
30200253|EAP|CPT® 86355||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So B Cells Total Count|1|<Self-pay>|<Self-pay>|<Self-pay>|121.80|FSC: 400601; BFG: 52|||121.80|FSC: 400601; BFG: 52|66.99|
30500056|EAP|CPT® 85415||0305 - LABORATORY - HEMATOLOGY|Hc So Plasminogen|1|<Self-pay>|<Self-pay>|<Self-pay>|199.50|FSC: 400601; BFG: 52|||199.50|FSC: 400601; BFG: 52|109.72|
30200254|EAP|CPT® 86357||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Nk Cells Total Count|1|<Self-pay>|<Self-pay>|<Self-pay>|121.80|FSC: 400601; BFG: 52|||121.80|FSC: 400601; BFG: 52|66.99|
30200255|EAP|CPT® 86359||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So T Cells Total Count|1|<Self-pay>|<Self-pay>|<Self-pay>|121.80|FSC: 400601; BFG: 52|||121.80|FSC: 400601; BFG: 52|66.99|
30200256|EAP|CPT® 86360||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So T Cells Absol Cd4 And Cd8|1|<Self-pay>|<Self-pay>|<Self-pay>|152.25|FSC: 400601; BFG: 52|||152.25|FSC: 400601; BFG: 52|83.74|
30500036|EAP|CPT® 85540||0305 - LABORATORY - HEMATOLOGY|Hc So Leukocyte Alk Phos W/ Count|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30500037|EAP|CPT® 85549||0305 - LABORATORY - HEMATOLOGY|Hc So Muramidase|1|<Self-pay>|<Self-pay>|<Self-pay>|61.95|FSC: 400601; BFG: 52|||61.95|FSC: 400601; BFG: 52|34.07|
30500093|EAP|CPT® 85670||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Thrombin Time Plasma|1|<Self-pay>|<Self-pay>|<Self-pay>|130.20|FSC: 400601; BFG: 52|||130.20|FSC: 400601; BFG: 52|71.61|
30500040|EAP|CPT® 85610||0305 - LABORATORY - HEMATOLOGY|Hc Prothombin Time|1|<Self-pay>|<Self-pay>|<Self-pay>|27.30|FSC: 400601; BFG: 52|||27.30|FSC: 400601; BFG: 52|15.01|
30500043|EAP|CPT® 85651||0305 - LABORATORY - HEMATOLOGY|Hc Nonauto Erythrocyte Sed Rate|1|<Self-pay>|<Self-pay>|<Self-pay>|11.55|FSC: 400601; BFG: 52|||11.55|FSC: 400601; BFG: 52|6.35|
30500047|EAP|CPT® 85730||0305 - LABORATORY - HEMATOLOGY|Hc Ptt Plasma Or Whole Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30700001|EAP|CPT® 81000||0307 - LABORATORY - UROLOGY|Hc Urinalysis Total Non-automated W/ Micro|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|FSC: 400601; BFG: 52|||25.20|FSC: 400601; BFG: 52|13.86|
30700002|EAP|CPT® 81001||0307 - LABORATORY - UROLOGY|Hc Urinalysis Total Automated W/ Micro|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
30700003|EAP|CPT® 81002||0307 - LABORATORY - UROLOGY|Hc Urinalysis Total Non-automated W/o Micro|1|<Self-pay>|<Self-pay>|<Self-pay>|19.95|FSC: 400601; BFG: 52|||19.95|FSC: 400601; BFG: 52|10.97|
30700004|EAP|CPT® 81003||0307 - LABORATORY - UROLOGY|Hc Urinalysis Total Automated W/o Micro|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
30700005|EAP|CPT® 81015||0307 - LABORATORY - UROLOGY|Hc Urinalysis Microscopic Only|1|<Self-pay>|<Self-pay>|<Self-pay>|10.50|FSC: 400601; BFG: 52|||10.50|FSC: 400601; BFG: 52|5.77|
30700007|EAP|CPT® 81025||0307 - LABORATORY - UROLOGY|Hc Urine Pregnancy Visual Color|1|<Self-pay>|<Self-pay>|<Self-pay>|23.10|FSC: 400601; BFG: 52|||23.10|FSC: 400601; BFG: 52|12.70|
30700008|EAP|CPT® 81050||0307 - LABORATORY - UROLOGY|Hc Timed Urine Vol Measure Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30600090|EAP|CPT® 87015||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Concentration For Infect Agent|1|<Self-pay>|<Self-pay>|<Self-pay>|57.75|FSC: 400601; BFG: 52|||57.75|FSC: 400601; BFG: 52|31.76|
30600017|EAP|CPT® 87109||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Culture- Mycoplasma - A|1|<Self-pay>|<Self-pay>|<Self-pay>|50.40|FSC: 400601; BFG: 52|||50.40|FSC: 400601; BFG: 52|27.72|
30600021|EAP|CPT® 87147||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Culture Immunologic Per Antiserum|1|<Self-pay>|<Self-pay>|<Self-pay>|50.00|FSC: 400601; BFG: 52|||50.00|FSC: 400601; BFG: 52|27.50|
30600093|EAP|CPT® 87186||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Microbe Susceptible- Mic - A|1|<Self-pay>|<Self-pay>|<Self-pay>|42.00|FSC: 400601; BFG: 52|||42.00|FSC: 400601; BFG: 52|23.10|
30600041|EAP|CPT® 87207||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Smear- Special Stain|1|<Self-pay>|<Self-pay>|<Self-pay>|95.55|FSC: 400601; BFG: 52|||95.55|FSC: 400601; BFG: 52|52.55|
30600036|EAP|CPT® 87209||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Smear Complex Stain|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30600037|EAP|CPT® 87210||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Smear - Infectious Wet Mount|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
30600096|EAP|CPT® 87253||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Virus Isolate Add'l Or Id|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
30600097|EAP|CPT® 87254||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Virus Isol- Shell Vial Techn|1|<Self-pay>|<Self-pay>|<Self-pay>|51.45|FSC: 400601; BFG: 52|||51.45|FSC: 400601; BFG: 52|28.30|
30600098|EAP|CPT® 87329||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Giardia Ag- Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30600051|EAP|CPT® 87338||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Hpylori Stool- Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30600099|EAP|CPT® 87340||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Hepatitis B Surface Ag- Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|34.65|FSC: 400601; BFG: 52|||34.65|FSC: 400601; BFG: 52|19.06|
30600102|EAP|CPT® 87385||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Histoplasma Capsule Ag- Eia - A|1|<Self-pay>|<Self-pay>|<Self-pay>|187.95|FSC: 400601; BFG: 52|||187.95|FSC: 400601; BFG: 52|103.37|
30600058|EAP|CPT® 87420||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Resp Syncytial Ag Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30000093|EAP|CPT® 99000||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Cch Specimen Handling|1|<Self-pay>|<Self-pay>|<Self-pay>|42.00|FSC: 400601; BFG: 52|||42.00|FSC: 400601; BFG: 52|23.10|
30600101|EAP|CPT® 87449||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Infectious Agent Antigen - Multi Step|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30600063|EAP|CPT® 87480||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Candida Na Direct Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
30600103|EAP|CPT® 87491||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Chlamydia Trachomatis Amplif Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
30600066|EAP|CPT® 87496||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Cytomegalov Amplif Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
30600070|EAP|CPT® 87510||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Gardnerella Dir Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
30600071|EAP|CPT® 87517||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Hep-b Na Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|141.75|FSC: 400601; BFG: 52|||141.75|FSC: 400601; BFG: 52|77.96|
30600105|EAP|CPT® 87521||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|HC SO HEP-C, AMPLIF NA PROBE|1|<Self-pay>|<Self-pay>|<Self-pay>|355.95|FSC: 400601; BFG: 52|||355.95|FSC: 400601; BFG: 52|195.77|
30600106|EAP|CPT® 87522||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|HC SO HEP-C, NA QUAN|1|<Self-pay>|<Self-pay>|<Self-pay>|141.75|FSC: 400601; BFG: 52|||141.75|FSC: 400601; BFG: 52|77.96|
30600074|EAP|CPT® 87529||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Herpes S- Amplif Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
30600119|EAP|CPT® 87902||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Hepatitis C - Dna Or Rna|1|<Self-pay>|<Self-pay>|<Self-pay>|850.50|FSC: 400601; BFG: 52|||850.50|FSC: 400601; BFG: 52|467.77|
30600108|EAP|CPT® 87536||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|HC SO HIV-1, NA QUAN|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
71000003|EAP|Custom 71000003||0710 - RECOVERY ROOM - GENERAL CLASSIFICATION|Hc Phase Ii Recovery First 30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|147.00|FSC: 400601; BFG: 52|||147.00|FSC: 400601; BFG: 52|80.85|
30600111|EAP|CPT® 87591||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Neisseria Amplif Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
71000004|EAP|Custom 71000004||0710 - RECOVERY ROOM - GENERAL CLASSIFICATION|Hc Phase Ii Recovery Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|24.15|FSC: 400601; BFG: 52|||24.15|FSC: 400601; BFG: 52|13.28|
30600083|EAP|CPT® 87660||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Trichomonas Vagin Dir Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
30600113|EAP|CPT® 87798||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Amplif Na Probe Nos Agent|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
30600115|EAP|CPT® 87799||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Na Quan Nos Agent|1|<Self-pay>|<Self-pay>|<Self-pay>|141.75|FSC: 400601; BFG: 52|||141.75|FSC: 400601; BFG: 52|77.96|
30600116|EAP|CPT® 87801||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Dna/rna Multi Org  - Amp Pr|1|<Self-pay>|<Self-pay>|<Self-pay>|232.05|FSC: 400601; BFG: 52|||232.05|FSC: 400601; BFG: 52|127.63|
30600118|EAP|CPT® 87899||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Agent Nos Assay W/optic|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
31200003|EAP|CPT® 88304||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Surg Path Level Iii|1|<Self-pay>|<Self-pay>|<Self-pay>|133.00|FSC: 400601; BFG: 52|||133.00|FSC: 400601; BFG: 52|73.15|
31200023|EAP|CPT® 88305||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Surg Path Level Iv Except Prostate Needle Biopsy|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
31200013|EAP|CPT® 88313||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Special Stains Group 2|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
31200019|EAP|CPT® 88348||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Electron Microscopy Diagnostic|1|<Self-pay>|<Self-pay>|<Self-pay>|1,059.45|FSC: 400601; BFG: 52|||1,059.45|FSC: 400601; BFG: 52|582.70|
31200021|EAP|CPT® 88365||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Insitu Hybridization (fish) Per Speciman Initial|1|<Self-pay>|<Self-pay>|<Self-pay>|352.00|FSC: 400601; BFG: 52|||352.00|FSC: 400601; BFG: 52|193.60|
31100019|EAP|CPT® 88184||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc So Flow Cytometry Tc 1st Marker|1|<Self-pay>|<Self-pay>|<Self-pay>|576.45|FSC: 400601; BFG: 52|||576.45|FSC: 400601; BFG: 52|317.05|
31100020|EAP|CPT® 88185||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc So Flow Cytometry Ea Addl Marker|1|<Self-pay>|<Self-pay>|<Self-pay>|138.60|FSC: 400601; BFG: 52|||138.60|FSC: 400601; BFG: 52|76.23|
76200001|EAP|HCPCS G0378||0762 - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM|Hc Observation|1|<Self-pay>|<Self-pay>|<Self-pay>|67.20|FSC: 400601; BFG: 52|||67.20|FSC: 400601; BFG: 52|36.96|
76200002|EAP|HCPCS G0378||0762 - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM|Hc Observation|1|<Self-pay>|<Self-pay>|<Self-pay>|76.65|FSC: 400601; BFG: 52|||76.65|FSC: 400601; BFG: 52|42.16|
27207030|EAP|Custom 27207030||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Forcep Biopsy Egd|1|<Self-pay>|<Self-pay>|<Self-pay>|51.05|FSC: 400601; BFG: 52|||51.05|FSC: 400601; BFG: 52|28.08|
27207037|EAP|Custom 27207037||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Retriever Rothnet Fb|1|<Self-pay>|<Self-pay>|<Self-pay>|563.35|FSC: 400601; BFG: 52|||563.35|FSC: 400601; BFG: 52|309.84|
28291|EAP|CPT® 28291|||HALLUX RIGIDUS W/CHEILECTOMY 1ST MP JT W/IMPLT|1|<Self-pay>|<Self-pay>|<Self-pay>|1,083.00|FSC: 46100; BFG: 52|||1,083.00|FSC: 46100; BFG: 52|595.65|
62321|EAP|CPT® 62321|||NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN|1|<Self-pay>|<Self-pay>|<Self-pay>|358.00|FSC: 46100; BFG: 52|||358.00|FSC: 46100; BFG: 52|196.90|
62323|EAP|CPT® 62323|||NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN|1|<Self-pay>|<Self-pay>|<Self-pay>|353.00|FSC: 46100; BFG: 52|||353.00|FSC: 46100; BFG: 52|194.15|
30102026|EAP|CPT® 81403||0302 - LABORATORY - IMMUNOLOGY|HC CCH SO JAK2 EXON 12 MUTATION|1|<Self-pay>|<Self-pay>|<Self-pay>|416.70|FSC: 400601; BFG: 52|||416.70|FSC: 400601; BFG: 52|229.18|
11045|EAP|CPT® 11045|||Pr Debridement, Skin, Sub-q Tissue,each Add 20 Sq Cm|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
99224|EAP|CPT® 99224|||SBSQ OBSERVATION CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|65.00|FSC: 46100; BFG: 52|||65.00|FSC: 46100; BFG: 52|35.75|
99225|EAP|CPT® 99225|||SBSQ OBSERVATION CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
99226|EAP|CPT® 99226|||SBSQ OBSERVATION CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|160.00|FSC: 46100; BFG: 52|||160.00|FSC: 46100; BFG: 52|88.00|
49000873|EAP|CPT® 62321||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Epidural Or Subarachnoid Cervical Or Thoracic For Pain Mgmt W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,483.65|FSC: 400601; BFG: 52|||1,483.65|FSC: 400601; BFG: 52|816.01|
49000875|EAP|CPT® 62323||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Epidural Or Subarachnoid Lumbar Or Sacral (caudal) For Pain Mgmt W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,483.65|FSC: 400601; BFG: 52|||1,483.65|FSC: 400601; BFG: 52|816.01|
49000879|EAP|CPT® 62327||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Placement Epidural Lumbar/sacral Cont Infusion For Pain Mgmt W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,835.40|FSC: 400601; BFG: 52|||1,835.40|FSC: 400601; BFG: 52|1,009.47|
42400005|EAP|CPT® 97161||0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Pt Evaluation Low Complexity|1|<Self-pay>|<Self-pay>|<Self-pay>|217.35|FSC: 400601; BFG: 52|||217.35|FSC: 400601; BFG: 52|119.54|
42400006|EAP|CPT® 97162||0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Pt Evaluation Moderate Complexity|1|<Self-pay>|<Self-pay>|<Self-pay>|282.45|FSC: 400601; BFG: 52|||282.45|FSC: 400601; BFG: 52|155.35|
42400007|EAP|CPT® 97163||0424 - PHYSICAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Pt Evaluation High Complexity|1|<Self-pay>|<Self-pay>|<Self-pay>|217.35|FSC: 400601; BFG: 52|||217.35|FSC: 400601; BFG: 52|119.54|
43400007|EAP|CPT® 97165||0434 - OCCUPATIONAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Ot Evaluation Low Complexity|1|<Self-pay>|<Self-pay>|<Self-pay>|204.75|FSC: 400601; BFG: 52|||204.75|FSC: 400601; BFG: 52|112.61|
43400008|EAP|CPT® 97166||0434 - OCCUPATIONAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Ot Evaluation Moderate Complexity|1|<Self-pay>|<Self-pay>|<Self-pay>|206.85|FSC: 400601; BFG: 52|||206.85|FSC: 400601; BFG: 52|113.77|
43400009|EAP|CPT® 97167||0434 - OCCUPATIONAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Ot Evaluation High Complexity|1|<Self-pay>|<Self-pay>|<Self-pay>|208.95|FSC: 400601; BFG: 52|||208.95|FSC: 400601; BFG: 52|114.92|
37000018|EAP|CPT® 99151||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Cch Mod Sedation < 5 Yrs Initial 15 Mins Same Md|1|<Self-pay>|<Self-pay>|<Self-pay>|156.45|FSC: 400601; BFG: 52|||156.45|FSC: 400601; BFG: 52|86.05|
37000020|EAP|CPT® 99152||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Mod Sedation > 5 Yrs Initial 15 Mins Same Md|1|<Self-pay>|<Self-pay>|<Self-pay>|151.20|FSC: 400601; BFG: 52|||151.20|FSC: 400601; BFG: 52|83.16|
37000019|EAP|CPT® 99153||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Mod Sedation Ea Addl 15 Mins Same Md|1|<Self-pay>|<Self-pay>|<Self-pay>|65.10|FSC: 400601; BFG: 52|||65.10|FSC: 400601; BFG: 52|35.80|
27207072|EAP|Custom 27207072||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Valve Bronch Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|19.55|FSC: 400601; BFG: 52|||19.55|FSC: 400601; BFG: 52|10.75|
30500094|EAP|CPT® 85362||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Fibrin Degradation Products|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
25800003|EAP|Custom 25800003||0258 - PHARMACY - IV SOLUTIONS|Hc Cch Dex 10% 1000ml|1|<Self-pay>|<Self-pay>|<Self-pay>|82.85|FSC: 400601; BFG: 52|||82.85|FSC: 400601; BFG: 52|45.57|
49000893|EAP|CPT® 63661||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Removal Spinal Neurostimulator Electrode Perc Array Includes Fluoro|1|<Self-pay>|<Self-pay>|<Self-pay>|4,312.35|FSC: 400601; BFG: 52|||4,312.35|FSC: 400601; BFG: 52|2,371.79|
49000894|EAP|CPT® 63663||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Revision Includes Replacement Of Spinal Neurostimulator Electrode Perc Array Includes Fluoro|1|<Self-pay>|<Self-pay>|<Self-pay>|16,214.10|FSC: 400601; BFG: 52|||16,214.10|FSC: 400601; BFG: 52|8,917.75|
49000895|EAP|CPT® 63685||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Insert/replace Spinal Neurostimulator Pulse Generator/receiver Direct/inductive Coupling|1|<Self-pay>|<Self-pay>|<Self-pay>|58,165.49|FSC: 400601; BFG: 52|||58,165.49|FSC: 400601; BFG: 52|31,991.02|
49000896|EAP|CPT® 63688||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Revision/removal Implanted Spinal Neurostimulator Pulse Generator/receiver|1|<Self-pay>|<Self-pay>|<Self-pay>|7,709.10|FSC: 400601; BFG: 52|||7,709.10|FSC: 400601; BFG: 52|4,240.00|
27207101|EAP|Custom 27207101||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Set Pneumothorax Wayne 14fr|1|<Self-pay>|<Self-pay>|<Self-pay>|992.50|FSC: 400601; BFG: 52|||992.50|FSC: 400601; BFG: 52|545.87|
27207106|EAP|Custom 27207106||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sensor Spo2 Neonatal Lncs Masimo|1|<Self-pay>|<Self-pay>|<Self-pay>|94.00|FSC: 400601; BFG: 52|||94.00|FSC: 400601; BFG: 52|51.70|
27207115|EAP|Custom 27207115||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Detector Co2 End Tidial Temp Controlled Below 75|1|<Self-pay>|<Self-pay>|<Self-pay>|72.35|FSC: 400601; BFG: 52|||72.35|FSC: 400601; BFG: 52|39.79|
27207150|EAP|Custom 27207150||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cautery Fine Tip High-temp|1|<Self-pay>|<Self-pay>|<Self-pay>|43.25|FSC: 400601; BFG: 52|||43.25|FSC: 400601; BFG: 52|23.79|
27207198|EAP|Custom 27207198||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sleeve Scd Express Thigh Med|1|<Self-pay>|<Self-pay>|<Self-pay>|298.00|FSC: 400601; BFG: 52|||298.00|FSC: 400601; BFG: 52|163.90|
27207199|EAP|Custom 27207199||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sleeve Scd Express Thigh Sm|1|<Self-pay>|<Self-pay>|<Self-pay>|256.10|FSC: 400601; BFG: 52|||256.10|FSC: 400601; BFG: 52|140.85|
27207200|EAP|Custom 27207200||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sleeve Scd Express Thigh Lg|1|<Self-pay>|<Self-pay>|<Self-pay>|327.75|FSC: 400601; BFG: 52|||327.75|FSC: 400601; BFG: 52|180.26|
27207236|EAP|Custom 27207236||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Ethilon Ps-2 4-0 18in|1|<Self-pay>|<Self-pay>|<Self-pay>|15.70|FSC: 400601; BFG: 52|||15.70|FSC: 400601; BFG: 52|8.63|
27207240|EAP|Custom 27207240||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Prolene 5-0 Pc3|1|<Self-pay>|<Self-pay>|<Self-pay>|24.60|FSC: 400601; BFG: 52|||24.60|FSC: 400601; BFG: 52|13.53|
27207244|EAP|Custom 27207244||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Prolene 4-0|1|<Self-pay>|<Self-pay>|<Self-pay>|24.60|FSC: 400601; BFG: 52|||24.60|FSC: 400601; BFG: 52|13.53|
27207261|EAP|Custom 27207261||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Prolene 6-0|1|<Self-pay>|<Self-pay>|<Self-pay>|19.90|FSC: 400601; BFG: 52|||19.90|FSC: 400601; BFG: 52|10.94|
27207266|EAP|Custom 27207266||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Forcep Disp Bx Hot 000852|1|<Self-pay>|<Self-pay>|<Self-pay>|128.65|FSC: 400601; BFG: 52|||128.65|FSC: 400601; BFG: 52|70.76|
63600501|EAP|CPT® 91301||0636 - PHARMACY - DRUGS REQUIRING DETAILED CODING|HC SARS-COV-2 (COVID-19) VACCINE 0.5ML|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
27207300|EAP|Custom 27207300||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Delivery Room Pack|1|<Self-pay>|<Self-pay>|<Self-pay>|83.70|FSC: 400601; BFG: 52|||83.70|FSC: 400601; BFG: 52|46.03|
27207349|EAP|Custom 27207349||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Collar Stifneck Baby No Neck|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 400601; BFG: 52|||75.00|FSC: 400601; BFG: 52|41.25|
27207350|EAP|Custom 27207350||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Collar Cervical Stifneck Adult|1|<Self-pay>|<Self-pay>|<Self-pay>|71.40|FSC: 400601; BFG: 52|||71.40|FSC: 400601; BFG: 52|39.27|
27207351|EAP|Custom 27207351||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Abdominal Binder/any Size|1|<Self-pay>|<Self-pay>|<Self-pay>|153.25|FSC: 400601; BFG: 52|||153.25|FSC: 400601; BFG: 52|84.29|
27207352|EAP|Custom 27207352||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bucks Traction/any Size|1|<Self-pay>|<Self-pay>|<Self-pay>|85.80|FSC: 400601; BFG: 52|||85.80|FSC: 400601; BFG: 52|47.19|
27207366|EAP|Custom 27207366||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Dressing Medium Granufoam Vac|1|<Self-pay>|<Self-pay>|<Self-pay>|277.80|FSC: 400601; BFG: 52|||277.80|FSC: 400601; BFG: 52|152.79|
27207367|EAP|Custom 27207367||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kit Cath Radial Artery Ak04020|1|<Self-pay>|<Self-pay>|<Self-pay>|119.65|FSC: 400601; BFG: 52|||119.65|FSC: 400601; BFG: 52|65.81|
27207371|EAP|Custom 27207371||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Insulated Stimuplex W/ext Set 21ga X4|1|<Self-pay>|<Self-pay>|<Self-pay>|66.10|FSC: 400601; BFG: 52|||66.10|FSC: 400601; BFG: 52|36.35|
27207381|EAP|Custom 27207381||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Optho-burr|1|<Self-pay>|<Self-pay>|<Self-pay>|52.85|FSC: 400601; BFG: 52|||52.85|FSC: 400601; BFG: 52|29.07|
27207386|EAP|Custom 27207386||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sheath Pinnacle 5fr|1|<Self-pay>|<Self-pay>|<Self-pay>|179.80|FSC: 400601; BFG: 52|||179.80|FSC: 400601; BFG: 52|98.89|
27400439|EAP|HCPCS L3807||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Cch Splint Wrist/ Forearm|1|<Self-pay>|<Self-pay>|<Self-pay>|102.90|FSC: 400601; BFG: 52|||102.90|FSC: 400601; BFG: 52|56.59|
30100884|EAP|CPT® 80047||0301 - LABORATORY - CHEMISTRY|Hc Cch Basic Metabolic Panel Ionized Ca|1|<Self-pay>|<Self-pay>|<Self-pay>|76.65|FSC: 400601; BFG: 52|||76.65|FSC: 400601; BFG: 52|42.16|
30100885|EAP|CPT® 80305||0301 - LABORATORY - CHEMISTRY|Hc Cch Drug Test Presumptive Direct Optical Observation|1|<Self-pay>|<Self-pay>|<Self-pay>|404.25|FSC: 400601; BFG: 52|||404.25|FSC: 400601; BFG: 52|222.34|
30100897|EAP|CPT® 82436||0301 - LABORATORY - CHEMISTRY|Hc Cch So Chloride Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30500097|EAP|CPT® 85732||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Ptt Substitution Plasma Fractions Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
30600235|EAP|CPT® 87172||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Pinworm Exam|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
30600236|EAP|CPT® 87265||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So B Pertussis/parapertussis Ag By Dfa|1|<Self-pay>|<Self-pay>|<Self-pay>|91.35|FSC: 400601; BFG: 52|||91.35|FSC: 400601; BFG: 52|50.24|
30600237|EAP|CPT® 87327||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Cryptococcus Neoform Ag Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
31200051|EAP|CPT® 88312||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Special Stains Group 1|1|<Self-pay>|<Self-pay>|<Self-pay>|196.99|FSC: 400601; BFG: 52|||196.99|FSC: 400601; BFG: 52|108.34|
30100599|EAP|CPT® 83916||0301 - LABORATORY - CHEMISTRY|Hc So Oligoclonal Bands|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
49000742|EAP|CPT® 49422||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Removal Tunneled Intraperitoneal Catheter|1|<Self-pay>|<Self-pay>|<Self-pay>|2,670.15|FSC: 400601; BFG: 52|||2,670.15|FSC: 400601; BFG: 52|1,468.58|
30100601|EAP|CPT® 82040||0301 - LABORATORY - CHEMISTRY|Hc So Assay Of Serum Albumin|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
30100602|EAP|CPT® 82042||0301 - LABORATORY - CHEMISTRY|Hc So Albumin Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|78.75|FSC: 400601; BFG: 52|||78.75|FSC: 400601; BFG: 52|43.31|
31000126|EAP|CPT® 81403||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Mpl Exon 10 Mutation|1|<Self-pay>|<Self-pay>|<Self-pay>|416.70|FSC: 400601; BFG: 52|||416.70|FSC: 400601; BFG: 52|229.18|
31000136|EAP|CPT® 88332||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Sp Consult Ea Addl Tb W/ Fs|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
27803470|EAP|HCPCS C1751||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|Hc Cch Triple Lumen Picc Line|1|<Self-pay>|<Self-pay>|<Self-pay>|1,233.75|FSC: 400601; BFG: 52|||1,233.75|FSC: 400601; BFG: 52|678.56|
31000165|EAP|CPT® 88331||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Sp Consult 1st Tb W/ Fs Sgl Sp|1|<Self-pay>|<Self-pay>|<Self-pay>|345.45|FSC: 400601; BFG: 52|||345.45|FSC: 400601; BFG: 52|190.00|
94200032|EAP|CPT® 98960||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Cch Self Mgmt Educ/train 1 Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|99.75|FSC: 400601; BFG: 52|||99.75|FSC: 400601; BFG: 52|54.86|
94200033|EAP|CPT® 98961||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Cch Self Mgmt Educ/train 2-4 Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|99.75|FSC: 400601; BFG: 52|||99.75|FSC: 400601; BFG: 52|54.86|
94200034|EAP|CPT® 98962||0942 - OTHER THERAPEUTIC SERVICES - EDUCATION/TRAINING|Hc Cch Self Mgmt Educ/train 5-8 Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|99.75|FSC: 400601; BFG: 52|||99.75|FSC: 400601; BFG: 52|54.86|
30100607|EAP|CPT® 84270||0301 - LABORATORY - CHEMISTRY|Hc Sex Hormone Binding Globulin|1|<Self-pay>|<Self-pay>|<Self-pay>|110.25|FSC: 400601; BFG: 52|||110.25|FSC: 400601; BFG: 52|60.64|
43000083|EAP|CPT® 97598||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Debridement Wound Selective Ea Addl 20 Sq Cm|1|<Self-pay>|<Self-pay>|<Self-pay>|130.20|FSC: 400601; BFG: 52|||130.20|FSC: 400601; BFG: 52|71.61|
71000008|EAP|Custom 71000008||0710 - RECOVERY ROOM - GENERAL CLASSIFICATION|Hc Cch Extended Recovery/hour|1|<Self-pay>|<Self-pay>|<Self-pay>|147.00|FSC: 400601; BFG: 52|||147.00|FSC: 400601; BFG: 52|80.85|
30900015|EAP|CPT® 89321||0309 - LABORATORY - OTHER LABORATORY|Hc Cch Semen Analysis Sperm Detection|1|<Self-pay>|<Self-pay>|<Self-pay>|51.44|FSC: 400601; BFG: 52|||51.44|FSC: 400601; BFG: 52|28.29|
49000899|EAP|CPT® 64680||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent; Celiac Plexus|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
71000001|EAP|Custom 71000001||0710 - RECOVERY ROOM - GENERAL CLASSIFICATION|Hc Phase I Recovery First 30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|280.35|FSC: 400601; BFG: 52|||280.35|FSC: 400601; BFG: 52|154.19|
71000002|EAP|Custom 71000002||0710 - RECOVERY ROOM - GENERAL CLASSIFICATION|Hc Phase I Recovery Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|117.60|FSC: 400601; BFG: 52|||117.60|FSC: 400601; BFG: 52|64.68|
37000008|EAP|Custom 37000008||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc General Anesthesia First 30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|321.30|FSC: 400601; BFG: 52|||321.30|FSC: 400601; BFG: 52|176.71|
37000009|EAP|Custom 37000009||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc General Anesthesia Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|107.10|FSC: 400601; BFG: 52|||107.10|FSC: 400601; BFG: 52|58.90|
75000165|EAP|CPT® 45398||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonscopy Flexible W/ Band Ligation|1|<Self-pay>|<Self-pay>|<Self-pay>|2,717.40|FSC: 400601; BFG: 52|||2,717.40|FSC: 400601; BFG: 52|1,494.57|
39000003|EAP|HCPCS P9012||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Cryoprecipitate Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|117.60|FSC: 400601; BFG: 52|||117.60|FSC: 400601; BFG: 52|64.68|
39000004|EAP|HCPCS P9016||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Leukocyte Poor Blood Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|492.45|FSC: 400601; BFG: 52|||492.45|FSC: 400601; BFG: 52|270.85|
39000005|EAP|HCPCS P9017||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Ffp Single Donor Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|194.25|FSC: 400601; BFG: 52|||194.25|FSC: 400601; BFG: 52|106.84|
39000007|EAP|HCPCS P9021||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Rbc Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|382.20|FSC: 400601; BFG: 52|||382.20|FSC: 400601; BFG: 52|210.21|
39000011|EAP|HCPCS P9039||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Rbc Deglycerolized Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|1,126.65|FSC: 400601; BFG: 52|||1,126.65|FSC: 400601; BFG: 52|619.66|
39000019|EAP|HCPCS P9035||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Platelets Pheresis Leuko Reduced Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|1,276.80|FSC: 400601; BFG: 52|||1,276.80|FSC: 400601; BFG: 52|702.24|
39000021|EAP|HCPCS P9037||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Platelets Pheresis Leuko Reduced Irradiated Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|1,672.65|FSC: 400601; BFG: 52|||1,672.65|FSC: 400601; BFG: 52|919.96|
39000023|EAP|HCPCS P9040||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Rbc Leuko Reduced Irradiated Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|697.20|FSC: 400601; BFG: 52|||697.20|FSC: 400601; BFG: 52|383.46|
39000026|EAP|HCPCS P9055||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Platelets Leuko Reduced Cmv Negative Apheresis/pheresis Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|1,756.65|FSC: 400601; BFG: 52|||1,756.65|FSC: 400601; BFG: 52|966.16|
39000029|EAP|HCPCS P9058||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Processing Rbc Leuko Reduced Cmv Negative Irradiated Each Unit|1|<Self-pay>|<Self-pay>|<Self-pay>|637.35|FSC: 400601; BFG: 52|||637.35|FSC: 400601; BFG: 52|350.54|
27207457|EAP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Guidewire Angled 150cm|1|<Self-pay>|<Self-pay>|<Self-pay>|231.75|FSC: 400601; BFG: 52|||231.75|FSC: 400601; BFG: 52|127.46|
27207459|EAP|Custom 27207459||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bag Infuser Pressure 1000ml|1|<Self-pay>|<Self-pay>|<Self-pay>|124.55|FSC: 400601; BFG: 52|||124.55|FSC: 400601; BFG: 52|68.50|
30100609|EAP|CPT® 83010||0301 - LABORATORY - CHEMISTRY|Hc So Haptoglobin Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|42.00|FSC: 400601; BFG: 52|||42.00|FSC: 400601; BFG: 52|23.10|
32000228|EAP|CPT® 73592||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Lower Extremity Infant 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
27205301|EAP|HCPCS C1894||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Introducer Sheath 20fr X 28cm|1|<Self-pay>|<Self-pay>|<Self-pay>|670.75|FSC: 400601; BFG: 52|||670.75|FSC: 400601; BFG: 52|368.91|
30100406|EAP|CPT® 82553||0301 - LABORATORY - CHEMISTRY|Hc So Ckmb|1|<Self-pay>|<Self-pay>|<Self-pay>|72.45|FSC: 400601; BFG: 52|||72.45|FSC: 400601; BFG: 52|39.85|
27000003|EAP|Custom 27000003||0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION|Hc Cch Oxygen Service Per Day|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
49000746|EAP|CPT® 64620||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent (rfa) Intercostal Nerve|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000747|EAP|CPT® 64630||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent (rfa) Pudendal Nerve|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
20604|EAP|CPT® 20604||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT|1|<Self-pay>|<Self-pay>|<Self-pay>|70.32|FSC: 46100; BFG: 52|||70.32|FSC: 46100; BFG: 52|38.68|
20606|EAP|CPT® 20606|||ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US|1|<Self-pay>|<Self-pay>|<Self-pay>|200.10|FSC: 46100; BFG: 52|||200.10|FSC: 46100; BFG: 52|110.05|
20611|EAP|CPT® 20611|||ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|<Self-pay>|<Self-pay>|<Self-pay>|133.00|FSC: 46100; BFG: 52|||133.00|FSC: 46100; BFG: 52|73.15|
45350|EAP|CPT® 45350|||SIGMOIDOSCOPY FLX WITH WITH BAND LIGATION(S)|1|<Self-pay>|<Self-pay>|<Self-pay>|753.00|FSC: 46100; BFG: 52|||753.00|FSC: 46100; BFG: 52|414.15|
45398|EAP|CPT® 45398|||COLONOSCOPY FLEXIBLE WITH BAND LIGATION(S)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,056.60|FSC: 46100; BFG: 52|||1,056.60|FSC: 46100; BFG: 52|581.13|
64488|EAP|CPT® 64488|||TAP BLOCK BILATERAL BY INJECTION(S)|1|<Self-pay>|<Self-pay>|<Self-pay>|203.00|FSC: 46100; BFG: 52|||203.00|FSC: 46100; BFG: 52|111.65|
48100065|EAP|CPT® 37221||0481 - CARDIOLOGY - CARDIAC CATH LAB|Hc Insertion Stent Iliac Artery Initial Vessel|1|<Self-pay>|<Self-pay>|<Self-pay>|20,307.00|FSC: 400601; BFG: 52|||20,307.00|FSC: 400601; BFG: 52|11,168.85|
48100067|EAP|CPT® 37223||0481 - CARDIOLOGY - CARDIAC CATH LAB|Hc Insertion Stent Iliac Artery Each Addl Vessel|1|<Self-pay>|<Self-pay>|<Self-pay>|3,831.45|FSC: 400601; BFG: 52|||3,831.45|FSC: 400601; BFG: 52|2,107.30|
40200051|EAP|CPT® 76942||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Guidance For Needle Placement|1|<Self-pay>|<Self-pay>|<Self-pay>|619.50|FSC: 400601; BFG: 52|||619.50|FSC: 400601; BFG: 52|340.72|
40200053|EAP|CPT® 76946||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Guidance For Amniocentesis|1|<Self-pay>|<Self-pay>|<Self-pay>|353.85|FSC: 400601; BFG: 52|||353.85|FSC: 400601; BFG: 52|194.62|
36000037|EAP|Custom 36000037||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Cancelled Procedure In Or|1|<Self-pay>|<Self-pay>|<Self-pay>|432.60|FSC: 400601; BFG: 52|||432.60|FSC: 400601; BFG: 52|237.93|
51000175|EAP|CPT® 99215||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Cancelled Procedure In Preop|1|<Self-pay>|<Self-pay>|<Self-pay>|275.10|FSC: 400601; BFG: 52|||275.10|FSC: 400601; BFG: 52|151.30|
27207510|EAP|Custom 27207510||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Bipap Performa W/ Headgear Sm|1|<Self-pay>|<Self-pay>|<Self-pay>|194.45|FSC: 400601; BFG: 52|||194.45|FSC: 400601; BFG: 52|106.95|
96127|EAP|CPT® 96127||0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES - GENERAL CLASSIFICATION|BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT|1|<Self-pay>|<Self-pay>|<Self-pay>|27.00|FSC: 46100; BFG: 52|||27.00|FSC: 46100; BFG: 52|14.85|
41000018|EAP|CPT® 94660||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Cpap Or Bipap|1|<Self-pay>|<Self-pay>|<Self-pay>|498.75|FSC: 400601; BFG: 52|||498.75|FSC: 400601; BFG: 52|274.31|
41000027|EAP|CPT® 94664||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Demo & Eval Of Aerosol Mdi Neb Or Ippb|1|<Self-pay>|<Self-pay>|<Self-pay>|498.75|FSC: 400601; BFG: 52|||498.75|FSC: 400601; BFG: 52|274.31|
43000006|EAP|CPT® 97018||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Paraffin Bath By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
43000007|EAP|CPT® 97022||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Whirlpool By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|99.75|FSC: 400601; BFG: 52|||99.75|FSC: 400601; BFG: 52|54.86|
43000008|EAP|CPT® 97032||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Electrical Stimulation Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|68.25|FSC: 400601; BFG: 52|||68.25|FSC: 400601; BFG: 52|37.54|
43000009|EAP|CPT® 97033||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Iontophoresis Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|159.60|FSC: 400601; BFG: 52|||159.60|FSC: 400601; BFG: 52|87.78|
43000010|EAP|CPT® 97035||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Ultrasound Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
43000011|EAP|CPT® 97110||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Therapeutic Exercises Rom & Flexibility Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|99.75|FSC: 400601; BFG: 52|||99.75|FSC: 400601; BFG: 52|54.86|
43000012|EAP|CPT® 97112||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Neuromuscular Reeducation Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
43000030|EAP|CPT® 97124||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Massage Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|74.55|FSC: 400601; BFG: 52|||74.55|FSC: 400601; BFG: 52|41.00|
43000014|EAP|CPT® 97140||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Manual Therapy Techniques Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|117.60|FSC: 400601; BFG: 52|||117.60|FSC: 400601; BFG: 52|64.68|
43000015|EAP|CPT® 97533||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Sensory Integrative Techniques Direct Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|87.15|FSC: 400601; BFG: 52|||87.15|FSC: 400601; BFG: 52|47.93|
43000016|EAP|CPT® 97542||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Wheelchair Mgmt Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|93.45|FSC: 400601; BFG: 52|||93.45|FSC: 400601; BFG: 52|51.40|
43000018|EAP|CPT® 97755||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Assistive Technology Assess Direct Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|103.95|FSC: 400601; BFG: 52|||103.95|FSC: 400601; BFG: 52|57.17|
43000019|EAP|CPT® 97760||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Orthotic Mgmt & Training Initial Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|103.95|FSC: 400601; BFG: 52|||103.95|FSC: 400601; BFG: 52|57.17|
43000020|EAP|CPT® 97761||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Prosthetic Training Upper/lower Extremity Initial Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|94.50|FSC: 400601; BFG: 52|||94.50|FSC: 400601; BFG: 52|51.97|
43000022|EAP|CPT® G0283||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Electrical Stimulation Non-wound Care By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|63.00|FSC: 400601; BFG: 52|||63.00|FSC: 400601; BFG: 52|34.65|
43000025|EAP|CPT® 97750||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Physical Performance Test W/ Report Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
43000017|EAP|CPT® 97150||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Group Therapy Procedure By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|FSC: 400601; BFG: 52|||59.85|FSC: 400601; BFG: 52|32.92|
43000023|EAP|CPT® 97530||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Therapeutic Activities Direct- Each 15 Minutes By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
43000026|EAP|CPT® 97535||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Self Care/home Mgmt Direct Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|100.80|FSC: 400601; BFG: 52|||100.80|FSC: 400601; BFG: 52|55.44|
43000027|EAP|CPT® 97537||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Community/work Reintegration Direct Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|92.40|FSC: 400601; BFG: 52|||92.40|FSC: 400601; BFG: 52|50.82|
46000012|EAP|CPT® 94618||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Pulmonary Stress Test (6 Min Walk)|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
61000027|EAP|CPT® 73219||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Upper Extremity Other Than Joint W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,327.85|FSC: 400601; BFG: 52|||2,327.85|FSC: 400601; BFG: 52|1,280.32|
61000028|EAP|CPT® 73222||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Upper Extremity Joint W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,607.55|FSC: 400601; BFG: 52|||1,607.55|FSC: 400601; BFG: 52|884.15|
61000029|EAP|CPT® 73223||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Upper Extremity Joint W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,327.85|FSC: 400601; BFG: 52|||2,327.85|FSC: 400601; BFG: 52|1,280.32|
61000030|EAP|CPT® 73718||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Lower Extremity Other Than Joint W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,713.60|FSC: 400601; BFG: 52|||1,713.60|FSC: 400601; BFG: 52|942.48|
61000031|EAP|CPT® 73719||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Lower Extremity Other Than Joint W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,327.85|FSC: 400601; BFG: 52|||2,327.85|FSC: 400601; BFG: 52|1,280.32|
61000032|EAP|CPT® 73722||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Lower Extremity Joint W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,607.55|FSC: 400601; BFG: 52|||1,607.55|FSC: 400601; BFG: 52|884.15|
61000033|EAP|CPT® 73723||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Lower Extremity Joint W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,698.50|FSC: 400601; BFG: 52|||2,698.50|FSC: 400601; BFG: 52|1,484.17|
61000035|EAP|CPT® 74183||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Abdomen W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,942.50|FSC: 400601; BFG: 52|||1,942.50|FSC: 400601; BFG: 52|1,068.37|
61000026|EAP|CPT® 73218||0610 - MAGNETIC RESONANCE TECHNOLOGY (MRT) - GENERAL CLASSIFICATION|Hc Mri Upper Extremity Other Than Joint W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,072.70|FSC: 400601; BFG: 52|||2,072.70|FSC: 400601; BFG: 52|1,139.98|
37000011|EAP|Custom 37000011||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Monitored Anesthesia Care/mac First 30 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|266.70|FSC: 400601; BFG: 52|||266.70|FSC: 400601; BFG: 52|146.68|
37000012|EAP|Custom 37000012||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Monitored Anesthesia Care/mac Each Addl 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|107.10|FSC: 400601; BFG: 52|||107.10|FSC: 400601; BFG: 52|58.90|
41000007|EAP|CPT® 94640||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Metered Dose Inhaler Treatment|1|<Self-pay>|<Self-pay>|<Self-pay>|391.65|FSC: 400601; BFG: 52|||391.65|FSC: 400601; BFG: 52|215.41|
41000010|EAP|CPT® 94640||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Aerosol Or Nebulizer Treatment|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
41000030|EAP|CPT® 94799||0410 - RESPIRATORY SERVICES - GENERAL CLASSIFICATION|Hc Incentive Spirometry Demo & Instruction|1|<Self-pay>|<Self-pay>|<Self-pay>|365.40|FSC: 400601; BFG: 52|||365.40|FSC: 400601; BFG: 52|200.97|
42000027|EAP|CPT® 97150||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Therapeutic Procedure Group|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|FSC: 400601; BFG: 52|||59.85|FSC: 400601; BFG: 52|32.92|
42000028|EAP|CPT® 97530||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Therapeutic Activities Direct Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|97.65|FSC: 400601; BFG: 52|||97.65|FSC: 400601; BFG: 52|53.71|
42000031|EAP|CPT® 97535||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Self Care/home Mgmt Direct Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|100.80|FSC: 400601; BFG: 52|||100.80|FSC: 400601; BFG: 52|55.44|
42000032|EAP|CPT® 97537||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Community/work Reintegration Training Direct Each 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|92.40|FSC: 400601; BFG: 52|||92.40|FSC: 400601; BFG: 52|50.82|
43400005|EAP|CPT® 97168||0434 - OCCUPATIONAL THERAPY - EVALUATION OR RE-EVALUATION|Hc Ot Re-evaluation|1|<Self-pay>|<Self-pay>|<Self-pay>|105.00|FSC: 400601; BFG: 52|||105.00|FSC: 400601; BFG: 52|57.75|
49000038|EAP|CPT® 20225||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bx Bone Trocar/needle Deep|1|<Self-pay>|<Self-pay>|<Self-pay>|3,608.85|FSC: 400601; BFG: 52|||3,608.85|FSC: 400601; BFG: 52|1,984.87|
51000044|EAP|CPT® 10060||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc I&d Abscess Simple|1|<Self-pay>|<Self-pay>|<Self-pay>|452.55|FSC: 400601; BFG: 52|||452.55|FSC: 400601; BFG: 52|248.90|
51000045|EAP|CPT® 10061||0361 - OPERATING ROOM SERVICES - MINOR SURGERY|Hc I&d Abscess Complicated|1|<Self-pay>|<Self-pay>|<Self-pay>|841.05|FSC: 400601; BFG: 52|||841.05|FSC: 400601; BFG: 52|462.58|
51000078|EAP|CPT® 20552||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Trigger Point Injection 1-2 Muscles|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
51000079|EAP|CPT® 20553||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Trigger Point Injection 3+ Muscles|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
72000004|EAP|CPT® 92950||0720 - LABOR ROOM/DELIVERY - GENERAL CLASSIFICATION|Hc Neonatal Resuscitation (cpr)|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
74000001|EAP|CPT® 95805||0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION|HC MULTIPLE SLEEP LATENCY TEST|1|<Self-pay>|<Self-pay>|<Self-pay>|2,418.15|FSC: 400601; BFG: 52|||2,418.15|FSC: 400601; BFG: 52|1,329.98|
74000003|EAP|CPT® 95810||0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION|HC POLYSOMNOGRAPHY 4+ PARAMETERS|1|<Self-pay>|<Self-pay>|<Self-pay>|3,777.90|FSC: 400601; BFG: 52|||3,777.90|FSC: 400601; BFG: 52|2,077.84|
74000004|EAP|CPT® 95811||0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION|HC POLYSOMNOGRAPHY 4+ PARAMETERS W/ CPAP OR BI-LEVEL VENT|1|<Self-pay>|<Self-pay>|<Self-pay>|4,777.50|FSC: 400601; BFG: 52|||4,777.50|FSC: 400601; BFG: 52|2,627.62|
74000008|EAP|CPT® 95819||0740 - EEG (ELECTROENCEPHALOGRAM) - GENERAL CLASSIFICATION|Hc Eeg Awake & Asleep|1|<Self-pay>|<Self-pay>|<Self-pay>|673.05|FSC: 400601; BFG: 52|||673.05|FSC: 400601; BFG: 52|370.18|
92100003|EAP|CPT® 93922||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Limited Extremity Study Up To 2 Levels Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|605.85|FSC: 400601; BFG: 52|||605.85|FSC: 400601; BFG: 52|333.22|
92100004|EAP|CPT® 93923||0921 - OTHER DIAGNOSTIC SERVICES - PERIPHERAL VASCULAR LAB|Hc Complete Ext Study 3+ Levels Or Provoc Fx Maneuvers|1|<Self-pay>|<Self-pay>|<Self-pay>|365.40|FSC: 400601; BFG: 52|||365.40|FSC: 400601; BFG: 52|200.97|
51000177|EAP|CPT® 20550||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Injection Tendon Sheath Ligament Aponeurosis|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
51000178|EAP|CPT® 20600||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Arthrocentesis Joint/bursa Small W/o Ultrasound Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
51000179|EAP|CPT® 20605||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Arthrocentesis Joint/bursa Intermediate W/o Ultrasound Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
51000180|EAP|CPT® 20610||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Arthrocentesis Joint/bursa Major W/o Ultrasound Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
51000182|EAP|CPT® 36593||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Declotting Vad Or Cath|1|<Self-pay>|<Self-pay>|<Self-pay>|796.95|FSC: 400601; BFG: 52|||796.95|FSC: 400601; BFG: 52|438.32|
51000183|EAP|CPT® 51701||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Insertion Straight Cath (non-indwelling)|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
51000184|EAP|CPT® 51702||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Insertion Foley Cath Simple (indwelling)|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
51000193|EAP|CPT® 96523||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Irrigation Vad (port Flush)|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
27207533|EAP|Custom 27207533||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Glidescope Blade|1|<Self-pay>|<Self-pay>|<Self-pay>|120.30|FSC: 400601; BFG: 52|||120.30|FSC: 400601; BFG: 52|66.16|
27207534|EAP|Custom 27207534||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Spinal Needle - Various Sizes|1|<Self-pay>|<Self-pay>|<Self-pay>|25.75|FSC: 400601; BFG: 52|||25.75|FSC: 400601; BFG: 52|14.16|
49000418|EAP|CPT® 38220||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bone Marrow Aspiration(s)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,657.95|FSC: 400601; BFG: 52|||1,657.95|FSC: 400601; BFG: 52|911.87|
49000419|EAP|CPT® 38221||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bone Marrow Biopsy(ies)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,657.95|FSC: 400601; BFG: 52|||1,657.95|FSC: 400601; BFG: 52|911.87|
49000420|EAP|CPT® 38222||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Bone Marrow Aspiration(s) And Biopsy(ies)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,657.95|FSC: 400601; BFG: 52|||1,657.95|FSC: 400601; BFG: 52|911.87|
27207598|EAP|Custom 27207598||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bag Drain W/ Urine Meter|1|<Self-pay>|<Self-pay>|<Self-pay>|23.30|FSC: 400601; BFG: 52|||23.30|FSC: 400601; BFG: 52|12.81|
43000031|EAP|CPT® 97034||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Contrast Baths Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
27207624|EAP|Custom 27207624||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Stapler Skin Ds-5|1|<Self-pay>|<Self-pay>|<Self-pay>|30.60|FSC: 400601; BFG: 52|||30.60|FSC: 400601; BFG: 52|16.83|
27207632|EAP|Custom 27207632||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Chromic 5-0|1|<Self-pay>|<Self-pay>|<Self-pay>|28.85|FSC: 400601; BFG: 52|||28.85|FSC: 400601; BFG: 52|15.87|
27201184|EAP|Custom 27201184||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Balloon Bakri|1|<Self-pay>|<Self-pay>|<Self-pay>|857.15|FSC: 400601; BFG: 52|||857.15|FSC: 400601; BFG: 52|471.43|
27400021|EAP|HCPCS L1902||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Boot Walker Large Prefabricated Off-the-shelf|1|<Self-pay>|<Self-pay>|<Self-pay>|408.45|FSC: 400601; BFG: 52|||408.45|FSC: 400601; BFG: 52|224.65|
27400023|EAP|HCPCS L1902||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Boot Walker Medium Prefabricated Off-the-shelf|1|<Self-pay>|<Self-pay>|<Self-pay>|334.95|FSC: 400601; BFG: 52|||334.95|FSC: 400601; BFG: 52|184.22|
27400031|EAP|HCPCS L1902||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Boot Walker Small Prefabricated Off-the-shelf|1|<Self-pay>|<Self-pay>|<Self-pay>|290.85|FSC: 400601; BFG: 52|||290.85|FSC: 400601; BFG: 52|159.97|
27207648|EAP|Custom 27207648||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tourniquet|1|<Self-pay>|<Self-pay>|<Self-pay>|15.80|FSC: 400601; BFG: 52|||15.80|FSC: 400601; BFG: 52|8.69|
27200952|EAP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cath Cricothyrotomy Set Melker|1|<Self-pay>|<Self-pay>|<Self-pay>|1,628.71|FSC: 400601; BFG: 52|||1,628.71|FSC: 400601; BFG: 52|895.79|
27201018|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Catheter Drain 10fr X 25cm|1|<Self-pay>|<Self-pay>|<Self-pay>|397.95|FSC: 400601; BFG: 52|||397.95|FSC: 400601; BFG: 52|218.87|
27201433|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Catheter Drainage 12f Multipurpose|1|<Self-pay>|<Self-pay>|<Self-pay>|397.95|FSC: 400601; BFG: 52|||397.95|FSC: 400601; BFG: 52|218.87|
27201435|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Catheter Drainage 14f Multipurpose|1|<Self-pay>|<Self-pay>|<Self-pay>|397.95|FSC: 400601; BFG: 52|||397.95|FSC: 400601; BFG: 52|218.87|
27201437|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Catheter Drainage 8.5f Multipurpose|1|<Self-pay>|<Self-pay>|<Self-pay>|314.35|FSC: 400601; BFG: 52|||314.35|FSC: 400601; BFG: 52|172.89|
27201304|EAP|Custom 27201304||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Catheter Triple Lumen 7fr 14cm|1|<Self-pay>|<Self-pay>|<Self-pay>|491.75|FSC: 400601; BFG: 52|||491.75|FSC: 400601; BFG: 52|270.46|
77100015|EAP|CPT® 0011A||0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION|HC SARS-COV-2 (COVID-19) VACCINE ADMIN 0.5ML 1ST DOSE|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 400601; BFG: 52|||35.00|FSC: 400601; BFG: 52|19.25|
77100016|EAP|CPT® 0012A||0771 - PREVENTIVE CARE SERVICES - VACCINE ADMINISTRATION|HC SARS-COV-2 (COVID-19) VACCINE ADMIN 0.5ML 2ND DOSE|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 400601; BFG: 52|||35.00|FSC: 400601; BFG: 52|19.25|
27201583|EAP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Guidewire .038 X 145 X-stiff|1|<Self-pay>|<Self-pay>|<Self-pay>|79.30|FSC: 400601; BFG: 52|||79.30|FSC: 400601; BFG: 52|43.61|
26000015|EAP|HCPCS M0243||0260 - IV THERAPY - GENERAL CLASSIFICATION|HC IV INFUSION CASIRIVIMAB AND IMDEVIMAB|1|<Self-pay>|<Self-pay>|<Self-pay>|696.00|FSC: 400601; BFG: 52|||696.00|FSC: 400601; BFG: 52|382.80|
27201300|EAP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Guidewire Stiff Glide 80cm|1|<Self-pay>|<Self-pay>|<Self-pay>|130.10|FSC: 400601; BFG: 52|||130.10|FSC: 400601; BFG: 52|71.55|
27300001|EAP|Custom 27300001||0273 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - TAKE HOME SUPPLIES|Hc Cch Self-care Covid Kit|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|FSC: 400601; BFG: 52|||15.75|FSC: 400601; BFG: 52|8.66|
27201330|EAP|Custom 27201330||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Kit Intrauterine Pressure Catheter|1|<Self-pay>|<Self-pay>|<Self-pay>|197.50|FSC: 400601; BFG: 52|||197.50|FSC: 400601; BFG: 52|108.62|
27200955|EAP|Custom 27200955||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Quick Pressure Monitor Set|1|<Self-pay>|<Self-pay>|<Self-pay>|215.93|FSC: 400601; BFG: 52|||215.93|FSC: 400601; BFG: 52|118.76|
27201233|EAP|Custom 27201233||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Sensor Perianal|1|<Self-pay>|<Self-pay>|<Self-pay>|227.25|FSC: 400601; BFG: 52|||227.25|FSC: 400601; BFG: 52|124.99|
27200041|EAP|Custom 27200041||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Sponge Surgicel 2 X 3|1|<Self-pay>|<Self-pay>|<Self-pay>|164.59|FSC: 400601; BFG: 52|||164.59|FSC: 400601; BFG: 52|90.52|
27201326|EAP|HCPCS C1751||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Tray Central Venous Catheter|1|<Self-pay>|<Self-pay>|<Self-pay>|197.00|FSC: 400601; BFG: 52|||197.00|FSC: 400601; BFG: 52|108.35|
27200141|EAP|Custom 27200141||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Versastep Plus 12mm Vs101512p|1|<Self-pay>|<Self-pay>|<Self-pay>|10.08|FSC: 400601; BFG: 52|||10.08|FSC: 400601; BFG: 52|5.54|
32000258|EAP|CPT® 74248||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Small Intestine Follow-through|1|<Self-pay>|<Self-pay>|<Self-pay>|644.00|FSC: 400601; BFG: 52|||644.00|FSC: 400601; BFG: 52|354.20|
43000101|EAP|CPT® 97129||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cognitive Function Interventions & Compensatory Mgt By Ot First 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|82.16|FSC: 400601; BFG: 52|||82.16|FSC: 400601; BFG: 52|45.19|
43000102|EAP|CPT® 97130||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cognitive Function Intervention & Compensatory Mgt By Ot Ea Addtl 15 Min|1|<Self-pay>|<Self-pay>|<Self-pay>|82.16|FSC: 400601; BFG: 52|||82.16|FSC: 400601; BFG: 52|45.19|
44000050|EAP|CPT® 97129||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Cognitive Function Interventions & Compensatory Mgt By St First 15 Mins|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
44000051|EAP|CPT® 97130||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Cognitive Function Intervention & Compensatory Mgt By St Ea Addtl 15 Min|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30000004|EAP|CPT® 36600||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Arterial Puncture- Blood For Dx|1|<Self-pay>|<Self-pay>|<Self-pay>|275.73|FSC: 400601; BFG: 52|||275.73|FSC: 400601; BFG: 52|151.65|
30000050|EAP|CPT® 36416||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Capillary Blood Draw|1|<Self-pay>|<Self-pay>|<Self-pay>|8.40|FSC: 400601; BFG: 52|||8.40|FSC: 400601; BFG: 52|4.62|
30100407|EAP|CPT® 80048||0301 - LABORATORY - CHEMISTRY|Hc Metabolic Panel Total Ca|1|<Self-pay>|<Self-pay>|<Self-pay>|204.75|FSC: 400601; BFG: 52|||204.75|FSC: 400601; BFG: 52|112.61|
30100408|EAP|CPT® 80051||0301 - LABORATORY - CHEMISTRY|Hc Electrolyte Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30100409|EAP|CPT® 80053||0301 - LABORATORY - CHEMISTRY|Hc Comprehen Metabolic Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|309.75|FSC: 400601; BFG: 52|||309.75|FSC: 400601; BFG: 52|170.36|
30100410|EAP|CPT® 80069||0301 - LABORATORY - CHEMISTRY|Hc Renal Function Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
30100412|EAP|CPT® 80076||0301 - LABORATORY - CHEMISTRY|Hc Hepatic Function Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|51.45|FSC: 400601; BFG: 52|||51.45|FSC: 400601; BFG: 52|28.30|
30000017|EAP|CPT® 86900||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Blood Typing Abo|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
40200063|EAP|CPT® 76641||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Breast Unilateral Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
40200064|EAP|CPT® 76642||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Breast Unilateral Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
40300005|EAP|CPT® 77063||0403 - OTHER IMAGING SERVICES - SCREENING MAMMOGRAPHY|Hc Screening Breast Tomosynthesis Digital Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|33.60|FSC: 400601; BFG: 52|||33.60|FSC: 400601; BFG: 52|18.48|
30600146|EAP|CPT® 87502||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Influenza Dna Amp Probe 1st 2 Types|1|<Self-pay>|<Self-pay>|<Self-pay>|169.05|FSC: 400601; BFG: 52|||169.05|FSC: 400601; BFG: 52|92.98|
30600129|EAP|CPT® 87140||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Culture If Ea Antiserum|1|<Self-pay>|<Self-pay>|<Self-pay>|34.65|FSC: 400601; BFG: 52|||34.65|FSC: 400601; BFG: 52|19.06|
30100413|EAP|CPT® 80158||0301 - LABORATORY - CHEMISTRY|Hc So Cyclosporine|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|FSC: 400601; BFG: 52|||59.85|FSC: 400601; BFG: 52|32.92|
30100417|EAP|CPT® 82390||0301 - LABORATORY - CHEMISTRY|Hc So Ceruloplasmin|1|<Self-pay>|<Self-pay>|<Self-pay>|35.70|FSC: 400601; BFG: 52|||35.70|FSC: 400601; BFG: 52|19.63|
30100419|EAP|CPT® 82785||0301 - LABORATORY - CHEMISTRY|Hc So Assay Of Ige|1|<Self-pay>|<Self-pay>|<Self-pay>|54.60|FSC: 400601; BFG: 52|||54.60|FSC: 400601; BFG: 52|30.03|
30100420|EAP|CPT® 82945||0301 - LABORATORY - CHEMISTRY|Hc So Glucose- Body Fluid Other Than Blood|1|<Self-pay>|<Self-pay>|<Self-pay>|12.60|FSC: 400601; BFG: 52|||12.60|FSC: 400601; BFG: 52|6.93|
30100422|EAP|CPT® 83003||0301 - LABORATORY - CHEMISTRY|Hc So Growth Hormone- Human|1|<Self-pay>|<Self-pay>|<Self-pay>|111.30|FSC: 400601; BFG: 52|||111.30|FSC: 400601; BFG: 52|61.21|
30100423|EAP|CPT® 83020||0301 - LABORATORY - CHEMISTRY|Hc So Hgb- Fract & Quan Ep|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 400601; BFG: 52|||35.00|FSC: 400601; BFG: 52|19.25|
30100424|EAP|CPT® 83021||0301 - LABORATORY - CHEMISTRY|Hc So Hgb Chromatography|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|FSC: 400601; BFG: 52|||59.85|FSC: 400601; BFG: 52|32.92|
30100426|EAP|CPT® 83051||0301 - LABORATORY - CHEMISTRY|Hc So Hgb Plasma|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
49000761|EAP|CPT® 62302||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Myelography Via Lumbar Injection Cervical W/ Rad S&i|1|<Self-pay>|<Self-pay>|<Self-pay>|1,821.75|FSC: 400601; BFG: 52|||1,821.75|FSC: 400601; BFG: 52|1,001.96|
30100432|EAP|CPT® 83970||0301 - LABORATORY - CHEMISTRY|Hc So Parathormone|1|<Self-pay>|<Self-pay>|<Self-pay>|136.50|FSC: 400601; BFG: 52|||136.50|FSC: 400601; BFG: 52|75.07|
30100433|EAP|CPT® 84145||0301 - LABORATORY - CHEMISTRY|Hc So Procalcitonin (pct)|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
49000762|EAP|CPT® 62303||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Myelography Via Lumbar Injection Thoracic W/ Rad S&i|1|<Self-pay>|<Self-pay>|<Self-pay>|1,821.75|FSC: 400601; BFG: 52|||1,821.75|FSC: 400601; BFG: 52|1,001.96|
30100434|EAP|CPT® 84260||0301 - LABORATORY - CHEMISTRY|Hc So Serotonin|1|<Self-pay>|<Self-pay>|<Self-pay>|184.80|FSC: 400601; BFG: 52|||184.80|FSC: 400601; BFG: 52|101.64|
49000763|EAP|CPT® 62304||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Myelography Via Lumbar Injection Lumbosacral W/ Rad S&i|1|<Self-pay>|<Self-pay>|<Self-pay>|1,821.75|FSC: 400601; BFG: 52|||1,821.75|FSC: 400601; BFG: 52|1,001.96|
30100435|EAP|CPT® 84480||0301 - LABORATORY - CHEMISTRY|Hc So T3 Total|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
49000764|EAP|CPT® 62305||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Myelography Via Lumbar Injection >= 2 Regions|1|<Self-pay>|<Self-pay>|<Self-pay>|1,821.75|FSC: 400601; BFG: 52|||1,821.75|FSC: 400601; BFG: 52|1,001.96|
30500061|EAP|CPT® 85520||0305 - LABORATORY - HEMATOLOGY|Hc So Heparin Assay|1|<Self-pay>|<Self-pay>|<Self-pay>|43.05|FSC: 400601; BFG: 52|||43.05|FSC: 400601; BFG: 52|23.68|
30500062|EAP|CPT® 85660||0305 - LABORATORY - HEMATOLOGY|Hc So Sickling Of Rbc- Reduction|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 400601; BFG: 52|||35.00|FSC: 400601; BFG: 52|19.25|
49000765|EAP|CPT® 22513||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Perc Kyphoplasty 1 Vertebral Body Thoracic W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|14,880.60|FSC: 400601; BFG: 52|||14,880.60|FSC: 400601; BFG: 52|8,184.33|
30200177|EAP|CPT® 86162||0302 - LABORATORY - IMMUNOLOGY|Hc So Complement Tot Hemolytic|1|<Self-pay>|<Self-pay>|<Self-pay>|67.20|FSC: 400601; BFG: 52|||67.20|FSC: 400601; BFG: 52|36.96|
49000766|EAP|CPT® 22514||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Perc Kyphoplasty 1 Vertebral Body Lumbar W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|14,880.60|FSC: 400601; BFG: 52|||14,880.60|FSC: 400601; BFG: 52|8,184.33|
30200179|EAP|CPT® 86334||0302 - LABORATORY - IMMUNOLOGY|Hc So Serum Immunofixation Electrophores|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|FSC: 400601; BFG: 52|||73.50|FSC: 400601; BFG: 52|40.42|
49000767|EAP|CPT® 22515||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Perc Kyphoplasty 1 Vertebral Body Ea Addl Thoracic Or Lumbar Vertebral Body W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|535.50|FSC: 400601; BFG: 52|||535.50|FSC: 400601; BFG: 52|294.52|
30200181|EAP|CPT® 86431||0302 - LABORATORY - IMMUNOLOGY|Hc So Quan Rheum Factor|1|<Self-pay>|<Self-pay>|<Self-pay>|18.90|FSC: 400601; BFG: 52|||18.90|FSC: 400601; BFG: 52|10.39|
30200182|EAP|CPT® 86665||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Eb Vca|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|FSC: 400601; BFG: 52|||59.85|FSC: 400601; BFG: 52|32.92|
51000534|EAP|CPT® 20604||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Arthrocentesis Joint/bursa Small W/ Ultrasound Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
30200184|EAP|CPT® 86777||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Toxoplasma|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
30200185|EAP|CPT® 86778||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Toxoplasma Igm|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
51000535|EAP|CPT® 20606||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Arthrocentesis Joint/bursa Intermediate W/ Ultrasound Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
30200187|EAP|CPT® 86788||0302 - LABORATORY - IMMUNOLOGY|Hc So West Nile Virus Ab Igm|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30200188|EAP|CPT® 86789||0302 - LABORATORY - IMMUNOLOGY|Hc So West Nile Virus Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|47.25|FSC: 400601; BFG: 52|||47.25|FSC: 400601; BFG: 52|25.99|
51000536|EAP|CPT® 20611||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Arthrocentesis Joint/bursa Major W/ Ultrasound Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|709.80|FSC: 400601; BFG: 52|||709.80|FSC: 400601; BFG: 52|390.39|
30600121|EAP|CPT® 87045||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Aerob Bacterial Culture- Stool|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
30600123|EAP|CPT® 87077||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Aerobic Bact Cult Addtl Id|1|<Self-pay>|<Self-pay>|<Self-pay>|26.25|FSC: 400601; BFG: 52|||26.25|FSC: 400601; BFG: 52|14.44|
30600124|EAP|CPT® 87081||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Culture Presumptive Pathog Screen - A|1|<Self-pay>|<Self-pay>|<Self-pay>|22.05|FSC: 400601; BFG: 52|||22.05|FSC: 400601; BFG: 52|12.13|
30600125|EAP|CPT® 87106||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Fungus Culture Def Id- Yeast|1|<Self-pay>|<Self-pay>|<Self-pay>|140.70|FSC: 400601; BFG: 52|||140.70|FSC: 400601; BFG: 52|77.38|
30600127|EAP|CPT® 87110||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Chlamydia Culture|1|<Self-pay>|<Self-pay>|<Self-pay>|95.55|FSC: 400601; BFG: 52|||95.55|FSC: 400601; BFG: 52|52.55|
30600133|EAP|CPT® 87176||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Homogeniz Tiss For Culture|1|<Self-pay>|<Self-pay>|<Self-pay>|52.50|FSC: 400601; BFG: 52|||52.50|FSC: 400601; BFG: 52|28.87|
30600134|EAP|CPT® 87177||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Ova & Parasites Dir Smr W Id|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
30600135|EAP|CPT® 87209||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Smear Complex Stain|1|<Self-pay>|<Self-pay>|<Self-pay>|86.10|FSC: 400601; BFG: 52|||86.10|FSC: 400601; BFG: 52|47.35|
30600136|EAP|CPT® 87210||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Smear - Infectious Wet Mount|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
30600137|EAP|CPT® 87230||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Toxin Assay- Tissue Culture|1|<Self-pay>|<Self-pay>|<Self-pay>|57.75|FSC: 400601; BFG: 52|||57.75|FSC: 400601; BFG: 52|31.76|
30600138|EAP|CPT® 87252||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Virus Isolate Tissue Cult Inoc|1|<Self-pay>|<Self-pay>|<Self-pay>|86.10|FSC: 400601; BFG: 52|||86.10|FSC: 400601; BFG: 52|47.35|
30600142|EAP|CPT® 87328||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Cryptosporidium Ag- Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30600145|EAP|CPT® 87497||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Cytomegalovirus Na Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|387.45|FSC: 400601; BFG: 52|||387.45|FSC: 400601; BFG: 52|213.10|
30100613|EAP|CPT® 80307||0301 - LABORATORY - CHEMISTRY|Hc Drug Test Presumptive Any Drug Class Any Device|1|<Self-pay>|<Self-pay>|<Self-pay>|192.15|FSC: 400601; BFG: 52|||192.15|FSC: 400601; BFG: 52|105.68|
30102032|EAP|CPT® 80145||0301 - LABORATORY - CHEMISTRY|Hc So Adalimumab|1|<Self-pay>|<Self-pay>|<Self-pay>|826.54|FSC: 400601; BFG: 52|||826.54|FSC: 400601; BFG: 52|454.60|
30100615|EAP|CPT® 80307||0301 - LABORATORY - CHEMISTRY|Hc Drug Test Presumptive Any Drug Class Any Device/procedure By Instrument Analyzer|1|<Self-pay>|<Self-pay>|<Self-pay>|192.15|FSC: 400601; BFG: 52|||192.15|FSC: 400601; BFG: 52|105.68|
30100616|EAP|CPT® 80307||0301 - LABORATORY - CHEMISTRY|Hc So Drug Test Presumptive Any Drug Class Any Device/procedure By Instrument Analyzer|1|<Self-pay>|<Self-pay>|<Self-pay>|192.15|FSC: 400601; BFG: 52|||192.15|FSC: 400601; BFG: 52|105.68|
30100617|EAP|CPT® 80307||0301 - LABORATORY - CHEMISTRY|Hc Drug Test Presumptive Any Drug Class Any Device/procedure By Instrument Analyzer|1|<Self-pay>|<Self-pay>|<Self-pay>|192.15|FSC: 400601; BFG: 52|||192.15|FSC: 400601; BFG: 52|105.68|
30100621|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC ALCOHOLS|1|<Self-pay>|<Self-pay>|<Self-pay>|300.30|FSC: 400601; BFG: 52|||300.30|FSC: 400601; BFG: 52|165.16|
30100622|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO ALCOHOLS|1|<Self-pay>|<Self-pay>|<Self-pay>|134.40|FSC: 400601; BFG: 52|||134.40|FSC: 400601; BFG: 52|73.92|
30102034|EAP|CPT® 80230||0301 - LABORATORY - CHEMISTRY|Hc Cch So Infliximab|1|<Self-pay>|<Self-pay>|<Self-pay>|183.75|FSC: 400601; BFG: 52|||183.75|FSC: 400601; BFG: 52|101.06|
51000236|EAP|CPT® 12020||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Treatment Wound Dehiscence Simple Closure|1|<Self-pay>|<Self-pay>|<Self-pay>|1,307.25|FSC: 400601; BFG: 52|||1,307.25|FSC: 400601; BFG: 52|718.99|
51000239|EAP|CPT® 20612||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Aspiration/injection Ganglion Cyst|1|<Self-pay>|<Self-pay>|<Self-pay>|662.55|FSC: 400601; BFG: 52|||662.55|FSC: 400601; BFG: 52|364.40|
30100636|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO ANTIDEPRESSANTS TRICYCLIC 1 OR 2 - A|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
49001014|EAP|CPT® 62328||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Lumbar Puncture Diagnostic W/fluoro Or Ct Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,476.30|FSC: 400601; BFG: 52|||1,476.30|FSC: 400601; BFG: 52|811.96|
51000256|EAP|CPT® 64425||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Injection Nerve Block Ilioinguinal/iliohypogastric|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
30100643|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO BENZODIAZEPINES 1-12|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
51000777|EAP|CPT® 20560||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Insertion Needle W/o Inj = < 2 Muscles|1|<Self-pay>|<Self-pay>|<Self-pay>|70.01|FSC: 400601; BFG: 52|||70.01|FSC: 400601; BFG: 52|38.51|
30100645|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO BENZODIAZEPINES 13 OR MORE|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
51000778|EAP|CPT® 20561||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Insertion Needle W/o Inj = > 3 Muscles|1|<Self-pay>|<Self-pay>|<Self-pay>|70.01|FSC: 400601; BFG: 52|||70.01|FSC: 400601; BFG: 52|38.51|
30100649|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO CANNABINOIDS NATURAL|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
30100655|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO FENTANYL|1|<Self-pay>|<Self-pay>|<Self-pay>|120.00|FSC: 400601; BFG: 52|||120.00|FSC: 400601; BFG: 52|66.00|
30100660|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO METHYLENEDIOXYAMPHETAMINES (MDA/MDEA/MDMA)|1|<Self-pay>|<Self-pay>|<Self-pay>|34.65|FSC: 400601; BFG: 52|||34.65|FSC: 400601; BFG: 52|19.06|
30100663|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO OPIATES 1 OR MORE|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
30100671|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO OXYCODONE|1|<Self-pay>|<Self-pay>|<Self-pay>|110.25|FSC: 400601; BFG: 52|||110.25|FSC: 400601; BFG: 52|60.64|
51000344|EAP|CPT® 92081||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Examination Visual Field Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
35200020|EAP|CPT® 74176||0352 - CT SCAN - BODY SCAN|Hc Ct Abdomen & Pelvis W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,067.45|FSC: 400601; BFG: 52|||2,067.45|FSC: 400601; BFG: 52|1,137.10|
35200021|EAP|CPT® 74177||0352 - CT SCAN - BODY SCAN|Hc Ct Abdomen & Pelvis W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,071.65|FSC: 400601; BFG: 52|||2,071.65|FSC: 400601; BFG: 52|1,139.41|
35200022|EAP|CPT® 74178||0352 - CT SCAN - BODY SCAN|Hc Ct Abdomen & Pelvis W/ & W/o Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|2,639.70|FSC: 400601; BFG: 52|||2,639.70|FSC: 400601; BFG: 52|1,451.83|
40200055|EAP|CPT® 76882||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Us Limited Joint W/imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|362.25|FSC: 400601; BFG: 52|||362.25|FSC: 400601; BFG: 52|199.24|
49000421|EAP|CPT® 19001||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Puncture Aspiration Breast Cyst Each Addl Cyst|1|<Self-pay>|<Self-pay>|<Self-pay>|172.20|FSC: 400601; BFG: 52|||172.20|FSC: 400601; BFG: 52|94.71|
51000385|EAP|CPT® 12031||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Repair Int Wound Scalp/axillae/trunk/extremities < = 2.5 Cm|1|<Self-pay>|<Self-pay>|<Self-pay>|901.95|FSC: 400601; BFG: 52|||901.95|FSC: 400601; BFG: 52|496.07|
76100110|EAP|CPT® 36510||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Catheterization Umbilical Vein Newborn|1|<Self-pay>|<Self-pay>|<Self-pay>|224.70|FSC: 400601; BFG: 52|||224.70|FSC: 400601; BFG: 52|123.58|
49000425|EAP|CPT® 38792||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection For Sentinel Node Identification|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
30600190|EAP|CPT® 87507||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Iadna-dna/rna Probe Tq 12-25|1|<Self-pay>|<Self-pay>|<Self-pay>|1,377.60|FSC: 400601; BFG: 52|||1,377.60|FSC: 400601; BFG: 52|757.68|
49000426|EAP|CPT® 49418||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Insertion Tunneled Intraperitoneal Catheter Complete Px|1|<Self-pay>|<Self-pay>|<Self-pay>|3,117.45|FSC: 400601; BFG: 52|||3,117.45|FSC: 400601; BFG: 52|1,714.60|
30600193|EAP|CPT® 87624||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Hpv High-risk Types|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
49000431|EAP|CPT® 64530||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Anesthetic Celiac Plexus|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
31200033|EAP|CPT® 88341||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Immunohisto/cyto Chem Each Addl Single Antibody Stain|1|<Self-pay>|<Self-pay>|<Self-pay>|259.35|FSC: 400601; BFG: 52|||259.35|FSC: 400601; BFG: 52|142.64|
31200035|EAP|CPT® 88342||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Immunohisto/cyto Chem Initial Single Antibody Stain|1|<Self-pay>|<Self-pay>|<Self-pay>|576.45|FSC: 400601; BFG: 52|||576.45|FSC: 400601; BFG: 52|317.05|
31200037|EAP|CPT® 88344||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Immunohisto/cyto Chem Each Multiplex Antibody Stain|1|<Self-pay>|<Self-pay>|<Self-pay>|260.40|FSC: 400601; BFG: 52|||260.40|FSC: 400601; BFG: 52|143.22|
31200039|EAP|CPT® 88364||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Insitu Hybridization (fish) Per Speciman Single Each Addl|1|<Self-pay>|<Self-pay>|<Self-pay>|256.20|FSC: 400601; BFG: 52|||256.20|FSC: 400601; BFG: 52|140.91|
27400190|EAP|HCPCS L3300||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Adjust-a-lift Heel Lift|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
27400096|EAP|HCPCS L3030||0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - PROSTHETIC/ORTHOTIC DEVICES|Hc Custom Foot Insert Each|1|<Self-pay>|<Self-pay>|<Self-pay>|735.00|FSC: 400601; BFG: 52|||735.00|FSC: 400601; BFG: 52|404.25|
27201706|EAP|Custom 27201706||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Drain Valve Heimlich Chest|1|<Self-pay>|<Self-pay>|<Self-pay>|358.75|FSC: 400601; BFG: 52|||358.75|FSC: 400601; BFG: 52|197.31|
99900135|EAP|HCPCS G1011||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Applied Pathways|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900136|EAP|HCPCS G1001||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Evicore|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
27201609|EAP|Custom 27201609||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Sleeve Compress Regular Knee|1|<Self-pay>|<Self-pay>|<Self-pay>|400.40|FSC: 400601; BFG: 52|||400.40|FSC: 400601; BFG: 52|220.22|
99900137|EAP|HCPCS G1002||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Medcurrent|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900138|EAP|HCPCS G1003||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Medicalis|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900139|EAP|HCPCS G1004||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Ndsc|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900140|EAP|HCPCS G1005||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|HC CLINICAL DECISION SUPPORT MECHANISM NIA|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900141|EAP|HCPCS G1006||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|HC CLINICAL DECISION SUPPORT MECHANISM TEST APPROPRIATE|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900142|EAP|HCPCS G1007||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Aim Specialty Health|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900143|EAP|HCPCS G1008||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Cranberry Peak|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900144|EAP|HCPCS G1009||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Sage Hms|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900145|EAP|HCPCS G1010||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Stanson|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900146|EAP|HCPCS G1011||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Qualified Tool Nos|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
27201713|EAP|Custom 27201713||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Pacing Catheter Reg Tip 5fr La|1|<Self-pay>|<Self-pay>|<Self-pay>|364.95|FSC: 400601; BFG: 52|||364.95|FSC: 400601; BFG: 52|200.72|
27205418|EAP|Custom 27205418||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Belmont Set Infusion 3-spike|1|<Self-pay>|<Self-pay>|<Self-pay>|682.50|FSC: 400601; BFG: 52|||682.50|FSC: 400601; BFG: 52|375.37|
30600198|EAP|CPT® 87651||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Strep A Amplif Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|103.95|FSC: 400601; BFG: 52|||103.95|FSC: 400601; BFG: 52|57.17|
30200223|EAP|CPT® 86705||0302 - LABORATORY - IMMUNOLOGY|Hc So Ab Hbcab Igm Ab|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
30100438|EAP|CPT® 82668||0301 - LABORATORY - CHEMISTRY|Hc So Erythropoietin|1|<Self-pay>|<Self-pay>|<Self-pay>|61.95|FSC: 400601; BFG: 52|||61.95|FSC: 400601; BFG: 52|34.07|
76200003|EAP|HCPCS G0379||0762 - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM|Hc Direct Admit To Observation|1|<Self-pay>|<Self-pay>|<Self-pay>|535.50|FSC: 400601; BFG: 52|||535.50|FSC: 400601; BFG: 52|294.52|
49000432|EAP|CPT® 64633||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent (rfa) Cervical/thoracic Paravert Joint Nerve Single Joint|1|<Self-pay>|<Self-pay>|<Self-pay>|4,312.35|FSC: 400601; BFG: 52|||4,312.35|FSC: 400601; BFG: 52|2,371.79|
49000433|EAP|CPT® 64635||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent (rfa) Lumbar/sacral Paravert Joint Nerve Single Joint|1|<Self-pay>|<Self-pay>|<Self-pay>|4,847.85|FSC: 400601; BFG: 52|||4,847.85|FSC: 400601; BFG: 52|2,666.32|
49000434|EAP|CPT® 64636||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent (rfa) Lumbar/sacral Paravert Joint Nerve Ea Addl Joint|1|<Self-pay>|<Self-pay>|<Self-pay>|1,830.15|FSC: 400601; BFG: 52|||1,830.15|FSC: 400601; BFG: 52|1,006.58|
49000435|EAP|CPT® 64634||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent (rfa) Cervical/thoracic Paravert Joint Nerve Ea Addl Joint|1|<Self-pay>|<Self-pay>|<Self-pay>|1,685.25|FSC: 400601; BFG: 52|||1,685.25|FSC: 400601; BFG: 52|926.89|
48300023|EAP|HCPCS C8928||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Echo Stress W/ Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|1,821.75|FSC: 400601; BFG: 52|||1,821.75|FSC: 400601; BFG: 52|1,001.96|
75000152|EAP|CPT® 45390||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Flexible W/ Endoscopic Mucosal Resection|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
51000837|EAP|CPT® 64625||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Destruction By Rfa Scroliliac Joint Incl Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|4,061.52|FSC: 400601; BFG: 52|||4,061.52|FSC: 400601; BFG: 52|2,233.84|
51000838|EAP|CPT® 64451||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Injection Nerve Sacroilic Joint Incl Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|1,476.52|FSC: 400601; BFG: 52|||1,476.52|FSC: 400601; BFG: 52|812.09|
51000839|EAP|CPT® 64454||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Injection Nerve Genicular Nerve Branches Incl Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|1,586.48|FSC: 400601; BFG: 52|||1,586.48|FSC: 400601; BFG: 52|872.56|
51000840|EAP|CPT® 64624||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Destruction By Neurolytic Agent (rfa) Genicular Nerve Branches Incl Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|4,061.52|FSC: 400601; BFG: 52|||4,061.52|FSC: 400601; BFG: 52|2,233.84|
99900155|EAP|HCPCS G1020||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Curbside|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900156|EAP|HCPCS G1021||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Ehealthline|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900157|EAP|HCPCS G1022||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Intermountain|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900158|EAP|HCPCS G1023||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Persivia|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
30600286|EAP|HCPCS U0001||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Cov 2 Cdc Testing|1|<Self-pay>|<Self-pay>|<Self-pay>|0.01|FSC: 400601; BFG: 52|||0.01|FSC: 400601; BFG: 52|0.01|
30600287|EAP|HCPCS U0002||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cov 2 2019 Ncov Covid19  Non Cdc Testing|1|<Self-pay>|<Self-pay>|<Self-pay>|341.25|FSC: 400601; BFG: 52|||341.25|FSC: 400601; BFG: 52|187.69|
30600288|EAP|HCPCS U0002||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Cov 2 2019 Ncov Covid19  Non Cdc Testing|1|<Self-pay>|<Self-pay>|<Self-pay>|341.25|FSC: 400601; BFG: 52|||341.25|FSC: 400601; BFG: 52|187.69|
43000106|EAP|CPT® 97012||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Traction Mechanical By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|57.75|FSC: 400601; BFG: 52|||57.75|FSC: 400601; BFG: 52|31.76|
30200324|EAP|CPT® 86769||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Sars Covid 2 Covid 19 Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
30600293|EAP|HCPCS U0003||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Sars Cov 2 Covid 19 Amp Prb High Throughput Tech|1|<Self-pay>|<Self-pay>|<Self-pay>|341.25|FSC: 400601; BFG: 52|||341.25|FSC: 400601; BFG: 52|187.69|
99900147|EAP|HCPCS G1012||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Agilemd|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900148|EAP|HCPCS G1013||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Evidencecare Imaging Advisor|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900149|EAP|HCPCS G1014||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Inveniqa Semantic Answers N Medicine|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900150|EAP|HCPCS G1015||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Reliant Medical Group|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900151|EAP|HCPCS G1016||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Speed Of Care|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900152|EAP|HCPCS G1017||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Healthhelp|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900153|EAP|HCPCS G1018||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Infinx|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
99900154|EAP|HCPCS G1019||0999 - PATIENT CONVENIENCE ITEMS - OTHER PATIENT CONVENIENCE ITEM|Hc Clinical Decision Support Mechanism Logicnets Auc Solution|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
31000580|EAP|HCPCS 0202U||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Infct Ds Bct Vir Respir Dna Rna 22 Trgt Sarscov2|1|<Self-pay>|<Self-pay>|<Self-pay>|732.00|FSC: 400601; BFG: 52|||732.00|FSC: 400601; BFG: 52|402.60|
36000064|EAP|HCPCS S2900||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Cch Robotic Surgical System|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 400601|||0.00|FSC: 400601|0.00|
30500099|EAP|CPT® 85250||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Clotting Factor Ix|1|<Self-pay>|<Self-pay>|<Self-pay>|63.00|FSC: 400601; BFG: 52|||63.00|FSC: 400601; BFG: 52|34.65|
30500100|EAP|CPT® 85270||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Clotting Factor Xi|1|<Self-pay>|<Self-pay>|<Self-pay>|58.80|FSC: 400601; BFG: 52|||58.80|FSC: 400601; BFG: 52|32.34|
27207888|EAP|Custom 27207888||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kit Disposable Mri For 65/115 Mr Injector System|1|<Self-pay>|<Self-pay>|<Self-pay>|131.00|FSC: 400601; BFG: 52|||131.00|FSC: 400601; BFG: 52|72.05|
26000016|EAP|HCPCS M0245||0260 - IV THERAPY - GENERAL CLASSIFICATION|HC IV INFUSION BAMLANIVIMAB AND ETESEVIMAB|1|<Self-pay>|<Self-pay>|<Self-pay>|696.00|FSC: 400601; BFG: 52|||696.00|FSC: 400601; BFG: 52|382.80|
27219047|EAP|Custom 27219047||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Yueh Centesis Disposable Cath|1|<Self-pay>|<Self-pay>|<Self-pay>|126.55|FSC: 400601; BFG: 52|||126.55|FSC: 400601; BFG: 52|69.60|
30100934|EAP|CPT® 80307||0301 - LABORATORY - CHEMISTRY|Hc Cch So Drug Test Presumptive Any Drug Class Any Device/procedure|1|<Self-pay>|<Self-pay>|<Self-pay>|192.15|FSC: 400601; BFG: 52|||192.15|FSC: 400601; BFG: 52|105.68|
30100945|EAP|CPT® 82731||0301 - LABORATORY - CHEMISTRY|Hc So Fetal Fibronectin|1|<Self-pay>|<Self-pay>|<Self-pay>|208.95|FSC: 400601; BFG: 52|||208.95|FSC: 400601; BFG: 52|114.92|
30100957|EAP|CPT® 84157||0301 - LABORATORY - CHEMISTRY|Hc Cch So Total Protein Fluid|1|<Self-pay>|<Self-pay>|<Self-pay>|12.60|FSC: 400601; BFG: 52|||12.60|FSC: 400601; BFG: 52|6.93|
30200268|EAP|CPT® 86701||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Antibody Hiv-1|1|<Self-pay>|<Self-pay>|<Self-pay>|118.65|FSC: 400601; BFG: 52|||118.65|FSC: 400601; BFG: 52|65.26|
30500102|EAP|CPT® 85461||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Fetal Hgb Screening Test|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|FSC: 400601; BFG: 52|||25.20|FSC: 400601; BFG: 52|13.86|
30600250|EAP|CPT® 87075||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Anerobic Bact Culture W Id|1|<Self-pay>|<Self-pay>|<Self-pay>|31.50|FSC: 400601; BFG: 52|||31.50|FSC: 400601; BFG: 52|17.32|
31200062|EAP|CPT® 88300||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Surg Path Level I Gross Only|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|FSC: 400601; BFG: 52|||25.20|FSC: 400601; BFG: 52|13.86|
31200063|EAP|CPT® 88302||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Surg Path Level Ii|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
31200064|EAP|CPT® 88304||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Surg Path Level Iii|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
31200065|EAP|CPT® 88309||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Surg Path Level Vi|1|<Self-pay>|<Self-pay>|<Self-pay>|1,447.95|FSC: 400601; BFG: 52|||1,447.95|FSC: 400601; BFG: 52|796.37|
31200066|EAP|CPT® 88311||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Decalcification|1|<Self-pay>|<Self-pay>|<Self-pay>|17.85|FSC: 400601; BFG: 52|||17.85|FSC: 400601; BFG: 52|9.82|
27209143|EAP|||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Electrode Onestep Adult Complete Resuscitation|1|<Self-pay>|<Self-pay>|<Self-pay>|154.80|FSC: 400601; BFG: 52|||154.80|FSC: 400601; BFG: 52|85.14|
27209144|EAP|||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Electrode Onestep Pediatric Cpr|1|<Self-pay>|<Self-pay>|<Self-pay>|146.25|FSC: 400601; BFG: 52|||146.25|FSC: 400601; BFG: 52|80.44|
30600298|EAP|CPT® 87636||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Iadna Sarscov2 & Infa & B Multi Amplified Probe Ta|1|<Self-pay>|<Self-pay>|<Self-pay>|254.10|FSC: 400601; BFG: 52|||254.10|FSC: 400601; BFG: 52|139.75|
32400006|EAP|CPT® 71047||0324 - RADIOLOGY - DIAGNOSTIC - CHEST X-RAY|Hc Radiology X-ray Chest 3 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
42000094|EAP|CPT® 97763||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Orthotic/prosthetic Management/ Training Subsequent Each 15 Mins By Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
43000090|EAP|CPT® 97763||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Orthotic/prosthetic Management/ Training Subsequent Each 15 Mins By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
36000068|EAP|HCPCS 0421T||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Cch Ablation Prostate Transurethral Waterjet|1|<Self-pay>|<Self-pay>|<Self-pay>|12,705.00|FSC: 400601; BFG: 52|||12,705.00|FSC: 400601; BFG: 52|6,987.75|
25000049|EAP|HCPCS A9698||0250 - PHARMACY - GENERAL CLASSIFICATION|Hc Cch Non-rad Contrast Material Noc|1|<Self-pay>|<Self-pay>|<Self-pay>|329.85|FSC: 400601; BFG: 52|||329.85|FSC: 400601; BFG: 52|181.42|
27202318|EAP|Custom 27202318||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Adhesive Medical Sterile|1|<Self-pay>|<Self-pay>|<Self-pay>|59.00|FSC: 400601; BFG: 52|||59.00|FSC: 400601; BFG: 52|32.45|
30100440|EAP|CPT® 82105||0301 - LABORATORY - CHEMISTRY|Hc So Alpha-fetoprotein- Serum|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
30100441|EAP|CPT® 84702||0301 - LABORATORY - CHEMISTRY|Hc So Hcg Quan|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30200194|EAP|CPT® 86038||0302 - LABORATORY - IMMUNOLOGY|Hc So Antinuclear Ab (ana)|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30200195|EAP|CPT® 86225||0302 - LABORATORY - IMMUNOLOGY|Hc So Dna Ab Native Or Ds|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30100443|EAP|HCPCS G0480||0301 - LABORATORY - CHEMISTRY|HC SO BARBITURATES|1|<Self-pay>|<Self-pay>|<Self-pay>|183.75|FSC: 400601; BFG: 52|||183.75|FSC: 400601; BFG: 52|101.06|
15271|EAP|CPT® 15271||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|APP SKN SUB GRFT T/A/L AREA/<100SCM /<1ST 25 SCM|1|<Self-pay>|<Self-pay>|<Self-pay>|206.00|FSC: 46100; BFG: 52|||206.00|FSC: 46100; BFG: 52|113.30|
15272|EAP|CPT® 15272|||APP SKN SUB GRFT T/A/L AREA/<100SCM EA ADL 25SCM|1|<Self-pay>|<Self-pay>|<Self-pay>|60.00|FSC: 46100; BFG: 52|||60.00|FSC: 46100; BFG: 52|33.00|
15275|EAP|CPT® 15275|||SUB GRFT F/S/N/H/F/G/M/D /<100SCM /<1ST 25 SCM|1|<Self-pay>|<Self-pay>|<Self-pay>|225.00|FSC: 46100; BFG: 52|||225.00|FSC: 46100; BFG: 52|123.75|
64633|EAP|CPT® 64633|||DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA|1|<Self-pay>|<Self-pay>|<Self-pay>|607.00|FSC: 46100; BFG: 52|||607.00|FSC: 46100; BFG: 52|333.85|
64634|EAP|CPT® 64634|||DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA|1|<Self-pay>|<Self-pay>|<Self-pay>|271.00|FSC: 46100; BFG: 52|||271.00|FSC: 46100; BFG: 52|149.05|
64635|EAP|CPT® 64635|||DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL|1|<Self-pay>|<Self-pay>|<Self-pay>|600.00|FSC: 46100; BFG: 52|||600.00|FSC: 46100; BFG: 52|330.00|
64636|EAP|CPT® 64636|||DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL|1|<Self-pay>|<Self-pay>|<Self-pay>|246.00|FSC: 46100; BFG: 52|||246.00|FSC: 46100; BFG: 52|135.30|
30600256|EAP|CPT® 87070||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc So Bacterial Culture - Othr Source|1|<Self-pay>|<Self-pay>|<Self-pay>|95.55|FSC: 400601; BFG: 52|||95.55|FSC: 400601; BFG: 52|52.55|
63600295|EAP|HCPCS J7120||0636 - PHARMACY - DRUGS REQUIRING DETAILED CODING|Hc Ringers Lactate Infusion To 1000 Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
31000181|EAP|CPT® 81270||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Jak2 Gene Analysis|1|<Self-pay>|<Self-pay>|<Self-pay>|206.27|FSC: 400601; BFG: 52|||206.27|FSC: 400601; BFG: 52|113.45|
31000287|EAP|CPT® 81420||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Fetal Chromosomal Aneuploidy Analysis|1|<Self-pay>|<Self-pay>|<Self-pay>|2,032.80|FSC: 400601; BFG: 52|||2,032.80|FSC: 400601; BFG: 52|1,118.04|
31100133|EAP|CPT® 88182||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc So Cell Marker Study|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
31100143|EAP|CPT® 88291||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc So Cg Mcg Int & Rep|1|<Self-pay>|<Self-pay>|<Self-pay>|135.25|FSC: 400601; BFG: 52|||135.25|FSC: 400601; BFG: 52|74.39|
31200083|EAP|CPT® 88377||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc So Insitu Hybridization Manual Per Specimen Multiplex Each|1|<Self-pay>|<Self-pay>|<Self-pay>|345.45|FSC: 400601; BFG: 52|||345.45|FSC: 400601; BFG: 52|190.00|
30900020|EAP|HCPCS G0103||0309 - LABORATORY - OTHER LABORATORY|Hc Cch So Psa Screening|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
32000248|EAP|CPT® 74019||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Abdomen 2 Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
32000249|EAP|CPT® 74021||0320 - RADIOLOGY - DIAGNOSTIC - GENERAL CLASSIFICATION|Hc Radiology Exam Abdomen 3 Or More Views|1|<Self-pay>|<Self-pay>|<Self-pay>|306.60|FSC: 400601; BFG: 52|||306.60|FSC: 400601; BFG: 52|168.63|
34100078|EAP|CPT® 78226||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Hepatobiliary System Imaging Incl Gallbladder|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100079|EAP|CPT® 78227||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Hepatobiliary System Imaging Incl Gallbladder W/ Drug|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
34100080|EAP|CPT® 78579||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Pulmunary Ventilation Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|935.55|FSC: 400601; BFG: 52|||935.55|FSC: 400601; BFG: 52|514.55|
34100081|EAP|CPT® 78582||0341 - NUCLEAR MEDICINE - DIAGNOSTIC PROCEDURES|Hc Nuc Med Pulmonary Ventilation And Perfusion Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|1,212.75|FSC: 400601; BFG: 52|||1,212.75|FSC: 400601; BFG: 52|667.01|
35000028|EAP|CPT® 74174||0350 - CT SCAN - GENERAL CLASSIFICATION|Hc Cta Abdomen And Pelvis W/ Contrast And Postprocessing|1|<Self-pay>|<Self-pay>|<Self-pay>|3,293.85|FSC: 400601; BFG: 52|||3,293.85|FSC: 400601; BFG: 52|1,811.62|
46000029|EAP|CPT® 94726||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Pulmonary Function Test Plethysmography|1|<Self-pay>|<Self-pay>|<Self-pay>|666.75|FSC: 400601; BFG: 52|||666.75|FSC: 400601; BFG: 52|366.71|
46000032|EAP|CPT® 94729||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Diffusing Capacity|1|<Self-pay>|<Self-pay>|<Self-pay>|143.85|FSC: 400601; BFG: 52|||143.85|FSC: 400601; BFG: 52|79.12|
49000447|EAP|CPT® 37191||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Insert Endovascular Vena Cava Filter|1|<Self-pay>|<Self-pay>|<Self-pay>|11,419.80|FSC: 400601; BFG: 52|||11,419.80|FSC: 400601; BFG: 52|6,280.89|
49000449|EAP|CPT® 37193||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Removal Endovascular Vena Cava Filter|1|<Self-pay>|<Self-pay>|<Self-pay>|3,055.50|FSC: 400601; BFG: 52|||3,055.50|FSC: 400601; BFG: 52|1,680.52|
49000452|EAP|CPT® 49082||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Abdominal Paracentesis W/o Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,990.80|FSC: 400601; BFG: 52|||1,990.80|FSC: 400601; BFG: 52|1,094.94|
49000453|EAP|CPT® 49083||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Abdominal Paracentesis W/ Imaging Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,990.80|FSC: 400601; BFG: 52|||1,990.80|FSC: 400601; BFG: 52|1,094.94|
27207949|EAP|Custom 27207949||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Valve Antireflux|1|<Self-pay>|<Self-pay>|<Self-pay>|31.00|FSC: 400601; BFG: 52|||31.00|FSC: 400601; BFG: 52|17.05|
27207965|EAP|Custom 27207965||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Packing Strip|1|<Self-pay>|<Self-pay>|<Self-pay>|15.30|FSC: 400601; BFG: 52|||15.30|FSC: 400601; BFG: 52|8.41|
27207967|EAP|Custom 27207967||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Dvt Hose Knee|1|<Self-pay>|<Self-pay>|<Self-pay>|32.90|FSC: 400601; BFG: 52|||32.90|FSC: 400601; BFG: 52|18.09|
27207968|EAP|Custom 27207968||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Dvt Hose Thigh|1|<Self-pay>|<Self-pay>|<Self-pay>|60.95|FSC: 400601; BFG: 52|||60.95|FSC: 400601; BFG: 52|33.52|
27207994|EAP|Custom 27207994||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Rfa Cannula|1|<Self-pay>|<Self-pay>|<Self-pay>|149.95|FSC: 400601; BFG: 52|||149.95|FSC: 400601; BFG: 52|82.47|
27208007|EAP|Custom 27208007||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Dressing Biopatch 1 In Disk 4mm|1|<Self-pay>|<Self-pay>|<Self-pay>|33.25|FSC: 400601; BFG: 52|||33.25|FSC: 400601; BFG: 52|18.29|
27208011|EAP|Custom 27208011||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kit Peritoneal Drainage|1|<Self-pay>|<Self-pay>|<Self-pay>|1,275.35|FSC: 400601; BFG: 52|||1,275.35|FSC: 400601; BFG: 52|701.44|
40100007|EAP|HCPCS G0279||0401 - OTHER IMAGING SERVICES - DIAGNOSTIC MAMMOGRAPHY|Hc Diagnostic Mammo Tomo Bilateral|1|<Self-pay>|<Self-pay>|<Self-pay>|415.80|FSC: 400601; BFG: 52|||415.80|FSC: 400601; BFG: 52|228.69|
25800006|EAP|HCPCS J7070||0258 - PHARMACY - IV SOLUTIONS|Hc Cch Dex 5% 1000ml|1|<Self-pay>|<Self-pay>|<Self-pay>|82.85|FSC: 400601; BFG: 52|||82.85|FSC: 400601; BFG: 52|45.57|
25800009|EAP|HCPCS J7060||0258 - PHARMACY - IV SOLUTIONS|Hc Cch Dex 5% 500ml|1|<Self-pay>|<Self-pay>|<Self-pay>|82.85|FSC: 400601; BFG: 52|||82.85|FSC: 400601; BFG: 52|45.57|
63600301|EAP|HCPCS J7121||0636 - PHARMACY - DRUGS REQUIRING DETAILED CODING|Hc Cch 5% Dex Ringers Lactate Infusion To 1000 Cc|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
43000092|EAP|CPT® 97545||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Work Hardening/conditioning Initial 2 Hours By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|241.50|FSC: 400601; BFG: 52|||241.50|FSC: 400601; BFG: 52|132.82|
43000093|EAP|CPT® 97546||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Work Hardening/conditioning Each Addl Hour By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|122.85|FSC: 400601; BFG: 52|||122.85|FSC: 400601; BFG: 52|67.57|
49000962|EAP|CPT® 62282||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Epidural Injection Neurolytic Lumbar/sacral|1|<Self-pay>|<Self-pay>|<Self-pay>|1,799.70|FSC: 400601; BFG: 52|||1,799.70|FSC: 400601; BFG: 52|989.83|
49000963|EAP|CPT® 62292||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Injection Into Disk Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|4,312.35|FSC: 400601; BFG: 52|||4,312.35|FSC: 400601; BFG: 52|2,371.79|
49000964|EAP|CPT® 62350||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Implant/revise Epidural Cath Via External Or Implantable Pump|1|<Self-pay>|<Self-pay>|<Self-pay>|9,741.90|FSC: 400601; BFG: 52|||9,741.90|FSC: 400601; BFG: 52|5,358.04|
49000965|EAP|CPT® 62355||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Removal Previously Implanted Intrathecal Or Epidural Catheter|1|<Self-pay>|<Self-pay>|<Self-pay>|4,312.35|FSC: 400601; BFG: 52|||4,312.35|FSC: 400601; BFG: 52|2,371.79|
49000966|EAP|CPT® 62362||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Implant/replace Drug Infusion Device Prog Pump W/w/o Prog|1|<Self-pay>|<Self-pay>|<Self-pay>|44,020.20|FSC: 400601; BFG: 52|||44,020.20|FSC: 400601; BFG: 52|24,211.11|
49000967|EAP|CPT® 62365||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Removalsubcutaneous Pump|1|<Self-pay>|<Self-pay>|<Self-pay>|9,589.65|FSC: 400601; BFG: 52|||9,589.65|FSC: 400601; BFG: 52|5,274.31|
49000973|EAP|CPT® 64722||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Decompress Nerve(s)|1|<Self-pay>|<Self-pay>|<Self-pay>|4,312.35|FSC: 400601; BFG: 52|||4,312.35|FSC: 400601; BFG: 52|2,371.79|
49000974|EAP|CPT® 64999||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Unlisted Procedure Nervous System|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
27208070|EAP|Custom 27208070||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Set Needle Biop/coax 16gx10cm|1|<Self-pay>|<Self-pay>|<Self-pay>|105.40|FSC: 400601; BFG: 52|||105.40|FSC: 400601; BFG: 52|57.97|
27208071|EAP|Custom 27208071||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Set Needle Biop/coax 16gx16cm|1|<Self-pay>|<Self-pay>|<Self-pay>|105.40|FSC: 400601; BFG: 52|||105.40|FSC: 400601; BFG: 52|57.97|
30000101|EAP|CPT® 86860||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc So Rbc Ab Elution Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|127.05|FSC: 400601; BFG: 52|||127.05|FSC: 400601; BFG: 52|69.88|
30000102|EAP|CPT® 86870||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc So Ab Id/ Rbc/ Ea Panel Ea Techn|1|<Self-pay>|<Self-pay>|<Self-pay>|576.45|FSC: 400601; BFG: 52|||576.45|FSC: 400601; BFG: 52|317.05|
30000103|EAP|CPT® 86886||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc So Antibody Titer|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|FSC: 400601; BFG: 52|||98.70|FSC: 400601; BFG: 52|54.28|
30000104|EAP|CPT® 86902||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Cch So Bld Type Ag Scrn W Reagent|1|<Self-pay>|<Self-pay>|<Self-pay>|576.45|FSC: 400601; BFG: 52|||576.45|FSC: 400601; BFG: 52|317.05|
30000105|EAP|CPT® 86905||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Cch So Bld Type Rbc Ag Not Abo/rhd|1|<Self-pay>|<Self-pay>|<Self-pay>|576.45|FSC: 400601; BFG: 52|||576.45|FSC: 400601; BFG: 52|317.05|
30000106|EAP|CPT® 86941||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc So Hemolysins/agglutinins Incubated|1|<Self-pay>|<Self-pay>|<Self-pay>|58.80|FSC: 400601; BFG: 52|||58.80|FSC: 400601; BFG: 52|32.34|
30000107|EAP|CPT® 86971||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc So Pretreat Rbc Enzymes|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
30000108|EAP|CPT® 86975||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc Cch So Serum Pretx Drug Incubate|1|<Self-pay>|<Self-pay>|<Self-pay>|214.20|FSC: 400601; BFG: 52|||214.20|FSC: 400601; BFG: 52|117.81|
30000109|EAP|CPT® 86978||0300 - LABORATORY - GENERAL CLASSIFICATION|Hc So Serum Pretx Rc Absorpt|1|<Self-pay>|<Self-pay>|<Self-pay>|114.45|FSC: 400601; BFG: 52|||114.45|FSC: 400601; BFG: 52|62.95|
30100968|EAP|CPT® 80081||0301 - LABORATORY - CHEMISTRY|Hc Cch Obstetric Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|252.00|FSC: 400601; BFG: 52|||252.00|FSC: 400601; BFG: 52|138.60|
30100969|EAP|CPT® 80150||0301 - LABORATORY - CHEMISTRY|Hc Cch So Amikacin|1|<Self-pay>|<Self-pay>|<Self-pay>|102.90|FSC: 400601; BFG: 52|||102.90|FSC: 400601; BFG: 52|56.59|
30100970|EAP|CPT® 80176||0301 - LABORATORY - CHEMISTRY|Hc Cch So Lidocaine|1|<Self-pay>|<Self-pay>|<Self-pay>|89.25|FSC: 400601; BFG: 52|||89.25|FSC: 400601; BFG: 52|49.09|
30100971|EAP|CPT® 80200||0301 - LABORATORY - CHEMISTRY|Hc Cch So Tobramycin|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
30100972|EAP|CPT® 89220||0301 - LABORATORY - CHEMISTRY|Hc Cch Aerosol Sputum Collection|1|<Self-pay>|<Self-pay>|<Self-pay>|339.15|FSC: 400601; BFG: 52|||339.15|FSC: 400601; BFG: 52|186.53|
30100973|EAP|CPT® 80420||0301 - LABORATORY - CHEMISTRY|Hc Cch So Dexamethasone Suppression Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|342.30|FSC: 400601; BFG: 52|||342.30|FSC: 400601; BFG: 52|188.26|
30100974|EAP|CPT® 82128||0301 - LABORATORY - CHEMISTRY|Hc Cch So Amino Acids Multiple Qual Ea|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
30100975|EAP|CPT® 82757||0301 - LABORATORY - CHEMISTRY|Hc Cch So Fructose Semen|1|<Self-pay>|<Self-pay>|<Self-pay>|72.45|FSC: 400601; BFG: 52|||72.45|FSC: 400601; BFG: 52|39.85|
30100976|EAP|CPT® 82760||0301 - LABORATORY - CHEMISTRY|Hc Cch So Galactose|1|<Self-pay>|<Self-pay>|<Self-pay>|180.60|FSC: 400601; BFG: 52|||180.60|FSC: 400601; BFG: 52|99.33|
30100977|EAP|CPT® 83663||0301 - LABORATORY - CHEMISTRY|Hc Cch So Fetal Lung - Fluoresc Polariz|1|<Self-pay>|<Self-pay>|<Self-pay>|469.35|FSC: 400601; BFG: 52|||469.35|FSC: 400601; BFG: 52|258.14|
30100978|EAP|CPT® 83872||0301 - LABORATORY - CHEMISTRY|Hc Cch So Mucin Synovial Fluid|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|FSC: 400601; BFG: 52|||59.85|FSC: 400601; BFG: 52|32.92|
30100979|EAP|CPT® 84081||0301 - LABORATORY - CHEMISTRY|Hc Cch So Phosphatidylglycerol|1|<Self-pay>|<Self-pay>|<Self-pay>|213.15|FSC: 400601; BFG: 52|||213.15|FSC: 400601; BFG: 52|117.23|
30100980|EAP|CPT® 84583||0301 - LABORATORY - CHEMISTRY|Hc Cch Urobilinogen Urine Semiquan|1|<Self-pay>|<Self-pay>|<Self-pay>|24.15|FSC: 400601; BFG: 52|||24.15|FSC: 400601; BFG: 52|13.28|
30100981|EAP|CPT® 84600||0301 - LABORATORY - CHEMISTRY|Hc Cch So Volatiles|1|<Self-pay>|<Self-pay>|<Self-pay>|77.70|FSC: 400601; BFG: 52|||77.70|FSC: 400601; BFG: 52|42.73|
30200286|EAP|CPT® 86280||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Hemagglutination Inhibition Test|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|FSC: 400601; BFG: 52|||98.70|FSC: 400601; BFG: 52|54.28|
30200287|EAP|CPT® 86325||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Iep Not Serum|1|<Self-pay>|<Self-pay>|<Self-pay>|108.15|FSC: 400601; BFG: 52|||108.15|FSC: 400601; BFG: 52|59.48|
30200288|EAP|CPT® 86593||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Syphilis Test Non-trep Quant|1|<Self-pay>|<Self-pay>|<Self-pay>|21.00|FSC: 400601; BFG: 52|||21.00|FSC: 400601; BFG: 52|11.55|
30200289|EAP|CPT® 86602||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Ab Actinomyces|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
30200290|EAP|CPT® 86759||0302 - LABORATORY - IMMUNOLOGY|Hc Cch So Rotavirus Antibody|1|<Self-pay>|<Self-pay>|<Self-pay>|48.30|FSC: 400601; BFG: 52|||48.30|FSC: 400601; BFG: 52|26.56|
30500108|EAP|CPT® 85008||0305 - LABORATORY - HEMATOLOGY|Hc Cch Bl Smear W/o Diff Wbc Count|1|<Self-pay>|<Self-pay>|<Self-pay>|7.35|FSC: 400601; BFG: 52|||7.35|FSC: 400601; BFG: 52|4.04|
30500109|EAP|CPT® 85041||0305 - LABORATORY - HEMATOLOGY|Hc Cch Automated Rbc Count|1|<Self-pay>|<Self-pay>|<Self-pay>|10.50|FSC: 400601; BFG: 52|||10.50|FSC: 400601; BFG: 52|5.77|
30500110|EAP|CPT® 85045||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Automated Reticulocyte Count|1|<Self-pay>|<Self-pay>|<Self-pay>|13.65|FSC: 400601; BFG: 52|||13.65|FSC: 400601; BFG: 52|7.51|
30500111|EAP|CPT® 85475||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Hemolysin Acid|1|<Self-pay>|<Self-pay>|<Self-pay>|185.85|FSC: 400601; BFG: 52|||185.85|FSC: 400601; BFG: 52|102.22|
30500112|EAP|CPT® 85611||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Pt Substitution Plasma Fractions Each|1|<Self-pay>|<Self-pay>|<Self-pay>|46.20|FSC: 400601; BFG: 52|||46.20|FSC: 400601; BFG: 52|25.41|
30600257|EAP|CPT® 87040||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Aerob Bacterial Blood Culture|1|<Self-pay>|<Self-pay>|<Self-pay>|88.20|FSC: 400601; BFG: 52|||88.20|FSC: 400601; BFG: 52|48.51|
30600258|EAP|CPT® 87086||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Bact Culture - Urine Quan Count|1|<Self-pay>|<Self-pay>|<Self-pay>|60.90|FSC: 400601; BFG: 52|||60.90|FSC: 400601; BFG: 52|33.49|
30600259|EAP|CPT® 87088||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Urine Bacteria Culture|1|<Self-pay>|<Self-pay>|<Self-pay>|45.15|FSC: 400601; BFG: 52|||45.15|FSC: 400601; BFG: 52|24.83|
30600260|EAP|CPT® 87168||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Macroscopic Exam Arthropod|1|<Self-pay>|<Self-pay>|<Self-pay>|58.80|FSC: 400601; BFG: 52|||58.80|FSC: 400601; BFG: 52|32.34|
30600261|EAP|CPT® 87278||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Legionella Pneumophila Ag By Dfa|1|<Self-pay>|<Self-pay>|<Self-pay>|40.95|FSC: 400601; BFG: 52|||40.95|FSC: 400601; BFG: 52|22.52|
30600262|EAP|CPT® 87320||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Chlamydia Trachomatis Ag Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|140.70|FSC: 400601; BFG: 52|||140.70|FSC: 400601; BFG: 52|77.38|
30600263|EAP|CPT® 87324||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Clostridium Ag Evaluation|1|<Self-pay>|<Self-pay>|<Self-pay>|74.55|FSC: 400601; BFG: 52|||74.55|FSC: 400601; BFG: 52|41.00|
30600264|EAP|CPT® 87335||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So E Coli 0157 Ag Eia|1|<Self-pay>|<Self-pay>|<Self-pay>|90.30|FSC: 400601; BFG: 52|||90.30|FSC: 400601; BFG: 52|49.66|
30600265|EAP|CPT® 87341||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Hepatitis B Surface Ag Eia Neutralization|1|<Self-pay>|<Self-pay>|<Self-pay>|34.65|FSC: 400601; BFG: 52|||34.65|FSC: 400601; BFG: 52|19.06|
30600266|EAP|CPT® 87590||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Neisseria Dir Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|96.60|FSC: 400601; BFG: 52|||96.60|FSC: 400601; BFG: 52|53.13|
30600267|EAP|CPT® 87640||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Staph A Dna Amp Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|115.50|FSC: 400601; BFG: 52|||115.50|FSC: 400601; BFG: 52|63.52|
30700009|EAP|CPT® 81002||0307 - LABORATORY - UROLOGY|Hc Cch So Urinalysis Total Non-automated W/o Micro|1|<Self-pay>|<Self-pay>|<Self-pay>|19.95|FSC: 400601; BFG: 52|||19.95|FSC: 400601; BFG: 52|10.97|
30700010|EAP|CPT® 81015||0307 - LABORATORY - UROLOGY|Hc Cch So Urinalysis Microscopic Only|1|<Self-pay>|<Self-pay>|<Self-pay>|23.10|FSC: 400601; BFG: 52|||23.10|FSC: 400601; BFG: 52|12.70|
30900022|EAP|CPT® 89300||0309 - LABORATORY - OTHER LABORATORY|Hc Cch Semen Presence & Motility W/ Huhner Test|1|<Self-pay>|<Self-pay>|<Self-pay>|29.40|FSC: 400601; BFG: 52|||29.40|FSC: 400601; BFG: 52|16.17|
31000338|EAP|CPT® 81220||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Vw Cystic Fibrosis Mutation Panel|1|<Self-pay>|<Self-pay>|<Self-pay>|313.95|FSC: 400601; BFG: 52|||313.95|FSC: 400601; BFG: 52|172.67|
31000339|EAP|CPT® 81240||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Prothrombin Variant|1|<Self-pay>|<Self-pay>|<Self-pay>|176.40|FSC: 400601; BFG: 52|||176.40|FSC: 400601; BFG: 52|97.02|
31000340|EAP|CPT® 81241||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Factor V Leiden|1|<Self-pay>|<Self-pay>|<Self-pay>|201.60|FSC: 400601; BFG: 52|||201.60|FSC: 400601; BFG: 52|110.88|
31000341|EAP|CPT® 81244||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Fmr1 Gene Characterization|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
31000342|EAP|CPT® 81291||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Mthfr Gene Analysis|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
31000343|EAP|CPT® 81383||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Hla Class Ii Typing 1 Allele Hr|1|<Self-pay>|<Self-pay>|<Self-pay>|218.40|FSC: 400601; BFG: 52|||218.40|FSC: 400601; BFG: 52|120.12|
31000344|EAP|CPT® 81510||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Ftl Cgen Abnor Three Anal|1|<Self-pay>|<Self-pay>|<Self-pay>|408.45|FSC: 400601; BFG: 52|||408.45|FSC: 400601; BFG: 52|224.65|
31000345|EAP|CPT® 81511||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Ftl Cgen Abnor Four Anal|1|<Self-pay>|<Self-pay>|<Self-pay>|492.45|FSC: 400601; BFG: 52|||492.45|FSC: 400601; BFG: 52|270.85|
31000346|EAP|CPT® 88333||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Intraop Cytologic Pathology Consult Initial|1|<Self-pay>|<Self-pay>|<Self-pay>|1,447.95|FSC: 400601; BFG: 52|||1,447.95|FSC: 400601; BFG: 52|796.37|
31000347|EAP|CPT® 88334||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Intraop Cytologic Pathology Consult Each Additional|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|FSC: 400601; BFG: 52|||73.50|FSC: 400601; BFG: 52|40.42|
31100144|EAP|CPT® 88108||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Cp Concentr Tech Smear|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
31100145|EAP|CPT® 88141||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Cp Cerv/vag|1|<Self-pay>|<Self-pay>|<Self-pay>|17.85|FSC: 400601; BFG: 52|||17.85|FSC: 400601; BFG: 52|9.82|
31100146|EAP|CPT® 88150||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Dx Pap Manual Screen|1|<Self-pay>|<Self-pay>|<Self-pay>|51.45|FSC: 400601; BFG: 52|||51.45|FSC: 400601; BFG: 52|28.30|
31100147|EAP|CPT® 88173||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Eval Of Fna Int & Rep|1|<Self-pay>|<Self-pay>|<Self-pay>|119.70|FSC: 400601; BFG: 52|||119.70|FSC: 400601; BFG: 52|65.83|
31200086|EAP|CPT® 88360||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Manual Tumor Im Histochem Per Specimen Single|1|<Self-pay>|<Self-pay>|<Self-pay>|576.45|FSC: 400601; BFG: 52|||576.45|FSC: 400601; BFG: 52|317.05|
31200087|EAP|CPT® 88361||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Computer Morphometric Analysis Per Specimen Single|1|<Self-pay>|<Self-pay>|<Self-pay>|323.40|FSC: 400601; BFG: 52|||323.40|FSC: 400601; BFG: 52|177.87|
31200088|EAP|CPT® 88368||0312 - LABORATORY PATHOLOGICAL - HISTOLOGY|Hc Cch So Insitu Hybridization Manual Per Specimen Single Initial|1|<Self-pay>|<Self-pay>|<Self-pay>|319.20|FSC: 400601; BFG: 52|||319.20|FSC: 400601; BFG: 52|175.56|
30500113|EAP|CPT® 85576||0305 - LABORATORY - HEMATOLOGY|Hc Cch So Plt Aggregation (in Vitro) Ea Agent|1|<Self-pay>|<Self-pay>|<Self-pay>|112.35|FSC: 400601; BFG: 52|||112.35|FSC: 400601; BFG: 52|61.79|
30100982|EAP|CPT® 80157||0301 - LABORATORY - CHEMISTRY|Hc So Carbamazepine Free|1|<Self-pay>|<Self-pay>|<Self-pay>|80.85|FSC: 400601; BFG: 52|||80.85|FSC: 400601; BFG: 52|44.47|
30600268|EAP|CPT® 87880||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Strep A Assay W/ Optic|1|<Self-pay>|<Self-pay>|<Self-pay>|74.55|FSC: 400601; BFG: 52|||74.55|FSC: 400601; BFG: 52|41.00|
40200069|EAP|CPT® 76800||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Cch Us Spine|1|<Self-pay>|<Self-pay>|<Self-pay>|301.35|FSC: 400601; BFG: 52|||301.35|FSC: 400601; BFG: 52|165.74|
30900023|EAP|HCPCS G0328||0309 - LABORATORY - OTHER LABORATORY|Hc Cch So Occult Bld Fhg Qual 1-3|1|<Self-pay>|<Self-pay>|<Self-pay>|74.55|FSC: 400601; BFG: 52|||74.55|FSC: 400601; BFG: 52|41.00|
43000094|EAP|CPT® 29126||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Apply Short Arm Splint By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
43000095|EAP|CPT® 29131||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Apply Finger Splint By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
43000096|EAP|CPT® 29260||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Strapping Elbow Or Wrist By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|85.05|FSC: 400601; BFG: 52|||85.05|FSC: 400601; BFG: 52|46.78|
51000705|EAP|CPT® 29700||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Cch Remove Gauntlet Boot Or Body Cast|1|<Self-pay>|<Self-pay>|<Self-pay>|635.25|FSC: 400601; BFG: 52|||635.25|FSC: 400601; BFG: 52|349.39|
49000977|EAP|CPT® 64632||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Cch Destruction By Neurolytic Agent (rfa) Plantar Digital Nerve|1|<Self-pay>|<Self-pay>|<Self-pay>|655.20|FSC: 400601; BFG: 52|||655.20|FSC: 400601; BFG: 52|360.36|
44400018|EAP|CPT® 92605||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Cch Evaluation For Non-speech Device First Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|80.85|FSC: 400601; BFG: 52|||80.85|FSC: 400601; BFG: 52|44.47|
44400019|EAP|CPT® 92606||0444 - SPEECH-LANGUAGE PATHOLOGY - EVALUATION OR RE-EVALUATION|Hc Cch Therapeutic Services For Non-speech Devices|1|<Self-pay>|<Self-pay>|<Self-pay>|80.85|FSC: 400601; BFG: 52|||80.85|FSC: 400601; BFG: 52|44.47|
48300025|EAP|CPT® 93351||0483 - CARDIOLOGY - ECHOCARDIOLOGY|Hc Cch Echo Stress Complete|1|<Self-pay>|<Self-pay>|<Self-pay>|1,303.05|FSC: 400601; BFG: 52|||1,303.05|FSC: 400601; BFG: 52|716.68|
46000041|EAP|CPT® 94200||0460 - PULMONARY FUNCTION - GENERAL CLASSIFICATION|Hc Cch Max Breathing Capacity/max Voluntary Ventilation|1|<Self-pay>|<Self-pay>|<Self-pay>|281.40|FSC: 400601; BFG: 52|||281.40|FSC: 400601; BFG: 52|154.77|
43000098|EAP|CPT® 96110||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Developmental Screen W/ Scoring And Documentation By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|475.65|FSC: 400601; BFG: 52|||475.65|FSC: 400601; BFG: 52|261.61|
44000048|EAP|CPT® 96110||0440 - SPEECH-LANGUAGE PATHOLOGY - GENERAL CLASSIFICATION|Hc Cch Developmental Screen W/ Scoring And Documentation By St|1|<Self-pay>|<Self-pay>|<Self-pay>|475.65|FSC: 400601; BFG: 52|||475.65|FSC: 400601; BFG: 52|261.61|
94000043|EAP|CPT® 96912||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Photochemotheraphy Puva|1|<Self-pay>|<Self-pay>|<Self-pay>|150.15|FSC: 400601; BFG: 52|||150.15|FSC: 400601; BFG: 52|82.58|
42000100|EAP|CPT® 97010||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Hot Or Cold Packs Therapy By Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|32.55|FSC: 400601; BFG: 52|||32.55|FSC: 400601; BFG: 52|17.90|
43000099|EAP|CPT® 97010||0430 - OCCUPATIONAL THERAPY - GENERAL CLASSIFICATION|Hc Cch Hot Or Cold Packs Therapy By Ot|1|<Self-pay>|<Self-pay>|<Self-pay>|32.55|FSC: 400601; BFG: 52|||32.55|FSC: 400601; BFG: 52|17.90|
42000102|EAP|CPT® 97026||0420 - PHYSICAL THERAPY - GENERAL CLASSIFICATION|Hc Infrared Therapy|1|<Self-pay>|<Self-pay>|<Self-pay>|51.45|FSC: 400601; BFG: 52|||51.45|FSC: 400601; BFG: 52|28.30|
72200007|EAP|Custom 72200007||0722 - LABOR ROOM/DELIVERY - DELIVERY|Hc Cch Delivery First 2 Hours|1|<Self-pay>|<Self-pay>|<Self-pay>|3,895.50|FSC: 400601; BFG: 52|||3,895.50|FSC: 400601; BFG: 52|2,142.52|
72200008|EAP|Custom 72200008||0722 - LABOR ROOM/DELIVERY - DELIVERY|Hc Cch Delivery Each Addl Half Hour|1|<Self-pay>|<Self-pay>|<Self-pay>|421.05|FSC: 400601; BFG: 52|||421.05|FSC: 400601; BFG: 52|231.58|
51000706|EAP|CPT® G0248||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Cch Demonstrate Home Inr Monitor|1|<Self-pay>|<Self-pay>|<Self-pay>|304.50|FSC: 400601; BFG: 52|||304.50|FSC: 400601; BFG: 52|167.47|
36000062|EAP|Custom 36000062||0360 - OPERATING ROOM SERVICES - GENERAL CLASSIFICATION|Hc Cch Procedure Room Minor|1|<Self-pay>|<Self-pay>|<Self-pay>|148.05|FSC: 400601; BFG: 52|||148.05|FSC: 400601; BFG: 52|81.43|
36000063|EAP|Custom 37000023||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Cch Procedure Room Major|1|<Self-pay>|<Self-pay>|<Self-pay>|955.50|FSC: 400601; BFG: 52|||955.50|FSC: 400601; BFG: 52|525.52|
76200004|EAP|HCPCS G0378||0762 - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM|Hc Cch Observation Ob|1|<Self-pay>|<Self-pay>|<Self-pay>|64.05|FSC: 400601; BFG: 52|||64.05|FSC: 400601; BFG: 52|35.23|
76200005|EAP|HCPCS G0378||0762 - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM|Hc Cch Observation Icu|1|<Self-pay>|<Self-pay>|<Self-pay>|96.60|FSC: 400601; BFG: 52|||96.60|FSC: 400601; BFG: 52|53.13|
94000044|EAP|Custom 94000044||0940 - OTHER THERAPEUTIC SERVICES - GENERAL CLASSIFICATION|Hc Cch Telemetry Observation|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
27208116|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Centesis 5frx15cm|1|<Self-pay>|<Self-pay>|<Self-pay>|105.75|FSC: 400601; BFG: 52|||105.75|FSC: 400601; BFG: 52|58.16|
27208117|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Centesis 5frx7cm|1|<Self-pay>|<Self-pay>|<Self-pay>|105.35|FSC: 400601; BFG: 52|||105.35|FSC: 400601; BFG: 52|57.94|
27208118|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter One Step Drainage|1|<Self-pay>|<Self-pay>|<Self-pay>|108.95|FSC: 400601; BFG: 52|||108.95|FSC: 400601; BFG: 52|59.92|
27208119|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Drainage Locking Plus|1|<Self-pay>|<Self-pay>|<Self-pay>|375.15|FSC: 400601; BFG: 52|||375.15|FSC: 400601; BFG: 52|206.33|
27208120|EAP|HCPCS C1729||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Guidewire Micropuncture Nitinol|1|<Self-pay>|<Self-pay>|<Self-pay>|314.35|FSC: 400601; BFG: 52|||314.35|FSC: 400601; BFG: 52|172.89|
27208165|EAP|Custom 27208165||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Percutaneous Drain Cath Fastener|1|<Self-pay>|<Self-pay>|<Self-pay>|31.10|FSC: 400601; BFG: 52|||31.10|FSC: 400601; BFG: 52|17.10|
27208121|EAP|Custom 27208121||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Concha Water Reservoir|1|<Self-pay>|<Self-pay>|<Self-pay>|18.55|FSC: 400601; BFG: 52|||18.55|FSC: 400601; BFG: 52|10.20|
27208122|EAP|Custom 27208122||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Humidifier Chamber|1|<Self-pay>|<Self-pay>|<Self-pay>|70.60|FSC: 400601; BFG: 52|||70.60|FSC: 400601; BFG: 52|38.83|
27208123|EAP|Custom 27208123||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Disposable Water Trap|1|<Self-pay>|<Self-pay>|<Self-pay>|5.90|FSC: 400601; BFG: 52|||5.90|FSC: 400601; BFG: 52|3.24|
27100025|EAP|Custom 27100025||0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - NON STERILE SUPPLY|Hc Cch Extractor Foreign Body Katz|1|<Self-pay>|<Self-pay>|<Self-pay>|194.54|FSC: 400601; BFG: 52|||194.54|FSC: 400601; BFG: 52|107.00|
27208124|EAP|Custom 27208124||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Trach Tube Exchanger|1|<Self-pay>|<Self-pay>|<Self-pay>|19.35|FSC: 400601; BFG: 52|||19.35|FSC: 400601; BFG: 52|10.64|
27100026|EAP|Custom 27100026||0271 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - NON STERILE SUPPLY|Hc Cch Cushion Waffel Seat Air 17x17x1.5|1|<Self-pay>|<Self-pay>|<Self-pay>|93.06|FSC: 400601; BFG: 52|||93.06|FSC: 400601; BFG: 52|51.18|
27208125|EAP|Custom 27208125||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Trach Care 12fr|1|<Self-pay>|<Self-pay>|<Self-pay>|70.60|FSC: 400601; BFG: 52|||70.60|FSC: 400601; BFG: 52|38.83|
27208126|EAP|Custom 27208126||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Trach Care 14fr|1|<Self-pay>|<Self-pay>|<Self-pay>|62.45|FSC: 400601; BFG: 52|||62.45|FSC: 400601; BFG: 52|34.35|
27208127|EAP|Custom 27208127||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Safety Drain|1|<Self-pay>|<Self-pay>|<Self-pay>|19.40|FSC: 400601; BFG: 52|||19.40|FSC: 400601; BFG: 52|10.67|
27208128|EAP|Custom 27208128||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Aerochamber W/ Medium Mask|1|<Self-pay>|<Self-pay>|<Self-pay>|156.30|FSC: 400601; BFG: 52|||156.30|FSC: 400601; BFG: 52|85.96|
27208129|EAP|Custom 27208129||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Trach Child|1|<Self-pay>|<Self-pay>|<Self-pay>|6.70|FSC: 400601; BFG: 52|||6.70|FSC: 400601; BFG: 52|3.68|
27208130|EAP|Custom 27208130||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Filter Breathing Circuit|1|<Self-pay>|<Self-pay>|<Self-pay>|35.80|FSC: 400601; BFG: 52|||35.80|FSC: 400601; BFG: 52|19.69|
27208131|EAP|HCPCS C1880||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Filter Set Femoral|1|<Self-pay>|<Self-pay>|<Self-pay>|2,789.90|FSC: 400601; BFG: 52|||2,789.90|FSC: 400601; BFG: 52|1,534.44|
27208132|EAP|Custom 27208132||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Introducer Celero|1|<Self-pay>|<Self-pay>|<Self-pay>|65.00|FSC: 400601; BFG: 52|||65.00|FSC: 400601; BFG: 52|35.75|
27208133|EAP|Custom 27208133||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Biopsy Device Celero|1|<Self-pay>|<Self-pay>|<Self-pay>|924.35|FSC: 400601; BFG: 52|||924.35|FSC: 400601; BFG: 52|508.39|
27208134|EAP|Custom 27208134||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tubing Wall Suction|1|<Self-pay>|<Self-pay>|<Self-pay>|52.75|FSC: 400601; BFG: 52|||52.75|FSC: 400601; BFG: 52|29.01|
27208135|EAP|Custom 27208135||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Nasal Tampon|1|<Self-pay>|<Self-pay>|<Self-pay>|74.65|FSC: 400601; BFG: 52|||74.65|FSC: 400601; BFG: 52|41.06|
27208136|EAP|Custom 27208136||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Eye Patch|1|<Self-pay>|<Self-pay>|<Self-pay>|29.05|FSC: 400601; BFG: 52|||29.05|FSC: 400601; BFG: 52|15.98|
27208137|EAP|Custom 27208137||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Nasal Pac System|1|<Self-pay>|<Self-pay>|<Self-pay>|189.85|FSC: 400601; BFG: 52|||189.85|FSC: 400601; BFG: 52|104.42|
27208138|EAP|Custom 27208138||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Manual Percussor|1|<Self-pay>|<Self-pay>|<Self-pay>|15.45|FSC: 400601; BFG: 52|||15.45|FSC: 400601; BFG: 52|8.50|
27208139|EAP|Custom 27208139||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Embolectomy 5fr|1|<Self-pay>|<Self-pay>|<Self-pay>|313.85|FSC: 400601; BFG: 52|||313.85|FSC: 400601; BFG: 52|172.62|
27208141|EAP|Custom 27208141||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Drape L&d|1|<Self-pay>|<Self-pay>|<Self-pay>|26.90|FSC: 400601; BFG: 52|||26.90|FSC: 400601; BFG: 52|14.79|
27208142|EAP|Custom 27208142||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Elliptosphere|1|<Self-pay>|<Self-pay>|<Self-pay>|183.90|FSC: 400601; BFG: 52|||183.90|FSC: 400601; BFG: 52|101.14|
27208143|EAP|Custom 27208143||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Electrode Spiral|1|<Self-pay>|<Self-pay>|<Self-pay>|18.65|FSC: 400601; BFG: 52|||18.65|FSC: 400601; BFG: 52|10.26|
27208144|EAP|Custom 27208144||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Irrigator Wound Shield|1|<Self-pay>|<Self-pay>|<Self-pay>|92.90|FSC: 400601; BFG: 52|||92.90|FSC: 400601; BFG: 52|51.09|
27208145|EAP|Custom 27208145||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Ear Wick|1|<Self-pay>|<Self-pay>|<Self-pay>|18.35|FSC: 400601; BFG: 52|||18.35|FSC: 400601; BFG: 52|10.09|
27208146|EAP|Custom 27208146||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Ocular Fluid Mgmt System|1|<Self-pay>|<Self-pay>|<Self-pay>|39.75|FSC: 400601; BFG: 52|||39.75|FSC: 400601; BFG: 52|21.86|
27208147|EAP|Custom 27208147||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Electrode Infant|1|<Self-pay>|<Self-pay>|<Self-pay>|14.35|FSC: 400601; BFG: 52|||14.35|FSC: 400601; BFG: 52|7.89|
27208148|EAP|Custom 27208148||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Applicator Vaginal|1|<Self-pay>|<Self-pay>|<Self-pay>|39.40|FSC: 400601; BFG: 52|||39.40|FSC: 400601; BFG: 52|21.67|
27208149|EAP|Custom 27208149||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline Wound Wash|1|<Self-pay>|<Self-pay>|<Self-pay>|23.60|FSC: 400601; BFG: 52|||23.60|FSC: 400601; BFG: 52|12.98|
27208150|EAP|Custom 27208150||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Stent Guide|1|<Self-pay>|<Self-pay>|<Self-pay>|297.20|FSC: 400601; BFG: 52|||297.20|FSC: 400601; BFG: 52|163.46|
27208151|EAP|Custom 27208151||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Probe Cover 48"|1|<Self-pay>|<Self-pay>|<Self-pay>|39.10|FSC: 400601; BFG: 52|||39.10|FSC: 400601; BFG: 52|21.50|
27208152|EAP|Custom 27208152||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Phototherapy Cover|1|<Self-pay>|<Self-pay>|<Self-pay>|15.25|FSC: 400601; BFG: 52|||15.25|FSC: 400601; BFG: 52|8.39|
27208153|EAP|Custom 27208153||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cable Pace|1|<Self-pay>|<Self-pay>|<Self-pay>|108.65|FSC: 400601; BFG: 52|||108.65|FSC: 400601; BFG: 52|59.76|
27208154|EAP|Custom 27208154||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Valve Tee Adapter|1|<Self-pay>|<Self-pay>|<Self-pay>|7.75|FSC: 400601; BFG: 52|||7.75|FSC: 400601; BFG: 52|4.26|
27208155|EAP|Custom 27208155||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Opticell Dressing|1|<Self-pay>|<Self-pay>|<Self-pay>|24.75|FSC: 400601; BFG: 52|||24.75|FSC: 400601; BFG: 52|13.61|
27208156|EAP|Custom 27208156||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Solosite Dressing|1|<Self-pay>|<Self-pay>|<Self-pay>|9.50|FSC: 400601; BFG: 52|||9.50|FSC: 400601; BFG: 52|5.22|
27208157|EAP|Custom 27208157||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Biatain 5x5 Foam|1|<Self-pay>|<Self-pay>|<Self-pay>|41.45|FSC: 400601; BFG: 52|||41.45|FSC: 400601; BFG: 52|22.80|
27208158|EAP|Custom 27208158||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mepilex Dressing|1|<Self-pay>|<Self-pay>|<Self-pay>|22.95|FSC: 400601; BFG: 52|||22.95|FSC: 400601; BFG: 52|12.62|
27208159|EAP|Custom 27208159||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Alginate Seasorb|1|<Self-pay>|<Self-pay>|<Self-pay>|29.80|FSC: 400601; BFG: 52|||29.80|FSC: 400601; BFG: 52|16.39|
27208160|EAP|Custom 27208160||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Alldress Dressing|1|<Self-pay>|<Self-pay>|<Self-pay>|12.50|FSC: 400601; BFG: 52|||12.50|FSC: 400601; BFG: 52|6.87|
27208161|EAP|Custom 27208161||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Curagel Dressing|1|<Self-pay>|<Self-pay>|<Self-pay>|12.55|FSC: 400601; BFG: 52|||12.55|FSC: 400601; BFG: 52|6.90|
27208162|EAP|Custom 27208162||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Comprifore Bandage|1|<Self-pay>|<Self-pay>|<Self-pay>|37.40|FSC: 400601; BFG: 52|||37.40|FSC: 400601; BFG: 52|20.57|
27208163|EAP|Custom 27208163||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Rapide|1|<Self-pay>|<Self-pay>|<Self-pay>|24.65|FSC: 400601; BFG: 52|||24.65|FSC: 400601; BFG: 52|13.56|
27208164|EAP|Custom 27208164||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Plain Fast Absorb|1|<Self-pay>|<Self-pay>|<Self-pay>|31.35|FSC: 400601; BFG: 52|||31.35|FSC: 400601; BFG: 52|17.24|
27208171|EAP|Custom 27208171||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Adjustable Peep Valve|1|<Self-pay>|<Self-pay>|<Self-pay>|50.35|FSC: 400601; BFG: 52|||50.35|FSC: 400601; BFG: 52|27.69|
27208172|EAP|Custom 27208172||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch 7' Oxygen Tubing|1|<Self-pay>|<Self-pay>|<Self-pay>|3.75|FSC: 400601; BFG: 52|||3.75|FSC: 400601; BFG: 52|2.06|
27208173|EAP|Custom 27208173||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Oxygen Face Tent|1|<Self-pay>|<Self-pay>|<Self-pay>|3.75|FSC: 400601; BFG: 52|||3.75|FSC: 400601; BFG: 52|2.06|
27208174|EAP|Custom 27208174||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Aerochamber W/ Small Mask|1|<Self-pay>|<Self-pay>|<Self-pay>|156.30|FSC: 400601; BFG: 52|||156.30|FSC: 400601; BFG: 52|85.96|
27208175|EAP|Custom 27208175||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Oxygen Trach Mask|1|<Self-pay>|<Self-pay>|<Self-pay>|9.60|FSC: 400601; BFG: 52|||9.60|FSC: 400601; BFG: 52|5.28|
27208176|EAP|Custom 27208176||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Vented V60|1|<Self-pay>|<Self-pay>|<Self-pay>|187.05|FSC: 400601; BFG: 52|||187.05|FSC: 400601; BFG: 52|102.88|
27208177|EAP|Custom 27208177||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Dragon Pedi|1|<Self-pay>|<Self-pay>|<Self-pay>|13.40|FSC: 400601; BFG: 52|||13.40|FSC: 400601; BFG: 52|7.37|
27208178|EAP|Custom 27208178||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Ez Wrap Cannula|1|<Self-pay>|<Self-pay>|<Self-pay>|11.55|FSC: 400601; BFG: 52|||11.55|FSC: 400601; BFG: 52|6.35|
27208179|EAP|Custom 27208179||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Filter Air Vent|1|<Self-pay>|<Self-pay>|<Self-pay>|35.80|FSC: 400601; BFG: 52|||35.80|FSC: 400601; BFG: 52|19.69|
27208180|EAP|Custom 27208180||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Filter Micro Pft|1|<Self-pay>|<Self-pay>|<Self-pay>|15.55|FSC: 400601; BFG: 52|||15.55|FSC: 400601; BFG: 52|8.55|
27208181|EAP|Custom 27208181||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bulb Insufflator Blue|1|<Self-pay>|<Self-pay>|<Self-pay>|38.95|FSC: 400601; BFG: 52|||38.95|FSC: 400601; BFG: 52|21.42|
27208182|EAP|Custom 27208182||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cpm Softgoods|1|<Self-pay>|<Self-pay>|<Self-pay>|87.45|FSC: 400601; BFG: 52|||87.45|FSC: 400601; BFG: 52|48.10|
27208183|EAP|Custom 27208183||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Pulley Set Pt|1|<Self-pay>|<Self-pay>|<Self-pay>|58.75|FSC: 400601; BFG: 52|||58.75|FSC: 400601; BFG: 52|32.31|
27208184|EAP|Custom 27208184||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Heelbo|1|<Self-pay>|<Self-pay>|<Self-pay>|23.75|FSC: 400601; BFG: 52|||23.75|FSC: 400601; BFG: 52|13.06|
27208185|EAP|Custom 27208185||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sponge Ob|1|<Self-pay>|<Self-pay>|<Self-pay>|25.75|FSC: 400601; BFG: 52|||25.75|FSC: 400601; BFG: 52|14.16|
27208186|EAP|Custom 27208186||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Latch Assist|1|<Self-pay>|<Self-pay>|<Self-pay>|34.20|FSC: 400601; BFG: 52|||34.20|FSC: 400601; BFG: 52|18.81|
27208187|EAP|Custom 27208187||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Ostomy Powder|1|<Self-pay>|<Self-pay>|<Self-pay>|14.75|FSC: 400601; BFG: 52|||14.75|FSC: 400601; BFG: 52|8.11|
27208188|EAP|Custom 27208188||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Ostomy Skin Prep|1|<Self-pay>|<Self-pay>|<Self-pay>|28.10|FSC: 400601; BFG: 52|||28.10|FSC: 400601; BFG: 52|15.45|
27208189|EAP|Custom 27208189||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Probe Skin|1|<Self-pay>|<Self-pay>|<Self-pay>|28.25|FSC: 400601; BFG: 52|||28.25|FSC: 400601; BFG: 52|15.54|
27208190|EAP|Custom 27208190||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Brace-cash Ortho|1|<Self-pay>|<Self-pay>|<Self-pay>|396.15|FSC: 400601; BFG: 52|||396.15|FSC: 400601; BFG: 52|217.88|
27208191|EAP|Custom 27208191||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Insert Moldable 8"|1|<Self-pay>|<Self-pay>|<Self-pay>|126.10|FSC: 400601; BFG: 52|||126.10|FSC: 400601; BFG: 52|69.35|
27208192|EAP|Custom 27208192||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Clipper Cord Clamp|1|<Self-pay>|<Self-pay>|<Self-pay>|50.75|FSC: 400601; BFG: 52|||50.75|FSC: 400601; BFG: 52|27.91|
27208193|EAP|Custom 27208193||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Calibration Tip For Bilichek|1|<Self-pay>|<Self-pay>|<Self-pay>|26.75|FSC: 400601; BFG: 52|||26.75|FSC: 400601; BFG: 52|14.71|
27208194|EAP|Custom 27208194||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Defib Pads Infant/child|1|<Self-pay>|<Self-pay>|<Self-pay>|452.85|FSC: 400601; BFG: 52|||452.85|FSC: 400601; BFG: 52|249.07|
27208195|EAP|Custom 27208195||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cable 4 Lead System|1|<Self-pay>|<Self-pay>|<Self-pay>|101.55|FSC: 400601; BFG: 52|||101.55|FSC: 400601; BFG: 52|55.85|
27208196|EAP|Custom 27208196||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Intranasal Atomization Device|1|<Self-pay>|<Self-pay>|<Self-pay>|24.15|FSC: 400601; BFG: 52|||24.15|FSC: 400601; BFG: 52|13.28|
27208197|EAP|Custom 27208197||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Matt Transfer 34"|1|<Self-pay>|<Self-pay>|<Self-pay>|209.15|FSC: 400601; BFG: 52|||209.15|FSC: 400601; BFG: 52|115.03|
27208198|EAP|Custom 27208198||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Leg Lift|1|<Self-pay>|<Self-pay>|<Self-pay>|62.25|FSC: 400601; BFG: 52|||62.25|FSC: 400601; BFG: 52|34.24|
27208199|EAP|Custom 27208199||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Liquid Sol-o-pak|1|<Self-pay>|<Self-pay>|<Self-pay>|132.35|FSC: 400601; BFG: 52|||132.35|FSC: 400601; BFG: 52|72.79|
27208200|EAP|Custom 27208200||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tube Ureteral Connecting|1|<Self-pay>|<Self-pay>|<Self-pay>|56.65|FSC: 400601; BFG: 52|||56.65|FSC: 400601; BFG: 52|31.16|
27208201|EAP|Custom 27208201||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sheet Angiography|1|<Self-pay>|<Self-pay>|<Self-pay>|77.45|FSC: 400601; BFG: 52|||77.45|FSC: 400601; BFG: 52|42.60|
27208202|EAP|Custom 27208202||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Guidewire .018x80cm|1|<Self-pay>|<Self-pay>|<Self-pay>|158.80|FSC: 400601; BFG: 52|||158.80|FSC: 400601; BFG: 52|87.34|
27208203|EAP|CPT® 83986||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Amniotest|1|<Self-pay>|<Self-pay>|<Self-pay>|18.60|FSC: 400601; BFG: 52|||18.60|FSC: 400601; BFG: 52|10.23|
27208204|EAP|Custom 27208204||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Strap Soft|1|<Self-pay>|<Self-pay>|<Self-pay>|23.20|FSC: 400601; BFG: 52|||23.20|FSC: 400601; BFG: 52|12.76|
27208228|EAP|Custom 27208228||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Armboard Adult|1|<Self-pay>|<Self-pay>|<Self-pay>|54.30|FSC: 400601; BFG: 52|||54.30|FSC: 400601; BFG: 52|29.86|
27208229|EAP|Custom 27208229||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bag 4000ml Drainage|1|<Self-pay>|<Self-pay>|<Self-pay>|32.35|FSC: 400601; BFG: 52|||32.35|FSC: 400601; BFG: 52|17.79|
27208230|EAP|Custom 27208230||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bag Resuscitation Infant Manual|1|<Self-pay>|<Self-pay>|<Self-pay>|90.85|FSC: 400601; BFG: 52|||90.85|FSC: 400601; BFG: 52|49.97|
27208231|EAP|Custom 27208231||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bag Resuscitation Pediatric Manual|1|<Self-pay>|<Self-pay>|<Self-pay>|99.15|FSC: 400601; BFG: 52|||99.15|FSC: 400601; BFG: 52|54.53|
27208232|EAP|Custom 27208232||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bag Infuser Pressure 500ml|1|<Self-pay>|<Self-pay>|<Self-pay>|101.85|FSC: 400601; BFG: 52|||101.85|FSC: 400601; BFG: 52|56.02|
27208233|EAP|Custom 27208233||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Basket Retrieval 3 Wire Spiral|1|<Self-pay>|<Self-pay>|<Self-pay>|1,341.55|FSC: 400601; BFG: 52|||1,341.55|FSC: 400601; BFG: 52|737.85|
27208234|EAP|Custom 27208234||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Canister Rigid|1|<Self-pay>|<Self-pay>|<Self-pay>|19.80|FSC: 400601; BFG: 52|||19.80|FSC: 400601; BFG: 52|10.89|
27208235|EAP|Custom 27208235||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cannula Divider Salter|1|<Self-pay>|<Self-pay>|<Self-pay>|15.30|FSC: 400601; BFG: 52|||15.30|FSC: 400601; BFG: 52|8.41|
27208236|EAP|Custom 27208236||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Cath Coude Tip 20fr|1|<Self-pay>|<Self-pay>|<Self-pay>|54.20|FSC: 400601; BFG: 52|||54.20|FSC: 400601; BFG: 52|29.81|
27208237|EAP|Custom 27208237||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Epidural|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 400601; BFG: 52|||35.00|FSC: 400601; BFG: 52|19.25|
27208238|EAP|Custom 27208238||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Femoral|1|<Self-pay>|<Self-pay>|<Self-pay>|79.25|FSC: 400601; BFG: 52|||79.25|FSC: 400601; BFG: 52|43.59|
27208239|EAP|Custom 27208239||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Cath 12fr|1|<Self-pay>|<Self-pay>|<Self-pay>|22.90|FSC: 400601; BFG: 52|||22.90|FSC: 400601; BFG: 52|12.59|
27208240|EAP|Custom 27208240||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Cath 18fr|1|<Self-pay>|<Self-pay>|<Self-pay>|29.20|FSC: 400601; BFG: 52|||29.20|FSC: 400601; BFG: 52|16.06|
27208241|EAP|Custom 27208241||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kit Foley Cath 14fr|1|<Self-pay>|<Self-pay>|<Self-pay>|29.90|FSC: 400601; BFG: 52|||29.90|FSC: 400601; BFG: 52|16.44|
27208242|EAP|Custom 27208242||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Cath 8fr|1|<Self-pay>|<Self-pay>|<Self-pay>|32.90|FSC: 400601; BFG: 52|||32.90|FSC: 400601; BFG: 52|18.09|
27208243|EAP|Custom 27208243||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Cath 10fr|1|<Self-pay>|<Self-pay>|<Self-pay>|34.85|FSC: 400601; BFG: 52|||34.85|FSC: 400601; BFG: 52|19.17|
27208244|EAP|Custom 27208244||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Catheter Trocar All Sizes|1|<Self-pay>|<Self-pay>|<Self-pay>|100.30|FSC: 400601; BFG: 52|||100.30|FSC: 400601; BFG: 52|55.16|
27208245|EAP|Custom 27208245||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kit Catheter Trocar|1|<Self-pay>|<Self-pay>|<Self-pay>|182.85|FSC: 400601; BFG: 52|||182.85|FSC: 400601; BFG: 52|100.57|
27208246|EAP|Custom 27208246||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Catheter 2 Way|1|<Self-pay>|<Self-pay>|<Self-pay>|49.35|FSC: 400601; BFG: 52|||49.35|FSC: 400601; BFG: 52|27.14|
27208247|EAP|Custom 27208247||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Catheter 3 Way|1|<Self-pay>|<Self-pay>|<Self-pay>|57.95|FSC: 400601; BFG: 52|||57.95|FSC: 400601; BFG: 52|31.87|
27208248|EAP|Custom 27208248||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Chest Drainage Dual Extension Set|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|FSC: 400601; BFG: 52|||41.25|FSC: 400601; BFG: 52|22.69|
27208249|EAP|Custom 27208249||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Connector Fiberoptic Double Swivel|1|<Self-pay>|<Self-pay>|<Self-pay>|81.80|FSC: 400601; BFG: 52|||81.80|FSC: 400601; BFG: 52|44.99|
27208250|EAP|Custom 27208250||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch T-pod Combat Pelvic Stabilization|1|<Self-pay>|<Self-pay>|<Self-pay>|486.70|FSC: 400601; BFG: 52|||486.70|FSC: 400601; BFG: 52|267.68|
27208251|EAP|Custom 27208251||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Duoderm 8x8|1|<Self-pay>|<Self-pay>|<Self-pay>|55.95|FSC: 400601; BFG: 52|||55.95|FSC: 400601; BFG: 52|30.77|
27208252|EAP|Custom 27208252||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Optifoam Dressing 7x7|1|<Self-pay>|<Self-pay>|<Self-pay>|52.00|FSC: 400601; BFG: 52|||52.00|FSC: 400601; BFG: 52|28.60|
27208253|EAP|Custom 27208253||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Quikclot Hemostatic|1|<Self-pay>|<Self-pay>|<Self-pay>|305.45|FSC: 400601; BFG: 52|||305.45|FSC: 400601; BFG: 52|168.00|
27208254|EAP|Custom 27208254||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Dressing Large Granufoam|1|<Self-pay>|<Self-pay>|<Self-pay>|335.10|FSC: 400601; BFG: 52|||335.10|FSC: 400601; BFG: 52|184.30|
27208255|EAP|Custom 27208255||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Electrode Small|1|<Self-pay>|<Self-pay>|<Self-pay>|66.15|FSC: 400601; BFG: 52|||66.15|FSC: 400601; BFG: 52|36.38|
27208256|EAP|Custom 27208256||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Electrode Meditrace|1|<Self-pay>|<Self-pay>|<Self-pay>|3.35|FSC: 400601; BFG: 52|||3.35|FSC: 400601; BFG: 52|1.84|
27208257|EAP|Custom 27208257||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foley Cath Urine Meter|1|<Self-pay>|<Self-pay>|<Self-pay>|71.35|FSC: 400601; BFG: 52|||71.35|FSC: 400601; BFG: 52|39.24|
27208258|EAP|Custom 27208258||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Forcep Grasping|1|<Self-pay>|<Self-pay>|<Self-pay>|860.90|FSC: 400601; BFG: 52|||860.90|FSC: 400601; BFG: 52|473.49|
27208259|EAP|Custom 27208259||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Forcep Biopsy Colon|1|<Self-pay>|<Self-pay>|<Self-pay>|231.35|FSC: 400601; BFG: 52|||231.35|FSC: 400601; BFG: 52|127.24|
27208260|EAP|Custom 27208260||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Forcep Biopsy Bronch|1|<Self-pay>|<Self-pay>|<Self-pay>|328.70|FSC: 400601; BFG: 52|||328.70|FSC: 400601; BFG: 52|180.78|
27208261|EAP|Custom 27208261||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Guidewire J Arrow|1|<Self-pay>|<Self-pay>|<Self-pay>|59.40|FSC: 400601; BFG: 52|||59.40|FSC: 400601; BFG: 52|32.67|
27208262|EAP|Custom 27208262||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Holder Tube Endotracheal Anchorfast|1|<Self-pay>|<Self-pay>|<Self-pay>|57.25|FSC: 400601; BFG: 52|||57.25|FSC: 400601; BFG: 52|31.49|
27208263|EAP|Custom 27208263||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Holder Transducer|1|<Self-pay>|<Self-pay>|<Self-pay>|46.65|FSC: 400601; BFG: 52|||46.65|FSC: 400601; BFG: 52|25.66|
27208264|EAP|Custom 27208264||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Introducer Device 3 Lumen|1|<Self-pay>|<Self-pay>|<Self-pay>|656.75|FSC: 400601; BFG: 52|||656.75|FSC: 400601; BFG: 52|361.21|
27208265|EAP|Custom 27208265||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Intubating Stylet|1|<Self-pay>|<Self-pay>|<Self-pay>|17.80|FSC: 400601; BFG: 52|||17.80|FSC: 400601; BFG: 52|9.79|
27208266|EAP|Custom 27208266||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kit Gastric Lavage|1|<Self-pay>|<Self-pay>|<Self-pay>|128.15|FSC: 400601; BFG: 52|||128.15|FSC: 400601; BFG: 52|70.48|
27208267|EAP|Custom 27208267||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Label System|1|<Self-pay>|<Self-pay>|<Self-pay>|15.25|FSC: 400601; BFG: 52|||15.25|FSC: 400601; BFG: 52|8.39|
27208268|EAP|Custom 27208268||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Airway Laryngeal Mask Sz 1 .5|1|<Self-pay>|<Self-pay>|<Self-pay>|144.30|FSC: 400601; BFG: 52|||144.30|FSC: 400601; BFG: 52|79.36|
27208269|EAP|Custom 27208269||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Airway Laryngeal Mask Sz 2|1|<Self-pay>|<Self-pay>|<Self-pay>|95.45|FSC: 400601; BFG: 52|||95.45|FSC: 400601; BFG: 52|52.50|
27208270|EAP|Custom 27208270||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Airway Laryngeal Mask Sz 2.5|1|<Self-pay>|<Self-pay>|<Self-pay>|195.15|FSC: 400601; BFG: 52|||195.15|FSC: 400601; BFG: 52|107.33|
27208271|EAP|Custom 27208271||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Airway Laryngeal Mask Sz 3|1|<Self-pay>|<Self-pay>|<Self-pay>|65.80|FSC: 400601; BFG: 52|||65.80|FSC: 400601; BFG: 52|36.19|
27208272|EAP|Custom 27208272||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Airway Laryngeal Mask Sz 4|1|<Self-pay>|<Self-pay>|<Self-pay>|52.30|FSC: 400601; BFG: 52|||52.30|FSC: 400601; BFG: 52|28.76|
27208273|EAP|Custom 27208273||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Airway Laryngeal Mask Sz 5|1|<Self-pay>|<Self-pay>|<Self-pay>|150.60|FSC: 400601; BFG: 52|||150.60|FSC: 400601; BFG: 52|82.83|
27208274|EAP|Custom 27208274||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Aspiration Transbronchial Endoscopy|1|<Self-pay>|<Self-pay>|<Self-pay>|474.10|FSC: 400601; BFG: 52|||474.10|FSC: 400601; BFG: 52|260.75|
27208275|EAP|Custom 27208275||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Endoscopy|1|<Self-pay>|<Self-pay>|<Self-pay>|163.70|FSC: 400601; BFG: 52|||163.70|FSC: 400601; BFG: 52|90.03|
27208276|EAP|Custom 27208276||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Huber 19ga|1|<Self-pay>|<Self-pay>|<Self-pay>|32.35|FSC: 400601; BFG: 52|||32.35|FSC: 400601; BFG: 52|17.79|
27208277|EAP|Custom 27208277||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Huber 22ga|1|<Self-pay>|<Self-pay>|<Self-pay>|60.60|FSC: 400601; BFG: 52|||60.60|FSC: 400601; BFG: 52|33.33|
27208278|EAP|Custom 27208278||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Spinal 22ga 5"|1|<Self-pay>|<Self-pay>|<Self-pay>|25.75|FSC: 400601; BFG: 52|||25.75|FSC: 400601; BFG: 52|14.16|
27208279|EAP|Custom 27208279||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Spinal 22ga 7"|1|<Self-pay>|<Self-pay>|<Self-pay>|17.70|FSC: 400601; BFG: 52|||17.70|FSC: 400601; BFG: 52|9.73|
27208280|EAP|Custom 27208280||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Spinal 25ga 5"|1|<Self-pay>|<Self-pay>|<Self-pay>|71.90|FSC: 400601; BFG: 52|||71.90|FSC: 400601; BFG: 52|39.54|
27208281|EAP|Custom 27208281||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Spinal Whitacre 22ga|1|<Self-pay>|<Self-pay>|<Self-pay>|30.80|FSC: 400601; BFG: 52|||30.80|FSC: 400601; BFG: 52|16.94|
27208282|EAP|Custom 27208282||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Stimuplex 20ga|1|<Self-pay>|<Self-pay>|<Self-pay>|75.40|FSC: 400601; BFG: 52|||75.40|FSC: 400601; BFG: 52|41.47|
27208283|EAP|Custom 27208283||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Stimuplex W/ext Set 22ga X 1 3/8"|1|<Self-pay>|<Self-pay>|<Self-pay>|68.05|FSC: 400601; BFG: 52|||68.05|FSC: 400601; BFG: 52|37.43|
27208284|EAP|Custom 27208284||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Insulated Stimuplex W/ext Set 21ga X2|1|<Self-pay>|<Self-pay>|<Self-pay>|64.60|FSC: 400601; BFG: 52|||64.60|FSC: 400601; BFG: 52|35.53|
27208285|EAP|Custom 27208285||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Tuohy 17ga|1|<Self-pay>|<Self-pay>|<Self-pay>|57.95|FSC: 400601; BFG: 52|||57.95|FSC: 400601; BFG: 52|31.87|
27208286|EAP|Custom 27208286||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Tuohy 18ga|1|<Self-pay>|<Self-pay>|<Self-pay>|57.95|FSC: 400601; BFG: 52|||57.95|FSC: 400601; BFG: 52|31.87|
27208287|EAP|Custom 27208287||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Tuohy 20ga|1|<Self-pay>|<Self-pay>|<Self-pay>|33.65|FSC: 400601; BFG: 52|||33.65|FSC: 400601; BFG: 52|18.51|
27208288|EAP|Custom 27208288||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Kit Ostomy Colostomy|1|<Self-pay>|<Self-pay>|<Self-pay>|22.60|FSC: 400601; BFG: 52|||22.60|FSC: 400601; BFG: 52|12.43|
27208289|EAP|Custom 27208289||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Packing Strip Iodoform|1|<Self-pay>|<Self-pay>|<Self-pay>|20.30|FSC: 400601; BFG: 52|||20.30|FSC: 400601; BFG: 52|11.16|
27208290|EAP|Custom 27208290||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Pad Electrode|1|<Self-pay>|<Self-pay>|<Self-pay>|66.65|FSC: 400601; BFG: 52|||66.65|FSC: 400601; BFG: 52|36.66|
27208291|EAP|Custom 27208291||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Defib Pad Adult|1|<Self-pay>|<Self-pay>|<Self-pay>|196.35|FSC: 400601; BFG: 52|||196.35|FSC: 400601; BFG: 52|107.99|
27208292|EAP|Custom 27208292||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Probe Bipolar Hemostasis Solar Single|1|<Self-pay>|<Self-pay>|<Self-pay>|930.75|FSC: 400601; BFG: 52|||930.75|FSC: 400601; BFG: 52|511.91|
27208293|EAP|Custom 27208293||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Reservoir 100ml|1|<Self-pay>|<Self-pay>|<Self-pay>|29.30|FSC: 400601; BFG: 52|||29.30|FSC: 400601; BFG: 52|16.11|
27208294|EAP|Custom 27208294||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sensor Spo2 Adult Lncs Masimo|1|<Self-pay>|<Self-pay>|<Self-pay>|72.35|FSC: 400601; BFG: 52|||72.35|FSC: 400601; BFG: 52|39.79|
27208295|EAP|Custom 27208295||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Set Airaway Adapter|1|<Self-pay>|<Self-pay>|<Self-pay>|67.75|FSC: 400601; BFG: 52|||67.75|FSC: 400601; BFG: 52|37.26|
27208296|EAP|Custom 27208296||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Sling Post-op|1|<Self-pay>|<Self-pay>|<Self-pay>|364.30|FSC: 400601; BFG: 52|||364.30|FSC: 400601; BFG: 52|200.36|
27208297|EAP|Custom 27208297||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Snare Polypectomy|1|<Self-pay>|<Self-pay>|<Self-pay>|63.90|FSC: 400601; BFG: 52|||63.90|FSC: 400601; BFG: 52|35.14|
27208298|EAP|Custom 27208298||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Splint One Step|1|<Self-pay>|<Self-pay>|<Self-pay>|115.00|FSC: 400601; BFG: 52|||115.00|FSC: 400601; BFG: 52|63.25|
27208299|EAP|Custom 27208299||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Ethilon|1|<Self-pay>|<Self-pay>|<Self-pay>|19.80|FSC: 400601; BFG: 52|||19.80|FSC: 400601; BFG: 52|10.89|
27208300|EAP|Custom 27208300||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Prolene 0|1|<Self-pay>|<Self-pay>|<Self-pay>|16.70|FSC: 400601; BFG: 52|||16.70|FSC: 400601; BFG: 52|9.18|
27208301|EAP|Custom 27208301||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Silk|1|<Self-pay>|<Self-pay>|<Self-pay>|21.05|FSC: 400601; BFG: 52|||21.05|FSC: 400601; BFG: 52|11.58|
27208302|EAP|Custom 27208302||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Suture Vicryl|1|<Self-pay>|<Self-pay>|<Self-pay>|21.40|FSC: 400601; BFG: 52|||21.40|FSC: 400601; BFG: 52|11.77|
27208303|EAP|Custom 27208303||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Syringe Glass Tip 5cc|1|<Self-pay>|<Self-pay>|<Self-pay>|40.70|FSC: 400601; BFG: 52|||40.70|FSC: 400601; BFG: 52|22.38|
27208304|EAP|Custom 27208304||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tape Foam|1|<Self-pay>|<Self-pay>|<Self-pay>|29.75|FSC: 400601; BFG: 52|||29.75|FSC: 400601; BFG: 52|16.36|
27208305|EAP|Custom 27208305||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tourniquet Abdominal Aortic Junctional|1|<Self-pay>|<Self-pay>|<Self-pay>|1,091.95|FSC: 400601; BFG: 52|||1,091.95|FSC: 400601; BFG: 52|600.57|
27208306|EAP|Custom 27208306||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tourniquet Combat|1|<Self-pay>|<Self-pay>|<Self-pay>|192.40|FSC: 400601; BFG: 52|||192.40|FSC: 400601; BFG: 52|105.82|
27208307|EAP|Custom 27208307||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tray Chest Tube|1|<Self-pay>|<Self-pay>|<Self-pay>|133.15|FSC: 400601; BFG: 52|||133.15|FSC: 400601; BFG: 52|73.23|
27208308|EAP|Custom 27208308||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tube Lavage|1|<Self-pay>|<Self-pay>|<Self-pay>|36.30|FSC: 400601; BFG: 52|||36.30|FSC: 400601; BFG: 52|19.96|
27208309|EAP|Custom 27208309||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Tube Trach Extended|1|<Self-pay>|<Self-pay>|<Self-pay>|424.15|FSC: 400601; BFG: 52|||424.15|FSC: 400601; BFG: 52|233.28|
27208310|EAP|Custom 27208310||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch 21' Oxygen Tubing|1|<Self-pay>|<Self-pay>|<Self-pay>|5.90|FSC: 400601; BFG: 52|||5.90|FSC: 400601; BFG: 52|3.24|
27208311|EAP|Custom 27208311||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Valve Bronch Suction|1|<Self-pay>|<Self-pay>|<Self-pay>|39.40|FSC: 400601; BFG: 52|||39.40|FSC: 400601; BFG: 52|21.67|
27208312|EAP|Custom 27208312||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Water Irrigation Pour|1|<Self-pay>|<Self-pay>|<Self-pay>|39.40|FSC: 400601; BFG: 52|||39.40|FSC: 400601; BFG: 52|21.67|
27208313|EAP|HCPCS A6010||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Collagen Dry Filler|1|<Self-pay>|<Self-pay>|<Self-pay>|171.00|FSC: 400601; BFG: 52|||171.00|FSC: 400601; BFG: 52|94.05|
27208314|EAP|HCPCS A6011||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Collagen Wet Filler|1|<Self-pay>|<Self-pay>|<Self-pay>|161.25|FSC: 400601; BFG: 52|||161.25|FSC: 400601; BFG: 52|88.69|
27208315|EAP|HCPCS A6196||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Alginate Dressing <= 16 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|36.00|FSC: 400601; BFG: 52|||36.00|FSC: 400601; BFG: 52|19.80|
27208316|EAP|HCPCS A6197||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Alginate Dressing >16 <= 48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|136.90|FSC: 400601; BFG: 52|||136.90|FSC: 400601; BFG: 52|75.29|
27208317|EAP|HCPCS A6198||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Alginate Dressing >48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|83.35|FSC: 400601; BFG: 52|||83.35|FSC: 400601; BFG: 52|45.84|
27208318|EAP|HCPCS A6199||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Alginate Dressing Wound Filler Per 6 In|1|<Self-pay>|<Self-pay>|<Self-pay>|34.35|FSC: 400601; BFG: 52|||34.35|FSC: 400601; BFG: 52|18.89|
27208319|EAP|HCPCS A6207||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Contact Layer >16 <= 48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|41.10|FSC: 400601; BFG: 52|||41.10|FSC: 400601; BFG: 52|22.60|
27208320|EAP|HCPCS A6209||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foam Dressing <= 16 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|27.80|FSC: 400601; BFG: 52|||27.80|FSC: 400601; BFG: 52|15.29|
27208321|EAP|HCPCS A6210||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foam Dressing >16 <= 48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|52.25|FSC: 400601; BFG: 52|||52.25|FSC: 400601; BFG: 52|28.74|
27208322|EAP|HCPCS A6212||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foam Dressing <= 16 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|59.55|FSC: 400601; BFG: 52|||59.55|FSC: 400601; BFG: 52|32.75|
27208323|EAP|HCPCS A6213||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foam Dressing >16 <= 48 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|78.45|FSC: 400601; BFG: 52|||78.45|FSC: 400601; BFG: 52|43.15|
27208324|EAP|HCPCS A6215||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foam Dressing Wound Filler Per Gm|1|<Self-pay>|<Self-pay>|<Self-pay>|22.85|FSC: 400601; BFG: 52|||22.85|FSC: 400601; BFG: 52|12.57|
27208325|EAP|HCPCS A6234||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing <= 16 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|23.95|FSC: 400601; BFG: 52|||23.95|FSC: 400601; BFG: 52|13.17|
27208326|EAP|HCPCS A6235||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing >16 <= 48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|57.20|FSC: 400601; BFG: 52|||57.20|FSC: 400601; BFG: 52|31.46|
27208327|EAP|HCPCS A6236||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing >48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|80.15|FSC: 400601; BFG: 52|||80.15|FSC: 400601; BFG: 52|44.08|
27208328|EAP|HCPCS A6237||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing <= 16 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|33.10|FSC: 400601; BFG: 52|||33.10|FSC: 400601; BFG: 52|18.20|
27208329|EAP|HCPCS A6238||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing >16 <= 48 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|60.50|FSC: 400601; BFG: 52|||60.50|FSC: 400601; BFG: 52|33.27|
27208330|EAP|HCPCS A6239||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing >48 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|80.15|FSC: 400601; BFG: 52|||80.15|FSC: 400601; BFG: 52|44.08|
27208331|EAP|HCPCS A6240||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing Wound Filler Paste Per Oz|1|<Self-pay>|<Self-pay>|<Self-pay>|42.55|FSC: 400601; BFG: 52|||42.55|FSC: 400601; BFG: 52|23.40|
27208332|EAP|HCPCS A6241||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrocolloid Dressing Wound Filler Dry Per Gm|1|<Self-pay>|<Self-pay>|<Self-pay>|33.80|FSC: 400601; BFG: 52|||33.80|FSC: 400601; BFG: 52|18.59|
27208333|EAP|HCPCS A6242||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrogel Dressing <= 16 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|22.85|FSC: 400601; BFG: 52|||22.85|FSC: 400601; BFG: 52|12.57|
27208334|EAP|HCPCS A6243||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrogel Dressing >16 <= 48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|27.80|FSC: 400601; BFG: 52|||27.80|FSC: 400601; BFG: 52|15.29|
27208335|EAP|HCPCS A6244||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrogel Dressing >48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|36.40|FSC: 400601; BFG: 52|||36.40|FSC: 400601; BFG: 52|20.02|
27208336|EAP|HCPCS A6245||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrogel Dressing <= 16 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|43.80|FSC: 400601; BFG: 52|||43.80|FSC: 400601; BFG: 52|24.09|
27208337|EAP|HCPCS A6246||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrogel Dressing >16 <= 48 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|88.90|FSC: 400601; BFG: 52|||88.90|FSC: 400601; BFG: 52|48.89|
27208338|EAP|HCPCS A6247||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrogel Dressing >48 Sq In W/adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|96.30|FSC: 400601; BFG: 52|||96.30|FSC: 400601; BFG: 52|52.96|
27208339|EAP|HCPCS A6248||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hydrogel Dressing Wound Filler Gel Per Oz|1|<Self-pay>|<Self-pay>|<Self-pay>|67.00|FSC: 400601; BFG: 52|||67.00|FSC: 400601; BFG: 52|36.85|
27208340|EAP|HCPCS A6251||0623 - MEDICAL/SURGICAL SUPPLIES - SURGICAL DRESSINGS|Hc Cch Absorptive Dressing <= 16 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|28.55|FSC: 400601; BFG: 52|||28.55|FSC: 400601; BFG: 52|15.70|
27208341|EAP|HCPCS A6252||0623 - MEDICAL/SURGICAL SUPPLIES - SURGICAL DRESSINGS|Hc Cch Absorptive Dressing >16 <= 48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|13.10|FSC: 400601; BFG: 52|||13.10|FSC: 400601; BFG: 52|7.20|
27208342|EAP|HCPCS A6253||0623 - MEDICAL/SURGICAL SUPPLIES - SURGICAL DRESSINGS|Hc Cch Absorptive Dressing >48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|19.20|FSC: 400601; BFG: 52|||19.20|FSC: 400601; BFG: 52|10.56|
27208343|EAP|HCPCS A6254||0623 - MEDICAL/SURGICAL SUPPLIES - SURGICAL DRESSINGS|Hc Cch Absorptive Dressing <= 16 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|16.45|FSC: 400601; BFG: 52|||16.45|FSC: 400601; BFG: 52|9.05|
27208344|EAP|HCPCS A6255||0623 - MEDICAL/SURGICAL SUPPLIES - SURGICAL DRESSINGS|Hc Cch Absorptive Dressing >16 <= 48 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|16.45|FSC: 400601; BFG: 52|||16.45|FSC: 400601; BFG: 52|9.05|
27208345|EAP|HCPCS A6256||0623 - MEDICAL/SURGICAL SUPPLIES - SURGICAL DRESSINGS|Hc Cch Absorptive Dressing >48 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|3.35|FSC: 400601; BFG: 52|||3.35|FSC: 400601; BFG: 52|1.84|
27208346|EAP|HCPCS A6260||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Wound Cleanser|1|<Self-pay>|<Self-pay>|<Self-pay>|19.60|FSC: 400601; BFG: 52|||19.60|FSC: 400601; BFG: 52|10.78|
27208347|EAP|HCPCS A6261||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Wound Filler Gel/paste Per Oz|1|<Self-pay>|<Self-pay>|<Self-pay>|94.85|FSC: 400601; BFG: 52|||94.85|FSC: 400601; BFG: 52|52.17|
27208348|EAP|HCPCS A6262||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Wound Filler Dry Form Per Gm|1|<Self-pay>|<Self-pay>|<Self-pay>|27.80|FSC: 400601; BFG: 52|||27.80|FSC: 400601; BFG: 52|15.29|
27208349|EAP|HCPCS A6441||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Padding Bandage >=3" <5"|1|<Self-pay>|<Self-pay>|<Self-pay>|9.55|FSC: 400601; BFG: 52|||9.55|FSC: 400601; BFG: 52|5.25|
27208350|EAP|HCPCS A6443||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Conforming Bandage >=3" <5"|1|<Self-pay>|<Self-pay>|<Self-pay>|6.80|FSC: 400601; BFG: 52|||6.80|FSC: 400601; BFG: 52|3.74|
27208351|EAP|HCPCS A6449||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Light Compression Bandage >=3" <5"|1|<Self-pay>|<Self-pay>|<Self-pay>|13.05|FSC: 400601; BFG: 52|||13.05|FSC: 400601; BFG: 52|7.18|
27208352|EAP|HCPCS A6454||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Self Adherent Bandage >=3" <5"|1|<Self-pay>|<Self-pay>|<Self-pay>|13.25|FSC: 400601; BFG: 52|||13.25|FSC: 400601; BFG: 52|7.29|
27208353|EAP|HCPCS A6456||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Zinc Paste Band|1|<Self-pay>|<Self-pay>|<Self-pay>|47.55|FSC: 400601; BFG: 52|||47.55|FSC: 400601; BFG: 52|26.15|
27208354|EAP|HCPCS A6550||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Negative Pressure Wound Therapy Dressing Set|1|<Self-pay>|<Self-pay>|<Self-pay>|100.40|FSC: 400601; BFG: 52|||100.40|FSC: 400601; BFG: 52|55.22|
27208355|EAP|Custom 27208355||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Negative Pressure Wound Therapy Pump|1|<Self-pay>|<Self-pay>|<Self-pay>|96.70|FSC: 400601; BFG: 52|||96.70|FSC: 400601; BFG: 52|53.18|
27208356|EAP|HCPCS G0168||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Wound Closure By Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|259.30|FSC: 400601; BFG: 52|||259.30|FSC: 400601; BFG: 52|142.61|
27208357|EAP|Custom 27208357||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Bubble Humidifier|1|<Self-pay>|<Self-pay>|<Self-pay>|19.35|FSC: 400601; BFG: 52|||19.35|FSC: 400601; BFG: 52|10.64|
27208358|EAP|Custom 27208358||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Adult Oxygen Mask Non Rebreather|1|<Self-pay>|<Self-pay>|<Self-pay>|21.20|FSC: 400601; BFG: 52|||21.20|FSC: 400601; BFG: 52|11.66|
27208359|EAP|Custom 27208359||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Aerosol|1|<Self-pay>|<Self-pay>|<Self-pay>|11.55|FSC: 400601; BFG: 52|||11.55|FSC: 400601; BFG: 52|6.35|
27208360|EAP|Custom 27208360||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Multivent|1|<Self-pay>|<Self-pay>|<Self-pay>|17.35|FSC: 400601; BFG: 52|||17.35|FSC: 400601; BFG: 52|9.54|
27208361|EAP|Custom 27208361||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Mask Pedi|1|<Self-pay>|<Self-pay>|<Self-pay>|11.55|FSC: 400601; BFG: 52|||11.55|FSC: 400601; BFG: 52|6.35|
27208362|EAP|Custom 27208362||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Nebulizer Updraft|1|<Self-pay>|<Self-pay>|<Self-pay>|29.95|FSC: 400601; BFG: 52|||29.95|FSC: 400601; BFG: 52|16.47|
27208364|EAP|HCPCS A6214||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foam Dressing >48 Sq In W/ Adhesive|1|<Self-pay>|<Self-pay>|<Self-pay>|81.75|FSC: 400601; BFG: 52|||81.75|FSC: 400601; BFG: 52|44.96|
27208365|EAP|HCPCS A6211||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Foam Dressing >48 Sq In|1|<Self-pay>|<Self-pay>|<Self-pay>|52.25|FSC: 400601; BFG: 52|||52.25|FSC: 400601; BFG: 52|28.74|
40200070|EAP|CPT® 76886||0402 - OTHER IMAGING SERVICES - ULTRASOUND|Hc Cch Us Infant Hips Limited|1|<Self-pay>|<Self-pay>|<Self-pay>|165.90|FSC: 400601; BFG: 52|||165.90|FSC: 400601; BFG: 52|91.24|
27208366|EAP|Custom 27208366||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline .2% W/dext 5% 1000cc|1|<Self-pay>|<Self-pay>|<Self-pay>|78.90|FSC: 400601; BFG: 52|||78.90|FSC: 400601; BFG: 52|43.39|
27208367|EAP|Custom 27208367||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline .45% W/dext 5% 1000cc|1|<Self-pay>|<Self-pay>|<Self-pay>|78.90|FSC: 400601; BFG: 52|||78.90|FSC: 400601; BFG: 52|43.39|
27208368|EAP|Custom 27208368||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline .9% W/dext 5% 1000cc|1|<Self-pay>|<Self-pay>|<Self-pay>|78.90|FSC: 400601; BFG: 52|||78.90|FSC: 400601; BFG: 52|43.39|
27208369|EAP|Custom 27208369||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline .9% 250cc|1|<Self-pay>|<Self-pay>|<Self-pay>|78.90|FSC: 400601; BFG: 52|||78.90|FSC: 400601; BFG: 52|43.39|
27208370|EAP|Custom 27208370||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline .9% 500cc|1|<Self-pay>|<Self-pay>|<Self-pay>|78.90|FSC: 400601; BFG: 52|||78.90|FSC: 400601; BFG: 52|43.39|
27208371|EAP|Custom 27208371||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline .9% 1000cc|1|<Self-pay>|<Self-pay>|<Self-pay>|78.90|FSC: 400601; BFG: 52|||78.90|FSC: 400601; BFG: 52|43.39|
27208372|EAP|Custom 27208372||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline .45% 1000cc|1|<Self-pay>|<Self-pay>|<Self-pay>|78.90|FSC: 400601; BFG: 52|||78.90|FSC: 400601; BFG: 52|43.39|
27208373|EAP|Custom 27208373||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Saline Irrigation Pour|1|<Self-pay>|<Self-pay>|<Self-pay>|39.40|FSC: 400601; BFG: 52|||39.40|FSC: 400601; BFG: 52|21.67|
37000026|EAP|Custom 37000026||0370 - ANESTHESIA - GENERAL CLASSIFICATION|Hc Cch Local Nurse Monitor|1|<Self-pay>|<Self-pay>|<Self-pay>|106.05|FSC: 400601; BFG: 52|||106.05|FSC: 400601; BFG: 52|58.33|
27208374|EAP|Custom 27208374||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Compression Bandage 4 In|1|<Self-pay>|<Self-pay>|<Self-pay>|51.10|FSC: 400601; BFG: 52|||51.10|FSC: 400601; BFG: 52|28.10|
27208375|EAP|Custom 27208375||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Compression Bandage 6 In|1|<Self-pay>|<Self-pay>|<Self-pay>|63.25|FSC: 400601; BFG: 52|||63.25|FSC: 400601; BFG: 52|34.79|
27208376|EAP|Custom 27208376||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Fastrack|1|<Self-pay>|<Self-pay>|<Self-pay>|47.90|FSC: 400601; BFG: 52|||47.90|FSC: 400601; BFG: 52|26.34|
27208377|EAP|Custom 27208377||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Esophageal Stethoscope|1|<Self-pay>|<Self-pay>|<Self-pay>|28.05|FSC: 400601; BFG: 52|||28.05|FSC: 400601; BFG: 52|15.43|
27208378|EAP|Custom 27208378||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Eye Shield|1|<Self-pay>|<Self-pay>|<Self-pay>|33.10|FSC: 400601; BFG: 52|||33.10|FSC: 400601; BFG: 52|18.20|
27208379|EAP|Custom 27208379||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Headrest|1|<Self-pay>|<Self-pay>|<Self-pay>|100.50|FSC: 400601; BFG: 52|||100.50|FSC: 400601; BFG: 52|55.27|
27208380|EAP|Custom 27208380||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Hme Filter|1|<Self-pay>|<Self-pay>|<Self-pay>|36.40|FSC: 400601; BFG: 52|||36.40|FSC: 400601; BFG: 52|20.02|
31000350|EAP|CPT® 81539||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Oncology Prostate Probability Score|1|<Self-pay>|<Self-pay>|<Self-pay>|2,034.90|FSC: 400601; BFG: 52|||2,034.90|FSC: 400601; BFG: 52|1,119.19|
30600270|EAP|CPT® 87486||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Chlamydia P Amplif Na Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|151.20|FSC: 400601; BFG: 52|||151.20|FSC: 400601; BFG: 52|83.16|
76100142|EAP|CPT® 54150||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Cch Circumcision W/ Regional Block|1|<Self-pay>|<Self-pay>|<Self-pay>|4,540.20|FSC: 400601; BFG: 52|||4,540.20|FSC: 400601; BFG: 52|2,497.11|
76200006|EAP|HCPCS G0378||0762 - TREATMENT/OBSERVATION ROOM - OBSERVATION ROOM|Hc Cch Observation Progressive/intermediate|1|<Self-pay>|<Self-pay>|<Self-pay>|55.65|FSC: 400601; BFG: 52|||55.65|FSC: 400601; BFG: 52|30.61|
27208444|EAP|Custom 27208444||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Needle Hawkins Ii|1|<Self-pay>|<Self-pay>|<Self-pay>|276.00|FSC: 400601; BFG: 52|||276.00|FSC: 400601; BFG: 52|151.80|
27208445|EAP|Custom 27208445||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Cch Drain Catheter Fastener-stayfix|1|<Self-pay>|<Self-pay>|<Self-pay>|42.50|FSC: 400601; BFG: 52|||42.50|FSC: 400601; BFG: 52|23.37|
27804527|EAP|HCPCS C1897||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|Hc Cch Infinion 16 Trial Lead Kit 50 Cm|1|<Self-pay>|<Self-pay>|<Self-pay>|1,794.45|FSC: 400601; BFG: 52|||1,794.45|FSC: 400601; BFG: 52|986.95|
49000981|EAP|CPT® 10005||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Fine Needle Aspiration Bx W/ Ultrasound Guidance First Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|1,550.85|FSC: 400601; BFG: 52|||1,550.85|FSC: 400601; BFG: 52|852.97|
49000982|EAP|CPT® 10006||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Fine Needle Aspiration Bx W/ Ultrasound Guidance Each Addl Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|387.45|FSC: 400601; BFG: 52|||387.45|FSC: 400601; BFG: 52|213.10|
49000985|EAP|CPT® 10009||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Fine Needle Aspiration Bx W/ Ct Guidance First Lesion|1|<Self-pay>|<Self-pay>|<Self-pay>|1,522.50|FSC: 400601; BFG: 52|||1,522.50|FSC: 400601; BFG: 52|837.37|
51000717|EAP|CPT® 43762||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Replacement G-tube W/o Imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|619.50|FSC: 400601; BFG: 52|||619.50|FSC: 400601; BFG: 52|340.72|
31100154|EAP|CPT® 88164||0311 - LABORATORY PATHOLOGICAL - CYTOLOGY|Hc Cch So Cytopathology Bethesda Pap Manual Screen|1|<Self-pay>|<Self-pay>|<Self-pay>|38.85|FSC: 400601; BFG: 52|||38.85|FSC: 400601; BFG: 52|21.37|
30100991|EAP|CPT® 84160||0301 - LABORATORY - CHEMISTRY|Hc Cch So Protein Total By Refractometry Any Source|1|<Self-pay>|<Self-pay>|<Self-pay>|16.80|FSC: 400601; BFG: 52|||16.80|FSC: 400601; BFG: 52|9.24|
11104|EAP|CPT® 11104|||PUNCH BIOPSY SKIN SINGLE LESION|1|<Self-pay>|<Self-pay>|<Self-pay>|178.74|FSC: 46100; BFG: 52|||178.74|FSC: 46100; BFG: 52|98.31|
11106|EAP|CPT® 11106|||INCISIONAL BIOPSY SKIN SINGLE LESION|1|<Self-pay>|<Self-pay>|<Self-pay>|1,809.00|FSC: 46100; BFG: 52|||1,809.00|FSC: 46100; BFG: 52|994.95|
31000368|EAP|CPT® 88230||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Tissue Culture Lymphocyte|1|<Self-pay>|<Self-pay>|<Self-pay>|385.35|FSC: 400601; BFG: 52|||385.35|FSC: 400601; BFG: 52|211.94|
31000369|EAP|CPT® 88233||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Tissue Culture Skin Or Solid Bx|1|<Self-pay>|<Self-pay>|<Self-pay>|465.15|FSC: 400601; BFG: 52|||465.15|FSC: 400601; BFG: 52|255.83|
31000371|EAP|CPT® 88235||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Tissue Culture Amniotic Fluid|1|<Self-pay>|<Self-pay>|<Self-pay>|712.95|FSC: 400601; BFG: 52|||712.95|FSC: 400601; BFG: 52|392.12|
31000373|EAP|CPT® 88237||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Tissue Culture Bm Blood Cells|1|<Self-pay>|<Self-pay>|<Self-pay>|611.10|FSC: 400601; BFG: 52|||611.10|FSC: 400601; BFG: 52|336.10|
31000382|EAP|CPT® 88262||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Chromosone Analysis 15-20 Cells|1|<Self-pay>|<Self-pay>|<Self-pay>|411.60|FSC: 400601; BFG: 52|||411.60|FSC: 400601; BFG: 52|226.38|
31000384|EAP|CPT® 88264||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch So Chrom Analysis 20-25 Cells|1|<Self-pay>|<Self-pay>|<Self-pay>|615.30|FSC: 400601; BFG: 52|||615.30|FSC: 400601; BFG: 52|338.41|
31000472|EAP|CPT® 88280||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Chrom Analy Addtl Karyot Ea Study|1|<Self-pay>|<Self-pay>|<Self-pay>|121.80|FSC: 400601; BFG: 52|||121.80|FSC: 400601; BFG: 52|66.99|
31000475|EAP|CPT® 88285||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Chrom Analy Addtl Cell Counts|1|<Self-pay>|<Self-pay>|<Self-pay>|92.40|FSC: 400601; BFG: 52|||92.40|FSC: 400601; BFG: 52|50.82|
31000476|EAP|CPT® 88289||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc So Chrom Analy Addtl Hi Resoln|1|<Self-pay>|<Self-pay>|<Self-pay>|166.95|FSC: 400601; BFG: 52|||166.95|FSC: 400601; BFG: 52|91.82|
30101007|EAP|CPT® 83018||0301 - LABORATORY - CHEMISTRY|Hc So Heavy Metal Quan - B|1|<Self-pay>|<Self-pay>|<Self-pay>|49.41|FSC: 400601; BFG: 52|||49.41|FSC: 400601; BFG: 52|27.18|
49000996|EAP|CPT® 36573||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Insertion Picc W/o Pump/port W/imaging > 5 Years Old|1|<Self-pay>|<Self-pay>|<Self-pay>|2,929.50|FSC: 400601; BFG: 52|||2,929.50|FSC: 400601; BFG: 52|1,611.22|
51000737|EAP|CPT® 51798||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Ultrasound Post Voiding Urine|1|<Self-pay>|<Self-pay>|<Self-pay>|132.30|FSC: 400601; BFG: 52|||132.30|FSC: 400601; BFG: 52|72.76|
51000738|EAP|CPT® 51700||0761 - TREATMENT/OBSERVATION ROOM - TREATMENT ROOM|Hc Bladder Irrigation|1|<Self-pay>|<Self-pay>|<Self-pay>|614.25|FSC: 400601; BFG: 52|||614.25|FSC: 400601; BFG: 52|337.84|
49000998|EAP|CPT® 32550||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Insertion Pleural Cath W/ Cuff|1|<Self-pay>|<Self-pay>|<Self-pay>|3,117.45|FSC: 400601; BFG: 52|||3,117.45|FSC: 400601; BFG: 52|1,714.60|
31000505|EAP|CPT® 81335||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch Tpmt Gene Analysis Common Variants|1|<Self-pay>|<Self-pay>|<Self-pay>|481.95|FSC: 400601; BFG: 52|||481.95|FSC: 400601; BFG: 52|265.07|
30101025|EAP|CPT® 82642||0301 - LABORATORY - CHEMISTRY|Hc Cch Dihydrotestosterone|1|<Self-pay>|<Self-pay>|<Self-pay>|39.90|FSC: 400601; BFG: 52|||39.90|FSC: 400601; BFG: 52|21.94|
39000037|EAP|||0390 - BLOOD AND BLOOD COMPONENT ADMINISTRATION, PROCESSING AND STORAGE - GENERAL CLASSIFICATION|Hc Cryo Pool Rule|1|<Self-pay>|<Self-pay>|<Self-pay>|588.00|FSC: 400601|||588.00|FSC: 400601|323.40|
30600278|EAP|CPT® 87158||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Culture Typing Other Methods|1|<Self-pay>|<Self-pay>|<Self-pay>|84.00|FSC: 400601; BFG: 52|||84.00|FSC: 400601; BFG: 52|46.20|
31900001|EAP|CPT® 81364||0319 - LABORATORY PATHOLOGICAL - OTHER|Hc Cch Hbb Full Gene Sequence|1|<Self-pay>|<Self-pay>|<Self-pay>|869.40|FSC: 400601; BFG: 52|||869.40|FSC: 400601; BFG: 52|478.17|
31000509|EAP|CPT® 81306||0310 - LABORATORY PATHOLOGICAL - GENERAL CLASSIFICATION|Hc Cch Nudt 15 Gene Analysis Common Variants|1|<Self-pay>|<Self-pay>|<Self-pay>|780.15|FSC: 400601; BFG: 52|||780.15|FSC: 400601; BFG: 52|429.08|
30600279|EAP|CPT® 87634||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch Iadna Dna/rna Amplified Probe|1|<Self-pay>|<Self-pay>|<Self-pay>|208.95|FSC: 400601; BFG: 52|||208.95|FSC: 400601; BFG: 52|114.92|
30600280|EAP|CPT® 87801||0306 - LABORATORY - BACTERIOLOGY AND MICROBIOLOGY|Hc Cch So Dna/rna Multi Org Amp (blood Panl Id By Pcr)|1|<Self-pay>|<Self-pay>|<Self-pay>|242.55|FSC: 400601; BFG: 52|||242.55|FSC: 400601; BFG: 52|133.40|
49000461|EAP|CPT® 62272||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Hc Lumbar Puncture Therapeutic W/o Guidance|1|<Self-pay>|<Self-pay>|<Self-pay>|1,455.30|FSC: 400601; BFG: 52|||1,455.30|FSC: 400601; BFG: 52|800.41|
51000456|EAP|CPT® 64430||0510 - CLINIC - GENERAL CLASSIFICATION|Hc Injection Anesthetic Pudendal Nerve|1|<Self-pay>|<Self-pay>|<Self-pay>|1,918.26|FSC: 400601; BFG: 52|||1,918.26|FSC: 400601; BFG: 52|1,055.04|
27202969|EAP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Hc Guidewire Amplatz Super Stiff|1|<Self-pay>|<Self-pay>|<Self-pay>|108.75|FSC: 400601; BFG: 52|||108.75|FSC: 400601; BFG: 52|59.81|
30100485|EAP|CPT® 82670||0301 - LABORATORY - CHEMISTRY|Hc So Estradiol|1|<Self-pay>|<Self-pay>|<Self-pay>|92.40|FSC: 400601; BFG: 52|||92.40|FSC: 400601; BFG: 52|50.82|
75000113|EAP|CPT® 43257||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Egd Flexible Transoral W/ Thermal Energy Delivery|1|<Self-pay>|<Self-pay>|<Self-pay>|2,937.90|FSC: 400601; BFG: 52|||2,937.90|FSC: 400601; BFG: 52|1,615.84|
30100487|EAP|CPT® 82533||0301 - LABORATORY - CHEMISTRY|Hc So Cortisol-total|1|<Self-pay>|<Self-pay>|<Self-pay>|53.55|FSC: 400601; BFG: 52|||53.55|FSC: 400601; BFG: 52|29.45|
75000116|EAP|CPT® 44392||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Stoma W/ Removal Hot Bx Forceps|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
75000117|EAP|CPT® 44394||0750 - GASTRO-INTESTINAL SERVICES - GENERAL CLASSIFICATION|Hc Colonoscopy Stoma W/removal By Snare|1|<Self-pay>|<Self-pay>|<Self-pay>|2,507.40|FSC: 400601; BFG: 52|||2,507.40|FSC: 400601; BFG: 52|1,379.07|
26600|EAP|CPT® 26600||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Closed Tx Metacarpal Fx W/o Manip,each|1|<Self-pay>|<Self-pay>|<Self-pay>|440.00|FSC: 46100; BFG: 52|||440.00|FSC: 46100; BFG: 52|242.00|
26770|EAP|CPT® 26770|||Pr Closed Rx Ip Jt Dislocation|1|<Self-pay>|<Self-pay>|<Self-pay>|406.00|FSC: 46100; BFG: 52|||406.00|FSC: 46100; BFG: 52|223.30|
27096|EAP|CPT® 27096|||INJECT SI JOINT ARTHRGRPHY&/ANES/STEROID W/IMAGE|1|<Self-pay>|<Self-pay>|<Self-pay>|485.00|FSC: 46100; BFG: 52|||485.00|FSC: 46100; BFG: 52|266.75|
27130|EAP|CPT® 27130|||Pr Total Hip Arthroplasty|1|<Self-pay>|<Self-pay>|<Self-pay>|2,040.00|FSC: 46100; BFG: 52|||2,040.00|FSC: 46100; BFG: 52|1,122.00|
27447|EAP|CPT® 27447|||Pr Total Knee Arthroplasty|1|<Self-pay>|<Self-pay>|<Self-pay>|2,038.00|FSC: 46100; BFG: 52|||2,038.00|FSC: 46100; BFG: 52|1,120.90|
27654|EAP|CPT® 27654|||Pr Repair Achilles Tendon,secondary|1|<Self-pay>|<Self-pay>|<Self-pay>|1,287.00|FSC: 46100; BFG: 52|||1,287.00|FSC: 46100; BFG: 52|707.85|
27685|EAP|CPT® 27685|||Pr Length/short Leg/ankl Tendon,single|1|<Self-pay>|<Self-pay>|<Self-pay>|1,175.00|FSC: 46100; BFG: 52|||1,175.00|FSC: 46100; BFG: 52|646.25|
27691|EAP|CPT® 27691|||Pr Xfer Single Deep Low Leg Tendon|1|<Self-pay>|<Self-pay>|<Self-pay>|1,235.00|FSC: 46100; BFG: 52|||1,235.00|FSC: 46100; BFG: 52|679.25|
27786|EAP|CPT® 27786||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Closed Tx Dist Fibula Fx W/o Manip|1|<Self-pay>|<Self-pay>|<Self-pay>|485.00|FSC: 46100; BFG: 52|||485.00|FSC: 46100; BFG: 52|266.75|
27792|EAP|CPT® 27792|||Pr Open Rx Lat Malleolus Fx|1|<Self-pay>|<Self-pay>|<Self-pay>|1,430.00|FSC: 46100; BFG: 52|||1,430.00|FSC: 46100; BFG: 52|786.50|
27840|EAP|CPT® 27840|||Pr Closed Rx Ankle Dislocatn|1|<Self-pay>|<Self-pay>|<Self-pay>|790.00|FSC: 46100; BFG: 52|||790.00|FSC: 46100; BFG: 52|434.50|
28124|EAP|CPT® 28124|||Pr Part Remv Phalanx Of Toe|1|<Self-pay>|<Self-pay>|<Self-pay>|715.00|FSC: 46100; BFG: 52|||715.00|FSC: 46100; BFG: 52|393.25|
28190|EAP|CPT® 28190||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Remv Foot Foreign Body,subcutaneous|1|<Self-pay>|<Self-pay>|<Self-pay>|385.00|FSC: 46100; BFG: 52|||385.00|FSC: 46100; BFG: 52|211.75|
28234|EAP|CPT® 28234|||Pr Incision Exten Foot/toe Tendon|1|<Self-pay>|<Self-pay>|<Self-pay>|655.00|FSC: 46100; BFG: 52|||655.00|FSC: 46100; BFG: 52|360.25|
99307|EAP|CPT® 99307||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|SBSQ NURSING FACILITY CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
99308|EAP|CPT® 99308||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|SBSQ NURSING FACIL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|105.00|FSC: 46100; BFG: 52|||105.00|FSC: 46100; BFG: 52|57.75|
99309|EAP|CPT® 99309||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|SBSQ NURSING FACIL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|140.00|FSC: 46100; BFG: 52|||140.00|FSC: 46100; BFG: 52|77.00|
99310|EAP|CPT® 99310||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|SBSQ NURS FACIL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|205.00|FSC: 46100; BFG: 52|||205.00|FSC: 46100; BFG: 52|112.75|
28800|EAP|CPT® 28800|||Pr Amputation Foot,midtarsal-chopart|1|<Self-pay>|<Self-pay>|<Self-pay>|1,020.00|FSC: 46100; BFG: 52|||1,020.00|FSC: 46100; BFG: 52|561.00|
29065|EAP|CPT® 29065||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Apply Long Arm Cast|1|<Self-pay>|<Self-pay>|<Self-pay>|220.00|FSC: 46100; BFG: 52|||220.00|FSC: 46100; BFG: 52|121.00|
29075|EAP|CPT® 29075||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Apply Cast,short Arm,elbow-finger|1|<Self-pay>|<Self-pay>|<Self-pay>|190.00|FSC: 46100; BFG: 52|||190.00|FSC: 46100; BFG: 52|104.50|
29125|EAP|CPT® 29125||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Apply Short Arm Splint,static|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|FSC: 46100; BFG: 52|||125.00|FSC: 46100; BFG: 52|68.75|
29405|EAP|CPT® 29405||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Apply Short Leg Cast|1|<Self-pay>|<Self-pay>|<Self-pay>|205.00|FSC: 46100; BFG: 52|||205.00|FSC: 46100; BFG: 52|112.75|
99326|EAP|CPT® 99326||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|DOMICIL/REST HOME NEW PT|1|<Self-pay>|<Self-pay>|<Self-pay>|215.00|FSC: 46100; BFG: 52|||215.00|FSC: 46100; BFG: 52|118.25|
29515|EAP|CPT® 29515||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Apply Short Leg Splint, Calf-foot|1|<Self-pay>|<Self-pay>|<Self-pay>|140.00|FSC: 46100; BFG: 52|||140.00|FSC: 46100; BFG: 52|77.00|
29540|EAP|CPT® 29540||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Strapping; Ankle &/or Foot|1|<Self-pay>|<Self-pay>|<Self-pay>|60.00|FSC: 46100; BFG: 52|||60.00|FSC: 46100; BFG: 52|33.00|
29580|EAP|CPT® 29580||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Apply Of Unna Boot|1|<Self-pay>|<Self-pay>|<Self-pay>|95.00|FSC: 46100; BFG: 52|||95.00|FSC: 46100; BFG: 52|52.25|
99334|EAP|CPT® 99334||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|DOM/R-HOME E/M EST PT|1|<Self-pay>|<Self-pay>|<Self-pay>|95.00|FSC: 46100; BFG: 52|||95.00|FSC: 46100; BFG: 52|52.25|
99335|EAP|CPT® 99335||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|DOM/R-HOME E/M EST PT|1|<Self-pay>|<Self-pay>|<Self-pay>|145.00|FSC: 46100; BFG: 52|||145.00|FSC: 46100; BFG: 52|79.75|
30300|EAP|CPT® 30300||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Remove Nasal Foreign Body|1|<Self-pay>|<Self-pay>|<Self-pay>|340.00|FSC: 46100; BFG: 52|||340.00|FSC: 46100; BFG: 52|187.00|
30901|EAP|CPT® 30901||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Ctrl Nosebleed,anter,simple|1|<Self-pay>|<Self-pay>|<Self-pay>|197.00|FSC: 46100; BFG: 52|||197.00|FSC: 46100; BFG: 52|108.35|
30903|EAP|CPT® 30903||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Ctrl Nosebleed,anter,complex|1|<Self-pay>|<Self-pay>|<Self-pay>|310.00|FSC: 46100; BFG: 52|||310.00|FSC: 46100; BFG: 52|170.50|
30905|EAP|CPT® 30905||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Ctrl Nosebleed,post,w/packs &/or Caut|1|<Self-pay>|<Self-pay>|<Self-pay>|465.00|FSC: 46100; BFG: 52|||465.00|FSC: 46100; BFG: 52|255.75|
31500|EAP|CPT® 31500|||Pr Insert Emergency Endotrach Airway|1|<Self-pay>|<Self-pay>|<Self-pay>|245.00|FSC: 46100; BFG: 52|||245.00|FSC: 46100; BFG: 52|134.75|
36556|EAP|CPT® 36556|||Pr Insert Non-tunnel Cv Cath,age 5 Or Older|1|<Self-pay>|<Self-pay>|<Self-pay>|842.00|FSC: 46100; BFG: 52|||842.00|FSC: 46100; BFG: 52|463.10|
36558|EAP|CPT® 36558|||INSJ TUNNELED CVC W/O SUBQ PORT/PMP AGE 5 YR/>|1|<Self-pay>|<Self-pay>|<Self-pay>|1,600.00|FSC: 46100; BFG: 52|||1,600.00|FSC: 46100; BFG: 52|880.00|
36561|EAP|CPT® 36561|||INSJ TUNNELED CTR VAD W/SUBQ PORT AGE 5 YR/>|1|<Self-pay>|<Self-pay>|<Self-pay>|1,602.00|FSC: 46100; BFG: 52|||1,602.00|FSC: 46100; BFG: 52|881.10|
36590|EAP|CPT® 36590|||RMVL TUN CTR VAD W/SUBQ PORT/PMP CTR/PRPH INSJ|1|<Self-pay>|<Self-pay>|<Self-pay>|397.00|FSC: 46100; BFG: 52|||397.00|FSC: 46100; BFG: 52|218.35|
36620|EAP|CPT® 36620|||Pr Insert Cath,art,percut,shortterm|1|<Self-pay>|<Self-pay>|<Self-pay>|90.00|FSC: 46100; BFG: 52|||90.00|FSC: 46100; BFG: 52|49.50|
38525|EAP|CPT® 38525|||Pr Bx/remv,lymph Node,deep Axill|1|<Self-pay>|<Self-pay>|<Self-pay>|675.00|FSC: 46100; BFG: 52|||675.00|FSC: 46100; BFG: 52|371.25|
43239|EAP|CPT® 43239||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|EGD TRANSORAL BIOPSY SINGLE/MULTIPLE|1|<Self-pay>|<Self-pay>|<Self-pay>|570.00|FSC: 46100; BFG: 52|||570.00|FSC: 46100; BFG: 52|313.50|
43249|EAP|CPT® 43249||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,450.00|FSC: 46100; BFG: 52|||1,450.00|FSC: 46100; BFG: 52|797.50|
43251|EAP|CPT® 43251||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|EGD REMOVAL TUMOR POLYP/OTHER LESION SNARE TECH|1|<Self-pay>|<Self-pay>|<Self-pay>|770.00|FSC: 46100; BFG: 52|||770.00|FSC: 46100; BFG: 52|423.50|
45331|EAP|CPT® 45331||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Pr Sigmoidoscopy, W/biopsy|1|<Self-pay>|<Self-pay>|<Self-pay>|370.00|FSC: 46100; BFG: 52|||370.00|FSC: 46100; BFG: 52|203.50|
45378|EAP|CPT® 45378||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD|1|<Self-pay>|<Self-pay>|<Self-pay>|653.00|FSC: 46100; BFG: 52|||653.00|FSC: 46100; BFG: 52|359.15|
45380|EAP|CPT® 45380||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|COLONOSCOPY W/BIOPSY SINGLE/MULTIPLE|1|<Self-pay>|<Self-pay>|<Self-pay>|772.00|FSC: 46100; BFG: 52|||772.00|FSC: 46100; BFG: 52|424.60|
45381|EAP|CPT® 45381||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|COLSC FLX WITH DIRECTED SUBMUCOSAL NJX ANY SBST|1|<Self-pay>|<Self-pay>|<Self-pay>|750.00|FSC: 46100; BFG: 52|||750.00|FSC: 46100; BFG: 52|412.50|
45385|EAP|CPT® 45385||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ|1|<Self-pay>|<Self-pay>|<Self-pay>|874.00|FSC: 46100; BFG: 52|||874.00|FSC: 46100; BFG: 52|480.70|
46221|EAP|CPT® 46221|||Pr Hemorrhoidectomy Internal Rubber Band Ligations|1|<Self-pay>|<Self-pay>|<Self-pay>|400.00|FSC: 46100; BFG: 52|||400.00|FSC: 46100; BFG: 52|220.00|
46600|EAP|CPT® 46600||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD|1|<Self-pay>|<Self-pay>|<Self-pay>|130.00|FSC: 46100; BFG: 52|||130.00|FSC: 46100; BFG: 52|71.50|
49505|EAP|CPT® 49505|||Pr Repair Ing Hernia,5+y/o,reducibl|1|<Self-pay>|<Self-pay>|<Self-pay>|945.00|FSC: 46100; BFG: 52|||945.00|FSC: 46100; BFG: 52|519.75|
49520|EAP|CPT® 49520|||Pr Repair Recurr Inguin Hern,reducibl|1|<Self-pay>|<Self-pay>|<Self-pay>|975.00|FSC: 46100; BFG: 52|||975.00|FSC: 46100; BFG: 52|536.25|
50590|EAP|CPT® 50590|||Pr Fragment Kidney Stone/ Eswl|1|<Self-pay>|<Self-pay>|<Self-pay>|1,900.00|FSC: 46100; BFG: 52|||1,900.00|FSC: 46100; BFG: 52|1,045.00|
51701|EAP|CPT® 51701|||Pr Insert,non-indwelling Bladder Catheter|1|<Self-pay>|<Self-pay>|<Self-pay>|154.00|FSC: 46100; BFG: 52|||154.00|FSC: 46100; BFG: 52|84.70|
51798|EAP|CPT® 51798||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Meas,post-void Res,us,non-imaging|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 46100; BFG: 52|||35.00|FSC: 46100; BFG: 52|19.25|
52000|EAP|CPT® 52000||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Cystourethroscopy For Diagnosis|1|<Self-pay>|<Self-pay>|<Self-pay>|275.00|FSC: 46100; BFG: 52|||275.00|FSC: 46100; BFG: 52|151.25|
52204|EAP|CPT® 52204|||Pr Cystourethroscopy,biopsies|1|<Self-pay>|<Self-pay>|<Self-pay>|735.00|FSC: 46100; BFG: 52|||735.00|FSC: 46100; BFG: 52|404.25|
52224|EAP|CPT® 52224|||Pr Cystourethroscopy,fulgur <.5cm Lesn|1|<Self-pay>|<Self-pay>|<Self-pay>|1,710.00|FSC: 46100; BFG: 52|||1,710.00|FSC: 46100; BFG: 52|940.50|
52310|EAP|CPT® 52310|||Pr Cystoscopy,remv Calculus,simple|1|<Self-pay>|<Self-pay>|<Self-pay>|435.00|FSC: 46100; BFG: 52|||435.00|FSC: 46100; BFG: 52|239.25|
52351|EAP|CPT® 52351|||Pr Cysto/uretero/pyeloscopy, Dx|1|<Self-pay>|<Self-pay>|<Self-pay>|938.00|FSC: 46100; BFG: 52|||938.00|FSC: 46100; BFG: 52|515.90|
54700|EAP|CPT® 54700|||Pr Incis/drain Scrotum/testis,epididym|1|<Self-pay>|<Self-pay>|<Self-pay>|375.00|FSC: 46100; BFG: 52|||375.00|FSC: 46100; BFG: 52|206.25|
55000|EAP|CPT® 55000|||Pr Drainage Of Hydrocele,tunica|1|<Self-pay>|<Self-pay>|<Self-pay>|175.00|FSC: 46100; BFG: 52|||175.00|FSC: 46100; BFG: 52|96.25|
55040|EAP|CPT® 55040|||Pr Removal Of Hydrocele,tunica,unilat|1|<Self-pay>|<Self-pay>|<Self-pay>|565.00|FSC: 46100; BFG: 52|||565.00|FSC: 46100; BFG: 52|310.75|
56405|EAP|CPT® 56405||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr I&d Of Vulva/perineum Abscess|1|<Self-pay>|<Self-pay>|<Self-pay>|205.00|FSC: 46100; BFG: 52|||205.00|FSC: 46100; BFG: 52|112.75|
56420|EAP|CPT® 56420||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr I&d Bartholin Gland Abscess|1|<Self-pay>|<Self-pay>|<Self-pay>|185.00|FSC: 46100; BFG: 52|||185.00|FSC: 46100; BFG: 52|101.75|
62270|EAP|CPT® 62270|||DIAGNOSTIC LUMBAR SPINAL PUNCTURE|1|<Self-pay>|<Self-pay>|<Self-pay>|240.00|FSC: 46100; BFG: 52|||240.00|FSC: 46100; BFG: 52|132.00|
64405|EAP|CPT® 64405||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|INJECTION AA&/STRD GREATER OCCIPITAL NERVE|1|<Self-pay>|<Self-pay>|<Self-pay>|240.00|FSC: 46100; BFG: 52|||240.00|FSC: 46100; BFG: 52|132.00|
64420|EAP|CPT® 64420|||INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL|1|<Self-pay>|<Self-pay>|<Self-pay>|427.00|FSC: 46100; BFG: 52|||427.00|FSC: 46100; BFG: 52|234.85|
64421|EAP|CPT® 64421|||INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL|1|<Self-pay>|<Self-pay>|<Self-pay>|650.00|FSC: 46100; BFG: 52|||650.00|FSC: 46100; BFG: 52|357.50|
64425|EAP|CPT® 64425|||INJECTION AA&/STRD ILIOINGUINAL IH NERVES|1|<Self-pay>|<Self-pay>|<Self-pay>|300.00|FSC: 46100; BFG: 52|||300.00|FSC: 46100; BFG: 52|165.00|
64445|EAP|CPT® 64445|||INJECTION AA&/STRD SCIATIC NERVE|1|<Self-pay>|<Self-pay>|<Self-pay>|205.00|FSC: 46100; BFG: 52|||205.00|FSC: 46100; BFG: 52|112.75|
64447|EAP|CPT® 64447|||INJECTION AA&/STRD FEMORAL NERVE|1|<Self-pay>|<Self-pay>|<Self-pay>|180.00|FSC: 46100; BFG: 52|||180.00|FSC: 46100; BFG: 52|99.00|
64450|EAP|CPT® 64450||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH|1|<Self-pay>|<Self-pay>|<Self-pay>|135.00|FSC: 46100; BFG: 52|||135.00|FSC: 46100; BFG: 52|74.25|
64520|EAP|CPT® 64520|||Pr Inject Nerv Blck,paravert Sympath|1|<Self-pay>|<Self-pay>|<Self-pay>|270.00|FSC: 46100; BFG: 52|||270.00|FSC: 46100; BFG: 52|148.50|
64640|EAP|CPT® 64640|||Pr Inject Rx Other Periph Nerve|1|<Self-pay>|<Self-pay>|<Self-pay>|601.00|FSC: 46100; BFG: 52|||601.00|FSC: 46100; BFG: 52|330.55|
64721|EAP|CPT® 64721|||Pr Revise Median N/carpal Tunnel Surg|1|<Self-pay>|<Self-pay>|<Self-pay>|638.00|FSC: 46100; BFG: 52|||638.00|FSC: 46100; BFG: 52|350.90|
65205|EAP|CPT® 65205||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Remv F.b.,eye,superf Conjunc|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|FSC: 46100; BFG: 52|||125.00|FSC: 46100; BFG: 52|68.75|
65220|EAP|CPT® 65220||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Remv F.b.,eye,cornea,no Slit|1|<Self-pay>|<Self-pay>|<Self-pay>|130.00|FSC: 46100; BFG: 52|||130.00|FSC: 46100; BFG: 52|71.50|
69000|EAP|CPT® 69000||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Drain Ext Ear Absc/blood,simple|1|<Self-pay>|<Self-pay>|<Self-pay>|280.00|FSC: 46100; BFG: 52|||280.00|FSC: 46100; BFG: 52|154.00|
69200|EAP|CPT® 69200||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Remv Fb,ext Aud Canal,w/o Anes|1|<Self-pay>|<Self-pay>|<Self-pay>|185.00|FSC: 46100; BFG: 52|||185.00|FSC: 46100; BFG: 52|101.75|
69210|EAP|CPT® 69210||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
71100|EAP|CPT® 71100|||Pr X-ray Ribs 2 Vw Unilat|1|<Self-pay>|<Self-pay>|<Self-pay>|108.00|FSC: 46100; BFG: 52|||108.00|FSC: 46100; BFG: 52|59.40|
71130|EAP|CPT® 71130|||Pr X-ray Sterno-clavicluar Jt|1|<Self-pay>|<Self-pay>|<Self-pay>|80.00|FSC: 46100; BFG: 52|||80.00|FSC: 46100; BFG: 52|44.00|
72040|EAP|CPT® 72040|||RADEX SPINE CERVICAL 2 OR 3 VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
72050|EAP|CPT® 72050|||RADEX SPINE CERVICAL 4 OR 5 VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|95.00|FSC: 46100; BFG: 52|||95.00|FSC: 46100; BFG: 52|52.25|
72052|EAP|CPT® 72052|||RADEX SPINE CERVICAL 6 OR MORE VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|115.00|FSC: 46100; BFG: 52|||115.00|FSC: 46100; BFG: 52|63.25|
72070|EAP|CPT® 72070|||Pr X-ray Thoracic Spine 2 Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|80.00|FSC: 46100; BFG: 52|||80.00|FSC: 46100; BFG: 52|44.00|
72100|EAP|CPT® 72100|||Pr X-ray Lumbar Spine 2/3 Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|80.00|FSC: 46100; BFG: 52|||80.00|FSC: 46100; BFG: 52|44.00|
72120|EAP|CPT® 72120|||RADEX SPINE LUMBOSACRAL ONLY BENDING 2/3 VIEWS|1|<Self-pay>|<Self-pay>|<Self-pay>|115.00|FSC: 46100; BFG: 52|||115.00|FSC: 46100; BFG: 52|63.25|
72170|EAP|CPT® 72170|||Pr X-ray Pelvis 1/2 Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|65.00|FSC: 46100; BFG: 52|||65.00|FSC: 46100; BFG: 52|35.75|
73000|EAP|CPT® 73000|||Pr X-ray Clavicle|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
73030|EAP|CPT® 73030|||Pr X-ray Shoulder 2+ Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73060|EAP|CPT® 73060|||Pr X-ray Humerus|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
73080|EAP|CPT® 73080|||Pr X-ray Elbow 3+ Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73090|EAP|CPT® 73090|||Pr X-ray Forearm 2 Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73100|EAP|CPT® 73100|||Pr X-ray Wrist 2 Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73110|EAP|CPT® 73110|||Pr X-ray Wrist 3+ Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73130|EAP|CPT® 73130|||Pr X-ray Hand 3+ Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|65.00|FSC: 46100; BFG: 52|||65.00|FSC: 46100; BFG: 52|35.75|
73140|EAP|CPT® 73140|||Pr X-ray Exam Of Finger(s)|1|<Self-pay>|<Self-pay>|<Self-pay>|60.00|FSC: 46100; BFG: 52|||60.00|FSC: 46100; BFG: 52|33.00|
73560|EAP|CPT® 73560|||Pr X-ray Knee 1 Or 2 View|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
73562|EAP|CPT® 73562|||Pr X-ray Knee 3 View|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
73564|EAP|CPT® 73564|||Pr X-ray Knee 4+ View|1|<Self-pay>|<Self-pay>|<Self-pay>|150.00|FSC: 46100; BFG: 52|||150.00|FSC: 46100; BFG: 52|82.50|
73590|EAP|CPT® 73590|||Pr X-ray Tib + Fib, 2vw|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
73600|EAP|CPT® 73600|||Pr X-ray Ankle 2 Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73610|EAP|CPT® 73610|||Pr X-ray Ankle 3+ Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73620|EAP|CPT® 73620|||Pr X-ray Foot 2 Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
73630|EAP|CPT® 73630|||Pr X-ray Foot 3+ Vw|1|<Self-pay>|<Self-pay>|<Self-pay>|80.00|FSC: 46100; BFG: 52|||80.00|FSC: 46100; BFG: 52|44.00|
73650|EAP|CPT® 73650|||Pr X-ray Heel|1|<Self-pay>|<Self-pay>|<Self-pay>|80.00|FSC: 46100; BFG: 52|||80.00|FSC: 46100; BFG: 52|44.00|
74420|EAP|CPT® 74420|||Pr X-ray, Urinary Tract Exam With Contrast|1|<Self-pay>|<Self-pay>|<Self-pay>|63.68|FSC: 46100; BFG: 52|||63.68|FSC: 46100; BFG: 52|35.02|
76815|EAP|CPT® 76815||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Us,pregnant Uterus,limited, 1/> Fetuses|1|<Self-pay>|<Self-pay>|<Self-pay>|122.00|FSC: 46100; BFG: 52|||122.00|FSC: 46100; BFG: 52|67.10|
76942|EAP|CPT® 76942|||Pr Sono Guide Needle Placement|1|<Self-pay>|<Self-pay>|<Self-pay>|125.40|FSC: 46100; BFG: 52|||125.40|FSC: 46100; BFG: 52|68.97|
97597|EAP|CPT® 97597||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Active Wound Care/20 Cm Or <|1|<Self-pay>|<Self-pay>|<Self-pay>|119.00|FSC: 46100; BFG: 52|||119.00|FSC: 46100; BFG: 52|65.45|
97598|EAP|CPT® 97598|||Pr Active Wound Care > 20 Cm|1|<Self-pay>|<Self-pay>|<Self-pay>|85.00|FSC: 46100; BFG: 52|||85.00|FSC: 46100; BFG: 52|46.75|
92950|EAP|CPT® 92950|||Pr Heart/lung Resuscitation (cpr)|1|<Self-pay>|<Self-pay>|<Self-pay>|490.00|FSC: 46100; BFG: 52|||490.00|FSC: 46100; BFG: 52|269.50|
99024|EAP|CPT® 99024|||Post-op Follow-up Visit|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 46100|||0.00|FSC: 46100|0.00|
99202|EAP|CPT® 99202||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT NEW SF MDM 15-29 MINUTES|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
99203|EAP|CPT® 99203||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT NEW LOW MDM 30-44 MINUTES|1|<Self-pay>|<Self-pay>|<Self-pay>|160.00|FSC: 46100; BFG: 52|||160.00|FSC: 46100; BFG: 52|88.00|
99204|EAP|CPT® 99204||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT NEW MODERATE MDM 45-59 MINUTES|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|FSC: 46100; BFG: 52|||250.00|FSC: 46100; BFG: 52|137.50|
99205|EAP|CPT® 99205||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT NEW HIGH MDM 60-74 MINUTES|1|<Self-pay>|<Self-pay>|<Self-pay>|310.00|FSC: 46100; BFG: 52|||310.00|FSC: 46100; BFG: 52|170.50|
99211|EAP|CPT® 99211||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT ESTABLISHED MINIMAL PROBLEM(S)|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 46100; BFG: 52|||35.00|FSC: 46100; BFG: 52|19.25|
99212|EAP|CPT® 99212||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT ESTABLISHED SF MDM 10-19 MIN|1|<Self-pay>|<Self-pay>|<Self-pay>|65.00|FSC: 46100; BFG: 52|||65.00|FSC: 46100; BFG: 52|35.75|
99213|EAP|CPT® 99213||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20-29 MIN|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
99214|EAP|CPT® 99214||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30-39 MIN|1|<Self-pay>|<Self-pay>|<Self-pay>|160.00|FSC: 46100; BFG: 52|||160.00|FSC: 46100; BFG: 52|88.00|
99215|EAP|CPT® 99215||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40-54 MIN|1|<Self-pay>|<Self-pay>|<Self-pay>|215.00|FSC: 46100; BFG: 52|||215.00|FSC: 46100; BFG: 52|118.25|
99217|EAP|CPT® 99217|||OBSERVATION CARE DISCHARGE MANAGEMENT|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
99218|EAP|CPT® 99218|||INITIAL OBSERVATION CARE/DAY 30 MINUTES|1|<Self-pay>|<Self-pay>|<Self-pay>|150.00|FSC: 46100; BFG: 52|||150.00|FSC: 46100; BFG: 52|82.50|
99219|EAP|CPT® 99219|||INITIAL OBSERVATION CARE/DAY 50 MINUTES|1|<Self-pay>|<Self-pay>|<Self-pay>|205.00|FSC: 46100; BFG: 52|||205.00|FSC: 46100; BFG: 52|112.75|
99220|EAP|CPT® 99220|||INITIAL OBSERVATION CARE/DAY 70 MINUTES|1|<Self-pay>|<Self-pay>|<Self-pay>|280.00|FSC: 46100; BFG: 52|||280.00|FSC: 46100; BFG: 52|154.00|
99221|EAP|CPT® 99221|||INITIAL HOSPITAL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|155.00|FSC: 46100; BFG: 52|||155.00|FSC: 46100; BFG: 52|85.25|
99222|EAP|CPT® 99222|||INITIAL HOSPITAL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|210.00|FSC: 46100; BFG: 52|||210.00|FSC: 46100; BFG: 52|115.50|
99223|EAP|CPT® 99223|||INITIAL HOSPITAL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|310.00|FSC: 46100; BFG: 52|||310.00|FSC: 46100; BFG: 52|170.50|
99231|EAP|CPT® 99231|||SBSQ HOSPITAL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
99232|EAP|CPT® 99232|||SBSQ HOSPITAL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
99233|EAP|CPT® 99233|||SBSQ HOSPITAL CARE/DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|160.00|FSC: 46100; BFG: 52|||160.00|FSC: 46100; BFG: 52|88.00|
99235|EAP|CPT® 99235|||OBSERVATION/INPATIENT HOSP CARE|1|<Self-pay>|<Self-pay>|<Self-pay>|330.00|FSC: 46100; BFG: 52|||330.00|FSC: 46100; BFG: 52|181.50|
99236|EAP|CPT® 99236|||OBSERVATION/INPATIENT HOSP CARE|1|<Self-pay>|<Self-pay>|<Self-pay>|395.00|FSC: 46100; BFG: 52|||395.00|FSC: 46100; BFG: 52|217.25|
99238|EAP|CPT® 99238|||PR HOSPITAL DISCHARGE DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|108.00|FSC: 46100; BFG: 52|||108.00|FSC: 46100; BFG: 52|59.40|
99239|EAP|CPT® 99239|||PR HOSPITAL DISCHARGE DAY|1|<Self-pay>|<Self-pay>|<Self-pay>|165.00|FSC: 46100; BFG: 52|||165.00|FSC: 46100; BFG: 52|90.75|
99241|EAP|CPT® 99241|||OFFICE CONSULT NEW/ESTAB|1|<Self-pay>|<Self-pay>|<Self-pay>|95.00|FSC: 46100; BFG: 52|||95.00|FSC: 46100; BFG: 52|52.25|
99242|EAP|CPT® 99242|||OFFICE CONSULTAT NEW/ESTAB|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|FSC: 46100; BFG: 52|||125.00|FSC: 46100; BFG: 52|68.75|
99243|EAP|CPT® 99243|||OFFICE CONSULT NEW/ESTAB|1|<Self-pay>|<Self-pay>|<Self-pay>|175.00|FSC: 46100; BFG: 52|||175.00|FSC: 46100; BFG: 52|96.25|
99244|EAP|CPT® 99244|||OFFICE CONSULT NEW/ESTAB|1|<Self-pay>|<Self-pay>|<Self-pay>|255.00|FSC: 46100; BFG: 52|||255.00|FSC: 46100; BFG: 52|140.25|
99251|EAP|CPT® 99251|||INITL INPATIENT CONSULT NEW/EST|1|<Self-pay>|<Self-pay>|<Self-pay>|85.00|FSC: 46100; BFG: 52|||85.00|FSC: 46100; BFG: 52|46.75|
99252|EAP|CPT® 99252|||INITL INPATIENT CONSULT NEW/EST|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
99253|EAP|CPT® 99253|||INITL INPATIENT CONSULT NEW/EST|1|<Self-pay>|<Self-pay>|<Self-pay>|165.00|FSC: 46100; BFG: 52|||165.00|FSC: 46100; BFG: 52|90.75|
99254|EAP|CPT® 99254|||INITL INPATIENT CONSULT NEW/EST|1|<Self-pay>|<Self-pay>|<Self-pay>|235.00|FSC: 46100; BFG: 52|||235.00|FSC: 46100; BFG: 52|129.25|
99255|EAP|CPT® 99255|||INITIAL INPATIENT CONSULT NEW/EST|1|<Self-pay>|<Self-pay>|<Self-pay>|285.00|FSC: 46100; BFG: 52|||285.00|FSC: 46100; BFG: 52|156.75|
99282|EAP|CPT® 99282|||EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
99283|EAP|CPT® 99283|||EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY|1|<Self-pay>|<Self-pay>|<Self-pay>|100.00|FSC: 46100; BFG: 52|||100.00|FSC: 46100; BFG: 52|55.00|
99284|EAP|CPT® 99284|||EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY|1|<Self-pay>|<Self-pay>|<Self-pay>|180.00|FSC: 46100; BFG: 52|||180.00|FSC: 46100; BFG: 52|99.00|
99285|EAP|CPT® 99285|||EMERGENCY DEPT VISIT HIGH SEVERITY&THREAT FUNCJ|1|<Self-pay>|<Self-pay>|<Self-pay>|265.00|FSC: 46100; BFG: 52|||265.00|FSC: 46100; BFG: 52|145.75|
99291|EAP|CPT® 99291|||CRITICAL CARE|1|<Self-pay>|<Self-pay>|<Self-pay>|415.00|FSC: 46100; BFG: 52|||415.00|FSC: 46100; BFG: 52|228.25|
99292|EAP|CPT® 99292|||CRITICAL CARE, ADDITIONAL|1|<Self-pay>|<Self-pay>|<Self-pay>|190.00|FSC: 46100; BFG: 52|||190.00|FSC: 46100; BFG: 52|104.50|
99356|EAP|CPT® 99356|||PROLONGED SVC I/P OR OBS SETTING 1ST HOUR|1|<Self-pay>|<Self-pay>|<Self-pay>|140.00|FSC: 46100; BFG: 52|||140.00|FSC: 46100; BFG: 52|77.00|
99357|EAP|CPT® 99357|||PROLONGED SVC I/P|1|<Self-pay>|<Self-pay>|<Self-pay>|140.00|FSC: 46100; BFG: 52|||140.00|FSC: 46100; BFG: 52|77.00|
99358|EAP|CPT® 99358|||PROLNG E/M SVC BEFORE&/AFTER|1|<Self-pay>|<Self-pay>|<Self-pay>|180.00|FSC: 46100; BFG: 52|||180.00|FSC: 46100; BFG: 52|99.00|
99387|EAP|CPT® 99387|||Pr Prevent Vst, New Pt 65 & Older|1|<Self-pay>|<Self-pay>|<Self-pay>|230.00|FSC: 46100; BFG: 52|||230.00|FSC: 46100; BFG: 52|126.50|
G0105|EAP|HCPCS G0105||0490 - AMBULATORY SURGICAL CARE - GENERAL CLASSIFICATION|Colorectal Scrn; Hi Risk Ind|1|<Self-pay>|<Self-pay>|<Self-pay>|725.00|FSC: 46100; BFG: 52|||725.00|FSC: 46100; BFG: 52|398.75|
15004|EAP|CPT® 15004|||Pr Wnd Prep Ped, Face/nck/hnd/ft/gen|1|<Self-pay>|<Self-pay>|<Self-pay>|610.00|FSC: 46100; BFG: 52|||610.00|FSC: 46100; BFG: 52|335.50|
19301|EAP|CPT® 19301|||Pr Mastectomy, Partial|1|<Self-pay>|<Self-pay>|<Self-pay>|1,000.00|FSC: 46100; BFG: 52|||1,000.00|FSC: 46100; BFG: 52|550.00|
77002|EAP|CPT® 77002|||FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT ADD ON|1|<Self-pay>|<Self-pay>|<Self-pay>|135.00|FSC: 46100; BFG: 52|||135.00|FSC: 46100; BFG: 52|74.25|
77073|EAP|CPT® 77073|||Pr X-rays, Bone Length Studies|1|<Self-pay>|<Self-pay>|<Self-pay>|89.83|FSC: 46100; BFG: 52|||89.83|FSC: 46100; BFG: 52|49.41|
Q4010|EAP|HCPCS Q4010|||Cast Sup Sht Arm Adult Fbrgl|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 46100; BFG: 52|||35.00|FSC: 46100; BFG: 52|19.25|
S2900|EAP|HCPCS S2900|||Robotic Surgical System|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|FSC: 46100|||0.00|FSC: 46100|0.00|
10021|EAP|CPT® 10021||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|FINE NEEDLE ASPIRATION BX W/O IMG GDN 1ST LESION|1|<Self-pay>|<Self-pay>|<Self-pay>|220.00|FSC: 46100; BFG: 52|||220.00|FSC: 46100; BFG: 52|121.00|
10060|EAP|CPT® 10060||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Drain Skin Abscess Simple/single|1|<Self-pay>|<Self-pay>|<Self-pay>|242.33|FSC: 46100; BFG: 52|||242.33|FSC: 46100; BFG: 52|133.28|
10061|EAP|CPT® 10061|||Pr Drain Skin Abscess Complic/multiple|1|<Self-pay>|<Self-pay>|<Self-pay>|310.00|FSC: 46100; BFG: 52|||310.00|FSC: 46100; BFG: 52|170.50|
10080|EAP|CPT® 10080||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Drain Pilonidal Cyst Simple|1|<Self-pay>|<Self-pay>|<Self-pay>|265.00|FSC: 46100; BFG: 52|||265.00|FSC: 46100; BFG: 52|145.75|
10120|EAP|CPT® 10120||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Incision/remove Fb Subq Simple|1|<Self-pay>|<Self-pay>|<Self-pay>|225.00|FSC: 46100; BFG: 52|||225.00|FSC: 46100; BFG: 52|123.75|
10160|EAP|CPT® 10160||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Puncture/drain, Abscess/hematoma/cyst|1|<Self-pay>|<Self-pay>|<Self-pay>|195.00|FSC: 46100; BFG: 52|||195.00|FSC: 46100; BFG: 52|107.25|
10180|EAP|CPT® 10180|||Pr I/d Complex, Postop Wound Infection|1|<Self-pay>|<Self-pay>|<Self-pay>|415.00|FSC: 46100; BFG: 52|||415.00|FSC: 46100; BFG: 52|228.25|
11042|EAP|CPT® 11042||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Debridement, Skin, Sub-q Tissue|1|<Self-pay>|<Self-pay>|<Self-pay>|185.00|FSC: 46100; BFG: 52|||185.00|FSC: 46100; BFG: 52|101.75|
11043|EAP|CPT® 11043|||Pr Debridement, Skin, Sub-q Tissue,muscle|1|<Self-pay>|<Self-pay>|<Self-pay>|490.00|FSC: 46100; BFG: 52|||490.00|FSC: 46100; BFG: 52|269.50|
11055|EAP|CPT® 11055||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Trim Hyperkeratotic Skin Lesion, One|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
11056|EAP|CPT® 11056|||Pr Trim Hyperkeratotic Skin Lesion,2-4|1|<Self-pay>|<Self-pay>|<Self-pay>|85.00|FSC: 46100; BFG: 52|||85.00|FSC: 46100; BFG: 52|46.75|
11403|EAP|CPT® 11403|||Pr Exc Skin Benig 2.1-3cm Trunk,arm,leg|1|<Self-pay>|<Self-pay>|<Self-pay>|285.00|FSC: 46100; BFG: 52|||285.00|FSC: 46100; BFG: 52|156.75|
11421|EAP|CPT® 11421|||Pr Exc Skin Benig 0.6-1cm Remaindr Body|1|<Self-pay>|<Self-pay>|<Self-pay>|235.00|FSC: 46100; BFG: 52|||235.00|FSC: 46100; BFG: 52|129.25|
11604|EAP|CPT® 11604|||Pr Exc Skin Malig 3.1-4cm Trunk,arm,leg|1|<Self-pay>|<Self-pay>|<Self-pay>|465.00|FSC: 46100; BFG: 52|||465.00|FSC: 46100; BFG: 52|255.75|
11621|EAP|CPT® 11621|||Pr Exc Skin Malig 0.6-1cm Remaindr Body|1|<Self-pay>|<Self-pay>|<Self-pay>|340.00|FSC: 46100; BFG: 52|||340.00|FSC: 46100; BFG: 52|187.00|
11641|EAP|CPT® 11641|||Pr Exc Skin Malig 0.6-1cm Face,facial|1|<Self-pay>|<Self-pay>|<Self-pay>|360.00|FSC: 46100; BFG: 52|||360.00|FSC: 46100; BFG: 52|198.00|
11719|EAP|CPT® 11719||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Trim Nail(s)|1|<Self-pay>|<Self-pay>|<Self-pay>|35.00|FSC: 46100; BFG: 52|||35.00|FSC: 46100; BFG: 52|19.25|
11720|EAP|CPT® 11720|||Pr Debridement Of Nail(s), 1-5|1|<Self-pay>|<Self-pay>|<Self-pay>|70.00|FSC: 46100; BFG: 52|||70.00|FSC: 46100; BFG: 52|38.50|
11721|EAP|CPT® 11721|||Pr Debridement Of Nails, 6 Or More|1|<Self-pay>|<Self-pay>|<Self-pay>|95.00|FSC: 46100; BFG: 52|||95.00|FSC: 46100; BFG: 52|52.25|
11730|EAP|CPT® 11730||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Removal,nail Plate,simple/single|1|<Self-pay>|<Self-pay>|<Self-pay>|154.00|FSC: 46100; BFG: 52|||154.00|FSC: 46100; BFG: 52|84.70|
11740|EAP|CPT® 11740||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Drain Blood From Under Nail|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|FSC: 46100; BFG: 52|||75.00|FSC: 46100; BFG: 52|41.25|
11750|EAP|CPT® 11750||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Removal Of Nail Bed|1|<Self-pay>|<Self-pay>|<Self-pay>|335.00|FSC: 46100; BFG: 52|||335.00|FSC: 46100; BFG: 52|184.25|
11755|EAP|CPT® 11755||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Biopsy, Nail Unit (sep Proc)|1|<Self-pay>|<Self-pay>|<Self-pay>|280.00|FSC: 46100; BFG: 52|||280.00|FSC: 46100; BFG: 52|154.00|
11760|EAP|CPT® 11760||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Reconstruc Of Nail Bed|1|<Self-pay>|<Self-pay>|<Self-pay>|340.00|FSC: 46100; BFG: 52|||340.00|FSC: 46100; BFG: 52|187.00|
11770|EAP|CPT® 11770||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Remv Pilonidal Lesion Simple|1|<Self-pay>|<Self-pay>|<Self-pay>|415.00|FSC: 46100; BFG: 52|||415.00|FSC: 46100; BFG: 52|228.25|
11900|EAP|CPT® 11900||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Injection, Intralesional, Up To And Including 7 Lesions|1|<Self-pay>|<Self-pay>|<Self-pay>|85.00|FSC: 46100; BFG: 52|||85.00|FSC: 46100; BFG: 52|46.75|
12001|EAP|CPT® 12001||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Repr Superf Wnd Body </= 2.5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|190.00|FSC: 46100; BFG: 52|||190.00|FSC: 46100; BFG: 52|104.50|
12002|EAP|CPT® 12002|||Pr Repr Superf Wnd Body 2.6-7.5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|205.00|FSC: 46100; BFG: 52|||205.00|FSC: 46100; BFG: 52|112.75|
12004|EAP|CPT® 12004||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Repr Superf Wnd Body 7.6-12.5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|240.00|FSC: 46100; BFG: 52|||240.00|FSC: 46100; BFG: 52|132.00|
12011|EAP|CPT® 12011||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Repr Superf Wnd Face </= 2.5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|200.00|FSC: 46100; BFG: 52|||200.00|FSC: 46100; BFG: 52|110.00|
12013|EAP|CPT® 12013||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Repr Superf Wnd Face 2.6-5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|225.00|FSC: 46100; BFG: 52|||225.00|FSC: 46100; BFG: 52|123.75|
12032|EAP|CPT® 12032|||Pr Layr Clos Wnd Trunk,arm,leg 2.6-7.5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|440.00|FSC: 46100; BFG: 52|||440.00|FSC: 46100; BFG: 52|242.00|
12034|EAP|CPT® 12034||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Layr Clos Wnd Trunk,arm,leg 7.6-12.5|1|<Self-pay>|<Self-pay>|<Self-pay>|460.00|FSC: 46100; BFG: 52|||460.00|FSC: 46100; BFG: 52|253.00|
12037|EAP|CPT® 12037|||Pr Layr Clos Wnd Trunk,arm,leg >30cm|1|<Self-pay>|<Self-pay>|<Self-pay>|704.00|FSC: 46100; BFG: 52|||704.00|FSC: 46100; BFG: 52|387.20|
12041|EAP|CPT® 12041||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Layr Clos Wnd Rest Body </= 2.5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|355.00|FSC: 46100; BFG: 52|||355.00|FSC: 46100; BFG: 52|195.25|
12051|EAP|CPT® 12051||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Layr Clos Wnd Face,facial </= 2.5cm|1|<Self-pay>|<Self-pay>|<Self-pay>|380.00|FSC: 46100; BFG: 52|||380.00|FSC: 46100; BFG: 52|209.00|
13131|EAP|CPT® 13131|||Pr Repr Cmpl Wnd Head,fac,hand,foot 1.1-2.5|1|<Self-pay>|<Self-pay>|<Self-pay>|610.00|FSC: 46100; BFG: 52|||610.00|FSC: 46100; BFG: 52|335.50|
16020|EAP|CPT® 16020||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Dress/debrid Small Burn <5%tbsa|1|<Self-pay>|<Self-pay>|<Self-pay>|120.00|FSC: 46100; BFG: 52|||120.00|FSC: 46100; BFG: 52|66.00|
17110|EAP|CPT® 17110||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Destruc Benign Lesion, Up To 14 Lesions|1|<Self-pay>|<Self-pay>|<Self-pay>|161.00|FSC: 46100; BFG: 52|||161.00|FSC: 46100; BFG: 52|88.55|
17250|EAP|CPT® 17250||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|CHEMICAL CAUTERIZATION OF GRANULATION TISSUE|1|<Self-pay>|<Self-pay>|<Self-pay>|120.00|FSC: 46100; BFG: 52|||120.00|FSC: 46100; BFG: 52|66.00|
19125|EAP|CPT® 19125|||Pr Excise Breast Les W Xray Marker|1|<Self-pay>|<Self-pay>|<Self-pay>|930.00|FSC: 46100; BFG: 52|||930.00|FSC: 46100; BFG: 52|511.50|
20103|EAP|CPT® 20103|||Pr Explore Wound,extremity|1|<Self-pay>|<Self-pay>|<Self-pay>|865.00|FSC: 46100; BFG: 52|||865.00|FSC: 46100; BFG: 52|475.75|
20525|EAP|CPT® 20525||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Removal Of Foreign Body Deep/complica|1|<Self-pay>|<Self-pay>|<Self-pay>|705.00|FSC: 46100; BFG: 52|||705.00|FSC: 46100; BFG: 52|387.75|
20526|EAP|CPT® 20526|||Pr Inject Carpal Tunnel|1|<Self-pay>|<Self-pay>|<Self-pay>|115.00|FSC: 46100; BFG: 52|||115.00|FSC: 46100; BFG: 52|63.25|
20550|EAP|CPT® 20550||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Inject Tendon Sheath/ligament|1|<Self-pay>|<Self-pay>|<Self-pay>|130.00|FSC: 46100; BFG: 52|||130.00|FSC: 46100; BFG: 52|71.50|
20551|EAP|CPT® 20551|||Pr Inject Tendon Origin/insert|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|FSC: 46100; BFG: 52|||125.00|FSC: 46100; BFG: 52|68.75|
20552|EAP|CPT® 20552||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Inject Trigger Point,si/mult, 1-2 Musc|1|<Self-pay>|<Self-pay>|<Self-pay>|120.00|FSC: 46100; BFG: 52|||120.00|FSC: 46100; BFG: 52|66.00|
20553|EAP|CPT® 20553|||Pr Inject Trigger Points,si/mult,3+musc|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|FSC: 46100; BFG: 52|||125.00|FSC: 46100; BFG: 52|68.75|
20600|EAP|CPT® 20600||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US|1|<Self-pay>|<Self-pay>|<Self-pay>|100.00|FSC: 46100; BFG: 52|||100.00|FSC: 46100; BFG: 52|55.00|
20605|EAP|CPT® 20605|||ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|FSC: 46100; BFG: 52|||110.00|FSC: 46100; BFG: 52|60.50|
20610|EAP|CPT® 20610||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US|1|<Self-pay>|<Self-pay>|<Self-pay>|155.00|FSC: 46100; BFG: 52|||155.00|FSC: 46100; BFG: 52|85.25|
20680|EAP|CPT® 20680|||Pr Removal Deep Implant|1|<Self-pay>|<Self-pay>|<Self-pay>|930.00|FSC: 46100; BFG: 52|||930.00|FSC: 46100; BFG: 52|511.50|
20692|EAP|CPT® 20692|||Pr Apply Bone Multiplan,ext Fix Dev|1|<Self-pay>|<Self-pay>|<Self-pay>|1,715.00|FSC: 46100; BFG: 52|||1,715.00|FSC: 46100; BFG: 52|943.25|
23120|EAP|CPT® 23120|||Pr Partial Removal, Clavicle|1|<Self-pay>|<Self-pay>|<Self-pay>|868.00|FSC: 46100; BFG: 52|||868.00|FSC: 46100; BFG: 52|477.40|
23500|EAP|CPT® 23500||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Closed Tx Clavicle Fracture W/o Manip|1|<Self-pay>|<Self-pay>|<Self-pay>|321.00|FSC: 46100; BFG: 52|||321.00|FSC: 46100; BFG: 52|176.55|
23650|EAP|CPT® 23650||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Closed Rx Shldr Dislocation|1|<Self-pay>|<Self-pay>|<Self-pay>|463.00|FSC: 46100; BFG: 52|||463.00|FSC: 46100; BFG: 52|254.65|
23655|EAP|CPT® 23655|||Pr Closed Rx Shldr Disloc,anesthesia|1|<Self-pay>|<Self-pay>|<Self-pay>|594.00|FSC: 46100; BFG: 52|||594.00|FSC: 46100; BFG: 52|326.70|
24075|EAP|CPT® 24075|||Pr Exc Tumor Soft Tiss Upper Arm/elbow Subq <3cm|1|<Self-pay>|<Self-pay>|<Self-pay>|735.00|FSC: 46100; BFG: 52|||735.00|FSC: 46100; BFG: 52|404.25|
24640|EAP|CPT® 24640||0521 - FREE-STANDING CLINIC - CLINIC VISIT BY MEMBER TO RHC/FQHC|Pr Closed Rx Radial Head Disloc,child|1|<Self-pay>|<Self-pay>|<Self-pay>|146.00|FSC: 46100; BFG: 52|||146.00|FSC: 46100; BFG: 52|80.30|
25111|EAP|CPT® 25111|||Pr Excis Primary Ganglion Wrist|1|<Self-pay>|<Self-pay>|<Self-pay>|495.00|FSC: 46100; BFG: 52|||495.00|FSC: 46100; BFG: 52|272.25|
25565|EAP|CPT® 25565|||Pr Closed Rx Rad/ulna Shaft Fx,manip|1|<Self-pay>|<Self-pay>|<Self-pay>|761.00|FSC: 46100; BFG: 52|||761.00|FSC: 46100; BFG: 52|418.55|
25176|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SEALER-LIGASURE CURVER SMALL JAW|1|<Self-pay>|<Self-pay>|<Self-pay>|1,200.63|Inv Loc: 4006001; OR Loc: 4006001|||1,200.63|Inv Loc: 4006001; OR Loc: 4006001|660.35|
25175|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SEALER-LAP BLUNG TIP|1|<Self-pay>|<Self-pay>|<Self-pay>|1,339.38|Inv Loc: 4006001; OR Loc: 4006001|||1,339.38|Inv Loc: 4006001; OR Loc: 4006001|736.66|
25176|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SEALER - LIGASURE CURVED SMALL JAW|1|<Self-pay>|<Self-pay>|<Self-pay>|1,018.90|Inv Loc: 4006001; OR Loc: 4006001|||1,018.90|Inv Loc: 4006001; OR Loc: 4006001|560.39|
25178|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-SCP 2/ACCUPORT SIDE-DELIVERY 11GA|1|<Self-pay>|<Self-pay>|<Self-pay>|5,900.00|Inv Loc: 4006001; OR Loc: 4006001|||5,900.00|Inv Loc: 4006001; OR Loc: 4006001|3,245.00|
25205|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|APPLIER CLIP AUTO ENDO 5CLIP|1|<Self-pay>|<Self-pay>|<Self-pay>|620.00|Inv Loc: 4006001; OR Loc: 4006001|||620.00|Inv Loc: 4006001; OR Loc: 4006001|341.00|
25184|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PROGRIP MESH 15X10CM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,048.24|Inv Loc: 4006001; OR Loc: 4006001|||1,048.24|Inv Loc: 4006001; OR Loc: 4006001|576.53|
25175|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SEALER LIGASURE BLUNT TIP|1|<Self-pay>|<Self-pay>|<Self-pay>|1,018.90|Inv Loc: 4006001; OR Loc: 4006001|||1,018.90|Inv Loc: 4006001; OR Loc: 4006001|560.39|
25177|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SEALER LIGASURE CURVED LARGE JAW OPEN|1|<Self-pay>|<Self-pay>|<Self-pay>|1,300.40|Inv Loc: 4006001; OR Loc: 4006001|||1,300.40|Inv Loc: 4006001; OR Loc: 4006001|715.22|
25179|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOE JOINT POROUS COATED SM|1|<Self-pay>|<Self-pay>|<Self-pay>|2,500.00|Inv Loc: 4006001; OR Loc: 4006001|||2,500.00|Inv Loc: 4006001; OR Loc: 4006001|1,375.00|
25180|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOE JOINT POROUS COATED MS|1|<Self-pay>|<Self-pay>|<Self-pay>|2,500.00|Inv Loc: 4006001; OR Loc: 4006001|||2,500.00|Inv Loc: 4006001; OR Loc: 4006001|1,375.00|
25181|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOE JOINT POROUS COATED MD|1|<Self-pay>|<Self-pay>|<Self-pay>|2,500.00|Inv Loc: 4006001; OR Loc: 4006001|||2,500.00|Inv Loc: 4006001; OR Loc: 4006001|1,375.00|
25182|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOE JOINT POROUS COATED ML|1|<Self-pay>|<Self-pay>|<Self-pay>|2,500.00|Inv Loc: 4006001; OR Loc: 4006001|||2,500.00|Inv Loc: 4006001; OR Loc: 4006001|1,375.00|
25183|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOE JOINT POROUS COATED LG|1|<Self-pay>|<Self-pay>|<Self-pay>|2,500.00|Inv Loc: 4006001; OR Loc: 4006001|||2,500.00|Inv Loc: 4006001; OR Loc: 4006001|1,375.00|
25192|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DILATOR-BALLOON 6-7-8 EZDILATE|1|<Self-pay>|<Self-pay>|<Self-pay>|860.00|Inv Loc: 4006001; OR Loc: 4006001|||860.00|Inv Loc: 4006001; OR Loc: 4006001|473.00|
25193|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DILATOR-BALLOON 8.5-9.5-10 EZDILATE|1|<Self-pay>|<Self-pay>|<Self-pay>|860.00|Inv Loc: 4006001; OR Loc: 4006001|||860.00|Inv Loc: 4006001; OR Loc: 4006001|473.00|
25194|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DILATOR-BALLOON 11-12-13 EZDILATE|1|<Self-pay>|<Self-pay>|<Self-pay>|860.00|Inv Loc: 4006001; OR Loc: 4006001|||860.00|Inv Loc: 4006001; OR Loc: 4006001|473.00|
25195|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INFLATION DEVICE FOR EGD|1|<Self-pay>|<Self-pay>|<Self-pay>|175.00|Inv Loc: 4006001; OR Loc: 4006001|||175.00|Inv Loc: 4006001; OR Loc: 4006001|96.25|
25196|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|QUICKCLIP PRO 230CM|1|<Self-pay>|<Self-pay>|<Self-pay>|739.90|Inv Loc: 4006001; OR Loc: 4006001|||739.90|Inv Loc: 4006001; OR Loc: 4006001|406.94|
25198|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLER EHELON FLEX 60|1|<Self-pay>|<Self-pay>|<Self-pay>|1,066.38|Inv Loc: 4006001; OR Loc: 4006001|||1,066.38|Inv Loc: 4006001; OR Loc: 4006001|586.51|
25199|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|RELOAD ENDO LINEAR WHITE 60|1|<Self-pay>|<Self-pay>|<Self-pay>|960.45|Inv Loc: 4006001; OR Loc: 4006001|||960.45|Inv Loc: 4006001; OR Loc: 4006001|528.25|
25206|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|VIDEOSCOPE FLEXIBLE AMBU ASCOPE|1|<Self-pay>|<Self-pay>|<Self-pay>|914.04|Inv Loc: 4006001; OR Loc: 4006001|||914.04|Inv Loc: 4006001; OR Loc: 4006001|502.72|
25230|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE CLIPPER 3M|1|<Self-pay>|<Self-pay>|<Self-pay>|12.30|Inv Loc: 4006001; OR Loc: 4006001|||12.30|Inv Loc: 4006001; OR Loc: 4006001|6.76|
70000007|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SECURESTRAP FIXATION DEVICE 5MM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,497.45|Inv Loc: 4006001; OR Loc: 4006001|||1,497.45|Inv Loc: 4006001; OR Loc: 4006001|823.60|
70000010|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|MASK LMA SUPREME AIRWAY SZ3|1|<Self-pay>|<Self-pay>|<Self-pay>|128.45|Inv Loc: 4006001; OR Loc: 4006001|||128.45|Inv Loc: 4006001; OR Loc: 4006001|70.65|
70000011|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|MASK LMA AIRWAY SUPREME SIZE 4|1|<Self-pay>|<Self-pay>|<Self-pay>|128.45|Inv Loc: 4006001; OR Loc: 4006001|||128.45|Inv Loc: 4006001; OR Loc: 4006001|70.65|
70000012|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|MASK LMA AIRWAY SUPREME SIZE 5|1|<Self-pay>|<Self-pay>|<Self-pay>|128.45|Inv Loc: 4006001; OR Loc: 4006001|||128.45|Inv Loc: 4006001; OR Loc: 4006001|70.65|
70000019|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ON-Q INFUSION PUMP|1|<Self-pay>|<Self-pay>|<Self-pay>|777.60|Inv Loc: 4006001; OR Loc: 4006001|||777.60|Inv Loc: 4006001; OR Loc: 4006001|427.68|
70000029|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR 3.0MM ROUND FLUTED 5120-10-30|1|<Self-pay>|<Self-pay>|<Self-pay>|358.70|Inv Loc: 4006001; OR Loc: 4006001|||358.70|Inv Loc: 4006001; OR Loc: 4006001|197.28|
70000030|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING SILVERLON 4IN X 8IN|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|Inv Loc: 4006001; OR Loc: 4006001|||125.00|Inv Loc: 4006001; OR Loc: 4006001|68.75|
70000031|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING SILVERLON 4IN X 11IN|1|<Self-pay>|<Self-pay>|<Self-pay>|167.50|Inv Loc: 4006001; OR Loc: 4006001|||167.50|Inv Loc: 4006001; OR Loc: 4006001|92.12|
70000038|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPONGE SURGIFOAM GELATIN 8CMX12.5CMX1CM SIZE 100|1|<Self-pay>|<Self-pay>|<Self-pay>|103.85|Inv Loc: 4006001; OR Loc: 4006001|||103.85|Inv Loc: 4006001; OR Loc: 4006001|57.12|
70000041|SUP|Custom 27000001||0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION|ENDOSCOPIC TATTOO 5ML|1|<Self-pay>|<Self-pay>|<Self-pay>|190.00|Inv Loc: 4006001; OR Loc: 4006001|||190.00|Inv Loc: 4006001; OR Loc: 4006001|104.50|
70000045|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|AUTOPLEX WITH VERAPLEX HV|1|<Self-pay>|<Self-pay>|<Self-pay>|1,612.00|Inv Loc: 4006001; OR Loc: 4006001|||1,612.00|Inv Loc: 4006001; OR Loc: 4006001|886.60|
70000046|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|IVAS 13G 15MM BALLOON KIT|1|<Self-pay>|<Self-pay>|<Self-pay>|3,333.32|Inv Loc: 4006001; OR Loc: 4006001|||3,333.32|Inv Loc: 4006001; OR Loc: 4006001|1,833.33|
70000047|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|13G IVAS DRILL|1|<Self-pay>|<Self-pay>|<Self-pay>|750.00|Inv Loc: 4006001; OR Loc: 4006001|||750.00|Inv Loc: 4006001; OR Loc: 4006001|412.50|
70000048|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|13G IVAS BONE BIOPSY|1|<Self-pay>|<Self-pay>|<Self-pay>|507.70|Inv Loc: 4006001; OR Loc: 4006001|||507.70|Inv Loc: 4006001; OR Loc: 4006001|279.23|
70000074|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAIN CHEST DRY SUCTION|1|<Self-pay>|<Self-pay>|<Self-pay>|158.60|Inv Loc: 4006001; OR Loc: 4006001|||158.60|Inv Loc: 4006001; OR Loc: 4006001|87.23|
70000075|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY THORACENTESIS SAFETY|1|<Self-pay>|<Self-pay>|<Self-pay>|283.15|Inv Loc: 4006001; OR Loc: 4006001|||283.15|Inv Loc: 4006001; OR Loc: 4006001|155.73|
70000076|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY THORACIC VENT|1|<Self-pay>|<Self-pay>|<Self-pay>|684.00|Inv Loc: 4006001; OR Loc: 4006001|||684.00|Inv Loc: 4006001; OR Loc: 4006001|376.20|
70000087|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HANDPIECE MINERVA|1|<Self-pay>|<Self-pay>|<Self-pay>|2,100.00|Inv Loc: 4006001; OR Loc: 4006001|||2,100.00|Inv Loc: 4006001; OR Loc: 4006001|1,155.00|
70000098|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PLEURX DRAINAGE KIT 1000ML|1|<Self-pay>|<Self-pay>|<Self-pay>|339.80|Inv Loc: 4006001; OR Loc: 4006001|||339.80|Inv Loc: 4006001; OR Loc: 4006001|186.89|
70000099|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ENDO STITCH SURGIDAC 2-0|1|<Self-pay>|<Self-pay>|<Self-pay>|775.20|Inv Loc: 4006001; OR Loc: 4006001|||775.20|Inv Loc: 4006001; OR Loc: 4006001|426.36|
70000100|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ENDO STITCH SURGIDAC 0|1|<Self-pay>|<Self-pay>|<Self-pay>|775.20|Inv Loc: 4006001; OR Loc: 4006001|||775.20|Inv Loc: 4006001; OR Loc: 4006001|426.36|
70000106|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLIP RESOLUTION|1|<Self-pay>|<Self-pay>|<Self-pay>|818.31|Inv Loc: 4006001; OR Loc: 4006001|||818.31|Inv Loc: 4006001; OR Loc: 4006001|450.07|
70000115|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET PERICARDIOCENTESIS G02433|1|<Self-pay>|<Self-pay>|<Self-pay>|530.00|Inv Loc: 4006001; OR Loc: 4006001|||530.00|Inv Loc: 4006001; OR Loc: 4006001|291.50|
70000116|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT CRICOTHYROTOMY 100/465/060|1|<Self-pay>|<Self-pay>|<Self-pay>|637.25|Inv Loc: 4006001; OR Loc: 4006001|||637.25|Inv Loc: 4006001; OR Loc: 4006001|350.49|
70000121|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KII DISSECTING BALLOON SYSTEM OVAL-AF|1|<Self-pay>|<Self-pay>|<Self-pay>|1,050.00|Inv Loc: 4006001; OR Loc: 4006001|||1,050.00|Inv Loc: 4006001; OR Loc: 4006001|577.50|
70000126|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEPS-GRASPING FORCEPS/RETRIEVAL BASKET FG-54D|1|<Self-pay>|<Self-pay>|<Self-pay>|643.44|Inv Loc: 4006001; OR Loc: 4006001|||643.44|Inv Loc: 4006001; OR Loc: 4006001|353.89|
70000132|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RELOAD PROXIMATE 75MM LINEAR GREEN|1|<Self-pay>|<Self-pay>|<Self-pay>|342.50|Inv Loc: 4006001; OR Loc: 4006001|||342.50|Inv Loc: 4006001; OR Loc: 4006001|188.37|
70000146|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEP BIOPSY DISP FB-231D|1|<Self-pay>|<Self-pay>|<Self-pay>|117.85|Inv Loc: 4006001; OR Loc: 4006001|||117.85|Inv Loc: 4006001; OR Loc: 4006001|64.82|
70000172|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY PERICARDIOCENTESIS CATHETER TRAY|1|<Self-pay>|<Self-pay>|<Self-pay>|627.00|Inv Loc: 4006001; OR Loc: 4006001|||627.00|Inv Loc: 4006001; OR Loc: 4006001|344.85|
70000173|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET MELKER EMERGENCY CUFFED CRICOTHYROTOMY CATHETER|1|<Self-pay>|<Self-pay>|<Self-pay>|675.00|Inv Loc: 4006001; OR Loc: 4006001|||675.00|Inv Loc: 4006001; OR Loc: 4006001|371.25|
70000174|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR OPTICAL RPF 5-12MM VISIPORT PLUS W/SLEEVE|1|<Self-pay>|<Self-pay>|<Self-pay>|309.15|Inv Loc: 4006001; OR Loc: 4006001|||309.15|Inv Loc: 4006001; OR Loc: 4006001|170.03|
70000192|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|MOSS GASTROSTOMY TUBE 18FR|1|<Self-pay>|<Self-pay>|<Self-pay>|765.00|Inv Loc: 4006001; OR Loc: 4006001|||765.00|Inv Loc: 4006001; OR Loc: 4006001|420.75|
70000194|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE EXCELON BRONCHIAL ASPIRATION NEEDLE 19G|1|<Self-pay>|<Self-pay>|<Self-pay>|558.95|Inv Loc: 4006001; OR Loc: 4006001|||558.95|Inv Loc: 4006001; OR Loc: 4006001|307.42|
70000195|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE EXCELON BRONCHIAL ASPIRATION NEEDLE 21G|1|<Self-pay>|<Self-pay>|<Self-pay>|558.95|Inv Loc: 4006001; OR Loc: 4006001|||558.95|Inv Loc: 4006001; OR Loc: 4006001|307.42|
70000203|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CERVICAL BALLOON W/STYLET COOK|1|<Self-pay>|<Self-pay>|<Self-pay>|208.75|Inv Loc: 4006001; OR Loc: 4006001|||208.75|Inv Loc: 4006001; OR Loc: 4006001|114.81|
70000226|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE ONESTEP COMPLETE RESUSCITATION|1|<Self-pay>|<Self-pay>|<Self-pay>|344.00|Inv Loc: 4006001; OR Loc: 4006001|||344.00|Inv Loc: 4006001; OR Loc: 4006001|189.20|
70000227|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE ONESTEP PEDIATRIC CPR|1|<Self-pay>|<Self-pay>|<Self-pay>|325.00|Inv Loc: 4006001; OR Loc: 4006001|||325.00|Inv Loc: 4006001; OR Loc: 4006001|178.75|
70000262|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SURGIFOAM ABSORBABLE GELATIN SPONGE|1|<Self-pay>|<Self-pay>|<Self-pay>|103.85|Inv Loc: 4006001; OR Loc: 4006001|||103.85|Inv Loc: 4006001; OR Loc: 4006001|57.12|
70000283|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEPS GRASPING 3FR SPIRAL BASKET DISPOSABLE|1|<Self-pay>|<Self-pay>|<Self-pay>|604.11|Inv Loc: 4006001; OR Loc: 4006001|||604.11|Inv Loc: 4006001; OR Loc: 4006001|332.26|
70000294|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE ANCHOR NANO CORKSCREW|1|<Self-pay>|<Self-pay>|<Self-pay>|4,250.00|Inv Loc: 4006001; OR Loc: 4006001|||4,250.00|Inv Loc: 4006001; OR Loc: 4006001|2,337.50|
70000298|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|FIBERLOOP 4-0 10" WHITE W/TAPERED NEEDLE, 12.7MM 1/2 CIRCLE|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
70000318|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DISPOSABLE BALLOON CATHETER (B5-2C)|1|<Self-pay>|<Self-pay>|<Self-pay>|560.60|Inv Loc: 4006001; OR Loc: 4006001|||560.60|Inv Loc: 4006001; OR Loc: 4006001|308.33|
70000323|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FLEXSEAL FMS SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|806.94|Inv Loc: 4006001; OR Loc: 4006001|||806.94|Inv Loc: 4006001; OR Loc: 4006001|443.82|
70000328|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH PROLENE 12X12 ETHICON PML|1|<Self-pay>|<Self-pay>|<Self-pay>|715.90|Inv Loc: 4006001; OR Loc: 4006001|||715.90|Inv Loc: 4006001; OR Loc: 4006001|393.74|
70000330|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH 30 X 30 CM NON-COATED POLYPROPYLENE|1|<Self-pay>|<Self-pay>|<Self-pay>|1,600.00|Inv Loc: 4006001; OR Loc: 4006001|||1,600.00|Inv Loc: 4006001; OR Loc: 4006001|880.00|
70000348|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH VICRYL 30X30 VKML|1|<Self-pay>|<Self-pay>|<Self-pay>|1,444.86|Inv Loc: 4006001; OR Loc: 4006001|||1,444.86|Inv Loc: 4006001; OR Loc: 4006001|794.67|
70000349|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KNIFE CUTTING INEGRA SAFEGUARD|1|<Self-pay>|<Self-pay>|<Self-pay>|868.30|Inv Loc: 4006001; OR Loc: 4006001|||868.30|Inv Loc: 4006001; OR Loc: 4006001|477.56|
70000350|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEPS CUTTING HALO PKS|1|<Self-pay>|<Self-pay>|<Self-pay>|1,442.82|Inv Loc: 4006001; OR Loc: 4006001|||1,442.82|Inv Loc: 4006001; OR Loc: 4006001|793.55|
70000351|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|JET-X MINI DISTAL RADIUS KIT|1|<Self-pay>|<Self-pay>|<Self-pay>|5,239.00|Inv Loc: 4006001; OR Loc: 4006001|||5,239.00|Inv Loc: 4006001; OR Loc: 4006001|2,881.45|
70000468|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER RESOLVE LOCKING DRAINAGE 10FR|1|<Self-pay>|<Self-pay>|<Self-pay>|299.25|Inv Loc: 4006001; OR Loc: 4006001|||299.25|Inv Loc: 4006001; OR Loc: 4006001|164.59|
70000490|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|COMMON BILE DUCT EXPLORATION SET|1|<Self-pay>|<Self-pay>|<Self-pay>|1,905.50|Inv Loc: 4006001; OR Loc: 4006001|||1,905.50|Inv Loc: 4006001; OR Loc: 4006001|1,048.02|
70000530|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PLASMA LOOP MEDIUM 12|1|<Self-pay>|<Self-pay>|<Self-pay>|1,322.88|Inv Loc: 4006001; OR Loc: 4006001|||1,322.88|Inv Loc: 4006001; OR Loc: 4006001|727.58|
70000523|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PLASMA BAND 12|1|<Self-pay>|<Self-pay>|<Self-pay>|1,322.88|Inv Loc: 4006001; OR Loc: 4006001|||1,322.88|Inv Loc: 4006001; OR Loc: 4006001|727.58|
70000524|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PLASMA BUTTON|1|<Self-pay>|<Self-pay>|<Self-pay>|1,380.00|Inv Loc: 4006001; OR Loc: 4006001|||1,380.00|Inv Loc: 4006001; OR Loc: 4006001|759.00|
70000525|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PLASMA OVAL BUTTON|1|<Self-pay>|<Self-pay>|<Self-pay>|1,093.50|Inv Loc: 4006001; OR Loc: 4006001|||1,093.50|Inv Loc: 4006001; OR Loc: 4006001|601.42|
70000526|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PLASMA ROLLER|1|<Self-pay>|<Self-pay>|<Self-pay>|1,322.88|Inv Loc: 4006001; OR Loc: 4006001|||1,322.88|Inv Loc: 4006001; OR Loc: 4006001|727.58|
70000566|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ENDOSCOPIC SUTURE DEVICE ENDO STITCH 10MM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,085.40|Inv Loc: 4006001; OR Loc: 4006001|||1,085.40|Inv Loc: 4006001; OR Loc: 4006001|596.97|
70000627|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 10FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000628|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 12FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000629|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 14FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000630|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 16FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000631|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 18FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000632|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 20FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000633|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 22FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000634|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER DILATATION HEYMAN FOLLOWER 24FR|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
70000638|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE BUGBEE 5FR 58CM LONG BE-558|1|<Self-pay>|<Self-pay>|<Self-pay>|346.15|Inv Loc: 4006001; OR Loc: 4006001|||346.15|Inv Loc: 4006001; OR Loc: 4006001|190.38|
70000680|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NCIRCLE TIPLESS STONE EXTRACTOR 2.2Fr. X 115CM|1|<Self-pay>|<Self-pay>|<Self-pay>|634.26|Inv Loc: 4006001; OR Loc: 4006001|||634.26|Inv Loc: 4006001; OR Loc: 4006001|348.84|
70000681|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NGAGE NITINOL STONE EXTRACTOR 1.7Fr. X 115CM|1|<Self-pay>|<Self-pay>|<Self-pay>|707.13|Inv Loc: 4006001; OR Loc: 4006001|||707.13|Inv Loc: 4006001; OR Loc: 4006001|388.92|
70000682|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BASKET UROLOGICAL TIPLESS 115cm 4 wire 1.5fr Nitinol 10mm DISPOSABLE NCIRCLE|1|<Self-pay>|<Self-pay>|<Self-pay>|716.13|Inv Loc: 4006001; OR Loc: 4006001|||716.13|Inv Loc: 4006001; OR Loc: 4006001|393.87|
70000683|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Basket Urological Tipless 115cm 4 wire 2.5fr Nitinol 10mm di|1|<Self-pay>|<Self-pay>|<Self-pay>|707.13|Inv Loc: 4006001; OR Loc: 4006001|||707.13|Inv Loc: 4006001; OR Loc: 4006001|388.92|
70000684|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Motion PTFE-Nitinol Hybrid Guidewire .038 150cm Straight 3cm|1|<Self-pay>|<Self-pay>|<Self-pay>|319.50|Inv Loc: 4006001; OR Loc: 4006001|||319.50|Inv Loc: 4006001; OR Loc: 4006001|175.72|
70000685|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|Motion PTFE-Nitinol Hybrid Guidewire .035 150cm Straight 3cm|1|<Self-pay>|<Self-pay>|<Self-pay>|319.50|Inv Loc: 4006001; OR Loc: 4006001|||319.50|Inv Loc: 4006001; OR Loc: 4006001|175.72|
70000686|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HIWIRE NITINOL CORE WIRE GUIDE WITH HYDROPHILIC COATING .035|1|<Self-pay>|<Self-pay>|<Self-pay>|165.55|Inv Loc: 4006001; OR Loc: 4006001|||165.55|Inv Loc: 4006001; OR Loc: 4006001|91.05|
70000687|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HIWIRE NITINOL CORE WIRE GUIDE WITH HYDROPHILIC COATING .035|1|<Self-pay>|<Self-pay>|<Self-pay>|167.85|Inv Loc: 4006001; OR Loc: 4006001|||167.85|Inv Loc: 4006001; OR Loc: 4006001|92.32|
70000688|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 6french X 20 cm|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000689|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 6french X 22 cm|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000690|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 6french X 24 cm|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000691|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 6french X 26 cm|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000692|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 6french X 28 cm|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000693|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 6french X 30 cm|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000694|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 6FRENCH MULTILENGTH|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000695|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 5FRENCH X 24CM|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000696|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|UNIVERSA FIRM URETERAL STENT SET 5FRENCH X 26CM|1|<Self-pay>|<Self-pay>|<Self-pay>|300.80|Inv Loc: 4006001; OR Loc: 4006001|||300.80|Inv Loc: 4006001; OR Loc: 4006001|165.44|
70000697|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AQ LONG TAPER URETERAL DILATOR 6-12FR 60CM|1|<Self-pay>|<Self-pay>|<Self-pay>|106.60|Inv Loc: 4006001; OR Loc: 4006001|||106.60|Inv Loc: 4006001; OR Loc: 4006001|58.63|
70000698|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|URETERAL DILATOR SET 6FR-18FR 60CM DILATORS WITH AQ HYDROPHI|1|<Self-pay>|<Self-pay>|<Self-pay>|871.55|Inv Loc: 4006001; OR Loc: 4006001|||871.55|Inv Loc: 4006001; OR Loc: 4006001|479.35|
70000699|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AMPLATZ RENAL DILATOR SET|1|<Self-pay>|<Self-pay>|<Self-pay>|660.93|Inv Loc: 4006001; OR Loc: 4006001|||660.93|Inv Loc: 4006001; OR Loc: 4006001|363.51|
70000700|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DUAL LUMEN URETERAL CATHETER 10FR 50CM|1|<Self-pay>|<Self-pay>|<Self-pay>|170.10|Inv Loc: 4006001; OR Loc: 4006001|||170.10|Inv Loc: 4006001; OR Loc: 4006001|93.55|
70000701|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FLEXOR URETERAL ACCESS SHEATH 12FR 28CM WITH AQ HYDROPHILIC|1|<Self-pay>|<Self-pay>|<Self-pay>|665.90|Inv Loc: 4006001; OR Loc: 4006001|||665.90|Inv Loc: 4006001; OR Loc: 4006001|366.24|
70000702|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FLEXOR URETERAL ACCESS SHEATH 12FR 35CM WITH AQ HYDROPHILIC|1|<Self-pay>|<Self-pay>|<Self-pay>|665.90|Inv Loc: 4006001; OR Loc: 4006001|||665.90|Inv Loc: 4006001; OR Loc: 4006001|366.24|
70000703|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FLEXOR URETERAL ACCESS SHEATH 12FR 45CM WITH AQ HYDROPHILIC|1|<Self-pay>|<Self-pay>|<Self-pay>|665.90|Inv Loc: 4006001; OR Loc: 4006001|||665.90|Inv Loc: 4006001; OR Loc: 4006001|366.24|
70000706|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CUP BIOPSY FORCEPS 3FR 115CM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,006.44|Inv Loc: 4006001; OR Loc: 4006001|||1,006.44|Inv Loc: 4006001; OR Loc: 4006001|553.54|
70000707|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ULTRAXX NEPHROSTOMY BALLOON SET 10MM X 15CM WITH TFE SHEATH|1|<Self-pay>|<Self-pay>|<Self-pay>|822.15|Inv Loc: 4006001; OR Loc: 4006001|||822.15|Inv Loc: 4006001; OR Loc: 4006001|452.18|
70000708|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|COOK QUANTA OPTICAL FIBER 272 UM - SINGLE USE|1|<Self-pay>|<Self-pay>|<Self-pay>|701.25|Inv Loc: 4006001; OR Loc: 4006001|||701.25|Inv Loc: 4006001; OR Loc: 4006001|385.69|
70000709|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|COOK QUANTA OPTICAL FIBER 200UM - SINGLE USE|1|<Self-pay>|<Self-pay>|<Self-pay>|701.25|Inv Loc: 4006001; OR Loc: 4006001|||701.25|Inv Loc: 4006001; OR Loc: 4006001|385.69|
70000710|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|COOK QUANTA OPTICAL FIBER 365UM - SINGLE USE|1|<Self-pay>|<Self-pay>|<Self-pay>|825.00|Inv Loc: 4006001; OR Loc: 4006001|||825.00|Inv Loc: 4006001; OR Loc: 4006001|453.75|
70000711|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|COOK QUANTA OPTICAL FIBER 1000UM - SINGLE USE|1|<Self-pay>|<Self-pay>|<Self-pay>|1,140.70|Inv Loc: 4006001; OR Loc: 4006001|||1,140.70|Inv Loc: 4006001; OR Loc: 4006001|627.38|
70000737|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FULGUR ELECTRODE SHORT TIP 105CM|1|<Self-pay>|<Self-pay>|<Self-pay>|511.00|Inv Loc: 4006001; OR Loc: 4006001|||511.00|Inv Loc: 4006001; OR Loc: 4006001|281.05|
70000742|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOCKPULSE PROBE 3.76MM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,389.72|Inv Loc: 4006001; OR Loc: 4006001|||1,389.72|Inv Loc: 4006001; OR Loc: 4006001|764.35|
70000747|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TEMPLATES 17G UA2006|1|<Self-pay>|<Self-pay>|<Self-pay>|261.00|Inv Loc: 4006001; OR Loc: 4006001|||261.00|Inv Loc: 4006001; OR Loc: 4006001|143.55|
70000753|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KNIFE LANCET OLYMPUS A3555|1|<Self-pay>|<Self-pay>|<Self-pay>|655.77|Inv Loc: 4006001; OR Loc: 4006001|||655.77|Inv Loc: 4006001; OR Loc: 4006001|360.67|
70000754|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KNIFE SEMI CIRCULAR A3558|1|<Self-pay>|<Self-pay>|<Self-pay>|655.77|Inv Loc: 4006001; OR Loc: 4006001|||655.77|Inv Loc: 4006001; OR Loc: 4006001|360.67|
25249|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|IRRISEPT DEVICE JET LAVAGE|1|<Self-pay>|<Self-pay>|<Self-pay>|308.25|Inv Loc: 4006001; OR Loc: 4006001|||308.25|Inv Loc: 4006001; OR Loc: 4006001|169.54|
70001043|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SCOPE CLEARIFY VISUALIZATION SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|95.04|Inv Loc: 4006001; OR Loc: 4006001|||95.04|Inv Loc: 4006001; OR Loc: 4006001|52.27|
70000679|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INJETAK CYSTOSCOPY NEEDLE 70CM|1|<Self-pay>|<Self-pay>|<Self-pay>|158.63|Inv Loc: 4006001; OR Loc: 4006001|||158.63|Inv Loc: 4006001; OR Loc: 4006001|87.25|
70001123|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PAD POSITIONING SYSTEM PINK|1|<Self-pay>|<Self-pay>|<Self-pay>|465.53|Inv Loc: 4006001; OR Loc: 4006001|||465.53|Inv Loc: 4006001; OR Loc: 4006001|256.04|
70001124|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE FIBERWIRE 3 AR 7227 01|1|<Self-pay>|<Self-pay>|<Self-pay>|49.50|Inv Loc: 4006001; OR Loc: 4006001|||49.50|Inv Loc: 4006001; OR Loc: 4006001|27.22|
70001136|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RETRACTOR O SMALL ALEXIS C8401|1|<Self-pay>|<Self-pay>|<Self-pay>|121.50|Inv Loc: 4006001; OR Loc: 4006001|||121.50|Inv Loc: 4006001; OR Loc: 4006001|66.82|
70001141|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ARTERIOCYTE BMA|1|<Self-pay>|<Self-pay>|<Self-pay>|4,050.00|Inv Loc: 4006001; OR Loc: 4006001|||4,050.00|Inv Loc: 4006001; OR Loc: 4006001|2,227.50|
70001150|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NGAGE NITINOL STONE EXTRACTOR 2.2Fr. X 115CM|1|<Self-pay>|<Self-pay>|<Self-pay>|463.79|Inv Loc: 4006001; OR Loc: 4006001|||463.79|Inv Loc: 4006001; OR Loc: 4006001|255.08|
70001108|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPACEOAR HYDROGEL SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|7,346.25|Inv Loc: 4006001; OR Loc: 4006001|||7,346.25|Inv Loc: 4006001; OR Loc: 4006001|4,040.44|
70000927|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE VISICOIL PLATINUM 18GA 20CM TWIN LINE MR|1|<Self-pay>|<Self-pay>|<Self-pay>|582.75|Inv Loc: 4006001; OR Loc: 4006001|||582.75|Inv Loc: 4006001; OR Loc: 4006001|320.51|
70000928|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE VISICOIL PLATINUM 19GS 20CM|1|<Self-pay>|<Self-pay>|<Self-pay>|312.75|Inv Loc: 4006001; OR Loc: 4006001|||312.75|Inv Loc: 4006001; OR Loc: 4006001|172.01|
70001104|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FIBER STRIPPER QUA-2004|1|<Self-pay>|<Self-pay>|<Self-pay>|248.18|Inv Loc: 4006001; OR Loc: 4006001|||248.18|Inv Loc: 4006001; OR Loc: 4006001|136.50|
70001105|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FIBER STRIPPER QUA-2005|1|<Self-pay>|<Self-pay>|<Self-pay>|248.18|Inv Loc: 4006001; OR Loc: 4006001|||248.18|Inv Loc: 4006001; OR Loc: 4006001|136.50|
70000767|SUP|HCPCS C1758||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET DILATOR CATHETER 5FR L65CM BALLOON 34CM|1|<Self-pay>|<Self-pay>|<Self-pay>|704.40|Inv Loc: 4006001; OR Loc: 4006001|||704.40|Inv Loc: 4006001; OR Loc: 4006001|387.42|
70000780|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY SUPRAPUBIC 14G BONANNO CATHETER|1|<Self-pay>|<Self-pay>|<Self-pay>|389.75|Inv Loc: 4006001; OR Loc: 4006001|||389.75|Inv Loc: 4006001; OR Loc: 4006001|214.36|
70000788|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CEMENT BONE VOID FILLER 10ML|1|<Self-pay>|<Self-pay>|<Self-pay>|4,158.00|Inv Loc: 4006001; OR Loc: 4006001|||4,158.00|Inv Loc: 4006001; OR Loc: 4006001|2,286.90|
70000789|SUP|HCPCS C1820||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM MICROSURESCAN MRI RECHARGEABLE NEUROSTEIMLULATOR|1|<Self-pay>|<Self-pay>|<Self-pay>|23,360.00|Inv Loc: 4006001; OR Loc: 4006001|||23,360.00|Inv Loc: 4006001; OR Loc: 4006001|12,848.00|
70000790|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|COMM HANDSET KIT TH90P01 GU SU PROX|1|<Self-pay>|<Self-pay>|<Self-pay>|3,900.00|Inv Loc: 4006001; OR Loc: 4006001|||3,900.00|Inv Loc: 4006001; OR Loc: 4006001|2,145.00|
70000791|SUP|HCPCS C1778||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM SURSCAN MRI LEAD KIT 2.16MM-28CM|1|<Self-pay>|<Self-pay>|<Self-pay>|9,108.00|Inv Loc: 4006001; OR Loc: 4006001|||9,108.00|Inv Loc: 4006001; OR Loc: 4006001|5,009.40|
70000792|SUP|HCPCS C1778||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM SURSCAN MRI LEAD KIT 2.16MM-33CM|1|<Self-pay>|<Self-pay>|<Self-pay>|9,108.00|Inv Loc: 4006001; OR Loc: 4006001|||9,108.00|Inv Loc: 4006001; OR Loc: 4006001|5,009.40|
70000793|SUP|HCPCS C1778||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM SURSCAN MRI LEAD KIT 2.16MM-41CM|1|<Self-pay>|<Self-pay>|<Self-pay>|9,108.00|Inv Loc: 4006001; OR Loc: 4006001|||9,108.00|Inv Loc: 4006001; OR Loc: 4006001|5,009.40|
70000794|SUP|HCPCS C1778||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM SURSCAN MRI LEAD KIT 4.32MM-28CM|1|<Self-pay>|<Self-pay>|<Self-pay>|9,108.00|Inv Loc: 4006001; OR Loc: 4006001|||9,108.00|Inv Loc: 4006001; OR Loc: 4006001|5,009.40|
70000795|SUP|HCPCS C1778||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM SURSCAN MRI LEAD KIT 4.32MM-33CM|1|<Self-pay>|<Self-pay>|<Self-pay>|9,108.00|Inv Loc: 4006001; OR Loc: 4006001|||9,108.00|Inv Loc: 4006001; OR Loc: 4006001|5,009.40|
70000796|SUP|HCPCS C1778||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM SURSCAN MRI LEAD KIT 4.32MM-41CM|1|<Self-pay>|<Self-pay>|<Self-pay>|9,108.00|Inv Loc: 4006001; OR Loc: 4006001|||9,108.00|Inv Loc: 4006001; OR Loc: 4006001|5,009.40|
70000797|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RECHARGE KIT|1|<Self-pay>|<Self-pay>|<Self-pay>|2,700.00|Inv Loc: 4006001; OR Loc: 4006001|||2,700.00|Inv Loc: 4006001; OR Loc: 4006001|1,485.00|
70000798|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BELT SIZE SMALL|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
70000799|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BELT SIZE MEDIUM|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
70000800|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BELT SIZE LARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
70000801|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BELT SIZE XLARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
70000802|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|VERIFY XTERNAL NEUROSTIMULATOR (ENS)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,200.00|Inv Loc: 4006001; OR Loc: 4006001|||1,200.00|Inv Loc: 4006001; OR Loc: 4006001|660.00|
70000803|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|REVISION KIT|1|<Self-pay>|<Self-pay>|<Self-pay>|1,185.00|Inv Loc: 4006001; OR Loc: 4006001|||1,185.00|Inv Loc: 4006001; OR Loc: 4006001|651.75|
70000804|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PERCUTANEOUS EXTERNSION CABLE FOR 2.16MM INTERSTIM|1|<Self-pay>|<Self-pay>|<Self-pay>|750.00|Inv Loc: 4006001; OR Loc: 4006001|||750.00|Inv Loc: 4006001; OR Loc: 4006001|412.50|
70000805|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PERCUTANEOUS EXTERNSION CABLE FOR 4.32MM INTERSTIM|1|<Self-pay>|<Self-pay>|<Self-pay>|750.00|Inv Loc: 4006001; OR Loc: 4006001|||750.00|Inv Loc: 4006001; OR Loc: 4006001|412.50|
70000806|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE 041839 FORAMN 5" 20GA 2PK|1|<Self-pay>|<Self-pay>|<Self-pay>|600.00|Inv Loc: 4006001; OR Loc: 4006001|||600.00|Inv Loc: 4006001; OR Loc: 4006001|330.00|
70000817|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|TISSUE REINFORCEMENT BIO-A|1|<Self-pay>|<Self-pay>|<Self-pay>|1,479.00|Inv Loc: 4006001; OR Loc: 4006001|||1,479.00|Inv Loc: 4006001; OR Loc: 4006001|813.45|
70000848|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HANDPICE AQUABEAM|1|<Self-pay>|<Self-pay>|<Self-pay>|5,000.00|Inv Loc: 4006001; OR Loc: 4006001|||5,000.00|Inv Loc: 4006001; OR Loc: 4006001|2,750.00|
70000849|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE LITHOTOMY|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
70000864|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|4-PORT WASTE MANAGEMENT MANIFOLD SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|144.80|Inv Loc: 4006001; OR Loc: 4006001|||144.80|Inv Loc: 4006001; OR Loc: 4006001|79.64|
70000899|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|BONE CHIPS CANCELLOUS 15CM 4-10MM|1|<Self-pay>|<Self-pay>|<Self-pay>|855.00|Inv Loc: 4006001; OR Loc: 4006001|||855.00|Inv Loc: 4006001; OR Loc: 4006001|470.25|
70000900|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLOSURE SKIN PRINEO DERMABOND 22CM|1|<Self-pay>|<Self-pay>|<Self-pay>|393.35|Inv Loc: 4006001; OR Loc: 4006001|||393.35|Inv Loc: 4006001; OR Loc: 4006001|216.34|
70000940|SUP|HCPCS C1767||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INTERSTIM II IPG 3058|1|<Self-pay>|<Self-pay>|<Self-pay>|23,360.00|Inv Loc: 4006001; OR Loc: 4006001|||23,360.00|Inv Loc: 4006001; OR Loc: 4006001|12,848.00|
70000941|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH 3D MID LEF MEDIUM|1|<Self-pay>|<Self-pay>|<Self-pay>|991.00|Inv Loc: 4006001; OR Loc: 4006001|||991.00|Inv Loc: 4006001; OR Loc: 4006001|545.05|
70000942|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH 3D MID LEFT LARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|630.03|Inv Loc: 4006001; OR Loc: 4006001|||630.03|Inv Loc: 4006001; OR Loc: 4006001|346.52|
70000943|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH 3D MID LEFT XLARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|695.40|Inv Loc: 4006001; OR Loc: 4006001|||695.40|Inv Loc: 4006001; OR Loc: 4006001|382.47|
70000944|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH 3D MID RIGHT MEDIUM|1|<Self-pay>|<Self-pay>|<Self-pay>|991.00|Inv Loc: 4006001; OR Loc: 4006001|||991.00|Inv Loc: 4006001; OR Loc: 4006001|545.05|
70000945|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH 3D MID LEFT LARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|630.03|Inv Loc: 4006001; OR Loc: 4006001|||630.03|Inv Loc: 4006001; OR Loc: 4006001|346.52|
70000946|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH 3D MID LEFT XLARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|695.40|Inv Loc: 4006001; OR Loc: 4006001|||695.40|Inv Loc: 4006001; OR Loc: 4006001|382.47|
70000947|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH FLAT SHEET 15X15CM|1|<Self-pay>|<Self-pay>|<Self-pay>|239.50|Inv Loc: 4006001; OR Loc: 4006001|||239.50|Inv Loc: 4006001; OR Loc: 4006001|131.72|
70000948|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH FLAT SHEET 25X35.5CM|1|<Self-pay>|<Self-pay>|<Self-pay>|410.00|Inv Loc: 4006001; OR Loc: 4006001|||410.00|Inv Loc: 4006001; OR Loc: 4006001|225.50|
70000949|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH VENTRALIGHT ECHO 2 11CM CIRCLE|1|<Self-pay>|<Self-pay>|<Self-pay>|1,188.00|Inv Loc: 4006001; OR Loc: 4006001|||1,188.00|Inv Loc: 4006001; OR Loc: 4006001|653.40|
70000950|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH VENTRALIGHT ECHO 2 10X15CM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,126.00|Inv Loc: 4006001; OR Loc: 4006001|||1,126.00|Inv Loc: 4006001; OR Loc: 4006001|619.30|
70000951|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH VENTRALIGHT ECHO 2 15CM CIRCLE|1|<Self-pay>|<Self-pay>|<Self-pay>|1,764.00|Inv Loc: 4006001; OR Loc: 4006001|||1,764.00|Inv Loc: 4006001; OR Loc: 4006001|970.20|
70000952|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH VENTRALIGHT ECHO 2 15CMX20CM|1|<Self-pay>|<Self-pay>|<Self-pay>|2,126.20|Inv Loc: 4006001; OR Loc: 4006001|||2,126.20|Inv Loc: 4006001; OR Loc: 4006001|1,169.41|
70000953|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH VENTRALIGHT ECHO 2 18X23CM|1|<Self-pay>|<Self-pay>|<Self-pay>|2,782.60|Inv Loc: 4006001; OR Loc: 4006001|||2,782.60|Inv Loc: 4006001; OR Loc: 4006001|1,530.43|
70000954|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|OPTIFIX 30 OBSORABLE FASTNER|1|<Self-pay>|<Self-pay>|<Self-pay>|1,000.00|Inv Loc: 4006001; OR Loc: 4006001|||1,000.00|Inv Loc: 4006001; OR Loc: 4006001|550.00|
70000955|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLIP APPLIER FILSHIE STERISHOT II|1|<Self-pay>|<Self-pay>|<Self-pay>|834.00|Inv Loc: 4006001; OR Loc: 4006001|||834.00|Inv Loc: 4006001; OR Loc: 4006001|458.70|
70000977|SUP|HCPCS C1771||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|LYNX SUPRAPUBIC MID-URETHRAL SLING SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|3,122.56|Inv Loc: 4006001; OR Loc: 4006001|||3,122.56|Inv Loc: 4006001; OR Loc: 4006001|1,717.41|
70000978|SUP|HCPCS L8606||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|COAPTITE IMPLANT 1ML|1|<Self-pay>|<Self-pay>|<Self-pay>|1,337.13|Inv Loc: 4006001; OR Loc: 4006001|||1,337.13|Inv Loc: 4006001; OR Loc: 4006001|735.42|
70000979|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|COAPTITE SIDEKICK NEEDLE 14.6" 21GA|1|<Self-pay>|<Self-pay>|<Self-pay>|276.00|Inv Loc: 4006001; OR Loc: 4006001|||276.00|Inv Loc: 4006001; OR Loc: 4006001|151.80|
70000980|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER SUREFORM 60 SPU IS4000|1|<Self-pay>|<Self-pay>|<Self-pay>|1,060.00|Inv Loc: 4006001; OR Loc: 4006001|||1,060.00|Inv Loc: 4006001; OR Loc: 4006001|583.00|
70000981|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RELOAD SUREFORM 60 2.5 WHITE|1|<Self-pay>|<Self-pay>|<Self-pay>|690.00|Inv Loc: 4006001; OR Loc: 4006001|||690.00|Inv Loc: 4006001; OR Loc: 4006001|379.50|
70000982|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RELOAD SUREFORM 60 3.5 BLUE|1|<Self-pay>|<Self-pay>|<Self-pay>|690.00|Inv Loc: 4006001; OR Loc: 4006001|||690.00|Inv Loc: 4006001; OR Loc: 4006001|379.50|
70000983|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RELOAD SUREFORM 60 4.3 GREEN|1|<Self-pay>|<Self-pay>|<Self-pay>|690.00|Inv Loc: 4006001; OR Loc: 4006001|||690.00|Inv Loc: 4006001; OR Loc: 4006001|379.50|
70000984|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER SUREFORM 45 SPU IS4000|1|<Self-pay>|<Self-pay>|<Self-pay>|1,380.00|Inv Loc: 4006001; OR Loc: 4006001|||1,380.00|Inv Loc: 4006001; OR Loc: 4006001|759.00|
70000985|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RELOAD SUREFORM 45 2.5 WHITE|1|<Self-pay>|<Self-pay>|<Self-pay>|600.00|Inv Loc: 4006001; OR Loc: 4006001|||600.00|Inv Loc: 4006001; OR Loc: 4006001|330.00|
70000986|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RELOAD SUREFORM 45 3.5 BLUE|1|<Self-pay>|<Self-pay>|<Self-pay>|600.00|Inv Loc: 4006001; OR Loc: 4006001|||600.00|Inv Loc: 4006001; OR Loc: 4006001|330.00|
70000987|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RELOAD SUREFORM 45 4.3 GREEN|1|<Self-pay>|<Self-pay>|<Self-pay>|600.00|Inv Loc: 4006001; OR Loc: 4006001|||600.00|Inv Loc: 4006001; OR Loc: 4006001|330.00|
70001041|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE VLOC 180 2-0|1|<Self-pay>|<Self-pay>|<Self-pay>|485.80|Inv Loc: 4006001; OR Loc: 4006001|||485.80|Inv Loc: 4006001; OR Loc: 4006001|267.19|
70001049|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|12MM STAPLER CANNULA SEAL|1|<Self-pay>|<Self-pay>|<Self-pay>|100.00|Inv Loc: 4006001; OR Loc: 4006001|||100.00|Inv Loc: 4006001; OR Loc: 4006001|55.00|
70001050|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE INSTRUMENT ARM|1|<Self-pay>|<Self-pay>|<Self-pay>|260.00|Inv Loc: 4006001; OR Loc: 4006001|||260.00|Inv Loc: 4006001; OR Loc: 4006001|143.00|
70001060|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLIPS HEM-O-LOK|1|<Self-pay>|<Self-pay>|<Self-pay>|130.70|Inv Loc: 4006001; OR Loc: 4006001|||130.70|Inv Loc: 4006001; OR Loc: 4006001|71.88|
70001068|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-V-LOC 90 3-0 VIOLET GS-21|1|<Self-pay>|<Self-pay>|<Self-pay>|174.50|Inv Loc: 4006001; OR Loc: 4006001|||174.50|Inv Loc: 4006001; OR Loc: 4006001|95.97|
70001069|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE V-LOC 180 0 GREEN GS-21|1|<Self-pay>|<Self-pay>|<Self-pay>|183.25|Inv Loc: 4006001; OR Loc: 4006001|||183.25|Inv Loc: 4006001; OR Loc: 4006001|100.79|
70001071|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TIP COVER ACCESSORY|1|<Self-pay>|<Self-pay>|<Self-pay>|100.00|Inv Loc: 4006001; OR Loc: 4006001|||100.00|Inv Loc: 4006001; OR Loc: 4006001|55.00|
70001072|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|8MM BLADELESS OBTURATOR|1|<Self-pay>|<Self-pay>|<Self-pay>|150.00|Inv Loc: 4006001; OR Loc: 4006001|||150.00|Inv Loc: 4006001; OR Loc: 4006001|82.50|
70001073|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|8MM BLADELESS OBTURATOR LONG|1|<Self-pay>|<Self-pay>|<Self-pay>|150.00|Inv Loc: 4006001; OR Loc: 4006001|||150.00|Inv Loc: 4006001; OR Loc: 4006001|82.50|
70001096|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DISPOSABLE LEG HOLDER|1|<Self-pay>|<Self-pay>|<Self-pay>|558.10|Inv Loc: 4006001; OR Loc: 4006001|||558.10|Inv Loc: 4006001; OR Loc: 4006001|306.95|
70001156|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE V LOC 180 2-0 9"|1|<Self-pay>|<Self-pay>|<Self-pay>|462.60|Inv Loc: 4006001; OR Loc: 4006001|||462.60|Inv Loc: 4006001; OR Loc: 4006001|254.43|
70001177|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPACEOAR VUE HYDROGEL SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|6,890.00|Inv Loc: 4006001; OR Loc: 4006001|||6,890.00|Inv Loc: 4006001; OR Loc: 4006001|3,789.50|
70001194|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|UTERINE MANIPULATOR 32MM CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|317.85|Inv Loc: 4006001; OR Loc: 4006001|||317.85|Inv Loc: 4006001; OR Loc: 4006001|174.82|
70001195|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|UTERINE MANIPULATOR 34MM CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|317.85|Inv Loc: 4006001; OR Loc: 4006001|||317.85|Inv Loc: 4006001; OR Loc: 4006001|174.82|
70001196|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|UTERINE MANIPULATOR 37MM CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|317.85|Inv Loc: 4006001; OR Loc: 4006001|||317.85|Inv Loc: 4006001; OR Loc: 4006001|174.82|
70001197|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|UTERINE MANIPULATOR 40MM CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|317.85|Inv Loc: 4006001; OR Loc: 4006001|||317.85|Inv Loc: 4006001; OR Loc: 4006001|174.82|
70001199|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE ENDOBRONCHIAL BRONCO-CATH 39FR LEFT|1|<Self-pay>|<Self-pay>|<Self-pay>|256.15|Inv Loc: 4006001; OR Loc: 4006001|||256.15|Inv Loc: 4006001; OR Loc: 4006001|140.88|
70001200|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE ENDOBRONCHIAL BRONCO-CATH 39FR RIGHT|1|<Self-pay>|<Self-pay>|<Self-pay>|256.15|Inv Loc: 4006001; OR Loc: 4006001|||256.15|Inv Loc: 4006001; OR Loc: 4006001|140.88|
70001201|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE ENDOBRONCHIAL BRONCO-CATH 41FR LEFT|1|<Self-pay>|<Self-pay>|<Self-pay>|256.15|Inv Loc: 4006001; OR Loc: 4006001|||256.15|Inv Loc: 4006001; OR Loc: 4006001|140.88|
70001202|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE ENDOBRONCHIAL BRONCO-CATH 41FR RIGHT|1|<Self-pay>|<Self-pay>|<Self-pay>|256.15|Inv Loc: 4006001; OR Loc: 4006001|||256.15|Inv Loc: 4006001; OR Loc: 4006001|140.88|
70001223|SUP|Custom 27000001||0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION|PUSHER SUTURE CUTTER SLOTTED CANNULA SET|1|<Self-pay>|<Self-pay>|<Self-pay>|850.00|Inv Loc: 4006001; OR Loc: 4006001|||850.00|Inv Loc: 4006001; OR Loc: 4006001|467.50|
70001224|SUP|Custom 27000001||0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - GENERAL CLASSIFICATION|AIR + MENISCAL SYSTEM CURVED UP|1|<Self-pay>|<Self-pay>|<Self-pay>|1,425.00|Inv Loc: 4006001; OR Loc: 4006001|||1,425.00|Inv Loc: 4006001; OR Loc: 4006001|783.75|
24060|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RETAINER-VISCERA FISH(3204)|1|<Self-pay>|<Self-pay>|<Self-pay>|122.00|Inv Loc: 4006001; OR Loc: 4006001|||122.00|Inv Loc: 4006001; OR Loc: 4006001|67.10|
22373|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INTRODUCER-CHOLANGICATH 6.0 PI-63|1|<Self-pay>|<Self-pay>|<Self-pay>|105.50|Inv Loc: 4006001; OR Loc: 4006001|||105.50|Inv Loc: 4006001; OR Loc: 4006001|58.02|
24190|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST SM RT|1|<Self-pay>|<Self-pay>|<Self-pay>|72.75|Inv Loc: 4006001; OR Loc: 4006001|||72.75|Inv Loc: 4006001; OR Loc: 4006001|40.01|
24191|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST MEDIUM RT|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|Inv Loc: 4006001; OR Loc: 4006001|||73.50|Inv Loc: 4006001; OR Loc: 4006001|40.42|
22000|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP LADIES LARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|76.35|Inv Loc: 4006001; OR Loc: 4006001|||76.35|Inv Loc: 4006001; OR Loc: 4006001|41.99|
22192|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|MANIPULATOR-UTERINE 4.5 (1151)|1|<Self-pay>|<Self-pay>|<Self-pay>|157.90|Inv Loc: 4006001; OR Loc: 4006001|||157.90|Inv Loc: 4006001; OR Loc: 4006001|86.84|
25130|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOURNIQUET-ABDOMINAL AORTIC JUNCTIONAL (AAJT)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,087.60|Inv Loc: 4006001; OR Loc: 4006001|||1,087.60|Inv Loc: 4006001; OR Loc: 4006001|598.18|
21336|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TIP-VACURETTE 8MM 20317|1|<Self-pay>|<Self-pay>|<Self-pay>|22.55|Inv Loc: 4006001; OR Loc: 4006001|||22.55|Inv Loc: 4006001; OR Loc: 4006001|12.40|
22001|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP MEN SMALL (106714)|1|<Self-pay>|<Self-pay>|<Self-pay>|53.65|Inv Loc: 4006001; OR Loc: 4006001|||53.65|Inv Loc: 4006001; OR Loc: 4006001|29.51|
23124|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WALKER-SHORT LEG LARGE 64101|1|<Self-pay>|<Self-pay>|<Self-pay>|266.00|Inv Loc: 4006001; OR Loc: 4006001|||266.00|Inv Loc: 4006001; OR Loc: 4006001|146.30|
24192|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST LARGE RT|1|<Self-pay>|<Self-pay>|<Self-pay>|73.50|Inv Loc: 4006001; OR Loc: 4006001|||73.50|Inv Loc: 4006001; OR Loc: 4006001|40.42|
21337|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBING-COLLECTION SET (23116)|1|<Self-pay>|<Self-pay>|<Self-pay>|45.75|Inv Loc: 4006001; OR Loc: 4006001|||45.75|Inv Loc: 4006001; OR Loc: 4006001|25.16|
22003|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP MEN LARGE (106726)|1|<Self-pay>|<Self-pay>|<Self-pay>|76.35|Inv Loc: 4006001; OR Loc: 4006001|||76.35|Inv Loc: 4006001; OR Loc: 4006001|41.99|
22007|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP LADIES SMALL (111027)|1|<Self-pay>|<Self-pay>|<Self-pay>|76.35|Inv Loc: 4006001; OR Loc: 4006001|||76.35|Inv Loc: 4006001; OR Loc: 4006001|41.99|
24024|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP MEN XLG (106727)|1|<Self-pay>|<Self-pay>|<Self-pay>|52.20|Inv Loc: 4006001; OR Loc: 4006001|||52.20|Inv Loc: 4006001; OR Loc: 4006001|28.71|
24646|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP ORTHOWEDGE (OQ1B)SMALL|1|<Self-pay>|<Self-pay>|<Self-pay>|75.35|Inv Loc: 4006001; OR Loc: 4006001|||75.35|Inv Loc: 4006001; OR Loc: 4006001|41.44|
23557|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WALKER-ROYLAN HI MEDIUM CA414-5|1|<Self-pay>|<Self-pay>|<Self-pay>|334.65|Inv Loc: 4006001; OR Loc: 4006001|||334.65|Inv Loc: 4006001; OR Loc: 4006001|184.06|
23560|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WALKER-ROLYAN HI SMALL CA414-4|1|<Self-pay>|<Self-pay>|<Self-pay>|334.65|Inv Loc: 4006001; OR Loc: 4006001|||334.65|Inv Loc: 4006001; OR Loc: 4006001|184.06|
21382|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TIP-VACURETTE 10MM (21553)|1|<Self-pay>|<Self-pay>|<Self-pay>|23.60|Inv Loc: 4006001; OR Loc: 4006001|||23.60|Inv Loc: 4006001; OR Loc: 4006001|12.98|
22421|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BASKET-HELICAL 4-WIRE 3.0FR 8.5MMX90CM|1|<Self-pay>|<Self-pay>|<Self-pay>|640.00|Inv Loc: 4006001; OR Loc: 4006001|||640.00|Inv Loc: 4006001; OR Loc: 4006001|352.00|
24193|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST XLG RT|1|<Self-pay>|<Self-pay>|<Self-pay>|68.85|Inv Loc: 4006001; OR Loc: 4006001|||68.85|Inv Loc: 4006001; OR Loc: 4006001|37.87|
24194|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST SMALL LT|1|<Self-pay>|<Self-pay>|<Self-pay>|72.15|Inv Loc: 4006001; OR Loc: 4006001|||72.15|Inv Loc: 4006001; OR Loc: 4006001|39.68|
24195|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST MED LT|1|<Self-pay>|<Self-pay>|<Self-pay>|68.85|Inv Loc: 4006001; OR Loc: 4006001|||68.85|Inv Loc: 4006001; OR Loc: 4006001|37.87|
24196|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST LARGE LT|1|<Self-pay>|<Self-pay>|<Self-pay>|68.85|Inv Loc: 4006001; OR Loc: 4006001|||68.85|Inv Loc: 4006001; OR Loc: 4006001|37.87|
25129|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DEVICE-T-POD COMBAT PELVIC STABLIZATION|1|<Self-pay>|<Self-pay>|<Self-pay>|449.95|Inv Loc: 4006001; OR Loc: 4006001|||449.95|Inv Loc: 4006001; OR Loc: 4006001|247.47|
24197|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-COCKUP WRIST XLG LT|1|<Self-pay>|<Self-pay>|<Self-pay>|72.15|Inv Loc: 4006001; OR Loc: 4006001|||72.15|Inv Loc: 4006001; OR Loc: 4006001|39.68|
24186|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PAD-DEFIB (M3718A) PHILIPS|1|<Self-pay>|<Self-pay>|<Self-pay>|151.05|Inv Loc: 4006001; OR Loc: 4006001|||151.05|Inv Loc: 4006001; OR Loc: 4006001|83.08|
23088|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLAMP-RAYPORT MUSCLE BIOPSY SU130-1112|1|<Self-pay>|<Self-pay>|<Self-pay>|146.55|Inv Loc: 4006001; OR Loc: 4006001|||146.55|Inv Loc: 4006001; OR Loc: 4006001|80.60|
21116|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-ONE STEP 4X15 (76415A)|1|<Self-pay>|<Self-pay>|<Self-pay>|26.05|Inv Loc: 4006001; OR Loc: 4006001|||26.05|Inv Loc: 4006001; OR Loc: 4006001|14.33|
23271|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PANTALOON SZ 4|1|<Self-pay>|<Self-pay>|<Self-pay>|585.00|Inv Loc: 4006001; OR Loc: 4006001|||585.00|Inv Loc: 4006001; OR Loc: 4006001|321.75|
22807|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PANTALOON SZ 8|1|<Self-pay>|<Self-pay>|<Self-pay>|585.00|Inv Loc: 4006001; OR Loc: 4006001|||585.00|Inv Loc: 4006001; OR Loc: 4006001|321.75|
23958|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ADAPTER-G-U TEK (URETERAL CATH CONNECTOR)|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|Inv Loc: 4006001; OR Loc: 4006001|||75.00|Inv Loc: 4006001; OR Loc: 4006001|41.25|
21142|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|EXTENSION-BUCKS TRACTION|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
24022|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PANTALOON SZ 2|1|<Self-pay>|<Self-pay>|<Self-pay>|585.00|Inv Loc: 4006001; OR Loc: 4006001|||585.00|Inv Loc: 4006001; OR Loc: 4006001|321.75|
24840|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CUFF-TOURNIQUET MEDIUM (YELLOW)|1|<Self-pay>|<Self-pay>|<Self-pay>|324.95|Inv Loc: 4006001; OR Loc: 4006001|||324.95|Inv Loc: 4006001; OR Loc: 4006001|178.72|
20539|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RESTRICTOR-FEMORAL CEMENT UNIVERSAL (B0001240)|1|<Self-pay>|<Self-pay>|<Self-pay>|660.00|Inv Loc: 4006001; OR Loc: 4006001|||660.00|Inv Loc: 4006001; OR Loc: 4006001|363.00|
21056|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CEMENT-VERSABOND BONE|1|<Self-pay>|<Self-pay>|<Self-pay>|487.50|Inv Loc: 4006001; OR Loc: 4006001|||487.50|Inv Loc: 4006001; OR Loc: 4006001|268.12|
21156|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STIMULATOR-NERVE (0003)|1|<Self-pay>|<Self-pay>|<Self-pay>|186.85|Inv Loc: 4006001; OR Loc: 4006001|||186.85|Inv Loc: 4006001; OR Loc: 4006001|102.77|
24912|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PROBE-RF 90 DEGREE WHIRLWIND|1|<Self-pay>|<Self-pay>|<Self-pay>|611.10|Inv Loc: 4006001; OR Loc: 4006001|||611.10|Inv Loc: 4006001; OR Loc: 4006001|336.10|
24913|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PROBE-RF 50 DEGREE CROSS|1|<Self-pay>|<Self-pay>|<Self-pay>|1,359.00|Inv Loc: 4006001; OR Loc: 4006001|||1,359.00|Inv Loc: 4006001; OR Loc: 4006001|747.45|
24914|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PROBE-RF 30 DEGREE HOOK|1|<Self-pay>|<Self-pay>|<Self-pay>|1,359.00|Inv Loc: 4006001; OR Loc: 4006001|||1,359.00|Inv Loc: 4006001; OR Loc: 4006001|747.45|
24155|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SYSTEM-CEMENT MIXING|1|<Self-pay>|<Self-pay>|<Self-pay>|671.90|Inv Loc: 4006001; OR Loc: 4006001|||671.90|Inv Loc: 4006001; OR Loc: 4006001|369.54|
24891|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-TOTAL HIP PREP|1|<Self-pay>|<Self-pay>|<Self-pay>|925.00|Inv Loc: 4006001; OR Loc: 4006001|||925.00|Inv Loc: 4006001; OR Loc: 4006001|508.75|
22128|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-UNIVERSAL CANNULA 7MM (012421)|1|<Self-pay>|<Self-pay>|<Self-pay>|126.00|Inv Loc: 4006001; OR Loc: 4006001|||126.00|Inv Loc: 4006001; OR Loc: 4006001|69.30|
22142|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-UNIVERSAL CANNULA 012405 (5MM)|1|<Self-pay>|<Self-pay>|<Self-pay>|132.30|Inv Loc: 4006001; OR Loc: 4006001|||132.30|Inv Loc: 4006001; OR Loc: 4006001|72.76|
22371|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-BOVIE NEEDLE (139102) DISPOSABLE|1|<Self-pay>|<Self-pay>|<Self-pay>|15.45|Inv Loc: 4006001; OR Loc: 4006001|||15.45|Inv Loc: 4006001; OR Loc: 4006001|8.50|
22396|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-LOOP LARGE (60-5180-104)|1|<Self-pay>|<Self-pay>|<Self-pay>|58.50|Inv Loc: 4006001; OR Loc: 4006001|||58.50|Inv Loc: 4006001; OR Loc: 4006001|32.17|
22397|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-LOOP MEDIUM (60-5180-102)|1|<Self-pay>|<Self-pay>|<Self-pay>|79.40|Inv Loc: 4006001; OR Loc: 4006001|||79.40|Inv Loc: 4006001; OR Loc: 4006001|43.67|
22398|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-EXTENDED BLADE 139107|1|<Self-pay>|<Self-pay>|<Self-pay>|16.15|Inv Loc: 4006001; OR Loc: 4006001|||16.15|Inv Loc: 4006001; OR Loc: 4006001|8.88|
22399|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-LOOP SMALL (60-5180-101)|1|<Self-pay>|<Self-pay>|<Self-pay>|58.80|Inv Loc: 4006001; OR Loc: 4006001|||58.80|Inv Loc: 4006001; OR Loc: 4006001|32.34|
24637|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BOVIE-W/SMOKE EVACUATOR 60-751005 (GOLDVAC)|1|<Self-pay>|<Self-pay>|<Self-pay>|156.00|Inv Loc: 4006001; OR Loc: 4006001|||156.00|Inv Loc: 4006001; OR Loc: 4006001|85.80|
24946|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BALL-PIN .045" YELLOW JURGAN|1|<Self-pay>|<Self-pay>|<Self-pay>|30.00|Inv Loc: 4006001; OR Loc: 4006001|||30.00|Inv Loc: 4006001; OR Loc: 4006001|16.50|
24947|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BALL-PIN .054/.062" GREEN JURGAN|1|<Self-pay>|<Self-pay>|<Self-pay>|30.00|Inv Loc: 4006001; OR Loc: 4006001|||30.00|Inv Loc: 4006001; OR Loc: 4006001|16.50|
24948|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BALL-PIN 5/64" BLUE JURGAN|1|<Self-pay>|<Self-pay>|<Self-pay>|30.00|Inv Loc: 4006001; OR Loc: 4006001|||30.00|Inv Loc: 4006001; OR Loc: 4006001|16.50|
24949|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BALL-PIN 3/32" CREAM JURGAN|1|<Self-pay>|<Self-pay>|<Self-pay>|30.00|Inv Loc: 4006001; OR Loc: 4006001|||30.00|Inv Loc: 4006001; OR Loc: 4006001|16.50|
21546|SUP|HCPCS C1757||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-EMBOLECTOMY 4FR *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|255.50|Inv Loc: 4006001; OR Loc: 4006001|||255.50|Inv Loc: 4006001; OR Loc: 4006001|140.52|
23180|SUP|HCPCS C1757||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-EMBOLECTOMY 3FR *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|255.50|Inv Loc: 4006001; OR Loc: 4006001|||255.50|Inv Loc: 4006001; OR Loc: 4006001|140.52|
24824|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TIP-VACURETTE 6MM (21665)|1|<Self-pay>|<Self-pay>|<Self-pay>|22.85|Inv Loc: 4006001; OR Loc: 4006001|||22.85|Inv Loc: 4006001; OR Loc: 4006001|12.57|
24955|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEP-DISSECTING 5MM/33CM|1|<Self-pay>|<Self-pay>|<Self-pay>|930.00|Inv Loc: 4006001; OR Loc: 4006001|||930.00|Inv Loc: 4006001; OR Loc: 4006001|511.50|
21555|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TIP-VACUETTE 12MM|1|<Self-pay>|<Self-pay>|<Self-pay>|198.95|Inv Loc: 4006001; OR Loc: 4006001|||198.95|Inv Loc: 4006001; OR Loc: 4006001|109.42|
20965|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-TRACHEOSTOMY 4DCT (SHILEY)|1|<Self-pay>|<Self-pay>|<Self-pay>|161.05|Inv Loc: 4006001; OR Loc: 4006001|||161.05|Inv Loc: 4006001; OR Loc: 4006001|88.58|
22134|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LEAD-UNIVERSAL W/ALLIGATOR CLIPS (5833SL)|1|<Self-pay>|<Self-pay>|<Self-pay>|337.50|Inv Loc: 4006001; OR Loc: 4006001|||337.50|Inv Loc: 4006001; OR Loc: 4006001|185.62|
22301|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-WEBRIL 6" 2554 STERILE|1|<Self-pay>|<Self-pay>|<Self-pay>|20.45|Inv Loc: 4006001; OR Loc: 4006001|||20.45|Inv Loc: 4006001; OR Loc: 4006001|11.25|
24166|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-TRACH 6.0 EXTENDED PROXIMAL 60XLTCP|1|<Self-pay>|<Self-pay>|<Self-pay>|304.05|Inv Loc: 4006001; OR Loc: 4006001|||304.05|Inv Loc: 4006001; OR Loc: 4006001|167.23|
24168|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-TRACH 7.0 EXTENDED PROXIMAL 70XLTCP|1|<Self-pay>|<Self-pay>|<Self-pay>|304.05|Inv Loc: 4006001; OR Loc: 4006001|||304.05|Inv Loc: 4006001; OR Loc: 4006001|167.23|
24945|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-LINQ ACCESSORY|1|<Self-pay>|<Self-pay>|<Self-pay>|475.00|Inv Loc: 4006001; OR Loc: 4006001|||475.00|Inv Loc: 4006001; OR Loc: 4006001|261.25|
25036|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-SCD KNEE LENGTH SMALL COMFORT|1|<Self-pay>|<Self-pay>|<Self-pay>|177.25|Inv Loc: 4006001; OR Loc: 4006001|||177.25|Inv Loc: 4006001; OR Loc: 4006001|97.49|
22016|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BOVIE CORD ENDOSCOPIC E0503|1|<Self-pay>|<Self-pay>|<Self-pay>|14.35|Inv Loc: 4006001; OR Loc: 4006001|||14.35|Inv Loc: 4006001; OR Loc: 4006001|7.89|
24169|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-TRACH 8.0 EXTENDED DISTAL 80XLTCD|1|<Self-pay>|<Self-pay>|<Self-pay>|304.05|Inv Loc: 4006001; OR Loc: 4006001|||304.05|Inv Loc: 4006001; OR Loc: 4006001|167.23|
24838|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-INTRAOSSEOUS AD 45MM:15GA (PTS 40KG+)|1|<Self-pay>|<Self-pay>|<Self-pay>|625.00|Inv Loc: 4006001; OR Loc: 4006001|||625.00|Inv Loc: 4006001; OR Loc: 4006001|343.75|
24083|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WARMER-SCOPE|1|<Self-pay>|<Self-pay>|<Self-pay>|42.50|Inv Loc: 4006001; OR Loc: 4006001|||42.50|Inv Loc: 4006001; OR Loc: 4006001|23.37|
21059|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STOCKINETTE-IMPERVIOUS LG 9"X48"1586|1|<Self-pay>|<Self-pay>|<Self-pay>|15.25|Inv Loc: 4006001; OR Loc: 4006001|||15.25|Inv Loc: 4006001; OR Loc: 4006001|8.39|
21073|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STOCKINETTE-IMPERVIOUS X-LG 12"X48" 1587|1|<Self-pay>|<Self-pay>|<Self-pay>|15.95|Inv Loc: 4006001; OR Loc: 4006001|||15.95|Inv Loc: 4006001; OR Loc: 4006001|8.77|
21688|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLANKET-WARMING FULL BODY|1|<Self-pay>|<Self-pay>|<Self-pay>|22.50|Inv Loc: 4006001; OR Loc: 4006001|||22.50|Inv Loc: 4006001; OR Loc: 4006001|12.37|
21689|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLANKET-ARMS OUT WARMING|1|<Self-pay>|<Self-pay>|<Self-pay>|22.50|Inv Loc: 4006001; OR Loc: 4006001|||22.50|Inv Loc: 4006001; OR Loc: 4006001|12.37|
24174|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HEARTSTART PADS DP2/DP6 (AED FR2)|1|<Self-pay>|<Self-pay>|<Self-pay>|139.85|Inv Loc: 4006001; OR Loc: 4006001|||139.85|Inv Loc: 4006001; OR Loc: 4006001|76.92|
24187|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PAD-DEFIB INFANT/CHILD M3719A|1|<Self-pay>|<Self-pay>|<Self-pay>|111.50|Inv Loc: 4006001; OR Loc: 4006001|||111.50|Inv Loc: 4006001; OR Loc: 4006001|61.32|
24200|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET-DILATOR AMPLATZ RENAL (075000)|1|<Self-pay>|<Self-pay>|<Self-pay>|637.95|Inv Loc: 4006001; OR Loc: 4006001|||637.95|Inv Loc: 4006001; OR Loc: 4006001|350.87|
25128|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOURNIQUET-COMBAT APPLICATION ORANGE|1|<Self-pay>|<Self-pay>|<Self-pay>|140.40|Inv Loc: 4006001; OR Loc: 4006001|||140.40|Inv Loc: 4006001; OR Loc: 4006001|77.22|
21568|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-GASTROSTOMY 24FR|1|<Self-pay>|<Self-pay>|<Self-pay>|150.95|Inv Loc: 4006001; OR Loc: 4006001|||150.95|Inv Loc: 4006001; OR Loc: 4006001|83.02|
21595|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-GASTROSTOMY 18FR 0100-18|1|<Self-pay>|<Self-pay>|<Self-pay>|155.10|Inv Loc: 4006001; OR Loc: 4006001|||155.10|Inv Loc: 4006001; OR Loc: 4006001|85.30|
21585|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-COLON 24FR *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|17.55|Inv Loc: 4006001; OR Loc: 4006001|||17.55|Inv Loc: 4006001; OR Loc: 4006001|9.65|
21586|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-COLON 28FR 30" LONG *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|20.35|Inv Loc: 4006001; OR Loc: 4006001|||20.35|Inv Loc: 4006001; OR Loc: 4006001|11.19|
21587|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-COLON 30FR 30" LONG *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|67.95|Inv Loc: 4006001; OR Loc: 4006001|||67.95|Inv Loc: 4006001; OR Loc: 4006001|37.37|
21588|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-COLON 32FR 30" LONG *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|175.05|Inv Loc: 4006001; OR Loc: 4006001|||175.05|Inv Loc: 4006001; OR Loc: 4006001|96.28|
21578|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-T 14FR CATTELL *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|66.80|Inv Loc: 4006001; OR Loc: 4006001|||66.80|Inv Loc: 4006001; OR Loc: 4006001|36.74|
21615|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|METER-URINE DRAIN 2000ML|1|<Self-pay>|<Self-pay>|<Self-pay>|50.35|Inv Loc: 4006001; OR Loc: 4006001|||50.35|Inv Loc: 4006001; OR Loc: 4006001|27.69|
21614|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BAG-URINE DRAINAGE|1|<Self-pay>|<Self-pay>|<Self-pay>|17.10|Inv Loc: 4006001; OR Loc: 4006001|||17.10|Inv Loc: 4006001; OR Loc: 4006001|9.40|
23869|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANNULA-DIVIDED SALTER (ANESTHESIA)|1|<Self-pay>|<Self-pay>|<Self-pay>|14.25|Inv Loc: 4006001; OR Loc: 4006001|||14.25|Inv Loc: 4006001; OR Loc: 4006001|7.84|
25039|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|APPLICATOR-AH FLEX TIP 38CM|1|<Self-pay>|<Self-pay>|<Self-pay>|75.40|Inv Loc: 4006001; OR Loc: 4006001|||75.40|Inv Loc: 4006001; OR Loc: 4006001|41.47|
24648|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBING SET FOR LEEP PROCEDURES (EVACUATION)|1|<Self-pay>|<Self-pay>|<Self-pay>|103.55|Inv Loc: 4006001; OR Loc: 4006001|||103.55|Inv Loc: 4006001; OR Loc: 4006001|56.95|
24818|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ADVINCULA DELINEATOR 2.5CM ULTEM PLASTIC CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|907.20|Inv Loc: 4006001; OR Loc: 4006001|||907.20|Inv Loc: 4006001; OR Loc: 4006001|498.96|
24819|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ADVINCULA DELINEATOR 3.0CM ULTEM PLASTIC CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|907.15|Inv Loc: 4006001; OR Loc: 4006001|||907.15|Inv Loc: 4006001; OR Loc: 4006001|498.93|
24820|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ADVINCULA DELINEATOR 3.5CM ULTEM PLASTIC CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|907.15|Inv Loc: 4006001; OR Loc: 4006001|||907.15|Inv Loc: 4006001; OR Loc: 4006001|498.93|
24821|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ADVINCULA DELINEATOR 4.0CM ULTEM PLASTIC CUP|1|<Self-pay>|<Self-pay>|<Self-pay>|907.15|Inv Loc: 4006001; OR Loc: 4006001|||907.15|Inv Loc: 4006001; OR Loc: 4006001|498.93|
24927|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-BALL LOOP 5MM 12CM SHAFT|1|<Self-pay>|<Self-pay>|<Self-pay>|113.40|Inv Loc: 4006001; OR Loc: 4006001|||113.40|Inv Loc: 4006001; OR Loc: 4006001|62.37|
21609|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CHEST DRAINAGE-WATER SEAL 2002-000|1|<Self-pay>|<Self-pay>|<Self-pay>|128.25|Inv Loc: 4006001; OR Loc: 4006001|||128.25|Inv Loc: 4006001; OR Loc: 4006001|70.54|
21401|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DEXTROSE 10% IN H2O 1000CC|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21412|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|GLYCINE IRRIGATION 1.5% 3000CC 2B7317|1|<Self-pay>|<Self-pay>|<Self-pay>|34.10|Inv Loc: 4006001; OR Loc: 4006001|||34.10|Inv Loc: 4006001; OR Loc: 4006001|18.75|
21641|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET-Y TYPE IRRIGATION *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|33.90|Inv Loc: 4006001; OR Loc: 4006001|||33.90|Inv Loc: 4006001; OR Loc: 4006001|18.64|
22054|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|VAMP MONITOR W/TRANS PX-VMP172|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|Inv Loc: 4006001; OR Loc: 4006001|||125.00|Inv Loc: 4006001; OR Loc: 4006001|68.75|
24890|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PERI-STRIPS DRY 45 UNIV. REINFOREMENT|1|<Self-pay>|<Self-pay>|<Self-pay>|623.25|Inv Loc: 4006001; OR Loc: 4006001|||623.25|Inv Loc: 4006001; OR Loc: 4006001|342.79|
21395|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DEXTROSE 5% IN H2O 500CC 2B0063Q|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21396|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DEXTROSE 5% IN H2O 1000CC 2B0064|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21397|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE .9% 250CC 2B1322Q|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21398|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE .9% 500CC 2B1323Q|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21399|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE .9% 1000CC 2B1324X|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21400|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE .9% W/DEXT 5% 1000CC 2B1064X|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21404|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LACTATED RINGER W/DEXT 5% 2B2074|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21406|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE .2% W/DEXT 5% 1000CC 2B1094|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21408|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WATER IRRIGATION 3000CC 2B7117|1|<Self-pay>|<Self-pay>|<Self-pay>|26.80|Inv Loc: 4006001; OR Loc: 4006001|||26.80|Inv Loc: 4006001; OR Loc: 4006001|14.74|
21409|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE .45% 1000CC 2B1314X|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21410|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE .45% W/DEXT 5% 1000CC 2B1074X|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21413|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE IRRIGATION POUR|1|<Self-pay>|<Self-pay>|<Self-pay>|39.40|Inv Loc: 4006001; OR Loc: 4006001|||39.40|Inv Loc: 4006001; OR Loc: 4006001|21.67|
21414|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WATER IRRIGATION POUR|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
24188|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LACTATED RINGERS 500ML INJECTION|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
23881|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CORD-BIPOLAR CODMAN|1|<Self-pay>|<Self-pay>|<Self-pay>|122.20|Inv Loc: 4006001; OR Loc: 4006001|||122.20|Inv Loc: 4006001; OR Loc: 4006001|67.21|
21428|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET-THORACENTESIS 4653-48|1|<Self-pay>|<Self-pay>|<Self-pay>|15.50|Inv Loc: 4006001; OR Loc: 4006001|||15.50|Inv Loc: 4006001; OR Loc: 4006001|8.52|
23020|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CONNECTOR-FIBEROPTIC DOUBLE SWIVEL 625191|1|<Self-pay>|<Self-pay>|<Self-pay>|51.45|Inv Loc: 4006001; OR Loc: 4006001|||51.45|Inv Loc: 4006001; OR Loc: 4006001|28.30|
21153|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BRUSH-INTRAMEDULLARY (6198001514)|1|<Self-pay>|<Self-pay>|<Self-pay>|225.25|Inv Loc: 4006001; OR Loc: 4006001|||225.25|Inv Loc: 4006001; OR Loc: 4006001|123.89|
24970|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANNULA RF 100MM 20G 10MM|1|<Self-pay>|<Self-pay>|<Self-pay>|900.00|Inv Loc: 4006001; OR Loc: 4006001|||900.00|Inv Loc: 4006001; OR Loc: 4006001|495.00|
24971|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANNULA RF 150MM 20G 10MM|1|<Self-pay>|<Self-pay>|<Self-pay>|900.00|Inv Loc: 4006001; OR Loc: 4006001|||900.00|Inv Loc: 4006001; OR Loc: 4006001|495.00|
24972|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANNULA RF 100MM 20G 5MM|1|<Self-pay>|<Self-pay>|<Self-pay>|900.00|Inv Loc: 4006001; OR Loc: 4006001|||900.00|Inv Loc: 4006001; OR Loc: 4006001|495.00|
24973|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PAD-ELECTRODE NEUTRAL|1|<Self-pay>|<Self-pay>|<Self-pay>|1,373.76|Inv Loc: 4006001; OR Loc: 4006001|||1,373.76|Inv Loc: 4006001; OR Loc: 4006001|755.57|
24157|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUCTION/IRRIGATION SYSTEM (210-114)|1|<Self-pay>|<Self-pay>|<Self-pay>|183.35|Inv Loc: 4006001; OR Loc: 4006001|||183.35|Inv Loc: 4006001; OR Loc: 4006001|100.84|
24159|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TIP-FEMORAL CANAL (210-008)|1|<Self-pay>|<Self-pay>|<Self-pay>|50.00|Inv Loc: 4006001; OR Loc: 4006001|||50.00|Inv Loc: 4006001; OR Loc: 4006001|27.50|
24156|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANNULA-FEMORAL PRESSURIZER (206-566)|1|<Self-pay>|<Self-pay>|<Self-pay>|135.85|Inv Loc: 4006001; OR Loc: 4006001|||135.85|Inv Loc: 4006001; OR Loc: 4006001|74.72|
20998|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INTUBATING-STYLET ENDOTRACH 15FR. BOUGIE|1|<Self-pay>|<Self-pay>|<Self-pay>|48.90|Inv Loc: 4006001; OR Loc: 4006001|||48.90|Inv Loc: 4006001; OR Loc: 4006001|26.89|
22110|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-GASTRIC LAVAGE #2055|1|<Self-pay>|<Self-pay>|<Self-pay>|194.35|Inv Loc: 4006001; OR Loc: 4006001|||194.35|Inv Loc: 4006001; OR Loc: 4006001|106.89|
23229|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUCTION/IRRIGATOR STRYKER 250-070-500|1|<Self-pay>|<Self-pay>|<Self-pay>|201.55|Inv Loc: 4006001; OR Loc: 4006001|||201.55|Inv Loc: 4006001; OR Loc: 4006001|110.85|
24889|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBING-FLOSTEADY IRRIGATION 250-800-006|1|<Self-pay>|<Self-pay>|<Self-pay>|267.55|Inv Loc: 4006001; OR Loc: 4006001|||267.55|Inv Loc: 4006001; OR Loc: 4006001|147.15|
21407|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SALINE IRRIGATION 3000CC 2B7127|1|<Self-pay>|<Self-pay>|<Self-pay>|26.50|Inv Loc: 4006001; OR Loc: 4006001|||26.50|Inv Loc: 4006001; OR Loc: 4006001|14.57|
23781|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LMA SZ 2.5 PEDI|1|<Self-pay>|<Self-pay>|<Self-pay>|31.00|Inv Loc: 4006001; OR Loc: 4006001|||31.00|Inv Loc: 4006001; OR Loc: 4006001|17.05|
23782|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LMA SZ 1 PEDI|1|<Self-pay>|<Self-pay>|<Self-pay>|31.00|Inv Loc: 4006001; OR Loc: 4006001|||31.00|Inv Loc: 4006001; OR Loc: 4006001|17.05|
22969|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LMA SZ 5|1|<Self-pay>|<Self-pay>|<Self-pay>|69.35|Inv Loc: 4006001; OR Loc: 4006001|||69.35|Inv Loc: 4006001; OR Loc: 4006001|38.14|
23780|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LMA SZ 2|1|<Self-pay>|<Self-pay>|<Self-pay>|31.00|Inv Loc: 4006001; OR Loc: 4006001|||31.00|Inv Loc: 4006001; OR Loc: 4006001|17.05|
23783|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LMA SZ 1.5 PEDI|1|<Self-pay>|<Self-pay>|<Self-pay>|69.35|Inv Loc: 4006001; OR Loc: 4006001|||69.35|Inv Loc: 4006001; OR Loc: 4006001|38.14|
24218|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AIRWAY-NASOPHARYNGEAL 26FR LTX FR|1|<Self-pay>|<Self-pay>|<Self-pay>|19.50|Inv Loc: 4006001; OR Loc: 4006001|||19.50|Inv Loc: 4006001; OR Loc: 4006001|10.72|
24220|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AIRWAY-NASOPHARYNGEAL 30FR LTX FR|1|<Self-pay>|<Self-pay>|<Self-pay>|19.45|Inv Loc: 4006001; OR Loc: 4006001|||19.45|Inv Loc: 4006001; OR Loc: 4006001|10.70|
24221|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AIRWAY-NASOPHARYNGEAL 32FR LTX FR|1|<Self-pay>|<Self-pay>|<Self-pay>|19.45|Inv Loc: 4006001; OR Loc: 4006001|||19.45|Inv Loc: 4006001; OR Loc: 4006001|10.70|
24223|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AIRWAY-NASOPHARYNGEAL 36FR LTX FR|1|<Self-pay>|<Self-pay>|<Self-pay>|19.55|Inv Loc: 4006001; OR Loc: 4006001|||19.55|Inv Loc: 4006001; OR Loc: 4006001|10.75|
22967|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LMA SZ 3|1|<Self-pay>|<Self-pay>|<Self-pay>|69.35|Inv Loc: 4006001; OR Loc: 4006001|||69.35|Inv Loc: 4006001; OR Loc: 4006001|38.14|
22968|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LMA SZ 4|1|<Self-pay>|<Self-pay>|<Self-pay>|69.35|Inv Loc: 4006001; OR Loc: 4006001|||69.35|Inv Loc: 4006001; OR Loc: 4006001|38.14|
22070|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BAG-PRESSURE INFUSOR-1000CC (IN-9000)|1|<Self-pay>|<Self-pay>|<Self-pay>|30.05|Inv Loc: 4006001; OR Loc: 4006001|||30.05|Inv Loc: 4006001; OR Loc: 4006001|16.53|
24931|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANISTER-WOUND VAC|1|<Self-pay>|<Self-pay>|<Self-pay>|201.80|Inv Loc: 4006001; OR Loc: 4006001|||201.80|Inv Loc: 4006001; OR Loc: 4006001|110.99|
21080|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING&SWATHE-UNIVERSAL 79-84230 (OR) *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|35.20|Inv Loc: 4006001; OR Loc: 4006001|||35.20|Inv Loc: 4006001; OR Loc: 4006001|19.36|
21157|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-FINGER STRIP-PADDED 2" ALUMINUM|1|<Self-pay>|<Self-pay>|<Self-pay>|49.20|Inv Loc: 4006001; OR Loc: 4006001|||49.20|Inv Loc: 4006001; OR Loc: 4006001|27.06|
21084|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING-ARM XSM 79-84022|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21081|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING-ARM LG 79-84027|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21082|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING-ARM MD 79-84025|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21083|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING-ARM SM 79-84023|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21097|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-BUCKS TRACTION SM (79-83063)|1|<Self-pay>|<Self-pay>|<Self-pay>|59.60|Inv Loc: 4006001; OR Loc: 4006001|||59.60|Inv Loc: 4006001; OR Loc: 4006001|32.78|
21098|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-BUCKS TRACTION MED (79-83065)|1|<Self-pay>|<Self-pay>|<Self-pay>|59.60|Inv Loc: 4006001; OR Loc: 4006001|||59.60|Inv Loc: 4006001; OR Loc: 4006001|32.78|
21099|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-BUCKS TRACTION LG|1|<Self-pay>|<Self-pay>|<Self-pay>|59.60|Inv Loc: 4006001; OR Loc: 4006001|||59.60|Inv Loc: 4006001; OR Loc: 4006001|32.78|
24285|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING-ULTRA POST-OP LARGE 11-0138-4-13130|1|<Self-pay>|<Self-pay>|<Self-pay>|235.40|Inv Loc: 4006001; OR Loc: 4006001|||235.40|Inv Loc: 4006001; OR Loc: 4006001|129.47|
24286|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING-ULTRA POST-OP MEDIUM 11-0138-2-13130|1|<Self-pay>|<Self-pay>|<Self-pay>|235.40|Inv Loc: 4006001; OR Loc: 4006001|||235.40|Inv Loc: 4006001; OR Loc: 4006001|129.47|
24287|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLING-ULTRA POST-OP SMALL 11-0138-2-13130|1|<Self-pay>|<Self-pay>|<Self-pay>|236.55|Inv Loc: 4006001; OR Loc: 4006001|||236.55|Inv Loc: 4006001; OR Loc: 4006001|130.10|
20852|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-SKIN 3M PRECISE DS-5|1|<Self-pay>|<Self-pay>|<Self-pay>|18.35|Inv Loc: 4006001; OR Loc: 4006001|||18.35|Inv Loc: 4006001; OR Loc: 4006001|10.09|
20853|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-SKIN 3M PRECISE DS-15|1|<Self-pay>|<Self-pay>|<Self-pay>|24.05|Inv Loc: 4006001; OR Loc: 4006001|||24.05|Inv Loc: 4006001; OR Loc: 4006001|13.23|
21114|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-ONE STEP 3X12|1|<Self-pay>|<Self-pay>|<Self-pay>|22.10|Inv Loc: 4006001; OR Loc: 4006001|||22.10|Inv Loc: 4006001; OR Loc: 4006001|12.15|
21115|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-ONE STEP 3X35 (86335)|1|<Self-pay>|<Self-pay>|<Self-pay>|50.05|Inv Loc: 4006001; OR Loc: 4006001|||50.05|Inv Loc: 4006001; OR Loc: 4006001|27.53|
21117|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-ONE STEP 4X30 (76430)|1|<Self-pay>|<Self-pay>|<Self-pay>|49.65|Inv Loc: 4006001; OR Loc: 4006001|||49.65|Inv Loc: 4006001; OR Loc: 4006001|27.31|
21119|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-ONE STEP 5X45 (86545)|1|<Self-pay>|<Self-pay>|<Self-pay>|87.30|Inv Loc: 4006001; OR Loc: 4006001|||87.30|Inv Loc: 4006001; OR Loc: 4006001|48.01|
21146|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ATHLETIC SUPPORTER-MEDIUM (WAIST 33-38")*LX*|1|<Self-pay>|<Self-pay>|<Self-pay>|46.85|Inv Loc: 4006001; OR Loc: 4006001|||46.85|Inv Loc: 4006001; OR Loc: 4006001|25.77|
21147|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ATHLETIC SUPPORTER-LARGE (WAIST 39-44") *LX*|1|<Self-pay>|<Self-pay>|<Self-pay>|46.85|Inv Loc: 4006001; OR Loc: 4006001|||46.85|Inv Loc: 4006001; OR Loc: 4006001|25.77|
21691|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|POUCH-IRRIGATION 3M #1016|1|<Self-pay>|<Self-pay>|<Self-pay>|17.25|Inv Loc: 4006001; OR Loc: 4006001|||17.25|Inv Loc: 4006001; OR Loc: 4006001|9.49|
22177|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAPE-FOAM 4" *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|19.80|Inv Loc: 4006001; OR Loc: 4006001|||19.80|Inv Loc: 4006001; OR Loc: 4006001|10.89|
22809|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ATHLETIC SUPPORTER-X-LARGE(WAIST 44"-50")*LX*|1|<Self-pay>|<Self-pay>|<Self-pay>|15.75|Inv Loc: 4006001; OR Loc: 4006001|||15.75|Inv Loc: 4006001; OR Loc: 4006001|8.66|
22972|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WRAP-COBAN 6" SELF ADHERENT 2086S|1|<Self-pay>|<Self-pay>|<Self-pay>|15.85|Inv Loc: 4006001; OR Loc: 4006001|||15.85|Inv Loc: 4006001; OR Loc: 4006001|8.72|
23922|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LABEL SYSTEM-CORRECT MEDICATION (OR)(3302)|1|<Self-pay>|<Self-pay>|<Self-pay>|19.15|Inv Loc: 4006001; OR Loc: 4006001|||19.15|Inv Loc: 4006001; OR Loc: 4006001|10.53|
20350|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SIGMOIDOSCOPE SPECULUM DISP|1|<Self-pay>|<Self-pay>|<Self-pay>|14.20|Inv Loc: 4006001; OR Loc: 4006001|||14.20|Inv Loc: 4006001; OR Loc: 4006001|7.81|
20577|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CONTAINER TRANSPEC (EZ-8390)|1|<Self-pay>|<Self-pay>|<Self-pay>|92.00|Inv Loc: 4006001; OR Loc: 4006001|||92.00|Inv Loc: 4006001; OR Loc: 4006001|50.60|
21644|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-PNEUMOTHORAX C-TPT-100|1|<Self-pay>|<Self-pay>|<Self-pay>|863.55|Inv Loc: 4006001; OR Loc: 4006001|||863.55|Inv Loc: 4006001; OR Loc: 4006001|474.95|
22050|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLANKET-HOT ICE ST012|1|<Self-pay>|<Self-pay>|<Self-pay>|87.10|Inv Loc: 4006001; OR Loc: 4006001|||87.10|Inv Loc: 4006001; OR Loc: 4006001|47.90|
21760|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PAD-POSITIONER DISP 1002-P|1|<Self-pay>|<Self-pay>|<Self-pay>|129.15|Inv Loc: 4006001; OR Loc: 4006001|||129.15|Inv Loc: 4006001; OR Loc: 4006001|71.03|
21290|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-LEEP SQUARE (DLP-SQ1)|1|<Self-pay>|<Self-pay>|<Self-pay>|76.50|Inv Loc: 4006001; OR Loc: 4006001|||76.50|Inv Loc: 4006001; OR Loc: 4006001|42.07|
22494|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-LOOP 25MM X 8MM (DLP-B11)|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|Inv Loc: 4006001; OR Loc: 4006001|||75.00|Inv Loc: 4006001; OR Loc: 4006001|41.25|
24781|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-VACUUM DELIVERY PALM PUMP KIWI|1|<Self-pay>|<Self-pay>|<Self-pay>|130.00|Inv Loc: 4006001; OR Loc: 4006001|||130.00|Inv Loc: 4006001; OR Loc: 4006001|71.50|
24089|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HEADREST-OSI 1937 7" RT INTUBATION SLOT|1|<Self-pay>|<Self-pay>|<Self-pay>|63.85|Inv Loc: 4006001; OR Loc: 4006001|||63.85|Inv Loc: 4006001; OR Loc: 4006001|35.12|
23092|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|APPLICATOR-VAGINAL|1|<Self-pay>|<Self-pay>|<Self-pay>|55.80|Inv Loc: 4006001; OR Loc: 4006001|||55.80|Inv Loc: 4006001; OR Loc: 4006001|30.69|
21289|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOURNICOT-LARGE TCL|1|<Self-pay>|<Self-pay>|<Self-pay>|16.50|Inv Loc: 4006001; OR Loc: 4006001|||16.50|Inv Loc: 4006001; OR Loc: 4006001|9.07|
22173|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STRAP-DISTRACTOR FOOT (01440)|1|<Self-pay>|<Self-pay>|<Self-pay>|245.90|Inv Loc: 4006001; OR Loc: 4006001|||245.90|Inv Loc: 4006001; OR Loc: 4006001|135.24|
22141|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PROTECTOR-ULNAR NERVE W95-534|1|<Self-pay>|<Self-pay>|<Self-pay>|41.50|Inv Loc: 4006001; OR Loc: 4006001|||41.50|Inv Loc: 4006001; OR Loc: 4006001|22.82|
22971|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HEADREST-SLOTTED RICHARD PADS (930161)|1|<Self-pay>|<Self-pay>|<Self-pay>|87.60|Inv Loc: 4006001; OR Loc: 4006001|||87.60|Inv Loc: 4006001; OR Loc: 4006001|48.18|
25021|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-BONE MARROW APRIATION|1|<Self-pay>|<Self-pay>|<Self-pay>|1,960.00|Inv Loc: 4006001; OR Loc: 4006001|||1,960.00|Inv Loc: 4006001; OR Loc: 4006001|1,078.00|
24902|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SCORPION MULTIFIRE (AR13995N)|1|<Self-pay>|<Self-pay>|<Self-pay>|850.00|Inv Loc: 4006001; OR Loc: 4006001|||850.00|Inv Loc: 4006001; OR Loc: 4006001|467.50|
25020|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-PRP (PLATELET RICH PLASMA)|1|<Self-pay>|<Self-pay>|<Self-pay>|885.00|Inv Loc: 4006001; OR Loc: 4006001|||885.00|Inv Loc: 4006001; OR Loc: 4006001|486.75|
25123|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-FIBERWIRE 2-0 AR-7220|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|Inv Loc: 4006001; OR Loc: 4006001|||110.00|Inv Loc: 4006001; OR Loc: 4006001|60.50|
25170|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET-BELMONT 3 SPIKE BAG (RAPID INFUSOR)|1|<Self-pay>|<Self-pay>|<Self-pay>|656.25|Inv Loc: 4006001; OR Loc: 4006001|||656.25|Inv Loc: 4006001; OR Loc: 4006001|360.94|
24843|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BRACE-KNEE POST-OP UNIVERSAL T-SCOPE|1|<Self-pay>|<Self-pay>|<Self-pay>|737.30|Inv Loc: 4006001; OR Loc: 4006001|||737.30|Inv Loc: 4006001; OR Loc: 4006001|405.51|
24904|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-KNEE/SHOULDER COLD THERAPY|1|<Self-pay>|<Self-pay>|<Self-pay>|923.85|Inv Loc: 4006001; OR Loc: 4006001|||923.85|Inv Loc: 4006001; OR Loc: 4006001|508.12|
20964|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-TRACHEOSTOMY 8DCT (SHILEY)|1|<Self-pay>|<Self-pay>|<Self-pay>|175.85|Inv Loc: 4006001; OR Loc: 4006001|||175.85|Inv Loc: 4006001; OR Loc: 4006001|96.72|
20967|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-TRACHEOSTOMY 6DCT (SHILEY)|1|<Self-pay>|<Self-pay>|<Self-pay>|161.05|Inv Loc: 4006001; OR Loc: 4006001|||161.05|Inv Loc: 4006001; OR Loc: 4006001|88.58|
21544|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-BRONCHO LFT 37FR CPAP|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
21545|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-BRONCHO RT 37FR CPAP|1|<Self-pay>|<Self-pay>|<Self-pay>|251.20|Inv Loc: 4006001; OR Loc: 4006001|||251.20|Inv Loc: 4006001; OR Loc: 4006001|138.16|
21552|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-BRONCHO RT 35FR 85815|1|<Self-pay>|<Self-pay>|<Self-pay>|284.35|Inv Loc: 4006001; OR Loc: 4006001|||284.35|Inv Loc: 4006001; OR Loc: 4006001|156.39|
21576|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-SALEM SUMP 18FR 266148 W/REFLEX VALVE|1|<Self-pay>|<Self-pay>|<Self-pay>|15.50|Inv Loc: 4006001; OR Loc: 4006001|||15.50|Inv Loc: 4006001; OR Loc: 4006001|8.52|
21610|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CHEST DRAINAGE-DUAL EXTENSION SET (714200)|1|<Self-pay>|<Self-pay>|<Self-pay>|73.25|Inv Loc: 4006001; OR Loc: 4006001|||73.25|Inv Loc: 4006001; OR Loc: 4006001|40.29|
21723|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-KNEE SM REG 7071|1|<Self-pay>|<Self-pay>|<Self-pay>|37.30|Inv Loc: 4006001; OR Loc: 4006001|||37.30|Inv Loc: 4006001; OR Loc: 4006001|20.51|
21724|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH SMALL REG 3130LF|1|<Self-pay>|<Self-pay>|<Self-pay>|66.40|Inv Loc: 4006001; OR Loc: 4006001|||66.40|Inv Loc: 4006001; OR Loc: 4006001|36.52|
21725|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-KNEE MED REG 7115|1|<Self-pay>|<Self-pay>|<Self-pay>|34.85|Inv Loc: 4006001; OR Loc: 4006001|||34.85|Inv Loc: 4006001; OR Loc: 4006001|19.17|
21726|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-KNEE LG REG 7203|1|<Self-pay>|<Self-pay>|<Self-pay>|34.85|Inv Loc: 4006001; OR Loc: 4006001|||34.85|Inv Loc: 4006001; OR Loc: 4006001|19.17|
21727|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-KNEE XLG REG 7604|1|<Self-pay>|<Self-pay>|<Self-pay>|34.75|Inv Loc: 4006001; OR Loc: 4006001|||34.75|Inv Loc: 4006001; OR Loc: 4006001|19.11|
21728|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH MED REG 3416LF|1|<Self-pay>|<Self-pay>|<Self-pay>|62.15|Inv Loc: 4006001; OR Loc: 4006001|||62.15|Inv Loc: 4006001; OR Loc: 4006001|34.18|
21729|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH LG REG 3728LF|1|<Self-pay>|<Self-pay>|<Self-pay>|61.80|Inv Loc: 4006001; OR Loc: 4006001|||61.80|Inv Loc: 4006001; OR Loc: 4006001|33.99|
21835|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-MEDITRACE (31115788)|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
22195|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-SCD THIGH LENGTH MEDIUM|1|<Self-pay>|<Self-pay>|<Self-pay>|248.30|Inv Loc: 4006001; OR Loc: 4006001|||248.30|Inv Loc: 4006001; OR Loc: 4006001|136.56|
23116|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-SCD THIGH LENGTH LARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|297.40|Inv Loc: 4006001; OR Loc: 4006001|||297.40|Inv Loc: 4006001; OR Loc: 4006001|163.57|
23629|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BAG-DRAINAGE TUR 4000ML|1|<Self-pay>|<Self-pay>|<Self-pay>|18.40|Inv Loc: 4006001; OR Loc: 4006001|||18.40|Inv Loc: 4006001; OR Loc: 4006001|10.12|
23708|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-SCD THIGH LENGTH SMALL|1|<Self-pay>|<Self-pay>|<Self-pay>|236.85|Inv Loc: 4006001; OR Loc: 4006001|||236.85|Inv Loc: 4006001; OR Loc: 4006001|130.27|
24126|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-SALEM SUMP 14FR (266247) W/REFLEX VALVE|1|<Self-pay>|<Self-pay>|<Self-pay>|71.40|Inv Loc: 4006001; OR Loc: 4006001|||71.40|Inv Loc: 4006001; OR Loc: 4006001|39.27|
24127|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-SALEM SUMP 16FR 266262 W/REFLEX VALVE|1|<Self-pay>|<Self-pay>|<Self-pay>|71.40|Inv Loc: 4006001; OR Loc: 4006001|||71.40|Inv Loc: 4006001; OR Loc: 4006001|39.27|
24656|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-KNEE XXLG REG 7470|1|<Self-pay>|<Self-pay>|<Self-pay>|71.30|Inv Loc: 4006001; OR Loc: 4006001|||71.30|Inv Loc: 4006001; OR Loc: 4006001|39.21|
24657|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-KNEE XXXLG REG 7472|1|<Self-pay>|<Self-pay>|<Self-pay>|71.70|Inv Loc: 4006001; OR Loc: 4006001|||71.70|Inv Loc: 4006001; OR Loc: 4006001|39.43|
24658|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH XLG REG 3181|1|<Self-pay>|<Self-pay>|<Self-pay>|92.35|Inv Loc: 4006001; OR Loc: 4006001|||92.35|Inv Loc: 4006001; OR Loc: 4006001|50.79|
24659|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH XXLG REG 3184|1|<Self-pay>|<Self-pay>|<Self-pay>|45.00|Inv Loc: 4006001; OR Loc: 4006001|||45.00|Inv Loc: 4006001; OR Loc: 4006001|24.75|
24661|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH SMALL LONG 3222LF|1|<Self-pay>|<Self-pay>|<Self-pay>|24.30|Inv Loc: 4006001; OR Loc: 4006001|||24.30|Inv Loc: 4006001; OR Loc: 4006001|13.36|
24662|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH MED SHORT 3310LF|1|<Self-pay>|<Self-pay>|<Self-pay>|68.05|Inv Loc: 4006001; OR Loc: 4006001|||68.05|Inv Loc: 4006001; OR Loc: 4006001|37.43|
24663|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH MED LONG 3549LF|1|<Self-pay>|<Self-pay>|<Self-pay>|66.20|Inv Loc: 4006001; OR Loc: 4006001|||66.20|Inv Loc: 4006001; OR Loc: 4006001|36.41|
24665|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH LG LONG 3856LF|1|<Self-pay>|<Self-pay>|<Self-pay>|65.90|Inv Loc: 4006001; OR Loc: 4006001|||65.90|Inv Loc: 4006001; OR Loc: 4006001|36.24|
24666|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH XLG SHORT 3180|1|<Self-pay>|<Self-pay>|<Self-pay>|126.55|Inv Loc: 4006001; OR Loc: 4006001|||126.55|Inv Loc: 4006001; OR Loc: 4006001|69.60|
24668|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH XXLG SHORT 3183|1|<Self-pay>|<Self-pay>|<Self-pay>|45.00|Inv Loc: 4006001; OR Loc: 4006001|||45.00|Inv Loc: 4006001; OR Loc: 4006001|24.75|
24669|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH XXLG LONG 3185|1|<Self-pay>|<Self-pay>|<Self-pay>|45.00|Inv Loc: 4006001; OR Loc: 4006001|||45.00|Inv Loc: 4006001; OR Loc: 4006001|24.75|
25028|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-SCD KNEE LENGTH MEDIUM EXPRESS|1|<Self-pay>|<Self-pay>|<Self-pay>|161.15|Inv Loc: 4006001; OR Loc: 4006001|||161.15|Inv Loc: 4006001; OR Loc: 4006001|88.63|
25029|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-SCD KNEE LENGTH LARGE EXPRESS|1|<Self-pay>|<Self-pay>|<Self-pay>|435.05|Inv Loc: 4006001; OR Loc: 4006001|||435.05|Inv Loc: 4006001; OR Loc: 4006001|239.28|
21845|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BINDER-ABDOMINAL 12" 30"-45"|1|<Self-pay>|<Self-pay>|<Self-pay>|64.80|Inv Loc: 4006001; OR Loc: 4006001|||64.80|Inv Loc: 4006001; OR Loc: 4006001|35.64|
23054|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BINDER-ABDOMINAL 9" 60-75"|1|<Self-pay>|<Self-pay>|<Self-pay>|81.50|Inv Loc: 4006001; OR Loc: 4006001|||81.50|Inv Loc: 4006001; OR Loc: 4006001|44.82|
24735|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOLDER-TRANSDUCER SINGLE USE|1|<Self-pay>|<Self-pay>|<Self-pay>|29.05|Inv Loc: 4006001; OR Loc: 4006001|||29.05|Inv Loc: 4006001; OR Loc: 4006001|15.98|
21780|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BINDER-ABDOMINAL 9" 46"-62"|1|<Self-pay>|<Self-pay>|<Self-pay>|61.60|Inv Loc: 4006001; OR Loc: 4006001|||61.60|Inv Loc: 4006001; OR Loc: 4006001|33.88|
21844|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BINDER-ABDOMINAL 12" 46"-62"|1|<Self-pay>|<Self-pay>|<Self-pay>|73.25|Inv Loc: 4006001; OR Loc: 4006001|||73.25|Inv Loc: 4006001; OR Loc: 4006001|40.29|
23044|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ARMBOARD-A-LINE ADULT 650|1|<Self-pay>|<Self-pay>|<Self-pay>|28.60|Inv Loc: 4006001; OR Loc: 4006001|||28.60|Inv Loc: 4006001; OR Loc: 4006001|15.73|
23055|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BINDER-ABDOMINAL 12" 60-75"|1|<Self-pay>|<Self-pay>|<Self-pay>|91.95|Inv Loc: 4006001; OR Loc: 4006001|||91.95|Inv Loc: 4006001; OR Loc: 4006001|50.57|
23574|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BINDER-ABDOMINAL 9" 30"-45"|1|<Self-pay>|<Self-pay>|<Self-pay>|53.05|Inv Loc: 4006001; OR Loc: 4006001|||53.05|Inv Loc: 4006001; OR Loc: 4006001|29.18|
20995|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STETHOSCOPE-ESOPHAGEAL 18FR (400 SERIES)|1|<Self-pay>|<Self-pay>|<Self-pay>|10.55|Inv Loc: 4006001; OR Loc: 4006001|||10.55|Inv Loc: 4006001; OR Loc: 4006001|5.80|
22094|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RESTRAINT-LIMB HOLDER M2029|1|<Self-pay>|<Self-pay>|<Self-pay>|10.75|Inv Loc: 4006001; OR Loc: 4006001|||10.75|Inv Loc: 4006001; OR Loc: 4006001|5.91|
23176|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PILLOW-SHOULDER ABDUCTION LARGE *LATEX|1|<Self-pay>|<Self-pay>|<Self-pay>|251.45|Inv Loc: 4006001; OR Loc: 4006001|||251.45|Inv Loc: 4006001; OR Loc: 4006001|138.30|
24217|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PILLOW-SHOULDER ABDUCTION SMALL *LATEX|1|<Self-pay>|<Self-pay>|<Self-pay>|250.35|Inv Loc: 4006001; OR Loc: 4006001|||250.35|Inv Loc: 4006001; OR Loc: 4006001|137.69|
24900|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WRAP-COBAN 2" SELF AHESIVE 30-402|1|<Self-pay>|<Self-pay>|<Self-pay>|32.25|Inv Loc: 4006001; OR Loc: 4006001|||32.25|Inv Loc: 4006001; OR Loc: 4006001|17.74|
23175|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PILLOW-SHOULDER ABDUCTION MEDIUM *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|204.90|Inv Loc: 4006001; OR Loc: 4006001|||204.90|Inv Loc: 4006001; OR Loc: 4006001|112.69|
22193|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PROTECTOR-EYE OPTIGUARD (DU28300)|1|<Self-pay>|<Self-pay>|<Self-pay>|25.20|Inv Loc: 4006001; OR Loc: 4006001|||25.20|Inv Loc: 4006001; OR Loc: 4006001|13.86|
20428|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLE-RELOAD 55MM TCR55|1|<Self-pay>|<Self-pay>|<Self-pay>|235.50|Inv Loc: 4006001; OR Loc: 4006001|||235.50|Inv Loc: 4006001; OR Loc: 4006001|129.52|
20429|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLE-RELOAD 75MM TCR75|1|<Self-pay>|<Self-pay>|<Self-pay>|351.40|Inv Loc: 4006001; OR Loc: 4006001|||351.40|Inv Loc: 4006001; OR Loc: 4006001|193.27|
20848|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-CIRCULAR 29MM|1|<Self-pay>|<Self-pay>|<Self-pay>|742.29|Inv Loc: 4006001; OR Loc: 4006001|||742.29|Inv Loc: 4006001; OR Loc: 4006001|408.26|
20849|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-CIRCULAR 25MM|1|<Self-pay>|<Self-pay>|<Self-pay>|742.26|Inv Loc: 4006001; OR Loc: 4006001|||742.26|Inv Loc: 4006001; OR Loc: 4006001|408.24|
20854|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-55MM LINEAR|1|<Self-pay>|<Self-pay>|<Self-pay>|439.40|Inv Loc: 4006001; OR Loc: 4006001|||439.40|Inv Loc: 4006001; OR Loc: 4006001|241.67|
20859|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-CIRCULAR 33MM|1|<Self-pay>|<Self-pay>|<Self-pay>|744.09|Inv Loc: 4006001; OR Loc: 4006001|||744.09|Inv Loc: 4006001; OR Loc: 4006001|409.25|
20860|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-75MM LINEAR CUTTER (TLC75)|1|<Self-pay>|<Self-pay>|<Self-pay>|655.70|Inv Loc: 4006001; OR Loc: 4006001|||655.70|Inv Loc: 4006001; OR Loc: 4006001|360.63|
21852|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-SKIN 35REG PXR35|1|<Self-pay>|<Self-pay>|<Self-pay>|35.70|Inv Loc: 4006001; OR Loc: 4006001|||35.70|Inv Loc: 4006001; OR Loc: 4006001|19.63|
22328|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PEANUT-ENDO 5MM|1|<Self-pay>|<Self-pay>|<Self-pay>|73.90|Inv Loc: 4006001; OR Loc: 4006001|||73.90|Inv Loc: 4006001; OR Loc: 4006001|40.64|
21572|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-LAVAGE 24FR|1|<Self-pay>|<Self-pay>|<Self-pay>|43.60|Inv Loc: 4006001; OR Loc: 4006001|||43.60|Inv Loc: 4006001; OR Loc: 4006001|23.98|
21584|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-LAVAGE 32FR (2132)|1|<Self-pay>|<Self-pay>|<Self-pay>|43.60|Inv Loc: 4006001; OR Loc: 4006001|||43.60|Inv Loc: 4006001; OR Loc: 4006001|23.98|
21592|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-LAVAGE 36FR (2136)|1|<Self-pay>|<Self-pay>|<Self-pay>|43.70|Inv Loc: 4006001; OR Loc: 4006001|||43.70|Inv Loc: 4006001; OR Loc: 4006001|24.03|
21855|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|OSTOMY-POST OP POUCH 9764 (CTF UP TO 4") LF|1|<Self-pay>|<Self-pay>|<Self-pay>|59.70|Inv Loc: 4006001; OR Loc: 4006001|||59.70|Inv Loc: 4006001; OR Loc: 4006001|32.83|
23968|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|OSTOMY-COLOSTOMY KIT 2 3/4" 19004|1|<Self-pay>|<Self-pay>|<Self-pay>|17.00|Inv Loc: 4006001; OR Loc: 4006001|||17.00|Inv Loc: 4006001; OR Loc: 4006001|9.35|
23969|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|OSTOMY-COLOSTOMY KIT 2 1/4" 19003|1|<Self-pay>|<Self-pay>|<Self-pay>|17.00|Inv Loc: 4006001; OR Loc: 4006001|||17.00|Inv Loc: 4006001; OR Loc: 4006001|9.35|
23991|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|OSTOMY-SKIN BARRIER 4"14606(BACK UP BARRIERS|1|<Self-pay>|<Self-pay>|<Self-pay>|17.35|Inv Loc: 4006001; OR Loc: 4006001|||17.35|Inv Loc: 4006001; OR Loc: 4006001|9.54|
22124|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LOOPS-LIGA MINI VL-201|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
23099|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAP-FINGER GRASPING DEVICE (9906)|1|<Self-pay>|<Self-pay>|<Self-pay>|63.90|Inv Loc: 4006001; OR Loc: 4006001|||63.90|Inv Loc: 4006001; OR Loc: 4006001|35.14|
20941|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-ENDOTRACH ORAL RAE 5.5 CUFFED|1|<Self-pay>|<Self-pay>|<Self-pay>|20.80|Inv Loc: 4006001; OR Loc: 4006001|||20.80|Inv Loc: 4006001; OR Loc: 4006001|11.44|
20942|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-ENDOTRACH ORAL RAE 6.0 CUFFED|1|<Self-pay>|<Self-pay>|<Self-pay>|20.80|Inv Loc: 4006001; OR Loc: 4006001|||20.80|Inv Loc: 4006001; OR Loc: 4006001|11.44|
20943|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-ENDOTRACH ORAL RAE 6.5 CUFFED|1|<Self-pay>|<Self-pay>|<Self-pay>|20.80|Inv Loc: 4006001; OR Loc: 4006001|||20.80|Inv Loc: 4006001; OR Loc: 4006001|11.44|
20944|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-ENDOTRACH ORAL RAE 7.0 CUFF|1|<Self-pay>|<Self-pay>|<Self-pay>|20.80|Inv Loc: 4006001; OR Loc: 4006001|||20.80|Inv Loc: 4006001; OR Loc: 4006001|11.44|
24165|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBE-TRACH 6.0 EXTENDED DISTAL 60XLTCD|1|<Self-pay>|<Self-pay>|<Self-pay>|315.05|Inv Loc: 4006001; OR Loc: 4006001|||315.05|Inv Loc: 4006001; OR Loc: 4006001|173.28|
21288|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOURNICOT-MEDIUM TCM|1|<Self-pay>|<Self-pay>|<Self-pay>|15.45|Inv Loc: 4006001; OR Loc: 4006001|||15.45|Inv Loc: 4006001; OR Loc: 4006001|8.50|
25030|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SET-AIRWAY ADAPTER (NOMOLINE SAMPLING LINE)|1|<Self-pay>|<Self-pay>|<Self-pay>|63.25|Inv Loc: 4006001; OR Loc: 4006001|||63.25|Inv Loc: 4006001; OR Loc: 4006001|34.79|
20996|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INTUBATING STYLET 14FR|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
22069|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BAG-PRESSURE INFUSOR-500CC|1|<Self-pay>|<Self-pay>|<Self-pay>|38.10|Inv Loc: 4006001; OR Loc: 4006001|||38.10|Inv Loc: 4006001; OR Loc: 4006001|20.95|
22095|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RETRIEVER-SUTURE|1|<Self-pay>|<Self-pay>|<Self-pay>|200.50|Inv Loc: 4006001; OR Loc: 4006001|||200.50|Inv Loc: 4006001; OR Loc: 4006001|110.27|
22155|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-ELASTIC 3" STERILE|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
22156|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-ELASTIC 4" STERILE|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
22157|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-ELASTIC 6" STERILE|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
22923|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-TUOHY 18GA 6"|1|<Self-pay>|<Self-pay>|<Self-pay>|778.40|Inv Loc: 4006001; OR Loc: 4006001|||778.40|Inv Loc: 4006001; OR Loc: 4006001|428.12|
23563|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PAD-DUAL DISPERSIVE ELECTRODE 9165|1|<Self-pay>|<Self-pay>|<Self-pay>|12.50|Inv Loc: 4006001; OR Loc: 4006001|||12.50|Inv Loc: 4006001; OR Loc: 4006001|6.87|
23976|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOWELS-STERILE 6PK|1|<Self-pay>|<Self-pay>|<Self-pay>|13.95|Inv Loc: 4006001; OR Loc: 4006001|||13.95|Inv Loc: 4006001; OR Loc: 4006001|7.67|
23984|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TOWELS-STERILE 2PK XRAY DETECTABLE(OR)|1|<Self-pay>|<Self-pay>|<Self-pay>|11.45|Inv Loc: 4006001; OR Loc: 4006001|||11.45|Inv Loc: 4006001; OR Loc: 4006001|6.30|
24222|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AIRWAY-NASOPHARYNGEAL 34FR LTX FR|1|<Self-pay>|<Self-pay>|<Self-pay>|19.55|Inv Loc: 4006001; OR Loc: 4006001|||19.55|Inv Loc: 4006001; OR Loc: 4006001|10.75|
24664|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH LG SHORT 3634LF|1|<Self-pay>|<Self-pay>|<Self-pay>|68.05|Inv Loc: 4006001; OR Loc: 4006001|||68.05|Inv Loc: 4006001; OR Loc: 4006001|37.43|
24887|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ADHESIVE-SKIN AFFIX|1|<Self-pay>|<Self-pay>|<Self-pay>|56.70|Inv Loc: 4006001; OR Loc: 4006001|||56.70|Inv Loc: 4006001; OR Loc: 4006001|31.18|
24962|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SYRINGE 5CC GLASS SLIP TIP LOSS RESISTANCE|1|<Self-pay>|<Self-pay>|<Self-pay>|746.60|Inv Loc: 4006001; OR Loc: 4006001|||746.60|Inv Loc: 4006001; OR Loc: 4006001|410.63|
25117|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANISTER RIGID 2000CC DISPOSABLE|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25118|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CANISTER RIGID 3000CC DISPOSABLE|1|<Self-pay>|<Self-pay>|<Self-pay>|19.80|Inv Loc: 4006001; OR Loc: 4006001|||19.80|Inv Loc: 4006001; OR Loc: 4006001|10.89|
22049|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BOVIE HANDTROL (ESPB3002)|1|<Self-pay>|<Self-pay>|<Self-pay>|25.85|Inv Loc: 4006001; OR Loc: 4006001|||25.85|Inv Loc: 4006001; OR Loc: 4006001|14.22|
24750|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BAG-PRESSURE INFUSOR-3000CC (IN950006)|1|<Self-pay>|<Self-pay>|<Self-pay>|61.55|Inv Loc: 4006001; OR Loc: 4006001|||61.55|Inv Loc: 4006001; OR Loc: 4006001|33.85|
21349|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BRUSH-BRONCHOSCOPY CYTOLOGY|1|<Self-pay>|<Self-pay>|<Self-pay>|67.15|Inv Loc: 4006001; OR Loc: 4006001|||67.15|Inv Loc: 4006001; OR Loc: 4006001|36.93|
21393|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|VALVE-BIOPSY BRONCH 52898 (MAJ-210)|1|<Self-pay>|<Self-pay>|<Self-pay>|473.25|Inv Loc: 4006001; OR Loc: 4006001|||473.25|Inv Loc: 4006001; OR Loc: 4006001|260.29|
21394|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|VALVE-SUCTION BRONCH 52897 (MAJ-209)|1|<Self-pay>|<Self-pay>|<Self-pay>|662.01|Inv Loc: 4006001; OR Loc: 4006001|||662.01|Inv Loc: 4006001; OR Loc: 4006001|364.11|
22126|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SNARE-POLYPECTOMY SD-210U-25|1|<Self-pay>|<Self-pay>|<Self-pay>|43.50|Inv Loc: 4006001; OR Loc: 4006001|||43.50|Inv Loc: 4006001; OR Loc: 4006001|23.92|
22132|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SNARE-POLYPECTOMY MINILOOP SD-210U-10|1|<Self-pay>|<Self-pay>|<Self-pay>|43.50|Inv Loc: 4006001; OR Loc: 4006001|||43.50|Inv Loc: 4006001; OR Loc: 4006001|23.92|
22136|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEPS-BIOPSY EGD FB-220U.A|1|<Self-pay>|<Self-pay>|<Self-pay>|31.60|Inv Loc: 4006001; OR Loc: 4006001|||31.60|Inv Loc: 4006001; OR Loc: 4006001|17.38|
22504|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEPS-BRONCH (DISP) FB-211D|1|<Self-pay>|<Self-pay>|<Self-pay>|121.55|Inv Loc: 4006001; OR Loc: 4006001|||121.55|Inv Loc: 4006001; OR Loc: 4006001|66.85|
23666|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEP-HOT BIOPSY  FD-230U|1|<Self-pay>|<Self-pay>|<Self-pay>|82.60|Inv Loc: 4006001; OR Loc: 4006001|||82.60|Inv Loc: 4006001; OR Loc: 4006001|45.43|
23672|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BASKET-RETRIEVAL 3-WIRE SPIRAL|1|<Self-pay>|<Self-pay>|<Self-pay>|604.11|Inv Loc: 4006001; OR Loc: 4006001|||604.11|Inv Loc: 4006001; OR Loc: 4006001|332.26|
24699|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PROBE-BIPOLAR HEMASTASIS SOLAR PROBE SNGL PLG|1|<Self-pay>|<Self-pay>|<Self-pay>|712.70|Inv Loc: 4006001; OR Loc: 4006001|||712.70|Inv Loc: 4006001; OR Loc: 4006001|391.98|
24728|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEPS-BIOPSY COLON FB222U (JUMBO BITE)|1|<Self-pay>|<Self-pay>|<Self-pay>|63.10|Inv Loc: 4006001; OR Loc: 4006001|||63.10|Inv Loc: 4006001; OR Loc: 4006001|34.70|
24700|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SMOKE EVACUATOR-LAPARASCOPIC|1|<Self-pay>|<Self-pay>|<Self-pay>|75.00|Inv Loc: 4006001; OR Loc: 4006001|||75.00|Inv Loc: 4006001; OR Loc: 4006001|41.25|
21227|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-CATHETER TROCAR 28FR 565044|1|<Self-pay>|<Self-pay>|<Self-pay>|147.45|Inv Loc: 4006001; OR Loc: 4006001|||147.45|Inv Loc: 4006001; OR Loc: 4006001|81.10|
24120|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RETRIEVER-NET (FOR EGD/COLON)(NEW-00711050)|1|<Self-pay>|<Self-pay>|<Self-pay>|450.00|Inv Loc: 4006001; OR Loc: 4006001|||450.00|Inv Loc: 4006001; OR Loc: 4006001|247.50|
24817|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FORCEP-GRASPING QUAD WIRE 00711175|1|<Self-pay>|<Self-pay>|<Self-pay>|695.00|Inv Loc: 4006001; OR Loc: 4006001|||695.00|Inv Loc: 4006001; OR Loc: 4006001|382.25|
21026|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BRACE-KNEE 19" 1882-500-19|1|<Self-pay>|<Self-pay>|<Self-pay>|475.00|Inv Loc: 4006001; OR Loc: 4006001|||475.00|Inv Loc: 4006001; OR Loc: 4006001|261.25|
21030|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BRACE-KNEE 24" 1882-500-24|1|<Self-pay>|<Self-pay>|<Self-pay>|550.00|Inv Loc: 4006001; OR Loc: 4006001|||550.00|Inv Loc: 4006001; OR Loc: 4006001|302.50|
23853|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-POSTERIOR TIBIA/FIBULA PADDED KNEELGTH|1|<Self-pay>|<Self-pay>|<Self-pay>|330.00|Inv Loc: 4006001; OR Loc: 4006001|||330.00|Inv Loc: 4006001; OR Loc: 4006001|181.50|
21118|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SPLINT-ONE STEP 5X30 (76530)|1|<Self-pay>|<Self-pay>|<Self-pay>|64.10|Inv Loc: 4006001; OR Loc: 4006001|||64.10|Inv Loc: 4006001; OR Loc: 4006001|35.25|
21161|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PILLOW-ABDUCTION MED M60-076-M|1|<Self-pay>|<Self-pay>|<Self-pay>|107.60|Inv Loc: 4006001; OR Loc: 4006001|||107.60|Inv Loc: 4006001; OR Loc: 4006001|59.18|
21612|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BAG-URINARY LEG,MEDIUM,19OZ|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21853|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ANTI-FOG SOLUTION (31142527)|1|<Self-pay>|<Self-pay>|<Self-pay>|11.15|Inv Loc: 4006001; OR Loc: 4006001|||11.15|Inv Loc: 4006001; OR Loc: 4006001|6.13|
22002|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP MEN MEDIUM (106725)|1|<Self-pay>|<Self-pay>|<Self-pay>|76.35|Inv Loc: 4006001; OR Loc: 4006001|||76.35|Inv Loc: 4006001; OR Loc: 4006001|41.99|
22114|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BONE CUBES-CANCELLOUS 15CC-5MM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,125.00|Inv Loc: 4006001; OR Loc: 4006001|||1,125.00|Inv Loc: 4006001; OR Loc: 4006001|618.75|
23159|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TUBING-INSUFFLATION TM-6000|1|<Self-pay>|<Self-pay>|<Self-pay>|21.75|Inv Loc: 4006001; OR Loc: 4006001|||21.75|Inv Loc: 4006001; OR Loc: 4006001|11.96|
24219|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|AIRWAY-NASOPHARYNGEAL 28FR LTX FR|1|<Self-pay>|<Self-pay>|<Self-pay>|19.45|Inv Loc: 4006001; OR Loc: 4006001|||19.45|Inv Loc: 4006001; OR Loc: 4006001|10.70|
24638|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTRODE-BLADE 6" EXTENDED INSULATION 139110|1|<Self-pay>|<Self-pay>|<Self-pay>|18.75|Inv Loc: 4006001; OR Loc: 4006001|||18.75|Inv Loc: 4006001; OR Loc: 4006001|10.31|
24660|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH SMALL SHORT 3071LF|1|<Self-pay>|<Self-pay>|<Self-pay>|68.85|Inv Loc: 4006001; OR Loc: 4006001|||68.85|Inv Loc: 4006001; OR Loc: 4006001|37.87|
24667|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HOSE-THIGH XLG LONG 3182|1|<Self-pay>|<Self-pay>|<Self-pay>|45.00|Inv Loc: 4006001; OR Loc: 4006001|||45.00|Inv Loc: 4006001; OR Loc: 4006001|24.75|
20066|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-1/4 TUB. 242.13 3H 25MM|1|<Self-pay>|<Self-pay>|<Self-pay>|115.00|Inv Loc: 4006001; OR Loc: 4006001|||115.00|Inv Loc: 4006001; OR Loc: 4006001|63.25|
20067|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-1/4 TUB. 242.14 4H 33MM|1|<Self-pay>|<Self-pay>|<Self-pay>|250.00|Inv Loc: 4006001; OR Loc: 4006001|||250.00|Inv Loc: 4006001; OR Loc: 4006001|137.50|
20068|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-1/4 TUB. 242.15 5H 41MM|1|<Self-pay>|<Self-pay>|<Self-pay>|225.00|Inv Loc: 4006001; OR Loc: 4006001|||225.00|Inv Loc: 4006001; OR Loc: 4006001|123.75|
20069|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-1/4 TUB. 242.16 6H 49MM|1|<Self-pay>|<Self-pay>|<Self-pay>|585.00|Inv Loc: 4006001; OR Loc: 4006001|||585.00|Inv Loc: 4006001; OR Loc: 4006001|321.75|
20070|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-1/4 TUB. 242.17 7H 57MM|1|<Self-pay>|<Self-pay>|<Self-pay>|180.00|Inv Loc: 4006001; OR Loc: 4006001|||180.00|Inv Loc: 4006001; OR Loc: 4006001|99.00|
20071|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-1/4 TUB. 242.18 8H 65MM|1|<Self-pay>|<Self-pay>|<Self-pay>|165.00|Inv Loc: 4006001; OR Loc: 4006001|||165.00|Inv Loc: 4006001; OR Loc: 4006001|90.75|
20072|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-L MINI OBL LT 242.33 3H 2.7MM|1|<Self-pay>|<Self-pay>|<Self-pay>|95.00|Inv Loc: 4006001; OR Loc: 4006001|||95.00|Inv Loc: 4006001; OR Loc: 4006001|52.25|
20073|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-T SMALL 242.41|1|<Self-pay>|<Self-pay>|<Self-pay>|196.25|Inv Loc: 4006001; OR Loc: 4006001|||196.25|Inv Loc: 4006001; OR Loc: 4006001|107.94|
20074|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-MINI STRAIGHT 243.13 3H|1|<Self-pay>|<Self-pay>|<Self-pay>|140.00|Inv Loc: 4006001; OR Loc: 4006001|||140.00|Inv Loc: 4006001; OR Loc: 4006001|77.00|
20075|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-MINI STRAIGHT 243.14 4H|1|<Self-pay>|<Self-pay>|<Self-pay>|142.50|Inv Loc: 4006001; OR Loc: 4006001|||142.50|Inv Loc: 4006001; OR Loc: 4006001|78.37|
20076|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-MINI STRAIGHT 243.15 5H|1|<Self-pay>|<Self-pay>|<Self-pay>|337.50|Inv Loc: 4006001; OR Loc: 4006001|||337.50|Inv Loc: 4006001; OR Loc: 4006001|185.62|
20077|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-L MINI OBL LT 243.33 2H 2.0MM|1|<Self-pay>|<Self-pay>|<Self-pay>|196.25|Inv Loc: 4006001; OR Loc: 4006001|||196.25|Inv Loc: 4006001; OR Loc: 4006001|107.94|
20078|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-T MINI 243.41|1|<Self-pay>|<Self-pay>|<Self-pay>|260.00|Inv Loc: 4006001; OR Loc: 4006001|||260.00|Inv Loc: 4006001; OR Loc: 4006001|143.00|
20139|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-L MINI OBL RT 243.34 2H|1|<Self-pay>|<Self-pay>|<Self-pay>|95.00|Inv Loc: 4006001; OR Loc: 4006001|||95.00|Inv Loc: 4006001; OR Loc: 4006001|52.25|
20140|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLATE-L MINI OBL RT 242.34 3H 2.7MM|1|<Self-pay>|<Self-pay>|<Self-pay>|166.25|Inv Loc: 4006001; OR Loc: 4006001|||166.25|Inv Loc: 4006001; OR Loc: 4006001|91.44|
20178|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.007|1|<Self-pay>|<Self-pay>|<Self-pay>|28.50|Inv Loc: 4006001; OR Loc: 4006001|||28.50|Inv Loc: 4006001; OR Loc: 4006001|15.67|
20179|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.008|1|<Self-pay>|<Self-pay>|<Self-pay>|48.50|Inv Loc: 4006001; OR Loc: 4006001|||48.50|Inv Loc: 4006001; OR Loc: 4006001|26.67|
20180|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.009|1|<Self-pay>|<Self-pay>|<Self-pay>|44.50|Inv Loc: 4006001; OR Loc: 4006001|||44.50|Inv Loc: 4006001; OR Loc: 4006001|24.47|
20181|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.010|1|<Self-pay>|<Self-pay>|<Self-pay>|78.75|Inv Loc: 4006001; OR Loc: 4006001|||78.75|Inv Loc: 4006001; OR Loc: 4006001|43.31|
20182|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.011|1|<Self-pay>|<Self-pay>|<Self-pay>|28.50|Inv Loc: 4006001; OR Loc: 4006001|||28.50|Inv Loc: 4006001; OR Loc: 4006001|15.67|
20183|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.012|1|<Self-pay>|<Self-pay>|<Self-pay>|28.50|Inv Loc: 4006001; OR Loc: 4006001|||28.50|Inv Loc: 4006001; OR Loc: 4006001|15.67|
20184|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.014|1|<Self-pay>|<Self-pay>|<Self-pay>|28.50|Inv Loc: 4006001; OR Loc: 4006001|||28.50|Inv Loc: 4006001; OR Loc: 4006001|15.67|
20185|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.016|1|<Self-pay>|<Self-pay>|<Self-pay>|28.50|Inv Loc: 4006001; OR Loc: 4006001|||28.50|Inv Loc: 4006001; OR Loc: 4006001|15.67|
20186|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.006|1|<Self-pay>|<Self-pay>|<Self-pay>|44.50|Inv Loc: 4006001; OR Loc: 4006001|||44.50|Inv Loc: 4006001; OR Loc: 4006001|24.47|
20187|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.008|1|<Self-pay>|<Self-pay>|<Self-pay>|102.50|Inv Loc: 4006001; OR Loc: 4006001|||102.50|Inv Loc: 4006001; OR Loc: 4006001|56.37|
20188|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.010|1|<Self-pay>|<Self-pay>|<Self-pay>|102.50|Inv Loc: 4006001; OR Loc: 4006001|||102.50|Inv Loc: 4006001; OR Loc: 4006001|56.37|
20189|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.012|1|<Self-pay>|<Self-pay>|<Self-pay>|102.50|Inv Loc: 4006001; OR Loc: 4006001|||102.50|Inv Loc: 4006001; OR Loc: 4006001|56.37|
20190|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.014|1|<Self-pay>|<Self-pay>|<Self-pay>|102.50|Inv Loc: 4006001; OR Loc: 4006001|||102.50|Inv Loc: 4006001; OR Loc: 4006001|56.37|
20191|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.016|1|<Self-pay>|<Self-pay>|<Self-pay>|93.75|Inv Loc: 4006001; OR Loc: 4006001|||93.75|Inv Loc: 4006001; OR Loc: 4006001|51.56|
20192|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.018|1|<Self-pay>|<Self-pay>|<Self-pay>|28.50|Inv Loc: 4006001; OR Loc: 4006001|||28.50|Inv Loc: 4006001; OR Loc: 4006001|15.67|
20193|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.0MM CORTEX 201.020|1|<Self-pay>|<Self-pay>|<Self-pay>|28.50|Inv Loc: 4006001; OR Loc: 4006001|||28.50|Inv Loc: 4006001; OR Loc: 4006001|15.67|
20194|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.006|1|<Self-pay>|<Self-pay>|<Self-pay>|43.00|Inv Loc: 4006001; OR Loc: 4006001|||43.00|Inv Loc: 4006001; OR Loc: 4006001|23.65|
20195|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.008|1|<Self-pay>|<Self-pay>|<Self-pay>|27.50|Inv Loc: 4006001; OR Loc: 4006001|||27.50|Inv Loc: 4006001; OR Loc: 4006001|15.12|
20196|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.010|1|<Self-pay>|<Self-pay>|<Self-pay>|88.75|Inv Loc: 4006001; OR Loc: 4006001|||88.75|Inv Loc: 4006001; OR Loc: 4006001|48.81|
20197|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.012|1|<Self-pay>|<Self-pay>|<Self-pay>|208.75|Inv Loc: 4006001; OR Loc: 4006001|||208.75|Inv Loc: 4006001; OR Loc: 4006001|114.81|
20198|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.014|1|<Self-pay>|<Self-pay>|<Self-pay>|97.50|Inv Loc: 4006001; OR Loc: 4006001|||97.50|Inv Loc: 4006001; OR Loc: 4006001|53.62|
20199|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.016|1|<Self-pay>|<Self-pay>|<Self-pay>|195.00|Inv Loc: 4006001; OR Loc: 4006001|||195.00|Inv Loc: 4006001; OR Loc: 4006001|107.25|
20200|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.018|1|<Self-pay>|<Self-pay>|<Self-pay>|49.00|Inv Loc: 4006001; OR Loc: 4006001|||49.00|Inv Loc: 4006001; OR Loc: 4006001|26.95|
20201|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.020|1|<Self-pay>|<Self-pay>|<Self-pay>|327.50|Inv Loc: 4006001; OR Loc: 4006001|||327.50|Inv Loc: 4006001; OR Loc: 4006001|180.12|
20202|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.022|1|<Self-pay>|<Self-pay>|<Self-pay>|27.50|Inv Loc: 4006001; OR Loc: 4006001|||27.50|Inv Loc: 4006001; OR Loc: 4006001|15.12|
20203|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 2.7MM CORTEX 202.024|1|<Self-pay>|<Self-pay>|<Self-pay>|46.50|Inv Loc: 4006001; OR Loc: 4006001|||46.50|Inv Loc: 4006001; OR Loc: 4006001|25.57|
20292|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MINI 1.5MM CORTEX 200.006|1|<Self-pay>|<Self-pay>|<Self-pay>|28.00|Inv Loc: 4006001; OR Loc: 4006001|||28.00|Inv Loc: 4006001; OR Loc: 4006001|15.40|
20307|SUP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|GUIDEWIRE-DRILL TIP ACUFEX 013978|1|<Self-pay>|<Self-pay>|<Self-pay>|232.25|Inv Loc: 4006001; OR Loc: 4006001|||232.25|Inv Loc: 4006001; OR Loc: 4006001|127.74|
20309|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN 3/32" 1625-38-000|1|<Self-pay>|<Self-pay>|<Self-pay>|13.50|Inv Loc: 4006001; OR Loc: 4006001|||13.50|Inv Loc: 4006001; OR Loc: 4006001|7.42|
20310|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .062 9" KM172-29-62|1|<Self-pay>|<Self-pay>|<Self-pay>|11.85|Inv Loc: 4006001; OR Loc: 4006001|||11.85|Inv Loc: 4006001; OR Loc: 4006001|6.52|
20313|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-CERCLAGE W/EYE 1.00MM 291.01|1|<Self-pay>|<Self-pay>|<Self-pay>|26.25|Inv Loc: 4006001; OR Loc: 4006001|||26.25|Inv Loc: 4006001; OR Loc: 4006001|14.44|
20314|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-CERCLAGE COIL 1.00MM 291.05|1|<Self-pay>|<Self-pay>|<Self-pay>|110.05|Inv Loc: 4006001; OR Loc: 4006001|||110.05|Inv Loc: 4006001; OR Loc: 4006001|60.53|
20317|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K-THREADED .035 KM172-29-35|1|<Self-pay>|<Self-pay>|<Self-pay>|32.50|Inv Loc: 4006001; OR Loc: 4006001|||32.50|Inv Loc: 4006001; OR Loc: 4006001|17.87|
20319|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-CERCLAGE W/EYE 1.25MM 291.02|1|<Self-pay>|<Self-pay>|<Self-pay>|48.25|Inv Loc: 4006001; OR Loc: 4006001|||48.25|Inv Loc: 4006001; OR Loc: 4006001|26.54|
20320|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-CERCLAGE COIL 1.25MM 291.06|1|<Self-pay>|<Self-pay>|<Self-pay>|160.00|Inv Loc: 4006001; OR Loc: 4006001|||160.00|Inv Loc: 4006001; OR Loc: 4006001|88.00|
20321|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K THREADED .062 KM172-29-62|1|<Self-pay>|<Self-pay>|<Self-pay>|32.50|Inv Loc: 4006001; OR Loc: 4006001|||32.50|Inv Loc: 4006001; OR Loc: 4006001|17.87|
20322|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K-THREADED .054 KM172-29-54|1|<Self-pay>|<Self-pay>|<Self-pay>|32.50|Inv Loc: 4006001; OR Loc: 4006001|||32.50|Inv Loc: 4006001; OR Loc: 4006001|17.87|
20323|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K-THREADED .045 KM172-29-45|1|<Self-pay>|<Self-pay>|<Self-pay>|32.50|Inv Loc: 4006001; OR Loc: 4006001|||32.50|Inv Loc: 4006001; OR Loc: 4006001|17.87|
20324|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .062 4" KM172-24-62|1|<Self-pay>|<Self-pay>|<Self-pay>|11.85|Inv Loc: 4006001; OR Loc: 4006001|||11.85|Inv Loc: 4006001; OR Loc: 4006001|6.52|
20325|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .054 4" KM172-24-54|1|<Self-pay>|<Self-pay>|<Self-pay>|11.85|Inv Loc: 4006001; OR Loc: 4006001|||11.85|Inv Loc: 4006001; OR Loc: 4006001|6.52|
20326|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .054 9" KM172-29-54|1|<Self-pay>|<Self-pay>|<Self-pay>|11.85|Inv Loc: 4006001; OR Loc: 4006001|||11.85|Inv Loc: 4006001; OR Loc: 4006001|6.52|
20327|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .045 4" KM172-24-45|1|<Self-pay>|<Self-pay>|<Self-pay>|11.85|Inv Loc: 4006001; OR Loc: 4006001|||11.85|Inv Loc: 4006001; OR Loc: 4006001|6.52|
20328|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .045 9" KM172-29-45|1|<Self-pay>|<Self-pay>|<Self-pay>|11.85|Inv Loc: 4006001; OR Loc: 4006001|||11.85|Inv Loc: 4006001; OR Loc: 4006001|6.52|
20329|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .035 4" KM172-24-35|1|<Self-pay>|<Self-pay>|<Self-pay>|11.85|Inv Loc: 4006001; OR Loc: 4006001|||11.85|Inv Loc: 4006001; OR Loc: 4006001|6.52|
20330|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .035 9" KM172-29-35|1|<Self-pay>|<Self-pay>|<Self-pay>|11.40|Inv Loc: 4006001; OR Loc: 4006001|||11.40|Inv Loc: 4006001; OR Loc: 4006001|6.27|
20334|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN THR 5/64" 1617-60-000|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|Inv Loc: 4006001; OR Loc: 4006001|||41.25|Inv Loc: 4006001; OR Loc: 4006001|22.69|
20345|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-SHOULDER PASSING 2.4MM 013972|1|<Self-pay>|<Self-pay>|<Self-pay>|233.55|Inv Loc: 4006001; OR Loc: 4006001|||233.55|Inv Loc: 4006001; OR Loc: 4006001|128.45|
20346|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-PASSING 2.4MM 11" 013658**DNO**|1|<Self-pay>|<Self-pay>|<Self-pay>|439.90|Inv Loc: 4006001; OR Loc: 4006001|||439.90|Inv Loc: 4006001; OR Loc: 4006001|241.94|
20357|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN THR 3/32" KM169-29-33|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|Inv Loc: 4006001; OR Loc: 4006001|||41.25|Inv Loc: 4006001; OR Loc: 4006001|22.69|
20358|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN THR 7/64" KM169-29-76|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|Inv Loc: 4006001; OR Loc: 4006001|||41.25|Inv Loc: 4006001; OR Loc: 4006001|22.69|
20359|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN THR 1/8" KM169-29-18|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|Inv Loc: 4006001; OR Loc: 4006001|||41.25|Inv Loc: 4006001; OR Loc: 4006001|22.69|
20360|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN THR 9/64" KM169-29-96|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|Inv Loc: 4006001; OR Loc: 4006001|||41.25|Inv Loc: 4006001; OR Loc: 4006001|22.69|
20361|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN THR 5/32" KM169-29-53|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|Inv Loc: 4006001; OR Loc: 4006001|||41.25|Inv Loc: 4006001; OR Loc: 4006001|22.69|
20362|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN THR 3/16" KM169-29-31|1|<Self-pay>|<Self-pay>|<Self-pay>|41.25|Inv Loc: 4006001; OR Loc: 4006001|||41.25|Inv Loc: 4006001; OR Loc: 4006001|22.69|
20363|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN 5/64" KM168-29-56|1|<Self-pay>|<Self-pay>|<Self-pay>|13.50|Inv Loc: 4006001; OR Loc: 4006001|||13.50|Inv Loc: 4006001; OR Loc: 4006001|7.42|
20364|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN 7/64" KM168-29-76|1|<Self-pay>|<Self-pay>|<Self-pay>|12.95|Inv Loc: 4006001; OR Loc: 4006001|||12.95|Inv Loc: 4006001; OR Loc: 4006001|7.12|
20365|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN 1/8" KM168-29-18|1|<Self-pay>|<Self-pay>|<Self-pay>|16.90|Inv Loc: 4006001; OR Loc: 4006001|||16.90|Inv Loc: 4006001; OR Loc: 4006001|9.29|
20366|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN 5/32" KM168-29-53|1|<Self-pay>|<Self-pay>|<Self-pay>|17.25|Inv Loc: 4006001; OR Loc: 4006001|||17.25|Inv Loc: 4006001; OR Loc: 4006001|9.49|
20367|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN 3/16" KM168-29-31|1|<Self-pay>|<Self-pay>|<Self-pay>|21.40|Inv Loc: 4006001; OR Loc: 4006001|||21.40|Inv Loc: 4006001; OR Loc: 4006001|11.77|
20368|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN 9/64" 9" KM168-29-96|1|<Self-pay>|<Self-pay>|<Self-pay>|16.90|Inv Loc: 4006001; OR Loc: 4006001|||16.90|Inv Loc: 4006001; OR Loc: 4006001|9.29|
20369|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-GUIDE AR1297L W/EYE 2.4MM|1|<Self-pay>|<Self-pay>|<Self-pay>|340.00|Inv Loc: 4006001; OR Loc: 4006001|||340.00|Inv Loc: 4006001; OR Loc: 4006001|187.00|
20370|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-GUIDE AR1254 2MM|1|<Self-pay>|<Self-pay>|<Self-pay>|105.00|Inv Loc: 4006001; OR Loc: 4006001|||105.00|Inv Loc: 4006001; OR Loc: 4006001|57.75|
20372|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PIN-STEINMAN SGL TROCAR 3/32|1|<Self-pay>|<Self-pay>|<Self-pay>|13.50|Inv Loc: 4006001; OR Loc: 4006001|||13.50|Inv Loc: 4006001; OR Loc: 4006001|7.42|
20407|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|GUIDE PIN-ZIMMER HIP 1181-20|1|<Self-pay>|<Self-pay>|<Self-pay>|86.40|Inv Loc: 4006001; OR Loc: 4006001|||86.40|Inv Loc: 4006001; OR Loc: 4006001|47.52|
20805|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-POLYPROPYLENE 3X6|1|<Self-pay>|<Self-pay>|<Self-pay>|602.65|Inv Loc: 4006001; OR Loc: 4006001|||602.65|Inv Loc: 4006001; OR Loc: 4006001|331.46|
20869|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|HEMOCLIP CARTRIDGE MED  523700|1|<Self-pay>|<Self-pay>|<Self-pay>|50.70|Inv Loc: 4006001; OR Loc: 4006001|||50.70|Inv Loc: 4006001; OR Loc: 4006001|27.88|
20870|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CLIP APPLIER-MULTI MED MCM20|1|<Self-pay>|<Self-pay>|<Self-pay>|255.35|Inv Loc: 4006001; OR Loc: 4006001|||255.35|Inv Loc: 4006001; OR Loc: 4006001|140.44|
20871|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS X-SML SMOOTH (128691)|1|<Self-pay>|<Self-pay>|<Self-pay>|933.00|Inv Loc: 4006001; OR Loc: 4006001|||933.00|Inv Loc: 4006001; OR Loc: 4006001|513.15|
20874|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CLIP APPLIER-MULTI LARGE MCL20|1|<Self-pay>|<Self-pay>|<Self-pay>|249.65|Inv Loc: 4006001; OR Loc: 4006001|||249.65|Inv Loc: 4006001; OR Loc: 4006001|137.31|
20877|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS SM SMOOTH 128693|1|<Self-pay>|<Self-pay>|<Self-pay>|345.50|Inv Loc: 4006001; OR Loc: 4006001|||345.50|Inv Loc: 4006001; OR Loc: 4006001|190.02|
20878|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS MED SMOOTH 128695|1|<Self-pay>|<Self-pay>|<Self-pay>|345.50|Inv Loc: 4006001; OR Loc: 4006001|||345.50|Inv Loc: 4006001; OR Loc: 4006001|190.02|
20879|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS LRG SMOOTH (128697)|1|<Self-pay>|<Self-pay>|<Self-pay>|345.50|Inv Loc: 4006001; OR Loc: 4006001|||345.50|Inv Loc: 4006001; OR Loc: 4006001|190.02|
20880|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS X-SML SPIKED (128690)|1|<Self-pay>|<Self-pay>|<Self-pay>|627.48|Inv Loc: 4006001; OR Loc: 4006001|||627.48|Inv Loc: 4006001; OR Loc: 4006001|345.11|
20881|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS SML SPIKED (128692)|1|<Self-pay>|<Self-pay>|<Self-pay>|888.00|Inv Loc: 4006001; OR Loc: 4006001|||888.00|Inv Loc: 4006001; OR Loc: 4006001|488.40|
20882|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS MED SPIKED 128694|1|<Self-pay>|<Self-pay>|<Self-pay>|654.00|Inv Loc: 4006001; OR Loc: 4006001|||654.00|Inv Loc: 4006001; OR Loc: 4006001|359.70|
20883|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STAPLES-RICHARDS LRG SPIKED|1|<Self-pay>|<Self-pay>|<Self-pay>|901.38|Inv Loc: 4006001; OR Loc: 4006001|||901.38|Inv Loc: 4006001; OR Loc: 4006001|495.76|
22138|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLUG-MESH SMALL 112750|1|<Self-pay>|<Self-pay>|<Self-pay>|854.91|Inv Loc: 4006001; OR Loc: 4006001|||854.91|Inv Loc: 4006001; OR Loc: 4006001|470.20|
22139|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLUG-MESH MEDIUM 112760|1|<Self-pay>|<Self-pay>|<Self-pay>|859.11|Inv Loc: 4006001; OR Loc: 4006001|||859.11|Inv Loc: 4006001; OR Loc: 4006001|472.51|
22140|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PLUG-MESH LARGE 0112970|1|<Self-pay>|<Self-pay>|<Self-pay>|716.25|Inv Loc: 4006001; OR Loc: 4006001|||716.25|Inv Loc: 4006001; OR Loc: 4006001|393.94|
22243|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-75|1|<Self-pay>|<Self-pay>|<Self-pay>|922.50|Inv Loc: 4006001; OR Loc: 4006001|||922.50|Inv Loc: 4006001; OR Loc: 4006001|507.37|
22244|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-80|1|<Self-pay>|<Self-pay>|<Self-pay>|922.50|Inv Loc: 4006001; OR Loc: 4006001|||922.50|Inv Loc: 4006001; OR Loc: 4006001|507.37|
22245|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-85|1|<Self-pay>|<Self-pay>|<Self-pay>|822.50|Inv Loc: 4006001; OR Loc: 4006001|||822.50|Inv Loc: 4006001; OR Loc: 4006001|452.37|
22246|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-90|1|<Self-pay>|<Self-pay>|<Self-pay>|822.50|Inv Loc: 4006001; OR Loc: 4006001|||822.50|Inv Loc: 4006001; OR Loc: 4006001|452.37|
22247|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-95|1|<Self-pay>|<Self-pay>|<Self-pay>|796.50|Inv Loc: 4006001; OR Loc: 4006001|||796.50|Inv Loc: 4006001; OR Loc: 4006001|438.07|
22248|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-100|1|<Self-pay>|<Self-pay>|<Self-pay>|685.00|Inv Loc: 4006001; OR Loc: 4006001|||685.00|Inv Loc: 4006001; OR Loc: 4006001|376.75|
22249|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-105|1|<Self-pay>|<Self-pay>|<Self-pay>|796.50|Inv Loc: 4006001; OR Loc: 4006001|||796.50|Inv Loc: 4006001; OR Loc: 4006001|438.07|
22250|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-110|1|<Self-pay>|<Self-pay>|<Self-pay>|596.25|Inv Loc: 4006001; OR Loc: 4006001|||596.25|Inv Loc: 4006001; OR Loc: 4006001|327.94|
22251|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-115|1|<Self-pay>|<Self-pay>|<Self-pay>|591.60|Inv Loc: 4006001; OR Loc: 4006001|||591.60|Inv Loc: 4006001; OR Loc: 4006001|325.38|
22252|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-120|1|<Self-pay>|<Self-pay>|<Self-pay>|591.60|Inv Loc: 4006001; OR Loc: 4006001|||591.60|Inv Loc: 4006001; OR Loc: 4006001|325.38|
22253|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-125|1|<Self-pay>|<Self-pay>|<Self-pay>|591.60|Inv Loc: 4006001; OR Loc: 4006001|||591.60|Inv Loc: 4006001; OR Loc: 4006001|325.38|
22254|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-130|1|<Self-pay>|<Self-pay>|<Self-pay>|591.60|Inv Loc: 4006001; OR Loc: 4006001|||591.60|Inv Loc: 4006001; OR Loc: 4006001|325.38|
22266|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-95-32|1|<Self-pay>|<Self-pay>|<Self-pay>|832.50|Inv Loc: 4006001; OR Loc: 4006001|||832.50|Inv Loc: 4006001; OR Loc: 4006001|457.87|
22267|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-100-32|1|<Self-pay>|<Self-pay>|<Self-pay>|685.00|Inv Loc: 4006001; OR Loc: 4006001|||685.00|Inv Loc: 4006001; OR Loc: 4006001|376.75|
22268|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-40-32|1|<Self-pay>|<Self-pay>|<Self-pay>|591.60|Inv Loc: 4006001; OR Loc: 4006001|||591.60|Inv Loc: 4006001; OR Loc: 4006001|325.38|
22269|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-45-32|1|<Self-pay>|<Self-pay>|<Self-pay>|660.00|Inv Loc: 4006001; OR Loc: 4006001|||660.00|Inv Loc: 4006001; OR Loc: 4006001|363.00|
22270|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-50-32|1|<Self-pay>|<Self-pay>|<Self-pay>|796.50|Inv Loc: 4006001; OR Loc: 4006001|||796.50|Inv Loc: 4006001; OR Loc: 4006001|438.07|
22271|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-55-32|1|<Self-pay>|<Self-pay>|<Self-pay>|660.00|Inv Loc: 4006001; OR Loc: 4006001|||660.00|Inv Loc: 4006001; OR Loc: 4006001|363.00|
22272|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-60-32|1|<Self-pay>|<Self-pay>|<Self-pay>|739.30|Inv Loc: 4006001; OR Loc: 4006001|||739.30|Inv Loc: 4006001; OR Loc: 4006001|406.61|
22273|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-65-32|1|<Self-pay>|<Self-pay>|<Self-pay>|922.50|Inv Loc: 4006001; OR Loc: 4006001|||922.50|Inv Loc: 4006001; OR Loc: 4006001|507.37|
22274|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-70-32|1|<Self-pay>|<Self-pay>|<Self-pay>|631.92|Inv Loc: 4006001; OR Loc: 4006001|||631.92|Inv Loc: 4006001; OR Loc: 4006001|347.56|
22275|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-75-32|1|<Self-pay>|<Self-pay>|<Self-pay>|615.00|Inv Loc: 4006001; OR Loc: 4006001|||615.00|Inv Loc: 4006001; OR Loc: 4006001|338.25|
22276|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-80-32|1|<Self-pay>|<Self-pay>|<Self-pay>|832.50|Inv Loc: 4006001; OR Loc: 4006001|||832.50|Inv Loc: 4006001; OR Loc: 4006001|457.87|
22277|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-85-32|1|<Self-pay>|<Self-pay>|<Self-pay>|615.00|Inv Loc: 4006001; OR Loc: 4006001|||615.00|Inv Loc: 4006001; OR Loc: 4006001|338.25|
22278|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-90-32|1|<Self-pay>|<Self-pay>|<Self-pay>|631.92|Inv Loc: 4006001; OR Loc: 4006001|||631.92|Inv Loc: 4006001; OR Loc: 4006001|347.56|
22280|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-105-32|1|<Self-pay>|<Self-pay>|<Self-pay>|685.00|Inv Loc: 4006001; OR Loc: 4006001|||685.00|Inv Loc: 4006001; OR Loc: 4006001|376.75|
22281|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-110-32|1|<Self-pay>|<Self-pay>|<Self-pay>|685.00|Inv Loc: 4006001; OR Loc: 4006001|||685.00|Inv Loc: 4006001; OR Loc: 4006001|376.75|
22282|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-115-32|1|<Self-pay>|<Self-pay>|<Self-pay>|591.60|Inv Loc: 4006001; OR Loc: 4006001|||591.60|Inv Loc: 4006001; OR Loc: 4006001|325.38|
22283|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-120-32|1|<Self-pay>|<Self-pay>|<Self-pay>|610.17|Inv Loc: 4006001; OR Loc: 4006001|||610.17|Inv Loc: 4006001; OR Loc: 4006001|335.59|
22284|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-30|1|<Self-pay>|<Self-pay>|<Self-pay>|591.60|Inv Loc: 4006001; OR Loc: 4006001|||591.60|Inv Loc: 4006001; OR Loc: 4006001|325.38|
22285|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-35|1|<Self-pay>|<Self-pay>|<Self-pay>|739.30|Inv Loc: 4006001; OR Loc: 4006001|||739.30|Inv Loc: 4006001; OR Loc: 4006001|406.61|
22286|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-40|1|<Self-pay>|<Self-pay>|<Self-pay>|531.10|Inv Loc: 4006001; OR Loc: 4006001|||531.10|Inv Loc: 4006001; OR Loc: 4006001|292.10|
22287|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-45|1|<Self-pay>|<Self-pay>|<Self-pay>|922.50|Inv Loc: 4006001; OR Loc: 4006001|||922.50|Inv Loc: 4006001; OR Loc: 4006001|507.37|
22288|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-50|1|<Self-pay>|<Self-pay>|<Self-pay>|873.65|Inv Loc: 4006001; OR Loc: 4006001|||873.65|Inv Loc: 4006001; OR Loc: 4006001|480.51|
22289|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-55|1|<Self-pay>|<Self-pay>|<Self-pay>|832.50|Inv Loc: 4006001; OR Loc: 4006001|||832.50|Inv Loc: 4006001; OR Loc: 4006001|457.87|
22290|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-60|1|<Self-pay>|<Self-pay>|<Self-pay>|922.50|Inv Loc: 4006001; OR Loc: 4006001|||922.50|Inv Loc: 4006001; OR Loc: 4006001|507.37|
22291|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-65|1|<Self-pay>|<Self-pay>|<Self-pay>|531.10|Inv Loc: 4006001; OR Loc: 4006001|||531.10|Inv Loc: 4006001; OR Loc: 4006001|292.10|
22292|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SCREW-MAGNA 1146-70|1|<Self-pay>|<Self-pay>|<Self-pay>|873.65|Inv Loc: 4006001; OR Loc: 4006001|||873.65|Inv Loc: 4006001; OR Loc: 4006001|480.51|
23100|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K .028 4" KM172-24-28|1|<Self-pay>|<Self-pay>|<Self-pay>|11.40|Inv Loc: 4006001; OR Loc: 4006001|||11.40|Inv Loc: 4006001; OR Loc: 4006001|6.27|
23103|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-SKIN PXW35|1|<Self-pay>|<Self-pay>|<Self-pay>|214.20|Inv Loc: 4006001; OR Loc: 4006001|||214.20|Inv Loc: 4006001; OR Loc: 4006001|117.81|
23148|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K 0.6MM X 150MM|1|<Self-pay>|<Self-pay>|<Self-pay>|18.40|Inv Loc: 4006001; OR Loc: 4006001|||18.40|Inv Loc: 4006001; OR Loc: 4006001|10.12|
23150|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K 1.0MM X 150MM|1|<Self-pay>|<Self-pay>|<Self-pay>|53.00|Inv Loc: 4006001; OR Loc: 4006001|||53.00|Inv Loc: 4006001; OR Loc: 4006001|29.15|
23151|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K 1.25MM X 150MM|1|<Self-pay>|<Self-pay>|<Self-pay>|27.75|Inv Loc: 4006001; OR Loc: 4006001|||27.75|Inv Loc: 4006001; OR Loc: 4006001|15.26|
23764|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|RELOADS-WHITE 45MM|1|<Self-pay>|<Self-pay>|<Self-pay>|615.50|Inv Loc: 4006001; OR Loc: 4006001|||615.50|Inv Loc: 4006001; OR Loc: 4006001|338.52|
23765|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|RELOADS-BLUE 45MM|1|<Self-pay>|<Self-pay>|<Self-pay>|618.45|Inv Loc: 4006001; OR Loc: 4006001|||618.45|Inv Loc: 4006001; OR Loc: 4006001|340.15|
23769|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-HEMORRHOIDAL CIRCULAR PPH03|1|<Self-pay>|<Self-pay>|<Self-pay>|1,192.59|Inv Loc: 4006001; OR Loc: 4006001|||1,192.59|Inv Loc: 4006001; OR Loc: 4006001|655.92|
23859|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-VENTRIO SM OVAL (8 X12) 5950030|1|<Self-pay>|<Self-pay>|<Self-pay>|1,017.20|Inv Loc: 4006001; OR Loc: 4006001|||1,017.20|Inv Loc: 4006001; OR Loc: 4006001|559.46|
23860|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-VENTRIO MEDIUM OVAL (11X14) 5950040|1|<Self-pay>|<Self-pay>|<Self-pay>|1,502.00|Inv Loc: 4006001; OR Loc: 4006001|||1,502.00|Inv Loc: 4006001; OR Loc: 4006001|826.10|
23861|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-VENTRIO LG OVAL (13X17) 5950050|1|<Self-pay>|<Self-pay>|<Self-pay>|1,901.20|Inv Loc: 4006001; OR Loc: 4006001|||1,901.20|Inv Loc: 4006001; OR Loc: 4006001|1,045.66|
23862|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-VENTRALEX LARGE CIRCLE 8.0CM 5950009|1|<Self-pay>|<Self-pay>|<Self-pay>|1,072.60|Inv Loc: 4006001; OR Loc: 4006001|||1,072.60|Inv Loc: 4006001; OR Loc: 4006001|589.93|
23863|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-VENTRIO XLRG OVAL(19X25CM) 5950070|1|<Self-pay>|<Self-pay>|<Self-pay>|2,661.80|Inv Loc: 4006001; OR Loc: 4006001|||2,661.80|Inv Loc: 4006001; OR Loc: 4006001|1,463.99|
23864|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-ONFLEX MEDIUM OVAL|1|<Self-pay>|<Self-pay>|<Self-pay>|615.00|Inv Loc: 4006001; OR Loc: 4006001|||615.00|Inv Loc: 4006001; OR Loc: 4006001|338.25|
23865|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-ONFLEX LARGE OVAL|1|<Self-pay>|<Self-pay>|<Self-pay>|735.00|Inv Loc: 4006001; OR Loc: 4006001|||735.00|Inv Loc: 4006001; OR Loc: 4006001|404.25|
23866|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-VENTRALEX SM CIRCLE 4.3CM 5950007|1|<Self-pay>|<Self-pay>|<Self-pay>|1,044.00|Inv Loc: 4006001; OR Loc: 4006001|||1,044.00|Inv Loc: 4006001; OR Loc: 4006001|574.20|
23867|SUP|HCPCS C1781||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MESH-VENTRALEX MED CIRCLE 6.4CM 5950008|1|<Self-pay>|<Self-pay>|<Self-pay>|1,257.90|Inv Loc: 4006001; OR Loc: 4006001|||1,257.90|Inv Loc: 4006001; OR Loc: 4006001|691.84|
23956|SUP|HCPCS C1768||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|GRAFT-019579P HEMASHIELD 8MM X 75MM X .3|1|<Self-pay>|<Self-pay>|<Self-pay>|620.10|Inv Loc: 4006001; OR Loc: 4006001|||620.10|Inv Loc: 4006001; OR Loc: 4006001|341.05|
24007|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|ANCHOR-5.5MM W/NEEDLE|1|<Self-pay>|<Self-pay>|<Self-pay>|907.50|Inv Loc: 4006001; OR Loc: 4006001|||907.50|Inv Loc: 4006001; OR Loc: 4006001|499.12|
24042|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SHUNT-CAROTID BYPASS 10F 000679|1|<Self-pay>|<Self-pay>|<Self-pay>|395.00|Inv Loc: 4006001; OR Loc: 4006001|||395.00|Inv Loc: 4006001; OR Loc: 4006001|217.25|
24056|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|TUBE-PEG SYSTEM 20FR PULL TYPE|1|<Self-pay>|<Self-pay>|<Self-pay>|843.00|Inv Loc: 4006001; OR Loc: 4006001|||843.00|Inv Loc: 4006001; OR Loc: 4006001|463.65|
24081|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|BUTTON-GASTROSTOMY 24FR 1.7CM (000285)|1|<Self-pay>|<Self-pay>|<Self-pay>|655.00|Inv Loc: 4006001; OR Loc: 4006001|||655.00|Inv Loc: 4006001; OR Loc: 4006001|360.25|
24082|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|BUTTON-GASTROSTOMY 24FR 2.4CM (000286)|1|<Self-pay>|<Self-pay>|<Self-pay>|655.00|Inv Loc: 4006001; OR Loc: 4006001|||655.00|Inv Loc: 4006001; OR Loc: 4006001|360.25|
24091|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-RELOAD 30MM 2.5MM XR30V VASCULAR|1|<Self-pay>|<Self-pay>|<Self-pay>|199.00|Inv Loc: 4006001; OR Loc: 4006001|||199.00|Inv Loc: 4006001; OR Loc: 4006001|109.45|
24093|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-RELOAD XR30G (USE W/TX30G 24092)|1|<Self-pay>|<Self-pay>|<Self-pay>|195.00|Inv Loc: 4006001; OR Loc: 4006001|||195.00|Inv Loc: 4006001; OR Loc: 4006001|107.25|
24144|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|BUTTON-GASTROSTOMY 28FR. 2.7CM (000262))|1|<Self-pay>|<Self-pay>|<Self-pay>|655.50|Inv Loc: 4006001; OR Loc: 4006001|||655.50|Inv Loc: 4006001; OR Loc: 4006001|360.52|
24177|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-TX60B 60MM REG LINEAR|1|<Self-pay>|<Self-pay>|<Self-pay>|419.05|Inv Loc: 4006001; OR Loc: 4006001|||419.05|Inv Loc: 4006001; OR Loc: 4006001|230.48|
24178|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-RELOADS 60MM BLUE XR60B|1|<Self-pay>|<Self-pay>|<Self-pay>|208.50|Inv Loc: 4006001; OR Loc: 4006001|||208.50|Inv Loc: 4006001; OR Loc: 4006001|114.67|
24180|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUTTY-ALLOMATRIX INJECTABLE 1CC|1|<Self-pay>|<Self-pay>|<Self-pay>|918.00|Inv Loc: 4006001; OR Loc: 4006001|||918.00|Inv Loc: 4006001; OR Loc: 4006001|504.90|
24185|SUP|HCPCS C1788||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PORT-POWER IMPLANTABLE MRI 8 FR 1808000|1|<Self-pay>|<Self-pay>|<Self-pay>|1,410.00|Inv Loc: 4006001; OR Loc: 4006001|||1,410.00|Inv Loc: 4006001; OR Loc: 4006001|775.50|
24205|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|KIT-RESORBABLE MINI BEAD (8400-0611)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,840.00|Inv Loc: 4006001; OR Loc: 4006001|||1,840.00|Inv Loc: 4006001; OR Loc: 4006001|1,012.00|
24209|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|INFUSION SET-POWERLOC 19GA (0671910)|1|<Self-pay>|<Self-pay>|<Self-pay>|32.50|Inv Loc: 4006001; OR Loc: 4006001|||32.50|Inv Loc: 4006001; OR Loc: 4006001|17.87|
24271|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STENT-URETERAL KIT 6 X 28 (5556028)|1|<Self-pay>|<Self-pay>|<Self-pay>|599.40|Inv Loc: 4006001; OR Loc: 4006001|||599.40|Inv Loc: 4006001; OR Loc: 4006001|329.67|
24273|SUP|HCPCS C2625||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STENT-URETERAL DBL PIGTAIL 7FR.X26CM(5607026)|1|<Self-pay>|<Self-pay>|<Self-pay>|583.45|Inv Loc: 4006001; OR Loc: 4006001|||583.45|Inv Loc: 4006001; OR Loc: 4006001|320.90|
24274|SUP|HCPCS C2625||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|STENT-URETERAL DBL PIGTAIL 7FR.X28CM(5607028)|1|<Self-pay>|<Self-pay>|<Self-pay>|583.45|Inv Loc: 4006001; OR Loc: 4006001|||583.45|Inv Loc: 4006001; OR Loc: 4006001|320.90|
24671|SUP|HCPCS C1751||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CATHETER-PICC SOLO TRIPLE LUMEN 5FR 3395108Q|1|<Self-pay>|<Self-pay>|<Self-pay>|631.20|Inv Loc: 4006001; OR Loc: 4006001|||631.20|Inv Loc: 4006001; OR Loc: 4006001|347.16|
24682|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-LINEAR GIA 030449|1|<Self-pay>|<Self-pay>|<Self-pay>|1,017.03|Inv Loc: 4006001; OR Loc: 4006001|||1,017.03|Inv Loc: 4006001; OR Loc: 4006001|559.37|
24727|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-LINEAR CONTOUR SC40G|1|<Self-pay>|<Self-pay>|<Self-pay>|1,349.55|Inv Loc: 4006001; OR Loc: 4006001|||1,349.55|Inv Loc: 4006001; OR Loc: 4006001|742.25|
24790|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-RELOAD 45MM TAN (VAS/MED) EGIA45AVM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,309.11|Inv Loc: 4006001; OR Loc: 4006001|||1,309.11|Inv Loc: 4006001; OR Loc: 4006001|720.01|
24791|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-RELOAD 45MM PURPLE (MED/THICK)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,360.83|Inv Loc: 4006001; OR Loc: 4006001|||1,360.83|Inv Loc: 4006001; OR Loc: 4006001|748.46|
24901|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|BONE CUBES-CANCELLOUS 15CC (7-8MM)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,230.00|Inv Loc: 4006001; OR Loc: 4006001|||1,230.00|Inv Loc: 4006001; OR Loc: 4006001|676.50|
24907|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUTTY-STIMUBLAST 2.5CC|1|<Self-pay>|<Self-pay>|<Self-pay>|1,320.00|Inv Loc: 4006001; OR Loc: 4006001|||1,320.00|Inv Loc: 4006001; OR Loc: 4006001|726.00|
24908|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUTTY-STIMBLAST 5CC|1|<Self-pay>|<Self-pay>|<Self-pay>|1,600.00|Inv Loc: 4006001; OR Loc: 4006001|||1,600.00|Inv Loc: 4006001; OR Loc: 4006001|880.00|
24909|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|GEL-STIMUBLAST 1CC|1|<Self-pay>|<Self-pay>|<Self-pay>|600.00|Inv Loc: 4006001; OR Loc: 4006001|||600.00|Inv Loc: 4006001; OR Loc: 4006001|330.00|
24932|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|ANCHOR 4.75MM BI0COMPOSITE SWIVELOCK|1|<Self-pay>|<Self-pay>|<Self-pay>|1,260.00|Inv Loc: 4006001; OR Loc: 4006001|||1,260.00|Inv Loc: 4006001; OR Loc: 4006001|693.00|
24934|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|ANCHOR 2.9MM BIOCOMPOSITE PUSHLOCK|1|<Self-pay>|<Self-pay>|<Self-pay>|1,200.00|Inv Loc: 4006001; OR Loc: 4006001|||1,200.00|Inv Loc: 4006001; OR Loc: 4006001|660.00|
24944|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|MONITOR-CARDIAC INSERTABLE REVEAL LINQ|1|<Self-pay>|<Self-pay>|<Self-pay>|9,690.00|Inv Loc: 4006001; OR Loc: 4006001|||9,690.00|Inv Loc: 4006001; OR Loc: 4006001|5,329.50|
25019|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CLOSURE-SKIN SURGICAL (16)(ZIPLINE)|1|<Self-pay>|<Self-pay>|<Self-pay>|425.00|Inv Loc: 4006001; OR Loc: 4006001|||425.00|Inv Loc: 4006001; OR Loc: 4006001|233.75|
25022|SUP|HCPCS C1771||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|SLING-TVT GYNECARE|1|<Self-pay>|<Self-pay>|<Self-pay>|2,338.90|Inv Loc: 4006001; OR Loc: 4006001|||2,338.90|Inv Loc: 4006001; OR Loc: 4006001|1,286.39|
25038|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|ARISTA ABSORBABLE HEMOSTATIC 3GM|1|<Self-pay>|<Self-pay>|<Self-pay>|881.00|Inv Loc: 4006001; OR Loc: 4006001|||881.00|Inv Loc: 4006001; OR Loc: 4006001|484.55|
25131|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|HEMOCLIP-CARTRIDGE SMALL|1|<Self-pay>|<Self-pay>|<Self-pay>|18.90|Inv Loc: 4006001; OR Loc: 4006001|||18.90|Inv Loc: 4006001; OR Loc: 4006001|10.39|
25161|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|NEOTRACT UROLIFT SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|7,600.00|Inv Loc: 4006001; OR Loc: 4006001|||7,600.00|Inv Loc: 4006001; OR Loc: 4006001|4,180.00|
25165|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|FOREFOOT IB IMPLANT SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|2,790.00|Inv Loc: 4006001; OR Loc: 4006001|||2,790.00|Inv Loc: 4006001; OR Loc: 4006001|1,534.50|
25166|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|HEMOSTAT-SURGICEL 2X3|1|<Self-pay>|<Self-pay>|<Self-pay>|416.40|Inv Loc: 4006001; OR Loc: 4006001|||416.40|Inv Loc: 4006001; OR Loc: 4006001|229.02|
25167|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|HEMOSTAT-SURGICEL 4X8|1|<Self-pay>|<Self-pay>|<Self-pay>|275.25|Inv Loc: 4006001; OR Loc: 4006001|||275.25|Inv Loc: 4006001; OR Loc: 4006001|151.39|
25168|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CLOSURE-SKIN SURGICAL 24 ZIPLINE|1|<Self-pay>|<Self-pay>|<Self-pay>|625.00|Inv Loc: 4006001; OR Loc: 4006001|||625.00|Inv Loc: 4006001; OR Loc: 4006001|343.75|
32152|SUP|HCPCS C1713||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|WIRE-K 1.6MM X 150MM|1|<Self-pay>|<Self-pay>|<Self-pay>|27.75|Inv Loc: 4006001; OR Loc: 4006001|||27.75|Inv Loc: 4006001; OR Loc: 4006001|15.26|
20581|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-CHROMIC 0 802H|1|<Self-pay>|<Self-pay>|<Self-pay>|12.55|Inv Loc: 4006001; OR Loc: 4006001|||12.55|Inv Loc: 4006001; OR Loc: 4006001|6.90|
20601|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-CHROMIC 4-0 G121H|1|<Self-pay>|<Self-pay>|<Self-pay>|13.60|Inv Loc: 4006001; OR Loc: 4006001|||13.60|Inv Loc: 4006001; OR Loc: 4006001|7.48|
20605|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-CHROMIC 4-0 1637G|1|<Self-pay>|<Self-pay>|<Self-pay>|26.65|Inv Loc: 4006001; OR Loc: 4006001|||26.65|Inv Loc: 4006001; OR Loc: 4006001|14.66|
20607|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-CHROMIC 5-0 687G|1|<Self-pay>|<Self-pay>|<Self-pay>|26.10|Inv Loc: 4006001; OR Loc: 4006001|||26.10|Inv Loc: 4006001; OR Loc: 4006001|14.35|
20618|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 0 J430T|1|<Self-pay>|<Self-pay>|<Self-pay>|19.05|Inv Loc: 4006001; OR Loc: 4006001|||19.05|Inv Loc: 4006001; OR Loc: 4006001|10.48|
20621|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 6-0 J492G|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
20628|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 3-0 J497H|1|<Self-pay>|<Self-pay>|<Self-pay>|15.35|Inv Loc: 4006001; OR Loc: 4006001|||15.35|Inv Loc: 4006001; OR Loc: 4006001|8.44|
20630|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 3-0 J784G|1|<Self-pay>|<Self-pay>|<Self-pay>|44.00|Inv Loc: 4006001; OR Loc: 4006001|||44.00|Inv Loc: 4006001; OR Loc: 4006001|24.20|
20632|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 5-0 J500H|1|<Self-pay>|<Self-pay>|<Self-pay>|15.10|Inv Loc: 4006001; OR Loc: 4006001|||15.10|Inv Loc: 4006001; OR Loc: 4006001|8.30|
20633|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 4-0 J494G|1|<Self-pay>|<Self-pay>|<Self-pay>|15.00|Inv Loc: 4006001; OR Loc: 4006001|||15.00|Inv Loc: 4006001; OR Loc: 4006001|8.25|
20652|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-SILK 3-0 CO13D|1|<Self-pay>|<Self-pay>|<Self-pay>|35.20|Inv Loc: 4006001; OR Loc: 4006001|||35.20|Inv Loc: 4006001; OR Loc: 4006001|19.36|
20683|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 5-0 8698G|1|<Self-pay>|<Self-pay>|<Self-pay>|18.85|Inv Loc: 4006001; OR Loc: 4006001|||18.85|Inv Loc: 4006001; OR Loc: 4006001|10.37|
20688|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 5-0 8321H|1|<Self-pay>|<Self-pay>|<Self-pay>|40.40|Inv Loc: 4006001; OR Loc: 4006001|||40.40|Inv Loc: 4006001; OR Loc: 4006001|22.22|
20689|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 0 8454H|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
20697|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 4-0 8557H|1|<Self-pay>|<Self-pay>|<Self-pay>|20.95|Inv Loc: 4006001; OR Loc: 4006001|||20.95|Inv Loc: 4006001; OR Loc: 4006001|11.52|
20700|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 4-0 8699G|1|<Self-pay>|<Self-pay>|<Self-pay>|17.75|Inv Loc: 4006001; OR Loc: 4006001|||17.75|Inv Loc: 4006001; OR Loc: 4006001|9.76|
20706|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHILON 5-0 698H|1|<Self-pay>|<Self-pay>|<Self-pay>|14.15|Inv Loc: 4006001; OR Loc: 4006001|||14.15|Inv Loc: 4006001; OR Loc: 4006001|7.78|
20708|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHILON 6-0 697H|1|<Self-pay>|<Self-pay>|<Self-pay>|14.45|Inv Loc: 4006001; OR Loc: 4006001|||14.45|Inv Loc: 4006001; OR Loc: 4006001|7.95|
20710|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MERSILENE CTX  RS22|1|<Self-pay>|<Self-pay>|<Self-pay>|132.90|Inv Loc: 4006001; OR Loc: 4006001|||132.90|Inv Loc: 4006001; OR Loc: 4006001|73.09|
20714|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 0 X444H|1|<Self-pay>|<Self-pay>|<Self-pay>|11.00|Inv Loc: 4006001; OR Loc: 4006001|||11.00|Inv Loc: 4006001; OR Loc: 4006001|6.05|
20716|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 0 CX27D|1|<Self-pay>|<Self-pay>|<Self-pay>|43.95|Inv Loc: 4006001; OR Loc: 4006001|||43.95|Inv Loc: 4006001; OR Loc: 4006001|24.17|
20717|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 1 X518H|1|<Self-pay>|<Self-pay>|<Self-pay>|10.80|Inv Loc: 4006001; OR Loc: 4006001|||10.80|Inv Loc: 4006001; OR Loc: 4006001|5.94|
20718|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 2 MX69G|1|<Self-pay>|<Self-pay>|<Self-pay>|66.25|Inv Loc: 4006001; OR Loc: 4006001|||66.25|Inv Loc: 4006001; OR Loc: 4006001|36.44|
20724|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHILON 4-0 1667H|1|<Self-pay>|<Self-pay>|<Self-pay>|14.30|Inv Loc: 4006001; OR Loc: 4006001|||14.30|Inv Loc: 4006001; OR Loc: 4006001|7.86|
20725|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHILON 5-0 1666H|1|<Self-pay>|<Self-pay>|<Self-pay>|14.30|Inv Loc: 4006001; OR Loc: 4006001|||14.30|Inv Loc: 4006001; OR Loc: 4006001|7.86|
20744|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-POLYSORB 4-0 SL-5627-G|1|<Self-pay>|<Self-pay>|<Self-pay>|43.15|Inv Loc: 4006001; OR Loc: 4006001|||43.15|Inv Loc: 4006001; OR Loc: 4006001|23.73|
20756|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-POLYSORB 3-0 SL-5628|1|<Self-pay>|<Self-pay>|<Self-pay>|34.95|Inv Loc: 4006001; OR Loc: 4006001|||34.95|Inv Loc: 4006001; OR Loc: 4006001|19.22|
20757|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 6-0 8695G|1|<Self-pay>|<Self-pay>|<Self-pay>|18.70|Inv Loc: 4006001; OR Loc: 4006001|||18.70|Inv Loc: 4006001; OR Loc: 4006001|10.28|
20777|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SPINAL 22GA 5" QUINCKE|1|<Self-pay>|<Self-pay>|<Self-pay>|19.25|Inv Loc: 4006001; OR Loc: 4006001|||19.25|Inv Loc: 4006001; OR Loc: 4006001|10.59|
20779|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SPINAL 22GA 7" QUINCKE|1|<Self-pay>|<Self-pay>|<Self-pay>|20.40|Inv Loc: 4006001; OR Loc: 4006001|||20.40|Inv Loc: 4006001; OR Loc: 4006001|11.22|
20785|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SPINAL 25GA 5" QUINCKE|1|<Self-pay>|<Self-pay>|<Self-pay>|17.50|Inv Loc: 4006001; OR Loc: 4006001|||17.50|Inv Loc: 4006001; OR Loc: 4006001|9.62|
20788|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SURGEONS 1/2C HEAVY PT 2167-2|1|<Self-pay>|<Self-pay>|<Self-pay>|16.50|Inv Loc: 4006001; OR Loc: 4006001|||16.50|Inv Loc: 4006001; OR Loc: 4006001|9.07|
20790|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SURGEONS 1826-4D TROCAR PT|1|<Self-pay>|<Self-pay>|<Self-pay>|23.35|Inv Loc: 4006001; OR Loc: 4006001|||23.35|Inv Loc: 4006001; OR Loc: 4006001|12.84|
20800|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SURGEONS 1/2C KELLYS INTES.|1|<Self-pay>|<Self-pay>|<Self-pay>|16.50|Inv Loc: 4006001; OR Loc: 4006001|||16.50|Inv Loc: 4006001; OR Loc: 4006001|9.07|
20801|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SURGEONS KEITH ABDOMINAL ST 1827-2D|1|<Self-pay>|<Self-pay>|<Self-pay>|16.50|Inv Loc: 4006001; OR Loc: 4006001|||16.50|Inv Loc: 4006001; OR Loc: 4006001|9.07|
20803|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SURGEONS 1/2 C TRO MAYO CATGUT|1|<Self-pay>|<Self-pay>|<Self-pay>|16.40|Inv Loc: 4006001; OR Loc: 4006001|||16.40|Inv Loc: 4006001; OR Loc: 4006001|9.02|
20835|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-LIVER BIOPSY 6"|1|<Self-pay>|<Self-pay>|<Self-pay>|70.95|Inv Loc: 4006001; OR Loc: 4006001|||70.95|Inv Loc: 4006001; OR Loc: 4006001|39.02|
20837|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SURGEONS 1/2C TAPER PT 1859-6R|1|<Self-pay>|<Self-pay>|<Self-pay>|20.00|Inv Loc: 4006001; OR Loc: 4006001|||20.00|Inv Loc: 4006001; OR Loc: 4006001|11.00|
20838|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-HUBER 19GA 1" (S02019-10)|1|<Self-pay>|<Self-pay>|<Self-pay>|41.50|Inv Loc: 4006001; OR Loc: 4006001|||41.50|Inv Loc: 4006001; OR Loc: 4006001|22.82|
20840|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-ILLI/STERNAL 15GA INTRAOSSEOUS DIN1515|1|<Self-pay>|<Self-pay>|<Self-pay>|47.30|Inv Loc: 4006001; OR Loc: 4006001|||47.30|Inv Loc: 4006001; OR Loc: 4006001|26.01|
20841|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-PNEUMONEEDLE INSUFFLATION PN150|1|<Self-pay>|<Self-pay>|<Self-pay>|303.10|Inv Loc: 4006001; OR Loc: 4006001|||303.10|Inv Loc: 4006001; OR Loc: 4006001|166.70|
20842|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-HUBER BENT 22GA 1" (S02022-10)|1|<Self-pay>|<Self-pay>|<Self-pay>|42.00|Inv Loc: 4006001; OR Loc: 4006001|||42.00|Inv Loc: 4006001; OR Loc: 4006001|23.10|
20843|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-ILLI/STERNAL 18GA INTRAOSSEOUS|1|<Self-pay>|<Self-pay>|<Self-pay>|49.55|Inv Loc: 4006001; OR Loc: 4006001|||49.55|Inv Loc: 4006001; OR Loc: 4006001|27.25|
20906|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-BONE WAX W31G|1|<Self-pay>|<Self-pay>|<Self-pay>|21.20|Inv Loc: 4006001; OR Loc: 4006001|||21.20|Inv Loc: 4006001; OR Loc: 4006001|11.66|
21057|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BOWL-CEMENT MIXING 5049-11|1|<Self-pay>|<Self-pay>|<Self-pay>|36.20|Inv Loc: 4006001; OR Loc: 4006001|||36.20|Inv Loc: 4006001; OR Loc: 4006001|19.91|
21177|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-ELASTIC 4" X 10' STERILE|1|<Self-pay>|<Self-pay>|<Self-pay>|18.25|Inv Loc: 4006001; OR Loc: 4006001|||18.25|Inv Loc: 4006001; OR Loc: 4006001|10.04|
21178|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-ELASTIC 6" X 10' STERILE|1|<Self-pay>|<Self-pay>|<Self-pay>|12.05|Inv Loc: 4006001; OR Loc: 4006001|||12.05|Inv Loc: 4006001; OR Loc: 4006001|6.63|
21181|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-ESMARK 6"|1|<Self-pay>|<Self-pay>|<Self-pay>|19.50|Inv Loc: 4006001; OR Loc: 4006001|||19.50|Inv Loc: 4006001; OR Loc: 4006001|10.72|
21182|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BANDAGE-ESMARK 4"|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
21187|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-DUODERM 8X8 (187662)|1|<Self-pay>|<Self-pay>|<Self-pay>|35.80|Inv Loc: 4006001; OR Loc: 4006001|||35.80|Inv Loc: 4006001; OR Loc: 4006001|19.69|
21208|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAPE-ELASTOPLAST 4" *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|24.90|Inv Loc: 4006001; OR Loc: 4006001|||24.90|Inv Loc: 4006001; OR Loc: 4006001|13.69|
21209|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAPE-ELASTOPLAST 2" *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|12.65|Inv Loc: 4006001; OR Loc: 4006001|||12.65|Inv Loc: 4006001; OR Loc: 4006001|6.96|
21210|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAPE-ELASTOPLAST 3" *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|17.50|Inv Loc: 4006001; OR Loc: 4006001|||17.50|Inv Loc: 4006001; OR Loc: 4006001|9.62|
21225|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY-PARACERVICAL/PUDENDAL BLOCK TRAY|1|<Self-pay>|<Self-pay>|<Self-pay>|32.85|Inv Loc: 4006001; OR Loc: 4006001|||32.85|Inv Loc: 4006001; OR Loc: 4006001|18.07|
21231|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-LAPORATOMY DYNJP3040A|1|<Self-pay>|<Self-pay>|<Self-pay>|64.45|Inv Loc: 4006001; OR Loc: 4006001|||64.45|Inv Loc: 4006001; OR Loc: 4006001|35.45|
21232|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-CYSTOSCOPY|1|<Self-pay>|<Self-pay>|<Self-pay>|28.80|Inv Loc: 4006001; OR Loc: 4006001|||28.80|Inv Loc: 4006001; OR Loc: 4006001|15.84|
21238|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-ARTHROSCOPY|1|<Self-pay>|<Self-pay>|<Self-pay>|205.90|Inv Loc: 4006001; OR Loc: 4006001|||205.90|Inv Loc: 4006001; OR Loc: 4006001|113.24|
21241|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-HIP DYNJP8320A|1|<Self-pay>|<Self-pay>|<Self-pay>|97.70|Inv Loc: 4006001; OR Loc: 4006001|||97.70|Inv Loc: 4006001; OR Loc: 4006001|53.73|
21243|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-HEAD/NECK DYNJP7010A|1|<Self-pay>|<Self-pay>|<Self-pay>|51.65|Inv Loc: 4006001; OR Loc: 4006001|||51.65|Inv Loc: 4006001; OR Loc: 4006001|28.41|
21244|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-C SECTION DYNJ30792A**LATEX***|1|<Self-pay>|<Self-pay>|<Self-pay>|329.80|Inv Loc: 4006001; OR Loc: 4006001|||329.80|Inv Loc: 4006001; OR Loc: 4006001|181.39|
21247|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-LITHOTOMY DYNJP9020A|1|<Self-pay>|<Self-pay>|<Self-pay>|34.95|Inv Loc: 4006001; OR Loc: 4006001|||34.95|Inv Loc: 4006001; OR Loc: 4006001|19.22|
21256|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-PLAIN .25 X 5|1|<Self-pay>|<Self-pay>|<Self-pay>|11.25|Inv Loc: 4006001; OR Loc: 4006001|||11.25|Inv Loc: 4006001; OR Loc: 4006001|6.19|
21257|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-PLAIN 1"|1|<Self-pay>|<Self-pay>|<Self-pay>|13.80|Inv Loc: 4006001; OR Loc: 4006001|||13.80|Inv Loc: 4006001; OR Loc: 4006001|7.59|
21258|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-IODOFORM .5X5|1|<Self-pay>|<Self-pay>|<Self-pay>|13.05|Inv Loc: 4006001; OR Loc: 4006001|||13.05|Inv Loc: 4006001; OR Loc: 4006001|7.18|
21259|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-IODOFORM .25"|1|<Self-pay>|<Self-pay>|<Self-pay>|13.05|Inv Loc: 4006001; OR Loc: 4006001|||13.05|Inv Loc: 4006001; OR Loc: 4006001|7.18|
21261|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-PLAIN .5|1|<Self-pay>|<Self-pay>|<Self-pay>|12.20|Inv Loc: 4006001; OR Loc: 4006001|||12.20|Inv Loc: 4006001; OR Loc: 4006001|6.71|
21262|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-PLAIN 2"|1|<Self-pay>|<Self-pay>|<Self-pay>|21.60|Inv Loc: 4006001; OR Loc: 4006001|||21.60|Inv Loc: 4006001; OR Loc: 4006001|11.88|
21263|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-IODOFORM 1"|1|<Self-pay>|<Self-pay>|<Self-pay>|15.85|Inv Loc: 4006001; OR Loc: 4006001|||15.85|Inv Loc: 4006001; OR Loc: 4006001|8.72|
21264|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACKING-IODOFORM 2"|1|<Self-pay>|<Self-pay>|<Self-pay>|18.75|Inv Loc: 4006001; OR Loc: 4006001|||18.75|Inv Loc: 4006001; OR Loc: 4006001|10.31|
21287|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|WRAP-COBAN 4" SELF ADHERENT 2084S|1|<Self-pay>|<Self-pay>|<Self-pay>|10.00|Inv Loc: 4006001; OR Loc: 4006001|||10.00|Inv Loc: 4006001; OR Loc: 4006001|5.50|
21299|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLIP APPLIER-ENDO CLIP (ER320)|1|<Self-pay>|<Self-pay>|<Self-pay>|420.15|Inv Loc: 4006001; OR Loc: 4006001|||420.15|Inv Loc: 4006001; OR Loc: 4006001|231.08|
21304|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CAUTERY-HIGH TEMP FINE TIP AA01|1|<Self-pay>|<Self-pay>|<Self-pay>|45.70|Inv Loc: 4006001; OR Loc: 4006001|||45.70|Inv Loc: 4006001; OR Loc: 4006001|25.13|
21355|SUP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|GUIDEWIRE-J ARROW 04235|1|<Self-pay>|<Self-pay>|<Self-pay>|47.65|Inv Loc: 4006001; OR Loc: 4006001|||47.65|Inv Loc: 4006001; OR Loc: 4006001|26.21|
21468|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-COUDE FOLEY 16FR *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|47.75|Inv Loc: 4006001; OR Loc: 4006001|||47.75|Inv Loc: 4006001; OR Loc: 4006001|26.26|
21471|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY PEDI 8FR SILICONE 100%|1|<Self-pay>|<Self-pay>|<Self-pay>|16.50|Inv Loc: 4006001; OR Loc: 4006001|||16.50|Inv Loc: 4006001; OR Loc: 4006001|9.07|
21473|SUP|HCPCS C1726||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY 12FR 5CC BALLOON *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|Inv Loc: 4006001; OR Loc: 4006001|||14.70|Inv Loc: 4006001; OR Loc: 4006001|8.08|
21480|SUP|HCPCS C1758||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-HEYMAN 4FR OLIVE TIP (136904)|1|<Self-pay>|<Self-pay>|<Self-pay>|152.10|Inv Loc: 4006001; OR Loc: 4006001|||152.10|Inv Loc: 4006001; OR Loc: 4006001|83.65|
21487|SUP|HCPCS C1751||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CATHETER-UMBILICAL 3.5FR (160333)|1|<Self-pay>|<Self-pay>|<Self-pay>|59.95|Inv Loc: 4006001; OR Loc: 4006001|||59.95|Inv Loc: 4006001; OR Loc: 4006001|32.97|
21491|SUP|HCPCS C1726||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATH-FOLEY 3-WAY 22FR 30CC BALLOON*LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|41.05|Inv Loc: 4006001; OR Loc: 4006001|||41.05|Inv Loc: 4006001; OR Loc: 4006001|22.58|
21493|SUP|HCPCS C1758||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-URETERAL 5FR OLIVE TIP (136505)|1|<Self-pay>|<Self-pay>|<Self-pay>|65.05|Inv Loc: 4006001; OR Loc: 4006001|||65.05|Inv Loc: 4006001; OR Loc: 4006001|35.78|
21494|SUP|HCPCS C1757||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-EMBOLECTOMY 5FR *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|255.50|Inv Loc: 4006001; OR Loc: 4006001|||255.50|Inv Loc: 4006001; OR Loc: 4006001|140.52|
21496|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY COUNCILL 16FR *LATEX*5CC 2WAY|1|<Self-pay>|<Self-pay>|<Self-pay>|59.45|Inv Loc: 4006001; OR Loc: 4006001|||59.45|Inv Loc: 4006001; OR Loc: 4006001|32.70|
21498|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATH-PACING SWAN-GANZ 5FR BIPO *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|290.65|Inv Loc: 4006001; OR Loc: 4006001|||290.65|Inv Loc: 4006001; OR Loc: 4006001|159.86|
21501|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-THORACIC 32FR (8032)|1|<Self-pay>|<Self-pay>|<Self-pay>|20.25|Inv Loc: 4006001; OR Loc: 4006001|||20.25|Inv Loc: 4006001; OR Loc: 4006001|11.14|
21505|SUP|HCPCS C1751||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CATHETER-UMBILICAL 5FR (8888160341)|1|<Self-pay>|<Self-pay>|<Self-pay>|61.40|Inv Loc: 4006001; OR Loc: 4006001|||61.40|Inv Loc: 4006001; OR Loc: 4006001|33.77|
21506|SUP|HCPCS C1751||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CATHETER-UMBILICAL 8FR (160234)|1|<Self-pay>|<Self-pay>|<Self-pay>|98.70|Inv Loc: 4006001; OR Loc: 4006001|||98.70|Inv Loc: 4006001; OR Loc: 4006001|54.28|
21508|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY KIT 14FR *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|22.20|Inv Loc: 4006001; OR Loc: 4006001|||22.20|Inv Loc: 4006001; OR Loc: 4006001|12.21|
21520|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-COUDE FOLEY 18FR|1|<Self-pay>|<Self-pay>|<Self-pay>|47.75|Inv Loc: 4006001; OR Loc: 4006001|||47.75|Inv Loc: 4006001; OR Loc: 4006001|26.26|
21521|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-COUDE FOLEY 20FR *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|47.75|Inv Loc: 4006001; OR Loc: 4006001|||47.75|Inv Loc: 4006001; OR Loc: 4006001|26.26|
21524|SUP|HCPCS C1726||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATH-FOLEY 3-WAY 20FR 30CC BALLOON *LATEX|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|Inv Loc: 4006001; OR Loc: 4006001|||59.85|Inv Loc: 4006001; OR Loc: 4006001|32.92|
21525|SUP|HCPCS C1726||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATH-FOLEY 3-WAY 24FR 30CC BALLOON *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|60.15|Inv Loc: 4006001; OR Loc: 4006001|||60.15|Inv Loc: 4006001; OR Loc: 4006001|33.08|
21548|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY SILICONE 16FR 5CC|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|Inv Loc: 4006001; OR Loc: 4006001|||14.70|Inv Loc: 4006001; OR Loc: 4006001|8.08|
21554|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY 10FR PEDI SILICONE|1|<Self-pay>|<Self-pay>|<Self-pay>|40.65|Inv Loc: 4006001; OR Loc: 4006001|||40.65|Inv Loc: 4006001; OR Loc: 4006001|22.36|
21556|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-RADIAL ARTERY 20GA RA-04020|1|<Self-pay>|<Self-pay>|<Self-pay>|43.40|Inv Loc: 4006001; OR Loc: 4006001|||43.40|Inv Loc: 4006001; OR Loc: 4006001|23.87|
21621|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAIN-SUCTION JACKSON-PRATT (SU130-1309)|1|<Self-pay>|<Self-pay>|<Self-pay>|21.90|Inv Loc: 4006001; OR Loc: 4006001|||21.90|Inv Loc: 4006001; OR Loc: 4006001|12.04|
21627|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|EVACUATOR-THREE SPRING 400ML|1|<Self-pay>|<Self-pay>|<Self-pay>|36.50|Inv Loc: 4006001; OR Loc: 4006001|||36.50|Inv Loc: 4006001; OR Loc: 4006001|20.07|
21629|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAIN-PVC MED 1/8" W/TROCAR|1|<Self-pay>|<Self-pay>|<Self-pay>|35.30|Inv Loc: 4006001; OR Loc: 4006001|||35.30|Inv Loc: 4006001; OR Loc: 4006001|19.41|
21630|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAIN-PVC SML 3/32" W/TROCAR|1|<Self-pay>|<Self-pay>|<Self-pay>|38.05|Inv Loc: 4006001; OR Loc: 4006001|||38.05|Inv Loc: 4006001; OR Loc: 4006001|20.93|
21633|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY-FOLEY CATH 16FR W/BAG|1|<Self-pay>|<Self-pay>|<Self-pay>|68.30|Inv Loc: 4006001; OR Loc: 4006001|||68.30|Inv Loc: 4006001; OR Loc: 4006001|37.56|
21634|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY-FOLEY CATH 18FR W/BAG|1|<Self-pay>|<Self-pay>|<Self-pay>|70.25|Inv Loc: 4006001; OR Loc: 4006001|||70.25|Inv Loc: 4006001; OR Loc: 4006001|38.64|
21657|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RESERVOIR-JACKSON PRATT SU130-1305 100ML|1|<Self-pay>|<Self-pay>|<Self-pay>|16.90|Inv Loc: 4006001; OR Loc: 4006001|||16.90|Inv Loc: 4006001; OR Loc: 4006001|9.29|
21659|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 5 B499T|1|<Self-pay>|<Self-pay>|<Self-pay>|14.60|Inv Loc: 4006001; OR Loc: 4006001|||14.60|Inv Loc: 4006001; OR Loc: 4006001|8.03|
21666|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-IOBAN LG 6651EZ|1|<Self-pay>|<Self-pay>|<Self-pay>|48.55|Inv Loc: 4006001; OR Loc: 4006001|||48.55|Inv Loc: 4006001; OR Loc: 4006001|26.70|
21667|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-IOBAN SM 6650EZ|1|<Self-pay>|<Self-pay>|<Self-pay>|23.50|Inv Loc: 4006001; OR Loc: 4006001|||23.50|Inv Loc: 4006001; OR Loc: 4006001|12.92|
21670|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-STERI U|1|<Self-pay>|<Self-pay>|<Self-pay>|11.10|Inv Loc: 4006001; OR Loc: 4006001|||11.10|Inv Loc: 4006001; OR Loc: 4006001|6.10|
21672|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-EZ ISOLATION BAG D1003|1|<Self-pay>|<Self-pay>|<Self-pay>|27.95|Inv Loc: 4006001; OR Loc: 4006001|||27.95|Inv Loc: 4006001; OR Loc: 4006001|15.37|
21675|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-UNIVERSAL X-RAY|1|<Self-pay>|<Self-pay>|<Self-pay>|59.65|Inv Loc: 4006001; OR Loc: 4006001|||59.65|Inv Loc: 4006001; OR Loc: 4006001|32.81|
21676|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-IOBAN 2 HIP 6617|1|<Self-pay>|<Self-pay>|<Self-pay>|87.70|Inv Loc: 4006001; OR Loc: 4006001|||87.70|Inv Loc: 4006001; OR Loc: 4006001|48.23|
21678|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-STERI #1050|1|<Self-pay>|<Self-pay>|<Self-pay>|12.20|Inv Loc: 4006001; OR Loc: 4006001|||12.20|Inv Loc: 4006001; OR Loc: 4006001|6.71|
21684|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LEGGING LITHOTOMY 8420|1|<Self-pay>|<Self-pay>|<Self-pay>|10.15|Inv Loc: 4006001; OR Loc: 4006001|||10.15|Inv Loc: 4006001; OR Loc: 4006001|5.58|
21880|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE HOOK LATERAL RELEASE 9730BA|1|<Self-pay>|<Self-pay>|<Self-pay>|203.50|Inv Loc: 4006001; OR Loc: 4006001|||203.50|Inv Loc: 4006001; OR Loc: 4006001|111.92|
21901|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-AIR DERMATOME 880-000-10|1|<Self-pay>|<Self-pay>|<Self-pay>|184.65|Inv Loc: 4006001; OR Loc: 4006001|||184.65|Inv Loc: 4006001; OR Loc: 4006001|101.56|
21902|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-GIGLI SAW 12" 2808-01|1|<Self-pay>|<Self-pay>|<Self-pay>|88.00|Inv Loc: 4006001; OR Loc: 4006001|||88.00|Inv Loc: 4006001; OR Loc: 4006001|48.40|
21918|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-MICRO OSCIL 2296-31-172 STRYKER|1|<Self-pay>|<Self-pay>|<Self-pay>|487.50|Inv Loc: 4006001; OR Loc: 4006001|||487.50|Inv Loc: 4006001; OR Loc: 4006001|268.12|
21999|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHOE-POST OP LADIES MEDIUM (111025)|1|<Self-pay>|<Self-pay>|<Self-pay>|76.35|Inv Loc: 4006001; OR Loc: 4006001|||76.35|Inv Loc: 4006001; OR Loc: 4006001|41.99|
22165|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MONOCRYL 0 Y340H|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
22183|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PDSII 0 Z990G CTX LOOP|1|<Self-pay>|<Self-pay>|<Self-pay>|23.50|Inv Loc: 4006001; OR Loc: 4006001|||23.50|Inv Loc: 4006001; OR Loc: 4006001|12.92|
22188|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MM CLEAR 4-0 PDS II Z662H|1|<Self-pay>|<Self-pay>|<Self-pay>|11.00|Inv Loc: 4006001; OR Loc: 4006001|||11.00|Inv Loc: 4006001; OR Loc: 4006001|6.05|
22189|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 2-0 GREEN BRAIDED 30IN 75CM|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
22236|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 2 J649G|1|<Self-pay>|<Self-pay>|<Self-pay>|62.05|Inv Loc: 4006001; OR Loc: 4006001|||62.05|Inv Loc: 4006001; OR Loc: 4006001|34.13|
22294|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-TRIANGLE 3054|1|<Self-pay>|<Self-pay>|<Self-pay>|595.00|Inv Loc: 4006001; OR Loc: 4006001|||595.00|Inv Loc: 4006001; OR Loc: 4006001|327.25|
22340|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ADHESION BARRIER-INTERCEED 3X4 4350|1|<Self-pay>|<Self-pay>|<Self-pay>|949.77|Inv Loc: 4006001; OR Loc: 4006001|||949.77|Inv Loc: 4006001; OR Loc: 4006001|522.37|
22365|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-LAPAROSCOPY 29604|1|<Self-pay>|<Self-pay>|<Self-pay>|51.95|Inv Loc: 4006001; OR Loc: 4006001|||51.95|Inv Loc: 4006001; OR Loc: 4006001|28.57|
22372|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-CHOLANGIO. PERCU 4.5FR 20018-M55|1|<Self-pay>|<Self-pay>|<Self-pay>|436.20|Inv Loc: 4006001; OR Loc: 4006001|||436.20|Inv Loc: 4006001; OR Loc: 4006001|239.91|
22411|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STENT-URETERAL KIT 6 X 26|1|<Self-pay>|<Self-pay>|<Self-pay>|565.00|Inv Loc: 4006001; OR Loc: 4006001|||565.00|Inv Loc: 4006001; OR Loc: 4006001|310.75|
22413|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STENT-URETERAL KIT 4.5 X 26 (5604526)|1|<Self-pay>|<Self-pay>|<Self-pay>|583.45|Inv Loc: 4006001; OR Loc: 4006001|||583.45|Inv Loc: 4006001; OR Loc: 4006001|320.90|
22426|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLIPS-FILSHIE AVM 851|1|<Self-pay>|<Self-pay>|<Self-pay>|633.33|Inv Loc: 4006001; OR Loc: 4006001|||633.33|Inv Loc: 4006001; OR Loc: 4006001|348.33|
22462|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-TUOHY 17GA 5"|1|<Self-pay>|<Self-pay>|<Self-pay>|34.35|Inv Loc: 4006001; OR Loc: 4006001|||34.35|Inv Loc: 4006001; OR Loc: 4006001|18.89|
22506|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-EXTREMITY DYNJ30793|1|<Self-pay>|<Self-pay>|<Self-pay>|79.65|Inv Loc: 4006001; OR Loc: 4006001|||79.65|Inv Loc: 4006001; OR Loc: 4006001|43.81|
22822|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-BRONCHO LFT 32FR CPAP|1|<Self-pay>|<Self-pay>|<Self-pay>|251.20|Inv Loc: 4006001; OR Loc: 4006001|||251.20|Inv Loc: 4006001; OR Loc: 4006001|138.16|
22890|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-MINI 6600 C ARM E9100AB|1|<Self-pay>|<Self-pay>|<Self-pay>|32.55|Inv Loc: 4006001; OR Loc: 4006001|||32.55|Inv Loc: 4006001; OR Loc: 4006001|17.90|
22891|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-C-ARMOR (5523)|1|<Self-pay>|<Self-pay>|<Self-pay>|205.50|Inv Loc: 4006001; OR Loc: 4006001|||205.50|Inv Loc: 4006001; OR Loc: 4006001|113.02|
22912|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAP-2.0MM 311.19|1|<Self-pay>|<Self-pay>|<Self-pay>|630.00|Inv Loc: 4006001; OR Loc: 4006001|||630.00|Inv Loc: 4006001; OR Loc: 4006001|346.50|
22913|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAP-2.7MM 311.26|1|<Self-pay>|<Self-pay>|<Self-pay>|690.00|Inv Loc: 4006001; OR Loc: 4006001|||690.00|Inv Loc: 4006001; OR Loc: 4006001|379.50|
22920|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAP-4.5MM|1|<Self-pay>|<Self-pay>|<Self-pay>|432.00|Inv Loc: 4006001; OR Loc: 4006001|||432.00|Inv Loc: 4006001; OR Loc: 4006001|237.60|
22927|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-1.1MM 310.11|1|<Self-pay>|<Self-pay>|<Self-pay>|277.50|Inv Loc: 4006001; OR Loc: 4006001|||277.50|Inv Loc: 4006001; OR Loc: 4006001|152.62|
22928|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-1.5MM 310.15|1|<Self-pay>|<Self-pay>|<Self-pay>|482.50|Inv Loc: 4006001; OR Loc: 4006001|||482.50|Inv Loc: 4006001; OR Loc: 4006001|265.37|
22929|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-2.0MM|1|<Self-pay>|<Self-pay>|<Self-pay>|336.00|Inv Loc: 4006001; OR Loc: 4006001|||336.00|Inv Loc: 4006001; OR Loc: 4006001|184.80|
22930|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-2.5MM 310.25/4806-110-25|1|<Self-pay>|<Self-pay>|<Self-pay>|336.00|Inv Loc: 4006001; OR Loc: 4006001|||336.00|Inv Loc: 4006001; OR Loc: 4006001|184.80|
22931|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-2.7MM 310.26|1|<Self-pay>|<Self-pay>|<Self-pay>|465.00|Inv Loc: 4006001; OR Loc: 4006001|||465.00|Inv Loc: 4006001; OR Loc: 4006001|255.75|
22932|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-3.5MM 310.35/4806-110-35|1|<Self-pay>|<Self-pay>|<Self-pay>|389.35|Inv Loc: 4006001; OR Loc: 4006001|||389.35|Inv Loc: 4006001; OR Loc: 4006001|214.14|
22933|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-3.2MM DIAM|1|<Self-pay>|<Self-pay>|<Self-pay>|358.10|Inv Loc: 4006001; OR Loc: 4006001|||358.10|Inv Loc: 4006001; OR Loc: 4006001|196.95|
22935|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRILL BIT-4.5MM|1|<Self-pay>|<Self-pay>|<Self-pay>|389.35|Inv Loc: 4006001; OR Loc: 4006001|||389.35|Inv Loc: 4006001; OR Loc: 4006001|214.14|
22981|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR-MED 4.0 EGG 5120-15-40|1|<Self-pay>|<Self-pay>|<Self-pay>|498.30|Inv Loc: 4006001; OR Loc: 4006001|||498.30|Inv Loc: 4006001; OR Loc: 4006001|274.06|
22982|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR-MED 5.0 EGG 5120-15-50|1|<Self-pay>|<Self-pay>|<Self-pay>|498.30|Inv Loc: 4006001; OR Loc: 4006001|||498.30|Inv Loc: 4006001; OR Loc: 4006001|274.06|
22983|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR-MED 2.5 RD 5120-10-25|1|<Self-pay>|<Self-pay>|<Self-pay>|450.20|Inv Loc: 4006001; OR Loc: 4006001|||450.20|Inv Loc: 4006001; OR Loc: 4006001|247.61|
22984|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR-MED 4.0 RD 5120-10-40|1|<Self-pay>|<Self-pay>|<Self-pay>|472.70|Inv Loc: 4006001; OR Loc: 4006001|||472.70|Inv Loc: 4006001; OR Loc: 4006001|259.98|
22987|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-LONG MED KM-33-1111|1|<Self-pay>|<Self-pay>|<Self-pay>|42.90|Inv Loc: 4006001; OR Loc: 4006001|||42.90|Inv Loc: 4006001; OR Loc: 4006001|23.59|
22988|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-MED AGGRESSIVE KM3-511|1|<Self-pay>|<Self-pay>|<Self-pay>|42.90|Inv Loc: 4006001; OR Loc: 4006001|||42.90|Inv Loc: 4006001; OR Loc: 4006001|23.59|
22990|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-LONG MED AGGRESSIVE KM3-525|1|<Self-pay>|<Self-pay>|<Self-pay>|42.90|Inv Loc: 4006001; OR Loc: 4006001|||42.90|Inv Loc: 4006001; OR Loc: 4006001|23.59|
22991|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-MED NARROW 2296-33-114|1|<Self-pay>|<Self-pay>|<Self-pay>|42.90|Inv Loc: 4006001; OR Loc: 4006001|||42.90|Inv Loc: 4006001; OR Loc: 4006001|23.59|
22992|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-LONG NARROW 2296-33-115|1|<Self-pay>|<Self-pay>|<Self-pay>|42.90|Inv Loc: 4006001; OR Loc: 4006001|||42.90|Inv Loc: 4006001; OR Loc: 4006001|23.59|
22993|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RASP-LONG TEAR CROSS CUT 5100-37-114|1|<Self-pay>|<Self-pay>|<Self-pay>|658.65|Inv Loc: 4006001; OR Loc: 4006001|||658.65|Inv Loc: 4006001; OR Loc: 4006001|362.26|
23051|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 3-0 X-963H|1|<Self-pay>|<Self-pay>|<Self-pay>|13.70|Inv Loc: 4006001; OR Loc: 4006001|||13.70|Inv Loc: 4006001; OR Loc: 4006001|7.53|
23068|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|KIT-ARTERIAL RADIAL AK04020C|1|<Self-pay>|<Self-pay>|<Self-pay>|97.50|Inv Loc: 4006001; OR Loc: 4006001|||97.50|Inv Loc: 4006001; OR Loc: 4006001|53.62|
23070|SUP|Custom 27800001||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|CATHETER-FEMORAL 4 1/4" FA04018|1|<Self-pay>|<Self-pay>|<Self-pay>|66.85|Inv Loc: 4006001; OR Loc: 4006001|||66.85|Inv Loc: 4006001; OR Loc: 4006001|36.77|
23074|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 4-0 J422H UNDYED|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
23087|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY 18FR W/30CC SILICONE|1|<Self-pay>|<Self-pay>|<Self-pay>|31.85|Inv Loc: 4006001; OR Loc: 4006001|||31.85|Inv Loc: 4006001; OR Loc: 4006001|17.52|
23091|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-SORBAVIEW LG 41/2" SQUARE|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
23094|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 0 8418H|1|<Self-pay>|<Self-pay>|<Self-pay>|12.00|Inv Loc: 4006001; OR Loc: 4006001|||12.00|Inv Loc: 4006001; OR Loc: 4006001|6.60|
23095|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 2-0 J105T|1|<Self-pay>|<Self-pay>|<Self-pay>|31.05|Inv Loc: 4006001; OR Loc: 4006001|||31.05|Inv Loc: 4006001; OR Loc: 4006001|17.08|
23097|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-ENDOSCOPY INJECTION NM200U-0425|1|<Self-pay>|<Self-pay>|<Self-pay>|114.05|Inv Loc: 4006001; OR Loc: 4006001|||114.05|Inv Loc: 4006001; OR Loc: 4006001|62.73|
23105|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 7-0 8800H|1|<Self-pay>|<Self-pay>|<Self-pay>|36.85|Inv Loc: 4006001; OR Loc: 4006001|||36.85|Inv Loc: 4006001; OR Loc: 4006001|20.27|
23117|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TAP-1.5MM 311.15|1|<Self-pay>|<Self-pay>|<Self-pay>|575.00|Inv Loc: 4006001; OR Loc: 4006001|||575.00|Inv Loc: 4006001; OR Loc: 4006001|316.25|
23195|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INTRODUCER-DEVICE 3LUM. AVA3XI|1|<Self-pay>|<Self-pay>|<Self-pay>|568.50|Inv Loc: 4006001; OR Loc: 4006001|||568.50|Inv Loc: 4006001; OR Loc: 4006001|312.67|
23196|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-CENTRAL VENUS 3 LUMEN 7.0FR.|1|<Self-pay>|<Self-pay>|<Self-pay>|394.00|Inv Loc: 4006001; OR Loc: 4006001|||394.00|Inv Loc: 4006001; OR Loc: 4006001|216.70|
23197|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-SWAN-GANZ 7.5FR. *LATEX*|1|<Self-pay>|<Self-pay>|<Self-pay>|959.05|Inv Loc: 4006001; OR Loc: 4006001|||959.05|Inv Loc: 4006001; OR Loc: 4006001|527.48|
23225|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BASIN SET-MAJOR DYNJ30789|1|<Self-pay>|<Self-pay>|<Self-pay>|102.75|Inv Loc: 4006001; OR Loc: 4006001|||102.75|Inv Loc: 4006001; OR Loc: 4006001|56.51|
23227|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BASIN SET-MINOR  DYNJ30791|1|<Self-pay>|<Self-pay>|<Self-pay>|69.35|Inv Loc: 4006001; OR Loc: 4006001|||69.35|Inv Loc: 4006001; OR Loc: 4006001|38.14|
23568|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|STAPLER-PROTACK 5MM ENDOSCOPIC (PTACK30)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,056.08|Inv Loc: 4006001; OR Loc: 4006001|||1,056.08|Inv Loc: 4006001; OR Loc: 4006001|580.84|
23570|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-MEDIUM NARROW 2296-33-412|1|<Self-pay>|<Self-pay>|<Self-pay>|42.90|Inv Loc: 4006001; OR Loc: 4006001|||42.90|Inv Loc: 4006001; OR Loc: 4006001|23.59|
23594|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND 1 X538H|1|<Self-pay>|<Self-pay>|<Self-pay>|11.05|Inv Loc: 4006001; OR Loc: 4006001|||11.05|Inv Loc: 4006001; OR Loc: 4006001|6.08|
23602|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BOOT-4" UNNA GEL CAST|1|<Self-pay>|<Self-pay>|<Self-pay>|20.00|Inv Loc: 4006001; OR Loc: 4006001|||20.00|Inv Loc: 4006001; OR Loc: 4006001|11.00|
23632|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SHEET-BILATERAL LIMB 29416|1|<Self-pay>|<Self-pay>|<Self-pay>|59.85|Inv Loc: 4006001; OR Loc: 4006001|||59.85|Inv Loc: 4006001; OR Loc: 4006001|32.92|
23682|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAIN-BLAKE ROUND HUBLESS (2228)|1|<Self-pay>|<Self-pay>|<Self-pay>|57.85|Inv Loc: 4006001; OR Loc: 4006001|||57.85|Inv Loc: 4006001; OR Loc: 4006001|31.82|
23689|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|FOLEY-16FR 5CC 2000ML URINE METER|1|<Self-pay>|<Self-pay>|<Self-pay>|77.85|Inv Loc: 4006001; OR Loc: 4006001|||77.85|Inv Loc: 4006001; OR Loc: 4006001|42.82|
23692|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MONOCRYL 4-0 Y494G|1|<Self-pay>|<Self-pay>|<Self-pay>|19.50|Inv Loc: 4006001; OR Loc: 4006001|||19.50|Inv Loc: 4006001; OR Loc: 4006001|10.72|
23697|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY-FOLEY CATH 14FR W/BAG|1|<Self-pay>|<Self-pay>|<Self-pay>|68.30|Inv Loc: 4006001; OR Loc: 4006001|||68.30|Inv Loc: 4006001; OR Loc: 4006001|37.56|
23713|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PIN-PASSING DRILL TIP MITEK CRUCIATE LIGAMENT|1|<Self-pay>|<Self-pay>|<Self-pay>|852.00|Inv Loc: 4006001; OR Loc: 4006001|||852.00|Inv Loc: 4006001; OR Loc: 4006001|468.60|
23773|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BALLOON-KIDNEY SHAPE  (OMSPDBS2)|1|<Self-pay>|<Self-pay>|<Self-pay>|1,085.76|Inv Loc: 4006001; OR Loc: 4006001|||1,085.76|Inv Loc: 4006001; OR Loc: 4006001|597.17|
23774|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-BLUNT TIP OMS-T12BT|1|<Self-pay>|<Self-pay>|<Self-pay>|918.80|Inv Loc: 4006001; OR Loc: 4006001|||918.80|Inv Loc: 4006001; OR Loc: 4006001|505.34|
23805|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 0 ENDOLOOP EJ10G|1|<Self-pay>|<Self-pay>|<Self-pay>|184.50|Inv Loc: 4006001; OR Loc: 4006001|||184.50|Inv Loc: 4006001; OR Loc: 4006001|101.47|
23809|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CUTTER-FLEX 45 ATS45(MUST ADD STAPLES)|1|<Self-pay>|<Self-pay>|<Self-pay>|667.26|Inv Loc: 4006001; OR Loc: 4006001|||667.26|Inv Loc: 4006001; OR Loc: 4006001|366.99|
23820|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 0 J727D|1|<Self-pay>|<Self-pay>|<Self-pay>|45.45|Inv Loc: 4006001; OR Loc: 4006001|||45.45|Inv Loc: 4006001; OR Loc: 4006001|25.00|
23840|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ESSURE SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|3,700.00|Inv Loc: 4006001; OR Loc: 4006001|||3,700.00|Inv Loc: 4006001; OR Loc: 4006001|2,035.00|
23841|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 0 J740D CT-1 W/TRAY|1|<Self-pay>|<Self-pay>|<Self-pay>|45.80|Inv Loc: 4006001; OR Loc: 4006001|||45.80|Inv Loc: 4006001; OR Loc: 4006001|25.19|
23848|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 1 J741D|1|<Self-pay>|<Self-pay>|<Self-pay>|46.00|Inv Loc: 4006001; OR Loc: 4006001|||46.00|Inv Loc: 4006001; OR Loc: 4006001|25.30|
23870|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-NUROLON 2-0 C526D|1|<Self-pay>|<Self-pay>|<Self-pay>|46.05|Inv Loc: 4006001; OR Loc: 4006001|||46.05|Inv Loc: 4006001; OR Loc: 4006001|25.33|
23872|SUP|HCPCS C1758||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-URETERAL OPEN ENDED TIP 5FR|1|<Self-pay>|<Self-pay>|<Self-pay>|81.05|Inv Loc: 4006001; OR Loc: 4006001|||81.05|Inv Loc: 4006001; OR Loc: 4006001|44.58|
23880|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-PNEUMONEEDLE INSUFFLATION PN120|1|<Self-pay>|<Self-pay>|<Self-pay>|272.10|Inv Loc: 4006001; OR Loc: 4006001|||272.10|Inv Loc: 4006001; OR Loc: 4006001|149.65|
23886|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL #1 J765D|1|<Self-pay>|<Self-pay>|<Self-pay>|45.35|Inv Loc: 4006001; OR Loc: 4006001|||45.35|Inv Loc: 4006001; OR Loc: 4006001|24.94|
23887|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-VICRYL 2-0 J775D|1|<Self-pay>|<Self-pay>|<Self-pay>|42.85|Inv Loc: 4006001; OR Loc: 4006001|||42.85|Inv Loc: 4006001; OR Loc: 4006001|23.57|
23889|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-NOVAFIL 2-0 4459-51|1|<Self-pay>|<Self-pay>|<Self-pay>|51.75|Inv Loc: 4006001; OR Loc: 4006001|||51.75|Inv Loc: 4006001; OR Loc: 4006001|28.46|
23890|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-NOVAFIL 0 4455-61|1|<Self-pay>|<Self-pay>|<Self-pay>|42.50|Inv Loc: 4006001; OR Loc: 4006001|||42.50|Inv Loc: 4006001; OR Loc: 4006001|23.37|
23893|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-HIP W/POUCH & ARMBOARD|1|<Self-pay>|<Self-pay>|<Self-pay>|71.00|Inv Loc: 4006001; OR Loc: 4006001|||71.00|Inv Loc: 4006001; OR Loc: 4006001|39.05|
23898|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-STIM INSULATED 21GAX2 W/EXT TUBING|1|<Self-pay>|<Self-pay>|<Self-pay>|39.55|Inv Loc: 4006001; OR Loc: 4006001|||39.55|Inv Loc: 4006001; OR Loc: 4006001|21.75|
23899|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-STIM 22GA X 1 3/8" W/EXT TUBING|1|<Self-pay>|<Self-pay>|<Self-pay>|43.15|Inv Loc: 4006001; OR Loc: 4006001|||43.15|Inv Loc: 4006001; OR Loc: 4006001|23.73|
23923|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHILON 3-0 1669H|1|<Self-pay>|<Self-pay>|<Self-pay>|14.30|Inv Loc: 4006001; OR Loc: 4006001|||14.30|Inv Loc: 4006001; OR Loc: 4006001|7.86|
23924|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-SOLOSITE 4"X4" (PT)|1|<Self-pay>|<Self-pay>|<Self-pay>|998.05|Inv Loc: 4006001; OR Loc: 4006001|||998.05|Inv Loc: 4006001; OR Loc: 4006001|548.93|
23926|SUP|HCPCS C1733||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-ABLATION NOVASURE NS2000US|1|<Self-pay>|<Self-pay>|<Self-pay>|2,060.36|Inv Loc: 4006001; OR Loc: 4006001|||2,060.36|Inv Loc: 4006001; OR Loc: 4006001|1,133.20|
23943|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-HUBER 22GA 3/4" (S02022-75)|1|<Self-pay>|<Self-pay>|<Self-pay>|37.50|Inv Loc: 4006001; OR Loc: 4006001|||37.50|Inv Loc: 4006001; OR Loc: 4006001|20.62|
23944|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-STIM 21G X 4"INSULATED W/EXT SET|1|<Self-pay>|<Self-pay>|<Self-pay>|56.45|Inv Loc: 4006001; OR Loc: 4006001|||56.45|Inv Loc: 4006001; OR Loc: 4006001|31.05|
23946|SUP|HCPCS C1757||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATH-EMBOLECTOMY 6FR|1|<Self-pay>|<Self-pay>|<Self-pay>|255.50|Inv Loc: 4006001; OR Loc: 4006001|||255.50|Inv Loc: 4006001; OR Loc: 4006001|140.52|
23949|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 6-0 8726H|1|<Self-pay>|<Self-pay>|<Self-pay>|37.65|Inv Loc: 4006001; OR Loc: 4006001|||37.65|Inv Loc: 4006001; OR Loc: 4006001|20.71|
23950|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MONOCRYL 3-0 Y936|1|<Self-pay>|<Self-pay>|<Self-pay>|19.05|Inv Loc: 4006001; OR Loc: 4006001|||19.05|Inv Loc: 4006001; OR Loc: 4006001|10.48|
23953|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-WARMER IRRIGATION SOLUTION (ORS-300)|1|<Self-pay>|<Self-pay>|<Self-pay>|380.15|Inv Loc: 4006001; OR Loc: 4006001|||380.15|Inv Loc: 4006001; OR Loc: 4006001|209.08|
23977|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-SAGITAL 25X90 (BR1-2590-35)|1|<Self-pay>|<Self-pay>|<Self-pay>|130.50|Inv Loc: 4006001; OR Loc: 4006001|||130.50|Inv Loc: 4006001; OR Loc: 4006001|71.77|
23979|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-SAGITAL 25X1 (BR4125-127-100)|1|<Self-pay>|<Self-pay>|<Self-pay>|120.00|Inv Loc: 4006001; OR Loc: 4006001|||120.00|Inv Loc: 4006001; OR Loc: 4006001|66.00|
23980|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-SAGITAL 11X1.27X90 (4111-127-090)|1|<Self-pay>|<Self-pay>|<Self-pay>|120.00|Inv Loc: 4006001; OR Loc: 4006001|||120.00|Inv Loc: 4006001; OR Loc: 4006001|66.00|
23981|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-SAGITAL 18X1.27X100 (4118-127-100)|1|<Self-pay>|<Self-pay>|<Self-pay>|120.00|Inv Loc: 4006001; OR Loc: 4006001|||120.00|Inv Loc: 4006001; OR Loc: 4006001|66.00|
23988|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 2-0 SH 8523H|1|<Self-pay>|<Self-pay>|<Self-pay>|19.75|Inv Loc: 4006001; OR Loc: 4006001|||19.75|Inv Loc: 4006001; OR Loc: 4006001|10.86|
24006|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-FIBERWIRE #2|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|Inv Loc: 4006001; OR Loc: 4006001|||110.00|Inv Loc: 4006001; OR Loc: 4006001|60.50|
24019|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MONOCRYL 4-0 Y823G|1|<Self-pay>|<Self-pay>|<Self-pay>|21.40|Inv Loc: 4006001; OR Loc: 4006001|||21.40|Inv Loc: 4006001; OR Loc: 4006001|11.77|
24050|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR PACK-FLEXIPATH 15MM (FPK02)|1|<Self-pay>|<Self-pay>|<Self-pay>|688.11|Inv Loc: 4006001; OR Loc: 4006001|||688.11|Inv Loc: 4006001; OR Loc: 4006001|378.46|
24059|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PROLENE 5-0 8325H (24")|1|<Self-pay>|<Self-pay>|<Self-pay>|39.60|Inv Loc: 4006001; OR Loc: 4006001|||39.60|Inv Loc: 4006001; OR Loc: 4006001|21.78|
24066|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-KALTOSTAT 2GRM ROPE-CALCIUM ALGINATE|1|<Self-pay>|<Self-pay>|<Self-pay>|15.70|Inv Loc: 4006001; OR Loc: 4006001|||15.70|Inv Loc: 4006001; OR Loc: 4006001|8.63|
24068|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRAPE-IOBAN LARGE 6619|1|<Self-pay>|<Self-pay>|<Self-pay>|101.85|Inv Loc: 4006001; OR Loc: 4006001|||101.85|Inv Loc: 4006001; OR Loc: 4006001|56.02|
24069|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CLOSURE DEVICE TROCARS (CTI-512N)|1|<Self-pay>|<Self-pay>|<Self-pay>|675.00|Inv Loc: 4006001; OR Loc: 4006001|||675.00|Inv Loc: 4006001; OR Loc: 4006001|371.25|
24084|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|GLOVES-CUT RESISTANT SZ XL (HAMAN)|1|<Self-pay>|<Self-pay>|<Self-pay>|285.00|Inv Loc: 4006001; OR Loc: 4006001|||285.00|Inv Loc: 4006001; OR Loc: 4006001|156.75|
24104|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-LINGEMAN PROCEDURE 3-N-1 PACK|1|<Self-pay>|<Self-pay>|<Self-pay>|331.95|Inv Loc: 4006001; OR Loc: 4006001|||331.95|Inv Loc: 4006001; OR Loc: 4006001|182.57|
24108|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATH-FOLEY 18FR 5CC 2WAY (SILVER COAT)SILICON|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|Inv Loc: 4006001; OR Loc: 4006001|||14.70|Inv Loc: 4006001; OR Loc: 4006001|8.08|
24109|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATH-FOLEY 20FR 5CC 2WAY (SILVER COAT)|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|Inv Loc: 4006001; OR Loc: 4006001|||14.70|Inv Loc: 4006001; OR Loc: 4006001|8.08|
24122|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-ASPIRATION TRANSBRONCHIAL ENDOSCOPY|1|<Self-pay>|<Self-pay>|<Self-pay>|266.65|Inv Loc: 4006001; OR Loc: 4006001|||266.65|Inv Loc: 4006001; OR Loc: 4006001|146.66|
24125|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-SILK 0 590H|1|<Self-pay>|<Self-pay>|<Self-pay>|15.35|Inv Loc: 4006001; OR Loc: 4006001|||15.35|Inv Loc: 4006001; OR Loc: 4006001|8.44|
24134|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-12MM BLUNT TIP|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
24135|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-12MM BLADED (BALLOON)|1|<Self-pay>|<Self-pay>|<Self-pay>|128.15|Inv Loc: 4006001; OR Loc: 4006001|||128.15|Inv Loc: 4006001; OR Loc: 4006001|70.48|
24136|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-5MMX100MM OPTICAL ACCESS CFR03|1|<Self-pay>|<Self-pay>|<Self-pay>|76.50|Inv Loc: 4006001; OR Loc: 4006001|||76.50|Inv Loc: 4006001; OR Loc: 4006001|42.07|
24137|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-12MM OPTICAL COR29|1|<Self-pay>|<Self-pay>|<Self-pay>|128.15|Inv Loc: 4006001; OR Loc: 4006001|||128.15|Inv Loc: 4006001; OR Loc: 4006001|70.48|
24140|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-12MM THREADED 12X150MM C0661|1|<Self-pay>|<Self-pay>|<Self-pay>|128.15|Inv Loc: 4006001; OR Loc: 4006001|||128.15|Inv Loc: 4006001; OR Loc: 4006001|70.48|
24148|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RETRIEVAL BAG-10MM MONARCH CD001|1|<Self-pay>|<Self-pay>|<Self-pay>|229.50|Inv Loc: 4006001; OR Loc: 4006001|||229.50|Inv Loc: 4006001; OR Loc: 4006001|126.22|
24160|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-MICRO SAW KM33-410|1|<Self-pay>|<Self-pay>|<Self-pay>|42.90|Inv Loc: 4006001; OR Loc: 4006001|||42.90|Inv Loc: 4006001; OR Loc: 4006001|23.59|
24161|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-GENERAL ENDOSCOPY DYNJP3100S|1|<Self-pay>|<Self-pay>|<Self-pay>|100.90|Inv Loc: 4006001; OR Loc: 4006001|||100.90|Inv Loc: 4006001; OR Loc: 4006001|55.49|
24162|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-5MM THREADED CTS02|1|<Self-pay>|<Self-pay>|<Self-pay>|38.25|Inv Loc: 4006001; OR Loc: 4006001|||38.25|Inv Loc: 4006001; OR Loc: 4006001|21.04|
24164|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-10/11 HANDLED BLADELESS C0150|1|<Self-pay>|<Self-pay>|<Self-pay>|128.15|Inv Loc: 4006001; OR Loc: 4006001|||128.15|Inv Loc: 4006001; OR Loc: 4006001|70.48|
24199|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-C-ARM (E9100AH)|1|<Self-pay>|<Self-pay>|<Self-pay>|108.50|Inv Loc: 4006001; OR Loc: 4006001|||108.50|Inv Loc: 4006001; OR Loc: 4006001|59.67|
24210|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-SPINAL WHITACRE 22G X 3 1/2" (405010)|1|<Self-pay>|<Self-pay>|<Self-pay>|25.10|Inv Loc: 4006001; OR Loc: 4006001|||25.10|Inv Loc: 4006001; OR Loc: 4006001|13.80|
24235|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-INTRAOSSEOUS AD 25MM:15GA (PTS 40KG+)|1|<Self-pay>|<Self-pay>|<Self-pay>|625.00|Inv Loc: 4006001; OR Loc: 4006001|||625.00|Inv Loc: 4006001; OR Loc: 4006001|343.75|
24236|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-INTRAOSSEOUS PD 15MM:15GA (PTS 3-39KG)|1|<Self-pay>|<Self-pay>|<Self-pay>|625.00|Inv Loc: 4006001; OR Loc: 4006001|||625.00|Inv Loc: 4006001; OR Loc: 4006001|343.75|
24257|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-4.0 RESECTOR 375-542-000|1|<Self-pay>|<Self-pay>|<Self-pay>|263.50|Inv Loc: 4006001; OR Loc: 4006001|||263.50|Inv Loc: 4006001; OR Loc: 4006001|144.92|
24258|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-TOMCAT 4.0MM 375-545-000|1|<Self-pay>|<Self-pay>|<Self-pay>|263.50|Inv Loc: 4006001; OR Loc: 4006001|||263.50|Inv Loc: 4006001; OR Loc: 4006001|144.92|
24259|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-5.5 RESECTOR 375-562-000|1|<Self-pay>|<Self-pay>|<Self-pay>|266.50|Inv Loc: 4006001; OR Loc: 4006001|||266.50|Inv Loc: 4006001; OR Loc: 4006001|146.57|
24260|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-AGGRESSIVE 3.5 375-638-000|1|<Self-pay>|<Self-pay>|<Self-pay>|266.50|Inv Loc: 4006001; OR Loc: 4006001|||266.50|Inv Loc: 4006001; OR Loc: 4006001|146.57|
24261|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-RESECTOR 3.5MM 375-532-000|1|<Self-pay>|<Self-pay>|<Self-pay>|240.95|Inv Loc: 4006001; OR Loc: 4006001|||240.95|Inv Loc: 4006001; OR Loc: 4006001|132.52|
24263|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-CUTTER 4.0 375-747-000|1|<Self-pay>|<Self-pay>|<Self-pay>|263.50|Inv Loc: 4006001; OR Loc: 4006001|||263.50|Inv Loc: 4006001; OR Loc: 4006001|144.92|
24265|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR-BARREL 4.0MM 6-FLUTED 375-941-000|1|<Self-pay>|<Self-pay>|<Self-pay>|278.35|Inv Loc: 4006001; OR Loc: 4006001|||278.35|Inv Loc: 4006001; OR Loc: 4006001|153.09|
24268|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-BRONCHO 39FR LFT 125139|1|<Self-pay>|<Self-pay>|<Self-pay>|251.20|Inv Loc: 4006001; OR Loc: 4006001|||251.20|Inv Loc: 4006001; OR Loc: 4006001|138.16|
24275|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-AGGRESSIVE 2.5MM (375-628-000)|1|<Self-pay>|<Self-pay>|<Self-pay>|285.45|Inv Loc: 4006001; OR Loc: 4006001|||285.45|Inv Loc: 4006001; OR Loc: 4006001|157.00|
24276|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR-ROUND 4.0MM 6 FLUTED 375-940-000|1|<Self-pay>|<Self-pay>|<Self-pay>|278.35|Inv Loc: 4006001; OR Loc: 4006001|||278.35|Inv Loc: 4006001; OR Loc: 4006001|153.09|
24280|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BUR-BARREL 5.5MM 6-FLUTE 375-951-000|1|<Self-pay>|<Self-pay>|<Self-pay>|278.35|Inv Loc: 4006001; OR Loc: 4006001|||278.35|Inv Loc: 4006001; OR Loc: 4006001|153.09|
24284|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ELECTROLUBE EL101|1|<Self-pay>|<Self-pay>|<Self-pay>|125.00|Inv Loc: 4006001; OR Loc: 4006001|||125.00|Inv Loc: 4006001; OR Loc: 4006001|68.75|
24316|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-SLOTTED WHISKER 4.0MM 375-548-000|1|<Self-pay>|<Self-pay>|<Self-pay>|263.50|Inv Loc: 4006001; OR Loc: 4006001|||263.50|Inv Loc: 4006001; OR Loc: 4006001|144.92|
24321|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PACK-SHOULDER CUSTOM DYNJ37891|1|<Self-pay>|<Self-pay>|<Self-pay>|260.45|Inv Loc: 4006001; OR Loc: 4006001|||260.45|Inv Loc: 4006001; OR Loc: 4006001|143.25|
24324|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SLEEVE-TROCAR 5MMX100 SMOOTH CFS02|1|<Self-pay>|<Self-pay>|<Self-pay>|38.45|Inv Loc: 4006001; OR Loc: 4006001|||38.45|Inv Loc: 4006001; OR Loc: 4006001|21.15|
24594|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-STIMUPLEX ULTRASOUND 21G X 2"|1|<Self-pay>|<Self-pay>|<Self-pay>|56.80|Inv Loc: 4006001; OR Loc: 4006001|||56.80|Inv Loc: 4006001; OR Loc: 4006001|31.24|
24622|SUP|HCPCS C1769||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|GUIDEWIRE-STIFF WIRE .038X145CM PTFE|1|<Self-pay>|<Self-pay>|<Self-pay>|104.15|Inv Loc: 4006001; OR Loc: 4006001|||104.15|Inv Loc: 4006001; OR Loc: 4006001|57.28|
24635|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MONOCRYL 3-0 Y427H PS2 27"|1|<Self-pay>|<Self-pay>|<Self-pay>|19.60|Inv Loc: 4006001; OR Loc: 4006001|||19.60|Inv Loc: 4006001; OR Loc: 4006001|10.78|
24675|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|PERI-STRIPS DRY 60 UNIV. REINFOREMENT|1|<Self-pay>|<Self-pay>|<Self-pay>|979.15|Inv Loc: 4006001; OR Loc: 4006001|||979.15|Inv Loc: 4006001; OR Loc: 4006001|538.53|
24684|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-RADIAL ARTERY 20G RA-40220(SHORT)|1|<Self-pay>|<Self-pay>|<Self-pay>|59.40|Inv Loc: 4006001; OR Loc: 4006001|||59.40|Inv Loc: 4006001; OR Loc: 4006001|32.67|
24687|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PDO 0 (POLYDIOXADONE)RA-1029Q|1|<Self-pay>|<Self-pay>|<Self-pay>|97.15|Inv Loc: 4006001; OR Loc: 4006001|||97.15|Inv Loc: 4006001; OR Loc: 4006001|53.43|
24689|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-PDO 2 (POLYDIOXANONE) RA-1065Q|1|<Self-pay>|<Self-pay>|<Self-pay>|111.00|Inv Loc: 4006001; OR Loc: 4006001|||111.00|Inv Loc: 4006001; OR Loc: 4006001|61.05|
24690|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-MONODERM 2-0 YA-1015Q|1|<Self-pay>|<Self-pay>|<Self-pay>|81.35|Inv Loc: 4006001; OR Loc: 4006001|||81.35|Inv Loc: 4006001; OR Loc: 4006001|44.74|
24704|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHILON 2-0 593H|1|<Self-pay>|<Self-pay>|<Self-pay>|13.30|Inv Loc: 4006001; OR Loc: 4006001|||13.30|Inv Loc: 4006001; OR Loc: 4006001|7.31|
24705|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-FIBERWIRE #4 AR-7230-02|1|<Self-pay>|<Self-pay>|<Self-pay>|110.00|Inv Loc: 4006001; OR Loc: 4006001|||110.00|Inv Loc: 4006001; OR Loc: 4006001|60.50|
24726|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-FIBERWIRE #5 AR-7211|1|<Self-pay>|<Self-pay>|<Self-pay>|200.00|Inv Loc: 4006001; OR Loc: 4006001|||200.00|Inv Loc: 4006001; OR Loc: 4006001|110.00|
24731|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DISPOSABLE BLADE ASSEMBLY 81010|1|<Self-pay>|<Self-pay>|<Self-pay>|645.00|Inv Loc: 4006001; OR Loc: 4006001|||645.00|Inv Loc: 4006001; OR Loc: 4006001|354.75|
24732|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-MINI BEAVER ST DOUBLE BEVEL 6900|1|<Self-pay>|<Self-pay>|<Self-pay>|27.75|Inv Loc: 4006001; OR Loc: 4006001|||27.75|Inv Loc: 4006001; OR Loc: 4006001|15.26|
24733|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-CLIPPER UNIVERSAL DYND70850|1|<Self-pay>|<Self-pay>|<Self-pay>|12.50|Inv Loc: 4006001; OR Loc: 4006001|||12.50|Inv Loc: 4006001; OR Loc: 4006001|6.87|
24734|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-CLIPPER,UNIVERSAL,GRAY|1|<Self-pay>|<Self-pay>|<Self-pay>|10.85|Inv Loc: 4006001; OR Loc: 4006001|||10.85|Inv Loc: 4006001; OR Loc: 4006001|5.97|
24757|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-CLIPPER NARROW MEDICLIP DYND70860|1|<Self-pay>|<Self-pay>|<Self-pay>|16.30|Inv Loc: 4006001; OR Loc: 4006001|||16.30|Inv Loc: 4006001; OR Loc: 4006001|8.96|
24759|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-5MM X150MM BLADED C0Q53|1|<Self-pay>|<Self-pay>|<Self-pay>|76.90|Inv Loc: 4006001; OR Loc: 4006001|||76.90|Inv Loc: 4006001; OR Loc: 4006001|42.29|
24761|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-RECIPROCATING BLADE 277-96-275|1|<Self-pay>|<Self-pay>|<Self-pay>|56.85|Inv Loc: 4006001; OR Loc: 4006001|||56.85|Inv Loc: 4006001; OR Loc: 4006001|31.27|
24778|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|RETRACTOR-O LARGE ALEXIS (C8403)|1|<Self-pay>|<Self-pay>|<Self-pay>|375.05|Inv Loc: 4006001; OR Loc: 4006001|||375.05|Inv Loc: 4006001; OR Loc: 4006001|206.28|
24813|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ETHIBOND EXCELL 5 MB66G|1|<Self-pay>|<Self-pay>|<Self-pay>|68.90|Inv Loc: 4006001; OR Loc: 4006001|||68.90|Inv Loc: 4006001; OR Loc: 4006001|37.89|
24816|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INCISION-SINGLE GELPOINT SYSTEM|1|<Self-pay>|<Self-pay>|<Self-pay>|1,387.14|Inv Loc: 4006001; OR Loc: 4006001|||1,387.14|Inv Loc: 4006001; OR Loc: 4006001|762.93|
24825|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-FOLEY SILICONE 14FR 5CC|1|<Self-pay>|<Self-pay>|<Self-pay>|14.70|Inv Loc: 4006001; OR Loc: 4006001|||14.70|Inv Loc: 4006001; OR Loc: 4006001|8.08|
24835|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-5X100KII BLADED Z-THREADED CTB03|1|<Self-pay>|<Self-pay>|<Self-pay>|76.50|Inv Loc: 4006001; OR Loc: 4006001|||76.50|Inv Loc: 4006001; OR Loc: 4006001|42.07|
24836|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-11X100 KII BLADED Z-THREADED CTB33|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
24837|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-12X100 KII BLADED Z-THREADED CTB73|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
24867|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|BLADE-CLIPPER COARSE HAIR DYND70845|1|<Self-pay>|<Self-pay>|<Self-pay>|11.75|Inv Loc: 4006001; OR Loc: 4006001|||11.75|Inv Loc: 4006001; OR Loc: 4006001|6.46|
24870|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-ENDOLOOP PDS 0 EZ10G|1|<Self-pay>|<Self-pay>|<Self-pay>|184.50|Inv Loc: 4006001; OR Loc: 4006001|||184.50|Inv Loc: 4006001; OR Loc: 4006001|101.47|
24877|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-CHOLANGIOGRAM LAPAROSCOPIC 9100|1|<Self-pay>|<Self-pay>|<Self-pay>|610.00|Inv Loc: 4006001; OR Loc: 4006001|||610.00|Inv Loc: 4006001; OR Loc: 4006001|335.50|
24878|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|INTRODUCER-MICROINTRODUCER 4.0 FR 21G/7CM|1|<Self-pay>|<Self-pay>|<Self-pay>|242.80|Inv Loc: 4006001; OR Loc: 4006001|||242.80|Inv Loc: 4006001; OR Loc: 4006001|133.54|
24885|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ENDOCLIP-5MM|1|<Self-pay>|<Self-pay>|<Self-pay>|711.35|Inv Loc: 4006001; OR Loc: 4006001|||711.35|Inv Loc: 4006001; OR Loc: 4006001|391.24|
24895|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-8MM BLADED THREADED KII|1|<Self-pay>|<Self-pay>|<Self-pay>|76.90|Inv Loc: 4006001; OR Loc: 4006001|||76.90|Inv Loc: 4006001; OR Loc: 4006001|42.29|
24903|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-CHG PATCH 1" DISK W/4MM CENTER|1|<Self-pay>|<Self-pay>|<Self-pay>|28.15|Inv Loc: 4006001; OR Loc: 4006001|||28.15|Inv Loc: 4006001; OR Loc: 4006001|15.48|
24920|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-TROCAR 36FR THORACIC 8888570564|1|<Self-pay>|<Self-pay>|<Self-pay>|37.90|Inv Loc: 4006001; OR Loc: 4006001|||37.90|Inv Loc: 4006001; OR Loc: 4006001|20.84|
24928|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-WOUND GRANUFOAM MEDIUM|1|<Self-pay>|<Self-pay>|<Self-pay>|244.45|Inv Loc: 4006001; OR Loc: 4006001|||244.45|Inv Loc: 4006001; OR Loc: 4006001|134.45|
24929|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-WOUND GRANUFOAM LARGE|1|<Self-pay>|<Self-pay>|<Self-pay>|288.75|Inv Loc: 4006001; OR Loc: 4006001|||288.75|Inv Loc: 4006001; OR Loc: 4006001|158.81|
24953|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|ENDO FASCIAL CLOSURE SYSTEM (EFX)|1|<Self-pay>|<Self-pay>|<Self-pay>|504.90|Inv Loc: 4006001; OR Loc: 4006001|||504.90|Inv Loc: 4006001; OR Loc: 4006001|277.69|
24954|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|GLOVES-SURGICAL 7 POWDER FREE RADIATION|1|<Self-pay>|<Self-pay>|<Self-pay>|159.25|Inv Loc: 4006001; OR Loc: 4006001|||159.25|Inv Loc: 4006001; OR Loc: 4006001|87.59|
24956|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|GRASPER-MINI GRIP ALLIGATOR|1|<Self-pay>|<Self-pay>|<Self-pay>|825.00|Inv Loc: 4006001; OR Loc: 4006001|||825.00|Inv Loc: 4006001; OR Loc: 4006001|453.75|
24957|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR 5X100MM OPTICAL Z-THREADED (CTR03)|1|<Self-pay>|<Self-pay>|<Self-pay>|76.50|Inv Loc: 4006001; OR Loc: 4006001|||76.50|Inv Loc: 4006001; OR Loc: 4006001|42.07|
24960|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-FLEX CYSTO INJECTION (MAJ-656)|1|<Self-pay>|<Self-pay>|<Self-pay>|248.05|Inv Loc: 4006001; OR Loc: 4006001|||248.05|Inv Loc: 4006001; OR Loc: 4006001|136.43|
24963|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|CATHETER-EPIDURAL POLYAMIDE PERFIX 20G|1|<Self-pay>|<Self-pay>|<Self-pay>|844.05|Inv Loc: 4006001; OR Loc: 4006001|||844.05|Inv Loc: 4006001; OR Loc: 4006001|464.23|
24964|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-TUOHY 20G 3 1/2" 332168|1|<Self-pay>|<Self-pay>|<Self-pay>|500.55|Inv Loc: 4006001; OR Loc: 4006001|||500.55|Inv Loc: 4006001; OR Loc: 4006001|275.30|
24965|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-TUOHY 17G 3 1/2"|1|<Self-pay>|<Self-pay>|<Self-pay>|539.05|Inv Loc: 4006001; OR Loc: 4006001|||539.05|Inv Loc: 4006001; OR Loc: 4006001|296.48|
24966|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-TUOHY 17G 4 1/2"|1|<Self-pay>|<Self-pay>|<Self-pay>|862.90|Inv Loc: 4006001; OR Loc: 4006001|||862.90|Inv Loc: 4006001; OR Loc: 4006001|474.59|
24967|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|LAPARSCOPIC INST PORT - TRIPORT OLYMPUS|1|<Self-pay>|<Self-pay>|<Self-pay>|1,088.64|Inv Loc: 4006001; OR Loc: 4006001|||1,088.64|Inv Loc: 4006001; OR Loc: 4006001|598.75|
24968|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-TUOHY 18G 3.5"|1|<Self-pay>|<Self-pay>|<Self-pay>|526.25|Inv Loc: 4006001; OR Loc: 4006001|||526.25|Inv Loc: 4006001; OR Loc: 4006001|289.44|
25014|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TROCAR-12MMX100MM BLUNT FIRST ENTRY|1|<Self-pay>|<Self-pay>|<Self-pay>|127.50|Inv Loc: 4006001; OR Loc: 4006001|||127.50|Inv Loc: 4006001; OR Loc: 4006001|70.12|
25033|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DEVICE-SUTURE CAPTURING CAPIO|1|<Self-pay>|<Self-pay>|<Self-pay>|1,386.00|Inv Loc: 4006001; OR Loc: 4006001|||1,386.00|Inv Loc: 4006001; OR Loc: 4006001|762.30|
25034|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|SUTURE-CAPIO 0 833-124|1|<Self-pay>|<Self-pay>|<Self-pay>|170.50|Inv Loc: 4006001; OR Loc: 4006001|||170.50|Inv Loc: 4006001; OR Loc: 4006001|93.77|
25040|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080275|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25041|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079886|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25042|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080048|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25043|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2076768|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25044|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080017|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25045|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2007343|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25046|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2075605|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25047|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079205|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25048|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096279|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25049|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096284|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25050|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2092132|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25051|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096621|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25052|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096498|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25053|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096203|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25054|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096245|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25055|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096607|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25056|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096573|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25057|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2093743|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25058|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096210|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25059|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080201|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25060|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096202|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25061|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2093576|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25062|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079184|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25063|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2076618|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25064|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096211|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25065|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080571|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25066|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080552|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25067|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2068973|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25068|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079967|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25069|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2002539|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25070|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2000801|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25071|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079946|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25072|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096133|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25073|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2093772|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25074|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096115|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25075|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080659|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25076|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080924|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25077|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2077424|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25078|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080200|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25079|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2094453|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25080|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2074295|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25081|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080191|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25082|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096111|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25083|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080644|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25084|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080879|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25085|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080792|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25086|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096701|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25087|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2096163|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25088|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080574|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25089|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2066162|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25090|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079213|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25091|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2067260|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25092|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2072812|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25093|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2076494|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25094|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079517|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25095|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2048073|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25096|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2064921|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25097|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2072091|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25098|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2075130|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25099|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2035662|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25100|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080437|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25101|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2048047|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25102|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079906|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25103|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2067275|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25104|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2069945|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25105|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079365|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25106|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2007247|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25107|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2063156|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25108|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2068653|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25109|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080784|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25110|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080631|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25111|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080809|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25112|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2080811|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25113|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2079109|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25114|SUP|HCPCS C1772||0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - OTHER IMPLANT|PUMP-SPECTRUM 2068391|1|<Self-pay>|<Self-pay>|<Self-pay>|0.00|Inv Loc: 4006001; OR Loc: 4006001|||0.00|Inv Loc: 4006001; OR Loc: 4006001|0.00|
25116|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|NEEDLE-STIM 20G 6"|1|<Self-pay>|<Self-pay>|<Self-pay>|1,088.01|Inv Loc: 4006001; OR Loc: 4006001|||1,088.01|Inv Loc: 4006001; OR Loc: 4006001|598.41|
25120|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-OPTIFOAM 4X4|1|<Self-pay>|<Self-pay>|<Self-pay>|14.15|Inv Loc: 4006001; OR Loc: 4006001|||14.15|Inv Loc: 4006001; OR Loc: 4006001|7.78|
25121|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-OPTIFOAM 6X6|1|<Self-pay>|<Self-pay>|<Self-pay>|23.95|Inv Loc: 4006001; OR Loc: 4006001|||23.95|Inv Loc: 4006001; OR Loc: 4006001|13.17|
25122|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-OPTIFOAM SACRUM 7X7|1|<Self-pay>|<Self-pay>|<Self-pay>|50.00|Inv Loc: 4006001; OR Loc: 4006001|||50.00|Inv Loc: 4006001; OR Loc: 4006001|27.50|
25164|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|TRAY-CHEST TUBE INSERTION|1|<Self-pay>|<Self-pay>|<Self-pay>|128.05|Inv Loc: 4006001; OR Loc: 4006001|||128.05|Inv Loc: 4006001; OR Loc: 4006001|70.43|
25169|SUP|Custom 27200001||0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES - STERILE SUPPLY|DRESSING-QUIKCLOT HEMOSTATIC|1|<Self-pay>|<Self-pay>|<Self-pay>|293.70|Inv Loc: 4006001; OR Loc: 4006001|||293.70|Inv Loc: 4006001; OR Loc: 4006001|161.53|