You are on page 1of 299

CDM #

0010017
0012005
0013003
0014506
0015008
0016006
0017004
0018002
0024000
0024505
0025007
0026005
0028001
0034009
0034504
0035006
0036004
0038000
0042002
0043000
0043505
0045005
0046003
0047001
0048009
0056002
0064501
0066001
0072009
0073007
0075002
0078006
0085001
0088005
0095000
0098004
0100024
0100040
0100081
0100123
0100164
0100222
0100230
0100248
0100263
0100271
0100289

CDM Description
PT TYPE A BED HOLD NO CHG
ROOM SEMI GENERAL
ROOM SEMI GENERAL
ROOM SEMI GENERAL ON OB
ROOM SEMI GENERAL
ROOM SEMI GENERAL
ROOM SEMI GENERAL
ROOM SEMI GENERAL
NEWBORN LVL II/PHTO
ROOM SEMI PVT OB
ROOM PVT GENERAL
ROOM SEMI PVT OB
ROOM PVT GENERAL
NEWBORN LEVEL I
NEWBORN LEVEL I
NEWBORN LEVEL I
NEWBORN LEVEL I
NEWBORN LEVEL I
ROOM INTER ICU/TELE
ROOM INTER CCU/TELE
NEWBORN LEVEL III
ROOM INTER ICU/TELE
ROOM SEMI PVT PED
ROOM SEMI PVT PSYCH
ROOM INTER ICU/TELE
NEWBORN LVL II/PHTO
ROOM SEMI OB HI RSK
ROOM SEMI OB HI RSK
ROOM ICU MED
ROOM ICU GENERAL
ROOM ICU GENERAL
ROOM ICU GENERAL
ROOM SEMI PVT OB
ROOM SEMI PVT OB
ROOM SEMI PVT PED
ROOM SEMI PVT PED
OBSERVATION PER HOUR
OBSERVATION PER HOUR
OBSERVATION PER HOUR
OBSERVATION PER HOUR
OBSERVATION PER HOUR
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
BLOOD COLLECTION VAD
CATH FOR SPECIMEN COLLECT
INS/REPL/DECL NONTUN/PIC
INJ TX/PRO/DX IVP SME DRG

239940119.xlsx.ms_office

Price
3,670.00
3,670.00
3,670.00
3,670.00
3,670.00
3,670.00
3,670.00
7,530.00
4,010.00
4,250.00
4,010.00
4,250.00
2,270.00
2,270.00
2,270.00
2,270.00
2,270.00
3,990.00
3,990.00
8,190.00
3,990.00
3,670.00
4,280.00
3,990.00
7,530.00
4,010.00
4,010.00
9,320.00
9,320.00
9,320.00
9,320.00
4,010.00
4,010.00
3,670.00
3,670.00
161.00
161.00
161.00
161.00
161.00
301.00
301.00
339.00
420.00
2,203.00
544.00

$0 Indicator
S

Page 1 of 299

CDM #
0100297
0100305
0100313
0100321
0100339
0100347
0100354
0100362
0100370
0100388
0100396
0100404
0100412
0100420
0100438
0100446
0100453
0100461
0100479
0100495
0100503
0100511
0100529
0100537
0100545
0100552
0100560
0100578
0100586
0100594
0100602
0100610
0100628
0100636
0100644
0100651
0100669
0100677
0100701
0100735
0100768
0100784
0100792
0100800
0100826
0100842
0100859

CDM Description
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PROPH SUBQ/IM
INSERT CATH BLADDER
IRRIG IMPLANTED VEN ACCES
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION PICC
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
BLOOD COLLECTION VAD
CATH FOR SPECIMEN COLLECT
INS/REPL/DECL NONTUN/PIC
INJ TX/PRO/DX IVP SME DRG
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PROPH SUBQ/IM
INSERT CATH BLADDER
IRRIG IMPLANTED VEN ACCES
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION PICC
CART ULTRAFILT 500
CART ULTRAFILT 500
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT

239940119.xlsx.ms_office

Price
544.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00
275.00
505.00
275.00
544.00
140.00
1,142.00
778.00
339.00
301.00
301.00
339.00
420.00
2,203.00
544.00
544.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00
275.00
505.00
275.00
544.00
140.00
1,142.00
778.00
339.00
4,500.00
4,500.00
532.00
544.00
544.00
11.00
532.00
544.00
544.00

$0 Indicator

Page 2 of 299

CDM #
0100867
0100875
0100883
0100891
0100909
0100958
0100966
0100974
0100982
0101014
0101022
0101030
0101048
0101055
0101063
0101071
0101089
0101097
0101105
0101113
0101121
0101139
0101147
0101154
0101162
0109884
0109892
0109900
0109918
0109934
0109942
0109967
0109975
0109983
0109991
0110007
0110015
0110023
0110031
0110049
0110056
0110064
0110072
0110080
0110098
0110106
0110114

CDM Description
VENIPUNCTURE
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF EA SEQ 1ST HR
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
BLOOD COLLECTION PICC
BLOOD COLLECTION VAD
CATH FOR SPECIMEN COLLECT
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
GLUCOSE BLOOD BY DEVICE
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IV PUSH SEQ

239940119.xlsx.ms_office

Price
11.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00
433.00
176.00
176.00
544.00
544.00
544.00
544.00
544.00
544.00
275.00
275.00
275.00
275.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
339.00
339.00
420.00
544.00
544.00
544.00
275.00
275.00
176.00
544.00
140.00
544.00
140.00
140.00
544.00
140.00
544.00
544.00

$0 Indicator

Page 3 of 299

CDM #
0110122
0110130
0110148
0110155
0110163
0110171
0110189
0110197
0110205
0110213
0110221
0110239
0110247
0110254
0110262
0110270
0110288
0110296
0110304
0110312
0110320
0110338
0110346
0110353
0110791
0110809
0110817
0110825
0110841
0110858
0110874
0110882
0110890
0110908
0110916
0110924
0110932
0110940
0110957
0110965
0110973
0110981
0110999
0111005
0111013
0111021
0111039

CDM Description
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
INS/REPL/DECL NONTUN/PIC
INSERT CATH BLADDER
IRRIG IMPLANTED VEN ACCES
MINOR PROCEDURE
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
TRANSFUS BLD/BLD COMP
VENIPUNCTURE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
BLOOD COLLECTION PICC
BLOOD COLLECTION VAD
CATH FOR SPECIMEN COLLECT
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
GLUCOSE BLOOD BY DEVICE
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PRO IVPUSH INIT

239940119.xlsx.ms_office

Price
544.00
275.00
544.00
2,203.00
505.00
275.00
1,142.00
1,230.00
433.00
945.00
334.00
532.00
544.00
544.00
778.00
11.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
339.00
339.00
420.00
544.00
544.00
544.00
275.00
275.00
176.00
544.00
140.00
544.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00

$0 Indicator

Page 4 of 299

CDM #
0111047
0111054
0111062
0111070
0111088
0111096
0111104
0111138
0111146
0111153
0111161
0111179
0111187
0111195
0111203
0111211
0111229
0111237
0111245
0111252
0111351
0111369
0111377
0111385
0111401
0111419
0111427
0111435
0111443
0200014
0200022
0202630
0300020
0300061
0300095
0300103
0300111
0300129
0300137
0300145
0300152
0300160
0300178
0300186
0300194
0300202
0300210

CDM Description
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
INS/REPL/DECL NONTUN/PIC
INSERT CATH BLADDER
IRRIG IMPLANTED VEN ACCES
MINOR PROCEDURE
OBSERVATION PER HOUR
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
TRANSFUS BLD/BLD COMP
VENIPUNCTURE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
IP/OBSV PSYCH SITTR/HR NC
DIRECT ADMIT OBSERV WH MF
AD EVOKED POTENTIALS LIM
TRANSFUS BLD/BLD COMP
ADMIN HEP B VACCINE
OBSERVATION PER HOUR
OBSERVATION PER HOUR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER

239940119.xlsx.ms_office

Price
275.00
544.00
2,203.00
505.00
275.00
1,142.00
161.00
1,230.00
433.00
945.00
334.00
532.00
544.00
544.00
778.00
11.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
176.00
343.00
778.00
301.00
161.00
161.00
544.00
140.00
275.00
544.00
140.00
140.00
544.00
544.00
544.00
140.00
1,142.00
544.00
505.00

$0 Indicator

Page 5 of 299

CDM #
0300228
0300236
0300244
0300269
0300285
0300293
0300301
0300327
0300335
0300343
0300368
0300376
0300384
0300392
0300400
0300418
0300426
0300434
0300442
0300459
0300467
0300475
0300491
0300509
0300517
0300525
0300541
0300558
0300566
0300574
0300582
0301127
0301150
0301176
0301184
0301192
0301218
0301234
0301242
0301259
0301267
0301275
0301283
0301291
0301309
0301317
0301325

CDM Description
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
INF IV HYDRA INIT 31-60MN
BLOOD COLLECTION PICC
BLOOD COLLECTION PICC
INJ TX/PRO/DX IVP SME DRG
INJ TX/PRO/DX IVP SME DRG
CART ULTRAFILT 500
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN

239940119.xlsx.ms_office

Price
420.00
275.00
778.00
339.00
301.00
301.00
2,203.00
544.00
140.00
275.00
140.00
140.00
544.00
544.00
544.00
140.00
1,142.00
544.00
505.00
420.00
275.00
778.00
339.00
301.00
301.00
2,203.00
544.00
339.00
339.00
544.00
544.00
4,500.00
532.00
544.00
544.00
11.00
532.00
544.00
544.00
11.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00

$0 Indicator

Page 6 of 299

CDM #
0301333
0381202
0381210
0381228
0381236
0381244
0381251
0381269
0381277
0381285
0381293
0381301
0381327
0381335
0381343
0381350
0381368
0381376
0381384
0381392
0381418
0381426
0381442
0381467
0381475
0381483
0381491
0381509
0381517
0381525
0381533
0381541
0381558
0381566
0381574
0381582
0381590
0381608
0381616
0381624
0381632
0381640
0381657
0381665
0381673
0381681
0381699

CDM Description
PACU COMPLEX ADDL 15MIN
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
BLOOD COLLECTION PICC
BLOOD COLLECTION VAD
CART ULTRAFILT 500
CATH FOR SPECIMEN COLLECT
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF INIT 1ST HR
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM NONHORMONAL
GLUCOSE BLOOD BY DEVICE
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
INS/REPL/DECL NONTUN/PIC
INSERT CATH BLADDER
IRRIG IMPLANTED VEN ACCES
MINOR PROCEDURE
OBSERVATION PER HOUR

239940119.xlsx.ms_office

Price
433.00
176.00
176.00
544.00
544.00
544.00
544.00
544.00
544.00
275.00
275.00
275.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
339.00
339.00
4,500.00
420.00
275.00
275.00
544.00
544.00
544.00
176.00
544.00
140.00
544.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00
275.00
544.00
2,203.00
505.00
275.00
1,142.00
161.00

$0 Indicator

Page 7 of 299

CDM #
0381723
0381731
0381749
0381756
0381764
0381780
0381798
0381806
0381822
0381848
0381855
0381863
0381871
0381889
0381905
0381913
0381939
0381947
0381954
0381962
0381970
0381988
0381996
0382002
0382010
0382028
0382036
0382044
0382051
0382069
0382077
0382085
0382093
0382101
0382119
0382127
0382135
0382143
0382150
0382168
0382192
0382200
0382218
0382226
0382234
0382259
0382267

CDM Description
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
CART ULTRAFILT 500
TRANSFUS BLD/BLD COMP
VENIPUNCTURE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
BLOOD COLLECTION PICC
BLOOD COLLECTION VAD
CATH FOR SPECIMEN COLLECT
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF INIT 1ST HR
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM NONHORMONAL
GLUCOSE BLOOD BY DEVICE
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
INS/REPL/DECL NONTUN/PIC
INSERT CATH BLADDER
IRRIG IMPLANTED VEN ACCES
MINOR PROCEDURE
OBSERVATION PER HOUR
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT

239940119.xlsx.ms_office

Price
1,230.00
433.00
945.00
334.00
532.00
544.00
544.00
4,500.00
778.00
11.00
301.00
301.00
301.00
301.00
339.00
339.00
420.00
275.00
275.00
544.00
544.00
544.00
176.00
544.00
140.00
544.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00
275.00
544.00
2,203.00
505.00
275.00
1,142.00
161.00
1,230.00
433.00
945.00
334.00
532.00
544.00
544.00

$0 Indicator

Page 8 of 299

CDM #
0382275
0382291
0382317
0388231
0388322
0388330
0388348
0388355
0400028
0400093
0400135
0400143
0400234
0400275
0400325
0405001
0405019
0405027
0405035
0405043
0405068
0405076
0405084
0405092
0405100
0405118
0405126
0405134
0405142
0405159
0405167
0405175
0405183
0405191
0405209
0405217
0405225
0405233
0480442
0481484
0486175
0486183
0486191
0486209
0486217
0486225
0486233

CDM Description
CART ULTRAFILT 500
TRANSFUS BLD/BLD COMP
VENIPUNCTURE
CHEMO INF EA SEQ 1ST HR
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
OBSERVATION PER HOUR
OBSERVATION PER HOUR
OBSERVATION PER HOUR
DIRECT ADMIT OBV SJ MG MT
OBSERVATION PER HOUR
OBSERVATION PER HOUR
OBSERVATION PER HOUR
OBSERVATION PER HOUR
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
BLOOD COLLECTION PICC
BLOOD COLLECTION VAD
CATH FOR SPECIMEN COLLECT
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
INS/REPL/DECL NONTUN/PIC
INSERT CATH BLADDER
IRRIG IMPLANTED VEN ACCES
MINOR PROCEDURE
TRANSFUS BLD/BLD COMP
INF TX/DX/PRO SEQ 1HR
PACEMK GEN REPL SNGL LEAD
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER

239940119.xlsx.ms_office

Price
4,500.00
778.00
11.00
275.00
301.00
301.00
301.00
301.00
161.00
161.00
161.00
176.00
161.00
161.00
161.00
161.00
301.00
301.00
339.00
339.00
420.00
544.00
140.00
544.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00
275.00
544.00
2,203.00
505.00
275.00
1,142.00
778.00
140.00
9,794.00
544.00
140.00
275.00
544.00
140.00
140.00
544.00

$0 Indicator

Page 9 of 299

CDM #
0486241
0486258
0486266
0486274
0486282
0486290
0486308
0486316
0486324
0486340
0486365
0486373
0486381
0486407
0486415
0486423
0486431
0486456
0486464
0486472
0486480
0486498
0486506
0486514
0486522
0486530
0486548
0486555
0486571
0486597
0486605
0486613
0486647
0486654
0486662
0486670
0486688
0486696
0486704
0486712
0486720
0486738
0486746
0486753
0486761
0486779
0486787

CDM Description
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES

239940119.xlsx.ms_office

Price
544.00
544.00
140.00
1,142.00
544.00
505.00
420.00
275.00
778.00
339.00
301.00
301.00
2,203.00
544.00
140.00
275.00
544.00
140.00
544.00
544.00
544.00
140.00
1,142.00
544.00
505.00
420.00
275.00
778.00
339.00
301.00
301.00
2,203.00
544.00
140.00
275.00
544.00
140.00
140.00
544.00
544.00
544.00
140.00
1,142.00
544.00
505.00
420.00
275.00

$0 Indicator

Page 10 of 299

CDM #
0486795
0486803
0486811
0486829
0486837
0486878
0486886
0486902
0486985
0486993
0487009
0487017
0487025
0487033
0487041
0487058
0487066
0487074
0487082
0487090
0487108
0487116
0487124
0487132
0487140
0487157
0487165
0487173
0487181
0487199
0487215
0487223
0487231
0487249
0487256
0487264
0487272
0487280
0487298
0487306
0487314
0487322
0487330
0487348
0487355
0487363
0487371

CDM Description
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
CHEMO IV PUSH INITIAL
CHEMO IV PUSH EA ADD
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO IV INF PUMP PROLONG
CHEMO INF EA SEQ 1ST HR
CHEMO INTRA-ART PUSH
CHEMO ART INF INIT 1ST HR
CHEMO ART INF EA ADD HR
CHEM ART INF PUMP PROLONG
CHEMO ADMIN THORACENTESIS
CHEMO ADMIN PERIT CAV IND
CHEMO ADMIN INTRATHECAL
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
BLOOD COLLECTION PICC
BLOOD COLLECTION PICC

239940119.xlsx.ms_office

Price
778.00
339.00
301.00
301.00
2,203.00
544.00
275.00
275.00
544.00
544.00
544.00
140.00
275.00
544.00
140.00
140.00
544.00
544.00
544.00
140.00
1,142.00
544.00
505.00
420.00
275.00
778.00
339.00
301.00
301.00
2,203.00
544.00
544.00
544.00
275.00
544.00
275.00
544.00
544.00
544.00
544.00
544.00
544.00
544.00
544.00
544.00
339.00
339.00

$0 Indicator

Page 11 of 299

CDM #
0487389
0487397
0487405
0487413
0487421
0487439
0487447
0487454
0487470
0487488
0487512
0487538
0487546
0487553
0487587
0487603
0487645
0487660
0487702
0487710
0487728
0487736
0487744
0487751
0487769
0487777
0487785
0487793
0487801
0487819
0487827
0487835
0487843
0487850
0487868
0487876
0487884
0487892
0487934
0487942
0487967
0488049
0488056
0488064
0488080
0488098
0488122

CDM Description
BLOOD COLLECTION PICC
BLOOD COLLECTION PICC
INJ TX/PRO/DX IVP SME DRG
INJ TX/PRO/DX IVP SME DRG
INJ TX/PRO/DX IVP SME DRG
INJ TX/PRO/DX IVP SME DRG
SUBACUTE CAR A/B HLD LVLI
SUBACUTE CAR C/D HLD LVLI
PUMP PORTABL REFILL/MAINT
PUMP IMPLANTD REFIL/MAINT
PHLEBOTOMY THERAPEUT
VENIPUNCTURE
PUMP PORTABL REFILL/MAINT
PUMP IMPLANTD REFIL/MAINT
PHLEBOTOMY THERAPEUT
VENIPUNCTURE
BLOOD COLLECTION PICC
OBSERVATION PER HOUR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES
TRANSFUS BLD/BLD COMP
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
INJ TX/PRO/DX IVP SME DRG
PUMP PORTABL REFILL/MAINT
PUMP IMPLANTD REFIL/MAINT
PHLEBOTOMY THERAPEUT

239940119.xlsx.ms_office

Price
339.00
339.00
544.00
544.00
544.00
544.00
722.00
722.00
544.00
544.00
532.00
11.00
544.00
544.00
532.00
11.00
339.00
161.00
544.00
140.00
275.00
544.00
140.00
140.00
544.00
544.00
544.00
140.00
1,142.00
544.00
505.00
420.00
275.00
778.00
339.00
301.00
301.00
2,203.00
544.00
275.00
275.00
544.00
544.00
544.00
544.00
544.00
532.00

$0 Indicator

Page 12 of 299

CDM #
0488148
0488163
0488189
0488197
0488205
0488221
0488247
0488254
0488262
0488288
0488304
0488312
0488320
0488338
0488346
0488353
0488361
0488379
0488387
0488395
0488403
0488411
0488429
0488437
0488445
0488452
0488460
0488478
0488486
0488494
0488502
0488510
0488528
0488577
0488585
0488593
0488601
0488676
0488684
0488692
0488700
0488718
0488726
0488742
0488759
0488767
0488775

CDM Description
VENIPUNCTURE
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF INIT 1ST HR

239940119.xlsx.ms_office

Price
11.00
532.00
544.00
544.00
11.00
532.00
544.00
544.00
11.00
532.00
544.00
544.00
11.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00
433.00
176.00
176.00
176.00
176.00
176.00
176.00
544.00
544.00
544.00
544.00

$0 Indicator

Page 13 of 299

CDM #
0488783
0488791
0488809
0488817
0488825
0488833
0488841
0488858
0488866
0488874
0488882
0488890
0488908
0488916
0488924
0488932
0488940
0488957
0488965
0488973
0488981
0488999
0489005
0489039
0489047
0489054
0489062
0489070
0489088
0489096
0489104
0489195
0489203
0489211
0489229
0489237
0489245
0489252
0489260
0489278
0489286
0489294
0489302
0489310
0489328
0489336
0489344

CDM Description
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA ADD HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF EA SEQ 1ST HR
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
PUMP PORTABL REFILL/MAINT
PUMP IMPLANTD REFIL/MAINT
IRRIG IMPLANTED VEN ACCES
INF IV TX/DX PUMP PROLONG
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR

239940119.xlsx.ms_office

Price
544.00
275.00
275.00
275.00
275.00
275.00
275.00
544.00
544.00
544.00
544.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
544.00
544.00
275.00
544.00
544.00
140.00
544.00
140.00

$0 Indicator

Page 14 of 299

CDM #
0489351
0489369
0489377
0489385
0489393
0489401
0489419
0489427
0489435
0489443
0489450
0489468
0489476
0489484
0489492
0489500
0489518
0489534
0489542
0489559
0489567
0489583
0489591
0489609
0489617
0489625
0489633
0489641
0489658
0489666
0489674
0489682
0489690
0489708
0489716
0489724
0489732
0489740
0489757
0489765
0489773
0489781
0489799
0489807
0489815
0489823
0489831

CDM Description
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PROPH SUBQ/IM
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/PRO/DX IVP SME DRG
VENIPUNCTURE
CATH FOR SPECIMEN COLLECT
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
BLOOD COLLECTION PICC
MINOR PROCEDURE
BLOOD COLLECTION VAD
INSERT CATH BLADDER
INS/REPL/DECL NONTUN/PIC
TRANSFUS BLD/BLD COMP
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PHLEBOTOMY THERAPEUT
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PROPH SUBQ/IM
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/PRO/DX IVP SME DRG
PUMP PORTABL REFILL/MAINT
PUMP IMPLANTD REFIL/MAINT
IRRIG IMPLANTED VEN ACCES
INF IV TX/DX PUMP PROLONG
VENIPUNCTURE
CATH FOR SPECIMEN COLLECT
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR

239940119.xlsx.ms_office

Price
140.00
140.00
275.00
544.00
544.00
544.00
544.00
11.00
420.00
176.00
544.00
544.00
544.00
275.00
275.00
339.00
1,142.00
339.00
505.00
2,203.00
778.00
945.00
334.00
1,230.00
433.00
532.00
544.00
140.00
544.00
140.00
140.00
140.00
275.00
544.00
544.00
544.00
544.00
544.00
544.00
275.00
544.00
11.00
420.00
176.00
544.00
544.00
544.00

$0 Indicator

Page 15 of 299

CDM #
0489849
0489856
0489864
0489872
0489880
0489914
0489922
0489930
0489948
0489963
0489971
0489989
0489997
0490003
0490060
0490078
0490086
0490094
0490102
0490110
0490128
0490151
0490169
0490177
0490185
0490193
0490201
0490219
0490227
0490235
0490243
0490250
0490268
0490276
0490284
0490292
0490300
0490318
0490326
0490334
0490342
0490359
0490367
0490375
0490383
0490391
0490409

CDM Description
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
APHERESIS PLASM THERAPEUT
BLOOD COLLECTION VAD
BLOOD COLLECTION PICC
INS/REPL/DECL NONTUN/PIC
MINOR PROCEDURE
INSERT CATH BLADDER
TRANSFUS BLD/BLD COMP
PACU COMPLEX 1ST 30MIN
PACU STANDARD 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD ADDL 15MIN
OBSERVATION PER HOUR
ADMIN HEP B VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
PHLEBOTOMY THERAPEUT
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
OBSERVATION PER HOUR
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
IRRIG IMPLANTED VEN ACCES
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
CATH FOR SPECIMEN COLLECT
VENIPUNCTURE
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM NONHORMONAL
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF INIT 1ST HR
BLOOD COLLECTION PICC
BLOOD COLLECTION VAD
INS/REPL/DECL NONTUN/PIC

239940119.xlsx.ms_office

Price
275.00
275.00
1,774.00
339.00
339.00
2,203.00
1,142.00
505.00
778.00
1,230.00
945.00
433.00
334.00
161.00
301.00
301.00
301.00
532.00
301.00
301.00
161.00
544.00
140.00
544.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00
275.00
544.00
275.00
544.00
544.00
420.00
11.00
176.00
544.00
544.00
275.00
275.00
544.00
339.00
339.00
2,203.00

$0 Indicator

Page 16 of 299

CDM #
0490417
0490425
0490433
0490441
0490458
0490466
0490474
0490482
0490516
0490524
0490532
0490540
0490557
0490565
0500025
0600015
0600031
0600056
0600080
0600098
0600122
0636647
0636654
0636662
0700047
0700062
0700120
0700161
0700187
0700278
0700310
0700328
0700336
0700344
0700351
0700369
0700377
0700385
0700393
0700401
0700419
0700427
0700435
0700443
0700450
0700468
0700476

CDM Description
INSERT CATH BLADDER
MINOR PROCEDURE
TRANSFUS BLD/BLD COMP
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
OBSERVATION PER HOUR
ADMIN HEP B VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
PHLEBOTOMY THERAPEUT
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
OBSERVATION PER HOUR
AD EVOKED POTENTIALS LIM
AD EVOKED POTENTIALS LIM
OB OBSERV PER HOUR
TRANSFUS BLD/BLD COMP
TRANSFUS BLD/BLD COMP
ADMIN HEP B VACCINE
OBSERV PER HR NON-OB
OBSERV PER HR NON-OB 218
OBSERV PER HR NON-OB 219
US PREG 1 OR >FETUSES LTD
I.U.P.C.
ANESTH GENERAL ADDL 15MIN
ANES PUDENDAL NRV INJ
LD-VAC EXTRACTOR DISP
US PREG FOLLOWUP/EA GEST
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
SURGERY LEVEL 3 1ST 30MIN
SURGERY LEVEL 3 ADD 15MIN
C-SECT L&D CT EA ADD BABY
C-SECT OR CT EA ADD BABY
DELIVERY C-SECT IN OR NC
DELIVERY C-SECT L&D NC
DELIVERY OF PLACENTA
DELIVERY VAGINAL HIGH RSK
DELIVERY VAGINAL ROUTINE
EPIDURAL PLACE VAG DELIV
FETAL DEM <23 EST W PROC
FETAL DEM <23 NEW W PROC
FETAL DEMISE <23WK EST PT

239940119.xlsx.ms_office

Price
505.00
1,142.00
778.00
1,230.00
433.00
945.00
334.00
161.00
301.00
301.00
301.00
532.00
301.00
301.00
161.00
343.00
343.00
161.00
778.00
778.00
301.00
161.00
161.00
161.00
740.00
106.00
599.00
205.00
196.00
1,107.00
4,408.00
1,545.00
5,731.00
2,009.00
7,450.00
2,611.00
3,066.00
12,275.00
9,822.00
1,458.00
2,153.00
2,153.00
2,153.00

$0 Indicator

S
S
S
S

Page 17 of 299

CDM #
0700484
0700500
0700518
0700526
0700534
0700542
0700559
0702951
0702969
0702977
0702985
0702993
0703009
0703017
0703025
0800011
0800029
0800052
0800060
0800078
0800086
0800094
0800102
0800110
0800144
0800151
0800169
1000017
1096916
1096924
1096932
1096940
1096957
1096965
1096973
1096981
1096999
1097005
1097013
1097021
1097039
1097047
1097054
1097062
1097070
1097088
1097096

CDM Description
FETAL DEMISE <23WK NEW PT
AMNIOCENTESIS
FETAL CST NONOXYTOCIN
INSERT CERVICAL DILATOR
ANESTH GENERAL 1ST 30MIN
ANESTH MAC/REG 1ST 30MIN
ANESTH MAC/REG ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
LOCAL ANESTHESIA
INPATIENT SURG L&D OR NC
EPIDURAL BLOOD PATCH
CERCLAGE REMOVAL
GROUP PSYCHOTHERAPY 30MIN
GROUP PSYCHOTHERAPY 60MIN
NEUROBEHAVIORL EXAM EA HR
INDIV PSYCHOTHERAPY 20-30
INDIV PSYCHOTHERAPY 45-50
NEUROPSYCH TESTING EA HR
FAMILY PSYCH W/O PT 15MIN
UNLIST PROC-TEAM/FAM CONF
PSYCH TESTING PHYS/HR
PSYCH DX INTERVIEW 30MIN
PSYCH DX INTERVIEW 60MIN
PSYCH DX INTERVIEW 90MIN
REINSTATE/CONVERSION TRX
EQ ROOM PVT GENERAL
EQ ROOM SEMI GENERAL
EQ ROOM SEMI M/S/GYN
EQ ROOM SEMI PVT OB
EQ ROOM SEMI PVT PED
EQ ROOM SEMI PVT PSYCH
EQ ROOM SEMI ONCOLOGY
EQ ROOM SEMI PVT REHAB
EQ ROOM NEWBORN LEVEL 1
EQ ROOM NEWBORN NICU II
EQ ROOM NEWBORN NICU III
EQ ROOM NEWBORN NICU IV
EQ ROOM SUBACUTE CARE
EQ ROOM ICU GENERAL
EQ ROOM INTER ICU/TEL
EQ ROOM ICU TRAUMA
EQ ROOM CCU GENERAL
EQ ROOM INTER CCU/TEL
EQ PHARMACY GENERAL

239940119.xlsx.ms_office

Price
2,153.00
917.00
953.00
577.00
1,707.00
750.00
264.00
1,230.00
433.00
945.00
334.00
350.00
894.00
3,716.00
161.00
272.00
733.00
228.00
452.00
733.00
295.00
212.00
733.00
399.00
733.00
1,192.00
1.00
-

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Page 18 of 299

CDM #
1097104
1097112
1097138
1097146
1097161
1097179
1097187
1097203
1097211
1097229
1097237
1097245
1097252
1097260
1097278
1097286
1097294
1097302
1097310
1097328
1097336
1097344
1097351
1097369
1097377
1097385
1097393
1097401
1097419
1097427
1097435
1097443
1097450
1097468
1097476
1097484
1097492
1097500
1097518
1097526
1097534
1097542
1097559
1097567
1097575
1097583
1097591

CDM Description
EQ PHARMACY W HCPCS
EQ PHARMACY SELF ADMIN
EQ PHARMACY REL TO RAD
EQ PHAR REL TO RAD W HCPC
EQ IV SOLUTION
EQ IV SOLUTION W HCPCS
EQ INFUSION/IV THERAPY
EQ SUPPLY NONSTERILE
EQ SUPPLY STERILE
EQ SUPPLY PROST/ORTHOTIC
EQ SUPPY PACEMAKER/LEADS
EQ SUPPLY IMPLANT EYE LNS
EQ SUPPLY IMPLANT
EQ LAB GENERAL
EQ LAB CHEMISTRY
EQ LAB IMMUNOLOGY
EQ LAB HEMATOLOGY
EQ LAB BACTERIOLOGY
EQ LAB UROLOGY
EQ LAB PATH CYTOLOGY
EQ LAB PATH HISTOLOGY
EQ LAB PATH BIOPSY
EQ RADIOLOGY GENERAL
EQ RADIOLOGY ARTHROGRAPHY
EQ RADIOLOGY ARTERIOGRAPH
EQ RADIOLOGY CHEST XRAY
EQ RAD THERAP CHEMO ADM
EQ RAD THERAP RADIATION
EQ RAD THERAP CHEMO IV
EQ NUC MED PROC DIAGNOS
EQ NUC MED PROC THERAPEU
EQ NUC MED RADIOPHARM DX
EQ NUC MED RADIOPHARM TX
EQ CT SCAN GENERAL
EQ CT SCAN HEAD
EQ CT SCAN BODY
EQ CT SCAN OTHER
EQ SURGERY GEN
EQ SURGERY MINOR
EQ ANESTHESIA GENERAL
EQ BLOOD COMPONENT GEN
EQ BLOOD ADMINISTRATION
EQ MAMMOGRAPHY DIAGNOSTIC
EQ ULTRASOUND
EQ MAMMOGRAPHY SCREENING
EQ PET SCAN
EQ RESPIRATORY GENERAL

239940119.xlsx.ms_office

Price
-

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Page 19 of 299

CDM #
1097609
1097617
1097625
1097633
1097641
1097658
1097666
1097674
1097682
1097690
1097708
1097716
1097724
1097732
1097740
1097757
1097765
1097773
1097781
1097799
1097807
1097815
1097823
1097831
1097849
1097856
1097864
1097872
1097880
1097898
1097906
1097914
1097922
1097930
1097948
1097955
1097971
1097989
1097997
1098003
1098011
1098029
1098037
1098045
1098052
1098060
1098078

CDM Description
EQ RESPIRATORY INHAL
EQ HBO HYPERBARIC O2
EQ RESPIRATORY STREN/ENDR
EQ PHYSICAL THER GENERAL
EQ PHYSICAL THER GEN-OTH
EQ PHYSICAL THER GEN-WRKC
EQ PHYSICAL THER GEN-MCAL
EQ PHYSICAL THER GROUP
EQ PHYSICAL THER GRP-OTH
EQ PHYSICAL THER GRP-WRKC
EQ PHYSICAL THER EVAL
EQ PHYSICAL THER EVAL-OTH
EQ PHYSICAL THER EVALWRKC
EQ PHYSICAL THER EVALMCAL
EQ OCCUP THER GENERAL
EQ OCCUP THER GEN-OTH
EQ OCCUP THER GEN - WRKC
EQ OCCUP THER GEN - MCAL
EQ OCCUP THER GROUP
EQ OCCUP THER GRP - OTH
EQ OCCUP THER GRP - WRKC
EQ OCCUP THER EVAL
EQ OCCUP THER EVAL - OTH
EQ OCCUP THER EVAL - WRKC
EQ OCCUP THER EVAL - MCAL
EQ SPEECH PATH GENERAL
EQ SPEECH PATH GROUP RATE
EQ SPEECH PATH EVAL
EQ SPEECH PATH EVAL-OTH
EQ EMERGENCY DEPARTMENT
EQ PULMONARY FUNCTION GEN
EQ AUDIOLOGY DIAGNOSTIC
EQ CARDIO GEN-NON CATHLAB
EQ CARDIO CATH LAB/EP LAB
EQ CARDIAC STRESS TEST
EQ ECHOCARDIOLOGY
EQ HBO NEGATIVE PRESSURE
EQ MRI GENERAL
EQ MRI BRAIN
EQ MRI SPINAL CORD
EQ MRA HEAD AND NECK
EQ MRA LOWER EXTREMITIES
EQ MRA NON HEAD/NCK/EXTRM
EQ SUPPLY FDA IDE 272
EQ TRAUMA RESPONSE LEV II
EQ RECOVERY ROOM GENERAL
EQ OB PROCEDURE

239940119.xlsx.ms_office

Price
-

$0 Indicator
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Page 20 of 299

CDM #
1098086
1098094
1098102
1098110
1098128
1098136
1098144
1098151
1098169
1098177
1098185
1098193
1098201
1098219
1098227
1098235
1098243
1098250
1098268
1098276
1098284
1098292
1098300
1098318
1098326
1098516
1098524
1098532
1098540
1098557
1098565
1098581
1098599
1098615
1098623
1098631
1098649
1098656
1098664
1098672
1098680
1098698
1098706
1098714
1098722
1098730
1098748

CDM Description
EQ EKG/ECG GENERAL
EQ EKG/ECG HOLTER MONITOR
EQ EEG GENERAL
EQ ENDOSCOPY/GI
EQ TREATMENT ROOM
EQ OB LABOR/OBSERV
EQ OBSERVATION ROOM
EQ VACCINE ADMIN PREVENT
EQ VACCINE ADMIN W HCPCS
EQ OB DELIVERY
EQ LITHOTRIPSY ESWL
EQ RENAL HEMODIALYSIS
EQ RENAL CCPD
EQ BEHAV HLTH TX GENERAL
EQ BEHAV HLTH INDIVID RX
EQ BEHAV HLTH GROUP RX
EQ BEHAV HLTH TESTING
EQ DIAGNOSTIC SVC OTHER
EQ PERIPHERAL VASCLR LAB
EQ ELECTROMYELOGRAM
EQ THERAPEUTIC SVC OTHER
EQ EDUCATION/TRAINING
EQ CARDIAC REHAB
EQ STATISTICAL
EQ BEHAV HLTH FAMILY RX
EQ ROOM NURSERY GENERAL
EQ ROOM SUBACUTE CARE II
EQ ROOM ICU SURGICAL
EQ ROOM ICU MEDICAL
EQ PHARM REL TO DX TEST
EQ PHAR REL TO DX W HCPCS
EQ INF/IV THERAPY W HCPCS
EQ SUPPLY IMPLANT W HCPCS
EQ CDM MANUAL REVIEW
EQ PHARMACY OTHER
EQ EDUCATION/TRAINING COM
EQ SUPPLY FDA IDE 275
EQ SUPPLY FDA IDE 278
EQ LAB OTHER
EQ PULMONARY REHAB
EQ IP INFANT AUDIOLOGY DX
EQ PHARMACY VACCINE
EQ VACCINE ADMIN OTHER
EQ SPEECH PATH EVAL-MCAL
EQ MRI OTHER
EQ LAB PATH GENERAL
EQ SPEECH PATH GEN - OTH

239940119.xlsx.ms_office

Price
-

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Page 21 of 299

CDM #
1098755
1098763
1098771
1098789
1098797
1098805
1098813
1098821
1098847
2000016
2000024
2000032
2000040
2000057
2000065
2000073
2000081
2000172
2000180
2000198
2000206
2000214
2000222
2000289
2000297
2000305
2000313
2000412
2000453
2000461
2000487
2000537
2000552
2000578
2000586
2000594
2000610
2000628
2000651
2000669
2000677
2000701
2000719
2000727
2000735
2000743
2000750

CDM Description
EQ SUPPLY IMPLANT OTHER
EQ PHARM EPO UNDER 10,000
EQ PHARM EPO OVER 10,000
EQ CARDIO CATH DELAY CPT
EQ SURGERY MINR DELAY CPT
EQ CATH/EP LAB PROCEDURES
EQ CATH/EP LAB RAD 320
EQ CATH/EP LAB RAD 323
EQ RENAL DIALYSIS NON HD
PT EVALUATION 15
PT EVALUATION 30
PT EVALUATION 45
PT EVALUATION 60
PT RE-EVALUATION 15
PT RE-EVALUATION 30
PT RE-EVALUATION 45
PT RE-EVALUATION 60
PT THERAPY GROUP 15
PT THERAPY GROUP 30
PT THERAPY GROUP 45
PT THERAPY GROUP 60
PT THERAPY GROUP 75
PT THERAPY GROUP 90
PT AQUATIC THERAPY EA 15
PT ASSIST TECH ASSESS 15
PT COM/WORK REINT EA 15
PT CONTRAST BATH EA 15
PT DIATHRM/MICROWV THR
PT E-STIM ATTEND EA 15
PT E-STIM UNATTENDED OTHR
PT EXERCISE THR EA 15
PT MANUAL THERAPY EA 15
PT MMT BODY W HANDS
PT NEUROMSCL RE-ED EA 15
PT ORTH/PROSTH CK EA 15
PT ORTHOTIC FIT/TRN EA 15
PT PHYS PRF TEST EA 15
PT PROSTHETIC TRN EA 15
PT THR ACTIVITY EA 15
PT TRACTION MECHANICAL
PT ULTRASOUND EA 15
PT WHEELCHAIR TRN EA 15
PT WHIRLPOOL ONE EXTRMITY
PT WHIRLPOOL WHOLE BODY
PT WND VAC SL DBR<50CM 15
PT WND VAC SL DBR<50CM 30
PT WND VAC SL DBR<50CM 45

239940119.xlsx.ms_office

Price
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
550.00
733.00
184.00
367.00
550.00

$0 Indicator
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Page 22 of 299

CDM #
2000768
2000776
2000784
2000792
2000800
2000834
2000859
2000891
2000909
2000925
2000933
2000941
2000958
2000966
2000982
2001360
2001428
2001451
2001477
2001493
2001501
2001519
2001527
2001543
2001550
2001568
2001576
2001584
2001592
2001618
2001626
2001691
2001717
2001725
2001741
2001758
2001766
2001782
2001790
2001808
2001816
2001824
2001832
2001840
2001857
2001865
2001873

CDM Description
PT WND VAC SL DBR<50CM 60
PT WND VAC SL DBR>50CM 15
PT WND VAC SL DBR>50CM 30
PT WND VAC SL DBR>50CM 45
PT WND VAC SL DBR>50CM 60
PT ADDL PERSON 15 NC
PT CASE MANAGEMENT 15 NC
PT NON-CPT CLNT SRV 15 NC
PT NON-CPT INSTRUCT 15 NC
PT TOTAL JOINT CLASS IN
OT EVALUATION 15
OT EVALUATION 30
OT EVALUATION 45
OT EVALUATION 60
OT EVALUATION 90
OT DVL COGNT SKILL EA 15
OT EXERCISE THR EA 15
OT INFRARED THERAPY
OT MANUAL THERAPY EA 15
OT NEUROMSCL RE-ED EA 15
OT ORTH/PROSTH CK EA 15
OT ORTHOTIC FIT/TRN EA 15
OT PARAFFIN BATH THERAPY
OT PROSTHETIC TRN EA 15
OT SELF CARE/HOME EA 15
OT SENSORY TECH EA 15
OT THR ACTIVITY EA 15
OT TRACTION MECHANICAL
OT ULTRASOUND EA 15
OT VASOPNEUMATIC TX
OT WHEELCHAIR TRN EA 15
OT ADDL PERSON 15 NC
OT CASE MANAGEMENT 15 NC
OT CONFERENCE EA 15 NC
OT EDUCATION PT/FAM 15 NC
OT NON-CPT CLNT SRV 15 NC
OT NON-CPT INSTRUCT 15 NC
ST EVALUATION SPEECH 15
ST EVALUATION SPEECH 30
ST EVALUATION SPEECH 45
ST EVALUATION SPEECH 60
ST EVALUATION SPEECH 75
ST EVALUATION SPEECH 90
ST EVAL SWALLOWING 15
ST EVAL SWALLOWING 30
ST EVAL SWALLOWING 45
ST EVAL SWALLOWING 60

239940119.xlsx.ms_office

Price
733.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
1,099.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
367.00
550.00
733.00
916.00
1,099.00
184.00
367.00
550.00
733.00

$0 Indicator

S
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Page 23 of 299

CDM #
2001881
2001899
2001907
2001915
2001923
2001931
2001949
2001980
2001998
2002012
2002020
2002038
2002046
2002061
2002079
2002087
2002095
2002103
2002111
2002194
2002236
2002244
2002251
2002269
2002277
2004638
2004687
2004695
2004703
2004711
2004802
2004810
2004828
2004836
2004844
2004851
2004869
2004877
2004885
2004935
2004943
2004950
2004968
2005098
2005106
2005114
2005163

CDM Description
ST EVAL SWAL VID/FLR 30
ST EVAL SWAL VID/FLR 45
ST EVAL SWAL VID/FLR 60
ST EVAL SWAL VID/FLR 75
ST EVAL SWAL VID/FLR 90
ST EVAL VOICE PROSTHETIC
ST EVL NONSP COMM DVC 1HR
ST TREATMENT GROUP 30
ST TREATMENT GROUP 45
ST TREATMENT SPEECH 15
ST TREATMENT SPEECH 30
ST TREATMENT SPEECH 45
ST TREATMENT SPEECH 60
ST TREATMENT SWALLOW 15
ST TREATMENT SWALLOW 30
ST TREATMENT SWALLOW 45
ST TREATMENT SWALLOW 60
ST TX NON-SPCH COMM DVC
ST MOD/TRN VOICE PROS 15
ST DVL COGNT SKILL EA 15
ST CASE MANAGEMENT 15 NC
ST CONFERENCE 15 NC
ST EDUCATON PAT/FAM 15 NC
ST NON-CPT CLNT SRV 15 NC
ST NON-CPT INSTRUCT 15 NC
OT TOTAL JOINT CLASS IN
PT WND VAC SL DBR<50CM 75
PT WND VAC SL DBR>50CM 75
PT WND VAC SL DBR<50CM 90
PT WND VAC SL DBR>50CM 90
ST TREATMENT SPEECH 75
ST TREATMENT SPEECH 90
ST TREATMENT SWALLOW 75
ST TREATMENT SWALLOW 90
PT STUDENT PRODUCT/DAY NC
OT STUDENT PRODUCT/DAY NC
ST STUDENT PRODUCT/DAY NC
PT WC CONTRST BATH ADD 15
PT WC CONTRST BATH INI 30
OT WC CONTRST BATH ADD 15
OT WC CONTRST BATH INI 30
PT APP SPLNT SHRT ARM DYN
PT APP SPLNT SHRT ARM STC
OT WC E-STIM MNL ADD 15
OT WC E-STIM MNL INI 30
OT WC E-STIM UNATTENDED
PT WC E-STIM MNL ADD 15

239940119.xlsx.ms_office

Price
367.00
550.00
733.00
916.00
1,099.00
733.00
733.00
184.00
275.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
367.00
184.00
184.00
916.00
916.00
1,099.00
1,099.00
916.00
1,099.00
916.00
1,099.00
184.00
367.00
184.00
367.00
367.00
367.00
184.00
367.00
184.00
184.00

$0 Indicator

S
S
S
S
S
S

S
S
S

Page 24 of 299

CDM #
2005171
2005189
2025351
2025369
2025377
2025385
2025435
2025443
2025658
2025666
2025674
2025682
2025948
2025955
2025963
2025971
2026029
2026037
2026045
2026052
2026060
2026078
2026086
2026094
2026102
2026110
2026128
2026136
2026144
2026193
2026201
2026227
2026235
2026243
2026250
2026268
2026326
2026334
2026441
2026458
2026474
2026482
2026490
2026508
2026516
2026524
2026532

CDM Description
PT WC E-STIM MNL INI 30
PT WC E-STIM UNATTENDED
PT WC PARAFFIN BATH THR
OT WC PARAFFIN BATH THR
OT WC ULTRASOUND ADD 15
OT WC ULTRASOUND INI 30
PT WC ULTRASOUND ADD 15
PT WC ULTRASOUND INI 30
ST FF ENDO EVAL W VID
ST FF ENDO EVAL SWAL VID
OT MC EVAL SWAL INI 30
OT MC EVAL SWAL ADD 15
OT MC EVALUATION ADD 15
OT MC EVALUATION INI 30
OT MC EXERCISE THR ADD 15
OT MC EXERCISE THR INI 30
OT MC SLF CARE/HME ADD 15
OT MC SLF CARE/HME INI 30
OT WC BRIEF ASSESS/EVAL
OT WC COMP AS/EVL EST PAT
OT WC COMP AS/EVL NEW PAT
OT WC EXERCISE THR ADD 15
OT WC EXERCISE THR INI 30
OT WC EXT AS/EVAL EST PAT
OT WC EXT AS/EVAL NEW PAT
OT WC INT AS/EVAL EST PAT
OT WC INT AS/EVAL NEW PAT
OT WC LTD AS/EVAL EST PAT
OT WC LTD AS/EVAL NEW PAT
OT WC NEUROMSCL ED ADD 15
OT WC NEUROMSCL ED INI 30
OT WC TREATMENT TAPING
OT WC TX INDV INST ADD 15
OT WC TX INDV INST INI 30
OT WC TX JOINT MOBILIZATN
OT WC TX SOFT TISS INI 30
PT MC EVALUATION ADD 15
PT MC EVALUATION INI 30
PT MC THERAPY COMBO ADD15
PT MC THERAPY COMBO INI30
PT WC BRIEF ASSESS/EVAL
PT WC COMP AS/EVL EST PAT
PT WC COMP AS/EVL NEW PAT
PT WC EXERCISE THR ADD 15
PT WC EXERCISE THR INI 30
PT WC EXT AS/EVAL EST PAT
PT WC EXT AS/EVAL NEW PAT

239940119.xlsx.ms_office

Price
367.00
184.00
184.00
184.00
184.00
367.00
184.00
367.00
733.00
1,099.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
733.00
1,099.00
184.00
367.00
550.00
733.00
367.00
550.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
733.00
1,099.00
184.00
367.00
550.00
733.00

$0 Indicator

Page 25 of 299

CDM #
2026565
2026573
2026581
2026599
2026649
2026656
2026664
2026672
2026714
2026722
2026730
2026748
2026755
2026771
2026789
2026821
2026854
2026862
2026870
2026888
2026938
2026946
2026953
2026961
2026979
2026987
2026995
2027001
2027019
2027027
2027035
2027043
2027050
2027068
2027076
2027084
2027092
2027100
2027118
2027126
2027134
2027142
2027159
2027167
2027175
2100014
2100022

CDM Description
PT WC INT AS/EVAL EST PAT
PT WC INT AS/EVAL NEW PAT
PT WC LTD AS/EVAL EST PAT
PT WC LTD AS/EVAL NEW PAT
PT WC NEUROMSCL ED ADD 15
PT WC NEUROMSCL ED INI 30
PT WC THR ACTIVITY ADD 15
PT WC THR ACTIVITY INI 30
PT WC TREATMENT TAPING
PT WC TX INDV INST INI 30
PT WC TX JOINT MOBILIZATN
PT WC TX SOFT TISS ADD 15
PT WC TX SOFT TISS INI 30
OT MC TREATMENT ADD 15
OT MC TREATMENT INI 30
OT WC TX SOFT TISS ADD 15
PT WC TX INDV INST ADD 15
PT DEBR SL SESSION 1ST 20
PT DEBR SL SESSION ADD 20
PT DEBR SL SESS EA 15 NC
PT WC FUNC ACTVTY ADD 15
PT WC FUNC ACTVTY INI 30
PT WC OR/PRS/ADL CK ADD15
PT WC OR/PRS/ADL CK INI30
PT WC ORTHOTIC TRN ADD 15
PT WC ORTHOTIC TRN INI 30
PT WC PROSTHC TRN ADD 15
PT WC PROSTHC TRN INI 30
PT WC TX FAB ORTH ADD 15
PT WC TX FAB ORTH INI 30
OT WC FUNC ACTVTY ADD 15
OT WC FUNC ACTVTY INI 30
OT WC OR/PRS/ADL CK ADD15
OT WC OR/PRS/ADL CK INI30
OT WC ORTHOTIC TRN ADD 15
OT WC ORTHOTIC TRN INI 30
OT WC PROSTHC TRN ADD 15
OT WC PROSTHC TRN INI 30
OT WC THR ACTIVITY ADD 15
OT WC THR ACTIVITY INI 30
OT WC TRAINING ADL ADD 15
OT WC TRAINING ADL INI 30
OT WC TX FAB ORTH ADD 15
OT WC TX FAB ORTH INI 30
PT L-CODE PRODUCTIV 15 NC
PT EVALUATION 15
PT EVALUATION 30

239940119.xlsx.ms_office

Price
367.00
550.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
184.00
550.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00

$0 Indicator

Page 26 of 299

CDM #
2100030
2100048
2100055
2100063
2100071
2100089
2100170
2100188
2100196
2100204
2100212
2100220
2100238
2100246
2100253
2100279
2100287
2100386
2100428
2100436
2100451
2100485
2100493
2100501
2100519
2100543
2100550
2100568
2100576
2100584
2100592
2100618
2100626
2100634
2100642
2100659
2100667
2100675
2100709
2100717
2100725
2100733
2100741
2100758
2100766
2100774
2100816

CDM Description
PT EVALUATION 45
PT EVALUATION 60
PT RE-EVALUATION 15
PT RE-EVALUATION 30
PT RE-EVALUATION 45
PT RE-EVALUATION 60
PT THERAPY GROUP 15
PT THERAPY GROUP 30
PT THERAPY GROUP 45
PT THERAPY GROUP 60
PT THERAPY GROUP 75
PT THERAPY GROUP 90
PT THERAPY GROUP 105
PT THERAPY GROUP 120
PT AQUATIC THERAPY EA 15
PT COM/WORK REINT EA 15
PT CONTRAST BATH EA 15
PT DIATHRM/MICROWV THR
PT E-STIM ATTEND EA 15
PT E-STIM UNATTENDED OTHR
PT EXERCISE THR EA 15
PT INFRARED THERAPY
PT IONTOPHORESIS EA 15
PT MANUAL THERAPY EA 15
PT MASSAGE EA 15
PT NEUROMSCL RE-ED EA 15
PT ORTH/PROSTH CK EA 15
PT ORTHOTIC FIT/TRN EA 15
PT PARAFFIN BATH THERAPY
PT PHYS PRF TEST EA 15
PT PROSTHETIC TRN EA 15
PT SENSORY TECH EA 15
PT THR ACTIVITY EA 15
PT TRACTION MECHANICAL
PT ULTRASOUND EA 15
PT ULTRAVIOLET THERAPY
PT VASOPNEUMATIC TX
PT WHEELCHAIR TRN EA 15
PT WND VAC SL DBR<50CM 15
PT WND VAC SL DBR<50CM 30
PT WND VAC SL DBR<50CM 45
PT WND VAC SL DBR<50CM 60
PT WND VAC SL DBR>50CM 15
PT WND VAC SL DBR>50CM 30
PT WND VAC SL DBR>50CM 45
PT WND VAC SL DBR>50CM 60
PT APP SPLNT SHRT ARM STC

239940119.xlsx.ms_office

Price
550.00
733.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
641.00
733.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
367.00

$0 Indicator

Page 27 of 299

CDM #
2100824
2100832
2100840
2101087
2101095
2101178
2101186
2101970
2101988
2102069
2102077
2102085
2102093
2102101
2102119
2102127
2102135
2102143
2102150
2102168
2102184
2102192
2102234
2102242
2102259
2102267
2102275
2102309
2102317
2102325
2102382
2102390
2102481
2102499
2102507
2102515
2102523
2102531
2102549
2102556
2102564
2102572
2102580
2102598
2102614
2102622
2102630

CDM Description
PT APP SPLNT SHRT ARM DYN
PT APP SPLINT FINGER STC
PT APP SPLINT FINGER DYN
PT SUSP TREAD OP PROGM
PT PRE EMP TESTING
PT MC EVALUATION INI 30
PT MC EVALUATION ADD 15
PT MC THERAPY COMBO INI30
PT MC THERAPY COMBO ADD15
PT WC BRIEF ASSESS/EVAL
PT WC LTD AS/EVAL NEW PAT
PT WC INT AS/EVAL NEW PAT
PT WC EXT AS/EVAL NEW PAT
PT WC COMP AS/EVL NEW PAT
PT WC LTD AS/EVAL EST PAT
PT WC INT AS/EVAL EST PAT
PT WC EXT AS/EVAL EST PAT
PT WC COMP AS/EVL EST PAT
PT WC GRP EX<5PTS INI 30
PT WC GRP EX<5PTS ADD 15
PT WC CONTRST BATH INI 30
PT WC CONTRST BATH ADD 15
PT WC E-STIM MNL INI 30
PT WC E-STIM MNL ADD 15
PT WC E-STIM UNATTENDED
PT WC EXERCISE THR INI 30
PT WC EXERCISE THR ADD 15
PT WC FUNC ACTVTY INI 30
PT WC FUNC ACTVTY ADD 15
PT WC FUNC CAP MEASURMENT
PT WC IONTOPHORES INI 30
PT WC IONTOPHORES ADD 15
PT WC MYOFSCL RL/SFT TIS
PT WC NEUROMSCL ED INI 30
PT WC NEUROMSCL ED ADD 15
PT WC OR/PRS/ADL CK INI30
PT WC OR/PRS/ADL CK ADD15
PT WC ORTHOTIC TRN INI 30
PT WC ORTHOTIC TRN ADD 15
PT WC PARAFFIN BATH THR
PT WC PHYS PRF TST INI 30
PT WC PHYS PRF TST ADD 15
PT WC POOL W EX INI 30
PT WC POOL W EX ADD 15<1H
PT WC PROSTHC TRN INI 30
PT WC PROSTHC TRN ADD 15
PT WC THR ACTIVITY INI 30

239940119.xlsx.ms_office

Price
367.00
367.00
367.00
367.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
1,099.00
184.00
367.00
550.00
733.00
184.00
92.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
1,099.00
367.00
184.00
367.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00

$0 Indicator

S
S

Page 28 of 299

CDM #
2102648
2102655
2102663
2102671
2102689
2102697
2102705
2102713
2102721
2102739
2102747
2102754
2102762
2102770
2102788
2102796
2102937
2102945
2102960
2102978
2102994
2103018
2103059
2103067
2103075
2103083
2103091
2103109
2103117
2103125
2103133
2103141
2103158
2103166
2103174
2103190
2103208
2103216
2103224
2103232
2103240
2103349
2103356
2103364
2103372
2103380
2103398

CDM Description
PT WC THR ACTIVITY ADD 15
PT WC TRACTION MECHANICAL
PT WC TRACTN MANL INI 30
PT WC TRACTN MANL ADD 15
PT WC TRAINING ADL INI 30
PT WC TRAINING ADL ADD 15
PT WC TREATMENT TAPING
PT WC TX INDV INST INI 30
PT WC TX INDV INST ADD 15
PT WC TX JOINT MOBILIZATN
PT WC TX FAB ORTH INI 30
PT WC TX FAB ORTH ADD 15
PT WC TX SOFT TISS INI 30
PT WC TX SOFT TISS ADD 15
PT WC ULTRASOUND INI 30
PT WC ULTRASOUND ADD 15
PT IONTO PADS PER BX
PT ADDL PERSON 15 NC
PT CASE MANAGEMENT 15 NC
PT CONFERENCE EA 15 NC
PT EDUCATION PT/FAM 15 NC
PT NON-CPT INSTRUCT 15 NC
PT GRP THER PROD
PT CERTIFIED MASSAGE TX
PT STROKE ADJUSTMENT GP
PT STROKE EDUCATION CL
PT CONSTRAINT IMT
PT POOL GRP PROD
PT STROKE GP PROD
PT ORTHO GP PROD
OT EVALUATION 15
OT EVALUATION 30
OT EVALUATION 45
OT EVALUATION 60
OT EVALUATION 75
OT EVALUATION 105
OT EVALUATION 120
OT RE-EVALUATION 15
OT RE-EVALUATION 30
OT RE-EVALUATION 45
OT RE-EVALUATION 60
OT THERAPY GROUP 15
OT THERAPY GROUP 30
OT THERAPY GROUP 45
OT THERAPY GROUP 60
OT THERAPY GROUP 75
OT THERAPY GROUP 90

239940119.xlsx.ms_office

Price
184.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
229.00
184.00
367.00
550.00
733.00
916.00
1,282.00
1,465.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00

$0 Indicator

S
S
S
S
S
S
S
S
S
S
S
S
S

Page 29 of 299

CDM #
2103406
2103414
2103455
2103554
2103562
2103596
2103604
2103612
2103620
2103653
2103661
2103679
2103687
2103695
2103703
2103711
2103729
2103745
2103752
2103760
2103778
2103794
2103802
2103810
2103828
2103836
2103851
2103869
2103893
2103919
2103943
2103984
2103992
2104008
2104016
2104149
2104156
2104164
2104255
2104263
2104313
2104321
2104339
2104347
2104354
2104362
2104396

CDM Description
OT THERAPY GROUP 105
OT THERAPY GROUP 120
OT CONTRAST BATH EA 15
OT DIATHRM/MICROWV THR
OT DVL COGNT SKILL EA 15
OT E-STIM ATTEND EA 15
OT E-STIM UNATTENDED OTHR
OT E-STIM UNATTENDED ULCR
OT EXERCISE THR EA 15
OT INFRARED THERAPY
OT IONTOPHORESIS EA 15
OT MANUAL THERAPY EA 15
OT MASSAGE EA 15
OT NEUROMSCL RE-ED EA 15
OT ORTH/PROSTH CK EA 15
OT ORTHOTIC FIT/TRN EA 15
OT PARAFFIN BATH THERAPY
OT PROSTHETIC TRN EA 15
OT SELF CARE/HOME EA 15
OT SENSORY TECH EA 15
OT THR ACTIVITY EA 15
OT ULTRASOUND EA 15
OT ULTRAVIOLET THERAPY
OT VASOPNEUMATIC TX
OT WHEELCHAIR TRN EA 15
OT WHIRLPOOL ONE EXTRMITY
OT WORK HARDNNG INI 2HR
OT WORK HARDNNG ADD HR
OT APP SPLNT SHRT ARM STC
OT APP SPLINT FINGER STC
CST VOLAR COCK UP
WRIST GAUNTLET
WHFO RIGID WO JOINTS FA
STATIC ELBOW SP
HFO WO JOINTS FA
OT CONSTRAINT IMT
OT MC EVALUATION INI 30
OT MC EVALUATION ADD 15
OT MC AQUATIC THR INI 30
OT MC AQUATIC THR ADD 15
OT MC CONTRST BATH INI 30
OT MC CONTRST BATH ADD 15
OT MC DEBR WO ANES INI 30
OT MC DEBR WO ANES ADD 15
OT MC DIATH/MICRO INI 30
OT MC DIATH/MICRO ADD 15
OT MC E-STIM ATTND INI 30

239940119.xlsx.ms_office

Price
641.00
733.00
184.00
184.00
184.00
184.00
184.00
367.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
550.00
1,465.00
733.00
367.00
367.00
76.00
136.00
201.00
210.00
126.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00

$0 Indicator

Page 30 of 299

CDM #
2104404
2104412
2104420
2104438
2104446
2104495
2104503
2104511
2104529
2104537
2104545
2104552
2104560
2104578
2104586
2104594
2104602
2104610
2104628
2104636
2104644
2104651
2104669
2104677
2104685
2104693
2104701
2104719
2104727
2104750
2104768
2104792
2104800
2104818
2104826
2104875
2104883
2104891
2104909
2104974
2104982
2104990
2105005
2105013
2105021
2105039
2105047

CDM Description
OT MC E-STIM ATTND ADD 15
OT MC E-STIM UNATT INI 30
OT MC E-STIM UNATT ADD 15
OT MC EXERCISE THR INI 30
OT MC EXERCISE THR ADD 15
OT MC INFRARED THR INI 30
OT MC INFRARED THR ADD 15
OT MC IONTOPHORES INI 30
OT MC IONTOPHORES ADD 15
OT MC MANUAL THR INI 30
OT MC MANUAL THR ADD 15
OT MC MASSAGE INI 30
OT MC MASSAGE ADD 15
OT MC NEUROMSCL ED INI 30
OT MC NEUROMSCL ED ADD 15
OT MC ORTH/PROS CK INI 30
OT MC ORTH/PROS CK ADD 15
OT MC ORTH FIT/TRN INI 30
OT MC ORTH FIT/TRN ADD 15
OT MC PARAFFIN THR INI 30
OT MC PARAFFIN THR ADD 15
OT MC PROSTHTC TRN INI 30
OT MC PROSTHTC TRN ADD 15
OT MC SLF CARE/HME INI 30
OT MC SLF CARE/HME ADD 15
OT MC SENSORY TECH INI 30
OT MC SENSORY TECH ADD 15
OT MC THR ACTIVITY INI 30
OT MC THR ACTIVITY ADD 15
OT MC ULTRASOUND INI 30
OT MC ULTRASOUND ADD 15
OT MC VASOPN TX INI 30
OT MC VASOPN TX ADD 15
OT MC WHEELCHR TRN INI 30
OT MC WHEELCHR TRN ADD 15
OT MC FAB SPLINT INI 30
OT MC FAB SPLINT ADD 15
OT MC TST DVLPMNTL INI 30
OT MC TST DVLPMNTL ADD 15
OT WC BRIEF ASSESS/EVAL
OT WC LTD AS/EVAL NEW PAT
OT WC INT AS/EVAL NEW PAT
OT WC EXT AS/EVAL NEW PAT
OT WC COMP AS/EVL NEW PAT
OT WC LTD AS/EVAL EST PAT
OT WC INT AS/EVAL EST PAT
OT WC EXT AS/EVAL EST PAT

239940119.xlsx.ms_office

Price
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
1,099.00
184.00
367.00
550.00

$0 Indicator

Page 31 of 299

CDM #
2105054
2105153
2105161
2105187
2105195
2105237
2105245
2105252
2105260
2105278
2105302
2105310
2105385
2105393
2105468
2105476
2105484
2105492
2105500
2105518
2105526
2105542
2105559
2105567
2105609
2105617
2105625
2105633
2105674
2105682
2105690
2105708
2105716
2105724
2105732
2105740
2105757
2105765
2105773
2105781
2105930
2105955
2105963
2105989
2105997
2106003
2106011

CDM Description
OT WC COMP AS/EVL EST PAT
OT WC GRP EX<5PTS INI 30
OT WC GRP EX<5PTS ADD 15
OT WC CONTRST BATH INI 30
OT WC CONTRST BATH ADD 15
OT WC E-STIM MNL INI 30
OT WC E-STIM MNL ADD 15
OT WC E-STIM UNATTENDED
OT WC EXERCISE THR INI 30
OT WC EXERCISE THR ADD 15
OT WC FUNC ACTVTY INI 30
OT WC FUNC ACTVTY ADD 15
OT WC IONTOPHORES INI 30
OT WC IONTOPHORES ADD 15
OT WC MYOFSCL RL/SFT TIS
OT WC NEUROMSCL ED INI 30
OT WC NEUROMSCL ED ADD 15
OT WC OR/PRS/ADL CK INI30
OT WC OR/PRS/ADL CK ADD15
OT WC ORTHOTIC TRN INI 30
OT WC ORTHOTIC TRN ADD 15
OT WC PARAFFIN BATH THR
OT WC PHYS PRF TST INI 30
OT WC PHYS PRF TST ADD 15
OT WC PROSTHC TRN INI 30
OT WC PROSTHC TRN ADD 15
OT WC THR ACTIVITY INI 30
OT WC THR ACTIVITY ADD 15
OT WC TRAINING ADL INI 30
OT WC TRAINING ADL ADD 15
OT WC TREATMENT TAPING
OT WC TX INDV INST INI 30
OT WC TX INDV INST ADD 15
OT WC TX JOINT MOBILIZATN
OT WC TX FAB ORTH INI 30
OT WC TX FAB ORTH ADD 15
OT WC TX SOFT TISS INI 30
OT WC TX SOFT TISS ADD 15
OT WC ULTRASOUND INI 30
OT WC ULTRASOUND ADD 15
OT ADDL PERSON 15 NC
OT CASE MANAGEMENT 15 NC
OT CONFERENCE EA 15 NC
OT EDUCATION PT/FAM 15 NC
OT NON-CPT CLNT SRV 15 NC
OT NON-CPT INSTRUCT 15 NC
OT GRP PRODUCTIVITY

239940119.xlsx.ms_office

Price
733.00
184.00
92.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
-

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CDM #
2106029
2106037
2106045
2106052
2106060
2106078
2106086
2106094
2106102
2106110
2106128
2106136
2106144
2106151
2106169
2106177
2106185
2106193
2106201
2106219
2106227
2106235
2106243
2106250
2106268
2106276
2106284
2106292
2106300
2106318
2106326
2106334
2106342
2106359
2106367
2106375
2106383
2106391
2106417
2106425
2106433
2106441
2106458
2106466
2106474
2106482
2106490

CDM Description
ST EVALUATION SPEECH 15
ST EVALUATION SPEECH 30
ST EVALUATION SPEECH 45
ST EVALUATION SPEECH 60
ST EVALUATION SPEECH 75
ST EVALUATION SPEECH 90
ST EVAL SWALLOWING 15
ST EVAL SWALLOWING 30
ST EVAL SWALLOWING 45
ST EVAL SWALLOWING 60
ST EVAL SWAL VID/FLR 30
ST EVAL SWAL VID/FLR 45
ST EVAL SWAL VID/FLR 60
ST EVAL SWAL VID/FLR 75
ST EVAL SWAL VID/FLR 90
ST EVAL VOICE PROSTHETIC
ST EVL NONSP COMM DVC 1HR
ST EVAL COMM DVC INI 60
ST EVAL COMM DVC ADD 30
ST TREATMENT GROUP 15
ST TREATMENT GROUP 30
ST TREATMENT GROUP 45
ST TREATMENT GROUP 60
ST TREATMENT SPEECH 15
ST TREATMENT SPEECH 30
ST TREATMENT SPEECH 45
ST TREATMENT SPEECH 60
ST NASOPHRNGSCPY W ENDO
ST TREATMENT SWALLOW 15
ST TREATMENT SWALLOW 30
ST TREATMENT SWALLOW 45
ST TREATMENT SWALLOW 60
ST TX NON-SPCH COMM DVC
ST MOD/TRN VOICE PROS 15
ST MOD/TRN VOICE PROS 30
ST MOD/TRN VOICE PROS 45
ST MOD/TRN VOICE PROS 60
ST MOD/TRN VOICE PROS 75
ST DEVELOPMENTAL TESTING
ST TEST NEUROBEHAVL EA HR
ST DVL COGNT SKILL EA 15
ST SELF CARE/HOME EA 15
ST COM/WORK REINT EA 15
ST ASSESS APHASIA PER HR
ST ACCENT MODIF EA 15M
ST CASE MANAGEMENT 15 NC
ST CONFERENCE 15 NC

239940119.xlsx.ms_office

Price
184.00
367.00
550.00
733.00
916.00
1,099.00
184.00
367.00
550.00
733.00
367.00
550.00
733.00
916.00
1,099.00
733.00
733.00
733.00
367.00
92.00
184.00
275.00
367.00
184.00
367.00
550.00
733.00
733.00
184.00
367.00
550.00
733.00
367.00
184.00
367.00
550.00
733.00
916.00
733.00
733.00
184.00
184.00
184.00
733.00
-

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CDM #
2106508
2106524
2106532
2109734
2109742
2109759
2109767
2109775
2109791
2109809
2109866
2109874
2109882
2109908
2109916
2109924
2109932
2109957
2109965
2109999
2110302
2110310
2110328
2110336
2110435
2110443
2110450
2110492
2110500
2110518
2110526
2110534
2110542
2110559
2110609
2110617
2110625
2110633
2110641
2110658
2110666
2110674
2110682
2110690
2110708
2110716
2110765

CDM Description
ST EDUCATON PAT/FAM 15 NC
ST NON-CPT INSTRUCT 15 NC
ST STROKE EDUCATION CL
PT L-CODE PRODUCTIV 15 NC
ELBOW ORTHO WO JOINTS CF
EO 2 CUF ADJ LOCK ACTV CF
EO RIGID WO JOINTS FA
EWHO W JOINT(S) CF
EWHFO W JOINT(S) CF
WHFO WO JOINT(S) FA
HINGE EXT FLEX WRST/FINGR
WHO W NONTORSION JT(S) CF
WRST COCK UP NONMOLDED FA
HFO FLEX GLOVE ELAST F FA
HFO WO JOINTS CF
HAND ORTHO WO JOINTS CF
HFO W JOINT(S) CF
FINGR ORTHOSIS WO JTS CF
FO NONTORSION JOINT CF
OT L-CODE PRODUCTIV 15 NC
FO PIP/DIP W JOINT FA
FO PIP/DIP WO JOINT FA
HFO NONTORSN JOINT(S) FA
WHFO NONTORSN JOINT(S) FA
EWHO RIGID WO JTS CF
SO CAP DESIGN WO JTS CF
WHFO W JOINT(S) FA
PT TOTAL JOINT CLASS IN
ST TREATMENT SPEECH 75
ST TREATMENT SPEECH 90
ST TREATMENT SWALLOW 75
ST TREATMENT SWALLOW 90
ST TREATMENT GROUP 75
ST TREATMENT GROUP 90
PT WND VAC SL DBR<50CM 75
PT WND VAC SL DBR>50CM 75
PT WND VAC SL DBR<50CM 90
PT WND VAC SL DBR>50CM 90
PT STUDENT PRODUCT/DAY NC
OT STUDENT PRODUCT/DAY NC
ST STUDENT PRODUCT/DAY NC
ST FF ENDO EVAL W VID
ST FF ENDO EVAL SWAL VID
APPL LAYRD COMPRES BK BIL
APPL LAYRED COMPRES BK RT
APPL LAYRED COMPRES BK LT
OT MC TREATMENT ADD 15

239940119.xlsx.ms_office

Price
539.00
2,738.00
201.00
2,532.00
2,532.00
467.00
3,043.00
1,850.00
154.00
243.00
506.00
506.00
599.00
398.00
412.00
200.00
182.00
275.00
300.00
2,391.00
201.00
750.00
916.00
1,099.00
916.00
1,099.00
458.00
550.00
916.00
916.00
1,099.00
1,099.00
733.00
1,099.00
415.00
286.00
286.00
184.00

$0 Indicator
S
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S

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CDM #
2110773
2110799
2110856
2110864
2110872
2110880
2110898
2110906
2110914
2110922
2110930
2110948
2110955
2110963
2200012
2200020
2200038
2200046
2200053
2200061
2200079
2200087
2200178
2200186
2200194
2200202
2200210
2200228
2200236
2200244
2200251
2200269
2200277
2200285
2200319
2200418
2200459
2200467
2200483
2200525
2200533
2200558
2200574
2200582
2200590
2200608
2200616

CDM Description
OT MC TREATMENT INI 30
STATIC AFO FA
PT DEBR SL SESSION 1ST 20
PT DEBR SL SESSION ADD 20
PT DEBR SL SESS EA 15 NC
OT DEBR SL SESSION 1ST 20
OT DEBR SL SESSION ADD 20
OT DEBR SL SESS EA 15 NC
PT CANALITH REPOSITIONING
PT NON-CPT CLNT SRV 15 NC
OT TOTAL JOINT CLASS
OT ORTHO GP PROD
OT POOL GRP PROD
OT SUSP TREAD OP PRGM
PT EVALUATION 15
PT EVALUATION 30
PT EVALUATION 45
PT EVALUATION 60
PT RE-EVALUATION 15
PT RE-EVALUATION 30
PT RE-EVALUATION 45
PT RE-EVALUATION 60
PT THERAPY GROUP 15
PT THERAPY GROUP 30
PT THERAPY GROUP 45
PT THERAPY GROUP 60
PT THERAPY GROUP 75
PT THERAPY GROUP 90
PT THERAPY GROUP 105
PT THERAPY GROUP 120
PT THERAPY GROUP 135
PT THERAPY GROUP 150
PT THERAPY GROUP 165
PT AQUATIC THERAPY EA 15
PT CONTRAST BATH EA 15
PT DIATHRM/MICROWV THR
PT E-STIM ATTEND EA 15
PT E-STIM UNATTENDED OTHR
PT EXERCISE THR EA 15
PT IONTOPHORESIS EA 15
PT MANUAL THERAPY EA 15
PT MMT BODY W HANDS
PT NEUROMSCL RE-ED EA 15
PT ORTH/PROSTH CK EA 15
PT ORTHOTIC FIT/TRN EA 15
PT PARAFFIN BATH THERAPY
PT PHYS PRF TEST EA 15

239940119.xlsx.ms_office

Price
367.00
85.00
550.00
367.00
550.00
367.00
184.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
641.00
733.00
824.00
916.00
1,007.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00

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Page 35 of 299

CDM #
2200624
2200640
2200657
2200665
2200673
2200707
2200830
2200855
2200871
2200897
2200905
2200921
2200939
2200947
2200954
2200962
2200970
2201077
2201135
2201143
2201150
2201168
2201176
2201184
2201192
2201200
2201234
2201242
2201358
2201382
2201390
2201416
2201432
2201440
2201457
2201465
2201481
2201499
2201507
2201515
2201523
2201531
2201549
2201556
2201564
2201580
2201606

CDM Description
PT PROSTHETIC TRN EA 15
PT SENSORY TECH EA 15
PT THR ACTIVITY EA 15
PT TRACTION MECHANICAL
PT ULTRASOUND EA 15
PT WHEELCHAIR TRN EA 15
PT ADDL PERSON 15 NC
PT CASE MANAGEMENT 15 NC
PT CPM SET UP 15 NC
PT NON-CPT CLNT SRV 15 NC
PT NON-CPT INSTRUCT 15 NC
OT EVALUATION 15
OT EVALUATION 30
OT EVALUATION 45
OT EVALUATION 60
OT EVALUATION 75
OT EVALUATION 90
OT EVAL SWALLOWING 60
OT THERAPY GROUP 15
OT THERAPY GROUP 30
OT THERAPY GROUP 45
OT THERAPY GROUP 60
OT THERAPY GROUP 75
OT THERAPY GROUP 90
OT THERAPY GROUP 105
OT THERAPY GROUP 120
OT COM/WORK REINT EA 15
OT CONTRAST BATH EA 15
OT DVL COGNT SKILL EA 15
OT E-STIM ATTEND EA 15
OT E-STIM UNATTENDED OTHR
OT EXERCISE THR EA 15
OT HUBBARD TANK EA 15
OT INFRARED THERAPY
OT IONTOPHORESIS EA 15
OT MANUAL THERAPY EA 15
OT NEUROMSCL RE-ED EA 15
OT ORTH/PROSTH CK EA 15
OT ORTHOTIC FIT/TRN EA 15
OT PARAFFIN BATH THERAPY
OT PHYS PRF TEST EA 15
OT PROSTHETIC TRN EA 15
OT SELF CARE/HOME EA 15
OT SENSORY TECH EA 15
OT THR ACTIVITY EA 15
OT ULTRASOUND EA 15
OT VASOPNEUMATIC TX

239940119.xlsx.ms_office

Price
184.00
184.00
184.00
184.00
184.00
184.00
184.00
367.00
550.00
733.00
916.00
1,099.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
641.00
733.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00

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S
S
S
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Page 36 of 299

CDM #
2201614
2201689
2201705
2201713
2201739
2201747
2201754
2201788
2201796
2201804
2201812
2201820
2201838
2201846
2201853
2201861
2201879
2201887
2201895
2201903
2201911
2201929
2201937
2201945
2201952
2201960
2201978
2201986
2201994
2202000
2202018
2202026
2202034
2202042
2202059
2202067
2202075
2202083
2202091
2202109
2202117
2202125
2202133
2202141
2202158
2202166
2202174

CDM Description
OT WHEELCHAIR TRN EA 15
OT ADDL PERSON 15 NC
OT CASE MANAGEMENT 15 NC
OT CONFERENCE EA 15 NC
OT EDUCATION PT/FAM 15 NC
OT NON-CPT CLNT SRV 15 NC
OT NON-CPT INSTRUCT 15 NC
ST EVALUATION SPEECH 15
ST EVALUATION SPEECH 30
ST EVALUATION SPEECH 45
ST EVALUATION SPEECH 60
ST EVALUATION SPEECH 75
ST EVALUATION SPEECH 90
ST EVAL SWALLOWING 15
ST EVAL SWALLOWING 30
ST EVAL SWALLOWING 45
ST EVAL SWALLOWING 60
ST EVAL SWAL VID/FLR 30
ST EVAL SWAL VID/FLR 45
ST EVAL SWAL VID/FLR 60
ST EVAL SWAL VID/FLR 75
ST EVAL SWAL VID/FLR 90
ST EVAL VOICE PROSTHETIC
ST EVL NONSP COMM DVC 1HR
ST EVAL COMM DVC INI 60
ST EVAL COMM DVC ADD 30
ST FF ENDO EVAL W VID
ST FF ENDO EVAL SWAL VID
ST TREATMENT GROUP 15
ST TREATMENT GROUP 30
ST TREATMENT GROUP 45
ST TREATMENT GROUP 60
ST TREATMENT SPEECH 15
ST TREATMENT SPEECH 30
ST TREATMENT SPEECH 45
ST TREATMENT SPEECH 60
ST NASOPHRNGSCPY W ENDO
ST TREATMENT SWALLOW 15
ST TREATMENT SWALLOW 30
ST TREATMENT SWALLOW 45
ST TREATMENT SWALLOW 60
ST TX NON-SPCH COMM DVC
ST MOD/TRN VOICE PROS 15
ST MOD/TRN VOICE PROS 30
ST MOD/TRN VOICE PROS 45
ST MOD/TRN VOICE PROS 60
ST MOD/TRN VOICE PROS 75

239940119.xlsx.ms_office

Price
184.00
184.00
367.00
550.00
733.00
916.00
1,099.00
184.00
367.00
550.00
733.00
367.00
550.00
733.00
916.00
1,099.00
733.00
733.00
733.00
367.00
733.00
1,099.00
92.00
184.00
275.00
367.00
184.00
367.00
550.00
733.00
733.00
184.00
367.00
550.00
733.00
367.00
184.00
367.00
550.00
733.00
916.00

$0 Indicator
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CDM #
2202190
2202208
2202216
2202224
2202232
2202240
2202265
2202273
2202281
2202299
2202307
2202489
2202497
2202505
2202513
2202521
2202539
2202547
2202554
2202604
2202612
2202687
2202794
2202802
2202810
2202869
2202877
2202885
2203057
2203065
2203073
2203081
2203131
2203149
2223584
2223592
2223600
2223618
2223626
2223634
2223733
2223741
2223758
2223766
2223774
2223782
2223790

CDM Description
ST DEVELOPMENTAL TESTING
ST TEST NEUROBEHAVL EA HR
ST DVL COGNT SKILL EA 15
ST SELF CARE/HOME EA 15
ST COM/WORK REINT EA 15
ST ASSESS APHASIA PER HR
ST CASE MANAGEMENT 15 NC
ST CONFERENCE 15 NC
ST EDUCATON PAT/FAM 15 NC
ST NON-CPT CLNT SRV 15 NC
ST NON-CPT INSTRUCT 15 NC
ST TREATMENT SPEECH 75
ST TREATMENT SPEECH 90
ST TREATMENT SWALLOW 75
ST TREATMENT SWALLOW 90
ST TREATMENT GROUP 75
ST TREATMENT GROUP 90
PT WC CONTRST BATH ADD 15
PT WC CONTRST BATH INI 30
OT WC CONTRST BATH ADD 15
OT WC CONTRST BATH INI 30
OT APP SPLNT SHRT ARM STC
OT WC E-STIM MNL ADD 15
OT WC E-STIM MNL INI 30
OT WC E-STIM UNATTENDED
PT WC E-STIM MNL ADD 15
PT WC E-STIM MNL INI 30
PT WC E-STIM UNATTENDED
PT WC PARAFFIN BATH THR
OT WC PARAFFIN BATH THR
OT WC ULTRASOUND ADD 15
OT WC ULTRASOUND INI 30
PT WC ULTRASOUND ADD 15
PT WC ULTRASOUND INI 30
PT STUDENT PRODUCT/DAY NC
OT STUDENT PRODUCT/DAY NC
ST STUDENT PRODUCT/DAY NC
OT MC TREATMENT ADD 15
OT MC TREATMENT INI 30
UPPER LIMB ORTHOTIC NOS
PT CANALITH REPOSITIONING
PT WC EXERCISE THR ADD 15
PT WC EXERCISE THR INI 30
PT WC FUNC ACTVTY ADD 15
PT WC FUNC ACTVTY INI 30
PT WC NEUROMSCL ED ADD 15
PT WC NEUROMSCL ED INI 30

239940119.xlsx.ms_office

Price
733.00
733.00
184.00
184.00
184.00
733.00
916.00
1,099.00
916.00
1,099.00
458.00
550.00
184.00
367.00
184.00
367.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
184.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
150.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00

$0 Indicator

S
S
S
S
S

S
S
S

Page 38 of 299

CDM #
2223808
2223816
2223824
2223832
2223840
2223857
2223865
2223873
2223881
2223899
2223907
2223915
2223923
2223931
2223949
2223956
2223964
2223972
2223980
2224012
2224020
2224038
2224046
2224053
2224061
2224079
2224087
2224095
2224103
2224111
2224129
2224137
2224145
2224152
2224160
2224178
2224186
2224194
2224202
2224210
2224228
2224236
2224244
2224251
2224269
2224277
2224285

CDM Description
PT WC OR/PRS/ADL CK ADD15
PT WC OR/PRS/ADL CK INI30
PT WC ORTHOTIC TRN ADD 15
PT WC ORTHOTIC TRN INI 30
PT WC PROSTHC TRN ADD 15
PT WC PROSTHC TRN INI 30
PT WC THR ACTIVITY ADD 15
PT WC THR ACTIVITY INI 30
PT WC TREATMENT TAPING
PT WC TX FAB ORTH ADD 15
PT WC TX FAB ORTH INI 30
PT WC TX INDV INST ADD 15
PT WC TX INDV INST INI 30
PT WC TX JOINT MOBILIZATN
PT WC TX SOFT TISS ADD 15
PT WC TX SOFT TISS INI 30
PT WC BRIEF ASSESS/EVAL
PT WC COMP AS/EVL EST PAT
PT WC COMP AS/EVL NEW PAT
PT WC INT AS/EVAL EST PAT
PT WC INT AS/EVAL NEW PAT
PT WC LTD AS/EVAL EST PAT
PT WC LTD AS/EVAL NEW PAT
OT WC EXERCISE THR ADD 15
OT WC EXERCISE THR INI 30
OT WC FUNC ACTVTY ADD 15
OT WC FUNC ACTVTY INI 30
OT WC NEUROMSCL ED ADD 15
OT WC NEUROMSCL ED INI 30
OT WC OR/PRS/ADL CK ADD15
OT WC OR/PRS/ADL CK INI30
OT WC ORTHOTIC TRN ADD 15
OT WC ORTHOTIC TRN INI 30
OT WC PROSTHC TRN ADD 15
OT WC PROSTHC TRN INI 30
OT WC THR ACTIVITY ADD 15
OT WC THR ACTIVITY INI 30
OT WC TRAINING ADL ADD 15
OT WC TRAINING ADL INI 30
OT WC TREATMENT TAPING
OT WC TX FAB ORTH ADD 15
OT WC TX FAB ORTH INI 30
OT WC TX INDV INST ADD 15
OT WC TX INDV INST INI 30
OT WC TX JOINT MOBILIZATN
OT WC TX SOFT TISS ADD 15
OT WC TX SOFT TISS INI 30

239940119.xlsx.ms_office

Price
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
733.00
1,099.00
367.00
550.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00

$0 Indicator

Page 39 of 299

CDM #
2224293
2224301
2224319
2224327
2224335
2224343
2224350
2224368
2224376
2224384
2224392
2224400
2224418
2224426
2224434
2224442
2224459
2224467
2224475
2224483
2224491
2300010
2300028
2300036
2300044
2300176
2300184
2300192
2300200
2300218
2300226
2300242
2300309
2300457
2300465
2300481
2300523
2300531
2300549
2300572
2300580
2300598
2300622
2300655
2300671
2300705
2300739

CDM Description
OT WC COMP AS/EVL EST PAT
OT WC COMP AS/EVL NEW PAT
OT WC EXT AS/EVAL EST PAT
OT WC EXT AS/EVAL NEW PAT
OT WC INT AS/EVAL EST PAT
OT WC INT AS/EVAL NEW PAT
OT WC LTD AS/EVAL EST PAT
OT WC LTD AS/EVAL NEW PAT
OT THERAPY GROUP 135
OT THERAPY GROUP 150
OT THERAPY GROUP 165
OT MC EVALUATION INI 30
OT MC EVALUATION ADD 15
PT MC EVALUATION INI 30
PT MC EVALUATION ADD 15
PT MC THERAPY COMBO INI30
PT MC THERAPY COMBO ADD15
OT WC BRIEF ASSESS/EVAL
PT WC EXT AS/EVAL NEW PAT
PT WC EXT AS/EVAL EST PAT
PT MC RE-EVAL INI 30
PT EVALUATION 15
PT EVALUATION 30
PT EVALUATION 45
PT EVALUATION 60
PT THERAPY GROUP 15
PT THERAPY GROUP 30
PT THERAPY GROUP 45
PT THERAPY GROUP 60
PT THERAPY GROUP 75
PT THERAPY GROUP 90
PT THERAPY GROUP 120
PT COM/WORK REINT EA 15
PT E-STIM ATTEND EA 15
PT E-STIM UNATTENDED OTHR
PT EXERCISE THR EA 15
PT IONTOPHORESIS EA 15
PT MANUAL THERAPY EA 15
PT MASSAGE EA 15
PT NEUROMSCL RE-ED EA 15
PT ORTH/PROSTH CK EA 15
PT ORTHOTIC FIT/TRN EA 15
PT PROSTHETIC TRN EA 15
PT THR ACTIVITY EA 15
PT ULTRASOUND EA 15
PT WHEELCHAIR TRN EA 15
PT WND VAC SL DBR<50CM 15

239940119.xlsx.ms_office

Price
733.00
1,099.00
550.00
733.00
367.00
550.00
184.00
367.00
824.00
916.00
1,007.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
733.00
550.00
367.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
733.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00

$0 Indicator

Page 40 of 299

CDM #
2300747
2300754
2300762
2300770
2300788
2300796
2300804
2300978
2301174
2301182
2301638
2301646
2301703
2301729
2301760
2301778
2301794
2301802
2301810
2301828
2302008
2302016
2302024
2302032
2302040
2302057
2302065
2302073
2302115
2302222
2302255
2302263
2302289
2302339
2302347
2302354
2302362
2302370
2302404
2302412
2302438
2302453
2302487
2302552
2302560
2302792
2302800

CDM Description
PT WND VAC SL DBR<50CM 30
PT WND VAC SL DBR<50CM 45
PT WND VAC SL DBR<50CM 60
PT WND VAC SL DBR>50CM 15
PT WND VAC SL DBR>50CM 30
PT WND VAC SL DBR>50CM 45
PT WND VAC SL DBR>50CM 60
PT MC PREL EVAL SNF ICF
PT MC EXERCISE THR INI 30
PT MC EXERCISE THR ADD 15
PT MC THERAPY COMBO INI30
PT MC THERAPY COMBO ADD15
PT ADDL PERSON 15 NC
PT CASE MANAGEMENT 15 NC
PT NON-CPT CLNT SRV 15 NC
PT NON-CPT INSTRUCT 15 NC
OT EVALUATION 15
OT EVALUATION 30
OT EVALUATION 45
OT EVALUATION 60
OT THERAPY GROUP 15
OT THERAPY GROUP 30
OT THERAPY GROUP 45
OT THERAPY GROUP 60
OT THERAPY GROUP 75
OT THERAPY GROUP 90
OT THERAPY GROUP 105
OT THERAPY GROUP 120
OT CONTRAST BATH EA 15
OT DVL COGNT SKILL EA 15
OT E-STIM ATTEND EA 15
OT E-STIM UNATTENDED OTHR
OT EXERCISE THR EA 15
OT MANUAL THERAPY EA 15
OT MASSAGE EA 15
OT NEUROMSCL RE-ED EA 15
OT ORTH/PROSTH CK EA 15
OT ORTHOTIC FIT/TRN EA 15
OT PROSTHETIC TRN EA 15
OT SELF CARE/HOME EA 15
OT THR ACTIVITY EA 15
OT ULTRASOUND EA 15
OT WHEELCHAIR TRN EA 15
OT MC EVALUATION INI 30
OT MC EVALUATION ADD 15
OT MC E-STIM ATTND INI 30
OT MC E-STIM ATTND ADD 15

239940119.xlsx.ms_office

Price
367.00
550.00
733.00
184.00
367.00
550.00
733.00
733.00
367.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
641.00
733.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
367.00
184.00
367.00
184.00

$0 Indicator

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CDM #
2302818
2302826
2302941
2302966
2302982
2302990
2303006
2303014
2303022
2303055
2303063
2303071
2303089
2303113
2303121
2303154
2303162
2303212
2303220
2303279
2303287
2303337
2303345
2303352
2303360
2303378
2303394
2303436
2303444
2303469
2303477
2303485
2303493
2303501
2303519
2303527
2303535
2303543
2303550
2303568
2303576
2303584
2303592
2303600
2303618
2303626
2303634

CDM Description
OT MC E-STIM UNATT INI 30
OT MC E-STIM UNATT ADD 15
OT MC MANUAL THR ADD 15
OT MC MASSAGE ADD 15
OT MC NEUROMSCL ED ADD 15
OT MC ORTH/PROS CK INI 30
OT MC ORTH/PROS CK ADD 15
OT MC ORTH FIT/TRN INI 30
OT MC ORTH FIT/TRN ADD 15
OT MC PROSTHTC TRN INI 30
OT MC PROSTHTC TRN ADD 15
OT MC SLF CARE/HME INI 30
OT MC SLF CARE/HME ADD 15
OT MC THR ACTIVITY INI 30
OT MC THR ACTIVITY ADD 15
OT MC ULTRASOUND INI 30
OT MC ULTRASOUND ADD 15
OT MC WHEELCHR TRN INI 30
OT MC WHEELCHR TRN ADD 15
OT MC FAB SPLINT INI 30
OT MC FAB SPLINT ADD 15
OT APP SPLNT SHRT ARM STC
OT APP SPLNT SHRT ARM DYN
OT APP SPLINT FINGER STC
OT APP SPLINT FINGER DYN
OT ADDL PERSON 15 NC
OT CASE MANAGEMENT 15 NC
OT NON-CPT CLNT SRV 15 NC
OT NON-CPT INSTRUCT 15 NC
ST EVALUATION SPEECH 15
ST EVALUATION SPEECH 30
ST EVALUATION SPEECH 45
ST EVALUATION SPEECH 60
ST EVALUATION SPEECH 75
ST EVALUATION SPEECH 90
ST EVAL SWALLOWING 15
ST EVAL SWALLOWING 30
ST EVAL SWALLOWING 45
ST EVAL SWALLOWING 60
ST EVAL SWAL VID/FLR 30
ST EVAL SWAL VID/FLR 45
ST EVAL SWAL VID/FLR 60
ST EVAL SWAL VID/FLR 75
ST EVAL SWAL VID/FLR 90
ST EVAL VOICE PROSTHETIC
ST EVL NONSP COMM DVC 1HR
ST EVAL COMM DVC INI 60

239940119.xlsx.ms_office

Price
367.00
184.00
184.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
367.00
367.00
367.00
184.00
367.00
550.00
733.00
916.00
1,099.00
184.00
367.00
550.00
733.00
367.00
550.00
733.00
916.00
1,099.00
733.00
733.00
733.00

$0 Indicator

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CDM #
2303642
2303675
2303683
2303691
2303709
2303717
2303725
2303733
2303741
2303766
2303774
2303782
2303790
2303808
2303816
2303824
2303832
2303840
2303857
2303881
2303899
2303923
2303931
2303949
2303956
2303964
2303972
2303980
2303998
2304004
2304012
2304020
2304038
2304046
2304095
2304103
2304111
2304129
2304152
2304160
2304178
2304186
2304194
2304202
2304293
2304301
2304335

CDM Description
ST EVAL COMM DVC ADD 30
ST TREATMENT GROUP 15
ST TREATMENT GROUP 30
ST TREATMENT GROUP 45
ST TREATMENT GROUP 60
ST TREATMENT SPEECH 15
ST TREATMENT SPEECH 30
ST TREATMENT SPEECH 45
ST TREATMENT SPEECH 60
ST TREATMENT SWALLOW 15
ST TREATMENT SWALLOW 30
ST TREATMENT SWALLOW 45
ST TREATMENT SWALLOW 60
ST TX NON-SPCH COMM DVC
ST MOD/TRN VOICE PROS 15
ST MOD/TRN VOICE PROS 30
ST MOD/TRN VOICE PROS 45
ST MOD/TRN VOICE PROS 60
ST MOD/TRN VOICE PROS 75
ST TEST NEUROBEHAVL EA HR
ST DVL COGNT SKILL EA 15
ST ASSESS APHASIA PER HR
ST CASE MANAGEMENT 15 NC
ST CONFERENCE 15 NC
ST EDUCATON PAT/FAM 15 NC
ST NON-CPT CLNT SRV 15 NC
ST NON-CPT INSTRUCT 15 NC
ST TREATMENT SPEECH 75
ST TREATMENT SPEECH 90
ST TREATMENT SWALLOW 75
ST TREATMENT SWALLOW 90
PT STUDENT PRODUCT/DAY NC
OT STUDENT PRODUCT/DAY NC
ST STUDENT PRODUCT/DAY NC
OT WC CONTRST BATH ADD 15
OT WC CONTRST BATH INI 30
PT WC CONTRST BATH INI 30
PT WC CONTRST BATH ADD 15
OT WC E-STIM MNL ADD 15
OT WC E-STIM MNL INI 30
OT WC E-STIM UNATTENDED
PT WC E-STIM MNL ADD 15
PT WC E-STIM MNL INI 30
PT WC E-STIM UNATTENDED
PT WC PARAFFIN BATH THR
OT WC PARAFFIN BATH THR
OT WC ULTRASOUND ADD 15

239940119.xlsx.ms_office

Price
367.00
92.00
184.00
275.00
367.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
367.00
184.00
367.00
550.00
733.00
916.00
733.00
184.00
733.00
916.00
1,099.00
916.00
1,099.00
184.00
367.00
367.00
184.00
184.00
367.00
184.00
184.00
367.00
184.00
184.00
184.00
184.00

$0 Indicator

S
S
S
S
S

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CDM #
2304343
2304350
2304368
2304582
2304590
2304608
2304616
2304640
2304665
2304673
2304681
2304699
2304723
2304731
2304749
2304756
2304764
2304772
2304798
2304806
2304814
2304822
2304830
2304848
2304855
2304863
2304871
2304889
2304897
2304905
2304913
2304921
2304939
2304947
2304954
2304962
2304970
2304988
2304996
2305001
2305019
2305027
2305035
2305043
2305050
2305068
2305076

CDM Description
OT WC ULTRASOUND INI 30
PT WC ULTRASOUND ADD 15
PT WC ULTRASOUND INI 30
OT WC COMP AS/EVL EST PAT
OT WC COMP AS/EVL NEW PAT
PT WC LTD AS/EVAL EST PAT
PT WC LTD AS/EVAL NEW PAT
PT WC TX JOINT MOBILIZATN
ST MC PREL EVAL SNF ICF
OT MC PREL EVAL SNF ICF
OT MC TREATMENT ADD 15
OT MC TREATMENT INI 30
PT DEBR SL SESSION 1ST 20
PT DEBR SL SESSION ADD 20
PT DEBR SL SESS EA 15 NC
OT DEBR SL SESSION 1ST 20
OT DEBR SL SESSION ADD 20
OT DEBR SL SESS EA 15 NC
PT WC EXERCISE THR ADD 15
PT WC EXERCISE THR INI 30
PT WC FUNC ACTVTY ADD 15
PT WC FUNC ACTVTY INI 30
PT WC NEUROMSCL ED ADD 15
PT WC NEUROMSCL ED INI 30
PT WC OR/PRS/ADL CK ADD15
PT WC OR/PRS/ADL CK INI30
PT WC ORTHOTIC TRN ADD 15
PT WC ORTHOTIC TRN INI 30
PT WC PROSTHC TRN ADD 15
PT WC PROSTHC TRN INI 30
PT WC THR ACTIVITY ADD 15
PT WC THR ACTIVITY INI 30
PT WC TREATMENT TAPING
PT WC TX FAB ORTH ADD 15
PT WC TX FAB ORTH INI 30
PT WC TX INDV INST ADD 15
PT WC TX INDV INST INI 30
PT WC TX SOFT TISS ADD 15
PT WC TX SOFT TISS INI 30
PT WND VAC SL DBR<50CM 75
PT WND VAC SL DBR<50CM 90
PT WND VAC SL DBR>50CM 75
PT WND VAC SL DBR>50CM 90
PT WC BRIEF ASSESS/EVAL
PT WC COMP AS/EVL EST PAT
PT WC COMP AS/EVL NEW PAT
PT WC EXT AS/EVAL EST PAT

239940119.xlsx.ms_office

Price
367.00
184.00
367.00
733.00
1,099.00
184.00
367.00
184.00
733.00
733.00
184.00
367.00
550.00
367.00
550.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
916.00
1,099.00
916.00
1,099.00
184.00
733.00
1,099.00
550.00

$0 Indicator

Page 44 of 299

CDM #
2305084
2305092
2305100
2305118
2305126
2305134
2305142
2305159
2305167
2305175
2305183
2305191
2305209
2305217
2305225
2305233
2305241
2305258
2305266
2305274
2305282
2305290
2305308
2305316
2305324
2305332
2305340
2305357
2305365
2305373
2305381
2305399
2305407
2305415
2400018
2400026
2400034
2400042
2400059
2400067
2400075
2400083
2400281
2400398
2400422
2400430
2400455

CDM Description
PT WC EXT AS/EVAL NEW PAT
PT WC INT AS/EVAL EST PAT
PT WC INT AS/EVAL NEW PAT
OT WC EXERCISE THR ADD 15
OT WC EXERCISE THR INI 30
OT WC FUNC ACTVTY ADD 15
OT WC FUNC ACTVTY INI 30
OT WC NEUROMSCL ED ADD 15
OT WC NEUROMSCL ED INI 30
OT WC OR/PRS/ADL CK ADD15
OT WC OR/PRS/ADL CK INI30
OT WC ORTHOTIC TRN ADD 15
OT WC ORTHOTIC TRN INI 30
OT WC PROSTHC TRN ADD 15
OT WC PROSTHC TRN INI 30
OT WC THR ACTIVITY ADD 15
OT WC THR ACTIVITY INI 30
OT WC TRAINING ADL ADD 15
OT WC TRAINING ADL INI 30
OT WC TREATMENT TAPING
OT WC TX FAB ORTH ADD 15
OT WC TX FAB ORTH INI 30
OT WC TX INDV INST ADD 15
OT WC TX INDV INST INI 30
OT WC TX JOINT MOBILIZATN
OT WC TX SOFT TISS ADD 15
OT WC TX SOFT TISS INI 30
OT WC EXT AS/EVAL EST PAT
OT WC EXT AS/EVAL NEW PAT
OT WC INT AS/EVAL EST PAT
OT WC INT AS/EVAL NEW PAT
OT WC LTD AS/EVAL EST PAT
OT WC LTD AS/EVAL NEW PAT
OT WC BRIEF ASSESS/EVAL
PT EVALUATION 15
PT EVALUATION 30
PT EVALUATION 45
PT EVALUATION 60
PT RE-EVALUATION 15
PT RE-EVALUATION 30
PT RE-EVALUATION 45
PT RE-EVALUATION 60
PT CONTRAST BATH EA 15
PT DVL COGNT SKILL EA 15
PT E-STIM ATTEND EA 15
PT E-STIM UNATTENDED OTHR
PT EXERCISE THR EA 15

239940119.xlsx.ms_office

Price
733.00
367.00
550.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
367.00
550.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
184.00
184.00
184.00
184.00
184.00

$0 Indicator

Page 45 of 299

CDM #
2400471
2400489
2400497
2400505
2400513
2400521
2400547
2400554
2400562
2400570
2400588
2400596
2400604
2400612
2400620
2400638
2400646
2400679
2400802
2400810
2400828
2400836
2401057
2401065
2401073
2401081
2401099
2401107
2401271
2401875
2401883
2401933
2401941
2401958
2401966
2401974
2401982
2401990
2402006
2402014
2402055
2402063
2402105
2402113
2402121
2402139
2402147

CDM Description
PT HUBBARD TANK EA 15
PT INFRARED THERAPY
PT IONTOPHORESIS EA 15
PT MANUAL THERAPY EA 15
PT MASSAGE EA 15
PT MMT BODY W HANDS
PT NEUROMSCL RE-ED EA 15
PT ORTH/PROSTH CK EA 15
PT ORTHOTIC FIT/TRN EA 15
PT PARAFFIN BATH THERAPY
PT PHYS PRF TEST EA 15
PT PROSTHETIC TRN EA 15
PT SELF CARE/HOME EA 15
PT SENSORY TECH EA 15
PT THR ACTIVITY EA 15
PT TRACTION MECHANICAL
PT ULTRASOUND EA 15
PT WHEELCHAIR TRN EA 15
PT APP SPLNT SHRT ARM STC
PT APP SPLNT SHRT ARM DYN
PT APP SPLINT FINGER STC
PT APP SPLINT FINGER DYN
PT PRE EMP TESTING
PT EMPLOYER CONSULT
PT MC EVALUATION INI 30
PT MC EVALUATION ADD 15
PT MC RE-EVAL INI 30
PT MC RE-EVAL ADD 15
PT MC CONFERENCE INI 30
PT MC THERAPY COMBO INI30
PT MC THERAPY COMBO ADD15
PT WC BRIEF ASSESS/EVAL
PT WC LTD AS/EVAL NEW PAT
PT WC INT AS/EVAL NEW PAT
PT WC EXT AS/EVAL NEW PAT
PT WC COMP AS/EVL NEW PAT
PT WC LTD AS/EVAL EST PAT
PT WC INT AS/EVAL EST PAT
PT WC EXT AS/EVAL EST PAT
PT WC COMP AS/EVL EST PAT
PT WC CONTRST BATH INI 30
PT WC CONTRST BATH ADD 15
PT WC E-STIM MNL INI 30
PT WC E-STIM MNL ADD 15
PT WC E-STIM UNATTENDED
PT WC EXERCISE THR INI 30
PT WC EXERCISE THR ADD 15

239940119.xlsx.ms_office

Price
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
367.00
367.00
367.00
367.00
367.00
184.00
367.00
184.00
367.00
367.00
184.00
184.00
367.00
550.00
733.00
1,099.00
184.00
367.00
550.00
733.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00

$0 Indicator

S
S

Page 46 of 299

CDM #
2402170
2402188
2402253
2402261
2402352
2402360
2402378
2402386
2402394
2402402
2402410
2402428
2402436
2402444
2402485
2402493
2402501
2402519
2402527
2402535
2402543
2402550
2402568
2402576
2402584
2402592
2402600
2402618
2402626
2402634
2402642
2402659
2402667
2402766
2402790
2402832
2402840
2402857
2402865
2402873
2402881
2402899
2402907
2402915
2402949
2402956
2402964

CDM Description
PT WC FUNC ACTVTY INI 30
PT WC FUNC ACTVTY ADD 15
PT WC IONTOPHORES INI 30
PT WC IONTOPHORES ADD 15
PT WC MYOFSCL RL/SFT TIS
PT WC NEUROMSCL ED INI 30
PT WC NEUROMSCL ED ADD 15
PT WC OR/PRS/ADL CK INI30
PT WC OR/PRS/ADL CK ADD15
PT WC ORTHOTIC TRN INI 30
PT WC ORTHOTIC TRN ADD 15
PT WC PARAFFIN BATH THR
PT WC PHYS PRF TST INI 30
PT WC PHYS PRF TST ADD 15
PT WC PROSTHC TRN INI 30
PT WC PROSTHC TRN ADD 15
PT WC THR ACTIVITY INI 30
PT WC THR ACTIVITY ADD 15
PT WC TRACTION MECHANICAL
PT WC TRACTN MANL INI 30
PT WC TRACTN MANL ADD 15
PT WC TRAINING ADL INI 30
PT WC TRAINING ADL ADD 15
PT WC TREATMENT TAPING
PT WC TX INDV INST INI 30
PT WC TX INDV INST ADD 15
PT WC TX JOINT MOBILIZATN
PT WC TX FAB ORTH INI 30
PT WC TX FAB ORTH ADD 15
PT WC TX SOFT TISS INI 30
PT WC TX SOFT TISS ADD 15
PT WC ULTRASOUND INI 30
PT WC ULTRASOUND ADD 15
PT IONTO PADS PER BX
PT CASE MANAGEMENT 15 NC
PT NON-CPT CLNT SRV 15 NC
PT NON-CPT INSTRUCT 15 NC
PT STROKE ACTIV CLASS
OT EVALUATION 15
OT EVALUATION 30
OT EVALUATION 45
OT EVALUATION 60
OT EVALUATION 75
OT EVALUATION 90
OT RE-EVALUATION 15
OT RE-EVALUATION 30
OT RE-EVALUATION 45

239940119.xlsx.ms_office

Price
367.00
184.00
367.00
184.00
367.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
229.00
184.00
367.00
550.00
733.00
916.00
1,099.00
184.00
367.00
550.00

$0 Indicator

S
S
S
S

Page 47 of 299

CDM #
2402972
2403178
2403186
2403293
2403327
2403335
2403350
2403392
2403400
2403426
2403434
2403442
2403459
2403467
2403475
2403483
2403491
2403509
2403525
2403541
2403558
2403616
2403624
2403632
2403673
2403715
2403731
2403749
2403871
2403889
2403913
2404119
2404127
2404135
2404143
2404150
2404168
2404234
2404242
2404291
2404309
2404317
2404325
2404333
2404341
2404390
2404408

CDM Description
OT RE-EVALUATION 60
OT COM/WORK REINT EA 15
OT CONTRAST BATH EA 15
OT DVL COGNT SKILL EA 15
OT E-STIM ATTEND EA 15
OT E-STIM UNATTENDED OTHR
OT EXERCISE THR EA 15
OT IONTOPHORESIS EA 15
OT MANUAL THERAPY EA 15
OT NEUROMSCL RE-ED EA 15
OT ORTH/PROSTH CK EA 15
OT ORTHOTIC FIT/TRN EA 15
OT PARAFFIN BATH THERAPY
OT PHYS PRF TEST EA 15
OT PROSTHETIC TRN EA 15
OT SELF CARE/HOME EA 15
OT SENSORY TECH EA 15
OT THR ACTIVITY EA 15
OT ULTRASOUND EA 15
OT VASOPNEUMATIC TX
OT WHEELCHAIR TRN EA 15
OT TEST NEUROBEHAVL EA HR
OT APP SPLNT SHRT ARM STC
OT APP SPLNT SHRT ARM DYN
CST VOLAR COCK UP
WRIST GAUNTLET
STATIC ELBOW SP
HFO WO JOINTS FA
OT MC EVALUATION INI 30
OT MC EVALUATION ADD 15
OT MC PHYS PRF TST INI 30
OT MC E-STIM ATTND INI 30
OT MC E-STIM ATTND ADD 15
OT MC E-STIM UNATT INI 30
OT MC E-STIM UNATT ADD 15
OT MC EXERCISE THR INI 30
OT MC EXERCISE THR ADD 15
OT MC IONTOPHORES INI 30
OT MC IONTOPHORES ADD 15
OT MC NEUROMSCL ED INI 30
OT MC NEUROMSCL ED ADD 15
OT MC ORTH/PROS CK INI 30
OT MC ORTH/PROS CK ADD 15
OT MC ORTH FIT/TRN INI 30
OT MC ORTH FIT/TRN ADD 15
OT MC SLF CARE/HME INI 30
OT MC SLF CARE/HME ADD 15

239940119.xlsx.ms_office

Price
733.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
733.00
367.00
367.00
76.00
136.00
210.00
126.00
367.00
184.00
367.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00

$0 Indicator

Page 48 of 299

CDM #
2404416
2404424
2404432
2404440
2404473
2404481
2404531
2404549
2404598
2404606
2404697
2404705
2404713
2404721
2404739
2404747
2404754
2404762
2404770
2404903
2404911
2404952
2404960
2404978
2404986
2404994
2405025
2405033
2405108
2405116
2405181
2405199
2405207
2405215
2405223
2405231
2405249
2405264
2405322
2405330
2405348
2405355
2405397
2405405
2405413
2405421
2405439

CDM Description
OT MC SENSORY TECH INI 30
OT MC SENSORY TECH ADD 15
OT MC THR ACTIVITY INI 30
OT MC THR ACTIVITY ADD 15
OT MC ULTRASOUND INI 30
OT MC ULTRASOUND ADD 15
OT MC WHEELCHR TRN INI 30
OT MC WHEELCHR TRN ADD 15
OT MC FAB SPLINT INI 30
OT MC FAB SPLINT ADD 15
OT WC BRIEF ASSESS/EVAL
OT WC LTD AS/EVAL NEW PAT
OT WC INT AS/EVAL NEW PAT
OT WC EXT AS/EVAL NEW PAT
OT WC COMP AS/EVL NEW PAT
OT WC LTD AS/EVAL EST PAT
OT WC INT AS/EVAL EST PAT
OT WC EXT AS/EVAL EST PAT
OT WC COMP AS/EVL EST PAT
OT WC CONTRST BATH INI 30
OT WC CONTRST BATH ADD 15
OT WC E-STIM MNL INI 30
OT WC E-STIM MNL ADD 15
OT WC E-STIM UNATTENDED
OT WC EXERCISE THR INI 30
OT WC EXERCISE THR ADD 15
OT WC FUNC ACTVTY INI 30
OT WC FUNC ACTVTY ADD 15
OT WC IONTOPHORES INI 30
OT WC IONTOPHORES ADD 15
OT WC MYOFSCL RL/SFT TIS
OT WC NEUROMSCL ED INI 30
OT WC NEUROMSCL ED ADD 15
OT WC OR/PRS/ADL CK INI30
OT WC OR/PRS/ADL CK ADD15
OT WC ORTHOTIC TRN INI 30
OT WC ORTHOTIC TRN ADD 15
OT WC PARAFFIN BATH THR
OT WC PROSTHC TRN INI 30
OT WC PROSTHC TRN ADD 15
OT WC THR ACTIVITY INI 30
OT WC THR ACTIVITY ADD 15
OT WC TRAINING ADL INI 30
OT WC TRAINING ADL ADD 15
OT WC TREATMENT TAPING
OT WC TX INDV INST INI 30
OT WC TX INDV INST ADD 15

239940119.xlsx.ms_office

Price
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
1,099.00
184.00
367.00
550.00
733.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
367.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00

$0 Indicator

Page 49 of 299

CDM #
2405447
2405454
2405462
2405470
2405488
2405496
2405504
2405629
2405660
2405678
2405686
2405694
2405702
2405710
2405728
2405736
2405876
2405884
2405892
2405900
2405918
2405926
2405934
2405942
2406080
2406122
2406130
2406148
2406155
2406163
2406171
2406189
2406478
2406486
2406510
2406619
2406650
2406668
2406692
2406734
2406783
2406882
2406908
2406916
2406932
2406940
2406957

CDM Description
OT WC TX JOINT MOBILIZATN
OT WC TX FAB ORTH INI 30
OT WC TX FAB ORTH ADD 15
OT WC TX SOFT TISS INI 30
OT WC TX SOFT TISS ADD 15
OT WC ULTRASOUND INI 30
OT WC ULTRASOUND ADD 15
OT CASE MANAGEMENT 15 NC
OT NON-CPT CLNT SRV 15 NC
OT NON-CPT INSTRUCT 15 NC
ST EVALUATION SPEECH 15
ST EVALUATION SPEECH 30
ST EVALUATION SPEECH 45
ST EVALUATION SPEECH 60
ST EVALUATION SPEECH 75
ST EVALUATION SPEECH 90
ST TREATMENT GROUP 15
ST TREATMENT GROUP 30
ST TREATMENT GROUP 45
ST TREATMENT GROUP 60
ST TREATMENT SPEECH 15
ST TREATMENT SPEECH 30
ST TREATMENT SPEECH 45
ST TREATMENT SPEECH 60
ST TEST NEUROBEHAVL EA HR
ST ASSESS APHASIA PER HR
ST CASE MANAGEMENT 15 NC
ST CONFERENCE 15 NC
ST EDUCATON PAT/FAM 15 NC
ST NON-CPT CLNT SRV 15 NC
ST NON-CPT INSTRUCT 15 NC
ST STROKE EDUCATION CL
PT L-CODE PRODUCTIV 15 NC
ELBOW ORTHO WO JOINTS CF
EWHO W JOINT(S) CF
WHO W NONTORSION JT(S) CF
HFO WO JOINTS CF
HAND ORTHO WO JOINTS CF
FINGR ORTHOSIS WO JTS CF
OT L-CODE PRODUCTIV 15 NC
FO PIP/DIP W JOINT FA
EWHO RIGID WO JTS CF
WHFO W JOINT(S) FA
HFO NONTORSN JOINT(S) FA
PT STUDENT PRODUCT/DAY NC
OT STUDENT PRODUCT/DAY NC
ST STUDENT PRODUCT/DAY NC

239940119.xlsx.ms_office

Price
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
916.00
1,099.00
92.00
184.00
275.00
367.00
184.00
367.00
550.00
733.00
733.00
733.00
539.00
2,532.00
1,850.00
506.00
506.00
398.00
200.00
2,391.00
750.00
275.00
-

$0 Indicator

S
S
S

S
S
S
S
S
S
S

S
S
S
Page 50 of 299

CDM #
2406965
2406973
2406981
2406999
2407005
2407013
2407021
2407054
2407062
2407070
2407088
2407096
2407104
2407112
2407120
2407138
2407146
2407153
2407161
2407179
2407187
2407195
2407203
2407211
2500015
2500023
2500031
2500049
2500056
2500064
2500072
2500080
2500171
2500189
2500197
2500205
2500213
2500221
2500239
2500247
2500429
2500437
2500452
2500494
2500502
2500510
2500544

CDM Description
ST FF ENDO EVAL W VID
ST FF ENDO EVAL SWAL VID
ST TREATMENT SWALLOW 75
ST TREATMENT SWALLOW 90
OT MC TREATMENT ADD 15
OT MC TREATMENT INI 30
NACL 0.9% IRRIGATION
SO CAP DESIGN WO JTS CF
EO 2 CUF ADJ LOCK ACTV CF
EO RIGID WO JOINTS FA
EWHFO W JOINT(S) CF
WHFO WO JOINT(S) FA
WHFO RIGID WO JOINTS FA
HINGE EXT FLEX WRST/FINGR
WRST COCK UP NONMOLDED FA
HFO FLEX GLOVE ELAST F FA
HFO W JOINT(S) CF
FO PIP/DIP WO JOINT FA
WHFO NONTORSN JOINT(S) FA
FO NONTORSION JOINT CF
STATIC AFO FA
PT CANALITH REPOSITIONING
OT GRP PRODUCTIVITY NC
OT STROKE ACTIV CLASS NC
PT EVALUATION 15
PT EVALUATION 30
PT EVALUATION 45
PT EVALUATION 60
PT RE-EVALUATION 15
PT RE-EVALUATION 30
PT RE-EVALUATION 45
PT RE-EVALUATION 60
PT THERAPY GROUP 15
PT THERAPY GROUP 30
PT THERAPY GROUP 45
PT THERAPY GROUP 60
PT THERAPY GROUP 75
PT THERAPY GROUP 90
PT THERAPY GROUP 105
PT THERAPY GROUP 120
PT E-STIM ATTEND EA 15
PT E-STIM UNATTENDED OTHR
PT EXERCISE THR EA 15
PT IONTOPHORESIS EA 15
PT MANUAL THERAPY EA 15
PT MASSAGE EA 15
PT NEUROMSCL RE-ED EA 15

239940119.xlsx.ms_office

Price
733.00
1,099.00
916.00
1,099.00
184.00
367.00
78.00
201.00
2,738.00
201.00
2,532.00
467.00
201.00
3,043.00
154.00
243.00
599.00
182.00
300.00
412.00
85.00
184.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
641.00
733.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00

$0 Indicator

S
S

Page 51 of 299

CDM #
2500551
2500569
2500577
2500593
2500627
2500635
2500643
2500866
2500874
2500882
2501070
2501211
2501674
2501682
2501732
2501740
2501757
2501765
2501773
2501781
2501799
2501807
2501815
2501823
2501831
2501856
2501864
2501906
2501914
2501922
2501930
2501948
2501971
2501989
2501997
2502052
2502060
2502151
2502185
2502193
2502227
2502300
2502318
2502326
2502334
2502342
2502359

CDM Description
PT ORTH/PROSTH CK EA 15
PT ORTHOTIC FIT/TRN EA 15
PT PARAFFIN BATH THERAPY
PT PROSTHETIC TRN EA 15
PT THR ACTIVITY EA 15
PT TRACTION MECHANICAL
PT ULTRASOUND EA 15
PT PRE EMP TESTING
PT MC EVALUATION INI 30
PT MC EVALUATION ADD 15
PT MC CONFERENCE INI 30
PT MC EXERCISE THR INI 30
PT MC THERAPY COMBO INI30
PT MC THERAPY COMBO ADD15
PT WC BRIEF ASSESS/EVAL
PT WC LTD AS/EVAL NEW PAT
PT WC INT AS/EVAL NEW PAT
PT WC EXT AS/EVAL NEW PAT
PT WC COMP AS/EVL NEW PAT
PT WC LTD AS/EVAL EST PAT
PT WC INT AS/EVAL EST PAT
PT WC EXT AS/EVAL EST PAT
PT WC COMP AS/EVL EST PAT
PT WC GRP EX<5PTS INI 30
PT WC GRP EX<5PTS ADD 15
PT WC CONTRST BATH INI 30
PT WC CONTRST BATH ADD 15
PT WC E-STIM MNL INI 30
PT WC E-STIM MNL ADD 15
PT WC E-STIM UNATTENDED
PT WC EXERCISE THR INI 30
PT WC EXERCISE THR ADD 15
PT WC FUNC ACTVTY INI 30
PT WC FUNC ACTVTY ADD 15
PT WC FUNC CAP MEASURMENT
PT WC IONTOPHORES INI 30
PT WC IONTOPHORES ADD 15
PT WC MYOFSCL RL/SFT TIS
PT WC OR/PRS/ADL CK INI30
PT WC OR/PRS/ADL CK ADD15
PT WC PARAFFIN BATH THR
PT WC THR ACTIVITY INI 30
PT WC THR ACTIVITY ADD 15
PT WC TRACTION MECHANICAL
PT WC TRACTN MANL INI 30
PT WC TRACTN MANL ADD 15
PT WC TRAINING ADL INI 30

239940119.xlsx.ms_office

Price
184.00
184.00
184.00
184.00
184.00
184.00
184.00
367.00
184.00
367.00
367.00
367.00
184.00
184.00
367.00
550.00
733.00
1,099.00
184.00
367.00
550.00
733.00
184.00
92.00
367.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
1,099.00
367.00
184.00
367.00
367.00
184.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00

$0 Indicator

Page 52 of 299

CDM #
2502367
2502375
2502383
2502391
2502409
2502433
2502441
2502458
2502466
2502573
2502607
2502631
2502649
2502656
2502664
2502672
2502698
2600013
2600021
2600039
2600047
2600054
2600062
2600070
2600088
2600179
2600187
2600195
2600203
2600211
2600229
2600237
2600245
2600435
2600450
2600500
2600542
2600583
2600617
2600625
2600864
2600872
2601060
2601664
2601672
2602589
2602621

CDM Description
PT WC TRAINING ADL ADD 15
PT WC TREATMENT TAPING
PT WC TX INDV INST INI 30
PT WC TX INDV INST ADD 15
PT WC TX JOINT MOBILIZATN
PT WC TX SOFT TISS INI 30
PT WC TX SOFT TISS ADD 15
PT WC ULTRASOUND INI 30
PT WC ULTRASOUND ADD 15
PT IONTO PADS PER BX
PT CASE MANAGEMENT 15 NC
PT EDUCATION PT/FAM 15 NC
PT NON-CPT CLNT SRV 15 NC
PT NON-CPT INSTRUCT 15 NC
PT EDUCATION CLASS
PT STUDENT PRODUCT/DAY NC
PT CANALITH REPOSITIONING
PT EVALUATION 15
PT EVALUATION 30
PT EVALUATION 45
PT EVALUATION 60
PT RE-EVALUATION 15
PT RE-EVALUATION 30
PT RE-EVALUATION 45
PT RE-EVALUATION 60
PT THERAPY GROUP 15
PT THERAPY GROUP 30
PT THERAPY GROUP 45
PT THERAPY GROUP 60
PT THERAPY GROUP 75
PT THERAPY GROUP 90
PT THERAPY GROUP 105
PT THERAPY GROUP 120
PT E-STIM UNATTENDED OTHR
PT EXERCISE THR EA 15
PT MANUAL THERAPY EA 15
PT NEUROMSCL RE-ED EA 15
PT PHYS PRF TEST EA 15
PT SENSORY TECH EA 15
PT THR ACTIVITY EA 15
PT MC EVALUATION INI 30
PT MC EVALUATION ADD 15
PT MC CONFERENCE INI 30
PT MC THERAPY COMBO INI30
PT MC THERAPY COMBO ADD15
PT CASE MANAGEMENT 15 NC
PT NON-CPT CLNT SRV 15 NC

239940119.xlsx.ms_office

Price
184.00
184.00
367.00
184.00
184.00
367.00
184.00
367.00
184.00
229.00
184.00
184.00
367.00
550.00
733.00
184.00
367.00
550.00
733.00
92.00
184.00
275.00
367.00
458.00
550.00
641.00
733.00
184.00
184.00
184.00
184.00
184.00
184.00
184.00
367.00
184.00
367.00
367.00
184.00
-

$0 Indicator

S
S
S
S
S
S

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Page 53 of 299

CDM #
2602639
2602647
2602654
2602662
2602670
2602688
2602696
2602704
2602712
2602720
2602860
2602878
2602886
2602894
2602902
2602910
2602928
2602936
2602969
2603140
2603215
2603272
2603298
2603421
2603439
2603702
2603710
2603942
2603959
2605095
2605137
2605145
2605152
2605160
2605178
2605186
2605194
2605202
2605210
2605376
2605384
2605392
2605400
2605418
2605426
2605434
2605442

CDM Description
PT NON-CPT INSTRUCT 15 NC
PT GRP THER PROD
OT EVALUATION 15
OT EVALUATION 30
OT EVALUATION 45
OT EVALUATION 60
OT EVALUATION 75
OT EVALUATION 90
OT EVALUATION 105
OT EVALUATION 120
OT THERAPY GROUP 15
OT THERAPY GROUP 30
OT THERAPY GROUP 45
OT THERAPY GROUP 60
OT THERAPY GROUP 75
OT THERAPY GROUP 90
OT THERAPY GROUP 105
OT THERAPY GROUP 120
OT COM/WORK REINT EA 15
OT EXERCISE THR EA 15
OT NEUROMSCL RE-ED EA 15
OT SELF CARE/HOME EA 15
OT THR ACTIVITY EA 15
OT MC EVALUATION INI 30
OT MC EVALUATION ADD 15
OT MC EXERCISE THR INI 30
OT MC EXERCISE THR ADD 15
OT MC SLF CARE/HME INI 30
OT MC SLF CARE/HME ADD 15
OT CASE MANAGEMENT 15 NC
OT NON-CPT CLNT SRV 15 NC
OT NON-CPT INSTRUCT 15 NC
OT GRP PRODUCTIVITY
ST EVALUATION SPEECH 15
ST EVALUATION SPEECH 30
ST EVALUATION SPEECH 45
ST EVALUATION SPEECH 60
ST EVALUATION SPEECH 75
ST EVALUATION SPEECH 90
ST TREATMENT GROUP 15
ST TREATMENT GROUP 30
ST TREATMENT GROUP 45
ST TREATMENT GROUP 60
ST TREATMENT SPEECH 15
ST TREATMENT SPEECH 30
ST TREATMENT SPEECH 45
ST TREATMENT SPEECH 60

239940119.xlsx.ms_office

Price
184.00
367.00
550.00
733.00
916.00
1,099.00
1,282.00
1,465.00
92.00
184.00
275.00
367.00
458.00
550.00
641.00
733.00
184.00
184.00
184.00
184.00
184.00
367.00
184.00
367.00
184.00
367.00
184.00
184.00
367.00
550.00
733.00
916.00
1,099.00
92.00
184.00
275.00
367.00
184.00
367.00
550.00
733.00

$0 Indicator
S
S

S
S
S
S

Page 54 of 299

CDM #
2605640
2605657
2605665
2605673
2605681
2605699
2605707
2605715
2605723
2605731
2605749
2605756
2605764
2605772
2605780
2605798
2605806
2605814
2605822
2605830
2605848
2605855
2605863
2605871
2605889
2605897
2605905
2605913
2605921
2605939
2605947
2605954
2605962
2605970
2605988
2605996
2606002
2606010
2606028
2606044
2701290
2701308
2701316
2701324
2701357
2701365
2701373

CDM Description
ST CASE MANAGEMENT 15 NC
ST CONFERENCE 15 NC
ST EDUCATON PAT/FAM 15 NC
ST NON-CPT CLNT SRV 15 NC
ST NON-CPT INSTRUCT 15 NC
ST G GP THER PROD
ST TREATMENT GROUP 75
ST TREATMENT GROUP 90
ST TREATMENT GROUP 105
ST TREATMENT GROUP 120
ST TREATMENT GROUP 135
ST TREATMENT GROUP 150
ST TREATMENT GROUP 165
ST TREATMENT GROUP 180
ST TREATMENT GROUP 195
ST TREATMENT GROUP 210
ST TREATMENT GROUP 225
ST TREATMENT GROUP 240
ST TREATMENT SPEECH 75
ST TREATMENT SPEECH 90
ST TREATMENT SPEECH 105
ST TREATMENT SPEECH 120
ST TREATMENT SPEECH 135
ST TREATMENT SPEECH 150
ST TREATMENT SPEECH 165
ST TREATMENT SPEECH 180
ST TREATMENT SPEECH 195
ST TREATMENT SPEECH 210
ST TREATMENT SPEECH 225
ST TREATMENT SPEECH 240
PT STUDENT PRODUCT/DAY NC
OT STUDENT PRODUCT/DAY NC
ST STUDENT PRODUCT/DAY NC
OT APP SPLNT SHRT ARM DYN
OT APP SPLNT SHRT ARM STC
ST TREATMENT SWALLOW 75
ST TREATMENT SWALLOW 90
OT MC TREATMENT ADD 15
OT MC TREATMENT INI 30
PT CANALITH REPOSITIONING
SOL 50 D5W
SOL 1000 D5 1/4 NS/20KCL
SOL 100 D5W
NACL 0.9% 100ML PB
SOL 500 DEXTRAN 40 NS GL
SOL 500 DEXTRAN 40 5D GL
SOL 500 D5 LACT RINGERS

239940119.xlsx.ms_office

Price
458.00
550.00
641.00
733.00
824.00
916.00
1,007.00
1,099.00
1,190.00
1,282.00
1,373.00
1,465.00
916.00
1,099.00
1,282.00
1,465.00
1,648.00
1,831.00
2,014.00
2,197.00
2,380.00
2,563.00
2,746.00
2,929.00
367.00
367.00
916.00
1,099.00
184.00
367.00
184.00
78.00
78.00
78.00
78.00
95.00
95.00
78.00

$0 Indicator
S
S
S
S
S
S

S
S
S

Page 55 of 299

CDM #
2701381
2701399
2701407
2701423
2701449
2701456
2701464
2701472
2701480
2701498
2701506
2701514
2701522
2701555
2701563
2701571
2701589
2701597
2701605
2701613
2701621
2701639
2701647
2706844
2706851
2706919
2706927
2706935
2706943
2706950
2706968
2706976
2706984
2706992
2707008
2707016
2707024
2707032
2707040
2707057
2707065
2707073
2707081
2707099
2707107
2707115
2707123

CDM Description
D5% RINGERS 1000ML INJ
LACTATED RINGERS 500ML
LACTATED RINGERS 1000ML
SOL 250 FAT EMUL 20 GL
NACL 0.9% 500ML INJ
NACL 0.9% 1000ML INJ
D5% 0.9 NACL 1000ML INJ
SOL 1000 1/2 NS
SOL 500 1/2 NS
SOL 500 D5 1/4
SOL 1000 D5 1/4 NS
SOL 500 D5 1/2 NS
SOL 1000 D5 1/2 NS
SOL 500 D5/W
NACL 0.9% 250ML INJ
D5% 250ML INJ
D5% 1000ML INJ
SOL 1000 D5 1/2NS 20KCL
SOL 1000 D5 1/2NS 30KCL
SOL 1000 D5 1/2NS 40KCL
SOL 50 NS
SOL 250 D10/H20 GL
SOL IV D5W NS 20KCL
HALO CERV VEST 2714X-3529
HALO MRI COMPAT 949X-1234
ORTHO L0140 30X-39
ORTHO L0172 88X-115
ORTHO L0172 115X-150
ORTHO L0174 254X-331
ORTHO L0180 254X-331
ORTHO L0190 331X-431
ORTHO L0200 431X-561
ORTHO L0464 730X-949
ORTHO L0472 431X-561
ORTHO L0482 949X-1234
ORTHO L0486 1234X-1605
ORTHO L0486 1605X-2087
ORTHO L0488 1605X-2087
ORTHO L0627 331X-431
ORTHO L0627 254X-331
ORTHO L0637 949X-1234
ORTHO L0640 949X-1234
ORTHO L0861 150X-195
ORTHO L0982 10-13
ORTHO L0984 39X-51
ORTHO L0984 51X-67
ORTHO L0999 51X-67

239940119.xlsx.ms_office

Price
78.00
78.00
78.00
262.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
17.00
17,645.00
6,170.00
195.00
575.00
750.00
1,655.00
1,655.00
2,155.00
2,805.00
4,745.00
2,805.00
6,170.00
8,025.00
10,435.00
10,435.00
2,155.00
1,655.00
6,170.00
6,170.00
975.00
65.00
255.00
335.00
335.00

$0 Indicator

Page 56 of 299

CDM #
2707131
2707149
2707156
2707172
2707180
2707198
2707206
2707214
2707222
2707230
2707248
2707255
2707263
2707271
2707289
2707297
2707305
2707313
2707321
2707339
2707347
2707354
2707362
2707370
2707388
2707396
2707404
2707412
2707420
2707438
2707446
2707453
2707461
2707479
2707487
2707495
2707503
2707529
2707537
2707545
2707552
2707560
2707578
2707586
2707594
2707602
2707610

CDM Description
ORTHO L0999 150X-195
ORTHO L0999 331X-431
ORTHO L1686 730X-949
ORTHO L1820 115X-150
ORTHO L1830 67X-88
ORTHO L1832 431X-561
ORTHO L1832 561X-730
ORTHO L1902 51X-67
ORTHO L1902 67X-88
ORTHO L1906 88X-115
ORTHO L1906 115X-150
ORTHO L1930 150X-195
ORTHO L1930 195X-254
ORTHO L1930 254X-331
ORTHO L1960 431X-561
ORTHO L1960 561X-730
ORTHO L1970 431X-561
ORTHO L1970 561X-730
ORTHO L1990 331X-431
ORTHO L1990 431X-561
ORTHO L2200 30X-39
ORTHO L2210 51X-67
ORTHO L2210 67X-88
ORTHO L2220 67X-88
ORTHO L2220 51X-67
ORTHO L2260 150X-195
ORTHO L2265 88X-115
ORTHO L2270 39X-51
ORTHO L2270 51X-67
ORTHO L2275 88X-115
ORTHO L2275 115X-150
ORTHO L2360 39X-51
ORTHO L2360 51X-67
ORTHO L2540 431X-561
ORTHO L2610 254X-331
ORTHO L2620 254X-331
ORTHO L2624 254X-331
ORTHO L2780 51X-67
ORTHO L2785 30X-39
ORTHO L2820 67X-88
ORTHO L2820 88X-115
ORTHO L2840 23X-30
ORTHO L2999 39X-51
ORTHO L2999 67X-88
ORTHO L2999 88X-115
ORTHO L2999 254X-331
ORTHO L2999 730X-949

239940119.xlsx.ms_office

Price
975.00
2,155.00
4,745.00
750.00
440.00
2,805.00
3,650.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,805.00
3,650.00
2,805.00
3,650.00
2,155.00
2,805.00
195.00
335.00
440.00
440.00
335.00
975.00
575.00
255.00
335.00
575.00
750.00
255.00
335.00
2,805.00
1,655.00
1,655.00
1,655.00
335.00
195.00
440.00
575.00
150.00
255.00
440.00
575.00
1,655.00
4,745.00

$0 Indicator

Page 57 of 299

CDM #
2707628
2707636
2707644
2707651
2707669
2707677
2707685
2707693
2707701
2707719
2707727
2707735
2707743
2707750
2707768
2707776
2707784
2707792
2707800
2707818
2707826
2707834
2707842
2707859
2707867
2707875
2707883
2707891
2707909
2707917
2707925
2707933
2707941
2707958
2707966
2707974
2707982
2707990
2708006
2708014
2708089
2708097
2708105
2708113
2708121
2708139
2708147

CDM Description
ORTHO L2999 195X-254
ORTHO L3221 88X-115
ORTHO L3260 88X-115
ORTHO L3224 39X-51
ORTHO L3224 51X-67
ORTHO L3225 51X-67
ORTHO L3225 67X-88
ORTHO L3260 39X-51
ORTHO L3260 67X-88
ORTHO L3390 30X-39
ORTHO L3649 115X-150
ORTHO L3674 730X-949
ORTHO L3740 730X-949
ORTHO L3760 254X-331
ORTHO L3807 115X-150
ORTHO L3807 150X-195
ORTHO L3900 1234X-1605
ORTHO L3908 39X-51
ORTHO L3908 51X-67
ORTHO L3931 254X-331
ORTHO L3960 730X-949
ORTHO L3980 195X-254
ORTHO L3980 254X-331
ORTHO L3995 23X-30
ORTHO L3995 17X-23
ORTHO L3999 39X-51
ORTHO L3999 67X-88
ORTHO L3999 254X-331
ORTHO L4205 39X-51
ORTHO L4205 195X-254
ORTHO L4360 195X-254
ORTHO L4360 254X-331
ORTHO L4396 115X-150
ORTHO L5400 949X-1234
ORTHO L5673 431X-561
ORTHO L8300 67X-88
ORTHO L8400 13X-17
ORTHO L8420 13X-17
ORTHO L8440 30X-39
ORTHO L8470 10-13
IMMOBIL/BIND 10-13
IMMOBIL/BIND 13X-17
IMMOBIL/BIND 17X-23
IMMOBIL/BIND 23X-30
IMMOBIL/BIND 30X-39
IMMOBIL/BIND 39X-51
IMMOBIL/BIND 51X-67

239940119.xlsx.ms_office

Price
1,270.00
575.00
575.00
255.00
335.00
335.00
440.00
255.00
440.00
195.00
750.00
4,745.00
4,745.00
1,655.00
750.00
975.00
8,025.00
255.00
335.00
1,655.00
4,745.00
1,270.00
1,655.00
150.00
115.00
255.00
440.00
1,655.00
255.00
1,270.00
1,270.00
1,655.00
750.00
6,170.00
2,805.00
440.00
85.00
85.00
195.00
65.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00

$0 Indicator

Page 58 of 299

CDM #
2708154
2708162
2708170
2708188
2708196
2708204
2708212
2708220
2708238
2708246
2708253
2708261
2708279
2708287
2708295
2708303
2708311
2708329
2708337
2708345
2708352
2708360
2708378
2708386
2708394
2708402
2708410
2708428
2708436
2708444
2708451
2708469
2708477
2708485
2708493
2708501
2708519
2708527
2708535
2708543
2708550
2708568
2708576
2708584
2708592
2708600
2708618

CDM Description
IMMOBIL/BIND 67X-88
IMMOBIL/BIND 88X-115
INST/SUPP NONST 10-13
INST/SUPP NONST 13X-17
INST/SUPP NONST 17X-23
INST/SUPP NONST 23X-30
INST/SUPP NONST 30X-39
INST/SUPP NONST 39X-51
INST/SUPP NONST 67X-88
CATH BLN DIL NON 195X-254
CATH DIALYSIS ST 39X-51
CATH DIALYSIS ST 67X-88
CATH DIALYSIS ST 88X-115
CATH DIALYSIS ST 115X-150
CATH DIALYSIS ST 150X-195
CATH DRAINAGE 10-13
CATH DRAINAGE 13X-17
CATH DRAINAGE 17X-23
CATH DRAINAGE 23X-30
CATH DRAINAGE 30X-39
CATH DRAINAGE 39X-51
CATH DRAINAGE 51X-67
CATH DRAINAGE 67X-88
CATH DRAINAGE 88X-115
CATH DRAINAGE 115X-150
CATH DRAINAGE 150X-195
CATH DRAINAGE 195X-254
CATH DRAINAGE 254X-331
CATH DRAINAGE 331X-431
CATH DRAINAGE 1234X-1605
CATH GENERAL 51X-67
CATH GENERAL 195X-254
CATH GENERAL 431X-561
CATH GENERAL 730X-949
CATH GENERAL 949X-1234
CATH INF PERIPH 10-13
CATH INF PERIPH 13X-17
CATH INF PERIPH 17X-23
CATH INF PERIPH 23X-30
CATH INF PERIPH 30X-39
CATH INF PERIPH 39X-51
CATH INF PERIPH 51X-67
CATH INF PERIPH 67X-88
CATH INF PERIPH 88X-115
CATH INF PERIPH 115X-150
CATH INF PERIPH 150X-195
CATH INF PERIPH 195X-254

239940119.xlsx.ms_office

Price
440.00
575.00
65.00
85.00
115.00
150.00
195.00
255.00
440.00
1,270.00
255.00
440.00
575.00
750.00
975.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
8,025.00
335.00
1,270.00
2,805.00
4,745.00
6,170.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00

$0 Indicator

Page 59 of 299

CDM #
2708626
2708634
2708642
2708659
2708667
2708675
2708683
2708691
2708709
2708717
2708725
2708733
2708741
2708758
2708790
2708808
2708816
2708824
2708832
2708840
2708857
2708865
2708873
2708899
2708907
2708915
2708923
2708931
2708949
2708956
2708964
2708972
2708980
2708998
2709004
2709012
2709020
2709038
2709046
2709053
2709061
2709079
2709087
2709095
2709103
2709111
2709129

CDM Description
CATH INF PERIPH 254X-331
CATH INF PERIPH 331X-431
CATH PTA N LSR 88X-115
CATH PTA N LSR 115X-150
CATH SUPRAPUB/CY 10-13
CATH SUPRAPUB/CY 13X-17
CATH SUPRAPUB/CY 17X-23
CATH SUPRAPUB/CY 23X-30
CATH SUPRAPUB/CY 30X-39
CATH SUPRAPUB/CY 51X-67
CATH SUPRAPUB/CY 331X-431
CATH URETERAL 10-13
CATH URETERAL 23X-30
CATH URETERAL 51X-67
CUT/CAUT DEV 10-13
CUT/CAUT DEV 13X-17
CATH GENERAL 10-13
CATH GENERAL 13X-17
CATH GENERAL 23X-30
CATH GENERAL 30X-39
CATH GENERAL 39X-51
CATH GENERAL 150X-195
CATH GENERAL 561X-730
GUIDEWIRE 10-13
GUIDEWIRE 13X-17
GUIDEWIRE 17X-23
GUIDEWIRE 23X-30
GUIDEWIRE 30X-39
GUIDEWIRE 39X-51
GUIDEWIRE 51X-67
GUIDEWIRE 88X-115
GUIDEWIRE 115X-150
GUIDEWIRE 331X-431
INST/SUPP STERL 10-13
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30
INST/SUPP STERL 30X-39
INST/SUPP STERL 39X-51
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 115X-150
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INTRO SHTH GENRL 10-13
INTRO SHTH GENRL 17X-23

239940119.xlsx.ms_office

Price
1,655.00
2,155.00
575.00
750.00
65.00
85.00
115.00
150.00
195.00
335.00
2,155.00
65.00
150.00
335.00
65.00
85.00
65.00
85.00
150.00
195.00
255.00
975.00
3,650.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
575.00
750.00
2,155.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
65.00
115.00

$0 Indicator

Page 60 of 299

CDM #
2709137
2709145
2709152
2709228
2709236
2709244
2709251
2709269
2709277
2709285
2709293
2709301
2709319
2709327
2709335
2709343
2709350
2709368
2709376
2709384
2709392
2709400
2709418
2709426
2709434
2709442
2709459
2709467
2709475
2709483
2709491
2709509
2709533
2709541
2709558
2709566
2709574
2709582
2709590
2709608
2709657
2709665
2719623
2719631
2719649
2719656
2719664

CDM Description
INTRO SHTH GENRL 23X-30
INTRO SHTH GENRL 30X-39
INTRO SHTH GENRL 51X-67
KIT/PACK SURG 51X-67
KIT/PACK SURG 67X-88
KIT/PACK SURG 88X-115
KIT/PACK SURG 115X-150
KIT/PACK SURG 150X-195
KIT/PACK SURG 254X-331
KIT/PACK SURG 561X-730
CLOSURE EXTERN 17X-23
CLOSURE EXTERN 23X-30
TUBING/CONNECT 23X-30
TUBING/CONNECT 30X-39
TUBING/CONNECT 39X-51
TUBING/CONNECT 51X-67
TUBING/CONNECT 67X-88
TUBING/CONNECT 88X-115
TUBING/CONNECT 115X-150
TUBING/CONNECT 150X-195
ORTHO L0172 10-13
ORTHO L0172 13X-17
ORTHO L0172 17X-23
ORTHO L0172 23X-30
ORTHO L0172 51X-67
ORTHO L1832 51X-67
ORTHO L1832 115X-150
ORTHO L4386 23X-30
ORTHO L4386 30X-39
ORTHO L4386 39X-51
ORTHO L3650 30X-39
ORTHO L3650 39X-51
ORTHO L3908 10-13
LEAD PMKR TRN VDD150X-195
CATH DIALYSIS LT 39X-51
CATH INTRASPINE 17X-23
CLOSURE IMPLNT 10-13
CLOSURE IMPLNT 13X-17
CLOSURE IMPLNT 17X-23
CLOSURE IMPLNT 23X-30
CLOSURE IMPLNT 115X-150
PORT INDWELLING 254X-331
ORTHO L4396 39X-51
ORTHO L0120 13X-17
ORTHO L0120 17X-23
BENZOC/TETRA/BUT 2-2-14%
DIATRI MEG/NA 66-10 120ML

239940119.xlsx.ms_office

Price
150.00
195.00
335.00
335.00
440.00
575.00
750.00
975.00
1,655.00
3,650.00
115.00
150.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
65.00
85.00
115.00
150.00
335.00
335.00
750.00
150.00
195.00
255.00
195.00
255.00
65.00
975.00
255.00
115.00
65.00
85.00
115.00
150.00
750.00
1,655.00
255.00
85.00
115.00
9.00
80.00

$0 Indicator

Page 61 of 299

CDM #
2719714
2719722
2719730
2719748
2719755
2719771
2719789
2719797
2719805
2719813
2719821
2719839
2719847
2719854
2719862
2719870
2719888
2719896
2719904
2719912
2719920
2719938
2719946
2719953
2719961
2719979
2719987
2719995
2720001
2720019
2720027
2720035
2720043
2720050
2720068
2720076
2720084
2720092
2720118
2720126
2720134
2720167
2720175
2720183
2720191
2720209
2720217

CDM Description
WATER STERILE 250ML INJ
HEPARIN 1000U/ML 1ML INJ
LORAZEPAM 1MG/0.5ML PEDPO
BACITRACIN 0.94GM OINT
ZINC OXIDE 20% 56.7GM TOP
WITCH HAZEL (100) PAD
ACETIC ACID 0.25% 1000ML
D10% 1000ML INJ
D10% 250ML INJ
D10% 500ML INJ
HEPARIN 1000U/500ML NS PB
D5% 0.2 NACL 1000ML INJ
D5% 0.2 NACL+KCL20 1000ML
D5% 0.2 NACL 500ML INJ
D5% 0.45 NACL+KCL10 1000M
D5% 0.45 NACL+KCL30 1000M
D5% 0.45 NACL+KCL40 1000M
D5% 0.9 NACL+KCL20 1000ML
D5% 0.9 NACL 500ML INJ
D5%+KCL 20MEQ 1000ML INJ
D5%+KCL 40MEQ 1000ML INJ
D5% 0.2 NACL 250ML INJ
D5% 0.45 NACL 250ML INJ
D70% 1000ML INJ
D5% 0.45 NACL 1000ML INJ
DIALYSIS 1.5% 2000ML SOL
DIALYSIS 4.25% 2000ML SOL
AMINO ACID 10% 500ML IV
BALANCED SALT 500ML OP IR
GLYCINE 3000ML IRRIG
NACL 0.45% 1000ML INJ
NACL 0.45% 500ML INJ
NACL 0.9% 10ML INJ
NACL 0.9%+KCL 40 1000ML
NACL 0.9% 50ML PB
WATER STERILE 2000ML INJ
WATER STERILE 1000ML INJ
INFLUENZA VIRUS VACC 6-35
LOCM 300-399MG/ML IODINE
SODIUM PHOS ENEMA 133ML
LACTATED RINGRS 3000ML IR
CLOSURE IMPLNT 30X-39
CLOSURE IMPLNT 39X-51
CLOSURE IMPLNT 51X-67
CLOSURE IMPLNT 88X-115
LIDOCAINE 2% 15GM JELLY
INST/SUPP NONST 150X-195

239940119.xlsx.ms_office

Price
78.00
71.00
9.00
21.00
25.00
15.00
116.00
95.00
65.00
78.00
71.00
78.00
65.00
78.00
65.00
65.00
65.00
65.00
78.00
65.00
65.00
149.00
149.00
65.00
78.00
65.00
65.00
568.00
128.00
15.00
78.00
78.00
250.00
65.00
71.00
58.00
58.00
149.00
7.00
9.00
65.00
195.00
255.00
335.00
575.00
15.00
975.00

$0 Indicator

Page 62 of 299

CDM #
2720225
2720233
2720241
2720258
2720266
2720274
2720282
2720290
2720316
2720324
2720332
2720340
2720357
2720365
2720373
2720381
2720399
2720407
2720415
2720423
2720431
2720472
2720480
2720498
2720506
2720514
2720522
2720530
2720548
2720555
2720563
2720571
2720589
2720597
2720605
2720613
2720621
2720639
2720647
2720654
2720662
2720670
2720688
2720696
2720704
2720712
2720720

CDM Description
INST/SUPP NONST 115X-150
INST/SUPP NONST 88X-115
IMMOBIL/BIND 115X-150
IMMOBIL/BIND 150X-195
IMMOBIL/BIND 195X-254
IMMOBIL/BIND 254X-331
ORTHO L3650 115X-150
INST/SUPP STERL 254X-331
ORTHO L0631 561X-730
ORTHO L0630 88X-115
CATH DRAINAGE 431X-561
CATH DRAINAGE 561X-730
CATH DRAINAGE 730X-949
ORTHO L0628 67X-88
ORTHO L0628 88X-115
ORTHO L0628 115X-150
ORTHO L4396 67X-88
ORTHO L4396 51X-67
ORTHO L4396 88X-115
CATH GENERAL 88X-115
CATH GENERAL 115X-150
KIT/PACK SURG 331X-431
KIT/PACK SURG 431X-561
KIT/PACK SURG 195X-254
LEAD NOT SNG/DUAL 88X-115
ORTHO L3650 51X-67
ORTHO L3650 67X-88
ORTHO L3650 88X-115
ORTHO L1620 88X-115
ORTHO L1620 67X-88
ORTHO L1620 51X-67
ORTHO L2112 88X-115
ORTHO L2112 67X-88
ORTHO L2112 51X-67
ORTHO L2570 331X-431
ORTHO L1845 561X-730
ORTHO L2112 431X-561
ORTHO L5301 2714X-3529
ORTHO L5620 254X-331
ORTHO L5629 254X-331
ORTHO L5637 331X-431
ORTHO L5647 949X-1234
ORTHO L5673 561X-730
ORTHO L5685 88X-115
ORTHO L5910 254X-331
ORTHO L5940 431X-561
ORTHO L5972 331X-431

239940119.xlsx.ms_office

Price
750.00
575.00
750.00
975.00
1,270.00
1,655.00
750.00
1,655.00
3,650.00
575.00
2,805.00
3,650.00
4,745.00
440.00
575.00
750.00
440.00
335.00
575.00
575.00
750.00
2,155.00
2,805.00
1,270.00
575.00
335.00
440.00
575.00
575.00
440.00
335.00
575.00
440.00
335.00
2,155.00
3,650.00
2,805.00
17,645.00
1,655.00
1,655.00
2,155.00
6,170.00
3,650.00
575.00
1,655.00
2,805.00
2,155.00

$0 Indicator

Page 63 of 299

CDM #
2720738
2720753
2720761
2720779
2720787
2720795
2720803
2720811
2720829
2720837
2720845
2720852
2720860
2720878
2720886
2720894
2720902
2720910
2720928
2720936
2720944
2720951
2720969
2720977
2720985
2720993
2721009
2721017
2721025
2721033
2721041
2721058
2721066
2721074
2721082
2721090
2721108
2721116
2721124
2721132
2721140
2721157
2721165
2721173
2721181
2721199
2721207

CDM Description
ORTHO L5986 730X-949
ORTHO L8440 39X-51
ORTHO L1220 195X-254
ORTHO L0970 115X-150
ORTHO L5624 331X-431
ORTHO L5631 331X-431
ORTHO L5649 1605X-2087
ORTHO L5650 561X-730
ORTHO L5651 949X-1234
ORTHO L5671 561X-730
ORTHO L5321 3529X-4588
ORTHO L5920 431X-561
ORTHO L5950 561X-730
ORTHO L8430 23X-30
ORTHO L8480 10-13
INST/SUPP NONST 730X-949
INST/SUPP NONST 254X-331
ORTHO L3040 51X-67
ORTHO L3310 67X-88
ORTHO L1932 730X-949
ORTHO L3020 150X-195
ORTHO L4350 88X-115
ORTHO L2580 431X-561
ORTHO L2232 67X-88
ORTHO L2280 431X-561
ORTHO L1686 949X-1234
ORTHO L2622 331X-431
ORTHO L2380 115X-150
ORTHO L2080 331X-431
ORTHO L1940 431X-561
ORTHO L8460 67X-88
ORTHO L0472 331X-431
ORTHO L2999 150X-195
ORTHO L2999 115X-150
ORTHO L2999 331X-431
ORTHO L2999 431X-561
ORTHO L2220 88X-115
ORTHO L2220 115X-150
ORTHO L1210 254X-331
ORTHO L1210 331X-431
ORTHO L1210 195X-254
ORTHO L2780 67X-88
ORTHO L2780 88X-115
ORTHO L2810 88X-115
ORTHO L2810 115X-150
CATH INTRASPINE 195X-254
CATH INTRASPINE 254X-331

239940119.xlsx.ms_office

Price
4,745.00
255.00
1,270.00
750.00
2,155.00
2,155.00
10,435.00
3,650.00
6,170.00
3,650.00
22,940.00
2,805.00
3,650.00
150.00
65.00
4,745.00
1,655.00
335.00
440.00
4,745.00
975.00
575.00
2,805.00
440.00
2,805.00
6,170.00
2,155.00
750.00
2,155.00
2,805.00
440.00
2,155.00
975.00
750.00
2,155.00
2,805.00
575.00
750.00
1,655.00
2,155.00
1,270.00
440.00
575.00
575.00
750.00
1,270.00
1,655.00

$0 Indicator

Page 64 of 299

CDM #
2721215
2721223
2721280
2721314
2721330
2721363
2721371
2721397
2721405
2721413
2721421
2721439
2721447
2721454
2721462
2721470
2721496
2721504
2721512
2721520
2721538
2721546
2721553
2721561
2721579
2721587
2721595
2721603
2721611
2721629
2721637
2721645
2721652
2721660
2721678
2721686
2721694
2721702
2721710
2721728
2721736
2721744
2721819
2721827
2721835
2721843
2721850

CDM Description
CATH INTRASPINE 331X-431
CATH INTRASPINE 150X-195
ORTHO L5321 561X-730
ORTHO L5705 730X-949
ORTHO L5964 949X-1234
ORTHO L0700 2087X-2714
ORTHO L2375 115X-150
ORTHO L0200 561X-730
ORTHO L0200 331X-431
CATH DIALYSIS ST 195X-254
ORTHO L4631 254X-331
ORTHO L5961 254X-331
ORTHO L2830 88X-115
ORTHO L2830 67X-88
ORTHO L2830 115X-150
ORTHO L2830 150X-195
ORTHO L5450 331X-431
ORTHO L5535 1605X-2087
ORTHO L5684 51X-67
ORTHO L5688 67X-88
ORTHO L1685 1234X-1605
ORTHO L3215 88X-115
ORTHO L5000 431X-561
ORTHO L0710 2087X-2714
INST/SUPP STERL 331X-431
ORTHO L0174 67X-88
ORTHO L4386 115X-150
TUBING/CONNECT 195X-254
TUBING/CONNECT 254X-331
CATH INF PERIPH 431X-561
CATH INF PERIPH 561X-730
CLOSURE IMPL 150X-195
CUT/CAUT DEV 195X-254
KIT/PACK SURG 30X-39
CATH GENERAL 17X-23
ORTHO L4380 254X-331
ORTHO L0637 431X-561
ORTHO L0120 23X-30
ORTHO L5700 2714X-3529
ORTHO L2114 561X-730
CATH INF PERIPH 730X-949
ORTHO L5540 2087X-2714
ORTHO L5986 561X-730
ORTHO L8420 23X-30
ORTHO L8400 23X-30
ORTHO L8420 17X-23
ORTHO L4205 30X-39

239940119.xlsx.ms_office

Price
2,155.00
975.00
3,650.00
4,745.00
6,170.00
13,570.00
750.00
3,650.00
2,155.00
1,270.00
1,655.00
1,655.00
575.00
440.00
750.00
975.00
2,155.00
10,435.00
335.00
440.00
8,025.00
575.00
2,805.00
13,570.00
2,155.00
440.00
750.00
1,270.00
1,655.00
2,805.00
3,650.00
975.00
1,270.00
195.00
115.00
1,655.00
2,805.00
150.00
17,645.00
3,650.00
4,745.00
13,570.00
3,650.00
150.00
150.00
115.00
195.00

$0 Indicator

Page 65 of 299

CDM #
2721868
2721876
2721884
2721892
2721900
2721918
2721926
2721934
2721942
2721959
2721967
2721975
2721983
2721991
2722015
2722023
2722031
2722049
2722056
2722064
2722072
2722080
2722098
3000031
3000049
3000056
3000064
3000072
3000080
3000098
3000106
3000122
3000130
3000155
3000163
3000171
3000221
3000239
3000247
3000254
3000262
3000270
3000288
3000296
3000304
3000338
3000361

CDM Description
ORTHO L4002 67X-88
INTRO SHTH GENRL 39X-51
KIT/PACK SURG 23X-30
KIT/PACK SURG 39X-51
ORTHO L0174 39X-51
ORTHO L0625 13X-17
KIT/PACK SURG 1605X-2087
ORTHO L2850 51X-67
ORTHO L2840 30X-39
ORTHO L0636 1234X-1605
ORHTO L2320 195X-254
ORTHO L1810 88X-115
ORTHO L0464 1234X-1605
ORTHO L1220 254X-331
ORTHO L3807 195X-254
ORTHO L2340 431X-561
ORTHO L1050 88X-115
ORTHO L2250 331X-431
ORTHO L1846 1234X-1605
ORTHO L2755 115X-150
ORTHO L2768 115X-150
ORTHO L2795 88X-115
ORTHO L0172 331X-431
LEUKOCYTE COUNT FECAL
OCCULT BLOOD FECES QL
H-OCCULT BLOOD OTHER
PH BODY FLUID NOS
UA QL/SEMIQT RED SUB
SPECIFIC GRAVITY UR
UA AUTO W/MICRO
UA AUTO W/O MICRO
UA MICRO ONLY
OCC BLD FEC QL 3 SPEC
AG RBC NON ABO/RH EA
AB ID RBC EACH PANEL
COOMBS INDIRECT TITER
ABO
RH (D)
CROSSMATCH IMMED SPIN
CROSSMATCH AHG
RBC AB SCR
FFP THAWING EA UNIT
TRANSFUSION REACTION
COOMBS DIRECT
DRAW CLOT AND HOLD
ABO CORD BLOOD
COOMBS INDIRECT QL

239940119.xlsx.ms_office

Price
440.00
255.00
150.00
255.00
255.00
85.00
10,435.00
335.00
195.00
8,025.00
1,270.00
575.00
8,025.00
1,655.00
1,270.00
2,805.00
575.00
2,155.00
8,025.00
750.00
750.00
575.00
2,155.00
92.00
92.00
92.00
138.00
78.00
109.00
133.00
90.00
70.00
92.00
160.00
522.00
122.00
93.00
93.00
324.00
353.00
191.00
152.00
165.00
93.00
192.00

$0 Indicator

S
S

Page 66 of 299

CDM #
3000379
3000395
3000429
3000437
3000445
3000460
3000510
3000528
3000536
3000544
3000551
3000569
3000577
3000593
3000601
3000627
3000635
3000650
3000668
3000676
3000684
3000700
3000718
3000726
3000734
3000742
3000759
3000775
3000783
3000791
3000817
3000825
3000833
3000841
3000866
3000874
3000882
3000890
3000908
3000916
3000924
3000940
3000957
3000965
3000973
3000999
3001021

CDM Description
OSL-F-IRRAD BLD/PLTPH
AUTOLOGOUS PROC/STOR
FETAL HGB ROSETTE
P-FVLEIDN MOL DX ISOLATIO
P-FVLEIDN-ENZDIGEST M2
P-FVLEIDN DNA PROBE M5
P-FVLEIDN MOLDX SCAN PHY
P-FVLEIDN MOL DX INTRP/RP
PLATELET AGG EA AGENT
D-DIMER QN
P-MOLEC NUC AMPLI EA
HEPARIN ANTI-XA LMWH
1-PLATELET AGG ASPIRIN
P-ANTITHROMBIN III AC
CELL COUNT CSF
CBC W/AUTO DIFF
EOSINOPHIL ABSOL AUTO
SED RATE RBC NON AUTO
HEMATOCRIT SPUN
PARTIAL THROMBO TIME
FIBRINOGEN ACTIVITY
HGB F KLEIHAUER-BETKE
CBC AUTO W/O DIFF
BLEEDING TIME
PLATELET AUTO
RETICULOCYTE MANUAL
PROTHROMBIN TIME
FERN TEST
RETICULOCYTE AUTO
SMEAR NASAL EOS
HEMOGLOBIN
HEMATOCRIT
P-PROTEIN C ACTIVITY
DIFFERENTIAL REVIEW
P-PROTEIN S FUNCTIONAL
CRYSTAL ID LT MICROSC
LEUKOCYTE ABSOL AUTO
BLOOD SMEAR INTERP
PTT SUBSTITUTION
BLOOD SMEAR MAN DIFF
FDP/FSP AGGLUTIN SQ
SEMEN ANALYSIS & MOTLTY
SEMEN ANALYSIS COMP
CELL COUNT BODY FLUID
1-PLATELET AGG PLAVIX
HEPARIN NEUTRALIZ
P-ENA AB SMITH

239940119.xlsx.ms_office

Price
53.00
433.00
92.00
114.00
227.00
565.00
95.00
114.00
346.00
240.00
273.00
256.00
346.00
278.00
243.00
268.00
174.00
114.00
88.00
205.00
224.00
193.00
151.00
192.00
137.00
138.00
161.00
97.00
138.00
114.00
88.00
88.00
273.00
288.00
114.00
174.00
88.00
205.00
126.00
273.00
82.00
319.00
243.00
346.00
371.00
104.00

$0 Indicator

Page 67 of 299

CDM #
3001039
3001047
3001054
3001062
3001070
3001138
3001179
3001187
3001195
3001203
3001211
3001229
3001237
3001245
3001252
3001260
3001278
3001286
3001294
3001310
3001328
3001336
3001344
3001351
3001369
3001377
3001393
3001419
3001427
3001468
3001484
3001492
3001500
3001518
3001526
3001534
3001542
3001559
3001575
3001591
3001609
3001617
3001625
3001658
3001674
3001682
3001690

CDM Description
P-ENA AB RNP
P-ENA AB SSB
P-ENA AB SCREEN
P-ENA AB SM/RNP
P-ENA AB RIBOSOMAL P
PART AGG AB CRYPTO CSF
CONCENTRATION AFB
CULT BLOOD
CULT STOOL SALM/SHIG
CULT BACT UROGENITAL
CULT BODY FLUID
CULT RESPIRATORY
CULT NOSE/THROAT
CULT WOUND
CULTURE ANAEROBIC
CULT ANAEROBIC ID
CULT AEROBIC ID
CULT SCRN SINGLE ORG
CULT UR W/COLONY CNT
CULT FUNG SKIN/HR/NAIL
CULT FUNGUS OTHER
CULT FUNGUS BLOOD
CULT FUNGUS ID YEAST
CULTURE AFB/TB/MYCO
CULT MYCOBACTERIA ID
CULT TYP SEROLOGICAL
O&P CONCENT & ID
SUSCEPT MIC PER PLATE
SMEAR FUNGAL STAIN
SMEAR TRICHROME
CULTURE VIRUS HERPES
IF ADENOVIRUS AG
IF B PERTUSSIS AG
IF INFLUENZA B AG
IF LEGIONELLA AG
IF PARAINFLUENZA AG
IF RSV AG
EIA QL ROTAVIRUS AG
DIR PROBE NEISSERIA
SMEAR GRAM/GEIMSA
SMEAR INDIA INK
H-KOH PREP ANY TYPE
WET MOUNT SMEAR
CULT ENVIRONMENTAL NC
H-ANA TITER
H-ANA SCREEN
P-ENA AB SCL 70

239940119.xlsx.ms_office

Price
104.00
104.00
224.00
104.00
104.00
109.00
328.00
293.00
279.00
293.00
293.00
293.00
137.00
293.00
137.00
201.00
108.00
137.00
98.00
150.00
201.00
293.00
66.00
293.00
187.00
90.00
137.00
150.00
113.00
235.00
337.00
190.00
190.00
110.00
190.00
190.00
190.00
122.00
217.00
113.00
108.00
92.00
92.00
122.00
235.00
104.00

$0 Indicator

Page 68 of 299

CDM #
3001708
3001740
3001757
3002052
3002086
3002094
3002102
3002110
3002128
3002136
3002144
3002177
3002185
3002193
3002201
3002219
3002243
3002250
3002268
3002276
3002284
3002292
3002300
3002318
3002326
3002334
3002342
3002391
3002409
3002417
3002425
3002433
3002490
3002508
3002524
3002532
3002557
3002565
3002581
3002599
3002607
3002615
3002623
3002631
3002649
3002656
3002664

CDM Description
P-ENA AB SSA
H-IF HERPES TYPE 1 AG
I-H PYLORI AB
H-EIA QL ROTAVIRUS AG
H-IF B PERTUSSIS AG
H-IF PARAINFLUENZA AG
H-IF RSV AG
H-IF ADENOVIRUS AG
H-IF INFLUENZA B AG
P-ENA AB JO1
BLD CULTURE HOLD
IMMUNO SHIGA I
IMMUNO SHIGA II
P-ENA AB CHROMATIN
EIA QL RSV AG
H-IF LEGIONELLA AG
P-VARICELLA ZOSTER AB
P-MYCOPLASMA AB
P-IA CA 15-3 27-29
P-IA TUMOR AG CA 125
P-MICROSOMAL ANTIBODY
P-RUBEOLA AB
P-ASO TITER
P-THYROGLOBULIN AB
P-COMPLEMENT AG C3
P-COMPLEMENT AG C4
P-CMV AB IGM
IMMUNOASSAY STREP A
EIA QL MULTI AG
MONO TEST SCRN
HCG PREG QL
PREG URINE VISUAL
SKIN TEST TB INTRADRM
EIA QL C DIFF TOX AG
H-RUBELLA AB
H-SYPHIL VDRL/RPR QL
EIA QL INFLU A/B AG
H-STS RPR TITER
P-SEX HORMONE BIND GL
P-BETA2 MICROGLOB SER
P-BETA2 MICROGLOB UR
P-IGA
P-IGG
P-IGM
P-GAMMAGLOBULIN IGE
LACTOSE TOL 3 SPEC
P-PREALBUMIN

239940119.xlsx.ms_office

Price
104.00
95.00
187.00
122.00
190.00
190.00
190.00
190.00
110.00
104.00
52.00
52.00
104.00
190.00
190.00
224.00
274.00
274.00
287.00
224.00
236.00
205.00
236.00
201.00
201.00
301.00
122.00
122.00
141.00
209.00
209.00
118.00
201.00
122.00
122.00
328.00
136.00
310.00
236.00
236.00
132.00
132.00
132.00
201.00
402.00
209.00

$0 Indicator

Page 69 of 299

CDM #
3002672
3002680
3002698
3002706
3002714
3002722
3002748
3002755
3002771
3002789
3002797
3002805
3002813
3002821
3002839
3002847
3002854
3002862
3002870
3002888
3002896
3002904
3002912
3002920
3002938
3002946
3002953
3002961
3002979
3002987
3002995
3003001
3003043
3003068
3003209
3003233
3003241
3003266
3003282
3003290
3003316
3003332
3003340
3003357
3003365
3003373
3003381

CDM Description
TRANSFERRIN
P-CERULOPLASMIN
P-DHEA-S
P-HAPTOGLOBIN QN
P-HEMOGLOBIN A2
P-HEMOGLOBIN F
P-HOMOCYSTEINE
P-PROXYPHENE URINE
P-AFP SERUM
P-CYCLOSPORINE
O-G6PD ENZYME SCREEN
P-HEMOGLOBIN ELECTRO
P-LEAD BLD
P-OLIGOCLONAL BANDS
PTH-INTACT
1-PROGESTERONE
P-TESTOSTERONE TOTAL
P-IGG CSF
P-ALBUMIN CSF (NEPH)
P-ALBUMIN SER (NEPH)
P-IMMUNOFIXATION SER
P-IMMUNOFIXATION URIN
P-PROTEIN ELECTRO SER
P-PROT ELECT 24HR UR
P-PROTEIN ELECT URINE
P-ERYTHROPOIETIN
P-IA TUMOR AG CA 19-9
PTH-INTRAOP
HIV-1 AB RAPID
P-CARDIOLIPIN AB IGG
O-GIARDIA AG EIA
P-CARDIOLIPIN AB IGM
TOBRAMYCIN
MICROALBUMIN UR QN
THYROXINE TOTAL
H-THYROID HORMONE UPTKE
TRIIODOTHYRONINE TOT
PSA FREE
1-LIDOCAINE
P-CARCINOEMBRYONIC AG
DIPROPYL/VALPROIC ACID
P-TRIIODOTHYRONINE FR
ALBUMIN SERUM/PLASMA/BLD
PHENOBARBITAL
H-FOLIC ACID RBC
BILIRUBIN TOTAL
ELECTROLYTE PANEL

239940119.xlsx.ms_office

Price
288.00
288.00
288.00
288.00
236.00
236.00
354.00
288.00
236.00
354.00
236.00
403.00
201.00
402.00
327.00
288.00
288.00
132.00
132.00
132.00
451.00
451.00
398.00
398.00
398.00
398.00
301.00
327.00
346.00
273.00
285.00
273.00
346.00
118.00
144.00
125.00
144.00
354.00
346.00
313.00
293.00
184.00
73.00
301.00
189.00
215.00
282.00

$0 Indicator

Page 70 of 299

CDM #
3003399
3003407
3003415
3003423
3003431
3003449
3003456
3003464
3003472
3003480
3003498
3003506
3003514
3003522
3003530
3003548
3003555
3003563
3003571
3003597
3003613
3003621
3003639
3003647
3003654
3003670
3003688
3003696
3003712
3003720
3003738
3003746
3003753
3003761
3003779
3003787
3003795
3003803
3003845
3003852
3003860
3003878
3003894
3003902
3003910
3003928
3003936

CDM Description
1-TOBRAMYCIN
BASIC METABOLIC PANEL
CREATININE UR
HEPATIC FUNC PANEL
GGT/GGTP
OSMOLALITY BLOOD
OSMOLALITY URINE
SODIUM URINE
CPK MB ONLY
ACETONE/KETONES QN
ALCOHOL
H-VITAMIN B12
DIGOXIN
PHENYTOIN TOTAL
CALCIUM TOTAL
CHLORIDE BLOOD
SODIUM SERUM/BLD/PLASMA
POTASSIUM BLD
CARBON DIOXIDE
MAGNESIUM
CREATININE BLOOD
PROTEIN TL SERUM/BLD/PLAS
UREA NITROGEN BLOOD
URIC ACID BLOOD
AMMONIA
P-THYROGLOBULIN
B TYPE BNP
CPK TOTAL
GENTAMICIN
PHOSPHORUS
AMYLASE
LACTATE DEHYDRO (LDH)
AST/SGOT
ALT/SGPT
AMYLASE FLD
LDH FLD
SALICYLATE
GLUCOSE BLOOD
BILIRUBIN DIRECT
CHLORIDE URINE
CREATININE FLD
H-FOLIC ACID SERUM
MISC LAB OVERRIDE
H-PSA-SCREEN
PHOSPHORUS UR 24HR
AMYLASE UR 24HR
CREATININE UR 24HR

239940119.xlsx.ms_office

Price
346.00
493.00
190.00
492.00
190.00
132.00
132.00
141.00
420.00
121.00
274.00
224.00
369.00
301.00
174.00
73.00
73.00
139.00
73.00
185.00
73.00
73.00
73.00
150.00
285.00
236.00
347.00
220.00
346.00
73.00
243.00
190.00
73.00
73.00
243.00
190.00
301.00
139.00
73.00
139.00
190.00
189.00
346.00
190.00
243.00
190.00

$0 Indicator

Page 71 of 299

CDM #
3003944
3003951
3003969
3003977
3003985
3003993
3004009
3004033
3004041
3004066
3004074
3004082
3004090
3004108
3004124
3004132
3004140
3004173
3004181
3004207
3004215
3004223
3004231
3004249
3004256
3004264
3004272
3004280
3004298
3004314
3004322
3004348
3004355
3004363
3004371
3004389
3004397
3004405
3004439
3004454
3004462
3004470
3004488
3004504
3004512
3004538
3004546

CDM Description
SODIUM UR 24HR
POTASSIUM UR 24HR
CHLORIDE UR 24HR
PROTEIN UR 24HR
CALCIUM UR QN 24HR
GLUCOSE UR QN 24HR
UREA NITROGEN UR 24HR
CHOLESTEROL TOTAL
CREATININE CLEARANCE
IRON BINDING CAPACITY
LACTATE/LACTIC ACID
LITHIUM
TRIGLYCERIDES
LIPID PANEL
URIC ACID UR 24HR
P-EIA QL HBSAG
CHOLESTEROL HDL
H-CARBOXYHEMOGLOBIN
BLOOD GAS PH PCO2 PO2
CARBON MONOXIDE QN
H-THYROXINE FREE
H-PROSTATE SPEC AG
P-HEP B CORE AB IGM
P-HEP A AB IGM
H-LUTEINIZING HORMONE
H-FOLLICL STIM HORMON
H-PROLACTIN
P-ESTRADIOL
H-HEMOGLOBIN A1C
H-CORTISOL AM PM DRAW
H-THYROXINE TOTAL
H-THYROID STIM HORMON
H-FERRITIN
P-HEPATITIS C AB
P-HEP B SURFACE AB
P-HEPATITIS B CORE AB
IRON
UREA NITROGEN URINE
PROTEIN TOTAL OTHER
GLUCOSE BODY FLUID
SWEAT COLL IONTOPHOR
RENAL FUNCTION PANEL
SPEC GRAV NON URINE
AMYLASE UR
CALCIUM UR RAN/UNTIMED
GLUCOSE UR QN
PHOSPHORUS UR

239940119.xlsx.ms_office

Price
141.00
139.00
139.00
190.00
174.00
138.00
152.00
136.00
251.00
67.00
289.00
235.00
136.00
401.00
150.00
159.00
136.00
361.00
266.00
40.00
144.00
346.00
158.00
158.00
346.00
346.00
346.00
354.00
209.00
354.00
144.00
346.00
235.00
158.00
273.00
273.00
209.00
152.00
190.00
138.00
345.00
701.00
52.00
243.00
174.00
138.00
190.00

$0 Indicator

Page 72 of 299

CDM #
3004553
3004561
3004579
3004603
3004611
3004629
3004637
3004645
3004652
3004660
3004678
3004728
3004736
3004744
3004769
3004777
3004785
3004793
3004819
3004843
3004868
3004876
3004884
3004900
3004926
3004942
3004959
3004967
3004975
3004983
3004991
3005006
3005014
3005030
3005048
3005063
3005071
3005089
3005105
3005113
3005121
3005139
3005147
3005154
3005162
3005170
3005188

CDM Description
PROTEIN TOTAL URINE
URIC ACID UR
LIPASE
ACETAMINOPHEN
PHOSPHATASE ALKALINE
BLOOD GAS PH
GTT 1ST 3 SPEC
GTT ADD SPECIMEN
POTASSIUM UR
CARBAMAZEPINE TOTAL
THEOPHYLLINE
HCG PREG QN
MYOGLOBIN
TROPONIN QN
COMP METABOLIC PANEL
VANCOMYCIN RANDOM
VANCOMYCIN PEAK
VANCOMYCIN TROUGH
P-HIV-1/HIV-2 AB RAPI
ALBUMIN FLUID OTHER
P-ACUTE HEPATITIS PAN
0-CALCIUM IONIZED
FETAL FIBRONECTIN
GLUCOSE POST DOSE
P-HEP A AB TOTAL
P-C-PEPTIDE
P-TACROLIMUS (FK-506)
P-INSULIN TOTAL
GLUCOSE 2HR PP
CHOLEST LDL DIR MEAS
CRP HIGH SENSITIVITY
OSL-F-RBC AB ELUTION
OSL-F-ANTIBODY ID
OSL-A-G6PD ENZYME QN
OSL-F-COOMBS INDIRECT TIT
OSL-F-AG RBC NON ABO/RH E
OSL-F-PRETREAT ABSORP
OSL-F-RBC PRETREAT CHEMIC
OSL-A-POLIOVIRUS AB 1
OSL-F-RBC PRETREAT ENZYME
OSL-A-WEST NILE AB IGM
OSL-A-WEST NILE AB IGG
OSL-F-PLT XM TEST FEE
OSL-F-RARE CELL PANEL
OSL-F-RBC PRETREAT DENSIT
OSL-F-ALLOADSORPTION
OSL-F-AUTOADSORPTION

239940119.xlsx.ms_office

Price
190.00
150.00
238.00
274.00
73.00
189.00
402.00
138.00
139.00
328.00
328.00
312.00
419.00
420.00
983.00
354.00
354.00
354.00
346.00
184.00
624.00
240.00
595.00
138.00
273.00
301.00
346.00
288.00
138.00
209.00
294.00
184.00
242.00
15.07
263.00
26.00
84.00
105.00
43.23
105.00
14.25
14.25
158.00
315.00
368.00
89.00
84.00

$0 Indicator

Page 73 of 299

CDM #
3005196
3005204
3005220
3005238
3005253
3005261
3005279
3005287
3005295
3005303
3005311
3005352
3005378
3005386
3005394
3005402
3005410
3005428
3005436
3005444
3005451
3005469
3005477
3005485
3005493
3005501
3005519
3005527
3005535
3005543
3005550
3005576
3005584
3005592
3005600
3005618
3005626
3005634
3005642
3005659
3005667
3005675
3005691
3005709
3005717
3005725
3005733

CDM Description
OSL-F-RH PHENOTYPE COMPLE
OSL-A-HEMOSIDERIN QL
OSL-A-HISTOPLSMA MYCEL AB
OSL-F-HLA TYP MULT AG A/B
OSL-A-CRYOGLOBULIN QL/SQN
OSL-A-CRYOGLOBULIN QT IGA
OSL-F-PRETRT SER RBC ID I
OSL-8-BIOTINIDASE
OSL-8-TRYPSINOGEN
OSL-A-HEP C RNA QUANT
OSL-A-INS-LIKE GF I
OSL-A-LEUK ALK PHOS W/COU
OSL-A-HEMOGLOBIN PLASMA
OSL-A-FACTOR VIII VW AG
OSL-A-FACTOR V
OSL-A-FACTOR VII
OSL-A-FACTOR VIII AHG
OSL-A-FACTOR IX
OSL-A-FACTOR X
OSL-A-FACTR XIII SOLUBILI
OSL-A-ANTI PLAT AB-DIRECT
OSL-A-ANTI PLAT AB-INDIR
OSL-A-MYELIN BAS PROTEIN
OSL-A-SMOOTH MUS AB ACTIN
OSL-A-CITRATE
OSL-A-SICKLE CELL/HGB S
OSL-A-HEP-ASSOC-AB-DET
OSL-A-INSULIN-TOTAL
OSL-A-FREE INSULIN
OSL-A-MYCOPLASMA ABDY IGG
OSL-A-HETEROPHILE AB SCR
OSL-A-IGD
OSL-A-COCCIDIOIDES AB CF
OSL-A-ASPERGILLIS (CF)
OSL-A-ASPERGILLUS AB (ID)
OSL-A-INTRINSIC FACTOR AB
OSL-A-LEGIONELLA AB
OSL-A-F TULARENSIS AB
OSL-A-THIOCYANATE
OSL-A-AMITRIPTYLINE
OSL-A-CHOLINESTERASE RBC
OSL-A-CYSTINE QUANT URINE
OSL-A-OXALATE URINE
OSL-A-PROTEIN S TOTAL
OSL-A-VITAMIN C
OSL-A-ZINC URINE
OSL-A-AMINO ACID FRACT PL

239940119.xlsx.ms_office

Price
131.00
5.25
13.82
235.00
5.32
6.08
105.00
15.95
15.95
47.36
21.92
9.50
8.08
25.38
19.51
19.80
19.80
21.05
19.80
9.82
27.54
27.54
19.02
10.27
30.74
19.97
20.30
13.48
14.32
14.65
5.72
6.08
12.68
16.64
16.64
16.66
16.92
11.50
12.86
19.79
8.50
18.65
14.24
26.11
10.93
12.59
18.65

$0 Indicator

Page 74 of 299

CDM #
3005741
3005758
3005766
3005774
3005782
3005790
3005808
3005824
3005832
3005840
3005857
3005865
3005873
3005881
3005899
3005907
3005915
3005923
3005931
3005949
3005956
3005972
3005980
3005998
3006004
3006012
3006038
3006053
3006061
3006087
3006095
3006103
3006111
3006129
3006137
3006145
3006152
3006160
3006178
3006194
3006202
3006210
3006228
3006236
3006244
3006251
3006269

CDM Description
OSL-A-AMINO ACID QUANT UR
OSL-A-ANDROSTENEDIONE
OSL-A-LEAD URINE
OSL-A-DIGITOXIN
OSL-A-NUCLEOTIDASE 5
OSL-A-HYDROXYPROGEST 17-D
OSL-A-ASSAY FECES PORPHYR
OSL-A-ALDOSTERONE SERUM
OSL-A-MERCURY BLOOD
OSL-A-PHOSPHATASE ALK ISO
OSL-A-ARSENIC BLD
OSL-A-BROMIDES BLOOD
OSL-A-RENIN
OSL-A-VIP
OSL-A-NA PROBE HEP C AMP
OSL-A-ANTITHROMBIN III AG
OSL-A-CHOLINESTERASE SERU
OSL-A-PORPHYRINS UR QN&FR
OSL-A-ESTRIOL
OSL-A-COPPER BLOOD
OSL-A-COPPER 24 URINE
OSL-A-TOXOPLASMA AB IGG
OSL-A-TOXOPLASMA AB IGM
OSL-A-AMIODARONE
OSL-A-CULT VIRUS ID TISSU
OSL-A-CULT MYCO/UREAPLAS
OSL-A-ALLERGEN RAST(EACH)
OSL-A-COCCI ANTIBDY BY CF
OSL-A-VASOPRESSIN ADH
OSL-A-CHROMIUM
OSL-A-CLOMIPRAMINE
OSL-A-CLONAZEPAM QUANT
OSL-A-COMPLEMENT FACTOR B
OSL-A-CRYOFIBRINOGEN
OSL-A-CYCLIC AMP PLASMA
OSL-A-CYCLIC AMP 24URN
OSL-A-DIPHENHYDRAMINE
OSL-A-DOXEPIN
OSL-A-DRUG SCREEN BLOOD
OSL-A-FACTOR II
OSL-A-FENTANYL
OSL-A-FIBRINOGEN ANTIGEN
OSL-A-FLUORIDE
OSL-A-FLUOXETINE & METAB
OSL-A-FLURAZEPAM
OSL-A-GLUCAGON
OSL-A-H.FLU B AB IGG

239940119.xlsx.ms_office

Price
18.65
32.37
13.38
15.14
12.33
30.03
28.16
45.06
14.12
5.72
20.98
15.14
24.32
17.68
38.80
11.96
8.71
16.26
26.74
13.72
13.72
16.58
15.36
30.28
22.80
17.01
5.78
12.68
37.53
22.42
15.14
20.45
13.27
9.48
28.52
28.52
83.00
17.14
62.59
14.36
76.72
9.39
97.00
30.28
21.89
15.80
16.58

$0 Indicator

Page 75 of 299

CDM #
3006277
3006285
3006293
3006301
3006319
3006327
3006343
3006350
3006368
3006376
3006384
3006392
3006400
3006418
3006434
3006442
3006467
3006475
3006483
3006491
3006509
3006517
3006525
3006533
3006541
3006558
3006566
3006574
3006582
3006590
3006608
3006616
3006632
3006640
3006657
3006665
3006673
3006699
3006707
3006715
3006723
3006731
3006749
3006756
3006764
3006814
3006822

CDM Description
OSL-A-HEMOGLOBIN UR
OSL-A-HEP C AB CONFIRM
OSL-A-HEPATITIS DELTA AB
OSL-A-HISTAMINE WHL BLD
OSL-A-HISTAMINE URINE
OSL-A-HISTOPLASMA AB (ID)
OSL-A-IBUPROFEN
OSL-A-IGG SUBCLASS 1
OSL-A-IGG SUBCLASS 2
OSL-A-IGG SUBCLASS 3
OSL-A-IGG SUBCLASS 4
OSL-A-IMIPRAMINE
OSL-A-UA QL/SEMIQT
OSL-A-MUMPS AB
OSL-A-NEURONAL AB SERUM
OSL-A-OSTEOCALCIN
OSL-A-PANCREATIC POLYPPTD
OSL-A-PHENYLALANINE QUNT
OSL-A-PHENYTOIN FREE
OSL-A-PHOSPHOLIPIDS SERUM
OSL-A-PROINSULIN
OSL-A-RUBELLA AB IGM
OSL-A-RUBEOLA IGM(ELISA)
OSL-A-SELENIUM
OSL-A-SEROTONIN WHL BLD
OSL-A-ENCEPH ST LOUIS AB
OSL-A-STREPTOZYME SCRN
OSL-A-THALLIUM 24HR URN
OSL-ATHALLIUM BLOOD
OSL-A-TRYPSINOGEN
OSL-A-FACTOR VIII VW MULT
OSL-A-SEROTONIN SERUM
OSL-9-FLOCYT FIRST MARKER
OSL-A-THYROID STIM IMM GL
OSL-A-VITAMIN A
OSL-8-PHENYLALANINE PKU
OSL-A-MEXILETINE
OSL-A-HEP BE AB
OSL-A-EIA QL HBEAG
OSL-A-T CELLS CD4 CD8 RAT
OSL-A-CARNITINE TOT/FREE
OSL-A-T CELLS CD4 COUNT
OSL-A-CMV AB IGG
OSL-A-CMV AB IGM
OSL-A-DHEA
OSL-A-ENDOMYSIAL AB
OSL-A-ETHOSUXIMIDE

239940119.xlsx.ms_office

Price
4.36
17.12
18.98
32.65
32.65
13.82
15.14
8.87
8.87
8.87
8.87
19.03
2.40
14.42
74.77
17.68
14.94
18.65
29.88
7.60
19.70
15.36
14.25
28.22
34.25
14.58
11.26
22.37
22.37
14.94
25.38
34.25
362.00
56.22
12.82
12.84
15.14
12.78
12.74
93.64
18.65
29.60
15.36
18.62
27.94
10.27
18.06

$0 Indicator

Page 76 of 299

CDM #
3006830
3006848
3006863
3006905
3006921
3006939
3006954
3006962
3006970
3006988
3006996
3007002
3007010
3007028
3007044
3007051
3007069
3007077
3007085
3007101
3007119
3007127
3007135
3007143
3007150
3007184
3007192
3007200
3007218
3007226
3007234
3007242
3007259
3007309
3007317
3007325
3007333
3007408
3007424
3007432
3007440
3007457
3007465
3007481
3007515
3007523
3007531

CDM Description
OSL-A-FRUCTOSAMINE
OSL-A-GABAPENTIN
OSL-A-HTLV I/II AB CONF
OSL-A-HSV I/II COM AB IGG
OSL-A-MECONIUM DRUG PANEL
OSL-A-ORG ACIDS TOTAL QN
OSL-A-MYOGLOBIN
OSL-A-PORPHOBILINOGEN UR
OSL-A-CATECHOL URINE FREE
OSL-A-KETOSTEROIDS(17-KS)
OSL-A-HYDROXYCORTICO 17
OSL-A-STONE ANALYSIS
OSL-A-VMA UR 24HR
OSL-A-HYDROXYINDOL 5-HIAA
OSL-A-ANTI MYOCARDIAL AB
OSL-A-CALCITONIN
OSL-A-CATECHOL FRACT BLD
OSL-A-TOCAINIDE
OSL-4-METHOTREXATE (BR)
OSL-A-ZINC SERUM
OSL-A-TRYPSIN FECES QL
OSL-A-FAT LIPIDS FECES QN
OSL-A-FAT LIPIDS FECES QL
OSL-A-VIT D 1 25 DIHYDROX
OSL-MISCELLANEOUS
OSL-A-ANCA IGG TITER
OSL-A-COXSACKIE B AB(S)
OSL-A-COXIEL(QFEVER)ABIFA
OSL-A-INFLUENZA A ANTIBDY
OSL-A-INFLUENZA B ANTIBDY
OSL-A-COXSACKIE A9 AB(S)
OSL-A-OSMOLALITY STOOL
OSL-A-PROTEIN C AG
OSL-A-VISCOSITY
OSL-A-MERCURY URINE
OSL-A-RAJII CELL ASSAY
OSL-A-THYROID BIND GLOBUL
OSL-A-HSV I/II ABYS IGM
OSL-A-C PNEUMONIAE IGG
OSL-A-FTA SERUM
OSL-A-LYME DISEASE AB
OSL-A-MHA TP
OSL-A-DEOXYCORTISOL
OSL-A-ALPHA-1 ANTITRYP PH
OSL-A-ACETYLCHOLINE BLOK
OSL-A-ACTH
OSL-A-ADENOSINE DEAMINASE

239940119.xlsx.ms_office

Price
16.66
15.14
21.40
15.36
136.98
18.20
14.27
9.12
27.92
14.15
19.37
14.26
17.14
14.26
12.16
29.61
27.92
87.00
104.50
12.59
7.60
18.57
5.63
36.24
13.33
86.46
13.40
14.99
14.99
14.41
22.40
13.29
12.91
14.12
26.94
16.35
15.36
13.08
14.64
18.83
14.64
32.37
15.98
14.94
42.70
7.60

$0 Indicator

Page 77 of 299

CDM #
3007556
3007572
3007580
3007598
3007606
3007614
3007622
3007648
3007655
3007663
3007671
3007697
3007713
3007739
3007747
3007754
3007762
3007770
3007788
3007812
3007846
3007853
3007861
3007879
3007887
3007895
3007911
3007929
3007937
3007945
3007952
3007960
3007986
3007994
3008000
3008018
3008026
3008034
3008042
3008059
3008067
3008083
3008091
3008109
3008117
3008125
3008133

CDM Description
OSL-A-AB ADENOVIRUS IGM
OSL-A-ANTIHISTONE ANTIBDY
OSL-A-AMINOLEVULINIC ACID
OSL-A-ALBUMIN FLUID OTHER
OSL-A-ALDOLASE
OSL-A-ALDOSTERONE URINE
OSL-A-ALPRAZOLAM
OSL-A-ALUMINUM SERUM
OSL-A-CREATINE SERUM
OSL-A-ESTROGEN FRACTIONAT
OSL-A-HEMOGLOBIN SERUM
OSL-A-BLASTOMYCES AB CF
OSL-A-CPK ISOENZYME
OSL-A-CHLAMYDIA AB IGM
OSL-A-COMPLEMENT C5
OSL-A-CYANIDE
OSL-A-PARIETAL CELL AB IG
OSL-A-COMPLEMENT C2
OSL-A-RSV AB
OSL-A-HYDROXYPROLINE TOTA
OSL-A-ISLET CELL ANTIBODY
OSL-A-LEAD VENOUS BLD
OSL-A-BORRELIA AMP PROBE
OSL-A-LYME IGG WEST BLOT
OSL-A-VOLATILES ISOPROP A
OSL-A-N-TELOPEP XLINK UR
OSL-A-PARVOVIRUS AB
OSL-A-TOT AMYLASE ISO
OSL-A-ACETYLCHOL BINDG AB
OSL-A-CA ENCEP ANTIBY IGG
OSL-A-ANTI-STRIAT MSCL AB
OSL-A-VITAMIN B-12 BIND C
OSL-A-BILE ACIDS
OSL-A-BRUCELLA AB IGG
OSL-A-COMPLEMENT C1
OSL-A-C1ESTERASE INHB FX
OSL-A-C1ESTERASE INHIB
OSL-A-FIBRINO PLAS NON-AG
OSL-A-PORPHYRIN TOTAL
OSL-A-PYRUVATE
OSL-A-RETINOL BINDING
OSL-A-ROCKYMTN FEVER ABS
OSL-8-GALACTOSE TRANSFER
OSL-8-HEMOGLOBIN FRACT CH
OSL-8-HYDROXYPROGEST 17-D
OSL-8-THYROID STIM HORMON
OSL-8-MASS SPEC ANLYTE NO

239940119.xlsx.ms_office

Price
14.23
10.27
18.20
2.83
10.74
45.06
20.45
28.18
65.25
35.71
7.60
14.26
14.81
42.12
13.27
21.45
12.16
13.27
10.27
26.87
18.38
13.38
38.80
17.12
17.77
20.50
33.24
7.17
14.94
14.58
12.16
15.84
18.94
9.76
124.30
13.27
13.27
6.12
7.60
12.01
15.03
42.80
15.95
15.95
15.95
15.95
16.00

$0 Indicator

Page 78 of 299

CDM #
3008141
3008158
3008166
3008208
3008216
3008224
3008232
3008240
3008265
3008281
3008299
3008307
3008315
3008323
3008331
3008356
3008364
3008372
3008380
3008406
3008422
3008430
3008448
3008471
3008513
3008521
3008539
3008554
3008562
3008570
3008596
3008604
3008612
3008620
3008638
3008646
3008653
3008661
3008679
3008687
3008711
3008737
3008745
3008752
3008760
3008778
3008786

CDM Description
OSL-A-FLECAINIDE
OSL-A-CARNITINE FREE
OSL-A-CAFFEINE (VIVARIN)
OSL-A-PHOSPHATASE ACID
OSL-A-ENCEPH WEST EQUINE
OSL-A-LEPTOSPIRA AB
OSL-A-ECHO VIRUS AB 6
OSL-A-DIHDROXYTEST (DHT)
OSL-A-CIQ IMM CX BINDING
OSL-4-AMPHETAMINE CONFIRM
OSL-4-TRICYCLIC CONFIRM
OSL-4-OPIATE CONFIRM
OSL-A-COMP TOTAL CH50
OSL-A-GASTRIN
OSL-A-SYPHIL VDRL/RPR QL
OSL-A-IA CA 15-3 27-29
OSL-A-IF PNEUMOCYSTIS AG
OSL-A-IF VARICLLA-ZOSTR A
OSL-A-PRIMIDONE
OSL-A-ANGIOTENSIN I CON E
OSL-A-SUGARS SINGLE QL
OSL-A-BHCG TUMOR MARKER
OSL-A-ALPHA-1 ANTITRYP TO
OSL-A-EIA QL HBSAG NEUT
OSL-A-HEP C GENOTYPE
OSL-A-CORTISOL FREE
OSL-A-APO E CARD RISK
OSL-A-T. CANDIDUS
OSL-A-H PYLORI AB IGG
OSL-A-CARDIOLIPIN AB IGG
OSL-A-NORTRIPTYLINE
OSL-A-LAMOTRIGINE
OSL-A-HLA TYP SNGL AB A/B
OSL-A-HEP C RNA QNT BDNA
OSL-A-RETICULIN AB IGG
OSL-A-VITAMIN E
OSL-A-CHROMOGRANIN A
OSL-A-HOMOVANILLIC ACID
OSL-A-HEP B PCR QN
OSL-A-DISOPYRAMIDE
OSL-A-CAROTENE
OSL-A-BACTERICIDAL TITER
OSL-A-CHLAMY-CTAMD
OSL-A-INFLUENZA A IGG
OSL-A-INFLUENZA A IGM
OSL-A-INFLUENZA B IGG
OSL-A-INFLUENZA B IGM

239940119.xlsx.ms_office

Price
15.14
19.97
15.14
7.60
14.58
12.43
14.41
28.54
26.94
104.00
104.00
104.00
22.46
19.50
4.56
23.01
10.27
10.27
18.34
16.14
6.09
14.07
14.85
11.42
284.62
18.48
36.26
13.25
16.04
24.23
14.98
15.14
28.53
47.36
51.02
15.68
23.01
11.40
47.36
15.14
10.20
16.54
38.80
14.99
14.99
14.99
14.99

$0 Indicator

Page 79 of 299

CDM #
3008794
3008802
3008810
3008828
3008836
3008844
3008877
3008885
3008927
3008984
3009065
3009073
3009172
3009180
3009198
3009206
3009214
3009222
3009230
3009248
3009255
3009263
3009271
3009289
3009297
3009305
3009313
3009321
3009339
3009347
3009354
3009362
3009370
3009420
3009438
3009446
3009495
3009511
3009529
3009545
3009552
3009594
3009602
3009636
3009644
3009651
3009669

CDM Description
OSL-4-HEPARIN-ASSOC ABS
OSL-A-HANTAVIRUS AB IGG
OSL-A-MMA SGL QN
OSL-C-TB CELL IMMUN MEASU
OSL-A-GLUTAMIC ACID ABY
VENIPUNCTURE IP STAT
COLLECT CAPILLAR BLOOD
VENIPUNCTURE OP
VENIPUNCTURE IP/ER
SPEC COLL NOT BLD STAT
OSL-A-SACCHAROMYCES IGG
OSL-A-SACCHAROMYCES IGA
P-NA PRB CHLAM AMP C TRAC
P-NEISSERIA AMP PROBE
P-EIA QL H PYLORI AG
P-MUMPS AB IGG
P-MITOCHON AB IGG
P-CMV AB IGG
P-EBV VCA AB IGG
P-EBV VCA AB IGM
P-EBV EBNA AG AB IGG
P-EBV EARLY AG AB
P-LYME ABS IGG/IGM
P-CENTROMERE AB IGG
P-CRYPTOSPORIDIUM EIA
P-GROWTH HORMONE
P-IGF-1 SOMATOMEDIN
P-SIROLIMUS/RAPAMUNE
P-LIPOPROTEIN A
P-INSULIN FASTING
P-CCP AB
P-KAPPA LAMBDA UR
OSL-A-ALUMINUM URIN 24HRCULT ENVIRON NON CHW FAC
PART AGG SCRN AB CRYPTO
EIA QL LEGION AG UR
OSL-A-OXCARBAZEPINE METAB
ANA SCREEN
CRYPTO STAIN
SUSCEPT B-LACTAM EA
SUSCPT DISK PER 1-12
SMEAR ACID FAST
H-CULTURE VIRUS HERPES
H-EIA QL INFLU A/B AG
H-EIA QL RSV AG
EIA QL MULTI AG
CULT TYP H. FLU AB

239940119.xlsx.ms_office

Price
107.00
47.50
18.20
75.00
14.94
11.00
11.00
11.00
13.56
13.56
206.00
206.00
334.00
201.00
236.00
236.00
153.00
153.00
153.00
153.00
334.00
104.00
334.00
236.00
258.00
321.00
236.00
288.00
201.00
258.00
28.18
51.00
109.00
122.00
15.14
235.00
235.00
52.00
52.00
187.00
337.00
328.00
190.00
122.00
90.00

$0 Indicator

Page 80 of 299

CDM #
3009685
3009693
3009701
3009719
3009727
3009735
3009743
3009750
3009768
3009776
3009792
3009800
3009818
3009826
3009842
3009859
3009867
3009875
3009883
3009909
3009917
3009925
3009933
3009941
3009958
3009966
3009982
3010014
3010030
3010048
3010055
3010063
3010071
3010089
3010097
3010105
3010113
3010139
3010212
3010253
3010261
3010279
3010295
3010303
3010311
3010337
3010345

CDM Description
MRSA ADMIT SCRN AXIL
MRSA ADMIT SCRN NP
MRSA ADMIT SCRN WND
MRSA DISCH SCRN NP
MRSA INTERIM SCR NP
MRSA INTERIM SCRN AXIL
IF HERPES TYPE 1 AG
IF HERPES TYPE 2 AG
H-IF HERPES TYPE 2 AG
OSL-A-ALK-PHOS OTHER %
OSL-A-ECHOVIRUS AB TYP 11
OSL-A-ECHOVIRUS AB TYP 30
OSL-A-ECHOVIRUS AB TYPE 9
OSL-A-C PNEUMONIAE IGM
OSL-A-C PSITACI IGM
OSL-A-C TRACHOMATIS IGG
OSL-A-HANTAVIRUS AB IGM
OSL-A-DIPHTHERIA AB IGG
OSL-A-TETANUS AB IGG
OSL-A-PNEUMO SERO 4 IGG
OSL-A-PNEUMO SERO 5 IGG
OSL-A-PNEUMO SERO 6B IGG
OSL-A-PNEUMO SERO 3 IGG
OSL-A-PNEUMO SERO 7F IGG
OSL-A-PNEUMO SERO 9N IGG
OSL-A-PNEUMO SERO 14* IGG
OSL-A-PNEUMO SERO 8 IGG
OSL-A-PNEUMO SERO 18C IGG
OSL-A-PNEUMO SERO 23F IGG
OSL-A-A.FLAVUS
OSL-A-A FUMIGATUS 2
OSL-A-A. FUMIGATUS 3
OSL-A-S. VIRIDIS
OSL-A-T. SACCHACI
OSL-A-N-TELOPEP XLINK SER
OSL-A-NOROVIRUS 1 BY PCR
OSL-A-NOROVIRUS 2 BY PCR
OSL-A-NORDOXEPIN
OSL-A-RUBELLA AB IGG
OSL-A-LD-1
OSL-A-LD TOTAL
OSL-A-PARVIRUSB-19 IGM IN
OSL-A-PHENYTOIN TOTAL
OSL-A-RSV AB IGM
OSL-A-ACETYLCHOL MOD AB
OSL-A-APOLIPOPROTEIN A-1
OSL-A-APOLIPOPROTEIN B

239940119.xlsx.ms_office

Price
137.00
137.00
137.00
137.00
137.00
137.00
95.00
95.00
95.00
16.35
14.41
14.41
14.41
14.04
14.04
13.08
47.50
16.58
16.58
16.58
16.58
16.58
16.58
16.58
16.58
16.58
16.58
16.58
16.58
13.25
13.25
13.25
13.25
13.25
20.50
38.80
38.80
15.14
16.58
14.15
6.68
16.62
14.94
14.25
14.94
15.34
15.34

$0 Indicator

Page 81 of 299

CDM #
3010352
3010378
3010410
3010428
3010436
3010444
3010469
3010477
3010485
3010493
3010501
3010535
3010568
3010576
3010584
3010592
3010600
3010618
3010634
3010642
3010659
3010667
3010675
3010683
3010691
3010709
3010717
3010725
3010733
3010741
3010758
3010766
3010774
3010782
3010790
3010808
3010816
3010824
3010832
3010840
3010857
3010865
3010873
3010881
3010899
3010907
3010915

CDM Description
OSL-A-ANTI-NEUTROPHIL AB
OSL-A-OVARIAN AB
OSL-A-AMPHETAMINE SERUM
OSL-A-BLASTOMYCES AB ID
OSL-A-ARSENIC HAIR
OSL-A-ARSENIC NAILS
OSL-A-ARSENIC URINE
OSL-A-ANTITHROMBIN ENZY
OSL-A-ANTI-DNASE-B AB
OSL-A-AMEBIASIS HISTO AB
OSL-A-A-1-ANTITRYPSIN FEC
OSL-A-APC RESIST PROFILE
OSL-A-BURGDORFERI IGG WB
OSL-A-CANNABINOID SERUM
OSL-A-CARDIOLIPIN AB IGM
OSL-A-CARDIOLIPIN AB IGA
OSL-A-CREATINE URINE
OSL-A-PSEUDOCHOLINESTERAS
OSL-A-ENDOMYS AB TITR IGA
OSL-A-LYME IGM WEST BLOT
OSL-A-C PSITTACI IGG
OSL-A-METANEPHRINES FREE
OSL-A-METHD QNT/CNF SER
OSL-A-MYCOPHENOLIC ACID
OSL-A-BETAHYDRXYBUTYRACID
OSL-A-CADMIUM BLOOD
OSL-A-CADMIUM URINE
OSL-A-COCCIDIOIDES AB CF
OSL-A-COCCIDIOIDES AB ID
OSL-A-COCCIDIOIDES AB IGG
OSL-A-COCCIDIOIDES AB IGM
OSL-A-CRYOGLOBULIN QT IGG
OSL-A-CRYOGLOBULIN QT IGM
OSL-A-H PYLORI AB IGM
OSL-A-H PYLORI AB IGA
OSL-A-SM MUS AB TIT IGG
OSL-A-RETICULIN AB IGA
OSL-A-RETIC AB IGA TITER
OSL-A-V ZOSTER DFA
OSL-A-VZV CULTURE
OSL-A-ORG. ID ROUTINE
OSL-A-ORG ID 16S RDNA SEQ
OSL-A-KIRBY-BAUER INTERP
OSL-A-MIC FASTIDIOUS ORG
OSL-A-MIC GRAM POS ROD
OSL-A-MIC SINGLE DRUG
OSL-A-NOCARDIA MIC

239940119.xlsx.ms_office

Price
15.88
74.40
17.18
14.26
154.70
154.70
20.98
13.10
14.66
13.70
14.85
16.94
17.12
19.97
24.23
24.23
68.25
8.71
13.33
17.12
13.08
18.73
18.05
15.14
9.03
25.58
25.58
12.68
12.68
12.68
12.68
6.08
6.08
16.04
16.04
13.33
12.16
13.33
10.27
28.21
8.93
5.78
7.62
9.55
9.55
9.55
9.55

$0 Indicator

Page 82 of 299

CDM #
3010923
3010931
3010949
3010956
3010964
3010972
3010980
3010998
3011004
3011012
3011020
3011038
3011053
3011061
3011111
3011129
3011145
3011152
3011160
3011178
3011186
3011194
3011202
3011210
3011228
3011236
3011251
3011269
3011277
3011293
3011301
3011319
3011327
3011335
3011350
3011368
3011384
3011392
3011400
3011426
3011475
3011483
3011491
3011517
3011525
3011533
3011541

CDM Description
OSL-A-ACINETOBACTER MIC
OSL-A-B CEPACIA MIC
OSL-A-CYSTIC PSEUDO MIC
OSL-A-S. MALTOPHILIA MIC
OSL-A-AUTOMATED SUSCEP
OSL-A-VITEK WITH INTERP
OSL-A-YEAST MIC
OSL-A-ANAEROBIC ORG ID
OSL-A-ANAEROBE SUSCEP
OSL-A-DIBUCAINE NUMBER
OSL-A-HEXOSAMINIDAS A&TOT
OSL-A-HTLV I/II AB
OSL-A-AB ADENOVIRUS IGG
EIA QL LEGION AG UR
OSL-A-C TRACHOMATIS IGM
OSL-A-PNEUMO SERO 1 IGG
OSL-A-PNEUMO SERO 9V IGG
OSL-A-PNEUMO SERO 12F IGG
OSL-A-PNEUMO SERO 19F IGG
OSL-A-ENCEP E EQUINE IGG
OSL-A-AMIKACIN PEAK
OSL-A-AMIKACIN RANDOM
OSL-A-AMIKACIN TROUGH
OSL-A-AMPH QNT/CNF UR
OSL-A-BARB QNT/CNF UR
OSL-A-BENZ QNT/CNF UR
OSL-A-B PERTUSSIS IGG
OSL-A-B PERTUSSIS IGM
OSL-A-B PERTUSSIS IGA
OSL-A-UR FREE LAMBDA
OSL-A-TOTAL PROTEIN
OSL-A-UR FREE KAPPA
OSL-A-URINE IFE INTERP
OSL-A-CHLAM TRACH DFA
OSL-A-PARTIC AGG SCR
OSL-A-CRYPTOCOCCUS AB
OSL-A-FACTOR XI ACTIVITY
OSL-A-CANDIDA AB ID
OSL-A-CHLORPROMAZINE
SPLITTING PRODUCT EA
OSL-A-DESMETHYL
OSL-A-CLOZAPINE
OSL-A-COCA QNT/CNF UR
OSL-A-CULT C DIFFICILE
OSL-A-CYSTICER IGG SER
OSL-A-CYSTICER IGG CSF
OSL-A-ANA IGG SCRN

239940119.xlsx.ms_office

Price
9.55
9.55
9.55
9.55
9.55
9.55
9.55
8.93
9.55
13.54
220.50
14.25
14.23
122.00
14.04
16.58
16.58
16.58
16.58
14.58
14.17
14.17
14.17
17.18
12.66
20.45
14.58
14.58
14.58
15.03
4.10
15.03
32.80
10.27
19.15
78.80
19.80
13.28
13.04
81.00
15.14
15.14
16.75
10.46
14.38
14.38
13.36

$0 Indicator

Page 83 of 299

CDM #
3011558
3011566
3011574
3011582
3011624
3011632
3011640
3011657
3011665
3011673
3011681
3011749
3011756
3011764
3011772
3011780
3011798
3011806
3011830
3011848
3011855
3011863
3011871
3011889
3011897
3011905
3011913
3011921
3011939
3011947
3011954
3011970
3011988
3012002
3012010
3012028
3012036
3012069
3012077
3012085
3012093
3012101
3012119
3012127
3012135
3012143
3012150

CDM Description
OSL-A-MICROSOML LVR-KDNY
OSL-A-MITO M2 AB IGG
OSL-A-NEUTRO CYTO IGG
OSL-A-SOL LIVER AG IGG
OSL-A-DESIPRAMINE
OSL-A-DIAZEPAM
OSL-A-NORDIAZEPAM
OSL-A-DNA CONTENT CELL
OSL-A-ENTEROVIRUS PCR
OSL-A-ERYTHROCYTE PORPHYR
OSL-A-CREAT NOT BLD
OSL-A-DRVVT
OSL-A-DRVVT 1:1 MIX
OSL-A-DRVVT CONFIRM
OSL-A-EBV BY PCR
OSL-A-ECHO VIRUS AB 7
OSL-A-ESTRONE TMS
OSL-A-FLUPHENAZINE
OSL-A-FTA AB IGG CSF
OSL-A-FUNGAL ID
OSL-A-ZINC PROTOPORPHYRIN
OSL-A-S TYPHI AB
OSL-A-BRUCELLA AB AGGLUT
OSL-A-ROCKYMTN FEVER IGM
OSL-A-TYPHUS IGG
OSL-A-TYPHUS IGM
OSL-A-Q FEVER 2 IGG
OSL-A-STREPTOZYME TITER
BLOOD SPLIT UNIT
CRYO THAWING
OSL-A-FACTORVIII ACTIVITY
OSL-A-RCF
P-VITAMIN D-3 25-OH
OSL-A-ALLERGEN LATEX
OSL-A-ZINC PROTOPORP
OSL-A-LEGIONELLA CULT
OSL-A-LEUCINE AMINOPEP
OSL-A-FLOW CYT FIRST MARK
OSL-A-FLOW CYT ADDL MARK
OSL-A-LYSOZYME SER
OSL-A-AFB AMPLIFIED
OSL-A-MAG AB, IGM
OSL-A-MAGNESIUM UR
OSL-A-MANGANESE SERUM
OSL-A-MEPHENYTOIN
OSL-A-MEPHOBARBITAL
OSL-A-MEPROBAMATE

239940119.xlsx.ms_office

Price
15.20
10.27
12.16
10.27
9.78
20.45
20.45
88.27
38.80
15.86
108.26
10.58
10.58
10.58
38.80
14.41
27.60
13.04
14.64
11.42
15.86
14.56
9.76
21.40
21.40
21.40
13.40
11.26
168.00
96.00
19.80
25.38
259.00
5.78
50.00
7.33
10.13
42.18
20.68
20.74
38.80
10.27
7.41
27.18
91.00
12.66
19.49

$0 Indicator

Page 84 of 299

CDM #
3012168
3012176
3012184
3012200
3012218
3012226
3012234
3012242
3012259
3012275
3012283
3012317
3012325
3012333
3012341
3012358
3012374
3012382
3012390
3012408
3012416
3012424
3012432
3012457
3012465
3012499
3012507
3012515
3012523
3012531
3012549
3012564
3012572
3012606
3012614
3012622
3012630
3012648
3012655
3012663
3012671
3012689
3012697
3012705
3012713
3012721
3012739

CDM Description
OSL-A-METHANOL
OSL-A-METHAQUALONE
OSL-A-METHEMALBUMIN
OSL-A-METHOTREXATE
OSL-A-METHSUXIMIDE
OSL-A-CONC INFECT AGNT
OSL-A-SMEAR SPECIAL STAIN
OSL-A-ALBUMIN SER
OSL-A-OLIGO BANDS
OSL-A-ELECTROPHORESIS
OSL-A-SERUM IFE
OSL-A-NEURON SP ENOLASE
OSL-A-B. HENSELAE AB IGG
OSL-A-B. HENSELAE AB IGM
OSL-A-B 2 MICROGLOB UR
OSL-A-ETHYLENE GLYCOL
OSL-A-FACTOR XII ACTIVITY
OSL-A-CHLORIDE, FECAL
OSL-A-POTASSIUM, FECAL
OSL-A-SODIUM, FECAL
OSL-A-FELBAMATE
OSL-A-AMINO ACIDS QNT CSF
OSL-A-MPO
OSL-A-GM1 AB IGG
OSL-A-GM1 AB IGM
GLUCOSE 1HR PP
OSL-A-TRAZODONE
OSL-A-GLUTETHIMIDE QNT
OSL-A-H INFLUENZAE IGG
OSL-A-PHENOTYPEPREDICTION
OSL-A-GENOTYPE ANAL NA
OSL-A-HALOPERIDOL
OSL-A-HSV 1 GLYCO G IGG
OSL-A-HSV 2 GLYCO G IGG
OSL-A-HEMOGLOBIN EVAL
OSL-A-ALKALINE AGAR ELECT
OSL-A-CITRATE AGAR ELECT
OSL-A-RBC SOLUBILITY
OSL-A-HCV AB REF RIBA
OSL-A-OPIAT QNT/CNF UR
OSL-A-A PULLULANS
OSL-A-PIGEON SERUM
OSL-A-M. FAENI
OSL-A-T. VULGARIS #1
OSL-A-A. FUMIGATUS #1
OSL-A-A. FUMIGATUS #6
OSL-A-IGF BIND PROTEIN 3

239940119.xlsx.ms_office

Price
17.77
132.00
99.00
15.14
16.38
7.00
7.00
5.32
22.23
11.87
20.73
23.01
11.25
11.25
17.71
16.47
21.39
5.32
11.48
5.43
15.14
18.65
10.27
10.27
10.27
138.00
15.14
101.00
16.58
230.31
200.00
16.10
14.58
21.40
19.97
17.17
17.17
5.80
15.78
21.51
13.25
13.25
13.25
13.25
13.25
13.25
15.62

$0 Indicator

Page 85 of 299

CDM #
3012747
3012754
3012762
3012796
3012804
3012812
3012820
3012838
3012846
3012861
3012879
3012887
3012895
3012960
3012986
3012994
3013000
3013026
3013034
3013042
3013059
3013067
3013075
3013083
3013091
3013109
3013141
3013158
3013174
3013182
3013208
3013216
3013224
3013232
3013240
3013257
3013265
3013273
3013281
3013307
3013315
3013331
3013349
3013356
3013612
3013620
3013638

CDM Description
OSL-A-HUMAN INSULIN AB
OSL-A-INSULIN GROW FACII
OSL-A-KEPPRA
OSL-A-LYSOZYME URINE
OSL-A-ASIALO IGG/IGM
OSL-A-GM1IGG/IGM
OSL-A-GD1A IGG/IGM
OSL-A-GD1B IGG/IGM
OSL-A-GQ1B IGG/IGM
OSL-A-ANNA IGG IFA
OSL-A-ANNA IGG TIT
OSL-A-ANNA IBLOT SER
OSL-A-NICOTINE/METAB SER
OSL-A-PAROXETINE QNT
OSL-A-PERPHENAZINE
OSL-A-PHENCYCLIDINE
OSL-A-PCP UR QNT/CNF UR
OSL-A-POLIOVIRUS AB 2
OSL-A-POLIOVIRUS AB 3
OSL-A-PROPX QNT/CNF UR
OSL-A-ACID PHOS PROST
OSL-A-PROTEIN S FREE
OSL-A-PROTEIN FRAC QNT
OSL-A-TOTAL PROTEIN CSF
OSL-A-PROTRIPTYLINE
OSL-A-PYRUVATE KINASE
OSL-A-SECOBARBITAL UR
OSL-A-SELENIUM SER
OSL-A-SOL TRANSFERRIN
OSL-A-PLT AB DIRECT/IGM
OSL-A-SERTRALINE
OSL-A-SOTALOL
OSL-A-SULFONAMIDES
OSL-A-TSH RECEPTOR AB
OSL-A-TESTOS FEM/CHILD
OSL-A-THIOTHIXENE
OSL-A-REVERSE T3
OSL-A-TRYPTASE
H-LACTATE/LACTIC ACID CSF
LACTOSE ADD SPECIMEN
OSL-A-NORMETHSUXIMIDE
MICROALBUMIN UR RAN
OSL-A-PANC AMYLASE ISO
KOH PREP ANY TYPE
OSL-A-ADRENAL AB
OSL-A-ACYLCARNITINE QNT
OSL-A-ALPHA SUBUNIT

239940119.xlsx.ms_office

Price
23.67
93.00
15.14
20.74
10.27
10.27
10.27
10.27
10.27
12.16
13.33
10.27
26.18
98.00
13.04
15.84
15.84
14.41
14.41
21.51
10.68
16.94
19.94
4.10
15.14
10.43
75.00
28.22
40.42
13.77
15.14
15.14
15.14
14.94
28.54
15.14
17.42
14.31
289.00
138.00
15.14
118.00
7.17
92.00
14.94
18.65
14.94

$0 Indicator

Page 86 of 299

CDM #
3013646
3013653
3013661
3013679
3013687
3013695
3013703
3013711
3013729
3013737
3013786
3013794
3013810
3013828
3013836
3013844
3013851
3013885
3013893
3013901
3013919
3013927
3013935
3013943
3013950
3013968
3013984
3013992
3014016
3014024
3014032
3014040
3014057
3014065
3014073
3014081
3014099
3014107
3014115
3014123
3014131
3014156
3014172
3014214
3014222
3014230
3014248

CDM Description
OSL-A-ACE CSF
OSL-A-A GALACTO
OSL-A-BETA-2 TRANSFERRIN
OSL-A-BICARBONATE URINE
OSL-A-BK VIRUS QNT PCR
OSL-A-DENGUE FEVER IGG
OSL-A-DENGUE FEVER IGM
OSL-A-DEOXYCORTICOSTERONE
OSL-A-EBV QUANT PCR
OSL-A-ECHINOCOCCUS IGG
OSL-A-MEASLES IGM CSF
OSL-A-MUMPS IGG CSF
OSL-A-VZV IGG CSF
OSL-A-VZV IGM CSF
OSL-A-HSV 1/2 IGG CSF
OSL-A-HSV 1/2 IGM CSF
OSL-A-LCM AB CSF
OSL-A-HCV RNA/GENO
OSL-A-HHV-6 AB IGG
OSL-A-HISTOPLASMA AG UR
OSL-A-HSV TYPING
OSL-A-HSV1 GLYCO G CSF
OSL-A-HSV2 GLYCO G CSF
OSL-A-HYALURONIC ACID
OSL-A-ZINC UR UG/DAY
OSL-A-IA 2 AB
OSL-A-IODINE URINE
OSL-A-INHIBIN-A
OSL-A-INHIBIN B
OSL-A-CALIFORNIA IGG CSF
OSL-A-CALIFORNIA IGM CSF
OSL-A-EASTERN IGG CSF
OSL-A-EASTERN IGM CSF
OSL-A-ST LOUIS IGG CSF
OSL-A-ST LOUIS IGM CSF
OSL-A-WESTERN IGG CSF
OSL-A-WESTERN IGM CSF
OSL-A-WEST NILE IGG CSF
OSL-A-WEST NILE IGM CSF
OSL-A-MEASLES IGG CSF
OSL-A-MEASLES IGM CSF
OSL-A-MUMPS IGM CSF
OSL-A-VZV AB IGM
OSL-A-NEUT OXI BURST
OSL-A-PREGNENOLONE
OSL-A-PSA ULTRA
OSL-A-RABIES AB IGG

239940119.xlsx.ms_office

Price
16.14
10.38
53.53
5.32
47.36
14.25
14.25
184.00
47.36
14.38
14.25
14.42
14.25
14.25
15.36
15.36
14.23
47.36
14.25
10.27
12.16
14.58
21.40
14.31
13.38
18.38
161.40
21.77
14.31
14.58
14.58
14.58
14.58
14.58
14.58
14.58
14.58
16.09
18.83
14.25
14.25
14.42
14.25
56.03
22.86
20.34
14.25

$0 Indicator

Page 87 of 299

CDM #
3014271
3014289
3014297
3014305
3014313
3014339
3014354
3014362
3014370
3014388
3014396
3014404
3014412
3014420
3014446
3014453
3014461
3014479
3014487
3014495
3014503
3014529
3014537
3014545
3014560
3014578
3014586
3014594
3014602
3014610
3014628
3014636
3014644
3014651
3014669
3014677
3014685
3014693
3014701
3014727
3014735
3014743
3014750
3014768
3014776
3014784
3014792

CDM Description
OSL-A-HOMOCYSTEINE
OSL-A-PTT
OSL-A-D-DIMER
OSL-A-PTT-D
OSL-A-PT-D
OSL-A-TOPIRAMATE
OSL-A-T CRUZI AB IGG
OSL-A-UREA NITROGEN FLUID
OSL-A-VITAMIN B2
OSL-A-ZONISAMIDE
OSL-A-PTHRP
OSL-A-VITAMIN B6
OSL-A-VITAMIN B1
OSL-A-BANANA
OSL-A-BRAZIL NUT
OSL-A-DOG DANDER
OSL-A-GARLIC
OSL-A-GLUTEN
OSL-A-HALIBUT
OSL-A-HAZELNUT
OSL-A-KIWI
OSL-A-MILK-COW
OSL-A-OAK TREE
OSL-A-OAT
OSL-A-PEA
OSL-A-PEANUT
OSL-A-PECAN
OSL-A-PEN V
OSL-A-PEN G
OSL-A-RICE
OSL-A-SALMON
OSL-A-SCALLOP
OSL-A-SHRIMP
OSL-A-SOYBEAN
OSL-A-TOMATO
OSL-A-WALNUT
OSL-A-WHEAT
OSL-A-A FUMIGATUS
OSL-A-A TENUIS
OSL-A-ACACIA TREE
OSL-A-ALDER
OSL-A-ALMOND
OSL-A-AMOXICILL
OSL-A-APPLE
OSL-A-AVOCADO
OSL-A-BEEF
OSL-A-BENT GRASS/REDT

239940119.xlsx.ms_office

Price
18.65
6.64
11.25
6.64
4.34
13.18
13.70
4.36
176.00
15.14
14.94
31.06
23.48
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78

$0 Indicator

Page 88 of 299

CDM #
3014800
3014818
3014826
3014834
3014842
3014859
3014867
3014891
3014909
3014917
3014925
3014933
3014941
3014958
3014966
3014974
3014982
3014990
3015005
3015013
3015047
3015054
3015062
3015070
3015088
3015096
3015104
3015112
3015120
3015138
3015146
3015153
3015161
3015179
3015187
3015195
3015203
3015211
3015237
3015245
3015252
3015260
3015278
3015286
3015302
3015310
3015336

CDM Description
OSL-A-BERMUDA GRASS
OSL-A-BOX ELDER/MAPLE
OSL-A-CANDIDA ALBICANS
OSL-A-CARROT
OSL-A-CASEIN
OSL-A-CASHEW
OSL-A-CAT DANDER
OSL-A-CHERRY
OSL-A-CHICKEN
OSL-A-CHOCOLATE
OSL-A-CLAM
OSL-A-COCONUT
OSL-A-CODFISH
OSL-A-COMMON RAGWEED
OSL-A-CORN
OSL-A-COTTONWOOD TREE
OSL-A-CRAB
OSL-A-CULTIVATED OAT
OSL-A-D FARINAE
OSL-A-D PTERONYSSINUS
OSL-A-DOG EPITHELIUM
OSL-A-EGG WHITE
OSL-A-EGG WHOLE
OSL-A-EGG YOLK
OSL-A-ELM TREE
OSL-A-ENGLISH PLANTAIN
OSL-A-EUCALYPTUS TREE
OSL-A-FALSE RAGWEED
OSL-A-FEATHER MIX
OSL-A-GERM COCKROACH
OSL-A-GOLDENROD
OSL-A-HONEYBEE VENOM
OSL-A-HONEYDEW/CANT
OSL-A-HORMODENDRUM
OSL-A-HORSE HAIR
OSL-A-HOUSE DUST GREER
OSL-A-HOUSE DUST STIER
OSL-A-IGE
OSL-A-JAPANESE CEDAR
OSL-A-JOHNSON GRASS
OSL-A-JUNE GRASS
OSL-A-KOCHIA/FIREBUSH
OSL-A-LAMBS QUARTERS
OSL-A-MARSH ELDER
OSL-A-MOUNTAIN CEDAR
OSL-A-MUGWORT
OSL-A-OLIVE TREE

239940119.xlsx.ms_office

Price
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
18.21
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78

$0 Indicator

Page 89 of 299

CDM #
3015344
3015351
3015385
3015393
3015401
3015419
3015427
3015435
3015443
3015450
3015468
3015476
3015484
3015492
3015500
3015534
3015542
3015559
3015575
3015583
3015591
3015609
3015617
3015625
3015633
3015641
3015666
3015674
3015682
3015716
3015740
3015765
3015773
3015807
3015815
3015831
3015856
3015872
3015880
3015906
3015930
3015948
3015963
3015971
3015989
3015997
3016003

CDM Description
OSL-A-ORANGE
OSL-A-PAPER WASP
OSL-A-PEN NOTATUM
OSL-A-PERENNIAL RYE
OSL-A-PHOMA BETAE
OSL-A-PIGWEED
OSL-A-PISTACHIO
OSL-A-PORK
OSL-A-POTATO
OSL-A-PRIVET TREE
OSL-A-RAGWEED
OSL-A-APRICOT
OSL-A-RUSSIAN THISTLE
OSL-A-SCALE
OSL-A-SESAME SEED
OSL-A-STRING BEAN
OSL-A-SYCAMORE TREE
OSL-A-TIMOTHY GRASS
OSL-A-TUNA
OSL-A-WATERMELON
OSL-A-WEST RAGWEED
OSL-A-ASPARAGUS
OSL-A-WHITE ASH TREE
OSL-A-WHITE HORNET
OSL-A-WILLOW TREE
OSL-A-YELLOW HORNET
H-SUSCEPT AGAR
SUSCEPT AGAR
OSL-A-PROTEIN C FUNCT
OSL-A-T. GONDII PCR
OSL-A-VITAMIN K1
OSL-A-PURKINJE AB SCR
OSL-A-PURKINJE AB TITER
CULT AEROBIC OTHER QN
CULT FUNGUS ID MOLD
PINWORM EXAM
CULTURE STOOL CAMPY
SUSCEPT AGAR
H-SUSCEPT AGAR
HOMOGENIZATION TISSUE
OSL-A-CANN QNT/CNF UR
OSL-A-COLD AGGLUTININS
ECG 12 LEAD TRACING ONLY
OSL-A-ANA IFA TITER IGG
OSL-A-D-XYLOSE
OSL-A-VITAMIN B1 WB
MACRO EXAM PARASITE

239940119.xlsx.ms_office

Price
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
90.00
90.00
15.29
38.80
15.15
12.16
13.33
293.00
137.00
92.00
90.00
90.00
90.00
116.00
19.97
8.91
502.00
12.34
13.10
23.48
117.00

$0 Indicator

Page 90 of 299

CDM #
3016029
3016052
3016060
3016086
3016094
3016102
3016110
3016128
3016136
3016144
3016151
3016169
3016177
3016185
3016193
3016201
3016219
3016235
3016243
3016326
3016334
3016342
3016359
3016367
3016375
3016383
3016391
3016409
3016417
3016425
3016433
3016458
3016466
3016474
3016482
3016490
3016516
3016524
3016532
3016540
3016565
3016573
3016581
3016599
3016607
3016615
3016623

CDM Description
MACRO EXAM ARTHROPOD
P-RUSS VIPER VEN DILUTE
P-PTT LUPUS ANTIGLNT STDY
P-CFMUT MOL DX ISOLATION
P-CFMUT MOL DX DGSTN M6
P-CFMUT DNA PROBE M6
P-CFMUT MOLDX SCAN PHY M6
P-CFMUT MOLDX NTRP/RPT M6
OSL-F-ABO TYPE
OSL-F-RH(D) TYPE
OSL-F-COOMBS DIRECT
OSL-F-RBC AB SCR
OSL-F-AB ID RBC EA PNL AD
OSL-F-CROSSMATCH WB/RBC
OSL-F-PLT XM SERVICE FEE
OSL-F-AG NEG HISTORICAL
OSL-F-AG NEG PRESLCT DNR
OSL-A-SEX HORMONE BIND
OSL-A-TESTOS ADULT MALE
OSL-A-VDRL TITER
OSL-A-VZV PCR
OSL-A-CULT CHLAMYDIA TRAC
OSL-A-CULT TYPE IF
OSL-A-HIV 1 GENOTYPING
OSL-A-FLU A/B RAPID CULT
OSL-A-ENA AB
OSL-A-JAK EXTRACT/ISOL
OSL-A-JAK MULTIPLEX
OSL-A-JAK MUTATION ID
OSL-A-JAK GEL SEPARATION
OSL-A-JAK2 INTERP/REPORT
P-PTMUT MOL DX ISOLATION
P-PTMUT MOL DX DIGESTION
P-PTMUT MOLEC GEL ELPH
P-PTMUT NUCLEIC AMP
P-PTMUT MOL DX INTERP/RPT
OSL-A-HCMUT MOLEC EXT/ISO
OSL-A-HCMUT MOL AMP NA1-2
OSL-A-HCMUT NUC PRB M4
OSL-A-HCMUT MOLDX NTRP/RP
OSL-A-MTHMT MOLEC EXT/ISO
OSL-A-MTHMT MOL AMP NA1-2
OSL-A-MTHMT NUC PRB M4
OSL-A-MTHMT MOLDX NTRP/RP
IMMUNOASSAY STREP A
CRYSTAL ID LT MICROSC
OSL-A-CCP ANTIBODY

239940119.xlsx.ms_office

Price
117.00
278.00
278.00
44.00
250.00
250.00
684.00
250.00
32.00
32.00
32.00
95.00
105.00
105.00
105.00
53.00
53.00
24.02
28.53
4.87
38.80
19.26
6.08
284.62
5.41
15.20
13.90
13.90
13.90
13.90
13.90
227.00
227.00
227.00
227.00
227.00
4.46
37.30
17.83
4.46
4.46
37.30
17.83
4.46
122.00
114.00
7.10

$0 Indicator

Page 91 of 299

CDM #
3016649
3016656
3016664
3016672
3016680
3016698
3016706
3016730
3016771
3016797
3016805
3016821
3016839
3016847
3016862
3016870
3016896
3016904
3016912
3016920
3016938
3016946
3016953
3016961
3016979
3016987
3016995
3017001
3017035
3017043
3017050
3017068
3017084
3017100
3017118
3017126
3017134
3017167
3017175
3017183
3017209
3017217
3017225
3017324
3017332
3017340
3017365

CDM Description
OSL-A-MOLEC EXT/ISO FACTV
OSL-A-MOLEC NUC AMP EA FV
OSL-A-MOLEC DX NUC PR FV
OSL-A-TRANSLOC RT-PCR FV
OSL-A-DNA AB SINGLE STRND
P-DNA AB DOUBLE STRAND
P-RHEUMATOID FCTR QN FLD
OSL-C-NA PRB AMP H1N1 PCR
MD CONSULT FNA NC
OSL-A-TRIGLYCERIDE VAPCHL
OSL-A-LIPOPROT HI RES FRC
OSL-A-MOLEC EXT/ISO PRDRW
OSL-A-NUC ACID AMP PRDRW
OSL-A-MOLDX RPT PRADERWL
OSL-A-IA QL/SQ MULT PM M2
OSL-A-IF INDIRECT PMPH M2
OSL-A-MOLEC EXT/ISO FRGLX
OSL-A-N ACID AMP FRGX M2
OSL-A-MOLDX HI RES FRGX
OSL-A-MOL EXT/ISO NA FRGX
OSL-A-MOL ENZ DIG FRGX M2
OSL-A-MOLEC SEP GEL FRGX
OSL-A-MOL DX NA TRNS FRGX
OSL-A-MOL DIAG NUC PRB FX
OSL-A-MOLDX RPT FRAGILEX
OSL-D-INSITU HYBRD EA PB
OSL-A-EIA QL HEP DELTA AG
P-HIV 1 QNT RT PCR
OSL-A-HEINZ BODIES DIRECT
OSL-A-HEINZ BODIES INDUCD
OSL-F-HLA MATCHING FEE
OSL-F-HLA CLS I/II AB SCN
OSL-A-PROTEIN S FUNCTIONL
OSL-A-PT MUT MOLC EX/ISOL
OSL-A-PT MUT AMPLI PRB
OSL-A-PT MUT DIAG NUC PRB
OSL-A-PTMUT TRNSLC RT-PCR
OSL-A-HIV DRG RES TSS CLT
OSL-A-HIV DRUGCULT EA M10
OSL-A-T3 FREE
OSL-A-THROMBIN TIME
OSL-A-STRAWBERRY
OSL-A-LOBSTER
PROTHROMBIN TIME SUB
OSL-F SPLITTING PRDUCT EA
OSL-F SPLIT PLATEPHERSIS
SMEAR WET MOUNT INFECT

239940119.xlsx.ms_office

Price
4.43
4.43
18.54
4.43
13.38
104.00
104.00
6.36
48.64
4.43
18.54
4.43
76.44
450.56
4.44
37.16
18.58
4.44
8.88
4.44
4.44
4.44
4.44
81.83
70.10
306.00
4.62
7.48
263.00
110.00
16.94
4.43
4.43
18.54
4.43
713.00
381.00
17.71
6.38
5.78
5.78
161.00
42.00
74.00
92.00

$0 Indicator

M
S

Page 92 of 299

CDM #
3017373
3017381
3017399
3017407
3017423
3017431
3017449
3017456
3017464
3017472
3017480
3017498
3017597
3017605
3017613
3017621
3017639
3017662
3017670
3017688
3017696
3017704
3017712
3017720
3017738
3017746
3017787
3017795
3017803
3017811
3017829
3017837
3017845
3017852
3017860
3017878
3017886
3017894
3017902
3017910
3017928
3017936
3017944
3017951
3017969
3017977
3017985

CDM Description
H-SMEAR WET MOUNT INFECT
OSL-A-THYROXINE FREE
OSL-A-PTH-INTACT
OSL-A-TOTAL CALCIUM
OSL-A-HIV 1 GENOTYPE
OSL-A-HIV DRG RS TISS CLT
OSL-A-HIV-1 DRG CLT EAM10
OSL-A-BARLEY
OSL-A-BAHIA
OSL-A-YELLOW JACKET
OSL-A-B-2 GLYCO1 AB IGG
OSL-A-B-2 GLYCO1 AB IGM
OSL-A-ALCOHOL SCR UR
OSL-A-ALCOHOL QNT/CNF UR
OSL-A-METHDQNT/CNF UR
OSL-A-HEROIN SCR UR
OSL-A-HEROIN QNT/CNF UR
OSL-4-THROMBIN TIME
OSL-A-BELL PEPPER/PAPRIKA
OSL-A-CABBAGE
OSL-A-GRAPE
OSL-A-LETTUCE
OSL-A-MESQUITE TREE
OSL-A-NAVY BEAN
OSL-A-SAGEBRUSH/WORMWOOD
OSL-A-HISTOPLSMA YEAST AB
OSL-A-MOL EXTRC/ISOL APOE
OSL-A-MOLEC NUC AMPL APOE
OSL-A-MOL DIAG PR APOE M2
OSL-A-TRANSLC RT-PCR APOE
P-ANA SCREEN
P-RHEUMATOID FCTR QN BLD
AMYLASE UR TIMED
OSL-A-HEPARIN NEUTRALIZ
OSL-A-LACTOFERRIN FECAL
ALBUMIN 5% 50ML
OSL-F-VOL REDUCT BLD/PROD
OSL-A-AMPICILLIN
OSL-A-ASCARIS
OSL-A-BAKERS/BREW YEAST
OSL-A-BLUE MUSSEL
OSL-A-BLUEBERRY
OSL-A-CHICKPEA
OSL-A-CHILI PEPPER
OSL-A-CLADOSPORIUM IGG
OSL-A-LENTIL
OSL-A-MACADAMIA NUT

239940119.xlsx.ms_office

Price
92.00
9.97
45.63
5.70
283.80
537.80
287.00
5.78
5.78
5.78
24.23
24.23
15.22
11.94
18.05
95.00
179.00
48.50
5.78
5.78
5.78
5.78
5.78
5.78
5.78
13.82
4.43
18.54
8.86
4.43
56.00
20.00
243.00
10.27
21.94
65.00
132.50
5.78
5.78
5.78
5.78
5.78
5.78
5.78
21.38
5.78
5.78

$0 Indicator

Page 93 of 299

CDM #
3017993
3018009
3018017
3018025
3018033
3018041
3018058
3018066
3018074
3018082
3018090
3018108
3018116
3018124
3018132
3018140
3018157
3018165
3018173
3018181
3018199
3018207
3018215
3018223
3018231
3018249
3018256
3018264
3018272
3018280
3018298
3018306
3018314
3018322
3018330
3018348
3018355
3018363
3018371
3018397
3018405
3018413
3018421
3018439
3018447
3018454
3018462

CDM Description
OSL-A-NUTMEG
OSL-A-ONION
OSL-A-PINEAPPLE
OSL-A-SQUID
OSL-A-TROUT
OSL-A-RYE (FOOD)
OSL-A-BIRCH TREE
OSL-A-COW HAIR/DANDER
OSL-A-DANDELION
OSL-A-ORCHARD GRASS
OSL-A-SWEET GUM TREE
OSL-A-IMMUKNOW TRNSPLT
P-RUBELLA AB IGG
P-EIA QL HBSAG NEUT
P-HSV 1 GLYCO G IGG
P-HSV 2 GLYCO G IGG
P-KAPPA TOT FLC SER NEPH
P-LAMBDA TOT FLC SER NEPH
P-FREE KAPPA SER NEPH
P-FREE LAMBDA SER NEPH
OSL-2-HIV/HTLV AB CONF
OSL-A-PLT AB HEPARIN
OSL-A-SEROTONIN REL ASSAY
SMEAR TRICHROME
OSL-4-DRUG SCRN A/N BLD
SMEAR MALARIA
OSL-A-AQUAPORIN-4 RCPT AB
OSL-A-MICROSPORIDIA DFA
P-ALPHA-1 ANTITRYP TOTL
P-BETA 2 GLYCO I AB IGG
P-BETA 2 GLYCO I AB IGM
P-CLOS DIFF TOXIN AMP
P-CMV AMP PROBE
P-IA QL/SQ MULTI GLIADA
P-IA QL/SQ MULTI GLIADG
P-IA QL/SQ MULTI TTGA
P-IA QL/SQ MULTI TTGG
P-NA PROBE AMP B.PARAPERT
P-NA PROBE AMP B.PERTUS
OSL-A-SIN NOMBRE VRS IGG
OSL-A-SIN NOMBRE VRS IGM
CULT UR PRESUM ID ISO#1
CULT UR PRESUM ID ISO#2
CULT UR PRESUM ID ISO#3
ASP FINE NDL W/O IMAGING
OSL-A-SULFONYLUREA HPLCMS
OSL-A-PHENOBARBITAL

239940119.xlsx.ms_office

Price
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
5.78
54.20
96.00
61.00
93.00
115.00
99.00
99.00
99.00
99.00
17.81
165.00
165.00
235.00
119.50
187.00
10.27
10.27
66.00
91.00
91.00
210.00
194.00
52.00
52.00
52.00
52.00
177.00
177.00
50.00
51.80
116.00
116.00
116.00
115.00
12.66

$0 Indicator

Page 94 of 299

CDM #
3018470
3018488
3018496
3018504
3018512
3018520
3018546
3018553
3018561
3018579
3018587
3018595
3018603
3018611
3018629
3018637
3018645
3018652
3018660
3018678
3018686
3018694
3018702
3018710
3018728
3018736
3018744
3018751
3018769
3018777
3018793
3018801
3018819
3018827
3018835
3018843
3018850
3018868
3018876
3018884
3018892
3018900
3018918
3018926
3018934
3018942
3018959

CDM Description
PARTICLE AGGLUTNTN TEST
CONCENTRATION ANY
CULT STL E COLI 0157
CULT STOOL YERSINIA
P-GBM ANTIBODY
P-HEP C RNA QUANT
P-PROTEINASE 3 AB
P-MYELOPEROXIDASE AB
P-HPV HIGH RISK
P-HPV GENOTYPE 16
P-HPV GENOTYPE 18
SICKLE CELL RBC
OSL-A-CPK TOTAL
OSL-A-TCELL CD4 CT A95885
OSL-A-% CD3 BAL
OSL-A-% CD4 BAL
OSL-A-% CD8 BAL
OSL-A-B CELLS TOTAL COUNT
OSL-A-NK CELLS TOTAL CNT
OSL-A-T CELLS TTL A95892
OSL-A-T CELLS CD4 CD8 RAT
OSL-A-T CELLS TTL A95853
OSL-A-T CELLS TTL A95950
AG TST REAGENT SERM EA AG
OSL-F-AG SCRN REAGENT EA
OSL-F-AG NEG RARE
PAMG-1 QUALITATIVE FMR
P-HSV TYPE 1 DNA PCR
P-HSV TYPE 2 DNA PCR
P-INFLUENZ NA AMP 1ST2TYP
DRUG SCR 8CLASS QUAL HIGH
DRUG SCRN ANY NUM SIMPLE
OSL-A-URINE DRUG SCREEN 9
OSL-A-URINE DRUG SCR 9A
OSL-A-B PERTUS AB IGA IB
OSL-A-B PERTUS AB IGG IB
OSL-A-BKVIRUS QNT PCR BLD
OSL-A-BKVIRUS QNT PCR URN
OSL-A-INTERFERON B SCRN
OSL-A-INTERFERON B TITER
OSL-A-PROBRAIN NAT PEP NT
OSL-A-ANTI-MULLERIAN HORM
OSL-A-FCTR XIII SOL 1:1MX
OSL-A-FAT FECES 24/48/72
OSL-A-FAT FECES HOMOG
OSL-A-ALLRGN LATEX (AL)
OSL-A-ALLRGN LATEX (NAL)

239940119.xlsx.ms_office

Price
109.00
328.00
90.00
90.00
52.00
351.00
52.00
52.00
177.00
177.00
177.00
113.00
7.21
62.86
27.84
27.85
27.85
34.63
42.16
34.63
41.69
51.95
41.85
160.00
63.00
315.00
346.00
242.00
242.00
483.00
280.00
291.00
136.98
152.20
14.58
14.58
47.36
47.36
191.19
191.19
37.94
10.27
9.82
18.57
6.50
28.70
28.70

$0 Indicator

Page 95 of 299

CDM #
3018967
3018975
3018983
3018991
3019007
3019015
3019023
3019031
3019049
3019056
3019064
3019072
3019080
3019098
3019106
3019114
3019122
3019130
3019148
3019155
3019163
3019171
3019189
3019197
3019205
3019213
3019221
3019239
3019247
3019254
3019262
3019270
3019288
3019296
3019304
3019312
3019320
3019338
3019346
3019353
3019361
3019379
3019387
3019395
3019403
3019411
3019429

CDM Description
OSL-A-ALLRGN LATEX (GL)
URINE VOLUME MEASURE
OSL-A-F TULARENSIS AB IGG
OSL-A-F TULARENSIS AB IGM
OSL-A-B PERTUS AB IGM IB
OSL-CL-MOLECULE ISO NA
OSL-CL-MOLECULAR DX
OSL-CL-NA PROBE EACH
OSL-CL-NUCLEIC AMPLI EA
OSL-CL-NUCLEIC AMPLI 2S
OSL-CL-NUCLEIC AMPLI ADD
OSL-CL-REV TRANSCRIPTION
OSL-CL-LYSE FOR NUC EXTR
OSL-CL-NA HIGH RESOLUTE
OSL-CL-MICRODISSECT MAN
OSL-CL-MTID OLA-SBCE-ASPE
OSL-A-SUS PHENTYP HIV
CLOS DIFF TOXIN AMP PROBE
MRSA AMP PROBE
INFLUENZ DNA AMP 1ST 2TYP
NA PROBE AMP INF AGNT
STREP B AMP PROBE
TB AMP PROBE
INFLUENZA NA RT AMP EA-A
INFLUENZA NA RT AMP EA-B
P-TB CELL IMMUN MEASURE
HEPARIN ANTI-XA UNFRC
IF INFLUENZA A AG
OSL-A-SPE TOTAL PROTEIN
OSL-A-SGPG IGM
P-PT MIX STUDY
P-PT SUBSTITUTION
P-PTT MIX STUDY
P-PTT IMM SUBSTITUTION
P-PTT 1HR SUBSTITUTION
P-T VAGINALIS RNA AMP
OSL-A-ENDOMYSIAL AB IGG
OSL-A-VITAMIN D2/D3 25-OH
BLOOD THAWING
BLOCK PROCESSING CLIENT
RECUT/DEEPER LVL CLIENT
CULT STOOL OTHER
PHLEB HRLY CHG CLIENT
OSL-A-MOUSE EPITHELIUM
OSL-A-MUCOR RACEMOSUS
OSL-A-WHITE MULBERRY TREE
EIA QL H PYLORI AG

239940119.xlsx.ms_office

Price
28.70
49.00
11.50
11.50
14.58
4.68
4.68
4.68
19.58
39.16
19.58
16.58
15.60
19.58
205.90
19.58
143.80
295.00
295.00
451.00
295.00
295.00
295.00
389.00
389.00
389.00
256.00
110.00
5.32
10.27
161.00
161.00
204.00
205.00
205.00
177.00
13.33
24.79
98.00
7.25
7.25
90.00
5.78
5.78
5.78
182.00

$0 Indicator

Page 96 of 299

CDM #
3019437
3019445
3100021
3100070
3100088
3100112
3100138
3100146
3100153
3100161
3100179
3100187
3100237
3100260
3100278
3100286
3100294
3100310
3100328
3100336
3100344
3100369
3100377
3100385
3100393
3100401
3100419
3100427
3100435
3100443
3100450
3100468
3100476
3100484
3100492
3100500
3100518
3100526
3100534
3100542
3100559
3100575
3100591
3100609
3100617
3100625
3100633

CDM Description
OSL-A-FACTR XIII ACTIVITY
OSL-A-NA PRB P JIROVECII
OSL-D-THIN PREP NONGYN
INTRAOP CYTOPATH CNSLT1
INTRAOP CYTOPATH CNSLT2
BONE MARROW SMEAR INTRP
OPA RECUT/DEEPER LVL FC1
OPA SPECIAL STAIN GP1FC1
OPA SPECIAL STAIN GP2FC1
OPA SPECIAL STAIN GP3FC1
OPA SPECIAL STAIN GP4FC1
OPA ASPIRATE
OPA TISSUE BLOCK
SMEAR W/PREP
OSL-D-FLUID/WASH/BRUSH
CYTOPATH CONC SMR&INT
OSL-D-PAP AUTOTHN MAN SC
SMEAR CYTO OTHER
OSL-D-CYTO OTHER W/PREP
FNA DIAG ADEQUCY 1ST EVAL
FNA INTERPRETATION
GROSS ONLY LEVEL I
GROSS & MICRO LVL II
GROSS & MICRO LVL III
GROSS & MICRO LVL IV
GROSS & MICRO LEVEL V
GROSS & MICRO LVL VI
DECALCIFICATION
SPECIAL STAIN I
STAIN GROUP II
OSL-D-HISTOSTN ENZYM EA
CONSULT PATH REFERRED
CONSULT PATH REQ PREP
CONSULT PATH COMP REV
CONSULT PATH SURGERY
FROZEN SECT FIRST BLOCK
FROZN SECT EA ADDL
OSL-D-ABB-IHC
OSL-D-IF EACH AB
OSL-D-ELECTRON MICRO DIA
OSL-D-SUG LEVEL IV
OSL-A-IRON
SURG PATH PROCEDURE
OSL-D-PROGESTERONE RECEPT
OSL-D-ESTROGEN RECEPTOR
OSL-D-SPECIAL STAIN I
OSL-D-STAIN GROUP II

239940119.xlsx.ms_office

Price
18.06
38.80
47.66
158.00
82.00
173.00
2.75
12.00
15.00
18.00
21.00
1.20
7.25
114.00
24.57
163.00
19.99
27.00
11.59
160.00
90.00
73.00
182.00
207.00
229.00
305.00
404.00
43.00
98.00
72.00
107.75
143.00
191.00
202.00
115.00
158.00
82.00
43.59
45.96
371.71
57.63
7.16
61.00
61.00
52.86
45.39

$0 Indicator

Page 97 of 299

CDM #
3100641
3100658
3100666
3100674
3100682
3100690
3100708
3100724
3100732
3100740
3100757
3100765
3100781
3100799
3100807
3100823
3100831
3100849
3100856
3100864
3100880
3100898
3100906
3100922
3100930
3100948
3100989
3100997
3101003
3101011
3101029
3101037
3101045
3101052
3101060
3101078
3101086
3101094
3101110
3101128
3101136
3101144
3101151
3101169
3101177
3101185
3101193

CDM Description
OSL-D-ABB-IHC EA ADDL STN
OSL-A-COPPER TISSUE
CYTOPATH FLUID SMEAR
OSL-4-CHROMO CT 15-20
OSL-4-CYTOG DNA PRB FISH
OSL-9-PERIPBLCHRCT15-20/2
OSL-9-BONEMRWCHRCT15-20/2
OSL-9-FLOW CYT FIRST MRKR
OSL-9-FLW CYT INTRP 16+MK
OSL-9-FLWCYT EAADD MKRM16
PAP AUTO THN MAN SCRN
CYTO THIN PREP NONGYN
OSL-A-CHROM COUNT 15-20/2
OSL-A-TISSUE CULTURE PC
OSL-A-CYTO/MOLCLR RPT PC
OSL-A-MCG DNA PROBE
OSL-A-CYTOGN CHRM IN SITU
OSL-A-CYTO/MOLCLR RPT PC
MD AFTER REGULAR HRS NC
MD STANDBY EA 30 MIN NC
OSL-A-CHRM CT 15-20/2 BLD
OSL-A-TISSUE CULTURE PRBL
OSL-A-CYTO/MOLCLR RPT BLD
OSL-A-MCG DNA PRB CLL FIS
OSL-A-CYTOGE INSIT100-300
OSL-A-CYTO/MOLCLR RPT CLL
OSL-A-CYTOGN INSTU100-300
OSL-A-TISS CLT BONE MARRW
OSL-A-CHRM ANL 20-25 BNMR
OSL-A-CYTO/MOLEC RPT BNMR
OSL-A-TISS CLT BLOOD CELL
OSL-A-CHRM ANL 20-25 LEUK
OSL-A-CYTO/MOLEC RPT LEUK
OSL-A-REPTILASE TEST
OSL-A-PTT SUBSTITUTION
OSL-A-PLATELET NEUTRALIZ
OSL-A-UROVYSION FISH UR
CYTOPATH C/V INTERPRET
OSL-9-FLOW CYT FIRST MRK
OSL-9-FLOW CYT EA ADD MRK
OSL-9-FLOW CYT IN 2-8 MRK
OSL-9-FLOW CYT IN 9-15
OSL-9-FLOW CYT IN 16+MRK
AUTOPSY W BR/SC
AUTOPSY INFANT W BR
AUTOPSY COMP SB/NB W BR
AUTOPSY COMP WO CNS

239940119.xlsx.ms_office

Price
25.00
13.72
51.00
1,024.00
176.50
275.00
540.00
42.96
100.00
407.04
73.00
106.00
271.00
306.00
42.00
80.00
119.00
73.00
215.00
201.00
34.00
167.48
461.76
56.76
119.00
275.00
271.00
44.00
275.00
271.00
44.00
10.89
7.16
19.87
460.00
100.00
50.00
25.00
80.00
90.00
100.00
-

$0 Indicator

S
S

S
S
S
S
Page 98 of 299

CDM #
3101201
3101219
3101227
3101235
3101243
3101250
3101268
3101276
3101284
3101300
3101318
3101326
3101334
3101342
3101359
3101367
3101375
3101383
3101391
3101409
3101417
3101425
3101433
3101441
3101458
3101466
3101474
3101482
3101490
3101508
3101516
3101524
3101532
3101540
3101557
3101565
3101573
3101581
3101599
3101607
3101615
3101623
3101631
3101649
3200011
3200029
3200037

CDM Description
AUTOPSY COMP W BR
AUTOPSY GROSS WO CNS
AUTOPSY GROSS W BR
AUTOPSY GROSS W BR/SC
AUTOPSY GROSS INFANT W BR
AUTOPSY LIMITED REGIONAL
AUTOPSY LIMITED SGL ORGAN
AUTOPSY MACERATED SB
AUTOPSY SB/NB W BR
OSL-D-CYTOPATH CONC SMR
OSL-D-CELL BUTTON
OSL-D-PAP STAIN
OSL-D-WRIGHT STAIN
OSL-D-HISTOCHEMICAL STAIN
OSL-PL-THIN PREP NGYN
P-PAP THIN PREP W/HPV
P-PAP THIN PREP
OSL-PL-CYTO FLD SLD PREP
OSL-D-MAN TUMOR IHC EA AB
OSL-CL-FLOW CYT MRK
OSL-CL-FLW CYT EA ADD MRK
OSL-CL-SS GROUP 1
OSL-CL-SS GROUP 2
OSL-CL-IHC EC ADD-ON
OSL-CL-IHC EACH AB
OSL-CL-CYTOSP CON TC SMR
OSL-CL-CMP MM ANAL EA AB
OSL-CL-SITU HYBR EA PRB
OSL-CL-TISSCUL BM BLDCELL
OSL-CL-CHRM ANA 20-25
OSL-CL-CHRM AN KAR EA STD
OSL-CL-CHRM ANA 15-20CELL
OSL-CL-CHRM AN ADD CELL
OSL-CL-CHRM ANA 5 CELLS
OSL-CL-TISSCUL LYMPHOCYTE
OSL-CL-TISSCUL SKIN OR BX
OSL-CL-TISSCUL AMNIO FLD
OSL-CL-MOLE PRB 251-500
OSL-CL-MORPHMETRIC TUMOR
OSL-CL-INSITU HYBRID AUTO
OSL-CL-INSITU HYBRID MAN
FNA DIAG ADEQUACY EA ADD
OSL-CL MAN TUMR IHC EA AB
IMMUNOHISTOCHEM EA AB
XR RIBS 2 VIEWS RT
XR RIBS 2 VIEWS LT
XR RIBS 3 VIEWS BIL

239940119.xlsx.ms_office

Price
36.12
7.50
1.50
1.65
63.61
53.57
30.02
43.59
62.00
12.00
72.37
60.65
65.64
57.58
44.41
92.81
98.23
176.50
174.10
35.07
176.50
26.54
246.90
162.80
196.60
205.70
331.30
70.02
230.50
200.90
130.00
46.30
221.00
1,043.00
1,043.00
1,167.00

$0 Indicator
S
S
S
S
S
S
S
S
S

S
S

Page 99 of 299

CDM #
3200045
3200052
3200060
3200078
3200086
3200094
3200102
3200110
3200128
3200136
3200144
3200151
3200169
3200177
3200185
3200193
3200201
3200219
3200227
3200235
3200243
3200250
3200268
3200276
3200284
3200292
3200300
3200318
3200334
3200342
3200359
3200367
3200375
3200383
3200391
3200409
3200417
3200425
3200433
3200441
3200458
3200466
3200474
3200482
3200490
3200508
3200516

CDM Description
XR FACIAL BONES <3 VIEWS
XR FACIAL BONES 3+ VIEWS
XR NASAL BONES 3+ VIEWS
XR SINUSES <3 VIEWS
XR SINUSES 3+ VIEWS
XR SKULL <4 VIEWS
XR SKULL 4+ VIEWS
XR BONE SURVEY LIMITED
XR TMJ OPEN/CLOSED BIL
XR NECK SOFT TISSUE
XR CHEST 2 VWS W APIC LOR
XR CHEST W OBLIQUES
XR CHEST SPECIAL VIEWS
MA MAMMO PLACE NDL EA LT
MA MAMMO PLACE NDL EA RT
XR CHEST 1 VIEW
XR CHEST 2 VIEWS
XR CHEST 4+ VIEWS
XR RIBS W/CHEST 4+ VW BIL
XR STERNUM 2+ VIEWS
XR STERNOCLAVIC JT(S) 3+
XR EYE FOREIGN BODY BIL
XR FINGER(S) 2+ VIEWS BIL
XR FINGER(S) 2+ VIEWS LT
XR FINGER(S) 2+ VIEWS RT
XR TOE(S) 2+ VIEWS BIL
XR TOE(S) 2+ VIEWS LT
XR TOE(S) 2+ VIEWS RT
XR CALCANEUS 2+ VIEWS BIL
XR FOOT 3+ VIEWS BIL
XR ANKLE 3+ VIEWS BIL
XR ANKLE 2 VIEWS BIL
XR LOW EXTRM INFANT 2+ LT
XR LOW EXTRM INFANT 2+ RT
XR LOW EXTRM INFANT 2+BIL
XR TIBIA & FIBULA 2VW BIL
XR TIBIA & FIBULA 1VW BIL
XR TIBIA & FIBULA 1VW LT
XR TIBIA & FIBULA 1VW RT
XR KNEE 4+ VIEWS BIL
XR KNEE 1 OR 2 VIEWS BIL
XR KNEE 3 VIEWS BIL
XR KNEE 3 VIEWS LT
XR KNEE 3 VIEWS RT
XR FEMUR 1 VIEW BIL
XR FEMUR 1 VIEW LT
XR FEMUR 1 VIEW RT

239940119.xlsx.ms_office

Price
886.00
1,473.00
891.00
619.00
1,372.00
1,006.00
1,748.00
1,799.00
1,365.00
610.00
994.00
1,062.00
740.00
1,030.00
1,030.00
893.00
920.00
1,020.00
1,310.00
1,167.00
752.00
929.00
716.00
496.00
496.00
719.00
496.00
496.00
929.00
1,167.00
1,043.00
929.00
640.00
640.00
929.00
1,167.00
1,043.00
719.00
719.00
1,310.00
929.00
1,167.00
806.00
806.00
1,043.00
719.00
719.00

$0 Indicator

Page 100 of 299

CDM #
3200524
3200540
3200557
3200565
3200573
3200581
3200599
3200607
3200615
3200623
3200631
3200649
3200656
3200664
3200672
3200680
3200698
3200706
3200714
3200722
3200730
3200748
3200755
3200763
3200771
3200797
3200805
3200813
3200821
3200839
3200847
3200854
3200862
3200870
3200888
3200896
3200904
3200912
3200920
3200938
3200946
3200953
3200961
3200979
3200987
3200995
3201001

CDM Description
XR FEMUR 2 VIEWS BIL
XR HIP 1 VIEW BIL
XR HIP 1 VIEW LT
XR HIP 1 VIEW RT
XR HAND 3+ VIEWS BIL
XR HAND 2 VIEWS BIL
XR HAND 1 VIEW BIL
XR HAND 1 VIEW LT
XR HAND 1 VIEW RT
XR WRIST 3+ VIEWS BIL
XR WRIST 2 VIEWS BIL
XR UPP EXTRM INFANT 2+ BI
XR UPP EXTRM INFANT 2+ LT
XR UPP EXTRM INFANT 2+ RT
XR FOREARM 1 VIEW BIL
XR FOREARM 1 VIEW LT
XR FOREARM 1 VIEW RT
XR FOREARM 2 VIEWS BIL
XR ELBOW 3+ VIEWS BIL
XR ELBOW 2 VIEWS BIL
XR HUMERUS 2+ VIEWS BIL
XR HUMERUS 1 VIEW BIL
XR HUMERUS 1 VIEW LT
XR HUMERUS 1 VIEW RT
XR SHOULDER 2+ VIEWS BIL
XR SCAPULA COMPLETE BIL
XR CLAVICLE COMPLETE BIL
XR RIBS W CHEST 3+ VWS LT
XR RIBS W CHEST 3+ VWS RT
XR SCOLIOSIS STANDING
XR THORACIC SPINE 4+ VIEW
XR SACROILIAC JTS <3 VWS
XR L SPINE CMP W BND 6+VW
XR SPINE ENTIRE AP & LAT
XR CERVICAL SPINE 2-3 VW
XR CERVICAL SPINE 4+ VIEW
XR C SPINE CMP +FLEX/EXT
XR THORACIC SPINE 3 VIEWS
XR THORACOLUMB SPINE 2 VW
XR SCOLIOSIS SUP & STAND
XR LUMBAR SPINE 2 OR 3 VW
XR LUMBAR SPINE 4+ VIEWS
XR L SPINE BEND ONLY 2-3V
XR THORACIC SPINE 2 VIEWS
XR PELVIS 1 OR 2 VIEWS
XR PELV&HIP INFANT/CHLD2+
XR PELVIS CMPL 3+ VIEWS

239940119.xlsx.ms_office

Price
1,167.00
1,043.00
719.00
719.00
1,310.00
929.00
653.00
450.00
450.00
1,167.00
929.00
929.00
640.00
640.00
1,043.00
719.00
719.00
1,043.00
1,043.00
929.00
1,167.00
1,043.00
719.00
719.00
1,310.00
1,117.00
929.00
1,167.00
1,167.00
895.00
1,517.00
806.00
2,070.00
1,895.00
1,052.00
1,348.00
1,895.00
1,386.00
957.00
1,207.00
957.00
1,748.00
843.00
1,073.00
603.00
679.00
1,016.00

$0 Indicator

Page 101 of 299

CDM #
3201019
3201027
3201035
3201043
3201050
3201068
3201076
3201084
3201092
3201100
3201118
3201126
3201134
3201142
3201167
3201175
3201183
3201191
3201209
3201217
3201225
3201233
3201266
3201316
3201415
3201423
3201431
3201449
3201456
3201464
3201472
3201480
3201498
3201506
3201514
3201522
3201530
3201548
3201555
3201563
3201571
3201589
3201597
3201605
3201613
3201621
3201639

CDM Description
XR SACRUM & COCCYX 2+ VWS
XR SACROILIAC JT 3+ VWS
IR ENTEROCLYSIS TUBE PERC
XR KNEE 4+ VIEWS RT
XR KNEE 4+ VIEWS LT
XR HIPS 2+ W PELVIS BIL
XR ABDOMEN 1 VIEW (AP)
XR ABD AP DECUB UPR+CHEST
XR ABD AP + OBLIQ+ CONE
XR ABDOMEN AP/DECUB/ERECT
XR UROGRM (IVP) WWO TOMO
XR CYSTOGRAM 3+ VIEWS
XR CYSTOURETHROGR RETRO
XR UROGRAM RETROGRADE
XR BONE AGE STUDIES
XR BONE LENGTH STUDIES
XR BONE SURVEY INFANT
XR BONE SURVEY COMPLETE
XR TOMOGRAM SINGLE PLANE
MA SURGICAL SPECIMEN EA
XR FILM COPY NC
XR FB LOCAL NOSE TO RECTM
MA MAMMO SCREENING BIL
MA MAMMO DIAG RT
XR KNEE AP STANDING BIL
XR CERVICAL SPINE 1 VIEW
XR THORACIC SPINE 1 VIEW
XR LUMBAR SPINE 1 VIEW
XR EYE FOREIGN BODY LT
XR EYE FOREIGN BODY RT
XR MANDIBLE <4 VIEWS
XR MANDIBLE 4+ VIEWS
XR ORBITS 4+ VIEWS
XR CLAVICLE COMPLETE LT
XR CLAVICLE COMPLETE RT
XR SCAPULA COMPLETE LT
XR SCAPULA COMPLETE RT
XR SHOULDER 1 VIEW LT
XR SHOULDER 1 VIEW RT
XR SHOULDER 2+ VIEWS LT
XR SHOULDER 2+ VIEWS RT
XR AC JTS W/WO WTS BIL
XR HUMERUS 2+ VIEWS LT
XR HUMERUS 2+ VIEWS RT
XR ELBOW 2 VIEWS LT
XR ELBOW 2 VIEWS RT
XR ELBOW 3+ VIEWS LT

239940119.xlsx.ms_office

Price
816.00
1,073.00
4,709.00
904.00
904.00
1,753.00
806.00
1,283.00
740.00
740.00
1,825.00
779.00
1,290.00
1,674.00
627.00
1,348.00
1,073.00
2,940.00
2,144.00
854.00
472.00
321.00
223.00
929.00
504.00
504.00
504.00
640.00
640.00
740.00
1,609.00
1,303.00
640.00
640.00
770.00
770.00
640.00
640.00
904.00
904.00
931.00
806.00
806.00
640.00
640.00
719.00

$0 Indicator

Page 102 of 299

CDM #
3201647
3201654
3201662
3201670
3201688
3201696
3201704
3201712
3201720
3201738
3201746
3201753
3201761
3201779
3201787
3201795
3201803
3201811
3201829
3201837
3201845
3201852
3201860
3201878
3201886
3201894
3201902
3201910
3201928
3201936
3201944
3201951
3201969
3201977
3202017
3202025
3202041
3202058
3202066
3202082
3202090
3202108
3202116
3202124
3202140
3202157
3202165

CDM Description
XR ELBOW 3+ VIEWS RT
XR FOREARM 2 VIEWS LT
XR FOREARM 2 VIEWS RT
XR WRIST 2 VIEWS LT
XR WRIST 2 VIEWS RT
XR WRIST 3+ VIEWS LT
XR WRIST 3+ VIEWS RT
XR HAND 2 VIEWS LT
XR HAND 2 VIEWS RT
XR HAND 3+ VIEWS LT
XR HAND 3+ VIEWS RT
XR HIP 2+ VIEWS LT
XR HIP 2+ VIEWS RT
XR FEMUR 2 VIEWS LT
XR FEMUR 2 VIEWS RT
XR KNEE 1 OR 2 VIEWS LT
XR KNEE 1 OR 2 VIEWS RT
XR TIBIA & FIBULA 2 VW LT
XR TIBIA & FIBULA 2 VW RT
XR ANKLE 2 VIEWS LT
XR ANKLE 2 VIEWS RT
XR ANKLE 3+ VIEWS LT
XR ANKLE 3+ VIEWS RT
XR FOOT 2 VIEWS LT
XR FOOT 2 VIEWS RT
XR FOOT 3+ VIEWS LT
XR FOOT 3+ VIEWS RT
XR CALCANEUS 2+ VIEWS LT
XR CALCANEUS 2+ VIEWS RT
XR PHAR/LARY W FLUO/MAG
IR FLUORO GUIDE NDL PLCMT
IR GI TUBE LONG INTRO
IR SINUS TRACT/FIST/ABSC
XR CHEST 4+ VWS W FLUORO
IR DISKOGRM LUMBAR SPINE
XR SWALLOW FUNCT CINE/VID
XR SPEECH EVAL W CINE/VID
XR FLUORO JOINT W STRESS
IR MYELOGRAM CERVICAL
IR MYELOGRAM LUMBAR
IR MYELOGRAM 2 OR>REGIONS
IR ENDO PANCREAS DUCT CTH
IR INTRALUMINL STRICT DIL
IR ENDO ERCP
XR UGI W AIR CON W KUB
XR ESOPHAGUS
XR UGI W KUB

239940119.xlsx.ms_office

Price
719.00
719.00
719.00
640.00
640.00
806.00
806.00
640.00
640.00
904.00
904.00
806.00
806.00
806.00
806.00
640.00
640.00
806.00
806.00
640.00
640.00
719.00
719.00
640.00
640.00
806.00
806.00
640.00
640.00
1,142.00
1,042.00
1,265.00
1,265.00
1,219.00
4,510.00
1,420.00
1,494.00
1,042.00
1,780.00
2,574.00
3,344.00
1,711.00
1,711.00
1,711.00
1,923.00
1,049.00
1,740.00

$0 Indicator

Page 103 of 299

CDM #
3202173
3202181
3202199
3202207
3202215
3202223
3202231
3202249
3202256
3202264
3202272
3202298
3202306
3202314
3202348
3202355
3202363
3202371
3202389
3202397
3202405
3202413
3202421
3202439
3202447
3202454
3202462
3202470
3202488
3202496
3202504
3202512
3202520
3202538
3202546
3202553
3202561
3202579
3202587
3202637
3202645
3202652
3202660
3202678
3202686
3202694
3202702

CDM Description
XR UGI W SMALL INTESTINE
XR UGI W AIR CON+SM BOWEL
XR SMALL BOWEL
XR COLON BE W OR WO KUB
XR COLON BE W AIR CON
IR CHOLE THRU EXIST CATH
XR CYSTOURETHROGRAM VOID
IR UROGRAM ANTEGRADE RT
IR UROGRAM ANTEGRADE LT
IR HYSTEROSALPINGOGRAM
IR VENOGRAM EXTREMITY BIL
IR LYMPHANG PELV/ABD UNI
IR ENDO BILIARY DUCT CATH
MOD SEDAT <5YRS 1ST 30M
IR ARTHROGRAM WRIST LT
IR ARTHROGRAM WRIST RT
IR ARTHROGRAM HIP LT
IR ARTHROGRAM HIP RT
IR ARTHROGRAM KNEE LT
IR ARTHROGRAM KNEE RT
MOD SEDAT =>5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
IR ARTHROGRAM SHOULDER LT
IR ARTHROGRAM SHOULDER RT
IR FLUOR VERTEBROPLT/AUGM
IR LEVEL I 1ST 60 MIN
IR LEVEL I INI ADD 30MIN
IR LEVEL II 1ST 60 MIN
IR LEVEL II INI ADD 30MIN
IR LEVEL III 1ST 60 MIN
IR LEVEL III INI AD 30MIN
EMBOLIZATION UTER FIBROID
XR CONSULT
IR VENOGRAM RENAL RT
IR VENOGRAM RENAL LT
IR VENOGRAM EXTREMITY LT
IR VENOGRAM EXTREMITY RT
IR ANGIO PULMONARY LT
IR ANGIO PULMONARY RT
IR ANGIO EXTREMITY LT
IR ANGIO EXTREMITY RT
IR ANGIO VERTEBRAL LT
IR ANGIO VERTEBRAL RT
IR ANGIO VERTEBRAL BIL
IR ANGIO CAROTD CERVIC LT
IR ANGIO CAROTD CERVIC RT
IR ANGIO CAROTD CEREBR LT

239940119.xlsx.ms_office

Price
2,339.00
2,518.00
2,199.00
1,799.00
2,261.00
1,629.00
991.00
1,075.00
1,075.00
1,117.00
2,108.00
4,334.00
1,711.00
1,580.00
1,453.00
1,453.00
1,453.00
1,453.00
1,453.00
1,453.00
1,580.00
549.00
1,453.00
1,453.00
4,510.00
2,602.00
1,065.00
3,645.00
1,824.00
5,265.00
2,632.00
8,046.00
3,845.00
3,845.00
1,453.00
1,453.00
4,131.00
4,131.00
4,131.00
4,131.00
4,131.00
4,131.00
5,992.00
4,131.00
4,131.00
4,131.00

$0 Indicator

Page 104 of 299

CDM #
3202710
3202728
3202736
3202751
3202769
3202777
3202801
3202819
3202827
3202835
3202843
3202850
3202868
3202876
3202884
3202892
3202900
3202918
3202934
3202942
3202959
3202967
3202975
3202983
3202991
3203007
3203015
3203023
3203031
3203049
3203056
3203064
3203072
3203080
3203098
3203106
3203130
3203148
3203155
3203171
3203189
3203197
3203205
3203213
3203221
3203239
3203254

CDM Description
IR ANGIO CAROTD CEREBR RT
IR ANGIO CAROTD EXTERN LT
IR ANGIO CAROTD EXTERN RT
IR SPLENOPORTOGRAM
IR REMOV INTRACATH MATER
IR REMOV PERICATH MATERL
IR URETER CATH/STENT PLC
IR CHOLE PERC TRANSHEP
IR RENAL PERC CTH INS UNI
IR AORTOGRAM THORAC W SER
IR AORTOGRAM ABD W SERIAL
IR AORTOGRM ABD W ILIOFEM
XR ANGIO EXTREM IN OR LT
XR ANGIO EXTREM IN OR RT
IR ANGIO CERVICOCER ARCH
IR ANGIO CAROTD CEREB BIL
IR ANGIO CAROTD CERV BIL
IR ANGIO EXTREMITY BIL
IR ANGIO VISC WO OR W FLS
IR ANGIO PULMONARY BIL
IR ANGIO AV DIAL SHUNT
IR SHUNTOGRAM NONVASCULAR
IR TRANSCATH THRPY EMBOLZ
IR TRANSCTH THERPY INFUS
IR TRNSCTH ANG EXIST CATH
IR THROMBOLYTIC CATH EXCH
IR PTA PERIPHERAL ARTERY
IR PTA RENAL/VISCERAL
IR PTA PERIPH ART EA ADD
IR PTA RENAL/VISC EA ADD
IR ANGIO EA ADD VESSEL
IR VENACAVAGRAM INFERIOR
IR VENACAVAGRAM SUPERIOR
IR VENOUS SAMPLE WWO ANG
IR VENOGRAM RENAL BIL
IR PTA VENOUS
IR BILIARY DRAIN TRANSHEP
IR TUBE/CATH CHANGE W CON
IR FLUOR GUIDE CATH DRAIN
GASTRO TUBE PERC PLACE
IR BILE DUCT DIL WWO STNT
IR NEPHRO/URET/URTHRA DIL
IR TRANSCATH RETRIEVE FB
IR BIOPSY TRANSCATH
IR STENT(S) NON COR/CAR
IR BILIARY DRN CATH/STENT
IR ANGIO CAROTD EXTERN BI

239940119.xlsx.ms_office

Price
4,131.00
4,131.00
4,131.00
4,610.00
5,011.00
5,011.00
1,577.00
1,779.00
1,577.00
4,708.00
4,708.00
4,708.00
3,034.00
3,034.00
4,708.00
5,992.00
5,992.00
5,992.00
4,510.00
5,992.00
4,610.00
1,240.00
6,461.00
6,461.00
2,145.00
2,145.00
6,097.00
5,696.00
2,647.00
2,647.00
1,577.00
4,510.00
4,510.00
4,510.00
5,574.00
5,696.00
4,510.00
3,471.00
2,908.00
2,215.00
6,461.00
1,779.00
6,461.00
2,647.00
5,696.00
4,510.00
5,992.00

$0 Indicator

Page 105 of 299

CDM #
3203262
3203270
3203288
3203296
3203320
3203338
3203361
3203379
3203387
3203395
3203403
3203411
3203429
3203437
3203452
3203460
3203478
3203486
3203494
3203502
3203510
3203528
3203536
3203544
3203551
3203569
3203577
3203585
3203668
3203684
3203700
3203726
3203734
3203940
3204625
3204633
3204641
3204658
3204674
3204682
3204690
3204708
3204716
3204724
3204732
3204740
3204757

CDM Description
IR ANGIO SPINAL
IR ANGIO ADRENAL BIL
IR ANGIO PELVIC
IR ANGIO PULM NON SELECT
IR PORTOGRAM W HEMODYNAMC
IR PORTOGRAM WO HEMODYNAM
IR VENOGRAM SINUS/JUGULAR
IR ENVAS REP ANEU PROSTHE
IR ENVAS REP INFRAREN AAA
XR ABDOMEN 1 VIEW PORT
XR CHEST 1 VIEW PORT
XR PORTABLE PER TRIP NC
XR HIP INTRAOPERATIVE BIL
XR CHOLANGIO/PANC INTRAOP
XR HIP INTRAOPERATIVE LT
XR HIP INTRAOPERATIVE RT
XR FLUORO < 1 HR
XR FLUORO 1-2 HOURS
XR FLUORO 2-3 HOURS
XR FLUORO 3-4 HOURS
XR FLUORO 4-5 HOURS
XR FLUORO 5-6 HOURS
XR FLUORO 6-7 HOURS
XR FLUORO 7-8 HOURS
XR FLUORO 8-9 HOURS
XR FLUORO 9-10 HOURS
XR FLUORO NDL LOCAL SPINE
XR FLUORO CVAD PL/RPL/REM
LOCM 100-199MG/ML IODINE
LOCM 200-299MG/ML IODINE
LOCM 300-399MG/ML IODINE
LOCM 400MG OR >/ML IODINE
GADOLINIUM-BAS MR CON/ML
VASC CLOS DEV 331X-431
INSERT TIPS
REVISE TIPS
VENOUS MECH THROMBECTOMY
VEN MECH THROMBECT EA ADD
PLACE NG/OG TUBE PHY SKIL
URETERAL STENT REM&REPL
URETERAL STENT REMOVE
URETER STNT REM&REP EXTNL
NEPHRO TB REMOVE W FLUORO
ENDOVAS TEMP OCCL VES BAL
CAROTID STNT TRANSCATH W
OCCLUSIVE DEVICE ART/VEIN
EVAL CV DVCE W FLUORO INJ

239940119.xlsx.ms_office

Price
5,574.00
5,574.00
5,147.00
4,510.00
5,574.00
5,574.00
5,574.00
3,031.00
12,096.00
806.00
893.00
3,836.00
1,514.00
2,647.00
2,647.00
1,984.00
3,743.00
5,502.00
7,261.00
9,019.00
10,779.00
12,537.00
14,292.00
16,053.00
17,810.00
1,984.00
1,984.00
1.00
1.00
1.00
1.00
42.00
2,155.00
8,046.00
8,046.00
8,046.00
3,296.00
1,575.00
5,803.00
5,803.00
5,803.00
1,873.00
8,046.00
5,616.00
3,385.00
2,470.00

$0 Indicator

Page 106 of 299

CDM #
3204765
3204781
3204807
3204815
3204823
3204831
3204849
3204856
3204864
3204872
3204880
3204898
3204906
3204914
3204922
3204930
3204948
3204955
3204963
3204971
3204989
3205002
3205010
3205028
3205036
3205051
3205069
3205077
3205085
3205093
3205101
3205119
3205127
3205135
3205143
3205150
3205168
3205176
3205184
3205192
3205200
3205218
3205226
3205234
3205242
3205259
3205267

CDM Description
EVAL GI TBE PRC W FLU INJ
XR TELERADIOGRPHY/EXAM NC
HOCM <=149MG/ML IODINE
CATH GUIDING 195X-254
CATH GUIDING 254X-331
CATH GUIDING 331X-431
CATH GUIDING 431X-561
CATH GUIDING 561X-730
GUIDEWIRE 195X-254
GUIDEWIRE 254X-331
GUIDEWIRE 331X-431
GUIDEWIRE 431X-561
VASCULAR IMPL 949X-1234
VASCULAR IMPL 1234X-1605
VASCULAR IMPL 1605X-2087
VASCULAR IMPL 2087X-2714
VASCULAR IMPL 2714X-3529
EMBL PROTCT SY 2087X-2714
INST/SUPP STERL2087X-2714
CATH GENERAL 949X-1234
VISIT LEVEL 1 EST PT
CATH INF PERIPH 195X-254
CATH INF PERIPH 150X-195
EMBOLIC LIQUID 2087X-2714
CATH INF PERIPH 115X-150
CANNULA 2087X-2714
CATH DIALYSIS LT 331X-431
CATH DIALYSIS LT 431X-561
CATH DIALYSIS ST 67X-88
CATH DIALYSIS ST 88X-115
CATH DRAINAGE 17X-23
CATH DRAINAGE 23X-30
CATH DRAINAGE 30X-39
CATH DRAINAGE 39X-51
CATH DRAINAGE 51X-67
CATH DRAINAGE 67X-88
CATH DRAINAGE 88X-115
CATH DRAINAGE 115X-150
CATH DRAINAGE 331X-431
CATH DRAINAGE 431X-561
CATH EP NON3D 949X-1234
CATH GENERAL 10-13
CATH GENERAL 13X-17
CATH GENERAL 17X-23
CATH GENERAL 23X-30
CATH GENERAL 30X-39
CATH GENERAL 39X-51

239940119.xlsx.ms_office

Price
2,470.00
1.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
1,270.00
1,655.00
2,155.00
2,805.00
6,170.00
8,025.00
10,435.00
13,570.00
17,645.00
13,570.00
13,570.00
6,170.00
239.00
1,270.00
975.00
13,570.00
750.00
13,570.00
2,155.00
2,805.00
440.00
575.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
2,155.00
2,805.00
6,170.00
65.00
85.00
115.00
150.00
195.00
255.00

$0 Indicator
S

Page 107 of 299

CDM #
3205275
3205283
3205291
3205309
3205317
3205325
3205333
3205341
3205358
3205366
3205374
3205382
3205390
3205408
3205416
3205424
3205432
3205440
3205457
3205465
3205473
3205481
3205499
3205507
3205515
3205523
3205531
3205549
3205556
3205564
3205572
3205580
3205598
3205606
3205614
3205622
3205630
3205648
3205655
3205663
3205671
3205689
3205697
3205705
3205713
3205721
3205739

CDM Description
CATH GENERAL 51X-67
CATH GENERAL 67X-88
CATH GENERAL 88X-115
CATH GENERAL 115X-150
CATH GENERAL 150X-195
CATH GENERAL 195X-254
CATH GENERAL 254X-331
CATH GENERAL 331X-431
CATH GENERAL 431X-561
CATH GENERAL 561X-730
CATH GUIDING 39X-51
CATH GUIDING 51X-67
CATH GUIDING 67X-88
CATH GUIDING 88X-115
CATH GUIDING 115X-150
CATH GUIDING 150X-195
CATH GUIDING 730X-949
CATH INF PERIPH 88X-115
CATH INF PERIPH 254X-331
CATH INF PERIPH 949X-1234
CATH OCCLUSN 150X-195
CATH OCCLUSN 195X-254
CATH OCCLUSN 254X-331
CATH OCCLUSN 331X-431
CATH OCCLUSN 949X-1234
CATH OCCLUSN 1234X-1605
CATH PTA N LSR 39X-51
CATH PTA N LSR 51X-67
CATH PTA N LSR 67X-88
CATH PTA N LSR 88X-115
CATH PTA N LSR 115X-150
CATH PTA N LSR 150X-195
CATH PTA N LSR 195X-254
CATH PTA N LSR 254X-331
CATH PTA N LSR 331X-431
CATH PTA N LSR 431X-561
CATH PTA N LSR 561X-730
CATH PTA N LSR 730X-949
CATH SUPRAPUB/CY 30X-39
CATH SUPRAPUB/CY 39X-51
CATH SUPRAPUB/CY 51X-67
CATH THROM EMB 67X-88
CATH THROM EMB 88X-115
CATH THROM EMB 150X-195
CATH THROM EMB 195X-254
CATH THROM EMB 254X-331
CATH THROM EMB 431X-561

239940119.xlsx.ms_office

Price
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
255.00
335.00
440.00
575.00
750.00
975.00
4,745.00
575.00
1,655.00
6,170.00
975.00
1,270.00
1,655.00
2,155.00
6,170.00
8,025.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
195.00
255.00
335.00
440.00
575.00
975.00
1,270.00
1,655.00
2,805.00

$0 Indicator

Page 108 of 299

CDM #
3205747
3205754
3205762
3205770
3205788
3205796
3205804
3205812
3205820
3205838
3205846
3205853
3205861
3205879
3205887
3205895
3205903
3205911
3205929
3205937
3205945
3205952
3205960
3205978
3205986
3205994
3206000
3206018
3206026
3206034
3206042
3206059
3206067
3206075
3206083
3206091
3206109
3206117
3206125
3206133
3206141
3206158
3206166
3206174
3206182
3206190
3206208

CDM Description
CATH THROM EMB 1234X-1605
CATH THROM EMB 1605X-2087
CATH THROM EMB 2087X-2714
CUT/CAUT DEV 331X-431
CUT/CAUT DEV 431X-561
CUT/CAUT DEV 561X-730
CUT/CAUT DEV 730X-949
CUT/CAUT DEV 949X-1234
GUIDEWIRE 10-13
GUIDEWIRE 13X-17
GUIDEWIRE 17X-23
GUIDEWIRE 23X-30
GUIDEWIRE 30X-39
GUIDEWIRE 39X-51
GUIDEWIRE 51X-67
GUIDEWIRE 67X-88
GUIDEWIRE 88X-115
GUIDEWIRE 115X-150
GUIDEWIRE 150X-195
VASCULAR IMPL 115X-150
VASCULAR IMPL 150X-195
VASCULAR IMPL 195X-254
VASCULAR IMPL 254X-331
VASCULAR IMPL 331X-431
VASCULAR IMPL 431X-561
VASCULAR IMPL 561X-730
VASCULAR IMPL 730X-949
CEMENT IMPLANT 195X-254
INST/SUPP STERL 10-13
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30
INST/SUPP STERL 30X-39
INST/SUPP STERL 39X-51
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 115X-150
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INST/SUPP STERL 254X-331
INST/SUPP STERL 331X-431
INST/SUPP STERL 730X-949
INST/SUPP STERL 949X-1234
INTRO SHTH GENRL 10-13
INTRO SHTH GENRL 13X-17
INTRO SHTH GENRL 17X-23

239940119.xlsx.ms_office

Price
8,025.00
10,435.00
13,570.00
2,155.00
2,805.00
3,650.00
4,745.00
6,170.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
1,270.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
4,745.00
6,170.00
65.00
85.00
115.00

$0 Indicator

Page 109 of 299

CDM #
3206216
3206224
3206232
3206240
3206257
3206265
3206273
3206281
3206299
3206307
3206315
3206323
3206331
3206349
3206356
3206364
3206372
3206380
3206398
3206406
3206414
3206422
3206430
3206448
3206455
3206463
3206471
3206489
3206497
3206505
3206513
3206521
3206539
3206547
3206554
3206562
3206570
3206588
3206596
3206604
3206612
3206620
3206638
3206646
3206653
3206661
3206679

CDM Description
INTRO SHTH GENRL 23X-30
INTRO SHTH GENRL 30X-39
INTRO SHTH GENRL 39X-51
INTRO SHTH GENRL 51X-67
INTRO SHTH GENRL 67X-88
INTRO SHTH GENRL 88X-115
INTRO SHTH GENRL 115X-150
INTRO SHTH GENRL 150X-195
INTRO SHTH GENRL 195X-254
INTRO SHTH GENRL 254X-331
INTRO SHTH GENRL 331X-431
INTRO SHTH GENRL 561X-730
INTRO SHTH GENRL 730X-949
INTRO SHTH PEEL 39X-51
INTRO SHTH PEEL 51X-67
INTRO SHTH PEEL 67X-88
INTRO SHTH PEEL 254X-331
INTRO SHTH PEEL 730X-949
KIT/PACK SURG 51X-67
KIT/PACK SURG 67X-88
KIT/PACK SURG 88X-115
KIT/PACK SURG 115X-150
KIT/PACK SURG 150X-195
KIT/PACK SURG 195X-254
KIT/PACK SURG 254X-331
KIT/PACK SURG 331X-431
KIT/PACK SURG 431X-561
KIT/PACK SURG 561X-730
KIT/PACK SURG 1234X-1605
KIT/PACK SURG 2714X-3529
KIT/PACK SURG 3529X-4588
PORT INDWELLING 431X-561
PORT INDWELLING 561X-730
RETRV DEV INSR 254X-331
RETRV DEV INSR 331X-431
RETRV DEV INSR 431X-561
RETRV DEV INSR 561X-730
RETRV DEV INSR 730X-949
STNT COATED W 949X-1234
STNT COATED W 1234X-1605
STNT COATED W 1605X-2087
STNT COATED W 2087X-2714
STNT COATED W 2714X-3529
STNT NCOAT WO 561X-730
STNT NCOAT WO 730X-949
STNT NCOAT WO 949X-1234
STNT NCOR T W 88X-115

239940119.xlsx.ms_office

Price
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
3,650.00
4,745.00
255.00
335.00
440.00
1,655.00
4,745.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
8,025.00
17,645.00
22,940.00
2,805.00
3,650.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
6,170.00
8,025.00
10,435.00
13,570.00
17,645.00
3,650.00
4,745.00
6,170.00
575.00

$0 Indicator

Page 110 of 299

CDM #
3206687
3206695
3206703
3206711
3206729
3206737
3206745
3206752
3206760
3206778
3206786
3206794
3206802
3206810
3206828
3206836
3206844
3206851
3206869
3206877
3206885
3206893
3206901
3206919
3206927
3206935
3206950
3206968
3206976
3206984
3206992
3207008
3207016
3207024
3207032
3207040
3207057
3207065
3207073
3207081
3207099
3207107
3207115
3207123
3207131
3207149
3207156

CDM Description
STNT NCOR T W 115X-150
STNT NCOR T W 150X-195
STNT NCOR T WO 88X-115
STNT NCOR T WO 115X-150
STNT NCOR T WO 150X-195
STNT NCOAT W 730X-949
STNT NCOAT W 949X-1234
STNT NCOAT W 1234X-1605
STNT NCOAT W 1605X-2087
TUBING/CONNECT 23X-30
TUBING/CONNECT 30X-39
TUBING/CONNECT 39X-51
TUBING/CONNECT 51X-67
TUBING/CONNECT 67X-88
VASC CLOS DEV 195X-254
FILTER VENA CAV 730X-949
FILTER VENA CAV 949X-1234
FILTER VENA CAV1234X-1605
CLOSURE EXTERN 23X-30
CATH DRAINAGE 10-13
CATH THROM EMB 331X-431
CATH THROM EMB 949X-1234
EMBL PROTCT SY 730X-949
VASCULAR IMPL 67X-88
VASCULAR IMPL 51X-67
VASCULAR IMPL 88X-115
VASCULAR IMPL 23X-30
VASCULAR IMPL 30X-39
PORT INDWELLING 331X-431
CUT/CAUT DEV 1234X-1605
CUT/CAUT DEV 1605X-2087
CUT/CAUT DEV 2087X-2714
STNT NCOAT W 4588X-5965
STNT NCOAT W 3529X-4588
STNT NCOAT W 2714X-3529
STNT NCOAT W 2087X-2714
STNT NCOAT WO 1234X-1605
STNT NCOAT WO 1605X-2087
STNT NCOAT WO 2087X-2714
STNT NCOAT WO 2714X-3529
RETRV DEV INSR 30X-39
RETRV DEV INSR 39X-51
RETRV DEV INSR 51X-67
RETRV DEV INSR 67X-88
RETRV DEV INSR 88X-115
RETRV DEV INSR 115X-150
RETRV DEV INSR 150X-195

239940119.xlsx.ms_office

Price
750.00
975.00
575.00
750.00
975.00
4,745.00
6,170.00
8,025.00
10,435.00
150.00
195.00
255.00
335.00
440.00
1,270.00
4,745.00
6,170.00
8,025.00
150.00
65.00
2,155.00
6,170.00
4,745.00
440.00
335.00
575.00
150.00
195.00
2,155.00
8,025.00
10,435.00
13,570.00
29,825.00
22,940.00
17,645.00
13,570.00
8,025.00
10,435.00
13,570.00
17,645.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00

$0 Indicator

Page 111 of 299

CDM #
3207164
3207172
3207180
3207198
3207206
3207214
3207222
3207230
3207248
3207255
3207263
3207271
3207289
3207297
3207305
3207313
3207321
3207347
3207354
3207362
3207370
3207388
3207396
3207404
3207412
3207420
3207438
3207446
3207453
3207461
3207479
3207487
3207495
3207503
3207511
3207529
3207537
3207545
3207552
3207560
3207578
3207586
3207594
3207602
3207610
3207628
3207636

CDM Description
RETRV DEV INSR 195X-254
GUIDEWIRE 561X-730
GUIDEWIRE 730X-949
STNT NCOAT W 561X-730
INJ TX/DX/PRO IVPUSH INIT
EMBL PROTCT SY 5965X-7755
EMBL PROTCT SY 561X-730
EMBL PROTCT SY 431X-561
RETRV DEV INSR 1605X-2087
CATH/NDL PLC AV SH DI INI
CATH/NDL PLC AV SH DI ADD
EST VIST/GTB REM/TRCH CHG
XR FLURO 1-2H OUT IMAG NC
XR FLURO 2-3H OUT IMAG NC
CLOSURE IMPLNT 51X-67
CATH DIALYSIS LT 150X-195
INTRO SHTH PEEL 195X-254
INST/SUPP NONST 254X-331
NACL 0.9% 10ML INJ
D5% 500ML INJ
D5% 250ML INJ
D5% 0.45 NACL 500ML INJ
D5% 0.9 NACL 1000ML INJ
D5% 0.9 NACL 500ML INJ
D5% 0.9 NACL 250ML INJ
NACL 0.9% IRRIGATION
NACL 0.9% 100ML PB
NACL 0.9% 50ML PB
NACL 0.9% 150ML INJ
PROBE CRYO ABL 2087X-2714
PROBE CRYO ABL 1605X-2087
CEMENT IMPLANT 949X-1234
INST/SUPP STERL1234X-1605
CATH BLN DIL NO1234X-1605
CATH BLN DIL NON949X-1234
CATH BLN DIL NON 730X-949
EMBL PROTCT SY 1605X-2087
EMBL PROTCT SY 1234X-1605
CATH BLN DIL NON 254X-331
CATH DIALYSIS ST 150X-195
CATH GUIDING 13X-17
CATH GUIDING 23X-30
CATH GUIDING 30X-39
CATH GUIDING 949X-1234
CATH OCCLUSN 51X-67
RETRV DEV INSR 2087X-2714
INTRO SHTH PEEL 23X-30

239940119.xlsx.ms_office

Price
1,270.00
3,650.00
4,745.00
3,650.00
544.00
38,775.00
3,650.00
2,805.00
10,435.00
7,471.00
3,060.00
239.00
335.00
975.00
1,270.00
1,655.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
13,570.00
10,435.00
6,170.00
8,025.00
8,025.00
6,170.00
4,745.00
10,435.00
8,025.00
1,655.00
975.00
85.00
150.00
195.00
6,170.00
335.00
13,570.00
150.00

$0 Indicator

S
S

Page 112 of 299

CDM #
3207644
3207651
3207669
3207677
3207685
3207693
3207701
3207719
3207727
3207735
3207743
3207750
3207768
3207776
3207784
3207792
3207800
3207818
3207826
3207834
3207842
3207859
3207867
3207875
3207883
3207891
3207909
3207917
3207925
3207933
3207941
3207958
3207966
3207974
3207982
3207990
3208006
3208014
3208022
3208030
3208048
3208055
3208063
3208071
3208089
3208097
3208105

CDM Description
IR PERITONEOGRAM
XR AC JTS W/WO WTS UNI
CEMENT IMPLANT 115X-150
CEMENT IMPLANT 150X-195
ANESTH GENERAL 1ST 30MIN
ANESTH GENERAL ADDL 15MIN
GADOBENATE(MULTIHANCE)/ML
GADOTRDL(PROHNCE MULT)/ML
VASC CLOS DEV 561X-730
VASC CLOS DEV 730X-949
INST/SUPP STERL3529X-4588
REVAS FEM POP ATHERECTOMY
REVAS FEM POP STENT ATHER
REVAS FEM POP TRANS ANGIO
REVAS FEMORAL POPLT STENT
REVAS ILIAC STENT INI VES
REVAS ILIAC TRNS ANG INI
REVAS IPSIL ILI ANGIO ADD
REVAS IPSIL ILI STENT ADD
REVAS TIB PERON ANGIO ADD
REVAS TIB PERON ATHER ADD
REVAS TIB PERON ATHER INI
REVAS TIB PERON STENT ADD
REVAS TIB PERON STENT INI
REVAS TIB PR STNT ATH ADD
REVAS TIB PR STNT ATH INI
REVAS TIBIAL PERN ANG INI
TRANSLUM ATHER ABD AORTA
TRANSLUM ATHER RENAL ART
TRANSLUM ATHEREC BRACH EA
TRANSLUM ATHEREC ILIAC EA
TRANSLUM ATHR VISCERAL EA
CEMENT IMPLANT 2087X-2714
CEMENT IMPLANT 561X-730
CEMENT IMPLANT 730X-949
STNT NCOR T WO 67X-88
CATH URETERAL 23X-30
CATH THROM EMB 561X-730
KIT/PACK SURG 949X-1234
KIT/PACK SURG 23X-30
CATH ATHRCT R 2714X-3529
CATH ATHRCT R 1234X-1605
CATH ATHRCT R 2087X-2714
CATH ATHRCT R 949X-1234
MSI EXT LOW AP/LAT RT NC
MSI SPINE AP/PA/LATERL NC
MSI EXT LOW AP/LAT LT NC

239940119.xlsx.ms_office

Price
2,259.00
698.00
750.00
975.00
1,707.00
599.00
10.00
10.00
3,650.00
4,745.00
22,940.00
7,471.00
7,471.00
7,471.00
7,471.00
7,471.00
7,471.00
2,894.00
2,894.00
2,894.00
2,894.00
7,471.00
2,894.00
7,471.00
2,894.00
7,471.00
7,471.00
7,471.00
7,471.00
7,471.00
7,471.00
7,471.00
13,570.00
3,650.00
4,745.00
440.00
150.00
3,650.00
6,170.00
150.00
17,645.00
8,025.00
13,570.00
6,170.00
-

$0 Indicator

L
L
L
Page 113 of 299

CDM #
3208113
3208121
3208139
3208147
3208154
3208162
3208170
3208188
3208196
3208204
3208212
3208220
3208238
3208246
3208253
3208261
3208279
3208287
3208295
3208303
3208311
3208329
3208337
3208345
3208352
3208360
3208378
3208386
3208394
3208402
3208410
3208428
3208436
3208444
3208451
3208469
3208477
3208485
3300019
3300027
3300035
3300043
3300050
3300068
3300076
3300084
3300092

CDM Description
MSI EXT UPPR AP/LAT LT NC
MSI EXT UPPR AP/LAT RT NC
MSI CHEST AP/OBLIQUE NC
MSI CRANIUM AP/LATERAL NC
MSI ABDOMEN/PELVIS NC
MSI VAGINA AND INLET NC
CEMENT IMPLANT 254X-331
KIT/PACK SURG 2087X-2714
PORT INDWELLING 254X-331
CATH DIALYSIS LT 254X-331
VASC CLOS DEV 150X-195
STNT NCOAT W 5965X-7755
CATH GUIDING 2087X-2714
PARACENTSIS ABD W IMAGING
INS IVC FILTER ENDOVAS
REPOS IVC FILTER ENDOVAS
RETR IVC FILTER ENDOVAS
CTH PLC RENAL ART SEL RT
CTH PLC RENAL SUPRSEL RT
CTH PLC RENAL ART SEL LT
CTH PLC RENAL SUPRSEL LT
CTH PLC RENAL SUPRSEL BIL
KIT/PACK SURG 39X-51
CATH INF PERIPH 23X-30
STNT COATED W 3529X-4588
VASCULAR IMPL13107X-17040
CEMENT IMPLANT 2714X-3529
CEMENT IMPLANT 1605X-2087
VASC ACCES THROMBL DECLOT
INST/SUPP STERL 431X-561
KIT/PACK SURG 730X-949
INTRO SHTH PEEL 17X-23
CATH GUIDING 1605X-2087
KIT/PACK SURG 4588X-5965
CCTA POST PROCESSING NC
KIT/PACK SURG 1605X-2087
CATH THROM EM 2714X-3529
CATH GUIDING 1234X-1605
RAD TX INTERMED 1-5MEV
SIMUL AIDED FIELD SIMPLE
SIMUL AIDED FIELD INTER
SIMUL AIDED FIELD COMPLEX
BASIC RAD DOSIM CALC PLAN
TELETX ISODOSE PLAN SIMP
TELETX ISODOSE PLAN INTER
TELETX ISODOSE PLAN CPLX
SPECIAL RAD DOSIMETRY TLD

239940119.xlsx.ms_office

Price
1,655.00
13,570.00
1,655.00
1,655.00
975.00
38,775.00
13,570.00
2,783.00
5,577.00
5,577.00
5,577.00
4,270.00
4,270.00
4,270.00
4,270.00
6,194.00
255.00
150.00
22,940.00
85,200.00
17,645.00
10,435.00
668.00
2,805.00
4,745.00
115.00
10,435.00
29,825.00
10,435.00
17,645.00
8,025.00
251.00
306.00
681.00
681.00
306.00
306.00
306.00
681.00
306.00

$0 Indicator
L
L
L
L
L
L

Page 114 of 299

CDM #
3300100
3300118
3300126
3300134
3300142
3300159
3300167
3300175
3300183
3300191
3300209
3300217
3300225
3300233
3300241
3300258
3300266
3300274
3300282
3300290
3300308
3300316
3300324
3300332
3300381
3300399
3300407
3300415
3300423
3300431
3330446
3400074
3400082
3400108
3400116
3400124
3400132
3400165
3400173
3400181
3400199
3400207
3400215
3400223
3400231
3400249
3400256

CDM Description
TX DEVICE DESIGN SIMPLE
TX DEVICE DESIGN INTERMED
TX DEVICE DESIGN COMPLEX
CONTINUING PHYSICS CONSLT
SPEC MED RAD PHYS CONSULT
THERAPEUT RAD PORT FILMS
RAD TX SIMPLE 1-5 MEV
IMRT PER SESSION
CT GUIDED THERAPY PLACEMT
SPECIAL TX PROCEDURE
URETHROCYSTOGRM RETRO INJ
IMP CATH BRACHY
RAD TX COMPLEX 1-5 MEV
BRACHY ISO PLAN SIMPLE
BRACHY ISO PLAN INTERMED
BRACHY ISO PLAN COMPLEX
SUPRV HANDL LOAD RADIOELE
RAD TX SIMPLE 6-10 MEV
RAD TX INTERMED 6-10MEV
RAD TX COMPLEX 6-10 MEV
RAD TX SIMPLE 11-19 MEV
RAD TX INTERMED 11-19MV
RAD TX COMPLEX 11-19 MEV
IGRT
SIMUL AIDED FIELD 3D
INTERSTITIAL COMPLEX
IMRT TREATMENT PLAN
HDR 1 CHANNEL
HDR 2-12 CHANNEL
HDR >12 CHANNEL
DESIGN MLC DEVIC FOR IMRT
NM CARD BLD POOL SPECT
NM BRAIN <4 VWS W FLOW
NM MONOCLONAL AB THRPY IV
NM RADIO RX THPY IA ADMIN
IN111 IBRITUMOM DX TO 5MC
Y90 IBRITUMMAB TX TO 40MC
NM THYROID UPTAKE SINGLE
NM THYROID UPTAKE MULTI
NM THYROID UPTAKE STIMUL
NM THYROID SCAN W UP SNGL
NM THYROID SCAN W UP MULT
NM THYROID SCAN
NM THYROID SCAN W VAS FLW
NM THYROID CA METS LTD
NM THYROID CA METS WB
NM PARATHYROID

239940119.xlsx.ms_office

Price
502.00
502.00
502.00
306.00
306.00
128.00
251.00
1,091.00
345.00
992.00
190.00
440.00
405.00
306.00
681.00
681.00
128.00
251.00
251.00
405.00
251.00
251.00
405.00
48.00
2,369.00
2,298.00
2,369.00
1,946.00
1,946.00
1,946.00
1,109.00
3,655.00
3,254.00
2,149.00
2,149.00
17,500.00
157,500.00
1,115.00
1,303.00
758.00
1,396.00
1,688.00
1,356.00
1,707.00
1,956.00
3,176.00
2,469.00

$0 Indicator

Page 115 of 299

CDM #
3400264
3400272
3400280
3400298
3400306
3400314
3400322
3400330
3400348
3400363
3400371
3400389
3400397
3400405
3400439
3400447
3400454
3400462
3400470
3400488
3400496
3400504
3400520
3400538
3400546
3400553
3400579
3400587
3400603
3400629
3400637
3400645
3400652
3400678
3400744
3400751
3400769
3400777
3400785
3400793
3400801
3400819
3400827
3400835
3400843
3400850
3400868

CDM Description
NM ADRENAL CORTEX/MEDULLA
NM BONE MARROW LTD
NM BONE MARROW MULTI AREA
NM BONE MARROW WHOLE BODY
NM LYMPH SYSTEM
NM LIVER SPECT
NM LIVER & SPLEEN
NM LIVER SPECT W VAS FLOW
NM LIVER & SPLEEN W VAS F
NM SALIVARY GLAND W SERIA
NM SALIVARY GLAND FUNCT
NM ESOPHAGEAL MOTILITY
NM GASTROESOPHAG REFLUX
NM GASTRIC EMPTYING
NM GASTROINTEST BL LOSS
NM INTESTINE MECK/VOLVUL
NM PERIT-VEN SHUNT PATEN
NM BONE LTD
NM BONE MULTIPLE
NM BONE WHOLE BODY
NM BONE 3 PHASE
NM BONE SPECT
NM TUMOR LOC WB MULTI DAY
NM CARDIAC SHUNT DETECT
NM VAS FLOW NON CARDIAC
NM VENOUS THROMBOSIS PEP
NM MYOCAR PLNR WALL SNGL
NM MYOCAR PLNR WALL MULT
NM MYOCARD INFARCT SPECT
NM MYOCAR SPECT WALL SNGL
NM MYOCAR SPECT WALL MULT
NM CARD BLOOD POOL SNGL
NM CARD BLOOD POOL MULTI
NM PUL PERF PARTICULATE
NM BRAIN TOMO SPECT
NM BRAIN FLOW ONLY
NM CSF FLOW CISTERNOGRAM
NM CSF SHUNT EVALUATION
NM CSF LEAK DETECTION
NM DACRYOCYSTOGRAPHY RX
NM CSF FLOW SPECT
NM KIDNEY SCAN
NM KIDNEY SCAN W FLOW
NM KIDNEY W FLOW & FUNC
NM KIDNEY SPECT
NM URINE BLADDER RESIDUAL
NM URETERAL REFLUX (VCUG)

239940119.xlsx.ms_office

Price
3,674.00
1,468.00
2,425.00
3,016.00
3,323.00
967.00
2,194.00
3,358.00
2,431.00
2,431.00
889.00
1,182.00
2,663.00
3,109.00
3,323.00
2,765.00
2,802.00
2,431.00
2,777.00
3,596.00
3,050.00
3,595.00
3,531.00
1,983.00
891.00
4,025.00
3,862.00
3,862.00
3,496.00
5,630.00
8,736.00
2,828.00
5,273.00
2,307.00
4,210.00
3,254.00
4,420.00
2,228.00
3,560.00
2,149.00
2,958.00
2,574.00
3,176.00
3,560.00
981.00
492.00
3,365.00

$0 Indicator

Page 116 of 299

CDM #
3400876
3400884
3400892
3400900
3400918
3400926
3400934
3400942
3400959
3400967
3400975
3400983
3400991
3401015
3401023
3401031
3401049
3401064
3401072
3401080
3401098
3401106
3401114
3401122
3401130
3401148
3401155
3401163
3401171
3401197
3401205
3401213
3401239
3401247
3401254
3401262
3401270
3401288
3401346
3401353
3401361
3401395
3401403
3401411
3401429
3401437
3401494

CDM Description
NM TESTES W FLOW
NM KIDNEY W FLW&FUN SNG W
NM KID W FLO/FN MULT WO&W
NM TUMOR LOCALIZE LTD
NM TUMOR LOCALIZE MULTI
NM TUMOR LOCAL WB SNG DAY
NM TUMOR LOCALIZE SPECT
NM INFLAM PROCESS LOC LTD
NM INFLAM PROCESS LOC WB
NM INFLAM PROCES LOC SPEC
NM COMPUTER <30 MIN STAT
NM COMPUTER >30 MIN STAT
PENTETATE DX AERO TO 75MC
GALLIUM GA-67 DX PER MCI
I-123 NA IO DX 100UCI/CAP
I-131 NA IODID CAP DX/MCI
IN-111 PENTETAT DX 0.5MCI
NM PERTECHNETATE PER MCI
PENTETATE DX UP TO 25MCI
SUCCIMER DX TO 10MCI
MEBROFENIN DX TO 15MCI
THALLIUM TL201 DX PER MCI
XENON XE-133 DX PER 10MCI
SESTAMBI DX PER DOSE
TETROFOSMIN DX TO 40MCI
MERTIATIDE DX TO 15MCI
EXAMETAZIME DX TO 25MCI
LABELED RBC DX TO 30MCI
PYROPHOSPHATE DX TO 25MCI
IN-111 PENTETR DX TO 6MCI
BICISATE DX TO 25MCI
IN-111 CAPROMAB TO 10MCI
SUL COLLOD FILTR TO 20MCI
SULFUR COLLOD DX TO 20MCI
MACROAG ALBUM DX TO 10MCI
MEDRONATE DX UP TO 30MCI
XR BONE DENSITY(DXA)AXAL
DISOFENIN DX UP TO 15MCI
NM AMINO INJ UP TO 250MG
SINCALIDE 5MCG INJ
NM DIPYRIDAMOLE INJ P10MG
NM RADIOPHARM THRPY ORAL
NM RADIO RX THPY INTRACAV
NM RADIO RX THPY COLLOID
NM RADIO RX THPY IV ADMIN
NM THYROID CA METS UPTAKE
I-131 NA IOD THER CAP/MCI

239940119.xlsx.ms_office

Price
3,050.00
4,229.00
5,288.00
3,444.00
3,526.00
3,861.00
3,531.00
3,444.00
4,320.00
3,531.00
150.00
175.00
125.00
50.00
7,205.00
4.00
85.00
1,685.00
140.00
80.00
182.00
240.00
260.00
980.00
5,220.00
515.00
158.00
11,605.00
3,495.00
10,900.00
330.00
105.00
60.00
90.00
214.00
315.00
84.00
165.00
101.00
2,149.00
1,463.00
1,463.00
1,128.00
395.00
65.00

$0 Indicator

S
S

Page 117 of 299

CDM #
3401502
3401510
3401528
3401536
3401544
3401569
3401577
3401585
3401593
3401619
3401627
3401643
3401650
3401718
3401726
3401734
3401742
3401759
3401775
3401783
3401791
3401809
3401817
3401825
3401833
3500014
3500030
3500055
3500063
3500071
3500089
3500097
3500105
3500113
3500139
3500147
3500154
3500162
3500170
3500188
3500212
3500220
3500238
3500246
3500253
3500261
3500279

CDM Description
ADENOSINE DX 30MG INJ
NM TELERADIOGRPY/EXAM NC
PET BRAIN METABOLIC EVAL
PET MYOCARD PERFUS MULTI
PET W CT SKULL THGH
INJ TX/DX/PROPH SUBQ/IM
NM BRAIN <4 VIEWS
PET W CT LTD AREA
PET W CT WHOLE BODY
I-123 NA IOD DX PER MCI
NM RADIOPHARM INPT ADMIT
REGADENOSON 0.1MG INJ
IN-111 WBC DX PER DOSE
I-131 OP RETURN CCI EDIT
I-123 IOBENGUANE TO 15MCI
SM153 LEXIDRON TO 150MCI
F-18 FDG DX UP TO 45MCI
EXAMETAZIME WBC DX/DOSE
NM HEPATOBILIARY SYSTEM
NM HEPATOBILIARY SYS W/RX
NM PUL VENTILATION IMAG
NM PUL VENT PERFUSN IMAG
NM PUL PERFUSN QUANT DIFF
NM PUL PERF VNT QUAN DIFF
I-123 IOFLUPNE TO5MCI/DSE
CT ANGIO HEAD W CON
CT ANGIO NECK W CON
CT HEAD WO CON
CT HEAD WO&W CON
CT HEAD W CON
CT MAXILLOFACIAL WO CON
CT ORBIT/SEL/FOS/EAR W
CT ORBIT/SEL/FOS/EAR WO
CT MAXILLOFACIAL WO LTD
CT SOFT TISSUE NECK WO
CT SOFT TISSUE NECK W CON
CT SOFT TISSUE NECK WO&W
CT MAXILLOFACIAL W CON
CT MAXILLOFACIAL WO&W CON
CT TELERADIOGRPY/EXAM NC
CT LEVEL II 1ST 60 MIN
CT LEVEL II INI ADD 30MIN
CT LEVEL I 1ST 60 MIN
CT LEVEL I INI ADD 30MIN
CT LEVEL III 1ST 60 MIN
CT LEVEL III INI AD 30MIN
CT LOW EXTREMITY W BIL

239940119.xlsx.ms_office

Price
355.00
2,645.00
2,951.00
2,645.00
275.00
3,254.00
2,645.00
2,645.00
2,875.00
0.01
483.00
5,490.00
0.01
14,175.00
14,175.00
0.01
5,520.00
3,454.00
3,454.00
3,365.00
6,273.00
3,365.00
6,273.00
4,950.00
4,197.00
4,197.00
3,784.00
5,629.00
3,784.00
3,784.00
5,036.00
5,036.00
2,294.00
3,784.00
3,784.00
7,751.00
3,784.00
5,629.00
3,374.00
1,687.00
1,863.00
931.00
4,875.00
2,436.00
5,488.00

$0 Indicator
S

Page 118 of 299

CDM #
3500287
3500295
3500303
3500311
3500337
3500360
3500378
3500386
3500394
3500436
3500477
3500485
3500493
3500501
3500527
3500535
3500550
3500568
3500576
3500584
3500592
3500600
3500618
3500626
3500634
3500642
3500659
3500667
3500675
3500683
3500691
3500709
3500717
3500725
3500733
3500741
3500758
3500766
3500865
3500873
3500923
3500949
3500956
3500964
3500972
3500980
3500998

CDM Description
CT LOW EXTREMITY WO BIL
CT UPP EXTREM W CON BIL
CT UPP EXTREM WO CON BIL
CT ANGIO CHEST W CON
CT ANGIO PELVIS W CON
CT UPP EXTREM WO&W LT
CT UPP EXTREM WO&W RT
CT ANGIO UPP EXTREM W LT
CT ANGIO UPP EXTREM W RT
CT ANGIO UPP EXTREM W BIL
CT ANGIO LOW EXTREM W BIL
CT ANGIO LOW EXTREM W LT
CT ANGIO LOW EXTREM W RT
CT ANGIO ABDOMEN W CON
CT GUIDE VERTBROPLTY/AUGM
CT ANGIO AORTA W RUNOFF
CT 3D WO SEPARATE WKSTATN
CT ABDOMEN WO CON
CT ABDOMEN W CON
CT ABDOMEN WO&W CON
CT GUIDED NEEDLE PLACEMNT
CT CERVICAL SPINE WO CON
CT CERVICAL SPINE W CON
CT CERVICAL SPINE WO&W
CT THORACIC SPINE WO CON
CT THORACIC SPINE W CON
CT THORACIC SPINE WO&W
CT LUMBAR SPINE WO CON
CT LUMBAR SPINE W CON
CT 3D W SEPARATE WKSTATN
CT LUMBAR SPINE WO&W CON
CT CHEST WO CON
CT CHEST W CON
CT CHEST WO&W CON
CT PELVIS WO CON
CT PELVIS W CON
CT PELVIS WO&W CON
CT GUIDE CATH DRAIN
CT HRT EVAL COR CA WO CON
CT HRT STRC/MORP/3D W CON
CT HRT STRC/MORP CONGENTL
CT UPP EXTREM WO CON LT
CT UPP EXTREM WO CON RT
CT UPP EXTREM W CON LT
CT UPP EXTREM W CON RT
CT LOW EXTREMITY WO LT
CT LOW EXTREMITY WO RT

239940119.xlsx.ms_office

Price
5,488.00
3,784.00
5,488.00
4,197.00
4,197.00
5,488.00
5,488.00
4,197.00
4,197.00
6,084.00
6,084.00
4,197.00
4,197.00
3,784.00
3,784.00
4,197.00
1,311.00
3,784.00
3,784.00
7,751.00
3,630.00
5,329.00
5,329.00
7,751.00
5,329.00
5,329.00
7,751.00
5,036.00
5,036.00
1,311.00
7,751.00
3,784.00
3,784.00
7,751.00
3,784.00
3,784.00
7,751.00
2,692.00
728.00
5,523.00
5,523.00
3,784.00
3,784.00
3,784.00
3,784.00
3,784.00
3,784.00

$0 Indicator

Page 119 of 299

CDM #
3501004
3501012
3501020
3501038
3501046
3501061
3501079
3501400
3501418
3501434
3501442
3501459
3501467
3501475
3501483
3501491
3501509
3501517
3501525
3501533
3501541
3501558
3501566
3501574
3600103
3600111
3600129
3600137
3600145
3600152
3600160
3600178
3600186
3600194
3600202
3600210
3600228
3600277
3600285
3600293
3600301
3600319
3600327
3600335
3600343
3600350
3600368

CDM Description
CT LOW EXTREMITY W LT
CT LOW EXTREMITY W RT
CT ORBIT/SEL/FOS/EAR WO&W
CT GUIDE TISSUE ABLATION
CT FOLLOW UP LTD OR LOCAL
CT VIRTUAL COLON SCREEN
CT VIRTUAL COLON DIAG WO
CT ANGIO HRT/COR ART 3D W
CT VIRTUAL COLON DIAG W
CT CEREBRL PERFUSION WCON
CT ABDOMEN PELVIS WO CON
CT ABDOMEN PELVIS W CON
CT ABDOMEN PELVIS WWO CON
CT ANGIO ABD/PELVIS W CON
CATH DRAINAGE 13X-17
CATH DRAINAGE 67X-88
CUT/CAUT DEV 1605X-2087
CUT/CAUT DEV 949X-1234
INST/SUPP STERL 13X-17
INST/SUPP STERL 39X-51
INTRO SHTH GENRL 67X-88
KIT/PACK SURG 23X-30
KIT/PACK SURG 30X-39
KIT/PACK SURG 39X-51
CANNULA 10-13
CANNULA 13X-17
CANNULA 17X-23
CANNULA 23X-30
CANNULA 30X-39
CANNULA 39X-51
CANNULA 51X-67
CANNULA 67X-88
CANNULA 88X-115
CANNULA 115X-150
CANNULA 150X-195
CANNULA 195X-254
CANNULA 254X-331
GRAFT MESH 254X-331
GRAFT MESH 3529X-4588
GRAFT MESH 1234X-1605
GRAFT MESH 2087X-2714
GRAFT MESH 949X-1234
GRAFT MESH 2714X-3529
GRAFT MESH 1605X-2087
GRAFT MESH 4588X-5965
GRAFT MESH 431X-561
GRAFT MESH 730X-949

239940119.xlsx.ms_office

Price
3,784.00
3,784.00
7,751.00
3,630.00
1,892.00
7,033.00
7,033.00
5,523.00
7,034.00
4,197.00
7,568.00
7,568.00
15,501.00
7,980.00
85.00
440.00
10,435.00
6,170.00
85.00
255.00
440.00
150.00
195.00
255.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
1,655.00
22,940.00
8,025.00
13,570.00
6,170.00
17,645.00
10,435.00
29,825.00
2,805.00
4,745.00

$0 Indicator

Page 120 of 299

CDM #
3600376
3600640
3600665
3600673
3600699
3600707
3600715
3600723
3601200
3601309
3601564
3601754
3601762
3601770
3602034
3602059
3602067
3602075
3602083
3602091
3602109
3602117
3602125
3602133
3602141
3602158
3602166
3602174
3602182
3602273
3602372
3602497
3603024
3603255
3603891
3604196
3604220
3604261
3604295
3604337
3604675
3604691
3604840
3605474
3605565
3605649
3605839

CDM Description
GRAFT MESH 5965X-7755
FILTER VENA CAV 730X-949
GRAFT MESH 88X-115
GRAFT MESH 30X-39
GRAFT MESH 195X-254
GRAFT MESH 115X-150
GRAFT MESH 39X-51
GRAFT MESH 67X-88
GRAFT MESH 51X-67
TALC PWD AER 115X-150
LAP BAND SYST 2714X-3529
GRAFT MESH 150X-195
GRAFT MESH 331X-431
GRAFT MESH 561X-730
STATISTICAL SURG PER MIN
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
SURGERY LEVEL 3 1ST 30MIN
SURGERY LEVEL 3 ADD 15MIN
SURGERY LEVEL 4 1ST 30MIN
SURGERY LEVEL 4 ADD 15MIN
SURGERY LEVEL 5 1ST 30MIN
SURGERY LEVEL 5 ADD 15MIN
SURGERY LEVEL 6 1ST 30MIN
SURGERY LEVEL 6 ADD 15MIN
LITHOTRIPSY ESWL UNI
LITHOTRIPSY ESWL BIL
CONN TISS HUMN 431X-561
CONRAY DYE 60% 50CC
CONN TISS HUMN 331X-431
UR BULK COLLG2.5M331X-431
BRACHY SRC I-125 STRANDED
GRAFT VASC S 195X-254
GRAFT VASC S 254X-331
GRAFT VASC S 561X-730
GRAFT VASC S 115X-150
GRAFT VASC S 331X-431
GRAFT VASC S 730X-949
GRAFT VASC S 88X-115
GRAFT VASC S 150X-195
GRAFT VASC S 1234X-1605
GRAFT VASC S 949X-1234
GRAFT VASC S 431X-561
ICD DUAL 13107X-17040
LEAD DUAL ICD 3529X-4588

239940119.xlsx.ms_office

Price
38,775.00
4,745.00
575.00
195.00
1,270.00
750.00
255.00
440.00
335.00
750.00
17,645.00
975.00
2,155.00
3,650.00
3,855.00
1,351.00
4,976.00
1,743.00
6,443.00
2,256.00
8,337.00
2,920.00
10,670.00
3,735.00
13,872.00
4,867.00
20,594.00
28,311.00
2,805.00
39.00
2,155.00
2,155.00
184.00
1,270.00
1,655.00
3,650.00
750.00
2,155.00
4,745.00
575.00
975.00
8,025.00
6,170.00
2,805.00
85,200.00
22,940.00

$0 Indicator

Page 121 of 299

CDM #
3605854
3605862
3605870
3605888
3605896
3605904
3605912
3605920
3605938
3605946
3605987
3606027
3606100
3606209
3606217
3606225
3606282
3606415
3606522
3606795
3606803
3606811
3606829
3606837
3606845
3606878
3606886
3607017
3607058
3607074
3607207
3607215
3607264
3607363
3607587
3607595
3607603
3607611
3607645
3607652
3608031
3608072
3608106
3608130
3608155
3608189
3608338

CDM Description
LEAD DUAL ICD 4588X-5965
LEAD DUAL ICD 5965X-7755
LEAD NOT S/D 431X-561
LEAD NOT S/D 561X-730
LEAD NOT S/D 730X-949
LEAD NOT S/D 13107X-17040
LEAD NOT S/D 949X-1234
LEAD LT VENTRC 1605X-2087
LEAD LT VENTRC 2087X-2714
LEAD LT VENTRC 2714X-3529
PACEMAKER S RR 4588X-5965
PACEMAKER D RR 4588X-5965
CUT/CAUT DEV 39X-51
BREAST PROSTH 561X-730
BREAST PROSTH 730X-949
BREAST PROSTH 1234X-1605
CLOSURE IMPLNT 431X-561
CUT/CAUT DEV 150X-195
ANCHOR/SCREW 431X-561
HIP HIGH DEMAND
HIP PRIMARY
KNEE PRIMARY
HIP BIPOLAR
HIP UNIPOLAR
CUT/CAUT DEV 331X-431
KNEE REPICCI/UNI
KNEE ROTATING PLATFORM
CONN TISS HUMN 150X-195
CUT/CAUT DEV 949X-1234
CUT/CAUT DEV 51X-67
CUT/CAUT DEV 13X-17
CUT/CAUT DEV 10-13
CONN TISS HUMN 67X-88
CAST EXTREMITY
FIX DEV EXT 10-13
FIX DEV EXT 17X-23
FIX DEV EXT 39X-51
FIX DEV EXT 115X-150
FIX DEV EXT 13X-17
FIX DEV EXT 23X-30
ANCHOR/SCREW 150X-195
NON JOINT DEV 88X-115
NON JOINT DEV 39X-51
ANCHOR/SCREW 51X-67
NON JOINT DEV 10-13
ANCHOR/SCREW 10-13
ANCHOR/SCREW 67X-88

239940119.xlsx.ms_office

Price
29,825.00
38,775.00
2,805.00
3,650.00
4,745.00
85,200.00
6,170.00
10,435.00
13,570.00
17,645.00
29,825.00
29,825.00
255.00
3,650.00
4,745.00
8,025.00
2,805.00
975.00
2,805.00
22,500.00
15,000.00
17,000.00
6,840.00
4,525.00
2,155.00
17,500.00
20,500.00
975.00
6,170.00
335.00
85.00
65.00
440.00
362.00
65.00
115.00
255.00
750.00
85.00
150.00
975.00
575.00
255.00
335.00
65.00
65.00
440.00

$0 Indicator

Page 122 of 299

CDM #
3608478
3608700
3609096
3609138
3609203
3609211
3609302
3609393
3609450
3609526
3609583
3609625
3610110
3610177
3610193
3610375
3610383
3610391
3610409
3610417
3610524
3610557
3610581
3610599
3610615
3610623
3610631
3610649
3610656
3610664
3610672
3610680
3610698
3610706
3610714
3610722
3610730
3610748
3610771
3610938
3610946
3610953
3610961
3610979
3610987
3610995
3611001

CDM Description
NON JOINT DEV 51X-67
NON JOINT DEV 13X-17
FIX DEV EXT 67X-88
ANCHOR/SCREW 30X-39
CONN TISS HUMN 561X-730
CONN TISS HUMN 949X-1234
GRAFT VASC S 1605X-2087
ANCHOR/SCREW 195X-254
ANCHOR/SCREW 13X-17
ANCHOR/SCREW 88X-115
NON JOINT DEV 23X-30
ANCHOR/SCREW 115X-150
ANCHOR/SCREW 561X-730
CUT/CAUT DEV 67X-88
NON JOINT DEV 115X-150
CUT/CAUT DEV 561X-730
FIX DEV EXT 150X-195
FIX DEV EXT 331X-431
CONN TISS HUMN 2714X-3529
CUT/CAUT DEV 431X-561
NON JOINT DEV 30X-39
ANCHOR/SCREW 1234X-1605
FIX DEV EXT 51X-67
FIX DEV EXT 88X-115
CLOSURE IMPLNT 10-13
CLOSURE IMPLNT 13X-17
CLOSURE IMPLNT 17X-23
CLOSURE IMPLNT 23X-30
CLOSURE IMPLNT 30X-39
CLOSURE IMPLNT 39X-51
CLOSURE IMPLNT 51X-67
CLOSURE IMPLNT 67X-88
CLOSURE IMPLNT 88X-115
CLOSURE IMPLNT 115X-150
CLOSURE IMPLNT 150X-195
CLOSURE IMPLNT 195X-254
CLOSURE IMPLNT 254X-331
CLOSURE IMPLNT 331X-431
ANCHOR/SCREW 1605X-2087
NON JOINT DEV 949X-1234
NON JOINT DEV 254X-331
CONN TISS HUMN 1605X-2087
CONN TISS HUMN 254X-331
CONN TISS HUMN 195X-254
CONN TISS HUMN 115X-150
CONN TISS HUMN 88X-115
NON JOINT DEV 17X-23

239940119.xlsx.ms_office

Price
335.00
85.00
440.00
195.00
3,650.00
6,170.00
10,435.00
1,270.00
85.00
575.00
150.00
750.00
3,650.00
440.00
750.00
3,650.00
975.00
2,155.00
17,645.00
2,805.00
195.00
8,025.00
335.00
575.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
10,435.00
6,170.00
1,655.00
10,435.00
1,655.00
1,270.00
750.00
575.00
115.00

$0 Indicator

Page 123 of 299

CDM #
3611019
3611027
3611035
3611043
3611092
3611308
3611548
3611621
3611860
3612207
3612231
3612298
3612355
3612447
3612470
3612967
3612983
3613007
3613205
3613239
3613247
3613262
3613627
3613643
3613650
3613700
3613809
3613817
3614138
3614435
3614518
3614658
3614666
3614716
3615903
3615911
3615929
3615937
3615945
3615952
3615960
3615978
3616901
3616927
3616984
3617008
3617016

CDM Description
ANCHOR/SCREW 331X-431
ANCHOR/SCREW 254X-331
ANCHOR/SCREW 23X-30
ANCHOR/SCREW 17X-23
CUT/CAUT DEV 30X-39
FIX DEV EXT 30X-39
NON JOINT DEV 67X-88
NON JOINT DEV 150X-195
CONN TISS HUMN 730X-949
CONN TISS HUMN 1234X-1605
ANCHOR/SCREW 730X-949
NON JOINT DEV 195X-254
NON JOINT DEV 331X-431
CONN TISS HUMN 2087X-2714
NON JOINT DEV 1234X-1605
ANCHOR/SCREW 949X-1234
NON JOINT DEV 561X-730
NON JOINT DEV 431X-561
NON JOINT DEV 730X-949
NROSTM RECHG 10082X-13107
NROSTM EXT 561X-730
NROSTM PROGRAM 949X-1234
NON JOINT DEV 1605X-2087
FIX DEV EXT 195X-254
FIX DEV EXT 254X-331
CUT/CAUT DEV 17X-23
CUT/CAUT DEV 730X-949
CUT/CAUT DEV 254X-331
CUT/CAUT DEV 23X-30
ANCHOR/SCREW 39X-51
CUT/CAUT DEV 195X-254
CUT/CAUT DEV 88X-115
CUT/CAUT DEV 115X-150
DUOVISC 5 ML
ANESTH GENERAL 1ST 30MIN
ANESTH GENERAL ADDL 15MIN
ANESTH MAC/REG 1ST 30MIN
ANESTH MAC/REG ADDL 15MIN
LOCAL ANESTHESIA
MOD SEDAT <5YRS 1ST 30M
MOD SEDAT =>5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
TVT/TOT W SLNG 1605X-2087
GRFTJAKT SQ CM 1605X-2087
IOL POSTERIOR 115X-150
JOINT DEVICE 115X-150
JOINT DEVICE 150X-195

239940119.xlsx.ms_office

Price
2,155.00
1,655.00
150.00
115.00
195.00
195.00
440.00
975.00
4,745.00
8,025.00
4,745.00
1,270.00
2,155.00
13,570.00
8,025.00
6,170.00
3,650.00
2,805.00
4,745.00
65,535.00
3,650.00
6,170.00
10,435.00
1,270.00
1,655.00
115.00
4,745.00
1,655.00
150.00
255.00
1,270.00
575.00
750.00
365.00
1,707.00
599.00
750.00
264.00
350.00
1,580.00
1,580.00
549.00
10,435.00
10,435.00
750.00
750.00
975.00

$0 Indicator

Page 124 of 299

CDM #
3617024
3617032
3617040
3617057
3617065
3617073
3617081
3617099
3617107
3617115
3617123
3617131
3617149
3617156
3617164
3617172
3617180
3617198
3617206
3617222
3617297
3617347
3617362
3617370
3617388
3617396
3617404
3617412
3617420
3617446
3617453
3617461
3617479
3617487
3617495
3617503
3617529
3617537
3617545
3617552
3617560
3617578
3617586
3617594
3617602
3617610
3617628

CDM Description
JOINT DEVICE 561X-730
JOINT DEVICE 730X-949
JOINT DEVICE 949X-1234
JOINT DEVICE 1234X-1605
STNT AORT/IL 2087X-2714
STNT AORT/IL 2714X-3529
TVT/TOT WO SLG 254X-331
TVT/TOT WO SLG 730X-949
CATH ABLT VAS N 561X-730
CATH BLN DIL NON 10-13
CATH BLN DIL NON 30X-39
CATH BLN DIL NON 51X-67
CATH BLN DIL NON 150X-195
CATH BLN DIL NON 195X-254
CATH BLN DIL NON 254X-331
CATH EP NON3D 115X-150
CATH EP NON3D 150X-195
CATH EP NO COOL 561X-730
CATH EP NO COOL 949X-1234
ENT IMPLANT 10-13
ENT IMPLANT 67X-88
ENT IMPLANT 254X-331
CATH GUIDING 17X-23
CATH GUIDING 23X-30
CATH GUIDING 30X-39
CATH GUIDING 39X-51
CATH GUIDING 51X-67
CATH GUIDING 67X-88
CATH GUIDING 431X-561
CATH DIALYSIS LT 67X-88
CATH DIALYSIS LT 88X-115
CATH DIALYSIS LT 115X-150
CATH DIALYSIS LT 150X-195
CATH DIALYSIS LT 195X-254
CATH DIALYSIS LT 254X-331
CATH DIALYSIS LT 331X-431
CATH DIALYSIS ST 88X-115
CATH DIALYSIS ST 115X-150
CATH DIALYSIS ST 150X-195
CATH DIALYSIS ST 195X-254
CATH DIALYSIS ST 254X-331
CATH DIALYSIS ST 331X-431
CATH INF PERIPH 10-13
CATH INF PERIPH 13X-17
CATH INF PERIPH 17X-23
CATH INF PERIPH 23X-30
CATH INF PERIPH 30X-39

239940119.xlsx.ms_office

Price
3,650.00
4,745.00
6,170.00
8,025.00
13,570.00
17,645.00
1,655.00
4,745.00
3,650.00
65.00
195.00
335.00
975.00
1,270.00
1,655.00
750.00
975.00
3,650.00
6,170.00
65.00
440.00
1,655.00
115.00
150.00
195.00
255.00
335.00
440.00
2,805.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
65.00
85.00
115.00
150.00
195.00

$0 Indicator

Page 125 of 299

CDM #
3617636
3617644
3617651
3617669
3617677
3617685
3617693
3617701
3617719
3617727
3617735
3617743
3617776
3617784
3617792
3617800
3617818
3617826
3617834
3617842
3617859
3617867
3617875
3617883
3617909
3617917
3617958
3617966
3617982
3617990
3618006
3618014
3618022
3618048
3618055
3618063
3618089
3618105
3618113
3618121
3618139
3618147
3618154
3618162
3618170
3618188
3618196

CDM Description
CATH INF PERIPH 39X-51
CATH INF PERIPH 51X-67
CATH INF PERIPH 67X-88
CATH INF PERIPH 88X-115
CATH INF PERIPH 115X-150
CATH INF PERIPH 150X-195
CATH INF PERIPH 195X-254
CATH INF PERIPH 254X-331
CATH INF PERIPH 331X-431
CATH INF PERIPH 431X-561
CATH INF PERIPH 561X-730
CATH INF PERIPH 730X-949
CATH OCCLUSN 39X-51
CATH OCCLUSN 67X-88
CATH OCCLUSN 115X-150
CATH OCCLUSN 150X-195
CATH URETERAL 10-13
CATH URETERAL 17X-23
CATH URETERAL 23X-30
CATH URETERAL 30X-39
CATH URETERAL 39X-51
CATH URETERAL 51X-67
CATH URETERAL 67X-88
CATH URETERAL 88X-115
CATH SUPRAPUB/CY 30X-39
CATH SUPRAPUB/CY 51X-67
CATH ATHRCT R 431X-561
CATH ATHRCT R 2714X-3529
CATH PTA N LSR 39X-51
CATH PTA N LSR 150X-195
CATH PTA N LSR 195X-254
CATH PTA N LSR 254X-331
CATH PTA N LSR 431X-561
CATH THROM EMB 39X-51
CATH THROM EMB 51X-67
CATH THROM EMB 67X-88
CATH THROM EMB 331X-431
INST/SUPP NONST 10-13
INST/SUPP NONST 13X-17
INST/SUPP NONST 17X-23
INST/SUPP NONST 23X-30
INST/SUPP NONST 30X-39
INST/SUPP NONST 39X-51
INST/SUPP NONST 51X-67
INST/SUPP NONST 67X-88
INST/SUPP NONST 88X-115
INST/SUPP NONST 115X-150

239940119.xlsx.ms_office

Price
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
255.00
440.00
750.00
975.00
65.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
195.00
335.00
2,805.00
17,645.00
255.00
975.00
1,270.00
1,655.00
2,805.00
255.00
335.00
440.00
2,155.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00

$0 Indicator

Page 126 of 299

CDM #
3618204
3618212
3618220
3618238
3618287
3618295
3618303
3618311
3618329
3618337
3618345
3618352
3618360
3618378
3618386
3618394
3618402
3618410
3618428
3618436
3618444
3618451
3618469
3618477
3618485
3618493
3618501
3618519
3618527
3618535
3618543
3618550
3618568
3618576
3618584
3618592
3618600
3618618
3618626
3618634
3618642
3618659
3618675
3618725
3618733
3618741
3618758

CDM Description
INST/SUPP NONST 150X-195
INST/SUPP NONST 195X-254
ABLATION DEV 730X-949
ABLATION DEV 949X-1234
CATH GENERAL 10-13
CATH GENERAL 13X-17
CATH GENERAL 17X-23
CATH GENERAL 23X-30
CATH GENERAL 30X-39
CATH GENERAL 39X-51
CATH GENERAL 51X-67
CATH GENERAL 67X-88
CATH GENERAL 88X-115
CATH GENERAL 115X-150
CATH GENERAL 150X-195
CATH GENERAL 195X-254
CATH GENERAL 254X-331
CATH GENERAL 331X-431
CATH GENERAL 431X-561
CATH GENERAL 561X-730
CATH GENERAL 730X-949
CONN TISS NHUM 254X-331
CONN TISS NHUM 431X-561
CONN TISS NHUM 949X-1234
CONN TISS NHUM 1234X-1605
CONN TISS NHUM 1605X-2087
CONN TISS NHUM 2087X-2714
CONN TISS NHUM 4588X-5965
CEMENT IMPLANT 17X-23
CEMENT IMPLANT 88X-115
CEMENT IMPLANT 150X-195
CEMENT IMPLANT 331X-431
TVT/TOT W SLNG 331X-431
TVT/TOT W SLNG 730X949
TVT/TOT W SLNG 1234X-1605
CATH DRAINAGE 13X-17
CATH DRAINAGE 17X-23
CATH DRAINAGE 23X-30
CATH DRAINAGE 30X-39
CATH DRAINAGE 39X-51
CATH DRAINAGE 51X-67
ADHESION BARR 10-13
ADHESION BARR 17X-23
ADHESION BARR 67X-88
ADHESION BARR 88X-115
ADHESION BARR 115X-150
ADHESION BARR 150X-195

239940119.xlsx.ms_office

Price
975.00
1,270.00
4,745.00
6,170.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
1,655.00
2,805.00
6,170.00
8,025.00
10,435.00
13,570.00
29,825.00
115.00
575.00
975.00
2,155.00
2,155.00
4,745.00
8,025.00
85.00
115.00
150.00
195.00
255.00
335.00
65.00
115.00
440.00
575.00
750.00
975.00

$0 Indicator

Page 127 of 299

CDM #
3618766
3618790
3618808
3618816
3618824
3618832
3618840
3618857
3618865
3618873
3618881
3618899
3618923
3618949
3618956
3618964
3618972
3618980
3618998
3619004
3619012
3619020
3619038
3619046
3619053
3619061
3619079
3619087
3619111
3619129
3619137
3619145
3619152
3619160
3619178
3619186
3619194
3619202
3619210
3619228
3619236
3619244
3619251
3619269
3619277
3619285
3619293

CDM Description
ADHESION BARR 195X-254
CONN TISS HUMN 3529X-4588
CONN TISS HUMN 4588X-5965
INST/SUPP STERL 561X-730
INST/SUPP STERL 730X-949
GUIDEWIRE 88X-115
GUIDEWIRE 115X-150
GUIDEWIRE 150X-195
GUIDEWIRE 195X-254
GUIDEWIRE 254X-331
GUIDEWIRE 331X-431
GUIDEWIRE 431X-561
GUIDEWIRE 949X-1234
CLOSURE EXTERN 10-13
CLOSURE EXTERN 13X-17
CLOSURE EXTERN 17X-23
CLOSURE EXTERN 23X-30
CLOSURE EXTERN 30X-39
CLOSURE EXTERN 39X-51
CLOSURE EXTERN 51X-67
CLOSURE EXTERN 67X-88
CLOSURE EXTERN 88X-115
CLOSURE EXTERN 115X-150
CLOSURE EXTERN 150X-195
CLOSURE EXTERN 195X-254
CLOSURE EXTERN 254X-331
CLOSURE EXTERN 331X-431
CLOSURE EXTERN 431X-561
GRAFT VASC 88X-115
GRAFT VASC 115X-150
GRAFT VASC 150X-195
GRAFT VASC 195X-254
GRAFT VASC 254X-331
GRAFT VASC 331X-431
GRAFT VASC 431X-561
GRAFT VASC 561X-730
GRAFT VASC 730X-949
GRAFT VASC 949X-1234
GRAFT VASC 1234X-1605
GRAFT VASC 1605X-2087
GRAFT VASC 2087X-2714
GRAFT VASC 2714X-3529
IMMOBIL/BIND 17X-23
IMMOBIL/BIND 23X-30
IMMOBIL/BIND 30X-39
IMMOBIL/BIND 39X-51
IMMOBIL/BIND 51X-67

239940119.xlsx.ms_office

Price
1,270.00
22,940.00
29,825.00
3,650.00
4,745.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
6,170.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
6,170.00
8,025.00
10,435.00
13,570.00
17,645.00
115.00
150.00
195.00
255.00
335.00

$0 Indicator

Page 128 of 299

CDM #
3619301
3619319
3619327
3619335
3619343
3619483
3619491
3619509
3619517
3619525
3619566
3619574
3619582
3619590
3619608
3619624
3619632
3619640
3619699
3619723
3619731
3619749
3619772
3619780
3619798
3619806
3619814
3619822
3619830
3619848
3619855
3619863
3619871
3619889
3619897
3619905
3619913
3619921
3619939
3619947
3619954
3619962
3619996
3620002
3620010
3620028
3620036

CDM Description
IMMOBIL/BIND 67X-88
IMMOBIL/BIND 88X-115
IMMOBIL/BIND 115X-150
FIX DEV EXT 431X-561
FIX DEV EXT 561X-730
PORT INDWELLING 195X-254
PORT INDWELLING 254X-331
PORT INDWELLING 331X-431
PORT INDWELLING 431X-561
PORT INDWELLING 561X-730
EXPANDER TISS 949X-1234
EXPANDER TISS 1234X-1605
EXPANDER TISS 2087X-2714
EXPANDER TISS 2714X-3529
EXPANDER TISS 3529X-4588
PUMP NONPRO TEMP 88X-115
PUMP NONPRO TEMP 115X-150
PUMP NONPRO TEMP 150X-195
PENILE INFLAT 4588X-5965
UR SPHINCT 1234X-1605
UR SPHINCT 2087X-2714
STNT COATED W 1605X-2087
STNT NCOR T WO 67X-88
STNT NCOR T WO 88X-115
STNT NCOR T WO 115X-150
STNT NCOR T WO 150X-195
STNT NCOR T W 88X-115
STNT NCOR T W 195X-254
INTRO SHTH PEEL 17X-23
INTRO SHTH PEEL 23X-30
INTRO SHTH PEEL 51X-67
INTRO SHTH PEEL 150X-195
INTRO SHTH NPEEL 561X-730
INTRO SHTH GENRL 23X-30
INTRO SHTH GENRL 30X-39
INTRO SHTH GENRL 39X-51
INTRO SHTH GENRL 51X-67
INTRO SHTH GENRL 88X-115
INTRO SHTH GENRL 115X-150
INTRO SHTH GENRL 195X-254
INTRO SHTH GENRL 431X-561
INTRO SHTH GENRL 730X-949
KIT/PACK SURG 51X-67
KIT/PACK SURG 67X-88
KIT/PACK SURG 88X-115
KIT/PACK SURG 115X-150
KIT/PACK SURG 150X-195

239940119.xlsx.ms_office

Price
440.00
575.00
750.00
2,805.00
3,650.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
6,170.00
8,025.00
13,570.00
17,645.00
22,940.00
575.00
750.00
975.00
29,825.00
8,025.00
13,570.00
10,435.00
440.00
575.00
750.00
975.00
575.00
1,270.00
115.00
150.00
335.00
975.00
3,650.00
150.00
195.00
255.00
335.00
575.00
750.00
1,270.00
2,805.00
4,745.00
335.00
440.00
575.00
750.00
975.00

$0 Indicator

Page 129 of 299

CDM #
3620044
3620051
3620069
3620077
3620085
3620093
3620101
3620119
3620127
3620135
3620143
3620150
3620168
3620176
3620184
3620192
3620200
3620218
3620226
3620234
3620267
3620275
3620283
3620291
3620309
3620317
3620325
3620333
3620341
3620358
3620366
3620374
3620382
3620390
3620408
3620416
3620424
3620432
3620440
3620457
3620465
3620473
3620481
3620499
3620507
3620515
3620523

CDM Description
KIT/PACK SURG 195X-254
KIT/PACK SURG 254X-331
KIT/PACK SURG 331X-431
KIT/PACK SURG 431X-561
KIT/PACK SURG 561X-730
TUBING/CONNECT 10-13
TUBING/CONNECT 13X-17
TUBING/CONNECT 17X-23
TUBING/CONNECT 23X-30
TUBING/CONNECT 30X-39
TUBING/CONNECT 39X-51
TUBING/CONNECT 51X-67
TUBING/CONNECT 67X-88
TUBING/CONNECT 115X-150
TUBING/CONNECT 150X-195
TUBING/CONNECT 195X-254
TUBING/CONNECT 254X-331
TUBING/CONNECT 431X-561
LASER FIBER 67X-88
LASER FIBER 2087X-2714
RETRV DEV INSR 431X-561
CATH DRAINAGE 10-13
CATH DRAINAGE 67X-88
CATH DRAINAGE 88X-115
CATH DRAINAGE 115X-150
CATH DRAINAGE 150X-195
CATH DRAINAGE 195X-254
CATH DRAINAGE 254X-331
CATH DRAINAGE 331X-431
CATH DRAINAGE 431X-561
CATH DRAINAGE 561X-730
CATH DRAINAGE 730X-949
CATH DRAINAGE 949X-1234
CATH DRAINAGE 2714X-3529
CUT/CAUT DEV 1234X-1605
INST/SUPP STERL 10-13
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30
INST/SUPP STERL 30X-39
INST/SUPP STERL 39X-51
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 115X-150
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254

239940119.xlsx.ms_office

Price
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
750.00
975.00
1,270.00
1,655.00
2,805.00
440.00
13,570.00
2,805.00
65.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
6,170.00
17,645.00
8,025.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00

$0 Indicator

Page 130 of 299

CDM #
3620531
3620549
3620556
3620564
3620572
3620580
3620598
3620606
3620614
3620622
3620630
3620648
3620655
3620663
3620671
3620689
3620697
3620705
3620713
3620721
3620739
3620747
3620754
3620762
3620770
3620788
3620796
3620804
3620812
3620820
3620838
3620846
3620853
3620879
3620887
3620895
3620903
3620911
3620929
3620937
3620945
3620952
3620960
3620978
3620986
3620994
3621000

CDM Description
INST/SUPP STERL 254X-331
INST/SUPP STERL 331X-431
INST/SUPP STERL 431X-561
INST/SUPP STERL 949X-1234
INST/SUPP STERL1605X-2087
INST/SUPP STERL2714X-3529
FIX DEV EXT 730X-949
FIX DEV EXT 949X-1234
FIX DEV EXT 1234X-1605
FIX DEV EXT 1605X-2087
GUIDEWIRE 10-13
GUIDEWIRE 13X-17
GUIDEWIRE 17X-23
GUIDEWIRE 23X-30
GUIDEWIRE 30X-39
GUIDEWIRE 39X-51
GUIDEWIRE 51X-67
GUIDEWIRE 67X-88
IMMOBIL/BIND 10-13
IMMOBIL/BIND 13X-17
IMMOBIL/BIND 195X-254
IMMOBIL/BIND 254X-331
TVT/TOT W SLNG 431X-561
ADHESION BARR 331X-431
ADHESION BARR 561X-730
ADHESION BARR 949X-1234
ADHESION BARR 1605X-2087
BREAST PROSTH 431X-561
CEMENT IMPLANT 51X-67
CEMENT IMPLANT 195X-254
CEMENT IMPLANT 431X-561
CEMENT IMPLANT 730X-949
CEMENT IMPLANT 2087X-2714
CONN TISS NHUM 88X-115
CONN TISS NHUM 115X-150
CONN TISS NHUM 150X-195
CONN TISS NHUM 195X-254
CONN TISS NHUM 331X-431
CONN TISS NHUM 561X-730
CONN TISS NHUM 730X-949
CONN TISS NHUM 2714X-3529
CONN TISS NHUM 3529X-4588
CONN TISS NHUM 5965X-7755
STNT NCOAT W 949X-1234
STNT NCOR T W 115X-150
NON JOINT DEV 3529X-4588
NON JOINT DEV 4588X-5965

239940119.xlsx.ms_office

Price
1,655.00
2,155.00
2,805.00
6,170.00
10,435.00
17,645.00
4,745.00
6,170.00
8,025.00
10,435.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
65.00
85.00
1,270.00
1,655.00
2,805.00
2,155.00
3,650.00
6,170.00
10,435.00
2,805.00
335.00
1,270.00
2,805.00
4,745.00
13,570.00
575.00
750.00
975.00
1,270.00
2,155.00
3,650.00
4,745.00
17,645.00
22,940.00
38,775.00
6,170.00
750.00
22,940.00
29,825.00

$0 Indicator

Page 131 of 299

CDM #
3621018
3621026
3621034
3621042
3621059
3621075
3621083
3621091
3621109
3621117
3621125
3621141
3621158
3621174
3621182
3621190
3621273
3621281
3621299
3621315
3621323
3621331
3621349
3621356
3621364
3621380
3621406
3621414
3621448
3621455
3621463
3621471
3621489
3621497
3621505
3621513
3621570
3621604
3621620
3621638
3621646
3621653
3621661
3621679
3621687
3621737
3621745

CDM Description
ANCHOR/SCREW 2714X-3529
ANCHOR/SCREW 3529X-4588
TVT/TOT W SLNG 561X-730
TVT/TOT W SLNG 949X-1234
TVT/TOT WO SLG 23X-30
TVT/TOT WO SLG 949X-1234
CLOSURE IMPLNT 561X-730
CLOSURE IMPLNT 730X-949
LEAD NEURO 3529X-4588
CLOSURE EXTERN 561X-730
LEAD NEURO 2087X-2714
LEAD NEURO 1234X-1605
CATH BLN DIL NON 67X-88
INTRO SHTH PEEL 30X-39
CUT/CAUT DEV 1605X-2087
ICD SINGLE 10082X-13107
CATH DIALYSIS LT 431X-561
BRACHY SRC I-125 NS
TRANSFUS BLD/BLD COMP
CATH URETERAL 150X-195
NON JOINT DEV 2087X-2714
CLOSURE EXTERN 2087X-2714
CLOSURE EXTERN 2714X-3529
CLOSURE EXTERN 1234X-1605
CLOSURE EXTERN 3529X-4588
CATH SUPRAPUB/CY150X-195
ANCHOR/SCREW 2087X-2714
ANCHOR/SCREW 4588X-5965
IOL POSTERIOR 730X-949
INST/SUPP STERL2087X-2714
INST/SUPP STERL3529X-4588
INST/SUPP STERL1234X-1605
INTRO SHTH PEEL 195X-254
STNT AORT/ILIA 5965X-7755
STNT NCOAT W 730X-949
TUBING/CONNECT 331X-431
CLOSURE EXTERN 730X-949
NON JOINT DEV 2714X-3529
KIT/PACK SURG 949X-1234
KIT/PACK SURG 1605X-2087
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
KIT/PACK SURG 1234X-1605
KIT/PACK SURG 730X-949
DAVINCI PT CT STATISTICAL
AUTOLOGOUS SALVAGE
UR BULK SYN 1M 195X-254

239940119.xlsx.ms_office

Price
17,645.00
22,940.00
3,650.00
6,170.00
150.00
6,170.00
3,650.00
4,745.00
22,940.00
3,650.00
13,570.00
8,025.00
440.00
195.00
10,435.00
65,535.00
2,805.00
184.00
778.00
975.00
13,570.00
13,570.00
17,645.00
8,025.00
22,940.00
975.00
13,570.00
29,825.00
4,745.00
13,570.00
22,940.00
8,025.00
1,270.00
38,775.00
4,745.00
2,155.00
4,745.00
17,645.00
6,170.00
10,435.00
4,976.00
1,743.00
8,025.00
4,745.00
873.00
1,270.00

$0 Indicator

Page 132 of 299

CDM #
3621778
3621802
3621810
3621828
3621836
3621844
3621851
3621869
3621877
3621950
3621968
3621976
3622008
3622016
3622024
3622073
3622081
3622099
3622107
3622115
3622123
3622156
3622164
3622172
3622180
3622198
3622214
3622222
3622230
3622248
3622255
3622263
3622271
3622289
3622297
3622305
3622362
3622412
3622438
3622487
3622495
3622503
3622560
3622578
3622586
3622594
3622602

CDM Description
NON JOINT DEV 5965X-7755
PROGRAM EXTERNAL 561X-730
INTRO SHTH GENRL 10-13
INTRO SHTH GENRL 13X-17
INTRO SHTH GENRL 17X-23
INTRO SHTH GENRL 67X-88
INTRO SHTH GENRL 150X-195
INTRO SHTH GENRL 254X-331
INTRO SHTH GENRL 331X-431
TUBING/CONNECT 88X-115
ADT/EXT NEURSTM1234X-1605
ADT/EXT NEURSTM 195X-254
FLW WND MTRX 1C2087X-2714
CEMENT IMPLANT 949X-1234
LASER FIBER 949X-1234
ADT/EXT NEURSTM 431X-561
ADT/EXT NEURSTM 561X-730
ADT/EXT NEURSTM 730X-949
ADT/EXT NEURSTM 949X-1234
CATH ATHRCT R 561X-730
CATH ATHRCT R 730X-949
CATH ATHRCT R 2087X-2714
CATH BLN DIL NON 13X-17
CATH BLN DIL NON 17X-23
CATH BLN DIL NON 23X-30
CATH BLN DIL NON 88X-115
CATH DRAINAGE 1234X-1605
CATH DRAINAGE 2087X-2714
CATH EP NO COOL 730X-949
CATH GUIDING 88X-115
CATH GUIDING 115X-150
CATH GUIDING 150X-195
CATH GUIDING 195X-254
CATH GUIDING 254X-331
CATH GUIDING 331X-431
CATH GUIDING 561X-730
CATH OCCLUSN 51X-67
CATH PTA N LSR 331X-431
CATH SUPRAPUB/CY 39X-51
CATH THROM EMB 254X-331
CATH URETERAL 13X-17
CATH URETERAL 115X-150
ADHESION BARR 254X-331
ADHESION BARR 431X-561
ADHESION BARR 730X-949
ADHESION BARR 1234X-1605
BREAST PROSTH 949X-1234

239940119.xlsx.ms_office

Price
38,775.00
3,650.00
65.00
85.00
115.00
440.00
975.00
1,655.00
2,155.00
575.00
8,025.00
1,270.00
13,570.00
6,170.00
6,170.00
2,805.00
3,650.00
4,745.00
6,170.00
3,650.00
4,745.00
13,570.00
85.00
115.00
150.00
575.00
8,025.00
13,570.00
4,745.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
3,650.00
335.00
2,155.00
255.00
1,655.00
85.00
750.00
1,655.00
2,805.00
4,745.00
8,025.00
6,170.00

$0 Indicator

Page 133 of 299

CDM #
3622610
3622628
3622636
3622644
3622651
3622669
3622677
3622685
3622693
3622719
3622800
3622818
3622826
3622834
3622842
3622859
3622867
3622875
3622883
3622891
3622909
3622933
3622982
3623006
3623014
3623022
3623030
3623048
3623055
3623063
3623071
3623089
3623097
3623105
3623113
3623121
3623139
3623147
3623154
3623162
3623170
3623220
3623238
3623758
3623766
3623774
3623782

CDM Description
CEMENT IMPLANT 23X-30
CEMENT IMPLANT 30X-39
CEMENT IMPLANT 39X-51
CEMENT IMPLANT 67X-88
CEMENT IMPLANT 115X-150
CEMENT IMPLANT 254X-331
CEMENT IMPLANT 561X-730
CEMENT IMPLANT 1234X-1605
CEMENT IMPLANT 1605X-2087
EXPANDER TISS 1605X-2087
JOINT DEVICE 195X-254
JOINT DEVICE 254X-331
JOINT DEVICE 331X-431
JOINT DEVICE 431X-561
JOINT DEVICE 1605X-2087
JOINT DEVICE 2087X-2714
JOINT DEVICE 2714X-3529
JOINT DEVICE 3529X-4588
JOINT DEVICE 4588X-5965
JOINT DEVICE 5965X-7755
JOINT DEVICE 7755X-10082
PUMP NONPRO TEMP 195X-254
TVT/TOT WO SLG 1605X-2087
UR SPHINCT 1605X-2087
INTRO SHTH GENRL 561X-730
INTRO SHTH PEEL 39X-51
INTRO SHTH PEEL 67X-88
INTRO SHTH PEEL 88X-115
INTRO SHTH PEEL 115X-150
LASER FIBER 88X-115
LASER FIBER 115X-150
LASER FIBER 150X-195
LASER FIBER 195X-254
LASER FIBER 254X-331
LASER FIBER 331X-431
LASER FIBER 431X-561
LASER FIBER 561X-730
LASER FIBER 730X-949
LASER FIBER 1234X-1605
LASER FIBER 1605X-2087
STNT NCOR T W 150X-195
LEAD NEURO 1605X-2087
LEAD NEURO 2714X-3529
TVT/TOT W SLNG 2087X-2714
TVT/TOT W SLNG 2714X-3529
TVT/TOT W SLNG 3529X-4588
GRAFT VASC 3529X-4588

239940119.xlsx.ms_office

Price
150.00
195.00
255.00
440.00
750.00
1,655.00
3,650.00
8,025.00
10,435.00
10,435.00
1,270.00
1,655.00
2,155.00
2,805.00
10,435.00
13,570.00
17,645.00
22,940.00
29,825.00
38,775.00
50,410.00
1,270.00
10,435.00
10,435.00
3,650.00
255.00
440.00
575.00
750.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
8,025.00
10,435.00
975.00
10,435.00
17,645.00
13,570.00
17,645.00
22,940.00
22,940.00

$0 Indicator

Page 134 of 299

CDM #
3623790
3623808
3623816
3623824
3623832
3623865
3623899
3623907
3623915
3623931
3623949
3623956
3623964
3623972
3623998
3624038
3624046
3624053
3624087
3624095
3624103
3624111
3624129
3624137
3624152
3624160
3632288
3661196
3661865
3661873
3661907
3661915
3661923
3661949
3661956
3661964
3661972
3661998
3662004
3662012
3662020
3662038
3662046
3662053
3662061
3662079
3662087

CDM Description
GRAFT VASC 4588X-5965
GRAFT VASC 5965X-7755
GRAFT VASC 7755X-10082
NROSTM NONRE 7755X-10082
TVT/TOT WO SLG 1234X-1605
NROSTM RECHG 2087X-2714
STNT AORT/IL 3529X-4588
STNT AORT/IL 4588X-5965
CATH INTRASPINE 561X-730
BREAST PROS SIL 730X-949
BREAST PROS SIL 431X-561
BREAST PROS SIL 561X-730
BREAST PROS SIL 949X-1234
BREAST PROS SIL1234X-1605
NON JOINT DEV 7755X-10082
HIP PREMIUM
KNEE PERFORMANCE
KNEE OXFORD
PENILE INFLAT 1234X-1605
PENILE INFLAT 1605X-2087
PENILE INFLAT 2087X-2714
PENILE INFLAT 2714X-3529
PENILE INFLAT 3529X-4588
PENILE INFLAT 5965X-7755
INFUS PMP PR 10082X-13107
CLOSURE EXTERN < 10
GRAFT MESH 7755X-10082
GRAFT VASC S 7755X-10082
NROSTM RECHG 13107X-17040
NEEDLE BRACHY 30X-39
NROSTM NONRE 17040X-22152
NROSTM RECHG 17040X-22152
BONE VOID FILL 730X-949
CATH INTRA US 730X-949
STNT NCOR T WO 195X-254
GRAFT VASC S 3529X-4588
TRABECULAR METAL 400
CATH SUPRAPUB/CY195X-254
LEAD NEURO 5965X-7755
JOINT DEVICE 67X-88
CLOSURE IMPLNT 1605X-2087
NROSTM PROGRAM 2714X-3529
ALLODERM SQ CM 561X-730
ALLODERM SQ CM 1605X-2087
ALLODERM SQ CM 3529X-4588
ALLODERM SQ CM 2714X-3529
GRFTJAKT SQ CM 2714X-3529

239940119.xlsx.ms_office

Price
29,825.00
38,775.00
50,410.00
50,410.00
8,025.00
13,570.00
22,940.00
29,825.00
3,650.00
4,745.00
2,805.00
3,650.00
6,170.00
8,025.00
50,410.00
34,000.00
21,500.00
25,000.00
8,025.00
10,435.00
13,570.00
17,645.00
22,940.00
38,775.00
65,535.00
45.00
50,410.00
50,410.00
85,200.00
195.00
110,760.00
110,760.00
4,745.00
4,745.00
1,270.00
22,940.00
2,000.00
1,270.00
38,775.00
440.00
10,435.00
17,645.00
3,650.00
10,435.00
22,940.00
17,645.00
17,645.00

$0 Indicator

Page 135 of 299

CDM #
3662095
3662103
3662129
3662137
3662145
3662152
3662160
3662178
3662186
3662194
3662202
3662210
3662228
3662236
3662244
3662251
3662269
3662277
3662285
3662293
3662301
3662319
3662327
3662335
3662343
3662350
3662368
3662376
3662392
3662400
3662418
3662426
3662434
3662442
3662459
3662467
3662475
3662483
3662491
3662509
3662517
3662525
3662533
3662558
3662566
3662574
3662582

CDM Description
GRFTJAKT SQ CM 2087X-2714
GRFTJAKT SQ CM 1234X-1605
INTEGRA SQ CM 2714X-3529
INTEGRA SQ CM 1234X-1605
INTEGRA SQ CM 2087X-2714
INTEGRA SQ CM 3529X-4588
PERMACOL SQ CM 1605X-2087
PERMACOL SQ CM 5965X-7755
BRACHY NONSTRAND 30X-39
PERMACOL SQ CM 2087X-2714
ALLODERM SQ CM 150X-195
ALLODERM SQ CM 195X-254
STNT AORT/IL 7755X-10082
STNT AORT/IL 10082X-13107
ALLODERM SQCM10082X-13107
ALLODERM SQ CM 4588X-5965
ALLODERM SQ CM 5965X-7755
GRAFT MESH 10082X-13107
JOINT DEVICE 88X-115
HARMONIC SCALPEL SHEARS
NROSTM PROGRAM 730X-949
NROSTM PROGRAM1234X-1605
NROSTM PROGRAM1605X-2087
UR SPHINCT 949X-1234
UR SPHINCT 730X-949
UR SPHINCT 561X-730
UR SPHINCT 431X-561
INTRAOP NERVE TEST PER HR
CATH OCCLUSN 195X-254
CONN TISS HUMN 5965X-7755
VERITAS SQ CM 5965X-7755
VERITAS SQ CM 4588X-5965
VERITAS SQ CM 3529X-4588
VERITAS SQ CM 2714X-3529
CLOSURE IMPLNT 949X-1234
CLOSURE IMPLNT 1234X-1605
BONE VOID FILL 1234X-1605
BONE VOID FILL 949X-1234
MD SUPPLIED BRST PROS SIL
MD SUPPLIED BRST PROSTH
BONE VOID FILL 431X-561
BONE VOID FILL 561X-730
DERMAGFT SQ CM 1234X-1605
CATH EP NON3D 331X-431
CATH EP NON3D 195X-254
MORCELLATOR 561X-730
MORCELLATOR 431X-561

239940119.xlsx.ms_office

Price
13,570.00
8,025.00
17,645.00
8,025.00
13,570.00
22,940.00
10,435.00
38,775.00
195.00
13,570.00
975.00
1,270.00
50,410.00
65,535.00
65,535.00
29,825.00
38,775.00
65,535.00
575.00
2,320.00
4,745.00
8,025.00
10,435.00
6,170.00
4,745.00
3,650.00
2,805.00
2,532.00
1,270.00
38,775.00
38,775.00
29,825.00
22,940.00
17,645.00
6,170.00
8,025.00
8,025.00
6,170.00
0.01
0.01
2,805.00
3,650.00
8,025.00
2,155.00
1,270.00
3,650.00
2,805.00

$0 Indicator

Page 136 of 299

CDM #
3662590
3662608
3662616
3662624
3662632
3662640
3662657
3662665
3662673
3662681
3662707
3662715
3662723
3662731
3662749
3662756
3662764
3662780
3662798
3662806
3662814
3662822
3662830
3662848
3662855
3662863
3662871
3662889
3662897
3662921
3662939
3662947
3662954
3662970
3662988
3662996
3663002
3663010
3663028
3663036
3663044
3663051
3663069
3663077
3663101
3663143
3663150

CDM Description
UR SPHINCT 2714X-3529
UR SPHINCT 3529X-4588
CATH BLN DIL NON 730X-949
IOL POSTERIOR CCI EDIT
IOL ANTERIOR CCI EDIT
ALLODERM SQ CM 1234X-1605
ALLODERM SQ CM 2087X-2714
CUT/CAUT DEV 2714X-3529
STNT NCORT T W 67X-88
ICD NOT S/D 17040X-22152
VOCAL CORD SYNTH 254X-331
SKIN SUB NOS 7755X-10082
SKIN SUB NOS 1605X-2087
SKIN SUB NOS 2087X-2714
SKIN SUB NOS 2714X-3529
FIX DEV EXT 2714X-3529
FIX DEV EXT 2087X-2714
PERMACOL SQCM10082X-13107
PERMACOL SQCM13107X-17040
PERMACOL SQ CM 949X-1234
PERMACOL SQ CM 2714X-3529
NEEDLE BRACHY 10-13
NEEDLE BRACHY 13X-17
NEEDLE BRACHY 17X-23
BRACHY NONSTRAND 23X-30
BRACHY NONSTRAND 39X-51
BRACHY NONSTRAND 17X-23
CONN TISS HUMN7755X-10082
CONN TISS HUM10082X-13107
RETRV DEV INSR 115X-150
RETRV DEV INSR 150X-195
RETRV DEV INSR 195X-254
LEAD NOT S/D 4588X-5965
GRAFT MESH 13107X-17040
X STOP IMPLANT 3529X-4588
ADT/EXT NEURSTM 30X-39
ADT/EXT NEURSTM 39X-51
CATH INTRASPINE 67X-88
CATH INTRASPINE 88X-115
CATH INTRASPINE 115X-150
CATH INTRASPINE 150X-195
KIT/PACK SURG 2714X-3529
PACEMAKER D RR 3529X-4588
INTEGRA SQ CM 1605X-2087
RADIESSE 0.1 ML INJ
TESTICULAR PROS1605X-2087
VERITAS SQ CM 2087X-2714

239940119.xlsx.ms_office

Price
17,645.00
22,940.00
4,745.00
0.01
0.01
8,025.00
13,570.00
17,645.00
440.00
110,760.00
1,655.00
50,410.00
10,435.00
13,570.00
17,645.00
17,645.00
13,570.00
65,535.00
85,200.00
6,170.00
17,645.00
65.00
85.00
115.00
150.00
255.00
115.00
50,410.00
65,535.00
750.00
975.00
1,270.00
29,825.00
85,200.00
22,940.00
195.00
255.00
440.00
575.00
750.00
975.00
17,645.00
22,940.00
10,435.00
1,425.00
10,435.00
13,570.00

$0 Indicator

Page 137 of 299

CDM #
3663176
3663184
3663226
3663234
3663242
3663259
3663275
3663291
3663309
3663317
3663325
3663333
3663358
3663366
3663374
3663382
3663390
3663408
3663416
3663424
3663432
3663440
3663457
3663465
3663473
3663481
3663499
3663507
3663515
3663523
3663531
3663549
3663556
3663564
3663580
3663606
3663614
3663648
3663655
3663689
3663697
3663705
3663713
3663721
3663739
3663747
3663754

CDM Description
LEAD NEURO TST 1234X-1605
KIT/PACK SURG 3529X-4588
PENILE NONINFL 3529X-4588
PENILE NONINFL 4588X-5965
EXPANDER TISS 730X-949
CATH DRAINAGE 3529X-4588
BONE GRFT IMP 2714X-3529
ORTHO L1830 13X-17
ORTHO L1820 561X-730
BONE GRFT IMP 4588X-5965
ALLODERM SQ CM 431X-561
ALLODERM SQ CM 949X-1234
ABLATION DEV 195X-254
SHUNT IMPLANT 115X-150
SHUNT IMPLANT 150X-195
SHUNT IMPLANT 195X-254
SHUNT IMPLANT 254X-331
SHUNT IMPLANT 331X-431
SHUNT IMPLANT 431X-561
SHUNT IMPLANT 561X-730
FILTER VENA CAV 30X-39
FILTER VENA CAV 561X-730
FILTER VENA CAV 949X-1234
FILTER VENA CAV1234X-1605
FILTER VENA CAV1605X-2087
SHUNT IMPLANT 88X-115
ICD DUAL 17040X-22152
LEAD NEURO 4588X-5965
CATH DIALYSIS LT 561X-730
CATH DIALYSIS LT 730X-949
CATH DIALYS LT 949X-1234
CATH DIALYS LT 1234X-1605
CATH DIALYS LT 1605X-2087
LEAD SNG ICD 4588X-5965
NROSTM NONRE 13107X-17040
PACEMAKER S RR 2714X-3529
PACEMKR N SN/DL4588X-5965
PACEMAKER S RR 3529X-4588
LEAD LT VENTRC 3529X-4588
STNT COATED W 2714X-3529
STNT COATED W 1234X-1605
STNT COATED W 949X-1234
CATH OCCLUSN 2087X-2714
HIP NON SYST 431X-561
HIP NON SYST 561X-730
HIP NON SYST 730X-949
HIP NON SYST 949X-1234

239940119.xlsx.ms_office

Price
8,025.00
22,940.00
22,940.00
29,825.00
4,745.00
22,940.00
17,645.00
85.00
3,650.00
29,825.00
2,805.00
6,170.00
1,270.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
195.00
3,650.00
6,170.00
8,025.00
10,435.00
575.00
110,760.00
29,825.00
3,650.00
4,745.00
6,170.00
8,025.00
10,435.00
29,825.00
85,200.00
17,645.00
29,825.00
22,940.00
22,940.00
17,645.00
8,025.00
6,170.00
13,570.00
2,805.00
3,650.00
4,745.00
6,170.00

$0 Indicator

Page 138 of 299

CDM #
3663762
3663770
3663788
3663796
3663804
3663812
3663820
3663838
3663846
3663853
3663861
3663879
3663887
3663895
3663903
3663911
3663929
3663937
3663945
3663952
3663960
3663978
3663986
3663994
3664000
3664018
3664026
3664034
3664042
3664109
3664117
3664125
3664133
3664141
3664158
3664166
3664174
3664182
3664224
3664232
3664240
3664257
3664265
3664273
3664281
3664323
3664331

CDM Description
HIP NON SYST 1234X-1605
HIP NON SYST 1605X-2087
HIP NON SYST 2087X-2714
HIP NON SYST 2714X-3529
HIP NON SYST 3529X-4588
HIP NON SYST 4588X-5965
HIP NON SYST 5965X-7755
HIP NON SYST 7755X-10082
HIP NON SYST 10082X-13107
HIP NON SYST 13107X-17040
HIP NON SYST 17040X-22152
KNEE NON SYST 431X-561
KNEE NON SYST 561X-730
KNEE NON SYST 730X-949
KNEE NON SYST 949X-1234
KNEE NON SYST 1234X-1605
KNEE NON SYST 1605X-2087
KNEE NON SYST 2087X-2714
KNEE NON SYST 2714X-3529
KNEE NON SYST 3529X-4588
KNEE NON SYST 4588X-5965
KNEE NON SYST 5965X-7755
KNEE NON SYST 7755X-10082
KNEE NON SYST10082X-13107
KNEE NON SYST13107X-17040
KNEE NON SYST17040X-22152
SKIN SUB NOS 10082X-13107
VASCULAR IMPL10082X-13107
ICD SINGLE 13107X-17040
PROBE CRYO ABL 2714X-3529
PROBE CRYO ABL 1605X-2087
PROBE CRYO ABL 2087X-2714
PROBE CRYO ABL 1234X-1605
PROBE CRYO ABL 4588X-5965
SEALANT PUL LIQ 730X-949
SEALANT PUL LIQ 561X-730
SEALANT PUL LIQ 949X-1234
LEAD SNG ICD 3529X-4588
NROSTM PROGRM13107X-17040
NROSTM PROGRM10082X-13107
ABLATION DEV 150X-195
ABLATION DEV 254X-331
MICROMATRIX PARTICL 100MG
MICROMATRIX PARTICL 200MG
MICROMATRIX PARTICL 500MG
NROSTM PROGRM 7755X-10082
ICD NOT S/D 22152X-28798

239940119.xlsx.ms_office

Price
8,025.00
10,435.00
13,570.00
17,645.00
22,940.00
29,825.00
38,775.00
50,410.00
65,535.00
85,200.00
110,760.00
2,805.00
3,650.00
4,745.00
6,170.00
8,025.00
10,435.00
13,570.00
17,645.00
22,940.00
29,825.00
38,775.00
50,410.00
65,535.00
85,200.00
110,760.00
65,535.00
65,535.00
85,200.00
17,645.00
10,435.00
13,570.00
8,025.00
29,825.00
4,745.00
3,650.00
6,170.00
22,940.00
85,200.00
65,535.00
975.00
1,655.00
1,264.00
2,528.00
5,925.00
50,410.00
143,990.00

$0 Indicator

Page 139 of 299

CDM #
3664349
3664356
3664364
3664372
3664380
3664398
3664406
3664513
3664521
3664539
3664547
3664554
3664562
3664570
3664588
3664596
3664604
3664612
3664620
3664638
3664646
3664653
3664679
3664695
3664703
3664711
3664729
3664737
3664745
3664752
3664760
3664778
3664786
3664794
3664802
3664810
3664828
3664836
3664844
3664851
3664869
3664877
3664885
3664893
3664901
3664919
3664927

CDM Description
NROSTM NONRE 22152X-28798
PROBE CRYO ABL 331X-431
PROBE CRYO ABL 431X-561
PROBE CRYO ABL 561X-730
CATH TRAN DIR 2087X-2714
CATH TRAN DIR 1605X-2087
CATH TRAN DIR 2714X-3529
PACMKR N SN/DL7755X-10082
MAKO PT CT STATISTICAL
KIT/PACK SURG 23X-30
HIP NON SYST 254X-331
KNEE NON SYST 254X-331
CEMENT IMPLANT 3529X-4588
INST/SUPP STERL4588X-5965
ORTHO L1830 10-13
LEAD NEURO TST7755X-10082
LEAD NEURO TST 4588X-5965
LEAD NEURO TST 3529X-4588
LEAD NEURO TST 2087X-2714
KIT/PACK SURG 4588X-5965
PENILE PROSTH CCI EDIT
COLLGN NV GUIDE1234X-1605
COLLGN NV GUIDE 949X-1234
COLLGN NV GUIDE1605X-2087
COLLGN NV GUIDE 730X-949
COLLGN NV GUIDE 561X-730
SHUNT IMPLANT 3529X-4588
KNEE NON SYST37438X-48670
KNEE NON SYST28798X-37438
KNEE NON SYST22152X-28798
MICROMATRIX PART 1000MG
KIT/PACK SURG 39X-51
SHUNT IMPLANT 2714X-3529
SHUNT IMPLANT 1234X-1605
VASCULAR IMPL 730X-949
VASCULAR IMPL 561X-730
VASCULAR IMPL 431X-561
VASCULAR IMPL 1234X-1605
VASCULAR IMPL 1605X-2087
VASCULAR IMPL 2087X-2714
MICROMATRIX PARTICL 60MG
SKIN SUB NOS 1234X-1605
CLOSURE IMPLNT 2714X-3529
CLOSURE IMPLNT 3529X-4588
GRAFT DURAL SUB 561X-730
LOOP RECORDER 3529X-4588
PORT INDWELLING2087X-2714

239940119.xlsx.ms_office

Price
143,990.00
2,155.00
2,805.00
3,650.00
13,570.00
10,435.00
17,645.00
50,410.00
150.00
1,655.00
1,655.00
22,940.00
29,825.00
65.00
50,410.00
29,825.00
22,940.00
13,570.00
29,825.00
0.01
8,025.00
6,170.00
10,435.00
4,745.00
3,650.00
22,940.00
243,350.00
187,190.00
143,990.00
6,750.00
255.00
17,645.00
8,025.00
4,745.00
3,650.00
2,805.00
8,025.00
10,435.00
13,570.00
1,600.00
8,025.00
17,645.00
22,940.00
3,650.00
22,940.00
13,570.00

$0 Indicator

Page 140 of 299

CDM #
3664935
3664943
3664950
3664968
3664976
3664984
3664992
3665007
3665015
3665023
3665031
3665049
3665056
3665064
3665072
3665080
3665098
3665106
3665114
3665148
3665155
3665163
3665171
3665189
3665197
3665205
3665213
3665221
3665239
3665247
3700010
3700028
3700036
3700044
3700051
3700069
3700077
3700085
3700093
3700101
3700119
3700127
3700135
3700275
3700424
3700515
3701539

CDM Description
DRAIN H2O SEAL 10-13
ALLODERM SQ CM7755X-10082
VASCULAR IMPL 88X-115
CONN TISS HUMN17040-22152
CATH ABLT VASC N949X-1234
CATH ABLT VASC N 730X-949
STNT NCOR T W 67X-88
VASCULAR IMPL13107X-17040
BRACHY NONSTRAND 10-13
TUBE IMPLANT 23X-30
STNT COATED W 2087X-2714
PACEMAKER D RR 5965X-7755
PACEMKR N SN/DL5965X-7755
SKIN SUB NOS 13107X-17040
ABLATION DEV 1234X-1605
LAP BAND SYST 561X-730
LAP BAND SYST 2087X-2714
STNT AORT/IL 13107X-17040
FIX DEV EXT 7755X-10082
CLOSURE EXTERN 1605X-2087
TENDON PROT CM22087X-2714
KIT/PACK SURG 30X-39
STRATTC25X40 22152X-28798
VERITAS SQ CM 7755X-10082
CONN TISS NHUM7755X-10082
CONN TIS NHUM10082X-13107
CONN TIS NHUM13107X-17040
STERILE TALC 4GM PWD
ENT IMPLANT 115X-150
UR BULK SYN 1M 254X-331
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
SURGERY LEVEL 3 1ST 30MIN
SURGERY LEVEL 3 ADD 15MIN
SURGERY LEVEL 4 1ST 30MIN
SURGERY LEVEL 4 ADD 15MIN
SURGERY LEVEL 5 1ST 30MIN
SURGERY LEVEL 5 ADD 15MIN
SURGERY LEVEL 6 1ST 30MIN
SURGERY LEVEL 6 ADD 15MIN
STATISTICAL SURG PER MIN
PEN ISOLATOR ATRICURE
HANDPIECE ATRICURE ABLAT
KIT VEIN HARVEST
SUTURE MIDCAB

239940119.xlsx.ms_office

Price
65.00
50,410.00
575.00
110,760.00
6,170.00
4,745.00
440.00
85,200.00
65.00
150.00
13,570.00
38,775.00
38,775.00
85,200.00
8,025.00
3,650.00
13,570.00
85,200.00
50,410.00
10,435.00
13,570.00
195.00
143,990.00
50,410.00
50,410.00
65,535.00
85,200.00
306.00
750.00
1,655.00
6,953.00
2,436.00
9,038.00
3,164.00
11,746.00
4,113.00
15,269.00
5,349.00
19,849.00
6,949.00
25,806.00
9,036.00
8,622.00
13,000.00
4,975.00
1,121.00

$0 Indicator

Page 141 of 299

CDM #
3701547
3701554
3701844
3701851
3701927
3701935
3701943
3701968
3701976
3701984
3701992
3702008
3702016
3702024
3702032
3702040
3702057
3702065
3702073
3702081
3702123
3702149
3702156
3702164
3702172
3702180
3702198
3702214
3702222
3702230
3702248
3702263
3702271
3702289
3702305
3702313
3702321
3702339
3702347
3702354
3702362
3702370
3702396
3702404
3702412
3702438
3702446

CDM Description
SUTURES MCABG CARDIAC
SUTURES VALVE
HARMONIC SCALPEL SHEARS
DISSECTOR ATRICURE
CATH DRAINAGE 23X-30
CATH DRAINAGE 30X-39
CATH DRAINAGE 39X-51
CUT/CAUT DEV 17X-23
CUT/CAUT DEV 150X-195
CUT/CAUT DEV 254X-331
CUT/CAUT DEV 331X-431
INST/SUPP STERL 30X-39
INST/SUPP STERL 39X-51
INST/SUPP STERL 115X-150
INST/SUPP STERL 254X-331
INST/SUPP STERL 561X-730
INST/SUPP STERL 730X-949
INST/SUPP STERL 949X-1234
INST/SUPP STERL1234X-1605
GUIDEWIRE 10-13
CONN TISS HUMN 2714X-3529
CONN TISS HUMN 5965X-7755
CONN TISS NHUM 254X-331
CONN TISS NHUM 331X-431
CONN TISS NHUM 4588X-5965
NON JOINT DEV 51X-67
ANCHOR/SCREW 51X-67
CATH DRAINAGE 13X-17
GRAFT VASC S 88X-115
GRAFT VASC S 115X-150
GRAFT VASC S 150X-195
GRAFT VASC S 254X-331
GRAFT VASC S 331X-431
GRAFT VASC S 431X-561
GRAFT VASC S 730X-949
GRAFT VASC S 949X-1234
GRAFT VASC S 1234X-1605
GRAFT VASC S 1605X-2087
GRAFT VASC S 4588X-5965
CLOSURE IMPLNT 10-13
CLOSURE IMPLNT 13X-17
CLOSURE IMPLNT 17X-23
CLOSURE IMPLNT 30X-39
CLOSURE IMPLNT 39X-51
CLOSURE IMPLNT 51X-67
CLOSURE IMPLNT 88X-115
CLOSURE IMPLNT 115X-150

239940119.xlsx.ms_office

Price
1,708.00
3,222.00
2,320.00
9,000.00
150.00
195.00
255.00
115.00
975.00
1,655.00
2,155.00
195.00
255.00
750.00
1,655.00
3,650.00
4,745.00
6,170.00
8,025.00
65.00
17,645.00
38,775.00
1,655.00
2,155.00
29,825.00
335.00
335.00
85.00
575.00
750.00
975.00
1,655.00
2,155.00
2,805.00
4,745.00
6,170.00
8,025.00
10,435.00
29,825.00
65.00
85.00
115.00
195.00
255.00
335.00
575.00
750.00

$0 Indicator

Page 142 of 299

CDM #
3702453
3702479
3702495
3702503
3702511
3702529
3702537
3702545
3702552
3702578
3702586
3702594
3702602
3702610
3702628
3702636
3702651
3702669
3702677
3702685
3702693
3702701
3702727
3702743
3702750
3702768
3702784
3702792
3702818
3702842
3702867
3702875
3702925
3702933
3702958
3702966
3702982
3702990
3703006
3703014
3703022
3703030
3703055
3703063
3703071
3703089
3703097

CDM Description
CLOSURE IMPLNT 150X-195
CLOSURE IMPLNT 254X-331
CLOSURE IMPLNT 431X-561
CLOSURE IMPLNT 561X-730
CLOSURE IMPLNT 730X-949
INTRO SHTH PEEL 30X-39
TUBING/CONNECT 195X-254
CLOSURE EXTERN 10-13
CLOSURE EXTERN 13X-17
CATH GENERAL 17X-23
CATH GENERAL 88X-115
CATH GENERAL 561X-730
CATH GENERAL 730X-949
CATH INF PERIPH 17X-23
CATH INF PERIPH 23X-30
CATH INF PERIPH 30X-39
CATH OCCLUSION 39X-51
CATH OCCLUSION 67X-88
CATH OCCLUSION 195X-254
CATH PTA N LSR 561X-730
CATH THROM EMBO 39X-51
CATH INF PERIPH 39X-51
CATH INF PERIPH 431X-561
ABLATION DEV 1605X-2087
ABLATION DEV 2087X-2714
ABLATION DEV 2714X-3529
ABLATION DEV 4588X-5965
CATH GENERAL 23X-30
PUMP NONPRO TEMP 150X-195
KIT/PACK SURG 150X-195
LASER FIBER 2087X-2714
PROBE CRYO ABL 2087X-2714
TUBING/CONNECT 88X-115
TUBING/CONNECT 254X-331
CANNULA 10-13
CANNULA 13X-17
CANNULA 23X-30
CANNULA 30X-39
CANNULA 39X-51
CANNULA 51X-67
CANNULA 67X-88
CANNULA 88X-115
CANNULA 150X-195
CANNULA 195X-254
CANNULA 254X-331
CANNULA 331X-431
CANNULA 431X-561

239940119.xlsx.ms_office

Price
975.00
1,655.00
2,805.00
3,650.00
4,745.00
195.00
1,270.00
65.00
85.00
115.00
575.00
3,650.00
4,745.00
115.00
150.00
195.00
255.00
440.00
1,270.00
3,650.00
255.00
255.00
2,805.00
10,435.00
13,570.00
17,645.00
29,825.00
150.00
975.00
975.00
13,570.00
13,570.00
575.00
1,655.00
65.00
85.00
150.00
195.00
255.00
335.00
440.00
575.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00

$0 Indicator

Page 143 of 299

CDM #
3703105
3703113
3703121
3703139
3703147
3703154
3703162
3703170
3703188
3703204
3703261
3703337
3703345
3703402
3703444
3703451
3703469
3703477
3703493
3703501
3703519
3703535
3703543
3703550
3703568
3703584
3703592
3703600
3703618
3703626
3703634
3703642
3703659
3703667
3703675
3703683
3703691
3703709
3703717
3703725
3703733
3703741
3703758
3703766
3703774
3703782
3703790

CDM Description
CATH DRAINAGE 10-13
INST/SUPP STERL 10-13
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 331X-431
CONN TISS NHUM 3529X-4588
CLOSURE EXTERN 17X-23
CLOSURE EXTERN 115X-150
CLOSURE EXTERN 150X-195
CONN TISS HUMN7755X-10082
INST/SUPP STERL 150X-195
CATH GENERAL 1605X-2087
INST/SUPP STERL 431X-561
VALVE AORT SYN 4588X-5965
KIT/PACK SURG 730X-949
CANNULA 17X-23
CATH GENERAL 51X-67
INST/SUPP STERL 195X-254
GUIDEWIRE 88X-115
CATH GENERAL 67X-88
CATH GENERAL 1234X-1605
VALVE HEART 2714X-3529
VALVE HEART 3529X-4588
VALVE HEART 4588X-5965
VALVE HEART 5965X-7755
RING HEART 1234X-1605
RING HEART 1605X-2087
RING HEART 2087X-2714
RING HEART 2714X-3529
RING HEART 3529X-4588
CATH DRAINAGE 150X-195
CATH DRAINAGE 195X-254
INTRO SHTH PEEL 67X-88
INTRO SHTH PEEL 88X-115
GUIDEWIRE 431X-561
GRAFT VASC S 10082X-13107
INTRO SHTH NPEEL 254X-331
CATH GENERAL 431X-561
GRAFT VASC 254X-331
INST/SUPP NONST 88X-115
GRAFT VASC 730X-949
GRAFT VASC 949X-1234
GRAFT VASC 1234X-1605

239940119.xlsx.ms_office

Price
65.00
65.00
85.00
115.00
150.00
335.00
440.00
575.00
2,155.00
22,940.00
115.00
750.00
975.00
50,410.00
975.00
10,435.00
2,805.00
29,825.00
4,745.00
115.00
335.00
1,270.00
575.00
440.00
8,025.00
17,645.00
22,940.00
29,825.00
38,775.00
8,025.00
10,435.00
13,570.00
17,645.00
22,940.00
975.00
1,270.00
440.00
575.00
2,805.00
65,535.00
1,655.00
2,805.00
1,655.00
575.00
4,745.00
6,170.00
8,025.00

$0 Indicator

Page 144 of 299

CDM #
3703808
3703816
3703824
3703832
3703840
3703857
3703865
3703873
3703881
3703899
3703907
3703915
3703923
3703931
3703949
3703956
3703964
3703972
3703980
3703998
3704004
3704012
3704020
3704038
3704046
3704095
3704103
3704111
3704129
3704137
3704145
3704152
3704160
3704210
3704228
3704236
3704244
3704251
3704269
3704277
3704285
3704293
3704301
3704319
3704327
3704335
3704343

CDM Description
CATH DRAINAGE 51X-67
CATH THROM EMBO 67X-88
GRAFT VASC 88X-115
LEAD NOT S/D 730X-949
CATH GUIDING 39X-51
CATH GUIDING 51X-67
CATH GUIDING 67X-88
CATH GUIDING 88X-115
CATH GUIDING 115X-150
CATH GUIDING 23X-30
CATH GUIDING 30X-39
CONN TISS NHUM 949X-1234
CONN TISS NHUM 1234X-1605
CONN TISS NHUM 1605X-2087
CONN TISS NHUM 2087X-2714
LEAD NOT S/D 431X-561
LEAD DUAL ICD 4588X-5965
ICD NOT S/D 17040X-22152
INTRO SHTH GENRL 10-13
INTRO SHTH GENRL 13X-17
INTRO SHTH GENRL 17X-23
INTRO SHTH GENRL 23X-30
INTRO SHTH GENRL 30X-39
INTRO SHTH GENRL 39X-51
INTRO SHTH GENRL 51X-67
INTRO SHTH PEEL 51X-67
INTRO SHTH PEEL 39X-51
INTRO SHTH PEEL 115X-150
INTRO SHTH PEEL 150X-195
CATH INF PERIPH 88X-115
CATH INF PERIPH 67X-88
CATH INF PERIPH 115X-150
CATH INF PERIPH 150X-195
CATH DRAINAGE 115X-150
CATH DRAINAGE 17X-23
CATH DRAINAGE 431X-561
CATH DRAINAGE 67X-88
CATH DRAINAGE 88X-115
GUIDEWIRE 13X-17
GUIDEWIRE 17X-23
ANCHOR/SCREW 30X-39
ANCHOR/SCREW 39X-51
CONN TISS NHUM 23X-30
CONN TISS NHUM 431X-561
GRAFT VASC 115X-150
GRAFT VASC 331X-431
GRAFT VASC 561X-730

239940119.xlsx.ms_office

Price
335.00
440.00
575.00
4,745.00
255.00
335.00
440.00
575.00
750.00
150.00
195.00
6,170.00
8,025.00
10,435.00
13,570.00
2,805.00
29,825.00
110,760.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
335.00
255.00
750.00
975.00
575.00
440.00
750.00
975.00
750.00
115.00
2,805.00
440.00
575.00
85.00
115.00
195.00
255.00
150.00
2,805.00
750.00
2,155.00
3,650.00

$0 Indicator

Page 145 of 299

CDM #
3704350
3704368
3704376
3704384
3704392
3704400
3704418
3704426
3704434
3704442
3704459
3704467
3704475
3704483
3704491
3704509
3704525
3704541
3704558
3704566
3704574
3704582
3704608
3704616
3704624
3704632
3704640
3704657
3704665
3704673
3704681
3704699
3704715
3704723
3704731
3704749
3704756
3704764
3704772
3704780
3704798
3704806
3704814
3704822
3704830
3704848
3704905

CDM Description
CONN TISS HUM10082X-13107
VASC CLOS DEV 331X-431
PROBE CRYO ABL 2714X-3529
VASCULAR IMPL10082X-13107
CATH OCCLUSION 51X-67
INST/SUPP NONST 17X-23
INST/SUPP NONST 67X-88
KIT/PACK SURG 10-13
KIT/PACK SURG 13X-17
KIT/PACK SURG 17X-23
TUBING/CONNECT 17X-23
ABLATION DEV 730X-949
ABLATION DEV 561X-730
ABLATION DEV 431X-561
ABLATION DEV 331X-431
CONN TISS HUMN 730X-949
D5% 0.2 NACL+KCL20 1000ML
LACTATED RINGRS 1000ML IR
LACTATED RINGRS 3000ML IR
D5% 250ML INJ
D5% 500ML INJ
D5% 0.2 NACL+KCL20 1000ML
D5% 500ML INJ
LACTATED RINGERS 1000ML
LACTATED RINGERS 1000ML
NACL 0.9% 150ML INJ
D5% 0.9 NACL 1000ML INJ
D5% 0.9 NACL 250ML INJ
D5% 0.9 NACL 500ML INJ
SOL IV NACL 0.9%HEP NA 2U
SOL IV NORMASOL-RPH7.4 1L
INST/SUPP STERL2714X-3529
CATH INF PERIPH 13X-17
INTRO SHTH GENRL 254X-331
INTRO SHTH GENRL 195X-254
INTRO SHTH GENRL 150X-195
VENT ASSIST 22152X-28798
VENT ASSIST 37438X-48670
VENT ASSIST 28798X-37438
CATH GENERAL 10-13
CATH GENERAL 13X-17
CUT/CAUT DEV 561X-730
CUT/CAUT DEV 431X-561
CUT/CAUT DEV 115X-150
TUBING/CONNECT 23X-30
TUBING/CONNECT 30X-39
VAS CLOS DEV 431X-561

239940119.xlsx.ms_office

Price
65,535.00
2,155.00
17,645.00
65,535.00
335.00
115.00
440.00
65.00
85.00
115.00
115.00
4,745.00
3,650.00
2,805.00
2,155.00
4,745.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
17,645.00
85.00
1,655.00
1,270.00
975.00
143,990.00
243,350.00
187,190.00
65.00
85.00
3,650.00
2,805.00
750.00
150.00
195.00
2,805.00

$0 Indicator

Page 146 of 299

CDM #
3704913
3704921
3704939
3704947
3704954
3704962
3704970
3704988
3705027
3705035
3705043
3705050
3705068
3705076
3705084
3705092
3705100
3705126
3705134
3705142
3705159
3705167
3705175
3705183
3705191
3705209
3705217
3705225
3705233
3705241
3705258
3705266
3705274
3705282
3705290
3705308
3705316
3705324
3705332
3705340
3705357
3705365
3705373
3705381
3705399
3705407
3705415

CDM Description
VAS CLOS DEV 561X-730
VAS CLOS DEV 730X-949
VAS CLOS DEV 949X-1234
GRAFT VASC S 13107X-17040
SEALANT PUL LIQ 561X-730
SEALANT PUL LIQ 730X-949
SEALANT PUL LIQ 949X-1234
CLOSURE IMPLNT 949X-1234
PACMKR N SN/DL7755X-10082
KIT/PACK SURG 88X-115
KIT/PACK SURG 30X-39
CATH GENERAL 30X-39
CATH GENERAL 39X-51
PORT INDWELLING 30X-39
PORT INDWELLING 39X-51
PORT INDWELLING 195X-254
PORT INDWELLING 254X-331
LEAD NOT S/D 561X-730
CATH GENERAL 115X-150
CATH GENERAL 195X-254
CATH GENERAL 150X-195
DRAIN CONTAINER 39X-51
GRAFT VASC 431X-561
GRAFT VASC 150X-195
VALVE HEART 1234X-1605
INTRO SHTH GENRL 331X-431
ICD SINGLE 10082X-13107
LEAD SNGL ICD 4588X-5965
LEAD NOT S/D ICD949X-1234
PROBE CRYO ABL 1605X-2087
VALVE HEART 10082X-13107
VASCULAR IMPL13107X-17040
GUIDEWIRE 150X-195
ICD DUAL 13107X-17040
LEAD SNG ICD 3529X-4588
VALVE HEART 13107X-17040
INST/SUPP NONST 51X-67
VALVE HEART 28798X-37438
CATH PTA N LSR 431X-561
STNT AORT/IL 13107X-17040
ANCHOR/SCREW 1605X-2087
ANCHOR/SCREW 150X-195
ANCHOR/SCREW 949X-1234
ANCHOR/SCREW 1605X-2087
ANCHOR/SCREW 730X-949
PROGRAM EXTERNL1234X-1605
CONN TISS NHUM 115X-150

239940119.xlsx.ms_office

Price
3,650.00
4,745.00
6,170.00
85,200.00
3,650.00
4,745.00
6,170.00
6,170.00
50,410.00
575.00
195.00
195.00
255.00
195.00
255.00
1,270.00
1,655.00
3,650.00
750.00
1,270.00
975.00
255.00
2,805.00
975.00
8,025.00
2,155.00
65,535.00
29,825.00
6,170.00
10,435.00
65,535.00
85,200.00
975.00
85,200.00
22,940.00
85,200.00
335.00
187,190.00
2,805.00
85,200.00
10,435.00
975.00
6,170.00
10,435.00
4,745.00
8,025.00
750.00

$0 Indicator

Page 147 of 299

CDM #
3705423
3705431
3705449
3705456
3705464
3705480
3705498
3705506
3705514
3705522
3705530
3705548
3705555
3705563
3800034
3800042
3800059
3800067
3800075
3800083
3800117
3800125
3800133
3800141
3800158
3800166
3800182
3800190
3800208
3800216
3800224
3800232
3800240
3800257
3800281
3800430
3800505
3800646
3800745
3800752
3800778
3800869
3800877
3800885
3800893
3800901
3800919

CDM Description
EXT RECHG SYS 1234X-1605
NROSTM RECHRG17040X-22152
LEAD NEURO 5965X-7755
CLOSURE IMPLNT 3529X-4588
ABLATION DEV 949X-1234
KIT/PACK SURG 1234X-1605
PACEMKR N SN/DL4588X-5965
CUT/CAUT DEV 51X-67
CUT/CAUT DEV 195X-254
INTRO SHTH LSR 2087X-2714
RETRV DEV INSR 431X-561
INST/SUPP STERL2087X-2714
KIT/PACK SURG 561X-730
CLOSURE EXTERN 39X-51
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
ANESTH GENERAL 1ST 30MIN
ANESTH GENERAL ADDL 15MIN
ANESTH MAC/REG 1ST 30MIN
ANESTH MAC/REG ADDL 15MIN
LOCAL ANESTHESIA
MOD SEDAT <5YRS 1ST 30M
MOD SEDAT =>5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
SURGERY LEVEL 3 1ST 30MIN
SURGERY LEVEL 3 ADD 15MIN
SURGERY LEVEL 4 1ST 30MIN
SURGERY LEVEL 4 ADD 15MIN
PT COUNT PRIMARY STAT
IOL ANTERIOR 115X-150
IOL ASTIGMATISM 331X-431
FIX DEV EXT 195X-254
OPS TPA 431X-561
CUT/CAUT DEV 150X-195
OPS VISION BLUE
CUT/CAUT DEV 10-13
CUT/CAUT DEV 13X-17
CUT/CAUT DEV 17X-23
CUT/CAUT DEV 23X-30
CUT/CAUT DEV 30X-39
CUT/CAUT DEV 195X-254

239940119.xlsx.ms_office

Price
8,025.00
110,760.00
38,775.00
22,940.00
6,170.00
8,025.00
29,825.00
335.00
1,270.00
13,570.00
2,805.00
13,570.00
3,650.00
255.00
945.00
334.00
1,230.00
433.00
1,707.00
599.00
750.00
264.00
350.00
1,580.00
1,580.00
549.00
1,567.00
550.00
2,024.00
705.00
2,587.00
907.00
3,361.00
1,178.00
750.00
2,155.00
1,270.00
2,805.00
975.00
120.00
65.00
85.00
115.00
150.00
195.00
1,270.00

$0 Indicator

Page 148 of 299

CDM #
3800927
3800935
3800943
3801172
3801180
3801198
3801206
3801214
3801222
3801230
3801248
3801255
3801263
3801271
3801297
3801321
3801339
3801347
3801354
3801362
3801370
3801388
3801396
3801404
3801412
3801735
3801743
3801750
3801768
3801776
3801784
3801792
3801800
3801818
3801826
3801834
3801842
3801966
3801974
3801982
3801990
3802006
3802014
3802022
3802030
3802048
3802055

CDM Description
CUT/CAUT DEV 331X-431
CUT/CAUT DEV 431X-561
CUT/CAUT DEV 561X-730
CANNULA 10-13
CANNULA 13X-17
CANNULA 17X-23
CANNULA 23X-30
CANNULA 30X-39
CANNULA 39X-51
CANNULA 51X-67
CANNULA 67X-88
CANNULA 88X-115
CANNULA 115X-150
CANNULA 150X-195
CANNULA 254X-331
GRAFT VASC S 331X-431
CLOSURE IMPLNT 10-13
CLOSURE IMPLNT 13X-17
CLOSURE IMPLNT 17X-23
CLOSURE IMPLNT 23X-30
CLOSURE IMPLNT 30X-39
CLOSURE IMPLNT 51X-67
CLOSURE IMPLNT 115X-150
CLOSURE IMPLNT 150X-195
CLOSURE IMPLNT 195X-254
CONN TISS HUMN 115X-150
CONN TISS HUMN 150X-195
CONN TISS HUMN 195X-254
CONN TISS HUMN 254X-331
CONN TISS HUMN 2087X-2714
CONN TISS HUMN 2714X-3529
CONN TISS HUMN 949X-1234
ANCHOR/SCREW 561X-730
ANCHOR/SCREW 730X-949
ANCHOR/SCREW 949X-1234
ANCHOR/SCREW 1234X-1605
ANCHOR/SCREW 1605X-2087
NON JOINT DEV 13X-17
CONN TISS HUMN 1234X-1605
NON JOINT DEV 17X-23
NON JOINT DEV 23X-30
NON JOINT DEV 30X-39
NON JOINT DEV 39X-51
NON JOINT DEV 431X-561
NON JOINT DEV 561X-730
NON JOINT DEV 730X-949
NON JOINT DEV 949X-1234

239940119.xlsx.ms_office

Price
2,155.00
2,805.00
3,650.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,655.00
2,155.00
65.00
85.00
115.00
150.00
195.00
335.00
750.00
975.00
1,270.00
750.00
975.00
1,270.00
1,655.00
13,570.00
17,645.00
6,170.00
3,650.00
4,745.00
6,170.00
8,025.00
10,435.00
85.00
8,025.00
115.00
150.00
195.00
255.00
2,805.00
3,650.00
4,745.00
6,170.00

$0 Indicator

Page 149 of 299

CDM #
3802063
3802071
3802113
3802139
3802147
3802303
3802337
3802352
3802436
3802444
3802550
3802568
3802600
3802618
3802626
3802634
3802642
3802659
3802683
3802709
3802717
3802741
3802758
3802790
3802816
3802832
3802899
3802949
3802956
3802972
3802998
3803038
3803079
3803111
3803186
3803202
3803210
3803228
3803251
3803269
3803301
3803343
3803392
3803400
3803491
3803509
3803517

CDM Description
NON JOINT DEV 1234X-1605
NON JOINT DEV 1605X-2087
ANCHOR/SCREW 195X-254
ANCHOR/SCREW 254X-331
NON JOINT DEV 51X-67
NON JOINT DEV 195X-254
NON JOINT DEV 115X-150
ANCHOR/SCREW 150X-195
ESSR BC SYS 1234X-1605
CLOSURE IMPLNT 431X-561
CUT/CAUT DEV 39X-51
CUT/CAUT DEV 51X-67
DYE INDOCYANINE GRN
OPS VISCOAT
OPS HEALON 0.4
VOCAL CORD SYNTH 331X-431
CLOSURE IMPLNT 88X-115
CLOSURE IMPLNT 39X-51
GRAFT MESH 115X-150
OPS MITOMYCIN
CLOSURE IMPLNT 331X-431
CUT/CAUT DEV 67X-88
CUT/CAUT DEV 88X-115
CUT/CAUT DEV 254X-331
FIX DEV EXT 88X-115
OPS HEALON 0.8
ANCHOR/SCREW 331X-431
GRAFT MESH 23X-30
GRAFT MESH 67X-88
NON JOINT DEV 150X-195
GRAFT MESH 39X-51
CUT/CAUT DEV 115X-150
OCULAR PERFLUORO 431X-561
CONN TISS HUMN 561X-730
ANCHOR/SCREW 431X-561
CONN TISS HUMN 331X-431
CONN TISS HUMN 730X-949
CONN TISS HUMN 1605X-2087
CONN TISS HUMN 431X-561
NON JOINT DEV 88X-115
OPS BOTULINUM TXN730X-949
ANCHOR/SCREW 115X-150
CLOSURE IMPLNT 254X-331
GRAFT MESH 150X-195
GRAFT MESH 51X-67
GRAFT MESH 195X-254
GRAFT MESH 88X-115

239940119.xlsx.ms_office

Price
8,025.00
10,435.00
1,270.00
1,655.00
335.00
1,270.00
750.00
975.00
8,025.00
2,805.00
255.00
335.00
225.00
447.00
437.00
2,155.00
575.00
255.00
750.00
509.00
2,155.00
440.00
575.00
1,655.00
575.00
667.00
2,155.00
150.00
440.00
975.00
255.00
750.00
2,805.00
3,650.00
2,805.00
2,155.00
4,745.00
10,435.00
2,805.00
575.00
4,745.00
750.00
1,655.00
975.00
335.00
1,270.00
575.00

$0 Indicator

Page 150 of 299

CDM #
3803525
3803533
3803541
3803558
3803574
3803582
3803590
3803616
3803657
3803665
3803723
3803780
3803798
3803814
3803830
3803871
3803889
3803947
3803970
3804028
3804077
3804085
3804150
3804200
3804226
3804275
3804358
3804481
3804580
3804705
3804747
3804754
3804770
3804804
3804812
3804820
3804994
3805496
3805835
3805843
3805850
3805868
3805876
3805884
3805892
3805900
3805918

CDM Description
GRAFT MESH 2087X-2714
NON JOINT DEV 331X-431
FIX DEV EXT 150X-195
ANCHOR/SCREW 67X-88
BREAST PROSTH 1234X-1605
GRAFT MESH 561X-730
GRAFT MESH 730X-949
GRAFT MESH 431X-561
GRAFT MESH 949X-1234
GRAFT MESH 1234X-1605
BREAST PROSTH 561X-730
FIX DEV EXT 67X-88
ANCHOR/SCREW 51X-67
ANCHOR/SCREW 23X-30
BREAST PROSTH 730X-949
OPS DUOVISC 0.5CC
OPS PROVISC 0.55 ML
NON JOINT DEV 254X-331
GRAFT MESH 30X-39
GRAFT MESH 331X-431
NON JOINT DEV 10-13
ANCHOR/SCREW 13X-17
ANCHOR/SCREW 10-13
ANCHOR/SCREW 39X-51
ANCHOR/SCREW 30X-39
ANCHOR/SCREW 88X-115
OCULAR AQU DRAIN 150X-195
NON JOINT DEV 67X-88
CLOSURE IMPLNT 67X-88
GRAFT MESH 2714X-3529
FIX DEV EXT 10-13
FIX DEV EXT 13X-17
FIX DEV EXT 23X-30
FIX DEV EXT 51X-67
FIX DEV EXT 115X-150
FIX DEV EXT 254X-331
GRAFT VASC S 431X-561
GRAFT MESH 254X-331
ENDO PROC UP TO 10 MIN
ENDO PROC 11-20 MIN
ENDO PROC 21-30 MIN
ENDO PROC 31-40 MIN
ENDO PROC 41-50 MIN
ENDO PROC 51-60 MIN
ENDO PROC 61-70 MIN
ENDO PROC 71-80 MIN
ENDO PROC 81-90 MIN

239940119.xlsx.ms_office

Price
13,570.00
2,155.00
975.00
440.00
8,025.00
3,650.00
4,745.00
2,805.00
6,170.00
8,025.00
3,650.00
440.00
335.00
150.00
4,745.00
634.00
321.00
1,655.00
195.00
2,155.00
65.00
85.00
65.00
255.00
195.00
575.00
975.00
440.00
440.00
17,645.00
65.00
85.00
150.00
335.00
750.00
1,655.00
2,805.00
1,655.00
1,694.00
2,398.00
3,099.00
3,804.00
4,504.00
5,210.00
5,913.00
6,617.00
7,320.00

$0 Indicator

Page 151 of 299

CDM #
3805926
3805934
3805942
3805959
3805967
3805975
3805983
3805991
3806007
3806015
3806023
3806056
3806106
3806114
3806122
3806205
3806437
3806494
3806510
3806528
3806536
3806544
3806551
3806569
3806577
3806585
3806601
3806619
3806627
3806635
3806643
3806650
3806676
3807724
3807757
3807765
3807773
3807781
3807799
3807807
3807815
3807823
3807831
3807849
3807856
3807864
3807872

CDM Description
ENDO PROC 91-100 MIN
ENDO PROC 101-110 MIN
ENDO PROC 111-120 MIN
ENDO PROC 121-130 MIN
ENDO PROC 131-140 MIN
ENDO PROC 141-150 MIN
ENDO PROC 151-160 MIN
ENDO PROC 161-170 MIN
ENDO PROC 171-180 MIN
ENDO PROC OVER 180 MIN
EST VIST/GTB REM/TRCH CHG
ENT IMPLANT 115X-150
ENT IMPLANT 150X-195
ENT IMPLANT 195X-254
ENT IMPLANT 254X-331
METAPHALNG JNT 561X-730
ANCHOR/SCREW 17X-23
IOL POSTERIOR 51X-67
IOL POSTERIOR 88X-115
IOL POSTERIOR 115X-150
IOL POSTERIOR 150X-195
IOL POSTERIOR 195X-254
IOL POSTERIOR 254X-331
IOL POSTERIOR 331X-431
IOL POSTERIOR 431X-561
IOL POSTERIOR 561X-730
CATH DRAINAGE 13X-17
CATH DRAINAGE 17X-23
CATH DRAINAGE 23X-30
CATH DRAINAGE 30X-39
CATH DRAINAGE 39X-51
CATH DRAINAGE 51X-67
ADHESION BARR 13X-17
CATH ABLT VAS N 561X-730
CATH BLN DIL NON 254X-331
CONN TISS HUMN 4588X-5965
CONN TISS NHUM 254X-331
CONN TISS NHUM 431X-561
CONN TISS NHUM 561X-730
CONN TISS NHUM 949X-1234
CONN TISS NHUM 1234X-1605
CONN TISS NHUM 2087X-2714
CONN TISS NHUM 2714X-3529
JOINT DEVICE 254X-331
JOINT DEVICE 331X-431
JOINT DEVICE 561X-730
JOINT DEVICE 730X-949

239940119.xlsx.ms_office

Price
8,024.00
8,727.00
9,431.00
10,135.00
10,839.00
11,542.00
12,245.00
12,948.00
13,652.00
14,355.00
239.00
750.00
975.00
1,270.00
1,655.00
3,650.00
115.00
335.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
85.00
115.00
150.00
195.00
255.00
335.00
85.00
3,650.00
1,655.00
29,825.00
1,655.00
2,805.00
3,650.00
6,170.00
8,025.00
13,570.00
17,645.00
1,655.00
2,155.00
3,650.00
4,745.00

$0 Indicator

Page 152 of 299

CDM #
3807880
3807914
3807922
3807930
3807948
3807955
3807963
3807971
3807989
3807997
3808003
3808011
3808029
3808037
3808045
3808052
3808094
3808102
3808110
3808128
3808136
3808144
3808151
3808169
3808193
3808201
3808219
3808227
3808235
3808243
3808300
3808318
3808326
3808334
3808359
3808367
3808375
3808383
3808391
3808409
3808417
3808425
3808466
3808482
3808490
3808508
3808516

CDM Description
JOINT DEVICE 949X-1234
INST/SUPP NONST 10-13
INST/SUPP NONST 13X-17
INST/SUPP NONST 17X-23
INST/SUPP NONST 23X-30
INST/SUPP NONST 30X-39
INST/SUPP NONST 39X-51
INST/SUPP NONST 51X-67
INST/SUPP NONST 67X-88
INST/SUPP NONST 88X-115
INST/SUPP NONST 115X-150
INST/SUPP NONST 150X-195
INST/SUPP NONST 195X-254
ABLATION DEV 730X-949
ABLATION DEV 949X-1234
ABLATION DEV 1234X-1605
CATH GENERAL 10-13
CATH GENERAL 13X-17
CATH GENERAL 17X-23
CATH GENERAL 23X-30
CATH GENERAL 30X-39
CATH GENERAL 39X-51
CATH GENERAL 51X-67
CATH GENERAL 67X-88
CATH GENERAL 195X-254
CATH GENERAL 254X-331
CATH GENERAL 331X-431
CATH GENERAL 431X-561
CATH GENERAL 561X-730
CATH GENERAL 730X-949
ADHESION BARR 88X-115
ADHESION BARR 115X-150
ADHESION BARR 150X-195
ADHESION BARR 195X-254
INST/SUPP STERL 561X-730
INST/SUPP STERL 730X-949
GUIDEWIRE 88X-115
GUIDEWIRE 115X-150
GUIDEWIRE 150X-195
GUIDEWIRE 195X-254
GUIDEWIRE 254X-331
GUIDEWIRE 331X-431
GUIDEWIRE 949X-1234
CLOSURE EXTERN 10-13
CLOSURE EXTERN 13X-17
CLOSURE EXTERN 17X-23
CLOSURE EXTERN 23X-30

239940119.xlsx.ms_office

Price
6,170.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
4,745.00
6,170.00
8,025.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
575.00
750.00
975.00
1,270.00
3,650.00
4,745.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
6,170.00
65.00
85.00
115.00
150.00

$0 Indicator

Page 153 of 299

CDM #
3808524
3808532
3808557
3808565
3808573
3808581
3808599
3808623
3808664
3808672
3808680
3808698
3808706
3808714
3808722
3808748
3808755
3808763
3808771
3808789
3808797
3808805
3808813
3808821
3808839
3808847
3808854
3808870
3808888
3808995
3809019
3809027
3809043
3809050
3809068
3809084
3809092
3809100
3809118
3809258
3809266
3809274
3809308
3809316
3809381
3809407
3809423

CDM Description
CLOSURE EXTERN 30X-39
CLOSURE EXTERN 39X-51
CLOSURE EXTERN 67X-88
CLOSURE EXTERN 88X-115
CLOSURE EXTERN 115X-150
CLOSURE EXTERN 150X-195
CLOSURE EXTERN 195X-254
CLOSURE EXTERN 431X-561
GRAFT VASC 115X-150
GRAFT VASC 150X-195
GRAFT VASC 195X-254
GRAFT VASC 254X-331
GRAFT VASC 730X-949
GRAFT VASC 431X-561
GRAFT VASC 561X-730
GRAFT VASC 949X-1234
GRAFT VASC 1234X-1605
GRAFT VASC 1605X-2087
GRAFT VASC 2087X-2714
GRAFT VASC 2714X-3529
IMMOBIL/BIND 17X-23
IMMOBIL/BIND 23X-30
IMMOBIL/BIND 30X-39
IMMOBIL/BIND 39X-51
IMMOBIL/BIND 51X-67
IMMOBIL/BIND 67X-88
IMMOBIL/BIND 88X-115
FIX DEV EXT 431X-561
FIX DEV EXT 561X-730
TVT/TOT WO SLG 254X-331
PORT INDWELLING 254X-331
CORNEAL DEVICE 2087X-2714
EXPANDER TISS 1234X-1605
PUMP NONPRO PERM 115X-150
PUMP NONPRO TEMP 88X-115
CATH DIALYSIS LT 150X-195
CATH DIALYSIS LT 195X-254
CATH DIALYSIS LT 254X-331
CATH DIALYSIS LT 331X-431
CATH INF PERIPH 115X-150
CATH INF PERIPH 150X-195
CATH INF PERIPH 195X-254
CATH INF PERIPH 730X-949
CATH URETERAL 10-13
CATH THROM EMBO 39X-51
PUMP NONPRO TEMP 254X-331
IOL POSTERIOR 39X-51

239940119.xlsx.ms_office

Price
195.00
255.00
440.00
575.00
750.00
975.00
1,270.00
2,805.00
750.00
975.00
1,270.00
1,655.00
4,745.00
2,805.00
3,650.00
6,170.00
8,025.00
10,435.00
13,570.00
17,645.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
2,805.00
3,650.00
1,655.00
1,655.00
13,570.00
8,025.00
750.00
575.00
975.00
1,270.00
1,655.00
2,155.00
750.00
975.00
1,270.00
4,745.00
65.00
255.00
1,655.00
255.00

$0 Indicator

Page 154 of 299

CDM #
3809431
3809456
3809464
3809472
3809480
3809506
3809514
3809589
3809597
3809613
3809639
3809647
3809654
3809688
3809712
3809720
3809738
3809746
3809753
3809761
3809779
3809787
3809795
3809829
3809845
3809878
3809894
3809910
3809928
3809951
3809969
3809977
3809985
3809993
3810009
3810017
3810025
3810033
3810041
3810058
3810082
3810090
3810108
3810124
3810132
3810140
3810157

CDM Description
IOL POSTERIOR 67X-88
LAP BAND SYST 2714X-3529
OCULAR PROSTH 10-13
OCULAR PROSTH 13X-17
OCULAR PROSTH 23X-30
OCULAR PROSTH 331X-431
OCULAR PROSTH 561X-730
RETINOL DEV SIL 13X-17
RETINOL DEV SIL 17X-23
RETINOL DEV SIL 331X-431
STNT NCOR T WO 88X-115
STNT NCOR T WO 115X-150
STNT NCOR T WO 150X-195
INTRO SHTH GENRL 23X-30
KIT/PACK SURG 51X-67
KIT/PACK SURG 88X-115
KIT/PACK SURG 115X-150
KIT/PACK SURG 150X-195
KIT/PACK SURG 195X-254
KIT/PACK SURG 331X-431
KIT/PACK SURG 431X-561
KIT/PACK SURG 561X-730
KIT/PACK SURG 1605X-2087
LASER FIBER 88X-115
LASER FIBER 150X-195
LASER FIBER 331X-431
LASER FIBER 561X-730
LASER FIBER 949X-1234
LASER FIBER 1234X-1605
TUBING/CONNECT 10-13
TUBING/CONNECT 13X-17
TUBING/CONNECT 17X-23
TUBING/CONNECT 23X-30
TUBING/CONNECT 30X-39
TUBING/CONNECT 39X-51
TUBING/CONNECT 51X-67
TUBING/CONNECT 67X-88
TUBING/CONNECT 88X-115
TUBING/CONNECT 115X-150
TUBING/CONNECT 150X-195
CATH DRAINAGE 10-13
CATH DRAINAGE 88X-115
CATH DRAINAGE 150X-195
INST/SUPP STERL 10-13
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30

239940119.xlsx.ms_office

Price
440.00
17,645.00
65.00
85.00
150.00
2,155.00
3,650.00
85.00
115.00
2,155.00
575.00
750.00
975.00
150.00
335.00
575.00
750.00
975.00
1,270.00
2,155.00
2,805.00
3,650.00
10,435.00
575.00
975.00
2,155.00
3,650.00
6,170.00
8,025.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
65.00
575.00
975.00
65.00
85.00
115.00
150.00

$0 Indicator

Page 155 of 299

CDM #
3810165
3810173
3810181
3810199
3810207
3810215
3810223
3810231
3810249
3810256
3810264
3810272
3810280
3810298
3810306
3810314
3810322
3810330
3810348
3810355
3810363
3810371
3810389
3810397
3810413
3810421
3810439
3810447
3810454
3810462
3810470
3810488
3810496
3810504
3810512
3810538
3810546
3810553
3810587
3810595
3810603
3810611
3810645
3810702
3810710
3810728
3810769

CDM Description
INST/SUPP STERL 30X-39
INST/SUPP STERL 39X-51
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 115X-150
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INST/SUPP STERL 254X-331
INST/SUPP STERL 431X-561
INST/SUPP STERL 949X-1234
INST/SUPP STERL1234X-1605
FIX DEV EXT 949X-1234
FIX DEV EXT 1234X-1605
GUIDEWIRE 10-13
GUIDEWIRE 13X-17
GUIDEWIRE 17X-23
GUIDEWIRE 23X-30
GUIDEWIRE 30X-39
GUIDEWIRE 39X-51
GUIDEWIRE 51X-67
GUIDEWIRE 67X-88
IMMOBIL/BIND 10-13
IMMOBIL/BIND 13X-17
BREAST PROSTH 431X-561
ENT IMPLANT 10-13
ENT IMPLANT 13X-17
ENT IMPLANT 17X-23
ENT IMPLANT 23X-30
ENT IMPLANT 30X-39
ENT IMPLANT 39X-51
ENT IMPLANT 51X-67
ENT IMPLANT 67X-88
ENT IMPLANT 88X-115
ENT IMPLANT 331X-431
GRAFT VASC S 561X-730
GRAFT VASC S 730X-949
NON JOINT DEV 2714X-3529
TVT/TOT W SLNG 949X-1234
TUBING/CONNECT 195X-254
CUT/CAUT DEV 730X-949
LEAD NEURO 2087X-2714
CATH BLN DIL NON 115X-150
IOL ANTERIOR 51X-67
FIX DEV EXT 730X-949
IOL POSTERIOR 730X-949
JOINT DEVICE 1605X-2087

239940119.xlsx.ms_office

Price
195.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
2,805.00
6,170.00
8,025.00
6,170.00
8,025.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
65.00
85.00
2,805.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
2,155.00
3,650.00
4,745.00
17,645.00
6,170.00
1,270.00
4,745.00
13,570.00
750.00
335.00
4,745.00
4,745.00
10,435.00

$0 Indicator

Page 156 of 299

CDM #
3810777
3810785
3810876
3810884
3810900
3810967
3810983
3811007
3811015
3811023
3811031
3811049
3811064
3811080
3811098
3811106
3811122
3811163
3811171
3811197
3811205
3811213
3811221
3811254
3811262
3811296
3811304
3811312
3811320
3811346
3811361
3811379
3811387
3811395
3811403
3811411
3811429
3811445
3811460
3811478
3811494
3811502
3811510
3811528
3811551
3811569
3811577

CDM Description
KIT/PACK SURG 1234X-1605
TVT/TOT W SLNG 1234X-1605
CATH DIALYSIS LT 431X-561
GRAFT VASC 331X-431
JOINT DEVICE 2087X-2714
NROSTM REMOTE 949X-1234
CLOSURE EXTERN 561X-730
CHANGE TUBE SIMPLE
VISIT LEVEL 2 EST PT
INPT BED HOLD/15MIN STAT
PACU NOBILL OTH DEPT EA15
CANNULA 23X-30
CANNULA 39X-51
CANNULA 67X-88
BRUSH CYTO/MICRO 13X-17
BRUSH CYTO/MICRO 88X-115
BRUSH CYTO/MICRO 150X-195
CATH GENERAL 115X-150
CATH ABL VAS NV 730X-949
CATH ABL VAS NV1234X-1605
CATH BLN DIL NON 195X-254
CATH BLN DIL NON 254X-331
CATH TISS DISS N 115X-150
CATH TISS DISS N 254X-331
CUT/CAUT DEV 13X-17
CUT/CAUT DEV 30X-39
CUT/CAUT DEV 115X-150
CUT/CAUT DEV 150X-195
CUT/CAUT DEV 195X-254
CUT/CAUT DEV 331X-431
GUIDEWIRE 150X-195
GUIDEWIRE 195X-254
GUIDEWIRE 254X-331
GUIDEWIRE 331X-431
TUBE IMPLANT 51X-67
TUBE IMPLANT 67X-88
TUBE IMPLANT 88X-115
TUBE IMPLANT 150X-195
STNT NON COR T W 88X-115
STNT NCOAT W 51X-67
STNT NCOAT W 88X-115
STNT NCOAT W1605X-2087
STNT NCOAT W2087X-2714
STNT NCOAT WO 39X-51
STNT NCOAT WO 88X-115
STNT NCOAT WO 1234X-1605
INST/SUPP STERL 10-13

239940119.xlsx.ms_office

Price
8,025.00
8,025.00
2,805.00
2,155.00
13,570.00
6,170.00
3,650.00
987.00
288.00
150.00
255.00
440.00
85.00
575.00
975.00
750.00
4,745.00
8,025.00
1,270.00
1,655.00
750.00
1,655.00
85.00
195.00
750.00
975.00
1,270.00
2,155.00
975.00
1,270.00
1,655.00
2,155.00
335.00
440.00
575.00
975.00
575.00
335.00
575.00
10,435.00
13,570.00
255.00
575.00
8,025.00
65.00

$0 Indicator

S
S

Page 157 of 299

CDM #
3811585
3811593
3811601
3811619
3811635
3811643
3811668
3811676
3811684
3811692
3811700
3811718
3811726
3811734
3811759
3811767
3811783
3811791
3811817
3811825
3811833
3811841
3811866
3811874
3811882
3811890
3811908
3811916
3811924
3811932
3811940
3881877
3881901
3881919
3881927
3881935
3881943
3881950
3881968
3881976
3881984
3881992
3882008
3882032
3882040
3882057
3882065

CDM Description
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30
INST/SUPP STERL 30X-39
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 115X-150
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INST/SUPP STERL 254X-331
INST/SUPP STERL 331X-431
KIT/PACK SURG 115X-150
TISSUE MARKER 17X-23
TUBING/CONNECT 30X-39
TUBING/CONNECT 51X-67
TUBING/CONNECT 67X-88
TUBING/CONNECT 115X-150
CLOSURE IMPLNT 150X-195
BUTTON ENDO 115X-150
GUIDEWIRE 88X-115
CATH TISS DISS N 254X-331
CATH ABLT VAS N 730X-949
NACL 0.9% 10ML INJ
D5W 500ML
D5 1/2 NS IL
NACL 0.9% 500ML
LR 500ML
NACL 0.9% IL
NACL 0.9% 100ML
SOD CHLORIDE 0.9% 50MLINJ
LR 1000ML IV
COCHLEAR DEV 28798X-37438
IM RETISERT 17040X-22152
NROSTM RECHG 17040X-22152
COCHLEAR DEV 22152X-28798
TVT/TOT WO SLG 730X-949
GLUCOSE BLOOD BY DEVICE
CATH INTRASPINE 561X-730
INST/SUPP NONST 730X-949
LEAD NEURO 1234X-1605
LEAD NEURO 1605X-2087
NROSTM RECHG 13107X-17040
EXT RECHG SYS 2087X-2714
OCULAR PROSTH 195X-254
AQUEOUS SHUNT 949X-1234
NROSTM RECHG 10082X-13107
NROSTM PROGRAM 949X-1234

239940119.xlsx.ms_office

Price
85.00
115.00
150.00
195.00
335.00
440.00
750.00
975.00
1,270.00
1,655.00
2,155.00
750.00
115.00
195.00
335.00
440.00
750.00
975.00
750.00
575.00
1,655.00
4,745.00
250.00
78.00
78.00
78.00
78.00
78.00
78.00
71.00
78.00
187,190.00
110,760.00
110,760.00
143,990.00
4,745.00
176.00
3,650.00
4,745.00
8,025.00
10,435.00
85,200.00
13,570.00
1,270.00
6,170.00
65,535.00
6,170.00

$0 Indicator

Page 158 of 299

CDM #
3882073
3882081
3882099
3882115
3882123
3882131
3882149
3882156
3882164
3882172
3882180
3882198
3882222
3882230
3882248
3882255
3882263
3882271
3882289
3882297
3882305
3882313
3882321
3882339
3882347
3882354
3882362
3882370
3882388
3882396
3882404
3882412
3882420
3882438
3882453
3882461
3882479
3882487
3882495
3882503
3882511
3882529
3882537
3882545
3882552
3882560
3882578

CDM Description
FIX DEV EXT 2714X-3529
FIX DEV EXT 1605X-2087
FIX DEV EXT 2087X-2714
ALLODERM SQ CM 150X-195
GRFTJAKT SQ CM 2087X-2714
GRFTJAKT SQ CM 1605X-2087
GRFTJAKT SQ CM 1234X-1605
GRFTJAKT EXP1C 1605X-2087
APLIGRAF SQ CM 1234X-1605
ALLODERM SQ CM 1605X-2087
ALLODERM SQ CM 2714X-3529
INTEGRA SQ CM 2087X-2714
LITHOTRIPSY ESWL BIL
LITHOTRIPSY ESWL UNI
ALLODERM SQ CM 195X-254
CLOSURE EXTERN <10
KIT/PACK SURG 254X-331
KIT/PACK SURG 67X-88
KIT/PACK SURG 730X-949
KIT/PACK SURG 949X-1234
NROSTM RECHRG 2087X-2714
NROSTM RECHRG 2714X-3529
NROSTM RECHRG 3529X-4588
NROSTM RECHRG 1234X-1605
GRAFT MESH 10082X-13107
GRAFT MESH 7755X-10082
IOL ANTERIOR 67X-88
IOL ANTERIOR 88X-115
IOL ANTERIOR 150X-195
INTEGRA SQ CM 1234X-1605
INTEGRA SQ CM 1605X-2087
INTEGRA SQ CM 949X-1234
INTEGRA SQ CM 730X-949
ALLODERM SQ CM 2087X-2714
ALLODERM SQ CM 1234X-1605
ALLODERM SQ CM 949X-1234
STNT NCOR T W/O 67X-88
STNT NCOR T W/O 51X-67
STNT NCOR T W/O 195X-254
CATH BLN DIL NON 331X-431
CATH BLN DIL NON 431X-561
UR BULK COLLG2.5M331X-431
UR BULK COLLG2.5M431X-561
US TRANSRECTAL
CLOSURE IMPLNT 561X-730
CLOSURE IMPLNT 730X-949
MD SUPPLIED IOL ASTIGMTSM

239940119.xlsx.ms_office

Price
17,645.00
10,435.00
13,570.00
975.00
13,570.00
10,435.00
8,025.00
10,435.00
8,025.00
10,435.00
17,645.00
13,570.00
28,311.00
20,594.00
1,270.00
45.00
1,655.00
440.00
4,745.00
6,170.00
13,570.00
17,645.00
22,940.00
8,025.00
65,535.00
50,410.00
440.00
575.00
975.00
8,025.00
10,435.00
6,170.00
4,745.00
13,570.00
8,025.00
6,170.00
440.00
335.00
1,270.00
2,155.00
2,805.00
2,155.00
2,805.00
424.00
3,650.00
4,745.00
0.01

$0 Indicator

Page 159 of 299

CDM #
3882586
3882594
3882602
3882610
3882628
3882636
3882644
3882651
3882669
3882677
3882693
3882701
3882719
3882727
3882735
3882743
3882750
3882768
3882776
3882792
3882818
3882826
3882834
3882859
3882867
3882875
3882883
3882891
3882909
3882917
3882925
3882933
3882941
3882958
3882966
3882974
3882982
3882990
3883006
3883014
3883022
3883030
3883048
3883055
3883063
3883071
3883089

CDM Description
MD SUPPLIED IOL PRESBYOPA
MD SUPPLIED PUNCPLUG PERM
MD SUPPLIED PUNCPLUG TEMP
MD SUPPLIED IUD MIRENA
MD SUPPLIED BRST PROSTH
MD SUPPLIED BRST PROS SIL
IOL ASTIGMATISM 431X-561
STNT COATED W 2087X-2714
STNT COATED W 2714X-3529
STNT COATED W 3529X-4588
BREAST PROSTH 949X-1234
IOL ASTIGMATISM 115X-150
IOL PRESBYOPIA 115X-150
IOL PRESBYOPIA 730X-949
IOL PRESBYOPIA 150X-195
FLW WND MTRX 1C2087X-2714
CATH BLN DIL NON 730X-949
IOL POSTERIOR CCI EDIT
IOL ANTERIOR CCI EDIT
ALLODERM SQ CM 431X-561
LASER FIBER 39X-51
VOCAL CORD SYNTH 254X-331
MD SUPPLIED IOL PRESB LNK
IOL PRESBYOP 730X-949 LNK
MD SUPPLIED IOL ASTIG LNK
IOL ASTIGMAT 331X-431 LNK
IOL ASTIGMAT 431X-561 LNK
CONN TISS NHUM 67X-88
SKIN SUB NOS 7755X-10082
SKIN SUB NOS 1605X-2087
SKIN SUB NOS 2087X-2714
SKIN SUB NOS 2714X-3529
AUD OSSEO DEV 2087X-2714
KIT/PACK SURG 2714X-3529
KIT/PACK SURG 2087X-2714
INTRO SHTH NPEEL 195X-254
INTRO SHTH GENRL 88X-115
INTRO SHTH GENRL 67X-88
INTRO SHTH GENRL 51X-67
CATH URETERAL 67X-88
CATH URETERAL 88X-115
CATH URETERAL 115X-150
EXPANDER TISS 431X-561
EXPANDER TISS 561X-730
EXPANDER TISS 195X-254
EXPANDER TISS 254X-331
CATH URETERAL 23X-30

239940119.xlsx.ms_office

Price
0.01
0.01
0.01
0.01
0.01
0.01
2,805.00
13,570.00
17,645.00
22,940.00
6,170.00
750.00
750.00
4,745.00
975.00
13,570.00
4,745.00
0.01
0.01
2,805.00
255.00
1,655.00
440.00
50,410.00
10,435.00
13,570.00
17,645.00
13,570.00
17,645.00
13,570.00
1,270.00
575.00
440.00
335.00
440.00
575.00
750.00
2,805.00
3,650.00
1,270.00
1,655.00
150.00

$0 Indicator

L
L
L
L
L

Page 160 of 299

CDM #
3883097
3883105
3883113
3883121
3883139
3883147
3883154
3883162
3883170
3883188
3883196
3883204
3883212
3883220
3883238
3883246
3883261
3883279
3883287
3883295
3883303
3883311
3883329
3883337
3883345
3883352
3883360
3883378
3883386
3883394
3883402
3883410
3883428
3883436
3883444
3883451
3883469
3883477
3883485
3883493
3883501
3883519
3883527
3883535
3883543
3883550
3883568

CDM Description
EYE TISSUE 3529X-4588
ADT/EXT NEURSTM 30X-39
ADT/EXT NEURSTM 39X-51
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
INST/SUP NONST 1605X-2087
INST/SUPP NONST1234X-1605
AUD OSSEO DEV 3529X-4588
INST/SUPP NONST2714X-3529
INST/SUPP NONST3529X-4588
RADIESSE 0.1 ML INJ
CUT/CAUT DEV 3529X-4588
CATH GENERAL 730X-949
INST/SUPP STERL 431X-561
EXPANDER TISS 3529X-4588
EXPANDER TISS 2714X-3529
CATH BLN DIL NON 561X-730
CATH BLN DIL NON 730X-949
JOINT DEVICE 2714X-3529
JOINT DEVICE 3529X-4588
JOINT DEVICE 4588X-5965
CONN TISS NHUM 3529X-4588
BREAST PROS SIL 730X-949
BREAST PROS SIL 431X-561
BREAST PROS SIL 561X-730
BREAST PROS SIL 949X-1234
OCULAR PROSTH 431X-561
CONN TISS HUMN 5965X-7755
GASTROESOPH REFLUX TEST
ESOPHAGEAL MOTILITY STUDY
CONN TISS NHUMN 88X-115
CONN TISS NHUMN 115X-150
BONE GRFT IMP 2714X-3529
ORTHO L1830 13X-17
SHUNT IMPLANT 115X-150
SHUNT IMPLANT 150X-195
SHUNT IMPLANT 195X-254
SHUNT IMPLANT 254X-331
SHUNT IMPLANT 331X-431
SHUNT IMPLANT 431X-561
SHUNT IMPLANT 561X-730
SHUNT IMPLANT 88X-115
LEAD NEURO 4588X-5965
CATH DIALYSIS LT 561X-730
CATH DIALYSIS LT 730X-949
CATH DIALYS LT 949X-1234
CATH DIALYS LT 1234X-1605

239940119.xlsx.ms_office

Price
22,940.00
195.00
255.00
2,024.00
709.00
10,435.00
8,025.00
22,940.00
17,645.00
22,940.00
1,425.00
22,940.00
4,745.00
2,805.00
22,940.00
17,645.00
3,650.00
4,745.00
17,645.00
22,940.00
29,825.00
22,940.00
4,745.00
2,805.00
3,650.00
6,170.00
2,805.00
38,775.00
4,504.00
7,320.00
575.00
750.00
17,645.00
85.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00
575.00
29,825.00
3,650.00
4,745.00
6,170.00
8,025.00

$0 Indicator

Page 161 of 299

CDM #
3883576
3883584
3883592
3883600
3883618
3883626
3883634
3883642
3883659
3883667
3883675
3883683
3883691
3883709
3883717
3883725
3883733
3883741
3883758
3883766
3883774
3883782
3883790
3883808
3883816
3883824
3883832
3883840
3883857
3883865
3883873
3883881
3883899
3883907
3883915
3883923
3883931
3883949
3883956
3883964
3883972
3883980
3883998
3884004
3884012
3884020
3884038

CDM Description
CATH DIALYS LT 1605X-2087
CLOSURE IMPLNT949X-1234
NROSTM NONRE 13107X-17040
CATH GUIDING 39X-51
CATH GUIDING 115X-150
CATH GUIDING 1234X-1605
CATH GUIDING 13X-17
CATH GUIDING 150X-195
CATH GUIDING 17X-23
CATH GUIDING 195X-254
CATH GUIDING 23X-30
CATH GUIDING 254X-331
CATH GUIDING 30X-39
LEAD NEURO 2714X-3529
NROSTM PROGRAM 1234X-1605
EXT RECHG SYS 1234X-1605
CATH INF PERIPH 13X-17
MICROMATRIX PARTICL 100MG
MICROMATX PART 200MG
MICROMATRIX PARTICL 500MG
GI TRAC CAPSLE ENDO ILEUM
PREG URINE VISUAL
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN HEP B VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
INST/SUPP STERL4588X-5965
SKIN SUB NOS 13108X-17040
INST/SUPP STRL 3529X-4588
CLOSURE IMPL 1234X-1605
ANCHOR/SCREW 2087X-2714
ORTHO L1830 10-13
GI TRAC CAPSLE ENDO ILEUM
PORT INDWELLING 561X-730
INTRO SHTH GENRL 10-13
ADT/EXT NEURSTM 51X-67
ADT/EXT NEURSTM 431X-561
ADT/EXT NEURSTM 561X-730
ADT/EXT NEURSTM 730X-949
STNT NCOAT W 561X-730
STNT NCOAT W 431X-561
STNT NCOAT W 331X-431
STNT NCOAT W 115X-150
STNT NCOAT W 150X-195
STNT NCOAT W 195X-254
STNT NCOAT W 254X-331

239940119.xlsx.ms_office

Price
10,435.00
6,170.00
85,200.00
255.00
750.00
8,025.00
85.00
975.00
115.00
1,270.00
150.00
1,655.00
195.00
17,645.00
8,025.00
8,025.00
85.00
1,264.00
2,528.00
5,925.00
6,617.00
209.00
301.00
301.00
301.00
301.00
301.00
29,825.00
85,200.00
22,940.00
8,025.00
13,570.00
65.00
119.00
3,650.00
65.00
335.00
2,805.00
3,650.00
4,745.00
3,650.00
2,805.00
2,155.00
750.00
975.00
1,270.00
1,655.00

$0 Indicator

Page 162 of 299

CDM #
3884046
3884053
3884061
3884079
3884087
3884095
3884103
3884129
3884137
3884145
3884152
3884160
3884178
3884186
3884194
3884202
3884210
3884228
3884236
3884244
3884251
3884269
3884277
3884285
3884293
3884301
3884319
3884327
3884335
3884343
3884350
3884368
3884376
3884384
3884392
3884400
3884418
3884426
3884434
3884442
3884459
3884467
3884475
3884483
3884491
3884509
3884517

CDM Description
STNT NCOAT W 331X-431
STNT NCOAT W 431X-561
STNT NCOAT W 561X-730
GI NONTIMED PROC STAT/MIN
SHUNT IMPLANT 2714X-3529
SHUNT IMPLANT 1234X-1605
SHUNT IMPLANT 3529X-4588
ESSR BC SYS 730X-949
EYE IMPLANT 195X-254
EYE IMPLANT 67X-88
EYE IMPLANT 730X-949
PORT INDWELLING2087X-2714
INTRO SHTH GENRL 254X-331
TESTICULR IMPL 1605X-2087
CATH PTA N LSR 39X-51
MICROMATRIX PART 1000MG
CATH ABLT VASC N949X-1234
CUT/CAUT DEV 949X-1234
STNT NCOAT WO 30X-39
BONE GRFT IMP 4588X-5965
LASER FIBER 39X-51
CATH GENERAL 30X-39
CATH GENERAL 331X-431
GUIDEWIRE 23X-30
GUIDEWIRE 115X-150
INTRO SHTH GENRL 23X-30
STNT NON COR T W 115X-150
TUBING/CONNECT 150X-195
TUBING/CONNECT 13X-17
TUBING/CONNECT 23X-30
TUBE IMPLANT 30X-39
KIT/PACK SURG 150X-195
CUT/CAUT DEV 88X-115
CEMENT IMPLANT 331X-431
IOL ANTERIOR 254X-331
COCHLEAR DEV 3529X-4588
INST/SUPP STRL 2714X-3529
INST/SUPP STRL 1605X-2087
JOINT DEVICE 431X-561
PORT INDWELLING 431X-561
CATH DRAINAGE 67X-88
CATH DRAINAGE 115X-150
CATH GENERAL 88X-115
CONN TISS HUMN 3529X-4588
CONN TISS NHUM 331X-431
CONN TISS NHUM 730X-949
CONN TISS NHUM 1605X-2087

239940119.xlsx.ms_office

Price
2,155.00
2,805.00
3,650.00
17,645.00
8,025.00
22,940.00
4,745.00
1,270.00
440.00
4,745.00
13,570.00
1,655.00
10,435.00
255.00
5,940.00
6,170.00
6,170.00
195.00
29,825.00
255.00
195.00
2,155.00
150.00
750.00
150.00
750.00
975.00
85.00
150.00
195.00
975.00
575.00
2,155.00
1,655.00
22,940.00
17,645.00
10,435.00
2,805.00
2,805.00
440.00
750.00
575.00
22,940.00
2,155.00
4,745.00
10,435.00

$0 Indicator

Page 163 of 299

CDM #
3884525
3884533
3884541
3884558
3884566
3884574
3884582
3884590
3884608
3884616
3884624
3884632
3884640
3884657
3884665
3884673
3884681
3884699
3884707
3884715
3884723
3884731
3884749
3884756
3884764
3884772
3884780
3884798
3884806
3884814
3884822
3884830
3884848
3884855
3884863
3900081
3900099
3900107
3900115
3900123
3900131
3900149
3900156
3900164
3900172
3900198
3900206

CDM Description
METAPHALNG JNT 730X-949
METAPHALNG JNT 949X-1234
JOINT DEVICE 1234X-1605
NON JOINT DEV 2087X-2714
NON JOINT DEV 3529X-4588
OCULAR PROSTH 17X-23
OCULAR PROSTH 30X-39
OCULAR PROSTH 39X-51
CATH BLN DIL NON 150X-195
CATH BLN DIL NON 195X-254
CORNEAL DEVICE 2714X-3529
BONE VOID FILL 730X-949
INFUS PMP PR 10082X-13107
OCULAR PROSTH 254X-331
INST/SUPP STERL 331X-431
BREAST PROS SIL1234X-1605
LACTATED RINGERS 1000ML
EYE EXAM W ANESTH LIMITED
COLLGN NV GUIDE1234X-1605
EYE TISSUE 2714X-3529
KIT/PACK SURG 13X-17
FACE IMPLANT 254X-331
CATH PTA N LSR 431X-561
CATH INF PERIPH 23X-30
EYE IMPLANT 39X-51
US TRANSRECTAL
INST/SUPP STERL 88X-115
MATRISTEM PER SQ 730X-949
CLOSURE EXTERN 1605X-2087
JOINT DEVICE 195X-254
KIT/PACK SURG 30X-39
TUBING/CONNECT 431X-561
LASER FIBER 730X-949
UR BULK SYN 1M 254X-331
CONN TISS NHUM 4588X-5965
RHO(D) IMMUNE GLOB 300MCG
RHO(D) IMMUNE GLOB 50MCG
RED CELLS EA DIR
RBC DEGLYCERO EA AUTO
RED CELLS EA AUTO
PLASMA CRYO REDUCE EA
WHOLE BLOOD EA
RED CELLS WASHED EA
PLATELETS PHER L/R EA
RED CELLS DEGLY EA
RED CELLS L/R EA
PLASMA FROZ 8-24 HR ADULT

239940119.xlsx.ms_office

Price
4,745.00
6,170.00
8,025.00
13,570.00
22,940.00
115.00
195.00
255.00
975.00
1,270.00
17,645.00
4,745.00
65,535.00
1,655.00
2,155.00
8,025.00
78.00
3,494.00
8,025.00
17,645.00
85.00
1,655.00
2,805.00
150.00
255.00
424.00
575.00
4,745.00
10,435.00
1,270.00
195.00
2,805.00
4,745.00
1,655.00
29,825.00
132.00
58.00
433.00
1,019.00
609.00
152.00
490.00
573.00
970.00
684.00
418.00
106.00

$0 Indicator

Page 164 of 299

CDM #
3900214
3900222
3900230
3900248
3900263
3900305
3900321
4100012
4100020
4100046
4100103
4100111
4100129
4100145
4100152
4100160
4100186
4100194
4100202
4100210
4100228
4100236
4100244
4100251
4100269
4100277
4100285
4100293
4100301
4100319
4100350
4100368
4100376
4100384
4100392
4100400
4100418
4100426
4100434
4100442
4100459
4100467
4100475
4100483
4100491
4100509
4100517

CDM Description
CRYOPRECIPITATE EA
PLASMA FROZ >8 HR JUMBO
PLASMA FROZ 8-24HR PEDIAT
GRANULOCYTES PHER EA
PLATELETS PHER EA
RED CELLS IRR EA
PLASMA CRYO REDUCE EA
BRNCHSPASM EVAL PRE/POST
SPIROMETRY
PR-SMOKING CESSATN PROG A
PULM REHAB PHASE III NC
EDUC PAT-FAM & COMMUN NC
PR-MDI SPACER DEVICE
THRP RSP-OTH INDV EA15MIN
THERAP STRG ENDR EA 15MIN
PULSE OX SINGLE DETERMIN
PULM STRESS TEST SIMPLE
THRP RSP STG END GR<=180M
CPAP/BIPAP OSA INIT/DAY
PSS W 4/> PARAM W TECH
PSS W 4/> P W CPAP/BIPAP
SLEEP STUDY ATTENDED
SLEEP UNATTEN W RESP EFFT
MSLT/MWT NARCO STUDY GLBL
SL-ORIENTATION VISIT
VISIT LEVEL 1 EST PT
VISIT LEVEL 1 EST PT
VISIT LEVEL 1 EST PT
VISIT LEVEL 1 EST PT
VISIT LEVEL 1 EST PT
EEG AWAKE & ASLEEP
EEG AWAKE & DROWSY
BLAND AERO TX INIT EA DAY
BLAND AERO TX SUBSEQUENT
INH TX INITIAL EA DAY
INH TX EA SUBSEQ TX/DAY
INTUBATION ET EMERGENCY
VENT INIT DAY INVASIVE
VENT SUBSEQ DAY INVASIVE
VENT INITIAL DAY NITRIC
VENT SUBSEQ DAY NITRIC
VENT INIT NITRIC 12HR NC
VENT SUBSEQ NITRC 12HR NC
CPAP/BIPAP OSA INIT/DAY
MANIPULAT CHEST WALL INIT
MANIPULAT CHEST WALL SUB
CPR

239940119.xlsx.ms_office

Price
106.00
316.00
36.00
3,710.00
970.00
514.00
345.00
518.00
375.00
94.00
108.00
108.00
132.00
448.00
1,271.00
372.00
6,646.00
6,646.00
6,646.00
2,286.00
2,286.00
239.00
239.00
239.00
239.00
239.00
1,471.00
1,397.00
803.00
570.00
483.00
425.00
1,083.00
7,225.00
6,963.00
7,225.00
6,963.00
3,156.00
357.00
244.00
2,327.00

$0 Indicator

S
S
S

S
S

Page 165 of 299

CDM #
4100525
4100533
4100541
4100558
4100566
4100574
4100582
4100590
4100608
4100616
4100624
4100632
4100640
4100657
4100665
4100673
4100681
4100699
4100707
4100715
4100723
4100731
4100749
4100756
4100772
4100798
4100814
4100855
4100863
4100871
4100889
4100897
4100905
4100913
4100939
4100947
4100954
4100962
4100970
4100988
4100996
4101002
4101010
4101028
4101036
4101044
4101051

CDM Description
AIRWAY MANAGEMENT NC
VITAL CAPACITY TOTAL
PULSE OX MULTI W EXERCISE
PULSE OX CONTIN OVERNIGHT
ARTERIAL PUNCTURE
CPR STATISTICAL
CLINICAL ROUNDS NC
INH TX INIT W VENT/DAY
INH TX SUBSEQUENT W VENT
TRACH TUBE CHG NO FISTULA
VENT INITIAL HFV 12HR NC
VENT SUBSEQ HFV 12HR NC
VENT INITIAL 12HR NC
VENT SUBSEQUENT 12HR NC
CPAP/BIPAP OSA SUB 12H NC
RT ASSESSMENT LIMITED NC
RT ASSESSMENT COMPLETE NC
PEAK FLOW MEASUREMENT NC
TRANSCUT MONITOR INITIAL
TRANSCUT MONITOR SUBSEQ
ARTERIAL CATH/CANN PERC
NEO-LOW RISK DEL NC
NEO-HIGH RISK DEL NC
PULSE OX SINGLE DETERMIN
VENT INIT DAY INVASIVE
VENT SUBSEQ DAY INVASIVE
INTUBATION ET EMERGENCY
NEO-LOW RISK DEL NC
BLAND AERO TX INIT EA DAY
BLAND AERO TX SUBSEQUENT
INH TX INITIAL EA DAY
INH TX EA SUBSEQ TX/DAY
VENT INITIAL DAY NITRIC
VENT SUBSEQ DAY NITRIC
CPR
RT ASSESSMENT LIMITED NC
RT ASSESSMENT COMPLETE NC
AIRWAY MANAGEMENT NC
NEO-HIGH RISK DEL NC
PULSE OX SINGLE DETERMIN
ARTERIAL PUNCTURE
VENT INITIAL HFV 12HR NC
VENT SUBSEQ HFV 12HR NC
VENT INITIAL 12HR NC
VENT SUBSEQUENT 12HR NC
INH TX INIT W VENT/DAY
INH TX SUBSEQUENT W VENT

239940119.xlsx.ms_office

Price
123.00
302.00
308.00
288.00
483.00
425.00
317.00
152.00
152.00
1,766.00
132.00
7,225.00
6,963.00
1,083.00
803.00
570.00
483.00
425.00
7,225.00
6,963.00
2,327.00
132.00
288.00
483.00
425.00

$0 Indicator
S

S
S

S
S
S
S
S
S
S
S

S
S

S
S
S
S

S
S
S
S

Page 166 of 299

CDM #
4101069
4101077
4101085
4101093
4101101
4101127
4101135
4101143
4101150
4101168
4101176
4101184
4101192
4101200
4101218
4101226
4101234
4101242
4101259
4101267
4101275
4101283
4101291
4101309
4101317
4101341
4101358
4101374
4101390
4101499
4101507
4101515
4101523
4101531
4101549
4101556
4101564
4101572
4101580
4101598
4101614
4101622
4101630
4101648
4101655
4101663
4101671

CDM Description
MANIPULAT CHEST WALL INIT
MANIPULAT CHEST WALL SUB
ART LINE DRAW STATISTIC
VENT INITIAL DAY HFV
VENT SUBSEQUENT DAY HFV
BLOOD GAS PH PCO2 PO2
METHEMOGLOBIN QN
VENT INIT NITRIC 12HR NC
VENT SUBSEQ NITRC 12HR NC
THORACENTESIS
SPIROMETRY
SMOKING CESSATION CLASS
EXECUTIVE TEST
EXECUTIVE TEST F/U
COMPREHENSIVE FTNESS TEST
COMPREHENSIVE FITNESS F/U
STANDARD FITNESS TEST
NUTRITIONAL ASSESSMENT
NUTRITIONAL ASSESSMNT F/U
BODY COMPOSIT ANALYSI F/U
HEALTH RISK APPRAISAL
HEALTH RISK APPRAISAL F/U
CORP WELLNESS SCREEN/LECT
BLUE CROSS SCREENING
O2 UPTAKE REST INDIRECT
EL STAGE II LINK
BRNCHSPASM EVAL PRE/POST
PULM STRESS TEST COMPLEX
PULM STRESS TEST SIMPLE
TRANSCUT MONITOR INITIAL
TRANSCUT MONITOR SUBSEQ
ART LINE DRAW STATISTIC
TOBACCO COUNS W SYMP 3-10
TOBACCO COUNSL W SYMP >10
TOBACCO COUNS W SYMP 3-10
TOBACCO COUNSL W SYMP >10
TOBACCO COUNS W SYMP 3-10
TOBACCO COUNSL W SYMP >10
BRNCH TRNS BX EA AD LOBE
BRONCH BX NDL ASP EA ADD
BRONCH ALVEOLAR LAVAGE
BRNCH STNT ADD MAJ BRNCHS
BRNCH W ENDOBR BX SNG/MUL
BRNCH W TRNSBR BX SNG LBE
BRONCH BRONCHOSCOPY DX
BRNCH BRNCHSCP DX W SEDAT
BRONCH LASER/CRYO DESTRCT

239940119.xlsx.ms_office

Price
357.00
244.00
7,225.00
6,963.00
639.00
37.00
1,242.00
375.00
654.00
518.00
1,714.00
448.00
152.00
152.00
81.00
120.00
81.00
120.00
81.00
120.00
1,359.00
1,359.00
2,302.00
2,302.00
2,302.00
2,302.00
2,915.00
2,915.00
2,915.00

$0 Indicator

S
S

S
S
S
S
S
S
S
S
S
S
S
S
S
L

Page 167 of 299

CDM #
4101689
4101697
4101705
4101713
4101721
4101739
4101747
4101754
4101762
4101796
4101804
4101812
4101820
4101838
4101846
4101853
4101861
4101879
4101887
4101903
4101911
4101929
4101937
4101945
4101952
4101960
4101978
4101986
4102018
4102059
4102067
4102075
4102117
4102125
4102133
4102158
4102166
4102174
4102182
4102190
4102208
4102216
4102224
4102232
4102240
4102265
4102281

CDM Description
BRONCH BRUSHING/PROTECTED
BRONCH PLC CATH INTRACAV
BRONCH THER ASPIRATE INIT
BRONCH THER ASPIRAT SUBQ
BRONCH W BX NEEDLE ASP
BRNCH STNT PLC INI BRNCHS
BRONCH W REMOVAL FB
BRNCH RVSE STNT PREV PLCD
BRONCH W EXCISION TUMOR
RT PROTOCOL NC
THRP RSP STRG END GR<=15M
THRP RSP STRG END GR<=30M
THRP RSP STRG END GR<=45M
THRP RSP STRG END GR<=60M
THRP RSP STRG END GR<=75M
THRP RSP STRG END GR<=90M
THRP RSP STG END GR<=105M
THRP RSP STG END GR<=120M
PULM REHAB INIT ASSESS NC
PULM REHAB PHASE I NC
PULSE OX MULTI W EXERCISE
CARDIOVAS STR TEST WO RX
INH TX CONTINOUS 1ST HR
INH TX CONT EA ADD HR
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
BRNCHOSPASM PROVOCAT EVAL
HIGH ALTITUDE SIMULATION
HAST W O2 TITRATION
O2 UPTAKE REST INDIRECT
PULM REHAB COPD W EX/SESS
VENIPUNCTURE
COLLECT CAPILLAR BLOOD
EEG 41-60 MINUTES
EEG ALL NIGHT RECORDING
EEG CEREBRAL SILENCE
EEG COMA OR SLEEP ONLY
EEG EXTENDED >1 HOUR
EEG SEIZURE ATTN>=16/24HR
EEG SEIZURE PORT>=16/24HR
EEG SEIZURE COMB>=16/24HR
ARTERIAL CATH/CANN PERC
AUDITOR EVOKE POTENT COMP
VENIPUNCTURE
NACL 0.9% IRRIGATION

239940119.xlsx.ms_office

Price
2,302.00
2,915.00
2,915.00
2,915.00
4,599.00
4,599.00
4,599.00
4,599.00
4,599.00
108.00
214.00
320.00
426.00
532.00
637.00
743.00
849.00
302.00
1,207.00
803.00
570.00
301.00
301.00
301.00
301.00
1,094.00
1,219.00
1,583.00
654.00
426.00
11.00
11.00
1,827.00
1,905.00
1,958.00
1,471.00
2,149.00
2,685.00
2,488.00
3,051.00
1,766.00
1,536.00
11.00
78.00

$0 Indicator

S
S

Page 168 of 299

CDM #
4102299
4102307
4102315
4102323
4102331
4102349
4102356
4102364
4102372
4102380
4102398
4102406
4102414
4102422
4102430
4102448
4102455
4102463
4102471
4102489
4102497
4102505
4102513
4102521
4102539
4102547
4102554
4102562
4102570
4102588
4102596
4102604
4102612
4102620
4102638
4102646
4102653
4102661
4102679
4102687
4102695
4102703
4102711
4102729
4102737
4102745
4102752

CDM Description
CATH GENERAL 10-13
INST/SUPP NONST 10-13
INST/SUPP NONST 67X-88
INST/SUPP STERL 13X-17
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INST/SUPP STERL 51X-67
INST/SUPP STERL 88X-115
INST/SUPP STERL 67X-88
INST/SUPP STERL 254X-331
BRUSH CYTO/MICRO 13X-17
TOBACCO COUNS NO SYMP3-10
TOBACCO COUNSL NO SYMP>10
TOBACCO COUNS NO SYMP3-10
TOBACCO COUNSL NO SYMP>10
TOBACCO COUNS NO SYMP3-10
TOBACCO COUNSL NO SYMP>10
BRUSH CYTO/MICRO 17X-23
INST/SUPP STERL 30X-39
INST/SUPP STERL 10-13
ACTIGRAPHY TEST >=72HOURS
VENT INITIAL DAY HFV
VENT SUBSEQUENT DAY HFV
CPAP/BIPAP VENT INIT/DAY
CPAP/BIPAP VNT SUB 12H NC
CPAP/BIPAP VENT INIT/DAY
CPAP/BIPAP VNT SUB 12H NC
EEG SEIZRE ATTN>=16/<12HR
EEG SEIZRE COMB>=16/<12HR
FLUTTER NC
ACAPELLA NC
CHEST VEST INIT NC
CHEST VEST SUBSEQ NC
INTRAPUL SRFCT VIA ETT NC
INTRAPUL SRFCT VIA ETT NC
WADA ACTIVATION TEST
EEG SEIZURE 8-CH/ 24 HR
INST/SUPP STERL 39X-51
CATH GENERAL 23X-30
TUBING/CONNECT 67X-88
TUBING/CONNECT 23X-30
VALVE TRACH SPEAK 67X-88
DIFFUSING CAPACITY
PLETHYSMOGRAPHY LUNG VOL
GAS DILUTION LUNG VOLUME
AIRWY RES PLSE OSCILLMTRY
NACL 0.9% 500ML INJ

239940119.xlsx.ms_office

Price
65.00
65.00
440.00
85.00
975.00
1,270.00
335.00
575.00
440.00
1,655.00
85.00
81.00
120.00
81.00
120.00
81.00
120.00
115.00
195.00
65.00
372.00
7,225.00
6,963.00
3,156.00
3,156.00
2,148.00
2,441.00
2,149.00
2,685.00
255.00
150.00
440.00
150.00
440.00
324.00
818.00
818.00
818.00
78.00

$0 Indicator

S
S

S
S
S
S
S
S

Page 169 of 299

CDM #
4102760
4102778
4500013
4500021
4500039
4500047
4500054
4500062
4500070
4500088
4500096
4500104
4500112
4500120
4500203
4500294
4500302
4500310
4500328
4500336
4500344
4500351
4500369
4500377
4500385
4500393
4500401
4500419
4500427
4500443
4500450
4500468
4500476
4500484
4500492
4500500
4500518
4500526
4500534
4500542
4500559
4500567
4500575
4500583
4500609
4500617
4500625

CDM Description
CATH GENERAL 13X-17
INST SUPP NONST 51X-67
ER LEVEL 1
ER LEVEL 1 W/PROCEDURE
ER LEVEL 2
ER LEVEL 2 W/PROCEDURE
ER LEVEL 3
ER LEVEL 3 W/PROCEDURE
ER LEVEL 4
ER LEVEL 4 W/PROCEDURE
ER LEVEL 5
ER LEVEL 5 W/PROCEDURE
LEFT W/O BEING SEEN STAT
ER CRIT CARE 30-74 W/PROC
VISIT LEVEL 1 EST PT
IV SOLUTION EACH
ED-S DERMABOND
ED-S ANKLE BRACE W/STRRUP
ED-S KNEE IMMOBILIZER
ED-S THUMB SPLINT SPICA
ED-S PAD DEFIB PEDIATRIC
ED-S PACKING NASAL EPI
ED-S BOOT WALKER
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INJ TX/DX/PROPH SUBQ/IM
INJ TX/DX/PRO INTRA-ARTER
GASTR INTB/ASP/LAV PHY SK
EMERG ROOM CPR
EMERGENCY ESRD DIALY TRMT
TRANSFUS BLD/BLD COMP
THROMBOLYSIS CORONARY IV
INTUBATION ENDOTRACHEAL
LAC RPR LEVEL 1
LAC RPR LEVEL 2
LAC RPR LEVEL 3
REM FB/SKN LES IMP LVL 1
REMOVE FB/IMPLANT LEVEL 3
INCIS/DRAIN/ASP LEVEL 1
INCIS/DRAIN/ASP LEVEL 3
DEBRID OPEN FX W/FB REMOV
DEBRIDE SKIN/SUBQ/MUS
TX FX/DISLOC LEVEL 2
TX DISLOC LEVEL 3 W ANES
APPLICATION OF CAST
APPLICATION OF SPLINT
STRAPPING

239940119.xlsx.ms_office

Price
85.00
335.00
685.00
685.00
1,074.00
1,074.00
1,732.00
1,732.00
2,689.00
2,689.00
4,117.00
4,117.00
6,374.00
239.00
78.00
219.00
91.00
83.00
71.00
135.00
250.00
125.00
301.00
301.00
275.00
544.00
672.00
2,327.00
2,240.00
778.00
1,038.00
1,083.00
671.00
1,268.00
6,032.00
698.00
3,827.00
1,194.00
4,839.00
1,784.00
1,521.00
1,478.00
3,600.00
468.00
442.00
442.00

$0 Indicator

Page 170 of 299

CDM #
4500633
4500641
4500658
4500666
4500674
4500682
4500690
4500708
4500724
4500732
4500740
4500757
4500765
4500773
4500781
4500799
4500807
4500823
4500831
4500849
4500856
4500864
4500872
4500880
4500898
4500906
4500914
4500922
4500930
4500948
4500955
4500963
4500971
4500989
4500997
4501011
4501029
4501037
4501045
4501052
4501284
4501391
4501409
4501417
4501425
4501433
4501441

CDM Description
WINDOWING/WEDGING OF CAST
CAUT PRO/CNTRL BLEED
THORACENTESIS/THORACOSTOM
INS/REPL TEMP PACER ELECT
VENIPUNCTURE VENOUS
VENIPUNCTURE CUTDOWN
CV CATH LEVEL 3
ARTERIAL PUNC/CATH/CANN
HEMORRHOID EXC/INC SIMPLE
INSERT CATH BLADDER
CHANGE TUBE SIMPLE
LUMBAR/SHUNT PUNCTURE
INJ NERVE/OTHR ASP/INJ JT
DRESS/DEBRIDE BURN
LAC RPR LVL3 ADD<5CM
REMOVE CERUMEN IMPACTED
INS PERITL CATH/CANN
TX FX/DISLOC LEVEL 3
EXCISE/REPR NAIL INGROWN
CV CATH/PICC LEVEL 2
OB/GYN PROCEDURE LEVEL 3
ANOSCPY/LARYNGOSCOPY DIAG
TRACHEOSTOMY EMERGENCY
PACING TRANSCUTANEOUS
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
MOD SEDAT =>5YRS 1ST 30M
MOD SEDAT <5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
CATH FOR SPECIMEN COLLECT
INF TX/DX CONCURRENT
BLADDER PROCEDURE LEVEL 2
PREG URINE VISUAL
GLUCOSE BLOOD BY DEVICE
UA NONAUTO W/O MICRO
TRAUMA LVL 2 ACTIVATE CC
ER TYPE B LEVEL 1
ER TYPE B LEVEL 1 W PROC
ER TYPE B LEVEL 2
ER TYPE B LEVEL 2 W PROC
ER TYPE B LEVEL 3
ER TYPE B LEVEL 3 W PROC

239940119.xlsx.ms_office

Price
442.00
575.00
1,242.00
22,774.00
11.00
105.00
6,257.00
214.00
1,484.00
505.00
987.00
2,047.00
850.00
460.00
778.00
251.00
6,156.00
4,794.00
698.00
5,241.00
6,832.00
400.00
2,633.00
683.00
544.00
140.00
544.00
140.00
140.00
544.00
544.00
1,580.00
1,580.00
549.00
420.00
140.00
1,913.00
209.00
176.00
109.00
4,206.00
685.00
685.00
1,074.00
1,074.00
1,732.00
1,732.00

$0 Indicator

Page 171 of 299

CDM #
4501458
4501466
4501474
4501482
4501490
4501508
4501516
4501524
4501532
4501540
4501557
4501565
4501573
4501581
4501607
4501623
4501631
4501649
4501656
4501664
4501672
4501680
4501698
4501706
4501722
4501730
4501748
4501755
4501763
4501771
4501789
4501797
4501813
4501847
4501854
4501870
4501888
4501896
4501904
4501912
4501938
4501946
4501953
4501961
4501979
4501987
4501995

CDM Description
ER TYPE B LEVEL 4
ER TYPE B LEVEL 4 W PROC
ER TYPE B LEVEL 5
ER TYPE B LEVEL 5 W PROC
TRAUMA LIMITED
TRAUMA LIMITED W/PROC
TRAUMA ESSENTIAL
TRAUMA ESSENTIAL W/PROC
TRAUMA COMPREHENSIVE
TRAUMA COMPREHENS W/PROC
TRAUMA LVL 2 ACTIVATE 4/5
TRAUMA COMPREH ADD 30MIN
ER CRITIC CARE ADD 30MIN
REMOV/BIVALV/RPR CAST
INJ TX/PRO/DX IVP SME DRG
CV CATH/PICC LEVEL 1
SKIN PROCEDURE COMPLEX
ALCOH/SUBST INTERV 15-30
ALCOH/SUBST INTERV >30MN
ELECTROLYTE PANEL QW
UREA NITROGEN BLOOD QW
CREATININE BLOOD QW
GLUCOSE BLOOD QW
ED POC CHEM PANEL FOL LNK
TOBACCO COUNS W SYMP 3-10
TOBACCO COUNSL W SYMP >10
EPIDURAL BLOOD PATCH
UA AUTO W/O MICRO QW
ENDOSCOPY PROC INTERMED
RECTAL PROCEDURE INTERMED
PARACENTESIS/PERIT LAVAGE
PLACE NDL INTRAOSSO INFUS
OPEN CHEST CARDIA MASSAGE
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
EXCISE BENIGN LESION
CESAREAN DELIVERY
PERICARDIOCENTES INITIAL
ADMIN HEP B VACCINE
DEBRID/AVUL NAIL EVAC HEM
CATH DRAINAGE 17X-23
CATH GENERAL 13X-17
CATH INF PERIPH 10-13
CATH INF PERIPH 88X-115
CLOSURE EXTERN 17X-23

239940119.xlsx.ms_office

Price
2,685.00
2,685.00
4,117.00
4,117.00
13,577.00
13,577.00
25,208.00
25,208.00
34,691.00
34,691.00
4,206.00
1,100.00
1,138.00
442.00
544.00
1,687.00
3,405.00
89.00
131.00
282.00
73.00
73.00
139.00
81.00
120.00
894.00
90.00
1,889.00
1,889.00
1,123.00
571.00
7,815.00
544.00
275.00
301.00
301.00
1,123.00
12,275.00
1,191.00
301.00
698.00
115.00
85.00
65.00
575.00
115.00

$0 Indicator

Page 172 of 299

CDM #
4502001
4502019
4502027
4502035
4502043
4502050
4502068
4502076
4502084
4502092
4502100
4502118
4502126
4502142
4502167
4502183
4502191
4502209
4502217
4502225
4502233
4502241
4502258
4502266
4502274
4502282
4502290
4502308
4502316
4502324
4502332
4502340
4502357
4502365
4502373
4502381
4502407
4502415
4502738
4502746
4502753
4502761
4502779
4502787
4502795
4502803
4502811

CDM Description
CLOSURE EXTERN 23X-30
CLOSURE IMPLNT 51X-67
INST/SUPP STERL 13X-17
INST/SUPP STERL 23X-30
INST/SUPP STERL 30X-39
INST/SUPP STERL 39X-51
INST/SUPP STERL 88X-115
INST/SUPP STERL 195X-254
INST/SUPP STERL 254X-331
KIT/PACK SURG 67X-88
ORTHO L0172 10-13
ORTHO L3908 10-13
TUBING/CONNECT 13X-17
OP/ED PSYCH SITTER/HR NC
TX FX/DISLOC LEVEL 1
TOBACCO COUNS NO SYMP3-10
TOBACCO COUNSL NO SYMP>10
INCIS/DRAIN/ASP LEVEL 2
LACTATE/LACTIC ACID
EXPLORE WOUND
CATH GENERAL 23X-30
CATH GENERAL 39X-51
CATH INF PERIPH 254X-331
CUT/CAUT DEV 561X-730
GUIDEWIRE 67X-88
INST/SUPP STERL 51X-67
INST/SUPP STERL 17X-23
KIT/PACK SURG 13X-17
KIT/PACK SURG 17X-23
KIT/PACK SURG 30X-39
ORTHO L0120 10-13
ORTHO L0172 23X-30
ORTHO L0625 10-13
ORTHO L1830 10-13
ORTHO L1830 13X-17
ORTHO L3650 10-13
INST/SUPP NONST 13X-17
VENIPUNCT >3YR PHY SKILL
CATH DRAINAGE 13X-17
CATH DRAINAGE 23X-30
CATH DRAINAGE 39X-51
CATH DIALYSIS ST 67X-88
CATH DRAINAGE 10-13
CATH DRAINAGE 195X-254
CATH GENERAL 10-13
CATH GENERAL 150X-195
CATH INF PERIPH 13X-17

239940119.xlsx.ms_office

Price
150.00
335.00
85.00
150.00
195.00
255.00
575.00
1,270.00
1,655.00
440.00
65.00
65.00
85.00
698.00
81.00
120.00
2,206.00
288.00
5,241.00
150.00
255.00
1,655.00
3,650.00
440.00
335.00
115.00
85.00
115.00
195.00
65.00
150.00
65.00
65.00
85.00
65.00
85.00
41.00
85.00
150.00
255.00
440.00
65.00
1,270.00
65.00
975.00
85.00

$0 Indicator

Page 173 of 299

CDM #
4502829
4502837
4502845
4502852
4502860
4502878
4502886
4502894
4502902
4502910
4502928
4502936
4502944
4502951
4502969
4502977
4502985
4502993
4503009
4503017
4503025
4503033
4503041
4503058
4503066
4503074
4503082
4503090
4503108
4503116
4503124
4503132
4503140
4503157
4503165
4503173
4503181
4503199
4503207
4503215
4503223
4503231
4503249
4503256
4503264
4503272
4503280

CDM Description
CATH INF PERIPH 150X-195
CATH INF PERIPH 195X-254
CATH INF PERIPH 23X-30
CATH INF PERIPH 30X-39
CATH INF PERIPH 39X-51
CATH INF PERIPH 67X-88
CATH SUPRAPUB/CY 30X-39
CLOSURE EXTERN 10-13
CLOSURE IMPLNT 13X-17
CLOSURE IMPLNT 23X-30
CUT/CAUT DEV 115X-150
GUIDEWIRE 10-13
GUIDEWIRE 150X-195
GUIDEWIRE 30X-39
GUIDEWIRE 331X-431
INST/SUPP NONST 10-13
INST/SUPP NONST 17X-23
INST/SUPP NONST 254X-331
INST/SUPP NONST 30X-39
INST/SUPP NONST 39X-51
INST/SUPP NONST 67X-88
INST/SUPP NONST 949X-1234
INST/SUPP STERL 10-13
INST/SUPP STERL 150X-195
INST/SUPP STERL1605X-2087
INTRO SHTH GENRL 10-13
INTRO SHTH GENRL 17X-23
INTRO SHTH GENRL 23X-30
INTRO SHTH GENRL 30X-39
INTRO SHTH GENRL 39X-51
INTRO SHTH GENRL 51X-67
KIT/PACK SURG 10-13
KIT/PACK SURG 150X-195
KIT/PACK SURG 195X-254
KIT/PACK SURG 23X-30
KIT/PACK SURG 331X-431
KIT/PACK SURG 39X-51
KIT/PACK SURG 51X-67
KIT/PACK SURG 88X-115
ORTHO L0150 10-13
ORTHO L0174 39X-51
ORTHO L3660 23X-30
ORTHO L4350 17X-23
ORTHO L4386 17X-23
ORTHO L4396 30X-39
TUBING/CONNECT 115X-150
TUBING/CONNECT 150X-195

239940119.xlsx.ms_office

Price
975.00
1,270.00
150.00
195.00
255.00
440.00
195.00
65.00
85.00
150.00
750.00
65.00
975.00
195.00
2,155.00
65.00
115.00
1,655.00
195.00
255.00
440.00
6,170.00
65.00
975.00
10,435.00
65.00
115.00
150.00
195.00
255.00
335.00
65.00
975.00
1,270.00
150.00
2,155.00
255.00
335.00
575.00
65.00
255.00
150.00
115.00
115.00
195.00
750.00
975.00

$0 Indicator

Page 174 of 299

CDM #
4503298
4503306
4503322
4503330
4503348
4503355
4503363
4503371
4503389
4503397
4503405
4503413
4503421
4503439
4503447
4503454
4503462
4503470
4503488
4503496
4503504
4503512
4503520
4503538
4503546
4503553
4503561
4503579
4503587
4503595
4503603
4600052
4600060
4600078
4600086
4600102
4600110
4600144
4600151
4600227
4600318
4600367
4600789
4600797
4600821
4600839
4600847

CDM Description
VALVE TRACH SPEAK 88X-115
CATH GENERAL 67X-88
ORTHO L0172 23X-30
ORTHO L0174 88X-115
ORTHO L0625 23X-30
TUBING/CONNECT 23X-30
CYSTOSTOMY PROC COMPLEX
CATH DIALYSIS ST 195X-254
CATH DIALYSIS ST 88X-115
ORTHO L1830 23X-30
TUBING/CONNECT 39X-51
CATH SUPRAPUB/CY 88X-115
CLOSURE IMPLNT 39X-51
CLOSURE IMPLNT 115X-150
TUBING/CONNECT 30X-39
BLADDER PROCEDURE LEVEL 1
INST/SUPP STERL 115X-150
CATH GENERAL 17X-23
CATH GENERAL 30X-39
CATH GENERAL 88X-115
CLOSURE IMPLNT 30X-39
KIT/PACK SURG 254X-331
CLOSURE EXTERN 51X-67
GUIDEWIRE 254X-331
IMMOBIL/BIND 10-13
IMMOBIL/BIND 13X-17
IMMOBIL/BIND 17X-23
CATH EP NON3D 88X-115
DECLOT THROMBOLYSIS
DENTAL PROC/REIMPLANT
OBSERVATION STATISTIC
INH TX INITIAL EA DAY
GLUCOSE BLOOD QW
POTASSIUM BLD
HEMOGLOBIN PLASMA
BRNCHSPASM EVAL PRE/POST
SPIROMETRY
PH BODY FLUID NOS QW
BLOOD GAS PH PCO2 PO2
BRNCHOSPASM PROVOCAT EVAL
PULSE OX MULTI W EXERCISE
O2 UPTAKE REST INDIRECT
ARTERIAL PUNCTURE
ART LINE DRAW STATISTIC
BRNCH TRNS BX EA AD LOBE
BRONCH BX NDL ASP EA ADD
BRONCH BRUSHING/PROTECTED

239940119.xlsx.ms_office

Price
575.00
440.00
150.00
575.00
150.00
150.00
6,032.00
1,270.00
575.00
150.00
255.00
575.00
255.00
750.00
195.00
502.00
750.00
115.00
195.00
575.00
195.00
1,655.00
335.00
1,655.00
65.00
85.00
115.00
575.00
850.00
698.00
483.00
139.00
149.00
135.00
518.00
375.00
138.00
639.00
1,094.00
302.00
654.00
288.00
1,359.00
1,359.00
2,302.00

$0 Indicator

Page 175 of 299

CDM #
4600854
4600862
4600870
4600888
4600896
4600904
4600912
4600920
4600938
4600946
4600953
4600961
4600979
4600987
4600995
4601001
4601019
4601027
4601035
4601043
4601050
4601068
4601076
4601084
4601092
4601100
4601118
4601126
4601134
4601142
4601159
4601167
4601209
4601217
4601225
4601233
4601241
4601258
4601266
4601274
4800017
4800249
4800280
4801262
4801270
4801288
4801296

CDM Description
BRONCH ALVEOLAR LAVAGE
BRNCH STNT ADD MAJ BRNCHS
BRNCH W ENDOBR BX SNG/MUL
BRNCH W TRNSBR BX SNG LBE
BRONCH BRONCHOSCOPY DX
BRNCH BRNCHSCP DX W SEDAT
BRONCH LASER/CRYO DESTRCT
BRONCH PLC CATH INTRACAV
BRONCH THER ASPIRATE INIT
BRONCH THER ASPIRAT SUBQ
BRONCH W BX NEEDLE ASP
BRNCH STNT PLC INI BRNCHS
BRONCH W REMOVAL FB
BRNCH RVSE STNT PREV PLCD
BRONCH W EXCISION TUMOR
PULM STRESS TEST SIMPLE
AIRWAY MANAGEMENT NC
INST/SUPP STERL 67X-88
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INST/SUPP STERL 254X-331
BRUSH CYTO/MICRO 13X-17
NACL 0.9% IRRIGATION
INST/SUPP NONST 10-13
CATH GENERAL 10-13
INST/SUPP STERL 51X-67
INST/SUPP NONST 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 13X-17
BRUSH CYTO/MICRO 17X-23
INST/SUPP STERL 30X-39
INST/SUPP STERL 10-13
INST/SUPP STERL 39X-51
CATH GENERAL 23X-30
CALCIUM IONIZED
PLETHYSMOGRAPHY LUNG VOL
GAS DILUTION LUNG VOLUME
AIRWY RES PLSE OSCILLMTRY
DIFFUSING CAPACITY
NACL 0.9% 500ML INJ
EP PER MINUTE STAT
LOCM 300-399MG/ML IODINE
CARDIAC DEVICE NO CHG
INTRAVENTRICULAR PACING
INDUCT ARRHYTHMIA W PACE
EP EVAL DEFIB W PROGRAM
TILT TABLE EVALUATION

239940119.xlsx.ms_office

Price
2,302.00
2,302.00
2,302.00
2,302.00
2,915.00
2,915.00
2,915.00
2,915.00
2,915.00
2,915.00
4,599.00
4,599.00
4,599.00
4,599.00
4,599.00
448.00
440.00
975.00
1,270.00
1,655.00
85.00
78.00
65.00
65.00
335.00
440.00
575.00
85.00
115.00
195.00
65.00
255.00
150.00
240.00
818.00
818.00
818.00
324.00
78.00
1.00
0.01
2,997.00
2,997.00
2,357.00
2,395.00

$0 Indicator

Page 176 of 299

CDM #
4801304
4801312
4801320
4801338
4801346
4801353
4801361
4801395
4801403
4801411
4801437
4801445
4801460
4801478
4801486
4801494
4801510
4801528
4801536
4801569
4801577
4801593
4801619
4801627
4801643
4801676
4801692
4801700
4801767
4801775
4801783
4801833
4801874
4801882
4801890
4801908
4801924
4801932
4801940
4801965
4801973
4801981
4801999
4802013
4802021
4802047
4802062

CDM Description
A/V NODE ABLATION
SVT ABLATION
VENT TACHY ABLATION
COMP EP EVAL INDUC LT ATR
PROG STIM & PACE IV DRUG
COMP EP EVAL W RT ATR PCE
COMP EP EVAL INDUC RT A/V
I&D HEMATOMA/SEROMA/FLUID
INTRACARDIAC EP 3D MAP
PACEMAKER LEAD REM DUAL
LEADS REPAIR TWO TRANSVEN
INTUBATION ENDOTRACHEAL
PERICARDIOCENT SUBSEQ
PACEMAKER INS/REPL ATRIAL
PACEMAKER INS/REPL VENT
PACEMKER INS TEMP SNGL
PACEMK INS EXIS DUAL LEAD
LEAD PACEMKR/DEFIB REPOSI
DEFIB SKIN POCKET REVISE
PACEMAKER LEAD REM SINGLE
DEFIB GEN REMOVAL ONLY
DEFIB INS EXIS SNGL LEAD
LEAD INSERT/REPLC INS GEN
CL FLUORO < 1 HR
EP EVAL PACING LEADS INIT
SWAN GANZ INSERTION
CARDIOVERSION ELCTIVE EXT
CPS SUPPORT INTERNAL
MAPPNG TACHYCARDIA SITES
PACEMAKER INS/REPL A/V
RIGHT HEART CATH
PERICARDIOCENTES INITIAL
INTRACARDIAC ECHO
LOOP RECORDER IMPLANT
LOOP RECORDER REMOVAL
PACEMKR SKN POCK REV/RELO
DEFIB LEAD REMVL TRANSVEN
L VENT LEAD INS W DEF/GEN
EP EVAL LEADS & GEN INIT
PACEMKR INS EXIS SNG LEAD
PACEMK GENERATOR REM ONLY
PACEMAKER UPGR SNGL-DUAL
L VENT LEAD INS & CONNECT
LEAD INSERT SNGL TRANSVEN
LEAD INSERT DUAL TRANSVEN
INSERT IAB DEVICE PERC
CL PER MINUTE STAT

239940119.xlsx.ms_office

Price
4,865.00
6,476.00
5,217.00
3,747.00
895.00
10,116.00
11,726.00
4,039.00
2,997.00
6,911.00
8,293.00
1,295.00
1,303.00
9,620.00
9,794.00
7,541.00
9,794.00
8,293.00
5,782.00
5,492.00
6,911.00
9,654.00
9,654.00
2,012.00
2,357.00
4,382.00
1,845.00
1,440.00
2,997.00
9,620.00
12,226.00
4,775.00
4,618.00
8,122.00
8,122.00
7,715.00
6,911.00
12,068.00
2,357.00
9,620.00
6,563.00
8,069.00
8,122.00
7,939.00
7,939.00
6,298.00
-

$0 Indicator

S
Page 177 of 299

CDM #
4802112
4802138
4802146
4802161
4802187
4802195
4802203
4802245
4802252
4802260
4802278
4802294
4802336
4802344
4802369
4802419
4802435
4802443
4802476
4802484
4802567
4802575
4802583
4802617
4802625
4802633
4802641
4802658
4802666
4802674
4802682
4802690
4802708
4802724
4802765
4802773
4802799
4802815
4802823
4802831
4802856
4802872
4802880
4802989
4802997
4803003
4803011

CDM Description
PACEMK INS EXIS DUAL LEAD
DEFIB INS EXIS SNGL LEAD
CL FLUORO CVAD PL/RPL/REM
STENT(S) DES SNGL VESS LD
STENT(S DES EA ADD VES LC
STENT(S DES EA ADD VES RC
STENT(S DES EA ADD VES LD
CL VENOGRAM EXTREMITY LT
CL VENOGRAM EXTREMITY RT
CL VENOGRAM EXTREMITY BIL
CL INTRAVAS US NONC EA AD
CL PTA VENOUS
US GUIDED PERICARDIOCENT
PACING TRANSCUTANEOUS
ECHO TEE WO CON
PACEMKER INS TEMP SNGL
PTA RENAL/VISCERAL
PTA AORTIC
PTA BRACHIOCEP EA VES
PTA VENOUS
VENOGRAM EXTREMTY INJ
VENA CAVA INTRO CATH
CATH PLACE VEN 1ST SELECT
CATH/NDL PLC RETROG BRACH
CATH/NDL PLACE EXTREM ART
CATH/NDL PLC AV SH DI INI
CTH PLC THOR/BRAC 1ST SEL
CTH PLC THOR/BRAC 2ND SEL
CTH PLC THOR/BRAC 3RD SEL
CTH PLC THOR/BRAC ADD 2-3
CTH PLC ABD/PEL/ 2ND INIT
CTH PLC ABD/PEL/ 3RD INIT
CTH PLC ABD/PEL/EX EA ADD
TRANSCATH RETRIEV FB
IVUS NON CORONARY INITIAL
IVUS NON CORONARY EA ADDL
ANGIO ILIAC W CARD CATH
STENT(S) DES SNGL VESS LC
STENT(S) DES SNGL VESS RC
INTUBATION ENDOTRACHEAL
CL VENACAVAGR SUPER ADD59
ART MECH THROMBECTMY PRIM
ART MECH THROMB PRIM ADD
THROMBECT AV FISTL W/GRFT
CL TRANSCTH THERPY INFUS
CL ANGIO AV DIAL SHUNT
OCCLUS/EMBOL NON CNS PERM

239940119.xlsx.ms_office

Price
9,794.00
9,654.00
1,910.00
27,740.00
27,740.00
27,740.00
27,740.00
1,453.00
1,453.00
2,031.00
409.00
5,484.00
805.00
683.00
2,935.00
7,541.00
10,998.00
10,998.00
10,998.00
10,998.00
1,252.00
2,502.00
1,252.00
2,086.00
2,086.00
6,540.00
1,252.00
1,670.00
2,086.00
2,086.00
1,670.00
2,086.00
2,086.00
4,162.00
6,662.00
4,795.00
2,324.00
27,740.00
27,740.00
1,295.00
3,891.00
5,337.00
5,001.00
6,566.00
6,223.00
4,439.00
6,566.00

$0 Indicator

Page 178 of 299

CDM #
4803029
4803037
4803045
4803052
4803060
4803078
4803086
4803094
4803102
4803110
4803128
4803136
4803144
4803151
4803169
4803193
4803201
4803227
4803235
4803243
4803250
4803284
4803300
4803318
4803383
4803474
4803508
4803516
4803524
4803565
4803607
4803615
4803623
4803631
4803649
4803656
4803664
4803680
4803698
4803714
4803722
4803730
4803755
4803771
4803789
4803797
4803805

CDM Description
CL TRANSCATH THRPY EMBOLZ
CL ANGIO CERVICOCER ARCH
CL ANGIO CAROTD EXTERN LT
CL ANGIO CAROTD EXTERN RT
CL ANGIO CAROTD EXTERN BI
CL ANGIO CAROTD CEREB LT
CL ANGIO CAROTD CEREB RT
CL ANGIO CAROTD CEREB BIL
CL ANGIO CAROTD CERVI LT
CL ANGIO CAROTD CERV BIL
CL ANGIO VERTEBRAL LT
CL ANGIO VERTEBRAL RT
CL ANGIO EXTREMITY LT
CL ANGIO EXTREMITY RT
CL ANGIO EXTREMITY BIL
CL ANGIO PULMONARY LT
CL ANGIO PULMONARY BIL
CL ANGIO INTERNAL MAMMARY
CL ANGIO EA ADD VESSEL
CL VENACAVAGRAM INFERIOR
CL VENACAVAGRAM SUPERIOR
CL ANGIO PULMONARY RT
CPS SUPPORT INTERNAL
CASE CANCEL
RIGHT HEART CATH
REM TUN CV CATH WO PORT/P
ANGIO IN SUPR AORT CD CTH
ANGIO IN PULM AORT CD CTH
ANGIO IN R VNT/AT CRD CTH
CL TRANSCATH RETRIEVE FB
INTERATRIAL CLOSURE PERC
INSERT IAB DEVICE PERC
PACEMKER INS TEMP DUAL
CARDIOVERSION ELCTIVE EXT
THROMBECTOMY CORONARY
CARDIAC CATH CPR
THROMBOLYSIS CORONARY IV
IVUS ADDL VESSEL STUDY
COR DOPL VEL/PRESS ADDL
ENDOMYOCARDIAL BIOPSY
PERICARDIOCENTES INITIAL
VALVULOPLASTY AORTIC
VALVULOPLASTY MITRAL
PTCA SINGLE VESSEL LD
PTCA SINGLE VESSEL LC
PTCA SINGLE VESSEL RC
COR ATHERECT SNGL VESS LD

239940119.xlsx.ms_office

Price
6,223.00
4,533.00
4,131.00
4,131.00
5,770.00
4,131.00
4,131.00
5,770.00
4,131.00
5,770.00
4,131.00
4,131.00
4,131.00
4,131.00
5,770.00
4,131.00
5,770.00
4,344.00
1,519.00
4,344.00
4,344.00
4,131.00
1,440.00
12,226.00
4,505.00
1,053.00
1,053.00
4,819.00
6,223.00
27,599.00
6,298.00
11,462.00
1,845.00
22,673.00
2,327.00
1,038.00
3,390.00
4,795.00
4,995.00
4,775.00
18,072.00
18,072.00
13,442.00
13,442.00
13,442.00
27,599.00

$0 Indicator

Page 179 of 299

CDM #
4803813
4803821
4803854
4803862
4803870
4803888
4803896
4803904
4803912
4803953
4803961
4803979
4803987
4803995
4804027
4804035
4804043
4804050
4804068
4804076
4804084
4804092
4804100
4804118
4804126
4804142
4804167
4804175
4804183
4804191
4804209
4804217
4804225
4804233
4804241
4804258
4804266
4804274
4804282
4804308
4804316
4804365
4804423
4804639
4806030
4806048
4806055

CDM Description
COR ATHERECT SNGL VESS LC
COR ATHERECT SNGL VESS RC
COR ATHERECT ADDL VESS RC
IC STENT PLC SNG VESS LD
IC STENT PLC SNG VESS LC
IC STENT PLC SNG VESS RC
IC STENT PLC ADDL VESS LD
IC STENT PLC ADDL VESS LC
IC STENT PLC ADDL VESS RC
PTCA EA ADDL VESSEL LC
PTCA EA ADDL VESSEL RC
PTCA EA ADDL VESSEL LD
OCCLUSIVE DEVICE ART/VEIN
CL AORTOGRM ABD W ILIOFEM
TILT TABLE EVALUATION
LOOP RECORDER IMPLANT
LOOP RECORDER REMOVAL
PACEMKR SKN POCK REV/RELO
L VENT LEAD INS W DEF/GEN
IVUS INITIAL VESSEL STUDY
COR DOPL VEL/PRESS INITAL
INTRACARDIAC ECHO
CTH PLC ABD/PEL/EX 1ST EA
CL INTRVAS US NONCOR INIT
PACEMAKER LEAD REM SINGLE
PACEMAKER INS/REPL VENT
CL STENT(S) NON COR/CAR
STENT NON COR PERC INITIL
STENT NON COR PERC ADDL
CL PTA PERIPH ART EA ADD
CL PTA PERIPHERAL ARTERY
CL ANGIO VISC WO OR W FLS
ANGIO RENAL W CARD CATH
CL PTA RENAL/VISCERAL
CL PTA RENAL/VISC EA ADD
CL ANGIO PELVIC
CATH PLACE AORTA
CL AORTOGRAM ABD W SERIAL
CL AORTOGRAM THORAC W SER
EP EVAL LEADS & GEN INIT
EP EVAL PACING LEADS INIT
CLOSURE EXTERN 17X-23
EMBL PROTCT SY 1234X-1605
LOCM 300-399MG/ML IODINE
PACEMAKER INS/REPL ATRIAL
PACEMAKER INS/REPL A/V
LEAD INSERT SNGL TRANSVEN

239940119.xlsx.ms_office

Price
27,599.00
27,599.00
13,800.00
27,599.00
27,599.00
27,599.00
13,800.00
13,800.00
13,800.00
8,341.00
8,341.00
8,341.00
2,113.00
4,533.00
2,395.00
8,122.00
8,122.00
7,715.00
12,068.00
4,795.00
4,795.00
4,618.00
1,252.00
643.00
5,492.00
9,794.00
5,484.00
6,668.00
4,169.00
2,550.00
5,871.00
4,344.00
2,324.00
5,484.00
2,550.00
4,957.00
3,335.00
4,533.00
4,533.00
2,357.00
2,357.00
115.00
8,025.00
1.00
9,620.00
9,620.00
7,939.00

$0 Indicator

Page 180 of 299

CDM #
4806071
4806113
4806139
4806170
4806196
4806204
4806220
4806246
4806253
4806261
4806303
4806329
4806519
4806527
4806535
4806584
4806592
4806717
4806725
4806733
4806758
4806790
4806808
4806816
4806824
4806832
4806840
4806857
4806865
4806873
4806881
4806899
4806907
4806915
4806923
4806956
4807020
4807038
4807046
4807053
4807079
4807087
4807095
4807103
4807111
4807129
4807137

CDM Description
LEAD REPAIR SINGLE TRANSV
PACEMK GENERATOR REM ONLY
DEFIB GEN REMOVAL ONLY
RECOV RM 30MIN STATISTIC
PACEMKR INS EXIS SNG LEAD
CL TRNSCTH ANG EXIST CATH
SURG CATH LAB PROC
LOOP RECORDER 3529X-4588
INSERT NONTUN CV CATH >5
INS TUN CV CATH WO PORT>5
INS CVAD PERIPH WPOR=>5YR
REPAIR CVAD W PORT OR PMP
CARDIOVERSION ELCTIVE INT
TRANSCATH THROMBL NON COR
TRANSCATH THRPY INFUS OTH
CATH PLC PULM L/R ART SEL
PORT INDWELLING 254X-331
CATH THROM EMB 254X-331
CATH THROM EMB 331X-431
CATH THROM EMB 431X-561
CATH THROM EMB 1234X-1605
VASC CLOS DEV 67X-88
VASC CLOS DEV 150X-195
VASC CLOS DEV 195X-254
GUIDEWIRE 10-13
GUIDEWIRE 13X-17
GUIDEWIRE 17X-23
GUIDEWIRE 23X-30
GUIDEWIRE 30X-39
GUIDEWIRE 39X-51
GUIDEWIRE 51X-67
GUIDEWIRE 67X-88
GUIDEWIRE 88X-115
GUIDEWIRE 115X-150
GUIDEWIRE 150X-195
GUIDEWIRE 561X-730
CATH TRAN DIR 2714X-3529
CATH ATHRCT R 949X-1234
CATH PTA N LSR 17X-23
CATH PTA N LSR 67X-88
CATH PTA N LSR 115X-150
CATH PTA N LSR 150X-195
CATH PTA N LSR 195X-254
CATH PTA N LSR 254X-331
CATH PTA N LSR 331X-431
CATH PTA N LSR 431X-561
CATH PTA N LSR 561X-730

239940119.xlsx.ms_office

Price
7,939.00
6,563.00
6,911.00
9,620.00
2,066.00
9,035.00
22,940.00
4,503.00
11,669.00
6,911.00
4,503.00
2,491.00
1,065.00
1,065.00
1,065.00
1,655.00
1,655.00
2,155.00
2,805.00
8,025.00
440.00
975.00
1,270.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
975.00
3,650.00
17,645.00
6,170.00
115.00
440.00
750.00
975.00
1,270.00
1,655.00
2,155.00
2,805.00
3,650.00

$0 Indicator

Page 181 of 299

CDM #
4807145
4807152
4807160
4807186
4807202
4807210
4807251
4807277
4807285
4807293
4807301
4807319
4807335
4807343
4807350
4807368
4807376
4807434
4807442
4807483
4807491
4807517
4807525
4807533
4807541
4807558
4807566
4807574
4807582
4807590
4807624
4807632
4807640
4807657
4807665
4807673
4807681
4807699
4807707
4807715
4807723
4807749
4807764
4807798
4807806
4807814
4807830

CDM Description
CATH PTA N LSR 730X-949
CATH PTA N LSR 1605X-2087
CATH PTA N LSR 2087X-2714
CATH EP NON3D 39X-51
CATH DIALYSIS LT 331X-431
CATH INF PERIPH 10-13
CATH INTRA US 561X-730
SEPTAL DEF SYS 3529X-4588
SEPTAL DEF SYS 4588X-5965
STNT COATED W 1234X-1605
STNT COATED W 1605X-2087
STNT COATED W 2087X-2714
STNT NCOAT W 561X-730
STNT NCOAT W 730X-949
STNT NCOAT W 949X-1234
STNT NCOAT W 1234X-1605
STNT NCOAT W 1605X-2087
FILTER VENA CAV 949X-1234
FILTER VENA CAV1234X-1605
PTA LASER 1605X-2087
PTA LASER 2087X-2714
CATH GUIDING 39X-51
CATH GUIDING 51X-67
CATH GUIDING 67X-88
CATH GUIDING 88X-115
CATH GUIDING 115X-150
CATH GUIDING 254X-331
CATH GUIDING 331X-431
CATH GUIDING 431X-561
CATH GUIDING 561X-730
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30
INST/SUPP STERL 30X-39
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 115X-150
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INST/SUPP STERL 254X-331
INST/SUPP STERL 949X-1234
INST/SUPP STERL1605X-2087
KIT/PACK SURG 195X-254
KIT/PACK SURG 331X-431
KIT/PACK SURG 949X-1234
INTRO SHTH PEEL 23X-30

239940119.xlsx.ms_office

Price
4,745.00
10,435.00
13,570.00
255.00
2,155.00
65.00
3,650.00
22,940.00
29,825.00
8,025.00
10,435.00
13,570.00
3,650.00
4,745.00
6,170.00
8,025.00
10,435.00
6,170.00
8,025.00
10,435.00
13,570.00
255.00
335.00
440.00
575.00
750.00
1,655.00
2,155.00
2,805.00
3,650.00
85.00
115.00
150.00
195.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
6,170.00
10,435.00
1,270.00
2,155.00
6,170.00
150.00

$0 Indicator

Page 182 of 299

CDM #
4807855
4807863
4807871
4807889
4807897
4807905
4807913
4807921
4807939
4807947
4807954
4807962
4807988
4807996
4808002
4808010
4808028
4808036
4808044
4808051
4808069
4808077
4808093
4808101
4808119
4808127
4808135
4808176
4808184
4808200
4808218
4808226
4808242
4808259
4808283
4808309
4808325
4808358
4808366
4808374
4808432
4808440
4808457
4808465
4808481
4808549
4808556

CDM Description
INTRO SHTH GENRL 10-13
INTRO SHTH GENRL 13X-17
INTRO SHTH GENRL 17X-23
INTRO SHTH GENRL 23X-30
INTRO SHTH GENRL 30X-39
INTRO SHTH GENRL 39X-51
INTRO SHTH GENRL 51X-67
INTRO SHTH GENRL 67X-88
INTRO SHTH GENRL 88X-115
INTRO SHTH GENRL 115X-150
INTRO SHTH GENRL 331X-431
INTRO SHTH GENRL 431X-561
STNT NCOR T WO 1605X-2087
CATH GENERAL 10-13
CATH GENERAL 13X-17
CATH GENERAL 17X-23
CATH GENERAL 23X-30
CATH GENERAL 30X-39
CATH GENERAL 39X-51
CATH GENERAL 51X-67
CATH GENERAL 67X-88
CATH GENERAL 88X-115
CATH GENERAL 195X-254
CATH GENERAL 331X-431
CATH GENERAL 561X-730
CATH GENERAL 730X-949
CATH GENERAL 949X-1234
RETRV DEV INSR 254X-331
PTA LASER 1234X-1605
CATH THROM EMB 1605X-2087
CATH GUIDING 13X-17
CATH GUIDING 17X-23
CATH GUIDING 30X-39
CATH THROM EMB 561X-730
VASC CLOS DEV 254X-331
CATH GENERAL 150X-195
CATH GENERAL 431X-561
CATH INF PERIPH 23X-30
CATH INF PERIPH 30X-39
CATH INF PERIPH 39X-51
RETRV DEV INSR 331X-431
RETRV DEV INSR 431X-561
RETRV DEV INSR 561X-730
CATH INTRA US 730X-949
CATH INTRA US 1234X-1605
RETRV DEV INSR 1605X-2087
CATH EP NON3D 51X-67

239940119.xlsx.ms_office

Price
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
750.00
2,155.00
2,805.00
10,435.00
65.00
85.00
115.00
150.00
195.00
255.00
335.00
440.00
575.00
1,270.00
2,155.00
3,650.00
4,745.00
6,170.00
1,655.00
8,025.00
10,435.00
85.00
115.00
195.00
3,650.00
1,655.00
975.00
2,805.00
150.00
195.00
255.00
2,155.00
2,805.00
3,650.00
4,745.00
8,025.00
10,435.00
335.00

$0 Indicator

Page 183 of 299

CDM #
4808630
4808648
4808713
4808721
4808747
4808754
4808762
4808770
4808796
4808861
4808879
4808929
4809026
4809059
4809075
4809109
4809133
4809273
4809281
4809299
4809315
4809323
4809331
4809349
4809356
4809364
4809372
4809380
4809406
4809414
4809422
4809430
4809455
4809463
4809489
4809497
4809505
4809521
4809539
4809547
4809554
4809562
4809570
4809596
4809604
4809620
4809638

CDM Description
CATH GUIDING 150X-195
CATH GUIDING 195X-254
CATH TRAN DIR 2087X-2714
GUIDEWIRE 195X-254
INST/SUPP STERL 39X-51
INST/SUPP STERL 431X-561
INST/SUPP STERL 561X-730
INST/SUPP STERL 730X-949
INTRO SHTH GENRL 195X-254
KIT/PACK SURG 67X-88
KIT/PACK SURG 88X-115
KIT/PACK SURG 561X-730
CATH DRAINAGE 88X-115
STNT COATED W 2714X-3529
CATH INTRA US 2714X-3529
RIGHT VENTRICULAR RECORD
IDE#G070165/S4 ENDEAV RES
CATH PTA N LSR 88X-115
CATH PTA N LSR 150X-195
CATH PTA N LSR 195X-254
CATH DRAINAGE 30X-39
CATH DRAINAGE 88X-115
CATH DRAINAGE 115X-150
CATH EP NON3D 39X-51
CATH EP NON3D 51X-67
CATH EP NON3D 88X-115
CATH EP NON3D 115X-150
CATH EP NON3D 150X-195
CATH EP NON3D 254X-331
CATH EP NON3D 331X-431
CATH EP NON3D 431X-561
CATH EP NON3D 561X-730
CATH EP NON3D 949X-1234
CATH EP>19NO3D 331X-431
CATH EP>19NO3D 730X-949
CATH EP>19NO3D 949X-1234
CATH EP>19NO3D 1234X-1605
CATH 3DVECT 2087X-2714
CATH 3DVECT 2714X-3529
CATH EP NO COOL 561X-730
CATH EP NO COOL 730X-949
CATH EP NO COOL1234X-1605
CATH EP NO COOL2087X-2714
CATH INTRA ECH 2087X-2714
VASC CLOS DEV 195X-254
LOOP RECORDER 3529X-4588
INTRO SHTH STER 949X-1234

239940119.xlsx.ms_office

Price
975.00
1,270.00
13,570.00
1,270.00
255.00
2,805.00
3,650.00
4,745.00
1,270.00
440.00
575.00
3,650.00
575.00
17,645.00
17,645.00
2,997.00
0.01
575.00
975.00
1,270.00
195.00
575.00
750.00
255.00
335.00
575.00
750.00
975.00
1,655.00
2,155.00
2,805.00
3,650.00
6,170.00
2,155.00
4,745.00
6,170.00
8,025.00
13,570.00
17,645.00
3,650.00
4,745.00
8,025.00
13,570.00
13,570.00
1,270.00
22,940.00
6,170.00

$0 Indicator

Page 184 of 299

CDM #
4809646
4809653
4809661
4809687
4809703
4809711
4809729
4809828
4809836
4809844
4809851
4809869
4809877
4809885
4809893
4809901
4809919
4809927
4809935
4809943
4809976
4809992
4810008
4810016
4810024
4810032
4810040
4810057
4810073
4810081
4810107
4810115
4810123
4810131
4810149
4810156
4810164
4810214
4810222
4810248
4810255
4810263
4810289
4810305
4810354
4810362
4810370

CDM Description
GUIDEWIRE 10-13
GUIDEWIRE 17X-23
GUIDEWIRE 23X-30
GUIDEWIRE 39X-51
GUIDEWIRE 67X-88
GUIDEWIRE 88X-115
GUIDEWIRE 115X-150
CATH GUIDING 39X-51
CATH GUIDING 51X-67
CATH GUIDING 88X-115
CATH GUIDING 115X-150
CATH GUIDING 150X-195
CATH GUIDING 195X-254
CATH GUIDING 254X-331
CATH GUIDING 331X-431
CATH GUIDING 561X-730
CATH GUIDING 730X-949
INTRO SHTH PEEL 17X-23
INTRO SHTH PEEL 67X-88
INTRO SHTH PEEL 115X-150
INTRO SHTH NPEEL 17X-23
INTRO SHTH NPEEL 88X-115
INTRO SHTH NPEEL 115X-150
INTRO SHTH NPEEL 150X-195
INTRO SHTH NPEEL 195X-254
INTRO SHTH NPEEL 254X-331
INTRO SHTH NPEEL 561X-730
INTRO SHTH GENRL 10-13
INTRO SHTH GENRL 17X-23
INTRO SHTH GENRL 23X-30
INTRO SHTH GENRL 39X-51
INTRO SHTH GENRL 51X-67
INTRO SHTH GENRL 67X-88
INTRO SHTH GENRL 88X-115
INTRO SHTH GENRL 115X-150
INTRO SHTH GENRL 150X-195
INTRO SHTH GENRL 195X-254
CATH EP COOL 254X-331
CATH EP COOL 561X-730
CATH EP COOL 1234X-1605
CATH EP COOL 1605X-2087
CATH EP COOL 2087X-2714
CATH GENERAL 17X-23
CATH GENERAL 30X-39
CATH GENERAL 331X-431
CATH GENERAL 561X-730
CATH GENERAL 730X-949

239940119.xlsx.ms_office

Price
65.00
115.00
150.00
255.00
440.00
575.00
750.00
255.00
335.00
575.00
750.00
975.00
1,270.00
1,655.00
2,155.00
3,650.00
4,745.00
115.00
440.00
750.00
115.00
575.00
750.00
975.00
1,270.00
1,655.00
3,650.00
65.00
115.00
150.00
255.00
335.00
440.00
575.00
750.00
975.00
1,270.00
1,655.00
3,650.00
8,025.00
10,435.00
13,570.00
115.00
195.00
2,155.00
3,650.00
4,745.00

$0 Indicator

Page 185 of 299

CDM #
4810388
4810420
4810438
4810446
4810453
4810461
4810487
4810495
4810503
4810511
4810537
4810545
4810552
4810578
4810586
4810594
4810602
4810651
4810669
4810677
4810685
4810743
4810750
4810768
4810776
4810826
4810834
4810842
4810859
4810867
4810875
4810883
4810891
4810909
4810917
4810925
4810933
4810941
4810958
4810966
4810974
4810982
4810990
4811014
4811022
4811030
4811048

CDM Description
CATH GENERAL 949X-1234
CLOSURE IMPLNT 23X-30
CLOSURE IMPLNT 88X-115
CLOSURE IMPLNT 150X-195
INST/SUPP STERL 23X-30
INST/SUPP STERL 30X-39
INST/SUPP STERL 51X-67
INST/SUPP STERL 67X-88
INST/SUPP STERL 88X-115
INST/SUPP STERL 115X-150
INST/SUPP STERL 195X-254
INST/SUPP STERL 331X-431
INST/SUPP STERL 949X-1234
TUBING/CONNECT 51X-67
TUBING/CONNECT 67X-88
TUBING/CONNECT 150X-195
CLOSURE EXTERN 17X-23
CATH EP NON3D 1605X-2087
CATH EP>19NO3D 115X-150
CATH EP>19NO3D 2714X-3529
CATH INTRA US 2087X-2714
CATH DIALYSIS LT 254X-331
CATH PACE TRANS 115X-150
CATH INF PERIPH 23X-30
INST/SUPP STERL 17X-23
PTA VENOUS
CL VENOGRAM EXTREMITY LT
CL VENOGRAM EXTREMITY RT
CATH INTRA ECH 2087X-2714
US GUIDED VASCULAR ACCESS
CATH GENERAL 10-13
FILTER VENA CAV 730X-949
FILTER VENA CAV 561X-730
CATH INTRA ECH 730X-949
CATH INTRA ECH 949X-1234
CATH INTRA ECH 1234X-1605
CATH INTRA ECH 1605X-2087
ANALY SNGL PACE W PROG
ANALY DEFIB WO REPROG
ANALY SNGL DEFIB W PROG
ANALY DUAL DEFIB W PROG
VENOUS MECH THROMBECTOMY
VEN MECH THROMBECT EA ADD
RETRV DEV INSR 195X-254
RETRV DEV INSR 150X-195
RETRV DEV INSR 115X-150
CL ENVAS REP INFRAREN AAA

239940119.xlsx.ms_office

Price
6,170.00
150.00
575.00
975.00
150.00
195.00
335.00
440.00
575.00
750.00
1,270.00
2,155.00
6,170.00
335.00
440.00
975.00
115.00
10,435.00
750.00
17,645.00
13,570.00
1,655.00
750.00
150.00
115.00
10,998.00
1,453.00
1,453.00
13,570.00
871.00
65.00
4,745.00
3,650.00
4,745.00
6,170.00
8,025.00
10,435.00
496.00
364.00
496.00
588.00
10,835.00
10,835.00
1,270.00
975.00
750.00
11,647.00

$0 Indicator

Page 186 of 299

CDM #
4811055
4811063
4811071
4811089
4811097
4811113
4811238
4811246
4811253
4811287
4811295
4811386
4811394
4811410
4811428
4811451
4811469
4811485
4811493
4811535
4811543
4811550
4811568
4811576
4811584
4811592
4811600
4811618
4811626
4811634
4811659
4811667
4811675
4811683
4811691
4811709
4811717
4811725
4811733
4811741
4811758
4811766
4811774
4811782
4811790
4811808
4811816

CDM Description
CL ENVAS REP ANEU PROSTHE
IDE#G090066 QUARTET CRT-D
IDE#G090066 QUARTET LEADS
IDE#G090109 CATH ABL LEAD
IDE#G000291 CYPRESS TRIAL
CATH/NDL PLC AV SH DI ADD
PTA RENAL LINKED
PTA VISCERAL LINKED
PTA AORTA LINKED
PTA BRACHIOCEPHALC LINKED
PTA VENOUS LINKED
STENT INITIAL LINKED
THROMBOLYSIS INFUSION LNK
EMBOLIZ NON-NEURO LINKED
RETREIVAL OF FB LINKED
TUN CTH INS NOPMP/PRT LNK
TUN CTH INS W/PORT LINKED
NON-TUN CATH INS LINKED
PORT-A-CATH INS LINKED
VENT ASSIST 22152X-28798
IMP VENTR ASST DEVICE
VENT ASSIST 22152X-28798
IMP VENTR ASST DEVICE
D5% 250ML INJ
NACL 0.9% 500ML INJ
D5% RINGERS 1000ML INJ
D5% 0.9 NACL 1000ML INJ
D5% 0.9 NACL 250ML INJ
D5% 0.9 NACL 500ML INJ
D5% 0.9 NACL 250ML INJ
D5% 0.45 NACL 1000ML INJ
IDE#G080186 DAPT STUDY
CARDIOVERSION INT W AICD
INTRO SHTH STER1234X-1605
INTRO SHTH STER 730X-949
TUBING/CONNECT 10-13
TUBING/CONNECT 13X-17
TUBING/CONNECT 17X-23
CATH THROM EMB 2087X-2714
EMBL PROTCT SYS 67X-88
EMBL PROTCT SYS 730X-949
LEAD NEURO TST 949X-1234
INTRO SHTH NPEEL 115X-150
INTRO SHTH NPEEL 150X-195
INTRO SHTH NPEEL 195X-254
INTRO SHTH PEEL 51X-67
INTRO SHTH PEEL 39X-51

239940119.xlsx.ms_office

Price
2,918.00
102,648.00
20,460.00
4,753.00
0.01
2,086.00
143,990.00
31,755.00
143,990.00
31,755.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
0.01
1,845.00
8,025.00
4,745.00
65.00
85.00
115.00
13,570.00
440.00
4,745.00
6,170.00
750.00
975.00
1,270.00
335.00
255.00

$0 Indicator

L
L
L
L
L
L
L
L
L
L
L
L
L

Page 187 of 299

CDM #
4811824
4811832
4811840
4811857
4811865
4811873
4811881
4811899
4811907
4811915
4811923
4811931
4811949
4811956
4811964
4811972
4811980
4811998
4812004
4812012
4812020
4812038
4812046
4812053
4812061
4812079
4812087
4812095
4812103
4812111
4812129
4812137
4812145
4812152
4812160
4812178
4812186
4812194
4812202
4812236
4812244
4812251
4812269
4812277
4812285
4812293
4812301

CDM Description
INTRO SHTH PEEL 30X-39
INTRO SHTH PEEL 23X-30
CATH PTA N LSR 254X-331
CATH PTA N LSR 331X-431
CATH PTA N LSR 431X-561
CATH PTA N LSR 115X-150
CL FLUORO VERTEBROPLASTY
VERTEBR AUGMENT EA ADD
VERTEBR AUGMENT LUMBAR
VERTEBR AUGMENT THORAC
VERTEBROPLAST INJ ADDL
VERTEBROPLA INJ LUMBAR
VERTEBROPLA INJ THORAC
CL ANGIO VERTEBRAL BIL
VASCULAR IMPL 67X-88
VASCULAR IMPL 51X-67
VASCULAR IMPL 88X-115
KIT/PACK SURG 3529X-4588
CATH INF PERIPH 67X-88
INTRO SHTH LSR 2087X-2714
INTRO SHTH LSR 1605X-2087
INTRO SHTH LSR 1234X-1605
INTRO SHTH LSR 949X-1234
SURGERY LEVEL 4 1ST 30MIN
SURGERY LEVEL 4 ADD 15MIN
SURGERY LEVEL 5 1ST 30MIN
SURGERY LEVEL 5 ADD 15MIN
VASC CLOS DEV 561X-730
VASC CLOS DEV 730X-949
GRAFT VASC S 10082X-13107
GRAFT VASC S 7755X-10082
GRAFT VASC S 5965X-7755
GRAFT VASC 730X-949
GRAFT VASC 115X-150
GRAFT VASC 1234X-1605
GRAFT VASC 254X-331
GRAFT VASC 331X-431
GRAFT VASC 561X-730
GRAFT VASC S 254X-331
GRAFT VASC S 331X-431
GRAFT VASC S 431X-561
GRAFT VASC S 561X-730
GRAFT VASC S 730X-949
GRAFT VASC S 17040X-22152
GRAFT VASC S 13107X-17040
CATH PTA N LSR 949X-1234
CATH PTA N LSR 1234X-1605

239940119.xlsx.ms_office

Price
195.00
150.00
1,655.00
2,155.00
2,805.00
750.00
4,344.00
15,368.00
22,282.00
22,282.00
5,509.00
7,987.00
7,987.00
5,770.00
440.00
335.00
575.00
22,940.00
440.00
13,570.00
10,435.00
8,025.00
6,170.00
15,052.00
5,272.00
19,568.00
6,851.00
3,650.00
4,745.00
65,535.00
50,410.00
38,775.00
4,745.00
750.00
8,025.00
1,655.00
2,155.00
3,650.00
1,655.00
2,155.00
2,805.00
3,650.00
4,745.00
110,760.00
85,200.00
6,170.00
8,025.00

$0 Indicator

Page 188 of 299

CDM #
4812319
4812327
4812335
4812343
4812350
4812368
4812376
4812384
4812392
4812400
4812418
4812426
4812434
4812442
4812459
4812467
4812475
4812483
4812491
4812509
4812517
4812525
4812558
4812566
4812574
4812582
4812590
4812608
4812616
4812624
4812632
4812640
4812657
4812665
4812699
4812707
4812715
4812723
4812731
4812749
4812756
4812764
4812772
4812780
4812798
4812806
4812822

CDM Description
CATH GUIDING 3529X-4588
REVAS TIB PR STNT ATH ADD
REVAS FEM POP STENT ATHER
REVAS TIB PERON ATHER ADD
REVAS FEM POP ATHERECTOMY
REVAS TIB PERON ATHER INI
REVAS TIB PR STNT ATH INI
REVAS IPSIL ILI STENT ADD
REVAS TIB PERON STENT ADD
REVAS ILIAC STENT INI VES
REVAS FEMORAL POPLT STENT
REVAS TIB PERON STENT INI
REVAS IPSIL ILI ANGIO ADD
REVAS TIB PERON ANGIO ADD
REVAS ILIAC TRNS ANG INI
REVAS FEM POP TRANS ANGIO
REVAS TIBIAL PERN ANG INI
TRANSLUM ATHER RENAL ART
TRANSLUM ATHR VISCERAL EA
TRANSLUM ATHER ABD AORTA
TRANSLUM ATHEREC BRACH EA
TRANSLUM ATHEREC ILIAC EA
LT HRT CTH VENTRICULGRPHY
RT LT HRT CTH LT VNTRICUL
COR ANGIO CATH PLACE
COR ANG CTH PLC BYPS GRFT
RT HRT CATH COR ANGIO
RT HRT CTH COR ANG BYP GR
LT HRT CTH COR ANG VNTRCU
LT HRT CTH ANG VNT BYP GR
RT LT HRT CTH COR ANG VNT
RT LT HRT CTH ANG VNT BYP
LEFT HEART CATH TRANSSEPT
DRUG ADMIN HEMODYN MEAS
LT HRT CTH VENTRICULGRPHY
RT LT HRT CTH LT VNTRICUL
COR ANGIO CATH PLACE
COR ANG CTH PLC BYPS GRFT
RT HRT CATH COR ANGIO
RT HRT CTH COR ANG BYP GR
LT HRT CTH COR ANG VNTRCU
LT HRT CTH ANG VNT BYP GR
RT LT HRT CTH COR ANG VNT
RT LT HRT CTH ANG VNT BYP
LEFT HEART CATH TRANSSEPT
DRUG ADMIN HEMODYN MEAS
ANGIO IN R VNT/AT CRD CTH

239940119.xlsx.ms_office

Price
22,940.00
19,775.00
24,001.00
18,524.00
22,750.00
22,750.00
24,001.00
14,356.00
14,356.00
18,584.00
18,584.00
18,584.00
13,189.00
13,189.00
17,415.00
17,415.00
17,252.00
16,993.00
16,993.00
16,993.00
16,993.00
16,993.00
27,489.00
35,456.00
25,495.00
28,081.00
37,598.00
40,182.00
34,511.00
37,096.00
42,478.00
45,062.00
24,558.00
2,215.00
27,489.00
35,456.00
25,495.00
28,081.00
37,598.00
40,182.00
34,511.00
37,096.00
42,478.00
45,062.00
24,558.00
2,215.00
4,819.00

$0 Indicator

Page 189 of 299

CDM #
4812830
4812848
4812855
4812863
4812871
4812889
4812897
4812905
4812954
4812996
4813002
4813010
4813028
4813077
4813085
4813093
4813101
4813127
4813135
4813143
4813150
4813176
4813192
4813200
4813218
4813234
4813242
4813259
4813267
4813291
4813325
4813333
4813341
4813358
4813366
4813382
4813408
4813416
4813424
4813432
4813440
4813457
4813507
4813515
4813523
4813531
4813549

CDM Description
GRAFT MESH 254X-331
CATH GENERAL 2714X-3529
CATH ATHRCT R 2714X-3529
CATH ATHRCT R 2087X-2714
CATH GENERAL 2087X-2714
CATH GENERAL 1234X-1605
CATH GENERAL 1605X-2087
LEAD DUAL ICD 4588X-5965
LEAD DUAL ICD 4588X-5965
LEAD DUAL ICD 5965X-7755
CATH OCCLUSN 51X-67
CATH OCCLUSN 67X-88
CATH OCCLUSN 254X-331
INST/SUPP STERL 254X-331
CATH GENERAL 1605X-2087
VASCULAR IMPL 730X-949
EMBOLIZATION UTER FIBROID
PACEMAKER D RR 3529X-4588
PACEMAKER D RR 4588X-5965
PACEMAKER S RR 2714X-3529
PACEMAKER S RR 4588X-5965
PACEMAKER S RR 3529X-4588
LEAD NOT S/D 431X-5610
LEAD NOT S/D 730X-949
LEAD NOT S/D 949X-1234
LEAD LT VENTRIC3529X-4588
LEAD SNGL ICD 4588X-5965
PACEMAKER D RR 2714X-3529
PACEMAKER D RR 3529X-4588
PACEMAKER S RR 2714X-3529
LEAD DUAL ICD 3529X-4588
LEAD NOT S/D 431X-561
LEAD NOT S/D 730X-949
LEAD NOT S/D 949X-1234
LEAD NOT S/D 561X-730
LEAD LT VENTRIC3529X-4588
LEAD LT VENTRIC1605X-2087
LEAD LT VENTRIC2087X-2714
PACMKR N SN/DL 4588X-5965
PACMKR N SN/DL7755X-10082
PACMKR N SN/DL10082-13107
PACEMAKER S RR 3529X-4588
VASCULAR IMPL 949X-1234
VASCULAR IMPL 1234X-1605
ICD DUAL 17040X-22152
ICD DUAL 13107X-17040
ICD NOT S/D 22152X-28798

239940119.xlsx.ms_office

Price
1,655.00
17,645.00
17,645.00
13,570.00
13,570.00
8,025.00
10,435.00
29,825.00
29,825.00
38,775.00
335.00
440.00
1,655.00
1,655.00
10,435.00
4,745.00
8,046.00
22,940.00
29,825.00
17,645.00
29,825.00
22,940.00
2,805.00
4,745.00
6,170.00
22,940.00
29,825.00
17,645.00
22,940.00
17,645.00
22,940.00
2,805.00
4,745.00
6,170.00
3,650.00
22,940.00
10,435.00
13,570.00
29,825.00
50,410.00
65,535.00
22,940.00
6,170.00
8,025.00
110,760.00
85,200.00
143,990.00

$0 Indicator

Page 190 of 299

CDM #
4813564
4813572
4813598
4813622
4813630
4813671
4813689
4813697
4813705
4813713
4813721
4813739
4813747
4813754
4813762
4813770
4813788
4813796
4813804
4813812
4813820
4813838
4813846
4813853
4813861
4813879
4813895
4813903
4813911
4813929
4813937
4813945
4813952
4813960
4813978
4813986
4813994
4814000
4814018
4814026
4814034
4814042
4814059
4814067
4814075
4814083
4814091

CDM Description
ICD NOT S/D 17040X-22152
ICD DUAL 13107X-17040
ICD DUAL 17040X-22152
ICD SINGLE 10082X-13107
ICD SINGLE 13107X-17040
INTRO SHTH STER1605X-2087
CATH EP NO COOL3529X-4588
CATH EP NO COOL5965X-7755
CATH DIALYSIS ST 88X-115
CATH DIALYSIS ST 115X-150
CATH DIALYSIS ST 67X-88
INTRO SHTH GENRL 561X-730
CATH OCCLUSN 195X-254
CATH ATHRCT R 1234X-1605
LEAD NOT S/D 561X-730
ICD NOT S/D 13107X-17040
ICD DUAL 10082X-13107
ICD NOT S/D 17040X-22152
ICD NOT S/D 22152X-28798
CAROTID STNT TRANSCATH W
VASC ACCES THROMBL DECLOT
STNT NCOAT W 561X-730
STNT NCOAT W 431X-561
STNT NCOAT W 331X-431
STNT NCOAT W 730X-949
CATH EP NON3D 1234X-1605
CATH TRAN DIR 1605X-2087
CATH TRAN DIR 2087X-2714
CATH TRAN DIR 2714X-3529
INTRO SHTH LSR 1234X-1605
INTRO SHTH LSR 1605X-2087
INTRO SHTH LSR 2087X-2714
INTRO SHTH PEEL 331X-431
INTRO SHTH PEEL 730X-949
VASC CLOS DEV 115X-150
VASC CLOS DEV 150X-195
CATH 3DVECT 1234X-1605
CATH 3DVECT 1605X-2087
CATH EP COOL 195X-254
CATH EP NO COOL1605X-2087
CATH EP NO COOL 431X-561
CATH EP NO COOL 949X-1234
CATH EP NON3D 67X-88
CATH GUIDING 431X-561
CATH GUIDING 949X-1234
CATH INF PERIPH 30X-39
CATH INTRA ECH 2714X-3529

239940119.xlsx.ms_office

Price
110,760.00
85,200.00
110,760.00
65,535.00
85,200.00
10,435.00
22,940.00
38,775.00
575.00
750.00
440.00
3,650.00
1,270.00
8,025.00
3,650.00
85,200.00
65,535.00
110,760.00
143,990.00
27,599.00
668.00
3,650.00
2,805.00
2,155.00
4,745.00
8,025.00
10,435.00
13,570.00
17,645.00
8,025.00
10,435.00
13,570.00
2,155.00
4,745.00
750.00
975.00
8,025.00
10,435.00
1,270.00
10,435.00
2,805.00
6,170.00
440.00
2,805.00
6,170.00
195.00
17,645.00

$0 Indicator

Page 191 of 299

CDM #
4814109
4814117
4814125
4814133
4814141
4814166
4814174
4814182
4814208
4814216
4814224
4814232
4814240
4814257
4814265
4814273
4814281
4814299
4814307
4814315
4814323
4814331
4814349
4814356
4814364
4814372
4814380
4814398
4814406
4814422
4814430
4814448
4814455
4814463
4814471
4814489
4814497
4814562
4814570
4814588
4814596
4814604
4814612
4814620
4814638
4814646
4814653

CDM Description
CATH OCCLUSN 39X-51
CATH OCCLUSN 88X-115
GUIDEWIRE 13X-17
INTRO SHTH PEEL 561X-730
PACEMKR D N RR 4588X-5965
LEAD SNGL ICD 3529X-4588
LEAD SNGL ICD 2714X-3529
PACMKR N SN/DL 5965X-7755
PACEMAKER S RR 4588X-5965
PACEMAKER S RR 5965X-7755
LEAD PMKR TRN VDD431X-561
ICD SINGLE 17040X-22152
LEAD PMKR TRN VDD561X-730
LEAD PMKR TRN VDD730X-949
PACEMAKER D RR 4588X-5965
PACEMAKER D RR 5965X-7755
CL BILIARY DRAIN TRANSHEP
CL CHOLE THRU EXIST CATH
CL CHOLE PERC TRANSHEP
CL BILIARY DRN CATH/STENT
BILIARY DRAIN STENT INST
CHOLANG TRANSHEP PERC INJ
CHOLANGIO EXIST CATH INJ
BILIARY DRAIN CATH INSERT
CATH DRAINAGE 67X-88
CATH DRAINAGE 51X-67
CATH DRAINAGE 39X-51
PACMKR N SN/DL 4588X-5965
GUIDEWIRE 22152X-28798
REM VAD EXTRACRP SGL VENT
INS VAD INTRACRP SGL VENT
SACRAL AUGMENT RT INJ
SACRAL AUGMENT LT INJ
GRAFT MESH 150X-195
CATH INF PERIPH 730X-949
CATH THROM EMB 195X-254
CLOSURE EXTERN 67X-88
PARACENTSIS ABD W IMAGING
INS IVC FILTER ENDOVAS
REPOS IVC FILTER ENDOVAS
RETR IVC FILTER ENDOVAS
CTH PLC RENAL ART SEL RT
CTH PLC RENAL SUPRSEL RT
CTH PLC RENAL ART SEL LT
CTH PLC RENAL SUPRSEL LT
CTH PLC RENL ART SEL BI59
CTH PLC RENL SUPRSEL BI59

239940119.xlsx.ms_office

Price
255.00
575.00
85.00
3,650.00
29,825.00
22,940.00
17,645.00
38,775.00
29,825.00
38,775.00
2,805.00
110,760.00
3,650.00
4,745.00
29,825.00
38,775.00
4,510.00
1,629.00
1,779.00
4,510.00
5,669.00
315.00
315.00
5,669.00
440.00
335.00
255.00
29,825.00
143,990.00
6,911.00
27,740.00
7,987.00
7,987.00
975.00
4,745.00
1,270.00
440.00
5,669.00
19,775.00
14,602.00
16,993.00
7,715.00
7,715.00
7,715.00
7,715.00
9,654.00
9,654.00

$0 Indicator

Page 192 of 299

CDM #
4814661
4814679
4814687
4814695
4814703
4814711
4814729
4814737
4814745
4814752
4814760
4814778
4814786
4814794
4814802
4814810
4814828
4814836
4814851
4814869
4814877
4814885
4814893
4814901
4814919
4814927
4814935
4814943
4814950
4814968
4814976
4814984
4814992
4815007
4815015
4815023
4815031
4815049
4815056
4815064
4815072
4815080
4815098
4815106
4815114
4815122
4815130

CDM Description
VASCULAR IMPL 254X-331
RETRV DEV INS 949X-1234
VALVE HEART 28798X-37438
VALVE HEART 28798X-37438
DEFIB GEN REPL SNGL LEAD
DEFIB INS EXIS MULT LEADS
DEFIB GEN REPL MULT LEAD
DEFIB GEN REPL DUAL LEAD
DEFIB INS EXIS DUAL LEADS
PACEMK GEN REPL SNGL LEAD
PACEMK INS EXIS MLT LEADS
PACEMK GEN REPL MULT LEAD
PACEMK GEN REPL DUAL LEAD
DEFIB GEN REPL SNGL LEAD
DEFIB INS EXIS MULT LEADS
DEFIB GEN REPL MULT LEAD
DEFIB GEN REPL DUAL LEAD
DEFIB INS EXIS DUAL LEADS
PACEMK INS EXIS MLT LEADS
PACEMK GEN REPL MULT LEAD
PACEMK GEN REPL DUAL LEAD
CATH EP NON3D 331X-431
CATH EP NON3D 730X-949
INS VAD EXTRACRP SGL VENT
INS VAD EXTRACRP SGL VENT
IDE#G090080 EAS-AC
ANESTH GENERAL 1ST 30MIN
ANESTH GENERAL ADDL 15MIN
ANESTH MAC/REG 1ST 30MIN
ANESTH MAC/REG ADDL 15MIN
CATH OCCLUSION 431X-561
INST/SUPP STERL 39X-51
LEADS REPAIR TWO TRANSVEN
STNT COATED W 3529X-4588
GUIDEWIRE 949X-1234
CANNULA 39X-51
REEXPLORE PACEMAKER GEN
CATH GUIDING 23X-30
CATH INTRA ECH 2714X-3529
LAA LIGATION PERC
LAA LIGATION PERC
REPL TUN CVAD W PORT CV
KIT/PACK SURG 730X-949
KIT/PACK SURG 730X-949
CATH PLACE VEN 2ND ORD
CL VENOGRAM SINUS/JUGULAR
CATH INF PERIPH 431X-561

239940119.xlsx.ms_office

Price
1,655.00
6,170.00
187,190.00
187,190.00
9,654.00
9,654.00
9,654.00
9,654.00
9,654.00
9,794.00
9,794.00
9,794.00
9,794.00
9,654.00
9,654.00
9,654.00
9,654.00
9,654.00
9,794.00
9,794.00
9,794.00
2,155.00
4,745.00
31,755.00
31,755.00
0.01
1,513.00
530.00
659.00
234.00
2,805.00
255.00
8,293.00
22,940.00
6,170.00
255.00
9,620.00
150.00
17,645.00
18,072.00
18,072.00
6,911.00
4,745.00
4,745.00
1,670.00
4,344.00
2,805.00

$0 Indicator

Page 193 of 299

CDM #
4815148
4815155
4815163
4815171
4816179
4816187
4816195
4816203
4816211
4816229
4816237
4816245
4816252
4816260
4816278
4816286
4816294
4816302
4816310
4816328
4816336
4816344
4816351
4816369
5000013
5000021
5000039
5000062
5000070
5000088
5000096
5100011
5100029
5100037
5100045
5100086
5100094
5100102
5100185
5100193
5100201
5100219
5100227
5100235
5100243
5100250
5100268

CDM Description
CATH PTA N LSR 88X-115
KIT/PACK SURG 254X-331
CLOSURE EXTERN 67X-88
STNT COATED W 2714X-3529
ANESTH GENERAL 1ST 30MIN
ANESTH GENERAL ADDL 15MIN
ANESTH MAC/REG 1ST 30MIN
ANESTH MAC/REG ADDL 15MIN
STNT NCOAT WO 949X-1234
STENT GRAFT 7755X-10082
STENT GRAFT 13107X-17040
CATH GENERAL 39X-51
CATH THROM EMB 431X-561
INST/SUPP STERL 150X-195
SEPTAL DEF SYS 4588X-5965
INTRO SHTH NPEEL 561X-730
SURGERY LEVEL 6 1ST 30MIN
SURGERY LEVEL 6 ADD 15MIN
TRANSCATHETER BIOPSY
CL BIOPSY TRANSCATH
CL VENOGRM HEPAT W HEMODY
THORACENTESIS
US GUIDED NEEDL PLACEMENT
INSERT TIPS
AD EVOKED POTENTIALS LIM
OT DEVELOPMENTAL TESTING
OT EVALUATION 30
OT RE-EVALUATION 30
OT MC EVALUATION INI 30
OT MC RE-EVAL INI 30
NURSE ASSESSMNT EA30 HRIF
CONTACT LAYER
PADDING BANDAGE
CONFORMING BANDAGE
LIGHT COMP BANDAGE
NEG PRESSURE WD>50CM 15MN
NEG PRESSUR WD<=50CM 15MN
HYPERBARIC O2 EACH 30 MN
VISIT LEVEL 1 EST PT
VISIT LEVEL 2 EST PT
VISIT LEVEL 3 EST PT
VISIT LEVEL 4 EST PT
VISIT LEVEL 5 EST PT
VISIT LEVEL 1 EST W PROC
VISIT LEVEL 2 EST W PROC
VISIT LEVEL 3 EST W PROC
VISIT LEVEL 4 EST W PROC

239940119.xlsx.ms_office

Price
575.00
1,655.00
440.00
17,645.00
1,513.00
530.00
659.00
234.00
6,170.00
50,410.00
85,200.00
255.00
2,805.00
975.00
29,825.00
3,650.00
23,000.00
8,050.00
6,844.00
2,647.00
4,344.00
1,242.00
1,294.00
8,046.00
343.00
458.00
405.00
405.00
405.00
405.00
112.00
76.00
8.00
5.00
19.00
1,500.00
1,314.00
670.00
239.00
288.00
324.00
360.00
444.00
239.00
288.00
324.00
360.00

$0 Indicator

Page 194 of 299

CDM #
5100276
5100284
5100318
5100326
5100334
5100417
5100425
5100433
5100441
5100458
5100466
5100474
5100482
5100490
5100508
5100516
5100524
5100532
5100540
5100557
5100565
5100573
5100581
5100599
5100607
5100615
5100623
5100631
5100649
5100656
5100664
5100672
5100680
5100698
5100706
5100714
5100722
5100730
5100797
5100805
5100839
5100847
5100854
5100870
5100888
5100896
5100904

CDM Description
VISIT LEVEL 5 EST W PROC
DEBR NON-SELECTIV SESSION
INJ TX/DX/PROPH SUBQ/IM
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
NEG PRESSUR WD<=50CM 30MN
NEG PRESSUR WD<=50CM 45MN
NEG PRESSUR WD<=50CM 60MN
NEG PRESSURE WD>50CM 30MN
NEG PRESSURE WD>50CM 45MN
NEG PRESSURE WD>50CM 60MN
VISIT LEVEL 1 NEW PT
VISIT LEVEL 1 NEW W PROC
VISIT LEVEL 2 NEW PT
VISIT LEVEL 2 NEW W PROC
VISIT LEVEL 3 NEW PT
VISIT LEVEL 3 NEW W PROC
VISIT LEVEL 4 NEW PT
VISIT LEVEL 4 NEW W PROC
VISIT LEVEL 5 NEW PT
VISIT LEVEL 5 NEW W PROC
HBO THERAPY 1ST 15 MN
HBO THERAPY EA ADD 15 MN
GLUCOSE BLOOD BY DEVICE
SKIN TEST CHECK
DRESSING CHANGES
IV-MIDLINE CATH INSERT
IV-THERAPEUTIC PHLEBOTOMY
IV-CENTRAL LINE CATH REPA
IV-CENTRAL LNE DECLOTTING
IV-CENTRAL LINE TIVAD ACC
IV-PICC INSERTION
DRAW BLOOD
IV-TROUBLE SHOOT COMPLEX
IV START SIMPLE
IV START COMPLEX
IV-SKIN TEST ADMIN
IV-TROUBLE SHOOT SIMP
APLIGRAF SQ CM EACH
INJ TX/PRO/DX IVP SME DRG
APPL LAYRD COMPRES BK BIL
APPL LAYRED COMPRES BK LT
APPL LAYRED COMPRES BK RT
INST/SUPP STERL 51X-67
TRANS O2 MEAS 1-2 LVL LTD
TRANS O2 MEAS 1-2 LVL BI
TRAN O2 MEAS >=3 LVL LTD

239940119.xlsx.ms_office

Price
444.00
773.00
275.00
544.00
544.00
1,380.00
1,449.00
1,521.00
1,577.00
1,653.00
1,738.00
239.00
239.00
288.00
288.00
324.00
324.00
360.00
360.00
444.00
444.00
335.00
335.00
176.00
144.00
544.00
415.00
286.00
286.00
335.00
717.00
949.00
1,039.00

$0 Indicator

S
S
S
S
S
S
S
S
S
S
S
S
S
S

Page 195 of 299

CDM #
5100912
5100920
5100938
5100946
5100953
5100979
5100987
5100995
5101001
5101019
5101027
5101035
5101043
5101050
5101084
5101092
5101100
5101118
5101126
5101134
5101142
5101159
5101167
5200019
5200035
5200043
5200050
5200068
5200076
5200084
5200092
5200100
5200118
5200126
5200159
5200167
5200183
5200191
5200209
5200217
5200233
5200324
5200332
5200340
5200357
5200365
5200613

CDM Description
TRANS O2 MEAS >=3 LVL BI
DEBR SL SESSION 1ST 20CM
DEBR SELCT SESSION ADD 20
DEBR SL SESSION EA 15 NC
INST/SUPP STERL 67X-88
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
TRIM SKIN LESION 1ST
TRIM SKIN LESION 2-4
DEBR SUBQ TISS 1ST 20SQCM
DEBR SUBQ TISS ADD 20SQCM
TRIM NONDYSTROPHIC NAILS
DEBRIDE NAIL UP TO 5
DEBRIDE NAIL 6 OR >
PACK WOUND DEHISCENCE
TX BURN 1ST DEG INITIAL
DRESS/DEBR BURN SMALL
DRESS/DEBR BURN MEDIUM
CHEMICAL CAUTERIZ TISSUE
REMOVE CERUMEN IMPACTED
BLOOD COLLECTION VAD
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
PUMP PORTABL REFILL/MAINT
PUMP IMPLANTD REFIL/MAINT
IRRIG IMPLANTED VEN ACCES
TRANSFUS BLD/BLD COMP
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
MINOR PROCEDURE
VENIPUNCTURE
PHLEBOTOMY THERAPEUT

239940119.xlsx.ms_office

Price
1,389.00
550.00
367.00
440.00
544.00
544.00
544.00
275.00
275.00
308.00
308.00
961.00
961.00
138.00
308.00
308.00
1,140.00
308.00
525.00
525.00
525.00
251.00
339.00
275.00
544.00
140.00
544.00
140.00
140.00
544.00
544.00
544.00
544.00
544.00
275.00
275.00
544.00
544.00
275.00
778.00
544.00
140.00
544.00
1,142.00
11.00
532.00

$0 Indicator

Page 196 of 299

CDM #
5201843
5201850
5201868
5201876
5201884
5201892
5201900
5201918
5201926
5201934
5201942
5201959
5201967
5201975
5201983
5201991
5202007
5202015
5202023
5202031
5202049
5202056
5202064
5202072
5202080
5202098
5202106
5202114
5202122
5202130
5202148
5202155
5202163
5202189
5202197
5202205
5202213
5202221
5202239
5202247
5202254
5202262
5202270
5202288
5202296
5202304
5202312

CDM Description
BLOOD COLLECTION VAD
CHEMO ADMIN INTRATHECAL
VISIT LEVEL 1 NEW PT
VISIT LEVEL 1 NEW W PROC
VISIT LEVEL 2 NEW PT
VISIT LEVEL 2 NEW W PROC
VISIT LEVEL 3 NEW PT
VISIT LEVEL 3 NEW W PROC
VISIT LEVEL 4 NEW PT
VISIT LEVEL 4 NEW W PROC
VISIT LEVEL 5 NEW PT
VISIT LEVEL 5 NEW W PROC
VISIT LEVEL 1 EST PT
VISIT LEVEL 1 EST W PROC
VISIT LEVEL 2 EST PT
VISIT LEVEL 2 EST W PROC
VISIT LEVEL 3 EST PT
VISIT LEVEL 3 EST W PROC
VISIT LEVEL 4 EST PT
VISIT LEVEL 4 EST W PROC
VISIT LEVEL 5 EST PT
VISIT LEVEL 5 EST W PROC
INF PATIENT VISIT STAT
ONCOL PATIENT VISIT STAT
VENIPUNCTURE
MINOR PROCEDURE
INF IV TX/DX PUMP PROLONG
CHEMO INTRA-ART PUSH
CHEMO ART INF INIT 1ST HR
CHEMO ART INF EA ADD HR
CHEMO ADMIN THORACENTESIS
CHEMO ADMIN PERIT CAV IND
CHEM ART INF PUMP PROLONG
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO IV PUSH INITIAL
CHEMO IV PUSH EA ADD
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR

239940119.xlsx.ms_office

Price
339.00
544.00
239.00
239.00
288.00
288.00
324.00
324.00
360.00
360.00
444.00
444.00
239.00
239.00
288.00
288.00
324.00
324.00
360.00
360.00
444.00
444.00
11.00
1,142.00
544.00
544.00
544.00
544.00
544.00
544.00
544.00
275.00
544.00
140.00
544.00
140.00
140.00
544.00
544.00
544.00
544.00
544.00
544.00
544.00
275.00

$0 Indicator

S
S

Page 197 of 299

CDM #
5202320
5202338
5202346
5202353
5202361
5202387
5202395
5202403
5202411
5202437
5202445
5203658
5203666
5203674
5203682
5203690
5203716
5203724
5203732
5203740
5203757
5203997
5204003
5204011
5204029
5204037
5204045
5204052
5204060
5204086
5204169
5204177
5204185
5204193
5204201
5204219
5204227
5204235
5204243
5204250
5204268
5204276
5204292
5204318
5204342
5204359
5204391

CDM Description
CHEMO IV INF PUMP PROLONG
CHEMO INF EA SEQ 1ST HR
PUMP PORTABL REFILL/MAINT
PUMP IMPLANTD REFIL/MAINT
IRRIG IMPLANTED VEN ACCES
TRANSFU BLOOD/COMP 1ST HR
TRANSFU BLOOD EA ADDL HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
PHLEBOTOMY THERAPEUT
PICC INSERT/REPLACE RN
BLOOD COLLECTION VAD
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
IRRIG IMPLANTED VEN ACCES
MINOR PROCEDURE
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
TRANSFUS BLD/BLD COMP
IC KIT CATH GROSHONG
IV SOL D5W 250 ML
IV SOL D5W 500 ML
IV SOL 0.9% NACL 100ML
IV SOL 0.9% NACL 250ML
IV SOL 0.9% NACL 500ML
IV SOL 0.9% NACL 1000M
IV SOL LR 1000 ML
IV SOL D5 1/2 500 ML
IV SOL D5 1/2 1000 ML
INJ TX/PRO/DX IVP SME DRG
INJ TX/PRO/DX IVP SME DRG
BLOOD COLLECTION PICC
BLOOD COLLECTION PICC
BLOOD COLLECTION PICC
VASC ACCES THROMBL DECLOT
INJ TX/PRO/DX IVP SME DRG

239940119.xlsx.ms_office

Price
544.00
275.00
544.00
544.00
275.00
778.00
458.00
140.00
544.00
532.00
2,713.00
339.00
544.00
140.00
544.00
275.00
1,142.00
532.00
544.00
544.00
11.00
275.00
544.00
140.00
544.00
140.00
140.00
544.00
544.00
778.00
725.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
544.00
544.00
339.00
339.00
339.00
668.00
544.00

$0 Indicator

Page 198 of 299

CDM #
5204409
5204474
5204482
5204490
5204508
5204516
5204524
5204532
5204573
5204581
5204599
5204615
5204631
5204649
5204664
5204706
5204714
5204722
5204730
5204748
5204755
5204763
5204771
5204789
5204797
5204805
5204813
5204821
5204839
5204847
5204854
5204896
5204904
5204912
5204920
5204938
5204946
5204961
5204979
5204987
5204995
5205000
5205018
5205026
5205034
5300017
5300025

CDM Description
INSERT CATH BLADDER
INSERT CATH BLADDER
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
CATH FOR SPECIMEN COLLECT
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
CATH FOR SPECIMEN COLLECT
IV SOL 1000 D51/2NS 20KCL
ADMIN OTHER IMMUN VAC ADD
ADMIN OTHER IMMUN VAC ONE
CATH FOR SPECIMEN COLLECT
INSERT CATH BLADDER
INS/REPL/DECL NONTUN/PIC
INS/REPL/DECL NONTUN/PIC
IV SOL D5W 50 ML
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
D5% LR 1000ML INJ
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
D5% 0.9 NACL 1000ML INJ
SOD CHLORIDE 0.9% 50MLINJ
CART ULTRAFILT 500
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR

239940119.xlsx.ms_office

Price
505.00
505.00
301.00
301.00
420.00
301.00
301.00
420.00
78.00
301.00
301.00
420.00
505.00
2,203.00
2,203.00
78.00
176.00
176.00
176.00
258.00
544.00
544.00
544.00
275.00
275.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
301.00
78.00
78.00
4,500.00
945.00
334.00
1,230.00
433.00
945.00
334.00
1,230.00
433.00
544.00
140.00

$0 Indicator

Page 199 of 299

CDM #
5300033
5300066
5300074
5300082
5300108
5300116
5300140
5300181
5300199
5300207
5300215
5300223
5300231
5300249
5300264
5300272
5300298
5300355
5300363
5300744
5300769
5300777
5300785
5300793
5300801
5300819
5300835
5300843
5300850
5300868
5300942
5300959
5300967
5300975
5300983
5300991
5301007
5301015
5301023
5301031
5301049
5301056
5301064
5301072
5301080
5301098
5301106

CDM Description
INJ TX/DX/PROPH SUBQ/IM
EPIDURAL BLOOD PATCH
FETAL NON STRESS TEST
FETAL CONTRAC STRESS TEST
AMNIOCENTESIS
EXTERNAL VERSION
AD EVOKED POTENTIALS LIM
BLOOD COLLECTION VAD
INF IV TX/DX PUMP PROLONG
INF TX/DX CONCURRENT
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
INF IV HYDRA INIT 31-60MN
MINOR PROCEDURE
TRANSFUS BLD/BLD COMP
VENIPUNCTURE
CPSP-INIT/CASE COORD
CPSP-HE INTERV/REASMT/IND
CPSP-HE INTERV/GROUP
CPSP-HE POST PARTUM/INDIV
CPSP-INTERV/REASMT/INDIV
CPSP-NU INTRTV/GROUP
CPSP-NU POST PARTUM/INDIV
CPSP-PS INTERV/REASMT/IND
CPSP-PS INTERV/GROUP
CPSP-PS POST PARTUM/INDIV
CPSP-GROUP
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
ANESTH GENERAL 1ST 30MIN
ANESTH GENERAL ADDL 15MIN
ANESTH MAC/REG 1ST 30MIN
ANESTH MAC/REG ADDL 15MIN
LOCAL ANESTHESIA
MOD SEDAT =>5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
INJ TX/PRO/DX IVP SME DRG
AMNISURE KIT

239940119.xlsx.ms_office

Price
275.00
894.00
544.00
1,021.00
917.00
917.00
343.00
339.00
544.00
140.00
140.00
544.00
544.00
544.00
140.00
544.00
1,142.00
778.00
11.00
501.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
505.00
420.00
945.00
334.00
1,230.00
433.00
301.00
301.00
1,707.00
599.00
750.00
264.00
350.00
1,580.00
549.00
544.00
250.00

$0 Indicator

Page 200 of 299

CDM #
5301114
5301155
5301163
5301171
5301189
5301197
5301205
5301221
5301239
5301247
5301254
5301262
5301288
5301296
5301304
5301312
5301320
5301338
5301346
5301353
5301361
5301379
5301387
5301395
5301403
5301437
5301445
5301452
5301478
5301486
5301494
5301510
5301528
5301536
5301544
5301551
5301569
5301577
5301585
5301593
5301601
5301619
5301627
5301635
5301643
5301650
5301668

CDM Description
BLOOD COLLECTION PICC
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
SURGERY LEVEL 3 1ST 30MIN
SURGERY LEVEL 3 ADD 15MIN
AMNIOTIC FLUID REDUC W/US
FETAL CST NONOXYTOCIN
CERCLAGE PLACEMENT
CERCLAGE REMOVAL
OUTPATIENT PROCEDURE NC
OB VISIT/FETAL MONITR EST
OB VISIT/FETAL MONITR NEW
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
INS/REPL/DECL NONTUN/PIC
IRRIG IMPLANTED VEN ACCES
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
ANESTH MAC/REG 1ST 30MIN
US PREG FOLLOWUP/EA GEST
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
ANESTH GENERAL 1ST 30MIN
ANESTH GENERAL ADDL 15MIN
US PREG 1 OR >FETUSES LTD
ANESTH MAC/REG ADDL 15MIN
LOCAL ANESTHESIA
MOD SEDAT =>5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
SURGERY LEVEL 3 1ST 30MIN

239940119.xlsx.ms_office

Price
339.00
4,408.00
1,545.00
5,731.00
2,009.00
7,450.00
2,611.00
1,031.00
953.00
3,716.00
3,716.00
1,309.00
1,309.00
544.00
140.00
140.00
140.00
544.00
140.00
544.00
544.00
544.00
275.00
544.00
2,203.00
275.00
532.00
544.00
544.00
11.00
750.00
1,107.00
301.00
301.00
1,707.00
599.00
740.00
264.00
350.00
1,580.00
549.00
4,408.00
1,545.00
5,731.00
2,009.00
7,450.00

$0 Indicator

Page 201 of 299

CDM #
5301676
5301684
5301700
5301718
5301726
5301734
5301809
5301817
5301825
5301833
5301841
5301858
5301866
5301874
5301882
5301890
5301908
5301916
5301924
5301932
5301940
5301981
5301999
5302013
5302021
5302039
5302047
5400023
5400056
5400064
5400072
5400080
5400098
5400114
5400122
5400155
5400163
5400171
5400189
5400197
5400205
5400213
5400221
5400239
5400247
5400254
5400262

CDM Description
SURGERY LEVEL 3 ADD 15MIN
CATH FOR SPECIMEN COLLECT
EPIDURAL BLOOD PATCH
AMNIOTIC FLUID REDUC W/US
GLUCOSE BLOOD BY DEVICE
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF EA SEQ 1ST HR
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
INS/REPL/DECL NONTUN/PIC
ADMIN HEP B VACCINE
ADMIN HEP B VACCINE
OB PT CARE PER HOUR NC
KIT/PACK SURG 730X-949
INST/SUPP STERL 30X-39
KIT/PACK SURG 150X-195
MINOR PROCEDURE
CARDIOVERSION ELCTIVE EXT
ARTERIAL CATH/CANN PERC
TILT TABLE EVALUATION
CSU CARD PROCPRD CT 1/2HR
TRANSFUS BLD/BLD COMP
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PROPH SUBQ/IM
INF IV HYDRA INIT 31-60MN
INF TX/DX/PRO SEQ 1HR
INF TX/DX CONCURRENT
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INF IV HYDRAT EA ADD HR
INF IV TX/DX PUMP PROLONG
INSERT CATH BLADDER
CATH FOR SPECIMEN COLLECT
IRRIG IMPLANTED VEN ACCES

239940119.xlsx.ms_office

Price
2,611.00
420.00
894.00
1,031.00
176.00
176.00
544.00
544.00
544.00
544.00
544.00
544.00
275.00
275.00
275.00
275.00
301.00
301.00
301.00
301.00
2,203.00
301.00
301.00
4,745.00
195.00
975.00
1,142.00
1,845.00
1,766.00
2,395.00
778.00
544.00
140.00
275.00
544.00
140.00
140.00
544.00
544.00
544.00
140.00
544.00
505.00
420.00
275.00

$0 Indicator

Page 202 of 299

CDM #
5400270
5400288
5400296
5400304
5400312
5400320
5400338
5400346
5400361
5400387
5400395
5400403
5400429
5400437
5400452
5400478
5400494
5400510
5400536
5400544
5400551
5400569
5400585
5400593
5400601
6100028
6100036
6100044
6100051
6100069
6100077
6100085
6100093
6100101
6100119
6100127
6100135
6100143
6100150
6100168
6100176
6100184
6100192
6100200
6100218
6100226
6100234

CDM Description
BLOOD COLLECTION VAD
ADMIN OTHER IMMUN VAC ONE
ADMIN OTHER IMMUN VAC ADD
INS/REPL/DECL NONTUN/PIC
INJ TX/PRO/DX IVP SME DRG
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
BLOOD COLLECTION PICC
PHLEBOTOMY THERAPEUT
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
GLUCOSE BLOOD BY DEVICE
CHEMO SQ/IM NONHORMONAL
CHEMO SQ/IM HORMONAL
CHEMO INF INIT 1ST HR
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
ADMIN INFLUENZA VACCINE
ADMIN PNEUMO VACCINE
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
ADMIN HEP B VACCINE
CARDIOVERSION ELCTIVE INT
CARDIOVERSION INT W AICD
MR ANGIO UPP EXTR WO&W BI
MR ANGIO UPP EXTR WO&W LT
MR ANGIO UPP EXTR WO&W RT
MR UPP EXTREM JNT WO&W BI
MR UPP EXTREM JNT WO&W RT
MR UPP EXTREM JNT W BIL
MR UPP EXTREM JNT WO BIL
MR UPP EXTREM WO&W BIL
MR UPP EXTREM W CON BIL
MR UPP EXTREM WO CON BIL
MR ANGIO ABDOMEN WO CON
MR ANGIO ABDOMEN WO&W CON
MR ANGIO LOW EXTREM W BIL
MR ANGIO LOW EXTREM W LT
MR ANGIO LOW EXTREM W RT
MR ANGIO LOW EXTR WO&W BI
MR ANGIO LOW EXTR WO&W LT
MR ANGIO LOW EXTR WO&W RT
MR ANGIO LOW EXTREM WO BI
MR ANGIO LOW EXTREM WO LT
MR ANGIO LOW EXTREM WO RT
MR LOW EXTREM W CON BIL

239940119.xlsx.ms_office

Price
339.00
301.00
301.00
2,203.00
544.00
945.00
334.00
339.00
532.00
544.00
544.00
11.00
176.00
544.00
544.00
544.00
275.00
275.00
301.00
301.00
1,230.00
433.00
301.00
2,491.00
1,845.00
6,827.00
4,709.00
4,709.00
6,933.00
4,781.00
4,781.00
4,781.00
6,933.00
4,781.00
4,781.00
5,185.00
8,759.00
6,827.00
4,709.00
4,709.00
9,897.00
6,827.00
6,827.00
6,827.00
4,709.00
4,709.00
4,781.00

$0 Indicator

Page 203 of 299

CDM #
6100242
6100259
6100267
6100275
6100283
6100291
6100309
6100317
6100325
6100333
6100341
6100358
6100366
6100374
6100382
6100390
6100408
6100416
6100424
6100440
6100457
6100465
6100473
6100481
6100499
6100507
6100515
6100523
6100531
6100549
6100556
6100564
6100572
6100580
6100598
6100606
6100614
6100622
6100630
6100648
6100655
6100663
6100671
6100689
6100697
6100705
6100713

CDM Description
MR LOW EXTREM W CON LT
MR LOW EXTREM W CON RT
MR LOW EXTREM WO&W CON BI
MR LOW EXTREM WO&W CON LT
MR LOW EXTREM WO&W CON RT
MR ABDOMEN W CON
MR ABDOMEN WO&W CON
GADOLINIUM-BAS MR CON/ML
MR C SPINE W CON
MR T SPINE W CON
MR L SPINE W CON
MR BRAIN W CON
MR BRAIN WO CON
MR ORB/FAC/NECK WO CON
MR CHEST WO CON
MR C SPINE WO CON
MR T SPINE WO CON
MR L SPINE WO CON
MR CARDIAC WO CON
MR ABDOMEN WO CON
MR PELVIS W CON
MR PELVIS WO CON
MR PELVIS WO&W CON
MR BRAIN WO&W CON
MR C SPINE WO&W CON
MR T SPINE WO&W CON
MR L SPINE WO&W CON
MR UPP EXTREM JNT W LT
MR UPP EXTREM JNT W RT
MR LOW EXTREM WO CON BIL
MR LOW EXTREM JNT WO BIL
MR 3D W SEPARATE WKSTATN
MR 3D WO SEPARATE WKSTATN
MR BREAST W CON BIL
MR GUIDED NDL BX/ASP/INJ
MR CHEST W CON
MR CHEST WO&W CON
MR ORB/FAC/NECK W CON
MR ORB/FAC/NECK WO&W CON
MR UPP EXTREM WO&W CON RT
MR UPP EXTREM W CON RT
MR UPP EXTREM W CON LT
MR UPP EXTREM JNT WO&W LT
MR ANGIO SPINE WO&W CON
MR ANGIO PELVIS WO CON
MR ANGIO ABDOMEN W CON
MR ANGIO NECK WO&W CON

239940119.xlsx.ms_office

Price
3,297.00
3,297.00
6,933.00
4,781.00
4,781.00
5,185.00
8,759.00
42.00
4,795.00
4,781.00
4,795.00
4,795.00
4,795.00
5,185.00
5,185.00
4,795.00
4,781.00
4,795.00
5,185.00
5,185.00
5,185.00
5,185.00
8,759.00
7,859.00
7,547.00
6,933.00
7,547.00
3,297.00
3,297.00
4,781.00
4,781.00
1,311.00
1,311.00
3,297.00
5,185.00
5,185.00
8,759.00
5,185.00
8,759.00
4,781.00
3,297.00
3,297.00
4,781.00
5,185.00
5,214.00
5,185.00
8,759.00

$0 Indicator

Page 204 of 299

CDM #
6100721
6100739
6100747
6100754
6100762
6100770
6100788
6100796
6100804
6100812
6100838
6100846
6100853
6100861
6100879
6100887
6100895
6100903
6100911
6100929
6100937
6100945
6100952
6100960
6100978
6100986
6101000
6101026
6101042
6101067
6101075
6101083
6101109
6101125
6101133
6101141
6101158
6101166
6101174
6101182
6101190
6101208
6101216
6101224
6101232
6101240
6300222

CDM Description
MR ANGIO NECK W CON
MR ANGIO NECK WO CON
MR ANGIO HEAD WO&W CON
MR ANGIO HEAD W CON
MR ANGIO HEAD WO CON
MR ANGIO CHEST WO CON
MR ANGIO CHEST W CON
MR ANGIO CHEST WO&W CON
MR ANGIO PELVIS W CON
MR ANGIO PELVIS WO&W CON
MR TMJ(S) UNI OR BIL
MR UPP EXTREM WO CON LT
MR UPP EXTREM WO CON RT
MR UPP EXTREM JNT WO LT
MR UPP EXTREM JNT WO RT
MR LOW EXTREM WO CON LT
MR LOW EXTREM WO CON RT
MR UPP EXTREM WO&W CON LT
MR LOW EXTREM JNT WO LT
MR LOW EXTREM JNT WO RT
MR LOW EXTREM JNT WO&W RT
MR LOW EXTREM JNT WO&W LT
MR LOW EXTREM JNT W RT
MR LOW EXTREM JNT W LT
MR TELERADIOGRPY/EXAM NC
MR ORAL CON PER 100ML
MR CARDIAC W STRESS IMG
MR CARDIAC WO&W CON
MR CARDIAC STRES WO&W CON
MR BREAST WO CON BIL
MR BREAST WO&W CON BIL
MR KNEE CUSTOM MEASURMENT
MR CARDIAC VELOCITY FLOW
MR LOW EXTREM JNT W BIL
MR LOW EXTREM JNT WO&W BI
GADOBENATE(MULTIHANCE)/ML
GADOTRDL(PROHNCE MULT)/ML
CATH DRAINAGE 13X-17
CATH DRAINAGE 67X-88
CATH GENERAL 67X-88
CATH INF PERIPH 431X-561
INST/SUPP STERL 13X-17
INST/SUPP STERL 17X-23
INST/SUPP STERL 23X-30
KIT/PACK SURG 254X-331
TUBING/CONNECT 13X-17
OP-TAKEHOME RX

239940119.xlsx.ms_office

Price
5,185.00
5,185.00
8,759.00
5,185.00
5,185.00
4,509.00
4,509.00
7,618.00
5,214.00
8,810.00
3,212.00
3,297.00
3,297.00
3,297.00
3,297.00
3,297.00
3,297.00
4,781.00
3,297.00
3,297.00
4,781.00
4,781.00
3,297.00
3,297.00
127.00
5,185.00
7,777.00
7,777.00
3,297.00
4,781.00
200.00
5,185.00
4,781.00
6,933.00
10.00
10.00
85.00
440.00
440.00
2,805.00
85.00
115.00
150.00
1,655.00
85.00
-

$0 Indicator

S
Page 205 of 299

CDM #
6300230
6300248
6300255
6300263
6300271
6300289
6300297
6300313
6300339
6300347
6300354
6300362
6300370
6300396
6300404
6300412
6300420
6300446
6300453
6300461
6300479
6300511
6300529
6300537
6300545
6300552
6300560
6300578
6300610
6300628
6300636
6300644
6300651
6300669
6300677
6300685
6300719
6300727
6300743
6300750
6300768
6300776
6300800
6300818
6300826
6300834
6300842

CDM Description
ACEBUTOLOL 200MG CAP
ACEBUTOLOL 400MG CAP
ACETAMIN 325MG SUPP
ACETAMIN 120MG SUPP
ACETAMIN 650MG SUPP
ACETAMINOPHEN 325MG TAB
ACETAMINOPHEN 500MG TAB
ACETAMINOPHEN 80MG CHEW
ACETAZOLAMIDE 125MG TAB
ACETAZOLAMIDE 250MG TAB
ACETAZOLAMID ER 500MG CAP
ACYCLOVIR 200MG CAP
GAVISCON TAB
ALBUTEROL 2MG TAB
ALBUTEROL 4MG TAB
ALLOPURINOL 100MG TAB
ALLOPURINOL 300MG TAB
AMANTADINE 100MG CAP
AMILORIDE 5MG TAB
AMILORIDE/HCTZ 5/50MG TAB
AMINOCAP ACID 500MG TAB
AMIODARONE 200MG TAB
AMITRIPTYLINE 100MG TAB
AMITRIPTYLINE 25MG TAB
AMITRIPTYLINE 50MG TAB
AMITRIPTYLINE 75MG TAB
AMITRIPTYLINE 10MG TAB
AMITRIPTYLINE 150MG TAB
AMOXICILLIN 250MG CAP
AMOXICILLIN 500MG CAP
AMOXICILLIN 250MG CHW TAB
AMOX/CLAV 500/125MG TAB
AMPICILLIN 250MG CAP
AMPICILLIN 500MG CAP
BELLADON ALK/PB 16.2MGTAB
PHENYL 0.25%/SHK/COCA SUP
VIT C(ASCOR ACID)500MG
ASPIRIN 325MG TAB
ASPIRIN 125MG SUPP
ASPIRIN 300MG SUPP
ASPIRIN 600MG SUPP
ASPIRIN 325MG TAB
ASPIRIN BUFFERD 325MG TAB
ASPIRIN 81MG CHW TAB
ASPIRIN EC 325MG TAB
ATENOLOL 100MG TAB
ATENOLOL 50MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
2.00
9.00
2.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
2.00
2.00
2.00
9.00
9.00
2.00
2.00
9.00
9.00

$0 Indicator

Page 206 of 299

CDM #
6300875
6300891
6300909
6300917
6300925
6300933
6300941
6300966
6300974
6300982
6300990
6301006
6301014
6301022
6301030
6301048
6301055
6301089
6301097
6301121
6301139
6301147
6301154
6301162
6301170
6301188
6301196
6301204
6301212
6301220
6301279
6301287
6301303
6301311
6301329
6301345
6301352
6301360
6301378
6301386
6301394
6301402
6301410
6301436
6301451
6301469
6301477

CDM Description
BACLOFEN 10MG TAB
BENZTROPINE 0.5MG TAB
BENZTROPINE 1MG TAB
BENZTROPINE 2MG TAB
BETHANECHOL 10MG TAB
BETHANECHOL 25MG TAB
BETHANECHOL 5MG TAB
BISACODYL 10MG SUPP
BISACODYL 5MG TAB
BROMOCRIPTINE 2.5MG TAB
BUMETANIDE 1MG TAB
BUMETANIDE 0.5MG TAB
BUSPIRONE 5MG TAB
BUSPIRONE 10MG TAB
VIT D(CALCITRIOL) 0.25MCG
VIT D(CALCITRIOL) 0.5MCG
CA CARB 1250MG TAB
CA GLUCONATE 500MG TAB
CA GLUCONATE 650MG TAB
OSCAL 250 TAB
CAPTOPRIL 12.5MG TAB
CAPTOPRIL 25MG TAB
CAPTOPRIL 50MG TAB
CAPTOPRIL 100MG TAB
CARBAMAZEPINE 200MG TAB
CARBAMAZEPINE 100MG CHW
CARBIDOPA/LEVODOP 10/100
CARBIDOPA/LEVOD 25/100MG
CARBIDOPA/LEVODOP 25/250M
CARISOPRODOL 350MG TAB
CEPHALEXIN 250MG CAP
CEPHALEXIN 500MG CAP
CHLOROQUINE PHOS 500MG
CHLOROTHIAZDE 250MG TAB
CHLOROTHIAZDE 500MG TAB
CHLORPHENIRAMINE 4MG TAB
CHLORPROMAZINE 25MG TAB
CHLORPROMAZINE 50MG TAB
CHLORPROMAZINE 100MG TAB
CHLORPROMAZINE 200MG TAB
CHLORPROMAZINE 10MG TAB
CHLORPROPAMIDE 250MG TAB
CHLORTHALIDONE 25MG TAB
CHOLINE SAL/MAG SAL 750MG
CHOLINE SAL/MAG SAL 500MG
CIMETIDINE 400MG TAB
CIMETIDINE 300MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
2.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
21.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
2.00

$0 Indicator

Page 207 of 299

CDM #
6301485
6301493
6301501
6301519
6301527
6301535
6301543
6301550
6301568
6301576
6301592
6301600
6301618
6301626
6301634
6301642
6301659
6301675
6301683
6301709
6301717
6301725
6301741
6301758
6301766
6301774
6301782
6301790
6301808
6301816
6301824
6301832
6301840
6301857
6301873
6301881
6301899
6301907
6301915
6301923
6301931
6301949
6301972
6301998
6302004
6302012
6302020

CDM Description
CIPROFLOXAC 500MG/5ML 100
CIPROFLOXACIN 250MG TAB
CIPROFLOXACIN 500MG TAB
LIBRAX CAP
CLINDAMYCIN 150MG CAP
CLOMIPHENE CIT 50MG TAB
CLONIDINE 0.1 MG TAB
CLONIDINE 0.2 MG TAB
CLONIDINE 0.3 MG TAB
CLOTRIMAZOLE 10MG TROCHE
COLCHICINE 0.6MG TAB
COLCHICINE 0.5MG TAB
ESTROGENS CONJ 2.5MG TAB
ESTROGENS CONJ 0.9MG TAB
ESTROGENS CONJ 0.625MG
ESTROGENS CONJ 0.3MG TAB
ESTROGENS CONJ 2.5MG TAB
CORTISONE ACET 25MG TAB
CORTISONE ACET 5MG TAB
CYCLOBENZAPRINE 10MG TAB
CYPROHEPTADINE 4MG TAB
DANAZOL 200MG CAP
DANAZOL 50MG CAP
DANTROLENE 50MG CAP
DANTROLENE 25MG CAP
DEMECLOCYCLINE 300MG TAB
DEMECLOCYCLINE 150MG TAB
DESIPRAMINE 10MG TAB
DESIPRAMINE 25MG TAB
DESIPRAMINE 50MG TAB
DESIPRAMINE 150MG TAB
DESIPRAMINE 75MG TAB
DESIPRAMINE 100MG TAB
DEXAMETHASONE 2MG TAB
DEXAMETHASONE 1.5MG TAB
DEXAMETHASONE 4MG TAB
DICLOFENAC NA DR 50MG TAB
DICLOFENAC NA DR 25MG TAB
DICLOXACILLIN 250MG CAP
DICLOXACILLIN 500MG CAP
DICYCLOMINE 10MG CAP
DICYCLOMINE 20MG TAB
DIFLUNISAL 500MG TAB
DIGOXIN 0.125MG TAB
DIGOXIN 0.25MG TAB
DIGOXIN 0.5MG TAB
DILTIAZEM 30MG TAB

239940119.xlsx.ms_office

Price
2.00
21.00
36.00
9.00
9.00
37.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
22.00
9.00
9.00
9.00
32.00
22.00
9.00
9.00
9.00
9.00
9.00
10.00
9.00
9.00
9.00
9.00
9.00
10.00
10.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00

$0 Indicator

Page 208 of 299

CDM #
6302038
6302046
6302053
6302061
6302079
6302087
6302095
6302103
6302111
6302129
6302137
6302145
6302152
6302178
6302186
6302194
6302202
6302210
6302228
6302236
6302244
6302251
6302269
6302277
6302285
6302293
6302301
6302319
6302335
6302376
6302392
6302418
6302434
6302442
6302459
6302475
6302509
6302517
6302525
6302558
6302574
6302590
6302608
6302616
6302624
6302657
6302665

CDM Description
DILTIAZEM 60MG TAB
DIMENHYDRINATE 50MG TAB
DIPHENHYDRAMINE 25MG CAP
DIPHENHYDRAMINE 50MG CAP
DIPYRIDAMOLE 25MG TAB
DIPYRIDAMOLE 75MG TAB
DIPYRIDAMOLE 50MG TAB
DISOPYRAMIDE 100MG CAP
DISOPYRAMIDE 150MG CAP
DISOPYRAMIDE SR 100MG CAP
DISOPYRAMIDE SR 150MG CAP
DISULFIRAM 250MG TAB
DIVALPROEX DR 250MG TAB
DOCUSATE NA 100MG CAP
DOCUSATE NA 250MG CAP
DOXEPIN 10MG CAP
DOXEPIN 25MG CAP
DOXEPIN 50MG CAP
DOXEPIN 150MG CAP
DOXEPIN 100MG CAP
DOXEPIN 75MG CAP
DOXYCYCLINE 100MG CAP
DOXYCYCLINE 100MG TAB
DOXYCYCLINE 50MG CAP
ENALAPRIL 5MG TAB
ENALAPRIL 10MG TAB
ENALAPRIL 20MG TAB
VIT D(ERGOCALCIF) 50000IU
ERGOTAMINE/CAFF 1/100MG
ERYTHRO STEAR 250MG TAB
ERYTHRO BASE DR 333MG TAB
ESTROPIPATE 0.75MG TAB
ETHACRYNIC ACID 25MG TAB
ETHAMBUTOL 100MG TAB
ETHAMBUTOL 400MG TAB
ETHOSUXIMIDE 250MG CAP
FAMOTIDINE 20MG TAB
FAMOTIDINE 40MG TAB
FERROUS FUM-DSS/1TAB
FERROUS GLU/300MG/1TAB
FERROUS SULFATE/300MG/TAB
FLAVOXATE 100MG TAB
FLECAINIDE 100MG TAB
FLUCYTOSINE 500MG CAP
FLUDROCORTISONE 0.1MG TAB
FLUPHENAZINE 10MG TAB
FLUPHENAZINE 5MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
2.00
2.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
2.00
9.00
9.00
9.00
10.00
9.00
9.00
12.00
12.00
9.00
9.00
9.00
10.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
10.00
2.00
2.00
2.00
2.00
9.00
9.00
111.00
9.00
10.00
9.00

$0 Indicator

Page 209 of 299

CDM #
6302673
6302681
6302699
6302707
6302715
6302723
6302731
6302749
6302756
6302764
6302772
6302780
6302798
6302806
6302822
6302830
6302848
6302855
6302863
6302871
6302889
6302897
6302905
6302913
6302921
6302939
6302947
6302954
6302962
6302970
6302988
6302996
6303002
6303010
6303028
6303036
6303044
6303051
6303069
6303077
6303085
6303093
6303101
6303119
6303127
6303135
6303143

CDM Description
FLUPHENAZINE 2.5MG TAB
FLUPHENAZINE 1MG TAB
FOLIC ACID 1MG TAB
FUROSEMIDE 20MG TAB
FUROSEMIDE 40MG TAB
FUROSEMIDE 80MG TAB
GLIPIZIDE XL 5MG TAB
GLIPIZIDE 10MG TAB
GLYBURIDE/1.25MG/1TAB
GLYBURIDE/5MG/1TAB
GLYBURIDE/2.5MG/1TAB
GLYCERIN ADULT SUPP
GLYCERIN INFANTS SUPP
GLYCOPYRROLATE/1MG/1TAB
GUANFACINE/1MG/TAB
HALOPERIDOL/20MG/1TAB
HALOPERIDOL/0.5MG/1TAB
HALOPERIDOL/10MG/1TAB
HALOPERIDOL/1MG/1TAB
HALOPERIDOL/2MG/1TAB
HALOPERIDOL/5MG/1TAB
HYDROCORT 25MG SUPP
TRIAMTERENE/HCTZ 37.5/25M
MAXZIDE TAB
HYDRALAZINE/100MG/TAB
HYDRALAZINE/25MG/TAB
HYDRALAZINE/50MG/TAB
HYDRALAZINE/10MG/TAB
HCTZ/25MG/TAB
HCTZ/50MG/TAB
HYDROCORTISONE/20MG/1TAB
HYDROCORTISONE/5MG/1TAB
HYDROCORTISONE/10MG/1TAB
HYDROXYCHLOROQUINE200MGTA
HYDROXYUREA/500MG/1CAP A
HYDROXYZINE/10MG/TAB
HYDROXYZINE/25MG/CAP
HYDROXYZINE/100MG/CAP
HYDROXYZINE/50MG/CAP
HYOSCYAMINE/0.375MG/CAP
HYOSCYAMINE/0.125MG/TAB
IBUPROFEN 800MG TAB
IBUPROFEN 300MG TAB
IBUPROFEN 600MG TAB
IBUPROFEN 400MG TAB
IBUPROFEN 200MG TAB
IMIPRAMINE 10MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
22.00
9.00
9.00
9.00
9.00
9.00
10.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
9.00
2.00
2.00
2.00
9.00

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Page 210 of 299

CDM #
6303150
6303168
6303176
6303184
6303192
6303200
6303218
6303242
6303259
6303267
6303275
6303283
6303291
6303309
6303317
6303325
6303333
6303341
6303358
6303374
6303382
6303390
6303408
6303416
6303424
6303432
6303440
6303457
6303481
6303499
6303507
6303515
6303523
6303531
6303606
6303614
6303648
6303663
6303671
6303697
6303705
6303754
6303762
6303770
6303796
6303804
6303812

CDM Description
IMIPRAMINE 25MG TAB
IMIPRAMINE 50MG TAB
INDAPAMIDE 2.5MG TAB
INDOMETHACIN 50MG SUPP
INDOMETHACIN 25MG CAP
INDOMETHACIN 50MG CAP
GLIMEPIRIDE 4MG TAB
ISONIAZID 300MG TAB
ISONIAZID 100MG TAB
ISOSORBIDE DIN 5MG ORAL
ISOSORBIDE DIN 20MG ORAL
ISOSORBIDE DIN 10MG ORAL
ISOSORBIDE DIN SR 40MG
KETOCONAZOLE 200MG TAB
KETOPROFEN 75MG CAP
LABETALOL 300MG TAB
LABETALOL 200MG TAB
LABETALOL 100MG TAB
LACTOBACILLUS ACIDOPHI A
LEVOTHYROXINE 0.025MG TAB
LEVOTHYROXINE 0.05MG TAB
LEVOTHYROXINE 0.1MG TAB
LEVOTHYROXINE 0.15MG TAB
LEVOTHYROXINE 0.175MG TAB
LEVOTHYROXINE 0.2MG TAB
LEVOTHYROXINE 0.3MG TAB
LEVOTHYROXINE 0.125MG TAB
LEVOTHYROXINE 0.075MG TAB
LISINOPRIL 5MG TAB
LISINOPRIL 10MG TAB
LISINOPRIL 20MG TAB
LITHIUM 300MG CAP
LOPERAMIDE 2MG CAP
LOVASTATIN 20MG TAB
SLO-MAG 64 MG
MAGNESIUM GLUC 500(29)MG
MEBENDAZOLE 100MG CHW TAB
MECLIZINE 12.5MG TAB
MECLIZINE 25MG TAB
MEDROXYPROGEST 10MG TAB
MEDROXYPROGEST 2.5MG TAB
URISED TAB
METHAZOLAMIDE 50MG TAB
METHENAMINE HIPP 1GM TAB
METHENAMINE 500MG TAB
METHIMAZOLE 10MG TAB
METHIMAZOLE 5MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
10.00
9.00
9.00
10.00
9.00
9.00
9.00
9.00
9.00
9.00
21.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
20.00
9.00
9.00
28.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00

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Page 211 of 299

CDM #
6303820
6303838
6303846
6303853
6303879
6303887
6303895
6303903
6303911
6303929
6303937
6303945
6303952
6303960
6303978
6303994
6304000
6304018
6304026
6304034
6304042
6304067
6304075
6304083
6304091
6304117
6304125
6304133
6304158
6304166
6304190
6304208
6304224
6304240
6304257
6304273
6304281
6304307
6304315
6304331
6304349
6304356
6304364
6304398
6304414
6304422
6304430

CDM Description
METHOCARBAMOL 500MG TAB
METHOCARBAMOL 750MG TAB
METHYLDOPA 250MG TAB
METHYLDOPA 500MG TAB
METHYLERGONOVINE 0.2MG
METHYLPRED 16MG TAB
METHYLPRED 2MG TAB
METOCLOPRAMIDE 10MG TAB
METOLAZONE 0.5MG TAB
METOLAZONE 2.5MG TAB
METOLAZONE 10MG TAB
METOPROLOL 50MG TAB
METOPROLOL 100MG TAB
METRONIDAZOLE 250MG TAB
METRONIDAZOLE 250MG TAB
MEXILETINE 150MG CAP
MEXILETINE 200MG CAP
MINOCYCLINE 50MG CAP
MINOCYCLINE 100MG CAP
MINOXIDIL 10MG TAB
MINOXIDIL 2.5MG TAB
MULTIVITAMINS THERAPEUTIC
MULTIVITAMINS W/MINERALS
NADOLOL 80MG TAB
NADOLOL 40MG TAB
NAPROXEN 375MG TAB
NAPROXEN 500MG TAB
NAPROXEN 250MG TAB
NEOMYCIN SULFATE/0.5MG/1T
NEOSTIGMINE 15MG TAB
NIACIN/50MG/1TAB
NIACIN/100MG/1TAB
NIACIN 500MG TAB
NIFEDIPINE 10MG CAP
NITROFURANTOIN/100MG/1TAB
NITROFURANTOIN MAC 100MG
NITROFURANTOIN MAC 25MG
NITROGLYCERIN/6.5MG/1CAP/
NORETHINDRONE ACETATE/5MG
NORTRIPTYLINE 25MG CAP
NYSTATIN 100000U VAG TAB
ORPHENADRINE SR 100MG TAB
OXYBUTYNIN 5MG TAB
PAPAVERINE SR 150MG CAP
PENICILLAMINE 250MG CAP
PENICILLIN V K 500MG TAB
PENICILLIN V K 250MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
21.00
9.00
9.00
10.00
21.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
23.00
9.00
9.00
9.00
9.00
9.00
9.00

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Page 212 of 299

CDM #
6304455
6304463
6304471
6304489
6304497
6304505
6304513
6304547
6304554
6304562
6304570
6304588
6304596
6304604
6304612
6304620
6304638
6304646
6304653
6304661
6304679
6304687
6304695
6304703
6304711
6304729
6304760
6304778
6304786
6304794
6304844
6304851
6304869
6304877
6304893
6304901
6304919
6304927
6304935
6304943
6304968
6304976
6304984
6304992
6305015
6305023
6305031

CDM Description
PENTOXIFYLLINE SR 400MG
PERPHENAZINE 2MG TAB
PERPHENAZINE 4MG TAB
PERPHENAZINE 8MG TAB
PERPHENAZINE 16MG TAB
PHENAZOPYRIDINE 100MG TAB
PHENAZOPYRIDINE 200MG TAB
PHENOXYBENZAMINE 10MG CAP
PHENYTOIN 30MG CAP
PHENYTOIN ER 100MG CAP
PHENYTOIN 50MG CHW TAB
VIT K(PHYTONADIONE) 5MG
PINDOLOL 10MG TAB
PIROXICAM 10MG CAP
PIROXICAM 20MG CAP
POTASSIUM CHLORIDE/8MEQ
PRAZOSIN 2MG CAP
PRAZOSIN 5MG CAP
PRAZOSIN 1MG CAP
PREDNISOLONE 5MG TAB
PREDNISONE 2.5MG TAB
PREDNISONE 5MG TAB
PREDNISONE 1MG TAB
PREDNISONE 10MG TAB
PREDNISONE 20MG TAB
PREDNISONE 50MG TAB
PRIMAQUINE PHOS 26.3MG
PRIMIDONE 250MG TAB
PRIMIDONE 50MG TAB
PROBENECID 500MG TAB
PROCHLORPERAZINE 5MG SUPP
PROCHLORPERAZINE 25MG SUP
PROCHLORPERAZINE 5MG TAB
PROCHLORPERAZINE 10MG TAB
PROMETHAZINE 12.5MG SUPP
PROMETHAZINE 12.5MG TAB
PROMETHAZINE 50MG SUPP
PROMETHAZINE 25MG SUPP
PROMETHAZINE 50MG TAB
PROMETHAZINE 25MG TAB
PROPRANOLOL 40MG TAB
PROPRANOLOL 60MG TAB
PROPRANOLOL LA 80MG CAP
PROPRANOLOL LA 120MG CAP
PROPRANOLOL 80MG TAB
PROPRANOLOL 10MG TAB
PROPRANOLOL 20MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
26.00
9.00
9.00
9.00
9.00
9.00
9.00
21.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
10.00
12.00
9.00
9.00
10.00
9.00
21.00
12.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00

$0 Indicator

Page 213 of 299

CDM #
6305049
6305098
6305106
6305114
6305122
6305130
6305155
6305163
6305171
6305189
6305197
6305205
6305262
6305296
6305304
6305312
6305320
6305338
6305346
6305361
6305379
6305387
6305395
6305403
6305437
6305445
6305452
6305460
6305478
6305486
6305494
6305510
6305536
6305544
6305551
6305569
6305577
6305585
6305643
6305650
6305668
6305676
6305684
6305692
6305700
6305718
6305726

CDM Description
PROPYLTHIOURACIL/50MG/1TA
PSEUDOEPHEDRINE 30MG TAB
PSEUDOEPHEDRINE 60MG TAB
PSEUDOEPHEDRINE 120MG TAB
PYRAZINAMIDE 500MG TAB
PYRIDOSTIGMINE 60MG TAB
PYRIDOXINE HCL/100MG/1TAB
PYRIDOXINE HCL/50MG/1TAB
PYRIDOXINE HCL/25MG/1TAB
PYRIMETHAMINE 25MG TAB
QUINIDINE GLUC SR 324MG
QUINIDINE SULF 200MG TAB
RANITIDINE 150MG TAB
ZIDOVUDINE 100MG CAP
RIFAMPIN 300MG CAP
SALSALATE 750MG TAB
SALSALATE 500MG TAB
SENNA/DOC 8.6MG/50MG TAB
SENNA/DOC 8.6MG/50MG TAB
SIMETHICONE 80MG CHW TAB
SODIUM BICARBONATE/650MG
SODIUM BICARBONATE/325MG
SODIUM CHLORIDE/1GM/1TAB
SODIUM FLUORIDE/1MG/1TAB
SPIRONOLACTONE/HCTZ 50/50
SPIRONOLACTONE/HCTZ 25/25
SPIRONOLACTONE 100MG TAB
SPIRONOLACTONE 50MG TAB
SPIRONOLACTONE 25MG TAB
SUCRALFATE 1GM TAB
SULFADIAZINE 500MG TAB
SULFASALAZINE 500MG TAB
SULINDAC 150MG TAB
SULINDAC 200MG TAB
TERBUTALINE 5MG TAB
TERBUTALINE 2.5MG TAB
TETRACYCLINE 250MG CAP
TETRACYCLINE 500MG CAP
THEOPHYLLINE TR 200MG(24H
THEOPHYLLINE TR 300MG(24H
THEOPHYLLINE 200MG TAB
THEOPHYLLINE 300MG TAB
VIT B1(THIAMINE) 50MG TAB
VIT B1(THIAMINE) 100MG
THIORIDAZINE 25MG TAB
THIORIDAZINE 10MG TAB
THIORIDAZINE 50MG TAB

239940119.xlsx.ms_office

Price
9.00
2.00
2.00
2.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
12.00
21.00
17.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00

$0 Indicator

Page 214 of 299

CDM #
6305734
6305742
6305759
6305767
6305775
6305783
6305791
6305809
6305817
6305833
6305858
6305866
6305882
6305890
6305924
6305932
6305940
6305957
6305965
6305973
6305981
6305999
6306005
6306013
6306062
6306070
6306088
6306096
6306104
6306112
6306138
6306153
6306161
6306179
6306187
6306195
6306203
6306211
6306229
6306237
6306245
6306278
6306294
6306328
6306336
6306344
6306351

CDM Description
THIORIDAZINE 100MG TAB
THIOTHIXENE 2MG CAP
THIOTHIXENE 5MG CAP
THYROID 30MG (1/2GR) TAB
THYROID 60MG (1GR) TAB
THYROID 120MG (2GR) TAB
THYROID 90MG (1 1/2GR) TA
THYROID 15MG (1/4GR) TAB
THYROID 180MG (3GR) TAB
TIMOLOL 10MG TAB
CHLORPROMAZINE 100MG TAB
SULFAMETHOXAZ/TMP 800/160
TOLAZAMIDE 250MG TAB
TOLAZAMIDE 500MG TAB
TRAZODONE 50MG TAB
TRAZODONE 100MG TAB
TRAZODONE 150MG TAB
TRIAMTERENE 100MG CAP
TRIAMTERENE 50MG CAP
TRIFLUOPERAZINE 5MG TAB
TRIFLUOPERAZINE 10MG TAB
TRIFLUOPERAZINE 2MG TAB
TRIHEXYPHENIDYL 2MG TAB
TRIHEXYPHENIDYL 5MG TAB
TRIMETHOPRIM 100MG TAB
VALPROIC ACID 250MG CAP
VANCOMYCIN 125MG CAP
VANCOMYCIN 250MG CAP
VERAPAMIL 80MG TAB
VERAPAMIL 120MG TAB
VIT A 10000IU CAP
VIT B COMPLX W C CAP
VIT E 100IU CAP
VIT E 200IU CAP
VIT E 400IU CAP
WARFARIN 2MG TAB
WARFARIN 2.5MG TAB
WARFARIN 5MG TAB
WARFARIN 7.5MG TAB
WARFARIN 10MG TAB
ZINC SULF 220MG CAP
EPINEPHR 2.25% 0.5ML INH
CROMOLYN 20MG 2ML SOL INH
ALBUTEROL 0.083% 3ML INH
NORCO 5/325 TAB
NORCO 7.5/325 TAB
ZINC GLUC 50MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
10.00
43.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
18.00
18.00
19.00

$0 Indicator

Page 215 of 299

CDM #
6306369
6306377
6306385
6306393
6306401
6306435
6306443
6306450
6306468
6306476
6306492
6306500
6306526
6306534
6306567
6306575
6306617
6306633
6306641
6306658
6306666
6306674
6306682
6306690
6306708
6306716
6306724
6306732
6306757
6306765
6306773
6306781
6306799
6306807
6306815
6306823
6306831
6306849
6306864
6306880
6306898
6306922
6306948
6306963
6306971
6306989
6306997

CDM Description
VIT E 1000IU CAP
LIDOCAINE 5% PATCH
ESTRADIOL 0.06MG 24HR PAT
LISINOPRIL 2.5MG TAB
TRIMETHOBENZAMIDE 300MG
SITAGLIPTIN 25MG TAB
SITAGLIPTIN 50MG TAB
SITAGLIPTIN 100MG TAB
LEVOFLOXACIN 750MG TAB
ENTECAVIR 0.5MG TAB
IPRATROPIUM 0.02% 2.5ML
ALBUTEROL 0.5% 0.25ML INH
LEVALBUTEROL 0.31MG/3ML
LEVALBUTEROL 0.63MG/3ML
ALBUTEROL 1.25MG/3ML INH
ALBUTEROL ER 4MG TAB
VIT C(ASCORB ACID) 250MG
AL SULF/CA ACET PWD TOP
CEFUROXIME 250MG TAB
CEFUROXIME 500MG TAB
CETYLPYRIDINIUM LOZ (9)
CHLORASEPTIC LOZENGE
CHOLESTYRAMINE 9GM PWDR
CLONIDINE 0.1MG/24HR PATC
CLONIDINE 0.2MG/24HR PATC
CLONIDINE 0.3MG/24HR PATC
COLESTIPOL GRAN 5GM PKT
AMYL/LIPASE/PRO 16/5/18
DEXAMETHASONE 0.5MG TAB
DILTIAZEM 24H ER 180MG CP
DILTIAZEM SR 90MG CAP
ERYTHRO EST 250MG CAP
ERYTHRO 1GM OP OINT
ERYTHRO STEAR 500MG TAB
ESTRAD 0.05MG 24HRWKL PAT
ESTRADIOL 0.1MG/24HR PAT
FLUTAMIDE 125MG CAP
HYDROCORT 100MG 60ML ENEM
LACTOBACILLUS ACIDOPHI B
LIDO VISC 2% 15ML VIAL
LIDOCAINE 2% UROJECT
METHYLPRED 4MG TAB
NEOSPORIN GU IRR 1ML
NICARDIPINE 20MG CAP
NICARDIPINE 30MG CAP
NICOTINE GUM 2MG (EA) TAB
NIMODIPINE 30MG CAP

239940119.xlsx.ms_office

Price
19.00
36.00
44.00
18.00
19.00
16.00
16.00
16.00
65.00
63.00
8.00
8.00
15.00
12.00
9.00
9.00
9.00
9.00
24.00
37.00
9.00
9.00
9.00
48.00
64.00
90.00
9.00
9.00
9.00
10.00
9.00
9.00
29.00
9.00
17.00
17.00
12.00
29.00
9.00
9.00
64.00
9.00
53.00
9.00
9.00
9.00
51.00

$0 Indicator

Page 216 of 299

CDM #
6307003
6307011
6307029
6307037
6307045
6307052
6307086
6307094
6307110
6307144
6307151
6307169
6307177
6307185
6307193
6307235
6307243
6307276
6307284
6307292
6307300
6307318
6307326
6307342
6307383
6307391
6307409
6307417
6307425
6307441
6307458
6307466
6307474
6307482
6307490
6307508
6307516
6307524
6307532
6307540
6307557
6307573
6307581
6307599
6307607
6307615
6307623

CDM Description
NITRO 15 PATCH
NITRO 2.5 PATCH
NITROFURAN 50MG CAP
NITROGLYCERIN/5MG/1EA/PAT
NITROGLYCERIN 7.5MG 1EA
PETROLATUM WHITE 5GM
PILOCARPINE 1% 2ML OP SOL
PILOCARPINE 2% 1ML OP SOL
PINDOLOL 5MG TAB
FLUOXETINE 20MG CAP
PSYLLIUM 1PKT
MESALAMINE 4GM 60ML ENEMA
SCOPOLAMINE 1.5MG/3DAY
TETRACAINE 0.5% 2ML OPS
THEOPHYLLINE 100MG TAB
THROMBIN 5000U PWDR
DICLOFENAC NA DR 75MG TAB
NEOSPORIN OINT 0.94GM
PANCREASE CAP
MISOPROSTOL 200MCG TAB
KCL 20MEQ TAB
DILTIAZEM SR 60MG CAP
VERAPAMIL 40MG TAB
ISOSORBIDE DIN SR 40MG
NIFEDIPINE XL 30MG TAB
NIFEDIPINE XL 60MG TAB
NIFEDIPINE XL 90MG TAB
OMEPRAZOLE 20MG CAP
GUAIFENESIN 600MG TBSA
CAPTOPRIL/HCTZ 25/15MG
DIVALPROEX DR 125MG TAB
ENALAPRIL 2.5MG TAB
MEDROXYPROGEST 5MG TAB
SELEGILINE 5MG TAB
PROPAFENONE 150MG TAB
PROPAFENONE 300MG TAB
BROMOCRIPTINE 5MG CAP
ESTRADIOL 2MG TAB
VIOKASE CAP
BUPROPION 100MG TAB
LISINOPRIL 40MG TAB
METHYLCELLULOSE 454GM PKT
FLUCONAZOLE 50MG TAB
FLUCONAZOLE 100MG TAB
FLUCONAZOLE 200MG TAB
BENZONATATE 100MG CAP
SLOW-FE TAB SA

239940119.xlsx.ms_office

Price
21.00
10.00
9.00
17.00
17.00
9.00
26.00
26.00
9.00
21.00
9.00
58.00
29.00
33.00
9.00
75.00
9.00
22.00
9.00
9.00
9.00
9.00
9.00
9.00
17.00
23.00
24.00
18.00
2.00
9.00
9.00
9.00
9.00
23.00
9.00
10.00
20.00
9.00
9.00
9.00
9.00
9.00
38.00
55.00
89.00
9.00
9.00

$0 Indicator

Page 217 of 299

CDM #
6307631
6307649
6307656
6307664
6307680
6307698
6307706
6307714
6307722
6307730
6307748
6307763
6307789
6307797
6307805
6307813
6307847
6307862
6307870
6307888
6307896
6307904
6307912
6307938
6307946
6307953
6307961
6307979
6307987
6308001
6308019
6308027
6308035
6308043
6308050
6308068
6308076
6308084
6308092
6308100
6308118
6308126
6308134
6308142
6308159
6308167
6308175

CDM Description
DEXAMETHASONE 1MG TAB
NITROGLYCERIN 10MG PATCH
NADOLOL 20MG TAB
FIBERCON 650MG
DAPSONE 100MG TAB
DAPSONE 25MG TAB
FLUCYTOSINE 250MG CAP
GEMFIBROZIL 600MG TAB
LITHIUM SR 450MG TAB
LITHIUM SR 300MG TAB
BUMETANIDE 2MG TAB
TRAZODONE 300MG TAB
VERAPAMIL ER 180MG TAB
CYCLOSPORINE 100MG CAP
CYCLOSPORINE 25MG CAP
WARFARIN 1MG TAB
NORTRIPTYLINE 10MG CAP
BACITRACIN 0.94GM OINT
DOXAZOSIN 1MG TAB
DOXAZOSIN 2MG TAB
DOXAZOSIN 4MG TAB
DOXAZOSIN 8MG TAB
MESALAMINE 500MG SUPP
SOD CARBOXYMETHYLCE 0.3ML
MISOPROSTOL 100MCG TAB
NEXIUM 20MG CAP
ALENDRONATE 70MG TAB
ONDANSETRON 8MG ODT TAB
FOLGARD RX 2.2 TAB
AMIODARONE 400MG TAB
TOLTERODINE 2MG TAB
TOLTERODINE 2MG TAB
DONEPEZIL 10MG TAB
MOEXIPRIL 15MG TAB
ESOMEPRAZOLE 40MG CAP
VALSARTAN/HCTZ 160/12.5MG
NATEGLINIDE 120MG TAB
GLUCOSMN/CHNDRI 500MG TAB
VIT B12 250MCG TAB
LISINOPRIL/HCTZ 20/12.5MG
RISEDRONATE 5MG TAB
REMINYL 4MG TAB
LEFLUNOMIDE 20MG TAB
LESCOL XL 80MG TAB
GUAIFEN/PHENYL 600/30MG
LAMICTAL 100MG TAB
ISOSORBIDE DIN 30MG ORAL

239940119.xlsx.ms_office

Price
9.00
17.00
9.00
2.00
9.00
9.00
60.00
9.00
9.00
9.00
9.00
22.00
9.00
38.00
10.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
21.00
9.00
9.00
21.00
66.00
100.00
9.00
28.00
14.00
14.00
22.00
9.00
21.00
9.00
9.00
9.00
9.00
9.00
12.00
10.00
36.00
10.00
9.00
14.00
9.00

$0 Indicator

Page 218 of 299

CDM #
6308183
6308191
6308209
6308217
6308225
6308233
6308258
6308274
6308282
6308290
6308316
6308324
6308332
6308340
6308357
6308365
6308373
6308381
6308399
6308407
6308415
6308423
6308431
6308449
6308456
6308464
6308472
6308480
6308498
6308506
6308548
6308555
6308563
6308571
6308589
6308597
6308605
6308613
6308621
6308639
6308647
6308654
6308662
6308670
6308688
6308696
6308704

CDM Description
MOBIC 15MG TAB
MELOXICAM 7.5MG TAB
GUAIFEN/PSEUD SA600/120MG
LEVOXYL 137MCG TAB
SEVELAMER HCL 800MG TAB
GALANTAMINE ER 8MG CAP
MONTELUKAST 4MG CHW TAB
LOSARTAN POT 100MG TAB
EMTRICTBN/TENOF 200/300MG
LOPINAVIR/RITONAVI 200/50
CALCIUM ACETATE 667MG CAP
ISRADIPINE 2.5MG CAP
ISRADIPINE 5MG CAP
ATENOLOL 25MG TAB
RAMIPRIL 5MG CAP
RAMIPRIL 2.5MG CAP
RAMIPRIL 1.25MG CAP
VERAPAMIL SR 120MG TAB
ACYCLOVIR 800MG TAB
KCL 10MEQ TAB
RANITIDINE 300MG
LACTASE 3000U
BENAZEPRIL 40MG TAB
BENAZEPRIL 20MG TAB
BENAZEPRIL 5MG TAB
BENAZEPRIL 10MG TAB
FOSINOPRIL 20MG TAB
FOSINOPRIL 10MG TAB
FELODIPINE SR 10MG TAB
FELODIPINE SR 5MG TAB
CLARITHROMYCN 500MG TAB
TICLOPIDINE 250MG TAB
NICOTINE 7MG PATCH
NICOTINE 14MG PATCH
NICOTINE 21MG PATCH
CLOMIPRAMINE 50MG CAP
CLOMIPRAMINE 75MG CAP
CLOMIPRAMINE 25MG CAP
CARBIDOPA/LEVO ER 50/200M
ETODOLAC 200MG CAP
ETODOLAC 300MG CAP
PRAZIQUANTEL 600MG TAB
LEVOTHYROXINE 0.088MG TAB
LEVOTHYROXINE 0.112MG TAB
QUINAPRIL 5MG TAB
QUINAPRIL 20MG TAB
TERAZOSIN 1MG CAP

239940119.xlsx.ms_office

Price
12.00
12.00
9.00
9.00
9.00
16.00
13.00
9.00
76.00
19.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
28.00
9.00
22.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
17.00
9.00
23.00
10.00
28.00
29.00
32.00
9.00
10.00
9.00
10.00
9.00
9.00
64.00
9.00
9.00
9.00
9.00
9.00

$0 Indicator

Page 219 of 299

CDM #
6308712
6308720
6308738
6308746
6308753
6308761
6308779
6308795
6308811
6308829
6308837
6308845
6308852
6308860
6308886
6308910
6308928
6308944
6308985
6309017
6309025
6309066
6309074
6309082
6309090
6309108
6309116
6309124
6309132
6309140
6309157
6309165
6309181
6309199
6309207
6309215
6309223
6309256
6309264
6309272
6309280
6309298
6309306
6309314
6309322
6309348
6309363

CDM Description
PRAVASTATIN 20MG TAB
PRAVASTATIN 10MG TAB
QUINAPRIL 10MG TAB
TERAZOSIN 2MG CAP
TERAZOSIN 5MG CAP
TERAZOSIN 10MG CAP
METOCLOPRAMIDE 5MG TAB
FE FUM(100MG)/VIT B12/IFC
CYCLOSPORINE 100MG CAP
CYCLOSPORINE 25MG CAP
SIMVASTATIN 40MG TAB
SIMVASTATIN 20MG TAB
SIMVASTATIN 5MG TAB
QUINAPRIL 40MG TAB
NABUMETONE 500MG TAB
LAMIVUDINE 150MG TAB
NICOTINE GUM 4MG (EA) TAB
VALSARTAN/HCTZ 80/12.5MG
CIPROFLOXACIN 750MG TAB
SERTRALINE 50MG TAB
SERTRALINE 100MG TAB
CEFPROZIL 500MG TAB
MESALAMINE 400MG TAB
METOPROLOL XL 200MG TAB
METOPROLOL XL 50MG TAB
ITRACONAZOLE 100MG CAP
METHAZOLAMIDE 25MG TAB
GLYBURIDE 1.5MG
CLARITHROMYCN 250MG TAB
GLYBURIDE 3MG
FLECAINIDE 50MG TAB
FINASTERIDE 5MG TAB
AMLODIPINE 2.5MG TAB
AMLODIPINE 5MG TAB
AMLODIPINE 10MG TAB
CEFPODOXIME 200MG TAB
METAXALONE 400MG TAB
SIROLIMUS 1MG TAB
METOPROLOL 25MG TAB
LOVASTATIN 40MG TAB
INDAPAMIDE 1.25MG TAB
LORASTADINE 10MG
ZOLPIDEM TART 5MG TAB
ZOLPIDEM TART 10MG TAB
ISOSORBIDE MON 20MG TAB
PROPRANOLOL LA 160MG CAP
POTASSIUM PHOSPHATE 500MG

239940119.xlsx.ms_office

Price
20.00
17.00
9.00
9.00
9.00
9.00
9.00
9.00
32.00
9.00
38.00
26.00
17.00
9.00
9.00
41.00
9.00
9.00
38.00
9.00
9.00
33.00
9.00
9.00
9.00
29.00
9.00
9.00
22.00
9.00
9.00
17.00
9.00
9.00
20.00
26.00
9.00
38.00
9.00
28.00
9.00
17.00
9.00
10.00
9.00
9.00
9.00

$0 Indicator

Page 220 of 299

CDM #
6309371
6309389
6309421
6309439
6309447
6309454
6309462
6309488
6309504
6309512
6309538
6309546
6309553
6309561
6309579
6309587
6309595
6309603
6309611
6309637
6309645
6309652
6309678
6309694
6309702
6309710
6309728
6309736
6309744
6309751
6309769
6309785
6309793
6309819
6309827
6309868
6309884
6309892
6309900
6309918
6309926
6309942
6309967
6309975
6309983
6309991
6310007

CDM Description
VIT B COMB TAB
LIOTHYRONINE 5MCG TAB
DEXTROAMPHETAMINE 5MG TAB
BACLOFEN 20MG TAB
DILTIAZEM 90MG TAB
DILTIAZEM 120MG TAB
THIORIDAZINE 200MG TAB
NIFEDIPINE 20MG CAP
DILTIAZEM 24H ER 180MG CP
SOTALOL 80MG TAB
DOCUSATE CA 240MG CAP
LIDO/PRILOCAINE 5GM CRM
KETOROLAC 10MG TAB
GABAPENTIN 300MG CAP
GABAPENTIN 400MG CAP
TORSEMIDE 20MG TAB
TORSEMIDE 100MG TAB
VENLAFAXINE 50MG TAB
VENLAFAXINE 75MG TAB
ONDANSETRON 8MG TAB
ONDANSETRON 4MG TAB
TORSEMIDE 10MG TAB
GUAIFENESIN DM TAB
URSODIOL 300MG CAP
VENLAFAXINE 25MG TAB
SIMVASTATIN 10MG TAB
ETODOLAC 400MG TAB
LISINOPRIL/HCTZ 20/25MG
LITHIUM 150MG CAP
L-LYSINE 500MG TAB
HYDROXYZINE HCL 25MG TAB
ISOSORBIDE MON 60MG TAB
MESALAMINE 250MG CAP
VIT B12 100MCG TAB
WARFARIN 4MG TAB
CLINDAMYCIN 300MG CAP
DILTIAZEM CD 240MG CAP
DILTIAZEM CD 120MG CAP
RAMIPRIL 10MG CAP
FLUOXETINE 10MG CAP
NORTRIPTYLINE 50MG CAP
BUPROPION SR 200MG TAB
FLUVASTATIN 20MG CAP
PAROXETINE 20MG TABLET
VERAPAMIL SR 240MG CAP
VERAPAMIL SR 120MG CAP
DIVALPROEX DR 500MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
10.00
2.00
32.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
101.00
60.00
9.00
2.00
12.00
9.00
12.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
17.00
9.00
9.00
9.00
12.00
10.00
9.00
9.00
12.00
9.00
9.00
9.00

$0 Indicator

Page 221 of 299

CDM #
6310023
6310031
6310049
6310056
6310064
6310072
6310080
6310106
6310114
6310122
6310130
6310148
6310155
6310163
6310189
6310197
6310205
6310213
6310221
6310239
6310247
6310254
6310262
6310288
6310296
6310304
6310312
6310320
6310338
6310346
6310353
6310361
6310379
6310387
6310395
6310411
6310429
6310437
6310460
6310478
6310494
6310528
6310536
6310544
6310551
6310585
6310593

CDM Description
VENLAFAXINE 100MG TAB
VENLAFAXINE 37.5MG TAB
PANCREASE MT10 EC
BUPROPION SR 150MG TAB
FEXOFENADINE 60MG TAB
NABUMETONE 750MG TAB
CARBAMAZEPINE XR 100MG
BUPROPION SR 150MG TAB
BUPROPION SR 24HR 300MG T
CAPSAICIN 0.075% 30GM CRM
MEMANTINE 5MG TAB
MEMANTINE 10MG TAB
NIACIN ER 1000MG TAB
NIACIN ER 500MG CAP
AMOX/K CLAV 1000/62.5 12H
ELETRIPTAN HBR 40MG TAB
FENOFIBRATE NANO 145MG TB
FENOFIBRATE NANO 48MG TAB
EZETIMIBE/SIMVAST 10/10MG
EZETIMIBE/SIMVAST 10/20MG
EZETIMIBE/SIMVAST 10/40MG
EZETIMIBE/SIMVAST 10/80MG
PANCRELIPASE MT 20
TETRACAINE 0.5% 15ML OPTH
SUMATRIPTAN 25MG TAB
LANSOPRAZOLE EC 15MG CAP
LANSOPRAZOLE EC 30MG CAP
COLESTIPOL 1GM TAB
ALENDRONATE 10MG TAB
LAMIVUDINE 150MG TAB
METFORMIN 500MG TAB
METFORMIN 850MG TAB
SODIUM PHOS ENEMA 133ML
VIT D(CHOLECALCIF) 400IU
ESTRADIOL 0.05MG BIWK PAT
GLIMEPIRIDE 1MG TAB
GLIMEPIRIDE 2MG TAB
GLIMEPIRIDE 4MG TAB
RITONAVIR 100MG CAP
TERBINAFINE 250MG TAB
TRANDOLAPRIL 2MG TAB
VALACYCLOVIR 500MG TAB
TRAMADOL 50MG TAB
GLIPIZIDE XL 10MG TAB
LIDO 2% JELLY 5ML
LOSARTAN POT 25MG TAB
LOSARTAN POT 50MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
8.00
8.00
12.00
48.00
8.00
8.00
11.00
9.00
10.00
47.00
12.00
8.00
10.00
10.00
10.00
10.00
8.00
12.00
59.00
23.00
23.00
9.00
10.00
24.00
9.00
9.00
9.00
16.00
9.00
9.00
9.00
12.00
29.00
9.00
20.00
9.00
9.00
35.00
9.00
9.00

$0 Indicator

Page 222 of 299

CDM #
6310619
6310627
6310635
6310643
6310650
6310668
6310676
6310684
6310692
6310700
6310718
6310726
6310734
6310742
6310759
6310775
6310791
6310809
6310817
6310858
6310866
6310874
6310882
6310890
6310908
6310916
6310932
6310957
6310965
6310973
6310999
6311005
6311013
6311021
6311039
6311047
6311062
6311070
6311088
6311104
6311112
6311229
6311237
6311245
6311252
6311260
6311278

CDM Description
GUAIFENESIN 200MG
ZAFIRLUKAST 20MG TAB
MYCOPHENOLATE 250MG CAP
ACARBOSE 50MG TAB
NEFAZODONE 100MG TAB
NAPROXEN SA 550MG
ISOSORBIDE MONO 10MG
ISOSORBIDE MON 30MG TAB
CA CARB 500MG CHW TAB
FAMCICLOVIR 125MG TAB
FAMCICLOVIR 250MG TAB
FAMCICLOVIR 500MG TAB
OCUVITE TAB
NEFAZODONE 200MG TAB
NEFAZODONE 150MG TAB
AZITHROMYCIN 600MG TAB
ESTROG/MEDPROG 0.625/2.5
BICALUTAMIDE 50MG TAB
FOLIC ACID 0.4MG TAB
GABAPENTIN 100MG CAP
THEOPHYLLINE TR 400MG(24H
FERROUS GLUCON 325MG TAB
AMOX/CLAV 875/125MG TAB
LEVOFLOXACIN 500MG TAB
LEVOFLOXACIN 250MG TAB
BENAZEPRIL 10MG TAB
PROPAFENONE 225MG TAB
DONEPEZIL HCL 5MG TAB
HYDROXYZINE HCL 100MG TAB
HYDROXYZINE HCL 50MG TAB
WARFARIN 6MG TAB
RISPERIDONE 1MG TAB
CETIRIZINE 10MG TAB
CETIRIZINE 5MG TAB
WARFARIN 3MG TAB
ATORVASTATIN 10MG TAB
NIACIN 250MG TAB
AZITHROMYCIN 250MG TAB
CARVEDILOL 3.125MG TAB
NELFINAVIR 250MG TAB
NEUTRA-PHOS K CONC PCKT
ZILEUTON 600MG TAB
PAROXETINE HCL 30MG TAB
PAROXETINE HCL 10MG TAB
TIZANIDINE 4MG TAB
RANITIDINE 75MG TAB
NEVIRAPINE 200MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
12.00
9.00
9.00
9.00
9.00
9.00
9.00
16.00
21.00
32.00
9.00
9.00
9.00
78.00
9.00
54.00
9.00
9.00
9.00
9.00
25.00
36.00
32.00
9.00
9.00
23.00
9.00
9.00
9.00
12.00
10.00
10.00
9.00
12.00
9.00
30.00
9.00
12.00
9.00
9.00
12.00
12.00
9.00
9.00
25.00

$0 Indicator

Page 223 of 299

CDM #
6311286
6311294
6311302
6311310
6311336
6311344
6311369
6311377
6311385
6311393
6311401
6311419
6311427
6311435
6311443
6311450
6311484
6311500
6311526
6311534
6311542
6311559
6311567
6311575
6311583
6311591
6311609
6311617
6311625
6311633
6311641
6311658
6311666
6311674
6311682
6311690
6311708
6311716
6311724
6311732
6311740
6311757
6311765
6311781
6311799
6311807
6311815

CDM Description
FELODIPINE SR 2.5MG TAB
PRAMIPEXOLE 0.25MG TAB
TOPIRAMATE 25MG TAB
TACROLIMUS 1MG CAP
BISOPROLOL 5MG TAB
CARVEDILOL 25MG TAB
CARBAMAZEPINE 12HR 200MG
CARBAMAZEPINE XR 400MG
CARVEDILOL 6.25MG TAB
CARVEDILOL 12.5MG TAB
CLOPIDOGREL 75MG TAB
ESTRADIOL 0.5MG TAB
LOSARTAN/HCTZ 50/12.5MG
MIDODRINE HCL 5MG TAB
MONTELUKAST 10MG TAB
OLANZAPINE 5MG TAB
TAMSULOSIN 0.4MG CAP
PEPTO-BISMOL TABLET
STAVUDINE 40MG CAP
ACYCLOVIR 400MG TAB
OXANDROLONE 2.5MG TAB
TESTOSTERONE 5MG 24HR PAT
ATORVASTATIN 20MG TAB
CITALOPRAM 20MG TAB
CELECOXIB 100MG CAP
CELECOXIB 200MG CAP
CEFDINIR 300MG CAP
VITAMIN A & D OINT 5GM
MOEXIPRIL 7.5MG TAB
FENOFIBRATE 67MG CAPSULE
BUPROPION SR 100MG TAB
PRAVASTATIN 40MG TAB
QUETIAPINE FUM 25MG TAB
RISPERIDONE 2MG TAB
RISPERIDONE 3MG TAB
RISPERIDONE 4MG TAB
TOLTERODINE 1MG TAB
TOLTERODINE 2MG TAB
IRBESARTAN 150MG TAB
IRBESARTAN 75MG TAB
REPAGLINIDE 0.5MG TAB
REPAGLINIDE 1MG TAB
REPAGLINIDE 2MG TAB
ROSIGLITAZONE 4MG TAB
RISPERIDONE 0.5MG TAB
RISPERIDONE 0.25MG TAB
ROSIGLITAZONE 8MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
15.00
9.00
9.00
9.00
9.00
9.00
9.00
17.00
9.00
9.00
9.00
15.00
26.00
9.00
9.00
24.00
12.00
22.00
20.00
17.00
12.00
9.00
14.00
20.00
9.00
10.00
10.00
9.00
20.00
9.00
22.00
25.00
28.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
13.00
14.00
14.00
23.00

$0 Indicator

Page 224 of 299

CDM #
6311823
6311831
6311849
6311864
6311880
6311906
6311914
6311922
6311930
6311948
6311955
6311963
6311971
6311989
6312003
6312011
6312029
6312037
6312045
6312052
6312060
6312078
6312086
6312094
6312102
6312110
6312128
6312136
6312144
6312151
6312169
6312177
6312185
6312193
6312201
6312219
6312235
6312243
6312250
6312276
6312284
6312292
6312359
6312367
6312383
6312409
6312417

CDM Description
ROSIGLITAZONE 2MG TAB
MIRTAZAPINE 30MG TAB
MIRTAZAPINE 15MG TAB
CA CARB 600MG TAB
DICLOFENAC/MISOPR 50/0.2M
OLANZAPINE 2.5MG TAB
ROPINIROLE 0.25MG TAB
ROPINIROLE 0.5MG TAB
ROPINIROLE 1MG TAB
ROPINIROLE 2MG TAB
METFORMIN 1000MG TAB
OSELTAMIVIR 75MG CAP
SUMATRIPTAN 50MG TAB
LEVALBUTEROL 1.25MG/3ML
DIPYRIDAML/ASA ER 200/25M
OXYBUTYNIN XL 5MG TAB
PIOGLITAZONE 15MG TAB
PIOGLITAZONE 30MG TAB
PIOGLITAZONE 45MG TAB
BISOPROLOL/HCTZ 2.5/6.25M
BISOPROLOL/HCTZ 5/6.25MG
BISOPROLOL/HCTZ 10/6.25MG
SEVELAMER 400MG TAB
ACETAMIN 80MG SUPP
FLUCONAZOLE 150MG TAB
OSCAL 500+D TABLET
RALOXIFENE 60MG TAB
VIT B12 500MCG TAB
METHYLPRED 8MG TAB
CLOZAPINE 25MG TAB
CLOZAPINE 100MG TAB
FLUVOXAMINE 100MG TAB
PRAMIPEXOLE 0.125MG TAB
PRAMIPEXOLE 1MG TAB
FLUVOXAMINE 50MG TAB
QUETIAPINE FUM 100MG TAB
SOTALOL 120MG TAB
MOXIFLOXACIN 400MG TAB
SOTALOL 160MG TAB
VENLAFAXINE XR 37.5MG CAP
VENLAFAXINE XR 150MG CAP
VENLAFAXINE XR 75MG CAP
LORATADIN/PSEUD ER 10/240
PENTOSAN 100MG CAP
LORATADINE/PSEUD 5/120MG
ESTROG/MEDPROG 0.625/1.25
RIZATRIPTAN 10MG TAB

239940119.xlsx.ms_office

Price
10.00
13.00
13.00
9.00
9.00
24.00
9.00
9.00
9.00
9.00
9.00
24.00
71.00
12.00
9.00
13.00
15.00
24.00
26.00
9.00
9.00
9.00
9.00
2.00
52.00
9.00
12.00
9.00
9.00
9.00
17.00
15.00
9.00
10.00
15.00
13.00
17.00
37.00
21.00
10.00
13.00
12.00
14.00
10.00
9.00
9.00
63.00

$0 Indicator

Page 225 of 299

CDM #
6312425
6312433
6312441
6312458
6312474
6312482
6312490
6312508
6312516
6312524
6312532
6312557
6312565
6312573
6312581
6312599
6312607
6312615
6312649
6312656
6312664
6312672
6312680
6312698
6312706
6312722
6312755
6312763
6312771
6312789
6312797
6312805
6312813
6312821
6312839
6312847
6312862
6312870
6312888
6312896
6312904
6312920
6312938
6312946
6312953
6312961
6312979

CDM Description
RIZATRIPTAN 5MG TAB
ZOLMITRIPTAN 5MG TAB
ZOLMITRIPTAN 2.5MG TAB
ESTRADIOL 0.025MG/24H BIW
MUPIROCIN 2% OINT 1GM
QUETIAPINE FUM 200MG TAB
CITALOPRAM 40MG TAB
ATORVASTATIN 40MG TAB
DOFETILIDE 250MCG CAP
DOFETILIDE 125MCG CAP
DOFETILIDE 500MCG CAP
RABEPRAZOLE 20MG TAB
OLANZAPINE 10MG TAB
PANTOPRAZOLE 40MG TAB
OLANZAPINE 7.5MG TAB
TOPIRAMATE 100MG TAB
CILOSTAZOL 100MG TAB
CILOSTAZOL 50MG TAB
CANDESARTAN 16MG TAB
CANDESARTAN 8MG TAB
FENOFIBRATE 200MG CAP
LOTREL 5/10 CAP
LOTREL 5/20 CAP
LOTREL 2.5/10 CAP
PRAMIPEXOLE 0.5MG TAB
LINEZOLID 600MG TAB
TOPIRAMATE 200MG TAB
EST ESTROG/METH 1.25/2.5M
RIVASTIGMINE 4.5MG CAP
NITROGLYCERIN OINT 2% 1GM
NIACIN ER 1000MG TAB
FOLGARD TAB
NIACIN 500MG TAB
BUSPIRONE 15MG TAB
NIACIN 750MG SA TAB
GLUCOVANCE 2.5/500MG TAB
ABACAVIR 300MG TAB
PAXIL CR 12.5MG TABLET
FENTANYL 400MCG LOZ
TENOFOVIR 300MG TAB
FLUOXETINE 90MG CAP
ABACAVIR/LAM 600/300 TAB
EFAVIRENZ 600MG TAB
VORICONAZOLE 200MG TAB
KEPPRA 500MG TABLET
DIPHENHYDRAMINE 25MG TAB
PAXIL CR 25MG TABLET

239940119.xlsx.ms_office

Price
63.00
68.00
60.00
26.00
24.00
24.00
12.00
17.00
9.00
9.00
9.00
20.00
37.00
15.00
24.00
15.00
9.00
9.00
9.00
9.00
13.00
10.00
10.00
10.00
9.00
147.00
18.00
9.00
10.00
9.00
9.00
9.00
9.00
10.00
9.00
9.00
25.00
11.00
35.00
49.00
71.00
62.00
49.00
94.00
8.00
8.00
12.00

$0 Indicator

Page 226 of 299

CDM #
6312987
6312995
6313001
6313019
6313027
6313035
6313043
6313050
6313068
6313076
6313100
6313134
6313142
6313159
6313167
6313175
6313217
6313225
6313233
6313258
6313266
6313274
6313282
6313308
6313316
6313332
6313357
6313365
6313373
6313381
6313399
6313407
6313415
6313423
6313431
6313456
6313472
6313480
6313498
6313506
6313530
6313555
6313563
6313571
6313639
6313647
6313654

CDM Description
PAXIL CR 37.5MG TABLET
AMYL/LIPASE/PRO 33/10/37
DESLORATADINE 5MG TAB
FENTANYL 200MCG LOZ
VALSARTAN 160MG TAB
METFORMIN XR 500MG TAB
OXCARBAZEPINE 300MG TAB
FENOFIBRATE 160MG TAB
ZONISAMIDE 100MG CAP
STAVUDINE 30MG CAP
METOPROLOL XL 25MG TAB
ENTACAPONE 200MG TAB
COLESEVELAM 625MG TAB
MULTIVIT W MINERALS TAB
TEMOZOLOMIDE 250MG CAP
TACROLIMUS 5MG CAP
ANAGRELIDE 0.5MG CAP
NAPROXEN NA 220MG CAP
FEXOFENADINE 180MG TAB
AMOXICILLIN 875MG TAB
EXEMESTANE 25MG TAB
IRBESARTN/HCTZ 150/12.5MG
IRBESARTN/HCTZ 300/12.5MG
ROSIGLITAZONE 2MG TAB
ROSIGLITAZONE 4MG TAB
BALSALAZIDE 750MG CAP
EXCEDRIN TABLET
RIVASTIGMINE 1.5MG CAP
FORADIL AEROLIZER12MCG CA
ZIPRASIDONE 20MG CAP
ZIPRASIDONE 40MG CAP
ZIPRASIDONE 60MG CAP
ZIPRASIDONE 80MG CAP
LEXAPRO 10MG TABLET
LEXAPRO 20MG TABLET
REBETOL 200MG CAPSULE
ULTRACET TABLET
VESANOID 10MG CAPSULE
VIT B12 1000MCG TAB
TIZANIDINE 2MG TAB
OLANZAPINE OD 5MG TAB
ARIPIPRAZOLE 10MG TAB
ARIPIPRAZOLE 15MG TAB
ARIPIPRAZOLE 20MG TAB
ALENDRONATE 5MG TAB
ALENDRONATE 35MG TAB
MICARDIS 20MG TAB

239940119.xlsx.ms_office

Price
12.00
8.00
9.00
27.00
8.00
8.00
9.00
11.00
9.00
19.00
9.00
9.00
8.00
8.00
969.00
62.00
21.00
8.00
10.00
8.00
28.00
8.00
9.00
8.00
11.00
8.00
8.00
10.00
9.00
18.00
18.00
18.00
18.00
8.00
9.00
36.00
8.00
62.00
8.00
10.00
22.00
28.00
28.00
40.00
8.00
46.00
8.00

$0 Indicator

Page 227 of 299

CDM #
6313662
6313670
6313696
6313704
6313712
6313720
6313761
6313779
6313787
6313795
6313803
6313811
6313829
6313837
6313845
6313852
6313860
6313878
6313886
6313894
6313902
6313928
6313936
6313944
6313969
6313977
6313985
6314009
6314066
6314074
6314082
6314090
6314108
6314116
6314124
6314132
6314140
6314157
6314165
6314181
6314199
6314207
6314215
6314223
6314249
6314256
6314264

CDM Description
TELMISARTAN 40MG TAB
TELMISARTAN 80MG TAB
MICARDISHCT80-12.5TAB
MIRALAX 12X17GMPEG3350PWD
MYCOSTATIN 200MUPASTILLES
FAMOTIDINE 10MG TAB
EZETIMIBE 10MG TAB
LEVOCAMITINE 330 CAP
MODAFINIL 100MG TAB
SERTRALINE 25MG TAB
OLMESARTAN 5MG TAB
OLMESARTAN 20MG TAB
OLMESARTAN 40MG TAB
OLMESARTAN-HCTZ 20-12.5MG
OLMESARTAN-HCTZ 40-12.5MG
UREA 40% 200GM TOP
ROSUVASTATIN 5MG TAB
ROSUVASTATIN 10MG TAB
ROSUVASTATIN 20MG TAB
ROSUVASTATIN 40MG TAB
IMATINIB 100MG CAP
MIDODRINE HCL 2.5MG TAB
MIDODRINE 10MG TAB
PROGESTERONE 100MG CAP
INSPRA 25MG TABLET
GLUCOTROL XL 2.5MG TAB
OXYBUTYNIN XL 10MG TAB
VALSARTAN 40MG TAB
DUTASTERIDE 0.5MG CAP
CARBAMAZEPINE ER 300MG
DULOXETINE 20MG CAP
DULOXETINE 30MG CAP
DULOXETINE 60MG CAP
DIVALPROEX SR 250MG TAB
DIVALPROEX SR 500MG TAB
EMTRICITABINE 200MG CAP
HYDROCHLOROTHIA 12.5M CAP
LANTHANUM CARBONTE 250MG
LANTHANUM CARBONTE 750MG
LOTENSIN HCT 20/12.5 TAB
LOTREL 10/20 MG CAP
LYRICA 25 MG CAP
MYCOPHENOLATE 500MG TAB
LIOTHYRONINE 25MCG TAB
LANTHANUM CARBONTE 1000MG
HYZAAR 100/25 MG TAB
LEXIVA 700 MG TAB

239940119.xlsx.ms_office

Price
8.00
8.00
8.00
8.00
8.00
8.00
8.00
8.00
14.00
8.00
8.00
8.00
8.00
8.00
8.00
203.00
8.00
8.00
8.00
8.00
84.00
8.00
17.00
8.00
15.00
8.00
15.00
8.00
10.00
8.00
11.00
13.00
13.00
8.00
8.00
32.00
8.00
8.00
8.00
8.00
11.00
9.00
17.00
8.00
16.00
8.00
31.00

$0 Indicator

Page 228 of 299

CDM #
6314272
6314280
6314298
6314306
6314314
6314322
6314330
6314348
6314371
6314389
6314397
6314405
6314421
6314439
6314447
6314462
6314488
6314496
6314504
6314538
6314546
6314561
6314603
6314611
6314629
6314637
6314652
6314678
6314686
6314694
6314744
6314751
6314769
6314777
6314785
6314793
6314801
6314819
6314827
6314835
6314900
6314918
6314926
6314934
6314942
6314959
6314967

CDM Description
LIPITOR 80 MG TAB
PANTOPRAZOLE 20MG TAB
SILDENAFIL 20MG TAB
ATAZANAVIR 100MG CAP
ATAZANAVIR SUL 150MG CAP
AMLODIPINE 5MG TAB
DARIFENACIN SR 24HR 7.5MG
ENABLEX 15 MG TAB
NEURONTIN 600 MG TAB
METAXALONE 800MG TAB
VIAGRA 25 MG
SILDENAFIL 50MG TAB
RIFAXIMIN 200MG TAB
CINACALCET 30MG TAB
CINACALCET 60MG TAB
ATOMOXETINE HCL 10MG CAP
ATOMOXETINE HCL 25MG CAP
ATOMOXETINE HCL 60MG CAP
STRATTERA 60 MG CAP
NISOLDIPINE ER 10MG TAB
NISOLDIPINE ER 20MG TAB
NISOLDIPINE SR 40MG TAB
ALFUZOSIN SR 10MG TAB
VALGANCICLOVIR 450MG TAB
VESICARE 5 MG TAB
VESICARE 10 MG TAB
DIDANOSINE DR 200MG CAP
DIDANOSINE DR 400MG CAP
OLANZAPINE OD 10MG TAB
CETIRIZINE/PSEUD ER 5-120
APREPITANT 40MG CAP
LEVALBUTEROL 1.25MG/3ML
RISEDRONATE 35MG TAB
LACTOBACILLUS RHAMN LGG
BUDESONIDE SR 3MG CAP
OMEGA-3 1000 MG
ISRADIPINE ER 5MG
VARENICLINE 0.5MG TAB
BOSENTAN 6.25MG TAB
SACCHAROMYCES 250MG CAP
ALPRAZOLAM 0.25MG TAB
ALPRAZOLAM 1MG TAB
ALPRAZOLAM 0.5MG TAB
FIORINAL CAP
FIORINAL TAB
APAP/BUT/CAFF 325/50/40MG
HYDROMORPHON 0.2MG/ML50ML

239940119.xlsx.ms_office

Price
13.00
8.00
31.00
41.00
41.00
12.00
12.00
12.00
8.00
10.00
32.00
32.00
30.00
30.00
60.00
14.00
14.00
15.00
15.00
8.00
8.00
8.00
8.00
81.00
12.00
12.00
16.00
32.00
35.00
8.00
108.00
15.00
54.00
8.00
15.00
8.00
8.00
8.00
106.00
8.00
9.00
9.00
9.00
9.00
9.00
9.00
79.00

$0 Indicator

Page 229 of 299

CDM #
6314975
6315006
6315030
6315048
6315055
6315063
6315071
6315089
6315113
6315121
6315139
6315154
6315204
6315212
6315220
6315238
6315246
6315261
6315279
6315337
6315352
6315360
6315386
6315394
6315402
6315410
6315436
6315451
6315477
6315485
6315493
6315501
6315519
6315527
6315543
6315550
6315576
6315584
6315592
6315600
6315618
6315626
6315634
6315659
6315675
6315683
6315691

CDM Description
HYDROMORPHONE 1MG/ML 50ML
CHLORAL HYD 100MG/1MLPEDP
CHLORDIAZEPOXIDE 5MG CAP
CHLORDIAZEPOXIDE 10MG CAP
CHLORDIAZEPOXIDE 25MG CAP
CLONAZEPAM 2MG TAB
CLONAZEPAM 1MG TAB
CLONAZEPAM 0.5MG TAB
APAP/CODEINE 300/30MG TAB
APAP/CODEINE 300/15MG TAB
APAP/CODEINE 300/60MG TAB
FIORINAL W/CODEINE #3 CAP
APAP/CODEINE 120ML ELX
APAP/CODEIN 300/30 12.5ML
DIAZEPAM 2MG TAB
DIAZEPAM 5MG TAB
DIAZEPAM 10MG TAB
LOMOTIL TAB
LOMOTIL LIQ 60ML
MIDAZOLAM 5MG/ML 5ML INJ
HYCODAN 5ML LIQ
HYDROCODONE-APAP/TAB
LORAZEPAM 0.5MG TAB
LORAZEPAM 2MG TAB
LORAZEPAM 1MG TAB
MEPHOBARBITAL 32MG TAB
OXAZEPAM 15MG CAP
OXAZEPAM 10MG CAP
NALOXONE/PENTAZOCINE 50MG
PHENOBARB 20MG/5ML 5ML EL
PHENOBARB 60MG TAB
PHENOBARB 15MG TAB
PHENOBARB 30MG TAB
PHENOBARB 100MG TAB
PROMETH/COD 6.25-10/5 5ML
PROPOXYPHENE 65MG CAP
TEMAZEPAM 7.5MG CAP
PROPOXYPHENE 100MG TAB
APAP/PROPOXY 650/100MG
APAP/PROPOXY 325/50MG TAB
TEMAZEPAM 15MG CAP
TEMAZEPAM 30MG CAP
TRIAZOLAM 0.25MG TAB
TRIAZOLAM 0.125MG TAB
TUSSIONEX SUSP 15ML SYRUP
LORTAB LIQ 15ML LIQ
PAREGORIC/DOSE LIQ

239940119.xlsx.ms_office

Price
91.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
38.00
178.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
21.00
9.00
9.00

$0 Indicator

Page 230 of 299

CDM #
6315741
6315782
6315790
6315808
6315816
6315832
6315840
6315857
6315865
6315915
6315931
6315949
6315956
6315972
6315980
6315998
6316004
6316012
6316038
6316046
6316053
6316129
6316160
6316178
6316186
6316194
6316210
6316228
6316236
6316251
6316269
6316277
6316285
6316293
6316301
6316319
6316335
6316343
6316350
6316368
6316376
6316384
6316392
6316418
6316467
6316475
6316491

CDM Description
APAP/CODEINE 120ML ELX
HYDROCOD/IBUPROF 7.5/200M
LORAZEPAM 2MG/ML 1ML SOL
GUAIFENESIN/COD 10ML SYRP
GUAIFENESIN/COD 120ML SYR
NORCO 10/325 TABLET
LOMOTIL LIQ 5ML
MODAFINIL 200MG TAB
PHENOBARB 20MG/5ML 7.5ML
MIDAZOLAM 2MG/ML 5ML SOL
DIAZEPAM 5MG/ML 2ML INJ
LORAZEPAM 2MG/ML 1ML INJ
LORAZEPAM 4MG/ML 1ML INJ
LORAZEPAM 4MG/ML 10ML INJ
LORAZEPAM 2MG/ML 10ML INJ
METHOHEXITAL 500MG INJ
MIDAZOLAM 5MG/ML 2ML INJ
MIDAZOLAM 5MG/ML 1ML INJ
PENTAZOCINE 30MG/ML 2ML
PHENOBARB 65MG/ML 1ML INJ
PHENOBARB 130MG/ML 1ML IN
MIDAZOLAM 1MG/ML 2ML INJ
THIOPENTAL 500MG INJ
MIDAZOLAM 1MG/ML 10ML INJ
FENTANYL 50MCG/ML 5ML INJ
BUPRENORPHINE 0.3MG INJ
COCAINE 4% 4ML SOL
COCAINE 10% 4ML SOL
CODEINE SULF 30MG TAB
CODEINE PHOS 30MG TAB
DRONABINOL 2.5MG CAP
DRONABINOL 5MG CAP
DRONABINOL 10MG CAP
HYDROMORP 1MG/ML 1ML SOL
HYDROMORPHONE/2MG/TAB
HYDROMORPHONE/4MG/TAB
MEPERIDINE 50MG TAB
METHADONE 10MG/5ML 5ML SO
METHADONE 10MG TAB
METHADONE 5MG TAB
METHYLPHENIDATE 10MG TAB
METHYLPHENIDATE 5MG TAB
METHYLPHENIDATE 20MG TAB
MORPHINE SR 30MG TAB
MORPHINE IR 15MG TAB
MORPHINE 10MG/5ML 5ML SOL
BELLADON/OPIUM 16/30MG SU

239940119.xlsx.ms_office

Price
37.00
9.00
9.00
9.00
37.00
9.00
9.00
23.00
9.00
86.00
71.00
71.00
71.00
564.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
113.00
189.00
9.00
9.00
30.00
10.00
23.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
10.00

$0 Indicator

Page 231 of 299

CDM #
6316509
6316525
6316533
6316541
6316566
6316590
6316616
6316624
6316632
6316640
6316657
6316665
6316707
6316731
6316749
6316756
6316772
6316780
6316798
6316806
6316814
6316822
6316830
6316848
6316855
6316863
6316871
6316913
6316921
6316939
6316947
6316954
6316962
6316970
6316988
6316996
6317002
6317036
6317044
6317051
6317085
6317093
6317101
6317119
6317127
6317135
6317168

CDM Description
BELLADON/OPIUM 16/60MG SU
APAP/OXYCODONE 325/5MG
OXYCODONE IR 5MG CAP
OPIUM TCT/DOSE LIQ
MORPHINE SR 60MG TAB
APAP/OXYCODONE 325/5MG
MORPHINE SR 15MG TAB
FENTANYL 50MCG/HR PATCH
FENTANYL 25MCG/HR PATCH
FENTANYL 100MCG/HR PATCH
FENTANYL 75MCG/HR PATCH
MORPHINE SR 100MG TAB
METHADONE 1MG/ML 1ML SOL
OXYCODONE 20MG/ML 1ML CON
OXYCODONE CR 40MG TAB
OXYCODONE CR 20MG TAB
OXYCODENE 5MG
HYDROCODONE/APAP 10/650
ALFENTANIL 500MCG/ML 2ML
ALFENTANIL 500MCG/ML 5ML
CODEINE PHOS 30MG/ML 2ML
CODEINE PHOS 30MG/ML 2ML
FENTANYL 50MCG/ML 2ML INJ
FENTANYL 10ML INJ
HYDROMORPHONE 4MG/ML 1ML
HYDROMORPHONE 2MG/ML 1ML
HYDROMORPHONE 2MG/ML 20ML
MEPERIDINE 25MG/ML 1ML IN
MEPERIDINE 50MG/ML 1ML IN
MEPERIDINE 75MG/ML 1ML IN
MEPERIDINE 100MG/ML 1ML
METHADONE 10MG/ML 1ML INJ
MORPHINE 15MG/ML 20ML INJ
MORPHINE 8MG/ML 1ML INJ
MORPHINE 2MG/ML 1ML INJ
MORPHINE 4MG/ML 1ML INJ
MORPHINE 10MG/ML 1ML INJ
MORPHINE 25MG/ML 4ML INJ
MORPHINE 2MG/ML 1ML INJ
MORPHINE 5MG/ML 1ML INJ
OXYMORPHONE 1MG/ML 1ML IN
PENTOBARB 50MG/ML 2ML INJ
SUFENTANIL 50MCG/ML 2ML
SUFENTANIL 50MCG/ML 5ML
SUFENTANIL 50MCG/ML 1ML
HYDROMORPHONE 10MG/ML 5ML
TESTOST CYP 200MG/ML 10ML

239940119.xlsx.ms_office

Price
10.00
9.00
9.00
30.00
23.00
9.00
9.00
86.00
58.00
139.00
114.00
9.00
1.00
9.00
9.00
9.00
9.00
9.00
71.00
71.00
71.00
71.00
71.00
75.00
71.00
71.00
112.00
71.00
71.00
71.00
71.00
71.00
99.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
176.00
71.00
109.00
205.00
99.00
90.00
308.00

$0 Indicator

Page 232 of 299

CDM #
6317200
6317218
6317226
6317259
6317267
6317275
6317291
6317309
6317366
6317374
6317390
6317408
6317416
6317465
6317523
6317549
6317564
6317580
6317598
6317606
6317614
6317622
6317655
6317671
6317689
6317705
6317721
6317747
6317754
6317762
6317770
6317796
6317838
6317853
6317861
6317879
6317895
6317903
6317911
6317929
6317937
6317945
6317952
6317960
6317978
6317986
6317994

CDM Description
MORPHINE 1MG/ML 50ML PCA
MEPERIDINE 10MG/ML 50ML P
HYDROMORPHONE 1MG/ML 1ML
MORPHINE 20MG/ML 1ML SOLN
MIDAZOLAM 5MG/ML 10ML INJ
OXYCODONE CR 10MG TAB
OXYCODONE CR 80MG TAB
FENTANYL 50MCG/ML 20ML IN
LYRICA 50 MG CAP
LYRICA 75 MG CAP
AZATHIOPRINE 50MG TAB
CYTARABINE LIPO 10MG INJ
CHLORAMBUCIL 2MG TAB
CYCLOPHOSPHAMIDE 50MG TAB
DAUNORUBICIN 5MG/ML 10ML
FLUOROURACIL 50MG/ML 10ML
IRINOTECAN 20MG/ML 5ML IN
MEGESTROL 20MG TAB
MEGESTROL 40MG TAB
MELPHALAN 2MG TAB
MESNA 100MG/ML 2ML INJ
MERCAPTOPURINE 50MG TAB
METHOTREXATE 2.5MG TAB
OCTREOTIDE 0.05MG/ML 1ML
OCTREOTIDE 0.5MG/ML 1ML
TAMOXIFEN 10MG TAB
GANCICLOVIR 500MG PWD INJ
LEUCOVORIN 5MG TAB
LEUCOVORIN 25MG TAB
ETOPOSIDE 50MG CAP
LEUCOVORIN 50MG INJ
LEUCOVORIN 100MG INJ
VINORELBINE 10MG/ML 1ML
ANASTROZOLE 1MG TAB
LEUPROLIDE 22.5MG 3MTH K
METHOTREXATE PF 50MG/2ML
CAPECITABINE 500MG TAB
TEMOZOLOMIDE 5MG CAP
TEMOZOLOMIDE 20MG CAP
TEMOZOLOMIDE 100MG CAP
ERLOTINIB 25MG TAB
ERLOTINIB 100MG TAB
ERLOTINIB 150MG TAB
ALBUMIN 25% 100ML INJ
ALBUMIN 5% 500ML INJ
AMINO ACIDS 10% 500ML INJ
CEFTRIAXONE 2GM 50ML PB

239940119.xlsx.ms_office

Price
162.00
71.00
71.00
9.00
71.00
9.00
37.00
71.00
9.00
9.00
9.00
880.00
9.00
21.00
304.00
71.00
360.00
9.00
9.00
9.00
89.00
10.00
21.00
71.00
205.00
10.00
213.00
54.00
222.00
204.00
148.00
197.00
228.00
32.00
2,668.00
71.00
36.00
113.00
335.00
418.00
136.00
224.00
253.00
715.00
715.00
568.00
432.00

$0 Indicator

Page 233 of 299

CDM #
6318018
6318026
6318034
6318059
6318067
6318075
6318083
6318109
6318117
6318125
6318133
6318141
6318158
6318166
6318208
6318240
6318257
6318265
6318281
6318398
6318414
6318422
6318430
6318471
6318489
6318497
6318521
6318547
6318554
6318562
6318570
6318588
6318596
6318604
6318612
6318638
6318646
6318711
6318729
6318745
6318810
6318851
6318885
6318901
6318919
6318927
6318943

CDM Description
DANTROLENE 20MG PWD INJ
DESMOPRESS 4MCG/ML 10ML
DIGOXIN IMMN FAB 38MG PWD
HEPAT B IMM GLOB 5ML IM
HEPAT B IMM GLOB 1ML IM
HEP-B VACCINE 20MCG/ML
INTERFERON ALF 2B 10MIL U
LEVOTHYROXINE 200MCG INJ
MEDROXYPROG 400MG/ML 1ML
NALOXONE 0.4MG/ML 10ML IN
PLASMA PRO FRACT 5% 250ML
PNEUMOCOCCAL VAC 25MCG/.5
RABIES IMMUN GLOB 150U 2M
RABIES IMM GLOB 150U 10ML
TOBRAMYCIN 1.2GM PWDR INJ
ASPARAGINASE 10000IU 10ML
BLEOMYCIN SULFATE 15U INJ
CARMUSTINE 100MG INJ
DOXORUBICIN 10MG INJ
VINCRISTINE 1MG/ML 1ML IN
IFOSFAMIDE 1GM INJ
CARBOPLATIN 50MG INJ
CARBOPLATIN 450MG INJ
ALPROSTADIL 500MCG PEDIV
ALTEPLASE 50MG INJ
AMIKACIN 250MG/ML 4ML INJ
FLUPHENAZINE DEC 25MG/1ML
LYMPHOCYTE IG 250MG 5ML
METHYLPRED NA 500MG INJ
PENTAMIDINE 300MG INJ
ALBUMIN 5% 250ML INJ
AMINO ACID W/E 8.5% 500ML
FAT EMULSION 10% 500ML IN
FAT EMULSION 20% 250ML IN
HETASTARCH 6% 500ML
EPOETIN 10000U INJ
EPOETIN 4000UNIT NONESRD
FAT EMULSION 20% 500ML IN
MANNITOL 20% 500ML PB
ARGININE 10% 300ML INJ
VANCOMYCIN 1GM INJ
RIFAMPIN 600MG INJ A
METHYLPRED NA 1GM INJ
SARGRAMOSTIM 500MCG INJ
FILGRASTIM G-CSF 300MCG
EPOETIN 3000UNIT NONESRD
FILGRASTIM 480MCG INJ

239940119.xlsx.ms_office

Price
292.00
936.00
1,217.00
946.00
314.00
844.00
581.00
395.00
336.00
362.00
359.00
93.00
1,125.00
5,500.00
653.00
315.00
975.00
316.00
382.00
348.00
570.00
458.00
1,713.00
737.00
3,819.00
760.00
380.00
684.00
71.00
684.00
368.00
298.00
408.00
262.00
327.00
751.00
327.00
391.00
361.00
645.00
382.00
492.00
410.00
811.00
615.00
236.00
869.00

$0 Indicator

Page 234 of 299

CDM #
6318950
6318968
6318976
6318992
6319008
6319016
6319024
6319032
6319040
6319081
6319099
6319131
6319156
6319164
6319172
6319180
6319198
6319206
6319214
6319222
6319230
6319255
6319263
6319271
6319289
6319313
6319321
6319362
6319370
6319388
6319396
6319404
6319412
6319420
6319438
6319446
6319453
6319479
6319495
6319503
6319545
6319552
6319560
6319578
6319602
6319610
6319628

CDM Description
FLUDARABINE 50MG PWDR INJ
FLUMAZENIL 0.1MG/ML 10ML
PAMIDRONATE 30MG PWD INJ
FOSCARNET NA 24MG/ML 250M
PACLITAXEL 6MG/ML 5ML INJ
MILRINONE LAC 1MG/ML 20ML
MILRINONE LAC 1MG/ML 10ML
CLADRIBINE 1MG/ML 10ML IN
ALTEPLASE 100MG INJ
ABCIXIMAB 10MG 5ML INJ
HEPAT A VACC 1440U 1ML IN
FENOLDOPAM 10MG/ML 1ML IN
LEVOFLOXACIN 750MG INJ
LEVOFLOXAC 750MG 150ML PB
RISPERIDONE 12.5MG/ML 2ML
RISPERIDONE 37.5MG/2ML IN
RASBURICASE 0.5MG INJ
INSULIN DRIP 100 UNITS
ZOLEDRONIC AC 4MG/5ML
BEVACIZUMAB 10MG INJ
CETUXIMAB 200MG INJ
CAFF CIT 20MG/ML 3ML INJ
ALLOPURINOL 500MG INJ
ANTIVEN CROTALIDAE IMM FA
THYROTROPIN ALFA 1.1MG IN
MOXIFLOXACIN 400MG PB
FACTOR VIIA RECOMB 1.2MG
PIPERAC/TAZO 2.25GM 50ML
PIPERACIL/TAZO 3.375GM 50
PIPERAC/TAZO 4.5GM 100ML
ENALAPRIL 1.25MG/ML 1ML
ENALAPRIL 1.25MG/ML 2ML
TRASTUZUMAB 10MG INJ
OXALIPLATIN 50MG PWD INJ
CYCLOPHOSPH 100MG/5ML INJ
CYTARABINE 100MG INJ
CISPLATIN 10MG PWDR INJ
VINBLASTINE 1MG INJ
LEUPROLIDE 7.5MG DEPOT KI
DACARBAZINE 100MG PWD INJ
AMPHO B(LIP) 5MG/ML 20ML
KETOROLAC 15MG/ML 1ML INJ
KETOROLAC 30MG/ML 1ML INJ
KETOROLAC 30MG/ML 2ML INJ
MEROPENEM 500MG INJ
ARGATROBAN 100MG/ML 2.5ML
ALTEPLASE 2MG INJ

239940119.xlsx.ms_office

Price
757.00
247.00
751.00
396.00
765.00
567.00
334.00
1,161.00
7,553.00
1,098.00
194.00
799.00
254.00
253.00
712.00
1,068.00
338.00
71.00
2,517.00
267.00
243.00
480.00
1,603.00
3,394.00
3,319.00
105.00
4,800.00
58.00
58.00
60.00
58.00
58.00
151.00
33.00
12.00
12.00
12.00
10.00
518.00
29.00
661.00
67.00
67.00
67.00
168.00
2,299.00
238.00

$0 Indicator

Page 235 of 299

CDM #
6319636
6319644
6319677
6319685
6319693
6319701
6319719
6319727
6319735
6319768
6319776
6319792
6319818
6319842
6319875
6319891
6319909
6319933
6319941
6319958
6319974
6320014
6320063
6320071
6320089
6320097
6320105
6320113
6320121
6320147
6320162
6320170
6320188
6320196
6320204
6320212
6320220
6320238
6320295
6320303
6320329
6320402
6320428
6320436
6320444
6320451
6320493

CDM Description
ENOXAPARIN 120MG 0.8ML IN
ENOXAPARIN 150MG 1ML INJ
TETANUS &DIPHTHERIA 0.5ML
FONDAPARINUX 2.5MG 0.5ML
CEFAZOLIN 1GM/50ML PB
CEFTRIAXONE 1GM 50ML PB
CLINDAMYCIN 300MG 50ML PB
CLINDAMYCIN 600MG 50ML PB
CLINDAMYCIN 900MG 50ML PB
IRON SUCROSE INJ 1 MG
FENTANYL/.2%ROPIV/NS
FENTANYL/.125%BUPIV/NS
LEVOTHYROXINE 500MCG INJ
BALANCED SALT 500ML OP IR
NEONATAL TPN
TROMETHAMINE 500ML INJ
GEMCITABINE HCL 200MG INJ
ANTITHROMBIN III 1000 IU
FOSPHENYTOIN 500MG/10ML
IBUTILIDE FM 0.1MG/ML 10M
MIDAZOLAM 50MG/50ML INJ
GLATIRAMER ACET 20MG 2ML
INTERFERON BETA 1B 0.3MG
PORACTANT 240MG 3ML INH
PORACTANT 120MG 1.5ML INH
PALIVIZUMAB 50MG INJ
EPIRUBICIN 2MG/ML 1ML INJ
CASPOFUNGIN 50MG INJ
DAPTOMYCIN 500MG IV
MITOMYCIN 5MG INJ
ETOPOSIDE 20MG/ML 5ML INJ
IMMUNE GLOB 5GM POWDER IV
CARMUSTINE POLIFE 7.7MG
MORPHINE PF 10MG/ML 20ML
ALBUMIN 25% 50ML INJ
DAPTOMYCIN 1MG INJ
LEPIRUDIN 50MG INJ
TPN A
NITROGLYCERIN 50MG/250 D5
PHENTOLAMINE 5MG 1ML INJ
SUCCINYLCHL 20MG/ML 10ML
IDARUBICIN 5MG INJ
LEUPROLIDE 3.75MG DEPOT K
ACYCLOVR 50MG/ML 10ML INJ
AMIKACIN 250MG/ML 2ML INJ
ESMOLOL 10MG/ML 250ML INJ
TRIAMCIN ACE 40MG/ML 5ML

239940119.xlsx.ms_office

Price
233.00
291.00
82.00
76.00
58.00
58.00
58.00
58.00
58.00
12.00
83.00
40.00
265.00
670.00
220.00
547.00
322.00
1,990.00
285.00
713.00
267.00
7,000.00
3,185.00
1,527.00
780.00
1,812.00
104.00
117.00
427.00
200.00
58.00
64.00
5,495.00
6.00
227.00
2.00
580.00
535.00
245.00
164.00
71.00
927.00
1,290.00
321.00
306.00
298.00
216.00

$0 Indicator

Page 236 of 299

CDM #
6320535
6320550
6320576
6320584
6320600
6320618
6320626
6320642
6320659
6320667
6320675
6320683
6320691
6320717
6320725
6320758
6320774
6320782
6320790
6320808
6320816
6320865
6320956
6320980
6320998
6321004
6321020
6321038
6321053
6321061
6321079
6321087
6321095
6321103
6321111
6321129
6321137
6321145
6321152
6321160
6321178
6321186
6321194
6321210
6321244
6321251
6321269

CDM Description
DINOPROST 0.5MG 3GM V GEL
DINOPROSTONE 10MG VAG SUP
FLUCONAZOLE 40MG/ML 35ML
EPTIFIBATIDE 75MG/100ML
DIP/TET/PERTUSS ACE 0.5ML
NITROGLYCER/D5W 100MCG/ML
ABATACEPT 10MG INJ
IMM GLOB FLEBOGAM 10GM IV
IMM GLOB FLEBGMA 500MG IV
IMM GLOB OCTAGAM 5% 100ML
IMM GLOB GAMAGRD 500MG IV
IMM GLOB GAMUNEX 500MG IN
NATALIZUMAB 1MG INJ
AMIODARONE 50MG/ML 3ML IN
SOD THIOSULFATE 12.5G/50M
AMPHO B LIPOSOME 50MG
RITUXIMAB 10MG/ML 10ML IN
BACLOFEN PF 0.5MG/ML 20ML
DOLASETRON 20MG/ML 5ML IN
EPOETIN 20000UNIT NONESRD
BOTULINUM(COS)TYPE A 100U
TENECTEPLASE 50MG INJ
ISOSULFAN BLUE 1% 10MG IJ
MILRINONE LAC 40MG PB
INS GLARGINE 100U/ML 10ML
NESIRITIDE 1.5MG INJ
INS NPH REG 70/30 PEN 3ML
EPOETIN 40000U NONESRD
INTERFERON BETA-1A 30MCG
ACETAZOLAMIDE 500MG INJ
AMIKACIN 50MG/ML PEDIV
AMINOCAP AC 250MG/ML 20ML
AMINOPHYLLINE 500MG/20ML
AMINOPHYLLINE 250MG INJ
AMMONIA SPIRIT AMPULE
AMPHOTERICIN B 50MG INJ
AMPICILLIN 125MG INJ
AMPICILLIN 500MG INJ
AMPICILLIN 250MG INJ
AMPICILLIN 1GM INJ
AMPICILLIN 2GM INJ
AMPICILLIN/SULBACTM 1.5GM
AMPICILLIN/SULBACT 3GM IN
ANTIVEN LATRODECTUS MACTA
ATRACURIUM 10MG/ML 10ML I
ATROPINE 0.4MG/ML 20ML IN
ATROPINE 1MG/ML 1ML INJ

239940119.xlsx.ms_office

Price
396.00
514.00
185.00
682.00
71.00
3.00
44.00
91.00
91.00
96.00
85.00
88.00
19.00
300.00
167.00
758.00
1,062.00
719.00
669.00
799.00
1,263.00
3,940.00
610.00
736.00
71.00
951.00
58.00
1,102.00
731.00
215.00
137.00
87.00
149.00
149.00
22.00
293.00
149.00
149.00
149.00
149.00
149.00
149.00
183.00
166.00
148.00
149.00
149.00

$0 Indicator

Page 237 of 299

CDM #
6321277
6321293
6321319
6321343
6321350
6321368
6321376
6321384
6321400
6321418
6321426
6321442
6321459
6321467
6321475
6321483
6321491
6321509
6321517
6321525
6321533
6321541
6321558
6321566
6321574
6321582
6321590
6321608
6321624
6321632
6321640
6321657
6321673
6321681
6321715
6321723
6321731
6321749
6321756
6321764
6321772
6321780
6321814
6321822
6321855
6321863
6321871

CDM Description
ATROPINE 0.5MG/ML 1ML INJ
ATROPINE 0.4MG/ML 1ML INJ
ATROPINE 1MG/ML 10ML INJ
AZTREONAM 500MG INJ
AZTREONAM 1GM INJ
AZTREONAM 2GM INJ
IRON DEXTRAN 50MG/ML 1ML
BACITRACIN 50000U INJ
BENZTROPINE 1MG/ML 2ML IN
BETAMETH NA P/AC 30MG/5ML
BETAMETH NA PHO 3MG/ML 1M
BUMETANIDE 0.25MG/ML 2ML
BUMETANIDE 0.25MG/ML 4ML
BUMETANIDE 0.25MG/ML 10ML
BUPIVAC/EPI 0.75% 30ML IN
BUPIVAC/EPI 0.75% 30ML IN
BUPIVACAIN/EPI 0.25% 50ML
BUPIVAC/EPI 0.25% 10ML IN
BUPIVACAINE 0.5% 30ML INJ
BUPIVACAINE PF 0.5% 30ML
BUPIVAC/EPI 0.75% 30ML IN
BUPIVAC/EPI 0.25% 10ML IN
BUPIVAC/EPI 0.5% 30ML
BUPIVAC/EPI 0.75% 30ML IN
BUTORPHANOL 1MG/ML 1ML IN
BUTORPHANOL 2MG/ML 1ML IN
CAFF/NA BENZ 250MG/ML 2ML
CALCITONIN 200IU/ML 2ML
CACL 13.6MEQ/10ML 10ML IN
CACL 10% 1GM 10ML INJ
CA GLUC 10% 10ML (1GM) IN
CARBOPROST 250MCG/ML 1ML
CEFAZOLIN 1GM INJ
CEFAZOLIN 500MG INJ
CEFOTAXIME 1GM PWD INJ
CEFOTAXIME 2GM PWD INJ
CEFOTETAN 1GM 50ML PB
CEFOTETAN 2GM 50ML PB
CEFOXITIN 1GM PWD INJ
CEFOXITIN 2GM PWD INJ
CEFTAZIDIME 1GM PWD INJ
CEFTAZIDIME 2GM PWD INJ
CEFTRIAXONE 1GM PWD INJ
CEFUROXIME 750MG 50ML PB
CHLOROTHIAZDE 500MG 20ML
CHLORPROMAZNE 25MG/ML 1ML
CHLORPROMAZNE 25MG/ML 2ML

239940119.xlsx.ms_office

Price
71.00
149.00
149.00
149.00
187.00
260.00
162.00
161.00
149.00
242.00
136.00
149.00
149.00
149.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
149.00
204.00
71.00
71.00
71.00
187.00
149.00
149.00
226.00
280.00
168.00
256.00
161.00
241.00
284.00
284.00
293.00
149.00
1,075.00
71.00
71.00

$0 Indicator

Page 238 of 299

CDM #
6321889
6321905
6321921
6321939
6321947
6321954
6321962
6321970
6321988
6321996
6322002
6322010
6322028
6322051
6322077
6322085
6322093
6322101
6322119
6322143
6322150
6322168
6322176
6322184
6322192
6322200
6322218
6322226
6322242
6322259
6322283
6322291
6322333
6322358
6322382
6322390
6322408
6322416
6322424
6322440
6322457
6322473
6322481
6322499
6322507
6322515
6322523

CDM Description
CIMETIDINE 300MG/50MLPEDI
CLINDAMYCIN 150MG/ML 4ML
ESTROGENS CONJ 25MG/5ML
COSYNTR(CORTROSYN) 0.25MG
VIT B12 1000MCG/ML 1ML IN
VIT B12 100MCG/ML 1ML INJ
DEFEROXAMINE 500MG INJ
DESMOPRESS 4MCG/ML 1ML IN
DEXAMETH 10MG/ML 10ML INJ
DEXAMETH PHOS 4MG/ML 5ML
DEXAMETH PHOS 4MG/ML 1ML
DEXAMETH ACET 8MG/ML 5ML
D50% PF 50ML INJ
DICYCLOMINE 10MG/ML 2ML
DIGOXIN 0.25MG/ML 2ML INJ
DIGOXIN 0.1MG/ML 1ML PEDI
DIHYDROERGOTAM 1MG/ML 1ML
DIMENHYDRINAT 50MG/ML 1ML
DIPHENHYDRAMIN 50MG/ML 1M
DOBUTAMINE 12.5MG/ML 20ML
DOPAMINE 40MG/ML 5ML INJ
DOPAMINE 80MG/ML 5ML INJ
DOPAMINE 160MG/ML 5ML INJ
DOXAPRAM 20MG/ML 20ML INJ
DOXYCYCLINE 100MG INJ
DROPERIDOL 2.5MG/ML 2ML
EDROPHONIUM 10MG/ML 10ML
EDROPHONIUM 10MG/ML 1ML
EPHEDRINE 50MG/ML 1ML INJ
EPINEPHRINE 0.1MG/ML 10ML
ERYTHROMY LACTO 500MG INJ
ERYTHROMY LACTO 1GM INJ
ETHACRYNIC ACID 50MG INJ
FAMOTIDINE 10MG/ML 2ML IN
FLUPHENAZINE 2.5MG/ML 10M
FOLIC ACID 5MG/ML 10ML IN
FUROSEMIDE 10MG/ML 10ML
FUROSEMIDE 40MG 4ML INJ
FUROSEMIDE 10MG/ML 2ML IN
GENTAMICIN 80MG INJ
GENTAMICIN 10MG/ML 2ML IN
GLUCAGON 1MG(1U) 1ML INJ
GLYCOPYRROLATE/0.2MG/1ML
GLYCOPYRROL 0.2MG/1ML 5ML
HAEMOPHILUS B CONJG 0.5ML
HALOPERIDOL 5MG/ML 1ML IN
HEPARIN 10000UNIT/ML 1ML

239940119.xlsx.ms_office

Price
2.00
215.00
115.00
149.00
71.00
71.00
149.00
130.00
192.00
71.00
71.00
71.00
99.00
71.00
71.00
71.00
71.00
71.00
71.00
340.00
149.00
208.00
202.00
202.00
264.00
71.00
71.00
71.00
149.00
99.00
149.00
113.00
206.00
149.00
229.00
167.00
71.00
71.00
71.00
71.00
71.00
152.00
149.00
149.00
84.00
71.00
71.00

$0 Indicator

Page 239 of 299

CDM #
6322531
6322556
6322564
6322572
6322580
6322598
6322606
6322622
6322630
6322648
6322655
6322663
6322689
6322697
6322705
6322721
6322739
6322754
6322770
6322804
6322812
6322838
6322853
6322861
6322911
6322929
6322937
6322945
6322986
6322994
6323000
6323018
6323026
6323034
6323059
6323067
6323075
6323083
6323091
6323109
6323125
6323133
6323141
6323166
6323174
6323216
6323224

CDM Description
HEPARIN 5000UNIT/ML 1ML
HEPARIN FLUSH 100/ML 10ML
HEPARIN FLUSH 10/ML 2ML
HEPARIN 1000UNIT/ML 10ML
HEPARIN 1000UNIT/ML 30ML
HEPARIN 1000U/ML 1ML INJ
HEPARIN FLUSH 100UN/10ML
HYDRALAZINE 20MG/ML 1ML
HYDROCORT NA SUC 1GM 8ML
HYDROCORT NA SUC 500MG 4M
HYDROCORT NA SUC 250MG 2M
HYDROCORT NA SUC 100MG 2M
HYDROXYZINE 50MG/ML 2ML
IMIPENEM 250MG INJ
IMIPENEM 500MG INJ
INDIGO CARMINE/5ML/INJ
INDOMETHACIN 1MG INJ
INSUL NPH 100U/ML 10ML
INS REG HUM 100U/ML 10ML
ISOPROTERENOL 1MG/5ML SYR
ISOPROTERENOL 1MG/5ML AMP
KANAMYCIN 1GM 3ML INJ
KETAMINE 100MG/ML 5ML INJ
LABETALOL 5MG/ML 20ML INJ
LIDO 1% 30ML VIAL
LIDO 1.5% 20ML VIAL
LIDO 1% 10ML VIAL
LIDO 1% 2ML AMP PF
LIDOCAINE/1PC/20ML
LIDOCAINE MPF 4% 5ML INJ
LIDO 2% 20ML VIAL
LIDO 2% 10ML AMP
LIDO MPF 2% 2ML VIAL
LIDO 1% 50ML VIAL
LIDO 2% 50ML VIAL
LIDO 2% W EPI 30ML VIAL
LIDO 1% W EPI 30ML VIAL
LIDO 1.5% W EPI 30ML VIAL
LIDO 2% W EPI 20ML VIAL
LIDO 1% W EPI 50ML VIAL
TRACE ELEMENTS 1ML INJ
MAGNESIUM SUL 1GM/2ML INJ
MAGNESIUM SUL 5GM/10ML IN
MANNITOL 25% 50ML INJ
MEASLES/MUMPS/RUBELLA VAC
METHYLENE BLUE 10MG/1ML
METHYLENE BLUE 10MG/1ML

239940119.xlsx.ms_office

Price
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
136.00
71.00
71.00
71.00
71.00
173.00
265.00
71.00
260.00
71.00
71.00
156.00
71.00
222.00
133.00
244.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
71.00
149.00
93.00
149.00
214.00
71.00
71.00

$0 Indicator

Page 240 of 299

CDM #
6323232
6323257
6323265
6323273
6323281
6323299
6323307
6323315
6323331
6323349
6323356
6323364
6323372
6323380
6323398
6323414
6323422
6323448
6323455
6323513
6323521
6323547
6323554
6323562
6323570
6323646
6323653
6323661
6323687
6323695
6323703
6323711
6323729
6323737
6323752
6323760
6323778
6323786
6323794
6323802
6323810
6323828
6323836
6323844
6323869
6323877
6323885

CDM Description
METHYLERGON 0.2MG/ML 1ML
METHYLPRED NA 125MG INJ
METHYLPRED NA 40MG INJ
METHYLPRED ACE 40MG/ML 1M
METHYLPRED ACE 80MG/ML 1M
METOCLOPRAMIDE 5MG/ML 10M
METOCLOPRAMIDE 5MG/ML 10M
METOPROLOL 1MG/ML 5ML INJ
MIDAZOLAM 1MG/ML 5ML INJ
MULTIVIT W VIT K 10ML INJ
NAFCILLIN 1GM INJ
NAFCILLIN 2GM INJ
NAFCILLIN 500MG INJ
NALBUPHINE 10MG/ML 10ML
NALBUPHINE 20MG/ML 1ML IN
NALOXONE 0.4MG/ML 1ML INJ
NALOXONE 1MG/ML 2ML INJ
NEOSTIGMINE 1:1000 1ML IN
NEOSTIGMINE 1:2000 1ML IN
NITROPRUSSIDE SODIUM/50MI
NOREPINEPHRINE 4MG/4ML IN
ORPHENADRINE 30MG/ML 2ML
OXYTOCIN 10U/ML 1ML INJ
PANCURONIUM 1MG/ML 10ML
PAPAVERINE 30MG/ML 2ML IN
PEN G K 20MIL UNIT INJ
PEN G K 5MIL U INJ
PEN G K 1MIL U/10ML INJ
PHENYLEPH 1% 10MG/ML 1ML
PHENYTOIN 50MG/ML 5ML INJ
PHENYTOIN 50MG/ML 2ML INJ
PHYSOSTIGMINE 1MG/ML 2ML
VIT K1(PHYTON)10MG/ML 1ML
PHYTONADI 1MG/0.5ML PEDIM
POTASSIUM ACET 40MEQ/20MI
KCL 40MEQ 20ML INJ
KCL 2MEQ/10ML PEDIV
KCL 30MEQ/15ML INJ
KCL 10MEQ 5ML INJ
K PHOS 4.4MEQ/3MM 5ML INJ
PROCAINAMIDE 500MG/ML 2ML
PROCAINAMIDE 100MG/ML 10M
PROCHLORPER 5MG/ML 2ML IN
PROGESTER/OIL 50MG/ML 10M
PROMETHAZINE 25MG INJ
PROMETHAZINE 50MG INJ
PROPRANOLOL 1MG/ML 1ML IN

239940119.xlsx.ms_office

Price
71.00
71.00
71.00
71.00
85.00
79.00
71.00
149.00
71.00
71.00
156.00
225.00
149.00
71.00
71.00
71.00
164.00
71.00
71.00
162.00
149.00
71.00
149.00
129.00
71.00
157.00
149.00
149.00
96.00
149.00
149.00
71.00
71.00
71.00
71.00
149.00
149.00
149.00
149.00
71.00
85.00
148.00
71.00
194.00
71.00
71.00
149.00

$0 Indicator

Page 241 of 299

CDM #
6323893
6323901
6323927
6323935
6323943
6323950
6323968
6323976
6323984
6323992
6324008
6324016
6324024
6324032
6324040
6324057
6324073
6324107
6324115
6324123
6324131
6324149
6324156
6324180
6324198
6324206
6324214
6324222
6324255
6324271
6324297
6324321
6324347
6324362
6324370
6324388
6324396
6324404
6324412
6324446
6324453
6324461
6324495
6324503
6324545
6324552
6324578

CDM Description
PROTAMINE SULF 10MG/ML25M
PROTAMINE SULF 10MG/ML 5M
PYRIDOSTIGMINE 10MG/2ML I
VIT B6(PYRIDOX)100MG/ML1M
RANITIDINE 25MG/ML 2ML IN
RUBELLA VACCINE (1DOSE)
SCOPOLAMINE 0.4MG/ML 1ML
SINCALIDE 5MCG INJ
SODIUM ACETATE/40MEQ/20MI
SOD BICARB 2.4MEQ/ML 5ML
SOD BICARB 5MEQ/10ML SYRD
SOD BICARB 10MEQ/10ML SYR
SOD BICARB 50MEQ/50ML INJ
SOD CHLORIDE 0.9% 10MLINJ
SOD CHLORIDE 23.4% 30MLIN
SOD CHLORIDE 0.9% 50MLINJ
SUCCINYLCHL 100MG/ML 10ML
TERBUTALINE 1MG/ML 1ML IN
TETANUS & DIPHTHERIA IN>7
TETANUS TOXOID ADSORBD/0I
TETANUS IMMUN GLOB 250U
VIT B1(THIAMINE)100MG/ML2
THROMBIN 20000U PWDR
TOBRAMYCIN 40MG/ML 2ML IN
SULFAMET/TMP 80/16MG 5ML
SULFAMET/TMP 80/16MG 10ML
SULFAMET/TMP 80/16MG 20ML
TRIAMCIN ACE 10MG/ML 5ML
TRIAMCIN ACE 40MG/ML 1ML
TRIAMCIN HEX 20MG/ML 1ML
TRIMETHOBENZ 100MG/ML 2ML
VANCOMYCIN 500MG INJ
VASOPRESSIN 20U/ML 1ML IN
VECURONIUM 1MG/ML 10ML IN
VERAPAMIL HCL/5MG/2ML/AMP
WARFARIN 5MG INJ
TRACE ELEMENTS 1ML
CEFTRIAXONE 250MG PWD INJ
CEFTRIAXONE 500MG PWD INJ
EPOETIN 2000U INJ NON
CLINDAMYCIN 150MG/ML 6ML
ATENOLOL 5MG/10ML 10ML IN
PROPOFOL 10MG/ML 20ML INJ
ADENOSINE THERA 6MG INJ
ESMOLOL 10MG/ML 10ML INJ
DEXAMETH PHOS 10MG/ML 1ML
CEFUROXIME 1.5GM INJ

239940119.xlsx.ms_office

Price
144.00
71.00
71.00
71.00
149.00
89.00
71.00
137.00
71.00
71.00
78.00
78.00
71.00
71.00
71.00
78.00
71.00
71.00
71.00
71.00
270.00
71.00
213.00
149.00
149.00
215.00
290.00
71.00
71.00
71.00
71.00
149.00
157.00
199.00
194.00
153.00
71.00
161.00
217.00
179.00
252.00
149.00
86.00
226.00
149.00
71.00
190.00

$0 Indicator

Page 242 of 299

CDM #
6324586
6324594
6324677
6324719
6324727
6324735
6324750
6324768
6324776
6324784
6324792
6324826
6324834
6324842
6324859
6324867
6324875
6324883
6324909
6324917
6324925
6324941
6324974
6324990
6325047
6325054
6325062
6325104
6325112
6325120
6325138
6325153
6325161
6325286
6325310
6325328
6325336
6325344
6325351
6325369
6325377
6325385
6325393
6325401
6325419
6325427
6325450

CDM Description
LIDOCAINE 2% 10ML SYRG
METHOCARBAML 100MG/ML 10M
D25% 10ML SYRINGE
PROPOFOL 500MG/50ML
CIPROFLOXACIN 200MG/100ML
CIPROFLOXA 400MG/40ML INJ
HALOPERIDOL DEC 50MG INJ
DILTIAZEM 5MG/ML 5ML INJ
DILTIAZEM 5MG/ML 10ML INJ
PEN G K 5MIL U INJ
CALCITRIOL 1MCG/ML 1ML IN
DT PED 0.5ML B
EPINEPHRINE 1:1000 30ML
ETOMIDATE 2MG/ML 10ML INJ
ETOMIDATE 2MG/ML 20ML INJ
ETHANOLAMINE 100MG INJ
SUMATRIPTAN 6MG INJ
FERRIC GLUC 62.5MG 5ML IN
HEPARIN FLUSH 5UNIT/5ML
RUBEOLA VIRUS VACCINE
FLUMAZENIL 0.1MG/ML 5ML I
CISATRACURIUM 2MG/ML 10ML
PARICALCITOL 5MCG/ML 1ML
BORTEZOMIB 3.5MG PWDR INJ
MAGNESIUM SUL 40GM PB
OCTREOTIDE 0.1MG/ML 1ML
ALBUMIN 5% 2.5GM/50ML INJ
ENOXAPARIN 30MG 0.3ML INJ
ONDANSETRON 2MG/ML 2ML IN
TORSEMIDE 10MG/ML 2ML INJ
ZIDOVUDINE 10MG/ML 20ML
CEFOTAXIME 500MG PWD INJ
LEVOFLOXACIN 500MG INJ
DORNASE 1MG/ML 2.5ML INH
RHO(D) IMMUNE GLOB 300MCG
VALPROIC ACID 100MG/ML 5M
VARICELLA VACPF1350U/0.5
POLIO VAC KILLED .5ML SYR
LEVOFLOXACIN 250MG 50MLPB
ENOXAPARIN 60MG 0.6ML INJ
LEVOFLOXAC 500MG 100ML PB
ROCURONIUM 10MG/ML 5ML IN
BACLOFEN 50MCG/ML 1ML INT
CEFEPIME 1GM PWD INJ
VECURONIUM 1MG/ML 20ML IN
DOLASETRON 20MG/ML 0.625M
DILTIAZEM 5MG/ML 25ML INJ

239940119.xlsx.ms_office

Price
71.00
71.00
78.00
65.00
187.00
284.00
169.00
168.00
245.00
127.00
128.00
71.00
71.00
129.00
148.00
175.00
155.00
150.00
58.00
109.00
155.00
75.00
75.00
2,336.00
78.00
71.00
147.00
86.00
123.00
71.00
156.00
149.00
238.00
138.00
660.00
149.00
194.00
114.00
167.00
136.00
230.00
87.00
273.00
150.00
262.00
86.00
175.00

$0 Indicator

Page 243 of 299

CDM #
6325468
6325476
6325518
6325534
6325542
6325567
6325575
6325583
6325609
6325617
6325625
6325633
6325641
6325674
6325682
6325708
6325716
6325732
6325740
6325773
6325781
6325849
6325856
6325880
6325898
6325906
6325914
6325922
6325948
6325971
6325989
6326003
6326029
6326037
6326045
6326060
6326094
6326102
6326110
6326136
6326144
6326151
6326169
6326185
6326201
6326219
6326227

CDM Description
PROPOFOL 1000MG/100ML INJ
ENOXAPARIN 100MG 1ML INJ
NICARDIPINE 2.5MG/ML 10ML
HEPARIN 25000U/250ML D5W
VIT A 50000IU/ML 2ML INJ
SODIUM PHOSPHATE 15ML
KETAMINE 50MG/ML 10ML INJ
CYCLOSPORINE 50MG/ML 5ML
PANCURONIUM 2MG/ML 2ML IN
BUPIVAC/EPI 0.5% 50ML INJ
BUPIVACAIN/EPI 0.25% 50ML
BUPIVACAINE 0.5% 50ML INJ
LIDOCAINE 2% 5ML VIAL
PIPER/TAZO 4/0.5GM INJ
PIPERACIL/TAZO 3.375GM IN
TORSEMIDE 10MG/ML 5ML INJ
MEDROXYPROGEST 150MG DEPO
HEPARIN 1000U/ML 2ML INJ
D10% 5ML INJ
TUBERCULIN 5TU/0.1ML 0.1M
EPINEPHRINE 0.3MG INJ KIT
EPOPROSTENOL 0.5MG 17ML
HEPARIN PF FLUSH 500U/5ML
FOSPHENYTOIN 50MG/2ML IN
ROPIVACAINE 2MG/ML 20ML
ROPIVACAINE 2MG/ML 100ML
MAGNESIUM SUL 4GM/100MLPB
LIDOCAINE 1% SYR 30ML
AZITHROMYCIN 500MG INJ
ENOXAPARIN 40MG 0.4ML INJ
HIB VACCINE PRP-T CONJ IM
EPTIFIBATIDE 2MG/ML 10ML
PIPERAC/TAZO 2/0.25GM INJ
ENOXAPARIN 80MG 0.8ML INJ
SOD CHLORIDE 0.9% 30ML
LINEZOLID 600MG PB
CEFEPIME 2GM PWD INJ
PANTOPRAZOLE 40MG INJ
PROPOFOL 10MG/ML 10ML INJ
MILRINONE LAC 20MG PB
VORICONAZOLE 200MG INJ
HUMULIN 70/30 3ML VIAL
INS ASP PRO 70-30 3ML PEN
OPRELVEKIN 5MG INJ
BIVALIRUDIN 250MG INJ
BUPIVACAINE PF 0.5% 10ML
ZIPRASIDONE 20MG INJ

239940119.xlsx.ms_office

Price
209.00
193.00
171.00
71.00
100.00
71.00
117.00
133.00
71.00
71.00
71.00
71.00
71.00
192.00
164.00
149.00
164.00
71.00
71.00
71.00
71.00
30.00
71.00
169.00
71.00
90.00
78.00
71.00
191.00
115.00
85.00
254.00
145.00
181.00
71.00
306.00
188.00
179.00
68.00
264.00
344.00
58.00
75.00
688.00
1,047.00
58.00
58.00

$0 Indicator

Page 244 of 299

CDM #
6326235
6326243
6326268
6326276
6326284
6326292
6326300
6326318
6326359
6326391
6326409
6326417
6326425
6326433
6326441
6326458
6326466
6326474
6326482
6326490
6326508
6326516
6326524
6326540
6326557
6326573
6326581
6326599
6326607
6326615
6326649
6326664
6326672
6326680
6326698
6326706
6326714
6326722
6326748
6326755
6326763
6326789
6326797
6326813
6326839
6326847
6326854

CDM Description
ERTAPENEM 1GM PWDR INJ
ALEMTUZUMAB 10MG/ML 3ML
TIGECYCLINE 50MG INJ
MYCOPHENOLATE 500MG 20ML
PROPOFOL 10MG/ML 50ML INJ
MENOMUNE VACCINE
INSULIN ASPART HUMAN 10ML
OMALIZUMAB 150MG INJ
CIPROFLOXACIN 400MG/200ML
DOXORUBICIN LIP 20MG/10ML
DACOGEN 50 MG VIAL
ROPIVACAINE 2MG/ML 10MG
HIB/HEP B VACC(COMVX) 0.5
HEPB VAC/DPAT/POLIO 0.5MG
NEOPROFEN 10MG/ML VIAL
ADENOSINE DX 3MG/ML 30ML
PACLITAXEL PBP 100MG PWD
CEFOXITIN 1GM PB
CEFOXITIN 2GM 50ML/D5W PB
PRECEDEX 100 MCG/ML 2MLS
OCTREOTIDE 30MG DEPOT KIT
FOMEPIZOLE 1GM/ML 1.5ML
OMNIPAQUE 300 MG/ML 50 ML
DAPTACEL 0.5 ML VIAL
FAMOTIDINE 20MG/50ML PB
IBANDRONATE 3MG/3ML INJ
FLUCONAZOL 200MG 100ML NS
FLUCONAZOLE 400MG 200ML
ACETYLCYST 20% 30ML IV
INSULIN DET100U/ML PEN3ML
PEGFILGRASTIM 6MG INJ
INSULN ASPART100/1 PEN3ML
INSULIN NPH100U/ML PEN3ML
INSUL NPH 100U/ML 10ML
ONDANSETRON 2MG/ML 2ML IN
PHENYLEPH 1% 10MG/ML 1ML
RABIES IM VAC KIT 2.5 IU
VON WILLEBRAND FACTR 1 IU
ACYCLOVIR 5% 15GM TOP
ALBUTEROL 0.5% 20ML INH
ALBUTEROL 17GM INH
ATROPINE 1% 3.5GM OP OINT
HYDROCORT 2.5% 30GM CRM
AZELASTINE 34GM NAS SPRY
BACITRACIN 30GM OINT
BACITRACIN 3.5GM OP OINT
BACITRACIN 3.5GM OP OINT

239940119.xlsx.ms_office

Price
156.00
3,723.00
153.00
90.00
114.00
209.00
121.00
41.00
213.00
1,052.00
3,063.00
58.00
117.00
147.00
1,173.00
464.00
2,086.00
58.00
58.00
157.00
6,547.00
3,009.00
50.00
58.00
58.00
694.00
58.00
198.00
277.00
58.00
6,504.00
58.00
58.00
58.00
33.00
58.00
354.00
1,750.00
72.00
49.00
52.00
30.00
28.00
81.00
30.00
38.00
26.00

$0 Indicator

Page 245 of 299

CDM #
6326862
6326870
6326888
6326896
6326912
6326938
6326946
6326953
6326961
6326979
6326987
6327001
6327019
6327027
6327035
6327068
6327076
6327084
6327092
6327100
6327118
6327134
6327142
6327175
6327183
6327209
6327217
6327225
6327233
6327258
6327282
6327308
6327316
6327324
6327332
6327340
6327373
6327381
6327415
6327423
6327431
6327472
6327514
6327530
6327548
6327555
6327563

CDM Description
BACITRACIN 30GM OINT
BACITRACIN 0.94GM OINT
EMOLLIENT 300ML TOP
BECLOMETH 42MCG 25GM NAS
BENZOCAINE 20% 60ML SPRY
BETAMETH VAL 0.1% 45GM CR
BETAMETH VAL 0.1% 15GM CR
BETAMETH VAL 0.1% 15GM OI
IMITREX 20MG NASAL SPRAY
IMITREX 5MG NASAL SPRAY
TIOTROPIUM 18MCG INHAL
CLOBETASOL 0.05% 15GM CRM
CLOBETASOL 0.05% 30GM CRM
CLOBETASOL 0.05% 15GM OIN
CLOTRIMAZOLE 1% 15GM CRM
CLOTRIMAZOLE 1% 30GM CRM
CLOTRIMAZOLE 1% 45GM CRM
ZINC/COD LIVER 30GM OINT
CROMOLYN 8.1GM INH
CROMOLYN 14.2GM INH
CYCLOSPORIN 100MG/ML 50ML
DESONIDE 0.05% 60GM CRM
DESOXIMETASONE 0.25% 15GM
DIBUCAINE 1% 30GM OINT
ECONAZOLE NIT 1% 30GM TOP
ERYTHRO 3.5GM OP OINT
FLUNISOLIDE M 250 MCG 7G
FLUOCINOLNE 0.01% 15GM CM
FLUOCINOLON/0.025PC/15G A
FLUOCINOLON/0.025PC/15G B
FLUOCINONIDE/0.05PC/15G A
FLUOCINONIDE/0.05PC/30G A
FLUOCINONIDE/0.05PC/15G B
FLUOCINONIDE/0.05PC/30G B
FLUOCINONIDE-EMOL/15GM
FLUOCINONIDE-EMOL/60GM
GENTAMICIN/15GM/OINT
GENTAMICIN 0.3% 3.5GM OPO
HYDROCORT/0.5PC/30GM/TOP
HYDROCORT/1PC/30GM/OINT
HYDROCORT/0.5PC/30GM/OINT
AZELASTINE 0.05% 6ML OPS
TALC 10 OZ USP PWDR
NTG OINT 2% 30GM A
NYSTATIN 15GM CRM
NYSTATIN/TRIAMC 15GM CRM
NYSTATIN/TRIAMC 30GM CRM

239940119.xlsx.ms_office

Price
24.00
21.00
29.00
63.00
29.00
61.00
43.00
43.00
78.00
78.00
108.00
58.00
68.00
58.00
35.00
51.00
60.00
24.00
71.00
101.00
485.00
78.00
43.00
28.00
51.00
29.00
60.00
33.00
48.00
48.00
49.00
58.00
49.00
58.00
49.00
84.00
30.00
37.00
14.00
14.00
14.00
188.00
32.00
30.00
37.00
48.00
63.00

$0 Indicator

Page 246 of 299

CDM #
6327571
6327589
6327597
6327613
6327621
6327639
6327654
6327662
6327670
6327712
6327720
6327738
6327753
6327761
6327779
6327787
6327795
6327829
6327837
6327845
6327852
6327860
6327878
6327886
6327944
6327951
6327977
6328009
6328017
6328025
6328033
6328041
6328058
6328074
6328108
6328124
6328132
6328140
6328157
6328165
6328173
6328181
6328199
6328207
6328215
6328223
6328249

CDM Description
NYSTATIN/TRIAMC 60GM CRM
NYSTATIN/TRIAMC 15GM OINT
NYSTATIN/TRIAMC 30GM OINT
PANAFIL 30GM OINTMENT
PETROLATUM-C-STEROL/45GM
POVIDONE-IODINE/1PC/28GM
SILVER SULFADIAZ 400GMTOP
SILVER SULFADIAZ 50GM TOP
SODIUM CHLORIDE/5PC/3.5GM
TOBRAMYCIN 3% 3.5GM OP ON
TOLNAFTATE 1% 15GM TOP
TRIAMCIN ACE 0.5% 15GM CR
TRIAMCIN ACE 0.025% 80GMC
TRIAMCIN ACE 0.1% 15GM CR
TRIAMCIN ACE 0.1% 15GM
TRIAMCIN ACE 0.1% 80GM
TRIAMCIN ACE 20GM INH
A AND D 60GM TOP
ZINC OXIDE 20% 30GM TOP
ACETIC ACID 2% 15ML OTIC
ACETIC ACID 0.25% 1000ML
ACETYLCYST 10% 10ML INH
ACETYLCYST 20% 10ML INH
ACETYLCYST 20% 30ML INH
MUPIROCIN 2% 15GM OINT
BENZOCAINE 20% 60ML SPRY
BENZOIN/118ML/TINC
CALAMINE/PRAMOXINE 180ML
CALAMINE 120ML LOT
CALAMINE 120ML LOT
EMOLLIENT 450GM TOP
BENZOCAINE/TETRA 56GM SPY
CHAPSTICK
CHLORASEPTIC 177ML SPRAY
CLOTRIMAZOLE 1% 45GM CRM
BAC/HC/NEO/POL B 7.5GM CR
VALGANCICL 450MG/7.5MLPED
CROMOLYN 4% NAS SPRAY
NA HYPOCHLOR 0.25% 473ML
DESMOPRESS 0.1MG 2.5ML NA
NEO-DECADRON OPH
DEXAMETHAS 0.1% 5ML OPSOL
EPINEPHR 2.25% 15ML INH
EPINEPHRINE 0.1% 30ML TOP
CONJ ESTROG 42.5GM VAGCRM
FLUNISOLIDE 0.025% 25ML
FLUOCINOLONE 0.01% 60ML

239940119.xlsx.ms_office

Price
97.00
48.00
62.00
278.00
46.00
32.00
86.00
36.00
30.00
38.00
30.00
84.00
49.00
38.00
37.00
63.00
29.00
26.00
24.00
48.00
116.00
52.00
60.00
124.00
46.00
43.00
36.00
30.00
24.00
23.00
30.00
58.00
22.00
22.00
49.00
37.00
43.00
49.00
49.00
133.00
49.00
48.00
58.00
33.00
52.00
62.00
64.00

$0 Indicator

Page 247 of 299

CDM #
6328256
6328298
6328314
6328322
6328363
6328371
6328389
6328397
6328405
6328439
6328454
6328470
6328488
6328504
6328520
6328538
6328546
6328553
6328561
6328579
6328595
6328603
6328611
6328629
6328637
6328686
6328694
6328710
6328728
6328744
6328769
6328777
6328785
6328793
6328819
6328827
6328835
6328843
6328850
6328868
6328876
6328892
6328900
6328926
6328934
6328959
6328975

CDM Description
FLUOCINONIDE/0.05%/15GM
HIBICLENS/240ML
HYDROGEN PEROXIDE/120ML
HYDROGEN PEROXIDE/480ML
IPRATROPIUM 14.7GM INH
KENALOG IN ORABASE 5GM A
LACHYDRIN LOTION 120ML
LACRILUBE 3.5GM
KERI LOTN .95ML
LIDO TOP 4% 50ML VIAL
LIDO 2% JELLY 30GM
LOTRISONE CREAM 15GM
MAG HYD/AL HYDRX/SIMET 30
METHYL SALICYL/MENTH 30GM
MICONAZOLE 2% 15GM CRM
MICONAZOLE 2% 30GM CRM
MICONAZOLE 2% 45GM VAG CR
EUCERIN CR 454GM
EUCERIN CR 120GM
MONISTAT SUPP #7
BAC/HC/NEO/POL 3.5GM OPO
NEOSPORIN OP 3.75GM
NEOSPORIN OINT 28GM
NEO/POLYM/BACIT 15GM OINT
NEOSPORIN CREAM 15GM B
NITROGLYCERIN/0.4GM/1TAB
NITROGLYCERIN/0.6MG/1TAB
NOVOLIN 70/30 10ML
NYSTATIN 15GM PWD TOP
PETROLATUM WHITE 30GM
PHENYLEPH 0.5% 15ML NAS S
PHISOHEX 5OZ
PILOCARPINE 4% 4GM OPGL
POVIDONE-IODINE 1% 118ML
PREPARATION-H 30GM
SELENIUM SUL 2.5% 120ML S
SILVER NITRATE APPLR (10)
LUBRIDERM LOTN 240ML
OCEAN NSL SPRY
SULFANILAMD 120GM VAG CRM
TAC 0.025% OINTMENT 80GM
TOLNAFTATE 1% 45GM PWDR
TRIAMCIN ACE 0.1% 60ML LO
TRIFLURIDINE 1% 8ML OPS
COAL TAR 1% 177ML SHAMP
KETOCONAZOLE 2% 120ML SHA
ACETIC ACID/HC 10ML OTIC

239940119.xlsx.ms_office

Price
49.00
32.00
23.00
24.00
184.00
37.00
38.00
32.00
30.00
67.00
36.00
48.00
24.00
26.00
37.00
58.00
48.00
37.00
29.00
63.00
38.00
38.00
30.00
51.00
29.00
22.00
22.00
52.00
58.00
23.00
18.00
37.00
52.00
30.00
29.00
38.00
22.00
29.00
24.00
58.00
28.00
28.00
81.00
130.00
30.00
27.00
53.00

$0 Indicator

Page 248 of 299

CDM #
6328983
6328991
6329023
6329031
6329049
6329064
6329072
6329080
6329098
6329106
6329114
6329122
6329148
6329155
6329163
6329171
6329189
6329221
6329239
6329247
6329254
6329270
6329288
6329296
6329304
6329312
6329361
6329387
6329403
6329411
6329429
6329437
6329445
6329452
6329486
6329502
6329510
6329528
6329536
6329544
6329551
6329569
6329577
6329585
6329619
6329635
6329643

CDM Description
ACETYLCHOLINE 1% 2ML OPS
ANTIPYRINE/BENZOC 15ML OT
ATROPINE 1% 5ML OP SOL
ATROPINE 1% 2ML OP SOL
BETAXOLOL 0.25% 5ML OPSOL
CARBAMIDE PEROX 15ML OTIC
CROMOLYN 4% 10ML OPH SOL
CYCLOPENTOLATE 1% 5ML OPS
CYCLOPENTOLATE 1% 2ML OPS
CYCLOPENTOLATE 2% 2ML OPS
DIPIVEFRIN 0.1% 5ML OPS
CADEXOMER IODINE 40GM GEL
FLUOROMETH 0.1% 5ML OPS
FLURBIPROFEN 0.03% 2.5ML
GENTAMICIN 0.3% 5ML OPS
HOMATROPINE/5/5ML/OPTH
HOMATROPINE/2/5ML/OPTH
LEVOBUNOLOL 0.5% 5ML OPS
LEVOBUNOLOL 0.5% 10ML OPS
METHYCELLULOSE/15ML A
METHYCELLULOSE/15ML B
NAPHAZOLINE 0.1% 15ML OPS
NAPHAZOLINE/ANTAZ 15ML OP
NAPHAZOLINE/PHENIR 15ML O
NEO-POLYMIXIN-DEXAMETHASO
NEOMYCIN-GRAMICID-POLYMIX
PHENYLEPH 2.5% 5ML OP SOL
PHENYLEPH 0.5% 15ML NAS D
PHENYLEPH 10% 5ML OP SOL
PILOCARPINE 2% 15ML OPS
PILOCARPINE 1% 15ML OPS
PILOCARPINE 4% 15ML OPS
PILOCARPINE HCL/6PC/15ML
PILOCARPINE 0.5% 15ML OPS
PREDNISOLONE ACETATE/1PC/
PREDNISOLONE ACETATE/0.12
PROPARACAIN 0.5% 15ML OPS
SCOPOLAMINE 0.25% 5ML OPS
SOD CHLORIDE-CAL SALT-POT
SODIUM-CALCIUM-MAG-K SALT
SODIUM CHLORIDE/5PC/15ML
SULFACETAMIDE/PREDNSL 5ML
SULFACETAMIDE 10% 15ML OP
SULFACETAMIDE 10% 5ML OPS
TIMOLOL 0.25% 5ML OP SOL
TIMOLOL 0.5% 5ML OP SOL
TIMOLOL 0.5% 10ML OP SOL

239940119.xlsx.ms_office

Price
68.00
29.00
33.00
28.00
60.00
28.00
53.00
38.00
29.00
29.00
71.00
96.00
48.00
43.00
33.00
38.00
37.00
51.00
72.00
36.00
33.00
38.00
38.00
38.00
49.00
38.00
33.00
28.00
18.00
36.00
36.00
37.00
38.00
36.00
37.00
38.00
37.00
33.00
30.00
36.00
30.00
38.00
38.00
36.00
49.00
53.00
83.00

$0 Indicator

Page 249 of 299

CDM #
6329650
6329668
6329676
6329684
6329700
6329726
6329742
6329759
6329767
6329783
6329791
6329817
6329825
6329833
6329890
6329908
6329916
6329924
6329932
6329940
6329957
6329981
6329999
6330021
6330039
6330047
6330062
6330088
6330096
6330112
6330120
6330138
6330146
6330153
6330161
6330179
6330187
6330211
6330229
6330245
6330260
6330286
6330294
6330302
6330310
6330328
6330344

CDM Description
TOBRAMYCIN 0.3% 5ML OPS
TRIETHANOLAM 10% 6ML OTO
TROPICAMIDE 0.5% 15ML OPS
TROPICAMIDE 1% 15ML OPS
MICONAZOLE 200MG 3 VAG
ORTHO-NOVYM 1/35 #28
LO/ORVAL #21
ORVAL #21
CA CARB 500MG CH TAB(ROLL
KETOCONAZOLE 2% 30GM CRM
LEVOBUNOLOL 0.25% 5ML OPS
EMOLLIENT 240ML TOP
TROLAMINE 10% 85GM TOP
BENZOCAINE 20% 60ML SPRY
BENZOCAINE 7.5% 9.45GM GE
ALCLOMETAS 0.05% 15GM CRM
SELENIUM SUL 1% 207ML SHA
CLINDAMYCIN TOP 60ML SOL
AVEENO OATMEAL BATH PKT
TOBRAM/DEX 0.3/0.1% 2.5ML
TOBRAMYCIN 3% 3.5GM OP ON
PERMETHRIN 5% 60GM CRM
METIPRANOLOL 0.3% 5ML OPS
CIPROFLOXAC 0.3%2.5ML OPS
POLYMYXIN/TRIMETH 10ML OP
CIPROFLOXACIN 0.3% 5ML OP
DICLOFENAC 0.1% 2.5ML OPS
BUTORPHANOL 2.5ML NAS SPR
CLINDAMYCIN 2% 40GM VAG
ZINC OXIDE 40% TOP
BETAMETH DIP 0.05 15GM CR
EXTRAOCULAR IRR 15ML OPS
DESONIDE 0.05% 15GM CRM
APRACLONIDIN 0.5% 5ML OPS
MICONAZOLE NIT 2% 60GM
BRIMONIDINE 0.2% 5ML OPS
BRIMONIDINE 0.15% 5ML OPS
MOXIFLOXACIN 0.5% OP SOL
KETOTIFEN 0.025% OPH
DOCOSANOL 10% 2GM TOP
PIMECROLIMUS 1% 30CR
LOTEPREDNOL0.5%OPTHSUS5ML
NYSTATIN 30GM CRM
OXYBUTYNIN 3.9MG PATCH
GATIFLOXACIN 0.3% 5ML OPS
DESMOPRESS 0.1MG 5ML NAS
NYSTATIN 15GM OINT

239940119.xlsx.ms_office

Price
38.00
30.00
53.00
58.00
26.00
52.00
62.00
64.00
22.00
63.00
46.00
28.00
29.00
26.00
26.00
36.00
24.00
29.00
29.00
32.00
51.00
43.00
33.00
37.00
51.00
54.00
54.00
116.00
75.00
28.00
58.00
28.00
33.00
77.00
26.00
52.00
122.00
43.00
20.00
37.00
8.00
81.00
8.00
27.00
129.00
228.00
43.00

$0 Indicator

Page 250 of 299

CDM #
6330385
6330401
6330419
6330427
6330476
6330492
6330526
6330534
6330567
6330583
6330609
6330617
6330625
6330633
6330658
6330666
6330674
6330682
6330690
6330708
6330716
6330732
6330740
6330757
6330773
6330781
6330815
6330823
6330856
6330864
6330872
6330880
6330898
6330914
6330922
6330948
6330955
6330989
6330997
6331011
6331037
6331045
6331060
6331078
6331086
6331094
6331110

CDM Description
ATROPINE 1% 15ML OP SOL
PHENYLEPH 0.25% 30ML NAS
BETAMETH VAL 0.1% 60ML LO
PRED FORTE OPH SUSP 10ML
FLUORESCEIN 1MG STRIP
ALLAN/CAMPHOR/PHENOL 6MG
LIDOCAINE 5% OINT 35GM
LANOLIN 30GM
ALBUTEROL 90MCG 6.7GM INH
TERCONAZOLE 0.4% 45GM VAG
TOBRAM/DEX 0.3/0.1% 5ML O
TERBINAFINE 1% 30GM TOP
VIT E 60GM CRM
DIPHENHYD 2% 30GM CRM
OFLOXACIN 0.3% 5ML OP SOL
COLLAGENASE 15GM OINT
COLLAGENASE 250U/GM 30GM
DIPHENHYDRAM 1% 30GM TOP
PRAMOXINE/HC 1% 10GM FOAM
MOMETASONE 0.1% 15GM CRM
CAPSAICIN 0.025% 60GM CRM
PORIDONE/IODINE 10% 240ML
HYDROGEN PEROXIDE 3% 240M
FLUTICASONE NSL SPRY 16GM
DORZOLAMIDE 2% 5ML OPSOL
SODIUM CHLORIDE 2PC/15ML
METRONIDAZ 0.75% 70GM VAG
PRAMOXINE/HC 1% 30GM TOP
TIMOLOL 0.5% 2.5ML OP GEL
TIMOLOL 0.5% 5ML OP GEL
PETROLATUM 49.8% PAST 42G
LATANOPROST 2.5ML OP SOL
BETAMETH DIP 0.05 45GM CR
MAFENIDE ACET 8.5% CR 57G
BENZOCAINE 10% 6GM GEL
ZINC OXIDE 71GM TOP
IPRATROPIUM 0.03% 30ML NA
FLUTICASONE 110MCG INH 13
FLUOROMETH 0.25% 5ML OPS
CALCITONIN 200IU 2ML NAS
IPRATROPIUM 0.06% 15ML NA
PENCICLOVIR 1% 1.5GM TOP
CALCIPOTRIENE 0.005% 60GM
CALCIPOTRIENE 0.005% 60GM
KETOROLAC .5% OPHT 10ML
KETOROLAC 0.5% 5ML OP SOL
UREA 20% 90GM TOP

239940119.xlsx.ms_office

Price
26.00
18.00
36.00
60.00
15.00
24.00
37.00
24.00
26.00
58.00
55.00
89.00
25.00
2.00
51.00
63.00
105.00
2.00
29.00
81.00
54.00
32.00
22.00
86.00
48.00
28.00
60.00
52.00
37.00
60.00
26.00
78.00
81.00
48.00
8.00
32.00
72.00
97.00
43.00
100.00
62.00
49.00
210.00
76.00
110.00
71.00
28.00

$0 Indicator

Page 251 of 299

CDM #
6331136
6331144
6331151
6331169
6331185
6331193
6331201
6331219
6331227
6331235
6331243
6331250
6331276
6331284
6331300
6331318
6331326
6331334
6331342
6331359
6331375
6331383
6331508
6331540
6331557
6331565
6331581
6331599
6331607
6331615
6331623
6331631
6331649
6331656
6331664
6331680
6331714
6331722
6331748
6331755
6331763
6331771
6331789
6331805
6331821
6331839
6331847

CDM Description
HYDROCORTISONE CR 1% 30GM
PAPAIN UREA 30GM OINT
FLUTICASONE 220MCG 12GM
MENTHOL ZINC OXIDE 71GM
MOMETASONE 17GM NAS SPRY
PHENYLEPH 2.5% 2ML OP SOL
SOD POLYSTYR 15GM SUS PED
BECAPLERMIN 15GM GEL
MINERAL OIL 133ML ENEMA
BUDESONIDE 200MCG DPI PWD
ALBUTEROL/IPRAT 14.7GM IH
FLUTICASONE 44MCG 13GM
BUDESONIDE 32MCG 8.6GM NA
TRIAMCIN ACE 16.5GM NAS
DORZOLAMIDE/TIMOLOL 10ML
OFLOXACIN 3% 5ML OTIC SOL
CIPROFLOXACIN/HC 10ML OTI
PERMETHRIN 60ML LIQ
CALCIPOTR 0.005% 60ML TOP
MICONAZOLE 2% 90GM PWDR
MENTHOL/CAMPHOR 222ML LOT
BRINZOLAMIDE 1% 5ML OPS
NTG 0.4MG SPRAY 14.49GM
OLOPATADINE 0.1% 5ML OPS
MUPIROCIN 2% 22GM OINT
MUPIROCIN 2% 15GM CRM
SALMETEROL 28 DPI
PIRBUTEROL 0.25MGINH 14GM
HYDROCORT AC 1% OINT 21GM
BECLOMETH 40MCG 7.3GM MDI
BECLOMETH 80MCG 7.3GM MDI
FLUTIC/SALM 100/50 28 INH
FLUTIC/SALM 250/50 28 INH
FLUTIC/SALM 500/50 28 INH
BUDESONIDE 0.5MG 2ML INH
MEPRON 750MG/5ML SUS
ALBUTEROL HFA 8.5GM INH
FENTANYL 12MCG PATCH
CIPROFLOX HC/DEX 7.5ML OT
ACETYLCYST 10% 4ML INHSOL
CYCLOSPORINE 0.05% OPEMOL
TORBRAMCYIN 60 MG/ML INH
CYCLOPENT/PHENYL 2ML OPS
MICONAZOLE 2% 28GM PWD
TRYPS/BALS/CASTO OINT 60G
TESTOSTERONE 1% 2.5GM TOP
PHENYLEPH 1% 15ML NAS SPR

239940119.xlsx.ms_office

Price
14.00
95.00
140.00
25.00
89.00
18.00
35.00
1,663.00
21.00
167.00
71.00
83.00
70.00
67.00
74.00
63.00
101.00
32.00
138.00
23.00
29.00
49.00
59.00
95.00
66.00
55.00
115.00
91.00
25.00
71.00
85.00
156.00
191.00
253.00
19.00
59.00
86.00
36.00
209.00
15.00
15.00
160.00
20.00
21.00
133.00
20.00
26.00

$0 Indicator

Page 252 of 299

CDM #
6331896
6332191
6332209
6332217
6332241
6332258
6332266
6332308
6332324
6332332
6332340
6332357
6332373
6332399
6332407
6332415
6332423
6332431
6332464
6332472
6332522
6332530
6332548
6332555
6332563
6332571
6332589
6332597
6332605
6332621
6332647
6332654
6332662
6332670
6332688
6332696
6332704
6332753
6332761
6332779
6332803
6332811
6332860
6332878
6332886
6332902
6332910

CDM Description
MEDICARE PART D NC
ACETAMIN 160MG/5ML 10ML
ACETAMIN 650MG/20.3ML SOL
CHARCOAL ACTIV 25GM 120ML
PAXIL 10MG/5ML SOL
BISMUTH 237ML SUSP
MISC ALCOHOLIC BEVERAGE
CHLOROTHIAZ 250MG/5ML 240
CHLORPROMAZN 50MG/ML 1ML
CIMETIDINE 300MG/5ML 5ML
CITRIC ACID/NA CIT 30ML
DIPHENHYD 12.5MG/5ML 5ML
DOCUSATE 100MG/10ML SOL
DOXEPIN 10MG/ML 1ML CONC
MEGACE ES
ERGOCALC 8000U/ML 60MLSOL
PEG-ELECTROLYTE 40000ML
ERYTHRO EST 250/5 5ML SUS
FERROUS GLU/300MG/5ML
FERROUS SULFATE/220MG/5ML
INDOMETHACIN 25MG/5ML 5ML
KAOLIN-PECTIN/30ML/SUSP
LOPERAMIDE 1MG/5ML 120ML
MAGNESIUM CITRATE 300ML
MAGNESIUM HYDROXIDE/30ML
MILES MIXTURE
MILK OF MAGNESIA/10ML/CON
MULTIVIT WO K 10ML INJ
CETIRIZINE 5MG/5ML 10ML
NITROFURANTOIN/50MG/10ML
PE-PHENYLPROP-BR-PHENIR
PENICIL VK 125MG/5ML 100M
PENICIL VK 250MG/5ML100M
PHENYTOIN 125MG/5ML 120ML
POLYSTYRENE SODIUM SULF
POTASSIUM CHLORIDE/20MEQ
POTASSIUM CHLORIDE/40MEQ
VANCOMYCIN 50MG/ML 5ML
FLEET PHOSPHO-SODA
SORBITOL 70% 30ML SOL
THEOPH 80MG/15ML 120ML EL
SULFAMET/TMP 200/40MG/5ML
RANITIDINE 15MG/ML 10ML
DEXTROMETHOR 30MG/5 90ML
IBUPROFEN SUSP 200MG
DIPHENHYD 12.5MG/5ML 10ML
ACYCLOVIR 200MG/5ML 5ML

239940119.xlsx.ms_office

Price
9.00
2.00
29.00
12.00
29.00
1.00
30.00
9.00
2.00
9.00
2.00
2.00
9.00
43.00
8.00
83.00
9.00
9.00
2.00
9.00
9.00
9.00
10.00
10.00
9.00
9.00
9.00
8.00
9.00
9.00
9.00
9.00
9.00
52.00
9.00
9.00
12.00
6.00
9.00
24.00
9.00
29.00
9.00
2.00
2.00
20.00

$0 Indicator
S

Page 253 of 299

CDM #
6332928
6332936
6332951
6332977
6332985
6333017
6333025
6333033
6333058
6333066
6333074
6333082
6333116
6333124
6333132
6333181
6333207
6333249
6333256
6333272
6333298
6333306
6333314
6333363
6333371
6333389
6333397
6333405
6333462
6333470
6333488
6333496
6333512
6333520
6333538
6333553
6333579
6333603
6333611
6333645
6333652
6333660
6333686
6333694
6333702
6333710
6333728

CDM Description
FLUOXETINE 20MG/5ML 5ML
PREDNISOL 5MG/5ML 5ML SYR
PROCHLORPERAZINE 5MG/5ML
CITRIC ACID/NA CIT 15ML
AMPICILLIN 125/5 100ML SU
SUCRALFATE 1GM/10ML 10ML
MEGESTROL 40MG/ML 2ML SU
PROMETHAZI 6.25MG/5ML 10M
CHARCOAL ACTIV 50GM 240ML
CHARCOAL ACTIV SORB 50GM
WINE 6OZ
LAMIVUDINE 10MG/ML 20ML
LOPERAMIDE 1MG/5ML 10ML
PHENYTOIN 100MG/4ML
FUROSEMIDE 40MG/5ML UD
MAALOX ES 30ML
AMOX/CLAV 250/5 150ML SUS
CEFUROXIME 125/5 100ML SU
AZITHROMYCIN 200/5 5ML SU
MAGIC MOUTHWASH 5ML
DICYCLOMINE 10MG/5ML 5ML
GLUCOSE 40% 37.5GM GEL
BUDESONIDE 0.25MG 2ML INH
AMOX/CLAV 200/5 5ML SUS
BACITRACIN 15GM OINT
BENZOCAINE 20% 9.45GM GEL
CYCLOSPOR MOD 100MG/1ML
CITALOPRAM 10MG/5ML 120ML
MINERAL OIL LT-STERILE 10
RIFAMPIN 300MG/30ML SUSP
NYSTATIN 5ML SUSP
VALPROIC 250MG/5ML 5ML
SENNA 5ML SYRUP
PYRIDOSTIG 60MG/5ML 5ML
PSEUD 30MG/5ML 30ML SYRP
PROMETHAZIN 6.25MG/5ML 5M
PREDNISONE SOL 5MG/5ML 5M
MINERAL OIL 30ML LIQ
METOCLOPRAMIDE 10MG/10ML
LACTULOSE/20GM/30ML/SYRP
CITRIC AC/K/NA CITRA 5ML
HYDROXYZINE 10MG/5ML
GUAIFENESIN/100MG/5ML/SYR
GUAIFENESIN DM/5ML
GUAIFEN SF 100MG/5 ML 5ML
GUAIFENESIN DM/10ML/LIQ
GUAIFENESIN 10ML

239940119.xlsx.ms_office

Price
29.00
9.00
9.00
9.00
9.00
9.00
10.00
9.00
28.00
30.00
1.00
32.00
9.00
9.00
9.00
10.00
12.00
9.00
26.00
9.00
9.00
14.00
22.00
30.00
10.00
23.00
15.00
10.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
2.00
2.00
2.00

$0 Indicator

Page 254 of 299

CDM #
6333751
6333777
6333785
6333827
6333843
6333850
6333868
6333884
6333892
6333918
6333934
6334015
6334049
6334056
6334064
6334072
6334080
6334098
6334106
6334114
6334122
6334155
6334163
6334189
6334205
6334213
6334221
6334247
6334262
6334296
6334312
6334346
6334403
6334429
6334445
6334486
6334510
6334577
6334585
6334635
6334643
6334700
6334726
6334734
6334767
6334775
6334783

CDM Description
GLYCERIN/30ML/LIQ
FERROUS SUL 300MG/5ML UD
FAMOTIDINE 40MG/5ML 5ML
CASTOR OIL 30ML LIQ
CARBAMAZEPINE 100/5 10ML
CA GLUBION 1.8GM/5ML 120M
AMANTADINE 50MG/5ML 1ML
ACETAMIN 80MG/0.8ML PEDP
ACETAMIN 160MG/5ML 120ML
AL HYDROX 600MG/5ML 360ML
AMOXICILLIN 125MG/5 80ML
ASCORBIC AC 100MG/ML SYRP
CEPHALEXIN 125/5 200ML SU
CEPHALEXIN 250/5 100ML SU
CEPHALEXIN 50MG/1ML PEDP
CLINDAMYCIN 75MG/5ML 100M
DEXAMETHASONE/0.5MG/0.5ML
DEXAMETH 0.5MG/5ML 5ML EL
DIGOXIN 0.05MG/ML 5ML ELX
FUROSEMIDE 10MG/ML 60ML
HALOPERIDOL/2MG/1ML/CONC
MAGNESIUM HYDROXIDE-AL HY
MAG HYDROX-AL HYDROX-SIME
MULTIVITAMINS 50ML
NYSTATIN 60ML SUSP
PEDIAZOLE SUSP 100ML
PENICIL VK 125MG/5ML 200M
PENICIL VK 250MG/5ML 200M
POTASSIUM IODIDE 1GM/1ML
SODIUM CARBOXYMETHYLCELLU
SIMETHICNE40MG/0.6ML 30ML
VIT E(TOCOPHER)50IU/ML 1M
AMOX/CLAV 125/5 150ML SUS
SULFAMET/TMP 200/40MG/5ML
CHLORHEXIDINE 120ML
NEO DEXAMETHASONE ORAL
AMOXICILLIN 250/5 5ML SUS
GUAIFEN/DM 100-10/5 120ML
LIDOCAINE VISC 2% 100ML
LACTULOSE 10G/15ML 473ML
MULTIVIT W MIN 240ML SOL
MULTIVIT THRAPEUTC 120ML
CHARCOAL ACTIV SORB 25GM
CEFUROXIME 250/5 50ML SUS
DOC NA 150MG/15ML 60ML
LUMIGAN 0.03% EYE DROPS
TRAVOPROST 0.004% 2.5MLOP

239940119.xlsx.ms_office

Price
9.00
2.00
33.00
9.00
9.00
26.00
9.00
2.00
22.00
30.00
28.00
36.00
38.00
60.00
97.00
51.00
48.00
23.00
29.00
38.00
52.00
10.00
10.00
36.00
62.00
61.00
26.00
26.00
30.00
29.00
43.00
48.00
26.00
26.00
26.00
23.00
30.00
2.00
26.00
51.00
28.00
24.00
30.00
93.00
2.00
444.00
150.00

$0 Indicator

Page 255 of 299

CDM #
6334791
6334809
6334817
6334833
6334841
6334874
6334882
6334890
6334908
6334916
6334924
6334932
6334940
6334965
6334973
6334999
6335012
6335020
6335038
6335046
6335061
6335079
6335087
6335103
6335111
6335129
6335137
6335145
6335152
6335160
6335178
6335186
6335194
6335202
6335210
6335228
6335244
6335251
6335269
6335277
6335285
6335293
6335301
6335319
6335327
6335368
6335376

CDM Description
PREDNISOL 15MG/5ML 5ML
METHADONE 10MG/ML 1ML CON
NEURONTIN 250/5ML SOL
CHLORHEXIDINE GLUC 15ML
AMOX/CLAV 600/5 5ML SUS
ACETAMIN 160MG/5ML 5ML EL
KEPPRA 100 MG/ML ORAL SLN
ZIDOVUDINE 10MG/ML PEDPO
OXYTOCIN 15UNITS PB
OXYTOCIN 20U LR 1000ML PB
D5% 0.45 NACL+KCL20 1000M
D5% 0.2 NACL+KCL20 1000ML
D5% LR 1000ML INJ
D5% 1/4 NS 500ML IV
NACL 0.9% 100ML INJ
WATER STERILE 100ML INJ
WATER STERILE 50ML INJ
STERILE WATER 500ML
D5% 0.9 NACL 1000ML INJ
D5% 0.9 NACL 500ML INJ
D5% 0.45 NACL 1000ML INJ
D5% 0.45 NACL 500ML INJ
D5% 0.2 NACL 1000ML INJ
D10% 1000ML INJ
D50% 500ML INJ
D20% 500ML INJ
D5% 250ML INJ
D5% 150ML INJ
D5% 1000ML INJ
D5% 500ML INJ
D70% 500ML INJ
D5% 100ML INJ
D5W 50ML
FAT EMULSION 10% 250ML IN
NACL 0.9% IL IRRG
NACL 0.9% 500MG IRRG
METRONIDAZOLE 500MG/100ML
LACTATED RINGERS 1000ML
LACTATED RINGERS 500ML
NACL 3% 500ML
NACL 0.9% 250ML INJ
NACL 0.45% 1000ML
NACL 0.9% 1000ML INJ
NACL 0.9% 500ML INJ
NACL 0.45% 500ML
DOPAMINE 400MG/250ML D5W
STERILE WATER 20ML/SYRING

239940119.xlsx.ms_office

Price
8.00
8.00
8.00
8.00
10.00
2.00
8.00
8.00
65.00
65.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
95.00
139.00
95.00
78.00
78.00
78.00
78.00
164.00
78.00
78.00
247.00
78.00
78.00
152.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
78.00
140.00
-

$0 Indicator

L
L
L

L
Page 256 of 299

CDM #
6335384
6335392
6335400
6335418
6335434
6335467
6335483
6335491
6335509
6335558
6335566
6335590
6335665
6335699
6335715
6335749
6335756
6335764
6335798
6335814
6335822
6335848
6335855
6335897
6335905
6335921
6335939
6335988
6335996
6336002
6336010
6336028
6336051
6336069
6336093
6336101
6336135
6336168
6336176
6336192
6336200
6336218
6336226
6336234
6336275
6336309
6336317

CDM Description
WATER STERILE 10ML INJ
D10% 500ML INJ
DEXTRAN 40 10%/D5 500ML
DEXTRAN 40 10%/NS 500ML
STERILE WATER IRR 250ML
ROPIVACAINE 2MG/ML 200ML
KCL 10MEQ 50ML INJ
KCL 20MEQ 100ML INJ
KCL 10MEQ 100ML INJ
DOPAMINE 800MG/500ML D5W
DOBUTAMINE 500MG/250ML PB
HEPARIN 1000U/500ML NS PB
MAGNESIUM SUL 1GM/100MLPB
ALPHA 1 PROT INHIB 10MG
LEVETIRACET 500MG/5ML INJ
NITROGLYCERIN/2.5MG/1CAP
MAGNESIUM OXIDE 400MG TAB
ESTRADIOL 0.1MG/24HR BIWK
METHACHOLINE 100MG/20ML
HEPARIN 5000U/0.5ML 0.5ML
CYCLOPENTOLAT 0.5%15ML OP
GRANISETRON PF 100MCG/ML
ZOLEDRONIC ACID 5MG/100ML
ALISKIREN 150MG TAB
APREPITANT 125MG CAP
CARVEDILOL SR 24HR 10MG C
CARVEDILOL SR 24HR 40MG C
PALONOSETRON 25MCG INJ
STREPTOMYCIN 1GM/2.5ML IN
EXENATIDE 250MCG/ML 2.4ML
EXENATIDE 250MCG/ML 1.2ML
CIDOFOVIR 75MG/ML 5ML INJ
VIT A 25000 IU CAP
INSULIN GLARGINE PEN
GONAK 2.5% OPHTHALMIC SOL
DESMOPRESS 0.1MG TAB
ADALIMUMAB 20 MG INJ
OXYCOD/APAP 10/325
DILTIAZEM 125MG/125ML PB
VANCOMYCIN 500MG INJ
CLOPIDOGREL 300MG TAB
SORAFENIB 200 MG TAB
BROMFENAC 0.09% 2.5ML OPS
AZITHROMYCIN 500MG TAB
PANTOPRAZOLE 40 MG PKT
RIVASTIGMINE 9.5MG/24HR
RIVASTIGMINE 4.6MG/24HR

239940119.xlsx.ms_office

Price
78.00
400.00
400.00
78.00
124.00
140.00
140.00
140.00
253.00
614.00
78.00
65.00
6.00
58.00
9.00
9.00
17.00
466.00
71.00
58.00
73.00
3,255.00
8.00
13.00
14.00
14.00
46.00
71.00
480.00
409.00
1,796.00
9.00
86.00
21.00
12.00
874.00
9.00
175.00
230.00
54.00
121.00
311.00
20.00
14.00
19.00
19.00

$0 Indicator
L

Page 257 of 299

CDM #
6336325
6336333
6336390
6336408
6336416
6336499
6336507
6336515
6336531
6336549
6336556
6336572
6336598
6336606
6336614
6336622
6336648
6336655
6336663
6336697
6336747
6336754
6336796
6336804
6336812
6336820
6336838
6336846
6336853
6336861
6336879
6336895
6336903
6336911
6336929
6336937
6336978
6337034
6337059
6337067
6337083
6337091
6337109
6337125
6337141
6337158
6337166

CDM Description
DEFARASIROX 250MG TAB SUS
PALIPERIDONE 3MG TAB
CEFPODOXIME 100MG TAB
MAGNESIUM SUL 4GM/100MLPB
DESOXIMETASONE 0.05% 15GM
ACARBOSE 25MG TAB
APAP/DIPHEN 500/25MG TAB
ACETIC ACID 0.25% 250ML
ACETIC ACID/HC 10ML OTIC
ACETYLCYST 10% 30ML INH
ACETYLCYSTEINE 600MG TAB
ACYCLOVIR 50MG/ML20ML INJ
ADENOSINE DX 3MG/ML 20ML
AGALSIDASE BETA 1 MG INJ
ALBENDAZOLE 200MG TAB
ALBUTEROL 2MG/5ML 5ML SYP
ALCOHOL DEHYDR 98% 5ML IN
ALENDRONATE 70MG/75ML SOL
ALENDRONATE 70MG TAB
MAG CAR/AL HYDR/ALGINC 30
ALUM/MAG HYDROX 200/200MG
AL HYDROX 320MG/5ML 30ML
AMIODARONE 5MG/1ML PEDPO
AMIODARONE 50MG/ML 18ML
AMLODIPINE 10MG TAB
AMLODIPINE 5MG TAB
AMLODIPI/BENAZPRL 5/20MG
AMLODIPI/BENAZPR 2.5/10MG
AMMONIUM LAC 5% 120ML LOT
AMOX/CLAV 400/5 100ML SUS
AMOX/CLAV 250MG/5ML SUS
AMOXICILLIN 400/5 50ML
AMOXICILLIN 400/5 100ML
AMPHET/DEXTROAMP 10MG TAB
CEFAZOLIN 2GM/100ML PB
TRIFLUOPERAZINE 1MG TAB
CHLOROPROCAINE 2% 20ML IN
AMYL/LIPASE/PRO 48/16/48
AMYL/LIPASE/PRO 65/20/65
AMYL/LIPASE/PRO 60/16/60
ANESTH SPRAY 105ML TOP
ACETAMIN/ISOMETHEP/DICHLO
ARIPIPRAZOLE 5MG TAB
VIT C(ASCORB ACID) 1000MG
VIT C(ASCORB ACID) 500MG
ATAZANAVIR SUL 200MG CAP
ATROPINE 0.1MG/ML 5ML INJ

239940119.xlsx.ms_office

Price
75.00
33.00
17.00
58.00
36.00
9.00
2.00
25.00
48.00
124.00
8.00
642.00
320.00
232.00
9.00
9.00
72.00
70.00
53.00
2.00
2.00
9.00
9.00
300.00
12.00
12.00
12.00
12.00
38.00
50.00
45.00
20.00
40.00
13.00
58.00
9.00
71.00
9.00
9.00
9.00
20.00
9.00
28.00
2.00
2.00
41.00
71.00

$0 Indicator

Page 258 of 299

CDM #
6337182
6337216
6337224
6337232
6337257
6337331
6337349
6337356
6337372
6337380
6337406
6337422
6337430
6337455
6337463
6337497
6337513
6337547
6337554
6337570
6337596
6337604
6337612
6337661
6337687
6337703
6337711
6337729
6337745
6337752
6337760
6337810
6337851
6337877
6337885
6337893
6337901
6337919
6337950
6337976
6337984
6337992
6338040
6338057
6338099
6338107
6338115

CDM Description
AZACITIDINE 100MG INJ
BACITRACIN 120GM TOP
BACITRACIN 454GM OINT
BACITRA/POLY B 15GM TOP
BALANCED SALT 500ML OP IR
MICONAZOLE NIT 2% 1GM PWD
BELLAD/PB 16.2MG/5ML ELX
BELLAD/PB 16.2MG/5ML ELX
BELLADON ALK/PB 16.2MGTAB
BENAZEPRIL 20MG TAB
BENZOCAINE 7.5% 9.45GM GE
BENZOCAINE 20% 5GM PASTE
BENZOCAINE 20% 13.3ML TOP
BENZOC/TETRA/BUT 2-2-14%
BENZOCA/CETYL 13.3ML SOL
BETAMETH DIP 0.05 45GM CR
BETAXOLOL 0.25% 2.5ML OPS
BRIMONIDINE 0.15% 10ML OP
BROMFENAC 0.09% 5ML OPS
BROM/DM/PSEUDO 120ML SYRP
BUPIVAC/EPI PF 0.25% 10M
BUPIVAC/EPI 0.5% 10ML INJ
BUPIVACAIN MPF 0.25% 10ML
CA CARB/VIT D 250/125MG
CALCITRIOL 1MCG/ML 15ML
CA CARB 1250MG/5ML 500ML
CA CARB 1250MG/5ML 5MLSUS
CA CARB 684MG TAB
CA CITRAT/VIT D 200/200MG
CA CARB/VIT D 315/200MG
CA CITRATE 200MG TAB
CANDESARTAN 4MG TAB
CARBAMAZEPINE 12HR 200MG
CARBIDOPA 25MG TAB
CARBD/LEV/ENT37.5/150/200
CARBOXYMETHYL 1% 0.3ML OP
CARDIOPLEGIC 1000ML IV SO
CARTEOLOL 1% 5ML OP SOL
CEFAZOLIN 250MG INJ
CEFTAZIDIME 500MG PWD INJ
CEFTRIAXONE 2GM 50ML PB
CEPHALEXIN 250MG CAP
CHLORHEXIDINE 0.12%
CHLORHEXIDINE 4% 960ML
HEPARIN 1000UNIT/ML 4ML
CHLOROQUINE 250MG TAB
VIT D(CHOLECALCIF) 1000IU

239940119.xlsx.ms_office

Price
1,100.00
28.00
106.00
8.00
128.00
30.00
8.00
9.00
8.00
9.00
9.00
9.00
9.00
9.00
9.00
58.00
60.00
210.00
390.00
28.00
71.00
71.00
71.00
8.00
9.00
30.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
12.00
9.00
35.00
57.00
75.00
142.00
432.00
36.00
9.00
35.00
71.00
11.00
9.00

$0 Indicator

Page 259 of 299

CDM #
6338123
6338156
6338172
6338180
6338198
6338214
6338230
6338263
6338271
6338305
6338321
6338339
6338362
6338370
6338388
6338396
6338404
6338412
6338420
6338446
6338453
6338479
6338495
6338511
6338537
6338545
6338552
6338578
6338586
6338602
6338610
6338636
6338644
6338727
6338743
6338750
6338768
6338784
6338792
6338818
6338826
6338834
6338883
6338909
6338925
6338933
6338941

CDM Description
VIT D(CHOLECALCIF) 400IU
CITALOPRAM 10MG TAB
CHLOROPROCAINE 3% 30ML IN
CISATRACURIUM 10MG/ML 20M
CLINDAMYCIN 150MG/ML 2ML
CIPROFLOXACIN 3.5GM OP OI
CHLORPHENIR 2MG/5ML 118ML
CIPROFLOX 5GM/100ML SUSP
CIPROFLOX 10GM/100ML SUSP
COSYNTR(CORTROSYN) 0.25MG
CROTAMITON 10% 60GM CRM
VIT B12(CYANOCBA) 2500MCG
CYCLOSPOR MOD 100MG/ML 50
CYCLOSPORINE 25MG CAP
CYCLOSPORINE 100MG CAP
D10% 0.45 NS 1000ML INJ
D10% 0.9 NACL 1000ML INJ
D5% 0.45 NACL+KCL10 500ML
D5% 0.2 NACL+KCL10 1000ML
D5% 0.9 NACL+KCL40 1000ML
D5% LR+KCL 20MEQ 1000ML
CIMETIDINE 200MG TAB
DELAVIRDINE 100MG TAB
DESMOPRESS 0.2MG TAB
DEXAMETH 1MG/ML 10ML ELX
DEXAMETH 0.1MG/ML 100ML
D10% 250ML INJ
D5%+KCL 10MEQ 1000ML INJ
D5%+KCL 30MEQ 1000ML INJ
D5% 25ML INJ
D50% 50ML INJ
D70% 1000ML INJ
DIALYSIS 1.5% 1500ML SOL
CLOZAPINE 100MG TAB
CLOZAPINE 25MG TAB
COENZYME Q10 50MG CAP
COENZYME Q10 30MG CAP
COCAINE 4% 10ML SOL
CODEINE SULF 15MG TAB
APAP/COD 120-12MG/5ML 15M
APAP/COD 120-12MG/5ML 5ML
APAP/CAFF/BUT/COD 30 MG
COLISTIMETHATE 150MG INJ
CLOTRIMAZOLE 2% 21GM VAG
COAL TAR 5% 85GM GEL
AMLODIPINE 1MG/1ML PEDPO
NEO LEVOCARN ORAL

239940119.xlsx.ms_office

Price
9.00
12.00
71.00
518.00
58.00
138.00
25.00
288.00
325.00
150.00
77.00
9.00
600.00
8.00
17.00
65.00
65.00
65.00
65.00
65.00
65.00
8.00
9.00
15.00
9.00
9.00
65.00
65.00
65.00
78.00
58.00
65.00
65.00
20.00
20.00
8.00
8.00
108.00
9.00
9.00
8.00
8.00
58.00
27.00
15.00
9.00
30.00

$0 Indicator

Page 260 of 299

CDM #
6338958
6338966
6338974
6338982
6338990
6339006
6339014
6339022
6339030
6339048
6339055
6339063
6339071
6339089
6339097
6339105
6339113
6339121
6339139
6339147
6339154
6339162
6339170
6339188
6339196
6339204
6339212
6339220
6339238
6339246
6339253
6339261
6339279
6339287
6339295
6339303
6339311
6339329
6339337
6339345
6339352
6339360
6339378
6339386
6339394
6339402
6339410

CDM Description
NEO METORPOLOL ORAL
NEO CALC GLUB ORAL
MORPHINE 0.4MG/ML PEDO
NYSTATIN 100000UN/1MLPEDP
ENALAPRIL 1MG/1ML PEDPO
NEO VANCOMYCIN ORAL
NEO NEUTRAPHOS ORAL
NEO PROPRANOLOL ORAL
NEO SOD BICARB ORAL
NEO SOD CHLORI ORAL
NEO PIPERACILL/TAZO INJ
KCL 2MEQ/ML PEDPO
NEO CHLORAL HYD ORAL
ACYCLOVIR 5MG/ML 60ML PED
NEO AMINOPHYLLINE INJ
NEO AMPHOTERICIN B INJ
AMPICILLIN 100MG/5ML PEDI
AMPICILLIN 30MG/ML PEDIV
CALCIUM GLUC 50MG/ML PEDI
DIGOXIN 25MCG/ML 1MLPEDIV
NEO FUROSEMIDE INJ
NEO HYDRALAZINE INJ
NEO METHYLPREDISOL NA INJ
NEO MIDAZOLAM INJ
NEO NAFCILLIN INJ
NEO PENICILLIN G K INJ
VANCOMYCIN 5MG/ML PEDIV
RANITIDINE 1MG/ML PEDIV
ADENOSINE 300MCG/1ML PEDI
ALBUMIN 25% 250MG/ML PEDI
ALBUMIN 5% 50MG/ML PEDIV
NEO AMIODARONE INJ
NEO FILGRASTIM INJ
NEO FILGRASTIM 50 INJ
NEO FLUMAZENIL
NEO FOSPHENYTOIN
NEO IMIPENEM/CILISTAT
AMIKACIN 5MG/ML 30ML PEDI
NEO AMPHO B LIP 2MG/ML
NEO CAFFEINE INJ
CEFAZOLIN 20MG/ML PEDIV
NEO CEFEPIME
CEFOTAXIME 40MG/1ML PEDIV
CEFTAZIDIME 40MG/2.5MLPED
CEFTRIAXONE 40MG/ML PEDIV
NEO CIMETIDINE INJ
NEO CLINDAMYCIN INJ

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
145.00
9.00
9.00
35.00
58.00
150.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
150.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00

$0 Indicator

Page 261 of 299

CDM #
6339428
6339436
6339444
6339451
6339469
6339477
6339485
6339493
6339501
6339519
6339527
6339535
6339543
6339550
6339568
6339576
6339584
6339592
6339600
6339618
6339626
6339634
6339642
6339667
6339675
6339683
6339691
6339709
6339717
6339725
6339766
6339774
6339790
6339808
6339816
6339832
6339840
6339857
6339865
6339873
6339881
6339899
6339915
6339923
6339964
6339972
6339980

CDM Description
NEO ERYTHROMYCIN INJ
FENTANYL 10MCG/ML PEDIV
NEO GANCICLOVIR
GENTAMICIN 2MG/ML PEDIV
HYDROCORT NA 1MG/ML PEDIV
INDOMETHACIN 0.1MG/1MLPED
NEO AMPHO B LIP 1MG/ML
NEO LORAZEPAM INJ
NEO METOCLOPRAMIDE INJ
NEO PENTOBARBITAL INJ
PHENOBARB 5MG/ML PEDIV
NEO PHENYTOIN INJ
NEO PIPERACILLIN
NEO REG INSULIN
NEO TOBRAMYCIN PEDIV
NEO VERCURONIUM
NEO VIT A 50K U/ML
NEO ZIDOVUDINE INJ
NEO MED CHAIN TRIGLY
NEO CALCITRIOL INJ
NEO CAL GLU 100MG/ML
NEO FLUCONAZOLE INJ
FOLIC AC 100MCG/ML PEDIV
NEO SOD BICARB 4.2
NEO TMP 16/SMX 80 INJ
NEO TROMETHAMINE
NEO HEP PF 0.5U/ML 50ML
NEO HEP PF 1U/ML 50ML
NEO HEP PF 10U/ML 3ML
NEO HEP PF 100U/ML 5ML
DILTIAZEM CD 300MG CAP
DILTIAZEM CD 360MG CAP
DIPHENHYDRAMINE 500MG INJ
ATROPINE/DIPHENOX 10ML LI
DIPH/TET/PERTUS 0.5ML PF
DISULFIRAM 500MG TAB
DOBUTAMINE 1GM/250ML PB
DOCETAXEL 40MG/ML 2ML INJ
DOLASETRON 100MG TAB
DOPAMINE 200MG/250ML D5W
DOPAMINE 40MG/ML 10ML INJ
DORZOLAMIDE 2% 10ML OPS
DOXEPIN 5% 45GM CREAM
VIT D(DOXERCALCIF) 2.5MCG
DOXYCYCLINE 200MG INJ
DOXYCYCLINE 25MG/5ML 60ML
ECONAZOLE NIT 1% 15GM TOP

239940119.xlsx.ms_office

Price
58.00
58.00
58.00
58.00
58.00
58.00
150.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
17.00
20.00
20.00
9.00
58.00
15.00
75.00
1,500.00
75.00
58.00
25.00
193.00
175.00
48.00
58.00
9.00
45.00

$0 Indicator

Page 262 of 299

CDM #
6340004
6340012
6340020
6340111
6340137
6340145
6340152
6340160
6340178
6340186
6340194
6340202
6340228
6340236
6340244
6340251
6340277
6340285
6340293
6340376
6340392
6340418
6340426
6340475
6340525
6340533
6340608
6340681
6340699
6340715
6340723
6340731
6340756
6340764
6340780
6340806
6340814
6340822
6340848
6340855
6340863
6340871
6340889
6340921
6340947
6340954
6340962

CDM Description
EDROPHONIUM 10MG/ML 15ML
EFAVIRENZ 200MG CAP
ELETRIPTAN 20MG TAB
VIT D2(ERGOCAL)500000IU/M
ERYTHRO ETHYL 200/5 120ML
ERYTHRO ETHYL 200/5 200ML
ERYTHRO ETHYL 200/5 60ML
ERYTHRO ETHYL 400/5 5ML
ERYTHROMYCIN 2% 60ML TOP
ERYTHRO BASE EC 250MG TAB
ERYTHRO BASE DR 500MG TAB
ERYTHRO BASE 500MG TAB
ESMOLOL 10MG/ML 250ML INJ
ESTRADIOL 0.075MG/24 BIWK
ESTRADIOL 0.01% 42.5GM VA
ESTRADIOL 1MG TAB
CONJ ESTRO/MEDROX 0.625/5
ESTRG CONJ/M-PROG0.45/1.5
ETANERCEPT 25MG/0.5ML
ETHYL CHLORIDE SPRY
ETODOLAC XL 400MG TAB
FLAVOCOXID 250 MG CAP
MITOTANE 500MG TAB
AMOXICILLIN 125/5 100ML
DACTINOMYCIN 0.5MG PWD IN
CICLOPIROXOLAMINE 1% 30GM
FLUOROURACIL 5% 25GM
FAMOTIDINE 40MG/5ML 50ML
FAT EMULSION 20% 200ML IN
FENOFIBRATE 130 MG CAP
FENOFIBRATE 134 MG CAP
FENOFIBRATE 43 MG CAP
FENOLDOPAM 10MG/ML 2ML IN
FENTANYL 100MCG LOZ
FERRIC SUBSULF 500ML SOL
FE SULF 300MG/5ML 50ML EL
FERROUS SULF 325MG TAB
FINASTERIDE 1MG TAB
FISH OIL 1000MG CAP
FLUCONAZOLE 100MG 50ML NS
FLUCONAZOLE 40MG/ML 1ML
FLUMAZENIL 0.1MG/ML 1ML I
FLUOCINOLONE 0.01% 120ML
FLUOROMETH 0.1% 10ML OPS
FLUOROURACIL 50MG/ML 10ML
FLUOROURACIL 5% 40GM CRM
FLUOXETINE 10MG TAB

239940119.xlsx.ms_office

Price
58.00
20.00
60.00
58.00
18.00
24.00
12.00
24.00
25.00
9.00
9.00
9.00
275.00
30.00
125.00
9.00
9.00
9.00
433.00
25.00
9.00
8.00
12.00
29.00
1,007.00
52.00
85.00
9.00
116.00
9.00
9.00
9.00
58.00
9.00
25.00
18.00
2.00
9.00
9.00
58.00
9.00
27.00
60.00
115.00
6.00
325.00
9.00

$0 Indicator

Page 263 of 299

CDM #
6340970
6341028
6341036
6341044
6341051
6341077
6341085
6341093
6341119
6341150
6341168
6341192
6341200
6341218
6341234
6341259
6341283
6341291
6341317
6341325
6341358
6341382
6341390
6341416
6341432
6341440
6341465
6341473
6341499
6341515
6341523
6341549
6341556
6341572
6341598
6341622
6341630
6341648
6341663
6341671
6341689
6341697
6341705
6341721
6341739
6341747
6341754

CDM Description
FLUOXETINE 20MG/5ML 30ML
FLUPHENAZINE DECA 5ML INJ
FLUPHENAZINE ENA 1ML INJ
FLUVASTATIN 40MG CAP
FOLIC ACID 0.05MG/ML SOL
FA-B12-B6 TAB
FONDAPARINUX 7.5MG/0.6ML
FULVESTRANT 25MG
GALANTAMINE 12MG TAB
GENTAMICIN 5MG/1ML PEDIV
GENTAMICIN 100MG/100ML PB
GENTAMICIN 0.3% 1ML OPS
GENTAMICIN 60MG/100ML PB
GENTAMICIN 80MG/50ML PB
GI COCKTAIL 50ML
GLUTAMINE 10GM PK
GOSERELIN ACET 10.8MG INJ
GUAIF/DM SUGAR-FR 120ML
GUAIFEN 100MG/5ML 15ML SY
GUAIFEN 100MG/5ML 15ML SF
GUAIFEN/PSEUD 400/120MG
HYDROCOD/GUAIFEN 5ML SYRP
GUANFACINE 2MG TAB
HALOPERIDOL 2MG/ML 7.5ML
HALOPERIDOL 5MG/2.5ML PED
HALOPERIDOL 100MG/ML 1ML
HEPARIN FLUSH 10/ML 2.5ML
HEPARIN FLUSH 250UN/2.5ML
HEPARIN 2000U/1000ML PB
HEPARIN PF 10U/ML 10ML IN
HEPARIN FLUSH 100U/1ML
HEPAT B IMM GLOB 0.5ML IM
HEPAT B VACC 0.5ML INJ
HYALURONIDS OVINE 200U/ML
HYDROCORT 1% 120ML TOP
HYDROCORT 2.5% 20GM CRM
HYDROCORT 2.5% 20GM OINT
HYDROCORT BUTYR 0.1% 15GM
HYDROCORT VAL 0.2% 15GM
HYDROMORPHONE 10MG/ML 1ML
HYDROMORPHONE 10MG/ML 5ML
HYDROMORPHON 0.2/ML 100ML
HYDROMORPHONE 1MG/ML 30ML
HYDROXYZINE 25MG/ML 1ML
HYDROXYZINE 50MG/ML 1ML
HYOSC/MET/MBLU/PHEN SAL
HYOSCYAMINE SL 0.125MG

239940119.xlsx.ms_office

Price
30.00
75.00
58.00
9.00
9.00
9.00
230.00
159.00
9.00
58.00
110.00
35.00
110.00
110.00
45.00
25.00
1,446.00
18.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
58.00
71.00
71.00
78.00
71.00
71.00
243.00
78.00
78.00
18.00
15.00
15.00
75.00
35.00
78.00
78.00
78.00
78.00
78.00
78.00
9.00
9.00

$0 Indicator

Page 264 of 299

CDM #
6341762
6341770
6341788
6341812
6341820
6341838
6341846
6341895
6341903
6341929
6341937
6341945
6341952
6341960
6342026
6342042
6342075
6342091
6342109
6342117
6342125
6342141
6342158
6342166
6342174
6342182
6342190
6342208
6342216
6342224
6342232
6342240
6342257
6342265
6342273
6342299
6342307
6342315
6342323
6342356
6342364
6342372
6342380
6342398
6342406
6342414
6342422

CDM Description
HYOSCYAMINE 15ML SOL
HYPROMELLOSE 0.5% OP 15ML
HYPROMELL GONIOSC2.5%15ML
IBUPROFEN 100MG/5ML 120ML
IBUPROFEN 100MG/5ML 120ML
IMATINIB 400MG TAB
INDOCYANINE GREEN 25MG IN
INTERFRN BETA1A 22MCG/0.5
INTERFRN BETA1A 44MCG/0.5
IODIXANOL 320MG/ML 100ML
IOHEXOL 180MG/ML 20ML INJ
IOHEXOL 240MG/ML 10ML INJ
IOHEXOL 350MG/ML 100ML IN
IOHEXOL 350MG/ML 150ML IN
IOTHALAMATE MEG 43% 50ML
IPRATROPIUM DOSE INH
ISONIAZID 50MG/5ML 5ML SY
ISOSORBIDE MON 120MG TAB
ISRADIPINE CR 10MG
ITRACONAZOLE KIT 10/1 25M
ITRACONAZOLE 10MG/ML 150M
LIDO/EPI 0.5%-1:200000 50
LIDO/EPI 1%-1:100000 20ML
LIDO/EPI1%-1:200000MPF30M
LIDO/EPI1%-1:200000MPF5ML
LIDO/EPI2%-1:200000MPF10M
LIDO/EPI2%-1:200000MPF20M
LIDOCAINE/EPI/TETRA 3ML
LIDO 0.4% 1GM 250ML PB
LIDO 0.4% 2GM 500ML PB
LIDOCAINE MPF 0.5% 50ML
LIDOCAINE 0.8% 2GM PB
LIDOCAINE 1% 20ML INJ
LIDOCAINE 1% 50ML INJ
LIDOCAINE 1% PF 5ML INJ
LIDOCAINE 2% 10GM JELLY
LIDOCAINE 2% 5GM JELLY
LIDOCAINE 2% MPF 30ML INJ
LIDOCAINE 2% MPF 5ML INJ
LIDOCAINE 5% 30GM CRM
LIDO/DEXT 5%/7.5% 2ML INJ
LIDOCAINE 4% 5GM CRM
LIDO/PRILOCAINE 30GM CRM
LIOTHYRONINE 50MCG TAB
LISINOPRIL/HCTZ 10/12.5MG
LITHIUM 300MG/5ML 5ML SYR
LOPINAVIR/RITON 300/5 5ML

239940119.xlsx.ms_office

Price
9.00
65.00
65.00
9.00
4.00
290.00
58.00
475.00
1,800.00
100.00
20.00
10.00
100.00
150.00
50.00
100.00
18.00
9.00
9.00
240.00
240.00
58.00
58.00
58.00
58.00
58.00
58.00
15.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
25.00
20.00
58.00
58.00
25.00
58.00
15.00
25.00
9.00
9.00
9.00
15.00

$0 Indicator

Page 265 of 299

CDM #
6342430
6342455
6342471
6342489
6342497
6342505
6342513
6342521
6342539
6342547
6342554
6342562
6342570
6342588
6342596
6342604
6342612
6342638
6342646
6342653
6342661
6342687
6342695
6342703
6342711
6342729
6342737
6342752
6342778
6342786
6342794
6342844
6342851
6342869
6342885
6342919
6342935
6342950
6342968
6342976
6342984
6342992
6343016
6343024
6343040
6343057
6343065

CDM Description
LOPINAVIR/RITON300/5 160M
LORATADINE 1MG/ML 5ML SYR
LORAZEPAM 2MG/ML 30ML SOL
LOSARTAN/HCTZ 50/12.5MG
LOTEPREDNOL ETAB.2%OPTH5M
LIDOCAINE 4% 4ML TOP/CANN
LUBRIDERM LOT 177ML
LUBRIDERM LOT 480ML
K PHOS 500MG(3.7MEQ K)TAB
KETAMINE 10MG/ML 20ML INJ
KETAMINE 20MG/0.2ML LIQ
KETOCONAZOLE 2% 15GM CRM
KETOCONAZOLE 2% 60GM CRM
KETONE STRIPS
KETOPROFEN 12.5MG TAB
KETOROLAC 0.5% 3ML OP SOL
KETOROLAC 0.4% 5ML OP SOL
LACTOBACILLUS LACT TAB
LABETALOL 5MG/ML 4ML INJ
LACTASE ENZ 9000U CHW
LACTATED RINGERS 250ML
LACTOBACILLUS ACID 5MU
LACTULOSE 240ML SYRP
LAMIVUDINE 100MG TAB
LAMOTRIGINE 25MG TAB
LAMOTRIGINE 5MG CHW TAB
LANOLIN OINT 7GM
LANSOPRAZOLE EC 30MG CAP
LEFLUNOMIDE 10MG TAB
LETROZOLE 2.5MG TAB
LEUPROLIDE 11.25MG 3MTH
LEVALBUTEROL HFA 45 MCG
LEVETIRACETAM 250MG TAB
LEVETIRACETAM 750MG TAB
LEVOCARNIT 100MG/ML 1ML S
MAG GLUCON 200MG/ML SUS 5
MAG HYD/AL HYDRX/SIME 355
MAGNESIUM SUL 2GM PB
MAGNESIUM SUL 20GM PB
MAGNESIUM SUL 1GM/2ML INJ
MAGNESIUM SUL 10GM/20ML
MANNITOL 10% 500ML PB
MENTHOL COUGH DRP SUG-FR
MEPERIDINE 50MG/5ML 5ML
MEPERIDINE 10MG/ML 30ML P
MESALAMINE 1GM SUPP
MESALAMINE 500MG SUPP

239940119.xlsx.ms_office

Price
500.00
9.00
50.00
12.00
75.00
25.00
9.00
18.00
9.00
58.00
9.00
35.00
50.00
15.00
9.00
85.00
110.00
9.00
58.00
9.00
58.00
9.00
35.00
12.00
12.00
12.00
15.00
24.00
9.00
36.00
2,408.00
65.00
9.00
18.00
9.00
9.00
9.00
58.00
58.00
58.00
58.00
96.00
2.00
9.00
58.00
12.00
9.00

$0 Indicator

Page 266 of 299

CDM #
6343123
6343131
6343149
6343156
6343206
6343271
6343297
6343305
6343313
6343321
6343339
6343370
6343388
6343396
6343404
6343412
6343420
6343438
6343446
6343453
6343461
6343503
6343537
6343545
6343552
6343586
6343594
6343610
6343628
6343636
6343651
6343669
6343677
6343701
6343719
6343727
6343735
6343743
6343750
6343768
6343776
6343784
6343792
6343800
6343818
6343826
6343834

CDM Description
METFORMIN ER 750MG
METHADONE 10MG/ML 20ML IN
METHADONE 40MG TAB
METHYL SALICYL/MENTH 30GM
METHYLCELLULOSE 500MG
METHYLPRED ACE 40MG/ML 1M
METRONIDAZ 0.75% 45GM TOP
METRONIDAZ 0.75% 45GM GEL
METRONIDAZ 1% 45GM TOP
METRONIDAZOLE 500MG INJ
METRONIDAZ 5MG/ML PEDPO
MIGLITOL 25MG TAB
MINERAL OIL 120ML LIQ
MINERAL OIL 480ML LIQ
MINOIL/PET HY-PHL OIN50GM
MIRTAZAPINE 15MG SOLTAB
MIRTAZAPINE 30MG SOLTAB
MITOMYCIN 0.3MG/1ML OPINJ
MITOMYCIN 20MG INJ
MITOXANTRONE 2MG/ML 2.5ML
MOLINDONE 10MG TAB
MOMETASONE 220MCG TWSTHL
MORPHINE 1MG/ML 250ML PB
MORPHINE 30MG TAB
MORPHINE 1MG/ML 50ML PCA
MULTIVIT/MINERL/LUTEIN TB
MULTIVIT FL FE 0.25-10MG
MULTIVITAMIN PRENATAL TAB
MULTIVIT W MINERALS TAB
MULTIVITAMIN/ZINC 1ML
MYCOPHENOLATE AC 360MG ER
NALOXONE 1MG/ML 10ML INJ
NALTREXONE 50MG TAB
NAPHAZOLINE 0.012% 15ML O
NAPROXEN EC 500MG TAB
NAPROXEN NA 220MG TAB
NEDOCROMIL 2% OPH 5ML
NEFAZODONE 50MG TAB
NELFINAVIR 625MG TAB
NEOMYCIN SUL 0.5% 30GM OI
NEO/POLY/PRAM CRM
NEO/POLY/HC7.5ML OTIC SUS
NEO/POLY/BAC OINT 15GM
NEO/POLY/HC 7.5ML OP SUSP
NEOSTIGMINE 1:1000 10ML
NEOSTIGMINE 1:2000 1ML IN
NEOSTIGMINE 1:4000 1ML IN

239940119.xlsx.ms_office

Price
9.00
166.00
9.00
9.00
2.00
15.00
124.00
108.00
222.00
58.00
9.00
27.00
9.00
12.00
15.00
9.00
9.00
31.00
108.00
188.00
9.00
204.00
58.00
9.00
58.00
2.00
2.00
9.00
2.00
2.00
18.00
58.00
9.00
30.00
9.00
9.00
205.00
9.00
20.00
15.00
9.00
55.00
2.00
75.00
58.00
58.00
58.00

$0 Indicator

Page 267 of 299

CDM #
6343842
6343867
6343875
6343883
6343909
6343917
6343925
6343974
6343982
6344014
6344022
6344048
6344055
6344063
6344071
6344089
6344105
6344113
6344121
6344139
6344147
6344154
6344188
6344196
6344238
6344246
6344253
6344261
6344279
6344287
6344303
6344311
6344329
6344337
6344345
6344394
6344402
6344477
6344485
6344527
6344543
6344550
6344568
6344576
6344584
6344592
6344600

CDM Description
NEPAFENAC 0.1% OPH 3ML
NICOTINE 10MG INH KIT
NIFEDIPINE CC 30MG TAB
NIFEDIPINE CC 60MG TAB
NITAZOXANIDE 500MG TAB
NITROFURAN 25MG/5ML 120ML
NTG SL 0.3MG (100) TAB
NTG 5MG/ML 5ML INJ
NTG SR 6.5MG CAP
NORTRIPTYL10MG/5ML 12.5ML
NORTRIPTYLINE 75MG CAP
NYSTATIN 30GM OINT
OCTREOTIDE 1MG/ML 5ML INJ
OCTREOTIDE 20MG DEPOT KIT
OCTREOTIDE 0.2MG/ML 5ML
OCULAR LUBRICANT PRE 15ML
OFLOXACIN 0.3% 10ML OTSOL
OLANZAPINE 10MG INJ
OLANZAPINE 10MG/10MLSWINJ
OLANZAPINE 15MG TAB
OLANZAPINE 20MG TAB
OMEGA3/FATTY AC/ETHYL 1GM
ONDANSETRON 4MG ODT TAB
ONDANSETRON 4MG/5ML 50ML
OXCARBAZEPINE 150MG TAB
OXCARBAZEPINE 300MG/5ML
OXCARBAZEPINE 600MG TAB
OXYBUTYNIN 5MG/5ML 5ML SY
OXYCODONE IR 15MG TAB
OXYCODONE 5MG/5ML 5ML SOL
OXYMETAZOL 0.025% OPH15ML
OXYMETAZOL 0.05% 15ML NAS
OXYMETAZOL 0.05% 15ML NAS
OXYTOCIN 10U/ML 10ML INJ
OXYTOCIN 10U/50ML PB
PAPAVERINE 30MG/ML 10ML
PAROXETINE 40MG TAB
PENTOBARBITAL 50MG/ML 20M
PEPPERMINT 30MLS SPIRIT
PETROLATUM OINT 454 GM
PHENOBARB 20MG/5ML 120ML
PHENOBARB 20MG/5ML 15ML
PHENOBARB 60MG/ML 1ML INJ
PHENOL 1.4% 180ML SPRY
PHENYLEPH 0.1MG/ML 10MLSO
PHENYLEPH 0.125% 15ML NAS
PHENYLEPH 0.25% 15ML NAS

239940119.xlsx.ms_office

Price
209.00
111.00
9.00
9.00
56.00
313.00
30.00
58.00
9.00
9.00
9.00
15.00
1,100.00
3,000.00
300.00
15.00
127.00
78.00
78.00
55.00
70.00
2.00
14.00
34.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
58.00
58.00
58.00
9.00
1,237.00
9.00
2.00
136.00
17.00
81.00
2.00
58.00
58.00
2.00

$0 Indicator

Page 268 of 299

CDM #
6344634
6344642
6344667
6344675
6344691
6344717
6344725
6344733
6344741
6344758
6344766
6344782
6344790
6344808
6344824
6344832
6344840
6344857
6344865
6344873
6344881
6344899
6344907
6344931
6344949
6344972
6344980
6345011
6345029
6345037
6345045
6345052
6345110
6345128
6345136
6345144
6345151
6345193
6345219
6345227
6345235
6345243
6345250
6345268
6345276
6345284
6345292

CDM Description
PHENYLEPH 2.5% 3ML OP SOL
PHENYLEPHR 30MG 250ML PB
PILOCARPINE 2% 2ML OP SOL
PILOCARPINE 5MG TAB
PIMOZIDE 2MG TAB
PIOGLIT/METFOR15/850MGTAB
PLASMA PRO FRACT 5% 500ML
PNEUMOCOCCAL VACC 2.5ML
PNEUMOCOCC 7-VAL PED VACC
POLYVNY/PROV 1.4/.6% .3ML
POLYVNY/PROV 1.4/.6% .3ML
KCL 20MEQ 50ML INJ
POTASSIUM IODIDE/IOD 15ML
K CIT 10MEQ TAB
K IODINE 1GM/ML 30ML SOL
K PHOS 4.4MEQ/3MM 15ML IN
K PHOS 4.4MEQ/3MM 50ML IN
POVIDONE IODINE5% OPH30ML
POVIDONE IODINE 10% TOP
POVIDONE IODINE 10% 120ML
POVIDONE IODINE 10% 15ML
POVIDONE IODINE 10% 177ML
POVIDON IOD 10%OINT3.75GM
POVIDONE IODINE5%OPH 50ML
PRAMOXINE 1% 118GM TOP
PRAMOXINE/ZINC 30GM TOP
PRAMOX/ZINC/MIN OIL 30GM
PREDNISOL 1% 10ML OP SUSP
PREDNISONE 5MG/5ML 120ML
PREGABALIN 100MG CAP
PREGABALIN 150MG CAP
LANSOPRAZOLE 30MG ODT TAB
PROMETH/DEXT 118ML SYRP
PROMETH/COD 120ML SYRP
PROPAPHENONE SR 225MG CAP
PROPAFENONE SR 325MG CAP
PROPAFENONE SR 425MG CAP
PSYLLIUM 100GM GRAN
PSYLLIUM 3.4GM SF PWDR
QUETIAPINE SR. 300MG TAB
QUETIAPINE SR. 50MG TAB
QUININE 324 MG
RABIES IMMUN GLOB 150U 1M
RANOLAZINE ER 500MG TAB
RASAGILINE 0.5MG TAB
REMIFENTANIL 2MG 5ML INJ
RHO(D) IG SD 5000U INJ

239940119.xlsx.ms_office

Price
2.00
58.00
15.00
9.00
9.00
12.00
483.00
150.00
79.00
2.00
2.00
58.00
9.00
9.00
2.00
58.00
58.00
18.00
2.00
9.00
2.00
9.00
2.00
27.00
53.00
18.00
19.00
108.00
54.00
9.00
9.00
25.00
14.00
18.00
17.00
19.00
19.00
2.00
2.00
30.00
14.00
16.00
250.00
12.00
26.00
65.00
2,453.00

$0 Indicator

Page 269 of 299

CDM #
6345326
6345334
6345359
6345375
6345383
6345391
6345409
6345417
6345433
6345441
6345458
6345466
6345474
6345490
6345508
6345516
6345524
6345532
6345540
6345557
6345565
6345581
6345615
6345623
6345631
6345664
6345680
6345698
6345714
6345722
6345748
6345763
6345789
6345805
6345821
6345847
6345870
6345896
6345912
6345938
6345946
6345953
6345995
6346001
6346027
6346043
6346050

CDM Description
RHO(D) IG SD 2500UNIT INJ
RIFABUTIN 150MG CAP
RIMEXOLONE 1% 5ML OP SUSP
RISEDRONATE 30MG TAB
RISPERIDONE ODT 0.5MG TAB
RISPERIDONE 1MG/ML SO PED
RISPERIDONE 1MG/ML 2ML SO
RISPERIDONE 1MG/ML 3ML SO
RISPERIDONE 1MG/ML 4ML SO
RISPERIDONE ODT 1MG TAB
RISPERIDONE ODT 2MG TAB
RISPERIDONE 50MG/2ML INJ
RITONAVIR 80MG/ML 1ML SOL
RIVASTIGMINE 2MG/ML 120ML
RIVASTIGMINE 3MG CAP
RIVASTIGMINE 6MG CAP
ROCURONIUM 10MG/ML 10ML
ROPINIROLE 4MG TAB
ROPINIROLE 5MG TAB
ROPIVACAINE 7.5MG/ML 20ML
ROPIVACAINE 5MG/ML 30ML
SALICYLIC/BENZALK 120ML
SAQUINAVIR 500MG TAB
SAQUINAVIR MESYL 200MG
SELEGILINE 6MG/24HR PAT
SEVOFLURANE 250ML LIQ
SILVER SULFAD 1% 20GM TOP
SILVER SULFADIAZ 85GM CRM
SIMVASTATIN 80MG TAB
SIROLIMUS 1MG/ML 1ML SOL
NA BICARB 7.5% 44.6MEQ50M
NA BICARB 8.4% 10MEQ 10ML
SOD PHOS/BIPHOS 45ML SOL
NACL 0.45%+KCL 20 1000ML
NACL 0.45% 100ML INJ
NACL 0.45% 250ML INJ
NACL 30ML NAS DRPS
NACL 0.9% 10ML INJ
NACL 0.9%+KCL 20 1000ML
NACL 0.9% 150ML INJ
NACL 0.9% 5ML INH
NACL 0.9% 3ML INH
NACL PWD 0.5 TSP 60ML SW
HYALURON/CHONDR 0.5ML OP
NA HYALURONATE OPTH
HYALURONAT 10/ML 0.55MLOP
HYALURONA 14/ML 0.85ML OP

239940119.xlsx.ms_office

Price
913.00
30.00
90.00
64.00
15.00
15.00
20.00
25.00
30.00
16.00
26.00
1,193.00
15.00
852.00
9.00
9.00
58.00
9.00
9.00
58.00
58.00
9.00
21.00
11.00
49.00
420.00
11.00
28.00
9.00
81.00
58.00
58.00
8.00
65.00
65.00
65.00
2.00
65.00
78.00
9.00
9.00
15.00
143.00
208.00
163.00
173.00

$0 Indicator

Page 270 of 299

CDM #
6346100
6346134
6346142
6346159
6346167
6346183
6346209
6346217
6346233
6346274
6346282
6346290
6346308
6346324
6346332
6346340
6346357
6346365
6346373
6346381
6346399
6346407
6346415
6346431
6346449
6346498
6346506
6346571
6346589
6346613
6346647
6346662
6346670
6346688
6346720
6346738
6346746
6346779
6346787
6346795
6346803
6346829
6346837
6346845
6346852
6346860
6346886

CDM Description
NA HYPOCHLOR 0.5% 1000ML
NA HYPOCHLOR 0.125% 1000M
NA HYPOCHLORITE FS 1000ML
NA PHOS 3MM/ML 15ML INJ
SULFACETAM 10% 3.5GM OP
PHENOL/NA PHENOLATE SPRAY
STAVUDINE 20MG CAP
WATER STERILE 1000ML INJ
WATER STERILE IRRIG 1000M
PREDNISOL/SULFAC 10ML OPS
SULFAMET/TMP 200/40MG/5ML
SULFAMETHOXAZ/TMP 800/160
TMP-SMZ 30ML INJ
SURESTEP PRO CONTRL SOL
TACROLIMUS 0.03% 30GM TOP
TACROLIUMS 0.1% 60GM OIN
TACROLIMUS 0.5MG CAP
TAP WATER ENEMA
TAZAROTENE 0.1% 30GM TOP
TERBINAFINE 1% 15GM TOP
TERIPARAT 750MCG/3ML PEN
TESTOSTERONE 1% 5GM TOP
TESTOSTERONE 2.5MG PATCH
TETRAHYDROZ 0.05% 15ML OP
THALIDOMIDE 50MG CAP
TIAGABINE 4MG TAB
TIMOLOL 0.5% 15ML OP SOL
TRAMADOL SR 100MG TAB
TREPROSTINIL 1MG/ML 20ML
TRIAMCIN ACE 0.025% 15GM
TRIAMCIN ACE 40MG/ML 1ML
TRIAMCIN 55MCG/INH 10GM N
TRIAMTERENE/HCTZ 37.5/25M
TRIETHANOLAM 10%12ML OTO
TROPICAMIDE 1% 3ML OP SOL
TROPICAMIDE 1% 2ML OP SOL
TRYPAN BLUE 0.06% OPH 0.5
URSODIOL 250MG TAB
VALPROIC 250MG/5ML 120ML
VALPROIC 250MG/5ML 60ML
VALSARTAN 320MG TAB
VASOPRESSN 20UNIT/ML 10ML
VERAPAMIL ER 180MG TAB
VERAPAMIL 5MG/2ML 4ML INJ
VERAPAMIL ER 240MG TAB
VERAPAMIL 24HR 360MG CAP
MULTIVIT MINERAL TAB

239940119.xlsx.ms_office

Price
54.00
54.00
54.00
58.00
124.00
15.00
19.00
58.00
15.00
165.00
9.00
18.00
58.00
24.00
205.00
415.00
9.00
256.00
21.00
1,420.00
23.00
15.00
2.00
258.00
11.00
26.00
12.00
1,300.00
15.00
58.00
295.00
9.00
25.00
15.00
15.00
15.00
9.00
36.00
18.00
10.00
58.00
9.00
58.00
10.00
12.00
2.00

$0 Indicator

Page 271 of 299

CDM #
6346894
6346902
6346910
6346944
6346951
6346969
6346985
6347017
6347041
6347066
6347173
6347223
6347256
6347264
6347306
6347330
6347371
6347389
6347413
6347421
6347439
6347454
6347462
6347470
6347488
6347546
6347702
6347728
6347751
6347777
6347785
6347835
6347868
6347876
6347892
6347926
6347959
6347975
6347983
6348031
6348049
6348148
6348171
6348189
6348197
6348205
6348254

CDM Description
VIT A&D CRM 60GM
VIT A&D ZINC OX 68GM
WATER PURIF 98.6% OPH 120
ZINC OXIDE PETRO OIN113GM
ZINC OXIDE 25% PASTE 8GM
TRYPS/BALSAM/CASTOR 60GM
ZIPRASIDONE 20MG INJ
WITCH HAZEL (40) PAD
CHLORTHALIDONE 50MG TAB
HYALURONIDASE 150 U/ML IN
BETAMETH VAL 0.1% 45GM OI
CARBACHOL 0.01% 1.5ML OPS
CARBACHOL 3% 15ML OP SOL
CEFADROXIL 500MG CAP
CHLORPROMAZINE 25MG SUPP
RENACIDIN 500ML SOL
CODEINE SULF 60MG TAB
CYCLOPENTOLATE 2% 5ML OPS
D30% 500ML INJ
D5% 0.45 NACL+KCL30 1000M
D5% 0.45 NACL+KCL40 1000M
D5% 0.2 NACL+KCL40 1000ML
D5% 0.9 NACL+KCL20 1000ML
D5%+KCL 20MEQ 1000ML INJ
D5%+KCL 40MEQ 1000ML INJ
DIAZEPAM 1MG/ML 5ML SOL
ERGOLOID MESYL 0.5MG TAB
ESTRADIOL 0.0375MG PATCH
FELBAMATE 600MG TAB
FLUOCINONIDE/0.05PC/60G B
FLUOCINONIDE 0.05% 60ML
GENTAMICIN/15GM/CREME
GLYCERIN/50PC/180ML/SOLN
GOLD THIOMALATE 50MG/1ML
GRISEOFULVIN UM/250MG TAB
IMIPRAMINE PAM 100MG CAP
INS ASP PR70-30 100U/ML10
IODINE TINCTURE 30ML
ISOSORBIDE DIN SL 5MG TAB
LIDOCAINE 10% SPRAY 33GM
LIDOCAINE OINT 2.5% 35GM
MAPROTILINE 25MG TAB
MEFLOQUIN 250MG TAB
MEPHOBARBITAL/100MG/1TAB
MEPIVACAINE PF 1% 30ML IN
MEPIVACAINE 1.5% 30ML INJ
MEXILETINE 250MG CAP

239940119.xlsx.ms_office

Price
15.00
15.00
15.00
15.00
15.00
15.00
58.00
15.00
9.00
71.00
61.00
179.00
49.00
9.00
12.00
93.00
9.00
63.00
185.00
78.00
78.00
78.00
78.00
78.00
78.00
24.00
9.00
16.00
9.00
84.00
83.00
43.00
48.00
529.00
9.00
9.00
121.00
23.00
9.00
91.00
38.00
9.00
38.00
9.00
71.00
71.00
9.00

$0 Indicator

Page 272 of 299

CDM #
6348262
6348346
6348353
6357669
6357677
6357776
6357834
6357859
6357909
6358022
6358030
6358121
6358139
6358238
6358246
6358253
6358261
6358345
6358352
6358378
6358386
6358394
6358402
6358410
6358436
6358444
6358451
6358469
6358501
6358527
6358535
6358568
6358576
6358584
6358618
6358626
6358642
6358659
6358675
6358683
6358691
6358709
6358717
6358725
6358733
6358741
6358758

CDM Description
MOMETASONE 0.1% 15GM OINT
NYSTATIN 500000U TAB
OXAPROZIN 600MG TAB
MICAFUNGIN NA 100MG INJ
PEN G PROC 1.2MIL U 2ML
INFLAMASE FORTE 5ML OP
PROPRANOLOL LA 60MG CAP
RIFAMPIN 150MG CAP
SENNA 326MG/5GM 56GM GRAN
TETRACAINE 1% 2ML INJ
TETRACAINE 2% 118ML
THIOTHIXENE 1MG CAP
THIOTHIXENE 10MG CAP
TRIAMCIN ACE 0.025% 60ML
TRIAMCIN ACE 0.5% 15GM
TRIAMCINOLONE/4MG/1TAB
TRIHEXYPHENIDY 2MG/5ML UD
ACYCLOVIR 5MG INJ
AMINOPHYLLIN 5MG/ML PEDIV
AMPICILLIN 30MG/ML PEDIV
AMPICIL/SUL 30MG/MLPEDIV
CEFOTAXIME 1GM/25ML PEDIV
PEDS CEFOTETAN 40MG/ML
CEFTAZIDIME 40MG/2.5MLPED
CEFTRIAXONE 40MG/ML PEDIV
CEFUROXIME 30MG/ML PEDIV
CLINDAMYCIN 6MG/ML PEDIV
DEXAMETH 0.1MG/ML PEDPO
DIPHENHYDRAM 50MG/ML PEDI
PEDS FAMOTIDINE 4MG/ML
PEDS FENTANYL 50MCG/ML
GENTAMICIN 2MG/ML PEDIV
HYDROCORT NA 1MG/ML PEDIV
IMM GLOB RSV 50MG/ML 50ML
PEDS METOCLOPRAM 2.5MG/ML
PEDS METRONIDAZOLE 5MG/ML
MORPHINE 1MG/ML 1ML PEDIV
PEDS NAFCILLIN 20MG/ML IV
NALOXONE 0.4MG/ML PEDIV
PEN G K 100000U/ML PEDIV
PENTOBARBITAL 50MG/ML 20M
PHENOBARB 10MG/ML PEDIV
PHENYTOIN 50MG/ML 2ML INJ
PIPERAC/TAZ 20MG/ML PEDIV
PIPERAC/TAZ 2GM/50MLPEDIV
RANITIDINE 1MG/ML PEDIV
TOBRAMYCIN 2MG/ML PEDIV

239940119.xlsx.ms_office

Price
37.00
9.00
9.00
300.00
71.00
37.00
9.00
10.00
32.00
71.00
89.00
9.00
9.00
75.00
68.00
10.00
9.00
10.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
150.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00

$0 Indicator

Page 273 of 299

CDM #
6358766
6358774
6358782
6358790
6358899
6358907
6358949
6358972
6358998
6359004
6359012
6359020
6359046
6359079
6359095
6359129
6359160
6359228
6359236
6359244
6359251
6359269
6359301
6359319
6359327
6359335
6359368
6359376
6359384
6359392
6359400
6359418
6359434
6359442
6359483
6359509
6359517
6359525
6359533
6359541
6359566
6359574
6359582
6359590
6359608
6359624
6359632

CDM Description
VANCOMYCIN 50MG/ML PEDIV
CADD CASSETTE
HES SOLUTION 450 MLS
ACETA/DIPHEN 500/38MG TAB
AL AMMONIUM SUL 5GM IRR
AL HYDROX 320MG/5ML 360ML
AMINOPHYLLINE 500MG INJ
AMOXICILLIN 400/5ML PED
CYANIDE ANTIDOTE KIT
CITRATE DEXTROSE 500MLSOL
ARFORMOTEROL 15MCG/2ML
VIT C(ASCOR ACID)250MG
ASA/CAFFEINE 400/32MG TAB
MICROFIB COLLAGEN 1GM JAR
AZITHROMYCIN 100/5 15ML
BENZOCAINE/MENTHOL LOZ
BUPIVAC/EPI PF 0.25% 10M
TPN CLINIMIX 4.25/10
TPN CLINIMIX E 4.25/10
TPN CLINIMIX 5/20 2000ML
TPN CLINIMIX 5/20 1000ML
TPN W ELECT 5/20 2000ML
CONIVAPTAN 20MG/4ML INJ
D5% 0.45 NACL+KCL10 1000M
DARUNAVIR 300MG TAB
DESFLURANE 240ML INH SOL
D12.5%W 250ML INJ
D15W 250ML PEDIV
D7.5%W 250ML INJ
DIATRIZOTE MEG/NA-66 30ML
DOCUSATE NA 250MG/25MLSOL
DONNAZYME 500MG TAB
EFAVIR/EMT/TEN600/200/300
MULTI-ELECTROLYTE 20ML IN
EPOETIN 40000U ESRD INJ
EPTIFIBATIDE 200MG/100ML
ETRAVIRINE 100MG TAB
FELBAMATE 400MG TAB
FENTANYL 50MCG/ML 1ML INJ
FLURANDREN 0.05% CR 15G
FONDAPARINUX 10MG/0.8ML
FONDAPARINUX 5MG/0.4ML IN
GLUCOSE 40% 37.5GM GEL
GLUCOSE 5GM TAB
GUAIFEN/COD 5ML SYRP
HEPARIN FLUSH 10U/ML 1ML
HEPARIN PF FLUSH 50UN/5ML

239940119.xlsx.ms_office

Price
58.00
58.00
2.00
15.00
15.00
58.00
15.00
545.00
58.00
16.00
2.00
2.00
236.00
9.00
2.00
58.00
75.00
75.00
75.00
75.00
75.00
1,030.00
65.00
23.00
328.00
58.00
58.00
58.00
30.00
9.00
9.00
122.00
15.00
785.00
1,865.00
19.00
9.00
58.00
149.00
110.00
110.00
2.00
2.00
9.00
58.00
58.00

$0 Indicator
S

Page 274 of 299

CDM #
6359640
6359673
6359699
6359707
6359715
6359723
6359731
6359749
6359756
6359764
6359772
6359780
6359806
6359848
6359905
6359939
6359947
6359988
6359996
6360002
6360051
6360077
6360085
6360093
6360119
6360143
6360150
6360168
6360176
6360184
6360234
6360267
6360275
6360283
6360291
6360309
6360325
6360366
6360382
6360390
6360408
6360416
6360424
6360432
6360440
6360457
6360465

CDM Description
HEPARIN FLUSH 100U/ML 5ML
HYDROMOR PCA 0.2MG/ML 25M
EPOETIN 2000UNIT PEDIV
IMM GLOB LYOPH 100MG PEDI
MEROPENEM 5MG/ML PEDIV
NEO PHYTONADI 1MG/0.5ML
NEO KCL 0.04MEQ/ML PERI
NEO KCL 0.08MEQ/ML CENT
NEO RIFAMPIN INJ
NEO NA BICAR 4.2 .25MEQ/M
NEO NA BICAR 4.2 .5MEQ/M
NEO BACTRIM 0.6MG/ML
OSELTAMIVIR 12MG/ML 25ML
PINK LADY ENEMA
RALTEGRAVIR 400MG TAB
RIZATRIPTAN 10MG ODT
SIMETHICONE 180MG CAP
MISC ALCOHOLIC BEVERAGE
SPIRONOL/HCTZ 5MG/ML PED
SURESTEP PRO TEST STRPS
VANCOMYCIN 1GM/200M PB
TRIAMCIN ACE 0.1% 80GM CR
UREA 10% 75GM CRM
WITCH HAZEL (40) PAD
THIOTHIXENE 5MG/ML 5ML CO
LABSTIX REAGENT STRPS
LANOLIN 1GM OINT
LAPATINIB 250MG TAB
LEVOFLOX 25MG/ML SOL 480M
LISTERINE ANTISEPTIC
MICONAZOLE 200MG 1 VAG
MORPHINE 1MG/ML50ML NS IN
MORPHINE 1MG/ML 30ML PCA
MULTISTIX REAGENT STRPS
PED MULTIVIT/IRON CHW
SPIRONOLACT 1MG/1ML PEDPO
OLANZAPINE 15MG TAB
NITRAZINE PAPERS
NEO APAP 40MG/0.4ML ORAL
NEO AMIODAR 5MG/ML ORAL
NEO AMOXICIL 25MG/ML ORAL
CAFFEINE CIT 20MG/ML PEDP
NEO CALCITRI 1MCG/ML ORAL
NEO DIGOXIN ORAL
NEO FAMOTID 8MG/ML ORAL
NEO FERROUS SULF ORAL
NEO FLUCONAZ 10MG/ML ORAL

239940119.xlsx.ms_office

Price
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
118.00
15.00
48.00
153.00
9.00
9.00
36.00
75.00
300.00
15.00
15.00
2.00
9.00
64.00
9.00
77.00
834.00
2.00
9.00
58.00
58.00
150.00
2.00
9.00
62.00
312.00
2.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00

$0 Indicator

Page 275 of 299

CDM #
6360473
6360481
6360499
6360507
6360515
6360523
6360531
6360549
6360556
6360564
6360572
6360580
6360598
6360606
6360614
6360622
6360630
6360655
6360663
6360721
6360739
6360747
6360762
6360770
6360788
6360796
6360804
6360812
6360820
6360838
6360846
6360853
6360861
6360879
6360887
6360895
6360903
6360911
6360929
6360937
6360945
6360952
6360978
6360986
6360994
6361000
6361018

CDM Description
NEO FOLIC ORAL
NEO FUROSEMIDE ORAL
NEO ALDCTZID 5-5MG/ML OR
NEO HYDRALAZINE ORAL
NEO HYROCORT 2MG/ML ORAL
NEO LORAZEPAM 2MG/ML ORA
NEO OPIUM TIN .4MG/ML ORA
NEO PENTOBAR 50MG/ML SOL
PHENOBARB 4MG/ML PEDPO
NEO MULTIVIT 1ML DRPS
NEO MULTIVIT/FE ORAL
NEO RANITID 15MG/ML ORAL
NEO SOTALOL 5MG/ML ORAL
NATEGLINIDE 60MG TAB
URSODIOL 20MG/ML 1MLPEDPO
VIT D 8000IU 1ML SOL
NEO VIT E(TOCOPHER) ORAL
STARTER TPN D10W NICU
STARTER TPN D5W NICU
ALISKIREN 300MG TAB
BUDESON/FORMOT 160/4.5MCG
BUDESON/FORMOT 80/4.5MCG
DORIPENEM 500MG INJ
DOXERCALCIFEROL 0.5MCG
FENTANYL 10MCG/ML 25ML PB
FENTANYL 10MCG/ML 50ML PB
HYDROMORPHONE 0.2/ML 30ML
AMPICIL/SUL 30MG/MLPEDIV
NEO ENALAPR 25 MCG/ML INJ
NEO FAMOTIDINE 2MG/ML INJ
NEO INS ASPART 1U/ML INJ
NEO MAG SUL 25MG/ML INJ
NEO METRONIDA 5MG/ML
NALOXONE 1MG/ML 1ML PEDIV
IODIXANOL 320MG/ML 50
LACTULOSE 0.2G/ML ENEMA
MARAVIROC 300MG TAB
MENINGOCOCC CNG VAC
NEBIVOLOL 10 MG TAB
NEBIVOLOL 2.5 MG TAB
NEBIVOLOL 5 MG TAB
ONDANSETRON 32MG PB
METHYLPRED 10MG/ML PEDIV
METHYLPRED 5MG/ML PEDIV
POSACONAZO 40MG/ML 5
VIT B6 (PYRIDOX) 1GM/10ML
RISPERIDONE ODT 3MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
58.00
58.00
9.00
400.00
343.00
115.00
15.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
83.00
20.00
49.00
235.00
9.00
9.00
9.00
71.00
58.00
58.00
62.00
58.00
32.00

$0 Indicator

Page 276 of 299

CDM #
6361034
6361059
6361075
6361091
6361117
6361125
6361133
6361141
6361190
6361232
6361240
6361257
6361265
6361299
6361307
6361323
6361331
6361349
6361356
6361364
6361372
6361380
6361406
6361422
6361430
6361471
6361489
6361497
6361513
6361521
6361547
6361554
6361562
6361570
6361596
6361604
6361612
6361620
6361638
6361646
6361661
6361679
6361687
6361695
6361703
6361711
6361729

CDM Description
PEMETREXED 10MG INJ
AMINOCAP ACID 10G/NS
REGADENOSON 0.1MG INJ
EYE COMPOUND DILATING
EYE COMPOUND DILATING
EYE DILATING GEL
CEFDINIR 250MG/5ML 60ML
NICARDIPIN/NS 0.1MG/ML
CEFAZOLIN 2GM PWD INJ
VALSARTAN/HCTZ 320/12.5MG
VALSARTAN/HCTZ 160/25MG
VALSARTAN/HCTZ 320/25
OLMESARTAN 40MG TAB
DEXAMETH PHOS 4MG/ML 30ML
PREGABALIN 200MG CAP
DIAZEPAM 5MG/ML 10ML INJ
PROPOFOL 10MG/ML 20ML INJ
GENTAMICIN 80MG/50ML PB
MISOPROSTOL 25MCG TAB
DEXTRAN 32 6%/D10 100ML
MORPHINE 25MG/ML 10ML INJ
MORPHINE 50MG/ML 50ML INJ
NEO HEP PF FLSH 10U/ML 2M
PANTOPRA OR 2MG/ML 20ML
TRIAMTERENE/HCTZ 50/25MG
AMPHET/DEXTROAMP SR 5MG
AMPHET/DEXTROAMPH SR 20MG
HYDROCORT 1% 1.5GM CRM
AMOXICILLIN 50MG/5ML 30ML
NTG 100MCG/ML 20 ML SY
GLYCER INFANT ENEMA 4ML
METHYLPRED NA 2GM INJ
PENTOBARBITAL 50MG/ML 50M
SOD CHLORIDE 3% INH 15ML
MAGNESIUM SUL 50GM/100ML
ROPIVACAIN 0.5%100MG/20ML
CEFEPIME 1GM/50ML PB
CEFEPIME 2GM/100ML PB
CEFOTAXIME 1GM PWD INJ
CEFOTAXIME 2GM/50ML PB
HEPARN PF 1U/ML 250 .45AD
HEPARN PF 1U/ML 250D10ADM
HEPARN PF 1U/ML 250 D5ADM
IMIPENEM 500MG INJ
ZOSYN 3.375/33.7 SW ADM
AMPICILLIN/SULBACT 3GM PB
PEN G NA 5MU/100ML ADM

239940119.xlsx.ms_office

Price
144.00
174.00
483.00
189.00
479.00
278.00
132.00
281.00
149.00
12.00
12.00
15.00
12.00
120.00
9.00
71.00
216.00
71.00
9.00
105.00
71.00
71.00
58.00
16.00
9.00
12.00
15.00
8.00
58.00
15.00
9.00
410.00
58.00
9.00
78.00
58.00
150.00
188.00
71.00
188.00
71.00
71.00
71.00
265.00
58.00
183.00
130.00

$0 Indicator

Page 277 of 299

CDM #
6361737
6361745
6361752
6361760
6361786
6361794
6361802
6361810
6361828
6361836
6361844
6361851
6361869
6361877
6361885
6361893
6361901
6361919
6361935
6361943
6361950
6361976
6361984
6361992
6362008
6362016
6362032
6362057
6362065
6362073
6362081
6362107
6362115
6362123
6362131
6362149
6362156
6362164
6362172
6362180
6362198
6362206
6362214
6362222
6362230
6362248
6362255

CDM Description
VANCOMYCIN 1GM/250ML PB
AMPICILLIN 2GM 100ML PB
CEFAZOLIN 2GM PWD INJ
MORPHINE 1MG/ML 100ML PCA
AMIODARONE 450/250 ADM
AZITHRMY 500MG/250ML PB
TIMOLOL 0.5% 2.5ML OP SOL
FACTOR IX RECOMB 250U INJ
FACTOR VIII RECOMB 250 IU
MORPHINE 1MG/ML 25ML PCA
OPED APAP 32MG/ML SOL
OPED AMOX 50MG/ML SUS
OPED AUGMENT 40MG/ML
OPED AZITH 40MG/ML SU
OPED CALC CAR 250MG/ML
OPED CEFDINIR 50MG/ML
OPED CEFUROX 50MG/ML
OPED CEPHALEX 50MG/ML
FACTOR VIIA RECOMB 1MG IN
APAP/OXYCODONE 325MG/7.5
A AND D 0.94GM TOP
FENTANYL 50MCG/ML 2ML INJ
PSEUDOEPHEDR 30MG/5ML PED
KETAMINE 100MG/ML 5ML INJ
MIDAZOLAM PF 1MG/ML 2ML
HYDROCORT 2.5% 28GM CRM
ACETYLCYST 20% 4ML INHSOL
FOSAPREPITANT 115MG INJ
ZIDOVUDINE 300MG TAB
GLYBURIDE/METFORM 5/500
DICLOFENAC 1.3% PATCH
BUDESONIDE 180MCG INH PWD
MULTIVIT W MINERAL PEDPO
EMOLLIENT TOP GEN
NYSTATIN PWDR 100MU 60GM
PROGESTERONE 100MG VAG SU
MESALAMINE 1.2GM TAB
ESTROG CONJ/M-PROG0.3/1.5
LACTOBAC ACIDOPH BULGAR
CARVEDILOL SR 24HR 20MG C
METHYLNALTRX 12MG 0.6M SC
CA CARB/VIT D 600MG/400IU
WHEAT DEXTRIN
BRIMONIDINE 0.1% 5ML OPS
MULTIVIT W MINERAL 15ML
OXYSTAT 1% CRM
VIT B NEPH COMPL CAP

239940119.xlsx.ms_office

Price
300.00
150.00
58.00
58.00
300.00
195.00
35.00
500.00
650.00
58.00
1.00
2.00
2.00
2.00
1.00
2.00
2.00
2.00
4,000.00
9.00
2.00
71.00
9.00
266.00
58.00
9.00
9.00
438.00
28.00
9.00
20.00
296.00
60.00
15.00
60.00
18.00
15.00
9.00
9.00
15.00
106.00
9.00
8.00
144.00
8.00
9.00
8.00

$0 Indicator

Page 278 of 299

CDM #
6362263
6362271
6362289
6362305
6362354
6362362
6362370
6362388
6362412
6362461
6362479
6362487
6362495
6362503
6362511
6362545
6362552
6362560
6362578
6362594
6362651
6362669
6362677
6362685
6362693
6362701
6362719
6362727
6362735
6362743
6362750
6362768
6362776
6362784
6362792
6362800
6362818
6362826
6362834
6362842
6362859
6362867
6362875
6362883
6362891
6362909
6362917

CDM Description
PSYLLIUM 500MG CAP
TIOTROPIUM 18MCG INHAL
TOPIRIMATE 50MG TAB
GALANTAMINE 8 MG TAB
HEPARIN 5000UNIT/ML 1ML
NOREPI/D5W 4MG/250 PRMX
FENT/ROP EPD 2MCG/ML ADM
MYCOPHEN 200MG/ML 175ML
DARBEPOET 60MCG/1ML NONES
IMM GLOB GAMUNEX 5GM INJ
IMMUNE GLOB 5GM POWDER IV
BETAMETH DIP 0.01% 82.5ML
CA ALGINATE 7.5CM DR
VARENICLINE 1MG TAB
ARIPIPRAZOLE 2MG TAB
CA CITRAT/VIT D 600MG/200
CARBOXYMETH 0.5% 15ML OPS
SINUS RINSE KIT
TRAVOPROST PF 0.004%2.5ML
PARICALCITOL 2MCG/ML 1ML
LINEZOLID 100MG/5ML 5ML
NEO RIFAMPIN ORAL
NEO SEPTRA ORAL
NEO ACETAZOL ORAL
NEO AUGMENT ORAL
NEO BACLOFEN ORAL
NEO CALC CARB SUS ORAL
NEO CAPTOPR SUS ORAL
NEO TEGRETOL ORAL
NEO COREG SUS ORAL
NEO KEFLEX ORAL
NEO CHLRTHZIDE ORAL
NEO CIMETIDINE ORAL
NEO BICITRA ORAL
NEO CLINDA ORAL
NEO CLONAZEPAM ORAL
NEO CLONIDINE ORAL
NEO BENADRYL SUS ORAL
NEO FAT EMULS OIL ORAL
NEO FLECAINIDE ORAL
NEO FLUCYTOSINE ORAL
NEO GANCICLOVIR ORAL
NEO HCTZ ORAL
NEO LAMIVUDINE ORAL
NEO LAMOTRIGINE ORAL
NEO LANSOPRAZOLE ORAL
NEO LEVETIRACETAM ORAL

239940119.xlsx.ms_office

Price
8.00
388.00
16.00
13.00
71.00
71.00
150.00
1,453.00
668.00
880.00
640.00
27.00
15.00
9.00
41.00
2.00
23.00
31.00
150.00
58.00
28.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00

$0 Indicator

Page 279 of 299

CDM #
6362925
6362933
6362941
6362958
6362966
6362974
6362982
6362990
6363006
6363014
6363022
6363030
6363048
6363055
6363063
6363071
6363089
6363097
6363105
6363113
6363121
6363139
6363147
6363154
6363162
6363170
6363188
6363196
6363204
6363238
6363253
6363261
6363287
6363295
6363303
6363311
6363337
6363352
6363360
6363378
6363386
6363394
6363402
6363410
6363428
6363436
6363444

CDM Description
NEO MAG SULF ORAL
NEO METOCLOPRAMIDE ORAL
NEO METOLAZONE ORAL
NEO METRONIDAZOLE ORAL
NEO MIDAZOLAM ORAL
NEO OMEPRAZOLE ORAL
NEO PHENYTOIN ORAL
NEO POT PHOS ORAL
NEO PREDNISONE ORAL
NEO PREDNISOLONE ORAL
NEO PYRIDOXINE ORAL
NEO SILDENAFIL ORAL
NEO SIMETHICONE ORAL
NEO SODIUM ACETATE ORAL
NEO SODIUM POLYSTY ORAL
ACYCLOVIR 40MG/ML 5ML PED
D5%+KCL 10MEQ 100ML INJ
PIMOZIDE 1 MG TAB
ESCITALOPRAM 5MG TAB
FEXOFEN/PSEUD180/240 24HR
OLOPATADINE 0.2% OP 2.5ML
BRINZOLAMIDE 1% 10ML OPSU
NEO SPIRONOLACTONE 4MG/ML
BUPROPION SR 200MG TAB
TEMSIROLIMUS 25MG/1ML INJ
FISH OIL 500MG
LEVOFLOX 25MG/ML SOL 1ML
CEFAZOLIN 2GM/100ML PB
AMPICILLIN 1GM 50ML PB
VITAMIN A 8000U CAP
NISOLDIPINE 8.5 MG
NISOLDIPINE 17 MG
NISOLDIPINE 34 MG
CHLORZOXAZONE 500MG TAB
LANSOPRAZOLE EC 15MG CAP
ACAMPROSATE 333MG DR TAB
PEN G K 5MIL UNIT/250 PB
GEMTUZUMAB 1MG/ML 5ML INJ
CLOFARABINE 1MG/ML INJ
BENDAMUSTINE 100MG INJ
ARSENIC TRIOX 1MG/ML 10ML
BACLOFEN 40MG/20ML IT
EPHEDRINE 50MG/5ML INJ
PARICALCITOL 1MCG CAP
CEFEPIME 1GM PWD INJ
CEFEPIME 2G D5W 100 OL
DOXYCYC 100MG/D5 100 OL

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
58.00
9.00
9.00
9.00
216.00
183.00
9.00
10.00
2,460.00
9.00
2.00
58.00
75.00
9.00
9.00
9.00
10.00
9.00
15.00
9.00
130.00
6,128.00
225.00
3,690.00
81.00
2,150.00
58.00
26.00
150.00
188.00
264.00

$0 Indicator

Page 280 of 299

CDM #
6363451
6363469
6363477
6363485
6363493
6363501
6363519
6363527
6363535
6363543
6363550
6363568
6363576
6363584
6363592
6363600
6363618
6363626
6363634
6363642
6363659
6363667
6363709
6363733
6363741
6363758
6363766
6363774
6363782
6363790
6363808
6363816
6363832
6363840
6363857
6363865
6363873
6363881
6363899
6363907
6363915
6363923
6363931
6363949
6363956
6363964
6363972

CDM Description
NEO SOD PHOS ORAL
FENTANYL 10MCG/ML 30ML PB
PRASUGREL 5 MG TAB
PRASUGREL 10 MG TAB
PARICALCITOL 2 MCG CAP
PARICALCITOL 4 MCG CAP
DRONEDARONE 400MG TAB
PEN G K 3MIL UNIT 50ML PB
OSELTAMIVIR 12MG/ML 75MG
OSELTAMIVIR 12MG/ML PED
CONIVAPTAN 20MG/100ML PB
OSELTAMIVIR 15MG/ML PED
TRIPTORELIN 11.25MG INJ
MEPERIDINE 10MG/ML 25MLPC
FENTANYL 5MCG/ML 2MLPEDIV
METRONIDAZ 50MG/ML PEDPO
OSELTAMIVIR PHOSPHTE 30MG
OSELTAMIVIR PHOSPHTE 45MG
MELATONIN 3MG TAB
BIAFINE 90GM TOP EMULSION
VITAMIN B COMPLEX CP
MYCOPHENOLIC AC 180MG TAB
MILNACIPRAN 25MG
CS HEP-LIDO-LR IVPB
FEBUXOSTAT(ULORIC)40MG TB
NEO HEP 0.5U/ML D5 100ML
NEO HEP 1U/ML D10 250ML
NAPHAZOLINE/PHENIR 15ML O
DOC NA 50MG/5ML 480ML SOL
INSULIN REG HUMAN PEN 3ML
MYCOPHENOLATE 200MG/ML 1M
AMOX/CLAV 400/5 5ML SUS
VEIN SOL LR/HEP/LIDO
NICARDIPINE 20MG 200 D5W
IRON SUCROSE 20MG/ML 5ML
FLUTIC/SALM 100/50 14 PWD
FENTANYL 50MCG/ML DRP PED
FLUTIC/SALM 250/50 14 PWD
FLUTIC/SALM 250/50 60 PWD
FLUTIC/SALM 500/50 14 PWD
FERRO SUL 7.5MG/0.3ML PED
NEO PHENOBARB 10MG/ML SUS
BISOPROLOL 10MG TAB
LUBIPROSTONE 8MCG CAP
FERUMOXYTOL ESRD 1MG INJ
FERUMOXY 30MG/1MLNONESRD
DARUNAVIR 400MG TAB

239940119.xlsx.ms_office

Price
9.00
58.00
19.00
19.00
50.00
87.00
15.00
118.00
30.00
5.00
1,050.00
6.00
1,020.00
58.00
58.00
58.00
24.00
24.00
9.00
100.00
9.00
12.00
8.00
75.00
15.00
58.00
58.00
14.00
9.00
58.00
15.00
10.00
81.00
281.00
78.00
202.00
403.00
202.00
455.00
224.00
597.00
8.00
9.00
14.00
2.00
2.00
47.00

$0 Indicator

Page 281 of 299

CDM #
6363980
6363998
6364004
6364020
6364038
6364046
6364053
6364061
6364079
6364087
6364095
6364103
6364111
6364129
6364137
6364145
6364152
6364160
6364178
6364186
6364194
6364202
6364210
6364228
6364236
6364244
6364251
6364269
6364277
6364285
6364293
6364301
6364319
6364327
6364335
6364343
6364350
6364368
6364376
6364384
6364392
6364400
6364418
6364426
6364434
6364442
6364459

CDM Description
DARUNAVIR 600MG TAB
PEDS PEDIALAX ENEMA
DIGOXIN 0.05MG/ML 60ML EL
HEPARIN 30000U/1000ML PB
BUPIV 0.5% 100ML ONQ PUMP
BUPRENORPHINE/NALOX 8/2MG
DORIPENEM 10MG INJ
EPOETIN 10000U ESRD INJ
EPOETIN 4000U ESRD INJ
CEFEPIME 1GM/50MLS D5
CEFEPIME 2GM/100MLS D5
MORPHINE 10MG/ML 1ML INJ
MORPHINE 5MG/ML 1ML INJ
INSULN NPH H HUMN PEN 3ML
INSUL LISPRO 100U/ML 10ML
INSULN LISPRO 100U/ML 3ML
DOXORUBICIN 50MG PWD INJ
BUPIVACAINE 0.5% 100ML
ROPIV 0.5% 400ML ONQ PUMP
BUPIVACAIN 0.5% 270ML
BUPIVACAIN 0.25% 400ML
ROPIV 0.2% 400ML ONQ PUMP
VANCO 1MG/0.1ML INTRAVITR
CEFTAZID 2.25MG/0.1ML OP
LIDOCAINE 2% LAVAGE SOLN
EPINEPHR 1:20000 20ML TOP
INFLIXIMAB 100MG INJ
VIT D(CHOLEC)400U/ML 50ML
VIT D3 200IU/0.5ML PEDPO
ATRACURIUM 10MG/ML 5ML IN
ASENAPINE 5MG TAB
IOHEXOL240 ORAL 50ML OMNC
METOPROLOL 12.5MG TAB
SELEGILINE 9MG/24HR PAT
PALIPERIDONE ER 234MG INJ
PALIPERIDONE ER 156MG INJ
PALIPERIDONE ER 117MG INJ
PNEUMOCOCCAL 13 VAL VACC
BUPIV 0.5% 400ML ONQ PUMP
SUFENTA/.2%ROPIV/NS 100ML
LIPASE 6000/PROT/AMYL
LIPASE 12000/PROT/AMYL
LIPASE 24000/PROT/AMYL
LIPASE 4200/PROT/AMYL
LIPASE 10500/PROT/AMYL
LIPASE 16800/PROT/AMYL
LIPASE 21000/PROT/AMYL

239940119.xlsx.ms_office

Price
52.00
15.00
62.00
71.00
125.00
20.00
3.00
751.00
327.00
80.00
128.00
78.00
78.00
58.00
78.00
58.00
90.00
320.00
995.00
410.00
573.00
1,033.00
156.00
156.00
20.00
20.00
1,583.00
22.00
9.00
85.00
27.00
9.00
62.00
3,495.00
2,330.00
1,748.00
272.00
580.00
120.00
8.00
8.00
9.00
8.00
8.00
8.00
9.00

$0 Indicator

Page 282 of 299

CDM #
6364467
6364475
6364483
6364509
6364517
6364525
6364533
6364541
6364558
6364566
6364574
6364582
6364590
6364608
6364616
6364624
6364632
6364640
6364657
6364665
6364673
6364681
6364699
6364707
6364715
6364723
6364731
6364749
6364756
6364764
6364772
6364780
6364798
6364806
6364814
6364822
6364830
6364848
6364855
6364863
6365878
6365886
6365894
6365902
6365910
6365928
6365936

CDM Description
PEDS ORAPRED 3MG/ML
NEO CARLSONS VIT D DROPS
INSULN LISP100U/ML PEN3ML
DARBEPOE 25MCG/0.42ML NON
DARBEPOET 40MCG/0.4ML NON
DARBEPOE 200MCG/0.4ML NON
DARBEPOET 60MCG/0.3ML NON
DARBEPOE100MCG/0.5ML NON
DARBEPO 25MCG/0.42ML ESRD
DARBEPOET 40MCG/0.4M ESRD
DARBEPO 200MCG/0.4ML ESRD
DARBEPOET 60MCG/0.3M ESRD
DARBEPOET/ALBM 100MCG/0.5
INSULIN LISP 75/25 PEN3ML
HEPARIN FLUSH 1U/3ML PEDI
IG PRIVIGEN 500MG/5ML IV
SEVELAMER 800MG TAB
SEVELAMER CARB 2.4GM PWD
SECRETIN (HUMAN) 16MCG
LOVASTATIN 10MG TAB
INFLUENZA VACC PF 6-35M
PEDS NYSTATIN SUSP
POLYSTYRENE NA SULF PWD
LACOSAMIDE 10MG/ML 20ML
MORPHINE PF 0.5MG/ML 2ML
LIDOCAINE MPF 2% 2ML INJ
FENTANYL 10MCGML 250ML PB
MIDAZOLAM 100MG/100ML PB
FENOFIBRIC ACID 135MG CAP
CEFEPIME 2GM/50ML PB
CEFEPIME 1GM/50ML PB
AFLURIA FLU VIRUS VACC >3
FLULAVAL FLU VIRUS VACC>3
FLUVIRIN FLU VIRUS VACC>3
FLUZONE FLU VIRUS VACC >3
LUBIPROSTONE 24 MCG CAP
FENTANYL 50MCG/ML 5ML INJ
MEPERIDINE 100MG/ML 1ML
MEROPENEM 20MG/ML PEDIV
MEPERIDINE 50MG/ML 1ML IN
MIDAZOLAM 2MG/ML SYRP 118
PEN G BENZ 600000U 1ML IN
PEN G BENZ 1.2MILLU 2ML
PEN G BENZ 2.4MILLU 4ML
PEN G BENZ/PROC 300000U
PEN G BENZ/PROC 1.2MIL U
PEN G BENZ/PROC 2.4MIL U

239940119.xlsx.ms_office

Price
9.00
9.00
58.00
290.00
465.00
2,323.00
697.00
1,162.00
290.00
465.00
2,323.00
697.00
1,162.00
58.00
58.00
105.00
9.00
10.00
1,038.00
9.00
58.00
9.00
52.00
102.00
58.00
71.00
58.00
78.00
15.00
128.00
80.00
78.00
78.00
78.00
78.00
20.00
71.00
71.00
34.00
71.00
128.00
71.00
71.00
124.00
58.00
71.00
116.00

$0 Indicator

Page 283 of 299

CDM #
6365944
6365951
6365969
6365977
6365985
6365993
6366009
6366017
6366025
6366033
6366041
6366058
6366066
6366074
6366082
6366090
6366108
6366116
6366124
6366132
6366140
6366157
6366165
6366173
6366181
6366199
6366207
6366215
6366223
6366231
6366249
6366256
6366264
6366272
6366280
6366306
6366314
6366322
6366330
6366348
6366355
6366363
6366371
6366389
6366397
6366405
6366413

CDM Description
TOPOTECAN HCL 4MG INJ
EPINEPHRINE 1MG/ML 1MLINJ
IMMUNE GLOB 10ML IM INJ
ESTRADIOL VAL 20MG/ML 1ML
NANDROLON DEC 100MG/ML 1M
NANDROLON DEC 200MG/ML 1M
NANDROLON DEC 100MG/ML 2M
FLUARIX FLU VIRUS VACC>3
TAPENTADOL 50MG TAB
DABIGATRAN 150MG CAP
DABIGATRAN 75MG CAP
MINERAL OIL LIGHT 25 ML
ESTROGENS CONJUGTD 0.45MG
TELAVANCIN 10MG INJ
BUPIVACAIN 0.25% 270ML
TOLVAPTAN 15MG TAB
CEFTAROLINE 10MG/600MG IN
IMM GLOB FLEBOGAM 500MG
CARDIOPLEGIA KCL 20 MEQ
CARDIOPLEGIA KCL 40 MEQ
CARDIOPLEGIA KCL 60 MEQ
VANCOMYCIN 750MG/150ML PB
HYDROCORT/IODOQUI 1% 28GM
FOSFOMYCIN GRAN 3GM PKT
ROPIV 1% 400MG/NS IRR KIT
VANCOMYCIN ENEMA 500MG
ETANERCEPT 50MG/ML INJ
CEFTAROLINE PER 10MG INJ
GLUCOSE 4GM TAB
LACOSAMIDE 50MG TAB
ACETAMIN 10MG/ML 100ML IN
TIOTROPIUM 18MCG CAPSULE
FENOFIBRIC ACID 135MG CAP
SEVELAMER CARB 0.8GM PKG
PHENOL EZ SWABS
SOD CHLORIDE 14.6% 40MLIN
PAROMOMYCIN 250MG CAP
CABAZITAXEL 60MG INJ
LIDOCAINE 4% TOP LOJ
OMEPRAZOLE 20MG PWDR
OLANZAPINE ER 1 MG/ML IM
OLANZAPINE ER 1 MG/ML IM
MAGNESIUM SUL 6GM/100MLPB
RIFAXIMIN 550MG TAB
PEDS FENTANYL INTRANASAL
ACYCLOVIR 5PC OINT 30GM
FACTOR VIII/VWF 1 IU INJ

239940119.xlsx.ms_office

Price
1,188.00
199.00
535.00
99.00
58.00
58.00
156.00
78.00
8.00
14.00
12.00
9.00
9.00
6.00
997.00
762.00
123.00
80.00
105.00
105.00
105.00
200.00
9.00
113.00
194.00
20.00
1,281.00
2.00
8.00
18.00
58.00
13.00
14.00
21.00
14.00
71.00
10.00
338.00
25.00
6.63
7.00
7.00
58.00
60.00
15.00
500.00
1,750.00

$0 Indicator

Page 284 of 299

CDM #
6366421
6366439
6366447
6366454
6366488
6366496
6366504
6366512
6366520
6366546
6366553
6366561
6366579
6366603
6366611
6366629
6366637
6366645
6366652
6366660
6366686
6366694
6366702
6366710
6366728
6366736
6366744
6366751
6366769
6366777
6366785
6366793
6366801
6366819
6366827
6366835
6366843
6366850
6366868
6366876
6366884
6366892
6366900
6366918
6366926
6366959
6366967

CDM Description
LIDOCAINE 1% 2ML INJ
SPIRIVA HANDIHALER ONLY
ACETAMIN 10MG/ML 100ML IN
MICONAZOLE 2% 60GM OINT
CYCLOPENTOLAT 0.5%15ML OP
VITAMIN B12 1000MCG SL TB
FIDAXOMICIN 200MG TAB
AMIODARONE 360MG/200ML PB
AMIODARONE 150MG/100ML PB
FOSAPREPITANT 150MG INJ
ROMIPLOSTIM 250MCG INJ
LURASIDONE 40 MG TAB
DENOSUMAB 60MG/ML 1ML INJ
BENZOCAINE 20% 0.5ML SPRY
NUTRILYTE 20ML ELECTROLYT
MAGIC MOUTHWASH 360-400ML
MAGNESIUM SUL 1G/12.5ML
ARGATROBAN 50MG/50ML IVPB
TROSPIUM 20 MG TAB
DARBEP 100MCG/1ML NONESRD
DESONIDE 0.05% 15GM OINT
EPOETIN 3000U ESRD INJ
PANCRELIPASE 5000U CAP
PEGLOTICASE 8 MG IV
ROPIVACAINE 0.1% 200ML
MEROPENEM 1 GM/100 MG
VIT K1(PHYTON)2MG/1ML INJ
TICAGRELOR 90 MG TABS
BELIMUMAB 400MG INJ
BELIMUMAB 120MG/1.5ML INJ
ANTIHEM/VWF 1036 IU 10ML
GUAIF/DM SUGAR-FR 5ML
NEO APAP 32MG/ML ORAL
CYCLOBENZAPRINE 5 MG TAB
FERROUS GLUC 324MG TAB
LEVOTHYROXINE 100MCG INJ
RIVAROXABAN 10 MG TAB
RIVAROXABAN 20 MG TAB
MIDAZOLAM 2MG/ML 5ML SYRP
MIDAZOLAM 2MG/ML 10ML SYR
LEVETIRA 100MG/ML 7.5 UDO
HYDROXYZIN 2MG/ML 10ML UD
GABAPENTIN 50MG/ML 2ML UD
GABAPENTI 50MG/ML 12ML UD
GABAPENTI 50MG/ML 16ML UD
NORCO 10/325 15ML
RASAGILINE MES 1MG TAB

239940119.xlsx.ms_office

Price
58.00
1.00
10.00
29.00
8.00
337.00
131.00
98.00
597.00
139.00
47.00
2,063.00
22.00
9.00
27.00
65.00
422.00
13.00
1,162.00
20.00
236.00
8.00
5,750.00
91.00
188.00
78.00
14.00
93.00
93.00
3,455.00
2.00
1.00
9.00
2.00
150.00
17.00
19.00
15.00
20.00
10.00
9.00
8.00
10.00
12.00
10.00
32.00

$0 Indicator
S

Page 285 of 299

CDM #
6366975
6366983
6366991
6367007
6367015
6367023
6367031
6367049
6367056
6367064
6367072
6367080
6367098
6367106
6367114
6367122
6367130
6367148
6367155
6367163
6367171
6367189
6367197
6367205
6367213
6367221
6367239
6367247
6367254
6367262
6367270
6367288
6367296
6367304
6367312
6367320
6367338
6367346
6367353
6367361
6367379
6367387
6367395
6367403
6367411
6367429
6367437

CDM Description
MORPH 20MG/ML OR SYR UDOS
OXYBUTYNIN 5MG/5ML ORS UD
CALCIUM GLUB 5ML OSY UDOS
CARBAMZPIN 20MG/ML 15 OS
PAXIL 10MG 5ML OSYR UDOS
PEPCID 8MG ML 2.5M OSY UD
PEPCID 8MG ML 5ML OSYR UD
PHENYTOIN 25MG ML OSY UD
VITAMIN C 100MG/ML OSYR U
ASPIRIN 325MG TAB
AMOX/CLAV 875/125MG TAB
ALPRAZOLAM 0.25MG TAB
CA CITRAT/VIT D 600MG/200
CA CARB 650MG TAB
CARBIDOPA/LEVOD 25/100MG
PREDNISOLON 3MG ML OSY UD
VALPRO ACD 50MG ML OSY UD
AMIODARONE 100MG T UDOS
LUBIPROSTONE 8MCG CAP
NEO DOBUTAMINE 1MG ML INJ
NEO DOBUTAMINE 2MG ML INJ
PEDS AZITHROMY 2MG ML INJ
BENZTROPINE 1MG TAB
BISOPROLOL 5MG TAB
CEFUROXIME 500MG TAB
CEPHALEXIN 250MG CAP
CIPROFLOXACIN 250MG TAB
LOSARTAN 25MG TAB UDOS
DULOXETINE 60MG CAP
OFATUMUMAB 1GM IV PR 10MG
OFATUMUMAB 100MG IV PR 10
DANTROLENE 100MG CAPS
DESIPRAMINE 25MG TAB
DICLOFENAC NA DR 75MG TAB
DILTIAZEM ER 120MG TAB
DILTIAZEM ER(12) 90MG CAP
VALSARTAN 160MG UDOS
VALSARTAN 80MG UDOS
DIPHENHYDRAMINE 25MG TAB
DONEPEZIL 5MG TAB
DARIFENACIN SR 24HR 15MG
OXYCOD ASPIRIN 3/325 UDOS
ERYTHRO BASE EC 250MG TAB
FEXOFENADINE 180MG TAB
POLYCARBOPHIL 625MG TB UD
CYCLOBENZAPRINE 5MG TAB
LANTHANUM CARBO 500MG UD

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
18.00
9.00
9.00
2.00
25.00
9.00
2.00
9.00
9.00
9.00
9.00
9.00
14.00
58.00
58.00
58.00
9.00
9.00
37.00
9.00
21.00
9.00
13.00
110.00
110.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
2.00
9.00
12.00
9.00
9.00
2.00
9.00
9.00

$0 Indicator

Page 286 of 299

CDM #
6367445
6367452
6367460
6367478
6367486
6367494
6367502
6367510
6367528
6367536
6367544
6367551
6367569
6367577
6367585
6367593
6367601
6367619
6367627
6367635
6367643
6367650
6367668
6367676
6367684
6367692
6367700
6367718
6367726
6367734
6367742
6367759
6367767
6367775
6367783
6367791
6367809
6367817
6367825
6367833
6367841
6367858
6367866
6367874
6367882
6367890
6367908

CDM Description
GLYBURIDE 1.25MG UDOS
GUANFACINE 1 MG TAB UDOS
GUANFACINE 2 MG TAB UDOS
NACL 7% INHALATION
HYDRALAZINE 50 MG TB UDOS
HYDROCHLOROTHIA 50MG UDOS
HYDROCORTISONE 20MG UDOS
HYDROMORPHONE 2MG UDOS
ISOSORB MONO 30MG ER UD
ISOSORB MONO 60MG ER UD
SITAGLIPTIN 25MG UDOS
LEVOFLOXACIN 750 MG UDOS
ESCITALOPRAM 10 MG UDOS
LISINOPRIL 2.5 MG UDOS
LISINOPRIL 10 MG UDOS
PREGABALIN 25MG CAP UDOS
DRONABINOL 2.5 MG UDOS
METFORMIN 250MG UDOS
METFORMIN 500MG UDOS
METHYLPHENIDATE 5MG UDOS
PREMARIN 0.625MG UDOS
PRENATAL MULTIVIT UDOS
PRIMIDONE 25MG UDOS
QUINAPRIL 20MG UDOS
RAMIPRIL 1.25MG UDOS
RANOLAZINE 500MG UDOS
SEVELAMER 800MG UDOS
REVATIO 25MG UDOS
ROPINIROLE 0.5MG UDOS
SELEGELINE 2.5 MG UDOS
SENSIPAR 30 MG UDOS
QUETIAPINE 200MG UDOS
QUETIAPINE 12.5MG UDOS
SIMETHICONE 80MG UDOS
SODIUM BICARB 650MG UDOS
EFAVIRENZ 600MG UDOS
CARBAMAZEPINE XR 100MG UD
THIAMINE 50MG UDOS
FENOFIBRATE 145MG UDOS
TRIHEXYPHENIDYL 5MG UDOS
VERAPAMIL 40MG UDOS
VITAMIN D 400IU UDOS
VYTORIN 10/20MG UDOS
PARICALCITOL 1 MCG UDOS
ZONEGRAN 100MG UDOS
OLANZAPINE 15MG UDOS
FENOFIBRATE 54 MG TAB

239940119.xlsx.ms_office

Price
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
16.00
65.00
9.00
9.00
9.00
9.00
30.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
9.00
12.00
9.00
31.00
9.00
9.00
30.00
24.00
9.00
2.00
9.00
49.00
9.00
9.00
12.00
9.00
9.00
9.00
10.00
26.00
9.00
55.00
9.00

$0 Indicator

Page 287 of 299

CDM #
6367916
6367924
6367932
6367940
6367957
6367965
6367973
6367981
6367999
6368005
6368013
6368021
6368039
6368047
6368054
6368062
6368070
6368088
6368096
6368104
6368112
6368120
6368138
6368146
6368153
6368161
6368179
6368187
6368195
6368203
6368211
6368229
6368237
6368245
6368252
6368260
6368278
6368286
6368294
6368302
7100019
7100027
7100035
7100043
7100050
7100076
7100084

CDM Description
NIMODIPINE 30MG NG SYR
BISMTH SUBSALICYLATE 30ML
RIVAROXABAN 15MG TAB
HEPARIN 25000 DEX20 500ML
MANNITOL INH PWD KIT
HEPARIN 25000 DEX30 500ML
HEPARIN 25000 DEX40 500ML
METOPROLOL 12.5MG UDOS
METOPROLOL 50MG UDOS
MUCINEX ER 600MG UDOS
NABUMETONE 750MG UDOS
NEOMYCIN 500MG UDOS
NEPHRO-VITE TAB UDOS
PANTOPRAZOLE 20MG UDOS
PAROXETINE 25MG ER UDOS
PHENOBARBITAL 100MG UDOS
PRAVASTATIN 20 MG UDOS
PRAZOSIN 5MG UDOS
IPILIMUMAB 200MG PER 1MG
IPILIMUMAB 50MG PER 1MG
BRENTUXIMAB 1MG
REMIFENTANIL 5000MCG PCA
MORPHINE PF 0.5MG/0.5ML
HYDROMORPHONE PF 2MG/1ML
CADEXOMER IODINE 40GM GEL
CADEXOMER IODINE 10GM GEL
VERAPAMIL SR 100MG CAP
FOSAPREPITANT PER 1 MG
BENDAMUSTINE PER 1 MG
AZACITIDINE 1MG PWD INJ
SUCROSE 24% 2ML SOL
LEVOLEUCOVORIN 0.5MG INJ
ILOPERIDONE 1MG TAB
ILOPERIDONE 4MG TAB
PRALATREXAT 20MG/1ML 1MG
PRALATREXAT 40MG/2ML 1MG
LIDOCAINE 1%BUFFERED 10ML
BUPIVAC LIPO 266MG/20ML
DIATRIZOATE MEG 30% 300ML
CITRIC AC/SIMET/NA BICARB
PACU - ANTI NAUSEA BAND
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PT COUNT STATISTICAL
INPT BED HOLD/15MIN STAT

239940119.xlsx.ms_office

Price
51.00
9.00
18.00
71.00
208.00
71.00
71.00
9.00
9.00
2.00
9.00
9.00
9.00
9.00
12.00
9.00
9.00
9.00
45,780.00
11,445.00
225.00
78.00
58.00
71.00
117.00
28.00
9.00
4.00
46.00
11.00
9.00
3.00
32.00
32.00
410.00
410.00
58.00
713.00
64.00
9.00
105.00
945.00
334.00
1,230.00
433.00
-

$0 Indicator

S
S
Page 288 of 299

CDM #
7100092
7100100
7100118
7100126
7100134
7100142
7100167
7100175
7100183
7100191
7100209
7100217
7100225
7100233
7100241
7100258
7100266
7100274
7100282
7100290
7100308
7100316
7100324
7100340
7100357
7100365
7100373
7200017
7200025
7200033
7200041
7200066
7200090
7200108
7200124
7200132
7200140
7200157
7200173
7200181
7200199
7200207
7200223
7200231
7200264
7200371
7200694

CDM Description
PACU NOBILL OTH DEPT EA15
TRANSFUS BLD/BLD COMP
AUTOLOGOUS SALVAGE
MODERATE SEDAT ADD 15MIN
MOD SEDAT =>5YRS 1ST 30M
MOD SEDAT <5YRS 1ST 30M
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
LOCAL ANESTHESIA
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX CONCURRENT
INF TX/DX/PRO EA ADD HR
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
GLUCOSE BLOOD BY DEVICE
VENIPUNCTURE
CATH GENERAL 17X-23
CATH GENERAL 13X-17
IMMOBIL/BIND 13X-17
KIT/PACK SURGI 10-13
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU NOBILL OTH DEPT EA15
MODERATE SEDAT ADD 15MIN
MOD SEDAT =>5YRS 1ST 30M
OPP RAS ONC RATE 1
OPP RAS ONC RATE 2
OPP RAS ONC RATE 3
PRE/POST VISIT PT CNT NC
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
LOCAL ANESTHESIA
GLUCOSE BLOOD BY DEVICE
OPP RAS ONC RATE 4
TRANSFUS BLD/BLD COMP
CHOLINESTRASE CHALLNG TST

239940119.xlsx.ms_office

Price
778.00
873.00
549.00
1,580.00
1,580.00
1,567.00
550.00
2,024.00
709.00
350.00
544.00
140.00
140.00
140.00
544.00
140.00
544.00
544.00
275.00
544.00
176.00
11.00
115.00
85.00
85.00
65.00
945.00
334.00
1,230.00
433.00
549.00
1,580.00
764.00
526.00
316.00
1,567.00
550.00
2,024.00
709.00
350.00
176.00
430.19
778.00
1,762.00

$0 Indicator
S

Page 289 of 299

CDM #
7300015
7300031
7300049
7300056
7300064
7300072
7300080
7300098
7300106
7300122
7300130
7300148
7300163
7300171
7300189
7300197
7300205
7300213
7300221
7300239
7300247
7300254
7300262
7300270
7300288
7300296
7300304
7300312
7300320
7300338
7300346
7300353
7300361
7300379
7300395
7300403
7300429
7300437
7300445
7300452
7300460
7300478
7300486
7300494
7300502
7300510
7300528

CDM Description
PRE/POST VISIT PT CNT NC
INJ TX/DX/PROPH SUBQ/IM
TRANSFUS BLD/BLD COMP
PHLEBOTOMY THERAPEUT
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INF TX/DX/PRO EA ADD HR
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PRO IV PUSH SEQ
INPT BED HOLD/15MIN STAT
IRRIG IMPLANTED VEN ACCES
INF IV HYDRA INIT 31-60MN
INF IV HYDRAT EA ADD HR
INF TX/DX CONCURRENT
MOD SEDAT =>5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
VISIT LEVEL 1 NEW PT
VISIT LEVEL 1 NEW W PROC
VISIT LEVEL 2 NEW PT
VISIT LEVEL 2 NEW W PROC
VISIT LEVEL 1 EST PT
VISIT LEVEL 1 EST W PROC
VISIT LEVEL 2 EST PT
VISIT LEVEL 2 EST W PROC
BLOOD COLLECTION VAD
LOCAL ANESTHESIA
INJ TX/PRO/DX IVP SME DRG
BLOOD COLLECTION PICC
GLUCOSE BLOOD BY DEVICE
PACU NOBILL OTH DEPT EA15
SURGERY LEVEL 3 1ST 30MIN
SURGERY LEVEL 3 ADD 15MIN
CHEMO SQ/IM HORMONAL
CHEMO SQ/IM NONHORMONAL
CHEMO INF EA ADD HR
CHEMO INF EA SEQ 1ST HR
CHEMO INF INIT 1ST HR
ADMIN INFLUENZA VACCINE
ADMIN OTHER IMMUN VAC ADD

239940119.xlsx.ms_office

Price
275.00
778.00
532.00
544.00
140.00
140.00
544.00
544.00
275.00
544.00
140.00
140.00
1,580.00
549.00
1,567.00
550.00
2,024.00
709.00
945.00
334.00
1,230.00
433.00
239.00
239.00
288.00
288.00
239.00
239.00
288.00
288.00
339.00
350.00
544.00
339.00
176.00
2,587.00
907.00
544.00
544.00
275.00
275.00
544.00
301.00
301.00

$0 Indicator
S

Page 290 of 299

CDM #
7300536
7300544
7300569
7300577
7300585
7300593
7300601
7300619
7300635
7300643
7300650
7300676
7300684
7300692
7300700
7300767
7300775
7300783
7300791
7300809
7300817
7300825
7300833
7300841
7300858
7300874
7300882
7300940
7300957
7300965
7300973
7300981
7300999
7301039
7301047
7301054
7301062
7301070
7301088
7301096
7301104
7301112
7301120
7301138
7301146
7301153
7301161

CDM Description
ADMIN OTHER IMMUN VAC ONE
ADMIN PNEUMO VACCINE
CARDIOVERSION ELCTIVE EXT
CATH FOR SPECIMEN COLLECT
INF IV TX/DX PUMP PROLONG
INJ TX/DX/PRO INTRA-ARTER
INS/REPL/DECL NONTUN/PIC
INSERT CATH BLADDER
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
ADMIN HEP B VACCINE
INPT BED HOLD/15MIN STAT
PACU NOBILL OTH DEPT EA15
PRE/POST VISIT PT CNT NC
INF TX/DX/PRO INIT 1ST HR
INF TX/DX/PRO SEQ 1HR
INJ TX/DX/PRO INTRA-ARTER
INJ TX/DX/PRO IV PUSH SEQ
INJ TX/DX/PRO IVPUSH INIT
INJ TX/DX/PROPH SUBQ/IM
INJ TX/PRO/DX IVP SME DRG
IRRIG IMPLANTED VEN ACCES
PUMP IMPLANTD REFIL/MAINT
PUMP PORTABL REFILL/MAINT
VENIPUNCTURE
GLUCOSE BLOOD BY DEVICE
SURGERY LEVEL 1 1ST 30MIN
SURGERY LEVEL 1 ADD 15MIN
SURGERY LEVEL 2 1ST 30MIN
SURGERY LEVEL 2 ADD 15MIN
SURGERY LEVEL 3 1ST 30MIN
SURGERY LEVEL 3 ADD 15MIN
INS/REPL/DECL NONTUN/PIC
INSERT CATH BLADDER
MINOR PROCEDURE
LOCAL ANESTHESIA
MOD SEDAT =>5YRS 1ST 30M
MODERATE SEDAT ADD 15MIN
TRANSFUS BLD/BLD COMP
CARDIOVERSION ELCTIVE EXT
VISIT LEVEL 1 EST PT
VISIT LEVEL 1 EST W PROC
VISIT LEVEL 1 NEW PT
VISIT LEVEL 1 NEW W PROC
VISIT LEVEL 2 EST PT
VISIT LEVEL 2 EST W PROC

239940119.xlsx.ms_office

Price
301.00
301.00
1,845.00
420.00
544.00
544.00
2,203.00
505.00
544.00
544.00
11.00
301.00
544.00
140.00
544.00
544.00
544.00
275.00
544.00
275.00
544.00
544.00
11.00
176.00
1,567.00
550.00
2,024.00
709.00
2,587.00
907.00
2,203.00
505.00
1,142.00
350.00
1,580.00
549.00
778.00
1,845.00
239.00
239.00
239.00
239.00
288.00
288.00

$0 Indicator

S
S
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Page 291 of 299

CDM #
7301179
7301187
7301195
7301203
7301211
7301229
7301294
7301302
8000028
8000036
8000044
8000051
8000085
8095499
8200016
8200024
8200040
8200057
8200081
8200149
8200172
8200180
8200206
8200214
8200222
8200248
8200263
8200271
8200289
8200305
8200321
8200339
8200354
8200396
8200404
8200412
8200420
8200438
8200446
8200453
8200461
8200479
8200495
8200503
8200537
9200015
9200023

CDM Description
VISIT LEVEL 2 NEW PT
VISIT LEVEL 2 NEW W PROC
PACU COMPLEX 1ST 30MIN
PACU COMPLEX ADDL 15MIN
PACU STANDARD 1ST 30MIN
PACU STANDARD ADDL 15MIN
PHLEBOTOMY THERAPEUT
PREG URINE VISUAL
DIALYSIS NOT HD 1 EVAL
CONT RENAL REPLCMNT THRPY
CONT RENAL REPLCMNT SUBSQ
HEMODIALYSIS ONE EVAL
APHERESIS PLASM THERAPEUT
EMERGENCY ESRD DIALY TRMT
ECG 1-3 LEAD TRACING ONLY
ECG 12 LEAD TRACING ONLY
CARDIOVAS STR TEST W RX
CARDIOVAS STR TEST WO RX
SIGNAL-AVERAGED ECG COMP
DOP ECHO COMP STUDY ADDON
CARDIOVAS STR TEST W RX
CARDIOVAS STR TEST WO RX
ECHO TEE WO CON
INJ FOR MICROBUBBLE STUDY
DOP ECHO LMTD STUDY ADDON
ECHO 2D COMP W CON
ECHO 2D LTD WO CON
ECHO 2D COM WO CON WO DOP
ECHO STR TEST COMP WO CON
DOP ECHO COLOR FLOW ADDON
ANALY PACE WO REPROG
ANALY SNGL PACE W PROG
ANALY DUAL PACE W PROG
ECHO 2D COMP WO CON MHI
ECHO TEE W CON
ECHO 2D LMTD W CON
ANALY MULT PACE W PROG
TTE W/DOPPLER COMPLETE
ANALY DEFIB WO REPROG
ANALY SNGL DEFIB W PROG
ANALY DUAL DEFIB W PROG
ANALY MULT DEFIB W PROG
TTE COMP W SPEC/CF W CON
HOLTER RECRD ONLY <= 48HR
US FETAL ECHO W/DOPPLER
US LEVEL I INI ADD 30MIN
US LEVEL II INI ADD 30MIN

239940119.xlsx.ms_office

Price
288.00
288.00
1,230.00
433.00
945.00
334.00
532.00
209.00
568.00
893.00
893.00
812.00
1,774.00
2,240.00
163.00
502.00
1,207.00
1,207.00
619.00
560.00
1,207.00
1,207.00
2,935.00
544.00
560.00
1,496.00
676.00
1,070.00
2,248.00
560.00
364.00
496.00
536.00
4,108.00
946.00
422.00
2,248.00
364.00
496.00
588.00
422.00
3,145.00
1,084.00
952.00
931.00
1,687.00

$0 Indicator

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CDM #
9200031
9200049
9200056
9200064
9200072
9200080
9200114
9200122
9200130
9200148
9200155
9200163
9200171
9200189
9200197
9200205
9200213
9200221
9200239
9200247
9200254
9200262
9200270
9200288
9200296
9200304
9200312
9200353
9200361
9200379
9200387
9200395
9200403
9200411
9200445
9200452
9200460
9200478
9200486
9200494
9200502
9200510
9200528
9200536
9200544
9200551
9200569

CDM Description
US PORTABLE PER TRIP NC
US V DPLX AB/PEL/RET CMP
US DOP ART EXT 1-2 LVL BI
US DOP ART EXT >=3 LVL BI
US V DPLX ART LOW EXT LT
US V DPLX ART UP EXT LT
US V DPLX ART LOW EXT BIL
US V DPLX ART UP EXT BIL
US V DOP ART LOWEXT W/S B
US V DPLX VENOUS EXT BIL
US V DOP VENOUS EXT BIL
US V DPLX PENILE VES CMP
US V DPLX AO/IVC/GRFT LTD
US DPLX EXTRACRAN UNI-LTD
US V DPLX ART LOW EXT RT
US V DPLX ART UP EXT RT
US V DPLX AB/PEL/RET LTD
US DPLX EXTRACRAN BIL-CMP
US GUIDED COMPRESS REPAR
US V DPLX VENOUS EXT LT
US V DPLX VENOUS EXT RT
US V DPLX AO/IVC/GRFT CMP
US V DOP TRANSCRAN CMP
US V DOP TRANSCRAN LTD
US TELERADIOGRAPY/EXAM NC
US LEVEL I 1ST 60 MIN
US LEVEL II 1ST 60 MIN
US RETROPERITONEAL LTD
US PREG+DETL EA ADDL GEST
US PREG+DETL SNGL1ST GEST
US GUIDED NEEDL PLACEMENT
US FOLLOW UP ABDOMEN
US FOLLOW UP RETROPERITON
US V DPLX PENILE VES LTD
US PREG TRANSVAGINAL
US PREG 1 OR >FETUSES LTD
US ABDOMEN COMPLETE
US RETROPERITONEAL COMPL
US PREG=>14WK SNG 1ST GES
US PELVIS NON OB COMP
US PREG FOLLOWUP/EA GEST
US SOFT TISS HEAD & NECK
US ABDOMEN LIMITED
US GUIDED AMNIOCENTESIS
US PREG<14WK SNGL1ST GEST
US PREG<14WKS EA ADD GEST
US SCROTUM

239940119.xlsx.ms_office

Price
2,238.00
949.00
1,389.00
1,910.00
1,910.00
2,769.00
2,769.00
2,769.00
2,769.00
1,848.00
1,340.00
928.00
1,106.00
1,910.00
1,910.00
1,126.00
2,238.00
2,827.00
1,910.00
1,910.00
928.00
2,769.00
1,848.00
1,863.00
3,374.00
1,294.00
1,115.00
1,115.00
1,294.00
1,115.00
1,115.00
1,126.00
1,388.00
740.00
1,526.00
1,893.00
1,115.00
1,244.00
1,107.00
1,671.00
918.00
602.00
1,115.00
1,374.00
1,671.00

$0 Indicator
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CDM #
9200577
9200585
9200593
9200601
9200619
9200627
9200635
9200643
9200650
9200668
9200676
9200684
9200692
9200700
9200718
9200726
9200734
9200742
9200759
9200791
9200817
9200825
9200833
9200841
9200858
9200866
9200874
9200882
9200890
9200908
9200924
9200932
9200940
9200957
9200965
9200973
9200981
9200999
9201005
9201013
9201021
9201039
9400011
9400029
9400037
9400045
9400052

CDM Description
US AAA SCREENING
US FETAL BIOPH PROF W NST
US GUIDE CATH DRAIN
US ENCEPHALOGRAM
US PORTABLE PER TRIP NC
US TRANSVAGINAL
US PREG=>14WKS EA ADD GES
US SPINAL CANAL & CONTENT
US FETAL ECHO W/DOPPLER
US GUIDE INTRAOP 1-2 HOUR
US PELVIS NON OB LTD F/U
US CHEST
US BREAST LT
US BREAST RT
US BREASTS BIL
US GUIDED VASCULAR ACCESS
US FETAL BIOP PROF WO NST
US 3D WO SEPARATE WKSTATN
US 3D W SEPARATE WKSTATN
US TRANSREC PROSTATE VOL
EXTRM VEIN ABLAT RF 1ST
EXTRM VEN ABLAT RF EA ADD
US DOP ART EXT >=3 LTD LT
US DOP ART EXT >=3 LTD RT
US KIDNEY TRANSPLANT
US DOP ART EXT 1-2 LTD RT
US DOP ART EXT 1-2 LTD LT
US V DOP ART LWEX W/S UNI
US V DOP VENOUS EX LTD LT
US V DOP VENOUS EX LTD RT
US EXTREM NONVAS COMP LT
US EXTREM NONVAS COMP RT
US EXTREM NONVASCULAR LTD
US EXTREM NONVAS LTD LT
US EXTREM NONVAS LTD RT
US V DOP VENOUS EX LTD LW
US V DOP VENOUS EX LTD UP
PARACENTSIS ABD W IMAGING
CATH DRAINAGE 17X-23
INST/SUPP STERL 195X-254
INST/SUPP STERL 39X-51
TISSUE MARKER 331X-431
SWS-PERINATOLOGY CLINICEP
SWS-POST PART RD
SWS-SWEET SUCCESS NEW PT.
SWS-RD INIT 1
SWS-RD INIT/INDIV

239940119.xlsx.ms_office

Price
918.00
1,614.00
2,692.00
1,671.00
1,593.00
1,373.00
1,244.00
952.00
424.00
952.00
1,009.00
829.00
829.00
1,203.00
837.00
1,614.00
1,311.00
1,311.00
1,593.00
3,930.00
1,966.00
1,039.00
1,039.00
1,851.00
717.00
717.00
1,910.00
1,274.00
1,274.00
1,244.00
1,244.00
1,263.00
872.00
872.00
1,274.00
1,274.00
2,783.00
115.00
1,270.00
255.00
2,155.00
58.00
113.00
58.00

$0 Indicator

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CDM #
9400060
9400078
9400086
9400094
9400110
9400128
9400136
9400144
9400151
9400169
9400177
9400391
9400409
9400417
9400433
9400490
9400508
9400532
9400557
9400573
9400581
9400599
9400607
9400631
9400649
9400656
9400672
9400680
9400698
9400722
9400755
9400763
9400854
9400862
9400904
9400912
9400920
9400938
9400946
9400953
9400961
9400979
9400987
9400995
9401001
9401019
9401027

CDM Description
SWS-RN INIT 1
SWS-RN INIT/INDIV
SWS-CLIENT ORIENT
SWS-PERINATAL ED/INDIV
SWS-RD INIT/GROUP
SWS-RN FOLLOW-UP/GROUP
SWS-RD FOLLOW-UP
SWS-RN FOLLOW-UP
SWS-INITIAL 1
SWS-SW INIT/INDIV
SWS-SW FOLLOW-UP
SWS-CASE MGMT INTENSIVE
CARD REHAB PHASE I INI NC
CARD REHAB PHASE I SUB NC
CARD REHAB INIT ASSESS NC
CARDIAC REHAB W ECG MON
CARD REHAB PHASE III NC
CARD REHAB HDL & CHOLEST
EDUC PAT-FAM & COMMUN NC
EEG AWAKE & ASLEEP
EEG ALL NIGHT RECORDING
ELECTROMYOGRAM
EEG CEREBRAL SILENCE
AUDITOR EVOKE POTENT COMP
EEG 41-60 MINUTES
EEG SEIZURE PORT>=16/24HR
EEG EXTENDED >1 HOUR
EEG AWAKE & DROWSY
NCV MOTOR NRV EA WO FWAVE
MUSCLE TEST 2 LIMBS
NEEDLE EMG 1 EXTREMITY
MUSCLE TEST 3 LIMBS
NCV MOTOR NRV EA W FWAVE
NCV SENSORY NERVE EA
EEG COMA OR SLEEP ONLY
EEG SEIZURE COMB>=16/24HR
EEG SEIZURE ATTN>=16/24HR
SWS-IND TRN COMM EA 30MIN
SWS-GRP TRN COMM EA 30MIN
SWS-PERINATAL ED/GROUP
CARD REHAB PHASE III MWF
CARD REHAB PHASE III TTH
CARD REHAB PHASE III PRO
EEG SEIZRE ATTN>=16/<12HR
EEG SEIZRE COMB>=16/<12HR
WADA ACTIVATION TEST
ELECTROCORTIC DURING SURG

239940119.xlsx.ms_office

Price
113.00
58.00
58.00
58.00
58.00
58.00
58.00
58.00
113.00
58.00
58.00
220.00
316.00
1,471.00
1,905.00
498.00
1,958.00
1,536.00
1,827.00
2,488.00
2,149.00
1,397.00
128.00
321.00
259.00
382.00
128.00
128.00
1,471.00
3,051.00
2,685.00
112.00
112.00
58.00
65.00
45.00
5.00
2,148.00
2,441.00
2,149.00
2,149.00

$0 Indicator

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CDM #
9401035
9401043
9401050
9401068
9401076
9401084
9401092
9401100
9401118
9500349
9500356
9500364
9500372
9500380
9500398
9500406
9500414
9500422
9500430
9500448
9500455
9500463
9500471
9500489
9500497
9500505
9500513
9500521
9500539
9500547
9500646

CDM Description
INST/SUPP STERL 561X-730
INST/SUPP STERL 331X-431
INST/SUPP STERL 254X-331
INST/SUPP STERL 150X-195
INST/SUPP STERL 195X-254
INST/SUPP STERL 431X-561
INST/SUPP STERL 949X-1234
INST/SUPP STERL 730X-949
INST/SUPP STERL 115X-150
NUTR. ASSESSMENT/CONSUL A
NUTR CONSULT-DIET INSTRUC
NUTR CONSULT-POOR APPETIT
NUTR CONSULT-WT LOSS <ADM
NUTR CONSULT-CHEWING PROB
NUTR CONSULT-SWALLOWING P
NUTR CONSULT-PRESSURE ULC
NUTR CONSULT-MENU ASSIST
NUTR CONSULT-CALORIE CT
NUTR CONSULT-FOOD/DIET CO
NUTR CONSULT-VISIT
NUTR CONSULT-TF/TPN ASSES
TF/TPN ASSESS A
CALORIE COUNT A
NUT ASSESS/CONSULT LTD A
DIET INSTR/EXT A
DIET INSTR/LIMITED A
NUTR ASSESS/CONSULT A
NUTR ASSESS FU BASIC
NUTR ASSESS FU COMPLEX
2 CALORIE SUPPLEMENT LTC
P-CARE CONSULT NC

239940119.xlsx.ms_office

Price
3,650.00
2,155.00
1,655.00
975.00
1,270.00
2,805.00
6,170.00
4,745.00
750.00
-

$0 Indicator

S
S
S
S
S
S
S
S
S
S
S
S
S
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Hospital Name: Woodland Memorial Hospital


OSHPD Facility No: 571086
Effective Date of Charges: June 1, 2012

In response to requests from hospitals and the public, OSHPD has developed this form to assist hospitals in collecting
and submitting the average charge for 25 common outpatient procedures performed by hospitals, as required by AB 1045
(Chapter 532, Statutes of 2005). In developing this form, OSHPD compiled the outpatient procedures reported by
hospitals in 2006, analyzed 2005 hospital ambulatory surgery data collected by OSHPD, and compared outpatient data
obtained from CMS and DHCS. Use of the OSHPD form is voluntary, but highly encouraged, as it allows hospitals to
report and the public to compare uniform information regarding common outpatient procedures.
Evaluation & Management Services (CPT Codes 99201-99499)
Average Charge
2012 CPT Code
99282
Emergency Room Visit, Level 2 (low to moderate severity)
$
1,074.00
99283
Emergency Room Visit, Level 3 (moderate severity)
$
1,732.00
99284
Emergency Room Visit, Level 4 (high severity)
$
2,689.00
99213
Outpatient Visit, established patient, 15 minutes
Laboratory & Pathology Services (CPT Codes 80048-89356)
Average Charge
2012 CPT Code
80048
Basic Metabolic Panel
$
493.00
82805
Blood Gas Analysis, including 02 saturation
85027
Complete Blood Count, automated
$
151.00
85025
Complete Blood Count, with differential WBC, automated
$
268.00
80053
Comprehensive Metabolic Panel
$
983.00
82550
Creatine Kinase (CK), (CPK), Total
$
220.00
80061
Lipid Panel
$
401.00
85730
Partial Thromboplastin Time
$
205.00
85610
Prothrombin Time
$
161.00
84443
Thyroid Stimulating Hormone
$
346.00
84484
Troponin, Quantitative
$
420.00
Urinalysis, without microscopy
81002 or 81003 $
109.00
Urinalysis, with microscopy
81000 or 81001 $
133.00
Radiology Services (CPT Codes 70010-79999)
Average
Charge
2012 CPT Code
74160
CT Scan, Abdomen, with contrast
70450
CT Scan, Head or Brain, without contrast
72193
CT Scan, Pelvis, with contrast
77057
Mammography, Screening, Bilateral
$
321.00
70553
MRI, Head or Brain, without contrast, followed by contrast
76700
Ultrasound, Abdomen, Complete
$
1,526.00
76805
Ultrasound, OB, 14 weeks or more, transabdominal
$
1,115.00
72110
X-Ray, Lower Back, four views
$
1,748.00
71020
X-Ray, Chest, two views
$
920.00
Medicine Services (CPT Codes 90281-99607)
Average Charge
2012 CPT Code
93510
Cardiac Catheterization, Left Heart, percutaneous
93307
Echocardiography, complete
$
1,070.00
93005
Electrocardiogram, routine, tracing only, w/o interpretation and report
94640
Inhalation Treatment, pressurized or nonpressurized
97001
Physical Therapy, Evaluation
$
184.00
97116
Physical Therapy, Gait Training
97110
Physical Therapy, Therapeutic Exercise
$
184.00

Hospital Name: Woodland Memorial Hospital


OSHPD Facility No: 571086
Effective Date of Charges: June 1, 2012
Surgery Services (CPT Codes 10021-69990)
Arthroscopy, Knee, with meniscectomy (medial or lateral)
Arthroscopy, Shoulder, with partial acromioplasty
Carpal Tunnel Surgery
Cataract Removal with Insertion of Intraocular Lens, 1 Stage
Colonoscopy, diagnostic
Colonoscopy, with biopsy
Colonoscopy, with lesion removal, by snare technique
Discission, secondary membranous cataract, laser surgery
Endoscopy, Upper GI, with biopsy
Endoscopy, Upper GI, diagnostic
Excision, Breast Lesion
Hernia Repair, Inguinal, 5 years and older
Injection, Diagnostic or Therapeutic substance, epidural, sacral
Injection, Anesthetic or Steroid, transforaminal epidural, sacral
Laparoscopic Cholecystectomy
Tympanostomy (insert ventilating tube, general anesthesia)
Tonsillectomy with Adenoidectomy, less than 12 years old
Other Common Outpatient Procedures (list as needed)

Average Charge
2012 CPT Code
29881
29826
64721
66984
45378
$
3,041.67
45380
45385
66821
43239
43235
19120
49505
62311
64483
47562
$
26,301.18
69436
42820
Average Charge
2012 CPT Code

Count of Reported Procedures (minimum 25 required)


Instructions for Completing AB 1045 Common Outpatient Procedure Form
1. Enter Hospital Name and OSHPD Facility Number. Revise Effective Date of Charges, if necessary.
2. Enter Average Charge for at least 25 commonly performed outpatient procedures. For Evaluation & Management
Services, report only the CDM charge for that CPT code. For all other procedures, include the CDM charge for that
CPT code along with typical related ancillary charges, such as supplies, drugs, lab, use of operating room, etc.
NOTE: The CPT codes are included on this form to help identify the listed outpatient procedures. As noted above,
charges for other provided services should be included, if they are typically provided as part of that procedure.
3. Do not change procedure descriptions or CPT code references. Use "Other Common Outpatient Procedures"
(rows 62-71) if you are unable to select procedures from list.
4. Submit completed form as Excel (.xls) file, along with chargemaster and percent change in gross revenue
calculation, by e-mail to chargemaster@oshpd.ca.gov or by standard mail on CD.
5. Contact ARSS Technical Support at (916) 326-3854 if you have any questions.

25

Facility
168 WOODLAND MEMORIAL HOSPITAL

Increase % Gross Rev - Initial


5.0%

$402,243,808

Gross Rev - Increase


$20,079,797

Gross Rev - Final Net Revenue


$422,323,605

$1,722,364

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