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Procedure Description Charge Amount 1302300005 ROOM MED Charge Procedure Description Amount 1302300005 ROOM MED SURG W TELEMETRY ENU 1,360.00 1302300012 ROOM MED SURG ENU 850.00 1302300019 ROOM SWING CUSTODIAL ENU 220.00 1302300020 ROOM SWING SKILL ENU 235.00 1302300043 ROOM HOSPICE BED ENU 765.00 1302300052 ROOM RESPITE CARE BED ENU 765.00 1302302346 OUTSIDE SERVICE FEE VAR SUP 1302310079 CATH INDWELL BLADDER SIMPLE 210.00 1302310109 CODE BLUE 1,035.00 1302310304 OBSERVATION PER HR 40.00 1302310305 OBSERVATION PER HR TELEMETRY 64.00 1302310556 NONBILLABLE OBSERVATION HR 0.00 1302310557 OBSERVATION DIRECT ADM 130.00 1302320288 SYSTEM CHEST TUBE 312.00 1302320935 SUPPLIES PICC LINE 230.00 1302322214 WOUND VAC FOAM 110.00 1302322259 BOOT WAFFLE 108.00 1302322407 KIT PREVALON TURNING POSITION 550.00 1302322466 HANGER BRACE SERVICE VAR SUP 1302350451 IV INF THERAPEUTIC EA ADD HR 210.00 1302350453 IV INF THERAPEUTIC UP TO 1HR 635.00 1302350457 GASTRIC INTUBATION/LAVAGE 930.00 1302350480 INSERT VENOUS CENTRAL LINE 1,660.00 1302350484 INJECTION SUB-Q/IM 125.00 1302350490 IV PUSH INITIAL DRUG 234.00 1302350603 IV PUSH EA SEQUENTIAL DRUG 153.00 1302350885 ADMIN IMMUNIZATION 120.00 1302350895 EXCISION NAIL & MATRIX 880.00 1302360067 ADMIN PNEUMOCOCCAL VACCINE 94.00 1302360068 ADMIN INFLUENZA VIRUS VACINE 94.00 1302360263 ADMIN TB SKIN TEST 77.00 1302360269 US PV RESIDUAL URINE 230.00 1302360274 IV PUSH EA ADD DRUG 168.00 1302360275 IV INF CONCURRENT THERAPEUTIC 345.00 1302360276 IV INF SEQUENTIAL THER UP TO 1 210.00 1302360293 INSERT STRAIGHT CATH THERAPEUT 195.00 1302360373 IV INF HYDRATION EA ADD HR 170.00 1302360374 IV INF HYDRATION UP TO 1HR 585.00 1302360696 BLOOD TRANSFUSION DAILY 1,020.00 1302360801 CATH FOR URINE SPECIMEN 21.00 1302360804 NURSING E/M ESTAB LVL 1 100.00 1314010056 BIPAP SETUP/SUPPLIES 204.00 1314010541 PULMONARY STRESS TEST 400.00 1314020026 AMBUBAG 42.00 1314020103 STRAP BIPAP CHIN 29.00 1314020104 CIRCUIT BIPAP 39.00 1314020105 STRAP BIPAP HEAD 27.00 1314020106 MASK BIPAP 60.00 1314020293 CIRCUIT IPPB 10.00 1314020629 SETUP/SUPPLIES HHN 24.00 1314020679 KIT ASTHMA 121.00 1314020747 SPACER MDI 48.00 1314020866 OXYGEN DAILY CHARGE 194.00 1314020920 DEVICE PEAK FLOW 47.00 1314021291 FLUTTER VALVE SUPPLY 92.00 1314022288 HHF WWO OXYGEN DAILY 194.00 1314050232 SPIROMETERY PULMONARY FUNCTION 190.00 1314050320 PULSE OXIMETRY PRE/POST EXER 74.00 1314050321 PULSE OXIMETRY OVERNIGHT 470.00 1314050323 PULSE OXIMETRY ASSESSMENT 48.00 1314050325 PULSE OXIMETER DAILY CHARGE 470.00 1314050354 CHEST PT MANUAL EA ADD 103.00 1314050355 CHEST PT MANUAL INITIAL 103.00 1314050359 PH ANALYSIS PLEURAL FLUID 80.00 1314050360 PH ANALYSIS ARTERIAL BLOOD 100.00 1314050361 PFT PROVOCHOLINE CHALLENGE 855.00 1314050362 PFT PRE-POST BRONCHODILATOR 550.00 1314050383 PEAK FLOW MEASUREMENT 60.00 1314050401 NEBULIZER TX PENTAMIDINE 385.00 1314050456 IONIZED CALCIUM 130.00 1314050522 INCENTIVE SPIROMETER W INSTRUC 130.00 1314050561 GLUCOSE 75.00 1314050605 ELECTROLYTE PANEL 115.00 1314050633 EEG AWAKE/ASLEEP/PHOTIC/HV 1,430.00 1314050677 COOXIMETRY 93.00 1314050802 BIPAP DAILY CHARGE 365.00 1314050816 ARTERIAL PUNCTURE W BLOOD DRW 44.00 1314050878 BLOOD GAS ANALYSIS 235.00 1314050889 ACT-ACTIVATED CLOTTING TIME 81.00 1314050893 REQUEST FOR SERVICE 0.00 1314060010 HOME RESP THERAPY DEMO 145.00 1314060021 EEG EXTENDED MONITOR > 1 HR 1,400.00 1314060022 EEG EXTENDED MONITOR 41-60M 1,255.00 1314060273 VENT CHARGE FIRST DAY 1,700.00 1314060296 BEDSIDE SPIRO PRE&POST BRONCHO 550.00 1314060297 BEDSIDE SPIROMETRY 190.00 1314060853 PLETHYS LUNG VOL/AIRWAY RESIST 710.00 1314060854 DIFFUSING CAPACITY 260.00 1314061146 SLEEP STUDY W CPAP SERVICE 4,670.00 1314061147 SLEEP STUDY WO CPAP SERVICE 4,670.00 1314061167 SLEEP STUDY HOME UNATTENDED 475.00 1314061272 CHEST PT VEST INITIAL OR SUB 103.00 1314061273 RESP TX INITIAL OR SUB 120.00 1314090155 INSERT ART LINE 1,585.00 1314202201 CARDIAC RHB PH2 EXERCISE/EA 215.00 1314210488 HOLTER SCANNING UP TO 24 HR 475.00 1314220891 6 MINUTE WALK TEST 145.00 1314250310 AMB CARDIAC TELE UP TO 30 DAYS 155.00 1314250326 PULMONARY REHAB PH 2/ SESSION 93.00 1314250328 PULM REHAB PH 3/EACH 5.00 1314250610 EKG STRESS 765.00 1314250622 ECHO 2D M MODE LIMITED 745.00 1314250627 ECHO STRESS 1,485.00 1314250628 ECHO PEDS CONG ANOM LIMITED 1,075.00 1314250629 ECHO PED CONG ANOM COMP 935.00 1314250630 ECHO DOPPLER PW CW LIMITED 175.00 1314250631 ECHO DOPPLER PW CW COMPLETE 385.00 1314250632 ECHO DOPPLER COLOR VEL MAPPING 355.00 1314250667 HOLTER SCANNING 48 HR 440.00 1314250668 HOLTER RECORD/HOOKUP 48 HR 360.00 1314250779 CARDIAC REHAB PH 3/ EACH 5.00 1314250923 ECHO 2D M MODE COMPLETE 1,485.00 1314250928 HOLTER RECD/HOOK UPTO 24H 480.00 1314250932 EKG 195.00 1314250989 ECHO CONTRAST 1.5 ML 312.00 1314260245 EKG PEDS 195.00 1314260388 STRESS ECHO C CON/ECHO PORTN 2,170.00 1314260673 CARD REHAB P2 NONMONITOR EXER 115.00 1314261189 ECHO 2D MMODE COMPLETE W CON 2,170.00 1314261190 ECHO 2D M MODE LIMITED W CON 1,150.00 1314261324 ECHO STRESS W EKG WO CONTRAST 2,250.00 1314261325 ECHO STRESS W EKG W CONTRAST 2,935.00 1314261326 ECHO STRESS WEKG WO CON WPHARM 2,250.00 1314261327 ECHO STRESS W EKG W CON WPHARM 2,935.00 1314261360 MYOCARDIAL STRAIN IMAGING 400.00 1321002341 CANNULA WO TROCAR 5 X 100 MM 14.00 1321002346 OUTSIDE SERVICE FEE VAR SUP 1321010000 INSERTION ARROW CATH 440.00 1321010003 3000CC LR NACL OR H20 IRRIGANT 22.00 1321010049 AVITINE 404.00 1321010065 BROVIAC INSERTION 680.00 1321010072 CATARACT SURGERY PKG 3,480.00 1321010073 CATH INSERT LEONARD/HICKMAN 815.00 1321010086 CLASS I 625.00 1321010089 CLASS II 2,180.00 1321010093 CLASS III 2,750.00 1321010096 CLASS IV 4,195.00 1321010099 CLASS V 5,905.00 1321010102 CLASS VI 7,345.00 1321010109 CODE BLUE OR 1,430.00 1321010210 GLYCINE 1.5% 3000 CC 47.00 1321010223 INDIGO LASEROPTIC SYSTEM 5,572.00 1321010263 LITHOTRIPSY PROBE 554.00 1321010276 MISC OPERATING RM I 24.00 1321010277 MISC OPERATING RM II 170.00 1321010278 MISC OPERATING RM III 340.00 1321010279 MISC OR VAR SUP 1321010289 MYRINGOTOMY W TUBE 630.00 1321010432 SOL. SOD CHLOR.IRRIG. 1000 CC 58.00 1321010433 SOL. WATER IRRIG 1000 CC 58.00 1321010464 TTS DILATATION 450.00 1321010477 VITRECTOMY 850.00 1321010485 XYLOCAINE JELLY 2% 53.00 1321020027 ANCHORS VESICA SUTURE 649.00 1321020032 ANCHOR CLIP ANGLED 82-8591 124.00 1321020046 SUPPLIES ARTHROSCOPY 1,334.00 1321020052 AUTOSUTURE TA-90 LONG 237.00 1321020053 AUTOSUTURE CEEA 25/28/31 1,248.00 1321020054 AUTOSUTURE ROTIC. 55-3.5/4.8/ 1,321.00 1321020056 AUTOSUTURE TA90 3.5/4.8 493.00 1321020070 BAG UA DRAINAGE 2000CC 38.00 1321020071 BAG UA DRAINAGE 4000 CC 42.00 1321020072 BAG UA LEG 13.00 1321020077 BALLOON DILATION CATHETER 533.00 1321020079 BALLOON INSERT DATASCOPE 34/40 2,537.00 1321020080 BALLOON UROMAX 847.00 1321020090 BLANKET BEAR HUGGER 121.00 1321020095 BAG BILE 35.00 1321020102 FORCEPS BIOPSY DISP 81.00 1321020107 CAUTERY BIPOLAR CORD 20.00 1321020115 BLADE SAW ALL 209.00 1321020135 BONE PLUGS ORTHO 310.00 1321020142 SUPPLIES BOWEL 321.00 1321020144 SUPPLIES BREAST BIOPSY 123.00 1321020179 CAST LONG LEG 123.00 1321020184 CAST SHORT ARM 40.00 1321020185 CAST SHORT LEG 68.00 1321020187 CAST SYNTHETIC LONG ARM 272.00 1321020188 CAST SYNTHETIC LONG LEG 588.00 1321020189 CAST SYNTHETIC SHORT ARM 172.00 1321020190 CAST SYNTHETIC SHORT LEG 295.00 1321020204 CATH FOLEY 24 30 CC 3 WAY 64.00 1321020205 CATH FOLEY ALL SIZES 59.00 1321020207 CATH GROSHONG MRI DUAL IMPLANT 2,233.00 1321020208 CATH GROSHONG MULTI LUMEN KIT0 1,193.00 1321020234 CATH SECURE 10.00 1321020236 CATH STAMEY 122.00 1321020246 CATH URETERAL 191.00 1321020249 CATHETER ALL PURPOSE 16FR 10.00 1321020266 CAUTERY EXTENDER 26.00 1321020268 CAUTERY SUCTION 35.00 1321020270 SUPPLIES CBI IRRIGATION 35.00 1321020273 CARTRIDGE CEMENT GUN 177.00 1321020289 CHOLANGIOCATH ALL SIZES 31.00 1321020290 SUPPLIES CHOLECYSTECTOMY 454.00 1321020296 CLASS VII 14,625.00 1321020305 CLIPS LARGE/ORANGE 77.00 1321020306 CLIPS MEDIUM/LARGE 40.00 1321020308 CLIPS SMALL/YELLOW 45.00 1321020344 CUFF TOURNIQUET 63.00 1321020354 DERMATONE WITH BLADE 158.00 1321020376 STRAP DOVER CATH 11.00 1321020381 DRAIN JACKSON PRATT W RESERVOI 105.00 1321020383 DRAIN JACKSON-PRATT 62.00 1321020384 DRAIN T 5 INCH ALL SIZES 28.00 1321020391 DRESSING GELFOAM SPONGE SZ LRG 90.00 1321020399 DRESSING SURGICEL 124.00 1321020404 DRILL BIT 45.00 1321020412 TUBE EAR ALL SIZES 86.00 1321020448 ENDO KITTNER 34.00 1321020450 SUTURE DEVICE ENDO 459.00 1321020451 SUTURE RELOAD ENDO 72.00 1321020452 POUCH ENDOCATCH SPECIMEN 480.00 1321020453 ELECTRODE HOOK ENDO 178.00 1321020454 IRRIGATOR STRYKER ENDO-FLO 231.00 1321020455 ENDOLOOP EACH 64.00 1321020456 ENDOPATH EZ45G 864.00 1321020457 ENDOPATH ZR45B/ZR45G (RELOAD) 350.00 1321020485 ESMARK 49.00 1321020488 LIGACLIPS ETHICON 190.00 1321020492 FIXTURES EXTERNAL 2,400.00 1321020533 STAPLER GIA 35V 833.00 1321020535 AUTOSUTURE GIA-60 RELOADER 281.00 1321020536 AUTOSUTURE GIA-60 STAPLER 448.00 1321020537 AUTOSUTURE GIA-80 RELOADER 358.00 1321020538 GIA-80 STAPLERAUTOSUTURE 594.00 1321020541 PATCH GORTEX SOFT TISSUE 1,884.00 1321020565 SUPPLIES GRAM 890.00 1321020568 CATH GROSHONG MULTI LUMEN KIT7 1,018.00 1321020577 GUIDEWIRE GLIDEWIRES 154.00 1321020581 GUIDEWIRE J&J CORDIS 503SERIES 251.00 1321020588 GUIDEWIRE URO 77.00 1321020593 HARDWARE VAR SUP 1321020625 SUPPLIES HEMI ARTHROPLASTY 743.00 1321020626 HEMICLIPS MEDIUM 90.00 1321020636 SUPPLIES HIP PINNING 445.00 1321020637 FORCEPS DISP HOT BIOPSY 124.00 1321020641 IMMOBILIZER KNEE 217.00 1321020644 IMPLANT DEVICE TVT J&J510041 2,578.00 1321020646 IMPLANTS TOE 528.00 1321020661 LENS INTRAOCCULAR 3,454.00 1321020669
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