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Brooks Rehabilitation Charge Master 12.28.18 Brooks Rehabilitation Charge Master 12.28.18 Mnemonic Name Charge Category Category Description Amount 200020 4 Rehab/Private 118 Rehabilitation - Room and Board- Private (Medical or General) $1,400.00 200021 4 Rehab/Semi Private 118 Rehabilitation - Room and Board- Private (Medical or General) $1,400.00 210020 2 Rehab/Private 118 Rehabilitation - Room and Board- Private (Medical or General) $1,400.00 210050 2 Rehab Peds/Private 118 Rehabilitation - Room and Board- Private (Medical or General) $1,400.00 220020 3 Rehab/Private 118 Rehabilitation - Room and Board- Private (Medical or General) $1,400.00 230020 2 E Rehab/Private 118 Rehabilitation - Room and Board- Private (Medical or General) $1,400.00 239020 3 East Rehab 118 Rehabilitation - Room and Board- Private (Medical or General) $1,400.00 220021 3 Rehab/Semi Private 128 Rehabilitation - Room and Board-Semi-Private Two Bed (Medical or General) $1,400.00 219999 LOA Charge 180 General Leave of Absence $- 149900 Legal Billing 229 Other Special Charges $- 208031 Specialty Bed 229 Other Special Charges $- 218031 Specialty Bed 229 Other Special Charges $- 228031 Specialty Bed 229 Other Special Charges $- 238031 Specialty Bed 229 Other Special Charges $- 239031 Specialty Bed 229 Other Special Charges $- 309369 Misc Charges 229 Other Special Charges $- NONTAX Non Tax Client Rev 229 Other Special Charges $- TAXSUP Taxable Supplies 229 Other Special Charges $- 147557 Physical Perf Test/Measure FCE 240 General - All Inclusive Ancillary $135.00 149712 Neuro Program 1/2 Day 240 General - All Inclusive Ancillary $550.00 149715 Neuro Program Per Day 240 General - All Inclusive Ancillary $950.00 149721 Pain Program Per Day 240 General - All Inclusive Ancillary $950.00 149722 Pain Program 1/2 Day 240 General - All Inclusive Ancillary $550.00 149736 SelfPay Half Day Stepdown 240 General - All Inclusive Ancillary $250.00 149917 Self Pay Full Day Complete 240 General - All Inclusive Ancillary $450.00 149918 Self Pay Half Day Complete 240 General - All Inclusive Ancillary $250.00 149919 Selfpay Full Day Stepdown 240 General - All Inclusive Ancillary $300.00 159712 SCI 1/2 Day Treatment 240 General - All Inclusive Ancillary $550.00 159715 SCI Full Day Treatment 240 General - All Inclusive Ancillary $950.00 99232AC Hospital Follow Up Level 2 AC 240 General - All Inclusive Ancillary $142.00 71226 Metronidazole 50 mg SU 250 General Pharmacy $9.00 71260 Morphine PF 200mg/20ml 250 General Pharmacy $432.00 71288 Exp Cabergoline 0.5mg 250 General Pharmacy $609.00 71293 Cyclophosphamide 100MG 250 General Pharmacy $69.00 71294 Melphalan 2mg 250 General Pharmacy $37.00 71295 Pralidoxime Cl up to 1g 250 General Pharmacy $523.00 71301 Exp Memropenem 100mg 250 General Pharmacy $113.00 71303 Exp Meropenem 100mg 250 General Pharmacy $367.00 71308 Ergonovine Mal Upto .2 250 General Pharmacy $88.00 71312 Exp Acetlycysteine 100 250 General Pharmacy $19.00 71318 Fondaparinux 7.5mg Inj 250 General Pharmacy $329.00 71323 Ibuprofen Lysine PF 20 250 General Pharmacy $2,122.00 71325 Micafungin 50mg Inj 250 General Pharmacy $260.00 71340 Doripenem 500mg Inj 250 General Pharmacy $113.00 71341 Doripenem 500mg/NS 10 250 General Pharmacy $436.00 71342 Heparin 1 Unit/ml 3 ml 250 General Pharmacy $17.00 71343 Heparin 10 Unit/ml 10 250 General Pharmacy $20.00 71369 Hydroxycobol 2.5gm Inj 250 General Pharmacy $1,237.00 "1 71370 Nicard 0.2mg/ml 200ml 250 General Pharmacy $916.00 71371 Fentanyl 75mcg Patch 250 General Pharmacy $211.00 71388 Melphalan 2mg 250 General Pharmacy $37.00 71451 Octreotide Depo 1M 20M 250 General Pharmacy $8,955.00 71494 Morphine 1mg/ml PCA 250 General Pharmacy $319.00 71495 Fentanyl 20mcg/ml PCA 250 General Pharmacy $319.00 71496 Hydromorph 0.2 mg/ml P 250 General Pharmacy $319.00 71516 Hydromorph 2mg Inj 250 General Pharmacy $164.00 71571 Phenobarb 130mg Inj 250 General Pharmacy $164.00 71579 Haldol Dec 100mg Inj 250 General Pharmacy $104.00 71582 Metformin 500mg Udl 250 General Pharmacy $17.00 71592 Zanamivr Inh-10 Dose 250 General Pharmacy $296.00 71608 D5NS/Potass Chlor 20meq/1000ml 250 General Pharmacy $441.00 71609 D50.45NACL/POT CHL.10MEQ 1000 250 General Pharmacy $507.00 71614 Sodium Citrate 3ml Syringe 250 General Pharmacy $23.00 71615 Oxymorphone 40mg Srtab 250 General Pharmacy $113.00 71616 Nilotinib HCL 200mg 250 General Pharmacy $305.00 71617 KCL 25 Meq/250 ml 250 General Pharmacy $341.00 71618 KCL 25 Meq/500ml 250 General Pharmacy $341.00 71619 Heparin 30000Unit/1000ml 250 General Pharmacy $517.00 71620 Oxymorphone 5mg Tab 250 General Pharmacy $77.00 71626 Ziconotide 500mcg/20ml 250 General Pharmacy $11,115.00 71650 Celecoxib 200mg Cap 250 General Pharmacy $33.00 71653 Famotidine 20mg Chewtab 250 General Pharmacy $17.00 71659 Cabazitaxel 60mg Inj 250 General Pharmacy $25,852.00 71669 Fluticasone 100 Inh 250 General Pharmacy $378.00 71670 Fluticasone 250 Inh 250 General Pharmacy $474.00 71677 Ceftriaxone 100mg/ml 250 General Pharmacy $88.00 71688 Dabigatran Etexilate 150mg Cap 250 General Pharmacy $38.00 71695 Interf Beta1A 30Mcg Inj 250 General Pharmacy $2,018.00 71907 Exp Derm Nonhm Ts Sq C 250 General Pharmacy $202.00 71909 Exp Derm Nonhm Ts Sq S 250 General Pharmacy $404.00 74400 Perflutren Lipd Mcrs 250 General Pharmacy $565.00 75052 Fentanyl 12Mcg per hr Patch 250 General Pharmacy $211.00 75062 Hyaluronidase Up to 15 250 General Pharmacy $167.00 75438 Ropivacaine 0.2% 20ml 250 General Pharmacy $78.00 75439 Ropivacaine 0.5% 30ml 250 General Pharmacy $121.00 75440 Levetiracetam 500mg Inj 250 General Pharmacy $151.00 75444 Conivaptan 20mg Inj 250 General Pharmacy $1,448.00 79430 Vzig 125 Unit/1.25ml 250 General Pharmacy $238.00 79431 Acyclovir 40mg/ml Udl 250 General Pharmacy $12.00 171202 Oseltamivir 25ml Susp 250 General Pharmacy $207.00 171275 Roflumilast 500mcg Tab 250 General Pharmacy $56.00 171282 Lidocaine 2% 5ml Inj 250 General Pharmacy $44.00 171285 Lidocaine 1% 10ml 250 General Pharmacy $152.00 171287 Valganciclovir 100ml 250 General Pharmacy $2,142.00 171290 Aripiprazole 9.75mg Inj 250 General Pharmacy $106.00 171311 Hydromorphone 2mg Inj 250 General Pharmacy $152.00 193045 Glucose Tolerance Bev 250 General Pharmacy $41.00 301031 Teds Thigh Xxlarge/Reg (351) 250 General Pharmacy $35.00 "2 301263 Tube Gastrostomy 22Fr 250 General Pharmacy $80.00 301264 Tube Gastrostomy 24Fr 250 General Pharmacy $80.00 305112 Trach Tube 6.0 250 General Pharmacy $150.00 305117 Drsg Mepilex Ag 4X4 250 General Pharmacy $23.00 314245 Adhesion Barrier 250 General Pharmacy $2,999.00 314506 Collagen Instat 3x4in 250 General Pharmacy $313.00 314995 Adcon Adhesion Barrier 250 General Pharmacy $4,177.00 378706 CPD Anticoagulant 250 General Pharmacy $251.00 423966 Pyrophosphate Vial 250 General Pharmacy $117.00 425354 Midazolam Syrup 250 General Pharmacy $88.00 425358 Rivaroxaban 10 Mg Tablet 250 General Pharmacy $63.00 425396 Ceftaroline Fosamil 600Mg Vial 250 General Pharmacy $488.00 425435 Hepa Imag Incl Gb 250 General Pharmacy $1,744.00 425436 Hepa Imag Incl Gb w ph 250 General Pharmacy $1,744.00 425453 Ceftaroline Fosamil 400Mg Vial 250 General Pharmacy $488.00 425640 Clotrimazole Crm 1% 45gm 250 General Pharmacy $51.00 434134 EYE IRRIGATION BLINK 8 250 General Pharmacy $73.00 436431 LACRILUBE 250 General Pharmacy $61.00 438110 BLINX 250 General Pharmacy $62.00 439620 VISCOAT INJ 250 General Pharmacy $1,318.00 476101 SADDLE BLOCK TRAYS ABB 250 General Pharmacy $337.00 476108 SPINAL TRAYS 22G PHARM 250 General Pharmacy $304.00 476118 TRAY SPINOCAN BURRON 2 250 General Pharmacy $117.00 476191 KITS L.T.A. 25/CS 250 General Pharmacy $248.00 477532 TRAY SPINAL BURRON 26G 250 General Pharmacy $117.00 477533 TRAY SPINAL SPINOCAN B 250 General Pharmacy $117.00 477534 TRAY SPINAL SPINOCAN B 250 General Pharmacy $117.00 477603 TRAY LUMBAR SYMPATHETI 250 General Pharmacy $333.00 480947 Dilator Jcd 14-0-0-38-2 250 General Pharmacy $218.00 482135 Dilator 9.0X38X20 250 General Pharmacy $201.00 485878 Dilator Vssl 4F 035 250 General Pharmacy $107.00 686832 Rhogam, 50Mg Dose 250 General Pharmacy $77.00 735167 Lidocaine/Epi 1.5% Sdv 250 General Pharmacy $111.00 750005 Pentazocine 30mg Amp 250 General Pharmacy $167.00 750008 Tetanus Toxiod 250 General Pharmacy $102.00 750030 Meperidine 10mg/ml 50m 250 General Pharmacy $717.00 750083 Morphine 500mg/20ml Inj 250 General Pharmacy $218.00 750300 Misoprostol 25mcg Tab 250 General Pharmacy $30.00 750355 Meperidine 25mg/ml Inj 250 General Pharmacy $110.00 750357 Sufentanil 100mcg 1ml 250 General Pharmacy $506.00 750358 Sufentanil 5ml Inj 250 General Pharmacy $1,222.00 750364 Fentanyl 1000mcg/20ml 250 General Pharmacy $409.00 750476 Didanosine 125mg 250 General Pharmacy $53.00 750971 Gen Code (250) 250 General Pharmacy $- 751635 Tramadol HCL 50 MG Tab 250 General Pharmacy $20.00 751900 ACETYLCYSTEINE 6GM INJ 250 General Pharmacy $493.00 752004 Bivalirudin 250mg Inj 250 General Pharmacy $1,264.00 752005 Acth Gel 80U/ml UDI 250 General Pharmacy $67.00 752029 Alcohol 95%ml 250 General Pharmacy $75.00 752035 Methyldopa 250mg 5ml Vial 250 General Pharmacy $104.00 "3 752047 Aminophylline 10mg Ud 250 General Pharmacy $69.00 752065 Physostigmine 2mg Amp 250 General Pharmacy $76.00 752071 Antivenin Crotal/Crofa 250 General Pharmacy $3,951.00 752072 Antivenom Blck Wid(Lact 250 General Pharmacy $321.00 752087 Asparaginase 10000U/10 250 General Pharmacy $533.00 752111 Amikacin 500mg Inj 250 General Pharmacy $62.00 752115 Atropine 0.4 MG/ML 20 250 General Pharmacy $125.00 752184 Calcitonin 100mcg Udi 250 General Pharmacy $75.00 752185 Calcitonin 200mcg Udi 250 General Pharmacy $166.00
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