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Cedars-Sinai Chargemaster 2021 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02600001 HB IV INFUS HYDRATION 31-60 MIN 96360 $2,049.01 $2,665.08 02600002 HB IV INFUSION HYDRATION ADDL HR 96361 $502.12 $649.97 02600003 HB IV INFUSION THERAPY 1ST HR 96365 $2,294.89 $2,984.91 02600004 HB IV THERAPY ADDL SEQ UP TO 1 HR 96367 $502.12 $649.97 02600005 HB IV THERAPY-CONCURRENT 96368 $700.35 $907.85 02600007 HB INFUSION SC INITIAL FIRST HR 96369 $942.60 $1,225.38 02600008 HB SC INFUSION ADD'L HOURS 96370 $468.23 $608.70 02600012 HB IV INFUSION THERAPY EA ADDL HR 96366 $502.12 $649.97 02600013 HB IV PUSH INITIAL 96374 $1,253.71 $1,629.84 02600014 HB IV PUSH ADDL SEQ NEW DRUG 96375 $893.88 $1,162.05 02600015 HB IVP ADDL SEQ SAME DRUG 96376 $940.84 $1,223.10 02600017 HB APPL ON-BODY INJECTOR SUBQ INJ 96377 $468.23 02700005 HB CYTOTOXIC SPILL KIT $252.20 02700007 HB 24 HR PH PROBE $3,194.60 02700008 HB FEMSTOP $762.42 02700009 HB PC IPPB KIT $348.08 02700016 HB PEFR-EQUIPMENT $913.64 02700018 HB PC AERO KIT $1,868.84 02700020 HB PC O/P USN EQUIPMENT $1,054.19 02700021 HB PC MICRO-SPIROMETER $11,489.64 02700022 HB PC O/P HHN EQUIPMENT $667.65 02700033 HB STOCKINETTE,2"X25YD/BOX $301.10 02700034 HB DILATOR, RDS $2,968.15 02700035 HB NEEDLE, BIOPSY/ASP/LOC/INJ $428.94 02700036 HB POWER MODULE BACK BATTERY Q0496 $1,971.27 02700042 HB HMGG, TRAVEL CASE Q0508 $758.94 02700044 HB METANEB RT DEVICE KIT $2,315.11 02700045 HB PC METANEB KIT $348.08 02700046 HB HM MODULAR CABLE Q0509 $27,908.70 02710001 HB SUPPORTER, SCROTAL $878.47 02710002 HB SPLINT FOREARM - SMALL $506.19 02710003 HB SPLINT, SUGARTONG $2,785.66 02710005 HB SPICA - HIP (SINGLE OR DOUBLE) $5,502.06 02710006 HB COLLAR, CERVICAL $683.29 02710009 HB CAST, SHORT ARM CAST $1,779.83 02710012 HB PADS R2 EP STUDY $777.89 02710013 HB SPLINT FINGER 2 INCHES $361.24 02710014 HB MUCUS CLEARING DEVICE $363.13 02710018 HB BILE BAG REG $636.70 02710019 HB FECAL INCONTINENCE COLLECTOR $519.25 02710022 HB PC PEP VALVE $411.14 02710023 HB SPLINT WRIST - LARGE $433.48 Ancillary FY22 1 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02710024 HB SPLINT WRIST - MEDIUM $433.48 02710027 HB PENTAMIDINE KIT $515.14 02710029 HB SPLINT, WRIST $1,215.76 02710032 HB SUPPORT LUMBO-SACRAL $1,329.46 02710033 HB KNEE IMMOBILIZER $1,372.86 02710035 HB AEROSOL INHAL, PENTAM ADD'L 10 $1,478.41 02710036 HB SPICA - THUMB OR FINGER $1,661.25 02710037 HB BI-VALVE OR DC CAST $400.08 02710038 HB KIT, OSTOMY 5PK (1 PIECE) $1,692.37 02710039 HB SPLINT, MOLDED $1,712.51 02710041 HB EAR LAVAGE $482.73 02710044 HB 02 CONNECTION TUBING MASK $485.54 02710045 HB HEADSET NAVIGATION DEVICE $501.06 02710047 HB SPLINT FOREARM - MEDIUM $613.49 02710050 HB SPICA CAST - INFANT $181.61 02710053 HB PC HELIOX ADMIN. PER HOUR $228.21 02710054 HB PC NITROGEN ADMIN. PER HOUR $228.21 02710055 HB ILEOSTOMY POUCH $848.98 02710056 HB UNIVALVE CAST OR SPLINT $264.08 02710057 HB PC H.H.N. KIT $435.35 02710058 HB SPLINT FOREARM - LARGE $728.90 02710059 HB SPLINT,THUMB $763.16 02710060 HB PAG-HEART NEB EQUIP $780.86 02710061 HB PASSY MUIR SPEAKING VALVE $803.67 02710063 HB STOMAHESIVE WAFER $821.54 02710064 HB SPLINT, ARM $979.70 02710067 HB PENTAMIDINE EQUIPMENT OP * $1,183.05 02710070 HB SPLINT, KNEE VELCRO $4,898.34 02710073 HB CAST, SHORT LEG WALKING $2,233.99 02710074 HB CAST, CYLINDER THIGH TO ANKLE $2,536.68 02710077 HB CAST, PATELLAR TENDON BEARING $3,161.24 02710078 HB CAST, LONG LEG $3,680.96 02710080 HB KIT, WOUND CLEASING $308.72 02710081 HB SPLINT, SHORT/LONG LEG $2,990.49 02710083 HB PUMP DISCONNECT KIT $137.29 02710085 HB SPLINT WRIST - SMALL $361.24 02710087 HB CAST, SHOE $740.63 02710089 HB CAST SHORT LEG $9,285.31 02710090 HB CAST, LONG ARM $4,478.11 02710091 HB CAST, LONG LEG WALKING $2,233.99 02710101 HB SPLINT, IMMOBILIZER KNEE $1,372.86 02710104 HB SPLINT,IMMOBILIZER SHOULDER $220.06 Ancillary FY22 2 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720001 HB BASKET GEMINI 3FR $1,923.83 02720003 HB CRYOCATH, FROSTBYTE CLAMP $14,214.18 02720008 HB MEDIA FOR IUI $226.08 02720009 HB WIRE, MICRO EXCHANGE $2,646.13 02720010 HB CATH PERIPHERAL DILITATION C1725 $2,729.50 02720016 HB LASER FIBER, 3 $4,212.23 02720017 HB NEUROPEN WITH NEUROENDOSCOPES $4,406.60 02720018 HB VALVE, DRAINAGE/FARRELL $305.78 02720021 HB CATH DELIVERY SYSTEM $6,746.55 02720023 HB LASER FIBER, 9 $8,693.09 02720025 HB CATH INTRA-AORTC BALLOON $15,893.93 02720034 HB CLIP SURGICAL SPRING CLIP $216.90 02720035 HB KIT, OSTOMY (2 PIECE) $1,150.21 02720036 HB LEVEL I TUBING D-50 $1,169.85 02720037 HB DRAIN 1 $370.43 02720039 HB ENDOSCOPIC VERSATEP $1,002.86 02720040 HB ENDO LLETZ BALL ELCTRODE $318.49 02720044 HB ENDOSCOPE SHEATH DISPOSABLE $584.69 02720045 HB COLOSTOMY BAG $585.72 02720046 HB KYPHON BONE FILLER DEVICE OR $1,213.38 02720047 HB CATHETER, EPISTAXIS BALLOON $597.74 02720048 HB ENDO ELECTRODE CUTTING LOOP $976.36 02720049 HB SHEATH, PERITONEAL/AMPLATZ $606.67 02720050 HB PC NASAL MASKS BIPAP $1,236.22 02720051 HB ENDO IRRIG ENDO-FLO 0037970 $616.13 02720053 HB BIOPSY BRUSH COOK 040310 $619.28 02720054 HB NEEDLE, SCLEROSING $1,265.85 02720055 HB CATH FOLEY W/THERMISTER $529.21 02720056 HB CANNULA, CORONARY PERFUSION DL $621.78 02720058 HB ELECTRODE, ACRIM/MENIS/PEN $622.94 02720059 HB CATHETER, UMBILICAL VES $623.04 02720064 HB CANNULA AVR CABG KIT $641.27 02720068 HB TRACH TUBE #14 $1,301.48 02720072 HB CLAMP, DISPOSABLE $417.20 02720073 HB FILTER, BLOOD TRANSFUSION * $678.92 02720074 HB PACING WIRE, TEMPORARY $828.77 02720075 HB LEADWIRE, EKG $157.17 02720077 HB FRAZIER SUCTION TIPS $333.38 02720080 HB HANDLE, ENDOSCOPIC GIA $1,015.79 02720081 HB TROCAR, ENDOSCOPIC 1 $572.82 02720082 HB CLIP GUN MAGAZINE $333.20 02720084 HB NEEDLE, SPINAL/DISC $723.71 Ancillary FY22 3 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720086 HB KIT, PACEMAKER 1 $728.70 02720088 HB INTRODUCER, OSTEO ONE STEP $8,207.28 02720089 HB CATHETER, THORACIC MM $745.40 02720090 HB CATHETER PASSER $963.06 02720093 HB PIN, DISTRACTION 1 $563.60 02720096 HB ENDO TIP CAUTERY PEDS RT ANGLE $754.44 02720098 HB LACRIMAL INTUBATION SET $760.76 02720099 HB ROD, OSTOMY $228.63 02720101 HB PEN, HEATING LACTOSORB PLATE $840.17 02720104 HB ENDO BIPOLAR EBF01 $785.02 02720107 HB GRASPER, ENDOSCOPIC 1 $1,164.25 02720108 HB PIN SKULL PINS MAYFIELD- OMI $226.37 02720110 HB PREP DURA $211.66 02720111 HB BLADE, TREPHINE $811.05 02720112 HB LTA KIT $357.08 02720114 HB TUBING, INSUFFLATION $439.25 02720115 HB KYPHON BONE ACCESS NEEDLE 11 G $348.92 02720116 HB ANTENNA,EXTRNL NEUROSTIMALUTOR $1,123.06 02720121 HB SPLINT DENVER SERIES $264.47 02720123 HB ADHESIVE, SKIN 1 $391.28 02720124 HB 23G BIPOLAR TAPERED FINE POINT $493.53 02720125 HB SYRINGE MEDRAD POWER INJECTOR $180.46 02720126 HB ARTHRO, MENISCAL SYSTEM $1,383.12 02720132 HB FILTER MILEX $87.34 02720133 HB SONOHYSTOGRAM CATHETER $257.16 02720135 HB NET, RETRIEVAL ROTH $1,321.32 02720137 HB OSTENE BONE HEMOSTASIS 2.5GRMS $874.45 02720139 HB TUBE, JEJUN FEED/SGL LUMEN $1,403.05 02720140 HB FORCEPS, BIOPSY 1 $537.00 02720144 HB TUBE,TRACH DCT/DFEN W/DISP CAN $1,547.28 02720145 HB KIT, NEUROSTIMULATOR 1 $1,048.05 02720148 HB MEDTRONIC REFILL KIT $1,548.79 02720153 HB TUNNELING ROD, CATH PASSER $1,325.98 02720154 HB TUBE, MIC (FEEDING) $2,318.28 02720159 HB TOOL, DISSECTING 2 $1,540.32 02720161 HB KIT, TRANFIX/BIO-TENODESIS $1,600.03 02720162 HB NEEDLE, ELECT/BEVEL/TROCAR $1,644.04 02720165 HB HEMOSTAT, SOF-GRIP $817.31 02720166 HB BAG DRAINAGE URINARY $269.93 02720168 HB CUTTER, LOCKING LEAD $1,065.94 02720169 HB PERF QUICK PRIME LINE $277.65 02720170 HB ENDO PROBE HANDPIECE $830.59 Ancillary FY22 4 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720171 HB PC MICRO BRUSH $2,020.50 02720172 HB STRIPPER VEIN DISPOSABLE $841.62 02720174 HB PLEUR-EVAC $2,373.68 02720175 HB SPENCER DEPTH ELECTRODES 8 CON $2,465.79 02720176 HB NEEDLE, OSTYCUT $850.28 02720177 HB T-TUBE, 2 $851.92 02720178 HB ENDO TROCAR 10MM BLNT OMST10BT $861.35 02720183 HB ILIUMINATOR, LIGHTMAT SURGICAL $871.58 02720184 HB PC BROCH OCC CATH C2628 $1,899.64 02720185 HB PERF HEMOCONCENTRATOR PEDS $899.03 02720187 HB TWIST DRILL SURGICAL 1 $905.31 02720189 HB KIT, KYPHOPLASTY INTRO SYSTEM $18,248.13 02720190 HB TRACH PERCUTANEOUS SET $735.97 02720191 HB ENDO SUCTION/IRRIG/PROBE $917.91 02720193 HB CATHETER, MULTI LUMEN $919.68 02720195 HB CANNULA, RETROGRADE CARDIOPLEG $930.89 02720198 HB CANNULA, RETROGRADE 1 $943.04 02720199 HB IV PUMP SET, NITROGLYCERIN $748.31 02720201 HB ARTHRO WAND 1 $1,895.51 02720202 HB BLADE, ACROM/BLASTER/MIONIZER $891.71 02720208 HB IRRIGATION SET, CYSTO $775.50 02720213 HB PERF RESERVOIR CARDIOTOMY $987.03 02720215 HB RESERVOIR, DRAIN 1 $281.65 02720216 HB DRAIN LUMBAR DRAINAGE SET $995.30 02720218 HB PACK, AFFINITY VAVD ACCESSORY $525.82 02720225 HB SHOULDER SUSPENSION KIT 2 $1,023.07 02720228 HB LP DRAINAGE KIT $1,037.33 02720229 HB TUBE, RECTAL $588.79 02720230 HB RADIAL ARTERY KIT $600.40 02720231 HB ENDO POLY LOOP $1,381.78 02720232 HB TUBING, PCA $607.94 02720233 HB TUBE, GASTROSTOMY 1 $620.13 02720235
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