KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
Kingman Regional Medical Center Charge Master FY19 CPT Procedure Charge Description: Price: code ROOM & CARE - ICU $4,950.00 ROOM & CARE - SCVICU ICU $4,950.00 ROOM & CARE - 2N SEMIPRIVT $2,150.00 ROOM & CARE - 2E SEMIPRIVT $2,150.00 ROOM & CARE - 2S SEMIPRIVT $2,150.00 ROOM & CARE - ORT SEMI PRIVATE $2,150.00 ROOM & CARE - 3B SEMIPRIVT $2,150.00 ROOM & CARE - 2C SEMIPRIVT $2,150.00 ROOM & CARE - OB SEMIPRIV $2,150.00 ROOM & CARE - ARU SEMIPRIVATE $1,350.00 ROOM & CARE - 2C PEDIATRIC $2,150.00 ROOM & CARE - OB GYN $1,628.00 ROOM & CARE - NURSERY $1,400.00 ROOM&CARE-NURSERY SPECIAL CARE $4,188.00 ROOM&CARE-ICU PROGRESSIVE CARE $2,667.00 ROOM & CARE - SCVICU TELEMETRY $2,667.00 ROOM & CARE - TELEMETRY $2,667.00 ROOM & CARE - ORTHO TELEMETRY $2,667.00 ROOM & CARE - 3RD FL TELEMETRY $2,667.00 ROOM & CARE - SCVICU $5,475.00 DELIVERY SERVICE $3,100.00 FETAL NON STRESS TEST $640.00 59025 OBSERVATION BED OB HOURLY $203.00 G0378 OB/SURGERY PER MINUTE $166.00 OB/EMER SURGERY PER MINUTE $180.00 ECMO/ECLS INITIATION VENOUS $2,948.00 33946 ECMO/ECLS INITIATION ARTERIAL $2,948.00 33947 OPERATING ROOM PER MINUTE $175.00 EMER OPERATING ROOM PER MINUTE $198.00 LITHOTRIPSY ESL $20,751.00 50590 GI TRACT CAPSULE ENDOSCOPY $4,494.00 91110 ANALYZE NEUROSTIM COMPLEX $470.00 95972 OP / SURGERY PER MINUTE $175.00 G-ESOPH REFLUX W/MUCOSAL PH $1,224.00 91035 GI TRACT CAPSULE ENDOSCOPY $2,556.00 0355T INSERT PICC W/O PORT >5YRS ICU $3,354.00 36569 DIALYSIS NOT HEMO ONE EVAL $1,223.00 90945 OAE SCREENING NEWBORN HEARING $38.00 92558 ECMO/ECLS DAILY MGMT-VENOUS $2,948.00 33948 ECMO/ECLS DAILY MGMT ARTERIAL $2,948.00 33949 EXTERNAL CEPHALIC VERSION $5,128.00 59412 BRONCHOSCOPY W/BIOPSY(S) (ICU) $2,903.00 31625 BRONCHOSCOPE DX WASHING (ICU) $2,849.00 31622 BRONCHOSCOPE DX W/BRUSH (ICU) $2,904.00 31623 BRONCHOSCOPE DX W/LAVAGE (ICU) $2,849.00 31624 MOBILITY INPATIENT VISIT $- ISOLATED ULTRAFILTRATION AQUAP $2,192.00 37799 EMER CVOR OPERATE ROOM PER MIN $297.00 CEREBRAL OXIMETRY $291.00 95999 ACT; ACTIVATED CLOTTING TIME $309.00 85347 ABG ANALYSIS WITH O2 SAT $234.00 82805 HEPARIN ASSAY $251.00 85520 PERF: PUMP W/OXYG/HEAT EA HOUR $3,313.00 99190 PERF: PUMP W/OXYG/HEAT 3/4 HR $2,318.00 99191 PERF: PUMP W/OXYG/HEAT 1/2 HR $1,658.00 99192 PERF: AUTOLOG BLOOD OP SALVAGE $760.00 86891 OPERATING ROOM PER MIN CVOR $238.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
ECHO TRANSESOPHAGEAL PROBE PLC $1,970.00 93313 ECHO TRANSESOPHAGEAL COMPLETE $2,561.00 93312 CARDIAC TRANSPORT TEAM (MAYO) $- OFFICE CONSULT HIGH $163.00 99245 OFFICE CONSULT MINOR $163.00 99241 OFFICE CONSULT LOW $163.00 99242 OFFICE CONSULT MODERATE $163.00 99243 OFFICE CONSULT MOD TO HIGH $163.00 99244 OFFICE VISIT BRIEF EST PATIENT $163.00 99211 OFFICE VISIT MINOR ESTAB PT $163.00 99212 OFFICE VISIT LOW/MOD ESTAB PT $163.00 99213 OFFICE VISIT MOD/HIGH ESTAB PT $163.00 99214 OFFICE VISIT HIGH EST PATIENT $163.00 99215 OFFICE VISIT MINOR NEW PT $163.00 99201 OFFICE VISIT LOW TO MOD NEW PT $163.00 99202 OFFICE VISIT MODERATE NEW PT $163.00 99203 OFFICE VISIT MOD/HIGH NEW PT $163.00 99204 OFFICE VISIT HIGH NEW PT $163.00 99205 EKG 12 LEAD, TRACING ONLY $220.00 93005 INJ EPIDURAL BLOOD OR CLOT PAT $2,047.00 62273 NERVE BLOCK FEMORAL CON/INF PF $231.00 64448 INTUBATION ET EMERGENT PROFEE $361.00 31500 INJ ANESTH SUPRASCAPULAR NERVE $254.00 64418 TAP BLOCK UNIL BY INJECTION PF $213.00 64486 TAP BLOCK UNIL BY INFUSION PF $245.00 64487 TAP BLOCK BILAT INJECTION PF $265.00 64488 TAP BLOCK BILAT BY INFUSION PF $295.00 64489 ECHO TRANSESOPHAGEAL COMPL PF $404.00 933122659 ECHO TRANSESOPH PROBE PLACE PF $75.00 933132659 ECHO TRANSESOPHAGE I&R ONLY PF $329.00 93314 TEE CONGENITAL GLOBAL WO/CO PF $483.00 93315 TEE CONGENITAL GLOBAL W/CON PF $483.00 93315 TEE CONGENITAL PROBE PLCMT PF $126.00 93316 TEE CONGENITAL INT&REP ONLY PF $360.00 93317 TEE FOR MONITORING PROFEE $395.00 93318 NERVE BLOCK SGL SCIATIC NRV PF $228.00 64445 INJ ANESTH;LUMB/THOR SYMPAT PF $275.00 64520 INSERT PICC W/O PORT AGE >5 PF $599.00 36569 PARAVERTEBRAL THORACIC SGL INJ $265.00 64461 PARAVERTEBRAL THORACIC 2ND+INJ $167.00 64462 PARAVERTEBRAL THORA CONT INFUS $257.00 64463 QUANT SERUM ACETONES/KETONES $141.00 82010 AMITRIPTYLINE $490.00 80346 ARSENIC $523.00 82175 PSA DIAGNOSTIC TOTAL $347.00 84153 CYANIDE (BLOOD) NATL $264.00 82600 COXSACKIE A VIRUS AB (A4,A16) $63.00 86658 ACTH $1,198.00 82024 DESIPRAMINE (NORIPRA $508.00 80335 ENA, ANY METHOD $104.00 86235 AMMONIA $394.00 82140 CH50-COMP TOTAL $548.00 86162 ALDOLASE $438.00 82085 AMYLASE SERUM $348.00 82150 ANTI-SMOOTH MUSCLE B $256.00 86256 ANTI-MITOCHONDRIAL AB $256.00 86256 ANTI-RNP/SM ANTIBODY $129.00 86235 ANGIOTENSIN CONV ENZ $126.00 82164 TOTAL BILIRUBIN $292.00 82247 BILIRUBIN /W DIRECT $300.00 82248 ISLET CELL ANTIBODY $181.00 86341
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BETA 2 MICROGLOBULIN $228.00 82232 IMIPRAMINE(TOFRANIL) $107.00 80335 CALCITONIN $444.00 82308 CALCIUM; TOTAL $247.00 82310 CALCIUM; IONIZED $329.00 82330 CARBON DIOXIDE (CO2) $199.00 82374 COMPLEMENT;FCN ACTIVITY EA $97.00 86161 CAROTENE (SERUM) $195.00 82380 IA QUANT; CA 125 $295.00 86304 CERULOPLASMIN $205.00 82390 IA QUANT; CA 19-9 $269.00 86301 DHEA $586.00 82626 CHLORIDE; BLOOD $199.00 82435 SERUM/WB TOT CHOLEST $200.00 82465 CHROMIUM-BLD* $259.00 82495 CREATININE BLOOD $185.00 82565 CREATININE CLEARANCE (24HRUA) $301.00 82575 BASIC METABOLIC PANEL TOTAL CA $403.00 80048 CPK; TOTAL $192.00 82550 CPK-MB $309.00 82553 ELECTROLYTE PANEL $414.00 80051 PROTEIN ELECTROPHORE $370.00 84165 CYCLOSPORINE $519.00 80158 IMMUNOASSAY ANALYTE QUANT NOS $1,353.00 83520 HEMOGLOBIN ELECTROPHORESIS $616.00 83020 ESTROGEN TOTAL (SERU $312.00 82672 FIBRINOGEN; ANTIGEN $269.00 85385 FIBRINOGEN SPLIT PRO $600.00 85362 GASTRIN $545.00 82941 GLUCOSE FASTING $300.00 82947 POST GLUCOSE DOSE $259.00 82950 GTT 3 SPECIMEN $369.00 82951 GLUCOSE TOLERANCE EA>3 SPECIM $122.00 82952 IRON $158.00 83540 IRON BINDING CAPACITY $175.00 83550 LACTIC ACID $172.00 83605 LDH $259.00 83615 LDH ISO ENZYMES W/TO $523.00 83625 LIPOPROTEIN; LDL $269.00 83721 LEAD $175.00 83655 LIPASE $338.00 83690 HEPATIC FUNCTION PANEL $537.00 80076 SOMATOMEDIN-C LEVEL $1,036.00 84305 SELENIUM,BLOOD $869.00 84255 MAGNESIUM $149.00 83735 OSMOLALITY-BLOOD $363.00 83930 LIBRIUM LEVEL $161.00 80346 PHOSPHATASE, ALKALINE $230.00 84075 ALK PHOS ISOENZYMES $588.00 84080 HDL $312.00 83718 FACTOR VIII COAGULATION $730.00 85240 PHOSPHORUS INORGANIC $199.00 84100 PEPTIDE C LEVEL-BLD $772.00 84681 PROTEIN C ACTIVITY $569.00 85303 PHENYLALANINE (PKU), BLOOD $148.00 84030 CLOTTING INHIBITR PROTEIN S TT $1,052.00 85305 POTASSIUM $269.00 84132 PROTEIN C ANTIGEN $569.00 85302 PROTEIN TOTAL $175.00 84155 ETHYLENE GLYCOL-NICH $540.00 82693 ALBUMIN; SERUM,PLASMA,WH BLD $160.00 82040
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
RHO D IMMUNE GLOB300MCG 1500IU $1,120.00 J2790 PH BLOOD $199.00 82800 BENZODIAZAPINES $161.00 80346 SALICYLATE (INC ASPIRIN) $247.00 G0480 SEROTONIN SERUM $1,301.00 84260 SODIUM $199.00 84295 CORTISOL $490.00 82533 ALFA-1-ANTITRYPSIN; TOTAL $484.00 82103 GROWTH HORMONE $177.00 83003 MORPHINE BLOOD FTS $134.00 80361 OPIATES, 1 OR MORE $134.00 80361 THORAZINE LEVEL $523.00 80342 ZINC $656.00 84630 SGOT $245.00 84450 ALUMINUM SERUM $259.00 82108 SGPT $245.00 84460 TRIGLYCERIDES $62.00 84478 UREA NITROGEN (BUN)QUALTATIVE $300.00 84520 URIC ACID $258.00 84550 VITAMIN A $523.00 84590 VITAMIN B6 (PYRIDOXA) $1,134.00 84207 ASCORBIC ACID, BLOOD $438.00 82180 VITAMIN K (FROZEN) $895.00 84597 T3;TOTAL $200.00 84480 T3 RIA $534.00 84480 T4;TOTAL $355.00 84436 T4 FREE $446.00 84439 T3 FREE $77.00 84481 LITHIUM $239.00 80178 PARATHORMONE LEVEL $1,459.00 83970 B12 LEVEL $484.00 82607 TRANSFERRIN $465.00 84466 CEA $369.00 82378 HEPATITIS A VIRUS AB IGM $418.00 86709 HEPATITIS C AB $301.00 86803 HEPATITIS B SUR AB $322.00 86706 HEPATITIS B SUR AG $390.00 87340 HEPATITIS B CORE AG IGM $369.00 86705 HEPATITIS BE AB $390.00 86707 HEPATITIS BE AG $390.00 87350 CARDIAC ENZ ISOENZYMES $390.00 82552 DIGOXIN, QUANTITATIVE $340.00 80162 FOLIC ACID SERUM $490.00 82746 ANTI-DNA-SINGLE STRA $490.00 86226 THYROID STIMULATING HORMONE $185.00 84443 TBG (THYROXINE BIND) $531.00 84442 INSULIN $438.00 83525 INSULIN ANTIBODIES $146.00 86337 CRYOGLOBULIN QUALI/SEMI-QUAN $181.00 82595 ASSY GG; IGA,IGD,IGG,IGM EACH $269.00 82784 IGE $181.00 82785 RENIN $624.00 84244 INTRINSIC FACTOR ANT $890.00 86340 GENTAMICIN $403.00 80170 PHENYTOIN; TOTAL $530.00 80185 PRIMIDONE $545.00 80188 L H $195.00 83002 FSH BY RIA $580.00 83001 TEGRETOL $418.00 80156 CLONOPIN $149.00 80346 DEPAKENE (VALPORIC A $523.00 80164
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
C3 COMPLEMENT $125.00 86160 C4 COMPLEMENT $125.00 86160 B12 BINDING CAPACITY $322.00 82608 THEOPHYLLINE LEVEL $498.00 80198 FERRITIN SERUM $464.00 82728 G6PD $134.00 82955 INSULIN LEVEL SERUM $355.00 83525 ERYTHROPOIETIN-SERUM $338.00 82668 ANTIBODY; HIV-1 $355.00 86701 ANTIBODY; HIV-1 AND HIV-2 SGL $269.00 86703 HLAB 27 $699.00 86812 ALPHA FETOPROTEIN TUMOR MARKER $244.00 82105 CPK ISOENZYMES $173.00 82552 ALDOSTERONE $253.00 82088 INFLUENZA B ANTIBODI $338.00 86710 VIP VASOACTIVE INT P $650.00 84586 VISCOSITY-SERUM $699.00 85810 DIHYDROXY VITAMIN D,1,25- $244.00 82652 MELLARIL(THIORIDAZIN) $686.00 80342 NORTRIPTYLINE $418.00 80335 VASOPRESSIN (ADH) $1,353.00 84588 DRUG TEST PRSMV CHEM ANLYZR $537.00 80307 MERCURY, QUANTITATIVE $523.00 83825 CADMIUM $166.00 82300 GOLD LEVEL $93.00 80375 ACETAMINOPHEN $745.00 G0480 SINEQUAN $464.00 80335 ASSAY CARBOXYHB QUANTITATIVE $351.00 82375 ARSENIC QUAN $451.00 82175 TOBRAMYCIN LEVEL $699.00 80200 PLACIDYL=BIO $842.00 80320 METHADONE-NAT'L $438.00 80358 MORPHINE-BIO SC $134.00 80361 AMINO ACIDS; 2-5, QUAN, EA** $2,154.00 82136 PHENOBARBITAL $842.00 80184 BARBITUATES,NES $674.00 80345 VANCOMYCIN-RANDOM $429.00 80202 GLUCOSE SPINAL FLUID NOT BLOOD $175.00 82945 PROTEIN TOTAL OTH SPECIMEN $175.00 84157 SPINAL FLUID CULTURE $378.00 87070 SMEAR - GRAM OR GIEMSA W/INTER $160.00 87205 SF OLIGOCLONAL IMMUN $221.00 83916 BLOOD,OCC, PEROXIDASE ACT QUAL $119.00 82271 VMA $490.00 84585 CATECHOLAMINES,FRACTIONATED $199.00 82384 ESTRIOL $164.00 82677 ESTRADIOL-SERUM $207.00 82670 CATECHOLAMINES, FRACTIONATED $245.00 82384 COLLECTION BLOOD VENIPUNCTURE $31.00 36415 MET HEMAGLOBIN $451.00 83050 HEMOGLOBIN $122.00 85018 HEMATOCRIT $137.00 85014 ASPERGILLUS ANTIBODY $151.00 86606 WBC AUTOMATED $149.00 85048 AUTOMATED RBC COUNT $126.00 85041 RBC FOLIC ACID $657.00 82747 DIFFERENTIAL $119.00 85007 CLOSTRIDIUM DIFF TOXIN $125.00 87324 PLATELET COUNT $187.00 85049 SICKLE CELL $126.00 85660 PROTIME $164.00 85610
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PTT $363.00 85730 AB ID; PLATELET AB $172.00 86022 NASAL SMEAR FOR EOSINOPHILS $126.00 89190 OSMOTIC FRAGILITY RBC;INCUBA** $119.00 85557 SMEAR, SPECIAL STAIN $126.00 87207 UNLISTED CHEMISTRY TEST $807.00 84999 CHROM & KARY 15-20 2 KAR $1,399.00 88262 HAPTOGLOBIN $213.00 83010 PYRUVATE KINASE** $716.00 84220 THROMBIN TIME $315.00 85670 ANTI-THROMBIN III LEVEL $674.00 85300 GLYCOHEMAGLOBIN $369.00 83036 GLUCAGON LEVEL $716.00 82943 OCCULT BLOOD;FECES 1-3 SPECIM $125.00 82270 PINWORM PREP $141.00 87172 FAT QUANTITATIVE $699.00 82710 FAT SCREEN STOOL $199.00 82705 SEMEN ALALYSIS;COMPLETE $160.00 89320 SEMEN ANALY; SPERM DETECTION $126.00 89321 CULTURE BACTERIA;AOS EX UA,BLD $355.00 87070 SENSITIVITY $195.00 87186 CULTURE BLOOD $460.00 87040 CANDIDA ANTIBODY $281.00 86628 SMEAR GRAM OR GIEMSA W/INTERP $125.00 87205 SMEAR GRAM OR GIEMSA W/INTERP $158.00 87205 SMEAR PSWI;FLURO OR AFB STAIN $141.00 87206 FUNGUS CULTURE ISO, OTH SOURCE $274.00 87102 TISSUE BY KOH SKIN,FUNGI MITES $125.00 87220 RSV (SCREEN) $580.00 86756 SALINE SUS WET MOUNT $116.00 87210 CULT TB;AFB;MYCOB W/ISO ID ISO $175.00 87116 CULTURE ANAEROBIC $418.00 87075 LEGIONELLA IMMUNOFLUOR ANT 1ST $465.00 88346 STREP A SCREEN $275.00 86171 MUMPS ANTIBODY $438.00 86735 SYPHILIS TEST NON-TREP QUANT $141.00 86593 IMMUNOFLOUR STUDY SGL ANTIBODY $465.00 88346 ASO TITRE $269.00 86060 MONO TEST $166.00 86403 RUBELLA $301.00 86762 ANTIBODY; HERPES SIMPLEX $149.00 86695 ANTIBODY;HERPES SIMPLEX NONSPE $545.00 86694 C-REACTIVE PROTEIN (CRP) $199.00 86140 LEGIONELLA SEROLOGY MOB $230.00 86713 COLD AGGLUTININ; TITER $246.00 86157 AB; CMV (CYTOMEGALOVIRUS) $315.00 86644 AB; CMV IGM (CYTOMEGALOVIRUS) $379.00 86645 IMMUNODIFFUSION;GEL QUAL EA AG $657.00 86331 GONADOTROPIN HCG; QUALITATIVE $278.00 84703 BETA SUB UNIT HCG $523.00 84702 PROGESTERONE $195.00 84144 PROLACTIN $807.00 84146 EBV-AB-(VCA-IGG) $405.00 86665 EBV-AB-(VCA-IGM) $405.00 86665 EBV-EARLY ANTIGENS $588.00 86663 EBV-NUCLEAR ANTIGEN $588.00 86664 BLASTOMYCOSIS NATL $104.00 86612 COCCIDIOIDES SCREEN $119.00 86635 HISTOPLASMA SEROLOGY $119.00 86698 VIRAL CULTURE** $379.00 87252 CHLAMYDIAL CULTURE $588.00 87110
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CHLAMYDIA $418.00 86631 UA AMYLASE $300.00 82150 UA CALCIUM $246.00 82340 CALCULI; IR SPECTROSCOPY $363.00 82365 UA CHLORIDES 24 HR $199.00 82436 UA CREATININE $249.00 82570 UA HEMOSIDERIN-NAT $315.00 83070 HYDROXYINDO ACID (5-HIAA) $100.00 83497 UA LEAD QUAN $561.00 83655 UA PORPHOBILINOGEN Q $369.00 84110 UA PHOSPHORUS 24 $271.00 84105 OXALATE $523.00 83945 PROTEIN E-PHORESIS/URINE/CSF $451.00 84166 UA POTASSIUM $300.00 84133 OSMOLALITY;URINE $329.00 83935 PROTEIN TT URINE EXCEPT REFRAC $125.00 84156 UA SODIUM $256.00 84300 UA URIC ACID $269.00 84560 UA MICROSCOPIC ONLY $97.00 81015 METANEPHRINES $490.00 83835 CA 15-3 (27-29) $269.00 86300 BLOOD TYPING; ABO $219.00 86900 BLOOD TYPING; RH D $208.00 86901 RBC AB SCRN, EA TECHIQ $208.00 86850 BB CROSSMATCH ANTIGLOBULIN $269.00 86922 BB CROSSMATCH IMM SPIN $624.00 86920 COOMBS; DIRECT EA ANTISERUM $345.00 86880 IMMUNE GLOBULN HUMAN PER 100IU $49.00 J2792 BB TYPE RBC ANIGENS, EA $449.00 86905 IMMUNODIFFUSION; NES $164.00 86329 BB CROSSMATCH INCUB $1,366.00 86921 COLLECT & HNDLNG SPECIMEN FEE $256.00 99000 ALBUMIN;OTH SRC QL EA SPECIMEN $160.00 82042 ALK PHOS-BODY FLUIDS $230.00 84075 AMYLASE-BODY FLUIDS $247.00 82150 DIFF CELL COUNT NOT BLOOD $125.00 89051 CRYSTAL ID SYNOVIAL FUILD W/WO $97.00 89060 LDH-BODY FLUIDS $243.00 83615 PH-BODY FLUIDS $199.00 83986 SPECIFIC GRAVITY-BOD $97.00 84315 URIC ACID OTHER SOURCE $239.00 84560 ANTI-DNA-DOUBLE STRA $293.00 86225 BARTONELLA ANTIBODY CATSCRATCH $399.00 86611 T3 UPTAKE $327.00 84479 FLUORESCENT AB; TITER, EA AB $205.00 86256 LUPUS IMMUNOFLURO AN 1ST STAIN $699.00 88346 CYSTINE UA QUAN $274.00 82131 DEMEROL UA MED TOX $134.00 80362 HIV ANTIGEN (P-24) $340.00 87390 DEMEROL SERUM $134.00 80361 UA AMYLASE 24 HOUR $340.00 82150 DIRECT BILIRUBIN $92.00 82248 CARDIOLIPIN AB,ISG/ISA/IGM EA $303.00 86147 MERCURY (BLOOD) $228.00 83825 RUSSELL VIPER VENOM TIME DILUT $301.00 85613 HELICOBACTOR PYLORI AB $298.00 86677 FACTOR VIII VW FACTOR AG $355.00 85246 FACTOR XI COAGULATION $832.00 85270 PARTICLE AGGLUTINATI SCR EA AB $141.00 86403 ANDROSTENEDIONE $363.00 82157 TOXOPLASMOSIS AB $181.00 86778
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
17-HYDROXYPROGESTERONE $315.00 83498 PROINSULIN $686.00 84206 BORDETELLA PERTUSSIS IGG,A,M $206.00 86615 DILANTIN (PHENYTOIN;FREE $464.00 80186 HEPATITIS A-B-C PROFILE $518.00 80074 LIPID PANEL $370.00 80061 APOLIPOPROTEIN EACH $190.00 82172 ANTI-STREPTOLYSIN O-SERUM $315.00 86060 VANCOMYCIN-TROUGH $429.00 80202 CHROM STUDY-TISSUE $1,190.00 88230 SPECTROPHOTOMETRY ANALYT NES** $351.00 84311 COPPER $228.00 82525 TESTOSTERONE TOTAL $269.00 84403 BACTERIAL ANTIGEN $149.00 86403 PREALBUMIN $686.00 84134 DHEAS $278.00 82627 HEAVY METAL QUANTITATIVE EACH* $475.00 83018 ANTI-THYROGLOBULIN AB $206.00 86800 THYROGLOBULIN BY RIA $246.00 84432 IMMUNOFIXATION SERUM $281.00 86334 CLOST DIFF TOXIN AB(SERU) $657.00 87230 VITAMIN B-1 (THIAMINE) $490.00 84425 POTASSIUM STOOL $629.00 84133 NEURON SPECIFIC ENOLASE $149.00 83520 RUBEOLA; AB MEASLES $230.00 86765 HOMOCYSTINE $686.00 83090 GAMMAGLOBULIN IGG 1 2 3 4 EACH $24.00 82787 HEPATITIS A VIRUS AB IG $181.00 86709 EPSTEIN-BARR VCA ANTIBODY $414.00 86665 CONCENTRATION FOR INF AGENTS $141.00 87015 VITAMIN E (ALPHA-TOCOPHEROL) $315.00 84446 VARICELLA ZOSTER $190.00 86787 UA AMINOLEVUL ACID-DELTA $239.00 82135 HISTAMINE $256.00 83088 MICROALBUMIN; URINE QUAN $63.00 82043 HIV-1 QUANTICATION $670.00 87536 HIV WESTERN BLOT REFLEX $228.00 86689 BRUCELLOSIS ABORTIVE(IG G,A,M) $113.00 86622 MYELIN BASIC PROTEIN(CSF) $335.00 83873 ANTIBODY; HERPES SIMPLEX 2 $220.00 86696 AMIKACIN $269.00 80150 INDIRECT, EA ANTIBODY TITER $327.00 86886 UA CITRATE ACID (24HR) $390.00 82507 URINE CULT BACT QUANT COUNT $340.00 87086 COMPLEMENT; AG, EA $97.00 86160 PARVOVIRUS B19 IGG IGM $351.00 86747 FACTOR IX COAGULATION $866.00 85250 HEPATITIS C RECOM/RIBA $390.00 86804 RICKETTSIA ANTIBODY $293.00 86757 HEMOGLOBIN;GLYCOSYLATED(A1C) $195.00 83036 ANTIBODY; HIV-1 DNA PCR $1,207.00 86701 AMPLIF NA PROBE NOS AGT EA ORG $351.00 87798 VDRL,RPR,STS;NON TREP QUAL $171.00 86592 CAMPYLOBACTER JEJUN AB $580.00 86625 CRYPTOSPORIDIUM/ISOSPORA $369.00 87272 INFECTIOUS AG NOS BY IF EA ORG $239.00 87299 LYME DIS BORRELIA BURGDORFERI $185.00 86618 BORRELIA BURGDORFERI LYME DIS $306.00 86618 ANTI-DNASE B ANTIBODY $239.00 86215 PLATELET ASSOC IGG $496.00 86023 ALPHA-FETOPROTEIN; SERUM $244.00 82105
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PTT,PLASMA FRACTIONS, EACH** $89.00 85732 AB; BACTERIUM, NES $301.00 86609 IMMUNOASSAY MULTI STEP METHOD $190.00 87338 CBC AUTO COMPLETE W/PLT $351.00 85025 BUN UREA NITROGEN URINE $301.00 84540 IMMUNOGLOBULIN G (IGG)SUBCL $490.00 82787 AB;TOXOPLASMA $206.00 86777 FACTOR V COAGULATION $716.00 85220 TISSUE PLASMINOGEN ACTIVATOR $244.00 85415 PSA; FREE* $499.00 84154 HEPATITIS C - DNA OR RNA $1,737.00 87902 ANTINUCLEAR ANTIBODIES(ANA)* $137.00 86038 CHLAMYDIA T AMPLIF NA PROBE $104.00 87491 SUSCEPTIBILITY AGAR DILUTIO/AG $63.00 87181 STOOL CULTURE AEROBIC BACTERIA $438.00 87045 STOOL CULTURE STOOL W/ISOL/PRE $438.00 87045 RUSSELL VIPER VENOM TIME;DILUT $446.00 85613 REPTILASE TEST** $651.00 85635 CLOTTING FACTOR X STUART-PROW $772.00 85260 FLUORESCENT AB; SCRN EACH AB $276.00 86255 TOPIRAMATE $569.00 80201 CLOTTING ANTITHROMBIN III ANTI $251.00 85301 CARDIOLIPIN ANTIBODY EA 1G** $230.00 86147 IMMUNOASSAY ANA,QUAN; BY RIA* $137.00 83520 DIHYDROTESTOSTERONE (DHT)* $245.00 80327 IMMUNOFIXATION ELECTROPHORES** $206.00 86334 ANTIBODY; MYCOPLASMA* $239.00 86738 IMMUNOSSAY OTH TUMOR AG QUAN** $217.00 86316 AB ID RBC EA PNL EA TECHN EA** $449.00 86870 PRETREAT RB, CHEM OR DRUGS $239.00 86970 AB; FUNGUS, NES $126.00 86671 AB ID; LEUKOCYTE AB $108.00 86021 BILE ACID; TOTAL $141.00 82239 CULT,FUNGI,DEF ID,EA ORG; MOLD $105.00 87107 CORTISOL; FREE $170.00 82530 PROTEIN WESTERN W/INT,REP,BLD $187.00 84181 INF AG DNA/RNA;MULT ORG AMP PR $553.00 87801 BIOTINIDASE, EA SPEC** $120.00 82261 EMTAMOEBA HISTOLYTICA GROUP $89.00 87337 CLOTTING FACTOR II PROTHOMBIN $94.00 85210 CLOTTING FACTOR XIII FIBRIN ST $120.00 85290 FLOW CYTOMETRY TC 1ST MARKER $449.00 88184 INSULIN; FREE $94.00 83527 AB;HEMOPHILUS INFLUENZA $119.00 86684 AB; PROTOZOA NES** $451.00 86753 ANTIBODY;HEPATITIS DELTA AGENT $84.00 86692 HIV-1 AG W/HIV-1 & HIV-2 AB $122.00 87389 BCR/ABL1 GENE MINOR BP $1,207.00 81207 CFTR GENE COM VARIANTS $1,113.00 81220 SERPINA1 GENE $611.00 81332 BCR/ABL1 GENE MAJOR BP $1,048.00 81206 F5 GENE FACTOR V $206.00 81241 HFE GENE $390.00 81256 JAK2 GENE $997.00 81270 MTHFR GENE $300.00 81291 F2 GENE $131.00 81240 HBA1/HBA2 GENE $446.00 81257 MOPATH PROCEDURE LEVEL 2 $2,204.00 81401 UNLISTED MOLECULAR PATHOLOGY $315.00 81219 SPERM ANTIBODIES $97.00 89325 ONCOPROTEIN DCP $281.00 83951
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
ALPHA-FETOPROTEIN L3 $281.00 82107 HLA II TYPING 1 ALLELE HR $213.00 81383 AB; JC (JOHN CUNNINGHAM) VIRUS $63.00 86711 APC GENE FULL SEQUENCE $3,074.00 81201 DRUG SCREEN QUANT CLOZAPINE $79.00 80159 DRUG SCREEN QUANT GABAPENTIN $57.00 80171 HLA II TYPING 1 LOC HR $213.00 81382 DRUG SCREEN QUANT LAMOTRIGINE $57.00 80175 DRUG SCREEN QUAN LEVETIRACETAM $57.00 80177 DRUG SCR QUANT MYCOPHENOLATE** $78.00 80180 DRUG SCREEN QUANT OXCARBAZEPIN $57.00 80183 HLA II TYPING 1 LOCUS LR $239.00 81376 MOPATH PROCEDURE LEVEL 5 $2,204.00 81273 MOPATH PROCEDURE LEVEL 6 $2,204.00 81405 MOPATH PROCEDURE LEVEL 7 $2,204.00 81406 MOPATH PROCEDURE LEVEL 4 $1,940.00 81170 SECRETIONS FAT STAIN $23.00 89125 CHROMA COL QUAL/QUAN ANALY NES $217.00 82542 CBC AUTO(HGB,HCT,RBC,WBC,PLAT) $278.00 85027 BLOOD SMEAR W/DIFF WBC COUNT $92.00 85007 HEMOGLOBIN; PLASMA $266.00 83051 VOLATILES $414.00 84600 THYROID STIMULATING IMMUNEGLOB $523.00 84445 GLYCATED PROTEIN $141.00 82985 NEUTRALIZATION TEST, VIRAL* $199.00 86382 VIRUS ISOLATION;TISSUE CULT** $239.00 87253 AB;HELMINTH NES** $192.00 86682 AB;INFLUENZA VIRUS $119.00 86710 CYTO/MOLEC CYTOG;INTER/REPORT* $278.00 88291 MOL CYTOG;DNA PROBE, EA* $251.00 88271 HISTOPLASMA CAPSULATUM* $432.00 87385 ACTIVATED PROTEIN C RESIS ASSY $166.00 85307 PREGNENOLONE $190.00 84140 CRYOFIBRINOGEN $81.00 82585 NICOTINE $219.00 80323 FIBRIN FAC/INH;ALPHA 2 ANTIPLA $73.00 85410 LIPOPROTEIN BLD, HR FRACTION $230.00 83701 ASPERGILLUS AG, EIA $96.00 87305 PLT AGGREGATION INVITRO EA AGT $246.00 85576 LACTOFERRIN FECAL (QUANT) $90.00 83631 HEXAGNAL PHOSPH PLTLT NEUTRL $81.00 85598 MACROSCOPIC EXAM PARASITE $18.00 87169 FLT3 GENE $355.00 81245 CANDIDA NA AMPLIFIED PROBE $152.00 87481 GARDNERELLA NA QUANTIFICATION $184.00 87512 HLA CLASS I TYPING 1 ALLELE HR $293.00 81381 COMPATIBILITY TEST EA UN;ELECT $269.00 86923 IGH VARI REGIONAL MUTATION $1,122.00 81263 HPV TYPES 16 & 18 ONLY $295.00 87625 HPV HIGH-RISK TYPES $134.00 87624 SIALIC ACID $52.00 84275 AB; GIARDIA LAMBLIA $52.00 86674 TESTOSTERONE BIOAVAILABLE $157.00 84410 GBA GENE COMMON VARIANTS $429.00 81251 FETAL CHROMOSOMAL ANEUPLOIDY $1,733.00 81420 HIV-1 PROBE&REVERS TRNSCRP J** $104.00 87535 HERPES 6 AMPLIFIED NA PROBE** $104.00 87532 DNA RNA AMPLIFIED PROBE** $104.00 87150 STR MARKERS SPECIMEN ANALY** $637.00 81265 STR MARKERS SPECI ANALY ADDL** $637.00 81266 CULT MYCOBACTERIA DEF ID EA** $32.00 87118
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CRYOPRESERVATION EA CELL LN** $30.00 88240 DRUG TEST DEF 8-14 CLASSES** $348.00 G0481 DRUG TEST DEF 15-21 CLASSES** $442.00 G0482 DRUG TEST DEF 22> CLASSES** $549.00 G0483 DRUG TEST DEF 1-7 CLASSES $254.00 G0480 FETAL CGEN ABNOR FOUR ANAL** $73.00 81511 G6PD FULL GENE SEQUENCING** $2,041.00 81479 SENSITIVITY MACROBROTH EA AGEN $19.00 87188 HEMOGLOBIN UNSTABLE SCREEN** $25.00 83068 OSTEOCALCIN G 1 A PROTEIN** $89.00 83937 MOPATH PROCEDURE LEVEL 4** $415.00 81403 MOPATH PROCEDURE LEVEL 5** $582.00 81404 MOPATH PROCEDURE LEVEL 1** $694.00 81400 FIBRINOLYSINS OR COAG SCREEN** $40.00 85390 CRYPTOSPORIDIUM AG IA** $36.00 87328 PHOSPHOHEXOSE ISOMERASE** $30.00 84087 PERIPHERAL BLD SMEAR PHY/REP** $55.00 85060 VALPROIC ACID (DA) FREE** $36.00 80165 MICRODISSECTION MANUAL** $676.00 88381 BCR/ABL1 GENE TRANSLOC ANALY** $476.00 81208 TARGET GENO SEQ ORGAN NEOPLASM $1,300.00 81445 IADNA-DNA/RNA PROBE TQ 12-25** $1,234.00 87507 17-HYDROXYPREGNENOLONE** $60.00 84143 TARGET GENO SEQ HEMATOLYMPHOID $1,641.00 81450 FLUORIDE** $50.00 82735 VANCOMYCIN DNA AMP PROBE $122.00 87500 STAPH A DNA AMP PROBE $122.00 87640 STREP B DNA AMP PROBE $122.00 87653 CORTICOSTERONE $78.00 82528 GLUTATHIONE $50.00 82978 CREATINE $16.00 82540 SHIGA-LIKE TOXIN AG IA $36.00 87427 INFLUENZA IA W/DIR OBS $170.00 87804 TRICHOMONAS VAGINALIS AMPLIF $152.00 87661 BARTONELLA AMPLIF NAP PROBE $134.00 87471 BRCA1&2 SEQ & COM DUP/DEL $6,081.00 81162 BRCA1&2 UNCOM DUP/DEL VAR $1,624.00 81213 C DIFF AMPLIFIED PROBE $122.00 87493 CANDIDA NA DIRECT PROBE $70.00 87480 TRICHOMONAS VAGIN DIR PROBE $70.00 87660 GARDNERELLA DIR NA PROBE $70.00 87510 ANABOLIC STEROIDS; 1 OR 2 $245.00 80327 BRCA1 GENE KNOWN FAM VARIANT $750.00 81215 BRCA2 GENE KNOWN FAM VARIANT $750.00 81217 SENSITIVITY-MYCOBACT EA AGNT $18.00 87190 OBSTETRIC PANEL INC HIV $261.00 80081 ONCOLOGY COLORECTAL SCREENING $935.00 81528 ONCOLOGY GYNECOLOGIC 1ST DRUG $1,485.00 81535 ONCOLOGY GYNECOLOGIC ADDL DRG $455.00 81536 IMMUNOFLUOR ANTB ADDL STAIN $73.00 88350 DRUG TEST PRSMV DIR OPT OBS $127.00 80305 DRUG TEST PRESUMPT INSTRUMENT $127.00 80306 ASHKENAZI JEWISH ASSOC DIS $4,897.00 81412 ANTIBODY ID,RBC ABS,EA PNL FR SRM* $449.00 86870 PRETREAT SERUM ABSORP EACH $282.00 86978 BB TYPE RH PHENOTYPING, COMP* $231.00 86906 BB EXTENDED PHENOTYPE* $686.00 86905 BB DIRECT ANTIGLOBULIN TEST* $105.00 86880 AB ELUTION(RBC),EA ELUTION** $645.00 86860 BONE MARROW EXAM * $309.00 88305 FACTOR VII COAGULATION $415.00 85230
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
FACTOR XII COAGULATION** $752.00 85280 FACTOR INHIBITOR TEST $94.00 85335 CSF, LACTIC ACID $172.00 83605 OSMOLALITY-URINE/STOOL $289.00 83935 ANTI-THYROID PEROXIDASE* $431.00 86376 COMPREHENSIVE METABOLIC PANEL $485.00 80053 URINE PREGNANCY,VISUAL COLOR $268.00 81025 ANTI-PHOSPATIDYLSERINE AB* $152.00 83520 RIBOFLAVIN (VIT B-2)* $432.00 84252 FK 506* $301.00 80197 FRAGMENT 1+2* $779.00 85999 SOLUABLE FIBRIN MONOMER** $464.00 85366 ZINC/FREE ERYTHROC PROTOP* $230.00 84202 ALLERG SP IGG QUAN OR SEMIQUAN $56.00 86001 MUMPS AB IGG* $219.00 86735 BETA 2 GLYCOPROTEIN I AB, EA $316.00 86146 GC/MS,ANES; QUAN;SS AND MP $231.00 82542 ALPHA-1-ANTITRYPSIN;PHENOTYPE* $351.00 82104 TRIIODOTHYRONINE T3;REVERSE* $467.00 84482 INF AGENT DETECT NOS IA MULTI* $137.00 87449 ROTAVIRUS AGENT IMMUNOASSAY** $221.00 87425 IMMUNOASSAY NF AGENT AB QUAN** $428.00 86317 COLLAGEN CROSS LINKS ANY METH $382.00 82523 ANTIBODY;VIRUS NES $94.00 86790 ANTIBODY;TETANUS $310.00 86774 HERPLEX S VIRUS AMPL NA PROBE $467.00 87529 T CELLS; TOTAL COUNT* $340.00 86359 T CELLS AB CD4/CD8 CT W/RATIO* $421.00 86360 FFP/CRO THAW EA UNIT $449.00 86927 NATRIURETIC PEPTIDE B TYPE $606.00 83880 FIBRIN DEGRAD PROD,D-DIMR;QUAN $449.00 85379 HEMOGLOBIN;SULFHEMOGLOBIN QUAN $93.00 83060 INHIBIN A $160.00 86336 ESTRONE $289.00 82679 AMPHETAMINE OR METHAMPHETAMINE $166.00 80324 CULTURE P PATHOG SCREEN ONLY $219.00 87081 PORPHYRINS,UA QUAN & FRACT $185.00 84120 FLOW CYTOMETRY EA ADDTL MARKER $264.00 88185 FLOW CYTOMETRY INTERP 16&>MARK $286.00 88189 C-REACTIVE PROTEIN HS $148.00 86141 FUNCTIONAL PLASMINOGEN $68.00 85420 RETICULOCYTE COUNT AUTOMATED $152.00 85045 UA DIP W/MICRO; AUTOMATED $239.00 81001 TIMED URINE VOL MEASURE, EA $33.00 81050 CULTURE BACT ANAEROBE ADDTL ID $75.00 87076 BMP IONIZED CALCIUM $332.00 80047 ENZYME DETECT SENSTITIVITY EA $125.00 87185 URINE BACTERIA CULTURE EA $221.00 87088 SENSITIVITY-DISK PER PLATE $65.00 87184 VITAMIN D, 25 HYDROXY $256.00 82306 OVA & PARASITES DIR SMR W/ID $103.00 87177 SMEAR COMPLEX STAIN OVA & PARA $194.00 87209 IMMUNOFIXATION E-PHORIS/UA/CSF $246.00 86335 NA QUAN NOS AG NOS RNA OR DNA $382.00 87799 ELECTROPHORESIS NES $332.00 82664 ESR; AUTOMATED $175.00 85652 SIROLIMUS $126.00 80195 VITAMIN NOS $247.00 84591 ANA TITER $256.00 86039 PLATELET NEUTRALIZATION $219.00 85597 DIR NA DNA/RNA PROBE MULT ORG $252.00 87800
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HIV-2 ANTIBODY $295.00 86702 STREP A AG, EIA $152.00 87430 HOMOGENIZATION TISS FOR CULTUR $89.00 87176 AGENT NOS ASSAY W OPTIC $108.00 87899 HEPATITIS-C, NA QUAN $837.00 87522 FUNGUS CULTURE DEF I.D. YEAST $129.00 87106 HGB CHROMATOGRAPHY $276.00 83021 MCG;IP SITU HYBR 100-300 CELLS $467.00 88275 ENTEROVIRUS, AMP PROBE TECH $274.00 87498 CHROM ANALY; 20-25 CELLS $1,257.00 88264 ANTI-PHOSPHATIDYLSERINE AB $199.00 86148 TISSUE CULTURE; BM, BLD CELLS $1,921.00 88237 GLUTAMYLTRANSFERASE GAMMA GGT $125.00 82977 AMINO ACIDS 6/>, QUAN, EA $172.00 82139 PNEUMOCYSTIS C AG BY IF $122.00 87281 HEPATITIS A ANTIBODY (HAAB) $247.00 86708 CULTURE; NA PROBE $179.00 87149 TB TEST CELL IMMUN MEASURE $415.00 86480 MR-STAPH, DNA, AMP PROBE $200.00 87641 PROTIME;SUB PLASMA FRACTION EA $78.00 85611 PAPPA, SERUM $151.00 84163 H PYLORI (C-13) BREATH TEST $564.00 83013 TREPONEMA PALLIDUM $190.00 86780 WEST NILE VIRUS ANTIBODY $246.00 86789 WEST NILE VIRUS ANTIBODY, IGM $246.00 86788 B CELLS, TOTAL COUNT $379.00 86355 MONONUCLEAR CELL ANTIGEN EA AG $266.00 86356 CULTURE; IF, EA ANTISERUM $83.00 87140 LIPOPROTEIN (A) $141.00 83695 GENET VIRUS ISOLATE, HSV $338.00 87255 ORGANIC ACIDS TOTAL QUANTIT EA $245.00 83918 CHLAMYDIA IGM ANTIBODY $221.00 86632 HERPES SIMPLEX VIRUS QUANTIT $206.00 87530 FETAL LUNG MATURITY; QUAN $392.00 83661 VIRUS ISOL SHELL VIAL TECHN EA $195.00 87254 GIARDIA AG, EIA $73.00 87329 HEPARIN ASSAY $251.00 85520 CALPROTECTIN, FECAL $177.00 83993 HUMAN EPIDIDYMIS PROTEIN 4 $187.00 86305 OCCULT BLD FHG,QUAL, 1-3 $148.00 82274 CULT FUNGUS W P ID;SKIN;HR;NL $89.00 87101 FACTOR 8 VWF MULTIMRIC ANALY $355.00 85247 COCAINE OR METABOLITE ASSAY $172.00 80353 SUGARS SGL QUAL EA SPECIMEN $50.00 84376 PROCALCITONIN (PCT) $174.00 84145 PLACENTA ALPHA MICRO IG C/V $264.00 84112 BLOOD TYPE ANTIGEN DONOR EA $449.00 86902 INFLUENZA DNA/RNA AMP PROBE $405.00 87502 INFLUENZA DNA/RNA AMP PROB ADD $186.00 87503 CHEMILUMINESCENT ASSAY $141.00 82397 LUTEINIZING RELEASING FACTOR $100.00 83727 FIBRINOGEN; ACTIVITY** $81.00 85384 DRAW BLOOD OFF VENOUS DEVICE $233.00 36591 DRUG TEST PRSMV CHEM ANLYZR** $173.00 80307 LIPOPROTEIN BLOOD BY NMR $200.00 83704 CLOTTING FUNCT ACTIVITY $104.00 85397 RESP VIRUS 6-11 TARGETS $931.00 87632 GENOTYPE ANAL NA-DNA/RNA CYTOM $1,123.00 87910 ASSAY LIPOPROTEIN PLA2 $347.00 83698 CYP2C19 GENE COM VARIANTS $1,012.00 81225 STREP A ASSAY W/OPTIC $114.00 87880
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
ALKALOIDS NOS $219.00 80323 BRCA1&2 SEQ & COM DUP/DEL $5,086.00 81211 EUGLOBULIN LYSIS $27.00 85360 CYTOGEN M ARRAY COPY NO&SNP $1,796.00 81229 FMR1 GENE DETECTION $475.00 81243 AEROBIC ISOLATE ID EA ISO $92.00 87077 MYCOBACTERIA T AMPLIF NA PROBE $438.00 87556 DIPHTHERIA AB $149.00 86648 QUAN MASS SPECTR EA SPECIMEN $165.00 83789 NEPHELOMETRY, EA ANALYTE NES $166.00 83883 SEX HORMONE BINDING GLOBULIN* $230.00 84270 INF AG BY DFA BORDETELLA PERTU $571.00 87265 UA DIP/TABL WO MICRO AUTOMATED $119.00 81003 CLOTTING FUNCT ACTIVAT EA ANAL $1,121.00 85347 GIARDIA LAMBLIA SERUM* $282.00 87269 UA SULFATE 24HR* $264.00 84392 RISTOCETIN COF AS/VWF ACTIVI** $680.00 85245 PARVOVIRUS ANTIBODY $480.00 86747 TROPONIN ASSAY QN $367.00 84484 MYOGLOBIN $363.00 83874 UA CHLORIDE RANDOM $199.00 82436 KLEIHAUER-BETKE TEST* $289.00 85460 CREATININE OTHER SOURCE $217.00 82570 HEPATITIS B VIRUS DNA, QUAN* $651.00 87517 SENSORY NEUROPATHY PANEL* $239.00 86255 PROTEIN S TOTAL $282.00 85305 PROTEIN S FREE $718.00 85306 NUCLEOTIDASE* $205.00 83915 TESTOSTERONE FREE $324.00 84402 IA ANALYTE QUAN;BY RIA** $173.00 83519 IA NOT INFECT AB/AG,QL/QN;MUL $185.00 83516 ORGANIC ACID, SINGLE, QUAN $149.00 83921 HEPB CORE AB; TOTAL AB $126.00 86704 HPV LOW-RISK TYPE $295.00 87623 AB; ENTEROVIRUS COXS,ECHO,POLI $130.00 86658 PANCREATIC ELASTASE, FECAL $119.00 82656 INF AG DET BY NA;CYTOMEGALOVIR $428.00 87497 NATURAL KILLER CELLS TOTAL CT $374.00 86357 NEISSERIA AMPLIF NA PROBE $104.00 87591 AB; COCCIDIOIDES $148.00 86635 LYMES AMPLIFIED NA PROBE $351.00 87476 T CELL; ABSOLUTE CD4 COUNT $268.00 86361 CCP ANTIBODY $118.00 86200 LACTOFERRIN, FECAL; QUAL $177.00 83630 ENZYME ACTIVITY BC; NOT RA** $160.00 82657 FLOW CYTOMETRY INTERP;2-8 MKRS $81.00 88187 FUNGUS CULTURE; BLOOD $103.00 87103 NICKEL $221.00 83885 STOOL CULT AEROB ADDL/EA PLATE $118.00 87046 FETAL FIBRONECTIN $1,223.00 82731 PROT; WB,W/I&R, IPFBI EACH* $983.00 84182 IMMUNOASSAY,ANALYTE,QUAL RIA* $1,085.00 83519 DEOXYRIB ACID (DNA) AB; NAT/DS $174.00 86225 RHEUMATOID FACTOR, QUAN $73.00 86431 IA ANALYSIS QUANT; BY RIA $164.00 83520 UA CREATININE, RANDOM $249.00 82570 UA BUN (UREA NITROGEN), RANDOM $205.00 84540 UA CALCIUM, RANDOM $205.00 82340 VIRUS ISOLATE;TISSUE CULT INOC $354.00 87252 ALLERGEN SPECIFIC IGE CRUDE EA $63.00 86003 FLOUR NONINFECT AGENT AB* $239.00 86255
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
AB; LYME'S (WB) CONFIRM $175.00 86617 QUANTITATIVE OF DRUG NES* $134.00 80299 LEVEL III SURG PATH GROSS/MCRO $497.00 88304 LEVEL II SURG PATH GROSS/MICRO $403.00 88302 LEVEL IV SURG PATH GROSS/MICRO $453.00 88305 LEVEL V SURG PATH GROSS/MICRO $1,228.00 88307 LEVEL VI SURG PATH GROSS/MICRO $1,551.00 88309 LEVEL I SURG PATH GROSS ONLY $210.00 88300 FROZEN SECT 1ST TB W FS SGL SP $340.00 88331 PATHOLOGY PAP SMEAR $232.00 88164 CHLAMYDIA T AMPLIF NA PROBE $104.00 87491 NEISSERIA AMPLIF NA PROBE $104.00 87591 CYTO FWB SMEAR & INTERP $408.00 88104 TISSUE FOR DRUG GROUP $161.00 87230 DETERM HISTOCHEM ID ENZYME $1,128.00 88319 SPECIAL STAINS GROUP 1 $369.00 88312 SPECIAL STAINS GROUP 11 $289.00 88313 IMMUNOHISTO ANTB 1ST STAIN $656.00 88342 UMC CONSULT/REPORT* $483.00 88321 UMC SURG PATH-COMPRE CON* $513.00 88325 UMC DERMATOLOGY CONS/REV $667.00 88321 AFIP DX SLIDES AND/OR BLK $645.00 88325 AFIP SPECIAL STAINS $170.00 88321 PATH DECALCIFICATION $246.00 88311 DETERM CYTOCHEM ID ENZYME $1,128.00 88319 FROZEN PATH CONSU INTRAOP ADDL $107.00 88332 CYTOPATHOLOGY CONCENTR TECH SM $441.00 88108 CELL COUNT MISC NOT BLOOD $140.00 89050 CELL COUNT W/DIFF CT NOT BLOOD $175.00 89051 FLOWCYTOMETRY,CELLCYCL/DNA ANA $810.00 88182 CHROMOSOME ANALY;15-20CELLS** $1,726.00 88262 TISSUE CULTURE; BM, BLD CELLS* $1,758.00 88237 FLOW CYTOMETRY 1ST MARKER $453.00 88184 FLOW CYTOMETRY EA ADD MARKER $231.00 88185 ELECTRON MICROSCOPY; DIAG $1,299.00 88348 CALCULI; IR SPECTROSCOPY $363.00 82365 STONE IR SPECTROSCOPY** $363.00 82365 BCR/ABL1 GENE TRANSLOC ANALY** $476.00 81208 HPV HIGH-RISK TYPES $134.00 87624 HPV TYPES 16 & 18 ONLY $295.00 87625 TRICHOMONAS VAGINALIS AMPLIFIED $152.00 87661 BCR/ABL1 GENE MAJOR BP $1,048.00 81206 JAK2 GENE $997.00 81270 EGFR GENE COM VARIANTS $2,204.00 81235 KRAS GENE $1,223.00 81275 BRAF GENE $767.00 81210 MICROSATELLITE INSTABILITY $1,044.00 81301 BCR/ABL1 GENE MINOR BP $1,207.00 81207 MOPATH PROCEDURE LEVEL 3 $561.00 81402 MOPATH PROCEDURE LEVEL 2 $2,204.00 81401 IMMUNOHISTO ANTIBODY SLIDE $449.00 88344 IGH GENE REARRANGE AMP METH $858.00 81261 IMMUNOHISTO ANTB ADDL SLIDE $247.00 88341 HISTOCHEMICAL STAINS ADDON I&R $248.00 88314 MORPHOMETRIC ISHQUA/SEMI MANUA $513.00 88377 MORPHOMETRIC ISHQU/SEM COMPUTR $513.00 88374 IMMUNOFLUOR ANTB ADDL STAIN $73.00 88350 KRAS GENE ADDL VARIANTS $460.00 81276 CHROM ANALY; ADDTL BANDING $169.00 88283 CHROM ANALY; ADDTL CELL COUNTS $56.00 88285 INTRAOP CYTO PATH 1ST SPEC $1,128.00 88333
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INTRAOP CYTO PATH ADD 2> $93.00 88334 IMMUNOFLOUR STUDY SGL AB $449.00 88346 MORPHOMETRIC ANAL AB EA MANUAL $449.00 88360 MORPHOMETRIC AN AB EA COMPUTER $449.00 88361 MOL CYTOGENETICS 25-99 CELLS $303.00 88274 MCG DNA PROBE EA (FISH) $288.00 88271 INSITU HYBRIDIZATION, MANUAL $449.00 88368 TISSUE CULTURE; OTHER TISSUE $1,008.00 88239 CHROM ANA;ADDL KARYOT EA STUDY $260.00 88280 MCG;IP SITU HYBR 100-300 CELLS $428.00 88275 AUTOPSY SELF PAY $3,162.00 88099 INSITU HYBRIDIZATION 1ST PROBE $421.00 88365 INSITU HYBRIDIZATION AUTO $507.00 88367 MICRODISSECTION MANUAL $676.00 88381 CHROM ANALY; 20-25 CELLS $1,257.00 88264 REF CONSULT W SLIDE PREP $507.00 88323 CYTP DX EVAL FNA 1ST EA SITE $384.00 88172 CYTOPATH EVAL OF FNA;INT&REP $131.00 88173 TRB@ GENE REARRANGE AMPLIFY $904.00 81340 TRG GENE REARRANGEMENT ANAL $873.00 81342 CHROMOSOME ANAL;5 CELLS 1 KARY $765.00 88261 DX PAP SMR AUTO SCRN W M RS $57.00 88148 CP CERV/VAG;ATL; MANUAL SCRN $106.00 88142 CYTOPATH CELL ENHANCE TECH $108.00 88112 INSITU HYBRIDIZATION FISH EA A $259.00 88364 PCA3/KLK3 ANTIGEN $608.00 81313 PATHOLOGY CONSULT DURING SURG $300.00 90371 MORPHOMETRICS NERVE $164.00 88356 DELETE $- J9228FB LEVEL 4 SURG PATH GROSS/MICRO $94.00 88305 IMMUNOHISTO ANTB 1ST STAIN $449.00 88342 IMMUNOHISTO SGL AB ADDL SLIDE $191.00 88341 SPECIAL STAINS GROUP 11 $67.00 88313 SPECIAL STAINS GROUP 1 $94.00 88312 CYTOLOGY - FLUID $199.00 8810426 LEVEL I SUR PATH GROSS ONLY PF $87.00 8830026 LEVEL 2 SUR PATH GROSS/MICR PF $147.00 8830226 LEVEL 3 SUR PATH GROSS/MICR PF $197.00 8830426 LEVEL 4 SUR PATH GROSS/MICR PF $359.00 8830526 LEVEL 5 SURG PA GROSS/MICRO PF $501.00 8830726 LEVEL VI SUR PATH GROSS/MIC PF $728.00 8830926 DECALCIFICATION PROCEDURE $109.00 8831126 SPECIAL STAINS GROUP 1 PROF $95.00 8831226 SPECIAL STAINS GROUP II PROF $76.00 8831326 CONSULTATION & REPRT $120.00 88321 CONSULT WITH SLIDES $429.00 8832326 CONSULT DURING SURG $328.00 88329 CONSULT FROZ SEC/1ST TB/SGL PF $255.00 8833126 DETERMINATIVE HISTOCHEMISTRY $125.00 8831926 IMMUNOHISTO ANTB 1ST STAIN PF $179.00 8834226 CONSULT FROZ SEC/ADDL TB/EA PF $250.00 8833226 CYTOPATHOLOGY CONCENTR TECH PF $212.00 8810826 CRYSTAL ID, EXCEPT URINE $67.00 8906026 PERIPHERAL BLOOD SMEAR PROFEE $84.00 85060 BONE MARROW SMEAR $269.00 85097 CYTOGENETICS & MOLECULAR I&R $297.00 88291 FLOW CYTOMETRY INTRP 16>MRK PF $783.00 88189 FLOW CYTOMETRY INTER 2 TO 8 PF $474.00 88187 FLOW CYTOMETRY INTR 9-15MRK PF $593.00 8818826 IMMUNOFLOUR STUDY SGL AB PF $303.00 8834626 INTRAOP CYTO PATH CONSULT 1ST $215.00 8833326
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 INTRAOP CYTO PATH CONS 2> PF $127.00 8833426 MANUAL TUMOR IM HISTO EA AB PF $236.00 8836026 COMPUTER MORPHOMETRIC EA AB PF $229.00 8836126 CYTPATH DX EVAL FNA 1ST EA PF $105.00 8817226 CYTOPATH EVL OF FNA;INT&REP PF $209.00 8817326 INVESTIGATE TRANSFUS REACT PF $207.00 8607826 IMMUNOHIST ANTIBODY EA ADDL PF $28.00 8834426 CYTOPATH C/V INTERPRET PROFEE $95.00 88141 CYTP FNA EVAL EA ADDL PROFEE $66.00 8817726 CYTOPATH CELL ENHANCE TECH PF $85.00 8811226 IMMUNOHISTO ANTIBODY SLIDE PF $44.00 8834126 MORPHOMETRICS NERVE PROF $244.00 8835626 HISTOCHEMICAL STAINS ADD-ON PF $46.00 8831426 MORPHOMETRIC ANA ISHQU/SEMI PF $197.00 88377 MORPHOMETRIC AN ISHQ/SEM CO PF $136.00 88374 IMMUNOFLUOR ANTB ADDL STAIN PF $57.00 8835026 LEVEL IV SUR PTH GROSS&MICR PF $79.00 8830526 IMMUNOHISTO ANTB 1ST STAIN PF $74.00 8834226 IMMUNOHISTO ANTIBODY SLIDE PF $44.00 8834126 SPECIAL STAINS GROUP II PROF $25.00 8831326 SPECIAL STAINS GROUP 1 PROFEE $56.00 8831226 INSITU HYBRIDIZATION 1ST PF $194.00 8836526 RBC LR EACH UNIT $717.00 P9016 CRYOPRECIPITATE EACH UNIT $266.00 P9012 FRESH FROZEN PLASMA 1 DONOR $266.00 P9017 PLATELETS PHERESIS LR IRR EU $1,498.00 P9037 RBC LR IRR EACH UNIT $1,531.00 P9040 PLATELETS PHERESIS LR EA UNIT $2,122.00 P9035 TRANSFUSION BLOOD PROD PER DAY $1,136.00 36430 INVESTIGATE TRANSFUS REACTION $507.00 86078 GLUCOSE; BLOOD REAGENT STRIP $45.00 82948 PROTHROMBIN TIME (POC) $18.00 85610QW EKG 12 LEAD, TRACING ONLY $204.00 93005 ECG > TO 48 HRS RECORDING $265.00 93225 ECG>48 HRS SCANNING ANALY W/R $265.00 93226 ECG > TO 48 HRS CONT RHYTHM PF $107.00 93227 ELECTROCARDIOGRAM PROF FEE $33.00 93010 CARDIOVERSION $1,987.00 92960 EEG, AWAKE & ASLEEP $839.00 95819 EEG AWAKE / DROWSY $1,719.00 95816 EEG AWAKE & ASLEEP PRO FEE $193.00 9581926 EEG AWAKE & DROWSY PRO FEE $232.00 9581626 EEG EXT MONITORING 41>60 MIN $559.00 95812 EEG EXT MONITOR 41>60MIN PF $204.00 9581226 EEG >1HR TOTAL RECORDING $549.00 95813 EEG >1HR TOTAL RECORD PROFEE $326.00 9581326 TELEHEALTH ORIG FACILITY FEE $103.00 Q3014 ABDOMEN EXAM 2 VIEWS/OP $260.00 74019 ABDOMEN EXAM 3+ VIEWS/OP $260.00 74021 CHEST X-RAY 2 VIEWS OP $133.00 71046 PELVIS 1 OR 2 VIEW/OP $220.00 72170 HUMERUS 2+ VIEW/OP $133.00 73060 ELBOW 3+ VIEW/OP $133.00 73080 WRIST MIN 3 + VIEWS/OP $133.00 73110 HAND MIN 3+ VIEW/OP $133.00 73130 KNEE 3 VIEW/OP $133.00 73562 TIBIA FIBULA 2 VIEW/OP $133.00 73590 ANKLE COMPL 3+ VIEW/OP $220.00 73610 FOOT 3+ VIEW/OP $133.00 73630 STERNUM 2+ VIEW/OP $133.00 71120 NASALBONE 3+ VIEWS/OP $133.00 70160
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 SACRUM/COCCYX MIN 2 VIEW/OP $133.00 72220 SACROILIAC JOINT 3+ VIEW/OP $239.00 72202 CLAVICLE COMPLETE/OP $133.00 73000 SHOULDER 1 VIEW/OP $133.00 73020 ACROMIOCLAVICULAR-JT/OP $220.00 73050 SCAPULA COMPLETE/OP $239.00 73010 OS CALCIS-HEEL/OP $133.00 73650 BONE AGE STUDY/OP $220.00 77072 FOREARM 2 VIEW/OP $133.00 73090 ABDOMEN X-RAY EXAM 1 VIEW/OP $133.00 74018 SELLATURCICA/OP $133.00 70240 NECK SOFT TISSUE/OP $133.00 70360 ELBOW 2 VIEW/OP $133.00 73070 WRIST 2 VIEW/OP $133.00 73100 KNEE 1 OR 2 VIEW/OP $133.00 73560 ANKLE 2 VIEW/OP $133.00 73600 FOOT 2 VIEW/OP $133.00 73620 CHEST SINGLE VIEW OP $133.00 71045 LUMBAR SPINE 2 OR 3 VIEWS/OP $220.00 72100 FINGERS O/P $133.00 73140 FEMUR 1 VIEW O/P $133.00 73551 FEMUR MINIMUM 2 VIEWS/OP $133.00 73552 HAND 2 VIEW/OP $246.00 73120 SHOULDER COMPL 2+ VIEW/OP $133.00 73030 TOES COMPL 2+ VIEW/OP $133.00 73660 KNEE COMPLETE MIN 4 VIEW/OP $246.00 73564 KNEES STAND AP 1 VIEW BIL/OP $133.00 73565 CHEST SGL VIEW PORTABLE $383.00 71045 CHEST SINGLE VIEW $383.00 71045 CHEST 2 VIEWS $602.00 71046 CHEST MINIMUM 4 VIEWS $814.00 71048 RIBS UNILATERAL 2 VIEWS $623.00 71100 RIBS BILATERAL 3 VIEWS $826.00 71110 STERNUM MINIMUM 2 VIEWS $671.00 71120 NASAL BONES COMPL, MIN 3 VIEWS $577.00 70160 SINUSES COMPLETE MIN 3 VIEWS $964.00 70220 SKULL COMPLETE MINIMUM 4 VIEWS $1,161.00 70260 TMJ $801.00 70330 SELLA TURCICA XRAY $482.00 70240 ORBITS $1,003.00 70200 SKULL LIMITED < 4 VIEWS $680.00 70250 MANDIBLE $929.00 70110 FACIAL BONES $786.00 70150 NECK SOFT TISSUE $482.00 70360 CERVICAL LIMITED 2 OR 3 VIEWS $662.00 72040 CERVICAL COMPLETE MIN 4 VIEWS $930.00 72050 CERVICAL SPINE COMPL 6/>VIEWS $1,075.00 72052 THORACIC SPINE 3 VIEWS $827.00 72072 PELVIS 1 OR 2 VIEWS $565.00 72170 LUMBAR SPINE MINIMUM 4 VIEWS $1,082.00 72110 LUMBAR SPINE 2 OR 3 VIEWS $774.00 72100 SACRUM/COCCYX MINIMUM 2 VIEWS $585.00 72220 CLAVICLE $538.00 73000 SHOULDER LMT $538.00 73020 ARTHROGRAM SHOULDER S & I $1,881.00 73040 SHOULDER COMPLETE MIN 2 VIEW $623.00 73030 ACROMIOCLAVICULAR-JT $550.00 73050 HUMERUS $586.00 73060 SCAPULA $544.00 73010 ELBOW $565.00 73080 FOREARM $500.00 73090
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
WRIST $610.00 73110 HAND MIN 3 VIEWS $565.00 73130 FINGERS $392.00 73140 ELBOW LMT $482.00 73070 HAND 2 VIEW $418.00 73120 WRIST LMT $482.00 73100 KNEE 3 VIEWS $630.00 73562 TIBIA $565.00 73590 ANKLE COMPLETE MIN. 3 VIEWS $570.00 73610 OS CALCIS-HEEL $538.00 73650 FOOT $565.00 73630 TOES COMPLETE MIN 2 VIEW $404.00 73660 KNEE, LMT, 1 OR 2 VIEWS $490.00 73560 BONE LENGTH SCANOGRAM $676.00 77073 ANKLE, LMT, AP & LT $482.00 73600 FOOT LMT $482.00 73620 ABDOMEN X-RAY EXAM 1 VIEW $530.00 74018 ABDOMEN X-RAY EXAM 2 VIEW $741.00 74020 PELVIS 3 VIEWS $1,022.00 72190 SWALLOWING FCN W CINE/VIDEO $1,515.00 74230 UGI $1,634.00 74247 SMALL BOWEL INCL SERIAL IMAGES $1,612.00 74250 UGI - SMALL BOWEL $2,523.00 74249 COLON CONTRAST ENEMA W/W/O KUB $1,835.00 74270 CYSTOGRAM MIN 3 VIEWS $1,556.00 74430 HYSTEROSALPINGOGRAM S & I $1,828.00 74740 VENOGRAPHY,EXTREMITY;BILATERAL $2,843.00 75822 VENOGRAM,EXTREMITY;UNILATERAL $2,280.00 75820 BONE AGE STUDY $671.00 77072 OSSEOUS SURVEY $1,443.00 77075 ABSCESS FISTULA/SINUS TRACT ST $1,200.00 76080 VENOGRAM SVC W SERIALOGRAPHY $3,276.00 75827 SPINE,LS,BENDING ONLY 2/3 VIEW $1,008.00 72120 ESOPHOGRAM $1,912.00 74220 ABDOMEN EXAM 2 VIEWS $268.00 74019 SC JOINTS $639.00 71130 ABDOMEN EXAM 3+ VIEWS $268.00 74021 KNEES STANDING,AP 1 VIEW BILAT $565.00 73565 SURGICAL SPECIMEN XRAY $1,112.00 76098 CHOLANGIOGRAM - IO S&I $1,260.00 74300 ANGIOGRAM PULMONARY UNILAT SEL $5,198.00 75741 CISTERNOGRAPHY $2,643.00 70015 FB DETECTION IN EYE $340.00 70030 MANDIBLE PARTIAL < 4 VIEWS $673.00 70100 FACIAL BONES < 3 VIEWS $670.00 70140 TMJ UNILATERAL $443.00 70328 CHEST X-RAY EXAM 3 VIEWS $822.00 71047 THORACOLUMBAR JUNCTION 2/>VW $662.00 72080 SACROILIAC JOINTS $769.00 72202 ELBOW ARTHROGRAM $1,338.00 73085 UPPER EXTREMITY, INFANT $492.00 73092 WRIST, ARTHROGRAM $1,602.00 73115 KNEE COMPLETE MIN 4 VIEWS $767.00 73564 KNEE, ARTHROGRAM $1,841.00 73580 LOWER EXT INFANT $642.00 73592 ANKLE, ARTHROGRAM $997.00 73615 UPPER G.I. W/AIR $1,854.00 74246 ENDO CATH - BILE DUCTS $1,284.00 74328 ENDO CATH BILIARY/PANCR DUCTS $1,514.00 74330 UROGRAM RETROGRADE $2,965.00 74420 CORPORA CAVERNOSOGRAM $1,648.00 74445
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 URETHROCYSTOGRAM VOIDING $1,747.00 74455 ANGIOGRAM SPINAL SELECT $8,893.00 75705 ANGIOGRAM EXTREMITY UNILATERAL $7,010.00 75710 ANGIOGRAM EXTREMITY BILATERAL $7,321.00 75716 ANGIOGRAM VISCERAL SELECT $8,893.00 75726 ANGIOGRAM PELVIC SELECT $8,893.00 75736 ANGIOGRAM PULMONARY NONSELECT $6,915.00 75746 ANGIOGRAM INTERNAL MAMMARY $6,915.00 75756 ANGIOGRAM SELECT EA ADD VESSEL $3,203.00 75774 VENOGRAM RENAL UNILAT $5,198.00 75831 VENOGRAM BILAT SELCTV RENAL $7,388.00 75833 VENOGRAM SINUS OR JUGL CATH $5,198.00 75860 PORTOGRAM PERC TRANSHEP W/HEMO $7,388.00 75885 TRANSCATHETER BIOPSY S & I $2,386.00 75970 CHG PERC TUBE OR DR CATH $739.00 75984 DRAINAGE CATH UNDER XR $3,006.00 75989 FLUORO GUIDE NDL PLCMT BIOPSY $589.00 77002 VENOGRAM IVC W SERIALOGRAPHY $7,883.00 75825 DRAIN/INJ SM JOINT/BURS W/O US $1,161.00 20600 ARTHRO/ASP/INJ ITM JT/BR WO US $929.00 20605 ARTHRO/ASP/IJ MAJ JNT/BR WO US $1,161.00 20610 FLUORO GUIDE SPINE INJ $589.00 77003 CISTERNAL/LAT C1-C2 W/MED INJ $2,047.00 61055 TIBIAL/PER REVASC STENT&ATHER $55,943.00 37231 INJ TRIGGER POINT 1/2 MUSCL $580.00 20552 INS CATH ABD/L-EXT ART ADDL $683.00 36248 REM/REPLACE NEPHROURETE CATH $3,536.00 50387 THER/PRO/DIAG INJ IV PUSH INIT $424.00 96374 EPIDURAL INJ SGL LUMBAR/SACR $1,398.00 62322 THORACENTESIS W/O IMAGING $1,615.00 32554 THROMBOLYTIC ART THERAPY $9,263.00 37211 THROMBOLYTIC VENOUS THERAPY $5,572.00 37212 PLACE CATH SUBCLAVIN ART S&I $7,674.00 36225 PLACE CATH THORACIC AORTA $7,674.00 36221 MYELOGRAPHY LUMBAR INJ CER S&I $1,715.00 62302 MYELOGRAPHY LUMBA INJ THOR S&I $1,841.00 62303 MYELOGRAPHY LUMBAR INJ L/S S&I $1,841.00 62304 MYELOGRAPHY LUMBAR IN 2>RG S&I $1,841.00 62305 DXA BONE STUDY 1>SITE INC VERT $285.00 77085 DXA FRACTURE ASSESSMENT $219.00 77086 ENTEROCLYSIS SM BOWEL INC MULT $1,594.00 74251 HIP ARTHROGRAM $2,135.00 73525 DEXA;AXIAL SKELETON $740.00 77080 FLUORO UP TO 1HR SEPARATE PROC $931.00 76000 BONE SURVEY INFANT XRAYS $1,372.00 77076 TOTAL BODY INFANT (FB) $489.00 76010 UGI W/O AIR $1,398.00 74241 MYELOGRAM INJ AND/OR CT LUMBAR $783.00 62284 SHOULDER ARTHROGRAM INJ $222.00 23350 ELBOW ARTHROGRAM INJ $222.00 24220 HIP ARTHROGRAPHY INJ WO ANESTH $222.00 27093 KNEE ARTHROGRAPHY INJ CONTRAST $221.00 27370 ANKLE ARTHROGRAPHY INJ $179.00 27648 INJ FOR CYSTOGRAM $222.00 51600 ABD ACUTE W/CHEST $1,076.00 74022 MOD CS BY SAME PHYS, 5 YRS + $386.00 99152 MOD CS BY SAME PHYS, <5 YEARS $386.00 99151 BONE SURVEY LTD $611.00 77074 RIBS BILAT W/PA CHEST $611.00 71111 RIBS UNI W/PA CHEST MIN 3 VIEW $362.00 71101 EGD REMOVE FOREIGN BODY $2,738.00 43247
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 ERCP,DX $6,376.00 43260 WRIST ARTHRO INJECTION $623.00 25246 FLUORO GUIDE CENTRAL VAD $962.00 77001 REPLACED PERIPHERALLY CVA CATH $4,264.00 36584 HYSTEROSALPINGIOGRAM INJ $730.00 58340 BX PLEURA; PERCUTANEOUS NEEDLE $2,919.00 32400 INSERT PICC W/O PORT >5 YRS $3,815.00 36569 ASPIRATION BL W/CATH INSERTION $5,043.00 51102 REPL TUNNELED VAD W PORT $7,727.00 36582 PERCUT VERTEBROPLASTY THORAC $10,614.00 22510 SPINE,LS,COMP INC BENDING VIEW $239.00 72114 INSERT CATH PLEURA W/O IMAGE $3,073.00 32556 X-RAY EXAM ENTIRE SPINE 1 VIEW $171.00 72081 X-RAY EXAM ENTIRE SPI 2/3 VIEW $282.00 72082 X-RAY EXAM ENTIRE SPI 4/5 VIEW $537.00 72083 X-RAY EXAM ENTIRE SPI 6/> VIEW $537.00 72084 HIP UNILATERAL W/PELVIS 1 VIEW $411.00 73501 HIP UNILATERAL W/PELVIS 2/3 VW $772.00 73502 HIP UNILATERAL W/PELVIS 4VIEWS $772.00 73503 HIP BILATERAL W/PELVIS 2 VIEW $624.00 73521 HIP BILAT W/PELVIS 3/4 VIEWS $624.00 73522 HIP BILATERAL W/PELVIS 5>VIEWS $624.00 73523 FEMUR 1 VIEW $171.00 73551 FEMUR MINIMUM 2 VIEWS $565.00 73552 INTRO NEE/CATH DIA W/TLB ANGIO $12,296.00 36902 PERC TRANSLUM THRMBC DIALY CIR $12,296.00 36904 TRANSLUM BALLOON ANGIO 1ST ART $12,296.00 37246 INTRO NEE/CATH DIAL W/TL STENT $24,851.00 36903 INTRO NEE/CATH DIALY CIRC INCL $1,744.00 36901 INTRO NEE/CATH THRMBC/NFS DIAL $24,851.00 36905 INTRO NEE/CATH W TCP INTRAV ST $37,669.00 36906 TRANSLUMINAL BALL ANGIO EA ART $12,296.00 37247 MOD SED OTH PHYS/QHP <5 <15MIN $386.00 99155 MOD SED OTH PHYS/QHP <5 <15MIN $386.00 99156 MOD SED OTH PHYS/QHP 5>ADD 15M $386.00 99157 MRI OR/FCE/NECK W/O CONTR $2,049.00 70540 MRI BRAIN WO CONTRAST $3,023.00 70551 MRI CHEST-THORAX W/O CONTR $2,776.00 71550 MRI C-SPINE W/O CONTR $3,483.00 72141 MRI T-SPINE W/O CONTR $3,520.00 72146 MRI PELVIS W/CONTR $3,419.00 72196 MRI UPPER EXT W/WO CONTR $3,456.00 73220 MRI LOWER EXT W/WO CONTR $2,609.00 73720 MRI ABDOMEN W/O CONTR $2,791.00 74181 MRI BRAIN W CONTRAST $3,592.00 70552 MRI C-SPINE W/CONTRAST $2,810.00 72142 MRI T-SPINE W/CONTRAST $2,810.00 72147 MRI L-SPINE W/CONTRAST $3,462.00 72149 MRI BRAIN W & WO CONTRAST $4,298.00 70553 MRI C-SPINE W & W/O CONTR $4,191.00 72156 MRI T-SPINE W/WO CONTR $4,278.00 72157 MRI L-SPINE W/WO CONTR $4,332.00 72158 MRI UPPER EXT JNT W/O CONTR $1,817.00 73221 MRI LOWER JNT W/O CONTR $2,630.00 73721 MRA CHEST W/WO CONTR $3,813.00 C8911 MRA PELVIS W/WO CONTRAST $3,023.00 C8920 MRA LOWER EXT W/WO CONTR $3,023.00 C8914 MRA ABD W/WO CONTR $3,023.00 C8902 MRI BREAST BIL W/WO CONTR $4,699.00 77059 MRI L-SPINE W/O CONTR $3,565.00 72148 MRI TMJ $2,750.00 70336
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 MRI ABDOMEN W/CONTR $3,019.00 74182 MRI ABDOMEN W/WO CONTR $4,056.00 74183 MRI LOWER JNT W/CONTR $2,830.00 73722 MRI LOWER JNT W/WO CONTR $3,920.00 73723 MRI LOWER EXT W/O CONTR $2,145.00 73718 MRI PELVIS W/O CONTR $2,959.00 72195 MRI UPPER EXT W/O CONTR $2,304.00 73218 MRI CHEST W/WO CONTR $4,881.00 71552 MRI PELVIS W/WO CONTR $4,007.00 72197 MRA HEAD W/O CONTR $3,030.00 70544 MRA HEAD W/CONTR $3,241.00 70545 MRA HEAD W/WO CONTR $3,876.00 70546 MRA; NECK WO CONTRAST $3,030.00 70547 MRA; NECK W & WO CONTRAST $3,951.00 70549 MRI ORBIT/FACE/NECK W/WO CONTR $4,407.00 70543 MRI UPPER JNT W/CONTR $2,750.00 73222 MRI UPPER JNT W/WO CONTR $4,137.00 73223 MOD CS BY SAME PHYS, 5 YRS + $218.00 99152 MOD CS BY SAME PHYS, <5 YRS $218.00 99151 MRA CHEST W/O CONTR $2,681.00 C8910 MRA,ABD WO CONTRAST $2,679.00 C8901 MRI BREAST BIL W/CONTR $5,027.00 C8906 MRI BREAST W/O CONTR $3,154.00 C8907 MRI RECONSTRUCTION 3D $471.00 76376 INJ GADOLINIUM, PER ML $55.00 A9579 MRA PELVIS W/CONTRAST $1,821.00 C8918 MRA PELVIS WO CONTRAST $1,182.00 C8919 CAD MRI BREAST $26.00 0159T MRI FETAL SNGL/1ST GESTATION $707.00 74712 MRI FETAL EA ADDL GESTATION $419.00 74713 MOD SED SAME PHY/QHP ADDL 15M $75.00 99153 GI BLEED SCAN $2,607.00 78278 LIVER & SPLEEN; STATIC ONLY $2,308.00 78215 PARTICULATE LUNG PERFUSION $2,273.00 78580 LOCALIZED BONE SCAN $2,109.00 78300 BONE SCAN TOTAL $3,393.00 78306 MUGA; SGL W WM & EF $2,452.00 78472 MECKELES SCAN $1,737.00 78290 HEPATOBILIARY SYS IMAGE SCAN $2,033.00 78226 TC-99M MEDRONATE,DIAG > 30MCI $159.00 A9503 TC-99M PENTETATE/MCI 1-25 $1,178.00 A9539 HEPATOBILIARY SYS IMAGE W/DRUG $1,759.00 78227 TC-99M MACROAG ALB/MCI 1-10 $908.00 A9540 I-123 DX NA IODIDE CAPS/100 UCI $1,112.00 A9516 THYROID SCAN/METS WHOLE BODY $2,523.00 78018 PARATHYROID PLANAR IMAGING $1,617.00 78070 WBC LOCAL LIMITED $2,688.00 78805 ABSC LOCALIZ; WB $4,015.00 78806 LYMPH OR LN NM SCAN $2,095.00 78195 LIVER SCAN (SPECT) $4,054.00 78205 GASTRIC EMPTYING IMAGE STUDY $1,996.00 78264 BONE SCAN 3 PHASE $3,904.00 78315 BONE DENSITOMETRY (SPECT) $4,054.00 78320 HT MUSCLE IMAGE,PLANAR, MULT $3,249.00 78454 HT MUSCLE IMAGE SPECT, SINGLE $4,870.00 78451 HT MUSCLE IMAGE SPECT, MULT $7,374.00 78452 LUNG VENTILAT/PERFUSION STUDY $4,434.00 78582 BRAIN,LIMITED;W VASC FLOW $2,331.00 78601 CSF FLOW; CISTEROGRAM $3,456.00 78630 KIDNEY FUNCTION W/O PHARMOC $1,225.00 78725 KIDNEY FUNCT; SGL W DRUGS $2,394.00 78708
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TUMOR LOCALIZ;SPECT $4,711.00 78803 ORAL RADIOPHARM RX(THERAPY) $2,266.00 79005 CERETEC/RADIOPHARMACUTICAL $4,578.00 A9521 TC-99M SULPH COLLOID/MCI 1-20 $1,104.00 A9541 THALLOUS CHLORIDE TL 201 PER 1 MCI $60.00 A9505 DX-TC 99M SESTAMIBI PER DOSE $1,977.00 A9500 INDIUM IN-111 PENTETREOTIDE, 1 TO 6 $10,721.00 A9572 SAMARIUM SM153 LEXIDRONAMM >150M $28,971.00 A9604 MAG 3 PER 1-15 MCI $1,183.00 A9562 IN111 PENTETATE PER 0.5MCI $472.00 A9548 TC-99M EXAMETAZINE/DOSE $4,577.00 A9521 TC-99M MEBROFENIN/MCI 1-15 $2,439.00 A9537 STRESS TEST CVSLR; TRACING $713.00 93017 TC-99M TETROFOSMIN/DOSE $642.00 A9502 TC-99 PERTECHETATE/MCI $580.00 A9512 TUMOR IMAGING WHOLE BODY 2DAYS $4,251.00 78804 TC-99 BISCATE PER VIAL $2,179.00 A9557 TC-99 LABELED RBC, 1-30 MCI $526.00 A9560 IODINE I-131 IODIDE CAP,DX PER MILC $269.00 A9524 SENTINEL NODE INJECTION $771.00 38792 I-131 IODINE CAP THERAPUTIC PER MCI $87.00 A9517 LUNG PERFUSION DIFFERENTIAL $786.00 78597 LUNG PERF&VENTILA DIFFERENTAL $1,089.00 78598 THYROID IMAGING W BLOOD FLOW $994.00 78013 THYROID IMAGING W/BLOOD FLOW $786.00 78014 PARATHYROID PLANAR W/WO SUBTRJ $978.00 78071 LYMPHANGIO EXTR ONLY;UNIL S&I $1,277.00 75801 INJECTION FOR LYMPHANGIOGRAPHY $553.00 38790 GASTRIC EMPTY STUDY W/SM BOWEL $1,963.00 78265 GASTRIC EMPTY W/SBT MULTI DAYS $2,120.00 78266 RADIOPHARMACEUTICAL THR IV ADM $636.00 79101 PROPOFOL 10MG/ML INJ (200ML) $4.00 J2704 VITAMINS A & D OINT 5MG UD $10.00 SULFANILAMIDE VAG OINT GM TUB $414.00 ACETAMINOPHEN 160MG/ML LIQ U/D $10.00 ACETAMINOPHEN 120MG SUPP $10.00 ACETAMINOPHEN 325MG SUPP $10.00 ACETAMINOPHEN 650MG SUPP $10.00 EPINEPHRINE TOP SOL 1:1000 30M $160.00 DOXORUBICIN HCL 10MG IJ (10MGG) $211.00 J9000 OXYMETAZOLIN NAS SPR 0.5% 15ML $103.00 SPRIONOLACTONE 25MG TABLET $10.00 METHYLDOPA 250MG TABLET $10.00 AMINOCAPRO AC 250MG/ML IJ 20ML $122.00 AMINOCAPROIC ACID 500MG TABLET $52.00 AMINOPHYLLINE 250MG INJ(500MG) $65.00 J0280 AMOXICILLIN 250MG CAPSULE $10.00 AMPICILLIN 250MG CAPSULE $10.00 AMPICILLIN 250MG INJECTION $122.00 J0290 AMPICILLIN 500MG INJECTION $122.00 J0290 AMPICILLIN 500MG INJ (1000MG) $122.00 J0290 AMPICILLIN 500MG INJ (2000MG) $122.00 J0290 AMPICILLIN 500MG(2GM) IVPB $122.00 J0290 AMYL NITRITE INH 0.3ML $70.00 SUCCINYLCHOLINE 20MG IJ(200MG $14.00 J0330 MECLIZINE 12.5MG TABLET $10.00 HEMORRHOIDAL OINTMENT 30GM $122.00 HEMORRHOIDAL SUPPOSITORY $10.00 HEMORRHOIDAL-HC SUPPOSITORY $10.00 HYDRALAZINE 10MG TABLET $10.00 HYDRALAZINE 25MG TABLET $10.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HYDRALAZINE 20MG INJ $165.00 J0360 PHYTONADIONE 1MG INJ (10MG) $14.00 J3430 PHYTONADIONE NEONATAL 1MG ING $134.00 J3430 TRIAMCINOLONE 0.1% CREAM 15GM $103.00 AMMONIA, AROMATIC INH 0.33ML $10.00 TRIHEXYPHENIDYL 2MG TAB $10.00 ASPIRIN 300MG SUPPOSITORY $14.00 ASPIRIN 600 MG SUPPOSITORY $14.00 ASPIRIN 325 ENT COATED TAB $10.00 ASPIRIN 325MG TABLET $- ASCORBIC ACID 250MG TABLET $10.00 HYDROXYZINE HCL 10MG TABLET $10.00 HYDROXYZINE HCL 25MG TABLET $10.00 HYDROXYZINE 10MG/5ML SYP U/D $10.00 LORAZAPAM 0.5MG TABLET $14.00 LORAZAPAM 1MG TABLET $14.00 LORAZAPAM 2MG INJECTION $126.00 J2060 ATROPINE 0.4MG/1ML INJECTION $2.00 J0461 ATROPINE 0.1MG/ML SYR(0.5MG) $2.00 J0461 ATROPINE 0.4MG/ML 20ML VL 8MG $2.00 J0461 ATROPINE 0.1MG/ML 10ML SYR(1MG $2.00 J0461 ATROPINE 1% OPHTH SOLN 2ML $108.00 AMOXICILLIN/CLAVUL 250MG TAB $36.00 AMOXICILLIN/CLAVUL 500MG TAB $38.00 AMOXICILL/CLAV 250MG/5ML SUSP $312.00 ANTIPYRINE/BENZO OTIC SOL 10ML $106.00 SULFASALAZINE 500MG TABLET $10.00 BELLADONNA & OPIUM 60MG SUPP $112.00 BACITRACIN 50,000 UNIT POWDER $159.00 BACITRACIN 0.9GM OINTMENT U/D $10.00 SULFAMET/TMP 80-16MG/ML 5ML IJ $125.00 SULFAMETHOX/TMP 400-800MG TAB $14.00 SULFAMETHOXAZOLE/TMP 800-160MG $10.00 SULFAMETHOX/TMP 800-160MG/20ML $28.00 SULFAMETH/TMP 200-40MG/5ML SUS $10.00 DIPHENHYDRAMINE 25MG CAP $10.00 DIPHENHYDRAMINE 50MG INJ $122.00 J1200 DIPHENHYDRAM 12.5MG/5ML UD ORA $10.00 PROBENECID 500MG TABLET $10.00 DICYCLOMINE 10MG CAPSULE $10.00 DICYCLOMINE 10MG INJECTION $120.00 J0500 BENZOIN TINCTURE 60ML $89.00 POVIDONE-IODINE OINTMENT 30GM $106.00 PEN G BENZ/PROC 100MU (1200MU) $26.00 J0558 PENICILLIN G BENZ 100MU(600MU) $26.00 J0561 PENICILLIN G BENZ 100MU(1200MU $26.00 J0561 BLEOMYCIN 15 UNIT INJ (15MG) $895.00 J9040 TERBUTALINE 2.5MG TABLET $10.00 TERBUTALINE 1MG INJ $325.00 J3105 BALANCED SALT OPH SOL 15ML $106.00 BUMETANIDE 1MG TABLET $10.00 BUMETANIDE 0.25MG INJ (1MG) $65.00 USTEKINUMAB 1MG SC IJ (90MG) $539.00 J3357 CALAMINE/PRAMOXINE LOT 120ML $125.00 CALAMINE LOTION 180ML $103.00 VERAPAMIL 5MG/2ML INJ $122.00 CALCITONIN 200IU/ML INJ $5,585.00 J0630 VERAPAMIL 40MG TABLET $10.00 CALCIUM CHL SYR 1GM/10ML $125.00 USTEKINUMAB 1MG IV INJ (130MG) $35.00 J3358 CAPTOPRIL 12.5MG TABLET $10.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CAPTOPRIL 50MG TABLET $10.00 SUCRALFATE 1GM TABLET $10.00 DILTIAZEM 30MG TABLET $10.00 CLONIDINE 0.1MG TABLET $10.00 CLONIDINE 0.2MG/24HR TOP PATCH $159.00 CLONIDINE 0.1MG/24HR TOP PATCH $103.00 CLONIDINE 0.3MG/24HR TOP PATCH $211.00 CEFACLOR 250MG CAPSULE $36.00 CEFOROXIME 250MG TABLET $42.00 BETAMETHASONE 6MG/ML INJ $33.00 J0702 USTEKINUMAB 1MG SC IJ (45MG) $539.00 J3357 THROAT LOZENGES (CEPACOL) $10.00 LACTULOSE 20GM/30ML SYRUP U/D $14.00 BENZOCAIN 20% THROAT SPR 60ML $222.00 CHARCOAL ACTIV 25GM LIQ 120ML $129.00 THROAT LOZENGE (CHLORASEPTIC) $10.00 THROAT SPR CHERRY LIQ 180ML $83.00 CHLORPHENIRAMINE 4MG TAB $10.00 CHLORAMPHENICOL 1GM INJ $152.00 J0720 CIPROFLOXACIN 250MG TAB $42.00 CIPROFLOXACIN 500MG TAB $46.00 MAGNESIUM CITR SOL 300ML $83.00 CLINDAMYCIN 150MG CAPSULE $10.00 CLINDAMYCIN 300MG INJ (900MG) $126.00 CLINDAMYCIN 300MG (600MG PMX) $126.00 CLINDAMYCIN 300MG (600MG) $126.00 CLINDAMYCIN 300MG IJ(300MG PM $126.00 CLINDAMYCIN 300MG INJ (300MG) $126.00 SULINDAC 200MG TAB $10.00 BENZTROPINE 1MG INJ $230.00 J0515 COLCHICINE 0.6MG TABLET $26.00 PROCHLORPERZINE 5MG TABLET $10.00 PROCHLORPERAZINE 25MG SUPP $14.00 AMIODARONE 200MG TAB $14.00 HYDROCORTISONE 100MG/60ML ENEM $103.00 CORTISPORIN OINT 15G $293.00 NEO/POLYMYXIN/HC OTIC SOL 10 $192.00 NEO/POLYMYXIN/HC OTIC SUS 10ML $192.00 COSYNTROPIN 0.25MG INJ $510.00 J0834 WARFARIN 2MG TAB $10.00 WARFARIN 2.5MG TAB $10.00 WARFARIN 5MG TAB $10.00 CYCLOPENTOLATE OPTH SOL 1% 2ML $172.00 CYTARABINE 100MG INJ (100MG) $186.00 J9100 CYCLOPHOSPHAMIDE 25MG OR (50MG $36.00 J8530 CYCLOPHOSPHAMIDE 100MG (500MG) $213.00 J9070 DANTROLENE 25MG CAPSULE $14.00 DEMECLOCYCLINE 150MG TAB $83.00 ESTRADIOL VAL 10 MG IJ(200MG) $48.00 J1380 MEPERIDINE 50MG INJ $125.00 J2175 VALPROIC ACID 250MG CAPSULE $28.00 METHYLPRED EXT REL 40MG/ML INJ $160.00 J1030 VALPROIC ACID 150MG/5ML SYP UD $10.00 MEDROXYPROGESTER ACET 1MG (150 $2.00 J1050 DEFEROXAMINE 500MG INJECTION $249.00 J0895 DIAPER RASH OINTMENT 28GM $113.00 TRAZODONE 50 MG TABLET $10.00 DEXAMETHASONE 0.5MG TABLET $10.00 DEXAMETHASONE 4MG TAB $10.00 DEXAMETHASONE SOD 1MG IJ (4MG $33.00 J1100 DEXAMETHASONE 1MG INJ (20MG) $33.00 J1100
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DEXTROSE SYRINGE 50% INJ 50ML $125.00 ACETAZOLAMIDE 500MG CAP $14.00 ACETAZOLAMIDE 250MG TAB $10.00 ACETAZOLAMIDE 500MG INJ $292.00 J1120 DIHYDROERGOTAMINE 1MG INJ $404.00 J1110 FLUCONAZONE 100MG TABLET $70.00 PHENYTOIN 50MG TABLET $10.00 PHENYTOIN 100MG CAPSULE $10.00 PHENYTOIN 100MG/4ML SUSP UD $10.00 HYDROMORPHONE 2MG TABLET $14.00 HYDROMORPHONE 4MG TABLET $14.00 HYDROMORPHONE 2MG INJ $125.00 J1170 DIPHTHERIA-TET 0.5ML <7 YRS IM $198.00 90702 OXYBUTYNIN 5MG TABLET $10.00 DOBUTAMINE 12.5MG INJ $125.00 J1250 BELLADONNA ALK/PB LIQ 5ML UD $28.00 DOPAMINE 40MG INJ (400MG) $14.00 J1265 DOCUSATE 100MG CAP $10.00 DACARBAZINE 100MG INJ (200MG) $278.00 J9130 BISACODYL 5MG TAB $10.00 BISACODYL 10MG SUPPOSITORY $10.00 TRIAMTERENE/HCTZ 37.5-25MG CAP $10.00 TRIAMTERENE 50MG CAPSULE $14.00 AMITRIPTYLINE 10MG TABLET $10.00 AMITRIPTYLINE 25MG TABLET $10.00 AMITRIPTYLINE 50MG TABLET $11.00 MORPHINE 8MG INJ $125.00 J2270 OCRELIZUMAB 1MG INJ 300MG $146.00 J2350 ERYTHROMYCIN 333MG ENT COATED $10.00 EPHEDRINE 50MG/1ML INJECTION $122.00 PRAMOXINE/HC AEROSOL FOAM 10GM $210.00 EPINEPHRINE 0.1MG(1MG/10ML)IJ $13.00 J0171 EPINEPHRINE 0.1MG IJ(1MG/1ML) $13.00 J0171 MAGNESIUM SULFATE POWDER 454GM $126.00 ERTHROMYCIN 500MG INJ $130.00 J1364 ERYTHROMYCIN 250MG TAB $10.00 HYDROCHLOROTHIAZIDE 25MG TAB $10.00 ETHYL CHLORIDE AEROSOL 104ML $311.00 FERROUS SULFATE 325MG TAB $10.00 MORPHINE 5MG 5ML INJ $125.00 J2270 FLUORESCEIN OPTH STRIP 0.6 MG $10.00 APAP/BUTALB/CAFF 325-50-40MG T $28.00 ASA/BUTAL/CAF/COD 325-50-30CAP $28.00 METRONIDAZOLE 250MG TAB $10.00 METRONIDAZOLE 500MG/100ML PREM $222.00 CYCLOBENZAPINE 10MG TAB $14.00 FLUDROCORTISONE 0.1MG TAB $10.00 FLUORESCEIN OPTH STRIP 1 MG $10.00 FLUOROURACIL 500MG (500MG) IJ $186.00 J9190 FOLIC ACID 1MG/0.2ML INJ $122.00 FOLIC ACID 1MG TAB $10.00 CEFTAZIDIME 500MG INJ (1GM) $165.00 J0713 CEFTAZIDIME 500MG IJ (1GM PMX $165.00 J0713 AMPHOTERICIN B 50MG INJ $159.00 J0285 FUROSEMIDE 10MG INJ (20MG) $65.00 J1940 FUROSEMIDE SYR 40MG (40MG) $65.00 J1940 FUROSEMIDE 20 MG TAB $10.00 FUROSEMIDE 40MG TAB $10.00 GENTAMICIN 0.1% TOP CR 15GM $106.00 GENTAMICIN 0.1% OPH OINT 4GM $201.00 GENTAMICIN 0.1% OPH SOL 5ML $103.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
GENTAMICIN 20MG/2ML INJ $122.00 J1580 GENTAMICIN 80MG/100ML PREMIX $312.00 J1580 ALGINIC AC/AL HYDR/MAG CAR 30M $14.00 LOCM OMNIPAQUE-350/ML INJ 50ML $2.00 Q9967 GELFOAM SIZE 100 SPO $275.00 GLUCAGON 1MG INJ $501.00 J1610 GLIPIZIDE 5MG TAB $10.00 GLYCERINE 1.5GM SUPPOSITORY $10.00 POLYETHYLENE GLYCOL 4000ML $122.00 GLYCERINE 3GM SUPPOSITORY $10.00 CARBAMIDE PEROXIDE OTIC 15ML $106.00 HALOPERIDOL 0.5MG TAB $10.00 HALOPERIDOL 1MG TAB $10.00 HALOPERIDOL 5MG TABLET $10.00 HALOPERIDOL 2MG/ML OR SOL 15ML $122.00 HALOPERIDOL 5MG INJ (5MG) $129.00 J1630 HALOPERIDOL DECANOATE 50MG INJ $381.00 J1631 HEPARIN 1000U/1ML (5000 UNIT) $25.00 J1644 HEPATITIS B IMM GLOB IJ $1,021.00 90371 LOCM OMNIPAQUE-350/ML IN 125ML $2.00 Q9967 HEPATITIS B VACC ADULT 1ML IJ $325.00 90746 DEXAMETHASONE 0.5MG/5ML OR SOL $18.00 J1100 DEXAMETHASON SOD 1MG IJ (10MG) $33.00 J1100 DEXAMETH SOD 1MG IJ (100MG) $33.00 J1100 MEPERIDINE 50MG TAB $14.00 HYDROCODON/HOMATROP SYP 5ML UD $14.00 HYDROXYUREA 500MG CAP $28.00 HYDROCORTISONE 1% OINT 30GM $103.00 HYDROGEN PEROXIDE 3% SOL 240ML $60.00 HYDROXYZINE HCL 25MG INJ $65.00 J3410 RABIES IMM.GLOB 150IU/ML(1500) $714.00 90375 TERAZOSIN 1MG CAPSULE $10.00 LOPERAMIDE 2MG CAP $14.00 PROPRANOLOL 10MG TABLET $10.00 PROPRANOLOL 40MG TABLET $10.00 PROPRANOLOL EXT REL 80MG CAP $14.00 PROPRANOLOL 1MG INJ $154.00 J1800 INDIGO CARMINE 8MG INJ 5ML $134.00 INDOMETHACIN 25MG CAPSULE $10.00 ISONIAZID 100MG TABLET $10.00 PILOCARPINE 1% OPH SOLN 15 ML $213.00 PILOCARPINE 2% OPTH SOLN 15 ML $213.00 ARTIFICIAL TEARS OPH SOLN 15ML $106.00 ISOSORBIDE DINITRAT XR 40MG $10.00 ISOSORBIDE DINITRATE 10MG TAB $10.00 ISOPROTERNOL 0.2MG/1ML INJ $3,203.00 ISOPROTERNOL 0.2MG/ML INJ 5ML $3,844.00 SOD POLY SULFON 15GM/60ML SUSP $36.00 SOD POLY SULFON 30GM/120ML ENM $159.00 CEPHALEXIN 250/5ML SUSP 100ML $126.00 CEPHALEXIN 250MG CAP $10.00 CEFAZOLIN 500MG INJ (1GM) $65.00 J0690 TRIAMICINOLONE 10MG IJ(200MG) $38.00 J3301 TRIAMCINOLONE 10MG INJ (40) $38.00 J3301 TRIAMCINOLONE 0.1% CREAM 60GM $106.00 TRIAMCINOLONE 0.5% CREAM 15GM $103.00 TRIAMCINOLONE 0.1% OINTMENT 80 $106.00 TRIAMCINOLON DENT PAST 0.1%5GM $210.00 TRIAMCINOLONE 0.1% OINT 15GM $103.00 KETAJECT 50MG/1ML $134.00 KETAMINE 10MG/ML INJ 20ML $125.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
POTASSIUM CHL XR 10MEQ TAB $10.00 POTASSIUM CHL EX REL 20MEQ TAB $10.00 POTASSIUM CHL 20MEQ PWD $10.00 POTASSIUM BICARB 25MEQ TAB $10.00 CLONAZEPAM 0.5MG TAB $14.00 ARTIFICIAL TEARS OPH OINT 7GM $192.00 DIGOXIN 0.125MG TABLET $11.00 DIGOXIN 0.25MG TABLET $11.00 DIGOXIN 0.5MG INJECTION $293.00 J1160 FUROSEMIDE 40MG/5ML LIQ 60ML $83.00 LEUCOVORAN 50MG INJ (50MG) $186.00 J0640 NOREPINEPHRINE 1MG/ML INJ 4ML $160.00 BACLOFEN 10MG TABLET $10.00 CHLORDIAZEPOX/MSP 5-2.5MG CAP $28.00 CHLORDIAZEPOXIDE 5MG CAP $14.00 CHLORDIAZEPOXIDE 25MG CAP $10.00 FLUOCINONIDE 0.05% CREAM 60GM $120.00 LIDOCAINE 1% INJ 50ML $129.00 LIDOCAINE 2% INJ 50ML $122.00 LIDOCAINE 1% EPINEPHRINE 50ML $134.00 LIDOCAINE 10MG/ML INJ 5ML $146.00 LIDOCAINE 2% TOP UROGEL APP 10 $146.00 LIDOCAINE 1% EPINEPHRINE 20ML $125.00 LIDOCAINE 2%/EPINEPHRINE 20ML $125.00 LITHIUM CARBONATE 300MG CAP $12.00 DIPHENOXYLAT/ATROPIN 2.5MG TAB $14.00 MINOXIDIL 2.5MG TAB $14.00 MINOXIDIL 10MG TAB $33.00 GEMFIBROZIL 600MG TAB $10.00 METOPROLOL 50MG TAB $10.00 METOPROLOL 1MG/ML INJ 5ML $125.00 CHLOTRIMAZOLE CREAM 15GM $122.00 CLOTRIMAZOLE SOLUTION 20ML $113.00 CLOTRAMIZOLE/BETAMETH CR 15GM $154.00 INDAPAMIDE 2.5MG TAB $10.00 ALOH/MGO/SIMETH SUSP 30ML $14.00 NITROFURATOIN 50MG CAPSULE $14.00 MAGNESIUM SULF 500MG INJ (1GM) $60.00 J3475 MAGNESIUM SULF 500MG INJ (5GM) $60.00 J3475 MANNITOL 25% INJ 50ML $122.00 J2150 BUPIVICAINE-MPF 0.75% INJ 30ML $122.00 BUPIVICAINE 0.25% INJ 30ML $122.00 BUPIVICAINE 0.5% INJ 50ML $125.00 BUPIVICAINE-MPF 0.5% INJ 30ML $122.00 NEO/POLY/DEXAMETH OPH SOLN 5ML $120.00 DEX/NEO/POLY OPHTH OINT 4GM $97.00 MEPERIDINE 100MG/1ML INJ $125.00 J2175 PHYTONADIONE 5MG TABLET $30.00 PYRIDOSTIGMINE 60MG TAB $10.00 PSYLLIUM POWDER 5.86GM $10.00 METHYLERGONOVINE 0.2MG TAB $33.00 METHYLERGONOVINE 0.2MG/1ML INJ $246.00 J2210 METHOTREXATE 5MG INJ (50MG) $46.00 J9250 METHOTREXATE 2.5MG TAB $46.00 J8610 METHYLENE BLUE 1% 1MG (10MG) $16.00 Q9968 METHYLENE BLUE 1% 1MG (100MG) $16.00 Q9968 METHYLPREDISOLONE 4MG TAB $14.00 MEXILITINE 150MG CAP $14.00 MEXILITINE 200MG CAP $28.00 GLYBURIDE 2.5MG TAB $10.00 GLYBURIDE 5MG TAB $10.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
APAP/DICHLO/ISOMETH 325/100/65 $14.00 MILK OF MAGNESIA CON SUSP 10ML $10.00 MINERAL OIL,STERILE TOP, 10ML $392.00 MINERAL OIL ORAL 30ML U/D $10.00 PRAZOSIN 1MG CAP $10.00 PRAZOSIN 5MG CAP $10.00 MINOCYCLINE 50 MG CAPSULE $14.00 AMELORIDE/HCTZ 5-50MG TAB $10.00 MICONAZOLE 2% TOP CR 30GM $103.00 MICONAZOLE 2% VAGINAL CRM 45GM $146.00 MICONAZOLE 2% VAGINAL SUPP 7'S $129.00 MORPHINE 10MG/1ML INJ SYRINGE $125.00 J2270 MORPHINE 30MG INMMED REL TAB $10.00 MORPHINE 15MG IMMED REL TAB $14.00 MORPHINE 15MG 20ML INJ $129.00 J2270 IBUPROFEN 400MG TAB $9.00 LOCM OMNIPAQUE-350/ML IN 150ML $2.00 Q9967 TRACE ELEMENTS INJECTION 1ML $122.00 ACETYLCYSTEINE 10% SOLN 4ML $50.00 ACETYLCYSTEINE 20% SOLN 30ML $67.00 MULTIVITAMINS INJ 10ML $170.00 MITOMYCIN 5MG INJ (20MG) $409.00 J9280 ETHAMBUTOL 400MG TAB $28.00 NYSTATIN/TRIAMCINOLONE CR 15 $103.00 NYSTATIN/TRIAM OINT 30GM $129.00 NYSTATIN 100000UNITS/ML OR 5ML $14.00 NYSTATIN CREAM 15GM $103.00 NYSTATIN TOPICAL POWDER 15GM $228.00 NYSTATIN OINTMENT 15GM $103.00 TROPICAMIDE 1% OPHTH SOL 15ML $113.00 SIMETHICONE 40MG/0.6ML SUSP 60 $83.00 SIMETHICONE 80MG CHEWABLE TAB $10.00 PRIMIDONE 50MG TAB $10.00 PRIMIDONE 250MG TABLETS $14.00 NAPROXEN 250MG TAB $10.00 NAPROXEN 375MG TAB $10.00 NALOXONE 0.4MG/1ML INJ $170.00 J2310 NALOXONE 1MG INJ (2 MG) $170.00 J2310 FLUNISOLDE NASAL SPRAY 25ML $440.00 TOBRAMYCIN 80MG INJ $125.00 J3260 TOBRAMYCIN 80MG INJ (1.2GM) $125.00 J3260 NEOMYCIN 500MG TAB $28.00 BACI/NEO/POLY OINT .9GM U/D $10.00 BACIT/NEOM/POLYM OINT 15GM $106.00 BACIT/NEOM/POLYM GU IRR 1MLIJ $165.00 BACIT/NEOM/POLYM OPHTH SOL 10M $222.00 PHENYLEPHRINE 1MG INJ (10MG) $36.00 J2370 PHENYLEPHRINE 2.5% OPH SOLN 15 $122.00 PHENYLEPHRINE 0.5%NAS SPR 15ML $122.00 NIACIN 100MG TAB $10.00 NICOTINE GUM 2MG EA $14.00 NITROGLYCERIN 2% OINT 1GM UD $10.00 NITROGYCERIN 0.4MG 25 TABS $36.00 NITROGLYCERIN 2.5MG XR CAPS $10.00 NITROGLYCERIN 0.4MG SPR 8.5GM $934.00 NITROPRUSSIDE 25MG/ML INJ 2ML $2,562.00 TAMOXIPHEN 10MG TAB $28.00 VECURONIUM 10MG INJ $134.00 ORPHENADRINE 100 MG TABLET $33.00 ORPHENADRINE 60MG/2ML INJ $126.00 J2360 LABETOLOL 5MG/ML 20ML INJ $125.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DISOPYRAMIDE 150MG CAP $10.00 NALBUPHINE 10MG INJ (10MG) $134.00 J2300 DIBUCAINE 1% OINTMENT 30GM $106.00 ESTROPIPATE 0.75MG TAB $10.00 VINCRISTINE 1MG INJ (1MG) $192.00 J9370 CALCIUM CARB 500MG TAB EA $10.00 NORTRIPTYLINE 10MG CAP $2.00 NORTRIPTYLINE 25MG CAP $14.00 PAPAVERINE 30MG INJ (60MG) $65.00 J2440 OPIUM TINCTURE 2MG/5ML U/D $14.00 CARBOPLATIN 50MG INJ (50MG) $125.00 J9045 PANCURONIUM 1MG/ML INJ 10ML $122.00 PENICILLIN G 600,000 5MU INJ $36.00 J2540 PENICILLIN VK 250MG TAB $10.00 FAMOTIDINE 20MG TAB $10.00 FAMOTIDINE 10MG INJ 2ML $122.00 OXYCODONE/APAP 5/325 MG TAB $14.00 DIPYRIDAMOLE 25MG TAB $10.00 PETROLATUM GEL 5GM PACKET $10.00 PROMETHAZINE 25MG TAB $10.00 PROMETH/COD 6.25-10MG/5ML UD $14.00 PROMET/DM 6.25-15MG/5ML SYP UD $10.00 PROMETHAZINE 25MG INJ $122.00 J2550 PROMETHAZINE 6.25MG/5ML SYP UD $10.00 PROMETHETHAZINE 12.5MG SUPP $42.00 PROMETHAZINE 25MG SUPP $36.00 PHENOBARBITAL 60MG/1ML INJ $125.00 J2560 PHENOBARBITAL 130MG/1ML INJ $126.00 J2560 PHENOBARBITAL 15MG TAB $14.00 PHENOBARBITAL 30MG TAB $14.00 PHENOBARBITAL 60MG TAB $14.00 PHENOBARBITAL 100MG TAB $14.00 PHENOBARBITAL 20MG/5ML ELXR UD $14.00 VASOPRESSIN 20 UNITS 1ML $257.00 OXYTOCIN 10 UNITS INJ $122.00 J2590 HYDROXYCHLORAQUINE 200MG TAB $28.00 CISPLATIN 10MG INJ (100MG) $186.00 J9060 DALBAVANCIN 5MG (500 MG) INJ $39.00 J0875 PNEUMOCOCCAL VACC 23 VAL 0.5ML $192.00 90732 MULTIVIT/IRON PED DROPS 50 ML $100.00 POTASSIUM ACET 40MEQ/20ML IJ $122.00 POTASSIUM CHL 2MEQ/ML (20MEQ) $122.00 J3480 POTASSIUM CHL 2MEQ IJ (40MEQ) $122.00 J3480 POTASSIUM IODIDE 1GM/ML SOLN $84.00 POTASSIUM PHOS 2MMOL/ML 5ML $122.00 PUD/PARICERV ANES LIDO 1% 20ML $210.00 TUBERCULIN TEST 5U/0.1ML INJ $125.00 86580 PREDNISOLONE 1% OPHTH SUSP 5ML $122.00 METHYLENE BLUE 0.5% 1MG (50MG) $15.00 Q9968 PREDNISONE 1 MG TAB $10.00 J7512 PREDNISONE 2.5MG TAB $10.00 J7512 PREDNISONE 5MG TABS $10.00 J7512 PREDNISONE 10MG TAB $10.00 J7512 PREDNISONE 20 MG TAB $10.00 J7512 ESTROGENS,CONJ 0.3MG TAB $25.00 ESTROGENS,CONJ 0.625MG TAB $25.00 ESTROGENS, CONJ 25MG INJ $609.00 J1410 IMIPENUM/CILASTATIN 250MG INJ $126.00 J0743 IMIPENUM/CILAST 250MG (500MG) $146.00 J0743 NIFEDIPINE 10MG CAP $10.00 NIFEDIPINE EXT REL 30MG TAB $28.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PROCHLORPERAZINE 5MG INJ $154.00 J0780 PROMETHAZINE 50MG INJ (50MG) $122.00 J2550 PROCAINAMIDE 100MG IJ (1000MG $122.00 J2690 PROPYLTHIOURACIL 50MG TAB $10.00 NEOSTIGMINE 0.5MG INJ (10MG) $10.00 J2710 PROTAMINE 10MG/ML 5 ML INJ $33.00 J2720 FLUOXITINE 20MG CAP $10.00 PSEUDOEPHEDRINE 30MG TAB $10.00 PHENAZOPYRIDINE 100MG TAB $10.00 PYRIDOXINE 50MG TAB $10.00 PYRIDOXINE 100MG INJ $125.00 J3415 CHOLESTYRAMINE 4GM POWDER $33.00 QUININE SULFATE 325MG CAP $38.00 RABIES VACC 2.5INTL UNITS/1ML $927.00 90675 PHENTOLAMINE MESYLATE 5MG INJ $1,050.00 J2760 METOCLOPRAMINE 5MG/5ML SYR U/D $10.00 METOCLOPRAMIDE 10MG/2ML INJ $122.00 J2765 TEMAZAPAM 15MG CAP $36.00 RIFAMPIN 300MG CAP $14.00 METHOCARBAMOL 500MG TAB $10.00 METHOCARBAMOL 750MG TAB $14.00 GLYCOPYRROLATE 0.2MG/1ML $122.00 J3490 CEFTRIAXONE 500MG INJ $97.00 J0696 CEFTRIAXONE 250MG INJ (1GM) $97.00 J0696 CEFTRIAXONE 250MG IJ (1GM PMX $97.00 J0696 CEFTRIAXONE 250MG INJ $165.00 J0696 MORPHINE CONC 20MG/ML OR 30ML $104.00 ACEBUTOLOL 200MG CAP $10.00 SELENIUM SULF 2.5% 120ML SUSP $73.00 SENNA 8.6MG TAB $10.00 SILVER SULFADIAZINE CR 400GM $253.00 SILVER SULFADIAZINE CREAM 50GM $125.00 SILVER NITRATE APPLICATOR $18.00 CARBIDOPA/LEVADOP 10-100MG TAB $10.00 CARBIDOPA/LEVADOP 25-100MG TAB $10.00 CARBIDOLA/LEVADOP 25-250MG TAB $10.00 DOXEPIN 10MG CAP $10.00 DOXEPIN 25MG CAP $10.00 MAGNESIUM CHLORIDE 64MG TAB $10.00 SODIUM BICARB 8.4% SYR 50ML $125.00 SODIUM BICARB 8.4% IJ 10ML $126.00 SODIUM BICARB 4.2% IJ 10ML $126.00 SODIUM ACET 2MEQ/ML IJ 20ML $122.00 NS PRESERV FREE DILUENT 10 ML $122.00 SODIUM CHL 0.9% SVN SOLN 3ML $38.00 SODIUM CHL 0.9% BACT IJ 30ML $122.00 SODIUM CHL 23.4% CONC IJ 30ML $122.00 J7030 SODIUM THIOSULF 25% IJ 50ML $279.00 HYDROCORTISONE 100MG INJ $125.00 J1720 HYDROCORTISONE 100MG(250MG)IJ $125.00 J1720 HYDROCORTISONE 100MG (1000MG) $125.00 J1720 METHYLPREDNISOLONE 40MG INJ $125.00 J2920 METHYLPREDNISOLONE 125MG INJ $159.00 J2930 METHYLPREDNISOL 125MG IJ500MGJ $159.00 J2930 METHYLPREDNISOL 125MG IJ(1000 $159.00 J2930 CARISOPRODOL 350MG TAB $10.00 SORBITOL 70% SOLUTION 30ML U/D $83.00 BUTORPHANOL 1MG INJ (2MG) $70.00 J0595 PRENATAL MULTIVITAMIN TAB $10.00 FENTANYL 100MCG INJ $125.00 J3010 PSEUDOEPHEDRIN 30MG/5ML LIQ UD $10.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DOCASATE CALCIUM 240MG CAP $10.00 AMANTADINE 100MG CAP $10.00 LEVOTHYROXINE 100MCG TAB $10.00 LEVOTHYROXINE 50MCG TAB $10.00 LEVOTHYROXINE 40MCG/ML INJ 5ML $268.00 FLECAINIDE 50MG TAB $36.00 METHIMAZOLE 5MG TAB $10.00 CARBAMAZEPINE 200MG TAB $10.00 TET/DIPTHERIA TOX IJ 0.5ML $113.00 90714 TET IMM GLOB 250UNIT IJ $982.00 J1670 TETRACYCLINE 250MG CAP $10.00 TETRACAINE 0.5% OPH SOLN 15ML $228.00 THEOPHYLLINE 300MG EXT REL TAB $10.00 THEOPHYLLINE 100MG EXT REL TAB $10.00 MULTIVITAMIN TAB $10.00 MULTIVITAMINS/MINERALS TAB $10.00 MULTIVITAMIN LIQUID 5ML U/D $10.00 THIAMINE 100MG TAB $10.00 THIAMINE 100MG INJ (200MG) $65.00 J3411 CHLORPROMAZINE 50MG INJ $125.00 J3230 CHLORPROMAZINE 25MG TAB $10.00 THYROID 30MG TAB $10.00 THYROID 60MG TAB $10.00 DEXMEDETOMIDINE 200MCG/50ML IJ $564.00 TIMOLOL 0.25% OPHTH SOLN 5ML $106.00 TIMOLOL 0.5% OPHTH SOLN 5ML $113.00 TOBRAMYCIN 0.3% OPHTH SOL 5ML $103.00 TOBRAMYCIN 0.3% OPHTH OINT 4GM $325.00 IMIPRAMINE 25MG TAB $10.00 KETOROLAC 15MG INJ (30MG) $65.00 J1885 KETOROLAC 15MG INJ (60MG) $65.00 J1885 ATRACURIUM 10MG/ML INJ 10ML $170.00 LABETOLOL 100MG TAB $10.00 SCOPALAMINE 1.5MG/24HR PATCH $46.00 NITROGLYCERIN 0.4MG/HR PATCH $33.00 PENTOXPHYLLIN 400MG TAB $14.00 NITROGLYCERIN 5MG/ML INJ $165.00 GUAIFEN/COD 100-12MG/5ML SYRUD $14.00 TETRACAINE 0.5% OPTH SOL 4 ML $106.00 ACETAMINOPHEN 325MG TAB $- ACETAMINOPHEN/CODEINE 325-30MG $14.00 ACETAMINOPHEN/CODEINE 325-60MG $14.00 ACETAMINOPHEN 100MG/ML DRP15ML $83.00 ACETAMIN/COD 240-24MG/10ML SUS $38.00 AMPICILLIN/SULBAC 1.5GM (3GM) $205.00 J0295 AMPICILL/SULBACTAM 1.5GM INJ $205.00 J0295 NAFCILLIN 1GM INJ $122.00 BETHANECHOL 25MG TAB $28.00 FLAVOXATE 100MG TAB $14.00 DIAZEPAM 2MG TAB $14.00 DIAZEPAM 5MG TAB $14.00 DIAZEPAM 5MG INJ (10MG) $65.00 J3360 ENLALPRIL 2.5MG TAB $10.00 ENALAPRIL 10MG TAB $10.00 ENALAPRILAT 1.25MG/ML INJ 2ML $152.00 VINBLASTINE SULF 1MG IJ(10MG) $18.00 J9360 ALBUTEROL 0.83% SVN SOL 3ML $38.00 ALBUTEROL 2MG TAB $10.00 MIDAZOLAM 1MG/ML INJ 10ML $65.00 J2250 ETOPOSIDE 10MG INJ (100MG) $36.00 J9181 MIDAZOLAM 1MG/ML VIAL 2MG $65.00 J2250
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DOXYCYCLINE 100MG ORAL $10.00 DOXYCYCLINE 100MG INJ $152.00 TETRAHYDRAZOLINE OPH SOLN 15ML $103.00 HYDROXYZINE PAMOATE 25MG CAP $10.00 Q0177 CYANOCOBOLAMIN 1000MCG INJ $122.00 J3420 VITAMIN D 50,000 UNIT CAPSULE $18.00 VITAMIN E 400 IU CAP $10.00 DICLOFENAC ENT COATED 75MG TAB $10.00 PROVASTATIN 10MG TAB $26.00 ACETIC ACID-HC OTIC SOLN 10ML $151.00 WATER FOR IJ,BACTERIOST 30ML $106.00 A4216 WATER FOR INJ, STERILE 20ML $122.00 A4216 WATER FOR INJ, STERILE 100ML $106.00 ALPRAZOLAM 0.25MG TAB $14.00 ALPRAZOLAM 1MG TAB $14.00 LIDOCAINE 2% INJ SYRINGE 5ML $122.00 LIDOCAINE 2% TOPICAL JELLY 5ML $170.00 LIDOCAINE-MPF 4% INJ 5ML $146.00 LIDOCAINE 0.5% INJ 50ML $125.00 LIDOCAINE TOP OINT 5% 35GM $306.00 LIDOCAINE 2% VISCOUS SOLN 20ML $14.00 LIDOCAINE-MPF 1% INJ 2ML $146.00 LIDOCAINE 1% INJ 20ML MDV $122.00 J2001 LIDOCAINE 4% TOPICAL SOLN 50M $83.00 LIDOCAINE/EPI-MPF 2% INJ 20ML $170.00 LIDOCAINE/EPI 1.5% INJ 30ML $146.00 RANITIDINE 150MG TAB $10.00 RANITIDINE 25MG INJ (50MG) $120.00 J2780 RANITIDINE 25MG (50MG IVPB) $122.00 J2780 ZINC OXIDE TOP OINT 28GM $103.00 ACYCLOVIR 5MG INJ (500MG) $1.00 J0133 ACYCLOVIR 200MG CAP $28.00 ALLOPURINOL 100MG TAB $10.00 CALCIUM GLUCONATE 1GM INJ $122.00 J0610 ESTRADIOL VAL 10MG IJ (100MG) $48.00 J1380 NICARDIPINE IMM REL 20MG TAB $10.00 EPOETIN 1000 U(NONESRD)(10000) $112.00 J0885 MORPHINE PF 10 MG $126.00 J2274 DESMOPRESSIN 1MCG INJ (4 MCG) $46.00 J2597 MEASLES/MUMPS/RUBELLA VACCINE $325.00 90707 MEDROXYPROGESTERONE 2.5MG TAB $10.00 AQUAPHOR/HYDROCORT CR 240GM $126.00 NICADIPINE IMM REL 20MG CAP $10.00 CALCITROL 0.025 MG CAPSULE $14.00 DICLOFENAC ENT COATED 50MG TAB $10.00 MIDAZOLAM 1MG INJ (50MG) $65.00 J2250 BUPIVICAINE 0.25%/EPI-MPF 30ML $129.00 BACITRACIN OPHTH OINT 4GM $106.00 LIDOCAINE 2% INJ 20ML MDV $122.00 FLUOROURACIL 500MG IJ(1000MG) $186.00 J9190 CIPROFLOXACIN 200MG (400MG PMX $192.00 J0744 LIDOCAINE 2%/EPINEPHRINE 50ML $126.00 DILTIAZEM EXT REL 90MG CAP $10.00 METOLAZONE 2.5MG TAB $14.00 KETOROLAC 10MG TAB $10.00 BUPIVACAINE 0.25% INJ 10ML $122.00 VERAPAMIL EXT REL 180MG TAB $28.00 NICOTINE 21MG/24HR PATCH $36.00 NICOTINE 14MG/24HR PATCH $36.00 NICOTINE 7MG/24HR PATCH $33.00 FLUMAZENIL 0.1MG/ML INJ 5ML $548.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HYDROCORTISONE 1% CRM 30GM $103.00 PROPRANOLOL EXT REL 60MG $14.00 AZATHIOPRINE 50MG TAB $28.00 J7500 FENTANYL 50MCG/HR PATCH $185.00 FENTANYL 75MCG/HR PATCH $275.00 METHYLPHENIDATE 5MG TAB $14.00 CHARCOAL/SORBITOL 25GM SOL 120 $129.00 BROMOCRIPTINE 2.5MG TAB $33.00 IBUPROFEN 20MG/ML SUSP 5ML U/D $14.00 LISINOPRIL 10MG TAB $10.00 THEOPHYLLINE EXT REL 200MG TAB $10.00 HYDROCORTISONE 2.5% CRM 30GM $106.00 CYCLOBENZAPRINE 10MG TAB/ER $38.00 ER/PROMETHAZINE 25MG SUPP #2 $70.00 AMOXICILLIN 250MG/5ML SUS 80ML $83.00 SULFACETAMIDE 10% OPH SOL 15ML $113.00 KETOROLAC 10MG TAB #4/ER $75.00 CARBIDOP/LEVODOP 50-200 XR TAB $14.00 URSODIOL 300MG CAP $36.00 THEOPHYLLINE EXT REL 100MG TAB $10.00 METROPROLOL EXT REL 50MG TAB $10.00 BENZONATATE 100MG CAP $14.00 LEUPROLIDE ACETATE DEPOT 7.5MG $4,635.00 J9217 ONDANSETRON 1MG (4MG) ORAL TAB $3.00 Q0162 SUMATRIPAN 6MG INJ $460.00 J3030 FENTANYL 25MCG/HR PATCH $159.00 MESNA 200MG INJ (1000 MG) $266.00 J9209 BUSPIRONE 5MG TAB $14.00 OCTREOTIDE 25MCG INJ (50MCG) $75.00 J2354 VERAPAMIL EXT REL 120MG TAB $28.00 METOCLOPRAMIDE 5 MG TABLET $10.00 MESALAMINE 4GM/60ML ENEMA $201.00 SERTRALINE 50MG TAB $33.00 OXAPROZIN 600MG TAB $50.00 AZITHROMYCIN 250MG TAB $42.00 DILTIAZEM EXT REL 180MG CAP $28.00 SOTALOL 80MG TAB $36.00 DILTIAZEM EXT REL 120MG CAP $14.00 SODIUM PHOSPHATE 4MEQ/ML 5ML $122.00 FLUOCINOLONE ACET 0.01% 15GM $89.00 DOXAZOSIN 4MG TAB $14.00 DOXAZOSIN 1MG TAB $10.00 NIACIN EXT REL 250MG CAP $10.00 PYRAZINAMIDE 500MG TAB $14.00 ATENOLOL 25MG TAB $10.00 GENTAMYCIN > 80MG INJ (80 MG) $122.00 J1580 CARDIZEM EXT REL 300MG CAPSULE $36.00 ASPIRIN 81MG CHEW TABLET $10.00 AMLODIPINE 5MG TAB $28.00 NABUMETONE 500MG TAB $28.00 ZOLPIDEM 5MG TAB $33.00 GRANISETRON 100MCG INJ $186.00 J1626 ACYCLOVIR 800MG TAB $55.00 LORATIDINE 10MG TAB $36.00 FENTANYL 100MCG/HR PATCH $350.00 ROCURONIUM 10MG/ML INJ 5ML $211.00 ISOSORBIDE MONO 30MG TAB $10.00 FLUOXETINE 10MG CAP $10.00 SUCRALFATE 1000MG/10ML SUSP UD $28.00 DILTIAZEM 5MG/ML INJ 5ML $125.00 MORPHINE EXT REL 15MG TAB $28.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SODIUM BICARBONATE 650MG TAB $10.00 CHLOROTHIAZIDE 500MG INJ $2,702.00 J1205 ETOMIDATE 2MG/ML INJ 10ML $201.00 CITRIC ACID/SOD CITR SUSP 30ML $10.00 BUPIVICAINE 0.75% SPINAL 3ML $126.00 FELODIPINE 5MG TAB $14.00 SINCALIDE 5MCG INJ (KINEVAC) $507.00 J2805 VANCOMYCIN 500MG(1250 MG IVPB) $222.00 J3370 CLOTRIMAZOLE 10MG TAB $28.00 VANCOMYCIN 500MG(1500 MG IVPB) $222.00 J3370 PIPER/TAZO 1.125GM IJ(3.375GM $97.00 J2543 ERTAPENEM 500MG (1GM) IVPB $160.00 J1335 MEPERIDINE 25MG/1ML INJ $125.00 J2175 CARBOPROST 250MCG/1ML INJ $486.00 IPRATROP 0.02% INH SOLN 2.5 ML $38.00 LIDOCAINE/PRILOCA 2.5% TOP CR $154.00 SALIVA SUBSTITUTE 120ML $89.00 J0171 PREDNISONE 5MG/5ML SOLN U/D $14.00 J7512 CIPROFLOXACIN 0.3% OPH SOL 5ML $391.00 TORSEMIDE 5MG TAB $10.00 TORSEMIDE 20MG TAB $14.00 ESMOLOL 10MG/ML INJ 10ML $252.00 BUPIVACAINE 0.5%/EPI INJ 30ML $122.00 VINORELBINE TART 10MG (10MG) $950.00 J9390 ESTRADIOL 0.5MG TAB $10.00 ACETAMINOPHEN 650MG/20.3ML UD $33.00 WARFARIN 1MG TAB $10.00 BENZTROPINE 0.5MG TAB $10.00 CYCLOSPORINE 100MG CAP $55.00 J7502 GABAPENTIN 300MG CAP $28.00 GABAPENTIN 100MG CAP $10.00 PAMIDRONATE 30MG INJ $2,975.00 J2430 AMIODARONE 30MG INJ (150MG) $36.00 J0282 FENTANYL 50MCG/ML INJ 5ML $125.00 J3010 VANCOMYCIN 500MG INJ (500MG) $125.00 J3370 DINOPROSTONE 10MG VAG INSERT $1,459.00 DIVALPROEX 250MG TAB $10.00 LEVOTHYROXINE 25MCG TAB $10.00 HYOSCYAMINE 0.125MG TABLET $10.00 CIPROFLOXACIN 200MG (200MG PMX $289.00 J0744 TRAMADOL 50MG TAB $10.00 TERAZOSIN 5MG CAP $10.00 ENOXAPARIN 10MG INJ (30MG) $75.00 J1650 FERROUS SULF LIQ 300MG/5ML UD $10.00 BENAZEPRIL 10MG TAB $14.00 SIMVASTATIN 10MG TAB $28.00 CARBAMAZEPINE XR 100 MG TAB $10.00 CYCLOSPORINE (NEOR) 25 MG CAP $17.00 J7515 STERILE WATER FOR INJ 50 ML $122.00 ALBENDAZOLE 200 MG TABLET $120.00 SACCHAROMYCES BOULAR 250MG CAP $11.00 PHENYLEPHRINE 2.5% OPH SOL 2ML $122.00 IMM GLOB 10% 500MG OCTAGAM 10G $253.00 J1568 IMM GLOB 10% 500MG OCTAGAM 5GM $253.00 J1568 NYSTATIN OINTMENT 30GM $103.00 ETHIODIZED OIL 10ML INJ $3,203.00 J3490 NEOSTIGMINE 0.5 INJ (5MG) $10.00 J2710 CARFILZOMIB 1MG INJ (30MG) $114.00 J9047 LAMIVUDINE 150MG TAB $46.00 BUPIVACAINE-MPF 0.5%/EPI 30ML $125.00 BUPIVACAINE-PF 0.25%/EPI 10ML $125.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
LEVOTHYROXINE 112MCG TAB $10.00 CEFTOLOZ/TAZO 50/25MG(1/0.5GM) $14.00 J0695 BISMUTH SUBSALICYLAT 262MG TAB $10.00 SUMATRIPTAN 25MG TAB $129.00 LOSARTAN 25MG TAB $14.00 METFORMIN 500MG TAB $14.00 HEPARIN 1000 UNIT/ML(10ML) IJ $25.00 J1644 CALCITROL 0.1MCG INJ (1MCG) $25.00 J0636 FERROUS GLUCONATE 324MG TAB $10.00 TERBINAFINE 250MG TAB $73.00 SALINE NASAL SPRAY SOLN 50ML $103.00 CALCIUM ACETATE 667MG TAB $10.00 GLIPIXIDE EXT REL 5MG TAB $10.00 FACT XIII ANTI-HEM FACT 1 UNIT $23.00 J7180 NITROFURANTOIN XR 100MG CAP $28.00 LIDOCAINE-MPF 1% INJ 30ML $198.00 VARICELLA VIRUS VACCINE $460.00 90716 MULTIVITAMIN RENAL FORMULA TAB $10.00 BRIMONIDINE 0.15% OPTHO 5ML $362.00 GUAIFENESIN 200MG/10ML SYP UD $33.00 PROPARACAINE 0.5%OPH SOLN 15ML $106.00 LIDOCAINE-MPF 2% INJ 2ML $122.00 MORPHINE-PF 0.5MG/ML INJ 10ML $126.00 J2274 MUPIROCIN 2% OINTMENT 15GM $392.00 ABCIXIMAB 10MG INJ $2,985.00 J0130 DRONABINOL 2.5MG CAPSULE $46.00 Q0167 IRINOTECAN 20MG INJ (100MG) $1,277.00 J9206 PIP/TAZO 1.125GM (3.375GM PMX) $97.00 J2543 CEFTAZ/AVIB 500/125MG(2/0.5GM) $190.00 J0714 CEFAZOLIN 500 MG (1GM) IV SYR $122.00 J0690 CEFAZOLIN 500 MG (2GM) IV SYR $107.00 J0690 CEFEPIME 500 MG (1GM) IV SYR $134.00 J0692 CEFEPIME 500 MG (2GM) IV SYR $113.00 J0692 CEFOXITIN 1000 MG (1GM) IV SYR $228.00 J0694 TALC, STERILE PWD AEROSOL 4GM $927.00 ESTRADIOL 0.25MG TOPICAL PATCH $70.00 ESTRADIOL 0.1MG TOPICAL PATCH $70.00 CEFOXITIN 1000 MG (2GM) IV SYR $228.00 J0694 L.E.T. TOPICAL SOLUTION 2ML $28.00 CALCITONIN 200IU/INH NAS 4MLSP $351.00 CAPSAICIN 0.075% TOP CR 30GM $152.00 QUINAPRIL 20MG TAB $14.00 TAMSULOSIN 0.4MG CAP $28.00 BACITRAC/POLYMYX TOP POWD 10GM $154.00 ATORVASTATIN 10MG TAB $33.00 CEFTRAIXONE 250MG (1GM) IV SYR $97.00 J0696 UREA 20% TOPICAL CREAM 114GM $152.00 MONTELUKAST 10MG TAB $33.00 MONTELUKAST 5MG CHEW TAB $36.00 PROPAFENONE 150MG TAB $28.00 LEVOFLOXACIN 250MG (500MG PMX) $351.00 J1956 EMS FULL BOX EXCHANGE $73.00 CEFTRIAXONE 250MG (2GM) IV SYR $97.00 J0696 MEROPENEM 100MG (500MG) IV SYR $25.00 J2185 LEVOFLOXACIN 500MG TAB $70.00 CHLORHEXIDINE 0.12% OR SOLN473 $89.00 LEVOFLOXACIN 250MG (250MG PMX) $351.00 J1956 IBUPROFEN 200MG TAB $9.00 RIFAMPIN 600MG INJ $673.00 MAGNESIUM OXIDE 400MG TAB $10.00 LOSARTAN 50MG TAB $28.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CLOPIDOGREL 75MG TAB $38.00 MEROPENEM 100MG(1000MG) IV SYR $23.00 J2185 MEGESTROL 20MG TAB $10.00 BENRALIZUMAB 1MG (30MG) INJ $428.00 C9399 LATANOPROST 0.005% OP SOL2.5ML $465.00 OFLOXACIN 0.3% OTIC SOLN 5ML $535.00 NICARDIPINE IMM REL 30MG CAP $14.00 WOUND WASH 0.9% SALINE SOL 210 $120.00 AZITHROMYCIN 500MG INJ $297.00 J0456 IBUTILIDE 1MG INJ $1,785.00 J1742 FLUCONAZOLE 200MG (200MG PMX) $837.00 J1450 FLUCONAZOLE 200MG (400MG PMX) $837.00 J1450 AZITHROMYCIN 200MG/5ML SUSP 15 $238.00 METHADONE 10MG TAB $14.00 J1230 METHADONE 5MG TAB $14.00 ENOXAPARIN 10MG INJ (60MG) $75.00 J1650 XYLOCAINE 0.5%/EPI INJ 50ML $125.00 VANCOMYCIN 500MG IJ (1GM PMX) $222.00 J3370 OLANZAPINE 10MG TAB $75.00 CELECOXIB 100MG CAP $28.00 ANAGRELIDE 0.5MG TAB $50.00 RAMIPRIL 2.5MG CAP $14.00 QUINUPRISTIN/DALFOPRIS 500MG V $773.00 J2770 DORZOLAMIDE 2% OPTH SOLN 10ML $305.00 DONEPEZIL 5MG TAB $42.00 CILOSTAZOL 100MG TAB $28.00 BISOPROLOL/HCTZ 2.5-6.25MG TAB $14.00 TOLTERODINE 2MG TAB $28.00 BUPROPION EXT REL 150MG TAB $28.00 ALTEPLASE CATHFLO 1MG IJ(2MG) $228.00 J2997 BISOPROLOL/HCTZ 5.6-6.25MG TAB $14.00 HEPATITIS A ADULT 1ML INJ $390.00 90632 TENECTEPLASE 1MG (50MG) INJ $340.00 J3101 FENTANYL 100MCG INJ (1000MCG) $125.00 J3010 QUINAPRIL 5MG TAB $14.00 CARVEDILOL 3.125MG TAB $10.00 VENLAFAXINE 37.5MG TAB $28.00 FEXOFENADINE 60MG TAB $14.00 LEVOTHYROXINE 88MCG TAB $10.00 PIPER/TAZ 1.125GM (3.375GM) SY $120.00 J2543 PIPER/TAZ 1.125GM (2.25GM) SYR $97.00 J2543 PIPER/TAZ 1.125GM (4.5GM) SYR $97.00 J2543 FLUORESCEIN 10% INJ 5ML $76.00 AVELUMAB 10MG (200MG)INJ $205.00 J9023 COPANLISIB 1MG (60MG) INJ $189.00 C9399 PROPAFENONE 225MG TAB $33.00 CYCLOSPORINE 25MG CAP $28.00 LEVOFLOXIN 250MG TAB $55.00 LEVALBUTEROL 0.63MG/3ML SVN SO $38.00 GUAIFENESIN EXT REL 600MG TAB $14.00 OLANZAPINE 2.5MG TAB $38.00 ASPIRIN/DIPYRID 200-250MG TAB $28.00 FLUTICASON 220MG/INH INH 12GM $927.00 OXYCODONE EXT REL 10MG TAB $28.00 FLUTICASONE 110MG/INH INH 12GM $468.00 DIVALPROEX DEL REL 125MG CAP $10.00 HYDROCORTISONE 20MG TAB $10.00 ASPIRIN ENTERIC COAT 81MG TAB $10.00 VENLAFAXINE EXT REL 37.5 MG $36.00 LISINOPRIL 2.5MG TAB $10.00 FAMOTIDINE 10MG TAB $10.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TIROFIBAN 0.25MG (12.MG/250ML $75.00 J3246 AZTREONAM 500MG INJ (1GM) $122.00 OCTREOTIDE 25MCG IJ(5000 MCG) $75.00 J2354 ENOXAPARIN 10MG INJ (40MG) $75.00 J1650 ENOXAPARIN 10MG INJ (80MG) $75.00 J1650 ENOXAPARIN 10MG INJ (100MG) $75.00 J1650 GABAPENTIN 400MG CAP $28.00 AMOXICILLIN/CLAVUL 875MG TAB $46.00 GLIMEPIRIDE 1MG TAB $10.00 GLIMEPIRIDE 4MG TAB $14.00 PACLITAXEL 30MG INJ (100MG) $224.00 J9267 IMMUNE GLOBULIN, 500MG INJ $289.00 J1566 CROTALIDE IMM FAB IJ 1GM SDV $17,112.00 J0840 CALCIUM CARBONATE 500MG + D TA $10.00 HYDROCLOROTHIAZIDE 12.5 MG TAB $10.00 GOSERELIN ACETATE IMPLANT 3.6 $2,235.00 J9202 GRANISETRON 100MCG IJ(1000MCGG) $73.00 J1626 ONDANSETRON 1MG INJ (4MG) $33.00 J2405 RITUXIMAB 100MG INJ (100MG) $5,130.00 J9310 DEXRAZOXANE 250 MG INJ $621.00 J1190 EPIRUBICIN HCL 2MG INJ $25.00 J9178 IFOSFOMIDE 1GM INJ (1000MG) $1,584.00 J9208 TOPOTECAN 0.1MG INJ (4MG) $152.00 J9351 TRASTUZUMAB 10MG INJ (440 MG) $414.00 J9355 LEVOTHYROXINE 137MCG TAB $10.00 BISM SUBSAL 524MCG/30ML SUSPUD $10.00 PREDNISOLONE 15MG/5ML SYRUP $10.00 AMLODIPINE 2.5MG TAB $28.00 LAMOTRIGINE 25MG TAB $33.00 VALPROATE 100MG/ML INJ 5ML $201.00 INTERFERON ALFA-2B 1MU (10MU) $103.00 J9214 FOSPHENYTOIN 50MG/1ML IJ 50MG $129.00 Q2009 FAMCICLOVIR 500MG TAB $70.00 PANTOPRAZOLE 40MG INJ $146.00 C9113 AMPHOTERICIN LIP CPLX 10MG IJ $159.00 J0287 OXYCODONE EXT REL 20MG TAB $36.00 ROPINIROLE 0.25MG TAB $28.00 RALOXIFENE 60MG TAB $33.00 REPAGLINIDE 1MG TAB $14.00 DESIPRAMINE 25MG TAB $10.00 SALMETEROL 50MCG INH POWDER 28 $604.00 TORSEMIDE 100MG TAB $36.00 PRAVASTATIN 20MG TAB $28.00 CANDESARTAN 16MG TAB $28.00 ZINC SULFATE 220MG CAP $10.00 FLUCONAZOLE 150MG TAB $106.00 ESTRADIOL 1MG TAB $10.00 VALACYCLOVIR 500MG TAB $38.00 ANTI-THYMOCYTE GLOB 25MG RABB $2,884.00 J7511 ALTEPLASE 1MG INJ $228.00 J2997 NICARDIPINE 2.5MG/10ML INJ $556.00 ALBUT/IPRATROP 2.5-0.5MG SVN $38.00 FLUTICASONE 0.05MG/INH NAS INH $519.00 BICALUTAMIDE 50MG TAB $9.00 CLINDAMYCIN 75MG/5ML SOL 100ML $325.00 ESTROGEN/PROGEST 0.635-2.5MG T $14.00 HYDROCORTISONE 5MG TAB $10.00 IMATINIB 100MG CAP $192.00 GLYCERIN/WITCH HAZEL PADS $106.00 BENZOCAINE TOPICAL SPRAY 60GM $125.00 ACIDOPHILUS/PECTIN CAP $33.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PAROXATINE 10MG TAB $33.00 ANASTROZOLE 1MG TAB $67.00 LEFLUNOMIDE 20MG TAB $83.00 SOD HYPOCHLORITE 0.25% SOLN473 $122.00 CADD CASSETTE 100ML $788.00 METRONIDAZOLE VAGINAL GEL 70GM $275.00 INSULIN GLARGINE 100U/ML 10ML $451.00 J1815 PIOGLITAZONE 15MG TABLET $36.00 VENLAFAXINE 25MG TABLET $25.00 OXAZEPAM 10MG CAP $14.00 CLINDAMYCIN 300MG (900MG PMX) $126.00 DICLOTACILLIN 250MG CAP $10.00 FLUTICASONE 44MCG/INH INH 12GM $381.00 RHO(D)IMM GLOB IJ 100IU(5000) $170.00 J2792 LEVOBUNOLOL 0.5% OPH SOLN 10ML $122.00 DOCUSATE/SENNA 50/8.6MG TAB $10.00 EPTIFIBATIDE 5MG INJ (20 MG) $106.00 J1327 MORPHINE 10MG/5ML OR SOLN UD $14.00 MORPHINE EXT REL 100MG TAB $42.00 NATEGLINIDE 60MG TAB $14.00 ATORVASTATIN 40MG TAB $38.00 THEOPHYLLINE EXT REL 400MG TAB $14.00 LEVETIRACETAM 500MG TAB $28.00 OXYCODONE IMM REL 5MG ORAL $14.00 MICONAZOLE 2%/ALOE VE OI 141GM $160.00 VITAMIN D 400 UNIT TAB $10.00 BUDESONIDE 0.25MG/2ML INH SUSP $42.00 METOPROLOL 25MG TAB $10.00 ITRACONAZOLE 100MG CAP $70.00 INFLIXIMAB NOT BIOSIM 10MG IJ $548.00 J1745 ATOVAQUONE 750MG/5ML SUSP $84.00 OC - PPD VACCINE TEST $60.00 FENOFIBRATE 54MG TAB $14.00 FENOFIBRATE 160MG TAB $33.00 ESTRADIOL/NORGES 300-30MCG TAB $28.00 BUDESONIDE 0.5%MG/2ML INH SUSP $55.00 GLYBURIDE 1.25MG TAB $10.00 FINASTERIDE 5MG TAB $33.00 DAPSONE 100MG TAB $10.00 TOPIRAMATE 25MG TAB $33.00 PAPAVERINE 30MG INJ (300MG) $65.00 J2440 COLLEGENASE-SANTYL OINT 30GM $486.00 OXCARBAZEPINE 150MG TAB $14.00 LAMOTRIGINE 100MG TAB $36.00 MORPHINE EXT REL 60MG TAB $36.00 MORPHINE EXT REL 30MG TAB $28.00 MIDODRINE 5MG TAB $33.00 TACROLIMUS 1MG CAP $38.00 J7507 ZOLEDRONIC ACID 1MG(ZOMETA 4MG $1,960.00 J3489 NEVIRAPINE 200MG TAB $50.00 LORAZEPAM 2MG INJ (20MG) $126.00 J2060 BACTRACIN TOP OINTMENT 30GM $113.00 VITAMIN A 10,000 UNIT CAP $10.00 ASCORB AC/IRON POL 50-150MGCAP $10.00 ESMOLOL 10MG/ML PREMIX 250ML $958.00 SODIUM CHLORIDE 1000MG TAB $10.00 EDROPHONIUM 10MG/ML 15ML $170.00 CEFOTAXIME 1000MG INJ $146.00 J0698 ZONISAMIDE 25MG TAB $18.00 SELENIUM 40MG/ML INJ 10ML $154.00 MISOPROSTOL 100MG TAB $14.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SPIRONOLACTONE 100MG TAB $14.00 FACT VIII(ANTIHEMOPHIL) PER IU $10.00 J7192 ALEMTUZUMAB 1MG INJ 12MG $4,928.00 J0202 SEVALAMER 400MG TAB $14.00 CASPOFUNGIN, 5MG INJ (50MG) $192.00 J0637 TRIMETHOPRIM 100MG TAB $14.00 PEGFILGASTIM 6MG INJ $24,350.00 J2505 PRAMIPEXOLE 0.125MG TAB $14.00 METOPROLOL EXT REL 25MG TAB $10.00 METOPROLOL EXT REL 12.5MG DOSE $14.00 METOPROLOL 12.5 TAB DOSE $10.00 SERTRALINE 25MG TAB $33.00 SOTALOL 40MG TAB $10.00 HEPA B VAC NEO 10MCG 0.5ML IJ $122.00 90744 AMIODARONE 100MG TAB $36.00 WARFARIN 0.5MG TAB $10.00 METRONIDAZOLE 250MG/NS50 $266.00 THROMBIN-JMI 5000UNIT TOP PWD $501.00 LORATADINE 5MG/5ML SYRUP U/D $28.00 OXYBUTYNIN SYRUP 5MG/5ML $23.00 FOSPHENYTOIN 50MG INJ (500MG) $129.00 Q2009 NITROGLYCERIN 0.6MG/HR PATCH $33.00 NITROGLYCERIN 0.1MG/HR PATCH $28.00 NITROGLYCERIN 0.2MG/HR PATCH $28.00 NITROGLYCERIN 0.3MG/HR PATCH $33.00 DEXAMETHASONE 1MG TAB $10.00 CEFPODOXIME 200MG TAB $42.00 CIPROFLOXACIN 5MG/100ML SUSP $664.00 CLARITHROMYCIN 250MG TAB $38.00 CAPSAICIN 0.025% CREAM 60GM $172.00 CARBAMAZEPINE 100MG/5ML U/D $10.00 SODIUM CHL 0.9% NEB SOLN 15ML $10.00 MILRINONE 5MG INJ (10MG) $112.00 J2260 MORPHINE 5MG/2ML SVN SOLN $42.00 METFORMIN 850MG TAB $14.00 CITALOPRAM 10MG TAB $33.00 DILTIAZEM EXT REL 60MG CAP $10.00 GLIPIZIDE EXT REL 2.5MG TAB $10.00 LIDOCAINE-MPF 1% INJ 5ML $122.00 INSULIN REGULAR 100U/ML 10ML $228.00 CARBAMAZEPINE 100MG TABLET $10.00 BETAMETHASONE DIPRO CREAM 45GM $106.00 FULVESTRANT 25MG (250MG)SDV $881.00 J9395 OCTREOTIDE DEPOT 1 MG (20 MG) $468.00 J2353 ESCITALOPRAM 10MG TAB $36.00 LINEZOLID 200MG INJ (600MG) $222.00 J2020 SOD FERRIC GLUC 12.5MG IJ (62 $46.00 J2916 LEVOFLOXACIN 250MG IJ(750MG) $351.00 J1956 ACETYLCSTEINE 20% OR SOLN 4ML $50.00 OXALIPLATIN 0.5 MG INJ (100MG) $91.00 J9263 HYLAN G-F 20 1MG INJ (16MG) $221.00 J7325 FILTER 0.22 MICRON IN-LINE $160.00 DIVALPROEX XR 500MG/24HR TAB $33.00 VITAMIN B COMPLEX TAB $10.00 MISOPROSTOL 25MCG DOSE $14.00 EMS DRUG EXCHANGE $38.00 OLARATUMAB 10MG (190MG) INJ $127.00 J9285 OLARATUMAB 10MG (500MG) INJ $127.00 J9285 DIP/TET/ACELL PERTUSSIS 0.5ML $159.00 DIP/TET/AC PERT/HEP B/POL0.5ML $501.00 ESTRADIOL CYP 5MG IJ (25MG) $59.00 J1000
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HEPATITIS B VACC NEONATE 0.5ML $122.00 90744 HAEMOPHILUS B CONJ VACC .5ML $289.00 90648 DEXAMETHASON SOD 1MG IJ(120MG $33.00 J1100 GUAIFENESIN 100MG/5ML SYP 473M $120.00 LIDOCAINE/EPI-MFP 1% INJ 30ML $192.00 PHYSOSTIGMINE SAL 2MG/2ML IJ $152.00 EUCERIN UEMOLLIENT CRM 120GM $125.00 GLYCERIN LIQUID 120ML $106.00 BUMETANIDE 0.5MG INJ (2.5MG) $65.00 GENTAMYCIN TOP OINTMENT 15GM $186.00 STOMAHESIVE PASTE 60GM $160.00 CASTOR OIL 60ML $103.00 DIPHENHYDRAMI 12.5MG/5ML 473ML $120.00 ONDANSETRON 1MG INJ (40MG) $67.00 J2405 CARBIDOP/LEVODOP 25-100 XR TAB $33.00 LEUPROL DEP 7.5MG(LUPRON22.5MG $4,635.00 J9217 BUPIVACAINE-MPF 0.5% 10ML $125.00 EPOPROSTENOL 0.5MG INJ $172.00 J1325 EFAVIRENZ 600MG TAB $146.00 MILRINONE 20MG/100ML PREMIX $516.00 J2260 AZTREONAM 500MG INJ (2GM) $90.00 ERTAPENEM 500MG INJ $160.00 J1335 GEMCITABINE 200MG IJ(200MG) $994.00 J9201 MORPHINE 4MG/1ML INJ SYRINGE $125.00 J2270 SALINE FLUSH 10ML PREFILL SYR $12.00 MISOPROSTOL 50MCG DOSE $14.00 QUETIAPINE 25MG TAB $33.00 QUETIAPINE 100MG TAB $38.00 BIVALIRUDIN 1MG INJ (250MG) $10.00 J0583 INSULIN 75/25 SINGLE DOSE $50.00 J1815 INSULIN GLARGINE IJ SINGL DOSE $50.00 J1815 INSULIN LISPRO INJ SINGLE DOSE $50.00 J1815 INSULIN 70/30 INJ SINGLE DOSE $50.00 J1815 INSULIN NPH INJ SINGLE DOSE $50.00 J1815 INSULIN REGULAR SINGLE DOSE $50.00 J1815 FLUCONAZOLE 200MG IJ(100MGPMX $419.00 AMIKACIN, 100MG INJ (500MG) $28.00 J0278 MEGESTROL SUSP 400MG/10ML UD $120.00 NESIRITIDE 0.1MG INJ $230.00 J2325 ONABOTULINUM TOX 1 UNIT (100UN $28.00 J0585 PERMETHRIN CREAM 5% 60 GM $262.00 AMANTADINE 50MG/5ML SYR U/D $14.00 OSELTAMIVIR 75MG CAP $73.00 CEFOXITIN 1GM INJ (1000MG) $210.00 J0694 SOD/POT PHOSPHATE POWDER PLAIN $14.00 LIDOCAINE 5% TOPICAL PATCH $55.00 GUAIFEN/DM 200-20MG/10ML SF UD $10.00 VEHICLE,SYRUP(SWEET)473ML $129.00 BORTEZOMIB 0.1MG INJ (3.5 MG) $278.00 J9041 PALONOSETRON 25MCG IJ(250 MCG $206.00 J2469 TOPIRAMATE 100MG TAB $50.00 IRON SUCROSE 1MG INJ (100MG) $1.00 J1756 PEMETREXED 10MG INJ(500 MG) $329.00 J9305 MENINGOCOCCAL VACCINE $837.00 90733 FILTER 0.2 MICRON INLINE BRAUN $122.00 CEFEPIME 500MG INJ $134.00 J0692 CAPTOPIZIL 6.25MG DOSE $14.00 OXYBUTYNIN EXT REL 5MG TAB $38.00 TALC, STERILE POWDER 5GM $879.00 BEVACIZUMAB 10MG INJ (100MG) $316.00 J9035 SEVELAMER 800 MG TAB $28.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
EZETIMIBE 10MG TAB $38.00 MEMANTINE 5MG TAB $36.00 ROSUVASTATIN 5MG TAB $36.00 ROSUVASTATIN 20MG TAB $36.00 SIMVASTATIN 40MG TAB $50.00 CARVEDILOL 12.5 MG TAB $33.00 RAMIPRIL 10MG CAP $33.00 AMPHOTERICIN B LIPOSOM 10MG IJ $404.00 J0289 PAROXETINE 40MG TAB $36.00 VENLAFAXINE EXT REL 150MG CAP $42.00 CITALOPRAM 40MG TAB $36.00 CYANOCOBOLAMIN 1000MCG TAB $25.00 CETUXIMAB 10MG INJ (100MG) $262.00 J9055 DOFETILIDE 125MCG CAP $33.00 LIPH TOPICAL SOLN 2ML $57.00 TIOTROPIUM 18MCG POWDER 1X6 $249.00 MEROPENEM IJ 100MG(500MG) $25.00 J2185 AZACTIDINE 1MG INJ (100MG) $33.00 J9025 OXCARBAZEPINE 600MG TAB $46.00 LANSOPRAZOLE 15MCG SOLU TAB $38.00 ACETYLCYSTEINE 100MG (6000MG) $18.00 J0132 PENTOSTATIN 10MG INJ $6,124.00 J9268 THYROID 15MG TAB $10.00 LINEZOLID 600MG TAB $465.00 DARBEPOETIN 1MCG(200MCG)N/ESRD $55.00 J0881 DARBEPOETIN 1MCG(300MCG)N/ESRD $36.00 J0881 DESFLURANE INH PER 1 MINUTE $10.00 SEVOFLORANE INH PER 1 MINUTE $10.00 EPINEPH RAC 2.25% 0.5ML SVN $73.00 ISOFLURANE INH PER MIN $10.00 LIDOCAINE-MPF 2% INJ 10ML AMP $165.00 DESMOPRESSION 0.1% NAS SPR 5ML $228.00 ENTACAPONE 200MG TAB $33.00 PACLITAXEL PROTEIN-BND 1MG IJ $125.00 J9264 BUPROPION 100MG TAB $25.00 RISPERDONE 1MG/ML OR SOLN 30ML $1,045.00 SUCROSE 24% 11ML CUP $14.00 LIOTHYRONINE 5MCG TAB $14.00 VALSARTAN 40MG TAB $25.00 VALSARTAN 160MG TAB $28.00 RIBAVIRIN 200MG CAPSULE $84.00 MIRTAZAPINE 15MG TAB $84.00 POTASSIUM CHL 10MEQ/100ML PMX $222.00 LOCM ISOVUE-300 50ML INJ $2.00 Q9967 LOCM ISOVUE-300 150ML INJ $2.00 Q9967 LOCM ISOVUE-370 125ML SYRINGE $2.00 Q9967 ENEMA (ADULT) 4.5OZ $28.00 ENEMA (PEDS) 2.25OZ $28.00 MODAFINIL 100MG TAB $55.00 OMALIZUMAB 5MG INJ (150 MG) $253.00 J2357 ENEMA (MINERAL OIL) 4.5OZ $28.00 PRAMIPEXOLE 0.5MG TAB $33.00 METAXALONE 800MG TAB $33.00 PANTOPRAZOLE 40MG TAB $57.00 DAPTOMYCIN 1MG INJ $1.00 J0878 LOCM ISOVUE-370 200ML INJ $2.00 Q9967 MUPIROCIN 2% NASAL OINT 1GM $116.00 TIGECYCLINE 1 MG INJ (50 MG) $4.00 J3243 FOLIC AC/PYRIDOX/CYANOCOBA TAB $14.00 LOPERAMIDE 1MG/5ML LIQUID U/D $28.00 DEXTROSE SYRINGE 25% 10ML $106.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
AGALSIDASE BETA 1MG INJ (35MG) $850.00 J0180 CLADRIBINE 1MG (10MG) INJ $166.00 J9065 MOUTHWASH MAGIC 237ML $170.00 PREGABALIN 25MG CAP $28.00 PREGABALIN 50MG CAP $28.00 PREGABALIN 100MG CAP $28.00 PERFLUTREN LIPID 1ML INJ $538.00 Q9957 EPOETIN 1000 U(NONESRD)(40000) $112.00 J0885 THYROTROPIN 0.9MG INJ $6,375.00 J3240 CORTISONE 25MG TAB $14.00 TRASTUZUMAB 10MG INJ (150 MG) $414.00 J9355 LEVALBUTEROL 1.25MG/3ML SVN $38.00 LEVALBUTEROL 0.31MG/3ML SVN $38.00 COCAINE HCL 4% SOL 4ML $152.00 LISINOPRIL 40MG TAB $14.00 SCOPOLAMINE 0.4MG INJ $125.00 PIPER/TAZO 1.125GM INJ (2.5GM) $97.00 J2543 DOXEPIN 150MG CAPSULE $18.00 BISOPROLOL 5MG TABLET $10.00 POLYETHYLENE GLYCOL 3350 PWD $14.00 LEVOFLOXACIN 750MG TABLET $154.00 DECITABINE 1MG INJ (50MG) $192.00 J0894 IVERMECTIN 3MG TAB $46.00 CISATRACURIUM 2MG/ML INJ 5ML $122.00 EPTIFIBATIDE 5MG(75MG) $106.00 J1327 DULOXETINE CAP 20MG $36.00 DULOXETINE CAP 30MG $38.00 CINACALCET 30MG TAB $91.00 MORPHINE PCA 5MG/ML 55ML SYR $639.00 HYDROMORPHONE PCA 2MG/ML 55ML $639.00 J1170 ROPIVACAINE 1MG 200ML (400MG) $1.00 J2795 LOCM VISIPAQUE 320MG/ML 150ML $2.00 Q9967 ROPIVICAINE 1 MG 10 ML (20MG) $1.00 J2795 CAFFEINE CITR 5MG IJ (20MG) $38.00 J0706 SITAGLIPTIN 25MG TAB $50.00 SITAGLIPTIN 100MG TAB $50.00 PANITUMUMAB 10MG INJ (100MG) $773.00 J9303 CAFFEINE/SOD BENZO 500MG IJ $159.00 ZIPRASIDONE 20MG CAP $46.00 RISPERIDONE 1MG TABLET $15.00 ZIPRASTIDONE 10MG INJ $97.00 J3486 KETAMINE 100MG/ML 5ML INJ $134.00 MIDAZOLAM 100MG/100ML PREMIX $65.00 J2250 FENTANYL 1000MCG/100 ML PREMIX $125.00 J3010 MYCOPHENOLATE 250MG TAB(500MG) $28.00 J7517 PHENYLEPHRINE 1% NAS SPR 0.5ML $100.00 DAPSONE 25MG TAB $14.00 DARBOPOETIN ALF1MCG(500)NONESR $36.00 J0881 ONDANSETRON 4MG/5ML ORAL SOLN $46.00 METHACHOLINE 1MG INH (100MG) $2.00 J7674 HOCM 350-399 MG/ML GASTROG 120 $2.00 Q9963 DEXRAZOXANE 250 MG IJ(500 MG) $621.00 J1190 CYANOKIT 5GM $4,576.00 FACT VIIA AHF 1 MCG IJ1000MCG $10.00 J7189 DUTASTERIDE 0.5MG CAP $38.00 CIPROFLOXACIN-HC OTIC SUSP10ML $688.00 ROPINIROLE 1 MG TAB $28.00 CARVIDOLOL CR 10 MG CAP $38.00 DEXMEDETOMIDINE 200MCG/2ML INJ $564.00 GAD-BASE CONT MAGNEVIST 1ML 15 $2.00 A9579 GAD-BASE CONT MAGNEVIST 1ML 20 $2.00 A9579
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
LEVALBUTEROL SOLN 1.25MG/0.5ML $38.00 OXYCODONE EXT REL 80MG TAB $89.00 CALCIUM CARB 500MG CHEW TAB EA $10.00 LIDOCAINE 2% INJ VIAL 5 ML $122.00 MANNITOL INH PWD 5 MG(19 CAPS) $18.00 J7665 FENTANYL 100MCG INJ (500MCG) $125.00 J3010 OXYCODONE/APAP 10/325 MG TAB $14.00 RIVAROXABAN 10 MG TABLET $33.00 METRONIDAZOL 100MG/5ML OR SUSP $26.00 PEMETREXED 10MG INJ (100MG) $329.00 J9305 MORPHINE 2MG/1ML INJ SYRINGE $125.00 J2270 CARBOPLATIN 50MG/5 ML (150MG) $125.00 J9045 TACROLIMUS 0.5 MG CAPS $17.00 NS IRRIGAT 1L POUR FOR CPD $89.00 RIFAXIMIN 550 MG TABLET $107.00 HEPARIN 20,000 UNITS/500ML PMX $25.00 J1644 ROPIVICAINE 1 MG (150MG/30ML) $1.00 J2795 LEVONORGESTROL 1.5MG PLANB TAB $143.00 LEVOTHYROXINE 20 MCG/ML IJ 5ML $268.00 IBUPROFEN 600 MG TABLET $12.00 LEVOLEUCOVORIN 0.5 MG (50 MG) $11.00 J0641 MITOMYCIN 5MG INJ (40 MG) $409.00 J9280 ANTIMICROBIAL BARRIER PWD 5 GM $67.00 DEXAMETHASON 5MG/5ML OR SOL $33.00 ZINC SULFATE 5 MG/ML INJ 5 ML $125.00 LIDOCAINE 2% WOUND GEL 4 ML $23.00 MORPHINE 15 MG/1 ML INJ $125.00 J2270 DENOSUMAB 1 MG INJ (60MG) $75.00 J0897 MIDAZOLAM 1 MG INJ (5 MG) $65.00 J2250 POVIDONE-IODINE 5% NAS SOL 4ML $73.00 MICAFUNGIN 1 MG INJ (50 MG) $2.00 J2248 VERAPAMIL 80 MG TABLET $10.00 MICAFUNGIN 1 MG INJ (100 MG) $2.00 J2248 NS PRESERV FREE DILUENT 50 ML $122.00 THIORIDAZINE 25 MG TABLET $10.00 MOUTHWASH MAGIC 119 ML SUSP $103.00 VALRUBICIN 200MG SOLN(800MG) $4,443.00 J9357 BUPROPION "XL" 150 MG TAB $28.00 TRICHLOROACETIC AC TOP 5% 30ML $103.00 IMMU GLOB GAMMAGARD 500MG(10GM $256.00 J1569 FONDAPARINUX 0.5 MG INJ (2.5) $67.00 J1652 NECITUMUMAB 1MG INJ (800MG) $16.00 J9295 ELOTUZUMAB 1MG INJ (300MG) $18.00 J9176 ELOTUZUMAB 1MG INJ (400MG) $18.00 J9176 DARATUMUMAB 10MG INJ (100MG) $140.00 J9145 DARATUMUMAB 10MG INJ (400MG) $140.00 J9145 FILGRAST G-CSF BIO 1MCG 300MCG $2.00 Q5101ZA FILGRAST G-CSF BIO 1MCG 480MCG $2.00 Q5101ZA VEDOLIZUMAB 1MG (300 MG) INJ $49.00 J3380 POSACONAZOLE 1 MG(300 MG) IJ $4.00 C9399 AVELUMAB 1MG (200MG) INJ $21.00 J9023 MEROPENEM 100MG (1000MG) IVPB $23.00 J2185 CISATRACURIUM 10MG/ML 20ML $378.00 INFLU VACC PF HIGH DOSE >65Y $119.00 90662 INFLUENZA VAC PF QUAD VAL 3YR+ $119.00 90686 INFLU VACC PF QUAD 6-35 M $119.00 90685 INFLUENZA VAC PF QUAD FLUBLOCK $119.00 90682 MORPHINE LIPOSOMAL 10MG/ML $1,231.00 J2274 MORPHINE PF IMG/ML 2ML INJ $134.00 J2274 ERYTHROMYCIN 200MG/5ML 100MLOR $84.00 PHENYLEPHRINE 0.125% NAS SOL15 $103.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BUPIVICAINE 0.75% INJ 10ML $126.00 CARVEDILOL CR 40MG CAP $38.00 ESTROGENS,CONJ 0.45MG TAB $25.00 ALBUMIN (HUMAN) 5% 250 ML INJ $669.00 P9045 PHARMACY NON-FORMULARY ITEM $- CLOPIDOGREL 300MG TAB $134.00 TDAP VACCINE 0.5ML $249.00 90715 MORPHINE PF PER 10MG (500MG) $126.00 J2274 HEPARIN FLUSH 300U/3ML $1.00 J1642 SULF HEX LIP MICR PER ML(5ML)V $93.00 Q9950 PANTOPRAZOLE SOD 40MG GRANULES $57.00 LOCM ISOVUE-300 150ML SYRINGE $2.00 Q9967 LOCM ISOVUE-M 300 15ML INJ $2.00 Q9967 LOCM ISOVUE-370 100ML INJ $2.00 Q9967 LOCM ISOVUE-370 50ML INJ $2.00 Q9967 LOCM ISOVUE-300 100ML INJ $2.00 Q9967 DOXERCALCIFEROL 1 MCG (4 MCG) $75.00 J1270 MIDAZOLAM 10MG/5ML SYRUP $50.00 LITHIUM CARBONATE ER 450MG TAB $23.00 EPOETIN 100 UNITS(ESRD) (4000) $12.00 Q4081 EPOETIN 100 UNIT (ESRD)(10000) $12.00 Q4081 EPOETIN 100 UNITS(ESRD) (3000) $12.00 Q4081 CHLORHEXIDINE ORAL SOLN 15ML $18.00 CLONAZEPAM 2MG TAB $23.00 TRIFLURIDINE 1% OPTH SOL 7.5ML $864.00 RISPERIDONE 0.25MG TABLET $38.00 QUETIAPINE 300MG TABLET $75.00 CEFAZOLIN/NS 500MG/50ML IVPB $113.00 J0690 IMIPENEN/CILA/NS 250MG IVPB $146.00 J0743 LABETALOL 5MG/ML 4ML INJ $113.00 MAGNESIUM SULF 500MG (2GM)PMX $60.00 J3475 PIPER/TAZO 1.125GM INJ (4.5GM) $97.00 J2543 BUSPIRONE 15MG TAB $14.00 TRAZADONE 150MG TABLET $14.00 LEVETIRACETAM 10MG (500MG)VIAL $2.00 J1953 FOMEPIZOLE 15MG INJ (1500MG) $79.00 J1451 LEVETIRACETAM 250MG TAB $28.00 EXENATIDE INJ 1.2 ML $1,138.00 J3490 ADMINISTRATION PNEUMOCOCC VAC $78.00 G0009 VORICONAZOLE 10MG INJ (200MG) $48.00 J3465 VORICONAZOLE 200MG TABLET $311.00 ADMINISTRATION FLU VIRUS VACC $72.00 G0008 ADMINISTRATION VACCS/TOXS,SGL $72.00 90471 LACTULOSE ENEMA 1000ML $298.00 NIPPLE CARE CREAM $38.00 ZINC OXIDE CREAM 113 GM $113.00 ERYTHROMYCIN OPHTH OINT 1 GM $103.00 ALBUTEROL HFA INHALER 8.5GM $262.00 NITROGLYCERIN SL SPRAY 4.9 GM $696.00 TRANEXAMIC ACID 100MG/ML 10ML $467.00 FENTANYL 12.5 MCG/HR PATCH $139.00 PROMETHAZINE HCL 12.5 MG ORAL $12.00 HEPARIN 1000 UNITS/ML(30ML)IJ $25.00 J1644 PROTAMINE 10MG/ML 25ML INJ $33.00 J2720 HOCM <=149 MG/ML 250ML CYSTOCO $2.00 Q9958 LEUPROLIDE DEP 7.5MG(30MG) IJ $4,635.00 J9217 AZITHROMYCIN 500MG/250ML IVPB $297.00 J0456 SILVER WOUND DRESSING GEL 45GM $165.00 PROTECTIVE BARRIER OINT 113GM $116.00 RANITIDINE 150MG/10ML LIQ $46.00 ZOSTER VACCINE LIVE $993.00 90736
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
MAGNESIUM SULF 50% ORAL 30ML $36.00 PEPPERMINT OIL 30 ML $125.00 MAGNESIUM SULF 500MG (1GM)PMX $60.00 J3475 CALCIUM GLUCONATE 1GM/50ML PMX $205.00 J0610 BUPIVICAINE 0.25% INJ 50ML $122.00 FENTANYL PCA 100MCG(550MCG/55M $125.00 J3010 APREPITANT 5MG ORAL (80MG) $33.00 J8501 CEFEPIME 500MG IJ (1GM PMX) $134.00 J0692 AZTREONAM 500MG IJ (1GM PMX) $104.00 AZTREONAM 500MG IJ (2GM) PMX $104.00 LITHIUM CARBONATE 150MG CAP $11.00 ENDOSCOPIC MARKER (SPOT) $143.00 SODIUM BICARB 8.4% VIAL 50ML $106.00 MCT OIL 946 ML $233.00 IXABEPILONE 1MG INJ (15 MG) $366.00 J9207 LIDOCAINE 2% VISCOUS SOL 100ML $84.00 LIDOCAINE-MPF 1% INJ 10ML $134.00 CASPOFUNGIN, 5MG INJ (70MG) $192.00 J0637 FONDAPARINUX 0.5 MG INJ (7.5) $67.00 J1652 POTASSIUM CHL 2MEQ/ML (30MEQ) $104.00 J3480 HUMAN PAPILLOMAVIRUS VACCINE $355.00 90649 CEFOTAXIME 1000MG INJ (2000MG) $126.00 J0698 VANCOMYCIN 125MG/5ML ORAL SOLN $106.00 SULFAMETH/TMP 80-16MG/ML 30ML $125.00 APLIGRAF PER 1 SQ CM $165.00 Q4101 NATALIZUMAB 1MG INJ (300MG) $48.00 J2323 METHYLPRED XR 80MG/ML (80MG) $323.00 J1040 BENDAMUSTINE (BENDEKA) 1MG INJ $84.00 J9034 DRONEDARONE 400MG TAB $18.00 TISSEEL SEALANT KIT 4 ML $1,177.00 VITAMIN D 1,000 UNIT TABLET $11.00 MAGNESIUM SULF 500MG (3GM)PMX $60.00 J3475 PRASUGREL 5MG TAB $36.00 PRASURGEL 10MG TAB $36.00 ALVIMOPAN 12 MG CAPSULE $306.00 SALINE NASAL GEL 14.1GM $23.00 DESMOPRESSIN 1MCG INJ (40 MCG) $46.00 J2597 IODINE SOLN STRONG(LUGOLS)14ML $149.00 CHLORHEXIDINE 4% TOP SOL 120ML $84.00 CEFOXITIN 1GM INJ (2000MG) $210.00 J0694 FERROUS SULF DRP 15MG/1ML 50ML $100.00 DEXA/TOBRA OPHTH SOLN 2.5ML $232.00 COLISTIMETHATE 150MG INJ $297.00 J0770 PEG SOLUTION KIT EA $251.00 OCTREOTIDE DEPOT 1 MG (30 MG) $468.00 J2353 LABETALOL 5MG/ML 40 ML INJ $175.00 CEFOXITIN 1GM (2GM/50ML) PMX $228.00 J0694 LABETOLOL 5MG/ML 5ML INJ $113.00 CEFOXITIN 1GM/50ML PREMIX $228.00 J0694 CEFAZOLIN 500MG (1GM/50ML)PMX $122.00 J0690 CEFTRIAXONE 250MG(1GM) IVPB $97.00 J0696 CEFTRIAXONE 250MG(2GM) IVPB $97.00 J0696 ARIPIPRAZOLE 5MG TABLET $75.00 ARIPIPRAZOLE 20MG TABLET $125.00 CEFDINIR 250 MG/5 ML 100ML SUS $379.00 HYDROMORPHONE 1 MG INJ $113.00 J1170 DESMOPRESSIN 0.2MG TAB $26.00 LOCM ISOVUE-370 150ML INJ $2.00 Q9967 DESMOPRESSIN 0.1MG TAB $26.00 BIOPATCH 1" PROTECTIVE PATCH $42.00 FLUTIC/SALM 45-21 MCG INH SPR $38.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
FLUTIC/SALM 115/21 MCG INH SPR $38.00 FLUTIC/SALM 230/21 MCG INH SPR $38.00 IPRATROPIUM 17MCG INHAL SPRAY $38.00 LEVALBUTEROL 45 MCG INH SPRAY $38.00 ALBUTEROL 90 MCG INHAL SPRAY $38.00 ALBUTER/IPRATR 100/20 INH SPRY $77.00 SKIN ADHESIVE TOP (DERMABOND) $589.00 FLUTICOSONE 110MCG INHAL SPRAY $38.00 FLUTICOSONE 220MCG INHAL SPRAY $38.00 ROMIPLOSTIM 10 MCG IJ(250 MCG $262.00 J2796 IMM GLOB LIQ 500MG (10GM) $289.00 J1459 HYDROCODONE/APAP 5-325 MG TAB $14.00 HYDROCODONE/APAP 10-325 MG TAB $18.00 NIFEDIPINE EXT REL 90MG TAB $33.00 MENINGOCOCCAL VACCINE IM $837.00 90734 OXYCODONE IMM REL 20MG TAB $26.00 ALUMINUM HYDROXIDE GEL 30ML $13.00 TEMSIROLIMUS INJ 1 MG (25MG) $262.00 J9330 LEVALBUTEROL 15GM INH CAN $262.00 REGADENOSON 0.1MG INJ (0.4MG) $281.00 J2785 METHYLPREDNISOLONE 32MG TAB $30.00 RABIES IMM GLOB 150IU/ML (300) $714.00 90375 ROPIVACAINE 1MG IJ(100MG/20ML) $1.00 J2795 FLUTIC/SALM 45-21MCG INH CAN $741.00 FLUTIC/SALM 115-21MCG INH CAN $894.00 FLUTIC/SALM 230-21MCG INH CAN $1,173.00 IPRATROPIUM 12.9GM INH CAN $604.00 ANTITHROMBIN III (HUMAN)PER IU $15.00 J7197 LIDOCAINE/EPI-MPF 1% INJ 10ML $192.00 MIDODRINE 2.5MG TAB $18.00 TOLVAPTAN 15MG TABLET $1,150.00 PIPER/TAZO 1.125GM(3.375GM BAG $120.00 J2543 HYDROCOD/APAP 5-325MG 4 TAB HP $46.00 RANOLAZINE 500MG TAB $26.00 DILTIAZEM 125MG/25ML $146.00 SEALANT PROGEL PLEURAL $4,962.00 C2615 DIGOXIN IMMUNE FAB 40MG VIAL $6,534.00 J1162 CABAZITAXEL 1MG INJ (60MG) $584.00 J9043 ERIBULIN 0.1MG INJ (1MG) SDV $478.00 J9179 GAD-BASE CONT OMNISCAN 1ML 15M $2.00 A9579 GAD-BASE CONT OMNISCAN 1ML 20M $2.00 A9579 LOCM OMNIPAQUE-180 20ML INJ $2.00 Q9965 LOCM OMNIPAQUE-300 150ML INJ $2.00 Q9967 LOCM OMNIPAQUE-300 50ML INJ $2.00 Q9967 LOCM OMNIPAQUE-M300 15ML INJ $2.00 Q9967 LOCM OMNIPAQUE-350 100ML INJ $2.00 Q9967 LOCM OMNIPAQUE-350 200ML INJ $2.00 Q9967 RIFAXIMIN 200 MG TABLET $40.00 BUPIVACAINE LIPOSOME 1 MG INJ $3.00 C9290 GUAIFENESIN/DM 5 ML CUP $10.00 ZONISAMIDE 100 MG CAP $23.00 HYPERTONIC SOD CHL SVN 3% 4ML $38.00 HYDROXYZINE PAMOATE 50 MG CAP $10.00 DEGARELIX 1 MG INJ (240 MG) $28.00 J9155 DEGARELIX 1 MG INJ (80 MG) $28.00 J9155 SKIN ADHESIVE ADVANCED (PEN) $589.00 LEVETIRACETAM 10MG(500MG/100ML $2.00 J1953 LEVETIRACETAM 10 MG(1GM/100ML) $2.00 J1953 IMM GLOB LIQ 500MG (20GM) $256.00 J1459 IMM GLOB LIQ 500MG (5GM) $256.00 J1459 CENTRUROIDES (SCORPION)IMM FAB $15,534.00 J0716
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DOXORUBICIN LIPOS 10 MG (20MG) $3,662.00 Q2050 RIVAROXABAN 15 MG TABLET $33.00 METHYLNALTREXONE 0.1 MG (8MG) $2.00 J2212 PHENYLEPHRINE 1MG/250ML PMX(10 $36.00 ROPIVACAINE 1MG 100ML (200MG) $1.00 J2795 PHENYLEPHRINE 100MCG/ML 5ML IN $36.00 J2370 HYDROMORPHONE PF 1MG/1ML INJ $113.00 J1170 THEOPHYLLINE 80MG/15ML ELIXIR $13.00 FOSAPREPITANT INJ 1 MG (150MG) $12.00 J1453 CEFEPIME 500MG INJ (2000MG) $134.00 J0692 NAFCILLIN 2000MG INJ $238.00 J3490 LEVETIRACETAM 500MG/5ML OR SOL $40.00 TETRACAINE 10MG/ML 2ML $106.00 SEVELAMER 800MG PACKET $40.00 NICOTINE GUM 4MG EACH $14.00 DENOSUMAB 1MG INJ(120MG) $75.00 J0897 PHENYLEPHRINE 1MG INJ (50MG) $36.00 J2370 AMIODARONE 30MG (150MG/100ML) $36.00 J0282 AMIODARONE 30MG(900MG/500ML) $36.00 J0282 SKIN ADHESIVE (LIQUIBAND) $589.00 EPINEPHRINE 0.1MG (8MG/250ML) $13.00 J0171 CEFEPIME 500 MG IJ (2GM PMX) $113.00 J0692 BENZOCAINE 20% SPRAY 0.5ML $44.00 VIPERSLIDE LUBRICANT PMX 100ML $406.00 RISPERIDONE-M 1MG SOLUBLE TAB $40.00 CISATRACURIUM 2MG/ML INJ 10ML $207.00 DILTIAZEM 5MG/ML 10ML INJ $251.00 CISPLATIN 10MG INJ (50MG) $186.00 J9060 POTASSIUM ACET 2MEQ/ML(50ML) $306.00 IRINOTECAN 20MG INJ (40MG) $1,277.00 J9206 METHOTREXATE 5MG INJ (250MG) $46.00 J9250 PACLITAXEL 30MG INJ (30MG) $224.00 J9267 RITUXIMAB 100MG INJ (500MG) $5,130.00 J9310 AMIODARONE 30MG INJ (900MG) $36.00 J0282 INSULIN ISOPH/REG 70-30 3ML IN $93.00 ETOMIDATE 2MG/ML INJ 20 ML $404.00 DERMAGRAFT PER 1 SQ CM $165.00 Q4106 ACYCLOVIR 5MG INJ (1000 MG) $1.00 J0133 VANCOMYCIN 500MG INJ (1000MG) $125.00 J3370 VANCOMYCIN 500MG INJ (5000MG) $125.00 J3370 INSULIN REGULAR 100U/ML 3ML $93.00 MAGNESIUM SULF 500MG IJ(10GM) $116.00 J3475 NICOTINE LOZENGE 4MG EACH $14.00 NICOTINE LOZENGE 2MG EACH $14.00 ACYCLOVIR 5% OINT 30 GM $1,646.00 FLUOROURACIL 500 MG (2500 MG) $186.00 J9190 IBANDRONATE 1MG INJ (3MG) $2,368.00 J1740 ENOXAPARIN 10MG INJ (120MG) $75.00 J1650 PACLITAXEL 30MG INJ (300MG) $224.00 J9267 BEVACIZUMAB 10MG INJ (400MG) $316.00 J9035 BLEOMYCIN 15 UNIT INJ (30MG) $895.00 J9040 DOXORUBICIN HCL 10MG IJ(50MG) $211.00 J9000 POTASSIUM PHOS 2MMOL/ML 15ML $367.00 POTASSIUM PHOS 2MMOL/ML 50ML $1,221.00 DEXTROSE VIAL 50% INJ 50ML $106.00 FOLIC ACID 5MG/ML 10ML INJ $1,221.00 FUROSEMIDE 10MG/ML 10ML(100MG) $65.00 J1940 OXALIPLATIN 0.5 MG INJ (50MG) $91.00 J9263 ETOPOSIDE 10MG INJ (500MG) $36.00 J9181 CARBOPLATIN 50MG/5ML IJ(450MG) $125.00 J9045 ALUMINUM HYDROXIDE GEL 473ML $129.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SYNTHETIC IMPL URINARY 1M(5ML) $600.00 L8606 DOCETAXEL 1MG INJ (160MG) $143.00 J9171 INSULIN ISOP 100U/ML IJ 3ML $93.00 INSULIN LISPRO 100U/ML INJ 3ML $93.00 PETROLATUM 50GM OINT $14.00 HYLAN G-F 20 1MG INJ (48MG) $221.00 J7325 CEFTAZIDIME 500MG (2GM IVPB) $165.00 J0713 SKIN BALM MAGIC 60GM $112.00 ALTEPLASE 1MG INJ (50 MG) $228.00 J2997 LAMIVUDINE/ZIDOV 150-300MG TAB $70.00 SITZMARKS CAPS EA (RADIOLOGY) $93.00 A4641 BELLADONNA & OPIUM 30 MG SUPP $96.00 OSELTAMIVIR 6 MG/ML SUSP 60 ML $431.00 ACETYLCYSTEINE 10% SOL 30 ML $67.00 TETRACAINE 0.5% OPH SOLN 2 ML $106.00 ESTROGENS CONJ VAG CRM 30 GM $572.00 HEPATIT B IMMGLOB 1ML(5ML)MULT $1,021.00 90371 TICAGRELOR 90MG TABLET $23.00 OXYCODONE IMM REL 15 MG TABLET $26.00 HEPARIN FLUSH 10U/3 ML (30U) $1.00 J1642 POTASS PHOS 15 MMOL/NS 250ML $274.00 POTASS PHOS 30 MMOL/NS 250ML $274.00 LC BEADS BLUE LAB 300-500 2 ML $11,437.00 DABIGATRAN 75 MG CAPSULE $15.00 MELATONIN 3 MG TABLET $10.00 NS DILUENT(NORMAL SALINE) PF $122.00 MEROPENEM 100MG (1000MG) INJ $25.00 J2185 MELATONIN 1 MG TABLET $10.00 CEFTRIAXONE 250 MG IJ (2GM)VL $122.00 J0696 IMMU GLOB GAMMAGARD 500MG(20GM $256.00 J1569 RHO(D)IMM GLOB IJ 100IU(2500) $170.00 J2792 CIPROFLOX/DEXAMETH OT SOL7.5ML $513.00 BUPIVACAIN 0.5% ONQ PUMP 400ML $981.00 CHLORHEXIDINE TOP SOLN 4% 15ML $10.00 DIVALPROEX ER (24HR) 250MG TAB $10.00 ON-Q BALL PUMP 270 ML DISPOSAB $326.00 SODIUM CHL 7% INHATION 4ML $38.00 DORNASE ALPHA 1MG INHL(2.5MG) $122.00 J7639 CARFILZOMIB 1MG INJ (60MG) $114.00 J9047 NITROGLYCERIN OINT 2% 30 GM $122.00 LIOTHYRONINE 25 MCG TABLET $15.00 PERMETHRIN 1% LOT/COMB 59 ML $33.00 TROALMINE SALIC 10% CR 85GM $129.00 PIPER/TAZO-NS 2.25 GM IVPB $97.00 J2543 PIPER/TAZO-NS 4.5GM/100ML IVPB $97.00 J2543 AMPI/SULB-NS 3.0GM/100ML IVPB $198.00 J0295 AMPICILLIN 1 GM/NS 50 IVPB $122.00 J0290 TRIAMCINOLONE HEXA 5MG (20MG) $18.00 J3303 AMYLASE/LIPASE/PROTEASE CAPS $13.00 DIGOXIN OR 0.25MG/5ML SOL $13.00 ALBUTEROL 2.5 MG/0.5ML SVN SOL $38.00 IMM GLOB LIQ 5% 500MG(10GM) $289.00 J1459 IMM GLOB LIQ 5% 500MG(5GM) $289.00 J1459 ATRACURIUM 10 MG/ML INJ 5 ML $108.00 ABATACEPT 10 MG INJ (250 MG) $97.00 J0129 SLFAMTH/TMP 80 16MG/ML 10ML IN $125.00 OSELTAMIVIR 30 MG CAP $42.00 OSELTAMIVIR 45 MG CAP $42.00 ACETYLCYSTEINE 600 MG CAPSULE $10.00 LEUPROL DEP 7.5MG(ELIGARD45MG) $4,635.00 J9217 OSELTAMIVIR 6 MG/ML OR 5 ML UD $49.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HYDROCOD/APAP 7.5 325 MG/15ML $33.00 EPOPROSTENOL 0.5MG (1.5MG)INJ $172.00 J1325 POVIDONE IODIN 7.5% SCRUB 60ML $10.00 EPOPROSTENOL DILUENT 50 ML $108.00 TOBRAMYCIN INH SOLN 300MG/5ML $491.00 J7682 LC BEAD YELLOW LBL 100-300 2ML $9,803.00 CLOPIDOGREL 75MG/15ML SUSP(CPD $38.00 MESALAMINE 400 MG DR CAPSULE $14.00 ROFLUMILAST 500 MG TABLET $26.00 DOCUSATE 100MG/10 ML LIQUID $14.00 GADOXETATE DISODIUM INJ 10 ML $48.00 A9581 MONTELUKAST 4 MG CHEW TAB $25.00 ESMOLOL 20 MG/ML PREMIX 100 ML $929.00 BUPROPION 75 MG TAB $25.00 CEFTAROLINE 10MG (600MG) INJ $40.00 J0712 LIDOCAINE LOJ 4% SOLN 4ML $141.00 DEXMEDETOMIDINE 400MCG/100ML $770.00 ACLIDINIUM SPR 400 MCG 30 DOSE $295.00 FIDAXOMICIN 200 MG TAB N/CHEMO $556.00 J8499 HEPATITIS B IM GLOB NEON 0.5ML $231.00 90371 CETUXIMAB 10MG INJ (200MG) $262.00 J9055 MISOPROSTOL 200 MCG TAB $14.00 PROTHROMB CMPLX PER UNIT(500 U $3.00 C9132 ZOLEDRON ACID 1MG IVPB(4MG ZOM $1,960.00 J3489 GI COCKTAIL ORAL 5 ML SYRINGE $18.00 CEFTAROLINE 10MG (400 MG) INJ $48.00 J0712 LANSOPRAZOLE 150 ML SUSP KIT $206.00 CYCLOBENZAPRINE 5 MG TAB $14.00 DORZOLAMIDE/TIMOL OPTH 10ML $286.00 EMOLLIENT LOTION 8 OZ $103.00 PRAMOXINE METHOL CREAM 1 OZ $103.00 KETAMINE 10MG/ML 5 ML SYRINGE $106.00 FLUCONAZOLE 200 MG TABLET $70.00 CEFTAROLINE 10MG(400MG) IVPB $48.00 J0712 CEFTAROLINE 10MG(600MG) IVPB $48.00 J0712 TOCILIZUMAB 1 MG (80 MG) INJ $14.00 J3262 TOCILIZUMAB 1MG (400 MG) INJ $14.00 J3262 EFAVIR/EMITRI/TENO 600/200/300 $301.00 ADENOSINE 6MG INJ $106.00 J0153 ADENOSINE DIAGNOSTIC 1MG(90MG) $11.00 J0153 SILDENAFIL 20 MG TAB $12.00 ACETAMINOPHEN 10MG INJ(1000MG) $10.00 J0131 ONDANSETRON ODT 4 MG TAB $10.00 FERRIC CARBOXYMALT(1MG) 750MG $2.00 J1439 APIXABAN 2.5 MG TABLET $21.00 APIXABAN 5 MG TABLET $21.00 FILGRASTIM(G-CSF)1MCG (300MCG) $3.00 J1442 FILGRASTIM(G-CSF)1MCG(480MCG) $3.00 J1442 ATROPINE SUL SYR 0.01MG(0.8MG) $2.00 J0461 SUCCINYLCHOLINE 20MG SYR(200MGG) $14.00 J0330 DAKINS 1/2 STR 0.25% 3L IR $238.00 BRENTUXIMAB VEDOTIN 1MG(50MG) $499.00 J9042 FLUCONAZOLE 200 MG IJ(800 MG) $837.00 J1450 MORPHINE CONC 20MG/ML 0.5 MLUD $13.00 DIBUCAINE 1% OINTMENT 60 GM $93.00 LEUPROLIDE ACET 7.5MG(LUPRON45 $4,078.00 J9217 METHENAMINE 1000 MG TAB $5.00 TIZANIDINE 4 MG TAB $5.00 CEFAZOLIN 500MG(2GM/50ML) IVPB $107.00 J0690 TOCILIZUMAB 1 MG(200MG) INJ $13.00 J3262 IMM GLOB LIQ 5% 500MG(1GM) $253.00 J1568
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PHOSPHORUS 250 MG TAB $5.00 EPIFIX/EPICORD 1SQCM (14MM) $769.00 Q4131 EPIFIX/EPICORD PER 1SQCM(2X3CM $769.00 Q4131 EPIFIX/EPICORD PER 1SQCM (4X4) $769.00 Q4131 PNEUMOCOCCAL VACC 13 VAL 0.5ML $454.00 90670 DEXAMETHASON 1MG/ML ORAL 30ML $70.00 J8540 MAG/POT/SOD SUL(SUPREP KT)12OZ $222.00 POLIDOCANOL 1% 2 ML INJ $70.00 FERUMOXYTOL NONESRD 1MG(510MG) $2.00 Q0138 NALBUPHINE 10MG INJ (20MG) $134.00 J2300 VANCOMYCIN ORAL 25MG/ML 300ML $279.00 SODIUM CITRATE 4% 3 ML SYRINGE $16.00 ARGININE HCL 10% 300 ML BOTTLE $112.00 CERTOLIZUMAB PEGOL 1MG(200MG) $18.00 J0717 PANITUMUMAB 10 MG INJ (400MG) $773.00 J9303 STERILE WATER FOR IRR 2000 ML $174.00 LACOSAMIDE 100 MG TAB $35.00 LEUPROL DEP 7.5(ELIGARD22.5MG) $4,635.00 J9217 ALPHA-1-PROTEINASE INHIB 10 MG $14.00 J0256 PORACTANT ALFA 80 MG/ML 1.5ML $1,467.00 EPINEPHRINE 1 MG/ML 30 ML INJ $126.00 APREPITANT 5MG ORAL(40MG) $33.00 J8501 SYNTHET IMPL URINARY 1ML(2.5ML $600.00 L8606 REMIFENTANIL 1 MG INJ $154.00 UROPLASTY ENDOSCOPIC NEEDLE $105.00 ZIV-AFLIBERCEPT 1MG (100 MG) $28.00 J9400 ZIV-AFLIBERCEPT 1MG (200 MG) $28.00 J9400 DEXAMETHASONE TO 1 MG PF(10MG) $33.00 J1100 METRONIDAZOLE 0.75% CR 45 GM $558.00 PLASMA-LYTE INJ 500 ML $351.00 CELECOXIB 400 MG CAP $35.00 PERTUZUMAB 1 MG INJ (420 MG) $35.00 J9306 TESTOSTERONE CYP 1MG (200MG) $1.00 J1071 TESTOSTERONE CYP 1MG (2000MG) $1.00 J1071 PROPOFOL 10MG INJ (200MG) $4.00 J2704 PROPOFOL 10MG INJ (500MG) $4.00 J2704 PROPOFOL 10MG INJ (1000MG) $4.00 J2704 PACLITAXEL 1MG INJ (100MG) $5.00 J9267 PACLITAXEL 1MG INJ (30MG) $5.00 J9267 PACLITAXEL 1MG INJ (300MG) $5.00 J9267 ADENOSINE 1MG INJ (90MG) $14.00 J0153 ADENOSINE 1MG INJ (6MG) $14.00 J0153 VANCOMYCIN 500MG IJ(1GM/250ML $222.00 J3370 FAMOTIDINE 20MG INJ (CPD) $122.00 PHYTONADIONE 1MG IJ (10MG)CPD $14.00 J3430 PROMETHAZINE 25MG INJ (CPD) $122.00 J2250 METHYLPREDNISOL 125 MG IJ CPD $159.00 J2930 LEVOTHYROXINE 175 MCG TAB $10.00 PREGABALIN 75 MG CAP $28.00 LEVOTHYROXINE 75 MCG TAB $10.00 PANTOPRAZOLE 40MG INJ (CPD) $146.00 C9113 WARFARIN 7.5 MG TABLET $10.00 LEVOTHYROXINE 125MCG TABLET $9.00 VITAMIN D 5000 UNIT TABLET $10.00 PEMBROLIZUMAB 1MG INJ (100MG) $139.00 J9271 ADO-TRASTUZUMAB EMT 1MG(100MG) $90.00 J9354 ADO-TRASTUZUMAB EMT 1MG(160MG) $90.00 J9354 TABO-FILGRASTIM 1 MCG (300 MCG $2.00 J1447 TABO-FILGRASTIM 1 MCG (480 MCG $2.00 J1447 VEMURAFENIB 240 MG MG TAB $141.00 GADOBUTROL IJ 0.1 ML (10 ML) $2.00 A9585
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
NORETH/ETH ESTR 1.5-0.03MG 21T $64.00 MICROSPHERE (QUADRAS)30-60 MCG $4,612.00 ENOXAPARIN 10MG INJ (150MG) $75.00 J1650 VANCOMYCIN 500MG (750MG IVPB) $222.00 J3370 ATEZOLIZUMAB 10 MG(1200MG)INJ $210.00 J9022 OFATUMUMAB 10 MG INJ (1000 MG) $144.00 J9302 ARIPIPRAZOLE 2 MG TABLET $75.00 EMOLLIENT SKIN CLNS 50 GM OINT $93.00 MEPOLIZUMAB 1MG (100 MG) INJ $73.00 J2182 SUGAMMADEX 100MG (200 MG) $131.00 C9399 OLANZAPINE 5 MG ODT $38.00 OLANZAPINE 0.5MG INJ (10 MG) $5.00 J3490 CANGRELOR 1MG INJ (50MG) $48.00 C9460 SUGAMMADEX 100 MG (500 MG) VL $131.00 C9399 TELAVANCIN 10MG INJ (750 MG) $15.00 J3095 NIVOLUMAB INJ 1MG (240MG) $77.00 J9299 SACUBITRIL/VALSART 97-103MG TB $21.00 SACUBITRIL/VALSART 49-51MG TAB $21.00 OLMESARTAN 20MG TAB $18.00 INDOMETHACIN 50 MG SUPP $52.00 OXFLOXACIN OPTH DROPS 0.3% 5ML $292.00 KETOCONAZOLE 200 MG TAB $9.00 NIVOLUMAB INJ 1MG (100MG) $77.00 J9299 DURVALUMAB 1MG (120MG) $19.00 C9399 IPILIMUMAB 1MG (50MG) DONATED $0.01 J9228FB IPILIMUMAB 1MG (200MG) DONATED $0.01 J9228FB NATALIZUMAB 1MG(300MG) DONATED $0.01 J2323FB DURVALUMAB 1MG (500MG) $19.00 C9399 NIVOLUMAB INJ 1MG (40MG) $77.00 J9299 IDARUCIZUMAB 50MG/ML 50ML VIAL $5,124.00 J3490 CLEVIDIPINE BUTYR 1MG (25MG) $9.00 C9248 BELATACEPT INJ 1MG (250MG) $12.00 J0485 GADOBUTROL INJ 0.1 ML $2.00 A9585 RAMUCIRUMAB 5MG INJ (100MG) $160.00 J9308 RAMUCIRUMAB 5MG INJ (500MG) $160.00 J9308 DAKINS FULL STR 0.5% 1000ML $219.00 DAKINS 1/2 STR 0.25% 1000ML IR $219.00 GOSERELIN ACET IMP 3.6MG(10.8) $2,051.00 J9202 POTASSIUM CHL 2MEQ/ML (60MEQ) $94.00 TOBRAMYCIN SULFATE 5GM POWDER $233.00 PHARMACY 340-B CHARGES $- NITROGLYCERIN 100MCG/ML IJ 10 $149.00 ZOLEDRON ACID 1MGIVPB(5MGRECL $1,960.00 J3489 IMM GLOB LIQ 10% 500MG(20GM) $253.00 J1568 GEMCITABINE 200MG INJ (2000MG) $1,007.00 J9201 ORITAVANCIN 10MG (400 MG) $87.00 J2407 EMOLLIENT SKIN CLN 3.5 GM OINT $10.00 PEGFILGASTIM 6MG SYR DELIV KIT $24,350.00 J2505 IPILIUMAB (YERVOY) 1MG (200MG) $454.00 J9228 IPILIUMAB (YERVOY) 1MG (50MG) $454.00 J9228 LOPINAVIR/RITONAV 200-50MG TAB $24.00 RADIUM RA223 DICH THER PER UCI $353.00 A9606 GOLIMUMAB 1MG FOR IV (50MG) $96.00 J1602 ACETAMINOPHEN 32MG/ML ORAL60ML $83.00 SODIUM TETRADEC SUL 10MG(20MG) $118.00 J3490 SODIUM TETRADEC SUL 10MG(60MG) $118.00 J3490 EMTRICITABIN-TENOF 200/300MG T $134.00 RALTEGRAVIR 400 MG TAB $58.00 HYDROCOD/APAP 7.5-325 MG TAB $14.00 NALOXONE 4 MG/0.1 ML NAS SPR $170.00 ARGATROBAN N/ESRD 1MG (250MG) $27.00 J0883
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
D5W INJ 100ML BAG $103.00 J7060 NS INJ 100ML BAG $103.00 NS INJ 50ML BAG $103.00 J7050 ALBUMIN (HUMAN) 25%,100ML(25GM $669.00 P9047 ALBUMIN (HUMAN) 25% 50ML (12.5 $669.00 P9047 NS INJ 250ML BAG $103.00 J7050 NS IRRIGATION 250ML BAG $89.00 EVACUATED CONTAINER 500ML $120.00 SOD CHLOR 3% INJ 500MG BAG $348.00 ALUM 1% STER WATER IRR 3L SOLN $270.00 D5 1/3NS INJ 500ML BAG $348.00 ALUM 1% STER WATER IRR 1L SOLN $243.00 NS INJ 100 ML ADD VANTAGE BAG $95.00 NS IRRIGATION 500ML POUR $89.00 D10W INJ 250ML BAG $103.00 STER WATER IRR 500ML POUR $89.00 STER WATER IRR 250ML POUR $89.00 TPN SOLN (3 IN 1) W/ELECT $2,684.00 STER WATER INJ 100ML VIAL $348.00 ACETIC ACID IRR 1000ML POUR $210.00 LACT RINGERS IRR 3000ML BAG $126.00 STER WATER IRR 1500ML POUR $89.00 NS IRRIGATION 1500ML POUR $172.00 MANNITOL 20% INJ 500ML PREMIX $419.00 HEPARIN 2U/ML INJ 500ML PREMIX $419.00 HETASTARCH 6% INJ 500ML $461.00 STER WATER IRR 3000ML BAG $210.00 NS IRRIGATION 1000ML POUR $89.00 STER WATER IRR 1000ML BAG $125.00 NS IRRIGATION 1000ML BAG $91.00 STER WATER IRR 1000ML POUR $89.00 D5W INJ 250ML BAG $103.00 J7060 D5W INJ 500ML BAG $348.00 J7060 D5W INJ 1000ML BAG $351.00 J7070 D5 1/4NS INJ 500ML BAG $348.00 D5 1/4NS INJ 1000ML BAG $348.00 D5 1/2NS 1000ML BAG $348.00 D5 1/2NS INJ 500ML BAG $348.00 D5 LR INJ 500ML BAG $348.00 D5 LR INJ 1000ML BAG $348.00 D10W INJ 1000ML BAG $348.00 LIDOCAINE IJ 4MG/ML 500ML PMX $419.00 J2001 D5 NS INJ 500ML BAG $348.00 J7042 D5 NS 1000ML BAG $348.00 J7042 LR INJ 500ML BAG $348.00 J7120 LR INJ 1000ML BAG $348.00 J7120 INTRALIPIDS 20% INJ 250ML $409.00 NS IRRIGATION 3000ML BAG $125.00 GLYCINE 1.5% IRR SOLN 3000ML $134.00 NS INJ 500ML BAG $348.00 J7040 NS INJ 1000ML BAG $348.00 J7030 VIAFLEX IV CONTAINER 1000ML $125.00 0.45% SOD CHLOR INJ 1000ML $348.00 SPIKE ADAPTER FOR IV 2CO471 $120.00 SECONDARY TUBING W/VENT $224.00 NS INJ 50ML SNAP BAG $103.00 J7050 NS INJ 100ML SNAP BAG $103.00 J7050 D5W INJ 50ML BAG $103.00 HEPARIN 2 UNITS/ML INJ 1000ML $410.00 POTAS CHL IJ 20MEQ/100ML PMX $222.00 POTASSIUM CHL 40MEQ/100ML PMX $222.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
EVACUATED CONTAINER 1000ML $120.00 VIAFLEX IV CONTAINER 250ML $120.00 VIAFLEX IV CONTAINER 50ML $120.00 DEXTROSE 70% INJ 2000ML SOLN $351.00 KCL 20MEQ IN D5 1/2NS 1000ML $419.00 KCL 30MEQ IN D5 1/2NS 1000ML $419.00 KCL 40MEQ IN D5 1/2NS 1000ML $419.00 KCL 20MEQ IN NS 1000ML $419.00 KCL 40MEQ IN NS 1000ML $419.00 KCL 20MEQ IN D5NS 1000ML $419.00 D5W INJ IN 500ML EXCEL BAG $391.00 VIAFLEX IV CONTAINER 150ML $120.00 NS INJ IN EXCEL BAG 250ML $122.00 MAGNES SULF IJ 40MG/ML 100ML $60.00 J3475 D5W INJ IN EXCELL BAG 250ML $154.00 DOPAMINE 40MG (400MG/250 ML PM $419.00 J1265 KCL 20MEQ IN 0.45% SOD CHL 1L $348.00 0.45% SOD CHLOR INJ 500ML $348.00 OXYTOCIN 20UNITS IN NS IJ 1L $325.00 DEXTROSE 70% INJ 1000 ML SOLN $210.00 LIDOCAINE 8MG/ML 250ML PMX IJ $419.00 J2001 DOPAMINE 3.2MG/ML250ML PMX IJ $23.00 J1265 DOBUTAMINE 2MG/ML 250ML PREMIX $419.00 J1250 NITROGLYCER 0.2MG/ML 250ML PMX $419.00 DILTIAZEM 1MG/ML 125ML PREMIX $329.00 NICARDIPINE 0.1MG/ML PMX 200ML $894.00 PLASMA-LYTE A INJ 1000ML $351.00 LR INJ 500ML EXCEL BAG $298.00 J7120 NS INJ 1000ML BAG COLD $298.00 J7030 MAGNESIUM SULF 40MG/ML 500ML $60.00 J3475 NS INJ 100ML RAD (BAXTER) $93.00 J7050 TROMETHAMINE (THAM) 500ML INJ $1,228.00 NOREPINEPHRINE 8MG/250ML PMX $329.00 PRISMASOL BGK 4/2.5 SOLN 5L $414.00 PRISMASOL BGK 2/3.5 SOLN 5L $414.00 PRISMASOL BGK 2/0 SOLN 5000ML $414.00 NS INJ IN EXCEL 500ML BAG $348.00 J7040 POTAS CHL IJ 40MEQ/250ML PMX $192.00 TPN-CLINIMIX-E20 2000 ML $2,684.00 NS INJ 150 ML BAG $103.00 J7050 INSULIN REG DRIP 100UNIT/NS100 $195.00 D10W 500 ML $348.00 CEFAZOLIN 500MG (3000MG) IVPB $99.00 J0690 VASOPRESSIN 1 UNIT/ML 100ML PM $1,187.00 CONIVAPTAN 1 MG(20MG/100ML)IJ $1,793.00 C9488 TPN-CLINIMIX (AA5%-D20W) 2L IV $2,434.00 IV CONTAINER BAG 500ML DISPOS $110.00 DEXTROSE 20% WATER 500ML $192.00 CARDIOPLEGIC SOLUTION 1000 ML $351.00 DEXAMETH SOD 1MG(12MG)/NS 50ML $30.00 J1100 EVAL PATIENT USE OF INHALER $382.00 94664 AIRWAY INHALATION TREATMENT $221.00 94640 OXYGEN DISPOSIBLE SUPPLY'S $216.00 INTUBATION, ET, EMERGENT $1,021.00 31500 CODE CALL $1,552.00 92950 MANIP CHEST WALL INIT/EVAL $232.00 94667 AIRWAY INHAL TRMT SPUTUM INDUC $380.00 94640 AEROSOL TRMT DISPOSABLE SUPPLY $306.00 PULSE OX CONTINUOUS MONITORING $767.00 94762 OXYGEN PER HR $2.00 PULSE OX, SGL $33.00 94760
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
VITAL CAPACITY TOTAL $305.00 94150 BRONCHODIALATION RESPONSIVENSS $743.00 94060 SPIROMETRY $420.00 94010 VENT ASSIST & MGMT 1 DAY $2,832.00 94002 VENT ASSIST & MGMT SUB $975.00 94003 CPAP OR BIPAP INIT & MGMT $1,069.00 94660 OXYGEN DAILY $210.00 CO EXPIRED GAS DETERMINE BY IR $623.00 94770 PATIENT ASSESSMENT EVALUATION $- MANIP CHEST WALL SUBSEQUENT $211.00 94668 METHACHOLINE CHALLENGE $915.00 94070 BLOOD GAS 02 $599.00 82803 BLOOD GAS $599.00 82803 BLOOD GAS VENOUS $599.00 82803 GASES BLOOD PH ONLY $154.00 82800 CARBOXYHEMOGLOBIN QUANT BLOOD $309.00 82375 ARTERIAL PUNCTURE BLOOD FOR DX $232.00 36600 CHLORIDE; BLOOD $172.00 82435 HEMOGLOBIN METHEMOGLOBIN $392.00 83050 CONT INHALATION TREAT 1ST HOUR $369.00 94644 PULSE OX, MULTIPLE $113.00 94761 POTASSIUM SERUM/PLASMA/W BLOOD $269.00 84132 SODIUM SERUM PLASMA/WHOLE BLD $199.00 84295 HEMOGLOBIN $122.00 85018 RESP MS THERAPY/1:1 PER 15 MIN $232.00 G0237 BRONCHOSPASM TEST EXER INDUCED $249.00 94617 BRONCHOSCOPE/LAVAGE DX $2,849.00 31624 BRONCHOSCOPY/WASH DX $2,849.00 31622 ARTERIAL LINE PLACEMENT $706.00 36620 PULM FUNCT TEST PLETHYSMOGRAP $204.00 94726 C0/MEMBANE DIFFUSE CAPACITY $419.00 94729 TRANSCUTANEOUS QUANT HGB $23.00 88738 SURFACTANT ADMIN THRU TUBE $120.00 94610 PULMONARY STRESS TEST/SIMPLE $256.00 94618 RESP FCN/STRENGH 2/> INDIV $86.00 G0239 RESP FCN THERAPY 1:1 PER 15MIN $157.00 G0238 PULMONARY REHAB W EXER PER 1HR $157.00 G0424 PULMONARY REHAB W EXER 1HR(KX) $157.00 G0424KX ELECTRICAL STIM UNATTENDED $88.00 G0283GP GAIT TRAINING EA 15 MIN $97.00 97116GP MASSAGE THERAPY EA 15 MIN $97.00 97124GP PARAFFIN BATH $72.00 97018GP ULTRASOUND EA 15 MIN $105.00 97035GP IONTOPHORESIS EA 15 MIN $105.00 97033GP PHYSICAL PERFORMANCE EA 15 MIN $105.00 97750GP VASOPNEUMATIC DEVICES $142.00 97016GP HOT PACK/COLD PACK THERAPY $34.00 97010GP NEUROMUSCULAR RE-EDU EA 15 MIN $121.00 97112GP CONTRAST BATHS EA 15 MIN $74.00 97034GP MANUAL THERAPY EA 15 MIN $111.00 97140GP ORTHOTIC MGMT INITIAL EA 15MIN $100.00 97760GP AQUATIC THERAPY W EX EA 15 MIN $121.00 97113GP SELF CARE/HOME MGMT EA 15 MIN $129.00 97535GP PROSTHETIC TRAIN INIT EA 15MIN $109.00 97761GP MECHANICAL TRACTION $74.00 97012GP ELECTRICAL STIM MAN EA 15MIN $95.00 97032GP TENS UNIT APPLICATION SURFACE $116.00 64550GP THERAPEUTIC ACTIVITY EA 15 MIN $105.00 97530GP THERAPEUTIC EXERCISE EA 15 MIN $105.00 97110GP WHEELCHAIR MGMT EA 15 MIN $105.00 97542GP SHOE SURGICAL SMALL $54.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SHOE SURGICAL MEDIUM $54.00 SHOE SURGICAL LARGE $54.00 STERILE WATER 30CC $13.00 SPLINT THUMB $111.00 WRIST BRACE $74.00 BRACE ANKLE (AIR GEL) $130.00 GROUP THERAPY (MIN 2 PEOPLE) $50.00 97150GP ORTHC/PROSTC MGMT SBSQ EA 15MN $95.00 97763GP PT/MOBILITY CURRENT STATUS $1.00 G8978GP PT/MOBILITY GOAL STATUS $1.00 G8979GP PT/MOBILITY D/C STATUS $1.00 G8980GP PT/BODY POS CURRENT STATUS $1.00 G8981GP PT/BODY POS GOAL STATUS $1.00 G8982GP PT/BODY POS D/C STATUS $1.00 G8983GP PT/CARRY CURRENT STATUS $1.00 G8984GP PT/CARRY GOAL STATUS $1.00 G8985GP PT/CARRY D/C STATUS $1.00 G8986GP PT/SELF CARE CURRENT STATUS $1.00 G8987GP PT/SELF CARE GOAL STATUS $1.00 G8988GP PT/SELF CARE D/C STATUS $1.00 G8989GP PT/SUB PT/OT CURRENT STATUS $1.00 G8993GP PT/SUB PT/OT GOAL STATUS $1.00 G8994GP PT/SUB PT/OT D/C STATUS $1.00 G8995GP NEUROPSYCH TST BY COMP W/REPRT $283.00 96120 PT EVAL LOW COMPLEX 20 MINUTES $162.00 97161GP PT EVAL MOD COMPLEX 30 MINUTES $243.00 97162GP PT EVAL HIGH COMPLEX 45 MINS $324.00 97163GP PT-RE-EVAL EST PLAN OF CARE $197.00 97164GP COGNITIVE THER INTRV PER VISIT $135.00 97127GP SPEECH/HEARING THERAPY, INDIV $308.00 92507GN SPEECH THERAPY GROUP 2 OR MORE $239.00 92508GN EVALUATE SWALLOWING FUNCTION $474.00 92610 TREATMENT OF SWALLOWING $308.00 92526GN EVAL FOR VOICE PROSTHETIC $489.00 92597GN THERAPEUTIC SP DEVICE SVC $307.00 92609GN ASSESSMENT OF APHASIA W/INTERP $287.00 96105 MOTION FLUORO SWALLOW FCN $219.00 92611GN EVAL FOR SPEECH DEVI RX 1ST HR $482.00 92607 DEVELOPMENTAL SCRN W/SCORE&TST $450.00 96110 COGNITIVE SKILLS DEVELOP 15MIN $135.00 97127GN COGNITIV THER W/FOC FNC EA VIS $135.00 97127GN SCREENING; PURETONE AIR ONLY $260.00 92551 SPEECH DEVICE EVAL ADDTL 30MIN $86.00 92608 FEES W CINE OR VIDEO $657.00 92612GN COGNITIVE PERFORM TEST PER HR $248.00 96125GN EVALUATION OF SPEECH FLUENCY $171.00 92521GN EVALUATION SPEECH PRODUCTION $139.00 92522GN EVAL SPEECH/SOUND/LANG COMPREH $288.00 92523GN BEHAVIORAL QUALIT ANALY VOICE $144.00 92524GN REMOVE IMPACT EAR WAX 1/BOTH $119.00 69210 BASIC VESTIBULAR EVALUATION $345.00 92540 SPONTANEOUS NYSTAGMUS TEST $219.00 92541 OPTOKINETIC NYSTAGMUS W RECORD $277.00 92544 OSCILLATING TRACKING W RECORD $277.00 92545 TYMPANOMETRY & REFLEX THRESH $277.00 92550 AUDIOMETRY PURETONE AIR $60.00 92552 AUDIOMETRY PURETONE BONE & AIR $277.00 92553 SPEECH AUDIOMETRY THRESHOLD $75.00 92555 SPEECH AUDIOMETRY W/RECOGNITIO $83.00 92556 COMPREHENSIVE AUDIOMETRY $221.00 92557 STENGER TEST, PURE TONE $98.00 92565
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TYMANOMETRY TESTING $70.00 92567 ACOUSTIC IMMITTANCE TESTING $185.00 92570 VISUAL REINFORCE AUDIOMETRY $177.00 92579 CONDITIONING PLAY AUDIOMETRY $177.00 92582 AUDITORY EP COMPREHENSIVE $700.00 92585 AUDITORY EP LIMITED $277.00 92586 EVOKED OTOACOUSTIC EMISS COMPL $508.00 92588 EVOKED OTOACOUSTIC EMIS LMT $514.00 92587 OFFICE VISIT BRIEF EST PATIENT $188.00 99211 CALORIC VESTIBULAR TEST W/REC $157.00 92537 CALORIC VESTIBULAR W/REC MONO $508.00 92538 HEARING AID;PHONAK AUDEO IX $3,533.00 V5257 HEARING AID;PHONAK AUDEO V $2,448.00 V5257 HEARING AID;PHONAK AUDEO III $1,595.00 V5257 HEARING AID;OTICON DUAL CON XW $3,294.00 V5257 HEARING AID;OTICON DUAL CON WV $2,209.00 V5257 HEARING AID;OTICON DUA MINI M9 $2,674.00 V5257 HEARING AID;OTICON DUA MINI M7 $2,054.00 V5257 HEARING AID;OTICON DUA MINI M5 $1,744.00 V5257 HEARING AID;EPOQ XW RITE/BTE $3,294.00 V5257 HEARING AID;EPOQ XW HS/LP/ITC $3,139.00 V5255 HEARING AID;EPOQ XW POWER RITE $3,449.00 V5257 HEARING AID;EPOQ W RITE/BTE $2,209.00 V5257 HEARING AID;EPOQ W PWR RITE/BT $2,364.00 V5257 HEAR AID;EPOQ HS/LP/ITC/CIC/MI $2,054.00 V5256 HEARING AID;VIGO CON PWR RT/BT $1,899.00 V5257 HEARING AID;VIGO CONN PRO PWR $2,054.00 V5257 HEARING AID;VIGO CP HS/LP/ITC $1,744.00 V5254 HEARING AID;VIGO CONN RITE/BTE $1,589.00 V5257 HEAR AID;VIGO CON PWR RITE/BIT $1,744.00 V5257 HEAR AID;VIGO CO HS/LP/ITC/MIC $1,434.00 V5254 HEARING AID;HIT PRO POWER BTE $1,512.00 V5257 HEARING AID;HIT PRO RITE/BTE $1,434.00 V5257 HEAR AID;HIT PRO HS/LP/ITC/CIC $1,357.00 V5254 HEAR AID;HIT RTE/BTE/HS/LP/ITC $1,124.00 V5257 HEARING AID;HIT POWER BTE $1,202.00 V5257 HEARING AID; GO PRO $1,047.00 V5257 HEARING AID; GO $954.00 V5257 HEAR SUPPLY;CONNECTLIN TV ADPT $233.00 V5267 HEAR SUPPLY;CONNECTL PHON ADPT $155.00 V5267 HEAR SUPPLY; STREAMER PRO $295.00 V5267 HEAR SUPPLY;STREAMER ANTENNA $9.00 V5267 HEAR SUPPLY;STREAMER POWER SUP $23.00 V5267 HEAR SUPPLY;CROS TRANSMITTER $1,083.00 V5267 HEAR SUPPLY;CROS RETENTION SET $16.00 V5267 HEAR SUPPLY;CROS TIP $54.00 V5267 HEAR SUPPLY;ICOM $386.00 V5267 HEAR SUPPLY;ICOM/TV BUNDLE $462.00 V5267 HEAR SUPPLY;MYPILOT REMOTE $581.00 V5267 HEAR SUPPLY;TV LINK TRANSMITTR $153.00 V5267 HEAR SUPPLY;KEYPILOT 2 $287.00 V5267 HEAR SUPPLY;WATCHPILOT 2 $543.00 V5267 HEAR SUPPLY;CONNECTLINE MICRPH $271.00 V5267 HEAR SUPPLY;OTICON RECEIVER $116.00 V5267 HEAR SUPPLY;POWER RECEIVER $116.00 V5267 HEAR SUPPLY;DOMES - 6,8,10 MM $5.00 V5267 HEAR SUPPLY;DOMES-PLUS $6.00 V5267 HEAR SUPPLY;DOMES-PWR 6,8,10MM $6.00 V5267 HEAR SUPPLY;MOLD FOR RECEIVER $47.00 V5264 HEARING SUPPLY;SOFT MOLD F/REC $62.00 V5264 HEAR SUPPLY;PWR MOLD F/PWR REC $78.00 V5264
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY HEAR SUPPLY;RESOUNDKINGMAN RECEIVER REGIONAL MEDICAL CENTER $116.00 CHARGE V5267MASTER FY19 HEAR SUPPLY;STARKEY RECEIVER $116.00 V5267 HEAR SUPPLY;PHONAK CSHELL $78.00 V5264 HEAR SUPPLY;PHONAK SLIMTIP $54.00 V5264 HEAR SUPPLY;DOMES - 10 PACK $12.00 V5267 HEAR SUPPLY;PHONAK WAX TRAPS $8.00 V5267 HEAR SUPPLY;PHONAK RECEIVER $78.00 V5267 HEAR SUPPLY;EASY PHONE $155.00 V5267 HEAR SVC;REMOTE BATTERY CHANGE $55.00 V5299 HEARING AID OFFICE VISIT $60.00 V5010 FIT OF HA PURCHASED EW>30MIN $60.00 V5011 HEARING AID REPAIR 6 MONTH FM $169.00 V5014 HEARING AID REPAIR 12 MONTH FM $189.00 V5014 HEAR AID REPAIR 6MO - REMOTES $110.00 V5014 HEAR AID REPAIR 12MO - REMOTES $120.00 V5014 HEAR AID REPAIR TRANSMIC 6MO $90.00 V5014 HEAR AID REP 6MO CLASSIC CROS $219.00 V5014 HEAR AID REP 6MO DIG/PROGRAM $229.00 V5014 HEAR AID REP 6MO FM 5YR POST I $189.00 V5014 HEAR AID REP 6M REMOTE 5Y POST $120.00 V5014 HEAR AID LOSS/DAMGE/EXT BF EXP $169.00 V5299 HEAR AID LOSS/DAM AF EXPIRATIO $179.00 V5299 HEAR AID REP REMAKE BTE PHONAK $69.00 V5014 HEAR AID REP RECASE ITE PHONAK $199.00 V5014 HEARING AID CLEAN AND CHECK $15.00 V5299 HEAR AID FIT/RESTOCK FEE $260.00 V5299 HEAR AID OUT OF WNTY 6MO REP $175.00 V5014 HEAR AID OUT OF WNTY 12MO REP $200.00 V5014 HEAR AID REPAIR; RESOUND <5YR $200.00 V5014 HEAR AID REPAIR;RESOUND >5YR $300.00 V5014 HEAR AID REP/RES LOSS/DAM/E 1Y $160.00 V5299 HEAR AID REP/RES LOSS/DAM/E 2Y $240.00 V5299 HEAR AID REP RECAS BTE STARKEY $60.00 V5014 HEAR AID REP 6M ANALOG STARKEY $120.00 V5014 HEAR AID REP 12M ANALG STARKEY $132.00 V5014 HEAR AID REP 6MO DIGIT PROGRAM $132.00 V5014 HEAR AID REP 12MO DIGIT PROG $190.00 V5014 HEAR AID (ALL) REPAIR 6MO ANAL $138.00 V5014 HEAR AID (ALL) REP 12MO ANALOG $150.00 V5014 HEAR AID EARMOLD;OTOBLAST W-1 $60.00 V5264 HEAR AID EARMOLD; F2,F2CRX,SF $49.00 V5264 HEAR AID EARMOLD;ALL ACRYLIC $45.00 V5264 HEAR AID EARMOLD;FIT TECH $56.00 V5264 HEAR AID EARMOLD;ALL ACRYLI 52 $64.00 V5264 HEAR AID EARMOLD;ACRY MP,UNI,O $60.00 V5264 HEAR AID EARMOLD;FIT TECH SIEM $74.00 V5264 HEAR AID EARMOLD;OTOBLAST CR $60.00 V5264 HEAR AID EARMOLD;ACRY HOLLOW C $71.00 V5264 HEAR AID SERVICE CONTRACT 1YR $265.00 V5299 HEAR AID; L/D DEDUCTIBLE $252.00 V5299 HEARING AID; SHIPPING FEE $20.00 V5299 HEARING AID;ALTA PRO ALL STYLE $3,604.00 V5261 HEARING AID; ALTA ALL STYLES $2,984.00 V5261 HEARING AID; BOLERO Q 90 $3,610.00 V5261 HEARING AID; BOLERO Q 70 $2,566.00 V5257 HEARING AID; BOLERO Q 50 $1,636.00 V5257 HEARING AID; VIRTO Q 90 $3,610.00 V5257 HEARING AID; VIRTO Q 70 $2,566.00 V5257 HEARING AID; VIRTO Q 50 $1,636.00 V5257 HEARING SUPPLY;COMPILOT $386.00 V5267 HEARING AID EARMOLD; 4RT $52.00 V5264
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HEARING AID EARMOLD; 39 $68.00 V5264 HEARING AID EARMOLD; 40 $54.00 V5264 HEARING AID EARMOLD; 42 $65.00 V5264 HEARING AID EARMOLD; 47 $65.00 V5264 HEARING AID EARMOLD; 49 $82.00 V5264 HEARING AID EARMOLD; 70 AQ $76.00 V5264 HEARING AID EARMOLD; AQUANOT $53.00 V5264 HEARING AID L/D EXTENS 2ND YR $39.00 V5299 HEARING AID REPAIR EXTENSION $116.00 V5299 HEARING AID L/D/R EXTENSION $140.00 V5299 HEARING AID;NERA PRO (ALL) $1,984.00 V5261 HEARING AID; NERA (ALL STYLES) $1,674.00 V5261 HEARING AID; RIA PRO (ALL) $1,481.00 V5261 HEARING AID; RIA (ALL STYLES) $1,171.00 V5261 HEARING AID REPAIR 6MO STARKEY $280.00 V5014 HEARING AID REP 12MO STARKEY $300.00 V5014 HEARING AID AFTER CARE PROGRAM $80.00 V5299 HEARING AID; AUDEO B90-R $4,028.00 V5257 HEARING AID; AUDEO B90 $3,569.00 V5257 HEARING AID; AUDEO B70-R $2,694.00 V5257 HEARING AID; AUDEO B70 $2,297.00 V5257 HEARING AID; AUDEO B50-R $1,911.00 V5257 HEARING AID; AUDEO B50 $1,529.00 V5257 HEARING AID; AUDEO B30 $1,341.00 V5257 HEARING AID; BOLERO B90 $3,569.00 V5257 HEARING AID; BOLERO B70 $2,297.00 V5257 HEARING AID; BOLERO B50 $1,529.00 V5257 HEARING AID; BOLERO B30 $1,341.00 V5257 HEARING AID; VIRTO V90 $3,569.00 V5257 HEARING AID; VIRTO V70 $2,297.00 V5257 HEARING AID; VIRTO V50 $1,529.00 V5257 HEARING AID; VIRTO V30 $1,341.00 V5257 HEARING AID; DYNAMO SP10 $3,559.00 V5257 HEARING AID; DYNAMO SP 8 $2,794.00 V5257 HEARING AID; DYNAMO SP 6 $1,978.00 V5257 HEARING AID; DYNAMO SP 4 $1,468.00 V5257 HEARING AID; OPN1 (ALL STYLES) $3,559.00 V5257 HEARING AID; OPN2 (ALL STYLES) $2,794.00 V5257 HEARING AID; OPN3 (ALL STYLES) $2,029.00 V5257 HEAR SUPPL;CROS II TRANSMITTER $1,337.00 V5267 HEAR SUPPLY;REMOTE MIC $252.00 V5267 HEAR SUPPLY;CHARGER CASE $125.00 V5267 HEAR SUPPLY;MINI CHARGER $74.00 V5267 HEAR SUPP;ROGER INSPIRO LAPMIC $1,880.00 V5267 HEAR SUPPLY;ROGER CLIP ON MIC $1,224.00 V5267 HEAR SUPPPLY;ROGER TOUCHSCR MI $1,903.00 V5267 HEAR SUPPLY;COMPILOT II $635.00 V5267 HEAR SUPPLY;COMPILOT AIR II $635.00 V5267 HEAR SUPPLY;COMPILOT AIR TV II $711.00 V5267 HEAR SUPP;COMPILOT AIRII W/MIC $762.00 V5267 HEAR SUPPLY;TV LINK II $- V5267 HEAR SUPPLY;WAX GUARD $10.00 V5264 HEAR SERVIC;EARMOLD IMPRESSION $30.00 V5275 BASIC VESTIBULAR EVAL PRO FEE $238.00 9254026 SPONTANEOUS NYSTAGMUS TEST PF $71.00 9254126 POSITIONAL NYSTAGMUS TEST 4>PF $51.00 9254226 OPTOKINETIC NYSTAGMUS W/REC PF $44.00 9254426 OSCILLATING TRACK TEST PRO FEE $40.00 9254526 SINUSOIDAL VERT AXIS ROTATE PF $31.00 9254626 COMPUTER DYN POSTUROGRAPH PF $77.00 9254826 COMPREHENSIVE AUDIOMETRY PF $48.00 92557
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TYMANOMETRY PRO FEE $15.00 92567 ACOUSTIC REFLEX TEST PRO FEE $50.00 9256826 ACOUSTIC IMMITTANCE TEST PF $35.00 9257026 VISUAL REINFORCE AUDIOMETRY PF $50.00 92579 AUDITORY EP COMPREHENSIVE PF $81.00 9258526 EVOKED OTOACOUSTIC EMIS LMT PF $55.00 9258726 EVOKED OTOACOUSTIC COMPLETE PF $45.00 9258826 CALORIC VESTIBULAR TEST BI PF $24.00 92537 CALORIC VESTIBULAR TEST W/R PF $24.00 92538 ER ROOM LEVEL 4 $558.00 99282 ER ROOM LEVEL 3 $1,120.00 99283 ER ROOM LEVEL 2 $1,426.00 99284 ER ROOM LEVEL 1 $1,957.00 99285 MED PICK-UP $324.00 99203 TRIAGE / LEVEL 1 VISIT $192.00 99281 TREATMENT NOSE FRACT W0 MANIP $472.00 21310 EXC BLES S/N/EX G 1.1-2.0CM $2,919.00 11422 ER ROOM CRITICAL CARE 30-74MIN $4,213.00 99291 I & D ABSC; SMPL OR SGL W/PUS $522.00 10060 FB REMOV SQ SIMPLE $691.00 10120 FB REMOV SQ COMPLEX $3,878.00 10121 I&D HEMATOMA SINGLE $3,967.00 10140 I&D SUBUNGUAL HEMATOMA $3,967.00 10140 DEB SUBQ TISSUE 20 SQ CM/< $823.00 11042 REMOV SKIN TAGS TO&INCL 15 LES $369.00 11200 REMOV SKIN TAGS EA ADD 10 LES $247.00 11201 AVULS NAIL PLATE PART/CMP SNGL $431.00 11730 AVULS NAIL PLATE P/C EA ADDTL $173.00 11732 EVACUATION SUBUNGUAL HEMATOMA $181.00 11740 EXC NAIL PART/PERM REMOV $894.00 11750 SIMPLE REP 2.5/LESS S/N/G/TR/E $713.00 12001 SIMPL REP 2.6-7.5 S/N/A/G/TR/E $860.00 12002 SIMPL REP 7.6-12.5 S/N/A/G/T/E $1,153.00 12004 SIMP REP 12.6-20.0 S/N/A/G/T/E $1,215.00 12005 SIMP REP 20.1-30.0 S/N/A/G/T/E $1,473.00 12006 SIMPLE REP >30.0 S/N/A/G/TR/E $1,304.00 12007 SIMPLE REP 2.5CM/< F/E/N/L/MM $929.00 12011 SIMPLE REPR 2.6-5.0 F/E/N/L/MM $1,089.00 12013 SIMPLE REPR 5.1-7.5 F/E/N/L/MM $1,153.00 12014 SIMPLE REP 7.6-12.5 F/E/N/L/MM $1,409.00 12015 SIMPL REP 12.6-20.0 F/E/N/L/MM $2,047.00 12016 SIMPL REP 12.6-20.0 F/E/N/L/MM $2,561.00 12017 LYR CLS S/A/T/EXT 2.5CM LESS $795.00 12031 LYR CLS S/A/T/EXT 2.6-7.5CM $1,029.00 12032 LYR CLS S/AX/TR/EXT 7.6-12.5CM $997.00 12034 LYR CLS S/A/T/EXT 12.6-20.0CM $1,354.00 12035 LYR CLS S/A/T/EXT 20.1-30.0CM $1,643.00 12036 LYR CLS S/A/T/EXT >30.0CM $5,912.00 12037 LYR CLS NCK/HND/FT/GEN =<2.5CM $822.00 12041 LYR CLS N/H/F/EXT 2.6-7.5CM $1,000.00 12042 LYR CLS N/H/F/EXT 7.6-12.5CM $1,444.00 12044 LYR CLS N/H/F/EXT 12.6-20.0CM $1,511.00 12045 LYR CLS N/H/F/EXT 20.1-30.0CM $1,954.00 12046 LYR CLS NCK/HND/FT/GEN >30.0CM $3,371.00 12047 LYR CLS F/E/E/N/L/MM =<2.5CM $977.00 12051 LYR CLS F/E/E/N/L/MM 2.6-5.0CM $1,111.00 12052 LYR CLS F/E/E/N/L/MM 5.1-7.5CM $1,288.00 12053 LYR CLS F/E/E/N/MM 7.6-12.5CM $1,601.00 12054 LYR CLS F/E/E/N/MM 2.6-20.0CM $2,131.00 12055 LYR CLS F/E/E/N/MM 20.1-30.0CM $2,488.00 12056 REPR COMPLX TRUNK 1.1-2.5CM $1,069.00 13100
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
REPR COMPLX TRUNK 2.6-7.5CM $1,312.00 13101 REPR COMPLX SC/AR/LG 1.1-2.5CM $1,091.00 13120 REPR COMPLX SC/AR/LG 2.6-7.5CM $1,776.00 13121 REPR COMPLX F/G/H/F 1.1-2.5CM $1,091.00 13131 REPR COMPLX F/G/H/F 2.6-7.5CM $2,627.00 13132 REPR COMPLEX E/N/E/L 1.1-2.5CM $1,360.00 13151 REPR COMPLEX E/N/E/L 2.6-7.5CM $3,323.00 13152 REPR CMPLX E/N/E/L EA ADD 5CM< $1,065.00 13153 BURN INITIAL 1ST DEG $352.00 16000 SM DSG/DEBRID P-THICK BURNS $419.00 16020 MED DSG/DEBRID P-THICK BURN $664.00 16025 LRG DSG/DEBRID PART THICK BURN $787.00 16030 INJ SGL TENDON SHEATH/LIGAMENT $569.00 20550 DRAIN/INJ SM JNT/BURSA WO US $791.00 20600 ARTHRO/ASP/INJ ITM JT/BR WO US $569.00 20605 ARTHRO/ASP/IJ MAJ JNT/BR WO US $569.00 20610 DISLOCATION JAW W REDUC $669.00 21480 DISLOC CLAVACLE W/O MANIPU $1,278.00 23540 DISLOC SHLDER W/MANIP WO ANES $1,496.00 23650 FRACT HUMERAL SHAFT W/O MANIP $1,980.00 24500 FRACT HUMERAL SHAFT W/MANIP $3,021.00 24505 DISLOC ELBOW W REDUC W ANES $3,074.00 24605 FRACT RADIAL & ULNAR WO MANIP $1,489.00 25560 FRACT RADIAL & ULNAR W/MANIP $2,976.00 25565 FRACT METACARPAL W MANIP $1,770.00 26605 FRACT PHALANG W/MAN W/WO TRACT $1,770.00 26725 FRACT DIST PHALANGEAL W MANIP $1,197.00 26755 DISLOC FINGER W MANIP W/O ANES $1,197.00 26770 DISLOC HIP ARTHROPLASTY WO ANE $2,525.00 27265 DISLOC HIP ARTHROPLASTY W ANES $4,141.00 27266 DISLOC KNEE W ANES $2,162.00 27552 DISLOC ANKLE W REDUC W/O ANES $1,857.00 27840 FRACT GREAT TOE W MANIP $854.00 28495 FRAC PHALANX OTHER W MANIP $981.00 28515 TOE DISLOC REDUCTION $981.00 28515 SPLINT-LONG ARM $513.00 29105 APPLY SPLINT-SHORT ARM $438.00 29125 SPLINT-FINGER-STATIC $293.00 29130 SPLINT-FINGER-DYNAMIC $409.00 29131 STRAPPING SHOULDER $293.00 29240 SPLINT-LONG LEG $499.00 29505 SPLINT-SHORT LEG $325.00 29515 BIVALVE, CAST $521.00 29700 FB REMOVAL NOSE $293.00 30300 CONTRL NASAL HEMORR-ANT-SMP $467.00 30901 CONTROL NASAL HEMMORR-CAUTERY $467.00 30901 CONTROL NASAL HEMMORR-ANT-CMPL $693.00 30903 CONTROL NASAL HEMORR-POST-INIT $1,004.00 30905 CONTROL NASAL HEMORR-POST-SUBQ $943.00 30906 INTUBATION ET EMERGENT $1,256.00 31500 LARYNGOSCOPY INDIR $383.00 31505 LARYNGOSCOPY INDIR FB REMOVAL $1,197.00 31511 LARYNGOSCOPY DIRECT $4,672.00 31515 CRICOTHYROID TRACH $1,712.00 31605 TUBE THORACOSTOMY W/CONN OPEN $2,050.00 32551 PERICARDIOCENTESIS $2,050.00 33010 INSERT TEMP PACEMAKER $15,370.00 33210 VENIPUNCT <3 YR $137.00 36400 VENIPUNCT >3 YR $104.00 36410 VENIPUNCT CUTDOWN <1 YR $309.00 36420 VENIPUNCT CUTDOWN 1 OR OVER $239.00 36425
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INS NON-TUNNEL CV CATH < 5YRS $2,543.00 36555 ARTERIAL PUNCTURE $322.00 36600 ARTERIAL LINE PLACEMENT $748.00 36620 INTRAOSSEOUS NEEDLE $854.00 36680 IV INFUS THROMBOLYSIS CEREBRAL $2,012.00 37195 LARYNGOSCOPY FLEX W/FB REMOVAL $1,675.00 31577 I&D RECTAL ABSCESS $4,253.00 46040 INCS THROMB HEM EXT $745.00 46083 ANOSCOPY DIAG INCL COLL SPECIM $352.00 46600 PERITONEAL LAVAGE $1,652.00 49084 DRAIN BLADDER W/CATH INSERTION $3,536.00 51102 I&D BARTHOLIN'S GLAND $674.00 56420 INTRO HEMO AGENT/PK VAG HEMORR $860.00 57180 VAGINAL DELIVERY $5,503.00 59409 LUMBAR PUNCTURE $1,488.00 62270 INJ ANESTH INTERCOST NERVE SGL $1,746.00 64420 INJ NERVE BLOCK $1,198.00 64450 FB REMOVAL CONJUNCTIVAL $399.00 65210 REMOVE FB EYE CORNEL W/SLIT LA $593.00 65222 FB REMOVAL EAR $617.00 69200 REMOVE IMPACT EAR WAX 1/BOTH $201.00 69210 GASTRIC LAVAGE $870.00 43753 CPR $920.00 92950 EXT PACEMAKER PLACMT $1,295.00 92953 CARDIOVERSION EMERGENCY $1,614.00 92960 IV INFUS THROMBOLYSIS CORON $1,426.00 92977 INSRT/PLCMT FLO DIR CATH-MONIT $3,969.00 93503 DEBRIDEMENT-SELECTIVE <20SQ CM $704.00 97597 REMOV WND TISS NON-SELECT $403.00 97602 FB BODY REMOVAL EYE $369.00 65205 INS NON-TUNNEL CV CATH 5 YRS> $2,193.00 36556 MOD CS BY SAME PHYS, <5 YRS $451.00 99151 MOD CS BY SAME PHYS,5 YRS + $525.00 99152 IV INFUSION THERAPY,INIT =<1HR $657.00 96365 THER/PROPH/DIA ADDL SEQ IV INF $174.00 96366 EPIDURAL BLOOD PATCH $2,007.00 62273 TREAT FRACTURE RADIUS/ULNA $2,789.00 25605 CL TX TRIMALL ANKLE FX;W MANIP $3,423.00 27818 CL TX TRIMALL ANKLE FX WO MAN $1,664.00 27816 TREATMENT TIBIA FRACT WO MANIP $1,857.00 27750 TREATMENT FIBULA FRAC WO MANIP $1,502.00 27780 NASOPHARYNGOSCOPY W ENDOSCOPE $346.00 92511 I&D ABSCESS; COMPL OR MULTIPLE $798.00 10061 CL TX HIP DISLOC W ANESTH $4,141.00 27252 OSTEOPATHIC MANIP 1-2 REGIONS $137.00 98925 I&D PILONIDIAL CYST; SMPL $1,272.00 10080 I&D; PERIANAL ABSCESS $1,576.00 46050 DRAIN FINGER ABSC; SIMPLE $691.00 26010 TREAT SHOULDER DISL W/ANESTH $2,787.00 23655 COMPLEX REP S/A/L;EA ADD 5CM/< $622.00 13122 BLEPHAROTOMY DRAIN ABSC EYELID $1,017.00 67700 TREAT ELBOW CHILD W/MANIP $604.00 24640 DELIVER PLACENTA $4,923.00 59414 PUNCTURE ASP OF ABSCESS/HEMA $691.00 10160 REPAIR TONGUE LACERAT <2.5CM $491.00 41250 DEBRIDEMENT WO FX;SKIN & SUBCU $2,395.00 11010 TREATMENT TIBIA FRACT W/MANIP $4,042.00 27752 BRONCHOSCOPY W/FB REMOVAL $2,760.00 31635 TELEHEALTH ORIGIN FACILITY FEE $103.00 Q3014 ASPIRATE/INJ GANGLION CYST $568.00 20612 CLSD TREATMENT OF ANKLE FRACT $2,815.00 27810
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DR ABSC HEMATOM-DENTOALVEOLAR $569.00 41800 REMOVAL OF IUD $568.00 58301 TREAT FRACTURE RADIUS W/MANIP $2,789.00 25505 CLSD TRMT DISTAL FIB FRAC W/M $1,607.00 27788 CL TX MCP DISLOC SGL W MANIP $800.00 26700 DRAIN EXT EAR,ABSC/HEMA SIMPL $1,272.00 69000 LARYNGOSCOPY FLEX;DIAGNOSTIC $716.00 31575 TRAUMA RESPONS W/HOSP CRITICAL $6,106.00 G0390 I&D ABSCESS; PERITONSILLAR $1,067.00 42700 REMOVE FB EXT EYE WO SLIT LAMP $440.00 65220 COMP REP H/A/G/EXTR;ADD 5 CM/< $832.00 13133 CHANGE CYSTOSTOMY TUBE SIMPLE $1,179.00 51705 OSTEOPATHIC MANIP 3-4 REGIONS $165.00 98926 TREATMENT ELBOW DISLOC WO ANES $645.00 24600 DEB SUBQ TISSUE ADDON =<20SQCM $1,068.00 11045 INJ ANESTH; FACIAL NERVE $1,029.00 64402 IMMUN ADMIN 1ST VAC/TOX <18 $78.00 90460 IMMUNE ADMIN ADDL VAC/TOX <18 $38.00 90461 DIAGNOSTIC LARYNGOSCOPY NO NBN $4,674.00 31525 THER/PROPH/DIAG INJ SC/IM $180.00 96372 CLOSES TX PATELLAR DISL WO ANE $495.00 27560 I & D VULVA/PERINEUM $651.00 56405 TRACHEOBRONCH THRU OLD TRACH I $2,108.00 31615 CHANGE OF WINDPIPE AIRWAY $477.00 31502 CHANGE GASTROSTOMY TUBE $783.00 43760 REPAIR LIP FT >1/2 VERTIC HGHT $1,044.00 40652 EGD REMOVAL OF FOREIGN BODY $2,738.00 43247 INJ(S);SGL OR MULT TP 1 OR 2 $580.00 20552 TREAT TOE DISLOCATION WO ANEST $472.00 28660 CL TX MTP JNT DISLOC; WO ANES $519.00 28630 REMOVAL FOREIGN BODY SUBQ FOOT $2,395.00 28190 DRAINAGE OF SCROTUM ABSCESS $3,459.00 55100 UGI DIAGNOSTIC $2,954.00 43235 ENDOSCOPIC US EXAM ESOPH $2,784.00 43237 DR ABSC CYST HEMAT-MOUTH SMPL $1,272.00 40800 I & D UPPER ARM OR ELBOW;BURSA $5,376.00 23931 APPLICATION OF LONG ARM CAST $677.00 29065 CL TX CMC FX DISLOC THUMB W/MA $2,815.00 26645 RECONSTRUCTION OF NAIL BED $1,091.00 11760 FIT OR INSERT PESSARY $572.00 57160 CL TX ARTFX MCP/IP JNT W MANIP $2,815.00 26742 PARACENTESIS ABD DIA/THER W/IMAGING $1,651.00 49083 DRAINAGE ABSCESS PALATE UVULA $903.00 42000 HYDRATION IV INF INIT;31-60MIN $570.00 96360 HYDRATE IV INFUSION,ADD-ON 1HR $181.00 96361 REMO EMBED FB MOUTH VESTI;SMPL $363.00 40804 PERITONECENTESIS ABD WO IMAGE $1,652.00 49082 ATT F/C/M/N/A/G/H/F;>10 SQ CM $5,009.00 14040 BIOPSY SALIVARY GLAND;INCISION $6,024.00 42405 AMPUTATE FIN/TH SGL;W DIR CLSE $4,158.00 26951 TREAT THUMB DISLOCATION $472.00 26641 EXCISI BEN LES T/A/L;1.1-2.0CM $1,338.00 11402 THER/PRO/DIAG INJ IV PUSH INIT $424.00 96374 CL TX METATARSAL FX; W MANIP $472.00 28475 TX/PRO/DX INJ NEW DRUG ADD-ON $230.00 96375 TX/PRO/DX INJ SAME DRUG ADD-ON $70.00 96376 TX/PROPH/DG ADDL SEQ IVINF>1HR $187.00 96367 THER/DIAG CONCURRENT INFUSION $181.00 96368 THORACOTOMY; W/CARDIAC MASSAGE $3,969.00 32160 DRAIN FINGER ABSC; COMPLICATED $3,177.00 26011 THORACENTESIS W/O IMAGING $1,615.00 32554
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CRITICAL CARE ADDL 30 MIN $1,700.00 99292 ADMIN VACCINES/TOXOIDS,SINGLE $99.00 90471 ADMIN VACCINE/TOXOID, EA ADDL $59.00 90472 DILATE URETH STRICT SOUND;MALE $804.00 53600 CLOSED TX KNEE DISL; WO ANESTH $472.00 27550 REP BLD VESSEL DIRECT;LWR EXTR $2,523.00 35226 REP ET HAND; WO FG EA TENDON $4,099.00 26410 REMOVAL OF SUPPORT IMPLANT $4,847.00 20670 INS TUNNEL CVAD 2X WO SUB PORT $8,310.00 36565 DRAIN EXT EAR ABSC/HEMAT;COMPL $2,579.00 69005 CL TRMT FRACT GREAT TOE WO MAN $472.00 28490 TREAT RADIUS FRACTURE W/MANIP $2,789.00 24655 CL TX SC/TX HUMERUS FX W/MANIP $2,815.00 24535 EXC BEN LES T/A/L; 0.6-1.0CM $1,223.00 11401 TREAT METACARP FX SGL;WO/MANIP $472.00 26600 CL TX DSTL RADIOULNAR DIS W/MA $604.00 25675 CL TX PHAL SHAFT FX WO MANIP $472.00 26720 CLTX DSTL RAD FX/EPIP SEP WO/M $604.00 25600 CL TX ULNAR SHAFT FX; WO MANIP $472.00 25530 DEEP FB REM - FOREARM/WRIST $5,378.00 25248 INSERT CATH PLEURA W/O IMAGE $3,073.00 32556 CL TX DISTAL FIB FX WO MANIP $472.00 27786 PARING/CUT BENIGN LESION SGL $298.00 11055 CL TX FEMORAL SHAFT FX W MANIP $2,888.00 27502 TREAT CLAVICLE DISLOC W/MANIP $1,380.00 23545 REM EMB FB DENTOALV;SFT TISSUE $6,223.00 41805 FEMORAL N BLOCK, SGL $1,488.00 64447 CL TREAT CLAVICLE FX W/MANIP $2,888.00 23505 CLOSED TX ULNAR FX PROXIMAL WM $2,815.00 24675 CLSD TX TRAUMA HIP DICLOC WO/A $590.00 27250 REP LAC/TONGUE/FM >2.6/CPLX $1,855.00 41252 CL TX CMC DISLOCATION W/MAN EA $604.00 26670 REMOVE EMBEDDED FB EYELID $634.00 67938 LARYNGOSCOPY W/FB REMOVAL $3,643.00 31530 INJ ANESTH;TRIGEMINAL NRV ANY $569.00 64400 CLOSED TX ULNAR STYLOID FRACT $604.00 25650 INJ ANESTH; GRTR OCCIPITAL NRV $586.00 64405 CLOSED TX MED ANKLE FX W/MNPJ $3,751.00 27762 INSERT PICC W/O PORT >5 YRS $3,815.00 36569 COMPLEX REP TRNK;EA ADDL 5CM/< $823.00 13102 DEBRID EXZ/INF SKIN; 10% BS $1,091.00 11000 CLTX RDCRPL/INTCARP DISL 1+W/M $603.00 25660 CL TX SHLDR DISLOC&FX GT;W/MAN $2,815.00 23665 DRAIN PILONDAL CYST COMPLICATE $2,530.00 10081 DRAIN/ASP/INJ JOINT/BURSA W/US $2,489.00 20604 DRAIN/INJ INTER JNT/BURSA W/US $2,662.00 20606 DRAIN/INJ MAJOR JNT/BURSA W/US $3,604.00 20611 ANOSCOPY DIAG INCL COLLECTION $394.00 46601 ANOSCOPY DIAG HRA W/BIOPSY $2,481.00 46607 INJ(S);SGL/MULT TRIGGER PT 3/> $569.00 20553 ADMIN FLU VIRUS VACCINE $72.00 G0008 DEBRIDEMENT OF NAILS 1-5 $301.00 11720 EXC BENIGN L S/N/EX G; 0.5CM/< $2,579.00 11420 DRAIN EXT AUDITORY CANAL ABSC $1,272.00 69020 TX SUPERFICIAL WND SMPL CLOSE $1,184.00 12020 ADJ GASTR BAND DIAM VIA INJ/AS $2,050.00 43999 CANTHOTOMY $4,224.00 67715 REMOVAL DEEP FB OF FOOT $3,691.00 28192 CL TX WB DSTL TIBIA W/MANIP $3,664.00 27825 CL LACERAT MOUTH VEST;2.5CM/< $1,015.00 40830 TRACHEOSTOMY EMERG;TRANSTRACHL $2,452.00 31603
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
REM IMPACT CERUMEN IRRI/LV UNI $157.00 69209 IRRIGATE CORPOR CAVERNOS PRIAP $597.00 54220 DX BRONCHOSCOPE W/WASH $2,849.00 31622 EXC TR-EXT B9+MARG 0.5CM/< $1,339.00 11400 INSERT NON-DWELL BLADDER CATH $256.00 51701 I & D UA/ELBOW DEEP ABSCESS $3,597.00 23930 INSERT TEMP URINARY CATH SMPLE $256.00 51702 CHEM CAUT GRANULATION TISSUE $662.00 17250 SHAVE LES S/N/H/F/G 0.6-1.0CM $329.00 11306 REMOVAL FB IN MUSCLE SIMPLE $2,631.00 20520 I & D FOREARM/WRIST;DEEP ABCSS $3,701.00 25028 MONITOR INTERST FLUID PRESSURE $1,272.00 20950 CLOSED TX PATELLAR FX WO MANIP $472.00 27520 ANOSCOPY;REMOVE FOREIGN BODY $1,914.00 46608 REMOVAL OF HEMORRHOID CLOT $4,226.00 46320 FINE NEEDLE ASPIRATE W/O IMAGE $691.00 10021 MOD SED OTH PHY/QHP 5>ADDL 15M $525.00 99157 MOD SED OTH PHYS/QHP 5> <15MIN $525.00 99156 MOD SED OTHER PHYS/QHP <5 <15M $525.00 99155 FORESKIN MANIP INCLUDING LYSIS $551.00 54450 TRMT NOSE BONE FX WO STABILIZ $2,452.00 21315 DECLOT VASCULAR DEVICE $947.00 36593 DEBRIDE SKIN TO BONE 20SQ CM/< $2,919.00 11044 MOD SED SAME PHY/QHP ADDL 15M $81.00 99153 REM FB FROM UA/ELBOW DEEP $5,479.00 24201 EXCIS FACE-MM B9+MARG 0.6-1CM $1,272.00 11441 UNLISTED PROCEDURE ESOPHAGUS $1,651.00 43499 BRONCHOSCOPE DX W/LAVAGE $2,849.00 31624 CL TX SHDR DISLOC W NK FX W/MA $2,874.00 23675 CL TX GR TUBEROSITY FX;W/MANIP $2,874.00 23625 CL TX CARPL SCAPHOID FX W/MANP $2,874.00 25624 CL TX PROX HUMERAL FX; W MANIP $2,874.00 23605 REMOVE SPINE ELTRD PERQ ARAY $3,627.00 63661 CARDIAC REHAB THER W/MONITOR $260.00 93798 CHEMO IV INFUSION 1ST HOUR $1,339.00 96413 CHEMO IV INFUSION ADDL HR $329.00 96415 THER/PROPH/DIA INJ SC/IM $188.00 96372 ROUTINE VENIPUNCTURE $26.00 36415 IV INFUSION THERAPY INIT =<1HR $787.00 96365 TRANSFUSION BLOOD PROD PER DAY $1,118.00 36430 PHLEBOTOMY THERAPEUTIC $400.00 99195 OFFICE VISIT BRIEF EST PATIENT $319.00 99211 DECLOT VASCULAR DEVICE $947.00 36593 DRAW BLOOD OFF VENOUS DEVICE $253.00 36591 THER/PROPH/DIA ADDL SEQ IV INF $192.00 96366 HYDRATE IV INFUSION,ADD-ON 1HR $172.00 96361 HYDRATION IV INF INIT;31-60MIN $537.00 96360 IRRIG DRUG DELIVERY DEVICE $300.00 96523 PROLONGED IV INF REQ PUMP>8HRS $1,146.00 C8957 REFILL/MAINT PORTABLE PUMP $468.00 96521 THER/DIAG CONCURRENT INFUSION $181.00 96368 TX/PROPH/DG ADDL SEQ IV INF $187.00 96367 TX/PRO/DX INJ NEW DRUG ADDON $230.00 96375 TX/PRO/DX INJ SAME DRUG ADDON $70.00 96376 COLLECT BLOOD FROM PICC $232.00 36592 THER/PROPH/DIAG INJ, IV PUSH $424.00 96374 APPL ON-BODY INJECT TIMED SUBQ $188.00 96377 OFFICE VISIT MODERAT NEW PT PF $265.00 99203 OFFICE VISIT MOD/HIG NEW PT PF $449.00 99204 OFFICE VISIT HIGH NEW PT $576.00 99205 OFFICE VISIT BRIEF EST PATI PF $82.00 99211
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
OFFICE VISIT MINOR ESTAB PT PF $153.00 99212 OFFICE VISIT LOW/MOD EST PT PF $255.00 99213 OFFICE VISIT MOD/HIG EST PT PF $376.00 99214 OFFICE VISIT HIGH ESTAB PT PF $379.00 99215 CONSULTS MODERATE $445.00 99243 CONSULTS MOD TO HIGH $581.00 99244 OFFICE CONSULTS HIGH $624.00 99245 HOSP CONSULT INPATIENT FOCUSED $216.00 99251 HOSP CONSULT INPATIENT DETAILL $367.00 99253 HOSP CONSULT, IP COMPREHENSIVE $505.00 99254 HOSP CONSULT INPATIENT COMPLEX $620.00 99255 INITIAL HOSP ADMIT LOW COMP PF $349.00 99221 INITIAL HOSP ADMIT MOD COMP PF $471.00 99222 INITIAL HOSP CARE COMPL 70M PF $691.00 99223 F/U HOSP VISIT, FOCUSED $135.00 99231 F/U HOSP VISIT EXPANDED $246.00 99232 F/U HOSP VISIT DETAILED $354.00 99233 HOSP INIT OBSERV MOD COMP PF $459.00 99219 HOSP INIT OBSERV HIGH COMP PF $630.00 99220 HOSP OBSERV SUBSQ P/D HIGH COM $357.00 99226 INS IA PERC BALLOON $5,597.00 33967 INSERT AAI PACEMAKER ATRIAL $20,326.00 33206 PERICARDIOCENTESIS;INITIAL $2,395.00 33010 ABORTED PROCEDURE $4,993.00 CARDIOVERSION CARDIAC CATH LAB $2,606.00 92960 BALLOON PTCA NON-COMPLIANT $11,821.00 C1725 CATHETER BALLOON BANDIT $10,291.00 C1725 VASCULAR CLOSURE DEVICE $3,060.00 C1760 AORTOGRAM ABD W/BILAT RUNOFF $8,124.00 75630 KIT ANGIOPLASTY INFLATE DEVICE $1,939.00 CATHETER TRANSLUMINAL NONLASER $2,141.00 C1887 PAR-VENOUS BIP TEMP PACE LEAD $1,776.00 GUIDE WIRE WHOLEY EXTENSION $949.00 C1769 CATHETER GUIDE RENAL $2,048.00 C1887 STENT COATED/COV/W DEL SYS $7,876.00 C1874 BALLOON PTA RENAL $4,902.00 C1725 EXTREMITY ANGIO-BILAT $7,321.00 75716 EXTREMITY ANGIO-UNIL $7,010.00 75710 ANGIOGRAM INTERNAL MAMMARY $6,915.00 75756 ANGIOGRAM SELECT EA ADD VESSEL $3,203.00 75774 VISCERAL ANGIOGRAM $8,893.00 75726 AORTOGRAM THORACIC SERIAL $8,893.00 75605 VENA CAVA FILTER $14,139.00 C1880 VENOGRAM RENAL BILAT SELECT $5,198.00 75833 VENOGRAM EXT UNILATERAL $2,292.00 75820 VENOGRAM, IVC SERIALOGRAPHY $5,288.00 75825 VENOGRAM, SVC SERIALOGRAPHY $5,288.00 75827 NONSELECTIVE CATH PLMT IN VEIN $135.00 36000 INS/REPL PACEMAKER;ATRIAL/VENT $45,576.00 33208 PACEMAKER DUAL CHAMBER RR $22,544.00 C1785 NONSELEC CATH SUP/INF VENA CAV $1,032.00 36010 NS CATH-EXTREMITY ARTERY $854.00 36140 INSERT 2 ELECTRODE PM-DEFIB $15,370.00 33217 RELOCATION PACER SKIN POCKET $4,107.00 33222 REPAIR LEAD PACE-DEFIB ONE SGL $6,458.00 33218 REPAIR LEAD PACE-DEFIB DUAL $6,458.00 33220 INSERT 1 ELECTRODE PM-DEFIB $15,370.00 33216 REMOVE DEFIB PULSE GENERATOR $8,623.00 33241 REMOVAL OF PM GENERATOR ONLY $15,370.00 33233 INSERT PULSE GEN SNGL LEAD $15,390.00 33212 INSERT PULSE GEN DUAL W/E LEAD $2,731.00 33213
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
REMOVE ELCTRD TRANSVENOUSLY $5,980.00 33244 INSERT SWAN-GANZ $5,469.00 93503 ACTIVE CLOTTING TIME (ACT) $338.00 85347 INJ PROC FOR EXTREM VENOGRAM $534.00 36005 SELEC CATH VEIN;1ST ORD FAMILY $1,566.00 36011 SELEC CATH,VEIN;2ND ORD FAMILY $1,163.00 36012 NONSELEC CATH RT HEART/MAIN PA $648.00 36013 SELECTIVE CATH-L/R PULMONA ART $792.00 36014 SELECT CATH-SEGMENTAL ARTERY $924.00 36015 NONSELECTIVE CATH - AORTA $1,514.00 36200 SEL CATH ART-BRACH-CEP;1ST ORD $2,375.00 36215 SEL CATH ART-BRAC-CEPH;2ND ORD $2,085.00 36216 SEL CATH ART-BRAC-CEPH;3RD ORD $2,419.00 36217 SEL CATH ART LOW EX ABD;1ST OR $1,680.00 36245 SEL CATH;ART-LOW EX ADB;2ND OR $1,887.00 36246 SELECT CATH,ART-L EXTR ABD/P;3RD OR $1,539.00 36247 MOD CS BY SAME PHYS,5 YRS + $1,909.00 99152 CORONARY WALL STENT $2,700.00 C1784 GUIDE WIRE PTCA AVE GTL OT GTE $1,283.00 C1769 PTCA CATH AVE (5,6,7,8,9,Z2) $1,283.00 PACEMAKER SGL CHAMBER NON RR $20,045.00 C2620 STENT ILIAC WALLSTENT ENDO $2,602.00 C1876 CATHETER GUIDE SCIMED CORD INF $12,015.00 C1887 CATHETER GUIDE CODIS POWERFLEX $13,995.00 C1887 CATH CORO ANGIO BALL RANGER $13,995.00 CATHETER GUIDE SCIMED 6FWISE $583.00 C1887 GUIDE WIRE HI-TORQUE WHOLLEY $583.00 C1769 PACEMAKER DUAL CHAM DR5342 INT $24,348.00 C1785 PACEMAKER DUAL CHAM DR5346 INT $24,348.00 C1785 STENT PERIPH INTRACOIL 40MM $12,861.00 C1876 STENT PERIPH INTRACOIL 60MM $12,861.00 C1876 STENT COATED W/DEL MEDTRONIC $13,995.00 C1874 STENT CORO MEDTRONIC BEST 18MM $13,995.00 C1874 STENT CORO MEDTRONIC BEST 15MM $13,995.00 C1874 STENT CORO MEDTRONIC BEST 12MM $13,995.00 C1874 ABDOMINAL AORTOGRAM $8,327.00 75625 NEEDLE CVD SMART 18GA $2,306.00 LEAD PACEMAKER NOT TRN VDD SGL $2,274.00 C1898 CATHETER BALLOON TISS DISSE NV $11,274.00 C1727 CATHETER WAVE WIRE 300CM $3,986.00 CATHETER WAVE WIRE 175CM $3,986.00 EMBOLIZATION PROTECTIVE SYSTEM $6,054.00 C1884 INTRAVAS DOPPLER;INITIAL VESSE $10,877.00 93571 IVUS CORONARY V INITIAL $11,741.00 92978 PERC TRANS CORONARY THROMBECT $12,707.00 92973 REPOSITION PACING-DEFIB LEAD $7,789.00 33215 RELOCATE POCKET FOR DEFIB $6,604.00 33223 AICD SINGLE CHAMBER DR $36,628.00 C1722 AICD SINGLE CHAMBER AR $36,628.00 C1722 AICD DUAL CHAMBER $43,808.00 C1721 LEAD AICD ENDO SGL COIL BR $6,077.00 C1777 LEAD AICD ENDO SGL COIL TA $11,274.00 C1777 LEAD CORONARY LT VENTRICULAR $11,274.00 C1900 PERICARDIOCENTESIS:SUBSEQUENT $2,050.00 33011 INSERT VVI PACEMKR VENTRICULAR $42,490.00 33207 ILIAC ANGIO W/CARDIAC CATH $1,588.00 G0278 REMOVE 2 PACER LEAD ONLY $8,623.00 33235 INSERT L VENTRIC PACE LEAD AO $10,693.00 33225 INSERT PACING LEAD & CONNECT $6,318.00 33224 REMOVE 1 PACER LEAD ONLY $7,980.00 33234 IVUS CORONARY V:EA ADDL $10,963.00 92979
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
IV DOPPLER EA ADDTL VESSEL $10,963.00 93572 INTUBATION,ET,EMERGENT $10,440.00 31500 INS VENA CAVA FILTER ENDOVASC $11,699.00 37191 CPR $1,340.00 92950 INS/REP PACE-DEFIB W/LD SGL/DU $22,994.00 33249 INSJ/RPLCMT DEFIB W/LEAD(S) $46,105.00 33240 REMOVE ELECTROID THORACOTOMY $6,863.00 33243 STENT DRUG ELUTING W/DEL SYS $12,777.00 C1874 TRANSCATH STENT CCA W/EMBO PRO $13,558.00 37215 TRANSCATH STENT CCA WO/EMB PRO $13,045.00 37216 STENT COATED W/O DELIVERY SYST $10,571.00 C1875 LOCM 300-399 MG/ML IODINE,1ML $2.00 Q9967 LOCM 300-399 MG/ML IODINE, 1ML $2.00 Q9967 CATHETER INTRAVASC U/S IVUS $4,488.00 C1753 INTRODUCER APPEL CS DEL SYSTEM $5,284.00 C1892 EP EVAL AICD INIT/REPL W/TEST $3,573.00 93641 LEADLESS C PM INS/RPL VENTR $34,893.00 0387T CATH ANGIOJET XVG $7,912.00 C1757 CATHETER ANGIOJET XMI $7,912.00 C1757 CATH EXCISER $7,912.00 C1757 CATHETER TRANSL ATHER,DIRECTNL $14,415.00 C1714 CATHETER TRANSL ATHER,ROTATION $4,303.00 C1724 PROGR EVAL IN PERSON LEADLS PM $83.00 0389T ANGIO PULMONARY UNILAT S&I $5,198.00 75741 ANGIO PULMONARY BILAT S&I $7,010.00 75743 MOD SED SAME PHY/QHP ADDL 15M $122.00 99153 TRANSCATH EMBOLIZATION TX S&I $3,879.00 75894 SEC ART M-THROMBECTOMY $13,953.00 37186 IMPL PT-ACT CARD EVENT RECORD $20,661.00 33282 EVENT RECORDER CARDIAC WO/MON $11,964.00 C1764 AICD OTHR THAN SGL/DUAL CHAMB $55,404.00 C1882 PERIPROC EVAL IP LEADLESSS PM $322.00 0390T INTERGT EVAL INPER LEADLESS PM $83.00 0391T INSERT ELECTRD/PM CATH SGL $16,178.00 33210 PERCU VALVULOPLASTY,AORITC VAL $19,562.00 92986 PACEMAKER OTH TH SGL/DUAL BI-V $23,628.00 C2621 STENT NON COA/NON COV W/D SYS $11,910.00 C1876 EP EVAL AICD SGL/DUAL W PACING $5,086.00 93642 REMOVE IMPL CARDIAC EVENT REC $3,807.00 33284 VENOGRAPHY,EXTREMITY;BILATERAL $2,634.00 75822 I&D HEMATOMA $4,902.00 10140 LEAD PACEMAKER/AICD COMBINATIO $22,590.00 C1899 PACEMAKER SINGLE CHAMBER RR $21,338.00 C1786 ARTERIAL CATH-SMPL/MONITO/TRAN $888.00 36620 PROGRAM EVAL IMPLNT DFB SGL LE $322.00 93282 ICD DEVICE INTERROGATE HEART $315.00 93289 PROGRAM EVAL IMPL DFB DUAL LD $322.00 93283 LEAD AICD ENDO DUAL COIL $10,266.00 C1895 REM IAB ASSIST DEVICE PERCUTAN $402.00 33968 CREATE PERICARDIAL WNDOW/PART $2,765.00 33025 TRANSCATH PERQ STENT/VERT ART $23,059.00 0075T INS NON-TUNNEL CV CATH 5 YRS/> $2,050.00 36556 FLUOROGUIDE FOR VEIN DEVICE $1,023.00 77001 ILIAC ANGIOPLASTY;INIT VESSEL $20,181.00 37220 ILIAC STENT; INITIAL VESSEL $32,041.00 37221 ILIAC ANGIOPLASTY;ADDL VESSEL $23,506.00 37222 ILIAC STENT; ADDT'L VESSEL $30,810.00 37223 FEM/POP UNILATERAL;ANGIOPLASTY $23,257.00 37224 FEM/POP UNILATERAL W/STENT $39,281.00 37226 TIB/PER ANGIOPLASTY INT VESSEL $21,916.00 37228 TIB/PERONEAL STENT;INIT VESSEL $33,406.00 37230
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TIB/PER ANGIOPLASTY ADDL VESS $18,950.00 37232 TIBIAL/PERON STENT ADDL VESSEL $30,810.00 37234 RIGHT HEART CATH ONLY $15,605.00 93451 LEFT HEART CATH (LV ONLY) $17,744.00 93452 RIGHT & LEFT HEART CATH ONLY $23,596.00 93453 CORONARY ANGIO W/O LV $15,015.00 93454 CORONARY ANGIO W/GRAFT W/O LV $20,247.00 93455 CORONARY ANGIO W/RHC W/O LV $21,429.00 93456 CORONARY ANGIO W/GRF RHC WO LV $18,838.00 93457 CORONARY ANGIO W/LV $20,909.00 93458 CORONARY ANGIO W/GRAFTS & W/LV $23,026.00 93459 CORONARY ANGIO W/RHC & W/LV $23,568.00 93460 CORONARY ANGIO W/GRFT RHC W/LV $22,595.00 93461 INJECT R CHAMBER ANGIO $509.00 93566 INJ SUPRVLV AORTO AORTIC ARCH $441.00 93567 INJ PULMONARY ANGIO CATH $509.00 93568 PERC TRANSCATH CLOSURE OF ASD $39,418.00 93580 INTRACARDIAC ECG AT OP $7,230.00 93662 FEM/POPL REVAS W/ATHERECTOMY $36,567.00 37225 FEM/POP REVASC STENT W/ATHER $63,326.00 37227 TIBIAL/PERON ATHER 1ST VESSEL $36,567.00 37229 TIBIAL/PER REVASC STENT W/ATHE $57,325.00 37231 TIBIAL/PER REVAS W/ATH ADD VES $29,253.00 37233 VENOUS MECH THROMBECT I/FLOURO $10,603.00 37187 DEBRIDEMENT SUB TISSUE <20SQCM $761.00 11042 OPERATING ROOM PER MINUTE CCL $166.00 DRUG ADMIN & HEMODYNMIC MEAS $386.00 93463 INSERT CATH REN ART 1ST BILAT $8,144.00 36252 INSERT CATH RENAL ART 1ST UNIL $8,144.00 36251 INSERT PACEMAKER ONLY;EXT LEAD $36,669.00 33221 REMOVE & REPL PM GEN SGL LEAD $15,370.00 33227 REMOVE & REPL PM GEN DUAL LEAD $20,326.00 33228 REMOVE &REPL PM GEN MULTI LEAD $36,669.00 33229 INSERT PULSE GEN W/DUAL LEADS $46,105.00 33230 INSERT PULSE GEN W/MULT LEADS $64,562.00 33231 RMVL& REPLC PULSE GEN 1 LEAD $46,105.00 33262 RMVL & RPLCMT DFB GEN 2 LEAD $46,105.00 33263 RMVL & REPL DFB GEN MLT LEADS $64,562.00 33264 REMOVE ENDOVASC VENA CAVA FLTR $8,310.00 37193 ILIAC ANEURYSM ENDOVAS REP S&I $1,460.00 75954 INS TUNNELED CV CATH AGE 5/> $6,988.00 36558 U/S GUIDE VASCULAR ACCESS $820.00 76937 PERC TRANSCATH CLOSURE OF VSD $41,650.00 93581 THROMBOLYTIC ART THERAPY $9,263.00 37211 THROMBOLYTIC VENOUS THERAPY $5,572.00 37212 THROMBOYLYTIC ART/VEIN THERAPY $6,065.00 37213 CESSJ THERAPY CATH REMOVAL $5,762.00 37214 PLACE CATH SUBCLAVIN ARTER S&I $7,674.00 36225 PLACE CATH CAROTID/INOM ART $7,674.00 36222 PLC CATH CAROTI/INOM ART EC&CA $8,893.00 36223 SEL CATH CAROTID ART INC/ANGIO $12,553.00 36224 PLACE CATH THORACIC AORTA $7,674.00 36221 PLACE CATH VERTEBRAL ARTERY $12,553.00 36226 PLACE CATH EXTERNAL CAROTID ARTERY $3,270.00 36227 PERC TC CARDIAC STENT W/AN 1ST $21,916.00 92928 PERC TL CARDIAC STENT/ATH/ANG $33,406.00 92933 PERC TL REVASC BYP GRAFT 1 VSL $21,916.00 92937 PERC TL CARDIAC REVASC MI 1VSL $21,129.00 92941 PERC TL CARDIA REVSC CHRO 1VSL $21,916.00 92943 PERC TC CARD STENT W/ANG ADDL $21,129.00 92929 PERC TL REVASC BYP GRAFT ADDL $21,129.00 92938
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PERC TL ANGIOPLAS 1 ART/BRANCH $13,913.00 92920 PERC TL ANGIO/ATHER 1 ART/BR $26,526.00 92924 PERC TL CARD ANGIO ART/BR ADDL $13,913.00 92921 PERC DRUG-EL CORONARY STENT SV $28,368.00 C9600 PERC DRUG-EL COR STENT/ATH SV $33,406.00 C9602 PERC DR-EL COR REVSC T CABG SV $28,368.00 C9604 PERC DRG-EL COR REVSC W/AMI SV $33,406.00 C9606 PERC DR-EL CORON REVAS CHR SV $33,406.00 C9607 PERC DR-EL COR STENT ADDL BRAN $28,368.00 C9601 PERC DR-EL COR STENT ATHE ADDL $28,368.00 C9603 PERC D-E COR REVASC CABG ADDL $28,368.00 C9605 PERC TL THROMB VEINS SUB DAY $11,236.00 37188 PERC TL THROMBECTOMY NON CORON $11,236.00 37184 UNLISTED VASC PROCEDURE $171.00 37799 TRANSCATH PLC OPN/PERQ STENT 1 $31,058.00 37236 TRANSCATH PLC OPN/PER STENT AD $15,018.00 37237 OPEN/PERQ PLACE STENT SAME INI $31,058.00 37238 OPEN/PERQ PLC STENT EA ADDL VN $15,018.00 32998 VASC EMBOLIZE/OCCLUDE ARTERY $31,655.00 37242 PERC TRANSCATH CLOSURE PDA $43,549.00 93582 PM DEVICE EVAL IN PERSON $108.00 93288 BALLOON DRUG ELUTING W/DS $4,887.00 C2623 INS/REP SUBQ DEFIBRILLATOR $64,562.00 33270 INS SUBQ IMPLANT DFB ELECTRODE $15,370.00 33271 REM SUBQ IMPLANT DFB ELECTRODE $6,551.00 33272 REPOS PREV IMPLANTED SUBQ DFB $6,551.00 33273 EP EVAL SUBQ ICD $2,438.00 93644 CAROTID INTIMA ATHEROMA EVAL $157.00 93895 EVENT RECORDER CARDIAC W/MONIT $13,180.00 C1764 CATHETER IMPELLA CP 3.5FR $60,845.00 CATHETER IMPELLA 2.5FR $48,677.00 CATHETER RE-ENTRY IVUS $7,775.00 C1753 POSITIONER WRIST SPLINT DISP $195.00 CATHETER GUIDE STEERABLE DESTI $3,272.00 C1766 CATHETER BALLOON CHOCOLATE PTA $3,135.00 C1725 INTRVASC US NONCORONARY 1ST VS $15,740.00 37252 INTRVAS US NONCORONARY ADDL VS $15,239.00 37253 ART PRESSURE WAVEFORM ANALYSIS $86.00 93050 ENDOVASC THOR AO REPR S & I $1,460.00 75956 THER/PRO/DIAG INJ IV PUSH INIT $424.00 96374 TX/PRO/DX INJ SAME DRUG ADD-ON $70.00 96376 INTRO NEED/CATH DIALY CIRCUIT $1,744.00 36901 INTRO ND/CATH DIAL W TLB ANGIO $12,296.00 36902 INTRO ND/CATH WTCP INTRA STENT $37,599.00 36906 INTRO ND/CATH DIAL W/TL STENT $24,851.00 36903 INTRO ND/CATH W TLBA PERIP DIA $24,851.00 36905 TRLUML BALOON ANGIOP ADDL ART $5,832.00 37247 TRLUML BALLOON ANGIOP 1ST ART $12,296.00 37246 PERC TL THROMBEC NSF DIAL CIR $12,296.00 36904 BALLOON ANGIOP CTR DIALYSI SEG $2,478.00 36907 STENT PLC CT DIALY SEG IMG S&I $2,478.00 36908 DIALYSIS CIRCUIT EMBOLIZATION $2,478.00 36909 TRLUML BALLOON ANGIOP 1ST VEIN $12,296.00 37248 TRLUML BALLOON ANGIO ADDL VEIN $5,832.00 37249 HOT PACK/COLD PACK $40.00 97010GO MASSAGE THERAPY EA 15 MIN $119.00 97124GO PARAFFIN BATH $83.00 97018GO THERAPEUTIC EXERCISE EA 15 MIN $113.00 97110GO ULTRASOUND EA 15 MIN $113.00 97035GO NEUROMUSCULAR RE-EDU EA 15 MIN $131.00 97112GO SELF CARE/HOME MGMT EA 15 MIN $139.00 97535GO
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SENSORY INTERGRATION EA 15 MIN $113.00 97533GO AQUATIC THERAPY W EX EA 15 MIN $131.00 97113GO THERAPEUTIC ACTIVITY EA 15 MIN $113.00 97530GO MANUAL THERAPY EA 15 MIN $120.00 97140GO PHYSICAL PERFORMANCE EA 15 MIN $131.00 97750GO ELECTRICAL STIM MANUAL EA 15MI $106.00 97032GO TENS UNIT APPLICATION SURFACE $136.00 64550GO WHEELCHAIR MANAGEMENT EA 15MIN $113.00 97542GO OT/APPLY LONG ARM SPLINT $258.00 29105 OT/APPLY SHORT ARM SPLINT;STAT $228.00 29125 OT/APPLY FINGER SPLINT;DYNAMIC $258.00 29131 OT/APPLY FINGER SPLINT;STATIC $195.00 29130 OT-EVAL LOW COMPLEX 30 MIN $175.00 97165GO OT-EVAL MOD COMPLEX 45 MIN $262.00 97166GO OT-EVAL HIGH COMPLEX 60 MIN $350.00 97167GO OT-RE-EVAL EST PLAN OF CARE $213.00 97168GO ELECTRICAL STIM UNATTENDED $104.00 G0283GO GROUP THERAPY (2 PT MIN) $65.00 97150GO COMMUNITY/WORK REINTEG EA 15MI $97.00 97537GO ORTHOT/PROST MGMT SBSQ ENC 15M $106.00 97763GO OT/MOBILITY CURRENT STATUS $1.00 G8978GO OT/MOBILITY GOAL STATUS $1.00 G8979GO OT/MOBILITY D/C STATUS $1.00 G8980GO OT/BODY POS CURRENT STATUS $1.00 G8981GO OT/BODY POS GOAL STATUS $1.00 G8982GO OT/BODY POS D/C STATUS $1.00 G8983GO OT/CARRY CURRENT STATUS $1.00 G8984GO COGNITIVE THER INTRV PER VISIT $135.00 97127GO OT/CARRY GOAL STATUS $1.00 G8985GO OT/CARRY D/C STATUS $1.00 G8986GO OT/SELF CARE CURRENT STATUS $1.00 G8987GO OT/SELF CARE GOAL STATUS $1.00 G8988GO OT/SELF CARE D/C STATUS $1.00 G8989GO OT/SUB PT/OT CURRENT STATUS $1.00 G8993GO OT/SUB PT/OT GOAL STATUS $1.00 G8994GO OT/SUB PT/OT D/C STATUS $1.00 G8995 CT-HEAD/BRAIN WO CONTRAST $2,104.00 70450 CT-HEAD/BRAIN W CONTRAST $2,769.00 70460 CT HEAD/BRAIN W & W/O CONTRAST $2,803.00 70470 CT-ORBIT,SELLA,MID/IN EAR W/O $2,595.00 70480 CT-ORBIT,SELLA,MID/INNER EAR W $2,486.00 70481 CT-ORBIT,SELLA,MID/IN EAR W&WO $2,935.00 70482 CT MAXILLOFAC/SINUS W/O $1,524.00 70486 CT MAXILLOFAC/SINUS W $2,161.00 70487 CT MAXILLOFAC/SINUS W/WO $3,036.00 70488 CT-SOFT TISSUE NECK WO CONTR $2,598.00 70490 CT-ST NECK W CONTR $2,746.00 70491 CT-ST NECK W&WO CONTR $2,776.00 70492 CT THORAX(CHEST);WO CONTRAST $2,473.00 71250 CT THORAX(CHEST);W CONTRAST $2,753.00 71260 CT THORAX(CHEST);W & WO CONTRA $2,948.00 71270 CT CERV SPINE WO CONTR $2,935.00 72125 CT CERV SPINE W CONTR $3,759.00 72126 CT THORACIC SPINE WO CONTR $3,200.00 72128 CT-THORACIC SPINE W CONTR $3,380.00 72129 CT-LUMBAR SPINE W/O CONTR $3,525.00 72131 CT-LUMBAR SPINE W CONTR $3,547.00 72132 CT PELVIS; WO CONTR $2,833.00 72192 CT PELVIS W CONTRAST $2,920.00 72193 CT PELVIS; W & WO CONTR $3,306.00 72194 CT U/EXTREM WO CONTRAST $2,658.00 73200
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CT U/EXTREM W CONTRAST $3,140.00 73201 CT U/EXTREM WWO CONTRAST $3,375.00 73202 CT L EXTR WO CONTRAST $2,658.00 73700 CT LO/EXTREM W CONTRAST $3,200.00 73701 CT L EXTR W AND WO CONTRAST $3,104.00 73702 CT ABD WO CONTRAST $1,722.00 74150 CT ABD W CONTRAST $2,967.00 74160 CT ABD W AND WO CONTRAST $3,324.00 74170 CT GUIDE NEEDLE PLACEMENT $2,643.00 77012 CT 3D RECONSTRUCTION $527.00 76376 CT CERVICAL SPINE W/WO CONTR $3,380.00 72127 CT THORACIC SPINE W/WO $3,380.00 72130 CT LUMBAR SPINE W/WO $3,686.00 72133 CT GUIDE PERC DRN W CATH PCMT $2,495.00 75989 CT LUNG CANCER SCREEN W/LD CT $213.00 G0297 CTA ABDOMEN W/WO $3,354.00 74175 CT ABD ANGIO W BIL ROFF $3,883.00 75635 CTA UPPER EXT W/WO $3,092.00 73206 CTA LOWER EXT W/WO $3,092.00 73706 CTA HEAD W&WO CONTR POST PROC $3,848.00 70496 CTA NECK W&WO CONTR POST PROC $4,062.00 70498 CTA CHEST W&WO CONTR POST PROC $4,235.00 71275 CTA PELVIS W&WO CONTR POST PRO $4,062.00 72191 CTA LOW EXT W&WO CONTR POST PR $4,235.00 73706 CTA ABD W&WO CONTR POST PROC $3,128.00 74175 CT VERTEBROPLAS THOR 1VERT BDY $6,897.00 22510 CT BIOPSY LIVER NEEDLE PERC $2,811.00 47000 CT BX PLEURA;PERCUTANEOUS NDL $2,811.00 32400 CT ASP/INJ RENAL CYST/PELVIS $1,807.00 50390 CT MYELOGRAM INJ &/O CT LUMBAR $677.00 62284 CT PERCUT VERTEBROPLASTY ADDL $6,897.00 22512 CT BX N PERC ABD/RETROPERITONE $2,811.00 49180 CT BIOPSY ST NECK THORAX $2,811.00 20206 CT BIOPSY KIDNEY PERC $2,811.00 50200 CT BIOPSY BONE SUPERFICIAL $1,540.00 20220 CT BX LUNG/MEDIAST PERC NEEDLE $2,811.00 32405 CT VERTEBROPLASTY LUMBAR $6,897.00 22511 CTA HEART CALCIUM EVAL $173.00 75571 CTA HEART W CONRAST W/3D MORPH $734.00 75572 CCT ANGIO HRT W/3D IMAGE $2,073.00 75574 CT PERC IMG-GUID DRN PERI/RETR $3,383.00 49406 CT GUIDE CATHETER FLUID DRAIN $2,109.00 10030 PERQ VERT CERVICOTHOR CT GUIDE $9,278.00 22510 PERQ VERTEBROPLASTY W CT GUIDE $9,278.00 22511 PERQ VERT EA ADDL C/LS W GUIDE $9,278.00 22512 MYELOGRAPHY LUMBAR INJ CRV S&I $1,422.00 62302 MYELOGRAPHY LUMBAR IN THOR S&I $1,496.00 62303 MYELOGRAPHY LUMBAR INJ2>REG SI $1,496.00 62305 MYELOGRAPHY LUMBAR INJ L/S S&I $1,496.00 62304 CT THORAXCHEST;LOW DOSE PROTOC $2,355.00 71250 CTA HRT W/WO CONRAST W/3D CONG $734.00 75573 LOCM 300-399 MC/ML IODINE 1ML $2.00 Q9967 LOCM 300-399MG/ML IODINE,1ML $2.00 Q9967 CONSCIOUS SEDATION <5YRS $321.00 99151 MOD CS BY SAME PHYS, 5 YRS + $321.00 99152 MOD SED SAME PHY/QHP ADDL 15M $78.00 99153 ARTHRO/ASP/INJ ITM JT/BR WO US $657.00 20605 ARTHRO/ASP/IJ MAJ JNT/BR WO US $820.00 20610 BIOPSY THYROID PERC CORE NDL $1,200.00 60100 CT BX SFT TISS DEEP THIGH/KNEE $2,811.00 20206 CT UROGRAM W & W/O CONTRAST $4,188.00 74178
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CT COLONOGRAPHY WO W/PP DYE $609.00 74261 CT BONE MARROW ASPIRATE DX $2,811.00 38220 CT BONE MARROW BIOPSY NEEDLE $2,811.00 38221 CT ABD & PELVIS W/O CONTRAST $4,196.00 74176 CT ABDOMEN & PELVIS W/CONTRAST $4,773.00 74177 CT ABD&PELVIS W&WO 1/>SECTION $5,966.00 74178 CT 3D RENDERING W/POSTPROCESS $724.00 76377 CTA ABDOMEN & PELV W/O & W/DYE $4,414.00 74174 CT THORACENTESIS WITH IMAGING $1,277.00 32555 CT DEEP BONE BX TRCR/NDL $3,496.00 20225 CT INSERT CATH PLEURA W/ IMAGE $2,050.00 32557 CT DX BONE MARROW BX& ASPIRATE $3,036.00 38222 BIOPSY/EXCIS LYMPH NODE NEEDLE $2,811.00 38505 INJ(S);SGL OR MULT TP 1 OR 2 $564.00 20552 INJ FOR CYSTOGRAM $217.00 51600 CYSTOGRAM MIN 3 VIEW $1,513.00 74430 CT INJ SAJ ARTHROGR/ANESTHETIC $1,826.00 27096 MOD SED SAME PHY/QHP ADDL 15M $78.00 99153 U/S THYROID/SOFT TISSUE $897.00 76536 U/S ABDOMEN (COMPLETE) $1,072.00 76700 U/S ABDOMEN LTD $735.00 76705 U/S LIVER $794.00 76705 U/S RENALS $950.00 76775 U/S PANCREAS $794.00 76705 U/S SPLEEN $794.00 76705 U/S ABD AORTA $989.00 76770 U/S OB >14 WEEKS SINGLE FETUS $808.00 76805 U/S OB US, LIMITED, FETUS(S) $452.00 76815 U/S PELVIC NON OB COMPLETE $842.00 76856 U/S SCROTUM AND CONTENTS $833.00 76870 INTRACRANIAL ART DOPPLER;COMPL $1,760.00 93886 U/S RETROPERITONEAL LIMITED $950.00 76775 U/S OB EA ADD'L GEST >14 WEEKS $873.00 76810 U/S PREGNANCY FOLLOW-UP REPEAT $500.00 76816 US BIOPHYSICAL PRF WNON STRESS $1,231.00 76818 U/S TRANSVAGINAL NON OB $449.00 76830 US PELVIC NON-OB LIMITED/FU $380.00 76857 U/S CAROTID EXT ART BILATERAL $2,817.00 93880 U/S CAROTID EXT ART LTD $2,817.00 93882 U/S DUPLEX LE ART/BPG; BILAT $2,817.00 93925 U/S LOWER EXT BYPASS LIMITED $2,817.00 93926 DUPLEX UE ART/BPG;BILAT $3,522.00 93930 U/S UPPER EXT BYPASS LIMITED $2,825.00 93931 U/S VENOUS EXT DUPLEX LIMITED $2,565.00 93971 US ABD/PELVIC VASCULAR COMPLET $2,565.00 93975 DUPLEX ARTERIAL FLOW;LIMITED $1,189.00 93976 U/S AORTIC BYPASS COMPLETE $2,817.00 93978 U/S PERICARDIOCENTESIS GUIDE $1,420.00 76930 U/S GUIDED NEEDLE PLACEMENT $1,219.00 76942 US VENOUS EXT DUPLEX BILAT COM $2,817.00 93970 U/S BIOPSY:HIP/PELVIS DEEP $5,073.00 20205 US EXT DOPPLER STUDY 3>LEVELS $1,163.00 93923 US POST TREADMILL DOPPLER BILA $1,003.00 93924 U/S CHEST $563.00 76604 US ANKLE/BRACH INDICES 1-2 LEV $544.00 93922 US BIOPHYSICAL WO NON STRESS $391.00 76819 U/S PERICARDIOCENTESIS, INIT $2,050.00 33010 MOD CS BY SAME PHYS, 5 YRS + $340.00 99152 U/S PERC N BX ABD/RETROPERITON $2,811.00 49180 US BX PLEURA;PERCUTANEOUS NDL $2,919.00 32400 U/S OB<14 WKS ADDL FETUS $270.00 76802
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
US BX LUNG/MEDIAST PERC NEEDLE $2,811.00 32405 US BIOPSY THYROID PERC CORE ND $1,272.00 60100 U/S BIOPSY LIVER NEEDLE PERC $2,811.00 47000 U/S FNA W GUIDANCE $1,272.00 10022 U/S GUIDE VASCULAR ACCESS $661.00 76937 U/S OB US DETAILED,SGL FETUS $686.00 76811 U/S OB <14 WEEKS SINGLE FETUS $310.00 76801 U/S TRANSVAGINAL OB $391.00 76817 US DUPLEX SCAN DIALYSIS ACCESS $508.00 93990 BIOPSY/EXC LYMPH NODE NEEDLE $2,811.00 38505 U/S BIOPSY KIDNEY PERC $2,811.00 50200 U/S BIOPSY ST PERC W GUIDE $2,811.00 20206 U/S I&D ABSC; COMPL OR MULTI $691.00 10061 U/S EXTR JOINT COMPLETE $534.00 76881 U/S EXTR NON-VASC LIMITED $345.00 76882 U/S DRAINAGE CATH UNDER XR $2,069.00 75989 TUBE THORACOSTOMY W/CONN OPEN $2,050.00 32551 U/S INJ PSEUDOANEURYSM $1,615.00 36002 U/S INFANT HIPS; DYNAMIC $504.00 76885 U/S PV RESIDUAL URINE $171.00 51798 PARACENTESIS ABD DIA/TH WO IMG $1,652.00 49082 PARACENTESIS ABD W/IMAGING $1,652.00 49083 U/S THORACENTESIS WITH IMAGING $1,615.00 32555 BIOPSY SALIVARY GLAND; NEEDLE $1,745.00 42400 US UNLIST PROC HEMIC/LYMPHATIC $837.00 38999 US VESSEL MAP HEMODIALYSIS ACC $647.00 G0365 US PERC IMG GUID DRN PERI/RETR $3,362.00 49406 ARTHRO/ASP/INJ ITM JT/BR WO US $748.00 20605 US PELVIC/PENIS/PERINEUM LIMIT $418.00 76857 ASPIRATION BL W/CATH INSERTION $4,626.00 51102 ARTHRO/ASP/IJ MAJ JNT/BR WO US $927.00 20610 NJ(S);SGL OR MULT TP 1/2 MUSCL $580.00 20552 U/S GUIDE CATHETER FLUID DRAINAGE $2,206.00 10030 U/S OB US NUCHAL MEAS ADD-ON $369.00 76814 PUNCTURE ASP OF ABSCESS/HEMA $691.00 10160 U/S I&D ABSCESS; SIMPLE OR SGL $449.00 10060 DRAIN/ASP/INJ JOINT/BURSA W/US $2,284.00 20604 DRAIN/INJ INTER JNT/BURSA W/US $2,441.00 20606 DRAIN/INJ MAJOR JNT/BURSA W/US $3,308.00 20611 U/S BREAST UNILATERAL,COMPLETE $771.00 76641 U/S BREAST UNILATERAL LIMITED $385.00 76642 US TRANSPL KIDNEY W/DOPPLER $391.00 76776 US ABDOMINAL AORTIC SCREEN AAA $287.00 76706 MOD SED SAME PHY/QHP ADDL 15M $81.00 99153 U/S REM FB UP ARM OR ELBOW;SUB $2,919.00 24200 REMOVE FOREIGN BODY DEEP THIGH/KNEE $5,632.00 27372 DIABETES,INIT ASSESS/INTER 15M $56.00 97802 DIABETES, INDIVIDUAL, 30MIN $116.00 97803 DIABETES GROUP SESSION/30MIN $106.00 97804 DIABETES,RE-ASSESS INDIV 15MIN $56.00 97803 MNT GRP REASSES FU 2 REF P/30M $106.00 G0271 MNT;GRP(2OR MORE) EA 30 MIN $132.00 97804 MNT, RE-ASSESS/INTERV 15MIN $66.00 97803 MNT,INIT ASSESS/INTERVAL 15MIN $56.00 97802 PUMP TRAINING F/U PER 15MIN $16.00 98960 CAFETERIA MEALS $- DIETICIAN SVCS CONTRACT PER HR $60.00 CT PLOT COMPLEX $622.00 77014 SIMULATION-SIMPLE $1,326.00 77280 SIMULATION-INTERMEDIATE $1,696.00 77285 SIMULATION-COMPLEX $2,393.00 77290
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SIMULATION; 3D $7,417.00 77295 BASIC DOSIMETRY CALC $629.00 77300 SPECIAL PORT PLAN $1,580.00 77321 TREATMENT DEVICE-SIMPLE $1,088.00 77332 TREATMENT DEVICE-INTERMEDIATE $1,807.00 77333 TREATMENT DEVICE-COMPLEX $1,531.00 77334 RADIATION PHYSICS CONSULT $963.00 77336 CHEMO ADMIN SQ/IM HORMONAL $159.00 96402 OFFICE VISIT BRIEF EST PATIENT $259.00 99211 PORT IMAGES THERAPEUTIC $291.00 77417 SPECIAL TREATMENT PROCEDURE $4,155.00 77470 OFFICE VISIT MINOR ESTAB PT $241.00 99212 OFFICE VISIT LOW/MOD ESTAB PT $241.00 99213 OFFICE VISIT MOD/HIGH ESTAB PT $243.00 99214 OFFICE VISIT HIGH EST PATIENT $329.00 99215 OFFICE VISIT LOW TO MOD NEW PT $241.00 99202 OFFICE VISIT MODERATE NEW PT $241.00 99203 OFFICE VISIT HIGH NEW PT $329.00 99205 OFFICE VISIT MOD/HIGH NEW PT $243.00 99204 IMRT CONFORMAL PLAN $5,621.00 77301 DESIGN MLC DEVICE FOR IMRT $956.00 77338 OFFICE CONSULTS LOW $178.00 99242 OFFICE CONSULTS MODERATE $188.00 99243 OFFICE CONSULTS MOD TO HIGH $194.00 99244 OFFICE CONSULT HIGH $264.00 99245 PLACE RT DEVICE/MARKR PROSTATE $2,617.00 55876 US GUIDED NEEDLE PLACEMENT $394.00 76942 RADIATION THERAPY IMAGE FUSION $286.00 77399 TELETHX ISODOSE PL SMPLE W/DOS $1,243.00 77306 TELETHX ISODOSE PL CPLX IN DOS $2,075.00 77307 RAD TRMT DEL >1 MEV SIMPLE $1,044.00 77402 IMRT INCL GUIDE/TRACK SIMPLE $1,194.00 77385 IMRT INCL GUIDE/TRACK COMPLEX $1,194.00 77386 RAD TRMT DELIVERY >1MEV INTERM $1,125.00 77407 RAD TRMT DELIVERY >1MEV COMPL $1,203.00 77412 RT TX PLANNING; SIMPLE PROFEE $229.00 77261 RT TX PLANNING;INTERMEDIATE PF $345.00 77262 RT TX PLANNING; COMPLEX PROFEE $510.00 77263 BASIC DOSIMETRY CALC PROFEE $106.00 7730026 SIMULATION; INTERMEDIATE PF $179.00 7728526 SIMULATION; COMPLEX PROFEE $266.00 7729026 SIMULATION; SIMPLE PROFEE $120.00 7728026 SET RADIATION THER FIELD 3D PF $836.00 7729526 IMRT/CONFORMAL RTH PLAN PROFEE $1,353.00 7730126 HEMIBODY PARTICLE TOTAL BDY PF $162.00 7732126 TX DEVICES SIMPLE PROFEE $85.00 7733226 TX DEVICES INTERMEDIATE PROFEE $133.00 7733326 TX DEVICES COMPLEX PROFEE $195.00 7733426 DESIGN MLC DEVICE FOR IMRT PF $726.00 7733826 RADIATION TX MANAGEMENT X5 PF $606.00 77427 RADIATION THRP MGMT 1-2 FRA PF $313.00 77431 SPECIAL RADIATION TREATMENT PF $332.00 7747026 OFFICE VISIT LOW/MOD NEW PT PF $241.00 99202 OFFICE VISIT MODERAT NEW PT PF $260.00 99203 OFFICE VISIT MOD/HIG NEW PT PF $409.00 99204 OFFICE VISIT HIGH NEW PT PROFEE $524.00 99205 OFFICE VISIT BRIEF EST PT PF $75.00 99211 OFFICE VISIT MINOR ESTAB PT PF $113.00 99212 OFFICE VISIT LOW/MOD EST PT PF $176.00 99213 OFFICE VISIT HIGH ESTAB PT PF $379.00 99215 OFFICE VISIT MOD/HIG EST PT PF $269.00 99214
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
OFFICE CONSULTS MODERATE $405.00 99243 OFFICE CONSULTS MOD TO HIGH $529.00 99244 OFFICE CONSULTS HIGH $568.00 99245 HOSP CONSULT INPATIENT DETAIL $335.00 99253 HOSP CONSULT, IP COMPREHENSIVE $460.00 99254 HOSP CONSULT INPATIENT COMPLEX $620.00 99255 HOSP CONSULT INPATIENT EXPAND $251.00 99252 OFFICE CONSULTS LOW $318.00 99242 INITIAL HOSP ADMIT LOW COMP PF $318.00 99221 INITIAL HOSP ADMIT MOD COMP PF $429.00 99222 INITIAL HOSP CARE COMPL 70M PF $630.00 99223 F/U HOSP VISIT DETAILED $354.00 99233 HOSP INIT OBSERV MOD COMP PF $418.00 99219 PLACE RT DEV/MARKR PROSTATE PF $334.00 55876 US GUIDED NEEDLE PLACEMENT PF $107.00 7694226 TELETHX ISODOSE PL SMP W/DO PF $238.00 7730626 TELETHX ISODOSE PL CPLX DOS PF $491.00 7730726 PET IMAGE W/CT LIMITED AREA $4,541.00 78814 PET W/CT WHOLE BODY $4,541.00 78816 PET W/CT SKULL BASE/MID THIGH $4,541.00 78815 FDG F-18 PER DS>45 MILLICURIES $1,284.00 A9552 OP/COMPREHENSIVE METABOLIC PAN $49.00 80053 OP/LIPID PROFILE $59.00 80061 OP/CBC W/AUTO DIFF WBC $28.00 85025 OP/AUTOM URINE DIP W MICRO $14.00 81001 OP/PSA DIAGNOSTIC TOTAL $82.00 84153 OP/DIGOXIN,QUANTITIVE $59.00 80162 OP PHENYTOIN, TOTAL $59.00 80185 OP/THEOPHYLLINE LEVEL $63.00 80198 OP/PROTIME $17.00 85610 OP/URINE CULTURE $36.00 87086 OP/SPUTUM CULTURE $39.00 87070 OP/GLYCOHEMOGLOBIN $43.00 83036 OP/IRON (SERUM) $29.00 83540 OP/URINALYSIS $14.00 81000 OP/T4* $30.00 84436 OP/TSH $75.00 84443 OP/CBC,AUTO(HGB,RBC,WBC,PLAT) $28.00 85027 OP/BLD COUNT;BLD SMEAR,MICRO E $15.00 85007 OP/PSA SCREENING $82.00 G0103 OP/T3 UPTAKE $29.00 84479 OP/AUTOMATED UA W/O MICRO $11.00 81003 OP/METABOLIC PANEL IONIZED CA $38.00 80047 OP/BASIC METABOLIC PANE TOT CA $38.00 80048 OP/AMMONIA $43.00 82140 OP/ALDOLASE $28.00 82085 OP/TOTAL BILIRUBIN $15.00 82247 OP/CALCIUM;TOTAL $15.00 82310 OP/CREATININE $15.00 82565 OP/CPK; TOTAL $19.00 82550 OP/PROTEIN ELECTROPHORE $37.00 84165 OP/IRON BINDING CAPACITY $26.00 83550 OP/LEAD $36.00 83655 OP/HEPATIC FUNCTION PANEL $24.00 80076 OP/MAGNESIUM $19.00 83735 OP/PROTEIN TOTAL $12.00 84155 OP/UREA NITROGEN(BUN)QUANITATI $12.00 84520 OP/URIC ACID $13.00 84550 OP/T4 FREE $27.00 84439 OP/B12 LEVEL $44.00 82607 OP/FOLIC ACID SERUM $44.00 82746
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
OP/INSULIN $48.00 83525 OP/IGD,IGG,IGM,EACH $42.00 82784 OP/IGE $52.00 82785 OP/FERRITIN SERUM $40.00 82728 OP/PHENOBARBITAL $55.00 80184 OP/COLLECT BLOOD VENIPUNCTURE $22.00 36415 OP/HEMOGLOBIN $6.00 85018 OP/PTT $17.00 85730 OP/SENSITIVITY $26.00 87186 OP/C-REACTIVE PROTEIN (CRP) $16.00 86140 OP/DIRECT BILIRUBIN $15.00 82248 OP/HEPATITIS A-B-C PROFILE $140.00 80074 OP/TESTOSTERONE TOTAL $76.00 84403 OP/EPSTEIN-BARR VCA ANTIBODY $54.00 86665 OP/ALPHA-FETOPROTEIN;SERUM $50.00 82105 OP/HEPATITIS C-DNA OR RNA $758.00 87902 OP/ANTINUCLEAR AB(ANA)** $36.00 86038 OP/AB ID;LEUKOCYTE AB $63.00 86021 OP/HEMOGLOBIN; PLASMA $22.00 83051 OP/ANTI-THYROID PEROXIDASE* $43.00 86376 OP/NATRIURETIC PEPTIDE B TYPE $100.00 83880 OP/RETICULOCYTE CT AUTOMATED $12.00 85045 OP/VITAMIN D, 25 HYDROXY $87.00 82306 OP/ESR; AUTOMATED $10.00 85652 OP/HEPATITIS-C, NA QUAN $126.00 87522 OP/CREATININE OTHER SOURCE $16.00 82570 OP/TESTOSTERONE FREE $75.00 84402 OP/IMMUNOASSAY,ANA QUAN;RIA** $56.00 83519 OP/IA NOTINF AB/AG,QL/QN $37.00 83516 OP/AB; COCCIDIOIDES $33.00 86635 OP/CCP ANTIBODY $38.00 86200 OP/DNA AB; NATIVE/DOUBLE STRND $40.00 86225 OP/RHEUMATOID FACTOR, QUAN $22.00 86431 OP/ALLERGEN SPECI IGE CRUDE EA $15.00 86003 OP/GLUCOSE FASTING $12.00 82947 OP/POTASSIUM $14.00 84132 OP/PROGESTERONE $62.00 84144 O/H OCCULT BLOOD OTH SOURCES $15.00 82271 O/H CBC W/AUTO DIFF WBC $40.00 85025 O/H URINALYSIS (ROUTINE) $9.00 81000 O/H LEAD LEVEL* $61.00 83655 ARSENIC $226.00 82175 O/H HEP B SUR AB $92.00 86706 O/H COMPREHEN METABOLIC PANEL $92.00 80048 O/H LIPID PROFILE $40.00 80061 O/H GLUCOSE QUANTI, BLOOD $54.00 82947 O/H VARICELLA ZOSTER $19.00 86787 O/H ANTIBODY; RUBEOLA $71.00 86765 O/H ANTIBODY; MUMPS $71.00 86735 O/H ANTIBODY; RUBELLA $71.00 86762 MSLT SLEEP STUDY PRO FEE $561.00 9580526 SLEEP STUDY ATTEND PAP-NAP PF $219.00 958072652 SLEEP STAGE 6/>YRS 4/>PARAM PF $888.00 9581026 SLEEP STAGING 4+ CPAP/BIPAP PF $1,123.00 9581126 SLEEP STUDY UNATT&RESP EFFT PF $213.00 9580626 SLEEP STDY UNATTENDED PROFEE $122.00 9580026 SLEEP STDY UNATTEND W/ANAL PF $117.00 9580126 MULTIPLE SLEEP LATENCY TESTING $3,178.00 95805 SLEEP STUDY ATTENDED PAP-NAP $1,954.00 9580752 SLEEP STAGING 6/>YRS 4/>PARAM $4,251.00 95810 SLEEP STAGING 4 + CPAP/BIPAP $5,707.00 95811
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SLEEP STUDY UNATT&RESP EFFT $443.00 95806 SLEEP STDY UNATTENDED $409.00 95800 SLEEP STDY UNATTEND W/ANAL $409.00 95801 OFFICE VISIT BRIEF EST PATIENT $241.00 G0463 COGNITIVE BEHA TRMT EA 15M GRP $64.00 96153 ASSESS HLTH/BEHAV EA 15MI INIT $164.00 96150 INTERVENE HLT/BEHA EA 15M INDV $164.00 96152 SLEEP TEST HOME W/TYPE III $307.00 G0399 HH SKILLED NURSE SVC EA 15MIN $256.00 G0299 HH AIDE SERV EA 15MIN $130.00 G0156 HH PHYSICAL THERAPY SERV 15MIN $256.00 G0151 HH CLINICAL SOC WRK SERV 15MIN $404.00 G0155 HH OCCUPATION THERAPY 15MIN $236.00 G0152 HH HOME VISIT EST PATIENT $256.00 99347 APPLICATOR COTTON TIP 6IN $1.00 DRESSING GAUZE SPONGE 2X2 NS $1.00 DRESSING GAUZE SPONGE 4X4 STER $21.00 BANDAGE ELASTIC ACE 3" $25.00 BANDAGE ELASTIC ACE 6" $57.00 DRESSING ANTIMICR DR SPNGE 4X4 $1.00 DRESSING KERLIX ROLL STER 4.5" $23.00 DRESSING NU GAUZ IOD 1/2" $100.00 DRESSING ABD PAD 8X10 $1.00 DRESSING TELFA PAD 2X3 $1.00 DRESSING TELFA PAD 3X4 $1.00 DRESSING TELFA PAD 3X8 $1.00 ADAPTIC DRESSING 8X3 $25.00 DRESSING VASELINE GAUZE 1X36 $24.00 DRESSING VASELINE GAUZ 3X36 $38.00 DRESSING OPSITE 14X10CM $24.00 DRESSING OPSITE 5X7.5CM $1.00 DRESSING OPSITE 25X14CM $54.00 CATHETER IV 20G $43.00 TRAY FOLEY ADD A W/O UA METER $152.00 TRAY FOLEY W BAG 16F $289.00 SET DRAIN BAG $63.00 TRAY IRRIGATION $38.00 SET SUTURE REMOVER DISP $38.00 TAPE MICROPORE 1" $9.00 TAPE MICROPORE 2" $52.00 TRANSPORE TAPE 1 IN $23.00 TAPE TRANSPORE 2" $52.00 THERMOMETER ORAL REG $25.00 BAG UA COLLECTOR LARGE $25.00 BETADINE SOLUTION 8 OZ $18.00 WIPES ADHESIVE REMOVER ALL TYP $1.00 A4456 DRESSING DUO DERM 8X8 $117.00 STOMAHESIVE BARR WAFER 2 3/4 $288.00 A4362 STOMAHESIVE BARR WAFER 1 1/4 $249.00 A4362 STOMAHESIVE WAFER 2 3/4 AC $266.00 A4362 STOMAHESIVE WAFER 4" $297.00 A4362 CATHETER FOLEY 5CC 18F $140.00 CATHETER PLUG STERILE $31.00 STOCKINETTE BY FOOT $1.00 PROTECTOR HEEL/ELBOW $151.00 CATHETER TUBE HOLDER $158.00 TRACHEOSTOMY CLEAN TUBE $91.00 STERI-STRIP 1/4 X 3 $1.00 DRESSING XEROFORM 5X9 $49.00 BANDAGE ELASTIC 4" $49.00 SWABSTICK BETADINE $1.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BANDAGE COMPRESSION KLING 6 IN $57.00 BANDAGE COMPRESSION COBAN 3 IN $52.00 DRESSING XEROFORM 4X4 $24.00 DRESSING DUODERM 6X6 XTRA THIN $67.00 DRESSING NU GAUZ 1/2 IN $141.00 DRESSING KALTOSTAT WOUND $48.00 ALOE VESTA $9.00 NEEDLE HUBER 20G 3/4 LNGTH $131.00 DRESSING NU GAUZ STERILE 2IN $129.00 TAPE MICROFOAM 2" $118.00 CREAM SKIN ALOE VESTA 8OZ $49.00 DRESSING UNNA FLEX BOOT PLUS $274.00 DRESSING NU GAUZ 1" $117.00 DRESSING NU GAUZ 1/4" $91.00 DRESSING DUODERM CGF 5X6 $252.00 DRESSING SAF-GEL 3OZ TUBE $253.00 MASKS FACE SURGICAL 1 BX $31.00 DRESSING DUODERM CGF 4X4 $76.00 A6234 DRESSING KALTOSTAT 2X2 $31.00 DRESSING DUODERM XTRA THIN 6X6 $146.00 BANDAGE ELASTIC 2" $24.00 DRESSING WND COLLAG<=16 4.75IN $63.00 A6021 DRESSING WND COLLAG<=16 4.34IN $54.00 A6021 SALINE WOUND WASH 210ML $38.00 DRESSING HYDROCOL 4X4 $83.00 DRESSING HYDROCOL 4X4 THIN EA $52.00 CATHETER FOLEY INTERMITTENT 14F $18.00 DRESSING AQUACEL PADS AG $106.00 DRESSING AQUACEL PADS PLAIN $84.00 DRESSING UNNA BOOT 4" GELOCAST $160.00 DRESSING COMBIDERM ACD 4X4 $31.00 DRESSING 1" PROTECTVE BIO PTCH $28.00 SKIN BARRIER SUR-FIT 2 1/4 $154.00 DEVICE WOUND MEASUREMENT DISP $9.00 TAPE SURG MEDIPORE CLOTH 2" $56.00 TAPE SURG MEDIPORE CLOTH 4" $92.00 STOMAHESIVE PASTE PER OZ(2OZ) $33.00 A4364 DRESSING ADAPTIC 8X3 $25.00 DRESSING ALLEVYN AG GENTLE $120.00 DRESSING MEPILEX BORDER 6 X 8 $78.00 CREAM SKIN ATRACTAIN 2 OZ $92.00 DRESSING POWDER ARGLAES 5GM $237.00 DRESSING AQUACEL AG ROPE $215.00 DRESSING ALLEVYN 4X4 $57.00 DRESSING MEPILEX 4 X 8 $135.00 DRESSING ALLEVYN HEEL $130.00 DRESSING MEPILEX BORDER 4 X 4 $87.00 DRESSING MEPILEX LITE 4X4 $41.00 CATHETER FOLEY TRAY - ADD $55.00 DRESSING SILVASORB GEL $203.00 A6248 DRESSING TRAY CHG W/CHLOROPREP $146.00 STAPLER REMOVER PSX DISPOSABLE $297.00 DRESSING HYDROCOL SACRAL 6X7 $145.00 DRESSING HYDROGEL 4X4 $42.00 TAPE MICROFOAM 3" $62.00 DRESSING FOAM HYDROFERA BL 6X6 $125.00 DRESSING FM HYDROFRA BL 4X4.75 $79.00 DRESSING FOAM HYDROFERA BL 4X4 $60.00 POUCH OSTOMY HIGH OUTPUT $21.00 WAFER OSTOMY CONVEX $21.00 WAFER OSTOMY NEW IMAGE $13.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
POUCH OSTOMY DRAINABLE $10.00 POUCH UROSTOMY NEW IMAGE $11.00 POWDER OSTOMY 1 OZ $25.00 RING OSTOMY BARRIER $24.00 WAFER OSTOMY BARRIER $12.00 BELT OSTOMY $26.00 A4367 HP HOME HEALTH PT HOME/RESID $428.00 Q5001 HOSPICE-CONTINOUS HOME CARE $2,490.00 Q5001 HP HOSPICE-INP RESPITE KRMC $440.00 Q5005 HP HOSPICE-INP GENERAL KRMC $1,894.00 Q5005 HP SKILLED NURSE SVC EA 15MIN $276.00 G0299 HP CLINICAL SOC WRK SERV 15MIN $397.00 G0155 HP AIDE SERV EA 15MIN $127.00 G0156 HOSPICE-SVS OF CSW TELEPHONE CALL $- G0155 HP HOME HEALTH ASSIST LIVING $428.00 Q5002 HP SKILLED NURSE SVC 15MIN PM $252.00 G0299PM HP AIDE SVC EA 15MIN PM $127.00 G0156PM HP HOSPICE HOUSE-INP RESPITE $401.00 Q5006 HP HOSPICE HOUSE-INP GENERAL $1,725.00 Q5006 HP HOSPICE HOUSE-RM & BOARD $246.00 HP HH AIDE SVC EA 15MIN PM $127.00 G0156PM HP HH CLINICAL SOC WRK 15MIN $397.00 G0155PM HP HH SKILLED NURSE VISIT $276.00 HP HH AID SERVICES VISIT $140.00 G0156 HP HH CSW SERVICES VISIT $436.00 G0155 SUBSEQUENT HOSPITAL CARE $176.00 99232 HOSPITAL DISCH MGMT <=30MIN $222.00 99238 HOME VISIT NEW PAT COMPR $685.00 99345 INITIAL HOSP CARE COMPR $601.00 99223 HOME VISIT EST PAT EXPANDED $239.00 99348 INITIAL HOSP CARE MOD/COMP $405.00 99222 SUBSEQUENT HOSPITAL CARE DETAILED $295.00 99233 HOSP DISCH MNGMT > 30 MIN $359.00 99239 COLLECTION BLOOD VENIPUNCTURE $22.00 36415 IV INFUSION THERAPY INIT =<1HR $729.00 96365 THER/PROPH/DIA ADDL SEQ IV INF $162.00 96366 PHLEBOTOMY THERAPEUTIC $370.00 99195 THER/PROPH/DIAG INJ, IV PUSH $424.00 96374 THER/PROPH/DIAG INJ, SC/IM $172.00 96372 DECLOTTING THROMBOLYTIC AGENT $877.00 36593 DRAW BLOOD OFF VENOUS DEVICE $214.00 36591 OFFICE VISIT BRIEF EST PATIENT $259.00 99211 CHEMO,IV PUSH,SNGL DRUG $876.00 96409 TX/PRO/DX INJ NEW DRUG ADD-ON $193.00 96375 CHEMO/IV PUSH, ADDL DRUG $512.00 96411 CHEMO IV INFUSION, 1 HR $1,240.00 96413 CHEM IV INFUSION, ADDL HR $278.00 96415 CHEMO,IV INFUS EA ADDL SEQ $605.00 96417 IRRIG VAD IMPL DRUG DEL DEVICE $253.00 96523 HYDRATION IV INF INIT;31-60MIN $453.00 96360 HYDRATE IV INFUSION,ADD-ON 1HR $145.00 96361 CHEMO ADMIN SQ/IM HORMONAL $733.00 96402 CHEMO ADMIN SQ/IM NON HORM $733.00 96401 TX/PROPH/DG ADDL SEQ IV INF $158.00 96367 THER/DIAG CONCURRENT INFUSION $153.00 96368 TX/PRO/DX INJ SAME DRUG ADDON $59.00 96376 PROLONG CHEMO INF W/PUMP >8HRS $1,067.00 96416 COLLECT BLOOD FROM PICC $215.00 36592 OFFICE VISIT MODERATE NEW PT $235.00 99203 OFFICE VISIT HIGH NEW PT $329.00 99205 OFFICE VISIT MOD/HIGH NEW PT $243.00 99204
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
OFFICE VISIT MINOR ESTAB PT $222.00 99212 OFFICE VISIT LOW/MOD ESTAB PT $235.00 99213 OFFICE VISIT MOD/HIGH ESTAB PT $302.00 99214 OFFICE VISIT HIGH EST PATIENT $329.00 99215 CONSULTS MODERATE $188.00 99243 CONSULTS MOD TO HIGH $194.00 99244 OFFICE CONSULTS HIGH $264.00 99245 REFILL/MAINT PORTABLE PUMP $348.00 96521 UNLIST CHEMOTHERAPY PROCEDURE $72.00 96549 THER/PROP/DIAG INJ/INF PROC $76.00 96379 CHEMO ADMIN EXTD IV INF W/PUMP $660.00 G0498 APPL ON-BODY INJECT TIMED SUBQ $174.00 96377 OFFICE VISIT BRIEF EST PATIENT $149.00 99211 HEMODIALYSIS, INPATIENT $2,644.00 90935 EMERG DIALYSIS ESRD PATIENT $2,644.00 G0257 OBSERVATION BED ICU HOURLY $139.00 G0378 DIRECT REFER HOSP OBSERV ICU $1,019.00 G0379 OBSERVATION BED 2E HOURLY $125.00 G0378 OBSERVATION BED 2S HOURLY $125.00 G0378 OBSERVATION BED PCU HOURLY $125.00 G0378 DIRECT REFER HOSP OBSERV PCU $1,019.00 G0379 OBSERVATION BED ORT HOURLY $125.00 G0378 DIRECT REFER HOSP OBSERV ORTHO $1,019.00 G0379 DIRECT REFER HOSP OBSERV CDU $1,019.00 G0379 OBSERVATION BED 3B HOURLY $125.00 G0378 DIRECT REFER HOSP OBSERV 3B $1,019.00 G0379 OBSERVATION BED CDU HOURLY $125.00 G0378 OBSERVATION BED 2C HOURLY $125.00 G0378 DIRECT REFER HOSP OBSERV 2C $1,019.00 G0379 OBSERVATION BED 2N HOURLY $125.00 G0378 DIRECT REFER HOSP OBSERV 2E $1,223.00 G0379 DIRECT REFER HOSP OBSERV 2N $1,223.00 G0379 DIRECT REFER HOSP OBSERV 2S $1,223.00 G0379 OBSERVATION BED PED HOURLY $125.00 G0378 DIRECT REFER HOSP OBSERV PED $1,019.00 G0379 IV INFUSION THERAPY INIT =<1HR $787.00 96365 THER/PROPH/DIA ADDL SEQ IV INF $175.00 96366 TX/PROPH/DG ADDL SEQ IVINF>1HR $171.00 96367 THER/DIAG CONCURRENT INFUSION $165.00 96368 TX/PRO/DX INJ SAME DRUG ADD-ON $64.00 96376 HYDRATE IV INFUSION,ADD-ON 1HR $157.00 96361 THER/PROPH/DIAG INJ SC/IM $172.00 96372 TX/PRO/DX INJ SAME DRUG ADD-ON $70.00 96376 TX/PRO/DX INJ NEW DRUG AD <15M $230.00 96375 THER/PROPH/DIAG INJ, IV PUSH $424.00 96374 HYDRATION IV INF INIT;31-60MIN $537.00 96360 INTERMEDIATE VISIT NEW PT PF $230.00 99203 OFFICE VISIT MOD/HIG NEW PT PF $383.00 99204 COMPLEX VISIT, NEW PATIENT $507.00 99205 CONSULT MINOR $105.00 99241 CONSULT LOW $222.00 99242 CONSULT MODERATE $311.00 99243 CONSULT MOD TO HIGH $487.00 99244 CONSULT HIGH $612.00 99245 OFFICE VISIT BRIEF EST PT PF $28.00 99211 OFFICE VISIT MINOR ESTAB PT PF $75.00 99212 INTERMEDIATE VISIT ESTB PAT PF $152.00 99213 OFFICE VISIT MOD/HIG EST PT PF $233.00 99214 OFFICE VISIT HIGH ESTAB PT PF $334.00 99215 PROLONGED SERV >1HR FACE/FACE $362.00 99354 PROLONGED SERV EA ADDL 1/2HR $228.00 99355
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PROLONGED EM WO CONTACT 1ST HR $273.00 99358 PROLONGED EM WO CONTACT 1ST HR $126.00 99358 PROLONG EM WO CONTACT ADD 30MN $58.00 99359 EPIDURAL INJ SGL CERV/THORACIC $337.00 62320 EPIDURAL INJ SGL LUMBAR/SACR $301.00 62322 EPIDURAL INJ CONT CERV/THORAC $314.00 62324 EPIDURAL INJ CONT LUMBAR/SACRA $301.00 62326 LYSIS EPI ADH MULTI 2 DAYS/> $1,163.00 62263 LYSIS EPI ADH ONE DAY NO FLUOR $257.00 62264 SPINAL PUNCTURE LUMBAR DIAG $237.00 62270 EPIDURAL BLOOD PATCH $375.00 62273 NEUROLYTIC;SUBARACHNOID INJ/IN $528.00 62280 NEUROLYTIC;EPIDURAL CERV/THORA $516.00 62281 NEUROLYTIC;EPIDURAL LUMB/CAUDA $483.00 62282 MYELOGRAM INJ AND/OR CT LUMBAR $279.00 62284 ANTH/ST TRA EPID;SGL CERV/THOR $435.00 64479 ANTH/ST TRA EPID;ADDL CER/THOR $240.00 64480 ANTH/ST TRAN EPID;SGL LUMB/SAC $369.00 64483 ANTH/ST TRAN EPID;ADDL LUM/SAC $204.00 64484 INJ PARAVERT F JNT CT 1 LEV PF $350.00 64490 INJ PARAVERT F JNT CT 2 LEV PF $198.00 64491 INJ PARAVERT F JNT L/S 1 LV PF $298.00 64493 INJ PARAVERT F JNT L/S 3 LV PF $158.00 64495 EVAL IMPLANTED PUMP WO PROGR $76.00 62367 EVAL IMPLANTED PUMP W PROGR $116.00 62368 IDET 1ST LEVEL (INCL FLOURO) $1,085.00 22526 IDET EACH ADDL LEVEL $869.00 22527 BH PSYCHOLOGIC TESTING BY PHYS $278.00 96101 PERQ VERTEBROPLASTY THORAC PF $1,855.00 22510 PERQ VERTEBROPLASTY ADD'L PF $787.00 22512 PERQ VERTEBROPLASTY LUMBOSACRA $1,752.00 22511 INJ ANESTH; TRIGEMINAL NRV ANY $233.00 64400 INJ ANES; GRTR OCCIPITAL NV PF $206.00 64405 INJ ANESTH; CERVICAL PLEXUS $267.00 64413 SGL INJ NBI BRACHIAL PLEXUS $227.00 64415 CONT INFUSE NB B PLEXUS SGL PF $553.00 64416 INJ ANESTH; AXILLARY NERVE $231.00 64417 INJ ANEST INTERCOST NVR SGL PF $198.00 64420 INJ ANESTH;INTERCOST NRV MULT $276.00 64421 NERVE BLK ILIOING/ILIOHYPOGAST $302.00 64425 NERVE BLOCK, SGL SCIATIC NRV $243.00 64445 NERVE BLK INJ SCIATIC CONT INF $526.00 64446 NERVE BLOCK, FEMORAL, SGL $219.00 64447 NERVE BLOCK FEM NERVE CONT INF $480.00 64448 NERVE BLK LUMB PLEXUS POST APP $472.00 64449 INJ ANES OTHR PERIP NRV/BRANCH $220.00 64450 INJ ANES,TRANSF EPID;L/S SGL $369.00 64483 INJ ANES; SPHENOPALATINE GANGL $288.00 64505 INJ ANESTH; STELLATE GANGLION $241.00 64510 NERVE BLOCK HYPOGASTRIC PLEXUS $409.00 64517 INJ ANES;LUMB/THOR SYMPATHETIC $267.00 64520 INJ ANESTH; CELIAC PLEXUS $301.00 64530 IMPL/REVISE EPID CATH FOR PAIN $1,533.00 62350 REM PREV IMPL EPIDURAL CATH $1,254.00 62355 IMPLANT SPINE INFUSION PUMP $1,345.00 62361 IMPL/REPL PR PUMP FOR INFUSION $1,683.00 62362 REM SQ RSVR/PUMP PREV EPID INF $1,309.00 62365 INS/REPL SPINE NSTIM PG/RCVR $1,576.00 63685 REV/REM IMPL SPINAL NS PG/RECV $1,243.00 63688 PERC IMPL NS ELECTROD;PERIP NV $451.00 64555 REV/REM PERIPHERA NS ELECTRODE $537.00 64585
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INSRT/REDO PN/GASTRIC STIMUL $595.00 64590 REVISE/RMV PN/GASTRIC STIMUL $480.00 64595 DESTR W NEUROLYTIC;INTRCSTL NV $564.00 64620 DESTR W NEUROLYTIC;PUDENDAL NV $629.00 64630 DESTR W NEUROLYT;OTH PER NV PF $555.00 64640 DESTR W NEUROLYTIC;CELIAC PLEX $543.00 64680 DESTR W NEUROLOGIC; SH PLEXUS $887.00 64681 INJECTION SKIN LESIONS UP TO 7 $91.00 11900 INJECTION SKIN LESION > THAN 7 $141.00 11901 INJ SGL TENDON SHTH/LIGAMNT PF $130.00 20550 INJ TENDON ORIGIN/INSERT $140.00 20551 INJ(S); SGL OR MULT TP 1 OR 2 $125.00 20552 INJ(S);SGL/MULT TRIG PT 3/> PF $143.00 20553 DRAIN/INJ SM JNT/BURSA W/O US $126.00 20600 ARTHRO/AS/INJ ITM J/B WO US PF $130.00 20605 ARTHRO/ASP/IJ MAJ J/B WO US PF $156.00 20610 INJ SAJ;ARTHROGR/ANE W/FLUO PF $251.00 27096 MOD CS BY SAME PHYS 5 YEAR + $195.00 99152 HOSP CONSULT INPATIENT FOCUSED $152.00 99251 INPATIENT CONSULT LOW SEVER PF $244.00 99252 HOSP CONSULT INPATIENT DETAIL $364.00 99253 SUBSEQUENT HOSP CARE LOW COMPL $119.00 99231 SUBSEQUENT HOSP CARE EXPANDED $213.00 99232 SUBSEQUENT HOSP CARE DETAILED $305.00 99233 SPECIAL REPORTS OR FORMS $93.00 99080 INJ DISKOGRAPHY EA LVL LUMBAR $526.00 62290 INJ DISKOGRAPHY EA LVL C/THO $507.00 62291 ACUPUNCT WO STIM INITIAL 15MIN $70.00 97810 ACUPUNCT WO STIM ADDL 15MIN PF $60.00 97811 INJ ANESTH; PUDENDAL NERVE $329.00 64430 PERC IMPL NS ELECTRODE ARRY PF $1,301.00 63650 ANALYZE NEUROSTIM COMPLEX PF $260.00 95972 ACUPUNCT W/STIM INIT 15MIN PF $77.00 97813 ACUPUNCTURE W/STIMUL ADDL 15M $68.00 97814 ACUPUNCT IMS STIM INIT 15MI PF $70.00 97810 ACUPUNCT IMS STIM ADDL 15MI PF $60.00 97811 LUMBAR PUNCTURE DIAG PROF FEE $463.00 62270 INJ PARAVERT F JT L/S 2 LVL PF $147.00 64494 INITIAL HOSP ADMIT MOD COMP PF $405.00 99222 INITIAL HOSP CARE COMPL 70M PF $601.00 99223 INITIAL HOSP ADMIT LOW COMP PF $300.00 99221 BEHAVE CHNG SMOKING <10MIN PF $40.00 99406 BEHAV CHNG SMOKING >10MIN PF $84.00 99407 INJ PARAVERT F JT C/T 3 LVL PF $221.00 64492 DESTROY LUMB/SAC FACET JNT PF $572.00 64635 DESTROY L/S FACET JNT ADDL PF $151.00 64636 DESTROY CERV/THOR FACET JNT PF $584.00 64633 DESTROY CER/T FACET JT ADDL PF $175.00 64634 HOSP INIT OBSER CARE DETAIL PF $243.00 99218 US GUIDED NEEDLE PLACEMENT PF $116.00 7694226 PUNC SHUNT TUB/RES ASP/INJ PF $297.00 61070 SHUNTOGRAM FOR NV SHUNT PROFEE $81.00 7580926 ANAL SP INF PMP W/MD REPRG&FIL $163.00 62370 FLUOROSCOPE EXAM SEPARATE PF $38.00 7600026 CHEMODENERVAT MUSCLE MIGRAI PF $433.00 64615 CHEMODENERVE MUS NECK UNIL PF $360.00 64616 INJ ANEST;SUPRASCAPULAR NRV PF $269.00 64418 DRAIN/INJ SM JNT/BUR W/US PF $242.00 20604 DRN/INJ INTERM JNT/BUR W/US PF $245.00 20606 DRAIN/INJ MAJ JNT/BURS W/US PF $271.00 20611 MYELOGRAPHY LUMBAR;CERV S&I PF $369.00 62302
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
MYELOGRAPHY LUMBAR/THOR S&I PF $369.00 62303 MYELOGRAPHY LUMBAR L/S S&I PF $362.00 62304 MYELOGRAPHY LUMBAR 2>REG SI PF $378.00 62305 CARPAL TUNNEL THERAPEU INJ PF $137.00 20526 EPIDURAL INJ SGL CV/TH W/IM PF $306.00 62321 INJ INTERLAMINAR LU/SA W/IM PF $238.00 62323 CHEMODENERV 1 EXTREM;5>MUS PF $422.00 64644 BRIEF VISIT, NEW PATIENT PF $80.00 99201 LIMITED VISIT, NEW PATIENT PF $150.00 99202 INTERMEDIATE VISIT NEW PT PF $230.00 99203 OFFICE VISIT MOD/HIG NEW PT PF $383.00 99204 COMPLEX VISIT, NEW PATIENT PF $507.00 99205 CONSULT MINOR PROF $105.00 99241 CONSULT LOW PROF $222.00 99242 CONSULT MODERATE PROF $311.00 99243 CONSULT MOD TO HIGH PROF $487.00 99244 CONSULT HIGH PROF $612.00 99245 OFFICE VISIT BRIEF EST PAT PF $28.00 99211 LIMITED VISIT ESTAB PATIENT PF $75.00 99212 INTERMEDIATE VISIT ESTB PAT PF $152.00 99213 OFFICE VISIT MOD/HIG EST PT PF $233.00 99214 OFFICE VISIT HIGH ESTAB PT PF $334.00 99215 PROLONG SERVICE >1HR FACE/FACE $362.00 99354 PROLONG SERVICE EA ADDL 1/2 HR $228.00 99355 PROLONG E/M WO CONTACT 1ST HR $273.00 99358 PROLONG E/M WO CONTACT 1ST HR $126.00 99358 PROLONG EM WO CONTACT ADD 30MN $58.00 99359 EPIDURAL INJ SGL CERV/THORACIC $337.00 62320 EPIDURAL INJ, SGL LUMBAR/SACR $301.00 62322 EPIDURAL INJ CONT CRV/THOR PF $314.00 62324 EPIDURAL INJ CONT LUM/SAC PF $291.00 62326 LYSIS EPI ADH MULTI 2 DAY/> PF $1,163.00 62263 LYSIS EPI ADH 1 DAY (NO FLUOR) $783.00 62264 SPINAL PUNCTURE LUMBAR DIAG PF $257.00 62270 EPIDURAL BLOOD PATCH PROFEE $375.00 62273 NEUROLYTIC;SUBARACHNOID IJ/INF $528.00 62280 NEUROLYTIC; EPIDURAL CRV/THOR $516.00 62281 NEUROLYTIC;EPIDURAL LUMBR/CAUD $483.00 62282 MYELOGRAM INJ &/OR CT LUMBA PF $279.00 62284 ANTH/ST TRANSF EPID;SGL CRV/TH $435.00 64479 ANES/ST TRAN EPID;ADDL CVR/THO $240.00 64480 ANES/ST TRANSF EPID;SGL LU/SAC $369.00 64483 ANES/ST TRANSF EPID;ADDL LU/SA $204.00 64484 INJ PARAVERT F JNT C/T 1LEV PF $350.00 64490 INJ PARAVERT F JNT C/T 2LVL PF $198.00 64491 INJ PARAVERT F JNT L/S 1LVL PF $298.00 64493 INJ PARAVERT F JNT L/S 3LVL PF $158.00 64495 EVAL IMPLANTED PUMP WO PROG PF $76.00 62367 EVAL IMPLANTED PUMP W PROGR PF $116.00 62368 IDET 1ST LEVEL (INCL FLOURO)PF $1,085.00 22526 IDET EACH ADDL LEVEL PROFEE $869.00 22527 BH PSYCHOLOGIC TESTING BY PHYS $278.00 96101 PERQ VERTEBROPLASTY THOR PF $1,855.00 22510 PERQS VERTEBROPLASTY ADDL PF $787.00 22512 PERQ VERTEBROPLASTY LUMB PF $1,752.00 22511 INJ ANESTH;TRIGEMINAL NVR PF $233.00 64400 INJ ANES; GRTR OCCIPITAL NV PF $206.00 64405 INJ ANESTH;CERVICAL PLEXUS PF $267.00 64413 SGL INJ NBI BRACHIAL PLEXUS PF $227.00 64415 CONT INFUSE NB BRACH PLEXU SGL $553.00 64416 INJ ANESTH; AXILLARY NERVE PF $228.00 64417
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INJ ANES INTERCOSTL NER SGL PF $198.00 64420 INJ ANESTH;INTERCOST NRV MULTI $276.00 64421 NERVE BLOCK ILIOING/ILIOHYPOGA $280.00 64425 NERVE BLOCK SGL SCIATIC NRV PF $243.00 64445 NERVE BLK INJ SCIATIC C/INF PF $526.00 64446 NERVE BLOCK, FEMORAL, SGL PF $219.00 64447 NERVE BLOCK FEMORAL NVR C/INF $480.00 64448 NERVE BLK LUMB PLEXUS POST AP $472.00 64449 INJ ANES;OTHR PERIPHER NRV/BRA $220.00 64450 INJ ANES,TRANSF EPID;LUM/SA SG $369.00 64483 INJ ANES;SPHENOPALATINE GANGL $254.00 64505 INJ ANES;STELLATE GANGLION PF $205.00 64510 NERVE BLK HYPOGASTRIC PLEXS PF $362.00 64517 INJ ANES;LUMB/THOR SYMPATHETIC $230.00 64520 INJ ANESTH;CELIAC PLEXUS PF $273.00 64530 IMPL/REVISE EPID CATH FOR PAIN $1,533.00 62350 REM PREV IMPL EPIDURAL CATH PF $1,254.00 62355 IMPLANT SPINE INFUSION PUMP PF $1,345.00 62361 IMPL/REPL PROG PUMP INFUS PF $1,683.00 62362 REM SQ RSVR/PUMP PREV EPID INF $1,309.00 62365 INS/REPL SPINE NSTIM PG/RCV PF $1,576.00 63685 REV/REM IMPL SPINAL NS PG/RECV $1,243.00 63688 PERC IMPL NS ELECTROD;PERI NRV $451.00 64555 REV/REM PERIPHERAL NS ELECTROD $537.00 64585 INSRT/RED PN/GASTRIC STIMUL PF $595.00 64590 REVISE/RMV PN/GASTRIC STIMU PF $480.00 64595 DESTR W NEUROLYTIC;INTERCOST N $501.00 64620 DESTR W NEUROLYTIC;PUDENDAL NV $572.00 64630 DESTR W NEUROLYTIC;OTH PERI PF $555.00 64640 DESTR W NEUROLYTIC;CELIAC PLEX $485.00 64680 DESTR W NEUROLOGIC;SH PLEXU PF $672.00 64681 INJ SKIN LESIONS =<7 PF $91.00 11900 INJ SKIN LESION >7 PF $141.00 11901 INJ SGL TENDON SHTH OR LIGAMENT PF $129.00 20550 INJ TENDON ORIGIN/INSERT PF $134.00 20551 INJ(S); SGL OR MULT TP 1 OR 2 $114.00 20552 INJ(S);SGL/MULT TRIG PT 3/> PF $96.00 20553 DRAIN/INJ SM JNT/BUR WO US PF $126.00 20600 ARTHRO/AS/INJ ITM J/B WO US PF $130.00 20605 ARTHRO/ASP/IJ MAJ J/B WO US PF $156.00 20610 INJ SAJ;ARTHROGR/ANES W/FLUORO $251.00 27096 MOD CS BY SAME PHYS 5/>YRS PF $195.00 99152 HOSP CONSULT INPATIENT FOCUSED $152.00 99251 INPATIENT CONSULT LOW SEVERITY $244.00 99252 HOSP CONSULT INPATIENT DETAIL $364.00 99253 SUBSEQUENT HOSP CARE LOW COMPL $119.00 99231 SUBSEQUENT HOSP CARE EXPANDED $213.00 99232 SUBSEQUENT HOSP CARE DETAILED $305.00 99233 SPECIAL REPORTS OR FORMS PF $93.00 99080 INJECT DISKOGRAPHY EA LVL LUMB $526.00 62290 INJ DISKOGRAPHY EA LVL C/THO $507.00 62291 ACUPUNCTURE,WO STIM INIT 15MIN $70.00 97810 ACUPUNCT WO STIM ADDL 15MIN PF $60.00 97811 INJ ANESTH; PUDENDAL NERVE PF $329.00 64430 PERC IMP NS ELECTRODE ARRAY PF $1,301.00 63650 ANALYZE NEUROSTIM COMPLEX PF $260.00 95972 ACUPUNCTURE W/STIM INIT 15 MIN $77.00 97813 ACUPUNCTURE W/STIM ADDL 15M PF $68.00 97814 ACUPUNCTURE,IMS STIM INIT 15MI $70.00 97810 ACUPUNCTURE,IMS STIM ADDL 15MI $60.00 97811 LUMBAR PUNCTURE DIAG PROF FEE $463.00 62270
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INJ PARAVERT F JNTLU/SA 2LV PF $147.00 64494 INITIAL HOSP ADMIT MOD COMP PF $363.00 99222 INITIAL HOSP CARE COMPL 70M PF $601.00 99223 INITIAL HOSP ADMIT LOW COMP PF $300.00 99221 BEHAVE CHNG SMOKING <10 MIN PF $37.00 99406 BEHAV CHNG SMOKING >10MIN PF $84.00 99407 INJ PARAVERT F JNT C/T 3LVL PF $221.00 64492 DESTROY LUMB/SAC FACET JNT PF $572.00 64635 DESTROY L/SA FACET JNT ADDL PF $151.00 64636 DESTROY CERV/THOR FACET JNT PF $584.00 64633 DESTROY C/TH FACET JNT ADDL PF $175.00 64634 HOSP INIT OBSERV CARE DET PF $243.00 99218 U/S GUIDED NEEDLE PLACEMENT PF $116.00 7694226 PUNC SHUNT TUBI/RES ASP/INJ PF $297.00 61070 SHUNTOGRAM FOR NV SHUNT PROFEE $81.00 7580926 ELEC SP INF PMP W/MD REPRG&FIL $163.00 62370 FLUOROSCOPE EXAM SEPARATE PF $38.00 7600026 CHEMODENERVAT MUSC MIGRAINE PF $433.00 64615 CHEMODENERVE MUS NECK DYS U PF $332.00 64616 OFFICE VISIT BRIEF EST PATIENT $163.00 99211 INJ ANEST;SUPRASCAPULAR NVR PF $269.00 64418 DRAIN/INJ SM JNT/BUR W/US PF $242.00 20604 DRN/INJ INTERM JNT/BUR W/US PF $245.00 20606 DRAIN/INJ MAJ JNT/BURS W/US PF $271.00 20611 MYELOGRAPHY LUMBAR;CERV S&I PF $369.00 62302 MYELOGRAPHY LUMBAR/THOR S&I PF $369.00 62303 MYELOGRAPHY LUMBAR L/S S&I PF $362.00 62304 MYELOGRAPHY LUMBAR 2>REG SI PF $378.00 62305 CHEMODENERV 1 EXTR;1-4 MUSC PF $329.00 64642 CHEMODENERV 1EXTR 1-4EA ADD PF $218.00 64643 GUIDE NERV DESTR NEEDLE EMG PF $70.00 95874 INJ INTERLAMINAR LUM/SA W/I PF $238.00 62323 INJ INTERLAMINAR CE/TH W/IM PF $261.00 62321 OFFICE VISIT BRIEF EST PATIENT $163.00 99211 THER/PROPH/DIAG INJ, SC/IM $173.00 96372 TX/PRO/DX INJ NEW DRUG ADD-ON $107.00 96375 THER/PROPH/DIAG INJ, IV PUSH $424.00 96374 INJ(S); SGL OR MULT TP 1 OR 2 $580.00 20552 INJ(S);SGL/MULT TRIGGER PT 3/> $580.00 20553 DRAIN/INJ SM JNT/BURSA WO/US $580.00 20600 ARTHRO/ASP/INJ ITM JT/BR WO US $580.00 20605 ARTHRO/ASP/IJ MAJ JNT/BR WO US $580.00 20610 INJ SGL TENDON SHEATH/LIGAMENT $580.00 20550 INJ TENDON ORIGIN/INSERT $580.00 20551 EPIDURAL BLOOD PATCH $1,878.00 62273 INJ ANESTH; TRIGEMINAL NVR ANY $580.00 64400 INJ ANESTH; GRTR OCCIPITAL NVR $586.00 64405 INJ ANESTH; CERVICAL PLEXUS $1,488.00 64413 SGL INJ NBI BRACHIAL PLEXUS $2,090.00 64415 CONT INFUSE NB BRACH PLEXU SGL $2,090.00 64416 INJ ANESTH; AXILLARY NERVE $1,488.00 64417 INJ ANEST INTERCOSTL NERVE SGL $1,488.00 64420 INJ ANESTH; STELLATE GANGLION $1,878.00 64510 ANES/ST TRANSF EPID;SGL CRV/TH $1,743.00 64479 ANES/ST TRANSF EPID;ADDL C/THO $888.00 64480 ANES/ST TRANSF EPID;SGL LUM/SA $1,743.00 64483 ANES/ST TRANSF EPID;ADDL LUM/S $888.00 64484 EPIDURAL INJ SGL CERV/THORACIC $1,967.00 62320 INJ PARAVERT F JNT LS 3LV FLUO $661.00 64495 EPIDURAL INJ SGL LUMBAR/SACR $1,118.00 62322 INJ PARAVERT F JT C/T 1LV FLUO $2,145.00 64490
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INJ PARAVERT F JNT L/S 1INC FL $1,763.00 64493 INJ PARAVERT F JNT C/T 2 LEV $826.00 64491 INJ SAJ; ARTHROGR/ANESTHETIC $1,878.00 G0260 MOD CS BY SAME PHYS 5 YEAR + $340.00 99152 PERC IMPL NS ELECTR ARRAY EPID $1,686.00 63650 ANALY NEUROSTIMULATOR COMPLEX $348.00 95972 FEMORAL N BLOCK, SGL $1,058.00 64447 NERVE BLOCK, SGL SCIATIC NRV $1,878.00 64445 LUMBAR PUNCTURE DIAGNOSTIC $1,058.00 62270 INJ DISKOGRAPHY EA LVL LUMBAR $1,722.00 62290 INJ DISKOGRAPHY EA LEV C/THOR $1,093.00 62291 INJ PARAVERT F JNT L/S 2LVL FL $661.00 64494 BEHAV CHNG SMOKING <10 MIN $67.00 99406 BEHAV CHNG SMOKING > 10 MIN $67.00 99407 OFFICE VISIT MINOR ESTAB PT $179.00 99212 EPIDURAL INJ CONT CERV/THORAC $1,516.00 62324 INJ ANESTH; PUDENAL NERVE $2,394.00 64430 INJ ANES INTERCOST NRV MULT RG $1,878.00 64421 INJ ANES LUMB/THOR SYMPATHETIC $1,594.00 64520 INJ ANES OTHR PERIPH NRV/BRA $1,198.00 64450 DESTR W NEUROLYTIC;INTERCOST N $4,045.00 64620 INJ PARAVERT F JNT C/T 3 LEV $592.00 64492 THER/PROPH/DIA ADDL SEQ IV INF $112.00 96366 IV INFUSION THERAPY INIT =<1HR $633.00 96365 OFFICE VISIT NEW PT LIMITED $186.00 99202 DESTROY LUM/SA FACET JNT AGENT $3,260.00 64635 DESTROY LUM/SAC FACET JNT ADDL $1,804.00 64636 DESTROY CE/THO FACET JNT AGENT $4,045.00 64633 DESTROY CV/THOR FACET JNT ADDL $630.00 64634 U/S GUIDED NEEDLE PLACEMENT $468.00 76942 CHEMODENERVATIOION MUSC MIGRAI $688.00 64615 ANL SP INF PMP W/MD REPRG&FIL $664.00 62370 CHEMODENERVE MUSC NECK DYS UNI $688.00 64616 INJ ANESTH;SUPRASCAPULAR NERVE $1,059.00 64418 DRAIN/ASP/INJ JOINT/BURSA W/US $800.00 20604 DRAIN/INJ INTER JNT/BURSA W/US $1,058.00 20606 DRAIN/INJ MAJOR JNT/BURSA W/US $800.00 20611 MYELOGRAPHY LUMB INJ CERV S&I $1,715.00 62302 MYELOGRAPHY LUMB INJ THOR S&I $1,841.00 62303 MYELOGRAPHY LUMBAR IJ 2>REG SI $1,841.00 62305 MYELOGRAPHY LUMBAR INJ L/S S&I $1,841.00 62304 CARPAL TUNNEL THERAPUTIC INJ $582.00 20526 DESTR W NEUROLYTIC;OTH PERI NV $1,629.00 64640 EPIDURAL INJ SGL C/THOR W/IMGE $1,967.00 62321 INJ INTERLAMINAR LUMB/SAC W/IM $1,294.00 62323 CHEMODENERVR 1 EXTREM;5>MUSCLE $1,294.00 64644 THER/PROPH/DIAG INJ, SC/IM $90.00 96372 TX/PRO/DX INJ NEW DRUG ADD-ON $113.00 96375 THER/PROPH/DIAG INJ, IV PUSH $424.00 96374 INJ(S); SGL OR MULT TP 1 OR 2 $580.00 20552 INJ(S);SGL/MULT TRIGGER PT 3/> $580.00 20553 DRAIN/INJ SM JNT/BURS WO U/S $510.00 20600 ARTHRO/ASP/INJ ITM JT/BR WO US $510.00 20605 ARTHRO/ASP/IJ MAJ JNT/BR WO US $510.00 20610 INJ SGL TENDON SHEATH/LIGAMENT $332.00 20550 INJ TENDON ORIGIN/INSERT $482.00 20551 EPIDURAL BLOOD PATCH $1,878.00 62273 INJ ANESTH; TRIGEMINAL NVR ANY $580.00 64400 INJ ANESTH; GRTR OCCIPITAL NVR $586.00 64405 INJ ANESTH; CERVICAL PLEXUS $1,488.00 64413 SGL INJ NBI BRACHIAL PLEXUS $2,090.00 64415
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CONT INFUSE NB BRACH PLEXU SGL $2,090.00 64416 INJ ANESTH; AXILLARY NERVE $1,488.00 64417 INJ ANEST INTERCOSTL NERVE SGL $1,488.00 64420 INJ ANESTH; STELLATE GANGLION $1,878.00 64510 ANES/ST TRANSF EPID;SGL C/THOR $1,743.00 64479 ANES/ST TRANSF EPID;ADDL C/THO $888.00 64480 ANTH/ST TRANSF EPID;SGL LUM/SA $1,743.00 64483 ANES/ST TRANSF EPID;ADDL LUM/S $888.00 64484 EPIDURAL INJ SGL CERV/THORACIC $1,967.00 62320 INJ PARAVERT F JNT LS 3LV FLUO $661.00 64495 EPIDURAL INJ SGL LUMBAR/SACR $1,118.00 62322 INJ PARAVERT F JNT C/T 1L FLUO $2,145.00 64490 INJ PARAVERT F JNT L/S 1 FLUOR $1,763.00 64493 INJ PARAVERT F JNT C/T 2 LEV $826.00 64491 INJ SAJ; ARTHROGR/ANESTHETIC $1,878.00 G0260 MOD CS BY SAME PHYS 5 YEAR + $340.00 99152 PERC IMPL NS ELECTR ARRAY EPID $1,686.00 63650 ANALYZE NEUROSTIMULATOR COMPLX $348.00 95972 FEMORAL N BLOCK, SGL $1,058.00 64447 NERVE BLOCK, SGL SCIATIC NRV $1,878.00 64445 LUMBAR PUNCTURE DIAGNOSTIC $1,058.00 62270 INJ DISKOGRAPHY EA LVL LUMBAR $1,722.00 62290 INJ DISKOGRAPHY EA LVL C/THOR $1,093.00 62291 INJ PARAVERT F JNT L/S 2L FLUO $661.00 64494 BEHAV CHNG SMOKING <10 MIN $67.00 99406 BEHAV CHNG SMOKING > 10 MIN $67.00 99407 OFFICE VISIT MINOR ESTAB PT $179.00 99212 EPIDURAL INJ CONT C/THORACIC $1,516.00 62324 INJ ANESTH; PUDENAL NERVE $2,394.00 64430 INJ ANES;INTERCOST NV MULT REG $1,878.00 64421 INJ ANES;LUMB/THOR SYMPATHETIC $1,594.00 64520 INJ ANES;OTHR PERIPH NRV/BRACH $1,198.00 64450 DESTR W NEUROLYTIC;INTRCSTL NV $4,045.00 64620 INJ PARAVERT F JNT C/T 3 LEV $592.00 64492 THER/PROPH/DIA ADDL SEQ IV INF $112.00 96366 IV INFUSION THERAPY INIT =<1HR $633.00 96365 LIMITED VISIT NEW PATIENT $186.00 99202 DESTROY LUM/SA FACET JNT AGENT $3,260.00 64635 DESTROY LUM/SAC FACET JNT ADDL $1,804.00 64636 DESTROY CE/THO FACET JNT AGENT $4,045.00 64633 DESTROY C/THOR FACET JNT ADDL $630.00 64634 U/S GUIDED NEEDLE PLACEMENT $468.00 76942 CHEMODENERV MUSCLE MIGRAINE $688.00 64615 ANL SP INF PMP W/MD REPRG&FIL $664.00 62370 CHEMODENERVE MUSC NECK DYS UNI $688.00 64616 INJ ANES;SUPRASCAPULAR NERVE $1,059.00 64418 DRAIN/INJ SM JNT/BURSA W/US PF $582.00 20604 DRAIN/INJ INTER JNT/BURSA W/US $1,058.00 20606 DRAIN/INJ MAJOR JNT/BURSA W/US $800.00 20611 MYELOGRAPHY LUMBAR INJ CER S&I $1,715.00 62302 MYELOGRAPHY LUMBAR INJ THOR SI $1,841.00 62303 MYELOGRAPHY LUMBAR INJ L/S S&I $1,841.00 62304 MYELOGRAPHY LUMB INJ 2>REG SI $1,841.00 62305 CHEMODENERV 1 EXTREM;1-4 MUSCL $1,133.00 64642 CHEMODENERV 1 EXTRM 1-4EA ADDL $1,025.00 64643 INJ ANES;SPHENOPALATINE GANGLI $625.00 64505 GUIDE NERV DESTR NEEDLE EMG $42.00 95874 INJ INTERLAMINAR LUMB/SAC W/IM $1,294.00 62323 INJ INTERLAMINAR C/THOR W/IMAG $1,294.00 62321 BRIEF VISIT, NEW PATIENT $378.00 99201 LIMITED VISIT, NEW PATIENT $352.00 99202
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INTERMEDIATE VISIT NEW PATIENT $405.00 99203 OFFICE VISIT MOD/HIGH NEW PT $518.00 99204 COMPLEX VISIT, NEW PATIENT $779.00 99205 OFFICE VISIT BRIEF EST PATIENT $259.00 99211 OFFICE VISIT MINOR ESTAB PT $356.00 99212 INTERMEDIATE VISIT ESTAB PT $377.00 99213 OFFICE VISIT MOD/HIGH ESTAB PT $518.00 99214 OFFICE VISIT HIGH EST PATIENT $593.00 99215 STRAPPING; UNNA BOOT $419.00 29580 APPLY RIG TOTAL CONT LEG CAST $703.00 29445 DEBRIDEMENT-NON SELECT WO ANES $388.00 97602 DEBRIDEMENT-SELECTIVE <20SQ CM $856.00 97597 DEBRIDEMENT-SELECT >20 SQ CM $856.00 97598 NEG PRESSURE WND TX <50 SQ CM $378.00 97605 PARING/CUTTI BENIGN LESION 2-4 $329.00 11056 NEG PRESSURE WND TX >50 SQ CM $697.00 97606 DEB SUBQ TISSUE 20 SQ CM/< $1,133.00 11042 DEBRIDE SKIN SUB TIS&MUS 20CM< $1,069.00 11043 DEBRIDE SKIN TO BONE 20SQ CM/< $2,629.00 11044 CHEM CAUT GRANULATION TISSUE $662.00 17250 BIOPSY OF SKIN SINGLE LESION $691.00 11100 I&D ABSCESS; SIMPLE OR SINGLE $754.00 10060 DEBRIDEMENT OF NAILS, 1-5 $301.00 11720 APPLY MULTILAY COMPRS LWR LEG $524.00 29581 DEBRI SUBQ TISS ADD=<20SQCM PF $1,007.00 11045 DEBRIDE MUS/FASCI ADDON 20SQCM $1,007.00 11046 DEBRIDE BONE ADDON ADDL 20SQCM $2,501.00 11047 PARING/CUT BENIGN LESION SGL $298.00 11055 SKIN SUB GRAFT TRNK/AR/LG>25CM $886.00 15271 SKIN SUB GRAFT T/A/L ADDL 25CM $326.00 15272 SKIN SUB GRAFT T/A/L>100 CHILD $1,348.00 15273 SKIN SUB GRFT T/A/L ADD100 CHI $886.00 15274 SKIN SUB GRAFT FA/NK/H/G >25CM $886.00 15275 SKIN SUB GRAFT F/N/H/G ADD CHI $870.00 15278 NEG PRESS WND TX NDME SES>50CM $436.00 97608 NEG PRESS WND TX NDME SES<50 $438.00 97607 SM DSG/DEBRID PART THICK BURNS $419.00 16020 SIMPL REPR 2.5CM/
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TX/PRO/DX INJ NEW DRUG ADDON $197.00 96375 PUNCT ASP BRST CYST INITIAL $1,272.00 19000 DIGITAL DIAG MAMMOGRAPHY BILAT $585.00 77066 DIGITAL DX UNIL MAMMO INCL CAD $383.00 77065 DIGITAL SCREEN BI MAMMOGRAM $284.00 77067 SURGICAL SPECIMEN $1,015.00 76098 BX BREAST 1ST LESION US IMAGE $2,811.00 19083 BX BREAST 1ST LESION STEROTCTC $2,811.00 19081 BX BREAST PLMT LOCAL ADDL SPEC $1,997.00 19082 BIOPSY BREAST US GUIDE EA ADDL $1,997.00 19084 BX BREAST 1ST LESION MR IMAGE $3,597.00 19085 BX BREAST MR GUIDE ADDL LESION $2,176.00 19086 PLCMT PERC DEV BRST 1ST LESION $1,213.00 19281 PLCMT PERC BREAST ADDL LESION $298.00 19282 PLCMT PERC BREAST 1ST LESION $1,213.00 19285 PLCMT PERC BREAST ADDL LESION $298.00 19286 SCR DIGITAL BREAST TOMOSYNTHES $51.00 77063 DIAG BREAST TOMOSYNTHESIS;UNIL $51.00 G0279 DIAG BREAST TOMOSYNTHES BILAT $51.00 G0279 INS CATH REN ART 1ST UNILAT $8,144.00 36251 INS CATH REN ART 2ND+ UNILAT $8,144.00 36253 REPLACE G/C TUBE PERC $1,907.00 49450 ILIAC REVASC TLBA INIT VESSEL $20,181.00 37220 ILIAC REVASC TLBA W/STENT 1ST $32,041.00 37221 ILIAC REVASC TLBA W/STENT ADDL $30,810.00 37223 ILIAC REVASC TLBA ADDL VESSEL $23,506.00 37222 FEM/POP UNILATERAL;ANGIOPLASTY $23,257.00 37224 FEM/POPL REVAS W/ATHER UNILAT $36,567.00 37225 CYST/ABCESS CONTRAST INJECTION $1,433.00 49424 PLACEMENT DUOD/JEJUNOSTOM TUBE $3,466.00 49441 REPLACE G-JEJUNOSTOMY TUBE $1,809.00 49452 INJ CONTRAST GASTRO/JEJUN TUBE $557.00 49465 CHANGE CYSTOSTOMY TUBE SIMPLE $1,111.00 51705 CISTERNAL/LAT C1-C2 PUNCT INJ $2,047.00 61055 NONSELEC CATH SUP/INF VENA CAV $1,032.00 36010 SELEC CATH VEIN;1ST ORD FAM $1,566.00 36011 SELEC CATH VEIN;2ND ORD FAMILY $1,163.00 36012 NONSELEC CATH RT HEART/MAIN PA $648.00 36013 SELECTIVE CATH-L/R PULMON ART $792.00 36014 SELECT CATH - SEGMENTAL ARTERY $924.00 36015 INTRO CATH AORTA $1,514.00 36200 SEL CATH ART-BRACH-CEP;1ST ORD $2,375.00 36215 SEL CATH ART-BRAC-CEPH;2ND ORD $2,085.00 36216 SEL CATH ART-BRAC-CEPH 3RD ORD $2,419.00 36217 SEL CATH ART LOW EX ABD;1ST OR $1,680.00 36245 PERC TRANSLUM THROMBECTOMY NC $11,236.00 37184 PERC TRANSLUM THROMB VEINS $10,603.00 37187 TRANSCATH STENT CCA W/EPS $13,558.00 37215 FEM/POPL REVASC W/STENT $34,701.00 37226 TIB/PERONEAL W/TLA INIT VESSEL $21,916.00 37228 TIB/PER REVASC ADD-ON $16,740.00 37232 REM TUNNELED CVAD W PORT/PUMP $3,595.00 36590 MECHANICAL REM OBSTRUCTED CVAD $6,118.00 36595 MECHANICAL REM OBSTR CVAD LUME $2,685.00 36596 REMOVE URETER STENT PERCUT $4,234.00 50384 OPERATING ROOM PER MIN IMAGING $166.00 LASER ABLTN EXT VEIN 1ST VEIN $6,505.00 36478 REMOVAL HEPATIC SHUNT TIPS $27,988.00 37183 INS CATH ABD/L-EXT ART 2ND ORD $1,887.00 36246 PERCUTANEOUS CHOLECYSTOSTOMY $7,060.00 47490 REPLACE DUOD/JEJ TUBE PERC $1,651.00 49451
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
REM/REPLACE NEPHROURETERA CATH $3,934.00 50387 PERC NEPHROSTOLITHOTOMY; <2 CM $15,840.00 50080 PERC PORTAL VEIN CATHETERIZATI $683.00 36481 IV INFUSION THERAPY INIT =<1HR $864.00 96365 IRRIG OF VAD IMPL DRUG DEL DEV $300.00 96523 EPIDURAL INJ SGL LUMBAR/SACR $1,398.00 62322 REMOVE ENDOVAS VENA CAVA FILTR $8,310.00 37193 INSERT VENACAVA FILTER ENDOVAS $11,699.00 37191 REMOVE FOREIGN BODY DEEP THIGH/KNEE $5,632.00 27372 ENTEROCLYSIS SMALL BOWEL $1,594.00 74251 TC PLCMNT OPEN/PERQ STENT 1ST $31,058.00 37236 DRAIN/INJ SM JNT/BURSA WO U/S $1,161.00 20600 VASC EMBOLIZE/OCCLUDE ORGAN $31,655.00 37243 ANTEGRADE UROGRAPHY $3,148.00 74425 PERCUT VERTEBROPLASTY LUMBAR $8,491.00 22511 INJ SINUS TRACT DIAG SINOGRAM $392.00 20501 THROMBOLYTIC ART THERAPY $9,263.00 37211 CESSJ THERAPY CATH REMOVAL $5,287.00 37214 ARTHRO/ASP/INJ ITM JT/BR WO US $929.00 20605 SEL CATH ART LOW EX ABD;3RD OR $1,539.00 36247 INJECT VENOGRAM $278.00 36005 INJ FOR CYSTOGRAM $222.00 51600 INJ PROC RENAL CYST $1,892.00 50390 PLACE CATH CAROTID/INOM ART $5,614.00 36222 PLACE CATH EXT CAROTID ART AO $3,270.00 36227 MOD CS BY SAME PHYS, 5 YRS + $386.00 99152 MOD CS BY SAME PHYS, <5 YEARS $386.00 99151 INS TUNNELED CVAD W/PORT 5YR/> $8,784.00 36561 INS NON-TUNNEL CV CATH 5 YRS> $2,050.00 36556 PERC IMG GUID DRAIN PERI/RETRO $4,164.00 49406 CHEMO ADMIN IV PUSH TECH $620.00 96420 VERTEBROPLASTY ADDL INJ TH/LUM $8,491.00 22512 INS TUNNELED CV CATH AGE 5/> $6,988.00 36558 THROMBOLYTIC VENOUS THERAPY $5,572.00 37212 EXCH PREVIOUS DRAIN CATH $3,595.00 49423 FLUORO GUIDE CENTRAL VAD $770.00 77001 REPLACED PERIPHERALLY CVA CATH $4,264.00 36584 VASC EMBOLIZE/OCCLUDE BLEED $31,655.00 37244 SPINAL PUNCT LUMBAR DIAGNOSTIC $1,630.00 62270 ARTHRO/ASP/IJ MAJ JNT/BR WO US $1,161.00 20610 GUIDE CATHETER FLUID DRAINAGE $2,382.00 10030 CHANGE URETEROSTOMY TUBE $3,536.00 50688 PERCUT VERTEBROPLASTY THORAC $10,614.00 22510 INJ TO SEE ILEAL CONDUIT $914.00 50690 REPLACE TUNNEL CV CATH $6,984.00 36581 REPOSITION CVC W FLUORO $2,709.00 36597 RPLC NON-TUNNEL CV CATH $2,709.00 36580 INJ W/FLUORO EVAL CV DEVICE $398.00 36598 REMOVAL TUNNELED CV CATHETER $2,822.00 36589 INSERT PICC W/O PORT >5 YRS $3,815.00 36569 REMOVE RENAL TUBE W/FLUORO $2,093.00 50389 INSERT INDWELLING PLEURAL CATH $6,070.00 32550 REM INDWELL TUNNL PLEURAL CATH $1,277.00 32552 REMOVE INTRAPERITONEAL CATH $6,734.00 49422 STAB PHLEB VARICOSE VEIN >20 $6,772.00 37766 REMOVE INTRVAS FOREIGN BODY $7,705.00 37197 PORTOGRAM PERC TRANSHEP WO HDM $2,620.00 75887 THROMBOYLYTIC ART/VEIN THERAPY $6,065.00 37213 INJ PERC EXTR ANEURYSM $1,615.00 36002 TRANSCATHETER BIOPSY $9,263.00 37200 STAB PHLEB VARICOSE VEIN 10>20 $5,572.00 37765
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
INSERT TUNNELED IP CATH PERC $7,785.00 49418 INSERT CATH REN ART 1ST BILAT $8,144.00 36252 BIOPSY/EXC LYMPH NODE NEEDLE $2,811.00 38505 ARTHROGRAM SHOULDER S&I $2,141.00 73040 SHOULDER ARTHROGRAM INJ $222.00 23350 VASC EMBOLIZE/OCCLUDE ARTERY $31,655.00 37242 TC PLCMT OPEN/PERQ STENT ADDL $12,547.00 37237 NG TUBE PLC W FLUORO $825.00 43752 VASC EMBOLIZE/OCCLUDE VENOUS $31,655.00 37241 OPEN/PERQ PLACE STENT SAME 1ST $31,058.00 37238 INSERT CATH PLEURA W/IMAGE $2,190.00 32557 INJ SCLEROSING SOLN-SGL VEIN $441.00 36470 ASPIRATION BL W/CATH INSERTION $5,043.00 51102 OFFICE VISIT LOW/MOD ESTAB PT $279.00 99213 DRAIN/ASP/INJ JOINT/BURSA W/US $2,489.00 20604 DRAIN/INJ INTERM JNT/BUR W/US $2,662.00 20606 DRAIN/INJ MAJOR JNT/BURSA W/US $3,604.00 20611 PERQ VERT CERVICOTHOR W/FLOURO $11,938.00 22510 PERQ VERTEBROPLASTY W/FLOURO $11,938.00 22511 PERQ VERT EA ADDL C/LS W GUIDE $11,424.00 22512 PERQ ABLAT LIVER TUM CRYOABLAT $11,434.00 47383 ABLATION PULM TUMOR PERQ CRYBL $11,434.00 32994 HYSTEROSALPINGIOGRAM INJ $670.00 58340 INJ SCLEROSING MULTI SAME LEG $408.00 36471 OPEN/PERQ PLC STENT EA ADDL $15,018.00 37239 MYELOGRAPHY LUMB INJ CERV S&I $1,715.00 62302 MYELOGRAPHY LUMB INJ THOR S&I $1,841.00 62303 MYELOGRAPHY LUMBAR INJ L/S S&I $1,841.00 62304 HIP ARTHROGRAPHY INJ WO ANESTH $222.00 27093 KNEE ARTHROGRAPHY INJ CONTRAST $221.00 27370 KNEE, ARTHROGRAM $1,841.00 73580 CHEMO CNS (INTRATHECAL) W LP $785.00 96450 BILIARY ENDO PERQ DX W/SPECIM $6,070.00 47552 URETHROGRAM RETROGRADE S&I $730.00 74450 RETRO INJ URETHRA $512.00 51610 NONSELECTIVE CATH PLMT IN VEIN $135.00 36000 INJ PX NFROSGRM&/URTRGRM GUIDE $1,464.00 50430 INJ PX NFROSGRM&/URTRGRM EXIST $1,464.00 50431 PLMT NEPHROSTOMY CATHETER COMP $4,209.00 50432 PLACE NEPHROURETERAL CATH NA $4,209.00 50433 CONVERT NEPHROSTOMY CATHETER $1,464.00 50434 EXCHANGE NEPHROSTOMY CATH COMP $1,464.00 50435 PLCMT URETERAL STENT PERQ COMP $6,266.00 50693 PLCMT URETERAL STNT PRQ NEW AC $6,266.00 50694 PLMT URETERAL STENT PRQ SEP NC $6,266.00 50695 BALLOON DILATE URETERAL STRICT $3,848.00 50706 ANGIO PULMONARY BILAT S&I $7,010.00 75743 SCLEROTHERAPY FLUID COLLECTION $2,631.00 49185 INJ CHOLANGIOGRAM EXIST ACCESS $982.00 47531 INJ CHOLANGIOGRAM NEW ACCESS $6,080.00 47532 PLMT BILIARY DRAIN CATH EXTERN $6,080.00 47533 PLMT BILIARY DRAINAGE CATH I/E $6,080.00 47534 CONVERSION EXT BIL DRG CATH $6,080.00 47535 EXCHANGE BILIARY DRG CATH $6,080.00 47536 REMOVE BILIARY DRAIN CATH PERC $1,550.00 47537 PERQ PLMT BILE DUCT STNT EXIST $11,503.00 47538 PERQ PLMT BILE DUCT STENT NEW $11,503.00 47539 PERQ PLMT BILEDUCT STENT W/BDC $11,503.00 47540 INJ SAJ; ARTHROGR/ANESTHETIC $1,878.00 27096 PLACE SOFT TISSUE LOC DVC PERC $1,342.00 10035 PLC SOFT TISS DEVICE PERC ADDL $676.00 10036
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BALLOON DILATE BILIARY DUC/AMP $3,848.00 47542 REMOVE DUCT GALLBLADDR CALCULI $4,287.00 47544 INTRO NEE/CATH DIALY CIR GUIDE $1,744.00 36901 INTRO NEE/CATH DIALY TLB ANGIO $12,296.00 36902 INTRO NEE/CATH DIAL W/TL STENT $24,851.00 36903 PERC TRANSL THRMBC/NSF DIA CIR $12,296.00 36904 INTRO NEE/CATH TLBA PERIP DIAL $24,851.00 36905 INTRO NEE/CATH TCP INTRAV STNT $37,599.00 36906 BALLOON ANGIOP CTR DIALYSIS SG $2,478.00 36907 STENT PLC CT DIALY SEG IMG S&I $2,478.00 36908 DIALYSIS CIRCUIT EMBOLIZATION $2,478.00 36909 TBA INC IMAGE GUIDE 1ST ARTERY $12,296.00 37246 TBA EACH ADDL ARTERY $5,832.00 37247 TBA W IMAGE INITIAL 1ST VEIN $12,296.00 37248 TBA EA ADDL VEIN $5,832.00 37249 MOD SED OTHER PHYS/QHP <5 <15M $357.00 99155 MOD SED OTH PHYS/QHP 5> <15MIN $357.00 99156 MOD SED OTH PHY/QHP 5>ADDL 15M $357.00 99157 MOD SED SAME PHY/QHP ADDL 15M $75.00 99153 BRIEF VISIT ESTAB PT W/RN $138.00 99211 CHEST TUBE REPOSITIONING $1,616.00 32999 OBSERVATION CARE DISCHG MGM PF $217.00 99217 HOSP INIT OBSERV CARE DTAIL PF $296.00 99218 HOSP INIT OBSERV MOD COMP PF $403.00 99219 HOSP INIT OBSERV HIGH COMP PF $552.00 99220 INITIAL HOSP ADMIT LOW COMP PF $300.00 99221 INITIAL HOSP ADMIT MOD COMP PF $411.00 99222 INITIAL HOSP CARE COMPL 70M PF $601.00 99223 HOSP OBSERV SUBSEQ PERDAY DETA $91.00 99224 HOSP OBSERV SUBSEQ PER DAY MOD $160.00 99225 HOSP OBSERV SUBSQ P/D HIGH COM $239.00 99226 SUBSQ HOSPITAL CARE LOW COMPL $105.00 99231 SUBSQ HOSP CARE EXPANDED PF $143.00 99232 SUBSQ HOSP CARE DETAILED PF $211.00 99233 OBSERVATION ADM/DSCH LOW SEVER $395.00 99234 OBSERVATION ADM/DSCH MOD SEVER $387.00 99235 OBSERVATION ADM/DSCH COMPEHENS $487.00 99236 HOSPITAL DISCHG MGMT <30MIN MD $172.00 99238 HOSPITAL DISCHG MGMT >30MIN MD $214.00 99239 OFFICE CONSULTATION DETAILED $273.00 99243 OFFICE CONSULT COMPREHENSIVE $356.00 99244 HOSP CONSULT INPATIENT EXPAND $218.00 99252 HOSP CONSULT INPATIENT DETAIL $269.00 99253 HOSP CONSULT IP COMPREHENSIVE $336.00 99254 ER VISIT LOW COMPLEXITY $124.00 99282 ER VISIT MOD COMPLEXITY $327.00 99283 ER VISIT DETAILED COMPLEXITY $490.00 99284 CRITICAL CARE FIRST 30-74 MIN $567.00 99291 CRITICAL CARE EA ADD'L 30 MIN $283.00 99292 INPATIENT CONSULT HIGH SEVERIT $620.00 99255 OFFICE CONSULTS LOW $206.00 99242 HOSP CONSULT INPATIENT FOCUSED $197.00 99251 OFFICE VISIT MINOR ESTAB PT PF $104.00 99212 OFFICE VISIT LOW/MOD EST PT PF $160.00 99213 OFFICE VISIT MOD/HIG EST PT PF $245.00 99214 OFFICE VISIT HIGH ESTAB PT PF $346.00 99215 BEHAVE CHNG SMOKING <10 MIN PF $40.00 99406 BEHAV CHNG SMOKING >10 MIN PF $84.00 99407 DX BRONCHOSCOPE/LAVAGE PROFEE $354.00 31624 INSERT ELECTRD/PM CATH SNGL PF $592.00 33210 INS NON-TUNNL CV CATH 5YRS/>PF $674.00 36556
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
ARTERIAL CATH-SMPL/MONITO/TR PF $166.00 36620 FLUORO GUIDE CENTRAL VAD PF $63.00 7700126 INTUBATION ET EMERGENT PROFEE $355.00 31500 BRONCHOSCOPY CLR AIRWAY INT PF $526.00 31645 CARDIOVERSION ELECTRIC EXT PF $386.00 92960 INS SWAN GANZ BEDSIDEIC EXT PF $416.00 93503 INITIAL HOSP ADMIT MOD COMP PF $434.00 99222 HOSP CONSULT IP EXPANDED PF $251.00 99252 CRITICAL CARE FIRST 30-74MI PF $702.00 99291 CRITICAL CARE EA ADDL 30MIN PF $353.00 99292 SUBSQ HOSP CARE LOW COMPLEX PF $105.00 99231 SUBSQ HOSP CARE EXPANDED PF $143.00 99232 SUBSQ HOSPITAL CARE DETAIL PF $211.00 99233 HOSPITAL DISCHG MGMT <30MIN PF $225.00 99238 TRACHEOSTOMY PLANNED PROF $1,290.00 31600 INITIAL HOSP CARE COMPL 70M PF $630.00 99223 TUBE THORACOSTOMY W/CON OPN PF $551.00 32551 HOSP CONSULT INPATIENT DETAIL $335.00 99253 OBSERVATION ADM/DSCH MOD SEVER $548.00 99235 HOSP INIT OBSERV MOD COMP PF $418.00 99219 SPINAL PUCNTURE LUMBAR PRO FEE $505.00 62270 OFFICE CONSULTS MINOR $97.00 99241 BX SFT TISS LEG/ANKLE SUPER PF $535.00 27613 HOSP CONSULT IP COMPREHENSIVE $336.00 99254 INPATIENT CONSULT HIGH SEVERIT $620.00 99255 OFFICE CONSULTS MINOR $97.00 99241 OFFICE CONSULTS LOW $206.00 99242 OFFICE CONSULTATION DETAILED $273.00 99243 OFFICE CONSULT COMPREHENSIVE $356.00 99244 OFFICE CONSULT HIGH $567.00 99245 HOSPITAL DISCHG MGMT >30MIN MD $214.00 99239 OBSERVATION CARE DISCH MGMT PF $226.00 99217 HOSP OBSERV SUBSEQ PER DAY DET $125.00 99224 HOSP OBSERV SUBSQ P/D HIGH COM $325.00 99226 OFFICE VISIT LOW/MOD NEW PT PF $237.00 99202 PSYCH DIAG EVAL W/MED SRVCS $519.00 90792 OFFICE CONSULTS MINOR $156.00 99241 OFFICE CONSULTS LOW $292.00 99242 OFFICE CONSULTATION DETAILED $399.00 99243 OFFICE CONSULT COMPREHENSIVE $589.00 99244 OFFICE CONSULT HIGH $720.00 99245 OFFICE VISIT MINOR NEW PT $138.00 99201 OFFICE VISIT LOW TO MOD NEW PT $237.00 99202 OFFICE VISIT MODERAT NEW PT PF $343.00 99203 OFFICE VISIT MOD/HIG NEW PT PF $527.00 99204 OFFICE VISIT HIGH NEW PT $656.00 99205 OFFICE VISIT MINIMAL EST PT PF $64.00 99211 OFFICE VISIT MINOR ESTAB PT PF $139.00 99212 OFFICE VISIT LOW/MOD EST PT PF $232.00 99213 OFFICE VISIT MOD/HIG EST PT PF $342.00 99214 OFFICE VISIT HIGH ESTAB PT PF $458.00 99215 HOSP CONSULT INPATIENT FOCUSED $242.00 99251 HOSP CONSULT INPATIENT EXPAND $242.00 99252 HOSP CONSULT INPATIENT DETAIL $369.00 99253 HOSP CONSULT, IP COMPREHENSIVE $532.00 99254 HOSP CONSULT, IP COMPREHENSIVE $644.00 99255 INITIAL HOSP ADMIT LOW COMP PF $324.00 99221 INITIAL HOSP ADMIT MOD COMP PF $440.00 99222 INITIAL HOSP CARE COMPL 70M PF $647.00 99223 SUBSEQUENT HOSP CARE LOW COMPL $125.00 99231 SUBSEQUENT HOSP CARE EXPANDED $230.00 99232
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SUBSEQUENT HOSP CARE DETAILED $330.00 99233 OFFICE CONSULTS MINOR FOCUSED $168.00 99241GT OFFICE CONSULTS LOW EXPANDED $211.00 99242GT OFFICE CONSULTATION DETAILED $273.00 99243GT OFFICE CONSULT COMPREHENSIVE $356.00 99244GT OFFICE CONSULT HIGH $459.00 99245GT HOSP OBSERV SUBSEQ PER DAY DET $91.00 99224GT HOSP OBSERV SUBSEQ PER DAY MOD $160.00 99225GT HOSP OBSERV SUBSQ P/D HIGH COM $239.00 99226GT HOSP CONSULT INPATIENT FOCUSED $144.00 99251GT HOSP CONSULT INPATIENT EXPAND $218.00 99252GT HOSP CONSULT INPATIENT DETAIL $269.00 99253GT HOSP CONSULT IP COMPREHENSIVE $336.00 99254GT HOSP CONSULT INPATIENT COMPLEX $436.00 99255GT SUBSQ HOSPITAL IP CARE LOW COM $105.00 99231GT SUBSEQUENT HOSP CARE EXPANDED $143.00 99232GT SUBSQ HOSP CARE DETAILED PF $211.00 99233GT TELECONSULT IP/ER 30 MIN $326.00 G0425GT TELECONSULT IP/ER 50 MIN $444.00 G0426GT TELECONSULT IP/ER 70 MIN $651.00 G0427GT TELECONSULT F/U IP 15MIN $124.00 G0406GT TELECONSULT F/U IP 25 MIN $225.00 G0407GT TELECONSULT F/U IP 35 MIN $323.00 G0408GT OFFICE VISIT MINIMAL EST PT PF $75.00 99211GT OFFICE VISIT MINOR ESTAB PT PF $104.00 99212GT OFFICE VISIT LOW/MOD EST PT PF $160.00 99213GT OFFICE VISIT MOD/HIG EST PT PF $245.00 99214GT OFFICE VISIT HIGH ESTAB PT PF $346.00 99215GT OFFICE VISIT MOD/HIG NEW PT PF $527.00 99204GT OFFICE VISIT MODERAT NEW PT PF $343.00 99203 OFFICE CONSULTS LOW $206.00 99242 OFFICE CONSULTS MINOR $97.00 99241 OFFICE CONSULTS MODERATE $288.00 99243 OFFICE CONSULTS MOD TO HIGH $451.00 99244 OFFICE VISIT HIGH ESTAB PT PF $334.00 99215 OFFICE VISIT LOW/MOD EST PT PF $160.00 99213 OFFICE VISIT MINOR ESTAB PT PF $104.00 99212 OFFICE VISIT MOD/HIG EST PT PF $245.00 99214 PET BRAIN METOBALIC EVAL PF $283.00 7860826 PET IMAGE W/CT LMTD PRO FEE $376.00 7881426 PET W/CT SKULL-THIGH PRO FEE $416.00 7881526 PET W/CT WHOLE BODY PRO FEE $427.00 7881626 REMOVE FB DEEP THIGH/KNEE PF $1,295.00 27372 FB DETECTION IN EYE PRO FEE $57.00 7003026 MANDIBLE PARTIAL < 4 PRO FEE $147.00 7010026 MANDIBLE PRO FEE $186.00 7011026 FACIAL BONES < 3 VIEW PRO FEE $110.00 7014026 FACIAL BONES PRO FEE $150.00 7015026 NASAL BONES COMPL MIN 3 PF $113.00 7016026 ORBITS PRO FEE $170.00 7020026 SINUSES COMPLETE MIN 3 PRO FEE $165.00 7022026 SKULL LIMITED < 4 VIEW PRO FEE $180.00 7025026 SKULL COMPLETE MIN 4 VIEW PF $210.00 7026026 TMJ UNILATERAL PRO FEE $99.00 7032826 TMJ PRO FEE $148.00 7033026 NECK SOFT TISSUE PRO FEE $116.00 7036026 CHEST X-RAY EXAM SINGLE VW PF $52.00 7104526 CHEST X-RAY EXAM SGL VIEW PF $52.00 7104526 CHEST X-RAY EXAM 2 VIEW PF $96.00 7104626 CHEST X-RAY EXAM 3 VIEWS PF $144.00 7104726 CHEST X-RAY EXAM 4+ VIEWS PF $207.00 7104826
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
RIBS UNILATERAL 2 VIEW PRO FEE $140.00 7110026 RIBS UNILAT W/PA CHEST PRO FEE $51.00 7110126 RIBS BILATERAL 3 VIEW PRO FEE $170.00 7111026 RIBS BILAT W/PA CHEST PRO FEE $78.00 7111126 STERNUM MINIMUM 2 VIEW PRO FEE $107.00 7112026 CERVICAL LIMITED 2/3 VIEWS PF $145.00 7204026 CERVICAL COMPLETE MIN 4 PF $197.00 7205026 CERVICAL SPINE COMPL PRO FEE $216.00 7205226 THORACIC SPINE 3 VIEW PRO FEE $126.00 7207226 THORACOLUMBAR JUNCT MIN 2 PF $136.00 7208026 LUMBAR SPINE 2 OR 3 VIEWS PF $136.00 7210026 LUMBAR SPINE MIN 4 VIEW PF $190.00 7211026 SPINE,LS,BENDING ONLY >3VI PF $146.00 7212026 PELVIS 1 OR 2 VIEWS PRO FEES $120.00 7217026 PELVIS 3 VIEWS PRO FEE $186.00 7219026 SACROILIAC JOINTS PRO FEE $118.00 7220226 SACRUM/COCCYX MINIMUM 2 PF $103.00 7222026 CLAVICLE PRO FEE $107.00 7300026 SCAPULA PRO FEE $113.00 7301026 SHOULDER LMT PRO FEE $110.00 7302026 SHOULDER COMPLETE MIN 2VIEW PF $123.00 7303026 ARTHROGRAM SHOULDER S&I PF $311.00 7304026 ACROMIOCLAVICULAR-JT PRO FEE $103.00 7305026 HUMERUS PRO FEE $108.00 7306026 ELBOW LMT PRO FEE $92.00 7307026 ELBOW PRO FEE $108.00 7308026 FOREARM PRO FEE $99.00 7309026 UPPER EXTREMITY INFANT PF $100.00 7309226 WRIST LMT PRO FEE $98.00 7310026 WRIST PRO FEE $116.00 7311026 HAND 2 VIEW PROFEE $70.00 7312026 HAND MIN 3 VIEWS PRO FEE $116.00 7313026 FINGERS PRO FEE $70.00 7314026 KNEE, LMT, 1 OR 2 VIEW PRO FEE $103.00 7356026 KNEE, 3 VIEWS PRO FEE $112.00 7356226 KNEE COMPLETE MIN 4 VIEW PF $120.00 7356426 KNEES STANDING AP 1VIEW BIL PF $117.00 7356526 KNEE, ARTHROGRAM PRO FEE $226.00 7358026 TIBIA PRO FEE $120.00 7359026 LOWER EXT INFANT PRO FEE $132.00 7359226 ANKLE, LMT, AP & LT PRO FEE $130.00 7360026 ANKLE COMPLETE MIN 3 VIEWS PF $116.00 7361026 FOOT LIMITED PRO FEE $98.00 7362026 FOOT PRO FEE $116.00 7363026 OS CALCIS-HEEL PRO FEE $113.00 7365026 TOES COMPLETE MIN 2 VIEW PROF $68.00 7366026 ABDOMEN X-RAY EXAM 1 VIEW PF $109.00 7401826 ABDOMEN 2 VIEW PRO FEE $163.00 7401926 ABD ACUTE W/CHEST PRO FEE $195.00 7402226 ESOPHOGRAM PRO FEE $391.00 7422026 ESOPHAGUS PRO FEE $247.00 7423026 UGI W/O AIR PRO FEE $248.00 7424126 UPPER G.I. W/AIR PRO FEE $333.00 7424626 UGI PRO FEE $294.00 7424726 UGI - SMALL BOWEL PRO FEE $401.00 7424926 SMALL BOWEL SERIES PRO FEE $265.00 7425026 COLON; CONTR ENEMA,PRO FEE $311.00 7427026 CHOLANGIOGRAM - IO S PRO FEE $342.00 7430026 ENDO-CATH BILIARY/PA PRO FEE $487.00 7433026 UROGRAM RETROGRADE PRO FEE $228.00 7442026 ANTEGRADE UROGRAPHY PRO FEE $435.00 7442526
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CYSTOGRAM MIN 3 VIEW PRO FEE $224.00 7443026 URETHROCYSTOGRAM VOIDING PF $188.00 7445526 HYSTEROSALPINGOGRAM PRO FEE $262.00 7474026 CHG PERC TUBE OR DR PRO FEE $105.00 7598426 TOTAL BODY INFANT (FB) PRO FEE $97.00 7601026 ABSCESS, FISTULA/SIN PRO FEE $498.00 7608026 SURGICAL SPECIMEN PRO FEE $90.00 7609826 FLUORO GUIDE CENTRAL VAD PF $86.00 7700126 FLUORO GUIDE SPINE INJ PRO FEE $92.00 7700326 BONE AGE STUDY PRO FEE $118.00 7707226 BONE SURVEY LTD PRO FEE $93.00 7707426 OSSEOUS SURVEY PRO FEE $410.00 7707526 BONE SURVEY INFANT XRAYS PF $515.00 7707626 DEXA;AXIAL SKELETON PRO FEE $55.00 7708026 INS NON-TUNNEL CV CATH 5 PF $589.00 36556 INSERT PICC W/O PORT >5 PF $589.00 36569 INJ FOR CYSTOGRAM PRO FEE $356.00 51600 ABDOMEN EXAM 2 VIEWS PF $38.00 7401926 BIOPSY PERC MUSCLE PRO FEE $189.00 20206 INJ SINUS TRACT DIAG SIN PF $124.00 20501 DRAIN/INJ SM JNT/BURS WO US PF $117.00 20600 ARTHRO/AS/INJ ITM J/B WO US PF $117.00 20605 SC JOINTS PRO FEE $126.00 7113026 ELBOW ARTHROGRAM PRO FEE $146.00 7308526 WRIST, ARTHROGRAM PRO FEE $289.00 7311526 HIP ARTHROGRAM PRO FEE $311.00 7352526 ANKLE, ARTHROGRAM PRO FEE $146.00 7361526 ENTEROCLYSIS SMALL BOWEL PF $110.00 7425126 BONE LENGTH SCANOGRAM PRO FEE $136.00 7707326 MOD CS BY SAME PHYS,+5 YR PF $181.00 99152 MOD CS BY SAME PHYS, <5 YR PF $181.00 99151 SHOULDER ARTHROGRAM INJ PRO FEE $162.00 23350 ABDOMEN EXAM 3+ VIEWS PF $44.00 7402126 INJ W/FLUORO EVAL CV DEV PF $378.00 36598 ENDO CATH - BILE DUCTS PRO FEE $397.00 7432826 TRANSCATHETER BIOPSY S&I PF $110.00 7597026 DRAINAGE CATH UNDER XR PRO FEE $406.00 7598926 FLUORO UP TO 1HR EXAM SEPAR PF $35.00 7600026 FLUORO GUIDE NDL PLCMT B PF $82.00 7700226 CISTERNOGRAPHY PRO FEE $191.00 7001526 ARTHRO/ASP/IJ MAJ J/B WO US PF $138.00 20610 ELBOW ARTHROGRAM INJ PRO FEE $216.00 24220 WRIST ARTHRO INJECTION PRO FEE $239.00 25246 HIP ARTHROGRAPHY INJ WO PF $219.00 27093 KNEE ARTHROGRAPHY INJ PRO FEE $162.00 27370 ANKLE ARTHROGRAPHY INJ PRO FEE $162.00 27648 BX PLEURA;PERCUTANEOUS N PF $282.00 32400 INJECT VENOGRAM PRO FEE $162.00 36005 INS TUNNELED CV CATH AGE 5/>PF $891.00 36558 INS TUNNELED CVAD W PORT 5/>PF $1,098.00 36561 REPLACE TUNNEL CV CATH PRO FEE $638.00 36581 RPLC NON-TUNNEL CV CATH PF $215.00 36580 REPLACED PERIF CVA CATH PF $216.00 36584 REMOVAL TUNNELED CV PRO FEE $865.00 36589 REPOSITION CVC W FLUORO PF $201.00 36597 EGD REMOVE FOREIGN BODY PROFEE $622.00 43247 ERCP,DX PRO FEE $1,080.00 43260 EXCH PREVIOUS DRAIN CATH PF $243.00 49423 INJ PROC RENAL CYST PRO FEE $324.00 50390 CHANGE URETEROSTOMY TUBE PF $256.00 50688 INJ TO SEE ILEAL CONDUIT PF $435.00 50690
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HYSTEROSALPINGIOGRAM INJ PF $179.00 58340 MYELOGRAM INJ &/OR CT LUMB PF $264.00 62284 REMOVE NEPHROSTOMY TUBE W/F PF $300.00 50389 REM TUNNELED CVAD W PORT/P PF $651.00 36590 IVC FILTER PLACEMENT PRO FEE $1,547.00 37191 INSERT INDWELL PLEURAL CATH PF $741.00 32550 REM INDW TUNNE PLEURAL CATH PF $519.00 32552 REMOVE PERM INTRAPERI CATH PF $1,148.00 49422 VENOGRAM EXTREM UNILATERAL PF $138.00 7582026 VENOGRAPHY EXTREMITY BILAT PF $173.00 7582226 TUBE THORACOSTOMY W/CON $551.00 32551 REMOVE INTRVAS FB INC GUIDE PF $876.00 37197 SEL CATH ART LOW EX ABD;3RD PF $1,093.00 36247 ASPIR BLADDER W/SUPR CATH PF $499.00 51102 PLC CATH EXT CAROTID ART PF $377.00 36227 ANGIOGRAM EXTREMITY UNILAT PF $181.00 7571026 ANGIOGRAM EXTREMITY BILAT PF $213.00 7571626 ANGIOGRAM PELVIC SELECT PROFEE $183.00 7573626 ANGIOGRAM PULMONARY UNI SEL PF $212.00 7574126 ANGIOGRAM PULMONARY NONSEL PF $185.00 7574626 ANGIOGRAM INTERNAL MAMMARY PF $206.00 7575626 ANGIOGRAM SEL EA ADD VESSEL PF $59.00 7577426 INJ PERC EXTR ANEURYSM PRO FEE $359.00 36002 REPL TUNNELED VAD W PORT PF $1,009.00 36582 TRANSCATHETER BIOPSY PROFEE $747.00 37200 VENOGRAM IVC W SERIAL PROFEE $183.00 7582526 VENOGRAM BILAT SELCTV RENAL PF $233.00 7583326 VENOGRAM SINUS OR JUGL CATH PF $188.00 7586026 PORTOGRAM PERC TRANS W/HEMO PF $231.00 7588526 PORTOGRAM PERC TRANS WO HEM PF $230.00 7588726 SPINAL PUNCTURE;LUMBAR THER PF $270.00 62272 INSERT TUNNELED IP CATH PROFEE $751.00 49418 BIOPSY/EXC LYMPH NODE BY N PF $501.00 38505 ILIAC REVASC TLBA 1ST VESS PF $1,382.00 37220 ILIAC REVASC STENT 1ST VESS PF $1,684.00 37221 ILIAC REVASC TLBA STENT ADD PF $712.00 37223 ILIAC REVASC TLBA ADDL PROFEE $626.00 37222 FEM/POP UNILAT;ANGIOPLASTY PF $1,522.00 37224 FEM/POPL REVAS W/ATHER UNI PF $2,056.00 37225 REPLACE G/C TUBE PERC PROFEE $217.00 49450 PLCMT DUOD/JEJUNOSTOMY TUBE PF $833.00 49441 ANGIOGRAM VISC SEL W/FLUSH PF $180.00 7572626 ANGIOGRAM SPINAL SELECT PF $343.00 7570526 VENOGRAM RENAL UNILAT PRO FEE $197.00 7583126 INJ CONT GASTRO/JEJUN TUBE PF $98.00 49465 CHANGE CYSTOSTOMY TUBE SIMP PF $298.00 51705 CISTERNAL/LAT C1-C2 MED INJ PF $437.00 61055 NONSELEC CATH SUP VENA CAVA PF $401.00 36010 SELEC CATH VEIN;1ST ORD FAM PF $519.00 36011 SELEC CATH,VEIN;2ND ORD FAM PF $585.00 36012 NONSELECT CATH RT MAIN PA PF $430.00 36013 SELECT CATH-L/R PULMON ART PF $492.00 36014 SELECT CATH-SEGMENTAL ARTER PF $570.00 36015 INTRO CATH AORTA PROFEE $513.00 36200 SEL CATH ART-BRAC-CEPH;1ST PF $806.00 36215 SEL CATH,ART-BRACH-CEPH;2ND PF $914.00 36216 SEL CATH ART-BRACH-THOR 3RD PF $1,088.00 36217 SEL CATH ART 1ST ORD ABD PF $814.00 36245 PERC TRANSLUM THROMB NONCOR PF $1,507.00 37184 PERC TRANSLUM THROMB VEINS PF $1,356.00 37187 PERC TRANSL THROM VEIN SUBDAY $964.00 37188
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TRANSCATH STENT CCA W/EPS PROF $3,645.00 37215 FEM/POPL REVASC W/STENT PROFEE $1,688.00 37226 TIB/PERONE ANGIOPL 1ST VESS PF $1,862.00 37228 TIB/PER REVASC ADD-ON PROFEE $673.00 37232 MECHANICAL REM OBSTRCT CVAD PF $607.00 36595 MECHANCIAL REM OBSTR CVAD LUM $148.00 36596 CONSULT MINOR $97.00 99241 CONSULT LOW $206.00 99242 CONSULT MODERATE $288.00 99243 OFFICE VISIT BRIEF EST PT PF $75.00 99211 OFFICE VISIT MINOR ESTAB PT PF $104.00 99212 OFFICE VISIT LOW/MOD EST PT PF $160.00 99213 OFFICE VISIT MOD/HIG EST PT PF $245.00 99214 OFFICE VISIT MODERAT NEW PT PF $255.00 99203 SPINAL PUNCTURE LUMBAR DIAG PF $505.00 62270 ARTHRO/ASP/IJ MAJ J/B WO US PF $138.00 20610 SPINE,LS,COMPL INC BENDING PF $54.00 7211426 U/S I&D ABSCESS SIMPLE/SIGL PF $295.00 10060 HOSP INITIAL OBSERV CARE DETAILED $303.00 99218 HOSP INIT OBSERV CARE HIGH COMPLEX $573.00 99220 HOSP ADMIT HIGH COMPLEXITY $630.00 99223 HOSP ADMIT, LOW COMPLEXITY $324.00 99221 ENDOVASC THOR AO REPR S&I PROF $1,177.00 7595626 REMOVE URETER STENT PERCUT PF $810.00 50384 US PV RESIDUAL URINE PROF $63.00 51798 LASER ABL EXT VEIN 1ST VEIN PF $1,171.00 36478 INSERT HEPATIC SHUNT (TIPS)PF $2,754.00 37182 REMOVAL HEPATIC SHUNT TIPS PF $1,300.00 37183 VENOGRAM SVC SERIALOGRAPHY PF $180.00 7582726 INS CATH ABD/L-EXT ART 2ND PF $901.00 36246 PERCU CHOLECYSTOSTOMY PF $1,075.00 47490 REM/REPLACE EXT NEPHRO CATH PF $323.00 50387 PERC NEPHROSTOLITHOTOMY<2CM PF $2,825.00 50080 PERC PORTAL VEIN CATHETERIZ PF $1,171.00 36481 EPIDURAL INJ,SGLE LUM/SACR PF $237.00 62322 REMOV ENDOVASCULAR IVC PF $1,203.00 37193 REMOVE FB DEEP THIGH/KNEE PROFEE $1,295.00 27372 SUBSEQUENT HOSP CARE EXPANDED $225.00 99232 ARTHRO/AS/INJ ITM J/B WO US PF $117.00 20605 REPLACE G-JEJUNOSTOMY TUBE PF $454.00 49451 INJ TRIGGER POINT 1/2 MUSCL PF $114.00 20552 CT PERC IM GUID DRN PER/RET PF $610.00 49406 U/S PERC IMG GUID DRN PERI/RETR PRO $610.00 49406 TRANSCATH PLACE OPEN/PER 1ST $1,439.00 37236 VASC EMBOLIZE/OCCLUDE ORGAN PF $1,714.00 37243 ARTHRO/ASP/IJ MAJ J/B WO US PF $138.00 20610 INSERT CATH PLEURA W/O IMG PF $414.00 32556 INJ TRIGGER POINT 1/2 MUSCL PF $114.00 20552 HYSTEROSALPINGIOGRAM INJ PROF $262.00 58340 INJ TRIGGER POINT 1/2 MUSCL PF $114.00 20552 URETHROGRAM RETROGRADE S&I PF $49.00 7445026 RETRO INJ URETHRA PROF $194.00 51610 XRAY EXM ENTIRE SPINE 1VIEW PF $44.00 7208126 XRAY EXAM ENTIRE SPINE 2/3 VWS $53.00 7208226 X-RAY EX ENTIRE SPINE 4/5 VWS $57.00 7208326 X-RAY EXAM ENTIRE SPINE 6/>VI $67.00 7208426 HIP UNILATERAL W/PELVIS 1VW PF $183.00 7350126 HIP UNILAT W/PELVIS 2/3 VW PF $203.00 7350226 HIP UNILAT W/PELVIS 4 VIEWS PF $203.00 7350326 HIP BILAT W/PELVIS 2 VIEW PF $203.00 7352126 HIP BILAT W/PELVIS 3/4 VIEW PF $203.00 7352226
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HIP BILAT W/PELVIS 5>VIEWS PF $203.00 7352326 FEMUR 1 VIEW PROF $28.00 7355126 FEMUR MINIMUM 2 VIEWS $166.00 7355226 MRI PELVIS W/WO CONT PRO FEE $275.00 7219726 MRI UPPER EXT W/O CO PRO FEE $301.00 7321826 MRI UPPER EXT W/WO CO PRO FEE $219.00 7322026 MRI UPPER EXT JNT W/O PRO FEE $237.00 7322126 MRI UPPER JNT W/CONT PRO FEE $273.00 7322226 MRI LOWER EXT W/O CO PRO FEE $300.00 7371826 MRI LOWER EXT W/WO CO PRO FEE $178.00 7372026 MRI LOWER JNT W/O CO PRO FEE $286.00 7372126 MRI LOWER JNT W/CONT PRO FEE $323.00 7372226 MRI LOWER JNT W/WO CO PRO FEE $203.00 7372326 MRI ABDOMEN W/O CONT PRO FEE $297.00 7418126 MRI ABDOMEN W/WO CON PRO FEE $318.00 7418326 MRI BREAST BIL W/WO PRO FEE $267.00 7705926 MRI TMJ PRO FEE $293.00 7033626 MRI OR/FCE/NECK W/O PRO FEE $285.00 7054026 MRA HEAD W/O CONTR PRO FEE $258.00 7054426 MRA HEAD W/WO CONTR PRO FEE $275.00 7054626 MRA; NECK WO CONTRAS PRO FEE $258.00 7054726 MRA; NECK W & WO CON PRO FEE $271.00 7054926 MRI BRAIN WO CONTRAS PRO FEE $322.00 7055126 MRI BRAIN W CONTRAST PRO FEE $295.00 7055226 MRI BRAIN W & WO CON PRO FEE $365.00 7055326 MRI C-SPINE W/O CONT PRO FEE $396.00 7214126 MRI T-SPINE W/O CONT PRO FEE $350.00 7214626 MRI T-SPINE W/CONTRA PRO FEE $320.00 7214726 MRI L-SPINE W/O CONT PRO FEE $296.00 7214826 MRI L-SPINE W/CONTRA PRO FEE $295.00 7214926 MRI C-SPINE W & W/O PRO FEE $346.00 7215626 MRI T-SPINE W/WO CON PRO FEE $346.00 7215726 MRI L-SPINE W/WO CON PRO FEE $318.00 7215826 MRI PELVIS W/O CONTR PRO FEE $315.00 7219526 MRI ORBIT/FACE/NECK W/WO PF $197.00 7054326 MRA HEAD W/CONTR PRO FEE $276.00 7054526 MRI CHEST-THORAX W/O CON PF $246.00 7155026 MRI CHEST W/WO CONTR PRO FEE $246.00 7155226 MRI C-SPINE W/CONTRAST PRO FEE $320.00 7214226 MRI PELVIS W/CONTR PRO FEE $365.00 7219626 MRI UPPER JNT W/WO CONTR PF $217.00 7322326 MRI ABDOMEN W/CONTR PRO FEE $322.00 7418226 MRI RECONSTRUCTION 3D PRO FEE $90.00 7637626 MRA ABD W/OR W/WO CONTRAST PF $365.00 7418526 MRA CHEST W OR W/WO CONTR PF $365.00 7155526 MRA L EXTREM W/OR W/WO CONT PF $365.00 7372526 MRA PELVIS W/OR W/WO CONTR PF $365.00 7219826 MOD CS BY SAME PHYS, 5+ YRS PF $181.00 99152 MOD CS BY SAME PHYS, <5 YR PF $181.00 99151 MRI FETAL SGL/1ST GESTATION PF $496.00 7471226 MRI FETAL EA ADDL GESTATION PF $294.00 7471326 PARATHYROID IMAGING PRO FEE $145.00 7807026 LIVER & SPLEEN; STAT PRO FEE $221.00 7821526 HEPATOBILIARY SCAN PRO FEE $249.00 7822626 HEPATOBILIARY SYS IMAGE WD PF $249.00 7822726 GASTRIC EMPTYING IMGE STUDY PF $171.00 7826426 GI BLEED SCAN PRO FEE $292.00 7827826 MECKELES SCAN PRO FEE $213.00 7829026 LOCALIZED BONE SCAN PRO FEE $225.00 7830026 BONE SCAN TOTAL PRO FEE $336.00 7830626 BONE SCAN 3 PHASE PRO FEE $384.00 7831526
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BONE DENSITOMETRY SPEC PRO FEE $410.00 7832026 PARTICULATE LUNG PERF PRO FEE $184.00 7858026 LUNG VENTILATION/PERFUS IMG PF $468.00 7858226 CSF FLOW; CISTEROGRAM PRO FEE $221.00 7863026 KIDNEY FUNCT; SGL W PRO FEE $282.00 7870826 WBC LOCAL LIMITED PRO FEE $179.00 7880526 ABSC LOCALIZ; WB PRO FEE $279.00 7880626 ORAL RADIOPHARM RX(THERAPY)PF $502.00 7900526 SENTINEL NODE INJECTION PF $402.00 38792 THYROID SCAN/METS MULTIP PF $130.00 7801826 LYMPH OR LN NM SCAN PRO FEE $251.00 7819526 LIVER SCAN (SPECT) PRO FEE $201.00 7820526 MUGA; SGL W WM & EF PRO FEE $199.00 7847226 BRAIN,LIMITED;W VASC FLO PF $187.00 7860126 KIDNEY FUNCTION W/O PHAR PF $144.00 7872526 TUMOR LOCALIZ;SPECT PRO FEE $361.00 7880326 WB TUMOR IMAGING 2 DAYS PF $249.00 7880426 LUNG PERFUSION DIFFERENTIAL PF $79.00 7859726 LUNG PERF&VENT DIFFERENTIAL PF $90.00 7859826 INSERT CATH REN ART 1ST BIL PF $1,187.00 36252 INSERT CATH REN ART 1ST UNILAT $651.00 36251 INS CATH RENAL ART 2ND UNILAT $1,089.00 36253 GASTRIC EMPTY STUDY W/SM BOWEL $159.00 7826526 GASTRIC EMPTY STDY W/SBT MULTI $176.00 7826626 RADIOPHARM THERAP IV ADMIN PF $313.00 7910126 CT-HEAD/BRAIN WO CON PRO FEE $272.00 7045026 CT-HEAD/BRAIN W CONT PRO FEE $333.00 7046026 CT HEAD/BRAIN W & W/ PRO FEE $330.00 7047026 CT-ORBIT,SELLA,MID/I PRO FEE $405.00 7048026 CT-ORBIT,SELLA,MID/I PRO FEE $390.00 7048126 CT-ORBIT,SELLA,MID/I PRO FEE $357.00 7048226 CT MAXILLOFAC/SINUS PRO FEE $177.00 7048626 CT MAXILLOFAC/SINUS PRO FEE $273.00 7048726 CT MAXILLOFAC/SINUS PRO FEE $365.00 7048826 CT-SOFT TISSUE NECK PRO FEE $357.00 7049026 CT-ST NECK W CONTR PRO FEE $365.00 7049126 CT-ST NECK W&WO CONT PRO FEE $350.00 7049226 CTA HEAD W & W/O CON PRO FEE $453.00 7049626 CTA NECK W & W/O CON PRO FEE $456.00 7049826 CT THORAX(CHEST);WO PRO FEE $258.00 7125026 CT THORAX(CHEST);W C PRO FEE $330.00 7126026 CT THORAX(CHEST);W & WO PF $345.00 7127026 CTA CHEST W & W/O CO PRO FEE $471.00 7127526 CT CERV SPINE WO CON PRO FEE $383.00 7212526 CT CERV SPINE W CONT PRO FEE $397.00 7212626 CT CERVICAL SPINE W/ PRO FEE $353.00 7212726 CT THORACIC SPINE WO PRO FEE $450.00 7212826 CT THORACIC SPINE W PRO FEE $397.00 7212926 CT THORACIC SPINE W/ PRO FEE $353.00 7213026 CT LUMBAR SPINE W/O PRO FEE $461.00 7213126 CT LUMBAR SPINE W CO PRO FEE $417.00 7213226 CT LUMBAR SPINE W/WO PRO FEE $353.00 7213326 CTA PELVIS W & W/O C PRO FEE $451.00 7219126 CT PELVIS; WO CONTR PRO FEE $330.00 7219226 CT PELVIS W CONTRAST PRO FEE $361.00 7219326 CT PELVIS; W & WO C PRO FEE $336.00 7219426 CT U/EXTREM WO CONTR PRO FEE $382.00 7320026 CT U/EXTREM W CONTRA PRO FEE $383.00 7320126 CT U/EXTREM WWO CONT PRO FEE $364.00 7320226 CT L EXTR WO CONTRA PRO FEE $382.00 7370026 CT LO/EXTREM W CONTR PRO FEE $383.00 7370126
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CT L EXTR W AND WO PRO FEE $405.00 7370226 CTA LOWER EXT W/WO PRO FEE $526.00 7370626 CTA LOW EXT W & W/O PRO FEE $526.00 7370626 CT ABD WO CONTRAST PRO FEE $221.00 7415026 CT ABD W CONTRAST PRO FEE $423.00 7416026 CT ABD W AND WO CON PRO FEE $394.00 7417026 CTA ABDOMEN W/WO PRO FEE $373.00 7417526 CTA ABD W & W/O CONT PRO FEE $373.00 7417526 CT ABD ANGIO W BIL R PRO FEE $482.00 7563526 CT GUIDE PERC DRN W PRO FEE $514.00 7598926 CT 3D RECONSTRUCTION PRO FEE $83.00 7637626 CT GUIDE NEEDLE PLAC PRO FEE $233.00 7701226 CTA UP EXT W & W/O CONTR PF $364.00 7320626 CT LUNG CANCER SCREEN PRO FEE $153.00 G029726 CT BIOPSY BONE SUPERFICIL PF $240.00 20220 DRAIN/INJ SM JNT/BURS WO US PF $117.00 20600 ARTHRO/AS/INJ ITM J/B WO US PF $120.00 20605 ARTHRO/ASP/IJ MAJ J/B WO US PF $144.00 20610 CT BIOPSY SOFT TISSUE NE PF $189.00 20206 CT VERTEBROPLASTY THORAC PF $1,718.00 22510 CT VERTEBROPLASTY LUMBAR PF $1,622.00 22511 CT PERC VERTEBROPLASTY ADDL PF $729.00 22512 CT ST BIOPSY:HIP/PELVS DEEP PF $466.00 20205 CT BX PLEURA;PERCUTANEOUS N PF $282.00 32400 CT BIOPSY LUNG/MEDIAST PERC PF $318.00 32405 CT BIOPSY LIVER NEEDLE PERC PF $314.00 47000 CT BIOPSY PERC N ABD/RETROP PF $285.00 49180 CYST/ABCESS CONTRAST PRO FEE $129.00 49424 CT BIOPSY KIDNEY PRO FEE $464.00 50200 CT ASP OR INJ RENAL CYST PF $324.00 50390 BIOPSY THYROID PERC CORE PF $255.00 60100 CT MYELOGRA INJ &/OR CT LUM PF $264.00 62284 MOD CS BY SAME PHYS, 5 YR + PF $181.00 99152 CTA HEART CALCIUM EVALUATE PF $89.00 7557126 CTA HEART W/CONT W/3D IMAGE PF $281.00 7557126 CTA HEART W WO CON 3D CONGE PF $376.00 7557326 CCT ANGIO HRT W/3D IMAGE PF $358.00 7557426 U/S THYROID/SOFT TISSUE PF $269.00 7653626 U/S ABDOMEN (COMPLETE) PRO FEE $286.00 7670026 U/S ABD. LTD. PRO FEE $240.00 7670526 U/S LIVER PRO FEE $402.00 7670526 U/S RENALS PRO FEE $389.00 7677526 U/S PANCREAS PRO FEE $420.00 7670526 U/S ABD AORTA PRO FEE $305.00 7677026 U/S OB >14 WEEKS SGL FETUS PF $242.00 7680526 U/S OB US, LMT, FETUS(S) PF $202.00 7681526 U/S PELVIC NON OB COMPLETE PF $305.00 7685626 U/S SCROTUM AND CONTENTS PF $170.00 7687026 U/S RETROPERITONEAL LIMITED PF $405.00 7677526 U/S OB EA ADD GEST >14WEEKS PF $569.00 7681026 U/S PREGNANCY F/U REPEAT PF $192.00 7681626 U/S BIOPHYSICAL PROF W/NS PF $428.00 7681826 U/S TRANSVAGINAL NON OB PF $226.00 7683026 U/S PELVIC NON OB LMT/FU PF $143.00 7685726 U/S CAROTID EXT ART BILAT PF $283.00 9388026 U/S CAROTID EXT ART LTD PF $305.00 9388226 U/S DUPLEX LE ART/BPG;BILAT PF $239.00 9392526 U/S LOWER EXT BYPASS LIMIT PF $261.00 9392626 DUPLEX UE ART/BPG;BILAT PF $239.00 9393026 U/S UPPER EXT BYPASS LMT PF $240.00 9393126 U/S VENOUS EXT DUPLEX LMT PF $305.00 9397126
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
U/S ABD/PELVIC VASC COMPL PF $522.00 9397526 DUPLEX ARTERIAL FLOW;LMT PF $609.00 9397626 U/S AORTIC BYPASS COMPLETE PF $326.00 9397826 U/S GUIDED NEEDLE PLACEMENT PF $232.00 7694226 U/S VENOUS EXT DUPL BILAT PF $326.00 9397026 U/S EXT DOPPLER 1-2 LEVEL PF $38.00 9392226 U/S EXT DOPPLER 3 OR MORE PF $82.00 9392326 U/S CHEST PRO FEE $131.00 7660426 U/S ANKLE/BRACHIAL INDICES PF $38.00 9392226 U/S BIOPHYS PRF WO NON STRE PF $378.00 7681926 U/S OB<14 WKS ADDL FETUS PF $127.00 7680226 US BX THYROID,PERC NEEDLE PF $354.00 60100 U/S FNA W GUIDANCE PRO FEE $196.00 10022 U/S OB US DETAILED SGL FETS PF $292.00 7681126 U/S OB <14 WEEKS SINGLE PF $94.00 7680126 U/S TRANSVAGINAL OB PRO FEE $81.00 7681726 U/S SPLEEN PRO FEE $420.00 7670526 U/S PERICARDIOCENTESIS GU PF $359.00 7693026 US POST TREADMILL DOPPLER PF $89.00 9392426 U/S GUIDE VASCULAR ACCES PF $443.00 7693726 U/S BIOPSY LIVER NEEDLE PER PF $678.00 47000 US BIOPSY LUNG/MEDIAST PERC PF $283.00 32405 U/S PERC N BX ABD/RETROPERI PF $285.00 49180 US BX PLEURA;PERCUTANEOUS PF $311.00 32400 MOD CS BY SAME PHYS, 5 Y PF $181.00 99152 U/S PERICARDIOCENTESIS,INT PF $403.00 33010 INTRACRANIAL ARTERY DOPPLER PF $216.00 9388626 US DUPLEX SCAN DIALYS ACCES PF $73.00 9399026 BIOPSY/EXC LYMP NODE NEEDLE PF $501.00 38505 US BIOPSY KIDNEY PERC PRO FEE $464.00 50200 US BIOPSY ST PERC W GUIDE PF $189.00 20206 US I&D ABSC; COMPL OR MULTI PF $378.00 10061 US EXTR JOINT COMPLETE PF $69.00 7688126 US EXTR NON-VASC LIMITED PF $54.00 7688226 US DRAINAGE CATH UNDER XR PF $406.00 75989 CT COLONOGRAPHY WO W/PP DYE PF $360.00 7426126 BONE MARROW ASPIRATE DX PF $489.00 3822026 BONE MARROW BIOPSY PROFEE $529.00 38221 CT ABD & PELVIS WO CONTRAST PF $276.00 7417626 CT ABDOMEN & PELVIS W/CONTR PF $392.00 7417726 CT ABD & PELVIS W & W/O 1+ PF $365.00 7417826 US INJ PSEUDOANEURYSM PRO FEE $359.00 36002 U/S INFANT HIPS;DYNAMIC PROFEE $121.00 7688526 CT 3D RENDERING W/POSTPROCESS $126.00 7637726 PARACENTESIS ABD DIA WO IMG PF $345.00 49082 PARACENTESIS ABD W/IMAGING PF $345.00 49083 CTA ABDOMEN & PELV WO/W/DYE PF $325.00 7417426 DRAIN/INJ SM JNT/BUR W/US PF $349.00 20604 DRAIN/INJ SM JNT/BUR W/US PF $349.00 20604 DRN/INJ INTERM JNT/BUR W/US PF $227.00 20606 DRN/INJ INTERM JNT/BUR W/US PF $227.00 20606 DRAIN/INJ MAJ JNT/BURS W/US PF $349.00 20611 DRAIN/INJ MAJ JNT/BURS W/US PF $349.00 20611 PERQ VERT CERVICOTHORACI CT PF $2,077.00 22510 PERQ VERT CERVICOTHORA FLOU PF $1,947.00 22510 PERQ VERTEBROPLASTY L/S CT PF $2,077.00 22511 PERQ VERTEBROPLASTY LS W FLOUR $1,947.00 22511 PERQ VERT EA ADDL C/LS W CT PF $2,077.00 22512 PERQ VERT EA ADDL C/LS W FLOUR $1,947.00 22512 PERQ ABLAT LIVER TUMOR CRYO PF $1,377.00 47383 STAB PHLEB VARICOSE VEIN 10>20 $993.00 37765
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
MYELOGRAPHY LUMBAR;CERV S&I PF $369.00 62302 MYELOGRAPHY LUMBAR;CERV S&I PF $369.00 62302 MYELOGRAPHY LUMBAR/THOR S&I PF $369.00 62303 MYELOGRAPHY LUMBAR/THOR S&I PF $369.00 62303 MYELOGRAPHY LUMBAR/2>REG SI PF $378.00 62305 MYELOGRAPHY LUMBAR/2>REG SI PF $378.00 62305 MYELOGRAPHY LUMBAR L/S S&I PF $362.00 62304 MYELOGRAPHY LUMBAR L/S S&I PF $362.00 62304 US THORACENTESIS W/IMAGING PF $337.00 32555 CT THORACENTESIS W/IMAGING PF $337.00 32555 ARTHRO/AS/INJ ITM J/B WO US PF $120.00 20605 CT BONE MARROW ASPIRATE&BX PF $244.00 38222 US TRANSPL KIDNEY W/DOPPLER PF $125.00 7677626 US PELVIC/PENIS/PERINUM LMT PF $143.00 7685726 U/S OB NUCHAL MEAS ADD ON PROF $109.00 7681426 U/S BIOPSY:HIP/PELVIS DEEP PF $514.00 20205 THROMBOLYTIC ART THERAPY PF $1,164.00 37211 THROMBOLYTIC VENOUS THERAPY PF $1,021.00 37212 THROMBOYLYTIC ART/VEIN THER PF $707.00 37213 CESSJ THERAPY CATH REMOVAL PF $370.00 37214 THYROID IMAGE SGL/MUL W BLD PF $73.00 7801426 PLACE CATH SUBCLAVIN ARTERY PF $941.00 36225 PLACE CATH THORACIC AORTA PF $508.00 36221 PLC CATH EXTERN CAROTID ART PF $349.00 36227 BIOPSY SALIVARY GLAND;NEEDL PF $165.00 42400 PARATHYROID PLANAR W/WO SUB PF $132.00 7807126 PERCUT VERTEBROPLASTY THORA PF $1,718.00 22510 ENDOVASC TAA REPR W/O SUBCL PF $5,154.00 33881 XR ENDOVASC THOR AO NOT LT SUB $983.00 7595726 CT DEEP BONE BX TRCR/NDL PF $353.00 20225 US UNLIST PROC HEMIC/LYMPHA PF $286.00 38999 PERCUT VERTEBROPLASTY LUMB PF $1,622.00 22511 PERCUT VERTEBROPLASTY THORA PF $1,718.00 22510 PERC VERTEBROP ADDL THOR/LUM $729.00 22512 LYMPHANGIO EXTREM ONLY;UNIL PF $144.00 7580126 INJECTION FOR LYMPHANGIOGRAPHY $270.00 38790 INSERT CATH PLEURA W/IMAGE PF $551.00 32557 U/S EXAM AAA SCREEN PF $90.00 7670626 SHOULDER ARTHROGRAM INJ PROF $162.00 23350 ARTHROGRAM SHOULDER S & I PF $311.00 7304026 STAB PHLEB VARICOSE VEIN>20 PF $1,847.00 37766 BX BREAST 1STLESION STRTCTC PF $514.00 19081 BX BREAST W/PLCMT LOC DEV ADDL $259.00 19082 REM OBSTRUCTN FROM CVD S&I PF $76.00 7590126 VASC EMBOLIZE/OCCLUD ARTERY PF $1,248.00 37242 VASC EMBOLIZE/OCCLUDE BLEED PF $1,737.00 37244 PERC IMG GUID DRN PERI/RETR PF $610.00 49406 PERC IMGE GUID DRAIN PER/RE PF $635.00 49407 US VESSEL MAP HEMODIAL ACCESS PROF $40.00 G0365 TC PLCMT OPEN/PER STENT ADD PF $542.00 37237 OPEN/PERQ PL STENT SAME 1ST VN $908.00 37238 VASC EMBOLIZE/OCCLUD VENOUS PF $1,119.00 37241 DRAIN/INJ SM JNT/BURS WO US PF $117.00 20600 NG TUBE PLC W FLUORO PROFEE $172.00 43752 INJ SCLEROSING SOLN SG VEIN PF $282.00 36470 U/S GUIDE CATH FLUID DRAIN PF $513.00 10030 ARTHRO/ASP/IJ MAJ J/B WO US PF $138.00 20610 CT GUIDE CATH FLUID DRAIN PF $513.00 10030 PUNCTURE ASP ABSC/HEMA PF $423.00 10160 PLCE CATH CAROTID/INOM ART PF $917.00 36222 DXA BONE STUDY1>INC VERT FX PF $33.00 7708526
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DXA FRACTURE ASSESSMENT PROF $26.00 7708626 U/S BREAST UNIL W AXIL COMP PF $320.00 7664126 U/S BREAST UNILA W AXIL LMT PF $73.00 7664226 MYELOGRAPHY LUMBAR INJ CERV SI $369.00 62302 MYELOGRAPHY LUMB INJ THOR S&I $369.00 62303 MYELOGRAPHY LUMB INJ LS S&I PF $362.00 62304 HIP ARTHROGRAPHY INJ WO ANE PF $219.00 27093 KNEE ARTHROGRAPHY INJ CONTR PF $162.00 27370 KNEE, ARTHROGRAM PROF $226.00 7358026 BIOPSY/EXC LYMPH NODE NDL PF $501.00 38505 HOSP OBSERV SUBSEQ PER DAY HIGH $239.00 99226 BILIARY ENDO PERQ EX W/SPEC PF $949.00 47552 INJ FOR CYSTOGRAM PROFEE $356.00 51600 CYSTOGRAM MIN 3 VIEW PROF $224.00 7443026 NONSELECTIVE CATH PLMT VEIN PF $103.00 36000 INJ SCLEROSING SOLN MUL VEI PF $335.00 36471 INJECTING A SACROILIAC JNT PF $251.00 27096 INJ PX NFROSGRM&URTRGRM GUI PF $556.00 50430 INJ PX NFROSGRM&/URTRGRM EX AC $556.00 50431 PLACEMENT NEPHROSTOMY CATH PF $734.00 50432 PLMT NEPHROURETERAL CATH PF $908.00 50433 CONVERT NEPHROSTOMY CATH COM $696.00 50434 EXCHG NEPHROSTOMY CATH COML PF $338.00 50435 PLACEMENT URETERAL STENT PERCU $728.00 50693 PLCMT URETRAL STENT PRQ NEW PF $942.00 50694 PLMT URETERAL STENT PRQ SEP NC $1,084.00 50695 ENDOLUMIN BX URTR RNL PLVS PF $524.00 50606 URETERAL EMBOLIZA/OCCL COMP PF $671.00 50705 BALLOON DIL URETERAL STRIC PF $624.00 50706 ANGIO PULMONARY BILAT S&I PROF $266.00 7574326 ENDOLUMINAL BX BILIARY TREE PF $557.00 47543 REMOVAL DUCT GLBLDR CALCULI PF $704.00 47544 SCLEROTHERAPY FLUID COLLECT PF $411.00 49185 PLMT BILIARY DRAIN CATH EXT PF $1,021.00 47533 INJECT CHOLANGIOGRAM EX ACC PF $321.00 47531 INJECT CHOLANGIOGRAM NW ACC PF $720.00 47532 PLMT BILIARY DRAIN CATH I/E PF $1,352.00 47534 EXCHANGE BILIARY DRG CATH PROF $494.00 47536 CONVERSION EXT BIL DRG CATH PF $777.00 47535 REM BILIARY DRAIN CATH PERC PF $332.00 47537 PERQ PLMT BILE DCT STT EXAC PF $1,098.00 47538 PERQ PLMT BILE DUC STENT NW PF $1,485.00 47539 PERQ PLMT BILE DUC ST W/BDC PF $1,773.00 47540 INJECTING A SACROILIAC JNT PF $251.00 27096 PLACE SOFT TISS LOC DEV 1ST PF $287.00 10035 PLACE SOFT TISS LOC DE ADDL PF $145.00 10036 BALLOON DILATE BIL DUCT/AMP PF $442.00 47542 INTRO NEE/CATH DIAL CIR INC PF $481.00 36901 INTRO NEE/CATH DIAL TLB ANGIO $715.00 36902 INTRO NEE/CATH DIAL TL STNT PF $978.00 36903 PERC TRANS THROMBEC NSF DIAL $1,126.00 36904 INTRO NEE/CATH TLBA PERIP DIAL $1,415.00 36905 INTRO NEE/CATH TCP INTRA STENT $1,650.00 36906 BALLOON ANGIOPLAS CTR DIAL SEG $452.00 36907 STENT PLCMT CTR DIALYS SEG PF $617.00 36908 DIALYSIS CIRCUIT EMBOLIZATI PF $627.00 36909 TLBA INC IMAGE 1ST ARTERY PROF $1,173.00 37246 TLBA EA ADDL ARTERY PRO $581.00 37247 TLBA W/IN 1ST VEIN PRO $1,009.00 37248 TLBA EA ADDL VEIN PRO $495.00 37249 MOD SED SAME PH/QHP ADDL15M PF $75.00 99153
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
MOD SED OTH PH/QH ADDL 15M PF $75.00 99157 ENDOVASC TAA REPR INCL SUBCL $5,391.00 33880 MOD SED SAME PH/QHP ADDL15M PF $45.00 99153 MOD SED SAME PH/QHP ADDL15M PF $45.00 99153 MOD SED SAME PH/QHP ADDL15M PF $45.00 99153 ENDOVASC RPR A-AO ENDOGRAFT PF $3,992.00 34701 EVASC RPR A-AO NDGF RUPTURE PF $5,965.00 34702 ENDOVASC RPR A-UNILAC ENDOGRFT PF $4,492.00 34703 EVASC RPR A-UNILAC END RUPT PF $7,475.00 34704 ENDOVASC RP A-BIILIAC NDGFT PF $4,954.00 34705 ENDOVASC RPR A-BIILIAC RUPT PF $7,455.00 34706 ENDOVASC RPR ILIO-ILIAC END PF $3,723.00 34707 ENDOVASC RPR ILIO-ILIA RUPT PF $5,992.00 34708 REM FB UP ARM/ELBOW;SUBQ PF $457.00 24200 EVASC PLACMT EXT PROSTH REPAIR $1,047.00 34709 EVASC RPR DLYD PLM XTN PRS 1ST $2,598.00 34710 EVASC RPR DLYD XTN PROSTH ADDL $967.00 34711 DIGITAL SCR BI IN/CAD MAMMO PF $113.00 7706726 DIGITAL DIAG INCL CAD MAMMO PF $205.00 7706626 DIGITAL UNILAT IN CAD MAMMO PF $179.00 7706526 BX BREAST 1ST LESION US IMG PF $483.00 19083 BIOPSY BREAST US GUIDE ADDL PF $242.00 19084 BX BREAST 1ST LESION MR IMG PF $562.00 19085 BIOPSY BREAST MR GUIDE ADDL PF $282.00 19086 PLCMT PERC DEV BRST 1ST LES PF $253.00 19281 PLCMT PER DEV BRST ADDL LES PF $113.00 19282 PLCMT PERC DEV BRST 1ST LES PF $253.00 19285 PLCMT PER DEV BRST ADDL LES PF $103.00 19286 PUNCT ASP BRST CYST-INITAL PF $186.00 19000 INSERT CATH PLEURA W/ IMAGE PF $551.00 32557 SCR DIGITAL BREAST TOMOSYNT PF $66.00 7706326 DIAG BREAST TOMOSYNTH;UNILA PF $61.00 G027926 DIAG BREAST TOMOSYNTH;BILAT PF $61.00 G027926 EVASC RPR ILIAC ART BIFUR $4,161.00 0254T BRONCHODILATION PRO FEE $59.00 9406026 METHACHOLINE CHALLENGE PRO FEE $114.00 9407026 PULM FUNC TEST PLETHYSMOGRAP $28.00 9472626 CO/MEMBRANE DIFFUSION CAPAC PF $50.00 9472926 DRESSING GAUZE SPONGE 2X2 NS $1.00 DRESSING GAUZE SPONGE 4X4 STER $1.00 BANDAGE GAUZ 4X4 STERILE $36.00 BANDAGE GAUZE STRIP STER 4X4 $42.00 STRETCH BAND 2 IN ST $14.00 BANDAGE STRETCH 3 IN ST $33.00 STRETCH BAND 4 IN ST $36.00 BANDAGE STRETCH 6 IN $23.00 UNNA BOOT 4 INCH GELCAST $276.00 BANDAGE ELASTIC 2" $42.00 BANDAGE ELASTIC ACE 3" $55.00 BANDAGE ELASTIC 4" $73.00 BANDAGE ELASTIC ACE 6" $89.00 DRESSING ANTIMICR DR SPNGE 4X4 $2.00 WRAP COBAN 1 INCH $36.00 DRAPE INCISE VI $144.00 KERLIX FLUFF $55.00 DRESSING KERLIX ROLL STER 4.5" $55.00 NU GAUZ 1/4IN $159.00 DRESSING NU GAUZ 1/2 IN $152.00 NU GAUZ 1 IN $186.00 DRESSING NU GAUZ STERILE 2IN $234.00 NU GAUZ IOD 1/4 IN $65.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRESSING NU GAUZ IOD 1/2" $186.00 NU GAUZ IOD 1 IN $201.00 NU GAUZ IOD 2 INCH $91.00 DRESSING ABD PAD 8X10 $10.00 DRAPE IOBAN LONG $348.00 DRESSING TELFA PAD 2X3 $1.00 DRESSING TELFA PAD 3X4 $1.00 DRESSING TELFA PAD 3X8 $2.00 DRESSING ADAPTIC 8X3 $38.00 DRESSING XEROFOAM $14.00 TUBEGUAZ 5/8IN FT $1.00 TUBEGAUZ 1IN $1.00 TUBEGAUZ 1 1/2 IN $1.00 DRESSING VASELINE GAUZE 1X36 $33.00 DRESSING VASELINE GAUZE 3X36 $38.00 BANDAGE ELASTOPLAST 4" $249.00 SPONGE PEANUT/CHERRY $97.00 DRESSING OPSITE 14X10CM $42.00 OPSITE IV $10.00 OPSITE DRESSING 25X14 CM $129.00 OPSITE DRES 28X3.0CM $234.00 DRAPE C-ARM $247.00 WRAP COBAN 2 INCH $67.00 WRAP COBAN 3 INCH $84.00 DRESSING XEROFORM 5X9 $15.00 1/2 X 72 VASLINE GAU $46.00 DRESSING XEROFORM 4X4 $23.00 ANGIO SET 22G 3/4" $91.00 BUTTERFLY 21G KIT $67.00 BUTTERFLY 23G KIT $14.00 BUTTERFLY 25G KIT $36.00 BUTTERFLY PED 25G $14.00 CAP BD INJECTION $67.00 NEEDLE ANGIOCATH 12G 3IN $210.00 ANGIO SET 18GA 1 IN $91.00 ANGIO SET 20GA 1 IN $91.00 WOUND SUCTION SET $519.00 CATH TRAY URETHRAL $103.00 KIT CATHETER URETH SOFT TIP 8F $146.00 TRAY FOLEY ADD A W/0 UA METER $275.00 FOLEY TRAY W/URINE M 16F DISP $468.00 FOLEY TRAY W/URINE M 18F DISP $468.00 SET DRAIN BAG $186.00 ENEMA BUCKET $46.00 TRAY IRRIGATION $46.00 PACK CYTOSCOPY/TURP $881.00 TRAY LUMBAR PUNCTURE ADULT $544.00 TRAY LUMBAR PUNCTURE INFANT $451.00 SET SUTURE REMOVER DISP $73.00 14 F SUCT CATH/GLOVE $36.00 CHOLANGIOGRAPHY KIT $1,274.00 SUCT CATH N GLOVE 18 $36.00 ARM BOARD ADULT $42.00 ANTI REFLUX VALVE $252.00 DIAPERS DAYTIME $122.00 BABY BOTTLE 8 OZ $46.00 BAG CONSTANT ICE $89.00 BEDPAN $42.00 DENTURE CUP $1.00 EMESIS BASIN $1.00 EYE PAD $1.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
EYE SHIELD $65.00 KIDNEY FILTER $1.00 FRACTURE PAN $36.00 GOWN SURG DISP LG * $152.00 INVALID RING $46.00 MAYO STAND COVER $46.00 RAZOR $2.00 SALEM SUMP 16F $83.00 SALEM SUMP 18F $83.00 PADS SANITARY EX LG $38.00 SLIPPERS XLG $46.00 3 WAY STOP COCK $42.00 SURGICEL HEMOSTAT 2X14 VIAL $544.00 SURGICEL HEMOSTAT 4X8 VIAL $801.00 SYRNG IRR PISTN 70CC $46.00 SYRNG BULB IRR 50CC $33.00 EAR SYRINGE DISP $42.00 TAPE MICROFOAM 3" $91.00 TAPE ADHESIVE 1" $36.00 TAPE MICROFOAM 2" $60.00 TAPE TRANSPORE 1" $38.00 TRANSPORE TAPE 2 IN $84.00 TONGUE PROTECTOR $36.00 ENDO TUBE 5.0MM $103.00 ENDO TUBE 6.0MM $31.00 ENDO TUBE 6.5MM $103.00 ENDO TUBE 7.0MM $97.00 ENDO TUBE 7.5MM $97.00 ENDO TUBE 8.0MM $97.00 ENDO TUBE 8.5MM $83.00 ENDO TUBE 9.0MM $31.00 INF FEED TUBE 5F $36.00 DRAIN PENROSE 1/4X18 $42.00 DRAIN PENROSE 1/2X18 $14.00 DRAIN PENROSE 1X18 $42.00 STOMACH TUBE 12F $33.00 STOMACH TUBE 14F $10.00 FEEDING TUBE 10F $46.00 STOMACH TUBE 18F $33.00 YANK SUCT TUBE DISP $36.00 URINE COLLECTOR PED $55.00 URINE COLLECTOR ADLT $73.00 URINAL DISP $33.00 TED STOCKING SMALL-SHORT $326.00 TED STOCKING MEDIUM-SHORT $326.00 TED STOCKING LARGE-SHORT $326.00 LEMON GLYC SWAB $1.00 DRAPE HALF SHEET 60X44 $23.00 MIDSTREAM URINE CLEAN CAT $103.00 MONITOR ELECTRODE $30.00 SKIN SCRUB SET WET $192.00 BETADINE SOLUTION 8 OZ $33.00 DEFIBRILLATOR PADS 2 $201.00 TUBE GUARD 18 FR $42.00 LUKENS TRAP $125.00 CAUTERY PENCIL $185.00 GRADUATE 32 OZ. $2.00 MONITOR ELECTRODE NEONATE/PEDS $125.00 BELT OSTOMY $30.00 ARM BOARD PED 2X5 $36.00 POUCH UROSTOMY NEW IMAGE $13.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DUO DERM 4X4 $67.00 SHUR CLEANSE 100ML $154.00 WOUND DRAIN POUCH LARGE $603.00 A5051 BRIEFS ADULT MED $185.00 BRIEFS ADULT LARGE $259.00 COUDE CATH 12F $247.00 COUDE CATH 14F $205.00 COUDE CATH 16F $501.00 FOLEY CATH 5CC 12F $264.00 FOLEY CATH 5CC 14F $264.00 FOLEY CATH 5CC 16F $222.00 FOLEY CATH 5CC 18F $222.00 FOLEY CATH 5CC 20F $264.00 FOLEY CATH 5CC 22F $338.00 FOLEY CATH 5CC 24F $252.00 FOLEY CATH 30CC 16F $252.00 FOLEY CATH 30CC 18F $461.00 FOLEY CATH 30CC 20F $264.00 FOLEY CATH 30CC 3WAY 24F & 26F $414.00 ROBINSON CATH 10F $213.00 ROBINSON CATH 12F $205.00 ROBINSON CATH 14F $205.00 ROBINSON CATH 16F $205.00 ROBINSON CATH 18F $205.00 SUCT CATH 10F $10.00 CATH PLUG STERILE $2.00 FOLEY CATH 10F 3CC $339.00 ABDOMINAL SUPPORT UNIV $222.00 BANDAGE PLASTER OF PARIS 4" $97.00 CAST PADDING 2" $33.00 CAST PADDING 3" $33.00 CAST PADDING 4" $38.00 CAST PADDING 6" $67.00 STIFFNECK COLLAR ALL $376.00 L0140 RIB BELT MALE UNIV $239.00 CERVICAL COLLAR SM $266.00 L0140 CERVICAL COLLAR MED $266.00 L0140 CRUTCHES ADULT 42-60 $548.00 E0114NU CRUTCHES TALL $548.00 E0114NU ARM SPLINT R SM CHLD $239.00 ARM SPLINT R CHILD $247.00 ARM SPLINT L ADULT $247.00 ARM SPLINT R ADULT $247.00 FINGER SPLINT 6 IN $46.00 FINGER GUARD MED $89.00 LEG SPLINT SM $850.00 LEG SPLINT YOUTH $982.00 LEG SPLINT ADULT $1,029.00 PLASTER SPLINT 3X15 $2.00 PLASTER SPLINT 4X15 $2.00 PLASTER SPLINT 5X30 $38.00 STOCKINETTE 2IN (YD) $14.00 STOCKINETTE 3IN (YD) $14.00 WRAP BIAS 3" $2.00 WRAP BIAS 4" $10.00 WRAP BIAS 6" $14.00 CLAV STRAP ADULT $500.00 SHOULDER\IMMOB MED $390.00 SHOULDER\IMMOB LG $390.00 ARM SLING YOUTH $103.00 SLING ARM UNIVERSAL $103.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
FING/THUMB SPLINT M $67.00 SCOTCHCAST 4" $234.00 DELTA ROLL 6" $125.00 SUTURE ETHILON 2 LR 470 $70.00 SUTURE ETHILON 4-0 $75.00 SUTURE VICRYL 0 603H $60.00 SUTURE SILK 2-0 685H $89.00 SUTURE ETHILON 5-0 $79.00 SUTURE ETHILON 3-0 $55.00 SUTURE ETHILON 6-0 $90.00 SUTURE SILK TIES ALL SIZES $198.00 SUTURE VICRYL 4-0 $38.00 SUTURE VICRYL 6-0 J492G $84.00 SUTURE VICRYL 4-0 PS $249.00 SUTURE SILK 3-0 $91.00 STAPLER REMOVER PSX DISPOSABLE $379.00 STERI-STRIP 1/2 X 4 S102 $55.00 STERI-STRIP 1/4 X 3 $38.00 UMBILICAL TAPE U11T $83.00 BONE WAX $224.00 SUTURE VICRYL 0 DYED $170.00 SUTURE VICRYL 5-0 $42.00 SUTURE PROLENE 5-0 $126.00 SUTURE PROLENE 4-0 8557H $126.00 SUTURE SILK 2-0 CR/8 C012D $198.00 SUTURE PROLENE 2-0 $70.00 SUTURE PROLENE 4-0 SH 8521H $192.00 SUTURE SILK 4-0 $83.00 SUTURE PROLENE 1 CTX $46.00 SUTURE DEX, EBOND, SIL $419.00 SUTURE PROLENE $159.00 SUTURE NUROLON $252.00 SUTURE CHRO,ELON,PLA $103.00 BERMAN AIRWAY 80MM $36.00 NASAL CANNULA $14.00 OXYMASK ADULT/PED $59.00 TRACH MASK $18.00 CANNULA PED NASAL $67.00 CONN TUBING NON COND $36.00 SPINAL ANESTH TRAY $523.00 COVERLET 4X8 $89.00 COVERLET 4X6 $67.00 DRAPE U-DRAPE $192.00 BLADE ARTHROSCOPIC SHAVER $1,391.00 GRAFT BIFURCATED $10,652.00 SPECIMEN CUP SURGERY $67.00 RESUSCITATOR ADULT BAG (AMBU) $478.00 LAP SPONGE 18X18 $83.00 SYRINGE 70CC TOOMEY $154.00 INNER CANNISTER 1500 $222.00 SUCT CANNISTER + RED $262.00 TRAY CIRCUMCISION $213.00 STAPLER TA LONG 90 4. $2,570.00 STAPLER RELOAD LINEAR 30MM $1,867.00 STAPLER EEA SINGLE USE DISP $2,110.00 STAPLER LDS POWERED $2,738.00 TRAY EYE EXAM $289.00 EAR WASHER BOTTLE SYSTEM DISP $171.00 EPIXTAXIS CATHETER $1,267.00 PARACENTISIS TRAY $312.00 SUCTION DISPOSABLE SUPPLY KIT $741.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SUCTION DAILY $312.00 SITZ BATH $125.00 THORACOTOMY $312.00 PURSESTRING $1,394.00 TUBE TAMER (HOLDER) $122.00 PORTACATH 20G X1 $159.00 THORACIC CATH 28F $500.00 THORACIC CATH 36F $252.00 KIT VEIN HARVEST VASOVIEW DISP $3,275.00 NERVE STIMULATOR $794.00 DOPPLER CHARGE PER U $213.00 TRAY TONSIL $213.00 BLADE DERMATONE $426.00 BLADE MYRINGOTOMY DISPOSABLE $687.00 PLEUR EVAC CHEST TUBE SYSTEM $1,052.00 C1729 TOURNIQUET BLADDER ALL SZ DISP $878.00 NEEDLES ANY SIZE $2.00 A4215 SYRINGES ANY SIZE $38.00 TRAY LACERATION $291.00 TRAY AMNIOCENTISIS $461.00 TRAY TRACHEOSTOMY $523.00 TRACHEOSTOMY CLEAN TUBE $122.00 PACEMAKER SETUP $549.00 PACEMAKER--CHG PER DAY $213.00 ELECTRODE EXT PACING $1,080.00 STOPCOCK 3-WAY $55.00 FAST PATCH ELECTRODE $516.00 PARVENUS LEAD $2,145.00 GRIPPER INF SET 20G $185.00 NEEDLE INFUSION SET HUBER $185.00 K PAD SET UP $213.00 CYTOLOGY BRUSH CELLEBRITY $125.00 CYTOLOGY BRUSH BILIARY $664.00 FEEDING PUMP TUBING SUPPLY DIS $419.00 THERAPY BED-TOTAL CARE $2,407.00 STERILE TOWELS $252.00 TOWELS STERILE 4-PAK DISP $266.00 TOWELS STERILE 2-PAK DISP $89.00 TONSIL SPONGES 5 PER $192.00 DRAPE SHEET UNILATERAL $451.00 SUCTION RESERVOIR KIT $625.00 SUCTION KIT 100CC $310.00 BLANKET HYPOTHERMIA COOLING $523.00 ISOLATION DISP SUPPLIES $1,278.00 FOLEY CATH 3WAY 22FR 3 $291.00 FOLEY CATH 3WAY 24FR $461.00 CUSHION CAST SHOE AL $321.00 FEEDING TUBE 8F $38.00 SUCTION CONNECTION TUBING $67.00 UNIV POOLE SUCT TUBE $91.00 GRAFT T/W TOCMX30CM $15,391.00 C1768 FOGARTY EMB CATH $1,215.00 PAD GROUNDING $62.00 FLUID WARMER CUFF $519.00 SURGICAL PATTIES $50.00 SPIROMETER INCENTIVE $93.00 PACK ABDOMINAL MAJOR CUSTOM $1,534.00 PACK BASIC ORTHO $2,088.00 EYE SPEAR PACKAGE DISP $38.00 COUDE ROB CATH 18F $222.00 COUDE ROB CATH 20F $239.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
FOLEY CATH 30CC 16F 3WAY $419.00 FOLEY CATHETER 18F 30CC 3WAY $414.00 FOLEY CATH 30CC 20F 3WAY $414.00 FOLEY CATH 3CC 8FR & 10FR $375.00 12 F FOLEY 5CC $222.00 CATHETER URETERAL CONE TIP $118.00 CATHETER ANGIO PIGTAIL 65CM 5F $113.00 C1887 DISP MAXI LOOP R,W,B $129.00 TABLE COVER $89.00 FIBER OPTIC LIGHT $186.00 PIN STEINMANN NON THREADED $249.00 C1713 PIN STEINMANN THREADED $451.00 SCREW CANNULATED 7.0MM ALL SZ $1,281.00 C1713 POST OP SHOE 1900 SE $501.00 ABD PILLOW (MEDIUM) $974.00 ELECTRODES - SINGLE PACK $42.00 TRACH SUCTION SYSTEM $516.00 CATHETER ANGIO 7FR $656.00 CATHETER INTRODUCER GUIDE ALL $599.00 C1887 CATHETER TRIPLE LUMEN $945.00 J WIRE $355.00 KIT MULTI LUMEN CATHETER $994.00 T-PORT EXTENSION $73.00 ARTERIAL CANN SUPPORT DISP $113.00 NEBULIZER MISTY S.V.N. $38.00 NOSE CLIP $33.00 STAPLER MULTIFIRE TA 55 4.8 $3,441.00 STAPLER ENDOSCOP LINEAR CUTTER $1,876.00 STAPLER MULTIFIRE 6GIA 30 2.5 $2,008.00 NEEDLE VERESS 120MM $119.00 VALVED TEE ADAPTER $42.00 FILTER BACTERIA MINI VIROBAC $46.00 TUBE T (GENERAL SURGERY) DISP $107.00 STERI-STRIP VIAL $36.00 BETADINE GAUZE $2.00 BUCKS TRACTION BOOTS $579.00 UNIVERSAL CUTAWAY SL $355.00 UNIV COCKUP WRIST SP RT $266.00 SCREW CORTICAL 2323 $266.00 C1713 SCREW CANCELLOUS 232 $211.00 C1713 K-WIRE THREADED $275.00 K-WIRE SMOOTH $172.00 PLATE SEMI TUBE TITANIUM $664.00 PLATE ONE-THIRD TUBE SS 5>12H $1,253.00 C1713 BANDAGE COMPRESSION KLING 4 IN $36.00 INTERCEED BARRIER $2,421.00 MAXI-SPLINT 3 X 24 $125.00 MAXI-SPLINT 4 X 24 $152.00 SPLINT MAXI 6 X 24 $224.00 PLATE MINI FRAGMENT SS 4>10H $1,624.00 C1713 CEMENT RESTRICTOR $1,296.00 CARDIAC OUTPUT DAILY $419.00 SWAN GANZ SET UP SUPPLIES $523.00 ARTERIAL LINE SET UP SUPPLIES $523.00 PIN BALL $192.00 TRAY LUMEN TWIN CATHETER $1,895.00 KIT RADIAL ARTERY CATERIZATION $348.00 TWIN CATH 2 LUMEN 18 $338.00 CATHETER SUBCLAVIAN TRIP LUMEN $1,726.00 C1751 PACK EENT $564.00 UVAC HANDLE W/TUBING $247.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CURETTE VACUUM ALL SIZES $266.00 KNEE IMB CONTOURED 1 $549.00 KNEE IMB STRAIGHT 19 $673.00 KNEE IMB CONTOURED 2 $606.00 DAILY ISOLATION FEE $418.00 CLAMP ADJUST LARGE EXT FIXATOR $3,257.00 CLAMP SMALL EXTERNAL FIXATION $2,052.00 CLAMP LARGE PIN 6 POSITION $2,556.00 CLAMP LARGE COMBO EXT FIXATOR $3,617.00 K-WIRE 2.0 MM $276.00 INTRODUCER SHEATH $1,190.00 C1766 CATHETER AORTIC BALLOON $11,615.00 FEMORAL PROS OPEN BX INTLOK PS $4,822.00 C1776 PORT INDWELLING DUAL LUMEN $9,140.00 C1788 DISSECTOR PEANUT $565.00 WASHER TISSUE NO-PROFILE TI $1,544.00 C1713 BEARING TIBIAL LIP CR 63/67X10 $2,714.00 C1713 PLATE FEM PERI DIS LAT LOC 10H $4,460.00 C1713 SUTURE PROLENE 3-0 PLEDGET $139.00 ARTERIAL LINE $565.00 GRASPER DISPOSABLE $2,862.00 DRILL BIT PERCUTANEOUS 3.2MM $657.00 DRILL BIT PERCUTANEOUS 3.7MM $1,281.00 THERAPY BED-CLINITRON $1,905.00 E0194 SCREW PERI SELF-TAP 4.5X26-46 $260.00 C1713 GUIDE WIRE PER DRILL TIP 3.2MM $367.00 C1769 TRANSDUCER SINGLE $436.00 DRILL BIT STEP NON-STERILE $986.00 BALLOON DIALATORS $3,980.00 BALLOON PUMP DAILY $5,443.00 NEEDLE W/ OBTURATOR $205.00 FOG REDUCTION DEV $252.00 KNIFE ENDOSCOPIC ROUND COLD $656.00 TED STOCKING LARGE-REG $326.00 TED STOCKING MEDIUM-REG $326.00 TED STOCKING MEDIUM-LONG $326.00 TED STOCKING SMALL-REG $326.00 GUEDEL AIRWAY-080 $33.00 AIRWAY GUEDEL ALL SIZES $33.00 TORQUE VICE .025 CM $264.00 MANIPULATOR UTERINE INJECTOR $741.00 RADIAL JAW BIOPSY FORECEPS $1,440.00 KNIFE ENDOSCOP STR COLD SACHSE $656.00 UNIV COCKUP WRIST LEFT $266.00 SCREW NCB CORTICAL 5.0MM $887.00 C1713 SCREW NCB UNICORTICAL 5.0MM $821.00 C1713 SCREW NCB CORTICAL 4.0MM $624.00 C1713 PLATE FEMUR PERIPROS DIS TI 9H $4,012.00 C1713 CABLE BUTTON HEX DRV TI 2.5MM $919.00 C1713 DRILL BIT Q-C 3.3X245MM $558.00 STOMAHESIVE SKIN BARRIER 4X4 $556.00 A4362 STOMAHESIVE SKIN BAR 8X8 $943.00 A4362 STOMAHESIVE WAFER 2 3/4 $154.00 A4364 OB SUPPLIES VAGINAL $4,318.00 OB SUPPLIES C-SECTION $13,827.00 DAILY SUPPLY/NUR SPECIAL CARE $218.00 BLADDER SCANNER PER DAY $122.00 GASTRIC LAVAGE TRAY $773.00 ART LINE INSERTION TRAY $1,104.00 TLSO BODY JACKET-BIVALVE $18,160.00 L0486 AFO CUSTOM MOLDED,SOLID ANKLE $2,527.00 L1960
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
AFO CUSTOM WITH ANKLE JOINTS $8,516.00 L1970 IPOP SHRINKER SOCK $231.00 L8440 LEAD PACE NT VDD SGL INGEV MRI $2,053.00 C1898 DRESSING INTEG BMWD PER 1SQ CM $580.00 Q4104 BLADE SAW 10 X 35 #5059-532 $604.00 SUTURE VICRYL 3-0 J427/J497 $108.00 SUTURE VICRYL 2-0 SH J417H $48.00 CLIP TITANIUM $235.00 IV CATHETER CLOSED SYST NEXIVA $108.00 SOMASENSOR NONINVASI ADULT DIS $1,356.00 CANNULA ARTERIOTOMY DLP $249.00 PERICARDIAL SUMP DISPOSIBLE $249.00 ADAPTER STRAIGHT PERFUSION DIS $143.00 SUTURE ETHIBOND PLEDGET 2-0SH $611.00 SUTURE ETHIBOND PLEDGET 2-0V5 $1,069.00 DRAIN SILICONE CHANNEL 24FR $378.00 NEEDLE FREE $90.00 PAD CARDIOTOMY SENSOR DISP $146.00 BAND ANNULOPLASTY RING IMPLANT $9,244.00 DRAPE MAJOR ABDOMINAL $264.00 TUBING PRESSURE LINE $116.00 DRAPE OPEN HEART DISPOSABLE $332.00 SUTURE PDS #1 CTX Z371 $60.00 PACK OPEN HEART DISPOSABLE $5,283.00 FILTER BLOOD DISPOSABLE $275.00 RESEVOIR BRAT DISP $779.00 CELL SAVER BOWL $1,209.00 TRANSDUCER ART PRESSURE LINE $381.00 PACK SUCTION $362.00 SAT CRIT ASSEMBLY $159.00 HEMOCONCENTRATOR 700 MIDI $1,138.00 OXYGENATOR PRIMOX ADULT COATED $2,856.00 PACK TUBING PERFUSION $316.00 KIT PERFUSION ADULT COATED SET $4,291.00 VALVE RSR PERICARDIAL AORTIC $19,687.00 BAND MITRAL ANNULOPLASTY RING $10,229.00 PACK CUSTOM OXYGENATOR+TUBE $3,387.00 CATHETER LEFT HEART VENT $279.00 CANNULA FEMORAL VENOUS NONVENT $2,445.00 BLANKET WARM UNDERBODY BAIR $321.00 BLANKET ST LOWER BODY OR/CAR $321.00 GUIDE WIRE STRAIGHT $394.00 C1769 CORD MONOPOLAR DISPOSABLE $221.00 SUTURE CHROMIC 0 $57.00 SUTURE ETHIBOND 1 $57.00 CAPSULE ENDOSCOPIC DISPOSIBLE $3,715.00 SKIN REPAIR CREAM 4FL OZ $75.00 GEL SHEET COOL MAGIC $57.00 AIRWAY NASOPHARYNGEAL 20F $84.00 AIRWAY NASOPHARYNGEAL 22F $112.00 AIRWAY NASOPHARYNGEAL 24FR $75.00 AIRWAY NASOPHARYNGEAL 26FR $57.00 AIRWAY NASOPHARYNGEAL 32FR $83.00 LARYNGEALSCOPE OPTICAL DISP $889.00 BANDAGE ELASTOPLAST 1" $36.00 BETADINE SOLUTION 4 OZ $13.00 CORD BIPOLAR DISPOSABLE $83.00 KIT EAR DRESSING $179.00 EXTRACTOR KATZ FOREIGN BOD DIS $477.00 NEEDLE EZ CLEAN 2.75 BOVIE TIP $59.00 NEEDLE NONSTICK CAUTERY BOVIE $104.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SURGICAL PATTIES 1/2 X 3 $75.00 HIBICLENS PREP SOLUTION $97.00 SUTURE ETHIBOND 4-0 $89.00 SUTURE ETHIBOND 5 CCS $247.00 SUTURE ETHIBOND 5 MS/4 $185.00 SUTURE ETHILON 7-0 $90.00 TAPE MERSILENE WOVEN RS22 $362.00 SUTURE ETHIBOND 4-0 TIES $75.00 SUTURE ETHIBOND 3-0 TIES $50.00 SUTURE ETHIBOND 2-0 $73.00 SUTURE ETHIBON 2-0 MS/4 $184.00 PLATE ONE-THIRD TUBULAR W/COLL $416.00 C1713 SUTURE PDS PLUS 0 $114.00 SUTURE PDS 5-0 $185.00 SUTURE PDS PLUS 1 $104.00 SUTURE PROLENE 0 CT-2 C827 $206.00 SUTURE PROLENE 6-0 8709 $164.00 SUTURE SILK 2-0 $33.00 SUTURE SILK 3-0 CR/8 C013D $156.00 SUTURE SURGICAL STEEL 4-0 $48.00 SUTURE ENDOSTITCH 2-0 SURGIDAC $480.00 SUTURE VICRYL 0 CR/8 $206.00 SUTURE VICRYL 0 TIES $84.00 SUTURE VICRYL 2-0 $46.00 SUTURE VICRYL 2 TP-1 J649 $177.00 SUTURE VICRYL 2-0 TIES $156.00 SUTURE VICRYL 3-0 TIES $143.00 SUTURE VICRYL 4-0 TIES $164.00 ADAPTER FEEDING DUAL PORT $103.00 PLATE FIBULAR DIS/LAT LOCK 8H $2,371.00 C1713 STOCKINETTE IMPERVIOUS LARGE $78.00 ESMARK BANDAGE 6" $127.00 TUBING TURP Y-TYPE $135.00 SCREW CANCELLOUS 4.0MM $174.00 C1713 SUCTION COAGULATOR 12FR $210.00 SUCTION TIP FRAZIER (ALL SIZE) $46.00 SUTURE PROLENE 7-0 8703H $156.00 TUBING SINGLE CYSTO IRRIGATION $97.00 EVACUATOR LAPAROSCOPIC SMOKE $275.00 CATHETER SOAKER 5" W/NEEDLE $616.00 DRAIN SYSTEM CHEST DRY SUCTION $355.00 NEEDLE ANGIOCATH 14GA 5" $213.00 FILTER WAND RESIST BUFFALO DIS $152.00 LAP SPONGE MINI $18.00 DRAPE SHOULDER ARTHROSCOPY DIS $303.00 DRAPE SHOULDER PACK II DISP $221.00 DRAPE UNDER BUTTOCK W/POUCH $84.00 ENDO LUBE DOPPLER $114.00 SHEARS HARMONIC CURVED DISP $3,095.00 SCOTCH CAST PADDING PER FOOT $97.00 SUTURE PLAIN GUT 2-0 $57.00 SUTURE PLAIN GUT 4-0 P-3 1644 $93.00 SUTURE PLAIN GUT 5-0 $93.00 SUTURE PLAIN GUT 6-0 $55.00 BANDAGE SYSTEM MULTI LAYER $186.00 BANDAGE SYSTEM LITE LF $175.00 PLATE DHS STANDARD BARREL $3,021.00 C1713 BUR FLUTED (ALL SZ) DISP $1,098.00 BUR SMALL BONE DISPOSABLE $230.00 ELECTRODE LIGASURE PRECISE $2,835.00 UNDERPAD *1* $2.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRAPE FLUID WARMER $361.00 SCREW CANNULATED 3.0 (ALL SZ) $1,106.00 C1713 SCREW HEADLESS COMPRESSION 3MM $1,377.00 C1713 SCREW STD FOOT/ANKLE (ALL SZ) $879.00 C1713 DRILL BIT FITTING STRYKR 2.0MM $656.00 WIRE OLIVE 1.1MM $748.00 SUTURE MAXBRAID ALL SIZES $314.00 CIRCUIT METANEB W/NEBULIZER $656.00 VASCULAR CLOSURE DEVICE $3,363.00 C1760 MESH HERNIA PLUG (ALL SIZES) $4,762.00 C1781 PLATE LCP PROXIMAL HUMERUS $6,063.00 C1713 STENT URETERAL COATED W/D/SYS $1,175.00 C2625 PLATE TIBIA PROXIMAL/DISTAL $5,849.00 C1713 DRAPE FEMORAL W/WINDOWS $172.00 GELFOAM SPONGE SMALL SURGIFOAM $94.00 GELFOAM SPONGE LARGE SURGIFOAM $239.00 SET URETERAL DILATOR $1,439.00 PLATE WRIST VOLAR $3,903.00 C1713 SCREW CANNULATED 5.0 $1,348.00 C1713 MESH HERNIA PARIETEX SKIR 15CM $3,145.00 C1781 MESH HERNIA PARIETEX PROG 15CM $1,993.00 C1781 MOUTHSEAL SOFT W/MOUTHPIECE $56.00 DRAPE THYROID STERILE $103.00 INSERT FOGERTY DISPOSABLE $173.00 MESH HERNIA PROGRIP LT/RT 12CM $4,277.00 C1781 MESH HERNIA PROGRIP 15CMX9CM $1,930.00 C1781 STENT CAROTID NCOA/NCOV W/DEL $7,241.00 C1876 TUBE ENDO 4.0 $26.00 NAIL FEMUR TROCHANTERIC SH TI $7,197.00 C1713 NAIL FEMUR TROCHANTERIC LG TI $7,279.00 C1713 RELOAD STAPLER TRT75MM $686.00 DRAPE FLOURO STERILE DISP $30.00 PROBE COVER ULTRASOUND DISP $50.00 PLATE WRIST DORSAL $4,351.00 C1713 MESH HERNIA 3D $1,509.00 C1781 MESH HUMAN ULTRA THICK 16X20CM $30,140.00 C1762 INSERT BIPOLAR TAPER $688.00 RING ACETABULAR CUP SIZE 20>28 $677.00 NEEDLE TROCAR 3MM $307.00 POSITIONER KNEE 2ND ASSIST $820.00 BAG BLOOD REINFUSION $144.00 PLATE FAN CMF TI $5,688.00 C1713 TIBIAL COMPONENT KNEE REVISION $8,061.00 C1776 AUGMENTATION BLOCK PART KNEE $5,792.00 SCREW DRIVER BLADE ORTHO DISP $848.00 CLIP DYNAMIZATION CLAMP $715.00 INTRO SHEATH FLX DRYSEA 12-22F $1,781.00 C1894 DRAPE CASSETTE XRAY DISPOSIBLE $70.00 CATHETER MICRO FRACT FLOW RXI $1,882.00 C1887 PLATE LCP TUBULAR SS $940.00 NEEDLE SPINAL PENCAN $97.00 NEEDLE SPINAL QUINCKE 5" $141.00 NEEDLE SPINAL WHITACRE 5" $185.00 TUBING J LOOP 6" $28.00 VALVE HEIMLICH CHEST $278.00 FORCEP BIOPSY CUP $2,526.00 KIT SHOULDER SUSPENSION $586.00 SEAL BIOPSY PORT $134.00 PLATE LCP NARROW SS 4>16 HOLE $3,068.00 C1713 MESH HERNIA ULTRAPRO $2,888.00 C1781 KIT EVICEL SEALANT FIBRIN 5ML $2,729.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CLAMP LG MULT-PUR PIN 6 POSITI $4,211.00 CLAMP TRANSVERS LG EXT FIXATOR $2,525.00 HEAD STD MAGNUM HIP IMPLANT $6,327.00 PLATE FEMUR DISTAL 3>18H RT $6,118.00 C1713 SCREW LAG TELESCOPING KEYED $4,031.00 C1713 NASAL CANNULA HI-FLOW ALL SIZE $106.00 MESH HERNIA COMPOSITE 15X20CM $4,526.00 C1781 MESH HERNIA COMPOSITE 25X35CM $8,503.00 C1781 PORT SAMPLE CELLSAVER $266.00 RETRACTOR WOUND MEDIUM DISP $388.00 SEAL PORT CAP $2,244.00 KIT CRICOTHYROIDOTOMY $515.00 HOOD COVER JOINT $348.00 VALVE AORTIC BOVINE $24,286.00 VALVE MITRAL BOVINE $25,470.00 TOTAL KNEE FEMUR COMPONENT $12,843.00 TIBIAL COMPONENT STANDARD $10,718.00 CUP ACETABULAR TOTAL HIP $6,761.00 LINER TOTAL HIP STANDARD $6,252.00 C1776 HEAD STD CERAMIC HIP IMPLANT $6,521.00 PLATE LCP WRIST FUSION $6,040.00 C1713 SCREW DRIVER CRUCIFORM/STARDRI $4,372.00 SCREW DRIVER CANNULATED DISP $2,339.00 PLATE LCP BROAD SS 6>9 HOLE $3,456.00 C1713 KIT ACL TIGHT ROPE TWIN TAIL $3,291.00 C1776 KIT PROXIMAL TENODESIS $3,028.00 C1713 BUTTON DOG BONE AC JOINT $2,053.00 C1713 SKIN CREAM ATRACTAIN 2 OZ $118.00 SKIN CREAM BAZA 2 OZ $57.00 CIRCUIT PNEUPAC VENTALATOR $185.00 PLATE VHS SUPRACONDYLAR 152MM $7,856.00 C1713 STEM HIP REVISION CEMENTED $26,509.00 STEM HUMERAL COMPREHENSIVE PPS $13,887.00 C1776 SLEEVE HUMERAL POSITIONING $2,105.00 TRAY GLENOID IMPLANT $6,413.00 GLENOID LINER $4,127.00 PLATE CLAVICLE NRW PROFILE $3,137.00 C1713 BALLOON ENDOLUMINAL CATHETER $2,913.00 C1725 GRAFT ENDO THORACIC $47,198.00 C1768 PERFECTPASSER CONNECTOR OPUS $1,076.00 ENDO CLINCH II DISPOSABLE $326.00 GUIDE WIRE GLIDEWIRE ADVANTAGE $1,270.00 C1769 INTRODUCER SHEATH RAABE (ALL) $718.00 INTRODUCER SHEATH BALKIN $785.00 INTRODUCER SHEATH ANSEL $584.00 CATHETER RE-ENTRY $6,221.00 NEEDLE RADIAL INTRODUCER $78.00 NEEDLE SPINAL QUINCKE 6" $134.00 NEEDLE SPINAL 25GA X 3.5 INCH $25.00 GUIDE EXTENSION $2,571.00 BALLOON CUTTING $4,855.00 C1725 VALVE BLEEDBACK CONTROL $421.00 DRESSING SIMPLACE WOUND VAC $375.00 DRESSING GRANUFOAM LG WND VAC $480.00 DRESSING WHITE FOAM SM WND VAC $144.00 DRESSING WHITE FOAM LG WND VAC $170.00 CANISTER WOUND VAC $271.00 DRAPE WOUND VAC $100.00 ADAPTER INTUBATION BRONCH $177.00 TRAY MEDIASTEINOSCOPY DISP $282.00 DRESSING AQUACEL PADS AG $135.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
POSITIONING PAD TRIANGLE $221.00 NAIL TI ELASTIC $1,987.00 C1713 CATHETER THROMBOLYSIS DRUG DEL $8,278.00 C1751 AIRWAY EXCHANGER SOFT TIP $414.00 SUCTION TUBE 16FR SHAFT $192.00 KIT ANESTH CIRCUIT ADULT DISP $509.00 FORCEP BIOPSY SPYGLASS $2,031.00 CATHETER DS DELIVERY SPYGLASS $5,429.00 MASK NEONATAL NEOPUFF $89.00 MASK CUVETTE 02 ADULT DISP $156.00 BLADE VISION STD/CHANNEL DISP $258.00 KIT JUGGERNAUT W/ANCHOR DISP $2,398.00 C1713 SUCTION MANIFOLD NEPTUNE $239.00 STEM EXTENSION OFFSET KNEE REV $6,455.00 C1713 LINER CONSTRAINED (HIP) $12,176.00 C1776 AUGMENTATION BLOCK FULL KNEE $13,198.00 CATHETER TRANSL ATHER ROTATION $4,423.00 C1724 CATHETER TL ATHER BURR ROTALNK $4,458.00 C1724 BALLOON BRONCHOSCOPY EBUS $186.00 KIT DRILL & PIN TOTAL KNEE $3,926.00 SHOE POSTOP REHAB $78.00 DRAIN BAG UA $106.00 SHELL HUMERAL SOCKET $5,377.00 C1776 PLATE BASE GLENOID HYDROXY $4,945.00 C1713 STENT BILIARY WALLFLEX $7,015.00 C1874 STAPLER EEA SINGLE USE XL DISP $2,650.00 EEA ORVIL GUIDE DEVICE $667.00 NEEDLE UROPLASTY COLLAGEN $362.00 KIT CATHETER PERITONEAL DIALYS $1,005.00 C1750 KIT EPIDURAL COMBINED $152.00 GUIDE WIRE BENTSON STRT TIP $135.00 C1769 GRAFT ALLOGRAFT SEMITENDINOSUS $5,017.00 C1713 STEEL SURGICAL 16 TO 24 GA $424.00 TRAY CUSTOM SPINAL ANETHESIA $187.00 MESH SOFT TISSUE REINFORCE 6X6 $3,010.00 C1781 LIGHT SURGICAL DISPOSABLE $728.00 KIT NAVATRACKER KNEE $4,348.00 TRAY BASIC BIOPSY $230.00 DRESSING BACTERIOSTATI WND 4X4 $93.00 DRESSING BACTERIOSTATI WND 6X6 $187.00 DRESSING BACTERIOST ISL 4X4.75 $118.00 MESH PORCINE 7" X 10" $4,256.00 C1763 SLING COLLAR W/CUFF UNIVERSAL $93.00 TRAY ENT DISPOSABLE $228.00 PAD SELF ADHERING FOAM $129.00 TOTAL ELBOW ULNA COMPONENT $19,250.00 C1776 TOTAL ELBOW HUMERAL COMPONENT $21,101.00 C1776 STENT ILIAC BALLOON $6,091.00 C1876 HEAD FEMORAL OXINIUM $10,866.00 BOOT PNEUMATIC WALKING PREFAB $1,221.00 L4360 AIRWAY FASTRACH DISPOSABLE $461.00 KNEE ORTHOTIC ADJ KNEE JOINTS $2,686.00 L1832 POSITIONER BEACH CHAIR DISP $355.00 STENT COATED/COV/W DEL SYS $7,876.00 C1874 HEAD HEMI UNIPOLAR HIP $2,829.00 HEAD HEMI BIPOLAR HIP $5,807.00 DRESSING WOUND OPTILOCK 5X5.5 $38.00 DRESSING WOUND MEPITEL ONE 3X4 $71.00 KIT BALLOON INSERT INTR AORTIC $1,136.00 CONNECTOR AUX WATER PORT DISP $42.00 STRETCH BAND 1 IN CONFORMING $2.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
PLATE ADAPTION CMF $3,032.00 C1713 CAST TOTAL CONTACT 3" OR 4" $743.00 DRESSING SILVERLON WOUND 2 X 8 $166.00 A6255 DRESSING SILVERLON WOUND 2X10 $213.00 A6255 DRESSING SILVERLON WOUND 4X12 $276.00 A6255 DRESSING SILVERLON WOUND 4X10 $275.00 A6255 RETRACTOR RING DISPOSABLE $590.00 NEEDLE ELECTRODE 1" $84.00 TUBE GASTROSTOMY FEEDING $292.00 NEEDLE INTERJECT 240 MM $310.00 CAST TOTAL CONTACT LARGE BOOT $656.00 CAST TOTAL CONTACT EXT LG BOOT $687.00 LINER TOTAL HIP RINGLOC $7,238.00 C1776 CABLE STAINLESS STEELE $2,183.00 CABLE COBALT CHROME $2,535.00 CABLE CRIMP SLEEVE STAINLESS $1,530.00 C1713 BLADE ARTHRO RESECT 3.5MM DISP $630.00 NASAL MUCOSAL ATOMIZATION $71.00 LARYNG-TRACH MUCOSAL AUTOMIZER $96.00 PLATE DHS 135 14>16H STERILE $3,916.00 C1713 POUCH DRAINABLE W/INVISICLOSE $26.00 STABILIZER KNEE TIBIAL INSERT $9,186.00 STEM TOTAL KNEE 12MM X 50MM $4,264.00 C1776 BLADE RECIPROCATING DBL OFFSET $350.00 BLADE SAGGITAL $374.00 DRESSING AQUACEL EXTRA 4"X5" $70.00 EMBOLIZATION PROTECTIVE SYSTEM $5,009.00 C1884 ENDO POUCH II RETRIEVAL $633.00 GRAFT HEMASHIELD PLATINUM $3,120.00 C1768 SET EXTENSION 17" FILTER $49.00 GRAFT TENDON GRACILI HUM 190MM $4,137.00 C1762 DRESSING AQUACEL ADHESIVE 5X5 $65.00 DRESSING AQUACEL ADHESIVE 4X4 $43.00 TUNNELER DENVER SHUNT $664.00 DRESSING TEGADERM FOAM 3.5X3.5 $35.00 DRESSING TEGADERM FOAM 5.5X6.0 $62.00 COIL TORNADO PLATINUM EMBOLIZA $637.00 PLATE LCP OLECRANON 112 MM $4,071.00 C1713 STATLOCK PICC PLUS $63.00 STENT ILIAC WALLSTENT ENDO $2,674.00 C1876 PACK PORT $1,710.00 KIT ANGIO PERIPHERAL VASCULAR $140.00 SUTURE PROLENE 6-0 MS-4 M8706 $712.00 BRACE KNEE POST OP T-SCOPE $680.00 DISSECTOR ROSEBUD $30.00 CATHETER SOFT-VU BRAIDED $166.00 BALLOON MUSTANG (ALL SIZES) $637.00 C1725 INFLATION DEVICE IN4130 $266.00 STENT VIATORR 10MM (TIPS) $12,421.00 C2617 DRESSING MEPILEX BORDER SACRUM $118.00 PLATE BB TAK $326.00 C1713 TUBING HIGH PRESSURE BRAID FLX $106.00 SHEATH SUPER R/O 7F $154.00 SYRINGE MEDALLION $31.00 DRAINAGE DEPOT W/FLEX TUBING $122.00 SUCTION DRAINAGE SYSTEM $251.00 DRESSING HYDROFERA BLUE 6X6 $159.00 DRESSING HYDROFERA BLUE 4X4.75 $103.00 DRESSING HYDROFERA BLUE 4X4 $77.00 POUCH OSTOMY HIGH OUTPUT $26.00 WAFER OSTOMY CONVEX $26.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
POUCH OSTOMY POST-OP HI OUTPUT $83.00 WAFER OSTOMY NEW IMAGE $15.00 POUCH OSTOMY DRAINABLE $12.00 RING OSTOMY BARRIER $30.00 WAFER OSTOMY BARRIER $14.00 DRESSING AB THERA OPEN ABD WND $2,118.00 SIZER VASCULAR GRAFT DISP $118.00 POSITIONER VACCUM SYSTEM DISP $4,343.00 STABILIZER VACUUM SYSTEM DISP $5,352.00 SURGICEL ABSORBABLE SNOW 4X4 $808.00 BIOPSY INSTRUMENT MONOPTY DISP $252.00 STENT NEPHROURETERAL $708.00 C2625 DRESSING AQUACEL EXTRA AG $120.00 EMBOLIZATION PARTICLES $696.00 C1884 CATHETER SOFT-VU NON BRAIDED $166.00 GLIDE CATH STRAIGHT TAPER $378.00 C1887 CATHETER ANGIOGRAPH RIM $171.00 CATHETER BERENSTEIN NON BRAID $166.00 CATHETER SUPERSELECTIVE MICRO $1,726.00 CATHETER INFUSION VALVED $604.00 C1752 ABLATOR SHORT (ATRICURE)DISP $8,561.00 ABLATOR LONG (ATRICURE) DISP $8,561.00 KIT CHEMO-EMBOLIZATION DISP $467.00 GUIDE WIRE HI-TORQUE VERSACORE $635.00 C1769 CATHETER HI-FLO STRAIGHT $1,677.00 GUIDE WIRE W/ICE HYDROPHILIC $611.00 C1769 GUIDE WIRE EXTENSION LOC $499.00 C1769 STENT TRANSHEPATIC BILIARY SYS $5,543.00 C2625 TUBE FEEDING JEJUNAL ALL SIZE $777.00 CATHETER BEACON TIP ADVANTAGE $130.00 STENT ENDOPROSTHESIS COA/COV/W $8,607.00 C1874 GUIDE WIRE STR TIP STEERABLE $2,073.00 C1769 BALLOON PTA DILATATION $7,302.00 C1725 TIBIAL TRAY FINN MOD INTLK CC $2,905.00 C1713 BALLOON PTA FOX SV $2,273.00 C1725 SET INTRODUCER NONVASCULAR $602.00 C1894 CATHETER BALLOON CODA $2,401.00 C1725 BALLOON PTA DILATATION COYOTE $1,812.00 C1725 BALLOON PTA DILATATION DORADO $1,007.00 C1725 SET PORTAL ACCESS TIPS $2,551.00 MARKER SPECIMEN MARGIN ST DISP $700.00 CANNULA VENOUS DUAL $322.00 COIL PUSHER 16 $777.00 GLIDE WIRE GT $1,036.00 C1769 SURGICEL NU-KIT HEMOSTAT 1X1 $158.00 AICD OTHR THN SGL/DUAL CHAMBER $55,404.00 C1882 LEAD CORONARY LT VENTRICULAR $11,274.00 C1900 LEAD PACEMAKER NOT TRN VDD SGL $6,205.00 C1898 LEAD AICD ENDO DUAL COIL $10,266.00 C1895 GELFOAM SPONGE 100C SURGIFOAM $175.00 SPONGE HEMORRHOIDECTOMY $181.00 POWDER SURGIFOAM 1 GM PER UNIT $440.00 KIT POWDER SURGIFOAM 1GM PER U $635.00 SURGICEL ABSORBABLE SNOW 2X4 $610.00 ENDOSCOPIC APPLICATOR DISP $327.00 APPLICATOR SEAL 35CM RIGID TIP $289.00 KIT SURGIFLO LYO THROMBIN SEAL $1,098.00 BONE CEMENT HI VISCOSITY RADIO $3,221.00 KIT PCD INTERVENTL PAIN W/11G $2,385.00 LEAD PACING MYOCARDIAL $499.00 GUIDE WIRE SENSOR 150 X .035 $370.00 C1769
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
NEEDLE BIOPSY BONE OSTEO-SITE $787.00 C1830 BRACE TLSO STERNAL $5,988.00 L0464 SOCK WOOL BELOW KNEE $106.00 L8420 SHRINKER ABOVE KNEE $367.00 L8460 ORTHOSIS UPPER EXT HUMERAL $1,566.00 L3980 CATHETER DRAINAGE NEPHROSTOMY $366.00 C1729 AIRWAY FASTRACH W/STABILZ DISP $559.00 FIXATION DEVICE STAYFIX $116.00 MANIFOLD SYSTEM 4-PORT $105.00 CATHETER BALLOON TRI-LOBE $2,638.00 C1725 TRAY BIOPSY ONCONTROL DISP $748.00 BONE CEMENT COBALT $653.00 NEEDLE COAXIAL BIOPSY DISP $119.00 SET VENA CAVA FILTER RETRIEVAL $1,239.00 C1773 RECOVERY CONE REMOVAL SYSTEM $2,528.00 C1773 TUBING HIGH PRESSURE BRAIDED $77.00 APPLICATOR SEALANT CONTROL TIP $224.00 GUIDE WIRE NIT-VU STRAIGHT $833.00 C1769 TUBE TRACH SHILEY CUFFED $298.00 PROCTOSCOPE LED DISP $251.00 CATHETER SUPPORT 5 FR $671.00 GUIDE WIRE EXT SUP 0.035X300CM $624.00 C1769 GUIDE WIRE SHAPABLE .014X300CM $1,007.00 C1769 GUIDE PIN THREADED 2.5 $548.00 SCREW LAG $2,313.00 C1713 PLATE KEYLESS 4 HOLE $2,993.00 BAG PHLEBOTOMY $108.00 GUIDE WIRE .045 X 1.1 MM $94.00 C1769 DRILL BIT CANNULATED 2.0MM DIS $922.00 PACK UPPER EXTREMITY DISP $616.00 PACK KNEE ARTHROSCOPY DISP $555.00 PACK GYN MINOR DISPOSABLE $543.00 PACK THORACIC DISPOSABLE $2,360.00 PACK ANESTHESIA HEART DISP $6,302.00 PIN DRILLING TRIM IT DISP $1,216.00 SCREW LAG CANNULATED 2.3 MM $610.00 C1713 SYRINGE MEDRAD INTERVEN DISP $68.00 SET PLEURX LOCK DRAINAGE LINE $288.00 CATHETER URETERAL OPEN ENDED $113.00 GUIDE WIRE ANGLED INTERMEDIATE $694.00 C1769 PACK PICC LINE DRAPE $275.00 SET CYSTO/BLADDER IRRIG 81" $43.00 KIT AERONEB SOLO NEBULIZR DISP $348.00 NEEDLE INTRODUCTION FAUCET TIP $339.00 BALLOON PTA DILATATION ATLAS $1,900.00 C1725 CATHETER BALLOON NEPHROMAX $1,634.00 C1726 CATHETER ACCESS KUMPE $238.00 SHEATH URETERAL ACCESS $629.00 KIT WOUND VAC PREVENA DISP $2,766.00 BALLOON NEPHROSTOMY $785.00 C1729 INTRODUCER VALVED PEELABLE $244.00 C1892 SET EXTENSION W/STOPCOCK 3WAY $44.00 CATHETER CENTESIS 5F-10CM $190.00 TRAY PARA/THORA K12T-06072 $210.00 SET LIVER ACCS & BIOPSY NEEDLE $2,647.00 KIT PEG TUBE SAFETY $865.00 MESH VENTRALEX ST SM CIRCLE $2,178.00 C1781 MESH VENTRALEX ST MED CIRCLE $2,605.00 C1781 MESH VENTRALIGHT W/E 15.2X20.3 $4,112.00 C1781 SYSTEM COLLECTION CO2 $139.00 SNARE POLYPECTOMY OVAL/HEXAGON $728.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRESSING ARGLAES ISL 4"X4.75" $195.00 PLATE MTP LP STR SHORT TI $3,928.00 C1713 KIT THD SLIDEONE HEMORRHO DISP $2,233.00 SUTURE CHROMIC 5-0 GUT K895H $146.00 STENT BILIARY RX $719.00 C1874 DRILL BIT UNIVERSAL $922.00 DRESSING CONTACT LAYER RESTORE $68.00 A6206 CATHETER POWERLINE DUAL LUMEN $1,752.00 C1751 DRESSING SURESITE $13.00 STATLOCK NASOGASTRIC W/SKN PRE $15.00 SHEATH LARYNGEAL CO-PILOT DISP $119.00 DRESSING SILVERLON WOUND 4 X 6 $154.00 A6255 PLATE DIST/RADIU VA-LCP 2.4MM $2,318.00 C1713 INTRODUCER ET ADLT COPILOT DIS $71.00 KIT C02 CONTRAST DELIVERY $276.00 FILTER C02 $14.00 STENT BILIARY DUODENAL/CTR $719.00 C2625 DRESSING MEPILEX AG SOFT 4 X 4 $89.00 DRESSING MEPILEX BORD AG 4X10 $119.00 DRESSING MEPILEX BORD AG 3X3 $71.00 DRESSING MEPILEX BORD AG 4X8 $165.00 DRESSING MEPILEX BORD AG 4X12 $238.00 KIT TRANSTIBIAL ACL DISP $810.00 SUCTION POLYP TRAP $89.00 BLADE PATELLA REAM W/PILO HOLE $1,074.00 BLADE SAW EXTENDED STERNUM $222.00 GUIDE WIRE CPE ESOPHA $1,184.00 C1769 INTRODUCER SHEATH FLEXOR 6F $658.00 C1894 SUTURE PROLENE BLUE $480.00 TUBE TRACH SHILEY DIST NONCUFF $894.00 A7520 KIT PLEUREX CATHETER SYSTEM $473.00 C1729 CONNECTOR VALVE POS MAXPL DISP $13.00 ELECTRODE COAGULATING KNIFE $683.00 SUTURE VICRYL 2-0 CT-1 27" $279.00 GUIDE WIRE STINGRAY $1,398.00 C1769 CATHETER BALLOON STINGRAY $3,650.00 C1725 CATHETER CROSSBOSS $3,736.00 C1887 DRESSING MEPILEX BORDER 4 X 10 $205.00 PACEMAKER OTH TH SGL/DUAL BI-V $27,815.00 C2621 PLATE ORBITAL RIM $1,530.00 C1713 SCREW CORTES TITANIUM PLUS DR $534.00 C1713 KIT HYOID/TONGUE SUSP SYS $14,309.00 C1713 BEARING TIBIAL $5,972.00 C1713 DRAPE LAPAROSCOPY W/GUSSETT $75.00 BED SAFETY ENCLOSURE RENTAL $122.00 E0316 TUBING CONNECTOR VINYL $143.00 TRAY SPECIAL PROCED IMAGE DISP $292.00 PROBE HEMOSTASIS BEAMER DISP $1,201.00 BALLOON DILATION BILIARY $1,279.00 C1726 INJECTION SYSTEM RAPID REFILL $181.00 SLEEVE AUGMENT TIBIAL $3,547.00 MANIFOLD SYSTEM 3-PORT $160.00 TRAY PERCUTANEOUS TRACH INTROD $1,179.00 JAGTOME CUT WIRE 20MM DISP $1,671.00 PROBE BREAST BIOPSY DISP $1,453.00 CATHETER EP DIAG TORQR 5FR $2,096.00 C1730 CATHETER EP WEBSTER $1,409.00 C1730 SNARE POLYPECTOMY CAPTIVATOR $143.00 APPLICATOR SEALANT EXTEND TIP $589.00 BAG PRESSURE INFUSOR 3000CC $234.00 STENT URETERAL TEMP W/O DEL $556.00 C2617
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
FORCEP BIOPSY 2.8 DISPOSABLE $90.00 SNARE ELECTROSURGICAL DISP $113.00 STRAP OPEN SECURE SHORT DISP $2,554.00 LIGASURE TISSUE FUSION DISP $2,802.00 LIGASURE SEALER/DIVIDER DISP $2,677.00 BAG PRESSURE INFUSER 1000ML $161.00 COIL CONCERTO $4,251.00 CANISTER VACUUM ATEC WITH LID $71.00 GUIDE PIN PT TROCAR TIP 3.2MM $173.00 NEEDLE MAMMO KOPAN $274.00 PLATE MINI LOCKING 2.0 4-HOLE $2,731.00 C1713 SCREW CORTEX SELF DRILLING 5MM $548.00 C1713 PACK PROCEDURE SEPRAFILM $613.00 SUTURE ANCHOR PEEK $2,170.00 DRESSING TEGADERM CHG IV SECUR $68.00 KIT CATH ARTERIAL LINE FEMORAL $235.00 PIN EMERGENCY RELEASE $606.00 SCREW STERNAL SELF DRILLING $1,106.00 C1713 SET VAC DUO TUBE $522.00 CASSETTE VAC VERALINK DISP $381.00 DRESSING VAC VERAFLO MED DISP $642.00 NEEDLE BREAST BIOPSY $362.00 ELECTRODE STRAIGHT OPTI 2 $252.00 STEM HIP NECK 127° ANGLE $8,597.00 HEAD UNIVERSAL BIPOLAR HIP $2,794.00 HEAD FEMORAL LFIT $2,562.00 SET BEADED CABLE AND SLEEVE $1,867.00 PACK DRAPE UNIVERSAL $154.00 SPLINT NASAL BREATH EASY $166.00 DRESSING NASAL SINU-FOAM $465.00 GUIDE WIRE SPARTACORE PERIPHER $624.00 C1769 DRESSING SORBA VIEW W/SHIELD $40.00 TUBE ENDOBRONCHIAL DBLE LUMEN $403.00 SPLINT FINGER STRIP $10.00 PACEMAKER DCP RR MRI ACCOLADE $9,530.00 C1785 TWISTER PLUS RETRIEVAL DEVICE $495.00 NEEDLE MAYO 1/2 CIRCLE $67.00 DRAPE STERILE XRAY CASS DISP $21.00 SUTURE ENDOSTITCH 0 SURGIDAC $165.00 DRAPE ISOLATION $191.00 CATHETER ASPIRATION EXPORT $1,941.00 C1757 TRAY HYSTEROSALPINGOGRAPHY $146.00 INJECTOR UTERINE ZUI $158.00 SENSOR SP02 FINGER $127.00 CONNECTOR TUBING INTERSEPT $41.00 EMBOSPHERE EMBOLIZATION MICRON $1,278.00 C1884 BONE CEMENT NORIAN DRILLABLE $3,729.00 C1713 SCREW CORTICAL 3.5 THRU 5.5MM $195.00 C1713 NEEDLE DELIVERY 12 GA DISP $274.00 SCREW BIO INTRAFIX 8-10 MM $1,445.00 C1713 IMPLANT TIGHTROPE SYNDEMOS SYS $2,818.00 C1713 KIT ACL DISPOSABLE $1,915.00 SHEATH TIBIAL LARGE $1,534.00 C1713 DRESSING VERA LINK LARGE $1,061.00 MESH DUAL PLUS 10CMX15CMX2MM $2,958.00 C1781 BRACE AFO RIG TIB PREFAB TCF $2,992.00 L1932 KIT HYPO/HYPER CH/LEG WRAP S/M $643.00 KIT HYPO/HYPER CH/LEG WRAP LG $669.00 BAG ISOLATION BOWEL $71.00 PEG CORTICAL LOCKING 2.3 MM $575.00 C1713 GUIDE WIRE 2.0 MM $260.00 C1769
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TUBE GASTROSTOMY REPL TRI 18F $417.00 KIT CATHETER PEDIATRIC $42.00 DRESSING ANTIMICROB PROCEL 1X1 $30.00 DRESSING ANTIMICROB PROCEL 2X2 $106.00 DRESSING ANTIMICROB PROCEL 2X5 $185.00 DRESSING ANTIMICRB PROCEL1.5X8 $220.00 DRESSING ANTIMCRB PROCEL1.5X10 $244.00 DRESSING ANTIMICROB PROCEL 3X3 $166.00 DRESSING ANTIMICROB PROCEL 4X4 $260.00 DRESSING ANTIMICROB PROCEL 8X8 $589.00 DRESSING ANTIMICROB PROCE12X12 $1,106.00 SCREW INTERFERENCE MILAGRO $2,251.00 C1713 TENDON ANTERIOR TIBIALIS HUMAN $5,843.00 C1762 PLATE X PURE TITANIUM 4 HOLE $982.00 C1713 TUBE TRACH TRIVANTAGE $1,665.00 DRILL BIT MINI $615.00 SHELL HEMISPHERICAL 3 HOLE $3,852.00 C1776 SLEEVE OFFSET $568.00 CANNULA TRACH INNER $31.00 GUIDE TAP DRIVER $589.00 STEM MONOBLOCK RSP $13,883.00 ADAPTER CATHETER LF $16.00 GRAFT ENDO AORTIC BODY $22,570.00 C1768 GRAFT ILIAC LIMB $10,222.00 C1768 KIT POLYMER SEAL-FILL $1,901.00 INJECTOR AUTOINJECTOR AAA $492.00 IMPLANT SINUS W/DELIVERY SYS $2,610.00 S1090 PROBE L TIP DISPOSABLE $224.00 CATHETER SIDEWINDER $544.00 BLADE ENT QUADCUT $1,022.00 BLADE TURBINATE INFERIOR 2.9MM $1,183.00 FELT PTFE SOFT $60.00 BLADE ENT TRICUT 4 MM $982.00 SHEATH FEMORAL INTRAFIX $2,465.00 C1713 CATHETER PERITONEAL DIALYSIS $1,737.00 C1750 SCREW ACETABULAR 26 MM $2,202.00 C1713 SCREW TAPERED 8 - 10 MM $1,327.00 C1713 TROCAR VERSAPORT BLADELESS $1,361.00 ELECTRODE L TIP HOOK $221.00 SEALANT TISSELL FIBRAN 2ML $568.00 SEALANT TISSELL FIBRAN 10ML $1,881.00 GRAFT VASCULAR HEMASHEILD GOLD $2,001.00 C1768 PIN FIXATOR CAS $639.00 C1713 TUBE TRACH PROXI CUFF EXT $386.00 ELECTRODE PAIRED SUBDERM 2-CH $579.00 ELECTRODE PAIRED SUBDERM 4-CH $699.00 MARKER TISSUE PROSTATE $909.00 A4648 GUIDE WIRE W/TROCAR $573.00 C1769 DRESSING MEXIPLEX 6X6 $44.00 DRESSING MEXIPLEX HEEL BORDER $103.00 DRESSING MEPITEL ONE 3X4 $56.00 DRAPE CARDIOVASCULAR UNIVERSAL $217.00 C02 CUVETTE ADULT DISPOSABLE $112.00 TROCAR KII FIOS ADV FIX DISP $170.00 BALLOON KII BLUNT TIP HAS DISP $206.00 SLEEVE KII ADV FIX DISPOSABLE $83.00 SLEEVE KII Z THREAD DISPOSABLE $83.00 TROCAR BLADED KII ADV FIX DISP $181.00 TROCAR KII Z THREAD DISPOSABLE $181.00 TROCAR HANDLED KII Z THRD DISP $206.00 TUBE TRACH EMG $1,597.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TROCAR LOW PROFILE $133.00 TROCAR DUAL PACK $185.00 WOUND POUCH $199.00 FORCEP GRASPING $2,174.00 RELOAD RADIAL ANY THICKNESS $2,145.00 LAPROSCOPIC ALEXIS SYS SM DISP $760.00 TROCAR BLADED 11MM/12MM $341.00 TROCAR BLADED 5 MM $233.00 NEEDLE EZ-IO W/STABLIZIER KIT $639.00 GRAFT HUMAN SURGISIS 13 X 15 $10,971.00 C1762 LIFT VIKING WO SCALE RENT P/D $87.00 LIFT VIKING W/SCALE RENT PDAY $91.00 BONE MATRIX DBX DBM PUT 0.5CC $519.00 C1713 BONE MATRIX DBX DBM PUT 1.0CC $743.00 C1713 BONE MATRIX DBM PUTTY 2.5CC $1,657.00 C1713 BONE MATRIX DBX DBM MIX 2.5CC $2,044.00 C1713 BONE MATRIX DBX DBM MIX 5.0CC $2,833.00 C1713 BONE MATRIX DBX DBM INJ 2.5CC $1,750.00 C1713 SCOPE WARMER SEAL DISPOSABLE $49.00 TROCAR FIXED 5 X 75 MM $133.00 TROCAR KII PISTOL GRIP $206.00 MESH VENTRAFLEX LARGE $2,309.00 C1781 CATHETER DILATION XFORCE $1,061.00 C1726 APPLICATOR CATHETER DUPLOCATH $297.00 APPLICATOR ENDOSCOP DUPLOSPRAY $473.00 FASTENER ORAL ET TUBE $81.00 DRILL BIT LOW PROFILE $482.00 PLAPLE 12 MM SS $2,066.00 C1713 SCREW LOW PROFILE CANN $845.00 C1713 IMPLANT SYS MPFL BIOCOMPOSITE $4,776.00 C1763 SCREW TENODESIS PEEK VENTED $1,779.00 C1713 IRRIGATOR BULB STERILE $348.00 SCREW CONICAL SELF TAPPING $625.00 C1713 KIT BIOSUTURETAK $1,228.00 ANCHOR SUTURETAK $1,930.00 C1713 CANNULA FAST FIX 360 STRAIGHT $2,452.00 CANNULA FAST FIX SLOTTED $777.00 SUTURE VICRYL TAPE COATED $131.00 TUBING CROSSFLOW PUMP $549.00 CANNULA SHOULDER DISP $161.00 MESH CIRCULAR HYBRID 10 CM $2,299.00 C1781 PLATE MEDIAL HOOK LOCKING $3,292.00 C1713 ATRICLIP (ALL SIZES) DISP $3,351.00 TUBING CROSSFLO/OUTFLO CASSETT $325.00 CANNULA INSTRUMENT 7X7MM DISP $185.00 VALVE CANNULATED ONE WAY $59.00 CARRIER SKIN GRAFT 8" DISP $222.00 PATCH PERICARDIAL PORC 7X15CM $3,491.00 C1763 APPLICATOR FLEXITIP HEMOSTAT $112.00 PIN PACK VERSITOMIC DISP $2,280.00 BLADE ACCESS RAIL PLATFORM STD $556.00 REDUCTION TOOL THREADED $1,426.00 TUBING CROSSFLOW/INFLOW CASS $325.00 SUTURE VICRYL COATED CT-1 $131.00 SHUNT VESSEL (ALL SIZES) $490.00 DRAIN BLAKE WOUND 24 FR $137.00 MICROCLIP LIGATING CLIPS TI $126.00 CATHETER BALLOON SL OTW STERL $811.00 C1725 HEMOSTAT AH ABSORBABLE ARISTA $833.00 SET FOGARTY SOFTJAW INSERT $131.00 CATHETER ANGIO IV W/O SAFE 14G $46.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SCREW LOW PROFILE LOCKING $811.00 C1713 SCREW LOW PROFILE CANCELLOUS $325.00 C1713 SCREW LOW PROF CANN LONG THRD $1,161.00 C1713 REAMER VERSITOMIC FLEXIBLE $5,007.00 TRAY VERSITOMIC $1,720.00 VALVE AORTIC ROOT PORCINE $14,592.00 GRAFT HERNIA SURGIS PORC 20X20 $20,076.00 C1763 PROBE ABLATION DISPOSABLE $5,529.00 C2618 ELECTRODE RADIUS LOOP $105.00 CANNULA ARTERIAL FEMORAL 23FR $1,369.00 TRANSDUCER ARTERIAL PRESS WWL $141.00 TUBING ORGANIZER CUSTOM (PERF) $134.00 DERMABOND SKIN CLOSURE $570.00 SET STABILIZER TISSUE OCTOPUS $5,012.00 RETRACTOR ACTIVATOR DISP $3,400.00 KIT COR-KNOT MINI COMBO $2,629.00 LOADING UNIT CORK-NOT 6CT DISP $986.00 CANNULA SMART CAPNOLINE PLUS $112.00 SUTURE ANCHOR SWIVEL LOCK $2,260.00 C1713 PROBE VASCULAR PARSONET $383.00 CLAMP VASCUSTATT MIDISTR GJAW $113.00 STEM FEMORAL VANGUARD CR $24,592.00 C1713 MESH BILAYER WND MATRIX BOVINE $28,556.00 C9363 OSCILLATING PEP THERAPY SYSTEM $283.00 POS AIRWAY PRESS SYS W/MANOMTR $135.00 MESH HUMAN PARASTOMAL $8,248.00 C1762 STEM FEMORAL COATED NON CEMENT $6,235.00 C1776 CLIP APPLIER 5 MM $579.00 TUBING PERFUSION ORGANIZE DISP $134.00 CLOSURE STERNAL TALON SM/EX SM $3,616.00 TENDON ACHILLES W/BONE BLOCK $5,479.00 C1762 SCREW INTERFERENCE PEEK $1,759.00 C1713 GUIDE PIN FLIPCUTTER $2,285.00 SMOOTHER TOOL CRUCIAL DISP $1,439.00 REAMER LOW PROFILE ALL SIZES $1,371.00 NAIL LOCKING POLARIS $5,090.00 C1713 GUIDE WIRE STRAIGHT SMOOTH $492.00 C1769 SUTURE EHTIBOND 3-0 SH-1 $145.00 SUTURE EHTIBOND 2-0 RB-1 $362.00 SUTURE EHTIBOND 2-0 SH2 $455.00 SUTURE ETHIBOND G/W 2-0 DA $458.00 SUTURE ETHIBOND 2-0 RB1 GR/WH $281.00 CANNULA GUNDRY SILICONE RCSP $508.00 VALVE MITRAL PROSTHETIC $18,417.00 PROBE CRYO 10 CM DISPOSABLE $7,561.00 C2618 INSERT REVERSED SHOULDER $4,510.00 STEM ASCEND FLEX STD PTC 4B $14,633.00 SCREW DRIVER BIT REVERSED HEX $1,221.00 PIN GLENOID REV ALIGN SHOULDER $877.00 C1713 POSITIONER CRADLE DISP $110.00 PLATE SHOULDER BASE GLENOID $5,516.00 C1713 SCREW PERI CONICAL 2.5MM $367.00 C1713 HUMERAL REVERSE SHOULDER TRAY $11,033.00 PLATE HUMERAL DOUBLE Y $1,341.00 C1713 ADAPTER HIP SPACER $1,889.00 BONE CEMENT SPACE MOLD(HD)HIP $4,269.00 BONE CEMENT SPACE MOLD(ST)HIP $5,338.00 TRAY UROLOGY DILATION/CATHERIZ $717.00 GLENOSPHERE HUMERAL COCR $2,808.00 C1713 DRIVER 5 FRENCH ARROW $508.00 CATHETER 5 FRENCH ARROW $2,403.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRIVER 7 FRENCH OTW ARROW $991.00 CATHETER 7 FRENCH ARROW $2,452.00 NEEDLE INJETAK CYTOSCOPI W/TIP $363.00 MESH VENTRALIGHT ST 4X6 $1,918.00 C1781 ENDOCUFF ENDOSCOPIC O/T DISP $170.00 PLUG LIGHT MEDIUM PERFIX $798.00 C1763 MATTRESS TRNSFR HOVERMATT DISP $426.00 VALVE AORTIC PROSTHETIC 23MM $17,767.00 GRAFT DECELLULAR DERMIS 3.5MM $9,370.00 C1762 MESH VENTRALIGHT W/ECHO 7"X 9" $4,035.00 C1781 MESH VENTRALGHT WE 20.3CMX25.4 $4,675.00 C1781 LEAD PACING BIPOLAR SUTURELESS $2,255.00 C1883 TENDON PATELLA HUMAN ALLOGRAFT $10,708.00 C1762 CORE BIOPSY SYSTEM LUNG DISP $4,484.00 SEALER BIPOLAR HEMOSTAT $2,480.00 SCOPE FLEX SLIM 3.8/1.2 DISP $1,153.00 BALLOON DILATOR ACH 30,35,40MM $2,241.00 TACKER FIXATION ABSORBABL 30CT $6,510.00 TACKER FIXATION ABSORBABL 15CT $1,186.00 BOOT W/STABILIZER WEDGE $314.00 E0191 PLATE STERNAL STRAIGHT 6-HOLE $2,231.00 C1713 GRAFT H MATRIX THICK SQ CM 5X4 $120.00 Q4134 DRESSING TEGADERM FOAM TOE $31.00 A6212 DRESSING MEPILEX BORDER 6 X 8 $78.00 A6212 THERASKIN PER SQ CM 13CM $388.00 Q4121 PLATE EXTENSION NEUTRAL $2,124.00 C1713 SCREW EXTENSION LINK $711.00 C1713 SUTURE PASSER CM-9011 $960.00 CATHETER BALLOON PASSPORT $1,297.00 C1725 GUIDE PIN SMOOTH TROCAR 1.6MM $354.00 SCREW CANNULATED 3.5MM $1,191.00 C1713 PATELLA 3 PEG SERIES ASYM $1,606.00 C1713 THERASKIN PER SQ CM 39CM $185.00 Q4121 BOOT TCC-EZ CHARCOT LARGE $471.00 BOOT TCC-EZ CHARCOT EXTRA LG $543.00 FOLEY CATHETER OPEN ENDED 20FR $56.00 A4344 FOLEY CATHETER 3 WAY 20FR $132.00 A4346 GRAFIX CORE PER SQ CM (5X5) $256.00 Q4132 GRAFIX CORE PER SQ CM (4X4) $305.00 Q4132 GRAFIX CORE PER SQ CM (3X4) $253.00 Q4132 GRAFIX CORE PER SQ CM (2X3) $428.00 Q4132 GRAFIX CORE PER SQ CM (1.5X2) $920.00 Q4132 SCREW CANNULATED INTERFER 7MM $484.00 C1713 SCREW CANNULATED INTERFER 10MM $558.00 C1713 SCREW CANNULATED INTERFER 8MM $484.00 C1713 SCREW HEXALOBE LOCK 3.5X8-45MM $518.00 C1713 WASHER SCREW CAN FOR 3.5-7.5MM $349.00 C1713 GUIDE PIN SMOOTH DRILL PT 3.2 $621.00 SCREW HEXALOBE NON LOCK 2.7MM $413.00 C1713 PLATE OLECRANON STD 11H $2,274.00 C1713 PLATE HUMERUS MEDIAL DIST LOCK $2,864.00 C1713 PLATE HUMERUS DISTAL PL 5H LT $2,281.00 C1713 STEM HUMERAL COMP MINI 6MM $6,648.00 C1776 PACK WRIST DIST/RADIUS FIXATOR $5,088.00 C1713 DRAPE STAGE HOLOGIC DISP $42.00 SCREW CORTICAL SELF TAP 4.5MM $200.00 C1713 SCREW LOCKING SELF TAPPING $877.00 C1713 PLATE FIXATOR TEMPORARY $1,787.00 SUR-FIT SKIN BARRIER DURA 6X6 $53.00 A4362 BANDAGE THERMAL COMPRESSION $16.00 SET PROCEDURE BRAT 2 $548.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
HEAD CONSTRAINED MOD CC 36MM $3,998.00 C1776 DRAPE LAPAROTOMY W/POUCHES $69.00 SCREW PERIARTICULAR LOCK 4.5MM $729.00 C1713 SCREW LOCK PERI CANN 5.5MM $946.00 C1713 GUIDE WIRE STD DRILL TIP 3.2MM $265.00 C1769 SCREW PERI SELFTAP 4.5X40-42MM $241.00 C1713 LOADING UNIT COR-KNOT SGL DISP $217.00 SCREW PERIART SELF-TAP 3.5MM $306.00 C1713 PLATE PROXIMAL ULNA LOCK RT 3H $2,968.00 C1713 SCREW CORTICAL SELF TAP 2.7MM $201.00 C1713 SCREW MICRO ACUTRAK 2 $1,905.00 C1713 PLATE FIBULAR DIS/LAT LOCK 6H $2,961.00 C1713 PLATE ONE-THIRD TUB LOCK 7H $887.00 C1713 TRAY EPIDURAL CONT PERIFIX $140.00 SCREW CANCELLOUS FT 4.0MM $247.00 C1713 BUR OVAL CARBIDE $187.00 BLADE SAGITTAL AGGRESSIVE THIN $202.00 BOOT NON PNEUMATIC WALK PREFAB $642.00 L4387 BLADE MEDIUM NARROW $185.00 BLADE AGGRESSIVE WIDE $202.00 SUTURE ETHIBOND PLEDGET 2-0SX $86.00 PLATE STANDARD VDR LT ACU-LOC $2,657.00 C1713 PLATE ULNA MIDSHAFT 8-HOLE $2,454.00 C1713 SCREW REMOVAL EASYOUTS 1.5MM $448.00 SCREW REMOVAL EASYOUTS 2.5MM $476.00 SET EXT SMALLBORE QUADFUSE $28.00 SCREW INTERFERENCE IFIX $1,692.00 C1713 SCREW CANCELL HX HEAD TI 6.0MM $1,051.00 C1713 NAIL FEMORAL LONG/SHORT TI $5,850.00 C1713 CEMENT MIX SYS W/FEM NOZZLE $442.00 GUIDE WIRE LAG SCREW $624.00 C1769 BALLOON ACCESS SYS RE-COLLAPSE $1,914.00 C1894 PIN THREADED BY 305MM/476MM $492.00 C1713 WASHER ORTHO TI $427.00 C1713 NUT CORTICAL TI $492.00 C1713 INTRODUCER SHEA FLEX DRYSE 24F $2,306.00 C1894 PLATE MANDIBLE DOUBLE Y 6-HOLE $1,572.00 C1713 SCREW MANDIBLE NL XD 2.0X12/14 $326.00 C1713 KIT WRENCH $139.00 KIT LEAD END CAP $102.00 C1713 DRILL BIT QUICK RELEASE 3.0MM $448.00 SCREW HEXALOBE NL 3.0MM $413.00 C1713 SCREW MANDIBLE LOCKING X-DRIVE $517.00 C1713 DRILL BIT QR 2.0/2.8MM X 5 $352.00 SCREW HEXALOBE LOCK 3.5X50MM $624.00 C1713 PIN TIBIAL 2.0MM $492.00 C1713 KIT DISIMPACTOR STOOL $472.00 BRACE ANKLE AIRCAST AIRSTIRRUP $233.00 L4350 SCREW CORTICAL ST PROXIMAL $1,018.00 C1713 NAIL TROCHANTERIC FEMORAL 9MM $6,614.00 C1713 SCREW CORTICAL SOLID 4.5X46MM $286.00 C1713 DRESSING QUIKCLOT HEMOST ZFOLD $244.00 A6023 DRESSING QUIKCLOT HEMOSTAT 4X4 $114.00 A6021 STEM TAPERLOC REDUCE DISTAL HO $5,983.00 STEM TAPERLOC REDUCE DISTAL SO $5,983.00 C1776 SCREW LAG SOLID FIX ASSY 120MM $2,233.00 C1713 SUTURE STRATAFIX SPIRAL $137.00 PLATE PERI DIS LAT FIB LOCK 8H $2,371.00 C1713 PLATE STERNAL STRAIGHT 4-HOLE $1,963.00 C1713 PLATE STERNAL LADDER 12-HOLE $2,124.00 C1713 CABLE TROCH REATTACH DEVICE TI $4,199.00 C1713
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SCREW TROCAR SS SCHANZ 4.0MM $287.00 C1713 KIT MONITOR PRESS COMPART DISP $559.00 MESH VENTRALGHT ST R 30.5X35.6 $5,869.00 C1781 K-WIRE FIXATION COATED $269.00 SCREW LOCKING FT 5.0MM $603.00 C1713 NEBULIZER VAR CCNA LG VOL $16.00 DEVICE TISSUE REMOVAL XL DISP $2,566.00 DEVICE TISSUE REMOVE LITE DISP $1,935.00 DEVICE TISSUE REMOVE REACH DIS $3,106.00 SLEEVE SUPRAPTLR PROTECT 12MM $400.00 PLATE OLECRANON 17 HOLE RT $2,979.00 C1713 HEAD RADIAL COMPONENT 22MM $6,156.00 C1776 SCREW LOW PROF CORTICAL 3.5MM $360.00 C1713 SCREW CORTICAL LOCKING 3.5MM $660.00 C1713 PLATE STD POLARUS 4H $4,304.00 C1713 SCREW LOW PROF HEXALOBE 4.3MM $705.00 C1713 PLATE THORACIC PRE CONTOUR 12H $3,945.00 C1713 SCREW LOCK SELF DRILL 2.4MM $808.00 C1713 SCREW FIXATION TEMPORARY $1,260.00 DRESSING AQUACEL FOAM ADH 7X7 $76.00 A6213 BANDAGE TUBULAR SIZE A $151.00 A6457 BANDAGE TUBULAR SIZE G $174.00 A6457 TIP HIGH FLOW $87.00 SHEATH RE COLLAPSIBLE 22F SOLO $1,914.00 BALLOON PTA CATHETER ARMADA $698.00 C1725 BALLOON PTA CATH ARMADA 6.0MM $759.00 C1725 LINER ACETAB 10°FACE CH 40MM F $4,082.00 C1776 HEAD FEMORAL CC MOD SELEX/MAG $1,882.00 C1776 MESH PRESHAPE W/KEYHO 6X13.7CM $702.00 C1781 DRESSING OPTIFOAM GENTLE 4 X 4 $49.00 A6212 MESH VENTRALGHT ST E 20.3X25.4 $4,412.00 C1781 LASER FIBER RT SL 272 MIC DISP $759.00 ELECTRODE BIPOLAR PLAS DIS 24F $1,335.00 ELECTRODE BIPOLAR PLASM LP 24F $1,335.00 GUIDE WIRE NITINOL HYDROPH TIP $260.00 C1769 INTRODUCER SHEATH DRYSE 12-16F $1,712.00 C1894 PLATE LCP FEMUR PROXIM HOOK 2H $3,357.00 C1713 PLATE LCP FEMUR PROX HOOK 6H $3,383.00 C1713 PACEMAKER DCP DR RR MRI ESSENT $7,798.00 C1785 PROBE ARTHROSCOPIC MEAS DISP $902.00 LIFTAEM AIR TRANSF 39X80 DISP $469.00 DRAIN CHEST DRY SUCTION $207.00 BAG BLOOD SELF-FILLING ATS $173.00 TOURNIQUET TACTICAL DISP $151.00 LIFTAEM AIR TRANSFR 48X80 DISP $719.00 SCREW NON LOCKING 2.3MM $509.00 C1713 GRAFT H MATRIX THICK SQ CM 7X5 $77.00 Q4134 SUTURE ANCHOR QUATTRO X CM9255 $1,675.00 C1713 BASKET STONE TIPLESS NITINOL $861.00 TENDON PATELLA HEMI ALLOGRAFT $5,598.00 C1762 SCREW NCB CORTICAL ST 5.0MM $877.00 C1713 CABLE BUTTON LOCKING PLATE $874.00 C1713 ATRICLIP PRO2 DEVICE $9,973.00 SUTURE ANCHOR PEEK KNOTLESS $1,788.00 C1713 PLATE FIBULAR DIS/LAT LOCK 4H $2,619.00 C1713 SUTURE ANCHOR FIBERTAK AR3600 $1,909.00 C1713 FEMORAL IMPLANT W INSERTER $2,928.00 C1776 IMPLANT PECTUS BAR 22.9CM $2,497.00 L8699 CUSHION INSERT PRONEVIEW DISP $154.00 CAST PADDING 5 IN $64.00 SCREW LOW PROF NL HEXALO 3.5MM $464.00 C1713
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SCREW HEXALOBE LOCKING 4.3MM $705.00 C1713 PACKING NASAL MEROGEL INJ $469.00 SUTURE TAPE FIBERTAK AR-3602 $1,594.00 BONE MATRIX DBM PUTTY 10.0CC $3,616.00 C1713 SUTURE TAPE FIBERTAK AR-3602-2 $1,660.00 KIT FIBERTAK DISPOSABLE $1,146.00 PLATE OLECRANON 3>5 HOLE $2,050.00 C1713 SCREW HEXALOBE LOCKING 2.7MM $518.00 C1713 SCREW HEXALOBE NONLOCK 3.5MM $443.00 C1713 STENT TRACHEOB C/C/WD 10/12MM $6,648.00 C1874 CABLE CERLAGE CRIMP COBALT $1,981.00 C1713 KIT WRIST EXTERNAL FIXATION $2,822.00 MESH HERNIA PHASIX 10.2X15.2CM $4,666.00 C1781 SET PAD PRESSURE PROTECTOR $305.00 REAMER GRAFT FILTER $849.00 REAMER TUBE ASSEMBLY 360MM $1,133.00 REAMER ROD W/BALL TIP 2.5MM $384.00 REAMER HEAD RIA 14MM $887.00 REAMER DRIVE SHAFT SEAL 2/PKG $113.00 SET INTROD PULL-APART PTFE 16F $298.00 C1752 GUIDE WIRE 3.2MM $265.00 C1769 ELECTRODE SQUARE LOOP 10MM $92.00 PLATE STERNAL L 4 HOLE $1,965.00 C1713 PLATE STERNAL X 8 HOLE $2,027.00 C1713 PLATE STERNAL MICS 12 HOLE $3,087.00 C1713 SUTURE SOFT ANCHOR JUGGK 2.9MM $1,621.00 C1713 SCREW PERI CORTICAL 3.5MM $260.00 C1713 STEM SL REVISION UNCEMEN 12/14 $13,555.00 SCREW CORTICAL SELF TAP 3.5MM $260.00 C1713 SCREW CONICAL 2.7MM $367.00 C1713 SCREW FIXATION SHORT POST TEMP $1,260.00 LINER ACETABULAR NEU E1 32MM C $4,082.00 C1776 STEM TAPERLOC MICRO STD OS TI $5,983.00 REAMER TIBIA CORE W/PLUNG 10MM $1,700.00 DRILL BIT CANNULATED 2.7MM $854.00 PLATE FEMORAL DIST/LAT LOCK $4,326.00 C1713 CATHETER ANGIOGR PIGTAIL 110CM $172.00 C1887 CATHETER ANGIO W/BEACON TIP $510.00 C1887 CATHETER ANGIOJET DVT THROMBEC $7,258.00 C1757 SCREW LOCK PERIARTICULAR 3.5MM $657.00 C1713 SET INTRODUCER COAT SH VSI 6F $244.00 C1894 NEBULIZER HI-FLO CONTINUOUS $46.00 PLATE RECON STRAIGHT LOCK 7H $2,009.00 C1713 PLATE RECON STRAIGHT LOCK 9H $2,133.00 C1713 CATHETER TURNPIKE 150CM $1,826.00 C1887 CATHETER TURNPIKE LP 150CM $1,867.00 C1887 AMBULANCE BLS NON-EMERGENCY $- A0428 CATHETER TURNPIKE SPIRAL 150CM $1,867.00 C1887 AMBULANCE BLS EMERGENCY $- A0429 AMBULANCE GROUND MILEAG PER MI $- A0425 PROBE INCREMENT W/ST PRASS TIP $863.00 GRAFT THORACIC ENDOPROTHESIS $41,119.00 C1768 CANNULA AORTIC W/VENT LINE $361.00 VENT VENTRICLE LEFT $164.00 CANNULA VENOUS RIGHT ANGLE 24F $213.00 CANNULA VENOUS SINGLE STAGE $192.00 FORCEPS BIOPSY 3FR DISP $2,422.00 FORCEPS BIOPSY STD CUP DISP $2,422.00 FORCEPS BIOPSY ELONG CUP DISP $2,422.00 SHEATH HAUSDORF LOCK 10F/12F $550.00 EXTRACTOR STONE NGAGE DISP $953.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
GRAFT PERICARDIUM 50X40 $3,295.00 C1763 GRAFT PERICARDIUM 100X50 $6,686.00 C1763 KIT INTE/BRACE LIGAMENT REPAIR $3,890.00 C1713 TRAY BIOPSY BREAST STEREOTACT $192.00 TRAY BREAST LOCALIZATION $137.00 TRAY BREAST U/S BIOPSY $207.00 GRAFT DECELLULARIZED DERMIS $5,969.00 C1762 DOWEL BONE HARVESTER 8MM $2,866.00 REAMER MEDIUM TRINKLE $2,220.00 NAIL SUPRACONDYLAR $4,952.00 C1713 GRAFT H MATRIX MED SQ CM 5X4CM $90.00 Q4134 SUTURE NICE LOOP ALL SIZES $441.00 STEM HUMERAL LONG CEMENTED $7,561.00 HEAD HUMERAL ASCEND $3,910.00 PLATE PROXIMAL DISTAL RADIUS $2,913.00 C1713 SLING TRANSOBTURATOR URETHRAL $3,005.00 C1771 GRAFT HERNIA PORCINE 19X35 $43,174.00 C1763 PLATE LCP HUMERUS POSTLAT DIST $3,756.00 C1713 PLATE LCP HUMERUS MEDIAL DIST $3,756.00 C1713 GRAFT PORCINE AB NONCX 10X15CM $10,108.00 C1781 KIT AIRWAY SIZING W/BALLOON $1,179.00 LOADER W/CATHETER IBV $2,817.00 VALVE SPIRATION IBV (ALL SZ) $7,030.00 SCREW CENTRAL HUMERUS $708.00 C1713 RING HUMERAL STANDARD $3,351.00 C1776 MESH VENTRIO ST HERNIA PATCH $2,824.00 C1781 SCREW CORTICAL NON TOGGLING $498.00 C1713 SPLINT ORTHO GLASS (ALL SIZES) $118.00 CANNULA W/DILATOR STR ANGIOVAC $27,989.00 CANNULA W/DILATOR ANG ANGIOVAC $27,989.00 CIRCUIT W/PUMP/BUBBL TRAY DISP $3,844.00 INTRODUCER SHEATH DRYSEAL 26F $1,602.00 C1894 DRESSING SILVERLON WOUND 4 X 4 $104.00 A6254 DRESSING SILVERLON WOUND 4X14 $324.00 A6256 SCREW LOCKING SELF DRILL 3.5MM $457.00 C1713 PLATE SHEAR BAR $592.00 C1713 PLATE RATCHET WHEEL $930.00 C1713 LOCKING ELEMENT $222.00 C1713 CATHETER VANSCHIE 5FR $175.00 SPECULUM VAGINAL KLEENSPE DISP $44.00 FORCEP SPONGE 9.5 DISPOSABLE $96.00 FORCEP ALLIGATOR 5.5 DISP $139.00 FORCEP ALLIGATOR MICR EAR DISP $171.00 LAPROSCOPIC ALEXIS SYS MD DISP $760.00 PLATE LCP HOOK 3.5MM $2,116.00 C1713 TOOL SINUS DILATION DISPOSABLE $4,582.00 SKIN PREP TECHNICARE $116.00 A5120 MESH VENTRALGHT ST W/E 15.2CM $3,187.00 C1781 SUTURE BRAIDED NICE LOOP SZ 5 $475.00 KIT MARKER DELIVERY $469.00 NEEDLE ASPIRATION $462.00 BRUSH CYTOLOGY NEEDLE TIPPED $368.00 BRUSH CYTOLOGY TRIPLE NEEDLE $544.00 FORCEP BIOPSY PREMARKED DISP $465.00 ADAPTER BRONCHOSCOPE DISP $368.00 KIT ENDOBRONCHIAL PROCEDURE $2,945.00 MARKER TISSUE LUNG $746.00 A4648 DRESSING SILVERLON WOUND 7MM $40.00 A6251 PATCH EKG SENSOR DISPOSABLE $38.00 GRAFT WOVEN GELWEAVE $5,963.00 C1768 PLATE STERNAL STRAIGHT 10-HOLE $2,352.00 C1713
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRESSING SILVERLON ISL WND 2X3 $68.00 A6254 FINGER SHIELD DISPOSABLE $40.00 DISSECTOR ARTICULATING GLIDEPA $4,868.00 C1727 CABLE TITANIUM CRIMP 1.7MM $1,904.00 C1713 HEMOSTAT ABSORBABLE ARISTA $1,004.00 PORT INDWELLING 9.3FR $963.00 C1788 PLATE STERNAL LADDER 18-HOLE $2,860.00 C1713 SCREW STERNAL LOCKING $586.00 C1713 BATTERY PACK STERILE KLS $559.00 LASER FIBER ENDOBEAM DISP $1,059.00 DRESSING GAUZE SURGITBE 5/8X50 $268.00 COIL PUSHER INSTANT DETACHER $1,213.00 NEEDLE SPINAL 22GA X 7 $87.00 DRESSING ECONO PASTE 3" PER YD $55.00 A6456 DRESSING TUBULAR PER YARD $15.00 A6457 KIT BRONCHIAL DIAGNOSTIC (ICU) $194.00 KIT BRONCHIAL DIAG W/BIOP ICU $661.00 PACK PERFUSION SYSTEM CUSTOM $2,020.00 ANCHOR TUBING SECURE DEVICE $38.00 KIT DRESSING PORT ACC W/CHLORA $171.00 KIT CORE BIOPSY MISSION DISP $298.00 CORE BIOPSY INSTRUMENT DISP $232.00 SUTURE PASSER TRANSOSSEOUS $364.00 GRAFT H MATRIX MED SQ CM 10X5 $67.00 Q4134 ANTIMICRIBIAL SKIN/WND CLEANSE $92.00 A6260 DRESSING SACHET S 8 X 8 $121.00 A6198 DRESSING SORBION SACH XL 18X10 $134.00 A6198 DRESSING SORBION SACHET 4 X 4 $54.00 A6196 DRESSING SACHET BORDER 4X4 $57.00 A6196 DRESSING SACHET BORDER 6X6 $60.00 A6197 DRESSING SANA GENTLE 5 X 5 $87.00 A6197 DRESSING SANA GENTLE 9 X 9 $134.00 A6198 DRESSING SANA MULTI STAR 6.5IN $40.00 A6197 PADS PRESSURE REDUCING 4 X 4 $116.00 DRESSING MEPILEX BORD AG 4X4 $94.00 A6212 DRAIN CHEST VALVE PNEUMOSTAT $195.00 NOZZLE SLIM DISPOSABLE $213.00 SPLINT TRACTION OTD $396.00 GRAFIX PRIME PER SQ CM (3X4) $288.00 Q4133 GRAFIX PRIME PER SQ CM (5X5) $281.00 Q4133 POSITIONER UNIVERSAL HEAD DISP $129.00 KIT BIOPSY VALVE DISPOSABLE $107.00 MESH TISSUE BIO-A 7CM X 10CM $2,057.00 C1781 CATHETER URETERAL DUAL LUMEN $198.00 C1758 GLIDE SHEET LOW FRICTION T 2.0 $370.00 ELECTRODE L HOOK DISP $1,133.00 CANNULATED TIBIAL IMPL W/DRIVE $1,914.00 C1713 MESH SOFT 3IN X 6IN $256.00 C1781 ROD THREAD OSTEONECROSIS IMPL $10,192.00 C1713 PLATE MANDIBLE STR W/WO GAP 4H $1,760.00 C1713 SCREW NON LOCKING 2.0MM $408.00 C1713 DRILL BIT WITH STOP $500.00 STENT VASCULAR COA/COV W/DEL $3,487.00 C1874 VISUALIZATION SY CLEARIFY DISP $239.00 DRESSING AQUACEL ROPE 2X45CM $36.00 CATHETER TURNPIKE SP CTO 135CM $2,274.00 C1887 SCREW CANCELLOUS PT 4.0MM $174.00 C1713 PLATE ONE-THIRD TUBULAR 6>8H $502.00 C1713 GRAFT VASCULAR ANTE-FLO 28MM $3,324.00 C1768 KIT MYRINGOTOMY PEDIATRIC $249.00 CATHETER OTW VENTURE 6FR $2,287.00 C1887
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
LINER ACETABULAR 10°FC 40MM G $3,266.00 C1776 BEARING TIBIAL LIP CR 87/91MM $2,352.00 C1713 BEARING TIBIAL LIP CR 79/83MM $2,352.00 C1713 GUIDE WIRE FIGHTER 190CM $408.00 C1769 GUIDE WIRE FIGHTER 300CM $408.00 C1769 SCREW CANCELLOUS HEXALOB 4.0MM $435.00 C1713 DRILL BIT QR LAG 2.7MM $788.00 PLATE ONE-THIRD TUBULAR 5 HOLE $471.00 C1713 BEARING TIBIAL ANT STBLZD $3,132.00 C1713 GUIDE WIRE BALL TIP 3.0MM $578.00 C1769 INTRODUCER SHEATH PERFORME 16F $468.00 C1894 NAIL FEMORAL GR TROCH TI 9.3MM $4,400.00 C1713 BALLOON PTA CATH LOW PROFILE $998.00 C1725 PLATE FIBULA LATERAL 4H $2,419.00 C1713 K-WIRE NON THREADED 1.3MM $97.00 DRILL BIT QR W/DEP MARK 2.0MM $730.00 DRILL BIT QR W/DEP MARK 2.8MM $730.00 SCREW HEXALOBE NL 2.7X34-48MM $430.00 C1713 DRILL BIT QUICK REL LAG 3.5MM $730.00 PLATE STANDARD VDR RT ACU-LOC $2,281.00 C1713 PLATE STD PROXIMAL VDR LONG $2,281.00 C1713 BRACE TLSO FLEX RIG PAN PREFAB $2,526.00 L0456 PLATE SHAFT STRAIGHT NARROW $2,231.00 C1713 SCREW SELF TAPPING 4.0MM $578.00 C1713 PIN THREADED 3.2MM X 508MM $608.00 C1713 NAIL CEPHALOMEDULLARY TI LONG $5,926.00 C1713 SCREW CORTICAL LOCKING 2.3MM $438.00 C1713 PLATE STERNAL MONOBLK GRANDPRE $472.00 C1713 BEARING TIBIAL LIPPED CR $2,178.00 C1713 FOLEY TRAY W/COUDE 16FR $173.00 WASHER ORTHO FLAT $302.00 C1713 DRILL BIT CANN W/AO 3.5MM DISP $1,095.00 K-WIRE W/TROCAR PIN $241.00 K-WIRE W/THREAD TROCAR PIN SGL $265.00 PLATE MANDIBLE CURVED 7-HOLE $1,630.00 C1713 SCREW MANDIBLE NL XD 2.0X7MM $378.00 C1713 CATHETER BALLOON EVERCROSS OTW $330.00 C1725 CATHETER BALLOON NANOCROSS 014 $532.00 C1725 DRILL BIT QUICK COUPLING 3.2MM $416.00 PLATE FEMORAL DIST/LAT LOCK 6H $3,888.00 C1713 BEARING TIBIAL POST STABILISED $2,178.00 C1713 SCREW CANNULATED 7.3MM ALL SZ $856.00 C1713 BEARING TIBIAL POST STABI PLUS $3,132.00 C1713 HEAD FEMORAL COCR MODULAR $1,525.00 C1776 STENT SE PERIPHERAL W/DS 20IN $2,135.00 C1876 GUIDE PIN MPFL TEMPLATE DISP $1,780.00 GUIDE LOCATABLE EDGE $2,810.00 NASAL ATOMIZATION DEVICE (MAD) $46.00 NASAL BRIDLE W/CLIP $519.00 NASAL BRIDLE CLIP $157.00 ORTHOSIS KAFO FRACTURE CUSTOM $5,727.00 L2128 SHOE INSERT PLASTIC W/ANKL JNT $473.00 L2180 DROP LOCK KNEE JNT ADD'L $324.00 L2182 SUTURE BUTTON TITANIUM AR8920 $613.00 C1713 PELVIC BAND/BELT LE FX ADDTL $1,444.00 L2192 SOFT INTERF MOLD PLAS AB KNEE $379.00 L2830 FEMORAL LENGTH SOCK FX/EQ EA $230.00 L2850 DROP LOCK RETAINER LE EACH $130.00 L2785 WEDGE HTO IBALANCE MD 14 $6,017.00 SCREW CORTICAL HTO IBALANCE $1,615.00 BONE CEMENT QUICKSET $7,284.00 C9359
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
GRAFIX PRIME PER SQ CM (2X3) $753.00 Q4133 GRAFIX PRIME PER SQ CM (1.5X2) $920.00 Q4133 GRAFIX PRIME PER SQ CM (1.4CM) $1,016.00 Q4133 SCREW ACETABULAR ALL SIZES $271.00 C1713 GRAFIX PRIME PER SQ CM (4X4) $305.00 Q4133 GRAFIX PRIME PER SQ CM 7.5X15 $168.00 Q4133 APPLICATOR ULTRA MIST DISP $253.00 BANDAGE COMPRESSION SYS 2LAYER $91.00 A6454 TUBING MOUTHPIECE ACCUPAP DISP $119.00 PAD WIGGLE JR PREMIE DISP $57.00 CIRCUIT W/CHAMBER KIT JR DISP $268.00 CIRCUIT W/CHAMB KIT ADULT DISP $323.00 NASAL CANNULA ADULT MED $140.00 NASAL CANNULA PREMIE RED $238.00 NASAL CANNULA NEONATE YELLOW $238.00 STENT SE PERIPHERAL W/DS 60IN $2,306.00 C1876 STENT SE PERIPHERAL W/DS 80IN $2,306.00 C1876 STENT SE PERIPHERAL W/DS 100IN $2,306.00 C1876 STENT SE PERIPHERAL W/DS 120IN $2,589.00 C1876 STENT SE PERIPHERAL W/DS 150IN $2,391.00 C1876 CATHETER MICRO 14 MICROCROSS $1,621.00 C1887 ANCHOR REELX STT KNOTLES 4.5MM $1,609.00 C1713 NEEDLE FLX SUTUR PASS RP360 DI $651.00 SUTURE FORCE FIBER TAPER #2 $181.00 PAD WIGGLE JR NEO/INF/PED DISP $96.00 STENT PERIPHERAL SUPERA ALL SZ $3,954.00 C1874 BONE CEMENT CERAMIC CERA 5CC $4,742.00 C1713 STENT TRACHEOB NC/C/WD 10X30MM $4,048.00 C1876 CANNULA ADJUSTABLE RETRACTOR $204.00 PLATE COMPRESSION BROAD 12H $889.00 C1713 SCREW CORTICAL 4.5MM X 30MM $160.00 C1713 SCREW CORTICAL 4.5MM X 36MM $160.00 C1713 LOCKING INSERT ORTHO SCREWS $280.00 CABLE PLUG FOR ORTHO PLATES $280.00 C1713 TRACH ADAPTER ADULT OPTIFLOW $131.00 COIL PERIPHERAL AA (ALL SIZES) $2,813.00 COIL PERIPHERAL FRAME 35D $3,266.00 COIL DETACHABLE CX (ALL SIZES) $2,797.00 COIL DETACHABLE CONTROLLER $2,884.00 GLIDE WIRE PROGREAT 2.8F/130CM $1,791.00 C1769 PUSHER STENT PANCREATIC $297.00 STENT PANCREATIC STRAIGHT $392.00 C2617 ADAPTER OFFSET W/SCREWS $2,874.00 C1713 MESH PRESHAPED W/KEYHOLE 1.8X4 $265.00 C1781 NASAL CANNULA ADULT SMALL $134.00 DRESSING SANA GENTLE 9X5 $104.00 SKIN BARRIER WIPE SENSICARE $3.00 A5120 SPACER CEMENT MOLD SHLDR 14MM $9,357.00 ELECTROSURGICAL DEVICE 10IN CD $166.00 BONE VOID FILLER CERAMENT 10ML $7,588.00 C1713 CATHETER ANGLED PIGTAIL 155° $141.00 C1887 INTRODUCER SHEATH TEARAWAY 15F $266.00 C1894 VENA CAVA FILTER JUGULAR $3,106.00 C1880 VENA CAVA FILTER FEMORAL $3,106.00 C1880 NASAL CANNULA ADULT LARGE $134.00 PACK TURN POSITION SYSTEM 2.0 $513.00 PACK BARIATRIC TURN POSITIO XX $1,132.00 PACK CUSHION SEAT POSITION SYS $504.00 PAD LIFTAEM BARIATRIC INFLATE $535.00 KIT VENA CAVA REMOV/REPOSITION $1,602.00 PLATE T NARROW LOCKING 7 HOLE $1,511.00 C1713
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
ELECTRODE RESECTION BUTTON $12,220.00 GUIDE WIRE ENDOSCOPIC RFA MRKD $767.00 C1887 CATHETER BALLOON RFA EXPRESS $5,779.00 C1726 CATHETER ABLATION RFA ULTRA $4,842.00 C1886 CATHETER ENDOSCOPIC RFA CHANN $4,073.00 CATHETER ABLATION RFA V2 $3,818.00 C1886 BALLOON SOFT SIZING 360 $1,739.00 C1726 CAP CLEANING RFA MED DISP $1,511.00 CATHETER ABLATION HALO 360 $4,842.00 C1886 MESH HERNIA PHASIX ROUND 7.6CM $2,905.00 C1781 PAD FOOT POSITIONING DISP $526.00 HEMOCLIP ENDOSCOPIC INSTINCT $540.00 SET TUBING LG BORE W/16X1.5 ND $56.00 NEEDLE INJECTOR CARR-LOCKE $374.00 GRAFT ALLOGRAFT CLOWARD HUMAN $2,306.00 C1762 BALLOON DRUG ELUTING W/DS $4,450.00 C2623 ELECTRODE HF RESECTION LOOP MD $1,752.00 KIT SCP COMP KNEE W/SD CANNULA $7,745.00 CANNULA ACCUPORT XL $821.00 CATHETER CENTERCROSS $2,809.00 C1887 PAD PERINEAL HIP POSITION DISP $423.00 PAD SEIZURE BED RAIL 2-PC DISP $112.00 HANDPIECE MRI BREAST BIOP 20MM $1,150.00 HANDPIECE MRI BREAST BIOP 12MM $1,150.00 MARKER TITANIUM BREAST BIOPSY $280.00 MARKER HOURGLASS BREAST BIOPSY $280.00 SET INTRODUCER LCAL MRI BREAST $698.00 NEEDLE SPINAL QUINCK 20GAX3.5" $15.00 PLATE BREAST BIOP MEDIAL GRID $162.00 PACK HIP DISPOSABLE $1,471.00 HIP UC SUPINE DISTRACTOR $4,996.00 NEEDLE FACIAL INCISING DISP $179.00 CLOSURE SYSTEM STERNALOCK $10,655.00 C1713 NEEDLE CATHETER COMBO DISP $961.00 C1729 SHEATH FLEXOR CHECK FLO DISP $411.00 C1729 GUIDE WIRE COMET FFR $2,583.00 C1769 GUIDE WIRE VOLCANO VERRATA FFR $2,497.00 C1769 BLADE PLASMA PEAK $1,335.00 WIRE SPHINCTER DASH W/DOME TIP $876.00 C1769 CIRCUIT ULTRAFILTRATION(AQPHR) $2,824.00 PEG FEMORAL TWIN COMPONENT $4,654.00 C1713 BLADE SAW STABLECUT $2,667.00 TIBIAL TRAY POST $4,654.00 C1713 BEARING MENISCAL ANATOMIC $2,333.00 C1713 SUTURE AUTO PASS SMI-02D $1,170.00 SUTURE ANCHOR Y-KNOT Y1301 $1,514.00 C1713 PLATE TIBIA MEDIAL DISTAL $4,794.00 C1713 GRAFT H MATRIX THICK SQCM 10X5 $77.00 Q4134 GRAFIX CORE PER SQ CM (1.6CM) $1,016.00 Q4132 TUBE SET AEROGEN SOLO CONT NEB $106.00 NEBULIZER ADAPTER MOUTHPI/TUBE $54.00 CCRT HEMO FILTER SET DISP $677.00 CCRT DRAIN BAG RENAL DISP $43.00 CCRT SPIKE ADAPTER DISP $32.00 CCRT CONNECTOR Y $27.00 INTRODUCER BREAST BIOPSY U/S $123.00 CATHETER DIAGN AMPLATZ/INFIN $67.00 STENT SE PERIPHERAL W/DS 40IN $2,135.00 C1876 GUIDE PIN PT TROCAR TIP 1.6MM $426.00 BLADE KNIFE PARALLEL GRAFT $345.00 SUTURE CUTTER/KNOT PUSH NOVOC $575.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BEARING TIBIAL LIP CR 63/67X18 $2,178.00 C1713 LEAD AICD ENDO DUAL COIL MRI $6,033.00 C1895 AICD VR VISIA MRI $27,737.00 C1722 SCREW CANNULATED P/T 3.0MM $821.00 C1713 TOURNIQUET CUFF CYLINDRI DISP $121.00 AICD VR EVERA MRI $27,737.00 C1722 LIGASURE RETRACT L HOOK 37CM $1,794.00 DRESSING WND COLLAG<=16 4.34IN $54.00 A6021 DRESSING WND COLLAG<=16 4.75IN $63.00 A6021 NAIL TIBIAL TI 8.3MM X 30CM $4,186.00 C1713 SCREW CORTICAL FIXED ANGLE FT $943.00 C1713 GUIDE WIRE DREAMWIRE ANGLED $568.00 C1769 PLATE MTP FUSION 1ST SMALL $2,673.00 C1713 PLATE MTP FUSION IN-LINE 2.5MM $2,324.00 C1713 PEG MULTI DIRECTIONAL THREADED $760.00 C1713 SCREW PEG LOCKING FT 2.5MM $426.00 C1713 SCREW PEG NON LOCKING $426.00 C1713 PLATE HUMERAL STD 4 HOLE $3,985.00 C1713 PACEMAKER DCP VR MRI ESSENTIO $6,361.00 C1786 DRESSING QUIKCLOT INT HEMO PAD $165.00 A6021 PACEMAKER SGL CHAMB RR SR MRI $6,706.00 C1786 PACEMAKER DCP RR DR MRI ADVISA $8,618.00 C1785 DRILL BIT ACUTRAK 2 $996.00 SCREW CANNULATED LOCKING 3.5MM $548.00 C1713 PLATE TIBIAL PROX LATERAL LOCK $3,646.00 C1713 CATHETER W/GUIDE WIRE $1,778.00 C1887 LEAD CORONARY LV ABILITY MRI $3,106.00 C1900 LEAD PM NT TR VDD SG CAPSU MRI $1,501.00 C1898 AICD SINGLE CHAMBER VR $20,930.00 C1722 AICD NOT SGL/DUAL CHAMBER MRI $38,694.00 C1882 AICD DUAL CHAMBER DR EVERA MRI $31,377.00 C1721 LEAD CORONARY LV PERFORMA MRI $4,171.00 C1900 NOZZLE ABSCESS CAP $44.00 PLATE CLAVICLE HOOK 7 HOLE $3,305.00 C1713 SCREW NON LOCKING 2.7MM $363.00 C1713 SCREW NON LOCKING 3.5MM $363.00 C1713 SCREW NON LOCKING 3.5MMX36MM $646.00 C1713 BOLT FEMORAL TROCHANTERIC $2,075.00 C1713 POSITION FLOOR LIFT SWING DISP $167.00 KIT ANKLE FIXA DEVI SS ZIPTI $2,195.00 C1713 PLATE ANKLE HOOK 3-HOLE $2,266.00 C1713 SCREW CANCELLOUS HX PT 4.0MM $502.00 C1713 LIGASURE IMPACT SEALER/DIVIDER $1,740.00 DRILL BIT QC 3.5X195MM $456.00 DRESSING STICK SOCK AID $22.00 LEG LIFTER RIGID $22.00 SPONGE W/BENDABLE HANDLE $14.00 SHOEHORN STEEL $77.00 SCREW SPADE POINT SS SCHANZ $298.00 C1713 CATHETER GUIDE TWIN PASS $1,326.00 C1887 CATHETER GUIDE TWINPASS TORQUE $1,706.00 C1887 TIBIAL TRAY 360 $5,763.00 C1776 TIBIAL CRUCIATE WING ADAPTER $2,298.00 C1713 ADAPTER OFFSET EXTENSION $2,508.00 C1713 TIBIAL AUGMENT W/BOLTS TI $2,508.00 C1713 STEM KNEE SPLINED $3,334.00 C1776 BLOCK FEMORAL AUGMENT POSTERIO $2,659.00 C1713 CATHETER GUIDING MICRO CORSAIR $2,759.00 C1887 STENT SE PERIPHERAL WDS 200IN $2,592.00 C1876 TIBIAL BASEPLATE PRIMARY $2,160.00 C1713 PROBE LITHOTRIPSY SH PULS DISP $1,974.00 C2618
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRESSING WND PREVENA P&P 13CM $897.00 KIT DRESSING WND PREVENA PLUS $1,152.00 LUER LOCK W/ROLLER CLAMP $37.00 PLATE TACK ELBOW $211.00 SCREW HEXALOBE VARIABLE ANGLE $498.00 C1713 PLATE HUMERUS LAT/DISTAL 6H $2,652.00 C1713 DRESSING WND PREVENA P&P 20CM $897.00 PLATE CLAVICLE MEDIA/ANT LOCK $2,905.00 C1713 LASER FIBER RT 365 MICRON DISP $741.00 PLATE LCP CLAVICLE SUPERIOR $2,530.00 C1713 PLATE LCP CLAVICLE SUPER ANTER $2,598.00 C1713 SET ARTHROSCOPY TUBE GRAV FLOW $123.00 SCREW CORTICAL DBLE LEAD 5.0MM $1,034.00 C1713 KIT SHOULDER Q-FIX 1.8MM DISP $1,597.00 GUIDE WIRE NITINOL ACCUCATH $244.00 C1769 COIL EMBOLIZATION DETACHABLE $1,840.00 SCREW LAG TELESCOPNG KEYLESS $2,580.00 C1713 OXISENSOR ABSOLUTE TISSUE LG $420.00 SUTURE PASSER CRESCENT XL $- THERAPY BED-ROTOPRONE $3,938.00 PLATE THORACIC STRAIGHT 8 HOLE $2,784.00 C1713 PLATE THORACIC PRE CONTOUR 16H $4,918.00 C1713 PLATE TIBIAL DIST/MED LOCK $4,182.00 C1713 SCREW PERIARTICULAR LOCK 3.5MM $548.00 C1713 SCREW LOCKING VARIABLE ANGLE $498.00 C1713 PLATE CLAVICLE LP 8H $2,905.00 C1713 SUTURE ANCHOR QUATTRO X CM9265 $1,482.00 C1713 NEEDLE TRANSBRONCH U/S ASPIRAT $855.00 LINER ACETABULAR CONSTRA E1 F $4,974.00 C1776 WOUND MEASUREMENT DEVICE DISP $6.00 PACK WOUND CARE PREVENTION #2 $504.00 PACK WOUND CARE PREVENTION #1 $488.00 CAPNOGRAPHY MONITOR $99.00 SCREW CANCELLOUS CANNULA 4.5MM $973.00 C1713 PACK ENDOVENOUS $299.00 KIT CATHETER EVLT 65CM $1,077.00 TUBING TUMESCENT SPKE W/O CHAM $49.00 PLATE MTP FUSION CLOSED SMALL $2,835.00 C1713 SCREW LOW PROFILE NL CORTICAL $378.00 C1713 TRAY TOENAIL REMOVAL DISP $180.00 SCREW CORTICAL TI 3.5MM $241.00 C1713 NEEDLE SPINAL 20GA X 3.5" $52.00 PLATE FIBULA LATERAL 5 HOLE $2,462.00 C1713 SCREW PERICANNUL CANCELL 6.5MM $302.00 C1713 SCREW TENODESIS BOLT 8X16MM $1,733.00 C1713 KIT DRILL BIT ACCESSORY $1,490.00 SLEEVE NAIL INSERTION $246.00 MESH HERNIA PHASIX ST RND 11CM $4,339.00 C1781 SCREW SET CEPHALOMEDULLARY TI $913.00 C1713 STENT SE BILIARY W/DS 80IN $2,214.00 C1876 NAIL TIBIAL TI 8.3MM X 36CM $3,888.00 C1713 SCISSOR LAPAROSCOPY INS DISP $1,103.00 SUTURE PDS PLUS CT-2 PDP344H $30.00 MESH HERNIA PHASIX SQ 30X30CM $39,398.00 C1781 MESH HERNIA PHASIX 15.2X20.3CM $8,169.00 C1781 GRAFT PORCINE AB NC 19X35CM $38,680.00 C1781 MESH HERNIA PHASIX ST 25X30CM $26,758.00 C1781 MESH HERNIA PHASIX ST 20X25CM $17,647.00 C1781 MESH HERNIA PHASIX ST 7CMX10CM $3,367.00 C1781 MESH HERNIA PHASIX ST 10X15CM $6,053.00 C1781 MESH HERNIA PHASIX ST 15X20CM $11,721.00 C1781
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
MESH HERNIA PHASIX 25.4X30.5CM $20,417.00 C1781 OXISENSOR ADLT EAR CONCHA DISP $91.00 NAIL FEMORAL RETROGRADE TI $5,417.00 C1713 KIT GELPOINT PLATFORM TAMIS $2,397.00 LINER ACETABULAR CONSTRA E1 D $5,275.00 C1776 SCREW LOW PROFILE DOME $226.00 C1713 CATHETER GUIDE ATTAIN COMMAND $660.00 C1887 BALLOON CATH VENOGRAM ATTAIN $295.00 C1725 PLATE FIBULA LATERAL 7>9 HOLE $2,592.00 C1713 INTRODUCER SHEATH AFX W/D 17F $1,273.00 NAIL CEPHALOMEDULLARY TI SHORT $4,026.00 C1713 SCREW LAG TI 10.5MM $2,046.00 C1713 DRILL BIT QC 4.5X195CM $416.00 CANNULA STANDARD 3.7MM $1,125.00 DRESSING WND COLLAG>16<=48SQIN $118.00 A6022 SCREW PERI CANNUL LOCK 5.5MM $913.00 C1713 NAIL TIBIAL CANNULATED TI $2,798.00 C1713 BALLOON PTA DILATAT ADMIRAL XT $330.00 C1725 BALLOON PTA DILATAT AMPHIRION $532.00 C1725 NAIL TIBIAL TI 9.3MM $4,186.00 C1713 BALLOON PTA PERIPH VIATRAC 14 $1,045.00 C1725 SCREW PERI SELFTAP 4.5X50-60MM $241.00 C1713 SCREW PERI SEL-TAP 4.5X65-70MM $241.00 C1713 EXTRACTOR HEX SCREW 3.5MM $1,278.00 SCREW PERI CANN CONICAL 5.5MM $913.00 C1713 LEAD AICD ENDO SGL COIL G $6,566.00 C1777 NAIL FEMORAL RETROGRADE PURPLE $5,417.00 C1713 STENT TRACHEOBRONCH PC $6,156.00 C1874 BALLOON DILATION PULMONARY CRE $970.00 C1726 PACEMAKER SGL CHAMB RR VR MRI $7,182.00 C1786 BALLOON PTA DILATATION PACIFIC $532.00 C1725 GUIDE WIRE STIFF ANGLED TIP $424.00 C1769 FIXATOR DIST RADIUS STABLELOC $3,480.00 CLOTH BATHING READYBATH $8.00 CATHETER BALLOON SIZNG 3-LUMEN $1,395.00 C1726 NEEDLE PULMONARY ASPIRATE 18G $723.00 BALLOON PTCA DILATAT NC EMERGE $985.00 C1725 NAIL BONE TOTAL KNEE DISP $447.00 KIT CATHETER DIALYS SHORT TERM $437.00 C1752 LINER ACETABULAR 10°FC 32MM C $3,024.00 C1776 ELECTRODE LAPAROSCO STRT DISP $163.00 BALLOON PTCA DILATATION EMERGE $780.00 C1725 SCREW CANNULATED 1/3/THR 4.0MM $973.00 C1713 K-WIRE STYLE 6 2.0MM $378.00 TAP QC LONG 6.5MM $532.00 SCREW PERIARTICULAR 6.5MM $378.00 C1713 BEARING TIBIAL PS 71/75X12MM $3,132.00 C1713 PLATE VOLAR DISTAL RADIUS $2,460.00 C1713 GRAFT STRAVIX PER SQ CM 3X6CM $627.00 Q4100 GRAFT STRAVIX PER SQ CM 2X4CM $903.00 Q4100 GUIDE WIRE TEAR DROP 3.0MM $791.00 C1769 SCREW MINI ACUTRAK 2 $1,764.00 C1713 SCREW EXPLOR $791.00 C1713 DRILL BIT QUICK RELEASE 2.3MM $410.00 SCREW HEXALOBE LOCKING 3.0MM $480.00 C1713 SPEAR ANGLED TIP DR FIBERTAK $1,140.00 DRILL BIT FIBERTAK $448.00 BALLOON DILATATION EUPHORA $741.00 C1725 BALLOON PTCA DILATAT SPRINTER $741.00 C1725 BALLOON DILATATION SPRINTER $741.00 C1725 BALLOON PTCA MAVERICK RX $985.00 C1725
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BEARING TIBIAL PS 63/67X10MM $3,132.00 C1713 SUTURE VICRYL COATED CT-2 $93.00 GRAFT DERMASPAN P SQ CM 4CMX7C $401.00 Q4126 HOSE AIRWAY CLEARANCE THERAPY DISP $103.00 BEARING TIBIAL CR $2,178.00 C1713 SCREW HEXALOBE LOCK 2.7X38MM $540.00 C1713 PLATE TIBIAL DL LOCKING 10HOLE $4,251.00 C1713 PLATE RECON STRAIGHT LOCK 8H $1,929.00 C1713 SCREW CANNULATED LONG/TH 4.0MM $756.00 C1713 CATHETER GUIDE LAUNCHER 8F $226.00 C1887 STEM HUMERAL COMP MINI $6,874.00 C1776 PLATE HUMERUS POSTLAT DISTAL $2,150.00 C1713 OXYGENATOR DIFFUSION MEMB QUAD $2,833.00 DRILL BIT Q-C 2.5 X 110CM $395.00 INTRODUCER SHEATH PERIPH 10F $71.00 C1894 STENT PERIPHERAL WDS PULSAR-18 $2,178.00 C1876 BALLOON TROCAR W/DISSEC HERNIA $1,595.00 RETRIEVAL NET FOR FB $401.00 PROBE SUCTION 3.5MM DISP $463.00 POSITION GEN LIFT SLING DISP $208.00 LINER ACETABULAR NEU E1 36MM H $3,024.00 C1776 PLATE PERI DIS LAT FIB LOCK 6H $2,422.00 C1713 SUTURE ANCHOR FIBERTAK AR3632 $1,406.00 C1713 SUTURE PROLENE 9-0 BV100-4 $151.00 SCREW MANDIBLE NL XDRIVE 2.3MM $406.00 C1713 PLATE FIBULA LATERAL 6H $2,506.00 C1713 PLATE FRAGMENT 2.7MMX60MM $1,825.00 C1713 SCREW DRIVER HEX STICK FIT T8 $456.00 SCREW DRIVER HEX STICK FIT T15 $958.00 CATHETER BALLOON PTA ULTRAVRSE $378.00 C1725 ELECTRODE LAPAROSCOPIC CORBITT $186.00 BLADE ARTHRO SMALL JNT CUTTER $211.00 BEARING TIB CR W/ANTI-OXIDANT $3,132.00 C1713 ENVELOPE ECM PACEMAKER/ICD $2,759.00 SCREW DRIVER BLADE LONG DISP $897.00 PLATE TEMPLATE STRAIGHT 24H $438.00 PLATE THORACIC PRE CONTOUR 24H $6,523.00 C1713 SCREW LOCKING RESCUE 2.7MM $748.00 GRAFT ILIAC INTERNAL COMPONENT $6,033.00 C1768 GRAFT ILIAC BRANCH COMPONENT $21,617.00 C1768 SENSOR SP02 FOREHEAD $171.00 CATHETER ANGIOGR PIGTAIL CURVE $55.00 PLATE ANKLE MEDIAL ANTI GLIDE $1,860.00 C1713 STAPLER ENDO GIA AUTOSUTURE DP $1,311.00 STAPLER ENDO GIA ULTRA XL DISP $1,121.00 BEARING TIBIAL NC PS 360 $4,927.00 C1713 NAIL PERITROCHANTRIC (PTN) $6,042.00 C1713 DRESSING VASELINE GAUZE 1/2X72 $9.00 PLATE DUAL COMPRESSION LOCK 8H $1,673.00 C1713 TUBE ENDOTRACH HVLP CUFF 5.0MM $13.00 HEADBAND SENSOR CPO2 DISP $52.00 BEARING TIBIAL AS ANTIOXIDANT $3,132.00 C1776 FIBERWIRE MULTI CONV CUT NDL $399.00 PACEMAKER DCP DR RR MRI AZURE $9,029.00 C1785 GLIDEWIRE GOLD HYDROPHILI COAT $650.00 C1769 CATHETER GUIDE EXT W/WIRE TRAP $2,020.00 C1887 SCREW CORTICAL FA HH TI 3.5MM $973.00 C1713 MESH HERNIA PATCH PARIETEX 6.6 $1,568.00 C1781 LEAD PACE NT VDD FINELINE MRI $1,836.00 C1898 CATH TL ATHER ROTAT DIAMONDBK $6,966.00 C1724 SCREW CORTICAL PERI ST SS4.5MM $265.00 C1713
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
LINER ACTABULAR 10° FC 40MM H $3,024.00 C1776 DRILL BIT CANN W/AO 2.0MM DISP $1,125.00 K-WIRE FIXATION TROC THR 1.1MM $882.00 CATH DRAINAGE THORACIC DISP $93.00 C1729 SCREW CORTICAL FT ST FA HH TI $973.00 C1713 LINER ACETAB CONSTRA E1 C 32MM $5,275.00 C1776 HEAD FEM CONSTR MOD CC TI 32MM $5,335.00 C1713 STEM FEM STS DISTL TI 17X150MM $7,743.00 C1776 MESH HERNIA PROGRIP 15CMX10CM $1,102.00 C1781 SCREW ST TI LCK 2.4X7MM $748.00 C1713 PLATE STERNUM JL 10 HOLE $2,690.00 C1713 CATHETER ANGIO PIG 145° 6SH $62.00 SURGICEL POWDER 3.0 GRAMS $650.00 SCREW CORTEX ST T15 SD RC 16MM $441.00 C1713 FIXATION DEVICE LIGAMENT TL #7 $1,790.00 SCREW INTERFERENCE IFIX 7X20MM $1,643.00 C1713 BRONCHOSCOPE FLEX REG 5.0 DISP $1,083.00 BRONCHOSCOPE FLEX LG 5.8 DISP $1,247.00 PACE LEAD ENDO FINELINEII 45CM $1,836.00 C1898 PACE LEAD ENDO FINELINEII 52MM $1,836.00 C1898 DISSECTOR KITTNER SS 38CMX5MM $103.00 CATHETER BALLOON ADVANCEG30821 $1,504.00 C1725 CATHETER BALLOON ADVANCEG30830 $652.00 C1725 SLEEVE STERILE RF HEAD COVER $62.00 PLATE OLECRANON LT 7 HOLE $2,106.00 C1713 SCREW PERI CORT SS ST 4.5X30MM $265.00 C1713 GUIDE WIRE COMBOWIRE 1.5CM OS $2,376.00 C1769 INTERPHALANGEAL PROX IMPL SZ50 $3,246.00 C1776 ASPIRATOR NASAL INFANT DISP $45.00 RASP HELIOCOIDAL 3.2X18.3MM $397.00 NAIL FEMORAL CPM TI 10MMX40CM $5,926.00 C1713 ELECTRODE RADIUS LOOP 20X10MM $85.00 ELECTRODE RADIUS LOOP 10X7MM $85.00 CATHETER PH-IMPEDANCE VERSFL-Z $400.00 ACCESS & DISSECTOR SYS 10-12MM $1,482.00 SCRW PERI LK CAN CONI 5.5X85MM $943.00 C1713 NAIL CPM TI 11.5MMX42CM $5,926.00 C1713 SCREW CORTICAL FT TI 5X60MM $973.00 C1713 SCREW HEXALOBE LP 4.3MMX60MM $653.00 C1713 NAIL LOCKING PROXIMAL RT 150MM $4,629.00 C1713 CATH ANGIOGRAP SOFT-VU 5FX65CM $113.00 CATHETER INFINITI PT JR4F 145° $127.00 SCREW HEXALOB LOCKING 3.5X36MM $480.00 C1713 SCREW HEXALOBE VA 2.7X12MM $498.00 C1713 SCREW HEXALOBE LP 4.3X24MM $653.00 C1713 SCREW CANC HEX FT 4.0X35MM $403.00 C1713 CATHETER WISEGUIDE 6FR VR-1 $201.00 C1887 CATHETER WISEGUIDE 7FR VR-1 $201.00 C1887 CATH GUIDE RUNWAY 6F JR 3.0 $201.00 C1887 CATH GUIDE MACH 1 7F JR 3.0 $201.00 C1887 TRAY TRANSVEN W/BIPOLAR PACING $756.00 KIT PROSTHETIC IMPLANT UROLIFT $1,995.00 L8699 ENDOSCOPIC OVERTUBE 25CM $800.00 CATHETER ANGIOGRAPH RC $83.00 CATHETER ANGIOGRAPH KUMPE $113.00 SET INTRODUCER MICROPUNCT STD $211.00 C1766 PLATE BREAST BIOPSY LATGRID LG $162.00 DRAPE UTILITY XL STER W/TAPE $32.00 CATHETER CLOSURE FAST $2,449.00 INTRODUCER MICRO 7F $165.00 SPLASHCAP WND SHIELD F/IRRIGA $28.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
STAPLE REMOVER SKIN PREMIUM $19.00 SCREW INTERFERENCE ACL $548.00 C1713 SCREW HEXAGON CANNULATED 3.5 $953.00 C1713 MENISCAL REPAIR SYS NOVOSTITCH $2,048.00 IV CATH SHIELD BD AUTOGUARD $16.00 BRACE REDDIE ALL SIZES $92.00 CANNULA NEUROTHERM PREMIUM $150.00 CANNULA RF CURVED $150.00 CANNULA PREMIUM SELECT (RF) $150.00 ACCUDRAIN EXT CSF W/ANTIREFLUX $1,470.00 DRAIN BAG ANTIREFLUX VLV 700ML $1,064.00 KIT FLEX SEAL STOOL CONTAINER $619.00 STRAP SMALL SNAP $89.00 STRAP LARGE SNAP $89.00 STRAP MEDIUM SNAP $89.00 KIT DRESSING BRIDGE W/SSNAP $332.00 KIT DRESSING W/FOAM SNAP $240.00 CARTRIDGE SNAP THERAPY $518.00 A9272 SPONGE ULTRAFOAM COLLAGEN $224.00 BRACE W/H/F/O W/O JNTS PRECAST $1,848.00 L3807 AMBULANCE WAIT TIME P/HALF HR $- A0420 AMBULANCE LIFE SUPPORT ER LEV1 $- A0427 SCREW ACETABULAR G7 6.5 $226.00 C1713 WRAP COFLEX 4 INCH $75.00 APPLICATOR PROCTO SWABS 8 IN $16.00 DISSECTOR ENDO ROTICULAT DISP $2,725.00 ENDO GIA STAPLER DISPOSABLE $2,047.00 ENDO GIA RELOADING UNIT DISP $2,528.00 ENDO BABCOCK $2,008.00 SALEM SUMP 14F $97.00 TROCAR TUNNELING DURA FLOW $190.00 CHLORA/DURA PREP $12.00 SUR-FIT SKIN BARRI STOMAHS 6X6 $103.00 A4362 STIFFNECK NO NECK-ADULT $418.00 L0140 TRANSPARENT POUCH 4" $103.00 A5051 DRESSING DUODERM 4X4 THIN $894.00 DRESSING DUODERM CGF 4X4 $642.00 SET PNEUMOTHORAX $1,876.00 SCREW LAG DHS/DCS 12.7MM $2,164.00 C1713 SCREW HEADLESS COMPRESS 4.0MM $881.00 C1713 ROD CARBON FIXATOR 4.0MM $642.00 C1713 SCREW CORTICAL 4.5MM $311.00 ROD CARBON FIXATOR 11.0MM $2,145.00 NAIL TIBIAL $10,395.00 C1713 DRILL BIT DISPOSABLE $1,653.00 SCREW BLUNT TROCAR SS SCHANZ $1,221.00 C1713 SCREW CANCELLOUS $2,411.00 C1713 REAMER HOLLOW COMPLETE $2,793.00 GUIDE WIRE WHOLEY MOD-J $1,594.00 C1769 SET PERICARDIOCENTESIS/THORACE $1,587.00 C1729 STAPLER SKIN 3M MS DISP $266.00 EVACUATOR BLADDER URO-VAC $510.00 PACKING NASAL $96.00 PACKING EPISTAXIS $326.00 AIRWAY NASOPHARYNGEAL 26FR $205.00 AIRWAY NASALESOPHAGAL 30F $205.00 WRAP COBAN 4 INCH $106.00 WRAP COBAN 6 INCH $134.00 HOLDER-FOLEY CATH $154.00 SUPPORTER SCROTAL (ALL SIZES) $211.00 STETHOSCOPE DISPOSABLE $122.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
TUBE ENDO TRACH 4.5 CUFFED $28.00 INTUBATING STYLET 14 FRENCH $44.00 INTUBATING STYLET 6 FRENCH $44.00 TROCAR 10/12MM $2,492.00 NASAL GASTRIC TUBE 12-20 FR $4,080.00 TUBE ENDO TRACH 3.0 UNCUFFED $26.00 COLLAR CERVO FIRM LG,MED,SMALL $300.00 L0140 TISSUE - PATIENT BOX $14.00 CAST SHOE LARGE $321.00 THORACIC CATH 24 FR $259.00 DEFIB ELECTRODE PADS $556.00 HUMIDIFIER CHAMBER DISP $143.00 BOWL SINGLE BASIN DISPOSABLE $11.00 PROBE HEMOSTASIS BICAP 7FR $4,530.00 BAG PRESSURE INFUSER 500 ML $156.00 INTUBATION STYLET $712.00 PROBE TEMPATURE DISPOSABLE $113.00 SUTURE RETRIEVER DISPOSABLE $579.00 TRAY THORACENTESIS ARROW TYPE $829.00 SUPPORT SACRO/LUMBAR XLG $548.00 LENS MORGAN MEDI FLOW $1,214.00 GUIDE WIRE HYDROPHILIC ICE COA $485.00 C1769 TOOTH PASTE $2.00 CANNULA NASAL STIFF $14.00 PEAK FLOW METER ADULT $170.00 CLIP HAIR PREP DISP $2.00 TUBING - VACUUM LASER $146.00 RETRIEVER LOOP $2,129.00 C1773 LOTION ALOE VESTA $122.00 PACK GYN/LAPAROSCOPY DISP $1,706.00 RETRIEVER STONE FORCEP $3,363.00 BASKET STONE RETRIEVER $1,230.00 MITT PRE-OP HAIR REMOVER $11.00 SUTURE PLAIN GUT 4-0 $57.00 KIT INTRODUCER PEEL-AWAY VASCU $238.00 C1892 TUBE TRACH ADULT $1,427.00 DIAPER INFANT 8-14 LB $42.00 SUTURE VICRYL 0 36" $113.00 LOADING UNIT GIA 80 $441.00 CUTTER LINEAR RELOAD W/LOCK $3,630.00 LIGACLIP APPLIER MEDIUM $2,319.00 LIGACLIP APPLIER LARGE $2,339.00 ENDOSCOPIC SCISSORS SHAFT DISP $404.00 PLATE DCS STANDARD HOLE 3>16 $4,753.00 C1713 GLIDE WIRE STIFF $1,329.00 CATH SUCTION 12FR GENTLE FLO $38.00 CUTTER LINEAR RELOAD CART 55MM $2,281.00 DRAIN FLAT JACKSON PRATT $275.00 FEEDING TUBE 14FR $478.00 ELECTRODE FULGURATE LG TIP 2F $1,795.00 SHEATH PEEL AWAY FIX CURVE 10F $1,022.00 C1892 DUBIN SPECIMAN DEVICE W/COMPRE $510.00 FORCEP RADIAL JAW LG W/NE 2.8 $159.00 CONVENIENCE BAG (EMESIS) $55.00 STERI-STRIP 1 X 5 $134.00 PANTY MESH OB LG $122.00 SHEATH PERCUTANEOUS $894.00 CATHETER BALLOON DILAT URETER $1,529.00 C1758 TRAP MUCOUS SPECIMEN $170.00 PONSKY PULL PEG $2,556.00 STOCKINETTE IMPERVIOUS XL $224.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
CATH COUPE 18FR 10CC $419.00 IV CATHETER 14G X 5-1/2 INCH $31.00 TUBE GASTROSTOMY REPLACE 16F $942.00 GRAFT VASCULAR $10,652.00 C1768 SUTURE MONOCRYL 5-0 $90.00 SUTURE MONOCRYL CT-1 Y947H $28.00 SUTURE MONOCRYL 3-0 $103.00 AIRWAY NASALESOPHAGAL 20FR $205.00 SUTURE CHROMIC 4-0 $67.00 CATH URETH CONE TIP 8FR $409.00 CATHETER CHOLANGIOGRAM KUMAR $324.00 SNARE POLYPECTOMY JUMB LP DISP $916.00 STENT NON COA/NON COV W/DS $14,127.00 C1876 PILLOW ABDUCTION $603.00 DRAPE FRACTURE TABLE $264.00 SUTURE CHROMIC 3-0 $60.00 NEEDLE AUTO STITCH $714.00 SUTURE CHROMIC 2-0 $60.00 ADAPTER LUER LOCK $15.00 SUTURE BOOT $186.00 CATH SONES 7.5X100CM 1.5 2H $2,277.00 NEEDLE WANG 22GA X 13MM $1,242.00 AIRWAY NASALESOPHAGAL 30FR $205.00 ADAPTER PTCA Y $794.00 STEERING HANDLE BARD $112.00 IMMOBILIZER SHOULDER ELASTIC $224.00 GUIDE WIRE HTF .014 $2,556.00 C1769 GUIDE WIRE CORONARY INTERVENT $2,556.00 C1769 CATHETER JURKINS/AMPLANTZ $623.00 C1887 CATHETER SHEATH W/UNI VALVE $667.00 C1894 DIALATOR VESSEL ALL SIZES $291.00 EXCHANGE WIRE .035 CORDIS $564.00 GUIDE WIRE J-WIRE $414.00 C1769 TRANSDUCER CCL $549.00 RETRACTOR ENDO 10MM $1,908.00 ESMARK BANDAGE 4" $90.00 DRAPE STERILE ALL SIZES DISP $57.00 KIT CCL LEFT HEART DISPOSABLE $916.00 DRESSING COBAN 4INX5YD STERILE $140.00 SUTURE PDS TP-1 MS2 $194.00 LIGACLIP APPLIER SMALL $2,300.00 STENT BILIARY PERCUFLEX 7F $1,299.00 C1874 ZEBRA WIRE .035 $2,333.00 BALLOON RETRIEVAL ERCP $1,010.00 VASCULAR LOOP MINI RED $33.00 DRAPE BRACHIAL $523.00 NEEDLE PAJUNK 3.75" $376.00 NEEDLE VERESS 150MM $119.00 CANNULA DUAL NARE O2/CO2 $31.00 TED HOSE KNEE HIGH SM X LONG $222.00 SHEARS ENDO MINI DISPOSIBLE $755.00 ELECTRODE ROLLER 24 $1,149.00 ELECTRODE CUTTING LOOP 24/26 $530.00 SUCTION IRRIGATION HANDLE DISP $1,017.00 ORIFICE TIP MULTI $498.00 FORCEP RADIAL JAW SM BRONK $1,710.00 COTTON ROLL 4INX1/2LB STERILE $414.00 GUIDE WIRE PEG SYSTEM $2,556.00 C1769 CAP INJECTION J-LOOP $97.00 CONNECTOR TUBING DISPOSIBLE $135.00 BLADE GIGLI SAW $603.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRAPE 3/4 DRAPE SHEET $91.00 SYRINGE 60CC ALLIANCE DEVICE $825.00 OINTMENT 2 OZ ALOE VISTA $43.00 DRESSING HYDRASORB 4X4 $73.00 CABLE VITALLIUM (ALL) $4,179.00 SPLINT FINGER ASSOC SIZE 1-7 $122.00 RETRIEVAL ENDO POUCH $1,832.00 CONTAINER 4OZ STERILE $1.00 PATCH PERICARDIAL BOVINE $2,795.00 PACK ANGIOGRAPHY DRAPE $1,207.00 CATHETER SWAN GANZ DIL THERMAL $1,153.00 C1751 SLING UNIVERSAL (PT/OT) $669.00 CELL SAVER KIT $2,744.00 TRAY EPIDURAL SINGLE SHOT $531.00 NEEDLE TUOHY EPIDURAL $113.00 POSITIONING ROLL $129.00 AIRWAY LARGNGEAL MASK $172.00 GAYMAR OVERLAYS CUSH BED SPR+ $1,496.00 TROCARS OPTIVIEW 12MM #512 O $2,344.00 NEEDLE SPINAL LUERLK 22G 5149 $213.00 BLADE SAW OSCILLATOR $604.00 BLADE SAW MICRO (ALL SIZES) $129.00 BLANKET WARM MULTI BAIR HUGGER $96.00 STAPLER SKIN $1,212.00 CANNULA ULTRA-TAPE TIP 5F MM17 $1,134.00 GAYMAR-DAILY CHARGE $275.00 ELECTRODES QK COMB/LIFEPAK 12 $848.00 WASH BASIN #13739-MAN $10.00 SHOELACE ELASTIC $48.00 LAPAROSCOPIC HERNIA STAPL #EMS $5,030.00 CIRCUIT VENTILATOR TUBING $67.00 OXISENSOR N25 NEO-NATAL $548.00 OXISENSOR D25 ADLT OXI TRNSDCR $593.00 OXISENSOR R15 NASAL OXI TRNSD $600.00 URINARY LEG BAG LARGE #10-1503 $67.00 A5112 SUPPORT PROFLEX WRIST LG RIGHT $498.00 NEEDLE BIOPSY BIOP CUT #441816 $516.00 DRAPE U-DRAPE #1015 $348.00 SCREW CANNULATED 7.3X30X16 $2,634.00 C1713 BIPAP/CPAP HEATED CIRCUIT $173.00 MASK NIV NONVENT SAFETY VALVE $126.00 WASHER ORTHO 7.0 TO 13.0 $282.00 C1713 GUIDE WIRE THREADED 2.8M 300M $1,229.00 C1769 ENDOSCOPIC CLIP APPLIER ALL SZ $1,915.00 NAIL FEMORAL TROCHANTERIC COMP $16,848.00 C1713 MENISECTOMY TIPS #C5010 DISP $91.00 SUTURE PDS II 3-0 $48.00 CUTTER PROXIMATE VASC LIN 55MM $3,858.00 CUTTER RELOAD PROXIMATE TVR55 $2,149.00 STAPLER RELOADABLE LINEAR 30 $3,201.00 BLANKET WARM UPPER BAIR HUGGER $146.00 BLANKET WARM LOWER BODY BAIR $146.00 SUTURE ETHILON 2-0 $42.00 DRAPE HIP W/POCKETS $825.00 ADAPTER TUOHY-BORST W/SIDE PRT $436.00 STONE REMOVE DEVICE 5.5F #3515 $5,094.00 DISPOSABLE PRESSURE DISC #PNO1 $84.00 FORCEP BIOPSY MULTIBITE 240CM $1,344.00 RELOAD STAPLER #TCR75 $2,887.00 STOCKINETTE TUBULAR SGL 6X2YDS $222.00 SUPPORT NEOPRENE THUMB RT $402.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
AIRWAY NASOPHARYNGEAL 28FR $83.00 KIT CEMENT MIXER $2,458.00 BANDAGE ELASTIC W/VELCRO 2X210 $73.00 BANDAGE ELASTIC VELCR ST 3X210 $97.00 SUTURE COTTONY II DACRON 3MM $981.00 BONE GRFT CANC CHPS410MM 15CC $5,386.00 PIN BALLS .035 JURGAN #W035 $213.00 SUTURE PLAIN GUT 3-0 $57.00 SUTURE MONOCRYL 4-0 $249.00 ROTH RETRIEVAL NET 2.5MM $1,344.00 BASKET STONE RETRIEVAL $2,145.00 END CAP ORTHO NAIL $1,819.00 C1713 PERI-VAC W/PIGTAIL #4304 $2,570.00 SUTURE ENDOSTITCH #173016 $2,085.00 HYDRATOME $2,730.00 NEEDLE TRU-CUT BIOPSY #2N2704X $549.00 POWDER OSTOMY 1 OZ $31.00 BIPAP DISPOSABLE HEADSTRAP $89.00 SLIPPER PATIENT XL(NAVY) PP $55.00 DRILL BIT CANNULATED DISP $2,563.00 SUTURE VICRYL 0 CP-1 / CT-1 $46.00 PACKING SPONGE VAGINAL 2" $91.00 SUTURE ETHIBOND 0 TIES $30.00 SUPPORT TENNIS ELBW LG 1295-10 $201.00 SUPPORT TENNIS ELBW MD 1295-09 $201.00 POUCH 1 PIECE DRAIN 0227-70 $125.00 WAFER SUR-FIT 4"X 4" #225-20 $152.00 SUTURE VICRYL 5-0 P-3 $84.00 CATHETER BILIARY DRAINAGE $575.00 C1729 SUTURE VICRYL 0 978H $113.00 CATH FOLEY 22FR 30CC 3WAY $164.00 REACHER AID $59.00 PLATE RECON TITAN 10 HOLE $4,591.00 SUTURE VICRYL 3-0 J258H $50.00 CUFF BP ADULT DISPOSABLE $82.00 NAIL HUMERAL ASSORTED $13,641.00 C1713 SUTURE PDS 4-0 $67.00 TUBING SUCTION BRAT 2 $688.00 GUIDE WIRE EXCHANGE $2,492.00 C1769 CATHETER BALLOON PUMP $6,289.00 STENT COA/COV W/DS ZEBD 7-7 $2,411.00 C1874 GUIDE WIRE GLIDE ANG/STRAIGHT $850.00 C1769 DRAPE EXTREMITY T $289.00 PONSKY TRI FUNNEL TUBE $1,052.00 PACK TOTAL HIP $7,883.00 PACK TOTAL HIP BCS $7,763.00 PACK TOTAL KNEE BCS $6,655.00 SUTURE VICRYL 3-0 J416H $50.00 GUIDE WIRE JAGTOME ANGLED $336.00 C1769 CLIP APPLIER POLYMER $1,719.00 CATH GROSHONG 7FR LOW PROF. $9,140.00 C1788 THERAPY BED-EXCEL AIR/FOAM $2,108.00 NEEDLE CONTRAST PRESSURE $336.00 STENT ESOPHAGEAL WALLFLEX $5,382.00 C1874 GUIDE WIRE STRAIGHT TIP $835.00 C1769 SCALPEL DISPOSABLE $103.00 SUTURE ANCHOR $3,768.00 C1713 SURGI-FISH VISCERA RET $561.00 SUTURE GORE-TEX $465.00 POSITIONER PAD LATERAL DISP $2,088.00 OMNI-JUGS W/SUCTION CAP $727.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRESSING TEGADERM TRNSP<16SQIN $9.00 A6257 C02 DETECTOR INDICATOR DISP $112.00 NAIL FEMORAL CANNULATED TI $4,114.00 C1713 WRAP KNEE B-COOL LARGE ARTHRO $129.00 BANDAGE ELASTIC DOUBLE $312.00 SURGI-BRA SURGICAL SUPPORT $383.00 MESH DUAL PLUS $2,068.00 C1781 TUBING INSUFLATION $259.00 HERNIA TACKER $4,385.00 HERNIA BALLOON $3,185.00 TACKER HERNIA ABSORBABLE $2,247.00 HEMOCLIP LIGATING ALL SIZES $419.00 BRACE KNEE W/HINGE $2,029.00 SCALPEL HARMONIC $3,160.00 NEEDLE ANGIOCATH 16GA $154.00 DERMA CARRIER II $468.00 BRACE JACE $3,061.00 L1833 SCREW CANNULATED 4.0 (ALL SZ) $2,164.00 C1713 BASKET 4-WIRE 3FR HELICAL $2,145.00 SUTURE PASSER NEEDLE & SLEEVE $5,921.00 ASTRYNGIN PASTE 8 GRAM $418.00 CABLE PACING SURGICAL DISP $224.00 MESH HERNIA DULEX 20CM X 30CM $23,391.00 C1781 CATHETER SUPRAPUBIC/CYSTOSCOP $781.00 C2627 SUCTION COAGULATOR IN-LINE $419.00 GRAFT VAS KNITTED DOUBLE $7,001.00 C1768 HEMASHIELD KNITTED $10,152.00 KIT PLEUREX CATHETER SY NO BTL $3,921.00 C1729 TRAY TRACHEOSTOMY CIAGLIA $3,335.00 TUBE ENDO BRONCHIAL $1,876.00 STENT VASCULAR (ALL SIZES) $15,269.00 C1876 CATHETER BALLOON BLUEMAX $5,287.00 C1725 INFLATOR ENCORE $1,769.00 INTRODUCER 8FR OR 10FR $600.00 CLIPS FILSHIE $1,288.00 DRILL BIT RADIOLUCENT DISP $2,481.00 LIGATOR MULT-BD 6 SHOOTER DISP $3,566.00 CABLE CRIMP SLEEVE $4,997.00 PLATE SS CABLE 3>11 HOLE $4,325.00 C1713 TUBE MYRINGOTOMY GROMMET $409.00 VALVULOTOME LEMAITRE $4,283.00 NAIL FEMORAL UNIFLEX $13,486.00 NAIL TIBIAL UNIFLEX $10,120.00 C1713 SCREW TITANIUM (VARIOUS SIZES) $2,309.00 C1713 ERBE DISPOSABLES $4,023.00 TUBE FEED JEJUNAL GASTROSTOMY $1,819.00 CATHETER HEMODIALYSIS LONGTERM $7,197.00 C1750 BRACE ABDUCTION POSTOP $4,569.00 L1686 BRACE HIP JOINT, HEAVY DUTY $3,957.00 L2620 BRACE ADJ FLEX/EX HIP JNT CTRL $1,556.00 L2624 BLADE ENDOSCOPIC $1,182.00 SLING TRANS VAGINAL $9,609.00 C1781 GUIDE WIRE AMPLATZ $1,255.00 C1769 KIT SNARE GOOSENECK $1,129.00 DILATOR AMPLATZ RENAL $1,081.00 CATHETER ANGIOSCALE $2,333.00 FLO-SWITCH $222.00 MONITOR SET-PRESSURE QUICK $1,427.00 MICROSNARE AMPLATZ GOOSENECK $3,412.00 CATHETER LATIS $2,478.00 CATHETER SOFT-VU FLUSH $535.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
DRILL & PIN SET $1,183.00 BUTTON PATELLA $7,605.00 C1713 FEMORAL COMPONENT KNEE ZIMMER $22,722.00 C1776 TIBIAL BASE PLATE FIX BEARING $15,791.00 TOTAL KNEE BEARING $6,882.00 STEM HUMERAL $21,058.00 SHELL ACETABULAR $4,287.00 C1776 LINER TOTAL HIP CERAMIC $8,821.00 C1776 SCREW DOME $2,333.00 HEAD FEMORAL STANDARD $8,141.00 WASHER WASHERLOC $6,479.00 SCREW WASHERLOC $2,256.00 SCREW BONE MULCH $7,265.00 C1713 GUIDE WIRE ACL $2,294.00 C1769 SCREW LOCKING IM ROD $2,047.00 C1713 GUIDE ROD IM $1,737.00 BONE PLUG / CEMENT RESTRICTOR $2,100.00 CENTRALIZER TOTAL HIP STEM $2,414.00 STEM TOTAL HIP (CEMENTED) $8,980.00 STEM TOTAL HIP NON-CEMENTED $16,241.00 SCREW ACUTRAK (ALL SIZES) $1,839.00 C1713 ENDOBRONCHIAL BLOCKER SET $2,174.00 BLADE OSTEOTOME ALL SIZES $1,770.00 HEAD RADIAL COMPONENT $14,910.00 C1776 STEM RADIAL COMPONENT $12,262.00 C1776 PACK PACEMAKER $1,710.00 BONE MATRIX INTERGRO PUTTY $3,643.00 C9359 MESH HERNIA $10,052.00 C1781 FORCEP BIPOLAR - BICOAG $5,526.00 ELECTRODE DISPOSABLE $3,469.00 DIALYZER ARTIFICIAL KIDNEY $544.00 BIOCARE ORAL SWAB $14.00 MOUTHWASH BIOTENE $83.00 BIOCARE ORAL BALANCE GEL $55.00 BIOCARE ORALCARE KIT $278.00 PADDING CYLINDER $500.00 HOLDER LIMB $278.00 SOCK AID W/FOAM HANDLES $33.00 SLING HEMI $894.00 A4565 GLOVE COMPRESSION SMALL $436.00 STICK HIP DRESSING 27" $130.00 KIT CEMENT PREP $837.00 BIOPSY PUNCH 4MM $67.00 COIL NESTOR PLATINUM EMBOLIZAT $530.00 ELECTRODE LIGASURE DISP (HAND) $3,532.00 FOOT STRAP DISPOSABLE $839.00 WRAP COMPRESSION FOOT EA DISP $265.00 INTRATUBAL OCCLUSION ESSUR DEV $9,249.00 A4264 SHUNT JAVID 7FR - 10FR $1,163.00 TRAY CHEST TUBE INSERTION DISP $492.00 VENA CAVA FILTER $2,833.00 C1880 WOUND VAC - DAILY $1,607.00 KIT JEJUNOSTOMY GASTRO $1,982.00 KIT DRESSING CENTRAL LNE W/BIO $186.00 AFO BRACE,PRE-TIBIAL SHELL $5,404.00 L2340 SOFT INTERFACE MOLDED B KNEE $406.00 L2820 BONE CEMENT W/ANTIBIOTIC $2,348.00 WAND COVAC/ULTRA/TURBO DISP $3,730.00 GRAFT TRUNK AAA ENDOLUMINAL $52,327.00 C1768 GRAFT CONTRALATERAL LEG ENDOPR $9,070.00 C1768 GRAFT AORTIC/ILIAC EXTENDER $16,933.00 C1768
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
IV CATHETER ACUVANCE ALL SIZES $134.00 SHUNT PRUITT INAHARA CAROTID $3,609.00 BRACE ANKLE MULT LIGAMEN AIR $603.00 L1906 PACK LAP PROCEDURE DISPOSABLE $1,366.00 LASER FIBER PROBE DISPOSABLE $3,961.00 STENT GRAFT COA/COV/W DS $25,044.00 C1874 SEPRA FILM $2,561.00 PEG & SCREWS HAND INNOVATIONS $1,432.00 C1713 DORSAL NAIL PLATES $8,749.00 TRACH VALVE-VENT SPEAKING $1,184.00 CATHETER TRANSL ATHER DIRECTNL $6,847.00 C1714 CAPSULE BRAVO STUDY DISP $1,469.00 FEMOSTOP COMPRESSION SYSTEM $1,566.00 BOOT MULTI W/OUTSOLE $1,534.00 DRAIN BLAKE SILICO W/WO TROCAR $696.00 BRACE VARUS/VALGUS CORRECTION $549.00 L2275 BRACE RIGID TSLO $6,472.00 L0482 STAPLER CONTOUR CURVED CUTTER $9,536.00 RELOAD CURVED CUTTER STAPLER $9,861.00 WAND EVAC 70 EXTRA DISP $2,841.00 IV TUBING - SURGERY $350.00 IV TUBING - CATH LAB/IR $326.00 IV TUBING - ER $338.00 IV TUBING - ONCOLOGY/INFUSION $468.00 CLIP RESOLUTION DEVICE $2,247.00 PACK VASCULAR $1,750.00 BRACE TLSO FLEX TRNK SJ-SS PRE $2,526.00 L0456 SURGICEL NU-KIT 3X4 HEMOSTAT $1,398.00 FELT PT FE 4 X 4 $264.00 BOOT COMLOCK ANKLE WALKER $642.00 L4387 SCREW CORTICAL SELF DRILLING $760.00 C1713 PLATE SS CONDYLAR RT/LT $2,802.00 C1713 BRACE TLSO2 SHELL STERNAL $3,675.00 L0460 SET CATH THROMBEC/EMBOLECTOMY $4,726.00 C1757 PLUG FISTULA SURGISIS $8,832.00 C1763 HANDPIECE VERSAJET EXACT DISP $6,729.00 SPLINT NOSE DENVER $741.00 NEEDLE INTROSSEOUS EZ-IO $696.00 GENERATOR NEURO W/REC BATT&CHG $75,326.00 C1820 HEMODIALYSIS BLOOD TUBING COMB $108.00 PATIENT PROGRAMMER NEURO STIM $6,504.00 C1787 ANGIOCATH 6FR MULTIPAK $530.00 INTRA-AORTIC STATLOCK $338.00 LEAD NEUROSTIMULATOR TEST KIT $9,000.00 C1897 CLOTH PREP PREOP 2% CHLORHEXID $152.00 CLOTH 2% CHLORHEXIDINE GLUCONA $73.00 RODS TITANIUM (INCL PRE BENT) $2,538.00 C1713 NEEDLE STIMULATING DISPOSABLE $249.00 WRAP COFLEX 3 INCH $60.00 DRESSING OPTIFOAM 6 X 6 $143.00 DRESSING VERSIVA 5.5 X 5.5 $103.00 FORCEP BIPOLAR CUT PKS $9,465.00 SPLINT WALKING $639.00 L4386 FILTER LAPAROSCOPIC DISPOSIBLE $235.00 GOWN WARMING BAIR PAWS KIT $247.00 NEEDLE INTRODUCER ONQ PAIN DEL $222.00 WATER CONCHA RESERVOIR $65.00 BIPAP CIRCUIT DISPOSABLE $116.00 CONCHA HEATER COLUMN $192.00 CIRCUIT ADULT/PED W/O PEEP $175.00 CIRCUIT ADULT W/PEEP $235.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
BIPAP MASK FULL FACE $376.00 SPIROMETER INCENTIVE PEDIATRIC $205.00 PEAK FLOW METER PEDIATRIC $160.00 EZPAP $281.00 RESUSCITATOR INFANT BAG (AMBU) $402.00 VEST CPT WRAP $797.00 FILTER HME $36.00 BIPAP MASK NASAL $186.00 TRACH DIRECT CONNECT ADULT $97.00 NEBULIZER W/6" AEROSOL TUBE $23.00 KIT VAPOTHERM $1,283.00 SHUNT CAROTID BYPASS $673.00 PORT POWER ISP MRI IMPLANT $4,049.00 C1788 SHEATH & TUNNELER ON-Q DISP $727.00 VERSALIGHT DISPOSABLE $908.00 NEEDLE SPINAL 22G X 3.5" $60.00 ACAPELLA VIBRATORY THERAPY $443.00 PATCH HEMOSTASIS $1,000.00 NEEDLE GRIPPER DISPOSIBLE $96.00 DRESSING ALLEVYN HEEL $165.00 DRESSING ALLEVYN AG GENTLE $179.00 POWDER ARGLAES 5GM $303.00 GRAFT ALLOGRAFT TISS ANTER TIB $7,265.00 C1713 ESOPHYX2 BITE BLOCK $440.00 VASCULAR EMBOLIZATION PLUG $5,105.00 C1760 BRACE LSO SC R ANT/POS PNL PRE $2,292.00 L0637 SCREW LOCKING $1,267.00 C1713 PLATE TACK CERV TEMPORARY $482.00 IV START KIT W IV CATHETER $165.00 CATHETER INFUS PERIP CNTR/ML $1,296.00 C1751 KIT VEIN HARVEST SYSTEM DISP $6,289.00 BLOWER MISTER DISPOSABLE $228.00 SUTURE PROLENE 6-0 8711/8695 $122.00 SUTURE PROLENE 7-0 8747H $404.00 SUTURE PROLENE 3-0 $125.00 SUTURE VICRYL 1 UNDYED $108.00 SUTURE PROLENE 5-0 C-1 $156.00 SUTURE PROLENE 6-0 8706H $146.00 SUTURE SILK 0 $42.00 SUTURE VICRYL 2-0 J259H $50.00 SUTURE SILK 0 C0210 $201.00 SUTURE SURGICAL STEEL 5 M653G $228.00 SUTURE SURGICAL ST 6/7 654/5G $230.00 CANNULA DLP AORTIC ROOT TIP $337.00 DRESSING AQUACEL AG ROPE $275.00 SAF-CLENS AF WOUND CLEANSER $159.00 A6260 CURRETTE 3MM STERILE DISP $75.00 DRESSING AQUACEL 2X2 $65.00 DRESSING DUODERM 5.5X5.5 $151.00 DRESSING HYDROCOL 4X4 $106.00 DRESSING HYDROCOL 4X4 THIN $71.00 DRESSING AQUACEL AG 6X6 $367.00 SILVASORB GEL $259.00 HEARTSTRING W/LOADER DISP $4,793.00 C1760 CATHETER SWAN GANZ/CCO CARD OP $2,226.00 C1751 DRAIN FLUTE 10MM DISPOSIBLE $239.00 STENT ESOPHEGAL POLYFLEX $4,082.00 C1876 SHUNT DENVER ASCITES $10,842.00 STENT COLONIC WALLFLEX $9,224.00 C1876 DRAPE SLUSH WARMER DISP $530.00 WIRE PACING MYOWIRE DISP $1,052.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
ANCHOR MAGNUM KNOTLSS IM 2.8MM $5,683.00 C1713 CANNULA VENOUS BYPASS $448.00 VENT TUBE REUTER-BOBBIN $490.00 RIGID DRESSING BELOW KNEE PS $1,485.00 L5450 MESH CONNECTIVE TISS NH PER CM $135.00 C1763 CATHETER HEMODIALYSIS TEMP $1,579.00 C1752 SKIN BARRIER 2.75 XL WAFER $64.00 A4362 STOMAHESIVE PASTE PER OZ 2OZ $43.00 POUCH SUR-FIT $36.00 A5063 ADAPTOR LOW PRESSURE SUR-FIT $11.00 DRESSING ALLEVYN 4X4 $73.00 AORTIC PUNCH $376.00 GRASPER GATOR DISPOSABLE $1,958.00 ENDO SILS PORT $3,755.00 TUBING BLOOD FLUID ADMIN DISP $417.00 DRESSING SAF-GEL 3OZ TUBE $175.00 SUTURE ETHIBOND 0 $57.00 SUTURE ETHIBOND 2-0 TIES $73.00 PROBE SPATULA TIP DISPOSABLE $613.00 KIT VEIN HARVEST ACCESSOR DISP $1,135.00 KIT TRANSDUCER TRIPLE MONITOR $478.00 HEART NET STERILE DISP $383.00 GRASPER MINILAP CLUTCH $2,873.00 PIN POSITIONING 4.5MM $1,237.00 INHALER SPACER ADULT DISP $120.00 INHALER SPACER CHILD DISP $217.00 GRAFT VASCULAR STRETCH WALL $2,945.00 C1768 INHALER SPACER INFANT DISP $217.00 ELECTRODE LIGASURE ADV LAPRO $4,000.00 TUBE SPIRETTE EASY ONE DISP $30.00 CANNULA FEMORAL BIOMED KIT $2,597.00 SUTURE GUIDE GABBY FRATER $700.00 KNIFE MICRO UNITOME $89.00 CANNULA CORONARY OSTIAL $324.00 ADAPTER Y PERFUSION $152.00 SUTURE NUROLON TIES $135.00 GRAFT CM STANDARD WALL 8X40 $2,945.00 TAPE MEDIPORE CLOTH SURG 4" $140.00 TAPE MEDIPORE CLOTH SURG 2" $84.00 KIT ORTHOSORB RESORBABLE PIN $3,845.00 C1713 CANNULA ARTERIAL EOPA $495.00 SET PERFUSION MULTI 4 LEG $251.00 CANNULA FEMORAL VENOUS VENTED $2,597.00 CANNULA ARTERIAL 18FR ELONG $461.00 SENSOR MONITOR BIS QUATTR DISP $210.00 GUIDE WIRE LUNDERQUIST $796.00 C1769 NEEDLE ASPIRATION/INJ KIT $796.00 ENDO GIA UNIVERSAL HANDLE DISP $2,760.00 DRAPE MINOR PROCED FENESTRATED $194.00 FELT PT FE 9.5 X4.8 MM $14.00 FLOW SET RANGER HIGH $379.00 FLO SEAL MATRIX 10ML $2,580.00 SET FLOW RANGER STANDARD $152.00 KIT ENDOMETRIAL ABLATION DISP $4,735.00 BALLOON ABLATION NOVASURE DISP $5,036.00 AIRWAY RETRIEVAL BASKET $2,346.00 PACK ALGO HEAR SCREEN NEWBORN $159.00 SET ANASCOPE STANDARD DISP $486.00 KIT PRESSURE INJ MULTI LUMEN $945.00 SUCTION COAGULATOR 10FR $187.00 RELOAD TRANSVERSE ANASTAMOISIS $1,021.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
SET LUMBAR CATHETER $1,497.00 PACK LVAD/ECMO CUSTOM DISP $2,610.00 PLATE LCP CONDYLAR $4,890.00 CO SEAL SURGICAL SEALANT 4ML $3,240.00 CPAP SYSTEM DISPOSABLE $350.00 SEALANT PROGEL PLEURAL $4,962.00 C2615 KIT DBL TRANSDUCE MONITR PRESS $198.00 GRASPER MINILAP BABCOCK $2,297.00 GEL WOUND REGENECARE HA 4ML $23.00 GEL WOUND REGENECARE 1/2 OZ $57.00 GEL MEDIHONEY 1.5 OZ TUBE $179.00 DRESSING MEDIHONEY 2X2 $75.00 SUTURE TEVDEK I HEART VALVE $1,850.00 ELECTRODE EXTENDED BLADE 4" $93.00 CUTTER FLIPCUTTER $2,177.00 SUTURE PASSER WIRE $714.00 NEEDLE SCORPION $1,069.00 RETROBUTTON ALL SIZES $1,796.00 KIT TRANSITIBIAL W/BLADE DISP $1,722.00 CORKSCREW ANCHOR SUTUR FT WIRE $2,483.00 SUTURE PASSER 6TH FINGER KNOT $760.00 ANCHOR SUTURETAK BIO-COMP W TT $2,483.00 DISTAL BICEPS REPAIR IMPLANT $4,962.00 SUTURELASSO CORKSCREW CURVE $994.00 SUTURELASSO BANANA CURV SH HAN $994.00 SUTURELASSO TIGHT CURVE LT/RT $1,069.00 CANNULA NOTCH TWISTIN W/O SQUI $286.00 CANNULA TWISTIN W/O SQUIRT CAP $286.00 CANNULA PASSPORT BUTTON $324.00 FIBERWIRE BLUE W/TAPE NEEDLE $213.00 TIGERWIRE (WHITE/BLACK) #2 38" $252.00 FIBERSTICK/FIBERWIRE BLUE#2 50 $436.00 FIBERWIRE BLUE W/CONV CUT NDLE $363.00 FIBERWIRE (BLUE) #2 38" $198.00 FIBERLOOP W/STRT NEEDLE #2 15 $453.00 TIGERLOOP W/STRT NEEDLE #2 20 $453.00 FIBERTAPE BLUE END TAPE WIRE 8 $902.00 KIT MINI TIGHTROPE REPAIR $3,781.00 SCOPE WARMER BLUE HEAT DISP $106.00 CHEST TUBE AXIOM $173.00 PROBE COVER LATEX FREE DISP $185.00 THORACOPORT ALL SIZES $519.00 K-WIRE FOOT/ANKLE $276.00 PIN CAP VINYL $59.00 PACK KNEE POSITIONER DISP $348.00 IRRIGATION SYSTEM UNIVERSAL $352.00 IMMOBILIZER SHOULDER SLINGSHOT $656.00 SURGICEL NU-KIT 6X9 HEMOSTAT $1,147.00 SURGICEL HEMOSTAT 2X3 VIAL $235.00 GELFOAM SPONGE MED SURGIFOAM $171.00 NEEDLE RETRACT-O-TAPE $173.00 KIT TOURNEQUET RUMEL $84.00 FELT PT FE 2X2 $252.00 CATHETER RETRIEVAL OPT EASE $1,069.00 CATHETER RETRIEVAL CONE $3,477.00 TAPE GLOW-N-TELL $404.00 WIPES CHOLOROSCRUB (2) $2.00 INTRODUCER SHEATH DRYLOCK $2,083.00 BLADE LARYNGOSCOPE DISPOSABLE $214.00 BINDER ABDOMINAL $473.00 CATHETER DRAINAGE RESOLVE $693.00 C1769
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19
KIT CONTRAST FLUID MANAGEMENT $67.00 BAND TR HEMOSTATIS DEVICE $453.00 INTRODUCER GLIDE SHEATH 5FR $549.00 INTRODUCER GLIDE SHEATH 6F $408.00 CATHETER DIAGNOSTIC JACKY/SAR $453.00 CATHETER DIAGNOSTIC TIG $453.00 CATHETER RADIAL EBU $501.00 CATHETER RADIAL IMA $523.00 CATHETER GUIDE TWIST LOCK $185.00 SET INTRODUCER MICROPUNCT STIF $306.00 C1766 CATHETER LUBEN 5FR $431.00 CATHETER INTRACARD ECHOCARDIO $8,588.00 C1759 INTRODUCER SHEATH TORQVUE W/DS $2,887.00 SEPTAL OCCLUDER IMPLANT $20,417.00 C1817 CATHETER ARTHRECTMY DIRECTIONL $11,832.00 C1714 GUIDE WIRE VIPER ADVANCE $1,239.00 C1769 THERAPY BED-AIR RENTAL FRAME $602.00 E0194 THERAPY BED-ENVISION/VERSACARE $794.00 PUMP BLOOD THORATEC (MAYO RRT) $50,098.00 ECMO CIRCUIT CUSTOM (MAYO RRT) $2,469.00 CANNULA 27FR AVALON (MAYO RRT) $9,813.00 DRESSING MEPILEX BORDER 4 X 4 $112.00 A6212 DRESSING MEPILEX BORD LF 3X3 $82.00 A6212 DRESSING MEPILEX SFT SIL 5 X 8 $198.00 DRESSING MEPILEX 4 X 8 $173.00 DRESSING MEPILEX LITE 4 X 4 $53.00 BOTTLE PLEURX $305.00 SET EXTENSION MINIBORE $15.00 WAND PLASMA COBLATOR DISP $1,462.00 MARKER TISSUE BREAST $538.00 A4648 MESH VENTRALGHT ST BIORESO 6X8 $3,084.00 C1781 SUTURE CARTRIDGE MENISCAL $1,785.00 KIT VASCULAR DIALATOR $894.00 CANNULA ARTERIAL 21FR $361.00
Rev. 01/19
PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY