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Charge Description Master Charge_Code Charge Description Charge Amount 11033402 MED/SURG UNIT PRIVATE ROOM $1,028.00 11436002 PSYCH UNIT PRIVATE ROOM $1,638.00 12033401 MED UNIT SEMI PRIVATE $973.00 12133401 MED/SURG SEMI PRIVATE $973.00 12231301 OB LABOR DELIVERY SEMI PRIVATE $1,082.00 12231401 POST PARTUM SEMI PRIVATE $973.00 12436001 PSYCH UNIT SEMI PRIVATE $1,638.00 12437001 SENIOR CARE PSYCH UNIT SEMI PRIVATE $1,638.00 12633402 MEDICAL STABILIZATION SEMI PRIVATE $1,638.00 14133402 MED/SURG PRIVATE ROOM $1,028.00 20032102 ICU ROOM $1,649.00 20633403 MED/SURG TELEMETRY ROOM $1,028.00 25000029 STIFF NECK COLLAR $79.00 25996508 LOCM 300-399MG/ML IODINE 1ML $108.00 25996701 LOCM 300-399MG/ML IODINE,1ML $2.00 26000001 FLU VACCINE $39.00 26000005 FLU VACCINE $39.00 26963600 HYDRATION IV INFUSION, INITIAL $223.00 26963605 INIT HYDRATION 31M-1HOUR $223.00 26963615 HYDRATE IV INFUSION, ADD-ON $39.00 26963616 IV INF; HYD; EA ADD HR UP TO 8 $200.00 26963655 INITIAL INFUSION UP TO ONE HR $378.00 26963665 THER/PRO/DX IV EACH ADDTL HR (+31 $378.00 26963675 TX/PRO/DX ADDL SEQ IV INF NEW SUB $378.00 26963685 CONCURRENT INFUSION (1/VISIT) $33.00 26963720 THER/PROPH/DIAG INJ, SC/IM $39.00 26963725 IM/SQ INJECTION $39.00 26963727 THER/PROPH/DIAG INJ, SC/IM $39.00 26963735 MEDICATION ADMINISTRATION IA $222.00 26963745 THER/PROPH/DIAG INJ IV PUSH $222.00 26963755 TX/PRO/DX INJ NEW DRUG ADDON $222.00 26963765 TX/PRO/DX INJ SAME DRUG ADDON $222.00 27000001 1 1/2 INCH KARAYAD/STOMA $237.00 27000002 1 1/2 INCH STOMA POUCH $210.00 27000003 1 1/2 INCH UROSTOMY $194.00 27000004 1 3/4 INCH KARAYA SEAL $237.00 27000005 1 3/4 INCH UROSTOMY $169.00 27000006 16FR SARATOGA SUMP $67.00 27000007 2 1/2 INCH KARAYA STOMA $237.00 27000008 2 INCH KARAYA STOMA $237.00 27000009 3 INCH KARAYA STOMA $186.00 27000010 3 INCH STARTER SET $143.00 27000011 ABDOMINAL BINDERS $91.00 27000012 ABDUCTION PILLOW MED $108.00 27000013 ADULT GASTRIC LAVAGE KIT $104.00 27000014 ALCOHOL BOTTLE $13.00 27000015 ALUM. FINGER SPLINT $18.00 27000016 ANESTHETIC SPRAY $20.00 27000017 ANKLE BRACE $8.00 27000018 ARM SLING LARGE $32.00 27000019 ARM SLING MEDIUM $32.00 27000020 ARM SLING -SMALL $45.00 27000021 ARROW TWIN CATH $36.00 27000022 ARTERIAL CATH RADIAL $50.00 27000023 BAG 1 3/4 INCH STOMA $189.00 27000024 BAG-KARAYA STOMA $186.00 27000025 BAG-UROSTOMY $169.00 27000026 BAL-PACING KIT $442.00 27000027 BANDAGE - COBAN 3 INCH $12.00 27000028 BANDAGE - COBAN 4 INCH $15.00 27000029 BANDAGE - ELASTIKON 4 INCH $33.00 27000030 BDG-ACE 2IN $7.00 27000031 BDG-ACE 3IN $11.00 27000032 BDG-ACE 4IN $13.00 27000033 BDG-ACE 6IN $19.00 27000034 BDG-ADAPTIC 3X3 $6.00 27000035 BDG-ADAPTIC 3X8 $9.00 27000036 BDG-KLING 2 IN $7.00 27000037 BDG-KLING 3IN $12.00 27000038 BDG-KLING 4IN $18.00 27000039 BDG-KLING 6IN $13.00 27000040 BILE BAG $29.00 27000041 CASSETTE/WARM INJECTION $123.00 27000042 CATH QUAD LUMEN $453.00 27000043 CATH SET ASH SPLIT $575.00 27000044 CATH TROCAR $55.00 27000045 CATH-3 WAY IRRIGATION $41.00 27000046 CATH-FOLEY 30CC $35.00 27000047 CATH-FOLEY 3CC BALL $18.00 27000048 CATH-FOLEY 5CC BAG $18.00 27000049 CATH-LOUDE $28.00 27000050 CATH-MAHURKER $368.00 27000051 CATH-MIDLINE STERILE $87.00 27000052 CATH-SWAN GANZ $47.00 27000053 CATH-THORACIC $32.00 27000054 CATH-THROACIC RT ANGLE $39.00 27000055 CATH-TRAY W/O CATH $49.00 27000056 CATH-TRAY W/O CATH $41.00 27000057 CERVICAL COLLAR $45.00 27000058 CLAVICLE BRACE $66.00 27000059 COUNCILL STYLET 6FR $61.00 27000061 DISP ADULT SENSOR $130.00 27000062 DERMOPLAST SPRAY $20.00 27000063 DISP MONITOR KIT $135.00 27000064 DISP PED OXYGEN SENSOR $22.00 27000065 DISP STETHOSCOPE $4.00 27000066 DOMES TRANSDUCER $33.00 27000067 DRAINS PENROSE $8.00 27000068 DRSD-MICROSPORE 3.5 X 8 $3.00 27000069 DRSG-ADAPTIC 1"" BOTTLE $28.00 27000070 DRSG-ADAPTIC 1/2"" BOTTLE $18.00 27000071 DRSG-ADAPTIC 2"" BOTTLE $28.00 27000072 DRSG-DUO-DERM 4X4 $19.00 27000073 DRSG-DUO-DERM 8X8 $85.00 27000074 DRSG-INSTRUMENT SET DISP $33.00 27000075 DRSG-TRANS LARGE $6.00 27000076 DRSG-TRANS MEDIUM $12.00 27000077 DRSG-TRANS SMALL $16.00 27000078 EAR WICK 12.24 $21.00 27000079 EAR WICK 9.15 $12.00 27000080 EAR WICK 9.24 $15.00 27000081 EPISTAXIS NASAL BALLOON $32.00 27000083 FEED TUBE INFANT $20.00 27000084 FINGER ANCHOR $16.00 27000085 FINGER SPLINT $22.00 27000086 FOOT DROP BOOT $173.00 27000087 GASTROSTOMY TUBE $168.00 27000088 GAUZE VASELINE 1.5""X72"" $35.00 27000089 GELFOAM 100 $110.00 27000090 GELFOAM 50 $74.00 27000091 HEIMLICH VALVE $23.00 27000092 HEMATERIA-CATH $32.00 27000093 IMMOBILIZER KNEE POST OP $16.00 27000094 IMMOBILIZER SHOULDER $58.00 27000095 INTRAOSSEOUS NEEDLE $87.00 27000096 IODOFOAM PACKING 1/4 INCH $22.00 27000097 IRRIG W.W. 3000CC $8.00 27000098 IRRIGATION 3000CC GYLCINE $11.00 27000099 IRRIGATION DRAINAGE BAG $25.00 27000100 IRRIGATION START SET $56.00 27000101 IRRIGATION T.U.R. SET $48.00 27000102 K PAD - LG, MED, SM $63.00 27000103 K THERMIA PAD $119.00 27000104 KNEE BRACE $13.00 27000107 MATTRESS; DISP W/AIR PUMP $82.00 27000108 MINNESITA TUBE $338.00 27000109 MISC-LARYNGOSCOPE $19.00 27000110 MISC-URI-METER $106.00 27000111 MONOMETER SET $80.00 27000112 MULTI LUNEN KIT $35.00 27000113 NASAL TAMPON MED $18.00 27000114 NU GAUZE 1/4IN / 1/2 IN $19.00 27000115 NU GAUZE 1IN / 2 IN $26.00 27000116 NUGAUZE IODO 1 INCH $22.00 27000117 NUGAUZE IODO 1/2 INCH $22.00 27000118 O B PACK $111.00 27000119 ORTHO SHOES $25.00 27000120 PACE TD SWAN-GANZ $877.00 27000121 PASTE/ADAPT HOLLISTER $16.00 27000122 PEDS GASTRIC LAVAGE KIT $12.00 27000123 PENROSE DRAIN $8.00 27000124 PLASTIC SUTURE $25.00 27000125 PLEUR EVAC SET UP $42.00 27000126 PNEUMATIC HOSE $311.00 27000127 PNEUMOTHORAX KIT $135.00 27000128 PORT A CATH HUBERT NEEDLE $29.00 27000129 POSITIVE DISPLACEMENT VALVE $55.00 27000130 PRESSURE MONT KIT $48.00 27000131 PREVENOUS LEAD $71.00 27000132 PUDENAL BLOCK $69.00 27000133 RAPID RHINO LARGE $76.00 27000134 RAPID RHINO MEDIUM $65.00 27000135 RAPID RHINO SMALL $68.00 27000136 RESI BAG PEDS $6.00 27000137 RESSIC BAG DISP ADULT $84.00 27000138 RHINO ROCKETT SM/MED $47.00 27000139 SARATOGA SUMP 20X12 $81.00 27000140 SCROTAL SUPPORT $20.00 27000141 SECURITY POUCH 1 25 INCH $74.00 27000142 SEQ COMPRESSION SLEEVE - LG $77.00 27000143 SEQ. COMPRESSION SLEEVE - MED $65.00 27000144 SET-SUTURE REMOVAL $11.00 27000145 SKIN STAPLER SMALL $19.00 27000146 STAPLE REMOVER $19.00 27000147 STERI-STRIP 1/2 $13.00 27000148 STERI-STRIP 1/4 $13.00 27000149 STOMA BAG 1 25" I6MED $101.00 27000150 T.E.D. HOSE $41.00 27000151 THORACENTESIS/PARACENTESIS $87.00 27000152 THOROCENTHESIS KIT $33.00 27000153 THUMP SPICA $58.00 27000154 TRACTION PELVIC BELT $6.00 27000155 TRANS PACING KIT $406.00 27000156 TRANSDUCER W/MONITOR $193.00 27000157 TRAU-SPINALDISP. $114.00 27000158 TRAY AMNIOCENTESIS $57.00 27000159 TRAY BIOPSY $62.00 27000160 TRAY BONE MARROW BIOPSY $53.00 27000161 TRAY CATHETER SWAN GANZ DISP $47.00 27000162 TRAY CVP $12.00 27000163 TRAY CYSTO CATH $59.00 27000164 TRAY DISP PNEUMOTHORAX $135.00 27000165 TRAY ER SUTURE $62.00 27000166 TRAY FOLEY 16 FR $44.00 27000167 TRAY LACERATION $15.00 27000168 TRAY PERCUTANEOUS $80.00 27000169 TRAY UMBILICAL CATH $104.00 27000170 TRAY/LUMBAR PUNCTURE $108.00 27000171 TRAY-PARACENTESIS $62.00 27000172 TRAY-SIGMOIDSCOPE $57.00 27000173 TRAY-THOROCENTESIS $74.00 27000174 TUBE CONNECTING 18 INCH $3.00 27000175 TUBE CONNECTING 72 INCH $5.00 27000176 TUBE-ENOD TRACH $42.00 27000177 TUBE-ESOPHAGEAL $458.00 27000178 UNNA BOOT $18.00 27000179 UROMETERS $20.00 27000180 UROSTOMY BAG 16 MED $74.00 27000181 V PADS $13.00 27000182 WALL SUCTION CANISTER $99.00 27000183 WRIST SPLINT $75.00 27000184 QUINTON CATHETER-DUAL LUNAM $585.00 27000185 SINGLE LUMEN CATHETER $77.00 27000186 PER SHEATH INTRO KIT $111.00 27000187 TRANSVENOUS PACING $643.00 27000188 CATHETER DIAGNOSTIC BSI CCL $77.00 27000189 CATHETER; THERMODILUTION $427.00 27000190 SHEATH DIAGNOSTIC $30.00 27000192 SUPRAPUBIC CATHETER SET $245.00 27000206 FULL DAY OF OXYGEN $65.00 27000210 PARTIAL DAY OF OXYGEN $40.00 27000235 LOCAL TRAY $104.00 27000236 E.STIM ELECTRODES $33.00 27000237 LEUKOTAPE $46.00 27000238 ORTHO CANE $24.00 27000239 ORTHO CRUTCHES $124.00 27000240 THERABAND/TUBING - YD $14.00 27000241 THERAPUTTY $14.00 27000242 E.STIM ELECTRODES $33.00 27000243 LEUKOTAPE $46.00 270002430 E.STIM ELECTRODES $33.00 27000244 ORTHO CANE $24.00 27000245 ORTHO CRUTCHES $124.00 27000246 THERABAND/TUBING - YD $14.00 27000247 THERAPUTTY $14.00 270002478 THERAPUTTY $14.00 27000248 E.STIM ELECTRODES $33.00 27000249 LEUKOTAPE $46.00 27000250 ORTHO CANE $24.00 27000251 ORTHO CRUTCHES $124.00 27000252 THERABAND/TUBING - YD $14.00 27000253 THERAPUTTY $14.00 27000300 ACCUGRID $49.00 27000301 ADHESION BARRIER (INTERCEED) $714.00 27000302 ARCH BARS $27.00 27000303 ARTHROSCOPY STAPLE $568.00 27000304 AUTOSUTURE CEEA-28 & 31 $1,308.00 27000305 BALANCE SALT SOLUTION $7.00 27000306 BALDE; RECIPROCATING $127.00 27000307 BALDE;DERMATONE;SMAL $55.00 27000308 BARD FOLEY 2 WAY $9.00 27000309 BARD FOLEY 3 WAY $9.00 27000310 BARD IMPLANTABLE MESH $1,566.00 27000311 BARD MALECOTS DRAINS $22.00 27000312 BARD POWER PORT $2,271.00 27000313 BIFURCATED GRAFT $402.00 27000314 BIGLIAN HUMERAL HEAD $2,242.00 27000315 BIGLIAN HUMERAL STEM $4,754.00 27000316 BIOCOAG BIPOLAR FORC $390.00 27000317 BIOMET HUMERAL HEAD $2,271.00 27000318 BIOMET HUMERAL STEM $4,785.00 27000319 BIOPOLAR;CUP;MULITPO $2,996.00 27000320 BLADE; OSCILLATING $179.00 27000321 BLADES;OPTHALMIC;BEA $93.00 27000322 BONE CEMENT $104.00 27000323 BONE PLUG $104.00 27000324 BONE STAPLE $8.00 27000325 BUTTON; NASAL SEPTAL $461.00 27000326 BUTTON; NASAL SINGLE $416.00 27000327 CANCELLOUS
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