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Hugh Chatham Memorial Hospital, Inc. Charge Listing Effective October 1, 2020 Revised 10/01/2020

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Hugh Chatham Memorial Hospital, Inc. Charge Listing Effective October 1, 2020 Revised 10/01/2020 HUGH CHATHAM MEMORIAL HOSPITAL, INC. CHARGE LISTING EFFECTIVE OCTOBER 1, 2020 REVISED 10/01/2020 CHARGE REVENU SUM NUMBER CHARGE DESCRIPTION E CODE CODE CPT CODE PRICE MED-SURG DEPARTMENTS 44493225 ZIO HOOK UP > 48 HOURS (2ND FLOOR) 730 64 0296T $ 456.50 44436591 VAD- INTERNAL-SPECIMEN COLLECTION 761 8A 36591 $ 247.50 44496523 VAD- FLUSH ONLY 761 8A 96523 $ 67.50 44436592 VAD- EXTERNAL-SPECIMEN COLLECTION 761 8A 36592 $ 100.00 44436593 VAD - DECLOT 761 8A 36593 $ 675.00 44490472 VACCINE ADMINISTRATION EACH ADDITIONAL 771 7N 90472 $ 72.00 44490471 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 60.75 44492977 THROMBOLYTIC ADMIN CORONARY 480 68 92977 $ 1,396.50 44432554 THORACENTESIS, NEEDLE OR CATH ASPIRATION 940 77 32554 $ 1,574.75 44400140 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 287.75 44400111 TELE-PSYCH WITH IVC 510 28 Q3014 $ 287.75 44499986 TELEMETRY 2ND FL PATIENTS 732 TM $ 89.50 49900112 SPEC COLLECTION SEVERE ACUTE RESPIRATORY 306 50 G2023 $ 46.75 44496415 REMICADE EACH ADDL HOUR 335 29 96415 $ 81.75 44499990 PULSE OX MONITORING 732 TM $ 105.25 49903553 PHASE III RECOVERY EA ADDL HR 710 36 $ 29.00 49903552 PHASE III RECOVERY 1ST HOUR 710 36 $ 214.00 49903556 PHASE 2 RECOVERY EA ADDL HR 710 36 $ 29.00 49903555 PHASE 2 RECOVERY 1ST HOUR 710 36 $ 214.00 44449082 PARACENTESIS 940 77 49082 $ 1,687.50 44400141 OUTPATIENT CLINIC VISIT 510 28 G0463 $ 216.00 44496368 IV THERAPY INFUSION, CONCURRENT 940 77 96368 $ 67.50 44490781 IV THERAPY INFUSION EACH ADDL HR 940 77 96366 $ 45.00 44496367 IV SEQUENTIAL INFUSION/NEW DRUG 940 77 96367 $ 67.50 44431110 IV PUSH INJECTION, INITIAL DRUG 940 77 96374 $ 225.00 44431112 IV PUSH INJECTION, EACH ADDL SEQUENTIAL 940 77 96375 $ 45.00 44496376 IV PUSH INJECTION, EACH ADDL SAME DRUG 940 77 96376 $ 39.50 44490784 IV INFUSION FOR THERAPY 1ST HOUR 260 47 96365 $ 320.25 44403151 IV HYDRATION INITIAL, UP TO 1 HOUR 940 77 96360 $ 371.25 44490761 IV HYDRATION EACH ADDL HOUR 260 47 96361 $ 81.50 44436556 INSERTION OF CENTRAL LINE, NON TUNNELED 940 77 36556 $ 1,105.75 44432556 INSERT CATH PLEURA W/O IMAGE 940 77 32556 $ 3,262.25 44451702 INDWELLING URINARY CATH INSERTION 761 OF 51702 $ 236.25 44451701 IN/OUT CATH (FOR RESIDUAL) 761 OF 51701 $ 236.25 44490782 IM SUBQ INJECTION 940 77 96372 $ 67.50 44490379 DIRECT ADMISSION TO OBSERVATION 762 TR G0379 $ 4,650.00 44409612 CATH/ URINE SPECIMEN COLLECTION 300 55 P9612 $ 37.75 44499991 CAPILLARY BLOOD COLLECTION 300 55 36416 $ 9.50 44431040 BLOOD ADMIN. 4 UNITS 391 61 36430 $ 1,744.50 44431030 BLOOD ADMIN. 3 UNITS 391 61 36430 $ 1,426.50 44431020 BLOOD ADMIN 2 UNITS 391 61 36430 $ 1,036.25 44431070 BLOOD ADMIN 1 UNIT 391 61 36430 $ 652.75 44451778 BLADDER SCAN (PHYSICIAN ORDERED) 761 8A 51798 $ 126.00 44490008 ADMINISTRATION PNEUMONIA VACCINE 771 7N G0009 $ 45.00 44496413 ADMINISTRATION OF REMICADE 1ST HOUR 335 29 96413 $ 558.00 44490791 ADMINISTRATION FLU VACCINE 771 7N G0008 $ 45.00 44490009 ADM PNEUMONIA VACCINE 771 7N G0009 $ 45.00 49903668 2ND FL OBSERATION PER HOUR 762 TR G0378 $ 34.50 44499985 PROCEDURE CHARGE 761 8A $ 540.50 33393225 ZIO HOOK UP> 48 HOURS (3RD FLOOR) 730 64 0296T $ 456.50 33336591 VAD-INTERNAL-SPECIMEN COLLECTION 761 8A 36591 $ 247.50 33336592 VAD-EXTERNAL-SPECIMEN COLLECTION 761 8A 36592 $ 100.00 33336593 VAD-DECLOT 761 8A 36593 $ 675.00 33396523 VAD - FLUSH ONLY 761 8A 96523 $ 67.50 33390471 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 60.75 33390472 VACCINE ADMINISTRAION EACH ADDITIONAL 771 7N 90472 $ 72.00 33332554 THORACENTESIS, NEEDLE OR CATH ASPIRATION 940 77 32554 $ 1,574.75 49900120 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 287.75 49900111 TELE-PSYCH WITH IVC 510 28 Q3014 $ 287.75 33399986 TELEMETRY 3RD FL PATIENT 732 TM $ 89.50 33300112 SPEC COLLECTION SEVERE ACUTE RESPIRATORY 306 50 G2023 $ 46.75 44490690 PULSE OX MONITOR 732 TM $ 105.25 49903554 PHASE III RECOVERY EA ADDL HR 710 36 $ 29.00 49903557 PHASE III RECOVERY 1ST HOUR 710 36 $ 214.00 49903566 PHASE 2 RECOVERY EA ADDL HR 710 36 $ 29.00 49903565 PHASE 2 RECOVERY 1ST HOUR 710 36 $ 214.00 33349082 PARACENTESIS 940 77 49082 $ 1,687.50 44403141 OUTPATIENT CLINIC VISIT 510 OC G0463 $ 216.00 33396368 IV THERAPY INFUSION, CONCURRENT 940 77 96368 $ 67.50 33390781 IV THERAPY INFUSION EACH ADDL HOUR 940 77 96366 $ 45.00 33331112 IV PUSH INJECTION, EACH ADDL SEQUENTIAL 940 77 96375 $ 45.00 44403133 IV PUSH INJECTION INITIAL DRUG 940 77 96374 $ 225.00 33331111 IV PUSH INJECTION EA ADDL SAME DRUG 940 77 96376 $ 39.50 33396367 IV ISEQUENTIAL INFUSION/NEW DRUG 940 77 96367 $ 67.50 33390762 IV INFUSION FOR THERAPY 1ST HOUR 940 77 96365 $ 320.25 33390760 IV HYDRATION INITIAL, UP TO 1 HOUR 940 77 96360 $ 371.25 33090761 IV HYDRATION EACH ADDL HOUR 940 77 96361 $ 81.50 33336556 INSERTION OF CENTRAL LINE NON TUNNELED 940 77 36556 $ 1,105.75 33332556 INSERT CATH PLEURA W/O IMAGE 940 77 32556 $ 3,262.25 33351702 INDWELLING UINARY CATH INSERTION 761 8A 51702 $ 236.25 33351701 IN & OUT CATH (FOR RESIDUAL) 761 OF 51701 $ 236.25 33371080 IM SUBJ INJECTION 940 77 96372 $ 67.50 33390379 DIRECT ADMISSION TO OBSERVATION 762 TR G0379 $ 4,650.00 33379241 CONSULTATION-F/U <10 MINUTES 761 8A 99201 $ 160.50 33379244 CONSULTATION/FOLLOW-UP (46-60 MINS.) 761 8A 99204 $ 705.75 33379243 CONSULTATION/FOLLOWUP (31-45) MINUTES 761 OF 99203 $ 238.25 33377242 CONSULTATION/FOLLOW UP (10-30 MINUTES) 761 8A 99201 $ 160.50 33379242 CONSULTATION/FOLLOW UP (10-30 MIN) 761 8A 99202 $ 160.50 33379240 CONSULTATION (W/MD DOCUMENTATION) 761 8A 99201 $ 160.50 33379612 CATH/ URINE SPECIMEN COLLECTION 300 55 P9612 $ 37.75 33390010 CAPILLARY BLOOD COLLECTION 300 55 36416 $ 9.50 44403158 BLOOD ADMIN. 4 UNITS 391 61 36430 $ 1,744.50 44403155 BLOOD ADMIN 3 UNITS 391 61 36430 $ 1,426.50 44403154 BLOOD ADMIN 2 UNITS 391 61 36430 $ 1,036.25 44403145 BLOOD ADMIN 1 UNIT 391 61 36430 $ 652.75 33351778 BLADDER SCAN (PHYSICIAN ORDER) 761 8A 51798 $ 126.00 33900009 ADMINSTRATION PNEUMONIA VACCINE 771 7N G0009 $ 45.00 33396413 ADMINISTRATION REMICADE 1ST HOUR 335 29 96413 $ 558.00 44403156 ADMINISTRATION OF REMICADE 1ST HOUR 335 29 96413 $ 558.00 33390008 ADMINISTRATION FLU VACCINE 771 7N G0008 $ 45.00 49903658 3RD FL OBSERVATION PER HOUR 762 TR G0378 $ 34.50 33396414 REMICADE EACH ADDL HOUR 335 29 96415 $ 81.75 33379985 PROCEDURE CHARGE 761 8A $ 540.50 49936591 VAD-INTERNAL SPECIMEN COLLECTION 761 8A 36591 $ 247.50 49936592 VAD-EXTERNAL-SPECIMEN COLLECTION 761 8A 36592 $ 100.00 49996523 VAD- FLUSH ONLY 761 8A 96523 $ 67.50 49936593 VAD DECLOT 761 8A 36593 $ 675.00 44403203 VACCINE ADMINISTRATION EACH ADDITIONAL 771 7N 90472 $ 72.00 44403176 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 60.75 49932554 THORACENTESIS, NEEDLE OR CATH ASPIRATION 940 77 32554 $ 1,574.75 44400220 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 287.75 44400210 TELE-PSYCH WITH IVC 510 28 Q3014 $ 287.75 44400112 SPEC COLLECTION SEVERE ACUTE RESPIRATORY 306 50 G2023 $ 46.75 44964130 REMICADE EA ADDL HOUR 335 29 96415 $ 81.75 44490890 PULSE OX MONITOR 732 TM $ 105.25 49903547 PHASE III RECOVERY EA ADDL HOUR 710 36 $ 29.00 49903542 PHASE III RECOVERY 1ST HOUR 710 36 $ 214.00 49903564 PHASE 2 RECOVERY EA ADDL HOUR 710 36 $ 29.00 49903563 PHASE 2 RECOVERY 1ST HOUR 710 36 $ 214.00 49949082 PARACENTESIS 940 77 49082 $ 1,687.50 49996368 IV THERAPY INFUSION, CONCURRENT 940 77 96368 $ 67.50 44403159 IV THERAPY INFUSION EACH ADDL HOUR 940 77 96366 $ 45.00 49996367 IV SEQUENTIAL INFUSION/NEW DRUG 940 77 96367 $ 67.50 44403172 IV PUSH INJECTION, INITIAL DRUG 940 77 96374 $ 225.00 33371050 IV PUSH INJECTION, EACH ADDL SEQUENTIAL 940 77 96375 $ 45.00 44996376 IV PUSH INJECTION, EA ADDL SAME DRUG 940 77 96376 $ 39.50 44403165 IV INFUSION FOR THERAPY 1ST HOUR 260 47 96365 $ 320.25 44407152 IV HYDRATION INITIAL UP TO 1 HOUR 940 77 96360 $ 371.25 44403152 IV HYDRATION EACH ADDL HOUR 940 77 96361 $ 81.50 49936556 INSERTION OF CENTRAL LINE NON TUNNELED 940 77 36556 $ 1,105.75 49932556 INSERT CATH PLEURA W/O IMAGE 940 77 32556 $ 3,262.25 44403140 IM SUBQ INJECTION 940 77 96372 $ 67.50 23360004 ICU PARTIAL DAY CHG PER HOUR 233 15 $ 35.75 23300001 ICU PARTIAL DAY 1ST 4 HRS. 233 15 $ 144.00 49903638 ICU OBSERVATION PER HOUR 762 TR G0378 $ 34.50 44493000 EKG (ICU) 730 64 93005 $ 208.25 49990379 DIRECT ADMISSION TO OBSERVATION 762 TR G0379 $ 4,650.00 44403134 CATH/ URINE SPECIMEN COLLECTION 300 55 P9612 $ 37.75 44490001 CAPILLARY BLOOD COLLECTION 300 55 36416 $ 9.50 44403168 BLOOD ADMIN. 4 UNITS 391 61 36430 $ 1,744.50 44403162 BLOOD ADMIN 3 UNITS 391 61 36430 $ 1,426.50 44403164 BLOOD ADMIN 2 UNITS 391 61 36430 $ 1,036.25 44403163 BLOOD ADMIN 1 UNIT 391 61 36430 $ 652.75 44451798 BLADDER SCAN PHYSICIAN ORDER 761 8A 51798 $ 126.00 44964150 ADMINISTRATION REMICADE 1ST HOUR. 335 29 96413 $ 558.00 68200009 ADMINISTRATION PNEUMONIA VACCINE 771 7N G0009 $ 45.00 44490792 ADMINISTRATION FLU VACCINE 771 7N G0008 $ 45.00 CHARGE REVENU SUM NUMBER CHARGE DESCRIPTION E CODE CODE CPT CODE PRICE OB DEPARTMENT 44403202 VACCINE ADMINISTRATION EACH ADDITIONAL 771 7N 90472 $ 72.00 44403199 VACCINE ADMINISTRATION (ONE ONLY) 771 7N 90471 $ 60.75 44400150 TELE-PSYCH WITHOUT IVC 510 28 Q3014 $ 287.75 44400110 TELE-PSYCH WITH IVC 510 28 Q3014 $ 287.75 44490789 TELEMETRY OB PATIENT 732 TM $ 89.50 72000112 SPEC COLLECTION SEVERE ACUTE RESPIRATORY 306 50 $ 46.75 30036416 REPEAT PKU LAB TEST 300 55 84030 $ 68.75 44403157 REMICADE EACH ADDL HOUR 335 29 96415 $ 81.75 47192552 PURE TONE AIR CONDUCTION THRESHOLD 471 8F 92551 $ 180.75 44403126 PULSE OX MONITOR 732 TM $ 105.25 49903541 PHASE III RECOVERY EA ADDL HOUR 710 36 $ 29.00 49903537 PHASE III RECOVERY 1ST HOUR 710 36 $ 214.00 49903562 PHASE 2 RECOVERY EA ADDL
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