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CDM HOSPITAL WEBSITE.062921.Xlsx GMHA FEE SCHEDULE UPDATED - JUNE 29, 2021 CHARGE CPT/HCPCS CHARGE CODE CODE DESCRIPTION RATE 01501000 ROOM & BOARD ICU$ 1,880.56 01501001 ROOM & BOARD NURSERY$ 536.20 01501002 ROOM & BOARD INTMED NURSERY$ 807.89 01501003 ROOM & BOARD NICU$ 1,219.32 01501004 ROOM & BOARD TELEMETRY$ 1,056.29 01501006 ROOM & BOARD PICU$ 1,623.29 01501008 ROOM & BOARD MED/SURG PRIVATE$ 804.94 01501009 ROOM & BOARD MED/SURG SEMI-PRI$ 731.07 01501011 ROOM & BOARD MEDICAL PRIVATE$ 868.65 01501012 ROOM & BOARD MEDICAL SEMI-PRIV$ 794.78 01501014 ROOM & BOARD PEDS PRIVATE$ 1,081.77 01501015 ROOM & BOARD PEDS SEMI-PRIVATE$ 1,007.92 01501017 ROOM & BOARD OB/GYN PRIVATE$ 887.39 01501018 ROOM & BOARD OB/GYN SEMI-PRIVA$ 813.51 01501020 ROOM & BOARD SURGICAL PRIVATE$ 846.89 01501021 ROOM & BOARD SURGICAL SEMI-PRI$ 773.02 01501055 ROOM & BOARD SNF$ 585.89 01501057 ROOM & BOARD ICF$ 486.29 01511006 ROOM & BOARD PCU$ 1,468.43 00900088 PHYSICAL EXAM-ANNUAL$ 125.42 00900178 99283 ER-OB/GYN SERVICE FEE$ 265.87 00900185 99282 ER-SPECIALTY SERVICE FEE$ 151.16 00900194 99285 ER-TRAUMA SERVICE FEE$ 1,476.89 00900227 99281 EMERGENCY ROOM$ 99.70 00900243 99284 ER-OBSERVATION SERVICE FEE$ 447.32 00900761 A4649 KNEE BRACE WRAPAROUND-XLGE$ 125.96 00900762 A4649 KNEE BRACE WRAPAROUND-MED$ 125.96 00900763 A4649 KNEE BRACE WRAPAROUND-SML$ 125.96 00900764 A4649 KEE BRACE WRAPAROUND-LGE$ 125.96 00900876 A4649 GLIDESCOPE SPECTRUM PEDS SZ-1$ 319.50 00900877 A4649 GLIDESCOPE SPECTRUM PEDS SZ-2$ 319.50 00901021 A4565 SLING ARM ENVELOPE SML$ 32.56 00901022 A4565 SLING ARM ENVELOPE MED$ 32.56 00901056 A4649 ANOSCOPE DISP$ 13.35 00901152 A4649 STRAP CLAVICLE-SMALL$ 90.22 00901153 A4649 STRAP CLAVICLE-MEDIUM$ 94.73 1 00901154 A4649 STRAP CLAVICLE-LARGE$ 94.73 00901155 A4649 STRAP CLAVICLE-XLARGE$ 94.73 00901223 A4565 SLING ARM ENVELOPE LGE$ 32.56 00901224 A4565 SLING ARM ENVELOPE XLGE$ 32.56 00901282 A4649 CATHETER BARTHOLIN GLAND 10/12$ 126.87 00901289 A4649 INTRODUCER ENDOTRACHEAL TUBE$ 30.07 00902000 A4649 MORGAN MEDI-FLO LENS$ 147.63 00909001 A4649 SET NEEDLE EZ-IO 25MM BLUE$ 625.79 00909018 A4649 SET NEEDLE EZ-IO 15MM PINK$ 625.79 00909079 A4649 SET NEEDLE EZ-IO 45MM YELLOW$ 625.79 00910047 A4649 SUCTION CUP LUCAS DISP$ 225.80 00910202 A4649 MORGAN LENS DELIVERY SET$ 42.81 00910221 A4649 SPANDAGE MTF2 /FT$ 7.04 00910222 A4649 SPANDAGE MTO1 /FT$ 7.04 00910223 A4649 SPANDAGE MTO2 /FT$ 7.04 00910224 A4649 SPANDAGE MTO3 /FT$ 7.04 00910225 A4649 SPANDAGE MTO4 /FT$ 7.04 00910226 A4649 SPANDAGE MTO5 /FT$ 7.04 00910227 A4649 SPANDAGE MTO6 /FT$ 7.04 00910228 A4649 SPANDAGE MTO7 /FT$ 7.04 00910229 A4649 SPANDAGE MT22 /FT$ 7.04 00910230 A4649 SPANDAGE MTO8 /FT$ 7.04 00910942 A4649 SET ADMIN GRAVITY FLOW$ 47.12 00911010 A4649 SPONGE RHINO ROCKET XLGE$ 108.87 00911270 A4649 GAUZE SURGITUBE 5/8/2FT$ 1.37 00911272 A4649 GAUZE SURGITUBE 1/2FT$ 1.70 00911300 A4649 SPONGE RHINO ROCKET SML$ 74.04 00911500 A4649 SPONGE RHINO ROCHET MED$ 83.52 00911800 A4649 SPONGE RHINO ROCKET LGE$ 96.80 00911891 A4649 GLIDESCOPE BFLEX 5.0 BRONCHO$ 839.25 00911892 A4649 GLIDESCOPE SPECTRUM LOPRO S3$ 245.77 00911893 A4649 GLIDESCOPE SPECTRUM LOPRO S4$ 245.77 00912140 A4649 LARYNGEAL MASK AIRWAY S-4$ 303.78 00912142 A4649 PACK NASAL RHINO 5.5CM ANT #55$ 276.60 00912147 A4649 PACK NASAL RHINO 7.5CM A-P BIL$ 197.34 00912149 A4649 PACK NASAL RHINO 7.5CM A-P BIL$ 653.63 00912150 A4649 LARYNGEAL MASK AIRWAY S-5$ 303.78 00920151 S9088 URGENT CARE FEE$ 80.41 00972941 A4649 EXTRACTOR FB OTO-RHINO REMOVER$ 512.45 01100049 MED REC COPIES </=10 COPIES$ 25.36 01100064 MED REC COPIES >10-PER PAGE$ 2.48 01104001 ITEMIZED BILLING=1-5COPIES$ 6.70 2 01104002 ITEMIZED BILLING=>5-PER COPY$ 1.01 01195001 HOSPITAL BIRTH CERTIFICATE$ 6.70 01195002 CERTIFICATION OF DEATH$ 3.36 01300440 A4649 BILIRUBIN THERAPY$ 29.26 01300606 A4649 CHIN STRAP-MICRO$ 31.40 01300607 A4649 CHIN STRAP-SMALL$ 31.40 01300608 A4649 TUBING-CANNULA HOLDER$ 7.86 01300609 A4649 NASAL PRONG SEAL-MICRO$ 2.70 01300610 A4649 NASAL PRONG SEAL-SMALL$ 2.70 01300611 A4649 NASAAL PRONG SEAL-LARGE$ 2.70 01300700 A4649 UMBILICAL CATHETER HOLDER-MICR$ 36.99 01300701 A4649 UMBILICAL CATHETER HOLDER-SML$ 36.99 01301038 A4649 NEO-FIT ET TUBE GRIP$ 111.33 01303336 A4649 MASK BILIRUBIN$ 31.08 01310449 A4649 CANNULA NASAL CPAP SZ-0$ 117.71 01310450 A4649 CANNULA NASAL CPAP SZ-1$ 117.71 01310451 A4649 CANNULA NASAL CPAP SZ-2$ 117.71 01311865 J3490 BABY SHAMPOO 120ML$ 4.87 01332100 A4649 TRAY PER-Q-CATH SINGLE-LUMEN 2$ 292.08 01335000 A4649 TRAY NEO V-CATH SINGLE-LUMEN 2$ 741.91 01370206 A4649 ORAL-NASAL SUCTION-CRV PREEMIE$ 15.98 01370207 A4649 ORAL-NASAL SUCTION-CRV STD$ 15.98 01370710 A4649 NEONATE ET HOLDER-ULTRA$ 80.80 01370711 A4649 NEONATE ET HOLDER-MICRO$ 80.80 01370712 A4649 NEONATE ET HOLDER-SMALL$ 80.80 01370713 A4649 NEONATE ET HOLDER-LARGE$ 80.80 01370714 A4649 NEONATE ET HOLDER-X-LARGE$ 80.80 01370742 A4649 CATHETER SUCTION ARGYLE 10FR$ 88.90 01392585 92652 NB HEARING SCREEN 2ND STEP$ 146.76 01392587 92587 NB HEARING SCREEN IST STEP$ 191.65 01395001 A4649 PEDS INTUBATION KIT 3.0$ 38.07 01395002 A4649 PEDS INTUBATION KIT 3.5$ 38.07 01395003 A4649 IV PUMP SET (SYRINGE)$ 39.71 01395004 A4649 IV PUMP SET (TUBING)$ 33.09 01395005 A4649 MICROBORE 60 EXT SET$ 12.97 01395006 A4649 PEDS INTUBATION KIT 2.5$ 50.96 01395007 A4649 T-CONNECTOR WITH M.L.S.$ 9.19 01396001 A4649 MASK OXYGEN-INFANT$ 31.03 01400010 0001A PFIZER-BIONTECH VACC ADMIN IST$ 16.94 01400020 0002A PFIZER-BIONTECH VACC ADMIN 2ND$ 28.39 01400110 0011A MODERNA VACCINE ADMIN 1ST$ 16.94 01400120 0012A MODERNA VACCINE ADMIN 2ND$ 28.39 3 01400236 M0239 BAMLANIVIMAB IV INFUSE/MONITOR$ 309.60 01400310 0031A JANSSEN VACCINE ADMIN$ 28.39 01410060 10060 I&D ABSCESS; SIMPLE OR SINGLE$ 216.97 01411042 11042 DEBRIDE SUBQ TISSUE 20 SQ CM/<$ 379.28 01411043 11043 DEBRIDE MUSC/FASCIA 20 SQ CM/<$ 379.28 01411044 11044 DEBRIDE BONE 20 SQ CM/<$ 1,107.28 01411045 11045 DEB SUBQ TISSUE ADD 20 SQ CM$ 72.33 01411046 11046 DEB MUSC/FASCIA ADD 20 SQ CM$ 154.40 01411047 11047 DEB BONE ADD 20 SQ CM$ 274.83 01429105 29105 LONG ARM SPLINT (SHOULDER HAND$ 178.24 01429125 29125 SHORT ARM SPLINT STATIC$ 120.03 01429126 29126 SHORT ARM SPLINT DYNAMIC$ 146.55 01429130 29130 FINGER SPLINT STATIC$ 84.35 01429131 29131 FINGER SPLINT DYNAMIC$ 98.25 01429240 29240 STRAPPING SHOULDER$ 131.09 01429260 29260 STRAPPING ELBOW/WRIST$ 111.42 01429280 29280 STRAPPING HAND/FINGER$ 109.06 01429505 29505 LONG LEG SPLINT (THIGH/ANKLE)$ 221.64 01429515 29515 SHORT LEG SPLINT (CALF/FOOT)$ 150.42 01431500 31500 INTUBATION$ 173.84 01431603 31603 TRACHEOSTOMY EMERG TRANSTRCHL$ 866.26 01431605 31605 TRACHEOSTOMY EMERG CRICOTHYRD$ 866.26 01431622 31622 DX BRONCOSCOPE W/ WASH$ 1,413.42 01431623 31623 DX BRONCOSCOPE W/ BRUSH$ 1,413.42 01431624 31624 DX BRONCOSCOPE W/ LAVAGE$ 1,413.42 01436420 36420 VEIN ACCESS CUTDOWN <1 YR$ 176.46 01436450 36450 EXCHNG BLOOD TRNSFUSE NEWBORN$ 398.24 01436625 36625 ARTERIAL CATH/CANNULA CUTDOWN$ 286.30 01443753 43753 NG/OG PLACEMENT$ 69.39 01451701 51701 INSERT BLADDER CATHETER$ 176.46 01451702 51702 FOLEY OR I&O CATH$ 90.03 01451798 51798 BLADDER SCANNING, NON-IMAGING$ 61.64 01486580 86580 TB SKIN TEST$ 24.00 01490471 90471 IMMUNIZATION 1 VACCINE$ 28.67 01490472 90472 IMMUNIZATION EACH ADD VACCINE$ 19.62 01492950 92950 CODE 72 (ARREST) PCV$ 319.00 01492953 92953 TEMP TRANCUTANEOUS PACING$ 630.27 01492960 92960 DEFIBRILLATION/CARDIOVERSION$ 630.53 01496360 96360 IV INFUS HYDR;31 MIN TO 1 HR$ 111.63 01496361 96361 IV INFUS HYDR;EA ADD HOUR$ 40.74 01496365 96365 IV INFUS TX; UP TO 1 HOUR$ 135.75 01496366 96366 IV INFUS TX;EA ADD HOUR$ 55.07 4 01496367 96367 IV INFUS TX; ADD DRUG UP 1 HR$ 81.45 01496368 96368 IV INFUS TX;CONCURRENT INFUS$ 45.24 01496372 96372 TX INJ SQ OR IM$ 32.42 01496374 96374 TX INJ IV$ 92.78 01496375 96375 TX IV EA ADD IV NEW DRUG$ 55.07 01496376 96376 TX INJ EA ADD IV SAME DRUG$ 41.49 01524009 OBSERVATION/HOUR MED/SURG$ 30.46 01524009 OBSERVATION/HOUR MED/SURG$ 30.46 01524012 OBSERVATION/HOUR MEDICAL$ 33.12 01524012 OBSERVATION/HOUR MEDICAL$ 33.12 01524013 OBSERVATION/HOUR TELE$ 44.01 01524013 OBSERVATION/HOUR TELE$ 44.01 01524015 OBSERVATION/HOUR PEDS$ 42.00 01524015 OBSERVATION/HOUR PEDS$ 42.00 01524018 OBSERVATION/HOUR OB$ 33.88 01524018 OBSERVATION/HOUR OB$ 33.88 01524021 OBSERVATION/HOUR SURGICAL$ 32.19 01524021 OBSERVATION/HOUR SURGICAL$ 32.19 01524022 OBSERVATION/HOUR PCU$ 61.19 01524022 OBSERVATION/HOUR PCU$ 61.19 01524023 OBSERVATION/HOUR ICU$ 78.35 01524023 OBSERVATION/HOUR ICU$ 78.35 01524024 OBSERVATION/HR PICU$ 67.64 01524024 OBSERVATION/HR PICU$ 67.64 01596401 96401 CHEMO ANTINEO NONHORMON SQ/IM$ 117.93 01596402 96402 CHEMO ANTINEO HORMON SQ/IM$ 54.00 01596409 96409 CHEMO IV PUSH SGL/INIT DRUG$ 221.03 01596411 96411 CHEMO IV PUSH EA ADD DRUG$ 117.93 01596413 96413 CHEMO IV 1 HR SGL/INIT DRUG$ 357.69 01596415 96415 CHEMO IV EACH ADDL HOUR$ 54.00 01596416 96416 CHEMO IV > 8 HOURS W/PUMP$ 357.69 01596417 96417 CHEMO IV DIFF DRUG 1 HOUR$ 54.00 01596420 96420 CHEMO INTRA-ARTERIAL PUSH$ 357.69 01596422 96422 CHEMO INTRA-ARTERIAL 1 HOUR$ 357.69 01596423 96423 CHEMO INTRAARTERIAL EA ADD HR$ 54.00 01596425 96425 CHEMO ARTERIAL > 8HRS W/PUMP$ 357.69 01596446 96446 CHEMO PERITONEUM VIA PORT$ 357.69 01596450 96450 CHEMO CNS W/ SPINAL PUNCTURE$ 357.69 01596521 96521 REFILL & MAINTAIN PUMP$ 221.03 01596523 96523 IRRIGATE DRUG DELIVERY DEVICE$ 71.40 01596542 96542 CHEMO INTRAVTRCL VIA RESERVOIR$ 221.03 01599999 R&B MISCELLANEOUS FEE$ 26.25 5 01600028 DELIVERY ROOM$ 1,047.23 01600044 59025 FETAL NON-STRESS TEST$ 190.53 01600047 L&D-MAJOR SURGERY 1ST HOUR$ 1,810.71 01600105 LR-OUTPT OBSERVATION NO DELIVE$ 283.13 01600110
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