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Charge Master Report- Price List The listed prices do not take into account insurance coverge or out of pocket expenses Charge Code Description Departme Rev Proc Rate Please contact us for price estimate clarification nt Code Code AMBULANCE SERVICE ALS - EMERGENT AMB AMBULANCE 540 A0427 1,503.50 AMBULANCE SERVICE ALS 1 AMB AMBULANCE 540 A0426 949.50 AMBULANCE SERVICE ALS 2 AMB AMBULANCE 540 A0433 2,176.00 AMBULANCE SERVICE BLS - EMERGENT AMB AMBULANCE 540 A0429 1,266.00 AMBULANCE SERVICE BLS AMB AMBULANCE 540 A0428 790.00 AMBULANCE GROUND MILEAGE, ALS AMB AMBULANCE 540 A0425 28.00 SPECIAL CARE TRANSPORT AMB AMBULANCE 540 A0434 2,571.00 31500 INTUBATION EMERG PR ANES SURGERY 963 31500 425.00 VENIPUNCTURE BY HC PRO FE ANES SURGERY 963 36410 28.50 INSERT NON TUNNEL CATH ANES SURGERY 963 36556 295.50 62270 SPINAL PUNCTURE DX ANES SURGERY 963 62270 235.00 FEMORAL NERVE BLOCK PF ANES SURGERY 963 64447 1,447.00 PERIPHERAL NERVE BLOCK PF ANES SURGERY 963 64450 136.50 64415 ANES SINGLE NERVE BLOCK INJECTION ANES SURGERY 963 64415 198.00 RBC'S/ LEUKO DEPLETED BB LAB 390 J3490 485.50 FRESH FROZEN PLASMA BB LAB 390 J3490 250.00 PLATELETS-PHERESIS BB LAB 390 J3490 1,274.00 RBC, IRRADIATED, LEUKO BB LAB 390 J3490 551.00 BLOOD PRODUCT (CYRO) CHARGE BB LAB 390 J3490 675.50 PLATELET IRRADIATED BB LAB 390 J3490 1,500.50 ABG - COMPLETE CR CARDOPULMONARY 301 82803 177.50 ABG, ARTERIAL PUNCTURE CR CARDOPULMONARY 300 36600 34.50 ABG, O2 SAT CR CARDOPULMONARY 301 82810 22.50 ABG, PCO2 CR CARDOPULMONARY 301 82803 56.50 ABG, PH CR CARDOPULMONARY 301 82800 44.00 ABG, PO2 CR CARDOPULMONARY 301 82803 99.00 BALLARD SWIVEL CR CARDOPULMONARY 410 15.50 BI PAP CR CARDOPULMONARY 410 94002 1,472.50 BI PAP/ PER SUB DAY CR CARDOPULMONARY 410 94003 1,472.50 CARDIO RESUSCITATION CR CARDOPULMONARY 410 159.50 CONT NEB PER HR/MX/DLY CR CARDOPULMONARY 410 94640 595.00 ENDOTR SUCT DAILY CHARGE CR CARDOPULMONARY 410 67.50 ENDOTRACHEAL INTUBATION CR CARDOPULMONARY 410 31500 570.50 INCENTIVE SPIRO THERAPY CR CARDOPULMONARY 410 94799 436.00 !1 MECH VENT INITIAL DAY CR CARDOPULMONARY 410 94002 1,472.50 MECH VENT/SUB CR CARDOPULMONARY 410 94003 1,472.50 NASOTRACHEAL SUCTIONING CR CARDOPULMONARY 410 31720 596.00 OXYGEN ANALYZER--CONT CR CARDOPULMONARY 410 40.50 P D & P SUBSEQUENT CR CARDOPULMONARY 410 94668 336.00 PEP THERAPY CR CARDOPULMONARY 410 94667 336.00 RESP MDI CR CARDOPULMONARY 410 94664 596.00 RESP NEBS CR CARDOPULMONARY 410 94664 596.00 TECH ASST SURG C SECTION CR CARDOPULMONARY 410 76.50 TRACHEAL LAVAGE & SUCTION CR CARDOPULMONARY 410 64.00 VEST THERAPY CR CARDOPULMONARY 410 94667 336.00 VEST THERAPY SUBQ CR CARDOPULMONARY 410 94668 336.00 CARBON MONOXIDE CR CARDOPULMONARY 460 82375 61.50 END TIDAL CO2 CR CARDOPULMONARY 460 94770 747.00 HOME OXYGEN EVALUATION CR CARDOPULMONARY 410 94618 315.00 METH HGB CR CARDOPULMONARY 460 83050 61.50 NOCTURNAL OXIMETRY I NPT CR CARDOPULMONARY 460 94762 409.00 OXIMETRY, PER HR CR CARDOPULMONARY 460 39.50 SPIROMETRY, BASIC CR CARDOPULMONARY 460 94010 409.00 PULMONARY FUNCTION TEST (PFT) CR CARDOPULMONARY 460 94060 747.00 EVENT MONITOR RECORDING CR CARDOPULMONARY 480 93270 121.00 EVENT MONITOR ANALYSIS CR CARDOPULMONARY 480 93271 368.00 EKG PROCEDURE CR CARDOPULMONARY 730 93005 168.00 RHYTHM ECG STRIP/1 MINUTE CR CARDOPULMONARY 730 93041 168.00 HOLTER UP TO 48HRS WITH SCAN & REPORT CR CARDOPULMONARY 731 93226 315.00 HOLTER MONITOR UP TO 48 HR RECORDING CR CARDOPULMONARY 731 93225 315.00 EXERCISE OXIMETRY CR CARDOPULMONARY 460 94761 72.00 PULSE OXIMETRY CR CARDOPULMONARY 460 94760 42.00 LDR NEONATE RESUSCITATION CR CARDOPULMONARY 410 99465 157.00 SPUTUM INDUCTION CR CARDOPULMONARY 410 89220 64.00 CONTINUOUS NEB (INITIAL) CR CARDOPULMONARY 410 94644 336.00 CONTINUOUS NEB EACH ADDL HOUR CR CARDOPULMONARY 410 94645 48.00 CPAP INITIATION AND MANAGEMENT CR CARDOPULMONARY 410 94660 596.00 LDR - ATTEND DELIVERY (REQUESTED BY PHY) CR CARDOPULMONARY 410 99464 225.00 TRANSTRACHEAL PERCUTANEOUS VENTILATION CR CARDOPULMONARY 410 31730 4,230.00 ABG - BICARB CR CARDOPULMONARY 301 82374 29.50 IRHYTHM ECG HOOK UP / RECORDING CR CARDOPULMONARY 730 0296T 355.00 ABG, SAMPLE KIT CR CARDOPULMONARY 270 31.50 AIRWAY, NASAL\ORAL CR CARDOPULMONARY 270 19.50 AIRWAY, ORAL CR CARDOPULMONARY 270 22.50 AMBU BAG CR CARDOPULMONARY 270 29.50 !2 AMBU BAG DISPOSIBLE CR CARDOPULMONARY 270 95.50 AMBU BAG MASK- ALL SIZES CR CARDOPULMONARY 270 49.50 BALLARD SUCT. CATH CR CARDOPULMONARY 270 81.00 BI PAP CIRCUIT CR CARDOPULMONARY 270 36.50 BVM, DISPOSABLE NEO-NATAL CR CARDOPULMONARY 270 78.00 CIRCUIT, MECH VENT CR CARDOPULMONARY 270 125.50 CONNECTING TUBE, OXYGEN CR CARDOPULMONARY 270 17.00 CONNECTING TUBE-10FT CR CARDOPULMONARY 270 28.00 CONNECTING TUBE-25FT CR CARDOPULMONARY 270 40.50 CONT. NEB SETUP CR CARDOPULMONARY 270 127.50 ENVIRONMENT TENT/SET-UP CR CARDOPULMONARY 270 74.00 H2O STER/DIST ALL SIZES/E CR CARDOPULMONARY 270 21.50 HUMIDVENT CR CARDOPULMONARY 270 22.50 HYPERTONIC SALINE 15ML/3% CR CARDOPULMONARY 270 21.50 INTUBATION TUBE CR CARDOPULMONARY 270 36.50 MASK, AEROSOL CR CARDOPULMONARY 270 29.50 MASK, FACE TENT CR CARDOPULMONARY 270 31.50 MASK, NONREBREATHER CR CARDOPULMONARY 270 31.50 MASK, PEDIATRIC CR CARDOPULMONARY 270 29.50 MASK, SIMPLE OXYGEN CR CARDOPULMONARY 270 29.50 MASK, TOTAL FACE BIPAP CR CARDOPULMONARY 270 174.00 NEOPUFF CIRCUIT CR CARDOPULMONARY 270 24.50 OXIMETER PROBE NEONATAL CR CARDOPULMONARY 270 132.00 OXIMETER PROBE PED CR CARDOPULMONARY 270 101.00 OXYMIZER CR CARDOPULMONARY 270 52.00 PEF METER CR CARDOPULMONARY 270 101.00 SALINE ALL SIZES CR CARDOPULMONARY 270 21.50 TRACH COLLAR CR CARDOPULMONARY 270 36.50 VEST FULL CR CARDOPULMONARY 270 273.50 VEST WRAP CR CARDOPULMONARY 270 187.50 THERAPEUTIC PROCEDURE STRENGTH / ENDURAN CR CARDOPULMONARY 410 G0237 102.00 VEST HFCWC CR CARDOPULMONARY 410 94669 596.00 IRHYTHM ECG REVIEW AND INTERPRETATION CRDP CARDOPULMONARY 960 0298T 50.00 TRAY ARTHROGRAM CS SUPPLIES 270 9.00 2 X 2 DRESSING CS SUPPLIES 270 12.00 4 X 4 4 PLY EACH 2/PKG CS SUPPLIES 270 13.00 4 X 4 STERILE DRESSING/10 CS SUPPLIES 270 21.50 ABD BINDER, DALE 62x75 CS SUPPLIES 270 149.50 ACE WRAP ALL SIZES CS SUPPLIES 270 22.50 AIR WALKER (REBOUND) LOW CS SUPPLIES 270 122.50 BINDER, ABDOMINAL SURGICA CS SUPPLIES 270 149.50 !3 CATH, FOLEY ALL SIZES CS SUPPLIES 270 61.50 CATH, LEG BAG CS SUPPLIES 270 19.50 CATH, MINI CS SUPPLIES 270 15.50 CATH, SECURE FOR LEG BAG CS SUPPLIES 270 10.00 CERVICAL, COLLAR FOAM CS SUPPLIES 270 42.00 CERVICAL, COLLAR STIFF CS SUPPLIES 270 101.00 COLOSTOMY BAG CS SUPPLIES 270 40.50 DRESSING CHANGE - LARGE CS SUPPLIES 270 46.50 DRESSING CHANGE - MEDIUM CS SUPPLIES 270 22.50 DRESSING CHANGE - SMALL CS SUPPLIES 270 12.00 DRESSING, BIOCLUSIVE 4X5 CS SUPPLIES 270 18.00 EYE PATCH, EA CS SUPPLIES 270 13.00 GLOVE, STER. MICROTOUCH CS SUPPLIES 270 13.00 IMMOBILIZER BOOT 79-95415 CS SUPPLIES 270 85.50 KCI PROVENA DISP VAC CS SUPPLIES 270 1,010.50 SALINE 1000CC CS SUPPLIES 270 19.50 SHOTS BIOCLUSIVE 4X5 CS SUPPLIES 270 18.00 SHOTS FOLEY CATH CS SUPPLIES 270 61.50 SHOTS NEDDLE HUEBER CS SUPPLIES 270 17.00 SHOTS SKIN PREP NO-STING CS SUPPLIES 270 8.00 SHOTS STATLOCK PICC SECU CS SUPPLIES 360 44.00 SHOTS SURG SCRUB SPONGE CS SUPPLIES 270 17.00 SHOTS SUTURE REMOVAL KIT CS SUPPLIES 270 12.00 SLING CS SUPPLIES 270 49.50 SPLINT, ANKLE AIR CS SUPPLIES 270 189.00 SPLINT, ANKLE ELAS WRAP CS SUPPLIES 270 31.50 SPLINT, FINGER-ALUM CS SUPPLIES 270 13.00 SPLINT, FINGER-FROG CS SUPPLIES 270 18.00 SPLINT, FOREARM #12-01T00 CS SUPPLIES 270 42.00 SPLINT, LONG ARM CS SUPPLIES 270 128.50 SPLINT, LONG LEG CS SUPPLIES 270 155.50 SPLINT, POSTERIOR CS SUPPLIES 270 82.50 SPLINT, SHORT ARM CS SUPPLIES 270 98.00 SPLINT, SHORT LEG CS SUPPLIES 270 136.50 SPLINT, SUGAR TONG SH ARM CS SUPPLIES 270 54.50 SUCTION CANNISTER CS SUPPLIES 270 19.50 SUCTION,TUBING 10' CS SUPPLIES 270 13.00 SYRINGE ALL CS SUPPLIES 270 13.00 TED HOSE KNEE LGTH/PR CS SUPPLIES 270 58.00 TRAY, BREAST LOC CS SUPPLIES 270 58.00 TUBE, NASAL GASTRIC CS SUPPLIES 270 19.50 UNNABOOT CS SUPPLIES 270 35.50 !4 CATH, INDWELLING TRAY CS SUPPLIES 270 A4312 70.00 SPLINT CS SUPPLIES 270 A4570 28.00 SPLINT, FINGER-VELCRO #39 CS SUPPLIES 270 A4570 37.50 SPLINT, FORE & WRIST w/VE CS SUPPLIES 270 A4570 74.00 SMALL JNT IMPLANT CS SUPPLIES 278 C1776 1,229.00 CRUTCHES COMPLETE CS SUPPLIES 270 151.00 BREAST PUMP KIT CS SUPPLIES 270 E0602 75.00 BREAST PUMP, MEDELA ELEC. CS SUPPLIES 271 E0603 290.00 SPLINT, KNEE UNIVERSAL CS SUPPLIES 270 64.50 SPLINT ANKLE STABILING SU CS SUPPLIES 270 71.00 CAST SHOE/KOOL KOLOR 1487 CS SUPPLIES 274 70.00 SHOE, MED/SURG POST-OP CS SUPPLIES 274 70.00 SHOULDER ABDUCTION FIG 8 CS SUPPLIES 270 231.00 SPLINT, SHOULDER IMMOB CH CS SUPPLIES 270 141.50 SPLINT, 10 LACE-UP WRIST CS SUPPLIES 270 44.50 SPLINT, WRIST COCK-UP CS SUPPLIES 270 76.50 SPLINT, WRIST-ELASTIC CS SUPPLIES 270 37.50 WRIST SUPPORT ELASTIC CS SUPPLIES 270 32.50 WRIST/ FOREAREM ELASTIC CS SUPPLIES 270 25.00 SPLINT, THUMB SPICA BRACE CS SUPPLIES 270 44.00 SPLINT, ANKLE 79-81197 CS SUPPLIES 270 71.00 SPLINT, ANKLE SUPPORT CS SUPPLIES 270 82.50 MAXTRAX AIR WALKER #79-95 CS SUPPLIES 270 99.00 INTRAOCULAR, CILCO-UV LEN CS SUPPLIES 276 V2632 2,325.00 .45NS 1000ML CS SUPPLIES 260 8.00 .45NS 500ML CS SUPPLIES 260 7.00 .9NS 1000ML CS SUPPLIES 260 7.00 .9NS 100ML CS SUPPLIES 260 6.00 .9NS 100ML ADVANTAGE CS SUPPLIES 260 12.00 .9NS 250ML CS SUPPLIES 260 6.00 .9NS 500ML CS SUPPLIES 260 6.00 .9NS 50ML CS SUPPLIES 260 6.00 .9NS 50ML ADVANTAGE CS SUPPLIES 260 12.00 .9NS IRRIGATION 3000ML CS SUPPLIES 260 27.00 .9NS IRRIGATION BTL 1000ML CS SUPPLIES 260 8.00 20MEQ KCL
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