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Procedure Description Charge Amount 0302000014 ROOM MED Charge Procedure Description Amount 0302000014 ROOM MED SURG MOSU 1,040.00 0302000015 ROOM MED SURG PEDS 3,500.00 0302000033 OUT PATIENT BED MOSU 0.00 0302000035 ROOM INTERMEDIATE MOSU 2,055.00 0302000043 ROOM HOSPICE MOSU 805.00 0302000045 ROOM MED SURG W TELE MOSU 1,530.00 0302000050 OBSERVATION INTERM PER HR MOSU 97.00 0302002283 FECAL MANAGEMENT SYSTEM 694.00 0302010232 CATH INDWELL BLADDER SIMPLE 185.00 0302010304 OBSERVATION MS PER HR MOSU 60.00 0302010305 OBSERVATION TELE PER HR MOSU 71.00 0302010556 NONBILLABLE OBSERVATION HR 0.00 0302010557 OBSERVATION DIRECT ADM MOSU 130.00 0302020287 SUPPLIES CHEST TUBE 228.00 0302050318 LUMBAR PUNCTURE DIAGNOSTIC 1,035.00 0302050451 IV INF THERAPEUTIC EA ADD HR 170.00 0302050453 IV INF THERAPEUTIC UP TO 1HR 635.00 0302050454 IRRIGATION BLADDER 780.00 0302050480 INSERT VENOUS CENTRAL LINE 1,315.00 0302050490 IV PUSH INITIAL DRUG 380.00 0302050534 I&D ABSCESS SIMPLE 675.00 0302050603 IV PUSH EA SEQUENTIAL DRUG 153.00 0302050648 HEMODIALYSIS SERVICE IP 1,455.00 0302050813 ARTHROCENTESIS MAJ JNT WO IMAG 630.00 0302050885 ADMIN IMMUNIZATION 145.00 0302050948 DIALYSIS INTRAPERITONEAL SERV 655.00 0302060002 INJECTION SUB-Q/IM 155.00 0302060008 CHEMO ADMIN IV INF EA ADD HR 410.00 0302060101 HEMODIALYSIS SERVICE OBS/OP 1,455.00 0302060269 US PV RESIDUAL URINE 240.00 0302060274 IV PUSH EA ADD DRUG 168.00 0302060275 IV INF CONCURRENT THERAPEUTIC 385.00 0302060276 IV INF SEQUENTIAL THER UP TO 1 191.00 0302060293 INSERT STRAIGHT CATH THERAPEUT 185.00 0302060372 CHEMO ADMIN IV INF SEQ 1 HR 525.00 0302060373 IV INF HYDRATION EA ADD HR 138.00 0302060374 IV INF HYDRATION UP TO 1HR 430.00 0302060696 BLOOD TRANSFUSION DAILY 1,250.00 0302061072 PLASMAPHERESIS SERVICE 2,965.00 0302061208 PORT FLUSH 190.00 0302090028 DEBRID OPEN WOUND <20SQCM 415.00 0302090112 DECLOG PERM CATH W THROMBO 760.00 0302090136 ADMIN INFLUENZA VACCINE 94.00 0302090137 ADMIN PNEUMOCOCCAL VACCINE 84.00 0303250810 PUNCTURE ASPIRATION 605.00 0302600006 ROOM INTERMEDIATE SURG 2,055.00 0302600015 ROOM MED SURG SURGICAL 1,040.00 0302600033 OUT PATIENT BED 0.00 0302600043 ROOM HOSPICE SURG 805.00 0302600045 ROOM MED SURG W TELE SURGICAL 1,530.00 0302602283 FECAL MANAGEMENT SYSTEM 694.00 0302610232 CATH INDWELL BLADDER SIMPLE 185.00 0302610304 OBSERVATION MS PER HR SURGICAL 60.00 0302610305 OBSERVATION W TELE PER HR SURG 71.00 0302610556 NONBILLABLE OBSERVATION HR 0.00 0302610557 OBSERVATION DIRECT ADM SURG 130.00 0302622411 PREVENA 125 THERAPY UNIT KIT 1,337.00 0302650260 REPAIR SMP SCLP/TRNK/E 2.6-7.5 310.00 0302650451 IV INF THERAPEUTIC EA ADD HR 170.00 0302650453 IV INF THERAPEUTIC UP TO 1HR 635.00 0302650454 IRRIGATION BLADDER 780.00 0302650484 INJECTION SUB-Q/IM 155.00 0302650490 IV PUSH INITIAL DRUG 380.00 0302650539 I&D ABSCESS COMPLICATED 1,155.00 0302650603 IV PUSH EA SEQUENTIAL DRUG 153.00 0302650648 HEMODIALYSIS SERVICE IP 1,455.00 0302650813 ARTHROCENT MAJOR JOINT/BURSA 630.00 0302650885 ADMIN IMMUNIZATION 145.00 0302650948 DIALYSIS INTRAPERITONEAL SERVI 655.00 0302660101 HEMODIALYSIS SERVICE OBS/OP 1,455.00 0302660269 US PV RESIDUAL URINE 240.00 0302660274 IV PUSH EA ADD DRUG 168.00 0302660275 IV INF CONCURRENT THERAPEUTIC 385.00 0302660276 IV INF SEQUENTIAL THER UP TO 1 191.00 0302660293 INSERT STRAIGHT CATH THERAPEUT 185.00 0302660373 IV INF HYDRATION EA ADD HR 138.00 0302660374 IV INF HYDRATION UP TO 1HR 430.00 0302660696 BLOOD TRANSFUSION DAILY 1,250.00 0302661072 PLASMAPHERESIS SERVICE 2,965.00 0302690136 ADMIN INFLUENZA VACCINE 94.00 0302690137 ADMIN PNEUMOCOCCAL VACCINE 84.00 0302900006 ROOM INTERMEDIATE PCU 2,055.00 0302900033 OUT PATIENT BED 0.00 0302900041 ROOM MED SURG PCU 1,040.00 0302900043 ROOM HOSPICE PCU 805.00 0302900049 ROOM MED SURG W TELE PCU 1,530.00 0302900050 OBSERVATION INTERM PER HR PCU 97.00 0302902283 FECAL MANAGEMENT SYSTEM 694.00 0302910232 INSERTION FOLEY CATHETER 185.00 0302910304 OBSERVATION MS PER HR PCU 60.00 0302910305 OBSERVATION TELE PER HOUR 71.00 0302910556 NONBILLABLE OBSERVATION HR 0.00 0302910557 OBSERVATION DIRECT ADM PCU 130.00 0302920287 CHEST TUBE INSERTION SUPPLIES 228.00 0302950262 REPAIR SMP SCLP/TRNK/EXT <2.5C 500.00 0302950318 LUMBAR PUNCTURE DIAGNOSTIC 1,035.00 0302950451 IV INF THERAPEUTIC EA ADD HR 170.00 0302950453 IV INF THERAPEUTIC UP TO 1HR 635.00 0302950454 IRRIGATION BLADDER 780.00 0302950484 INJECTION SUB-Q/IM 155.00 0302950490 IV PUSH INITIAL DRUG 380.00 0302950497 INJECTION PERIPHERAL NERVE BLO 1,085.00 0302950603 IV PUSH EA SEQUENTIAL DRUG 153.00 0302950648 HEMODIALYSIS SERVICE IP 1,455.00 0302950885 ADMININSTRATION IMMUNIZATION 145.00 0302950948 DIALYSIS INTRAPERITONEAL SERV 655.00 0302960101 HEMODIALYSIS SERVICE OBS/OP 1,455.00 0302960269 US PV RESIDUAL URINE 240.00 0302960274 IV PUSH EA ADD DRUG 168.00 0302960275 IV INF CONCURRENT THERAPEUTIC 385.00 0302960276 IV INF SEQUENTIAL THER UP TO 1 191.00 0302960293 INSERT STRAIGHT CATH THERAPEUT 185.00 0302960373 IV INF HYDRATION EA ADD HR 138.00 0302960374 IV INF HYDRATION UP TO 1HR 430.00 0302960680 NERVE BLK GREATER OCCIPITAL 900.00 0302960696 BLOOD TRANSFUSION DAILY 1,250.00 0302960777 NERVE BLOCK TRIGEMINAL 830.00 0302960801 CATH FOR URINE SPECIMEN 23.00 0302961072 PLASMAPHERESIS SERVICE 2,965.00 0302961208 PORT FLUSH 190.00 0302990112 DECLOG PERM CATH W THROMBO 760.00 0302990136 ADMIN INFLUENZA VACCINE 94.00 0302990137 ADMIN PNEUMOCOCCAL VACCINE 84.00 0323050996 PUNCTURESHUNT ASP OR INJ 900.00 0303560293 CATHERIZATION STRAIGHT 185.00 0303400015 ROOM MED SURG PEDS 3,500.00 0303400033 OUT PATIENT BED 0.00 0303400041 ROOM MED SURG 1,040.00 0303410085 CIRCUMCISION PROCEDURE PEDS 405.00 0303410232 INSERTION FOLEY CATHETER 185.00 0303410304 OBSERVATION MS PER HOUR PEDS 104.00 0303410556 NONBILLABLE OBSERVATION HR 0.00 0303410557 OBSERVATION DIRECT ADM PEDS 130.00 0303440608 RECOVERY PHASE II PER 30 MIN 280.00 0303450318 PUNCTURE SPINAL/LUMBAR 1,035.00 0303450451 IV INF THERAPEUTIC EA ADD HR 170.00 0303450453 IV INF THERAPEUTIC UP TO 1HR 635.00 0303450484 INJECTION SUB-Q/IM 155.00 0303450490 IV PUSH INITIAL DRUG 380.00 0303450603 IV PUSH EA SEQUENTIAL DRUG 153.00 0303450763 CHEMO IV PUSH INITIAL DRUG 860.00 0303450764 CHEMO ADMIN SUBQ/IM NON HORMON 410.00 0303450885 ADMININSTRATION IMMUNIZATION 145.00 0303450919 ADMIN IMMUNIZATION EA ADD VACC 60.00 0303460005 CHEMO ADMIN IV INFUSION 1 HR 945.00 0303460008 CHEMO ADMIN IV INF EA ADD HR 410.00 0303460101 HEMODIALYSIS SERVICE OBS/OP 1,455.00 0303460263 ADMIN TB SKIN TEST 84.00 0303460269 US PV RESIDUAL URINE 240.00 0303460274 IV PUSH EA ADD DRUG 168.00 0303460275 IV INF CONCURRENT THERAPEUTIC 385.00 0303460276 IV INF SEQUENTIAL THER UP TO 1 191.00 0303460293 INSERT STRAIGHT CATH THERAPEUT 185.00 0303460371 CHEMO IV PUSH EA ADD DRUG 605.00 0303460372 CHEMO ADMIN IV INF SEQ 1 HR 525.00 0303460373 IV INF HYDRATION EA ADD HR 138.00 0303460374 IV INF HYDRATION UP TO 1HR 430.00 0303460541 BLD DRAW W COMPLETLY IMPL VAD 230.00 0303460542 BLOOD DRAW FROM PERIPH VAD PIC 150.00 0303460696 BLOOD TRANSFUSION DAILY 1,250.00 0303460801 CATH FOR URINE SPECIMEN 21.00 0303460804 NURSING E/M ESTAB LVL 1 125.00 0303460805 NURSING E/M ESTAB LVL 2 200.00 0303460806 NURSING E/M ESTAB LVL 3 250.00 0303460807 NURSING E/M ESTAB LVL 4 350.00 0303460808 NURSING E/M ESTAB LVL 5 425.00 0303460809 NURSING E/M NEW LVL 1 175.00 0303460810 NURSING E/M NEW LVL 2 250.00 0303460811 NURSING E/M NEW LVL 3 325.00 0303460812 NURSING E/M NEW LVL 4 270.00 0303460813 NURSING E/M NEW LVL 5 525.00 0303460918 HEMODIALYSIS SERV NON ESRD OP 1,455.00 0303461072 PLASMAPHERESIS SERVICE 2,965.00 0303461162 CHEMICAL CAUTERY TISSUE 415.00 0303461208 PORT FLUSH 190.00 0303461270 CAR SEAT TEST 1 HOUR 150.00 0303461271 CAR SEAT TEST EA ADD 30 MIN 50.00 0303490112 DECLOG PERM CATH W THROMBO 760.00 0303490136 ADMIN INFLUENZA VACCINE 94.00 0303490137 ADMIN PNEUMOCOCCAL VACCINE 84.00 0303500014 ROOM MED SURG W TELE CVCU 1,530.00 0303500033 OUT PATIENT BED 0.00 0303500035 ROOM INTERMEDIATE CVCU 2,055.00 0303500036 ROOM CRITICAL CVCU 2,875.00 0303500041 ROOM MED SURG CVCU 1,040.00 0303500043 ROOM HOSPICE CVCU 805.00 0303500050 OBSERVATION INTERM PER HR CVCU 97.00 0303502283 FECAL MANAGEMENT SYSTEM 694.00 0303510232 INSERTION FOLEY CATHETER 185.00 0303510304 OBSERVATION MS PER HOUR CVCU 60.00 0303510305 OBSERVATION TELE PER HR CVCU 71.00 0303510556 NONBILLABLE OBSERVATION HR 0.00 0303510557 OBSERVATION DIRECT ADM CVCU 130.00 0303520275 CENTRAL LINE CATH INSERT BUCKT 318.00 0303520287 SUPPLIES CHEST TUBE 228.00 0303521666 SAFEGUARD PRESSURE BANDAGE 119.00 0303521958 SAFEGUARD PRESSURE BANDAGE 122.00 0303550451 IV INF THERAPEUTIC EA ADD HR 170.00 0303550453 IV INF THERAPEUTIC UP TO 1HR 635.00 0303550480 INSERT VENOUS CENTRAL LINE 2,690.00 0303550490 IV PUSH INITIAL DRUG 380.00 0303550603 IV PUSH EA SEQUENTIAL DRUG 153.00 0303550648 HEMODIALYSIS SERVICE IP 1,455.00 0303550777 CARDIOVERSION ELECTIVE 1,590.00 0303550885 ADMININSTRATION IMMUNIZATION 145.00 0303550948 DIALYSIS INTRAPERITONEAL SERVI 655.00 0303560002 INJECTION SUB-Q/IM 155.00 0303560057 CRRT-HEMO SERVICE 1,555.00 0303560101 HEMODIALYSIS SERVICE OBS/OP 1,455.00 0303560229 ECMO/RVAD PER 24HR SERVICE 2,010.00 0303560269 US PV RESIDUAL URINE 240.00 0303560274 IV PUSH EA ADD DRUG 168.00 0303560275 IV INF CONCURRENT THERAPEUTIC 385.00 0303560276 IV INF SEQUENTIAL THER UP TO 1 191.00 0303560373 IV INF HYDRATION EA ADD HR 138.00 0303560374 IV INF HYDRATION UP TO 1HR 430.00 0303560696 BLOOD TRANSFUSION DAILY 1,250.00 0303560928 THORACENTESIS ASP W IMAGING 2,105.00 0303561072 PLASMAPHERESIS SERVICE 2,965.00 0303561208 PORT FLUSH 190.00 0303590136 ADMIN INFLUENZA VACCINE 94.00
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