Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02600001 HB IV INFUS HYDRATION 31-60 MIN 96360 $ 1,942.19 $ 2,526.14 02600002 HB IV INFUSION HYDRATION ADDL HR 96361 $ 475.94 $ 616.09 02600003 HB IV INFUSION THERAPY 1ST HR 96365 $ 2,175.25 $ 2,829.30 02600004 HB IV THERAPY ADDL SEQ UP TO 1 HR 96367 $ 475.94 $ 616.09 02600005 HB IV THERAPY-CONCURRENT 96368 $ 636.68 $ 825.32 02600007 HB INFUSION SC INITIAL FIRST HR 96369 $ 893.46 02600008 HB SC INFUSION ADD'L HOURS 96370 $ 443.82 02600012 HB IV INFUSION THERAPY EA ADDL HR 96366 $ 475.94 $ 616.09 02600013 HB IV PUSH INITIAL 96374 $ 1,188.35 $ 1,544.87 02600014 HB IV PUSH ADDL SEQ NEW DRUG 96375 $ 847.28 $ 1,101.47 02600015 HB IVP ADDL SEQ SAME DRUG 96376 $ 855.31 $ 1,111.91 02700005 HB CYTOTOXIC SPILL KIT $ 240.19 02700007 HB 24 HR PH PROBE $ 3,042.48 02700008 HB FEMSTOP $ 726.11 02700009 HB PC IPPB KIT $ 331.50 02700016 HB PEFR-EQUIPMENT $ 870.13 02700018 HB PC AERO KIT $ 1,779.85 02700020 HB PC O/P USN EQUIPMENT $ 1,003.99 02700021 HB PC MICRO-SPIROMETER $ 10,942.51 02700022 HB PC O/P HHN EQUIPMENT $ 635.86 02700033 HB STOCKINETTE,2"X25YD/BOX $ 286.76 02700034 HB , RDS $ 2,826.81 02700035 HB NEEDLE, BIOPSY/ASP/LOC/INJ $ 408.51 02700036 HB HMII POWER MODULE Q0496 $ 1,877.40 02700042 HB HMGG, TRAVEL CASE Q0508 $ 722.80 02700044 HB METANEB RT DEVICE KIT $ 2,204.87 02700045 HB PC METANEB KIT $ 331.50 02710001 HB SUPPORTER, SCROTAL $ 836.64 02710002 HB SPLINT FOREARM - SMALL $ 482.09 02710003 HB SPLINT, SUGARTONG $ 2,653.01 02710005 HB SPICA - HIP (SINGLE OR DOUBLE) $ 5,240.06 02710006 HB COLLAR, CERVICAL $ 650.75 02710009 HB CAST, SHORT ARM CAST $ 1,695.08 02710012 HB PADS R2 EP STUDY $ 740.85 02710013 HB SPLINT FINGER 2 INCHES $ 344.04 02710014 HB MUCUS CLEARING DEVICE $ 345.84 02710018 HB BILE BAG REG $ 606.38 02710019 HB FECAL INCONTINENCE COLLECTOR $ 494.52 02710022 HB PC PEP VALVE $ 391.56 02710023 HB SPLINT WRIST - LARGE $ 412.84 02710024 HB SPLINT WRIST - MEDIUM $ 412.84 02710027 HB PENTAMIDINE KIT $ 490.61 02710029 HB SPLINT, WRIST $ 1,157.87 02710032 HB SUPPORT LUMBO-SACRAL $ 1,266.15 02710033 HB KNEE IMMOBILIZER * $ 1,307.49

Ancillary FY21 1 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02710035 HB AEROSOL INHAL, PENTAM ADD'L 10 $ 1,408.01 02710036 HB SPICA - THUMB OR FINGER $ 1,582.14 02710037 HB BI-VALVE OR DC CAST $ 381.03 02710038 HB KIT, OSTOMY 5PK (1 PIECE) $ 1,611.78 02710039 HB SPLINT, MOLDED $ 1,630.96 02710041 HB EAR LAVAGE $ 459.74 02710044 HB 02 CONNECTION TUBING MASK $ 462.42 02710045 HB HEADSET NAVIGATION DEVICE $ 477.20 02710047 HB SPLINT FOREARM - MEDIUM $ 584.28 02710050 HB SPICA CAST - INFANT $ 172.96 02710053 HB PC HELIOX ADMIN. PER HOUR $ 217.34 02710054 HB PC NITROGEN ADMIN. PER HOUR $ 217.34 02710055 HB ILEOSTOMY POUCH $ 808.55 02710056 HB UNIVALVE CAST OR SPLINT $ 251.50 02710057 HB PC H.H.N. KIT $ 414.62 02710058 HB SPLINT FOREARM - LARGE $ 694.19 02710059 HB SPLINT,THUMB $ 726.82 02710060 HB PAG-HEART NEB EQUIP $ 743.68 02710061 HB PASSY MUIR SPEAKING VALVE $ 765.40 02710063 HB STOMAHESIVE WAFER $ 782.42 02710064 HB SPLINT, ARM $ 933.05 02710067 HB PENTAMIDINE EQUIPMENT OP * $ 1,126.71 02710070 HB SPLINT, KNEE VELCRO $ 4,665.09 02710073 HB CAST, SHORT LEG WALKING $ 2,127.61 02710074 HB CAST, CYLINDER THIGH TO ANKLE $ 2,415.89 02710077 HB CAST, PATELLAR TENDON BEARING $ 3,010.70 02710078 HB CAST, LONG LEG $ 3,505.68 02710080 HB KIT, WOUND CLEASING $ 294.02 02710081 HB SPLINT, SHORT/LONG LEG $ 2,848.09 02710083 HB PUMP DISCONNECT KIT $ 130.75 02710085 HB SPLINT WRIST - SMALL $ 344.04 02710087 HB CAST, SHOE $ 705.36 02710089 HB CAST SHORT LEG $ 8,843.15 02710090 HB CAST, LONG ARM $ 4,264.87 02710091 HB CAST, LONG LEG WALKING $ 2,127.61 02710101 HB SPLINT, IMMOBILIZER KNEE $ 1,307.49 02710104 HB SPLINT,IMMOBILIZER SHOULDER $ 209.58 02720001 HB BASKET GEMINI 3FR $ 1,832.22 02720003 HB CRYOCATH, FROSTBYTE $ 13,537.31 02720008 HB MEDIA FOR IUI $ 215.31 02720009 HB WIRE, MICRO EXCHANGE $ 2,520.12 02720010 HB CATH PERIPHERAL DILITATION C1725 $ 2,599.52 02720016 HB LASER FIBER, 3 $ 4,011.65 02720017 HB NEUROPEN WITH NEUROENDOSCOPES $ 4,196.76 02720018 HB VALVE, DRAINAGE/FARRELL $ 291.22

Ancillary FY21 2 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720021 HB CATH DELIVERY SYSTEM $ 6,425.29 02720023 HB LASER FIBER, 9 $ 8,279.13 02720025 HB CATH INTRA-AORTC BALLOON $ 15,137.08 02720034 HB CLIP SURGICAL SPRING CLIP $ 206.57 02720035 HB KIT, OSTOMY (2 PIECE) $ 1,095.44 02720036 HB LEVEL I TUBING D-50 $ 1,114.14 02720037 HB 1 $ 352.79 02720039 HB ENDOSCOPIC VERSATEP $ 955.10 02720040 HB ENDO LLETZ BALL ELCTRODE $ 303.32 02720044 HB ENDOSCOPE SHEATH DISPOSABLE $ 556.85 02720045 HB COLOSTOMY BAG $ 557.83 02720046 HB KYPHON BONE FILLER DEVICE OR $ 1,155.60 02720047 HB , EPISTAXIS BALLOON $ 569.28 02720048 HB ENDO ELECTRODE CUTTING LOOP $ 929.87 02720049 HB SHEATH, PERITONEAL/AMPLATZ $ 577.78 02720050 HB PC NASAL MASKS BIPAP $ 1,177.35 02720051 HB ENDO IRRIG ENDO-FLO 0037970 $ 586.79 02720053 HB BIOPSY BRUSH COOK 040310 $ 589.79 02720054 HB NEEDLE, SCLEROSING $ 1,205.57 02720055 HB CATH FOLEY W/THERMISTER $ 504.01 02720056 HB CANNULA, CORONARY PERFUSION DL $ 592.17 02720058 HB ELECTRODE, ACRIM/MENIS/PEN $ 593.28 02720059 HB CATHETER, UMBILICAL VES $ 593.37 02720064 HB CANNULA AVR CABG KIT $ 610.73 02720068 HB TRACH TUBE #14 $ 1,239.50 02720072 HB CLAMP, DISPOSABLE $ 397.33 02720073 HB FILTER, BLOOD TRANSFUSION * $ 646.59 02720074 HB PACING WIRE, TEMPORARY $ 789.30 02720075 HB LEADWIRE, EKG $ 149.69 02720077 HB FRAZIER TIPS $ 317.50 02720080 HB HANDLE, ENDOSCOPIC GIA $ 967.42 02720081 HB , ENDOSCOPIC 1 $ 545.54 02720082 HB CLIP GUN MAGAZINE $ 317.33 02720084 HB NEEDLE, SPINAL/DISC $ 689.25 02720086 HB KIT, PACEMAKER 1 $ 694.00 02720088 HB INTRODUCER, OSTEO ONE STEP $ 7,816.46 02720089 HB CATHETER, THORACIC MM $ 709.90 02720090 HB CATHETER PASSER $ 917.20 02720093 HB PIN, DISTRACTION 1 $ 536.76 02720096 HB ENDO TIP CAUTERY PEDS RT ANGLE $ 718.51 02720098 HB LACRIMAL INTUBATION SET $ 724.53 02720099 HB ROD, OSTOMY $ 217.74 02720101 HB PEN, HEATING LACTOSORB PLATE $ 800.16 02720104 HB ENDO BIPOLAR EBF01 $ 747.64 02720107 HB GRASPER, ENDOSCOPIC 1 $ 1,108.81

Ancillary FY21 3 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720108 HB PIN SKULL PINS MAYFIELD- OMI $ 215.59 02720109 HB DRESSING WEBRIL $ 66.69 02720110 HB PREP DURA $ 201.58 02720111 HB BLADE, TREPHINE $ 772.43 02720114 HB TUBING, INSUFFLATION $ 418.33 02720115 HB KYPHON BONE ACCESS NEEDLE 11 G $ 332.30 02720116 HB ANTENNA,EXTRNL NEUROSTIMALUTOR $ 1,069.58 02720121 HB SPLINT DENVER SERIES $ 251.88 02720123 HB ADHESIVE, SKIN 1 $ 372.65 02720124 HB 23G BIPOLAR TAPERED FINE POINT $ 470.03 02720125 HB SYRINGE MEDRAD POWER INJECTOR $ 171.87 02720126 HB ARTHRO, MENISCAL SYSTEM $ 1,317.26 02720132 HB FILTER MILEX $ 83.18 02720133 HB SONOHYSTOGRAM CATHETER $ 244.91 02720135 HB NET, RETRIEVAL ROTH $ 1,258.40 02720137 HB OSTENE BONE HEMOSTASIS 2.5GRMS $ 832.81 02720139 HB TUBE, JEJUN FEED/SGL LUMEN $ 1,336.24 02720140 HB , BIOPSY 1 $ 511.43 02720144 HB TUBE,TRACH DCT/DFEN W/DISP CAN $ 1,473.60 02720145 HB KIT, NEUROSTIMULATOR 1 $ 998.14 02720148 HB MEDTRONIC REFILL KIT $ 1,475.04 02720153 HB TUNNELING ROD, CATH PASSER $ 1,262.84 02720154 HB TUBE, MIC (FEEDING) $ 2,207.89 02720159 HB TOOL, DISSECTING 2 $ 1,466.97 02720161 HB KIT, TRANFIX/BIO-TENODESIS $ 1,523.84 02720162 HB NEEDLE, ELECT/BEVEL/TROCAR $ 1,565.75 02720165 HB , SOF-GRIP $ 778.39 02720166 HB BAG DRAINAGE URINARY $ 257.08 02720168 HB CUTTER, LOCKING LEAD $ 1,015.18 02720169 HB PERF QUICK PRIME LINE $ 264.43 02720170 HB ENDO PROBE HANDPIECE $ 791.04 02720171 HB PC MICRO BRUSH $ 1,924.29 02720172 HB STRIPPER VEIN DISPOSABLE $ 801.54 02720174 HB PLEUR-EVAC $ 2,260.65 02720175 HB SPENCER DEPTH ELECTRODES 8 CON $ 2,348.37 02720176 HB NEEDLE, OSTYCUT $ 809.79 02720177 HB T-TUBE, 2 $ 811.35 02720178 HB ENDO TROCAR 10MM BLNT OMST10BT $ 820.33 02720183 HB ILIUMINATOR, LIGHTMAT SURGICAL $ 830.08 02720184 HB PC BROCH OCC CATH C2628 $ 1,809.18 02720185 HB PERF HEMOCONCENTRATOR PEDS $ 856.22 02720187 HB TWIST SURGICAL 1 $ 862.20 02720189 HB KIT, KYPHOPLASTY INTRO SYSTEM $ 17,379.17 02720190 HB TRACH PERCUTANEOUS SET $ 700.92 02720191 HB ENDO SUCTION/IRRIG/PROBE $ 874.20

Ancillary FY21 4 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720193 HB CATHETER, MULTI LUMEN $ 875.89 02720195 HB CANNULA, RETROGRADE CARDIOPLEG $ 886.56 02720198 HB CANNULA, RETROGRADE 1 $ 898.13 02720199 HB IV PUMP SET, NITROGLYCERIN $ 712.68 02720201 HB ARTHRO WAND 1 $ 1,805.25 02720202 HB BLADE, ACROM/BLASTER/MIONIZER $ 849.25 02720208 HB IRRIGATION SET, CYSTO $ 738.57 02720213 HB PERF RESERVOIR CARDIOTOMY $ 940.03 02720215 HB RESERVOIR, DRAIN 1 $ 268.24 02720216 HB DRAIN LUMBAR DRAINAGE SET $ 947.90 02720218 HB PACK, AFFINITY VAVD ACCESSORY $ 500.78 02720225 HB SHOULDER SUSPENSION KIT 2 $ 974.35 02720228 HB LP DRAINAGE KIT $ 987.93 02720229 HB TUBE, RECTAL $ 560.75 02720230 HB RADIAL ARTERY KIT $ 571.81 02720231 HB ENDO POLY LOOP $ 1,315.98 02720232 HB TUBING, PCA $ 578.99 02720233 HB TUBE, GASTROSTOMY 1 $ 590.60 02720235 HB CABLE, LEAD EKG WIRE $ 1,004.27 02720236 HB RESUSCITATION BAG $ 270.57 02720243 HB ANESTHESIA BREATHING TRACT $ 986.51 02720246 HB NEEDLE SET, BX/ASPIR, ECHO TIP $ 640.64 02720247 HB TROCAR, ENDOSCOPIC 2 $ 1,026.85 02720248 HB INFLATION DEVICE ENDO $ 1,029.84 02720251 HB BLADE, INCISOR/ABRADER $ 1,035.82 02720253 HB INTRODUCER ACCUSTICK $ 661.63 02720254 HB CANNULA ANTERIOR CHAMBER $ 414.58 02720257 HB MARKER, SPOT TATOO $ 347.43 02720259 HB MICRO PUNCTURE SET $ 352.37 02720262 HB CAPSULE, WIRELESS AGILE $ 1,373.56 02720263 HB STAPLER, ENDOSCOPIC 5 $ 2,887.62 02720264 HB TAP, DISPOSABLE 1 $ 1,061.46 02720265 HB TUBING PENUMBRA STERILE $ 2,996.51 02720266 HB PC PNEUMOTHORAX SET $ 3,240.76 02720267 HB BASKET, RETRIEVAL II $ 2,656.10 02720269 HB BASKET RETRIEVABLE INSERTABLE C1889 $ 1,080.74 02720271 HB ELECTRODE, ESU 1 $ 1,083.76 02720272 HB CATH EPID TUN-L XL 16GA X 3.5 $ 1,085.76 02720276 HB KIT, IRRIGATION OSTOMY $ 899.23 02720279 HB SECONDARY PIGGY BACK $ 831.60 02720280 HB UNIVER MICROINTRODUCER KIT 7FR $ 914.55 02720283 HB ENDO SWITCH BLADE TIPS $ 526.50 02720285 HB COLLAGEN, HEMOSTAT INSTAT 1 $ 789.82 02720286 HB PICC SELDING CONVERSION SET $ 514.64 02720287 HB PROBE ESPOHAGEAL RECTAL DISP $ 526.37

Ancillary FY21 5 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720288 HB DRAIN, VENTRICULAR $ 1,163.68 02720289 HB CATHETER, VENTRICULAR 2 $ 1,173.01 02720290 HB NEEDLE, KYPHON $ 1,177.35 02720294 HB 8-CONTACT STRIP ELECTRODE $ 2,932.58 02720296 HB KYPHX SYRINGE A08A $ 1,197.52 02720297 HB PC YAG LASER FIBER $ 6,383.49 02720298 HB INFUSION SET, BUTTERFLY $ 206.47 02720299 HB NEEDLE, SCALP VEIN $ 206.47 02720303 HB TUBING SET $ 1,231.12 02720306 HB SMART NEEDLE $ 1,844.01 02720308 HB NEEDLE, FNA $ 1,867.85 02720311 HB ORAL APPLIANCE $ 1,944.61 02720312 HB GUIDE, DRILL 1 $ 1,215.67 02720315 HB CEMENT CART.SYS 540198000 $ 1,287.34 02720318 HB CATHETER, THORACIC $ 275.50 02720321 HB ENDO DISSECT, LONG/SHORT $ 3,024.03 02720322 HB , ABDOMINAL MOBIUS $ 1,311.26 02720324 HB TUBING CUSA MANIFOLD $ 1,311.26 02720325 HB TUBE HARVESTER WITH PINS $ 3,674.19 02720326 HB LACRICATH 1 $ 4,369.03 02720329 HB CANNULA, HYDRODISSECTOR $ 146.37 02720331 HB ADHESIVE, INDERMIL $ 367.39 02720334 HB APPLICATOR TIP 1 $ 723.96 02720335 HB BLADE, GENERAL 2 $ 1,328.13 02720337 HB CATH CHIOU SP 075920 $ 1,329.22 02720338 HB NEEDLE, BIOPSY/ASP/LOC/INJ MRI $ 805.57 02720339 HB PERF RESEVOIR CARDIO 90300018 $ 1,338.23 02720340 HB ELECTRODES $ 1,339.64 02720342 HB GASTROSTOMY GIAS-100 $ 1,343.93 02720343 HB NEURO BECKER EDMS $ 1,350.20 02720345 HB INTRODUCER, NEEDLE $ 808.55 02720346 HB ABC DISPOSABLE TIP (NOZZLE) $ 1,356.41 02720353 HB POUCH, EAKINS $ 253.78 02720355 HB BLOOD CONSERVATION SYSTEM $ 1,393.49 02720356 HB INFLATION APPARATUS $ 1,407.05 02720357 HB TWIST DRILL, SURGICAL 2 $ 1,407.05 02720362 HB SEALANT HEMOSTATIC 1 $ 1,940.23 02720363 HB PERF CDI 500 SHUNT SENSOR $ 1,437.03 02720365 HB ENDO SHEARS, LONG/SHORT $ 2,288.17 02720366 HB CATHETER, PENUMBRA NEURON GUIDE $ 1,456.07 02720367 HB MONITORING KIT, VENTRICULAR $ 6,690.54 02720368 HB REAMER, MODULAR SHAFT 1 $ 1,462.91 02720369 HB CANNULA, CORONARY PERF $ 1,466.72 02720374 HB MONITORING KIT, INTRACRANIAL P $ 8,544.22 02720378 HB PROBE, SOMN/ULTRSND/ARTHRO $ 1,505.04

Ancillary FY21 6 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720379 HB NAV-X EP MAP ELECTRODE $ 9,184.59 02720380 HB PROBE, ABLATION $ 12,063.41 02720381 HB KIT, ENDO MUCOSAL RESECTION $ 2,371.15 02720382 HB TUBE, GASTROSTOMY 2 $ 1,529.86 02720384 HB BONE MILL BM200 $ 1,535.81 02720387 HB CATHETER, BILIARY DILAT C1726 $ 1,573.23 02720388 HB SEPARATOR PENUMBRA $ 13,629.44 02720389 HB IMPEDANCE PROBE $ 1,580.71 02720390 HB CANNULA, ERCP BALL/CONTOUR $ 799.60 02720391 HB RETRACTOR, FAN ENDOSCOPIC $ 1,583.70 02720392 HB NEEDLE, ENTRY $ 140.92 02720394 HB KIT, PENUMBRA $ 21,979.02 02720395 HB SPHINCTERTOME DBL LUMEN $ 1,461.07 02720398 HB BRUSH, FEMORAL/CYTO $ 314.36 02720400 HB IV BAG-O-JET $ 293.60 02720401 HB CATHETER, UMBILICAL $ 321.13 02720402 HB POSITION COLLAR CERVICAL SOFT $ 324.57 02720403 HB CANNULA, ARTHRO/ENDO $ 329.30 02720404 HB TUBING TO EVACUATOR MACHINE $ 329.30 02720406 HB NEEDLE, ENDO VERESS 1 $ 332.30 02720407 HB URODYNAMIC PUMP TUBING $ 332.30 02720411 HB ENDO CLOSURE PROC/KIT CTI-512N $ 1,355.75 02720412 HB ENDO VERSASTEP NEEDLE 14G $ 341.28 02720415 HB CLIP, HEMOLOK $ 350.28 02720420 HB DRAIN ABRAMSON TRIPLE LUMEN $ 356.24 02720422 HB MICROPUNCTURE SET C1894 $ 584.39 02720423 HB WIRE, TOUHY-BORST Y-VALVE CONN $ 362.12 02720425 HB TUBING, IRRIGATION 1 $ 604.81 02720426 HB COLOSTOMY CLAMP $ 363.33 02720428 HB PRESSURE TUBING $ 445.15 02720429 HB TUBING, STACKHOUSE/EVACUATOR $ 371.23 02720430 HB DRAINAGE SET, CHEST SNGL LINE $ 372.60 02720432 HB BALLOON, KYPHON $ 6,070.38 02720433 HB CANNULA 8.25MM X 7 CM AR 6530 $ 374.25 02720435 HB BIOPSY KIT $ 374.57 02720438 HB RETAINER, VISCERA SURGIFISH $ 381.03 02720442 HB CANNULA, ARTHRO 1 $ 386.17 02720446 HB DRAIN, PENROSE $ 327.59 02720450 HB PC CONCHA WATER $ 126.57 02720453 HB ENDO TIP COVER INTUI 400180-0 $ 410.16 02720454 HB CANNULA, VENOUS 2 STAGE OVAL $ 410.93 02720455 HB PERF ARTERIAL FILTER (351) $ 416.13 02720459 HB CATHETER, ROBINSON $ 417.32 02720461 HB BIOPSY DEVICE KYPHON $ 418.88 02720462 HB , SURGICAL 2 $ 423.56

Ancillary FY21 7 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720464 HB TUBING ARTERIAL LINE M/F $ 414.39 02720465 HB SET MINI TRIFUSE $ 132.06 02720466 HB KNIFE, HANDLE BEV/LARYN $ 430.01 02720468 HB STATLOCK $ 297.12 02720469 HB BLADE, SAW 1 $ 469.46 02720472 HB PROBE, FLOW PUMP $ 449.08 02720473 HB SURGIFOAM, ABSORBABLE SPONGE 2 $ 449.08 02720474 HB DRESSING VAC $ 449.69 02720475 HB ENDO PROBE ELECTRODE $ 453.29 02720477 HB CATHETER, FOLEY 5CC/30CC $ 1,185.50 02720478 HB CANNULA, OPS VALVE $ 464.81 02720480 HB BALLOON, EXTRACT/BASKET $ 1,222.26 02720483 HB CANNULA, INNER DISP $ 472.59 02720484 HB BLADE, AORTIC PUNCH $ 473.57 02720485 HB KIT, REFILL NEUROSTIMULATION $ 479.00 02720486 HB NEEDLE, JAM/INF/CAR/MNS/DURA $ 479.00 02720493 HB INSEMI-CATHETER $ 166.16 02720496 HB ENDO IRRIGATOR HYDRO-SURG PLUS $ 768.61 02720497 HB TUBING, $ 163.03 02720501 HB TUBE, GASTROSTOMY 2 $ 1,279.94 02720503 HB ABDOMINAL BINDER $ 1,213.49 02720508 HB CANNULA , VENOUS RETURN $ 532.87 02720509 HB DILATOR $ 541.85 02720510 HB PERICARDIOCENTESIS KIT $ 1,339.90 02720512 HB SNARE, POLYPECTOMY $ 789.35 02720513 HB CONTAINER, PLEURX EVAC $ 552.98 02720514 HB BLADE, LARYNGOSCOPE $ 553.84 02720515 HB CATHETER, CHOLANGIOGRAM $ 553.84 02720522 HB MONITORING TRANSDUCER VENOUS $ 1,631.53 02720523 HB MONITORING TRANSDUCER ARTERY $ 1,439.19 02720525 HB CATHETER, COUNCIL C1729 $ 1,646.34 02720526 HB CANNULA, IRRIGATING 2 $ 1,646.58 02720531 HB BALLOON, PRESSURE DEVICE $ 1,693.39 02720532 HB ENDO CLIP APPLIER 5MM $ 1,694.50 02720533 HB BLADE, HARMONIC $ 1,700.47 02720536 HB PROBE, COAGULATING BEAM $ 1,275.36 02720537 HB INJECTOR $ 1,490.18 02720538 HB TUBE, BRONCHCATH, RT/LT $ 802.87 02720541 HB ANORECTAL CATHETER $ 1,041.61 02720545 HB TUBE, ET $ 367.07 02720546 HB URINARY DRAIN BAG $ 380.38 02720549 HB INFUSION US LYSIS SYSTEM $ 10,748.12 02720556 HB SHEATH, BANNANA PEEL $ 1,427.35 02720557 HB CATHETER, COUNCIL STIFFNERS $ 361.70 02720558 HB GASTROSTOMY PLV-24-.38 $ 644.88

Ancillary FY21 8 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720559 HB HEMOSTASIS PATCH $ 809.79 02720560 HB INFLATION DEVICE KYPHON $ 947.13 02720562 HB KIT, TIPS $ 3,557.33 02720563 HB 2 CONTACT STRIP ELECTRODE $ 1,329.94 02720567 HB CATHETER, ARGON COAG PROBE $ 1,752.79 02720568 HB NASOGASTRIC TUBE IRRIGATION $ 542.92 02720570 HB CATHETER, BILIARY MANOMETRY $ 1,854.60 02720572 HB BLADE, DISSECTING DIEGO $ 1,212.48 02720575 HB BLADE, PIVOTAL/FIXED HEAD $ 87.09 02720582 HB CANNULA SEAL $ 433.20 02720583 HB CANNULA AORTIC $ 1,284.61 02720586 HB CANNULA, ARTERIAL 2 $ 1,997.64 02720588 HB CANNULA, IMA $ 305.84 02720589 HB CANNULA, OPHTHALMIC $ 487.97 02720591 HB CANNULA, VENOUS 5 $ 4,367.94 02720599 HB CATHETER, VENTRICULAR 1 $ 410.16 02720600 HB CLIP CORONARY ARTERY RETRACTON $ 224.55 02720601 HB CLIP OMNI CLIP GUN $ 736.46 02720602 HB CLIP SURGICLIP PREMIUM $ 2,404.50 02720604 HB CUTTER, ENDOSCOPIC 4 $ 2,954.85 02720606 HB DISSECTOR, BLUNT CHERRY $ 368.23 02720609 HB ENDO ENDOPOUCH PRO RETRIEVAL $ 738.39 02720611 HB ENDO LAP DISC HAND DVICE LD111 $ 4,793.03 02720612 HB , ENDOSCOPIC 1 $ 1,248.42 02720613 HB ENDO SURESEAL II $ 220.37 02720615 HB HANDPIECE, ENDOSCOPIC 1 $ 975.44 02720619 HB EXTRACTOR, STONE TIPLESS 2 $ 2,487.84 02720621 HB GELPORT, SEAL CAP $ 3,778.12 02720622 HB HEMOCLIP $ 403.22 02720623 HB CATHETER, HYDRAGLIDE 1 $ 337.47 02720624 HB ISOLATOR, ENDO XCL / XCR $ 13,044.70 02720627 HB IV MICRODRIP SET $ 66.93 02720631 HB KIT, WIRE STYLET $ 620.53 02720632 HB KIT, NEEDLE EYE SNARE WRKSTN $ 5,145.14 02720633 HB KIT, PROCEDURAL CARDIOVASCULAR $ 266.71 02720634 HB KIT, REPAIR CATHETER $ 1,230.17 02720636 HB KYPHON OSTEO INTRODUCER SYSTEM $ 10,867.43 02720637 HB LEAD EXTENDER, BULLDOG $ 1,477.43 02720638 HB MIDAS REX LUBRICANT/DIFFU $ 374.25 02720639 HB NEEDLE KEITH $ 98.78 02720645 HB TUBE, GASTROSTOMY $ 542.92 02720646 HB PACK, PHACO $ 1,368.17 02720649 HB PERFUSION HEMOCONCENTRATOR $ 1,185.35 02720652 HB PERF SUCTION CELL SAVER $ 287.78 02720654 HB PERFUSION ASSIST PACK $ 3,062.62

Ancillary FY21 9 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720655 HB MICRO RECIPROCATING $ 758.52 02720656 HB REAMER, CORING/HEAD $ 2,047.74 02720658 HB RELOAD, GIA ENDO 1 $ 1,327.36 02720659 HB SET SPINAL TRIGEMINAL GANGLION $ 2,430.93 02720660 HB SHUNT, CARDIOVASCULAR 1 $ 1,168.24 02720661 HB KIT, CATHETER $ 544.00 02720662 HB ENDO TACKER SYSTEM 5MM $ 2,586.62 02720669 HB T-TUBE, 1 $ 314.36 02720671 HB TUBING LEVEL 1 IR 600 $ 179.65 02720672 HB TUBING TUR 2 LEAD $ 272.53 02720673 HB TUBING, TEFLON $ 1,733.68 02720678 HB BASKET RETRIEVABLE INSERTABLE C1889 $ 1,936.98 02720681 HB BIOGLUE, SKNCLSR SYRINGE 3 $ 5,183.67 02720682 HB BLADE, GENERAL 1 $ 574.26 02720683 HB CABLE, MICROTARGETING $ 1,181.16 02720685 HB CANNULA, ENDO/ERCP/IRRIG $ 517.12 02720687 HB CATH THORACIC 36FR $ 542.26 02720690 HB CATHETER, DELIVERY SPY SCOPE $ 5,055.76 02720692 HB CATHETER, FOLEY 3WAY 5CC/30CC $ 639.05 02720693 HB CATHETER, BAKRI TAMPONADE $ 1,760.75 02720694 HB CATHETER, PICC DBL LUMEN C1751 $ 954.56 02720695 HB CATHETER, TEXAS EXTERNAL $ 163.03 02720696 HB CATHETER, TROCAR MM $ 1,447.57 02720697 HB CATHETER, PENUMBRA DELIVERY 6F $ 3,989.87 02720698 HB COLOSTOMY BAG 45MM $ 506.56 02720699 HB CORE BIOPSY NEEDLE-EUS $ 2,236.16 02720700 HB CANNULA, J HOOK $ 144.88 02720702 HB CANNULA, VENOUS 1 $ 781.41 02720703 HB CANNULA, VENOUS 2 $ 1,443.75 02720706 HB COOK NEEDLE $ 645.93 02720708 HB DRAIN PLEUR-EVAC ADULT/PEDS $ 517.92 02720712 HB EYE RETRACTOR FLEXIBLE $ 1,125.64 02720714 HB GUN, BIOGLUE APPLICATOR 1 $ 2,141.93 02720716 HB INTRO BLUE-ON-BLUE 8FR 260-120 $ 541.87 02720717 HB IV BLOOD PUMP Y-TYPE OR $ 174.01 02720718 HB KIT, DEEP BRAIN STIMULATION $ 351.10 02720721 HB LIGACLIP $ 257.01 02720723 HB BACKGROUND MATERIAL $ 194.58 02720727 HB PERI PATCH REPAIR KIT $ 470.87 02720736 HB CATHETER, CONNECTOR CTU $ 194.30 02720737 HB CVC INSERTION KIT $ 662.85 02720738 HB BRUSH, CYTOLOGY RX $ 1,395.54 02720739 HB DEPT ELECTRODE PASSING NEEDLE $ 1,002.23 02720742 HB DRAIN, URINARY $ 380.38 02720744 HB PROBE, EHL $ 3,205.77

Ancillary FY21 10 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720745 HB ELECTRODE, FETAL SCALP $ 437.91 02720747 HB ENDO ARTICULATIN LIN CUT ATW35 $ 1,634.94 02720748 HB EP MAP REFERENCE PATCH $ 7,510.12 02720750 HB NEEDLE, GUN SEMI-AUTO DISP $ 658.64 02720754 HB INDEFLATOR PTCA $ 969.10 02720760 HB CAST PLASTER SPLINT $ 154.91 02720763 HB ELC URINARY DRAIN BAG 154002 $ 134.12 02720765 HB TUBE, TRACHEOSOFT $ 892.69 02720766 HB CATHETER, FASTNER PERCU-STAY $ 138.33 02720767 HB FLOW CONTRL DEVICE 44-201 $ 149.69 02720768 HB DISSECTOR, SPONGE PEANUTS $ 100.79 02720769 HB BLADE, BEAVER $ 155.13 02720770 HB PIN GUIDE $ 946.04 02720771 HB IV PCA TUBING $ 161.67 02720772 HB STAPLER, ENDOSCOPIC 1 $ 1,242.41 02720773 HB MERIT MEDICAL RESPONSE KIT $ 1,345.00 02720777 HB CANNULA, BISHOP HARMON $ 118.47 02720778 HB TUBE, REPLACMNT Y-PORT $ 206.95 02720779 HB LENS GLIDE $ 173.62 02720781 HB DILATOR, VESSEL $ 192.09 02720783 HB DECUBICARE PAD $ 277.59 02720784 HB ADAPTER TUOHY-BORST TBA-6 $ 332.30 02720787 HB TUNNELER, SURGICAL 1 $ 519.85 02720789 HB TUBING HOTLINE $ 621.41 02720790 HB POUCH/WAFER PEDS $ 730.28 02720791 HB NEEDLE, VERTEBROPLASTY $ 800.22 02720794 HB MONITORING KIT, INTRAUTERINE P $ 1,048.64 02720795 HB ELECTRODE TEMP PACING 6F $ 1,152.32 02720799 HB ELECTRODE, ESU 3 $ 1,637.61 02720800 HB BLADE, OPTHALMOLOGIC 1 $ 413.84 02720806 HB INTRODUCER SHEATH $ 237.08 02720807 HB CLIP, DISPOSABLE 1 $ 997.91 02720808 HB ENDO ANTI FOG $ 166.34 02720809 HB NEEDLE, OSTYCUT BIOPSY $ 987.93 02720811 HB PC ENDOTRACHEAL TUBE # $ 1,003.99 02720813 HB ESU INSULATED COATED BLADE $ 124.18 02720814 HB SMOKE HOUSE FILTER $ 188.60 02720817 HB CATHETER, AIRWAY $ 195.62 02720818 HB BAG, DRAINAGE 600ML TRU-CLOSE $ 197.59 02720819 HB NEEDLE, CHIBA $ 197.59 02720822 HB PC CONCHA COLUMN $ 311.73 02720823 HB ADHESIVE REPAIR SUPPLY $ 204.16 02720825 HB BUTTERFLY, IV INFUSION $ 205.47 02720829 HB CHROMOVISION LIGHT HANDLE $ 206.57 02720835 HB TUBE STOMACH EVACUATOR 32FR $ 221.55

Ancillary FY21 11 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720842 HB NEEDLE CYSTOME $ 214.21 02720843 HB CANNULA, INTRACARDIAC SUMP $ 251.74 02720845 HB NEEDLE, LONG, AMNIO, ECHOTIP $ 437.92 02720846 HB OT STRAPPING MATERIAL $ 61.03 02720847 HB RELOAD, ENDOSTITCH 1 $ 308.97 02720849 HB THEMOCOOL TUBING SET $ 314.36 02720850 HB TUBING, PRESSURE 1 $ 254.46 02720854 HB TUBING SMOKE EVACUATOR $ 211.66 02720858 HB CLIP APPLIER LIGACLIP $ 855.25 02720859 HB SCALPEL, SURGICAL 1 $ 37.58 02720860 HB MASTISOL LIQUID ADHESIVE $ 74.85 02720861 HB TOUEY-WEISS NEEDLE $ 933.05 02720863 HB SUCTION, RESEVOIR J-P $ 951.99 02720864 HB CATHETER, URINARY EXTERNAL $ 80.86 02720865 HB OPTHALMIC SURG KIT $ 80.86 02720871 HB NEEDLE, INTRODUCER MANAN $ 177.82 02720876 HB BAG, DRAINAGE URINARY $ 105.77 02720880 HB KIT, UROSTOMY $ 198.70 02720883 HB SNARE 1 $ 258.55 02720884 HB TIP,PULSEVAC FLEX / IRRIGATION $ 274.88 02720889 HB NEEDLE, RADIOFREQUENCY $ 444.53 02720896 HB CORD, DISPOSABLE 1 $ 293.95 02720899 HB PERF PMP PCK MEMBRANE 62003-01 $ 1,742.41 02720902 HB CATHETER, RENAL DILATOR $ 1,777.93 02720904 HB SPLINT 1 $ 637.55 02720905 HB ENDOVASCULAR/RENAL DILATOR SET $ 1,805.25 02720911 HB TRANSDUCER, NEONATE $ 668.28 02720912 HB BLADE, MYRINGOTOMY $ 277.19 02720913 HB CANNULA, ARTERIAL FEMORAL 4 $ 1,852.54 02720914 HB CATH ROBINSON $ 635.81 02720915 HB BLADE, SAW 2 $ 1,008.00 02720916 HB NEEDLE, BIOPSY 3 $ 1,894.79 02720919 HB KYPHON BONE BIOSPY DEVICE $ 1,365.18 02720921 HB PC CYTOLOGY BRUSH $ 1,375.86 02720922 HB PC TOTAL FACE MASK $ 2,596.39 02720926 HB PC BRONCHOSCOPY FORCEPS $ 3,380.14 02720928 HB CATH PACK -CATH LAB * $ 1,024.30 02720929 HB NERVE STIMULATOR 1 $ 1,953.24 02720931 HB EXTRACTOR, STONE $ 1,959.47 02720932 HB PC WANG NEEDLE $ 2,215.63 02720933 HB CATHETER, SWAN-GANZ W/THROMBO $ 1,988.75 02720934 HB BASKET, LITHOCATCH/PARACHUTE $ 2,002.85 02720935 HB FORCEPS, ENDOSCOPIC 3 $ 2,032.78 02720936 HB ENDO CLIP $ 2,067.21 02720937 HB TAP, DISPOSABLE 3 $ 2,087.45

Ancillary FY21 12 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720943 HB FORCEPS, BIOPSY I $ 433.08 02720944 HB KIT, CRANIAL ACCESS $ 2,180.03 02720949 HB TUBING, IVAC PUMP NICU $ 1,017.84 02720950 HB CATH SIZING BALLOON $ 2,302.40 02720954 HB TWIST DRILL, SURGICAL 3 $ 1,844.18 02720957 HB SNARE, GOOSE NECK $ 3,796.09 02720958 HB CATHETER, DRAINAGE APDL $ 1,185.56 02720962 HB CATHETER, ACHALASIA DILATOR $ 2,707.01 02720965 HB BLADE, $ 1,667.91 02720966 HB KIT, LEAD ACCSRY INTR/REV $ 2,565.67 02720968 HB NEEDLE, SPINAL $ 305.39 02720969 HB PERF RESERVOIR OXGYENATOR $ 2,620.90 02720972 HB SET LEVEL I DISP $ 774.59 02720980 HB INTRODUCER/SHEATH, CV 1 $ 2,653.56 02720981 HB TIP, CATHETER INTRODUCER $ 2,653.56 02720983 HB FORCEPS, ENDOSCOPIC 4 $ 2,676.44 02720984 HB TUBE, REAMER/IRRIG/ASPIRATOR $ 2,680.81 02720986 HB ELECTRODE, VERSA/LOW IMPEDENCE $ 2,713.47 02720987 HB PIN, GUARD $ 362.89 02720990 HB CATH ARTHERECTOMY C1714 $ 24,412.72 02720991 HB CATHETER, ATHERECTOMY BALLOON C1714 $ 16,465.75 02720992 HB ARTHRO WAND 2 $ 2,835.10 02720994 HB CATHETER, BALLOON PTA C1725 $ 2,793.56 02720996 HB CATH DUOSTAT PTCA C1725 $ 1,020.63 02720999 HB CATH DILITATION PTA C1725 $ 2,851.53 02721000 HB FORCEPS, SPYBITE BIOPSY $ 3,052.92 02721001 HB SHEARS, HARMONIC 2 $ 3,092.57 02721004 HB CAPSULE, ENDOSCOPE DEL SYS $ 3,227.27 02721005 HB LIGASURE, ESU 2 $ 3,235.99 02721008 HB CATH INFUSION PTCA C1725 $ 2,913.13 02721011 HB FORCEP BX PIRANHA 505-160 $ 3,356.02 02721014 HB CATHETER, BALLOON SMALL VSL DEV. C1725 $ 6,329.38 02721015 HB TAP, DISPOSABLE 4 $ 3,475.49 02721016 HB TIB TUNNEL CANN AR-1802D $ 383.19 02721019 HB TUBE, TRACHEOSTOMY 1 $ 604.81 02721020 HB TUBE, TRACHEOSTOMY 2 $ 1,578.52 02721021 HB CATH DILITATION PTCA C1725 $ 2,832.38 02721022 HB HEMORRHOID STAPLER $ 3,541.61 02721027 HB CANNULA, VENOUS FEMORAL 2 $ 3,682.33 02721031 HB CATHETER, BALLOON MICROSYS STEALTH C1726 $ 7,123.43 02721032 HB CATH DILATION VALVULOPLASTY C1726 $ 12,392.41 02721039 HB CATHETER,BALLOON BIL DILAT C1726 $ 3,288.06 02721042 HB BLADE, SHAVER 3 $ 4,098.47 02721044 HB CATH DILATION SEPTOSTOMY C1726 $ 2,301.22 02721045 HB CATHETER, ABLA ESOPHAGUS C1888 $ 5,336.05

Ancillary FY21 13 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721047 HB BONE CEMENT REMOVAL SYSTEM $ 4,232.12 02721049 HB CATHETER,DISCYPHOR SYS W/GUIDE $ 4,431.27 02721050 HB NEEDLE, TRANSJUGULAR LIVER $ 4,437.24 02721051 HB CATHETER, CRE BAL DILAT C1726 $ 2,191.26 02721052 HB ANCHOR, AMPLATZ C1713 $ 1,221.11 02721053 HB CATHETER, DRAINAGE NEPHROSTOMY C1729 $ 1,063.41 02721056 HB NEURO MICROTARGETING DEVICE $ 4,987.63 02721059 HB PROBE, NIM 2 $ 5,244.55 02721060 HB CATHETER, DRAINAGE 2 C1729 $ 1,006.67 02721061 HB CATHETER, DRAINAGE C1729 $ 1,197.90 02721062 HB CATHETER, DRAINAGE BILIARY C1729 $ 1,057.00 02721064 HB CATHETER, NASO BIL DRAINAGE C1729 $ 841.24 02721065 HB CATHETER, EP,19 OR FEW ELEC C1730 $ 6,427.66 02721067 HB CATHETER, BICAP PROBE $ 6,245.35 02721068 HB LASER FIBER, 6 $ 6,605.13 02721069 HB CATH EP <19 ELECTRODES C1730 $ 7,961.26 02721073 HB KIT, ENDOVESSEL HARVEST $ 6,649.18 02721074 HB CATH EP ABLATION 3D C1732 $ 10,743.94 02721075 HB CATH EP DIAG/ABLAT 3D MAP C1732 $ 13,096.20 02721076 HB CATH EP ABLATION NON 3D C1733 $ 10,554.31 02721079 HB CATHETER, HEMO, LONG TERM C1750 $ 1,135.72 02721080 HB 64-CONTACT STRIP ELECTRODE $ 7,397.61 02721081 HB CATHETER, PENUMBRA REPERFUSION $ 7,400.10 02721083 HB CATHETER, MICROSYS INFUSION C1751 $ 3,910.68 02721084 HB CATHETER, CENTRAL VEN TPL LMN C1751 $ 1,518.25 02721085 HB CATHETER, CENTRAL VEN SNGL LMN C1751 $ 312.97 02721088 HB UK INFUSION CATHETER $ 1,289.91 02721091 HB CATHETER, SINUS 1 $ 11,956.04 02721092 HB MICROSYS CATHETER 2-TIP $ 3,101.69 02721094 HB MICROSYS CATHETER 1-TIP C2628 $ 2,953.99 02721095 HB CATHETER, CENTRAL VEN DBL LMN C1751 $ 1,177.50 02721098 HB CATHETER PERM-A-CATH C1751 $ 2,825.82 02721099 HB CATH ENDOPROSTHESIS DELVRY C1874 $ 14,222.85 02721101 HB CATHETER, PORT-A-CATH C1751 $ 151.83 02721105 HB $ 3,479.58 02721107 HB BLADE, SHAVER 1 $ 1,657.46 02721109 HB BLOOD ADMIN SET Y TYPE $ 239.45 02721110 HB BLOOD PUMP SET W/FILT 7' * $ 440.27 02721111 HB BRAVO CAPSULE $ 2,880.87 02721112 HB CANISTER, V.A.C. $ 592.86 02721113 HB CATH FOLEY $ 879.05 02721114 HB CATH ROBINSON 2-EYE 26FR $ 334.32 02721115 HB CATH ULTRASOUND INTRAVASC C1753 $ 6,277.74 02721116 HB CATHETER, EPIDURAL ARROW 19 GA C1754 $ 7,189.35 02721117 HB CATHETER, THROMBCT/EMBOLECT-120CM C1757 $ 7,945.06

Ancillary FY21 14 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721118 HB CATH THROMBCT/EMBOLECT-50CM C1757 $ 5,740.86 02721119 HB CATHETER, DIAGNOSTIC $ 650.27 02721121 HB CATHETER, FOGARTY C1757 $ 4,448.18 02721122 HB CATHETER, THROMBCT/EMBOLECT-50CM C1757 $ 5,646.64 02721124 HB CATH ULTRASOUND ACUNAV C1759 $ 22,821.13 02721125 HB CATHETER, TRANS/LU,NONLRS 3 C1725 $ 3,646.97 02721128 HB INTRO/SHEATH EP FIXED NON-PEEL C1766 $ 1,049.05 02721129 HB CATHETER, BALLOON DILATION2 C1726 $ 4,255.17 02721131 HB CATHETER, BALLOON DILATION4 C1726 $ 2,212.42 02721132 HB GUIDEWIRE, 0.18/GOLD C1769 $ 1,228.83 02721135 HB GUIDE WIRE PTCA C1769 $ 1,324.95 02721137 HB CATHETER, BALLOON DILATION7 C1726 $ 4,703.19 02721138 HB GUIDEWIRE C1769 $ 392.62 02721139 HB GUIDEWIRE, TERUMO AMPLATZ C1769 $ 584.39 02721140 HB GUIDE WIRE ACCESSORY KIT C1769 $ 1,536.68 02721141 HB CATHETER, BALLOON DILATION3 C1726 $ 1,811.25 02721143 HB GUIDEWIRE, MM C1769 $ 221.32 02721144 HB CATHETER, DRAINAGE 3 C1729 $ 2,571.63 02721145 HB GUIDEWIRE, LONG .018-.015 C1769 $ 584.39 02721146 HB GUIDEWIRE EXCHANGE PTCA C1769 $ 2,691.67 02721147 HB CATHETER, DRAINAGE 1 C1729 $ 275.46 02721149 HB CATHETER FLOWIRE C1769 $ 2,592.47 02721150 HB GUIDE WIRE CATH LAB C1769 $ 1,981.48 02721151 HB GLIDEWIRE/GUIDEWIRE C1769 $ 1,529.20 02721152 HB GUIDEWIRE, INTERVENTIONAL COON C1769 $ 217.34 02721154 HB GUIDE WIRE EP C1769 $ 255.83 02721155 HB GLIDE WIRE TERUMO C1769 $ 511.89 02721156 HB GUIDEWIRE J BENTSON COONS C1769 $ 584.39 02721157 HB GUIDEWIRE, TERUMO C1769 $ 584.39 02721158 HB STENT, OASIS NON-COAT/COV W/DEL C1876 $ 501.23 02721159 HB GUIDEWIRE, US 1408/1809/2500 C1769 $ 584.39 02721160 HB GUIDEWIRE, AMPLATZ SS C1769 $ 584.39 02721161 HB JAGWIRE I C1769 $ 1,373.56 02721163 HB COIL, PUSHER $ 1,628.88 02721164 HB CATHETER, INFUSION 1 C1751 $ 819.66 02721166 HB GUIDEWIRE, MICROSYS MICROWIRE C1769 $ 2,693.94 02721170 HB GUIDE WIRE CATH EP LAB C1769 $ 894.52 02721171 HB GUIDEWIRE, PLATINUM .018 TIPPED C1769 $ 2,268.16 02721174 HB CATHETER, GUIDING MICROSYS C1887 $ 3,387.94 02721175 HB GUIDEWIRE, PMG NITREZ 18-60 C1769 $ 284.57 02721176 HB GUIDE WIRE-J BENTSON COONS C1769 $ 586.62 02721177 HB MRI ENDORECTAL INSERTABLE COIL C1770 $ 1,265.20 02721179 HB RTRVL DVC, COIL C1773 $ 3,910.68 02721180 HB SNARE RETRIEVER DEVICE C1773 $ 2,018.99 02721181 HB RTRVL DVC, FILTER IVC C1773 $ 1,165.78

Ancillary FY21 15 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721182 HB RTRVL DVC, SNARE GNC C1773 $ 3,146.37 02721185 HB PT/PRGMR, NEUROSTIMULATOR 4 C1787 $ 7,310.26 02721187 HB EMBOLIC PROTECTION SYSTEM * C1884 $ 12,549.13 02721190 HB CATHETER, URETERAL 1 C1758 $ 499.98 02721191 HB EMBOLIC PROTECTION SYSTEM* C1884 $ 17,747.80 02721192 HB EMBOLIZATION PROTECTIVE SYSTEM C1884 $ 9,787.40 02721193 HB CATH ANGIOPLASTY LASER C1885 $ 19,114.11 02721194 HB CATH THERMODILUTION C1887 $ 2,314.11 02721196 HB CATH DIAGNOSTIC ANGIO C1887 $ 235.39 02721197 HB CATHETER, GUIDING C1887 $ 1,282.76 02721200 HB CATHETER, GUIDING 1 C1887 $ 773.79 02721201 HB CATH GUIDING PEDS C1887 $ 1,335.24 02721202 HB CATH GUIDING RAPIDO DEL SYS C1887 $ 7,255.73 02721203 HB GUIDEWIRE 6 C1769 $ 3,195.16 02721204 HB THROMBOLITIC INFUSION WIRE C1887 $ 2,036.11 02721205 HB CATHETER, GUIDING 4 C1887 $ 2,311.79 02721206 HB CATH BERMAN C1887 $ 1,922.66 02721207 HB CATH DIAGNOSTC ANGIO MULTIPACK C1887 $ 1,786.68 02721208 HB INTRO/SHEATH, GUIDING C1892 $ 644.10 02721209 HB INTRO/SHEATH, GUIDING 1 C1892 $ 710.64 02721211 HB EP INTRO/SHEATH, GUIDING 1 C1892 $ 609.21 02721212 HB INTRO/SHEATH GUIDE EP TRNSPTL C1893 $ 1,552.68 02721213 HB INTRO/SHEATH FIXED NON PEEL C1893 $ 1,713.44 02721215 HB NEEDLE, TRANSEPTAL $ 2,111.23 02721216 HB INTRODUCER SHEATH, NON GUIDING C1894 $ 309.80 02721220 HB INTRO/SHEATH, CONTRALATERA C1894 $ 495.43 02721222 HB INTRO/SHEATH, BLKN LONG C1894 $ 763.40 02721224 HB INTRO/SHEATH C1894 $ 385.56 02721225 HB CATHETER, OCCLUSION BALLOON C2628 $ 1,599.32 02721230 HB GUIDEWIRE 3 C1769 $ 1,605.73 02721232 HB EP CATHETER-EZ STEER NAV BI-D C2630 $ 26,307.95 02721237 HB K-WIRE, SUPPLY 2 $ 1,015.57 02721238 HB ENDOSCOPIC STRYKEFLOW II $ 640.06 02721239 HB TOOL, DISSECTING 1 $ 960.38 02721241 HB K-WIRE, SUPPLY 3 $ 1,557.37 02721244 HB PERFUSION BIO PUMP 1 $ 1,652.10 02721246 HB FILTER, BUFFALO KTP $ 612.34 02721248 HB PT/PRGMR, NEUROSTIMULATOR 5 C1787 $ 7,881.69 02721252 HB CUTTER, ENDOSCOPIC 2 $ 1,937.89 02721254 HB K-WIRE, SUPPLY 1 $ 394.00 02721255 HB RELOAD, ENDOSCOPIC 2 $ 1,471.52 02721256 HB EXTENSION, SINUS GUIDE $ 801.38 02721258 HB ARTHRO FLOOR SUCTION MAT OR $ 462.17 02721259 HB PRESSURIZER, FEMORAL CEMENT $ 713.15 02721260 HB CATHETER, GUIDING PERF/INFUS 3 C1887 $ 2,740.67

Ancillary FY21 16 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721262 HB SUCTION MINI POINT WAND $ 403.22 02721264 HB BLADE, FULL RADIUS $ 977.81 02721270 HB INTRO/SHEATH, GUIDING 2 C1892 $ 1,048.11 02721271 HB SPRAY SET, BIO TISSEEL $ 718.22 02721272 HB CATHETER, EP COOL-TIP C2630 $ 5,902.54 02721276 HB INTRODUCER/SHEATH,NONGDNG 3 C1894 $ 2,604.58 02721284 HB INTRODUCER/SHEATH,NONGDNG 2 C1894 $ 727.04 02721287 HB PROBE, CRYOABLATION 3 C2618 $ 13,537.31 02721288 HB CATHETER, SUPRAPUBIC 1 C2627 $ 645.03 02721291 HB CATHETER, STAMEY SUPRAPUBIC C2627 $ 646.63 02721293 HB CATHETER, OCCLUSION 1 C2628 $ 3,078.15 02721294 HB INTRODUCER/SHEATH, LASER 2 C2629 $ 14,933.45