KNOX COMMUNITY HOSPITAL VALID JANUARY 1, 2020 CHARGE DESCRIPTION CHARGE AMOUNT - BALLOON CATHETER FOX PLUS 5.0X60X135 $ 360.00 HIP DRAPE W/ POUCH C $ 67.80 INJECT FOR SPINE DISK X-RAY $ 576.00 MINI TREK OTW 1.5X12MM $ 672.00 MINI TREK OTW 1.5X20MM $ 520.00 MINI TREK OTW 1.5X6MM $ 672.00 MINI TREK OTW 1.5X8MM $ 672.00 MINI TREK OTW 2X12MM $ 520.00 MINI TREK OTW 2X15MM $ 672.00 MINI TREK OTW 2X8MM $ 672.00 N BLOCK INJ SCIATIC SNG $ 1,627.07 NJX INTERLAMINAR CRV/THRC $ 1,912.10 NON STRESS TEST $ 409.63 PROQUAD VACCINE $ 480.69 REVISE/REMOVE NEURORECEIVER $ 7,059.73 TREK OTW 2.25X12MM $ 560.00 TREK OTW 2.25X15MM $ 520.00 TREK OTW 2.25X30MM $ 560.00 TREK OTW 2.5 X 15MM $ 520.00 TREK OTW 2.5 X 20MM $ 520.00 TREK OTW 2.5X30MM $ 560.00 TREK OTW 2.5X8MM $ 672.00 TREK OTW 2.75 X 12MM $ 520.00 TREK OTW 2.75 X 15MM $ 520.00 TREK OTW 2.75X30MM $ 520.00 TREK OTW 3.25X12MM $ 672.00 TREK OTW 3.25X15MM $ 672.00 TREK OTW 3.25X30MM $ 672.00 TREK OTW 3.5X20MM $ 672.00 TREK OTW 3.5X30MM $ 520.00 TREK OTW 3.5X8MM $ 672.00 TREK OTW 3.75X12MM $ 560.00 TREK OTW 3.75X30MM $ 672.00 TREK OTW 3X15MM $ 520.00 TREK OTW 3X20MM $ 520.00 TREK OTW 3X30MM $ 560.00 TREK OTW 3X8MM $ 560.00 TREK OTW 4.5X15MM $ 520.00 TREK OTW 4X12MM $ 520.00 TREK OTW 4X15MM $ 520.00 TREK OTW 4X20MM $ 520.00 TREK OTW 4X30MM $ 672.00 TREK OTW 4X8MM $ 672.00 TREK OTW 5X15MM $ 672.00 CHARGE DESCRIPTION CHARGE AMOUNT REMOVE SGLE TOE PHALNGE EA $ 363.04 REMOVE SGLE TOE PHALNGE EA $ 3,438.80 REMOVE SGLE TOE PHALNGE EA $ 3,801.84 #1 LPT ANGLED GREAT TOE $ 3,125.00 #3 TIBIAL COMPONENT (ZIMMER) $ 5,076.00 **PD & P INITIAL $ 268.98 ..DISP HOOD MED INFANT $ 59.00 ..OXISENSOR NEO/ADULT $ 62.40 ..TEE $ 2,445.19 .014 180 CM PROWATER FLEX GUIDEWIRE $ 340.00 .014 X 300CM HT ADVANC $ 65.60 .014 X 300CM HT ADVANCE $ 65.60 .014 X 300CM VIPERWIRE $ 600.00 .062 GUIDE WIRE TROCAR TIP $ 86.00 .3.2MM GUIDE PIN $ 270.00 .ACTINOMYCES AB $ 48.41 .ADDITIONAL SPECIMEN (GTT) $ 49.98 .AMINO ACIDS;QUANT $ 108.15 .BB ABO $ 122.05 .BB ANTIBODY ELUTION EA $ 464.65 .BB ANTIGEN TYPING ARC $ 387.76 .BB ANTIGEN TYPING KCH $ 323.13 .BB ANTIGLOBIN TECHNIQUE $ 354.80 .BB ARC IMMEDIATE SPIN $ 230.90 .BB ARC IRRADIATED COMPONENT $ 101.57 .BB ARC PLATELETS $ 291.00 .BB AUTOLOGOUS R C CHARGE $ 293.00 .BB CORD DAT $ 140.04 .BB CRYOPREC RC CHARGE $ 65.00 .BB FFP THAWING EACH UNIT $ 457.00 .BB FRESH FROZEN PLASMA $ 210.66 .BB IMMEDIATE SPIN $ 70.96 .BB INCUBATION $ 175.48 .BB PLATELET MIX & POOL $ 216.92 .BB PLATELET PHERERSIS (LR) $ 1,634.68 .BB PLATLETS LEUKOREDUCED $ 306.94 .BB PLATLETS PHERESIS LR IRR $ 280.11 .BB PRBC DEGLYCE $ 599.46 .BB RBC LR CMV NEG IRR $ 989.83 .BB RED BLOOD CELLS LEUKOREDU $ 700.32 .BB RH TYPE $ 61.95 .BB WASHED PACKED CELLS $ 657.55 .BLASTOMYCES ANTIBODY $ 197.53 .CARBOXYHEMOGLOBIN $ 95.00 .CHLORIDE OTHER SOURCE $ 70.04 .CULTURE AFB ID $ 92.70 CHARGE DESCRIPTION CHARGE AMOUNT .CULTURE ANAEROBIC ID $ 107.73 .CULTURE FUNGI ID MOLD $ 133.84 .CULTURE FUNGI ID YEAST $ 91.32 .CULTURE FUNGUS (SKIN NAIL) $ 95.28 .CULTURE FUNGUS OTHER $ 119.48 .CULTURE STOOL ADDIT PATHOGENS $ 71.01 .CULTURE STOOL ISO SAL SHIG $ 141.04 .CULTURE TYPING IMMUNO $ 104.03 .DIPTHERIA ANTIBODIES $ 181.54 .EB VIRAL CAPSID VCA $ 103.88 .EHRLICHIA $ 236.90 .FLOW CYTOMETRY $ 567.46 .FLOW CYTOMETRY EACH ADDITIONAL $ 100.45 .FLOW CYTOMETRY INTERPRETATION $ 150.38 .FUNGUS AB NOT SPECIFIED $ 200.26 .GAMMA GLOBULIN EACH $ 84.96 .HEP. B CORE AB IGM $ 95.84 .HETEROPHILE ANTIBODY $ 52.53 .HIGH RESOLUTION STUDY $ 335.78 .IEP OTHER FLUID $ 279.62 .IMMUNE COMPLEXES $ 97.85 .IMMUNOELECTROPHORESIS $ 70.02 .IMMUNOFIXATION ELECTROPHORESIS $ 202.98 .INFECTIOUS AGENT BY NA $ 290.46 .ISOENZYMES $ 103.00 .KAROTYPES AND BANDING $ 374.11 .LATEX TYPING $ 30.60 .LYMPHOCYTE TRANSFORMATION $ 206.00 .MATURATION INDEX $ 19.57 .METH HEMOGLOBIN $ 47.50 .MM DUCTOGRAM INJECTION $ 354.91 .NEPHELOMETRY $ 226.03 .O2 SATURATION $ 47.50 .PROTOZOA $ 108.15 .PTT FRACTION $ 460.35 .RSV AG DFA $ 66.95 .RSV AG EIA $ 66.95 .SENSITIVITY $ 82.00 .SENSITIVITY ONE DRUG $ 149.25 .SUGARS MULTI QUALITITIVE $ 166.86 .TETANUS ANTIBODIES $ 199.82 .THIN PREP IN FLUID $ 90.44 .TISSUE CULTURE $ 463.00 .UA DIPSTICK CHARGE ONLY $ 50.98 .URINALYSIS COMPLETE $ 55.00 .URINE COLLECTION TIMED VOLUME $ 22.20 CHARGE DESCRIPTION CHARGE AMOUNT .WEST NILE AB $ 94.76 .WEST NILE AB IgM $ 94.76 0.45% SOD CHL W/ 20MEQ KCL 1000ML $ 7.37 0.9% SODIUM CHLORIDE AVIVA 500ML $ 45.27 0296 DUAL COIL 64CM RELIANCE $ 11,058.00 1 D10 LRG DXTEND MBLOCK HUM $ 5,988.50 1 D10 STD DXTEND MBLOCK HUM $ 5,988.50 1 PROFUNDUS TENDON REPAIR $ 1,835.68 1 REPR/SUTR LEG EXTENSOR TENDON $ 899.25 1' REPR/SUTR LEG FLEXOR TENDON $ 881.00 1.0MM DRILL BIT MINI-QUICK CON $ 126.36 1.2 X 5 GUDIE PIN SCREW $ 452.00 1.25MM X 145CM MICROCROWN $ 6,790.00 1.3MM DRIVER BIT $ 144.40 1.4 WIRE WRIGHT MEDICAL $ 80.00 1.5 LG 300MM GLENO GUIDE PIN $ 238.44 1.5MM DRILL BIT $ 630.00 1.5MM DRILL BIT MINI-QUICK CON $ 126.36 1.5MM DRIVER BIT $ 129.96 1.5MM LOCK PLATE STRAIGHT $ 1,330.00 1.5MM LOCK PLATE T-SHAPE $ 1,330.00 1.5MM LOCK PLATE T-SHAPE SMALL $ 1,190.00 1.6 WIRE WRIGHT MEDICAL $ 80.00 1.6MM TIP K WIRE (DEPUY) $ 100.72 1.6MM KIRSCHNER WIRE TROCAR POINT 150MM $ 72.72 1.6MM X 6IN K-WIRE HALF BAY PT $ 92.40 1.8MM DRILL BIT WITH DEPTH MARK/QC/110MM $ 597.00 1.8MM KIRSCHNER WIRE W/ TROCAR POINT 150 $ 336.60 10 X 79/83 TIBIAL BEARING $ 2,537.50 10% D - WATER IV SOLN 500 ML $ 67.90 10CM ELECTRODES $ 270.00 10CM10MM EXPOSED TIP GAUGE CURVED NEEDLE $ 72.00 10MM/130 DEG TI CANN TFNA 340 MM LEFT $ 5,857.50 10X 63/67 TIBIAL BEARING $ 2,537.50 10X71/75 TIBIAL BERARING VANGRD $ 2,537.50 11-DESOXYCORTISOL $ 116.39 11FRX15CM TRI-FLOW DIALYSIS FULL TRAY $ 356.00 11FRX20CM TRI-FLOW DIALYSIS FULL TRAY $ 356.00 12 LEAD EKG; GLOBAL $ 41.05 12 LEAD EKG; INT REP $ 21.15 12 LEAD EKG; TRACING ONLY $ 19.88 12.7 X 85 VHS LAG SCREW W/ COMP SCREW $ 1,188.00 12/14 ARTICUL 40MM M SPC +1.5 $ 2,500.00 12/14 ARTICUL 40MM M SPEC +12 $ 2,500.00 12MM PC STEM GLOBAL ADVANTAGE $ 5,791.06 12X71/75 TIBIAL BEARING VANGRD $ 3,416.00 CHARGE DESCRIPTION CHARGE AMOUNT 13 X 145 ECHO FEMORAL $ 6,192.50 14 FR 30CM INTRODUCER $ 204.00 14FRX15CM SLXTEMP DIALYSIS FULL TRAY $ 860.00 14FRX20CM SLXTEMP DIALYSIS FULL TRAY $ 688.00 14MM 2.0 CORTEX SCREW TAPPING $ 144.40 14MM x 130mm HUMERAL STEM $ 11,606.40 15.5F X 32CM T-3 CT MAX BARRIER LUMEN $ 876.00 150 CM GUIDEWIRE $ 53.40 15CM ELECTRODES $ 270.00 15CM EXPOSED TIP 20 GAUGE CURVED NEEDLE $ 72.00 15MM ARTICULAR COMP TOE2 2.5MM $ 5,272.00 17-OH PREGNENOLONE $ 162.74 17-OH PROGESTERONE $ 208.06 19.0 TORIC LENS SN6AT4 $ 1,732.50 1999/46 LV LEAD $ 2,012.50 2 REPR TORN COLLAT ANKLE LIGAM $ 1,605.93 2 SUTURE ABD WALL FOR EVISCERATION $ 2,059.78 2,4MM LOCK SCREW SLF-TPNG W STARDRIVE 10 $ 536.20 2. 5MM METAGLENE GUIDE PIN $ 238.44 2.0 DRILL(SMART TOE) $ 1,064.00 2.0/2.5MM DRIVER BIT $ 144.40 2.0DRILL BIT $ 659.68 2.0MM LCP PLATE 6 HOLES / 45MM $ 1,007.00 2.0MM LCP T-PLATE 2 HOLES HEAD/HOLES $ 1,782.20 2.0MM LCP Y-PLATE 3 HOLES HEAD / 7 HOLES $ 1,782.20 2.0MM X 100MM DRILL BIT $ 350.60 2.0mm x5" QUICK RELEASE DRILL $ 432.00 2.4 MM LOCKING SCREW SLF-TPNG STAR 16MM $ 468.00 2.4MM / 1.8MM DOUBLE DRILL SLEEVE $ 1,604.00 2.4MM CORTEX SCREW SLF-TPNG T8 STAR 10MM $ 223.20 2.4MM CORTEX SCREW SLF-TPNG T8 STAR 12MM $ 225.00 2.4MM CORTEX SCREW SLF-TPNG T8 STAR 14MM $ 225.00 2.4MM CORTEX SCREW SLF-TPNG T8 STAR 16MM $ 225.00 2.4MM CORTEX SCREW SLF-TPNG T8 STAR 18MM $ 225.00 2.4MM CORTEX SCREW SLF-TPNG T9 STAR 20MM $ 250.28 2.4MM DRILL BIT/QC/100MM $ 720.00 2.4MM LOCKING SCRE SLF-TPNG STAR 22MM $ 468.00 2.4MM LOCKING SCRE SLF-TPNG STAR 24MM $ 471.60 2.4MM LOCKING SCREW SLF-TPNG STAR 18MM $ 468.00 2.4MM LOCKING SCREW SLF-TPNG STAR 20MM $ 536.20 2.4MM LOCKING SCREW SLF-TPNG W STAR 14MM $ 468.00 2.4MM LOCKING SCREW SLF-TPNG W STARD 12M $ 468.00 2.4MM LOCKING SCREW SLF-TPNG W/ STARDRIV $ 520.60 2.4MM TI VA-LCP 2-CLM VLR DST RADIUS PL $ 3,389.40 2.5 LG 120MM DRILL BIT $ 289.44 2.5 MM DRILL BIT ZIMMER $ 1,200.00 CHARGE DESCRIPTION CHARGE AMOUNT 2.5 SET IMPELLA $ 50,000.00 2.5MM BREAKAWAY GUIDE PIN APG $ 772.00 2.5MM DRILL BIT $ 370.40 2.5MM DRILL BIT MINI-QUICK CON $ 126.36 2.5MM LOCK PLATE STRAIGHT $ 1,584.00 2.5MM LOCK PLATE T-SHAPE $ 1,584.00 2.5MM LOCK PLATE Y-SHAPE $ 1,584.00 2.5MM PIN ZIMMER $ 672.00 2.5MM X 200MM DRILL TIP GUIDE WIRE $ 259.48 2.7MM / 2.0MM DOUBLE DRILL SLEEVE $ 1,314.80 2.7MM CALIB DRILL BIT $ 402.88 2.7MM CORTEX SCREW SLF-TPNG T8 STAR 12MM $ 151.20 2.7MM CORTEX SCREW SLF-TPNG T8 STAR 14MM $ 153.00 2.7MM CORTEX SCREW SLF-TPNG T8 STAR 16MM $ 170.20 2.7MM CORTEX SCREW SLF-TPNG T8 STAR 18MM $ 170.20 2.7MM CORTEX SCREW SLF-TPNG T8 STAR 20MM $ 170.20 2.7MM CORTEX SCREW SLF-TPNG T8 STAR 22MM $ 151.20 2.7MM CORTEX SCREW SLF-TPNG T8 STAR 26MM $ 151.20 2.7MM CORTICAL SCREW FT 10MM $ 161.12 2.7MM CORTICAL SCREW FT 14MM $ 153.08 2.7MM CORTICAL SCREW FT 46MM $ 153.08 2.7MM CORTICAL SCREW FT 50MM $ 153.08 2.7MM LCP L-PLATE OBLIQUE LEFT 2H HEAD $ 1,618.80 2.7MM LCP L-PLATE OBLIQUE RIGHT 2H HEAD $ 1,618.80 2.7MM LCP L-PLATE RIGHT 2H HEAD/3H SHAFT $ 1,618.80 2.7MM LCP T- PLATE 2 HOLES HEAD/3 HOLES $ 2,596.83 2.7MM X 14MM CORTICAL SCREW $ 324.00 2.7MM X 26MM $ 643.20 2.8MM X 5" QUICK RELEASE DRILL $ 340.00 2.9 X 70MM CANN DRILL $ 805.76 2-0 30CM STRATAFIX SPIRAL PDS PLUS VIO $ 92.48 20 MINUTE HEART CHECK $ 20.00 20.0 FR/20CM DILATOR COONS TPAER $ 100.80 22.5CM SKIMMER ANGLE TIP BLADE $ 1,702.60 24 HR URINE 17-OH CORTICOSTEROIDS $ 133.00 24 HR URINE CITRATE $ 240.70 24 HR URINE CREATININE CLEARANCE/CREAT $ 130.25 24 HR URINE HYDROXYPROLINE $ 82.40 24 HR URINE OXALATES $ 163.50 24 HR URINE UREA CLEARANCE $ 80.50 28MM DIA COCR MOD HD STD NK $ 3,090.50 2D TTE W OR W/O FOL