Procedure Code Description Revenue Code Charge 61413012 ADJUSTMENT M/S PEDS 113 3,251.00 61413021 ADJUST TELM/PULM/NURO/ORT 113 6,653.00 61713103 ADJ M/S PEDS 113 3,251.00 61716119 M/S PEDS - PRIVATE 113 3,626.00 61801013 ADJ M/S PEDS 113 3,251.00 61802019 ADJ BMT ACUTE 113 6,653.00 62067021 M/S PEDS - PRIVATE 113 3,626.00 62093001 M/S PEDS - PRIVATE 113 3,626.00 62093011 ADJ M/S PEDS 113 3,251.00 62093013 ADJ TELEM/PULM/TRACH/NURO 113 6,653.00 62123001 M/S PEDS - PRIVATE 113 3,626.00 62123011 ADJ M/S PEDS 113 3,251.00 62133003 M/S PEDS - PRIVATE 113 3,626.00 62133013 ADJ M/S PEDS 113 3,251.00 62153003 M/S PEDS - PRIVATE 113 3,626.00 62153013 ADJ M/S PEDS 113 3,251.00 62153015 ADJ TELEM/PULM/TRACH/NURO 113 6,653.00 62183003 M/S PEDS - PRIVATE 113 3,626.00 62183013 ADJ M/S PEDS 113 3,251.00 62183017 ADJ TELEM/PULM/TRAC/NURO 113 6,653.00 62211003 M/S PEDS - PRIVATE 113 3,626.00 62211015 ADJ M/S PEDS 113 3,251.00 62212001 MS/PEDS - BMT HIP 113 6,160.00 62212011 ADJ BMT-ACUTE CARE 113 6,653.00 62213001 M/S PEDS HEMONC 113 3,626.00 62213011 ADJ M/S HEM ONC 113 6,653.00 62214015 ADJ M/S CARDIAC MONITORNG 113 6,653.00 62243003 M/S PEDS - PRIVATE 113 3,626.00 62243011 ADJ TELEM/PULM/TRAC/NURO 113 6,653.00 62243013 ADJ M/S PEDS 113 3,251.00 62253003 M/S PEDS - PRIVATE 113 3,626.00 62253011 ADJ TELM/PULM/NURO/OBS 113 6,653.00 62253013 ADJ M/S PEDS 113 3,251.00 62263003 M/S PEDS - PRIVATE 113 3,626.00 62263011 ADJ TELEM/PULM/TRAC/NURO 113 6,653.00 62263013 ADJ M/S PEDS 113 3,251.00 72309250 M/S PEDS - PRIVATE 113 3,626.00 72309252 ADJ EDA ACUTE 113 3,251.00 72319250 M/S PEDS - PRIVATE 113 3,626.00 61419990 BEHAV - PRIVATE 114 2,330.00 62128001 M/S REHAB - PRIVATE 118 3,626.00 62063001 M/S PEDS - SEMI-PRIVATE 123 3,294.00 62063011 ADJ M/S PEDS 123 3,251.00 62063013 ADJ TELEM/PULM/TRAC/NURO 123 6,653.00 61418002 BEHAV - SEMI-PRIVATE 124 2,255.00 61418009 ADJ BIOBEHAV 124 2,436.00 61412011 ADJ REHAB 128 3,251.00 62128011 ADJ ACUTE REHAB 128 3,251.00 61716120 M/S PEDS - 5+ BEDS 153 3,010.00 70276135 M/S PEDS - 5+ BEDS 153 3,010.00 61712010 NICU LVL II - CONTINUING 172 3,924.00 61712059 ADJ NICU LEV 2 172 4,238.00 62067015 ADJ NICU LEV 2 172 4,238.00 62093111 ADJ NICU LEV 2 172 4,238.00 62153111 ADJ NICU LEV 2 172 4,238.00 62183111 ADJ NICU LEV 2 172 4,238.00 62263111 ADJ NICU LEV 2 172 4,238.00 61712012 NICU LEV III - INTERMED 173 6,160.00 61712089 ADJ NICU LEV 3 173 6,653.00 62067016 ADJ NICU LEV 3 173 6,653.00 62067019 NICU LEV III - INTERMED 173 6,160.00 62093113 ADJ NICU LEV 3 173 6,653.00 62153113 ADJ NICU LEV 3 173 6,653.00 62183113 ADJ NICU LEV 3 173 6,653.00 62263113 ADJ NICU LEV 3 173 6,653.00 61712014 NICU LVL IV - INTENSIVE 174 8,276.00 61712069 ADJ NICU LEV 4 174 8,939.00 62067017 ADJ NICU LEV 4 174 8,940.00 62093115 ADJ NICU LEV 4 174 8,940.00 62153115 ADJ NICU LEV 4 174 8,940.00 62183115 ADJ NICU LEV 4 174 8,940.00 62263115 ADJ NICU LEV 4 174 8,940.00 61717002 ICU 203 8,276.00 61717019 ADJ ICU 203 8,940.00 62093107 ICU 203 8,276.00 62093117 ADJ ICU 203 8,940.00 62153001 ICU 203 8,276.00 62153011 ADJ ICU 203 8,940.00 62183001 ICU 203 8,276.00 62183011 ADJ ICU 203 8,940.00 62243117 ADJ ICU 203 8,940.00 71480139 ADJ O/S ICU-SJ 203 5,411.00 61418217 ADJ INTENSIVE BIOBEHAV 204 2,821.00 61719991 ICU - TRAUMA 208 12,414.00 62097007 ICU - TRAUMA 208 12,414.00 62159990 ICU - TRAUMA 208 12,414.00 62189990 ICU - TRAUMA 208 12,414.00 72320025 ICU - TRAUMA 208 12,414.00 70855007 EVENT RECORD/INTERP 222 90.00 70855009 EVENT RECORD W/OXI INTERP 222 90.00 61419999 SITTER per 1 HR 239 53.00 61719999 SITTER per 1 HR 239 53.00 62069999 SITTER per 1 HR 239 53.00 62099999 SITTER per 1 HR 239 53.00 62129999 SITTER per 1 HR 239 53.00 62139999 SITTER per 1 HR 239 53.00 62159999 SITTER per 1 HR 239 53.00 62189999 SITTER per 1 HR 239 53.00 62219999 SITTER per 1 HR 239 53.00 62249999 SITTER per 1 HR 239 53.00 62259999 SITTER per 1 HR 239 53.00 62269999 SITTER per 1 HR 239 53.00 72309999 SITTER per 1 HR 239 53.00 72319999 SITTER per 1 HR 239 53.00 71701002 ACETAMINPHN 160MG/5ML LIQ 250 8.84 71701003 Acetaminophen 160 mg/5 mE 250 8.19 71701044 ALBENDAZOLE 200MG TAB 250 667.65 71701048 LEVOFLOXCN 25MG/ML PO 250 7.90 71701051 Riluzole 50 mg tab 250 225.80 71701061 MEDROXYPROGEST ACE 5MG TB 250 3.18 71701090 AMINOCPROIC 250MG PO 250 69.79 71701095 AMIODARONE 200MG TB 250 5.15 71701101 PROCHLORPRAZINE 5MG TB 250 4.85 71701102 PROMETHAZINE 12.5MG TB 250 5.30 71701121 CO-Q10 60MG CP 250 3.74 71701131 APIXABAN 5MG TAB 250 9.48 71701173 CREON 24000U CP 250 37.54 71701204 AMOX/CLAV 1000MG XR TAB 250 40.00 71701206 CREON 6000U CP 250 9.47 71701231 CREON 12000U CP 250 18.85 71701234 Epi 0.025%-Lidocaine 0.75 250 141.70 71701251 AMOXICLLN 250MG CP 250 4.69 71701252 MALARONE 250/100MG TAB 250 41.00 71701256 ATENOLOL 12.5 MG DOSE 250 5.30 71701294 BACLOFEN 5MG DOSE 250 5.32 71701337 BROMOCRIPTINE 2.5MG TB 250 26.94 71701385 CA CARB 500MG CHW TB 250 3.26 71701396 LEUCOVORIN CALCM 15MG TAB 250 72.04 71701446 Eslicarbazepine 400 mg Tb 250 209.00 71701524 CETIRIZINE 5MG DOSE 250 15.67 71701624 CLONIDINE 0.05MG DOSE 250 5.26 71701637 CLOZAPINE 100MG TB 250 5.31 71701694 DESMOPRESSIN 0.05MG DOSE 250 9.55 71701732 TETRACYCLINE 250MG CP 250 47.70 71701738 LANSOPRAZL 15MG SOLUTB 250 96.74 71701739 LANSOPRAZOLE 30MG SOLUTB 250 98.25 71701745 DIPHENHYDRMN 25MG CP 250 4.34 71701756 LORATADINE 10MG REDITB 250 5.30 71701801 NAPROXEN 375MG EC TB 250 7.28 71701834 MELATONN 3MG TB 250 3.71 71701858 LEVOFLOXACN 500MG TB 250 114.18 71701887 NA PHOS 93MG PO 250 10.72 71701898 MIRTAZAPINE 15MG TB 250 14.00 71701909 BETHANECHOL CHL 10MG TB 250 9.07 71701931 PRAVASTATIN 20MG TB 250 15.77 71701949 CITALOPRAM 10MG TB 250 14.77 71701954 ALENDRONATE 70MG TB 250 124.03 71701956 NADOLOL 20MG TB 250 23.18 71701960 GLYCOPYRROLATE 1MG TB 250 11.15 71701961 GLYCOPYRROLATE ORAL 1ML 250 7.90 71701969 GUANFACINE 0.5MG DOSE 250 5.30 71701977 HALOPERIDOL 5MG TAB 250 6.36 71701986 PRAZOSIN 1MG CP 250 11.36 71701996 METHIMAZOLE 10MG TB 250 4.91 71701997 EVEROLIMUS 0.25 MG TAB 250 50.26 71702014 HYDROCORTSONE 2.5MG DOSE 250 5.30 71702024 HYDROXYUREA 300MG CAP 250 15.27 71702035 HYDROXYZINE 10MG TB 250 3.45 71702040 HYDROXYZINE 25MG TB 250 4.14 71702041 FLUCONAZOLE 200MG TB 250 264.11 71702042 FLUCONAZOLE 150MG TAB 250 84.77 71702060 IBUPROFEN 100MG/5ML PO 250 1.96 71702063 Ibuprofen 100 mg/5 mL DyE 250 5.17 71702071 VERAPAMIL 120MG SR CP 250 31.00 71702105 ISONIAZID 300MG TB 250 7.61 71702107 VERAPAMIL 80MG TB 250 5.00 71702124 Isavuconazonium 186 mg Ce 250 596.50 71702132 Ivermectin 3mg Tablet 250 33.25 71702153 FLORASTOR ES 250MG CP 250 5.81 71702174 LEVOTHYRXINE 12.5MCGDOSE 250 5.26 71702194 LEVOTHYRXINE 62.5MCGDOSE 250 5.30 71702228 LISINOPRIL 1MG/ML SOLN 250 22.07 71702263 DISOPYRAMIDE 10MG/ML PO 250 1.32 71702296 OMEGA 3 ACID 1000MG 250 22.10 71702322 MECLIZINE 25MG TAB 250 5.30 71702331 MEGSTRL ACET 625MG/5ML PO 250 100.85 71702680 ONDANSETRON 0.8MG/ML PO 250 31.97 71702682 ONDANSETRN 2MG/2.5ML PO 250 15.10 71702700 OXCARBAZEPINE 150MG TB 250 9.28 71702705 OXCARBAZEPINE 300MG TB 250 16.50 71702750 PAROXETINE 10MG/5ML PO 250 11.65 71702755 PAROXETINE 20MG TB 250 16.96 71702770 PENICILLIN 50MG/ML VK PO 250 2.21 71702785 PEPPERMINT OIL 30ML 250 29.54 71702802 PHENAZOPYRIDN 10MG/ML PO 250 1.24 71702865 POLY-VI-SOL CHW TB 250 5.02 71702870 MVI PED 1ML PO 250 2.01 71702872 MULTIVIT W/FLUORIDE LIQ 250 4.23 71702875 POLY-VI-SOL+FE 1ML PO 250 2.06 71702885 POT CIT/CITRIC ACID 1ML P 250 1.20 71702985 PROMETHAZINE 1.25MG/ML PO 250 1.47 71702995 PROMETHAZNE 25MG TB 250 5.30 71703084 RANITIDINE 75MG DOSE 250 2.11 71703131 LURASIDONE 20MG 250 271.68 71703132 LURASIDONE 40MG 250 265.43 71703184 SERTRALINE 12.5MG DOSE 250 5.28 71703193 Succroferric Oxyhydroxidt 250 86.92 71703194 SEVELAMER 800MG PKT 250 114.52 71703198 SEVELAMER CARB 2400MG PKT 250 121.18 71703199 SEVELAMER CARB 800MG TB 250 58.12 71703277 SOD POLYSTYRENE SULF 15G 250 41.00 71703287 LEVONORGESTREL 1.5MG TAB 250 221.56 71703339 SULFAMETH/TMP SS 1/2 TAB 250 5.09 71703442 TOPIRAMATE 25MG SPRNKL CP 250 17.22 71703475 TRIHEXYPHENIDYL 5MG TAB 250 4.30 71703485 URSODIOL 300MG CP 250 51.70 71703488 VALGANCICLOVIR 50MG/ML PO 250 62.77 71703490 VALPROIC ACID 250MG CP 250 6.92 71703495 VALPROIC ACD 50MG/ML PO 250 1.77 71703499 VENLAFAXINE 37.5MG TAB 250 12.72 71703556 WARFARIN NA 5MG TB 250 4.93 71703559 WARFARIN 0.5MG DOSE 250 5.30 71703575 ZOLPIDEM 5MG TB 250 28.30 71703580 ZONISAMIDE 100MG CP 250 11.08 71703590 CIPRO 250MG/5ML PO 250 8.20 71703596 DOXYCYCLINE CA 10MG/ML SR 250 7.62 71703598 NITAZOXANIDE 20MG/ML ORAL 250 3.12 71703599 NITAZOXANIDE 500MG TAB 250 679.99 71703601 DEXTROMETHORPHAN POLSTIRX 250 0.77 71703634 Oseltamivir 30 mg/5 mL 250 13.85 71703718 DEKAS ESSENTIAL CAP 250 3.59 71703719 DEKAS ESSENT ORAL SOL 250 8.61 71703722 DEKAS PLUS CHEWABLE TAB 250 4.87 71703723 DEKAS PLUS ORAL SOL 250 9.19 71703724 DEKAS PLUS SOFTGEL CAP 250 5.02 71703732 ARIPIPRAZOLE 2.5MG DOSE 250 86.23 71703789 ESCITALOPRAM 5MG DOSE 250 25.01 71703865 DULOXETINE 20MG CP 250 47.36 71703866 DULOXETINE 30MG CP 250 35.31 71703900 BALSALAZIDE 750MG TB 250 7.39 71703905 BUDESONIDE 35MG EC CP 250 113.18 71703910 NACL 1GM TB 250 2.39 71703930 RIFAXIMIN 200MG TB 250 122.91 71703936 POSACONAZOLE 40MG/ML PO 250 84.54 71703937 POSACONAZOLE 100MG TAB 250 419.58 71703940 CA CIT +VIT D TB 250 7.26 71703942 VIT D3 2000U TB 250 4.07 71703945 GRISEOFULVN MCRO 25MG/ML 250 3.12 71703953 Deferasirox 90 mg Tab 250 243.00 71703954 Deferasirox 360 mg Tab 250 970.90 71703955 KALETRA 80MG/ML PO 250 27.26 71703960 BOSENTAN 62.5MG TB 250 298.95 71703970 ETHOSUXIMIDE 50MG/ML PO 250 3.12 71703975