Bristol Bay Area Health Corporation Chargemaster As of: 12/20/2018 Section 2718(e) of the Public Health Service Act, which was enacted as part of the Affordable Care Act, requires that each hospital operating within the United States, for each year, to make public a list of the hospital’s standard charges for items and services provided by the hospital. The following list fulfill this requirement. Physician Hospital Village Description # Charge Charge Charge 1 1 cc sterile syringe&needle - 4.00 4.00 2 1 pc ost pou w built-in conv 34.00 34.00 3 1 pc ost pouch w filter 19.00 19.00 4 100 insulin syringes - 102.00 102.00 5 12-24hr sealed lead acid 102.00 102.00 6 1pc ost pch drain hgh output 25.00 25.00 7 1ST PSYC COLLAB CARE MGMT 216.00 - 8 1ST/SBSQ PSYC COLLAB CARE 98.00 - 9 2 pc drainable ost pouch 25.00 25.00 10 20+ cc syringe only 9.00 9.00 11 22nf nonsealed leadacid 367.00 367.00 12 22nf sealed leadacid battery 390.00 390.00 13 2VHPV VACCINE 3 DOSE IM 130.00 14 3 cc sterile syringe&needle - 4.00 4.00 15 3-D RADIOTHERAPY PLAN 2,806.00 - 16 3D RENDER W/INTRP POSTPROCES 158.00 - 17 3D RENDER W/INTRP POSTPROCES 180.00 - 18 4VHPV VACCINE 3 DOSE IM - 163.00 163.00 19 5% dextrose and 0.45% saline 2.00 2.00 20 5% dextrose/normal saline - 5.00 5.00 21 5% dextrose/water - 5.00 5.00 22 5+ cc sterile syringe&needle 5.00 5.00 23 9VHPV VACCINE 2/3 DOSE IM - 130.00 130.00 24 A/d tx program, per hour 72.00 72.00 25 Abatacept injection 67.00 67.00 26 ABD PARACENTESIS 733.00 2,550.00 733.00 27 Abdominal pad 316.00 316.00 28 Abduct control hip semi-flex 493.00 493.00 29 Abduct rotation bar w/o shoe 204.00 204.00 30 Abduction bar jointed adjust 977.00 977.00 31 Abduction bar-straight 518.00 518.00 32 Abduction rotation bar shoe 223.00 223.00 33 ABLATE INF TURBINATE SUPERF 655.00 3,780.00 655.00 34 Abobotulinumtoxina 24.00 24.00 35 Above knee surgical stocking - 27.00 27.00 36 ABRASION LESION SINGLE 833.00 624.00 833.00 37 ABSCESS DRAINAGE UNDER X-RAY 248.00 - 38 ABSCESS IMAGING LTD AREA 1,432.00 - 39 ABSCESS IMAGING WHOLE BODY 1,432.00 - 40 Absorpt drg <=16 sq in w/bdr - 3.00 3.00 41 Absorpt drg <=16 sq in w/o b 9.00 9.00 42 Absorpt drg > 48 sq in w/o b 9.00 9.00 43 Absorpt drg >16 <=48 w/o bdr - 15.00 15.00 44 Absorpt drg >16<=48 in w/bdr 14.00 14.00 45 Acetaminophen injection 2.00 2.00 46 Acetazolamid sodium injectio 85.00 85.00 47 ACETONE ASSAY 86.00 86.00 48 ACETYLCHOLINESTERASE ASSAY 44.00 - 49 Acetylcysteine injection 11.00 11.00 50 Acetylcysteine non-comp unit 5.00 5.00 51 ACNE SURGERY 231.00 624.00 - 52 ACOUSTIC IMMITANCE TESTING 104.00 236.00 - 53 ACOUSTIC REFL THRESHOLD TST 77.00 88.00 77.00 54 ACTH STIMULATION PANEL 128.00 - 55 ACTH STIMULATION PANEL 307.00 - 56 ACTH STIMULATION PANEL 341.00 - 57 ACUPUNCT W/O STIMUL 15 MIN 106.00 - Physician Hospital Village Description # Charge Charge Charge 58 ACUPUNCT W/O STIMUL ADDL 15M 88.00 - 59 ACUPUNCT W/STIMUL 15 MIN 105.00 105.00 60 ACUPUNCT W/STIMUL ADDL 15M 53.00 53.00 61 ACUTE GI BLOOD LOSS IMAGING 732.00 - 62 ACUTE HEPATITIS PANEL - 184.00 184.00 63 ACUTE VENOUS THROMBUS IMAGE 943.00 - 64 Acyclovir injection 2.00 2.00 65 ACYLCARNITINES QUAL 54.00 - 66 ACYLCARNITINES QUANT 66.00 - 67 Adalimumab injection - 969.00 969.00 68 Add le poly knee custom kafo 443.00 443.00 69 Add pwr joystick 636.00 636.00 70 Add ue prost a/e ultlite mat 689.00 689.00 71 Add ue prost b/e acrylic 740.00 740.00 72 Add ue prost be/wd, ultlite 616.00 616.00 73 Add ue prost s/d ultlite mat 744.00 744.00 74 Additional switch, ext power 827.00 827.00 75 Adenosine inj 1mg - 25.00 - 76 ADENOVIRUS AG IA 47.00 - 77 ADENOVIRUS AG IF 47.00 - 78 ADENOVIRUS ANTIBODY 83.00 83.00 79 ADENOVIRUS ASSAY W/OPTIC 47.00 - 80 Adhesive remover per ounce 6.00 6.00 81 Adhesive remover, wipes - 2.00 2.00 82 Adhesive, liquid or equal 25.00 25.00 83 Adj motion knee jnt lerman t 411.00 411.00 84 Adj shoulder ext/flex device 972.00 972.00 85 Adj skin pro w/c cus wd<22in 742.00 742.00 86 Adj skin pro wc cus wd>=22in 945.00 945.00 87 Adj skin pro/pos cus<22in 749.00 749.00 88 Adj skin pro/pos wc cus>=22 948.00 948.00 89 Adjst forearm pro/sup device 849.00 849.00 90 Adjust ankle ext/flex device 423.00 423.00 91 Adjust elbow ext/flex device 423.00 423.00 92 Adjust finger ext/flex devc 423.00 423.00 93 Adjust knee ext/flex device 423.00 423.00 94 Adjust toe ext/flex device 423.00 423.00 95 Adjust wrist ext/flex device 423.00 423.00 96 Adjustable angle footplate 209.00 209.00 97 Adjustment gastric band 165.00 165.00 98 Admin hepatitis b vaccine - 39.00 39.00 99 Admin influenza virus vac - 39.00 39.00 100 Admin pneumococcal vaccine - 39.00 39.00 101 ADRENAL CORTEX & MEDULLA IMG 2,723.00 - 102 Adrenalin epinephrine inject - 5.00 5.00 103 Adult size brief/diaper lg 4.00 4.00 104 Adult size brief/diaper med 4.00 4.00 105 Adult size brief/diaper sm - 4.00 4.00 106 Aerosol compressor adjust pr 146.00 146.00 107 Aerosol mask used w nebulize - 5.00 5.00 108 Afluria vacc, 3 yrs & >, im 35.00 35.00 109 Afo ankle gauntlet pre ots 232.00 232.00 110 Afo doub solid stirrup calf 1,410.00 1,410.00 111 Afo multilig ank sup pre ots - 387.00 387.00 112 Afo plastic - 349.00 349.00 113 Afo rig ant tib prefab tcf/= - 1,342.00 1,342.00 114 Afo sing bar clasp attach sh 897.00 897.00 115 Afo sprng wir drsflx calf bd 605.00 605.00 116 Afo w/ankle joint, prefab 940.00 940.00 117 Afo, walk boot type, cus fab 2,761.00 2,761.00 118 AG DETECT NOS IA MULT 47.00 - 119 AG DETECT NOS IA SINGLE 38.00 - 120 AG DETECT POLYVAL IA MULT 38.00 - Physician Hospital Village Description # Charge Charge Charge 121 AG DETECTION POLYVAL IF 47.00 - 122 Agalsidase beta injection 352.00 352.00 123 AGENT NOS ASSAY W/OPTIC 47.00 - 124 AGGLUTININS FEBRILE ANTIGEN 133.00 133.00 125 Air pressure mattress 157.00 157.00 126 Air pressure pad for mattres 783.00 783.00 127 AIRWAY INHALATION TREATMENT - 162.00 113.00 128 Ak pelvic control belt light 446.00 446.00 129 Ak pelvic control belt pad/l 571.00 571.00 130 Ak sleeve susp neoprene/equa 422.00 422.00 131 Ak/knee disartic pelvic band 301.00 301.00 132 Ak/knee disartic pelvic join 554.00 554.00 133 Ak/knee disartic silesian ba 378.00 378.00 134 ALANINE AMINO (ALT) (SGPT) - 51.00 51.00 135 Albumin (human), 25%, 20 ml 59.00 59.00 136 Albumin (human), 25%, 50ml 148.00 148.00 137 Albumin (human), 5%, 250 ml 143.00 143.00 138 Albumin (human),5%, 50ml 33.00 33.00 139 ALBUMIN ISCHEMIA MODIFIED 133.00 - 140 Albuterol comp con 4.00 4.00 141 Albuterol ipratrop non-comp - 5.00 5.00 142 Albuterol non-comp con 2.00 2.00 143 Albuterol non-comp unit - 8.00 8.00 144 Alcohol and/or drug assess - 158.00 158.00 145 Alcohol and/or drug interven 19.00 19.00 146 Alcohol and/or drug services 11.00 11.00 147 Alcohol and/or drug services 18.00 18.00 148 Alcohol and/or drug services 20.00 20.00 149 Alcohol and/or drug services 79.00 79.00 150 Alcohol or peroxide per pint 8.00 8.00 151 Alcohol wipes per box - 11.00 11.00 152 Alcohol/drug abuse svc nos - 250.00 250.00 153 Alcohol/subs interv >30 min 343.00 135.00 - 154 Alcohol/subs interv 15-30mn 175.00 135.00 - 155 Alcohol/substance abuse skil 20.00 20.00 156 ALCOHOLS BIOMARKERS 1OR 2 60.00 - 157 ALCOHOLS BIOMARKERS 3/MORE 60.00 - 158 ALDOSTERONE SUPPRESSION EVAL 492.00 - 159 Alefacept 125.00 125.00 160 Alginate dressing <=16 sq in 25.00 25.00 161 Alginate drsg >16 <=48 sq in 64.00 64.00 162 Alginate drsg wound filler 24.00 24.00 163 Alglucerase injection 126.00 126.00 164 Alglucosidase alfa injection 412.00 412.00 165 Alkalin batt for glucose mon 4.00 4.00 166 ALKALOIDS NOS - 131.00 - 167 ALLERGEN SPECIFIC IGG 20.00 - 168 ALLG SPEC IGE CRUDE XTRC EA - 51.00 51.00 169 ALLG SPEC IGE MULTIALLG SCR 31.00 - 170 Alloderm 97.00 97.00 171 Alloskin 28.00 28.00 172 Alloskin 42.00 42.00 173 Alpha 1 proteinase inhibitor 14.00 14.00 174 ALPHA-1-ANTITRYPSIN PHENO 57.00 - 175 ALPHA-1-ANTITRYPSIN TOTAL 83.00 83.00 176 ALPHA-FETOPROTEIN AMNIOTIC 66.00 - 177 ALPHA-FETOPROTEIN L3 252.00 - 178 ALPHA-FETOPROTEIN SERUM - 83.00 83.00 179 Als 1 412.00 - 180 Als 2 943.00 - 181 Als1-emergency 652.00 - 182 Alteplase recombinant - 156.00 156.00 183 Alternating pressure pad 206.00 206.00 Physician Hospital Village Description # Charge Charge Charge 184 Amb infusion pump mechanical 73.00 73.00 185 Ambulance response/treatment 500.00 - 186 Ambulatory surgical boot eac - 35.00 35.00 187 Amifostine 612.00 612.00 188 Amikacin sulfate injection 3.00 3.00 189 AMINES VAGINAL FLUID QUAL 15.00 - 190 AMINO ACID SINGLE QUAL 51.00 51.00 191 AMINO ACIDS MULT QUAL 51.00 51.00 192 AMINO ACIDS QUAN 6 OR MORE 651.00 651.00 193 AMINO ACIDS QUANT 2-5 66.00 - 194 AMINO ACIDS SINGLE QUANT 422.00 422.00 195 Aminolevulinic acid hcl top 402.00 402.00 196 Aminophyllin 250 mg inj 5.00 5.00 197 Amiodarone hcl - 5.00 5.00 198 AMNIOTIC FLUID SCAN 27.00 - 199 Amobarbital 125 mg inj 381.00 381.00 200 AMPHETAMINES 3OR 4 86.00 - 201 AMPHETAMINES 5 OR MORE 86.00 - 202 Ampho b cholesteryl sulfate 42.00 42.00 203 Amphotericin b 53.00 53.00 204 Amphotericin b lipid complex 36.00 36.00 205 Amphotericin b liposome inj 43.00 43.00 206 Ampicillin 500 mg inj - 10.00 10.00 207 Ampicillin sodium per 1.5 gm - 20.00 20.00 208 AMPUTATION OF FINGER/THUMB 2,387.00 4,800.00 - 209 Amputee adapter 203.00 203.00 210 ANABOLIC STEROID 1 OR 2 142.00 - 211 ANABOLIC STEROID 3 OR MORE 142.00 - 212 ANALGESICS NON-OPIOID 1 OR 2 - 112.00 - 213 ANALGESICS NON-OPIOID 3-5 112.00 - 214 ANALGESICS NON-OPIOID 6/MORE 112.00 - 215 ANALYSIS NERVE 109.00 - 216 ANALYSIS SKELETAL MUSCLE 109.00 - 217 ANALYSIS TUMOR 109.00 - 218 ANALYZE NEUROSTIM NO PROG 276.00 200.00 276.00 219 ANALYZE PACEMAKER SYSTEM 840.00 100.00 - 220 ANDROSTANEDIOL