KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 Kingman Regional Medical Center Charge Master FY19 CPT Procedure Charge Description: Price: code ROOM & CARE - ICU $4,950.00 ROOM & CARE - SCVICU ICU $4,950.00 ROOM & CARE - 2N SEMIPRIVT $2,150.00 ROOM & CARE - 2E SEMIPRIVT $2,150.00 ROOM & CARE - 2S SEMIPRIVT $2,150.00 ROOM & CARE - ORT SEMI PRIVATE $2,150.00 ROOM & CARE - 3B SEMIPRIVT $2,150.00 ROOM & CARE - 2C SEMIPRIVT $2,150.00 ROOM & CARE - OB SEMIPRIV $2,150.00 ROOM & CARE - ARU SEMIPRIVATE $1,350.00 ROOM & CARE - 2C PEDIATRIC $2,150.00 ROOM & CARE - OB GYN $1,628.00 ROOM & CARE - NURSERY $1,400.00 ROOM&CARE-NURSERY SPECIAL CARE $4,188.00 ROOM&CARE-ICU PROGRESSIVE CARE $2,667.00 ROOM & CARE - SCVICU TELEMETRY $2,667.00 ROOM & CARE - TELEMETRY $2,667.00 ROOM & CARE - ORTHO TELEMETRY $2,667.00 ROOM & CARE - 3RD FL TELEMETRY $2,667.00 ROOM & CARE - SCVICU $5,475.00 DELIVERY SERVICE $3,100.00 FETAL NON STRESS TEST $640.00 59025 OBSERVATION BED OB HOURLY $203.00 G0378 OB/SURGERY PER MINUTE $166.00 OB/EMER SURGERY PER MINUTE $180.00 ECMO/ECLS INITIATION VENOUS $2,948.00 33946 ECMO/ECLS INITIATION ARTERIAL $2,948.00 33947 OPERATING ROOM PER MINUTE $175.00 EMER OPERATING ROOM PER MINUTE $198.00 LITHOTRIPSY ESL $20,751.00 50590 GI TRACT CAPSULE ENDOSCOPY $4,494.00 91110 ANALYZE NEUROSTIM COMPLEX $470.00 95972 OP / SURGERY PER MINUTE $175.00 G-ESOPH REFLUX W/MUCOSAL PH $1,224.00 91035 GI TRACT CAPSULE ENDOSCOPY $2,556.00 0355T INSERT PICC W/O PORT >5YRS ICU $3,354.00 36569 DIALYSIS NOT HEMO ONE EVAL $1,223.00 90945 OAE SCREENING NEWBORN HEARING $38.00 92558 ECMO/ECLS DAILY MGMT-VENOUS $2,948.00 33948 ECMO/ECLS DAILY MGMT ARTERIAL $2,948.00 33949 EXTERNAL CEPHALIC VERSION $5,128.00 59412 BRONCHOSCOPY W/BIOPSY(S) (ICU) $2,903.00 31625 BRONCHOSCOPE DX WASHING (ICU) $2,849.00 31622 BRONCHOSCOPE DX W/BRUSH (ICU) $2,904.00 31623 BRONCHOSCOPE DX W/LAVAGE (ICU) $2,849.00 31624 MOBILITY INPATIENT VISIT $- ISOLATED ULTRAFILTRATION AQUAP $2,192.00 37799 EMER CVOR OPERATE ROOM PER MIN $297.00 CEREBRAL OXIMETRY $291.00 95999 ACT; ACTIVATED CLOTTING TIME $309.00 85347 ABG ANALYSIS WITH O2 SAT $234.00 82805 HEPARIN ASSAY $251.00 85520 PERF: PUMP W/OXYG/HEAT EA HOUR $3,313.00 99190 PERF: PUMP W/OXYG/HEAT 3/4 HR $2,318.00 99191 PERF: PUMP W/OXYG/HEAT 1/2 HR $1,658.00 99192 PERF: AUTOLOG BLOOD OP SALVAGE $760.00 86891 OPERATING ROOM PER MIN CVOR $238.00 Rev. 01/19 PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 ECHO TRANSESOPHAGEAL PROBE PLC $1,970.00 93313 ECHO TRANSESOPHAGEAL COMPLETE $2,561.00 93312 CARDIAC TRANSPORT TEAM (MAYO) $- OFFICE CONSULT HIGH $163.00 99245 OFFICE CONSULT MINOR $163.00 99241 OFFICE CONSULT LOW $163.00 99242 OFFICE CONSULT MODERATE $163.00 99243 OFFICE CONSULT MOD TO HIGH $163.00 99244 OFFICE VISIT BRIEF EST PATIENT $163.00 99211 OFFICE VISIT MINOR ESTAB PT $163.00 99212 OFFICE VISIT LOW/MOD ESTAB PT $163.00 99213 OFFICE VISIT MOD/HIGH ESTAB PT $163.00 99214 OFFICE VISIT HIGH EST PATIENT $163.00 99215 OFFICE VISIT MINOR NEW PT $163.00 99201 OFFICE VISIT LOW TO MOD NEW PT $163.00 99202 OFFICE VISIT MODERATE NEW PT $163.00 99203 OFFICE VISIT MOD/HIGH NEW PT $163.00 99204 OFFICE VISIT HIGH NEW PT $163.00 99205 EKG 12 LEAD, TRACING ONLY $220.00 93005 INJ EPIDURAL BLOOD OR CLOT PAT $2,047.00 62273 NERVE BLOCK FEMORAL CON/INF PF $231.00 64448 INTUBATION ET EMERGENT PROFEE $361.00 31500 INJ ANESTH SUPRASCAPULAR NERVE $254.00 64418 TAP BLOCK UNIL BY INJECTION PF $213.00 64486 TAP BLOCK UNIL BY INFUSION PF $245.00 64487 TAP BLOCK BILAT INJECTION PF $265.00 64488 TAP BLOCK BILAT BY INFUSION PF $295.00 64489 ECHO TRANSESOPHAGEAL COMPL PF $404.00 933122659 ECHO TRANSESOPH PROBE PLACE PF $75.00 933132659 ECHO TRANSESOPHAGE I&R ONLY PF $329.00 93314 TEE CONGENITAL GLOBAL WO/CO PF $483.00 93315 TEE CONGENITAL GLOBAL W/CON PF $483.00 93315 TEE CONGENITAL PROBE PLCMT PF $126.00 93316 TEE CONGENITAL INT&REP ONLY PF $360.00 93317 TEE FOR MONITORING PROFEE $395.00 93318 NERVE BLOCK SGL SCIATIC NRV PF $228.00 64445 INJ ANESTH;LUMB/THOR SYMPAT PF $275.00 64520 INSERT PICC W/O PORT AGE >5 PF $599.00 36569 PARAVERTEBRAL THORACIC SGL INJ $265.00 64461 PARAVERTEBRAL THORACIC 2ND+INJ $167.00 64462 PARAVERTEBRAL THORA CONT INFUS $257.00 64463 QUANT SERUM ACETONES/KETONES $141.00 82010 AMITRIPTYLINE $490.00 80346 ARSENIC $523.00 82175 PSA DIAGNOSTIC TOTAL $347.00 84153 CYANIDE (BLOOD) NATL $264.00 82600 COXSACKIE A VIRUS AB (A4,A16) $63.00 86658 ACTH $1,198.00 82024 DESIPRAMINE (NORIPRA $508.00 80335 ENA, ANY METHOD $104.00 86235 AMMONIA $394.00 82140 CH50-COMP TOTAL $548.00 86162 ALDOLASE $438.00 82085 AMYLASE SERUM $348.00 82150 ANTI-SMOOTH MUSCLE B $256.00 86256 ANTI-MITOCHONDRIAL AB $256.00 86256 ANTI-RNP/SM ANTIBODY $129.00 86235 ANGIOTENSIN CONV ENZ $126.00 82164 TOTAL BILIRUBIN $292.00 82247 BILIRUBIN /W DIRECT $300.00 82248 ISLET CELL ANTIBODY $181.00 86341 Rev. 01/19 PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 BETA 2 MICROGLOBULIN $228.00 82232 IMIPRAMINE(TOFRANIL) $107.00 80335 CALCITONIN $444.00 82308 CALCIUM; TOTAL $247.00 82310 CALCIUM; IONIZED $329.00 82330 CARBON DIOXIDE (CO2) $199.00 82374 COMPLEMENT;FCN ACTIVITY EA $97.00 86161 CAROTENE (SERUM) $195.00 82380 IA QUANT; CA 125 $295.00 86304 CERULOPLASMIN $205.00 82390 IA QUANT; CA 19-9 $269.00 86301 DHEA $586.00 82626 CHLORIDE; BLOOD $199.00 82435 SERUM/WB TOT CHOLEST $200.00 82465 CHROMIUM-BLD* $259.00 82495 CREATININE BLOOD $185.00 82565 CREATININE CLEARANCE (24HRUA) $301.00 82575 BASIC METABOLIC PANEL TOTAL CA $403.00 80048 CPK; TOTAL $192.00 82550 CPK-MB $309.00 82553 ELECTROLYTE PANEL $414.00 80051 PROTEIN ELECTROPHORE $370.00 84165 CYCLOSPORINE $519.00 80158 IMMUNOASSAY ANALYTE QUANT NOS $1,353.00 83520 HEMOGLOBIN ELECTROPHORESIS $616.00 83020 ESTROGEN TOTAL (SERU $312.00 82672 FIBRINOGEN; ANTIGEN $269.00 85385 FIBRINOGEN SPLIT PRO $600.00 85362 GASTRIN $545.00 82941 GLUCOSE FASTING $300.00 82947 POST GLUCOSE DOSE $259.00 82950 GTT 3 SPECIMEN $369.00 82951 GLUCOSE TOLERANCE EA>3 SPECIM $122.00 82952 IRON $158.00 83540 IRON BINDING CAPACITY $175.00 83550 LACTIC ACID $172.00 83605 LDH $259.00 83615 LDH ISO ENZYMES W/TO $523.00 83625 LIPOPROTEIN; LDL $269.00 83721 LEAD $175.00 83655 LIPASE $338.00 83690 HEPATIC FUNCTION PANEL $537.00 80076 SOMATOMEDIN-C LEVEL $1,036.00 84305 SELENIUM,BLOOD $869.00 84255 MAGNESIUM $149.00 83735 OSMOLALITY-BLOOD $363.00 83930 LIBRIUM LEVEL $161.00 80346 PHOSPHATASE, ALKALINE $230.00 84075 ALK PHOS ISOENZYMES $588.00 84080 HDL $312.00 83718 FACTOR VIII COAGULATION $730.00 85240 PHOSPHORUS INORGANIC $199.00 84100 PEPTIDE C LEVEL-BLD $772.00 84681 PROTEIN C ACTIVITY $569.00 85303 PHENYLALANINE (PKU), BLOOD $148.00 84030 CLOTTING INHIBITR PROTEIN S TT $1,052.00 85305 POTASSIUM $269.00 84132 PROTEIN C ANTIGEN $569.00 85302 PROTEIN TOTAL $175.00 84155 ETHYLENE GLYCOL-NICH $540.00 82693 ALBUMIN; SERUM,PLASMA,WH BLD $160.00 82040 Rev. 01/19 PREVENTION | DIAGNOSIS | TREATMENT | RECOVERY KINGMAN REGIONAL MEDICAL CENTER CHARGE MASTER FY19 RHO D IMMUNE GLOB300MCG 1500IU $1,120.00 J2790 PH BLOOD $199.00 82800 BENZODIAZAPINES $161.00 80346 SALICYLATE (INC ASPIRIN) $247.00 G0480 SEROTONIN SERUM $1,301.00 84260 SODIUM $199.00 84295 CORTISOL $490.00 82533 ALFA-1-ANTITRYPSIN; TOTAL $484.00 82103 GROWTH HORMONE $177.00 83003 MORPHINE BLOOD FTS $134.00 80361 OPIATES, 1 OR MORE $134.00 80361 THORAZINE LEVEL $523.00 80342 ZINC $656.00 84630 SGOT $245.00 84450 ALUMINUM SERUM $259.00 82108 SGPT $245.00 84460 TRIGLYCERIDES $62.00 84478 UREA NITROGEN (BUN)QUALTATIVE $300.00 84520 URIC ACID $258.00 84550 VITAMIN A $523.00 84590 VITAMIN B6 (PYRIDOXA) $1,134.00 84207 ASCORBIC ACID, BLOOD $438.00 82180 VITAMIN K (FROZEN) $895.00 84597 T3;TOTAL $200.00 84480 T3 RIA $534.00 84480 T4;TOTAL $355.00 84436 T4 FREE $446.00 84439 T3 FREE $77.00 84481 LITHIUM $239.00 80178 PARATHORMONE LEVEL $1,459.00 83970 B12 LEVEL $484.00 82607 TRANSFERRIN $465.00 84466 CEA $369.00 82378 HEPATITIS A VIRUS AB IGM $418.00 86709 HEPATITIS C AB $301.00 86803 HEPATITIS B SUR AB $322.00 86706 HEPATITIS B SUR AG $390.00 87340 HEPATITIS B CORE AG IGM $369.00 86705 HEPATITIS BE AB $390.00 86707 HEPATITIS BE AG $390.00 87350 CARDIAC ENZ ISOENZYMES $390.00 82552 DIGOXIN, QUANTITATIVE $340.00 80162 FOLIC ACID SERUM $490.00 82746 ANTI-DNA-SINGLE STRA $490.00 86226 THYROID STIMULATING HORMONE $185.00 84443 TBG (THYROXINE BIND) $531.00 84442 INSULIN $438.00 83525 INSULIN ANTIBODIES $146.00 86337 CRYOGLOBULIN QUALI/SEMI-QUAN $181.00 82595 ASSY GG; IGA,IGD,IGG,IGM EACH $269.00 82784 IGE $181.00 82785 RENIN $624.00 84244 INTRINSIC FACTOR ANT $890.00 86340 GENTAMICIN $403.00 80170 PHENYTOIN; TOTAL $530.00 80185 PRIMIDONE $545.00 80188 L H $195.00 83002 FSH BY RIA $580.00 83001 TEGRETOL $418.00 80156 CLONOPIN $149.00 80346 DEPAKENE (VALPORIC A $523.00 80164 Rev.