Tyrone Regional Health Network Charge Master 2019 Disclaimer: *Please note the charges provided are an estimate and is not a guarantee of the final billing charges. The charges are subject to change without notice. Charge Code Description CPT4 HCPCS MA WC Charge 542A0130 AMED WHEELCHAIR VAN - ONE WAY A0426 $214.00 542A0426 AMED EMERGENCY LEVEL 1 ECH WAY A0426 $835.00 542A0428 AMED - BLS A0428 $377.00 542T2005 AMED STRETCHER VAN T2005 $167.00 623A6211 SURGICAL DRESSINGS A6211 $51.00 623A6213 SURGICAL DRESSINGS A6213 $32.00 623A6260 SURGICAL DRESSING A6260 $14.00 623A6441 SURGICAL DRESSING A6441 $6.00 623A6442 SURGICAL DRESSINGS A6442 $3.00 623A6443 SURGICAL DRESSINGS A6443 $4.00 762G0379 DIRECT ADMIT TO OBS G0379 $164.00 11001013 MED/SURG PRIVATE PREM PAT REQ 1013 $15.00 11001020 MED/SURG R & B PRIVATE PAT REQ 1020 $15.00 12001001 MED/SURG R & B SEMI PRIVATE 1001 $749.00 16401012 SWING BED R & B 1012 $642.00 20601005 TELEMETRY R & B 1005 $963.00 27003283 WOUND VAC $126.00 27005165 BINDER XL ABDOMINAL $148.00 27005166 BINDER XXL ABDOMINAL $148.00 27005234 FLANGE 2.75 WAFER A4409 $9.00 27006024 WOUND CLOSURE TRAY $37.00 27008399 KANGAROO EPUMP ENTERAL SET $7.00 27031515 FIRST STEP SELECT $121.00 27055001 MED-SURG SUPPLIES $33.00 27203143 STOMA PASTE A4406 $19.00 27205018 ENDO TUBE 3.5 UNCUFFED MURPHY $4.00 27205102 TRAY SUTURE REMOVAL STERILE $7.00 27205234 FLANGE 2.75 WAFER A4409 $9.00 27205235 POUCH 2.75 OPAGUE A4425 $7.00 27205236 FLANGE 2.25 WAFER A4409 $9.00 27205237 POUCH 2.25 OPAGUE A4425 $7.00 27205238 POUCH 1 PC DURA ADHESIVE A4388 $10.00 27205239 STOMA POWDER A4371 $15.00 27205241 TAIL CLOSURE ACTIVE A4421 $5.00 27255002 STERILE SUPPLY $11.00 41399183 HYPERBARIC O2 99183 $1,400.00 54210428 AMED-BLS MD APPT A0428 $290.00 76190765 IV INFUSION THERAPY 1ST HOUR 96365 907 65 $327.00 76190766 IV INFUSION THERAPY ADDED HOUR 96366 907 66 $132.00 76201010 OBSERVATION R & B (HOURLY) G0378 $36.00 76210001 OBSERVATION M/S HR 1 G0378 $295.00 76210003 OBSERVATION POST PROC HR 1 G0378 $412.00 76210004 OBSERVATION M/S FOLLOW HRS G0378 $36.00 76210005 OBSERVATION POST PROC FOLL HRS G0378 $36.00 76296360 IV HYDRATION, INITIAL 96360 $216.00 76296361 IV HYDRATION, ADD HR 96361 $88.00 76296365 IV INFUSION, INITIAL 96365 $327.00 76296366 IV INFUSION, ADD HR 96366 $132.00 76296367 IV INFUSION, SEQUENTIAL 96367 $160.00 76296368 IV INFUSION, CONCURRENT 96368 $119.00 76296372 ALL SUBQ OR IM INJECTIONS 96372 $98.00 45099211 EST OP VISIT 5 MINUTES 99211 $72.00 45099212 EST OP VISIT 10 MINS 99212 $89.00 45099213 EST OP VISIT 15 MINUTES 99213 $109.00 45099214 EST OP VISIT 25 MINUTES 99214 $126.00 45099215 EST OP VISIT 40 MINUTES 99215 $302.00 49099211 EST OP VISIT 5 MINUTES 99211 $72.00 49099212 EST OP VISIT 10 MINUTES 99212 $89.00 49099213 EST OP VISIT 15 MINUTES 99213 $109.00 49099214 EST OP VISIT 25 MINUTES $126.00 49099215 EST OP VISIT 40 MINUTES $302.00 92011688 FETAL NON-STRESS TEST 59025 X06 21 11688 $228.00 92059020 OXYTOCIN STRESS TEST, FETAL 59020 $299.00 21001003 ICU/CCU R & B 1003 $1,284.00 76210002 OBSERVATION TELE/ICU HR 1 G0378 $354.00 76210006 OBSERVATION TELE/ICU FOLL HRS G0378 $42.00 771G0008 ADMINISTER FLU VACCINE G0008 $38.00 771G0009 ADMINISTRATION OF PNEUMOVAX G0009 $38.00 27001866 IV EXTENSION SET $5.00 27007493 PHLEBOTOMY BAG W/ 17Gx1 NEEDLE $27.00 36010010 PRE-OP SETUP LEVEL 1 $375.00 36010011 PRE-OP SETUP LEVEL 2 $428.00 36010012 PRE-OP SETUP LEVEL LOCAL $161.00 36010013 PRE-OP SETUP LEVEL STEREOTACT $268.00 49035900 TELEMETRY MONITOR 35900 $55.00 50090760 IV INFUS HYDRATION INIT 1ST HR 96360 907 60 $216.00 50090761 IV INFUS EACH ADD HR UP TO 8 96361 907 61 $88.00 50090765 THERAPEUTIC IV INFUSION 1ST HR 96365 907 65 $327.00 50090766 EACH ADD HOUR UP TO 8 HRS 96366 907 66 $132.00 50090767 ADD SEQUENTIAL INFUSION 1ST HR 96367 907 67 $160.00 50090768 CONCURRENT INFUSION 96368 907 68 $119.00 50090773 INTRTA-ARTERIAL 96373 907 73 $152.00 50090774 IV PUSH SINGLE OR INITIAL DRUG 96374 907 74 $162.00 50090775 EACH ADD SEQ IV PUSH NEW DRUG 96375 907 75 $148.00 63690658 FLU VACCINE INTRAMUSCULAR Q2036 $25.00 63690662 FLU VACCINE HIGH RISK 90662 $72.00 63690688 FLU VACCINE INTRAMUSCULAR 90686 $38.00 71020000 STEPDOWN RECOV 1ST HR $375.00 71020000ER STEPDOWN EXT RECOVERY PER HOUR $31.21 71020001 STEPDOWN RECOV ADD 30 MIN $214.00 76113000 TREATMENT ROOM 76113 $0.00 76136430 TRANSFUSION BLOOD OR COMPONTS 36430 $672.00 76190384 RH IG FULL-DOSE IM 90384 $345.00 76190471 IMMUNIZATION ADMIN 1ST VACCINE 90471 $38.00 76190472 IMMUNIZATION ADMIN ADD VACCINE 90472 $36.00 76192960 CARDIOVERSION, ELECTIVE EXTERN 92960 $888.00 76196360 IV HYDRATION, INITIAL 96360 $216.00 76196361 IV HYDRATION, ADD HR 96361 $88.00 76196365 IV INFUSION, INITIAL 96365 963 65 $327.00 76196366 IV INFUSION, ADD HR 96366 907 66 $132.00 76196367 IV INFUSION, SEQUENTIAL 96367 $160.00 76196368 IV INFUSION, CONCURRENT 96368 $119.00 76196372 ALL SUBQ OR IM INJECTIONS 96372 $98.00 76196374 IV PUSH, INITIAL 96374 963 74 $162.00 76196375 IV PUSH, SEQUENTIAL DIFFERENT 96375 $148.00 76196376 IV PUSH, SEQUENTIAL SAME 96376 $135.00 76196409 CHEMO ADMIN IV PUSH SING/INIT 96409 $268.00 76196413 IV INFUS, 1ST HR SINGLE/INI 96413 $750.00 76196415 IV INFUS, ADDITIONAL HOURS 96415 $110.00 99900014 ATELLAS 3606 STUDY $1,127.00 99900015 ATELLAS 3606 STDY FAILED SCRN $144.00 27005168 TOUHY EPIDURAL NEEDLE $17.00 27005277 TRAY UNIVERSAL BLOCK $17.00 36120526 INJ THERAPEUTIC CARPAL TUNNEL 20526 $440.00 36120550 INJ TENDON SHEATH/LIGAMENT 20550 $407.00 36120552 TRIGGER POINT INJ,1OR2 MUSCLE 20552 $549.00 36120553 TRIGGER POINT INJ, 3 OR MORE 20553 $576.00 36120600 INJ SMALL JOINT 20600 $247.00 36120605 INJ INTERMEDIATE JOINT 20605 $265.00 36120610 INJ MAJOR JOINT/BURSAE 20610 $278.00 36127096 SACROILLIAC JOINT BLOCK 27096 $653.00 36162272 SPINAL PUNCTURE THERA DRAINAGE 62272 $553.00 36162273 EPIDURAL BLOOD PATCH 62273 $1,543.00 36164400 INFRA ORBITAL NERVE BLOCK 64400 $533.00 36164402 POSTAURICULAR NERVE BLOCK 64402 $768.00 36164405 NERVE BLOCK OCCIPITAL 64405 $955.00 36164413 CERVICAL PLEXUS BLOCK 64413 $901.00 36164415 BRACHIAL PLEXUS BLOCK 64415 $1,030.00 36164417 AXILLARY NERVE BLOCK 64417 $901.00 36164418 NERVE BLOCK SUPRASCAPULAR 64418 $840.00 36164420 INTERCOST NB SINGLE 64420 $772.00 36164421 INTERCOST NB MULTI 64421 $843.00 36164425 NERVE BLOCK ILIOINGUINAL 64425 $1,197.00 36164430 PUDENDAL NERVE BLOCK 64430 $1,202.00 36164445 SCIATIC NERVE BLOCK 64445 $901.00 36164447 NERVE BLOCK FEMORAL NERVE SING 64447 $901.00 36164450 PARIETAL NERVE BLOCK 64450 $665.00 36164479 INJ TRANS EPI CERV/THOR SINGLE 64479 $1,241.00 36164480 INJ TRANS EPI CERV/THOR ADDED 64480 $1,225.00 36164483 INJ TRANS EPI LUMB/SACR SINGLE 64483 $1,233.00 36164484 INJ TRANS EPI LUMB/SACR EACH 64484 $563.00 36164490 PARVRTEBRAL CERV/THOR SNGL LVL 64490 $1,298.00 36164491 PARVRTBRL CERV/THOR 2ND LVL 64491 $611.00 36164492 PARVRTBRL CERV/THOR 3+ LVL 64492 $461.00 36164493 PARAVERTEBRAL LUM/SACR SINGLE 64493 $1,298.00 36164494 PARAVERTEBAL LUMB/SAC 2ND LVL 64494 $611.00 36164495 PARAVERTEBAL LUMB/SAC 3+ LVL 64495 $461.00 36164505 SPHENOPALATINE GANGLION BLOCK 64505 $462.00 36164510 INJ ANES, STELLATE GANGLION 64510 $901.00 36164517 GANGLION IMPAR BLOCK 64517 $1,318.00 36164520 PARAVERTEBRAL SYMP LUM/THORACI 64520 $1,224.00 36164530 CELIAC SPLANCHIC BLOCK 64530 $1,298.00 36164600 NERVE BLOCK PERIORBITAL 64600 $2,389.00 36164680 DEST BY NEURO AGENT CELIAC PLE 64680 $1,298.00 36164774 NERVE BLOCK LAT CUTANEOUS 64774 $1,543.00 51116402 PAIN CLINIC EVALUATION 16402 $0.00 51120550 PAIN CLNC TRGR PT INJ 1-2 MUSC 20552 W90 49 20550 $549.00 51120605 PAIN INJ. INTERMEDATE. JOINT 20605 206 05 20605 $265.00 51120610 PAIN CLINIC SACROILLILAC 20610 206 10 20610 $278.00 51127096 SACROILIAC JOINT INJECTION 27096 270 96 27096 $653.00 51162270 SPINAL PUNCTURE, LUMBAR DIAG 62270 $1,017.00 51164405 PAIN INJ GREAT OCCIPITAL NERVE 64405 644 05 64405 $955.00 51164421 PAIN INJECT INTERCOSTAL NERVES 64421 644 21 64421 $843.00 51164425 ILIOINGUINAL, ILIOHYPOGASTRIC 64425 $1,197.00 51164450 PAIN OTH PERIPHERAL NERVE BLK 64450 644 50 64450 $665.00 51164520 PAIN LUMBAR OR THORACIC SYMPA 64520 X06 20 64520 $1,224.00 51193672 ALL SUBQ OR IM INJECTIONS 96372 907 72 $98.00 51196372 ALL SUBQ OR IM INJECTIONS 96372 $98.00 51199201 INITIAL NEW PATIENT 99201 $95.00 51199204 NEW PATIENT, MODERATE COMPLEX 99204 T10 15 $211.00 51199205 NEW PATIENT, HIGH COMPLEXITY 99205 T10 15 $331.00 51199211 EST OP VISIT 5 MINUTES 99211 992 11 $72.00 51199212 EST OP VISIT 10 MINUTES 99212 992 12 $89.00 51199213 EST PATIENT, LOW COMPLEXITY 99213 992 13 $109.00 51199214 EST PATIENT, MODERATE COMPLEX 99214 992 14 99214 $126.00 51199215 EST PATIENT, HIGH COMPLEXITY 99215 992 15 $302.00 51199244 OFFICE CONSULT - MOD/HIGH SEV 99244 $385.00 270127301 TRAY EPIDURAL SINGLE SHOT $50.00 361644131 MULTI FACET NERVE INJ CERVICAL 64413 $901.00 275C1779 ACCOLADE DR PACEMAKER - BSC C1779 $9,875.00 275C1780 ACCOLADE MRI DR PACEMAKER BSC C1779 $11,125.00 275C1784 ST JUDE ACCENT SR RF PACEMAKER C1786 $7,089.00 275C1785 DUAL CHAMBER RESPONS PACEMAKER C1785 $15,724.00 275C1786 SINGLE CHAMBER PACEMAKER C1786 $10,738.00 275C1787 ST JUDE ASSURITY PACEMAKER $6,359.00 275C1898 PACEMAKER PASSIVE C1898 $1,663.00 276V2630 ANTER CHAMBER INTEROCUL LENSE V2630 $480.00 276V2632 POST CHMBR INTEROCULAR LENSE V2632 $424.00 278C1767 MEDTRONIC NEUROSTIMULATOR C1767 $32,890.00 278C1778 LEAD KIT ST JUDE C1778 $8,132.00 278C1779 ST.JUDE ISOFLEX OPTIM LEAD C1713 $1,231.00 278C1787 PATIENT PROGRAMMER ST JUDE C1787 $3,184.00 278C1820 16 CHNL RECHARGE STIM ST JUDE C1820 $36,915.00 278C1894 MEDTRONIC LEAD INTRODUCER