Px Code Procedure Description Unit Price 11000001 Room & Board - Private General $1,931.00 11200001 ROOM & BOARD - OB PRIVATE $1,931.00 11300001 Room & Board - Private Pediatric $1,931.00 11400001 ROOM & BOARD - BHU $3,097.00 11600001 ROOM & BOARD - CHEM DEP $4,142.00 11800001 ROOM & BOARD - REHAB $1,931.00 11800002 ROOM & BOARD - IP REHAB $2,301.00 16400001 ROOM & BOARD - ISOLATION $2,225.70 16400002 ROOM & BOARD - PCU ISOLATION $3,390.00 17100001 Nursery Newborn - Level I $1,936.00 17200001 Nursery Newborn - Level II $4,583.00 17300003 Nursery Newborn - Level III $5,941.00 17900001 ROOM & BOARD - SICK BABY LVL 1 $2,382.00 17900002 ROOM & BOARD - HEALTHY BOARDER $2,382.00 18000001 HB LEAVE OF ABSENCE (LOA) $0.01 20000001 Intensive Care General $4,851.00 20600001 Post ICU (AKA Intermediate) $4,123.21 20600004 ROOM & BOARD - TELEMETRY PCU $2,225.70 20600005 ROOM & BOARD - PCU PRIVATE $4,123.00 20600006 ROOM & BOARD - CARDIAC CARE MED SURG $1,931.00 20600007 ROOM & BOARD - CARDIAC CARE TELEMETRY $2,550.00 21000001 HB CORONARY CARE GENERAL $4,851.00 25000001 HB RX 250-PHARMACY $602.48 25000012 HB SOLUTION BAX 5B9896 4.25%2000M $96.66 25000013 HB SOLUTION BAX 5B9866 1.5%2000ML $86.52 25500001 HB RX 255-DRUGS INCIDENT TO RADIOLOGY $5,715.25 25800001 HB RX 343-DX RADIOPHARM $678.82 26000001 HB ADMIN IV HYDRATE; EA ADDTL HR $283.00 26000002 HB ADMIN IV INF TX/DX; 1ST HR $1,045.50 26000003 HB ADMIN IV INF TX/DX; EA ADDTL HR $376.00 26000004 HB ADMIN IV INF TX/DX; EA SEQUENTI $547.50 26000005 HB ADMIN IV INF TX/DX; CONCURRENT $778.50 26000006 HB ADMIN IV PUSH TX/DX; EA NEW MED $440.50 26000007 HB ADMIN IV PUSH; EA ADDTL SAME DRUG SEQ $440.50 26000008 HB ADMIN IV HYDRATE; 1ST HOUR $1,049.00 26000010 HB ADMIN IV PUSH TX/DX; 1ST MED $479.50 26000011 HB ADMIN INJ IM/SUBQ TX/DX MED $329.00 26000013 HB IRRIGATE VAD (FLUSH PORT/PICC) $367.50 26000015 HB APPLICATION OF ON-BODY INJECTOR $128.00 26000017 HB ADMIN SQ INFUSION; 1ST HOUR $1,019.50 26000018 HB ADMIN SQ INFUSION; EA ADDL HR $300.00 26000019 HB ADMIN ADD SQ INF; NEW SITE $412.50 27000004 HB COMPRESSED AIR $170.00 27000484 HB STAPLER ETH PRW35 $200.00 27000641 HB CARTRIDGE VAP PF-DPC-LOW $261.00 27000710 HB PACK C-SEC PB2235659 $2.00 27000727 HB PLEUR-EVAC MAQ 3600-100 CHEST DRAIN $93.75 27000728 HB PACK VAG PB3235659B $2.00 27000740 HB PACK LABOR PB1235659 $2.00 27000751 HB OXYGEN 02/SUPPLEMENTAL $725.00 27040684 HB CATHETER SET RE-ENTRY NEPHROS $286.37 27040765 HB MYOSURE XL $500.00 27040927 HB DAILY OXYGEN CHARGE $725.00 27045040 HB SHUNT MAQ OF-1500L LNG STD 20.25MM 16.25MM $235.00 27140004 HB OXYGEN PER SHIFT $362.50 27200209 HB SUTURE ARX AR-7230-01 $66.00 27200578 HB BUR WRI ALL 57SXXXX $1,770.00 27200754 HB VIPERSLIDE CSI VPR-SLD LUBRICT $252.00 27200772 HB CATH COR 426-2022X SLEEK $858.00 27200947 HB CATH TER 40-5023 $115.50 27200953 HB STAPLER CAR ESPRR35 SKIN $52.94 27200956 HB INTRODUCER GOR DSF2233 DRYSEAL FLEX $420.00 27200975 HB CATH BOS ALL H74939189XXXXX EMERGE PTCA DILATION $560.00 27201339 HB CATH EV3 ALL 410XX-01 CRAGG-MCNAMARA $420.00 27201728 HB SCD SLEEVE THIGH REGULAR $90.00 27201840 HB TROCAR APP CFF03/CFR03 $270.00 27201971 HB INTRODUCER MMD ALL CLS-10XX (31.93) $103.23 27202016 HB LIGASURE COV LF1737 / LS1520 (496.38) $1,489.14 27202093 HB BALLOON ACL BC0724A $750.00 27202200 HB CATH ELS D97120F5 SWANGANZ $352.26 27202396 HB SYRINGE BOS 5060-05 $478.00 27202486 HB TROCAR APM COR47 $99.00 27202560 HB NEW SET-UP ADULT HEMODIALYSIS $160.00 27202622 HB SHEAR ETH ESFC9 HARMONIC $3,032.78 27202675 HB POWDER MHP SM0007-USA $645.00 27202706 HB SYSTEM ADL 301-5400 SMOKE EVAC $236.00 27202759 HB CATH ARR AB-19608K $536.00 27202760 HB SUTURE SUS RA-1065Q $60.10 27202762 HB DRESSING MOL 395790 $70.22 27202780 HB SHEATH TER ALL RSSXXX PINNACLE (8.50) $29.00 27202784 HB GUIDEWIRE ABB 12776-01 PROWATE $510.00 27202870 HB SUTURE ARX AR7200 $55.50 27202921 HB CATH ARR ASK-05501-USC KIT $414.00 27202942 HB CRRT OR SHIFT TX SET-UP $5,606.00 27203172 HB CATH BOS H749391240845 QUANTUM APEX 4.5 X 8MM BALLOON $560.00 27203339 HB STAPLER J&J PSE45A $888.77 27203383 HB CATH ABB ALL 10124XX-XX TREK $900.00 27203409 HB CATH ABB C408646 DRAGONFLY OPTIS KIT $3,584.00 27203515 HB REAMER ARX ALL AR-14XXLP $874.00 27203618 HB SNARE BOS M00562551/M00562531 $96.00 27203798 HB CATH ARR ALL CS-15XX2-VSP $884.94 27203833 HB BALLOON ABB 1012447-06 TREK $750.00 27203901 HB DRILL GUIDE COC 93363 $607.50 27203944 HB CATH MED ALL 2AF2X4 ADVANCE (4500) $13,500.00 27204066 HB DERMABOND ETH DNX12 TOPICAL SKIN ADHESIVE $79.00 27204181 HB CHARGER STJ 3730ANS $4,416.00 27204202 HB INTRODUCER MED KPX153PB-CDS ONE TIME USE $10,350.00 27204245 HB CATH OLY MAJ-1351 BALLOON DILATION $51.55 27204256 HB CATH MED ALL NCEUPXXXXXX (140) $3,075.00 27204321 HB SYRINGE BOS M00566001 RAPID REFIL SYSTEM $246.00 27204544 HB CATH MED ALL ADM0X00XXX3P (1490) ADMIRAL $3,750.00 27204575 HB TROCAR ARX AR-1934-24DS $48.00 27204585 HB TROCAR APP CFF01 $270.00 27204784 HB NEEDLE ARX AR-12990N/AR16991N SCORPION $585.00 27204835 HB ELECTRODE BOS 3501 EMBLEM $12,000.00 27205075 HB SUTURE ARX AR-7276T LABRALTAPE 1.5MM 3IN $210.00 27205167 HB SLEEVE APP CFS02 FIXATION EXTERNAL $24.00 27205188 HB CATH BBM 33540 EPIDURAL $21.11 27205511 HB BASKET BOS M00546550 $1,485.00 27205532 HB CLOSURE ZLM PS1160 $240.00 27205584 HB DRIVER WRI 57S02020 / 57S02025 $815.00 27205585 HB DRILL BIT WRI 57S00022 / 57S00030 $1,030.00 27205604 HB PROSTEP WRI 57S100MT MICA TRANSLATOR $614.00 27205656 HB CATH MED ALL AB35W0XXXX135 $1,008.00 27205756 HB KWIRE WRI DSDS1014S 1.4MM X 150MM L $100.00 27205805 HB SOCKET ARX AR-4505 PORTAL SKID $135.00 27205851 HB POWERBOX WRI 5770POWER NSK $1,770.00 27206004 HB SCOPE AUR MBR-000011 SINGLE USE MONARCH BRONCHOSCOPE $5,959.00 27206005 HB INTRODUCER AUR MBR-000017 BRONCHOSCOPE KIT $282.00 27206006 HB BRUSH AUR MBR-000015 CYTOLOGY $329.00 27206122 HB DRILL ARX AR-8943-112 $400.00 27240005 HB CATH URETERAL 1 $1,557.00 27240006 HB CATH URETERAL 2 $3,440.00 27240043 HB OTH STER SUPP LVL 1 $77.00 27240044 HB OTH STER SUPP LVL 16 $61,715.00 27240045 HB DRILL BIT/BLADE LVL1 $438.00 27240046 HB DRILL BIT/BLADE LVL2 $1,041.50 27240047 HB DRILL BIT/BLADE LVL3 $2,330.00 27240048 HB DRILL BIT/BLADE LVL4 $3,024.50 27240049 HB DRILL BIT/BLADE LVL5 $5,040.00 27240050 HB DRILL BIT/BLADE LVL6 $7,056.50 27240051 HB DRILL BIT/BLADE LVL7 $9,072.50 27240052 HB DRILL BIT/BLADE LVL8 $16,319.00 27240053 HB DRILL BIT/BLADE LVL9 $20,939.00 27240054 HB SUTURE LEVEL 3 $959.00 27240055 HB SUTURE LEVEL 4 $2,051.50 27240056 HB SUTURE LEVEL 5 $4,693.00 27240057 HB SUTURE LEVEL 6 $3,419.00 27240058 HB SUTURE LEVEL 7 $4,786.50 27240059 HB SUTURE LEVEL 9 $15,429.00 27240060 HB STAPLER/RELOAD 1 $685.00 27240061 HB STAPLER/RELOAD 2 $2,051.50 27240062 HB STAPLER/RELOAD 3 $3,529.50 27240063 HB STAPLER/RELOAD 4 $6,553.50 27240064 HB STAPLER/RELOAD 5 $10,080.00 27240065 HB STAPLER/RELOAD 6 $13,587.50 27240066 HB NEEDLES 2 $1,232.50 27240067 HB NEEDLES 3 $4,196.50 27240068 HB NEEDLES 4 $7,864.50 27240069 HB OTH STER SUPP LVL 2 $1,056.00 27240070 HB OTH STER SUPP LVL 3 $1,582.00 27240071 HB OTH STER SUPP LVL 4 $2,110.00 27240072 HB OTH STER SUPP LVL 5 $1,945.00 27240073 HB OTH STER SUPP LVL 6 $2,333.00 27240074 HB OTH STER SUPP LVL 7 $2,723.00 27240075 HB OTH STER SUPP LVL 8 $3,111.00 27240076 HB OTH STER SUPP LVL 9 $4,668.00 27240077 HB OTH STER SUPP LVL 10 $6,223.00 27240078 HB OTH STER SUPP LVL 11 $7,779.00 27240079 HB OTH STER SUPP LVL 12 $15,557.00 27240080 HB OTH STER SUPP LVL 13 $18,279.00 27240081 HB OTH STER SUPP LVL 14 $30,084.00 27240082 HB OTH STER SUPP LVL 15 $50,140.00 27240083 HB TUBE DRAIN CATH 3 $738.00 27240084 HB TUBE DRAIN CATH 4 $1,319.00 27240085 HB TUBE DRAIN CATH 5 $1,847.00 27240086 HB TUBE DRAIN CATH 6 $8,557.00 27241052 HB CATH CAR 8888570549 DRAIN $13.44 27241053 HB DRAIN AUM 2002-000 CHEST $78.63 27241076 HB CATH BOS M004200624S0 $105.00 27241077 HB CATH BOS M0042011010 $1,152.00 27241078 HB CATH BOS H749518050 $1,896.00 27241079 HB CATH JJH D7T20282CT $3,420.00 27241080 HB CATH COV SD300LG NVG EDG $2,596.32 27241081 HB NEEDLE ARG 253030 BRST LOC $60.00 27241082 HB NEEDLE ARG 253125 BRST LOC $66.00 27241083 HB NEEDLE ART 253100 BRST LOC $84.00 27241084 HB MARKER DEV STAR1401 BRST $236.16 27241087 HB CATH BAR LX35130560 $3,600.00 27241088 HB CATH BAR LX351306100 $3,600.00 27241089 HB CATH BAR LX35130660 $3,600.00 27241090 HB CATH BAR LX351304100 BALLOON $3,900.00 27241091 HB CATH BAR LX35130440 BALLOON $3,900.00 27241092 HB CATH BAR LX351305100 BALLOON $3,900.00 27241093 HB CATH BAR LX35130540 BALLOON $3,900.00 27241094 HB CATH BAR LX35130640 BALLOON $3,900.00 27241095 HB CATH BAR LX35130460 BALLOON $4,650.00 27241096 HB CATH BAR LX35130480 BALLOON $4,650.00 27241097 HB CATH BAR LX351304150 BALLOON $4,725.00 27241098 HB CATH BAR LX351306150 BALLOON $4,725.00 27241099 HB CATH BAR LX351305150 BALLOON $4,800.00 27241100 HB CATH BOS M001175000 BALLOON $598.08 27241101 HB NEEDLE ARG 252075 $74.40 27241105 HB PACK MED DYNJCH301A VAGINAL $63.74 27241106 HB PACK MED DYNJCHCS02A C-SECTION $158.11 27241107 HB PACK MED DYNJ41314 D&C $61.91 27241108 HB PACK MED DYNJ41313 ABDOMINAL $119.88 27241109 HB CATHETER COK G14057 70CM 5 FR 14FR $31.55 27241110 HB CATHETER COK G14521 70CM 5FR URETERAL $41.62 27241111 HB CATHETER ALL BOS M005583XX ENDO DILATOR $854.88 27241112 HB TUBE BAR 331 CATH 20FR DRAIN $202.50 27241113 HB SUTURE ETH D9306 RB1 30IN $545.97 27241117 HB SYRINGE BOS M00550601 GAUGE ASSY 60CC $87.60 27241119 HB BLADE STR 2296-003-111 OSC SAW 25MM $92.94 27245015 HB APPLICATOR ETH MS1995 ENDOSCOPIC 34CM SURGIFLO $416.09 27245063 HB