Mad River Community Hospital Charge Master Item Descr IPprice 1000517 INFUSE DRUG INITIAL 2ND SITE $ 626 1000525 INFUSE DRUG INITIAL 3RD SITE $ 626 1044804 CRITICAL CARE 1 (30>74 MIN) $ 7,993 1044820 CRITICAL ADD 30 MIN $ 1,569 1044986 ER LEVEL TRIAGE $ 109 1045009 ER LEVEL I $ 505 1045017 ER LEVEL II $ 1,011 1045025 ER LEVEL III $ 1,740 1045033 ER LEVEL IV $ 2,889 1045041 ER LEVEL V $ 4,427 1045141 CODE TRAUMA W/ PRE-HOSPITAL NOTIFICATION $ 8,000 1045143 CODE TRAUMA W/O NOTIFICATION (1) $ 8,000 1045144 GASTROSTOMY TUBE CHANGE W/O U/S $ 1,071 1045145 EXCISION OF THROMBOSED EXT HEMORRHOID $ 4,370 1045146 REDUCE FX DISTAL HUM SUPRA W/O MANIP $ 1,035 1045147 REDUCE FX DISTAL HUM SUPRA W/MANIP $ 5,253 1045148 REDUCTION DISL IP JOINT FINGER W/O ANES $ 1,003 1045150 REDUCTION OF HIP FRACTURE W/O GEN ANES $ 1,003 1045152 INSERT SUPRAPUBIC CATHETER $ 7,913 1045223 INJ IMMUN 1 VACCINE $ 135 1045231 INJ IMMUN ADD VACCINE $ 135 1045241 TRAUMA ALERT W/ PRE-HOSPITAL NOTIF $ 8,000 1045243 TRAUMA ALERT W/O NOTIFICATION (1) $ 8,000 1045256 HYDRATION INITIAL 31-60 MIN $ 689 1045314 HYDRATE EACH ADD HOUR>31MIN $ 689 1045330 INFUSE DRUG EACH ADD HOUR >31MIN $ 466 1045371 INFUSE DRUG INITIAL 1ST 16-60 MIN $ 689 1045413 INTRA-ARTERIAL INJECTION OR INFUSION $ 274 1045415 THORACOSTOMY $ 4,587 1045417 I&D PILONIDAL CYST $ 2,665 1045419 I&D BARTHOLIN CYST $ 750 1045421 INFUSE DRUG CONCURR $ 466 1045439 IV PUSH INITIAL DRUG $ 274 1045454 IV PUSH EACH NEW DRUG $ 274 1045488 IV PUSH SAME DRUG>30MIN $ 274 1045702 CPR $ 988 1045744 INJECTION IM/SQ EACH INJECTION $ 135 1045800 SBIRT- SCREEN BRIEF / REFER 15-30 MIN $ 285 1045850 SBIRT-SCREENING BRIEF > 30 MIN $ 340 1046312 INFUSE DRUG NEW, SEQUENTIAL $ 466 1046317 SPLINT SHORT ARM $ 490 1046322 SUTURE BODY <2.5 CM $ 788 1046327 I&D OF ABCESS SIMPLE OR SINGLE $ 788 1046332 SPLINT SHORT LEG $ 632 1046337 SUTURE BODY 2.6-7.5CM $ 788 1046347 SUTURE DBL BODY(NO E) 2.6-7CM $ 1,450 1046352 SUTURE FACE < 2.5CM $ 788 1046357 SPLINT LONG ARM $ 632 1046362 EXPLORE OF PENETRATING WOUND EXTREMITY $ 2,673 1046367 SUTURE FACE 2.6-5 CM $ 788 1046372 INJECT ANESTHETIC TO FACIAL NERV $ 490 1046377 INTUBATION EMERGENT ENDOTRACHEAL $ 833 1046382 SHOULDER DISLOCATION TREAT W/ANESTHESIA $ 6,300 1046385 SHOULDER DISLOCATION TREAT WO ANESTHESIA $ 1,003 1046387 ER TRANFUSION BLOOD PRODUCTS $ 1,750 1046392 SPLINT FINGER $ 261 1046397 SUTURE BODY 7.6-12.5 CM $ 788 1046402 AVULSION OF NAIL PLATE, SINGLE $ 788 1046407 SUTURE DBL NECK,EXTREM, GENITALA <2.5 $ 1,450 1046412 DISTAL RAD FX/EPIPHYSEAL SPEARATION TX $ 6,300 1046417 FINE NEEDLE ASPIRATION W/O GUIDANCE $ 1,450 1046422 SUTURE DBL FACE <2.5 CM $ 1,450 1046427 SUTURE DBL BODY 2.6-12.5CM NO HND/FT $ 1,450 1046432 EXCISION NAIL/NAIL MATRIX PERM REMOVAL $ 1,450 1046437 SUTURE DBL BODY NO E <2.5CM $ 1,450 1046447 GUIDED FLUID COLLECTION DRAINAGE $ 2,673 1046452 FB REMOVAL SUBQ WITH INCISION SIMPLE $ 1,448 1046457 NASAL FRACTURE CLOSED $ 1,003 1046462 LAC REPAIR LIP, FULL THICK, VERMILION $ 2,146 1046467 DRAIN INFECT MAJOR JOINT/BURSA NO U/S $ 1,142 1046469 DRAIN INFECT MAJOR JOINT/BURSA W U/S $ 1,142 1046472 REPAIR OF NAIL BED $ 2,278 1046475 REPAIR BLOOD VESSEL LESION $ 7,946 1046477 SPLINT LONG LEG $ 632 1046482 I&D ABCESS COMPLICATED OR MULTI $ 1,450 1046487 DEBRIDEMENT < 20 SQ CM (INCISIONAL) $ 1,450 1046492 N/G OR O/G PLACEMENT(BY PHYSICIAN) $ 1,161 1046497 REMOVE IMPACT EAR WAX W/ INSTRUMENTATION $ 261 1046498 REMOVE IMPACTED CERUMEN IRRIGATION $ 257 1046499 FB REMOV EXT EAR CANAL W/INSTRUMENT $ 490 1046502 FB REMOVAL INTRANA $ 490 1046507 FB REMOVAL EYE N/ SLIT LAMP $ 1,540 1046512 CONTROL NOSEBLEED COMPLEX $ 490 1046517 REPEAT CONTROL OF NOSEBLEED $ 833 1046522 MOD SED < 5 YRS INITIAL 15M $ 97 1046527 MOD SED > 5 YRS INITIAL 15M $ 102 1046532 LUMBAR PUNCTURE $ 2,536 1046537 PARA/THORACENTESIS W/IMMAGING $ 2,859 1046542 CENTRAL LINE PLACEMENT OVER 5 YRS $ 4,587 1046547 CENTRAL LINE PLACEMENT UNDER 5 YRS $ 4,587 1046552 GASTRIC LAVAGE $ 1,161 1046553 FAST EXAM ER $ 534 1046557 FINGER DISLOCATE W/O ANES $ 1,000 1046562 THROMBOLYSIS INTRAVENOUS INFUSION $ 1,389 1046567 EVACUATION OF SUBLINGUAL HEMATOMA $ 490 1046572 SUTURE BODY 12.6 TO 20 CM $ 1,450 1046577 FB REMOVAL FOOT W/INCISION $ 2,674 1046582 INJECTION(S) TRIGGER POINT $ 1,142 1046587 FINGER REDUCTION WITH ANES $ 1,170 1046592 INJECTION PERIPHERAL NERVE W/ANES $ 2,536 1046597 FB REMOVAL SUBQ W INCISION COMPLEX $ 6,291 1046692 SUTURE DBL FACE 2.6 - 5 CM $ 1,450 1046695 SUTURE DBL NECK/EXTREM/GENITAL 2.6-7.5 $ 1,450 1046697 SUTURE FACE 5.1 TO 7.5 CM $ 788 1046702 PUNCTURE ASPIRATION ABSESS, CYST, HEMOTO $ 1,450 1046707 REDUCTION OF NASAL FRACTURE - CLOSED $ 5,312 1046713 CONTROL NOSE BLEED, SIM PACKING/CAUTERY $ 490 1046715 I&D HEMATOMA $ 6,291 1046718 I&D DENTALALVEOLAR ABCESS, CIST, HEMATOM $ 490 1046720 SUTURE FACE 7.6-12. $ 788 1046722 SUTURE FACE 12.6-20 $ 1,450 1046725 SUTURE BODY 21.0-30.0 CM $ 1,450 1046728 SUTURE DBL FACE 5.1-7.5 CM $ 1,450 1046729 KNEE DISLOCATION TREAT W/O ANES $ 1,035 1046730 SUT DBL NECK/EXTREM/GENITAL 2.6-7.5 $ 1,300 1046732 REDUCE FRACTURE OF RADIUS $ 6,300 1046733 REDUCTION OF FRACTURE RADIUS & ULNA $ 6,300 1046734 ABDOMINAL PARACENTESIS W/O IMMAGING $ 3,470 1046735 ABDOMINAL PARACENTESIS W/O IMMAGING $ 3,503 1046736 REDUCTION OF FRACTURE LESSER TOE $ 1,003 1046737 ANKLE DISLOCATION TREAT NO ANES $ 1,003 1046738 REDUCTION OF FRACTURE GREAT TOE $ 1,003 1046739 REDUCTION DISLOCTION ANKLE W/ ANESTHESIA $ 6,300 1046740 FB REMOVAL EYE W/ SLIT LAMP $ 490 1064034 OXIMETRY SQT. SINGLE $ 88 1083178 TRANSFUSION BLD/PDCT $ 1,750 1084367 ER ELECT CARDIOVERS $ 1,103 1090641 FOLEY CATH SIMPLE $ 261 1090645 INSERT HEMLICH VALVE W/ ULTRASOUND $ 4,587 1090658 FOLEY CATH COMPLEX $ 421 1550283 PHOTO FACIAL W LEVUL $ 1,270 2510014 OBSERVATION HRLY ICU $ 185 2510022 OBSERVATION HRLY MS $ 99 2510105 OBSV DISCH MGMT ICU $ 343 2510154 OBSV SAME DAY ICU $ 1,835 2510204 OBSV 1ST DAY ICU $ 1,835 2510253 OBSV EACH ADD DAY ICU $ 1,835 2520054 OBSV DIRECT ADMIT ICU MS OB $ 570 2520104 OBSV DISCH MGMT MS OB $ 343 2520153 OBSV SAME DAY MS OB $ 1,835 2520203 OBSV 1ST DAY MS OB $ 1,835 2520252 OBSV EACH ADD DAY MS OB $ 1,835 3171326 PAIN MGMT PROC LVL 2 $ 3,669 3171342 PAIN MGMT PROC LVL 3 $ 3,843 3171367 PAIN MGMT PROC LVL 4 $ 4,018 3171383 PAIN MGMT PROC LVL 1 $ 3,494 3171409 PAIN MGMT PROC LVL 5 $ 4,193 3171425 PAIN MGMT PROC LVL 6 $ 5,241 3210108 PULM REHAB ASSESINTL $ 121 3210124 PUL REHAB SESSION $ 150 3230106 PULM STRESS TEST SIMPLE $ 490 3250005 PUL REHAB ASESS SUBQ $ 263 3250054 PUL REHAB THER ACT 15 MIN $ 150 3250070 PUL REHAB THER PRD PER 15 MIN $ 141 3260004 SELF MGMNT TRAINING $ 150 4000008 OUTPATIENT LEVEL 1 ESTAB PATIENT $ 211 4000602 OUTPATIENT LEVEL 4 ESTAB PATIENT $ 919 4000604 OUTPATIENT LEVEL 5 ESTAB PATIENT $ 1,069 4000701 OUTPATIENT LEVEL 3 ESTAB PATIENT $ 718 4000909 OUTPATIENT LEVEL 2 ESTAB PATIENT $ 481 4013227 FETAL NONSTRESS TEST $ 361 4013276 HEAR SCREEN NEWBORN $ 149 4013284 UTERINE MONTR-INTRNL $ 408 4013359 CIRCUMCISION $ 1,917 4013409 VAGINAL DELIVERY $ 2,432 4013474 URINE DIPSTICK POC $ 43 4013475 ROM PLUS RUPTURE OF MEMBRANE TEST $ 128 4013631 NSY INTNSIVE CARE HR $ 179 4013698 EXTERNAL VERSION $ 2,432 4013763 NEWBORN RESUSCITATE $ 898 4013854 VERSION,EXTRNL CPHLC $ 434 4020016 PHOTOTHERAPY-LIGHTS $ 135 4020040 PHOTOTHERAPY BLANKET $ 133 4020354 OXISENSOR INFANT $ 115 4051532 NITRAZINE POC $ 83 4070209 OUTPATIENT NEW LEVE $ 211 4070225 NEW OUTPATIENT LEVE $ 481 4070241 OUTPATIENT LEVEL 3 NEW PATIENT $ 718 4070258 OUTPATIENT LEVEL 4 NEW PATIENT $ 919 4070282 OUTPATIENT LEVEL 5 NEW PATIENT $ 1,083 4090019 CAR SEAT TESTING 60 MIN $ 34 4090027 CAR SEAT TEST ADD 30MIN $ 16 4180024 MNT REASSESS IND $ 45 4180040 MNT CHANGE IN DX $ 45 4181022 MNT INITIAL IND $ 45 4200008 OUTPATIENT LEVEL 1 ESTAB PATIENT $ 211 4200602 OUTPATIENT LEVEL 4 ESTAB PATIENT $ 919 4200604 OUTPATIENT LEVEL 5 ESTAB PATIENT $ 1,069 4200701 OUTPATIENT LEVEL 3 ESTAB PATIENT $ 718 4200909 OUTPATIENT LEVEL 2 ESTAB PATIENT $ 481 4211005 SURGERY FIRST HOUR $ 7,946 4211153 SURGERY ADDL 1/2 HR $ 3,973 4261174 EXTRA NURSE 30 MIN $ 125 4270209 OUTPATIENT LEVEL 1 NEW PATIENT $ 211 4270225 OUTPATIENT LEVEL 2 NEW PATIENT $ 481 4270241 OUTPATIENT LEVEL 3 NEW PATIENT $ 718 4270258 OUTPATIENT LEVEL 4 NEW PATIENT $ 919 4270282 OUTPATIENT LEVEL 5 NEW PATIENT $ 1,083 4270290 OUTPATIENT OBSV 1HR $ 158 4270308 RECOVERY ROOM 30MIN $ 179 4271009 RECOVERY ROOM 1HR $ 359 4283178 TRANSFUSION BLD/PDCT $ 1,750 4284367 ELECT CARDIOVERSION $ 1,103 4284368 MOD SED SAME PHYS<5 YRS INITIAL 15MIN ** $ 97 4284369 MOD SED SAM PHYS EA ADDL 15 MIN ** $ 47 4284370 MOD SED OTH PHYS 5> YRS INITIAL 15MIN ** $ 310 4376022 PICC LINE PLACEMENT $ 188 4376105 PICC LINE ATTEMPT >5 $ 4,018 4376162 PICC LINE PLCEMNT <5 $ 4,018 4376188 PICC LINE PLCEMNT >5 $ 4,018 4403305 ANES ETHRA 1ST 30MIN $ 431 4505059 SET PRIMARY CARESITE MINI DRIP ** $ 23 4505125 PNEUMOTHORAX CATH KIT ** $ 189 4505232 IV SECONDARY SET V1921 ** $ 23 4505265 IV START PKS ** $ 23 4505323 SOLN IRRIG H2O 1000ML 500001 $ 23 4505331 SOLN IRRIG 0.9% NACL 1000ML 520001 $ 23 4505455 STOPCOCK 3-WAY $ 23 4505463 STOPCOCK 4-WAY $ 23 4505638 IV PRIMARY SET ** $ 31 4505687 CENTRAL VEIN CATH KIT ** $ 78 4505711 SOLN L5100 5%D 1000ML $ 23 4505729 SOLN L5101 5%D 500ML $ 23 4505737 SOLN L5102 D5W 250CC $ 23 4505745 SOLN S5104-52 5%D 100ML PARTIAL $ 23 4505752 SOLN S5104 5%D 50ML PARTIAL $ 23 4505778 SOLN L7510 5%D/LR 1000ML $ 23 4505786 SOLN L7511 5%D/LR 500ML $ 23 4505794 SOLN 6120 5%D/0.45% NACL 1000ML $ 23 4505802 SOLN L6121 5%D/0.45% NACL 500ML $ 23 4505810 SOLN L6160 5%D / .2% NACL 1000ML $ 23 4505828 SOLN L6161