Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02600001 HB IV INFUS HYDRATION 31-60 MIN 96360 $ 1,942.19 $ 2,526.14 02600002 HB IV INFUSION HYDRATION ADDL HR 96361 $ 475.94 $ 616.09 02600003 HB IV INFUSION THERAPY 1ST HR 96365 $ 2,175.25 $ 2,829.30 02600004 HB IV THERAPY ADDL SEQ UP TO 1 HR 96367 $ 475.94 $ 616.09 02600005 HB IV THERAPY-CONCURRENT 96368 $ 636.68 $ 825.32 02600007 HB INFUSION SC INITIAL FIRST HR 96369 $ 893.46 02600008 HB SC INFUSION ADD'L HOURS 96370 $ 443.82 02600012 HB IV INFUSION THERAPY EA ADDL HR 96366 $ 475.94 $ 616.09 02600013 HB IV PUSH INITIAL 96374 $ 1,188.35 $ 1,544.87 02600014 HB IV PUSH ADDL SEQ NEW DRUG 96375 $ 847.28 $ 1,101.47 02600015 HB IVP ADDL SEQ SAME DRUG 96376 $ 855.31 $ 1,111.91 02700005 HB CYTOTOXIC SPILL KIT $ 240.19 02700007 HB 24 HR PH PROBE $ 3,042.48 02700008 HB FEMSTOP $ 726.11 02700009 HB PC IPPB KIT $ 331.50 02700016 HB PEFR-EQUIPMENT $ 870.13 02700018 HB PC AERO KIT $ 1,779.85 02700020 HB PC O/P USN EQUIPMENT $ 1,003.99 02700021 HB PC MICRO-SPIROMETER $ 10,942.51 02700022 HB PC O/P HHN EQUIPMENT $ 635.86 02700033 HB STOCKINETTE,2"X25YD/BOX $ 286.76 02700034 HB DILATOR, RDS $ 2,826.81 02700035 HB NEEDLE, BIOPSY/ASP/LOC/INJ $ 408.51 02700036 HB HMII POWER MODULE Q0496 $ 1,877.40 02700042 HB HMGG, TRAVEL CASE Q0508 $ 722.80 02700044 HB METANEB RT DEVICE KIT $ 2,204.87 02700045 HB PC METANEB KIT $ 331.50 02710001 HB SUPPORTER, SCROTAL $ 836.64 02710002 HB SPLINT FOREARM - SMALL $ 482.09 02710003 HB SPLINT, SUGARTONG $ 2,653.01 02710005 HB SPICA - HIP (SINGLE OR DOUBLE) $ 5,240.06 02710006 HB COLLAR, CERVICAL $ 650.75 02710009 HB CAST, SHORT ARM CAST $ 1,695.08 02710012 HB PADS R2 EP STUDY $ 740.85 02710013 HB SPLINT FINGER 2 INCHES $ 344.04 02710014 HB MUCUS CLEARING DEVICE $ 345.84 02710018 HB BILE BAG REG $ 606.38 02710019 HB FECAL INCONTINENCE COLLECTOR $ 494.52 02710022 HB PC PEP VALVE $ 391.56 02710023 HB SPLINT WRIST - LARGE $ 412.84 02710024 HB SPLINT WRIST - MEDIUM $ 412.84 02710027 HB PENTAMIDINE KIT $ 490.61 02710029 HB SPLINT, WRIST $ 1,157.87 02710032 HB SUPPORT LUMBO-SACRAL $ 1,266.15 02710033 HB KNEE IMMOBILIZER * $ 1,307.49 Ancillary FY21 1 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02710035 HB AEROSOL INHAL, PENTAM ADD'L 10 $ 1,408.01 02710036 HB SPICA - THUMB OR FINGER $ 1,582.14 02710037 HB BI-VALVE OR DC CAST $ 381.03 02710038 HB KIT, OSTOMY 5PK (1 PIECE) $ 1,611.78 02710039 HB SPLINT, MOLDED $ 1,630.96 02710041 HB EAR LAVAGE $ 459.74 02710044 HB 02 CONNECTION TUBING MASK $ 462.42 02710045 HB HEADSET NAVIGATION DEVICE $ 477.20 02710047 HB SPLINT FOREARM - MEDIUM $ 584.28 02710050 HB SPICA CAST - INFANT $ 172.96 02710053 HB PC HELIOX ADMIN. PER HOUR $ 217.34 02710054 HB PC NITROGEN ADMIN. PER HOUR $ 217.34 02710055 HB ILEOSTOMY POUCH $ 808.55 02710056 HB UNIVALVE CAST OR SPLINT $ 251.50 02710057 HB PC H.H.N. KIT $ 414.62 02710058 HB SPLINT FOREARM - LARGE $ 694.19 02710059 HB SPLINT,THUMB $ 726.82 02710060 HB PAG-HEART NEB EQUIP $ 743.68 02710061 HB PASSY MUIR SPEAKING VALVE $ 765.40 02710063 HB STOMAHESIVE WAFER $ 782.42 02710064 HB SPLINT, ARM $ 933.05 02710067 HB PENTAMIDINE EQUIPMENT OP * $ 1,126.71 02710070 HB SPLINT, KNEE VELCRO $ 4,665.09 02710073 HB CAST, SHORT LEG WALKING $ 2,127.61 02710074 HB CAST, CYLINDER THIGH TO ANKLE $ 2,415.89 02710077 HB CAST, PATELLAR TENDON BEARING $ 3,010.70 02710078 HB CAST, LONG LEG $ 3,505.68 02710080 HB KIT, WOUND CLEASING $ 294.02 02710081 HB SPLINT, SHORT/LONG LEG $ 2,848.09 02710083 HB PUMP DISCONNECT KIT $ 130.75 02710085 HB SPLINT WRIST - SMALL $ 344.04 02710087 HB CAST, SHOE $ 705.36 02710089 HB CAST SHORT LEG $ 8,843.15 02710090 HB CAST, LONG ARM $ 4,264.87 02710091 HB CAST, LONG LEG WALKING $ 2,127.61 02710101 HB SPLINT, IMMOBILIZER KNEE $ 1,307.49 02710104 HB SPLINT,IMMOBILIZER SHOULDER $ 209.58 02720001 HB BASKET GEMINI 3FR $ 1,832.22 02720003 HB CRYOCATH, FROSTBYTE CLAMP $ 13,537.31 02720008 HB MEDIA FOR IUI $ 215.31 02720009 HB WIRE, MICRO EXCHANGE $ 2,520.12 02720010 HB CATH PERIPHERAL DILITATION C1725 $ 2,599.52 02720016 HB LASER FIBER, 3 $ 4,011.65 02720017 HB NEUROPEN WITH NEUROENDOSCOPES $ 4,196.76 02720018 HB VALVE, DRAINAGE/FARRELL $ 291.22 Ancillary FY21 2 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720021 HB CATH DELIVERY SYSTEM $ 6,425.29 02720023 HB LASER FIBER, 9 $ 8,279.13 02720025 HB CATH INTRA-AORTC BALLOON $ 15,137.08 02720034 HB CLIP SURGICAL SPRING CLIP $ 206.57 02720035 HB KIT, OSTOMY (2 PIECE) $ 1,095.44 02720036 HB LEVEL I TUBING D-50 $ 1,114.14 02720037 HB DRAIN 1 $ 352.79 02720039 HB ENDOSCOPIC VERSATEP $ 955.10 02720040 HB ENDO LLETZ BALL ELCTRODE $ 303.32 02720044 HB ENDOSCOPE SHEATH DISPOSABLE $ 556.85 02720045 HB COLOSTOMY BAG $ 557.83 02720046 HB KYPHON BONE FILLER DEVICE OR $ 1,155.60 02720047 HB CATHETER, EPISTAXIS BALLOON $ 569.28 02720048 HB ENDO ELECTRODE CUTTING LOOP $ 929.87 02720049 HB SHEATH, PERITONEAL/AMPLATZ $ 577.78 02720050 HB PC NASAL MASKS BIPAP $ 1,177.35 02720051 HB ENDO IRRIG ENDO-FLO 0037970 $ 586.79 02720053 HB BIOPSY BRUSH COOK 040310 $ 589.79 02720054 HB NEEDLE, SCLEROSING $ 1,205.57 02720055 HB CATH FOLEY W/THERMISTER $ 504.01 02720056 HB CANNULA, CORONARY PERFUSION DL $ 592.17 02720058 HB ELECTRODE, ACRIM/MENIS/PEN $ 593.28 02720059 HB CATHETER, UMBILICAL VES $ 593.37 02720064 HB CANNULA AVR CABG KIT $ 610.73 02720068 HB TRACH TUBE #14 $ 1,239.50 02720072 HB CLAMP, DISPOSABLE $ 397.33 02720073 HB FILTER, BLOOD TRANSFUSION * $ 646.59 02720074 HB PACING WIRE, TEMPORARY $ 789.30 02720075 HB LEADWIRE, EKG $ 149.69 02720077 HB FRAZIER SUCTION TIPS $ 317.50 02720080 HB HANDLE, ENDOSCOPIC GIA $ 967.42 02720081 HB TROCAR, ENDOSCOPIC 1 $ 545.54 02720082 HB CLIP GUN MAGAZINE $ 317.33 02720084 HB NEEDLE, SPINAL/DISC $ 689.25 02720086 HB KIT, PACEMAKER 1 $ 694.00 02720088 HB INTRODUCER, OSTEO ONE STEP $ 7,816.46 02720089 HB CATHETER, THORACIC MM $ 709.90 02720090 HB CATHETER PASSER $ 917.20 02720093 HB PIN, DISTRACTION 1 $ 536.76 02720096 HB ENDO TIP CAUTERY PEDS RT ANGLE $ 718.51 02720098 HB LACRIMAL INTUBATION SET $ 724.53 02720099 HB ROD, OSTOMY $ 217.74 02720101 HB PEN, HEATING LACTOSORB PLATE $ 800.16 02720104 HB ENDO BIPOLAR EBF01 $ 747.64 02720107 HB GRASPER, ENDOSCOPIC 1 $ 1,108.81 Ancillary FY21 3 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720108 HB PIN SKULL PINS MAYFIELD- OMI $ 215.59 02720109 HB DRESSING WEBRIL $ 66.69 02720110 HB PREP DURA $ 201.58 02720111 HB BLADE, TREPHINE $ 772.43 02720114 HB TUBING, INSUFFLATION $ 418.33 02720115 HB KYPHON BONE ACCESS NEEDLE 11 G $ 332.30 02720116 HB ANTENNA,EXTRNL NEUROSTIMALUTOR $ 1,069.58 02720121 HB SPLINT DENVER SERIES $ 251.88 02720123 HB ADHESIVE, SKIN 1 $ 372.65 02720124 HB 23G BIPOLAR TAPERED FINE POINT $ 470.03 02720125 HB SYRINGE MEDRAD POWER INJECTOR $ 171.87 02720126 HB ARTHRO, MENISCAL SYSTEM $ 1,317.26 02720132 HB FILTER MILEX $ 83.18 02720133 HB SONOHYSTOGRAM CATHETER $ 244.91 02720135 HB NET, RETRIEVAL ROTH $ 1,258.40 02720137 HB OSTENE BONE HEMOSTASIS 2.5GRMS $ 832.81 02720139 HB TUBE, JEJUN FEED/SGL LUMEN $ 1,336.24 02720140 HB FORCEPS, BIOPSY 1 $ 511.43 02720144 HB TUBE,TRACH DCT/DFEN W/DISP CAN $ 1,473.60 02720145 HB KIT, NEUROSTIMULATOR 1 $ 998.14 02720148 HB MEDTRONIC REFILL KIT $ 1,475.04 02720153 HB TUNNELING ROD, CATH PASSER $ 1,262.84 02720154 HB TUBE, MIC (FEEDING) $ 2,207.89 02720159 HB TOOL, DISSECTING 2 $ 1,466.97 02720161 HB KIT, TRANFIX/BIO-TENODESIS $ 1,523.84 02720162 HB NEEDLE, ELECT/BEVEL/TROCAR $ 1,565.75 02720165 HB HEMOSTAT, SOF-GRIP $ 778.39 02720166 HB BAG DRAINAGE URINARY $ 257.08 02720168 HB CUTTER, LOCKING LEAD $ 1,015.18 02720169 HB PERF QUICK PRIME LINE $ 264.43 02720170 HB ENDO PROBE HANDPIECE $ 791.04 02720171 HB PC MICRO BRUSH $ 1,924.29 02720172 HB STRIPPER VEIN DISPOSABLE $ 801.54 02720174 HB PLEUR-EVAC $ 2,260.65 02720175 HB SPENCER DEPTH ELECTRODES 8 CON $ 2,348.37 02720176 HB NEEDLE, OSTYCUT $ 809.79 02720177 HB T-TUBE, 2 $ 811.35 02720178 HB ENDO TROCAR 10MM BLNT OMST10BT $ 820.33 02720183 HB ILIUMINATOR, LIGHTMAT SURGICAL $ 830.08 02720184 HB PC BROCH OCC CATH C2628 $ 1,809.18 02720185 HB PERF HEMOCONCENTRATOR PEDS $ 856.22 02720187 HB TWIST DRILL SURGICAL 1 $ 862.20 02720189 HB KIT, KYPHOPLASTY INTRO SYSTEM $ 17,379.17 02720190 HB TRACH PERCUTANEOUS SET $ 700.92 02720191 HB ENDO SUCTION/IRRIG/PROBE $ 874.20 Ancillary FY21 4 of 170 Cedars-Sinai Medical Center Chargemaster Prices Effective July 1, 2020 CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720193 HB CATHETER, MULTI LUMEN $ 875.89 02720195 HB CANNULA, RETROGRADE CARDIOPLEG $ 886.56 02720198 HB CANNULA, RETROGRADE 1 $ 898.13 02720199 HB IV PUMP SET, NITROGLYCERIN $ 712.68 02720201 HB ARTHRO WAND 1 $ 1,805.25 02720202 HB BLADE, ACROM/BLASTER/MIONIZER $ 849.25 02720208 HB IRRIGATION SET, CYSTO $ 738.57 02720213 HB PERF RESERVOIR CARDIOTOMY $ 940.03 02720215 HB RESERVOIR, DRAIN 1 $ 268.24 02720216 HB DRAIN LUMBAR DRAINAGE SET $ 947.90 02720218 HB PACK, AFFINITY VAVD ACCESSORY $ 500.78 02720225 HB SHOULDER SUSPENSION KIT 2 $ 974.35 02720228 HB LP DRAINAGE KIT $ 987.93 02720229 HB TUBE, RECTAL $ 560.75 02720230 HB RADIAL ARTERY KIT $ 571.81 02720231 HB ENDO POLY LOOP $ 1,315.98 02720232 HB TUBING, PCA $ 578.99 02720233 HB TUBE, GASTROSTOMY 1 $ 590.60 02720235 HB CABLE, LEAD