10/10/19 Levi Hospital Page: 1 · 2019-10-15 · mod1 mod2 mod3 mod4 ... 0827 use 827 lab i 300 322.20 n n 0867 use 867 lab i 300 225.90 n n 0893 use 893 lab i 300 128.88 n n 10 ed

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Charge Code Charge Code Description Department Status Proc

Code

Rate Taxable Rate

Exception

Charge Master Report- Price List

Levi Hospital

User Login Name: hlhApplication Code: BL

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Mod1 Mod2 Mod3 Mod4

0000001 PRIVATE ROOM 110 1,750.00 NPSYC A N

0000002 PRIVATE ROOM GENERAL MEDICAL 110 1,750.00 NACUT A N

0000003 PRIVATE ROOM 4TH FLOOR 110 1,750.00 NPSYC A N

0000005 SEMI PRIVATE 124 1,500.00 NPSYC A N

0000006 PRIVATE ROOM 114 1,750.00 NPSYC A N

0000007 N/C MCR 180 0.00 NPSYC A N

0000008 EMTALA SCREENING SERVICE 451 600.00 NED A N

0000101 MEDICAL SUPPLY 270 0.00 NCS A N

0001001 ECG 730 93005 128.40 NEKG A N

0475 use 475 300 75.60 NLAB I N

0661 use 661 300 158.10 NLAB I N

0662 use 662 300 77.10 NLAB I N

0757 use 757 300 90.30 NLAB I N

0766 use 766 300 162.30 NLAB I N

0772 use 772 300 269.10 NLAB I N

0806 use 806 300 221.10 NLAB I N

0827 use 827 300 322.20 NLAB I N

0867 use 867 300 225.90 NLAB I N

0893 use 893 300 128.88 NLAB I N

10 ED VISIT-LOW COMPLEXITY 456 99282 95.40 NED A N

1001 ECG 730 93005 110.40 NRAD A N

101 MEDICAL SUPPLY 270 0.00 NCS A N

1011 RADIOLOGY 320 0.00 NRAD A N

1012 ABD 1 VIEW 320 74000 57.60 NRAD A N

1013 ABD 2 VIEW 320 74019 72.00 NRAD A N

1015 ABD AC SERIES 324 74022 93.60 NRAD A N

1017 KUB 324 74000 100.80 NRAD A N

1018 CHEST 1 VIEW-FRONTAL 324 71010 54.00 NRAD A N

1019 CHEST 2 VIEWS FRONT/LATERAL 324 71020 69.60 NRAD A N

1021 CHEST AP LORDT 320 71021 84.00 NRAD A N

1022 RIB 2 VIEW 320 71100 68.40 NRAD A N

1023 RIB 3 VIEW 320 71101 80.40 NRAD A N

1025 STERNUM MIN 2 V. 320 71120 70.80 NRAD A N

1026 S/C JT 3 VIEW 320 71130 78.00 NRAD A N

1027 ACROMIC CLAV J 320 73050 73.20 NRAD A N

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Levi Hospital


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Mod1 Mod2 Mod3 Mod4

1029 CLAV COMPLETE 320 73000 56.40 NRAD A N

1031 ELBOW 2 VIEWS 320 73070 55.20 NRAD A N

1032 FINGER 2 VIEW 320 73140 50.40 NRAD A N

1033 FOREARM-2V. 320 73090 56.40 NRAD A N

1035 HAND AP 2V. 320 73120 55.20 NRAD A N

1036 HAND 3 VIEW 320 73130 60.00 NRAD A N

1037 HUMERUS 2 VIEW 320 73060 61.20 NRAD A N

1038 TMJ BILAT 320 70330 92.40 NRAD A N

1039 SCAPULA COMPLETE 320 73010 58.80 NRAD A N

1040 SHOULDER 1 VIEW 320 73020 50.40 NRAD A N

1041 SHOULDER 2 VIEWS 320 73030 62.40 NRAD A N

1042 SCOLISIS UP 320 72069 181.20 NRAD A N

1043 WRIST 2 VIEWS 320 73100 55.20 NRAD A N

1046 ANKLE 2 VIEWS 320 73600 55.20 NRAD A N

1047 BILATERAL RIB W/CHEST 320 71111 104.40 NRAD A N

1048 FEMUR 2 VIEWS 320 73552 61.20 NRAD A N

1049 FOOT AP 1 VIEW 320 73620 55.20 NRAD A N

1050 HIP UNILATERAL 1 V. 320 73500 54.00 NRAD I N

1050A HIP UNILATERAL 1 VIEW 320 73501 54.00 NRAD A N

1051 HIP JT 2 VIEWS 320 73510 69.60 NRAD I N

1052 BILAT HIP 4 V 320 73520 80.40 NRAD A N

1055 TIB & FIB 320 73590 57.60 NRAD A N

1056 ELBOWS BILATERAL 320 73070 102.00 NRAD A N50

1057 TOES 320 73660 50.40 NRAD A N

1059 OS CALCIS 2 VS 320 73650 54.00 NRAD A N

1061 FACIAL BONES>3V 320 70140 94.80 NRAD A N

1062 FACIAL BNS COM-MIN 3V 320 70150 136.80 NRAD A N

1063 JAW MANDIBLE 320 70100 105.60 NRAD A N

1064 SPINE,CERVICAL 2 OR 3 VIEWS 320 72040 72.00 NRAD A N

1065 JAW MAND & MAX 320 70110 127.20 NRAD A N

10658 CARRY FINAL 1 430 0.01 NOT A Y

1066 L/S 4 OR MORE VIEW 320 72110 105.60 NRAD A N

1069 NOSE 320 70160 60.00 NRAD A N

1072 SINUSES < 3V. 320 70210 64.80 NRAD A N

1073 SINUS PARANSL 3 VIEW MIN 320 70220 84.00 NRAD A N

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Mod1 Mod2 Mod3 Mod4

1075 SKULL 2 VIEW<4 VIEWS 320 70250 74.40 NRAD A N

1079 TEMPOROMANDB/A 320 70328 57.60 NRAD A N

1082 CERV SP 1 VIEW 320 72020 90.00 NRAD A N

1083 CERV SP 4 VIEW 320 72050 104.40 NRAD A N

1084 CERV SP COMPLETF/EXT. 320 72052 128.40 NRAD A N

1086 ORBIT 320 70200 90.00 NRAD A N

1087 SPINE SINGLE VIEW 320 72020 48.00 NRAD A N

1089 THORACIC SP-2 V. 320 72070 72.00 NRAD A N

1091 L/S 2 OR 3 VIEW 320 72100 76.80 NRAD A N

1092 L/S BEN COMP 320 72114 135.60 NRAD A N

1094 RIB BILAT 3 V 320 71110 87.60 NRAD A N

1095 PELVIS- 1 or 2 VIEWS 320 72170 57.60 NRAD A Y

1097 SACRO ILIAC JTS <3V. 320 72200 58.80 NRAD A N

1098 SACRUM 2 VIEW 320 72220 61.20 NRAD A N

11 ED VISIT-MOD COMPLEXITY 456 99283 142.20 NED A N

11000 DYNA-FLEX BANDAGE 2 INCH 270 5.64 NCS A N

11001 ACE BANDAGE 3 INCH 270 5.88 NCS A N

11002 ACE BANDAGE 4 INCH 270 99070 8.16 NCS A N

11003 ACE BANDAGE 6 INCH 270 11.04 NCS A N

11004 DYNA-FLEX COMPRESSION SYSTEM 270 0.00 NCS A N

11007 ALCOHOL ISOPROPYL, RUBBING 16Z 270 5.28 NCS I N

11009 ALCOHOL PREP PAD, BOX OF 200 270 4.92 NCS I N

11011 APPLICATOR 6" NONSTERILE-100PK 270 5.64 NCS A N

11012 APPLICATOR 6" STERILE - 2 PKG 270 0.60 NCS A N

11013 AIRWAY ADULT 270 1.56 NCS A N

11014 AIRWAY CHILD 270 2.16 NCS A N

11016 THERMAL MUG 270 12.24 NCS A N

11017 ABDOMINAL PAD 5X9 270 0.96 NCS A N

1102 FOOT 2 VIEW 320 73620 105.60 NRAD A N

11021 ARM BAND, I.D. CLEAR 270 0.00 NCS A N

11023 EXTRA LARGE DIAPER 270 3.00 NCS A N

11024 ATTENDS - LARGE 270 2.64 NCS A N

11025 BANDAID SPOT - BOX OF 100 270 7.56 NCS I N

11026 BANDAID STRIP - BOX OF 100 270 11.40 NCS I N

11027 BED PAN REGULAR 270 4.20 NCS A N

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11028 BED PAN FRACTURE 270 4.80 NCS A N

1103 FOOT 3 VIEW 320 73630 121.20 NRAD A N

11034 WHIRLPOOL CONCENTRATE IODINE G 270 55.44 NCS A N

11036 PROVIDONE SWABS 270 2.16 NCS A N

11044 BAG BROWN - SIZE 1-25/PK 270 2.16 NCS A N

11047 BAG BROWN - SIZE 6-25/PK 270 11.40 NCS I N

11051 CATHETER 20 FR - 5CC 270 39.24 NCS A N

11052 CATHETER 16 FR - 5CC 270 41.40 NCS A N

11054 CATHETER KIT 14 FR 5CC 270 55.08 NCS A N

11055 CATHETER PLUG PLASTIC-STERILE 270 8.23 NCS A N

11057 CATHETER TRAY URETHAL 14 FR 270 27.36 NCS A N

11063 CHUX 10 IN PK 270 14.16 NCS A N

11064 COTTON BALL BAGS 270 9.00 NCS A N

11066 MOUTHWASH CHLORASEPTIC 6 OZ. 270 41.20 NCS A N

11072 CUPS PLASTIC JUICE-5OZ-100/PKG 270 5.64 NCS I N

11074 CUPS SOUFFLE - MEDICINE CUP 270 5.64 NCS I N

11076 DENTURE CUPS PLASTIC 270 0.72 NCS A N

11077 CULTURETTE 270 5.83 NCS A N

11079 STAPLE REMOVER KIT 270 13.92 NCS A N

11086 DOUCHE KIT 270 7.56 NCS A N

11090 LEG BAG - DISPOSABLE 270 8.04 NCS A N

11099 MINERAL OIL ENEMA 4.5 OZ. 270 15.42 NCS A N

11100 PHOSPHATE ENEMA 4.5 OZ 270 14.90 NCS A N

11101 ENEMA CLEANING SET 270 5.16 NCS A N

11102 CASTILE SOAP PACKAGE 1OZ 270 0.48 NCS A N

11103 EMESIS BASIN 270 0.48 NCS A N

11104 INFUSION SET 21GA-3/4" 270 11.28 NCS A N

11117 KLING 1 INCH BANDAGE 270 0.00 NCS A N

11118 GAUZE 3" KLING 3 X 5 YARD ROLL 270 2.16 NCS A N

11119 GAUZE SPONGES 270 24.24 NCS A N

11121 GAUZE SPONGES 4X4 - 10/PK 270 4.68 NCS A N

11123 GAUZE SPONGES 4X4 - 2/PK 270 0.48 NCS A N

11124 VINYL GLOVES PF BOX 270 54.36 NCS I N

11125 TRIFLEX STERILE LATEX GLOVE 270 5.28 NCS A N

11126 GLOVES SURGICAL SIZE 7 1/2 270 148.32 NCS A N

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Mod1 Mod2 Mod3 Mod4

11129 SWABSTICK-LEMON 3-PKG 270 1.32 NCS A N

11135 HUMIDIFIER DISPOSABLE 270 23.59 NCS A N

11138 ALCOHOL JEL DISINFECT 8 OZ 270 2.64 NCS A N

11139 IRRIGATION TRAY 270 5.40 NCS A N

11140 CYSTO/BLADDER IRRIGATION SET 270 12.72 NCS A N

11144 IRR SOL. 3000ML BAGS 270 6.00 NCS A N

11145 SOLUTION WATER FOR IRRAGATION 270 7.32 NCS A N

11146 IV CATHETER 18GA 1 1/4" 270 3.36 NCS A N

11147 SOLUTION IRRIGATION SALINE .9% 270 10.56 NCS A N

11148 STER SALINE 0.9% SOL.100ML 270 3.36 NCS A N

11153 KLEENEX 270 3.72 NCS A N

11157 BABY WIPES 270 17.28 NCS A N

11158 LAUNDRY DETERGENT 270 117.24 NCS A N

11159 MOISTURIZING LOTION 4 OZ. 270 3.60 NCS A N

11171 MIDSTREAM KIT 270 0.84 NCS A N

11172 EGG CRATE MATTRESS 270 85.68 NCS A N

11174 NEEDLE 16 GA INCH OF 100 270 128.40 NCS A N

11175 NEEDLE 20 GA 1 1/2 INCH OF 100 270 147.48 NCS A N


11177 NEEDLE 21 GA 1 INCH OF 100 270 93.60 NCS A N



11181 NEEDLE 21 GA 2 INCH BOX 270 121.68 NCS A N

11184 OXYGEN SUPPLY TUBING 270 2.04 NCS A N

11187 SANITIZER AVAGARD PUMP 270 29.64 NCS I N

11188 SANITIZER HAND FOAM 270 19.80 NCS I N

11189 SITZ BATH DISPOSABLE 270 34.80 NCS A N

11190 STRAINER/KIDNEY STONES 270 1.98 NCS A N

11195 VANISH PT SYR 3ML 22G 1 1/2" 270 5.88 NCS A N

11196 SYRINGE 3CC 22 GA 1 INCH 270 1.68 NCS A N

11197 SYRINGE 3CC 25 GA 5/8 INCH 270 1.68 NCS A N

11198 SYRINGE 3CC 22 GA 1 1/2 INCH 270 3.36 NCS A N

11199 SYRINGE 3CC W/0 NEEDLE 270 0.60 NCS A N

11200 SYRINGE 5CC W/O NEEDLE 270 0.36 NCS A N

11201 SYRINGE 10 CC W/O NEEDLE 270 0.96 NCS A N

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11202 SYRINGE 20 CC W/O NEEDLE 270 1.44 NCS A N

11205 INSULIN SYRINGE 1CC 270 2.16 NCS A N

11206 SYRINGE INSULIN 1/2 CC 270 2.04 NCS A N

11207 SYRINGE 60CC 270 5.52 NCS A N

11208 CATH TIP SYRINGE 60CC 270 0.60 NCS A N

11219 SCALPEL # 10 270 3.24 NCS A N

11220 SPUTUM COLLECTION 270 7.20 NCS A N


11232 TAPE ZONAS PORUS 1 INCH 270 12.69 NCS A N

11234 PROVON LOTION 4 OZ. 270 14.76 NCS A N

11236 TELFA 2X3 PAD 270 3.62 NCS A N

11237 TELFA 3X3 PAD 270 0.72 NCS A N

11238 TABLE PAPER 18 INCH WIDE 270 9.84 NCS A N

11243 URINAL MALE 270 3.36 NCS A N

11244 URINE TECH SYSTEM 125 TUBES 270 16.86 NCS A N

11245 LUBRICATING JELLY 5 GR. 270 0.36 NCS A N

11247 WASH BASIN 270 3.48 NCS A N

11250 OXYGEN MASK 270 5.76 NCS A N

11251 STOP COCK 3 WAY 270 4.92 NCS A N

11252 TONGUE DEPRESSORS 250/BOX 270 29.40 NCS A N

11254 TEX CATHETER-URO SHEATH 270 3.72 NCS A N

11255 EXTERNAL CATH. NON LATEX 270 67.12 NCS A N

11256 CPR MASK 270 22.68 NCS A N

1126 KNEE 2 VIEWS 320 73560 58.80 NRAD A N

1127 WRIST 3 VIEW 320 73110 62.40 NRAD A N

11275 VASOLINE 5 GR. PACK 270 0.36 NCS A N

11278 NASAL CANULLA DISPOSABLE 270 1.92 NCS A N

11279 INFUSION SET 7/8" 19GA 270 11.28 NCS A N

11291 LIMB HOLDER 270 12.84 NCS A N

11296 STERI STRIP SKIN CLOSURES 270 6.36 NCS A N

11303 HEEL-ELBOW PROTECTORS 270 15.00 NCS A N

11307 CATHETER TRAY 18 FR - 5CC 270 39.24 NCS A N

11308 INVALID RING - DONUT 270 27.24 NCS A N

11311 MOUTHWASH 3 OZ. 270 2.04 NCS A N

11319 CATH ONLY 18FOLEY 30CC 270 28.64 NCS A N

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1135 ANKLE COMP 3 V 320 73610 61.20 NRAD A N

11353 INFUS SET BTRFLY 3/4" 23GA 270 6.24 NCS A N

1136 T-SP COMP 320 72074 93.60 NRAD A N

11365 ARM BOARD 270 3.36 NCS A N

1137 THORACOLUMBAR 320 72080 74.40 NRAD A N

11374 IV CATHETER 1" 20GA 270 8.40 NCS A N

11375 INTAKE GLASS 8 OZ. CLEAR 270 0.36 NCS A N

11383 SYRINGE TUBERCULIN 1CC 270 2.52 NCS A N

11385 CUPS MED PLASTIC 100 TUBE 270 5.64 NCS I N

11387 SUTURE REMOVAL TRAY DISPOSABLE 270 3.24 NCS A N

11389 TAPE MICROPORE 1 INCH 270 5.28 NCS A N

1139 SKULL 4 VIEWS 320 70260 104.40 NRAD A N

11394 BETADINE SWABSTICK - 3/PK 270 0.84 NCS A N

11398 SCAPEL # 15 270 3.24 NCS A N

11399 PERI BOTTLE 270 6.15 NCS A N

11402 TAPE LEUKOSILK 1 INCH 270 7.56 NCS A N

11404 DRAINAGE BAGS - BEDSIDE 270 26.28 NCS A N

11405 CATHETER KIT 18 FR 5CC 270 66.60 NCS A N

11406 CATHETER ONLY 22FR 30CC 270 26.64 NCS A N

11409 GLOVES SURGEON PERRY 8 SZ 270 6.86 NCS A N

11443 GAUZE 3 X8 VASELINE 270 3.12 NCS A N

11444 VOLUMETRIC EXERCISER 270 33.72 NCS A N

11448 ENTERNAL FEEDING CONTAINER 270 45.24 NCS A N

11454 BABY POWDER 4 OZ. BOTTLE 270 2.28 NCS A N

11455 PEROXIDE 16 OZS 270 10.56 NCS A N

11458 CATHETER SUCTION 18 FR 270 9.07 NCS A N


11461 PATIENT CARD/RADIOLOGY 270 84.00 NCS I N

11467 TRACHEAL TUBE 7.0 MM 270 39.07 NCS A N

11468 TRACHAEL TUBE 7.5 MM 270 39.07 NCS A N





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Mod1 Mod2 Mod3 Mod4


11477 FEEDING TUBE 270 81.12 NCS A N

11478 CATHETER KIT 16 FRENCH 5CC 270 94.32 NCS A N


11480 IV ADMINISTRATION 270 6.00 NCS A N

11483 SECONDARY MEDICATION SET 270 8.16 NCS A N

11484 ALCOHOL GALLON 270 20.16 NCS A N

11485 PRN ADAPTER 0.1 ML CAPACITY 270 63.00 NCS I N

11489 SHARPS COLLECTOR 1 QT SMALL 270 0.00 NCS A N

11490 OVAL EYE PATCH 270 0.60 NCS A N

11491 SECURITY VEST MED 270 55.68 NCS A N

11492 SECURITY VEST LARGE 270 74.38 NCS A N

11493 PT. RENT 02 CYLINDER 270 103.68 NCS A N

11494 ATTENDS - MEDIUM 270 2.16 NCS A N

11495 TECHNI-CARE SCRUB 8OZ 270 28.80 NCS A N

11496 IODINE SCRUB 8OZS 270 10.92 NCS A N

11497 BIO-DRESSING 270 13.99 NCS A N

11498 OPSITE 6" X 8" 270 8.64 NCS A N

11499 SHARP CONTAINER 5 GALLON 270 77.16 NCS A N

11500 BIOCLUSIVE TRANS DRESING 2X3 270 9.00 NCS A N

11501 IV CATHETER 22GA 1" 270 8.40 NCS A N

11502 PRN ADAPTER 0.3 ML CAPACITY 270 2.40 NCS A N

11503 TED KNEE LENGTH, X-LG/REG 270 15.48 NCS A N

11504 TED KNEE LENGTH, MED/REG 270 15.48 NCS A N

11505 TED THIGH LENGTH, LG/REG 270 69.48 NCS A N

11506 TED THIGH LENGTH, SM/REG 270 69.48 NCS A N

11507 TED KNEE LENGTH,LG/REG 270 96.99 NCS A N

11511 GAUZE 2" 4-5 YD ROLL 270 1.08 NCS A N

11513 YANKAUER SUCTION 270 9.48 NCS A N

11514 TUBE 16 FR NG 270 3.12 NCS A N

11515 TUBE SUCTION CONNECTING 270 0.00 NCS A N

11516 ELECTRODES 3M 270 3.36 NCS A N

11517 SHAVING CREAM 270 3.48 NCS A N

11518 RAZOR - DISPOSABLE 270 0.72 NCS A N

11519 IV CATHETER EXTENSION SET 270 8.47 NCS A N

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11520 TOOTHPASTE 1.5 OZ 270 2.76 NCS A N

11521 TOOTHBRUSH 270 1.08 NCS A N

11522 SOAP 270 1.44 NCS A N

11523 GRADUATE 32 OZ. 270 19.32 NCS A N

11524 COMB 270 0.72 NCS A N

11527 THICK-IT 270 16.08 NCS A N

11528 Y-TYPE BLOOD SOL 270 14.42 NCS A N

11529 DIGITAL PROBE COVERS 270 15.96 NCS A N

11530 TRACH CARE KIT W/GLOVES 270 26.89 NCS A N

11531 ENTERNAL PUMP FEED SET-ROSS#71 270 26.16 NCS A N

11532 ISOLATION GOWN 270 3.48 NCS A N

11533 SERVERE LACERATION TRAY 270 161.76 NCS A N

11535 LACERATION TRAY - STERILE 270 39.12 NCS A N

11538 SIMPLE LACERATION TRAY 270 14.76 NCS A N

11539 KETO-DIASTIX - BOTTLE OF 50 270 47.17 NCS A N

11540 COLLECTOR - SPCMN NURSE HAT 270 2.52 NCS A N

11544 RATE FLOW REGULATOR EXT SET 270 26.16 NCS A N

11545 TUBE CONNECTOR 5'-1 530A 270 10.36 NCS A N

11546 GAUZE 4" KLING 4-5 YRD STR 270 1.68 NCS A N

11547 BITE STICK 270 2.76 NCS A N

11549 CONTINA-FLO SET IV 270 36.84 NCS A N

11550 INTRECATH W. STYLET 22GA X 8 270 29.02 NCS A N

11551 THERMOSCAN PROBE COVER 273 63.00 NCS A N




11556 TOOTHETTE BRUSH, 1 PER POL 270 2.16 NCS A N

11557 TAPE LEUKOSILK-2" 270 6.72 NCS A N

11558 CUPS STYROFOAM - 12 OZ 270 0.00 NCS A N

11559 FIXODENT 1.4OZ TUBE 270 10.56 NCS A N

11560 ABDUCTION PILLOW 270 151.20 NCS A N

11561 FLEETS ENEMA CLEANSING 270 11.04 NCS A N

11562 BOUFFADNT CAP DIETARY 270 0.00 NCS A N

11563 TED STOCKING, THIGH LGH, SML 270 26.52 NCS A N

11565 DERMAGRAM SPRAY - 4 OZ 270 14.76 NCS A N

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11566 EFFERDENT TABLETS - PKG 270 0.60 NCS A N

11567 SENSOR BED MATS 270 161.76 NCS A N

11568 NEBULIZER UNIT - DISPOSABLE 270 6.48 NCS A N

11569 PROCEDURE MASK 270 60.00 NCS A N

11570 GLASSES PROTECTIVE - CLEAR 270 16.08 NCS A N

11571 COL PRESS INSTANT ICE PACK 270 6.86 NCS I N

11572 BIRTHING ROOM PACK 270 60.36 NCS A N

11575 IV T EXTENSION (HEPLOCK SET) 270 18.84 NCS A N

11580 EXAM GLOVE - UNPOWDERED 270 33.24 NCS I N

11581 BANDAID LARGE 2 X 4 270 20.52 NCS I N

11582 BOUFFANT CAP DIETARY 270 0.00 NCS A N

11585 SANITARY PADS PKG 270 20.16 NCS A N

11586 INJECTION TRAY 270 33.12 NCS A N

11588 HEMOCULT II SLIDE TEST 270 15.72 NCS A N

11591 POVIDONE IODINE SOLUTION 270 4.44 NCS A N

11592 PREP SOLUTION 270 1.56 NCS A N

11593 PACKING STRIPS 1/2 X 5 YDS 270 13.08 NCS A N

11594 GLUCOSE TEST STRIP PRECISION 270 295.68 NCS A N

11595 EXTENSION TUBING 270 5.88 NCS A N

11597 SUCTION CANISTER 270 20.04 NCS A N

11603 DEVON NEEDLE CONTAINER 270 16.32 NCS A N

11605 CHRISTMAS TREE ADAPTER 270 3.72 NCS A N

11606 FEMALE CATHETER 270 2.88 NCS A N

11607 COMM AFFAIRS BID SHEET 270 162.60 NCS I N

11608 HOW TO SURVIVE LOSS OF LOVED 1 270 42.00 NCS A N

11609 SURVIVING WORKBOOK 270 42.84 NCS A N

11610 DEODORANT 270 7.08 NCS A N

11611 THE COURAGE TO HEAL PAMPHLET 270 71.40 NCS A N

11614 BODY AND HAIR WASH 270 2.28 NCS A N

11615 TED STOCKING 3922 NUM 270 126.00 NCS A N

11616 CATH SECURE KIT 270 6.60 NCS A N

11618 I V START KIT 270 5.28 NCS A N

11619 XL SLIPPER 270 7.44 NCS A N

11620 POLYMEM 2X3 DRESSING 270 23.28 NCS A N

11621 POLYMEM31/2"X31/2" DRESSING 270 66.60 NCS A N

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11622 POLYMEM ROLL 270 79.08 NCS A N

11623 INCONTINENCE CARE KIT 270 42.12 NCS A N

11624 DAIL 1 GALLON PT. USE 270 0.00 NCS A N

11625 AA BOOK 270 83.32 NCS A N

11628 ULTEC 270 12.60 NCS A N

11630 OPSITE DRESSING 2X2 INCH 270 1.56 NCS A N

11631 OPSITE 4" X 5.1/2" 270 23.16 NCS A N

11632 DRAIN BAG 270 17.88 NCS A N

11633 CATH TRAY 14 FR 270 94.56 NCS A N

11634 STIRLE H2O 120ML 270 1.86 NCS A N

11636 LANCETS 270 159.60 NCS A N

11637 IV LURE LOCK CAP 270 0.93 NCS A N

11638 GLUCOSE HIGH/LOW CONTROLS 270 30.72 NCS A N

11639 POLYMEM 6.5X7 SZ 270 53.64 NCS A N

11641 LEG STRAPS 270 34.44 NCS A N

11642 DURODERM 6X6 SZ 270 18.39 NCS A N

11665 DURO DERM 4X4 SZ 270 51.36 NCS A N

11666 ALLDERM 4 X4 DRESSING 270 6.72 NCS A N

11667 ALLDERM 6 X 6 DRESSING 270 14.76 NCS A N

11668 MESALT DRESSING 270 10.56 NCS A N

11669 HYPERGEL DRESSING GEL 270 29.52 NCS A N

11670 NORMLGEL DRESSING GEL 270 31.56 NCS A N

12 ED VISIT-DETAILED/MOD. COMP. 456 99284 273.60 NED A N

1200 DEXA-HIP 320 77080 450.00 NRAD A N

1202 DEXA-FOREARM 320 77081 120.00 NRAD A N

1203 KNEE 3 VIEWS 320 73562 57.60 NRAD A N

1204 THORACOLUMBAR, 2 VIEWS 320 72080 58.80 NRAD A N

1205 KNEES-BILATERAL 320 73560 138.00 NRAD A N50

1206 FEET BILATERAL 320 73620 138.00 NRAD A N50

1207 HANDS BILATERAL 320 73120 138.00 NRAD A N50

1208 SHOULDER BILATERAL 320 73020 102.00 NRAD A N50

1209 ANKLE - BILATERAL 320 73600 108.00 NRAD A N50

1212 KNEES-BILAT-RT 320 54.00 NRAD A N

1212A KNEES BILATERAL LT 320 54.00 NRAD A N

1213 FEET BILAT - RT 320 54.00 NRAD A N

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Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 12

Mod1 Mod2 Mod3 Mod4

1213A FEET BILATERAL LT 320 54.00 NRAD A N

1214 HANDS BILAT - RT 320 73120 54.00 NRAD A N

1214A HANDS BILATERAL LT 320 73120 54.00 NRAD A N

1215 SHOULDER BILAT - RT 320 54.00 NRAD I N

1215A SHOULDER BILATERAL LT 320 54.00 NRAD I N

1216 ANKLE BILAT-RT 320 54.00 NRAD A N

1216A ANKLE BILATERAL LT 320 54.00 NRAD A N

1217 HIP- 2-3 VIEWS 320 73502 180.00 NRAD A N

1218 HIP- MIN. 4 VIEWS 320 73503 244.80 NRAD A N

1222 RADIOLOGIC EXAM CHEST 2 VIEWS 320 71046 69.60 NRAD A N

1225 RADIOLOGIC EXAM CHEST SINGLE VIEW 320 71045 54.00 NRAD A N

13 ED VISIT-COMPREHENSIVE/HIGH 456 99285 403.20 NED A N

1301 PHYSICAL THERAPY 420 97799 0.00 NOPRH A NGP

1302 PARRAFFIN BATH 420 97018 36.00 NOPRH A NGP

1303 AQUATIC THERAPY 420 97113 74.88 NOPRH A N59GP

1304 VASOPNEUMATIC COMPRESSION 420 97016 40.32 NOPRH A NGP

1306 TRACTION MECHANICAL 420 97012 53.28 NOPRH A N59GP

1307 ULTRASOUND/15 420 97035 36.00 NOPRH A N59GP

1308 PT RE-EVAL 420 97002 100.80 NOPRH A N59GP

1309 WHIRLPOOL 420 97022 57.60 NOPRH A N59GP

1311 DIATHERMY 420 97024 59.04 NOPRH A NGP

1315 EXERCISE(2 OR MORE:GROUP) 420 97150 72.00 NOPRH A N59GP

1317 HUBBARD TANK/15 420 97036 139.68 NOPRH A NGP

1318 HOT PACK/COLD PACK 420 97010 36.00 NOPRH A YGP

1321 MASSAGE 420 97124 56.16 NOPRH A N59GP

1322 MODILITIES UNSPEC 420 97039 36.00 NOPRH A NGP

1323 ELEC STIM MAN./15 420 97032 53.28 NOPRH A N59GP

1324 ELEC STIM UNATT. 420 97014 50.40 NOPRH A YGP

1331 TENS UNIT INITAL 420 97032 93.60 NOPRH A NGP

1332 PHONOPHORESIS 420 97039 43.20 NOPRH A NGP

1337 FLUIDOTHERAPY 420 97039 50.40 NOPRH A NGP

1339 IONTOPHORESIS/15 420 97033 53.28 NOPRH A N59GP

1344 PT INITIAL EVALUATION 420 97001 180.00 NOPRH A N59GP

1345 CANALITH REPOS/EPLEY MANEUVER 420 92700 72.00 NOPRH A NGP

1346 GAIT TRAINING 420 97116 64.80 NOPRH A N59GP

Rev

Code

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Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 13

Mod1 Mod2 Mod3 Mod4

1347 PHYSICAL MED/REHAB PROCEDURE 410 97799 14.40 NOPRH A N

1348 ORTHOTICS FIT.AND TRAINING/15 420 97763 80.00 NOPRH A NGP

1349 PHYSICAL PERFORMANCE /15 MIN 420 97750 79.20 NOPRH A NGP

1350 BIOFEEDBACK 420 90901 108.00 NOPRH A NGP

1351 BANDAG WOUND DRESS 420 16020 136.80 NOPRH A NGP

1352 DISCHARGE 420 0.00 NOPRH A N

1353 CONTRAST BATH/15 420 97034 59.04 NOPRH A NGP

1354 DEBRIDEMENT 420 16020 136.80 NOPRH A NGP

1355 MED.REPORT FOR INSURANCE/ATTY 420 99080 185.76 NOPRH A NGP

1356 THER. ACTIVITIES/15 420 97530 66.24 NOPRH A NGP

1357 ICE MASSAGE/15 420 97124 56.16 NOPRH A NGP

1358 MAN. THER. TECH/15 420 97140 63.36 NOPRH A N59GP

1360 THER. PROCEDURE/15 420 97110 66.24 NOPRH A N59GP

1361 NEUROMUS RE-ED 420 97112 69.12 NOPRH A N59GP

1362 PROSTHETIC TRAINING/15 MIN. 420 97761 66.24 NOPRH A NGP

1363 WORK HARDENING/CONDIT(2HRS) 420 97545 180.00 NOPRH A NGP

1364 WORK HARDENING/CONDIT(ADDL HR) 420 97546 57.60 NOPRH A NGP

1365 ATHLETIC TRAINER EVAL 420 97005 180.00 NOPRH A NGP

1366 AT RE-EVAL 420 97006 86.40 NOPRH A NGP

1367 MOBILITY CURRENT 0 420 0.01 NOPRH A Y

1368 MOBILITY GOAL 0 420 0.01 NOPRH A Y

1369 MOBILITY DISCHARGE 0 420 0.01 NOPRH A Y

1370 BODY POSITION CURRENT 0 420 0.01 NOPRH A Y

1371 BODY POSITION GOAL 0 420 0.01 NOPRH A Y

1372 BODY POS FINAL 0 420 0.01 NOPRH A Y

1373 CARRY CURRENT 0 420 0.01 NOPRH A Y

1374 CARRY GOAL 0 420 0.01 NOPRH A Y

1375 CARRY FINAL 0 420 0.01 NOPRH A Y

1376 SELF CARE CURRENT 0 420 0.01 NOPRH A Y

1377 SELF CARE GOAL 0 420 0.01 NOPRH A Y

1378 SELF CARE FINAL 0 420 0.01 NOPRH A Y

1379 OTHER CURRENT 0 420 0.01 NOPRH A Y

1380 OTHER GOAL 0 420 0.01 NOPRH A Y

1381 OTHER FINAL 0 420 0.01 NOPRH A Y

1382 MOBILITY CURRENT 1 420 0.01 NOPRH A Y

Rev

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Code

Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4


1384 MOBILITY FINAL 1 420 0.01 NOPRH A Y

1385 INFRARED-MODALITY 1+ AREAS 420 97026 36.00 NOPRH A NGP

1386 BODY POS CURRENT 1 420 0.01 NOPRH A Y









1395 OTHER CURRENT 1 420 0.01 NOPRH A Y



1398 MOBILITY CURR 20 420 0.01 NOPRH A Y



1401 BODY POS CURRENT 20 420 0.01 NOPRH A Y









1410 OTHER CURR 20 420 0.01 NOPRH A Y






1416 BODY POS CURR 40 420 0.01 NOPRH A Y

1417 BODY POS GOAL 40 420 0.01 NOPRH A Y

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Code

Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4


1419 CARRY CURR 40 420 0.01 NOPRH A Y



1422 SELF CARE CURR 40 420 0.01 NOPRH A Y























1445 MOBILILTY FINAL 80 420 0.01 NOPRH A Y




1449 CARRY CURR 80 420 0.01 NOPRH A Y


1451 MEDICATIONS 250 0.00 NPHAR A N

1452 MEDICATIONS PASS 253 0.00 NPHAR A N

Rev

Code

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Code

Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4

1453 MEDICATIONS 250 0.00 NPHAR A N








1461 MOBILITY CURR 100% 420 0.01 NOPRH A Y















1476 SUB CURR 0 420 0.01 NOPRH A Y



1479 SUB CURRENT 40 420 0.01 NOPRH A Y


1481 SUB CURRENT 80 420 0.01 NOPRH A Y

1482 SUB CURR 100 420 0.01 NOPRH A Y

1483 SUB GOAL 0 420 0.01 NOPRH A Y





Rev

Code

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Code

Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4


1489 SUB GOAL 100 420 0.01 NOPRH A Y

1490 SUB FINAL 0 420 0.01 NOPRH A Y







15000 MOBILITY CURRENT 0 420 0.01 NLS A Y







15007 MOBILITY GOAL 0 420 0.01 NLS A Y



1501 PHYSICAL THERAPY (LS) 420 97799 0.00 NLS A NGP





15014 MOBILITY FINAL 0 420 0.01 NLS A Y






1502 PARRAFFIN BATH 420 97018 36.00 NLS A NGP


15021 BODY POS CURRENT 0 420 0.01 NLS A Y



Rev

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Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4





15028 BODY POS GOAL 0 420 0.01 NLS A Y


1503 AQUATIC THERAPY 420 97113 74.88 NLS A N59GP






15035 BODY POS FINAL 0 420 0.01 NLS A Y





1504 VASOPNEWMATIC COMPRESSION 420 97016 40.32 NLS A N59GP



15042 CARRY CURRENT 0 420 0.01 NLS A Y







15049 CARRY GOAL 0 420 0.01 NLS A Y

15050 CARRY GOAL 1 420 0.01 NLS A Y

15051 CARRY GOAL 20 420 0.01 NLS A Y

15052 CARRY GOAL 40 420 0.01 NLS A Y

15053 CARRY GOAL 60 420 0.01 NLS A Y

15054 CARRY GOAL 80 420 0.01 NLS A Y

15055 CARRY GOAL 100 420 0.01 NLS A Y

15056 CARRY FINAL 0 420 0.01 NLS A Y

Rev

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Code

Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4




1506 TRACTION MECHANICAL 420 97012 53.28 NLS A N59GP




15063 SELF CARE CURRENT 0 420 0.01 NLS A Y







1507 ULTRASOUND/15 420 97035 36.00 NLS A N59GP

15070 SELF CARE GOAL 0 420 0.01 NLS A Y







15077 SELF CARE FINAL 0 420 0.01 NLS A Y



1508 PT RE-EVAL 420 97002 100.80 NLS A N59GP





15084 OTHER CURRENT 0 420 0.01 NLS A Y





Rev

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Code

Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4


1509 WHIRLPOOL 420 97022 57.60 NLS A N59GP


15091 OTHER GOAL 0 420 0.01 NLS A Y

15092 OTHER GOAL 1 420 0.01 NLS A Y

15093 OTHER GOAL 20 420 0.01 NLS A Y

15094 OTHER GOAL 40 420 0.01 NLS A Y

15095 OTHER GOAL 60 420 0.01 NLS A Y

15096 OTHER GOAL 80 420 0.01 NLS A Y

15097 OTHER GOAL 100 420 0.01 NLS A Y

15098 OTHER FINAL 0 420 0.01 NLS A Y







15105 SUB CURRENT 0 420 0.01 NLS A Y



15108 SUB CURR 40 420 0.01 NLS A Y


1511 DIATHERMY 420 97024 59.04 NLS A NGP



15112 SUB GOAL 0 420 0.01 NLS A Y

15113 SUB GOAL 1 420 0.01 NLS A Y

15114 SUB GOAL 20 420 0.01 NLS A Y

15115 SUB GOAL 40 420 0.01 NLS A Y

15116 SUB GOAL 60 420 0.01 NLS A Y

15117 SUB GOAL 80 420 0.01 NLS A Y

15118 SUB GOAL 100 420 0.01 NLS A Y

15119 SUB FINAL 0 420 0.01 NLS A Y

15120 SUB FINAL 1 420 0.01 NLS A Y

15121 SUB FINAL 20 420 0.01 NLS A Y

Rev

Code

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Code

Rate Taxable Rate

Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4

15122 SUB FINAL 40 420 0.01 NLS A Y

15123 SUB FINAL 60 420 0.01 NLS A Y

15124 SUB FINAL 80 420 0.01 NLS A Y

15125 SUB FINAL 100 420 0.01 NLS A Y

1515 EXERCISE(2 OR MORE;GROUP) 420 97150 72.00 NLS A N59GP

1517 HUBBARD TANK/15 420 97036 139.68 NLS A NGP

1518 HOT PACK/COLD PACK 420 97010 36.00 NLS A YGP

1521 MASSAGE 420 97124 56.16 NLS A N59GP

1522 MODILITIES UNSPEC 420 97039 36.00 NLS A NGP

1523 ELEC STIM MAN./15 420 97032 53.28 NLS A N59GP

1524 ELEC STIM UNATT. 420 97014 50.40 NLS A YGP

1531 TENS UNIT INITAL 420 97032 93.60 NLS A NGP

1532 PHONOPHORESIS 420 97039 43.20 NLS A NGP

1537 FLUIDOTHERAPY 420 97039 50.40 NLS A NGP

1539 IONTOPHORESIS 420 97033 53.28 NLS A N59GP

1544 PT INITIAL EVALUATION 420 97001 180.00 NLS A N59GP

1545 CANALITH REPOS/EPLEY MANE 420 92700 72.00 NLS A NGP

1546 GAIT TRAINING 420 97116 64.80 NLS A N59GP

1547 PHYSICAL MED/REHAB PROCEDURE 420 97799 14.40 NLS A N

1548 ORTHOTICS FIT & TRAINING 420 97760 80.00 NLS A NGP

1549 PHYSICAL PERFORMANCE/15 420 97750 79.20 NLS A NGP

1550 BIOFEEDBACK 420 97110 108.00 NLS A NGP

1551 BANDAGE WOUND DRESS 420 16020 136.80 NLS A NGP

1552 DISCHARGE 420 99999 0.00 NLS A NGP

1553 CONTRAST BATH/15 420 97034 59.04 NLS A NGP

1554 DEBRIDEMENT 420 16020 136.80 NLS A NGP

1555 MED REPORT FOR INSURANCE 420 99080 185.76 NLS A NGP

1556 THER. ACTIVITIES 420 97530 66.24 NLS A NGP

1557 ICE MASSAGE/15 420 97124 56.16 NLS A NGP

1558 MAN. THER. TECH/15 420 97140 63.36 NLS A N59GP

1560 THER PROCEDURE/15 420 97110 66.24 NLS A N59GP

1561 NEUROMUS RE-ED 420 97112 69.12 NLS A N59GP

1562 PROSTHETIC TRAINING/15 MIN 420 97761 66.24 NLS A NGP

1563 WORK HARDENING/CONDIT(2HR 420 97545 180.00 NLS A NGP

1564 WORK HARDENING/CONDIT(ADD 420 97546 57.60 NLS A NGP

Rev

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Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 22

Mod1 Mod2 Mod3 Mod4

1565 ATHLETIC TRAINER EVAL 420 97005 180.00 NLS A NGP

1566 AT RE-EVAL 420 97006 86.40 NLS A NGP

1585 INFRARED-MODALITY 1+ AREAS 420 97026 36.00 NLS A NGP

1586 PT.EVAL-LOW COMPLEX, W/O COMORB. 420 97161 180.00 NLS A NGP

1587 PT EVAL-MOD.COMPLEX, 1-2 COMORB. 420 97162 180.00 NLS A NGP

1588 PT EVAL-HIGH COMPLEX, 3 COMORB. 420 97163 180.00 NLS A NGP

1589 PT RE-EVAL OF ESTABLISHED POC 420 97164 111.84 NLS A NGP

1600 OCCUPATIONAL THER.-DO NOT USE! 430 0.00 NOT A N

16001 MOBILITY CURR 0 430 0.01 NOT A Y




16005 MOBILITY CURRENT 60 430 0.01 NOT A Y



16008 MOBILITY GOAL 0 430 0.01 NOT A Y


1601 SENSORY INTEGRATION/15 430 97533 64.80 NOT A NGO






16015 MOBILITY FINAL 0 430 0.01 NOT A Y





1602 RE-EVAL 430 97004 100.80 NOT A NGO



16022 BODY POS CURR 0 430 0.01 NOT A Y

16023 BODY POS CURR 1 430 0.01 NOT A Y

16024 BODY POS CURRENT 20 430 0.01 NOT A Y


Rev

Code

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16:04


Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 23

Mod1 Mod2 Mod3 Mod4




16029 BODY POS GOAL 0 430 0.01 NOT A Y







16036 BODY POS FINAL 0 430 0.01 NOT A Y







16043 CARRY CURR 0 430 0.01 NOT A Y

16044 CARRY CURRENT 1 430 0.01 NOT A Y






16050 CARRY GOAL 0 430 0.01 NOT A Y

16051 CARRY GOAL 1 430 0.01 NOT A Y

16052 CARRY GOAL 20 430 0.01 NOT A Y

16053 CARRY GOAL 40 430 0.01 NOT A Y

16054 CARRY GOAL 60 430 0.01 NOT A Y

16055 CARRY GOAL 80 430 0.01 NOT A Y

16056 CARRY GOAL 100 430 0.01 NOT A Y




1606 TRACTION MECHANICAL 430 97012 53.28 NOT A NGO

Rev

Code

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Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 24

Mod1 Mod2 Mod3 Mod4





16064 SELF CARE CURRENT 0 430 0.01 NOT A Y







16071 SELF CARE GOAL 0 430 0.01 NOT A Y







16078 SELF CARE FINAL 0 430 0.01 NOT A Y







16085 OTHER CURRENT 0 430 0.01 NOT A Y







16092 OTHER GOAL 0 430 0.01 NOT A Y

16093 OTHER GOAL 1 430 0.01 NOT A Y

16094 OTHER GOAL 20 430 0.01 NOT A Y

Rev

Code

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16:04


Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 25

Mod1 Mod2 Mod3 Mod4

16095 OTHER GOAL 40 430 0.01 NOT A Y

16096 OTHER GOAL 60 430 0.01 NOT A Y

16097 OTHER GOAL 80 430 0.01 NOT A Y

16098 OTHER GOAL 100 430 0.01 NOT A Y

16099 OTHER FINAL 0 430 0.01 NOT A Y







16106 SUBS CURRENT 0 430 0.01 NOT A Y







16113 SUBS GOAL 0 430 0.01 NOT A Y

16114 SUBS GOAL 1 430 0.01 NOT A Y

16115 SUBS GOAL 20 430 0.01 NOT A Y

16116 SUBS GOAL 40 430 0.01 NOT A Y

16117 SUBS GOAL 60 430 0.01 NOT A Y

16118 SUBS GOAL 80 430 0.01 NOT A Y

16119 SUBS GOAL 100 430 0.01 NOT A Y

16120 SUB FINAL 0 430 0.01 NOT A Y

16121 SUBS FINAL 1 430 0.01 NOT A Y

16122 SUBS FINAL 20 430 0.01 NOT A Y

16123 SUBS FINAL 40 430 0.01 NOT A Y

16124 SUBS FINAL 60 430 0.01 NOT A Y

16125 SUBS FINAL 80 430 0.01 NOT A Y

16126 SUBS FINAL 100 430 0.01 NOT A Y

1613 OT POOL EXERCISE 430 97113 74.88 NOT A NGO

1614 EVALUATION 430 97003 165.60 NOT A NGO

1615 MODILITIES UNSPEC 430 97039 36.00 NOT A NGO

Rev

Code

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16:04


Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 26

Mod1 Mod2 Mod3 Mod4

1618 WHIRLPOOL/FLUIDOTHERAPY 430 97022 57.60 NOT A NGO

1621 OT EVAL PSYCH 430 97003 165.60 NOT A NGO

1623 OT FOLLOW-UP PSY-DO NOT USE!!! 430 97799 44.64 NOT A NGO

1624 ORTHOTIC FAB/TRAINING/15 430 97760 60.48 NOT A NGO

1625 DISCHARGE 430 97016 0.00 NOT A NGO

1626 HOME PROGRAM 420 97799 63.36 NOT A NGP

1627 SPLINT/ORTH ADJ/DO NOT USE!! 430 97760 60.48 NOT A NGO

1628 ULTRASOUND/15 430 97035 36.00 NOT A NGO

1629 PARRIFFIN 430 97018 36.00 NOT A NGO

1630 THER ACT/DIR PAT/15 430 97530 96.48 NOT A NGO

1631 TENS UNIT INITAL 430 97032 93.60 NOT A N

1632 OT GROUP THERAPY 430 97150 72.00 NOT A NGO

1640 PROF TIME PSY 430 97799 0.00 NOT A NGO

1642 PROF TIME OPT 430 97799 0.00 NOT A NGO

1647 PHYSICAL MED/REHAB PROCEDURE 430 97799 14.40 NOT A N

1650 IONTOPHORESIS/15 430 97033 53.28 NOT A NGO

1652 ELEC STIM MAN/15 430 97032 53.28 NOT A NGO

1653 EXERCISE (2 OR MORE:GROUP) 430 97150 72.00 NOT A NGO

1655 MANUAL PROCEDURE/15 430 97140 57.60 NOT A NGO

1662 OT PSYCH LIFESKILL-DO NOT USE! 430 97530 96.48 NOT I NGO

1666 ELEC STIM. UNATT 430 97014 50.40 NOT A YGO

1667 HOT/COLD PACK 430 97010 36.00 NOT A YGO

1671 PHONOPHORESIS 430 97039 53.28 NOT A NGO

1672 THER. ACTIVITIES/15 430 97530 57.60 NOT A NGO

1673 THER. PROCEDURE 430 97110 53.28 NOT A NGO

1674 NEUROMUS RE-ED 430 97112 57.60 NOT A NGO

1675 ADL PER/15 430 97535 57.60 NOT A NGO

1676 COG PER/15 430 97127 103.68 NOT A YGO

1677 SELF CARE/15-DO NOT USE!!!!!!! 430 97535 57.60 NOT I NGO

1678 COMM. TRAINING/15 430 97537 43.20 NOT A NGO

1680 ORTHOTIC TRAIN-DO NOT USE!!!!! 430 97760 59.04 NOT I NGO

1681 WORK HARDENING/CONDIT(2HRS) 430 97545 180.00 NOT A NGO

1682 WORK HARDENING/CONDIT(ADDL HR) 430 97546 57.60 NOT A NGO

1682A OT SWALLOW CURR STAT 0 430 0.01 NOT A Y

1682B OT SWALLOW CURRENT STAT 1 430 0.01 NOT A Y

Rev

Code

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Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 27

Mod1 Mod2 Mod3 Mod4

1682C OT SWALLOW CURRENT 20 430 0.01 NOT A Y

1682D OT SWALLOW CURRENT 40 430 0.01 NOT A Y

1682E OT SWALLOW CURRENT 60 430 0.01 NOT A Y

1682F OT SWALLOW CIRRENT 80 430 0.01 NOT A Y

1682G OT SWALLOW CURRENT 100 430 0.01 NOT A Y

1682H OT SWALLOW GOAL STAT 0 430 0.01 NOT A Y

1682I OT SWALLOW GOAL STAT 1 430 0.01 NOT A Y

1682J OT SWALLOW GOAL STAT 20 430 0.01 NOT A Y

1682K OT SWALLOW GOAL STAT 40 430 0.01 NOT A Y

1682L OT SWALLOW GOAL STAT 60 430 0.01 NOT A Y

1682M OT SWALLOW GOAL STAT 80 430 0.01 NOT A Y

1682N OT SWALLOW GOAL STAT 100 430 0.01 NOT A Y

1682O OT SWALLOW DC STAT 0 430 0.01 NOT A Y

1682P OT SWALLOW DC STAT 1 430 0.01 NOT A Y

1682Q OT SWALLOW DC STAT 20 430 0.01 NOT A Y

1682R OT SWALLOW DC STAT 40 430 0.01 NOT A Y

1682S OT SWALLOW DC STAT 60 430 0.01 NOT A Y

1682T OT SWALLOW DC STAT 80 430 0.01 NOT A Y

1682U OT SWALLOW DC STAT 100 430 0.01 NOT A Y

1683A OT ATTEN CURRENT STAT 0 430 0.01 NOT A Y

1683B OT ATTEN CURRENT STAT 1 430 0.01 NOT A Y

1683C OT ATTEN CURRENT STAT 20 430 0.01 NOT A Y

1684 CONTRAST BATH/15 430 97034 28.80 NOT A NGO

1684D OT ATTNE CURRENT STAT 40 430 0.01 NOT A Y

1684E OT ATTEN CURRENT STAT 60 430 0.01 NOT A Y

1684F OT ATTEN CURRENT STAT 80 430 0.01 NOT A Y

1684G OT ATTEN CURRENT STAT 100 430 0.01 NOT A Y

1684H OT ATTEN GOAL STAT 0 430 0.01 NOT A Y

1684I OT ATTEN GOAL STAT 1 430 0.01 NOT A Y

1684J OT ATTEN GOAL STAT 20 430 0.01 NOT A Y

1684K OT ATTEN GOAL STAT 40 430 0.01 NOT A Y

1684L OT ATTEN GOAL STAT 60 430 0.01 NOT A Y

1684M OT ATTEN GOAL STAT 80 430 0.01 NOT A Y

1684N OT ATTEN GOAL STAT 100 430 0.01 NOT A Y

1684O OT ATTEN DC STAT 0 430 0.01 NOT A Y

Rev

Code

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16:04


Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 28

Mod1 Mod2 Mod3 Mod4

1684P OT ATTEN DC STAT 1 430 0.01 NOT A Y

1684Q OT ATTEN DC STAT 20 430 0.01 NOT A Y

1684R OT ATTEN DC STAT 40 430 0.01 NOT A Y

1684S OT ATTEN DC STAT 60 430 0.01 NOT A Y

1684T OT ATTEN DC STAT 80 430 0.01 NOT A Y

1684U OT ATTEN DC STAT 100 430 0.01 NOT A Y

1685 INFRARED-MODALITY 1+ AREAS 430 97026 36.00 NOT A NGO

1685A OT MEMORY CURRENT STAT 0 430 0.01 NOT A Y

1685B OT MEMORY CURRENT STAT 1 430 0.01 NOT A Y

1685C OT MEMORY CURRENT STAT 20 430 0.01 NOT A Y

1685D OT MEMORY CURRENT STAT 40 430 0.01 NOT A Y

1685E OT MEMORY CURRENT STAT 60 430 0.01 NOT A Y

1685F OT MEMORY CURRENT STAT 80 430 0.01 NOT A Y

1685G OT MEMORY CURRENT STAT 100 430 0.01 NOT A Y

1685H OT MEMORY GOAL STAT 0 430 0.01 NOT A Y

1685I OT MEMORY GOAL STAT 1 430 0.01 NOT A Y

1685J OT MEMORY GOAL STAT 20 430 0.01 NOT A Y

1685K OT MEMORY GOAL STAT 40 430 0.01 NOT A Y

1685L OT MEMORY GOAL STAT 60 430 0.01 NOT A Y

1685M OT MEMORY GOAL STAT 80 430 0.01 NOT A Y

1685N OT MEMORY GAL STAT 100 430 0.01 NOT A Y

1685O OT MEMORY DC STAT 0 430 0.01 NOT A Y

1685P OT MEMORY DC STAT 1 430 0.01 NOT A Y

1685Q OT MEMORY DC STAT 20 430 0.01 NOT A Y

1685R OT MEMORY DC STAT 40 430 0.01 NOT A Y

1685S OT MEMORY DC STAT 60 430 0.01 NOT A Y

1685T OT MEMORY DC STAT 80 430 0.01 NOT A Y

1685U OT MEMORY DC STAT 100 430 0.01 NOT A Y

1686 FINGER ORTHOSIS, W/O JOINTS CUSTOM FAB. 430 L3933 432.00 NOT A N

1687 HAND/FINGER ORTHODIC, CUST FAB 274 L3913 576.00 NOT A NGO

1688 ELBOW ORTHOSIS, W/O JOINTS 430 L3702 547.03 NOT A N

1689 ELBOW WRIST HAND ORTHOSIS W/O JOINTS 430 L3763 1,323.36 NOT A N

1701 GROUP THERAPY 915 90853 62.40 NSOC I N

1702 MASTER TREATMENT PLAN 911 90889 75.60 NSOC A N

1703 FAMILY PSYCHOTHERAPY W/PT PRES 916 90847 222.00 NSOC A N

Rev

Code

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16:04


Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 29

Mod1 Mod2 Mod3 Mod4

1704 INDIVIDUAL THER 50 MIN 914 90837 192.00 NSOC A N

1705 INDIVIDUAL THER 1/2 HR 914 90832 126.00 NSOC A N

1706 FAMILY THERAPY W/PT PRESENT 916 90847 216.00 NSOC A N

1707 SOCIAL WORK SER 1 HR 911 90832 151.20 NSOC A N

1708 MEDICATION MANAGEMENT 919 90863 102.00 NSOC A N

1709 SOCIAL HISTORY 911 90791 292.80 NSOC A N

1711 SOCIAL WORK SER 1/2 HR 911 90832 75.60 NSOC A N

1712 DISCH PLAN 911 90887 100.80 NSOC A N

1713 GROUP THERAPY INTERACTIVE 915 90853 151.20 NSOC A N

1716 SOC SER 15 MIN 911 90832 43.20 NSOC A N

1718 FAMILY PSYCHOTHERAPY W/0 PT 916 90846 178.80 NSOC A N

1719 MISCELL (MAMIE RUBLE) 961 0.00 NSWMC I N

1728 DELETE 961 0.00 NSWMC I N



1801 PT EVAL- LOW COMPLEXITY W/O COMORBID. 420 97161 180.00 NOPRH A NGP

1802 PT EVAL.-MOD. COMPLEX.1-2 COMORB. 420 97162 180.00 NOPRH A NGP

1803 PT EVAL-HIGH COMPLEX. 3 COMORB. 420 97163 180.00 NOPRH A NGP

1804 PT RE-EVAL OF ESTABLISHED POC 420 97164 111.84 NOPRH A NGP

1901 OT EVAL-LOW COMPLEXITY, 1-3 DEFICITS 430 97165 165.60 NOT A NGO

1902 OT EVAL-MOD. COMPLEXITY, 3-5 DEFICITS 430 97166 165.60 NOT A N

1903 OT EVAL-HIGH COMPLEXITY, 5+ DEFICITS 430 97167 165.60 NOT A NGO

1904 OT RE-EVAL OF ESTABLISHED POC 430 97168 100.80 NOT A NGO

1905 MASSAGE 430 97124 56.16 NOT A NGO

20550 TENDON/LIGAMENT 960 20550 138.00 NCL A N

20551 TENDON ORIGIN,INSERTION 960 20551 108.00 NCL A N

20552 SINGLE/MULTI TRIGGER PTS 1OR2 960 20552 108.00 NCL A N

20553 SINGLE/MULTI TRIGGER PTS 3+ 960 20553 120.00 NCL A N

2060 MISC LAURA COMBS LCSW 961 0.00 NSWLC A N

20600 SMALL JOINT/BURSA 960 20600 144.00 NCL A N

20605 INTERMEDIATE 960 20605 144.00 NCL A N

2061 CRISIS EACH ADDITIONAL 961 90840 146.40 NSWLC A N

20610 MAJOR BURSA 960 20610 156.00 NCL A N

2062 CRISIS PSYCHOTHERAPY EVAL 961 90839 211.20 NSWLC A N

2063 FAN THER W/O PATIENT 961 90846 204.00 NSWLC A N

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2064 FAM THER W/PATIENT 961 90847 204.00 NSWLC A N

2065 GROUP PSYCHTHERAPY 961 90853 96.00 NSWLC A N

2066 INITAL EVALUATION 961 90791 273.60 NSWLC A N

2067 PSYCHIATRIC DIAGNOSTIC 961 90791 180.00 NSWLC A N

2068 PSYCHOTHERAPY 30 MINUTES 961 90832 116.40 NSWLC A N



22004 COLD PAC 270 99070 5.04 NCS A N

22005 HOT PACK INSTANT 270 99070 0.76 NCS A N

22018 BELT BACK MEDIUM 270 73.48 NCS A N

22019 BELT BACK LARGE 270 73.48 NCS A N

22024 BELT RIB ALL SIZES 270 36.84 NCS A N

22025 BELT PELVIC TRACTION 270 79.80 NCS A N

22029 ELECTRO GEL 270 11.88 NCS A N

22030 CRUTCHES 270 48.48 NCS A N

22031 PILLOW CERVICAL 270 99070 123.60 NCS A N

22032 SHOULDER ORTHOSIS BAUR 270 L3670 120.00 NCS A N

22033 CANE 270 E0100 26.76 NCS A N

22034 PACK CONTOUR HYDROCOLATOR 270 0.00 NCS A N

22035 QUAD CANE 270 53.40 NCS A N

22036 WRIST AND FOREARM SPLINT 270 99070 34.08 NCS A N

22037 WALKER 270 124.80 NCS A N

22038 SYRINGE 10 CC 21/1.5 VAN POINT 270 2.52 NCS A N

22039 SWIMSUIT MENS ALL SIZES 270 34.86 NCS A N

22041 PILLOW HEAD REST 270 22.68 NCS A N

22054 SHOULDER BRACE SULLY 270 29240 188.40 NCS A N

22055 IONTOPORESIS ELECTRODES 270 A4556 18.00 NCS A N

22056 ELECTRODES 270 A4556 15.60 NCS A N

22057 LUMBO SACRAL SUPPORT ALL SIZES 270 155.84 NCS A N

22058 GENU SOFTEC 270 L1845 456.00 NCS A N

22060 SHOULDER PULLEY 270 99070 48.00 NCS A N

22061 THERABAND 270 99070 4.80 NCS A N

22062 WHIRLPOOL ADDITIVE 270 99070 14.40 NCS A N

22063 SI BELT 270 99070 72.00 NCS A N

22064 LUMBAR CORSET 270 72.00 NCS A N

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22065 HOME TRACTION UNIT 270 99070 60.00 NCS A N

22066 CHO-PAT KNEE STRAP 270 60.00 NCS A N

22067 THERACANE 270 60.00 NCS A N

22068 GYMNIC BALL 270 42.00 NCS A N

22069 KNEE/SHOULDER TAPING KIT 270 99070 42.00 NCS A N

22070 BRACE ANKLE 270 L1906 114.00 NCS A N

22071 ANKLE BRACE 270 L1902 72.00 NCS A N

22072 FLUORI-METHANE 270 6.00 NCS A N

22073 STANDER ACCESSORY 270 E1399 288.00 NCS A N

22074 STANDER 270 E0637 0.00 NCS A N

22090 TENNIS ELBOW SUPPORT 270 48.00 NCS A N

22091 CERVICAL COLLAR ALL SIZES 270 19.68 NCS A N

22113 AFO LT. & RT. ALL SIZES 270 154.09 NCS A N

22128 LUMBAR ROLL 270 99070 33.60 NCS A N

22129 CERVICAL ROLL 270 42.48 NCS A N

22130 TREAT YOUR OWN BACK 270 35.04 NCS A N

22132 LUMBAR ROLL 270 54.60 NCS A N

22134 GAIT BELT #6531 270 25.32 NCS A N

22135 ALUMINUM SPLINT 270 7.68 NCS A N

22136 THERA TUBING 270 11.34 NCS A N

22137 THERA PUTTY 270 99070 22.22 NCS A N

22138 REACHER 270 54.48 NCS A N

22139 SOCK AID 270 29.28 NCS A N

22140 DRESSING STICK 270 18.00 NCS A N

22141 ELASTIC SHOE LACES 270 11.16 NCS A N

22142 ISONTONER GLOVES 270 24.96 NCS A N

22144 MOLESHIN PER 6" 270 5.70 NCS A N

22145 STOCKINETTE 1 YARD 270 14.16 NCS A N

22146 VELCRO 270 4.80 NCS A N

22148 BUTTON HOOK EACH 270 14.16 NCS A N

22149 SCOOT GUARD 270 5.10 NCS A N

22150 SHOE HORN EACH 270 29.28 NCS A N

22151 DYCEM PER INCH 270 3.60 NCS A N

226 EVAL OF ORAL & PHARYN SWALLOW 440 92610 204.48 NST A NGN

227 DYSPHASIA TX 440 92526 190.08 NST A NGN

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228 SPEECH THERAPY 440 92507 205.92 NST A NGN

228A SPEECH THERAPY-MEDICAID 440 92507 36.00 NST A N

230 EVAL RX NSGD 440 92605 250.56 NST I NGN

231 THER SERVICE,NSGD 440 92606 135.36 NST I NGN

232 EVAL RX,SGD(1ST HR) 440 92607 344.16 NST A NGN

233 EVAL RX,SGD(ADD.30 MIN) 440 92608 141.12 NST A NGN

234 THERAPEUTIC SERVICE,SGD 440 92609 295.20 NST A NGN

235 EVAL/ORAL SWALLOW 440 92610 204.48 NST I NGN

236 ASSES APHASIA W/ REPORT 440 96105 276.48 NST A NGN

237 DEVELOP TEST,W/INT & REPORT 440 96110 31.68 NST I NGN

238 NEUROBEHAVIORAL STATUS/HR 440 96116 165.60 NST I NGN

239 DEVEL COGNITIVE SKILL(15) 440 97532 51.84 NST I NGN

239A DEVEL COGNITIVE SKILL(15) 440 97127 51.84 NST A YGN

240 EVAL OF SPEECH FLUENCY 440 92521 305.28 NST A NGN

241 EVAL SPEECH SOUND PRODUCTION 440 92522 250.56 NST A NGN

242 EVAL SPCH SOUND W/ EVAL LANG 440 92523 516.96 NST A NGN

243 BEH AND QUALITATIVE ANALYIS 440 92524 259.20 NST A NGN

244 SESORY INTEGRATIVE TECH. 15 MI 440 97533 56.16 NST A NGN

245 SELFCARE/HOME MGMNT TRAIN.15 M 440 97535 67.68 NST A NGN

246 STAN COGNITIVE TEST W/ REPORT 440 96125 305.28 NST A NGN

247 EVAL AUDITORY REHAB 1ST HOUR 440 92626 203.04 NST A NGN

248 EVAL AUDITORY REHAB EA 15 MIN 440 92627 48.96 NST A NGN

249 SWALLOWING CURRENT - 0% 440 0.01 NST A Y

249A MEMORY CURRENT 40-59% 440 0.01 NST A Y

250 SWALLOWING CURRENT 1-19% 440 0.01 NST A Y





252A MEMORY CURRENT 100% 440 0.01 NST A Y


253A MEMORY PROJECTED 0% 440 0.01 NST A Y


254A MEMORY PROJECTED 1-19% 440 0.01 NST A Y

255 SWALLOWING CURRENT 100% 440 0.01 NST A Y

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256 SWALLOWING PROJECTED GOAL 0% 440 0.01 NST A Y


257 SWALLOWING PROJECTED 1-19% 440 0.01 NST A Y





259A MEMORY PROJECTED 100% 440 0.01 NST A Y


260A MEMORY D/C 0% 440 0.01 NST A Y


261A MEMORY D/C 1-19% 440 0.01 NST A Y

262 SWALLOWING PROJECTED 100% 440 0.01 NST A Y

262A MEMORY D/C 20-39% 440 0.01 NST A Y

263 SWALLOWING D/C 0% 440 0.01 NST A Y

263A MEMORY D/C 40-59% 440 0.01 NST A Y

264 SWALLOWING D/C 1-19% 440 0.01 NST A Y

264A MEMORY D/C 60-79% 440 0.01 NST A Y


265A MEMORY D/C 80-99% 440 0.01 NST A Y


266A MEMORY D/C 100% 440 0.01 NST A Y


267A VOICE CURRENT 0% 440 0.01 NST A Y


26852 SCHOOL ASSESSMENT FORM 270 0.00 NCS A N

268A VOICE CURRENT 1-19% 440 0.01 NST A Y

269 SWALLOWING D/C 100% 440 0.01 NST A Y


270 MOTOR SPEECH CURRENT 0% 440 0.01 NST A Y


271 MOTOR SPEECH CURRENT 1-19% 440 0.01 NST A Y



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273A VOICE CURRENT 100% 440 0.01 NST A Y


274A VOICE PROJECTED 0% 440 0.01 NST A Y


275A VOICE PROJECTED 1-19% 440 0.01 NST A Y

276 MOTOR SPEECH 100% 440 0.01 NST A Y


277 MOTOR SPEECH PROJECTED 0% 440 0.01 NST A Y


278 MOTOR SPEECH PROJECTED 1-19% 440 0.01 NST A Y




280 MOTOR SPEECH PREJECTED 40-59% 440 0.01 NST A Y

280A VOICE PROJECTED 100% 440 0.01 NST A Y


281A VOICE D/C 0% 440 0.01 NST A Y


282A VOICE D/C 1-19% 440 0.01 NST A Y

283 MOTOR SPEECH PROJECTED 100% 440 0.01 NST A Y

283A VOICE D/C 20-39% 440 0.01 NST A Y

284 MOTOR SPEECH D/C 0% 440 0.01 NST A Y

284A VOICE D/C 40-59% 440 0.01 NST A Y

285 MOTOR SPEECH D/C 1-19% 440 0.01 NST A Y

285A VOICE D/C 60-79% 440 0.01 NST A Y


286A VOICE D/C 80-99% 440 0.01 NST A Y


287A VOICE D/C 100% 440 0.01 NST A Y


288A OTHER SLP CURRENT 0% 440 0.01 NST A Y


289A OTHER SLP CURRENT 1-19% 440 0.01 NST A Y

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290 MOTOR SPEECH D/C 100% 440 0.01 NST A Y


291 SL COMPREHENSION CURRENT 0% 440 0.01 NST A Y


292 SL COMP CURRENT 1-19% 440 0.01 NST A Y





294A OTHER SLP CURRENT 100% 440 0.01 NST A Y


295A OTHER SLP PROJECTED 0% 440 0.01 NST A Y


296A OTHER SLP PROJECTED 1-19% 440 0.01 NST A Y

297 SL COMP CURRENT 100% 440 0.01 NST A Y

297A OTHER SLP 20-39% 440 0.01 NST A Y

298 SL COMP PROJECTED 0% 440 0.01 NST A Y


299 SL COMP PROJECTED 1-19% 440 0.01 NST A Y





301A OTHER SLP PROJECTED 100% 440 0.01 NST A Y


302A OTHER SLP D/C 0% 440 0.01 NST A Y


303A OTHER SLP D/C 1-19% 440 0.01 NST A Y

304 SL COMP PROJECTED 100% 440 0.01 NST A Y

304A OTHER SLP 20-39% 440 0.01 NST A Y

305 SL COMP D/C 0% 440 0.01 NST A Y

305A OTHER SLP 40-59% 440 0.01 NST A Y

306 SL COMP D/C 1-19% 440 0.01 NST A Y


307 SL COMP D/C 20-39% 440 0.01 NST A Y

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308 SL COMP D/C 40-59% 440 0.01 NST A Y

308A OTHER SLP D/C 100% 440 0.01 NST A Y

309 SL COMP D/C 60-79% 440 0.01 NST A Y

310 SL COMP D/C 80-99% 440 0.01 NST A Y

311 SL COMP D/C 100% 440 0.01 NST A Y

312 SL EXPRESSION CURRENT 0% 440 0.01 NST A Y

313 SL EXPRESSION CURRENT 1-19% 440 0.01 NST A Y





318 SL EXPRESSION CURRENT 100% 440 0.01 NST A Y

319 SL EXPRESSION PROJECTED 0% 440 0.01 NST A Y

320 SL EXPRESSION PROJECTED 1-19% 440 0.01 NST A Y

32010 TONGS GIANT 15 INCH 273 0.00 NCS A N

32012 MEAT CUTTER BOARD 273 54.48 NCS A N

32014 DOOR KNOB EXTENSION 273 3.36 NCS A N


32119 MODIFIED SAFETY PIN SPLINT 273 0.00 NCS A N

32124 FOAM INSERT 273 46.08 NCS A N

32125 ARM TRAY #94121 273 167.04 NCS A N

32127 NORTH COAST REACHER 273 0.00 NCS A N

32136 DENTURE BRUSH 273 20.88 NCS A N

32137 WALKER BASKETS A772-1 273 0.00 NCS A N




327 SL EXPRESSION PROJECTED 100% 440 0.01 NST A Y

328 SL EXPRESSION D/C 0% 440 0.01 NST A Y

329 SL EXPRESSION D/C 1-19% 440 0.01 NST A Y




333 SL EXPRESSION 80-99% 440 0.01 NST A Y

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334 SL EXPRESSION 100% 440 0.01 NST A Y

335 ATTENTION CURRENT 0% 440 0.01 NST A Y

336 ATTENTION CURRENT 1-19% 440 0.01 NST A Y

337 ATTENTION 20-39% 440 0.01 NST A Y



340 METHADONE 300 80101 75.60 NLAB I N


342 ATTENTION CURRENT 100% 440 0.01 NST A Y

343 ATTENTION PROJECTED 0% 440 0.01 NST A Y

344 ATTENTION PROJECTED 1-19% 440 0.01 NST A Y





349 ATTENTION PROJECTED 100% 440 0.01 NST A Y

350 ATTENTION D/C 0% 440 0.01 NST A Y

352 ATTENTION D/C 1-19% 440 0.01 NST A Y





357 ATTENTION D/C 100% 440 0.01 NST A Y

358 MEMORY CURRENT 0% 440 0.01 NST A Y

359 MEMORY CURRENT 1-19% 440 0.01 NST A Y

360 MEMORY CURRENT 20-39% 440 0.01 NST A Y

361 LAB TEST 300 0.00 NLAB I N

362 ALPHA 1 ANTITRYPSIN 300 82103 61.50 NLAB A N

363 AMITRIPTYLINE 300 80152 85.20 NLAB I N

364 ARSENIC 300 82175 87.00 NLAB A N

365 MERCURY 300 83825 96.00 NLAB A N

366 PHOSPHOLIPID ANTIBODY (AB) 300 84311 54.00 NLAB I N

367 ACETAMINOPHEN/TYLENOL 300 82003 96.60 NLAB I N

368 COPPER 300 82525 53.10 NLAB A N

369 TRANSFERRIN 300 84466 63.00 NLAB A N

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370 MICROALBUMIN URINE 300 82043 28.20 NLAB A N

371 DNA,SINGLE STRANDED AB 300 86226 57.30 NLAB A N

372 LYSOZYME, SERUM 300 85549 72.00 NLAB A N

373 A.N.A. TITER 300 86039 52.80 NLAB A N

374 APOLIPOPROTEIN EACH 300 82172 74.10 NLAB A N

375 HOMOCYSTINE 300 83090 163.20 NLAB A N

376 ALKALINE PHOS,FRACTIONATED 300 84080 70.80 NLAB A N

377 ALCOHOL (ETHANOL) 300 80320 74.00 NLAB A N

378 AMINO ACID 300 82131 77.10 NLAB A N

379 AMMONIA BLOOD 300 82140 38.70 NLAB A N

380 LDL CHOL,DIRECT 300 83721 45.00 NLAB A N

381 A.L.A. 300 82135 75.30 NLAB A N

382 ALBUMIN SERUM 300 82040 23.70 NLAB A N

383 A.N.A. SCREEN 300 86038 57.30 NLAB A N

384 CHOLESTEROL 300 82465 27.60 NLAB A N

385 COOMBS INDIRECT/ANTIBODY SCREE 300 86850 24.90 NLAB I N

386 CLOZAPINE 300 80299 91.20 NLAB I N

387 WEST NILE VIRUS AB 300 86789 61.80 NLAB A N

388 URINE PROTEIN ELECTROPHORESIS 300 84166 51.60 NLAB A N

389 C-PEPTIDE 300 84681 92.40 NLAB A N

390 ANTIBODY TYPE 2 CARTILAGE 300 83520 182.40 NLAB I N

391 BLOOD CULTURE 300 87040 49.50 NLAB A N

392 ALBUMIN,URINE 300 82042 24.60 NLAB A N

393 URINE CREATININE 300 82570 24.00 NLAB A N

394 TREPONEMA PALLIDUM FTA ABS 300 86780 54.00 NLAB A N

395 BRUCELLA AGGL 300 86000 6.90 NLAB A N

396 BUN URINE 300 84540 21.60 NLAB A N

397 CEA 300 82378 150.00 NLAB A N

399 CALCIUM URINE 300 82340 27.60 NLAB A N

4000 MISCELL 961 0.00 NOPRH A N

4001 INPATIENT EVAL (30) 961 99221 102.00 NPSYC A N

4002 INPATIENT EVAL (50) 961 99222 174.00 NPSYC A N

4003 INPATINET EVAL (70) 961 99223 234.00 NPSYC A N

4005 SUBSEQUENT CARE (15) 961 99231 57.60 NPSYC A N


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4009 HOSPITAL DISCHARGE 961 99238 144.00 NPSYC A N

4010 ADMIT/DISCH SAME DAY LOW 961 99234 219.60 NPSYC I N

4011 ADMIT/DISCH SAME DAY-MED 961 99235 297.60 NPSYC I N

4012 ADMIT/DISCH SAME DAY-H 961 99236 364.80 NPSYC I N

4013 OBSERSERVATION-SAME DAY-LOW COMPLEX 762 99234 406.80 NOBS A N

4014 OBSERVATION-SAME DAY- MODERATE 762 99235 513.60 NOBS A N

4015 OBSERVATION-SAME DAY-HIGH COMP. 762 99236 661.20 NOBS A N

4016 OBSERVATION-DISCHARGE 762 99217 216.00 NOBS A N

4017 OBSERVATION-LOW 762 99218 304.80 NOBS A N

4018 OBSERVATION-MODERATE 762 99219 411.60 NOBS A N

4019 OBSERVATION- HIGH COMPLEX. 762 99220 562.80 NOBS A N

403 CATECHOLAMINES FRAC. 300 82384 120.00 NLAB A N

404 HIV AG W/ HIV1 HIV2 AB 300 87389 189.00 NLAB A N

405 COMPLEMENT C4 300 86160 57.30 NLAB A N

406 CERULOPLASMIN 300 82390 51.60 NLAB A N

407 THYROXINE BINDING GLOBULIN(TBG 300 84442 70.80 NLAB A N

408 T-3 FREE 300 84481 72.60 NLAB A N

409 CHOLINESTERASE 300 82480 37.50 NLAB A N

410 CLOT RETRACT 300 85170 16.80 NLAB A N

411 CARBAMAZEPINE/TEGRETOL 300 80156 118.00 NLAB A N

412 CO-2/BICARBONATE 300 82374 21.60 NLAB A N

413 CAROTENE 300 82380 42.00 NLAB A N

414 COLD AGGL TITER 300 86157 38.10 NLAB A N

415 COMPLEMENT C3 300 86160 57.30 NLAB A N

416 BLOOD TYPING,ABO 300 86900 14.40 NLAB A N

417 COOMBS DIRECT 300 86880 24.90 NLAB A N

418 T-3 REVERSE 300 84482 79.80 NLAB A N

419 C-REACTIVE PROTEIN 300 86140 24.00 NLAB A N

420 PARVOVIRUS AB 300 86747 64.20 NLAB A N

421 CREAT CLEARANCE 300 82575 45.00 NLAB A N

422 CREATININE 300 82565 24.00 NLAB A N

423 CREAT URINE 300 82570 24.00 NLAB I N

424 CPK ISOENZYMES 300 82552 63.90 NLAB A N

425 BNP 300 83880 145.20 NLAB A N

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426 CRP-HS 300 86141 66.00 NLAB A N

427 PARATHYROID HORMONE (PTH) 300 83970 196.20 NLAB A N

428 DIGOXIN 300 80162 63.00 NLAB A N

429 DILANTIN/PHENYTOIN 300 80185 107.00 NLAB A N

430 PATHOLOGY CONSULT 300 80500 75.90 NLAB A N

431 HERPES CULTURE 300 87255 124.50 NLAB A N

432 ESTROGENS TOTAL 300 82672 175.00 NLAB A N

433 GRAM STAIN 300 87205 35.00 NLAB A N

436 FIBRINOGEN AG 300 85385 40.20 NLAB A N

437 FOLIC ACID 300 82746 118.00 NLAB A N

438 DNA-N (DS) AB 300 86225 65.10 NLAB A N

44027 TAPE TRANSPARENT 273 0.00 NCS A N

44053 INDEX CARDS 5 X 8 273 0.00 NCS A N

44059 PENCIL #2 273 0.60 NCS A N

44074 LIQUID PAPER WHITE 273 0.00 NCS A N

44081 TAPE ALLERGIC 273 63.84 NCS A N

44083 PEN BIC/PM FINE ALL 273 0.48 NCS A N

44084 BIC ROUNDS FINE PINT ALL 273 0.00 NCS A N

44095 PEN PILOT FINE RED/BLACK 273 4.20 NCS A N

44096 JUMBO BLACK MARKERS 273 3.36 NCS A N

44097 PEN BLACK/RED SHARPIE FINE PT 273 3.00 NCS A N

44130 STENO PAD 273 0.00 NCS I N

44136 LOGO 9X12 ENVELOPE 270 26.28 NCS I N

44137 LOGO 10 X13 ENVEL 25/PK 273 31.68 NCS I N

44138 COPY 8 1/2 X14 PAPER 273 153.36 NCS I N

44146 JUMBO PAPER CLIPS 273 6.36 NCS A N

44148 PAPER CLIPS REG 273 3.36 NCS A N

44166 STAPLES REG 273 8.40 NCS A N

44172 MEDI TAG REDI TAG 273 23.88 NCS A N

44180 COLUMNAR PAD WJ G7213 273 14.88 NCS A N

44181 COLUMNAR SHEET WJ 50-36 273 0.00 NCS A N

44182 COLUMNAR PAD WJ G7110 273 10.92 NCS A N

44241 DR BANDY REMIT ENVELOPE 273 94.56 NCS I N

44327 COMP PAPER 9 1/2X11 2 PLY 273 148.92 NCS I N

44369 HIGHLIGHTER ALL COLORS 273 3.36 NCS A N

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44373 POST IT NOTES 3X3- 12'S 273 0.00 NCS A N

44376 POST IT NOTES 1X1-12'S 273 44.88 NCS A N

44381 DRY ERASE MARKER 273 0.00 NCS A N

44383 GLUE STICKS 273 4.20 NCS A N

44396 AA BATTERY 273 2.04 NCS A N

44399 PAPER 1PT 91/2 X 11 CONT 273 0.00 NCS I N

450 GLU TOLER (ADD) 300 82952 24.00 NLAB A N

45009 ENVELOPE MAN.6 1/2X9 1/2 273 15.36 NCS A N

45017 ENVELOPE PATIENT VALUABLE 25/P 273 77.76 NCS I N

45068 MED.REC.FILE FOLDER BLANK 273 63.00 NCS I N

45090 MEDICAL RECORD CODACOLOR NUMB. 273 36.00 NCS A N

45091 MED.REC. FILE FOLDER NUMBERED 273 0.00 NCS I N

451 FEBRILE AGGL-EA AG 300 86000 24.00 NLAB A N

45108 ENVELOPE #10 CLASSIC 273 243.60 NCS A N

45110 LETTERHEAD 2ND SHEET 273 142.80 NCS I N

45111 LETTERHEAD CLASSIC 273 130.20 NCS I N

45112 ENVELOPE #10 WINDOW 273 130.20 NCS I N

45118 ENVELOPE WINDOW 4X7 1/2 273 68.40 NCS A N

45135 ENVELOPE WHITE 6 1/2X9 1/2 273 12.60 NCS A N

45136 ENVELOPE WHITE 9X12 25/PK 273 14.76 NCS A N

45143 PERSONNEL ENVELOPES 1 BOX 273 0.00 NCS I N

45177 LABEL BILL NOW DUE & PAYABLE 273 0.00 NCS I N

45186 ENVELOPE #10 REGULAR 273 117.60 NCS I N

45198 FINAL NOTICE LABEL 273 0.00 NCS A N

452 IGF-1 300 84305 69.96 NLAB A N

45200 LABEL YEAR 273 0.00 NCS I N

45208 LABEL PAST DUE 273 0.00 NCS I N

45241 SMALL REMIT ENVELOPE BANDY 273 0.00 NCS I N

45242 ENVELOPE REMITTANCE 2 SIDED 273 130.20 NCS I N

455 VASOPRESSIN (ADH) 300 84588 158.10 NLAB A N

456 GGT 300 82977 34.20 NLAB A N

457 B2-GLYCOPROTEIN 1 ABS 300 86146 75.60 NLAB A N

458 HGB FRACTIONATION 300 83020 61.80 NLAB A N

459 SERUM KETONES 300 82009 21.60 NLAB A N

460 HETEROPHILE AB (SCREEN) 300 86308 24.00 NLAB A N

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Mod1 Mod2 Mod3 Mod4

461 HEAVY MEATAL SCREEN 300 83015 90.00 NLAB A N

462 HETEROPHILE AB TITER 300 86309 30.00 NLAB A N

463 HISTOPLASMA 300 86698 60.60 NLAB A N

464 LIGHT CHAINS, FREE 300 83883 122.40 NLAB A N

465 BETA-HCG QUANT. 300 84702 42.00 NLAB A N

466 HYDROXYCORTICOSTEROIDS 300 83491 83.10 NLAB A N

467 HEAVY METAL QUANT,EACH 300 83018 93.60 NLAB A N

468 TPMT THIOPURINE METHLTRAN 300 82542 384.00 NLAB A N

469 HAPTOGLOBIN 300 83010 60.60 NLAB A N

470 HDL CHOL 300 83718 40.50 NLAB A N

471 IG G 300 82784 25.20 NLAB A N

472 IG A 300 82784 25.20 NLAB A N

473 IG M 300 82784 25.20 NLAB A N

474 IGE 300 82785 71.70 NLAB A N

477 HEPATITIS B CORE AB TOTAL 300 86704 55.20 NLAB A N

480 LDH ISOENZYMES 300 83625 60.60 NLAB A N

481 TOXOPLASMA AB 300 86777 63.96 NLAB A N

482 LIPASE SERUM 300 83690 32.40 NLAB A N

483 MYOGLOBIN 300 83874 55.20 NLAB A N

486 HLA B58 01 300 81381 264.60 NLAB I N

487 MAGNESIUM 300 83735 55.00 NLAB A N

488 PL-7 AUTOAB 300 83516 200.40 NLAB A N

489 PL-12 AUTOAB 300 83516 200.40 NLAB A N

490 METHEMOGLOBIN 300 83050 24.30 NLAB A N

491 AGGLN MRSA LATEX 300 87147 153.00 NLAB A N

492 AGGLN STAPH 300 87147 41.00 NLAB A N

493 MONO SCREEN 300 86308 24.00 NLAB A N

494 OVA/PARASITIES 300 87177 42.00 NLAB A N

495 CMV AB IGM 300 86645 82.80 NLAB A N

496 EHRLICHIA AB 300 86666 47.40 NLAB A N

497 HEPATITIS B CORE AB IGM 300 86705 54.60 NLAB A N

498 FOBT fecal occult blood diagnostic 300 82272 18.00 NLAB A N

499 PORPHOBILINOGEN 300 84110 27.90 NLAB A N

500 PORPHYRINS 300 84120 41.10 NLAB A N

5000 MISC INTENSIVE OUT PAT 914 0.00 NTR A N

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Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4

5005 PSYCHOTHERAPY 20-30 MIN 914 90832 90.00 NTR A N

5006 PSYCHOTHERAPY 45-50 MIN 914 90834 186.00 NTR A N

5007 GROUP PSYCHOTHERAPY 905 90853 96.00 NTR A Y

5008 PSYCHOTHERAPY 60 MINS 914 90837 250.93 NTR A N

501 RIBOSOMAL P ABS 300 83516 61.80 NLAB A N

5010 FAM THER W/PATIENT 916 90847 204.00 NTR A N

5011 FAM THER W/O PATIENT 916 90846 204.00 NTR A N

5012 E&M -NEW PATIENT- 10 MINUTES 510 99201 57.60 NTR A N

5013 E&M-NEW PATIENT-20 MINUTES 510 99202 115.20 NTR A N




5017 E&M-ESTAB. PAT-5 MIN. 510 99211 43.20 NTR A N

5018 E&M-ESTAB. PAT-10 MINUTES 510 99212 82.80 NTR A N

5019 E&M-ESTAB.PAT-15 MIN. 510 99213 122.40 NTR A N

502 URINE PROTEIN 300 81002 16.20 NLAB A N

5020 E&M-ESTAB.PAT-25 MIN. 510 99214 162.00 NTR A N

5021 E&M- ESTAB. PAT-40 MIN. 510 99215 201.60 NTR A N

5022 EVAL & MGMT-MEDICARE 510 G0463 288.00 NTR A N

503 LEFLUNOMIDE 300 80375 180.00 NLAB A N

504 PRIMIDONE 300 80188 78.60 NLAB A N

505 PREGNANCY QUAL SERUM 300 84703 61.00 NLAB A N

506 URINALYSIS, MANUAL/ NO MICRO 300 81002 16.20 NLAB A N

507 WBC AUTO DIFF 300 85004 16.20 NLAB A N

508 R B C 300 85041 14.40 NLAB A N

509 CULTURE ISOLATE ID 300 87077 37.20 NLAB A N

510 RH FACTOR 300 86901 45.00 NLAB A N

511 CONCENTRATION INFECT AGENT 300 87015 90.00 NLAB A N

512 HEPATITIS B SURFACE AG 300 87340 48.00 NLAB A N

513 SALICYLATE 300 80196 33.60 NLAB I N

514 SICKLE CELL 300 85660 26.40 NLAB A N

515 SEROTONIN 300 84260 148.20 NLAB A N

516 SPUTUM CULTURE 300 87070 40.80 NLAB A N

517 STOOL CULTURE 300 87045 45.00 NLAB A N

518 HEPATITIS B SURFACE AB 300 86706 49.80 NLAB A N

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Exception


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Mod1 Mod2 Mod3 Mod4

519 FECAL WBC 300 89055 24.00 NLAB A N

520 THYROID PEROXIDASE 300 86376 52.44 NLAB A N

521 SUSCEPTIBILITY STUDY MICRODILUTION 300 87186 45.00 NLAB A N

52126 DOCTOR THERAPY ORDERS 273 73.56 NCS I N

52127 OUT PAT PT DAILY NOTES 273 0.00 NCS I N

52131 LUMBAR SPINE FORM 273 12.48 NCS A N

522 THROAT CULTURE 300 87070 40.80 NLAB A N

523 T-4 TOTAL 300 84436 27.60 NLAB A N

524 TULAREMIA 300 86668 54.00 NLAB A N

525 UREA CLEARANCE 300 84545 27.00 NLAB A N

526 VENIPUNCTURE 300 36415 20.00 NLAB A N

527 UROBIL OUAL UA 300 84578 12.00 NLAB A N

528 UROBIL QT UA 300 84580 33.60 NLAB A N

529 STREP SCREEN 300 87081 31.80 NLAB A N

530 V M A 300 84585 74.10 NLAB A N

531 HEPATITIS BE AG 300 87350 53.70 NLAB A N

532 ZINC SERUM 300 84630 48.90 NLAB A N

533 ACID PHOS TOTAL 300 84060 35.40 NLAB A N

534 ALK PHOS 300 84075 24.00 NLAB A N

535 AST (SGOT) 300 84450 24.00 NLAB A N

536 LDH 300 83615 27.60 NLAB A N

538 RETIC COUNT,AUTO 300 85045 19.50 NLAB A N

539 CULTURE I.D. 300 87088 66.00 NLAB A N

540 URINE/MANUAL & MICRO 300 81000 17.10 NLAB A N

541 POTASSIUM,SERUM 300 84132 41.00 NLAB A N

54149 FINANCIAL FILE FOLDER 100PK 273 157.80 NCS I N

542 ANTI-THROMBIN III 300 85300 56.10 NLAB A N

543 WBC, AUTOMATED 300 85004 14.40 NLAB A N

544 SODIUM URINE 300 84300 23.10 NLAB A N

545 GLUCOSE 300 82947 41.00 NLAB A N

546 ASO-TITER 300 86060 34.80 NLAB A N

547 CHLORIDE 300 82435 21.60 NLAB A N

548 INFLUENZA VIRUS AB 300 86710 66.30 NLAB A N

549 URIC ACID URINE 300 84560 21.60 NLAB A N

550 PROTEIN ELECTROPHORESIS 300 84165 51.60 NLAB A N

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Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4

55028 EMPLOYMENT APPLICATION #100 273 102.96 NCS I N

55031 MEDICATION ORDER CLARIFICATION 273 85.08 NCS I N

55032 ACTION NOTICE 273 54.12 NCS I N

55033 ELECTROCARDIOGRAM 273 24.72 NCS A N

55037 DAILY FLOOR CENSUS 5TH FLOOR 273 54.60 NCS I N

55048 REVIEW SHEET 3 PAGES 273 22.08 NCS I N

55051 DR. BANDY CHARGE LIST 273 0.00 NCS I N

55057 LUMBO SACRAL SUPPORT ALL 450 0.00 NCS A N

55060 MAINTENANCE REQUEST 25/PK 273 41.16 NCS I N

55068 PHYSICIAN ORDER HOSPICE 273 0.00 NCS A N

55069 DAILY FLOOR CENSUS 4TH FLOOR 273 64.20 NCS I N

55070 INTERDIS PT. TEACHING SHEET 270 35.16 NCS A N

55071 PHYSICIAN ORDERS 273 88.20 NCS I N

55072 PHYS ORDERS OPIATE DETOX 270 121.80 NCS I N

55073 MEDICATION ADMIN.RECORD 273 120.60 NCS I N

55074 PHYSICIAN ADMISSION ORDER 273 70.20 NCS I N

55075 GRAPHIC CHART 273 72.24 NCS A N

55076 MOUNT SHEET REHAB SERVICES 273 62.64 NCS A N

55077 CERT RETURN TO SCHOOL/WORK 273 0.00 NCS I N

55078 HOURS OF SLEEP 4TH FLOOR 273 0.00 NCS I N

55079 HOURS OF SLEEP 5TH FLOOR 273 0.00 NCS I N

55080 PEDI WAIVER AND CONSENT 273 0.00 NCS A N

55081 PEDI TELEPHONE CALL RECORD 273 0.00 NCS A N

55082 PEDIATRIC PROGRESS NOTES LINES 273 0.00 NCS A N

55089 HEMATOLOGY 273 63.84 NCS I N

55097 THERPY PROGRESS NOSTE 273 33.60 NCS I N

551 LITHIUM 300 80178 54.00 NLAB A N

55148 PROGRESS NOTES 273 24.96 NCS I N

55149 CONTRIBUTION PAD 273 0.00 NCS I N

55150 PHARMACY CHARGE 3 PART 273 0.00 NCS I N

55151 HEALTH INSUR.CLAIM FORM CONT. 273 285.60 NCS A N

55152 UNSCHEDULED OP CONTACT FORM 273 146.16 NCS I N

55153 AUTH/CONSENT FOR TRANSFER 273 91.44 NCS I N

55154 DRUG HISTORY FLOW SHEET 273 22.08 NCS I N

55155 INJECTABLE SHEET 273 42.00 NCS I N

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Exception


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Mod1 Mod2 Mod3 Mod4

55162 LABORATORY REQUISITION 273 146.52 NCS I N

55163 LABORATORY REQUEST-NEW 273 146.16 NCS I N

55166 REFERRAL FORM 273 17.76 NCS A N

55168 RX BLANKS DR. X 3 273 0.00 NCS I N

55178 MASTER INDEX CARD 273 42.84 NCS A N

55183 AMBULANCE SERVICE TRANSFER 273 12.60 NCS A N

55184 LEVI CLINIC PROGRESS NOTES 273 22.08 NCS I N

55185 NURSING WORK SHEET 24HR 273 0.00 NCS I N

55192 REQUEST FOR TIME OFF 273 32.16 NCS I N

55193 CONSULTATION FORM 273 25.20 NCS I N

55199 CHARGE/TRTMNT OTHER FACILITY 273 22.80 NCS I N

552 R A QUANT 300 86431 26.40 NLAB A N

55201 PURCHASE REQUEST 50/PK 273 21.00 NCS I N

55205 CHARGE SHEET MULTI DEPT. 273 49.56 NCS A N

55209 PRESCRIPTION PAD 273 28.20 NCS I N

55221 APPLIC.FOR VOLUNTARY ADMISS. 273 55.44 NCS A N

55230 HEMATOLOGY REPORT CONTINOUS 273 663.12 NCS I N

55231 PATIENT TRANSFER FORM 2 PGS. 273 27.36 NCS A N

55233 ACT.OF DAILY LIVING FLOW SHT. 273 39.12 NCS A N

55237 MEDIUM DIAPER 273 0.00 NCS A N

55238 PHYS ORDERS ALCOHOL DETOX 273 121.80 NCS I N

55240 DR. BANDY CHARGE SHEETS 273 129.24 NCS I N

55241 DISCHARGE FORM 100/PAK 273 73.56 NCS I N

55243 PATIENT EQUIPMENT 273 79.80 NCS A N

55244 FUNCTIONAL INDEP.MEASURE 273 31.92 NCS A N

55249 CHRONOLOGICAL MED. LIST 273 20.64 NCS A N

55251 PATIENT ACUITY CLASS WORKSHEET 273 66.12 NCS A N

55252 O.T.REHAB PROGRESS NOTE 273 68.76 NCS A N

55253 O.T.PSYCH PROGRESS NOTE 273 68.76 NCS A N

55254 P.T. THERAPY CHARGE 273 68.76 NCS A N

55255 MEDICATION DOCUMENTATION 273 120.60 NCS I N

55256 MEDICATION RECORD 273 140.76 NCS I N

55257 ACTIVITIES THER ADM SUMMARY 999 68.76 NCS I N

55258 ACTIVITIES THER DISC SUMM 999 68.76 NCS I N

55259 SPEECH CHARGE NOTE 999 68.76 NCS A N

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Mod1 Mod2 Mod3 Mod4

55277 URINALYSIS 273 63.84 NCS I N

55278 WET CHEMISTRY 273 63.84 NCS I N

55279 CHEMISTRY 273 63.84 NCS I N

55281 X-RAY CHARGE 999 7.32 NCS I N

55282 ADVANCE MEDICAL DIRECT. 273 125.16 NCS I N

55283 NURSING ASSESSMENT HOME MED 273 50.40 NCS I N

55285 MASTER TREAT PLAN REVIEW 270 0.00 NCS I N

55286 INITIAL ASSESS & EVAL PEDI 270 0.00 NCS I N

55287 LEVI INQUIRY/ASSESSMENT FORM 273 0.00 NCS A N

55288 H.R. PTO TRACKING 450 413.64 NCS I N

55289 PHYS ADMIT STIMULANT DETOX 270 121.80 NCS I N

55290 MAS TREAT DISCHARGE REVIEW 270 0.00 NCS A N

55291 BIOPSYCHOSOCIAL INTEGRATED 270 0.00 NCS A N

55292 MED MANAGEMENT CONSULT REFER 270 0.00 NCS A N

55293 MED MANAGEMENT NOTES PEDI 270 0.00 NCS A N

55295 PATIENT CHARGE CARDS 270 65.16 NCS I N

55296 OUTPATIENT MEDICATION LOG 273 0.00 NCS A N

55297 NURSING HOME REPORT/ASSES 273 0.00 NCS A N

55298 INPAT ADULT PSY PROGRESS NOTES 273 0.00 NCS I N

55299 AUTH RELEASE MEDICAL INFO 273 0.00 NCS I N

553 URIC ACID SERUM 300 84550 20.70 NLAB A N

55300 OT UPDATE EVALUTION 273 0.00 NCS A N

55301 OCCUPATIONAL THERAPY SCREEN 273 0.00 NCS A N

55302 OT INITAL EVAL/DISC SUMMARY 273 0.00 NCS A N

55303 OCCUPATIONAL THER INITIAL EVAL 273 0.00 NCS A N

55304 OT DISCHARGE SUMMARY 273 0.00 NCS A N

55305 OUTPATIENT SAMPLE MED INSTRUCT 273 0.00 NCS I N

554 PROTEIN,TOTAL, ANY SOURCE 300 84155 14.40 NLAB A N

555 BUN 300 84520 24.00 NLAB A N

556 PLATELET COUNT 300 85049 21.30 NLAB A N

557 PROTIME (PT) 300 85610 18.30 NLAB A N

558 SMOOTH MUSCLE ABS 300 83516 57.30 NLAB A N

559 OCCULT BLOOD SCREEN 300 82270 15.60 NLAB A N

560 BILIRUBIN,DIRECT 300 82248 24.00 NLAB A N

561 PHOSPHOROUS 300 84100 21.60 NLAB A N

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Mod1 Mod2 Mod3 Mod4

562 CALCIUM 300 82310 24.00 NLAB A N

563 TRIGLYCERIDES 300 84478 36.60 NLAB A N

564 SODIUM 300 84295 23.10 NLAB A N

565 GLU TOLERANCE (3) 300 82951 63.90 NLAB A N

566 HLAB-27 300 86812 123.30 NLAB A N

568 TOTAL PROTEIN,SERUM 300 84155 16.80 NLAB A N

569 BILIRUBIN;TOTAL 300 82247 24.00 NLAB A N

570 T-3 TOTAL 300 84480 63.90 NLAB A N

571 ANTI-PM-1 300 86235 45.60 NLAB A N

572 LAP COUNT 300 85540 41.10 NLAB A N

573 TROPONIN 300 84484 62.40 NLAB A N

574 METANEPHRINES 300 83835 66.30 NLAB A N

575 CRYOGLOBULINS 300 82595 30.00 NLAB A N

576 ANTI-JO-1 300 86235 45.60 NLAB A N

577 HEPATITUS BE AB 300 86707 53.70 NLAB A N

578 OSMOLALITY SERUM 300 83930 29.70 NLAB A N

580 OSMOLALITY URINE 300 83935 32.40 NLAB A N

581 HEMOGLOBIN,AUTOMATED 300 85018 15.00 NLAB A N

582 SENSITIVITY STUDIES 300 87181 38.00 NLAB A N

583 PROLACTIN 300 84146 92.10 NLAB A N

584 FERRITIN 300 82728 65.10 NLAB A N

585 LUTEINIZING HORMONE 300 83002 88.80 NLAB A N

587 CORTISOL TOTAL 300 82533 75.00 NLAB A N

588 SY FL CELL CT 300 89051 30.30 NLAB A N

589 SY FL MUCIN 300 83872 23.10 NLAB A N

590 SY FL URIC ACID 300 84560 21.60 NLAB A N

591 AMYLASE 300 82150 30.00 NLAB A N

592 ALDOLASE 300 82085 46.20 NLAB A N

593 C K (CREATINE KINASE) 300 82550 31.50 NLAB A N

594 HEPATITIS A IMG AB 300 86709 52.50 NLAB A N

595 VITAMIN D 25 HYDROXY 300 82306 138.00 NLAB A N

5950 Calcitriol(1,25 di-OH Vitamin D) 300 82652 180.00 NLAB I N

596 TSH 300 84443 136.00 NLAB A N

597 CBC-AUTO DIFF 300 85025 58.00 NLAB A N

598 PHENOBARBITAL 300 80184 54.90 NLAB A N

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Exception


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Mod1 Mod2 Mod3 Mod4

599 CBC NO DIFF 300 85027 48.00 NLAB A N

600 CULTURE, ROUTINE 300 87070 69.00 NLAB A N

6000 MISC DAVID SMITH,LCSW 961 0.00 NSWDS A N

6005 PROF IOP/20-30 MINS 961 90804 114.00 NSWDS I N

6006 PROF IOP/45-50 MINS 961 90806 180.00 NSWDS I N

6007 GROUP PSYCHOTHERAPY 961 90853 96.00 NSWDS A N

6008 PROF IOP/75-80 MIN 961 90808 183.60 NSWDS I N

601 HEPATITIS C AB CONF 300 86804 212.40 NLAB A N

6010 FAM THER W/PATIENT 961 90847 204.00 NSWDS A N

6011 FAM THER W/O PATIENT 961 90846 204.00 NSWDS A N

6012 PSYCHIATRIC DIAGNOSTIC 961 90791 180.00 NSWDS A N

6013 IND PSYCHOTHERAPY INT 961 90812 114.00 NSWDS I N

6014 PSYCHOTHERAPY 30 MINUTES 961 90832 116.40 NSWDS A N



6017 INITIAL EVALUATION 961 90791 273.60 NSWDS A N

6018 CRISIS PSYCHOTHERAPY FIRST 60 961 90839 211.20 NSWDS A N

6019 CRISIS EACH ADDITIONAL 30 MIN 961 90840 146.40 NSWDS A N

602 HEMATOCRIT AUTOMATED 300 85014 11.40 NLAB A N

6020 OFFICE VISIT- NEW 20 MINUTE 961 99202 115.20 NAPRN A N

6021 OFFICE VISIT- NEW 30 MINUTE 961 99203 172.80 NAPRN A N

6022 OFFICE VISIT- ESTAB. 10 MINUTE 961 99212 82.80 NAPRN A N

6023 OFFICE VISIT- ESTAB. 15 MINUTE 961 99213 122.40 NAPRN A N

6024 OFFICE VISIT- NEW 10 MINUTES 961 99201 57.60 NAPRN A N

6025 OFFICE VISIT- ESTAB. 5 MINUTES 961 99211 43.20 NAPRN A N

6026 OFFICE VISIT- ESTAB. 25 MIN 961 99214 168.00 NAPRN A N

603 N.GONORRHOEAE,DIRECT PROBE 300 87590 93.30 NLAB A N

604 SY FL PROTEIN 300 84157 16.80 NLAB A N

605 SY FL RA 300 86430 26.40 NLAB A N

606 CHLAMYDIA TRACH,DIRECT PROBE 300 87490 93.30 NLAB A N

607 SY FL CRYSTAL 300 89060 58.20 NLAB A N

608 PREALBUMIN 300 84134 69.60 NLAB A N

609 ALT (SGPT) 300 84460 24.00 NLAB A N

610 PROTIEN S TOTAL 300 85305 93.60 NLAB A N

611 HALOPERIDOL 300 80173 67.80 NLAB A N

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Exception


Levi Hospital


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Mod1 Mod2 Mod3 Mod4

612 VALPROIC ACID (DEPAKOTE) 300 80164 111.00 NLAB A N

614 CRYSTAL EXAM 300 89060 24.00 NLAB A N

615 SED RATE MANUAL 300 85651 21.60 NLAB A N

616 R P R/ VDRL 300 86592 35.00 NLAB A N

617 HERPES SIMPLEX 1 AB 300 86695 45.00 NLAB A N

618 URINE GLUCOSE 300 81002 16.20 NLAB A N

619 PROTEIN C ACTIVITY 300 85303 108.00 NLAB A N

620 HEP B-DIRECT PROBE 300 87515 93.30 NLAB A N

621 VITAMIN B12 300 82607 122.00 NLAB A N

622 ESTRADIOL 300 82670 227.00 NLAB A N

623 HEP B-AMPLIFIED PROBE 300 87516 163.20 NLAB A N

625 HEMOGLOBIN ELECTROPHORESES 300 83021 82.80 NLAB A N

626 HEP C-DIRECT PROBE 300 87520 93.30 NLAB A N

627 ACID PHOS,PROSTATIC 300 84066 45.90 NLAB A N

628 HEP C-AMPLIFIED PROBE 300 87521 163.20 NLAB A N

629 PM-SCL AB 300 86331 108.00 NLAB A N

630 HISTONE 300 86235 61.80 NLAB A N

6307 GROUP PSYCHOTHERAPY 961 90853 96.00 NSWBW A N

631 MITOCHONDRIAL ABS 300 83516 57.30 NLAB A N

6310 FAM THER W/PATIENT 961 90847 204.00 NSWBW A N

6311 FAM THER W/O PATIENT 961 90846 204.00 NSWBW A N

6312 PSYCHIATRIC DIAGNOSTIC 961 90791 180.00 NSWBW A N

6314 PSYCHOTHERAPY 30 MINUTES 961 90832 116.40 NSWBW A N



6317 INITIAL EVALUATION 961 90791 273.60 NSWBW A N

6318 CRISIS PSYCHOTHERAPY FIRST 60 MIN 961 90839 211.20 NSWBW A N

6319 CRISIS EACH ADDITIONAL 30 MIN 961 90840 146.40 NSWBW A N

632 HERPES SIMPLES 2AB 300 86696 91.20 NLAB A N

633 OXYCARBAZEPINE 300 82542 82.50 NLAB A N

634 HEP C-QUANTIFICATION 300 87522 183.00 NLAB A N

635 URINE IEP 300 86325 105.60 NLAB A N

636 HEMOCULT ICT 300 82274 42.00 NLAB A NQWQW

637 THEOPHYLLINE 300 80198 67.20 NLAB A N

638 CH-50 300 86162 96.60 NLAB A N

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Exception


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Mod1 Mod2 Mod3 Mod4

639 FSH 300 83001 88.80 NLAB A N

640 HEPATITIS DELTA AB 300 86692 81.90 NLAB A N

64005 NEEDLE- SAFTEY 20 ga 1 inch 270 0.22 NCS A N

64006 NEEDLE-SAFETY-22ga 1 inch 270 0.22 NCS A N

64007 NEEDLE-SAFETY 23ga 1 inch 270 0.22 NCS A N

64008 CATHETER TRAY INSERT-18FR 5cc 270 15.20 NCS A N

64009 CATHETER TRAY INSERTt-14FR 5cc 270 12.58 NCS A N

6401 Crisis each additional 961 90840 146.40 NSWSW A N

64010 CATHETER TRAY FOLEY-16FR 5cc 270 14.14 NCS A N

64011 FILTER NEEDLE-19ga 1 inch 270 0.49 NCS A N

64012 TABLE PAPER-21 inch 270 2.36 NCS A N

6402 Crisis psychotherapy 961 90839 211.20 NSWSW A N

6403 Family ther w/o patient 961 90846 204.00 NSWSW A N

6404 Family ther w/patient 961 90847 204.00 NSWSW A N

6405 Group psychotherapy 961 90853 96.00 NSWSW A N

6406 Initial Evaluation 961 90791 273.60 NSWSW A N

6407 Psychiatric Diagnostic 961 90801 180.00 NSWSW A N

6408 Psychotherapy 30 min 961 90832 125.72 NSWSW A N

6409 Psychotherapy 45 minutes 961 90834 175.20 NSWSW A N

641 VISCOSITY 300 85810 50.10 NLAB A N

6410 Psychotherapy 60 minutes 961 90837 265.20 NSWSW A N

642 GENTAMICIN 300 80170 78.60 NLAB A N

643 HIV-1 AB 300 86701 71.00 NLAB A N

644 HIV-WESTON BLOT 300 86689 92.10 NLAB A N

645 RMSF AGGL 300 86000 6.90 NLAB A N

64550 TENS-APPLICATION OF SURFACE 420 97032 93.60 NOPRH A N

646 IMMUNO-ELECTROPHORESIS 300 86320 106.50 NLAB A N

648 TESTOSTERONE TOTAL 300 84403 210.00 NLAB A N

649 CARBAMAZEPINE, FREE 300 80157 56.70 NLAB A N

650 A N C A 300 86256 71.70 NLAB A N

651 ANGIOTENSIN (ACE) 300 82164 68.40 NLAB A N

652 CYCLOSPORIN 300 80158 86.40 NLAB A N

653 URINE KETONES 300 81005 10.50 NLAB A N

654 PHENYTOIN,FREE 300 80186 67.50 NLAB A N

655 QUINIDINE 300 80194 69.60 NLAB A N

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Mod1 Mod2 Mod3 Mod4

657 MOLECULAR AMPLIFICATION 300 81210 78.00 NLAB I N

659 GEL ELECTROPHORESIS 300 81205 90.00 NLAB I N

66003 MICROKLENZ 6 OZ 270 25.68 NCS A N

66037 CLOROX BLEACH GALLON 273 0.00 NCS A N

66054 CARRA2X 3 FOAM 270 2.52 NCS A N

66055 CARRA4 X4 FOAM 270 7.82 NCS A N

66056 CARRA 6 X8 FOAM 270 86.86 NCS A N

66062 CARRA CLEAN SPRAY 8 OZ 270 26.16 NCS A N

66066 CARRASMART HYDROC. 6X6 270 67.12 NCS A N

6610 HEPATIC (LIVER FUNCTION) 300 80076 37.20 NLAB A N

66200 SANI CLOTH Q77272 273 26.64 NCS I N

663 ISLET CELLS-ANTI PANCREATIC 300 86341 54.00 NLAB A N

66303 CARRASMART HYDROC. 4X4 270 16.58 NCS A N

66333 CARRASYN V HYDROGEL 270 30.24 NCS A N

664 HEPATITIS C RNA/PCR QUALITATIV 300 85379 168.60 NLAB A N

66420 ADVERSE DRUG FORMS 270 25.20 NCS I N

66425 XXXL SCRUB TOP 270 7.92 NCS A N

66426 XXXL SCRUB BOTTOM 270 3.00 NCS A N

66427 MED SCRUB TOP 270 6.60 NCS A N

66428 MED SCRUB BOTTOM 270 7.32 NCS A N

66429 LARGE SCRUB TOP 270 7.92 NCS A N

66430 LARGE SCRUB BOTTOM 270 7.92 NCS A N

66431 X-LARGE SCRUB TOP 270 7.32 NCS A N

66432 X-LARGE SCRUB BOTTOM 270 8.40 NCS A N

66433 XXL SCRUB TOP 270 7.20 NCS A N

66434 XXL SCRUB PANT 270 7.32 NCS A N

665 VANCOMYCIN 300 80202 65.10 NLAB A N

666 D-DIMER 300 87521 168.60 NLAB I N

667 T-3 UPTAKE 300 84479 30.90 NLAB A N

668 LYME DISEASE AB EACH 300 86618 80.70 NLAB A N

669 ANCA PROFILE 300 83520 230.22 NLAB I N

670 G6PD QUANTITATIVE 300 82955 37.59 NLAB A N

67000 SLIPPER XX LARGE 270 2.10 NCS A N

67001 SLIPPER LARGE 270 2.10 NCS A N

67002 ATTENDS- XLARGE 270 0.62 NCS A N

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67003 SMALL SCRUB SHIRT 270 1.35 NCS A N

67004 SMALL SCRUB PANT 270 1.64 NCS A N

67005 ANKLE SUPPORT 270 15.60 NCS A N

67006 COLOSTOMY BARRIER 270 21.18 NCS A N

67007 OSTOMY POUCH 270 90.97 NCS A N

67008 ADAPT PASTE 270 10.76 NCS A N

67009 SKIN BARRIER WIPE 270 12.64 NCS A N

67010 PURELL HAND SANITIZER REFILL 270 12.98 NCS A N

67011 URETHRAL FLO CATH 270 1.57 NCS A N

67012 7.0 ENDOTRACHEAL TUBE 270 3.07 NCS A N




67016 AMBU BAG 270 21.72 NCS A N

67017 DEFIBRILLATOR PAPER 270 62.23 NCS A N

67018 ELECTRODES 270 39.19 NCS A N

67019 BAUERFEIND GENUTRAIN KNEE BRACE 270 A4466 85.20 NCS A N

67020 SYRINGE FLU-3ML 25 GA 5/8 IN 270 26.40 NCS A N

67021 SURGICAL GLOVE-BANDY 270 85.57 NCS A N

67022 TAPE MEDIPORE 270 70.68 NCS A N

67023 ENDOTRACHEAL TUBE 270 3.07 NCS A N

67024 PURELL HAND SANITIZER FOAM REFILL 270 28.40 NCS A N

67025 HYDROGEN PEROXIDE- 1 GALLON 270 9.14 NCS A N

67026 BLOOD PRESSURE CUFF- ADULT VINYL 270 30.96 NCS A N

67027 DISPOSABLE STETHOSCOPE 270 2.74 NCS A N

67028 THERMO PROBE COVERS-LUMEON 270 9.37 NCS A N

67029 BATTERY C 270 1.50 NCS A N

67030 NEEDLES-PEN ULTRA FINE 8MM 270 38.79 NCS A N

67031 ENVELOPE 6 X 9 LOGO 270 125.13 NCS A N

67032 ELECTRODE-CLOTH GEL 270 0.00 NCS A N

67033 COLD PACK INSTANT 270 0.88 NCS A N

67034 LIP BALM 270 1.00 NCS A N

67035 VALVED HOLDING CHAMBER 270 10.00 NCS A N

671 RED BLOOD CELL COUNT 300 85041 14.40 NLAB A N

672 PSA,TOTAL 300 84153 149.00 NLAB A N

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673 URINE CULT 300 87086 65.00 NLAB A N

674 ANCA(PANCA/CANCA) 300 86256 106.98 NLAB I N

675 PLATELET NEUTRALIZATION 300 85597 85.20 NLAB A N

676 C1Q BIND IMMUNE COMPLEXES 300 86332 72.10 NLAB A N

677 COLD AGGL,SCREEN 300 86156 31.50 NLAB A N

678 DRUG SCREEN URINE 300 80305 118.00 NLAB A N

679 ALDOSTERONE 300 82088 186.30 NLAB A N

680 RUSSELL VIPER VENOM/DIL 300 85613 26.40 NLAB A N

681 PTT 300 85730 27.60 NLAB A N

682 LUPUS ANTICOAGULANTS 300 85613 0.00 NLAB I N

683 TPMT GENETICS 300 81201 24.00 NLAB I N




688 CARBON MONOXIDE 300 82375 36.00 NLAB A N

689 DRUG SCREEN PANEL 72033 300 80305 420.00 NLAB A N

690 T PROTEIN UR QUANT 24 HR 300 84156 14.40 NLAB A N

691 ANTI-CENTROMERE 300 86235 88.80 NLAB A N

692 ANTI-RNASE 300 83520 90.00 NLAB A N

693 ANTI RNA POLYMERASE 300 83516 378.30 NLAB I N

694 ANTI-U3-RNP ANTIFIBRILLARIN 300 86235 144.90 NLAB A N

695 IMMUNO GLOBULIN IGG 4 300 82787 46.80 NLAB A N

696 QUANTIFERON GOLD TB SPOT 300 86480 117.00 NLAB A N

697 C3/C4 300 86160 114.60 NLAB I N

7000 MISC MICHELLE CRANDELL 961 0.00 NSWMC A N

7005 PROF IOP/20-30 MINS 961 90832 114.00 NSWMC A N

7006 PROF IOP/45-50 MINS 961 90834 180.00 NSWMC A N

7007 GROUP PSYCHOTHERAPY 961 90853 96.00 NSWMC A N

7008 PROF IOP/75-80 MIN 961 90837 183.60 NSWMC A N

7010 FAM THER W/PATIENT 961 90847 204.00 NSWMC A N

7011 FAM THER W/O PATIENT 961 90846 204.00 NSWMC A N

7012 PSYCHIATRIC DIAFNOSTIC 961 90791 180.00 NSWMC A N

7014 PSYCHOTHERAPY 30 MINUTES 961 90832 116.40 NSWMC A N



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7017 INITAL EVALUATION 961 90791 273.60 NSWMC A N

7018 CRISIS PSYCHOTHERAPY FAMIL 961 90839 211.20 NSWMC A N

7019 CRISIS EACH ADDITIONAL 961 90840 146.40 NSWMC A N

702 PROTEIN S ANTIGEN 300 85305 102.00 NLAB A N

703 HEXAGONAL PHASE PHOSPHOLIPID 300 85598 172.80 NLAB A N

704 PTT-LA INCUB MIX 300 85732 103.20 NLAB A N

705 PTT-LA MIX 300 85732 103.20 NLAB A N

706 DRVVT MIX 300 85613 122.40 NLAB A N

707 DRVVT CONFIRM 300 85613 122.40 NLAB A N

708 THROMBIN MIXING STUDY 300 85670 71.40 NLAB A N

730 SERUM KETONES/QUANT 300 82010 30.90 NLAB A N

731 CARDIOLIP ABS EACH 300 86147 75.60 NLAB A N

734 LEUKOCYTE ABS 300 86021 71.70 NLAB A N

735 CLOSTRIDIUM DIFF TOXIN 300 87324 42.00 NLAB A N

736 DRUG SCREEN SERUM 300 80305 69.60 NLAB I N

737 HGB A1C (GLYCATED) 300 83036 78.00 NLAB A N

738 RENIN 300 84244 104.40 NLAB A N

739 SY FL GLUCOSE 300 82945 24.00 NLAB A N

741 TOTAL PROTEIN,URINE 300 84156 16.80 NLAB A N

742 TESTOSTERONE FREE 300 84402 123.30 NLAB A N

746 R A SCREEN 300 86430 26.40 NLAB A N

747 PROCAINAMIDE 300 80190 79.80 NLAB A N

748 IMMUNOASSAY, QUANT 300 83520 61.80 NLAB A N

749 CK/MB 300 82553 54.90 NLAB A N

750 WBC MANUAL DIFF 300 85007 31.00 NLAB A N

751 LYME WESTERN BLOT 300 86617 138.00 NLAB A N

752 LEGIONELLA AB 300 86713 71.70 NLAB A N

753 IMMUNOASSAY,QUANT,RIA 300 83519 39.90 NLAB A N

754 WET PREP 300 87210 20.40 NLAB A N

755 C A 125 300 86304 96.60 NLAB A N

756 C - 1 ESTERASE INHIBITOR 300 86161 57.30 NLAB A N

7570 ELECTROLYTES 300 80051 32.40 NLAB A N

758 GLUCOSE (FS) 300 82962 25.50 NLAB A N

759 5 HIAA 300 83497 61.80 NLAB A N

760 NORTRIPTYLINE 300 80182 65.10 NLAB I N

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Mod1 Mod2 Mod3 Mod4

76075 PRO READ TO BE DELETE 960 0.00 NCL A N

761 T B SKIN TEST 300 86580 33.90 NLAB A N

762 LYME AB,ELISA/EIA 300 86618 48.00 NLAB A N

7660 BMP (BASIC METABOLIC PANEL) 300 80048 65.00 NLAB A N

767 ALPHA-FETOPROTEIN (AFP) 300 82105 79.80 NLAB A N

77080 PROFESSIONAL READING 960 77080 90.00 NCL A N26

7720 CMP-(COMPREHENSIVE METABOLIC) 300 80053 86.00 NLAB A N

773 CD 4 300 86361 96.00 NLAB A N

776 VOLUME MEASUREMENT 300 81050 14.40 NLAB A N

778 NASAL EOSIN CT 300 89190 36.90 NLAB A N

779 PINWORM PREP(TAPE TEST/WORMS) 300 87172 24.00 NLAB A N

780 DILUTE PROTHROMBIN TIME 300 85705 45.60 NLAB A N

782 ANTICARDIOLIPIN(IGG,IGA,IGM) 300 86147 116.40 NLAB I N

784 IMMUNOFIXATION,IFE SERUM 300 0.00 NLAB I N

800 LEAD 300 83655 57.30 NLAB A N

8000 MISC TRISHA WILLIS, LCSW 961 0.00 NSWTW A N

8007 GROUP PSYCHOTHERAPY 961 90853 96.00 NSWTW A N

801 FTA-ABS 300 86592 58.20 NLAB I N

8010 FAM THER W/PATIENT 961 90847 204.00 NSWTW A N

8011 FAM THER W/O PATIENT 961 90846 204.00 NSWTW A N

8012 PSYCHIATRIC DIAGNOSTIC 961 90791 180.00 NSWTW A N

8014 PSYCHOTHERAPY 30 MINUTES 961 90832 116.40 NSWTW A N



8017 INITIAL EVALUATION 961 90791 273.60 NSWTW A N

8018 CRISIS PSYCHOTHERAPY FIRST 60 961 90839 211.20 NSWTW A N

8019 CRISIS EACH ADDITIONAL 30 MIN 961 90840 146.40 NSWTW A N

802 CRYOFIBRINOGEN 300 82585 39.30 NLAB A N

803 BENZODIAZEPINES 300 80154 87.60 NLAB I N

804 HIV ANTIGEN 300 87390 81.00 NLAB A N

805 PLASMA PHENYLALANINE 300 84030 13.20 NLAB A N

806 Hepatitis Panel 300 80074 370.00 NLAB A N

807 HEPATITIS A AB TOTAL 300 86708 57.30 NLAB A N

808 VARICELLA-ZOSTER AB EACH 300 86787 61.80 NLAB A N

809 VALPROIC ACID,FREE 300 80299 72.00 NLAB I N

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810 P-ANCA/MPO ABS(ANTIMYELOPEROXIDASE) 300 83520 63.90 NLAB A N

811 MARIJUANA 300 80101 65.40 NLAB I N

812 RUBELLA AB 300 86762 68.40 NLAB A N

813 WOUND CULTURE 300 87070 69.00 NLAB A N

814 RICKETTSIA AB RMSF 300 86757 90.00 NLAB A N

815 CHLAMYDIA CULTURE 300 87110 93.00 NLAB A N

816 VIRAL AB-NONSPECIFIED 300 86790 54.00 NLAB A N

817 BODY FLUID CULTURE 300 87070 40.80 NLAB A N

820 IRON / TIBC 300 42.99 NLAB I N

821 IRON 300 83540 30.90 NLAB A N

822 TIBC 300 83550 42.00 NLAB A N

823 PLATELET ANTIBODIES 300 86022 294.00 NLAB A N

824 PLATELET ASSOC IMMUNGLOB 300 86023 294.00 NLAB A N

825 MICROSOMAL AB 300 86376 69.60 NLAB A N

826 THYROGLOBULIN AB 300 86800 76.20 NLAB A N

828 IFE,SERUM 300 86334 106.50 NLAB A N

829 IFE,URINE 300 86335 106.50 NLAB A N

830 T CELL COUNT 300 86359 179.40 NLAB A N

831 CYCLIC CITRULL PEPTIDE(CCP)AB 300 86200 90.00 NLAB A N

833 ANTI RNP & SMITH PROFILE 300 86235 128.88 NLAB I N

834 HYDROXYPROLINE,TOTAL 300 83505 130.20 NLAB A N

835 CTX OSTEOMARK 300 82523 214.20 NLAB A N

836 URINE AUTOMATED & MICRO 300 81001 32.00 NLAB A N

837 SED RATE AUTO 300 85652 24.00 NLAB A N

838 EBV NUCLEAR AG 300 86664 86.40 NLAB A N

839 EBV VCA-IGG 300 86665 83.10 NLAB A N

840 EBV(EA) 300 86663 76.20 NLAB A N

845 POTASSIUM, URINE 300 84133 20.40 NLAB A N

846 ANTI-RNP 300 86235 64.44 NLAB A N

848 THYROID PEROXIDASE 300 86376 52.44 NLAB I N

849 ANTI-SSB 300 86235 64.44 NLAB A N

851 VIT. B1 (THIAMINE) 300 84425 99.90 NLAB A N

852 ANTI-SMITH 300 86235 64.44 NLAB A N

853 ANTISCLERODOMA 300 86235 64.44 NLAB A N

854 ANTI-SSA 300 86235 64.44 NLAB A N

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Mod1 Mod2 Mod3 Mod4

855 INDERAL (PROPRANOLOL) 300 80299 67.20 NLAB I N

856 HEPATITIS C AB 300 86803 66.00 NLAB A N

857 D H E A 300 82626 114.60 NLAB A N

858 ERYTHROPOIETIN 300 82668 89.70 NLAB A N

861 URINE PREGNANCY 300 81025 53.00 NLAB A N

862 ACTH 300 82024 72.90 NLAB A N

863 PROGESTERONE 300 84144 170.00 NLAB A N

864 FREE T4 300 84439 42.60 NLAB A N

865 ANTI-GBM 300 83516 57.30 NLAB A N

8670 RENAL PANEL 300 80069 44.40 NLAB A N

868 HEP C RNA,QUANT 300 87522 174.00 NLAB A N

870 CORTICOSTERONE 300 82528 120.00 NLAB A N

871 TOBRAMYCIN 300 80200 76.20 NLAB A N

872 PROTEIN C-AG 300 85302 76.20 NLAB A N

873 FIBRINOGEN ACTIVITY 300 85384 40.20 NLAB A N

874 CD 4 / CD 8 300 86360 177.30 NLAB A N

875 PAP SMEAR LIQUID BASED 300 88175 54.00 NLAB A N

876 H.PYLORI 300 86677 70.80 NLAB A N

877 LIDOCAINE 300 80176 66.00 NLAB A N

878 CHLAMYDIA DNA PROBE 300 87491 96.30 NLAB A N

879 GC DNA PROBE 300 87591 96.30 NLAB A N

881 CORTISOL,URINE 300 82530 76.50 NLAB A N

882 MPO ABS ANTI& PR-3 ABS ANTI 300 83520 89.64 NLAB I N

888 AFB CULTURE 300 87116 27.80 NLAB A N

889 AFB CONCENTRATION 300 87015 17.18 NLAB A N

890 AFB SMEAR 300 87206 13.81 NLAB A N

891 C-ANCAPR-3 ABS (ANTIPROTEINASE 3) 300 83520 63.90 NLAB A N

894 LEUKOCYTE COUNT AUTOMATED 300 85048 8.94 NLAB A N

897 ANTI-U 1- RNC 300 83516 114.00 NLAB I N

898 ANTI-PM-SCL 300 86235 126.60 NLAB A N

899 HEP C DNA W/TITER 300 87521 97.10 NLAB I N

9 ED VISIT-STRAIGHTFORWARD 456 99281 48.60 NED A N

90 INJECTION 960 0.00 NCL A N

900 HEP B VIRUS PCR QUANT 300 87517 252.00 NLAB A N

902 MEASLES 300 86765 68.40 NLAB A N

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Mod1 Mod2 Mod3 Mod4

903 MUMPS 300 86735 68.40 NLAB A N

90471 VACCINE ADMINISTRATION 960 90471 30.00 NCL A N

906 URINE MICROSCOPIC ONLY 300 81015 17.40 NLAB A N

90658 FLU 960 90658 0.00 NCL A N

907 Lipid Profile 300 80061 99.00 NLAB A N

90724 FLU 960 90723 5.70 NCL A N

90741 VACCINE ADMINISTRATION 960 0.00 NCL A N

90765 INFUSION 960 0.00 NCL A N

90780 1ST HOUR INFUSION 960 0.00 NCL A N

90781 EACH ADDITIONAL HOUR/INFUSION 960 0.00 NCL A N

90901 BIOFEEDBACK TRAINING 420 90901 108.00 NOPRH A N

90911 BIOFEEDBACK 420 90911 108.00 NOPRH A N

93010 EKG INTERPRETRATION 960 93010 24.00 NCL A N

95831 EXTREMITY(EXCLUDING HANDS) 420 95831 36.00 NOPRH A N

95832 HAND-MUSCLE TESTING-MANUEL 420 95832 37.44 NOPRH A N

95833 MUSCLE TESTING MANUAL EX HANDS 420 95833 64.80 NOPRH A N

95834 MUSCLE TESTING MANUAL W/HANDS 420 95834 79.20 NOPRH A N

95851 EXTREMITY(EX HANDS) RANGE MOT 420 95851 21.60 NOPRH A N

95852 HAND-RANGE OF MOTION MEASUR 420 95852 21.60 NOPRH A NGP

96365 INFUSION TIME RECLAST 960 96365 0.00 NCL A N

96410 FIRST HOUR INFUSION 960 0.00 NCL A N

96412 EACH ADDITION HR/INFUSION 960 0.00 NCL A N

96413 1ST HOUR INFUSION 960 96413 360.00 NCL A N

96415 EACH ADDTIONAL HOUR/INFUSION 960 96415 108.00 NCL A N

97001 EVALUATION PHYSICAL THERAPY 420 97001 180.00 NOPRH A NGP

97002 PHYSICAL THERAPY RE-EVALUATION 420 97002 100.80 NOPRH A NGP

97010 HOT/COLD PACKS-MODALITY 1+AREA 420 97010 36.00 NOPRH A YGP

97012 TRACTION MECH MODALITY 1+ AREA 420 97012 53.28 NOPRH A NGP

97014 ELECTICAL STIMULATION UNATTEND 420 97014 50.40 NOPRH A NGP

97016 VASOPNEUMATAIC DEVICE 1+ AREA 420 97016 40.32 NOPRH A NGP

97018 PARAFFIN BATH 420 97018 36.00 NOPRH A NGP

97022 WHIRLPOOL MODALITY 1+ AREAS 420 97022 57.60 NOPRH A NGP

97024 DIATHERMY OR MICROWAVE 420 97024 59.04 NOPRH A NGP

97026 INFRARED-MODALITY 1+ AREAS 420 97026 36.00 NOPRH A NGP

97032 ELECTRICAL STIMULATION(MAMUAL) 420 97032 53.28 NOPRH A NGP

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97033 IONTOPHORESIS-MODALITY 1+ AREA 420 97033 53.28 NOPRH A NGP

97034 CONTRAST BATHS 420 97034 59.04 NOPRH A NGP

97035 ULTRASOUND MODALITY 1+ AREAS 420 97035 36.00 NOPRH A NGP

97036 HUBBARD TANK-MODALITY 1+ AREAS 420 97036 139.68 NOPRH A NGP

97039 FLUIDOTHERAPY 420 97039 50.40 NOPRH A NGP

97110 THER.PROCEDURE/15 420 97110 66.24 NOPRH A NGP

97112 NEUROMUSCULAR REEDUCATION 420 97112 69.12 NOPRH A NGP

97113 AQUA THER W/EXERCUSES 420 97113 74.88 NOPRH A NGP

97116 GAIT TRAIN &/OR STAIR CLIMBING 420 97116 64.80 NOPRH A NGP

97124 MASSAGE-THERAPEUTIC PROCEDURE 420 97124 56.16 NOPRH A NGP

97140 MANUAL THERAPY TECH 1+ REGIONS 420 97140 63.36 NOPRH A NGP

97150 GROUP (2+ INDIVIDUALS) 420 97150 72.00 NOPRH A NGP

97530 THERAPEUTIC ACTIVITIES DIRECT 420 97530 66.24 NOPRH A NGP

97533 SENSORY INTEGRATIVE TECHNIQUE 420 97533 50.40 NOPRH A NGP

97535 SELF CARE/HOME MANGE/TRAINING 420 97535 57.60 NOPRH A NGP

97537 COMMUNITY/WORK REIN TRAIN 420 97537 51.84 NOPRH A NGP

97542 WHEELCHAIR MANAGEMENT/PROPULSI 420 97542 53.28 NOPRH A NGP

97545 WORK HARDENING/CONDITION 2HOUR 420 97545 180.00 NOPRH A NGP

97546 WORK HARDENING/CONDITIONING HR 420 97546 57.60 NOPRH A NGP

97597 WOUND CARE SELECT <=20 SQ CM 420 97597 93.60 NOPRH A NGP

97598 WOUND CARE SELECT >20 SQ CM 420 97598 144.00 NOPRH A NGP

97602 WOUND CARE NON SELECT 420 97602 216.00 NOPRH A N

97750 PHYSICAL PERFORMANCE TESTING 420 97750 79.20 NOPRH A NGP

97755 ASSISTIVE TECH ASS-DIR CONTACT 420 97755 79.20 NOPRH A NGP

97760 ORTHOTICS FITTING & TRAINING 420 97760 59.04 NOPRH A NGP

97761 PROSTHETIC TRAIN UPPER&/OR LOW 420 97761 66.24 NOPRH A NGP

97762 ORTHOTIC/PROSTHETIC CHECKOUT 420 97762 50.40 NOPRH A NGP

99200 COLLECTION FEE CHARGE 960 0.00 NCL A N

99203 30 MINUTES 960 99203 168.00 NCL A N

99204 45 MINUTES 960 99204 264.00 NCL A N

99205 60 MINUTES 960 99205 336.00 NCL A N

99211 5 MINUTES 960 99211 36.00 NCL A N

99212 10 MINUTES 960 99212 72.00 NCL A N

99213 15 MINUTES 960 99213 114.00 NCL A N

99214 25 MINUTES 960 99214 168.00 NCL A N

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99215 40 MINUTES 960 99215 240.00 NCL A N

99218 OBSERVATION 960 99218 108.00 NCL A N

99219 OBSERVATION CARE 960 99219 180.00 NCL A N

99221 30 MINUTES 960 99221 168.00 NCL A N

99222 50 MINUTES 960 99222 240.00 NCL A N

99223 70 MINUTES 960 99223 312.00 NCL A N

99231 15 MINUTES 960 99231 72.00 NCL A N

99232 25 MINUTES 960 99232 120.00 NCL A N

99233 35 MINUTES 960 99233 180.00 NCL A N

99234 IN-PATIENT FOLLOW-UP 960 99234 204.00 NCL A N

99235 IN PATIENT FOLLOWUP 960 99235 264.00 NCL A N

99238 DISCHARGE SERVICES 960 99238 120.00 NCL A N

99239 DISCHARGE SERVICES 960 99239 168.00 NCL A N

99243 40 MINUTES 960 99243 192.00 NCL A N

99244 60 MINUTES 960 99244 282.00 NCL A N

99245 80 MINUTES 960 99245 342.00 NCL A N

99253 55 MINUTES 960 99253 192.00 NCL A N

99254 80 MINUTES 960 99254 264.00 NCL A N

99255 110 MINUTES 960 99255 312.00 NCL A N

99261 10 MINUTES 960 0.00 NCL A N

99262 20 MINUTES 960 0.00 NCL A N

99263 30 MINUTES 960 0.00 NCL A N

99273 CONSULT 960 0.00 NCL A N



99291 ONE HOUR 960 99291 324.00 NCL A N

99292 30 MINUTES 960 99292 162.00 NCL A N

99301 30 MINUTES 960 0.00 NCL A N

99302 40 MINUTES 960 0.00 NCL A N

99303 50 MINUTES 960 0.00 NCL A N

99307 15 MINUTES 960 99307 66.00 NCL A N

99308 25 MINUTES 960 99308 96.00 NCL A N

99310 35 MIN SNF 960 99310 192.00 NCL A N

99311 15 MINUTES 960 0.00 NCL A N

99312 25 MINUTES 960 0.00 NCL A N

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99313 35 MINUTES 960 0.00 NCL A N

99358 PROLONG E/M SVC- 31- HR 961 99358 190.80 NAPRN A N

99359 PROLONG E/M SVC 30 MIN 961 99359 90.00 NAPRN A N

99999997 PROF IOP 20-30 MINS 961 90804 114.00 NHIST I N

99999998 MIGRATION BALANCING ADJUSTMENT 999 0.00 NHIST I N

99999999 MIGRATION DEFAULT 999 0.00 NHIST I N

G0008 ADMIN OF FLU SHOT 960 44.40 NCL A Y

G0283 ELECTRICAL STIMULATION(UNATTEN 420 50.40 NOPRH A Y

G0359 FIRST HOUR INFUSION 960 0.00 NCL A N

G0360 EACH ADDITIONAL HOUR/INFUSION 960 0.00 NCL A N

G8490 INTENT TO DO RA GRP QTY MEASUR 960 0.01 NCL A Y

G8499 ALL RA QTY MEASURE DONE 960 0.01 NCL A Y

G8553 E PRESCRIPTIONS 960 0.01 NCL A Y

G9141 ADMINISTRATION H1N1 960 0.00 NCL A Y

G9142 H1N1 VACCINE 960 0.00 NCL A Y

J0129 ORENCIA 960 J0129 48.00 NCL A N

J0702 CELESTONE 960 J0702 0.00 NCL A N

J1020 DEPOMEDROL 960 J1020 6.00 NCL A N



J1600 GOLD SODIUM THIOMALATE 960 J1600 18.00 NCL A N

J1745 INFLIXIMAB (REMICADE)/UNIT10MG 960 J1745 108.00 NCL A N

J2910 AUROTHIOGULCOSE SOLGANAL 960 J2910 19.20 NCL A N

J3302 TRIMCINOLONE DIACETATE 960 J3302 6.00 NCL A N

J3303 TRIMCINOLONE HEXACETONIDE 960 J3303 6.00 NCL A N

J3488 RECLAST 960 J3488 0.00 NCL A N

J3489 RECLASS 960 J3489 0.00 NCL A N

J3490 UNCLASSIFIED DRUGS 920 J3490 202.16 NCL A N

J3590 ORENCIA NDC 0003-2187-10 960 J3590 0.00 NCL A N

J7050 SALINE 250 ML 960 J7050 24.00 NCL A N

J7320 SYNVISC 960 J7325 300.00 NCL A N

J9250 METHOTREXATE 960 J9250 1.80 NCL A N

J9260 METHOTREXATE 960 J9260 18.00 NCL A N

Q2038 FLU VACCINE 960 Q2038 19.20 NCL A N

Q2051 RECLAST 960 Q2051 0.00 NCL A N

Rev

Code

10/10/19

16:04


Code

Rate Taxable Rate

Exception


Levi Hospital


Page: 63

Mod1 Mod2 Mod3 Mod4

2,170Number of Charge Code Printed:

All Charge CodesCharge Code:

All DepartmentsDepartments:

All UB Revenue CodesUB Revenue Codes:

All Procedure CodesProcedure Codes:

All Service CodesService Codes:

All Inventory Item NumbersInventory Item Numbers:

All Statistics Account NumbersStatistic Account Numbers:

AllTaxable:

AllActive:

ChargeCodeReport Order:

Price As Of : 10/10/19

Documents

10/10/19 Levi Hospital Page: 1 · 2019-10-15 · mod1 mod2 mod3 mod4 ... 0827 use 827 lab i 300 322.20 n n 0867 use 867 lab i 300 225.90 n n 0893 use 893 lab i 300 128.88 n n 10 ed