UIC Medical Center chargemaster database 2010

1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 1
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

00101401 ROOM & BOARD VARIABLE 11/01/94 001 0110 0841
00120302 ROOM & BOARD/SEMI-PRIVATE VARIABLE 03/01/94 001 0120 0205
00120304 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 03/01/94 001 0120 0205
00120307 ROOM & BOARD/CCU VARIABLE 03/01/94 001 0200 0205
00120309 ROOM & BOARD/CCICU VARIABLE 03/01/94 001 0200 0205
00120502 ROOM & BOARD/SEMI-PRIVATE VARIABLE 03/01/94 001 0121 0277
00120504 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 03/01/94 001 0121 0277
00120507 ROOM & BOARD/CCU VARIABLE 03/01/94 001 0200 0277
00120509 ROOM & BOARD/MICU VARIABLE 03/01/94 001 0202 0277
00120802 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0123 0208
00120804 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0123 0208
00120806 ROOM & BOARD/STEP DOWN VARIABLE 07/01/99 001 0206 0208
00120809 ROOM & BOARD/PICU VARIABLE 01/04/93 001 0203 0208
00121002 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0120 0210
00121004 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0120 0210
00121006 ROOM & BOARD/STEP DOWN VARIABLE 06/01/95 001 0206 0210
00121007 ROOM & BOARD/CCU VARIABLE 01/04/93 001 0210 0210
00121008 ROOM & BOARD/CTU VARIABLE 01/04/93 001 0210 0210
00121009 ROOM & BOARD/SICU VARIABLE 01/05/94 001 0201 0210
00121202 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0212
00121204 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0212
00121209 ROOM & BOARD/SICU VARIABLE 01/04/93 001 0201 0277
00122101 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0221
00122102 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0221
00122103 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0221
00122104 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0221
00122201 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0222
00122202 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0222
00122203 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0222
00122204 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0222
00122206 ROOM & BOARD/STEP DOWN VARIABLE 01/04/93 001 0206 0222
00122301 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0223
00122302 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0223
00122303 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0223
00122304 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0223
00122401 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0224
00122402 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0224
00122403 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0224
00122404 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0224
00122501 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0225
00122502 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0225
00122503 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0225
00122504 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0225
00122506 ROOM & BOARD/STEP DOWN VARIABLE 12/31/03 001 0206 0225
00122510 ROOM & BOARD/ICU ORGAN TRANSPL VARIABLE 01/04/93 001 0201 0225
00122701 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0112 0227
00122702 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0122 0227
00122703 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0112 0227
00122704 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0122 0227
00122706 ROOM & BOARD/STEP DOWN VARIABLE 01/04/93 001 0206 0227
00122712 ROOM & BOARD/NURSERY VARIABLE 11/30/93 001 0170 0227
00122801 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0228
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 2
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

00122802 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0228
00122803 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0228
00122804 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0228
00122806 ROOM & BOARD/STEP DOWN VARIABLE 01/04/93 001 0206 0228
00123301 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0233
00123302 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0233
00123303 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0233
00123304 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0233
00123401 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0110 0234
00123402 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0128 0234
00123403 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0110 0234
00123404 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0120 0234
00123501 ROOM & BOARD/PRIVATE VARIABLE 09/01/03 001 0111 0295
00123502 ROOM & BOARD/SEMI-PRIVATE VARIABLE 09/01/03 001 0121 0295
00123503 ROOM & BOARD/PVT MED NECESSITY VARIABLE 09/01/03 001 0111 0295
00123504 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 09/01/03 001 0121 0295
00123601 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0236
00123602 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0236
00123603 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0236
00123604 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0236
00123701 ROOM & BOARD/PRIVATE VARIABLE 04/15/08 001 0111 0233
00123702 ROOM & BOARD/SEMI-PRIVATE VARIABLE 04/15/08 001 0121 0233
00123703 ROOM & BOARD/PVT MED NECESSITY VARIABLE 04/15/08 001 0111 0233
00123704 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 04/15/08 001 0121 0233
00124101 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0241
00124102 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0241
00124103 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0241
00124104 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0241
00124106 ROOM & BOARD/STEP DOWN VARIABLE 01/04/93 001 0206 0241
00124114 ROOM & BOARD/PRIVATE VIP VARIABLE 01/04/93 001 0141 0241
00124115 ROOM & BOARD/PVT VIP W/LOUNGE VARIABLE 01/04/93 001 0141 0241
00124201 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0242
00124202 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0242
00124203 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0242
00124204 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0242
00124301 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0243
00124302 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0243
00124303 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0243
00124304 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0243
00124306 ROOM & BOARD/STEPDOWN VARIABLE 11/30/03 001 0206 0243
00124401 ROOM & BOARD/PRIVATE VARIABLE 03/01/97 001 0111 0244
00124402 ROOM & BOARD/SEMI-PRIVATE VARIABLE 03/01/97 001 0121 0244
00124403 ROOM & BOARD/PVT MED NECESSITY VARIABLE 03/01/97 001 0111 0244
00124404 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 03/01/97 001 0121 0244
00124406 ROOM & BOARD/STEPDOWN VARIABLE 03/01/97 001 0206 0244
00125701 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0111 0257
00125702 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0121 0257
00125703 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0111 0257
00125704 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0121 0257
00126501 ROOM & BOARD/PRIVATE VARIABLE 09/01/03 001 0111 0236
00126502 ROOM & BOARD/SEMI-PRIVATE VARIABLE 09/01/03 001 0121 0236
00126503 ROOM & BOARD/PVT MED NECESSITY VARIABLE 09/01/03 001 0111 0236
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 3
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

00126504 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 09/01/03 001 0121 0236
00127001 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0113 0270
00127002 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0123 0270
00127003 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0113 0270
00127004 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0123 0270
00127006 ROOM & BOARD/STEP DOWN VARIABLE 07/01/93 001 0206 0270
00127012 ROOM & BOARD/NURSERY VARIABLE 01/01/00 001 0170 0270
00127015 RM & BOARD/NNICU-LEVEL 3 VARIABLE 01/01/07 001 0174 0270
00127601 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0110 0276
00127602 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0120 0276
00127603 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0114 0276
00127604 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0124 0276
00127702 ROOM AND BOARD/SEMI-PRIVATE VARIABLE 06/30/08 001 0120 0297
00129106 ROOM & BOARD/STEP DOWN VARIABLE 01/04/93 001 0171 0291
00129111 ROOM & BOARD/NNICU VARIABLE 01/04/93 001 0174 0291
00129112 ROOM & BOARD/NURSERY VARIABLE 01/04/93 001 0170 0291
00129201 ROOM & BOARD/PRIVATE VARIABLE 01/04/93 001 0112 0292
00129202 ROOM & BOARD/SEMI-PRIVATE VARIABLE 01/04/93 001 0122 0292
00129203 ROOM & BOARD/PVT MED NECESSITY VARIABLE 01/04/93 001 0112 0292
00129204 ROOM & BOARD/PVT ONLY BD AVAIL VARIABLE 01/04/93 001 0122 0292
00129206 ROOM & BOARD/STEP DOWN VARIABLE 01/04/93 001 0206 0292
00129212 ROOM & BOARD/NURSERY VARIABLE 01/04/93 001 0170 0292
00129213 ROOM & BOARD/NNICU-LEVEL 2 VARIABLE 06/01/07 001 0172 0291
00129214 ROOM AND BOARD/NNICU-LEVEL 2+ VARIABLE 06/01/07 001 0173 0291
00129215 ROOM AND BOARD/NNICU-LEVEL 3 VARIABLE 06/01/07 001 0174 0291
00184105 ROOM & BOARD/S-PVT 3/MORE BEDS VARIABLE 11/01/94 001 0132 0841
00184106 ROOM & BOARD/STEP DOWN VARIABLE 11/01/94 001 0206 0841
00184109 ROOM & BOARD/ICU VARIABLE 11/01/94 001 0200 0841
00184112 ROOM & BOARD/NURSERY VARIABLE 11/01/94 001 0170 0841
00184113 ROOM & BOARD/BIRTHING ROOM VARIABLE 11/01/94 001 0724 0841
30010998 CHARGE TRANSFER/RELOCATION-RM VARIABLE 07/01/85 001 0324
03780689 AMBULANCE SERVICE EXTERNAL 07/01/84 004 0540 4401
03780699 AIR AMBULANCE SERVICE EXTERNAL 06/01/88 004 0540 4401
44299966 ELOXATIN 50MG EXTERNAL 08/01/00 004 0250 5011
01204500 CIMT STUDY SUPPLY ITEMS 91.00 06/30/10 005 0921 2725
01701000 MDI SPACER 23.00 06/30/10 005 0270 5301
01701003 HOOD PEDS 60.00 06/30/10 005 0270 5301
01701006 VEST ADULT 91.00 06/30/10 005 0270 5301
01701009 VEST PEDS 91.00 06/30/10 005 0270 5301
01701012 PEAK FLOWMETER 68.00 06/30/10 005 0270 5301
01701015 SUCTION TUBE REPLACEMENT PEDS 60.00 06/30/10 005 0270 5301
02230001 MANOMETRIC PRESSURE SENSOR 983.00 06/30/10 005 0270 2825
02230002 URINARY SUPPLIES 87.00 06/30/10 005 0270 2825
02230003 ELECTRODIAGNOSTIC GLOVE 112.00 06/30/10 005 0270 2825
02230004 MONTHLY RENTAL ANAL STIMULATOR 261.00 06/30/10 E1399 E0745 E1399 005 0290 2825
02230006 VAGINAL SENSOR 649.00 06/30/10 005 0270 2825
02230007 RECTAL SENSOR 649.00 06/30/10 005 0270 2825
02230095 FECAL SUPPLIES 22.00 06/30/10 005 0270 2825
02230099 MISCELLANEOUS MEDICAL SUPPLIES EXTERNAL 11/01/94 005 0270 2825
02230102 PIE PACK 94.00 06/30/10 005 0270 2825
02230105 VAGINAL WEIGHTS 156.00 06/30/10 005 0270 2825
02230108 PELVIC FLOOR EDUCATOR 48.00 06/30/10 005 0270 2825
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 4
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

02230111 THERABAND 8.00 06/30/10 005 0270 2825
02400267 OT EVALUATION-PEDS 189.00 06/30/10 97003GO 97003GO 97003GO 005 0430 5901
02400269 OT SFCARE/HME MGMT TRN-PED-15M 95.00 06/30/10 97535GO 97535GO 97535GO 005 0430 5901
02400960 SOCK AID 28.00 06/30/10 005 0270 5901
02400973 THERAPUTTY 26.00 06/30/10 005 0270 5901
02400989 DYCEM 10.00 06/30/10 005 0270 5901
02401012 COBAN 7.00 06/30/10 005 0270 5901
02401026 HAND EXERCISER 22.00 06/30/10 005 0270 5901
02401027 EXERSTIX 56.00 06/30/10 005 0270 5901
02401028 HAND HELPER 6.00 06/30/10 005 0270 5901
02401037 LAP BOARD 69.00 06/30/10 005 0270 5901
02401042 CYLINDRICAL FOAM 13.00 06/30/10 005 0270 5901
02401077 ROCKER KNIFE SOLID 33.00 06/30/10 005 0270 5901
02401089 SHOE HORN 19.00 06/30/10 005 0270 5901
02401096 DRESSING STICK 13.00 06/30/10 005 0270 5901
02401100 REACHER 43.00 06/30/10 005 0270 5901
02401102 THERABAND 12.00 06/30/10 005 0270 5901
02401116 HEMI-SLING 84.00 06/30/10 005 0270 5901
02401117 WASH MITT 17.00 06/30/10 005 0270 5901
02401180 PRE-FABRICATED RESTING SPLINT 66.00 06/30/10 005 0270 5901
02401196 WHEELCHAIR GLOVES 53.00 06/30/10 005 0270 5901
02401204 JOINT JACK 74.00 06/30/10 005 0270 5901
02401220 BUTTON HOOK 20.00 06/30/10 005 0270 5901
02401348 SLIDING BOARD 98.00 06/30/10 005 0270 5901
02401388 UNIVERSAL CUFF 17.00 06/30/10 005 0270 5901
02401413 LEG LIFTER 22.00 06/30/10 005 0270 5901
02401416 INSPECTION MIRROR 49.00 06/30/10 005 0270 5901
02401418 SPRING FINGER SPLINT 26.00 06/30/10 005 0270 5901
02401435 SUPPLY CHARGE 10.00 06/30/10 005 0270 5901
02401436 LONG HAND SPONGE 10.00 06/30/10 005 0270 5901
02447522 PEDIATRIC SPLINT 28.00 06/30/10 005 0270 5901
02447530 LOWER EXTREMITY SPLINT 136.00 06/30/10 005 0270 5901
02447548 ELBOW SPLINT 97.00 06/30/10 005 0270 5901
02447563 HAND/WRIST SPLINT 85.00 06/30/10 005 0270 5901
02447571 HAND SPLINT 38.00 06/30/10 005 0270 5901
02447589 FINGER SPLINT 41.00 06/30/10 005 0270 5901
02447593 O-T SUPPLIES/EQUIPMENT EXTERNAL 11/01/94 005 0270 5901
02480159 OT AQUATIC THERAPY PER 15M-WS 118.00 06/30/10 97113G0 97113G0 97113GO 93.39 005 0430 5901
02480161 OT GROUP THERA PROC PER 15M-WS 90.00 06/30/10 97150GO 97150GO 97150GO 93.19 005 0420 5901
03130401 ADAPTOR/EXT PACELEAD/NEUROSTIM EXTERNAL 01/01/03 005 0278 0801
03130402 ANOR/SCWFOROPBNE/BNESOFTIS/BNE EXTERNAL 01/01/03 005 0278 0801
03130403 BRACHYTHERAPY NEEDLE EXTERNAL 01/01/03 005 0270 0801
03130404 BRACHYTHERAPY SEED GOLD198 EXTERNAL 01/01/03 005 0270 0801
03130405 BRACHYTXSEED-DOSERATEIRI192 EXTERNAL 01/01/03 005 0270 0801
03130406 BRACHYTXY SEED, IODINE 125 EXTERNAL 01/01/03 005 0270 0801
03130407 BRACHYTXSEDNON-DOSERATEIRID192 EXTERNAL 01/01/03 005 0270 0801
03130408 BRACYTHERAPY SEED PALADUM 103 EXTERNAL 01/01/03 005 0270 0801
03130409 BRACYTHERAPY SEED, YTTRIUM 90 EXTERNAL 01/01/03 005 0270 0801
03130410 CARD-DEFIBRILLATOR, 2 CHAMBER EXTERNAL 01/01/03 C1721 005 0275 0801
03130411 CARD-DEFIB, VS 1 OR 2 CHAMBER EXTERNAL 01/01/03 C1882 005 0275 0801
03130412 CARD-DEFIB, 1 CHAMBER EXTERNAL 01/01/03 C1722 005 0275 0801
03130413 CATHETER,ABLATION,NON-CARDIAV EXTERNAL 01/01/03 005 0272 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 5
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03130414 CATHETER BAL DILATATION NONVAS EXTERNAL 01/01/03 005 0272 0801
03130415 CATH BAL TISSUE DISSEC NONVASC EXTERNAL 01/01/03 005 0272 0801
03130416 CATH BRACHYTHERAPY SEED ADM EXTERNAL 01/01/03 005 0272 0801
03130417 CATHETER, DRAINAGE, BILIARY EXTERNAL 01/01/03 C1729 C1729 C1729 005 0272 0801
03130418 CATHELECPHYSIODIAGVS3DMAP<19E1 EXTERNAL 01/01/03 C1730 005 0272 0801
03130419 CATHELECPYSIODIAGVS3DMAP>20EL EXTERNAL 01/01/03 C1731 005 0272 0801
03130420 CATHELECPYSIODX/ABL3DORVECMAP EXTERNAL 01/01/03 C1732 005 0272 0801
03130421 CATHELEDX/AB13DORVECMAPVSTEMCT EXTERNAL 01/01/03 005 0272 0801
03130422 CATHELECDX/ABL3DORVECTMAPTEMCT EXTERNAL 01/01/03 005 0272 0801
03130423 CATHETER, GUIDING EXTERNAL 01/01/03 C1887 005 0272 0801
03130424 CATHETER HEMODIALYSIS L/T EXTERNAL 01/01/03 C1750 005 0272 0801
03130425 CATHETER HEMODIALYSIS S/T EXTERNAL 01/01/03 C1752 005 0272 0801
03130426 CATHINFUSINSETPERIPHERCENT/MID EXTERNAL 01/01/03 C1751 005 0278 0801
03130427 CATH INTRACARDIAC ECHOCARDIOGR EXTERNAL 01/01/03 005 0272 0801
03130429 CATHETER, INTRASPINAL EXTERNAL 01/01/03 005 0272 0801
03130430 CATH INTRAVASCULAR ULTRA EXTERNAL 01/01/03 005 0272 0801
03130431 CATHETER, OCCLUSION EXTERNAL 01/01/03 C2628 005 0272 0801
03130432 CATH PACING TRANSESOPHAGEAL EXTERNAL 01/01/03 005 0272 0801
03130433 CATH SUPRAPUBIC/CYSTOSCOPIC EXTERNAL 01/01/03 005 0272 0801
03130434 CATH THROMBECTO/EMBOLECTO EXTERNAL 01/01/03 005 0272 0801
03130435 CATH TRANSLUMINAL ANGIO LASER EXTERNAL 01/01/03 C1885 005 0272 0801
03130436 CATHTRANSLUMINALANGIONLASER EXTERNAL 01/01/03 C1725 005 0272 0801
03130437 CATHTRANSLUMINALATHERECTDIRECT EXTERNAL 01/01/03 005 0270 0801
03130438 CATHTRANSLUMATHERECTOMYROTATE EXTERNAL 01/01/03 C1724 005 0272 0801
03130439 CATHETER, URETERAL EXTERNAL 01/01/03 005 0272 0801
03130440 CLOSURE DEVICE, VASC. EXTERNAL 01/01/03 005 0278 0801
03130441 COCHLEAR IMPLANT SYSTEM EXTERNAL 01/01/03 L8614 L8614 L8614 005 0278 0801
03130442 CONNECTIVE TISSUE, HUMAN EXTERNAL 01/01/03 005 0278 0801
03130443 CONNECTIVE TISSUE, NON HUMAN EXTERNAL 01/01/03 005 0278 0801
03130444 DIALY ACCESS SYSTEM (IMPLANT) EXTERNAL 01/01/03 C1751 C1751 C1751 005 0278 0801
03130445 EVENT RECORDER, CARDIAC EXTERNAL 01/01/03 005 0270 0801
03130446 GENERATOR NEUROSTIM (IMPLANT) EXTERNAL 01/01/03 L8686 C1767 C1767 005 0278 0801
03130447 GRAFT VASCULAR EXTERNAL 01/01/03 005 0278 0801
03130448 GUIDE WIRE EXTERNAL 01/01/03 005 0272 0801
03130449 INFUS PUMP NON-PROGRAM PERM EXTERNAL 01/01/03 C1891 005 0278 0801
03130450 INFUS PUMP NON-PROGRAM TEMP EXTERNAL 01/01/03 C2626 005 0278 0801
03130451 INFUSION PUMP PROGRAMMABLE EXTERNAL 01/01/03 C1772 005 0278 0801
03130452 INTR/SHEHGUINTRAELEFIXCVDVSPEL EXTERNAL 01/01/03 005 0272 0801
03130453 INTRO/SHEHGUINTRAELEFIXCVDPEL EXTERNAL 01/01/03 005 0272 0801
03130454 INTRO/SHVSGUINTRACARELCPHONLAS EXTERNAL 01/01/03 005 0272 0801
03130455 INTR/SHVSGUINTRACARELCTROPHOLA EXTERNAL 01/01/03 005 0272 0801
03130456 JOINT DEVICE (IMPLANTABLE) EXTERNAL 01/01/03 005 0278 0801
03130457 LDCARDIOVERDEFIBENDOCARD2XCOIL EXTERNAL 01/01/03 C1895 005 0275 0801
03130458 LDCARDIOVERDEFIBENDOCARD1XCOIL EXTERNAL 01/01/03 C1777 005 0275 0801
03130459 LDCARDDEFIBENDOCARDVS1XOR2XCOI EXTERNAL 01/01/03 C1896 005 0275 0801
03130460 LEAD NEUROSTIMULATOR IMPLANT EXTERNAL 01/01/03 C1778 C1778 C1778 005 0278 0801
03130461 LD NEUROSTIM TEST KIT (IMPLANT EXTERNAL 01/01/03 C1897 L8686 005 0278 0801
03130462 LDPACEMAKRVSTRANSVENOUSVDD1XPA EXTERNAL 01/01/03 C1898 005 0275 0801
03130463 LD PACEMAKER TRANSVENOUSVDD1XP EXTERNAL 01/01/03 C1779 005 0275 0801
03130464 LD PACEMAKER/CARDIOVERT DEFIB. EXTERNAL 01/01/03 C1899 005 0275 0801
03130465 LENS INTRAOCULAR (NEW TECH) EXTERNAL 01/01/03 005 0276 0801
03130466 MATERIAL FOR VOCAL CORD MED EXTERNAL 01/01/03 005 0278 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 6
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03130467 MESH (IMPLANTABLE) EXTERNAL 01/01/03 C1781 C1781 C1781 005 0278 0801
03130468 MORCELLATOR EXTERNAL 01/01/03 005 0272 0801
03130469 OCULAR DEVICE INTRAOPT DETACH EXTERNAL 01/01/03 005 0278 0801
03130470 PACEMAKER2XCHAMBERNRATERESPON EXTERNAL 01/01/03 005 0275 0801
03130471 PACEMAKER2XCHAMBER RATE RESPON EXTERNAL 01/01/03 005 0275 0801
03130472 PACEMAKER VS 1X OR 2X CHAMBER EXTERNAL 01/01/03 005 0275 0801
03130473 PCEMAKER1XCHAMERNONRATERESPONS EXTERNAL 01/01/03 C2620 005 0275 0801
03130474 PACEMAKER1XCHAMBERRATERESPONSE EXTERNAL 01/01/03 C1786 005 0275 0801
03130475 PATIENT PROGRAM NEUROSTIM EXTERNAL 01/01/03 005 0278 0801
03130476 PORT, INDWELLING (IMPLANT) EXTERNAL 01/01/03 C1788 005 0278 0801
03130477 PROBE, CRYOABLATION EXTERNAL 01/01/03 C2618 C2618 C2618 005 0272 0801
03130478 PROSTHESIS, BREAST EXTERNAL 01/01/03 C1789 C1789 C1789 005 0278 0801
03130479 PROSTHESIS PENILE INFLATABLE EXTERNAL 01/01/03 C1813 005 0278 0801
03130480 PROSTHESIS PENILE NON INFLAT EXTERNAL 01/01/03 C2622 005 0278 0801
03130481 PROSTH URINARY SPHINCTER (IMPL EXTERNAL 01/01/03 005 0278 0801
03130482 RECE AND/OR TRANSMITTER NEUROS EXTERNAL 01/01/03 005 0278 0801
03130483 REPRDEVICEURINEINCONTWSLINGGRA EXTERNAL 01/01/03 C1771 C1771 C1771 005 0278 0801
03130484 REPRDEVIEURINEINCONTW/OSLINGGR EXTERNAL 01/01/03 005 0272 0801
03130485 RETRIEVAL DEVICE EXTERNAL 01/01/03 005 0272 0801
03130486 SEALANT, PULMONARY, LIQUID EXTERNAL 01/01/03 005 0272 0801
03130487 SEPTALDEFECT IMPT SYSINTRACARD EXTERNAL 01/01/03 005 0278 0801
03130488 STNT COAT/COVER W DLY SYS EXTERNAL 04/01/05 C1874 C1874 005 0278 0801
03130489 STNT COAT/COVER W/O DLY SYS EXTERNAL 01/01/03 C1875 005 0278 0801
03130490 STNTNONCORONARY TEMP W DELYSYS EXTERNAL 01/01/03 C2625 005 0278 0801
03130491 STNTNONCORONARY TEMPW/ODELYSYS EXTERNAL 01/01/03 C2617 005 0278 0801
03130492 STNTNONCOAT/NONCOVER W DELV SY EXTERNAL 01/01/03 C1876 005 0278 0801
03130493 STNTNONCOAT/NONCOVERW/ODELVSYS EXTERNAL 01/01/03 C1877 005 0278 0801
03130494 TISSUE MARKER (IMPLANTABLE) EXTERNAL 01/01/03 005 0278 0801
03130495 VENA CAVA FILTER EXTERNAL 01/01/03 005 0278 0801
03130500 ALLODERM EXTERNAL 08/01/05 005 0270 0801
03130503 ANGIOPLASTY RING EXTERNAL 01/01/06 005 0270 0801
03130506 BALLOON, DILITATION EXTERNAL 01/01/06 005 0270 0801
03130509 BONE CEMENT-SPACER OR PUTTY EXTERNAL 01/01/06 005 0270 0801
03130512 CANNULA, VENOUS EXTERNAL 01/01/06 005 0270 0801
03130515 CASTING EXTERNAL 01/01/06 005 0270 0801
03130518 CATHETER, DILITATION EXTERNAL 01/01/06 C1725 C1725 C1725 005 0272 0801
03130520 CATHETER, ELANA EXTERNAL 02/01/08 005 0270 0801
03130521 CATHETER, GLIDE EXTERNAL 01/01/06 005 0270 0801
03130524 CATHETER, PERITONEAL EXTERNAL 01/01/06 005 0270 0801
03130527 CATHETER, VENTRICULAR EXTERNAL 01/01/06 005 0270 0801
03130530 CLIP, ANEURYISM EXTERNAL 01/01/06 005 0278 0801
03130533 CONNECTIVE TISSUE, AMNIOTIC EXTERNAL 01/01/06 005 0270 0801
03130535 DUAL CHAMBER PACEMAKER GENRTR EXTERNAL 01/01/07 C1785 C1785 C1785 005 0275 0801
03130536 DURAFORM EXTERNAL 01/01/06 005 0270 0801
03130539 DURAGEN INJECTION, UP TO 20ML EXTERNAL 01/01/06 J1390 J1390 J1390 005 0636 0801
03130542 ELECTRODE, LINEAR EXTERNAL 01/01/06 005 0270 0801
03130545 ENDOMECHANICAL (STAPLER) EXTERNAL 01/01/06 005 0270 0801
03130548 ENDOMECHANICAL (TROCAR) EXTERNAL 01/01/06 005 0270 0801
03130549 E-PACK SUTURE PACK EXTERNAL 11/01/06 005 0270 0801
03130551 GASTROTOMY SET EXTERNAL 01/01/06 005 0270 0801
03130554 GENERATOR, GENESIS KIT EXTERNAL 01/01/06 L8686 C1767 C1767 005 0278 0801
03130557 GENERATOR, NEUROPULSE EXTERNAL 01/01/06 L8686 C1767 C1767 005 0278 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 7
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03130559 NEUROSTMPULSE GEN,RCHGBLE W/EX EXTERNAL 01/01/10 L8687 L8687 L8687 005 0270 0801
03130560 GLIDEWIRE EXTERNAL 01/01/06 005 0270 0801
03130563 IMPLANT, BAHA EXTERNAL 01/01/06 005 0278 0801
03130566 IMPLANT, CHIN EXTERNAL 01/01/06 005 0270 0801
03130569 IMPLANT, CRANIAL EXTERNAL 01/01/06 005 0278 0801
03130572 IMPLANT, CRANIOFACIAL EXTERNAL 01/01/06 005 0270 0801
03130573 LEAD,ENTERRA THERAPY EXTERNAL 12/01/07 005 0278 0801
03130574 IMPLANT, ENTERRA THERAPY EXTERNAL 03/01/06 005 0278 0801
03130575 IMPLANT, ESSURE EXTERNAL 01/01/06 99070 005 0278 0801
03130578 IMPLANT, FRACTURE CARE EXTERNAL 01/01/06 005 0278 0801
03130581 IMPLANT, GELSOFT EXTERNAL 01/01/06 005 0278 0801
03130584 IMPLANT, GLAUCOMA EXTERNAL 01/01/06 005 0270 0801
03130587 IMPL, INTEMSH (PENILE IMPLANT) EXTERNAL 01/01/06 C1813 C1813 C1813 005 0278 0801
03130590 IMPLANT, ORBITAL EXTERNAL 01/01/06 005 0270 0801
03130593 IMPLANT, PERTUS EXTERNAL 01/01/06 005 0270 0801
03130596 IMPLANT, PRIMARY HIP EXTERNAL 01/01/06 005 0278 0801
03130599 IMPLANT, PRIMARY KNEE EXTERNAL 01/01/06 005 0278 0801
03130602 IMPLANT, REVISION HIP EXTERNAL 01/01/06 005 0278 0801
03130605 IMPLANT, REVISION EXTERNAL 01/01/06 005 0270 0801
03130611 IMPLANT, SHOULDER EXTERNAL 01/01/06 005 0278 0801
03130614 IMPLANT, SPINAL EXTERNAL 01/01/06 005 0278 0801
03130617 IMPLANT, SURGISIS EXTERNAL 01/01/06 005 0278 0801
03130620 IMPLANT, THYROPLASTY DEVICE EXTERNAL 01/01/06 005 0270 0801
03130623 IMPLANT, TISSUE EXPANDER EXTERNAL 01/01/06 005 0278 0801
03130626 IMPLANT, VOICE PROSTHESIS EXTERNAL 01/01/06 005 0270 0801
03130629 IMPLANT, ZYGOMA EXTERNAL 01/01/06 005 0270 0801
03130632 INTERCEED EXTERNAL 01/01/06 005 0270 0801
03130633 COLLGN IMPL-URINARY 2.5ML SYR EXTERNAL 01/01/06 L8603 L8603 L8603 005 0278 0801
03130634 SYNTH IMPL,URINRY TRCT 1ML SYR EXTERNAL 06/01/06 L8606 L8606 L8606 005 0270 0801
03130635 INTRODUCER SET EXTERNAL 01/01/06 005 0270 0801
03130638 LAP BAND EXTERNAL 01/01/06 005 0278 0801
03130641 LAPRSCPC CHOLARYOGRAM SET EXTERNAL 01/01/06 005 0270 0801
03130644 MESH, INTERMESH EXTERNAL 01/01/06 005 0270 0801
03130647 NEEDLE, ACCESS PORT EXTERNAL 01/01/06 005 0270 0801
03130650 PATCH, HUMAN PERICARDIUM EXTERNAL 01/01/06 005 0270 0801
03130653 PROBE, MICROFLOW EXTERNAL 01/01/06 005 0270 0801
03130656 PUMP, BMP INFUSION EXTERNAL 01/01/06 C1772 C1772 C1772 005 0278 0801
03130659 PUMP, PAIN EXTERNAL 01/01/06 005 0270 0801
03130662 PUMP, SYNCHROMED EXTERNAL 01/01/06 C1772 C1772 E0783 005 0278 0801
03130663 RITA -RADIO FREQ NEEDLE ABLAT EXTERNAL 06/01/06 005 0270 0801
03130665 ROBOTIC INSTRUMENTATION FEE EXTERNAL 01/01/06 005 0270 0801
03130668 ROBOTIC SUPPLIES EXTERNAL 01/01/06 005 0270 0801
03130671 SAPHENOUS VEIN EXTERNAL 01/01/06 005 0270 0801
03130674 SEAMGUARD EXTERNAL 01/01/06 005 0270 0801
03130677 SEPRAFILM EXTERNAL 01/01/06 005 0270 0801
03130680 SLING, ARM EXTERNAL 01/01/06 005 0270 0801
03130683 SLING, INTERVAGINAL EXTERNAL 01/01/06 005 0270 0801
03130686 SLUSH SYSTEM USAGE FEE EXTERNAL 01/01/06 005 0270 0801
03130689 STENT, BILIARY (1) EXTERNAL 01/01/06 005 0270 0801
03130691 STENT, BILIARY 2 EXTERNAL 01/01/06 C1876 C1876 C1876 005 0278 0801
03130694 STENT, BILIARY 3 EXTERNAL 01/01/06 005 0270 0801
03130697 STENT, BILIARY 4 EXTERNAL 01/01/06 005 0270 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 8
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03130700 STENT, URETERAL EXTERNAL 01/01/06 005 0270 0801
03130703 STIMULATOR, BONE GROWTH EXTERNAL 01/01/06 005 0270 0801
03130706 STIMULATOR, MUSCLE EXTERNAL 01/01/06 005 0270 0801
03130709 SURGICAL PACK, SILICONE OIL EXTERNAL 01/01/06 005 0270 0801
03130712 SURGICAL PACK, VITRECTOMY EXTERNAL 01/01/06 005 0270 0801
03130715 TUBES, VENT EXTERNAL 11/01/05 005 0270 0801
03130718 TVT SYSTEM EXTERNAL 01/01/06 C1771 C1771 C1771 005 0278 0801
03130721 VALVE REPLCMNT, AORTIC 1 EXTERNAL 01/01/06 005 0270 0801
03130724 VALVE REPLCMNT, AORTIC 2 EXTERNAL 01/01/06 005 0270 0801
03130727 VALVE REPLCMNT, AORTIC 3 EXTERNAL 01/01/06 005 0270 0801
03130730 VALVE REPLCMNT, AORTIC 4 EXTERNAL 01/01/06 005 0270 0801
03130733 VALVE REPLCMNT, MITRAL 1 EXTERNAL 01/01/06 005 0270 0801
03130736 VALVE REPLCMNT, MITRAL 2 EXTERNAL 01/01/06 005 0270 0801
03130739 VALVE REPLCMNT, MITRAL 3 EXTERNAL 01/01/06 005 0270 0801
03130742 VALVE REPLCMNT,MITRAL 4 EXTERNAL 01/01/06 005 0270 0801
03130745 VALVE, DELTA LEVEL EXTERNAL 01/01/06 005 0270 0801
03130748 VALVE, GLAUCOMA EXTERNAL 01/01/06 005 0270 0801
03130751 VALVE, PERICARDIAL EXTERNAL 01/01/06 005 0270 0801
03130754 VALVE, TISSUE HEART EXTERNAL 01/01/06 005 0270 0801
03130757 VERTESTACK EXTERNAL 01/01/06 005 0270 0801
03130760 VITOSS, (BONE FILLER) EXTERNAL 01/01/06 005 0270 0801
03130763 SCD SLEEVES EXTERNAL 08/01/05 005 0270 0801
03130766 SINUPLASTY BALLOON & CATHETER EXTERNAL 05/01/06 C1726 C1726 C1726 005 0272 0801
03130769 INTERGRATED KERATOPROSTHESIS 17500.00 06/30/10 C1818 C1818 C1818 005 0278 0801
03130772 ARTIFICIAL CORNEA EXTERNAL 01/01/07 L8609 L8609 L8609 005 0278 0801
03130775 IRIS SUPPORTED IOL EXTERNAL 08/01/07 V2631 V2631 005 0276 0801
03130778 HARMONIC SCALPEL EXTERNAL 10/01/07 005 0270 0801
03130781 IMPLANT, AUDITORY BRAINSTEM EXTERNAL 08/01/08 L8614 L8614 L8614 005 0278 0801
03132040 IMPLNTABLE NEUROSTMLTR,RECHARG EXTERNAL 04/01/07 L8685 C1820 C1820 005 0278 0801
03135000 PERFLUORON /2ML 1400.00 07/15/10 005 0250 0801
03135003 PERFLUORON /5 OR 7ML VIAL 1400.00 07/15/11 005 0250 0801
03201001 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 005 0300 0806
03201011 ECG 12 LEADS 207.00 06/30/10 93005 93005 93005 005 0730 0806
03356871 STIMUPLEX NEEDLE 43.00 06/30/10 005 0270 0803
03370050 ECHOCARDIO DURING STRESS TEST 1317.00 06/30/10 93350 93350 93350 005 0480 0803
03386181 SPINAL KIT 289.00 06/30/10 005 0270 0803
03386207 BRACHIAL PLEXUS KIT 406.00 06/30/10 005 0270 0803
03386215 EPIDURAL KIT (B BRAUN) 260.00 06/30/10 005 0270 0803
03386348 RADIAL ARTERY CATH SET 152.00 06/30/10 005 0270 0803
03386355 CVP SINGLE KIT 203.00 06/30/10 005 0270 0803
03386357 CORDIS 194.00 06/30/10 005 0270 0803
03386358 MULTI LUMEN CVC KIT 248.00 06/30/10 005 0270 0803
03386359 RAPID INFUSION CATHETER(RIC) 42.00 06/30/10 005 0270 0803
03386371 PULMONARY ARTERY CATH (PLAIN) 614.00 06/30/10 005 0270 0803
03386389 SWAN-GANZ CATH 1786.00 06/30/10 005 0270 0803
03386472 LMA SUPREME 101.00 06/30/10 005 0270 0803
03386488 REINFORCED TRACHEAL TUBE 218.00 06/30/10 005 0270 0803
03386504 ORAL/NASAL RAE TUBE 47.00 06/30/10 005 0270 0803
03386512 DOUBLE LUMEN ENDOTRACH TUBE 445.00 06/30/10 005 0270 0803
03386513 AMBU BAG 43.00 06/30/10 005 0270 0803
03386535 LASER-SHIELD ENDOTRACHEAL TUBE 589.00 06/30/10 005 0270 0803
03386538 DOUBLE LUM SHEATH INTROD KIT 201.00 06/30/10 005 0272 0803
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 9
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03386541 UNIVENT ENDOTRACHEAL TUBE 423.00 06/30/10 005 0270 0803
03386544 STIMUCATH CONTINUOUS NER BLOCK 333.00 06/30/10 005 0270 0803
03386547 ENDOBRONCHIAL BLOCKER SET 441.00 06/30/10 005 0270 0803
03386553 FLOTRACH 282.00 06/30/10 005 0636 0803
03386556 BIS SENSOR 70.00 06/30/10 005 0270 0803
03386559 OB INFUSION PUMP 15.00 06/30/10 005 0270 0803
03386562 MLT TRACHEAL TUBE 26.00 06/30/10 005 0270 0803
03386568 QUAD LUMEN CVC CATH 311.00 06/30/10 A4301 A4301 A4301 005 0272 0803
03386574 HOT LINE TUBING 41.00 06/30/10 005 0270 0803
03386577 LEVEL 1 NORMOTHERMIC SET 126.00 06/30/10 005 0270 0803
03386580 BELMONT INFUSER DISPOSABLE 805.00 06/30/10 005 0270 0803
03386583 LMA DISP 15.00 06/30/10 005 0270 0803
03386586 LMA FLEX DISP 30.00 06/30/10 005 0270 0803
03386589 LMA FASTRACH 216.00 06/30/10 005 0270 0803
03386592 LMA UNIQUE 40.00 06/30/10 005 0270 0803
03386595 PRONE VIEW CUSHION INSERT 76.00 06/30/10 005 0270 0803
03386598 GERTIE MARX NEEDLE 24G X3.5" 98.00 06/30/10 005 0270 0803
03386605 STIMULATION NEEDLE 182.00 06/30/10 005 0270 0803
03386610 EPIDURAL CATH KIT(ARROW) 150.00 06/30/10 005 0270 0803
03386615 CRICOTHYROTOMY CATHETER SET 393.00 06/30/10 005 0270 0803
03386620 LIVER SETUP 3077.00 06/30/10 005 0270 0803
03386623 IO NEEDLE SET 348.00 06/30/10 005 0270 0803
03386626 GLIDERITE RIGID STYLETS 112.00 06/01/10 005 0270 0803
03555548 IV PUMP-PER LINE/PUMP CHARGE 144.00 06/30/10 005 0270 4520
03555550 BAXTER PUMP (MICRO) 108.00 06/30/10 005 0270 4520
03555555 OMNI-FLOW PUMP 281.00 06/30/10 005 0251 4520
03555558 BAXTER 6200 PUMP 137.00 06/30/10 005 0258 4520
03555617 IV SET/2NDARY FOR OMNIFLW PUMP 39.00 06/30/10 005 0270 4520
03555760 ABBOTT SET/FILTER 70.00 06/30/10 005 0270 4520
03555761 ABBOTT SET 65.00 06/30/10 005 0270 4520
03708201 REPLACE. PADS CPM 115.00 06/30/10 29799 29799 29799 93.59 93.59 005 0360 4205
03708219 CPM EXERCISER 283.00 06/30/10 005 0270 4205
03725585 BALANCED SUSPENSION 532.00 06/30/10 005 0270 4205
03725668 HEAD HALTER 89.00 06/30/10 005 0270 4205
03725676 OVERHEAD FRAME 149.00 06/30/10 005 0270 4205
03725692 SPLINT THOMAS-LEG 228.00 06/30/10 29505 29505 29505 93.54 93.54 005 0360 4205
03725700 SPLINT THOMAS-LEG 228.00 06/30/10 29505 29505 29505 93.54 93.54 005 0360 4205
03750567 BUCK'S TRACTION 244.00 06/30/10 005 0270 4205
03750575 FOOTBOARD, FOAM 130.00 06/30/10 005 0270 4205
03750583 FOOTBOARD 103.00 06/30/10 005 0270 4205
03750591 UNDERMATRESS CHAMP 311.00 06/30/10 005 0270 4205
03750609 OVERHEAD FRAME W T 212.00 06/30/10 005 0270 4205
03750617 SHOCK BLOCKS FOOT 72.00 06/30/10 005 0270 4205
03750625 SHOCK BLOCKS FOOT 72.00 06/30/10 005 0270 4205
03750633 SHOCK BLOCKS FT 10 89.00 06/30/10 005 0270 4205
03750658 BUCK'S TRACTION BOOTS 212.00 06/30/10 005 0270 4205
03750674 TRACTION SKIN KIT 89.00 06/30/10 005 0270 4205
03750690 TRACTION SKIN KIT 89.00 06/30/10 005 0270 4205
03750708 TRACTION SKN STRPS 35.00 06/30/10 005 0270 4205
03750716 KNEE SLING, SMALL 72.00 06/30/10 005 0270 4205
03750724 KNEE SLING, LARGE 115.00 06/30/10 005 0270 4205
03788526 HEAD HALTER W/CERVICAL TRACTN 171.00 06/30/10 005 0270 4205
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 10
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03788815 BAL SUSP W/KNEE EXERCISER 615.00 06/30/10 005 0270 4205
03788823 RUSSELS 90/90 FEMORAL 267.00 06/30/10 005 0270 4205
03788831 PED GAL TRAC BRYANTS TX 212.00 06/30/10 005 0270 4205
03788849 PELVIC SLING 202.00 06/30/10 005 0270 4205
03790270 SUPPLIES EXTERNAL 06/01/03 005 0270 9999
03790274 SUPPLIES-PROSTHETIC/ORTHOTIC EXTERNAL 06/01/03 005 0274 9999
03798402 CAST CART 656.00 06/30/10 005 0270 4205
03798403 STRYKER INTR COMP PRSS MON SYS 5451.00 06/30/10 005 0270 4205
04001173 BILIRUBIN DIRECT-SERUM 43.00 06/30/10 82248 82248 82248 005 0301 2612
04002842 ASPERGILLUS AB BY ID 85.00 06/30/10 86606 86606 86606 005 0300 2608
04002845 CAFFEINE 146.00 06/30/10 80299 80299 80299 005 0301 2608
04002848 SCHISTOSOMA ABS 127.00 06/30/10 86682 86682 86682 005 0300 2608
04002851 STRONGYLOIDES AB, IGG BY ELISA 127.00 06/30/10 86682 86682 86682 005 0300 2608
04002854 B. PERTUSSIS AB, IGG 107.00 06/30/10 86615 86615 86615 005 0300 2608
04002857 CHROMIUM 134.00 06/30/10 82495 82495 82495 005 0301 2608
04078178 PLATELET FILTER 130.00 06/30/10 A4755 005 0270 2670
04308309 NM INJ-SINCALIDE(CCK) 5 MCG 268.00 06/30/10 J2805 J2805 J2805 005 0636 2070
04311990 PV CONNECT DRAINAGE/CHEST TUBE 27.00 06/30/10 005 0270 2030
04311993 PV CHEST DRAINAGE SYS/CATHETER 111.00 06/30/10 C1729 C1729 C1729 005 0270 2030
04311996 PV CATHETER EXTRACTOR 106.00 06/30/10 005 0270 2030
04317007 PATTIES - SURGICAL 1/2 X 1/2 27.00 06/30/10 005 0270 4750
04317037 3.0 MONOSOFT SN5669/SUTURE 137.00 06/30/10 005 0270 4750
04317575 PV COIL INTERLOCK 1105.00 06/30/10 005 0270 2030
04359788 US VACUUM BOTTLE 12.00 06/30/10 005 0270 2035
04381328 NV ACCUMETRICES SUPPLY-ASPIRIN 80.00 06/30/10 005 0250 2032
04381332 NV ACCUMETRICES SUPPLY -P2Y12 127.00 06/30/10 005 0270 2032
04381336 PV SYRINGE & TUBE DISPOSABLE 59.00 06/30/10 005 0270 2032
04381339 NV SYRINGE & TUBE DISPOSABLE 74.00 06/30/10 005 0270 2030
04381346 NV PENUMBRA-REPERFUSION CATH 3332.00 06/30/10 005 0272 2032
04510001 CT-1A CASE CART 4340.00 06/30/10 005 0270 0801
04510002 CT-1B CASE CART 1739.00 06/30/10 005 0270 0801
04510003 CT-2 CASE CART 1554.00 06/30/10 005 0270 0801
04510004 CT-3 CASE CART 984.00 06/30/10 005 0270 0801
04510005 CT-4 CASE CART 571.00 06/30/10 005 0270 0801
04510006 CT-5 CASE CART 408.00 06/30/10 005 0270 0801
04510007 CT-6 CASE CART 631.00 06/30/10 005 0270 0801
04510008 CT-7 CASE CART 213.00 06/30/10 005 0270 0801
04510009 OR CT LP CASE CART 4379.00 06/15/10 005 0270 0801
04510021 CTAP CASE CART 4073.00 06/30/10 005 0270 0801
04510022 CTEP CASE CART 6841.00 06/30/10 005 0270 0801
04510023 CTIP CASE CART 4489.00 06/30/10 005 0270 0801
04510024 CTMP CASE CART 3921.00 06/30/10 005 0270 0801
04510025 CLTL CASE CART 5792.00 06/30/10 005 0270 0801
04510031 CYSTO CASE CART 170.00 06/30/10 005 0270 0801
04510041 EMERGENCY CASE CART 631.00 06/30/10 005 0270 0801
04510045 TRAUMA CASE CART 963.00 06/30/10 005 0270 0801
04510051 G-1 CASE CART 486.00 06/30/10 005 0270 0801
04510052 G-1 (GB) CASE CART 358.00 06/30/10 005 0270 0801
04510053 G-1 (THY) CASE CART 1584.00 06/30/10 005 0270 0801
04510054 G-2 CASE CART 398.00 06/30/10 005 0270 0801
04510055 G-3 CASE CART 755.00 06/30/10 005 0270 0801
04510056 G-4 CASE CART 385.00 06/30/10 005 0270 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 11
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04510057 G-5 CASE CART 476.00 06/30/10 005 0270 0801
04510060 G-1LS LAPARO CASE CART 702.00 06/30/10 005 0270 0801
04510071 GU-2 CASE CART 565.00 06/30/10 005 0270 0801
04510072 GU-3 CASE CART 725.00 06/30/10 005 0270 0801
04510073 GU-4 CASE CART 836.00 06/30/10 005 0270 0801
04510081 GYN-1 CASE CART 414.00 06/30/10 005 0270 0801
04510082 GYN-2 CASE CART 448.00 06/30/10 005 0270 0801
04510083 GYN-3 CASE CART 942.00 06/30/10 005 0270 0801
04510084 GYN-4 CASE CART 652.00 06/30/10 005 0270 0801
04510085 GYN-5 CASE CART 891.00 06/30/10 005 0270 0801
04510086 GYN-6 CASE CART 934.00 06/30/10 005 0270 0801
04510087 GYN-7 CASE CART 747.00 06/30/10 005 0270 0801
04510088 GYN-8 CASE CART 611.00 06/30/10 005 0270 0801
04510089 GYN-9 CASE CART 467.00 06/30/10 005 0270 0801
04510090 GYN-10 CASE CART 445.00 06/30/10 005 0270 0801
04510101 NEURO-1 CASE CART 1562.00 06/30/10 005 0270 0801
04510102 NEURO-2 CASE CART 1350.00 06/30/10 005 0270 0801
04510103 NEURO-3 CASE CART 2223.00 06/30/10 005 0270 0801
04510104 NEURO-4 CASE CART 711.00 06/30/10 005 0270 0801
04510105 NEURO-5 CASE CART(TRANSPHENOD) 747.00 06/30/10 005 0270 0801
04510106 NEURO-6 CASE CART 428.00 06/30/10 005 0270 0801
04510111 ONCOL-1 CASE CART 998.00 06/30/10 005 0270 0801
04510112 ONCOL-2 CASE CART 1583.00 06/30/10 005 0270 0801
04510113 ONCOL-3 CASE CART 819.00 06/30/10 005 0270 0801
04510114 ONCOL-4 CASE CART 186.00 06/30/10 005 0270 0801
04510115 ONCOL-5 CASE CART 1026.00 06/30/10 005 0270 0801
04510116 ONCOL-6 CASE CART 657.00 06/30/10 005 0270 0801
04510117 ONCOL-7 CASE CART 927.00 06/30/10 005 0270 0801
04510118 ONCOL 8 CASE CART 1046.00 06/30/10 005 0270 0801
04510120 SKIN GRAFT CASE CART 683.00 06/30/10 005 0270 0801
04510121 ORAL-1 CASE CART 589.00 06/30/10 005 0270 0801
04510122 ORAL-2 CASE CART 556.00 06/30/10 005 0270 0801
04510123 ORAL-3 CASE CART 141.00 06/30/10 005 0270 0801
04510124 OR ORAL 4 CASE CART 3330.00 06/15/10 005 0270 0801
04510125 OR ORAL 5 CASE CART 3330.00 06/15/10 005 0270 0801
04510126 OR ORAL 6 CASE CART 3330.00 06/15/10 005 0270 0801
04510131 ORTHO-1 CASE CART 1016.00 06/30/10 005 0270 0801
04510132 ORTHO-2 CASE CART 711.00 06/30/10 005 0270 0801
04510133 ORTHO-3 CASE CART 709.00 06/30/10 005 0270 0801
04510134 ORTHO-4 CASE CART 1038.00 06/30/10 005 0270 0801
04510135 ORTHO-5 CASE CART 1149.00 06/30/10 005 0270 0801
04510136 ORTHO-6 CASE CART 945.00 06/30/10 005 0270 0801
04510137 ORTHO-7 CASE CART 864.00 06/30/10 005 0270 0801
04510138 ORTHO-8 CASE CART 279.00 06/30/10 005 0270 0801
04510141 P-1 CASE CART 1902.00 06/30/10 005 0270 0801
04510142 P-2 CASE CART 1315.00 06/30/10 005 0270 0801
04510143 P-3 CASE CART 931.00 06/30/10 005 0270 0801
04510144 P-4 CASE CART 1192.00 06/30/10 005 0270 0801
04510151 PEDS-1 CASE CART 589.00 06/30/10 005 0270 0801
04510152 PEDS-2 CASE CART 433.00 06/30/10 005 0270 0801
04510153 PEDS-3 CASE CART 574.00 06/30/10 005 0270 0801
04510161 T-1 CASE CART 827.00 06/30/10 005 0270 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 12
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04510162 T-2 CASE CART 981.00 06/30/10 005 0270 0801
04510163 T-3 CASE CART 632.00 06/30/10 005 0270 0801
04510164 T-4 CASE CART 590.00 06/30/10 005 0270 0801
04510165 T-5 CASE CART 1562.00 06/30/10 005 0270 0801
04510166 OR T5 B CASE CART 265.00 06/15/10 005 0270 0801
04510171 V-1 CASE CART 742.00 06/30/10 005 0270 0801
04510172 V-2 CASE CART 724.00 06/30/10 005 0270 0801
04510173 V-3 CASE CART 594.00 06/30/10 005 0270 0801
04510174 V-4 CASE CART 901.00 06/30/10 005 0270 0801
04510175 V-5 CASE CART 1250.00 06/30/10 005 0270 0801
04510176 V-6 CASE CART 739.00 06/30/10 005 0270 0801
04510177 V-7 CASE CART 554.00 06/30/10 005 0270 0801
04510180 O.R. BARIATRIC CASE CART 536.00 06/30/10 005 0270 0801
04510183 O.R. TURP CASE CART 132.00 06/30/10 005 0270 0801
04510186 O.R. ORTHO 3PF CASE CART 508.00 06/30/10 005 0270 0801
04510189 O.R. ORTHO 4 PEDS CASE CART 239.00 06/30/10 005 0270 0801
04510193 OR PLASTIC 2 CASE CART 851.00 06/15/10 005 0270 0801
04510196 OR PLASTIC 3 CASE CART 381.00 06/15/10 005 0270 0801
04510199 OR PLASTIC 4 CASE CART 582.00 06/15/10 005 0270 0801
04510202 OR SKIN GRAFTS CASE CART 243.00 06/15/10 005 0270 0801
04510205 OR ORTHO 4 PODIATRY CASE CART 347.00 06/15/10 005 0270 0801
04510208 OR ORTHO 5B DR HUTCH CASE CART 719.00 06/15/10 005 0270 0801
04510220 OR ENT EAR CASE CART 531.00 06/15/10 005 0270 0801
04510221 OR ENT HEAD NECK CASE CART 539.00 06/15/10 005 0270 0801
04510222 OR ENT LARYNG CASE CART 154.00 06/15/10 005 0270 0801
04510223 OR ENT RHINO CASE CART 436.00 06/15/10 005 0270 0801
04510224 OR ENT TA CASE CART 277.00 06/15/10 005 0270 0801
04510225 OR ENT TRACHEOSTOMY CASE CART 393.00 06/15/10 005 0270 0801
04510226 OR EYE CATARACT CASE CART 381.00 06/15/10 005 0270 0801
04510227 OR EYE OCULOPLASTY CASE CART 361.00 06/15/10 005 0270 0801
04510228 OR EYE STRABISMUS CASE CART 191.00 06/15/10 005 0270 0801
04510229 OR EYE VITRECTOMY CASE CART 498.00 06/15/10 005 0270 0801
04510231 OR G1 LS CASE CART 627.00 06/15/10 005 0270 0801
04510232 OR G1 ROB 14 KIDNEY TX CASE CA 1480.00 06/15/10 005 0270 0801
04510235 OR G1 ROBOT 12 LS CASE CART 1539.00 06/15/10 005 0270 0801
04510238 OR G1 ROBOT 14 LS CASE CART 1448.00 06/15/10 005 0270 0801
04510241 OR GU 2 CASE CART 330.00 06/15/10 005 0270 0801
04510242 OR GU 3 CASE CART 433.00 06/15/10 005 0270 0801
04510243 OR GU 4 CASE CART 661.00 06/15/10 005 0270 0801
04600018 ARTERIAL BLOOD SAMP 47.00 06/30/10 005 0270 4750
04600021 SYS 5-LEAD DISPOABLE LEADWIRE 60.00 06/30/10 005 0270 4750
04600024 KIT OLM INTERCRAN PRESS MON 2342.00 06/30/10 005 0270 4750
04600027 TRAY ONE MARROW W/ASP NDL 15G 64.00 06/30/10 005 0270 4750
04600030 NEEDLE 13GAX3-1/2IN JAMSHIDI 59.00 06/30/10 005 0270 4750
04600033 NDL 13GX4IN JMSH BONE MAR BIOP 56.00 06/30/10 005 0270 4750
04600036 NEEDLE 15GA ADJ LGTH BONE 34.00 06/30/10 005 0270 4750
04600039 NEEDLE 18GA ADG LGTHBONE 35.00 06/30/10 005 0270 4750
04600042 ENDOTRACH TUBE HOLDER 27.00 06/30/10 005 0270 4750
04600045 MELKER EMRG CRICOTHYOTOMY TUBE 455.00 06/30/10 005 0270 4750
04600048 KIT ORAL CARE VAP GUARD PREMIE 32.00 06/30/10 005 0270 4750
04600051 PUMP IV SET 30ML 119" 0.2 FILT 37.00 06/30/10 005 0270 4750
04600054 TRAY NOSEBLEED 65.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 13
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04600057 PUMP SET EPIDURAL(CURLIN) 27.00 06/30/10 005 0270 4750
04600060 SET VENT PNB FOR PERIPH NER BL 28.00 06/30/10 005 0270 4750
04600063 SET INTRO 6FR FLX CHCK-FLO55CM 172.00 06/30/10 005 0270 4750
04600066 CATH TAMPONADE 24FR 54CM BALLN 760.00 06/30/10 005 0270 4750
04600083 SET INTR 6FR FLEX CHCK-FLO55CM 172.00 06/30/10 005 0270 4750
04600086 POSITIONR DCP UTL PRONING 7X10 63.00 06/30/10 005 0270 4750
04600089 CATH SILICONE 40.00 06/30/10 005 0270 4750
04600092 CATH SET W/SILICONE 76.00 06/30/10 005 0270 4750
04600095 PATTIES - SURGICAL 25.00 06/30/10 005 0270 4750
04600098 DEVICE FIXATION 36.00 06/30/10 005 0270 4750
04600101 CIRCT2 IV NEONAT HTD DUAL LIMB 28.00 06/30/10 005 0270 4750
04600104 HYPR INFLAT NEOPRENE BAG SYS 23.00 06/30/10 005 0270 4750
04600109 CATH MALECOT 20FR 74.00 06/30/10 005 0270 4750
04600112 SENSOR LNCS NEONATAL/ADULT 39.00 06/30/10 005 0270 4750
04600116 ADAPT STRT AIRWY W/TUBE ANES 175.00 06/30/10 005 0270 4750
04600119 SET MONITOR COMBITRANS 159.00 06/15/10 005 0270 4750
04600122 SET VISTA PMP W/ULTRASTE BASIC 54.00 06/15/10 005 0270 4750
04600125 SEALANT HEMOSTATIC 5ML MATRIX 630.00 07/01/10 005 0270 4750
04600128 SEALANT HEMOSTATIC 10ML MATRIX 1158.00 07/01/10 005 0270 4750
04601050 STAND ADMIN SET 2Y20 DROP 100" 50.00 06/30/10 005 0270 4750
04601051 GRAVITY SET #42293E 19.00 06/30/10 005 0270 4750
04601052 BURETTE SET #72103 36.00 06/30/10 005 0270 4750
04601053 NITRO SET #72953 50.00 06/30/10 005 0270 4750
04601054 BLOOD SET #72980E 57.00 06/30/10 005 0270 4750
04601055 T CONNECTOR #20050E 20.00 06/30/10 005 0270 4750
04601056 MIDDLE INJECTION SET #72033E 32.00 06/30/10 005 0270 4750
04601057 GRAVITY INFUSION #72964E 36.00 06/30/10 005 0270 4750
04601058 TAXOL ADMIN SET #72923 56.00 06/30/10 005 0270 4750
04601059 SYRINGE SET #72983 30.00 06/30/10 005 0270 4750
04601060 BURETTE ADD ON SET #82113E 30.00 06/30/10 005 0270 4750
04601061 MANIFOLD 3 PORT SET #20511E 30.00 06/30/10 005 0270 4750
04601064 HOLDER ORAL ENDOTRACHEAL TUBE 27.00 06/30/10 005 0270 4750
04602161 SENTECH AIR CHAIR PAD 19.00 06/30/10 005 0270 4752
04602165 ISOFLEX MATTRESS REPLACEMENT 42.00 06/30/10 005 0270 4752
04602168 FLOTATION DEVICE 35.00 06/30/10 005 0270 4752
04602261 SENTECH AIR CHAIR PAD 19.00 06/30/10 005 0270 4752
04602899 URINAL FEMALE 44.00 06/30/10 005 0270 4750
04602907 CUFF NEONATAL #8311 19.00 06/30/10 005 0270 4750
04602915 CUFF NEONATAL #8312 19.00 06/30/10 005 0270 4750
04602923 CUFF NEONATAL #8133 19.00 06/30/10 005 0270 4750
04602932 CUFF ADULT B/P SMALL DISP 51.00 06/30/10 005 0270 4750
04602933 CUFF ADULT B/P MED DISP 51.00 06/30/10 005 0270 4750
04602934 CUFF ADULT B/P LARGE DISP 51.00 06/30/10 005 0270 4750
04602949 AIRWAY ESOP OBT 13 229.00 06/30/10 005 0270 4750
04602956 AIRWAY BIPHRY 2.5 36.00 06/30/10 005 0270 4750
04602998 AIRWAY BIPHRY 3.0 36.00 06/30/10 005 0270 4750
04603004 AIRWAY BIPHRY 3.5 36.00 06/30/10 005 0270 4750
04603012 AIRWAY BIPHRY 4.0 36.00 06/30/10 005 0270 4750
04603020 AIRWAY SM.CH 60MM 21.00 06/30/10 005 0270 4750
04603061 BREA PUMP KIT L.G. 27.00 06/30/10 005 0270 4750
04603079 CANNULA 4 SIC FNST 19.00 06/30/10 005 0270 4750
04603087 CANNULA 6 SIC FNST 19.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 14
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04603103 CANNULA 8 SIC FNST 19.00 06/30/10 005 0270 4750
04603152 CANNULA 10 SIC FNST 19.00 06/30/10 005 0270 4750
04603160 CANNULA DCT 6 DSP 204.00 06/30/10 005 0270 4750
04603178 CANNULA DIC 6 DSP 18.00 06/30/10 005 0270 4750
04603186 CANNULA DCT 8 DSP 204.00 06/30/10 005 0270 4750
04603194 CANNULA DIC 8 DSP 18.00 06/30/10 005 0270 4750
04603195 CANNULA DCT 10 DSP 204.00 06/30/10 005 0270 4750
04603196 CANNULA CDWL PARACENTESIS NDL 96.00 06/30/10 005 0270 4750
04603228 CAP DECNLTN 4 DCC 19.00 06/30/10 005 0270 4750
04603244 CAP DECNLTN 6 DCC 19.00 06/30/10 005 0270 4750
04603251 CAP DECNLTN 8 DCC 19.00 06/30/10 005 0270 4750
04603277 CAP DECNLTN 10 DCC 19.00 06/30/10 005 0270 4750
04603285 CRVL COLLA PED 14L 60.00 06/30/10 005 0270 4750
04603293 CRVL COLLA PED 17L 60.00 06/30/10 005 0270 4750
04603301 CESAREAN SEC PACK 580.00 06/30/10 005 0270 4750
04603319 CHEST DR VLE HMLGH 44.00 06/30/10 005 0270 4750
04603350 DOME CF TA1017 51.00 06/30/10 005 0270 4750
04603360 FILM PLASTIC WRAP 42.00 06/30/10 005 0270 4750
04603364 OPTICATH INTRAVASC 4FR/25CM 1165.00 06/30/10 005 0270 4750
04603365 OPTICATH INTRAVASC 4FR/40CM 1165.00 06/30/10 005 0270 4750
04603368 GUID WIRE TSF28145 47.00 06/30/10 005 0270 4750
04603369 GUIDE WIRE .018 X 50CM 96.00 06/30/10 005 0270 4750
04603370 GUIDE WIRE .021 X 50CM 96.00 06/30/10 005 0270 4750
04603376 PAD HYPOTHER DSP 159.00 06/30/10 005 0270 4750
04603377 BLANKET HYPO DHP-810 25X64 94.00 06/30/10 005 0270 4750
04603384 PAD BED 36X72 ACCU 50.00 06/30/10 005 0270 4750
04603392 HACKMAN CATH S 224 359.00 06/30/10 005 0270 4750
04603400 HICKMA CATH RP KIT 602.00 06/30/10 005 0270 4750
04603418 HICKMA RP KIT 210 239.00 06/30/10 005 0270 4750
04603424 POUCH IRRIGATION 59.00 06/30/10 005 0270 4750
04603426 POU DRN SF 1-1/2 72.00 06/30/10 005 0270 4750
04603434 POU DRN SF 1-2/3 84.00 06/30/10 005 0270 4750
04603442 POU DRN SF 2-1/4 84.00 06/30/10 005 0270 4750
04603459 POU DRN SF 2-3/4 72.00 06/30/10 005 0270 4750
04603462 POUCH DRAINABLE 4" 109.00 06/30/10 005 0270 4750
04603467 POU DRN SF 1 1/4 72.00 06/30/10 005 0270 4750
04603475 POU DRN SF 1 1|2 69.00 06/30/10 005 0270 4750
04603509 POU DRN SF 1 3|4 72.00 06/30/10 005 0270 4750
04603517 POU DRN SF 1 1|4 69.00 06/30/10 005 0270 4750
04603533 POU URTMY SF 1 1|4 114.00 06/30/10 005 0270 4750
04603534 POUCH UROSTOMY W/CUT F/SKIN 242.00 06/30/10 005 0270 4750
04603535 POUCH UROSTOMY SURFIT 136.00 06/30/10 005 0270 4750
04603541 POU URTMY SF 1 1|2 107.00 06/30/10 005 0270 4750
04603558 POU URTMY SF 1 3|4 114.00 06/30/10 005 0270 4750
04603566 POU URTMY SF 2 1|4 114.00 06/30/10 005 0270 4750
04603568 POUCH UROSTOMY 2 3/4" 140.00 06/30/10 005 0270 4750
04603574 POU URTMY SF 1 1|4 107.00 06/30/10 005 0270 4750
04603582 POU URTMY SF 1 1|2 103.00 06/30/10 005 0270 4750
04603590 POU URTMY SF 1 3|4 101.00 06/30/10 005 0270 4750
04603608 POU URTMY SF 2 1|4 107.00 06/30/10 005 0270 4750
04603851 SLEEVE THIGH LENGTH STER O.R. 590.00 06/30/10 005 0270 4750
04603852 SLEEVE THIGH LENGTH SMALL 512.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 15
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04603853 SLEEVE THIGH LENGTH REGULAR 292.00 06/30/10 005 0270 4750
04603854 SLEEVE THIGH LENGTH LARGE 344.00 06/30/10 005 0270 4750
04603855 SLEEVE THIGH LENGTH LG DVT40 388.00 06/30/10 005 0270 4750
04603857 SLEEVE ACCESS DOOR FRONT/BACK 51.00 06/30/10 005 0270 4750
04603858 SLEEVE ATHROMBIC CALF/THIGH 578.00 06/30/10 005 0270 4750
04603859 SLEEVE ATHROMBIC CALF 473.00 06/30/10 005 0270 4750
04603861 STRYKER AIR 1 OVERLAY 45.00 06/30/10 005 0270 4752
04603866 STRYKER GO BED WITH AIR MRS 147.00 06/30/10 005 0270 4752
04603869 FLXICAIR LOW AIR LOSS BED W/SC 325.00 06/30/10 005 0270 4752
04603870 ROHO PEDS OVERLAY 37.00 06/30/10 005 0270 4752
04603871 STRYKER AIR 1 OVERLAY 45.00 06/30/10 005 0270 4752
04603874 STRYKER BARI 10A W/FOAM MATTRE 258.00 06/30/10 005 0270 4752
04603875 INNOVETIVE ORTHODERM I 195.00 06/30/10 005 0291 4750
04603879 STRYKER BARI 10A W/FOAM MATTRE 258.00 06/30/10 005 0270 4752
04603884 MILLENIUM LIFT W/SCALE 111.00 06/30/10 005 0270 4752
04603885 STRETCHAIR 111.00 06/30/10 005 0270 4752
04603886 SIZEWISE TRAPEZE 63.00 06/30/10 005 0270 4752
04603887 BED SIDE COMMODE 27.00 06/30/10 005 0270 4752
04603889 S.F. URSTMY 70MM223 35.00 06/30/10 005 0270 4750
04603890 K.C.I., AIR MAXUS AIR MATTRESS 114.00 06/30/10 005 0270 4752
04603894 STRYKER GO BED WITH XPRT 368.00 06/30/10 005 0270 4752
04603895 WOUND VAC THERAPY BED 320.00 06/30/10 005 0270 4752
04603897 S.F. URSTMY 70MM223 44.00 06/30/10 005 0270 4750
04603900 K.C.I. BARMAX BARICTOIC BED 377.00 06/30/10 005 0270 4752
04603902 KCI FIRST STEP AIR MATTRESS 113.00 06/30/10 005 0270 4752
04603904 KCI BARIKARE W/SCALE 434.00 06/30/10 005 0270 4752
04603905 CATH C-V ACCU KIT 115.00 06/30/10 005 0270 4750
04603906 SENTECH THERATURN 111.00 06/30/10 005 0270 4752
04603909 STRYKER GO BED WITH XPRT 368.00 06/30/10 005 0270 4752
04603912 HOVERMATT TRANFER SYSTEM 96.00 06/30/10 005 0270 4752
04603913 SKIN STAPLER DSP 139.00 06/30/10 005 0270 4750
04603915 STRYKER GO BED W/AIR II MRS 147.00 06/30/10 005 0270 4752
04603918 KINAIR MED SURG BED W/O SCALES 59.00 06/30/10 005 0270 4752
04603921 MONITORING KIT S. 87.00 06/30/10 005 0270 4750
04603922 KIT COMPL INTRACRANIAL MONITOR 2139.00 06/30/10 005 0270 4750
04603923 KIT MICROVENT MONITOR/DRAINAGE 2356.00 06/30/10 005 0270 4750
04603925 STRYKER BED W/SCALE + FOAM MAT 96.00 06/30/10 005 0270 4752
04603928 AIR CHAIR 26.00 06/30/10 005 0270 4752
04603931 STRYKER AIR II MRS 59.00 06/30/10 005 0270 4752
04603934 STRYKER AIR 1 OVERLAY 45.00 06/30/10 005 0270 4752
04603937 SELECTAIR MAX REPLACEMENT 71.00 06/30/10 005 0270 4752
04603939 MONITORING KIT 1290 141.00 06/30/10 005 0270 4750
04603940 PEDIDYNE 602.00 06/30/10 005 0270 4752
04603943 STRYKER AIR II MRS 59.00 06/30/10 005 0270 4752
04603946 STRYKER GO BED WITH XPRT 368.00 06/30/10 005 0270 4752
04603947 CANNULA DIC 10 122.00 06/30/10 005 0270 4750
04603950 BARIATRIC WHEELCHAIR 59.00 06/30/10 005 0270 4752
04603953 BARIATRIC WHEELCHAIR RENTAL 82.00 06/30/10 005 0270 4752
04603956 STRYKER AIR II MRS 59.00 06/30/10 005 0270 4752
04603959 CLINITRON II AIR-FLUID THERAPY 181.00 06/30/10 005 0270 4752
04603962 STRYKER ARISE 1000 EX 32.00 06/30/10 005 0270 4752
04603965 CLINITRON II 181.00 06/30/10 005 0270 4752
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 16
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04603968 CLINITRON RITEHITE 306.00 06/30/10 005 0270 4752
04603971 TRAPEZE-STRYKER BARI10A BED 35.00 06/30/10 005 0270 4752
04603974 02 ZNED LATERAL ROT MATT 48" 30.00 06/30/10 005 0270 4752
04603988 CANNULA DCT 4 204.00 06/30/10 005 0270 4750
04603996 CANNULA DIC 4 122.00 06/30/10 005 0270 4750
04604001 SECURE BED 29.00 06/30/10 005 0270 4752
04604002 CATH FGRTY,IR4FR. 60.00 06/30/10 005 0270 4750
04604004 ROJO FULL SIZE OVERLAY 53.00 06/30/10 005 0270 4752
04604010 CATH KIT CV C1608AK 144.00 06/30/10 005 0270 4750
04604014 CATH MAC WITH ADAPTER 50.00 06/30/10 005 0270 4750
04604028 CATH KIT SP MULTI 275.00 06/30/10 005 0270 4750
04604036 CATH PRTNL AD2 359.00 06/30/10 005 0270 4750
04604044 CATH PRTNL AD3 390.00 06/30/10 005 0270 4750
04604045 CATH DBL LUMEN DIALYSIS 12 FR 447.00 06/30/10 005 0270 4750
04604046 CATH DIALYS TRIPLE LUMEN 16 CM 470.00 06/30/10 005 0270 4750
04604047 CATH DIALYS TRIPLE LUMEN 20 CM 573.00 06/30/10 005 0270 4750
04604048 CATH DOUBLE LUMEN 5FR 16G 40CM 292.00 06/30/10 005 0270 4750
04604049 WIRE GUIDE .018 50CM 2MM CURV 84.00 06/30/10 005 0270 4750
04604050 CATH PED DBL LUM 4FR 25CM 18G 284.00 06/30/10 005 0270 4750
04604051 CATH SG 7.5 821H 576.00 06/30/10 005 0270 4750
04604052 CATH MIDLINE 20G X 6" 512.00 06/30/10 005 0270 4750
04604053 DEVICE ACCESS VENOUS 22G X 6.5 235.00 06/30/10 005 0270 4750
04604054 TRAY PREP CATHETER MIDLINE 60.00 06/30/10 005 0270 4750
04604055 WIRE GUIDE DBL .021 50CM 93.00 06/30/10 005 0270 4750
04604060 PROBE SKIN TEMPERATURE DISP 24.00 06/30/10 005 0270 4750
04604069 DOMES TRANDUCER TA 35.00 06/30/10 005 0270 4750
04604077 INJECTION DLVY.SYST 136.00 06/30/10 005 0270 4750
04604085 MONITOR KIT BP-CPMS400 69.00 06/30/10 005 0270 4750
04604086 MONITORING SET 3.0FR CPMS-301 69.00 06/30/10 005 0270 4750
04604087 MONITORING SET 4.0FR CPMS-401 69.00 06/30/10 005 0270 4750
04604088 MONITORING SET 5.0FR CPMS-501 72.00 06/30/10 005 0270 4750
04604100 COOK ACCESS-LUER LOCK CHK-FLO 109.00 06/30/10 005 0270 4750
04604105 LOCK LUER CHK-FLO 6.0-25-7.5 109.00 06/30/10 005 0270 4750
04604108 GAYMAR BLANKET VEST 180.00 06/30/10 005 0270 4750
04604111 GAYMAR LEGWRAPS 90.00 06/30/10 005 0270 4750
04604200 TUBE ENDOTRACH 5.0C 19.00 06/30/10 005 0270 4750
04604201 TRACH TUBE ADLT FOME-CUFF BIV 353.00 06/30/10 005 0270 4750
04604202 TRACH TUBE ADLT AIRE-CUFF BIV 302.00 06/30/10 005 0270 4750
04604203 TRACH TUBE ADLT CUFFLESS BIV 203.00 06/30/10 005 0270 4750
04604204 TRACH TUBE ADLT TTS BIV 302.00 06/30/10 005 0270 4750
04604205 TRACH TUBE KIT ADLT TTS HA BIV 628.00 06/30/10 005 0270 4750
04604206 TRACH TUBE KIT ADLT MR HA BIV 628.00 06/30/10 005 0270 4750
04604211 TRACH TUBE PEDIA CUFFLESS BIV 255.00 06/30/10 005 0270 4750
04604212 TRACH TUBE PEDIA TTS BIV 802.00 06/30/10 005 0270 4750
04604213 TRACH TUBE PEDIA FLEXTEND BIV 447.00 06/30/10 005 0270 4750
04604214 TRACH TUBE KIT PEDIA ADJ BIV 353.00 06/30/10 005 0270 4750
04604218 TUBE ENDOTRACH 8.0C 19.00 06/30/10 005 0270 4750
04604226 TUBE TRACH 30F 6 CF 154.00 06/30/10 005 0270 4750
04604242 TUBE TRACH SCT 8 140.00 06/30/10 005 0270 4750
04604259 TUBE TRACH SCT 10 140.00 06/30/10 005 0270 4750
04604267 TUBE TRACH HI-LO 7 67.00 06/30/10 005 0270 4750
04604341 TUBE TRACH HI-LO 7. 67.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 17
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04604358 TUBE TRACH HI-LO 8. 59.00 06/30/10 005 0270 4750
04604366 TOOTH BRUSH BTLUP. HANDLE 16.00 06/30/10 005 0270 4750
04604374 HOOK HEMI HARNESS S/M 243.00 06/30/10 005 0270 4750
04604382 HOOK HEMI HARNESS M/L 243.00 06/30/10 005 0270 4750
04604390 LOOP SCISSOR PT. END 44.00 06/30/10 005 0270 4750
04604408 MATTING DYCEM N/S 18.00 06/30/10 005 0270 4750
04604424 CRUTCH PADS W/HAND GRIPS 40.00 06/30/10 005 0270 4750
04604432 CONES, LONG #112811 351.00 06/30/10 005 0270 4750
04604457 CONES, MEDS #112812 351.00 06/30/10 005 0270 4750
04604465 CONES, SHT. 112813 351.00 06/30/10 005 0270 4750
04604473 SPLINT MED. 112733 109.00 06/30/10 005 0270 4750
04604481 SPLINT SHT. 112734 109.00 06/30/10 005 0270 4750
04604499 SPLINT LONG. 112735 197.00 06/30/10 005 0270 4750
04604501 ANKLE BRACE - STANDARD RIGHT 147.00 06/30/10 005 0270 4750
04604502 ANKLE BRACE-STANDARD LEFT 147.00 06/30/10 005 0270 4750
04604504 ANKLE TRAINING BRACE-RIGHT 147.00 06/30/10 005 0270 4750
04604505 ANKLE TRAINING BRACE-LEFT 147.00 06/30/10 005 0270 4750
04604508 ANKLE BRACE PEDS RIGHT 121.00 06/30/10 005 0270 4750
04604509 ANKLE BRACE PEDS-LEFT 121.00 06/30/10 005 0270 4750
04604512 MATTRESS EHOB OVERLAY 99.00 06/30/10 005 0270 4750
04604515 MATTRESS WATER INFT 141.00 06/30/10 005 0270 4750
04604523 OPTICATH P7710 1128.00 06/30/10 005 0270 4750
04604531 ROTO KENETIC BED 460.00 06/30/10 005 0270 4750
04607393 TUBE FEEDING DOBHOF 131.00 06/30/10 005 0270 4750
04607401 IV ADMIN SOL 2C0017 18.00 06/30/10 005 0270 4750
04607419 CONTINU-FLO 2C0123- 23.00 06/30/10 005 0270 4750
04607420 SET IV TUBING UPSTREAM .22 MIC 27.00 06/30/10 005 0270 4750
04607427 WAFER STOMA 4X4 1-1/4#256-05 67.00 06/30/10 005 0270 4750
04607428 WAFER STOMA 4X4 1-1/2#256-10 67.00 06/30/10 005 0270 4750
04607429 WAFER STOMA 4X4 1-3/4#256-11 72.00 06/30/10 005 0270 4750
04607430 WAFER STOMA 4X4 2-1/4#256-12 72.00 06/30/10 005 0270 4750
04607433 SKIN BARRIER 4" 121.00 06/30/10 005 0270 4750
04607435 SCOOP DISH 27.00 06/30/10 005 0270 4750
04607443 PEELER MIRACLE BK-3 18.00 06/30/10 005 0270 4750
04607450 QUAD-QUIP MITT BK-6 47.00 06/30/10 005 0270 4750
04608276 ADAPTOR MULTI-FLOW 35.00 06/30/10 005 0270 4750
04608284 SHIELD BRST CARE F&D 27.00 06/30/10 005 0270 4750
04608292 MINI-DRIP ADD-A-LIN 16.00 06/30/10 005 0270 4750
04608293 TUBING FOR TAXOL INFUSION 36.00 06/30/10 005 0270 4750
04608318 TRAY HYSTEROSAPLINA 44.00 06/30/10 005 0270 4750
04608326 TRAY PARACERVICAL P 47.00 06/30/10 005 0270 4750
04608346 TRAY OVERHEAD LAMI 714.00 06/30/10 005 0270 4750
04608347 TRAY LAP LAMI 548.00 06/30/10 005 0270 4750
04610009 PAD DECUBITIS 24X30 27.00 06/30/10 005 0270 4750
04610033 INTRAUTERINE TRANS 35.00 06/30/10 005 0270 4750
04610108 FLUID SPECIMEN COL 33.00 06/30/10 005 0270 4750
04610124 MANNITL 20% OSMITRO 81.00 06/30/10 005 0270 4750
04610132 MANNITL 20% OSMITRL 72.00 06/30/10 005 0270 4750
04610155 SUPP0RT MEN MED 33.00 06/30/10 005 0270 4750
04610156 SUPPORT MEN LG 27.00 06/30/10 005 0270 4750
04610157 SUPPORTER MEN XL W/STRAP 59.00 06/30/10 005 0270 4750
04610158 SUPPORT MEN SM 51.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 18
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04610159 SUPPORT MEN LARGE 50.00 06/30/10 005 0270 4750
04610160 SUPPORT MEN MEDIUM 27.00 06/30/10 005 0270 4750
04610173 TUBE ENDOTRACH 9.0 18.00 06/30/10 005 0270 4750
04610181 TUBE ENDOTRACH 5.5 19.00 06/30/10 005 0270 4750
04610207 COLLAR CONTOUR SMAL 81.00 06/30/10 005 0270 4750
04610215 COLLAR CONTOUR MEDI 81.00 06/30/10 005 0270 4750
04610249 SKIN STAPLE REMOVER 36.00 06/30/10 005 0270 4750
04610256 BLOOD SET ABBOTT 60.00 06/30/10 005 0270 4750
04610264 DRESS TEGADERM 2X2- 18.00 06/30/10 005 0270 4750
04610272 DRESS TEGADERM 4X4- 61.00 06/30/10 005 0270 4750
04610273 DRESSING POLYMEM 2" X 3" 364.00 06/30/10 005 0270 4750
04610274 DRESSING POLYMEM 3 1/2 X 3 1/2 600.00 06/30/10 005 0270 4750
04610275 DRESSING POLYMEM 5" X 5" 475.00 06/30/10 005 0270 4750
04610280 CATHETER HOLDER 36.00 06/30/10 005 0270 4750
04610285 DRESSNG ANTIMICROBIAL BIOPATCH 24.00 06/30/10 005 0270 4750
04610298 HICKMAN CATH REPAIR 311.00 06/30/10 005 0270 4750
04610306 SPLINT TX X-SM 143.00 06/30/10 005 0270 4750
04610314 SPLINT TX SMALL 143.00 06/30/10 005 0270 4750
04610322 SPLINT TX MEDIUM 143.00 06/30/10 005 0270 4750
04610330 SPLINT TX LARGE 143.00 06/30/10 005 0270 4750
04610348 SPLINT TX X-LGE 143.00 06/30/10 005 0270 4750
04610350 SPLINT-ELBOW FREEDOM -SMALL 47.00 06/30/10 005 0270 4750
04610352 SPLINT-ELBOW FREEDOM-MEDIUM 47.00 06/30/10 005 0270 4750
04610354 SPLINT-ELBOW FREEDOM-LARGE 47.00 06/30/10 005 0270 4750
04610355 IV BURETROL-+SOL 2C1202S 27.00 06/30/10 005 0270 4750
04610363 MONITORING KIT MK3- 96.00 06/30/10 005 0270 4750
04610371 DRAINAGE SET BILARY 57.00 06/30/10 005 0270 4750
04610375 KIT PLEURX DRAINAGE 210.00 06/30/10 005 0270 4750
04610389 DRAINAGE SET LARGE 35.00 06/30/10 005 0270 4750
04610390 COLLECTOR WOUND DRAIN/BARRIER 57.00 06/30/10 005 0270 4750
04610413 E-Z CONFORT BELT G- 36.00 06/30/10 005 0270 4750
04610421 E-Z CONFORT BELT T- 36.00 06/30/10 005 0270 4750
04610488 WAFER STOMA 4X4 #217-12 59.00 06/30/10 005 0270 4750
04610489 WAFER STOMA 4X4WF 0219-01 72.00 06/30/10 005 0270 4750
04610490 SKIN BARRIER #4425 2 1/2" 72.00 06/30/10 005 0270 4750
04610491 PROTECTANT PROSHIELD+SKIN4 OZ 47.00 06/30/10 005 0270 4750
04610496 WAFER, STOMA 8X8 204.00 06/30/10 005 0270 4750
04610520 LAPIDUS PAD SP#230 98.00 06/30/10 005 0270 4750
04610553 VACURETTE ST. 7MM C 27.00 06/30/10 005 0270 4750
04610561 VACURETTE ST. 8MM C 27.00 06/30/10 005 0270 4750
04610579 VACURETTE ST. 10MM 27.00 06/30/10 005 0270 4750
04610595 VACURETTE ST. 12MM 27.00 06/30/10 005 0270 4750
04610603 VACURETTE TUBING SE 36.00 06/30/10 005 0270 4750
04610991 CATH. BROV. PED KIT 294.00 06/30/10 005 0270 4750
04612001 VAC DRESSING - LARGE 167.00 06/30/10 005 0270 4750
04612004 VAC DRESSING - SMALL 102.00 06/30/10 005 0270 4750
04612468 TUR-Y-ADM. SET 2C40 21.00 06/30/10 005 0270 4750
04612476 JEJUNOSTOMY KIT 154.00 06/30/10 005 0270 4750
04612484 UROSTOMY LO-PCH W-K 191.00 06/30/10 005 0270 4750
04612492 UROSTOMY LO-PCH W-K 191.00 06/30/10 005 0270 4750
04612500 UROSTOMY LO-PCH W-K 191.00 06/30/10 005 0270 4750
04612526 UROSTOMY LO-PCH W-K 191.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 19
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04612534 UROSTOMY LO-PCH W-K 191.00 06/30/10 005 0270 4750
04612725 CATH DRAIN SAFET-CENTESIS TRAY 227.00 06/30/10 005 0270 4750
04612731 TRAY PERCUTANEOUS CEN VEN CATH 344.00 06/30/10 005 0270 4750
04612732 CATHETER, MULTI-LUMEN CENT VEN 239.00 06/30/10 005 0270 4750
04612733 CATH VENTRICULAR ICP LG 35 CM 406.00 06/30/10 005 0270 4750
04612734 KIT VENTRICOLOSTOMY INSERTION 1142.00 06/30/10 005 0270 4750
04612740 CATHETER, VENOUS MULTI-LUMEN 245.00 06/30/10 005 0270 4750
04612757 ELECTRODE BARD S-T 18.00 06/30/10 005 0270 4750
04612760 SENSOR ADULT FLEXIBLE 371.00 06/30/10 005 0270 4750
04612763 SENSOR ADULT SP02 FLEX DISP 39.00 05/01/10 005 0270 4750
04612914 SHOULDER IMMOB. M-F 164.00 06/30/10 005 0270 4750
04612922 HOT PACK 10.00 06/30/10 005 0270 4750
04612930 COLD PACK 11.00 06/30/10 005 0270 4750
04612948 PACK PERINEAL INSTANT COLD 11.00 06/30/10 005 0270 4750
04613045 BATHTUB GRIP RR 215.00 06/30/10 005 0270 4750
04613052 BATHTUB GRIP SR 5"- 301.00 06/30/10 005 0270 4750
04613060 BATHTUB GRIP SR 5"+ 294.00 06/30/10 005 0270 4750
04613078 BATHTUB BENCH 11" 199.00 06/30/10 005 0270 4750
04613086 SHOE FASTENER BLK. 16.00 06/30/10 005 0270 4750
04613094 SHOE FASTENER BRN. 16.00 06/30/10 005 0270 4750
04613110 QUAD-QUIP WASH MITT 47.00 06/30/10 005 0270 4750
04613128 PUTTY 1OZ JAR 21.00 06/30/10 005 0270 4750
04613797 ENTERAL PUMP SET DO 59.00 06/30/10 005 0270 4750
04613805 GLOVES, STD. PRE-SZ 114.00 06/30/10 005 0270 4750
04613839 TT TUCKER TUBE 4-TV 1372.00 06/30/10 005 0270 4750
04613840 DOME TRANSDUCER W/SYT.SQ81107 54.00 06/30/10 005 0270 4750
04613847 TT TUCKER TUBE 5-TV 1253.00 06/30/10 005 0270 4750
04613854 TT TUCKER TUBE 6-TV 1356.00 06/30/10 005 0270 4750
04613862 TT TUCKER TUBE 7-TV 1586.00 06/30/10 005 0270 4750
04613896 LARYN TUBE SZ. 6 LG 197.00 06/30/10 005 0270 4750
04613904 LARYN TUBE SZ. 8 LG 197.00 06/30/10 005 0270 4750
04613912 LARYN TUBE SZ. 10 L 197.00 06/30/10 005 0270 4750
04613920 COVERALLS X-LRG 19.00 06/30/10 005 0270 4750
04614068 HUMIDIFIER 2-GAL 103.00 06/30/10 005 0270 4750
04614076 GAUZE, PACKING, IOD 18.00 06/30/10 005 0270 4750
04614084 GAUZE, PACKING, IOD 19.00 06/30/10 005 0270 4750
04614092 GAUZE, PACKING, PL. 18.00 06/30/10 005 0270 4750
04614100 GAUZE, PACKING, PL. 18.00 06/30/10 005 0270 4750
04614126 GAUZE, PACKING, PL. 18.00 06/30/10 005 0270 4750
04614134 GAUZE VASELINE 1"X 47.00 06/30/10 005 0270 4750
04614142 GAUZE PACKING IODO 19.00 06/30/10 005 0270 4750
04614159 GAUZE PACKING IODO 33.00 06/30/10 005 0270 4750
04614200 TAPE CASTING EXTRA FAST 2" 39.00 06/30/10 005 0270 4750
04614201 TAPE CASTING EXTRA FAST 3" 54.00 06/30/10 005 0270 4750
04614202 TAPE CASTING EXTRA FAST 5" 69.00 06/30/10 005 0270 4750
04615420 GAUZE PACKING PL. 2 33.00 06/30/10 005 0270 4750
04615425 04692208CARD STRIPS 2/PKG 40.00 06/30/10 005 0270 4750
04615435 DAILY MEDICAL SUPPLIES 31.00 06/30/10 005 0270 4750
04615438 ADMISSION KIT 27.00 06/30/10 005 0270 4750
04615439 KIT ADMISSION HIGH RISK 18.00 06/30/10 005 0270 4750
04615446 KITS, ADM CHLD 19.00 06/30/10 005 0270 4750
04615453 PACKS, LAP ST. 60.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 20
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04615461 PADS, EYE 25-PKG 35.00 06/30/10 005 0270 4750
04615479 PADS, MODESS 12-PKG 16.00 06/30/10 005 0270 4750
04615487 TAMPAX, SUPER 40-BX 33.00 06/30/10 005 0270 4750
04615495 URINOMETER, LG 67.00 06/30/10 005 0270 4750
04615503 CATH UMBILICAL 5 FR 47.00 06/30/10 005 0270 4750
04615511 COTTON, STERILE 1 51.00 06/30/10 005 0270 4750
04615529 DIAPERS, ADLT MED 1 27.00 06/30/10 005 0270 4750
04615537 DIAPERS, DAYTIME 51.00 06/30/10 005 0270 4750
04615545 DIAPERS, NEWBORN 27.00 06/30/10 005 0270 4750
04615552 DIAPERS, PREMIE 27.00 06/30/10 005 0270 4750
04615560 DIAPERS, TODDLER 40.00 06/30/10 005 0270 4750
04615578 PAD, BRA DSP. 50.00 06/30/10 005 0270 4750
04615602 CATH, PEZZER 10 FR. 35.00 06/30/10 005 0270 4750
04615610 CATH, PEZZER 26 FR. 40.00 06/30/10 005 0270 4750
04616506 SECONDARY SET W/IV EX FILTER 31.00 06/30/10 005 0270 4750
04617001 PATTIES SURG 1/2X3 80-1407 27.00 06/30/10 005 0270 4750
04617004 PATTIES SURG 3X3 80-1409 27.00 06/30/10 005 0270 4750
04617007 PATTIES-SURGICAL 1/2X1/2 27.00 06/30/10 005 0270 4750
04617010 HEMOVAC JP MEDIUM 37.00 06/30/10 005 0270 4750
04617013 PATTIES SURGICAL 1/2 80-1402 27.00 06/30/10 005 0270 4750
04617016 PATTIES SURGICAL 1X3 80-1408 27.00 06/30/10 005 0270 4750
04617019 PATTIES SURG 1/4X1/4 80-1399 35.00 06/30/10 005 0270 4750
04617022 TEMP-A-DOT 29.00 06/30/10 005 0270 4750
04617025 BIS/EXTEND SENSOR 105.00 06/30/10 005 0270 4750
04617028 TUBE TRACH CFN #6 86.00 06/30/10 005 0270 4750
04617031 CATH. 9FR BALLOON 2384.00 06/30/10 005 0270 4750
04617034 ANGEL WING TRANSFER FEMALE 27.00 06/30/10 005 0270 4750
04617037 ENDOSHEATH SYSTEM SLIDE-ON 61.00 06/30/10 005 0270 4750
04621634 SLING ARM LG 20.00 06/30/10 005 0270 4750
04621635 SLING ARM MEDIUM 32.00 06/30/10 005 0270 4750
04621636 SLING ARM SM 27.00 06/30/10 005 0270 4750
04623499 INTRODUCER DESLT SHEATH 161.00 06/30/10 005 0270 4750
04623564 TUBE ENDOTRA CF 6.0 18.00 06/30/10 005 0270 4750
04623572 TUBE ENDOTRA CF 6.5 18.00 06/30/10 005 0270 4750
04623580 TUBE ENDOTRA CF 7.0 19.00 06/30/10 005 0270 4750
04623598 ENDOTRACHEAL TUBE 7.5 CF 33.00 06/30/10 005 0270 4750
04623606 TUBE ENDOTRA CF 10. 18.00 06/30/10 005 0270 4750
04623614 T BLAKEMORE CH SZ # 409.00 06/30/10 005 0270 4750
04623622 T BLAKEMORE 16FR ME 409.00 06/30/10 005 0270 4750
04623630 T BLAKEMORE 20FR AD 409.00 06/30/10 005 0270 4750
04623648 T TRACH PED W-OBT # 128.00 06/30/10 005 0270 4750
04623655 T TRACH PED W-OBT # 116.00 06/30/10 005 0270 4750
04623663 T TRACH PED W-OBT # 128.00 06/30/10 005 0270 4750
04623671 T TRACH PED W-OBT # 140.00 06/30/10 005 0270 4750
04623689 T TRACH PED W-OBT # 128.00 06/30/10 005 0270 4750
04623697 TUBE TRACH 36F 6FEN 197.00 06/30/10 005 0270 4750
04623705 TUBE TRACH 36F 8FEN 184.00 06/30/10 005 0270 4750
04623713 T TRACH 26F 4CFS SH 154.00 06/30/10 005 0270 4750
04623714 TUBE TRACH CFN 4 203.00 06/30/10 005 0270 4750
04623715 TUBE TRACH CFN 6 154.00 06/30/10 005 0270 4750
04623721 T TRACH 36F 8CFS SH 154.00 06/30/10 005 0270 4750
04623722 TUBE TRACH 8CFN SHLY 147.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 21
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04623739 T TRACH 39F 10CFS S 149.00 06/30/10 005 0270 4750
04623740 TUBE TRACH SIZE 10 LPC 225.00 06/30/10 005 0270 4750
04623741 TUBE TRACH #6 PERC 212.00 06/30/10 005 0270 4750
04623742 TUBE TRACH #8 PERC 212.00 06/30/10 005 0270 4750
04623747 T TRACH 26F 4CFS SH 193.00 06/30/10 005 0270 4750
04623770 FOLEY CATH TRAY 16- 36.00 06/30/10 005 0270 4750
04623796 INTRACATHETER 22G 8 18.00 06/30/10 005 0270 4750
04623804 INTRACATHETER 14G 8 18.00 06/30/10 005 0270 4750
04623812 INTRACATHETER 16G 2 41.00 06/30/10 005 0270 4750
04623820 INTRAFLO FLSH SYS C 40.00 06/30/10 005 0270 4750
04624711 ELECT. NEO. H-5743 35.00 06/30/10 005 0270 4750
04624745 INTRO KIT SHTH. 6F 161.00 06/30/10 005 0270 4750
04624752 MANOMETER STABD CVP 454.00 06/30/10 005 0270 4750
04624778 N. ELEC 48"PLT E-28 27.00 06/30/10 005 0270 4750
04624786 N. HUBER ST-1.5 22G 19.00 06/30/10 005 0270 4750
04624794 N. HUBER ST 19G X 1 19.00 06/30/10 005 0270 4750
04624802 N. HUB ST 19G X 1.5 16.00 06/30/10 005 0270 4750
04624803 NEEDLE HP WI-22GAX1.25 R/A 21.00 06/30/10 005 0270 4750
04624804 NEEDLE HUBER 22GA X 1 R/A 18.00 06/30/10 005 0270 4750
04624805 NEEDLE HUBER 22GA .75 R/A 21.00 06/30/10 005 0270 4750
04624806 NEEDLE HUBER 19G X 1" STR 16.00 06/30/10 005 0270 4750
04624807 NEEDLE HUBER 22G X 1" STR 16.00 06/30/10 005 0270 4750
04624810 BONE MARROW NEEDLE 96.00 06/30/10 005 0270 4750
04624813 ASPIRATE NEEDLE 51.00 06/30/10 005 0270 4750
04624816 BONE MARROW TRAY 63.00 06/30/10 005 0270 4750
04624820 NEEDLE SET INTRA 15GA EZ-10 104.00 06/30/10 005 0270 4750
04624828 DOMES, H.P. 7007D 35.00 06/30/10 005 0270 4750
04624844 LAC. RING. 500ML 16.00 06/30/10 005 0270 4750
04624851 P. KIT TRANSMYCRDL 503.00 06/30/10 005 0270 4750
04624869 PAD DUO THER DISP. 67.00 06/30/10 005 0270 4750
04624877 LACERATION TRAY ER 69.00 06/30/10 005 0270 4750
04624885 CATH PEZZ. 12F 28F 36.00 06/30/10 005 0270 4750
04624886 CATHETER PEZZER 14FR 36.00 06/30/10 005 0270 4750
04624887 CATHETER PEZZER 16FR 51.00 06/30/10 005 0270 4750
04624888 CATHETER PEZZER 18FR 47.00 06/30/10 005 0270 4750
04624889 CATHETER PEZZER 20FR 54.00 06/30/10 005 0270 4750
04624890 CATHETER PEZZER 22FR 63.00 06/30/10 005 0270 4750
04624891 CATHETER PEZZER 24FR 63.00 06/30/10 005 0270 4750
04624892 CATHETER PEZZER 28FR 63.00 06/30/10 005 0270 4750
04624893 CATH PEZZER 30F 40.00 06/30/10 005 0270 4750
04624901 PLASMA TRANS. SET 16.00 06/30/10 005 0270 4750
04624919 STS. DECANN AST. SZ 33.00 06/30/10 005 0270 4750
04624943 TU. FD. ENTFLEX 12F 118.00 06/30/10 005 0270 4750
04624968 TU. FD. MJ 357-02 16.00 06/30/10 005 0270 4750
04624976 TU. TRACH H-L 8.5 59.00 06/30/10 005 0270 4750
04624984 TU. TRACH H-L 9.0 59.00 06/30/10 005 0270 4750
04624992 VAGINAL IRR. TRAY 16.00 06/30/10 005 0270 4750
04625007 GLOVE TRCTN XL-LSR 81.00 06/30/10 005 0270 4750
04625015 STEINMAN PIN TRAY 164.00 06/30/10 005 0270 4750
04625023 STEINMAN P TR UNTHR 69.00 06/30/10 005 0270 4750
04625031 STEINMAN P-TREADED 69.00 06/30/10 005 0270 4750
04625049 PRECIPITATE PACK 57.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 22
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04625114 PCH DRNBL CUSTOM 22 109.00 06/30/10 005 0270 4750
04625122 CARBO ZINC #3220 EA 57.00 06/30/10 005 0270 4750
04625126 CATHETER- BOWEL SYSTEM 1632.00 06/30/10 005 0270 4750
04625148 COLLY SEALS STRD. # 41.00 06/30/10 005 0270 4750
04625171 COMB. CONE/TU #7724 57.00 06/30/10 005 0270 4750
04625197 DEO. TBLT QAD #1100 98.00 06/30/10 005 0270 4750
04625220 POUCH DRAINABLE PEDS 15/BX 164.00 06/30/10 005 0270 4750
04625221 DUALSK. PRM #8382 87.00 06/30/10 005 0270 4750
04625239 DUALSK. PRM #8383 84.00 06/30/10 005 0270 4750
04625247 P AD GA 5/8 3127-05 33.00 06/30/10 005 0270 4750
04625288 OR SET SUR-FIT 1.32 40.00 06/30/10 005 0270 4750
04625289 OR SUR-FIT SET 1-38MM 223-21 33.00 06/30/10 005 0270 4750
04625290 OR SUR-FIT SET 1-45MM 223-22 36.00 06/30/10 005 0270 4750
04625291 OR SUR-FIT SET 1-57MM 223-23 36.00 06/30/10 005 0270 4750
04625292 OR SUR-FIT SET 2-45MM 223-11 33.00 06/30/10 005 0270 4750
04625293 OR SUR-FIT SET 2-38MM 223-10 33.00 06/30/10 005 0270 4750
04625294 OR SUR-FIT SET 2-57MM 223-12 33.00 06/30/10 005 0270 4750
04625296 OR SET SUR-FIT 2.70 33.00 06/30/10 005 0270 4750
04625304 APPL. BELT #1755-10 36.00 06/30/10 005 0270 4750
04625312 SAF-T-GARD PCH #815 33.00 06/30/10 005 0270 4750
04625353 C/ILL SET 223-27/28 35.00 06/30/10 005 0270 4750
04625354 SET SUR-FIT CLS.100MM 223-27 40.00 06/30/10 005 0270 4750
04625361 S-F DR PCH #223-53 81.00 06/30/10 005 0270 4750
04625379 S-F OR LOOP #223/53 54.00 06/30/10 005 0270 4750
04625387 BREAST SHIELD LGE. 36.00 06/30/10 005 0270 4750
04625403 BUT. MOORE TR 10X15 141.00 06/30/10 005 0270 4750
04625411 CATH SUBC. DBL. 7F 195.00 06/30/10 005 0270 4750
04625496 SYRINGE FILL TUBE QFT-200 11.00 06/30/10 005 0270 4750
04625569 AQUA-K-PAD 12X15 33.00 06/30/10 005 0270 4750
04625577 AQUA-K-PAD 17X24 44.00 06/30/10 005 0270 4750
04625722 ELECTRODE, PACING DEFIBRILLATN 225.00 06/30/10 005 0270 4750
04625723 PACING ELECTRODE-PEDS 225.00 06/30/10 005 0270 4750
04625726 ELECTRODE-ADULT 19.00 06/30/10 005 0270 4750
04625734 ELECTRODE-INFANT 19.00 06/30/10 005 0270 4750
04625742 ELECTRODE-PREMI 19.00 06/30/10 005 0270 4750
04625743 ELECTRODE PBF 19.00 06/30/10 005 0270 4750
04625759 AID DOOR OPENING 27.00 06/30/10 005 0270 4750
04625767 AID FLEXIBLE SOCK/S 144.00 06/30/10 005 0270 4750
04625775 AID TOTAL HIP SOCK 60.00 06/30/10 005 0270 4750
04625783 AIDES BUTTON AMPUTE 21.00 06/30/10 005 0270 4750
04625791 AIDES BUTTON REGULA 27.00 06/30/10 005 0270 4750
04625809 AIDES BUTTON RUBBER 41.00 06/30/10 005 0270 4750
04625817 BE O.K. PUTTY 2OZ 35.00 06/30/10 005 0270 4750
04625825 BENCH BATH TRANSFER 644.00 06/30/10 005 0270 4750
04625833 BOARD DELUXE CUTTIN 143.00 06/30/10 005 0270 4750
04625841 BOARD STANDARD TRAN 262.00 06/30/10 005 0270 4750
04625858 BOWS KNO 21.00 06/30/10 005 0270 4750
04625861 BREAST SHELLS - 1 PAIR 29.00 06/30/10 005 0270 4750
04625866 BRUSH MAGIC SOAPER 41.00 06/30/10 005 0270 4750
04625874 BRUSH SUCTION 27.00 06/30/10 005 0270 4750
04625882 BRUSH SUCTION BOTTLE 19.00 06/30/10 005 0270 4750
04625890 BRUSH SUCTION DENTA 27.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 23
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04625908 BUILD UP HNDL FORK 21.00 06/30/10 005 0270 4750
04625916 BUILD UP SERRATED K 35.00 06/30/10 005 0270 4750
04625924 BUILD UP HNDL SOUP 21.00 06/30/10 005 0270 4750
04625932 BUILD UP HNDL T-SPO 21.00 06/30/10 005 0270 4750
04625965 CONES HAND REG 51.00 06/30/10 005 0270 4750
04625966 CONE HAND LG 44.00 06/30/10 005 0270 4750
04625973 CUFF LEATHER ADL LG 36.00 06/30/10 005 0270 4750
04625981 CUFF LEATHER ADL ME 47.00 06/30/10 005 0270 4750
04625999 CUFF LEATHER ADL SM 47.00 06/30/10 005 0270 4750
04626005 CUFF WEIGHT 3 LBS 75.00 06/30/10 005 0270 4750
04626021 FORK SIDE CUTTER LE 41.00 06/30/10 005 0270 4750
04626039 FORK SIDE CUTTER RI 41.00 06/30/10 005 0270 4750
04626047 FRAME WRITING 27.00 06/30/10 005 0270 4750
04626054 GUARD FOOD PLASTIC 41.00 06/30/10 005 0270 4750
04626062 HOUER KEY/ARTHRITIC 27.00 06/30/10 005 0270 4750
04626070 HOLDER CARD 35.00 06/30/10 005 0270 4750
04626088 HOLDER CARD DISCS 40.00 06/30/10 005 0270 4750
04626096 HOLDER UTENSIL QUAD 40.00 06/30/10 005 0270 4750
04626104 HOOK APRON 21.00 06/30/10 005 0270 4750
04626112 KNIFE ONE HAND MEAT 36.00 06/30/10 005 0270 4750
04626120 KNIFE ROCKER 84.00 06/30/10 005 0270 4750
04626138 LACE SHOE BLACK 41.00 06/30/10 005 0270 4750
04626146 LACE SHOE BROWN 41.00 06/30/10 005 0270 4750
04626153 LACE SHOE WHITE 41.00 06/30/10 005 0270 4750
04626161 LAP TRAY RIMMED 371.00 06/30/10 005 0270 4750
04626179 MED SHOE PUT "R"ON" 57.00 06/30/10 005 0270 4750
04626187 MUG SPILL PROOF 35.00 06/30/10 005 0270 4750
04626195 OPENER ZIM JAR 47.00 06/30/10 005 0270 4750
04626443 SITZ BATH 13.00 06/30/10 005 0270 4750
04626446 NASAL PCKNG 8.0CM MERCEL 400-2 28.00 06/30/10 005 0270 4750
04626449 SET NEONATAL SUCTION-Y-IN-LINE 56.00 06/30/10 005 0270 4750
04626450 CATHETER COUDE TIP 42.00 06/30/10 005 0270 4750
04626452 SET NEONT SUC-Y-IN-LINE6FR 49.00 06/30/10 005 0270 4750
04626455 CATH UMBICAL VSSL 3.5FR 51.00 06/30/10 005 0270 4750
04626458 DIAPER PREMIE SMLL 800-1250 GM 32.00 06/30/10 005 0270 4750
04626461 KIT OBSTET DISPOS EMERG 36.00 06/30/10 005 0270 4750
04626464 TRAY FOLEY CATHETER 14FR 47.00 06/30/10 005 0270 4750
04626467 AIRCON XL3000 SILC CUT OFF TIP 27.00 06/30/10 005 0270 4750
04626470 DETECTOR CO2 EASY CAPII 40.00 06/30/10 005 0270 4750
04626473 DETECTOR CO2 PEDI-CAP 34.00 06/30/10 005 0270 4750
04626476 HOPE NEBULIZER 42.00 06/30/10 005 0270 4750
04626479 AIRWY SILICNE PHARYNGEAL 7.5FR 37.00 06/30/10 005 0270 4750
04626482 CHAMBER(SMA)W/COMFRT SEAL MASK 42.00 06/30/10 005 0270 4750
04626485 CHAMBER MED W/COMFRT SEAL MASK 42.00 06/30/10 005 0270 4750
04626488 RESUSCTATR ADULT W/MASK SPURII 37.00 06/30/10 005 0270 4750
04626491 RESUSCITATR PEDS W/MASK SPURII 28.00 06/30/10 005 0270 4750
04626494 LIMB HOLDER DISP INFANT 23.00 06/30/10 005 0270 4750
04626497 TUBE TRACHEOSTOMY D.I.C. 8 99.00 06/30/10 005 0270 4750
04626503 CATHR FOLEY SILV 30FR 30CC 2W 32.00 06/30/10 005 0270 4750
04626506 CATHETER FOLEY 18FR 5CC 30.00 06/30/10 005 0270 4750
04626509 CATHETR SILVER COATED 20FR 5CC 30.00 06/30/10 005 0270 4750
04626512 CATHETER FOLEY 2-WAY 16FR 30CC 32.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 24
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04626515 CATHETER FOLEY 2-WAY 18FR 30CC 32.00 06/30/10 005 0270 4750
04626518 CATHETER FOLEY 2-WAY 22FR 30CC 32.00 06/30/10 005 0270 4750
04626521 CATH FOLEY SILV 2WAY 28FR 30CC 32.00 06/30/10 005 0270 4750
04626524 CATHETER FOLEY 3-WAY 22FR 5CC 53.00 06/30/10 005 0270 4750
04626527 CATH FOLEY SILV 3WAY 24FR 5CC 32.00 06/30/10 005 0270 4750
04626530 CATH FOLY SILVR 3WAY 24FR 30CC 60.00 06/30/10 005 0270 4750
04626533 TRAY CIRCUM GOMCO DLX 1.1W/STP 73.00 06/30/10 005 0270 4750
04626536 SET CYSTO IRRIG 2C-40-40 25.00 06/30/10 005 0270 4750
04626539 NDLE INFUS ST 22GAX3/4IN 1.9CM 33.00 06/30/10 005 0270 4750
04626542 NDLE INFUSN SET 22GAX1IN2.5CM 33.00 06/30/10 005 0270 4750
04626545 NDLE INFUS SET 20GA /4IN 1.9CM 33.00 06/30/10 005 0270 4750
04626548 NDLE INFUS SET 20GAX 1IN 2.5CM 33.00 06/30/10 005 0270 4750
04626551 NDLE INFUS Y-SITE 1/2INX1.3CM 28.00 06/30/10 005 0270 4750
04626554 BELT SECURITY WAIST 48.00 06/30/10 005 0270 4750
04626557 SENSOR PEDS ADHESIVE MASIMO 39.00 06/30/10 005 0270 4750
04626560 SENSOR INFANT ADHESIVE MASIMO 45.00 06/30/10 005 0270 4750
04626563 SENSOR NEONATAL ADHESVE MASIMO 42.00 06/30/10 005 0270 4750
04626566 STOCKING GRAD COMPRSS LG CALF 62.00 06/30/10 005 0270 4750
04626569 STCKING GRAD COMPRSS XLG CALF 65.00 06/30/10 005 0270 4750
04626572 TRAY UMBILICAL CATH DISP 33.00 06/30/10 005 0270 4750
04626575 TRAY PARACENTHESIS 15G X 3.25 179.00 06/30/10 005 0270 4750
04626578 TUBE TRACHEOSTOMY LPC 9 100.00 06/30/10 005 0270 4750
04626581 TUBE TRACH DFEN 9 105.00 06/30/10 005 0270 4750
04626584 BAG URETERAL DRAINAGE 30.00 06/30/10 005 0270 4750
04626587 TRAY UNIVERSAL DRAINAGE 32.00 06/30/10 005 0270 4750
04626590 COLLAR PHILADELPHIA ADJUSTABLE 58.00 06/30/10 005 0270 4750
04626593 SPLINT WRIST SMALL RIGHT 35.00 06/30/10 005 0270 4750
04626596 IMMOBILIZER KNEE 14 IN FOAM 87.00 06/30/10 005 0270 4750
04626599 WIPE 1ML NOSTING BARR FILM CAV 40.00 06/30/10 005 0270 4750
04626602 PROTECT TBE DOUBLE GD SKIN 6OZ 30.00 06/30/10 005 0270 4750
04626605 ALCOHOLICS ANON-4THED-P-CARD 36.00 06/30/10 005 0270 4750
04627003 RAILS BATHTUB SAFET +5 147.00 06/30/10 005 0270 4750
04627004 RAIL BATHTUBSAFETY -5 100.00 06/30/10 005 0270 4750
04627011 REACH ZIPPER PULL L 21.00 06/30/10 005 0270 4750
04627029 REACHER DRESSING ST 103.00 06/30/10 005 0270 4750
04627037 REACHER EXTEND-A-HN 118.00 06/30/10 005 0270 4750
04627045 REACHER EXTEND-A-HN 140.00 06/30/10 005 0270 4750
04627052 SADDLE SHOULDER LG 187.00 06/30/10 005 0270 4750
04627060 SADDLE SHOULDER LG 187.00 06/30/10 005 0270 4750
04627078 SADDLE SHOULDER MD 145.00 06/30/10 005 0270 4750
04627086 SADDLE SHOULDER MD 187.00 06/30/10 005 0270 4750
04627094 SADDLE SHOULDER SM 187.00 06/30/10 005 0270 4750
04627110 SADDLE SHOULDER SM 187.00 06/30/10 005 0270 4750
04627128 SCISSOR NAIL 97.00 06/30/10 005 0270 4750
04627136 SHOE HRN STAINLES S 44.00 06/30/10 005 0270 4750
04627144 SEAT ALL-PURPOSE BA 314.00 06/30/10 005 0270 4750
04627169 SLING ARM CUFF STYL 63.00 06/30/10 005 0270 4750
04627193 SLING MEDIUM 72.00 06/30/10 005 0270 4750
04627219 SPLINT HND ACCES KI 35.00 06/30/10 005 0270 4750
04627227 SPLINT HND ACCES KI 35.00 06/30/10 005 0270 4750
04627235 SPLINT HND ACCES KI 93.00 06/30/10 005 0270 4750
04627243 SPLINT HND ACCES KI 93.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 25
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04627250 SPLINT HND ACCES KI 93.00 06/30/10 005 0270 4750
04627268 SPLINT HND ACCES KI 93.00 06/30/10 005 0270 4750
04627284 SPLINT HND ACCES KI 93.00 06/30/10 005 0270 4750
04627292 SPLINT HND FUNCT PO 107.00 06/30/10 005 0270 4750
04627300 SPLINT HND FUNCT PO 107.00 06/30/10 005 0270 4750
04627318 SPLINT HND FUNCT PO 118.00 06/30/10 005 0270 4750
04627334 SPLINT HND FUNCT PO 118.00 06/30/10 005 0270 4750
04627342 SPLINT HND FUNCT PO 122.00 06/30/10 005 0270 4750
04627359 SPLINT HND FUNCT PO 118.00 06/30/10 005 0270 4750
04627367 SPLINT HND FUNCT PO 122.00 06/30/10 005 0270 4750
04627375 SPLINT HND FUNCT PO 118.00 06/30/10 005 0270 4750
04627383 SPLINT WRIST FUTURO 72.00 06/30/10 005 0270 4750
04627391 SPLINT WRIST FUTURO 87.00 06/30/10 005 0270 4750
04627409 SPLINT WRIST FUTURO 87.00 06/30/10 005 0270 4750
04627417 SPLINT WRIST FUTURO 87.00 06/30/10 005 0270 4750
04627425 SPLINT WRIST FUTURO 72.00 06/30/10 005 0270 4750
04627429 SPLINT WRIST SM RIGHT #145201 35.00 06/30/10 005 0270 4750
04627433 SPLINT WRIST FUTURO 72.00 06/30/10 005 0270 4750
04627524 NEEDLE CRICOTHY ER 47.00 06/30/10 005 0270 4750
04627532 SURFIT COVERS #1801 41.00 06/30/10 005 0270 4750
04627540 SURFIT COVERS #1801 36.00 06/30/10 005 0270 4750
04627557 SURFIT COVERS #1801 47.00 06/30/10 005 0270 4750
04627565 SURFIT COVERS #1801 36.00 06/30/10 005 0270 4750
04627581 STOMAHES PASTE #183 51.00 06/30/10 005 0270 4750
04627598 FILTER BLOOD 3 LEAK LG 27.00 06/30/10 005 0270 4750
04627599 BLOOD WARMING BAG 56.00 06/30/10 005 0270 4750
04627607 TUBE TRACH NEONA 00 147.00 06/30/10 005 0270 4750
04627615 TUBE TRACH NEONA 0 144.00 06/30/10 005 0270 4750
04627623 TUBE TRACH NEONA 1 164.00 06/30/10 005 0270 4750
04627624 TUBE TRACH SINGLE CANNULA SZ 9 143.00 06/30/10 005 0270 4750
04630310 SPLINT, ELBOW FREEDOM-SMALL 59.00 06/30/10 005 0270 4750
04630312 LAVAGE TRAY-LNT 900 199.00 06/30/10 005 0270 4750
04630320 INTRO CORDIS SHEATH 143.00 06/30/10 005 0270 4750
04630338 INTRO CORDIS SHEATH 143.00 06/30/10 005 0270 4750
04630346 INTRO CORDIS SHEATH 143.00 06/30/10 005 0270 4750
04630353 INTRO CORDIS SHEATH 143.00 06/30/10 005 0270 4750
04630361 INTRO CORDIS SHEATH 143.00 06/30/10 005 0270 4750
04630379 INTR KIT PS 8FR 161.00 06/30/10 005 0270 4750
04630380 KIT INTRODUCER 9 FR 233.00 06/30/10 005 0270 4750
04630395 ACCURA TEMPS DISP 74.00 06/30/10 005 0270 4750
04630396 CAUTERY PENCIL I-STAT OPH 4100 50.00 06/30/10 005 0270 4750
04630397 CAUTERY PENCIL I-STAT OPH 4200 44.00 06/30/10 005 0270 4750
04630454 ROPE NYLON N.P.C. 84.00 06/30/10 005 0270 4750
04630460 AID HAND HELPER 115.00 06/30/10 005 0270 4750
04630478 BAR SPREADER N.P.C. 21.00 06/30/10 005 0270 4750
04630486 COLLAR PHILADELPHIA 173.00 06/30/10 005 0270 4750
04630494 COLLAR PHILADELPHIA 173.00 06/30/10 005 0270 4750
04630510 COLLAR PHILADELPHIA 173.00 06/30/10 005 0270 4750
04630512 SPLINT ELBOW INFANT 41.00 06/30/10 005 0270 4750
04630513 SPLINT ELBOW TODDLER 41.00 06/30/10 005 0270 4750
04630528 JOINT JCK FING FLNT 98.00 06/30/10 005 0270 4750
04630536 JOINT JCK FING FLNT 98.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 26
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04630551 SPLNT PAD CLAV MED 60.00 06/30/10 005 0270 4750
04630569 SLING THIGH 87.00 06/30/10 005 0270 4750
04630577 SPLNT PAD CLAV. MED 60.00 06/30/10 005 0270 4750
04630585 SPLNT PAD CLAV MED 60.00 06/30/10 005 0270 4750
04630593 SPLNT SAFE-PIN SPRN 93.00 06/30/10 005 0270 4750
04630601 SPLNT SAFE-PIN SPRN 57.00 06/30/10 005 0270 4750
04630604 SPLINT -ELBOW FREEDOM-LARGE 59.00 06/30/10 005 0270 4750
04630607 SPLINT, ELBOW FREEDOM-MED 59.00 06/30/10 005 0270 4750
04630610 SPLINT, ELBOW FREEDOM-SMALL 59.00 06/30/10 005 0270 4750
04630613 SPLINT, ELBOW -TODDLER 59.00 06/30/10 005 0270 4750
04630616 SPLINT, ELBOW- INFANT 47.00 06/30/10 005 0270 4750
04630627 SLING HARRIS-HEMO R 75.00 06/30/10 005 0270 4750
04630635 SLING HARRIS-HEMO L 75.00 06/30/10 005 0270 4750
04630668 DOMES DIAPH TRANSDU 41.00 06/30/10 005 0270 4750
04630676 CERVICAL COLLAR SMA 41.00 06/30/10 005 0270 4750
04630684 CERVICAL COLLAR MED 51.00 06/30/10 005 0270 4750
04630691 SPLINT SFTY PIN SP. LG 47.00 06/30/10 005 0270 4750
04630692 CERVICAL COLLAR LAR 41.00 06/30/10 005 0270 4750
04630693 COLLAR STRAIGHT FOAM PEDS 69.00 06/30/10 005 0270 4750
04630724 DOME TRANSDUCER 40.00 06/30/10 005 0270 4750
04630725 DOME TRANSDUCER 35.00 06/30/10 005 0270 4750
04630726 DOMES TRANSDU INFAN 51.00 06/30/10 005 0270 4750
04630734 DOMES TRANS ST MEMB 40.00 06/30/10 005 0270 4750
04630759 DOMES STER DISP #55 47.00 06/30/10 005 0270 4750
04630761 KIT IUPC W/DISP TRANSDUCER 140.00 06/30/10 005 0270 4750
04630762 KIT IUPC W/TRANSDUCER AMNIONFU 170.00 06/30/10 005 0270 4750
04630764 KIT DIALYSIS CATHETER 384.00 06/30/10 005 0270 4750
04630767 ELECTROD SPIRAL #24 35.00 06/30/10 005 0270 4750
04630817 FOAM CUSHION 16.5X1 44.00 06/30/10 005 0270 4750
04630924 LAPIDUS AIRFLOAT SY 187.00 06/30/10 005 0270 4750
04630925 PAD LAPIDUS MATTRESS W/PUMP 281.00 06/30/10 005 0270 4750
04630926 PAD LAPIDUS /FM-SYST 63.00 06/30/10 005 0270 4750
04630999 RESTRAINT ANKLE 89.00 06/30/10 005 0270 4750
04631005 RESTRAINT WRIST 529.00 06/30/10 005 0270 4750
04631013 BAG, URINE METER 83.00 06/30/10 005 0270 4750
04631021 URISTIX REAGENT 100 101.00 06/30/10 005 0270 4750
04631039 ENDOTRACHEAL TUBE 3.0 U/C 33.00 06/30/10 005 0270 4750
04631088 TRACHEAL TUBE METAL 317.00 06/30/10 005 0270 4750
04631096 TRACHEAL TUBE METAL 317.00 06/30/10 005 0270 4750
04631112 TRACHEAL TUBE METAL 425.00 06/30/10 005 0270 4750
04631153 TRACH TUBE SHILEY 1 163.00 06/30/10 005 0270 4750
04631195 BANDAGE DOME 4 35.00 06/30/10 005 0270 4750
04631203 BANDAGE ELASTP 6 35.00 06/30/10 005 0270 4750
04631210 BANDAGE ELSTP 1" 16.00 06/30/10 005 0270 4750
04631211 BANDAGE ELASTP 2" 35.00 06/30/10 005 0270 4750
04631212 BANDAGE ELSTP 3" 21.00 06/30/10 005 0270 4750
04631215 BANDAGE ELSTP 6" 27.00 06/30/10 005 0270 4750
04631221 BLADE ASSEMBLY PREMIUM 40 35.00 06/30/10 005 0270 4750
04631229 CATH COUDE FOLEY 10 50.00 06/30/10 005 0270 4750
04631237 CATH COUDE FOLEY 20 50.00 06/30/10 005 0270 4750
04631245 CATH COUDE FOLEY 22 74.00 06/30/10 005 0270 4750
04631252 CATH COUDE FOLEY 24 50.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 27
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04631260 CATH COUDE FOLEY 26 60.00 06/30/10 005 0270 4750
04631275 CATHETER BIPOLAR PACING 6FR 284.00 06/30/10 005 0270 4750
04631278 CATH F0LEY 16-5CC 33.00 06/30/10 005 0270 4750
04631286 CATH F0LEY 18-5CC 33.00 06/30/10 005 0270 4750
04631294 CATH F0LEY 20-5CC 33.00 06/30/10 005 0270 4750
04631302 CATH F0LEY 22-5CC 41.00 06/30/10 005 0270 4750
04631310 CATH F0LEY 26-5CC 51.00 06/30/10 005 0270 4750
04631344 CATH F0LEY 14-30CC 40.00 06/30/10 005 0270 4750
04631351 CATH F0LEY 28-30CC 44.00 06/30/10 005 0270 4750
04631352 CATHETER FOL 30F 30CC 44.00 06/30/10 005 0270 4750
04631369 CATH F0LEY 16-30CC 63.00 06/30/10 005 0270 4750
04631377 CATH FOLEY 18-30CC 63.00 06/30/10 005 0270 4750
04631401 CATH FOLEY 3-WAY 18 63.00 06/30/10 005 0270 4750
04631402 CATHETER FOL 3W 16F 63.00 06/30/10 005 0270 4750
04631427 CATH F0LEY 3-WAY 20 63.00 06/30/10 005 0270 4750
04631428 CATHETER FOL 3W 20F 30CC 75.00 06/30/10 005 0270 4750
04631429 CATHETER FOLEY 3W 18FR 5CC 59.00 06/30/10 005 0270 4750
04631435 CATH F0LEY 3-WAY 22 33.00 06/30/10 005 0270 4750
04631436 CATHETER FOL 3W 22F 30CC 75.00 06/30/10 005 0270 4750
04631437 CATHETER FOLEY 3-WAY 16FR 5CC 44.00 06/30/10 005 0270 4750
04631443 CATH FOLEY 3-WAY 24F 27.00 06/30/10 005 0270 4750
04631450 CATH FOLEY 10-3CC 67.00 06/30/10 005 0270 4750
04631468 MENTOR TEL-E-CATH 27.00 06/30/10 005 0270 4750
04631476 CATH FOLEY 3-WAY 26 27.00 06/30/10 005 0270 4750
04631477 CATHETER FOL 3W 24F 30CC 50.00 06/30/10 005 0270 4750
04631484 CATH FOLEY 3-WAY 28 27.00 06/30/10 005 0270 4750
04631485 CATHETER FOL 3W 26F 30CC 33.00 06/30/10 005 0270 4750
04631492 CATH THORACIC 20FR 27.00 06/30/10 005 0270 4750
04631500 CATH THORACIC 24FR 27.00 06/30/10 005 0270 4750
04631518 CATH THORACIC 26FR 27.00 06/30/10 005 0270 4750
04631526 CATH THORACIC 28FR 27.00 06/30/10 005 0270 4750
04631527 DRAPE INCISE 48X50 #1060 50.00 06/30/10 005 0270 4750
04631674 KIT BLOOD FETAL ST 87.00 06/30/10 005 0270 4750
04631682 CLINITEST REAG 2DRP 51.00 06/30/10 005 0270 4750
04631708 WATER RES THPY ST 1 21.00 06/30/10 005 0270 4750
04631716 WATER RES THPY ST 3 21.00 06/30/10 005 0270 4750
04631732 IN RENO-M-DIP 14% 27.00 06/30/10 005 0270 4750
04631757 BOOT BIO LINERS 41.00 06/30/10 005 0270 4750
04631773 SWEEN CREAM 47.00 06/30/10 005 0270 4750
04631781 ADMIN. SET W-DOME 98.00 06/30/10 005 0270 4750
04631799 ADMIN. SET W-DOME-T 296.00 06/30/10 005 0270 4750
04631807 SPONGE LONG SCRUB 19.00 06/30/10 005 0270 4750
04631808 SPONGE LONG SCRUB BK 16.00 06/30/10 005 0270 4750
04631849 KIT CATH CTRL VEIN 126.00 06/30/10 005 0270 4750
04631872 UNDERWATER DRAINAGE 69.00 06/30/10 005 0270 4750
04631880 VENESECT"N MINOR OR 97.00 06/30/10 005 0270 4750
04634231 INVALID RING,RUBBER 47.00 06/30/10 005 0270 4750
04634561 AORTOGRAM TRAY 41.00 06/30/10 005 0270 4750
04634637 DISP INF LUMB PUNCT 50.00 06/30/10 005 0270 4750
04634777 GASTRIC LAVAGE,TBC 81.00 06/30/10 005 0270 4750
04634778 KIT GASTRIC LAVAGE 34 FR 276.00 06/30/10 005 0270 4750
04634892 PARACENTESIS TRAY 41.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 28
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04634975 SKIN BIOPSY TRAY 16.00 06/30/10 005 0270 4750
04636606 TUBE ENDOTRACH 5.0CM UNCUFFED 11.00 06/30/10 005 0270 4750
04636607 TUBE ENDOTRACH 5.5CM UNCUFFED 11.00 06/30/10 005 0270 4750
04636608 TUBE ENDOTRACH 2.0CM UNCUFFED 60.00 06/30/10 005 0270 4750
04636609 TUBE ENDOTRACH 6.0CM UNCUFFED 11.00 06/30/10 005 0270 4750
04636610 TUBE ENDOTRACH 6.5CM UNCUFFED 11.00 06/30/10 005 0270 4750
04636616 TUBE TRACH PED W OB 140.00 06/30/10 005 0270 4750
04636624 O-B SURGA SHIELDS 27.00 06/30/10 005 0270 4750
04638257 ABDOMINAL BINDERS 187.00 06/30/10 005 0270 4750
04638265 BUNNY BOOTS 107.00 06/30/10 005 0270 4750
04638273 CANES 19.00 06/30/10 005 0270 4750
04638281 CAST SHOES 35.00 06/30/10 005 0270 4750
04638282 SHOE CAST PEDIATRIC 35.00 06/30/10 005 0270 4750
04638283 SHOE CAST, MEDIUM 35.00 06/30/10 005 0270 4750
04638284 SHOE CAST, LARGE 35.00 06/30/10 005 0270 4750
04638285 CAST SOFT FABRIC 5" 4 YD 41.00 06/30/10 005 0270 4750
04638299 CLAVICAL STRAPS 67.00 06/30/10 005 0270 4750
04638300 SPLINT CLAVICAL, ADULT 82.00 06/30/10 005 0270 4750
04638301 SPLINT CLAVICAL, YOUTH 67.00 06/30/10 005 0270 4750
04638307 CRUTCHES (ALL SIZES) 133.00 06/30/10 005 0270 4750
04638308 CRUTCHES (CHILD SIZE) 107.00 06/30/10 005 0270 4750
04638314 IMMOBILIZER KNEE 13 126.00 06/30/10 005 0270 4750
04638315 KNEE IMMOBILIZERS 18 191.00 06/30/10 005 0270 4750
04638323 KNEE IMMOBILIZERS 2 191.00 06/30/10 005 0270 4750
04638331 PELVIC BELT UNIVERS 145.00 06/30/10 005 0270 4750
04638349 RIB BINDERS 67.00 06/30/10 005 0270 4750
04638356 BIO BOOTS 187.00 06/30/10 005 0270 4750
04638364 HEEL PROTECTOR 100.00 06/30/10 005 0270 4750
04644484 GUIDE NEEDLE 20 GAUGE 61.00 06/30/10 005 0270 4750
04645898 MID STREAM KIT 21.00 06/30/10 005 0270 4750
04645906 NIGHT DRAINAGE VALV 21.00 06/30/10 005 0270 4750
04645914 STOMA POUCH DRAIN 3 296.00 06/30/10 005 0270 4750
04645922 STOM POUC DRAN 3322 296.00 06/30/10 005 0270 4750
04645948 STMA PCH DRAIN 3223 296.00 06/30/10 005 0270 4750
04645955 STMA POUCH DRAIN #3 296.00 06/30/10 005 0270 4750
04645956 FECAL CONTAIN DEVICE W/SILICON 76.00 06/30/10 005 0270 4750
04645963 STMA PCH DRAIN 3225 255.00 06/30/10 005 0270 4750
04645997 UROSTOMY BAG #7472- 195.00 06/30/10 005 0270 4750
04646003 UROSTOMY BAG #7478- 181.00 06/30/10 005 0270 4750
04646011 UROSTOMY BAG #7473- 181.00 06/30/10 005 0270 4750
04646029 UROSTOMY BAG #7479- 181.00 06/30/10 005 0270 4750
04646037 UROSTOMY BAG #7474- 181.00 06/30/10 005 0270 4750
04646128 BONGRT MAX-E POUC O 96.00 06/30/10 005 0270 4750
04646136 BONGRT MAX-E PCH O/ 96.00 06/30/10 005 0270 4750
04646144 BONGRT MAX-E D/F AD 93.00 06/30/10 005 0270 4750
04646243 BONGORT URINARY POU 81.00 06/30/10 005 0270 4750
04646250 BONGORT URINARY PCH 87.00 06/30/10 005 0270 4750
04646284 BONGORT O-E DRAIN B 67.00 06/30/10 005 0270 4750
04646285 DRAIN IRRIGAT 2-1/4" CNTR LOCK 115.00 06/30/10 005 0270 4750
04646326 BONGRT O/E DRAIN BL 59.00 06/30/10 005 0270 4750
04646334 BONGORT DISP POUCH 72.00 06/30/10 005 0270 4750
04646359 ADJUSTABLE APPLIANC 44.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 29
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04646632 ADHESIVE MEDICAL SPRAY 42.00 07/01/10 005 0270 4750
04646763 ADJUSTABLE APPL BEL 40.00 06/30/10 005 0270 4750
04646839 BEAD-O-RING 21.00 06/30/10 005 0270 4750
04648050 WHITE FOAM VAC DRESSING 35.00 06/30/10 005 0270 4750
04648066 DRESSING OWENS 3"X8 440.00 06/30/10 005 0270 4750
04648223 PACK DRAINAGE HEAVY 21.00 06/30/10 005 0270 4750
04648470 BANDAGE ELASTIC 2" 21.00 06/30/10 005 0270 4750
04648488 BANDAGE ELASTIC 3" 21.00 06/30/10 005 0270 4750
04648496 BANDAGE ELASTIC 4" 21.00 06/30/10 005 0270 4750
04648504 BANDAGE ELASTIC 6" 21.00 06/30/10 005 0270 4750
04648510 BANDAGE BUBBLE STERILE 31.00 06/30/10 005 0270 4750
04648520 BANDAGE ELASTOPLAST 41.00 06/30/10 005 0270 4750
04648587 JELLY LUBRICATING PCT 11.00 06/30/10 005 0270 4750
04648595 LUBRICATING JEL PAC 35.00 06/30/10 005 0270 4750
04648637 PACKING 4"X7 YDS 147.00 06/30/10 005 0270 4750
04648694 DRESSING XEROFORM 1"X8" 44.00 06/30/10 005 0270 4750
04648695 DRESSING XEROFORM 5"X9" 13.00 06/30/10 005 0270 4750
04649171 ADMINISTRATION SET 44.00 06/30/10 005 0270 4750
04649187 TUBING ARTL PRSSRE PT06 11.00 06/30/10 005 0270 4750
04649188 TUBING ARTL PRSSRE P212 11.00 06/30/10 005 0270 4750
04649189 ARTERIAL PRESSURE T 271.00 06/30/10 005 0270 4750
04649213 BIOPSY PLEURAL-ABRA 59.00 06/30/10 005 0270 4750
04649214 TRAY PLEURAL BIOPSY 103.00 06/30/10 005 0270 4750
04649237 TRAY CATHERIZATION 33.00 06/30/10 005 0270 4750
04649262 CERVICAL BIOPSY TRA 35.00 06/30/10 005 0270 4750
04649270 CERVICAL SUTURE TRA 50.00 06/30/10 005 0270 4750
04649288 CHEST TUBE INSERTIO 114.00 06/30/10 005 0270 4750
04649312 CLIP REMOVAL TRAY 35.00 06/30/10 005 0270 4750
04649320 COLOCENTISIS TRAY 54.00 06/30/10 005 0270 4750
04649338 D & C TRAY 35.00 06/30/10 005 0270 4750
04649344 TRAY DRESSING CHG CSTM 16.00 06/30/10 005 0270 4750
04649345 TRAY DRESSING/CLINIC 27.00 06/30/10 005 0270 4750
04649346 DRESSING TRAY 50.00 06/30/10 005 0270 4750
04649353 ENDOMETRIAL BIOPSY 41.00 06/30/10 005 0270 4750
04649361 ENT TR/ER TRACHEOST 50.00 06/30/10 005 0270 4750
04649379 ENT TRAY W-HEAD MIR 50.00 06/30/10 005 0270 4750
04649387 FILIFORM TRAY 114.00 06/30/10 005 0270 4750
04649395 GYNE PROBE TRAY 35.00 06/30/10 005 0270 4750
04649411 IUD SET-UP TRAY 50.00 06/30/10 005 0270 4750
04649429 KIDNEY BIOPSY TRAY 75.00 06/30/10 005 0270 4750
04649437 LIPIODOL TRAY 35.00 06/30/10 005 0270 4750
04649440 NEEDLE LIVER BIOPSY(18GX10CM) 155.00 06/30/10 005 0270 4750
04649445 LIVER BIOPSY TRAY 75.00 06/30/10 005 0270 4750
04649446 KIT JEJUNOST NEEDLE CATH 7 FR 361.00 06/30/10 005 0270 4750
04649452 LUMBAR PUNCT TRAY A N/C 06/30/10 005 0270 4750
04649460 LUMBAR PUNCT TR AD 107.00 06/30/10 005 0270 4750
04649478 LUMBAR PUNCT TRAY C 44.00 06/30/10 005 0270 4750
04649486 MED PROCTO TRAY 101.00 06/30/10 005 0270 4750
04649494 MINOR SURGERY TRAY 63.00 06/30/10 005 0270 4750
04649502 NEONATAL LUMBAR PUN 96.00 06/30/10 005 0270 4750
04649510 PACKING TRAY 40.00 06/30/10 005 0270 4750
04649536 PELVIC TRAY SMALL 35.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 30
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04649544 PELVIC TRAY MEDIUM 35.00 06/30/10 005 0270 4750
04649551 PELVIC TRAY LARGE 40.00 06/30/10 005 0270 4750
04649569 PERICARDICENTESIS T 50.00 06/30/10 005 0270 4750
04649577 PLASTIC DRESSING TR 50.00 06/30/10 005 0270 4750
04649578 TRAY PLASTIC DRSSNG S 19.00 06/30/10 005 0270 4750
04649585 PROCTOSCOPE EXAM TR 97.00 06/30/10 005 0270 4750
04649593 PRESSURE ADM CUFFS 616.00 06/30/10 005 0270 4750
04649594 CUFF PRESSURE ADM. 1ML 281.00 06/30/10 005 0270 4750
04649601 SUBCLAVIAN TRAY 50.00 06/30/10 005 0270 4750
04649619 SUBDURAL TRAY 50.00 06/30/10 005 0270 4750
04649627 THORACENTESIS TRAY 122.00 06/30/10 005 0270 4750
04649634 TRAY TRACH ST W/O GLOVE 11.00 06/30/10 005 0270 4750
04649635 TRACHEOSTOMY CARE T 40.00 06/30/10 005 0270 4750
04649643 TRACHEOSTOMY EXCHG 35.00 06/30/10 005 0270 4750
04649668 TROCAR-CHEST W-CATH 100.00 06/30/10 005 0270 4750
04649676 TROCAR-CHEST W-CATH 100.00 06/30/10 005 0270 4750
04649684 TROCAR-CHEST W-CATH 75.00 06/30/10 005 0270 4750
04649692 TROCAR-CHEST W-CATH 100.00 06/30/10 005 0270 4750
04649700 TROCAR-CHEST W-CATH 100.00 06/30/10 005 0270 4750
04649718 TROCAR-CHEST W-CATH 60.00 06/30/10 005 0270 4750
04649726 UMBILICAL ARTERY CA 21.00 06/30/10 005 0270 4750
04649742 VAGINAL SPECULU TRA 35.00 06/30/10 005 0270 4750
04649767 VENESECTION/MINOR O 69.00 06/30/10 005 0270 4750
04649791 CURETTE SET (DERM) 54.00 06/30/10 005 0270 4750
04649792 TRAY CURRETTE SET 27.00 06/30/10 005 0270 4750
04649809 CYSTO IRRIG SET 2C4 75.00 06/30/10 005 0270 4750
04649825 EXCHANGE TRANSFUSION 287.00 06/30/10 005 0270 4750
04649827 TUBE COLLAR POSEY ENDOTRACH 44.00 06/30/10 005 0270 4750
04649831 TRAY STERNAL PNCT/CH 18.00 06/30/10 005 0270 4750
04649833 SET GASTRIC FEEDING W/BAG 21.00 06/30/10 005 0270 4750
04649834 SET FEEDING W/PUMP 115.00 06/30/10 005 0270 4750
04649837 TUBE FEEDING WEIGHTED 3GM 8FR 114.00 06/30/10 005 0270 4750
04649840 TUBE FEEDING SILK EFT 8FR 43" 109.00 06/30/10 005 0270 4750
04649841 TUBE FEED SILK WEIGHTD 8FR 43" 107.00 06/30/10 005 0270 4750
04649842 TUBE FEEDING SILK 5FR 89.00 06/30/10 005 0270 4750
04649843 TUBE FEEDING 6FR 81.00 06/30/10 005 0270 4750
04649844 SET TUBE FEEDING ACCESS BOLUS 50.00 06/30/10 005 0270 4750
04649845 TUBE FEED ACCESS SURE LOK EXT 50.00 06/30/10 005 0270 4750
04649849 TUBE CONTINUOUS FEED 18FR 41.00 06/30/10 005 0270 4750
04649850 TUBE BOLUS 18FR 41.00 06/30/10 005 0270 4750
04649858 INSTRUMENT SET PACK 47.00 06/30/10 005 0270 4750
04649874 LEVIN TBE ST 12,14 21.00 06/30/10 005 0270 4750
04649890 STERNAL PUNCTURE SE 75.00 06/30/10 005 0270 4750
04649908 SUTURE REMOVAL SET 40.00 06/30/10 005 0270 4750
04649924 UTERINE DIALATOR SE 35.00 06/30/10 005 0270 4750
04649932 ADHESIVE SOLVENT 100.00 06/30/10 005 0270 4750
04649940 AIRWAY INFANT 11.00 06/30/10 005 0270 4750
04649941 AIRWAY SMALL 11.00 06/30/10 005 0270 4750
04649942 TRAY/CL VAGINAL SPEC 35.00 06/30/10 005 0270 4750
04649981 BREAST PUMP 84.00 06/30/10 005 0270 4750
04649982 KIT BREAST DUAL HYGIENE 174.00 06/30/10 005 0270 4750
04649983 KIT BREAST PUMP HAND 1 DUAL 163.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 31
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04650000 SENSOR EXTEND BIS 105.00 06/30/10 005 0270 4750
04650003 BLD PRESS CUFF INFANT-N/S DUAL 17.00 06/30/10 005 0270 4750
04650006 CANNULA D.I.C. 6. 126.00 06/30/10 005 0270 4750
04650009 CANNULATOME 329.00 06/30/10 005 0270 4750
04650012 CANNULATING RX AUTOTOME 831.00 06/30/10 005 0270 3333
04651995 INTRACATH 8 INCH 21.00 06/30/10 005 0270 4750
04652001 INTRACATH 24 INCH 44.00 06/30/10 005 0270 4750
04652043 INTRACATH- 8 INCH 21.00 06/30/10 005 0270 4750
04652068 PELVIC TRAY, CHILD 27.00 06/30/10 005 0270 4750
04652076 TRAY PERITONEAL DLYSIS 51.00 06/30/10 005 0270 4750
04652092 PLASTIC IRRIGATING 16.00 06/30/10 005 0270 4750
04652126 TRAY SPECULUM (6) 21.00 06/30/10 005 0270 4750
04652175 TRACHEOTOMY CHANGE 16.00 06/30/10 005 0270 4750
04652266 PELVIC TRAY (CLINIC 16.00 06/30/10 005 0270 4750
04652274 EYE PREP TRAY 67.00 06/30/10 005 0270 4750
04652332 VENESECTION TRAY 50.00 06/30/10 005 0270 4750
04652340 VENESECTION INSTRUM 36.00 06/30/10 005 0270 4750
04652381 SENGSTAKEN TUBE TRA 318.00 06/30/10 005 0270 4750
04652431 BOTTLE CHEST DRAIN AD 33.00 06/30/10 005 0270 4750
04652432 TRAY CARDIAC CLOSURE 143.00 06/30/10 005 0270 4750
04652433 TRAY CHEST TUBE INSERT 57.00 06/30/10 005 0270 4750
04652563 BIOPSY CERV. PUNCH 16.00 06/30/10 005 0270 4750
04652670 CIRCUMCISION TRAY DSP 1.1 143.00 06/30/10 005 0270 4750
04655152 PACING KITS 580.00 06/30/10 005 0270 4750
04655153 PROBE PULSE OXIMETRY NEONATAL 82.00 06/30/10 005 0270 4750
04655154 PROBE PULSE OXIMETRY INFANT 100.00 06/30/10 005 0270 4750
04655155 PROBE PULSE OXIMETRY PED 73.00 06/30/10 005 0270 4750
04655156 PROBES TEMP SKIN DISP 36.00 06/30/10 005 0270 4750
04655157 PROBES TEMP SKIN C100 59.00 06/30/10 005 0270 4750
04655160 PACING PROBE 596.00 06/30/10 005 0270 4750
04655178 APPLIANCE BELT ADJ 27.00 06/30/10 005 0270 4750
04655301 AIRWAY-MED 21.00 06/30/10 005 0270 4750
04655304 AIRWAY- 7.5 PHARYNGEAL 35.00 06/30/10 005 0270 4750
04655319 AIRWAY-LARGE 21.00 06/30/10 005 0270 4750
04655343 HEMOVAC-MED 179.00 06/30/10 005 0270 4750
04655344 CLOSED WOUND DRAINAGE DEVICE 149.00 06/30/10 005 0270 4750
04655368 LEVIN TUBE 16 21.00 06/30/10 005 0270 4750
04655459 FLOTATION WATER MAT 314.00 06/30/10 005 0270 4750
04655475 INTRODUCER 6 FRENCH 137.00 06/30/10 005 0270 4750
04655478 INTRODUCER 5 FRENCH 167.00 06/30/10 005 0270 4750
04655481 INTRODUCER 4.5 FRENCH 137.00 06/30/10 005 0270 4750
04655484 GUIDE NEEDLE 20 GAUGE 61.00 06/30/10 005 0270 4750
04655487 PICC POLY 4 FRENCH SINGLE LUM 602.00 06/30/10 005 0270 4750
04655490 PICC POLY 5 FRENCH DUAL LUM 602.00 06/30/10 005 0270 4750
04655493 PICC POWER 6 FRENCH DUAL LUM 602.00 06/30/10 005 0270 4750
04655496 PICC POWER 5 FRENCH SING LUM 602.00 06/30/10 005 0270 4750
04655499 PICC POLY 4 FRENCH DUAL LUM 602.00 06/30/10 005 0270 4750
04657083 ASEPTO SYRINGE 155.00 06/30/10 005 0270 4750
04657091 BASIN, STERILE 21.00 06/30/10 005 0270 4750
04658008 CANNISTER SUCTION 21.00 06/30/10 005 0270 4750
04658065 DISPOZ-A-BAG 16.00 06/30/10 005 0270 4750
04658099 ENDOTRACHEAL TUBE 2.5 U/C 33.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 32
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04658100 ENDOTRACHEAL TUBE 3.0 U/C 33.00 06/30/10 005 0270 4750
04658107 ENDOTRACHEAL TUBE 3.5 U/C 33.00 06/30/10 005 0270 4750
04658115 ENDOTRACHEAL TUBE 4.0 U/C 33.00 06/30/10 005 0270 4750
04658123 ENDOTRACHEAL TUBE 4 35.00 06/30/10 005 0270 4750
04658131 ENDOTRACHEAL TUBE 5.5 CF 33.00 06/30/10 005 0270 4750
04658149 ENDOTRACHEAL TUBE 6.0 CF 33.00 06/30/10 005 0270 4750
04658156 ENDOTRACHEAL TUBE 6.5 CF 33.00 06/30/10 005 0270 4750
04658164 ENDOTRACHEAL TUBE 7.0 CF 33.00 06/30/10 005 0270 4750
04658172 ENDOTRACHEAL TUBE 7.5 CF 33.00 06/30/10 005 0270 4750
04658180 ENDOTRACHEAL TUBE 8.0 CF 33.00 06/30/10 005 0270 4750
04658198 ENDOTRACHEAL TUBE 8.5 CF 33.00 06/30/10 005 0270 4750
04658206 ENDOTRACHEAL TUBE 9.0 CF 33.00 06/30/10 005 0270 4750
04658214 ENDOTRACHEAL TUBE 9.5 CF 33.00 06/30/10 005 0270 4750
04658222 ENDOTRACHEAL TUBE 10.0 CF 39.00 06/30/10 005 0270 4750
04658248 GASTRIC LAVAGE 205.00 06/30/10 005 0270 4750
04658255 HEMOVAC 179.00 06/30/10 005 0270 4750
04658321 INTERCATH 24" 17G 1 21.00 06/30/10 005 0270 4750
04658347 LEVINE TUBE 21.00 06/30/10 005 0270 4750
04658405 CUFF VITA HOHN 7FR DUAL LUMEN 999.00 06/30/10 005 0270 4750
04658406 CUFF VITA HOHN 5FR SINGLE LUMN 800.00 06/30/10 005 0270 4750
04658407 DRAIN BAG GRAV TRU-CLOSE600ML 73.00 06/30/10 005 0270 4750
04658408 SET PERCUTAN CHEST TUBE 2800 341.00 06/30/10 005 0270 4750
04658409 AUTO TRANSFUSION RECEPTICAL 248.00 06/30/10 005 0270 4750
04658410 SET PERCUTAN CHEST TUBE 2400 341.00 06/30/10 005 0270 4750
04658411 SET PERCUTAN CHEST TUBE 3200 341.00 06/30/10 005 0270 4750
04658412 PLEUR-VAC ADULT 500.00 06/30/10 005 0270 4750
04658413 DRAIN LUMB SYS FOR SPIN FLUID 514.00 06/30/10 005 0270 4750
04658414 STERILE DRAINAGE BAG 77.00 06/30/10 005 0270 4750
04658415 DRAINAGE EXTERNAL VENTRICULAR 677.00 06/30/10 005 0270 4750
04658416 TRANSFUSION DRAINAGE SET 746.00 06/30/10 005 0270 4750
04658417 PREFILTER FOR TRANSFUSN DRNAGE 54.00 06/30/10 005 0270 4750
04658418 BACTER FILTER TRANSFUSN DRNAGE 54.00 06/30/10 005 0270 4750
04658419 CATH SINGLE LUMEN 2.5FR 2.5CM 159.00 06/30/10 005 0270 4750
04658420 CATH SINGLE LUMEN 3.0 FR 5.0CM 168.00 06/30/10 005 0270 4750
04658421 CATH SINGLE LUMEN 3.0FR 12.7CM 181.00 06/30/10 005 0270 4750
04658422 CATH DOUBLE LUMEN 4.0FR 5CM 276.00 06/30/10 005 0270 4750
04658423 CATH SET MUDGE PED AV 5/6 FR 281.00 06/30/10 005 0270 4750
04658424 CATH CHEST TUBE 16FR 394.00 06/30/10 005 0270 4750
04658425 CATH INTRODUCER 6.0 FR 5CM 125.00 06/30/10 005 0270 4750
04658426 CATHETER WIRE 0.15" 30CM 75.00 06/30/10 005 0270 4750
04658427 CATHETER WIRE .025" 50CM 81.00 06/30/10 005 0270 4750
04658428 CATHETER WIRE .025" 80CM 81.00 06/30/10 005 0270 4750
04658429 CATHETER WIRE .035" 100CM 81.00 06/30/10 005 0270 4750
04658430 CATH STRAIGHT 11.5FR 13.5CM 255.00 06/30/10 005 0270 4750
04658431 CTH LNG STRAIGHT 11.5FR 19.5CM 255.00 06/30/10 005 0270 4750
04658432 CATH 11.5FR 24CM 255.00 06/30/10 005 0270 4750
04658433 CATH CURVED 11.5FR 13.5CM 271.00 06/30/10 005 0270 4750
04658434 CATH LONG CURVED 11.5FR 19.5CM 271.00 06/30/10 005 0270 4750
04658435 CATH MAHURKAR 11.5FR 13.5CM 542.00 06/30/10 005 0270 4750
04658436 CATHETER DBL LUMEN 4FR 8CM 371.00 06/30/10 005 0270 4750
04658437 CATHETER DBL LUMEN 5FR 15CM 361.00 06/30/10 005 0270 4750
04658438 CATHETER TRIPLE LUMEN 5FR 8CM 383.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 33
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04658439 CATHETER TRIPLE LUMEN 5FR 15CM 302.00 06/30/10 005 0270 4750
04658440 CATHETER TRIPLE LUMEN 7FR 20CM 384.00 06/30/10 005 0270 4750
04658441 CATH TRIPLE LUMEN 5FR 25CM 369.00 06/30/10 005 0270 4750
04658442 TRAY CHEST TUBE 20FR 436.00 06/30/10 005 0270 4750
04658443 TRAY CHEST TUBE 12FR 436.00 06/30/10 005 0270 4750
04658444 CATH TRIPLE LUMEN 5FR 5CM 394.00 06/30/10 005 0270 4750
04658453 RUBBER RING 93.00 06/30/10 005 0270 4750
04658461 SALEM SUMP TUBE 14 21.00 06/30/10 005 0270 4750
04658487 NEEDLE SPINAL 20GA X 3-1/2" 16.00 06/30/10 005 0270 4750
04658488 NEEDLE SPINAL 22GA X 1-1/2" 16.00 06/30/10 005 0270 4750
04658489 NEEDLE SPINAL 22GA X 3-1/2" 16.00 06/30/10 005 0270 4750
04658490 NEEDLE SPINAL 25GA X 3-1/2" 16.00 06/30/10 005 0270 4750
04658491 NEEDLE SPINAL 18GA X 2-1/2" 11.00 06/30/10 005 0270 4750
04658492 NEEDLE SPINAL 18GA X 3-1/2" 16.00 06/30/10 005 0270 4750
04658493 NEEDLE SPINAL 14GA X 2" 13.00 06/30/10 005 0270 4750
04658494 NEEDLE SPINAL 20GA X 1-1/2" 13.00 06/30/10 005 0270 4750
04658495 STOPCOCK PH-3W K69 11.00 06/30/10 005 0270 4750
04658496 SYRINGE FILL TUBE QFT-200 11.00 06/30/10 005 0270 4750
04658503 SWANZ GANZ #5 229.00 06/30/10 005 0270 4750
04658511 SWANZ GANZ #7 317.00 06/30/10 005 0270 4750
04658599 SILVER TUBE AGENTO 350.00 06/30/10 005 0270 4750
04658602 TUBE TRACH SILAST 97.00 06/30/10 005 0270 4750
04658603 TRACHEAL TUBE SILASTIC SZ 3 236.00 06/30/10 005 0270 4750
04658606 TRACHEAL TUBE SILASTIC SZ 6 236.00 06/30/10 005 0270 4750
04658628 URETHRAL DRAINAGE BAG 35.00 06/30/10 005 0270 4750
04658636 URINARY DRAINAGE BAG 35.00 06/30/10 005 0270 4750
04658883 CATHETER COMDE FOLE 63.00 06/30/10 005 0270 4750
04658884 CATHETER COUDE 10 FR 3CC 50.00 06/30/10 005 0270 4750
04658891 CATHETER COUD FOLEY 50.00 06/30/10 005 0270 4750
04658899 SILVER TUBE- AGENTO 350.00 06/30/10 005 0270 4750
04658909 CATHETER COUD FOLEY 77.00 06/30/10 005 0270 4750
04658917 CATHETER COUD FOLEY 74.00 06/30/10 005 0270 4750
04658925 CATHETER COUD PLAIN 27.00 06/30/10 005 0270 4750
04658958 CATHETER COUD PLAIN 27.00 06/30/10 005 0270 4750
04658966 CATHETER COUD PLAIN 27.00 06/30/10 005 0270 4750
04658974 CATHETER COUD PLAIN 27.00 06/30/10 005 0270 4750
04658982 CATHETER COUD PLAIN 27.00 06/30/10 005 0270 4750
04658990 CATHETER COUD PLAIN 27.00 06/30/10 005 0270 4750
04659048 DISP U-BAGS, PEDS 11.00 06/30/10 005 0270 4750
04659055 UROSTOMY DRAIN TUBE 40.00 06/30/10 005 0270 4750
04659071 DISP BIOPSY NEEDLE 11CM X 4 60.00 06/30/10 005 0270 4750
04659072 NEEDLE BIOPSY 15.2CM X 6" 60.00 06/30/10 005 0270 4750
04659073 INSTRU BIOPSY 14G NEEDLE 16 CM 201.00 06/30/10 005 0270 4750
04659074 INSTRUMENT BIOPSY MAXICORE 140.00 06/30/10 005 0270 4750
04659089 DRAIN SET W/CAP 33.00 06/30/10 005 0270 4750
04659097 HEMOVAC 93.00 06/30/10 005 0270 4750
04659112 CATHETER FGRTY EMBOL 5F 145.00 06/30/10 005 0270 4750
04659113 FOGARTY EMBOLEC CAT 339.00 06/30/10 005 0270 4750
04659121 FOGARTY EMBOLEC CAT 199.00 06/30/10 005 0270 4750
04659122 CATHETER ENTERECLYSIS 538.00 06/30/10 005 0270 4750
04659123 CATH MAGLINITE ENTEROCLYSIS 467.00 06/30/10 005 0270 4750
04659220 DRAIN KARAYA BG 1.2 205.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 34
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04659238 DRAIN KARAYA BG 1.5 149.00 06/30/10 005 0270 4750
04659246 DRAIN KARAYA BG 1.7 215.00 06/30/10 005 0270 4750
04659253 DRAIN KARAYA BAGS- 199.00 06/30/10 005 0270 4750
04659261 DRAIN KARAYA BAGS-2 205.00 06/30/10 005 0270 4750
04659279 DRAIN KARAYA BAGS-3 205.00 06/30/10 005 0270 4750
04659287 POUCH W/ADHESIVE F.S. 1-1/4" 126.00 06/30/10 005 0270 4750
04659288 POUCH W/ADHESIVE F.S. 1-1/2" 93.00 06/30/10 005 0270 4750
04659291 POUCH RETRACTED PENIS 10/BOX 163.00 06/30/10 005 0270 4750
04659436 S\G THERMODIL CATH- 459.00 06/30/10 005 0270 4750
04660001 ISOLATION CART 514.00 06/30/10 005 0270 4750
04660336 OPTICATH INTRAVASC 4FR/25CM 1165.00 06/30/10 005 0270 4750
04660854 CATHETER SUCTION 5 FR NEONATAL 96.00 06/30/10 005 0270 4750
04660855 CATHETER SUCTION KIT 5FR 11.00 06/30/10 005 0270 4750
04660856 CATHETER SUCT KIT 6.5FR 11.00 06/30/10 005 0270 4750
04660857 CATHETER SUCT KIT 8FR 11.00 06/30/10 005 0270 4750
04660858 CATHETER SUCT KIT 10FR 11.00 06/30/10 005 0270 4750
04660859 CATHETER SUCT KIT 14FR 13.00 06/30/10 005 0270 4750
04660860 CATHETER SUCT KIT 18FR 11.00 06/30/10 005 0270 4750
04660864 CATH TRACH SUCTION SYS 8FR 96.00 06/30/10 005 0270 4750
04660865 CATHETER SUCTION 6 FR 93.00 06/30/10 005 0270 4750
04660866 CATHETER SUCTION 8 FR 93.00 06/30/10 005 0270 4750
04660867 CATHETER SUCTION 10 FR 75.00 06/30/10 005 0270 4750
04660868 CATHETER SUCTION 14 FR 91.00 06/30/10 005 0270 4750
04660869 CATHETER SUCTION 16 FR 75.00 06/30/10 005 0270 4750
04660870 CATH SUCT CLOSED SYS PEDS 10FR 82.00 06/30/10 005 0270 4750
04660996 CATH. 10FR. 20CC W/TRAP-5'S 40.00 06/30/10 005 0270 4750
04661002 CATHETER EXTERNAL 11.00 06/30/10 005 0270 4750
04661003 CATHETER EXT MALE MED 11.00 06/30/10 005 0270 4750
04661010 PACK URETHRAL CATH TRAY 19.00 06/30/10 005 0270 4750
04661028 CATH. RAD. ARTY KIT 57.00 06/30/10 005 0270 4750
04661036 MYELOGRAM TRAY 20GX31/2 72.00 06/30/10 005 0270 4750
04661051 TUBE HI-LO LANZ 9.5 203.00 06/30/10 005 0270 4750
04661052 TUBE TRACH HI-LOW LANZ 10.5 203.00 06/30/10 005 0270 4750
04661053 TUBE TRACH W/FLEX 351.00 06/30/10 005 0270 4750
04661069 TUBE TRACH HI-LO 165 6.5 170.00 06/30/10 005 0270 4750
04661085 TRANSDUCER SYSTEM 147.00 06/30/10 005 0270 4750
04661093 TRANSPAC DSP 71.00 06/30/10 005 0270 4750
04661094 KIT MONITORING SET W/SAFESET 142.00 06/30/10 005 0270 4750
04661101 COMMUNI TRACH TUBE 7.0 341.00 06/30/10 005 0270 4750
04661119 CATHETER 5CC 24FR 59.00 06/30/10 005 0270 4750
04661120 CATHETER FOLEY 12FR 5CC 44.00 06/30/10 005 0270 4750
04661127 CATHETER 2-WAY 30CC 59.00 06/30/10 005 0270 4750
04661135 CATHETER 2-WAY 30CC 57.00 06/30/10 005 0270 4750
04661143 CATHETER 2-WAY 30CC 51.00 06/30/10 005 0270 4750
04661150 CATHETER 2-WAY 30CC 51.00 06/30/10 005 0270 4750
04661166 CATHETER FOL 2W 28F 5CC 40.00 06/30/10 005 0270 4750
04661167 CATHETER FOL 2W 30F 5CC 40.00 06/30/10 005 0270 4750
04661168 CATHETER 2-WAY 30CC 57.00 06/30/10 005 0270 4750
04661176 CATHETER FOLEY 2W 16FR 30CC 13.00 06/30/10 005 0270 4750
04661192 AIRWAY WEISS EMG. SYST. 640.00 06/30/10 005 0270 4750
04661194 SET PERCUTANEOUS TRACH 882.00 06/30/10 005 0270 4750
04661195 CATH MELKER CRICOTHYROTOMY 404.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 35
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04661196 CATH AIRWAY EXCHANGE 163.00 06/30/10 005 0270 4750
04661200 FORCEP HICKMAN 4 1/2" 72.00 06/30/10 005 0270 4750
04661218 CATHETER FOGARTY EMBOL 12FR 145.00 06/30/10 005 0270 4750
04661219 CATHETER FOGARTY EMBOL 6FR 184.00 06/30/10 005 0270 4750
04661220 CATHETER FOGARTY EMBOL 4FR 89.00 06/30/10 005 0270 4750
04661226 CATHETER FOLEY 3CC 67.00 06/30/10 005 0270 4750
04661234 CATHETER FOLEY 5CC 51.00 06/30/10 005 0270 4750
04661242 CATHETER 30CC 35.00 06/30/10 005 0270 4750
04661259 CATH HICKMAN R/ATR KIT 359.00 06/30/10 005 0270 4750
04661267 CATH TRAY FOLEY 5CC 87.00 06/30/10 005 0270 4750
04661283 CATH TRAY FOLEY 5CC 60.00 06/30/10 005 0270 4750
04661341 CATHETER KENDAL 18F 50.00 06/30/10 005 0270 4750
04661366 CATHETER KENDAL 14F 44.00 06/30/10 005 0270 4750
04661382 BLOOD SET 84" STR 21.00 06/30/10 005 0270 4750
04661390 BLOOD SET Y-TYPE 82 21.00 06/30/10 005 0270 4750
04661416 BLOOD WARMING COIL 173.00 06/30/10 005 0270 4750
04661424 HEMOSET W/CHAIR CLAMP 57.00 06/30/10 005 0270 4750
04661432 SET BLOOD ABB 45100 36.00 06/30/10 005 0270 4750
04661457 FILTER BLOOD 4C2423 41.00 06/30/10 A4755 005 0270 4750
04661465 FILTER BLOOD FW 4C2195 56.00 06/30/10 A4755 005 0270 4750
04661473 CVP MANOMETER 56.00 06/30/10 005 0270 4750
04661474 CVP MANOMETER 4-WAY 36.00 06/30/10 005 0270 4750
04661481 SET CONTINUOUS IRRIG W/CATH 40.00 06/30/10 005 0270 4750
04661499 DIAL-A-FLOW IV 30 18.00 06/30/10 005 0270 4750
04661504 SET IV METERED CHAMBER W/FILTR 50.00 06/30/10 005 0270 4750
04661505 SET IV METERED CHAMBR NO FILTR 36.00 06/30/10 005 0270 4750
04661506 TUBING IV FOR SYRINGE INFUSION 30.00 06/30/10 005 0270 4750
04661507 IV SET 2C0129 84.00 06/30/10 005 0270 4750
04661508 IV SET PED 2C9123 11.00 06/30/10 005 0270 4750
04661509 IV SET 2C1580 11.00 06/30/10 005 0270 4750
04661510 IV SET 2C1584 16.00 06/30/10 005 0270 4750
04661515 IV SET W 1 (Y-SET) 21.00 06/30/10 005 0270 4750
04661523 IV SET NUB-DRUO W1 21.00 06/30/10 005 0270 4750
04661530 IV VENOSET SECONDARY 18.00 06/30/10 005 0270 4750
04661531 IV SET VENOSET 78 SC 16.00 06/30/10 005 0270 4750
04661549 IV SET BURETRO INL 84.00 06/30/10 005 0270 4750
04661556 IV SET BURETRO PLAI 84.00 06/30/10 005 0270 4750
04661564 IV SET EXTENSION-30 11.00 06/30/10 005 0270 4750
04661571 SETIV GEMINI VEN/NON-VENT#2420 31.00 06/30/10 005 0270 4750
04661572 IV SAIF SET 10 MICRON 16.00 06/30/10 005 0270 4750
04661573 SET IV ADMIN GEMINI SHORT#2255 31.00 06/30/10 005 0270 4750
04661574 SET IV GEMINI NITRO & FAT EMUL 40.00 06/30/10 005 0270 4750
04661575 SET IV ADMIN MANIGOLD GEMINI 56.00 06/30/10 005 0270 4750
04661576 SET IV ADMIN GEMINI 60 DROP 27.00 06/30/10 005 0270 4750
04661577 SET IV GEMINI 3-SAFE SITE 57.00 06/30/10 005 0270 4750
04661578 SET IV ADD I-MED GEM VENT/NON 50.00 06/30/10 005 0270 4750
04661579 SET IV GEMINI VENT/NON VENT 20 69.00 06/30/10 005 0270 4750
04661580 FILTER PALL ULTIPOR 16.00 06/30/10 005 0270 4750
04661581 SET BLOOD ADMIN GEMINI Y SITE 54.00 06/30/10 005 0270 4750
04661582 BAG COLLECTION 16.00 06/30/10 005 0270 4750
04661583 CONTAINER CHEMO DISP 8 GALLONS 75.00 06/30/10 005 0270 4750
04661584 SET IV ADMIN PCA LONG MINIBORE 37.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 36
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04661585 SET IV IMED N/VENT METER CHMBR 84.00 06/30/10 005 0270 4750
04661586 SET IV ADMIN OMNIFLOW P M-BORE 89.00 06/30/10 005 0270 4750
04661587 SET IV IMED N/VENT .2 MIC FILT 31.00 06/30/10 005 0270 4750
04661588 SET IV ADMIN IMED N/VENT 2 INJ 31.00 06/30/10 005 0270 4750
04661589 SET IV IMED W, W/O PROP CHMBR 60.00 06/30/10 005 0270 4750
04661590 SET IV ADMIN W/2 Y SITES EX DR 41.00 06/30/10 005 0270 4750
04661591 SET IV ADMIN SEC FOR OMNI-FLOW 16.00 06/30/10 005 0270 4750
04661592 SET BLOOD 4C2193 27.00 06/30/10 005 0270 4750
04661593 SET MICRO PUMP W/Y INJ 63.00 06/30/10 005 0270 4750
04661594 SET SOLUSET MICRO PUMP 150ML 51.00 06/30/10 005 0270 4750
04661595 FOOT CUSHION PAD 67.00 06/30/10 005 0270 4750
04661596 CASSETTES IMED 54.00 06/30/10 005 0270 4750
04661597 SET EXTENSION 60" MINI-VOL 16.00 06/30/10 005 0270 4750
04661598 ADMIN SET ERIKA 21.00 06/30/10 005 0270 4750
04661606 CATH TRAY S/G 136.00 06/30/10 005 0270 4750
04661614 BATH CON POTASSIUM 21.00 06/30/10 005 0270 4750
04661630 DRESSING 4X4 DUODERM 101.00 06/30/10 005 0270 4750
04661631 DRESSING 4X4 EXT-THIN DUODERM 109.00 06/30/10 005 0270 4750
04661632 DRESSING TEGADERM 4X4 SOD CLOR 271.00 06/30/10 005 0270 4750
04661635 DRESSING 6X6 DUODERM 204.00 06/30/10 005 0270 4750
04661648 DRESSING 8X8 DUODERM 230.00 06/30/10 005 0270 4750
04661649 DRESSING 4"X5" DUODERM 174.00 06/30/10 005 0270 4750
04661650 DRESSING DUODERM 6"X7" 378.00 06/30/10 005 0270 4750
04661655 URINOMETER SM. 19.00 06/30/10 005 0270 4750
04661663 CANNULA INNER 8.0 18.00 06/30/10 005 0270 4750
04661671 CANNULA INNER 9.0 18.00 06/30/10 005 0270 4750
04661674 CATHETER LAB 40CC PROFILE 8FR. 4217.00 06/30/10 005 0270 4750
04661675 CATHETER BALLOON DL 10.5FR 4371.00 06/30/10 005 0270 4750
04661689 CATH COUDE 14FR. 5CC 60.00 06/30/10 005 0270 4750
04661697 CATHETER MALECOT 10F 63.00 06/30/10 005 0270 4750
04661698 CATHETER MALECOT 12F 63.00 06/30/10 005 0270 4750
04661699 CATHETER MALECOT 14F 63.00 06/30/10 005 0270 4750
04661700 CATHETER MALECOT 16F 69.00 06/30/10 005 0270 4750
04661701 CATHETER MALECOL 18F 63.00 06/30/10 005 0270 4750
04661702 CATHETER MALECOT 20F 47.00 06/30/10 005 0270 4750
04661703 CATHETER MALECOT 22F 47.00 06/30/10 005 0270 4750
04661704 CATHETER MALECOT 24F 47.00 06/30/10 005 0270 4750
04661706 CATHETER MALECOT 26F 47.00 06/30/10 005 0270 4750
04661707 CATHETER MALECOT 28F 47.00 06/30/10 005 0270 4750
04661708 CATHETER MALECOT 34F 47.00 06/30/10 005 0270 4750
04661709 CATHETER MALECOT 36F 47.00 06/30/10 005 0270 4750
04661710 CATHETER MALECOT 38F 60.00 06/30/10 005 0270 4750
04661711 CATHETER MALECOT 40F 60.00 06/30/10 005 0270 4750
04661712 CATHETER MALECOT 30F 75.00 06/30/10 005 0270 4750
04661739 CATH STYLET RUSCH 27.00 06/30/10 005 0270 4750
04661896 TUBE TRACHEAL MTL 4L 97.00 06/30/10 005 0270 4750
04661911 ALCOHOL RUBBING 16 21.00 06/30/10 005 0270 4750
04661937 HIBICLENS 32 OZ 44.00 06/30/10 005 0270 4750
04661945 HIBICLENS 8OZ 21.00 06/30/10 005 0270 4750
04661952 HYDROGEN PEROXID 3% 21.00 06/30/10 005 0270 4750
04661960 ISOPROPXL ALCOH 70% 21.00 06/30/10 005 0270 4750
04661978 ISOPROPY ALCOHOL 70 40.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 37
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04661986 POVIDINE IODINE 16 21.00 06/30/10 005 0270 4750
04661994 POVIDINE IODINE GAL 60.00 06/30/10 005 0270 4750
04662000 CATH SP CNF CRVD 390.00 06/30/10 005 0270 4750
04662018 CATH URO BRD 10F 21.00 06/30/10 005 0270 4750
04662026 CATH THRMDLT 7.5F 517.00 06/30/10 005 0270 4750
04662028 PROBE CHANDLR TRANSLUM V PAC 586.00 06/30/10 005 0270 4750
04662029 SET CATHETER H/S 272.00 06/30/10 005 0270 4750
04662030 CATHETER FOR H/S 7FR 136.00 06/30/10 005 0270 4750
04662034 CATH THRMDLT 3F 456.00 06/30/10 005 0270 4750
04662042 CATH THRMDLT 2.5F 424.00 06/30/10 005 0270 4750
04662059 CATH THRMDLT 3.5F 456.00 06/30/10 005 0270 4750
04662067 CATH THRMDLT 4.0F 456.00 06/30/10 005 0270 4750
04662125 GRANULES DUODERM 5'S 100.00 06/30/10 005 0270 4750
04662133 CUFF BP DSP CHLD 41.00 06/30/10 005 0270 4750
04662141 PAD CONVL 20X72X2 60.00 06/30/10 005 0270 4750
04662158 PAD WHEELCHAIR 4" FM 21.00 06/30/10 005 0270 4750
04662165 RESTRAINT LH FOAM ADJ 11.00 06/30/10 005 0270 4750
04662166 RESTRAINT L.H. ADJ 19.00 06/30/10 005 0270 4750
04662174 BOOT VASCULAR BIO-SNC SM 245.00 06/30/10 005 0270 4750
04662175 BOOT VASCULAR BIO-SNC MED 245.00 06/30/10 005 0270 4750
04662176 BOOT VASCULAR BIO-SNC LG 197.00 06/30/10 005 0270 4750
04662180 HOSE SPPRT JOBST S-M-L-114334 189.00 06/30/10 005 0270 4750
04662181 HOSE SPPRT JOBST S-M-L-114340 189.00 06/30/10 005 0270 4750
04662182 HOSE SUPPORT SGV S/M/L 1634 181.00 06/30/10 005 0270 4750
04662183 HOSE SUPPORT SGV S-M-L 1640 181.00 06/30/10 005 0270 4750
04662190 SHOE, REESE, WOMEN SMALL 65.00 06/30/10 005 0270 4750
04662191 SHOE, REESE, WOMEN MED 65.00 06/30/10 005 0270 4750
04662192 SHOE, REESE, WOMEN LARGE 65.00 06/30/10 005 0270 4750
04662193 SHOE, REESE, MEN SMALL 54.00 06/30/10 005 0270 4750
04662194 SHOE, REESE, MEN MED 54.00 06/30/10 005 0270 4750
04662195 SHOE, REESE, MEN LARGE 65.00 06/30/10 005 0270 4750
04662196 PILLOW, HIP ABDUCTION SMALL 409.00 06/30/10 005 0270 4750
04662197 PILLOW, HIP ABDUCTION MED 436.00 06/30/10 005 0270 4750
04662198 PILLOW, HIP ABDUCTION LARGE 409.00 06/30/10 005 0270 4750
04662199 SEAT, TOILET RAISED 120.00 06/30/10 005 0270 4750
04664162 RESTRAINTS, POSEY SM 87.00 06/30/10 005 0270 4750
04664163 VEST PSY SAFTY MED 93.00 06/30/10 005 0270 4750
04664164 VEST PSY SFTY LG 93.00 06/30/10 005 0270 4750
04664238 LARYN TUBE, NUMBER 98.00 06/30/10 005 0270 4750
04664378 COLOPLAST FISTULA P 60.00 06/30/10 005 0270 4750
04664402 IRRIGATION SET 107.00 06/30/10 005 0270 4750
04664403 COMB C/T STRT SET 125.00 06/30/10 005 0270 4750
04664404 COLLECTOR FECAL INCONTIN MED 33.00 06/30/10 005 0270 4750
04664436 RELIASEAL #12 1-2 T 44.00 06/30/10 005 0270 4750
04664444 SKIN PREP WIPES 47.00 06/30/10 005 0270 4750
04664451 SKIN BOND CEMENT 16.00 06/30/10 005 0270 4750
04664485 PERI-WASH SPRAY 41.00 06/30/10 005 0270 4750
04664519 HOLLISTER DRNBL BG 116.00 06/30/10 005 0270 4750
04664550 CONVERT-A-POUCH FAC 36.00 06/30/10 005 0270 4750
04664634 SUPERIOR ORTHOPEDIC 69.00 06/30/10 005 0270 4750
04664667 ADHESIVE GASKETS-LA 54.00 06/30/10 005 0270 4750
04665000 SENSOR FLOTRAC 784.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 38
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04665052 FLIP-TOP VALVE 21.00 06/30/10 005 0270 4750
04665128 URINARY DIVER PCH C 109.00 06/30/10 005 0270 4750
04665136 URINARY DIVER POUC 87.00 06/30/10 005 0270 4750
04665144 SKIN BOND CEMENT 33.00 06/30/10 005 0270 4750
04665193 UNI-SOLVE ADH REM N 98.00 06/30/10 005 0270 4750
04665195 FOAM INCONTINENCE KIT 63.00 06/30/10 005 0270 4750
04665219 REFINED,KARAYA GUM 36.00 06/30/10 005 0270 4750
04665235 BANISH LIQUID DEODO 87.00 06/30/10 005 0270 4750
04665318 GASKET SEALTITE 7/8" 33.00 06/30/10 005 0270 4750
04665319 GASKET SEALTITE 3 5/8" 35.00 06/30/10 005 0270 4750
04665320 GASKET SEALTITE 3" 1" 40.00 06/30/10 005 0270 4750
04665615 CONVRI-A-PCH FACE P 57.00 06/30/10 005 0270 4750
04665616 FACE PLATE 1/2 OP 47.00 06/30/10 005 0270 4750
04665617 FACE PLATE CO-APC CV 3/4" 60.00 06/30/10 005 0270 4750
04665618 FACE PLATE CO AP CV 7/8" 67.00 06/30/10 005 0270 4750
04665619 FACE PLATE CO AP CV 1" 63.00 06/30/10 005 0270 4750
04665620 FACE PLATE CO AP CV 1-1/8" 59.00 06/30/10 005 0270 4750
04665621 FACE PLATE CON CV 1-1/4" 59.00 06/30/10 005 0270 4750
04667001 PACK-CUSTOM D&C 150.00 06/30/10 005 0270 4750
04667004 PACK CUSTOM TUBAL LIGATION 140.00 06/30/10 005 0270 4750
04667009 POVIDINE IODIN-SCRU 21.00 06/30/10 005 0270 4750
04667017 POVIDINE IODIN-SCRU 69.00 06/30/10 005 0270 4750
04667025 POVIDINE IODINE WHR 63.00 06/30/10 005 0270 4750
04667026 IODINE POVIDONE SOL WHRPL 50.00 06/30/10 005 0270 4750
04667027 IODINE POVIDONE WHRPL CON 60.00 06/30/10 005 0270 4750
04667033 STAPHENE AEROSOL 60 27.00 06/30/10 005 0270 4750
04667041 STAPHENE CONCENTRAT 103.00 06/30/10 005 0270 4750
04667058 WATER DISTILLED GAL 11.00 06/30/10 005 0270 4750
04669617 CATHETER COUDE FOLE 54.00 06/30/10 005 0270 4750
04669690 CATH,UMBILICAL ARTE 13.00 06/30/10 005 0270 4750
04670044 TRAY AMNIOCENTESIS ST 54.00 06/30/10 005 0270 4750
04670045 AMNIOCENTESIS TRAY 27.00 06/30/10 005 0270 4750
04670046 TRAY ANGIO CUSTOM 290.00 06/30/10 005 0270 4750
04670047 TRAY EUBOLIZATION SURGICAL 225.00 06/30/10 005 0270 4750
04670052 IUD SET-UP TRAY 27.00 06/30/10 005 0270 4750
04670060 VENESECTION TRAY HR 118.00 06/30/10 005 0270 4750
04670086 W-A BIOP FORCEP FOR 27.00 06/30/10 005 0270 4750
04670094 MEDICON BIOP FORCEP 27.00 06/30/10 005 0270 4750
04670110 HOLTER PUMP TUBING A 36.00 06/30/10 005 0270 4750
04670111 TUBING HOLTER PUMP B 36.00 06/30/10 005 0270 4750
04670112 TUBING HOLTER PUMP C 36.00 06/30/10 005 0270 4750
04670113 TUBING HOLTER PUMP D 36.00 06/30/10 005 0270 4750
04670128 IV FILTER, 0.22 MIC 16.00 06/30/10 005 0270 4750
04670136 TUBE TRACH REPROCS PATIENT 27.00 06/30/10 005 0270 4750
04670144 TUBE TRACHEAL SHILEY LPC 4FR 173.00 06/30/10 005 0270 4750
04670145 TUBE TRACHEAL SHLY LPC 8F 197.00 06/30/10 005 0270 4750
04670151 TUBE TRACHEAL SHILEY LPC 6FR 163.00 06/30/10 005 0270 4750
04670177 UMBILICAL ART. CATH 16.00 06/30/10 005 0270 4750
04670185 MISCELLANEOUS MEDICAL SUPPLY EXTERNAL 11/01/94 005 0270 4750
04670188 INTRODUCER 17 GAUGE 89.00 06/30/10 005 0270 4750
04670189 INTRODUCER 19 GAUGE 89.00 06/30/10 005 0270 4750
04670193 POUCH KR SE 1-1/2" 12" 215.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 39
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04670201 BARD PARKER CVP SET 27.00 06/30/10 005 0270 4750
04670204 GOWN STD BAIR PAWS 40.00 06/30/10 005 0270 4750
04670207 GOWN XLG BAIR PAWS 53.00 06/30/10 005 0270 4750
04670219 SWAN-GANZ CATHETER 116.00 06/30/10 005 0270 4750
04670227 SWAN-GANZ CATHETER 159.00 06/30/10 005 0270 4750
04670235 HAIR TRANSPLANT TRA 27.00 06/30/10 005 0270 4750
04670250 DISCOGRAPHY SET 27.00 06/30/10 005 0270 4750
04670268 SUTURE REMOVAL KIT, 21.00 06/30/10 005 0270 4750
04670276 CHEST DRAIN BOTTLE, 57.00 06/30/10 005 0270 4750
04670280 CHEST DRAIN VALVE 140.00 06/30/10 005 0270 4750
04670284 NIPPLE SHIELD 11.00 06/30/10 005 0270 4750
04670292 PLATINUM NEEDLE ELE 16.00 06/30/10 005 0270 4750
04670300 UNIVERSAL ILEAL BLA 155.00 06/30/10 005 0270 4750
04670318 BRONCOSCOPY TRAY 27.00 06/30/10 005 0270 4750
04670326 ENDOMETRIAL BIOPSY 19.00 06/30/10 005 0270 4750
04670342 LIP CARE TRAY 11.00 06/30/10 005 0270 4750
04670359 NEONATL LUMB PUNCT 16.00 06/30/10 005 0270 4750
04670367 VENESECT'N-MIN SURG 47.00 06/30/10 005 0270 4750
04670375 BIOP PLUERAL TRX AB 19.00 06/30/10 005 0270 4750
04670391 TUBE ENDOTRACH CF 8.5FR 16.00 06/30/10 005 0270 4750
04670409 HEGAR DILATORS NO.9 69.00 06/30/10 005 0270 4750
04670417 HEGAR DILATORS NO.8 63.00 06/30/10 005 0270 4750
04670425 HEGAR DILATORS NO.7 63.00 06/30/10 005 0270 4750
04670433 HEGAR DILATORS NO.6 59.00 06/30/10 005 0270 4750
04670441 HEGAR DILATORS NO.5 59.00 06/30/10 005 0270 4750
04670458 HEGAR DILATORS NO.1 69.00 06/30/10 005 0270 4750
04670466 SILICATH 5CC 14-24 19.00 06/30/10 005 0270 4750
04670516 URINARY BAG W MEASU 19.00 06/30/10 005 0270 4750
04670532 BOTTLE U/W DRAINAGE 2MCC 57.00 06/30/10 005 0270 4750
04670623 STOMAHESIVE 31.00 06/30/10 005 0270 4750
04670631 LOOP OSTOMY SET 60.00 06/30/10 005 0270 4750
04670649 READ-RINGS 16.00 06/30/10 005 0270 4750
04670655 MS004338 SYS Q CARE Q4 W/PR20 66.00 06/30/10 005 0270 4750
04673114 IOBAN DRAPE 33X17 40.00 06/30/10 005 0270 4750
04673122 IOBAN DRAPE 35X33 67.00 06/30/10 005 0270 4750
04673123 DRAPE UNIV CAMERA LASER ARM 56.00 06/30/10 005 0270 4750
04673130 CATHETER GUARD ARROW 40.00 06/30/10 005 0270 4750
04673148 MINIFILTER HEMO KIT 616.00 06/30/10 005 0270 4750
04673155 CATH ADULT CST STR 246.00 06/30/10 005 0270 4750
04673163 CATH CHRONIC ADULT 246.00 06/30/10 005 0270 4750
04673171 CATH PRNTL-PED 390.00 06/30/10 005 0270 4750
04673189 IV MICROBORE SER 36" 16.00 06/30/10 005 0270 4750
04673601 BANDAGE COBAN WRAP SLF ADH 27.00 06/30/10 005 0270 4750
04673791 TUBE TRACH SCT SZ 6 140.00 06/30/10 005 0270 4750
04673809 TUBE TRACH SCT SZ 8 CFL 326.00 06/30/10 005 0270 4750
04673817 UTERINE SAMPLING DEV 159.00 06/30/10 005 0270 4750
04673825 EPIDURAL ANESTH KIT 89.00 06/30/10 005 0270 4750
04673833 EPISTAT KIT XMD 235.00 06/30/10 005 0270 4750
04673841 CATH VSC ACC 2.7F 357.00 06/30/10 005 0270 4750
04673858 CATH VSC ACC 4.2F 317.00 06/30/10 005 0270 4750
04673866 CATH VSC ACC 6.6F 248.00 06/30/10 005 0270 4750
04673876 CATH REPAIR KIT 2.7F 311.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 40
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04673882 CATH RPR KIT 4.2F 311.00 06/30/10 005 0270 4750
04673890 CATH RPR KIT 6.6F 246.00 06/30/10 005 0270 4750
04673916 CATH EXTERNAL MALE 16.00 06/30/10 005 0270 4750
04673924 CATH HEMO/PERM 552.00 06/30/10 005 0270 4750
04673926 CATH PERM OVAL 40CM 2 LUMEN ID 1145.00 06/30/10 005 0270 4750
04673932 CATH JEJUNOSTOMY 444.00 06/30/10 005 0270 4750
04673957 WIRE GUIDE C-SCF 54.00 06/30/10 005 0270 4750
04673965 CATH SM VEIN BD #6780 16.00 06/30/10 005 0270 4750
04673973 CATH CRV CHR-ADLT 390.00 06/30/10 005 0270 4750
04673981 CATH TNCKHF CHR PRNTL 262.00 06/30/10 005 0270 4750
04673999 CATH TNCKHF PERI PED 246.00 06/30/10 005 0270 4750
04674005 CATH PRNTL 8FR 41.00 06/30/10 005 0270 4750
04674013 CATH W/INTRO RND 9.0 552.00 06/30/10 005 0270 4750
04674021 CATH W/INTRO RND 12.0 552.00 06/30/10 005 0270 4750
04674039 CATH D/L RND RPR KIT WHT 246.00 06/30/10 005 0270 4750
04674042 CATH PEZZER DRAIN 28FR/30FR 55.00 06/30/10 005 0270 4750
04674045 CATH PEZZER DRAIN 22FR 31.00 06/30/10 005 0270 4750
04674048 CATH TRAUMA LARE BORE 522.00 06/30/10 005 0270 4750
04674054 CATH D/L RND RPR KIT RED 246.00 06/30/10 005 0270 4750
04674055 MRI DUAL-PORT 3742.00 06/30/10 005 0270 4750
04674057 HICKMAN SUBCUT PORT-SNGL LUMEN 2825.00 06/30/10 005 0270 4750
04674058 HICKMAN SUBCUT PORT-DUAL LUMEN 3742.00 06/30/10 005 0270 4750
04674062 CATH HCKMAN W/INTRO 9.6F 451.00 06/30/10 005 0270 4750
04674063 KIT HICKMAN TRIPLE LUMEN 12.5F 1131.00 06/30/10 005 0270 4750
04674064 DRAIN SILICONE FLAT 7MM 44.00 06/30/10 005 0270 4750
04674065 SILICONE FLAT DRAIN 10 MM 44.00 06/30/10 005 0270 4750
04674070 IV EXTENSION SET W/"T" 16.00 06/30/10 005 0270 4750
04674088 CONNECTOR REDUC Y 3/8-1/4 18.00 06/30/10 005 0270 4750
04674096 BLOOD Y TUBE SET 4C2196 19.00 06/30/10 005 0270 4750
04674104 HEMONATE FILTER SET 18.00 06/30/10 005 0270 4750
04674112 HEMO-TAP INJ SITE SET 16.00 06/30/10 005 0270 4750
04674120 CHEMISTRIPS BG 149.00 06/30/10 005 0270 4750
04674121 CHEMSTRIPS-BG BTL 89.00 06/30/10 005 0270 4750
04674138 BUCKLE METAL BLT 1 1/2 27.00 06/30/10 005 0270 4750
04674146 DRAIN BNGT LG #1104 109.00 06/30/10 005 0270 4750
04674153 FACE PLT POUCH SZ 5/8 67.00 06/30/10 005 0270 4750
04674161 LIMB HOLDER PEDIATRIC 18.00 06/30/10 005 0270 4750
04674179 TRANSDUCER DSP T6012 AD 57.00 06/30/10 005 0270 4750
04674187 TRANSDUCER NEONATAL DSP 57.00 06/30/10 005 0270 4750
04674188 TRANSDUCER NEONATAL PED SAFE 67.00 06/30/10 005 0270 4750
04674190 SET TRANSDUCER MANIFOLD 36.00 06/30/10 005 0270 4750
04674195 TRANSPAC T4812 AD TPL 207.00 06/30/10 005 0270 4750
04674203 PROBE TEMP HP20185 DSP 69.00 06/30/10 005 0270 4750
04674211 BONE CEMENT SURGICAL 245.00 06/30/10 005 0270 4750
04674229 CIRCUMCISION TRAY DSP 1.3 143.00 06/30/10 005 0270 4750
04675044 CATH D/L GROSHON #2295 1491.00 06/30/10 005 0270 4750
04675093 CATH S/L GROSHON W/CONNECTOR 1100.00 06/30/10 005 0270 4750
04675119 MINIFILTER KIT AMCIO 655.00 06/30/10 005 0270 4750
04675127 DIAFILTER 10 W/LG TUBING SET 609.00 06/30/10 005 0270 4750
04675226 TRAY PER Q TRAY PQ483A 197.00 06/30/10 005 0270 4750
04676065 DRAIN SILICONE FLAT 10MM 44.00 06/30/10 005 0270 4750
04679194 CATH KIT PED TWO LUMEN 197.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 41
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04679195 KIT CATHETER CENTRAL VENOUS 1915.00 06/30/10 005 0270 4750
04679442 CANNULA W/90DEG TIP KP 7.1 69.00 06/30/10 005 0270 4750
04679913 BURNPAD INTSRB 2'X 3' 40.00 06/30/10 005 0270 4750
04679921 CATH KNRT STRFGT TFL 4.0 118.00 06/30/10 005 0270 4750
04680000 SET HOMECHOICE AUTO PD 4-PRONG 33.00 06/30/10 005 0270 4750
04680003 COVER F/BILI-BLANKET DISP 48.00 06/30/10 005 0270 4750
04680006 ADPTR AIRWAY ADULT DISP 30.00 06/30/10 005 0270 4750
04680009 EAR PROBE(COLORADO PACK) 35.00 06/30/10 005 0270 4750
04680012 LEADWIRE SET PINCH 5LD AHA 24" 306.00 06/30/10 005 0270 4750
04680015 LEADWIRE SET SNAP 5LEAD 24IN 314.00 06/30/10 005 0270 4750
04680018 NDLE INFUS SET Y-STE 20GAX1IN 27.00 06/30/10 005 0270 4750
04680021 NDLE INTRO NEOCATH SPLIT 2FR 89.00 06/30/10 005 0270 4750
04680024 TRAY INSERT NEONATAL PICC 74.00 06/30/10 005 0270 4750
04680027 TRAY QUICK CHEST TUBE 10FR 468.00 06/30/10 005 0270 4750
04680030 MONITOR SUBDURAL IPC 2636.00 06/30/10 005 0270 4750
04680033 BOLT MICRO VENTRICULAR 2352.00 06/30/10 005 0270 4750
04680481 TUBE COMMUNITRACH SZ9 378.00 06/30/10 005 0270 4750
04685928 CATH KIT MULTI LUMEN #14703 197.00 06/30/10 005 0270 4750
04692064 SPRING PIP EXT 1 3/4 SZAA 75.00 06/30/10 005 0270 4750
04692072 NEEDLE SPINAL 20G X 2 1/2 16.00 06/30/10 005 0270 4750
04692075 NEEDLE SPINAL 20GA X4IN 161.00 06/15/10 005 0270 4750
04692078 NEEDLE SPINAL 20GA X6IN 113.00 06/15/10 005 0270 4750
04692080 NEEDLE SPINAL 22GX 2 1/2 16.00 06/30/10 005 0270 4750
04692088 CATH RPR KIT 60170 EXT SGMT 359.00 06/30/10 005 0270 4750
04692096 CATH REPAIR KIT 60171 R/D 359.00 06/30/10 005 0270 4750
04692104 0.45% NACL 500 ML 11.00 06/30/10 005 0270 4750
04692112 STYLETTE NEO PEDILETTE 500 18.00 06/30/10 005 0270 4750
04692120 CATH UMBLICVSSL 5 FR 47.00 06/30/10 005 0270 4750
04692121 CATH UMBIL VES DUAL LUM3.5FR 163.00 06/30/10 005 0270 4750
04692122 CATH UMBIL VES DUAL LUM 5FR 163.00 06/30/10 005 0270 4750
04692123 CATHETER PCVC 2FR 292.00 06/30/10 005 0270 4750
04692128 MINI-VOL EXT SET 36" 16.00 06/30/10 005 0270 4750
04692136 DRESSING RETNR X SPAN TBLR 4" 100.00 06/30/10 005 0270 4750
04692139 DRESSINET BANDAGE TUBULAR SZ 1 72.00 06/30/10 005 0270 4750
04692140 DRESSINET BANDAGE TUBULAR SZ 5 201.00 06/30/10 005 0270 4750
04692144 JUG. PUNCT. KIT-PEDS 103.00 06/30/10 005 0270 4750
04692152 TRAY KLASTIN SET 54.00 06/30/10 005 0270 4750
04692160 CATH ECC 2184.00 114.00 06/30/10 005 0270 4750
04692168 SOD CHLOR .45 NACL 1000ML 16.00 06/30/10 005 0270 4750
04692176 TUBE TRACH L/C 431576505.0 16.00 06/30/10 005 0270 4750
04692184 TUBE TRACH L/C 43157655.5 16.00 06/30/10 005 0270 4750
04692192 TUBE TRACH L/C 43157660 6.0 16.00 06/30/10 005 0270 4750
04692200 TUBE TRACH L/C 431576656.5 16.00 06/30/10 005 0270 4750
04692208 TUBE TRACH L/C 431576707.0 16.00 06/30/10 005 0270 4750
04692216 TUBE TRACH L/C 431576757.5 16.00 06/30/10 005 0270 4750
04692224 TUBE TRACH L/C 43157680-8.0 16.00 06/30/10 005 0270 4750
04692232 TUBE TRACH L/C 43157-6858.5 16.00 06/30/10 005 0270 4750
04692240 TUBE TRACH L/C 43157-6909.0 16.00 06/30/10 005 0270 4750
04692248 STOOL SYSTEM-PARA.PAK(LV-PVA) 16.00 06/30/10 005 0270 4750
04692256 SEIZURE PRECAUTION KIT 54.00 06/30/10 005 0270 4750
04692264 COLLECTOR FECAL IN CT#9822 39.00 06/30/10 005 0270 4750
04692272 SPLINT FINGER ALUM 1 X 18 25.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 42
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692280 SPLINT FINGER ALUM 1/2 X 9 25.00 06/30/10 005 0270 4750
04692288 SPLINT FINGER ALUM 3/4 X 18 25.00 06/30/10 005 0270 4750
04692304 CHEMSTRIPS 7LH 417117-1C 164.00 06/30/10 005 0270 4750
04692306 HEMOGLOBIN COVETTES - HEMOCUE 262.00 06/30/10 005 0270 4750
04692312 GAUZE KERLIX 4 1/2'X 4 1/3"RL 27.00 06/30/10 005 0270 4750
04692320 ELECTRODES - PREMIE S/C 1022 101.00 06/30/10 005 0270 4750
04692328 ELECTRODE LIMBANDSH 10-20-1 44.00 06/30/10 005 0270 4750
04692336 CERVICAL COLLAR EXTRA SHORT 57.00 06/30/10 005 0270 4750
04692344 CERVICAL COLLAR SHORT 57.00 06/30/10 005 0270 4750
04692352 CERVICAL COLLAR REGULAR 57.00 06/30/10 005 0270 4750
04692360 CERVICAL COLLAR TALL 57.00 06/30/10 005 0270 4750
04692368 CERVICAL COLLAR PEDIATRIC 57.00 06/30/10 005 0270 4750
04692369 COLLAR PEDS REGULAR 51.00 06/30/10 005 0270 4750
04692376 THERMOMETER TEMP-A-DOT #5125 59.00 06/30/10 005 0270 4750
04692384 FILTER MICROBAR PRES MONITORNG 36.00 06/30/10 005 0270 4750
04692386 TRACTION HALO CROWN SMALL 2356.00 06/30/10 005 0270 4750
04692388 TRACTION HALO CROWN LARGE 2356.00 06/30/10 005 0270 4750
04692389 AIR FLOW VEST SHORT 4888.00 06/30/10 005 0270 4750
04692391 AIR FLOW VEST TALL 4888.00 06/30/10 005 0270 4750
04692393 VEST HALO PEDIATRIC 7421.00 06/30/10 005 0270 4750
04692394 VEST HALO CHILD 3668.00 06/30/10 005 0270 4750
04692395 VEST HALO (PED OR ADULT) 4888.00 06/30/10 005 0270 4750
04692397 VEST HALO X-LARGE 3668.00 06/30/10 005 0270 4750
04692398 VEST HALO XX-LARGE 3668.00 06/30/10 005 0270 4750
04692399 LINER FOR HALO VEST SM-XXLARGE 218.00 06/30/10 005 0270 4750
04692400 RING TRACTION ADJUSTABLE 1684.00 06/30/10 005 0270 4750
04692401 LINER AIR FLO VEST SHORT 218.00 06/30/10 005 0270 4750
04692402 LINER AIR FLO VEST TALL 218.00 06/30/10 005 0270 4750
04692403 CUSTOM HALO TRACTION SET 2244.00 06/30/10 005 0270 4750
04692404 LINER REPLACMT SM. CLASSIC II 205.00 06/30/10 005 0270 4750
04692405 LINER REPLACMT LG. CLASSIC II 205.00 06/30/10 005 0270 4750
04692406 LINER REPLACEMENT INF. CUSTOM 205.00 06/30/10 005 0270 4750
04692407 LINER REPLMT EX.LG. CLASSIC II 205.00 06/30/10 005 0270 4750
04692408 DRESSING TEGADERM 6"X8" 21.00 06/30/10 005 0270 4750
04692409 LINER REPLACEMENT CHILD 205.00 06/30/10 005 0270 4750
04692410 LINER REPLACEMENT TODDLER 419.00 06/30/10 005 0270 4750
04692411 VEST OPENBACK GRAPH W/TRACT SM 7418.00 06/30/10 005 0270 4750
04692412 LINER SET NYLON ACRYL VEST SM 413.00 06/30/10 005 0270 4750
04692413 VEST OPENBACK GRAPH W/TRAC MED 7418.00 06/30/10 005 0270 4750
04692414 LINER SET NYLON ACRYL VEST MED 413.00 06/30/10 005 0270 4750
04692415 VEST OPENBACK GRAPH W/TRAC LGE 9065.00 06/30/10 005 0270 4750
04692416 STRAP ADHESIVE 8"X11" 44.00 06/30/10 005 0270 4750
04692417 LINER SET NYLON ACRYL VEST LGE 413.00 06/30/10 005 0270 4750
04692418 TONGUE DRIVER 935.00 06/30/10 005 0270 4750
04692419 PINS 5 HEAD LOCKING NUTS2-1/2" 225.00 06/30/10 005 0270 4750
04692420 PINS 5 HEAD LOCKING NUTS 3" 225.00 06/30/10 005 0270 4750
04692424 CATH PERMA 40CM 616.00 06/30/10 005 0270 4750
04692432 NEDL 19GX3/4 90DEG ANGLE INF 21.00 06/30/10 005 0270 4750
04692440 KITS MATERNITY 107.00 06/30/10 005 0270 4750
04692441 KIT OBSTETRICAL VACUUM DELIVRY 116.00 06/30/10 005 0270 4750
04692448 TRAY CATH INSERTION 140.00 06/30/10 005 0270 4750
04692472 STRAP ABD 25.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 43
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692480 SHIELD AND BRA PADS 50.00 06/30/10 005 0270 4750
04692488 ASPIRATOR INFANT 51.00 06/30/10 005 0270 4750
04692496 STAT WASH SET 486.00 06/30/10 005 0270 4750
04692504 BLOOD REINFUSION BAG 60.00 06/30/10 005 0270 4750
04692510 UNDERPADS AIRFLO DRY 6/PKG 35.00 06/30/10 005 0270 4750
04692512 HOUDINI SUIT POSEY MEDIUM 128.00 06/30/10 005 0270 4750
04692513 HOUDINI SUIT POSEY LARGE 109.00 06/30/10 005 0270 4750
04692514 HOUDINI SUIT POSEY X-LARGE 109.00 06/30/10 005 0270 4750
04692520 TOUCHLESS CATHETER KIT MALE 21.00 06/30/10 005 0270 4750
04692521 TOUCHLESS CATHETER KIT FEMALE 21.00 06/30/10 005 0270 4750
04692528 CUSTOM CLINE CT KIT NAMIC 54.00 06/30/10 005 0270 4750
04692536 TUBE TRACHEOSOMY HI-LO SZ 9 191.00 06/30/10 005 0270 4750
04692540 SOLUTION HIGH-LOW CONTROL 35.00 06/30/10 005 0270 4750
04692541 STRIPS REAGENT F/ADVANTAGE H 136.00 06/30/10 005 0270 4750
04692544 CUFF BP DSP ADULT 36.00 06/30/10 005 0270 4750
04692545 CUFF DSP ADLT LG. 41.00 06/30/10 005 0270 4750
04692546 CUFF DSP CHILD 41.00 06/30/10 005 0270 4750
04692547 CUFF DSP INFANT 41.00 06/30/10 005 0270 4750
04692548 CONTAINER EMPTY STERILE 3 L 50.00 06/30/10 005 0270 4750
04692549 SET TRANSFER SOL 48" 1.2M CAPO 76.00 06/30/10 005 0270 4750
04692550 EVACUATOR EWALD STOMACH 145.00 06/30/10 005 0270 4750
04692552 POWDER STOMADHESIVE 1 OZ 31.00 06/30/10 005 0270 4750
04692553 CHEMSTRIP B.G. ACCU-CHEK II 155.00 06/30/10 005 0270 4750
04692554 PAK IV STARTER 13.00 06/30/10 005 0270 4750
04692555 DEXTROSTIX 121.00 06/30/10 005 0270 4750
04692556 STRIPS REAGENT F/GLUCOSE TEST 170.00 06/30/10 005 0270 4750
04692557 ADAPTER TITANIUM LK F/PD CATH 835.00 06/30/10 005 0270 4750
04692558 SET CYCLER TRANSFER 9" 76.00 06/30/10 005 0270 4750
04692559 OUTLET PORT CLAMP 18.00 06/30/10 005 0270 4750
04692560 P.D. DRAINAG & BAG 35.00 06/30/10 005 0270 4750
04692561 TRANSFER SET 48 168.00 06/30/10 005 0270 4750
04692562 SHORT DISCONNECT TRANS SET 149.00 06/30/10 005 0270 4750
04692563 DISCONNECT CAP CAPO 13.00 06/30/10 005 0270 4750
04692564 ULTRA-FLASH DISCONNECT 4 SET 40.00 06/30/10 005 0270 4750
04692565 CONNECTION COLLAR 19.00 06/30/10 005 0270 4750
04692566 OUTLET PORT CLAMP 31.00 06/30/10 005 0270 4750
04692567 4-PRONG PED CYCLER SET 84.00 06/30/10 005 0270 4750
04692568 SPIKE PROTECTOR 16.00 06/30/10 005 0270 4750
04692569 CAPO DISCONNECT CAP 18.00 06/30/10 005 0270 4750
04692570 SPIKE-SYRINGE ADAPTER 21.00 06/30/10 005 0270 4750
04692571 CONNECT SHIELD III 21.00 06/30/10 005 0270 4750
04692572 3-LITER STERILE DRAIN BAG 35.00 06/30/10 005 0270 4750
04692573 CAPO TRANSFER SET 50.00 06/30/10 005 0270 4750
04692577 SET CATH DUO-FLOW PED CATH KIT 404.00 06/30/10 005 0270 4750
04692578 A-V CANNULA KIT 159.00 06/30/10 005 0270 4750
04692579 FEMERAL ARTERY CATH CAVH VEN 189.00 06/30/10 005 0270 4750
04692580 PERM CATH REPAIR KIT 36X10CM 586.00 06/30/10 005 0270 4750
04692581 PERM CATH REPAIR KIT 28CM 644.00 06/30/10 005 0270 4750
04692582 PEDIATRIC DIALYZER 269.00 06/30/10 005 0270 4750
04692583 NEONATAL DIALYZER 314.00 06/30/10 005 0270 4750
04692584 PEDIATRIC HEMOFILTER 494.00 06/30/10 005 0270 4750
04692585 PD CATH 37CM STRAIGHT PEDS 236.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 44
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692586 P.D CATH 31CM STR NEONATAL 236.00 06/30/10 005 0270 4750
04692587 P.D CATH 40CM UNIVERSAL 236.00 06/30/10 005 0270 4750
04692588 PULL-APART INTRODUCER SET 7FR 204.00 06/30/10 005 0270 4750
04692589 PERI PATCH P.D CATH EXTENSION 494.00 06/30/10 005 0270 4750
04692590 MINIFILTER PEDIATRIC 644.00 06/30/10 005 0270 4750
04692591 MINIFILTER NEONATAL 602.00 06/30/10 005 0270 4750
04692592 NEONATAL 5FRX2 1/2 6.4CM 359.00 06/30/10 005 0270 4750
04692593 PEDIATRIC 7FR X4" 10CM 359.00 06/30/10 005 0270 4750
04692594 CATH 9FRX4 3/4" 12CM 248.00 06/30/10 005 0270 4750
04692595 CATH 10FR 15CM 248.00 06/30/10 005 0270 4750
04692596 CAVH SET 5FRX3" 7.6CM 248.00 06/30/10 005 0270 4750
04692597 CAVH SET 14GAX3" 7.6CM 248.00 06/30/10 005 0270 4750
04692598 CAVH SET 16GAX2 1/2" 6.4CM 248.00 06/30/10 005 0270 4750
04692599 PERI PATCH GLUE MOLD 98.00 06/30/10 005 0270 4750
04692600 SILICONE ADHESIVE TYPEA 59.00 06/30/10 005 0270 4750
04692601 PEDIATRIC BLOOD TUBING CAVH 98.00 06/30/10 005 0270 4750
04692602 ILLUM RETNL KNIFE 462.00 06/30/10 005 0270 4750
04692604 POSTERIOR/ANTERIOR CHAMBER 159.00 06/30/10 005 0270 4750
04692606 TRI-STAR 3CC VISC FLUID 225.00 06/30/10 005 0270 4750
04692607 TRI-STAR 12CC VISC FLUID 225.00 06/30/10 005 0270 4750
04692608 WET-FIELD HEMO ERASER 20GA 56.00 06/30/10 005 0270 4750
04692609 WET-FIELD HEMO ERASER 23GA 170.00 06/30/10 005 0270 4750
04692610 TIP I/A 3MM ALCON 1197.00 06/30/10 005 0270 4750
04692611 T-TUBE STD 8MM E.B. HOOD 767.00 06/30/10 005 0270 4750
04692612 T-TUBE STD L8 E.B. HOOD 831.00 06/30/10 005 0270 4750
04692613 T-TUBE MTG4 14SD 706.00 06/30/10 005 0270 4750
04692614 T-TUBE EL 8MM E.B. HOOD 890.00 06/30/10 005 0270 4750
04692615 SPLINT REUTER BIVALVE 5 MM 676.00 06/30/10 005 0270 4750
04692616 NON-VENTED IRRIGATION SPIKE 528.00 06/30/10 005 0270 4750
04692617 NASO-TAPON MEROCEL SET 676.00 06/30/10 005 0270 4750
04692618 CORNING TRY-TUBE 706.00 06/30/10 005 0270 4750
04692619 BEAVER BLADE #5230 98.00 06/30/10 005 0270 4750
04692620 BEAVER BLADE #5510 82.00 06/30/10 005 0270 4750
04692621 BEAVER BLADE #5520 82.00 06/30/10 005 0270 4750
04692622 BEAVER BLADE #5530 82.00 06/30/10 005 0270 4750
04692623 BEAVER BLADE #5531 75.00 06/30/10 005 0270 4750
04692624 BEAVER BLADE #5620 98.00 06/30/10 005 0270 4750
04692625 BEAVER BLADE #7630 98.00 06/30/10 005 0270 4750
04692626 ALCON DBL CANG 23G. OP EROD 444.00 06/30/10 005 0270 4750
04692627 MICRN MOTOR FILTER 41.00 06/30/10 005 0270 4750
04692628 MICRN IMPL JAR 2000CC 54.00 06/30/10 005 0270 4750
04692629 MICRN ABSOLU BIO FILT 126.00 06/30/10 005 0270 4750
04692630 MASTI LIQ ADHS 2/3CC 263.00 06/30/10 005 0270 4750
04692633 XOMED REUT BOB TYTAV-TUBE 155.00 06/30/10 005 0270 4750
04692634 MTGY EX-L TERM CANNULA 706.00 06/30/10 005 0270 4750
04692635 XOMED PRAS MONO STIM PROBE 292.00 06/30/10 005 0270 4750
04692636 MICRON SURGICAL KNIFE #1521 276.00 06/30/10 005 0270 4750
04692637 MICRN PVC TUBE #LS 7010 47.00 06/30/10 005 0270 4750
04692638 KLEIN VENT TUBE #10-20000 93.00 06/30/10 005 0270 4750
04692639 TRI-STAR 35CC VISC FL #9200-11 203.00 06/30/10 005 0270 4750
04692640 VTROPAGH 1.1MM CANN 25-22-0070 800.00 06/30/10 005 0270 4750
04692641 VTROPHG LH ANG CUT #1251 800.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 45
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692642 VTROPHG WIDE ANG CUT #127 879.00 06/30/10 005 0270 4750
04692643 VTROPHG LH ANG CUT #127-L 879.00 06/30/10 005 0270 4750
04692644 HOSE FOR SMOKE EVAC STERILE 126.00 06/30/10 005 0270 4750
04692645 FILTER CHAR FOR SMOKE EVAC 357.00 06/30/10 005 0270 4750
04692646 FILTER ULPA FOR SMOKE EVAC 1224.00 06/30/10 005 0270 4750
04692647 DISP IRIS SUTURE DEVICE 27G 63.00 06/30/10 005 0270 4750
04692648 E-Z SCRUB 116 W/PCMX 40.00 06/30/10 005 0270 4750
04692649 EEG NEEDLE ELECTRODES #82-2710 242.00 06/30/10 005 0270 4750
04692650 HOSE FOR SMOKE EVAC NON-ST 81.00 06/30/10 005 0270 4750
04692651 TRACH T-TUBE ST 14MM EB 767.00 06/30/10 005 0270 4750
04692652 TRACH T-TUBE LONG 16MM EB 831.00 06/30/10 005 0270 4750
04692653 XOMED UMBBEL V-TUBE 1.OMM 96.00 06/30/10 005 0270 4750
04692654 XOMED T-TUBE 1.1MM 118.00 06/30/10 005 0270 4750
04692656 XOMED REU BOB 1.1MM 197.00 06/30/10 005 0270 4750
04692657 XOMED MYRING KNIVES 50.00 06/30/10 005 0270 4750
04692658 XOMED MICRO GARD 101.00 06/30/10 005 0270 4750
04692659 XOMED KIT EXT NAS LARGE 116.00 06/30/10 005 0270 4750
04692660 XOMED KIT EXT NAS SM 128.00 06/30/10 005 0270 4750
04692661 XOMED KIT EXT NAS MED 116.00 06/30/10 005 0270 4750
04692662 XOMED ARMSTRONG START 93.00 06/30/10 005 0270 4750
04692663 WECK GEL SPEARS 18.00 06/30/10 005 0270 4750
04692664 VITRECTOMY SET ALCON 920.00 06/30/10 005 0270 4750
04692665 VASELINE INTENSIVE CARE 60.00 06/30/10 005 0270 4750
04692666 UNIPAK FOR 45 DEG 612.00 06/30/10 005 0270 4750
04692667 UNIPAK ALCON 740.00 06/30/10 005 0270 4750
04692668 TRI-STAR 45 DEG ANG TISS PICK 318.00 06/30/10 005 0270 4750
04692669 FILTER YAG STACKHOUSE 59.00 06/30/10 005 0270 4750
04692670 IRRIGATION OUTCOME PROBE 701.00 06/30/10 005 0270 4750
04692671 LARYN STONT E.B HOOD 528.00 06/30/10 005 0270 4750
04692672 INFUSION CANNULA 6MM 404.00 06/30/10 005 0270 4750
04692673 MICRO-GARD ZEISS 239.00 06/30/10 005 0270 4750
04692674 MODEL 7240 VITAL VEU 225.00 06/30/10 005 0270 4750
04692676 LARYN STONT E.B. HOOD #LSM SM 528.00 06/30/10 005 0270 4750
04692677 LIGHT GUIDE SET 269.00 06/30/10 005 0270 4750
04692678 AERTO NEEDLE 23CR AB 19.00 06/30/10 005 0270 4750
04692679 AIR INJECTION 27G 19.00 06/30/10 005 0270 4750
04692680 AIR INJECTION 30G 3/4" 18.00 06/30/10 005 0270 4750
04692681 ALCON OVERFLOW BAG 60.00 06/30/10 005 0270 4750
04692682 ALCON SLIT KNIFE 3.2MM 109.00 06/30/10 005 0270 4750
04692683 CASSETTE I/A SER 344.00 06/30/10 005 0270 4750
04692684 CLEANER MILK INSTRUMENT 114.00 06/30/10 005 0270 4750
04692685 CULTURETT II 353.00 06/30/10 005 0270 4750
04692686 3M MICRO FOAM SURG TAPE 21.00 06/30/10 005 0270 4750
04692687 NEEDLE FRAGMENTATION 19G 444.00 06/30/10 005 0270 4750
04692688 OCUL OCCLUDRS AB SURG 16.00 06/30/10 005 0270 4750
04692689 PADGETT BLADE MODEL #B 56.00 06/30/10 005 0270 4750
04692690 PAK I/A ALCON #508-C 383.00 06/30/10 005 0270 4750
04692691 PERM TIT SURCLIP US SURG M9.75 850.00 06/30/10 005 0270 4750
04692692 PERM TIT SURCLIP US SURG S-90 838.00 06/30/10 005 0270 4750
04692693 PROBE HGM ENDO-OCULAR #T-020A 75.00 06/30/10 005 0270 4750
04692694 REMOVER SURGI-STAIN 444.00 06/30/10 005 0270 4750
04692695 SILSTC TUB INFUS 3/BX 269.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 46
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692696 STERI-DRAPE 3M 21.00 06/30/10 005 0270 4750
04692697 SUCTION COAGULATOR DISP 50.00 06/30/10 005 0270 4750
04692698 SUCTION LINERS 16.00 06/30/10 005 0270 4750
04692699 TECNOL LASER MASK 11.00 06/30/10 005 0270 4750
04692700 TRI-STAR LIGHT PIDE FIDOPT 121.00 06/30/10 005 0270 4750
04692701 TRI-STAR 30 DEG ANG LISS PICK 318.00 06/30/10 005 0270 4750
04692702 RING DEVICE 1.0MM MICROUS ANA 511.00 06/30/10 005 0270 4750
04692703 RING DEVICE 1.5MM MICRONAS ANA 511.00 06/30/10 005 0270 4750
04692704 RING DEVICE 2.0MM MICROVAS ANA 511.00 06/30/10 005 0270 4750
04692705 UNIPAK PHACO 30 TIP 639.00 06/30/10 005 0270 4750
04692706 EYE SPECULUM 159.00 06/30/10 005 0270 4750
04692707 DRAINAGE SYSTEM 554.00 06/30/10 005 0270 4750
04692708 MVR BLADES 101.00 06/30/10 005 0270 4750
04692709 SCLERAL PLUG 19G 644.00 06/30/10 005 0270 4750
04692710 SCLERAL PLUG 20G 644.00 06/30/10 005 0270 4750
04692711 KARICKOFF KERATOSCOPE 334.00 06/30/10 005 0270 4750
04692712 NASOPHOR CALC ALGINAT APPLIC 114.00 06/30/10 005 0270 4750
04692713 CRUIBAR CIS SET 454.00 06/30/10 005 0270 4750
04692714 SHEEHY TYTAN TYPE TUBE 87.00 06/30/10 005 0270 4750
04692715 NON-FENESTRATED DRAPE 63.00 06/30/10 005 0270 4750
04692717 FIBEROPTIC HAND PIECE NASAL 1106.00 06/30/10 005 0270 4750
04692718 FIBER OPTI W/HAND PIECE 1197.00 06/30/10 005 0270 4750
04692719 FIBER W/HAND PIECE 1073.00 06/30/10 005 0270 4750
04692720 FIBER OPTIC HAND PIECE CONTROL 1073.00 06/30/10 005 0270 4750
04692721 NASAL HAND PIECE 1106.00 06/30/10 005 0270 4750
04692722 GAS CARTRIDGES 371.00 06/30/10 005 0270 4750
04692723 MICRINS SUCTION TUBE CONTROL 59.00 06/30/10 005 0270 4750
04692724 MICRINS SOFT SUCTION MATT 126.00 06/30/10 005 0270 4750
04692726 TREPHINE 13.0 MM 170.00 06/30/10 005 0270 4750
04692727 TREPHINE 14.0 MM 170.00 06/30/10 005 0270 4750
04692728 TREPHINE 15.0 MM 170.00 06/30/10 005 0270 4750
04692729 TREPHINE 11.0 MM 170.00 06/30/10 005 0270 4750
04692730 TREPHINE 10.0 MM 170.00 06/30/10 005 0270 4750
04692731 TREPHINE 9.0 MM 170.00 06/30/10 005 0270 4750
04692732 TREPHINE 8.7 MM 170.00 06/30/10 005 0270 4750
04692733 TREPHINE 8.5 MM 170.00 06/30/10 005 0270 4750
04692734 TREPHINE 8.2 MM 170.00 06/30/10 005 0270 4750
04692735 TREPHINE 8.0 MM 170.00 06/30/10 005 0270 4750
04692736 TREPHINE 7.7 MM 170.00 06/30/10 005 0270 4750
04692737 TREPHINE 7.5 MM 170.00 06/30/10 005 0270 4750
04692738 TREPHINE 7.2 MM 170.00 06/30/10 005 0270 4750
04692739 TREPHINE 7.0 MM 170.00 06/30/10 005 0270 4750
04692740 TREPHINE 6.5 MM 170.00 06/30/10 005 0270 4750
04692741 TREPHINE 6.0 MM 170.00 06/30/10 005 0270 4750
04692742 TREPHINE 5.5 MM 170.00 06/30/10 005 0270 4750
04692743 TREPHINE 5.0 MM 170.00 06/30/10 005 0270 4750
04692744 INSULATING SLEEVE 371.00 06/30/10 005 0270 4750
04692745 EXTRA LONG CANNULA SET 706.00 06/30/10 005 0270 4750
04692746 PLUG 20 GA 767.00 06/30/10 005 0270 4750
04692747 SINUE PAK 552.00 06/30/10 005 0270 4750
04692748 DERMACARE 63.00 06/30/10 005 0270 4750
04692749 PHACO PACK WITHOUT REFLUX 462.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 47
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692750 ANTERIOR VITRECTOMY PACK 706.00 06/30/10 005 0270 4750
04692751 PACK POSTERIOR UITRECTOMY BASI 329.00 06/30/10 005 0270 4750
04692752 PACK POSTERIOR UITRECTOMY DELX 454.00 06/30/10 005 0270 4750
04692753 INFUSION CANNULA 4MM ALCON COP 462.00 06/30/10 005 0270 4750
04692754 TREPHINE 6.0MM KATENAK 239.00 06/30/10 005 0270 4750
04692755 TREPHINE 6.5MM KATENA 239.00 06/30/10 005 0270 4750
04692756 TREPHINE 7MM KATENA 239.00 06/30/10 005 0270 4750
04692757 TREPHINE 7.0MM KATENA 239.00 06/30/10 005 0270 4750
04692758 TREPHINE 7.2MM KATENA 239.00 06/30/10 005 0270 4750
04692759 TREPHINE 7.5MM KATENA 239.00 06/30/10 005 0270 4750
04692760 TREPHINE 7.7MM KATENA 239.00 06/30/10 005 0270 4750
04692761 TREPHINE 8.0MM KATENA 239.00 06/30/10 005 0270 4750
04692762 TREPHINE 8.2MM KATENA 239.00 06/30/10 005 0270 4750
04692763 TREPHINE 8.5MM KATENA 239.00 06/30/10 005 0270 4750
04692764 TREPHINE 8.7MM KATENA 239.00 06/30/10 005 0270 4750
04692765 TREPHINE 9.0MM KATENA 239.00 06/30/10 005 0270 4750
04692766 TREPHINE 9.5MM KATENA 239.00 06/30/10 005 0270 4750
04692769 KNIFE ILLUMRETNL TR 419.00 06/30/10 005 0270 4750
04692770 PNEUM INTRAOCULAR MIROSCISSOR 835.00 06/30/10 005 0270 4750
04692771 BACK FLUSH WITH BRUSH NEEDLE 281.00 06/30/10 005 0270 4750
04692772 BACK FLUSH W/ACTIVE ASPIRATION 281.00 06/30/10 005 0270 4750
04692773 CUTTER PNEUMATIC PED 1277.00 06/30/10 005 0270 4750
04692774 PNEUM INTRAOCULAR MICROSCISSOR 835.00 06/30/10 005 0270 4750
04692775 LACRIMAL INTUBATION W/SUTURE 353.00 06/30/10 005 0270 4750
04692776 DE FOGGER ULTRA STOP15006 C 255.00 06/30/10 005 0270 4750
04692777 CL SCOPE 6GM FOG/CONCEP 3100 44.00 06/30/10 005 0270 4750
04692778 CUTTER PNUEMATIC VITREOUS PEDS 1213.00 06/30/10 005 0270 4750
04692779 PULSE OXIMETER ADULT DISP LEAD 116.00 06/30/10 005 0270 4750
04692780 LITE PIPE 20GA DISP 100.00 06/30/10 005 0270 4750
04692781 DIAMOND DRILL OTO-FLEX 1.0MM 444.00 06/30/10 005 0270 4750
04692782 DIAMOND DRILL OTO-FLEX 2.3MM 444.00 06/30/10 005 0270 4750
04692783 DIAMOND DRILL OTO-FLEX 0.6MM 558.00 06/30/10 005 0270 4750
04692784 DIAMOND DRILL OTO-FLEX 0.7MM 558.00 06/30/10 005 0270 4750
04692785 CARBIDE SKIT/OTODRILL 0.8MM 558.00 06/30/10 005 0270 4750
04692800 PACK ENT 87.00 06/30/10 005 0270 4750
04692801 PACK OB DSP 72.00 06/30/10 005 0270 4750
04692805 SUR DRAINAGE POUCH 13/4" 93.00 06/30/10 005 0270 4750
04692806 DURAHESIVE WAFER 13/4" 121.00 06/30/10 005 0270 4750
04692807 CARTRIDGE HEMOPERFUSION 50ML 41.00 06/30/10 005 0270 4750
04692808 TUBE CONNECTION CRIST STD SIZE 41.00 06/30/10 005 0270 4750
04692809 SET IRRIGATION TUR FOUR LEAD 47.00 06/30/10 005 0270 4750
04692810 KIT ARTERIAL LINE 20GX5" CATH 115.00 06/30/10 005 0270 4750
04692811 GUARD CATHETER ARW 56.00 06/30/10 005 0270 4750
04692812 RADIAL ARTERY CATH SET 44.00 06/30/10 005 0270 4750
04692813 GROUNDING PADS INFANT 109.00 06/30/10 005 0270 4750
04692814 APPLICATOR TUBIGRIP 4-3/4" 114.00 06/30/10 005 0270 4750
04692815 APPLICATOR TUBIGRIP 5-3/4" 114.00 06/30/10 005 0270 4750
04692816 GEL WOUND DRESSING 159.00 06/30/10 005 0270 4750
04692817 CLEANSER WOUND 50.00 06/30/10 005 0270 4750
04692818 SLEEVE SCD STERILE 243.00 06/30/10 005 0270 4750
04692819 SLEEVE SCD SMALL 33.00 06/30/10 005 0270 4750
04692820 SLEEVE SCD REGULAR 35.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 48
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692821 SLEEVE SCD LARGE 344.00 06/30/10 005 0270 4750
04692822 MANIPULATOR H-K-UTER 143.00 06/30/10 005 0270 4750
04692823 AUTOTRANSFUSN CHEST DRNAGE SYS 482.00 06/30/10 005 0270 4750
04692824 PEDS POUCH 1-7/8" 96.00 06/30/10 005 0270 4750
04692825 IMMOBILIZR SHOULDR WOMEN 30X36 195.00 06/30/10 005 0270 4750
04692826 IMMOBILIZR SHOULDR WOMEN 36X42 238.00 06/30/10 005 0270 4750
04692828 IMMOBILIZER SHOULDR MENS 24X30 195.00 06/30/10 005 0270 4750
04692829 IMMOBILIZER SHOULDR MENS 30X36 195.00 06/30/10 005 0270 4750
04692830 IMMOBILIZER SHOULDR MENS 36X42 238.00 06/30/10 005 0270 4750
04692831 STOCKING GRAD COMPRESS SM BE 275.00 06/30/10 005 0270 4750
04692832 STOCKING GRAD COMPRESS MED BE 275.00 06/30/10 005 0270 4750
04692833 STOCKING GRAD COMPRESS LGE BE 275.00 06/30/10 005 0270 4750
04692834 STOCKING GRAD COMPRESS SM BL 336.00 06/30/10 005 0270 4750
04692835 STOCKING GRAD COMPRESS MED BL 336.00 06/30/10 005 0270 4750
04692836 STOCKING GRAD COMPRESS LGE BL 275.00 06/30/10 005 0270 4750
04692837 SUPP MAMMARY CARDIOVASC LARGE 132.00 06/30/10 005 0270 4750
04692838 SUPP MAMMARY CARDIOVASC X-LG 132.00 06/30/10 005 0270 4750
04692839 SUPP MAMMARY CARDIOVASC XX-LG 140.00 06/30/10 005 0270 4750
04692840 SUPP MAMMARY CARDIOVASC XXX-L 140.00 06/30/10 005 0270 4750
04692841 BOOT CRADLE 120.00 06/30/10 005 0270 4750
04692842 FINGER CONTROL MITTEN 75.00 06/30/10 005 0270 4750
04692843 TRAY PER-Q-CATHETER 262.00 06/30/10 005 0270 4750
04692844 NEONATE CRATE 60.00 06/30/10 005 0270 4750
04692845 TRAY PER-Q-CATH 3.8FR SILASTIC 327.00 06/30/10 005 0270 4750
04692846 CATHETER VOLUMETRIC 7.5FR 394.00 06/30/10 005 0270 4750
04692847 BANDAGE LATEX RUBBER 6"X4 YDS 181.00 06/30/10 005 0270 4750
04692848 BL ACCUCHECK MON GLUCOMETER II 281.00 06/30/10 005 0270 4750
04692849 DIAG TEST FOR GLUCOSE25/BTL 93.00 06/30/10 005 0270 4750
04692850 DIAG TEST FOR GLUCOSE 50/BTL 163.00 06/30/10 005 0270 4750
04692851 DIAG TEST FOR GLUCOSE 100/BTL 41.00 06/30/10 005 0270 4750
04692852 LANCET DEVICE SOFT TOUCH 63.00 06/30/10 005 0270 4750
04692853 LOAD MATIC 204.00 06/30/10 005 0270 4750
04692854 SYRINGE INSULIN GUIDES 54.00 06/30/10 005 0270 4750
04692855 KNIFE CRESCENT OPTHALMOLOGY 89.00 06/30/10 005 0270 4750
04692856 COLLAR REHAB CHILD REG 170.00 06/30/10 005 0270 4750
04692857 COLLAR REHAB CHILD SHORT 170.00 06/30/10 005 0270 4750
04692858 COLLAR REHAB EXTRA-TALL 170.00 06/30/10 005 0270 4750
04692859 COLLAR REHAB SHORT SMALL 168.00 06/30/10 005 0270 4750
04692861 COLLAR REHAB TALL LARGE 168.00 06/30/10 005 0270 4750
04692864 COLLAR REPLACE PAD ADULT SHORT 57.00 06/30/10 005 0270 4750
04692865 COLLAR REPLACEM PAD ADULT REGU 57.00 06/30/10 005 0270 4750
04692866 COLLAR REPLACEMENT PAD ADULT T 57.00 06/30/10 005 0270 4750
04692867 COLLAR REPLACEMNT PAD ADULT-ET 57.00 06/30/10 005 0270 4750
04692868 COLLAR REPLACE PAD CHILD SHORT 57.00 06/30/10 005 0270 4750
04692869 COLLAR REPLACE PAD CHILD REGUL 57.00 06/30/10 005 0270 4750
04692870 BANDAGE ESMARK 3X9 47.00 06/30/10 005 0270 4750
04692871 CATH FOLEY POSYS 6FR 2 WAY LUM 57.00 06/30/10 005 0270 4750
04692872 TUBING EPIDURAL PUMP 101.00 06/30/10 005 0270 4750
04692873 GASTROSTOMY DEVICE 18FR 1.7CM 949.00 06/30/10 005 0270 4750
04692874 GASTROSTOMY DEVICE 18FR 2.4CM 949.00 06/30/10 005 0270 4750
04692875 SET CATH REPAIR CVC-CR-HCS 6.5 212.00 06/30/10 005 0270 4750
04692876 CATH DBL LUM CVC 4FR X 8CM PED 163.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 49
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692877 CATH DBL LUM CVC 4F X 13CM PED 163.00 06/30/10 005 0270 4750
04692878 CATH DBL LUM CVC 4F X 25CM PED 292.00 06/30/10 005 0270 4750
04692879 CATH DBL LUM CVC 4F X 30CM PED 163.00 06/30/10 005 0270 4750
04692880 CATH DBL LUM CVC 5F X 40CM PED 297.00 06/30/10 005 0270 4750
04692881 CATH TRIPLE LUMEN 5.0 FR X CM 297.00 06/30/10 005 0270 4750
04692882 CATH PED TRIPLE LUM 5FR X 20CM 286.00 06/30/10 005 0270 4750
04692883 CATHETER BROVAIAC PERITONEAL 500.00 06/30/10 005 0270 4750
04692884 NEEDLE 16G ASPIR STERNAL/ILIAC 67.00 06/30/10 005 0270 4750
04692885 NEEDLE 18G STD/TP TRAOSSE INFU 116.00 06/30/10 005 0270 4750
04692886 SHEATH ENDO OLYMPUS MODEL 76.00 06/30/10 005 0270 4750
04692887 PUMP FEMO STOP N/STR 731.00 06/30/10 005 0270 4750
04692888 COMPRESSION ARCH STERILE 409.00 06/30/10 005 0270 4750
04692889 SET NORMOTHERMIC LEVEL 1 149.00 06/30/10 005 0270 4750
04692890 CATHETER DUAL - LUMEN PICC 5F 419.00 06/30/10 005 0270 4750
04692891 CATH TRIPLE LUM ANTISEP SURFAC 292.00 06/30/10 005 0270 4750
04692895 SQUEEZE BEAR FOR HEART THERAPY 69.00 06/30/10 005 0270 4750
04692896 COLLAR PEDS MIAMI 239.00 06/30/10 005 0270 4750
04692897 COLLAR STOUT MIAMI 239.00 06/30/10 005 0270 4750
04692898 COLLAR REGULAR MIAMI 292.00 06/30/10 005 0270 4750
04692899 COLLAR MEDIUM MIAMI 292.00 06/30/10 005 0270 4750
04692900 COLLAR TALL MIAMI 239.00 06/30/10 005 0270 4750
04692901 CATHETER QUAD LUMEN 504.00 06/30/10 005 0270 4750
04692902 CATHETER RADIAL ARTERYKIT 20G 75.00 06/30/10 005 0270 4750
04692903 SET ENTRO BAG 57.00 06/30/10 005 0270 4750
04692904 CHEST ACCESS WARMING BLANKET 96.00 06/30/10 005 0270 4750
04692905 MULTI-ACCESS WARMING BLANKET 117.00 06/30/10 005 0270 4750
04692906 PEDIATRIC WARMING BLANKET 117.00 06/30/10 005 0270 4750
04692907 FULL BODY WARMING BLANKET 117.00 06/30/10 005 0270 4750
04692908 CATH REPAIR KIT 9 FR DBL LUMEN 333.00 06/30/10 005 0270 4750
04692909 CATH REPAIR KIT 7 FR DBL LUMEN 333.00 06/30/10 005 0270 4750
04692910 CATH REPAIR KIT 5 FR DBL LUMEN 333.00 06/30/10 005 0270 4750
04692911 CATH REPAIR KIT 3FR SGLE LUMEN 326.00 06/30/10 005 0270 4750
04692912 CATH REPAIR KIT 4FR SNGL LUMEN 269.00 06/30/10 005 0270 4750
04692913 CATH 4FR OPTICATH INTRAVASCULR 1053.00 06/30/10 005 0270 4750
04692914 CATHETER OXIMETRY JUGULAR 1081.00 06/30/10 005 0270 4750
04692915 CATH SWAN GANZ THERMODILUT 7.5 149.00 06/30/10 005 0270 4750
04692916 KIT SHEATH INTRODUCER PERCUTAN 126.00 06/30/10 005 0270 4750
04692917 CREAM ANTIFUNG 2% MIC NIT 5 OZ 61.00 06/30/10 005 0270 4750
04692918 STOCKING ANTI-EMBOLISM SM-LONG 50.00 06/30/10 005 0270 4750
04692919 STOCKINGANTI-EMBOL X-LGE-REG 60.00 06/30/10 005 0270 4750
04692920 STOCKING ANTI-EMBOL X-SML-LONG 60.00 06/30/10 005 0270 4750
04692921 STOCKING ANTI-EMBOL X-SML-REG 50.00 06/30/10 005 0270 4750
04692922 STOCKING ANTI-EMBOL X-LGE-LONG 60.00 06/30/10 005 0270 4750
04692923 STOCKING ANTI-EMBOL MED-REG KN 31.00 06/30/10 005 0270 4750
04692924 STOCKING ANTI-EMBOL MED-LNG KN 31.00 06/30/10 005 0270 4750
04692925 STOCKING ANTI-EMBOLISM SM-REG 50.00 06/30/10 005 0270 4750
04692926 STOCKING ANTI-EMBOL MED-REG TH 50.00 06/30/10 005 0270 4750
04692927 STOCKING ANTI-EMBOL MED-LNG TH 50.00 06/30/10 005 0270 4750
04692928 STOCKING ANTI-EMBOLISM LGE-REG 50.00 06/30/10 005 0270 4750
04692929 STOCKING ANTI-EMBOLISM LGE-LNG 50.00 06/30/10 005 0270 4750
04692930 STOCKING ANTI-EMBOL LGE-SHORT 72.00 06/30/10 005 0270 4750
04692931 STOCKING ANTI-EMBOL MED-SHORT 72.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 50
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04692932 STOCKING ANTI-EMBOL SMALL-SHRT 72.00 06/30/10 005 0270 4750
04692933 CATH MULTILUMEN PEDS 22G 5.5F 284.00 06/30/10 005 0270 4750
04692934 CATH 2-LUMEN 16G 7F 20CM RADIO 225.00 06/30/10 005 0270 4750
04692935 STOCKING ANTI-EMBOL X-LGE/X-LN 33.00 06/30/10 005 0270 4750
04692936 STOCKING ANTI-EMBOL LGE REG TH 67.00 06/30/10 005 0270 4750
04692937 CABLE F/PULSE GENERATOR DISP 116.00 06/30/10 005 0270 4750
04692938 SOL PERI DIALYSIS 1.5/1500ML 82.00 06/30/10 005 0258 4750
04692939 SOL PERI DIALYSIS 2.5/1500ML 87.00 06/30/10 005 0258 4750
04692940 VENTIL CIRCUIT MECHANICAL DISP 101.00 06/30/10 005 0270 4750
04692941 IODINE INS HEXABRIX 30ML 174.00 06/30/10 005 0270 4750
04692942 IODINE INJ HEXABRIX 75 ML 388.00 06/30/10 005 0270 4750
04692944 OMNIPAGUE 240 50ML 179.00 06/30/10 Q9960 Q9960 Q9960 005 0250 4750
04692945 OMNIPAQUE INJ 41% 20ML 265.00 06/30/10 Q9962 Q9962 Q9962 005 0255 4750
04692946 OMNIPAQUE INJ 300MG 30ML 286.00 06/30/10 Q9962 Q9962 Q9962 005 0255 4750
04692947 OMNIPAQUE INJ 300MG 50ML 213.00 06/30/10 Q9962 Q9962 Q9962 005 0255 4750
04692948 OMNIPAQUE INJ 350MG 50ML 225.00 06/30/10 Q9962 Q9962 Q9962 005 0255 4750
04692949 OMNIPAQUE INJ 350MG 150ML 616.00 06/30/10 Q9962 Q9962 Q9962 005 0255 4750
04692950 OMNIPAQUE 300 100ML 502.00 06/30/10 Q9962 Q9962 Q9962 005 0255 4750
04692951 OMNIPAQUE 300 150ML 584.00 06/30/10 Q9962 Q9962 Q9962 005 0270 4750
04692952 OMNIPAGUE 300 FLEXIPAK 100ML 404.00 06/30/10 Q9962 Q9962 Q9962 005 0255 4750
04692953 OMNIPAGUE CONTRAST 180 20ML 204.00 06/30/10 Q9965 Q9965 Q9965 005 0255 4750
04692954 HEXIBRIX SINGOGAPHIN 20ML 161.00 06/30/10 005 0270 4750
04692955 PACK CRANIOTOMY 940.00 06/30/10 005 0270 4750
04692956 PACK OPEN HEART STERILE 4036.00 06/30/10 005 0270 4750
04692957 BLADE BEAVER #5700 69.00 06/30/10 005 0270 4750
04692958 BLADE BEAVER #6600 89.00 06/30/10 005 0270 4750
04692959 DRAPE OPERATION MICRO 44.00 06/30/10 005 0270 4750
04692960 SET HCG URINE CONTROL 84.00 06/30/10 005 0270 4750
04692961 CATH COOK MAGLINTE ENTERO MECL 667.00 06/30/10 005 0270 4750
04692962 TRACH II - MINI 128.00 06/30/10 005 0270 4750
04692963 SENSOR MAT BEDCHECK 170.00 06/30/10 005 0270 4750
04692979 SUCTION DRAINAGE SYSTEM 1000ML 103.00 06/30/10 005 0270 4750
04692980 SET CYCLER TRNSFR SET 4" W/CAP 212.00 06/30/10 005 0270 4750
04692981 PROBE 30 DEG TURBOSONW/2000 755.00 06/30/10 005 0270 4750
04692982 PROBE 45 DEG TURBOSON W/2000 755.00 06/30/10 005 0270 4750
04692983 RETRACTOR FLEXIBLE IRIS GRIESH 460.00 06/30/10 005 0270 4750
04692984 PENCIL CAUTERYLIGHTWEIGHT 44.00 06/30/10 005 0270 4750
04692985 PRNTNL DLYS ACUTE 318.00 06/30/10 005 0270 4750
04692986 CATH PERINEALX DIALY W/EXT SET 73.00 06/30/10 005 0270 4750
04692987 SET EASY LCK PD TRNSF 6" SYS-2 76.00 06/30/10 005 0270 4750
04692988 SET ADM Y-TYPE DIA PD SOL W/DR 56.00 06/30/10 005 0270 4750
04692989 SET DRAINAGE CYCLER 84.00 06/30/10 005 0270 4750
04692990 SET CYCLER II PRONG W/UNIV CON 181.00 06/30/10 005 0270 4750
04692991 SET 10 PRONG MAINFOLD 67.00 06/30/10 005 0270 4750
04692992 SET 4 PRONG CYCLER W/UNIV CONN 118.00 06/30/10 005 0270 4750
04692993 SET MINI EXT LIFE PD TR W/CLAM 203.00 06/30/10 005 0270 4750
04692994 TRAY CATHE PREPARATION MODEL-1 51.00 06/30/10 005 0270 4750
04692995 SET GIERMICL EXCH DEV CAPDSOL 225.00 06/30/10 005 0270 4750
04692996 BAG DRAINAGE PD 3500ML CAPACTY 50.00 06/30/10 005 0270 4750
04692997 SET 4 PRONG CYCLER 118.00 06/30/10 005 0270 4750
04692998 SLIDE SHEILD COLLAR 225.00 06/30/10 005 0270 4750
04692999 DRAIN SILICONE FLAT 7MM 44.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 51
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04693000 ADAPTER SWIVL FIBEROP BRONCHOS 72.00 06/30/10 005 0270 4750
04693001 CATHETER ARTRL EMBOL 4FR FOGAR 215.00 06/30/10 005 0270 4750
04693002 CATHETER ARTRL EMBOL 5FR FOGAR 255.00 06/30/10 005 0270 4750
04693003 CATHETER ARTRIAL EMBOL 6FR FOG 203.00 06/30/10 005 0270 4750
04693004 CATHETER IRRG 6FR (FOGERTY) 118.00 06/30/10 005 0270 4750
04693005 TRAY BIOPSY CT 56.00 06/30/10 005 0270 4750
04693006 LOOP A-V 1/4 X 3/8 239.00 06/30/10 005 0270 4750
04693007 LOOP A-V 1/4 X 1/4 INFANT 239.00 06/30/10 005 0270 4750
04693008 LOOP A-V 3/8 X 3/8 PEDIATRIC 239.00 06/30/10 005 0270 4750
04693009 TUBE FEEDING 8FR 36" POLYURETH 47.00 06/30/10 005 0270 4750
04693010 TUBE FEEDING 10FR 36" POLYURET 47.00 06/30/10 005 0270 4750
04693011 SET CYCLER 3 PRONG PED 82.00 06/30/10 005 0270 4750
04693012 CYCLER PD + FREEDOM 170.00 06/30/10 005 0270 4750
04693013 CYCLER 90/2 170.00 06/30/10 005 0270 4750
04693014 SET TRANFER LUER LOCK PREMIER 82.00 06/30/10 005 0270 4750
04693015 SET SAFE LOCK PREMIER TRANSFER 82.00 06/30/10 005 0270 4750
04693016 SET EXTENSION CONVERTABLE 50.00 06/30/10 005 0270 4750
04693017 SET 8" CATHETER EXTENSION 63.00 06/30/10 005 0270 4750
04693018 COMPAC II 215.00 06/30/10 005 0270 4750
04693019 MINIFOLD 2 PRONG 57.00 06/30/10 005 0270 4750
04693020 MINIFOLD 8 PRONG 56.00 06/30/10 005 0270 4750
04693021 SPIKE SAFE LCK ADAPT UNIVPORT 50.00 06/30/10 005 0270 4750
04693022 PREFILLED 4 SEG MULTI TUB SEG 69.00 06/30/10 005 0270 4750
04693023 SET CYCLER 5 PRONG PED 84.00 06/30/10 005 0270 4750
04693024 SOLUTION PD 4.2% / 5 LITER BAG 50.00 06/30/10 005 0270 4750
04693025 SOLUTION PD 2.5% / 5 LITER BAG 50.00 06/30/10 005 0270 4750
04693026 AVITENE 5 GM 1594.00 06/30/10 005 0270 4750
04693027 AVITENE 1 GM 430.00 06/30/10 005 0270 4750
04693028 AVITENE WEB 430.00 06/30/10 005 0270 4750
04693029 GELFILM ENVELOPE 706.00 06/30/10 005 0270 4750
04693030 GELFOAM POWDER 149.00 06/30/10 005 0270 4750
04693031 GELFOAM SZ 100 COMPRESSED 119.00 06/30/10 005 0270 4750
04693032 GELFOAM SIZE 100 119.00 06/30/10 005 0270 4750
04693033 SURGICEL 1/2 X2 40.00 06/30/10 005 0270 4750
04693034 SURGICEL 2X14 #1951 122.00 06/30/10 005 0270 4750
04693035 SURGICEL 4X8 #1952 132.00 06/30/10 005 0270 4750
04693036 PACK CUSTOM EYE CATARACT 275.00 06/30/10 005 0270 4750
04693037 PACK STERILE T & A 161.00 06/30/10 005 0270 4750
04693038 PACK STERILE EYE MUSCLE 218.00 06/30/10 005 0270 4750
04693039 PACK STERILE EAR 262.00 06/30/10 005 0270 4750
04693040 TUBE SILAS W/MONOFILAMNT GUIDE 512.00 06/30/10 005 0270 4750
04693048 SET PD CHANGE TRAY 50.00 06/30/10 005 0270 4750
04693055 CATHETER 2 LUMEN PICC 419.00 06/30/10 005 0270 4750
04693056 FLUID PERITONEAL PED 1.5% 2L 82.00 06/30/10 005 0270 4750
04693057 FLUID PERITONEAL PED 2.5% 2L 84.00 06/30/10 005 0270 4750
04693058 FLUID PERITONEAL PED 4.25% 87.00 06/30/10 005 0270 4750
04693059 FLUID PERITONEAL PED 1.5% 5L 132.00 06/30/10 005 0270 4750
04693060 FLUID PERITONEAL PED 2.5% 5L 140.00 06/30/10 005 0270 4750
04693061 FLUID PERITONEAL PED 4.25% 5L 143.00 06/30/10 005 0270 4750
04693065 KIT PED EMPTY ENEMA SCREW CAP 395.00 06/30/10 005 0270 4750
04693066 KIT TRIDATE BOWEL EVAC 243.00 06/30/10 005 0270 4750
04693067 BARIUM RING 185.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 52
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04693068 ENTROBAG SET 246.00 06/30/10 005 0270 4750
04693085 BLAZER JACKET 1 ZIPPER LG 76.00 06/30/10 005 0270 4750
04693086 BLAZER JACKET 1 ZIPPER EX-LG 76.00 06/30/10 005 0270 4750
04693087 BLAZER ICU 3 ZIPPER X-SM 89.00 06/30/10 005 0270 4750
04693088 BLAZER ICU 3 ZIPPER SM 89.00 06/30/10 005 0270 4750
04693089 BLAZER ICU 3 ZIPPER MED 89.00 06/30/10 005 0270 4750
04693090 BLAZER ICU 3 ZIPPER X-LG 96.00 06/30/10 005 0270 4750
04693091 BLAZER JACKET 1 ZIPPER X-SM 99.00 06/30/10 005 0270 4750
04693092 BLAZER JACKET 1 ZIPPER MED 76.00 06/30/10 005 0270 4750
04693093 BLAZER JACKET 1 ZIPPER SM 76.00 06/30/10 005 0270 4750
04693094 BLAZER ICU 3 ZIPPER LG 89.00 06/30/10 005 0270 4750
04693100 CANE ADULT UNI-POISE SINGL STD 41.00 06/30/10 005 0270 4750
04693101 CANE SING PT OFFSET GRIP ADULT 44.00 06/30/10 005 0270 4750
04693102 CANE ADULT ALUM QUAD BASEWIDE 75.00 06/30/10 005 0270 4750
04693103 CANE ADULT ALUM QUAD NARR BASE 69.00 06/30/10 005 0270 4750
04693104 PLATFORM ATTACHMENT 314.00 06/30/10 005 0270 4750
04693105 WALKER ADULT STANDARD 164.00 06/30/10 005 0270 4750
04693106 WALKER ADULT EXTRA WIDE 235.00 06/30/10 005 0270 4750
04693107 WALKER YOUTH STANDARD 164.00 06/30/10 005 0270 4750
04693108 WALKER CHILD FOLDING YOUTH 311.00 06/30/10 005 0270 4750
04693109 WALKER TODDLER STANDARD 371.00 06/30/10 005 0270 4750
04693110 WHEEL ATTACHMENT /PAIR 54.00 06/30/10 005 0270 4750
04693111 BRAKE GLIDE /PAIR 87.00 06/30/10 005 0270 4750
04693112 PAD DRY BURN 24"X36" 36.00 06/30/10 005 0270 4750
04693113 VIGILON 13X24 128.00 06/30/10 005 0270 4750
04693114 CATHETER PICC 4FR 347.00 06/30/10 005 0270 4750
04693115 CATH BILRY PROBE 5FR FOGARTY 290.00 06/30/10 005 0270 4750
04693116 CATH BILRY PROBE 6FR FOGARTY 302.00 06/30/10 005 0270 4750
04693117 KIT ARTERIAL LINE 122.00 06/30/10 005 0270 4750
04693118 KIT MEMBRANE ACCESSORY 655.00 06/30/10 005 0270 4750
04693119 KIT FIXATION 706.00 06/30/10 005 0270 4750
04693120 SCISSORS ROGER WIRE CUTTER 161.00 06/30/10 005 0270 4750
04693121 GAUZE,PACKING 5 YRD -2/PGK 27.00 06/30/10 005 0270 4750
04693122 SUTURE (DERMABOND)SKIN ADHESIV 132.00 06/30/10 005 0270 4750
04693123 POUCH DRAINABLE PED #20922 179.00 06/30/10 005 0270 4750
04693124 TRAY CATH SET-UP 373.00 06/30/10 005 0270 4750
04693126 PACK E.P.S. 197.00 06/30/10 005 0270 4750
04693128 TRAY PACEMAKER 215.00 06/30/10 005 0270 4750
04693130 PACK AUXILLARY 145.00 06/30/10 005 0270 4750
04693132 TRAY CATH PED 265.00 06/30/10 005 0270 4750
04693134 DECLOGGING F/ENTERAL FDNG TUBE 142.00 06/30/10 005 0270 4750
04693136 RESUSCT W/O MSK BBY BLU#7400 143.00 06/30/10 005 0270 4750
04693138 AMBU BAG - CHILD 59.00 06/30/10 005 0270 4750
04693139 AMBU BAG - ADULT 60.00 06/30/10 005 0270 4750
04693141 HYPAQUE 30 50.00 06/30/10 005 0270 4750
04693143 PEAK FLOW METER 102.00 06/30/10 005 0270 4750
04693145 DISPOSABLE FOOT PAD-REG. SIZE 334.00 06/30/10 005 0270 4750
04693146 DISPOSABLE FOOT PAD-LGE SIZE 334.00 06/30/10 005 0270 4750
04693150 CEREBRAL OXIMETER 218.00 06/30/10 005 0270 4750
04693152 DRESSING KIT LARGE (VAC) 221.00 06/30/10 005 0270 4750
04693154 CANNISTER KIT W/ISO (VAC) 191.00 06/30/10 005 0270 4750
04693160 VIGILON DRESSING 4X4 10.00 06/30/10 005 0270 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 53
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04693170 RETRACT 9-14CM ALEXIS O C-SECT 54.00 06/30/10 005 0270 4750
05010406 MRI OSI SYRINGE & TUBING 48.00 06/30/10 005 0270 3101
05010418 MRI OSI GADOBENATE-MULTIHANCE 22.00 06/30/10 A9578 A9578 A9578 005 0255 3101
06124010 COCHLEAR IMPLANT CI22 42317.00 06/30/10 005 0278 0801
06124025 AUDITORY OSSEO INTEGRATED DEV EXTERNAL 03/01/08 L8690 L8690 L8690 005 0278 0801
07120001 OB VAGINAL DELIVERY CASE CART 174.00 06/30/10 005 0270 0801
07120002 OB SURGERY CASE CART 480.00 06/30/10 005 0270 0801
07120003 OB TUBAL LIGATION CASE CART 172.00 06/30/10 005 0270 0801
07120004 OB DILATN & CURETTGE CASE CART 210.00 06/30/10 005 0270 0801
08900503 E-R CHICAGO FIRE DEPT SUPPLIES 152.00 06/30/10 005 0270 6812
08900509 IV -INFUSION PUMP 158.00 06/30/10 005 0270 6812
08900521 E-R HOT PACKS 68.00 06/30/10 005 0270 6812
08900524 E-R COLD PACK 27.00 06/30/10 005 0270 6812
08900527 E-R BULB SYRINGE 29.00 06/30/10 005 0270 6812
08900530 E-R THERMOMETER 21.00 06/30/10 005 0270 6812
08900533 E-R PELVIC TRAY 55.00 06/30/10 005 0270 6812
08900536 E-R SUTURE TRAY 110.00 06/30/10 005 0270 6812
08900539 E-R PERITONEAL LAVAGE TRAY 150.00 06/30/10 005 0270 6812
08900542 E-R DIAPERS EA 11.00 06/30/10 005 0270 6812
08900545 E-R N/G TUBES 31.00 06/30/10 005 0270 6812
08900548 E-R EAR/ULCER SYRINGE 14.00 06/30/10 005 0270 6812
08900554 E-R STERI STRIPS 17.00 06/30/10 005 0270 6812
08900557 E-R CERVICAL COLLARS(HARD) 55.00 06/30/10 005 0270 6812
08900560 ELECTRODES, ADULT 2/SET 240.00 06/30/10 005 0270 6812
08900563 ELECTRODES,PEDIATRIC 2/SET 240.00 06/30/10 005 0270 6812
09001080 ADDACEL 0.5ML INJECTION 109.00 06/30/10 005 0250 6812
09001110 ALBUTEROL SOLN INHAL 2.5MG/3ML 59.00 06/30/10 005 0250 6812
09001112 ALBUTEROL SOLN INHAL 0.5% 20ML 88.00 06/30/10 005 0250 6812
09001651 DERMABOND 126.00 06/30/10 005 0270 6812
09003315 OMNIPAQUE 350MG/ML 32.00 06/30/10 Q9962 Q9962 Q9962 005 0636 6812
09003320 ONDANSETRON(ZOFRAN)4MG/2ML INJ 52.00 06/30/10 005 0250 6812
09004400 SURGICEL 4X4 332.00 06/30/10 005 0251 6812
12666530 QUINTON PERMACATH 36CM 719.00 06/30/10 C1750 C1750 C1750 005 0272 0602
12666533 QUINTON PERMACATH 19.5CM 605.00 06/30/10 C1750 C1750 C1750 005 0272 0602
12666834 ASPIRATION NEEDLE 352.00 06/30/10 005 0270 0602
12666837 BARD LIVER BIOPSY NEEDLE 483.00 06/30/10 005 0270 0602
12667530 SURGICAL TRAY 362.00 06/30/10 A4550 A4550 A4550 005 0270 0602
13710396 AERO CHAMBER SPACER W/MASK EXTERNAL 10/19/93 005 0270 5012
13710397 SPACER DEVICE INSPIREASE EXTERNAL 10/19/93 005 0270 5012
13721061 IPRATROPIUM 0.02% SVN 2.5ML EXTERNAL 01/01/95 005 0251 5012
13725044 ONDANSETRON 4MG ORAL DISSOLVIN EXTERNAL 10/09/00 Q0179 Q0179 Q0179 005 0637 5012
13752800 REQ & VOUCHERS UFAS ONLY EXTERNAL 12/07/87 005 0270 5012
13752801 RX BLANKS UFAS ONLY EXTERNAL 12/07/87 005 0270 5012
17200459 TRACHEOTOMY TUBE-PORTEX 82.00 06/30/10 005 0270 0641
17201237 TRACHEOSTOMY TUBE-BIVONA 757.00 06/30/10 A7520 A7520 A7520 005 0270 0634
17201302 TRACHEAL SUCTION CATHETER 8.00 06/30/10 A4624 A4624 A4624 005 0270 0634
17201305 TRACHEOSTOMY CARE KIT NEW TRCH 20.00 06/30/10 A4625 A4625 A4625 005 0270 0634
40101001 CYTOLOGY BRUSH 72.00 06/30/10 005 0270 3309
40101002 CYTOLOGY BRUSH-ERCP 545.00 06/30/10 005 0270 3309
40101003 DISPOSABLE BIOPSY FORCEP 46.00 06/30/10 005 0270 3309
40101004 DISPOSABLE SCLERO NEEDLE 262.00 06/30/10 005 0270 3309
40101005 PEG-KIT 394.00 06/30/10 005 0270 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 54
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40101006 JEJUNOSTOMY TUBE 280.00 06/30/10 005 0270 3309
40101007 REPLACEMENT G-TUBE 129.00 06/30/10 005 0270 3309
40101008 FEEDING TUBE 418.00 06/30/10 005 0270 3309
40101009 DISPOSABLE PROCTOSCOPE SUCTION 129.00 06/30/10 005 0270 3309
40101031 BALLOON DILATORS-ESOPHAGEAL 496.00 06/30/10 005 0272 3309
40101032 BALLOON DILATORS-ACHALASIA 606.00 06/30/10 005 0272 3309
40101033 BALLOON DILATORS-PYLORIC 496.00 06/30/10 005 0272 3309
40101034 BALLOON DILATORS-BILIARY 1150.00 06/30/10 005 0272 3309
40101035 BALLOON DILATORS-COLON 496.00 06/30/10 005 0272 3309
40101041 SMALL BOWEL BIOPSY CAPSULE 198.00 06/30/10 005 0270 3309
40101044 SNARES-MONOPOLAR 157.00 06/30/10 005 0270 3309
40101045 SNARES-BIPOLAR 194.00 06/30/10 005 0270 3309
40101046 GOLD PROBE 940.00 06/30/10 005 0270 3309
40101051 ERCP-CANNULA 511.00 06/30/10 005 0270 3309
40101052 ERCP-BALLOON STONE EXTRACTOR 829.00 06/30/10 005 0270 3309
40101053 PAPILLOTOME-MONOPOLAR 937.00 06/30/10 005 0270 3309
40101054 STONE TOME 1341.00 06/30/10 005 0270 3309
40101055 BASKET STONE RETRIEVER 829.00 06/30/10 005 0270 3309
40101056 LITHOTRIPTOR 2923.00 06/30/10 005 0270 3309
40101057 STENT 1015.00 06/30/10 005 0272 3309
40101058 DILATING CATHETER 418.00 06/30/10 005 0272 3309
40101059 GUIDE WIRE-REGULAR 1015.00 06/30/10 005 0272 3309
40101060 GUIDE WIRE-GEENEN 109.00 06/30/10 005 0272 3309
40101061 ERCP NASAL-BILIARY DRAIN 487.00 06/30/10 005 0270 3309
40101063 BILIARY MANOMETRY CATHETER 978.00 06/30/10 005 0272 3309
40101064 WIRE GUIDED PAPILLOTOME 2517.00 06/30/10 005 0270 3309
40101065 STENT RETRIEVER 485.00 06/30/10 005 0270 3309
40101066 ASPIRATION NEEDLE 356.00 06/30/10 005 0270 3309
40101067 LOW PROFILE G-TUBE 590.00 06/30/10 005 0270 3309
40101068 EWALD TUBE 209.00 06/30/10 005 0270 3309
40101069 FOREIGN BODY RETRIEVAL ACC 234.00 06/30/10 005 0270 3309
40101074 COLON DECOMPRESSION SET 402.00 06/30/10 005 0270 3309
40101075 DISPOSABLE LIVER BIOPSY TRAY 229.00 06/30/10 005 0270 3309
40101077 LIGATOR KIT 460.00 06/30/10 005 0270 3309
40101078 CLO-TEST 39.00 06/30/10 005 0270 3309
40101079 ESOPHAGEAL STENT 9923.00 06/30/10 005 0272 3309
40101080 WALL STENT 9730.00 06/30/10 005 0278 3309
40101081 MULTIPLE BAND LIGATOR 1360.00 06/30/10 005 0270 3309
40101082 LEVEEN INFLATOR 420.00 06/30/10 005 0270 3309
40101083 ALLIANCE SYRINGE 139.00 06/30/10 005 0270 3309
40101084 GLIDE WIRE 860.00 06/30/10 005 0272 3309
40101085 JAG WIRE 860.00 06/30/10 005 0272 3309
40101086 ZEBRA WIRE 829.00 06/30/10 005 0272 3309
40101087 PATH FINDER 514.00 06/30/10 005 0270 3309
40101088 MONOLITH 974.00 06/30/10 005 0270 3309
40101089 SPHYCTERAME 1517.00 06/30/10 005 0270 3309
40101090 DISPOSABLE BASKET 381.00 06/30/10 005 0270 3309
40101091 PEDS MIC G-TUBE 542.00 06/30/10 005 0270 3309
40101092 EUS NEEDLE 924.00 06/30/10 005 0270 3309
40101093 BARD LIVER BIOPSY NEEDLE 343.00 06/30/10 005 0270 3309
40101095 QUICK CORE BIOPSY NEEDLE 367.00 06/30/10 005 0270 3309
40101100 GLO TIP SPRAY CATHETER-5 FR 80.00 06/30/10 005 0270 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 55
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40101105 GLO TIP SPRAY CATHETER-7 FR 73.00 06/30/10 005 0270 3309
40101110 INJ INERT SUBS UP GI(ENTERYX) 6877.00 06/30/10 005 0278 3309
40101115 ARGON PROBE 901.00 06/30/10 005 0270 3309
40101120 DSPOSABLE AIR CNTRST/ENEMA KIT 35.00 06/30/10 005 0270 3309
40101125 ONE-STEP BUTTON 537.00 06/30/10 005 0270 3309
40101128 AGILE PATENCY CAPSULE 311.00 06/30/10 005 0270 3309
40101131 DBE DISPOSABLE OVERTUBE 852.00 06/30/10 005 0270 3309
40101155 DISPOSABLE ESOPHYX KIT 10276.00 06/30/10 005 0270 3309
40101160 SPARE ESOPHY-X CATRIDGES 756.00 06/30/10 005 0270 3309
40112900 ADD'L BRONCHIAL DILATN BALLOON EXTERNAL 10/01/08 C1726 C1726 C1726 005 0272 3309
40112901 ADDITIONAL BRONCHIAL STENT EXTERNAL 10/01/08 C1897 C1897 C1897 005 0272 3309
40112907 PLEUREX CATHETER 1286.00 06/30/10 005 0270 3309
40112910 PLEUREX DRAINAGE BOTTLE 1560.00 06/30/10 005 0270 3309
40112913 SAFE CENTESIS THORACIC TUBE 226.00 06/30/10 005 0270 3309
40112916 WAYNE PNEUMOTHORAX TRAY 445.00 06/30/10 005 0270 3309
40112919 ENDO EASE ADVANCE SYSTEM 1156.00 06/30/10 005 0270 3309
40412028 MULTI SPIRO W/ADD'L AGENTS 842.00 06/30/10 94070 94070 94070 005 0460 3321
40412900 ADD'L BRONCHIAL DILATN BALLOON EXTERNAL 08/04/97 C1726 C1726 C1726 005 0272 3321
40412901 ADDITIONAL BRONCHIAL STENT EXTERNAL 08/04/97 C1897 C1897 C1897 005 0272 3321
40412904 ON-SITE CLOSURE DEVICE 665.00 06/30/10 C1760 C1760 C1760 005 0278 3321
40412907 PLEUREX CATHETER 1286.00 06/30/10 005 0720 3321
40412910 PLEUREX DRAINAGE BOTTLE 1560.00 06/30/10 005 0270 3321
41010148 IMPELLA CATHETER 2.5 LITER 56670.00 06/30/10 005 0270 3330
41010151 TR BAND 125.00 06/30/10 005 0270 3330
41020170 TRANSLM PRPH ATHRCTOMY FEM-POP 2902.00 06/30/10 35483 35483 35483 005 0320 3330
41030005 CARDIAC CATH EXTRA SUPPLIES EXTERNAL 11/01/94 005 0270 3330
41030006 ENDOMYOCARD BIOPSY EXTRA SUPPL EXTERNAL 11/01/94 005 0270 3330
41030007 INTRA-COR ULTRASND EXTRA SUPPL EXTERNAL 11/01/94 005 0270 3330
41030009 ANGIOPLASTY EXTRA SUPPLIES EXTERNAL 11/01/94 005 0270 3330
41030010 ATHERECTOMY EXTRA SUPPLIES EXTERNAL 11/01/94 005 0270 3330
41030020 CATH CUTDOWN EXTRA SUPPLIES 975.00 06/30/10 005 0270 3330
41030041 POLAR CATH 4/40MM BALLOON 1904.00 06/30/10 005 0270 3330
41030043 POLAR CATH 5/40MM BALLOON 1904.00 06/30/10 005 0270 3330
41030045 CRYO INFLATION DEVICE 3016.00 06/30/10 005 0270 3330
41030047 NITROUS OXIDE CATRIDGE 159.00 06/30/10 005 0270 3101
41030050 CARDIAC CATH PACK TRAY 276.00 06/30/10 005 0270 3330
41030520 BIPOLAR PACING CATHETER 254.00 06/30/10 C1730 C1730 C1730 005 0272 3330
41030528 SJM PACING CABLE 239.00 06/30/10 C1730 C1730 C1730 005 0272 3330
41030624 BIPOLAR PACING CATHETER&CABLE 529.00 06/30/10 005 0272 3330
41030663 SILVER HAWK ATHERECTOMY DEVICE 9657.00 06/30/10 C1714 C1714 C1714 005 0278 3330
41030672 ASAHI GUIDEWIRE (SPECIALTY) 378.00 06/30/10 005 0278 3330
41030675 GUIDE LINER 1383.00 06/01/10 005 0270 3330
41030678 TORNUS CATHETER 2783.00 06/01/10 005 0270 3330
41030681 VENTURE CATHETER 2275.00 06/01/10 005 0270 3330
41310583 ON-SITE CLOSURE DEVICE 665.00 06/30/10 C1760 C1760 C1760 005 0278 3330
41310590 CLOSURE DEVICE - MYNX 800.00 06/30/10 C1760 C1760 C1760 005 0278 3330
41320353 COOL PATH ABLATION CATHETER 4610.00 06/30/10 005 0272 3333
41320360 COOL PATH TUBING 302.00 06/30/10 005 0272 3333
41330005 EPS LAB EXTRA SUPPLIES EXTERNAL 11/01/94 005 0270 3333
41330050 EPS PACK TRAY 283.00 06/30/10 005 0270 3333
41330053 R2 PADS 111.00 06/30/10 005 0270 3333
44010607 HOME BLOOD GLUCOSE MONITOR EXTERNAL 01/01/09 E0607 E0607 E0607 005 0270 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 56
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44012616 GAUZE PADS 4X4 EXTERNAL 08/01/00 A6216 A6216 A6216 005 0272 5011
44014206 B-D MF SYRG .5CC/28G MIS EXTERNAL 09/01/03 A4206 A4206 A4206 005 0270 5011
44014207 SYRINGE W/ NDLE, STERILE 2CC @ EXTERNAL 07/01/07 A4207 A4207 A4207 005 0270 5011
44014208 SYRINGE W/ NDLE, STERILE 3CC,@ EXTERNAL 07/01/07 A4208 A4208 A4208 005 0270 5011
44014209 SYRNG W/NDLE,STER 5CC OR >,@ EXTERNAL 07/01/07 A4209 A4209 A4209 005 0270 5011
44014211 SUPPLIES OF SELF-ADMIN INJ EXTERNAL 07/01/07 A4211 A4211 A4211 005 0270 5011
44014213 SYRINGE,STERILE,20CC OR >,EACH EXTERNAL 07/01/07 A4213 A4213 A4213 005 0270 5011
44014215 NEEDLE,STERILE,ANY SIZE,EACH EXTERNAL 09/01/03 A4215 A4215 A4215 005 0270 5011
44014222 INFUS SUPP,EXT DRUG INF PMP,BG EXTERNAL 07/01/02 A4222 A4222 A4222 005 0270 5011
44014253 BLOOD GLUC TEST STRIPS, PER 50 EXTERNAL 08/01/00 A4253 A4253 A4253 005 0270 5011
44014258 SPRING-POWERED DEV FOR LANCET EXTERNAL 03/01/04 A4258 A4258 A4258 005 0270 5011
44014259 LANCETS, PER 100 EXTERNAL 08/01/00 A4259 A4259 A4259 005 0270 5011
44014324 CATHETER EXT CONDOM EXTERNAL 08/01/03 005 0270 5011
44014326 CATHETER EXT CONDOM EXTERNAL 08/01/07 A4326 A4326 A4326 005 0270 5011
44014338 CATHETER INDWELLING FOLEY EXTERNAL 03/01/04 A4338 A4338 A4338 005 0270 5011
44014344 CATHETER, SILICONE FOLEY EXTERNAL 01/01/08 A4344 A4344 A4344 005 0270 5011
44014348 CATHETER-FOLEY 24 FR EXTERNAL 06/01/04 A4338 A4338 A4338 005 0270 5011
44014349 CATHETER, MALE EXT EXTERNAL 07/01/07 A4349 A4349 A4349 005 0270 5011
44014357 BAG URINARY DRAINAGE EXTERNAL 08/01/03 A4357 A4357 A4357 005 0270 5011
44014358 URINARY DRAINAGE LEG BAG EXTERNAL 08/01/00 A4358 A4358 A4358 005 0270 5011
44014450 TAPE SILK(DURAPORE)2X10 YDS EXTERNAL 01/01/07 A4450 A4450 A4450 005 0270 5011
44014452 TAPE PAPER(MICROPORE)2X10YDS EXTERNAL 05/01/04 A4452 A4452 A4452 005 0270 5011
44014462 ABDOMINAL BINDER EXTERNAL 08/01/03 005 0270 5011
44014490 SURG STOCK ABOVE KNEE LNGTH,EA EXTERNAL 07/01/07 A4490 A4490 A4490 005 0270 5011
44014495 SURGICAL STOCKING THIGH LENGTH EXTERNAL 07/01/07 A4495 A4495 A4495 005 0270 5011
44014500 SURG STOCK BELOW KNEELENGTH,EA EXTERNAL 07/01/07 A4500 A4500 A4500 005 0270 5011
44014510 SURG STOCKING FULL-LENGTH,EA EXTERNAL 07/01/07 A4510 A4510 A4510 005 0270 5011
44014554 DISPOSABLE UNDERPADS,ALL SIZES EXTERNAL 09/01/04 A4554 A4554 A4554 005 0270 5011
44014614 PEAK FLOW RATE METER,HAND HELD EXTERNAL 07/01/07 A4614 A4614 A4614 005 0270 5011
44014656 NEEDLE 19GA 1.5IN BD EXTERNAL 11/01/03 005 0270 5011
44014657 SYRINGE,W/ OR W/OUT NEEDLE, EA EXTERNAL 11/01/03 A4657 A4657 A4657 005 0270 5011
44014662 ABDOMINAL PAD 5X9 EXTERNAL 08/01/03 A6403 A6403 A6403 005 0270 5011
44014663 BLOOD PR ADULT CUFF LARGE EXTERNAL 08/01/07 A4663 A4663 A4663 005 0270 5011
44014697 SYRINGE 5CC LUER LOCK 100/BOX EXTERNAL 11/01/03 005 0270 5011
44016212 ALLEVYN ADHESIVE 5X5 10/BOX EXTERNAL 08/01/04 005 0270 5011
44016222 XEROFORM 1X8 DRESSING EXTERNAL 03/01/07 A6222 A6222 A6222 005 0270 5011
44016223 XEROFROM 5"X 9" MIS EXTERNAL 01/01/03 005 0270 5011
44016231 SPONGE GAUZE 4X4 12 PLY ST EXTERNAL 08/01/03 005 0270 5011
44016233 VIGILON 13X24 EXTERNAL 01/01/03 005 0270 5011
44016235 DUODERM CGF 2.5X2.5 MIS EXTERNAL 07/01/06 A6235 A6235 A6235 005 0270 5011
44016236 DUODERM CGF 8X8 MIS EXTERNAL 09/01/04 005 0270 5011
44016237 DUODREM CGF 4X4 OR LSS,EA DRSS EXTERNAL 01/01/07 A6237 A6237 A6237 005 0270 5011
44016238 DUODERM CGF 4X4 MIS EXTERNAL 11/01/03 A6238 A6238 A6238 005 0270 5011
44016242 HYDROGL DRSS W/O BORD,16SQ"< EXTERNAL 07/01/07 A6242 A6242 A6242 005 0270 5011
44016243 HYDRGL DRSS,W/O BORD,>16<48SQ" EXTERNAL 07/01/07 A6243 A6243 A6243 005 0270 5011
44016244 HYDROGEL DRESS,W/O BORD,>48SQ" EXTERNAL 07/01/07 A6244 A6244 A6244 005 0270 5011
44016245 HYDRGL DRSS,W/ADH BRD,16SQ"OR< EXTERNAL 07/01/07 A6245 A6245 A6245 005 0270 5011
44016246 HYDRGL DRSS,W/AD BRD,>16<48SQ" EXTERNAL 07/01/07 A6246 A6246 A6246 005 0270 5011
44016247 HYDRGL DRSS,W/ADH BORD,>48SQ" EXTERNAL 07/01/07 A6247 A6247 A6247 005 0270 5011
44016248 CARRASYN V DRESSING GEL EXTERNAL 06/01/03 A6248 A6248 A6248 005 0270 5011
44016257 TEGADERM DRESSING,<16SQ IN EA EXTERNAL 01/01/07 A6257 A6257 A6257 005 0270 5011
44016258 TEGADERM DRESS>16<=48SQ IN EA EXTERNAL 01/01/07 A6258 A6258 A6258 005 0270 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 57
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44016259 TEGADRM DRESSING,48SQ IN EA EXTERNAL 09/01/04 A6259 A6259 A6259 005 0270 5011
44016261 CURASOL WOUND DRESSING GEL EXTERNAL 09/01/07 A6261 A6261 A6261 005 0270 5011
44016404 KERLIX EXTERNAL 08/01/00 A6404 A6404 A6404 005 0270 5011
44016424 BANDAGE ELASTIC 6X5 YARDS EXTERNAL 11/01/05 A6444 A6444 A6444 005 0270 5011
44016432 DRESSING NON-ADHERING EXTERNAL 06/01/04 005 0270 5011
44016440 GELOCAST 4X4 EXTERNAL 06/01/04 005 0270 5011
44019275 HOME GLUCOSE DISPOSABLE MONITR EXTERNAL 01/01/07 A9275 A9275 A9275 005 0270 5011
44023671 SOLU-MEDROL 1000MG INJ EXTERNAL 08/01/00 005 0250 5011
44032001 LINEZOLID/HEPARIN LOC EXTERNAL 03/01/06 005 0250 5011
44040607 HOME BLOOD GLUCOSE MONITOR EXTERNAL 09/01/06 E0607NU E0607NU E0607NU 005 0270 5011
44040780 INFUSION PUMP, LESS THAN 8 HRS EXTERNAL 01/01/06 E0780 E0780 E0780 99.25 005 0270 5011
44050882 ARANESP,ESRD USE INJ 1 MCG EXTERNAL 12/01/05 J0882 J0882 J0882 005 0636 5011
44051594 FLEBOGAMMA 10GM VIAL EXTERNAL 05/01/05 005 0250 5011
44052545 PENTAMIDINE ISETHIONATE/300MG EXTERNAL 01/01/09 005 0250 5011
44052917 FERRLECIT AMPUL 62.5MG/5ML/SC EXTERNAL 08/01/00 005 0250 5011
44052918 FERRLECIT AMPUL 62.5MG/5ML/SC EXTERNAL 08/01/00 005 0250 5011
44052919 FERRLECIT AMPUL 62.5MG/5ML/SC EXTERNAL 08/01/00 005 0250 5011
44053411 VANCOMYCIN 1GM INJ NOVA EXTERNAL 07/01/06 J3411 J3411 J3411 005 0636 5011
44053490 UNSPECIFIED MEDICATION EXTERNAL 07/01/02 J3490 J3490 J3490 005 0636 5011
44054259 MICROLET LANCET EXTERNAL 05/01/06 005 0250 5011
44056238 DUODERM CGF DRS 187970 CONV EXTERNAL 09/01/06 005 0250 5011
44057322 SYNVISC PREFILLED SYRINGE EXTERNAL 01/01/08 J7322 J7322 J7322 005 0636 5011
44057620 ALBUTERL & IPRATROPIUM BROMIDE EXTERNAL 08/01/00 J7609 J7609 J7609 005 0636 5011
44058700 TEMODAR 5MG CAP EXTERNAL 08/01/00 J8700 J8700 J8700 005 0636 5011
44080510 PHAR SUPP FEE 1ST MO POST-TXP 139.00 06/30/10 Q0510 Q0510 Q0510 005 0259 5011
44080511 PHAR SUPP FEE 1ST RXIN 30-DAY 67.00 06/30/10 Q0511 Q0511 Q0511 005 0259 5011
44080512 PHAR SUPP FEE SUBSQ RX IN 30-D 45.00 06/30/10 Q0512 Q0512 Q0512 005 0259 5011
44084081 EPOETIN ALFA 100 UNITS (< 10K) EXTERNAL 01/01/07 Q4081 Q4081 Q4081 005 0634 5011
44084084 SYNVISC PREFILLED SYRINGE EXTERNAL 12/31/07 J7322 J7322 J7322 005 0636 5011
44087502 NEORAL ORAL SOLN 100 EXTERNAL 08/01/00 J7502 J7502 J7502 005 0636 5011
44087506 PREDNISONE TABS 20MG EXTERNAL 08/01/00 J7506 J7506 J7506 005 0636 5011
44087507 PROGRAF CAPS PER 1 MG EXTERNAL 08/01/00 J7507 J7507 J7507 005 0636 5011
44087517 CELLCEPT TABS 500MG/R EXTERNAL 08/01/00 005 0636 5011
44089926 EPOGEN INJ 10MU/ML/AMGEN EXTERNAL 08/01/00 005 0250 5011
44090632 VAQTA SDV 50U/1ML 10 EXTERNAL 09/01/07 005 0250 5011
44090659 INFLUENZA VACCINE-WHOLE EXTERNAL 01/01/04 90658 90658 90658 005 0636 5011
44090690 VIVOTIF BERN EC CAP EXTERNAL 11/01/05 005 0250 5011
44090732 PNEUMOVAX 23 INJ 50 MCG/ML EXTERNAL 01/01/04 90732 90732 90732 005 0636 5011
44090740 HEP-B VACCINE-SERIES OF 3 EXTERNAL 01/01/04 90740 90740 90740 005 0636 5011
44090746 RECOMBINAX HB INJ 40MCG/ML EXTERNAL 08/01/00 90740 90740 90740 005 0636 5011
44090747 HEP-B VACCINE-SERIES OF 4 EXTERNAL 01/01/04 90747 90747 90747 005 0636 5011
44092499 SERUM TEARS EXTERNAL 01/01/09 92499 92499 92499 005 0510 5011
44184081 EPOETIN ALFA 100UNITS (> 10K) EXTERNAL 01/01/07 Q4081 Q4081 Q4081 005 0635 5011
44200001 KEPPRA 500MG TAB EXTERNAL 08/01/00 005 0250 5011
44200002 AMLACTIN CREAM 12% EXTERNAL 08/01/00 005 0250 5011
44200003 CENOLATE EXTERNAL 01/01/06 005 0250 5011
44200032 NAFCILLIN 2GM VIAL EXTERNAL 09/01/04 005 0250 5011
44200288 DURAGESIC SYSTEM 75MCG/HR EXTERNAL 08/01/00 005 0250 5011
44200290 MAGNESIUM S04 50% 10ML INJ EXTERNAL 08/01/00 J3475 J3475 J3475 005 0636 5011
44200505 SODIUM PHOSPHORUS EXTERNAL 01/01/05 005 0250 5011
44200827 LIDODERM PATCH 5%/ EXTERNAL 08/01/00 005 0250 5011
44210005 ACCU-CHECK ADVANTAGE KIT EXTERNAL 08/01/00 005 0270 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 58
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44210071 ACYCLOVIR INJ PER 50 MG EXTERNAL 01/01/04 005 0250 5011
44210073 AZTREONAM INJ. 500MG EXTERNAL 01/01/07 S0073 S0073 S0073 005 0250 5011
44210076 ACETAMINOPHEN ELIXIR PER 1MG EXTERNAL 02/01/07 005 0250 5011
44210077 CLINDAMYCIN PHOS INJ, 300MG EXTERNAL 01/01/07 S0077 S0077 S0077 005 0250 5011
44210164 APAP W/COD #3 TAB 300-30 100S EXTERNAL 08/01/00 005 0250 5011
44210202 ACETAZOLAMIDE 500MG VIAL 10ML EXTERNAL 08/01/00 005 0250 5011
44210355 ZOVIRAX OINT 5%/ EXTERNAL 08/01/00 005 0250 5011
44210366 ACYCLOVIR TABS 400MG/500'S EXTERNAL 08/01/00 005 0250 5011
44210395 AEROCHAMBER AEROSOL INHALER DV EXTERNAL 08/01/00 005 0270 5011
44210399 VENTOLIN INHALER 90MCG EXTERNAL 08/01/00 005 0270 5011
44210407 ASSES PEAK FLOW METER/ EXTERNAL 08/01/00 005 0270 5011
44210484 ALPRAZOLAM TABS 0.5MG EXTERNAL 08/01/00 005 0250 5011
44210820 AMITRIPTYLINE TABS 25MG EXTERNAL 08/01/00 005 0250 5011
44210834 AMITRIPTYLINE HCL TABS 100MG/ EXTERNAL 08/01/00 005 0250 5011
44210913 AMOXICILLIN CAPS 500MG EXTERNAL 08/01/00 005 0250 5011
44211092 AMPICIL VL 1GM 10ML EXTERNAL 08/01/00 005 0250 5011
44211171 RECOMBINATE INJ 401-800U EXTERNAL 08/01/00 005 0250 5011
44211382 ASPIRIN TABS EC 325MG EXTERNAL 08/01/00 005 0250 5011
44211418 ASPIRIN 81MG LOW-DOSE EXTERNAL 08/01/00 005 0250 5011
44211488 LIPITOR TABS 20MG EXTERNAL 08/01/00 005 0250 5011
44211768 BACITRACIN OINT 500U/G/ EXTERNAL 08/01/00 005 0250 5011
44211866 BECONASE AQ SPRAY 42MCG/ EXTERNAL 08/01/00 005 0250 5011
44211873 LOTENSIN TABS 10MG/ EXTERNAL 08/01/00 005 0250 5011
44212193 BETAMETHASONE DIPROP CRM .05% EXTERNAL 08/01/00 005 0250 5011
44212270 URECHOLINE 25MG TABS EXTERNAL 08/01/00 005 0250 5011
44212350 BISACODYL TABS EC 5MG/ EXTERNAL 08/01/00 005 0250 5011
44213000 TEGRETOL TABS 200MG EXTERNAL 08/01/00 005 0250 5011
44213230 CEPHALEXIN CAPS 500MG EXTERNAL 08/01/00 005 0250 5011
44213231 MAXIPIME 2GM INJ EXTERNAL 08/01/00 005 0250 5011
44214173 CIPRO TABS 500MG/ EXTERNAL 08/01/00 005 0250 5011
44214184 CLEOCIN HCL CAPS 300MG/ EXTERNAL 08/01/00 005 0250 5011
44214250 CLONIDINE HCL TABS 0.1MG/ EXTERNAL 08/01/00 005 0250 5011
44214325 CLOTRIMAZOLE CRM 1%/ EXTERNAL 08/01/00 005 0250 5011
44214660 CODEINE SULF 30MG TB 100S EXTERNAL 08/01/00 005 0250 5011
44214839 HYDROCORTISONE CRM 2.5% EXTERNAL 08/01/00 005 0250 5011
44214845 HYDROCORTISONE CREAM 0.5% EXTERNAL 08/01/00 005 0250 5011
44214853 HYDROCORTISONE OINT 1%/ EXTERNAL 08/01/00 005 0250 5011
44215020 CYANOCOBALAM 1000MCG/ML EXTERNAL 08/01/00 005 0250 5011
44215190 DTIC INJ 200MG EXTERNAL 08/01/00 005 0250 5011
44216680 LANOXIN TABS 0.125MG/ EXTERNAL 08/01/00 005 0250 5011
44216860 DOCUSATE SODIUM CAPS 100MG EXTERNAL 08/01/00 005 0250 5011
44216946 HAEMOPHILUS B VACCINE EXTERNAL 08/01/00 005 0250 5011
44216991 DIPHENHYDRAMINE HCL CAPS 25MG EXTERNAL 08/01/00 005 0250 5011
44216992 DIPHENHYDRAMINE ELIXIR PER 1MG EXTERNAL 02/01/07 005 0250 5011
44217270 DOXEPIN HCL CAPS 25MG EXTERNAL 08/01/00 005 0250 5011
44217371 DOXYCYCLINE HYCL CAPS 100MG/S EXTERNAL 08/01/00 005 0250 5011
44217906 ERY-TABS EC 500MG/ EXTERNAL 08/01/00 005 0250 5011
44217910 ERYTHROMYCINOP OINT EXTERNAL 08/01/00 005 0250 5011
44218078 DESOGEN TAB EXTERNAL 08/01/00 005 0250 5011
44218260 FERROUS SULFATE TABS 325MG EXTERNAL 08/01/00 005 0250 5011
44218295 PLENDIL 10MG TABLETS 100CT EXTERNAL 08/01/00 005 0250 5011
44218332 DIFLUCAN TABS 150MG EXTERNAL 08/01/00 005 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 59
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44218336 DIFLUCAN TABS 100MG/ EXTERNAL 08/01/00 005 0250 5011
44218830 FOLIC ACID TABS 1MG/SCHEIN PH EXTERNAL 08/01/00 005 0250 5011
44218832 FLOVENT AEROSOL 220MCG/GLAXO EXTERNAL 08/01/00 005 0250 5011
44218981 FUROSEMIDE TABS 40MG/1000S EXTERNAL 08/01/00 005 0250 5011
44219020 NEURONTIN CAPS 100MG EXTERNAL 08/01/00 005 0250 5011
44219028 NEURONTIN CAPS 400MG/ EXTERNAL 08/01/00 005 0250 5011
44219092 GELFOAM SPONG127 MIS EXTERNAL 08/01/00 A6247 A6247 A6247 005 0270 5011
44219163 GEMFIBROZIL TABS 600MG EXTERNAL 08/01/00 005 0250 5011
44219347 GLYBURIDE 5MG TAB EXTERNAL 08/01/00 005 0250 5011
44219421 GUAIFENESIN 200MG TAB EXTERNAL 08/01/00 005 0250 5011
44219443 GUIATUSS DM SYRUP 120ML EXTERNAL 08/01/00 005 0250 5011
44219971 HYDRALAZINE HCL TABS 100MG/ EXTERNAL 08/01/00 005 0250 5011
44220010 HYDROCHLOROTHIAZIDE TABS 25MG EXTERNAL 08/01/00 005 0250 5011
44220040 HYDROCHLOROTHIAZIDE TABS 50MG EXTERNAL 08/01/00 005 0250 5011
44220090 HYDROCODONE/APAP TAB 5-500MG* EXTERNAL 08/01/00 005 0250 5011
44220091 HYDROCODONE/APAP 10MG/325MG EXTERNAL 04/01/07 005 0250 5011
44220391 HYDROXYUREA CAPS 500MG/ EXTERNAL 08/01/00 005 0250 5011
44220533 IBUPROFEN TABS 400MG EXTERNAL 08/01/00 005 0250 5011
44220540 IBUPROFEN TABS 600MG EXTERNAL 08/01/00 005 0250 5011
44220548 IBUPROFEN TABS 800MG EXTERNAL 08/01/00 005 0250 5011
44220574 ORTHO-NOVUM 1/35-28 TABS/ EXTERNAL 08/01/00 005 0250 5011
44220730 INDOMETHACIN 25MG CAP EXTERNAL 08/01/00 005 0250 5011
44220761 INDOMETHACIN CAPS 50MG EXTERNAL 08/01/00 005 0250 5011
44221130 ISONIAZID TABS 300MG/MAJOR PH EXTERNAL 08/01/00 005 0250 5011
44221363 ISOSORBIDE DIN TABS CR 40MG/G EXTERNAL 08/01/00 005 0250 5011
44221454 KAOLIN PEC SUSP 195-4.33MG/ML EXTERNAL 08/01/00 005 0250 5011
44221573 COMBIVIR 150/300TABS EXTERNAL 08/01/00 005 0250 5011
44221594 PREVACID CAPS CR 30MG/ EXTERNAL 08/01/00 005 0250 5011
44221841 EMLA CRM W/TEGADERM DRESSING/5 EXTERNAL 08/01/00 005 0250 5011
44221842 EMLA CRM 30GM TUBE EXTERNAL 08/01/00 005 0250 5011
44222010 LITHIUM CARB 300MG CAP EXTERNAL 08/01/00 005 0250 5011
44222059 LORAZEPAM TABS 1MG EXTERNAL 08/01/00 005 0250 5011
44222084 CLARITIN-D TABS CR 5MG-120MG/ EXTERNAL 08/01/00 005 0250 5011
44222085 CLARITIN TABS CR 10MG/SCHERIN EXTERNAL 08/01/00 005 0250 5011
44222161 MAALOX MINT CREME SUSP/ EXTERNAL 08/01/00 005 0250 5011
44222247 MAG-OX 400TABS 400MG/ EXTERNAL 08/01/00 005 0250 5011
44222451 MMR VIRUS VACCINE,LIVE,INJ. EXTERNAL 08/01/00 005 0250 5011
44222490 MECLIZINE 25MG TAB EXTERNAL 08/01/00 005 0250 5011
44222541 MEGACE ORAL SUSP EXTERNAL 08/01/00 005 0250 5011
44222690 MENOMUNE-A/C/Y/W-135 INJ EXTERNAL 08/01/00 005 0250 5011
44223001 PURINETHOL TABS 50MG EXTERNAL 08/01/00 005 0250 5011
44223010 REGULOID ORANGE PWD 500MG/371 EXTERNAL 08/01/00 005 0250 5011
44223052 GLUCOPHAGE TABS 500MG/ EXTERNAL 08/01/00 005 0250 5011
44223223 TAPAZOLE 10MG TAB EXTERNAL 08/01/00 005 0250 5011
44223710 METOPROLOL 50MG TAB EXTERNAL 08/01/00 005 0250 5011
44223747 METRONIDAZOLE 500MG EXTERNAL 08/01/00 005 0250 5011
44223751 METOPROPOL 100MG TABLET EXTERNAL 04/01/04 005 0250 5011
44223757 METROGEL 0.75%/GALDERMA 28GM EXTERNAL 08/01/00 005 0250 5011
44223780 MICONAZOLE NITRATE CREAM EXTERNAL 08/01/00 005 0250 5011
44223821 MILK OF MAGNESIA SUSP EXTERNAL 08/01/00 005 0250 5011
44223875 REMERON TABS 15MG/ EXTERNAL 08/01/00 005 0250 5011
44224041 ONE TAB DAILY MULTIVITAMIN/GOL EXTERNAL 08/01/00 005 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 60
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44224111 MI-ACID II SUSP EXTERNAL 08/01/00 005 0250 5011
44224230 NAPROXEN SODIUM TABS 250MG/ EXTERNAL 08/01/00 005 0250 5011
44224231 NAPROXEN TABS 500MG EXTERNAL 08/01/00 005 0250 5011
44224410 NEO/POLY/HYDR/OTIC SUSP/10ML/B EXTERNAL 08/01/00 005 0250 5011
44224533 NICODERM CQ 21MG PATCH/ EXTERNAL 08/01/00 005 0250 5011
44224590 ADALAT CC TABS CR 60MG EXTERNAL 08/01/00 005 0250 5011
44224725 NITROSTAT TABS SL 0.4MG/100'S EXTERNAL 08/01/00 005 0250 5011
44225018 PRILOSEC 20MG CAP EXTERNAL 08/01/00 005 0250 5011
44225041 OCUFLOX OPHTH SOLN 0.3%/ EXTERNAL 08/01/00 005 0250 5011
44225065 ORPHENADRINE 100MG ER TAB EXTERNAL 08/01/00 005 0250 5011
44225074 ORTHO-NOVUM 1/35-28 TABS/ EXTERNAL 08/01/00 005 0250 5011
44225543 PAXIL TABS 20MG/ EXTERNAL 08/01/00 005 0250 5011
44225551 PAREGORIC 16OZ EXTERNAL 08/01/00 005 0250 5011
44225554 PEG-L-ASPARAGINASE 750IU PERML EXTERNAL 08/01/00 005 0250 5011
44225840 PENICILLIN VK TABS 500MG/ EXTERNAL 08/01/00 005 0250 5011
44226198 ELIMITE CRM 5% EXTERNAL 08/01/00 005 0250 5011
44226310 PHENAZOPYRIDINE TABS 100MG EXTERNAL 08/01/00 005 0250 5011
44226521 PHENOBARBITAL 97.2MG/ EXTERNAL 08/01/00 005 0250 5011
44226565 LORAZEPAM 0.5MG TAB EXTERNAL 06/01/03 005 0250 5011
44226764 DILANTIN KAPSEALS 100MG EXTERNAL 08/01/00 005 0250 5011
44227217 PNEUMOVAX 23 INJ 50MCG/ML EXTERNAL 08/01/00 90732 90732 90732 005 0636 5011
44227241 K-DUR 10 TABS CR 10MEQ/ EXTERNAL 08/01/00 005 0250 5011
44228170 PROPRANOLOL HCL TABS 40MG EXTERNAL 08/01/00 005 0250 5011
44228401 PSEUDOEPHEDRINE 60MG TAB EXTERNAL 08/01/00 005 0250 5011
44228410 PSEUDOEPHEDRINE HCL TABS 30MG EXTERNAL 08/01/00 005 0250 5011
44228480 PYRIDOXINE HCL TABS 50MG/RUGB EXTERNAL 08/01/00 005 0250 5011
44228495 PYRAZINAMIDE TABS 500MG EXTERNAL 08/01/00 005 0250 5011
44228637 RANITIDINE HCL TABS 300MG EXTERNAL 08/01/00 005 0250 5011
44228643 RANITIDINE HCL TABS 150MG/ EXTERNAL 08/01/00 005 0250 5011
44228762 RIFAMPIN 300MG EXTERNAL 08/01/00 005 0250 5011
44228868 KALETRA CAPSULES EXTERNAL 08/01/00 005 0250 5011
44228916 RISPERIDONE 1MG TAB EXTERNAL 08/01/00 005 0250 5011
44228989 FUROSEMIDE 20MG TAB EXTERNAL 06/01/03 005 0250 5011
44229002 SERVENT INHL AEROSOL 25MCG13 EXTERNAL 08/01/00 005 0250 5011
44229078 SALSALATE TABS 500MG EXTERNAL 08/01/00 005 0250 5011
44229442 FLEET PHOPHO SODA FLAV 1.5OZ EXTERNAL 08/01/07 005 0250 5011
44229520 SODIUM BICARB 650MG TAB EXTERNAL 08/01/00 005 0250 5011
44229592 SOD BICARB 8.4% INJ EXTERNAL 08/01/00 005 0250 5011
44229696 MORPHINE 30MG IR EXTERNAL 08/01/03 005 0250 5011
44229697 NYSTATIN 100000U SUS EXTERNAL 09/01/03 005 0250 5011
44229698 APAP/CODEINE 300-600 TAB EXTERNAL 11/01/03 005 0250 5011
44229699 APAP/CODEINE 120-12/5ML ELX EXTERNAL 11/01/03 005 0250 5011
44229700 ECLIPSE HOMEPUMP 2ML/HR 270ML EXTERNAL 11/01/03 005 0270 5011
44229701 TOBRAMYCIN 0.3% OP SOL EXTERNAL 11/01/03 005 0250 5011
44229702 BLEPHAMIDE OP SUS EXTERNAL 12/01/03 005 0250 5011
44229703 RENAGEL 800MG TAB EXTERNAL 11/01/03 005 0250 5011
44229704 FOSAMAX 70MG TAB EXTERNAL 01/01/04 005 0250 5011
44229705 COPEGUS 200MG EXTERNAL 01/01/04 005 0250 5011
44229706 NASAL 0.65% SPRAY EXTERNAL 01/01/04 005 0250 5011
44229708 ONCOLOGY MOUTHWASH EXTERNAL 01/01/04 005 0250 5011
44229709 SALAGEN 5MG TABLETS EXTERNAL 01/01/04 005 0250 5011
44229710 HUMIRA PFS 40MG EXTERNAL 03/01/04 005 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 61
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44229711 MEYTHYLDOPA 500MG TAB EXTERNAL 04/01/04 005 0250 5011
44229712 POTASSIUM PHOS 15MMP/5ML EXTERNAL 04/01/04 005 0250 5011
44229713 PACERONE 200MG TAB EXTERNAL 03/11/05 005 0250 5011
44229714 PROBENECID 500MG TAB EXTERNAL 06/01/04 005 0250 5011
44229715 DEXAMETHASONE 4MG TAB EXTERNAL 07/01/04 005 0250 5011
44229716 ALPHAGAN P 0.15% SOL EXTERNAL 09/01/04 005 0250 5011
44229717 LUMIGAN 0.03%SOL EXTERNAL 09/01/04 005 0250 5011
44229718 PRAVACHOL 20MG TAB EXTERNAL 10/01/04 005 0250 5011
44229719 ACTOS 45MG TAB EXTERNAL 10/01/04 005 0250 5011
44229720 HYDROCERIN CRE EXTERNAL 09/01/04 005 0250 5011
44229721 NIX CREME RINSE EXTERNAL 09/01/04 005 0250 5011
44229722 AVANDIA 8MG TAB EXTERNAL 10/01/04 005 0250 5011
44229723 DITROPAN XL 5MG TAB EXTERNAL 10/01/04 005 0250 5011
44229724 SUSTIVA 600MG EXTERNAL 11/01/04 005 0250 5011
44229725 XALATAN 0.005% SOL EXTERNAL 10/01/04 005 0250 5011
44229726 LEXAPRO 10MG TABLET EXTERNAL 01/01/05 005 0250 5011
44229728 OXYCODONE 5MG TAB EXTERNAL 03/01/05 005 0250 5011
44229732 CHOLESTYRAMINE LIGHT PWD EXTERNAL 05/01/05 005 0250 5011
44229733 PLAVIX 75MG TAB EXTERNAL 07/09/05 005 0250 5011
44229735 TYPHIM VI VACC PFS LLK EXTERNAL 10/01/05 005 0250 5011
44229736 LABETALOL HCL 200MG TABLET EXTERNAL 12/01/05 005 0250 5011
44229737 PREDNISOLONE 1%OP SUS EXTERNAL 11/01/05 005 0250 5011
44229738 HOMATROPINE 5%OP SOL EXTERNAL 11/01/05 005 0250 5011
44229739 MENACTRA(MENINGOCOCCAL/DIPTH) EXTERNAL 04/01/08 005 0250 5011
44229740 MENACTRA(MENNINGOCOCCAL DIPTH) EXTERNAL 01/01/06 005 0250 5011
44229741 SANDOSTATIN LAR DEPOT 30MG EXTERNAL 01/01/06 005 0250 5011
44229742 FAMVIR 500MG TABLET 30CT EXTERNAL 01/01/06 005 0250 5011
44229743 LYRICA 50MG CAP EXTERNAL 05/01/06 005 0250 5011
44229744 TRUTOL 100 EXTERNAL 06/01/06 005 0250 5011
44229748 METOLAZONE 5MG TAB EXTERNAL 06/01/06 005 0250 5011
44229750 FLOMAX 0.4 MG CAP EXTERNAL 06/01/06 005 0250 5011
44229751 XOPENEX HFA 200DOSE MDI 15GRAM EXTERNAL 07/01/06 005 0250 5011
44229752 SPIRIVA HANDIHALER EXTERNAL 07/01/06 005 0250 5011
44229753 FURADUNTIN 25MG/5ML SUS EXTERNAL 08/01/06 005 0250 5011
44229754 SIMVASTATIN 20MG TAB EXTERNAL 09/01/06 005 0250 5011
44229756 VALTREX 1000MG CAPLET EXTERNAL 09/01/06 005 0250 5011
44229759 GARDASIL VACCINE SDV 0.5ML EXTERNAL 02/01/07 005 0250 5011
44229760 TRAZODONE 150MG TAB EXTERNAL 12/01/06 005 0250 5011
44229761 TRI-NESSA TAB WAT 6X28 EXTERNAL 12/01/06 005 0250 5011
44229762 ABILIFY 10MG TAB EXTERNAL 01/01/07 005 0250 5011
44229764 FOCALIN XR 5MG CAP EXTERNAL 03/01/07 005 0250 5011
44229766 LEUKERAN(CHLORAMBUCIL) 2MG TAB EXTERNAL 04/01/07 005 0250 5011
44229767 CLINDAMYCIN LOTION EXTERNAL 01/01/07 005 0250 5011
44229768 DICLOFENAC 75MG EC TAB EXTERNAL 08/01/07 005 0250 5011
44229770 DICLOXACILL 500MG CAP EXTERNAL 08/01/07 005 0250 5011
44229771 HALOBETAS 0.05% OINT EXTERNAL 08/01/07 005 0250 5011
44229772 FLEET PHOSPHO SODA FLAV 1.5OZ EXTERNAL 08/01/07 005 0250 5012
44229773 FUOROM OPH SUS 0.1% PAC 15ML EXTERNAL 08/01/07 005 0250 5011
44229774 DIAZEPAM 10MG TABLET EXTERNAL 09/01/07 005 0250 5011
44229775 CARISOPODOL 350MG EXTERNAL 10/01/07 005 0250 5011
44229776 THERMAZENE 1% CREAM 50G EXTERNAL 10/01/09 005 0250 5011
44229777 TOBRADEX OPTH SUSP ALC@5ML EXTERNAL 10/01/09 005 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 62
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44229778 METHYLPREDNISOLONE PF OPHTH EXTERNAL 10/01/09 005 0250 5011
44229779 CARVEDILOL 25MG EXTERNAL 10/01/09 005 0250 5011
44229780 NACL IRRIG SOLN 0.9% EXTERNAL 05/01/00 005 0250 5011
44229781 BACITRACIN OP OIN EXTERNAL 10/01/09 005 0250 5011
44229782 ERYTHR O/O FOUGERS 1/8OZ EXTERNAL 10/01/09 005 0250 5011
44229783 PATADY OP SOL0.2% ALC @ 2.5ML EXTERNAL 10/01/09 005 0250 5011
44229784 CIALIS 5MG TABLET EXTERNAL 10/01/09 005 0250 5011
44229785 LEVAQUIN 750MG TAB EXTERNAL 10/01/09 005 0250 5011
44229786 APAP 650MG + DIPHEN 50MG EXTERNAL 10/01/09 005 0250 5011
44229787 SENNOSIDES-S 8.6/50MG TAB EXTERNAL 10/01/09 005 0250 5011
44229788 MORPHINE 30MG SR TAB (XAN) EXTERNAL 10/01/09 005 0250 5011
44229789 NIFEDIPINE 10MG EXTERNAL 10/01/09 005 0250 5011
44229790 VARICELLA VIRUS VACCINE EXTERNAL 10/01/09 005 0250 5011
44229791 OXYCONTIN 10MG CR TAB EXTERNAL 10/01/09 005 0250 5011
44229792 METHOCARBAMOL 750MG EXTERNAL 10/01/09 005 0250 5011
44229793 PROVENTIL HFA INH 6.7GM 200DSE EXTERNAL 10/01/09 005 0250 5011
44229794 MELOXIC TAB 15MG SAN 100@ EXTERNAL 10/01/09 005 0250 5011
44229795 APAP 650MG + DIPHEN 50MG EXTERNAL 10/01/09 005 0250 5011
44229796 PANTOPRAZOLE SODUIM 40MG CAP EXTERNAL 10/01/09 005 0250 5011
44229797 GABAPENTIN 600 MG TABLETS EXTERNAL 10/01/09 005 0250 5011
44229798 HYDROCOD+ACETAM 7.5/750MG EXTERNAL 10/01/09 005 0250 5011
44229799 TEARS NATURA II OP SOL EXTERNAL 10/01/09 005 0250 5011
44229800 FENTANYL PATCH 25MCG/HR EXTERNAL 10/01/09 005 0250 5011
44229801 BENEFIBER PWD 8.6OZ EXTERNAL 10/01/09 005 0250 5011
44229802 VITAMIN D CAP 1.25MG EXTERNAL 10/01/09 005 0250 5011
44229803 HYDROC B+AC TAB 5/325 EXTERNAL 10/01/09 005 0250 5011
44229804 FLUDROCORTIS TAB 0.1MG GPC EXTERNAL 10/01/09 005 0250 5011
44229805 SOD BICAR TAB 10GR WAT EXTERNAL 10/01/09 005 0250 5011
44229806 VOLTAREN 1% GEL EXTERNAL 10/01/09 005 0250 5011
44229807 DOCUSATE 100MG EXTERNAL 09/09/09 005 0250 5011
44229808 PROCTOSOL-HC CRM 2.5% RAN 1OZ@ EXTERNAL 10/01/09 005 0250 5011
44229809 AMITRIPTYLINE 10MG TABLETS EXTERNAL 10/01/09 005 0250 5011
44229810 SYNVISC ONE EXTERNAL 10/01/09 005 0250 5011
44229811 FLECTOR PATCH 1.3% EXTERNAL 10/01/09 005 0250 5011
44229812 AMPICIL CAP 500MG EXTERNAL 10/01/09 005 0250 5011
44229813 SM SUPER B COMPLEX +C CAP EXTERNAL 09/01/07 005 0250 5011
44229814 OXYCONTIN CR 15MG TABLETS EXTERNAL 10/01/09 005 0250 5011
44229815 HYDROCODONE/APAP 10MG/325MG EXTERNAL 09/01/09 005 0250 5011
44229816 VIGAMOX 0.5% OPTH SOL EXTERNAL 10/01/09 005 0250 5011
44229817 OXYCODONE ER 40MG TAB EXTERNAL 10/01/09 005 0250 5011
44229818 SM SUPER B COMPLEX +C CAP EXTERNAL 01/01/09 005 0250 5011
44229819 OXYCOD HCL TAB 15MG EXTERNAL 10/01/09 005 0250 5011
44229820 OXYCOD ER TAB 20MG EXTERNAL 10/01/09 005 0250 5011
44229821 WARFARIN 1MG EXTERNAL 10/01/09 005 0250 5011
44229822 GABAPENTIN 100MG EXTERNAL 10/01/09 005 0250 5011
44229823 C-(I)VFEND 1% OPHTH (20ML) SOL EXTERNAL 10/01/09 005 0250 5011
44229824 FORTAMET ER TAB 1000MG EXTERNAL 10/01/09 005 0250 5011
44229825 OXYCONTIN CR 30MG TABLETS EXTERNAL 10/01/09 005 0250 5011
44229826 GABAPENTIN CAP 300MG EXTERNAL 09/01/09 005 0250 5011
44229827 INFLUENZA VACC 0.5ML 2009-2010 EXTERNAL 09/01/09 005 0250 5011
44229828 PHOSPHA 250 NEUTR TAB RIS@100 EXTERNAL 09/01/09 005 0250 5011
44229829 BISCACODYL 10MG SUP EXTERNAL 09/01/09 005 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 63
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44229830 VALTREX CAPLET 500MG EXTERNAL 10/01/09 005 0250 5011
44229831 NITROFURAN CAP 100MG EXTERNAL 10/01/09 005 0250 5011
44229832 METHYLPRED TAB 4MG EXTERNAL 10/01/09 005 0250 5011
44229833 AF CAPSICUM CRM 0.025% EXTERNAL 10/01/09 005 0250 5011
44229834 AMLOPINE TAB 5MG EXTERNAL 10/01/09 005 0250 5011
44229835 MISOPROSTOL 200MCG TAB EXTERNAL 11/01/09 005 0250 5011
44229836 ZYMAR 0.3% EYE DROPS EXTERNAL 11/01/09 005 0250 5011
44229837 DIOVAN 160MG TAB EXTERNAL 12/10/09 005 0250 5011
44229838 FRAGMIN SYR 18000IU/0.72ML EXTERNAL 12/10/09 005 0250 5011
44229839 RENA-VITE TAB OTC EXTERNAL 12/01/09 005 0250 5011
44229841 LABETALOL 300MG TAB EXTERNAL 02/01/10 005 0250 5011
44229842 ENEMA 4.5 OZ EXTERNAL 02/01/10 005 0250 5011
44229843 HALFLYTE+BISACODYL KIT EXTERNAL 02/01/10 005 0250 5011
44229844 OXYCOD/APAP 5-325MG TAB EXTERNAL 02/01/10 005 0250 5011
44229845 FAMOTIDINE INJ 10MG/ML EXTERNAL 01/01/10 005 0250 5011
44229846 NAPROXEN 375MG TAB EXTERNAL 03/01/10 005 0250 5011
44229847 STROMECTOL 3MG TAB EXTERNAL 03/01/10 005 0250 5011
44229848 NEOMYCIN 500MG TAB EXTERNAL 03/01/10 005 0250 5011
44229849 TAGAMET HB 200MG TAB EXTERNAL 04/01/10 005 0250 5011
44229850 CLOBETASOL PROPIONATE 0.05%CRM EXTERNAL 04/01/10 005 0250 5011
44229851 CHLORHEXIDINE GLUCONATE 0.12% EXTERNAL 04/01/10 005 0250 5011
44229854 PREVPAC CARD 14-DAY EXTERNAL 04/01/10 005 0250 5011
44229855 METANX TAB EXTERNAL 04/01/10 005 0250 5011
44229856 CYMBALTA 30MG CAP EXTERNAL 04/01/10 005 0250 5011
44229857 ATRIPLA (EFA/EMT&TEN) EXTERNAL 06/01/10 005 0250 5011
44229858 NICODERM CQ CLR PATCH 7MG 14 EXTERNAL 07/01/10 005 0250 5011
44229859 CIPRODEX OTIC SUSP 7.5ML ALCON EXTERNAL 07/15/10 005 0250 5011
44229860 LIDOCAINE HCL JELLY 2% 30ML EXTERNAL 07/01/10 005 0250 5011
44229861 ZINC OXIDE OINTMENT USP EXTERNAL 07/01/10 005 0250 5011
44229862 PANTOPRAZOLE D-R 20 MG TABLETS EXTERNAL 07/01/10 005 0250 5011
44229863 LISINOPRIL TAB 2.5MG EXTERNAL 08/01/10 005 0250 5011
44229941 SOD CITR/CITR ACID SOL 473ML EXTERNAL 08/01/00 005 0250 5011
44230087 SOD POLYS SULF 1GM/4ML SUSP/ EXTERNAL 08/01/00 005 0250 5011
44230150 SULFACET SOD OPHTH SOLN 10%/B EXTERNAL 08/01/00 005 0250 5011
44230719 IMITREX TABS 25MG/ EXTERNAL 08/01/00 005 0250 5011
44230851 TERAZOL 3 VAGINAL CRM 0.8%/ EXTERNAL 08/01/00 005 0250 5011
44230852 TERAZOL 3 VAG SUPPS 80MG EXTERNAL 08/01/00 005 0250 5011
44231051 TETANUSD/DIPHTH INJ 5ML EXTERNAL 08/01/00 005 0250 5011
44231400 THIOGUANINE 40MG TAB EXTERNAL 08/01/00 005 0250 5011
44231727 TIMOLOL OPHTH SOLN 0.5%5ML EXTERNAL 08/01/00 005 0250 5011
44231747 COSOPT EYE DROPS/ EXTERNAL 08/01/00 005 0250 5011
44232275 AZMACORT INHALER 100MCG/SPRAY EXTERNAL 08/01/00 005 0250 5011
44232365 CERUMENEX DROPS EXTERNAL 08/01/00 005 0250 5011
44232760 APLISOL 5U/0.1ML INJ EXTERNAL 08/01/00 005 0250 5011
44232921 DEPAKOTE TABS 250MG/ EXTERNAL 08/01/00 005 0250 5011
44233070 NAPHCON-A OPHTH SOLN/ EXTERNAL 08/01/00 005 0250 5011
44233380 WATER INJ FTV 10ML/ EXTERNAL 08/01/00 005 0250 5011
44234090 AMIKACIN SULF 500MG/2ML EXTERNAL 08/01/00 005 0250 5011
44235800 FLUZONE SPLT 2000-01 INJ EXTERNAL 08/01/00 90658 90658 90658 005 0636 5011
44237366 GLEEVEC 100MG CAP EXTERNAL 08/01/00 005 0250 5011
44238040 THIAMINE SDV 2CMG 2ML APP 25 EXTERNAL 08/01/00 005 0250 5011
44241024 CELEXA 20MG TAB 100/BTL FOREST EXTERNAL 08/01/00 005 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 64
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44241650 ROXANOL LIQ 20MG/ML EXTERNAL 08/01/00 005 0250 5011
44242210 ARGININE SOLUTION 300ML EXTERNAL 08/01/00 005 0250 5011
44242725 GENTAMICIN 100MG EXTERNAL 08/01/00 005 0250 5011
44247411 LAC-HYDRIN LOT 12%/ EXTERNAL 08/01/00 005 0250 5011
44247415 ENALAPRIL 20MG TAB ZEN 1000 EXTERNAL 08/01/00 005 0250 5011
44253490 AVASTIN PER 100MG EXTERNAL 04/01/04 J3490 J3490 J3490 005 0636 5011
44255539 BLOOD PRESSURE KIT EXTERNAL 08/01/00 005 0270 5011
44255540 NON STERILE EXAM GLOVES/ EXTERNAL 08/01/00 005 0270 5011
44255732 INFUSOR INTERMATE LV2 2ML/HR/ EXTERNAL 07/01/02 005 0250 5011
44255888 CATHETER ALL PURPOSE EXTERNAL 07/01/03 005 0270 5011
44256056 PLASTIPAK TB 25G/5/8 SYRINGE/ EXTERNAL 08/01/00 005 0250 5011
44256281 B-D U100 INSULIN SYRINGE/B-D EXTERNAL 08/01/00 005 0270 5011
44260000 VIGILON 13 X 24 EXTERNAL 08/01/00 005 0270 5011
44261627 NICOTROL INH EXTERNAL 06/01/04 005 0250 5011
44262014 INTRAVENOUS ADMINISTRATION SET EXTERNAL 07/01/02 005 0270 5011
44262041 LOPERAMIDE HCL CAPS 2MG/100'S EXTERNAL 08/01/00 005 0250 5011
44262048 LISINOPRIL 20MG TABL EXTERNAL 08/01/00 005 0250 5011
44262056 AMMONIUM LACTATE LOT 12%/225G EXTERNAL 08/01/00 005 0250 5011
44262121 NEUTRA-PHOS POW EXTERNAL 08/01/00 005 0250 5011
44262122 RETIN-A CRM 0.05%ORTHO 45 EXTERNAL 08/01/00 005 0250 5011
44262148 PEPCID TABS 20MG EXTERNAL 08/01/00 005 0250 5011
44262164 FIORICET TABS/SANDOZ EXTERNAL 08/01/00 005 0250 5011
44262215 B-D SAFETY-LOK 3CE SYRINGE/B-D EXTERNAL 08/01/00 005 0270 5011
44262363 ANUSOL HC SUPP 25MG EXTERNAL 08/01/00 005 0250 5011
44262392 CEENU CAPS 100MG/BRISTOL EXTERNAL 08/01/00 005 0250 5011
44262394 DAKINS SOLUTION 1/4 STRENGTH EXTERNAL 05/01/00 005 0250 5011
44262410 SPECTAZOLE CRM 1%30GM EXTERNAL 08/01/00 005 0250 5011
44262415 NAFTIN CRM 1% 60GM EXTERNAL 08/01/00 005 0250 5011
44262437 CEENU CAPS 10MG/BRISTOL EXTERNAL 08/01/00 005 0250 5011
44262517 TRIAM. 1% OINT/FOUGERA 15GM EXTERNAL 08/01/00 005 0250 5011
44262617 NICOTINE 14MG PATCH EXTERNAL 08/01/00 005 0250 5011
44262630 NIASPAN TABS CR 500MG EXTERNAL 08/01/00 005 0250 5011
44262808 HOLLISTER 3724/ EXTERNAL 01/01/02 005 0251 5011
44262908 B-D YALE 27G 1/2 NEEDLE/B-D EXTERNAL 08/01/00 005 0270 5011
44262931 SOFTCLIX LANCETS EXTERNAL 08/01/00 A4259 A4259 A4259 005 0270 5011
44262957 HYTRIN SEC CAPS 1MG/ EXTERNAL 08/01/00 005 0250 5011
44262961 HEMORRHOIDAL-HC 25MG SUP EXTERNAL 08/01/00 005 0250 5011
44262990 RECOMBIVAX HB INJ 40MCG/ML EXTERNAL 08/01/00 90740 90740 90740 005 0636 5011
44263134 NEPHRO-VITE TAB EXTERNAL 08/01/00 005 0250 5011
44269990 RECOMBIVAX-HB VL 40MCG PF 1MG EXTERNAL 06/01/03 90740 90740 90740 005 0636 5011
44280004 ACCU-CHECK COMFORT CURVE STRIP EXTERNAL 08/01/00 005 0270 5011
44280017 MEVACOR TABS 20MG 1000'S EXTERNAL 08/01/00 005 0250 5011
44280019 SYNVISC PREFILLED SYRINGE EXTERNAL 12/31/07 J7322 J7322 J7322 005 0636 5011
44280634 EPO ESRD <10,000 UNITS (DPA) EXTERNAL 01/01/07 J0886 J0886 J0886 005 0634 5011
44280635 EPO ESRD =>10,000 UNITS (DPA) EXTERNAL 01/01/07 J0886 J0886 J0886 005 0635 5011
44282400 MARCAINE 0.75% 30ML EXTERNAL 08/01/00 005 0250 5011
44299911 LACTULOSE SOL HI-T 32OZ EXTERNAL 08/01/00 005 0250 5011
44299912 CHOLESTYRAMINE PWD 4G EXTERNAL 06/01/10 005 0250 5011
44299914 VFEND TAB 200MG EXTERNAL 08/01/00 005 0250 5011
44299915 AVELOX 400MG TAB EXTERNAL 08/01/00 005 0250 5011
44299916 TRECATOR-SC 250MG EXTERNAL 08/01/00 005 0250 5011
44299918 VITAMIN A&D OIN EXTERNAL 04/01/03 005 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 65
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44299919 THALIDOMIDE 50MG CAP EXTERNAL 08/01/00 005 0250 5011
44299920 NULYTELY CHERRY SOL EXTERNAL 08/01/00 005 0250 5011
44299922 TRIMETHOPRIM POLYMYXN SOL EXTERNAL 08/01/00 005 0250 5011
44299925 CHLOROXAZON 500MG EXTERNAL 06/01/03 005 0250 5011
44299936 ACYCLOVIR 200MG CAP EXTERNAL 06/01/03 005 0250 5011
44299937 OYSTER CAL 500MG TAB EXTERNAL 06/01/03 005 0250 5011
44299938 TWINRIX VAC SDV 20MCG EXTERNAL 07/01/03 90636 90636 90636 005 0636 5011
44299960 DAUNRUBICIN HCL 20MG 10VHA+ EXTERNAL 08/01/02 005 0250 5011
44299965 LANTUS 100U/ML INJ EXTERNAL 08/01/00 005 0250 5011
44299967 TRIPEDIA INJ EXTERNAL 08/01/00 005 0250 5011
44299968 ORTHO TRI-CYCLEN TAB EXTERNAL 08/01/00 005 0250 5011
44299969 FLOXIN 400MG TAB EXTERNAL 08/01/00 005 0250 5011
44299970 ORAMORPH SR 15MG TAB EXTERNAL 08/01/00 005 0250 5011
44299971 ARTHROTEC 75 TAB EXTERNAL 08/01/00 005 0250 5011
44299972 GEODON 80MG CAP EXTERNAL 08/01/00 005 0250 5011
44299973 DILTIAZEM CD 120MG/24 CAP EXTERNAL 08/01/00 005 0250 5011
44299974 REBETRON 1000/PEN KIT EXTERNAL 08/01/00 005 0250 5011
44299976 EPIVIR TABS 150MG/GLAXO EXTERNAL 08/01/00 005 0250 5011
44299977 HAVRIX A VAC 1ML VIAL/SMITHKLI EXTERNAL 08/01/00 005 0250 5011
44299979 ARTHROTEC 50 TAB EC 50-0.2MG/ EXTERNAL 08/01/00 005 0250 5011
44299980 IMATINIB 100MG CAP EXTERNAL 08/01/00 005 0250 5011
44299981 ENGERIX-B 20MCG/ML INJ EXTERNAL 08/01/00 90740 90740 90740 005 0636 5011
44299982 EXTENSION SET 0.22 MICROM EXTERNAL 07/01/02 005 0250 5011
44299983 DILAUDID-HP 500MG/50ML EXTERNAL 08/01/00 005 0250 5011
44299984 CITROMA (CIT/MAG) 296 SWAN EXTERNAL 08/01/00 005 0250 5011
44299985 PARAGUARD IUD EXTERNAL 08/01/00 005 0270 5011
44299986 MEDTRONIC REFILL KIT EXTERNAL 08/01/00 005 0250 5011
44299987 APLISOL 5U/0.1ML INJ EXTERNAL 08/01/00 005 0250 5011
44299988 ZIAGEN 300MG TAB/GLAXO EXTERNAL 08/01/00 005 0250 5011
44299989 RETROVIR/ZIDOVUDINE CAPS 100MG EXTERNAL 08/01/00 005 0250 5011
44299990 ROCALTROL 0.5%MCG CAP EXTERNAL 08/01/00 005 0250 5011
44299991 ZOLEDRONIC ACID PWD EXTERNAL 08/01/00 J3487 J3487 J3487 005 0636 5011
44299992 ADVAIR DISKUS 500/50(#60) EXTERNAL 08/01/00 005 0250 5011
44299994 SINGULAIR 10MG TAB/MERCK& CO EXTERNAL 08/01/00 005 0250 5011
44299995 HIBTITER VACCINE INJ/WYETH-AYE EXTERNAL 08/01/00 005 0250 5011
44299996 POL VACCINE INJ/PASTEUR MER C EXTERNAL 08/01/00 005 0250 5011
44299997 VENOFER 100MG/5ML EXTERNAL 08/01/00 005 0250 5011
44299998 MATULANE CAP 50MG/SIGMA-TAU EXTERNAL 08/01/00 005 0250 5011
44299999 CAMPATH VIAL 30MG EXTERNAL 07/01/02 005 0250 5011
00510010 HEMATOCRIT/HEMOGLOBIN N/C 06/30/10 006 0305 0212
01310021 ESOPHAGOSCOPY; DIAGNOSTIC 959.00 06/30/10 43200 43200 43200 006 0360 2730
01310022 ESOPHAGOSCOPY; BIOPSY 1319.00 06/30/10 43202 43202 43202 006 0360 2730
01310023 ESOPHAGOSCOPY; REMOVE POLYP(S) 967.00 06/30/10 43217 43217 43217 006 0360 2730
01310024 ESOPHAGOSCOPY; DILATION 1390.00 06/30/10 43220 43220 43220 006 0360 2730
01310027 EGD; COMPLEX DIAGNOSTIC 1842.00 06/30/10 43235 43235 43235 006 0360 2730
01310028 EGD; BIOPSY 1859.00 06/30/10 43239 43239 43239 006 0360 2730
01310029 EGD; REMOVE FOREIGN BODY 1781.00 06/30/10 43247 43247 43247 006 0360 2730
01310030 EGD; REMOVAL OF POLYP(S) 2113.00 06/30/10 43251 43251 43251 006 0360 2730
01310031 EGD; CONTROL OF HEMORRHAGE 2113.00 06/30/10 43255 43255 43255 006 0360 2730
01310032 EGD; DILAT OF PYLORUS/STENOSIS 2025.00 06/30/10 43245 43245 43245 006 0360 2730
01310033 EGD; PERCUTAN GASTROSTOMY TUBE 1762.00 06/30/10 43246 43246 43246 006 0360 2730
01310037 DILATE ESOPH BY SOUND/BOUGIE 967.00 06/30/10 43450 43450 43450 006 0360 2730
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 66
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01310038 DILATE ESOPH, GUIDEWIRE/STRING 967.00 06/30/10 43453 43453 43453 006 0360 2730
01310039 DILATE ESOPHAGUS BY BALLOON 1390.00 06/30/10 43220 43220 43220 006 0750 2730
01310042 ESOPHAGOGASTRIC TAMPONADE 1293.00 06/30/10 43460 43460 43460 006 0360 2730
01310043 ESOPH ACID REFLUX TEST 24HR PH 439.00 06/30/10 91038 91038 91038 006 0750 2730
01310044 ESOPHAGOS-SCLEROSIS OF VARICES 967.00 06/30/10 43204 43204 43204 006 0360 2730
01310050 SIGMOIDOSCOPY; FOR BIOPSY 839.00 06/30/10 45331 45331 45331 006 0360 2730
01310051 SIGMOIDOSCOPY-REM FOREIGN BODY 1017.00 06/30/10 45332 45332 45332 006 0360 2730
01310052 SIGMOIDOSCOPY; REMOVE POLYP(S) 1135.00 06/30/10 45333 45333 45333 006 0360 2730
01310055 ANOSCOPY; DIAGNOSTIC 142.00 06/30/10 46600 46600 46600 006 0360 2730
01310060 LIVER BIOPSY; PERCUT NEEDLE 969.00 06/30/10 47000 47000 47000 006 0360 2730
01310062 ERCP 2094.00 06/30/10 43260 43260 43260 006 0360 2730
01310063 ERCP; SPINCTEROTOMY 3308.00 06/30/10 43262 43262 43262 006 0360 2730
01310071 PIEE BOWEL EVACUATION 686.00 06/30/10 45999 45999 45999 006 0360 2730
01310072 ENDOSCOPIC PHOTOGRAPH 435.00 06/30/10 91299 91299 91299 006 0750 2730
01310073 ESOPHAGEAL MOTILITY STUDY 1180.00 06/30/10 91010 91010 91010 006 0750 2730
01310074 ESOPHAGUS ACID PERFUSION 421.00 06/30/10 91030 91030 91030 006 0750 2730
01310075 GASTRIC ANALYSIS 225.00 06/30/10 89130 89130 89130 006 0300 2730
01310076 GASTRIC INTUBATION 179.00 06/30/10 91055 91055 91055 006 0750 2730
01310077 SECRETIN STIMULATION 1293.00 06/30/10 91052 91052 91052 006 0750 2730
01310078 ANORECTAL MANOMETRY 826.00 06/30/10 91122 91122 91122 006 0750 2730
02180471 POST-OPERATIVE FOLLOW UP VISIT N/C 06/30/10 006 0510 2820
03107390 GLUCOSE; BLOOD, STICK TEST 40.00 06/30/10 82948 82948 82948 006 0301 0805
03107400 PROTHROMBIN TIME 59.00 06/30/10 85610 85610 85610 006 0305 0805
03132030 PROTHROMBIN TIME 59.00 06/30/10 85610QW 85610QW 85610QW 006 0305 0801
03701552 BONE MARROW; ASPIRATION ONLY 315.00 06/30/10 38220 38220 38220 006 0361 3312
03701553 BONE MARROW BIOP NEEDLE/TROCAR 256.00 06/30/10 38221 38221 38221 006 0361 3312
03701801 CD34-FLOW CYTOMETRY 230.00 06/30/10 88182 88182 88182 006 0311 3313
03701802 CFU-GM (TISSUE CULTURE ASSAY) 497.00 06/30/10 88237 88237 88237 006 0310 3313
03701803 CRYOPRESERVATION OF STEM CELLS 1581.00 06/30/10 86890 86890 86890 006 0300 3313
03701804 NUCLEATED CELL COUNT/VIABILITY 109.00 06/30/10 85027 85027 85027 006 0305 3313
03701805 STERILITY-BLOOD PRODUCT 187.00 06/30/10 87040 87040 87040 006 0306 3313
03701810 STEM CELL PREP-AUTOLOGOUS 1624.00 06/30/10 006 0310 3313
03701821 STEM CELL INCUB W/CHEMOPURGING 8934.00 06/30/10 38211 38211 38211 006 0300 3313
03701822 CD34 SELECTION 12282.00 06/30/10 38211 38211 38211 006 0300 3313
03701831 CD34-FLOW CYTOMETRY 230.00 06/30/10 88182 88182 88182 006 0311 3313
03701832 CFU-GM (TISSUE CULTURE ASSAY) 497.00 06/30/10 88237 88237 88237 006 0310 3313
03701833 CRYOPRESERVATION OF STEM CELLS 1581.00 06/30/10 86890 86890 86890 006 0300 3313
03701834 NUCLEATED CELL COUNT/VIABILITY 109.00 06/30/10 85027 85027 85027 006 0305 3313
03701835 STERILITY-BLOOD PRODUCT 187.00 06/30/10 87040 87040 87040 006 0306 3313
03701840 STEM CELL PREP-ALLOGENEIC 1624.00 06/30/10 006 0360 3313
03701851 T-CELL DEPLETION 8934.00 06/30/10 38210 38210 38210 006 0300 3313
03701852 CD34 SELECTION 12995.00 06/30/10 38212 38212 38212 006 0300 3313
03701861 BONE MARROW HARVESTING 2023.00 06/30/10 38230 38230 38230 41.99 41.99 006 0360 3313
03701862 BONE MARROW FILTRATION 228.00 06/30/10 86999 86999 86999 006 0300 3313
03701863 CD34-FLOW CYTOMETRY 230.00 06/30/10 88182 88182 88182 006 0311 3313
03701864 CFU-GM (TISSUE CULTURE ASSAY) 497.00 06/30/10 88237 88237 88237 006 0310 3313
03701865 AUTOLOGOUS BN MARROW PROCESSNG 950.00 06/30/10 86891 86891 86891 006 0300 3313
03701866 CRYOPRESERVATION OF STEM CELLS 1581.00 06/30/10 86890 86890 86890 006 0300 3313
03701867 NUCLEATED CELL COUNT/VIABILITY 109.00 06/30/10 85027 85027 85027 006 0305 3313
03701868 STERILITY-BLOOD PRODUCT 187.00 06/30/10 87040 87040 87040 006 0306 3313
03701881 STEM CELL INCUB W/CHEMOPURGING 12282.00 06/30/10 38212 38212 38212 006 0300 3313
03701882 CD34 SELECTION 10234.00 06/30/10 86999 86999 86999 006 0300 3313
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 67
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03701891 BONE MARROW HARVESTING 2023.00 06/30/10 38230 38230 38230 41.99 41.99 006 0360 3313
03701892 BONE MARROW FILTRATION 228.00 06/30/10 86999 86999 86999 006 0300 3313
03701893 CD34-FLOW CYTOMETRY 230.00 06/30/10 88182 88182 88182 006 0311 3313
03701894 CFU-GM (TISSUE CULTURE ASSAY) 497.00 06/30/10 88237 88237 88237 006 0310 3313
03701895 CRYOPRESERVATION OF STEM CELLS 1581.00 06/30/10 86890 86890 86890 006 0300 3313
03701896 NUCLEATED CELL COUNT/VIABILITY 109.00 06/30/10 85027 85027 85027 006 0305 3313
03701897 STERILITY-BLOOD PRODUCT 187.00 06/30/10 87040 87040 87040 006 0306 3313
03701911 PROC BN MAR MINOR ABO INCOMPAT 489.00 06/30/10 86999 86999 86999 006 0300 3313
03701912 PROC BN MAR MAJOR ABO INCOMPAT 879.00 06/30/10 86999 86999 86999 006 0300 3313
03701913 T-CELL DEPLETION 8934.00 06/30/10 38210 38210 38210 006 0300 3313
03701914 CD34 SELECTION 10234.00 06/30/10 86999 86999 86999 006 0300 3313
03701921 THAWING OF STEM CELLS 358.00 06/30/10 86931 86931 86931 006 0300 3313
03701922 CD34-FLOW CYTOMETRY 230.00 06/30/10 88182 88182 88182 006 0311 3313
03701923 CFU-GM (TISSUE CULTURE ASSAY) 497.00 06/30/10 88237 88237 88237 006 0310 3313
03701924 BN MAR/STEM CELL INFUS ALLOGEN 540.00 06/30/10 38242 38242 38242 41.03 41.03 006 0360 3313
03701925 BN MAR/STEM CELL INFUS AUTOLOG 540.00 06/30/10 38241 38241 38241 41.01 41.01 006 0360 3313
03701926 NUCLEATED CELL COUNT/VIABILITY 109.00 06/30/10 85027 85027 85027 006 0305 3313
03701927 STERILITY-BLOOD PRODUCT 187.00 06/30/10 87040 87040 87040 006 0306 3313
03701941 COMPLEX THAWING (IL2 INCUB) 5837.00 06/30/10 86931 86931 86931 006 0300 3313
03701947 ALLOGENIC DONOR LYMPHOCYTE INF 443.00 06/30/10 38242 38242 38242 41.08 006 0300 3313
03701948 CRYOPRESERVATION OF DLI 1764.00 06/30/10 38207 38207 38207 41.00 006 0300 3313
03701949 T/B CELL PANEL CYTOMETRY 2157.00 06/30/10 38207 38207 38207 41.00 006 0306 3313
03702100 PERIPH STMCLL CRYOPRSRV NP 1608.00 06/30/10 006 0300 3313
03702101 PERIPH STMCL CRYPRSRV AFTR4 NP 1899.00 06/30/10 006 0300 3313
03702102 STORAGE OVER 1 YR (PER YR) NP 272.00 06/30/10 006 0300 3313
03702103 QUANTITATION-CD34 CELLS NP 180.00 06/30/10 006 0300 3313
03702104 STEM CELL ASSAY (CFU-GM) NP 150.00 06/30/10 006 0300 3313
03702105 CELL VIABILITY, STERILITY NP 150.00 06/30/10 006 0300 3313
03702106 MARROW WASH/CRYOPRSRV NP 2338.00 06/30/10 006 0300 3313
03702107 MARROW WASH/CRYOPRSRV AFTR4 NP 2921.00 06/30/10 006 0300 3313
03702108 RBC DEPLETE/CRYOPRSV NP 2628.00 06/30/10 006 0300 3313
03702109 RBC DEPLETE/CRYOPRSRV AFTR4 NP 3212.00 06/30/10 006 0300 3313
03702121 ALLOGENEIC CORD BLOOD INFUSION 540.00 06/30/10 38242 38242 38242 006 0362 3313
03702124 THAW & RECONSTITUTE CORD BLOOD 2105.00 06/30/10 38207 38207 38207 006 0300 3313
03702127 STEM CELL PEDS SEND OUT TEST EXTERNAL 03/01/09 006 0819 3313
03702401 NUCLEIC ACID ISOLATION 147.00 06/30/10 83890 83890 83890 006 0301 3314
03702403 ENZYMATIC DIGESTION 37.00 06/30/10 83892 83892 83892 006 0301 3314
03702405 ELECTROPHERESIS 148.00 06/30/10 83894 83894 83894 006 0301 3314
03702407 NUCLEIC ACID PROBE 180.00 06/30/10 83896 83896 83896 006 0301 3314
03702409 POLYMERASE CHAIN REACTION 244.00 06/30/10 83898 83898 83898 006 0301 3314
03702413 INTERPRETATION AND REPORT 43.00 06/30/10 83912 83912 83912 006 0301 3314
03715644 HLA, DR TYPING NONKIDNEY PAT 558.00 06/30/10 86817 86817 86817 006 0302 1907
03715651 HLA DR TYP NONKIDNEY CADAV/FAM 558.00 06/30/10 86817 86817 86817 006 0302 1907
03732169 TIS TYP MIXED LYMPHOCYTE CULT 1099.00 06/30/10 86821 86821 86821 006 0302 1907
03732177 HLA, DR TYPING PATIENT 615.00 06/30/10 86817 86817 86817 006 0302 1907
03732185 HLA, DR TYPING CADAVER/FAMILY 615.00 06/30/10 86817 86817 86817 006 0302 1907
03732193 FINAL CROSSMATCH 350.00 06/30/10 86805 86805 86805 006 0302 1907
03732201 PATERNITY TESTING 1402.00 06/30/10 86910 86910 86910 006 0300 1907
03732482 RAPID SCREEN KIDNEY PAT PRA 275.00 06/30/10 86807 86807 86807 006 0302 1907
03732508 RAPID ANTIBODY SCREEN PRA 275.00 06/30/10 86807 86807 86807 006 0302 1907
03772884 LYMPHOCYTE CULTURE, MIXED 863.00 06/30/10 86821 86821 86821 006 0302 1907
03779830 HLA; A-B-C RECIPIENT 598.00 06/30/10 86813 86813 86813 006 0302 1907
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 68
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03779848 HLA; A-B-C FAMILY MEMBERS 598.00 06/30/10 86813 86813 86813 006 0302 1907
03779863 ANTIBODY SCREENING 275.00 06/30/10 86807 86807 86807 006 0302 1907
03780150 HLA PHENOTYPNG NKIDNEY PATIENT 598.00 06/30/10 86813 86813 86813 006 0302 1907
03780168 HLA PHENOTYPING NKIDNEY FAMILY 598.00 06/30/10 86813 86813 86813 006 0302 1907
03781331 BLOOD CROSSMATCH 350.00 06/30/10 86805 86805 86805 006 0302 1907
03781356 W27 ANTIGEN TEST 113.00 06/30/10 86812 86812 86812 006 0302 1907
03781357 RECIPIENT IMMUNE ASSESS TEST 446.00 06/30/10 86849 86849 86849 006 0302 1907
03781358 FREEZE/STORE PARATHYROID TISSU EXTERNAL 07/01/98 006 0300 1907
03781365 CLASS I, SEROLOGIC 598.00 06/30/10 86813 86813 86813 006 0302 1907
03781366 CLASS II, SEROLOGIC 529.00 06/30/10 86817 86817 86817 006 0302 1907
03781367 MOLEC CLASS I LR & CLASS II LR 807.00 06/30/10 86849 86849 86849 006 0302 1907
03781368 MOLEC CLASS I LR & CLASS II HR 1095.00 06/30/10 86849 86849 86849 006 0302 1907
03796213 E-R HEMATOCRIT/HEMOGLOBIN N/C 06/30/10 006 0305 6812
03796215 E-R HEMOGLOBIN 32.00 06/30/10 85018 85018 85018 006 0305 6812
04000083 17 HYDROXY-CORT 135.00 06/30/10 83491 83491 83491 006 0301 2608
04000091 VENIPUNCTURE ONLY 24.00 06/30/10 36415 36415 36415 006 0300 2611
04000093 PHLEBOTOMY VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 006 0300 2611
04000094 PHLEBOTOMY CAPILLARY COLL 16.00 06/30/10 36416 36416 36416 006 0300 2611
04000109 17 KETOSTEROIDS 65.00 06/30/10 83586 83586 83586 006 0301 2608
04000192 ABO & RH TYPING N/C E 06/30/10 006 0300 2670
04000193 BLOOD TYPING; ABO 64.00 C 06/30/10 86900 86900 86900 006 0300 2670
04000194 RH(D) 66.00 C 06/30/10 86901 86901 86901 006 0300 2670
04000210 TYPE AND AB SCREEN N/C E 06/30/10 006 0300 2670
04000211 BLOOD TYPING; ABO 64.00 C 06/30/10 86900 86900 86900 006 0300 2670
04000212 RH(D) 66.00 C 06/30/10 86901 86901 86901 006 0300 2670
04000213 ANTIBODY SCREEN 156.00 C 06/30/10 86850 86850 86850 006 0300 2670
04000216 FATTY ACIDS PROFILE 663.00 06/30/10 82544 82544 82544 006 0301 2608
04000232 ACETONE QUAL 69.00 06/30/10 82009 82009 82009 006 0301 2612
04000290 HELICOBACTER PYLORI ANTIBODY 50.00 06/30/10 86677 86677 86677 006 0302 2608
04000291 URINE SCREEN 41.00 06/30/10 81007 81007 81007 006 0300 2639
04000299 DIRECT SMEAR:AFB STAIN 59.00 06/30/10 87206 87206 87206 006 0306 2639
04000302 AFB CULTURE-WITHOUT CONCNTRTN 173.00 06/30/10 87116 87116 87116 006 0306 2639
04000305 ENTEROVIRUS-AMPLIFIED PROBE 216.00 06/30/10 87498 87498 87498 006 0306 2639
04000308 STAPH AUREUS-MRSA AMP PROBE 264.00 06/30/10 87641 87641 87641 006 0306 2639
04000311 GROUP B STREP-AMPLFD PROBE 216.00 06/30/10 87653 87653 87653 006 0306 2639
04000314 CLOSTRIDIUM DIFFICILE-AMP PROB 325.00 06/30/10 87798 87798 87798 006 0306 2639
04000320 INFLUENZA A MLTIPLX-AMP PRB N/C E 06/30/10 006 0306 2639
04000321 SEASONAL FLU A H1 130.00 C 06/30/10 87798 87798 87798 006 0306 2639
04000322 SEASONAL FLU A H3 130.00 C 06/30/10 87798 87798 87798 006 0306 2639
04000323 NOVEL H1N1 130.00 C 06/30/10 87798 87798 87798 006 0306 2639
04000330 EBV MULTIPLEX SEROLOGY N/C E 06/30/10 006 0302 2639
04000331 EBV VCA - IGG 65.00 C 06/30/10 86665 86665 86665 006 0302 2639
04000332 EBV EA - IGG 47.00 C 06/30/10 86663 86663 86663 006 0302 2639
04000333 EBV NA - IGM 55.00 C 06/30/10 86664 86664 86664 006 0302 2639
04000334 EBV VCA - IGM 65.00 C 06/30/10 86665 86665 86665 006 0302 2639
04000340 HSV MULTIPLEX SEROLOGY N/C E 06/30/10 006 0302 2639
04000341 HSV-1 IGG 86.00 C 06/30/10 86695 86695 86695 006 0302 2639
04000342 HSV-2 IGG 86.00 C 06/30/10 86695 86695 86695 006 0302 2639
04000345 KIRBY BAUER SUSCEPTIBILITY 169.00 06/30/10 87184 87184 87184 006 0306 2639
04000380 ALDOLASE 81.00 06/30/10 82085 82085 82085 006 0301 2608
04000407 CA 27.29 139.00 06/30/10 86300 86300 86300 006 0302 2608
04000408 CA 15-3 139.00 06/30/10 86300 86300 86300 006 0302 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 69
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04000409 CA 19-9 143.00 06/30/10 86301 86301 86301 006 0302 2608
04000410 CA125 156.00 06/30/10 86304 86304 86304 006 0302 2608
04000420 SOLUBLE TRANSFERRIN RECEPTOR 48.00 06/30/10 84238 84238 84238 006 0301 2608
04000422 WBC ALK.PHOS.STAIN 101.00 06/30/10 85540 85540 85540 006 0305 2613
04000433 RENIN 154.00 06/30/10 84244 84244 84244 006 0301 2608
04000435 ERYTHROPOIETIN 152.00 06/30/10 82668 82668 82668 006 0301 2608
04000436 HEPATITIS DELTA AB 123.00 06/30/10 86692 86692 86692 006 0302 2608
04000437 VITAMIN B6 200.00 06/30/10 84207 84207 84207 006 0301 2608
04000438 CYTOMEGALOVIRUS AB-IGM 133.00 06/30/10 86645 86645 86645 006 0302 2612
04000440 FK506 345.00 06/30/10 80197 80197 80197 006 0300 2612
04000442 LEPTOSPIRA ANTIBODY 102.00 06/30/10 86720 86720 86720 006 0302 2608
04000443 PARVOVIRUS B19 AB, IGM 111.00 06/30/10 86747 86747 86747 006 0302 2608
04000444 PARVOVIRUS B19, AB, IGG 111.00 06/30/10 86747 86747 86747 006 0302 2608
04000446 COMPLEMENT C2 116.00 06/30/10 86160 86160 86160 006 0302 2608
04000451 IRON, TISSUE 69.00 06/30/10 83540 83540 83540 006 0301 2608
04000453 INSULIN, RANDOM 96.00 06/30/10 83525 83525 83525 006 0301 2608
04000455 INSULIN, FASTING 96.00 06/30/10 83525 83525 83525 006 0301 2608
04000457 INSULIN, 30 MINUTES 98.00 06/30/10 83525 83525 83525 006 0301 2608
04000459 INSULIN, 60 MINUTES 98.00 06/30/10 83525 83525 83525 006 0301 2608
04000460 AMEBIASIS (E.HISTOLYTICA)AB 106.00 06/30/10 86753 86753 86753 006 0302 2608
04000465 INSULIN, 90 MINUTES 96.00 06/30/10 83525 83525 83525 006 0301 2608
04000467 INSULIN, 120 MINUTES 96.00 06/30/10 83525 83525 83525 006 0301 2608
04000475 ALPHA-2 ANTIPLASMIN 185.00 06/30/10 85410 85410 85410 006 0305 2608
04000481 C-REACTIVE PROTEIN,HIGH SENS 141.00 06/30/10 86141 86141 86141 006 0300 2612
04000487 REPTILASE TIME 55.00 06/30/10 85635 85635 85635 006 0305 2608
04000490 TISSUE PLASMINOGEN ACT,ACTIVTY 216.00 06/30/10 85415 85415 85415 006 0305 2608
04000493 TISSUE PLASMINOGEN ACT,ANTIGEN 216.00 06/30/10 85415 85415 85415 006 0305 2608
04000505 HGB F FRACT,CHROM 140.00 06/30/10 83021 83021 83021 006 0301 2612
04000513 AMYLASE SERUM 71.00 06/30/10 82150 82150 82150 006 0301 2612
04000554 AMYLASE FLUID 71.00 06/30/10 82150 82150 82150 006 0301 2612
04000560 HEPARIN ANTI-XA, LMWH 185.00 06/30/10 85520 85520 85520 006 0305 2613
04000561 THIOPURINE METHYLTRANS,RBC 282.00 06/30/10 82657 82657 82657 006 0301 2608
04000562 NEURONAL NUCLEAR IGG AB 136.00 06/30/10 86256 86256 86256 006 0302 2608
04000563 CHROMAGNIN A 76.00 06/30/10 86316 86316 86316 006 0302 2608
04000564 ECHINOCOCCUS AB 127.00 06/30/10 86682 86682 86682 006 0302 2608
04000565 RIBISOMAL P PROTEIN AB 118.00 06/30/10 86235 86235 86235 006 0302 2608
04000566 ACYLGLYCINES,QUANT URINE 320.00 06/30/10 82544 82544 82544 006 0301 2608
04000567 THIOTHIXENE LEVEL 146.00 06/30/10 80299 80299 80299 006 0301 2608
04000568 BETA-2 MICROGLOBULIN,URINE 124.00 06/30/10 82232 82232 82232 006 0301 2608
04000571 TETANUS ANTIBODY 126.00 06/30/10 86774 86774 86774 006 0302 2608
04000572 ALPHA 1 ANTITRYPSIN GENOTYPE N/C E 06/30/10 006 0301 2608
04000573 ALPHA 1 ANTITRYPSIN TOTAL 81.50 C 06/30/10 82103 82103 82103 006 0301 2608
04000575 A1AT MOLECULAR ISOLATION 47.00 C 06/30/10 83891 83891 83891 006 0301 2608
04000576 A1AT NUCLEAR AMPLIFICATION#1 139.00 C 06/30/10 83898 83898 83898 006 0301 2608
04000577 A1AT NUCLEAR AMPLIFICATION#2 139.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04000578 A1AT NUCLEIC ACID PR #1 83.00 C 06/30/10 83896 83896 83896 006 0301 2608
04000579 A1AT NUCLEIC ACID PR #2 83.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04000580 A1AT NUCLEIC ACID PR#3 83.00 C 06/30/10 83896 83896 83896 006 0301 2608
04000581 A1AT NUCLEIC ACID PR #4 83.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04000588 ASO TITER 82.00 06/30/10 86060 86060 86060 006 0302 2608
04000590 ALK PHOS, BONE SPECIFIC 105.00 06/30/10 84080 84080 84080 006 0301 2608
04000593 N-TELOPEPTIDE 175.00 06/30/10 83520 83520 83520 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 70
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04000594 OSTEOCALCIN 137.00 06/30/10 83937 83937 83937 006 0301 2608
04000595 PREALBUMIN 95.00 06/30/10 84134 84134 84134 006 0301 2612
04000596 PYRIDINIUM X-LINK (2 HR) 197.00 06/30/10 82523 82523 82523 006 0301 2608
04000597 PYRIDINIUM X-LINK (24 HR) 142.00 06/30/10 82523 82523 82523 006 0301 2608
04000598 VITAMIN E 107.00 06/30/10 84446 84446 84446 006 0301 2608
04000599 HISTOPLASMA AG 132.00 06/30/10 87449 87449 87449 006 0306 2608
04000601 THYROID STIM IMMUNOGLOBULIN 325.00 06/30/10 84445 84445 84445 006 0301 2608
04000602 AMIODARONE 161.00 06/30/10 82491 82491 82491 006 0301 2608
04000603 GABAPENTIN 79.00 06/30/10 82491 82491 82491 006 0301 2608
04000604 LAMOTRIGINE 72.00 06/30/10 80299 80299 80299 006 0301 2608
04000619 BETA 2 MICROGLOBULIN, SERUM 124.00 06/30/10 82232 82232 82232 006 0301 2608
04000620 IGF BP3 208.00 06/30/10 83519 83519 83519 006 0301 2608
04000621 ISLET CELL AB, IGG 143.00 06/30/10 86341 86341 86341 006 0302 2608
04000622 LATEX, ALLERGEN 52.00 06/30/10 86003 86003 86003 006 0302 2608
04000623 PROSTATE SPEC AG, FREE/TOTAL 118.00 06/30/10 84153 84153 84153 006 0301 2608
04000625 LDL PARTICLE SIZE 215.00 06/30/10 83704 83704 83704 006 0301 2608
04000627 HAMS TEST 112.00 06/30/10 85475 85475 85475 006 0305 2608
04000629 ARGININE VASOPRESSIN HORMONE 88.00 06/30/10 84588 84588 84588 006 0301 2608
04000631 BLADDER TUMOR AG (URINE) 151.00 06/30/10 86294 86294 86294 006 0302 2608
04000633 CLOZAPINE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04000635 HERPES SIMPLEX VIRUS BY PCR 273.00 06/30/10 87529 87529 87529 006 0306 2608
04000637 HUMAN HERPES VIRUS 6 119.00 06/30/10 86790 86790 86790 006 0302 2608
04000639 LEGIONELLA AG, URINE 132.00 06/30/10 87449 87449 87449 006 0306 2608
04000641 NICOTINE/COTININE (SERUM) 161.00 06/30/10 83887 83887 83887 006 0301 2608
04000645 PLASMINOGEN ACTIVATR INHIBITOR 216.00 06/30/10 85415 85415 85415 006 0305 2608
04000647 STRIATED MUSCLE AB, IGG 141.00 06/30/10 86255 86255 86255 006 0302 2608
04000649 TOPIRAMATE 122.00 06/30/10 80201 80201 80201 006 0300 2608
04000651 VARICELLA ZOSTER IGM 82.00 06/30/10 86787 86787 86787 006 0302 2608
04000652 ANA TITER REFLEX 36.00 06/30/10 86039 86039 86039 006 0302 2608
04000654 HEP C GENOTYPING BY PCR 880.00 06/30/10 87902 87902 87902 006 0306 2651
04000665 CYTOPLASMIC NEUTRO AB (ANCA) N/C E 06/30/10 006 0301 2608
04000666 MYELOPEROXIDASE (ANCA) 120.00 C 06/30/10 83516 83516 83516 006 0301 2608
04000667 SERINE PROTEASE 3(ANCA) 120.00 C 06/30/10 8351691 8351691 8351691 006 0301 2608
04000668 ANCA TITER 39.00 C 06/30/10 86256 86256 86256 006 0302 2608
04000670 HEAVY METAL SCREEN (BLOOD) N/C E 06/30/10 006 0301 2608
04000671 ARSENIC LEVEL, BLOOD 49.00 C 06/30/10 82175 82175 82175 006 0301 2608
04000672 LEAD LEVEL, BLOOD 83.00 C 06/30/10 83655 83655 83655 006 0301 2608
04000673 MERCURY LEVEL, BLOOD 105.00 C 06/30/10 83825 83825 83825 006 0301 2608
04000675 HCV ANTIBODY(RIBA) 236.00 06/30/10 86804 86804 86804 006 0302 2608
04000680 PRENATAL, 1ST TRIMESTER SCREEN N/C E 06/30/10 006 0301 2608
04000681 QUANT BETA HCG 113.00 C 06/30/10 84702 84702 84702 006 0301 2608
04000682 PREG ASSOC PLASMA PROT A 113.00 C 06/30/10 84163 84163 84163 006 0301 2608
04000685 HIV 1 VIRTUAL PHENOTYPE 480.00 06/30/10 87900 87900 87900 006 0300 2608
04000693 ACYLCARNITINE PROFILE 228.00 06/30/10 82017 82017 82017 006 0301 2608
04000695 CARNITINE (FREE/TOTAL) 191.00 06/30/10 82379 82379 82379 006 0301 2608
04000697 FATTY ACID PROFILE 305.00 06/30/10 82726 82726 82726 006 0301 2608
04000699 PNEUMOCOCCAL ANTIBODY 126.00 06/30/10 86317 86317 86317 006 0302 2608
04000701 PURKINJE CELL CYTO ANTIBODY 141.00 06/30/10 86255 86255 86255 006 0302 2608
04000703 RISPERIDONE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04000705 TOTAL PORPHYRINS 125.00 06/30/10 84311 84311 84311 006 0301 2608
04000707 ACETYLCOL REC AB,BLOCKING 208.00 06/30/10 83519 83519 83519 006 0301 2608
04000709 ACETYLCHOL REC AB,MODULATING 208.00 06/30/10 83519 83519 83519 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 71
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04000710 PROSTATE SPEC AG, FREE/TOTAL N/C E 06/30/10 006 0301 2608
04000711 PROSTATE SPEC AG, TOTAL 59.00 C 06/30/10 84153 84153 84153 006 0301 2608
04000712 PROSTATE SPEC AG, FREE 59.00 C 06/30/10 84154 84154 84154 006 0301 2608
04000740 POLIO VIRUS ANTIBODIES N/C E 06/30/10 006 0302 2608
04000741 POLIO TYPE 1 AB 92.00 C 06/30/10 86658 86658 86658 006 0302 2608
04000742 POLIO TYPE 2 AB 92.00 C 06/30/10 8665891 8665891 8665891 006 0302 2608
04000743 POLIO TYPE 3 AB 92.00 C 06/30/10 8665891 8665891 8665891 006 0302 2608
04000804 CULTURE-TISSUE:ISOL PRESUMP ID N/C E 06/30/10 006 0306 2639
04000805 CULTURE-ISOL,PRESUMP ID 169.00 C 06/30/10 87070 87070 87070 006 0306 2639
04000806 HOMOGENIZATION TISSUE FOR CULT 96.00 C 06/30/10 87176 87176 87176 006 0306 2639
04000810 CULTURE-BLOOD 187.00 06/30/10 87040 87040 87040 006 0306 2639
04000830 CULTURE-FLUID:ISOL,PRESUMP ID N/C E 06/30/10 006 0306 2639
04000831 CULTURE-ISOL,PRESUMP ID 152.00 C 06/30/10 87070 87070 87070 006 0306 2639
04000832 CONCENTRATION 34.00 C 06/30/10 87015 87015 87015 006 0306 2639
04000836 CULTURE-BRONCH:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04000885 CULTURE-EAR:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04000893 CULTURE-EYE:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04000919 CULTURE-NOSE:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04000935 CULTURE-CSF:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04000943 CULTURE-SPUTUM:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04000992 CULTURE-GENITAL:ISOL,PRESMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04001008 CULTURE-WOUND:ISOL-PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04001020 VITAMIN B1, PLASMA 68.00 06/30/10 84425 84425 84425 006 0301 2608
04001021 VAP CHOLESTEROL 95.00 06/30/10 83701 83701 83701 006 0301 2608
04001022 NIACIN 140.00 06/30/10 84591 84591 84591 006 0301 2608
04001023 GHB,URINE 185.00 06/30/10 80100 80100 80100 006 0301 2608
04001024 GHB 124.00 06/30/10 80100 80100 80100 006 0300 2608
04001025 ESTRIOL 48.00 06/30/10 82677 82677 82677 006 0301 2608
04001026 DEOXYCORTICOSTERONE 185.00 06/30/10 82633 82633 82633 006 0301 2608
04001033 B.PERTUSSIS AB,IGM 107.00 06/30/10 86615 86615 86615 006 0302 2608
04001035 B.PERT AB,IGG AND IGM N/C E 06/30/10 86615 86615 86615 006 0302 2608
04001036 B.PERTUSSIS AB,IGG 107.00 C 06/30/10 86615 86615 86615 006 0302 2608
04001037 B.PERTUSSIS AB,IGM 107.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04001040 B.PERT AB,IGG AND IGA N/C E 06/30/10 86615 86615 86615 006 0302 2608
04001041 B.PERTUSSIS AB,IGG 107.00 C 06/30/10 86615 86615 86615 006 0302 2608
04001042 B.PERTUSSIS AB,IGA 107.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04001045 B.PERT AB, IGA,IGG,IGM N/C E 06/30/10 86615 86615 86615 006 0302 2608
04001046 B.PERTUSSIS AB,IGA 68.00 C 06/30/10 86615 86615 86615 006 0302 2608
04001047 B.PERTUSSIS AB,IGG 107.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04001048 B.PERTUSSIS AB,IGM 107.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04001050 FLUNITRAZE AND METAB,UR 388.00 06/30/10 G0431 G0431 G0431 006 0301 2608
04001065 FLUNI AND METAB,UR CONF 428.00 06/30/10 80102 80102 80102 006 0301 2608
04001070 FLUNI AND METAB CONF 428.00 06/30/10 80102 80102 80102 006 0301 2608
04001080 REDUCING SUBSTANCES-STOOL 30.00 06/30/10 81002 81002 81002 006 0307 2608
04001085 VAP CHOLESTEROL N/C E 06/30/10 84478 84478 84478 006 0301 2608
04001086 VAP LIPID FRACT 58.00 C 06/30/10 83701 83701 83701 006 0301 2608
04001087 VAP TRIGLYCERIDES 70.00 C 06/30/10 84478 84478 84478 006 0301 2608
04001090 ENTEROVIRUS, QUANT 738.00 06/30/10 87799 87799 87799 006 0306 2608
04001100 CMV ANTIVIRAL RESISTANCE N/C E 06/30/10 006 0300 2608
04001101 CMV ISOLATION/EXTRACTION 210.00 C 06/30/10 83891 83891 83891 006 0301 2608
04001102 CMV SEPARATION BY GEL ELEC 220.00 C 06/30/10 83894 83894 83894 006 0301 2608
04001103 CMV AMPLIFICATION, EA SEQ, 1 172.00 C 06/30/10 83898 83898 83898 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 72
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04001104 CMV AMPLIFICATION, EA SEQ, 2 172.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04001105 CMV AMPLIFICATION, EA SEQ, 3 172.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04001106 CMV AMPLIFICATION, EA SEQ, 4 172.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04001107 CMV MUT ID BY SEQ, EA SEG, 1 87.00 C 06/30/10 83904 83904 83904 006 0301 2608
04001108 CMV MUT ID BY SEQ, EA SEG, 2 87.00 C 06/30/10 8390491 8390491 8390491 006 0301 2608
04001109 CMV MUT ID BY SEQ, EA SEG, 3 87.00 C 06/30/10 8390491 8390491 8390491 006 0301 2608
04001110 CMV MUT ID BY SEQ, EA SEG, 4 87.00 C 06/30/10 8390491 8390491 8390491 006 0301 2608
04001111 CMV MUT ID BY SEQ, EA SEG, 5 87.00 C 06/30/10 8390491 8390491 8390491 006 0301 2608
04001112 CMV MUT ID BY SEQ, EA SEG, 6 87.00 C 06/30/10 8390491 8390491 8390491 006 0301 2608
04001113 CMV MUT ID BY SEQ, EA SEG, 7 87.00 C 06/30/10 8390491 8390491 8390491 006 0301 2608
04001114 CMV MUT ID BY SEQ, EA SEG, 8 87.00 C 06/30/10 8390491 8390491 8390491 006 0301 2608
04001117 HHV-6 QUANT BY PCR 438.00 06/30/10 87533 87533 87533 006 0301 2608
04001120 HHV-7 QUANT BY PCR 438.00 06/30/10 87799 87799 87799 006 0306 2608
04001123 HHV-8 QUANT BY PCR 438.00 06/30/10 87799 87799 87799 006 0306 2608
04001127 TRANSFERRIN, CARB DEF 213.00 06/30/10 82373 82373 82373 006 0301 2608
04001130 H.PYLORI AB,IGM 51.00 06/30/10 86677 86677 86677 006 0302 2608
04001133 INTERLEUKIN 6 253.00 06/30/10 82397 82397 82397 006 0301 2608
04001136 LYME AB, CSF 66.00 06/30/10 86618 86618 86618 006 0300 2608
04001139 PAROXETINE QUANT 146.00 06/30/10 80299 80299 80299 006 0301 2608
04001142 SULFONYLUREA, URINE 176.00 06/30/10 82486 82486 82486 006 0301 2608
04001145 IA-2 ANTIBODY 143.00 06/30/10 86341 86341 86341 006 0302 2608
04001148 IODINE, URINE 143.00 06/30/10 83789 83789 83789 006 0300 2608
04001151 TB BY AMP DETECTION,CSF 132.00 06/30/10 87556 87556 87556 006 0306 2608
04001172 BILIRUBIN-TOTAL SERUM 40.00 06/30/10 82247 82247 82247 006 0301 2612
04001198 BILIRUBIN-TOTAL FLUID 40.00 06/30/10 82247 82247 82247 006 0301 2612
04001202 PHOTOPHORESIS 4039.00 06/30/10 36522 36522 36522 006 0390 2660
04001388 UREA N SERUM 49.00 06/30/10 84520 84520 84520 006 0301 2612
04001400 PLATELET COUNT, AUTOMATED 25.00 06/30/10 85049 85049 85049 006 0305 2613
04001412 BONE MARROW STUDY 274.00 06/30/10 85097 85097 85097 006 0305 2613
04001415 FLOW CYTOMETRY, 1ST MARKER 36.00 06/30/10 88184 88184 88184 006 0311 2613
04001418 FLOW CYTOMETRY, ADD'L MARKERS 36.00 06/30/10 88185 88185 88185 006 0311 2613
04001421 OCCULT BLOOD (IFOB) 61.00 06/30/10 82274 82274 82274 006 0301 2613
04001453 BROMIDE 125.00 06/30/10 84311 84311 84311 006 0301 2608
04001610 CALCIUM SERUM 55.00 06/30/10 82310 82310 82310 006 0301 2612
04001628 CALCIUM URINE 81.00 06/30/10 82340 82340 82340 006 0301 2612
04001693 CAROTENE 85.00 06/30/10 82380 82380 82380 006 0301 2608
04001743 BODY FLUID CELL COUNT 72.00 06/30/10 89050 89050 89050 006 0300 2613
04001746 BRONCHIAL LAVAGE DIFFERENTIAL 101.00 06/30/10 89051 89051 89051 006 0300 2613
04001826 CERULOPLASMIN 92.00 06/30/10 82390 82390 82390 006 0301 2608
04001827 MICROALBUMIN-URINE 112.00 06/30/10 82043 82043 82043 006 0301 2612
04001829 CITRATE - URINE 60.00 06/30/10 82507 82507 82507 006 0301 2608
04001830 ECHOVIRUS AB - SERUM 92.00 06/30/10 86658 86658 86658 006 0302 2608
04001842 SENDOUT, MISC EXTERNAL 11/01/94 84999 84999 84999 006 0300 2608
04001859 CHLORIDE SERUM 41.00 06/30/10 82435 82435 82435 006 0301 2612
04001909 CHLORIDE URINE 42.00 06/30/10 82436 82436 82436 006 0301 2612
04001925 CHLORIDE FLUID 47.00 06/30/10 82435 82435 82435 006 0301 2612
04001958 CHOLESTEROL 59.00 06/30/10 82465 82465 82465 006 0301 2612
04002022 CLOT RET.TIME 38.00 06/30/10 85170 85170 85170 006 0305 2613
04002026 HEMOGLOBIN 24.00 06/30/10 85018 85018 85018 006 0305 2613
04002030 HEMATOCRIT 23.00 06/30/10 85014 85014 85014 006 0305 2613
04002034 WBC COUNT 25.00 06/30/10 85048 85048 85048 006 0305 2613
04002038 HCG, QUALITATIVE SERUM 89.00 06/30/10 84703 84703 84703 006 0301 2613
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 73
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04002055 CO2 46.00 06/30/10 82374 82374 82374 006 0301 2612
04002060 FOOD,COMMON-ALLERGEN PROF N/C E 06/30/10 006 0302 2608
04002061 ALLERGEN, EACH 11.00 C 06/30/10 86003 86003 86003 006 0302 2608
04002071 ALLERGEN, EACH 52.00 06/30/10 86003 86003 86003 006 0302 2608
04002075 INHALANT,MIDWT-ALLERGEN PROF N/C E 06/30/10 006 0302 2608
04002076 ALLERGEN, EACH 11.00 C 06/30/10 86003 86003 86003 006 0302 2608
04002080 AMPHETAMINE, UR CONF 111.00 06/30/10 82145 82145 82145 006 0301 2608
04002083 BARBITURATE,UR CONF 104.00 06/30/10 82205 82205 82205 006 0301 2608
04002086 BENZODIAPEZINE, UR CONF 122.00 06/30/10 80154 80154 80154 006 0300 2608
04002089 OPIATE, UR CONF 133.00 06/30/08 83925 83925 83925 006 0300 2608
04002095 AFP MATERNAL SCREEN 135.00 06/30/10 82105 82105 82105 006 0301 2608
04002097 17 OH PROGESTERONE,QUANT 155.00 06/30/10 83498 83498 83498 006 0301 2608
04002100 KAPPA-LAMBDA ONT FLC W/RATIO N/C E 06/30/10 006 0301 2608
04002101 NEPHALOMETRY 1 126.00 C 06/30/10 83883 83883 83883 006 0301 2608
04002102 NEPHALOMETRY 2 126.00 C 06/30/10 8388391 8388391 8388391 006 0301 2608
04002103 PH, FECAL 53.00 06/30/10 83986 83986 83986 006 0301 2608
04002104 TRYPSIN, FECAL 110.00 06/30/10 84488 84488 84488 006 0301 2608
04002110 SOYBEAN ALLERGEN 11.00 06/30/10 8600391 8600391 8600391 006 0302 2608
04002120 FOOD, COMMON-ALLERGEN PROF N/C E 06/30/10 006 0302 2608
04002121 EGG WHITE ALLERGEN 11.00 C 06/30/10 86003 86003 86003 006 0302 2608
04002122 COW'S MILK ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002123 WHEAT ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002124 CORN ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002125 PEANUT ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002126 SCALLOP ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002127 SHRIMP ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002128 WALNUT ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002129 CLAM ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002130 PERCH ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002131 SOYBEAN ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002140 FOOD,COMPRHNSIVE-ALLERGEN-PROF N/C E 06/30/10 006 0302 2608
04002141 ALLERGEN TEST 11.00 C 06/30/10 86003 86003 86003 006 0302 2608
04002142 BEEF ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002143 BELL PEPPER ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002144 CABBAGE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002145 CARROT ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002146 CHICKEN ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002147 PERCH ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002148 CORN ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002149 CRAB ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002150 EGG WHITE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002151 GRAPE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002152 LETTUCE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002153 COW'S MILK ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002154 NAVY BEAN ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002155 OAT ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002156 ORANGE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002157 PEANUT ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002158 POTATO ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002159 PORK ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002160 RICE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002161 RYE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 74
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04002162 SHRIMP ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002163 SOYBEAN ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002164 TOMATO ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002165 TUNA ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002166 WHEAT ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04002170 TPMT GENETICS N/C E 06/30/10 006 0301 2608
04002171 TPMT ISOLATION/EXTRACTION 98.00 C 06/30/10 83891 83891 83891 006 0301 2608
04002172 TPMT NUCLEAR AMPLIFICATION#1 98.00 C 06/30/10 83898 83898 83898 006 0301 2608
04002173 TPMT NUCLEAR AMPLIFICATION#2 98.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04002174 TPMT NUCLEAR AMPLIFICATION#3 98.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04002175 TPMT NUCLEIC ACID PR #1 98.00 C 06/30/10 83896 83896 83896 006 0301 2608
04002176 TPMT NUCLEIC ACID PR #2 98.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04002177 TPMT NUCLEIC ACID PR #3 98.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04002178 TPMT NUCLEIC ACID PR #4 98.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04002179 TPMT NUCLEIC ACID PR #5 98.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04002180 TPMT NUCLEIC ACID PR #6 98.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04002184 FAT QUAL, URINE 25.00 06/30/10 89125 89125 89125 006 0305 2608
04002187 NT-PRO BNP 200.00 06/30/10 83880 83880 83880 006 0301 2608
04002190 H PYLORI AB,IGA 33.00 06/30/10 86677 86677 86677 006 0302 2608
04002238 COPPER 99.00 06/30/10 82525 82525 82525 006 0301 2608
04002241 N-TELOPEPTIDE, SERUM 318.00 06/30/10 82523 82523 82523 006 0300 2608
04002250 RHEUMATOID FACTOR IGG,M,A N/C E 06/30/10 006 0302 2608
04002251 RHEUMATOID FACTOR IGM 98.00 C 06/30/10 86431 86431 86431 006 0302 2608
04002252 RHEUMATOID FACTOR IGA 98.00 C 06/30/10 86430 86430 86430 006 0302 2608
04002253 RHEUMATOID FACTOR IGG 98.00 C 06/30/10 8643091 8643091 8643091 006 0302 2608
04002256 VITAMIN B2 440.00 06/30/10 84252 84252 84252 006 0300 2608
04002260 INSULIN, FREE AND TOTAL N/C E 06/30/10 006 0300 2608
04002261 INSULIN, FREE 29.00 C 06/30/10 83527 83527 83527 006 0300 2608
04002262 INSULIN, TOTAL 29.00 C 06/30/10 83525 83525 83525 006 0300 2608
04002265 MERCAPTOPURINE 323.00 06/30/10 80299 80299 80299 006 0300 2608
04002270 LYMPH MITOGEN PROLIFERATION N/C E 06/30/10 006 0300 2608
04002271 LYMPH MITOGEN PROLIFERATION 1 267.00 C 06/30/10 86353 86353 86353 006 0300 2608
04002272 LYMPH MITOGEN PROLIFERATION 2 267.00 C 06/30/10 8635391 8635391 8635391 006 0300 2608
04002273 LYMPH MITOGEN PROLIFERATION 3 267.00 C 06/30/10 8635391 8635391 8635391 006 0300 2608
04002277 ANTIBODY SCREEN, ADD'L TECHNIQ 156.00 06/30/10 86850 86850 86850 006 0302 2670
04002281 CORD BLOOD-ABO, RH, DA N/C E 06/30/10 006 0300 2670
04002282 BLOOD TYPING; ABO 64.00 C 06/30/10 86900 86900 86900 006 0300 2670
04002283 RH(D) 66.00 C 06/30/10 86901 86901 86901 006 0300 2670
04002284 DAT 72.00 C 06/30/10 86880 86880 86880 006 0300 2670
04002290 PLATELET CROSSMATCH 52.00 06/30/10 86022 86022 86022 006 0302 2670
04002294 ACUTE HEPATITIS PANEL 546.00 06/30/10 80074 80074 80074 006 0300 2612
04002300 ANTIBODY ID INCL. ELUTION N/C E 06/30/10 006 0302 2670
04002301 ANTIBODY ELUTION 215.00 C 06/30/10 86860 86860 86860 006 0302 2670
04002302 ANTIBODY IDENTIFICATION 182.00 C 06/30/10 86870 86870 86870 006 0302 2670
04002311 C-REACTIVE PROTEIN 98.00 06/30/10 86140 86140 86140 006 0302 2612
04002352 CREATINE KINASE 52.00 06/30/10 82550 82550 82550 006 0301 2612
04002386 CREATININE URINE 61.00 06/30/10 82570 82570 82570 006 0301 2612
04002428 COMPATIBILITY TEST 153.00 06/30/10 86920 86920 86920 006 0300 2670
04002436 CRYOGLOBULINS QUAL 63.00 06/30/10 82595 82595 82595 006 0301 2608
04002440 GENE REARRANGEMENT ANALYSIS N/C E 06/30/10 006 0301 2651
04002441 MOLECULAR ISOLATION 122.00 C 06/30/10 83890 83890 83890 006 0301 2651
04002442 ENZYMATIC DIGESTION 66.00 C 06/30/10 83892 83892 83892 006 0301 2651
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 75
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04002443 MOLECULAR SEPARATION 161.00 C 06/30/10 83894 83894 83894 006 0301 2651
04002444 NUCLEIC ACID W/AMPLIFICATION 172.00 C 06/30/10 83898 83898 83898 006 0301 2651
04002447 CYTOMEGALOVIRUS PCR 290.00 06/30/10 83898 83898 83898 006 0301 2651
04002460 HER-2/NEU FISH N/C E 06/30/10 006 0310 2651
04002461 IMMUNOCYTO (IN SITU HYBRID #1) 292.00 C 06/30/10 88342 88342 88342 006 0310 2651
04002462 IMMUNOCYTO (IN SITU HYBRID #2) 292.00 C 06/30/10 88342 88342 88342 006 0310 2651
04002465 HUMAN METAPNEUMOVIRUS PCR 161.00 06/30/10 87798 87798 87798 006 0300 2651
04002470 RBC DIRECT,LEUKOREDUCD,PHR 693.00 06/30/10 P9016 P9016 P9016 006 0380 2670
04002473 RBC DIRECT,LEUKOREDUCD,PHR 2 693.00 06/30/10 83898 83898 83898 006 0380 2670
04002476 CPD RED CELL.LEUKOREDUCD 610.00 06/30/10 87516 87516 87516 006 0300 2670
04002479 DIRECTED RED CELL,PHR 358.00 06/30/10 82397 82397 82397 006 0300 2670
04002482 RED CELL,PEDIATRIC SPLIT 155.00 06/30/10 P9011 P9011 P9011 006 0380 2670
04002485 PIT POOL,LEUKOREDUCD,IRRAD,5D 211.00 06/30/10 86965 86965 86965 006 0390 2670
04002488 PIT POOL,LEUKOREDUCED,5D 211.00 06/30/10 86965 86965 86965 006 0390 2670
04002491 RBC DIRECT,LEUKREDUCD,IRRAD,2 741.00 06/30/10 P9040 P9040 P9040 006 0380 2670
04002494 RBC DIRECT,LEUKOREDUCD,IRR,PHR 741.00 06/30/10 P9040 P9040 P9040 006 0380 2670
04002497 RBC,LEUKOREDUCED,IRRAD,PHR2 741.00 06/30/10 P9040 P9040 P9040 006 0390 2670
04002500 DIRECTED RED CELL,IRRAD,PHR 545.00 06/30/10 P9038 P9038 P9038 006 0380 2670
04002503 CPD RED CELL, IRRAD 653.00 06/30/10 P9040 P9040 P9040 006 0390 2670
04002506 RED CELL,IRRAD,PHR PART 2 545.00 06/30/10 P9038 P9038 P9038 006 0380 2670
04002509 RED CELL,IRRAD,PHR 545.00 06/30/10 P9038 P9038 P9038 006 0390 2670
04002512 PLATELET,LEUKOREDUCD,VOL DEPLT 316.00 06/30/10 87797 87797 87797 006 0300 2670
04002515 PLATELET PHR,LEUKOREDUCD 2 1458.00 06/30/10 P9035 P9035 P9035 006 0300 2670
04002518 PLATELET PHR,LEUKOREDUCED 3 2256.00 06/30/10 P9035 P9035 P9035 006 0390 2670
04002521 PLT OHR,LEUKOREDUCD, IRRAD 2 2377.00 06/30/10 P9035 P9035 P9035 006 0390 2670
04002524 PLT PHR,LEUKOREDUCED, IRRAD 3 1994.00 06/30/10 P9037 P9037 P9037 006 0390 2670
04002531 MOLECULAR EXTRACT/ISOL(CMVPCR) 147.00 06/30/10 83890 83890 83890 006 0301 2651
04002551 HIV RNA QUANT BY PCR 486.00 06/30/10 87536 87536 87536 006 0306 2651
04002552 HCV RNA QUANT BY BDNA 571.00 06/30/10 87522 87522 87522 006 0306 2651
04002555 CMV RNA BY NASBA 374.00 06/30/10 87496 87496 87496 006 0306 2651
04002588 ADENOVIRUS BY PCR 52.00 06/30/10 87798 87798 87798 006 0306 2651
04002590 FLU A,B, RSV,PCR W/O REFLEX N/C E 06/30/10 006 0306 2651
04002591 FLU A BY (REAL TIME)PCR 208.00 C 06/30/10 87798 87798 87798 006 0306 2651
04002592 FLU B BY (REAL TIME)PCR 208.00 C 06/30/10 8779891 8779891 8779891 006 0306 2651
04002593 RSV BY (REAL TIME)PCR 208.00 C 06/30/10 8779891 8779891 8779891 006 0306 2651
04002600 FLU A,B,RSV PCR W REFLEX N/C E 06/30/10 87798 87798 87798 006 0306 2651
04002601 FLU A BY (REAL TIME)PCR 208.00 C 06/30/10 87798 87798 87798 006 0306 2651
04002602 FLU B BY (REAL TIME) PCR 208.00 C 06/30/10 8779891 8779891 8779891 006 0306 2651
04002603 RSV BY (REAL TIME) PCR 208.00 C 06/30/10 8779891 8779891 8779891 006 0306 2651
04002610 PARAINFLUENZA PCR N/C E 06/30/10 006 0300 2651
04002611 PARAINFLUENZA 1 BY PCR 95.00 C 06/30/10 87798 87798 87798 006 0300 2651
04002612 PARAINFLUENZA 2 BY PCR 95.00 C 06/30/10 8779891 8779891 8779891 006 0300 2651
04002613 PARAINFLUENZA 3 BY PCR 95.00 C 06/30/10 8779891 8779891 8779891 006 0300 2651
04002621 AMPLICATION,SINGLE PRIMER PAIR 45.00 C 06/30/10 83898 83898 83898 006 0301 2651
04002622 SEPARATION, ELECTROPHORESIS 48.00 C 06/30/10 83894 83894 83894 006 0301 2651
04002642 DHEA SO 4 66.00 06/30/10 82627 82627 82627 006 0301 2608
04002659 HISTAMINE 101.00 06/30/10 83088 83088 83088 006 0301 2608
04002667 ANGIO-CONVERTING ENZYME 125.00 06/30/10 82164 82164 82164 006 0301 2608
04002675 CALCIFEROL (VIT D) 130.00 06/30/10 82306 82306 82306 006 0301 2608
04002680 TESTOSTERONE,FEM/CHILD 115.00 06/30/10 84403 84403 84403 006 0301 2608
04002683 5 'NUCLEOTIDASE 82.00 06/30/10 83915 83915 83915 006 0301 2608
04002684 CF SEPARATION BY HIGH RESOL 84.00 06/30/10 83909 83909 83909 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 76
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04002691 SERUM HCG (QUANT) 186.00 06/30/10 84702 84702 84702 006 0301 2612
04002717 C-PEPTIDE REACT. 134.00 06/30/10 84681 84681 84681 006 0301 2608
04002720 RABIES ANTIBODY 126.00 06/30/10 86317 86317 86317 006 0302 2608
04002725 CORTISOL (URINE) 146.00 06/30/10 82533 82533 82533 006 0301 2608
04002730 CORTISOL LEVEL 161.00 06/30/10 82533 82533 82533 006 0301 2612
04002733 INSULIN GROWTH FACTOR-1 92.00 06/30/10 84305 84305 84305 006 0301 2608
04002741 ANDROSTENEDIONE 67.00 06/30/10 82157 82157 82157 006 0301 2608
04002758 ARSENIC (MISC) 116.00 06/30/10 82175 82175 82175 006 0301 2608
04002790 BODY FLUID DIFFERENTIAL 101.00 06/30/10 89051 89051 89051 006 0300 2613
04002824 BLOOD SMEAR,MANUAL DIFF 50.00 06/30/10 85007 85007 85007 006 0305 2613
04002825 BLOOD SMEAR,MANUAL DIFF 50.00 06/30/10 85007 85007 85007 006 0300 2613
04002826 BLOOD SMEAR,MORPH SCAN 33.00 06/30/10 85008 85008 85008 006 0300 2613
04002830 RETINOL BINDING PROTEIN 126.00 06/30/10 83883 83883 83883 006 0301 2608
04002833 PROCOLLAGEN TYPE-I PROPEPTIDE 208.00 06/30/10 83519 83519 83519 006 0301 2608
04002836 DESYREL (TRAZODONE) 52.00 04/26/10 80299 80299 80299 006 0301 2608
04002839 21-HYDROXYLASE ANTIBODY 208.00 06/30/10 83519 83519 83519 006 0301 2608
04002860 ZINC PROTOPORPHYRIN,INDUSRT 100.00 06/30/10 84202 84202 84202 006 0301 2608
04002863 TRYPSINOGEN 208.00 06/30/10 83519 83519 83519 006 0301 2608
04002866 VASC ENDOTHELIAL GROWTH FACT 175.00 06/30/10 83520 83520 83520 006 0301 2608
04002869 OVARIAN AB 141.00 06/30/10 86255 86255 86255 006 0301 2608
04002872 ANTI-NEUTROPHIL AB 177.00 06/30/10 86021 86021 86021 006 0300 2608
04002880 ADAMTS13 ACTIVITY & INHIBITOR N/C E 06/30/10 006 0301 2608
04002881 FACTOR VVIII,VW FACTOR ANTIGEN 99.00 C 06/30/10 85246 85246 85246 006 0301 2608
04002882 FACTOR INHIBITOR TEST 104.00 C 06/30/10 85335 85335 85335 006 0300 2608
04002890 HSV 1/2 GLYCO G-SPECIFIC, IGG N/C E 06/30/10 006 0301 2608
04002891 HSV 1 GLYCOPROTEIN G AB,IGG 92.00 C 06/30/10 86695 86695 86695 006 0300 2608
04002892 HSV 2 GLYCOPROTEIN G IGG AB 92.00 C 06/30/10 86696 86696 86696 006 0302 2608
04002900 HUNTINGTON DISEASE N/C E 06/30/10 006 0301 2608
04002901 HUNTD MOLECULAR ISOLATION 104.00 C 06/30/10 83890 83890 83890 006 0301 2608
04002902 HUNTD NUCLEAR AMPLIFICATION#1 131.00 C 06/30/10 83898 83898 83898 006 0301 2608
04002903 HUNTD NUCLEAR AMPLIFICATION#2 131.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04002910 ZAP 70 N/C E 06/30/10 006 0301 2608
04002911 FLOW CYTOMETRY MARKER,FIRST 112.00 C 06/30/10 88184 88184 88184 006 0311 2608
04002912 FLOW CYTOMETRY MARKER,ADD'L 147.00 C 06/30/10 88185 88185 88185 006 0311 2608
04002913 FLOW CYTOMETRY MARKER,ADD'L 147.00 C 06/30/10 88185 88185 88185 006 0311 2608
04002914 FLOW CYTOMETRY INTERP 142.00 06/30/10 88187 88187 88187 006 0311 2608
04002917 IGF 1 (ESOTERIX) 373.00 06/30/10 84305 84305 84305 006 0301 2608
04002920 SIGNATURE CHIP WG N/C E 06/30/10 006 0310 2608
04002921 MOLECULAR PROBE EVALUATION WG1 617.00 C 06/30/10 88386 88386 88386 006 0310 2608
04002922 MOLECULAR PROBE EVALUATION WG2 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002923 MOLECULAR PROBE EVALUATION WG3 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002924 MOLECULAR PROBE EVALUATION WG4 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002925 MOLECULAR PROBE EVALUATION WG5 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002926 MOLECULAR PROBE EVALUATION WG6 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002927 NUCLEIC ACID EXTRACTION WG 617.00 C 06/30/10 83891 83891 83891 006 0310 2608
04002928 NUCLEIC ACID EXTRACTION WG 540.00 06/30/10 8389191 8389191 8389191 006 0310 2608
04002930 SIGNATURE CHIP OS N/C E 06/30/10 006 0310 2608
04002931 MOLECULAR PROBE EVALUATION OS1 617.00 C 06/30/10 88386 88386 88386 006 0310 2608
04002932 MOLECULAR PROBE EVALUATION OS2 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002933 MOLECULAR PROBE EVALUATION OS3 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002934 MOLECULAR PROBE EVALUATION OS4 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002935 MOLECULAR PROBE EVALUATION OS5 540.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 77
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04002936 MOLECULAR PROBE EVALUATION OS6 617.00 C 06/30/10 8838691 8838691 8838691 006 0310 2608
04002937 NUCLEIC ACID EXTRACTION OS 617.00 C 06/30/10 83891 83891 83891 006 0301 2608
04002938 NUCLEIC ACID EXTRACTION OS 540.00 06/30/10 8389191 8389191 8389191 006 0301 2608
04002940 PROMETHEUS IBD7 N/C E 06/30/10 006 0301 2608
04002941 ASCA IGA 165.00 C 06/30/10 83520 83520 83520 006 0301 2608
04002942 ASCA IGG 165.00 C 06/30/10 8352091 8352091 8352091 006 0301 2608
04002943 ANTI-OMPC IGA 165.00 C 06/30/10 8352091 8352091 8352091 006 0301 2608
04002944 ANTI-CBIR1 165.00 C 06/30/10 8352091 8352091 8352091 006 0301 2608
04002945 IBD AUTOANTIBODY 165.00 C 06/30/10 8352091 8352091 8352091 006 0301 2608
04002946 IBD PERINUCLEAR PATTERN 165.00 C 06/30/10 88347 88347 88347 006 0310 2608
04002947 IBD DNASE SENSITIVITY 165.00 C 06/30/10 8834791 8834791 8834791 006 0310 2608
04002950 TPMT ENZYME ACTIVITY ASSAY N/C E 06/30/10 006 0301 2608
04002951 TPMT ENZYME ACTIVITY 295.00 C 06/30/10 82657 82657 82657 006 0301 2608
04002952 TPMT ENZYME RESULT 295.00 C 06/30/10 82491 82491 82491 006 0301 2608
04003000 PROTEIN ELECT W RFLX-SER N/C E 06/30/10 006 0301 2608
04003001 PROTEIN ELECT-SER 32.00 C 06/30/10 84165 84165 84165 006 0301 2608
04003002 PROTEIN BY REFRACT 20.00 C 06/30/10 84160 84160 84160 006 0301 2608
04003005 C TELOPEPTIDE,BETA X-LINKED 239.00 06/30/10 82523 82523 82523 006 0301 2608
04003010 CHLAMYDIA IGG ANTIBODIES N/C E 06/30/10 006 0301 2608
04003011 C. TRACHOMATIS, IGG 30.00 C 06/30/10 86631 86631 86631 006 0301 2608
04003012 C. PNEUMONIAE, IGG 30.00 C 06/30/10 8663191 8663191 8663191 006 0301 2608
04003013 C. PSITTACI, IGG 30.00 C 06/30/10 8663191 8663191 8663191 006 0301 2608
04003020 PROMETHEUS CELIAC SEROLOGY N/C E 06/30/10 006 0301 2608
04003021 GLIADIN IGG 148.00 C 06/30/10 83520 83520 83520 006 0301 2608
04003022 GLIADIN IGA 148.00 C 06/30/10 8352091 8352091 8352091 006 0301 2608
04003023 TISSUE TRANSGLUTAMINASE IGA 148.00 C 06/30/10 8352091 8352091 8352091 006 0301 2608
04003024 ENDOMYSIAL IGA 148.00 C 06/30/10 88347 88347 88347 006 0301 2608
04003025 TOTAL IGA 148.00 C 06/30/10 82784 82784 82784 006 0301 2608
04003030 WEST NILE AMPLIFIED PROBE 504.00 06/30/10 87798 87798 87798 006 0301 2608
04003129 PROTEIN ELECT-SER 115.00 06/30/10 84165 84165 84165 006 0301 2608
04003137 PROTEIN ELECT-CSF 125.00 06/30/10 84166 84166 84166 006 0301 2608
04003160 9 DRUG SCREEN W/CONF N/C E 06/30/10 006 0301 2608
04003161 AMPHETAMINES 12.00 C 06/30/10 G0431 G0431 G0431 006 0301 2608
04003162 BARBITURATES 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003163 BENZODIAZEPINES 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003164 PROPOXYPHENE 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003165 COCAINE 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003166 METHADONE 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003167 OPIATES 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003168 PHENCYCLIDINE 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003169 CANNABANOIDS 12.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04003183 BARBITURATES CONF CHARGE 104.00 06/30/10 82205 82205 82205 006 0301 2608
04003186 CANNABANOIDS CONF CHARGE 72.00 06/30/10 82542 82542 82542 006 0301 2608
04003189 BENZODIAZEPINE CONF CHARGE 46.00 06/30/10 80154 80154 80154 006 0301 2608
04003192 AMPHETAMINES CONF CHARGE 111.00 06/30/10 82145 82145 82145 006 0301 2608
04003195 COCAINE CONF CHARGE 113.00 06/30/10 82520 82520 82520 006 0301 2608
04003198 PHENCYCLIDINE CONF CHARGE 113.00 06/30/10 83992 83992 83992 006 0301 2608
04003201 OPIATES CONF CHARGE 133.00 06/30/10 83925 83925 83925 006 0301 2608
04003204 METHADONE CONF CHARGE 125.00 06/30/10 83840 83840 83840 006 0301 2608
04003207 PROPOXYPHENE CONF CHARGE 133.00 06/30/10 83925 83925 83925 006 0301 2608
04003212 TOT IRON BINDING CAP 104.00 06/30/10 83550 83550 83550 006 0301 2612
04003220 HUNTINGTON SB N/C E 06/30/10 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 78
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04003221 HD SB ISOLATION/EXTRACTION 95.00 C 06/30/10 83891 83891 83891 006 0301 2608
04003222 HD SB EZYMATIC DIGESTION, EACH 71.00 C 06/30/10 83892 83892 83892 006 0301 2608
04003223 HD SB SEPARATION BY GEL EL 81.00 C 06/30/10 83894 83894 83894 006 0301 2608
04003224 HD SB NUCLEIC ACID TRANSFER 84.00 C 06/30/10 83897 83897 83897 006 0301 2608
04003225 HD SB NUCLEIC ACID PR #1 68.00 C 06/30/10 83896 83896 83896 006 0301 2608
04003230 WARFARIN SENSITIVITY N/C E 06/30/10 006 0301 2608
04003231 CYP2C9 ALLELE 1 42.00 C 06/30/10 83890 83890 83890 006 0301 2608
04003232 CYP2C9 ALLELE 2 148.00 C 06/30/10 83898 83898 83898 006 0301 2608
04003233 VKORC1 ALLELE 1 85.00 C 06/30/10 83896 83896 83896 006 0301 2608
04003234 VKORC1 ALLELE 2 85.00 C 06/30/10 83896 83896 83896 006 0301 2608
04003235 WARFARIN INTERPRET 68.00 06/30/10 83896 83896 83896 006 0301 2608
04003249 CMV QUANT PCR,UR OR BF 152.00 06/30/10 87497 87497 87497 006 0306 2608
04003252 HCV REAL TIME PCR 163.00 06/30/10 87522 87522 87522 006 0306 2608
04003255 ARSENIC,FRACTIONATED 116.00 06/30/10 82175 82175 82175 006 0301 2608
04003525 HGB ELECT-ACID 133.00 06/30/10 83020 83020 83020 006 0301 2608
04003616 FIBRINOGEN QUANT 102.00 06/30/10 85384 85384 85384 006 0305 2613
04003731 FOLIC ACID 181.00 06/30/10 82746 82746 82746 006 0301 2612
04003871 FUNGUS CULTURE-OTHER 189.00 06/30/10 87102 87102 87102 006 0306 2639
04004050 INTRA OPERATIVE PTH 283.00 06/30/10 83970 83970 83970 006 0301 2612
04004093 GLUCOSE, QUANTITATIVE BLOOD 48.00 06/30/10 82947 82947 82947 006 0301 2612
04004101 CSF GLUCOSE 55.00 06/30/10 82945 82945 82945 006 0301 2612
04004119 GLUCOSE URINE 55.00 06/30/10 82945 82945 82945 006 0301 2612
04004125 ALBUMIN, FLUID 71.00 06/30/10 82042 82042 82042 006 0301 2612
04004135 GLUCOSE POSTPRANDIAL 62.00 06/30/10 82950 82950 82950 006 0301 2612
04004235 BASIC METABOLIC PROFILE 146.00 06/30/10 80048 80048 80048 006 0300 2612
04004236 COMPREHENSIVE METBOLIC PROFILE 232.00 06/30/10 80053 80053 80053 006 0300 2612
04004275 GLUCOSE FLUID 55.00 06/30/10 82945 82945 82945 006 0301 2612
04004279 PTH-INTACT 358.00 06/30/10 83970 83970 83970 006 0301 2612
04004283 POTASSIUM FLUID 41.00 06/30/10 84132 84132 84132 006 0301 2612
04004291 SODIUM OTHER 41.00 06/30/10 84302 84302 84302 006 0301 2612
04004309 CREATININE FLUID 48.00 06/30/10 82565 82565 82565 006 0301 2612
04004530 F. TULARENSIS AB 145.00 06/30/10 86668 86668 86668 006 0302 2608
04004549 F. TULERENSIS AB 101.00 06/30/10 86668 86668 86668 006 0302 2608
04004556 COCCIDIOMYCOSIS AB 85.00 06/30/10 86635 86635 86635 006 0302 2608
04004598 BLASTOMYCOSIS AB 85.00 06/30/10 86612 86612 86612 006 0302 2608
04004606 HISTOPLASMOSIS AB 89.00 06/30/10 86698 86698 86698 006 0302 2608
04004614 CANDIDA ANTIBODY 84.00 06/30/10 86628 86628 86628 006 0302 2608
04004820 AMIKACIN 141.00 06/30/10 80150 80150 80150 006 0300 2612
04004885 PROTHROMBIN FRAGMENT 1+2 175.00 06/30/10 83520 83520 83520 006 0301 2608
04004887 IRON SERUM 85.00 06/30/10 83540 83540 83540 006 0301 2612
04004937 IVY BLEEDING TIME 92.00 06/30/10 85002 85002 85002 006 0305 2613
04005000 GLUCOSE (POCT) 41.00 06/30/10 82948 82948 82948 006 0301 2615
04005003 PROCESSING FEE ONLY 60.00 06/30/10 99001 99001 99001 006 0300 2615
04005017 THEOPHYLLINE 131.00 06/30/10 80198 80198 80198 006 0300 2612
04005140 LDH ISOENZYMES 103.00 06/30/10 83625 83625 83625 006 0301 2608
04005207 LDH SERUM 64.00 06/30/10 83615 83615 83615 006 0301 2612
04005231 LDH-FLUID 64.00 06/30/10 83615 83615 83615 006 0301 2612
04005330 LEAD BLOOD 108.00 06/30/10 83655 83655 83655 006 0301 2612
04005348 LEAD URINE 83.00 06/30/10 83655 83655 83655 006 0301 2608
04005452 FETAL LUNG MATURITY SCREEN 100.00 06/30/10 83663 83663 83663 006 0301 2612
04005454 LIPASE 81.00 06/30/10 83690 83690 83690 006 0301 2612
04005598 TROPONIN-I 154.00 06/30/10 84484 84484 84484 006 0301 2612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 79
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04005603 17-0H PROGESTERONE 59.00 06/30/10 83498 83498 83498 006 0301 2608
04005611 PROGESTERONE 172.00 06/30/10 84144 84144 84144 006 0301 2612
04005660 HEP A AB,TOTAL 117.00 06/30/10 86708 86708 86708 006 0302 2612
04005736 MAGNESIUM SERUM 63.00 06/30/10 83735 83735 83735 006 0301 2612
04005744 MAGNESIUM URINE 63.00 06/30/10 83735 83735 83735 006 0301 2612
04005918 FAT-QUALITATIVE 57.00 06/30/10 89125 89125 89125 006 0300 2613
04005942 MICROSCOPIC-STOOL 57.00 06/30/10 87205 87205 87205 006 0306 2613
04005959 INFECTIOUS MONO TEST 141.00 06/30/10 86308 86308 86308 006 0302 2639
04005961 ID BY NA AMP PROBE,CULT, ISOL 130.00 06/30/10 87150 87150 87150 006 0302 2639
04005964 HIV CULTURE N/C E 06/30/10 006 0302 2639
04005965 TISSUE CULT INOC & OBSERVATION 401.00 C 06/30/10 87252 87252 87252 006 0306 2639
04005966 EIA FOR HIV-1 P24 137.00 C 06/30/10 87390 87390 87390 006 0306 2639
04006050 ANTIFUNGAL LEVEL BIOASSAY 215.00 06/30/10 80299 80299 80299 006 0300 2639
04006072 SUGAR WATER FRAG 125.00 06/30/10 85555 85555 85555 006 0305 2608
04006080 FREE T3 163.00 06/30/10 84481 84481 84481 006 0301 2608
04006161 ELECTROLYTES (SERUM) 87.00 06/30/10 80051 80051 80051 006 0300 2612
04006256 IRON PROFILE N/C E 06/30/10 006 0301 2612
04006257 IRON, SERUM; AUTOMATED 85.00 C 06/30/10 83540 83540 83540 006 0301 2612
04006258 IRON BIND CAPACITY SERUM; AUTO 117.00 C 06/30/10 83550 83550 83550 006 0301 2612
04006298 IG LEVELS-CSF N/C E 06/30/10 006 0301 2608
04006299 IMMUNOGLOBULIN G 41.00 C 06/30/10 82784 82784 82784 006 0301 2608
04006300 IMMUNOGLOBULIN A 41.00 C 06/30/10 8278491 8278491 8278491 006 0301 2608
04006301 IMMUNOGLOBULIN M 41.00 C 06/30/10 8278491 8278491 8278491 006 0301 2608
04006312 CULT-NASOPHARX:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04006320 SUSCEPTIBILTY-BETA LACTAMASE 24.00 06/30/10 87185 87185 87185 006 0306 2639
04006324 ANTIBIOTIC MIC-PANEL 109.00 06/30/10 87186 87186 87186 006 0306 2639
04006325 ANTIBIOTIC MIC/MBC N/C E 06/30/10 006 0306 2639
04006326 MINIMUM INHIBITORY CONC 109.00 C 06/30/10 87186 87186 87186 006 0306 2639
04006327 MINIMUM BACTERICIDAL CONC 75.00 C 06/30/10 87187 87187 87187 006 0300 2639
04006330 ANTIFUNGAL MIC/MFC N/C E 06/30/10 006 0306 2639
04006331 MINIMUM INHIBITORY CONC 109.00 C 06/30/10 87186 87186 87186 006 0306 2639
04006332 MINIMUM FUNGACIDAL CONC 75.00 C 06/30/10 87187 87187 87187 006 0306 2639
04006340 4 HR GLUCOSE TOLERANCE N/C E 06/30/10 006 0301 2612
04006341 GLUCOSE TOL TEST, 3 SPECIMENS 79.00 C 06/30/10 82951 82951 82951 006 0301 2612
04006342 GLUCOSE TOL TEST,3HR SPECIMEN 48.00 C 06/30/10 82952 82952 82952 006 0301 2612
04006343 GLUCOSE TOL TEST,4HR SPECIMEN 48.00 C 06/30/10 82952 82952 82952 006 0301 2612
04006346 DIRECT SMEAR-GRAM STAIN 46.00 06/30/10 87205 87205 87205 006 0306 2639
04006350 STREP A CULTURE 78.00 06/30/10 87081 87081 87081 006 0306 2639
04006351 STREP B CULTURE 78.00 06/30/10 87081 87081 87081 006 0306 2639
04006353 STREP A ANTIGEN 89.00 06/30/10 87430 87430 87430 006 0306 2639
04006395 OCCULT BLOOD SCREEN 38.00 06/30/10 82270 82270 82270 006 0301 2613
04006396 OCCULT BLOOD - GASTRIC 47.00 06/30/10 82271 82271 82271 006 0301 2613
04006432 GLUCOSE TOL TEST,3HR SPECIMEN 48.00 06/30/10 82952 82952 82952 006 0301 2612
04006528 OSMOLARITY SERUM 67.00 06/30/10 83930 83930 83930 006 0301 2612
04006595 NASAL WASH FOR RSV W/O REFLEX 126.00 06/30/10 87807 87807 87807 006 0300 2639
04006600 INFLUENZA A&B VIRUS W/O REFLEX N/C E 06/30/10 006 0306 2639
04006601 INFLUENZA A DFA 69.00 C 06/30/10 87276 87276 87276 006 0306 2639
04006817 PTT 86.00 06/30/10 85730 85730 85730 006 0305 2613
04006874 PEROXIDASE STAIN 182.00 06/30/10 88312 88312 88312 006 0310 2613
04006965 PH 112.00 06/30/10 82800 82800 82800 006 0301 2612
04007158 NEONATAL SCREEN PROCESSING N/C 06/30/10 84030 84030 84030 006 0301 2608
04007161 ALK. PHOS. 76.00 06/30/10 84075 84075 84075 006 0301 2612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 80
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04007229 PHOSPHORUS SERUM 47.00 06/30/10 84100 84100 84100 006 0301 2612
04007245 PHOSPHORUS URINE 59.00 06/30/10 84105 84105 84105 006 0301 2612
04007252 UREA NITROGEN, FLUID 49.00 06/30/10 84520 84520 84520 006 0301 2612
04007286 A1 FETOPROTEIN-QNT 210.00 06/30/10 82105 82105 82105 006 0301 2612
04007288 PACE PROFILE N/C E 06/30/10 006 0301 2608
04007289 ALPHA-FETOPROTEIN; SERUM 135.00 C 06/30/10 82105 82105 82105 006 0301 2608
04007290 ESTRIOL 110.00 C 06/30/10 82677 82677 82677 006 0301 2608
04007291 CHORIONIC GONADOTROPIN; QUANT 160.00 C 06/30/10 84702 84702 84702 006 0301 2608
04007400 DSDNA IFA TITER 55.00 06/30/10 86225 86225 86225 006 0300 2608
04007410 SEQUENTIAL SCRN 1ST TRIMESTER N/C E 06/30/10 006 0300 2608
04007411 PREG-ASSOC PROT A (PAPPA) 135.00 C 06/30/10 84163 84163 84163 006 0300 2608
04007412 HCG, QUANTITATIVE 90.00 C 06/30/10 84702 84702 84702 006 0300 2608
04007420 SEQUENTIAL SCRN 2ND TRIMESTER N/C E 06/30/10 006 0300 2608
04007421 MS ALPHAFETOPROTEIN 100.00 C 06/30/10 82105 82105 82105 006 0300 2608
04007422 ESTRIOL 120.00 C 06/30/10 82677 82677 82677 006 0300 2608
04007423 HCG, QUANTITATIVE 90.00 C 06/30/10 84702 84702 84702 006 0300 2608
04007424 INHIBIN-A 65.00 C 06/30/10 86336 86336 86336 006 0300 2608
04007500 BME MARROW ENGRAFTMENT POST N/C E 06/30/10 006 0301 2608
04007501 BME ISOLATION/EXTRACTION 95.00 C 06/30/10 83891 83891 83891 006 0301 2608
04007502 BME SEPARATION GEL ELECT 81.00 C 06/30/10 83894 83894 83894 006 0301 2608
04007503 BME AMPL NUCLEIC ACID,MULTPLX 100.00 C 06/30/10 83901 83901 83901 006 0301 2608
04007504 BME INTERPRETATION AND REPORT 84.00 C 06/30/10 83912 83912 83912 006 0301 2608
04007510 BONE MARROW ENGRAFTMENT PRE N/C E 06/30/10 006 0301 2608
04007511 BME ISOLATION/EXTRACTION 95.00 C 06/30/10 83891 83891 83891 006 0301 2608
04007512 BME SEPARATION BY HIGH RESOL 95.00 C 06/30/10 83909 83909 83909 006 0301 2608
04007513 BME AMPLI NUCLEIC ACD,MULTIPLX 123.00 C 06/30/10 83900 83900 83900 006 0301 2608
04007514 BME INTERPRETATION AND REPORT 84.00 C 06/30/10 83912 83912 83912 006 0301 2608
04007520 BONE MARROW ENGRAFTMENT DONOR N/C E 06/30/10 006 0301 2608
04007521 BME ISOLATION/EXTRACTION 40.71 C 06/30/10 83891 83891 83891 006 0301 2608
04007522 BME SEPARATION BY HIGH RESOL 40.71 C 06/30/10 83909 83909 83909 006 0301 2608
04007523 BME AMPLI NECEIC ACD,MULTIPLX 52.71 C 06/30/10 83900 83900 83900 006 0301 2608
04007524 BME INTERPRETATION AND REPORT 36.00 C 06/30/10 83912 83912 83912 006 0301 2608
04007526 FREE HGB-URINE 48.00 06/30/10 83069 83069 83069 006 0301 2608
04007534 HEP B SURFACE AG (CONF) 162.00 06/30/10 87341 87341 87341 006 0306 2612
04007666 PORPHOBILI-QNT 83.00 06/30/10 84110 84110 84110 006 0301 2608
04007716 POTASSIUM SERUM 41.00 06/30/10 84132 84132 84132 006 0301 2612
04007724 POTASSIUM URINE 49.00 06/30/10 84133 84133 84133 006 0301 2612
04007757 O2 SATURATION 93.00 06/30/10 82810 82810 82810 006 0301 2612
04007760 INTRA OPERATIVE PTH 281.00 06/30/10 83970 83970 83970 006 0301 2612
04007880 PROTEIN QUANT URINE 79.00 06/30/10 84156 84156 84156 006 0301 2612
04007922 PROTEIN TOTAL SERUM 79.00 06/30/10 84155 84155 84155 006 0301 2612
04007989 PROTEIN TOTAL FLUID 79.00 06/30/10 84157 84157 84157 006 0301 2612
04008094 PROTHROMBIN TIME 59.00 06/30/10 85610 85610 85610 006 0305 2613
04008097 LUPUS ANTICOAGULANT 267.00 06/30/10 85597 85597 85597 006 0305 2613
04008098 LUPUS ANTICOAGULANT DRVVT 134.00 06/30/10 85613 85613 85613 006 0305 2613
04008235 CHLAMYDIA DFA-DIRECT SMEAR 88.00 06/30/10 87206 87206 87206 006 0306 2639
04008391 RETICULOCYTE COUNT 56.00 06/30/10 85045 85045 85045 006 0305 2613
04008482 CALCITONIN 177.00 06/30/10 82308 82308 82308 006 0301 2608
04008490 ACTH 247.00 06/30/10 82024 82024 82024 006 0301 2608
04008508 PROLACTIN 216.00 06/30/10 84146 84146 84146 006 0301 2612
04008524 TBG 117.00 06/30/10 84442 84442 84442 006 0301 2608
04008532 CALCULI ID 109.00 06/30/10 82365 82365 82365 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 81
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04008540 OXALATE 97.00 06/30/10 83945 83945 83945 006 0301 2608
04008557 ESTRADIOL 199.00 06/30/10 82670 82670 82670 006 0301 2612
04008565 FERRITIN 197.00 06/30/10 82728 82728 82728 006 0301 2612
04008581 GASTRIN 63.00 06/30/10 82941 82941 82941 006 0301 2608
04008656 SALICYLATE-QUANT SERUM 117.00 06/30/10 80196 80196 80196 006 0300 2612
04008659 VANCOMYCIN LEVEL 177.00 06/30/10 80202 80202 80202 006 0300 2612
04008801 FACT 8 INHIBIT HUMAN,BETHESDA N/C E 06/30/10 006 0305 2608
04008802 FACTOR 8 ACTIVITY,HUMAN 217.00 C 06/30/10 85240 85240 85240 006 0305 2608
04008803 FACTOR 8 INHIBITOR,HUMAN 213.00 C 06/30/10 85335 85335 85335 006 0305 2608
04008805 ADENOSINE DEAMINASE,FLUID 125.00 06/30/10 84311 84311 84311 006 0301 2608
04008806 BETA-2-TRANSFERRIN 161.00 06/30/10 86334 86334 86334 006 0302 2608
04008807 COXIELLA BURNETTI AB 84.00 06/30/10 86638 86638 86638 006 0302 2608
04008808 DIPTHERIA AB 135.00 06/30/10 86648 86648 86648 006 0302 2608
04008809 ESTRONE (E1) 58.00 06/30/10 82679 82679 82679 006 0301 2608
04008811 FACT 8 INHIBIT,PORCINE,BETHESD N/C E 06/30/10 006 0305 2608
04008812 FACTOR 8 ACTIVITY,PORCINE 217.00 C 06/30/10 85240 85240 85240 006 0305 2608
04008813 FACTOR 8 INHIBITOR,PORCINE 213.00 C 06/30/10 85335 85335 85335 006 0305 2608
04008815 HALOPERIDOL LEVEL 130.00 06/30/10 80173 80173 80173 006 0300 2608
04008817 H INFLUENZAE B IGG ANTIBODY 67.00 06/30/10 86684 86684 86684 006 0302 2608
04008818 JO-1 IGG ANTIBODY 118.00 06/30/10 86235 86235 86235 006 0302 2608
04008821 ACETYLCHOLINE RECEPT AB PANEL N/C E 06/30/10 006 0301 2608
04008822 ACETYLCHOLINE REC BINDING AB 208.00 C 06/30/10 83519 83519 83519 006 0301 2608
04008823 ACETYLCHOLINE REC BLOCKING AB 208.00 C 06/30/10 8351991 8351991 8351991 006 0301 2608
04008824 ACETYLCHLINE REC MODUALTING AB 208.00 06/30/10 83519 83519 83519 006 0301 2608
04008827 OSMOLALITY (FECAL) 151.00 06/30/10 84999 84999 84999 006 0301 2608
04008828 VASOACTIVE INTESTINAL PEPTIDE 125.00 06/30/10 84586 84586 84586 006 0301 2608
04008831 HPV DNA PROBE N/C 06/30/10 006 0306 2608
04008832 LOW RISK HPV 153.00 06/30/10 87621 87621 87621 006 0306 2608
04008833 HIGH RISK HPV(THINPREP) 153.00 06/30/10 8762191 8762191 8762191 006 0306 2608
04008841 BARTONELLA QUINTANA AB N/C E 06/30/10 006 0302 2608
04008842 B QUINTANA IGG AB 83.00 C 06/30/10 86611 86611 86611 006 0302 2608
04008843 B QUINTANA IGM AB 83.00 C 06/30/10 8661191 8661191 8661191 006 0302 2608
04008851 LYME AB BY WESTERN BLOT N/C E 06/30/10 006 0302 2608
04008852 LYME IGG AB,WESTERN BLOT 140.00 C 06/30/10 86617 86617 86617 006 0302 2608
04008853 LYME IGM AB, WESTERN BLOT 86.00 C 06/30/10 8661791 8661791 8661791 006 0302 2608
04008860 RUBELLA IGM AB 83.00 06/30/10 86762 86762 86762 006 0302 2608
04008870 HSV TYPE I,II IGM AB 100.00 06/30/10 86694 86694 86694 006 0302 2608
04008880 ROCKY MTN SPOTTED FEVER AB N/C E 06/30/10 006 0302 2608
04008881 ROCKY MTN FEVER IGG AB 44.00 C 06/30/10 86757 86757 86757 006 0302 2608
04008882 ROCKY MTN FEVER IGM AB 44.00 C 06/30/10 8675791 8675791 8675791 006 0302 2608
04008904 SEDIMENTATION RATE 62.00 06/30/10 85651 85651 85651 006 0305 2613
04009060 PREGNANCY TEST - URINE 89.00 06/30/10 84703 84703 84703 006 0301 2613
04009063 CD4 LYMPHOCYTES 96.00 06/30/10 86361 86361 86361 006 0302 2613
04009076 SICKLE CELL SCREEN 51.00 06/30/10 85660 85660 85660 006 0305 2613
04009126 SODIUM SERUM 45.00 06/30/10 84295 84295 84295 006 0301 2612
04009134 SODIUM URINE 52.00 06/30/10 84300 84300 84300 006 0301 2612
04009159 SODIUM CSF 37.00 06/30/10 84302 84302 84302 006 0301 2612
04009225 SPERM COUNT 123.00 06/30/10 89320 89320 89320 006 0300 2613
04009230 IRON STAIN, BONE MARROW 157.00 06/30/10 88313 88313 88313 006 0310 2613
04009316 URIC ACID FLUID 56.00 06/30/10 84550 84550 84550 006 0301 2612
04009324 ALK. PHOS. FLUID 76.00 06/30/10 84075 84075 84075 006 0301 2612
04009340 ALBUMIN SERUM 62.00 06/30/10 82040 82040 82040 006 0301 2612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 82
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04009357 CHOLESTEROL-HDL 92.00 06/30/10 83718 83718 83718 006 0301 2612
04009360 BILIRUBIN,TOTAL SERUM -RD 40.00 06/30/10 82247CF 82247CF 82247CF 006 0301 2612
04009363 BILIRUBIN, DIRECT SERUM-RD 43.00 06/30/10 82248CF 82248CF 82248CF 006 0301 2612
04009366 SODIUM SERUM-RD 45.00 06/30/10 84295CF 84295CF 84295CF 006 0301 2612
04009369 SGPT(ALT) - RD 76.00 06/30/10 84460CF 84460CF 84460CF 006 0301 2612
04009375 UREA NITROGEN SERUM - RD 49.00 06/30/10 84520CD 84520CD 84520CD 006 0301 2612
04009378 CALCIUM SERUM -RD 55.00 06/30/10 82310CD 82310CD 82310CD 006 0301 2612
04009381 CHLORIDE SERUM - RD 41.00 06/30/10 82435CD 82435CD 82435CD 006 0301 2612
04009384 CARBON DIOXIDE - RD 46.00 06/30/10 82374CD 82374CD 82374CD 006 0301 2612
04009387 CREATININE SERUM -RD 48.00 06/30/10 82565CD 82565CD 82565CD 006 0301 2612
04009390 POTASSIUM SERUM - RD 41.00 06/30/10 84132CD 84132CD 84132CD 006 0301 2612
04009393 ALBUMIN SERUM - RD 62.00 06/30/10 82040CD 82040CD 82040CD 006 0301 2612
04009396 PROTEIN TOTAL SERUM - RD 79.00 06/30/10 84155CD 84155CD 84155CD 006 0301 2612
04009399 SGOT(AST) - RD 79.00 06/30/10 84450CD 84450CD 84450CD 006 0301 2612
04009402 PHOSPHORUS SERUM 47.00 06/30/10 84100CD 84100CD 84100CD 006 0301 2612
04009405 ALKALINE PHOSHATASE - RD 76.00 06/30/10 84075CD 84075CD 84075CD 006 0301 2612
04009408 LDH SERUM - RD 64.00 06/30/10 83615CD 83615CD 83615CD 006 0301 2612
04009412 SODIUM SERUM-RD 45.00 06/30/10 84295CD 84295CD 84295CD 006 0301 2612
04009852 FREE T4 167.00 06/30/10 84439 84439 84439 006 0301 2612
04009969 SGOT 79.00 06/30/10 84450 84450 84450 006 0301 2612
04009977 SGPT 76.00 06/30/10 84460 84460 84460 006 0301 2612
04010041 TRIGLYCERIDES 63.00 06/30/10 84478 84478 84478 006 0301 2612
04010099 BLOOD GASES (O.R.) 140.00 06/30/10 82803 82803 82803 006 0301 2612
04010111 HEMOGLOBIN 37.00 06/30/10 85018 85018 85018 006 0305 2612
04010115 B-NATRIURETIC HORMONE 205.00 06/30/10 83880 83880 83880 006 0301 2612
04010118 FETAL FIBRONECTIN 206.00 06/30/10 82731 82731 82731 006 0301 2608
04010512 URIC ACID SERUM 56.00 06/30/10 84550 84550 84550 006 0301 2612
04010538 URIC ACID URINE 56.00 06/30/10 84560 84560 84560 006 0301 2612
04010587 URINALYSIS-CHEM SCR 45.00 06/30/10 81003 81003 81003 006 0300 2613
04010660 Y CHROMOSONE MICRO DELETION N/C 06/30/10 006 0301 2608
04010661 YCMD ISOLATION/EXTRACTION 359.00 06/30/10 86353 86353 86353 006 0301 2608
04010662 YCMD SEPARATION BY GEL EL 547.00 06/30/10 86821 86821 86821 006 0302 2608
04010663 YCMD AMPLI NUCLEIC ACD,MULTIPL 81.00 06/30/10 83894 83894 83894 006 0301 2608
04010664 YCMD AMPLIFICATION #1 68.00 06/30/10 83896 83896 83896 006 0301 2608
04010665 INTERPRETATION AND REPORT 84.00 06/30/10 83912 83912 83912 006 0301 2608
04010670 B CELL, CLONALITY BY PCR N/C E 06/30/10 006 0301 2608
04010671 B CELL,ISOLATION/EXTRACTION 13.00 C 06/30/10 83891 83891 83891 006 0301 2608
04010672 B CELL,NUC ACID AMP MULTPLX,EA 41.00 C 06/30/10 83901 83901 83901 006 0301 2608
04010673 B CELL,SEPARATION GEL ELECT 13.00 C 06/30/10 83894 83894 83894 006 0301 2608
04010674 B CELL, INTERP AND REPORT 13.00 C 06/30/10 83912 83912 83912 006 0301 2608
04010680 T CELL, CLONALITY BY PCR N/C E 06/30/10 006 0301 2608
04010681 T CELL,ISOLATION/EXTRACTION 13.00 C 06/30/10 83891 83891 83891 006 0301 2608
04010682 T CELL,NUC ACID AMP MULTPLX,EA 19.00 C 06/30/10 83901 83901 83901 006 0301 2608
04010683 T CELL, SEPARATION GEL ELECT 13.00 C 06/30/10 83894 83894 83894 006 0301 2608
04010684 T CELL,INTERP AND REPORT 13.00 C 06/30/10 83912 83912 83912 006 0301 2608
04010691 CHAIN OF CUSTODY, EACH 9.00 C 06/30/10 80101 80101 80101 006 0300 2608
04010700 INFLAMMATORY BOWEL DIS TEST N/C E 06/30/10 006 0302 2608
04010701 S. CEREVISIAE AB, IGG 127.00 C 06/30/10 86671 86671 86671 006 0302 2608
04010702 S. CEREVISIAE AB, IGA 127.00 C 06/30/10 86671 86671 86671 006 0302 2608
04010703 NEUTROPHIL CYTOPLASMIC AB 58.00 C 06/30/10 86255 86255 86255 006 0302 2608
04010710 PHOSPHATIDYLSERINE IG LEVELS N/C E 06/30/10 006 0302 2608
04010711 PHOSPHATIDYLSERINE AB,IGG 58.00 C 06/30/10 86148 86148 86148 006 0302 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 83
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04010712 PHOSPHATIDYLSERINE AB,IGM 58.00 C 06/30/10 8614891 8614891 8614891 006 0302 2608
04010713 PHOSPHATIDYLSERINE AB,IGA 58.00 C 06/30/10 8614891 8614891 8614891 006 0302 2608
04010720 EHRLICHIA CHAFFEENSIS AB N/C E 06/30/10 006 0302 2608
04010721 E.CHAFFEENSIS IGG AB 68.00 C 06/30/10 86666 86666 86666 006 0302 2608
04010722 E.CHAFFEENSIS IGM AB 68.00 C 06/30/10 8666691 8666691 8666691 006 0302 2608
04010740 AMIODARONE AND METABOLITE N/C E 06/30/10 006 0301 2608
04010741 AMIODARONE LEVEL 46.00 C 06/30/10 80299 80299 80299 006 0301 2608
04010742 DESAMIODARONE LEVEL 41.00 C 06/30/10 8029991 8029991 8029991 006 0301 2608
04010750 CLOMIPRAMINE AND METABOLITE N/C E 06/30/10 006 0301 2608
04010751 CLOMIPRAMINE LEVEL 48.00 C 06/30/10 80299 80299 80299 006 0301 2608
04010752 DESMETHYLCLOMIPRAMINE 48.00 C 06/30/10 8029991 8029991 8029991 006 0301 2608
04010760 METHSUXIMIDE AND METABOLITE N/C E 06/30/10 006 0301 2608
04010761 METHSUXIMIDE LEVEL 48.00 C 06/30/10 83858 83858 83858 006 0301 2608
04010762 NORMETHSUXIMIDE LEVEL 48.00 C 06/30/10 80299 80299 80299 006 0301 2608
04010790 HEMOCHROMATOSIS MUTATION DET N/C E 06/30/10 006 0301 2608
04010791 HMD-MOLECULAR ISOLATION 45.29 C 06/30/10 83890 83890 83890 006 0301 2608
04010792 HMD-AMPLIFICATION,MULTIPLEX 107.00 C 06/30/10 83900 83900 83900 006 0301 2608
04010793 HMD-NUCLEIC ACID PROBE#1 40.14 C 06/30/10 83896 83896 83896 006 0301 2608
04010794 NUCLEIC ACID PROBE#2 29.00 C 06/30/10 83896 83896 83896 006 0301 2608
04010800 FLUOXETINE/NORFLUOXETINE N/C E 06/30/10 006 0301 2608
04010801 FLUOXETINE LEVEL 38.00 C 06/30/10 80299 80299 80299 006 0301 2608
04010802 NORFLUOXETINE LEVEL 38.00 C 06/30/10 8029991 8029991 8029991 006 0301 2608
04010805 PYRUVATE KINASE 129.00 06/30/10 84220 84220 84220 006 0300 2608
04010808 OXALATE,S OR PL 97.00 06/30/10 83945 83945 83945 006 0300 2608
04010811 LIPO ASSOC PHOSPHO A2 175.00 06/30/10 83698 83698 83698 006 0300 2608
04010817 APC RESISTANCE PANEL 64.00 06/30/10 85307 85307 85307 006 0300 2608
04010820 MEASLES, AB IGM 98.00 06/30/10 86765 86765 86765 006 0300 2608
04010826 BLASTO AG,SER,CSF,UR 132.00 06/30/10 87449 87449 87449 006 0306 2608
04010830 FLT3 MUT DET BY PCR N/C E 06/30/10 006 0300 2608
04010831 FLT3 ISOLATION/EXTRACTION 57.00 C 06/30/10 83891 83891 83891 006 0300 2608
04010832 FLT3 NUCLEAR AMPLIFICATION#1 57.00 C 06/30/10 83898 83898 83898 006 0300 2608
04010833 FLT3 NUCLEAR AMPLIFICATION#2 143.00 C 06/30/10 83898 83898 83898 006 0300 2608
04010834 ENZYMATIC DIGESTION, EACH 83.00 C 06/30/10 83892 83892 83892 006 0300 2608
04010835 FLT3 NUCLEIC ACID PR #1 80.00 C 06/30/10 83896 83896 83896 006 0300 2608
04010836 FLT3 NUCLEIC ACID PR #2 68.00 C 06/30/10 83896 83896 83896 006 0300 2608
04010837 FLT3 SEPARATION BY HIGH RESOL 57.00 C 06/30/10 83909 83909 83909 006 0300 2608
04010840 HIV PHENOSENSE (SEE 04010920) N/C E 06/30/10 006 0306 2608
04010841 HIV PHENOTYPING 826.00 C 06/30/10 87901 87901 87901 006 0306 2608
04010842 HIV PHEN;DNA,CULT,1ST 10 DRUGS 1210.00 C 06/30/10 87903 87903 87903 006 0306 2608
04010843 HIV PHEN;ADD'L DRUG 11 297.00 C 06/30/10 87904 87904 87904 006 0306 2608
04010844 HIV PHEN;ADD'L DRUG 12 297.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04010845 HIV PHEN;ADD'L DRUG 13 297.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04010846 HIV PHEN;ADD'L DRUG 14 297.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04010847 HIV PHEN;ADD'L DRUG 15 297.00 C 06/30/10 8790491 8790491 8790491 006 0300 2608
04010850 LGV DIFFERENTIATION AB N/C E 06/30/10 006 0302 2608
04010851 LGV DIFFERENTIATION AB #1 91.00 C 06/30/10 86631 86631 86631 006 0302 2608
04010852 LGV DIFFERENTIATION AB #2 91.00 C 06/30/10 8663191 8663191 8663191 006 0302 2608
04010853 LGV DIFFERENTIATION AB #3 91.00 C 06/30/10 8663191 8663191 8663191 006 0302 2608
04010855 LGV DIFFERENTIATION AB #5 91.00 C 06/30/10 8663191 8663191 8663191 006 0302 2608
04010856 LGV DIFFERENTIATION AB #6 91.00 C 06/30/10 8663191 8663191 8663191 006 0302 2608
04010857 LGV DIFFERENTIATION AB #7 91.00 C 06/30/10 8663191 8663191 8663191 006 0302 2608
04010858 LGV DIFFERENTIATION AB #8 91.00 C 06/30/10 8663191 8663191 8663191 006 0302 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 84
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04010859 LGV DIFFERENTIATION AB #9 91.00 C 06/30/10 8663291 8663291 8663291 006 0302 2608
04010860 LGV DIFFERENTIATION AB #10 91.00 C 06/30/10 8663291 8663291 8663291 006 0302 2608
04010861 LGV DIFFERENTIATION AB #11 91.00 C 06/30/10 8663291 8663291 8663291 006 0302 2608
04010862 LGV DIFFERENTIATION AB #12 91.00 C 06/30/10 8663291 8663291 8663291 006 0302 2608
04010870 INHALANTS,ENVIR PRO 10 N/C E 06/30/10 006 0302 2608
04010871 D FARINAE (MITES) ALLERGEN 11.00 C 06/30/10 86003 86003 86003 006 0302 2608
04010872 D. PTERONYSSINUS ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010873 DOG EPITHELIUM ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010874 HORMODENDRUM ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010875 ASP FUMIGATUS ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010876 ALTERNARIA TENUIS ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010877 CAT EPI, DANDER ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010878 FEATHER ALLERGEN MIX 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010879 P NOTATUM ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010880 HOUSE DUST ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0302 2608
04010901 ALTERNARIA TENUIS ALLERGEN 11.00 C 06/30/10 86003 86003 86003 006 0300 2608
04010902 JUNE GRASS/KY BLUE GRASS 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010903 BOX ELDER/MAPLE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010904 OAK TREE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010905 ELM TREE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010906 BIRCH TREE ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010907 G COCKROACH ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010908 RAGWEED ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010909 ORCH GR/COCKSFOOT ALLRGN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010910 MARSH ELDER ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010912 DOG DANDER ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010913 D FARINAE (MITES) ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010914 D. PTERONYSSINUS ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010915 ASP FUMIGATUS ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010916 HORMODENDRUM ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 006 0300 2608
04010917 QUANTITATIVE IGE 120.00 C 06/30/10 82785 82785 82785 006 0302 2608
04010920 HIV PHENOSENSE N/C E 06/30/10 006 0306 2608
04010921 HIV PHENOTYPING 826.00 C 06/30/10 87900 87900 87900 006 0306 2608
04010922 HIV GENOTYPE ANALYSIS 135.00 C 06/30/10 87901 87901 87901 006 0306 2608
04010923 HIV PHEN;DNA,CULT,1ST 10 DRUGS 1210.00 C 06/30/10 87903 87903 87903 006 0306 2608
04010924 HIV PHEN;ADD'L DRUG 11 135.00 C 06/30/10 87904 87904 87904 006 0306 2608
04010925 HIV PHEN;ADD'L DRUG 12 135.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04010926 HIV PHEN;ADD'L DRUG 13 135.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04010927 HIV PHEN;ADD'L DRUG 14 135.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04010928 HIV PHEN;ADD'L DRUG 15 135.00 C 06/30/10 8790491 8790491 8790491 006 0300 2608
04010929 HIV PHEN;ADD'L DRUG 16 135.00 C 06/30/10 8790491 8790491 8790491 006 0300 2608
04010930 HIV PHEN;ADD'L DRUG 17 135.00 C 06/30/10 8790491 8790491 8790491 006 0300 2608
04010931 HIV PHEN;ADD'L DRUG 18 135.00 C 06/30/10 8790491 8790491 8790491 006 0300 2608
04010932 HIV PHEN;ADD'L DRUG 19 135.00 C 06/30/10 8790491 8790491 8790491 006 0300 2608
04010933 HIV PHEN;ADD'L DRUG 20 135.00 C 06/30/10 8790491 8790491 8790491 006 0300 2608
04011007 VITAMIN A 112.00 06/30/10 84590 84590 84590 006 0301 2608
04011056 VITAMIN B-12 200.00 06/30/10 82607 82607 82607 006 0301 2612
04011189 CYANIDE 112.00 06/30/10 82600 82600 82600 006 0301 2608
04011247 AMITRIPTYLINE/NORTRIPTYLINE 119.00 06/30/10 80152 80152 80152 006 0300 2608
04011270 PHENOTHIAZINES URINE SCR 69.00 06/30/10 G0431 G0431 G0431 006 0301 2608
04011296 AMPHETAMINES URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04011338 METHEMOGLOBIN 91.00 06/30/10 83050 83050 83050 006 0301 2612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 85
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04011361 XYLOSE URINE 133.00 06/30/10 84620 84620 84620 006 0301 2608
04011395 LIDOCAINE 151.00 06/30/10 80176 80176 80176 006 0300 2608
04011403 MANGANESE 58.00 06/30/10 83785 83785 83785 006 0301 2608
04011585 MERCURY-URINE 105.00 06/30/10 83825 83825 83825 006 0301 2608
04011593 ARSENIC URINE 116.00 06/30/10 82175 82175 82175 006 0301 2608
04011601 COPPER; URINE 99.00 06/30/10 82525 82525 82525 006 0301 2608
04011627 ZINC SERUM 91.00 06/30/10 84630 84630 84630 006 0301 2608
04011694 DOXEPIN N/C E 06/30/10 80166 80166 80166 006 0300 2608
04011695 THERAP DRUG MONIT; MEAS 1 DRUG 44.00 C 06/30/10 80299 80299 80299 006 0300 2608
04011696 DOXEPIN 105.00 C 06/30/10 80166 80166 80166 006 0300 2608
04011700 ETHCHLORVYNOL 99.00 06/30/10 82690 82690 82690 006 0301 2608
04011726 METHANOL, QUANTITATIVE 74.00 06/30/10 84600 84600 84600 006 0301 2608
04011734 METHAQUALONE URINE SCREEN 144.00 06/30/10 82486 82486 82486 006 0301 2608
04011775 GLUTETHIMIDE QUANT 263.00 04/26/10 82980 82980 82980 006 0301 2608
04011804 FELBAMATE 67.00 06/30/10 80299 80299 80299 006 0301 2608
04011809 CARBOXYHEMOGLOBIN 184.00 06/30/10 82375 82375 82375 006 0301 2612
04011812 FLUPHENAZINE 109.00 06/30/10 84022 84022 84022 006 0301 2608
04011816 LORAZEPAM 122.00 06/30/10 80154 80154 80154 006 0300 2608
04011820 NICOTINE AND COTININE META, UR 126.00 06/30/10 83887 83887 83887 006 0301 2608
04011824 OLANZAPINE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011828 OXCARBAZEPINE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011832 ACETAZOLAMIDE(DIAMOX),SERUM 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011833 ACETAMINOPHEN URINE SCR 144.00 06/30/10 82003 82003 82003 006 0301 2612
04011836 CARBAMAZ-10,11 EPOX FREE, UR 145.00 06/30/10 80156 80156 80156 006 0300 2608
04011841 ACETAMINOPHEN SERUM 144.00 06/30/10 82003 82003 82003 006 0301 2612
04011844 SEROQUEL(QUETIAPINE), SP 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011848 ZONISAMIDE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011850 CARBAMAZEPINE EPOXIDE & TOTAL N/C E 06/30/10 006 0300 2608
04011851 CARBAMAZEPINE, TOTAL 73.00 C 06/30/10 80156 80156 80156 006 0300 2608
04011852 CARBAMAZ-10,11 EPOXIDE (SERUM) 73.00 C 06/30/10 82131 82131 82131 006 0300 2608
04011856 TIAGABINE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011858 BARBITURATES SERUM SCREEN 82.00 06/30/10 G0431 G0431 G0431 006 0300 2608
04011860 LEVETIRACETAM (KEPPRA) 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011864 THIORIDAZINE(MELLARIL) LEVEL 146.00 06/30/10 80299 80299 80299 006 0301 2608
04011866 BARBITURATES URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04011882 ETHANOL, QUANTITATIVE 133.00 06/30/10 82055 82055 82055 006 0301 2612
04011916 IMIPRAMINE/DESIPRAMINE 114.00 06/30/10 80174 80174 80174 006 0300 2608
04011919 CELIAC DISEASE PANEL,IGA 95.00 06/30/10 82784 82784 82784 006 0301 2608
04011925 ENDOMYSIAL ANTIBODY,TITER 136.00 06/30/10 86256 86256 86256 006 0301 2608
04011931 ZIPRASIDONE LEVEL 146.00 06/30/10 80299 80299 80299 006 0301 2608
04012013 PROPOXYPHENE URINE SCR 82.00 06/30/10 83925 83925 83925 006 0300 2608
04012039 SALICYLATE URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2608
04012071 D-DIMER 141.00 06/30/10 85379 85379 85379 006 0305 2613
04012112 METHOTREXATE 160.00 06/30/10 80299 80299 80299 006 0300 2612
04012138 GLYCATED HEMOGLOBIN 191.00 06/30/10 83036 83036 83036 006 0301 2612
04012146 VALPROIC ACID 160.00 06/30/10 80164 80164 80164 006 0300 2612
04012211 G6PD-QUAL 61.00 06/30/10 82960 82960 82960 006 0301 2613
04012220 XYLOSE ABSORB, ADULT 133.00 06/30/10 84620 84620 84620 006 0301 2608
04012223 XYLOSE ABSORB, AD 5G 133.00 06/30/10 84620 84620 84620 006 0301 2608
04012226 SMOOTH MUSCLE TITER 136.00 06/30/10 86256 86256 86256 006 0302 2608
04012232 SELENIUM 132.00 06/30/10 84255 84255 84255 006 0301 2608
04012235 TRYPTASE 175.00 06/30/10 83520 83520 83520 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 86
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04012238 ISOVALERIC ACID 161.00 06/30/10 82491 82491 82491 006 0301 2608
04012241 PROPIONIC ACID 212.00 06/30/10 82131 82131 82131 006 0301 2608
04012244 PANCREATIC ELASTASE 356.00 06/30/10 83520 83520 83520 006 0301 2608
04012247 VITAMIN K1 240.00 06/30/10 84597 84597 84597 006 0301 2608
04012253 CORTISOL,SALIVA 146.00 06/30/10 82533 82533 82533 006 0301 2608
04012716 HAPTOGLOBIN QUANT 110.00 06/30/10 83010 83010 83010 006 0301 2608
04012906 5HIAA 110.00 06/30/10 83497 83497 83497 006 0301 2608
04012955 SERUM TRICYCLICS SCREEN 390.00 06/30/10 G0431 G0431 G0431 006 0300 2608
04012989 PENTOBARBITAL 104.00 06/30/10 82205 82205 82205 006 0301 2608
04013000 HEP B SURFACE AG-SH 26.00 06/30/10 87340 87340 87340 006 0306 2612
04013001 HEP B SURF AG,CONF-SH 26.00 06/30/10 87341 87341 87341 006 0306 2612
04013002 HEP B SURFACE AB,TOTAL-SH 27.00 06/30/10 86706 86706 86706 006 0302 2612
04013003 HEP B CORE AB,TOTAL-SH 30.00 06/30/10 86704 86704 86704 006 0302 2612
04013004 HEP C AB,TOTAL-SH 35.00 06/30/10 86803 86803 86803 006 0302 2612
04013005 HEP A AB,TOTAL-SH 33.00 06/30/10 86708 86708 86708 006 0302 2612
04013006 VARICELLA IGG AB-SH 27.00 06/30/10 86787 86787 86787 006 0302 2612
04013007 RUBELLA IGG AB-SH 30.00 06/30/10 86762 86762 86762 006 0302 2612
04013008 MEASLES IGG AB-SH 27.00 06/30/10 86765 86765 86765 006 0302 2612
04013009 MUMPS IGG AB-SH 27.00 06/30/10 86735 86735 86735 006 0302 2612
04013012 MUMPS IGM ANTIBODY 102.00 06/30/10 86735 86735 86735 006 0302 2608
04013136 CRYOFIBRINOGEN 63.00 06/30/10 82585 82585 82585 006 0301 2608
04013169 LACTIC ACID 99.00 06/30/10 83605 83605 83605 006 0301 2612
04013177 VISCOSITY INDEX 94.00 06/30/10 85810 85810 85810 006 0305 2608
04013250 GLUGAGON 61.00 06/30/10 82943 82943 82943 006 0301 2608
04013268 MYOGLOBIN-SERUM 132.00 06/30/10 83874 83874 83874 006 0301 2608
04013276 PROSTATIC ACID PHOS 83.00 06/30/10 84066 84066 84066 006 0301 2608
04013300 THYROGLOBULIN, SERUM 119.00 06/30/10 84432 84432 84432 006 0301 2608
04013318 ELECTROLYTES-STOOL 67.00 06/30/10 82438 82438 82438 006 0301 2608
04013326 IRON-URINE 69.00 06/30/10 83540 83540 83540 006 0301 2608
04013433 UREA N URINE 67.00 06/30/10 84540 84540 84540 006 0301 2612
04013565 CULTURE-TRACH:ISOL,PRESUMP ID 152.00 06/30/10 87070 87070 87070 006 0306 2639
04013623 SUSCEPTIBILITY:MIC(MICROSCAN) 109.00 06/30/10 87186 87186 87186 006 0306 2639
04014175 HEP A AB,IGM 172.00 06/30/10 86709 86709 86709 006 0302 2612
04014183 HEP B CORE AB,TOTAL 143.00 06/30/10 86704 86704 86704 006 0302 2612
04014274 OSMOLALITY URINE 75.00 06/30/10 83935 83935 83935 006 0301 2612
04014324 CARBAMAZEPINE 152.00 06/30/10 80156 80156 80156 006 0300 2612
04014340 AMN FLD SURFACTNT 100.00 06/30/10 83662 83662 83662 006 0301 2612
04014423 PROTEIN ELECT. BF 172.00 06/30/10 84166 84166 84166 006 0301 2612
04014449 MYOGLOBIN QUANT 132.00 06/30/10 83874 83874 83874 006 0301 2608
04014514 FACT. 5 ASSAY 394.00 06/30/10 85220 85220 85220 006 0305 2613
04014522 FACT. 2 ASSAY 328.00 06/30/10 85210 85210 85210 006 0305 2613
04014530 FACT. 12 ASSAY 394.00 06/30/10 85280 85280 85280 006 0305 2613
04014548 FACT. 9 ASSAY 344.00 06/30/10 85250 85250 85250 006 0305 2613
04014555 FACT. 8 ASSAY 294.00 06/30/10 85240 85240 85240 006 0305 2613
04014563 FACT. 10 ASSAY 227.00 06/30/10 85260 85260 85260 006 0305 2613
04014571 FACT. 7 ASSAY 258.00 06/30/10 85230 85230 85230 006 0305 2613
04014654 HEP B SURFACE AB 162.00 06/30/10 86706 86706 86706 006 0302 2612
04014662 HEP B SURFACE AG 162.00 06/30/10 87340 87340 87340 006 0306 2612
04014663 ANTI-HTLV 58.00 06/30/10 86790 86790 86790 006 0302 2608
04014672 TORCH EIA N/C E 06/30/10 006 2608
04014673 IMMUNOASSAY FOR TOXO 113.00 C 06/30/10 86778 86778 86778 006 0302 2608
04014674 IMMUNOASSAY FOR RUBELLA 83.00 C 06/30/10 86762 86762 86762 006 0302 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 87
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04014675 IMMUNOASSAY FOR CMV 116.00 C 06/30/10 86645 86645 86645 006 0302 2608
04014676 IMMUNOASSAY FOR HSV 100.00 C 06/30/10 86694 86694 86694 006 0302 2608
04014682 C4B BINDING PROTEIN 175.00 06/30/10 83520 83520 83520 006 0301 2608
04014714 HSV TYPE I,II IGG ANTIBODIES 100.00 06/30/10 86694 86694 86694 006 0302 2608
04015025 MYCOPLASMA CULTURE-NONGENITAL 105.00 06/30/10 87109 87109 87109 006 0306 2639
04015081 T3-TOTAL 191.00 06/30/10 84480 84480 84480 006 0301 2612
04015107 DIGITOXIN 146.00 06/30/10 80299 80299 80299 006 0300 2608
04015156 FACT. 11 ASSAY 344.00 06/30/10 85270 85270 85270 006 0305 2613
04015727 SPECTRAL SCAN 118.00 06/30/10 82143 82143 82143 006 0301 2608
04015735 CSF CHOLRIDE 59.00 06/30/10 82438 82438 82438 006 0301 2612
04015743 CSF PROTEIN 79.00 06/30/10 84157 84157 84157 006 0301 2612
04015784 BLOOD GASES 218.00 06/30/10 82805 82805 82805 006 0301 2612
04015792 CREATININE SERUM 48.00 06/30/10 82565 82565 82565 006 0301 2612
04015818 AMYLASE URINE 71.00 06/30/10 82150 82150 82150 006 0301 2612
04015859 THYROGLOBULIN AB 105.00 06/30/10 86800 86800 86800 006 0302 2608
04015867 PHENYTOIN 147.00 06/30/10 80185 80185 80185 006 0300 2612
04015868 PHENYTOIN, FREE 189.00 06/30/10 80186 80186 80186 006 0300 2612
04015875 HGH 125.00 06/30/10 83003 83003 83003 006 0301 2608
04015900 CRITICAL CARE PANEL N/C E 06/30/10 006 0301 2612
04015901 GASES, BLOOD W/O2 SATURATION 218.00 C 06/30/10 82805 82805 82805 006 0301 2612
04015902 POTASSIUM, BLOOD 41.00 C 06/30/10 84132 84132 84132 006 0301 2612
04015903 CALCIUM, IONIZED 108.00 C 06/30/10 82330 82330 82330 006 0301 2612
04015904 HEMOGLOBIN 37.00 C 06/30/10 85018 85018 85018 006 0300 2612
04015905 GLUCOSE 48.00 C 06/30/10 82947 82947 82947 006 0301 2612
04015909 STOOL FAT (72 ) 165.00 06/30/10 82710 82710 82710 006 0301 2608
04015915 CREATININE CLEARANCE 73.00 06/30/10 82575 82575 82575 006 0301 2612
04015958 DIRECT ANTI-GLOB. 72.00 06/30/10 86880 86880 86880 006 0300 2670
04015966 ANTIBODY IDENT-RBC 441.00 06/30/10 86870 86870 86870 006 0300 2670
04016030 ANTIBODY TITER-RBC 155.00 06/30/10 86886 86886 86886 006 0300 2670
04016066 RBC LR,SYRINGE PEDS 193.00 06/30/10 P9011 P9011 P9011 006 0390 2670
04016069 RBC LR IR,SYRINGE PEDS 193.00 06/30/10 P9011 P9011 P9011 006 0390 2670
04016072 PLT LR,IR SYRINGE PEDS 266.00 06/30/10 P9033 P9033 P9033 006 0390 2670
04016075 PLT IR, SYRG PEDS 244.00 06/30/10 P9032 P9032 P9032 006 0390 2670
04016078 PLT PHR LR,IR SYRG PEDS 284.00 06/30/10 P9037 P9037 P9037 006 0390 2670
04016081 RBC IR,SYRINGE PEDS 190.00 06/30/10 P9011 P9011 P9011 006 0390 2670
04016121 COLD AGGL TITER 83.00 06/30/10 86157 86157 86157 006 0302 2608
04016154 VDRL QUANT CSF 60.00 06/30/10 86592 86592 86592 006 0302 2608
04016165 HSV TYPE 1/2 GLYCOPROT G AB N/C E 06/30/10 006 0302 2608
04016166 HSV TYPE 1 GLYCOPROTEIN G AB 92.00 C 06/30/10 86695 86695 86695 006 0302 2608
04016167 HSV TYPE 2 GLYCOPROTEIN G AB 92.00 C 06/30/10 86696 86696 86696 006 0302 2608
04016175 TESTOST-FREE,TOTAL,SHBG MALE N/C E 06/30/10 006 0301 2608
04016176 TESTOSTERONE LEVEL 51.00 C 06/30/10 84403 84403 84403 006 0301 2608
04016177 SEX HORMONE BINDING GLOBULIN 49.00 C 06/30/10 84270 84270 84270 006 0301 2608
04016180 TESTOST-FREE,TOTAL,SHBG FEMALE N/C E 06/30/10 006 0301 2608
04016181 TESTOSTERONE LEVEL 58.00 C 06/30/10 84403 84403 84403 006 0301 2608
04016182 SEX HORMONE BINDING GLOBULIN 102.00 C 06/30/10 84270 84270 84270 006 0301 2608
04016241 DOUBLE FRESH FROZ.PL.POC 393.00 06/30/10 P9017 P9017 P9017 006 0390 2670
04016289 MATERNAL STUDIES N/C E 06/30/10 006 0300 2670
04016290 BLOOD TYPING; ABO 64.00 C 06/30/10 86900 86900 86900 006 0300 2670
04016291 RH(D) 66.00 C 06/30/10 86901 86901 86901 006 0300 2670
04016292 ANTIBODY SCREEN 156.00 C 06/30/10 86850 86850 86850 006 0300 2670
04016352 RBC AG TYPING 91.00 06/30/10 86903 86903 86903 006 0300 2670
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 88
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04016370 PLATELET COMPATIBILITY TESTING 141.00 06/30/10 86922 86922 86922 006 0300 2670
04016377 BLOOD COMPONENT IRRADIATION 108.00 06/30/10 86945 86945 86945 006 0300 2670
04016378 SPEC.DONOR DRAWING 95.00 06/30/10 86945 86945 86945 006 0300 2670
04016380 SPECIFIC DONOR DRAWING N/C E 06/30/10 006 0300 2670
04016381 DIRECTED DONOR TRACKING 89.00 C 06/30/10 86999 86999 86999 006 0300 2670
04016382 IRRADIATION OF BLOOD PROC 94.00 C 06/30/10 86945 86945 86945 006 0300 2670
04016431 GRANULOCYTE,PHERESIS,IRRAD 2012.00 06/30/10 P9050 P9050 P9050 006 0385 2670
04016434 PLTS,PHERESIS,HLA MATCH,LKRD,I 2327.00 06/30/10 P9052 P9052 P9052 006 0380 2670
04016436 CULTURE-URINE CLEAN VOID 95.00 06/30/10 87086 87086 87086 006 0306 2639
04016437 CRYOPPT,POOLED 487.00 06/30/10 P9012 P9012 P9012 006 0390 2670
04016440 VOLUME REDUCTION,BLD PRODUCTS 51.00 06/30/10 86960 86960 86960 006 0390 2670
04016444 CULTURE-URINE CATH 95.00 06/30/10 87086 87086 87086 006 0306 2639
04016451 CULTURE-STERILITY 152.00 06/30/10 87070 87070 87070 006 0306 2639
04016469 CULTURE-URINE CYSTO 95.00 06/30/10 87086 87086 87086 006 0306 2639
04016477 CULTURE ENV + INSTRU 152.00 06/30/10 87070 87070 87070 006 0306 2639
04016500 RBC, SYRINGE-PEDS 190.00 06/30/10 P9011 P9011 P9011 006 0390 2670
04016503 PLASMA, SYRINGE-PEDS 205.00 06/30/10 P9017 P9017 P9017 006 0383 2670
04016506 PLATELETS, SYRINGE-PEDS 253.00 06/30/10 P9019 P9019 P9019 006 0384 2670
04016509 PLATELETS LR, SYRG PEDS 244.00 06/30/10 P9031 P9031 P9031 006 0384 2670
04016512 PLATELETS PHER LR-SYRG 338.00 06/30/10 P9035 P9035 P9035 006 0384 2670
04016618 SUSCEPTIBILITY-MIC(VITEK) 109.00 06/30/10 87186 87186 87186 006 0306 2639
04016634 BACTERIAL AGGLUTINATION 39.00 06/30/10 87147 87147 87147 006 0306 2639
04016642 DIR SMEAR: GIEMSA STAIN 70.00 06/30/10 87207 87207 87207 006 0300 2639
04016659 VIRUS ISOLATION-BLD/TISSUE 253.00 06/30/10 87254 87254 87254 006 0306 2639
04016675 SPECIAL HANDLING 17.00 06/30/10 87999 87999 87999 006 0306 2639
04016683 CBC WITH AUTO DIFFERENTIAL 126.00 06/30/10 85025 85025 85025 006 0300 2613
04016725 NASAL SMEAR EOS 55.00 06/30/10 89190 89190 89190 006 0305 2608
04016741 RBC OSMOTIC FRAGILITY 171.00 06/30/10 85555 85555 85555 006 0305 2608
04016758 SPECIFIC GRAVITY 31.00 06/30/10 84315 84315 84315 006 0301 2613
04018374 OVA + PARASITES-PINWORM 94.00 06/30/10 87172 87172 87172 006 0306 2639
04018382 PARASITES, BLOOD 126.00 06/30/10 87207 87207 87207 006 0306 2639
04018408 DIR SMEAR-TRICHOMONAS WET PREP 65.00 06/30/10 87210 87210 87210 006 0306 2639
04018411 TRICHOMONAS CULTURE N/C E 06/30/10 006 0306 2639
04018412 CULTURE, TRICHOMONAS 78.00 C 06/30/10 87081 87081 87081 006 0306 2639
04018413 WET MOUNTING FOR PARASITES 65.00 C 06/30/10 87210 87210 87210 006 0306 2639
04018416 OVA + PARASITES-WORM ID 81.00 06/30/10 87169 87169 87169 006 0306 2639
04018418 M TUBERCULOSIS DIRECT-MTD 137.00 06/30/10 87555 87555 87555 006 0306 2639
04018424 GENTAMICIN 160.00 06/30/10 80170 80170 80170 006 0300 2612
04018432 RBC FOLATE 140.00 06/30/10 82747 82747 82747 006 0301 2608
04018465 PROLACTIN STIM-SUP 216.00 06/30/10 84146 84146 84146 006 0301 2612
04018500 ACID PHOSPHATASE,TOTAL 64.00 06/30/10 84060 84060 84060 006 0301 2608
04018506 APOLIPROPROTEIN - A-1 97.00 06/30/10 82172 82172 82172 006 0301 2608
04018509 ASPERGILLUS FUMIGATUS 52.00 06/30/10 86003 86003 86003 006 0302 2608
04018512 ASPERGILLUS GALACTOMANNAN AG 287.00 06/30/10 87305 87305 87305 006 0306 2608
04018515 BETA-HYDROXYBUTYRIC ACID 89.00 06/30/10 82010 82010 82010 006 0301 2608
04018518 CORTISOL,FREE SERUM 138.00 06/30/10 82530 82530 82530 006 0301 2608
04018521 CYCLIC CITRULLINATED PEP AB 119.00 06/30/10 86200 86200 86200 006 0300 2608
04018524 FRUCTOSAMINE 79.00 06/30/10 82985 82985 82985 006 0301 2608
04018527 MAGNESIUM, FECAL 78.00 06/30/10 83735 83735 83735 006 0301 2608
04018530 METANAPHRINES,PLASMA 105.00 06/30/10 83835 83835 83835 006 0301 2608
04018533 MYCOPHENOLIC ACID 146.00 06/30/10 80299 80299 80299 006 0301 2608
04018536 PHOSPHORUS, STOOL 57.00 06/30/10 84100 84100 84100 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 89
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04018539 SETRALINE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04018542 SULFONYLUREA HYPOGLYCEMIA 146.00 06/30/10 82486 82486 82486 006 0301 2608
04018545 TRANSGLUTAMINASE AB,IGA-TISSUE 80.00 06/30/10 83516 83516 83516 006 0301 2608
04018548 TRANSGLUTAMINASE AB,IGG-TISSUE 120.00 06/30/10 83516 83516 83516 006 0301 2608
04018551 TECHOIC ACID ANTIBODY 65.00 06/30/10 86329 86329 86329 006 0302 2608
04018554 TOXOPLASMA GONDII BY PCR 385.00 06/30/10 87799 87799 87799 006 0302 2608
04018600 A1 ANTITRYPSIN PHENOTYPE N/C E 06/30/10 006 0301 2608
04018601 A1 ANTITRYPSIN TOTAL 41.00 C 06/30/10 82103 82103 82103 006 0301 2608
04018602 A1 ANTITRYPSIN PHENO 41.00 C 06/30/10 82104 82104 82104 006 0301 2608
04018610 AMYLASE ISOENZYMES N/C E 06/30/10 006 0301 2608
04018611 AMYLASE,PANCREATIC 33.00 C 06/30/10 82150 82150 82150 006 0301 2608
04018612 AMYLASE,SALIVARY 33.00 C 06/30/10 8215091 8215091 8215091 006 0301 2608
04018620 APOE,CARDIOVASC RISK N/C E 06/30/10 006 0301 2608
04018621 APOE, ISOLATION/EXTRACTION 46.00 C 06/30/10 83891 83891 83891 006 0301 2608
04018622 APOE,NUC ACID AMPLIFICATION 144.00 C 06/30/10 83898 83898 83898 006 0301 2608
04018623 APOE,NUC ACID PROBE#1 89.00 C 06/30/10 83896 83896 83896 006 0301 2608
04018624 APOE,NUC ACID PROBE#2 89.00 C 06/30/10 83896 83896 83896 006 0301 2608
04018630 AFP DOUBLE N/C E 06/30/10 006 0301 2608
04018631 ALPHA-FETOPROTEIN,SERUM 135.00 C 06/30/10 82105 82105 82105 006 0301 2608
04018632 HCG,QUANTITATIVE 160.00 C 06/30/10 84702 84702 84702 006 0301 2608
04018640 HYPERSENS PNEUMONITIS I N/C E 06/30/10 006 0302 2608
04018641 ASPERGILLUS FUMIGATUS#1 20.00 C 06/30/10 86331 86331 86331 006 0302 2608
04018642 ASPERGILLUS FUMIGATUS#6 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018643 AUREOBASIDIUM PULLULANS 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018644 PIGEON SERUM 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018645 MICROPOLYSPORA FAENI 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018646 THERMOATINOMYCES VULGARIS#1 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018650 HYPERSENS PNEUMONITIS II N/C E 06/30/10 006 0302 2608
04018651 ASPERGILLUS FLAVUS 20.00 C 06/30/10 86331 86331 86331 006 0302 2608
04018652 ASPERGILLUS FUMIGATUS#2 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018653 ASPERGILLUS FUMIGATUS#3 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018654 SACCHOROMONOSPORA VIRIDIS 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018655 THERMOACTINOMYCES CANDIDUS 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018656 THERMOACTINOMYCES SACCHARI 20.00 C 06/30/10 8633191 8633191 8633191 006 0302 2608
04018660 IGA SUBCLASSES N/C E 06/30/10 006 0302 2608
04018661 IGA, GAMMAGLOBULIN 45.00 C 06/30/10 82784 82784 82784 006 0301 2608
04018662 IGA1 IMMUNODIFFUSION 51.00 C 06/30/10 82787 82787 82787 006 0302 2608
04018663 IGA2 IMMUNODIFFUSION 51.00 C 06/30/10 8278791 8278791 8278791 006 0302 2608
04018670 NEUTROPHIL OXIDTVE BURST ASSAY 278.00 06/30/10 86352 86352 86352 006 0311 2608
04018671 NOBA,STIMULATED 152.00 06/30/10 88184 88184 88184 006 0311 2608
04018672 NOBA,UNSTIMULATED 100.00 06/30/10 88185 88185 88185 006 0311 2608
04018673 NEUTROPHIL OXID,INTERPRETATION 26.00 06/30/10 88187 88187 88187 006 0311 2608
04018680 PAROXYSMAL NOCT HEMOGLOBINURIA N/C E 06/30/10 006 0311 2608
04018681 CD55 152.00 C 06/30/10 88184 88184 88184 006 0311 2608
04018682 CD59 100.00 C 06/30/10 88185 88185 88185 006 0311 2608
04018690 SACCHAROMYCESCEREVISIAE AB N/C E 06/30/10 006 0302 2608
04018691 S. CEREVISIAE IGG AB 60.00 C 06/30/10 86671 86671 86671 006 0302 2608
04018692 S. CEREVISIAE IGA AB 60.00 C 06/30/10 8667191 8667191 8667191 006 0302 2608
04018700 DRUG SCREEN(MECONIUM) N/C E 06/30/10 006 0301 2608
04018701 AMPHETAMINES(MECONIUM) 26.00 C 06/30/10 G0431 G0431 G0431 006 0301 2608
04018702 COCAINES(MECONIUM) 26.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04018703 OPIATES(MECONIUM) 26.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 90
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04018704 PHENCYCLIDINE(MECONIUM) 26.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04018705 CANNABINOIDS(MECONIUM) 26.00 C 06/30/10 G043191 G043191 G043191 006 0301 2608
04018706 DRG SCRN TISSUE PREP 26.00 C 06/30/10 80103 80103 80103 006 0301 2608
04019000 SINGLE STRANDED DNA AB, IGG 128.00 06/30/10 86226 86226 86226 006 0302 2608
04019001 DOUBLE STRANDED DNA AB,IGG 57.00 06/30/10 86225 86225 86225 006 0302 2608
04019007 ANTI-SM-(SMITH), IGG 118.00 06/30/10 86235 86235 86235 006 0302 2608
04019008 ANTI-RNP, IGG 118.00 06/30/10 86235 86235 86235 006 0302 2608
04019009 ANTI-SSA-(RO), IGG 118.00 06/30/10 86235 86235 86235 006 0302 2608
04019010 ANTI-SSB-(LA), IGG 118.00 06/30/10 86235 86235 86235 006 0302 2608
04019011 HISTONE ANTIBODY,IGG 118.00 06/30/10 86235 86235 86235 006 0302 2608
04019012 SCL70 ANTIBODY, IGG 118.00 06/30/10 86235 86235 86235 006 0302 2608
04019017 CENTROMERE ANTIBODY, IGG 112.00 06/30/10 83516 83516 83516 006 0302 2608
04019021 CARDIOLIPIN ANTIBODY, IGM 149.00 06/30/10 86147 86147 86147 006 0302 2608
04019022 CARDIOLIPIN ANTIBODY IGG 149.00 06/30/10 86147 86147 86147 006 0302 2608
04019023 CARDIOLIPIN ANTIBODY IGA 149.00 06/30/10 86147 86147 86147 006 0302 2608
04019031 COMPLEMENT ACTIVITY CH50 162.00 06/30/10 86162 86162 86162 006 0302 2608
04019035 ANA SCREEN, IGG 54.00 06/30/10 86038 86038 86038 006 0302 2608
04019039 RHEUMATOID FACTOR 75.00 06/30/10 86431 86431 86431 006 0302 2608
04019042 BETA 2 GLYCOPROTEIN AB,IGA 113.00 06/30/10 86146 86146 86146 006 0302 2608
04019050 B2 GLYCOPROTEIN I AB N/C E 06/30/10 006 0302 2608
04019051 ANTI-B2 GPI,IGM 113.00 C 06/30/10 86146 86146 86146 006 0302 2608
04019052 ANTI-B2 GPI, IGG 113.00 C 06/30/10 8614691 8614691 8614691 006 0302 2608
04019060 ANA COMPREHENSIVE PANEL N/C E 06/30/10 006 0302 2608
04019061 ANA AB TITER 112.00 C 06/30/10 86039 86039 86039 006 0302 2608
04019062 DS DNA AB, IGG 26.00 C 06/30/10 86225 86225 86225 006 0302 2608
04019063 EXTRACTABLE NUCLEAR AB SCREEN 67.00 C 06/30/10 86235 86235 86235 006 0302 2608
04019064 ANTI-SM-(SMITH),IGG 118.00 C 06/30/10 8623559 8623559 8623559 006 0302 2608
04019065 ANTI-RNP, IGG 118.00 C 06/30/10 8623559 8623559 8623559 006 0302 2608
04019066 ANTI-SSA-(RO), IGG 118.00 C 06/30/10 8623559 8623559 8623559 006 0302 2608
04019067 ANTI-SSB-(LA),IGG 118.00 C 06/30/10 8623559 8623559 8623559 006 0302 2608
04020008 URINALYSIS 71.00 06/30/10 81001 81001 81001 006 0300 2613
04020016 BLOOD COUNT 90.00 06/30/10 85027 85027 85027 006 0305 2613
04020834 TOBRAMYCIN 153.00 06/30/10 80200 80200 80200 006 0300 2608
04020867 GEL ELECT-CSF 161.00 06/30/10 83916 83916 83916 006 0301 2608
04020881 CHOLESTEROL-SH 10.00 06/30/10 82465 82465 82465 006 0301 2612
04020885 AMNIOTIC FLUID L/S AND PG N/C E 06/30/10 006 0301 2608
04020886 L/S RATIO, AMNIOTIC FLUID 90.00 C 06/30/10 83661 83661 83661 006 0301 2608
04020887 PHOSPHATYDYLGLYCEROL 154.00 C 06/30/10 84081 84081 84081 006 0301 2608
04020909 DEHYDROEPIANDROST 66.00 06/30/10 82626 82626 82626 006 0301 2608
04020917 RBC PROTOPORPHYRIN 100.00 06/30/10 84202 84202 84202 006 0301 2608
04020920 CMV QUANT BY PCR 363.00 06/30/10 87497 87497 87497 006 0306 2651
04020923 EBV QUANT BY PCR 152.00 06/30/10 87799 87799 87799 006 0306 2608
04020926 BKV QUANT BY PCR 259.00 06/30/10 87799 87799 87799 006 0306 2651
04020929 PARVOVIRUS QUANT BY PCR 385.00 06/30/10 87799 87799 87799 006 0306 2608
04020932 ADENOVIRUS QUANT BY PCR 385.00 06/30/10 87799 87799 87799 006 0306 2608
04020935 VZV QUANT BY PCR 385.00 06/30/10 87799 87799 87799 006 0306 2608
04020938 JCV QUANT BY PCR 385.00 06/30/10 87799 87799 87799 006 0306 2608
04020940 HSV TYPE 1 AND 2 QUANT BY PCR N/C E 06/30/10 006 0306 2608
04020941 HSV TYPE 1 QUANT BY PCR 198.00 C 06/30/10 87530 87530 87530 006 0306 2608
04020942 HSV TYPE 2 QUANT BY PCR 198.00 C 06/30/10 8753091 8753091 8753091 006 0306 2608
04020990 TB SUSC.TEST-EACH AGENT 69.00 06/30/10 87188 87188 87188 006 0306 2639
04020993 STAPH ID - PNA FISH 137.00 06/30/10 87149 87149 87149 006 0306 2639
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 91
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04020996 CANDIDA ID - PNA FISH 167.00 06/30/10 87149 87149 87149 006 0306 2639
04020999 ENTEROCOCCUS ID - PNA FISH 144.00 06/30/10 87800 87800 87800 006 0306 2639
04021000 ADENOVIRUS ANTIBODIES N/C E 06/30/10 006 0302 2608
04021001 ADENOVIRUS IGG AB 39.00 C 06/30/10 86603 86603 86603 006 0302 2608
04021002 ADENOVIRUS IGM AB 39.00 C 06/30/10 8660391 8660391 8660391 006 0302 2608
04021010 INFLUENZA ANTIBODIES N/C E 06/30/10 006 0302 2608
04021011 INFLUENZA A IGG AB 23.00 C 06/30/10 86710 86710 86710 006 0302 2608
04021012 INFLUENZA A IGM AB 23.00 C 06/30/10 8671091 8671091 8671091 006 0302 2608
04021013 INFLUENZA B IGG AB 23.00 C 06/30/10 8671091 8671091 8671091 006 0302 2608
04021014 INFLUENZA B IGM AB 23.00 C 06/30/10 8671091 8671091 8671091 006 0302 2608
04021020 PARAINFLUENZA ANTIBODIES N/C E 06/30/10 86790 86790 86790 006 0302 2608
04021021 PARAINFLUENZA 1 IGG AB 26.00 C 06/30/10 8679091 8679091 8679091 006 0302 2608
04021022 PARAINFLUENZA 1 IGM AB 26.00 C 06/30/10 8679091 8679091 8679091 006 0302 2608
04021023 PARAINFLUENZA 2 IGM AB 26.00 C 06/30/10 8679091 8679091 8679091 006 0302 2608
04021024 PARAINFLUENZA 2 IGM AB 26.00 C 06/30/10 8679091 8679091 8679091 006 0302 2608
04021025 PARAINFLUENZA 3 IGG AB 26.00 C 06/30/10 8679091 8679091 8679091 006 0302 2608
04021026 PARAINFLUENZA 3 IGM AB 26.00 C 06/30/10 8679091 8679091 8679091 006 0302 2608
04021030 RSV ANTIBODIES N/C E 06/30/10 006 0302 2608
04021031 RSV IGG AB 41.00 C 06/30/10 86756 86756 86756 006 0302 2608
04021032 RSV IGM AB 41.00 C 06/30/10 8675691 8675691 8675691 006 0302 2608
04021040 COXSACKIE B VIRUS AB N/C E 06/30/10 006 0320 2608
04021041 COXSACKIE B1 AB 28.00 C 06/30/10 86658 86658 86658 006 0302 2608
04021042 COXSACKIE B2 AB 28.00 C 06/30/10 8665891 8665891 8665891 006 0302 2608
04021043 COXSACKIE B3 AB 28.00 C 06/30/10 8665891 8665891 8665891 006 0302 2608
04021044 COXSACKIE B4 AB 28.00 C 06/30/10 8665891 8665891 8665891 006 0302 2608
04021045 COXSACKIE B5 AB 28.00 C 06/30/10 8665891 8665891 8665891 006 0302 2608
04021046 COXSACKIE B6 AB 92.00 C 06/30/10 8665891 8665891 8665891 006 0302 2608
04021050 PACE PROFILE-QUAD SCREEN N/C E 06/30/10 006 0301 2608
04021051 ALPHA-FETOPROTEIN;SERUM 135.00 C 06/30/10 82105 82105 82105 006 0301 2608
04021052 ESTRIOL 110.00 C 06/30/10 82677 82677 82677 006 0301 2608
04021053 HCG QUANT 160.00 C 06/30/10 84702 84702 84702 006 0301 2608
04021054 INHIBIN A 78.00 C 06/30/10 86336 86336 86336 006 0300 2608
04025452 IMMUNO FIX. URINE 170.00 06/30/10 86335 86335 86335 006 0302 2608
04025478 IMMUNO FIX. SERUM 161.00 06/30/10 84160 84160 84160 006 0302 2608
04028226 ABO & ISO AGGLUTININ N/C E 06/30/10 006 0301 2670
04028227 BLOOD TYPING; ABO 64.00 C 06/30/10 86900 86900 86900 006 0300 2670
04028228 TITER 155.00 C 06/30/10 86886 86886 86886 006 0300 2670
04029819 DIRECT SMEAR-PAS FOR FUNGUS 149.00 06/30/10 88312 88312 88312 006 0310 2639
04031253 TOXOCARA ANTIBODIES 127.00 06/30/10 86682 86682 86682 006 0302 2608
04034001 FREE VALPROIC ACID 134.00 06/30/10 80164 80164 80164 006 0300 2608
04034004 INHIBIN LEVEL 115.00 06/30/10 86336 86336 86336 006 0300 2608
04034007 PTH RELATED PEPTIDE 101.00 06/30/10 83519 83519 83519 006 0301 2608
04034010 17 OH PREGNENOLONE 123.00 06/30/10 84143 84143 84143 006 0301 2608
04034014 ACE (CSF) 125.00 06/30/10 82164 82164 82164 006 0301 2608
04034017 BRUCELLA ANTIBODY 82.00 06/30/10 86622 86622 86622 006 0302 2608
04034019 CLOMIPRAMINE 176.00 06/30/10 82492 82492 82492 006 0301 2608
04034022 ENDOMYSIAL ANTIBODY 59.00 06/30/10 83516 83516 83516 006 0300 2608
04034025 LDL, DIRECT 98.00 06/30/10 83721 83721 83721 006 0301 2612
04034028 LIPOPROTEIN(A) 170.00 06/30/10 83695 83695 83695 006 0301 2608
04034031 PROINSULIN 95.00 06/30/10 84206 84206 84206 006 0301 2608
04034034 VITAMIN B1 LEVEL 151.00 06/30/10 84425 84425 84425 006 0301 2608
04034037 VITAMIN C (PLASMA) 101.00 06/30/10 82180 82180 82180 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 92
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04035718 HIV1 GEL ELECT SEPARATION #3 33.00 06/30/10 83894 83894 83894 006 0301 2651
04035740 HIV-1 GENOTYPING 1213.00 06/30/10 87901 87901 87901 006 0306 2651
04035770 P210 B3A2-QANTITATIVE PCR N/C E 06/30/10 006 0301 2651
04035771 P210 ISOLATION/EXTRACTION 220.00 C 06/30/10 83891 83891 83891 006 0301 2651
04035772 P210 AMPLI NUCLEIC ACID#1 217.00 C 06/30/10 83898 83898 83898 006 0301 2651
04035773 P210 AMPLI NUCLEIC ACID#2 217.00 C 06/30/10 8389891 8389891 83898 006 0301 2651
04035774 P210 NUCLEIC ACID PROBE #1 191.00 C 06/30/10 83896 83896 83896 006 0301 2651
04035775 P210 NUCLEIC ACID PROBE#2 191.00 C 06/30/10 8389691 8389691 83896 006 0301 2651
04035780 P210 B2A2-QUANTITIVE PCR N/C E 06/30/10 006 0301 2651
04035781 P210 ISOLATION/EXTRACTION 220.00 C 06/30/10 83891 83891 838912B 006 0300 2651
04035782 P210 AMPLI NUCLEIC ACID#1 217.00 C 06/30/10 83898 83898 838982B 006 0301 2651
04035783 P210 AMPLI NUCLEIC ACID#2 217.00 C 06/30/10 8389891 8389891 8389891 006 0301 2651
04035784 P210 NUCLEIC ACID PROBE#1 191.00 C 06/30/10 83896 83896 838962B 006 0301 2651
04035785 P210 NUCLEIC ACID PROBE#2 191.00 C 06/30/10 8389691 8389691 838962B 006 0301 2651
04035790 P190 ELA2-QUANTITTATIVE PCR N/C E 06/30/10 006 0301 2608
04035791 P190 ISOLATION/EXTRACTION 104.00 C 06/30/10 83891 83891 838912B 006 0301 2608
04035792 P190 AMPLI NUCLEIC ACID #1 140.00 C 06/30/10 83898 83898 83898 006 0301 2608
04035793 P190 AMPLI NUCLEIC ACID #2 140.00 C 06/30/10 8389891 8389891 8389891 006 0301 2608
04035794 P190 NUCLEIC ACID PROBE#1 136.00 C 06/30/10 83896 83896 83896 006 0301 2608
04035795 P190 NUCLEIC ACID PROBE#2 136.00 C 06/30/10 8389691 8389691 8389691 006 0301 2608
04035797 P190 EZYMATIC DIGESTION, EACH 80.00 C 06/30/10 83892 83892 83892 006 0301 2608
04035798 P190 REVERSE TRANSCRIPTION 59.00 C 06/30/10 83902 83902 83902 006 0301 2608
04035799 P190SEPARATION BY GEL EL 46.00 C 06/30/10 83894 83894 83894 006 0301 2608
04035850 RAS MUTATION N/C E 06/30/10 006 0300 2651
04035851 TISSUE PREP/DISSECT/EXAM 108.00 C 06/30/10 88387 88387 88387 006 0300 2651
04035852 ISOLATION / EXTRACTION 1 34.00 C 06/30/10 83891 83891 83891 006 0300 2651
04035853 ISOLATION / EXTRACTION 2 34.00 C 06/30/10 8389191 8389191 8389191 006 0300 2651
04035854 AMPLICATION,SNGLE PRIMER PAIR1 51.00 C 06/30/10 83898 83898 83898 006 0300 2651
04035855 AMPLICATION,SNGLE PRMER PAIR#2 51.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035856 MUTATION ID BY SEQ EA SEG 61.00 C 06/30/10 83904 83904 83904 006 0300 2608
04035860 BRAF MUTATION N/C E 06/30/10 006 0300 2651
04035861 TISSUE PREP/DISSECT/EXAM 108.00 C 06/30/10 88387 88387 88387 006 0300 2651
04035862 ISOLATION / EXTRACTION 1 34.00 C 06/30/10 83891 83891 83891 006 0300 2651
04035863 ISOLATION / EXTRACTION 2 34.00 C 06/30/10 8389191 8389191 8389191 006 0300 2651
04035864 AMPLI,SINGLE PRIMER PAIR 1 51.00 C 06/30/10 83898 83898 83898 006 0300 2651
04035865 AMPLI,SINGLE PRIMER PAIR 2 51.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035866 MUTATION ID BY SEQ EA SEGMNT 60.00 C 06/30/10 83904 83904 83904 006 0300 2651
04035871 TISSUE PREP/DISSECT/EXAM 108.00 C 06/30/10 88387 88387 88387 006 0300 2651
04035872 ISOLATION / EXTRACTION 1 34.00 C 06/30/10 83891 83891 83891 006 0300 2651
04035873 ISOLATION / EXTRACTION 2 34.00 C 06/30/10 8389191 8389191 8389191 006 0300 2651
04035874 ISOLATION / EXTRACTION 3 34.00 C 06/30/10 8389191 8389191 8389191 006 0300 2651
04035875 ISOLATION / EXTRACTION 4 34.00 C 06/30/10 8389191 8389191 8389191 006 0300 2651
04035876 ISOLATION / EXTRACTION 5 34.00 C 06/30/10 8389191 8389191 8389191 006 0300 2651
04035877 AMPLICTN,SINGLE PRIMER PAIR 1 38.00 C 06/30/10 83898 83898 83898 006 0300 2651
04035878 AMPLI,SINGLE PRIMER PAIR 2 38.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035879 AMPLI,SINGLE PRIMER PAIR 3 38.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035880 AMPLI,SINGLE PRIMER PAIR 4 38.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035881 AMPLIC,SINGLE PRIMER PAIR 5 38.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035882 AMPLI,SINGLE PRIMER PAIR 6 38.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035883 AMPLI,SINGLE PRIMER PAIR 7 38.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035884 AMPLI,SINGLE PRIMER PAIR 8 38.00 C 06/30/10 8389891 8389891 8389891 006 0300 2651
04035885 MUTATION ID BY SEQ EA SEG 1 55.00 C 06/30/10 83904 83904 83904 006 0300 2651
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 93
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04035886 MUTATION ID BY SEQ EA SEG 2 55.00 C 06/30/10 8390491 8390491 8390491 006 0300 2651
04035887 MUTATION ID BY SEQ EA SEG 3 55.00 C 06/30/10 8390491 8390491 8390491 006 0300 2651
04035888 MUTATION ID BY SEQ EA SEG 4 55.00 C 06/30/10 8390491 8390491 8390491 006 0300 2651
04035890 BCR ABL MUTATION N/C E 06/30/10 006 0300 2651
04035891 ISOLATION / EXTRACTION 1 117.00 C 06/30/10 83891 83891 83891 006 0300 2651
04035892 ISOLATION / EXTRACTION 2 117.00 C 06/30/10 83891 83891 83891 006 0300 2651
04035893 AMPLICATION,SGLE PRIMER PAIR 1 116.00 C 06/30/10 83898 83898 83898 006 0300 2651
04035894 AMPLICATION,SGLE PRIMER PAIR 2 116.00 C 06/30/10 83898 83898 83898 006 0300 2651
04035895 MUTATION ID BY SEQ EA SEG 174.00 C 06/30/10 83904 83904 83904 006 0300 2651
04036080 HIV QUAL BY PCR 137.00 06/30/10 87999 87999 87999 006 0306 2608
04036087 CHLAMYDIA CULTURE 152.00 06/30/10 87110 87110 87110 006 0306 2608
04036090 T AND B CELL SCREEN N/C E 06/30/10 006 0311 2613
04036091 FLOW CYTOMETRY,1ST MARKER 122.00 C 06/30/10 88184 88184 88184 006 0311 2613
04036092 FLOW CYTOMETRY,ADD'L MARKERS 122.00 C 06/30/10 88185 88185 88185 006 0311 2613
04036100 T-CELL SCREEN N/C E 06/30/10 006 0311 2613
04036101 FLOW CYTOMETRY, 1ST MARKER 122.00 C 06/30/10 88184 88184 88184 006 0311 2613
04036102 FLOW CYTOMETRY,ADD'L MARKERS 122.00 C 06/30/10 88185 88185 88185 006 0311 2613
04036103 VOID 3.00 06/30/10 006 0311 2613
04036110 LYMPHOMA PHENOTYPING 1 N/C E 06/30/10 006 0311 2613
04036111 FLOW CYTOMETRY, 1ST MARKER 36.00 C 06/30/10 88184 88184 88184 006 0311 2613
04036112 FLOW CYTOMETRY, ADD'L MARKERS 36.00 C 06/30/10 88185 88185 88185 006 0311 2613
04036113 FLOW CYTOMETRY,INTERP 78.00 C 06/30/10 88189 88189 88189 006 0311 2613
04036120 LEUKEMIA PHENOTYPING 1 N/C E 06/30/10 006 0311 2613
04036121 FLOW CYTOMETRY, 1ST MARKER 36.00 C 06/30/10 88184 88184 88184 006 0311 2613
04036122 FLOW CYTOMETRY, ADD'L MARKERS 36.00 C 06/30/10 88185 88185 88185 006 0311 2613
04036123 FLOW CYTOMETRY,INTERP 78.00 C 06/30/10 88189 88189 88189 006 0311 2613
04036130 LEUKEMIA PHENOTYPING 2 N/C E 06/30/10 006 0311 2613
04036131 FLOW CYTOMETRY,1ST MARKER 36.00 C 06/30/10 88184 88184 88184 006 0311 2613
04036132 FLOW CYTOMETRY,ADD'L MARKERS 36.00 C 06/30/10 88185 88185 88185 006 0311 2613
04036135 FLOW CYTOMETRY, ADD'L MARKERS 36.00 06/30/10 88185 88185 88185 006 0311 2613
04036140 LEUK/LYMPHOMA PHENOTYPING N/C E 06/30/10 006 0311 2613
04036141 FLOW CYTOMETRY, 1ST MARKER 36.00 C 06/30/10 88184 88184 88184 006 0311 2613
04036142 FLOW CYTOMETRY,INTERP 78.00 C 06/30/10 88189 88189 88189 006 0311 2613
04036150 T AND B CELL SCREEN N/C E 06/30/10 006 0302 2613
04036151 CD4, CD8, CD4/8 RATIO 122.00 C 06/30/10 86360 86360 86360 006 0302 2613
04036152 CD3, TOTAL B LYMPHOCYTES 122.00 C 06/30/10 86359 86359 86359 006 0302 2613
04036153 CD3+/CD16-,C56+, NK CELLS 122.00 C 06/30/10 86357 86357 86357 006 0302 2613
04036154 CD19, TOTAL B-LYMPHOCYTES 122.00 C 06/30/10 86355 86355 86355 006 0302 2613
04036160 T-CELL SCREEN N/C E 06/30/10 006 0302 2613
04036161 CD4, CD8, CD4/8 RATIO 122.00 C 06/30/10 86360 86360 86360 006 0302 2613
04036162 CD3, TOTAL B LYMPHOCYTES 122.00 C 06/30/10 86359 86359 86359 006 0302 2613
04036657 GAMMA GT 67.00 06/30/10 82977 82977 82977 006 0301 2612
04036665 FREE FATTY ACIDS 128.00 06/30/10 82725 82725 82725 006 0301 2608
04036673 INTRINSIC FACT.AB 115.00 06/30/10 86340 86340 86340 006 0302 2608
04036681 INSULIN ANTIBODY 159.00 06/30/10 86337 86337 86337 006 0302 2608
04036699 REVERSE T3 82.00 06/30/10 84482 84482 84482 006 0301 2608
04036710 APOLIPOPROTEIN B/A1 RATIO N/C E 06/30/10 006 0300 2608
04036711 APOLIPOPROTEIN B 40.00 C 06/30/10 82172 82172 82172 006 0300 2608
04036712 APOLIPOPROTEIN A 40.00 C 06/30/10 8217291 8217291 8217291 006 0300 2608
04036715 TRICYCLIC QUANT AND ID 98.00 06/30/10 80100 80100 80100 006 0300 2608
04036720 THIOPURINE METABOLITE N/C E 06/30/10 006 0300 2608
04036721 METABOLITE 6-TGN 378.00 C 06/30/10 82491 82491 82491 006 0300 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 94
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04036722 METABOLITE 6-MMPN 378.00 C 06/30/10 8249191 8249191 8249191 006 0300 2608
04036725 POSACONAZOLE SERUM 175.00 06/30/10 82491 82491 82491 006 0300 2608
04036728 VORICONAZOLE SERUM 148.00 06/30/10 80299 80299 80299 006 0300 2608
04036772 DISOPRAMIDE (NORPACE) 52.00 04/26/10 80299 80299 80299 006 0300 2608
04036871 HEP BE AG 87.00 06/30/10 87350 87350 87350 006 0306 2608
04036889 HEP BE AB 86.00 06/30/10 86707 86707 86707 006 0302 2608
04036892 HEP B SURF AB,QUANT 99.00 06/30/10 86317 86317 86317 006 0302 2608
04036897 RUBELLA IGG AB-E1A 94.00 06/30/10 86762 86762 86762 006 0302 2612
04037135 TUPTAKE 129.00 06/30/10 84479 84479 84479 006 0301 2612
04037140 PROCESSING FEE ONLY 60.00 06/30/10 99001 99001 99001 006 0300 2615
04037201 VITAMIN B1,PLASMA 68.00 06/30/10 84425 84425 84425 006 0301 2608
04037204 VAP CHOLESTEROL 145.00 06/30/10 83701 83701 83701 006 0301 2608
04037207 NIACIN 140.00 06/30/10 84591 84591 84591 006 0301 2608
04037210 GHB, URINE 185.00 06/30/10 80100 80100 80100 006 0301 2608
04037213 GHB 185.00 06/30/10 80100 80100 80100 006 0301 2608
04037216 ESTRIOL 46.00 06/30/10 82677 82677 82677 006 0301 2608
04037219 DEOXYCORTICOSTERONE 185.00 06/30/10 82633 82633 82633 006 0301 2608
04037222 HPV DNA PROBE(DIGENE) 153.00 06/30/10 87621 87621 87621 006 0300 2608
04037225 B.PERTUSSIS AB,IGM 68.00 06/30/10 86615 86615 86615 006 0302 2608
04037230 B.PERT AB,IGG AND IGM N/C E 06/30/10 86615 86615 006 0302 2608
04037231 B.PERTUSSIS AB,IGG 107.00 C 06/30/10 86615 86615 86615 006 0302 2608
04037232 B.PERTUSSIS AB,IGM 107.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04037240 B.PERT AB,IGG AND IGA N/C E 06/30/10 86615 86615 86615 006 0302 2608
04037241 B.PERTUSSIS AB,IGG 107.00 C 06/30/10 86615 86615 86615 006 0302 2608
04037242 B.PERTUSSIS AB,IGA 68.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04037245 B.PERT AB, IGA,IGG,IGM N/C E 06/30/10 86615 86615 86615 006 0302 2608
04037246 B.PERTUSSIS AB,IGA 107.00 C 06/30/10 86615 86615 86615 006 0302 2608
04037247 B.PERTUSSIS AB,IGG 107.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04037248 B.PERTUSSIS AB,IGM 68.00 C 06/30/10 8661591 8661591 8661591 006 0302 2608
04037255 FLUNITRAZE AND METAB 388.00 06/30/10 G0431 G0431 G0431 006 0301 2608
04037256 FLUNITRAZEPAM 82.00 06/30/10 80101 80101 80101 006 0301 2608
04037276 REDUCING SUBSTANCES-STOOL 30.00 06/30/10 81002 81002 81002 006 0300 2608
04037300 IMMUNOFIX,ELECTROPHOR N/C E 06/30/10 006 0301 2608
04037301 IMMUNOGLOBULIN G 21.00 C 06/30/10 82784 82784 82784 006 0301 2608
04037302 IMMUNOGLOBULIN A 21.00 C 06/30/10 8278491 8278491 8278491 006 0301 2608
04037303 IMMUNOGLOBULIN M 21.00 C 06/30/10 8278491 8278491 8278491 006 0301 2608
04037304 PROTEIN ELECT-SER 34.00 C 06/30/10 84165 84165 84165 006 0301 2608
04037305 IMMUNOFIX. SERUM 63.00 C 06/30/10 86334 86334 86334 006 0302 2608
04037306 PROTEIN BY REFRACT 20.00 C 06/30/10 84160 84160 84160 006 0300 2608
04037310 IMMUNOFIX,ELECTROPHOR,UR N/C E 06/30/10 006 0301 2608
04037311 PROTEIN QUANT URINE 12.00 C 06/30/10 84156 84156 84156 006 0301 2608
04037312 IMMUNO FIX. URINE 82.00 C 06/30/10 86335 86335 86335 006 0302 2608
04037313 NEPHALOMETRY 1,UR 40.00 C 06/30/10 83883 83883 83883 006 0301 2608
04037314 NEPHALOMETRY 2,UR 40.00 C 06/30/10 8388391 8388391 8388391 006 0301 2608
04037320 PROTEIN ELECT-SER N/C E 06/30/10 006 0301 2608
04037321 PROTEIN ELECT-SER 32.00 C 06/30/10 84165 84165 84165 006 0301 2608
04037322 PROTEIN BY REFRACT 20.00 C 06/30/10 84160 84160 84160 006 0301 2608
04037340 HEAT SHOCK PROTEIN 70 488.00 06/30/10 84182 84182 84182 006 0301 2608
04038141 VZV IGG AB:IMMUNE STATUS 96.00 06/30/10 86787 86787 86787 006 0302 2612
04038880 HIV AB-CONFIRMATION WB-SH 182.00 06/30/10 86689 86689 86689 006 0302 2608
04038888 HIV-1,2 AB SCREEN-SH 20.00 06/30/10 86703 86703 86703 006 0302 2639
04040001 HLA ABC,CLASS I,SEROLOGIC 506.00 06/30/10 86813 86813 86813 006 0302 2619
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 95
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04040002 HLA DR/DQ,CLASS II,SEROLOGIC 502.00 06/30/10 86817 86817 86817 006 0302 2619
04040003 HLA CROSSMATCH 316.00 06/30/10 86805 86805 86805 006 0302 2619
04040004 RAPID ANTIBODY SCREEN(PRA) 277.00 06/30/10 86807 86807 86807 006 0302 2619
04040006 HLA TYPING,SINGLE ANTIGEN,B-27 183.00 06/30/10 86812 86812 86812 006 0302 2619
04040008 HLA TYPE,SNGL ANTIGEN,A LOCUS 238.00 06/30/10 86812 86812 86812 006 0302 2619
04040175 DONOR HLA ABC,CLASS I,SEROLOG 506.00 06/30/10 86813 86813 86813 006 0302 2619
04040179 DONOR HLA DR/DQ,CLASS II,SEROL 480.00 06/30/10 86817 86817 86817 006 0302 2619
04040183 DONOR CROSSMATCH 290.00 06/30/10 86805 86805 86805 006 0302 2619
04040187 DONOR HLA ABC CLASS I,DNA,LR 990.00 06/30/10 83891 83891 83891 006 0301 2619
04040191 DONOR HLA A CLASS I,DNA,LR,HR 542.00 06/30/10 83891 83891 83891 006 0301 2619
04040195 DONOR HLA B CLASS I,DNA,LR,HR 702.00 06/30/10 83891 83891 83891 006 0300 2619
04040199 DONOR HLA C CLASS I,DNA,LR,HR 519.00 06/30/10 83891 83891 83891 006 0301 2619
04040203 DONOR HLA DR-DQ CLSS II,DNA,LR 675.00 06/30/10 83891 83891 83891 006 0301 2619
04040207 DONOR HLA DR-B1 CLSS II,DNA,HR 730.00 06/30/10 83891 83891 83891 006 0300 2619
04040211 DONOR HLA DR-B3,4,5 CLASS II 469.00 06/30/10 83891 83891 83891 006 0301 2619
04040215 DONOR HLA DQ-B1 CLSS II,DNA,HR 469.00 06/30/10 83891 83891 83891 006 0301 2619
04050009 HLA TYPE SNGL ANTIGEN, B LOCUS 238.00 06/30/10 86812 86812 86812 006 0302 2619
04050010 HLA,ABC CLASS I,DNA,LR N/C E 06/30/10 006 0301 2619
04050011 ISOL/EXT HIGH PURIFNUCL ACID 54.00 C 06/30/10 83891 83891 83891 006 0301 2619
04050012 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050013 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050014 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050020 HLA ABC CLASS I,DNA,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050021 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050030 HLA ABC CLASS I,DNA,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050031 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050035 HLA ABC CLASS I,DNA,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050036 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050040 HLA A LOC CLASS I,LR N/C E 06/30/10 006 0301 2619
04050041 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050042 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050043 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050044 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050050 HLA CLASS I,LR ADD'L N/C E 06/30/10 006 0301 2619
04050051 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050060 HLA B LOCUS CLASS I,LR N/C E 06/30/10 006 0301 2619
04050061 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050062 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050063 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050064 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050070 HLA B CLASS I,LR ADD'L N/C E 06/30/10 006 0301 2619
04050071 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050080 HLA C LOC CLASS I,LR N/C E 06/30/10 006 0301 2619
04050081 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050082 AMPL NUCL ACID,PRIMER PR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050083 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050084 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050090 HLA DR-DQ CLASS II,LR N/C E 06/30/10 006 0301 2619
04050091 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050092 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050093 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050100 HLA DR-DQ CLASSII,LR,ADD'L N/C E 06/30/10 006 0301 2619
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 96
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04050101 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050110 HLA DR-B1 CLASS II, HR N/C E 06/30/10 006 0301 2619
04050111 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050112 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050113 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050130 HLA DR-B3,4,5 CLASS II,HR N/C E 06/30/10 006 0301 2619
04050131 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050132 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050133 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050140 HLA DQ-B1,CLASS II,HR N/C E 06/30/10 006 0301 2619
04050141 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050142 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050143 AMPL NUCL ACID,PRIMER PR.ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050144 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050146 HLA DQ-B1 CLASS II,HR ADD'L N/C E 06/30/10 006 0301 2619
04050147 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050150 HLA A LOC CLASS I,HR N/C E 06/30/10 006 0301 2619
04050151 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050153 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050154 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050160 HLA B LOCUS CLASSI,HR N/C E 06/30/10 006 0301 2619
04050161 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050162 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050163 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050170 HLA C LOC CLASS I,HR N/C E 06/30/10 006 0301 2619
04050171 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050172 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050173 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050180 HLA DQ-A1 CLASS II,HR N/C E 06/30/10 006 0301 2619
04050181 ISOL/EXTR HGHLY PURIF NUC ACID 54.00 C 06/30/10 83891 83891 83891 006 0301 2619
04050182 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050183 AMPL NUCL ACID,PRIMER PAIR 61.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050184 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050185 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050190 NARCOLEPSY SCREEN DQA1,DQB1 N/C E 06/30/10 006 0301 2619
04050191 ISOL/EXTR HGHLY PURIF NUC ACID 54.00 C 06/30/10 83891 83891 83891 006 0301 2619
04050192 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050193 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050194 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050195 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050196 NARCOLEPSY DQA1,DQB1 ADD'L N/C E 06/30/10 006 0301 2619
04050197 AMPL NUCL ACID,PRIMER PR ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050198 NARCOLEPSY DQA1,DQB1 ADD'L N/C E 06/30/10 006 0301 2619
04050199 AMPL NUCL ACID,PRIMER PR ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050200 RHEUMATOID ARTH SCR,DR4 LR N/C E 06/30/10 006 0301 2619
04050201 ISOL/EXTR HGHLY PURIF NUC ACID 54.00 C 06/30/10 83891 83891 83891 006 0301 2619
04050202 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050203 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050204 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050205 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050208 RHEUMATOID ARTH SCR,DR4 LR ADD N/C E 06/30/10 006 0301 2619
04050209 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 97
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04050210 HLA,A,B CLASS I,LR N/C E 06/30/10 006 0301 2619
04050211 ISOL/EXT HIGH PURIF NUCL ACID 54.00 C 06/30/10 83891 83891 83891 006 0301 2619
04050212 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050213 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050214 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050215 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050216 HLA A,B CLASS I,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050217 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050218 HLA A,B CLASS I,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050219 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050230 DONOR HLA ABC CLASS I,DNA,LR N/C E 06/30/10 006 0301 2619
04050231 ISOL/EXT HIGH PURIF NUCL ACID 54.00 C 06/30/10 83891 83891 83891 006 0301 2619
04050232 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050233 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050234 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050235 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050236 DONOR HLA ABC CLASS I,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050237 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050238 DONOR HLA ABC CLASS I,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050239 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050240 DONOR HLA ABC CLASS I,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050241 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050250 DONOR HLA A CLASS I,LR N/C E 06/30/10 006 0301 2619
04050251 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050252 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050253 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050254 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050255 DONOR HLA A CLASS I,LR ADD'L N/C E 06/30/10 006 0301 2619
04050256 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050260 DONOR HLA A CLASS I,DNA,HR N/C E 06/30/10 006 0301 2619
04050261 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050262 AMPL NUCL ACID, PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050263 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050270 DONOR HLA B CLASS I, LR N/C E 06/30/10 006 0301 2619
04050271 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050272 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050273 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050274 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050275 DONOR HLA B CLASS I,LR ADD'L N/C E 06/30/10 006 0301 2619
04050276 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050280 DONOR HLA B CLASS I,HR N/C E 06/30/10 006 0301 2619
04050281 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050282 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050283 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050290 DONOR HLA C CLASS I,LR N/C E 06/30/10 006 0301 2619
04050291 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050292 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050293 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050294 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050300 DONOR HLA C CLASS I, LR N/C E 06/30/10 006 0301 2619
04050301 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050302 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 98
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04050303 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050310 DONOR HLA DR-DQ CLSS II,DNA,LR N/C E 06/30/10 006 0301 2619
04050311 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050312 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050313 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050314 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050315 DONOR HLA DR-DQ CL II,LR,ADD'L N/C E 06/30/10 006 0301 2619
04050316 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050320 DONOR HLA DR-B1 CLSS II,HR N/C E 06/30/10 006 0301 2619
04050321 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050322 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050323 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050330 DONOR HLA DR-B3,4,5 CL II,HR N/C E 06/30/10 006 0301 2619
04050331 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050332 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050333 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050340 DONOR HLA DQ-B1 CLSS II,DNA HR N/C E 06/30/10 006 0301 2619
04050341 SEPARATION GEL ELECTROPHORESIS 61.00 C 06/30/10 83894 83894 83894 006 0301 2619
04050342 AMPL NUCL ACID,PRIMER PAIR 25.00 C 06/30/10 83898 83898 83898 006 0301 2619
04050343 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050344 INTERPRETATION/REPORT 52.00 C 06/30/10 83912 83912 83912 006 0301 2619
04050345 HLA DQ-B1 CLASS II,HR ADD'L N/C E 06/30/10 006 0301 2619
04050346 AMPL NUCL ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050400 ISOL/EXT HIGH PURIFED NUC ACID 54.00 06/30/10 83891 83891 83891 006 0301 2619
04050410 AMPL NUC ACID,PRIMER PR,ADD'L 25.00 06/30/10 8389891 8389891 8389891 006 0301 2619
04050411 AMPL NUC ACID,PRIMER X2 N/C E 06/30/10 006 0301 2619
04050412 AMPL NUC ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050413 AMPL NUC ACID,PRIMER X3 N/C E 06/30/10 006 0301 2619
04050414 AMPL NUC ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050415 AMPL NUC ACID ,PRIMERX4 N/C E 06/30/10 006 0301 2619
04050416 AMPL NUC ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050417 AMPL NUC ACID,PRIMERX5 N/C E 06/30/10 006 0301 2619
04050418 AMPL NUC ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050419 AMPL NUC ACID, PRIMERX10 N/C E 06/30/10 006 0301 2619
04050420 AMPL NUC ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050421 AMPL NUC ACID, PRIMERX20 N/C E 06/30/10 006 0301 2619
04050422 AMPL NUC ACID PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050423 AMPL NUC ACID, PRIMER X30 N/C E 06/30/10 006 0301 2619
04050424 AMPL NUC ACID,PRIMER PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050500 DONOR ISO/EXT HGH PUR NUC ACID 54.00 06/30/10 83891 83891 83891 006 0301 2619
04050510 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 06/30/10 8389891 8389891 8389891 006 0301 2619
04050511 DONOR AMP NUC AC,PRIM X2 N/C E 06/30/10 006 0301 2619
04050512 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050513 DONOR AMP NUC AC,PRIM X3 N/C E 06/30/10 006 0301 2619
04050514 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050515 DONOR AMP NUC AC,PRIM X4 N/C E 06/30/10 006 0301 2619
04050516 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050517 DONOR AMP NUC AC,PRIM X5 N/C E 06/30/10 006 0301 2619
04050518 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050519 DONOR AMP NUC AC,PRIM X10 N/C E 06/30/10 006 0301 2619
04050520 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050521 DONOR AMP NUC AC, PRIM X20 N/C E 06/30/10 006 0301 2619
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 99
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04050522 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050523 DONOR AMP NUC AC,PRIM X30 N/C E 06/30/10 006 0301 2619
04050524 DONOR AMP NUC AC,PRIM PR,ADD'L 25.00 C 06/30/10 8389891 8389891 8389891 006 0301 2619
04050962 2 HOUR GLUCOSE TOLERANCE TEST 135.00 06/30/10 82951 82951 82951 006 0301 2612
04050965 3 HR GLUCOSE TOLERANCE N/C E 06/30/10 006 0301 2612
04050966 GLUCOSE TOL TEST, 3 SPECIMENS 135.00 C 06/30/10 82951 82951 82951 006 0301 2612
04050967 GLUCOSE TOL TEST, 3HR SPECIMEN 48.00 C 06/30/10 82952 82952 82952 006 0301 2612
04050973 5 HR GLUCOSE TOLERANCE N/C E 06/30/10 006 2612
04050974 GLUCOSE TOL TEST, 3 SPECIMENS 79.00 C 06/30/10 82951 82951 82951 006 0301 2612
04050975 GLUCOSE TOL TEST, 3HR SPECIMEN 48.00 C 06/30/10 82952 82952 82952 006 0301 2612
04050976 GLUCOSE TOL TEST, 4HR SPECIMEN 48.00 C 06/30/10 82952 82952 82952 006 0301 2612
04050977 GLUCOSE TOL TEST, 5HR SPECIMEN 48.00 C 06/30/10 82952 82952 82952 006 0301 2612
04051169 BETKE-FETAL HGB 74.00 06/30/10 85460 85460 85460 006 0305 2613
04051276 IGG QUANT 101.00 06/30/10 82784 82784 82784 006 0301 2612
04051284 IGA QUANT 101.00 06/30/10 82784 82784 82784 006 0301 2612
04051292 IGM QUANT 101.00 06/30/10 82784 82784 82784 006 0301 2612
04051300 C3 QUANT 147.00 06/30/10 86160 86160 86160 006 0302 2612
04053506 AFB CULTURE-WITH CONCENTRATION N/C E 06/30/10 006 0306 2639
04053507 CONCENTRATION FOR AFB 76.00 C 06/30/10 87015 87015 87015 006 0306 2639
04053508 CULTURE, ISOLATION 173.00 C 06/30/10 87116 87116 87116 006 0306 2639
04053520 EUGLOBULIN LYSIS 120.00 06/30/10 85360 85360 85360 006 0305 2608
04053611 RPR-QUAL 54.00 06/30/10 86592 86592 86592 006 0302 2639
04053612 SYPHILLIS INITIAL SEROLOGY 50.00 06/30/10 86780 86780 86780 006 0302 2639
04053629 SYPHILLIS FOLLOW UP SEROLOGY 73.00 06/30/10 86593 86593 86593 006 0302 2639
04053637 FTA-ABS 96.00 06/30/10 86780 86780 86780 006 0302 2608
04053640 FTA-ABS CONFIRMATION 21.00 06/30/10 86780 86780 86780 006 0302 2608
04053645 T4 TOTAL 134.00 06/30/10 84436 84436 84436 006 0301 2612
04054155 QUANTITATIVE IGE 120.00 06/30/10 82785 82785 82785 006 0301 2608
04056002 GRANULOCYTE,PHERESIS 1893.00 06/30/10 P9050 P9050 P9050 006 0380 2670
04056358 IGD QUANT. 95.00 06/30/10 82784 82784 82784 006 0301 2608
04056366 TRANSFERRIN 103.00 06/30/10 84466 84466 84466 006 0301 2608
04056374 ALPHA-1-ANTITRYPSIN 113.00 06/30/10 82103 82103 82103 006 0301 2608
04056473 RED BLOOD CELLS LEUKOREDUCED 693.00 06/30/10 P9016 P9016 P9016 006 0390 2670
04056759 CK-MB 158.00 06/30/10 82553 82553 82553 006 0301 2612
04056763 HEPATIC FUNCTION PROFILE 164.00 06/30/10 80076 80076 80076 006 0300 2612
04056777 RENAL FUNCTION PANEL 176.00 06/30/10 80069 80069 80069 006 0300 2612
04056779 LIPID PROFILE 184.00 06/30/10 80061 80061 80061 006 0300 2612
04059501 PH-BODY FLUID 47.00 06/30/10 83986 83986 83986 006 0301 2612
04059519 MEXILETINE 96.00 06/30/10 80299 80299 80299 006 0300 2608
04059527 1,25,DIHYDROXY VITD 256.00 06/30/10 82652 82652 82652 006 0301 2608
04059535 CLONOPIN 122.00 06/30/10 80154 80154 80154 006 0300 2608
04059536 FREE CARBAMAZEPINE 103.00 06/30/10 80157 80157 80157 006 0300 2608
04059543 ETHYLNE GLYCOL 60.00 06/30/10 82693 82693 82693 006 0301 2608
04059550 SEROTININ 235.00 06/30/10 84260 84260 84260 006 0301 2608
04059568 VERAPAMIL/NORVERAPAMIL 270.00 06/30/10 82492 82492 82492 006 0300 2608
04063005 CHLAMYDIA BY AMP PROBE-SH 50.00 06/30/10 87491 87491 87491 006 0306 2639
04063016 DIR AG: STOOL FOR ROTAVIRUS 132.00 06/30/10 87425 87425 87425 006 0300 2639
04063024 VIRUS ISOLATION:HERPES SCREEN 183.00 06/30/10 87254 87254 87254 006 0306 2639
04063025 RESPIRATORY VIRUS SCREEN 201.00 06/30/10 87254 87254 87254 006 0306 2639
04063035 GC BY AMPLIFIED PROBE-SH 50.00 06/30/10 87591 87591 87591 006 0306 2639
04063321 CPK ISOENZYMES 119.00 06/30/10 82552 82552 82552 006 0301 2608
04063347 ALKPHOS ISOENZYME 105.00 06/30/10 84080 84080 84080 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 100
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04063350 CULTURE-TISSUE AND QUANTITY N/C E 06/30/10 006 0306 2639
04063351 CULTURE-QUANT. 185.00 C 06/30/10 87071 87071 87071 006 0306 2639
04063352 HOMOGENIZATION-TISSUE QUANT 57.00 C 06/30/10 87176 87176 87176 006 0306 2639
04063360 CULTURE-STOOL:ISOL,PRESUMP ID N/C E 06/30/10 006 0306 2639
04063361 CULTURE-STOOL:SALM.-SHIGELLA 171.00 C 06/30/10 87045 87045 87045 006 0306 2639
04063362 CULTURE,ADD'L PATHOGEN(CAMPY) 39.00 C 06/30/10 87046 87046 87046 006 0306 2639
04063363 CULTURE-YERSINA,PLESIOM,AEROMS 39.00 C 06/30/10 8704691 8704691 8704691 006 0306 2639
04063370 OVA & PARASITES N/C E 06/30/10 006 0306 2639
04063371 OVA & PARASITE-DIR.SMR,CONC ID 191.00 C 06/30/10 87177 87177 87177 006 0306 2639
04063372 TRICHROME STAIN 88.00 C 06/30/10 87209 87209 87209 006 0306 2639
04063375 MYCOPLASMA CULTURE-GENITAL 105.00 06/30/10 87109 87109 87109 006 0306 2639
04063380 CULT-URINE VOID AND COL. COUNT N/C E 06/30/10 006 0306 2639
04063381 CULTURE-URINE VOID,COLNY COUNT 95.00 C 06/30/10 87086 87086 87086 006 0306 2639
04063382 CULTURE-URINE ISOL & PRESMP ID 75.00 C 06/30/10 87088 87088 87088 006 0306 2639
04063410 OVA & PARASITES:FLUID N/C E 06/30/10 006 0306 2639
04063411 OVA & PARASITE-DIR SMR,CONC ID 191.00 C 06/30/10 87177 87177 87177 006 0306 2639
04063412 TRICHROME STAIN 88.00 C 06/30/10 87209 87209 87209 006 0306 2639
04063415 PARASTES,BLOOD-THCK&THIN EXAMS N/C E 06/30/10 006 0306 2639
04063416 BLOOD-THIN SMEAR EXAM 126.00 C 06/30/10 87207 87207 87207 006 0306 2639
04063417 BLOOD-THICK SMEAR PREP 34.00 C 06/30/10 87015 87015 87015 006 0306 2639
04063418 BLOOD-THICK SMEAR EXAM 126.00 C 06/30/10 87207 87207 87207 006 0306 2639
04063420 MACRO EXAM-ARTHROPOD(TICK) 109.00 06/30/10 87168 87168 87168 006 0306 2639
04063422 CRYPTOCOCCAL AG-CSF-QUANT 151.00 06/30/10 86406 86406 86406 006 0302 2639
04063424 CRYPTOCOCCAL AG-SERUM QUANT 151.00 06/30/10 86406 86406 86406 006 0300 2639
04063426 KOH PREP-SKIN,HAIR,NAILS 71.00 06/30/10 87220 87220 87220 006 0306 2639
04063427 KOH PREP-OTHER SOURCE 65.00 06/30/10 87210 87210 87210 006 0306 2639
04063428 CULTURE ANAEROBE-PRESUMP ID 189.00 06/30/10 87075 87075 87075 006 0306 2639
04063429 ORGANISM ID-ANAEROBE,DEFIN 65.00 06/30/10 87076 87076 87076 006 0306 2639
04063430 CRYPTOSPORIDIUM-OVA&PARASITE N/C E 06/30/10 006 0306 2639
04063431 OVA&PARASITE-DIR SM,CONC,ID 191.00 C 06/30/10 87177 87177 87177 006 0306 2639
04063432 ACID FAST STAIN(CRYPTO) 70.00 C 06/30/10 87272 87272 87272 006 0306 2639
04063433 TRICHROME STAIN 87.00 C 06/30/10 88313 88313 88313 006 0310 2639
04063435 ORGANISM ID-YEAST 95.00 06/30/10 87106 87106 87106 006 0306 2639
04063437 ORGANISM ID-BACTERIAL EXTENDED 125.00 06/30/10 87077 87077 87077 006 0306 2639
04063440 HSV I&II-DIRECT N/C E 06/30/10 006 0306 2639
04063441 HSV I-DIRECT 75.00 C 06/30/10 87274 87274 87274 006 0306 2639
04063442 HSV II-DIRECT 75.00 C 06/30/10 87273 87273 87273 006 0306 2639
04063445 SUSCEPTIBILTY DISK DIFF(PANEL) 113.00 06/30/10 87184 87184 87184 006 0306 2639
04063447 SUSCEPT-GRAD STRIP-EA.AGENT 70.00 06/30/10 87181 87181 87181 006 0306 2639
04063465 VIRUS ISOLATION-BODY FLUID 134.00 06/30/10 87254 87254 87254 006 0306 2639
04063501 WEST NILE VIRUS ELISA-IGG 92.00 06/30/10 86317 86317 86317 006 0302 2639
04063502 WEST NILE VIRUS ELISA-IGM 83.00 06/30/10 86317 86317 86317 006 0302 2639
04063510 STRAIN CHARACTERIZTN-REP-PCR N/C E 06/30/10 006 0301 2639
04063511 MOLECULAR ISOL/EXTRACTION 36.00 C 06/30/10 83890 83890 83890 006 0301 2639
04063512 NUCLEIC ACID PROBE 32.00 C 06/30/10 83896 83896 83896 006 0301 2639
04063513 AMPLIFICATION OF NUCL ACID 61.00 C 06/30/10 83898 83898 83898 006 0301 2639
04063514 INTERP AND REPORT 67.00 C 06/30/10 83912 83912 83912 006 0301 2639
04064470 WEST NILE VIRUS AB,IGG&IGM-CSF N/C E 06/30/10 006 0302 2608
04064471 WEST NILE VIRUS ANTIBODY-IGG 65.00 C 06/30/10 86789 86789 86789 006 0302 2608
04064472 WEST NILE VIRUS ANTIBODY-IGM 65.00 C 06/30/10 86788 86788 86788 006 0302 2608
04064475 WST NILE VIRS AB,IGG&IGM-SERUM N/C E 06/30/10 006 0302 2608
04064476 WEST NILE VIRUS ANTIBODY-IGG 65.00 C 06/30/10 86789 86789 86789 006 0302 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 101
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04064477 WEST NILE VIRUS ANTIBODY-IGM 65.00 C 06/30/10 86788 86788 86788 006 0302 2608
04064480 VON WILLEBRAND MULTIMERIC N/C E 06/30/10 006 0301 2608
04064481 VON WILLEBRAND FACTOR 58.00 C 06/30/10 85247 85247 85247 006 0300 2608
04064482 VWF FACTOR 8 ACTIVITY 58.00 C 06/30/10 85240 85240 85240 006 0300 2608
04064483 VON WILLEBRAND FACTOR AG 58.00 C 06/30/10 85246 85246 85246 006 0300 2608
04064484 VWF RISTOCETIN COFACTOR 58.00 C 06/30/10 85245 85245 85245 006 0300 2608
04065995 PYRUVIC ACID 112.00 06/30/10 84210 84210 84210 006 0301 2608
04066431 G-6-PD QUANT. 90.00 06/30/10 82955 82955 82955 006 0301 2608
04069922 LYSOZYMES 115.00 06/30/10 85549 85549 85549 006 0305 2608
04072665 REPTILASE TIME 1:1 MIX 40.00 06/30/10 85635 85635 85635 006 0300 2608
04072769 ALUMINUM 139.00 06/30/10 82108 82108 82108 006 0301 2608
04072777 BILE ACIDS 61.00 06/30/10 82240 82240 82240 006 0301 2608
04072830 SALMONELLA TYPHI ANTIBODIES N/C E 06/30/10 006 0302 2608
04072831 SALMONELLA TYPHI H TYPE A 29.00 C 06/30/10 86768 86768 86768 006 0302 2608
04072832 SALMONELLA TYPHI H TYPE B 29.00 C 06/30/10 8676891 8676891 8676891 006 0302 2608
04072833 SALMONELLA TYPHI H TYPE D 29.00 C 06/30/10 86768 86768 86768 006 0302 2608
04072834 SALMONELLA TYPHI O TYPE D 29.00 C 06/30/10 86768 86768 86768 006 0302 2608
04072835 SALMONELLA TYPHI O TYPE VI 29.00 C 06/30/10 86768 86768 86768 006 0302 2608
04072836 SALMONELLA H GROUP D 23.00 06/30/10 8600091 8600091 8600091 006 0302 2608
04072837 M TUBERCULOSIS AMP DET 247.00 06/30/10 87556 87556 87556 006 0306 2608
04072840 HIV PHENOTYPE ANALYSIS N/C E 06/30/10 006 0306 2608
04072841 HIV PHEN;DNA,CULT,1ST 10 DRUGS 1210.00 C 06/30/10 87903 87903 87903 006 0306 2608
04072842 HIV PHEN;ADD'L DRUG 11 46.00 C 06/30/10 87904 87904 87904 006 0306 2608
04072843 HIV PHEN;ADD'L DRUG 12 46.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04072844 HIV PHEN;ADD'L DRUG 13 46.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04072845 HIV PHEN;ADD'L DRUG 14 46.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04072846 HIV PHEN;ADD'L DRUG 15 46.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04072847 HIV PHEN;ADD'L DRUG 16 46.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04072848 HIV PHEN;ADD'L DRUG 17 46.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04072849 HIV PHEN;ADD'L DRUG 18 46.00 C 06/30/10 8790491 8790491 8790491 006 0306 2608
04072870 PATHOLOGY,FISH:HER-2/NEU N/C E 06/30/10 006 0310 2608
04072871 IN SITU HYBRIDIZATION,EA PROBE 58.00 C 06/30/10 88365 88365 88365 006 0310 2608
04072872 INTRPHSE INSITU HYBRD,25-99CEL 103.00 C 06/30/10 88274 88274 88274 006 0310 2608
04072873 MOLECULAR CYTOGEN DNA PR,EACH 81.00 C 06/30/10 88271 88271 88271 006 0310 2608
04072874 MOLECULAR CYTOGEN DNA PR,EACH 81.00 C 06/30/10 8827191 8827191 8827191 006 0310 2608
04072903 ALPHA 1 ANTITRYPSIN,FECES 113.00 06/30/10 82103 82103 82103 006 0301 2608
04072906 ANTITHROMBIN ANTIGEN 187.00 06/30/10 85301 85301 85301 006 0305 2608
04072909 ITRACONAZOLE,SERUM LEVEL 146.00 06/30/10 80299 80299 80299 006 0300 2608
04072912 PARVOVIRUS B 19 BY PCR 120.00 06/30/10 87798 87798 87798 006 0306 2608
04072915 CYSTICERCOSIS AB,IGG CSF 58.00 06/30/10 86682 86682 86682 006 0302 2608
04072918 CYSTICERCOSIS AB,IGG 58.00 06/30/10 86682 86682 86682 006 0302 2608
04072924 RNP ANTIBODY 30.00 06/30/10 86235 86235 86235 006 0302 2608
04072927 DSDNA ANTIBODY 30.00 06/30/10 86225 86225 86225 006 0302 2608
04072930 SMITH ANTIBODY 30.00 06/30/10 86235 86235 86235 006 0302 2608
04072933 SSA ANTIBODY 30.00 06/30/10 86235 86235 86235 006 0302 2608
04072936 SSB ANTIBODY 30.00 06/30/10 86235 86235 86235 006 0302 2608
04072939 CRYOGLOBULIN IGG,QUANT 18.00 06/30/10 82784 82784 82784 006 0301 2608
04072942 CRYOGLOBULIN IGA,QUANT 18.00 06/30/10 82784 82784 82784 006 0301 2608
04072945 CRYOGLOBULIN IGM,QUANT 18.00 06/30/10 82784 82784 82784 006 0301 2608
04072948 ENDOMYSIAL AB TITER 43.00 06/30/10 86256 86256 86256 006 0302 2608
04072953 BETHESDA QUANT,FACTOR VIII 213.00 06/30/10 85335 85335 85335 006 0305 2608
04072956 HTLV I/II AB CONFIRMATION 81.00 06/30/10 86689 86689 86689 006 0302 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 102
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04072959 ANCA,MYELOPEROXIDASE ANTIBODY 35.00 06/30/10 83516 83516 83516 006 0301 2608
04072962 ANCA,SERINE PROTEASE 3 ANTBODY 35.00 06/30/10 83516 83516 83516 006 0301 2608
04072968 STRIATED MUSCLE AB TITER 136.00 06/30/10 86256 86256 86256 006 0302 2608
04073049 O.P. TRANSFUSION PLAT/CRYP 663.00 06/30/10 36430 36430 36430 99.05 99.05 006 0391 2660
04073056 O.P. TRANSFUSION RBC/FP 663.00 06/30/10 36430 36430 36430 99.04 99.04 006 0391 2660
04073064 THERAPEUTIC APHERESIS FOR WBC 2478.00 06/30/10 36511 36511 36511 99.71 99.71 006 0390 2660
04073072 DIR AG:NASAL WASH FOR RSV 126.00 06/30/10 87807 87807 87807 006 0300 2639
04073075 MRSA SCREEN, RT PCR 154.00 06/30/10 87641 87641 87641 006 0301 2639
04076018 CRYPTOCOCCAL AG-CSF-QUAL 103.00 06/30/10 86403 86403 86403 006 0302 2639
04076026 CRYPTOCOCCAL AG-SERUM-QUAL 103.00 06/30/10 86403 86403 86403 006 0302 2639
04076059 MYELIN BASIC PROT. 94.00 06/30/10 83873 83873 83873 006 0301 2608
04076091 GC CULTURE 78.00 06/30/10 87081 87081 87081 006 0306 2639
04076119 TOXIC ALCOHOL SCREEN N/C E 06/30/10 006 0301 2608
04076120 ETHANOL, QUANTITATIVE 116.00 C 06/30/10 82055 82055 82055 006 0301 2608
04076121 ACETONE, QUANTITATIVE 60.00 C 06/30/10 82010 82010 82010 006 0301 2608
04076122 ISOPROPANOL, QUANTITATIVE 74.00 C 06/30/10 84600 84600 84600 006 0301 2608
04076123 METHANOL, QUANTITATIVE 74.00 C 06/30/10 84600 84600 84600 006 0301 2608
04076141 THIOCYANATE 120.00 06/30/10 84430 84430 84430 006 0301 2608
04076158 DESIPRAMINE 109.00 06/30/10 80160 80160 80160 006 0300 2608
04076166 NORTRIPTYLINE 114.00 06/30/10 80182 80182 80182 006 0300 2608
04076182 ZINC URINE 91.00 06/30/10 84630 84630 84630 006 0301 2608
04076208 ACETONE, QUANTITATIVE 60.00 06/30/10 82010 82010 82010 006 0301 2608
04076216 ISOPROPANOL, QUANTITATIVE 74.00 06/30/10 84600 84600 84600 006 0301 2608
04076281 BENZODIAZEPINE URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04076307 COCAINE URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04076315 METHADONE URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04076323 OPIATES URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04076331 CANNABINOIDS (MARIJUANA) URINE 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04076349 PHENCYCLIDINE URINE SCREEN 69.00 06/30/10 G0431 G0431 G0431 006 0300 2612
04076356 BENZODIAZEPINE SERUM SCREEN 122.00 06/30/10 80154 80154 80154 006 0300 2608
04076406 CODEINE,URINE 146.00 06/30/10 80299 80299 80299 006 0300 2608
04076457 LYME ANTIBODIES EIA 142.00 06/30/10 86618 86618 86618 006 0300 2608
04076459 ANTIBIOTIC SYNERGY STUDIES 232.00 06/30/10 87186 87186 87186 006 0306 2639
04076460 ANTIFUNGAL MIC 109.00 06/30/10 87186 87186 87186 006 0306 2639
04076480 CHLAMYDIA/GC BY AMPLIFIED PROB N/C E 06/30/10 006 0306 2639
04076481 CHLAMYDIA BY AMPLIFIED PROBE 233.00 C 06/30/10 87491 87491 87491 006 0306 2639
04076482 GC BY AMPLIFIED PROBE 233.00 C 06/30/10 87591 87591 87591 006 0306 2639
04076486 OCCULT BLOOD, STOOL 38.00 06/30/10 82270 82270 82270 006 0301 2613
04076554 FE STAIN 158.00 06/30/10 85536 85536 85536 006 0305 2613
04076588 BIREFRINGENT CRYSTS 50.00 06/30/10 89060 89060 89060 006 0300 2613
04076620 ERYTH SED RATE 62.00 06/30/10 85652 85652 85652 006 0305 2613
04076646 REDUCING SUBSTANCES-URINE 44.00 06/30/10 81002 81002 81002 006 0300 2613
04076653 THROMBIN TIME 89.00 06/30/10 85670 85670 85670 006 0305 2613
04076711 CORTISOL STIM/SUP 161.00 06/30/10 82533 82533 82533 006 0301 2612
04076729 CORTISOL-PM 161.00 06/30/10 82533 82533 82533 006 0301 2612
04076737 ALDOSTERONE,URINE 84.00 06/30/10 82088 82088 82088 006 0301 2608
04076760 11-DEOXYCORTISOL 153.00 06/30/10 82634 82634 82634 006 0301 2608
04076786 DIHYDROTESTOST. 136.00 06/30/10 82651 82651 82651 006 0301 2608
04076836 ACETYLOCHOL.REC.AB 208.00 06/30/10 83519 83519 83519 006 0301 2608
04076893 LEGIONNAIRES 122.00 06/30/10 86713 86713 86713 006 0302 2608
04077040 HEMOGLOBIN ALK FRACTIONATION 157.00 06/30/10 83020 83020 83020 006 0301 2612
04077073 PLASMA HEMOGLOBIN 84.00 06/30/10 83051 83051 83051 006 0301 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 103
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04077099 SMOOTH MUSCLE AB 120.00 06/30/10 83516 83516 83516 006 0300 2608
04077107 HEMOSIDERIN SCREEN 58.00 06/30/10 83070 83070 83070 006 0301 2608
04077206 ANTI-DNASE B 96.00 06/30/10 86215 86215 86215 006 0302 2608
04077297 PARIETAL CELL AB 141.00 06/30/10 86255 86255 86255 006 0302 2608
04077339 ALA 125.00 06/30/10 82135 82135 82135 006 0301 2608
04077347 AMMONIA 109.00 06/30/10 82140 82140 82140 006 0301 2612
04077362 CHOLINESTERASE; SERUM 80.00 06/30/10 82480 82480 82480 006 0301 2608
04077396 IONIZED CALCIUM 108.00 06/30/10 82330 82330 82330 006 0301 2612
04077465 HUNTINGTON EXTRACT 26.00 06/30/10 83890 83890 83890 006 0301 2608
04077506 ESTROGENS, FRACTIONATED 81.00 06/30/10 82671 82671 82671 006 0301 2608
04077545 MEPHENYTOIN 132.00 06/30/10 80185 80185 80185 006 0300 2608
04077574 PRIMIDONE-WITH PHNO N/C E 06/30/10 006 2608
04077575 PRIMIDONE 107.00 C 06/30/10 80188 80188 80188 006 0300 2608
04077576 PHENOBARBITAL 133.00 C 06/30/10 80184 80184 80184 006 0300 2608
04077578 PRIMIDONE 157.00 06/30/10 80188 80188 80188 006 0300 2612
04077586 PHENOBARBITAL 141.00 06/30/10 80184 80184 80184 006 0300 2612
04077635 PROCAINAMIDE W/METABOLITE 196.00 06/30/10 80192 80192 80192 006 0300 2608
04077685 PLATELET AGGREGATION 365.00 06/30/10 85576 85576 85576 006 0305 2613
04077686 HEPARIN THROMBOCYTOPENIA (HIT) 610.00 06/30/10 86022 86022 86022 006 0300 2613
04077727 FACT.13 ASSAY 177.00 06/30/10 85291 85291 85291 006 0305 2608
04077768 PLASMINOGEN 373.00 06/30/10 85420 85420 85420 006 0305 2613
04077874 MRSA CULTURE 152.00 06/30/10 87081 87081 87081 006 0306 2639
04077891 CEA 207.00 06/30/10 82378 82378 82378 006 0301 2612
04077909 CORTISOL-AM 161.00 06/30/10 82533 82533 82533 006 0301 2612
04077966 DIGOXIN 141.00 06/30/10 80162 80162 80162 006 0300 2612
04077974 FOLLIC STIM HORM 206.00 06/30/10 83001 83001 83001 006 0301 2612
04078006 PLACENTAL LACTOGEN 148.00 06/30/10 83632 83632 83632 006 0301 2608
04078014 LUTEINIZING HORM. 206.00 06/30/10 83002 83002 83002 006 0301 2612
04078022 TESTOSTERONE 175.00 06/30/10 84403 84403 84403 006 0301 2608
04078030 ALDOSTERONE,SERUM 84.00 06/30/10 82088 82088 82088 006 0301 2608
04078048 TSH STIM-SUP 191.00 06/30/10 84443 84443 84443 006 0301 2612
04078055 TSH 191.00 06/30/10 84443 84443 84443 006 0301 2612
04078067 THER APHERESIS,RED BLOOD CELLS 2478.00 06/30/10 36512 36512 36512 99.73 99.73 006 0390 2660
04078069 THER APHERESIS,PLATELETS 2478.00 06/30/10 36513 36513 36513 99.74 99.74 006 0390 2660
04078071 THER APHERESIS,PLASMA 2478.00 06/30/10 36514 36514 36514 99.71 99.71 006 0390 2660
04078073 PERIPH STEM CELL COLL,ALLGENIC 3085.00 06/30/10 38205 38205 38205 41.08 41.08 006 0390 2660
04078075 PERIPH STEMCELL COLL,AUTOLOGUS 3085.00 06/30/10 38206 38206 38206 41.07 41.07 006 0390 2660
04078186 PLATELET POOLING 211.00 06/30/10 86965 86965 86965 006 0300 2670
04078188 HGB A2 FRACT,CHROM 104.00 06/30/10 83021 83021 83021 006 0301 2612
04078190 DEFEROXAMINE ADMIN UP TO 1 HR 200.00 06/30/10 96365 96365 96365 006 0260 2660
04078191 DEFEROXAMINE ADMIN EA ADD'L HR 200.00 06/30/10 96366 96366 96366 006 0260 2660
04078193 ERYTHROPOIETIN ADMINISTRATION 200.00 06/30/10 96365 96365 96365 006 0260 2660
04078194 O.P. INFUSION-PLASMA PROD. 846.00 06/30/10 36430 36430 36430 99.07 99.07 006 0391 2660
04078195 THERAPEUTIC IV INFUSION (IVIG) 276.00 06/30/10 96374 96374 96374 006 0260 2660
04078196 C4 QUANT 147.00 06/30/10 86160 86160 86160 006 0302 2612
04078201 THERAPEUTIC IV INJECTION 276.00 06/30/10 96374 96374 96374 006 0260 2660
04078204 COMPLEMENT C5 116.00 06/30/10 86160 86160 86160 006 0302 2608
04078207 THERAPEUTIC INFUSION, 1 HR 167.00 06/30/10 96365 96365 96365 006 0260 2660
04078209 THERAP INFUSION,ADD'L HR 89.00 06/30/10 96366 96366 96366 006 0260 2660
04078211 CHEMO,IV INFUSION, I HOUR 257.00 06/30/10 96413 96413 96413 99.25 006 0335 2660
04078212 COMPLEMENT C1Q 116.00 06/30/10 86160 86160 86160 006 0302 2608
04078215 THERAP INFUSION SPEC,ADD'L HR 55.00 06/30/10 96415 96415 96415 99.25 006 0335 2660
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 104
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04078221 THERAPEUTIC PHLEBOTOMY 227.00 06/30/10 99195 99195 99195 006 0940 2660
04078222 C'1 ESTERASE INHIB N/C E 06/30/10 006 0302 2608
04078223 COMPLEMENT; C'1 ESTERASE 62.00 C 06/30/10 86161 86161 86161 006 0302 2608
04078224 COMPLEMENT; C'4 ESTERASE 116.00 C 06/30/10 86160 86160 86160 006 0302 2608
04078237 HEP B CORE AB.IGM 159.00 06/30/10 86705 86705 86705 006 0302 2612
04078246 LITHIUM 88.00 06/30/10 80178 80178 80178 006 0300 2612
04078279 MICROSOMAL AB-IFA 106.00 06/30/10 86376 86376 86376 006 0302 2608
04078280 LIVER/KIDNEY MICROSOMAL AB 106.00 06/30/10 86376 86376 86376 006 0302 2608
04078287 MITOCHONDRIAL AB 136.00 06/30/10 86256 86256 86256 006 0302 2608
04078327 MONOCLONAL ANTIBODY PANEL 640.00 06/30/10 88182 88182 88182 006 0311 2613
04078328 T-CELL SCREEN 246.00 06/30/10 88182 88182 88182 006 0311 2613
04078329 T AND B CELL SCREEN 424.00 06/30/10 88182 88182 88182 006 0311 2613
04078330 CD 34 STEM CELL ASSAY 246.00 06/30/10 86367 86367 86367 006 0311 2613
04078385 CYTOPLASMIC NEUTRO AB 141.00 06/30/10 86255 86255 86255 006 0302 2608
04078386 PLATELET AB 268.00 06/30/10 86022 86022 86022 006 0302 2608
04078394 ETHOSUXIMIDE 107.00 06/30/10 80168 80168 80168 006 0300 2608
04078404 TSH RECEPTOR AB 208.00 06/30/10 83520 83520 83520 006 0301 2608
04078414 PORPHYRIN-QUANT URINE 135.00 06/30/10 84120 84120 84120 006 0301 2608
04078420 SEX HORMONE BINDING GLOBULIN 102.00 06/30/10 84270 84270 84270 006 0301 2608
04078427 PROSTATE SPECIFIC AG SCREEN 191.00 06/30/10 84153 G0103 84153 006 0300 2612
04078428 PROSTATE SPECIFIC ANTIGEN 196.00 06/30/10 84153 84153 84153 006 0301 2612
04078430 IGG SUBCLASS N/C E 06/30/10 006 2608
04078431 IMMUNOGLOBULIN G1 44.00 C 06/30/10 82787 82787 82787 006 0301 2608
04078432 IMMUNOGLOBULIN G2 44.00 C 06/30/10 8278791 8278791 8278791 006 0301 2608
04078433 IMMUNOGLOBULIN G3 44.00 C 06/30/10 8278791 8278791 8278791 006 0301 2608
04078434 IMMUNOGLOBULIN G4 44.00 C 06/30/10 8278791 8278791 8278791 006 0301 2608
04078437 TOCAINIDE 146.00 06/30/10 80299 80299 80299 006 0300 2608
04078439 PNEUMOCOCCAL AB 96.00 06/30/10 86738 86738 86738 006 0302 2608
04078440 FT4 BY EQUIL DIALYSIS 113.00 06/30/10 84439 84439 84439 006 0301 2608
04078500 CATECHOLAMINES; FRACTIONATED 213.00 06/30/10 82384 82384 82384 006 0301 2608
04078501 CATECHOLAMINES; BLOOD 103.00 06/30/10 82383 82383 82383 006 0301 2608
04078502 HOMOVANILLIC ACID (HVA), URINE 108.00 06/30/10 83150 83150 83150 006 0301 2608
04078503 METANEPHRINES, URINE 105.00 06/30/10 83835 83835 83835 006 0301 2608
04078504 VANILLYMANDELIC ACID, URINE 130.00 06/30/10 84585 84585 84585 006 0301 2608
04078507 GLUTAMIC ACID DECARB ANTIBODY 208.00 06/30/10 83519 83519 83519 006 0301 2608
04078510 CHLAMYDIA IGM ANTIBODIES N/C E 06/30/10 006 0302 2608
04078511 C. TRACHOMATIS, IGM 72.00 C 06/30/10 86632 86632 86632 006 0302 2608
04078512 C. PNEUMONIAE, IGM 72.00 C 06/30/10 8663291 8663291 8663291 006 0302 2608
04078513 C. PSITTACI, IGM 72.00 C 06/30/10 8663291 8663291 8663291 006 0302 2608
04078520 GLIADIN ANTIBODY(IGG/IGA) N/C E 06/30/10 006 0301 2608
04078521 GLIADIN ANTIBODY, IGG 59.00 C 06/30/10 83516 83516 83516 006 0301 2608
04078522 GLIADIN ANTIBODY, IGA 59.00 C 06/30/10 8351691 8351691 8351691 006 0301 2608
04078525 GLOMERULAR BASE MEMBRANE N/C E 06/30/10 006 0302 2608
04078526 GLOMER,BASEMENT AB,IGA 141.00 C 06/30/10 86255 86255 86255 006 0300 2608
04078527 GLOMER,BASEMENT AB, IGG 141.00 C 06/30/10 86255 86255 86255 006 0302 2608
04078540 HEMOCHROMATOSISMUTATION DET N/C 06/30/10 006 0301 2608
04078555 B.HENSELAE IGG/IGM ANTIBODIES N/C E 06/30/10 86609 86609 86609 006 0302 2608
04078556 B.HENSELAE IGG ANTIBODY 38.00 C 06/30/10 86611 86611 86611 006 0302 2608
04078557 B.HENSELAE IGM ANTIBODY 38.00 C 06/30/10 8661191 8661191 8661191 006 0302 2608
04078559 SIROLIMUS ASSAY 225.00 06/30/10 80195 80195 80195 006 0301 2612
04078560 AMNIOSTAT-PG 154.00 06/30/10 84081 84081 84081 006 0301 2608
04078580 SPECIMEN TRANSPORT TO REF LAB 43.00 06/30/10 99001 99001 99001 006 0300 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 105
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04078585 NIDA DOT, 5 DRUGS N/C E 06/30/10 006 0300 2608
04078586 NIDA DOT,EACH DRUG 10.00 C 06/30/10 G0431 G0431 G0431 006 0300 2608
04078588 UREAPLASMA/MYCOPL CULTURE 140.00 06/30/10 87109 87109 87109 006 0306 2608
04078590 CHAIN OF CUSTODY, 5 DRUGS N/C 06/30/10 006 0300 2608
04078599 FAT, FECAL, RANDOM QUAL 36.00 06/30/10 82705 82705 82705 006 0301 2608
04078603 IGG SUBCLASS 4 31.00 06/30/10 82787 82787 82787 006 0301 2608
04078605 VIRUS ISOLATION-RESPIRATORY N/C E 06/30/10 006 0306 2639
04078606 SHELL VIAL,ID-RESPIRATORY POOL 126.00 C 06/30/10 87254 87254 87254 006 0306 2639
04078607 SHELL VIAL,ID-CMV 126.00 C 06/30/10 87254 87254 87254 006 0306 2639
04078608 GALACTOSE PLASMA, QUANT 424.00 06/30/10 82760 82760 82760 006 0301 2608
04078610 VIRUS ISOLATION-STOOL-ENTERO 177.00 06/30/10 87254 87254 87254 006 0306 2639
04078611 SEROTONIN RELEASE 650.00 06/30/10 86022 86022 86022 006 0302 2608
04078614 CELIAC DUAL AG SCREEN 95.00 06/30/10 83516 83516 83516 006 0301 2608
04078615 VIRUS ISOLATION-URINE N/C E 06/30/10 006 0306 2639
04078616 SHELL VIAL,ID-ADENOVIRUS 90.00 C 06/30/10 87254 87254 87254 006 0306 2639
04078617 SHELL VIAL,ID-CMV 90.00 C 06/30/10 87254 87254 87254 006 0306 2639
04078620 VIRUS ISOLATION-DERM-VZV 177.00 06/30/10 87254 87254 87254 006 0306 2639
04078625 VIRUS ISOLATION-EYE N/C E 06/30/10 006 0306 2639
04078626 SHELL VIAL,ID-HSV 70.00 C 06/30/10 87254 87254 87254 006 0306 2639
04078627 SHELL VIAL,ID-ADENOVIRUS 70.00 C 06/30/10 87254 87254 87254 006 0306 2639
04078630 HSV TYPING N/C E 06/30/10 006 0306 2639
04078631 HSV I 55.00 C 06/30/10 87253 87253 87253 006 0306 2639
04078632 HSV II 55.00 C 06/30/10 87253 87253 87253 006 0306 2639
04078640 OVA&PARASITE W/CRPTO&GIARDIA N/C E 06/30/10 006 0306 2639
04078641 OVA&PARASITE-DIR SMR CONC,ID 151.00 C 06/30/10 87177 87177 87177 006 0306 2639
04078642 CRYPTOSPORIDIUM-DFA 35.00 C 06/30/10 87272 87272 87272 006 0306 2639
04078643 GIARDIA-DFA 42.00 C 06/30/10 87269 87269 87269 006 0306 2639
04078644 TRICHROME STAIN 64.00 C 06/30/10 87209 87209 87209 006 0306 2639
04078650 OVA&PARASITE-IMMUNO COMPR N/C E 06/30/10 006 0306 2639
04078651 OVA&PARASITE-DIR SMR,CONC,ID 151.00 C 06/30/10 87177 87177 87177 006 0306 2639
04078652 CRYPTOSPORIDIUM-DFA 35.00 C 06/30/10 87272 87272 87272 006 0306 2639
04078653 GIARDIA-DFA 42.00 C 06/30/10 87269 87269 87269 006 0306 2639
04078654 MICROSPORIDIA 70.00 C 06/30/10 87207 87207 87207 006 0306 2639
04078655 CYCLOSPORA 45.00 C 06/30/10 87206 87206 87206 006 0306 2639
04078656 TRICHROME STAIN 64.00 C 06/30/10 87209 87209 87209 006 0306 2639
04078660 AFB SUSC.TEST-12 DRUGS EACH N/C E 06/30/10 006 0306 2639
04078661 AFB DRUG-1 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078662 AFB DRUG-2 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078663 AFB DRUG-3 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078664 AFB DRUG-4 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078665 AFB DRUG-5 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078666 AFB DRUG-6 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078667 AFB DRUG-7 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078668 AFB DRUG-8 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078669 AFB DRUG-9 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078670 AFB DRUG-10 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078671 AFB DRUG-11 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078672 AFB DRUG-12 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078680 TB SUSC. TEST-5 DRUGS EACH N/C E 06/30/10 006 0306 2639
04078681 TB DRUG-1 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078682 TB DRUG-2 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078683 TB DRUG-3 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 106
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04078684 TB DRUG-4 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078685 TB DRUG-5 66.00 C 06/30/10 87188 87188 87188 006 0306 2639
04078690 SKIN SCRAPINGS-SCABIES 81.00 06/30/10 87220 87220 87220 006 0306 2639
04078700 INFLUENZA A & B VIRUS W/REFLEX N/C E 06/30/10 006 0306 2639
04078701 INFLUENZA A DFA 69.00 C 06/30/10 87276 87276 87276 006 0306 2639
04078702 INFLUENZA B DFA 69.00 C 06/30/10 87275 87275 87275 006 0306 2639
04081430 AT3 ASSAY 276.00 06/30/10 85300 85300 85300 006 0305 2613
04082059 FTA CONFIRM 18.00 06/30/10 86780 86780 86780 006 0302 2608
04082493 MYCOBACTER SP ID-DIR PROBE,EA 151.00 06/30/10 87550 87550 87550 006 0306 2639
04082496 MYCOBACTERIA TB ID-DIR PROBE 135.00 06/30/10 87555 87555 87555 006 0306 2639
04082499 MYCOBACTERIA MAI ID-DIR PROBE 135.00 06/30/10 87560 87560 87560 006 0306 2639
04082640 MICROSATELLITE INSTABILITY N/C E 06/30/10 006 0301 2651
04082641 MSIAC CELL LYSIS #1 57.00 C 06/30/10 83907 83907 83907 006 0301 2651
04082642 MSIAC CELL LYSIS #2 57.00 C 06/30/10 83907 83907 83907 006 0301 2651
04082643 MSIAC MOLECULAR ISOLATION #1 79.00 C 06/30/10 83890 83890 83890 006 0301 2651
04082644 MSIAC MOLECULAR ISOLATION #2 79.00 C 06/30/10 83890 83890 83890 006 0301 2651
04082645 MSIAC AMPLI NUCL ACD,MULTIPX#1 91.00 C 06/30/10 83900 83900 83900 006 0301 2651
04082646 MSIAC AMPLI NUCL ACD,MULTPLX#2 91.00 C 06/30/10 83900 83900 83900 006 0301 2651
04082647 MSIAC AMPLI NUCL ACD,MULTPLX#3 91.00 C 06/30/10 83900 83900 83900 006 0301 2651
04082648 MSIAC AMPLI NUCL ACD,MULTPLX#4 91.00 C 06/30/10 83900 83900 83900 006 0301 2651
04082649 MSIAC SEPARAT BY HIGH RESOL#1 64.00 C 06/30/10 83909 83909 83909 006 0301 2651
04082650 MSIAC SEPARAT BY HIGH RESOL#2 64.00 C 06/30/10 83909 83909 83909 006 0301 2651
04082651 MSIAC AMPLIFICATION #1 47.00 C 06/30/10 83901 83901 83901 006 0301 2651
04082652 MSIAC AMPLIFICATION #2 47.00 C 06/30/10 83901 83901 83901 006 0301 2651
04082660 PRADER WILLI/ANGLEMAN SYND N/C E 06/30/10 006 0301 2608
04082661 PW ISOLATION/EXTRACTION 81.00 C 06/30/10 83891 83891 83891 006 0301 2608
04082662 PW ENZYMATIC DIGESTION, EACH 81.00 C 06/30/10 83892 83892 83892 006 0301 2608
04082663 PW SEPARATION BY EL GEL 81.00 C 06/30/10 83894 83894 83894 006 0301 2608
04082664 PW INTERPRETATION/REPORT 81.00 C 06/30/10 83912 83912 83912 006 0301 2608
04082670 AFP4 N/C E 06/30/10 006 0301 2608
04082671 AFP MATERNAL SCREEN 35.00 C 06/30/10 82105 82105 82105 006 0301 2608
04082672 ESTRIOL 35.00 C 06/30/10 82677 82677 82677 006 0301 2608
04082673 QUANT BETA HCG 35.00 C 06/30/10 84702 84702 84702 006 0301 2608
04082674 INHIBIN A 35.00 C 06/30/10 86336 86336 86336 006 0301 2608
04082680 CF MUTATION ANALYSIS N/C E 06/30/10 006 0301 2608
04082681 CF ENZYMATIC DIGESTION, EACH 84.00 C 06/30/10 83892 83892 83892 006 0301 2608
04082682 CF AMPLI NUCLEIC ACID,MULTIPLX 84.00 C 06/30/10 83900 83900 83900 006 0301 2608
04082683 CF AMPLIFICATION #1 84.00 C 06/30/10 83901 83901 83901 006 0301 2608
04082684 CF SEPARATION BY HIGH RESOL 84.00 C 06/30/10 83909 83909 83909 006 0301 2608
04082686 MUTATION IDENTIFICATION 84.00 C 06/30/10 83914 83914 83914 006 0301 2608
04082690 INTRON8 POLY T VAR N/C E 06/30/10 006 0301 2608
04082691 CF ISOLATION/EXTRACTION 82.00 C 06/30/10 83891 83891 83891 006 0301 2608
04082692 CF ISOL/EXTRACTION 82.00 C 06/30/10 83893 83893 83893 006 0301 2608
04082693 CF SEPARATION BY GEL EL 82.00 C 06/30/10 83894 83894 83894 006 0301 2608
04082694 CF NUCLEIC ACID PROBE 82.00 C 06/30/10 83896 83896 83896 006 0301 2608
04082695 CF NUCLEIC ACID AMPL,EA 82.00 C 06/30/10 83896 83896 83896 006 0301 2608
04082699 CADMIUM, URINE 40.00 04/26/10 82300 82300 82300 006 0300 2608
04082700 SUBTELOMERE ANALYSIS N/C E 06/30/10 006 0301 2608
04082701 CHROM IN SITU HYBRID(10-30) 771.00 C 06/30/10 88273 88273 88273 006 0301 2608
04082702 DNA PROBE 1 771.00 C 06/30/10 88271 88271 88271 006 0301 2608
04082703 INTERPRETATION/REPORT 771.00 C 06/30/10 88291 88291 88291 006 0301 2608
04082707 FACTOR 13 1:1 MIX 58.00 05/17/10 8529191 8529191 8529191 006 0300 2608
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 107
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04085244 FACTOR VIII R:ANTIGEN 373.00 06/30/10 85244 85244 85244 006 0305 2613
04085300 PROTEIN S FREE 341.00 06/30/10 85306 85306 85306 006 0305 2613
04085302 PROTEIN C FUNCTIONAL 373.00 06/30/10 85303 85303 85303 006 0305 2613
04085308 PROTEIN S TOTAL 251.00 06/30/10 85305 85305 85305 006 0305 2613
04085315 PROTEIN C ANTIGEN 294.00 06/30/10 85302 85302 85302 006 0305 2613
04085340 PTT MIXING STUDIES 217.00 06/30/10 85335 85335 85335 006 0305 2613
04085345 PRO-TIME MIXING STUDIES 217.00 06/30/10 85335 85335 85335 006 0305 2613
04085426 RISTOCETIN COFACTOR 599.00 06/30/10 85245 85245 85245 006 0305 2613
04085662 MEASLES AB-IGG 75.00 06/30/10 86765 86765 86765 006 0302 2612
04085670 MUMPS AB-IGG 75.00 06/30/10 86735 86735 86735 006 0302 2612
04086574 HSV TYPING 134.00 06/30/10 87253 87253 87253 006 0306 2639
04086834 C DIFF TOXIN-EIA STOOL 165.00 06/30/10 87324 87324 87324 006 0306 2639
04086835 DIR AG: STOOL FOR C DIFFICILE 75.00 06/30/10 87230 87230 87230 006 0306 2639
04086836 CLOSTRIDIUM DIFFICILE TOXIN 75.00 06/30/10 87230 87230 87230 006 0306 2639
04086837 ORGANISM ID-MYCOBACTERIA 166.00 06/30/10 87118 87118 87118 006 0306 2639
04086838 FUNGUS CULTURE-BLOOD 172.00 06/30/10 87103 87103 87103 006 0306 2639
04086839 ORGANISM ID-MOLD 125.00 06/30/10 87107 87107 87107 006 0306 2639
04086840 ORGANISM ID-BACTERIAL ROUTINE 51.00 06/30/10 87077 87077 87077 006 0306 2639
04086842 ORGANISM ID-URINE ISOLATES 51.00 06/30/10 87077 87077 87077 006 0306 2639
04086843 FUNGUS CULTURE-SKIN,HAIR,NAILS 225.00 06/30/10 87101 87101 87101 006 0306 2639
04086845 ORGANISM ID-GLC 132.00 06/30/10 87143 87143 87143 006 0306 2639
04086846 ANTIBIOTIC SENS ANAEROBE MIC 109.00 06/30/10 87186 87186 87186 006 0306 2639
04086848 DIR SMEAR: PNEUMOCYSTIS DFA 131.00 06/30/10 87281 87281 87281 006 0300 2639
04086849 GIARDIA DFA 139.00 06/30/10 87269 87269 87269 006 0300 2639
04086850 TOXOPLASMA IGG: EIA 106.00 06/30/10 86777 86777 86777 006 0302 2608
04086851 TOXOPLASMA IGM: EIA 113.00 06/30/10 86778 86778 86778 006 0302 2608
04086852 HSV II AB: EIA 69.00 06/30/10 86696 86696 86696 006 0302 2639
04086853 HSV I AB: EIA 61.00 06/30/10 86695 86695 86695 006 0302 2639
04086855 CMV IGG AB: EIA 106.00 06/30/10 86644 86644 86644 006 0302 2612
04086856 RESPIRATORY VIRUS ID 157.00 06/30/10 88347 88347 88347 006 0310 2639
04086857 VZ DIRECT 126.00 06/30/10 87290 87290 87290 006 0300 2639
04087088 CULTURE-URINE ISOL&PRESUMP ID 75.00 06/30/10 87088 87088 87088 006 0306 2639
04088534 COMPATIBILITY SCREEN 35.00 06/30/10 86904 86904 86904 006 0300 2670
04088536 ANTI-HCV 184.00 06/30/10 86803 86803 86803 006 0302 2612
04088539 BLD/RBC LEUKOREDUCED CMV NEG 599.00 06/30/10 P9051 P9051 P9051 006 0390 2670
04088542 RBC LEUKOREDUCED CMV NEG IRRAD 701.00 06/30/10 P9058 P9058 P9058 006 0390 2670
04088545 RED BLOOD CELLS IRRADIATED 545.00 06/30/10 P9038 P9038 P9038 006 0390 2670
04088548 WB LEUKOREDUCED IRRADIATED 672.00 06/30/10 P9056 P9056 P9056 006 0390 2670
04088551 RBC LEUKORDUCD,FRZ,DEGLY,WASHD 590.00 06/30/10 P9054 P9054 P9054 006 0390 2670
04088554 RBC LEUKORDCD.FRZ,DEGLY,WSH,IR 690.00 06/30/10 P9057 P9057 P9057 006 0390 2670
04088557 PLTS APHERESIS HLA MTCH LEUKOR 2209.00 06/30/10 P9052 P9052 P9052 006 0390 2670
04088560 PLTS,PHERES,LEUKORDCD,CMVN,IRR 2022.00 06/30/10 P9053 P9053 P9053 006 0390 2670
04088563 PLTS,PHERESIS,LEUKORDCD,CMV NG 1922.00 06/30/10 P9055 P9055 P9055 006 0390 2670
04088566 PLATELETS, LEUKOREDUCED 316.00 06/30/10 P9031 P9031 P9031 006 0390 2670
04088569 PLATELETS IRRADIATED 316.00 06/30/10 P9032 P9032 P9032 006 0390 2670
04088572 PLATELETS LEUKOREDUCED IRRAD 341.00 06/30/10 P9033 P9033 P9033 006 0390 2670
04088575 PLATELETS PHERESIS LEUKORED 2256.00 06/30/10 P9035 P9035 P9035 006 0390 2670
04088578 PLATELETS PHERESIS IRRADIATED 1994.00 06/30/10 P9036 P9036 P9036 006 0390 2670
04088581 PLTS PHERESIS,LEUKORDCD,IRRAD 1994.00 06/30/10 P9037 P9037 P9037 006 0390 2670
04088584 PLASMA CRYOPRECIPITATE REDUCED 245.00 06/30/10 P9044 P9044 P9044 006 0390 2670
04088755 HIV RAPID 196.00 06/30/10 86701 86701 86701 006 0302 2639
04088757 HIV-1 & HIV-2 AB SCREEN 141.00 06/30/10 86703 86703 86703 006 0302 2639
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 108
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04088765 HIV AB-CONFIRMATION WB 182.00 06/30/10 86689 86689 86689 006 0302 2608
04088767 EBV IGG AB TO EARLY D 35.00 06/30/10 86663 86663 86663 006 0302 2608
04088768 EBVNA IGG AB-EIA 35.00 06/30/10 86664 86664 86664 006 0302 2608
04088769 EBVCA IGM AB-EIA 108.00 06/30/10 86665 86665 86665 006 0302 2608
04088770 EBVCA IGG AB-EIA 99.00 06/30/10 86665 86665 86665 006 0302 2608
04088773 COXSACKIE A9 ANTIBODY 92.00 06/30/10 86658 86658 86658 006 0302 2608
04088775 VIRUS ID 90.00 06/30/10 87253 87253 87253 006 0306 2639
04088780 BACTERICIDAL ASSAY-SCHLICTER 160.00 06/30/10 87197 87197 87197 006 0306 2639
04088781 H.PYLORI STOOL ANTIGEN 248.00 06/30/10 87338 87338 87338 006 0306 2639
04088783 MICROSPORIDIA STAIN 91.00 06/30/10 87207 87207 87207 006 0306 2639
04088785 CYCLOSPORA STAIN 59.00 06/30/10 87206 87206 87206 006 0306 2639
04088799 CULTURE FOR VRE 78.00 06/30/10 87081 87081 87081 006 0306 2639
04088810 RESP VIRUS ISOL-ADENO & CMV N/C E 06/30/10 006 0306 2639
04088811 SHELL VIAL,ID-ADENOVIRUS 90.00 C 06/30/10 87254 87254 87254 006 0306 2639
04088812 SHELL VIAL, ID - CMV 90.00 C 06/30/10 8725459 8725459 8725459 006 0306 2639
04088815 FUNGUS CULT-VAGNL,THROAT,URINE 114.00 06/30/10 87102 87102 87102 006 0306 2639
04088818 ACANTHAMOEBA SMEAR 65.00 06/30/10 87210 87210 87210 006 0306 2639
04088821 WEST NILE VIRUS AB,IGG-CSF 65.00 06/30/10 86789 86789 86789 006 0302 2608
04088824 WEST NILE VIRUS AB,IGG-SERUM 65.00 06/30/10 86789 86789 86789 006 0302 2608
04088827 WEST NILE VIRUS AB,IGM-CSF 65.00 06/30/10 86788 86788 86788 006 0302 2608
04088830 WEST NILE VIRUS AB,IGM-SERUM 65.00 06/30/10 86788 86788 86788 006 0302 2608
04088833 PROTEIN S,FUNCTIONAL 98.00 06/30/10 85306 85306 85306 006 0305 2608
04088836 LOXAPINE AND METABOLITE 146.00 06/30/10 80299 80299 80299 006 0301 2608
04088839 LEPTIN 175.00 06/30/10 83520 83520 83520 006 0301 2608
04088842 HPV DNA PROBE, HIGH RISK 153.00 06/30/10 87621 87621 87621 006 0306 2608
04088848 HBV REAL TIME PCR QUANT 458.00 06/30/10 87517 87517 87517 006 0306 2651
04088850 QUANTIFERON-TB GOLD N/C E 06/30/10 006 0301 2639
04088851 LYMPHOCYTE-MITOGEN 100.00 C 06/30/10 86353 86353 86353 006 0302 2639
04088852 IMMNASSAY INF AGENT MULTI STEP 30.00 C 06/30/10 93520 83520 83520 006 0301 2639
04088855 STRN CHARACTRZTN-COMPREHENSV 39.00 06/30/10 83912 83912 83912 006 0301 2639
04088870 HCV FIBROSURE N/C E 06/30/10 006 0301 2608
04088871 FIBR ALPH2 MACROGL,QUANT 99.00 C 06/30/10 83883 83883 83883 006 0301 2608
04088872 FIBR APOLIPOPROTEIN A1 99.00 C 06/30/10 82172 82172 82172 006 0301 2608
04088873 FIBR HAPTOGLOBIN,QUANT 99.00 C 06/30/10 83010 83010 83010 006 0301 2608
04088874 FIBROSURE BILIRUBIN, TOT 99.00 C 06/30/10 82247 82247 82247 006 0301 2608
04088875 FIBROSURE GGT 99.00 C 06/30/10 82977 82977 82977 006 0301 2608
04088876 FIBROSURE ALT P5P 99.00 C 06/30/10 84460 84460 84460 006 0301 2608
04088900 ARBOVIRUS AB IGG, SERUM N/C E 06/30/10 006 0301 2608
04088901 WEST NILE VIRUS AB, IGG, SERUM 43.00 C 06/30/10 86790 86790 86790 006 0302 2608
04088902 ST. LOUIS ENCEPHALITIS IGG,SER 43.00 C 06/30/10 86653 86653 86653 006 0302 2608
04088903 CALIF ENCEPHALITIS ANTIBDY IGG 43.00 C 06/30/10 86651 86651 86651 006 0302 2608
04088904 EASTERN EQUINE ENCEPH IGG 43.00 C 06/30/10 86652 86652 86652 006 0302 2608
04088905 WESTERN EQUINE ENCEPH IGG, SER 43.00 C 06/30/10 86654 86654 86654 006 0302 2608
04090217 CYCLOSPORIN & METABOLITE 305.00 06/30/10 80158 80158 80158 006 0300 2612
04101279 CYTOPATH SMEAR, THIN LAYER 105.00 06/30/10 88142 88142 88142 006 0311 2201
04101282 CYTOPATH SMEAR,OTHER SOURCE 200.00 06/30/10 88160 88160 88160 006 0311 2201
04153137 MACRO EXAM FOR NON-MICRO STUDY 50.00 01/01/10 88387 88387 88387 006 0310 2201
04153140 MACRO EXAM W/TOUCHPR, F.S. 50.00 01/01/10 88388 88388 88388 006 0310 2201
04300127 FL DISCOGRAPHY LUMBAR EA LEVEL 686.00 06/30/10 62290 62290 62290 006 0320 2006
04300130 FL DISCOGRPHY CERV/THOR EA LEV 469.00 06/30/10 62291 62291 62291 006 0361 2006
04300133 FL DISCOGRPHY LUMBR MULTI LEV 1314.00 06/30/10 62292 62292 62292 006 0320 2006
04300136 FL DISCOGRAPHY CERV/THOR S/L 5248.00 06/30/10 72285 72285 72285TC 006 0320 2006
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 109
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04300139 FL DISCOGRAPHY LUMBAR S/I 5248.00 06/30/10 72295 72295 72295TC 006 0320 2006
04311141 PV REMOVL-IMPLNTBLE CONTRACEPT 779.00 06/30/10 11976 11976 11976 006 0361 2030
04312300 CT DOUBLE HELICAL ABD W CONT 1830.00 06/30/10 74160 74160 74160TC 006 0320 2040
04317566 PV DRAIN LUNG/CHEST ABSC 576.00 06/30/10 32201 32201 32201 006 0361 2030
04320302 NV ACCUMETRICES BLOOD COLLECT 12.00 06/30/10 36415 36415 36415 006 0300 2032
04321610 NV PERC TRANSLMNL MECH THROMBE 7012.00 06/30/10 37184 37184 37184 006 0361 2032
04381172 NV BALLOON OCCLUSION 4288.00 06/30/10 C2628 C2628 C2628 006 0272 2032
04381275 PV INFLATION UNIT 284.00 06/30/10 006 0270 2030
04381322 NV ACCUMETRICES ASPIRIN/P2Y12 77.00 06/30/10 85576 85576 85576 006 0309 2032
08900015 GLUCOSE; BLOOD, TICK TEST 40.00 06/30/10 82948 82948 82948 006 0301 6812
08900018 BLOOD; OCCULT, FECES SCREENING 35.00 06/30/10 82270 82270 82270 006 0301 6812
08900021 ACETONE; QUALITATIVE 65.00 06/30/10 82009 82009 82009 006 0301 6812
08900046 CATHETER URETH FOLEY 143.00 06/30/10 51702 51702 51702 006 0450 6812
08900515 E-R CLOT FACTOR VIII ONE STAGE 127.00 06/30/10 006 0258 6812
08901000 E-R HEMOGLOBIN 34.00 06/30/10 85018 85018 85018 006 0305 6812
09001123 AMLODIPINE 10MG 5.00 06/30/10 006 0251 6812
09050001 PREGNANCY TEST - URINE 85.00 06/30/10 84703 84703 84703 006 0301 6812
12667600 TRANSFERASE;ASPART AMINO 79.00 06/30/10 84450 84450 84450 006 0301 0602
12667605 TRANSFERASE;ALANINE AMINO 76.00 06/30/10 84460 84460 84460 006 0301 0602
13400022 DILAT URETH STRICT (F&F) 183.00 06/30/10 53620 53620 53620 006 0360 0664
18101165 UREA NITROGEN; QUANTITATIVE 41.00 06/30/10 84520 84520 84520 006 0301 4603
18101166 CREATININE; BLOOD 48.00 06/30/10 82565 82565 82565 006 0301 4603
18101172 BILIRUBIN; BLOOD, TOTAL 41.00 06/30/10 82247 82247 82247 006 0301 4603
18101173 BILIRUBIN; TOTAL AND DIRECT 43.00 06/30/10 82248 82248 82248 006 0301 4603
18101609 IONIZED CALCIUM ANALYSIS 107.00 06/30/10 82330 82330 82330 006 0301 4603
18101610 CALCIUM 44.00 06/30/10 82310 82310 82310 006 0301 4603
18101859 CHLORIDES 27.00 06/30/10 82435 82435 82435 006 0301 4603
18102055 CO2 COMBINING POWER 30.00 06/30/10 82374 82374 82374 006 0301 4603
18104093 GLUCOSE 48.00 06/30/10 82947 82947 82947 006 0301 4603
18107716 POTASSIUM 41.00 06/30/10 84132 84132 84132 006 0301 4603
18109126 SODIUM 41.00 06/30/10 84295 84295 84295 006 0301 4603
18115750 SWEAT COLLECTION IONTOPHORESIS 320.00 06/30/10 89230 89230 89230 006 0300 4603
18115781 BLOOD COUNT; HEMATOCRIT 38.00 06/30/10 85013 85013 85013 006 0305 4603
18115784 BLOOD GASES PEDS STAT 114.00 06/30/10 82803 82803 82803 006 0301 4603
18151037 TOTAL CO2 30.00 06/30/10 82374 82374 82374 006 0301 4603
18156044 BILIRUBIN DIRECT 43.00 06/30/10 82248 82248 82248 006 0301 4603
18160000 NEWBORN SCREENING TESTS N/C 06/30/10 006 0720 2608
18160001 BIOTINIDASE N/C 06/30/10 84999 84999 84999 006 0301 4603
18160002 CONGENITAL ADRENAL HYPERPLASIA N/C 06/30/10 83498 83498 83498 006 0301 4603
18160003 HYPOTHYROIDISM N/C 06/30/10 84443 84443 84443 006 0301 4603
18160004 PHENYLKETONURIA N/C 06/30/10 84030 84030 84030 006 0301 4603
18160005 SICKLE CELL N/C 06/30/10 83020 83020 83020 006 0301 4603
18160006 GALACTOSEMIA N/C 06/30/10 82776 82776 82776 006 0301 4603
18210075 SKIN/TISSUE FIBROBLAST 45 CELL N/C 06/30/10 006 4605
18210076 TIS CULT CHROM ANALYS-TIS BIOP 667.00 06/30/10 88233 88233 88233 006 0310 4605
18210077 CHROMOSOME ANALYSIS; 45 CELLS 644.00 06/30/10 88263 88263 88263 006 0310 4605
18210301 INTERPHASE 25-99 581.00 C 06/30/10 88274 88274 88274 006 0310 4605
18210302 PROBE X 120.00 C 06/30/10 88271 88271 88271 006 0310 4605
18210303 PROBE Y 120.00 C 06/30/10 8827159 8827159 8827159 006 0310 4605
18210304 PROBE 18 120.00 C 06/30/10 8827159 8827159 8827159 006 0310 4605
18210305 PROBE 21 120.00 C 06/30/10 8827159 8827159 8827159 006 0310 4605
18210306 PROBE 13 120.00 C 06/30/10 8827159 8827159 8827159 006 0310 4605
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 110
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

18210308 ALPHAFETOPROTEIN-AMN FLD 63.00 06/30/10 82106 82106 82106 006 0301 2608
18210309 ACETYLCHOLINESTERASE-AMN FLD 75.00 06/30/10 82013 82013 82013 006 0301 2608
18210310 CHROMOSOME ANALYSIS-AMN FLD N/C E 06/30/10 006 0310 4605
18210311 TISSUE CULTURE-AMN FLD 527.00 C 06/30/10 88235 88235 88235 006 0310 4605
18210312 CHROM ANALY-15 CELLS,1 KARYOTP 644.00 C 06/30/10 88267 88267 88267 006 0310 4605
18210313 CHROM ANALY-ADD'L KARYOTYPE 98.00 C 06/30/10 88280 88280 88280 006 0310 4605
18210314 CHROM ANALY-INTERP/REPORT 114.00 C 06/30/10 88291 88291 88291 006 0311 4605
18210320 CVS CHROMOSOME ANALYSIS N/C E 06/30/10 006 0310 4605
18210321 CVS EVALUATION OF FNA 173.00 C 06/30/10 88172 88172 88172 006 0311 4605
18210322 CVS TISSUE CULTURE 533.00 C 06/30/10 88235 88235 88235 006 0310 4605
18210323 CVS 15 CELLS,1 KARYOTYPE 644.00 C 06/30/10 88267 88267 88267 006 0310 4605
18210324 CVS ADD'L KARYOTYPE 124.00 C 06/30/10 88280 88280 88280 006 0310 4605
18210325 CVS INTERP/REPORT 114.00 06/30/10 88291 88291 88291 006 0311 4605
18210330 CHROMOSOME ANALYSIS-PERIPH BLD N/C E 06/30/10 006 0310 4605
18210331 TISSUE CULTURE-PERIPH BLD 451.00 C 06/30/10 88230 88230 88230 006 0310 4605
18210332 CHROM ANALY-15 CELLS,2 KARYOTY 563.00 C 06/30/10 88262 88262 88262 006 0310 4605
18210340 CHROMOSOME ANALYSIS-POC N/C E 06/30/10 006 0310 4605
18210341 TISSUE CULTURE-POC 606.00 C 06/30/10 88233 88233 88233 006 0310 4605
18210342 CHROM ANLY-15-20 CLLS,2 KARYOT 612.00 C 06/30/10 88262 88262 88262 006 0310 4605
18210350 CHROMOSOME ANALYSIS-LEUKEMIA N/C E 06/30/10 006 0310 4605
18210351 TISSUE CULTURE-LEUKEMIA 521.00 C 06/30/10 88237 88237 88237 006 0310 4605
18210352 CHROM ANALY 15-20 CELLS,2 KARY 815.00 C 06/30/10 88262 88262 88262 006 0310 4605
18210370 HIGH RES. CHROM ANALYSIS-BID N/C E 06/30/10 006 0310 4605
18210371 TISS CULT-CHROM ANAL-LYMPHOCYT 451.00 C 06/30/10 88230 88230 88230 006 0310 4605
18210372 CHROM ANAL-15CELLS,2 KARYOTYPE 473.00 C 06/30/10 88262 88262 88262 006 0310 4605
18210373 ADD'L HIGH RESOLUTION STUDY 103.00 C 06/30/10 88289 88289 88289 006 0310 4605
18210380 CHROM ANALYSIS-SKIN BIOPSY N/C E 06/30/10 006 0310 4605
18210381 TISSUE CULT-OTHER SOLID TISSUE 502.00 C 06/30/10 88233 88233 88233 006 0310 4605
18210382 CHROM ANAL-15CELLS,2 KARYOTYPE 473.00 C 06/30/10 88262 88262 88262 006 0310 4605
18210391 TISSUE CULT-OTHER SOLID TISSUE 502.00 06/30/10 88233 88233 88233 006 0310 4605
18210392 MOSIAC CHROMOSOME STUDY 499.00 06/30/10 88263 88263 88263 006 0310 4605
18210393 CHROM ANALY-15 CELLS,2 KARYO 473.00 06/30/10 88262 88262 88262 006 0310 4605
18210400 EFFUS CHROM ANAL-SOL TUMOR/ASC N/C E 06/30/10 006 0310 2608
18210401 TISSUE CULT-OTHER SOLID TISSUE 700.00 C 06/30/10 88239 88239 88239 006 0310 2608
18210402 CHROM ANALY-15CELLS,2KARYOTYPE 711.00 C 06/30/10 88262 88262 88262 006 0310 2608
18210410 FISH,METAPHASE N/C E 06/30/10 006 0310 4605
18210411 FISH,10-30 CELLS 371.00 C 06/30/10 88273 88273 88273 006 0310 4605
18210412 FISH, DNA PROBE 371.00 C 06/30/10 88271 88271 88271 006 0310 4605
18210450 FISH, INTERPHASE N/C E 06/30/10 006 0310 4605
18210451 FISH, 100-300 CELLS 484.00 C 06/30/10 88275 88275 88275 006 0310 4605
18210452 FISH, DNA PROBE 426.00 C 06/30/10 88271 88271 88271 006 0310 4605
18210460 FISH, INTERPHASE, BLADDER N/C E 06/30/10 006 0310 4605
18210461 FISH, CELL CONCENTRATION 130.00 C 06/30/10 88108 88108 88108 006 0310 4605
18210462 FISH, DNA PROBES-1 167.00 C 06/30/10 88271 88271 88271 006 0310 4605
18210463 FISH, DNA PROBES-2 167.00 C 06/30/10 8827159 8827159 8827159 006 0310 4605
18210464 FISH, DNA PROBES-3 167.00 C 06/30/10 8827159 8827159 8827159 006 0310 4605
18210465 FISH, PROBES-4 167.00 C 06/30/10 8827159 8827159 8827159 006 0310 4605
18210466 FISH, 25-99 CELLS-1 167.00 C 06/30/10 88274 88274 88274 006 0310 4605
18210467 FISH, 25-99 CELLS-2 167.00 C 06/30/10 8827459 8827459 8827459 006 0310 4605
18210468 FISH, 25-99 CELLS-3 167.00 C 06/30/10 8827459 8827459 8827459 006 0310 4605
18210469 FISH, 25-99 CELLS-4 167.00 C 06/30/10 8827459 8827459 8827459 006 0310 4605
18210475 FISH, ADD'L PROBE 167.00 06/30/10 8827159 8827159 8827159 006 0310 4605
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 111
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

18210480 FISH, 100-300 CELLS ADD'L 259.00 06/30/10 8827559 8827559 8827559 006 0310 4605
18210485 TISSUE CULTURE, ADD'L-AMN FLD 527.00 06/30/10 88235 88235 88235 006 0310 4605
18210490 TISSUE CULTURE-PER BLD/BM 451.00 06/30/10 88230 88230 88230 006 0310 4605
18210495 FISH, DNA PROBES 1 190.00 06/30/10 88271 88271 88271 006 0310 4605
18210500 FISH, DNA PROBES 2 190.00 06/30/10 8827159 8827159 8827159 006 0310 4605
18210505 FISH, IN SITU HYB 1 317.00 06/30/10 88274 88274 88274 006 0310 4605
18210510 FISH, IN SITU HYB 2 317.00 06/30/10 8827459 8827459 8827459 006 0310 4605
18210550 CYTOGEN FISH PARAFFIN TECH 259.00 06/30/10 88368 88368 88368 006 0310 4605
18510003 SANFILIPPO C 386.00 06/30/10 82658 82658 82658 006 0301 4616
18510005 OLIGOS/SIALIC ACID 95.00 06/30/10 84377 84377 84377 006 0301 4616
18510006 PTERIDINE REDUCTASE (FIB) 183.00 06/30/10 82657 82657 82657 006 0301 4616
18510013 SPHINGOMYELINASE 386.00 06/30/10 82658 82658 82658 006 0301 4616
18510014 REDUCING SUBSTANCES 51.00 06/30/10 84376 84376 84376 006 0301 4616
18510017 BETA-HEXOSAMINIDASE 95.00 06/30/10 83080 83080 83080 006 0301 4616
18510023 IDURONOSULFATASE 386.00 06/30/10 82658 82658 82658 006 0301 4616
18510024 GALACTOSAMINE-6-SULFATASE 386.00 06/30/10 82658 82658 82658 006 0301 4616
18510028 GALACTOSE-1-PHOSPHATE 242.00 06/30/10 84378 84378 84378 006 0301 4616
18510030 AMINO ACID QUANT-URNE(6ORMORE) 298.00 06/30/10 82139 82139 82139 006 0301 4616
18510033 ORGANIC ACIDS-BLOOD 132.00 06/30/10 83919 83919 83919 006 0301 4616
18510034 ACID MUCOPOLYSACCHARIDES 184.00 06/30/10 83864 83864 83864 006 0301 4616
18510035 PHENYLALANINE (FLUORO) - FP 66.00 06/30/10 84030 84030 84030 006 0301 4616
18510036 AMINO ACID QUAL-URINE (MULTI) 176.00 06/30/10 82128 82128 82128 006 0301 4616
18510037 AMINO ACID QUNT-BLD(6 OR MORE) 298.00 06/30/10 82139 82139 82139 006 0301 4616
18510038 GAL-1-P04 URIDYLTRNSFRSE QUANT 276.00 06/30/10 82775 82775 82775 006 0301 4616
18510041 PTERIN QUAL (URINE) 95.00 06/30/10 82486 82486 82486 006 0301 4616
18510042 DIHYDROPTERIDINE REDUCTASE(FP) 95.00 06/30/10 82657 82657 82657 006 0301 4616
18510043 BIOTINIDASE 56.00 06/30/10 82261 82261 82261 006 0301 4616
18510045 ORGANIC ACIDS-URINE 132.00 06/30/10 83919 83919 83919 006 0301 4616
18510047 N-ACETYLASPARTIC ACID 132.00 06/30/10 83919 83919 83919 006 0301 4616
18510048 AMPS ELECTROPHORESIS 121.00 06/30/10 83866 83866 83866 006 0301 4616
18510049 SUCCINYL ACETONE, URINE 132.00 06/30/10 83919 83919 83919 006 0301 4616
18510050 METHYLMALONIC ACID, BLOOD 220.00 06/30/10 83921 83921 83921 006 0301 4616
18510058 AMPS TLC 99.00 06/30/10 83866 83866 83866 006 0301 4616
18510062 AMINO ACID QUNT-CSF(6 OR MORE) 298.00 06/30/10 82139 82139 82139 006 0301 4616
18510063 AMINO ACID QUAL - CSF (MULTI) 176.00 06/30/10 82128 82128 82128 006 0301 4616
18510064 HOMOCYSTEINE 73.00 06/30/10 83090 83090 83090 006 0301 4616
18510065 SUGARS, TLC 83.00 06/30/10 84375 84375 84375 006 0301 4616
18510101 ARYLSULFATASE A 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510102 ARYLSULFATASE B 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510104 ALPHA-FUCOSIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510106 BETA-GALACTOCEREBROSIDASE 311.00 06/30/10 82658 82658 82658 006 0301 4616
18510107 ALPHA-GALACTOSIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510108 BETA-GALACTOSIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510110 ALPHA-GLUCOSIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510111 BETA-GLUCOSIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510112 BETA-GLUCURONIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510113 ALPHA-HEXOSAMINIDASE 186.00 06/30/10 82657 82657 82657 006 0301 4616
18510114 ALPHA-L-IDURONIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510115 ALPHA-MANNOSIDASE 83.00 06/30/10 82657 82657 82657 006 0301 4616
18510121 AMINO ACID QUAL-BLOOD (MULTI) 176.00 06/30/10 82128 82128 82128 006 0301 4616
18510390 AMINO ACID QUANT-CSF(2-5) 132.00 06/30/10 82136 82136 82136 006 0301 4616
18510392 THAW & EXPAND- FROZEN CELLS 62.00 06/30/10 88241 88241 88241 006 0300 4616
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 112
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

18510395 AMINO ACID QUANT-URINE(SINGLE) 72.00 06/30/10 82131 82131 82131 006 0301 4616
18510398 AMINO ACID QUANT -URINE (2-5) 132.00 06/30/10 82136 82136 82136 006 0301 4616
18510401 AMINO ACID QUAL-URINE(SINGLE) 66.00 06/30/10 82127 82127 82127 006 0301 4616
18510404 AMINO ACID QUANT - BLOOD (2-5) 132.00 06/30/10 82136 82136 82136 006 0301 4616
18510407 AMINO ACID QUANT-BLOOD(SINGLE) 72.00 06/30/10 82131 82131 82131 006 0301 4616
18510411 GAL-1-PO4 UIDYLTRNSFRSE QUAL 273.00 06/30/10 82776 82776 82776 006 0301 4616
18510414 OROTIC ACID QUAL 132.00 06/30/10 83919 83919 83919 006 0301 4616
18510417 AMINO ACID QUANT - CSF (2-5) 132.00 06/30/10 82136 82136 82136 006 0301 4616
18510420 AMINO ACID QUANT - CSF(SINGLE) 72.00 06/30/10 82131 82131 82131 006 0301 4616
18510423 AMINO ACID QUAL - CSF (SINGLE) 66.00 06/30/10 82127 82127 82127 006 0301 4616
18510426 AMINO ACD QUANT-TYROSINE BLOOD 72.00 06/30/10 84510 84510 84510 006 0301 4616
18510429 AMINO ACID QUAL-BLOOD(SINGLE) 66.00 06/30/10 82127 82127 82127 006 0301 4616
18510432 AMINO ACID QUNT-CSF(6 OR MORE) 283.00 06/30/10 82139 82139 82139 006 0301 4616
18512567 SANFILIPPO C 718.00 06/30/10 82658 82658 82658 006 0301 4615
18512609 OLIGOS/SIALIC ACID 247.00 06/30/10 84377 84377 84377 006 0301 4615
18512610 SUGARS, TLC 152.00 06/30/10 84375 84375 84375 006 0301 4615
18512625 PTERIDINE REDUCTASE (FIB) 374.00 06/30/10 82657 82657 82657 006 0301 4615
18512642 AMPS ELECTROPHORESIS 324.00 06/30/10 83866 83866 83866 006 0301 4615
18512643 AMPS TLC 200.00 06/30/10 83866 83866 83866 006 0301 4615
18512658 OROTIC ACID QUAL 407.00 06/30/10 83919 83919 83919 006 0301 4615
18520101 ARYLSULFATASE A 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520102 ARYLSULFATASE B 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520104 ALPHA-FUCOSIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520106 BETA-GALACTOCEREBROSIDASE 712.00 06/30/10 82658 82658 82658 006 0301 4615
18520107 ALPHA-GALACTOSIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520108 BETA-GALACTOSIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520110 ALPHA-GLUCOSIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520111 BETA-GLUCOSIDASE 288.00 06/30/10 82963 82963 82963 006 0301 4615
18520112 BETA-GLUCURONIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520113 ALPHA-HEXOSAMINIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520114 ALPHA-L-IDURONIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18520115 ALPHA-MANNOSIDASE 381.00 06/30/10 82657 82657 82657 006 0301 4615
18530106 SPHINGOMYELINASE 718.00 06/30/10 82658 82658 82658 006 0301 4615
18530114 REDUCING SUBSTANCES QUAL 116.00 06/30/10 84376 84376 84376 006 0301 4615
18530155 BETA-HEXOSAMINIDASE 226.00 06/30/10 83080 83080 83080 006 0301 4615
18530205 IDURONOSULFATASE 718.00 06/30/10 82658 82658 82658 006 0301 4615
18530221 GALACTOSAMINE-6-SULFATASE 718.00 06/30/10 82658 82658 82658 006 0301 4615
18530262 GALACTOSE-1-PHOSPHATE 675.00 06/30/10 84378 84378 84378 006 0301 4615
18530300 AMINO ACID QUANT-URINE(SINGLE) 137.00 06/30/10 82131 82131 82131 006 0301 4615
18530301 AMINO ACID QUANT-BLOOD(SINGLE) 137.00 06/30/10 82131 82131 82131 006 0301 4615
18530302 AMINO ACID QUANT-CSF(SINGLE) 137.00 06/30/10 82131 82131 82131 006 0301 4615
18530303 AMINO ACID QUANT-URINE(2-5) 237.00 06/30/10 82136 82136 82136 006 0301 4615
18530304 AMINO ACID QUANT-BLOOD(2-5) 273.00 06/30/10 82136 82136 82136 006 0301 4615
18530305 AMINO ACID QUANT - CSF (2-5) 237.00 06/30/10 82136 82136 82136 006 0301 4615
18530306 AMINO ACID QUAN-TYROSINE BLOOD 138.00 06/30/10 84510 84510 84510 006 0301 4615
18551334 AMINO ACID QUANT-URINE 1114.00 06/30/10 82139 82139 82139 006 0301 4615
18551375 ORGANIC ACIDS-BLOOD 407.00 06/30/10 83919 83919 83919 006 0301 4615
18551376 METHYLMALONIC ACID, BLOOD 285.00 06/30/10 83921 83921 83921 006 0301 4615
18551383 ACID MUCOPOLYSACCHARIDES 454.00 06/30/10 83864 83864 83864 006 0301 4615
18556069 PHENYLALANINE (FLUORO) - FP 116.00 06/30/10 84030 84030 84030 006 0301 4615
18579346 AMINO ACID QUAL (MULTIPLE)-CSF 368.00 06/30/10 82128 82128 82128 006 0301 4615
18579347 AMNO ACID QUANT-CSF(6 OR MORE) 1114.00 06/30/10 82139 82139 82139 006 0301 4615
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 113
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

18579348 HOMOCYSTEINE 206.00 06/30/10 83090 83090 83090 006 0301 4615
18579349 AMINO ACD QUAL-BLOOD(MULTIPLE) 423.00 06/30/10 82128 82128 82128 006 0301 4615
18579350 AMINO ACID QUAL-URINE(MULTI) 423.00 06/30/10 82128 82128 82128 006 0301 4615
18579368 AMINO ACID QUANT-BLD(6ORMORE) 1114.00 06/30/10 82139 82139 82139 006 0301 4615
18579403 AMINO ACID QUAL (SINGLE) -CSF 74.00 06/30/10 82127 82127 82127 006 0301 4615
18579406 AMINO ACID QUAL (SINGLE)-BLOOD 85.00 06/30/10 82127 82127 82127 006 0301 4615
18579409 AMINO ACID QUAL (SINGLE)-URINE 74.00 06/30/10 82127 82127 82127 006 0301 4615
18579426 GAL-1-P04URIDYLTRANSFERASE QU 734.00 06/30/10 82775 82775 82775 006 0301 4615
18595471 PTERIN QUAL (URINE) 354.00 06/30/10 82486 82486 82486 006 0301 4615
18595489 DIHYDROPTERIDINE REDUCTASE(FP) 327.00 06/30/10 82657 82657 82657 006 0301 4615
18595497 BIOTINIDASE 126.00 06/30/10 82261 82261 82261 006 0301 4615
18595500 ORGANIC ACIDS-URINE 407.00 06/30/10 83919 83919 83919 006 0301 4615
18595501 N-ACETYLASPARTIC ACID 407.00 06/30/10 83919 83919 83919 006 0301 4615
18595502 SUCCINYL ACETONE, URINE 407.00 06/30/10 83919 83919 83919 006 0301 4615
40100098 ESOPHAGOS; W/INSERT GUIDE WIRE 1951.00 06/30/10 43226 43226 43226 42.92 42.92 006 0360 3309
40100099 ESOPHAGOSCOPY; W/BALLOON DILAT 1795.00 06/30/10 43220 43220 43220 42.92 42.92 006 0360 3309
40100100 ESOPHAGOSCOPY; ESOPHAGL STENT 1918.00 06/30/10 43219 43219 43219 42.81 42.81 006 0360 3309
40100101 ESOPHAGOSCOPY; DIAGNOSTIC 1407.00 06/30/10 43200 43200 43200 42.23 42.23 006 0360 3309
40100102 ESOPHAGOSCOPY; WITH BIOPSY 1758.00 06/30/10 43202 43202 43202 42.24 42.24 006 0360 3309
40100103 ESOPHAGOSCOPY; VARICEAL LIGATN 1730.00 06/30/10 43205 43205 43205 42.24 42.24 006 0360 3309
40100104 ESOPHAGOSCOPY; W/SCLEROTHERAPY 1660.00 06/30/10 43204 43204 43204 42.33 42.33 006 0360 3309
40100105 ESOPHAGOSCOPY; ABLATN OF TUMOR 2583.00 06/30/10 43228 43228 43228 42.23 42.23 006 0360 3309
40100106 ESOPHAGOS W/REMOV FOREIGN BODY 2064.00 06/30/10 43215 43215 43215 42.23 42.23 006 0360 3309
40100107 ESOPHAGOS SNARE REMOVAL POLYPS 1758.00 06/30/10 43217 43217 43217 42.33 42.33 006 0360 3309
40100108 DILATION OF ESOPHAGUS-SAVORY 1599.00 06/30/10 43453 43453 43453 42.92 42.92 006 0360 3309
40100109 DILATION OF ESOPHAGUS-MALONEY 999.00 06/30/10 43450 43450 43450 42.92 42.92 006 0360 3309
40100110 DILATION OF ESOPHAGUS-BALLOON 2026.00 06/30/10 43458 43458 43458 42.92 42.92 006 0360 3309
40100111 ESOPHAGOGASTRC TAMPONADE W/BAL 1979.00 06/30/10 43460 43460 43460 96.06 96.06 006 0360 3309
40100114 UGI ENDO SIMPL PRIM EX,SEP PRO 1980.00 06/30/10 43234 43234 43234 44.13 44.13 006 0360 3309
40100115 EGD; COMPLEX DIAGNOSTIC 2378.00 06/30/10 43235 43235 43235 42.33 42.33 006 0360 3309
40100116 EGD; BIOPSY 2334.00 06/30/10 43239 43239 43239 45.11 45.11 006 0360 3309
40100117 EGD; SCLEROTHERAPY 2624.00 06/30/10 43243 43243 43243 45.13 45.13 006 0360 3309
40100119 EGD; FOR PEG PLACEMENT 2306.00 06/30/10 43246 43246 43246 43.11 43.11 006 0360 3309
40100120 EGD; SAVARY DILATION 2339.00 06/30/10 43248 43248 43248 45.13 45.13 006 0360 3309
40100121 EGD; FEEDING TUBE PLACEMENT 2624.00 06/30/10 43241 43241 43241 45.13 45.13 006 0360 3309
40100122 EGD; REMOVE FOREIGN BODY 2323.00 06/30/10 43247 43247 43247 45.13 45.13 006 0360 3309
40100123 EGD; SNARE REMOVAL OF POLYP(S) 2624.00 06/30/10 43251 43251 43251 42.33 42.33 006 0360 3309
40100124 EGD; INTESTINAL BIOPSY 1414.00 06/30/10 44100 44100 44100 45.16 45.16 006 0360 3309
40100125 EGD; BALLOON DILATION/PYLORIC 2547.00 06/30/10 43245 43245 43245 44.22 44.22 006 0360 3309
40100126 EGD; ABLATION OF TUMOR 2495.00 06/30/10 43258 43258 43258 42.33 42.33 006 0360 3309
40100128 EGD; LUGOLS DIRECTED BIOPSY 2334.00 06/30/10 43239 43239 43239 45.16 45.16 006 0360 3309
40100130 EGD; VARICEAL LIGATION 2624.00 06/30/10 43244 43244 43244 42.33 42.33 006 0360 3309
40100131 EGD; BALLOON DILATN ESOPHAGUS 2871.00 06/30/10 43249 43249 43249 42.81 42.81 006 0360 3309
40100132 EGD; CONTROL OF BLEEDING 2624.00 06/30/10 43255 43255 43255 42.33 42.33 006 0360 3309
40100134 RECTAL BIOPSY 1195.00 06/30/10 45100 45100 45100 49.23 49.23 006 0360 3309
40100135 SIGMOIDOSCOPY; DIAGNOSTIC 705.00 06/30/10 45330 45330 45330 45.24 45.24 006 0360 3309
40100136 SIGMOIDOSCOPY; BIOPSY 839.00 06/30/10 45331 45331 45331 45.25 45.25 006 0360 3309
40100138 SIGMOIDOSCOPY; POLYPECTOMY 2128.00 06/30/10 45333 45333 45333 45.42 45.42 006 0360 3309
40100139 SIGMOIDOSCOPY REM FOREIGN BODY 1999.00 06/30/10 45332 45332 45332 45.24 45.24 006 0360 3309
40100140 SIGMOIDOSC DECOMPRESS VOLVULUS 2302.00 06/30/10 45337 45337 45337 45.42 45.42 006 0360 3309
40100144 FLEX SIGMOID SCREEN (MEDICARE) 810.00 06/30/10 G0104 006 0750 3309
40100145 PROCTOSIGMOIDOSCOPY DIAGNOSTIC 930.00 06/30/10 45300 45300 45300 48.23 48.23 006 0360 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 114
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40100146 PROCTOSIGMOIDOSCOPY; BIOPSY 1892.00 06/30/10 45305 45305 45305 48.24 48.24 006 0360 3309
40100147 PROCTOSIGMOIDOSCOPY POLYPCTOMY 2114.00 06/30/10 45309 45309 45309 48.23 48.23 006 0360 3309
40100148 PROCTOSIGMOID REM FOREIGN BODY 2095.00 06/30/10 45307 45307 45307 48.23 48.23 006 0360 3309
40100149 PROCTOSIGMOID SNARE REM POLYPS 2306.00 06/30/10 45315 45315 45315 48.23 48.23 006 0360 3309
40100155 COLONOSCOPY; DIAGNOSTIC 3307.00 06/30/10 45378 45378 45378 45.23 45.23 006 0360 3309
40100156 COLONOSCOPY; BIOPSY 3070.00 06/30/10 45380 45380 45380 45.25 45.25 006 0360 3309
40100157 COLONOSCOPY; HOT BIOPSY 3123.00 06/30/10 45384 45384 45384 45.25 45.25 006 0360 3309
40100158 COLONOSCOPY; POLYPECTOMY 2641.00 06/30/10 45385 45385 45385 45.42 45.42 006 0360 3309
40100159 COLONOSCOPY; REM FOREIGN BODY 3512.00 06/30/10 45379 45379 45379 45.23 45.23 006 0360 3309
40100161 COLONOSCOPY W/ELECTROCAUTERY 3208.00 06/30/10 45382 45382 45382 45.43 45.43 006 0360 3309
40100163 IRC 370.00 06/30/10 46930 46930 46930 49.43 49.43 006 0360 3309
40100164 COLONOSCOPY SCRN-HI RISK(MED) 2425.00 06/30/10 G0105 45.23 45.23 006 0360 3309
40100165 ANOSCOPY; DIAGNOSTIC 127.00 06/30/10 46600 46600 46600 49.21 49.21 006 0360 3309
40100166 ANOSCOPY; BIOPSY 211.00 06/30/10 46606 46606 46606 49.21 49.21 006 0360 3309
40100168 ANOSCOPY; ABLAT OF HEMORRHOIDS 826.00 06/30/10 46615 46615 46615 49.23 49.23 006 0360 3309
40100170 ANOSCOPY; SCLEROTHERAPY 537.00 06/30/10 46500 46500 46500 49.42 49.42 006 0360 3309
40100175 ERCP 3655.00 06/30/10 43260 43260 43260 51.10 51.10 006 0360 3309
40100176 ERCP; PAPILLOTOMY 4123.00 06/30/10 43262 43262 43262 51.85 51.85 006 0360 3309
40100177 ERCP; MEASURE ODDI 4489.00 06/30/10 43263 43263 43263 51.85 51.85 006 0360 3309
40100178 ERCP; REMOVE STONE(S) 3725.00 06/30/10 43264 43264 43264 52.94 52.94 006 0360 3309
40100179 ERCP; LITHOTRIPSY 4489.00 06/30/10 43265 43265 43265 98.52 98.52 006 0360 3309
40100180 ERCP; NASOBILIARY DRAIN TUBE 4489.00 06/30/10 43267 43267 43267 52.97 52.97 006 0360 3309
40100181 ERCP; INSERTION OF STENT 4489.00 06/30/10 43268 43268 43268 51.87 51.87 006 0360 3309
40100182 ERCP; CHANGE/REMOVE STENT 4026.00 06/30/10 43269 43269 43269 97.05 97.05 006 0360 3309
40100183 ERCP; BALLOON DILATION 4489.00 06/30/10 43271 43271 43271 51.84 51.84 006 0360 3309
40100184 ERCP; ABLATION OF TUMOR 3473.00 06/30/10 43272 43272 43272 45.30 45.30 006 0360 3309
40100185 ERCP; BIOPSY 3573.00 06/30/10 43261 43261 43261 51.10 51.10 006 0360 3309
40100188 FEEDING TUBE PLACEMENT 1366.00 06/30/10 43241 43241 43241 44.13 44.13 006 0360 3309
40100193 UNLISTED PROCEDURE,ESOPHAGUS 1031.00 06/30/10 43499 43499 43499 006 0360 3309
40100199 ENDO CANNULIZATION OF PAPILLA 3337.00 06/30/10 43273 43273 43273 006 0360 3309
40100205 FLUOROSCOPY; UP TO ONE HOUR 458.00 06/30/10 76000 76000 76000 89.04 006 0320 3309
40100208 DOPPLER IMAGING, LIMITED STUDY 577.00 06/30/10 93976 93976 93976 88.76 88.76 006 0921 3309
40100211 SMALL BOWEL ENTEROSCOPY; DX 3064.00 06/30/10 44360 44360 44360 45.13 45.13 006 0360 3309
40100212 SMALL BOWEL ENTEROSCOPY BIOPSY 3201.00 06/30/10 44361 44361 44361 45.16 45.16 006 0360 3309
40100213 SM BOWEL ENTEROS; REM FOR BODY 3598.00 06/30/10 44363 44363 44363 45.13 45.13 006 0360 3309
40100214 SM BOWEL ENTEROS; POLYPECTOMY 3696.00 06/30/10 44364 44364 44364 45.13 45.13 006 0360 3309
40100215 SM BOWEL ENTEROSCOPY; CAUTERY 3546.00 06/30/10 44366 44366 44366 45.13 45.13 006 0360 3309
40100216 SM BOWEL ENTEROS; HOT BIOPSY 3532.00 06/30/10 44365 44365 44365 45.13 45.13 006 0360 3309
40100217 SMALL BOWEL CONV. G TO J TUBE 2821.00 06/30/10 44373 44373 44373 45.13 45.13 006 0360 3309
40100218 JEJUNOSTOMY; INITIAL PLACEMENT 2624.00 06/30/10 44372 44372 44372 43.11 43.11 006 0360 3309
40100222 ILEOSCOPY 2364.00 06/30/10 44380 44380 44380 45.13 45.13 006 0360 3309
40100223 ILEOSCOPY; WITH BIOPSY 2425.00 06/30/10 44382 44382 44382 45.14 45.14 006 0360 3309
40100224 ENDOSCOPY OF BOWEL POUCH 1956.00 06/30/10 44385 44385 44385 006 0360 3309
40100226 COLONOSCOPY VIA COLOSTOMY 1918.00 06/30/10 44388 44388 44388 45.23 45.23 006 0360 3309
40100227 COLONOSCOPY VIA COLOSTOMY BIOP 1981.00 06/30/10 44389 44389 44389 45.25 45.25 006 0360 3309
40100229 COLONOS VIA COLOST CNTRL HEMOR 1979.00 06/30/10 44391 44391 44391 45.43 45.43 006 0360 3309
40100232 COLONOS VIA COLOST; REM POLYPS 1611.00 06/30/10 44394 44394 44394 45.42 45.42 006 0360 3309
40100236 CHANGE G-TUBE NON-EGD 337.00 06/30/10 43760 43760 43760 45.13 45.13 006 0360 3309
40100237 REPOSITION FEEDING TUBE BY EGD 1259.00 06/30/10 43761 43761 43761 45.13 45.13 006 0360 3309
40100238 FEEDING TUBE PLACEMNT NON-ENDO 224.00 06/30/10 43752 43752 43752 45.13 45.13 006 0360 3309
40100240 ESOHAGOSCOPY W/US EXAM 2051.00 06/30/10 43231 43231 43231 42.23 006 0360 3309
40100241 ESOPHAGOSCOPY W/FNA 2227.00 06/30/10 43232 43232 43232 42.24 006 0360 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 115
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40100245 EGD W/DRAINAGE PSEUDOCYST 2012.00 06/30/10 43240 43240 43240 45.13 006 0360 3309
40100246 EGD US EXAM W/FNA E/S/D/J 2862.00 06/30/10 43242 43242 43242 45.16 006 0360 3309
40100250 SIGMOIDSCOPY;BALLON DILATION 2469.00 06/30/10 45340 45340 45340 46.85 46.85 006 0360 3309
40100256 EGD W/STENT PLACEMENT 3583.00 06/30/10 43256 43256 43256 42.81 006 0360 3309
40100258 COLONOSCOPY W/STENT PLACEMENT 4783.00 06/30/10 45387 45387 45387 45.23 45.23 006 0360 3309
40100264 COLONOSCOPY W/DIL-BALLOON 2703.00 06/30/10 45386 45386 45386 006 0360 3309
40100267 UNLISTED BILIARY TRACT PROC 2627.00 06/30/10 47999 47999 47999 006 0360 3309
40100280 ENDO PATH PANC DUCT RAD 357.00 06/30/10 74329 74329 74329 006 0320 3309
40100283 ENDO CATH BILIARY & PANC DUCTS 1166.00 06/30/10 74330 74330 74330 51.10 006 0320 3309
40100284 FLURO FOR DILATION 571.00 06/30/10 74360 74360 74360 52.98 006 0320 3309
40100301 ESOPHAGEAL MOTILITY 1180.00 06/30/10 91010 91010 91010 42.29 42.29 006 0750 3309
40100302 ESOPH MOTIL; MECHOLY/SMLR STIM 1074.00 06/30/10 91011 91011 91011 42.29 42.29 006 0750 3309
40100303 ESOPH MOTIL; ACID PERFUSN TEST 1517.00 06/30/10 91012 91012 91012 42.29 42.29 006 0750 3309
40100305 ESOPH ACID REFLUX TEST 24HR PH 1350.00 06/30/10 91038 91038 91038 42.29 42.29 006 0750 3309
40100311 GASTRIC ANALYSIS TEST 1136.00 06/30/10 91052 91052 91052 89.39 89.39 006 0750 3309
40100313 EGD, US EXAM E/S/D/J 3391.00 06/30/10 43259 43259 43259 45.13 45.13 006 0360 3309
40100314 LIVER BIOPSY; PERCUTAN NEEDLE 969.00 06/30/10 47000 47000 47000 50.11 50.11 006 0360 3309
40100315 ABDOMINAL PARACENTESIS-INITIAL 339.00 06/30/10 49080 49080 49080 54.91 54.91 006 0360 3309
40100316 ABDOMINAL PARACENTESIS-SUBSEQ 383.00 06/30/10 49081 49081 49081 54.91 54.91 006 0360 3309
40100319 LAPAROSCOPY 2626.00 06/30/10 49320 49320 49320 54.21 54.21 006 0360 3309
40100320 LAPAROSCOPIC LIVER BIOPSY 4137.00 06/30/10 49321 49321 49321 54.24 54.24 006 0360 3309
40100321 BREATH HYDROGEN ABSORPTN TEST 455.00 06/30/10 91065 91065 91065 44.19 44.19 006 0750 3309
40100352 24 HOUR PH MONITORING 1350.00 06/30/10 91038 91038 91038 89.39 89.39 006 0750 3309
40100403 CLO TEST 848.00 06/30/10 83013 83013 83013 006 0300 3309
40100404 KOH FOR FUNGI 71.00 06/30/10 87220 87220 87220 006 0306 3309
40100409 GASTRIN AFTER SECRETIN STIMUL 77.00 06/30/10 82938 82938 82938 006 0301 3309
40100412 GLUCOSE STICK 41.00 06/30/10 82948 82948 82948 006 0301 3309
40100420 URINE PREGNANCY TEST 71.00 06/30/10 81025 81025 81025 006 0300 3309
40100500 ESOPHAGOSCOPY; REMOVE TUMOR 2375.00 06/30/10 43216 43216 43216 42.23 42.23 006 0360 3309
40100502 ESOPHASGOSCOPY;W/INSRT GDE WRE 2741.00 06/30/10 43226 43226 43226 42.92 42.92 006 0360 3309
40100505 CAPSULE ENDOSCOPY 2150.00 06/30/10 91110 91110 91110 88.90 006 0320 3309
40100508 UGI ENDO;W/ENDO ULTRSOUND EXAM 3933.00 06/30/10 43259 43259 43259 42.23 42.23 006 0360 3309
40100509 UPPER GI ENDOSCOPY W/EUS 3933.00 06/30/10 43259 43259 43259 44.13 44.13 006 0360 3309
40100510 GI ENDO ULTRASOUND-RAD S+I 1265.00 06/30/10 76975 76975 76975 88.74 006 0402 3309
40100511 GI EUS RADIOLOGICAL INTERPRET 1265.00 06/30/10 76975 76975 76975 88.74 006 0402 3309
40100512 OTHER G-I CAPSULE-ENTEROSCOPY 1816.00 06/30/10 44376 44376 44376 45.14 45.14 006 0360 3309
40100514 ENTEROSCOPIC ILEUM BIOPSY 2266.00 06/30/10 44377 44377 44377 45.16 45.16 006 0360 3309
40100516 ENTERSCPY ILEUM; W/CNTRL BLEED 2950.00 06/30/10 44378 44378 44378 45.13 45.13 006 0360 3309
40100518 SIGMOIDSCOPY;W/CONTRL OF BLEED 1944.00 06/30/10 45334 45334 45334 45.24 45.24 006 0360 3309
40100524 INTRALUMINAL DILAT STRICT-RAD 475.00 06/30/10 74360 74360 74360 46.85 006 0320 3309
40100530 ESOPH MOTILITY STUDY 1180.00 06/30/10 91010 91010 91010 89.32 89.32 006 0750 3309
40100532 ESOPH;ACID REFLUX; PROLONG REC 1350.00 06/30/10 91038 91038 91038 89.39 89.39 006 0750 3309
40100534 INITIAL HEMORRHOID LIGATION 1381.00 06/30/10 46945 46945 46945 49.45 49.45 006 0360 3309
40100536 ULTRASOUND GUIDED LIVER BIOPSY 778.00 06/30/10 76942 76942 76942 88.76 006 0402 3309
40100538 LARGE VOLUME PARACENTESIS 1769.00 06/30/10 49420 49420 49420 54.91 54.91 006 0360 3309
40100540 BOTOX 412.00 06/30/10 64640 64640 64640 04.07 04.07 006 0360 3309
40100542 CONSCIOUS SEDATION 456.00 06/30/10 99143 99143 99143 89.68 89.68 006 0370 3309
40100544 FINE NEEDLE ASPIRATION CYTOLOG 485.00 06/30/10 10022 10022 10022 85.91 85.91 006 0360 3309
40100546 ULTRASD GUID FOR PARACENTESIS 778.00 06/30/10 76942 76942 76942 88.74 006 0402 3309
40100548 IV INFUS;UP TO 1 HR(MEDICARE) 174.00 06/30/10 96365 96365 96365 006 0260 3309
40100550 IV INFUSION; EACH ADD HOUR 580.00 06/30/10 96366 96366 96366 006 0260 3309
40100552 IV INFUSION:UP TO 1 HOUR 144.00 06/30/10 96365 96365 96365 006 0260 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 116
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40100554 INJECTION,ANESTHETIC AGENT 777.00 06/30/10 64530 64530 64530 05.31 006 0360 3309
40100557 NEUROLYSIS, CELIAC PLEXUS 617.00 06/30/10 64680 64680 64680 04.2 006 0360 3309
40100560 EGD WITH SUBMUCOSAL INJECTION 1987.00 06/30/10 43236 43236 43236 42.24 42.24 006 0360 3309
40100566 COLONOSCOPY W/SUBMUCOSAL INJ 1972.00 06/30/10 45381 45381 45381 45.43 45.43 006 0360 3309
40100575 24 HOUR PROBE 337.00 06/30/10 006 0270 3309
40100601 OCCULT BLOOD,FECES 62.00 06/30/10 82270 82270 82270 006 0301 3309
40100621 COLONOSCOPY SCRN LOW RISK(MED) 1954.00 06/30/10 G0121 G0121 45.23 006 0360 3309
40100623 COLONOSCOPY: REMOV BY ABLATION 2321.00 06/30/10 45383 45383 45383 45.43 45.43 006 0360 3309
40100626 EGD: REMOV HOT BX OR BIPOL CAU 2291.00 06/30/10 43250 43250 43250 006 0360 3309
40100630 UNLISTED PROCEDURE;INTESTINE 4036.00 06/30/10 44799 44799 44799 006 0360 3309
40100635 SIGMOID; PLACE STENT TRANSENDO 4783.00 06/30/10 45345 45345 45345 006 0360 3309
40100640 SIGMOID; REMOVAL BY ABLATION 2302.00 06/30/10 45339 45339 45339 006 0360 3309
40100645 SIGMOID;REMOVAL BY SNARE TECHN 1848.00 06/30/10 45338 45338 45338 006 0360 3309
40100650 SIGMOID:ULTRASOUND EXAMINATION 2120.00 06/30/10 45341 45341 45341 45.24 45.24 006 0360 3309
40100655 SIGMOID:ULTRASOUND FNA 3329.00 06/30/10 45342 45342 45342 006 0360 3309
40100657 ENDOSCOPY,BOWEL POUCH/BIOP 2306.00 06/30/10 44386 44386 44386 45.14 45.14 006 0360 3309
40100660 COLON/ST;PLACE STENT TRANSENDO 2357.00 06/30/10 44397 44397 44397 006 0360 3309
40100665 COLON/ST;REMOVAL BY ABLATION 2168.00 06/30/10 44393 44393 44393 006 0360 3309
40100670 COLON/ST;REMV HOT BX-BIPOL CAU 2168.00 06/30/10 44392 44392 44392 006 0360 3309
40100675 COLON/ST;REMOVAL OF FOR BODY 2168.00 06/30/10 44390 44390 44390 006 0360 3309
40100677 COLON PROX TO SPL FLEX W/ENDO 2871.00 06/30/10 45391 45391 45391 006 0360 3309
40100680 ESOPHSCOPY;CONT BLEED ANY METH 1465.00 06/30/10 43227 43227 43227 006 0360 3309
40100685 SMALL INTST;PLACE STNT TRNSEND 3891.00 06/30/10 44370 44370 44370 006 0360 3309
40100690 SMALL INTEST;REMOV BY ABLATION 2321.00 06/30/10 44369 44369 44369 006 0360 3309
40100695 G TUBE REMOVAL 120.00 06/30/10 99212 99212 99212 006 0510 3309
40100700 ENDO CATH BILI DUCTAL SYS RAD 485.00 06/30/10 74328 74328 74328 51.1 51.1 006 0320 3309
40100705 ENDO PATH BILIARY DUCT RAD 406.00 06/30/10 74328 74328 74328 51.1 51.1 006 0320 3309
40100711 EGD, US EXAM,ESOPHAGUS 2814.00 06/30/10 43237 43237 43237 42.33 42.33 006 0360 3309
40100714 EGD, US EXAM W/FNA, ESOPHAGUS 2756.00 06/30/10 43238 43238 43238 42.33 42.33 006 0360 3309
40100717 FLUOROSCOPY FOR G-TUBE PLCMNT 812.00 06/30/10 49440 49440 49440 43.11 43.11 006 0320 3309
40100719 J/D TUBE PLCEMNT -FLUORO GUID 812.00 06/30/10 49441 49441 49441 006 0320 3309
40100720 UNLISTED PROCEDURE-STOMACH 1174.00 06/30/10 43999 43999 43999 006 0360 3309
40100723 PH MONITORING-CATHETER BASED 1495.00 06/30/10 91034 91034 91034 006 0750 3309
40100726 BIL ENDO,INTRAOPER CHODCHSCPY 2243.00 06/30/10 47550 47550 47550 006 0360 3309
40100729 ESOPH INJ, SUBMUCOUSAL ANY SUB 1407.00 06/30/10 43201 43201 43201 006 0360 3309
40100750 UNLISTED GASTROENTER PROCEDURE EXTERNAL 02/01/03 91299 91299 91299 006 0750 3309
40101012 HOT BIOPSY DISPOSABLE FORCEPS 1278.00 06/30/10 006 0270 3309
40101015 DISPOSABLE ENTEROSCOPIC DEVICE 137.00 06/30/10 006 0270 3309
40101140 SPYSCOPE 10FR ACC&DEL CATHETER 2412.00 06/30/10 006 0270 3309
40101143 SPYGLASS FIBER OPTIC PROBE 762.00 06/30/10 006 0270 3309
40101146 SPYBITE BIOPSY FORCEPS 1572.00 06/30/10 006 0270 3309
40101149 AUTOLITH BIL PRBE(1.9FR,250CM) 1111.00 06/30/10 006 0270 3309
40111001 BRONCHOS W/BRUSH, WASH, LAVAGE 2274.00 06/30/10 31622 31622 31622 006 0360 3309
40111002 BRONCHOS W/ENDOBRONCH BIOPSY 2147.00 06/30/10 31625 31625 31625 006 0360 3309
40111003 BRONCHOS W/TRANSBRONCH BIOPSY 2441.00 06/30/10 31628 31628 31625 006 0360 3309
40111004 BRONCHOS W/TRNSBRONCH ASP BIOP 2718.00 06/30/10 31629 31629 31629 006 0360 3309
40111005 BRONCHOS W/FOREIGN BODY REMOVL 3901.00 06/30/10 31635 31635 31635 006 0360 3309
40111006 BRONCHOS W/BRONCH TOILET-INIT 2343.00 06/30/10 31645 31645 31645 006 0362 3309
40111007 BRONCHOS W/BRNCH TOILET-SUBSEQ 2343.00 06/30/10 31646 31646 31646 006 0360 3309
40111008 BRONCHOS W/TRACH/BRONCH DILATN 1787.00 06/30/10 31630 31630 31630 006 0360 3309
40111009 BRNCHSCOPY W/PL OF TRACH STNT 6241.00 06/30/10 31631 31631 31631 006 0360 3309
40112008 THORACENTESIS 383.00 06/30/10 32421 32421 32421 006 0360 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 117
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40112019 BRONCHOSCOPY -ADD'L LOBE 1057.00 06/30/10 31632 31632 31632 006 0360 3309
40112022 BRONCHOSCPY W/PL BRONCHIO STNT 2445.00 06/30/10 31636 31636 31636 006 0360 3309
40112025 BRONCHOSCOPY W/TUMOR EXCIS 2445.00 06/30/10 31641 31641 31641 006 0360 3309
40112031 BRONCHOSCPY W ADD'L STENTS 1056.00 06/30/10 31637 31637 31637 006 0360 3309
40410001 SPIROMETRY W/MAX VOLUNT VENTIL 255.00 06/30/10 94010 94010 94010 89.37 006 0460 3321
40410002 SPIROMETRY BEFORE/AFTER BRONCH 394.00 06/30/10 94060 94060 94060 89.37 006 0460 3321
40410006 AIRWAYS RESISTANCE 451.00 06/30/10 94360 94360 94360 89.38 006 0460 3321
40410010 THORACIC GAS VOLUME 413.00 06/30/10 94260 94260 94260 89.38 006 0460 3321
40410014 ARTERIAL PUNCTURE 159.00 06/30/10 36600 36600 36600 38.98 38.98 006 0510 3321
40410018 CARBON MONOXIDE DIFFUSING CAP 409.00 06/30/10 94720 94720 94720 89.38 006 0460 3321
40410022 AEROSOL CHALLENGE 683.00 06/30/10 94070 94070 94070 89.37 006 0460 3321
40410026 EXERCISE TESTING-SIX MIN WALK 414.00 06/30/10 94620 94620 94620 89.38 006 0460 3321
40410027 CARDIOPULMONARY EXERCISE TEST 584.00 06/30/10 93017 93017 93017 89.44 006 0482 3321
40410030 EXERCISE-OXYGEN DESATURATION 505.00 06/30/10 94680 94680 94680 89.38 006 0460 3321
40410034 MAX INSPIR AND EXPIR PRESSURES 108.00 06/30/10 94799 94799 94799 89.38 006 0460 3321
40410038 LUNG VOLUMES-HELIUM DILUTION 312.00 06/30/10 94240 94240 94240 89.38 006 0460 3321
40410040 CALORIMETRY 396.00 06/30/10 94681 94681 94681 89.38 006 0460 3321
40410042 SPIROMETRY BEDSIDE 255.00 06/30/10 94010 94010 94010 89.37 006 0460 3321
40410045 CO2 RESPONSE CURVE 312.00 06/30/10 94400 94400 94400 89.38 006 0460 3321
40410046 SPIROMETRY SCREENING 147.00 06/30/10 94010 94010 94010 89.37 006 0460 3321
40410047 HYPOXIA RESPONSE CURVE 312.00 06/30/10 94450 94450 94450 89.38 006 0460 3321
40410050 RESPIRATORY FLOW VOLUME LOOP 170.00 06/30/10 94375 94375 94375 89.38 006 0460 3321
40410054 AIRWAYS RESIST AFTER BRONCHODI 451.00 06/30/10 94360 94360 94360 89.38 006 0460 3321
40410058 THORAC GAS VOL AFTER BRONCHODI 413.00 06/30/10 94260 94260 94260 89.38 006 0460 3321
40410062 VITAL CAPACITY, TOTAL 87.00 06/30/10 94150 94150 94150 89.37 006 0460 3321
40410066 MAXIMUM VOLUNTARY VENTILATION 185.00 06/30/10 94200 94200 94200 89.37 006 0460 3321
40410070 ARTERIAL CATH; PERCUTANEOUS 149.00 06/30/10 36620 36620 36620 38.91 38.91 006 0360 3321
40410074 SPUTUM INDUCTION; INITIAL 91.00 06/30/10 94664 94664 94664 93.96 006 0460 3321
40410077 OXIMETRY, SINGLE 115.00 06/30/10 94760 94760 94760 89.38 006 0460 3321
40410078 OXIMETRY REST AND EXERCISE 161.00 06/30/10 94761 94761 94761 89.38 006 0460 3321
40410080 PULMONARY COMPLIANCE STUDY 779.00 06/30/10 94750 94750 94750 89.38 006 0460 3321
40410090 CONSCIOUS SEDATION 428.00 06/30/10 99144 99144 99144 89.68 006 0370 3321
40411001 BRONCHOS W/BRUSH, WASH, LAVAGE 2274.00 06/30/10 31622 31622 31622 33.24 33.24 006 0360 3321
40411002 BRONCHOS W/ENDOBRONCH BIOPSY 2147.00 06/30/10 31625 31625 31625 33.24 33.24 006 0360 3321
40411003 BRONCHOS W/TRANSBRONCH BIOPSY 2441.00 06/30/10 31628 31628 31628 33.27 33.27 006 0360 3321
40411004 BRONCHOS W/TRNSBRONCH ASP BIOP 2718.00 06/30/10 31629 31629 31629 33.26 33.26 006 0360 3321
40411005 BRONCHOS W/FOREIGN BODY REMOVL 3901.00 06/30/10 31635 31635 31635 98.15 98.15 006 0360 3321
40411006 BRONCHOS W/BRONCH TOILET-INIT 2343.00 06/30/10 31645 31645 31645 33.23 33.23 006 0360 3321
40411007 BRONCHOS W/BRNCH TOILET-SUBSEQ 2343.00 06/30/10 31646 31646 31646 33.23 33.23 006 0360 3321
40411008 BRONCHOS W/TRACH/BRONCH DILATN 1787.00 06/30/10 31630 31630 31630 33.91 33.91 006 0360 3321
40411009 BRNCHSCOPY W/PL OF TRACH STNT 6241.00 06/30/10 31631 31631 31631 33.23 33.23 006 0360 3321
40412001 CARDIAC OUTPUT; INITIAL W/CS 468.00 06/30/10 93561 93561 93561 89.68 89.98 006 0481 3321
40412002 CARDIAC OUTPUT; SUBSEQ W/CS 307.00 06/30/10 93562 93562 93562 89.68 89.68 006 0481 3321
40412003 CARDIOPULMONARY RESUSCITATION 551.00 06/30/10 92950 92950 92950 99.60 006 0480 3321
40412004 PLACEMENT CENT VEN CATH >AGE 5 1128.00 06/30/10 36556 36556 36556 38.95 38.95 006 0360 3321
40412005 CHEST TUBE INSERTION W/CS 661.00 06/30/10 32551 32551 32551 34.04 34.04 006 0360 3321
40412006 ENDOTRACHEAL INTUBATION 316.00 06/30/10 31500 31500 31500 96.04 96.04 006 0360 3321
40412007 BIOPSY PLEURA; PERCUTAN NEEDLE 750.00 06/30/10 32400 32400 32400 34.24 34.24 006 0360 3321
40412008 THORACENTESIS 383.00 06/30/10 32421 32421 32421 34.91 34.91 006 0360 3321
40412009 TRANSTHORACIC NEEDLE ASPIRATN 185.00 06/30/10 32420 32420 32420 34.91 34.91 006 0360 3321
40412010 TRANSTRACHEAL ASPIRATION 185.00 06/30/10 31612 31612 31612 31.99 31.99 006 0360 3321
40412011 PLACEMENT OF SWAN-GANZ CATH 516.00 06/30/10 93503 93503 93503 89.64 006 0480 3321
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 118
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40412012 PNEUMOTHORAX TUBE 872.00 06/30/10 32422 32422 32422 34.91 34.91 006 0360 3321
40412013 NON-BRONCHOSCOPIC BAL 426.00 06/30/10 31899 31899 31899 31.99 31.99 006 0360 3321
40412016 INTUBE,ENDOTRACH-EMERG PROC 252.00 06/30/10 31500 31500 31500 006 0460 3321
40412019 BRONCHOSCOPY -ADD'L LOBE 1057.00 06/30/10 31632 31632 31632 006 0360 3321
40412022 BRONCHOSCPY W/PL BRONCHIO STNT 2445.00 06/30/10 31636 31636 31636 006 0361 3321
40412025 BRONCHOSCOPY W/TUMOR EXCIS 2445.00 06/30/10 31641 31641 31641 006 0360 3321
40412031 BRONCHOSCPY W ADD'L STENTS 1056.00 06/30/10 31637 31637 31637 006 0360 3321
40412913 SAFE CENTESIS THORACIC TUBE 226.00 06/30/10 006 0270 3321
41010081 GASES, BLOOD; PH, PCO2, PO2 92.00 06/30/10 82803 82803 82803 006 0301 3330
41010082 GASES, BLOOD; BY OXIMETRY 64.00 06/30/10 82810 82810 82810 006 0301 3330
41010083 COAGULATION TIME; ACTIVATED 40.00 06/30/10 85347 85347 85347 006 0305 3330
41310083 EPS COAGULATION TIME ACTIVATED 40.00 06/30/10 85347 85347 85347 006 0305 3330
04300100 CD CHEST-COMPARISON ONLY N/C 06/30/10 007 0320 2006
04300103 CD CR-COMPARISON ONLY N/C 06/30/10 007 0320 2006
04300106 CD CHEST-READING ONLY N/C 06/30/10 007 0320 2006
04300109 CD CR-READING ONLY N/C 06/30/10 007 0320 2006
04300112 FL REPL OF G TUBE 91.00 06/30/10 49450 49450 49450 007 0361 2006
04300115 FL REPL OF J TUBE 622.00 06/30/10 49451 49451 49451 007 0361 2006
04300118 FL REPL OF GJ CODE 91.00 06/30/10 49452 49452 49452 007 0361 2006
04300121 FL CONT INJ-GASTRIC TUBE 264.00 06/30/10 49465 49465 49465 007 0361 2006
04300124 XR CHEST & ABD FOR PEDS 195.00 06/30/10 71010 71010 71010 007 0320 2006
04300500 FL LAP BAND ADJUSTMENT 526.00 06/30/10 74230 74230 74230TC 007 0320 2006
04301001 MAM SCREENING UNILATERAL-LT 461.00 06/30/10 7705752 7705752 7705752 007 0403 2006
04301002 MAM SCREENING UNILATERAL-RT 461.00 06/30/10 7705752 7705752 7705752 007 0320 2006
04302832 CARDIAC GATED EQUIL MULTI-VIEW 1383.00 06/30/10 78472 78472 78472TC 88.92 007 0341 2070
04307521 THERAPEUTIC PORT FILM(S) 122.00 06/30/10 77417 77417 77417TC 92.29 007 0333 2050
04307600 PV US BX LYMPH NODE 2103.00 06/30/10 38505 38505 38505 007 0361 2030
04307603 PV PERC INJ OF ABLATIVE AGENT 822.00 06/30/10 47399 47399 47399 007 0320 2030
04307606 PV US PARACENTESIS SURG SUBSEQ 1314.00 06/30/10 49081 49081 49081 007 0320 2030
04307609 PV DRAIN PELVIC ABSCESS PERC 3584.00 06/30/10 58823 58823 58823 007 0361 2030
04307612 PV US BX PANCREAS NDLE 1728.00 06/30/10 48102 48102 48102 007 0320 2030
04307615 PV US BX THYROID CORE NDLE LT 1026.00 06/30/10 60100LT 60100LT 60100LT 007 0320 2030
04307618 PV US BX THYROID CORE NDLE RT 1026.00 06/30/10 60100RT 60100RT 60100RT 007 0320 2030
04307621 PV REMOVAL INDW TUNNEL CATH 253.00 06/30/10 32552 32552 32552 007 0361 2030
04307624 PV FIBRINOLYS VIA CHEST TUBE 992.00 06/30/10 32561 32561 32561 007 0361 2030
04307627 PV FIBRINO VIA CHST TUBE-SUBSQ 992.00 06/30/10 32562 32562 32562 007 0361 2030
04307906 NON IONIC CNTRST 300MG(50ML) 46.00 06/30/10 Q9962 Q9962 Q9962 007 0636 2030
04307933 ANGIO BRACHIAL RETROGRADE S&I 1933.00 06/30/10 75658 75658 75658 88.49 007 0323 2030
04307943 ANGIOGRAPHY ARTERIOUNEOUS SHUN 647.00 06/30/10 75791 75791 75791TC 88.49 007 0323 2030
04307945 ANGIOGRAM THRU EXISTING CATH 869.00 06/30/10 75898 75898 75898 88.49 007 0323 2030
04307952 PV CLOT REMOVAL 4148.00 06/30/10 36870 36870 36870 007 0361 2030
04307955 PV CHEST TUBE-EMPYEMA 1301.00 06/30/10 32551 32551 32551 007 0361 2030
04307958 PV PLEURODESIS 947.00 06/30/10 32560 32560 32560 007 0361 2030
04307961 PV BLOOD SPEC-IMPLANT DEVICE 99.00 06/30/10 36591 36591 36591 007 0361 2030
04307964 PV BLOOD SPEC-CENTRAL LINE 134.00 06/30/10 36592 36592 36592 007 0361 2030
04307967 PV CHEM DECLOTTING-VASC ACCESS 453.00 06/30/10 36593 36593 36593 007 0361 2030
04307970 PV PL OF J TUBE 1547.00 06/30/10 49441 49441 49441 007 0361 2030
04307973 PV PL OF CECOSTOMY TUBE 1986.00 06/30/10 49442 49442 49442 007 0361 2030
04307976 PV CONVERSION GTUBE TO GJ TUBE 1547.00 06/30/10 49446 49446 49446 007 0361 2030
04307979 PV REPL OF G TUBE 622.00 06/30/10 49450 49450 49450 007 0361 2030
04307982 PV REPL OF J TUBE 622.00 06/30/10 49451 49451 49451 007 0361 2030
04307985 PV REPL OF GJ TUBE 622.00 06/30/10 49452 49452 49452 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 119
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04307988 PV MECH REMOV-GASTRIC TUBE 591.00 06/30/10 49460 49460 49460 007 0361 2030
04307991 PV CONT INJ-GASTRIC TUBE 264.00 06/30/10 49465 49465 49465 007 0361 2030
04307994 PV REMV/REPL-URE STNT VIA URE 4324.00 06/30/10 50385 50385 50385 007 0361 2030
04307997 PV RMV-URETERAL STNT VIA URETH 1440.00 06/30/10 50386 50386 50386 007 0361 2030
04308000 PV ASP-BLADDER BY NEEDLE 367.00 06/30/10 51100 51100 51100 007 0361 2030
04308003 PV ASP-BLDDER TROCAR-INTRACATH 189.00 06/30/10 51101 51101 51101 007 0361 2030
04308006 PV ASP-BLDR W INSRT SPPUB CATH 3520.00 06/30/10 51102 51102 51102 007 0361 2030
04308010 PV GAS ARGON 421.00 06/30/10 007 0270 2030
04308012 PV GAS HELIUM ULTRA PURITY 421.00 06/30/10 007 0270 2030
04308228 BRACHYTHERAPY RADIOELEMENTS 465.00 06/30/10 Q3001 Q3001 Q3001 99.99 007 0270 2070
04308230 NM IN 111 DTPA PER 0.5 MCI 3133.00 06/30/10 A9548 A9548 A9548 99.99 007 0343 2070
04308231 NM CERETEC UPTO 25MCI 1687.00 06/30/10 A9521 A9521 A9521 99.99 007 0636 2070
04308234 THALLIUM TL-201,DIAG-PER MCI 108.00 06/30/10 A9505 A9505 A9505 99.99 007 0343 2070
04308238 NM DIPYRIDAMOLE PERS PER 10 MG 42.00 06/30/10 J1245 J1245 J1245 007 0636 2070
04308239 P32 CHROMIC PHOSPHATE 15 MCI 5204.00 06/30/10 Q3001 Q3001 Q3001 99.99 007 0270 2070
04308240 NM P32 SODIUM PHOS PER MCI 377.00 06/30/10 A9563 A9563 A9563 99.99 007 0344 2070
04308242 MOAB TUMOR IMAGING (OVARIAN) 1485.00 06/30/10 78803 78803 78803TC 88.38 007 0341 2070
04308243 MOAB TUMOR IMAGING (COLON) 1485.00 06/30/10 78803 78803 78803TC 88.38 007 0341 2070
04308244 MOAB TUMOR IMAGING (PROSTATE) 1485.00 06/30/10 78803 78803 78803TC 88.38 007 0341 2070
04308245 ULTRA TAG KIT 150.00 06/30/10 A4641 A4641 A4641 99.99 007 0636 2070
04308246 NM PROSTASCINT UD 7819.00 06/30/10 A9507 A9507 A9507 99.99 007 0343 2070
04308249 NM MYOVIEW PER STUDY DOSE 257.00 06/30/10 A9502 A9502 A9502 007 0343 2070
04308303 GLIASITE ACESS/REMOVAL KIT 279.00 06/30/10 A4649 A4649 A4649 007 0270 2070
04308306 NM I-123 DIAG UPTO 10MCI 4750.00 06/30/10 A9582 A9582 A9582 007 0636 2070
04308714 SCHILLING I 580.00 06/30/10 78270 78270 78270TC 92.04 007 0341 2070
04308722 SCHILLING II (IFC) 662.00 06/30/10 78271 78271 78271TC 92.04 007 0341 2070
04309480 COMPUTER IMAGE PROCESS >30 MIN 250.00 06/30/10 78891 78891 78891TC 92.19 007 0341 2070
04310001 CT VIR COLONSCPY-DIAG W/O CONT 1142.00 06/30/10 74261 74261 74261TC 007 0350 2040
04310004 CT VIR COLONSCOPY-DIAG W CONT 1314.00 06/30/10 74262 74262 74262TC 007 0350 2040
04310007 CA CT HEART W CONT-FUNCTIONAL 1187.00 06/30/10 75572 75572 75572TC 007 0350 2040
04310010 CA CT HEART W CNT - DISEASE ST 1514.00 06/30/10 75573 75573 75573TC 007 0350 2040
04310223 CT SCAN FOR NEEDLE BIOPSY 1608.00 06/30/10 77012 77012 77012TC 88.38 007 0350 2040
04310800 NM MYO PERF SPECT REST/EX-SGLE 2036.00 06/30/10 78451 78451 78451TC 007 0340 2070
04310803 NM MYO PERF SPECT REST/EX-MULT 2036.00 06/30/10 78452 78452 78452TC 007 0340 2070
04310806 NM MYO PERF REST/EX-SINGLE 2036.00 06/30/10 78453 78453 78453TC 007 0340 2070
04310809 NM MYO PERF REST/EX-MULTI 2036.00 06/30/10 78454 78454 78454TC 007 0340 2070
04310812 NM I-123 DIAG PER STUDY <15MCI 7700.00 06/30/10 A9582 A9582 A9582 007 0343 2070
04310815 NM SAMARIUM 153 PER DSE<150MCI 566.00 06/30/10 A9604 A9604 A9604 007 0343 2070
04310900 LIVER - SPECT 1690.00 06/30/10 78205 78205 78205TC 88.97 007 0341 2070
04310902 BONE - SPECT 1505.00 06/30/10 78320 78320 78320TC 92.14 007 0341 2070
04310907 BRAIN IMAGING (SPECT) 1821.00 06/30/10 78607 78607 78607TC 88.91 007 0341 2070
04310908 RENAL IMAGING (SPECT) DMSA 1161.00 06/30/10 78710 78710 78710TC 92.03 007 0341 2070
04310910 MYO PERF IMAG SINGL STDY-REINJ 793.00 06/30/10 78451 78451 78451TC 88.92 007 0341 2070
04310915 BRAIN IMAG COMPLETE W/VAS FLOW 1485.00 06/30/10 78606 78606 78606TC 88.91 007 0341 2070
04310917 KIDNEY IMAG W/VASC FLOW & FUNC 1161.00 06/30/10 78707 78707 78707TC 92.03 007 0341 2070
04310918 RENAL IMAG VASC FLW/LASIX STIM 1296.00 06/30/10 78708 78708 78708TC 92.03 007 0341 2070
04310919 RENAL TRANSPLANT EVALUATION 1161.00 06/30/10 78707 78707 78707TC 92.03 007 0341 2070
04310921 VOL-DILUTION-LEAKAGE-PLASMA VI 695.00 06/30/10 78111 78111 78111TC 88.97 007 0341 2070
04310924 MONOCLONAL AB TUMOR LOCL SPECT 1485.00 06/30/10 78803 78803 78803TC 88.38 007 0341 2070
04310925 NM ONCOSCINT UPTO 6MCI 3381.00 06/30/10 A9542 A9542 A9542 99.99 007 0343 2070
04310926 INDIUM-111 CHLORIDE 1740.00 06/30/10 A4641 A4641 A4641 99.99 007 0636 2070
04310929 NM SR-89 (METASTRON)RX PER MCI 1960.00 06/30/10 A9600 A9600 A9600 007 0344 2070
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 120
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04310930 BONE PAIN PALIATION THERAPY 2136.00 06/30/10 79101 79101 79101TC 92.19 007 0342 2070
04310931 PARATHYROID IMAGING 1014.00 06/30/10 78070 78070 78070TC 88.97 007 0341 2070
04310932 NM CARDIOLITE UPTO 40MCI 339.00 06/30/10 A9500 A9500 A9500 99.99 007 0636 2070
04310936 GALLIUM ABSCSS LOCALIZ-WH BODY 1654.00 06/30/10 78806 78806 78806TC 92.18 007 0340 2070
04310939 HEPATOBIL (SER IMAG) & PHR INT 1392.00 06/30/10 78223 78223 78223TC 88.74 007 0340 2070
04310941 BONE SCAN, MULTIPHASE STUDY 1702.00 06/30/10 78315 78315 78315TC 88.31 007 0340 2070
04310948 NMU ACUTECT TC99M (VIAL) 1703.00 06/30/10 A9504 A9504 78990 99.99 007 0343 2070
04310967 LTD GALLIUM IMAG 1216.00 06/30/10 78800 78800 78800TC 92.12 007 0341 2070
04310975 MN P-32 THERAPY (POLYCYTHEMIA) 1357.00 06/30/10 79101 79101 79101TC 92.05 007 0342 2070
04310980 NM MOAB RADIOLABELED THERAPY 1745.00 06/30/10 79403 79403 79403TC 007 0342 2070
04310983 NM TUMOR LOCAL WB 2 DAYS OR > 2313.00 06/30/10 78804 78804 78804TC 007 0341 2070
04310986 NM VENGRM-MAA LOWER EX BILAT 1000.00 06/30/10 78458 78458 78458TC 007 0341 2070
04310989 NM THERAPY HYPERTHYROIDSM 1237.00 06/30/10 79005 79005 79005TC 007 0342 2070
04311138 PV DUPLEX SCAN EXTR VEINS-BL 495.00 06/30/10 93970 93970 93970 007 0921 2030
04311800 BIOPSY LUNG/MEDIASTUM PERCT NE 1940.00 06/30/10 32405 32405 32405 34.25 34.25 007 0360 2030
04311812 TRANSLUMINAL B-ANGIOPLAS AORTI 4019.00 06/30/10 35472 35472 35472 39.59 39.59 007 0361 2030
04311815 TRANSLUMB-ANGIOPLASTY BRACHEOC 3538.00 06/30/10 35475 G0392 35475 39.59 39.59 007 0361 2030
04311816 TRANSLUMINAL B-ANGIOPLAS VENOU 3497.00 06/30/10 35476 35476 35476 39.59 39.59 007 0361 2030
04311823 INTRO CATH SUPERLINE VENA CAVA 1146.00 06/30/10 36010 36010 36010 38.99 38.99 007 0361 2030
04311825 SEL CATH PLCE VENOUS 2ND ORD 1316.00 06/30/10 36012 36012 36012 38.93 38.93 007 0361 2030
04311832 ARTERIO VENOUS SHUNT FOR DIALY 1200.00 06/30/10 36147 36147 36147 007 0361 2030
04311837 SCP ABD/PELVIC/LW EXTREM 1ST O 1399.00 06/30/10 36245 36245 36245 38.91 38.91 007 0361 2030
04311849 INSERT OF IMPLANT VEN ACC PORT 2448.00 06/30/10 36557 36557 36557 86.07 86.07 007 0361 2030
04311876 LIVER BIOPSY 1471.00 06/30/10 47000 47000 47000 50.11 50.11 007 0361 2030
04311879 PERCUTANEOUS CHOLECYSTOSTOMY 3204.00 06/30/10 47490 47490 47490 51.03 51.03 007 0361 2030
04311882 INTRODUC PERC TRANHEPATIC CATH 2116.06 06/30/10 47510 47510 47510 38.93 38.93 007 0361 2030
04311889 INSERT INTRAPERITONEAL CAN OR 3076.00 06/30/10 49420 49420 49420 54.93 54.93 007 0361 2030
04311893 PV INJ PYLGRPHY THRU TUBE-LT 411.00 06/30/10 50394 50394LT 50394LT 87.75 87.75 007 0361 2030
04311899 CISTERNAL/LATERAL CERVICAL PUN 787.00 06/30/10 61055 61055 61055 03.92 03.92 007 0361 2030
04311900 SPINAL PUNCTURE, LUMBAR, DIAGN 334.00 06/30/10 62270 62270 62270 03.31 03.31 007 0361 2030
04311901 INJECTION FOR MYELOGRAM 730.00 06/30/10 62284 62284 62284 87.21 87.21 007 0361 2030
04311907 CT DISP SYRINGE & TUBING 76.00 06/30/10 007 0621 2040
04311909 CT LOW EXTREM W/WO CNTRST LT 2154.00 06/30/10 73702LT 73702LT 73702TC 88.38 007 0350 2040
04311912 CT LOW EXTREM W/CNTRST LT 1857.00 06/30/10 73701LT 73701LT 73701TC 88.38 007 0350 2040
04311915 CT LOW EXTREM W/O CNTRST LT 1558.00 06/30/10 73700LT 73700LT 73700TC 88.38 007 0350 2040
04311918 CT UP EXTREM W/WO CNTRST LT 2154.00 06/30/10 73202LT 73202LT 73202TC 007 0350 2040
04311921 CT UP EXTREM W/CNTRST LT 1857.00 06/30/10 73201LT 73201LT 73201TC 88.38 007 0350 2040
04311924 CT UP EXTRM W/O CNTRST LT 1558.00 06/30/10 73200LT 73200LT 73200TC 88.38 007 0350 2040
04311958 PV UROGRAPHY,ANTEGRADE S&1-LT 579.00 06/30/10 74425LT 74425LT 74425TC 87.73 007 0320 2030
04311966 TRANSCATHETER INTRO INTRAVAS S 3378.00 06/30/10 75960 75960 75960TC 38.93 007 0320 2030
04311981 ANGIOGRAPHY SUPPLIES GROUP 1 93.00 06/30/10 007 0621 2030
04311984 PV G/J TUBE 875.00 06/30/10 B4087 B4087 B4087 007 0621 2030
04311987 PV GLIDE CATHETER 1000.00 06/30/10 C1760 C1760 C1760 007 0621 2030
04312000 PV MARKING CATHETER 385.00 06/30/10 C1760 C1760 C1760 007 0255 2030
04312003 PV MAGIC TORQUE WIRE EXTERNAL 08/22/97 C1769 C1769 C1769 007 0621 2030
04312005 VENOGRAPHY EXTREM UNILAT S & I 772.00 06/30/10 75820 75820 75820TC 88.66 007 0323 2030
04312014 AORTOGRAPHY ABD W/BILAT ILIOF 2161.00 06/30/10 75630 75630 75630 88.42 007 0323 2030
04312024 FLUOROSCOPY VASCULAR PROCEDURE 1072.00 06/30/10 76001 76001 76001TC 89.04 007 0320 2030
04312049 SCP THOR/BRACHIOCEPHAL 3RD ORD 1888.00 06/30/10 36217 36217 36217 38.91 38.91 007 0361 2030
04312052 TRANSCATH EMBOLIZATION-INT CRN 5489.00 06/30/10 61624 61624 61624 38.81 38.81 007 0361 2030
04312054 EMBOLIZATION AUM, FISTULA 5092.00 06/30/10 61710 61710 61710 38.80 38.80 007 0361 2030
04312055 EMBOLIZATION AVM SPINAL 5092.00 06/30/10 62294 62294 62294 39.53 39.53 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 121
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04312066 TRANSCATHETER THERAPY INFUSION 4669.00 06/30/10 75896 75896 75896TC 89.04 007 0323 2030
04312071 ANGIO ADRENAL UNILAT SELEC S&I 3318.00 06/30/10 75731 75731 75731TC 88.47 007 0323 2030
04312072 ANGIO ADRENAL BILAT SELEC S&I 3318.00 06/30/10 75733 75733 75733TC 88.47 007 0323 2030
04312078 VENOGRAPHY SINUS/JUG CATH S&I 2313.00 06/30/10 75860 75860 75860TC 88.61 007 0323 2030
04312079 VENOGRAPHY SUPER SAG SINUS S&I 2313.00 06/30/10 75870 75870 75870TC 88.61 007 0323 2030
04312087 TRANSLUM BAL ANGIO VENOUS S&I 3023.00 06/30/10 75978 75978 75978TC 89.04 007 0323 2030
04312096 CT KIT, DRAINAGE 313.00 06/30/10 007 0621 2040
04312101 CT ABLATION NEEDLE 8373.00 06/30/10 007 0272 2040
04312104 CT COPY FILM 12.00 06/30/10 007 0621 2040
04312111 CT BIOPSY ASPIRATION TRAY 118.00 06/30/10 007 0621 2040
04312113 CT ORBIT SELLA EAR W/O CONTR 1605.00 06/30/10 70480 70480 70480TC 87.03 87.03 007 0350 2040
04312114 CT ORBIT SELL POST EAR W/CONTR 1905.00 06/30/10 70481 70481 70481 87.03 87.03 007 0350 2040
04312115 CT ORBIT SELL EAR W + W/O CON 2202.00 06/30/10 70482 70482 70482TC 87.03 87.03 007 0350 2040
04312116 CT MAXILLOFACIAL W/O CONTRAST 1605.00 06/30/10 70486 70486 70486TC 87.09 007 0350 2040
04312117 CT MAXILLOFACIAL WITH CONTRAST 1905.00 06/30/10 70487 70487 70487TC 87.03 87.03 007 0350 2040
04312118 CT MAXILLOFACIAL W + W/O CONTR 2202.00 06/30/10 70488 70488 70488TC 87.03 87.03 007 0350 2040
04312119 CT SOFT TISSUE NECK W/O CONTRA 1429.00 06/30/10 70490 70490 70490TC 87.09 007 0350 2040
04312120 CT SOFT TISSUE NECK W/CONTRAST 1727.00 06/30/10 70491 70491 70491TC 87.09 007 0350 2040
04312121 CT SOFT TISSUE NECK W-W/O CONT 2026.00 06/30/10 70492 70492 70492TC 87.09 007 0350 2040
04312122 CT CHEST W/O CONTRAST 1723.00 06/30/10 71250 71250 71250TC 87.41 007 0350 2040
04312123 CT CHEST WITH CONTRAST 2018.00 06/30/10 71260 71260 71260TC 87.41 007 0350 2040
04312124 CT CHEST W + W/O CONTRAST 2317.00 06/30/10 71270 71270 71270TC 87.41 007 0350 2040
04312125 CT CERVICAL SPINE W/O COTRAST 1774.00 06/30/10 72125 72125 72125TC 88.38 007 0350 2040
04312126 CT CERVICAL SPINE WITH CONTRAS 2074.00 06/30/10 72126 72126 72126TC 88.38 007 0350 2040
04312127 CT CERVICAL SPINE W + W/O CONT 2370.00 06/30/10 72127 72127 72127TC 88.38 007 0350 2040
04312128 CT THORACIC SPINE W/O CONTRAST 1725.00 06/30/10 72128 72128 72128TC 88.38 007 0350 2040
04312129 CT THORACIC SPINE WITH CONTRST 2028.00 06/30/10 72129 72129 72129TC 88.38 007 0350 2040
04312130 CT THORACIC SPINE W + W/O CONT 2319.00 06/30/10 72130 72130 72130TC 88.38 007 0350 2040
04312131 CT LUMBAR SPINE W/O CONTRAST 1906.00 06/30/10 72131 72131 72131TC 88.38 007 0350 2040
04312132 CT LUMBAR SPINE WITH CONTR 2203.00 06/30/10 72132 72132 72132TC 88.38 007 0350 2040
04312133 CT LUMBAR SPINE W + W/O CONTRA 2502.00 06/30/10 72133 72133 72133TC 88.38 007 0350 2040
04312134 CT PELVIS W/O CONTRAST 1603.00 06/30/10 72192 72192 72192TC 88.38 007 0350 2040
04312135 CT PELVIS WITH CONTRAST 1902.00 06/30/10 72193 72193 72193TC 88.38 007 0350 2040
04312136 CT PELVIS WITH + W/O CONTRAST 2200.00 06/30/10 72194 72194 72194TC 88.38 007 0350 2040
04312143 CT SCAN FOR NEEDLE BIOPSY 1608.00 06/30/10 77012 77012 77012TC 88.38 007 0350 2040
04312144 CT SCAN FOR LOCALIZATION 1608.00 06/30/10 77011 77011 77011TC 88.38 007 0350 2040
04312146 CT LIMITED/LOCALIZED FOLLOW-UP 407.00 06/30/10 76380 76380 76380TC 88.38 007 0350 2040
04312148 CTA NECK INCL POST PROCESSING 2120.00 06/30/10 70498 70498 70498TC 87.04 87.04 007 0350 2040
04312149 CTA ABD,AORTA &ILEOFEMORAL +3D 1600.00 06/30/10 75635 75635 75635TC 88.01 007 0350 2040
04312150 CTA HEAD INCL POST PROCESSING 1766.00 06/30/10 70496 70496 70496TC 87.04 87.04 007 0350 2040
04312152 CTA ABDOMEN INCL POST PROCESSI 1882.00 06/30/10 74175 74175 74175TC 88.01 007 0350 2040
04312156 ASPIR&INJ RNL CYST/PELV-NDL LT 1167.00 06/30/10 50390 50390LT 50390LT 007 0361 2040
04312158 ASPIR&INJ RNL CYST/PELV-NDL RT 1167.00 06/30/10 50390 50390RT 50390RT 007 0361 2040
04312160 BIOPSY BONE TROCAR OR NDLE DEP 1204.36 06/30/10 20225 20225 20225 77.49 77.49 007 0361 2040
04312162 BIOPSY LIVER NDLE PERCUTANEOUS 1471.00 06/30/10 47000 47000 47000 50.11 50.11 007 0361 2040
04312164 BIOPSY OF SALIVARY GLAND NEEDL 486.00 06/30/10 42400 42400 42400 26.11 26.11 007 0361 2040
04312166 BIOPSY PANCREAS PERCUTAN NDLE 1199.00 06/30/10 48102 48102 48102 52.11 52.11 007 0361 2040
04312168 BIOPSY,MUSCLE, PERCUTAN NDLE 805.00 06/30/10 20206 20206 20206 83.21 83.21 007 0361 2040
04312169 BIOPSY, PLEURA; PERCUTAN NDLE 750.00 06/30/10 32400 32400 32400 34.24 34.24 007 0361 2040
04312170 BX ABD/RETROPER MASS PERQ NDLE 1199.00 06/30/10 49180 49180 49180 54.22 54.22 007 0361 2040
04312172 BX BONE TROCAR/NEEDLE SUPERFIC 736.00 06/30/10 20220 20220 20220 77.49 77.49 007 0361 2040
04312174 BX LUNG/MEDIAST PERCUT NDLE LT 1940.00 06/30/10 32405 32405LT 32405LT 33.27 33.27 007 0361 2040
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 122
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04312176 BX LUNG/MEDIAST PERCUT NDLE RT 1940.00 06/30/10 32405 32405RT 32405RT 33.27 33.27 007 0361 2040
04312178 BX SPINAL CORD PERCUTAN NEEDLE 857.00 06/30/10 62269 62269 62269 03.32 03.32 007 0361 2040
04312180 BX THYROID PERCUTAN CORE NDLE 486.00 06/30/10 60100 60100 60100 06.11 06.11 007 0361 2040
04312183 CISTERNAL PUNC W/INJ MED-DX/TX 699.00 06/30/10 61055 61055 61055 01.01 01.01 007 0361 2040
04312185 CNTRST INJ ABS PRV CATH SEP PR 319.00 06/30/10 49424 49424 49424 007 0361 2040
04312187 CT LOW EXTRM W/&W/O CONTR BILA 4304.00 06/30/10 7370250 7370250 73702TC 88.38 88.38 007 0350 2040
04312189 CT LOWER EXTRM W/&W/O CONTR RT 2154.00 06/30/10 73702RT 73702RT 73702TC 88.38 88.38 007 0350 2040
04312191 CT LOWER EXTREM W/CNTRST BILAT 3112.00 06/30/10 7370150 7370150 73701TC 88.38 88.38 007 0350 2040
04312192 CT LOWER EXTREM W/CNTRST RIGHT 1857.00 06/30/10 73701RT 73701RT 73701TC 88.38 88.38 007 0350 2040
04312196 CT LOW EXTREM W/O CONTRST RT 1558.00 06/30/10 73700RT 73700RT 73700TC 88.38 88.38 007 0350 2040
04312204 CT UPPER EXTREMITY W/CNTRST RT 1857.00 06/30/10 73201RT 73201RT 73201TC 88.38 88.38 007 0350 2040
04312208 CT UP EXTREM W/O CONTRST RIGHT 1558.00 06/30/10 73200RT 73200RT 73200TC 88.38 88.38 007 0350 2040
04312212 CTA LE INCL POST PROCESSING-LT 1726.00 06/30/10 73706LT 73706LT 73706TC 007 0350 2040
04312214 CTA LE INCL POST PROCESSING-RT 1726.00 06/30/10 73706RT 73706RT 73706TC 007 0350 2040
04312216 CTA PELVIS W/WO CONTRAST 1660.00 06/30/10 72191 72191 72191TC 007 0350 2040
04312219 CTA UE INCL POST PROCESSING-LT 1610.00 06/30/10 73206LT 73206LT 73206TC 007 0350 2040
04312221 CTA UE INCL POST PROCESSING-RT 1610.00 06/30/10 73206RT 73206RT 73206TC 007 0350 2040
04312225 CT DRAIN PERIRENAL/RNL ABS LT 2557.00 06/30/10 50021 50021LT 50021LT 55.01 55.01 007 0361 2030
04312227 CT DRAIN PERIRENAL/RNL ABS RT 2557.00 06/30/10 50021 50021RT 50021RT 55.01 55.01 007 0361 2030
04312229 DRAIN PERITONEAL ABSC; PERQ 1179.00 06/30/10 49021 49021 49021 007 0361 2040
04312231 DRAIN RETROPERITONEAL ABS PERQ 1070.00 06/30/10 49061 49061 49061 007 0361 2040
04312233 DRAIN SUBDIAPHRAGMA ABSC PERQ 1070.00 06/30/10 49041 49041 49041 54.91 54.91 007 0361 2040
04312235 EXT DRN PSEUDOCYST PANC PERCUT 1066.90 06/30/10 48511 48511 48511 52.01 52.01 007 0360 2040
04312237 HEPATOT PERC DRN ABSC 1/2STAGE 1070.00 06/30/10 47011 47011 47011 007 0361 2040
04312239 I&D APPENDICEAL ABSC PERCUTANE 1070.00 06/30/10 44901 44901 44901 47.2 47.2 007 0361 2040
04312241 INJ PROC MYELOGRAPHY&CAT SPINA 730.00 06/30/10 62284 62284 62284 007 0361 2040
04312243 CT DRAIN RENAL PELVIS PERQ LT 4479.00 06/30/10 50392 50392LT 50392LT 007 0361 2030
04312245 CT DRAIN RENAL PELVIS PERQ RT 4479.00 06/30/10 50392 50392RT 50392RT 007 0361 2030
04312247 CT INTRO URETER CTH RNL PLV LT 6168.00 06/30/10 50393 50393LT 50393LT 007 0361 2030
04312249 CT INTRO URETER CTH RNL PLV RT 6168.00 06/30/10 50393 50393RT 50393RT 007 0361 2030
04312251 PERQ ASPIR SPIN CORD CYST/SYRN 910.00 06/30/10 62268 62268 62268 03.31 03.31 007 0361 2040
04312253 PNEUMONOSTW/PERQ DRN ABSC/CYST 576.00 06/30/10 32201 32201 32201 007 0361 2040
04312255 RENAL BX PERQ TROCAR/NDLE LEFT 1573.00 06/30/10 50200 50200LT 50200LT 55.23 55.23 007 0361 2040
04312257 RENAL BX PERQ TROCAR/NDLE RGHT 1573.00 06/30/10 50200 50200RT 50200RT 55.23 55.23 007 0361 2040
04312259 THORACENTESIS ASPIR NIT/SUBSQT 824.00 06/30/10 32421 32421 32421 007 0361 2040
04312265 DENTA SCAN-1 ARCH N/C 06/30/10 007 0350 2040
04312266 DENTA SCAN-2 ARCH N/C 06/30/10 007 0350 2040
04312270 CT UP ESTRM W/WO CONTRAST RT 2154.00 06/30/10 73202RT 73202RT 73202TC 88.38 007 0350 2040
04312273 CT PERC LIVER ABLATION 7820.00 06/30/10 47382 47382 47382 50.29 50.29 007 0361 2040
04312276 CT BONE ABLATION INCL CT GUIDE 6492.00 06/30/10 20982 20982 20982 007 0361 2040
04312279 LOW OSMLR (300-349MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2040
04312282 LOW OSMLR (350-399MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2040
04312285 CT GUIDE PARENCHYML TISS ABLAT 1210.00 06/30/10 77013 77013 77013TC 007 0350 2040
04312288 CTA CHEST N-C POST PROCESSING 2120.00 06/30/10 71275 71275 71275TC 007 0350 2040
04312291 CT LOW OSMLR(300-399MG)CONT/MI 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2040
04312540 OUTSIDE READING-ROCKFORD N/C 06/30/10 007 0999 2006
04312550 CONSCIOUS SEDATION 456.00 06/30/10 99143 99143 99143 89.68 007 0370 2006
04313441 RAD TRT DEL-INTR 6-10 MEV 904.00 06/30/10 77408 77408 77408TC 92.29 007 0333 2050
04313458 RAD TRT DEL-CPLX 6-10 MEV 1075.00 06/30/10 77413 77413 77413TC 92.29 007 0333 2050
04313466 RAD TRT DEL-SMPL-20+ MEV 1004.00 06/30/10 77406 77406 77406TC 92.29 007 0333 2050
04313474 RAD TRT DEL-INTR-20+ MEV 1145.00 06/30/10 77411 77411 77411TC 92.29 007 0333 2050
04313482 RAD TRT DEL-CPLX-20+ MEV 789.00 06/30/10 77416 77416 77416TC 92.29 007 0333 2050
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 123
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04313524 SPECIAL PORT PLAN 831.00 06/30/10 77321 77321 77321TC 92.29 007 0333 2050
04313532 BRACHY ISODOSE INTERMEDIATE 1152.00 06/30/10 77327 77327 77327TC 92.29 007 0333 2050
04313540 BRACHY ISODOSE COMPLEX 1552.00 06/30/10 77328 77328 77328TC 92.29 007 0333 2050
04313543 HDR SOURCE CHARGE 329.00 06/30/10 C1717 C1717 C1717 007 0278 2050
04313546 BRACHY SOURCE,NON-HDR,IR-192 EXTERNAL 01/01/06 C1719 007 0278 2050
04313549 BRACHY SOURCE,NO-STRANDED I125 123.00 06/30/10 Q3001 Q3001 Q3001 007 0278 2050
04313555 BRACHY SOURCE,HI-INTENS,I125 432.00 06/30/10 C2634 C2634 C2634 007 0278 2050
04313573 INTRACAVIT APP/EXT SIMPLE 1719.00 06/30/10 77761 77761 77761TC 92.28 007 0333 2050
04313581 INTRACAVITARY APPLICATION INTR 2549.00 06/30/10 77762 77762 77762TC 92.27 007 0333 2050
04313599 INTERSTITIAL APPLICATION INTR 2655.00 06/30/10 77777 77777 77777TC 92.29 007 0333 2050
04313601 REMOTE AFTER HD BRACHY-1 CHAN 3153.00 06/30/10 77785 77785 77785TC 92.29 007 0333 2050
04313602 REM AFTER HD BRACY 2-12 CHAN 2511.00 06/30/10 77786 77786 77786TC 92.29 007 0333 2050
04313603 REM AFTERLD HD BRACHY >12 CHAN 2052.00 06/30/10 77787 77787 77787TC 92.29 007 0333 2050
04313604 HDR BRACHY OVER 12 SOURCE POSN 1870.00 06/30/10 77784 77784 77784TC 92.29 007 0333 2050
04313607 T-P SIMULATOR INTR 3099.00 06/30/10 77285 77285 77285TC 88.39 007 0333 2050
04313615 TREAT DEVICES SMPL 447.00 06/30/10 77332 77332 77332TC 92.29 007 0333 2050
04313649 TREAT DEVICES INTR 563.00 06/30/10 77333 77333 77333TC 92.29 007 0333 2050
04313656 TREAT DEVICES CPX 901.00 06/30/10 77334 77334 77334TC 92.29 007 0333 2050
04313658 WKLY MEDICAL RAD PHYS CONSULT 537.00 06/30/10 77336 77336 77336TC 92.29 007 0333 2050
04313659 SPECIAL PHYSICS SERVICE 568.00 06/30/10 77370 77370 77370TC 92.29 007 0333 2050
04313661 3-D RECONSTRUC-STEREO TREATMNT 4674.00 06/30/10 77295 77295 77295TC 88.39 007 0333 2050
04313662 STEREOTACTIC MGMT CEREBRAL 255.00 06/30/10 77432 77432 77432TC 92.29 007 0333 2050
04313663 STEREOTACTIC TREATMENT 2709.00 06/30/10 G0251 G0251 G0251 92.29 007 0333 2050
04313673 HEAD MASK FABRICATION 1782.00 06/30/10 77334 77334 77334TC 92.29 007 0333 2050
04313674 WKLY MED PHYS CONSUL-STEREO 537.00 06/30/10 77336 77336 77336TC 92.29 007 0333 2050
04313677 MLC DEVICE(S)FOR INTEN MOD THE 488.00 06/30/10 77338 77338 77338 007 0333 2050
04313710 PROVISION OF RADIOISOTOPES EXTERNAL 01/10/95 92.19 007 0333 2050
04313711 3-D RECONSTRUCT/SIMULATION 4674.00 06/30/10 77295 77295 77295TC 88.39 007 0333 2050
04313712 CT SCAN FOR LOCALIZATION 1532.00 06/30/10 77011 77011 77011TC 88.38 007 0350 2050
04313713 US GUIDE,INTRAOP 772.00 06/30/10 76998 76998 76998TC 87.03 007 0402 2050
04313714 SPECIAL TREATMENT 2004.00 06/30/10 77470 77470 77470TC 92.29 007 0333 2050
04313715 LIGHT-CAST ACCESSORY 901.00 06/30/10 77334 77334 77334TC 92.29 007 0333 2050
04313716 ALPHA CRADLE ACCESSORY 901.00 06/30/10 77334 77334 77334TC 92.29 007 0333 2050
04313717 CONTRAST MEDIA 310.00 06/30/10 007 0255 2050
04313718 RAD TRMT-SIMPLE (11-19MEV) 904.00 06/30/10 77404 77404 77404TC 92.29 007 0333 2050
04313719 RAD TRMT-INTR (11-19 MEV) 904.00 06/30/10 77409 77409 77409TC 92.29 007 0333 2050
04313720 RAD TRMT-CPLX (11-19 MEV) 895.00 06/30/10 77414 77414 77414TC 92.29 007 0333 2050
04313721 CONTOUR DRAWING 200.00 06/30/10 77399 77399 77399TC 92.29 007 0333 2050
04313723 CT CONTRAST NON-IONIC (50 ML) 170.00 06/30/10 007 0255 2050
04313724 CT CONTRAST NON-IONIC (100 ML) 331.00 06/30/10 007 0255 2050
04313725 CT CONTRAST NONIONIC (150 ML) 484.00 06/30/10 007 0255 2050
04313728 LOW OSMLR (300-349MG) CONT/ML 3.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2050
04313790 COPY X-RAYS (EACH) 36.00 06/30/10 007 0621 2050
04313791 COPY X-RAYS (5-10) 140.00 06/30/10 007 0621 2050
04313792 COPY X-RAYS (10-20) 271.00 06/30/10 007 0621 2050
04313793 COPY RT MEDICAL RECORDS 117.00 06/30/10 007 0621 2050
04313901 DUPLEX LOWER EXTR ARTER LIMIT 394.00 06/30/10 93926 93926 93926 88.77 007 0921 2035
04313903 DUPLEX UPPER EXTRA ARTER LIMIT 765.00 06/30/10 93931 93931 93931 92.19 007 0921 2035
04313904 DUPLEX EXTREMITY VEINS CPL 744.00 06/30/10 93970 93970 93970 92.19 007 0921 2035
04313905 DUPLEX EXTREMITY VEINS LIMIT 722.00 06/30/10 93971 93971 93971 92.19 007 0921 2035
04313906 DUPLEX ART, VEN ABD/PEL/RET 1046.00 06/30/10 93975 93975 93975 88.76 007 0921 2035
04313907 DUPLEX AORTA IVC ILIAC CPL 955.00 06/30/10 93978 93978 93978 92.19 007 0921 2035
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 124
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04313909 DUPLEX SCAN PENILE VESSEL FLOW 765.00 06/30/10 93980 93980 93980 88.79 007 0921 2035
04313911 US RESEARCH PERONEAL ARTERY N/C 06/30/10 93981 93981 93981 007 0402 2035
04313953 ULTRASON GUDINCE NEEDLE BIOPSY 778.00 06/30/10 76942 76942 76942TC 88.79 007 0402 2035
04313961 ECHO PREGNANT UTERUS; COMPLETE 901.00 06/30/10 76801 76801 76801TC 88.78 007 0402 2035
04313987 US GUIDE,INTRAOP 769.00 06/30/10 76998 76998 76998TC 88.79 007 0402 2035
04313992 US BLADDER/RESIDUAL 701.00 06/30/10 51798 51798 51798 007 0361 2035
04313995 ECHO NEONATAL HEAD 446.00 06/30/10 76506 76506 76506TC 88.71 007 0402 2035
04314000 SM BOWEL MULT FILMS-ENTERO CTH 851.00 06/30/10 74251 74251 74251TC 96.08 007 0320 2006
04314002 X-RAYS,BONE SURVEY,INFANT 704.00 06/30/10 77076 77076 77076TC 88.33 007 0320 2006
04314007 HIP, ARTHROGRAPHY, LEFT-S/I 800.00 06/30/10 73525LT 73525LT 73525TC 88.32 007 0320 2006
04314017 SWALLOW FUNC PHAR/ESOPH W/VIDE 249.00 06/30/10 74230 74230 74230TC 007 0320 2006
04314018 UPPER GI SNG CONTRAST W/O KUB 337.00 06/30/10 74240 74240 74240TC 007 0320 2006
04314050 ECHO PROSTATE, TRANSRECTAL 193.00 06/30/10 76872 76872 76872TC 88.79 007 0402 2035
04314051 US EXAM K TRANSPL W/DOPPLER 558.00 06/30/10 76776 76776 76776TC 88.75 007 0402 2035
04314052 ULTRASON GUIDE CYST/RENAL ASP 778.00 06/30/10 76942 76942 76942TC 88.79 007 0402 2035
04314053 ECHO RETROPERITONEAL; LIMITED 495.00 06/30/10 76775 76775 76775TC 88.76 007 0402 2035
04314055 ECHO GUIDE PERC ABSCESS DRN SI 886.00 06/30/10 75989 75989 75989TC 89.04 007 0402 2035
04314058 US BLADDER 485.00 06/30/10 76857 76857 76857TC 007 0402 2035
04314061 US GROIN 485.00 06/30/10 76857 76857 76857TC 007 0402 2035
04314064 US PROSTATE NON-TRANSRECTAL 485.00 06/30/10 76857 76857 76857 007 0402 2035
04314067 US PANCREAS TRANSPLANT W DOPP 264.00 06/30/10 93976 93976 93976 007 0921 2035
04314070 US IVC W DOPP 382.00 06/30/10 76705 76705 76705 007 0402 2035
04314073 US SOFT TISSUE CHEST/ABD 365.00 06/30/10 76880 76880 76880 007 0402 2035
04314076 US BX GUN ADDITIONAL 354.00 06/30/10 007 0270 2035
04314079 US GUIDE WIRE 267.00 06/30/10 99070 99070 99070 007 0270 2035
04314082 US CATHETER ADDITIONAL 267.00 06/30/10 99070 99070 007 0270 2035
04314085 US BEDSIDE EXAM 155.00 06/30/10 99060 99060 99060 007 0510 2035
04315010 CHEST,PA & LAT W/APICAL PROJ 187.00 06/30/10 71021 71021 71021TC 87.44 007 0320 2006
04315011 CHEST,PA & LAT W/OBL PROJCTS 187.00 06/30/10 71022 71022 71022TC 87.44 007 0320 2006
04315012 CHEST, TWO VIEWS W/FLOUROSCOPY 250.00 06/30/10 71023 71023 71023TC 87.44 007 0320 2006
04315016 RIBS, BILAT INC PA CHEST 462.00 06/30/10 71111 71111 71111TC 87.43 007 0320 2006
04315017 VIDEO SWALLOW FUNCTION 526.00 06/30/10 74230 74230 74230TC 87.69 007 0320 2006
04315020 UPPER GI SNG CONTRAST SM BOWEL 915.00 06/30/10 74245 74245 74245TC 87.62 007 0320 2006
04315022 UPPER GI AIR CONTRAST W KUB 924.00 06/30/10 74247 74247 74247TC 87.62 007 0320 2006
04315023 UPPER GI AIR CONT W SM BOWEL 967.00 06/30/10 74249 74249 74249TC 87.62 007 0320 2006
04315025 COLON AIR CONTR W HIGH DEN BAR 861.00 06/30/10 74280 74280 74280TC 87.65 007 0320 2006
04315026 COLON, THERAPEUT FOR INTUSSUSC 846.00 06/30/10 74283 74283 74283TC 87.61 007 0320 2006
04315027 FORGN BODY/CHILD NOSE/REC/1FIL 120.00 06/30/10 76010 76010 76010TC 88.33 007 0320 2006
04315028 CYSTOGRAPHY, S & I 641.00 06/30/10 74430TC 74430 74430 87.77 007 0320 2006
04315029 MAMMOGRAM, ONE BREAST 252.00 06/30/10 77055 77055 77055TC 87.37 007 0401 2006
04315031 SPINE, ENTIRE, SURVY STDY AP&L 362.00 06/30/10 72010 72010 72010TC 87.29 007 0320 2006
04315032 SPINE, SINGLE VIEW-CERVICAL 231.00 06/30/10 72020 72020 72020TC 87.29 007 0320 2006
04315033 SPINE, THORACIC, AP & LAT W/SW 358.00 06/30/10 72072 72072 72072TC 87.23 007 0320 2006
04315035 SPINE,LMBSCRL BNDING VWS ONLY 283.00 06/30/10 72120 72120 72120TC 87.24 007 0320 2006
04315036 PELVIS, COMPLETE MIN 3 VIEWS 384.00 06/30/10 72190 72190 72190TC 88.26 007 0320 2006
04315043 UPPER EXTREMITY, INFANT AP &LA 249.00 06/30/10 73092 73092 73092TC 88.22 007 0320 2006
04315046 HAND, TWO VIEWS 199.00 06/30/10 73120 73120 73120TC 88.23 007 0320 2006
04315049 HIPS, BILATERAL INC AP PELVIS 374.00 06/30/10 73520 73520 73520TC 88.26 007 0320 2006
04315050 PELVIS & HIPS INF/CHILD 2 VIEW 196.00 06/30/10 73540 73540 73540TC 88.26 007 0320 2006
04315053 BOTH KNEES, STANDING AP 221.00 06/30/10 73565 73565 73565TC 88.27 007 0320 2006
04315054 LOWER EXTREMITY, INFANT AP&LAT 339.00 06/30/10 73592 73592 73592TC 88.27 007 0320 2006
04315057 ABDOMEN, ACUTE/OBSTRUCTIVE 319.00 06/30/10 74022 74022 74022TC 88.19 007 0320 2006
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 125
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04315058 X-RAYS,BONE LENGTH STUDIES 179.00 06/30/10 77073 77073 77073TC 88.39 007 0320 2006
04315059 MAM SCREENING BILAT 191.00 06/30/10 77057 77057 77057TC 87.37 007 0403 2006
04315061 MAM NDLE LOC ADDTL(CHOOSE S&I) 924.00 06/30/10 19291 19291 19291 85.99 85.99 007 0361 2006
04315065 CATHETER, OB/GYN SPECIAL 101.00 06/30/10 007 0272 2006
04315067 MAMMOGRAM, SCREENING 191.00 06/30/10 77057 77057 77057TC 87.37 007 0403 2006
04315068 MAM SCREENING WHI 191.00 06/30/10 77057 77057 77057TC 87.37 007 0403 2006
04315070 MAM SCREENING-EMPLOYEE 191.00 06/30/10 77057 77057 77057TC 87.37 007 0403 2006
04315071 ELBOW-RT, AP & LAT 206.00 06/30/10 73070RT 73070RT 73070TC 88.22 007 0320 2006
04315072 ELBOW-LT, AP & LAT 206.00 06/30/10 73070LT 73070LT 73070TC 88.22 007 0320 2006
04315074 SHOULDER, RIGHT, ONE VIEW 223.00 06/30/10 73020RT 73020RT 73020TC 87.21 007 0320 2006
04315075 SHOULDER, LEFT, ONE VIEW 223.00 06/30/10 73020LT 73020LT 73020TC 87.21 007 0320 2006
04315076 HIP-RT, UNILATERAL, 1 VIEW 217.00 06/30/10 73500RT 73500RT 73500TC 88.26 007 0320 2006
04315077 HIP-LT, UNILATERAL, 1 VIEW 217.00 06/30/10 73500LT 73500LT 73500TC 88.26 007 0320 2006
04315078 KNEE-RIGHT, 3 VIEWS 305.00 06/30/10 73562RT 73562RT 73562TC 88.27 007 0320 2006
04315079 KNEE-LEFT, 3 VIEWS 305.00 06/30/10 73562LT 73562LT 73562TC 88.27 007 0320 2006
04315080 WRIST-LEFT, PA & LAT 196.00 06/30/10 73100LT 73100LT 73100TC 88.23 007 0320 2006
04315081 WRIST-RIGHT, PA & LAT 196.00 06/30/10 73100RT 73100RT 73100TC 88.23 007 0320 2006
04315082 KNEE-LEFT, 4+ VIEWS 283.00 06/30/10 73564LT 73564LT 73564TC 88.27 007 0320 2006
04315083 KNEE- RIGHT, 4+ VIEWS 283.00 06/30/10 73564RT 73564RT 73564TC 88.27 007 0320 2006
04315084 FOOT-LEFT, AP & LAT 214.00 06/30/10 73620LT 73620LT 73620TC 88.28 007 0320 2006
04315085 FOOT-RIGHT, AP & LAT 214.00 06/30/10 73620RT 73620RT 73620TC 88.28 007 0320 2006
04315088 ANKLE-RIGHT, AP & LAT 199.00 06/30/10 73600RT 73600RT 73600TC 88.28 007 0320 2006
04315089 ANKLE-LEFT, AP & LAT 199.00 06/30/10 73600LT 73600LT 73600TC 88.28 007 0320 2006
04315101 GUIDANCE FOR NEEDLE, BREAST 445.00 06/30/10 77032LT 77032LT 77032TC 89.04 007 0320 2006
04315105 RIBS 3 VIEWS+PA CHEST LT 371.00 06/30/10 71101 71101 71101TC 87.43 007 0320 2006
04315109 RIBS LT - 2 VIEWS 283.00 06/30/10 71100LT 71100LT 71100TC 87.43 007 0320 2006
04315110 MANDIBLE 4 VIEWS OR MORE 316.00 06/30/10 70110 70110 70110TC 87.16 007 0320 2006
04315111 HIP DURING OPERAT PROCED-LT 672.00 06/30/10 73530 73530 73530TC 88.26 007 0320 2006
04315113 HIP ARTHROGRAPHY CT S&I 800.00 06/30/10 73525LT 73525LT 73525TC 88.32 007 0320 2006
04315115 X-RAY OF MAMMARY DUCTSLT 518.00 06/30/10 77053LT 77053LT 77053TC 89.04 007 0320 2006
04315116 ABSC FISTULA/SINUS TRACT S&I 595.00 06/30/10 76080 76080 76080TC 89.04 007 0320 2006
04315118 MAM NDLE LOC LT(CHOOSE S&I) 904.00 06/30/10 19290 19290LT 19290LT 85.99 007 0361 2006
04315121 STEREOTACT GUID FOR BRST BX-LT 957.00 06/30/10 77031LT 77031LT 77031TC 85.19 007 0320 2006
04315123 SPINE CERVICAL 1 VIEW 231.00 06/30/10 72020 72020 72020TC 87.29 007 0320 2006
04315124 FACIAL BONES-3 OR MORE VIEWS 310.00 06/30/10 70150 70150 70150TC 87.16 007 0320 2006
04315127 SI JOINTS 3 OR MORE VIEWS 283.00 06/30/10 72202 72202 72202TC 88.26 007 0320 2006
04315130 MAMMOGRAM, ONE BREAST- LT 200.00 06/30/10 77055LT 77055LT 77055TC 87.37 007 0401 2006
04315133 MAMMOGRAM,ONE BREAST- RT 200.00 06/30/10 77055RT 77055RT 77055TC 87.37 007 0401 2006
04315136 MAMMOGRAM-BILAT 368.00 06/30/10 77056GG 77056GG 77056TC 87.37 007 0401 2006
04315139 MAMMOGRAM-LT 368.00 06/30/10 77055GGL 77055GGL 77055TC 87.37 007 0401 2006
04315142 MAMMOGRAM-RT 368.00 06/30/10 77055GGR 77055GGR 77055TC 87.37 007 0401 2006
04315145 MAM US UNI OR BILAT 286.00 06/30/10 76645 76645 76645TC 88.73 007 0402 2006
04315148 MAM US GUID NDLE PLCM S&I BILA 1321.00 06/30/10 7694250 7694250 76942TC 88.79 007 0402 2006
04315151 MAM US GUIDE NDLE PLCMT S&I LT 740.00 06/30/10 76942LT 76942LT 76942TC 88.79 007 0402 2006
04315154 MAM US GUIDE NDLE PLCMT S&I RT 740.00 06/30/10 76942RT 76942RT 76942TC 88.79 007 0402 2006
04316061 US DRAIN SUBCT HEMAT/FLUID/SER 2183.00 06/30/10 10140 10140 10140 007 0360 2035
04316064 US PROSTATE NON-TRANSRECTAL 485.00 06/30/10 76857TC 76857 76857 007 0402 2035
04317448 PV FINE NDLE ASP W/O IMAG GUID 286.00 06/30/10 10021 10021 10021 007 0361 2030
04317449 PV FINE NEEDLE ASP W IMAG GUID 484.00 06/30/10 10022 10022 10022 007 0320 2030
04317452 PV US DRN SUBCT HEM/FLUID/SER 428.00 06/30/10 10140 10140 10140 007 0361 2030
04317467 CONSCIOUS SEDATION 394.00 06/30/10 99144 99144 99144 99.29 99.29 007 0370 2030
04317468 PSEUDOANEURYSM TX INJ-THROMBIN 302.00 06/30/10 36002 36002 36002 007 0320 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 126
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04317470 PV NON TUNNELED C-LINE <5YRS 1081.00 06/30/10 36555 36555 36555 007 0361 2030
04317473 PV NON TUNNELE C-LINE >5YRS 1128.00 06/30/10 36556 36556 36556 007 0361 2030
04317476 PV TUNNEL CATH <5 YEARS 2228.00 06/30/10 36557 36557 36557 007 0361 2030
04317479 PV TUNNEL CATH 5 YRS OR OLDER 2228.00 06/30/10 36558 36558 36558 007 0361 2030
04317482 PV CHEST PORT <5 YRS 2742.00 06/30/10 36560 36560 36560 007 0361 2030
04317485 PV CHEST PORT 5 YRS OR OLDER 3133.00 06/30/10 36561 36561 36561 007 0361 2030
04317488 PV ARM PORT <5 YRS 2742.00 06/30/10 36570 36570 36570 007 0361 2030
04317491 PV ARM PORT 5 YRS OR OLDER 3921.00 06/30/10 36571 36571 36571 007 0361 2030
04317494 PV PICC LINE <5 YRS 1081.00 06/30/10 36568 36568 36568 007 0361 2030
04317497 PV PICC LINE 5 YRS OR OLDER 1128.00 06/30/10 36569 36569 36569 007 0361 2030
04317500 PV REPAIR C-LINE 1389.00 06/30/10 36575 36575 36575 007 0361 2030
04317503 PV REPAIR PORT 851.00 06/30/10 36576 36576 36576 007 0361 2030
04317506 PV QUINTON, C-LINE CHANGE 770.00 06/30/10 36580 36580 36580 007 0361 2030
04317509 PV TUNNEL CATH CHANGE 1748.00 06/30/10 36581 36581 36581 007 0361 2030
04317512 PV PICC LINE CHANGE 1462.00 06/30/10 36584 36584 36584 007 0361 2030
04317515 PV CHEST PORT CHANGE 2100.00 06/30/10 36582 36582 36582 007 0361 2030
04317518 PV ARM PORT CHANGE 2013.00 06/30/10 36585 36585 36585 007 0361 2030
04317521 PV TUNNEL CATH REMOVAL 738.00 06/30/10 36589 36589 36589 007 0361 2030
04317524 PV PORT REMOVAL 1034.00 06/30/10 36590 36590 36590 007 0361 2030
04317527 PV FIBRIN SHEATH STRIP 4746.00 06/30/10 36595 36595 36595 007 0361 2030
04317530 PV C-LINE REPOSITION 768.56 06/30/10 36597 36597 36597 007 0361 2030
04317533 PV DECLOT C-LINE-TPA INF/WIRE 1126.00 06/30/10 36596 36596 36596 007 0361 2030
04317536 PV DECLOT CATH - TPA 2130.00 06/30/10 36593 36593 36593 007 0361 2030
04317539 PV VENIPUNCT AGE 3 OR OLDER 105.00 06/30/10 36410 36410 36410 38.93 38.93 007 0361 2030
04317545 PV ULT GUIDE VAS ACCESS W/DOC 340.00 06/30/10 76937 76937 76937TC 88.79 88.79 007 0402 2030
04317548 FLUROGUIDE FOR VEIN DEVICE 351.00 06/30/10 77001 77001 77001TC 39.50 39.50 007 0323 2030
04317551 PV ULT GUIDE NEEDLE PLACEMENT 778.00 06/30/10 76942 76942 76942TC 88.79 88.79 007 0402 2030
04317554 MOD SEDATION ADD 15 MIN 77.00 06/30/10 99145 99145 99145 007 0370 2006
04317556 PV LIVER BX W OTHER PROC. 1401.00 06/30/10 47001 47001 47001 007 0361 2030
04317557 MOD SEDATION<5 YRS-30 MIN 390.00 06/30/10 99143 99143 99143 007 0370 2006
04317560 MOD SEDATION> 5YRS-30 MIN 296.00 06/30/10 99144 99144 99144 007 0370 2006
04317569 PV UNLISTED VASCULAR PROCEDURE 2850.00 06/30/10 37799 37799 37799 007 0361 2030
04317572 PV LOOPOGRM/UROGRAPH ANTEGRADE 580.00 06/30/10 74425 74425 74425TC 007 0320 2030
04317601 PV NEW PT OFFICE VISIT-LEVEL I 100.00 06/30/10 99201 99201 99201 007 0510 2030
04317602 PV NEW PT OFFICE VISIT-LEV II 120.00 06/30/10 99202 99202 99202 007 0510 2030
04317603 PV NEW PT OFF VISIT-LEVEL III 155.00 06/30/10 99203 99203 99203 007 0510 2030
04317604 PV NEW PT OFFICE VISIT-LEV IV 197.00 06/30/10 99204 99204 99204 007 0510 2030
04317605 PV NEW PT OFFICE VISIT-LEVEL V 225.00 06/30/10 99205 99205 99205 007 0510 2030
04317611 PV ESTAB PT OFF VISIT LEV I 100.00 06/30/10 99211 99211 99211 007 0510 2030
04317612 PV ESTAB PT OFF VISIT LEVEL II 120.00 06/30/10 99212 99212 99212 007 0510 2030
04317613 PV ESTAB PT OFF VISIT LEV III 155.00 06/30/10 99213 99213 99213 007 0510 2030
04317614 PV ESTAB PT OFF VISIT LEV IV 197.00 06/30/10 99214 99214 99214 007 0510 2030
04317615 PV ESTAB PT OFF VISIT LEV V 225.00 06/30/10 99215 99215 99215 007 0510 2030
04319999 CT ANIMAL RESEARCH 511.00 06/30/10 007 0329 2040
04320001 INJECTION SINUS TRACT;DIAG 819.00 06/30/10 20501 20501 20501 007 0361 2030
04320004 ENDVASC ABDO REPAIR W/TUBE 4850.00 06/30/10 34800 34800 34800 007 0360 2030
04320007 ENDOVASC ABDO REPAIR W/DEVICE 5139.00 06/30/10 34802 34802 34802 007 0360 2030
04320010 ENDO VASC ABDO REPAIR W/DEVICE 5995.00 06/30/10 34804 34804 34804 007 0361 2030
04320013 ENDOVASC ABDO OCCLUD DEVICE 4522.00 06/30/10 34808 34808 34808 007 0360 2030
04320016 ENDOVASC EXTEND PROSTH, INIT 5995.00 06/30/10 34825 34825 34825 007 0360 2030
04320019 ENDOVASC EXTEN PROSTH,ADDL 4850.00 06/30/10 34826 34826 34826 007 0360 2030
04320022 ENDOVASC ILIAC REPR W/GRAFT BI 7707.00 06/30/10 3490050 3490050 3490050 007 0360 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 127
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04320025 ENDOVASC ILIAC REPR W/GRAFT LT 4850.00 06/30/10 34900LT 34900LT 34900LT 007 0360 2030
04320028 ENDOVASC ILIAC REPR W/GRAFT RT 4850.00 06/30/10 34900RT 34900RT 34900RT 007 0360 2030
04320031 TRNSLM BLN ANGP OP RNAL ART BI 5507.00 06/30/10 3545050 3545050 3545050 007 0361 2030
04320034 TRNSLM BLN ANGP OP RNAL ART LT 3636.00 06/30/10 35450LT 35450LT 35450LT 007 0361 2030
04320037 TRNSLM BLN ANGP OP RNAL ART RT 3636.00 06/30/10 35450RT 35450RT 35450RT 007 0361 2030
04320040 TRNSLUM BLN ANGP OPEN AORTIC 3636.00 06/30/10 35452 35452 35452 007 0361 2030
04320043 TRNSLUM BLN ANGP OPEN ILIAC BI 5507.00 06/30/10 3545450 3545450 3545450 007 0361 2030
04320046 TRNSLUM BLN ANGP OPEN ILIAC LT 3636.00 06/30/10 35454LT 35454LT 35454LT 007 0361 2030
04320049 TRNSLUM BLN OPEN ILIAC RT 3636.00 06/30/10 35454RT 35454RT 35454RT 007 0361 2030
04320052 TRNSLUM BLN ANGP OPN FEMPOP BI 5507.00 06/30/10 3545650 3545650 3545650 007 0361 2030
04320055 TRNSLUM BLN ANGP OPN FEMPOP LT 3636.00 06/30/10 35456LT 35456LT 35456LT 007 0361 2030
04320058 TRNSLUM BLN ANGP OPN FEMPOP RT 3636.00 06/30/10 35456RT 35456RT 35456RT 007 0361 2030
04320061 TRNSLM BLN ANGP OP BRA/BRNC BI 4818.00 06/30/10 3545850 3545850 3545850 007 0361 2032
04320064 TRNSLM BLN ANGP OP BRA/BRNC-LT 3497.00 06/30/10 35458LT 35458LT 35458LT 007 0361 2032
04320067 TRNSLM BLN ANGP OP BRA/BRNC RT 3497.00 06/30/10 35458RT 35458RT 35458RT 007 0361 2032
04320070 TRNSLM BLN ANGP OP TIB-PER LT 3636.00 06/30/10 35459LT 35459LT 35459LT 007 0361 2030
04320073 TRNSLM BLN ANGP OP TIB-PER RT 3636.00 06/30/10 35459RT 35459RT 35459RT 007 0361 2030
04320076 TRNSLM BLN ANGP OP TIB-PER BI 5507.00 06/30/10 3545950 3545950 3545950 007 0361 2030
04320079 TRNSLM BLN ANGP OPEN VENOUS 3636.00 06/30/10 35460 35460 35460 007 0361 2030
04320082 TRNSLM BLN PQ TIB-PERBR LT 3497.00 06/30/10 35470LT 35470LT 35470LT 007 0361 2030
04320085 TRNSLM BLN PQ TIB-PERBR RT 3497.00 06/30/10 35470RT 35470RT 35470RT 007 0361 2030
04320088 TRNSLM BLN PQ TIB-PERBR BI 5125.00 06/30/10 3547050 3547050 3547050 007 0361 2030
04320091 TRNSLM BLN ANG PER RNL ART BI 6091.00 06/30/10 3547150 3547150 3547150 007 0361 2030
04320094 TRNSLM BLN ANG PER RNL ART LT 4121.00 06/30/10 35471LT 35471LT 35471LT 007 0361 2030
04320097 TRNSLM BLN ANG PER RNL ART RT 4121.00 06/30/10 35471RT 35471RT 35471RT 007 0361 2030
04320100 TRASLUM B-ANGIOPLAS PQ AORTIC 3642.00 06/30/10 35472 35472 35472 39.59 39.59 007 0361 2032
04320103 TRNSLUM BLN ANG PERQ;ILIAC BI 4919.00 06/30/10 3547350 3547350 3547350 007 0361 2030
04320106 TRNSLUM BLN ANG PERQ;ILIAC LT 3937.00 06/30/10 35473LT 35473LT 35473LT 007 0361 2030
04320109 TRNSLUM BLN ANG PERQ;ILIAC RT 3937.00 06/30/10 35473RT 35473RT 35473RT 007 0361 2030
04320112 TRNSLUM BLN ANG PER FEMPOP BI 4976.00 06/30/10 3547450 3547450 3547450 007 0361 2030
04320115 TRNSLUM BLN ANG PER FEMPOP LT 4885.00 06/30/10 35474LT 35474LT 35474LT 007 0361 2030
04320118 TRNSLUM BLN ANG PER FEMPOP RT 4885.00 06/30/10 35474RT 35474RT 35474RT 007 0361 2030
04320121 TRNSLM BLN ANGP PG BRA/BRNC BI 5366.00 06/30/10 3547550 3547550 3547550 007 0361 2032
04320124 TRNSLM BLN ANGP PG BRA/BRNC LT 3642.00 06/30/10 35475LT 35475LT 35474LT 007 0361 2032
04320127 TRNSLM BLN ANGP PG BRA/BRNC RT 3642.00 06/30/10 35475RT 35475RT 35475RT 007 0361 2032
04320130 TRANSLUMINAL B-ANGIOPLAS VENOU 3642.00 06/30/10 35476 35476 35476 39.59 39.59 007 0361 2032
04320133 TRNSLM PERPH ATHERT PRQ RNL BI 6439.00 06/30/10 3549050 3549050 3549050 007 0361 2030
04320136 TRNSLM PERPH ATHERT PRQ RNL LT 5473.00 06/30/10 35490LT 35490LT 35490LT 007 0361 2030
04320139 TRNSLM PERPH ATHERT PRQ RNL RT 5473.00 06/30/10 35490RT 35490RT 35490RT 007 0361 2030
04320142 TRNSLM PERPH ATHERT PRQ AORTIC 4791.00 06/30/10 35491 35491 35491 39.50 39.50 007 0361 2032
04320145 TRNSLM PERPH ATHR PRQ ILIAC BI 6439.00 06/30/10 3549250 3549250 3549250 007 0361 2030
04320148 TRNSLM PERPH ATHR PRQ ILIAC LT 5473.00 06/30/10 35492LT 35492LT 35492LT 007 0361 2030
04320151 TRNSLM PERPH ATHR PRQ ILIAC RT 5473.00 06/30/10 35492RT 35492RT 35492RT 007 0361 2030
04320154 TRNSLM PERPH ATHR PQ FEMPOP BI 6439.00 06/30/10 3549350 3549350 3549350 007 0361 2030
04320157 TRNSLM PERPH ATHR PQ FEMPOP LT 5473.00 06/30/10 35493LT 35493LT 35493LT 007 0361 2030
04320160 TRNSLM PERPH ATHR PQ FEMPOP RT 5473.00 06/30/10 35493RT 35493RT 35493RT 007 0361 2030
04320163 TRNSLM PRPH ATHR PQ BRA/BRN BI 6439.00 06/30/10 3549450 3549450 3549450 007 0361 2032
04320166 TRNSLM PRPH ATHR PQ BRA/BRN LT 4791.00 06/30/10 35494LT 35494LT 35494LT 007 0361 2032
04320169 TRNSLM PRPH ATHR PQ BRA/BRN RT 4791.00 06/30/10 35494RT 35494RT 35494RT 007 0361 2032
04320172 TRNSLM PRPH ATHR PQ TIB-PER BI 6439.00 06/30/10 3549550 3549550 3549550 007 0361 2030
04320175 TRNSLM PRPH ATHR PQ TIB-PER LT 5473.00 06/30/10 35495LT 35495LT 35495LT 007 0361 2030
04320178 TRNSLM PRPH ATHR PQ TIB-PER RT 5473.00 06/30/10 35495RT 35495RT 35495RT 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 128
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04320181 PLACE NEEDLE IN VEIN 298.00 06/30/10 36000 36000 36000 38.93 38.93 007 0361 2032
04320184 INJECT EXTREMITY VENOGRAPHY BI 1373.00 06/30/10 3600550 3600550 3600550 007 0361 2030
04320187 INJECT EXTREMITY VENOGRAPHY LT 787.00 06/30/10 36005LT 36005LT 36005LT 007 0361 2030
04320190 INJECT EXTREMITY VENOGRAPHY RT 787.00 06/30/10 36005RT 36005RT 36005RT 007 0361 2030
04320193 INTRO CATH SUP/INF VENA CAVA 1146.00 06/30/10 36010 36010 36010 38.99 38.99 007 0361 2030
04320196 SEL CATH PLCMT VNOUS#1 ORD BI 1359.00 06/30/10 3601150 3601150 3601150 007 0361 2030
04320199 SEL CATH PLCMT VNOUS #1 ORD-LT 1000.00 06/30/10 36011LT 36011LT 36011LT 007 0361 2030
04320202 SEL CATH PLCMT VNOUS #1 ORD-RT 1000.00 06/30/10 36011RT 36011RT 36011RT 007 0361 2030
04320205 SEL CATH PLCMT VNOUS #2 ORD BI 1884.00 06/30/10 3601250 3601250 3601150 007 0361 2030
04320208 SEL CATH PLCMT VNOUS #2 ORD LT 1252.00 06/30/10 36012LT 36012LT 36012LT 007 0361 2030
04320211 SEL CATH PLCMT VNOUS #2 ORD RT 1252.00 06/30/10 36012RT 36012RT 36012RT 007 0361 2030
04320214 INTRO CATH RT HRT OR MAIN PUL 902.00 06/30/10 36013 36013 36013 38.91 38.91 007 0361 2030
04320217 SELECT CATH PLCMT PULM ART LT 1080.00 06/30/10 36014LT 36014LT 36014LT 007 0361 2030
04320220 SELECT CATH PLCMT PULM ART RT 1080.00 06/30/10 36014RT 36014RT 36014RT 007 0361 2030
04320223 SEL CATH PLCMT SEG PULM ART LT 3161.00 06/30/10 36015LT 36015LT 36015LT 007 0361 2030
04320226 SEL CATH PLCMT SEG PULM ART RT 3161.00 06/30/10 36015RT 36015RT 36015RT 007 0361 2030
04320229 INTR NDLE/INTRCTH CRTID ART BI 2932.00 06/30/10 3610050 3610050 3610050 007 0361 2032
04320232 INTR NDLE/INRCTH CRTID ART LT 2198.00 06/30/10 36100LT 36100LT 36100LT 007 0361 2032
04320235 INTR NDLE/INTRCTH CRTID ART RT 2198.00 06/30/10 36100RT 36100RT 36100RT 007 0361 2032
04320238 INTR NEEDLE RTROGRADE BRACH BI 2785.00 06/30/10 3612050 3612050 3612050 007 0361 2032
04320241 INTR NEEDLE RTROGRADE BRACH LT 1709.00 06/30/10 36120LT 36120LT 36120LT 007 0361 2032
04320244 INTR NEEDLE RTROGRADE BRACH RT 1709.00 06/30/10 36120RT 36120RT 36120RT 007 0361 2032
04320247 INTR/NDLE/INTRCTH EXTRM ART BI 1027.00 06/30/10 3614050 3614050 3614050 007 0361 2030
04320250 INTR/NDLE/INTRCTH EXTRM ART LT 659.00 06/30/10 36140LT 36140LT 36140LT 007 0361 2030
04320253 INTR/NDLE/INTRCTH EXTRM ART RT 659.00 06/30/10 36140RT 36140RT 36140RT 007 0361 2030
04320256 INT NDLE AV SHNT CREAT DEAL BI 1327.00 06/30/10 3614750 3614750 3614750 007 0361 2030
04320259 INT NDLE AV SHNT CREAT DEAL LT 1311.00 06/30/10 36147LT 36147LT 36147LT 007 0361 2030
04320262 INT NDLE AV SHNT CREAT DEAL RT 1311.00 06/30/10 36147RT 36147RT 36147RT 007 0361 2030
04320265 INTRODUCTION CATHETER AORTA 926.00 06/30/10 36200 36200 36200 38.91 38.91 007 0361 2030
04320268 SEL CATH PLCMT ART EA 1 ORD BI 3874.00 06/30/10 3621550 3621550 3621550 007 0361 2032
04320271 SEL CATH PLCMT ART EA 1 ORD LT 2178.00 06/30/10 36215LT 36215LT 36215LT 007 0361 2032
04320274 SEL CATH PLCMT ART EA 1 ORD RT 2178.00 06/30/10 36215RT 36215RT 36215RT 007 0361 2032
04320277 SEL CATH PLCMT ART EA 2 ORD BI 3184.00 06/30/10 3621650 3621650 3621650 007 0361 2032
04320280 SEL CATH PLCMT ART EA 2 ORD LT 2190.00 06/30/10 36216LT 36216LT 36216LT 007 0361 2032
04320283 SEL CATH PLCMT ART EA ORD RT 2190.00 06/30/10 36216RT 36216RT 36216RT 007 0361 2032
04320286 SEL CATH PLCMT ART EA 3 ORD BI 3695.00 06/30/10 3621750 3621750 3621750 007 0361 2032
04320289 SEL CATH PLCMT ART EA 3 ORD LT 2269.00 06/30/10 36217LT 36217LT 36217LT 007 0361 2032
04320292 SEL CATH PLCMT ART EA 3 ORD RT 2269.00 06/30/10 36217RT 36217RT 36217RT 007 0361 2032
04320295 SEL CATH PLCMT ART ADDL 2&3 BI 2528.00 06/30/10 3621850 3621850 3621850 007 0361 2032
04320298 SEL CATH PLCMT ART ADDL 2&3 LT 1552.00 06/30/10 36218LT 36218LT 36218LT 007 0361 2032
04320301 SEL CATH PLCMT ART ADDL 2&3 RT 1552.00 06/30/10 36218RT 36218RT 36218RT 007 0361 2032
04320304 SEL CATH PLCMT ART EA 1 ABD BI 2166.00 06/30/10 3624550 3624550 3624550 007 0361 2030
04320305 PV INTR NDL AV SHNT DLS ADD LT 142.00 06/30/10 36148LT 36148LT 36148LT 007 0320 2030
04320307 SEL CATH PLCMT ART EA 1 ABD LT 1432.00 06/30/10 36245LT 36245LT 36245LT 007 0361 2030
04320308 PV INTR ND AV SHNT DLYS ADD RT 142.00 06/30/10 36148RT 36148RT 36148RT 007 0320 2030
04320310 SEL CATH PLCMT ART EA 1 ABD RT 1432.00 06/30/10 36245RT 36245RT 36245RT 007 0361 2030
04320313 SEL CATH PLCMT ART INI 2ABD BI 1876.00 06/30/10 3624650 3624650 3624650 007 0361 2030
04320316 SEL CATH PLCMT ART INI 2ABD LT 1395.00 06/30/10 36246LT 36246LT 36246LT 007 0361 2030
04320319 SEL CATH PLCMT ART INI 2ABD RT 1395.00 06/30/10 36246RT 36246RT 36246RT 007 0361 2030
04320322 SEL CATH PLCMT ART INI 3ABD BI 2194.00 06/30/10 3624750 3624750 3624750 007 0361 2030
04320325 SEL CATH PLCMT ART INI 3ABD LT 1707.00 06/30/10 36247LT 36247LT 36247LT 007 0361 2030
04320328 SEL CATH PLCMT ART INI 3ABD RT 1707.00 06/30/10 36247RT 36247RT 36247RT 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 129
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04320331 SEL CATH PLCMT ADDL 2&3 ABD BI 1644.00 06/30/10 3624850 3624850 3624850 007 0361 2030
04320334 SEL CATH PLCMT ADDL 2&3 ABD LT 1190.00 06/30/10 36248LT 36248LT 36248LT 007 0361 2030
04320337 SEL CATH PLCMT ADDL 2&3 ABD RT 1190.00 06/30/10 36248RT 36248RT 36248RT 007 0361 2030
04320340 PERCUT PRTL VEIN CATH ANY METH 2401.00 06/30/10 36481 36481 36481 38.93 38.93 007 0361 2030
04320355 VENUS CATH/SELECT ORGAN BLOOD 29.00 06/30/10 36500 36500 36500 38.93 38.93 007 0361 2030
04320358 MECH REMOV TUNNELED CV CATH 2585.00 06/30/10 36595 36595 36595 007 0361 2030
04320364 EXTERNAL CANNULA DECLOTTING 2657.00 06/30/10 36860 36860 36860 39.49 39.49 007 0361 2030
04320367 CANULA DECLOTTING 2657.00 06/30/10 36861 36861 36861 39.49 39.49 007 0361 2030
04320370 INSERT HEPATIC SHUNT (TIPS) 8931.00 06/30/10 37182 37182 37182 007 0361 2030
04320373 REVISE HEPATIC SHUNT (TIPS) 6713.00 06/30/10 37183 37183 37183 007 0361 2030
04320376 TRANSCATHETER BIOPSY 1836.00 06/30/10 37200 37200 37200 38.21 38.21 007 0361 2030
04320379 TRNSCATH THERP INFUS THRMBLYS 1556.00 06/30/10 37201 37201 37201 99.29 99.29 007 0361 2032
04320382 TRNSCTH THRP INFUS-NOT THROMBO 1358.00 06/30/10 37202 37202 37202 99.29 99.29 007 0361 2032
04320385 TRNSCATH RETREIV PQ IVASC FB 2962.00 06/30/10 37203 37203 37203 38.00 38.00 007 0361 2032
04320388 TRNSCATH OCCLUDPERQ NON CNS 6179.00 06/30/10 37204 37204 37204 39.53 39.53 007 0361 2032
04320391 TRANSCATH IVAS STENT PERQ INIT 8618.00 06/30/10 37205 37205 37205 39.50 39.50 007 0361 2032
04320394 TRANSCATH IVASC STENT PERQ EA 6810.00 06/30/10 37206 37206 37206 39.50 39.50 007 0361 2032
04320397 TRANSCTH IVASC STENT OPEN INIT 7695.00 06/30/10 37207 37207 37207 007 0361 2032
04320400 TRNSCTH IVASC STNT OPN EA ADDL 7695.00 06/30/10 37208 37208 37208 007 0361 2032
04320403 EXCHG PRV PLCD INT CATH DUR TX 2124.00 06/30/10 37209 37209 37209 38.91 38.91 007 0361 2032
04320406 INTRAVASC US DUR DX/TX INI VES 5144.00 06/30/10 37250 37250 37250 007 0361 2030
04320409 INTRVSC US DUR DX/TX EA AD VES 5144.00 06/30/10 37251 37251 37251 007 0361 2030
04320412 INTRPT PART CMPL-INFER VEN CAV 3107.00 06/30/10 37620 37620 37620 38.7 38.7 007 0361 2030
04320415 INJECT PROC SPLENOPORTOGRAPHY 1952.00 06/30/10 38200 38200 38200 007 0361 2030
04320418 INJECT PROC LYMPHANGIOGRAPHY 1709.00 06/30/10 38790 38790 38790 007 0361 2032
04320421 UGI ENDO W/PLCMT GASTRO TUBE 1584.00 06/30/10 43246 43246 43246 007 0361 2030
04320424 PERCUTANEOUS PLACMNT OF G-TUBE 2386.00 06/30/10 43246 43246 43246 43.11 43.11 007 0361 2030
04320427 CHANGE OF GASTROSTOMY TUBE 337.00 06/30/10 43760 43760 43760 007 0361 2030
04320430 REPOSITION GASTROSTOMY TUBE 1245.00 06/30/10 43761 43761 43761 007 0361 2030
04320433 TUBE/NDLE CATH JEJNSMY-INTRAOP 626.00 06/30/10 44015 44015 44015 007 0360 2030
04320435 PV US RF ABLATION LIVER OPEN 2147.00 06/30/10 47380 47380 47380 007 0360 2030
04320436 INTRO LONG GI TUBE-SEP PROC 440.00 06/30/10 44500 44500 44500 007 0361 2030
04320438 PV US RF ABLATION LIVER PERC 7823.00 06/30/10 47382 47382 47382 007 0361 2030
04320439 INJ PROC FOR PERC TRANSHEPATIC 1067.00 06/30/10 47500 47500 47500 87.51 87.51 007 0361 2030
04320442 INJ PROC CHKNGO THRU XST CATH 694.00 06/30/10 47505 47505 47505 87.54 87.54 007 0361 2030
04320445 INTR PRQ TRNSP CATH BILARY DRA 2116.06 06/30/10 47510 47510 47510 38.93 38.93 007 0361 2030
04320448 INTR PRQ TRNSP STNT BILARY DRA 1548.00 06/30/10 47511 47511 47511 38.93 38.93 007 0361 2030
04320451 CHANGE PERC BILARY DRAINAGE C 1992.00 06/30/10 47525 47525 47525 97.05 97.05 007 0361 2030
04320454 REV&OR REINSERT TRANSHEP TUBE 1056.00 06/30/10 47530 47530 47530 007 0361 2030
04320455 PV CHOLNGOSCPY WW/O BRUSH/WASH 2140.00 06/30/10 47552 47552 47552 007 0361 2030
04320457 BILI ENDO W/DILAT WO STENT 2790.00 06/30/10 47555 47555 47555 51.98 51.98 007 0361 2030
04320460 BILI ENDO W/DILAT W/ STENT 2659.00 06/30/10 47556 47556 47556 51.98 51.98 007 0361 2030
04320463 LAP SURG W/TRNSHP CHOLNG WO BX 5077.00 06/30/10 47560 47560 47560 007 0361 2030
04320466 LAP SURG W/TRNSHP CHOLANG W/BX 2626.00 06/30/10 47561 47561 47561 007 0361 2030
04320469 LAPRSCPY SURG CHOLCT W/CHOLANG 3232.00 06/30/10 47563 47563 47563 007 0360 2030
04320472 BILARY DUCT STONE EXTRT T-TUBE 2121.00 06/30/10 47630 47630 47630 51.96 51.96 007 0361 2030
04320475 INJ PROC INTRAOP PANCRTOGRAPHY 2007.00 06/30/10 48400 48400 48400 007 0320 2030
04320478 BX ABD/RETROPRTN MASS PERQ NDL 1199.00 06/30/10 49180 49180 49180 54.22 54.22 007 0361 2030
04320481 EXCHAN ABSC/CYST CATH-GUID-SP 2441.00 06/30/10 49423 49423 49423 007 0361 2030
04320484 INJ PRO-EVL PERITON-VENO SHUNT 406.00 06/30/10 49427 49427 49427 007 0361 2030
04320487 DRAIN P'RENAL/RNL ABS PERQ BIL 1995.00 06/30/10 5002150 5002150 5002150 55.01 55.01 007 0361 2030
04320490 DRAIN PERIRNL/RNAL ABS PERQ LT 1164.00 06/30/10 50021LT 50021LT 50021LT 55.01 55.01 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 130
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04320493 DRAIN PERITNL/RNAL ABS PERQ RT 1164.00 06/30/10 50021RT 50021RT 50021RT 55.01 55.01 007 0361 2030
04320496 PERQ NEPHROSTOLI UP TO 2 CM BI 3305.00 06/30/10 5008050 5008050 5008050 007 0361 2030
04320499 PERQ NEPHROSTOLI UP TO 2 CM LT 6811.00 06/30/10 50080LT 50080LT 50080LT 007 0361 2030
04320502 PERQ NEPHROSTOLI UP TO 2 CM RT 6811.00 06/30/10 50080RT 50080RT 50080RT 007 0361 2030
04320505 PERQ NEPHROSTOL UP OVR 2 CM BI 3305.00 06/30/10 5008150 5008150 5008150 007 0361 2030
04320508 PERQ NEPHROSTOL UP OVR 2 CM LT 6811.00 06/30/10 50081LT 50081LT 50081LT 007 0361 2030
04320511 PERQ NEPHROSTOL UP OVR 2 CM RT 6811.00 06/30/10 50081RT 50081RT 50081RT 007 0361 2030
04320514 RENAL BX PERQ TROCAR/NEEDLE BI 2203.00 06/30/10 5020050 5020050 5020050 007 0361 2030
04320517 RENAL BX PERQ TROCAR/NEEDLE LT 1573.00 06/30/10 50200LT 50200LT 50200LT 55.23 55.23 007 0361 2030
04320520 RENAL BX PERQ TROCAR/NEEDLE RT 1573.00 06/30/10 50200RT 50200RT 50200RT 55.23 55.23 007 0361 2030
04320523 ASPIR&INJ RENL CYS/PLV-NDL BI 1531.00 06/30/10 5039050 5039050 5039050 007 0361 2030
04320526 ASPIR&INJ RENL CYS/PLV-NDL LT 1167.00 06/30/10 50390LT 50390LT 50390LT 55.92 55.92 007 0361 2030
04320529 ASPIR&INJ RENL CYS/PLV-NDL RT 1167.00 06/30/10 50390RT 50390RT 50390RT 55.92 55.92 007 0361 2030
04320532 INTRO IN'CATH-RNL PLVS-DRAN BI 2972.00 06/30/10 5039250 5039250 5039250 007 0361 2030
04320535 INTRO IN'CATH-RNL PLVS-DRAN LT 1980.00 06/30/10 50392LT 50392LT 50392LT 007 0361 2030
04320538 INTRO IN'CATH-RNL PLVS-DRAN RT 1980.00 06/30/10 50392RT 50392RT 50392RT 007 0361 2030
04320541 INTRO URETER CATH-RENAL PLV BI 1761.00 06/30/10 5039350 5039350 5039350 007 0361 2030
04320544 INTRO URETER CATH-RENAL PLV LT 1980.00 06/30/10 50393LT 50393LT 50393LT 007 0361 2030
04320547 INTRO URETER CATH-RENAL PLV RT 1980.00 06/30/10 50393RT 50393RT 50393RT 007 0361 2030
04320550 INTRO-GIDE-RNL PELV W/DILAT BI 2693.00 06/30/10 5039550 5039550 5039550 007 0361 2030
04320553 INTRO-GIDE-RNL PELV W/DILAT LT 1756.71 06/30/10 50395LT 50395LT 50395LT 007 0361 2030
04320556 INTRO-GIDE-RNL PELV W/DILAT RT 1756.71 06/30/10 50395RT 50395RT 50395RT 007 0361 2030
04320559 MANOMTRC STUDIES-NEPHR TUBE BI 2693.00 06/30/10 5039650 5039650 5039650 007 0361 2030
04320562 MANOMTRC STUDIES-NEPHR TUBE LT 1709.00 06/30/10 50396LT 50396LT 50396LT 007 0361 2030
04320565 MANOMTRC STUDIES-NEPHR TUBE RT 1709.00 06/30/10 50396RT 50396RT 50396RT 007 0361 2030
04320568 CHANGE NEPHRO/PYELSTMY TUBE BI 2298.00 06/30/10 5039850 5039850 5039850 007 0361 2030
04320571 CHANGE NEPHRO/PYELSTMY TUBE LT 1380.00 06/30/10 50398LT 50398LT 50398LT 007 0361 2030
04320574 CHANGE NEPHRO/PYELSTMY TUBE RT 1380.00 06/30/10 50398RT 50398RT 50398RT 007 0361 2030
04320577 INJ PROC-URETERGR THRU CATH BI 773.00 06/30/10 5068450 5068450 5068450 007 0361 2030
04320580 INJ PROC-URETERGR THRU CATH LT 467.00 06/30/10 50684LT 50684LT 50684LT 007 0361 2030
04320583 INJ PROC-URETERGR THRU CATH RT 467.00 06/30/10 50684RT 50684RT 50684RT 007 0361 2030
04320586 CHANGE OF URETEROSTOMY TUBE BI 1735.00 06/30/10 5068850 5068850 5068850 007 0361 2030
04320589 CHANGE OF URETEROSTOMY TUBE LT 1056.00 06/30/10 50688LT 50688LT 50688LT 007 0361 2030
04320592 CHANGE OF URETEROSTOMY TUBE RT 1056.00 06/30/10 50688RT 50688RT 50688RT 007 0361 2030
04320595 CHANGE OF BLADDER TUBE SIMPLE 253.00 06/30/10 51705 51705 51705 007 0361 2030
04320598 CHANGE OF BLADDER TUBE COMPLEX 1200.00 06/30/10 51710 51710 51710 007 0361 2030
04320601 CYSTOURETHROSCOPY; W/BRUSH BX 1952.00 06/30/10 52007 52007 52007 007 0361 2030
04320604 CYSTURETH W/URTER &/PYLSCPY DX 1798.00 06/30/10 52351 52351 52351 007 0361 2030
04320607 DILAT URETHL STRICTE-MALE INIT 1952.00 06/30/10 53600 53600 53600 007 0361 2030
04320610 DILAT URETHL STRICTE-MALE SBSQ 1952.00 06/30/10 53601 53601 53601 007 0361 2030
04320613 DILAT URTH STRCT MALE GEN ANES 1952.00 06/30/10 53605 53605 53605 007 0361 2030
04320616 DLAT URT STRCT FLLFRM MALE 1ST 1952.00 06/30/10 53620 53620 53620 007 0361 2030
04320619 DLAT URT STRCT FLLFRM MALE SUB 1952.00 06/30/10 53621 53621 53621 007 0361 2030
04320622 URTR STNT RMVL FM BLAD WO SCOP 1244.00 06/30/10 53899 53899 53899 007 0361 2030
04320623 PV CATH/INTRO SALINE/CONT-HSG 249.00 07/01/10 58340 58340 58340 007 0320 2030
04320625 TRNSCR INT FALOP TUB CTH-DX BI 3183.00 06/30/10 5834550 5834550 5834550 007 0361 2030
04320628 TRNCSR INT FALOP TUB CTH-DX LT 2612.00 06/30/10 58345LT 58345LT 58345LT 007 0361 2030
04320631 TRNSCR INT FALOP TUB CTH-DX RT 2612.00 06/30/10 58345RT 58345RT 58345RT 007 0361 2030
04320634 PUNC SHNT TUBE/RSRVOIR-ASPIRAT 1017.00 06/30/10 61070 61070 61070 007 0361 2030
04320637 TRANSCATH OCCLUSION PERQ CNS 4573.00 06/30/10 61624 61624 61624 38.81 38.81 007 0361 2032
04320640 TRANSCATH OCCL PERQ NON CUS 6423.58 06/30/10 61626 61626 61626 38.82 38.82 007 0361 2032
04320641 NA TEMP OCC OF CAROTID 7143.00 06/30/10 61623 61623 61623 38.82 38.82 007 0361 2032
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 131
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04320643 CHOLANGIOGRAPHY INTRAOPERATIVE 2633.00 06/30/10 74300 74300 74300TC 87.54 007 0320 2030
04320646 CHLNGIGRPHY ADD SET-INTRAOPERA 2378.00 06/30/10 74301 74301 74301TC 87.54 87.54 007 0320 2030
04320649 CHOLANGGRPHY THRU EXST TUBE 957.00 06/30/10 74305 74305 74305TC 87.53 87.53 007 0320 2030
04320652 CHOLANGIOGRAPHY,PERC TRANSHEP 1207.00 06/30/10 74320 74320 74320TC 87.53 87.53 007 0320 2030
04320655 POST OP BIL DUCT CALC RMVL 810.00 06/30/10 74327 74327 74327TC 51.98 51.98 007 0320 2030
04320658 INTRO LONG GI TUB W/MULT FILM 961.00 06/30/10 74340 74340 74340TC 007 0320 2030
04320661 PERC PLACEMENT OF GI TUBE 812.00 06/30/10 49440 49440 49440 43.11 43.11 007 0320 2030
04320664 PERQ PLCMT ENTEROCLYSIS TUBE 2154.00 06/30/10 74355 74355 74355TC 007 0320 2030
04320667 PERC TRANSHEPATIC DIALT BIL D 2108.00 06/30/10 74363 74363 74363 51.84 51.84 007 0320 2030
04320670 INTRO INTRACTH-RENAL PELVIS BI 2367.00 06/30/10 7447550 7447550 74475TC 007 0320 2030
04320673 INTRO INTRACTH-RENAL PELVIS LT 1427.00 06/30/10 74475LT 74475LT 74475TC 007 0320 2030
04320676 INTRO INTRACTH-RENAL PELVIS RT 1427.00 06/30/10 74475RT 74475RT 74475TC 007 0320 2030
04320679 INTR URTERL CATH RNL PELVIS BI 2487.00 06/30/10 7448050 7448050 74480TC 007 0320 2030
04320682 INTR URTERL CATH RNL PELVIS LT 1513.00 06/30/10 74480LT 74480LT 74480TC 007 0320 2030
04320685 INTR URTERL CATH RNL PELVIS RT 1513.00 06/30/10 74480RT 74480RT 74480TC 007 0320 2030
04320688 DILAT NPHRST/URETER/URETHRA BI 2378.00 06/30/10 7448550 7448550 74485TC 007 0320 2030
04320691 DILAT NPHRST/URETER/URETHRA LT 1427.00 06/30/10 74485LT 74485LT 74485TC 007 0320 2030
04320694 DILAT NPHRST/URETER/URETHRA RT 1427.00 06/30/10 74485RT 74485RT 74485TC 007 0320 2030
04320697 TRANSCERV CATH FALLOP TUBE BI 1138.00 06/30/10 7474250 7474250 74742TC 007 0320 2030
04320700 TRANSCERV CATH FALLOP TUBE LT 699.00 06/30/10 74742LT 74742LT 74742TC 007 0320 2030
04320703 TRANSCERV CATH FALLOP TUBE RT 699.00 06/30/10 74742RT 74742RT 74742TC 007 0320 2030
04320706 AORTOGRAPHY, THORA SERIALGRPH 2003.84 06/30/10 75605 75605 75605TC 88.42 88.42 007 0320 2030
04320709 AORTOGRAPHY ABDOMINAL SERIAL 2208.00 06/30/10 75625 75625 75625TC 88.42 88.42 007 0320 2030
04320712 ANGO CRVCO CATH INCL VESSL ORG 3157.90 06/30/10 75650 75650 75650TC 88.41 88.41 007 0320 2032
04320715 ANGIO BRANCHIAL RETROGRADE BI 3149.00 06/30/10 7565850 7565850 75658TC 007 0320 2032
04320718 ANGIO BRACHIAL RETROGRADE LT 2110.00 06/30/10 75658LT 75658LT 75658TC 007 0320 2032
04320721 ANGIO BRACHIAL RETROGRADE RT 2110.00 06/30/10 75658RT 75658RT 75658TC 007 0320 2032
04320724 ANGIO EXT CAROTD UNI SELECT LT 4007.00 06/30/10 75660LT 75660LT 75660TC 007 0320 2032
04320727 ANGIO EXT CAROTD UNI SELECT RT 4007.00 06/30/10 75660RT 75660RT 75660TC 007 0320 2032
04320730 ANGIO CAROTID SELECTIVE BI 6589.00 06/30/10 75662 75662 75662TC 88.41 88.41 007 0320 2032
04320733 ANGIO CAROTID CERBRL UNI LT 2770.00 06/30/10 75665LT 75665LT 75665TC 007 0320 2032
04320736 ANGIO CAROTID CERBRL UNI RT 2770.00 06/30/10 75665RT 75665RT 75665TC 007 0320 2032
04320739 ANGIO CAROTID CERBRL UNI BI 4007.00 06/30/10 75671 75671 75671TC 88.41 88.41 007 0320 2032
04320742 ANGIO CAROTID CERV UNI LT 2618.00 06/30/10 75676 75676LT 75676TC 007 0320 2032
04320745 ANGIO CAROTID CERV UNI RT 2618.00 06/30/10 75676RT 75676RT 75676TC 007 0320 2032
04320748 ANGIOGRAPHY CAROTID CERV BI 4007.00 06/30/10 75680 75680 75680TC 88.41 88.41 007 0320 2032
04320751 ANGIO VERTEBRAL LT 3128.00 06/30/10 75685LT 75685LT 75685TC 007 0320 2032
04320754 ANGIO VERTEBRAL RT 3128.00 06/30/10 75685RT 75685RT 75685TC 007 0321 2032
04320757 ANGIO VERTEBRAL BILATERAL 4681.00 06/30/10 7568550 7568550 75685TC 007 0323 2032
04320760 ANGIO CERVICAL 3128.00 06/30/10 75685 75685 75685TC 88.41 88.41 007 0320 2032
04320763 ANGIO INTRACRANIAL 3128.00 06/30/10 75685 75685 75685TC 88.41 88.41 007 0320 2032
04320766 ANGIO SPINAL SELECTIVE LT 2004.00 06/30/10 75705LT 75705LT 75705TC 007 0320 2032
04320769 ANGIO SPINAL SELECTIVE RT 2004.00 06/30/10 75705RT 75705RT 75705TC 007 0320 2032
04320772 ANGIO SPINAL SELECTIVE LT 2775.00 06/30/10 7570550 7570550 75705TC 007 0320 2032
04320775 ANGIO EXTREMITY UNILATERAL LT 2595.00 06/30/10 75710LT 75710LT 75710TC 007 0320 2032
04320778 ANGIO EXTREMITY UNILATERAL RT 2595.00 06/30/10 75710RT 75710RT 75710TC 007 0320 2032
04320781 ANGIO EXTREMITY BILATERAL 3537.00 06/30/10 75716 75716 75716TC 88.49 88.49 007 0320 2032
04320784 ANGIO RENAL UNI SELECTIVE LT 3065.00 06/30/10 75722LT 75722LT 75722TC 007 0320 2030
04320787 ANGIO RENAL UNI SELECTIVE RT 3065.00 06/30/10 75722RT 75722RT 75722TC 007 0320 2030
04320790 ANGIO RENAL UNI SELECTIVE BI 3425.00 06/30/10 75724 75724 75724TC 88.45 88.45 007 0320 2030
04320793 ANGIO VISCERAL SEL/SUPRASELECT 3576.00 06/30/10 75726 75726 75726TC 88.49 88.49 007 0320 2030
04320795 NV ANGIOGRAPHY PELV SELECT S/I 7161.00 06/30/10 75736 75736 75736 007 0320 2032
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 132
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04320796 ANGIO PELV SEL/SUPRASELECT 3258.00 06/30/10 75736 75736 75736TC 88.49 88.49 007 0320 2030
04320799 ANGIO PULM UNI SELECTIVE LEFT 2386.00 06/30/10 75741LT 75741LT 75741TC 007 0320 2030
04320802 ANGIO PULM UNI SELECTIVE RIGHT 2386.00 06/30/10 75741RT 75741RT 75741TC 007 0320 2030
04320805 ANGIOGRAPHY PULM BILAT SELECT 3025.00 06/30/10 75743 75743 75743TC 88.43 88.43 007 0320 2030
04320808 ANGIO PULM NON SELECT CATH 2459.00 06/30/10 75746 75746 75746TC 88.43 88.43 007 0320 2030
04320811 ANGIO INTERNAL MAMMARY BI 3457.00 06/30/10 7575650 7575650 75756TC 007 0320 2030
04320814 ANGIO INTERNAL MAMMARY LT 2386.00 06/30/10 75756TC 75756LT 75756LT 007 0320 2030
04320817 ANGIO INTERNAL MAMMARY RT 2386.00 06/30/10 75756RT 75756RT 75756TC 007 0320 2030
04320820 ANGIO SELECT EACH ADDL VESSEL 2493.00 06/30/10 75774 75774 75774TC 88.49 88.49 007 0320 2032
04320823 ANGIO ARTERIOVENOUS SHUNT LT 707.00 06/30/10 75791LT 75791LT 75791TC 007 0320 2030
04320826 ANGIO ARTERIOVENOUS SHUNT RT 707.00 06/30/10 75791RT 75791RT 75791TC 007 0320 2030
04320829 ANGIO ARTERIOVERIOUS SHUNT BI 1049.00 06/30/10 7579150 7579150 75791TC 007 0320 2030
04320832 LYMPHANGIOG EXTREM ONLY UNI LT 1471.00 06/30/10 75801LT 75801LT 75801TC 007 0320 2030
04320835 LYMPHANGIOG EXTREM ONLY UNI RT 1471.00 06/30/10 75801RT 75801RT 75801TC 007 0320 2030
04320838 LYMPHANGIO EXTRM ONLY BI 2327.00 06/30/10 75803 75803 75803TC 007 0320 2030
04320841 LYMPHANGIO PELV/ABD UNI LEFT 1471.00 06/30/10 75805LT 75805LT 75805TC 007 0320 2030
04320844 LYMPHANGIO PELV/ABD UNI RIGHT 1471.00 06/30/10 75805RT 75805RT 75805TC 007 0320 2030
04320847 LYMPHANGIO PELVIC/ABD BI 2327.00 06/30/10 75807 75807 75807TC 007 0320 2030
04320850 SHUNTOGRAM-PREV PLCED NONVASCU 3305.00 06/30/10 75809 75809 75809TC 007 0320 2030
04320853 SPLENOPORTOGRAPHY 3121.00 06/30/10 75810 75810 75810TC 88.64 88.64 007 0320 2030
04320856 VENOGRAPHY EXTREM UNI LEFT 810.00 06/30/10 75820LT 75820LT 75820TC 007 0320 2030
04320859 VENOGRAPHY EXTREM UNI RIGHT 810.00 06/30/10 75820RT 75820RT 75820TC 007 0320 2030
04320862 VENOGRAPHY EXTREMITY BILATERAL 1114.00 06/30/10 75822 75822 75822TC 88.66 88.66 007 0320 2030
04320865 VENOGRAPHY CAVAL INFERIOR 2296.00 06/30/10 75825 75825 75825TC 88.51 88.51 007 0320 2030
04320868 VENOGRAPHY CAVAL SUPERIOR 1962.00 06/30/10 75827 75827 75827TC 88.51 88.51 007 0320 2030
04320871 VENGRPH RENAL UNI SELECTIVE LT 2313.00 06/30/10 75831LT 75831LT 75831TC 007 0320 2030
04320874 VENGRPH RENAL UNI SELECTIVE RT 2313.00 06/30/10 75831RT 75831RT 75831TC 007 0320 2030
04320877 VENOGRAPHY RENAL BILAT SELECT 3794.00 06/30/10 75833 75833 75833TC 88.65 88.65 007 0320 2030
04320880 VENOGRPHY ADRNAL UNI SELECT LT 2313.00 06/30/10 75840LT 75840LT 75840TC 007 0320 2030
04320883 VENOGRPHY ADRNAL UNI SELECT RT 2313.00 06/30/10 75840RT 75840RT 75840TC 007 0320 2030
04320886 VENOGRAPHY ADREN BILAT SELECT 3794.00 06/30/10 75842 75842 75842TC 88.65 88.65 007 0320 2030
04320889 VENOGRAPHY SINUS/JUG CATH 2313.00 06/30/10 75860 75860 75860TC 88.61 88.61 007 0320 2030
04320892 VENOGRAPHY SUPER SAG SINUS 2313.00 06/30/10 75870 75870 75870TC 88.61 88.61 007 0320 2030
04320895 VENOGRAPHY EPIDURAL 1978.00 06/30/10 75872 75872 75872TC 89.04 89.04 007 0320 2030
04320898 VENOGRAPHY ORBITAL 2313.00 06/30/10 75880 75880 75880TC 89.04 89.04 007 0320 2030
04320901 PERQ TRANSHEPAT PORTOG W/EVAL 3934.00 06/30/10 75885 75885 75885TC 88.64 88.64 007 0320 2030
04320904 PERQ TRANSHEPAT PORTOG NO EVAL 3550.00 06/30/10 75887 75887 75887TC 88.64 88.64 007 0320 2030
04320907 HEPAT VENOG WEDGED/FREE W/EVAL 3472.00 06/30/10 75889 75889 75889TC 89.04 89.04 007 0320 2030
04320910 HEPAT VENOG WEDGD/FREE NO EVAL 3616.00 06/30/10 75891 75891 75891TC 89.04 89.04 007 0320 2030
04320913 VENOUS SAMPL-CATH W/WO ANGIO 1889.00 06/30/10 75893 75893 75893TC 89.04 89.04 007 0320 2032
04320916 TRNSCATH TX EMBOLIZ ANY METHOD 4905.00 06/30/10 75894 75894 75894TC 89.04 89.04 007 0320 2032
04320919 TRNSCATH TX INFUS ANY METHOD 4306.00 06/30/10 75896 75896 75896TC 89.04 89.04 007 0320 2032
04320922 ANGIO VIA EXST CTH F/U STDY-TX 964.00 06/30/10 75898 75898 75898TC 88.49 88.49 007 0320 2032
04320925 EXCHANGE PREV PLCD ART CATH 4917.00 06/30/10 75900 75900 75900TC 38.91 38.91 007 0320 2032
04320928 REMOVE CVA DEVICE OBSTRUCTION 2555.00 06/30/10 75901 75901 75901TC 007 0320 2032
04320931 REMOVE CVA LUMEN OBSTRUCTION 2555.00 06/30/10 75902 75902 75902TC 007 0320 2032
04320934 PERQ PLACEMENT IVC FILTER 2862.00 06/30/10 75940 75940 75940TC 89.04 89.04 007 0320 2030
04320937 INTRAVASC US;INIT VESSEL 816.00 06/30/10 75945 75945 75945TC 007 0320 2030
04320940 INTRAVASC US EA ADDL NON-CORN 981.00 06/30/10 75946 75946 75946TC 007 0320 2030
04320943 ENDOVASC REPAIR ABD AO ANURYSM 7707.00 06/30/10 75952 75952 75952TC 007 0320 2030
04320946 PLACE PROSTHESIS FOR ANEURYSM 7707.00 06/30/10 75953 75953 75953TC 007 0320 2030
04320949 ILIAC ANEURYSM ENDVAS RPAIR BI 12294.00 06/30/10 7595450 7595450 75954TC 007 0320 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 133
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04320952 ILIAC ANEURYSM ENDVAS RPAIR LT 7707.00 06/30/10 75954LT 75954LT 75954TC 007 0320 2030
04320955 ILIAC ANEURYSM ENDVAS RPAIR RT 7707.00 06/30/10 75954RT 75954RT 75954TC 007 0320 2030
04320958 TRANSCATH INTRO IV STENT EA 2414.00 06/30/10 75960 75960 75960TC 38.93 38.93 007 0320 2032
04320961 TRNSCTH RETRV PERQ IV FRGN BDY 3872.00 06/30/10 75961 75961 75961TC 89.04 89.04 007 0320 2032
04320964 TRANSLM BALON ANGPLSTY PERI BI 3864.00 06/30/10 7596250 7596250 75962TC 007 0320 2030
04320967 TRANSLM BALON ANGPLSTY PERI LT 2668.00 06/30/10 75962LT 75962LT 75962TC 007 0320 2030
04320970 TRANSLM BALON ANGPLSTY PERI RT 2668.00 06/30/10 75962RT 75962RT 75962TC 007 0320 2030
04320973 TRNSLM BAL ANGPL/ADD PRIPH BI 3613.00 06/30/10 7596450 7596450 75964TC 007 0320 2032
04320976 TRNSLM BAL ANGPL/ADD PRIPH LT 2198.00 06/30/10 75964LT 75964LT 75964TC 007 0320 2032
04320979 TRNSLM BAL ANGPL/ADD PRIPH RT 2198.00 06/30/10 75964RT 75964RT 75964TC 007 0320 2032
04320982 TRANSLM BALLOON ANGPL RENAL BI 3492.00 06/30/10 7596650 7596650 75966TC 007 0320 2030
04320983 NV 3D PROC W INDPNDT W/STN 588.00 06/30/10 76377 76377 76377 007 0320 2032
04320985 TRANSLM BALLOON ANGPL RENAL LT 2313.00 06/30/10 75966LT 75966LT 75966TC 007 0320 2030
04320988 TRANSLM BALLOON ANGPL RENAL RT 3488.39 06/30/10 75966RT 75966RT 75966TC 007 0320 2030
04320991 TRANSLUMINAL BALLOON ANGIO REN 2481.00 06/30/10 75966 75966 75966TC 89.04 89.04 007 0320 2030
04320994 TRNSLUM BAL ANG EA ADDL VISCER 3126.00 06/30/10 75968 75968 75968TC 89.04 89.04 007 0320 2030
04320997 TRANSCATHETER BIOPSY 2274.00 06/30/10 75970 75970 75970TC 89.04 89.04 007 0320 2030
04321003 PERQ TRANSHEP BILIARY DRAINAGE 1602.00 06/30/10 75980 75980 75980TC 89.04 89.04 007 0320 2030
04321006 PERQ PLCMT CATH INOPER OBSTRUC 2624.00 06/30/10 75982TC 75982 75982 89.04 89.04 007 0320 2030
04321009 CHANGE OF PERQ DRAIN W MONITOR 1096.00 06/30/10 75984 75984 75984TC 89.04 89.04 007 0320 2030
04321012 FLURO GUID DRAIN WINDWILL CATH 844.00 06/30/10 75989 75989 75989TC 89.04 89.04 007 0320 2030
04321015 TRNSLM ARTHRECT PERIPH ART BI 3549.00 06/30/10 7599250 7599250 75992TC 007 0320 2030
04321018 TRNSLM ARTHRECT PERIPH ART LT 2199.00 06/30/10 75992LT 75992LT 75992TC 007 0320 2030
04321021 TRNSLM ARTHRECT PERIPH ART RT 2199.00 06/30/10 75992RT 75992RT 75992TC 007 0320 2030
04321024 TRNSLM ATHRCT EA ADD PERIPH BI 2203.00 06/30/10 7599350 7599350 75993TC 007 0320 2030
04321027 TRNSLM ATHRCT EA ADD PERIPH LT 1685.00 06/30/10 75993LT 75993LT 75993TC 007 0320 2030
04321030 TRNSLM ATHRCT EA ADD PERIPH RT 1685.00 06/30/10 75993RT 75993RT 75993TC 007 0320 2030
04321033 TRANSLUMINAL ATHERECT RENAL BI 2815.00 06/30/10 7599450 7599450 75994TC 007 0320 2030
04321036 TRANSLUMINAL ATHERECT RENAL LT 2199.00 06/30/10 75994LT 75994LT 75994TC 007 0320 2030
04321039 TRANSLUMINAL ATHERECT RENAL RT 2199.00 06/30/10 75994RT 75994RT 75994TC 007 0320 2030
04321042 TRNSLUM ATHERECT VISCERAL 2199.00 06/30/10 75995 75995 75995TC 39.50 39.50 007 0320 2030
04321045 TRNSLM ATHERECT EA ADDL VISCER 2199.00 06/30/10 75996 75996 75996TC 39.50 39.50 007 0320 2030
04321063 NA VERTEBROPLASTY THORACIC 3971.00 06/30/10 22520 22520 22520 007 0361 2032
04321066 NA VERTEBROPLASTY LUMBAR 3971.00 06/30/10 22520 22521 22521 007 0361 2032
04321072 NA VERTEBROPLASTY ADDITIONAL 3971.00 06/30/10 22522 22522 22522 007 0361 2032
04321075 US BX THYROID CORE NDLE-RT 486.00 06/30/10 60100RT 60100RT 60100RT 007 0361 2035
04321078 US FINE NDLE ASP-LT 559.00 06/30/10 10022LT 10022LT 10022LT 007 0361 2035
04321081 US FINE NDLE ASP-RT 509.00 06/30/10 10022RT 10022RT 10022RT 007 0361 2035
04321084 US BX RENAL TRANSPLANT-LT 1573.00 06/30/10 50200LT 50200LT 50200LT 007 0361 2035
04321087 US BX RENAL TRANSPLANT-RT 1573.00 06/30/10 50200RT 50200RT 50200RT 007 0361 2035
04321091 NV TL MECH THRMBCTMY ART PRI 5964.00 06/30/10 37184 37184 37184 007 0361 2032
04321094 NV TL MECH THRMBCTMY VEINS-PRI 5964.00 06/30/10 37187 37187 37187 007 0361 2032
04321117 INJECTION FOR KIDNEY X-RAY BI 460.00 06/30/10 5039450 5039450 5039450 007 0361 2030
04321127 PV CHEMOTHERAPY INFUSION 1621.00 06/30/10 96420 96420 96420 007 0335 2030
04321147 TRNSLM BLN ANGP PG BRA/BRNC BI 5366.00 06/30/10 3547550 3547550 3547550 007 0361 2030
04321150 TRNSLM BLN ANGP PG BRA/BRNC LT 3642.00 06/30/10 35475LT 35475LT 35475LT 007 0361 2030
04321153 TRNSLM BLN ANGP PG BRA/BRNC RT 3642.00 06/30/10 35475RT 35475RT 35475RT 007 0361 2030
04321156 TRANSLUMINAL B-ANGIOPLAS VENOU 3642.00 06/30/10 35476 35476 35476 39.59 39.59 007 0361 2030
04321159 TRNSLM PERPH ATHERT PRQ AORTIC 4791.00 06/30/10 35491 35491 35491 39.50 39.50 007 0361 2030
04321162 TRNSLM PRPH ATHR PQ BRA/BRN BI 6439.00 06/30/10 3549450 3549450 3549450 007 0361 2030
04321165 TRNSLM PRPH ATHR PQ BRA/BRN LT 4791.00 06/30/10 35494LT 35494LT 35494LT 007 0361 2030
04321168 TRNSLM PRPH ATHR PQ BRA/BRN RT 4791.00 06/30/10 35494RT 35494RT 35494RT 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 134
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04321171 PLACE NEEDLE IN VEIN 298.00 06/30/10 36000 36000 36000 38.93 38.93 007 0361 2030
04321174 INTR NDLE/INTRCTH CRTID ART BI 3582.00 06/30/10 3610050 3610050 3610050 007 0361 2030
04321177 INTR NDLE/INTRCTH CRTID ART LT 2198.00 06/30/10 36100LT 36100LT 36100LT 007 0361 2030
04321180 INTR NDLE/INTRCTH CRTID ART RT 2198.00 06/30/10 36100RT 36100RT 36100RT 007 0361 2030
04321183 INTR NEEDLE RTROGRADE BRACH BI 3403.00 06/30/10 3612050 3612050 3612050 007 0361 2030
04321186 INTR NEEDLE RTROGRADE BRACH LT 2088.00 06/30/10 36120LT 36120LT 36120LT 007 0361 2030
04321189 INTR NEEDLE RTROGRADE BRACH RT 2088.00 06/30/10 36120RT 36120RT 36120RT 007 0361 2030
04321192 SEL CATH PLCMT ART EA 1 ORD BI 3874.00 06/30/10 3621550 3621550 3621550 007 0361 2030
04321195 SEL CATH PLCMT ART EA 1 ORD LT 2178.00 06/30/10 36215LT 36215LT 36215LT 007 0361 2030
04321198 SEL CATH PLCMT ART EA 1 ORD RT 2178.00 06/30/10 36215RT 36215RT 36215RT 007 0361 2030
04321201 SEL CATH PLCMT ART EA 2 ORD BI 3184.00 06/30/10 3621650 3621650 3621650 007 0361 2030
04321204 SEL CATH PLCMT ART EA 2 ORD LT 2190.00 06/30/10 36216LT 36216LT 36216LT 007 0361 2030
04321207 SEL CATH PLCMT ART EA 2 ORD RT 2190.00 06/30/10 36216RT 36216RT 36216RT 007 0361 2030
04321210 SEL CATH PLCMT ART EA 3 ORD BI 4033.00 06/30/10 3621750 3621750 3621750 007 0361 2030
04321213 SEL CATH PLCMT ART EA 3 ORD LT 2269.00 06/30/10 36217LT 36217LT 36217LT 007 0361 2030
04321216 SEL CATH PLCMT ART EA 3 ORD RT 2269.00 06/30/10 36217RT 36217RT 36217RT 007 0361 2030
04321222 SEL CATH PLCMT ART ADDL 2&3 LT 1552.00 06/30/10 36218LT 36218LT 36218LT 007 0361 2030
04321225 SEL CATH PLCMT ART ADDL 2&3 RT 1552.00 06/30/10 36218RT 36218RT 36218RT 007 0361 2030
04321228 TRNSCATH THERP INFUS THRMBLYS 1556.00 06/30/10 37201 37201 37201 99.29 99.29 007 0361 2030
04321231 TRNSCTH THRP INFUS-NOT THROMBO 2000.00 06/30/10 37202 37202 37202 99.29 99.29 007 0361 2030
04321234 TRNSCTH RETRIEV PQ IVASC FB 3343.00 06/30/10 37203 37203 37203 38.00 38.00 007 0361 2030
04321237 TRNSCTH OCCLUDPERQ NON CNS 6179.00 06/30/10 37204 37204 37204 39.53 39.53 007 0361 2030
04321240 TRNSCTH IVASC STENT PERQ INIT 8618.00 06/30/10 37205 37205 37205 39.50 39.50 007 0361 2030
04321243 TRANSCTH IVASC STENT PERQ EA 6810.00 06/30/10 37206 37206 37206 39.50 39.50 007 0361 2030
04321246 TRANSCTH IVASC STENT OPEN INIT 9405.00 06/30/10 37207 37207 37207 007 0361 2030
04321249 TRNSCTH IVASC STNT OPN EA ADDL 9405.00 06/30/10 37208 37208 37208 007 0361 2030
04321252 EXCHG PRV PLCD INT CATH DUR TX 2095.18 06/30/10 37209 37209 37209 38.91 38.91 007 0361 2030
04321255 INJECT PROC LYMPHANGIOGRAPHY 1709.00 06/30/10 38790 38790 38790 007 0361 2030
04321258 TRANSCATH OCCLUSION PERQ CNS 4573.00 06/30/10 61624 61624 61624 38.81 38.81 007 0361 2030
04321261 TRANSCATH OCCL PERQ NON CNS 4791.00 06/30/10 61626 61626 61626 38.82 38.82 007 0361 2030
04321264 ANGO CRVCO CATH INCL VESSL ORG 3157.90 06/30/10 75650 75650 75650TC 88.41 88.41 007 0320 2030
04321267 ANGIO BRACHIAL RETROGRADE BI 3149.00 06/30/10 7565850 7565850 75658TC 007 0320 2030
04321270 ANGIO BRACHIAL RETROGRADE LT 2110.00 06/30/10 75658LT 75658LT 75658TC 007 0320 2030
04321273 ANGIO BRACHIAL RETROGRADE RT 2110.00 06/30/10 75658RT 75658RT 75658TC 007 0320 2030
04321275 PV INFLATION UNIT 882.00 06/30/10 007 0270 2030
04321276 ANGIO EXT CAROTD UNI SELECT LT 4007.00 06/30/10 75660LT 75660LT 75660TC 007 0320 2030
04321279 ANGIO EXT CAROTD UNI SELECT RT 4007.00 06/30/10 75660RT 75660RT 75660TC 007 0320 2030
04321282 ANGIO EXT CAROTID SELECTIVE BI 6589.00 06/30/10 75662 75662 75662TC 88.41 88.41 007 0320 2030
04321284 ANGIO CAROTID CERBRL UNI LT 2770.00 06/30/10 75665LT 75665LT 75665TC 007 0320 2030
04321287 ANGIO CAROTID CERBRL UNI RT 2770.00 06/30/10 75665RT 75665RT 75665TC 007 0320 2030
04321290 ANGIO CAROTID CERBRL UNI BI 4007.00 06/30/10 75671 75671 75671TC 88.41 88.41 007 0320 2030
04321293 ANGIO CAROTID CERV UNI LT 2618.00 06/30/10 75676LT 75676LT 75676TC 007 0320 2030
04321296 ANGIO CAROTID CERV UNI RT 2618.00 06/30/10 75676RT 75676RT 75676TC 007 0320 2030
04321299 ANGIOGRAPHY CARTOID CERV BI 4007.00 06/30/10 75680 75680 75680TC 88.41 88.41 007 0320 2030
04321302 ANGIO VERTEBRAL LT 3128.00 06/30/10 75685LT 75685LT 75685TC 007 0320 2030
04321305 ANGIO VERTEBRAL RT 3128.00 06/30/10 75685RT 75685RT 75685TC 007 0321 2030
04321308 ANGIO VERTEBRAL BILATERAL 4681.00 06/30/10 7568550 7568550 75685TC 007 0323 2030
04321317 ANGIO SPINAL SELECTIVE LT 1641.00 06/30/10 75705LT 75705LT 75705TC 007 0320 2030
04321320 ANGIO SPINAL SELECTIVE RT 1641.00 06/30/10 75705RT 75705RT 75705TC 007 0320 2030
04321323 ANGIO SPINAL SELECTIVE LT 2775.00 06/30/10 7570550 7570550 75705TC 007 0320 2030
04321326 ANGIO EXTREMITY UNILATERAL LT 2595.00 06/30/10 75710LT 75710LT 75710TC 007 0320 2030
04321329 ANGIO EXTREMITY UNILATERAL RT 2595.00 06/30/10 75710RT 75710RT 75710TC 007 0320 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 135
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04321332 ANGIO EXTREMITY BILATERAL 3537.00 06/30/10 75716 75716 75716TC 88.49 88.49 007 0320 2030
04321335 ANGIO SELECT EACH ADDL VESSEL 2493.00 06/30/10 75774 75774 75774TC 88.49 88.49 007 0320 2030
04321338 VENOUS SAMPL-CATH W/WO ANGIO 1889.00 06/30/10 75893 75893 75893TC 89.04 89.04 007 0320 2030
04321341 TRNSCATH TX EMBOLIZ ANY METHOD 4905.00 06/30/10 75894 75894 75894TC 89.04 89.04 007 0320 2030
04321344 TRNSCATH TX INFUS ANY METHOD 4306.00 06/30/10 75896 75896 75896TC 89.04 89.04 007 0320 2030
04321347 ANGIO VIA EXST CTH F/U STDY-TX 964.00 06/30/10 75898 75898 75898TC 88.49 88.49 007 0320 2030
04321350 EXCHANGE PREV PLCD ART CATH 4917.00 06/30/10 75900 75900 75900TC 38.91 38.91 007 0320 2030
04321353 REMOVE CVA DEVICE OBSTRUCTION 2555.00 06/30/10 75901 75901 75901TC 007 0320 2030
04321356 REMOVE CVA LUMEN OBSTRUCTION 2555.00 06/30/10 75902 75902 75902TC 007 0320 2030
04321359 TRANSCATH INTRO IV STENT EA 2414.00 06/30/10 75960 75960 75960TC 38.93 38.93 007 0320 2030
04321362 TRNSCTH RETRV PERQ IV FRGN BDY 3872.00 06/30/10 75961 75961 75961TC 89.04 89.04 007 0320 2030
04321365 TRNSLM BAL ANGPL /ADD PRIPH BI 3613.00 06/30/10 7596450 7596450 75964TC 007 0320 2030
04321368 TRNSLM BAL ANGPL /ADD PRIPH LT 2198.00 06/30/10 75964LT 75964LT 75964TC 007 0320 2030
04321371 TRNSLM BAL ANGPL /ADD PRIPH RT 2198.00 06/30/10 75964RT 75964RT 75964TC 007 0320 2030
04321374 PV INTERSTIT RAD SRCE APP-CPLX 4642.00 06/30/10 77778 77778 77778TC 007 0333 2030
04321600 NV UNLISTED VASCULAR PROCEDURE 2850.00 06/30/10 37799 37799 37799 007 0361 2032
04321697 NV PLC NDLE CATH INTO HD/NECK 4361.00 06/30/10 41019 41019 41019 007 0361 2032
04321700 CONSCIOUS SEDATION UP TO 2 HR 495.00 06/30/10 99144 99144 99144 89.68 89.68 007 0371 2032
04321712 NON-ION CNTRST 200-299MG(50ML) 46.00 06/30/10 Q9960 Q9960 Q9960 007 0636 2032
04321714 LOW OSMLR (300-349MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2032
04321716 NON-IONIC CNTRST 300-MG(50ML) 46.00 06/30/10 Q9962 Q9962 Q9962 007 0636 2032
04321718 LOW OSMLR (350-399MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2032
04321722 GADOLINIUM BASED MR CONT/ML 15.00 06/30/10 A9579 A9579 A9579 007 0636 2032
04321724 CATHETER-DIAG 89.00 06/30/10 C1730 C1730 C1730 007 0272 2032
04321728 CATHETER-GUIDE 876.00 06/30/10 C1887 C1887 C1887 007 0272 2032
04321732 CATHETER-MICRO 2281.00 06/30/10 C1887 C1887 C1887 007 0272 2032
04321736 WIRE-DIAG 112.00 06/30/10 C1769 C1769 C1769 007 0272 2032
04321740 WIRE-GLIDE 260.00 06/30/10 C1769 C1769 C1769 007 0272 2032
04321744 WIRE-MICRO 1556.00 06/30/10 C1769 C1769 C1769 007 0272 2032
04321748 NEURONET SNARE KIT/RETRIEVAL 8332.00 06/30/10 C1773 C1773 C1773 007 0272 2032
04321752 STENT COAT W/DEL(NEUROFORM) 21000.00 06/30/10 C1876 C1876 C1876 007 0278 2032
04321756 STENT NONCOAT W/DEL(PRECISE) 7350.00 06/30/10 C1876 C1876 C1876 007 0278 2032
04321760 CLOSER DEVICE 994.00 06/30/10 C1760 007 0278 2032
04321764 BALLOON ANGIO PLASTY 3115.00 06/30/10 C1725 C1725 C1725 007 0272 2032
04321768 BALLOON ANGIO PLASTY 3FR 4375.00 06/30/10 C1725 C1725 C1725 007 0272 2032
04321772 COILS PLATINUM 675.00 06/30/10 C1770 C1770 C1770 007 0272 2032
04321776 COILS NEURO PLATINUM 4900.00 06/30/10 C1884 C1884 C1884 007 0278 2032
04321780 COILS NEURO HYDRO/MATRIX 6300.00 06/30/10 C1884 C1884 C1884 007 0272 2032
04321784 INTRODUCER SPECIAL 1104.00 06/30/10 C1893 C1893 C1893 007 0272 2032
04321788 TRUFILL GLUE 12365.00 06/30/10 C1884 C1884 C1884 007 0272 2032
04321792 PVA/EMBOSPHERE 939.00 06/30/10 007 0621 2032
04321796 INFLATOR DEVICE 284.00 06/30/10 007 0621 2032
04321800 ANGIO TRAY 243.00 06/30/10 007 0621 2032
04321804 INTRODUCER REG 112.00 06/30/10 C1766 C1766 C1766 007 0272 2032
04321808 INTRO MICR/MICR PUNCT SET/PEDS 112.00 06/30/10 C1894 C1894 C1894 007 0272 2032
04321810 NV COVERED STENT W DEL SYS EXTERNAL 03/01/10 C1874 C1874 C1874 007 0270 2032
04321812 DERMA BOND/CHITO SEAL/SP.SUTUR 247.00 06/30/10 007 0270 2032
04321816 SP.DRPE/COV CAP/U.S.PROBE COVR 81.00 06/30/10 007 0272 2032
04321820 RHV(ROTATING HEMOSTATIC VALVE) 109.00 06/30/10 007 0272 2032
04321824 FOLEY CATH 68.00 06/30/10 A4344 A4344 A4344 007 0272 2032
04321828 SP.SYRINGE/STOP COCK 19.00 06/30/10 007 0272 2032
04321832 NA DETACHABLE DEVICE FOR COILS 586.00 06/30/10 007 0272 2032
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 136
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04321836 NA OMNI SCAN 20ML 186.00 06/30/10 Q9960 Q9960 Q9960 007 0636 2032
04321840 NA CONCENTRIC RETRIEVER 10663.00 06/30/10 C1773 C1773 C1773 007 0272 2032
04321844 NA MERCI MICROCATHETER 2800.00 06/30/10 C1887 C1887 C1887 007 0272 2032
04321848 NA MERCI BALLOON CATHETER 2800.00 06/30/10 C1725 C1725 C1725 007 0272 2032
04321852 NA VERTIBRAL PLASTY KIT 2142.00 06/30/10 007 0272 2032
04321854 NV ACT 41.00 06/30/10 85347 85347 85347 007 0300 2032
04321856 NA VERTIBRAL PLASTY CEMENT 419.00 06/30/10 007 0272 2032
04321859 NA VERT BIOPSY NEEDLE 180.00 06/30/10 007 0270 2032
04321860 PV POSSIS ANGIOJET XPEEDIOR 4096.00 06/30/10 007 0272 2030
04321864 PV POSSIS ANGIOJET 4F XMI 5087.00 06/30/10 007 0272 2030
04321868 PV POSSIS ANGIOJET 5F LF 4373.00 06/30/10 007 0272 2030
04321872 PV POSSIS ANGIOJET PUMP SET 895.00 06/30/10 007 0272 2030
04321875 NA INTRODU CATHETER AORTA 926.00 06/30/10 36200 36200 36200 007 0361 2032
04321878 NA SCP ABD/PELV LW EXT 1 ORD 2166.00 06/30/10 36245 36245 36245 007 0361 2032
04321881 NA SCP ABD/PELV LW EXT 2 ORD 1876.00 06/30/10 36246 36246 36246 007 0361 2032
04321884 NA SCP ABD/PELV LW EXT 2,3 ORD 1644.00 06/30/10 36248 36248 36248 007 0361 2032
04321887 NA SCP ABD/PELV LW EXT 3 ORD 2194.00 06/30/10 36247 36247 36247 007 0361 2032
04321890 NA SEL CATH PLAC VEN SYS 2 OR 2433.00 06/30/10 36012 36012 36012 007 0361 2032
04321893 NA STNT,CCA W DST EMB PRT LT 13950.00 06/30/10 37215LT 37215LT 37215LT 007 0361 2032
04321896 NA STNT,CCA W DST EMB PRT RT 13950.00 06/30/10 37215RT 37215RT 37215RT 007 0361 2032
04321899 NA STNT,CCA WO DST EMB PT LT 7695.00 06/30/10 37216LT 37216LT 37216LT 007 0361 2032
04321902 NA STNT,CCA WO DST EMB PT RT 7695.00 06/30/10 37216RT 37216RT 37216RT 007 0361 2032
04321905 NEEDLE LOCALIZATION BY XRAY 2932.00 06/30/10 31656 31656 31656 007 0361 2032
04321908 NA TRANSLMNL ANGIO PER ART 2668.00 06/30/10 75962 75962 75962TC 007 0320 2032
04321911 NA VENOGRAPHY OBITAL S&I 2313.00 06/30/10 75880 75880 75880TC 007 0320 2032
04321914 NA VENOGRAPHY SINUS/JUGUL CATH 2313.00 06/30/10 75860 75860 75860TC 007 0323 2032
04321917 NA VENOGRAPHY SUPERIOR SAGIT 2313.00 06/30/10 75870 75870 75870TC 007 0323 2032
04321920 NA KYPHOPLASTY LUMBAR 6887.00 06/30/10 22524 22524 22524 007 0361 2032
04321923 NA UNLIST PROC UNDER FLUOR S&I 664.00 06/30/10 76499 76499 76499TC 007 0320 2032
04321926 NA KYPHOPLASTY EACH ADD 6117.00 06/30/10 22525 22525 22525 007 0361 2032
04321929 NA UNL PROC UND FLRO S&I-2D LV 408.00 06/30/10 76499 76499 76499TC 007 0320 2032
04321932 NA UNL PROC,KYPHOPLASTY-3RD LV 2244.00 06/30/10 22899 22899 22899 007 0361 2032
04321935 NA KYPHOPLASTY - THORACIC 6484.00 06/30/10 22523 22523 22523 007 0361 2032
04321940 NA KYPH LATITUDE CURETTE 598.00 06/30/10 007 0272 2032
04321943 NA KYPH BONE FILLER DEVICE 353.00 06/30/10 007 0272 2032
04321946 NA KYPH INFLATABLE BONE TAMP 3433.00 06/30/10 007 0272 2032
04321950 NA KYPHOPACK KIT 10869.00 06/30/10 007 0272 2032
04321954 NA ACCUNET EMBOLIC PROTECTION 5533.00 06/30/10 007 0272 2032
04321956 NV LIQ EMBOLIC SYS-ONYXHD 500 20845.00 06/30/10 007 0270 2032
04321958 NA ACCULINK CAROTID STENT 8029.00 06/30/10 C1876 C1876 C1876 007 0278 2032
04321962 NA CEREBRAL STENT PLACEMENT 13950.00 06/30/10 0075T 0075T 0075T 007 0360 2032
04321966 NA CEREBRAL STENT PLCMNT ADD 9123.00 06/30/10 0076T 0076T 0076T 007 0360 2032
04321969 CT MOD SEDATION ADD 15 MIN 77.00 06/30/10 99145 99145 99145 007 0370 2040
04321972 CT MOD SEATION<5 YRS -30MIN 390.00 06/30/10 99143 99143 99143 007 0370 2040
04321975 CT MOD SEDATION>5YRS-30MIN 296.00 06/30/10 99144 99144 99144 007 0370 2040
04321978 CD CT BODY-COMPARISON ONLY N/C 06/30/10 007 0350 2040
04321981 CD CT HEAD-COMPARISON ONLY N/C 06/30/10 007 0350 2040
04321984 CD CT MUSC-SKEL-COMPARE ONLY N/C 06/30/10 007 0350 2040
04321987 CD CT BODY-READING ONLY N/C 06/30/10 007 0350 2040
04321990 CD CT HEAD-READING ONLY N/C 06/30/10 007 0350 2040
04321993 CD CT MUSC-SKEL - READING ONLY N/C 06/30/10 007 0350 2040
04322055 IRNSLUM BLN ANGP OPN FEMPOP LT 3182.00 06/30/10 35456LT 35456LT 35456LT 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 137
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04322486 PV ABSCESSOGRAM (TUBE CIC) 442.00 06/30/10 49424 49424 49424 54.97 54.97 007 0361 2030
04322489 PV DRAINAGE CATH REMOVAL 3738.00 06/30/10 47999 47999 47999 007 0361 2030
04322492 PV REMOVAL OF URETHERAL STENT 659.00 06/30/10 52310 52310 52310 007 0361 2030
04322495 PV BILIARY CATH REMOVAL-UNLST 3738.00 06/30/10 47999 47999 47999 007 0361 2030
04322498 PV NEPHROSTOMY CATH REMOVAL 208.00 06/30/10 53899 53899 53899 007 0361 2030
04323046 PV ABSCESSOGRAM (TUBE CIC) S/I 627.00 06/30/10 76080 76080 76080TC 007 0320 2030
04323501 CONSCIOUS SEDATION UP TO 2 HR 495.00 06/30/10 99144 99144 99144 89.68 89.68 007 0371 2030
04323504 CONSCIOUS SEDATION UP TO 4 HR 737.00 06/30/10 99144 99144 99144 89.68 89.68 007 0371 2030
04323516 CATHETER-DIAG 89.00 06/30/10 C1730 C1730 C1730 007 0272 2030
04323519 CATHETER-GUIDE 876.00 06/30/10 C1887 C1887 C1887 007 0272 2030
04323522 CATHETER-MICRO 2100.00 06/30/10 C1887 C1887 C1887 007 0272 2030
04323525 CATHETER-DRAIN 531.00 06/30/10 C1729 C1729 C1729 007 0272 2030
04323528 CATHETER-HEMO 1264.00 06/30/10 C1750 C1750 C1750 007 0278 2030
04323531 CATHETER-INFUSION 691.00 06/30/10 C1752 C1752 C1752 007 0272 2030
04323534 CATHETER-HEMO TEMP 773.00 06/30/10 C1752 C1752 C1752 007 0272 2030
04323537 WIRE-DIAG 112.00 06/30/10 C1769 C1769 C1769 007 0272 2030
04323540 WIRE-GLIDE 260.00 06/30/10 C1769 C1769 C1769 007 0272 2030
04323543 WIRE-MICRO 1556.00 06/30/10 C1769 C1769 C1769 007 0272 2030
04323546 SNARE KIT/RETRIEVAL 1678.00 06/30/10 C1773 C1773 C1773 007 0272 2030
04323549 STNT CT W/DEL(WALLGRFT,VIABHN) 13300.00 06/30/10 C1874 C1874 C1874 007 0278 2030
04323551 STNT NONCT W/DEL(SMRT,WALSTNT) 5078.00 06/30/10 C1876 C1876 C1876 007 0278 2030
04323554 STENT NONCOAT W/O DELIVERY 5499.00 06/30/10 C1877 C1877 C1877 007 0278 2030
04323557 CLOSER DEVICE 994.00 06/30/10 C1760 C1760 C1760 007 0278 2030
04323560 SINGLE LUMEN PORT 1665.00 06/30/10 C1788 C1788 C1788 007 0278 2030
04323563 DBL LUMEN PORT 2271.00 06/30/10 C1788 C1788 C1788 007 0278 2030
04323566 IVC FILTER 4035.00 06/30/10 C1880 C1880 C1880 007 0278 2030
04323569 BALLOON ANGIO PLASTY 1046.00 06/30/10 C1725 C1725 C1725 007 0272 2030
04323572 BALLOON ANGIO PLASTY 4FR 1714.00 06/30/10 C1725 C1725 C1725 007 0272 2030
04323575 COILS PLATINUM 675.00 06/30/10 C1770 C1770 C1770 007 0272 2030
04323578 INTRODUCER SPECIAL 747.00 06/30/10 C1893 C1893 C1893 007 0272 2030
04323581 LIVER BX KIT/TIPS KIT 2277.00 06/30/10 C1894 C1894 C1894 007 0272 2030
04323584 PVA/EMBOSPHERE 1519.00 06/30/10 007 0621 2030
04323587 INFLATOR DEVICE 376.00 06/30/10 007 0621 2030
04323590 PV CATH REPAIR KIT 283.00 06/30/10 007 0270 2030
04323593 PV ACT 41.00 06/30/10 85347 85347 85347 007 0300 2030
04323600 ANGIO TRAY 243.00 06/30/10 007 0272 2030
04323603 PICC LINE/C LINE TRAY 65.00 06/30/10 007 0272 2030
04323606 INTRODUCER REG/BANANA PEEL 126.00 06/30/10 C1766 C1766 C1766 007 0272 2030
04323609 INTRDCER MICR/MICR PNC ST/PEDS 112.00 06/30/10 C1894 C1894 C1894 007 0272 2030
04323612 DRM BND/CHTO SL/SP SUT/PRC STY 269.00 06/30/10 007 0272 2030
04323615 SP DRP/CV CAP/US PRBE CV/BG SH 72.00 06/30/10 007 0272 2030
04323618 RHV(ROTATING HEMOSTATIC VALVE) 167.00 06/30/10 007 0272 2030
04323621 GTUBE FST/SEGURA BSKT(GALL ST) 980.00 06/30/10 C1769 C1769 C1769 007 0272 2030
04323624 FOLEY CATH 85.00 06/30/10 A4344 A4344 A4344 007 0272 2030
04323627 SP.SYRINGE/STOP COCK 19.00 06/30/10 007 0272 2030
04323630 PV TREROTOLA PTD DEVICE 2297.00 06/30/10 C1724 C1724 C1724 007 0272 2030
04323633 PV MOTOR DRIVE 415.00 06/30/10 007 0272 2030
04323636 PV OMNI SCAN 20ML 186.00 06/30/10 Q9960 Q9960 Q9960 007 0636 2030
04323639 PV INRAD NEEDLE 114.00 06/30/10 007 0272 2030
04323642 PV RECOVERY FILTER DEVICE 2081.00 06/30/10 C1894 C1894 C1894 007 0272 2030
04323645 PV LACERATION TRAY 31.00 06/30/10 007 0272 2030
04323648 LOW OSMLR (300-349MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 138
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04323651 LOW OSMLR (350-399MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2030
04323654 GADOLINIUM BASED MR CONT/ML 15.00 06/30/10 A9579 A9579 A9579 007 0636 2030
04323657 PV DENVER PLEU KIT 1500.00 06/30/10 007 0272 2030
04323663 PV US ECHO BIOPSY INSTRUMENT 111.00 06/30/10 007 0621 2030
04323666 PV US ECHO THERMOABLATION NDLE 9304.00 06/30/10 007 0272 2030
04323669 PV US BX SUPPLIES 247.00 06/30/10 007 0272 2030
04323672 PV LOW OSMLR(300-399MG)CONT/MI 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2030
04323675 PV FL HYSTERSALPINGOGRAPHY S/I 893.00 06/30/10 74740 74740 74740 007 0320 2030
04325056 NM INTRACAVITARY THERAPY COLLO 596.00 06/30/10 79200 79200 79200TC 92.19 007 0342 2070
04329398 RADIOPHARM THERAPY, ORAL 1167.00 06/30/10 79005 79005 79005TC 007 0342 2070
04329401 RADPHARM THERAPY, INTRSTIT COL 3098.00 06/30/10 79300 79300 79300TC 007 0342 2070
04329736 SPLEEN IN CONJ LIV 1216.00 06/30/10 78215 78215 78215TC 88.97 007 0341 2070
04329739 CD NM BRAIN COMPARISON ONLY N/C 06/30/10 007 0341 2070
04329742 CD NM GRAL-COMPARISON ONLY N/C 06/30/10 007 0341 2070
04329745 CD NM BRAIN-READING ONLY N/C 06/30/10 007 0341 2070
04329748 CD NM GRAL-READING ONLY N/C 06/30/10 007 0341 0341
04331000 PV TL ANGPLASTY VENOUS 2450.15 06/30/10 75978 75978 75978TC 89.04 89.04 007 0320 2030
04331048 PV FLUORO EXAM UP TO 1 HR 893.00 06/30/10 76000 76000 76000TC 89.04 89.04 007 0320 2030
04331054 NEEDLE LOCALIZATION BY XRAY 821.00 06/30/10 77002 77002 77002TC 007 0320 2030
04331057 PV FLUORO GUID FOR SPINAL INJ 1216.00 06/30/10 77003 77003 77003TC 007 0320 2030
04331060 PV EX ABS/FIST/SINUS TRK STD 2036.00 06/30/10 76080 76080 76080TC 89.04 89.04 007 0320 2030
04331063 PV AMPLATZER PLUG 1489.00 06/30/10 C1884 C1884 C1884 007 0272 2030
04331066 PV CUTTING BALLOONS 3081.00 06/30/10 C1757 C1757 C1757 007 0272 2030
04331069 PV INJ OF EXIS CENT. VEN DEVI 768.56 06/30/10 36598 36598 36598 007 0361 2030
04331072 PV ADD VSLS TL THRMBCTMY ART 2822.00 06/30/10 37185 37185 37185 007 0360 2030
04331075 PV MOD SEDATION ADD 15 MIN 77.00 06/30/10 99145 99145 99145 007 0370 2030
04331078 PV MOD SEDATION<5 YRS-30 MIN 390.00 06/30/10 99143 99143 99143 007 0370 2030
04331081 PV MOD SEDATION> 5YRS-30 MIN 296.00 06/30/10 99144 99144 99144 007 0370 2030
04331084 PV REM & REPL URETRAL STENT-EX 1746.00 06/30/10 50387 50387 50387 007 0361 2030
04331087 PV REM & REPL URETRAL STENT-IN 3526.00 06/30/10 50382 50382 50382 007 0361 2030
04331090 PV REM OF NEPHROSTOMY TUBE 566.00 06/30/10 50389 50389 50389 007 0361 2030
04331093 PV REM URETRAL STENT-INT 4026.00 06/30/10 50384 50384 50384 007 0361 2030
04331096 PV TL MECH THRMBCTMY ART-PRI 5964.00 06/30/10 37184 37184 37184 007 0360 2030
04331099 PV TL MECH THRMBCTMY ART-SEC 2822.00 06/30/10 37186 37186 37186 007 0360 2030
04331102 PV TL MECH THRMBCTMY VEINS-PRI 5964.00 06/30/10 37187 37187 37187 007 0361 2030
04331105 PV TL MECH THRMBCTMY VEINS-SEC 5964.00 06/30/10 37188 37188 37188 007 0360 2030
04331108 PV FORCEP BIOPSY KIT 1785.00 06/30/10 007 0272 2030
04331111 PV TRELLIS INFUSION SYSTEM 7907.00 06/30/10 007 0272 2030
04331114 PV US GUIDED PARACENTESIS S&I 778.00 06/30/10 76942 76942 76942TC 007 0402 2030
04331117 PV US PARACENTESIS SURGICAL 906.00 06/30/10 49080 49080 49080 007 0361 2030
04331120 PV INST INDW TUN PLEU CATH 6186.00 06/30/10 32550 32550 32550 007 0361 2030
04331123 PV INST INDW TUN PLEU CATH-S&I 844.00 06/30/10 75989TC 75989 75989 007 0320 2030
04331126 PV STNT URTRL NC TEMP W/O DEL 508.00 06/30/10 C2617 C2617 C2617 007 0278 2030
04331129 PV BIOPSY BRUSH 557.00 06/30/10 007 0270 2030
04331132 PV CATHETER REPAIR KIT 398.00 06/30/10 007 0270 2030
04331135 PV NON-INV EXTR VEINS-BI STUDY 308.00 06/30/10 93965 93965 93965 007 0921 2030
04331138 PV DUPLEX SCAN EXTR VEINS-BL 495.00 06/30/10 93970 93970 93970 007 0921 2030
04331141 PV DUPLEX SCAN EXTR VEINS-RT 359.00 06/30/10 93971 93971 93971 007 0921 2030
04331144 PV DUPLEX SCAN EXTR VEINS-LT 359.00 06/30/10 93971 93971 93971 007 0921 2030
04331147 PV RAD FREQ EVAT IN/IMG-1 VEIN 8597.00 06/30/10 36475 36475 36475 007 0361 2030
04331150 PV RAD FREQ EVAT-2ND VEIN SUB 8597.00 06/30/10 36476 36476 36476 007 0361 2030
04331153 PV LASER EVAT INCL IMG-1ST VEI 5261.00 06/30/10 36478 36478 36478 007 0361 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 139
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04331156 PV LASER EVAT-2ND VEIN & SUB 8597.00 06/30/10 36479 36479 36479 007 0361 2030
04331159 PV INJ-SPIDER VEIN LIMB/TRUNK 283.00 06/30/10 36468 36468 36468 007 0361 2030
04331162 PV INJ-SINGLE VEIN 283.00 06/30/10 36470 36470 36470 007 0361 2030
04331165 PV INJ-MULTIPLE VEIN SAME LEG 283.00 06/30/10 36471 36471 36471 007 0361 2030
04331168 PV STAB PHL-VARI VE-LT 10-20 6831.00 06/30/10 37765 37765 37765 007 0361 2030
04331171 PV STAB PHL-VAR VE-RT 10-20 6831.00 06/30/10 37765 37765 37765 007 0361 2030
04331174 PV STAB PHLEB-VAR VE-LT>20 INC 6831.00 06/30/10 37766 37766 37766 007 0361 2030
04331177 PV STAB PHL-VAR VEINS-RT>20 IN 6831.00 06/30/10 37766 37766 37766 007 0361 2030
04331180 PV INJ LUMBAR 1468.00 06/30/10 62311 62311 62311 007 0361 2030
04331185 PV UTERINE FIBROID EMBOLIZATN 13221.00 06/30/10 37210 37210 37210 007 0361 2030
04331188 PV TL ANGPLSTY AVF/GRFT-ARTERY 3642.00 06/30/10 35475 35475 35475 007 0320 2030
04331191 PV TL ANGPLSTY AVF/GRFT-VENOUS 3642.00 06/30/10 35476 35476 35476 007 0361 2030
04332938 CARDIAC GATED EQUIL-SINGL VIEW 1383.00 06/30/10 78472 78472 78472TC 88.92 007 0341 2070
04334074 LABELLED LEUKOCYTE IMAGING-LTD 1967.00 06/30/10 78805 78805 78805TC 92.19 007 0341 2070
04334082 LABELLD LEUKOCYTE IMAG-WH BODY 1654.00 06/30/10 78806 78806 78806TC 92.18 007 0341 2070
04335618 ESOPGL REF RADINLD 1358.00 06/30/10 78262 78262 78262TC 88.97 007 0341 2070
04335626 GASTRIC EMPTY SOLID 1373.00 06/30/10 78264 78264 78264TC 92.04 007 0341 2070
04337234 BONE SCAN 1485.00 06/30/10 78306 78306 78306TC 88.94 007 0341 2070
04337237 NM 3D PROC W INDPNDT W/STN 588.00 06/30/10 76377 76377 76377TC 007 0350 2070
04337240 NM 3D PROC W/O INDPNDT W/STN 426.00 06/30/10 76376 76376 76376TC 007 0350 2070
04338703 CT ABDOMEN WITH CONTRAST 1829.00 06/30/10 74160 74160 74160TC 88.01 007 0350 2040
04338745 CT HEAD OR BRAIN WITH CONTRAST 1430.00 06/30/10 70460 70460 70460TC 87.03 007 0351 2040
04338748 CT 3D PROC W INDPNDT W/STN 588.00 06/30/10 76377 76377 76377TC 007 0350 2040
04338751 CT 3D PROC W/O INDPNDT W/STN 426.00 06/30/10 76376 76376 76376TC 007 0350 2040
04338754 CT CEREBRAL PERFUSION 487.00 06/30/10 0042T 0042T 0042T 007 0350 2040
04338760 CT RF ABLATION-RENAL TUMOR LT 3544.00 06/30/10 50592 50592 50592 007 0360 2040
04338763 CT RF ABLATION-RENAL TUMOR RT 3544.00 06/30/10 50592 50592 50592 007 0360 2040
04338764 CT ABL REN TUMOR PERC CRYOTHRP 6887.00 06/30/10 50593 50593 50593 007 0360 2040
04338766 CT VIRTUAL CLNSCPY DIAGNOSTIC 1142.00 06/30/10 74262 74262 74262TC 007 0350 2040
04338769 CT FINE NEEDLE ASPIRATION 431.00 06/30/10 10022 10022 10022 007 0360 2040
04338772 CT VIRTUAL CLNSCPY SCREENING 957.00 06/30/10 74263 74263 74263 007 0350 2040
04340001 MAM NDLE LOC RT(CHOOSE S&I) 904.00 06/30/10 19290 19290RT 19290RT 85.99 85.99 007 0361 2006
04340004 SPINE, SINGLE VIEW-THORACIC 231.00 06/30/10 72020 72020 72020 87.29 87.29 007 0320 2006
04340007 SPINE, SINGLE VIEW-LUMBAR 231.00 06/30/10 72020 72020 72020TC 87.29 87.29 007 0320 2006
04340010 SHOULDER, ARTHROGRPGY LEFT-S/I 704.00 06/30/10 73040LT 73040LT 73040TC 88.32 88.32 007 0320 2006
04340013 SHOULDER, ARTHROGRPGY RGHT-S/I 704.00 06/30/10 73040RT 73040RT 73040TC 88.32 88.32 007 0320 2006
04340016 HIP DURING OPERATIVE PROCED-RT 672.00 06/30/10 73530RT 73530RT 73530TC 88.26 88.26 007 0320 2006
04340022 KNEE-ARTHROGRAPHY, LEFT- S/I 820.00 06/30/10 73580LT 73580LT 73580TC 88.32 88.32 007 0320 2006
04340025 KNEE-ARTHROGRAPHY, RIGHT -S/I 820.00 06/30/10 73580RT 73580RT 73580TC 88.32 88.32 007 0320 2006
04340028 ANKLE ARTHROGRAPHY, LEFT- S/I 704.00 06/30/10 73615LT 73615LT 73615TC 88.32 88.32 007 0320 2006
04340031 ANKLE ARTHROGRAPHY, RIGHT- S/I 704.00 06/30/10 73615RT 73615RT 73615TC 88.32 88.32 007 0320 2006
04340034 MAM DUCTOGRAM 1 DUCT S&I RT 518.00 06/30/10 77053RT 77053RT 77053TC 89.04 89.04 007 0320 2006
04340037 HANDS-ARTHRITIS 166.00 06/30/10 77077 77077 77077TC 92.14 92.14 007 0320 2006
04340040 X-RAYS,BONE SURVEY,LIMITED 745.00 06/30/10 77074 77074 77074TC 88.33 88.33 007 0320 2006
04340043 MAM NDLE CORE BX LT 1096.00 06/30/10 19102 19102LT 19102LT 85.11 85.11 007 0361 2006
04340046 MAM NDLE CORE BX RT 1096.00 06/30/10 19102 19102RT 19102RT 85.11 85.11 007 0361 2006
04340049 MAM VA BX LT 1773.00 06/30/10 19103 19103LT 19103LT 85.11 85.11 007 0361 2006
04340052 MAM VA BX RT 1773.00 06/30/10 19103 19103RT 19103RT 85.11 85.11 007 0361 2006
04340055 CHANGE OF GASTROSTOMY TUBE 337.00 06/30/10 43760 43760 43760 007 0361 2006
04340058 CHLNGIGRPHY ADD SET-INTRAOP-SI 439.00 06/30/10 74301 74301 74301TC 87.54 87.54 007 0320 2006
04340061 CINERAD/VIDRD CMPLMNT ROUTE EX 204.00 06/30/10 76125 76125 76125TC 007 0320 2006
04340064 CISTRNAL PUNCT W/INJ MED-DX/TX 787.00 06/30/10 61055 61055 61055 01.01 01.01 007 0361 2006
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 140
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04340071 OMNIPAQUE 300MG (50ML) 46.00 06/30/10 Q9962 Q9962 Q9962 007 0636 2006
04340072 OMNIPAQUE 300MG (30ML) 29.00 06/30/10 Q9962 Q9962 Q9962 007 0636 2006
04340073 CNTRST INJ ABSCPRV CATH SEPPRO 319.00 06/30/10 49424 49424 49424 007 0361 2006
04340076 CORPORA CAVERNOSOGRAPHY RAD SI 482.00 06/30/10 74445 74445 74445TC 007 0320 2006
04340079 ENDO CATH BIL DCTAL SYS RAD SI 516.00 06/30/10 74328 74328 74328TC 007 0320 2006
04340082 ENDO CATH-PANCRT DUCT SYS-S&I 411.00 06/30/10 74329 74329 74329TC 007 0320 2006
04340085 FLUORO GUID NDLE-SPIN INJ PROC 806.00 06/30/10 77003 77003 77003TC 007 0320 2006
04340088 NEEDLE LOCALIZATION BY XRAY 821.00 06/30/10 77002 77002 77002TC 007 0320 2006
04340091 FLUORO-TIME > 1HR- 1072.00 06/30/10 76001 76001 76001TC 007 0320 2006
04340094 MAM CLIP PLCMT LT 429.00 06/30/10 19295 19295LT 19295LT 007 0361 2006
04340097 MAM CLIP PLCMT RT 429.00 06/30/10 19295 19295RT 19295RT 007 0361 2006
04340100 INJ PROC CHLNGO THRU XST CATH 694.00 06/30/10 47505 47505 47505 87.54 87.54 007 0361 2006
04340103 INJ PROC MYLGRAPHY&/CAT SPINAL 730.00 06/30/10 62284 62284 62284 007 0361 2006
04340106 MAM DUCTOGRAM LT(CHOOSE S&I) 618.00 06/30/10 19030 19030LT 19030LT 007 0361 2006
04340109 MAM DUCTOGRAM RT(CHOOSE S&I) 618.00 06/30/10 19030 19030RT 19030RT 007 0361 2006
04340112 INJ PYELGRPH-NEPHRST TUBE LT 396.00 06/30/10 50394 50394LT 50394LT 007 0361 2006
04340115 INJ PYELGRPH-NEPHRST TUBE RT 396.00 06/30/10 50394 50394RT 50394RT 007 0361 2006
04340118 INJ PROC RETRO URETHRCYSTGRPHY 1309.00 06/30/10 51610 51610 51610 007 0361 2006
04340121 INJ PROC-CYSTOGRAPHY 801.00 06/30/10 51600 51600 51600 007 0361 2006
04340124 INJECTION SINUS TRACT; DIAG 819.00 06/30/10 20501 20501 20501 83.98 007 0361 2006
04340133 X-RAY OF MAMMARY DUCTS-LT 416.00 06/30/10 77054LT 77054LT 77054TC 007 0320 2006
04340136 X-RAY OF MAMMARY DUCTS-RT 416.00 06/30/10 77054RT 77054RT 77054TC 007 0320 2006
04340139 GUIDANCE FOR NEEDLE,BREAST-RT 445.00 06/30/10 77032RT 77032RT 77032TC 89.04 89.04 007 0320 2006
04340142 MYELOGRAPHY CERVICAL RAD S&I 1485.00 06/30/10 72240 72240 72240TC 87.21 87.21 007 0320 2006
04340145 MYLOGRPHY ENTRE SP CANL RAD SI 2090.00 06/30/10 72270 72270 72270TC 87.21 87.21 007 0320 2006
04340148 MYLGRAPHY LUMBSACR RAD S&I 1420.00 06/30/10 72265 72265 72265TC 87.21 87.21 007 0320 2006
04340151 MYLGRAPHY POSTER FOSSA RAD S&I 1420.00 06/30/10 70010 70010 70010TC 87.21 87.21 007 0320 2006
04340154 MYELOGRAPHY THORACIC RAD S&I 1420.00 06/30/10 72255 72255 72255TC 87.21 87.21 007 0320 2006
04340157 MAM ASPIRATION OF CYST ADDL LT 426.00 06/30/10 19001 19001LT 19001LT 85.91 85.91 007 0361 2006
04340160 MAM ASPIRATION OF CYST ADDL RT 426.00 06/30/10 19001 19001RT 19001RT 85.91 85.91 007 0361 2006
04340163 MAM ASPIRATION OF CYST-RT 455.00 06/30/10 19000 19000RT 19000RT 85.91 85.91 007 0361 2006
04340166 MAM ASPIRATION OF CYST LT 455.00 06/30/10 19000 19000LT 19000LT 85.91 85.91 007 0361 2006
04340169 ELBOW ARTHROGRPHY, LEFT-S/I 709.00 06/30/10 73085LT 73085LT 73085TC 88.32 88.32 007 0320 2006
04340172 ELBOW ARTHROGRPHY, RIGHT-S/I 709.00 06/30/10 73085RT 73085RT 73085TC 88.32 88.32 007 0320 2006
04340181 WRIST ARTHROGRAPHY, LEFT-S/I 704.00 06/30/10 73115LT 73115LT 73115TC 88.32 88.32 007 0320 2006
04340184 WRIST ARTHROGRAPHY, RIGHT-S/I 704.00 06/30/10 73115RT 73115RT 73115TC 88.32 88.32 007 0320 2006
04340187 HIP ARTHROGRPHY, RIGHT-S&I 800.00 06/30/10 73525RT 73525RT 73525TC 88.32 88.32 007 0320 2006
04340190 SI JNT ARTHROGRPHY S&I 704.00 06/30/10 73542 73542 73542TC 88.32 88.32 007 0320 2006
04340193 XRAY STRESS VIEW 331.00 06/30/10 77071 77071 77071TC 007 0320 2006
04340196 RADIOLOGIC EX MAND PART<4 VIEW 174.00 06/30/10 70100 70100 70100TC 007 0320 2006
04340199 RADIOLOGIC EXAM FCE BNS<3 VIEW 227.00 06/30/10 70140 70140 70140TC 007 0320 2006
04340208 RIBS, RIGHT 2 VIEWS 283.00 06/30/10 71100RT 71100RT 71100RT 87.43 87.43 007 0320 2006
04340211 RIBS, RIGHT INC P.A. CHEST 371.00 06/30/10 71101RT 71101RT 71101TC 87.43 87.43 007 0320 2006
04340214 STEREOTACT GUID,BRST BX-RT 957.00 06/30/10 77031RT 77031RT 77031TC 85.19 85.19 007 0320 2006
04340220 VASOGRPHY/VESICULOGRPHY-RAD SI 482.00 06/30/10 74440 74440 74440TC 007 0320 2006
04341376 COMPUTER IMAGE PROCESS <30 MIN 151.00 06/30/10 78890 78890 78890TC 92.19 007 0341 2070
04341384 RAI THERAPY FOR MALIGNANCY 1485.00 06/30/10 79005 79005 79005TC 92.29 007 0342 2070
04341418 VIEW(S), ADDITIONAL (1 TO 3) 115.00 06/30/10 76499 76499 76499TC 88.39 007 0320 2006
04341421 ABDOMEN FOLLOW UP 229.00 06/30/10 7400076 7400076 74000TC 007 0320 2006
04341424 ARTHROCENTESIS ASP AND/OR INJ 768.00 06/30/10 20610 20610 20610 007 0360 2006
04341425 CHEST FOLLOW UP 181.00 06/30/10 7101076 7101076 71010TC 007 0320 2006
04341427 MAMMOGRAM,SCREENING 167.00 06/30/10 77057 77057 77057TC 007 0403 2006
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 141
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04341715 PANOREX FACIAL AP 196.00 06/30/10 70355 70355 70355TC 88.39 007 0320 2006
04341718 MAM IMG GUIDED PLC TIS MARKER 429.00 06/30/10 19295 19295 19295 007 0361 2006
04341721 SNIF TEST 472.00 06/30/10 76496 76496 76496TC 007 0320 2006
04341731 PERI-JUG SHNT DET 1485.00 06/30/10 78291 78291 78291TC 88.97 007 0341 2070
04341996 GI BLEED RADNCLD 1358.00 06/30/10 78278 78278 78278TC 88.97 007 0341 2070
04347977 GASTRIC EMPTYING LIQUID 1373.00 06/30/10 78264 78264 78264TC 92.04 007 0341 2070
04350000 US THORACENTESIS THERP W/TUBE 1255.00 06/30/10 32422 32422 32422 007 0361 2035
04350003 US ASP-BLADDER BY NEEDLE 367.00 06/30/10 51100 51100 51100 007 0361 2035
04350006 NV BX BONE TROCAR/NDLE DEEP 835.00 06/30/10 20225 20225 20225 007 0360 2032
04350009 NV BONE ABLATION INCL CT GUIDE 6492.00 06/30/10 20982 20982 20982 007 0360 2032
04353729 ECHO BIOPSY NEEDLE GROUP 1 75.00 06/30/10 007 0621 2035
04353730 ECHO BIOPSY NEEDLE GROUP 2 220.00 06/30/10 007 0621 2035
04353740 ECHO THERMOABLATION NEEDLE 8373.00 06/30/10 007 0621 2035
04353742 US ECHO THERMABLTION NDLE XLIE 8855.00 06/30/10 007 0270 2035
04353744 ECHO ASP BX GUIDE 101.00 06/30/10 007 0621 2035
04353745 ECHO FILM COPY 12.00 06/30/10 007 0621 2035
04353748 US PARACENT<10 DAYS 339.00 06/30/10 49081 49081 49081 007 0361 2035
04353751 US LYMPOCELE DRAINAGE 606.00 06/30/10 49062 49062 49062 007 0360 2035
04353754 US RF ABLATION-RENAL TUMOR BL 6730.00 06/30/10 5059250 5059250 5059250 007 0360 2035
04353757 US RF ABLATION-RENAL TUMOR LT 3544.00 06/30/10 50592 50592 50592 007 0360 2035
04353760 US RF ABLATION-RENAL TUMOR RT 3544.00 06/30/10 50595 50592 50592 007 0360 2035
04353765 US ABL REN TUMOR PERC CRYOTHRP 6887.00 06/30/10 50593 50593 50593 007 0360 2035
04355509 THYROID SCAN ONLY 825.00 06/30/10 78010 78010 78010TC 88.97 007 0341 2070
04355525 LUNG PERFUSION 805.00 06/30/10 78580 78580 78580TC 92.15 007 0341 2070
04355533 LUNG VENTILATION 966.00 06/30/10 78593 78593 78593TC 92.15 007 0341 2070
04355541 BLOOD POOL SCAN NON-CARDIAC 744.00 06/30/10 78445 78445 78445TC 92.05 007 0341 2070
04355566 DIFF PULM FUNCT CALC 1718.00 06/30/10 78596 78596 78596TC 92.15 007 0341 2070
04355569 MOD CS BY SAME PHYS,5YRS + 428.00 06/30/10 99144 99144 99144 007 0370 2070
04355572 NM LYMPHATICS-INJECTION ONLY 421.00 06/30/10 38792 38792 38792 007 0361 2070
04355582 RAI METAST SURV 1485.00 06/30/10 78018 78018 78018TC 88.97 007 0341 2070
04355585 US BX BREAST NEEDLE CORE RT 1096.00 06/30/10 19102 19102RT 19102RT 85.12 85.12 007 0361 2035
04355586 US BX BREAST NEEDLE CORE LT 1096.00 06/30/10 19102 19102LT 19102LT 85.12 85.12 007 0361 2035
04355600 US CONSCIOUS SEDATION 428.00 06/30/10 99144 99144 99144 89.68 007 0370 2035
04355657 TESTICULAR SCN+ANG 918.00 06/30/10 78761 78761 78761TC 88.97 007 0341 2070
04355665 CARDIAC SHUNT DETECTION 1216.00 06/30/10 78428 78428 78428TC 92.05 007 0341 2070
04355756 UROGRAPHY W NEPHROTOMOGRAPHY 738.00 06/30/10 74415 74415 74415TC 87.72 007 0320 2006
04356077 CT ABCESS DRAINAGE 1872.00 06/30/10 75989 75989 75989TC 89.04 007 0350 2040
04356721 ECHO BREAST 286.00 06/30/10 76645 76645 76645TC 88.73 007 0402 2035
04356725 ECHO COVER, STERILE PROBE 35.00 06/30/10 007 0621 2035
04356726 ECHO TRANSVAGINAL 415.00 06/30/10 76830 76830 76830TC 88.79 007 0402 2035
04356728 ECHOGRAPHY CHEST 390.00 06/30/10 76604 76604 76604TC 88.73 007 0402 2035
04356730 ECHO SOFT TISSUE NECK 545.00 06/30/10 76536 76536 76536TC 88.71 007 0402 2035
04356731 ECHO THYROID-LIMITED 545.00 06/30/10 76536 76536 76536TC 88.71 007 0402 2035
04356732 ECHO SCROTUM AND CONTENTS 605.00 06/30/10 76870 76870 76870TC 88.79 007 0402 2035
04356738 ULTRASON GUIDNCE THORACENTESIS 778.00 06/30/10 76942 76942 76942TC 88.79 007 0402 2035
04356740 ECHOGRAPHY SPINAL CANAL 497.00 06/30/10 76800 76800 76800TC 88.79 007 0402 2035
04356742 ECHO - PARACENTISIS 778.00 06/30/10 76942 76942 76942TC 88.79 007 0402 2035
04356744 ECHO, THORACENTISIS-SURGICAL 630.00 06/30/10 32421 32421 32421 34.91 34.91 007 0361 2035
04356746 ECHO-CATH/INTRA SAL/CONTR HYST 324.00 06/30/10 58340 58340 58340 87.83 87.83 007 0361 2035
04356747 FETAL BIOPHYSICAL W/WO STRESS 495.00 06/30/10 76819 76819 76819TC 88.78 007 0402 2035
04356748 ECHO-HYSTEROSONOGRAPHY 327.00 06/30/10 76831 76831 76831TC 88.79 007 0402 2035
04356750 ECHO-ABDOMINAL PARACENTISIS 339.00 06/30/10 49080 49080 49080 54.91 54.91 007 0361 2035
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 142
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04356753 NM MOD SEDATION ADD 15 MIN 77.00 06/30/10 99145 99145 99145 007 0370 2070
04356756 NM MOD SEDATION<5 YRS-30 MIN 390.00 06/30/10 99143 99143 99143 007 0370 2070
04356759 NM MOD SEDATION> 5YRS-30 MIN 296.00 06/30/10 99144 99144 99144 007 0370 2070
04356776 US MOD SEDATION<5 YRS-30 MIN 390.00 06/30/10 99143 99143 99143 007 0370 2035
04356779 US MOD SEDATION> 5YRS-30 MIN 296.00 06/30/10 99144 99144 99144 007 0370 2035
04359782 US BX SUPPLIES 223.00 06/30/10 007 0270 2035
04359791 US CHEST DRAINAGE SYSTEM 139.00 06/30/10 007 0270 2035
04360888 CONTRST MEDIA-GASTROVIEW 120ML 109.00 06/30/10 Q9962 Q9962 Q9962 007 0636 2006
04360891 LOW OSMLR (300-349MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2006
04360894 LOW OSMLR (350-399MG) CONT/ML 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2006
04360897 MAM VAC ASST TIS MARKER 272.00 06/30/10 C1879 C1879 C1879 007 0278 2006
04360900 MAM US VAC ASST TUBING 68.00 06/30/10 007 0270 2006
04360903 MAM US VAC ASST PROBE 1147.00 06/30/10 007 0270 2006
04360906 MAM US GUIDED PROBE 142.00 06/30/10 007 0270 2006
04360909 MAM BX SUPPLIES 272.00 06/30/10 007 0270 2006
04360912 MAM COVER STERILE PROBE 35.00 06/30/10 007 0270 2006
04362372 CNTRST MDIA-HXABRX 300-399MG 172.00 06/30/10 Q9962 Q9962 Q9962 007 0636 2006
04362403 NM CR-51 PER STUDY UPTO 10 UCI 161.00 06/30/10 A9553 A9553 A9553 99.99 007 0343 2070
04362406 NM CO57/58 DICOPACUPTO 1 UCI 1232.00 06/30/10 A9546 A9546 A9546 99.99 007 0636 2070
04362409 NM MDP UD <30MCI 39.00 06/30/10 A9503 A9503 A9503 99.99 007 0343 2070
04362412 NM MYOVIEW UPTO 40MCI 257.00 06/30/10 A9502 A9502 A9502 99.99 007 0343 2070
04362421 NM GALLIUM PER MCI 91.00 06/30/10 A9556 A9556 A9556 99.99 007 0343 2070
04362424 NM HEPATOLITE UD 77.00 06/30/10 A9510 A9510 A9510 99.99 007 0343 2070
04362427 NMTC PERTECHNATATE PER MCI 39.00 06/30/10 A9512 A9512 A9512 99.99 007 0343 2070
04362430 NM SULFUR COLLOID UP TO 20MCI 143.00 06/30/10 A9541 A9541 A9541 99.99 007 0636 2070
04362433 NM C057(SCHILLINGS)UP TO 1MCI 740.00 06/30/10 A9559 A9559 A9559 99.99 007 0343 2070
04362451 NM TC99M CHOLETEC UPTO 15MCI 180.00 06/30/10 A9537 A9537 A9537 99.99 99.99 007 0343 2070
04362454 NM TC99M GLUCOSCAN UPTO 25MCI 129.00 06/30/10 A9550 A9550 A9550 99.99 99.99 007 0343 2070
04362457 NM TC99M MAA UPTO 10MCI 48.00 06/30/10 A9540 A9540 A9540 99.99 99.99 007 0343 2070
04362460 NM 1-131 DIAG SOLUT PER MCI 30.00 06/30/10 A9529 A9529 A9529 99.99 99.99 007 0343 2070
04362463 NM 1-131 THERAPY SOLUT PER MCI 30.00 06/30/10 A9530 A9530 A9530 99.99 99.99 007 0344 2070
04362466 NM 1-131 UPTAKE CAPSULE UD 82.00 06/30/10 A9531 A9531 A9531 99.99 99.99 007 0343 2070
04362469 NM TC-DMSA UPTO 10MCI 456.00 06/30/10 A9551 A9551 A9551 99.99 99.99 007 0343 2070
04362472 NM TC-MAG-3 UPTP 15MCI 812.00 06/30/10 A9562 A9562 A9562 99.99 99.99 007 0343 2070
04362475 NM 1-111 OCTREOSCAN PER 6 MCI 9433.00 06/30/10 A9572 A9572 A9572 007 0343 2070
04362478 NM ULTRA TAG UPTO 30 MCI 2226.00 06/30/10 A9560 A9560 A9560 99.99 99.99 007 0343 2070
04362481 NM XENON-133 PER 10 MCI 175.00 06/30/10 A9558 A9558 A9558 99.99 99.99 007 0343 2070
04362484 TECHNETIUM TC99 ARCITUMOMAB 6859.00 06/30/10 A9568 A9568 A9568 99.99 99.99 007 0343 2070
04362487 IODINE I-125 SODIUM IODIDE 154.00 06/30/10 A9527 A9527 A9527 99.99 99.99 007 0344 2070
04362490 NM P-32 CHROM PHOS PER MCI 485.00 06/30/10 A9564 A9564 A9564 99.99 99.99 007 0344 2070
04362493 NM 1-131 THER CAPSULE PER MCI 77.00 06/30/10 A9517 A9517 A9517 99.99 99.99 007 0344 2070
04362496 BRACHYTHERPY SOURCE,YTTRIUM-90 56771.00 06/30/10 C2616 C2616 C2616 007 0278 2070
04370023 WRIST INJ FOR ARTHROGRAM RT 1113.00 06/30/10 25246RT 25246RT 25246RT 88.32 007 0361 2006
04370025 WRIST INJ FOR ARTHROGRAM LT 1113.00 06/30/10 25246LT 25246LT 25246LT 88.32 007 0361 2006
04370027 ELBOW INJ FOR ARTHROGRAM RT 1161.00 06/30/10 24220RT 24220RT 24220RT 88.32 007 0361 2006
04370029 ELBOW INJ FOR ARTHROGRAM LT 1161.00 06/30/10 24220LT 24220LT 24220LT 88.32 007 0361 2006
04370031 SHOULDER INJ FOR ARTHROGRAM RT 433.00 06/30/10 23350RT 23350RT 23350RT 88.32 007 0361 2006
04370033 SHOULDER INJ FOR ARTHROGRAM LT 433.00 06/30/10 23350LT 23350LT 23350LT 88.32 007 0361 2006
04370035 INJECTION, ELBOW ARTHROGRAM 1161.00 06/30/10 24220 24220 24220 88.32 88.32 007 0361 2006
04370038 INJECTION, HIP ARTHROGRAM 608.00 06/30/10 27093 27093 27093 88.32 88.32 007 0361 2006
04370040 INJECTION, SHOULDER ARTHROGRAM 433.00 06/30/10 23350 23350 23350 88.32 88.32 007 0361 2006
04370041 INJECTION, WRIST ARTHROGRAM 1113.00 06/30/10 25246 25246 25246 88.32 88.32 007 0361 2006
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 143
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04370043 INJECTION, KNEE ARTHROGRAM 1003.00 06/30/10 27370 27370 27370 88.32 88.32 007 0361 2006
04370044 INJECTION, ANKLE ARTHROGRAM 468.00 06/30/10 27648 27648 27648 88.32 88.32 007 0361 2006
04370045 IAC 261.00 06/30/10 70134 70134 70134TC 87.16 007 0320 2006
04370047 INJECTION, SIALOGRAPHY 162.00 06/30/10 42550 42550 42550 87.09 87.09 007 0361 2006
04370075 INJECTION, NASOLACRIMAL 197.00 06/30/10 68850 68850 68850 87.05 87.05 007 0361 2006
04370110 CISTERNOGRAPHY 1420.00 06/30/10 70015 70015 70015TC 87.02 87.02 007 0320 2006
04370219 MASTOIDS 120.00 06/30/10 70130 70130 70130TC 87.16 007 0320 2006
04370268 FACIAL BONES 310.00 06/30/10 70150 70150 70150TC 87.16 007 0320 2006
04370300 NASAL BONES MIN 3 VIEWS 267.00 06/30/10 70160 70160 70160TC 87.16 007 0320 2006
04370359 NASOLACRIMAL, S+I 332.00 06/30/10 70170 70170 70170TC 87.05 007 0320 2006
04370391 OPTIC FORAMINA 159.00 06/30/10 70190 70190 70190TC 95.14 007 0320 2006
04370394 RAD EXAM, EYE-FRGN BDY DETECT 170.00 06/30/10 70030 70030 70030TC 007 0320 2008
04370441 ORBITS COMPLETE 357.00 06/30/10 70200 70200 70200TC 95.14 007 0320 2006
04370490 PARANASAL SIN PAR 2 VIEWS 196.00 06/30/10 70210 70210 70210TC 87.16 007 0320 2006
04370508 PARANASAL SIN COM PAR MIN 3 VW 342.00 06/30/10 70220 70220 70220TC 87.16 007 0320 2006
04370540 SELLA TURCICA 198.00 06/30/10 70240 70240 70240TC 87.16 007 0320 2006
04370599 SKULL PARTIAL< 4 VIEWS 297.00 06/30/10 70250 70250 70250TC 87.17 007 0320 2006
04370607 SKULL COMPLETE 419.00 06/30/10 70260 70260 70260TC 87.17 007 0320 2006
04370714 T M J BILATERAL 262.00 06/30/10 70330 70330 70330TC 87.13 007 0320 2006
04370771 NECK SOFT TISSUE 263.00 06/30/10 70360 70360 70360TC 87.09 007 0320 2006
04370854 SALIVARY GLAND 155.00 06/30/10 70380 70380 70380TC 87.09 007 0320 2006
04370896 SIALOGRAPHY 271.00 06/30/10 70390 70390 70390TC 87.09 007 0320 2006
04371019 CHEST SINGLE VIEW, FRONTAL 181.00 06/30/10 71010 71010 71010TC 87.44 007 0320 2006
04371022 CHEST SINGLE VIEW-INSPIRATION 181.00 06/30/10 71010 71010 71010TC 007 0320 2006
04371023 CHEST SINGLE VIEW-EXPIRATION 200.00 06/30/10 71035 71035 71035TC 007 0320 2006
04371027 CHEST TWO VIEWS 214.00 06/30/10 71020 71020 71020TC 87.44 007 0320 2006
04371035 CHEST FOUR VIEWS 291.00 06/30/10 71030 71030 71030TC 87.44 007 0320 2006
04371514 RIBS BILATERAL 297.00 06/30/10 71110 71110 71110TC 87.43 007 0320 2006
04371704 STERNUM 180.00 06/30/10 71120 71120 71120TC 87.43 007 0320 2006
04371753 STERNOCLAVICULAR JOINTS 188.00 06/30/10 71130 71130 71130TC 87.43 007 0320 2006
04372058 SPINE CERVICAL 2 OR 3 VIEWS 275.00 06/30/10 72040 72040 72040TC 87.22 007 0320 2006
04372065 MYELO 2/MORE REGIONS S/I 2090.00 06/30/10 72270 72270 72270TC 87.21 87.21 007 0320 2006
04372074 SPINE CERVICAL COMPLETE 426.00 06/30/10 72050 72050 72050TC 87.22 007 0320 2006
04372108 SPINE THORACIC AP & LAT 249.00 06/30/10 72070 72070 72070TC 87.23 007 0320 2006
04372116 THORACO-LUMBAR 2 VIEWS 317.00 06/30/10 72080 72080 72080TC 87.23 007 0320 2006
04372132 SPINE LUMBAR 2 OR 3 VIEWS 311.00 06/30/10 72100 72100 72100TC 87.24 007 0320 2006
04372157 SPINE LUMBOSOCRAL COMPL W/OBLS 404.00 06/30/10 72110 72110 72110TC 87.24 007 0320 2006
04372165 SPINE,LUMB COMPLETE W BENDING 479.00 06/30/10 72114 72114 72114TC 87.24 007 0320 2006
04372173 SCOLIOSIS COMPLETE 339.00 06/30/10 72069 72069 72069TC 87.23 007 0320 2006
04372207 PELVIS AP 323.00 06/30/10 72170 72170 72170TC 88.26 007 0320 2006
04372272 SI JOINTS; 3/MORE VIEWS 283.00 06/30/10 72202 72202 72202TC 88.26 007 0320 2006
04372280 SACRUM OR COCCYX,MIN 2 VIEWS 249.00 06/30/10 72220 72220 72220TC 88.26 007 0320 2006
04372447 FOLEY CATHETER 80.00 06/30/10 007 0621 2006
04372454 CATH.TRAY 48.00 06/30/10 007 0621 2006
04372462 FOLEY CATHETER TRAY 137.00 06/30/10 007 0621 2006
04372505 CLAVICLE, RIGHT,COMPLETE 275.00 06/30/10 73000RT 73000RT 73000TC 87.43 007 0320 2006
04372506 CLAVICLE, LEFT, COMPLETE 275.00 06/30/10 73000LT 73000LT 73000TC 87.43 007 0320 2006
04372554 SCAPULA, RIGHT 297.00 06/30/10 73010RT 73010RT 73010TC 87.43 007 0320 2006
04372555 SCAPULA, LEFT 297.00 06/30/10 73010LT 73010LT 73010TC 87.43 007 0320 2006
04372612 SHOULDER-RT,COMPLETE-MIN2 VIEW 269.00 06/30/10 73030RT 73030RT 73030TC 87.21 007 0320 2006
04372613 SHOULDER-LT COMPLETE MIN2 VIEW 269.00 06/30/10 73030LT 73030LT 73030TC 87.21 007 0320 2006
04372652 AC JOINTS 262.00 06/30/10 73050 73050 73050TC 88.33 007 0320 2006
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 144
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04372694 PROV DIAG RADIONUCLIDE 134.00 06/30/10 A4641 A4641 78990 99.99 007 0636 2070
04372696 NM I-111 ZEVALIN UPTO 5 MCI 5472.00 06/30/10 A9542 A9542 A9542 99.99 007 0343 2070
04372699 NM YT-90 ZEAV PR TX UPTO 40MCI 1051.00 06/30/10 A9543 A9543 A9543 99.99 007 0344 2070
04372703 HUMERUS, LEFT 275.00 06/30/10 73060LT 73060LT 73060TC 88.21 007 0320 2006
04372704 HUMERUS, RIGHT 275.00 06/30/10 73060RT 73060RT 73060TC 88.21 007 0320 2006
04372752 ELBOW-RT, COMPLETE,MIN 3 VIEWS 249.00 06/30/10 73080RT 73080RT 73080TC 88.22 007 0320 2006
04372753 ELBOW-LT, COMPLETE,MIN 3 VIEWS 249.00 06/30/10 73080LT 73080LT 73080TC 88.22 007 0320 2006
04372802 FOREARM, RIGHT AP & LAT 219.00 06/30/10 73090RT 73090RT 73090TC 88.22 007 0320 2006
04372803 FOREARM, LEFT, AP & LAT 219.00 06/30/10 73090LT 73090LT 73090TC 88.22 007 0320 2006
04372869 WRIST-LT,COMPLETE,MIN 3 VIEWS 283.00 06/30/10 73110LT 73110LT 73110TC 88.23 007 0320 2006
04372870 WRIST-RT,COMPLETE, MIN 3 VIEWS 283.00 06/30/10 73110RT 73110RT 73110TC 88.23 007 0320 2006
04372901 HAND-LEFT, MIN 3 VIEWS 255.00 06/30/10 73130LT 73130LT 73130TC 88.23 007 0320 2006
04372902 HAND-RIGHT, MIN 3 VIEWS 255.00 06/30/10 73130RT 73130RT 73130TC 88.23 007 0320 2006
04372960 FINGER(S)-RIGHT, MIN 2 VIEWS 196.00 06/30/10 73140RT 73140RT 73140TC 88.23 007 0320 2006
04372961 FINGER(S)-LEFT, MIN 2 VIEWS 196.00 06/30/10 73140LT 73140LT 73140TC 88.23 007 0320 2006
04372975 INFUSN/INSTILLATION 11-15 MCI 9118.00 06/30/10 77750 77750 77750TC 92.28 007 0333 2050
04373016 HIP-LT,UNILAT, MIN 2 VIEWS 296.00 06/30/10 73510LT 73510LT 73510TC 88.26 007 0320 2006
04373017 HIP-RT,UNILAT, MIN 2 VIEWS 296.00 06/30/10 73510RT 73510RT 73510TC 88.26 007 0320 2006
04373029 HIP INJ FOR ARTHROGRAM LT 608.00 06/30/10 27093LT 27093LT 27093LT 88.32 007 0361 2006
04373030 HIP INJ FOR ARTHROGRAM RT 608.00 06/30/10 27093RT 27093RT 27093RT 88.32 007 0361 2006
04373048 KNEE INJ FOR ARTHROGRAM LT 1003.00 06/30/10 27370LT 27370LT 27370LT 88.32 007 0361 2006
04373049 KNEE INJ FOR ARTHROGRAM RT 1003.00 06/30/10 27370RT 27370RT 27370RT 88.32 007 0361 2006
04373050 ANKLE INJ FOR ARTHROGRAM LT 468.00 06/30/10 27648LT 27648LT 27648LT 88.32 007 0361 2006
04373051 ANKLE INJ FOR ARTHROGRAM RT 468.00 06/30/10 27648RT 27648RT 27648RT 88.32 007 0361 2006
04373081 FEMUR-LEFT AP & LAT 297.00 06/30/10 73550LT 73550LT 73550TC 88.27 007 0320 2006
04373082 FEMUR-RIGHT, AP & LAT 297.00 06/30/10 73550RT 73550RT 73550TC 88.27 007 0320 2006
04373115 KNEE-RIGHT, 1 OR 2 VIEWS 253.00 06/30/10 73560RT 73560RT 73560TC 88.27 007 0320 2006
04373116 KNEE-LEFT, 1 OR 2 VIEWS 253.00 06/30/10 73560LT 73560LT 73560TC 88.27 007 0320 2006
04373156 TIBIA & FIBULA-RT, AP & LAT 249.00 06/30/10 73590RT 73590RT 73590TC 88.27 007 0320 2006
04373157 TIBIA & FIBULA-LT, AP & LAT 249.00 06/30/10 73590LT 73590LT 73590TC 88.27 007 0320 2006
04373198 ANKLE-LT,COMPLETE,MIN 3 VIEWS 255.00 06/30/10 73610LT 73610LT 73610TC 88.28 007 0320 2006
04373199 ANKLE-RT,COMPLETE,MIN 3 VIEWS 255.00 06/30/10 73610RT 73610RT 73610TC 88.28 007 0320 2006
04373240 FOOT-RT,COMPLETE,MIN 3 VIEWS 270.00 06/30/10 73630RT 73630RT 73630TC 88.28 007 0320 2006
04373241 FOOT-LT,COMPLETE,MIN 3 VIEWS 270.00 06/30/10 73630LT 73630LT 73630TC 88.28 007 0320 2006
04373263 CALCANEUS-RIGHT 212.00 06/30/10 73650TC 73650RT 73650RT 88.28 007 0320 2006
04373264 CALCANEUS-LEFT-2 VIEWS OR MORE 212.00 06/30/10 73650TC 73650LT 73650LT 88.28 007 0320 2006
04373289 TOE(S)-RIGHT 199.00 06/30/10 73660TC 73660RT 73660RT 88.28 007 0320 2006
04373290 TOE(S)-LEFT 199.00 06/30/10 73660TC 73660LT 73660LT 88.28 007 0320 2006
04373304 ABDOMEN ONE VIEW 229.00 06/30/10 74000TC 74000 74000 88.19 007 0320 2006
04373312 ABDOMEN TWO VIEWS 270.00 06/30/10 74020TC 74020 74020 88.19 007 0320 2006
04373353 ESOPHAGUS 479.00 06/30/10 74220TC 74220 74220 87.69 007 0320 2006
04373379 UPPER GI SNG CONTRAST W KUB 634.00 06/30/10 74241TC 74241 74241 87.62 007 0320 2006
04373411 SMALL BOWEL W MULT SERIAL FILM 656.00 06/30/10 74250TC 74250 74250 87.63 007 0320 2006
04373445 COLON, SINGLE CONTRAST 640.00 06/30/10 74270TC 74270 74270 87.65 007 0320 2006
04373486 CHOLECYSTOGRAPHY ORAL CONTRAST 252.00 06/30/10 74290TC 74290 74290 87.59 007 0320 2006
04373502 CHOLANGIOGRAPHY DURING SURGERY 518.00 06/30/10 74300TC 74300 74300 87.54 007 0320 2006
04373635 UROGRAPHY INTRAVENOUS 596.00 06/30/10 74400TC 74400 74400 87.73 007 0320 2006
04373650 UROGRAPHY RETROGRADE 781.00 06/30/10 74420TC 74420 74420 87.74 007 0320 2006
04373718 URETHROCYSTOGRAPHY RETRO S & I 638.00 06/30/10 74450TC 74450 74450 87.76 007 0320 2006
04373726 URETHROCYSTOGRAPHY VOID S & I 646.00 06/30/10 74455TC 74455 74455 87.76 007 0320 2006
04373940 HYSTERO SALPINGO GRAPHY S/I 1014.00 06/30/10 74740TC 74740 74740 87.83 007 0320 2006
04374386 US ASP&INJ INTRMED JNT/BURSA 1321.00 06/30/10 20605 20605 20605 007 0360 2035
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 145
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04374422 NM ADRENAL IMAG CORTEX&MEDULLA 559.00 06/30/10 78075 78075 78075TC 92.19 007 0341 2070
04374425 NM LIVER IMAGE W VASCULAR FLOW 1121.00 06/30/10 78202 78202 78202TC 92.02 007 0341 2070
04374428 NM SALIVARY GLAND IMAG 1025.00 06/30/10 78230 78230 78230TC 92.12 007 0341 2070
04374434 NM VENO THRMB IMAG PEPT ACUTE 1216.00 06/30/10 78456 78456 78456TC 007 0341 2070
04374439 BEXXAR DX PER STUDY DOSE 8167.00 06/30/10 007 0341 2070
04374449 NM CSF LEAKAGE DETECT&LOC 794.00 06/30/10 78650 78650 78650TC 007 0341 2070
04374458 NM THROMBUS DETECT(DVT) LT 508.00 06/30/10 78457LT 78457LT 78457TC 92.05 007 0341 2070
04374461 NM THROMBUS DETECT(DVT)RT 508.00 06/30/10 78457RT 78457RT 78457TC 92.05 007 0341 2070
04374464 NM I131 ABLAT GLAND THYROID CA 778.00 06/30/10 79005 79005 79005TC 007 0342 2070
04374467 NM I123 DIAG PER 100UCI 105.00 06/30/10 A9516 A9516 A9516 007 0343 2070
04374470 NM AMINOPHYLLIN UP TO 25MCG 29.00 06/30/10 J0280 J0280 J0280 007 0636 2070
04374473 NM TC PYROPHOSPHATE<25MCI 51.00 06/30/10 A9538 A9538 A9538 007 0343 2070
04374476 NM TC DTPA<25MCI 40.00 06/30/10 A9539 A9539 A9539 007 0343 2070
04374479 NMI131 BEXXAR DX PER STUDY DOS 9126.00 06/30/10 A9544 A9544 A9544 007 0343 2070
04374482 BEXXAR RX PER RX DOSE 59421.00 06/30/10 A9545 A9545 A9545 007 0344 2070
04374485 PV EKOS LYSUS INFUSION SYSTEM 7700.00 06/30/10 C1751 C1751 C1751 007 0272 2030
04374488 NM I 123 DIAG CAP PER 100 UCI 46.00 06/30/10 007 0341 2070
04374492 ECHO-PORT N/C 06/30/10 007 0402 2035
04374526 TRANSLUMINAL BALOON ANGIO PER 2316.00 06/30/10 75962 75962 75962TC 89.04 007 0323 2030
04374530 US NEEDLE BREAST LT 227.00 06/30/10 19290 19290LT 19290LT 85.99 007 0361 2035
04374533 US NEEDLE BREAST RT 227.00 06/30/10 19290 19290RT 19290RT 85.99 007 0361 2035
04374536 US NEEDLE LOC BRST RT, EA ADDL 247.00 06/30/10 19291 19291RT 19291RT 85.99 007 0361 2035
04374539 US NEEDLE LOC,BRST LT EA ADD'L 247.00 06/30/10 19291 19291LT 19291LT 85.99 007 0361 2035
04374542 US BREAST SURG SPECIMEN 100.00 06/30/10 76098 76098 76098TC 88.39 007 0320 2035
04374545 US BX LYMPH NODE 408.00 06/30/10 38505 38505 38505 40.11 007 0361 2035
04374548 US PERC CHOLECYSTOSTOMY 3204.00 06/30/10 47490 47490 47490 51.03 007 0361 2035
04374551 US AORTA 469.00 06/30/10 76775 76775 76775TC 007 0402 2035
04374554 US FINE NEEDLE ASPIRATION 431.00 06/30/10 10022 10022 10022 45.29 007 0361 2035
04374625 ECHO ABDOMINAL; COMPLETE 718.00 06/30/10 76700 76700 76700TC 88.76 007 0402 2035
04374633 ECHO PELVIC; COMPLETE 583.00 06/30/10 76856 76856 76856TC 88.79 007 0402 2035
04374641 ECHO RETROPERT CPL 504.00 06/30/10 76770 76770 76770TC 88.76 007 0402 2035
04374674 ECHO ABDOMINAL; LIMITED 558.00 06/30/10 76705 76705 76705TC 95.13 007 0402 2035
04374676 PUNCT ASPIRAT CYST BREAST LEFT 455.00 06/30/10 19000 19000LT 19000LT 85.91 85.91 007 0361 2035
04374678 PUNCT ASPIRAT CYST BREAST RT 455.00 06/30/10 19000 19000RT 19000RT 85.91 85.91 007 0361 2035
04374680 PUNC ASP CYS BRST EA AD CYS LT 204.00 06/30/10 19001 19001LT 19001LT 85.91 85.91 007 0361 2035
04374682 PUNC ASP CYS BRST EA AD CYS RT 204.00 06/30/10 19001 19001RT 19001RT 85.91 85.91 007 0361 2035
04374684 BIOPSY MUSCLE PERCUTANE NEEDLE 805.00 06/30/10 20206 20206 20206 83.21 83.21 007 0361 2035
04374686 BX BONE TROCAR/NEEDLE SUPERFIC 736.00 06/30/10 20220 20220 20220 77.49 77.49 007 0361 2035
04374688 LUNG/CHEST ABSCESS DRAINAGE 576.00 06/30/10 32201 32201 32201 007 0361 2035
04374690 BIOPSY PLEURA PERCUTANE NEEDLE 750.00 06/30/10 32400 32400 32400 34.24 34.24 007 0361 2035
04374692 BX LUNG/MEDIASTI PERCUT NDL LT 1940.00 06/30/10 32405 32405LT 32405LT 33.27 33.27 007 0361 2035
04374694 BX LUNG/MEDIASTI PERCUT NDL RT 1940.00 06/30/10 32405 32405RT 32405RT 33.27 33.27 007 0361 2035
04374696 BIOPSY SALIVARY GLAND NEEDLE 486.00 06/30/10 42400 42400 42400 26.11 26.11 007 0361 2035
04374698 APPENDX ABSCESS DRAINAGE 867.00 06/30/10 44901 44901 44901 47.2 47.2 007 0361 2035
04374700 BIOP LIVER NEEDLE PERCUTANECUS 1471.00 06/30/10 47000 47000 47000 50.11 50.11 007 0361 2035
04374702 LIVER ABSCESS DRAINAGE 1070.00 06/30/10 47011 47011 47011 007 0361 2035
04374704 BIOP PANCREAS PERCUTANEOUS NDL 1199.00 06/30/10 48102 48102 48102 52.11 52.11 007 0361 2035
04374706 EXT DRAIN PSEUDOCST PANC PERCU 1070.00 06/30/10 48511 48511 48511 52.01 52.01 007 0360 2035
04374720 DRAIN PERITONEAL ABSC; PERQ 867.00 06/30/10 49021 49021 49021 007 0361 2035
04374722 DRAIN SUBDIAPHRAGMAT ABSC PERQ 867.00 06/30/10 49041 49041 49041 54.91 54.91 007 0361 2035
04374724 DRAIN RETROPERITONEAL ABS PERQ 867.00 06/30/10 49061 49061 49061 007 0361 2035
04374726 BX ABD/RETROPRTN MASS PERQ NDL 1199.00 06/30/10 49180 49180 49180 54.22 54.22 007 0361 2035
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 146
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04374728 DRAIN PERIRNL/RNAL ABS PERQ LT 1164.00 06/30/10 50021 50021LT 50021LT 55.01 55.01 007 0361 2035
04374730 DRAIN PERIRNL/RNAL ABS PERQ RT 1164.00 06/30/10 50021 50021RT 50021RT 55.01 55.01 007 0361 2035
04374732 RENAL BX PERQ TROCAR/NEEDLE LT 1573.00 06/30/10 50200 50200LT 50200LT 55.23 55.23 007 0361 2035
04374734 RENAL BX PERQ TROCAR/NEEDLE RT 1573.00 06/30/10 50200 50200RT 50200RT 55.23 55.23 007 0361 2035
04374736 ASPIR&INJ RNAL CYS/PLV-NDLE LT 1167.00 06/30/10 50390 50390LT 50390LT 55.92 55.92 007 0361 2035
04374738 ASPIR&INJ RNAL CYS/PLV-NDLE RT 1167.00 06/30/10 50390 50390RT 50390RT 55.92 55.92 007 0361 2035
04374740 BX THYROID PERCUTANS CORE NDLE 486.00 06/30/10 60100 60100 60100 06.11 06.11 007 0361 2035
04374742 US EXAM K TRANSPL W/DOPPLER 558.00 06/30/10 76776RT 76776RT 76776TC 88.75 88.75 007 0402 2035
04374746 US INFNT HIP REL TM-IMG DOC DY 524.00 06/30/10 76885 76885 76885TC 007 0402 2035
04374748 US INFNT HIP REL TM-IMG DOC ST 524.00 06/30/10 76886 76886 76886TC 007 0402 2035
04374750 US GUID CMPRSS REPR PSEUD-ANEU 1069.00 06/30/10 76936 76936 76936TC 007 0402 2035
04374754 ULTRASOUND STUDY FOLLOW-UP 172.00 06/30/10 76970 76970 76970TC 007 0402 2035
04374756 DUPLEX LOWER EXTR ARTER LMT RT 394.00 06/30/10 93926 93926RT 93926RT 88.79 88.79 007 0921 2035
04374758 DUPLEX UPPER EXTR ARTER LMT RT 765.00 06/30/10 93931 93931RT 93931RT 88.79 88.79 007 0921 2035
04374765 US RF ABLATION LIVER, OPEN 2148.00 06/30/10 47380 47380 47380 007 0360 2035
04374766 US GUIDE TISSUE ABLAT 763.00 06/30/10 76940 76940 76940TC 88.97 88.97 007 0402 2035
04374767 US RF ABLATION LIVER PERQ 4458.00 06/30/10 47382 47382 47382 007 0361 2035
04374768 US PELVIC FOLLOW UP 407.00 06/30/10 76857 76857 76857TC 88.79 88.79 007 0402 2035
04374769 US DUPLEX UPPER EXT ART LT 394.00 06/30/10 93931 93931LT 93931LT 88.77 88.77 007 0921 2035
04374770 US DUPLEX LOW EXT ART LT 394.00 06/30/10 93926 93926LT 93926LT 88.77 88.77 007 0921 2035
04374771 US LOW EXT NON VASC LT 406.00 06/30/10 76880LT 76880LT 76880TC 88.79 88.79 007 0402 2035
04374772 US LOW EXT NON VASC RT 406.00 06/30/10 76880RT 76880RT 76880TC 88.79 88.79 007 0402 2035
04374773 US UPPER EXT NON VASC LT 406.00 06/30/10 76880TC 76880LT 76880LT 88.79 88.79 007 0402 2035
04374774 US DUPLEX UPPER EXT VEIN LT 722.00 06/30/10 93971 93971LT 93971LT 88.77 88.77 007 0921 2035
04374775 US DUPLEX UPPER EXT VEIN RT 722.00 06/30/10 93971 93971RT 93971RT 88.77 88.77 007 0921 2035
04374776 US DUPLEX LOW EXT VEIN LT 722.00 06/30/10 93971 93971LT 93971LT 88.77 88.77 007 0921 2035
04374777 US DUPLEX LOW EXT VEIN RT 722.00 06/30/10 93971 93971RT 93971RT 88.77 88.77 007 0921 2035
04374778 US BX BONE TROCAR/NDLE DEEP 1829.00 06/30/10 20225 20225 20225 77.49 007 0361 2035
04374779 US EXAM K TRANSPL W/DOPPLER 558.00 06/30/10 76776LT 76776LT 76776TC 88.75 88.75 007 0402 2035
04374780 US UPPER EXT NON VASC RT 406.00 06/30/10 76880RT 76880RT 76880TC 007 0402 2035
04374783 US ASP&INJ SMALL JOINT-LT 1502.00 06/30/10 20600 20600LT 20600LT 007 0360 2035
04374784 US ASP&INJ SMALL JOINT-RT 1502.00 06/30/10 20600 20600RT 20600RT 007 0360 2035
04374786 US ASP&INJ INTRMD JNT/BURSA-LT 1321.00 06/30/10 20605 20605LT 20605LT 007 0360 2035
04374787 US ASP&INJ INTRMD JNT/BURSA-RT 1321.00 06/30/10 20605 20605RT 20605RT 007 0360 2035
04374789 US ASP&INJ MAJOR JOINT-LT 964.00 06/30/10 20610 20610LT 20610LT 007 0361 2035
04374790 US ASP&INJ MAJOR JOINT-RT 964.00 06/30/10 20610 20610RT 20610RT 007 0360 2035
04374792 US ASP ABSCS,HMTMA,BULLA,CYST 809.00 06/30/10 10160 10160 10160 007 0360 2035
04374922 HAND-LOAD 470.00 06/30/10 77790 77790 77790TC 92.29 007 0333 2050
04374930 INTERSTITIAL APPLICATION SMPL 1477.00 06/30/10 77776 77776 77776TC 92.29 007 0333 2050
04374948 INTERSTITIAL APPLICATION CPLX 4423.00 06/30/10 77778 77778 77778TC 92.29 007 0333 2050
04374955 INTRACAVITARY APPLICATION CPLX 3657.00 06/30/10 77763 77763 77763TC 92.27 007 0333 2050
04374971 INFUSN/INSTILLATION 1-10 MCI 9118.00 06/30/10 77750 77750 77750TC 92.28 007 0333 2050
04374974 UNLISTED PROC.,CLIN BRACHYTHPY 1921.00 06/30/10 77799 77799 77799TC 007 0333 2050
04374980 CT SCAN FOR THERAPY GUIDE 490.00 06/30/10 77014 77014 77014TC 88.38 007 0350 2050
04374997 SPECIAL DOSIMETRY TLD 739.00 06/30/10 77331 77331 77331TC 92.29 007 0333 2050
04375047 HAND-LEFT, 2 VIEWS 199.00 06/30/10 73120TC 73120LT 73120LT 88.23 007 0320 2006
04375048 HAND - RIGHT, 2 VIEWS 199.00 06/30/10 73120TC 73120RT 73120RT 88.23 007 0320 2006
04375088 LARYNGOSCOPY 247.00 06/30/10 31575 31575 31575 31.42 31.42 007 0360 2050
04375150 T-P SIMULATOR SMPL 983.00 06/30/10 77280 77280 77280TC 88.39 007 0333 2050
04375168 T-P SIMULATOR CPLX 1962.00 06/30/10 77290 77290 77290TC 88.39 007 0333 2050
04375242 RAD TRT DELIVRY-SUPERFIC/ORTHO 448.00 06/30/10 77401 77401 77401TC 92.29 007 0333 2050
04375267 SURFACF APL 413.00 06/30/10 77789 77789 77789TC 92.29 007 0333 2050
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 147
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04375268 SURFACE APPL/EYE PLAQUE 2887.00 06/30/10 77789 77789 77789TC 92.29 007 0333 2050
04375283 RAD TRT DEL-SMPL 6-10 MEV 837.00 06/30/10 77403 77403 77403TC 92.29 007 0333 2050
04375309 ISODOSE PLAN SMPL 594.00 06/30/10 77305 77305 77305TC 92.29 007 0333 2050
04375317 ISODOSE PLAN INT 887.00 06/30/10 77310 77310 77310TC 92.29 007 0333 2050
04375325 ISODOSE PLAN CPLX 1562.00 06/30/10 77315 77315 77315TC 92.29 007 0333 2050
04375326 ISODOSE PLAN CPLX-STEREO 1562.00 06/30/10 77315 77315 77315TC 92.29 007 0333 2050
04375366 BASIC DOSE CALCULATION 383.00 06/30/10 77300 77300 77300TC 88.39 007 0333 2050
04375390 BRACHY ISODOSE SPL 912.00 06/30/10 77326 77326 77326TC 92.29 007 0333 2050
04375429 PV US GUIDE TISSUE ABLATION 849.00 06/30/10 76940 76940 76940TC 007 0402 2030
04375432 PV US BX MUSCLE NDLE 780.00 06/30/10 20206 20206 20206 007 0361 2030
04375435 PV PLACEMENT OF CLOSURE DEVICE 1692.00 07/01/10 G0269 G0269 G0269 007 0320 2030
04375500 CATH&INTRO SALINE/CONT FOR HSG 324.00 06/30/10 58340 58340 58340 87.83 87.83 007 0361 2006
04375503 FLUOROGUIDE FOR VEIN DEVICE 351.00 06/30/10 77001TC 77001 77001 39.50 39.50 007 0320 2006
04375507 FLUOROSCOPY UP TO ONE HOUR 458.00 06/30/10 76000TC 76000 76000 89.04 007 0320 2006
04375515 FILM COPY X-RAY 15.00 06/30/10 007 0999 2006
04375549 X-RAYS FOR BONE AGE 280.00 06/30/10 77072TC 77072 77072 88.33 007 0320 2006
04375552 PERQ VERTEBRPLASTY/VRT AUG S&I 1608.00 06/30/10 72291 72291 72291TC 87.29 007 0320 2032
04375556 X-RAYS,BONE LENGTH STUDIES 179.00 06/30/10 77073TC 77073 77073 88.33 007 0320 2006
04375572 XRAYS,BONE SURVEY COMPLETE 741.00 06/30/10 77075TC 77075 77075 88.33 007 0320 2006
04375663 MAMMOGRAM,BILAT 319.00 06/30/10 77056TC 77056 77056 87.37 007 0401 2006
04375671 TOMO SINGLE PLANE-NOT IVP 243.00 06/30/10 76100TC 76100 76100 88.39 007 0320 2006
04375762 EXAM BEDSIDE OR N/C 06/30/10 007 0999 2006
04375770 POST RADIONUCLIDE THERAPY IMAG 1485.00 06/30/10 78802 78802 78802TC 88.38 007 0341 2070
04375773 US MOD SEDATION ADD 15 MIN 77.00 06/30/10 99145 99145 99145 007 0370 2035
04375776 US DUPLEX PORTAL HEPATIC 996.00 06/30/10 93975 93975 93975 007 0921 2035
04375779 US RENAL DUPLEX BIL 996.00 06/30/10 93975 93975 93975 007 0921 2035
04375782 US SCROTAL DUPLEX 996.00 06/30/10 93975 93975 93975 007 0921 2035
04375785 US PELV DUPLEX COMPLETE 996.00 06/30/10 93975 93975 93975 007 0921 2035
04375812 CT HEAD OR BRAIN W/O CONTRAST 1112.00 06/30/10 70450 70450 70450TC 87.03 007 0351 2040
04375820 CT HEAD OR BRAIN W & W/O CONTR 1602.00 06/30/10 70470 70470 70470TC 87.03 007 0351 2040
04375838 CHEST DECB APCL 233.00 06/30/10 71035TC 71035 71035 87.44 007 0320 2006
04375853 CT ABDOMEN W/O CONTRAST 1531.00 06/30/10 74150 74150 74150TC 88.01 007 0350 2040
04375861 CT ABDOMEN W & W/O CONTRAST 2127.00 06/30/10 74170 74170 74170TC 88.01 007 0350 2040
04375865 CT ABD W/WO DOUBLE HELICAL 2274.00 06/30/10 74170 74170 74170TC 88.01 007 0350 2040
04375871 CT BIOPSY NEEDLE 180.00 06/30/10 007 0270 2040
04375874 CT CATHETER DRAINAGE 528.00 06/30/10 C1729 C1729 C1729 007 0272 2040
04375876 CT ASP& INJ MAJOR JOINT-LT 964.00 06/30/10 20610LT 20610LT 20610LT 007 0361 2040
04375877 CT ASP& INJ MAJOR JOINT-RT 964.00 06/30/10 20610RT 20610RT 20610RT 007 0361 2040
04375880 CT ASP& INJ SMALL JOINT -LT 1502.00 06/30/10 20600LT 20600LT 20600LT 007 0361 2040
04375883 CT ASP& INJ SMALL JOINT -RT 1502.00 06/30/10 20600RT 20600RT 20600RT 007 0361 2040
04375885 US PELV DUPLEX COMPLETE 996.00 06/30/10 93975 93975 93975 007 0921 2035
04375886 CT ASP&INJ INTRMD JNT/BURSA-LT 1321.00 06/30/10 20605LT 20605LT 20605LT 007 0361 2040
04375887 US DUPLEX LIMITED 565.00 06/30/10 74320 74320 74320 007 0402 2035
04375888 US FINE NDLE ASP ADD'L MOD-LT 509.00 06/30/10 10022LT 10022LT 10022LT 007 0320 2035
04375889 CT ASP&INJ INTRMD JNT/BURSA-RT 1321.00 06/30/10 20605RT 20605RT 20605RT 007 0361 2040
04375891 US FINE NDLE ASP ADD'L MOD-RT 509.00 06/30/10 10022RT 10022RT 10022RT 007 0361 2035
04375894 US BX ADD'L LYMPH NODE 1032.00 06/30/10 38505 38505 38505 007 0361 2035
04375895 ENDOSCPC CATH BIL/PANC DUCT SI 1166.00 06/30/10 74330TC 74330 74330 51.10 007 0320 2006
04375897 US BX LIVER ADD'L LESION 1401.00 06/30/10 47000 47000 47000 007 0361 2035
04375900 US TRNSVAGIN PREG UTERUS<14WKS 264.00 06/30/10 76817 76817 76817 007 0402 2035
04375902 CT RESEARCH ADIPOSE SLICE MEAS 172.00 06/30/10 74150 74150 74150 007 0350 2040
04375905 CT RESEARCH ABDOMEN W/O CONTRA 228.00 06/30/10 74150 74150 74150 007 0350 2040
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 148
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04375908 CT RESEARCH HEART CALCIUM STUD 383.00 06/30/10 75571 75571 75571TC 007 0350 2040
04375969 MAM US FINE NDLE ASPIRATION 431.00 06/30/10 10022 10022 10022 007 0361 2006
04375981 MAM US NDLE LOC BRST LT EA ADD 247.00 06/30/10 19291 19291LT 19291LT 007 0361 2006
04375984 MAM US NDLE LOC BRST RT EA ADD 281.00 06/30/10 19101 19101RT 19101RT 007 0360 2006
04375987 US PUNC ASP CYST BRST EA AD BI 907.00 06/30/10 19000 1900050 1900050 007 0361 2006
04375996 MAM US BX BRST NDLE CORE BILAT 2188.00 06/30/10 19102 1910250 1910250 007 0361 2006
04375999 MAM US NDLE LOC BREAST BILAT 551.00 06/30/10 19290 1929050 1929050 007 0361 2006
04376002 CHANGE OF TUBE/CATH W CONT 700.00 06/30/10 75984TC 75984 75984 007 0320 2006
04376005 INJ ANKLE ARTHOGRAM LT 468.00 06/30/10 27648LT 27648LT 27648LT 007 0361 2006
04376008 INJ ANKLE ARTHOGRAM RT 468.00 06/30/10 27648RT 27648RT 27648RT 007 0361 2006
04376011 INJ ELBOW ARTHOGRAM LT 1161.00 06/30/10 24220LT 24220LT 24220LT 007 0361 2006
04376014 INJ ELBOW ARTHOGRAM RT 1161.00 06/30/10 24220RT 24220RT 24220RT 007 0361 2006
04376017 INJ HIP ARTHOGRAM LT 608.00 06/30/10 27093LT 27093LT 27093LT 007 0361 2006
04376020 INJ HIP ARTHOGRAM RT 608.00 06/30/10 27093RT 27093RT 27093RT 007 0361 2006
04376023 INJ KNEE ARTHOGRAM LT 1003.00 06/30/10 27370LT 27370LT 27370LT 007 0361 2006
04376026 INJ KNEE ARTHOGRAM RT 1003.00 06/30/10 27370RT 27370RT 27370RT 007 0361 2006
04376029 INJ SHOULDER ARTHOGRAM LT 433.00 06/30/10 23350LT 23350LT 23350LT 007 0361 2006
04376032 INJ SHOULDER ARTHOGRAM RT 433.00 06/30/10 23350RT 23350RT 23350RT 007 0361 2006
04376035 INJ SI JOINT ARTHOGRAM 1405.00 06/30/10 27096 G0259 27096 007 0361 2006
04376038 INJ WRIST ARTHOGRAM LT 1113.00 06/30/10 25246LT 25246LT 25246LT 007 0361 2006
04376041 INJ WRIST ARTHOGRAM RT 1113.00 06/30/10 25246RT 25246RT 25246RT 007 0361 2006
04376044 LUMB PUNC, DIAGNOSTIC 828.00 06/30/10 62270 62270 62270 007 0361 2006
04376047 LUMB PUNCT, THERAPEUTIC 828.00 06/30/10 62272 62272 62272 007 0361 2006
04376050 UP EXT INFANT AP & LAT LT 249.00 06/30/10 73092LT 73092LT 73092TC 007 0320 2006
04376053 UP EXT INFANT AP & LAT RT 249.00 06/30/10 73092RT 73092RT 73092TC 007 0320 2006
04377261 TREATMENT PLAN SIMPLE 98.00 06/30/10 77261 77261 77261TC 89.04 007 0333 2050
04377262 TREATMENT PLAN INTERM 98.00 06/30/10 77262 77262 77262TC 89.04 007 0333 2050
04377263 TREATMENT PLAN COMPLEX 98.00 06/30/10 77263 77263 77263TC 89.04 007 0333 2050
04377264 FLUOROGUIDE FOR SPINE INJECT 627.00 06/30/10 77003 77003 77003TC 87.29 007 0320 2050
04377271 INTENSITY MODU RAD THER>1 SESS 2344.00 06/30/10 77418 77418 77418TC 007 0333 2050
04377272 INTENSITY MOD THER-THERA PLAN 5283.00 06/30/10 77301 77301 77301TC 007 0333 2050
04377275 SRS PLANNING 5011.00 06/30/10 007 0333 2050
04377276 SRS TREATMENT/DEL IN 1 SESS. 17299.00 06/30/10 G0173 G0173 G0173 007 0333 2050
04377280 NASOPHARYNGOSCOPY 102.00 06/30/10 92511 92511 92511 007 0471 2050
04377283 OFFICE/OUTPAT VIS, NEW,LVL 1 100.00 06/30/10 99201 99201 99201 007 0510 2050
04377286 OFFICE/OUTPAT VIS, NEW,LVL 2 120.00 06/30/10 99202 99202 99202 007 0510 2050
04377289 OFFICE/OUTPAT VIS, NEW,LVL 3 155.00 06/30/10 99203 99203 99203 007 0510 2050
04377292 OFFICE/OUTPAT VIS, NEW,LVL 4 197.00 06/30/10 99204 99204 99204 007 0510 2050
04377295 OFFICE/OUTPAT VIS, NEW,LVL 5 225.00 06/30/10 99205 99205 99205 007 0510 2050
04377298 OFFICE/OUTPAT VIS, EST,LVL 1 100.00 06/30/10 99211 99211 99211 007 0510 2050
04377301 OFFICE/OUTPAT VIS, EST,LVL 2 120.00 06/30/10 99212 99212 99212 007 0510 2050
04377304 OFFICE/OUTPAT VIS, EST,LVL 3 155.00 06/30/10 99213 99213 99213 007 0510 2050
04377307 OFFICE/OUTPAT VIS, EST,LVL 4 197.00 06/30/10 99214 99214 99214 007 0510 2050
04377310 OFFICE/OUTPAT VIS, EST,LVL 5 225.00 06/30/10 99215 99215 99215 007 0510 2050
04377322 OFFICE CONSULTATION LVL 4 237.00 06/30/10 99244 99244 99244 007 0510 2050
04377326 MOD SEDATION <5 YRS -30MIN 390.00 06/30/10 99143 99143 99143 007 0370 2050
04377329 MOD SEDATION>5YRS - 30MIN 296.00 06/30/10 99144 99144 99144 007 0370 2050
04377332 MOD SEDATION ADD'L 15 MIN 77.00 06/30/10 99145 99145 99145 007 0370 2050
04377400 ULTRASOUND LOCALIZATION 265.00 06/30/10 76950 76950 76950TC 007 0333 2050
04378006 RAIU THYROID UP 824.00 06/30/10 78000 78000 78000TC 92.29 007 0341 2070
04378097 TUMOR IMAGING-NEURO ENDOCRINE 1733.00 06/30/10 78802 78802 78802TC 92.18 007 0341 2070
04378204 HEPATO BIL SCAN 1216.00 06/30/10 78220 78220 78220TC 88.97 007 0341 2070
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 149
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04378626 RED CELL MASS 664.00 06/30/10 78121 78121 78121TC 88.97 007 0341 2070
04378634 NM CARDIAC GATED EQUIL RVEF 151.00 06/30/10 78496 78496 78496TC 92.05 007 0341 2070
04378638 NM MYO PERF PLANAR MULTI-PHASE 1170.00 06/30/10 78461 78461 78461TC 88.92 007 0341 2070
04378642 NM GLIASITE TREATMENT 1059.00 06/30/10 77470 77470 77470TC 92.29 007 0333 2070
04378646 NM RADIOGRAM LOC TUMOR 1694.00 06/30/10 78802 78802 78802TC 92.18 007 0341 2070
04378650 NM RADIOPHRM THRPY-INTRA ART 5538.00 06/30/10 79445 79445 79445 007 0342 2070
04378654 NM THERA RAD TRTMNT PLAN-INTER 152.00 06/30/10 77262 77262 77262 007 0333 2070
04379095 UROGRAPHY ANTEGRADE S & I 579.00 06/30/10 74425 74425 74425TC 87.77 007 0320 2006
04379160 TUMOR LOCALIZ-WHOLE BODY 1733.00 06/30/10 78802 78802 78802TC 92.18 007 0341 2070
04379163 MOD CS BY SAME PHYS,5YRS+ 428.00 06/30/10 99144 99144 99144 007 0371 2070
04379236 SHUNT EVALUATION(VENTRI-PERIT) 1051.00 06/30/10 78645 78645 78645TC 87.02 007 0341 2070
04379244 LYMPHATIC SCAN 1253.00 06/30/10 78195 78195 78195TC 88.97 007 0341 2070
04379269 CYSTOGRAM 1485.00 06/30/10 78740 78740 78740TC 87.77 007 0341 2070
04379293 NM UPPER EXTREMITY VENOGRAM 508.00 06/30/10 78445 78445 78445TC 92.05 007 0341 2070
04379301 VENOGRAM-MAA (UPR EXTREMITIES) 1000.00 06/30/10 78458 78458 78458TC 88.97 007 0341 2070
04379305 NM NEUTROSPEC PER 25 MCI 1837.00 06/30/10 A9566 A9566 A9566 007 0343 2070
04379308 NM ADENOSINE PER 30MG 530.00 06/30/10 J0152 J0152 J0152 007 0636 2070
04379310 NM AMINOPHYLLIN UP TO 250MG 43.00 06/30/10 J0280 J0280 J0280 007 0636 2070
04379312 NM TC PYROPHOSPHATE <25MCI 37.00 06/30/10 007 0341 2070
04379314 NM TC DTPA <25MCI 33.00 06/30/10 007 0341 2070
04379315 NM GATED BLOODPOOL SPECT 1487.00 06/30/10 78494 78494 78494TC 007 0340 2070
04379316 NM SPEC MED RAD PHYSIC CONSLT 401.00 06/30/10 77370 77370 77370TC 007 0333 2070
04379327 BONE MARROW SCAN 1861.00 06/30/10 78103 78103 78103TC 88.94 007 0341 2070
04379330 NM THERA RAD TRTMNT PLAN;SMPLE 127.00 06/30/10 77261 77261 77261TC 007 0333 2070
04379333 NM BSC RAD DOSIMETRY CALC-TRT 494.00 06/30/10 77300 77300 77300TC 007 0333 2070
04379336 NM SUPER,HNDLG LDING,RAD SRCE 374.00 06/30/10 77790 77790 77790TC 007 0333 2070
04379376 ABDOMINAL SURVEY 1485.00 06/30/10 78290 78290 78290TC 88.97 007 0341 2070
04379384 CARDIAC FIRST PASS IMAGE, REST 1607.00 06/30/10 78481 78481 78481TC 88.92 007 0341 2070
04379386 NM THROMBUS DETECT(DVT) BILAT 259.00 06/30/10 7845850 7845850 78458TC 92.05 007 0340 2670
04379388 NM 3D IMAGE PROCESSING 612.00 06/30/10 007 0350 2070
04379392 MYOCARD IMAG PLAN INFARCT AVID 653.00 06/30/10 78466 78466 78466TC 92.05 007 0341 2070
04379395 RADIOPHARM THERAPY,IV 1747.00 06/30/10 79101 79101 79101TC 007 0342 2070
04379398 RADIOPHARM THERAPY,ORAL 1167.00 06/30/10 79005 79005 79005TC 007 0342 2070
04379401 RADIOPHRM THERAPY,INTRSTIT COM 3098.00 06/30/10 79300 79300 79300TC 007 0342 2070
04379404 PET ONCOLOGY HEAD & NECK N/C 06/30/10 007 0341 2070
04379410 PET ONCOLOGY WHOLE BODY N/C 06/30/10 007 0341 2070
04379413 PET ONCLGY WHL BODY W LOW EXT N/C 06/30/10 007 0341 2070
04379416 PET NEUROLOGICAL ONCOLOGY N/C 06/30/10 007 0341 2070
04379418 CHOLANGGRPHY THRU EXST TUBE SI 298.00 06/30/10 74305 74305 74305TC 87.53 007 0320 2006
04379419 PET NEUROLOGICAL NON-ONCOLOGY N/C 06/30/10 007 0341 2070
04379421 LOWER EXT INFANT AP & LAT LT 339.00 06/30/10 73592LT 73592LT 73592TC 007 0320 2006
04379422 PET CARDIAC VIABILITY N/C 06/30/10 007 0341 2070
04379424 LOWER EXT INFANT AP & LAT RT 339.00 06/30/10 73592RT 73592RT 73592TC 007 0320 2006
04379427 LOW OSMLR(200-249MG) CONT/ML 4.00 06/30/10 Q9966 Q9966 Q9966 007 0636 2006
04379430 LOW OSMLR(250-299MG) CONT/ML 4.00 06/30/10 Q9966 Q9966 Q9966 007 0636 2006
04379433 CT HEART W/O CONT-QUAN CALCIUM 959.00 06/30/10 75571 75571 75571TC 007 0359 2040
04379439 CA CTA W CONT W CALCIUM SCORE 1161.00 06/30/10 75574 75574 75574TC 007 0359 2040
04379451 CT HEART WW/O CONT- DISEASE ST 959.00 06/30/10 75573 75573 75573 007 0359 2040
04379454 CT HEART WW/O CONT-FUNC ADD-ON 359.00 06/30/10 75574 75574 75574TC 007 0359 2040
04379460 FL LOW OSMOLR(200-299MG)CONT/M 4.00 06/30/10 Q9966 Q9966 Q9966 007 0636 2006
04379463 FL LOW OSMLR(300-399MG)CONT/MI 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2006
04381175 CATHETER ANGIOPLASTY-NEURO 2161.00 06/30/10 007 0621 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 150
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04381178 CATHETER MICRO-PV 1987.00 06/30/10 007 0621 2030
04381181 CATHETER MICRO-NEURO 1459.00 06/30/10 007 0621 2030
04381184 GUIDEWIRE-INTERVENTIONAL 219.00 06/30/10 007 0621 2030
04381187 GUIDEWIRE - MICRO 1342.00 06/30/10 007 0621 2030
04381188 PV GEL FOAM 70.00 06/30/10 007 0270 2030
04381190 INTRODUCER LONGSHEATH 994.00 06/30/10 007 0621 2030
04381192 PV CAUTERY DEVICE 248.00 06/30/10 007 0270 2030
04381196 STENT COVERED IN DS 5667.00 06/30/10 007 0621 2030
04381199 STENT NONCOVERED IN DS 5522.00 06/30/10 007 0621 2030
04381201 PV VENACURE KIT 1746.00 06/30/10 007 0270 2030
04381203 ENVSC AAA REPAIR W/DVCE-2LM 5995.00 06/30/10 34803 34803 34803 007 0360 2030
04381206 INSTL AGNT RNLPV/URTR,TUBE BL 1507.00 06/30/10 5039150 5039150 5039150 007 0361 2030
04381209 INSTL AGNT RNLPV/URTR,TUBE LT 1007.00 06/30/10 50391LT 50391LT 50391LT 007 0361 2030
04381212 INSTL AGNT RNLPV/URTR,TUBE RT 1007.00 06/30/10 50391RT 50391RT 50391RT 007 0361 2030
04381215 PV INTRO NDL RETRO BRACH LT 2088.00 06/30/10 36120LT 36120LT 36120LT 007 0361 2030
04381218 PV ABSCESS DRAINAGE LIVER 1066.90 06/30/10 47011 47011 47011 007 0361 2030
04381221 PV ABSCESS DRAINAGE LIVER S&I 1496.00 06/30/10 75989 75989 75989TC 007 0320 2030
04381224 PV CHLENDOCHAL STENT 659.00 06/30/10 47801 47801 47801 007 0361 2030
04381227 PV ILEOCONDUIT INJECTION 1355.00 06/30/10 50690 50690 50690 007 0361 2030
04381230 PV THORACENTESIS NEEDLE ONLY 630.00 06/30/10 32421 32421 32421 007 0361 2030
04381233 PV THORCNTSIS NEEDLE ONLY-S&I 2396.00 06/30/10 32421 32421 32421 007 0361 2030
04381236 PV THERPTIC THORCNTSIS W TUBE 1620.00 06/30/10 32422 32422 32422 007 0361 2030
04381237 PV US BX PANCREAS NDLE 1199.00 06/30/10 48102 48102 48102 007 0320 2030
04381239 PV ABSCESS DRANGE PERITONEAL 1066.90 06/30/10 49021 49021 49021 007 0361 2030
04381242 PV ABCS DRANGE RETROPERTNAL 1066.90 06/30/10 49061 49061 49061 007 0361 2030
04381245 PV PERTNAL DILSIS CATH MNPLN 453.00 06/30/10 90999 90999 90999 007 0800 2030
04381248 PERTNAL DILSISCATH MNPLN-S&I 847.00 06/30/10 74190 74190 74190TC 007 0320 2030
04381251 PV US GUIDANCE PUNCTURE,I/J 778.00 06/30/10 76942 76942 76942TC 007 0402 2030
04381254 PV CHLANGSCPY PERC W BIOPSY 2591.00 06/30/10 47553 47553 47553 007 0361 2030
04381257 PV THER/PROPH DIAG IV INF,INIT 271.00 06/30/10 96365 96365 96365 007 0260 2030
04381260 PV PICCLINE MIDLINE 336.00 06/30/10 C1751 C1751 C1751 007 0272 2030
04381263 PV INJ PYLGRPHY THRU TUBE-RT 411.00 06/30/10 50394 50394RT 50394RT 007 0361 2030
04381266 PV UROGRAPHY,ANTEGRADE S&I-RT 579.00 06/30/10 74425RT 74425RT 74425TC 007 0320 2030
04381267 PV BALLOON OCCLUSION 1606.00 06/30/10 007 0270 2030
04381269 PV DRAIN PSEUDOCST PANC PERQ 1623.00 06/30/10 48511 48511 48511 007 0360 2030
04381270 NA AD VES PL SPASM-DIF VAS FAM 2503.00 06/30/10 61642 61642 61642 007 0361 2032
04381272 PV POLAR CATH 557.00 06/30/10 007 0270 2030
04381273 NA AD VES PL SPASM-SAME VAS FA 2503.00 06/30/10 61641 61641 61641 007 0361 2032
04381276 NA BAL ANGIOPLASTY-VASOSPASM 3460.00 06/30/10 61640 61640 61640 007 0361 2032
04381278 PV NITROUS OXIDE CARTRIDGE 48.00 06/30/10 007 0270 2030
04381279 NA BALLOON ANGPLASTY-ICN 3460.00 06/30/10 61630 61630 61630 007 0361 2032
04381281 PV NEW PT OFF VISIT/SELF REF 155.00 06/30/10 99203 99203 99203 007 0510 2030
04381282 NA MOD SEDATION ADD 15 MIN 96.00 06/30/10 99145 99145 99145 007 0370 2032
04381284 PV ESTABLISHED PT OFF VISIT 155.00 06/30/10 99213 99213 99213 007 0510 2030
04381285 NA MOD SEDATION<5 YRS-30 MIN 390.00 06/30/10 99143 99143 99143 007 0370 2032
04381287 PV PHY REF/CONSULTATIONS 155.00 06/30/10 99213 99213 99213 007 0510 2030
04381288 NA MOD SEDATION> 5YRS-30 MIN 296.00 06/30/10 99144 99144 99144 007 0370 2032
04381290 PV ART DOPPLER ABI 267.00 06/30/10 93922 93922 93922 007 0921 2030
04381291 NA TRNS CATH PL INTRA VAS STNT 8029.00 06/30/10 61635 61635 61635 007 0361 2032
04381293 PV ART DOPPLER ABI W SEG BL PR 267.00 06/30/10 93923 93923 93923 007 0921 2030
04381294 PV INTERVENTIONAL CONSULT N/C 06/30/10 007 0510 2032
04381296 PV ART DOPPLER ABI W REST & ST 267.00 06/30/10 93924 93924 93924 007 0921 2030
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 151
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04381297 PV INTERVENTIONAL FOLLOW UP N/C 06/30/10 007 0510 2032
04381299 PV VENOUS DOPPLER 267.00 06/30/10 93965 93965 93965 007 0921 2030
04381300 NA TL ANGIOPLASTY VENOUS 2178.00 06/30/10 75978 75978 75978TC 007 0323 2032
04381302 PV DPLX SCAN- LOW EXT VEINS BL 425.00 06/30/10 93970 93970 93970 007 0921 2030
04381303 NA BALLOON ANGIOPLASTY 3460.00 06/30/10 61630 61630 61630 007 0361 2032
04381305 PV DPLX SCN-LOW EXT VNS/LMT ST 309.00 06/30/10 93971 93971 93971 007 0921 2030
04381306 NA TRNSCTH PLC INTRV ST INTRCR 8029.00 06/30/10 61635 61635 61635 007 0361 2032
04381308 PV POWER PICC 335.00 06/30/10 007 0272 2030
04381309 NA WINGSPAN STENT 17328.00 06/30/10 007 0270 2032
04381311 PV POWER LINE 787.00 06/30/10 A4300 A4300 A4300 007 0272 2030
04381312 NA GATEWAY BALLOON 3091.00 06/30/10 007 0270 2032
04381315 NV EXTREMITY UNI S&I LT 2595.00 06/30/10 75710 75710 75710TC 007 0323 2032
04381318 NV EXTREMITY UNI S&I RT 2595.00 06/30/10 75710 75710 75710TC 007 0323 2032
04381321 NV AORTA ABD SERIALGRAPH S/I 2383.00 06/30/10 75625 75625 75625TC 007 0320 2032
04381324 PV CT GUIDANCE TISSUE ABLATION 1283.00 06/30/10 77013 77013 77013TC 007 0350 2030
04381325 PV MAA STIMULATION-COMPLEX 937.00 06/30/10 77290 77290 77290 007 0333 2030
04381327 PV CT RFA LUNG TUMOR-PERC 6560.00 06/30/10 32998 32998 32998 007 0361 2030
04381330 PV NASO/ORO GASTRIC TUBE PLMNT 229.00 06/30/10 43752 43752 43752 007 0320 2030
04381333 PV 3D PROC W INDPNDT W/STN 588.00 06/30/10 76377 76377 76377 007 0320 2030
04381337 PV ABL REN TUMOR PERC CRYOTHRP 6887.00 06/30/10 50593 50593 50593 007 0360 2030
04381340 NA LOW OSMLR(300-399MG)CONT/MI 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 2032
04381349 NV PENUMBRA-SEPARATOR 6982.00 06/30/10 007 0272 2032
04381350 PV US PARACENTESIS SURGICAL 382.16 06/30/10 49080 49080 49080 007 0360 2030
04381352 NV PENUMBRA-ASPIRATION TUBING 1111.00 06/30/10 007 0272 2032
04381353 PV US DRAIN SUBDIAPHRAGM ABSC 1066.90 06/30/10 49041 49041 49041 007 0320 2030
04392056 MAGLINTE CATHETER SET 607.00 06/30/10 007 0621 2006
04395471 MAM SURGICAL SPECIMEN 160.00 06/30/10 76098TC 76098 76098 88.39 007 0320 2006
04399997 INSTRUMNT COUNT-F/OR SERVICES N/C 06/30/10 74000TC 74000 74000 007 0320 2006
04399998 FLUOROSCOPY FOR OR SERVICES N/C 06/30/10 76496 76496 76496 007 0320 2006
05010001 MRI OSI BRAIN W/O CONT 2537.00 06/30/10 70551 70551 70551 007 0610 3101
05010004 MRI OSI CHEST W/O CONT 2537.00 06/30/10 71550 71550 71550 007 0610 3101
05010007 MRI OSI CERVICAL SPINE W/O CON 2537.00 06/30/10 72141 72141 72141 007 0610 3101
05010010 MRI OSI CHEST W CONT 2885.00 06/30/10 71551 71551 71551 007 0610 3101
05010013 MRI OSI THORA SPINE W/O CONT 2384.00 06/30/10 72146 72146 72146 007 0610 3101
05010016 MRI OSI LUMBAR SPINE W/O CONT 2537.00 06/30/10 72148 72148 72148 007 0610 3101
05010019 MRI OSI ABDOMEN W/O CONT 2537.00 06/30/10 74181 74181 74181 007 0610 3101
05010022 MRI OSI ABDOMEN W CONT 2883.00 06/30/10 74182 74182 74182 007 0610 3101
05010025 MRI OSI BRAIN WW/O CONT 3443.00 06/30/10 70553 70553 70553 007 0610 3101
05010028 MRI OSI PELVIS W/O CONT 2537.00 06/30/10 72195 72195 72195 007 0610 3101
05010031 MRI OSI PELVIS W CONT 2845.00 06/30/10 72196 72196 72196 007 0610 3101
05010034 MRI OSI TM JOINT 2537.00 06/30/10 70336 70336 70336 007 0610 3101
05010037 MRI OSI LUMBAR SPINE WW/O CONT 3458.00 06/30/10 72158 72158 72158 007 0610 3101
05010040 MRI OSI ELBOW WW/O CONT LT 3152.00 06/30/10 73223LT 73223LT 73223LT 007 0610 3101
05010043 MRI OSI THORACIC SPINE WW/O CO 3443.00 06/30/10 72157 72157 72157 007 0610 3101
05010046 MRI OSI CERVICAL SPINE WW/O CO 3443.00 06/30/10 72156 72156 72156 007 0610 3101
05010049 MRI OSI GADOLIUM BASED CONT/ML 15.00 06/30/10 A9579 A9579 A9579 007 0636 3101
05010052 MRA OSI UE WW/O CONT 3034.00 06/30/10 73225 73225 73225 007 0610 3101
05010055 MRI OSI BREAST WW/O CONT BILAT 3254.00 06/30/10 77059 C8908 77059 007 0610 3101
05010058 MRI OSI ORBIT/FACE/NECK W CONT 2845.00 06/30/10 70542 70542 70542 007 0610 3101
05010061 MRI OSI ORB/FACE/NECK WW/O CON 3458.00 06/30/10 70543 70543 70543 007 0610 3101
05010064 MRA OSI HEAD W/O CONT 1725.00 06/30/10 70544 70544 70544 007 0610 3101
05010067 MRA OSI HEAD W CONT 2208.00 06/30/10 70545 70545 70545 007 0610 3101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 152
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05010070 MRA OSI HEAD W/WO CONT 2361.00 06/30/10 70546 70546 70546 007 0610 3101
05010073 MRA OSI NECK W/O CONT 1700.00 06/30/10 70547 70547 70547 007 0610 3101
05010076 MRA OSI NECK W CONT 2005.00 06/30/10 70548 70548 70548 007 0610 3101
05010079 MRA OSI NECK WW/O CONT 2361.00 06/30/10 70549 70549 70549 007 0610 3101
05010082 MRI OSI ABDOMEN WW/O CONT 3443.00 06/30/10 74183 74183 74183 007 0610 3101
05010085 MRI OSI FOOT W CONT LT 2845.00 06/30/10 73719LT 73719LT 73719TC 007 0610 3101
05010088 MRI OSI FOOT WW/O CONT LT 3152.00 06/30/10 73720LT 73720LT 73720TC 007 0610 3101
05010091 MRI OSI HAND W CONT LT 2845.00 06/30/10 73219LT 73219LT 73219LT 007 0610 3101
05010094 MRI OSI HAND W/O CONT LT 2537.00 06/30/10 73218LT 73218LT 73218LT 007 0610 3101
05010097 MRI OSI HAND WW/O CONT LT 3152.00 06/30/10 73220LT 73220LT 73220LT 007 0610 3101
05010100 MRI OSI HIP W CONT LT 2845.00 06/30/10 73722LT 73722LT 73722TC 007 0610 3101
05010103 MRI OSI ANKLE W CONT LT 2845.00 06/30/10 73722LT 73722LT 73722TC 007 0610 3101
05010106 MRI OSI ELBOW W CONT LT 2845.00 06/30/10 73222LT 73222LT 73222TC 007 0610 3101
05010109 MRI OSI HIP WW/O CONT LT 3000.00 06/30/10 73723LT 73723LT 73723LT 007 0610 3101
05010112 MRI OSI FOOT W/O CONT LT 2537.00 06/30/10 73718LT 73718LT 73718TC 007 0610 3101
05010115 MRI OSI LE W CONT LT 2845.00 06/30/10 73719LT 73719LT 73719TC 007 0610 3101
05010118 MRI OSI KNEE W CONT LT 2845.00 06/30/10 73722LT 73722LT 73722TC 007 0610 3101
05010121 MRI OSI KNEE WW/O CONT LT 3000.00 06/30/10 73723LT 73723LT 73723LT 007 0610 3101
05010124 MRI OSI LE W/O CONT LT 2537.00 06/30/10 73718LT 73718LT 73718TC 007 0610 3101
05010127 MRI OSI SHOULDER W CONT LT 2845.00 06/30/10 73222LT 73222LT 73222TC 007 0610 3101
05010130 MRI OSI SHOULDER WW/O CONT LT 3152.00 06/30/10 73223LT 73223LT 73223TC 007 0610 3101
05010133 MRI OSI UE W/O CONT LT 2537.00 06/30/10 73218LT 73218LT 73218TC 007 0610 3101
05010136 MRI OSI UE W CONT LT 2845.00 06/30/10 73219LT 73219LT 73219TC 007 0610 3101
05010139 MRI OSI WRIST W CONT LT 2845.00 06/30/10 73222LT 73222LT 73222TC 007 0610 3101
05010142 MRI OSI WRIST WW/O CONT LT 3152.00 06/30/10 73223LT 73223LT 73223TC 007 0610 3101
05010145 MRA OSI PELVIS W/O CONT 1678.00 06/30/10 72198 C8919 72198 007 0610 3101
05010148 MRA OSI PELVIS W CONT 2085.00 06/30/10 72198 C8918 72198 007 0610 3101
05010151 MRA OSI PELVIS WW/O CONT 2290.00 06/30/10 72198 C8920 72198 007 0610 3101
05010154 MRA OSI ABD W/O CONT 2223.00 06/30/10 74185 C8901 74185 007 0610 3101
05010157 MRA OSI ABD W CONT 2493.00 06/30/10 74185 C8900 74185 007 0610 3101
05010160 MRA OSI ABD WW/O CONT 3034.00 06/30/10 74185 C8902 74185 007 0610 3101
05010163 MRI OSI BREAST W/O CONT LT 2829.00 06/30/10 77058LT C8904 77058LT 007 0610 3101
05010166 MRI OSI BREAST W CONT LT 3136.00 06/30/10 77058LT C8903 77058TC 007 0610 3101
05010169 MRI OSI BREAST W/O CONT RT 2829.00 06/30/10 77058RT C8904 77058TC 007 0610 3101
05010172 MRI OSI BREAST W CONT RT 3136.00 06/30/10 77058RT C8903 77058TC 007 0610 3101
05010175 MRI OSI BREAST W/O CONT BILAT 3213.00 06/30/10 77059 77059 77059 007 0610 3101
05010178 MRI OSI BREAST W CONT BILAT 3468.00 06/30/10 77059 77059 77059 007 0610 3101
05010181 MRA OSI CHEST W/O CONT 1678.00 06/30/10 71555 C8910 71555 007 0610 3101
05010184 MRA OSI CHEST W CONT 1882.00 06/30/10 71555 C8909 71555 007 0610 3101
05010187 MRA OSI CHEST WW/O CONT 2335.00 06/30/10 71555 C8911 71555 007 0610 3101
05010190 MRA OSI LE W/O CONT 1678.00 06/30/10 73725 C8913 73725 007 0610 3101
05010193 MRA OSI LE W CONT 1882.00 06/30/10 73725 C8912 73725 007 0610 3101
05010196 MRA OSI LE WW/O CONT 2290.00 06/30/10 73725 C8914 73725 007 0610 3101
05010199 MRI OSI PERC LIVER ABLATION 7820.00 06/30/10 47382 47382 47382 007 0610 3101
05010202 MRI OSI ANKLE W/O CONT RT 2537.00 06/30/10 73721RT 73721RT 73721TC 007 0610 3101
05010205 MRI OSI ANKLE W CONT RT 2845.00 06/30/10 73722RT 73722RT 73722TC 007 0610 3101
05010208 MRI OSI ELBOW W CONT RT 2845.00 06/30/10 73222RT 73222RT 73222TC 007 0610 3101
05010211 MRI OSI ELBOW W/O CONT RT 2537.00 06/30/10 73221RT 73221RT 73221TC 007 0610 3101
05010214 MRI OSI FOOT WW/O CONT RT 3152.00 06/30/10 73720RT 73720RT 73720TC 007 0610 3101
05010217 MRI OSI HAND WW/O CONT RT 3152.00 06/30/10 73220RT 73220RT 73220TC 007 0610 3101
05010220 MRI OSI HAND W/O CONT RT 2537.00 06/30/10 73218RT 73218RT 73218TC 007 0610 3101
05010223 MRI OSI HIP WW/O CONT RT 3000.00 06/30/10 73723RT 73723RT 73723TC 007 0610 3101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 153
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05010226 MRI OSI FOOT W CONT RT 2845.00 06/30/10 73719RT 73719RT 73719TC 007 0610 3101
05010229 MRI OSI LE W/O CONT RT 2537.00 06/30/10 73718RT 73718RT 73718TC 007 0610 3101
05010232 MRI OSI HAND W CONT RT 2845.00 06/30/10 73219RT 73219RT 73219TC 007 0610 3101
05010235 MRI OSI ELBOW WW/O CONT RT 3152.00 06/30/10 73223RT 73223RT 73223TC 007 0610 3101
05010238 MRI OSI ANKLE WW/O CONT LT 3000.00 06/30/10 73723LT 73723LT 73723TC 007 0610 3101
05010241 MRI OSI BRAIN W CONT 2883.00 06/30/10 70552 70552 70552 007 0610 3101
05010244 MRI OSI BREAST WW/O CONT RT 2599.00 06/30/10 77058RT 77058RT 77058TC 007 0610 3101
05010247 MRI OSI CERVICAL SPINE W CONT 2885.00 06/30/10 72142 72142 72142 007 0610 3101
05010250 MRI OSI CHEST WW/O CONT 3443.00 06/30/10 71552 71552 71552TC 007 0610 3101
05010253 MRI OSI LUMBAR SPINE W CONT 2845.00 06/30/10 72149 72149 72149TC 007 0610 3101
05010256 MRI OSI ORB/FACE/NECK W/O CONT 2537.00 06/30/10 70540 70540 70540 007 0610 3101
05010259 MRI OSI PELVIS WW/O CONT 3458.00 06/30/10 72197 72197 72197TC 007 0610 3101
05010262 MRI OSI THORACIC SPNE W/O CONT 2971.00 06/30/10 72147 72147 72147TC 007 0610 3101
05010265 MRI OSI HIP W/O CONT RT 2537.00 06/30/10 73721RT 73721RT 73721TC 007 0610 3101
05010268 MRI OSI WRIST WW/O CONT RT 3152.00 06/30/10 73223RT 73223RT 73223TC 007 0610 3101
05010271 MRI OSI WRIST W/O CONT RT 2537.00 06/30/10 73221RT 73221RT 73221TC 007 0610 3101
05010274 MRI OSI WRIST W CONT RT 2845.00 06/30/10 73222RT 73222RT 73222TC 007 0610 3101
05010277 MRI OSI WRIST W/O CONT LT 2537.00 06/30/10 73221LT 73221LT 73221TC 007 0610 3101
05010280 MRI OSI SHOULDER WW/O CONT RT 3152.00 06/30/10 73223RT 73223RT 73223TC 007 0610 3101
05010283 MRI OSI SHOULDER W/O CONT RT 2537.00 06/30/10 73221RT 73221RT 73221TC 007 0610 3101
05010286 MRI OSI SHOULDER W CONT RT 2845.00 06/30/10 73222RT 73222RT 73222TC 007 0610 3101
05010289 MRI OSI SHOULDER W/O CONT LT 2537.00 06/30/10 73221LT 73221LT 73221TC 007 0610 3101
05010292 MRI OSI LE W CONT RT 2845.00 06/30/10 73719RT 73719RT 73719TC 007 0610 3101
05010295 MRI OSI KNEE WW/O CONT RT 3000.00 06/30/10 73723RT 73723RT 73723TC 007 0610 3101
05010298 MRI OSI KNEE W/O CONT RT 2537.00 06/30/10 73721RT 73721RT 73721TC 007 0610 3101
05010301 MRI OSI KNEE W CONT RT 2845.00 06/30/10 73722RT 73722RT 73722TC 007 0610 3101
05010307 MRI OSI HIP W CONT RT 2845.00 06/30/10 73722RT 73722RT 73722TC 007 0610 3101
05010310 MRI OSI FOOT W/O CONT RT 2537.00 06/30/10 73718RT 73718RT 73718TC 007 0610 3101
05010313 MRI OSI ELBOW W/O CONT LT 2537.00 06/30/10 73221LT 73221LT 73221TC 007 0610 3101
05010316 MRI OSI BREAST WW/O CONT LT 3131.00 06/30/10 77058LT C8905 77058TC 007 0610 3101
05010319 MRI OSI ANKLE WW/O CONT RT 3000.00 06/30/10 73723RT 73723RT 73723TC 007 0610 3101
05010322 MRI OSI ANKLE W/O CONT LT 2537.00 06/30/10 73721LT 73721LT 73721TC 007 0610 3101
05010325 MRI OSI UE WW/O CONT LT 3152.00 06/30/10 73220LT 73220LT 73220TC 007 0610 3101
05010328 MRI OSI UE WW/O CONT RT 3152.00 06/30/10 73220RT 73220RT 73220TC 007 0610 3101
05010331 MRI OSI UE W/O CONT RT 2537.00 06/30/10 73218RT 73218RT 73218TC 007 0610 3101
05010334 MRI OSI UE W CONT RT 2845.00 06/30/10 73219RT 73219RT 73219TC 007 0610 3101
05010337 MRI OSI LE WW/O CONT LT 3152.00 06/30/10 73720LT 73720LT 73720LT 007 0610 3101
05010340 MRI OSI LE WW/O CONT RT 3152.00 06/30/10 73720RT 73720RT 73720TC 007 0610 3101
05010343 MRI OSI HIP W/O CONT LT 2537.00 06/30/10 73721LT 73721LT 73721TC 007 0610 3101
05010346 MRI OSI 3D PROC W INDPNDT W/ST 588.00 06/30/10 76377 76377 76377 007 0610 3101
05010349 MRI OSI 3D PRC W/O INDPDT W/ST 426.00 06/30/10 76376 76376 76376TC 007 0610 3101
05010352 MRA OSI UE W CONT 2493.00 06/30/10 73225 73225 73225TC 007 0610 3101
05010355 MRA OSI UE W/O CONT 2223.00 06/30/10 73225 73225 73225TC 007 0610 3101
05010358 MRI OSI BRAIN NCT NT RQ PH ADM 2537.00 06/30/10 70554 70554 70554TC 007 0610 3101
05010361 MRI OSI NOVA STDY HEAD OR NECK 929.00 06/30/10 76498 76498 76498TC 007 0610 3101
05010364 MRI OSI NOVA STUDY HEAD & NECK 1592.00 06/30/10 76498 76498 76498TC 007 0610 3101
05010367 MRI OSI BRAIN FUNCT REQ PHY AD 2463.00 06/30/10 70555 70555 70555TC 007 0610 3101
05010370 MRI OSI BRAIN FUNCT MAP BY PHY 537.00 06/30/10 96020 96020 96020 007 0610 3101
05010373 MRI OSI CARD MRPH FUNC WO CONT 3477.00 06/30/10 75557 75557 75557TC 007 0610 3101
05010376 MRI OSI CRD MRPH FNC WO CNT WF 3602.00 06/30/10 75565 75565 75565TC 007 0610 3101
05010379 MRI OSI CRD MRPH FNC WO CNT W 3477.00 06/30/10 75559 75559 75559TC 007 0610 3101
05010382 MRI OS CRD MRPH FN WO CNT F/V 3602.00 06/30/10 75565 75565 75565TC 007 0610 3101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 154
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05010385 MRI OSI CARD MRPH FNC WWO CONT 2372.00 06/30/10 75561 75561 75561TC 007 0610 3101
05010388 MRI OSI CRD MRPH FNC WWO CNT Q 3903.00 06/30/10 75565 75565 75565TC 007 0610 3101
05010391 MRI OSI CRD MRPH UNC WWO CONT 4029.00 06/30/10 75563 75563 75563 007 0610 3101
05010397 MRI OSI BREAST CAD 194.00 06/30/10 0159T 0159T 0159T 007 0610 3101
05010400 MRI OSI IAC/SELLA W MODIFIER 3442.00 06/30/10 70553 70553 70553TC 007 0610 3101
05010403 MRI OSI DOUBLE DOSE CONTRAST 186.00 06/30/10 Q9960 Q9960 Q9960 007 0255 3101
05010409 MRI OSI BRAIN/IAC AND/OR SELLA 3442.00 06/30/10 70553 70553 70553TC 007 0610 3101
05010412 MRI OSI GADTEIDOL-PROHNCE MULT 29.00 06/30/10 A9576 A9576 A9576 007 0255 3101
05010415 MRI OSI GDBNATE-MLTIHNCE/ML 29.00 06/30/10 A9577 A9577 A9577 007 0255 3101
05010420 MR EOVIST (GADOXERTE DISOD)/ML 33.00 06/30/10 A9581 A9581 A9581 007 0636 3101
05010421 MRI OSI CARD F/V MAPPING 3602.00 06/30/10 75565 75565 75565TC 007 0610 3101
05020001 CT OSI 3D PROC W INDPNDT W/STN 588.00 06/30/10 76377 76377 76377TC 007 0350 3101
05020004 CT OSI 3D PROC W/O INDPT W/STN 426.00 06/30/10 76376 76376 76376 007 0350 3101
05020007 CT OSI ABDOMEN W IV CONT 1829.00 06/30/10 74160 74160 74160TC 007 0350 3101
05020010 CT OSI ABDOMEN W/O IV CONT 1531.00 06/30/10 74150 74150 74150 007 0350 3101
05020013 CT OSI ABDOMEN WW/O IV CONT 2127.00 06/30/10 74170 74170 74170TC 007 0350 3101
05020016 CT OSI CEREBRAL PERFUSION 487.00 06/30/10 0042T 0042T 0042T 007 0350 3101
05020019 CT OSI CERVICAL SPINE W CONT 2074.00 06/30/10 72126 72126 72126TC 007 0350 3101
05020022 CT OSI CERVICAL SPINE W/O CONT 1774.00 06/30/10 72125 72125 72125TC 007 0350 3101
05020025 CT OSI CERVICAL SPINE WW/O CON 2370.00 06/30/10 72127 72127 72127TC 007 0350 3101
05020028 CT OSI CHEST W CONT 2018.00 06/30/10 71260 71260 71260TC 007 0350 3101
05020031 CT OSI CHEST W/O CONT 1723.00 06/30/10 71250 71250 71250TC 007 0350 3101
05020034 CT OSI CHEST WW/O CONT 2317.00 06/30/10 71270 71270 71270TC 007 0350 3101
05020037 CT OSI DBLE HLICL ABD WW/O CON 2274.00 06/30/10 74170 74170 74170TC 007 0350 3101
05020040 CT OSI HEAD OR BRAIN W CONT 1430.00 06/30/10 70460 70460 70460TC 007 0610 3101
05020043 CT OSI HEAD OR BRAIN W/O CONT 1112.00 06/30/10 70450 70450 70450TC 007 0350 3101
05020046 CT OSI HEAD OR BRAIN WW/O CONT 1602.00 06/30/10 70470 70470 70470TC 007 0350 3101
05020049 CT OSI LE W CONT LT 1857.00 06/30/10 73701LT 73701LT 73701TC 007 0350 3101
05020052 CT OSI LE W CONT RT 1857.00 06/30/10 73701RT 73701RT 73701TC 007 0350 3101
05020055 CT OSI LE W/O CONT LT 1558.00 06/30/10 73700LT 73700LT 73700TC 007 0350 3101
05020058 CT OSI LE W/O CONT RT 1558.00 06/30/10 73700RT 73700RT 73700TC 007 0350 3101
05020061 CT OSI LE WW/O CONT LT 2154.00 06/30/10 73702LT 73702LT 73702TC 007 0350 3101
05020064 CT OSI LE WW/O CONT RT 2154.00 06/30/10 73702RT 73702RT 73702TC 007 0350 3101
05020067 CT OSI LIMITED/LOCALIZED FO/UP 407.00 06/30/10 76380 76380 76380 007 0350 3101
05020070 CT OSI LUMBAR SPINE W CONT 2203.00 06/30/10 72132 72132 72132 007 0350 3101
05020073 CT OSI LUMBAR SPINE W/O CONT 1906.00 06/30/10 72131 72131 72131 007 0350 3101
05020076 CT OSI LUMBAR SPINE WW/O CONT 2502.00 06/30/10 72133 72133 72133 007 0350 3101
05020079 CT OSI MAXILLOFACIAL W CONT 1905.00 06/30/10 70487 70487 70487 007 0350 3101
05020082 CT OSI MAXILLOFACIAL W/O CONT 1605.00 06/30/10 70486 70486 70486 007 0350 3101
05020085 CT OSI MAXILLOFACIAL WW/O CONT 2202.00 06/30/10 70488 70488 70488 007 0350 3101
05020088 CT OSI ORBIT,SELLA,EAR W CONT 1905.00 06/30/10 70481 70481 70481 007 0350 3101
05020091 CT OSI ORBIT,SELLA,EAR W/O CON 1605.00 06/30/10 70480 70480 70480 007 0350 3101
05020094 CT OSI ORBIT,SELLA,EAR WW/O CO 2202.00 06/30/10 70482 70482 70482 007 0350 3101
05020097 CT OSI PELVIS W IV CONT 1902.00 06/30/10 72193 72193 72193 007 0350 3101
05020100 CT OSI PELVIS W/O IV CONT 1603.00 06/30/10 72192 72192 72192TC 007 0350 3101
05020103 CT OSI PELVIS WW/O IV CONT 2200.00 06/30/10 72194 72194 72194TC 007 0350 3101
05020106 CT OSI SOFT TISSUE NECK W CONT 1727.00 06/30/10 70491 70491 70491TC 007 0350 3101
05020109 CT OSI SOFT TISS NECK W/O CONT 1429.00 06/30/10 70490 70490 70490TC 007 0350 3101
05020112 CT OSI SOFT TISS NCK WW/O CONT 2026.00 06/30/10 70492 70492 70492TC 007 0350 3101
05020115 CT OSI SYR & TUBE, DISPSBLE 57.00 06/30/10 007 0270 3101
05020118 CT OSI THORACIC SPINE W CONT 2028.00 06/30/10 72129 72129 72129TC 007 0350 3101
05020121 CT OSI THORACIC SPINE W/O CONT 1725.00 06/30/10 72128 72128 72128TC 007 0350 3101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 155
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05020124 CT OSI THORAC SPINE WW/O CONT 2319.00 06/30/10 72130 72130 72130TC 007 0350 3101
05020127 CT OSI UE W CONT LT 1857.00 06/30/10 73201LT 73201LT 73201TC 007 0350 3101
05020130 CT OSI UE W CONT RT 1857.00 06/30/10 73201RT 73201RT 93201TC 007 0350 3101
05020133 CT OSI UE W/O CONT LT 1558.00 06/30/10 73200LT 73200LT 73200TC 007 0350 3101
05020136 CT OSI UE W/O CONT RT 1558.00 06/30/10 73200RT 73200RT 73200TC 007 0350 3101
05020139 CT OSI UE WW/O CONT LT 2154.00 06/30/10 73202LT 73202LT 73202TC 007 0350 3101
05020142 CT OSI UE WW/O CONT RT 2154.00 06/30/10 73202RT 73202RT 73202TC 007 0350 3101
05020145 CT OSI VIRT COLONSCPY DIAG 1142.00 06/30/10 007 0350 3101
05020148 CT OSI VIRT COLONSCPY SCREEN 957.00 06/30/10 007 0350 3101
05020151 CTA OSI ABD AORTA ILEOFEM + 3D 1600.00 06/30/10 75635 75635 75635TC 007 0350 3101
05020154 CTA OSI ABDOMEN INCL POST PROC 1882.00 06/30/10 74175 74175 74175TC 007 0350 3101
05020157 CTA OSI CHST N-C INCL POST PRO 2120.00 06/30/10 71275 71275 71275TC 007 0350 3101
05020160 CTA OSI HEAD INCL POST PROCESS 1766.00 06/30/10 70496 70496 70496TC 007 0350 3101
05020163 CTA OSI LE INCL PST PROCESS-LT 1726.00 06/30/10 73706 73706 73706TC 007 0350 3101
05020166 CTA OSI LE INCL PST PROCESS-RT 1726.00 06/30/10 73706RT 73706RT 73706TC 007 0350 3101
05020169 CTA OSI NCK INCL PST PROCESS 2120.00 06/30/10 70498 70498 70498TC 007 0350 3101
05020172 CTA OSI PLVIS INCL PST PROCESS 1660.00 06/30/10 72191 72191 72191TC 007 0350 3101
05020175 CTA OSI UE INCL PST PRCESS-LT 1610.00 06/30/10 73206 73206 73206TC 007 0350 3101
05020178 CTA OSI UE INCL POST PRC-RT 1610.00 06/30/10 73206 73206 73206TC 007 0350 3101
05020181 CT OSI LOW OSMLR(300-99MG)CONT 4.00 06/30/10 Q9967 Q9967 Q9967 007 0636 3101
05507479 MRI BRAIN W/O CONT 2537.00 06/30/10 70551 70551 70551TC 88.91 007 0611 2101
05507480 MRI CHEST W/O CONT 2537.00 06/30/10 71550 71550 71550TC 88.92 007 0610 2101
05507481 MRI CERVICAL SPINE W/O CONT 2537.00 06/30/10 72141 72141 72141TC 88.93 007 0612 2101
05507482 MRI CHEST W CONT 2885.00 06/30/10 71551 71551 71551TC 007 0610 2101
05507484 MRI THORACIC SPINE W/O CONT 2384.00 06/30/10 72146 72146 72146TC 88.93 007 0612 2101
05507486 MRI LUMBAR SPINE W/O CONT 2537.00 06/30/10 72148 72148 72148TC 88.93 007 0612 2101
05507490 MRI ABDOMEN W/O CONT 2537.00 06/30/10 74181 74181 74181TC 88.97 007 0610 2101
05507492 MRI ABDOMEN W CONT 2883.00 06/30/10 74182 74182 74182TC 007 0610 2101
05508453 MRI BRAIN WW/O CONT 3443.00 06/30/10 70553 70553 70553TC 88.91 007 0611 2101
05512092 MRI PELVIS W/O CONT 2537.00 06/30/10 72195 72195 72195TC 88.95 007 0610 2101
05512093 MRI PELVIS W CONT 2845.00 06/30/10 72196 72196 72196TC 88.95 007 0610 2101
05512104 MRI TM JOINT 2537.00 06/30/10 70336 70336 70336TC 88.97 007 0610 2101
05512114 MRI LUMBAR SPINE WW/O 3458.00 06/30/10 72158 72158 72158TC 88.93 007 0612 2101
05512115 MRI ELBOW WW/O CONT LT 3152.00 06/30/10 73223LT 73223LT 73223TC 88.94 007 0610 2101
05512117 MRI THORACIC SPINE WW/O CONT 3443.00 06/30/10 72157 72157 72157TC 88.93 007 0612 2101
05512120 MRI CERVICAL SPINE WW/O CONT 3443.00 06/30/10 72156 72156 72156TC 88.93 007 0612 2101
05512123 MRI GADOLINIUM BASED CONT/ML 15.00 06/30/10 A9579 A9579 A9579 007 0636 2101
05512147 MRA UE WW/O CONT 3034.00 06/30/10 73225 73225 73225TC 88.94 007 0610 2101
05512150 MRI CARD F/V MAPPING 3602.00 06/30/10 75565 75565 75565TC 007 0610 2101
05512155 MRI BREAST WWO CONT 3254.00 06/30/10 77059 C8908 77059TC 88.97 007 0610 2101
05512175 MRI ORBIT/FACE/NECK W CONT 2845.00 06/30/10 70542 70542 70542TC 88.97 007 0610 2101
05512176 MRI ORBIT/FACE/NECK WW/O CONT 3458.00 06/30/10 70543 70543 70543TC 88.97 007 0610 2101
05512177 MRA HEAD W/O CONT 1725.00 06/30/10 70544 70544 70544TC 88.41 88.41 007 0610 2101
05512178 MRA HEAD W CONT 2208.00 06/30/10 70545 70545 70545TC 88.41 88.41 007 0610 2101
05512179 MRA HEAD WW/O CONT 2361.00 06/30/10 70546 70546 70546TC 88.41 88.41 007 0610 2101
05512180 MRA NECK W/O CONT 1700.00 06/30/10 70547 70547 70547TC 88.41 88.41 007 0610 2101
05512181 MRA NECK W CONT 2005.00 06/30/10 70548 70548 70548TC 88.41 88.41 007 0610 2101
05512182 MRA NECK WW/O CONT 2361.00 06/30/10 70549 70549 70549TC 88.41 88.41 007 0610 2101
05512188 MRI ABDOMEN WW/O CONT 3443.00 06/30/10 74183 74183 74183TC 88.97 007 0610 2101
05512189 MRI GUIDANCE S/I 631.00 06/30/10 77021 77021 77021TC 88.97 007 0610 2101
05512195 MRI FOOT W CONT LT 2845.00 06/30/10 73719LT 73719LT 73719TC 88.94 007 0610 2101
05512196 MRI FOOT WW/O CONT LT 3152.00 06/30/10 73720LT 73720LT 73720TC 88.94 007 0610 2101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 156
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05512197 MRI HAND W CONT LT 2845.00 06/30/10 73219LT 73219LT 73219TC 88.94 007 0610 2101
05512198 MRI HAND WO CONT LT 2537.00 06/30/10 73218LT 73218LT 73218TC 88.94 007 0610 2101
05512199 MRI HAND WW/O CONT LT 3152.00 06/30/10 73220LT 73220LT 73220TC 88.94 007 0610 2101
05512200 MRI HIP W CONT LT 2845.00 06/30/10 73722LT 73722LT 73722TC 88.94 007 0610 2101
05512201 MRI ANKLE WITH CONT-LT 2845.00 06/30/10 73722LT 73722LT 73722TC 88.94 007 0610 2101
05512202 MRI ELBOW W CONT LT 2845.00 06/30/10 73222LT 73222LT 73222TC 88.94 007 0610 2101
05512203 MRI HIP WW/O CONT LT 3000.00 06/30/10 73723LT 73723LT 73723TC 88.94 007 0610 2101
05512204 MRI FOOT W/O CONT LT 2537.00 06/30/10 73718LT 73718LT 73718TC 88.94 007 0610 2101
05512205 MRI LE W CONT LT 2845.00 06/30/10 73719LT 73719LT 73719TC 88.94 007 0610 2101
05512206 MRI KNEE W CONT LT 2845.00 06/30/10 73722LT 73722LT 73722TC 88.94 007 0610 2101
05512207 MRI KNEE WW/O CONT LT 3000.00 06/30/10 73723LT 73723LT 73723TC 88.94 007 0610 2101
05512208 MRI LE W/O CONT LT 2537.00 06/30/10 73718LT 73718LT 73718TC 88.94 007 0610 2101
05512214 MRI SHOULDER W CONT LT 2845.00 06/30/10 73222LT 73222LT 73222TC 88.94 007 0610 2101
05512216 MRI SHOULDER WW/O CONT LT 3152.00 06/30/10 73223LT 73223LT 73223TC 88.94 007 0610 2101
05512218 MRI UE W/O CONT LT 2537.00 06/30/10 73218LT 73218LT 73218TC 88.94 007 0610 2101
05512220 MRI UE W CONT LT 2845.00 06/30/10 73219LT 73219LT 73219TC 88.94 007 0610 2101
05512226 MRI WRIST W CONT LT 2845.00 06/30/10 73222LT 73222LT 73222TC 88.94 007 0610 2101
05512228 MRI WRIST WW/O CONT LT 3152.00 06/30/10 73223LT 73223LT 73223TC 88.94 007 0610 2101
05512240 MRA PELVIS W/O CONTRAST 1678.00 06/30/10 72198 C8919 72198TC 88.95 88.95 007 0610 2101
05512243 MRA PELVIS W CONT 2085.00 06/30/10 72198 C8918 72198LT 88.95 88.95 007 0610 2101
05512246 MRA PELVIS W W/O CONTRAST 2290.00 06/30/10 72198 C8920 72198TC 88.95 88.95 007 0610 2101
05512249 MRA ABD W/O CONTRAST 2223.00 06/30/10 74185 C8901 74185TC 88.95 88.95 007 0610 2101
05512251 MRA ABD W CONTRAST 2493.00 06/30/10 74185 C8900 74185TC 88.95 88.95 007 0610 2101
05512253 MRA ABD W W/O CONTRAST 3034.00 06/30/10 74185 C8902 74185TC 88.95 88.95 007 0610 2101
05512254 MRI BREAST W/O CONT LT 2829.00 06/30/10 77058LT C8904LT 77058TC 88.97 88.97 007 0610 2101
05512256 MRI BREAST W CONT LT 3136.00 06/30/10 77058LT C8903LT 77058TC 88.97 88.97 007 0610 2101
05512262 MRI BREAST W/O CONT RT 2829.00 06/30/10 77058RT C8904RT 77058TC 88.97 88.97 007 0610 2101
05512265 MRI BREAST W CONT RT 3136.00 06/30/10 77058RT C8903RT 77058TC 88.97 88.97 007 0610 2101
05512271 MRI BREAST W/O CONT BILAT 4257.00 06/30/10 77059 C8907 77059TC 88.97 88.97 007 0610 2101
05512274 MRI BREAST W CONT BILAT 4594.00 06/30/10 77059 C8906 77059TC 88.97 88.97 007 0610 2101
05512281 MRA CHEST W/O CONT 1678.00 06/30/10 71555 C8910 71555TC 88.92 88.92 007 0610 2101
05512284 MRA CHEST W CONT 1882.00 06/30/10 71555 C8909 71555TC 88.92 88.92 007 0610 2101
05512287 MRA CHEST WW/O CONT 2290.00 06/30/10 71555 C8911 71555TC 88.92 88.92 007 0610 2101
05512290 MRA LE W/O CONT 1678.00 06/30/10 73725 C8913 73725TC 88.94 88.94 007 0610 2101
05512293 MRA LE W CONT 1882.00 06/30/10 73725 C8912 73725TC 88.94 88.94 007 0610 2101
05512296 MRA LE WW/O CONT 2290.00 06/30/10 73725 C8914 73725TC 88.94 88.94 007 0610 2101
05512302 MRI PERC LIVER ABLATION 7820.00 06/30/10 47382 47382 47382 50.29 50.29 007 0360 2101
05512400 MRI BX BONE TROCAR/NDLE SUPERF 736.00 06/30/10 20220 20220 20220 77.49 77.49 007 0361 2101
05512406 MRI ANKLE W/O CONT RT 2537.00 06/30/10 73721RT 73721RT 73721TC 88.94 88.94 007 0610 2101
05512410 MRI ANKLE W CONT RT 2845.00 06/30/10 73722RT 73722RT 73722TC 88.94 88.94 007 0610 2101
05512412 MRI ELBOW W CONT RT 2845.00 06/30/10 73222RT 73222RT 73222TC 88.94 88.94 007 0610 2101
05512414 MRI ELBOW W/O CONT RT 2537.00 06/30/10 73221RT 73221RT 73221TC 88.94 88.94 007 0610 2101
05512420 MRI FOOT WW/O CONT RT 3152.00 06/30/10 73720RT 73720RT 73720TC 88.94 88.94 007 0610 2101
05512424 MRI HAND WW/O CONT RT 3152.00 06/30/10 73220RT 73220RT 73220TC 88.94 88.94 007 0610 2101
05512426 MRI HAND W/O CONT RT 2537.00 06/30/10 73218RT 73218RT 73218TC 88.94 88.94 007 0610 2101
05512432 MRI HIP WW/O CONT RT 3000.00 06/30/10 73723RT 73723RT 73723TC 88.94 88.94 007 0610 2101
05512446 MRI FOOT W CONT RT 2845.00 06/30/10 73719RT 73719RT 73719TC 88.94 88.94 007 0610 2101
05512452 MRI LE W/O CONT RT 2537.00 06/30/10 73718RT 73718RT 73718TC 88.94 88.94 007 0610 2101
05512462 MRI HAND W CONT RT 2845.00 06/30/10 73219RT 73219RT 73219TC 88.94 88.94 007 0610 2101
05512466 MRI ELBOW WW/O CONT RT 3152.00 06/30/10 73223RT 73223RT 73223TC 88.94 88.94 007 0610 2101
05512470 MRI ANKLE WW/O CONT LT 3000.00 06/30/10 73723LT 73723LT 73723TC 88.94 88.94 007 0610 2101
05512476 MRI BRAIN W CONT 2883.00 06/30/10 70552 70552 70552TC 007 0610 2101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 157
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05512484 MRI BREAST WW/O CONT RT 3131.00 06/30/10 77058RT C8905RT 77058TC 88.92 007 0610 2101
05512485 MRI CERVICAL SPINE W CONT 2885.00 06/30/10 72142 72142 72142TC 007 0610 2101
05512487 MRI CHEST WW/O CONT 3443.00 06/30/10 71552 71552 71552TC 007 0610 2101
05512500 MRI LUMBAR SPINE W CONT 2845.00 06/30/10 72149TC 72149 72149 007 0610 2101
05512503 MRI ORBIT/FACE/NECK W/O CONT 2537.00 06/30/10 70540 70540 70540TC 88.97 88.97 007 0610 2101
05512506 MRI PELVIS WW/O CONT 3458.00 06/30/10 72197 72197 72197TC 88.97 88.97 007 0610 2101
05512509 MRI THORACIC SPINE W CONT 2971.00 06/30/10 72147 72147 72147TC 007 0610 2101
05512524 MRI HIP W/O CONT RT 2537.00 06/30/10 73721RT 73721RT 73721TC 007 0610 2101
05512570 MRI MAGNETIC RES SPECTROSCOPY 1806.00 06/30/10 76390 76390 76390TC 88.90 007 0610 2101
05512600 MRI WRIST WW/O CONT RT 3152.00 06/30/10 73223RT 73223RT 73223TC 88.94 007 0610 2101
05512603 MRI WRIST W/O CONT RT 2537.00 06/30/10 73221RT 73221RT 73221TC 88.94 007 0610 2101
05512606 MRI WRIST W CONT RT 2845.00 06/30/10 73222RT 73222RT 73222TC 88.94 007 0610 2101
05512609 MRI WRIST W/O CONT LT 2537.00 06/30/10 73221LT 73221LT 73221TC 88.94 007 0610 2101
05512612 MRI SHOULDER WW/O CONT RT 3152.00 06/30/10 73223RT 73223RT 73223TC 88.94 007 0610 2101
05512615 MRI SHOULDER W/O CONT RT 2537.00 06/30/10 73221RT 73222RT 73222TC 88.94 007 0610 2101
05512618 MRI SHOULDER W/ CONT RT 2845.00 06/30/10 73222RT 73222RT 73222TC 88.94 007 0610 2101
05512621 MRI SHOULDER W/O CONT LT 2537.00 06/30/10 73221LT 73221LT 73221TC 88.94 007 0610 2101
05512624 MRI LE W CONT RT 2845.00 06/30/10 73719RT 73719RT 73719TC 88.94 007 0610 2101
05512627 MRI KNEE WW/O CONT RT 3000.00 06/30/10 73723RT 73723RT 73723TC 88.94 007 0610 2101
05512630 MRI KNEE W/O CONT RT 2537.00 06/30/10 73721RT 73721RT 73721TC 88.94 007 0610 2101
05512633 MRI KNEE W/CONT RT 2845.00 06/30/10 73722RT 73722RT 73722TC 88.94 007 0610 2101
05512636 MRI KNEE W/O CONT LT 2537.00 06/30/10 73721LT 73721LT 73721TC 88.94 007 0610 2101
05512639 MRI HIP W/CONT RT 2845.00 06/30/10 73722RT 73722RT 73722TC 88.94 007 0610 2101
05512642 MRI FOOT W/O CONT RT 2537.00 06/30/10 73718RT 73718RT 73718TC 007 0610 2101
05512645 MR ELBOW W/O CONT LT 2537.00 06/30/10 73221LT 73221LT 73221TC 88.94 007 0610 2101
05512651 MRI BREAST WW/O CONT LT 3131.00 06/30/10 77058LT C8905LT 77058TC 88.97 007 0610 2101
05512654 MRI ANKLE WW/O CONT RT 3000.00 06/30/10 73723RT 73723RT 73723TC 88.94 007 0610 2101
05512657 MR ANKLE W/O CONT LT 2537.00 06/30/10 73721LT 73721LT 73721TC 88.94 007 0610 2101
05512660 MRI UE WW/O CONT LT 3152.00 06/30/10 73220LT 73220LT 73220TC 88.94 007 0610 2101
05512663 MRI UE WW/O CONT RT 3152.00 06/30/10 73220RT 73220RT 73220TC 88.94 007 0610 2101
05512666 MRI UE W/O CONT RT 2537.00 06/30/10 73218RT 73218RT 73218TC 88.94 007 0610 2101
05512669 MRI UE W CONT RT 2845.00 06/30/10 73219RT 73219RT 73219TC 88.94 007 0610 2101
05512672 MRI LE WW/O CONT LT 3152.00 06/30/10 73720TC 73720LT 73720LT 88.94 007 0610 2101
05512675 MRI LE WW/O CONT RT 3152.00 06/30/10 73720TC 73720RT 73720RT 88.94 007 0610 2101
05512678 MRI HIP W/O CONT LT 2537.00 06/30/10 73721TC 73721LT 73721LT 88.94 007 0610 2101
05512765 MRI 3D PROC W INDPNDT W/STN 588.00 06/30/10 76377TC 76377 76377 007 0350 2101
05512768 MRI 3D PROC W/O INDPNDT W/STN 426.00 06/30/10 76376TC 76376 76376 007 0350 2101
05512771 MRI MOD SEDATION ADD 15 MIN 77.00 06/30/10 99145 99145 99145 007 0370 2101
05512774 MRI MOD SEDATION<5 YRS-30 MIN 390.00 06/30/10 99143 99143 99143 007 0370 2101
05512777 MRI MOD SEDATION> 5YRS-30 MIN 296.00 06/30/10 99144 99144 99144 007 0370 2101
05512780 MRA UE W CONT 2493.00 06/30/10 73225TC 73225 73225 007 0610 2101
05512783 MRA UE W/O CONT 2223.00 06/30/10 73225TC 73225 73225 007 0610 2101
05512815 CD CT MUSC-SKEL READING ONLY N/C 06/30/10 007 0350 2101
05512818 MRI GUIDED PARENCHYMAL TISSUE 1012.00 06/30/10 77022TC 77022 77022 007 0610 2101
05512821 MRI BRAIN FUNCT NOT REQUIRING 2537.00 06/30/10 70554TC 70554 70554 007 0611 2101
05512824 MRI NOVA STUDY HEAD OR NECK 929.00 06/30/10 76498TC 76498 76498 007 0615 2101
05512827 MRI NOVA STUDY HEAD AND NECK 1592.00 06/30/10 76498TC 76498 76498 007 0615 2101
05512830 MRI BRAIN FUNCT REQU PHY ADMN 2463.00 06/30/10 70555 70555 70555 007 0611 2101
05512833 MRI BRAIN FUNCT MAP BY PHY 537.00 06/30/10 96020 96020 96020 007 0900 2101
05512842 MRI CARD MRPH FUNC WO CONT 3153.00 06/30/10 75557TC 75557 75557TC 007 0610 2101
05512848 MRI CARD MRPH FUNCT WO CONT W 3477.00 06/30/10 75559 75559 75559 007 0610 2101
05512854 MRI CARD MRPH FUNC WWO CONT 3477.00 06/30/10 75561 75561 75561 007 0610 2101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 158
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05512860 MRI CARD MRPH FUNCT WWO CONT W 4029.00 06/30/10 75563 75563 75563 007 0610 2101
05512866 MRI BREAST CAD 194.00 06/30/10 0159T 0159T 0159T 007 0610 2101
05512890 MRI IAC/SELLA W MODIFIER 3442.00 06/30/10 7055359 7055359 7055359 007 0610 2101
05512895 MRI BRAIN/IAC AND/OR SELLA 3442.00 06/30/10 70553 70553 70553 007 0610 2101
05513510 MR EOVIST (GADOXE DISODIUM)/ML 38.00 06/30/10 A9581 A9581 A9581 007 0636 2101
05513512 MRI VA BX-LT 1773.00 06/30/10 19103LT 19103LT 19103LT 007 0320 2101
05513515 MRI VA BX-RT 1773.00 06/30/10 19103RT 19103RT 19103RT 007 0360 2101
05513518 MRI BX SUPPLY KIT 2208.00 06/30/10 99070 99070 99070 007 0270 2101
05513521 MRI TISSUE MARKER CLIP 300.00 06/30/10 007 0270 2101
05513524 MRI GUIDED NDLE PLACEMENT-S/I 868.00 06/30/10 77021 77021 77021 007 0621 2101
05513527 MRI IMAGE GUID CLIP PLCMNT-LT 441.00 06/30/10 19125LT 19125LT 19125LT 007 0360 2101
05513530 MRI IMAGE GUID CLIP PLCMNT-RT 428.00 06/30/10 19295RT 19295RT 19295RT 007 0360 2101
05513536 MRI ADENOSINE DX 30MG 613.00 07/01/10 J0152 J0152 J0152 007 0636 2101
05513539 MRI DIPYRIDAMOLE PERS PER 10MG 36.00 07/01/10 J1245 J1245 J1245 007 0636 2101
05513550 MRI RESEARCH STUDY N/C 06/30/10 007 0610 2101
05513600 MRI SYRINGE & TUBING 48.00 06/30/10 007 0270 2101
05519999 MR ANIMAL RESEARCH 716.00 06/30/10 007 0329 2101
11050590 3D PROC W INDP W/STN-M.D. 92.00 $ 06/30/09 76377 76377 76377TC 007 0972 0612
40100261 LIGATION OF HEMORRHOID 809.00 06/30/10 46221 46221 46221 49.45 49.45 007 0360 3309
40100563 SIGMOIDOSCOPY W/SUBMUCOSAL INJ 2752.00 06/30/10 45335 45335 45335 007 0360 3309
41010217 PERC FEM-POP ATHERECTOMY 5473.00 06/30/10 35493 35493 35493 007 0361 3330
41020164 TRNSLM ARTHRECT PERIPH ART I&S 2199.00 06/30/10 75992 75992 75992TC 007 0320 3330
41040000 INTRODUCTION CATHETER AORTA 926.00 06/30/10 36200 36200 36200 007 0361 3330
41040003 SEL CATH PLCMT ART EA 1 ABD BI 2166.00 06/30/10 3624550 3624550 3624550 007 0361 3330
41040006 SEL CATH PLCMT ART EA 1 ABD LT 1432.00 06/30/10 36245LT 36245LT 36245LT 007 0361 3330
41040009 SEL CATH PLCMT ART EA 1 ABD RT 1432.00 06/30/10 36245RT 36245RT 36245RT 007 0361 3330
41040012 SEL CATH PLCMT ART EA 1 ORD BI 3874.00 06/30/10 3621550 3621550 3621550 007 0361 3330
41040015 SEL CATH PLCMT ART EA 1 ORD LT 2178.00 06/30/10 36215LT 36215LT 36215LT 007 0361 3330
41040018 SEL CATH PLCMT ART EA 1 ORD RT 2178.00 06/30/10 36215RT 36215RT 36215RT 007 0361 3330
41040021 SEL CATH PLCMT ART EA 2 ORD BI 3184.00 06/30/10 3621650 3621650 3621650 007 0361 3330
41040024 SEL CATH PLCMT ART EA 2 ORD LT 2190.00 06/30/10 36216LT 36216LT 36216LT 007 0361 3330
41040027 SEL CATH PLCMT ART EA 2 ORD RT 2190.00 06/30/10 36216RT 36216RT 36216RT 007 0361 3330
41040033 ANGIO EXT CAROTD UNI SELECT LT 4007.00 06/30/10 75660TC 75660LT 75660LT 007 0320 3330
41040036 ANGIO EXT CAROTD UNI SELECT RT 4007.00 06/30/10 75660TC 75660RT 75660RT 007 0320 3330
41040039 ANGIO EXT CAROTID SELECTIVE BI 6589.00 06/30/10 75662TC 75662 75662 007 0320 3330
41040042 ANGIO CAROTID CERBRL UNI LT 2770.00 06/30/10 75665TC 75665LT 75665LT 007 0320 3330
41040045 ANGIO CAROTID CERBRL UNI RT 2770.00 06/30/10 75665TC 75665TC 75665RT 007 0320 3330
41040048 ANGIO CAROTID CERBRL UNI BI 4007.00 06/30/10 75671TC 75671 75671 007 0320 3330
41040051 ANGIO CAROTID CERV UNI LT 2618.00 06/30/10 75676TC 75676LT 75676LT 007 0320 3330
41040054 ANGIO CAROTID CERV UNI RT 2618.00 06/30/10 75676TC 75676RT 75676RT 007 0320 3330
41040057 ANGIOGRAPHY CARTOID CERV BI 4007.00 06/30/10 75680TC 75680 75680 007 0320 3330
41040060 ANGIO EXTREMITY UNILATERAL LT 2595.00 06/30/10 75710TC 75710LT 75710LT 007 0320 3330
41040063 ANGIO EXTREMITY UNILATERAL RT 2595.00 06/30/10 75710TC 75710RT 75710RT 007 0320 3330
41040066 ANGIO EXTREMITY BILATERAL 3537.00 06/30/10 75716TC 75716 75716 007 0320 3330
41040069 AORTOGRAPHY ABDOMINAL SERIAL 2208.00 06/30/10 75625TC 75625 75625 88.42 88.42 007 0320 3330
41040072 ANGIO RENAL UNI SELECTIVE LT 3065.00 06/30/10 75722TC 75722LT 75722LT 007 0320 3330
41040075 ANGIO RENAL UNI SELECTIVE RT 3065.00 06/30/10 75722TC 75722RT 75722RT 007 0320 3330
41040078 ANGIO RENAL UNI SELECTIVE BI 3425.00 06/30/10 75724TC 75724 75724 88.45 88.45 007 0320 3330
41040081 SEL CATH PLCMT ART 2ABD BI 1876.00 06/30/10 3624650 3624650 3624650 007 0361 3330
41040084 SEL CATH PLCMT ART INI 2ABD LT 1395.00 06/30/10 36246LT 36246LT 36246LT 007 0361 3330
41040087 SEL CATH PLCMT ART INI 2ABD RT 1395.00 06/30/10 36246RT 36246RT 36246RT 007 0361 3330
41040090 SEL CATH PLCMT ART INI 3ABD BI 2194.00 06/30/10 3624750 3624750 3624750 007 0361 3330
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 159
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41040093 SEL CATH PLCMT ART INI 3ABD LT 1707.00 06/30/10 36247LT 36247LT 36247LT 007 0361 3330
41040096 SEL CATH PLCMT ART INI 3ABD RT 1707.00 06/30/10 36247RT 36247RT 36247RT 007 0361 3330
41040099 SEL CATH PLCMT ADDL 2&3 ABD BI 1644.00 06/30/10 3624850 3624850 3624850 007 0361 3330
41040102 SEL CATH PLCMT ADDL 2&3 ABD LT 1190.00 06/30/10 36248LT 36248LT 36248LT 007 0361 3330
41040105 SEL CATH PLCMT ADDL 2&3 ABD RT 1190.00 06/30/10 36248RT 36248RT 36248RT 007 0361 3330
41040108 TRNSCTH IVASC STENT PERQ INIT 8618.00 06/30/10 37205 37205 37205 39.50 39.50 007 0361 3330
41040111 TRANSCTH IVASC STENT PERQ EA 6810.00 06/30/10 37206 37206 37206 39.50 39.50 007 0361 3330
41040114 TRANSCATH INTRO IV STENT EA 2414.00 06/30/10 75960TC 75960 75960 38.93 38.93 007 0320 3330
41040117 TRANSLM BALLOON ANGPL RENAL BI 3492.00 06/30/10 75966TC 7596650 7596650 007 0320 3330
41040120 TRANSLM BALLOON ANGPL RENAL LT 2313.00 06/30/10 75966TC 75966LT 75966LT 007 0320 3330
41040123 TRANSLM BALLOON ANGPL RENAL RT 2313.00 06/30/10 75966TC 75966RT 75966RT 007 0320 3330
41040126 TRANSLM BALON ANGPLSTY PERI BI 3864.00 06/30/10 75962TC 7596250 7596250 007 0320 3330
41040129 TRANSLM BALON ANGPLSTY PERI LT 2668.00 06/30/10 75962TC 75962LT 75962LT 007 0320 3330
41040132 TRANSLM BALON ANGPLSTY PERI RT 2668.00 06/30/10 75962TC 75962RT 75962RT 007 0320 3330
41040135 TRNSLM BAL ANGPL/ADD PRIPH BI 3613.00 06/30/10 75964TC 7596450 7596450 007 0320 3330
41040138 TRNSLM BAL ANGPL/ADD PRIPH LT 2198.00 06/30/10 75964TC 75964LT 75964LT 007 0320 3330
41040141 TRNSLM BAL ANGPL/ADD PRIPH RT 2198.00 06/30/10 75964TC 75964RT 75964RT 007 0320 3330
41040144 TRNSLM BLN ANG PER RNL ART BI 7444.00 06/30/10 3547150 3547150 3547150 007 0361 3330
41040147 TRNSLM BLN ANG PER RNL ART LT 5037.00 06/30/10 35471LT 35471LT 35471LT 007 0361 3330
41040150 TRNSLM BLN ANG PER RNL ART RT 5037.00 06/30/10 35471RT 35471RT 35471RT 007 0361 3330
41040153 TRNSLUM BLN ANG PERQ;ILIAC BI 6012.00 06/30/10 3547350 3547350 3547350 007 0361 3330
41040156 TRNSLUM BLN ANG PERQ;ILIAC LT 3937.00 06/30/10 35473LT 35473LT 35473LT 007 0361 3330
41040159 TRNSLUM BLN ANG PERQ;ILIAC RT 3937.00 06/30/10 35473RT 35473RT 35473RT 007 0361 3330
41040162 TRNSLUM BLN ANG PER FEMPOP BI 6082.00 06/30/10 3547450 3547450 3547450 007 0361 3330
41040165 TRNSLUM BLN ANG PER FEMPOP LT 4885.00 06/30/10 35474LT 35474LT 35474LT 007 0361 3330
41040168 TRNSLUM BLN ANG PER FEMPOP RT 4885.00 06/30/10 35474RT 35474RT 35474RT 007 0361 3330
41040171 INTR NEEDLE RTROGRADE BRACH BI 2785.00 06/30/10 3612050 3612050 3612050 007 0361 3330
41040174 INTR NEEDLE RTROGRADE BRACH LT 1709.00 06/30/10 36120LT 36120LT 36120LT 007 0361 3330
41040177 INTR NEEDLE RTROGRADE BRACH RT 1709.00 06/30/10 36120RT 36120RT 36120RT 007 0361 3330
41040180 INTR/NDLE/INTRCTH EXTRM ART BI 1027.00 06/30/10 3614050 3614050 3614050 007 0361 3330
41040183 INTR/NDLE/INTRCTH EXTRM ART LT 659.00 06/30/10 36140LT 36140LT 36140LT 007 0361 3330
41040186 INTR/NDLE/INTRCTH EXTRM ART RT 659.00 06/30/10 36140RT 36140RT 36140RT 007 0361 3330
41040190 SCP THOR/BRACHIOCEPHAL 3RD ORD 1888.00 06/30/10 36217 36217 36217 007 0361 3330
41040194 ANGIO BRACHIAL RETROGRADE S&I 1933.00 06/30/10 75658 75658 75658TC 007 0323 3330
41040197 TRANSCATHETER THERAPY INFUSION 4669.00 06/30/10 75896 75896 75896TC 007 0323 3330
41040200 ANGIOGRAM THRU EXISTING CATH 869.00 06/30/10 75898 75898 75898TC 007 0323 3330
41040209 AO ARCH. STUDY S & I 2500.00 06/30/10 75650TC 75650TC 75650TC 007 0320 3330
41040212 TIBIOPERONEAL TRK PTA(EA VSSL) 3497.00 06/30/10 35470 35470 35470 007 0361 3330
44089900 ERYTHRPOIETIN 1000 UNITS EXTERNAL 01/01/03 007 0636 5011
53400001 BLADDER SCAN 66.00 06/30/10 78730 78730 78730 007 0341 0234
03107360 PRE-PROCEDURE CARE 365.00 06/30/10 008 0710 0805
03107370 POST-PROCEDURE CARE FIRST HOUR 252.00 06/30/10 008 0710 0805
03107371 POST-PROCEDURE CARE >1-1.5 HRS 375.00 06/30/10 008 0710 0805
03107372 POST-PROCEDURE CARE >1.5-2 HRS 497.00 06/30/10 008 0710 0805
03107373 POST-PROCEDURE CARE >2-2.5 HRS 621.00 06/30/10 008 0710 0805
03107374 POST-PROCEDURE CARE >2.5-3 HRS 744.00 06/30/10 008 0710 0805
03107375 POST-PROCEDURE CARE >3-3.5 HRS 868.00 06/30/10 008 0710 0805
03107376 POST-PROCEDURE CARE >3.5-4 HRS 991.00 06/30/10 008 0710 0805
03107380 POST PROC CARE EA ADDL 30MIN 126.00 06/30/10 008 0710 0805
03107381 POST-PROC ADD'L 0.5 HR >4 HRS 130.00 06/30/10 008 0710 0805
03107383 MINOR PROCEDURE ROOM 269.00 06/30/10 008 0360 0805
03107395 URINE; PREGNANCY QUICK VIEW 134.00 06/30/10 81025 81025 81025 008 0300 0805
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 160
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03110220 ACTIVATED CLOTTING TIME 231.00 06/30/10 008 0480 0804
03110221 CPB SERVICE 6760.00 06/30/10 008 0480 0804
03110222 CPB STANDBY 693.00 06/30/10 008 0480 0804
03110223 INTRAAORTIC BALLOON INSERTION 5889.00 06/30/10 92992 92992 92992 35.41 008 0480 0804
03110224 PHYSIOLOGICAL MONITORING 334.00 06/30/10 008 0480 0804
03110225 HEMOCONCENTRATION 2040.00 06/30/10 008 0480 0804
03110226 AUTOTRANSFUSION 1121.00 06/30/10 36430 36430 36430 99.02 99.02 008 0391 0804
03110227 ISOLATED LIMB PERFUSION 7350.00 06/30/10 008 0480 0804
03110228 CDI IN-LINE MONITORNG SUPPLIES 2181.00 06/30/10 008 0480 0804
03110229 INTRAAORTIC BALLOON MAINTEN 244.00 06/30/10 92992 92992 92992 35.41 008 0480 0804
03110230 LVAD, RVAD, AND ECMO 5606.00 06/30/10 008 0480 0804
03110231 VENO-VENOUS BYPASS LIVER TRANS 10576.00 06/30/10 008 0480 0804
03110232 RAPID INFUSION SYSTEM 3748.00 06/30/10 008 0480 0804
03110300 CARDIAC SURGERY PANEL N/C E 06/30/10 008 0300 0804
03110301 PH, PCO2, PO2, HCO3 116.00 06/30/10 82803 82803 82803 008 0301 0804
03110302 O2 SAT BY SPECTROPHOTOMETRY 91.00 C 06/30/10 82810 82810 82810 008 0301 0804
03110303 POTASSIUM, BLOOD 62.00 C 06/30/10 84132 84132 84132 008 0301 0804
03110304 CALCIUM, IONIZED 160.00 C 06/30/10 82330 82330 82330 008 0301 0804
03110305 HEMOGLOBIN 40.00 C 06/30/10 85018 85018 85018 008 0305 0804
03110306 HEMATOCRIT 46.00 C 06/30/10 85013 85013 85013 008 0305 0804
03110307 GLUCOSE 74.00 C 06/30/10 82947 82947 82947 008 0301 0804
03110622 BRONCHOS W/BRUSH,WASH,LAVAGE 3538.00 06/30/10 31622 31622 31622 008 0360 0804
03110635 BRONCHOS W/FOREIGN BODY REMOVL 6073.00 06/30/10 31635 31635 31635 008 0360 0804
03110645 BRONCHOS W/BRONCH TOILET-INIT 3649.00 06/30/10 31645 31645 31645 008 0360 0804
03110646 BRONCHOS W/BRNCH TOILET-SUBSQ 2233.00 06/30/10 31646 31646 31646 008 0360 0804
03120101 O.R. TIME-FIRST 1/2 HR 2595.00 06/30/10 008 0360 0801
03120102 O.R. TIME- >1/2 TO 1 HR 3363.00 06/30/10 008 0360 0801
03120103 O.R. TIME- >1 TO 1-1/2 HRS 4152.00 06/30/10 008 0360 0801
03120104 O.R. TIME- >1-1/2 TO 2 HRS 4931.00 06/30/10 008 0360 0801
03120105 O.R. TIME- >2 TO 2-1/2 HRS 5713.00 06/30/10 008 0360 0801
03120106 O.R. TIME- >2-1/2 TO 3 HRS 6492.00 06/30/10 008 0360 0801
03120107 O.R. TIME- >3 TO 3-1/2 HRS 7275.00 06/30/10 008 0360 0801
03120108 O.R. TIME- >3-1/2 TO 4 HRS 8047.00 06/30/10 008 0360 0801
03120109 O.R. TIME- >4 TO 4-1/2 HRS 8825.00 06/30/10 008 0360 0801
03120110 O.R. TIME- >4-1/2 TO 5 HRS 9606.00 06/30/10 008 0360 0801
03120111 O.R. TIME- >5 TO 5-1/2 HRS 10388.00 06/30/10 008 0360 0801
03120112 O.R. TIME- >5-1/2 TO 6 HRS 11168.00 06/30/10 008 0360 0801
03120113 O.R. TIME- >6 TO 6-1/2 HRS 11948.00 06/30/10 008 0360 0801
03120114 O.R. TIME- >6-1/2 TO 7 HRS 12724.00 06/30/10 008 0360 0801
03120115 O.R. TIME- >7 TO 7-1/2 HRS 13504.00 06/30/10 008 0360 0801
03120116 O.R. TIME- >7-1/2 TO 8 HRS 14282.00 06/30/10 008 0360 0801
03120117 O.R. TIME- >8 TO 8-1/2 HRS 15055.00 06/30/10 008 0360 0801
03120118 O.R. TIME- >8-1/2 TO 9 HRS 15840.00 06/30/10 008 0360 0801
03120119 O.R. TIME- >9 TO 9-1/2 HRS 16617.00 06/30/10 008 0360 0801
03120120 O.R. TIME- >9-1/2 TO 10 HRS 17398.00 06/30/10 008 0360 0801
03120121 O.R. TIME- >10 TO 10-1/2 HRS 18178.00 06/30/10 008 0360 0801
03120122 O.R. TIME- >10-1/2 TO 11 HRS 18954.00 06/30/10 008 0360 0801
03120123 O.R. TIME- >11 TO 11-1/2 HRS 19734.00 06/30/10 008 0360 0801
03120124 O.R. TIME- >11-1/2 TO 12 HRS 20514.00 06/30/10 008 0360 0801
03120125 O.R. TIME-ADL'1/2 HR OVR 12 HR 787.00 06/30/10 008 0360 0801
03120130 MINOR PROCEDURE ROOM 328.00 06/30/10 008 0360 0801
03120160 FLUOROSCOPY UP TO 1 HR 514.00 06/30/10 76000 76000 76000 008 0320 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 161
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03120202 O.R. TIME EACH ADD'L 30 MIN 779.00 06/30/10 008 0360 0801
03120230 O.R. EMERGENCY/AFTER HOURS 1320.00 06/30/10 008 0360 0801
03121001 O.R. SURGICAL SPECIMEN 177.00 06/30/10 008 0360 0801
03121040 ROBOTIC USAGE FEE 3307.00 06/30/10 008 0360 0801
03121051 O.R. INSTRUMENT USAGE 278.00 06/30/10 008 0360 0801
03121055 O.R. MICROSCOPE USAGE 643.00 06/30/10 008 0360 0801
03121059 O.R. POWER EQUIPMENT USAGE 415.00 06/30/10 008 0360 0801
03121060 O.R. STEREOTACTIC FRAME USAGE 1205.00 06/30/10 008 0360 0801
03121063 O.R. ULTRASONIC SURG ASPIRATOR 4673.00 06/30/10 008 0360 0801
03121067 O.R. YAG LASER USAGE 2044.00 06/30/10 008 0360 0801
03121068 O.R. CO2 LASER USAGE 709.00 06/30/10 008 0360 0801
03121075 UPPER ENDOSCOPY EQUIP USAGE 755.00 06/30/10 008 0360 0801
03121076 LOWER ENDOSCOPY EQUIP USAGE 1055.00 06/30/10 008 0360 0801
03121078 MICRO SURGE USAGE FEE 229.00 06/30/10 008 0270 0801
03121080 EEE VTI USAGE FEE 1321.00 06/30/10 008 0270 0801
03121081 HARMONIC SCALPEL USAGE FEE 1455.00 06/30/10 008 0270 0801
03121082 CUSA USAGE FEE 1674.00 06/30/10 008 0270 0801
03121083 CRYO USAGE FEE 1455.00 06/30/10 008 0270 0801
03121084 NEURO MICROSCOPE USAGE FEE 1762.00 06/30/10 008 0270 0801
03121085 INDIGO LASER USAGE FEE 816.00 06/30/10 008 0270 0801
03121086 GENZYME USAGE FEE 452.00 06/30/10 008 0270 0801
03121087 LIGASURE USAGE FEE 276.00 06/30/10 008 0270 0801
03121088 VIDEO SYSTEM(OLYM) USAGE FEE 1455.00 06/30/10 008 0270 0801
03121089 GAMMA PROBE USAGE FEE 1723.00 06/30/10 008 0270 0801
03121090 ARGON BEAM USAGE FEE 1191.00 06/30/10 008 0270 0801
03121092 NEURO TRECK MONITOR USAGE FEE 1231.00 06/30/10 008 0270 0801
03121093 NEURO HEAD FRAME USAGE FEE 858.00 06/30/10 008 0270 0801
03121094 NEURO ELECTRODE USAGE FEE 280.00 06/30/10 008 0270 0801
03121097 3D PLAN & IMAGE GUID SURG SYS 1934.00 06/30/10 008 0270 0801
03121100 LITHOTRIPSY INSTRUMENT FEE EXTERNAL 07/01/10 008 0270 0801
03121201 O.R. SURGEON ADMIN LOCAL ANEST 132.00 06/30/10 008 0370 0801
03121211 O.R. MISCELLANEOUS SUPPLIES EXTERNAL 11/01/94 008 0270 0801
03121215 O.R. BASIC SUTURES EXTERNAL 04/15/96 008 0270 0801
03121216 O.R. SPECIALTY SUTURES EXTERNAL 04/15/96 008 0270 0801
03121251 O.R. IMPLANT EXTERNAL 11/01/94 008 0278 0801
03121281 O.R. CRASH CART 280.00 06/30/10 008 0270 0801
03131001 SEL CATH PLCMT ART EA ORD RT 1859.00 06/30/10 36216RT 36216RT 36216RT 008 0361 0801
03131004 SEL CATH PLCMT ART INI 2ABD LT 1285.00 06/30/10 36246LT 36246LT 36246LT 008 0360 0801
03132001 AORTOGRAPHT ABD W/BILAT ILIOF 2513.00 06/30/10 75630TC 75630 75630 008 0323 0801
03132004 ANGIO CAROTID CERBRL UNI RT 2042.00 06/30/10 75676TC 75676RT 75676RT 008 0320 0801
03132007 TRANSLM BALON ANGPLSTY PERI LT 2254.00 06/30/10 75962TC 75962LT 75962LT 008 0320 0801
03132010 TRNSLM BAL ANGPL/ADD PRIPH LT 2093.00 06/30/10 75964TC 75964LT 75964LT 008 0320 0801
03132013 TRANSCATH INTRO IV STENT -EA 2298.00 06/30/10 75960TC 75960 75960 008 0320 0801
03132015 VIDEO SWALLOW FUNCTION 526.00 06/30/10 74230TC 74230 74230 008 0320 0801
03132018 NEEDLE LOCALIZATION BY XRAY 821.00 06/30/10 77002TC 77002 77002 008 0320 0801
03132021 THER INJ,IM OR SUB -SALINE 86.00 06/30/10 96372 96372 96372 008 0940 0801
03132024 ANGIO EXTREMITY UNILATERAL RT 2595.00 06/30/10 75710TC 75710RT 75710RT 008 0320 0801
03132027 TRANSLM BALON ANGPLSTY PERI RT 2668.00 06/30/10 75962TC 75962RT 75962RT 008 0320 0801
03163008 GYNE LASER PROCED 438.00 06/30/10 58999 58999 58999 008 0360 0805
03177371 POST-PROCEDURE CARE >1-1.5 HRS 247.00 06/30/10 008 0710 0497
03177372 POST-PROCEDURE CARE >1.5-2 HRS 327.00 06/30/10 008 0710 0497
03177373 POST-PROCEDURE CARE >2-2.5 HRS 411.00 06/30/10 008 0710 0497
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 162
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03177374 POST-PROCEDURE CARE >2.5-3 HRS 491.00 06/30/10 008 0710 0497
03177375 POST-PROCEDURE CARE >3-3.5 HRS 572.00 06/30/10 008 0710 0497
03739065 LITHOTRIPTER 11164.00 06/30/10 50590 50590 50590 98.51 98.51 008 0360 2801
03784038 O.R. ENDOSCOPY/EEI 233.00 06/30/10 008 0360 0801
06110000 O.R. FIRST 1/2 HR 2331.00 06/30/10 008 0360 0801
06110001 O.R. >1/2 TO 1 HR 2200.00 06/30/10 008 0360 0801
06110002 O.R. >1 TO 1-1/2 HRS 2919.00 06/30/10 008 0360 0801
06110003 O.R. >1-1/2 TO 2 HRS 3636.00 06/30/10 008 0360 0801
06110004 O.R. >2 TO 2-1/2 HRS 4360.00 06/30/10 008 0360 0801
06110005 O.R. >2-1/2 TO 3 HRS 5078.00 06/30/10 008 0360 0801
06110006 O.R. >3 TO 3-1/2 HRS 5802.00 06/30/10 008 0360 0801
06110007 O.R. >3-1/2 TO 4 HRS 6523.00 06/30/10 008 0360 0801
06110008 O.R. >4 TO 4-1/2 HRS 7244.00 06/30/10 008 0360 0801
06110009 O.R. >4-1/2 TO 5 HRS 7967.00 06/30/10 008 0360 0801
06110010 O.R. >5 TO 5-1/2 HRS 8692.00 06/30/10 008 0360 0801
06110011 O.R. >5-1/2 TO 6 HRS 9403.00 06/30/10 008 0360 0801
06110012 O.R. >6 TO 6-1/2 HRS 10128.00 06/30/10 008 0360 0801
06110013 O.R. >6-1/2 TO 7 HRS 10850.00 06/30/10 008 0360 0801
06110014 O.R. >7 TO 7-1/2 HRS 11570.00 06/30/10 008 0360 0801
06110015 O.R. >7-1/2 TO 8 HRS 12291.00 06/30/10 008 0360 0801
06110016 O.R. >8 TO 8-1/2 HRS 13013.00 06/30/10 008 0360 0801
06110017 O.R. >8-1/2 TO 9 HRS 13736.00 06/30/10 008 0360 0801
06110018 O.R. >9 TO 9-1/2 HRS 14452.00 06/30/10 008 0360 0801
06110019 O.R. >9-1/2 TO 10 HRS 15174.00 06/30/10 008 0360 0801
06110020 O.R. >10 TO 10-1/2 HRS 15895.00 06/30/10 008 0360 0801
06110021 O.R. >10-1/2 TO 11 HRS 16615.00 06/30/10 008 0360 0801
06110022 O.R. >11 TO 11-1/2 HRS 17340.00 06/30/10 008 0360 0801
06110023 O.R. >11-1/2 TO 12 HRS 18059.00 06/30/10 008 0360 0801
06110024 O.R. ADD'L 1/2 HR OVER 12 HRS 726.00 06/30/10 008 0360 0801
06110099 O.R. EMERGENCY/AFTER HOURS 1320.00 06/30/10 008 0360 0801
06110101 O.R. CULTURE 35.00 06/30/10 008 0360 0801
06110102 O.R. FROZEN SECTION 125.00 06/30/10 008 0360 0801
06110151 LIPOSUCTION SYSTEM 352.00 06/30/10 008 0360 0801
06110152 SMOKE EVACUATOR 180.00 06/30/10 008 0360 0801
06110153 DAISY - VITRECTOMY 674.00 06/30/10 008 0360 0801
06110154 DAISY - PHACO 651.00 06/30/10 008 0360 0801
06110350 O.R. SUTURES GROUP 1 14.00 06/30/10 008 0270 0801
06110351 O.R. SUTURES GROUP 2 23.00 06/30/10 008 0270 0801
06110352 O.R. SUTURES GROUP 3 48.00 06/30/10 008 0270 0801
06110353 O.R. SUTURES GROUP 4 67.00 06/30/10 008 0270 0801
06110354 O.R. SUTURES GROUP 5 83.00 06/30/10 008 0270 0801
06110400 O.R. CATARACT CASE PACK 572.00 06/30/10 008 0270 0801
06110401 O.R. EAR PACK 531.00 06/30/10 008 0270 0801
06110402 O.R. MUSCLE PACK 404.00 06/30/10 008 0270 0801
06110403 O.R. T & A PACK 252.00 06/30/10 008 0270 0801
06110606 SCLERAL IMPLANT 491.00 06/30/10 008 0278 0801
06110607 SCLERAL SILICONE SPONGE 184.00 06/30/10 008 0278 0801
06110608 SYNTHES IMPLANTS EXTERNAL 07/01/97 008 0278 0801
06110609 KRUPIN EYE VALVE WITH DISK 1985.00 06/30/10 008 0278 0801
06110702 TEFLON WIRE PISTON 247.00 06/30/10 008 0270 0801
06110703 PLATINUM RIBBON LOOP 357.00 06/30/10 008 0270 0801
06110704 SHEENY TITANIUM TUBE 74.00 06/30/10 008 0270 0801
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 163
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

06122001 ENT SUPPLIES LEVEL 1 117.00 06/30/10 008 0360 0801
06122005 ENT SUPPLIES LEVEL 5 541.00 06/30/10 008 0360 0801
06122006 ENT SUPPLIES LEVEL 6 594.00 06/30/10 008 0360 0801
06122007 ENT SUPPLIES LEVEL 7 761.00 06/30/10 008 0360 0801
06122008 ENT SUPPLIES LEVEL 8 861.00 06/30/10 008 0360 0801
06122009 ENT SUPPLIES LEVEL 9 947.00 06/30/10 008 0360 0801
06122011 ENT SUPPLIES LEVEL 11 1175.00 06/30/10 008 0360 0801
06122801 EYE IMPLANT LEVEL 1 48.00 06/30/10 008 0278 0801
06122802 EYE IMPLANT LEVEL 2 52.00 06/30/10 008 0278 0801
06122803 EYE IMPLANT LEVEL 3 171.00 06/30/10 008 0278 0801
06122804 EYE IMPLANT LEVEL 4 256.00 06/30/10 008 0278 0801
06122805 EYE IMPLANT LEVEL 5 256.00 06/30/10 008 0278 0801
06122806 EYE IMPLANT LEVEL 6 572.00 06/30/10 008 0278 0801
06122807 EYE IMPLANT LEVEL 7 803.00 06/30/10 008 0278 0801
06122808 EYE IMPLANT LEVEL 8 1300.00 06/30/10 008 0278 0801
06122809 EYE IMPLANT LEVEL 9 1411.00 06/30/10 008 0278 0801
06122810 EYE IMPLANT LEVEL 10 1684.00 06/30/10 008 0278 0801
06122812 EYE IMPLANT LEVEL 12 3568.00 06/30/10 008 0278 0801
06122821 INTRAOCULAR LENS LEVEL 1 256.00 06/30/10 008 0276 0801
06122825 INTRAOCULAR LENS LEVEL 5 635.00 06/30/10 008 0276 0801
06122826 INTRAOCULAR LENS LEVEL 6 702.00 06/30/10 008 0276 0801
06123030 O.R. SUPPLIES EXTERNAL 07/01/97 008 0270 0801
06123040 O.R. PROSTHESIS EXTERNAL 07/01/97 008 0274 0801
06123050 O.R. IMPLANT EXTERNAL 07/01/97 008 0278 0801
06123060 O.R. INTRAOCULAR LENS EXTERNAL 07/01/97 008 0276 0801
06123070 O.R. SUTURES EXTERNAL 07/01/97 008 0270 0801
06124000 O.R. YAG LASER USAGE 1989.00 06/30/10 008 0360 0801
06124001 O.R. DIODE LASER USAGE 979.00 06/30/10 008 0360 0801
06124005 O.R. ARGON LASER USAGE 907.00 06/30/10 008 0360 0801
06124007 O.R. MICROSCOPE USAGE 162.00 06/30/10 008 0360 0801
06124020 COCHLEAR IMPLANT SYSTEM EXTERNAL 10/01/05 L8614 L8614 L8614 008 0278 0801
06179293 O.R. CAVITRON USAGE 3274.00 06/30/10 008 0360 0801
06179301 O.R. CO2 LASER USAGE 487.00 06/30/10 008 0360 0801
06184038 O.R. ENDOSCOPY EQUIP USAGE 503.00 06/30/10 008 0360 0801
06184095 0-R SURG SPEC EEI 104.00 06/30/10 008 0360 0801
06184319 O.R. CORNEAL TISSUE 9512.00 06/30/10 008 0360 0801
06187064 SURGEON ADMIN LOCAL ANEST EEI 24.00 06/30/10 008 0370 0801
07130001 VENOUS CARTH/SELEC ORGAN BLOOD 27.00 06/30/10 36500 36500 36500 38.93 38.93 008 0360 0801
07130002 TRANSCATHETER INTRO INTRAVAS 2757.00 06/30/10 75960 75960 75960 38.93 008 0320 0801
07130003 FLUOROSCOPY UP TO 1 HR 514.00 06/30/10 76000 76000 76000 89.04 008 0320 0801
07130004 AORTOGRAPHY ABDOMINAL SERIAL 2583.00 06/30/10 75625 75625 75625 88.42 008 0323 0801
07130005 AORTOGRAPHT ABD W/BILAT ILIOF 2513.00 06/30/10 75630 75630 75630 88.42 008 0323 0801
07130006 TROPONIN-I 146.00 06/30/10 84484 84484 84484 008 0301 0801
07130007 PLATELET CPMPATIBILITY TESTING 133.00 06/30/10 86922 86922 86922 008 0300 0801
07130008 ANESTHESIA>9.5-10 HRS 3640.00 06/30/10 008 0370 0801
07130009 THROMBIN 10,000 VIAL 79.00 06/30/10 008 0250 0801
07130010 NORMAL SALINE 91.00 06/30/10 008 0636 0801
07130011 HEPARINIZED SALINE 42.00 06/30/10 008 0636 0801
07130012 KANAMYCIN/BACITRACIN/IRRIGATN 113.00 06/30/10 008 0636 0801
07130013 AMBULANCE 1231.00 06/30/10 008 0540 0801
07130014 BAIR HUGGER 109.00 06/30/10 008 0370 0801
05010304 MRI OSI KNEE W/O CONT LT 2537.00 06/30/10 73721LT 73721LT 73721LT 009 0610 3101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 164
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

07110130 URINE DIP 69.00 06/30/10 81001 81001 81001 009 0300 0846
07110133 URINE PREGNANCY TEST 71.00 06/30/10 81025 81025 81025 009 0300 0846
07112237 EFM 0-3HRS 108.00 06/30/10 95861 95861 95861 009 0510 0841
07112245 EFM 3-7HRS 150.00 06/30/10 95863 95863 95863 009 0510 0841
07140001 EMER DEPT OB INSPECT/MINIMAL 123.00 06/30/10 99281 99281 99281 009 0450 0841
07140002 EMER DEPT OB LEVEL 1 336.00 06/30/10 99282 99282 99282 009 0450 0841
07140003 ISOLATION, INFECTIOUS PATIENT 147.00 06/30/10 009 0720 0841
07140004 INDUCTION OF LABOR; ONE HOUR 75.00 06/30/10 009 0720 0841
07140041 ELECTRON FETAL MONITOR; 1ST HR 286.00 06/30/10 59025 59025 59025 75.34 009 0920 0847
07140042 ELECTRON FETAL MONITOR ADDL HR 59.00 06/30/10 59025 59025 59025 75.34 009 0920 0847
07140043 FETAL NON-STRESS TEST 300.00 06/30/10 59025 59025 59025 75.35 009 0920 0847
07140044 FETAL OXYTOCIN STRESS TEST 358.00 06/30/10 59020 59020 59020 75.35 75.35 009 0920 0847
07140045 ULTRASONIC GUIDE FOR AMNIOCENT 829.00 06/30/10 76946 76946 76946 88.79 009 0402 0847
07140046 ECHO PREGNANT UTERUS; COMPLETE 793.00 06/30/10 76805 76805 76805 88.78 009 0402 0847
07140047 ECHOGRAPHY PREGNANT UTERUS F/U 370.00 06/30/10 76816 76816 76816 88.78 009 0402 0847
07140048 ECHOGRAPHY PREGNANT UTERUS LTD 591.00 06/30/10 76815 76815 76815 88.78 009 0402 0847
07140049 FETAL BIOPHYSICAL PROFILE 545.00 06/30/10 76818 76818 76818 88.79 009 0402 0847
07140050 PERIUMBILICAL BLOOD SAMPLING 1117.00 06/30/10 59012 59012 59012 75.33 75.33 009 0490 0847
07140052 AMNIOCENTESIS 551.00 06/30/10 59000 59000 59000 75.1 75.1 009 0490 0847
07140053 CHORIONIC VILLUS SAMPLING 235.00 06/30/10 59015 59015 59015 75.35 75.35 009 0490 0847
07140061 RHYTHM ECG, ONE TO THREE LEADS 71.00 06/30/10 93041 93041 93041 89.52 009 0730 0841
07140062 AUTOMATIC BLOOD PRESSR MONITOR 92.00 06/30/10 009 0270 0841
07140063 CARDIOPULMONARY MONITORING 71.00 06/30/10 93799 93799 93799 89.59 009 0730 0841
07140064 PLACEMNT CENT VEN CATH; >AGE 5 1128.00 06/30/10 36558 36558 36558 38.95 38.95 009 0360 0841
07140065 481HRT CATH; PLCEMNT SWAN-GANZ 2738.00 06/30/10 93503 93503 93503 89.64 009 0481 0841
07140066 FETAL SCALP BLOOD SAMPLING 235.00 06/30/10 59030 59030 59030 75.33 75.33 009 0720 0841
07140067 FETAL SCALP BLOOD SAMP; REPEAT 235.00 06/30/10 59030 59030 59030 75.33 75.33 009 0720 0841
07140068 FETAL CORD BLOOD SAMPLING 235.00 06/30/10 59030 59030 59030 75.33 75.33 009 0360 0841
07140101 DELIVERY ROOM 1323.00 06/30/10 009 0721 0841
07140102 DELIVERY ROOM POSTPARTUM 828.00 06/30/10 59430 59430 59430 009 0720 0841
07140111 CESAREAN SECTION, CLASSIC 3533.00 06/30/10 59515 59515 59515 009 0360 0841
07140112 CESAREAN SECTION W/HYSTERECTMY 3864.00 06/30/10 59525 59525 59525 009 0360 0841
07140113 CESAREAN SECTION W/TUBAL LIGAT N/C E 06/30/10 009 0360 0841
07140114 CESAREAN SECTION, CLASSIC 3533.00 C 06/30/10 59515 59515 59515 009 0360 0841
07140115 LIGATN/TRANSEC FALLOPIAN TUBES 87.00 C 06/30/10 58605 58605 58605 66.32 66.32 009 0360 0841
07140116 TOTAL HYSTERECTOMY 2891.00 06/30/10 58150 58150 58150 68.4 68.4 009 0360 0841
07140121 LIGATN/TRANSEC FALLOPIAN TUBES 2784.00 06/30/10 58605 58605 58605 66.32 66.32 009 0360 0841
07140122 LAPAROTOMY HODGKIN'S OR LYMPHO 2277.00 06/30/10 49220 49220 49220 54.91 54.91 009 0360 0841
07140123 LAPAROSCOPY VISUAL PELVIC AREA 2626.00 06/30/10 49320 49320 49320 54.21 54.21 009 0360 0841
07140131 CERCLAGE OF UTERINE CERVIX 2784.00 06/30/10 57700 57700 57700 67.69 67.69 009 0360 0841
07140132 EPISIOTOMY OR VAGINAL REPAIR 2530.00 06/30/10 59300 59300 59300 73.6 73.6 009 0360 0841
07140133 TRTMNT MISSED/INCOMPL ABORTION 2629.00 06/30/10 59820 59820 59820 69.02 69.02 009 0360 0841
07140134 TRTMNT SPONTAN ABORTN, 1ST TRI 839.00 06/30/10 58120 58120 58120 69.09 69.09 009 0360 0841
07140141 DOUBLE SETUP EXAM BEFORE DELIV 831.00 06/30/10 009 0720 0841
07140171 MATERNAL OBSERVATION; 1ST HOUR 567.00 06/30/10 009 0762 0841
07140172 MATERNAL OBSERVATION; ADD'L HR 165.00 06/30/10 009 0762 0841
07140181 MATERNAL TRANSPORT REFERRAL HO 1016.00 06/30/10 009 0720 0841
07140190 D&E CASE CART 657.00 06/30/10 009 0270 0841
07140201 AMNIO THERAP AMNIOTIC FL RDUC 270.00 06/30/10 59001 59001 59001 009 0361 0841
07140204 AMNIOCENTESIS; DIAGNOSTIC 551.00 06/30/10 59000 59000 59000 009 0402 0841
07140207 CHRNIC VLLUS SAMP ANY METH 235.00 06/30/10 59015 59015 59015 009 0361 0841
07140210 CORDOCENTESIS ANY METHOD 238.00 06/30/10 59012 59012 59012 009 0361 0841
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 165
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

07140213 FETAL BIOP PRFLE W/NOSTRS 816.00 06/30/10 76818 76818 76818 009 0402 0841
07140216 FETAL CNTRCTION STRESS TST 358.00 06/30/10 59020 59020 59020 009 0720 0841
07140219 FETAL MNTR-LBR-CNSLT MD SI 220.00 06/30/10 59050 59050 59050 009 0720 0841
07140222 FETAL NON-STRESS TEST 286.00 06/30/10 59025 59025 59025 009 0720 0841
07140225 FETL BIOPHYS PRFLE W/O NST 812.00 06/30/10 76819 76819 76819 009 0402 0841
07140228 INDUCED ABORTION BY D&E 1879.00 06/30/10 59841 59841 59841 69.01 69.01 009 0361 0841
07140231 INDUCED ABORT D & C 1879.00 06/30/10 59840 59840 59840 009 0514 0841
07140234 TRNSFION INTRAUTER FETAL 754.00 06/30/10 36460 36460 36460 009 0360 0841
07140237 URIN PG TST COLR COMP METH 87.00 06/30/10 81025 81025 81025 009 0300 0841
07140240 US PG UTERUS BSCAN W/IMG CMPL 793.00 06/30/10 76805 76805 76805 009 0402 0841
07140243 US PG UTERUS BSCAN W/IMG LTD 591.00 06/30/10 76815 76815 76815 009 0402 0841
07140246 US PG UTERUS BSCN CMPL MX GST 1134.00 06/30/10 76810 76810 76810 009 0402 0841
07140249 US PG UTERUS B-SCAN F/U/REPT 370.00 06/30/10 76816 76816 76816 009 0402 0841
07140301 INTRAUTERINE PRESSURE CATHETER 147.00 06/30/10 009 0270 0841
07230060 AMINO THERAP AMNIOTIC FL RDUC 332.00 06/30/10 59001 59001 59001 009 0361 0847
07230063 FETAL SCALP BLOOD SAMPLING 235.00 06/30/10 59030 59030 59030 009 0720 0847
07230066 US PG UTRUS B-SCAN CMPL MX GES 1134.00 06/30/10 76810 76810 76810 009 0402 0847
07230069 FETL BIOPHYS PROFILE; W/O NST 468.00 06/30/10 76819 76819 76819 009 0402 0847
04076489 P.A.S. STAIN 157.00 06/30/10 88313 88313 88313 010 0310 2613
04076497 SUDAN BLACK B STAIN 157.00 06/30/10 88313 88313 88313 010 0310 2613
04076505 ACID PHOS. STAIN 157.00 06/30/10 88313 88313 88313 010 0310 2613
04076521 A-NAPT.BUTYR.STAIN 157.00 06/30/10 88313 88313 88313 010 0310 2613
04076539 NASD CHLOREST'ASE 157.00 06/30/10 88313 88313 88313 010 0310 2613
04076547 MISC SPECIAL STAIN 157.00 06/30/10 88313 88313 88313 010 0310 2613
04076615 FLUID CELL COUNT/DIFF 123.00 06/30/10 89051 89051 89051 010 0300 2613
04100447 COPPER, TISSUE 226.00 06/30/10 82525 82525 82525 010 0301 2201
04100451 IRON, TISSUE 344.00 06/30/10 83540 83540 83540 010 0301 2201
04101198 BLOOD SMEAR, MD INTERP 38.00 06/30/10 85060 85060 85060 010 0305 2201
04101200 BONE MARROW ASPIRATE INTERP 91.00 06/30/10 85097 85097 85097 010 0305 2201
04101214 HISTOCHEM STAINING 263.00 06/30/10 88314 88314 88314 010 0310 2201
04101229 SPECIAL STAINS GP II,STRUCTURL 149.00 06/30/10 88313 88313 88313 010 0310 2201
04101230 SPECIAL STAINS-GP I MICROORGAN 157.00 06/30/10 88312 88312 88312 010 0310 2201
04101233 HEMATOX & EOSIN STAIN FR GRANT 65.00 06/30/10 88313 88313 88313 010 0310 2201
04101234 BONE DECALCIFICATION 88.00 06/30/10 88311 88311 88311 010 0310 2201
04101235 HEMATOX & EOSIN (GRANT ONLY) 34.00 06/30/10 010 0310 2201
04101255 IMMUFLUORESCENT STAINING 177.00 06/30/10 88346 88346 88346 010 0310 2201
04101289 HIST/CYT EXM(TOH PRP),INI SITE 85.00 06/30/10 88333 88333 88333 010 0310 2201
04101292 HIST/CYT EXM TCH PRP,AD'L SITE 85.00 06/30/10 88334 88334 88334 010 0310 2201
04102410 GROSS & MICRO LEVEL IV 360.00 06/30/10 88305 88305 88305 010 0310 2201
04103830 FROZEN SECTION 194.00 06/30/10 88331 88331 88331 010 0310 2201
04109415 GROSS & MICRO LEVEL V 636.00 06/30/10 88307 88307 88307 010 0310 2201
04109416 SKIN /MULTI-MARGINS 468.00 06/30/10 88305 88305 88305 010 0310 2201
04109423 GROSS & MICRO LEVEL VI 899.00 06/30/10 88309 88309 88309 010 0310 2201
04109431 INTRA-OP CONSULT (NOT FROZEN) 47.00 06/30/10 88329 88329 88329 010 0310 2201
04109456 IMMUNOPEROXIDASE 238.00 06/30/10 88342 88342 88342 010 0310 2201
04109506 EM DIAGNOSTIC & SCANNING 537.00 06/30/10 88349 88349 88349 010 0310 2201
04109878 TISSUE, GROSS ONLY LEVEL I 120.00 06/30/10 88300 88300 88300 010 0310 2201
04109879 GROSS & MICRO LEVEL II 219.00 06/30/10 88302 88302 88302 010 0310 2201
04109886 GROSS & MICRO LEVEL III 263.00 06/30/10 88304 88304 88304 010 0310 2201
04110001 GROSS ONLY-EYE 70.00 06/30/10 88300 88300 88300 010 0310 2201
04110002 MICRO ID-EYE 136.00 06/30/10 88302 88302 88302 010 0310 2201
04110003 SMALL BIOPSY - EYE 136.00 06/30/10 88304 88304 88304 010 0310 2201
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 166
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04110004 BIOPSY - EYE 214.00 06/30/10 88305 88305 88305 010 0310 2201
04110005 COMPLEX DISSECTION-EYE 307.00 06/30/10 88307 88307 88307 010 0310 2201
04110006 COMPREHENSIVE EXAM-EYE 339.00 06/30/10 88309 88309 88309 010 0310 2201
04110007 DECALCIFICATION - EYE 69.00 06/30/10 88311 88311 88311 010 0310 2201
04110008 SPEC STAIN,GP I BACTERIA-EYE 149.00 06/30/10 88312 88312 88312 010 0310 2201
04110009 SPEC STAIN,GP 2,STRUCT-EYE 149.00 06/30/10 88313 88313 88313 010 0310 2201
04110010 CONSULT,REFERRED SLIDES-EYE 63.00 06/30/10 88321 88321 88321 010 0310 2201
04110011 CONSULT REQ PREP SLIDES-EYE 72.00 06/30/10 88323 88323 88323 010 0310 2201
04110012 CONSULTATION,COMPREHENSIVE-EYE N/C 06/30/10 88325 88325 88325 010 0310 2201
04110013 IMMUNOPEROXIDASE - EYE 148.00 06/30/10 88342 88342 88342 010 0310 2201
04110014 ME TISSUE PROCESSING N/C 06/30/10 88399 88399 88399 010 0310 2201
04110015 IMMUNOFLUORESCENT STAIN-EYE 148.00 06/30/10 88346 88346 88346 010 0310 2201
04111001 LEVEL I - EYE PROF 68.00 06/30/10 88300 88300 88300 010 0300 2201
04111002 LEVEL II - EYE PROF 105.00 06/30/10 88302 88302 88302 010 0971 2201
04111003 LEVEL III - EYE PROF 152.00 06/30/10 88304 88304 88304 010 0971 2201
04111004 LEVEL IV - EYE PROF 207.00 06/30/10 88305 88305 88305 010 0971 2201
04111005 LEVEL V - EYE PROF 315.00 06/30/10 88307 88307 88307 010 0971 2201
04111006 LEVEL VI - EYE PROF 472.00 06/30/10 88309 88309 88309 010 0971 2201
04111007 DECALCIFICATION - EYE PROF 57.00 06/30/10 88311 88311 88311 010 0300 2201
04111008 SPEC STAIN GP I-EYE PROF 63.00 06/30/10 88312 88312 88312 010 0971 2201
04111009 SPEC STAIN GP II - EYE PROF 69.00 06/30/10 88313 88313 88313 010 0971 2201
04111010 CONSULT REFRD SLIDES-EYE PROF 166.00 06/30/10 88321 88321 88321 010 0971 2201
04111011 CONSULT RQ PREP SLIDE-EYE PROF 166.00 06/30/10 88323 88323 88323 010 0971 2201
04111013 IMMUNOPEROXIDASE - EYE PROF 144.00 06/30/10 88342 88342 88342 010 0971 2201
04111015 IMMUNFLUORSCENT STAIN-EYE PROF 120.00 06/30/10 88346 88346 88346 010 0971 2201
04111018 NEUROPATH GROSS & MICRO LVL II 312.00 06/30/10 88302 88302 88302 010 0310 2201
04111021 SELECT,CELLULAR W INTERP-HOSP 137.00 06/30/10 88112 88112 88112 010 0300 2201
04111025 MORPHOMETRIC ANAL TUMOR EA AB 286.00 06/30/10 88360 88360 88360 010 0310 2201
04111028 SURG ISH PARAFFIN TECH 259.00 06/30/10 88368 88368 88368 010 0310 2201
04113722 FROZEN ADDITIONAL 116.00 06/30/10 88332 88332 88332 010 0310 2201
04129780 FINE NEEDLE ASPIRATION BIOPSY 282.00 06/30/10 10021 10021 10021 010 0361 2201
04129781 RADIO GUIDED FINE NEEDLE ASPIR 593.00 06/30/10 10022 10022 10022 45.29 010 0361 2201
04129782 EVALUATION OF FNA ADEQUACY 209.00 06/30/10 88172 88172 88172 010 0311 2201
04129793 FINE NEEDLE ASP BX INTERP &RPT 271.00 06/30/10 88173 88173 88173 010 0311 2201
04144553 CYTOPATH CYTOSPIN-SMEARS/INTER 200.00 06/30/10 88108 88108 88108 010 0311 2201
04153055 IMMUNOFLUOR-INDIRECT, EACH AB 246.00 06/30/10 88347 88347 88347 010 0310 2201
04153058 ELECTRON MICROSCOPY DIAGNOSTIC 1335.00 06/30/10 88348 88348 88348 010 0310 2201
04153063 IN SITU HYBRIDIZATION 264.00 06/30/10 88365 88365 88365 010 0310 2201
04153070 CRYSTAL ID 66.00 06/30/10 89060 89060 89060 010 0300 2201
04153129 DETERM HISTOCHEM ENZYME ID 27.00 06/30/10 88319 88319 88319 010 0310 2201
04153132 CONFIRM PATH DIAG 190.00 06/30/10 88321 88321 88321 010 0310 2201
04153133 CONSULT REQUIRING SLIDE PREP 134.00 06/30/10 88323 88323 88323 010 0310 2201
04153134 MULT CASES OF OUTSIDE SLIDES 138.00 06/30/10 88325 88325 88325 010 0310 2201
04159646 CYTOPATH SMEAR, THIN LAYER-SH 30.00 06/30/10 88142 88142 88142 010 0311 2201
04159659 CYTOPATH SMEARS DIRECT W/INTER 182.00 06/30/10 88104 88104 88104 010 0311 2201
04159709 CYTOPATHOLOGY OTHER 85.00 06/30/10 88161 88161 88161 010 0311 2201
04159715 CYTOPATH SMEAR, INITIAL-SH 20.00 06/30/10 88164 88164 88164 010 0311 2201
04159717 CYTOPATH, SMEARS, UP TO 3 75.00 06/30/10 88164 88164 88164 010 0311 2201
04159795 PREP UNSTAIND SLDES-GRANT ONLY 28.00 06/30/10 88399 88399 88399 010 0310 2201
04159801 AUTOPSY WITH BRAIN N/C 06/30/10 88025 88025 88025 010 0310 2201
04159802 AUTOPSY SPECIAL STAIN N/C 06/30/10 88313 88313 88313 010 0310 2201
04159803 AUTOPSY IMMUNOPEROXIDASE N/C 06/30/10 88342 88342 88342 010 0310 2201
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 167
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04159804 AUTOPSY GROSS & MICRO W/O CNS N/C 06/30/10 88020 88020 88020 010 0310 2201
04159807 KELSCH ORAL BIOPSY N/C 06/30/10 88305 88305 88305 010 0310 2201
04159821 AUTOPSY, INFANT W/BRAIN N/C 06/30/10 88028 88028 88028 010 0310 2201
04159822 AUTOPSY,STLBRN/NWBRN W/BRAIN N/C 06/30/10 88029 88029 88029 010 0310 2201
04159823 AUTOPSY,SINGLE ORGAN N/C 06/30/10 88037 88037 88037 010 0310 2201
04159824 AUTOPSY, REGIONAL N/C 06/30/10 88036 88036 88036 010 0310 2201
04188175 TECH THIN LAYER PAP W/SCREEN 140.00 06/30/10 88175 88175 88175 010 0311 2201
41320062 DUAL CHMB PMKR EVAL W/O REPROG 305.00 06/30/10 93280 93280 93280 89.45 010 0921 3333
03370012 TRANSESOPH ECHO 1740.00 06/30/10 93312 93312 93312 011 0480 0803
03370020 DOPPLER ECHOCARDIOGRAPHY 687.00 06/30/10 93320 93320 93320 011 0480 0803
03370022 DOPPLER ECHOCAR;F/U OR LIMITED 456.00 06/30/10 93321 93321 93321 011 0480 0803
03370025 DOPPLER COLOR FLOW VEL MAPPING 251.00 06/30/10 93325 93325 93325 011 0480 0803
03370113 TRNSESPH ECHO -CON CARD DEFRM 1773.00 06/30/10 93313 93313 93313 011 0480 0803
03370118 TRNSESPH ECHO FOR MONITORING 1773.00 06/30/10 93318 93318 93318 011 0480 0803
03385936 ANESTHESIA 0 TO .5 HRS UIH 1324.00 06/30/10 011 0370 0803
03385939 ANESTHESIA-EACH ADD'L 30 MIN 229.00 06/30/10 011 0370 0803
03385944 ANESTHESIA >.5 TO 1 HRS UIH 1492.00 06/30/10 011 0370 0803
03385951 ANESTHESIA >1 TO 1.5 HRS UIH 1709.00 06/30/10 011 0370 0803
03385969 ANESTHESIA >1.5 TO 2 HRS UIH 1928.00 06/30/10 011 0370 0803
03385977 ANESTHESIA >2 TO 2.5 HRS UIH 2145.00 06/30/10 011 0370 0803
03385985 ANESTHESIA >2.5 TO 3 HRS UIH 2365.00 06/30/10 011 0370 0803
03385993 ANESTHESIA >3 TO 3.5 HRS UIH 2587.00 06/30/10 011 0370 0803
03386009 ANESTHESIA >3.5 TO 4 HRS UIH 2805.00 06/30/10 011 0370 0803
03386017 ANESTHESIA >4 TO 4.5 HRS UIH 3020.00 06/30/10 011 0370 0803
03386025 ANESTHESIA >4.5 TO 5 HRS UIH 3242.00 06/30/10 011 0370 0803
03386033 ANESTHESIA >5 TO 5.5 HRS UIH 3459.00 06/30/10 011 0370 0803
03386041 ANESTHESIA >5.5 TO 6 HRS UIH 3678.00 06/30/10 011 0370 0803
03386058 ANESTHESIA >6 TO 6.5 HRS UIH 3899.00 06/30/10 011 0370 0803
03386060 ANESTHESIA >6.5 TO 7 HRS UIH 4118.00 06/30/10 011 0370 0803
03386074 ANESTHESIA >7 TO 7.5 HRS UIH 4337.00 06/30/10 011 0370 0803
03386082 ANESTHESIA >7.5 TO 8 HRS UIH 4554.00 06/30/10 011 0370 0803
03386090 ANESTHESIA >8 TO 8.5 HRS UIH 4776.00 06/30/10 011 0370 0803
03386108 ANESTHESIA >8.5 TO 9 HRS UIH 4992.00 06/30/10 011 0370 0803
03386116 ANESTHESIA >9 TO 9.5 HRS UIH 5211.00 06/30/10 011 0370 0803
03386124 ANESTHESIA >9.5 TO 10 HRS UIH 5432.00 06/30/10 011 0370 0803
03386132 ANESTHESIA >10 TO 10.5 HRS UIH 5649.00 06/30/10 011 0370 0803
03386140 ANESTHESIA >10.5 TO 11 HRS UIH 5872.00 06/30/10 011 0370 0803
03386157 ANESTHESIA >11 TO 11.5 HRS UIH 6085.00 06/30/10 011 0370 0803
03386165 ANESTHESIA >11.5 TO 12 HRS UIH 6301.00 06/30/10 011 0370 0803
03386173 ANESTH ADD'L .5 HR >12 HRS UIH 224.00 06/30/10 011 0370 0803
03386177 CARDIAC SETUP 3875.00 06/30/10 011 0370 0803
03386178 CRANIOTOMY SETUP 1642.00 06/30/10 011 0370 0803
03386397 PRECORDIAL DOPPLER 93.00 06/30/10 011 0370 0803
03386421 EEG/SPECTRAL ARRAY 193.00 06/30/10 011 0370 0803
03386462 FLUID WARMER (BELMONT) 439.00 06/30/10 011 0370 0803
03386464 BAIR HUGGER BLANKET 29.00 06/30/10 011 0370 0803
03386465 TRANSPORT MONITOR 94.00 06/30/10 011 0370 0803
03386478 PULSE OXIMETER(ADHESIVE)SENSOR 39.00 11/01/09 011 0370 0803
03386520 FIBEROPTIC SCOPE 501.00 06/30/10 011 0370 0803
03386525 IV INFUSION PUMP 209.00 06/30/10 011 0370 0803
03386530 STRYKER PAIN PUMP 1480.00 06/30/10 011 0270 0803
04111022 SELECT, CELLULAR W INTERP M.D. 117.00 $ 06/30/09 88112 88112 88112 011 0971 2201
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 168
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04311852 PV GENERAL ANESTHESIA EXTERNAL 07/15/08 011 0370 2030
04359785 US GENERAL ANESTHESIA EXTERNAL 07/15/08 011 0370 2035
04372465 FL GENERAL ANESTHESIA EXTERNAL 07/15/08 011 0370 2006
04379380 NM GENERAL ANESTHESIA EXTERNAL 07/15/08 011 0370 2070
04381343 NV GENERAL ANESTHESIA EXTERNAL 07/15/08 011 0370 2032
05513533 MRI GENERAL ANESTHESIA EXTERNAL 07/15/08 011 0370 2101
11700029 ACCU-CHECK 44.00 06/30/10 82962QW 82962QW 82962QW 011 0301 3400
03153744 RECOVERY ROOM FIRST HOUR 438.00 06/30/10 012 0710 0802
03153748 RECOVERY RM-EA ADD'L 30MIN 109.00 06/30/10 012 0710 0802
03153751 RECOVERY ROOM >1 TO 1.5 HRS 654.00 06/30/10 012 0710 0802
03153769 RECOVERY ROOM >1.5 TO 2 HRS 869.00 06/30/10 012 0710 0802
03153777 RECOVERY ROOM >2 TO 2.5 HRS 1085.00 06/30/10 012 0710 0802
03153785 RECOVERY ROOM >2.5 TO 3 HRS 1300.00 06/30/10 012 0710 0802
03153793 RECOVERY ROOM >3 TO 3.5 HRS 1514.00 06/30/10 012 0710 0802
03153801 RECOVERY ROOM >3.5 TO 4 HRS 1732.00 06/30/10 012 0710 0802
03153819 RECOVERY ROOM >4 TO 4.5 HRS 1948.00 06/30/10 012 0710 0802
03153827 RECOVERY ROOM >4.5 TO 5 HRS 2161.00 06/30/10 012 0710 0802
03153835 RECOVERY ROOM >5 TO 5.5 HRS 2377.00 06/30/10 012 0710 0802
03153843 RECOVERY ROOM >5.5 TO 6 HRS 2592.00 06/30/10 012 0710 0802
03153850 RECOVERY ROOM >6 TO 6.5 HRS 2809.00 06/30/10 012 0710 0802
03153868 RECOVERY ROOM >6.5 TO 7 HRS 3024.00 06/30/10 012 0710 0802
03153876 RECOVERY ROOM >7 TO 7.5 HRS 3240.00 06/30/10 012 0710 0802
03153884 RECOVERY ROOM >7.5 TO 8 HRS 3455.00 06/30/10 012 0710 0802
03153891 R.R. ADD'L 1/2 HR OVER 8 HRS 222.00 06/30/10 012 0710 0802
03153895 MINOR PROCEDURE ROOM 299.00 06/30/10 012 0360 0802
03154001 HEMATOCRIT 35.00 06/30/10 85013 85013 85013 012 0305 0802
03154002 HEMOGLOBIN 34.00 06/30/10 85018 85018 85018 012 0305 0802
03154003 GLUCOSE; BLOOD, STICK TEST 40.00 06/30/10 82948 82948 82948 012 0301 0802
03154051 WARMING COVER 116.00 06/30/10 012 0270 0802
07140161 0B RECOVERY ROOM 0 TO 1 HR 414.00 06/30/10 012 0710 0841
07140162 OB RECOVERY ROOM ADDT'L 1/2 HR 150.00 06/30/10 012 0710 0841
40100441 RECOVERY-BRONCHO-3 HRS 1252.00 06/30/10 012 0710 3309
40100442 RECOVERY-BRONCHO-1/2 HR 177.00 06/30/10 012 0710 3309
40100451 RECOVERY-ULTRASND LIVER 3 HRS 1252.00 06/30/10 012 0710 3309
40100452 RECOVERY-ULTRASND LIVER 1/2HR 177.00 06/30/10 012 0710 3309
40100460 RECOVERY,EXTENDED,O/P 615.00 06/30/10 012 0710 3309
02500350 URINE DIPSTICK WITH MICRO 38.00 06/30/10 81000 81000 81000 013 0300 1910
02500390 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 013 0510 1910
03776927 TISSUE\GROSS ONLY 64.00 06/30/10 88300 88300 88300 013 0310 4523
03776935 TISSUE\GROSS&MICRO 157.00 06/30/10 88302 88302 88302 013 0310 4523
03776943 RESECT, GROSS MICRO 157.00 06/30/10 88302 88302 88302 013 0310 4523
03776950 FRZN SECT\GROSS & MICRO 186.00 06/30/10 88331 88331 88331 013 0310 4523
03776968 FRZN SECT ADDT'L 64.00 06/30/10 88332 88332 88332 013 0310 4523
03776976 ELECTRON MICROSCOPE 948.00 06/30/10 88348 88348 88348 013 0310 4523
03776984 SPEC STAINS;GRP I MICROORG-EA 143.00 06/30/10 88312 88312 88312 013 0310 4523
03776992 CONFIRM DX O\S SLID 184.00 06/30/10 88321 88321 88321 013 0310 4523
03779178 PATH ENUCL GLOBE 243.00 06/30/10 88302 88302 88302 013 0310 4523
03779186 BIOPSY SPECIMEN 178.00 06/30/10 67415 67415 67415 013 0360 4523
03779905 AQUEOUS-VITR ASPIR 116.00 06/30/10 65810 65810 65810 013 0360 4523
07110071 IV SOLUTIONS 103.00 06/30/10 013 0258 0846
07110072 IV MEDICATIONS 48.00 06/30/10 013 0250 0846
07110073 IVPB SOLUTIONS 72.00 06/30/10 013 0258 0846
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 169
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

07110074 MEDICATIONS, P.O. 11.00 06/30/10 013 0250 0846
07110075 NARCOTIC 38.00 06/30/10 013 0250 0846
07110076 I-MED/I-MED CASSETTE 124.00 06/30/10 013 0250 0846
07110077 SUPPOSITORIES 11.00 06/30/10 013 0250 0846
07110091 CHICAGO FIRE DEPT SUPPLIES 102.00 06/30/10 013 0270 0846
07110092 HOT PACK 9.00 06/30/10 013 0270 0846
07110093 COLD PACK 10.00 06/30/10 013 0270 0846
07110094 STERI STRIPS 14.00 06/30/10 013 0270 0846
07122006 PATIENT OBSERVATION; 2-3 HOURS 610.00 06/30/10 00.69 013 0762 0846
07122007 PATIENT OBSERVATION; 4-7 HOURS 919.00 06/30/10 00.69 013 0762 0846
07122021 TRANSFUSN BLOOD/BLD COMPONENTS 140.00 06/30/10 36430 36430 36430 99.07 99.07 013 0391 0846
07122061 RHYTHM ECG, ONE TO THREE LEADS 71.00 06/30/10 93041 93041 93041 89.52 013 0730 0846
07122063 CARDIOPULMONARY MONITORING 71.00 06/30/10 93799 93799 93799 89.59 013 0730 0846
07122071 IV SOLUTIONS 108.00 06/30/10 013 0258 0846
07122072 IV MEDICATIONS 50.00 06/30/10 013 0250 0846
07122073 IVPB SOLUTIONS 87.00 06/30/10 013 0258 0846
07122075 NARCOTIC 46.00 06/30/10 013 0250 0846
08520900 TORSO SUPP PTOSIS SUP CUST FIT EXTERNAL 12/01/90 013 0270 4201
08520920 TORSO SUPP PEND ABD SUPP C FIT 171.00 06/30/10 013 0270 4201
08523223 ORTHOPEDIC MENS SURGICAL BOOT EXTERNAL 12/01/90 L3260 L3260 L3260 013 0270 4201
08524220 REPLACE PART/ORTHO DEVICE EXTERNAL 12/01/90 013 0270 4201
08525662 LE SCKT INSERT BEL KN SIL GEL EXTERNAL 12/01/90 L5673 L5673 L5673 013 0270 4201
12400670 INJ W/PHAR AGENTS PAPAVER-M.D. 165.00 $ 06/30/09 54235 54235 54235 013 0975 0620
12666069 OFFC CONSULT LVL2 HOSPITL 158.00 06/30/10 99242 99242 99242 013 0510 0602
12666070 OFFC CONSULT LVL2-DOCTOR 152.00 $ 06/30/09 99242 99242 99242 013 0983 0602
12666141 PERDIODIC HEALTH SCREEN 0-21YR 102.00 06/30/10 99381 99381 99381 013 0510 0602
12666142 MAKE UP VISIT 0-21 YRS 100.00 06/30/10 99211 99211 99211 013 0510 0602
12666143 DAY CARE EXAM 2-6 YRS 102.00 06/30/10 99382 99382 99382 013 0510 0602
12666144 ATHLETIC EXAM 3-20 YRS 102.00 06/30/10 99383 99383 99383 013 0510 0602
12666145 CAMP EXAM 0-20 YRS 102.00 06/30/10 99381 99381 99381 013 0510 0602
12666146 WIC EXAM 102.00 06/30/10 99381 99381 99381 013 0510 0602
12666147 DCFS EXAM 102.00 06/30/10 99381 99381 99381 013 0510 0602
12666148 SCHOOL EXAM 0-20 YRS 102.00 06/30/10 99381 99381 99381 013 0510 0602
13001701 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 013 0510 0625
13010821 URINE DIPSTICK WITH MICRO 38.00 06/30/10 81000 81000 81000 013 0300 0626
13010827 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 013 0510 0626
13011629 ECHO ABDOMINAL; COMPLETE-HOSP 689.00 06/30/10 76700 76700 76700 013 0402 0626
13011630 ECHO ABDOMINAL; COMPLETE-M.D. 88.00 $ 06/30/09 76700 7670026 7670026 013 0972 0626
13020802 URINE DIPSTICK W/ MICRO 38.00 06/30/10 81000 81000 81000 013 0300 0627
13020811 WOUND CARE W/O DEBRIDEMENT 164.00 06/30/10 11040 11040 11040 013 0360 0627
13031681 URINE DIPSTICK W/ MICRO 38.00 06/30/10 81000 81000 81000 013 0300 0611
13031701 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 013 0510 0611
13041085 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 013 0510 0628
13041573 TAT REM TR ARM LEG <.5CM-HOSP 301.00 06/30/10 11400 11400 11400 013 0360 0628
13041574 TAT REM TR ARM LEG <.5CM-M.D. 145.00 $ 06/30/10 11400 11400 11400 013 0975 0628
13041575 TAT REM TR ARM LEG .6-1CM-HOSP 378.00 06/30/10 11401 11401 11401 013 0360 0628
13041576 TAT REM TR ARM LEG .6-1CM-M.D. 194.00 $ 06/30/09 11401 11401 11401 013 0975 0628
13041577 TAT RM TR ARM LEG 1.1-2CM-HOSP 442.00 06/30/10 11402 11402 11402 013 0360 0628
13041578 TAT RM TR ARM LEG 1.1-2CM-M.D. 217.00 $ 06/30/09 11402 11402 11402 013 0975 0628
13041579 TAT RM TR ARM LEG 2.1-3CM-HOSP 516.00 06/30/10 11403 11403 11403 013 0360 0628
13041580 TAT RM TR ARM LEG 2.1-3CM-M.D. 276.00 $ 06/30/09 11403 11403 11403 013 0975 0628
13041581 EX BEN LES TRK,ARM->4.0CM-HOSP 2657.00 06/30/10 11406 11406 11406 013 0360 0628
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 170
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13041582 EX BEN LES TRK,ARM->4.0CM-M.D. 459.00 $ 06/30/09 11406 11406 11406 013 0975 0628
13041585 TAT REM SC NK HN FT <.5CM-HOSP 287.00 06/30/10 11420 11420 11420 013 0360 0628
13041586 TAT REM SC NK HN FT<.5CM-M.D. 159.00 $ 06/30/09 11420 11420 11420 013 0975 0628
13041587 TAT REM SC NK HN .6-1CM-HOSP 494.00 06/30/10 11421 11421 11421 013 0360 0628
13041588 TAT REM SC NK HN .6-1CM-M.D. 215.00 $ 06/30/09 11421 11421 11421 013 0975 0628
13041589 TAT REM SC NK HN 1.1-2CM-HOSP 488.00 06/30/10 11422 11422 11422 013 0360 0628
13041590 TAT REM SC NK HN 1.1-2CM-M.D. 260.00 $ 06/30/09 11422 11422 11422 013 0975 0628
13041591 TAT REM SC NK HN 2.1-3CM-HOSP 893.00 06/30/10 11423 11423 11423 013 0360 0628
13041592 TAT REM SC NK HN 2.1-3CM-M.D. 304.00 $ 06/30/09 11423 11423 11423 013 0975 0628
13041593 EX BEN LES,SC,NK-3.1-4 CM-HOSP 1556.00 06/30/10 11424 11424 11424 013 0360 0628
13041594 EX BEN LES,SC,NK-3.1-4 CM-M.D. 352.00 $ 06/30/09 11424 11424 11424 013 0975 0628
13041595 EX BEN LES-SC,NK,- >4.0CM-HOSP 2183.00 06/30/10 11426 11426 11426 013 0360 0628
13041596 EX BEN LES-SC,NK,- >4.0CM-M.D. 540.00 $ 06/30/09 11426 11426 11426 013 0975 0628
13041597 TAT REM FACE <.5CM-HOSP 301.00 06/30/10 11440 11440 11440 013 0360 0628
13041598 TAT REM;FACE <.5CM-M.D. 189.00 $ 06/30/09 11440 11440 11440 013 0975 0628
13041599 TAT REM FACE .6 - 1CM-HOSP 857.00 06/30/10 11441 11441 11441 013 0360 0628
13041600 TAT REM FACE .6-1CM-M.D. 250.00 $ 06/30/09 11441 11441 11441 013 0975 0628
13041601 TAT REM FACE 1.1 - 2CM-HOSP 566.00 06/30/10 11442 11442 11442 013 0360 0628
13041602 TAT REM FACE 1.1-2CM-M.D. 280.00 $ 06/30/09 11442 11442 11442 013 0975 0628
13041603 TAT REM FACE 2.1 - 3CM-HOSP 758.00 06/30/10 11443 11443 11443 013 0360 0628
13041604 TAT REM FACE 2.1-3CM-M.D. 346.00 $ 06/30/09 11443 11443 11443 013 0975 0628
13041605 EX BEN LES FACE-3.1-4.0CM-HOSP 1089.00 06/30/10 11444 11444 11444 013 0360 0628
13041606 EX BEN LES FACE-3.1-4.0CM-M.D. 445.00 $ 06/30/09 11444 11444 11444 013 0975 0628
13041609 EXC BEN LES FACE->4.0 CM-HOSP 1888.00 06/30/10 11446 11446 11446 013 0360 0628
13041610 EXC BEN LES FACE->4.0 CM-M.D. 628.00 $ 06/30/09 11446 11446 11446 013 0975 0628
13050200 CORP CAVERN IRRIG PRIAP-HOSP 294.00 06/30/10 54220 54220 54220 013 0360 0624
13050201 CORP CAVERN IRRIG PRIAP-M.D. 303.00 $ 08/01/09 54220 54220 54220 013 0975 0624
13050212 CYSTO W/DILATION - HOSP 2385.00 06/30/10 52281 52281 52281 013 0360 0624
13050213 CYSTO W/DILATION - M.D. 351.00 $ 08/01/09 52281 52281 52281 013 0975 0624
13050216 DEST LES,PENIS,SIMP:LASER-HOSP 3942.00 06/30/10 54057 54057 54057 013 0360 0624
13050217 DEST LES,PENIS,SIMP:LASER-M.D. 202.00 $ 08/01/09 54057 54057 54057 013 0975 0624
13050220 DILAT FEMALE URETH INIT-HOSP 150.00 06/30/10 53660 53660 53660 013 0360 0624
13050221 DILAT FEMALE URETH INIT-M.D. 93.00 $ 08/01/09 53660 53660 53660 013 0975 0624
13050224 FRENOPLASTY - HOSP 1114.00 06/30/10 41520 41520 41520 013 0360 0624
13050225 FRENOPLASTY - M.D. 503.00 $ 08/01/09 41520 41520 41520 013 0975 0624
13050234 SUPER PUBIC CATH 144.00 06/30/10 51703 51703 51703 013 0510 0624
13050235 SUPER PUBIC CATH - M.D. 183.00 $ 08/01/09 51703 51703 51703 013 0983 0624
13050240 INSRT BLAD CATH (FOLEY) 98.00 06/30/10 51702 51702 51702 013 0360 0624
13050241 INSRT BLAD CATH (FOLEY) - M.D. 68.00 $ 08/01/09 51702 51702 51702 013 0975 0624
13050244 VOIDING PRESSURE STUDIES-HOSP 582.00 06/30/10 51728 51728 51728 013 0920 0624
13050245 VOIDING PRESSURE STUDIES-M.D. 629.00 $ 01/01/10 51728 51728 51728 013 0982 0624
13050248 US GUID NDLE PLMT IMG S&I-HOSP 754.00 07/27/10 76942 76942 76942 013 0402 0624
13050249 US GUID NDLE PLMT IMG S&I-M.D. 73.00 $ 08/01/09 7694226 7694226 7694226 013 0972 0624
13050254 URETHRAL PRESSURE PROFILE-HOSP 527.00 06/30/10 51727 51727 51727 013 0360 0624
13050255 URETHRAL PRESSURE PROFILE-M.D. 631.00 $ 01/01/10 51727 51727 51727 013 0975 0624
13050256 VOID& URETH PRESS STUDIES-HOSP 582.00 06/30/10 51729 51729 51729 013 0360 0624
13050257 VOID& URETH PRESS STUDIES-M.D. 675.00 $ 01/01/10 51729 51729 51729 013 0975 0624
13051323 STRAIGHT CATH, URETHA 86.00 06/30/10 51701 51701 51701 013 0360 0624
13051324 STRAIGHT CATH, URETHA - M.D. 105.00 $ 08/01/09 51701 51701 51701 013 0975 0624
13051341 EMG ANAL OR URETH SPHINCT-HOSP 326.00 06/30/10 51785 51785 51785 013 0490 0624
13051342 EMG ANAL OR URETH SPHINCT-M.D. 174.00 $ 08/01/09 5178526 5178526 5178526 013 0982 0624
13051401 DILAT URETH STRICT (S&D)-HOSP 127.00 06/30/10 53600 53600 53600 013 0360 0624
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 171
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13051402 DILAT URETH STRICT (S&D)-M.D. 146.00 $ 08/01/09 53600 53600 53600 013 0975 0624
13051407 DILAT URETH STRICT (F&F)-HOSP 183.00 06/30/10 53620 53620 53620 013 0360 0624
13051408 DILAT URETH STRICT (F&F)-M.D. 198.00 $ 08/01/09 53620 53620 53620 013 0975 0624
13051449 FULG PENILE CONDYLOMA,EXT-HOSP 355.00 06/30/10 54055 54055 54055 013 0360 0624
13051450 FULG PENILE CONDYLOMA,EXT-M.D. 192.00 $ 08/01/09 54055 54055 54055 013 0975 0624
13051501 BLADDER INSTILLATION 183.00 06/30/10 51720 51720 51720 013 0360 0624
13051502 BLADDER INSTILLATION-M.D. 190.00 $ 08/01/09 51720 51720 51720 013 0975 0624
13051509 CYSTOMETROGRAM-COMPLEX-HOSP. 524.00 06/30/10 51726 51726 51726 013 0510 0624
13051510 CYSTOMETROGRAM-COMPLEX-M.D. 196.00 $ 08/01/09 5172626 5172626 5172626 013 0983 0624
13051513 UROFLOWMETRY, COMPLEX-HOSP 187.00 06/30/10 51741 51741 51741 013 0920 0624
13051514 UROFLOWMETRY, COMPLEX - M.D. 132.00 $ 08/01/09 5174126 5174126 5174126 013 0982 0624
13051517 CYSTOSCOPY-HOSP 995.00 06/30/10 52000 52000 52000 013 0360 0624
13051518 CYTOSCOPY - M.D 280.00 $ 08/01/09 52000 52000 52000 013 0975 0624
13051521 CYSTOSCOPY,BLADDER BIOP-HOSP 1158.00 06/30/10 52204 52204 52204 013 0360 0624
13051522 CYSTOSCOPY,BLADDER BIOPSY-M.D. 318.00 $ 08/01/09 52204 52204 52204 013 0975 0624
13051525 CYSTOSCOPY,REM URE STENT-HOSP 1175.00 06/30/10 52310 52310 52310 013 0360 0624
13051526 CYSTOSCOPY,REM URE STENT-M.D. 345.00 $ 08/01/09 52310 52310 52310 013 0975 0624
13051529 VASECTOMY-HOSP. 1255.00 06/30/10 55250 55250 55250 013 0360 0624
13051530 VASECTOMY-M.D. 506.00 $ 08/01/09 55250 55250 55250 013 0975 0624
13051537 ECHO TRANSRECT,ULTRASOUND-HOSP 210.00 06/30/10 76872 76872 76872 013 0402 0624
13051538 ECHO,TRANSRECT,ULTRASOUND-M.D. 78.00 $ 08/01/09 7687226 7687226 7687226 013 0972 0624
13051545 BIOPSY,PROST,NEEDLE PUNCH-HOSP 858.00 06/30/10 55700 55700 55700 013 0360 0624
13051546 BIOPSY,PROST NEEDL PUNCH-M.D. 301.00 $ 08/01/09 55700 55700 55700 013 0983 0624
13051551 MEATOTOMY - HOSP 3029.00 06/30/10 53020 53020 53020 013 0360 0624
13051552 MEATOTOMY - M.D. 219.00 $ 01/01/10 53020 53020 53020 013 0975 0624
13051737 BLADDER SCAN-HOSP 109.00 06/30/10 51798 51798 51798 013 0402 0624
13051738 BLADDER SCAN - M.D. 52.00 $ 08/01/09 51798 51798 51798 013 0972 0624
13051765 BLADDER IRRIG,LAVAGE 211.00 06/30/10 51700 51700 51700 013 0360 0624
13051766 BLADDER IRRIG,LAVAGE-M.D 100.00 $ 08/01/09 51700 51700 51700 013 0975 0624
13051767 CYSTO,W/INSRT URETER CATH-HOSP 2542.00 06/30/10 51045 51045 51045 013 0360 0624
13051768 CYSTO,W/INSRT URETER CATH-M.D. 1032.00 $ 08/01/09 51045 51045 51045 013 0975 0624
13051769 CHANGE CYSTO TUBE,SIMP-HOSP 219.00 06/30/10 51705 51705 51705 013 0360 0624
13051770 CHANGE CYSTO TUBE,SIMP-M.D. 149.00 $ 08/01/09 51705 51705 51705 013 0975 0624
13051771 INJECT CORPORA CAVERNOSA 194.00 06/30/10 54235 54235 54235 013 0360 0624
13051772 INJECT CORPORA CAVERNOSA-M.D. 165.00 $ 08/01/09 54235 54235 54235 013 0975 0624
13051773 URINE DIPSTICK W/O MICRO 35.00 06/30/10 81002 81002 81002 013 0300 0624
13051777 BLOOD OCCT. FECAL SCREEN 34.00 06/30/10 82270 82270 82270 013 0301 0624
13060741 DEBRIDEMENT STERNAL WOUND-HOSP 3389.00 06/30/10 21627 21627 21627 013 0360 0623
13060742 DEBRIDEMENT STERNAL WOUND-M.D. 1129.00 $ 06/30/09 21627 21627 21627 013 0975 0623
13060781 URINE DIPSTICK W/MICRO 35.00 06/30/10 81002 81002 81002 013 0300 0623
13060789 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 013 0510 0623
13300242 AEROSOL INHALATION, ADD'L HR 115.00 06/30/10 94645 94645 94645 013 0460 0648
16320001 VOICE EVALUATION 174.00 06/30/10 92506GN 92506GN 92506GN 89.04 013 0444 4306
16320002 SPEECH & LANGUAGE EVAL 539.00 06/30/10 92506GN 92506GN 92506GN 89.04 013 0444 4306
16320003 PREOPERATIVE SPEECH EVALUATION 539.00 06/30/10 92506GN 92506GN 92506GN 89.04 013 0444 4306
16320004 DYSPHAG/FEEDING EVALUATION 100.00 06/30/10 92610 92610 92610 89.04 013 0444 4306
16320005 SPEECH & LANG THER INDIVIDUAL 476.00 06/30/10 92507GN 92507GN 92507GN 95.42 013 0440 4306
16320006 SPEECH & LANG THER GROUP 200.00 06/30/10 92508GN 92508GN 92508GN 95.42 013 0443 4306
16320007 VIDEOSWALLOW STUDY 599.00 06/30/10 92611 92611 92611 89.04 013 0440 4306
16320008 LARYNGEAL FUNCTION STUDY 272.00 06/30/10 92520GN 92520GN 92520GN 89.7 013 0440 4306
16320009 NASAL FUNCTION STUDY 293.00 06/30/10 92512GN 92512GN 92512GN 89.7 013 0510 4306
16320010 DYSPHAG/FEED THER INDIV 91.00 06/30/10 92526GN 92526GN 92526GN 99.99 013 0440 4306
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 172
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

16320011 LARYNG FUNC SPECIAL TEST 105.00 06/30/10 92520GN 92520GN 92520GN 89.7 013 0440 4306
16320012 MED EVAL LARYN W/STROBOS 274.00 06/30/10 92506GN 92506GN 92520GN 89.04 013 0444 4306
16320013 EVAL/FITTING VOICE PROSTH 467.00 06/30/10 92607 92607 92607 93.75 013 0440 4306
16320014 SPECIAL REPORTS 50.00 06/30/10 99080GN 99080GN 99080GN 89.15 013 0510 4306
16320015 VOICE THERAPY; INDIVIDUAL 251.00 06/30/10 92507GN 92507GN 92507GN 95.42 013 0440 4306
16320016 VOICE THERAPY; GROUP 157.00 06/30/10 92508GN 92508GN 92508GN 95.42 013 0443 4306
16320017 MOD VOICE PROS/AUG DEVICE 398.00 06/30/10 W7145 92507 92507 93.75 013 0440 4306
16320018 SPCH TX IND ADLT/15MN-60DA DC 476.00 06/30/10 92507GN 92507GN 92507GN 95.42 013 0440 4306
16320019 DYSPHG/FD TX ADLT/15MN 60DA DC 91.00 06/30/10 92526GN 92526GN 92526GN 99.99 013 0440 4306
16320020 VOICE TX IND ADLT 15MN-60DA DC 476.00 06/30/10 92507GN 92507GN 92507GN 95.42 013 0440 4306
16320021 MOD VX PRS/AG DV/ADLT/15MN 60D 476.00 06/30/10 92507 92507 92507 93.75 013 0440 4306
16320022 VOICE EVALUATION/15 MIN/0-20 Y 334.00 06/30/10 92506GN 92506GN 92506GN 89.04 013 0444 4306
16320023 SPEECH-LANG EVAL/15MIN/0-20YRS 539.00 06/30/10 92506GN 92506GN 92506GN 89.04 013 0444 4306
16320024 DYSPHG/FEED EVAL/15MIN/0-20YRS 398.00 06/30/10 92610 92610 92610 89.04 013 0444 4306
16320025 VIDEOSWALLOW STUDY/15MN/0-20YR 599.00 06/30/10 92611 92611 92611 89.04 013 0440 4306
16320026 SPEECH/LNG TX/INDV/15MN/0-20YR 476.00 06/30/10 92507GN 92507GN 92507GN 95.42 013 0440 4306
16320027 DYSPHAG/FEED TX/15MIN/0-20YRS 373.00 06/30/10 92526GN 92526GN 92526GN 99.99 013 0440 4306
16320028 VOICE THERA/INDIV/15MN/0-20YRS 251.00 06/30/10 92507GN 92507GN 92507GN 95.42 013 0440 4306
16320029 LARYN FUNC STUDY/15MIN/0-20YRS 105.00 06/30/10 92520GN 92520GN 92520GN 89.7 013 0440 4306
16320030 MD EVL LRYNX W/STRB/15M/0-20YR 272.00 06/30/10 92520GN 92520GN 92520GN 89.04 013 0444 4306
16320031 NASAL FUNC STUDY/15MIN/0-20YRS 293.00 06/30/10 92512GN 92512GN 92512GN 89.7 013 0510 4306
16320035 SPEAKING VALVE 272.00 06/30/10 L8501 L8501 L8501 013 0274 4306
16320190 MOD VX PRS/AG DV/30MIN 175.00 06/30/10 92507GN 92507GN 92507GN 93.24 93.24 013 0440 4306
16320193 MOD VX PRS/AG DV/ 60MIN 346.00 06/30/10 92507GN 92507GN 92507GN 93.24 93.24 013 0440 4306
17010001 FINE NEEDLE ASPIR SUPERFIC TIS 220.00 06/30/10 10021 10021 10021 013 0361 4523
17010002 FINE NEEDLE ASPIR DEEP TISSUE 221.00 06/30/10 10022 10022 10022 013 0361 4523
17010005 CYTOPATHOLOGY SCREEN/INTERPRET 194.00 06/30/10 88160 88160 88160 013 0311 4523
17010011 CYTOPATHOLGY SMEARS W/INTERPRT 173.00 06/30/10 88104 88104 88104 013 0311 4523
17010014 CYTOPATH CONC TECH SMEARS/INT 122.00 06/30/10 88108 88108 88108 013 0311 4523
17010021 CORNEAL EPITHELIAL SCRAPING 98.00 06/30/10 88304 88304 88304 013 0310 4523
17010022 UNSTAINED SLIDES FOR ANALYSIS 74.00 06/30/10 88399 88399 88399 013 0310 4523
17010023 REVERSING A BLOCK 74.00 06/30/10 88399 88399 88399 013 0310 4523
17010024 HAND PROCESSING PER SPECIMEN 74.00 06/30/10 88399 88399 88399 013 0310 4523
17010025 RECUT SLIDES/LEVELS/SERIAL SEC 74.00 06/30/10 88399 88399 88399 013 0310 4523
17010041 LEVEL 1 GROSS EXAM ONLY 43.00 06/30/10 88300 88300 88300 013 0310 4523
17010042 LEVEL 2 GROSS & MICROSCOP EXAM 118.00 06/30/10 88302 88302 88302 013 0310 4523
17010043 LEVEL 3 GROSS & MICROSCOP EXAM 136.00 06/30/10 88304 88304 88304 013 0310 4523
17010044 LEVEL 4 GROSS & MICROSCOP EXAM 246.00 06/30/10 88305 88305 88305 013 0310 4523
17010045 LEVEL 5 GROSS & MICROSCOP EXAM 491.00 06/30/10 88307 88307 88307 013 0310 4523
17010046 LEVEL 6 GROSS & MICROSCOP EXAM 388.00 06/30/10 88309 88309 88309 013 0310 4523
17010051 ADD'L CHARGE- EMERGENCY BLOCK 74.00 06/30/10 88399 88399 88399 013 0310 4523
17010055 DECALCIFICATION PROCEDURE 26.00 06/30/10 88311 88311 88311 013 0310 4523
17010061 PATHOLOGY CONSULT DURING SURG N/C 06/30/10 88329 88329 88329 013 0310 4523
17010062 PATH CONSULT W/FROZEN SECTION 186.00 06/30/10 88331 88331 88331 013 0310 4523
17010063 PATH CONSLT TIS BL W/FROZ SECT 68.00 06/30/10 88332 88332 88332 013 0310 4523
17010067 ELECTRON MICROSCOPY DIAGNOSTIC 948.00 06/30/10 88348 88348 88348 013 0310 4523
17010071 SPCL STN;GRP I MICRORGNSM EA 143.00 06/30/10 88312 88312 88312 013 0310 4523
17010072 SPL STN;GRP 2 ALL BUT IC/IP EA 36.00 06/30/10 88313 88313 88313 013 0310 4523
17010075 IMMUNOHISTOCHEM;EA ANTIBODY 194.00 06/30/10 88342 88342 88342 013 0310 4523
40101910 DROPERIDOL 2.5MG/ML VIAL 45.00 06/30/10 013 0254 3309
40101913 KETAMINE 100MG/ML 20.00 06/30/10 013 0250 3309
40101914 ROBINUL .2MG/ML-4 ML VIAL 43.00 06/30/10 013 0254 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 173
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

93780834 OFFICE EMERGENCY-DR. 18.00 $ 08/10/08 99058 99058 99058 013 0983 4502
02500161 DEBRIDE SKIN PART THICK-M.D. 59.00 $ 06/30/09 11040 11040 11040 014 0975 1910
04002451 CRYOPPT-PROC 98.00 06/30/10 P9012 P9012 P9012 014 0390 2670
04016063 BLOOD ADMIN CHARGE 140.00 06/30/10 36430 36430 36430 014 0391 2670
04016238 FRESH FROZ.PL.PROC 207.00 06/30/10 P9017 P9017 P9017 014 0390 2670
04016279 PLT.CONC.-PROC. 235.00 06/30/10 P9019 P9019 P9019 014 0390 2670
04016295 RBC PACKED-PROC 377.00 06/30/10 P9021 P9021 P9021 014 0390 2670
04016303 RBC FROZ-DEGLYC PROC 539.00 06/30/10 P9039 P9039 P9039 014 0390 2670
04016311 RHO(D) IG PROC 517.00 06/30/10 J2790 J2790 J2790 014 0636 2670
04016428 BLOOD,PEDS-PROC 155.00 06/30/10 P9011 P9011 P9011 014 0390 2670
04056465 RBC WASH-PACK PROC 385.00 06/30/10 P9022 P9022 P9022 014 0390 2670
04077024 WHOLE BLOOD PROC. 453.00 06/30/10 P9010 P9010 P9010 014 0390 2670
04078156 AUTOLOGOUS DONOR PROCESSING 762.00 06/30/10 86890 86890 86890 014 0390 2670
04078170 PLATELETS, PHERESIS 1893.00 06/30/10 P9034 P9034 P9034 014 0390 2670
04078218 RBC LEUKOREDUCED,IRRAD 741.00 06/30/10 P9040 P9040 P9040 014 0390 2670
04088543 FRESH FROZ.PL.(8-24HR) PROC 232.00 06/30/10 P9059 P9059 P9059 014 0390 2670
08900012 E-R BLOOD TRANSFUSION 94.00 06/30/10 36430 36430 36430 014 0391 6812
11050226 TETANUS TOXOID 38.00 06/30/10 90703 90703 90703 014 0636 0612
11060226 TETANUS TOXOID 38.00 06/30/10 90703 90703 90703 014 0636 0612
11900100 INTENSIVE O/P PSYCH-PER DIEM 601.00 06/30/10 S9480 S9480 015 0913 0519
11900121 GROUP THERAPY 15 MIN 66.00 06/30/10 90853 90853 90853 015 0915 0519
11900122 GROUP THERAPY 20 MIN 47.00 06/30/10 90853 90853 90853 015 0915 0519
11900123 GROUP THERAPY 30 MIN 119.00 06/30/10 90853 90853 90853 015 0915 0519
11900124 GROUP THERAPY 45 MIN 182.00 06/30/10 90853 90853 90853 015 0915 0519
11900125 GROUP THERAPY 60 MIN 235.00 06/30/10 90853 90853 90853 015 0915 0519
11900126 GROUP THERAPY 75 MIN 299.00 06/30/10 90853 90853 90853 015 0915 0519
11900127 GROUP THERAPY 90 MIN 363.00 06/30/10 90853 90853 90853 015 0915 0519
11900132 PSYCHOED GROUP 15MIN 82.00 06/30/10 90853 G0177 90853 00.53 015 0900 0519
11900133 PSYCHOED GROUP 30MIN 149.00 06/30/10 90853 G0177 90853 015 0900 0519
11900134 EDUCATION/TRAINING 45 MIN 173.00 06/30/10 90853 G0177 90853 015 0900 0519
11900135 PSYCHOED GROUP 60MIN 294.00 06/30/10 90853 G0177 90853 015 0900 0519
11900136 PSYCHOED GROUP 75MIN 373.00 06/30/10 90853 G0177 90853 015 0900 0519
11900137 PSYCHOED GROUP 90MIN 342.00 06/30/10 90853 G0177 90853 015 0900 0519
11900138 PSYCHOED GROUP 105MIN 404.00 06/30/10 90853 G0177 90853 015 0900 0519
11900139 PSYCHOED GROUP 120MIN 464.00 06/30/10 90853 G0177 90853 015 0900 0519
11900141 ACTIVITY THERAPY 15 MIN 49.00 06/30/10 90889 G0176 90889 015 0904 0519
11900142 ACTIVITY THERAPY 20 MIN 46.00 06/30/10 90889 G0176 90889 015 0904 0519
11900143 ACTIVITY THERAPY 30 MIN 95.00 06/30/10 90889 G0176 90889 015 0904 0519
11900144 ACTIVITY THERAPY 45 MIN 143.00 06/30/10 90889 G0176 90889 015 0904 0519
11900145 ACTIVITY THERAPY 60 MIN 188.00 06/30/10 90889 G0176 90889 015 0904 0519
11900146 ACTIVITY THERAPY 75 MIN 235.00 06/30/10 90889 G0176 90889 015 0904 0519
11900147 ACTIVITY THERAPY 90 MIN 281.00 06/30/10 90889 G0176 90889 015 0904 0519
11900148 ACTIVITY THERAPY 105 MIN 328.00 06/30/10 90889 G0176 90889 015 0904 0519
11900149 ACTIVITY THERAPY 120 MIN 374.00 06/30/10 90889 G0176 90889 015 0904 0519
11900150 ACTIVITY THERAPY 150 MIN 467.00 06/30/10 90889 G0176 90889 015 0904 0519
11900151 ACTIVITY THERAPY 180 MIN 561.00 06/30/10 90889 G0176 90889 015 0904 0519
11900152 ACTIVITY THERAPY 210 MIN 654.00 06/30/10 90889 G0176 90889 015 0904 0519
11900160 PHARMD ASSMT/TX 109.00 06/30/10 90899 90899 90899 015 0900 0519
11900211 INDIV THERAPY (PHD) 30 MIN 98.00 06/30/10 90816 90816 90816 015 0914 0519
11900220 FAMILY THERAPY 90 MIN 502.00 06/30/10 90847 90847 90847 94.42 015 0916 0519
11900225 INTRPT/EXPLAN RESULT EXAM/DATA 119.00 06/30/10 90887 90887 90887 015 0900 0519
11900230 OT COGNTVE/SI SK DEV GRP 30MIN 198.00 06/30/10 G0129 G0129 93.83 015 0430 0519
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 174
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11900231 OT COGNTVE/SI SK DEV GRP 45MIN 302.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900232 OT COGNTVE/SI SK DEV GRP 60MIN 375.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900233 OT COGNTVE/SI SK DEV GRP 75MIN 504.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900234 OT COGNTVE/SI SK DEV GRP 90MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900235 OT COG/SK DEV IND 30 MIN 179.00 06/30/10 97532 G0129 G0129 93.83 015 0430 0519
11900236 OT COG/SK DEV IND 45 MIN 261.00 06/30/10 97532 G0129 G0129 93.83 015 0430 0519
11900237 OT COG/SK DEV IND 60 MIN 345.00 06/30/10 97532 G0129 G0129 93.83 015 0430 0519
11900238 OT COGNTVE/SI SK DEV IND 75MIN 504.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900239 OT COGNTVE/SI SK DEV IND 90MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900241 OT COMM/WORK/AVOC GROUP 30 MIN 198.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900242 OT COMM/WORK/AVOC GROUP 45 MIN 302.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900243 OT COMM/WORK/AVOC GROUP 60MIN 375.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900244 OT COMM/WORK/AVOC GROUP 75MIN 504.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900245 OT COMM/WORK/AVOC GROUP 90MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900246 OT COMM/WORK/REIN IND 30 MIN 179.00 06/30/10 97537 G0129 G0129 93.83 015 0430 0519
11900247 OT COMM/WORK/REIN IND 45 MIN 261.00 06/30/10 97537 G0129 G0129 93.83 015 0430 0519
11900248 OT COMM/WORK/REIN IND 60 MIN 345.00 06/30/10 97537 G0129 G0129 93.83 015 0430 0519
11900249 OT COMM/WORK/REIN IND 75 MIN 345.00 06/30/10 97537 G0129 G0129 93.83 015 0430 0519
11900250 OT COMM/WORK/REIN IND 90 MIN 510.00 06/30/10 97537 G0129 G0129 93.83 015 0430 0519
11900255 OT EVAL 15 MIN 95.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900256 OT EVAL 30 MIN 198.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900257 OT EVAL 90 MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900261 OT FUNC PERFORMANCE GRP 30 MIN 198.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900262 OT FUNC PERFORMANCE GRP 45 MIN 302.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900264 OT FUNC PERFORMANCE GRP 75 MIN 504.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900266 OT PERF TRN IND 30 MIN 179.00 06/30/10 97530 G0129 G0129 93.83 015 0430 0519
11900267 OT PERF TRN IND 45 MIN 261.00 06/30/10 97530 G0129 G0129 93.83 015 0430 0519
11900268 OT PERF TRN IND 60 MIN 345.00 06/30/10 97530 G0129 G0129 93.83 015 0430 0519
11900269 OT FUNC PERFORMANCE IND 75 MIN 504.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900270 OT FUNC PERFORMANCE IND 90 MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900275 OT RE-EVAL 15 MIN 95.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900276 OT RE-EVAL 30 MIN 198.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900277 OT RE-EVAL 90 MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900280 OT SELF CARE/HME MGT GRP 30MIN 198.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900281 OT SELF CARE/HME MGT GRP 45MIN 302.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900282 OT SELF CARE/HME MGT GRP 60MIN 375.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900283 OT SELF CARE/HME MGT GRP 75MIN 504.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900284 OT SELF CARE/HME MGT GRP 90MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900285 OT SELF CARE/HME MGT IND 30MIN 179.00 06/30/10 97535 G0129 G0129 93.83 015 0430 0519
11900286 OT SELF CARE/HME MGT IND 45MIN 261.00 06/30/10 97535 G0129 G0129 93.83 015 0430 0519
11900287 OT SELF CARE/HME MGT IND 60MIN 375.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900288 OT SELF CARE/HME MGT IND 75MIN 504.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900289 OT SELF CARE/HME MGT IND 90MIN 582.00 06/30/10 G0129 G0129 93.83 015 0430 0519
11900295 PREP OF PT'S REPORT/STATUS 206.00 06/30/10 90889 90889 90889 015 0900 0519
11900300 FAMILY THERAPY 90MIN 502.00 06/30/10 90847 90847 90847 94.42 015 0916 0519
11900301 GROUP THERAPY 15 MIN-IOP 111.00 06/30/10 90853 90853 90853 94.43 015 0915 0519
11900302 GROUP THERAPY 20 MIN-IOP 147.00 06/30/10 90853 90853 90853 94.43 015 0915 0519
11900303 GROUP THERAPY 30 MIN-IOP 219.00 06/30/10 90853 90853 90853 94.43 015 0915 0519
11900304 GROUP THERAPY 45 MIN-IOP 325.00 06/30/10 90853 90853 90853 94.43 015 0915 0519
11900305 GROUP THERAPY 60 MIN-IOP 433.00 06/30/10 90853 90853 S9480 94.43 015 0915 0519
11900306 GROUP THERAPY 75 MIN-IOP 541.00 06/30/10 90853 90853 90853 94.43 015 0915 0519
11900307 GROUP THERAPY 90 MIN-IOP 647.00 06/30/10 90853 90853 90853 94.43 015 0915 0519
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 175
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11900311 INDIV THERAPY 30 MIN-IOP 85.00 06/30/10 90816 90816 90816 94.45 015 0914 0519
11900312 INDIV THERAPY 45 MIN-IOP 130.00 06/30/10 90818 90818 90818 94.45 015 0914 0519
11900313 INDIV THERAPY 60 MIN-IOP 170.00 06/30/10 90818 90818 90818 94.45 015 0914 0519
11900316 INTERP/EXPN RSLTS EXM/DATA-IOP 119.00 06/30/10 90887 90887 90887 015 0900 0519
11900321 OT COGTVE/SI SK DV GP 15MN-IOP 55.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900322 OT COGTVE/SI SK DV GP 30MN-IOP 79.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900323 OT COGTVE/SI SK DV GP 45MN-IOP 116.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900324 OT COGTVE/SI SK DV GP 60MN-IOP 154.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900325 OT COGTVE/SI SK DV GP 75MN-IOP 154.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900326 OT COGTVE/SI SK DV GP 90MN-IOP 230.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900327 OT CGTVE/SI SK DV IND 15MN-IOP 100.00 06/30/10 97532 97532 97532 93.83 015 0430 0519
11900331 OT COMM/WORK/AVOC GRP 15MN-IOP 55.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900332 OT COMM/WORK/AVOC GRP 30MN-IOP 79.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900333 OT COMM/WORK/AVOC GRP 45MN-IOP 116.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900334 OT COMM/WORK/AVOC GRP 60MN-IOP 154.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900335 OT COMM/WORK/AVOC GRP 75MN-IOP 154.00 06/30/10 97150 97150 97150 94.43 015 0430 0519
11900336 OT COMM/WORK/AVOC GRP 90MN-IOP 230.00 06/30/10 97150 97150 97150 94.43 015 0430 0519
11900337 OT COMM/WORK/AVOC IND 15MN-IOP 43.00 06/30/10 97537 97537 97537 94.43 015 0430 0519
11900341 OT EVAL 15 MIN-IOP 88.00 06/30/10 97003 97003 97003 94.43 015 0430 0519
11900342 OT EVAL 30 MIN 258.00 06/30/10 97003 97003 97003 94.43 015 0430 0519
11900343 OT EVAL 60 MIN 258.00 06/30/10 97003 97003 97003 94.43 015 0430 0519
11900344 OT EVAL 90 MIN-IOP 517.00 06/30/10 97003 97003 97003 94.43 015 0430 0519
11900345 OT EVAL 45 MIN 258.00 06/30/10 97003 97003 97003 015 0430 0519
11900351 OT GROUP- 15 MIN 82.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900352 OT GROUP- 30 MIN 149.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900353 OT GROUP- 45 MIN 228.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900354 OT GROUP- 60 MIN 294.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900355 OT GROUP- 75 MIN 373.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900356 OT GROUP 90MIN 453.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900357 OT FUNC PERFM INDIV 15 MIN-IOP 70.00 06/30/10 97530 97530 97530 93.83 015 0430 0519
11900361 OT RE-EVAL 15 MIN-IOP 44.00 06/30/10 97004 97004 97004 93.83 015 0430 0519
11900362 OT RE-EVAL 30 MIN 149.00 06/30/10 97004 97004 97004 93.83 015 0430 0519
11900363 OT RE-EVAL 60 MIN-IOP 149.00 06/30/10 97004 97004 97004 93.83 015 0430 0519
11900364 OT RE-EVAL 90 MIN-IOP 247.00 06/30/10 97004 97004 97004 93.83 015 0430 0519
11900365 OT RE-EVAL 45 MIN 149.00 06/30/10 97004 97004 97004 015 0430 0519
11900371 OT SLF CRE/HME MGM GP 15MN-IOP 55.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900372 OT SLF CRE/HME MGM GP 30MN-IOP 79.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900373 OT SLF CRE/HME MGM GP 45MN-IOP 116.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900374 OT SLF CRE/HME MGM GP 60MN-IOP 154.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900375 OT SLF CRE/HME MGM GP 75MN-IOP 154.00 06/30/10 97150 97150 97150 93.38 015 0430 0519
11900376 OT SLF CRE/HME MGM GP 90MN-IOP 230.00 06/30/10 97150 97150 97150 93.83 015 0430 0519
11900378 OT SLF CRE/HME MGM IND15MN-IOP 58.00 06/30/10 97535 97535 97535 93.83 015 0430 0519
11900380 PREPARE PT'S REPORT/STATUS 77.00 06/30/10 90889 90889 90889 015 0900 0519
11900385 OT EVAL 60 MIN 237.00 06/30/10 G0129GO 97003GO 93.83 015 0434 0519
11900387 OT RE-EVAL 60 MIN 237.00 06/30/10 G0129GO 97004GO 93.83 015 0434 0519
11900391 OT FUNC PERFORM INDIV 15 MIN 94.00 06/30/10 G0129GO 97530GO 93.83 015 0430 0519
11900393 OT FUNC PERFORM GROUP 15 MIN 173.00 06/30/10 G0129GO 97530GO 93.83 015 0430 0519
11900394 OT SLF CARE/HME MGMT IND 15MIN 95.00 06/30/10 97535 G0129 G0129 93.83 015 0430 0519
11900395 OT SLF CARE/HME MGMT GRP 15MIN 173.00 06/30/10 G0129GO 97535GO 93.83 015 0430 0519
11900396 OT COMM/WORK/AVOC INDIV 15 MIN 94.00 06/30/10 G0129GO 97537GO 94.43 015 0430 0519
11900397 OT COMM/WORK/AVOC GROUP 15 MIN 173.00 06/30/10 G0129GO 97537GO 93.83 015 0430 0519
11900398 OT COGNTVE/SI SK DEV IND 15MIN 94.00 06/30/10 G0129GO G0129GO 93.83 015 0430 0519
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 176
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11900399 OT COGNTVE/SI SK DEV GRP 15MIN 173.00 06/30/10 G0129GO G0129GO 93.83 015 0433 0519
11900400 FAMILY THERAPY 30 MIN 169.00 06/30/10 90847 90847 90847 015 0916 0519
11900401 FAMILY THERAPY 45 MIN 238.00 06/30/10 90847 90847 90847 94.42 015 0916 0519
11900402 FAMILY THERAPY 60 MIN 285.00 06/30/10 90847 90847 90847 94.42 015 0916 0519
11900403 FAMILY THERAPY 75 MIN 344.00 06/30/10 90847 90847 90847 0.53 015 0916 0519
11900411 INDIV THERAPY 20-30 MIN 126.00 06/30/10 90804 90804 90804 94.39 015 0914 0519
11900412 INDIV THERAPY 45-50 MIN 178.00 06/30/10 90806 90806 90806 94.39 015 0914 0519
11900413 INDIV THERAPY 75-80 MIN 257.00 06/30/10 90808 90808 90808 94.39 015 0914 0519
11900501 GROUP THERAPY 30MIN-IOP 119.00 06/30/10 90853 90853 90853 015 0915 0519
11900504 GROUP THERAPY-45 MIN-IOP 182.00 06/30/10 90853 90853 90853 015 0915 0519
11900507 GROUP THERAPY-60 MIN-IOP 235.00 06/30/10 90853 90853 90853 015 0915 0519
11900511 PSYCHOED GROUP30 MIN-IOP 119.00 06/30/10 90853 90853 90853 015 0915 0519
11900514 PSYCHOED GROUP-45 MIN-IOP 182.00 06/30/10 90853 90853 90853 015 0915 0519
11900517 PSYCHOED GROUP-60 MIN-IOP 235.00 06/30/10 90853 90853 90853 015 0915 0519
11900521 ACTIVITY THERAPY 30 MIN-IOP 95.00 06/30/10 90853 90853 90853 015 0900 0519
11900524 ACTIVITY THERAPY 45 MIN-IOP 144.00 06/30/10 90853 90853 90853 015 0915 0519
11900527 ACTIVITY THERAPY 60 MIN-IOP 190.00 06/30/10 90853 90853 90853 015 0915 0519
11900530 ACTIVITY THERAPY 240 MIN-IOP 659.00 06/30/10 90853 90853 90853 015 0915 0519
11900541 OT GROUP 30 MIN-IOP 119.00 06/30/10 90853 90853 90853 015 0915 0519
11900544 OT GROUP 45 MIN-IOP 182.00 06/30/10 90853 90853 90853 015 0915 0519
11900547 OT GROUP 60 MIN-IOP 235.00 06/30/10 90853 90853 90853 015 0915 0519
11900551 GROUP THERAPY 105 MIN 429.00 06/30/10 90853 90853 90853 015 0915 0519
11900554 GROUP THERAPY 120 MIN 492.00 06/30/10 90853 90853 90853 015 0915 0519
11900561 INTERACTIVE GROUP THERAPY 15MN 65.00 06/30/10 90857 90857 90857 015 0915 0519
11900564 INTERACTIVE GROUP THERAPY 30MN 118.00 06/30/10 90857 90857 90857 015 0915 0519
11900567 INTERACTIVE GROUP THERAPY 45MN 181.00 06/30/10 90857 90857 90857 015 0915 0519
11900570 INTERACTIVE GROUP THERAPY 60MN 234.00 06/30/10 90857 90857 90857 015 0915 0519
11900573 INTERACTIVE GROUP THERAPY 75MN 296.00 06/30/10 90857 90857 90857 015 0915 0519
11900576 INTERACTIVE GROUP THERAPY 90MN 360.00 06/30/10 90857 90857 90857 015 0915 0519
11900611 OT GROUP 105MIN 535.00 06/30/10 97150 97150 97150 015 0430 0519
11900613 MEDADMIN 15-20 MIN 132.00 06/30/10 90862 90862 90862 015 0900 0519
11900614 OT GROUP 120MIN 614.00 06/30/10 97150 97150 97150 015 0430 0519
11900617 OT GROUP 135MIN 693.00 06/30/10 97150 97150 97150 015 0430 0519
11900631 MEDADMIN 15-20 MIN 132.00 06/30/10 90862 90862 90862 015 0900 0519
11900632 MEDADMIN-30 MIN 211.00 06/30/10 90862 90862 90862 015 0900 0519
11900641 IT EVAL/MGMT 20-30 MIN 179.00 06/30/10 90805 90805 90805 015 0914 0519
11900644 IT EVAL/MGMT 45-50 MIN 286.00 06/30/10 90807 90807 90807 015 0914 0519
11900647 IT EVAL/MGMT 75-80 MIN 308.00 06/30/10 90809 90809 90809 015 0914 0519
11900650 DIAGNOSTIC EVALUATION 263.00 06/30/10 90809 90809 90809 015 0900 0519
11900660 CASE MGMT (UNSPEC SERVICES) 77.00 06/30/10 90899 90899 90899 015 0900 0519
11900665 NURSING ASSMT (UNSPEC SERVCES) 109.00 06/30/10 90899 90899 90899 015 0900 0519
11900670 TEAM 84.00 06/30/10 99366 99366 99366 015 0513 0519
11900680 OT PHYS PERF TEST AMPS 30 MIN 198.00 06/30/10 97001 97001 97001 015 0420 0519
11900683 OT PHYS PERF TEST AMPS 45 MIN 289.00 06/30/10 97001 97001 97001 015 0420 0519
11900686 OT PHYS PERF TEST AMPS 60 MIN 382.00 06/30/10 97001 97001 97001 015 0420 0519
11900690 OT THERAPEUTIC EX IND 15MIN 120.00 06/30/10 97110 97110 97110 015 0430 0519
11900693 OT THERAPEUTIC EX IND 30MIN 225.00 06/30/10 97110 97110 97110 015 0430 0519
11910001 PSYCH DIAG INTERVIEW EXAM 135.00 06/30/10 90801 90801 90801 015 0900 0517
11910004 PSYCH DIAG INTERACTIVE INT EXM 121.00 06/30/10 90802 90802 90802 015 0900 0517
11910006 IND PSYC THERAPY 20-30 MIN OP 81.00 06/30/10 90804 90804 90804 015 0900 0517
11910011 IND PSYC W/MED EVAL 20-30 MIN 97.00 06/30/10 90805 90805 90805 015 0900 0517
11910016 IND PSYCHOTHERAPY 45-50 MIN 121.00 06/30/10 90806 90806 90806 015 0900 0517
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 177
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11910021 IND PSY THRPY W/MED EVAL 45-50 163.00 06/30/10 90807 90807 90807 015 0900 0517
11910026 IND PSYCHOTHERAPY 75-80 MIN 121.00 06/30/10 90808 90808 90808 015 0900 0517
11910031 IND PSY THRPY W/MED EVAL 75-80 121.00 06/30/10 90809 90809 90809 015 0900 0517
11910036 PSYCHOANALYSIS 121.00 06/30/10 90845 90845 90845 015 0900 0517
11910041 FAMILY PSYCH THRPY W/O PATIENT 141.00 06/30/10 90846 90846 90846 015 0900 0517
11910046 FAMILY PSYCH THRPY W/ PATIENT 189.00 06/30/10 90847 90847 90847 015 0900 0517
11910051 MULTIPLE-FAMILY GROUP 81.00 06/30/10 90849 90849 90849 015 0900 0517
11910056 GROUP PSYCHOTHERAPY 82.00 06/30/10 90853 90853 90853 015 0900 0517
11910061 PHARMACOLOGIC MANAGEMENT 87.00 06/30/10 90862 90862 90862 015 0900 0517
11910071 PSYCH EVAL HOSP RECORD TO DIAG 79.00 06/30/10 90885 90885 90885 015 0900 0517
11910076 INTERPRET RESULTS-PSYCH EXAMS 79.00 06/30/10 90887 90887 90887 015 0900 0517
11910081 PREPARE REPORT-PSYCH STATUS 79.00 06/30/10 90889 90889 90889 015 0900 0517
11910086 UNLISTED PSYCH SRVCE PR PROCED 284.00 06/30/10 90899 90899 90899 015 0900 0517
11910090 NEUROBEHAVIOR STATUS EXAM 146.00 06/30/10 96116 96116 96116 015 0918 0517
11910111 TELEPHONE CALL - SIMPLE/BRIEF 92.00 06/30/10 99441 99441 99441 015 0960 0517
11910116 TELEPHONE CALL - INTERMEDIATE 92.00 06/30/10 99442 99442 99442 015 0960 0517
11910121 TELEPHONE CALL-COMPLEX/LENGTHY 92.00 06/30/10 99442 99442 99442 015 0960 0517
11910126 OFFC VST NEW LVL1 100.00 06/30/10 99201 99201 99201 015 0510 0517
11910127 OFFC VST NEW LVL2 120.00 06/30/10 99202 99202 99202 015 0510 0517
11910128 OFFC VST NEW LVL3 155.00 06/30/10 99203 99203 99203 015 0510 0517
11910129 OFFC VST NEW LVL 4 197.00 06/30/10 99204 99204 99204 015 0510 0517
11910130 OFFC VST NEW LVL5 225.00 06/30/10 99205 99205 99205 015 0510 0517
11910131 OFFC VST EST LVL1 100.00 06/30/10 99211 99211 99211 015 0510 0517
11910132 OFFC VST EST LVL2 120.00 06/30/10 99212 99212 99212 015 0510 0517
11910133 OFFC VST EST LVL3 155.00 06/30/10 99213 99213 99213 015 0510 0517
11910134 OFFC VST EST LVL4 197.00 06/30/10 99214 99214 99214 015 0510 0517
11910135 OFFC VST EST LVL5 225.00 06/30/10 99215 99215 99215 015 0510 0517
11910136 OFFC CONSULT LVL1 67.00 06/30/10 99241 99241 99241 015 0510 0517
11910137 OFFC CONSULT LVL2 80.00 06/30/10 99242 99242 99242 015 0510 0517
11910138 OFFC CONSULT LVL3 155.00 06/30/10 99213 99213 99213 015 0510 0517
11910139 OFFC CONSULT LVL4 110.00 06/30/10 99244 99244 99244 015 0510 0517
11910140 OFFC CONSULT LVL5 146.00 06/30/10 99245 99245 99245 015 0510 0517
11910150 PSYCH TEST BY PSYCH-PHYS 146.00 06/30/10 96101 96101 96101 015 0918 0517
11910153 PSYCH TEST BY TECHNICIAN 235.00 06/30/10 96102 96102 96102 015 0918 0517
11910156 PSYCH TST ADMIN BY COMPUT 146.00 06/30/10 96103 96103 96103 015 0918 0517
11910159 NEUROPSY TST -PSYC-PHYS PER HR 166.00 06/30/10 96118 96118 96118 015 0918 0517
11910162 NEUROPSYTST-TECHN PER HOUR 235.00 06/30/10 96119 96119 96119 015 0918 0517
11910165 NEUROPSY TST ADMIN W/COMP 146.00 06/30/10 96120 96120 96120 015 0918 0517
11910175 HLT/BEHAV ASSES-15 MIN-INIT 59.00 06/30/10 96150 96150 96150 015 0900 0517
11910176 HLT/BEHA ASSE-15 MIN-RE-ASSES 59.00 06/30/10 96151 96151 96151 015 0900 0517
11910177 HLT/BEHAV INTERV-15 MIN-INDIV 59.00 06/30/10 96152 96152 96152 015 0900 0517
11910178 HLT/BEHAV INTERV-15 MIN-GROUP 41.00 06/30/10 96153 96153 96153 015 0900 0517
11910179 HLT/BEHAV INTERV-15 MIN-FAMILY 59.00 06/30/10 96154 96154 96154 015 0900 0517
11910200 IT INTERACTIVE 20-30 MINUTES 81.00 06/30/10 90810 90810 90810 015 0900 0517
11910203 IT EM INTERACTIVE 20-30 MIN 81.00 06/30/10 90811 90811 90811 015 0900 0517
11910206 IT INTERACTIVE 45-50 MINUTES 121.00 06/30/10 90812 90812 90812 015 0900 0517
11910209 IT EM INTERACTIVE 45-50 MIN 121.00 06/30/10 90813 90813 90813 015 0900 0517
11910212 IT INTERACTIVE 75-80 MINUTES 121.00 06/30/10 90814 90814 90814 015 0900 0517
11910215 IT EM INTERACTIVE 75-80 MIN 121.00 06/30/10 90815 90815 90815 015 0900 0517
11910218 OFFIC VST MONIT/CHANGE RX 303.00 06/30/10 M0064 M0064 M0064 015 0510 0517
11910221 ELE ANALY IMP NROSTM;W/O REPRG 144.00 06/30/10 95970 95970 95970 015 0510 0517
17120913 DESTRUCT MAC DRUSEN-HOSP 1983.00 06/30/10 015 0510 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 178
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44014520 INCONTNENT GARMENT,ANY TYPE,EA EXTERNAL 07/01/07 A4520 A4520 A4520 015 0270 5011
91600001 VID EXTERNAL 03/01/04 94.44 015 0961 9999
91600009 VOID EXTERNAL 03/01/04 94.44 015 0961 9999
01410001 ECG 12 LEADS-ADLT 207.00 06/30/10 93005 93005 93005 016 0730 2805
01410002 ECG 12 LEADS-PEDS 207.00 06/30/10 93005 93005 93005 016 0730 2805
04002620 2009 H1N1 SWINE FLU A N/C E 06/30/10 016 0301 2651
04010780 AMPLIFICATION,EACH 83.00 C 06/30/10 8389891 8389891 8389891 016 0301 2608
04010854 LGV DIFFERENTIATION AB #4 91.00 C 06/30/10 8663191 8663191 8663191 016 0302 2608
04010900 RESP DIS PAN REG 8 N/C E 06/30/10 016 0302 2608
04010911 CAT EPI, DANDER ALLERGEN 11.00 C 06/30/10 8600391 8600391 8600391 016 0300 2608
04018560 B&T CELL CLONALITY BY PCR N/C 06/30/10 016 0301 2608
04035870 EGFR MUTATION N/C E 06/30/10 016 0300 2651
08521930 AFO CUSTOM FITTED PLASTIC EXTERNAL 12/01/90 L1930 L1930 L1930 016 0270 4201
08526000 PART HAND THUMB REMAINING EXTERNAL 12/01/90 L6000 L6000 L6000 016 0270 4201
12000232 MUSCLE TESTING (HAND)-M.D. 32.00 $ 06/30/09 95832 95832 95832 016 0983 0520
18210300 FISH, PRENATAL N/C E 06/30/10 016 0310 4605
19924402 OFFC CONSULT LVL4-DOCTOR 331.00 $ 06/30/09 99244 99244 99244 016 0983 0599
41560001 ECG 12 LEADS-ADULT 207.00 06/30/10 93005 93005 93005 89.52 89.52 016 0730 3306
41560002 ECG 12 LEADS-PEDIATRIC 207.00 06/30/10 93005 93005 93005 89.52 89.52 016 0730 3306
41560003 ECG PORTABLE-ADULT 207.00 06/30/10 93005 93005 93005 89.52 89.52 016 0730 3306
41560004 ECG PORTABLE-PEDIATRIC 207.00 06/30/10 93005 93005 93005 89.52 89.52 016 0730 3306
41560005 HOLTER MONITOR TEST 562.00 06/30/10 93225 93225 93225 89.50 89.50 016 0731 3306
41560006 ECG 1 LEAD RHYTHM STRIP 71.00 06/30/10 93041 93041 93041 89.52 016 0730 3306
41560007 SIGNAL AVERAGED ECG 429.00 06/30/10 93278 93278 93278 89.59 016 0730 3306
41560008 EVENT MONITOR HOOK-UP 386.00 06/30/10 93270 93270 93270 016 0730 3306
41560009 ECG-24HR W/SCAN ANALY W/REPORT 866.00 06/30/10 93226 93226 93226 016 0731 3306
01700091 SUCTION OF ARTIFICIAL AIRWAY N/C 06/30/10 017 0410 5301
01700098 HI-FLO HUMD O2 1ST DY(NEO/PED) 515.00 06/30/10 017 0270 5301
01700587 CO2 MONITOR INITIATION 326.00 06/30/10 94770 94770 94770 017 0460 5301
01700589 CO2 MONITOR SUBSEQUENT DAYS 631.00 06/30/10 94770 94770 94770 017 0460 5301
01700595 END TIDAL CO2 DETECTOR 104.00 06/30/10 017 0270 5301
01700597 AIRWAY MONITOR SETUP N/C 06/30/10 94762 94762 94762 017 0460 5301
01700600 AIRWAY MONITOR 1500-2300 103.00 06/30/10 94799 94799 94799 017 0460 5301
01700602 PULSE OXIMETRY INITIATION 956.00 06/30/10 94762 94762 94762 017 0460 5301
01700603 PULSE OXIMETRY SUBSEQUENT DAYS 836.00 06/30/10 94762 94762 94762 017 0460 5301
01700608 PULSE OXIMETRY SPOT CHECK 82.00 06/30/10 94760 94760 94760 017 0460 5301
01700610 RIBAVIRIN TX INITIATION 100.00 06/30/10 94664 94664 94664 017 0412 5301
01700611 RIBAVIRIN TX 211.00 06/30/10 94664 94664 94664 017 0412 5301
01700615 PULMONARY SCREENING 212.00 06/30/10 94060 94060 94060 017 0460 5301
01700621 ARTERIAL PUNCTURE 42.00 06/30/10 36600 36600 36600 017 0360 5301
01700624 HOME CARE INSTRUCTION /30 MIN 108.00 06/30/10 94799 94799 94799 017 0460 5301
01700632 PEAK FLOW MEASUREMENT 48.00 06/30/10 94010 94010 94010 017 0460 5301
01700701 CO2 MONITOR INITIATION/RE-INIT 343.00 06/30/10 94770 94770 94770 017 0460 5301
01700707 CO2 END TIDAL DETECTOR 87.00 06/30/10 017 0270 5301
01700711 AIRWAY MONITOR INITIATION 135.00 06/30/10 94799 94799 94799 017 0460 5301
01700713 AIRWAY MONITOR - SUBSQ DAY 103.00 06/30/10 94799 94799 94799 017 0460 5301
01700719 PULSE OXIMETRY INIATION/RE INI 294.00 06/30/10 94762 94762 94762 017 0460 5301
01700728 RIBIVARIN INIATION/RE-INIATION 100.00 06/30/10 94664 94664 94664 017 0412 5301
01700730 RIBIVARIN TREATMENT 159.00 06/30/10 017 0250 5301
01700732 PULMONARY SCREENING INITIATION N/C 06/30/10 94010 94010 94010 017 0460 5301
01700734 PULMONARY SCREENING PRE-TREAT N/C 06/30/10 94060 94060 94060 017 0460 5301
01700738 PEAK FLOW MEAUREMENT N/C 06/30/10 94010 94010 94010 017 0460 5301
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 179
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01700739 PEAK FLOWMETER EQUIPMENT 91.00 06/30/10 017 0270 5301
01700741 VENTI-MASK INITIAT/RE-INITIAT 82.00 06/30/10 017 0270 5301
01700743 VENTI-MASK 8 HOURS 81.00 06/30/10 017 0270 5301
01700745 MASK BIPAP/CPAP INITIAT/RE-INI 544.00 06/30/10 017 0270 5301
01700747 MASK BIPAP/CPAP -8 HOURS 344.00 06/30/10 017 0270 5301
01700753 "T" INITIATION/RE-INITIATION 126.00 06/30/10 017 0270 5301
01700756 "T" -8 HOURS 81.00 06/30/10 017 0270 5301
01700763 FACE TENT INITIATION/RE-INIT. 133.00 06/30/10 017 0270 5301
01700766 FACE TENT- 8 HOURS 85.00 06/30/10 017 0270 5301
01700769 TRACH COLLAR INITIA./RE-INIATI 126.00 06/30/10 017 0270 5301
01700770 TRACH COLLAR-8 HOURS 81.00 06/30/10 017 0270 5301
01700772 HOOD INITIATION/REINITIATION 180.00 06/30/10 017 0270 5301
01700774 HOOD-8 HOURS 74.00 06/30/10 017 0270 5301
01700776 HOOD REPLACEMENT 32.00 06/30/10 017 0270 5301
01700780 MASK W/RESERVOIR INIT/RE-INIT 100.00 06/30/10 017 0270 5301
01700782 MASK W/RESERVOIR - 8 HOURS 65.00 06/30/10 017 0270 5301
01700790 SUCTION CLOSED/OPEN INITIATION 73.00 06/30/10 017 0410 5301
01700792 RESUSCITATION KIT 180.00 06/30/10 017 0270 5301
01700800 MASK REPLACEMENT 23.00 06/30/10 017 0270 5301
01700803 SPUTUM INDUCT INITIAT/RE-INITI 124.00 06/30/10 94664 94664 94664 017 0412 5301
01700806 INCENTIVE SPIROMETRY INITIATIO 130.00 06/30/10 94010 94010 94010 017 0410 5301
01700821 IPPB INITIATION 68.00 06/30/10 93.91 017 0412 5301
01700823 IPPB TREATMENT 62.00 06/30/10 93.91 017 0412 5301
01700831 VENT MGMT INPAT, INIT DAY 653.00 06/30/10 94002 94002 94002 017 0412 5301
01700832 VENT MGMT PER 8 HOURS 257.00 06/30/10 94003 94003 94003 017 0412 5301
01700833 MECHANICAL VENTILATION CIRCUIT 86.00 06/30/10 017 0270 5301
01700835 HME 38.00 06/30/10 017 0270 5301
01700837 FILTER 38.00 06/30/10 017 0270 5301
01700840 VENT MGMT INPAT, INIT DAY-HFV 680.00 06/30/10 94002 94002 94002 017 0412 5301
01700841 VENT MGMT PER DAY-HFV 804.00 06/30/10 94004 94004 94004 017 0412 5301
01700843 MECH VENT HFV CIRCUIT 109.00 06/30/10 017 0270 5301
01700846 SIMPLE MASK INITIA./RE-INITIA 100.00 06/30/10 017 0270 5301
01700848 SIMPLE MASK- 8 HOURS 61.00 06/30/10 89.38 017 0270 5301
01700852 NASAL CANNULA INITIA/RE-INITIA 105.00 06/30/10 017 0270 5301
01700855 NASAL CANNULA-24 HOURS 106.00 06/30/10 017 0270 5301
01700858 CANNULA REPLACEMENT 10.00 06/30/10 017 0270 5301
01700862 AEROS MASK INITIATION/RE-INTIA 126.00 06/30/10 017 0270 5301
01700865 AEROS MASK - 8 HOURS 81.00 06/30/10 017 0270 5301
01700867 PENTAMIDINE INITIATION 196.00 06/30/10 94642 94642 94642 017 0412 5301
01700869 PENTAMIDINE TREATMENT 196.00 06/30/10 94642 94642 94642 017 0412 5301
01700871 SMALL VOL NEB TX INITIATION 91.00 06/30/10 94664 94664 94664 017 0412 5301
01700875 SMALL VOL NEB TX 113.00 06/30/10 9464076 9464076 9464076 017 0460 5301
01700877 SMALL VOLUME NEBULIZER 29.00 06/30/10 017 0270 5301
01700879 SMALL VOLUME NEBULIZER W/ FILT 41.00 06/30/10 017 0270 5301
01700881 AEROS TX CONTIN INITIA/RE-INIT 51.00 06/30/10 017 0270 5301
01700883 AEROSOL TX CONTINUOUS-8 HOURS 183.00 06/30/10 017 0270 5301
01700885 LARGE/MINI NEBULIZER 3.00 06/30/10 017 0270 5301
01700887 ULTRASONIC TX INITIA/RE-INITIA 98.00 06/30/10 94664 94664 94664 017 0410 5301
01700888 ULTRASONIC TX 132.00 06/30/10 94640 94640 94640 017 0412 5301
01700890 TENT INITIATION/RE-INITIATION 180.00 06/30/10 017 0270 5301
01700891 TENT-8 HOURS 81.00 06/30/10 017 0270 5301
01700893 TENT (CANOPY) 51.00 06/30/10 017 0270 5301
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 180
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01700895 NITRIC OXIDE INITIA/RE-INITIA. 523.00 06/30/10 017 0270 5301
01700897 NITRIC OXIDE - 8 HOURS 228.00 06/30/10 017 0270 5301
01700901 METERDOSE INHALER INITIATION 71.00 06/30/10 94664 94664 94664 017 0412 5301
01700903 METERDOSE INHALER SPACER INITI 71.00 06/30/10 94664 94664 94664 017 0460 5301
01700904 METERDOSE INHALER SPACER TX 54.00 06/30/10 94664 94664 94664 017 0460 5301
01700905 METERDOSE INHALER TX 69.00 06/30/10 94640 94640 94640 017 0460 5301
01700907 CLOSED SUCTION/INITIA-REINITIA N/C 06/30/10 017 0412 5301
01700910 TRANCUT MONITOR O2 INITIATION 265.00 06/30/10 94799 94799 94799 017 0460 5301
01700911 TRANSCUTANEOUS MONITOR-8 HOURS 150.00 06/30/10 94799 94799 94799 017 0460 5301
01700916 TRANCUTANEOUS MON CO2-8 HOURS 150.00 06/30/10 94799 94799 94799 017 0460 5301
01700921 VNT MGMT INPT,INIT DAY-RSP STM 156.00 06/30/10 94002 94002 94002 017 0412 5301
01700931 NASAL AIRWAY INITIATION 159.00 06/30/10 017 0270 5301
01700937 INTUBATION/EXTUBATION PROCEDUR 300.00 06/30/10 31500 31500 31500 017 0360 5301
01700939 HEATER 40.00 06/30/10 017 0270 5301
01700941 EVAL / INSTRUCTION-PER 30 MIN 144.00 06/30/10 94664 94664 94664 017 0410 5301
01700945 OXYGEN E-CYLINDER USE 126.00 06/30/10 017 0270 5301
01700950 DRY POWDER INHALER (DPI) INITI 71.00 06/30/10 94664 94664 94664 017 0412 5301
01700953 DRY POWDER INHALER (DPI) TX 65.00 06/30/10 94640 94640 94640 017 0412 5301
01700962 NASAL AIRWAY SUBSEQUENT DAYS 140.00 06/30/10 017 0270 5301
01700970 HIGH FLOW OXYGEN INITIATION 250.00 06/30/10 017 0270 5301
01700973 HIGH FLOW OXYGEN SUBSQ DAY 150.00 06/30/10 017 0270 5301
01700980 HIFLO HUM O2-1ST DAY(NEO/PED) 515.00 06/30/10 017 0270 5301
01700983 HIFLO HUM O2 SUBS DAY(NEO/PED) 277.00 06/30/10 017 0270 5301
01705201 SLP DISORDR SCRN W/O CPAP-INI 103.00 06/30/10 95806 95806 95806 017 0761 5301
01705202 SLP DISORDR SCRN W/O CPAP-8HR 250.00 06/30/10 95806 95806 95806 017 0761 5301
01705205 SLEEP DISORD SCRN CPAP-INIT 137.00 06/30/10 95806 95806 95806 017 0761 5301
01705206 SLEEP DISORD SCRN CPAP-8HR 386.00 06/30/10 95806 95806 95806 017 0761 5301
01706001 SLEEP DISORDER FACE MASK 114.00 06/30/10 017 0270 5301
01706004 SLEEP DISORDER NASAL MASK 114.00 06/30/10 017 0270 5301
01706007 SLEEP DISORDER NASAL PILLOW 142.00 06/30/10 017 0270 5301
01707000 AIRWAY CLEARANCE FLUTTER INITI 86.00 06/30/10 94667 94667 94667 017 0410 5301
01707003 AIRWY CLEARNCE FLTTR SUBS TX 68.00 06/30/10 94668 94668 94668 017 0410 5301
01707006 AIRWY CLRNCE ACAPELLA INITIAL 86.00 06/30/10 94667 94667 94667 017 0410 5301
01707009 AIRWAY CLRNCE ACAPELL SUBS TX 68.00 06/30/10 94668 94668 94668 017 0410 5301
01707012 VEST INITIATION 109.00 06/30/10 94667 94667 94667 017 0410 5301
01707015 VEST SUBSEQUENT TREATMENT 68.00 06/30/10 94668 94668 94668 017 0410 5301
01707018 LABOR & DELIVERY (1/2 HR.) 478.00 06/30/10 31500 31500 31500 017 0410 5301
01707021 SURFACTANT INSTALLATION 109.00 06/30/10 94610TC 94610TC 94610TC 017 0410 5301
01707024 CHEST P.T. INITIATION 60.00 06/30/10 94667 94667 94667 017 0410 5301
01707027 CHEST P.T. SUBSEQUENT TX 34.00 06/30/10 94668 94668 94668 017 0410 5301
01707030 RAPID RESPONSE CALL 239.00 06/30/10 94664 94664 94664 017 0410 5301
01707033 EVALUATION / INSTRUCTIONS 72.00 06/30/10 94664 94664 94664 017 0410 5301
01707036 SMOKING CESS SESS >10MIN 87.00 06/30/10 99407 99407 99407 017 0410 5301
01707039 ASTHMA INSTRUCTIONS 103.00 06/30/10 94799 94799 94799 017 0410 5301
01707921 VENTIMASK INITIATION 333.00 06/30/10 94640 94640 94640 017 0412 5301
01707922 VENTIMASK SUBSEQUENT DAY 136.00 06/30/10 94640 94640 94640 017 0412 5301
01707923 VENTIMASK 2300-0700 81.00 06/30/10 017 0270 5301
01707925 VENTIMASK 1500-2300 130.00 06/30/10 017 0270 5301
01707965 MASK BIPAP/CPAP INITIATION 957.00 06/30/10 017 0270 5301
01707966 MASK BIPAP/CPAP SUBSEQUENT DAY 931.00 06/30/10 017 0270 5301
01707967 MASK CPAP 2300-0700 326.00 06/30/10 017 0270 5301
01707968 MASK CPAP 0700-1500 326.00 06/30/10 017 0270 5301
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 181
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01707969 MASK CPAP 1500-2300 326.00 06/30/10 017 0270 5301
01720305 "T" INITIATION 241.00 06/30/10 94664 94664 94664 017 0412 5301
01720313 "T" SUBSEQUENT DAY 93.00 06/30/10 017 0412 5301
01720347 "T" CONT 2300-0700 81.00 06/30/10 017 0270 5301
01720362 "T" CONT 1500-2300 98.00 06/30/10 017 0270 5301
01720370 FACE TENT INITIATION 241.00 06/30/10 94664 94664 94664 017 0460 5301
01720388 FACE TENT SUBSEQUENT DAY 98.00 06/30/10 017 0412 5301
01720412 FACE TENT CON 2300-0700 130.00 06/30/10 017 0270 5301
01720438 FACE TENT CON 1500-2300 130.00 06/30/10 017 0270 5301
01720446 TRACH COLLAR INITIATION 241.00 06/30/10 94664 94664 94664 017 0412 5301
01720453 TRACH COLLAR SUBSEQUENT DAYS 93.00 06/30/10 017 0412 5301
01720487 TRACH COLLAR 2300-0700 98.00 06/30/10 017 0270 5301
01720503 TRACH COLLAR 1500-2300 130.00 06/30/10 017 0270 5301
01720586 AEROS MASK 1500-2300 130.00 06/30/10 017 0270 5301
01720594 HOOD INITIATION 172.00 06/30/10 94664 94664 94664 017 0412 5301
01720602 HOOD SUBSEQUENT DAYS 145.00 06/30/10 017 0270 5301
01720636 MASK W/RESERVOIR INITIATION 333.00 06/30/10 94640 94640 94640 017 0412 5301
01720644 MASK W/RESERVOIR SUBSEQ DAYS 136.00 06/30/10 94640 94640 94640 017 0412 5301
01720651 MASK W/RESERV 1500-2300 132.00 06/30/10 94640 94640 94640 017 0460 5301
01720677 MASK W/RESERV 2300-0700 81.00 06/30/10 017 0270 5301
01720700 HYPERBARIC OXYGEN 30 MIN INTER EXTERNAL 04/01/09 C1300 C1300 C1300 017 0413 5301
01720800 RESUSCITATION BAG 75.00 06/30/10 017 0270 5301
01720810 MICRO SPIROMETER 340.00 06/30/10 E1399 E1399 E1399 017 0292 5301
01720925 RESUSCITATION KIT 109.00 06/30/10 017 0270 5301
01723432 SPUTUM INDUCTION 69.00 06/30/10 94665 017 0412 5301
01724001 NITROGEN- INITIATION 396.00 06/30/10 017 0270 5301
01724002 NITROGEN SUBSEQUENT DAYS 381.00 06/30/10 017 0270 5301
01724011 HELIUM/OXYGEN-INITIATION 396.00 06/30/10 017 0270 5301
01724012 HELIUM/OXYGEN SUBSEQUENT DAYS 381.00 06/30/10 017 0270 5301
01729025 VENT PT TRANSP VARIABLE 04/01/09 017 0410 5301
01736178 CO2-O2 GAS TX INITIATION 123.00 06/30/10 94799 94799 94799 017 0410 5301
01736180 CO2-O2 GAS TX SUBSEQUENT DAYS 103.00 06/30/10 94799 94799 94799 017 0410 5301
01754643 C.P.R. 1ST HALF HR 524.00 06/30/10 92950 92950 92950 017 0480 5301
01754650 VENT MGMT INITIATION 2736.00 06/30/10 017 0412 5301
01754668 VENT MGMT SUBSEQUENT DAYS 2167.00 06/30/10 017 0412 5301
01754676 MECH VENT 2300-0700 812.00 06/30/10 017 0270 5301
01754684 MECH VENT 0700-1500 594.00 06/30/10 94002 94002 94002 017 0412 5301
01754692 MECH VENT 1500-2300 594.00 06/30/10 94002 94002 94002 017 0412 5301
01754695 MECH VENT RENTAL INITIATION 356.00 06/30/10 017 0270 5301
01754696 VENT MGMT HFV INITIATION 2270.00 06/30/10 94004 94004 94004 017 0412 5301
01754697 VENT MGMT HFV SUBSEQUENT DAYS 1817.00 06/30/10 94004 94004 94004 017 0412 5301
01754700 SIMPLE MASK INITIATION 237.00 06/30/10 94640 94640 94640 017 0412 5301
01754718 SIMPLE MASK SETUP 216.00 06/30/10 94640 94640 94640 017 0412 5301
01754726 SIMPLE MASK 2300-0700 78.00 06/30/10 017 0270 5301
01754742 SIMPLE MK 1500-2300 65.00 06/30/10 017 0270 5301
01754809 NASAL CANNULA INITIATION 237.00 06/30/10 94640 94640 94640 017 0412 5301
01754817 NASAL CANNULA SUBSEQUENT DAY 216.00 06/30/10 94640 94640 94640 017 0460 5301
01754845 NASAL CANNULA 207.00 06/30/10 017 0270 5301
01754874 OXYGEN TENT-CANOPY 47.00 06/30/10 017 0270 5301
01754890 AEROS MASK O2 INITIATION 210.00 06/30/10 94664 94664 94664 017 0412 5301
01754908 AEROS MASK O2 SUBSEQUENT DAYS 211.00 06/30/10 94664 94664 94664 017 0270 5301
01754916 AEROS MASK STNBY N/C 06/30/10 94664 94664 94664 017 0412 5301
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 182
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01754919 PENTAMIDINE SETUP 130.00 06/30/10 94642 94642 94642 017 0412 5301
01754924 SMALL VOL NEB TX SETUP 91.00 06/30/10 94664 94664 94664 017 0412 5301
01754932 SMALL VOL NEB TX PROC N/C 06/30/10 94664 94664 94664 017 0412 5301
01754936 NEB TX CONTIN INITIATION 221.00 06/30/10 94664 94664 94664 017 0412 5301
01754937 NEB TX CONTIN SUBSEQUENT TX 165.00 06/30/10 94664 94664 94664 017 0270 5301
01754940 ULTRASONIC TX INITIATION 93.00 06/30/10 94664 94664 94664 017 0412 5301
01754957 ULTRASONIC TX 91.00 06/30/10 94664 94664 94664 017 0412 5301
01754965 ULTRASONIC TX N/C 06/30/10 94640 94640 94640 017 0460 5301
01755040 NITRIC OXIDE INITIATION 181.00 06/30/10 94799 94799 94799 017 0410 5301
01755041 NITRIC OXIDE - SUBSEQUENT DAYS 136.00 06/30/10 017 0270 5301
01755046 SPUTUM INDUCT INITIATION 76.00 06/30/10 94664 94664 94664 017 0412 5301
01755087 BEDSIDE PARAMETERS 82.00 06/30/10 94150 94150 94150 017 0460 5301
01762448 METER DOSE INHALER SPACER 54.00 06/30/10 94665 017 0412 5301
01762450 METER DOSE INHAL SETUP N/C 06/30/10 94664 94664 94664 017 0412 5301
01762458 METER DOSE INHAL PROC 46.00 06/30/10 017 0412 5301
01762466 CLOSED SUCTION EQUIP SETUP 60.00 06/30/10 017 0270 5301
01762547 TRANSCUT MON O2 INITIATION 691.00 06/30/10 94762 94762 94762 017 0460 5301
01762554 TRANSCUT MON O2 SUBSEQ DAY 604.00 06/30/10 94762 94762 94762 017 0460 5301
01762778 INTUBATION/EXTUBATION PROC 300.00 06/30/10 31500 31500 31500 017 0360 5301
01762786 HEATER N/C 06/30/10 017 0270 5301
01762794 EVALUATION INTUB 74.00 06/30/10 017 0270 5301
41040030 SEL CATH PLCMT ART EA 3 ORD RT 2269.00 06/30/10 36217RT 36217RT 36217RT 017 0361 3330
01802585 P.T. EQUIPMENT USAGE EXTERNAL 11/01/94 018 0270 3601
01802590 P.T. SUPPLIES EXTERNAL 11/01/94 018 0270 3601
01802592 P.T. SUPPLIES 5.00 06/30/10 018 0270 3601
01802600 P.T. SUPPLIES $5 7.00 06/30/10 018 0270 3601
01802618 P.T. SUPPLIES $10 15.00 06/30/10 018 0270 3601
01802626 P.T. CARDIAC REHAB-PHASE I 108.00 06/30/10 97110GP 97110GP 97110GP 018 0420 3601
01802630 PT-ULTRAVIOLET LIGHT 72.00 07/01/10 97028 97028 97028 018 0420 3601
01802634 P.T. CARDIAC REHAB-PHASE II 133.00 06/30/10 97110GP 97110GP 97110GP 018 0420 3601
01824125 P.T. HUBBARD TANK 209.00 06/30/10 97036GP 97036GP 97036GP 018 0420 3601
01824132 P.T. WALKING TANK 125.00 06/30/10 97113GP 97113GP 97113GP 018 0420 3601
01824489 P.T. WHIRLPOOL 118.00 06/30/10 97022GP 97022GP 97022GP 018 0420 3601
01824539 P.T. MODALITY-CR 48.00 06/30/10 97039GP 97039GP 97039GP 018 0420 3601
01824547 P.T. MODALITY-ONR 48.00 06/30/10 97039GP 97039GP 97039GP 018 0420 3601
01824554 P.T. MODALITY-OP 48.00 06/30/10 97039GP 97039GP 97039GP 018 0420 3601
01824562 P.T. MODALITY-PEDS 48.00 06/30/10 97039GP 97039GP 97039GP 018 0420 3601
01824612 P.T. EVALUATION/TREATMENT-CR 113.00 06/30/10 97110GP 97110GP 97110GP 018 0420 3601
01824620 P.T. EVALUATION/TREATMENT-ONR 113.00 06/30/10 97110GP 97110GP 97110GP 018 0420 3601
01824638 P.T. EVALUATION/TREATMENT-OP 113.00 06/30/10 97110GP 97110GP 97110GP 018 0420 3601
01824646 P.T. EVALUATION/TREATMENT-PEDS 113.00 06/30/10 97110GP 97110GP 97110GP 018 0420 3601
01850400 APPLICATION OF LONG LEG CAST 527.00 06/30/10 29345 29345 29345 018 0420 3601
01850410 APPLICATION OF SHORT LEG CAST 452.00 06/30/10 29405 29405 29405 018 0420 3601
01850492 P.T. SPECIAL ASSESSMENT-CR 108.00 06/30/10 97750GP 97750GP 97750GP 018 0420 3601
01850500 DEVELOPMENTAL TESTING -15MIN 102.00 06/30/10 96111GP 96111GP 96111GP 018 0420 3601
01850502 P.T. SPECIAL ASSESSMENT-ONR 108.00 06/30/10 97750GP 97750GP 97750GP 018 0420 3601
01850505 NEG PRESS WOUND THERAPY-15MIN 77.00 06/30/10 97605GP 97605GP 97605GP 018 0420 3601
01850510 P.T. SPECIAL ASSESSMENT-OP 108.00 06/30/10 97750GP 97750GP 97750GP 018 0420 3601
01850515 P.T. SPECIAL ASSESSMENT-PEDS 108.00 06/30/10 97750GP 97750GP 97750GP 018 0420 3601
01850520 PT EVALUATION-ADULT OP 208.00 06/30/10 97001GP 97001GP 97001GP 018 0420 3601
01850522 PT EVALUATION-ONR 208.00 06/30/10 97001GP 97001GP 97001GP 018 0420 3601
01850524 PT EVALUATION-PEDIATRIC 208.00 06/30/10 97001GP 97001GP 97001GP 018 0420 3601
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 183
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01850526 PT EVALUATION-CARDIOPULMONARY 208.00 06/30/10 97001GP 97001GP 97001GP 018 0420 3601
01850531 PT RE-EVALUATION-ADULT OP 105.00 06/30/10 97002GP 97002GP 97002GP 018 0420 3601
01850533 PT RE-EVALUATION -ONR 105.00 06/30/10 97002 97002 97002GP 018 0420 3601
01850535 PT RE-EVALUATION - PEDIATRICS 105.00 06/30/10 97002GP 97002GP 97002GP 018 0420 3601
01850537 PT RE-EVALUAT-CARDIOPULMONARY 105.00 06/30/10 97002GP 97002GP 97002GP 018 0420 3601
01850541 PT-SPECIAL ASSESSMENT 46.00 06/30/10 97799GP 97799GP 97799GP 018 0420 3601
01850546 HOT OR COLD PACK 82.00 06/30/10 97010GP 97010GP 97010GP 018 0420 3601
01850549 MECHANICAL TRACTION 110.00 06/30/10 97012GP 97012GP 97012GP 018 0420 3601
01850552 ELECTRICAL STIMULATION 79.00 06/30/10 97014GP G0283GP G0283GP 018 0420 3601
01850555 VASOPNEUMATIC COMPRESSION 79.00 06/30/10 97016GP 97016GP 97016GP 018 0420 3601
01850558 PARAFFIN BATH 60.00 06/30/10 97018GP 97018GP 97018GP 018 0420 3601
01850560 MANUAL ELEC. STIM. PER 15 MIN. 122.00 06/30/10 97032GP 97032GP 97032GP 018 0420 3601
01850565 IONTOPHORESIS/PER 15 MINS. 184.00 06/30/10 97033GP 97033GP 97033GP 018 0420 3601
01850569 CONTRAST BATHS-PER 15 MIN. 90.00 06/30/10 97034GP 97034GP 97034GP 018 0420 3601
01850575 ULTRASOUND-PER 15 MIN. 111.00 06/30/10 97035GP 97035GP 97035GP 93.39 018 0420 3601
01850600 UNLISTED MODALITY 68.00 06/30/10 97039GP 97039GP 97039GP 93.39 018 0420 3601
01850602 THER EXER-ADULT OP-PER 15 MIN 124.00 06/30/10 97110GP 97110GP 97110GP 93.39 018 0420 3601
01850604 THER. EXERCISE-ONR-PER 15 MIN. 124.00 06/30/10 97110GP 97110GP 97110GP 93.39 018 0420 3601
01850606 THER. EXER. -PEDS- PER 15 MIN. 124.00 06/30/10 97110GP 97110GP 97110GP 93.39 018 0420 3601
01850608 THER. EXER. CARDIO.-PER 15 MIN 124.00 06/30/10 97110GP 97110GP 97110GP 93.39 018 0420 3601
01850612 MOTOR RETRAIN-ADULT OP/15 MIN 120.00 06/30/10 97112GP 97112GP 97112GP 93.39 018 0420 3601
01850614 MOTOR RETRAINING-ONR/15 MIN 120.00 06/30/10 97112GP 97112GP 97112GP 93.39 018 0420 3601
01850616 MOTOR RETRAINING-PEDS/15 MIN 120.00 06/30/10 97112GP 97112GP 97112GP 93.39 018 0420 3601
01850618 MOTOR RETRAIN-CARD/PUL/15 MIN 120.00 06/30/10 97112GP 97112GP 97112GP 93.39 018 0420 3601
01850620 AQUA THER W/THER EXER/15 MIN 125.00 06/30/10 97113GP 97113GP 97113GP 93.33 018 0420 3601
01850622 GAIT TRAINING-ADULT OP/15 MIN 102.00 06/30/10 97116GP 97116GP 97116GP 93.22 018 0420 3601
01850624 GAIT TRAINING-ONR/15 MIN 102.00 06/30/10 97116GP 97116GP 97116GP 93.22 018 0420 3601
01850626 GAIT TRAINING-PEDS/15 MIN 102.00 06/30/10 97116GP 97116GP 97116GP 93.22 018 0420 3601
01850628 GAIT TRAINING-CARD-PUL/15 MIN 102.00 06/30/10 97116GP 97116GP 97116GP 93.22 018 0420 3601
01850631 MASSAGE 96.00 06/30/10 97124GP 97124GP 97124GP 93.39 018 0420 3601
01850635 UNLISTED THERAPEUTIC PROCEDURE 74.00 06/30/10 97139GP 97139GP 97139GP 93.39 018 0420 3601
01850639 MANUAL LYMPH DRAINAGE/15 MIN 122.00 06/30/10 97140GP 97140GP 97140GP 93.39 018 0420 3601
01850641 MANUAL THER TECHNIQUES/15 MIN 122.00 06/30/10 97140GP 97140GP 97140GP 93.39 018 0420 3601
01850643 GROUP THERAPY-ADULT OP 95.00 06/30/10 97150GP 97150GP 97150GP 93.39 018 0420 3601
01850645 GROUP THERAPY-ONR 95.00 06/30/10 97150GP 97150GP 97150GP 93.39 018 0420 3601
01850647 GROUP THERAPY-PEDS 95.00 06/30/10 97150GP 97150GP 97150GP 93.39 018 0420 3601
01850649 GROUP THERAPY-CARDIOPULMONARY 95.00 06/30/10 97150GP 97150GP 97150GPP 93.39 018 0420 3601
01850651 ORTHOTIC FIT/TRAIN PER 15 MIN 100.00 06/30/10 97760GP 97760GP 97760GP 93.24 018 0420 3601
01850654 PROSTHETIC TRAINING PER 15 MIN 115.00 06/30/10 97761GP 97761GP 97761GP 93.24 018 0420 3601
01850657 FUNCT. PERF. TRAIN/PER 15 MIN 109.00 06/30/10 97530GP 97530GP 97530GP 93.39 018 0420 3601
01850660 SELF CARE/HOME MANAGE/PER 15MI 100.00 06/30/10 97535GP 97535GP 97535GP 93.83 018 0420 3601
01850663 COMMUNITY/WORK REINTEG/PER 15 83.00 06/30/10 97537GP 97537GP 97537GP 93.85 018 0430 3601
01850666 WHEELCHAIR MANAGEMENT/PER15 MI 83.00 06/30/10 97542GP 97542GP 97542GP 93.85 018 0420 3601
01850669 WORK HARDENING(FIRST 2 HOURS) 66.00 06/30/10 97545GP 97545GP 97545GP 93.85 018 0420 3601
01850671 WORK HARDENING (EACH ADDED HR) 87.00 06/30/10 97546GP 97546GP 97546GP 93.85 018 0420 3601
01850673 ORTHOTIC/PROSTETHIC CHECKOUT 93.00 06/30/10 97762GP 97762GP 97762GP 93.39 018 0420 3601
01850675 PHYSICAL PERF TEST/PER 15 MIN. 108.00 06/30/10 97750GP 97750GP 97750GP 93.04 018 0420 3601
01850677 COGNITIVE RETRAINING/PER 15 MN 96.00 06/30/10 97532GP 97532GP 97532GP 93.89 018 0420 3601
01850680 UNLISTED REHABILITATION SERVIC 63.00 06/30/10 97799GP 97799GP 97799GP 89.04 018 0420 3601
01850685 DEBRIDEMENT 116.00 06/30/10 97597 97597 97597 86.28 86.28 018 0510 3601
01850690 UNNA BOOT APPLICATION 127.00 06/30/10 29580 29580GP 29580GP 93.46 93.46 018 0420 3601
01850692 SUPERVISED EXERCISE-ONR 95.00 06/30/10 97150GP 97150GP 97150GP 93.39 018 0420 3601
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 184
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01850694 SUPERVISED EXERCISE-ADULT OP 95.00 06/30/10 97150GP 97150GP 97150GP 018 0420 3601
01850696 SUPERVISED EXERCISE-PEDS 95.00 06/30/10 97150GP 97150GP 97150GP 93.39 018 0420 3601
01850698 SUPERIVSED EXERCISE - CARDIO 95.00 06/30/10 97150GP 97150GP 97150GP 018 0420 3601
01851000 ADULT WALKER W/O WHEELS 104.00 06/30/10 E0135NU E0135NU E0135NU 018 0292 3601
01851001 XTRA WIDE WALKER W/O WHEELS 172.00 06/30/10 E0135NU E0135NU E0135NU 018 0292 3601
01851002 YOUTH WALKER W/O WHEELS 124.00 06/30/10 E0135NU E0135NU E0135NU 018 0292 3601
01851003 CHILD WALKER W/O WHEELS 124.00 06/30/10 E0135NU E0135NU E0135NU 018 0292 3601
01851004 TODDLER WALKER W/O WHEELS 142.00 06/30/10 E0135NU E0135NU E0135NU 018 0292 3601
01851020 ADULT WALKER W/WHEELS 215.00 06/30/10 E0143NU E0143NU E0143NU 018 0292 3601
01851021 XTRA WIDE WALKER W/WHEELS 257.00 06/30/10 E0143 E0143 E0143 018 0292 3601
01851022 YOUTH WALKER W/WHEELS 215.00 06/30/10 E0143 E0143 E0143 018 0292 3601
01851032 BRAKE EXTENSION 70.00 06/30/10 E0159 E0159 E0159 018 0292 3601
01851040 PLATFORM ATTACHMENT 142.00 06/30/10 E0154 E0154 E0154 018 0292 3601
01851050 FOREARM CRUTCHES 140.00 06/30/10 E0110NU E0110NU E0110NU 018 0292 3601
01851060 WIDE BASE QUAD CANE 54.00 06/30/10 E0105NU E0105NU E0105NU 018 0292 3601
01851061 NARROW BASE QUAD CANE 54.00 06/30/10 E0105NU E0105NU E0105NU 018 0292 3601
01851070 CANE/CRUTCH ARMREST 142.00 06/30/10 E0153 E0153 E0153 018 0292 3601
01851080 UNIPOSE CANE 44.00 06/30/10 E0100NU E0100NU E0100NU 018 0292 3601
01851090 TALL ADULT ALUMINUM CRUTCHES 94.00 06/30/10 E0114NU E0114NU E0114NU 018 0292 3601
01851091 REG ADULT ALUMINUM CRUTCHES 94.00 06/30/10 E0114NU E0114NU E0114NU 018 0292 3601
01851092 YOUTH ALUMINUM CRUTCHES 68.00 06/30/10 E0114NU E0114NU E0114NU 018 0292 3601
01851093 CHILD ALUMINUM CRUTCHES 68.00 06/30/10 E0114NU E0114NU E0114NU 018 0292 3601
02481001 PT EVALUATION-OP-WS 208.00 06/30/10 97001GP 97001GP 97001GP 93.01 018 0420 3601
02481002 PT WORKSITE EVALUATION-OP-WS 208.00 06/30/10 97001GP 97001GP 97001GP 93.01 018 0420 3601
02481003 PT RE-EVALUATION - OP-WS 105.00 06/30/10 97002GP 97002GP 97002GP 93.01 018 0420 3601
02481004 PT WORKSITE RE-EVAL OP-WS 86.00 06/30/10 97002GP 97002GP 97002GP 93.01 018 0420 3601
02481006 PT HOT OR COLD PACKS-WS 82.00 06/30/10 97010 97010GP 97010GP 93.35 018 0420 3601
02481008 PT TRACTION, MECHANICAL-WS 110.00 06/30/10 97012GP 97012GP 97012GP 93.21 018 0420 3601
02481010 PT ELECTR STIM-UNATTENDED-WS 79.00 06/30/10 97014GP G0283GP G0283GP 93.34 018 0420 3601
02481014 PT PARAFFIN BATH-WS 60.00 06/30/10 97018GP 97018GP 97018GP 93.35 018 0420 3601
02481028 PT ELECTRICAL STIM-MANUAL-WS 122.00 06/30/10 97032GP 97032GP 97032GP 93.34 018 0420 3601
02481029 PT IONTOPHORESIS-WS 111.00 06/30/10 97033GP 97033GP 97033GP 93.39 018 0420 3601
02481030 PT CONTRAST BATHS-WS 69.00 06/30/10 97034GP 97034GP 97034GP 93.33 018 0420 3601
02481031 PT ULTRASOUND-WS 111.00 06/30/10 97035GP 97035GP 97035GP 93.39 018 0420 3601
02481035 PT UNLISTED MODALITY-WS 48.00 06/30/10 97039GP 97039GP 97039GP 93.39 018 0420 3601
02481061 PT THERAPEUTIC EXERCISE-WS 117.00 06/30/10 97110GP 97110GP 97110GP 93.19 018 0420 3601
02481063 PT AQUATIC THERAPY-WS 116.00 06/30/10 97113GP 97113GP 97113GP 93.39 018 0420 3601
02481067 PT MANUAL THERAPY-WS 122.00 06/30/10 97140GP 97140GP 97140GP 018 0420 3601
02481070 PT GROUP THERAPY-WS 95.00 06/30/10 97150GP 97150GP 97150GP 93.39 018 0420 3601
02481093 PT WORK HARDEN PROC(0-2HRS)-WS 87.00 06/30/10 97545GP 97545GP 97545GP 93.39 018 0420 3601
02481094 PT WORK REINTEGR TRNG(JOB)-WS 83.00 06/30/10 97537GP 97537GP 97537GP 93.83 018 0420 3601
02481101 PT WORK ENV/MOD ANALYSIS-WS 83.00 06/30/10 97537GP 97537GP 97537GP 93.83 018 0420 3601
02481130 PT-FCE (PHYSICAL PERF TEST)-WS 958.00 06/30/10 97750GP 97750GP 97750GP 93.01 018 0420 3601
02481131 PT-PST OFFR SCR-PHY PRF TST-WS 254.00 06/30/10 97750GP 97750GP 97750GP 93.01 018 0420 3601
03759800 EMG OF ANAL/URETHRAL SPHINCTER 340.00 06/30/10 51785 51785 51785 89.23 89.23 018 0490 3708
03759865 NEURMUSCULAR JUNCTION TEST 213.00 06/30/10 95937 95937 95937 04.89 018 0922 3708
03772710 TENSILON TEST 580.00 06/30/10 95857 95857 95857 93.01 018 0922 3708
03772736 BLINK REFLEX, ELECTRODIAG TEST 320.00 06/30/10 95933 95933 95933 95.25 95.25 018 0740 3708
03772745 H-REFLEX RECRD GASTROC/SOL MUS 161.00 06/30/10 95934 95934 95934 99.99 018 0922 3708
03772746 H-REFLEX OTH THAN GAST/SOL MUS 176.00 06/30/10 95936 95936 95936 99.99 018 0922 3708
03772750 H-RFLEX RECRD GAST/SOL-BILAT 240.00 06/30/10 9593450 9593450 9593450 018 0922 3708
03772870 EMG, THORACIC PARASPINALS 445.00 06/30/10 95869 95869 95869 018 0922 3708
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 185
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03772873 EMG, OTHER THAN PARASPINALS 320.00 06/30/10 95870 95870 95870 018 0922 3708
03772876 SINGLE FIBER EMG 177.00 06/30/10 95872 95872 95872 93.08 018 0922 3708
03783659 ELECTROMYOGRAPHY/1 EXTREMITY 381.00 06/30/10 95860 95860 95860 93.08 018 0922 3708
03783675 ELECTROMYOGRAPHY/2 EXTREMITIES 537.00 06/30/10 95861 95861 95861 93.08 018 0922 3708
03783691 ELECTROMYOGRAPHY/3 EXTREMITIES 649.00 06/30/10 95863 95863 95863 93.08 018 0922 3708
03783717 ELECTROMYOGRAPHY/4 EXTREMITIES 865.00 06/30/10 95864 95864 95864 93.08 018 0922 3708
03783730 EMG, HEMIDIAPHRAGM 172.00 06/30/10 95866 95866 95866 018 0922 3708
03783733 CR NERV SU MUS UNI 270.00 06/30/10 95867 95867 95867 93.08 018 0922 3708
03783758 CR NERV SU MUS BIL 524.00 06/30/10 95868 95868 95868 93.08 018 0922 3708
03783816 NCV/LATEN EA MOTOR W/O F-WAVE 111.00 06/30/10 95900 95900 95900 89.15 018 0922 3708
03783817 NCV/LATENCY EA MOTOR W/ F-WAVE 299.00 06/30/10 95903 95903 95903 89.13 018 0922 3708
03783832 NERVE COND VEL/LAT SENSORY, EA 152.00 06/30/10 95904 95904 95904 89.15 018 0922 3708
03783834 DYNAMIC SURFACE EMG 402.00 06/30/10 96002 96002 96002 89.15 018 0922 3708
03783837 AUTO NERV SYS TEST; SUDO 199.00 06/30/10 95923 9592356 95923 018 0922 3708
03783840 FACIAL NRVE;DESTRCT NEUROAGT 324.00 06/30/10 64612 64612 64612 018 0360 3708
03783843 NECK MUSCLE(S);DES BY NEURO AG 324.00 06/30/10 64613 64613 64613 018 0360 3708
03783846 DESTROY NRVE-EXTRMITY OR TRUNK 257.00 06/30/10 64614 64614 64614 018 0360 3708
03783849 AUTOMOMIC TESTING-M.D. 130.00 06/30/10 95921 9592126 95921 018 0922 3708
03783852 SYMPATHETIC SKIN RESPONSE-M.D. 83.00 06/30/10 95923 9592326 95923 018 0922 3708
12666446 SPONT NYSTAGMUS TESTING-M.D. 43.00 $ 06/30/09 92541 9254126 9254126 018 0983 0602
12666454 CALORIC VESTIBULAR TEST-M.D. 12.00 $ 06/30/09 92543 9254326 9254326 018 0983 0602
12666458 OPTOKINETIC NYST TESTING-M.D. 28.00 $ 06/30/09 92544 9254426 9254426 018 0983 0602
12666683 DXA BONE DENSITY,VERT FX-HOSP 105.00 06/30/10 77082 77082 77082 018 0320 0602
13700146 DOBUTAMINE 500MG FOR 250ML LVP EXTERNAL 03/07/91 J1250 J1250 018 0636 5012
13700147 DOBUTAMINE 250MG FOR 250ML LVP EXTERNAL 03/07/91 J1250 J1250 018 0636 5012
13700160 CEFAZOLIN 333MG/ML INJ EXTERNAL 08/15/96 J0690 J0690 018 0636 5012
13700391 HEPARIN SODIUM 500 UNITS INJ EXTERNAL 01/17/05 J1644 J1644 018 0636 5012
13700499 HEPARIN SODIUM (UNITS/ML FOR P EXTERNAL 12/17/96 J1642 J1642 018 0636 5012
13710343 ACYCLOVIR 400MG ORAL SUSP EXTERNAL 09/27/01 J0133 J0133 J0133 018 0251 5012
13710430 HCTZ-SPIRONOLACTONE 2.5MG SUSP EXTERNAL 07/01/84 018 0250 5012
13714707 DEXAMETHASONE 0.4MG/ML PEDS IN EXTERNAL 06/27/01 J1100 J1100 018 0636 5012
13717965 EPOETIN ALPHA 2000 UNITS/ML IN EXTERNAL 01/01/08 Q4081 Q4081 Q4081 018 0636 5012
13719328 GLATIRAMER ACETATE INJ - 1 BOX EXTERNAL 01/01/07 018 0636 5012
13721801 LIDOCAINE 1% INJECTION (NO PRE EXTERNAL 01/01/95 J2001 J2001 018 0251 5012
13724274 EPOETIN ALPHA 15,000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 018 0634 5012
13732191 TRIAMCINOLONE ACET 40MG/ML INJ EXTERNAL 07/01/84 J3301 J3301 018 0636 5012
44039234 MYOZYME, 10MG EXTERNAL 01/01/08 J0220 J0220 J0220 018 0636 5011
44082003 APROTININ, 10,000 KIU EXTERNAL 01/01/07 J0365 J0365 J0365 018 0636 5011
19900115 CHEMO IV INFUSION: EA ADDL HR 425.00 06/30/10 96415 96415 96415 019 0335 0599
03729058 ELECTROCORTICOGRAM 209.00 06/30/10 95829 95829 95829 020 0740 3701
43010005 EEG AWAKE AND ASLEEP 500.00 06/30/10 95819 95819 95819 89.14 020 0740 3701
43010020 SOMATOSENSORY ER UPPER LIMBS 712.00 06/30/10 95925 95925 95925 89.13 020 0922 3701
43010021 SOMATOSENSORY TEST LOWER LIMBS 400.00 06/30/10 95926 95926 95926 89.13 020 0922 3701
43010025 AUDITORY EVOKED RESPONSE 537.00 06/30/10 92585 92585 92585 95.41 020 0471 3701
43010030 VISUAL EVOKED POTENTIAL 375.00 06/30/10 95930 95930 95930 89.13 020 0922 3701
43010035 INTRAOPER NEUROPHYSIOL TEST/HR 688.00 06/30/10 95920 95920 95920 89.14 020 0740 3701
43010037 NEUROMSUCULAR JUNCTION TEST 213.00 06/30/10 95937 95937 95937 89.19 89.19 020 0922 3701
43010040 EEG AMBULATORY MONITOR, 24 HRS 1468.00 06/30/10 95950 95950 95950 89.19 89.19 020 0740 3701
43010041 NERVE CONDUCTION TEST-MOTOR 212.00 06/30/10 95900 95900 95900 020 0922 3701
43010043 VIDEO EEG MONITORING 4544.00 06/30/10 95951 95951 95951 020 0740 3701
43010044 NERVE CONDUCTION TEST-SENSORY 181.00 06/30/10 95904 95904 95904 020 0922 3701
43010045 EEG DURING NONINTRACRNIAL SURG 2992.00 06/30/10 95955 95955 95955 89.14 020 0740 3701
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 186
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

43010047 EMG 243.00 06/30/10 95870 95870 95870 020 0922 3701
43010048 AMBULATORY EEG,INCOMPLETE 789.00 06/30/10 9595052 9595052 9595052 020 0740 3701
43010051 VIDEO EEG MONITOR-INCOMP<15HR 2582.00 06/30/10 9595152 9595152 9595152 020 0740 3701
43010055 EEG/VIDEO REC/INTERPRET < 2HRS 1111.00 06/30/10 95951 95951 95951 89.19 89.19 020 0740 3701
43010057 EEG/VIDEO REC/INTERPRET 2-4HRS 1600.00 06/30/10 95951 95951 95951 89.19 89.19 020 0740 3701
43010058 EEG NONCAROTID MONIT(AVM CLIP) 765.00 06/30/10 95822 95822 95822 020 0740 3701
43010061 EEG/VIDEO REC/INTERPRET 4-8HRS 2582.00 06/30/10 95951 95951 95951 89.19 89.19 020 0740 3701
43010069 EEG/VIDEO REC/INTERPRET 8-16HR 4544.00 06/30/10 95951 95951 95951 89.19 89.19 020 0740 3701
43010080 ELECTROCORTICOGRAM AT SURGERY 2213.00 06/30/10 95829 95829 95829 89.14 020 0740 3701
43010090 DIGITAL ANALYSIS OF EEG 466.00 06/30/10 95957 95957 95957 89.14 020 0740 3701
43010100 EEG AWAKE 485.00 06/30/10 95816 95816 95816 89.14 020 0740 3701
43010110 MULTIPLE SLEEP LATENCY TEST 1365.00 06/30/10 95805 95805 95805 89.17 020 0740 3701
43010130 GRID: CORTEX STIMUL; FIRST HR 702.00 06/30/10 95961 95961 95961 89.14 020 0740 3701
43010131 GRID: CORTEX STIMUL; EA ADD HR 668.00 06/30/10 95962 95962 95962 89.14 020 0740 3701
43010150 EEG EXTENDED; UP TO ONE HOUR 796.00 06/30/10 95812 95812 95812 89.14 020 0740 3701
43010151 EEG EXTENDED GREATER THAN 1 HR 1123.00 06/30/10 95813 95813 95813 89.14 020 0740 3701
43010154 EMG NEEDLE-UNILATERAL 415.00 07/01/10 95867 95867 95867 020 0922 3701
43010157 NEEDLE EMG-BILATERAL 805.00 07/01/10 95868 95868 95868 020 0922 3701
43010175 SOMATOSENSORY TST TRUNK - HEAD 458.00 06/30/10 95927 95927 95927 020 0922 3701
43010178 TRNSLM BLN ANGP PG BRA/BRNC BI 5366.00 06/30/10 3547550 3547550 3547550 020 0361 3330
43010181 TRNSLM BLN ANGP PG BRA/BRNC LT 3642.00 06/30/10 35475LT 35475LT 35475LT 020 0361 3330
43010184 TRNSLM BLN ANGP PG BRA/BRNC RT 3642.00 06/30/10 35475RT 35475RT 35475RT 020 0361 3330
43010187 NA STNT,CCA W DST EMB PRT LT 13950.00 06/30/10 37215LT 37215LT 37215LT 020 0360 3330
43010190 NA STNT,CCA W DST EMB PRT RT 13950.00 06/30/10 37215RT 37215RT 37215RT 020 0360 3330
43010193 NA STNT,CCA WO DST EMB PT LT 7695.00 06/30/10 37216LT 37216LT 37216LT 020 0360 3330
43010196 NA STNT,CCA WO DST EMB PT RT 7695.00 06/30/10 37216RT 37216RT 37216RT 020 0360 3330
18600101 PERITONEAL DIALYSIS-ACUTE 994.00 06/30/10 90947 90947 90947 39.95 021 0802 3324
18600102 CAVH/SCUF 1898.00 06/30/10 90945 90945 90945 39.95 021 0800 3324
18600103 CAVHD 1898.00 06/30/10 90945 90945 90945 39.95 021 0800 3324
18600104 HEMODIALYSIS-ACUTE 2094.00 06/30/10 90935 90999 90935 39.95 021 0801 3324
18600105 HEMODIALYSIS OUTPT CHRONIC 1009.00 06/30/10 90935 90999 90935 39.95 021 0821 3324
18600106 HEMODIALYSIS INPT CHRONIC 2094.00 06/30/10 90935 90999 90935 39.95 021 0801 3324
18600110 PD CHRONIC INPATIENT 429.00 06/30/10 90945 90945 90945 021 0803 3324
18600118 HEMOPERFUSION 1799.00 06/30/10 90997 90997 90997 39.95 021 0800 3324
18600120 TRANSFUS BLOOD/BLOOD COMP 846.00 06/30/10 36430 36430 36430 021 0391 3324
18600201 CAPD CHRONIC 429.00 06/30/10 90945 90945 90945 39.95 021 0841 3324
18600202 CAPD TRAINING 901.00 06/30/10 90993 90993 90993 39.95 021 0840 3324
18600203 CCPD CHRONIC 429.00 06/30/10 90945 90945 90945 39.95 021 0851 3324
18600204 CCPD TRAINING 990.00 06/30/10 90993 90993 90993 39.95 021 0841 3324
18600301 EPO ADMINISTRATION 100 UNITS 14.00 06/30/10 021 0634 3324
18600302 EPOETIN ALFA, ESRD 75.00 06/30/10 J0886 J0886 J0886 021 0634 3324
18600303 EPO ADMINISTRATN 10,000 UNITS 357.00 06/30/10 021 0635 3324
18600306 UROKINASE 5,000 UNITS 129.00 06/30/10 J3364 J3364 J3364 021 0636 3324
18600310 INJ VANCOMYCIN HCL 500 MG 28.00 06/30/10 J3370 J3370 J3370 021 0636 3324
18600315 INFUSION,ALBUMIN (HUM),5%,50ML 282.00 06/30/10 P9041 P9041 P9041 021 0636 3324
18600320 INFUS,ALBUMIN (HUM),25%,50ML 282.00 06/30/10 P9041 P9041 P9041 021 0636 3324
18600325 ARANESP 1 MCG 16.00 06/30/10 J0882 J0882 J0882 021 0636 3324
18600330 INJECT, EPOETIN ALFA,100 UNITS 4.00 06/30/10 Q4081 Q4081 Q4081 021 0634 3324
18600340 EPOETIN ALFA,100UNIT ESRD/DIAL 4.00 06/30/10 Q4081 Q4081 Q4081 021 0634 3324
18600400 INFLUENZA A(H1N1) IMMUNE ADMIN 66.00 06/30/10 G9141 G9141 G9141 021 0771 3324
40511868 CAVH/SCUF 1893.00 06/30/10 90945 90945 90945 39.95 021 0801 3324
40518325 HEMODIALYSIS OUTPT CHRONIC 807.00 06/30/10 90935 90999 90935 39.95 021 0821 3324
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 187
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40518400 6HR/OBS ACUTE DIALYSIS 669.00 06/30/10 90935 90935 90935 021 0821 3324
40518499 HEMODIALYSIS INPT CHRONIC 2094.00 06/30/10 90935 90999 90935 39.95 021 0801 3324
40518505 IV-PB 46.00 06/30/10 021 0270 3324
40518510 TRANSPOSE BLOOD/BLOOD COMPNNTS 846.00 06/30/10 36430 36430 36430 021 0380 3324
40518520 HOME HEMODIALYSS OUTPT CHRONIC 807.00 06/30/10 90999 90999 90999 021 0821 3324
40518530 HOME HEMODIALYSIS TRAINING 901.00 06/30/10 90993 90993 90993 021 0841 3324
40520000 PV REPAIR C-LINE 1389.00 06/30/10 36575 36575 36575 021 0490 3324
40520064 ADMIN/PNEUMOCOCCAL VACCINE 69.00 06/30/10 G0009 G0009 G0009 021 0771 3324
40520067 ADMIN/HEPATITIS B VACCINE 84.00 06/30/10 G0010 G0010 G0010 021 0771 3324
40553397 HEMOPERFUSION 1712.00 06/30/10 90997 90997 90997 39.95 021 0800 3324
40585159 BLOOD ADMINISTRATION SET 86.00 06/30/10 A4755 021 0270 3324
40591504 PD CHRONIC 429.00 06/30/10 90945 90945 90945 39.95 021 0841 3324
40591520 PD TRAINING 901.00 06/30/10 90993 90993 90993 39.95 021 0841 3324
40591522 CCPD CHRONIC 429.00 06/30/10 90945 90945 90945 39.95 39.95 021 0851 3324
40591524 CCPD TRAINING 901.00 06/30/10 90993 90993 90993 39.95 39.95 021 0851 3324
40593005 STAT ACUTE INPT HEMODIALYSIS 1612.00 06/30/10 90935 90935 90935 39.95 021 0801 3324
40593017 EPO ADMINISTRATION/500 UNITS 27.00 06/30/10 021 0634 5011
40593018 EPO ADMINISTRATION/1,000 UNITS 48.00 06/30/10 021 0634 5011
40593031 UROKINASE 5,000 UNITS 122.00 06/30/10 J3364 J3364 J3364 021 0636 5011
40594000 RENAL DIALYSIS SERVICES-WSVA 556.00 06/30/10 021 0820 3324
40594001 RENAL DIALYSIS SERVICES-WSVA 372.00 06/30/10 021 0820 3324
40600001 PAV HOME HMODIALYSIS OTPT CHR 811.00 06/30/10 90935 90999 90935 021 0821 3500
40600005 PAV HOME HEMODIALYSIS TRAINING 592.00 06/30/10 90935 90935 90935 021 0841 3500
40600010 PV REPAIR C-LINE 1389.00 06/30/10 36575 36575 36575 021 0361 3500
03702201 STEM CELL-BONE MARROW PROCURE 67015.00 06/30/10 38240 38240 38240 41.03 41.03 022 0362 3307
03702203 NAT MARROW SEARCH PGRM/SEARCH 2299.00 06/30/10 38240 38240 38240 41.03 41.03 022 0361 3307
03702205 DONOR SEARCH ACTIVATION 2299.00 06/30/10 38240 38240 38240 41.03 41.03 022 0362 3307
03702207 DONOR LYMPHOCYTE ACQUISITION 14763.00 06/30/10 38242 38242 38242 022 0819 3307
03702209 CORD BLOOD ACQUISITION- DOM 41166.00 06/30/10 38240 38240 38240 022 0362 3307
03702211 CORD BLOOD ACQUISITION- INT 47128.00 06/30/10 38240 38240 38240 022 0362 3307
03702214 CONFIRM TYPE BLOOD SAMPLE 1014.00 06/30/10 38240 38240 38240 022 0362 3307
03702217 CORD BLOOD SHIPMENT UNIT 48462.00 06/30/10 38240 38240 38240 022 0819 3307
03702220 CORD HR-A TYPING ,STD 1300.00 06/30/10 38240 38240 38240 022 0362 3307
03702223 CORD HR-B TYPING STD 1326.00 06/30/10 38240 38240 38240 022 0362 3307
03702226 CORD HR -DRB1,3,4,5 564.00 06/30/10 86812 86812 86812 022 0362 3307
03702229 CORD IR,CONFIRMATORY TYP,STD 1071.00 06/30/10 38242 38242 38242 022 0819 3307
03702232 CORD IR,CONFIRMATORY TYP,URG 1554.00 06/30/10 38242 38242 38242 022 0819 3307
03702235 FORMAL SEARCH 2299.00 06/30/10 38240 38240 38240 022 0362 3307
03702241 INFECT DISEASE MARKERS-RSULTS 624.00 06/30/10 38240 38240 38240 022 0362 3307
03702244 PBSC WORKUP CANCELLATION 3169.00 06/30/10 022 0362 3307
03702247 PRIM PBSC PRECOLLECTION SAMPLE 824.00 06/30/10 38242 38242 38242 022 0819 3307
03702250 PRIMARY PBSC COLLECTION 49361.00 06/30/10 38242 38242 38242 022 0819 3307
03702253 SECONDARY PBSC COLLECTION 49361.00 06/30/10 38242 38242 38242 022 0819 3307
03702256 PRIMARY PBSC PHYS EXAM 3187.00 06/30/10 38240 38240 38240 022 0362 3307
03702259 PRIM PBSC INFORMATION SESSION 1365.00 06/30/10 38240 38240 38240 022 0362 3307
03711893 CADAVER DONOR-LIVER ACQUIS 92684.00 06/30/10 022 0812 1902
03720000 TRANSPORTATION FEE-LIVER EXTERNAL 05/17/96 022 0812 1902
03720001 LIVING RELATD LIVER ACQUISTION 92684.00 06/30/10 022 0811 1902
03720010 TRANSPRT FEE-SMALL BOWEL ACQUI EXTERNAL 04/01/03 022 0812 1902
03720020 CADAVER SMLL BOWEL ACQUISITION 51612.00 06/30/10 022 0812 1902
03720030 LIVING RELATED SMALL BOWEL ACQ 51612.00 06/30/10 022 0811 1902
03720100 LIVE DONOR SMALL BOWEL ACQUISI 83466.00 06/30/10 44136 44136 44136 022 0360 1902
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 188
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03720110 INTEST TRNSPLT-CADAVER DNR EXTERNAL 05/01/05 44135 44135 44135 022 0360 1902
03738978 CADAVER DONOR-PANCREAS ACQUIS 92684.00 06/30/10 022 0812 1904
03738984 ORGAN TRANSPORTATION FEE EXTERNAL 05/05/93 022 0812 1901
03739000 TRANSPORTATION FEE-HEART EXTERNAL 05/17/96 022 0812 1903
03739001 TRANSPORTATION FEE-PANCREAS EXTERNAL 05/17/96 022 0812 1904
03739002 ISLET CELLS-AUTO 51612.00 06/30/10 022 0811 1904
03739004 ISLET CELLS-CADAVER 51612.00 06/30/10 022 0812 1904
03739006 ISLET CELLS-TRANSPORTATION FEE EXTERNAL 07/01/02 022 0812 1904
03739008 LIVING DONOR-PANCREAS ACQUIS 92684.00 06/30/10 022 0811 1904
02210001 NEUROMUSC REEDUCATN EVAL/15MIN 216.00 06/30/10 97112 97112GO 97112GO 93.39 024 0430 2825
02210002 NEUROMUSC REEDUCAT TRTMNT/15MN 180.00 06/30/10 97112 97112GO 97112GO 93.39 024 0430 2825
02210005 ANORECTAL MANOMETRY 826.00 06/30/10 91122 91122 91122 49.29 49.29 024 0750 2825
02210006 ELECTRICAL STIM; EACH 15 MIN 122.00 06/30/10 97032 97032GO 97032GO 93.39 024 0430 2825
02250003 OFFICE VISIT NEW, LEVEL 3 155.00 06/30/10 99203 99203 99203 024 0510 2825
02250004 OFFICE VISIT NEW, LEVEL 4 197.00 06/30/10 99204 99204 99204 024 0510 2825
02250009 OFFICE VISIT EST, LEVEL 3 155.00 06/30/10 99213 99213 99213 024 0510 2825
02250014 OFFICE CONSULTATION, LEVEL 3 155.00 06/30/10 99213 99213 99213 024 0510 2825
02250040 ENDOSCOPY OF BOWEL POUCH 1956.00 06/30/10 44385 44385 44385 024 0360 2825
02250045 ECHO TRANSRECTAL ULTRASND 592.00 06/30/10 76872 76872 76872 024 0402 2825
02250050 NERVE COND VEL/LATEN MOTOR, EA 419.00 06/30/10 95900 95900 95900 89.15 024 0922 2825
02250053 PUDENDAL NERVE LATENCY EXAM 419.00 06/30/10 95900 95900 95900 024 0922 2825
02250056 ELECTROMYOGRAPHY 204.00 06/30/10 51784 51784 51784 024 0490 2825
02250059 BALLOON COMPLIANCE TESTING 365.00 06/30/10 91120 91120 91120 024 0750 2825
02250061 ANOSCOPY 127.00 06/30/10 46600 46600 46600 024 0360 2825
02250064 RIGID PROCTOSCOPY 272.00 06/30/10 45300 45300 45300 024 0360 2825
02250067 OCCUPAT THRPY EVAL PER 30MIN 258.00 06/30/10 97003 97003 97003 024 0430 2825
02250070 THERAPEUTIC EXERCISES PER 15MI 110.00 06/30/10 97110GO 97110GO 97110GO 024 0430 2825
02250076 MANUAL THERAPY -15MIN 122.00 06/30/10 97140GO 97140GO 97140GO 024 0430 2825
02250079 THERAPEUTIC ACTIVITIES- 15MIN 37.00 06/30/10 97530GO 97530GO 97530GO 024 0430 2825
02250082 ADL TRAINING PER 15 MIN 100.00 06/30/10 97535GO 97535GO 97535GO 024 0430 2825
02250090 BIOFEEDBACK TRAINING 96.00 06/30/10 90901 90901 90901 024 0430 2825
02250095 BIOFEEDBACK THERAPY W/EMG 144.00 06/30/10 90911GO 90911GO 90911GO 024 0430 2825
02250097 SIGMOIDOSCOPY FLEX DIAG 781.00 06/30/10 45330 45330 45330 024 0360 2825
02250098 I&D OF ISCHIORECT ABSCESS 1157.00 06/30/10 46040 46040 46040 024 0360 2825
02400101 EVALUATION OCCUPATIONAL THER 189.00 06/30/10 97003G0 97003GO 97003GO 93.09 024 0430 5901
02400102 REEVALUATION OCCUPATIONAL THER 101.00 06/30/10 97004G0 97004GO 97004GO 93.09 024 0430 5901
02400105 HOT/COLD PACK 78.00 06/30/10 97010G0 97010GO 97010GO 93.35 024 0430 5901
02400107 PARAFFIN BATH 57.00 06/30/10 97018G0 97018GO 97018GO 93.35 024 0430 5901
02400112 MECHANICAL TRACTION 104.00 06/30/10 97012G0 97012GO 97012GO 93.21 024 0430 5901
02400114 ELECTRICAL STIM-UNATTENDED 75.00 06/30/10 G0283G0 G0283GO G0283GO 93.34 024 0430 5901
02400116 ULTRASOUND, 15 MIN 105.00 06/30/10 97035G0 97035GO 97035GO 93.39 024 0430 5901
02400118 ELECTRICAL STIM-MANUAL 116.00 06/30/10 97032G0 97032GO 97032GO 93.39 024 0430 5901
02400119 THERAPEUTIC EXERCISES 15 MIN 117.00 06/30/10 97110GO 97110GO 97110GO 93.39 024 0430 5901
02400120 NEUROMUSCULAR REEDUCATN 15 MIN 114.00 06/30/10 97112G0 97112GO 97112GO 93.39 024 0430 5901
02400121 AQUATIC THERAPY/EXERCISE 15 MN 118.00 06/30/10 97113G0 97113GO 97113GO 93.39 024 0430 5901
02400123 IONTOPHORESIS 86.00 06/30/10 97033G0 97033GO 97033GO 93.35 024 0430 5901
02400124 CONTRAST BATHS 86.00 06/30/10 97034GO 97034GO 97034GO 93.35 024 0430 5901
02400125 UNLISTED MODALITY 68.00 06/30/10 97022GO 97022GO 97022GO 93.38 024 0430 5901
02400126 GROUP THERAPEUTIC PROC 15 MIN 90.00 06/30/10 97150G0 97150GO 97150GO 93.39 024 0430 5901
02400128 SUPERVISED EXERCISE 90.00 06/30/10 97150G0 97150GO 97150GO 024 0430 5901
02400130 MANUAL THERAPY 15 MIN 116.00 06/30/10 97140G0 97140GO 97140GO 024 0430 5901
02400131 ORTHOTIC FIT/TRAIN UE 15 MIN 95.00 06/30/10 97760G0 97760GO 97760GO 024 0430 5901
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 189
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

02400133 THER ACTIV/FUNC PERFORM 15 MIN 103.00 06/30/10 97530G0 97530GO 97530GO 93.39 024 0430 5901
02400134 SELF-CARE/HOME MGMT TRAIN 15MN 95.00 06/30/10 97535G0 97535GO 97535GO 93.83 024 0430 5901
02400135 COMMUN/WORK REINTEGRATN 15 MIN 85.00 06/30/10 97537G0 97537GO 97537GO 93.83 024 0430 5901
02400136 WHEELCHAIR MGMT/TRAINING 15MIN 86.00 06/30/10 97542G0 97542GO 97542GO 99.99 024 0430 5901
02400139 ORTHO/PROSTH USE CHECKOUT 15MN 88.00 06/30/10 97762G0 97762GO 97762GO 93.24 024 0430 5901
02400140 PHYSICAL PERFORMANCE TEST 15MN 102.00 06/30/10 97750G0 97750GO 97750GO 93.01 024 0430 5901
02400141 COGNITIVE SKILLS DEVELOP 15MIN 91.00 06/30/10 97532G0 97532GO 97532GO 93.83 024 0430 5901
02400143 SPECIAL ASSESSMENT 102.00 06/30/10 97750GO 97750GO 97750GO 93.09 024 0430 5901
02400146 OT ELECTRICAL TRAUMA EVALUATN 102.00 06/30/10 97750G0 97750GO 97750GO 93.01 93.01 024 0430 5901
02400149 WHIRLPOOL/FLUIDOTHERAPY-WS 68.00 06/30/10 97022GO 97022GO 97022GO 024 0430 5901
02400152 OT RE-EVALUATION-PEDS 101.00 06/30/10 97004GO 97004GO 97004GO 024 0430 5901
02400160 OT THER ACTIV/FUNC PERFORM-PED 103.00 06/30/10 97530GO 97530GO 97530GO 024 0430 5901
02400261 DEVELOPMENTAL TESTING LTD 15MN 118.00 06/30/10 96110G0 96110GO 96110GO 94.02 024 0430 5901
02400262 DEVELOPMENTAL TESTING EXT 1 HR 276.00 06/30/10 96111GO 96111GO 96111GO 94.02 024 0430 5901
02400265 NEUROBEHAV STAT/COG EVAL 1 HR 225.00 06/30/10 96116G0 96116GO 96116GO 89.13 024 0900 5901
02400271 OT NEUROMUSC REEDUC-PEDS-15M 114.00 06/30/10 97112GO 97112GO 97112GO 93.39 024 0430 5901
02400275 OT THERA EXERCISE-PEDS-15MIN 117.00 06/30/10 97110GO 97110GO 97110GO 93.19 024 0430 5901
02400279 OT COGNIT SKILLS DEV-PEDS-15M 91.00 06/30/10 97532GO 97532GO 97532GO 024 0430 5901
02400285 SENSORY INTEGRATION-PEDS 76.00 06/30/10 97533G0 97533G0 97533GO 024 0430 5901
02450001 OT EVALUATION 189.00 06/30/10 97003GO 97003GO 97003GO 93.09 024 0434 5904
02450003 OT RE-EVALUATION 101.00 06/30/10 97004GO 97004GO 97004GO 93.09 024 0434 5904
02450041 OT FUNC PERFORMANCE INDIV 103.00 06/30/10 97530GO 97530GO 97530GO 93.39 024 0430 5904
02450047 OT SELF CARE/HOME MGMT INDIV 95.00 06/30/10 97535GO 97535GO 97535GO 93.83 024 0430 5904
02450051 OT COMM/WORK/AVOC INDIV 85.00 06/30/10 97537GO 97537GO 97537GO 93.83 024 0430 5904
02450061 OT COGNITIVE/SI SK DEV INDIV 91.00 06/30/10 97532GO 97532GO 97532GO 93.83 024 0430 5904
02450071 THERAPUTIC EXERCISE 117.00 06/30/10 97110GO 97110GO 97110GO 93.19 93.19 024 0430 5904
02450074 PHYSICAL PERFORMANCE TEST 102.00 06/30/10 97750GO 97750GO 97750GO 93.01 93.01 024 0430 5904
02450077 SPECIAL ASSESSMENT 102.00 06/30/10 97750GO 97750GO 97750GO 93.01 93.01 024 0430 5904
02450080 OT GROUP TX 1 84.00 06/30/10 97150GO 97150GO 97150GO 024 0433 5904
02450083 OT GROUP TX 2 84.00 06/30/10 97150GO 97150GO 97150GO 024 0433 5904
02450086 OT GROUP TX 3 84.00 06/30/10 97150GO 97150GO 97150GO 024 0433 5904
02450090 OT INTENSIVE GROUP 1 166.00 06/30/10 97150GO 97150GO 97150GO 024 0433 5904
02450093 OT INTENSIVE GROUP 2 166.00 06/30/10 97150GO 97150GO 97150GO 024 0433 5904
02450096 OT INTENSIVE GROUP 3 166.00 06/30/10 97150GO 97150GO 97150GO 024 0433 5904
02450100 NEUROBEHAV STAT/COG EVAL 1 HR 225.00 06/30/10 96116GO 96116GO 96116GO 024 0900 5904
02480001 OT EVALUATION - OP-WS 189.00 06/30/10 97003GO 97003GO 97003GO 93.09 024 0430 5901
02480003 OT RE-EVALUATION - OP-WS 101.00 06/30/10 97004GO 97004GO 97004GO 93.09 024 0430 5901
02480006 OT HOT OR COLD PACKS-WS 78.00 06/30/10 97010GO 97010GO 97010GO 93.35 024 0430 5901
02480008 OT TRACTION, MECHANICAL-WS 104.00 06/30/10 97012G0 97012GO 97012GO 93.21 024 0430 5901
02480010 OT ELECTR STIM-UNATTENDED-WS 75.00 06/30/10 G0283G0 G0283GO G0283GO 93.34 024 0430 5901
02480014 OT PARAFFIN BATH-WS 57.00 06/30/10 97018GO 97018GO 97018GO 93.35 024 0430 5901
02480018 WHIRLPOOL/FLUIDOTHERAPY 68.00 06/30/10 97022GO 97022GO 97022GO 024 0430 5901
02480028 OT ELECTRICAL STIM-MANUAL-WS 116.00 06/30/10 97032GO 97032GO 97032GO 93.34 024 0430 5901
02480029 OT IONTOPHORESIS-WS 86.00 06/30/10 97033GO 97033GO 97033GO 93.39 024 0430 5901
02480030 OT CONTRAST BATHS-WS 86.00 06/30/10 97034G0 97034GO 97034GO 93.33 024 0430 5901
02480031 OT ULTRASOUND-WS 105.00 06/30/10 97035GO 97035GO 97035GO 93.39 024 0430 5901
02480035 OT UNLISTED MODALITY-WS 51.00 06/30/10 97039GO 97039GO 97039GO 93.39 024 0430 5901
02480060 OT SUPERVISED EXERCISE-WS 90.00 06/30/10 97150GO 97150GO 97150GO 93.19 024 0430 5901
02480061 OT THERAPEUTIC EXERCISE-WS 117.00 06/30/10 97110GO 97110GO 97110GO 93.19 024 0430 5901
02480093 OT WORK HARDEN (0-2 HRS)-WS 86.00 06/30/10 97545G0 97545GO 97545GO 93.39 024 0430 5901
02480094 OT WORK REINTEG TRN(JBSITE)-WS 85.00 06/30/10 97537GO 97537GO 97537GO 93.83 024 0430 5901
02480095 OT WORK HARDEN(EA ADDL HR)-WS 86.00 06/30/10 97546GO 97546GO 97546GO 93.85 024 0430 5901
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 190
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

02480101 OT WORK ENV/MODIF ANALY-WS 85.00 06/30/10 97537G0 97537GO 97537GO 93.83 024 0430 5901
02480120 OT NEUROMUSCULR REEDUCATION-WS 114.00 06/30/10 97112GO 97112GO 97112GO 93.39 024 0430 5901
02480130 OT FCE -(PHYSICAL PERF TST)-WS 102.00 06/30/10 97750GO 97750GO 97750GO 93.01 024 0430 5901
02480131 OT PST OFFR SCN-PHY PRF TST-WS 102.00 06/30/10 97750GO 97750GO 97750GO 93.01 024 0430 5901
02480133 OT THER ACTIV/FUNC PERFORM-WS 103.00 06/30/10 97530GO 97530GO 97530GO 93.39 024 0430 5901
02480134 OT SLF-CARE/HOME MGMT TRAIN-WS 95.00 06/30/10 97535G0 97535GO 97535GO 93.83 024 0430 5901
02480135 OT COMMN/WORK REINTEGRATION-WS 85.00 06/30/10 97537G0 97537GO 97537GO 93.35 024 0430 5901
02480139 OT ORTH/PROSTH USE CHECKOUT-WS 88.00 06/30/10 97762G0 97762GO 97762GO 93.24 024 0430 5901
02480140 OT PHYSICAL PERF TEST-WS 102.00 06/30/10 97750G0 97750GO 97750GO 93.06 024 0430 5901
02480141 OT GROUP THERAPEUTIC PROCEDURE 90.00 06/30/10 97150G0 97150GO 97150GO 93.39 024 0430 5901
02480143 OT SPECIAL ASSESSMENT-WS 89.00 06/30/10 97799G0 97799GO 97799GO 93.06 024 0430 5901
02480145 OT MANUAL THERAPY-WS 116.00 06/30/10 97140G0 97140GO 97140GO 024 0430 5901
02480153 OT WORK ENV/MODIFIC ANLYS-WS 118.00 06/30/10 97113G0 97113GO 97113GO 93.39 024 0430 5901
02480157 OT MANUAL THERAPY PER 15M-WS 116.00 06/30/10 97140GO 97140GO 97140GO 024 0430 5901
02480231 ORTHOTIC MGMT & TRAIN-WS 95.00 06/30/10 97760GO 97760GO 97760GO 024 0430 5901
02480241 OT COGNITIVE SKILLS DEVELOP-WS 91.00 06/30/10 97532G0 97532GO 97532GO 024 0430 5901
07400001 REEVALUATION OCCUPAT THERAPY 117.00 06/30/10 97004GO 97004GO 97004GO 024 0430 0848
07400004 PHYSICAL PERFORMANCE TEST 15MN 99.00 06/30/10 97750GO 97750GO 97750GO 024 0430 0848
07400007 NEUROBEHAV STAT/COG EVAL 1 HR 263.00 06/30/10 96116GO 96116GO 96116GO 024 0900 0848
07400010 SPECIAL ASSESSMENT 99.00 06/30/10 97750GO 97750GO 97750GO 024 0430 0848
07400013 SELF-CARE/HOME MGMT TRAIN 15MN 100.00 06/30/10 97535GO 97535GO 97535GO 024 0430 0848
07400015 THER ACTIV/FUNC PERFORM 15 MIN 113.00 06/30/10 97530GO 97530GO 97530GO 024 0430 0848
07400018 NEUROMUSCULAR REEDUCATN 15 MIN 113.00 06/30/10 97112GO 97112GO 97112GO 024 0430 0848
07400021 THERAPEUTIC EXERCISES 15 MIN 113.00 06/30/10 97110GO 97110GO 97110GO 024 0430 0848
07400024 COGNITIVE SKILLS DEVELOP 15MIN 104.00 06/30/10 97532GO 97532GO 97532GO 024 0430 0848
07400027 DEVELOPMENTAL TESTING LTD 15MN 113.00 06/30/10 96110GO 96110GO 96110GO 024 0430 0848
07400030 DEVELOPMENTAL TESTING EXT 1 HR 263.00 06/30/10 96111GO 96111GO 96111GO 024 0430 0848
07400033 SENSORY INTEGRATION-PEDS 90.00 06/30/10 97533GO 97533GO 97533GO 024 0430 0848
07400036 MANUAL THERAPY 15 MIN 113.00 06/30/10 97140GO 97140GO 97140GO 024 0430 0848
03715636 MISCELLANEOUS SUPP 189.00 06/30/10 29799 29799 29799 93.59 93.59 026 0360 4205
03715637 MISCELLAN ORTHOPAEDIC SUPPLY EXTERNAL 11/01/94 026 0274 4205
03716774 CAST-ADULT ARM, SH 243.00 06/30/10 29075 29075 29075 93.53 93.53 026 0360 4205
03716782 CAST-CHILD ARM, SH 243.00 06/30/10 29075 29075 29075 93.53 93.53 026 0360 4205
03716790 CAST-ADULT ARM, LO 292.00 06/30/10 29065 29065 29065 93.53 93.53 026 0360 4205
03716808 CAST-CHILD ARM, LO 292.00 06/30/10 29065 29065 29065 93.53 93.53 026 0360 4205
03716816 CAST-ADULT PART, B 615.00 06/30/10 29799 29799 29799 93.59 93.59 026 0360 4205
03716824 CAST-CHILD PART BO 615.00 06/30/10 29799 29799 29799 93.59 93.59 026 0360 4205
03716832 CAST-ADULT TOTAL B 558.00 06/30/10 29799 29799 29799 93.59 93.59 026 0360 4205
03716840 CAST-CH TOTAL BODY 506.00 06/30/10 29040 29040 29040 93.53 93.53 026 0360 4205
03716857 CAST-ADULT HIP, SI 561.00 06/30/10 29305 29305 29305 93.51 93.51 026 0360 4205
03716858 HIP SPICA CAST; 1 LEG 489.00 06/30/10 026 0274 4205
03716865 CAST-CHILD HIP, SI 739.00 06/30/10 29305 29305 29305 93.51 93.51 026 0360 4205
03716873 CAST-ADULT HIP, DO 739.00 06/30/10 29325 29325 29325 93.51 93.51 026 0360 4205
03716881 CAST-CHILD HIP, DO 670.00 06/30/10 29325 29325 29325 93.54 93.54 026 0360 4205
03716899 CAST-ADULT LEG, SH 355.00 06/30/10 29405 29405 29405 93.53 93.53 026 0360 4205
03716907 CAST-CHILD LEG, SH 355.00 06/30/10 29405 29405 29405 93.53 93.53 026 0360 4205
03716915 CAST-ADULT LEG, LO 366.00 06/30/10 29345 29345 29345 93.53 93.53 026 0360 4205
03716917 CYLINDER CAST 283.00 06/30/10 026 0274 4205
03716919 BRACE CAST 699.00 06/30/10 026 0274 4205
03716923 CAST-CHILD LEG, LO 366.00 06/30/10 29345 29345 29345 93.53 93.53 026 0360 4205
03716931 PETALLIC BEARING CAST 338.00 06/30/10 29799 29799 29799 93.59 93.59 026 0360 4205
03716947 BODY JACKET CAST 615.00 06/30/10 026 0274 4205
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 191
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03716949 CAST-ADULT SHOULDE 485.00 06/30/10 29055 29055 29055 93.51 93.51 026 0360 4205
03716951 SCOLIOTIC CAST 838.00 06/30/10 026 0274 4205
03716956 CAST-CHILD SHOULDE 447.00 06/30/10 29055 29055 29055 93.51 93.51 026 0360 4205
03716964 SPLINT-AD ARM, SHO 155.00 06/30/10 29125 29125 29125 93.54 93.54 026 0360 4205
03716972 SPLINT-CH ARM, SHO 108.00 06/30/10 29125 29125 29125 93.54 93.54 026 0360 4205
03716980 SPLINT-AD ARM, LO 176.00 06/30/10 29105 29105 29105 93.54 93.54 026 0360 4205
03716998 SPLINT-CH ARM, LON 176.00 06/30/10 29105 29105 29105 93.54 93.54 026 0360 4205
03717004 SPLINT-AD LEG, SHO 195.00 06/30/10 29515 29515 29515 93.54 93.54 026 0360 4205
03717012 SPLINT-CH LEG, SHO 109.00 06/30/10 29515 29515 29515 93.54 93.54 026 0360 4205
03717020 SPLINT-AD LEG, LO 228.00 06/30/10 29505 29505 29505 93.54 93.54 026 0360 4205
03717038 SPLINT-CH LEG, LON 228.00 06/30/10 29505 29505 29505 93.54 93.54 026 0360 4205
03717053 CAST-ADULT LEG,CYL 333.00 06/30/10 29365 29365 29365 93.53 93.53 026 0360 4205
03717061 CAST-CHILD LEG,CYL 333.00 06/30/10 29365 29365 29365 93.53 93.53 026 0360 4205
03717079 CAST-BABY LEG,LATE 173.00 06/30/10 29450 29450 29450 93.53 93.53 026 0360 4205
03717087 CAST-BABY LEG,BILA 173.00 06/30/10 29450 29450 29450 93.53 93.53 026 0360 4205
03717095 CAST-THUMB SPICA 243.00 06/30/10 29075 29075 29075 93.53 93.53 026 0360 4205
03717103 CAST-WALKING HEEL 70.00 06/30/10 29440 29440 29440 93.59 93.59 026 0360 4205
03717111 SPLINT-FINGER 80.00 06/30/10 29130 29130 29130 93.54 93.54 026 0360 4205
03717129 SLING 73.00 06/30/10 29799 29799 29799 93.59 93.59 026 0360 4205
03717137 DRESSING CHANGE 73.00 06/30/10 29799 29799 29799 93.59 93.59 026 0360 4205
03717141 CAST REINFORCEMENT 72.00 06/30/10 026 0274 4205
03717150 SOFT VELPEAU STRAPPING 244.00 06/30/10 026 0274 4205
03717151 VELPEAU CAST 479.00 06/30/10 026 0274 4205
03725587 BALANCED SUSPENSION TX W/PIN 615.00 06/30/10 026 0270 4205
03750659 CAST BOOT 129.00 06/30/10 29580 29580 29580 93.59 93.59 026 0360 4205
03788850 PELVIC BELT TRACTION 283.00 06/30/10 026 0270 4205
03788851 PELVIC BELT 103.00 06/30/10 026 0274 4205
03798400 STRYKER FRAME 564.00 06/30/10 026 0270 4205
03798401 STRYKER FRAME, DAILY 115.00 06/30/10 026 0270 4205
08516530 COMPRESSION STOCKINGS 48.00 06/30/10 A6530 A6530 A6530 026 0270 4201
08516543 LYMPHEDEMA GLOVE 168.00 06/30/10 A6504 A6504 A6504 026 0270 4201
08516544 LYMPHEDEMA SLEEVE 79.00 06/30/10 A6506 A6506 A6506 026 0270 4201
08520110 OTC HELMET 186.00 06/30/10 A8001 A8001 A8001 026 0270 4201
08520120 CERV FLEX NON-ADJ FOAM COLLAR 35.00 06/30/10 L0120 L0120 L0120 026 0270 4201
08520172 CERV COLLAR THERMOPLASTIC FOAM 156.00 06/30/10 L0172 L0172 L0172 026 0270 4201
08520190 CERV MLT POST COL OCC/MAND SUP 521.00 06/30/10 L0190 L0190 L0190 026 0270 4201
08520310 TLSO FLEXIBLE CUST FABRICATED EXTERNAL 12/01/90 E0310 E0310 E0310 026 0270 4201
08520486 MTPM, 2PC INTER MATL 2491.00 06/30/10 L0486 L0486 L0486 026 0270 4201
08520500 LUMB-SACRAL-ORTHO FLEX CUST FT 156.00 06/30/10 L0450 L0450 L0450 026 0270 4201
08520625 LUMBOSACRAL ORTHOSIS 137.00 06/30/10 L0625 L0625 L0625 026 0270 4201
08520632 LUMBOSACRAL ORTHOSIS MTPM 1521.00 06/30/10 L0632 L0632 L0632 026 0270 4201
08520830 HALO WITH TLSO 3046.00 06/30/10 L0830 L0830 L0830 026 0270 4201
08521085 CTLSO/SOLIO ORTH OUTRIG BILAT EXTERNAL 12/01/90 L1085 L1085 L1085 026 0270 4201
08521210 TLSO LATERAL THORACIC EXTEN EXTERNAL 12/01/90 L1210 L1210 L1210 026 0270 4201
08521686 HO, POST OP, CST FIT 1085.00 06/30/10 L1686 L1686 L1686 026 0270 4201
08521800 KNEE ORTHOSIS ELASTIC W/STAYS 108.00 06/30/10 026 0270 4201
08521830 IMMOBILIZER CANVAS LONGITUDIAL EXTERNAL 12/01/90 L1830 L1830 L1830 026 0270 4201
08521832 KO. IMMOB CANVAS 558.00 06/30/10 L1830 L1830 L1830 026 0270 4201
08521845 KO DBLE UPRT THIGH/CF W/ADJ JT 936.00 06/30/10 L1845 L1845 L1845 026 0270 4201
08521855 KO MOLD PLASTIC THIGH/CALF SEC EXTERNAL 01/01/08 L1845 L1845 L1845 026 0270 4201
08521940 AFO MOLDED TO PT MODEL PLASTIC EXTERNAL 12/01/90 L1940 L1940 L1940 026 0270 4201
08521945 AFO BI-VALVE PTB MOLDED TOPT EXTERNAL 04/04/97 L1945 L1945 L1945 026 0270 4201
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 192
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08521960 AFO POSTERIOR SOLID ANKLE PLAS 647.00 06/30/10 L1960 L1960 L1960 026 0270 4201
08521970 AFO PLASTIC MOLD TO PT/ANK JNT 764.00 06/30/10 L1970 L1970 L1970 026 0270 4201
08522036 KAFO FULL PLASTIC MOLDED TO PT 1362.00 06/30/10 L2036 L2036 L2036 026 0270 4201
08522112 AFO FRAC ORTH TIB FRAC SOFT 498.00 06/30/10 L2112 L2112 L2112 026 0270 4201
08522220 LE DORSIFLEXT PLANTER FLEXION EXTERNAL 12/01/90 L2220 L2220 L2220 026 0270 4201
08522275 LE ALIGNMENT CORRECTION ORTHOS 136.00 06/30/10 L2275 L2275 L2275 026 0270 4201
08522430 LE KN STR KN JNT POLYCENT JNT EXTERNAL 12/01/90 L2430 L2430 L2430 026 0270 4201
08522624 PLV CONTR HP JT ADJ FLEX EXTEN 427.00 06/30/10 L2624 L2624 L2624 026 0270 4201
08522820 SOFT INTERF MOLDED PLAS BEL KN 95.00 06/30/10 L2820 L2820 L2820 026 0270 4201
08522830 SOFT INTERF MOLDED PLAS ABV KN 126.00 06/30/10 L2830 L2830 L2830 026 0270 4201
08522999 UNLIST PROC FOR LE ORTHOSES EXTERNAL 12/01/90 L2999 L2999 L2999 026 0270 4201
08523001 FOOT INSERT SPENCO EXTERNAL 12/01/90 L3001 L3001 L3001 026 0270 4201
08523002 FOOT INSRT PLASTAZATE OR EQUAL EXTERNAL 12/01/90 L3002 L3002 L3002 026 0270 4201
08523003 FOOT INSERT SILICONE GEL EXTERNAL 12/01/90 L3003 L3003 L3003 026 0270 4201
08523040 FT ARCH SUPP REMOVA LONGITUD 102.00 06/30/10 L3040 L3040 L3040 026 0270 4201
08523222 ORTHOPEDIC MENS SHOES HIGHTOP EXTERNAL 12/01/90 L3222 L2999 L3222 026 0270 4201
08523260 POST OP SHOE 177.00 06/30/10 L3260 L3260 L3260 026 0270 4201
08523323 PR DH II SHOE 166.00 06/30/10 L3260 L3260 L3260 026 0270 4201
08523330 LIFTS-ELEV METAL EXTEN SKATE EXTERNAL 12/01/90 L3330 L3330 L3330 026 0270 4201
08523332 LIFTS-ELEV INSD SHOE TAPERED EXTERNAL 12/01/90 L3332 L3332 L3332 026 0270 4201
08523334 LIFTS-ELEV HEEL/INCH 41.00 06/30/10 L3334 L3334 L3334 026 0270 4201
08523360 SOLE WEDGE OUTSIDE SOLE 32.00 06/30/10 L3360 L3360 L3360 026 0270 4201
08523455 HEEL-NEW LEATHER STANDARD EXTERNAL 12/01/90 L3455 L3455 L3455 026 0270 4201
08523660 SO FIG 8 DESIGN ABDUC RESTRAIN 107.00 06/30/10 L3660 L3660 L3660 026 0270 4201
08523908 WHFO WRIST EXT CONT CANV/LEATH 112.00 06/30/10 L3908 L3908 L3908 026 0270 4201
08523924 WHFO OPPENHEIMER EXTERNAL 01/01/08 L3931 L3931 L3931 026 0270 4201
08523963 SEWHO MOLD SHDR/ARM/FOREARM/WR EXTERNAL 12/01/90 L3960 L3960 L3960 026 0270 4201
08523980 UE FRACTURE ORTHOSIS HUMERAL EXTERNAL 01/01/08 L3980 L3980 L3980 026 0270 4201
08523986 UE FRAC ORTHO COMB HUM RAD/ULN 601.00 06/30/10 026 0270 4201
08523999 UNLIST PROC FOR UP LIMB ORTHOS EXTERNAL 12/01/90 L3999 L3999 L3999 026 0270 4201
08524210 REPAIR/REPLACE ORTHOTIC DEVICE 41.00 06/30/10 L4210 L4210 L4210 026 0270 4201
08524350 SPLINT ANK CNTRL AIRCAST/EQUAL 108.00 06/30/10 L4350 L4350 L4350 026 0270 4201
08524360 SPLINT-WALKING PNEUMATIC EXTERNAL 12/09/96 L4360 L4360 L4360 026 0270 4201
08524398 PRESSURE RELIEF ANKLE/FT ORTHO 335.00 06/30/10 L4398 L4398 L4398 026 0270 4201
08524810 KNEE ORTHOSIS, HINGED 119.00 06/30/10 026 0270 4201
08525000 PART FT SHOE INSRT W/LONG ARCH 601.00 06/30/10 L5000 L5000 L5000 026 0270 4201
08525400 POST SUR/EARLY FIT APPL DRESS 1990.00 06/30/10 L5400 L5400 L5400 026 0270 4201
08525500 RT DIAB SHOE 105.00 06/30/10 L5500 L5500 L5500 026 0270 4201
08525718 KN-SHIN SYS POLYCENTRC FRIC SW EXTERNAL 12/01/90 L5718 L5718 L5718 026 0270 4201
08525940 BEL KNEE ULTRA-LIGHT MATERIAL EXTERNAL 12/01/90 L5940 L5940 L5940 026 0270 4201
08525962 BEL KN NEW SKIN FOAMED SKINNED EXTERNAL 07/26/96 L5962 L5962 L5962 026 0270 4201
08525964 ABOVE KNEE FOAM COVER EXTERNAL 12/01/97 L5964 L5964 L5964 026 0270 4201
08525970 ALL LE PROSTH FT EXT KEEL SACH EXTERNAL 07/16/96 L5970 L5970 L5970 026 0274 4201
08525972 ALL LE PROSTH FLEX KEEL FOOT EXTERNAL 11/27/96 L5972 L5972 L5972 026 0270 4201
08525976 CARBON COPY II FOOT EXTERNAL 03/26/97 L5976 L5976 L5976 026 0270 4201
08525999 UNLIST PROC FOR LE PROSTHESIS EXTERNAL 12/01/90 L5999 L5999 L5999 026 0270 4201
08526010 PART HAND LIT/RING FING REMAIN EXTERNAL 12/01/90 L6010 L6010 L6010 026 0270 4201
08526020 PART HAND NO FINGER REMAINING EXTERNAL 12/01/90 L6020 L6020 L6020 026 0270 4201
08526641 UE EXCURSION AMP PULLEY TYPE EXTERNAL 12/01/90 L6641 L6641 L6641 026 0270 4201
08526780 TERM DEV HOOKS DORR/EQU #SS555 EXTERNAL 01/01/07 L7008 L7008 L7008 026 0270 4201
08528110 ELAS STOCKINGS BEL KNEE HVY WT EXTERNAL 12/01/90 L8110 L2999 L8110 026 0270 4201
08528140 PR THIGH HIGH HOSE 98.00 06/30/10 026 0270 4201
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 193
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08528210 ELAS SUPPRT STOCKNGS CUST MADE EXTERNAL 04/16/98 026 0270 4201
08528420 BK WOOL /SOFT SOCK 29.00 06/30/10 L8420 L8420 L8420 026 0270 4201
08528440 BK STUMP SHRINKER 70.00 06/30/10 L8440 L8440 L8440 026 0270 4201
08528460 AK STUMP SHRINKER 85.00 06/30/10 L8460 L8460 L8460 026 0270 4201
08528470 SOCK, SINGLE PLY 9.00 06/30/10 L8470 L8470 L8470 026 0270 4201
13300174 INTRADERMAL TB TEST 46.00 06/30/10 86580 86580 86580 027 0302 0648
13300258 CATHETERIZ URETHRA COMP-HOSP 144.00 06/30/10 51703 51703 51703 027 0360 0648
13300259 CATHETERIZ URETHRA COMP-M.D. 183.00 $ 06/30/09 51703 51703 51703 027 0975 0648
13300464 LOC TRTMNT-1ST DEGR BURN-HOSP 61.00 06/30/10 16000 16000 16000 027 0360 0648
13300465 LOC TRTMNT-1ST DEGR BURN-M.D. 96.00 $ 06/30/09 16000 16000 16000 027 0975 0648
13300470 DRESS/DEBRIDEMENT-SMALL-HOSP 98.00 06/30/10 16020 16020 16020 027 0360 0648
13300471 DRESS/DEBRIDEMENT-SMALL-M.D. 114.00 $ 06/30/09 16020 16020 16020 027 0975 0648
13300474 PHYSICAL THERAPY-EA 15MIN-HOSP 42.00 06/30/10 97110 97110GP 97110GP 027 0420 0648
13300475 PHYSICAL THERAPY-EA 15MIN-M.D. 60.00 $ 08/10/08 97110 97110GP 97110GP 027 0977 0648
13300558 BIOPSY OF SKIN ONE LESION-HOSP 165.00 06/30/10 11100 11100 11100 027 0360 0648
13300559 BIOPSY OF SKIN ONE LESION-M.D. 95.00 $ 06/30/09 11100 11100 11100 027 0975 0648
13300600 CHEMODENERV MUSCLE-EXTREM-HOSP 524.00 06/30/10 64614 64614 64614 027 0360 0648
13300601 CHEMODENERV MUSCLE-EXTREM-M.D. 279.00 $ 06/30/09 64614 64614 64614 027 0975 0648
13300630 DEBRIDE SKIN PART THICK-HOSP 147.00 06/30/10 11040 11040 11040 027 0360 0648
13300631 DEBRIDE SKIN PART THICK-M.D. 59.00 $ 06/30/09 11040 11040 11040 027 0975 0648
13300650 DEST NEUR AGNT-PERIPHERAL-HOSP 355.00 06/30/10 64640 64640 64640 027 0360 0648
13300651 DEST NEUR AGNT-PERIPHERAL-M.D. 365.00 $ 06/30/09 64640 64640 64640 027 0975 0648
13300686 FAMILY CONFERENCE - HOSP 98.00 06/30/10 90887 90887 90887 027 0900 0648
13300687 FAMILY CONFERENCE - M.D. 155.00 $ 06/30/09 90887 90887 90887 027 0961 0648
13300694 GAIT TRAINING THERAPY-HOSP 33.00 06/30/10 97116 97116 97116 027 0420 0648
13300695 GAIT TRAINING THERAPY-M.D. 52.00 $ 06/30/09 97116 97116 97116 027 0977 0648
13300780 MED EVALUATION S/L/H 202.00 06/30/09 92506 92506GN 92506GN 027 0440 0648
13300784 S/L/H CONTIN. SUPERVISION 99.00 06/30/10 92507 92507GN 92507GN 027 0440 0648
13300810 NASO/ORO GASTR TUBE PLACE-HOSP 219.00 06/30/10 43752 43752 43752 027 0360 0648
13300811 NASO/ORO GASTR TUBE PLACE-M.D. 85.00 $ 06/30/09 43752 43752 43752 027 0975 0648
02500500 METHYLPREDNISOLONE 2MG/ML 10.00 06/30/10 J2920 J2920 J2920 028 0636 1910
02500503 THYMOGLOBULIN (25MG) 1009.00 06/30/10 J7511 J7511 J7511 028 0636 1910
02500506 BENADRYL 50MG IV 6.00 06/30/10 J1200 J1200 J1200 028 0636 1910
02500509 FLEBOGAMMA 500MG 98.00 06/30/10 J1572 J1572 J1572 028 0636 1910
02500512 IMMUNE GLOBULIN(IVIG) FOR IV U 205.00 06/30/10 90283 90283 90283 028 0636 1910
02500515 PNEUMOVAX INJECTION 130.00 06/30/10 90732 90732 90732 028 0636 1910
03522495 MEDFUSION SYRINGE PUMP CHARGE 125.00 06/30/10 028 0251 4520
03525571 PCA/EPIDURAL PUMP CHARGE 194.00 06/30/10 028 0251 4520
03785840 CONTACT LENS MATERIALS (C) EXTERNAL 01/01/01 V2510 V2510 V2510 028 0270 4502
03790250 PHARMACY EXTERNAL 06/01/03 028 0250 9999
03790636 PHARMACY -DETAILED CODING EXTERNAL 06/01/03 028 0636 9999
04631583 5% DEX 0.45 INJ 500 84.00 06/30/10 028 0258 4750
04631591 2.5% DEXT-0.45 INJ 32.00 06/30/10 028 0258 4750
04631609 5% DEX-0.25 NACL 50 84.00 06/30/10 028 0258 4750
04631617 10% DEXT W-WATER 10 84.00 06/30/10 028 0258 4750
04631625 5% DEX WATER INJ 50 84.00 06/30/10 028 0258 4750
04631633 10% DEX W-WATER 500 84.00 06/30/10 028 0258 4750
04631641 0.9% SOD CHL 500ML 84.00 06/30/10 028 0258 4750
04631666 5% DEX-LACT RING 10 84.00 06/30/10 028 0258 4750
04661762 DEXTROSE 5% SC 0.2 PL 1ML 84.00 06/30/10 028 0258 4750
04661770 DEXTROSE 5% SC 0.5 PL 1ML 84.00 06/30/10 028 0258 4750
04661788 DEXTROSE 5% PL 1ML 84.00 06/30/10 028 0258 4750
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 194
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04661796 IV 0.9% SODIUM CHLORIDE 1M ML 84.00 06/30/10 028 0258 4750
04661804 SODIUM CHLORIDE GL 0.9% IRR 1L 21.00 06/30/10 028 0258 4750
04661812 SODIUM CHLORIDE PL IV 500ML 102.00 06/30/10 028 0258 4750
04661820 SODIUM CHLORIDE PL 0.9 IV 1L 21.00 06/30/10 028 0258 4750
04661838 SODIUM CHLORIDE VPL 0.9 IRR 1L 84.00 06/30/10 028 0258 4750
04661846 SODIUM CHLORIDE VPL 0.9 IRR 3L 89.00 06/30/10 028 0258 4750
04661853 WATER FOR IRRIGATION 1MBT 84.00 06/30/10 028 0258 4750
04661861 FLUID IRRIG WATER STERIL 500ML 57.00 06/30/10 028 0258 4750
04661862 IV TROPHAMIN 10% AM ACID 500ML 213.00 06/30/10 028 0258 4750
04661863 IV TRAVASOL 10% AM ACID 2000ML 155.00 06/30/10 028 0258 4750
04661864 IV SMITROL 20% H2O 500ML 54.00 06/30/10 028 0258 4750
04661879 WATER FOR IRRIGATION 1MPL 21.00 06/30/10 028 0258 4750
04661887 WATER FOR IRRIGATION 3M VP 51.00 06/30/10 028 0258 4750
04661895 WATER FOR IRRIGATION 1M BG 21.00 06/30/10 028 0258 4750
04661903 WATER ST RESP 2ML 84.00 06/30/10 028 0258 4750
04661929 DEXTROSE-TRUTOL 75 21.00 06/30/10 028 0258 4750
04662075 IV DSN 10CC 16.00 06/30/10 028 0258 4750
04662083 IN9% N/S 100CC 16.00 06/30/10 028 0258 4750
04662109 IV RINGER LACT 1ML 44.00 06/30/10 028 0258 4750
04662117 DEX 5 LACT RING 5 ML 44.00 06/30/10 028 0258 4750
04692892 SOL PERI DIALYSIS 1.5% DEX 76.00 06/30/10 028 0258 4750
04692893 SOL PERI DIALYSIS 2.5% DEX 96.00 06/30/10 028 0258 4750
04692894 SOL PERI DIALYSIS 4.25 DEX 97.00 06/30/10 028 0258 4750
04692964 FLUID IV PD SOL DEX 1.5% 500ML 33.00 06/30/10 028 0258 4750
04692965 FLUID N PD SOL DEX 1.5% 1000ML 35.00 06/30/10 028 0258 4750
04692966 FLUD IV PD SOL DEX 1.5% 1500ML 35.00 06/30/10 028 0258 4750
04692967 FLUD IV PD SOL DEX 1.5% 2000ML 35.00 06/30/10 028 0258 4750
04692968 FLUID IV PD SOL DEX 2.5% 500ML 35.00 06/30/10 028 0258 4750
04692969 FL PERITNL SOL DEX 2.5% 1000ML 36.00 06/30/10 028 0258 4750
04692970 FLUID IV D SOL DEX 2.5% 1500ML 36.00 06/30/10 028 0258 4750
04692971 FLD IV PD SOL DEX 2.5% 2000ML 36.00 06/30/10 028 0258 4750
04692972 FLD IV PD SOL DEX 4.25 % 500ML 35.00 06/30/10 028 0258 4750
04692973 FLD PERIT SOL DEX 4.25% 1000ML 40.00 06/30/10 028 0258 4750
04692974 FLD IV PD SOL DEX 4.25% 2000ML 36.00 06/30/10 028 0258 4750
04692975 FLD IV PD SOL DEX 4.25% 1500ML 36.00 06/30/10 028 0258 4750
04692976 SOLUTION PD 1.5%D 5 LITER BAG 136.00 06/30/10 028 0258 4750
04692977 SOLUTION PD 2.5%D 5 LITER BAG 140.00 06/30/10 028 0258 4750
04693041 SOL PD-2 1.5% DEX 1500ML 33.00 06/30/10 028 0258 4750
04693042 SOL PD 1.5% DEX 1000ML 33.00 06/30/10 028 0258 4750
04693043 SOL PD 4.25% DEX 1500ML 33.00 06/30/10 028 0258 4750
04693044 SOL PD 4.25% 1500ML 33.00 06/30/10 028 0258 4750
04693045 SOL PD 1.5% DEX 2000ML 81.00 06/30/10 028 0258 4750
04693046 SOL PD 4.25% DEX 1000ML 187.00 06/30/10 028 0258 4750
04693069 SOLUTION PD 2.5% DEX 1500ML 33.00 06/30/10 028 0258 4750
04693070 SOLUTION PD 1.5% DEX 500ML 33.00 06/30/10 028 0258 4750
04693071 SOLUTION PD 1.5% NA 5L BG 50.00 06/30/10 028 0258 4750
04693072 SOLUTION PE 2.5% DEX 1000ML 33.00 06/30/10 028 0258 4750
04693073 SOLUTION PD 2.5% DEX 1500ML 33.00 06/30/10 028 0258 4750
04693075 SOLUTION PD 2.5% DEX 33.00 06/30/10 028 0258 4750
04693077 SOLUTION PD 2.5% DEX 2000ML 33.00 06/30/10 028 0258 4750
04693078 SOLUTION PD 4.25% DEX 2000ML 33.00 06/30/10 028 0258 4750
05513503 MRI GADOTERIDOL-PROHANCE MP/MI 29.00 06/30/10 A9576 A9576 A9576 028 0636 2101
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 195
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

05513506 MRI GADOBENATE-MULTIHANCE/MI 29.00 06/30/10 A9577 A9577 A9577 028 0636 2101
05513509 MRI GADOBENATE MULTHANCE/MULTI 22.00 06/30/10 A9578 A9578 A9578 028 0636 2101
08900009 E-R IV SOLUTION 315.00 06/30/10 028 0258 6812
08900030 E-R TETANUS,HYPT,D.T. 33.00 06/30/10 90702 90702 90702 028 0636 6812
08900200 E-R TPA 2174.00 06/30/10 028 0250 6812
08900500 E-R P.P.D. 39.00 06/30/10 028 0258 6812
08900512 E-R INHALAID DEVICE 154.00 06/30/10 028 0250 6812
08900518 E-R KERLIX (2) 16.00 06/30/10 028 0250 6812
08900551 E-R FLEETS ENEMA 38.00 06/30/10 028 0250 6812
09001020 ACET 120MG/CODEINE 12MG 5ML 21.00 06/30/10 028 0250 6812
09001021 ACETAMIN ELIXIR 120/5ML 13.00 06/30/10 028 0250 6812
09001025 ACETAMIN 160MG/5ML LIQ 14.00 06/30/10 028 0250 6812
09001027 ACETAMINOPHEN 60MG/1.9ML SUSP 8.00 06/30/10 028 0250 6812
09001030 ACETAMIN 325MG/10ML LIQ 17.00 06/30/10 028 0250 6812
09001035 ACETAMIN 80MG/0.8ML LIQ 13.00 06/30/10 028 0250 6812
09001042 ACETAMIN-HYDROCDNE 325/10MG TB 8.00 06/30/10 028 0250 6812
09001045 ACETAMINOPHEN 120MG SUPP 21.00 06/30/10 028 0250 6812
09001047 ACETAMINOPHEN 100MG SUSP 8.00 06/30/10 028 0250 6812
09001049 ACETAMINOPHEN 325MG TAB 8.00 06/30/10 028 0250 6812
09001050 ACETAMINOPHEN 500MG CAP 21.00 06/30/10 028 0250 6812
09001053 ACETAMINOPHEN 80MG SUPP 15.00 06/30/10 028 0250 6812
09001055 ACETAMINOPHEN 650MG SUPP 13.00 06/30/10 028 0250 6812
09001070 ACETYLCYSTEINE 6GM/30ML VIAL 78.00 06/30/10 028 0250 6812
09001085 ADENOSINE 6MG INJ 132.00 06/30/10 J0150 J0150 J0150 028 0636 6812
09001105 ALBUTEROL INHALER- 17G 88.00 06/30/10 028 0250 6812
09001115 AMIODARONE 150MG INJ 345.00 06/30/10 028 0258 6812
09001120 AMLODIPINE 5MG 3.00 06/30/10 028 0251 6812
09001130 TPA (ALTEPLASE) 100MG VIAL 10369.00 06/30/10 J2997 J2997 J2997 028 0636 6812
09001155 AMINOPHYLLINE 250MG/10ML INJ 65.00 06/30/10 J0280 J0280 028 0636 6812
09001160 FACTOR 8 INJ PER UNIT 3195.00 06/30/10 J7192 J7192 028 0636 6812
09001165 FACTOR 9 INJ PER UNIT 7870.00 06/30/10 J7194 J7194 028 0636 6812
09001170 AMOXICILLIN 125MG/5ML SUSP 11.00 06/30/10 028 0250 6812
09001175 AMOXICILLIN 500MG CAPS 17.00 06/30/10 028 0250 6812
09001190 AMPICILLIN 500MG INJ VIAL 88.00 06/30/10 J0290 J0290 028 0636 6812
09001191 AMPICILLIN 2GM INJ 53.00 06/30/10 J0290 J0290 J0290 028 0636 6812
09001195 ARIPIPRAZOLE 7.5MG/ML 1.3 ML V 34.00 06/30/10 028 0258 6812
09001220 AROMATIC AMMONIA 0.3ML 22.00 06/30/10 028 0250 6812
09001225 ARTIFICIAL TEARS 15ML 42.00 06/30/10 028 0250 6812
09001237 ASPIRIN 325MG EC TAB 8.00 06/30/10 028 0250 6812
09001245 ASPIRIN 81MG EC TAB 6.00 06/30/10 028 0251 6812
09001260 ATROPINE 1MG/10ML INJ SYR 46.00 06/30/10 J0461 J0461 J0461 028 0636 6812
09001262 ATROPINE 1% OPHTH SOLN 2ML 45.00 06/30/10 028 0250 6812
09001290 AZITHROMYCIN SUSP 1GM 81.00 06/30/10 J0456 J0456 028 0636 6812
09001299 AZITHROMYCIN IVPB 53.00 06/30/10 028 0250 6812
09001315 PENICILLIN BENZ IM 1.2 MU SYRG 125.00 06/30/10 028 0250 6812
09001325 BACTRIM DS TABLET 16.00 06/30/10 028 0250 6812
09001330 BENZTROPINE 2MG INJ 62.00 06/30/10 J0515 J0515 028 0636 6812
09001360 BRETYLIUM 500MG/10ML INJ SYR 46.00 06/30/10 028 0250 6812
09001367 BSS IRRIGATING SOLN 30ML 53.00 06/30/10 028 0250 6812
09001370 BUPIVICAINE 0.75% INJ 30ML VL 76.00 06/30/10 028 0250 6812
09001390 CAL CARBO(OYS SHELL) 500MG TAB 6.00 06/30/10 028 0250 6812
09001420 CAL CHLORIDE 1 GM/10ML INJ SYR 59.00 06/30/10 028 0250 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 196
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

09001423 CAL GLUCONATE 1GM INH SYR 42.00 06/30/10 J0610 J0610 028 0636 6812
09001432 CARBAMIDE PEROX-OTIC DRPS 15ML 9.00 06/30/10 028 0250 6812
09001440 CEFAZOLIN 1GM INJ VIAL 87.00 06/30/10 J0690 J0690 J0690 028 0636 6812
09001442 CEFAZOLIN 1GM/50CC RTU PIGGYBK 168.00 06/30/10 J0690 J0690 J0690 028 0636 6812
09001450 CEFOXITIN 2GM/D5W 50ML 79.00 06/30/10 J0694 J0694 J0694 028 0636 6812
09001452 CEFOXITIN IVPB 1GM 201.00 06/30/10 J0694 J0694 J0694 028 0636 6812
09001480 CEFTRIAXONE 250MG INJ VIAL 213.00 06/30/10 J0696 J0696 J0696 028 0636 6812
09001481 CEFTRIAXONE 1GM INJ VIAL 341.00 06/30/10 J0696 J0696 J0696 028 0636 6812
09001482 CEFTRIAXONE 1GM IVPB 240.00 06/30/10 J0696 J0696 J0696 028 0636 6812
09001525 CHARCOAL ACTIV SUSP 25GM TUBE 26.00 06/30/10 028 0250 6812
09001530 CHARCOAL ACTIVATED 50GM SUSP 34.00 06/30/10 028 0250 6812
09001571 CIMETIDINE 300MG/50ML NS RTUPB 97.00 06/30/10 028 0250 6812
09001576 CIPROFLOXACIN OPHTH SOLN 2.5ML 111.00 06/30/10 028 0250 6812
09001585 CLINDAMYCIN 600MG/50ML D5W IVP 168.00 06/30/10 028 0250 6812
09001586 CLINDAMYCIN 900MG IV 132.00 06/30/10 028 0250 6812
09001592 CLINDAMYCIN 300MG CAPS 21.00 06/30/10 028 0250 6812
09001610 COCAINE HCL 4% VISCOUS 5ML 108.00 06/30/10 028 0250 6812
09001625 COLCHICINE 0.6MG TAB 10.00 06/30/10 028 0250 6812
09001630 CORTISPORIN OTIC SOLN 10ML 56.00 06/30/10 028 0250 6812
09001631 CORTISPORIN OTIC SUSP 10ML 49.00 06/30/10 028 0250 6812
09001633 COTRIMOXAZOLE INJ VIAL 80/16MG 88.00 06/30/10 028 0250 6812
09001634 COTRIMOXAZOLE 20ML SUSPENSION 15.00 06/30/10 028 0250 6812
09001636 COTRIMOXADOE 30 ML INJ 48.00 06/30/10 028 0250 6812
09001650 CYANIDE ANTIDOTE KIT 509.00 06/30/10 028 0250 6812
09001700 DEXAMETHASONE 10MG/ML INJ 44.00 06/30/10 J1100 J1100 028 0636 6812
09001705 DEXAMETHASONE 4MG/ML 5ML VIAL 5.00 06/30/10 J1100 J1100 J1100 028 0636 5011
09001710 DEXAMETHASONE 4MG TAB 6.00 06/30/10 028 0250 6812
09001750 DEXTROSE 2.5GM/10ML INJ SYR 65.00 06/30/10 028 0250 6812
09001751 DEXTROSE 50% 50ML 25GM SYR 65.00 06/30/10 028 0250 6812
09001753 DEXTROSE 5% IV 108.00 06/30/10 028 0250 6812
09001798 DIAZEPAM 5MG TABLET 16.00 06/30/10 028 0250 6812
09001800 0IAZEPAM 10MG/2ML INJ SYR 76.00 06/30/10 J3360 J3360 028 0636 6812
09001815 DICYCLOMINE 10MG/ML 2ML INJ 70.00 06/30/10 J0500 J0500 J0500 028 0636 6812
09001816 DICYCLOMINE 20MG TAB 14.00 06/30/10 028 0250 6812
09001835 DIGOXIN 0.25MG/ML INJ 48.00 06/30/10 J1160 J1160 J1160 028 0636 6812
09001845 DILTIAZEM INJ 50MG/10ML 111.00 06/30/10 028 0250 6812
09001860 DIPHENHYDRAMINE 50MG INJ 61.00 06/30/10 J1200 J1200 028 0636 6812
09001867 DIPHENHYDRAMINE 25MG LIQUID 17.00 06/30/10 028 0250 6812
09001870 DIPHENHYDRAMINE 25MG CAP 56.00 06/30/10 028 0250 6812
09001875 DIPHENHYDRAMINE 50MG/ML INJ SY 49.00 06/30/10 J1200 J1200 028 0636 6812
09001880 DIPHTHERIA/TETANUS TOXOID SYR 73.00 06/30/10 90702 90702 90702 028 0636 6812
09001885 DIPHTHERIA/TETANUS TOXOID ADLT 51.00 06/30/10 90701 90701 90701 028 0250 6812
09001890 DIPHTHERIA/TETANUS TOXOID PEDS 80.00 06/30/10 028 0250 6812
09001900 DOCUSATE SOD 100MG CAPSULE 6.00 06/30/10 028 0250 6812
09001910 DONNATAL ELIXIR 5ML 26.00 06/30/10 028 0250 6812
09001920 DOPAMINE 400MG/250ML D5W 170.00 06/30/10 028 0250 6812
09001930 DOXYCYLINE TAB 100MG 21.00 06/30/10 028 0250 6812
09001959 EMLA CREAM 5GM 65.00 06/30/10 028 0250 6812
09001970 ENALAPRIL 2.5MG TAB 13.00 06/30/10 028 0250 6812
09001971 ENALAPRIL INJ 2.5MG/2ML 167.00 06/30/10 028 0250 6812
09001973 ENALAPRIL 10MG TAB 6.00 06/30/10 028 0250 6812
09001975 ENALAPIRIL 20 MG TAB 16.00 06/30/10 028 0250 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 197
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

09001977 ENALAPRIL 5MG TAB 8.00 06/30/10 028 0250 6812
09001980 EPINEPHRINE 1:1000 1ML INJ 54.00 06/30/10 J0170 J0170 028 0636 6812
09001985 EPINEPHRINE 1MG/10ML INJ SYR 65.00 06/30/10 028 0250 6812
09001990 EPINEPHRINE 1MG/ML INJ SYR 46.00 06/30/10 J0170 J0170 028 0636 6812
09001993 EPINEPHRINE RACEMIC INHAL .5ML 13.00 06/30/10 028 0250 6812
09001997 EPINEPHRINE RACEMIC INHAL 15ML 85.00 06/30/10 028 0250 6812
09002000 ENOXAPARIN 30MG SYRUP 77.00 06/30/10 028 0250 6812
09002005 ENOXAPARIN 100 MG SYRINGE 161.00 06/30/10 028 0250 6812
09002017 ERYTHROMYCIN 200MG/5ML SUSP 15.00 06/30/10 028 0250 6812
09002019 ERYTHROMYCIN 1GM INJ W/250 NSP 98.00 06/30/10 028 0250 6812
09002020 ERYTHROMYCIN OPHTH OINT 3.5GM 65.00 06/30/10 028 0250 6812
09002021 ERYTHROMYCIN 500MG INJ 49.00 06/30/10 J1364 J1364 028 0636 6812
09002035 ESMOLOL 2.5GM/10ML INJ W/FILTR 345.00 06/30/10 028 0250 6812
09002037 ETOMIDATE 10 ML 68.00 06/30/10 028 0251 6812
09002038 EXACTACAIN SPRAY 60GM 106.00 06/30/10 028 0250 6812
09002040 FAMOTIDINE 20MG TAB 16.00 06/30/10 028 0250 6812
09002045 FAMOTIDINE INJ 20MG IVPB 48.00 06/30/10 028 0250 6812
09002055 FENTANYL INJ 100MCG/2ML 51.00 06/30/10 J3010 J3010 028 0636 6812
09002060 FENTANYL CITR INJ 50ML 56.00 06/30/10 J3010 J3010 028 0636 6812
09002065 FLOURESCIN STRIP 9.00 06/30/10 028 0250 6812
09002070 FLUMAZENIL 0.1MG/ML, 10ML INJ 294.00 06/30/10 028 0250 6812
09002075 FLUMENAZENIL .01 ML INJ 140.00 06/30/10 028 0250 6812
09002080 FLUCONAZOLE 2MG INJ 299.00 06/30/10 028 0250 6812
09002085 FLUCONAZOLE 150 ML INJ 299.00 06/30/10 028 0250 6812
09002090 FOLIC ACID 1MG IV INJ 41.00 06/30/10 028 0250 6812
09002091 FOLIC ACID 1MG TAB 10.00 06/30/10 028 0250 6812
09002105 FOSPHENYTOIN 500MG INJ 378.00 06/30/10 028 0250 6812
09002115 FRIGIDERM ANES SPRAY 227GM/CAN 106.00 06/30/10 028 0250 6812
09002140 FUROSEMIDE 100MG INJ 51.00 06/30/10 028 0250 6812
09002145 FUROSEMIDE 20MG INJ 42.00 06/30/10 J1940 J1940 J1940 028 0636 6812
09002150 FUROSEMIDE 40MG/4ML INJ SYR 45.00 06/30/10 028 0250 6812
09002155 FUROSEMIDE (LASIX) 40MG TAB 5.00 06/30/10 028 0250 6812
09002165 GAITFLOXACIN OPTH SOLN 17.00 06/30/10 028 0250 6812
09002175 GASTROVIEW-36ML 22.00 06/30/10 028 0250 6812
09002200 GENT 0.3% OPHTH OINT 3.5GM 110.00 06/30/10 028 0250 6812
09002203 GENTAMICIN 120MG/100ML RTU PB 95.00 06/30/10 028 0250 6812
09002204 GENTAMICIN 20MG/2CC INJ VIAL 87.00 06/30/10 J1580 J1580 J1580 028 0636 6812
09002205 GENTAMICIN 80MG INJ VIAL 87.00 06/30/10 J1580 J1580 J1580 028 0636 6812
09002210 GENT SULF IJ 1000U/ML PER 80MG 53.00 06/30/10 J1580 J1580 J1580 028 0636 6812
09002235 GLUCAGON 1MG INJ VIAL/DILUENT 140.00 06/30/10 J1610 J1610 028 0636 6812
09002265 GLYCERIN SUPPOSITORY, PED 10.00 06/30/10 028 0250 6812
09002270 GLYBURIDE TAB 5MG 13.00 06/30/10 028 0250 6812
09002280 GLYCOPYRROLATE 0.2MG/ML, 1ML 44.00 06/30/10 028 0250 6812
09002350 HALOPERIDOL 5MG INJ 45.00 06/30/10 J1630 J1630 028 0636 6812
09002389 HEPARIN LF 100U/ML INJ 46.00 06/30/10 J1642 J1642 028 0636 6812
09002390 HEPARIN 1000U/ML, 10ML INJ 45.00 06/30/10 J1644 J1644 028 0636 6812
09002395 HEPARIN 25,000/250ML 1/2NS 125.00 06/30/10 J1644 J1644 028 0636 6812
09002396 HEPARIN PORCINE 1000ML INJ 49.00 06/30/10 028 0250 6812
09002398 HEPARIN SODIUM 5,000 UNITS SYR 6.00 06/30/10 J1644 J1644 J1644 028 0636 6812
09002400 HEPARIN SODIUM 1000UNIT SYR 6.00 06/30/10 J1644 J1644 J1644 028 0636 6812
09002415 HOMATROPINE 5% OPHTH SOL 5ML 40.00 06/30/10 028 0250 6812
09002425 HURRICAINE TOPICAL SPRAY 60ML 60.00 06/30/10 028 0250 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 198
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

09002427 HYALURONIDASE INJ 150MG/ML 65.00 06/30/10 J3470 J3470 028 0636 6812
09002430 HYDRALAZINE 20MG INJ 64.00 06/30/10 J0360 J0360 J0360 028 0636 6812
09002433 HYDRALAZINE 10MG TAB 6.00 06/30/10 028 0250 6812
09002438 HYDRALAZINE 25MG TAB 6.00 06/30/10 028 0250 6812
09002440 HYDROCODONE/APAP 5/500 TABLET 16.00 06/30/10 028 0250 6812
09002442 HYDROCHLROTHIAZIDE 25MG TAB 8.00 06/30/10 028 0250 6812
09002450 HYDROCORTISONE 100MG INJ 44.00 06/30/10 J1720 J1720 J1720 028 0636 6812
09002469 HYDROMORPHONE 1 MG INJ 35.00 06/30/10 J1170 J1170 J1170 028 0636 6812
09002470 HYDROMORPHONE 2MG/ML INJ 35.00 06/30/10 J1170 J1170 028 0636 6812
09002471 HYDROMORPHONE 4MG TAB 30.00 06/30/10 028 0250 6812
09002490 HYDROXYZINE 100MG/2ML INJ 51.00 06/30/10 028 0250 6812
09002495 HYDROXYZINE 25MG TAB 10.00 06/30/10 028 0250 6812
09002547 IBUPROFEN ORAL SUSP 50MG/2.5ML 10.00 06/30/10 028 0250 6812
09002550 IBUPROFEN 100MG/5ML SUSP 17.00 06/30/10 028 0250 6812
09002555 IBUPROFEN 400MG TAB 16.00 06/30/10 028 0250 6812
09002560 IBUPROFEN 600MG TAB 16.00 06/30/10 028 0250 6812
09002565 IBUPROFEN 800MG TAB 14.00 06/30/10 028 0250 6812
09002577 IBUPROFEN ORAL SUSP 30MG/1.5ML 8.00 06/30/10 028 0250 6812
09002587 INSULIN 70/30 10ML #1 8.00 06/30/10 028 0250 6812
09002620 IPECAC SYRUP 15ML 15.00 06/30/10 028 0250 6812
09002640 ISOPROTERENOL 1MG/5ML INJ SYR 174.00 06/30/10 028 0250 6812
09002650 IMIPENEM CILASTAT POWDER 112.00 06/30/10 028 0258 6812
09002675 IPRATROPIUM INH SOLN 500MCG 159.00 06/30/10 028 0250 6812
09002690 KAYEXALATE SUSP 15GM 22.00 06/30/10 028 0250 6812
09002695 KETAMINE 10MG/ML 20ML 58.00 06/30/10 028 0258 6812
09002700 KETAMINE 100MG/ML 5MG INJ 95.00 06/30/10 028 0250 6812
09002714 KETOROLAC 15MG INJ 76.00 06/30/10 J1885 J1885 J1885 028 0636 6812
09002715 KETORALAC 60MG/2ML INJ 119.00 06/30/10 J1885 J1885 J1885 028 0636 6812
09002755 LABETOLOL 100MG/20ML INJ 213.00 06/30/10 028 0250 6812
09002760 LACTULOSE 10GM POWDER 13.00 06/30/10 028 0250 6812
09002762 LATEX ALLERGY KIT 10.00 06/30/10 028 0258 6812
09002764 LET TOPICAL ANESTH SOLN 52.00 06/30/10 028 0250 6812
09002766 LEVONORGESTREL PAK, 0.75MG TAB 73.00 06/30/10 028 0250 6812
09002767 LEVOFLOXACIN 250MG TAB 28.00 06/30/10 028 0250 6812
09002768 LEVOFLAXIN INJ 500MG 159.00 06/30/10 028 0251 6812
09002769 LEVOFLAXIN TAB 500MG 37.00 06/30/10 028 0251 6812
09002770 LEVOFLAXIN 750MG TAB 19.00 06/30/10 028 0251 6812
09002771 LEVOFLAXIN 500MG/100ML IVPB 1036.00 06/30/10 028 0251 6812
09002772 LEVOFLAXIN 750MG/100ML IVPB 973.00 06/30/10 028 0251 6812
09002774 LIDOCAINE 1% W/EPI 10ML INJ 60.00 06/30/10 028 0250 6812
09002777 LIDOCAINE 1% 10ML INJ VIAL 68.00 06/30/10 028 0258 6812
09002782 LIDOCAINE 2% URO-JET 10ML 23.00 06/30/10 028 0251 6812
09002785 LIDOCAINE 100MG/10ML SYRINGE 53.00 06/30/10 J2001 J2001 J2001 028 0636 6812
09002798 LIDOCAINE 2% PF 10ML INJ 70.00 06/30/10 028 0250 6812
09002801 LIDOCAINE 2% TOPIC JELLY 48.00 06/30/10 028 0250 6812
09002804 LIDOCAINE 1GM/250ML D5W RTU 112.00 06/30/10 028 0250 6812
09002810 LIDOCAINE VISCOUS 2% 20ML 27.00 06/30/10 028 0250 6812
09002815 LIDOCNE-BUFF 1% INJ 10ML SYR 45.00 06/30/10 028 0250 6812
09002820 LIDOCNE-BUF 1%-PER 10ML 59.00 06/30/10 028 0250 6812
09002830 LISINOPIRIL 10MG TAB 6.00 06/30/10 028 0251 6812
09002835 LISINOPIRIL 5MG TAB 6.00 06/30/10 028 0251 6812
09002840 LORAZEPAM 1MG TAB 14.00 06/30/10 028 0250 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 199
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

09002845 LORAZEPAM 2MG/2ML INJ TUBEX 51.00 06/30/10 J2060 J2060 028 0636 6812
09002875 LUBRICANT OPHTH OINT 3.5GM 88.00 06/30/10 028 0250 6812
09002900 MAGNESIUM SULF 1GM INJ VIAL 87.00 06/30/10 028 0250 6812
09002910 MAGNESIUM CITRATE 13.00 06/30/10 028 0250 6812
09002915 MAGNESIUM OXIDE 400MG TAB 6.00 06/30/10 028 0251 6812
09002925 MANNITOL 20% IV 500ML IV BAG 140.00 06/30/10 028 0250 6812
09002945 MECLIZINE 25MG TAB 16.00 06/30/10 028 0250 6812
09002955 MEPERIDINE 25MG INJ 8.00 06/30/10 028 0250 6812
09002960 MEPERIDINE 100MG INJ TUBEX 33.00 06/30/10 J2175 J2175 J2175 028 0636 6812
09002965 MEPERIDINE 50MG INJ TUBEX 33.00 06/30/10 J2175 J2175 J2175 028 0636 6812
09002970 MEPERIDINE 75 MG INJ TUBEX 33.00 06/30/10 J2175 J2175 J2175 028 0636 6812
09003010 METHOHEXITAL INJ 84.00 06/30/10 028 0250 6812
09003020 METHYLPREDNISOLONE INJ 125ML 46.00 06/30/10 J2930 J2930 028 0636 6812
09003025 METHYLPREDNISOLONE INJ 40MG 42.00 06/30/10 J2920 J2920 028 0636 6812
09003045 METOCLOPRAMIDE 10MG/2ML INJ 68.00 06/30/10 J2765 J2765 028 0636 6812
09003050 METOPROLOL 5MG/5ML INJ AMP 55.00 06/30/10 028 0250 6812
09003053 METOPROLOL 50MG TAB 10.00 06/30/10 028 0250 6812
09003055 METROPOLOL TARTRATE INJ 56.00 06/30/10 028 0251 6812
09003057 METRONIDAZOLE IVPB 500MG 123.00 06/30/10 028 0250 6812
09003059 METRONIDAZOLE TAB 500MG 17.00 06/30/10 028 0250 6812
09003069 MIDAZOLAM 2MG/2ML INJ VIAL 90.00 06/30/10 J2250 J2250 J2250 028 0636 6812
09003070 MIDAZOLAM 5MG/5ML INJ VIAL 78.00 06/30/10 J2250 J2250 J2250 028 0636 6812
09003073 MIDAZOLAM 1MG INJ 60.00 06/30/10 J2250 J2250 028 0636 6812
09003095 MORPHINE 4MG INJ 9.00 06/30/10 J2275 J2275 J2275 028 0636 6812
09003100 MORPHINE SULF 10MG INJ TUBEX 35.00 06/30/10 J2270 J2270 J2270 028 0636 6812
09003102 MORPHINE 2 MG INJ 23.00 06/30/10 J2270 J2270 J2270 028 0636 6812
09003140 MULTIVITAMIN INJ (MVI) 10ML 45.00 06/30/10 028 0250 6812
09003145 MULTIVITAMIN CHEW TAB 6.00 06/30/10 028 0250 6812
09003148 MULTIVITAMIN TABLET 6.00 06/30/10 028 0250 6812
09003160 MYLANTA II 30ML 21.00 06/30/10 028 0250 6812
09003180 NAFCILLIN INJ 1GM 45.00 06/30/10 028 0250 6812
09003215 NALOXONE 2MG INJ AMP 53.00 06/30/10 028 0250 6812
09003230 NEO/POLY/DEXA OPHTH OINT 3.5GM 41.00 06/30/10 028 0250 6812
09003235 NEOSPORIN OINT 30MG TUBE 15.00 06/30/10 028 0250 6812
09003240 NIFEDIPINE 10MG CAP 13.00 06/30/10 028 0250 6812
09003270 NITROGLYCERIN 2% OINT PKT 23.00 06/30/10 028 0250 6812
09003275 NITROGLYCERIN 400MCG SL TAB 23.00 06/30/10 028 0250 6812
09003280 NITROGLYCERIN 50MG/250ML D5W 122.00 06/30/10 028 0250 6812
09003310 NITROPRUSSIDE 50MG INJ VIAL 103.00 06/30/10 028 0250 6812
09003323 ONDANESTRON 4MG ODT 92.00 06/30/10 Q0179 Q0179 Q0179 028 0636 6812
09003326 ONDANESTRON 2MG ORAL PPK LIQ 18.00 06/30/10 Q0179 Q0179 Q0179 028 0636 6812
09003420 OVRAL TABLETS #4 150.00 06/30/10 028 0250 6812
09003430 OXYTOCIN 10U/ML INJ VIAL 88.00 06/30/10 J2590 J2590 028 0636 6812
09003535 PENICILLIN GK 1 MU INJ 88.00 06/30/10 J0570 J0570 J0570 028 0636 6812
09003536 PENICILLIN VK 250MG UD 11.00 06/30/10 028 0250 6812
09003540 PENTOBARBITAL 50MG INJ 123.00 06/30/10 J2515 028 0636 6812
09003550 PHENOBARBITAL 130MG/ML INJ 44.00 06/30/10 J2560 028 0636 6812
09003552 PHENOBARBITAL 30MG TAB 10.00 06/30/10 028 0250 6812
09003580 PHENYLEPHRINE 0.5% NASAL SPRAY 47.00 06/30/10 028 0250 6812
09003585 PHENYLEPHRINE 2.5% OPHTH 2ML 34.00 06/30/10 028 0250 6812
09003600 PHENYTOIN 100MG CAP 12.00 06/30/10 028 0250 6812
09003602 PHENYTOIN 120 MG ORAL SUSP 6.00 04/01/10 028 0250 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 200
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

09003605 PHENYTOIN 250MG/5ML INJ 22.00 06/30/10 028 0250 6812
09003607 PHENYTOIN CHEWABLE TAB 6.00 05/01/10 028 0250 6812
09003630 PHYTONADIONE 10MG INJ 67.00 06/30/10 J3430 J3430 028 0636 6812
09003640 PILOCARPINE 2% OPHTH 15ML 30.00 06/30/10 028 0250 6812
09003665 PIPERACILLIN INJ 3GM 122.00 06/30/10 028 0250 6812
09003700 POTASSIUM CHLORIDE 10MEQ INJ 88.00 06/30/10 J3480 J3480 J3430 028 0636 6812
09003705 POTASSIUM CHLORIDE 40MEQ INJ 88.00 06/30/10 J3480 J3480 J3480 028 0636 6812
09003710 POTASSIUM CL 20MEQ TAB 17.00 06/30/10 028 0250 6812
09003735 PREDNISOLONE 7.5MG/2.5ML SOLN 13.00 06/30/10 J7510 J7510 J7510 028 0636 6812
09003740 PREDNISOLONE 10MG/3.3ML SOLN 15.00 06/30/10 J7510 J7510 J7510 028 0636 6812
09003744 PREDNISOLONE SOLN 5MG/5ML 16.00 06/30/10 J7510 J7510 J7510 028 0636 6812
09003750 PREDNISONE 20MG TAB 14.00 06/30/10 028 0250 6812
09003755 PREDNISONE 5MG TAB 13.00 06/30/10 J7506 J7506 028 0636 6812
09003757 PRED/GENT OPHTH OINT 3.5GM 77.00 06/30/10 028 0250 6812
09003775 PROCAINAMIDE 1GM INJ VIAL 101.00 06/30/10 J2690 J2690 J2690 028 0636 6812
09003780 PROCAINE PCN G 600,000U INJ 48.00 06/30/10 028 0250 6812
09003800 PROCHLORPERAZINE 10MG INJ 76.00 06/30/10 J0780 J0780 028 0636 6812
09003805 PROCHLORPERAZINE 25MG SUPP 18.00 06/30/10 028 0250 6812
09003808 PROCHLORPERAZINE 5MG INJ 49.00 06/30/10 J0780 J0780 028 0636 6812
09003840 PROMETHAZINE INJ 25MG AMPULE 42.00 06/30/10 J2550 J2550 J2550 028 0636 6812
09003860 PROPARACAINE 0.5% OPHT 15ML 46.00 06/30/10 028 0250 6812
09003870 PROPOFOL 100ML 179.00 06/30/10 028 0250 6812
09003872 PROPOFOL 20ML 36.00 06/30/10 028 0250 6812
09003874 PROPOFOL 50ML 93.00 06/30/10 028 0250 6812
09003885 PSEUDOEPHEDRINE 30MG TAB 10.00 06/30/10 028 0250 6812
09003990 ROCURONIUM 10MG/ML INJ 111.00 06/30/10 028 0250 6812
09004000 RANITIDINE 50 MG,IV PIGGYBACK 68.00 06/30/10 028 0250 6812
09004050 RISPERIDONE 1MG ORAL SOLN 16.00 06/30/10 028 0251 6812
09004052 RISPERIDONE DISINTEGRATING TAB 10.00 06/30/10 028 0250 6812
09004130 SILVER NITRATE STICK 65.00 06/30/10 028 0250 6812
09004150 SILVER SULFADIAZINE 1% CR 25GM 55.00 06/30/10 028 0250 6812
09004185 SODIUM BICARB INJ 10ML SYRINGE 51.00 06/30/10 028 0250 6812
09004190 SODIUM BICARB 50MEQ/50ML INJ 45.00 06/30/10 028 0250 6812
09004210 SODIUM CHLORIDE 0.9% INJ 10ML 41.00 06/30/10 J7040 J7040 J7040 028 0636 6812
09004215 SODIUM CHLORIDE INH 3ML UD 13.00 06/30/10 028 0250 6812
09004260 SODIUM SULFACET 10%OPH SOL 5ML 77.00 06/30/10 028 0250 6812
09004265 SOD POLY SULFONATE 1GM SUSP 25.00 06/30/10 028 0251 6812
09004270 SULFADIZINE SIVER CREAM 18.00 06/30/10 028 0250 6812
09004280 SORBITAL 70% 30ML 13.00 06/30/10 028 0250 6812
09004320 STERILE WATER INJ 10ML VIAL 54.00 06/30/10 028 0250 6812
09004330 STREP TEST KIT (RAPID) 10.00 06/30/10 028 0251 6812
09004340 STREPTOKINASE 1.5MU INJ 1637.00 06/30/10 J2995 J2995 028 0636 6812
09004365 SUCCINYLCHOLINE 20MG/ML 10ML 42.00 06/30/10 J0330 J0330 028 0636 6812
09004370 SUCROSE ORAL SOLUTION 12ML 14.00 06/30/10 028 0250 6812
09004380 SULFACET 10% OPHTH SOLN 5ML 77.00 06/30/10 028 0250 6812
09004385 SUMATRIPTAN 6MG INJ 180.00 06/30/10 J3030 J3030 028 0636 6812
09004440 TAMIFLU 75 MG CAP 32.00 06/30/10 028 0250 6812
09004450 TERBUTALINE 1MG INJ AMP 48.00 06/30/10 J3105 J3105 J3105 028 0636 6812
09004465 TETRACAINE 0.5% OPHTH SOLN 1ML 44.00 06/30/10 028 0250 6812
09004490 THEOPHYL 800MG/500ML D5W 112.00 06/30/10 J2810 J2810 028 0636 6812
09004540 THIAMINE 100MG INJ TUBEX 46.00 06/30/10 028 0250 6812
09004560 THIOPENTAL SOD 500MG INJ SYR 53.00 06/30/10 028 0250 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 201
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

09004570 TOBRA/DEXA OPHTH OINT 3.5GM 119.00 06/30/10 028 0250 6812
09004590 TRAMADOL 50 MG TAB 8.00 06/30/10 028 0251 6812
09004650 TRIAMCINOLONE INJ 40MG 27.00 06/30/10 J3301 J3301 J3301 028 0636 6812
09004680 TROPICAMIDE 1% OPHTH SOL 2ML 30.00 06/30/10 028 0250 6812
09004685 TUBERCULIN PPD 16.00 06/30/10 028 0250 6812
09004725 UROKINASE 5000U/ML INJ 237.00 06/30/10 J3364 J3364 J3364 028 0636 6812
09004740 VANCOMYCIN 1GM INJ W/250ML D5W 118.00 06/30/10 028 0250 6812
09004750 VECURONIUM 1MG/ML 10ML INJ 115.00 06/30/10 028 0250 6812
09004780 VERAPAMIL 5MG/2ML INJ AMP 42.00 06/30/10 028 0250 6812
09004800 ZIPRASDONE 10MG/.5 ML,1 ML INJ 29.00 06/30/10 J3486 J3486 J3486 028 0636 6812
09004951 MEDICATION, IV INJECTION 108.00 06/30/10 028 0250 6812
09004952 MEDICATION, IV PIGGYBACK 224.00 06/30/10 028 0250 6812
09004953 MEDICATION, INTRAMUSCULAR INJ 108.00 06/30/10 028 0250 6812
09004954 MEDICATION, ORAL 22.00 06/30/10 028 0250 6812
09004955 MEDICATION, SUPPOSITORY 21.00 06/30/10 028 0250 6812
09004956 MEDICATION, RESPIRATORY 48.00 06/30/10 028 0250 6812
09004957 MEDICATION, OINTMENT 36.00 06/30/10 028 0250 6812
09005469 HYDROMORPHONE 1 MG INJ 5.00 06/30/10 J1170 J1170 J1170 028 0636 6812
12667400 BONIVA INJECTION-1MG 317.00 06/30/10 J1740 J1740 J1740 028 0636 0602
12667500 NORMAL SALINE SOL. 1000CC 50.00 06/30/10 J7030 J7030 J7030 028 0636 0602
12667503 NORMAL SALINE SOL. 500ML 48.00 06/30/10 J7040 J7040 J7040 028 0636 0602
12667506 5% DEX/NORM SALINE 500ML 22.00 06/30/10 J7042 J7042 J7042 028 0636 0602
12667509 NORM SALINE SOLUT,250CC 26.00 06/30/10 J7050 J7050 J7050 028 0636 0602
12667512 5% DEXTROSE/WATER 500ML 22.00 06/30/10 J7060 J7060 J7060 028 0636 0602
12667515 D-5-W,100CC 31.00 06/30/10 J7070 J7070 J7070 028 0636 0602
12667518 DEXTRAN 40,500ML 22.00 06/30/10 J7100 J7100 J7100 028 0636 0602
12667521 RINGER'S LACT INFU 1000CC 31.00 06/30/10 J7120 J7120 J7120 028 0636 0602
12667524 HYP SAL,50/100MEQ,20CC VL 22.00 06/30/10 J7130 J7130 J7130 028 0636 0602
12667533 DEXAMETHASONE PHOSP 1ML 5.00 06/30/10 J1100 J1100 J1100 028 0636 0602
12667700 COSYNTROPIN /0.25MG EXTERNAL 01/01/10 J0834 J0834 J0834 028 0636 0602
13700106 ASCORBIC ACID 500MG/ML INJ EXTERNAL 03/05/91 028 0251 5012
13700130 CALCIUM GLUCONATE 9.2MEQ EXTERNAL 03/07/91 J0610 J0610 028 0636 5012
13700145 DOBUTAMINE 250MG FOR 250ML LVP EXTERNAL 03/07/91 J1250 J1250 028 0636 5012
13700152 DOPAMINE INJ 400MG EXTERNAL 03/07/91 J1265 J1265 J1265 028 0251 5012
13700154 DOPAMINE 800MG FOR 250ML LVP EXTERNAL 03/07/91 J1265 J1265 J1265 028 0636 5012
13700183 FOLIC ACID 5MG/ML INJ EXTERNAL 03/08/91 028 0251 5012
13700185 FUROSEMIDE INJ***MG EXTERNAL 03/08/91 J1940 J1940 028 0636 5012
13700248 POTASSIUM CL 2MEQ/D5W 250ML EXTERNAL 08/08/01 J3480 J3480 J3480 028 0636 5012
13700291 METHYLPRED SOD SUCC 40MG/ML IN EXTERNAL 03/12/91 J2920 J2920 028 0636 5012
13700292 METHYLPRED SOD SUCC(MG)INJ*FOR EXTERNAL 03/12/91 J2930 J2930 028 0636 5012
13700295 METHYLPREDNISOLONE 2MG/ML PEDS EXTERNAL 03/12/91 J2920 J2920 028 0636 5012
13700301 MULTIVITAMIN ADULT ADDITIVE W/ EXTERNAL 03/12/91 028 0251 5012
13700311 METHYLPRED SOD SUCC(MG)INJ *FO EXTERNAL 10/03/00 J2930 J2930 028 0636 5012
13700312 METHYLPRED SOD SUCC 62.5 MG/ML EXTERNAL 10/03/00 J2930 J2930 028 0636 5012
13700313 MULTIVITAMIN ADULT ADDITIVE W/ EXTERNAL 12/28/98 028 0258 5012
13700358 POTASSIUM PHOSPHATE 3MMOL/ML EXTERNAL 03/13/91 028 0251 5012
13700360 POTASSIUM PHOSPHATE 4.4MEQ/ML EXTERNAL 09/09/96 028 0258 5012
13700370 POTASSIUM PHOSPHATE MMOL/KG PE EXTERNAL 11/16/98 028 0258 5012
13700371 POTASSIUM PHOSPHATE MMOLS *TPN EXTERNAL 11/16/98 028 0258 5012
13700372 POTASSIUM PHOSPHATE MEQ/KG PED EXTERNAL 11/14/00 028 0258 5012
13700390 HEPARIN SODIUM 1500 UNITS INJ EXTERNAL 01/17/05 J1644 J1644 028 0636 5012
13700482 HEPARIN PF UNITS/ML EXTERNAL 09/24/97 J1644 J1644 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 202
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13700483 HEPARIN PF 25 UNITS EXTERNAL 12/14/98 J1644 J1644 028 0636 5012
13700484 HEPARIN PF 50 UNITS EXTERNAL 12/14/98 J1644 J1644 028 0636 5012
13700485 HEPARIN PF 100 UNITS/ML EXTERNAL 02/15/05 J1644 J1644 J1644 028 0258 5012
13700492 HEPARIN SODIUM 1,000 UNITS/ML EXTERNAL 08/28/97 J1644 J1644 028 0636 5012
13700705 DEXTROSE 10%/AMINO ACIDS 4.25% EXTERNAL 03/22/91 028 0258 5012
13710000 VITAMIN A & D OINT 60GM EXTERNAL 02/21/95 028 0250 5012
13710004 ABCIXIMAB 9 MG FOR 250 ML LVP EXTERNAL 12/17/96 J0130 J0130 J0130 028 0636 5012
13710006 ABCIXIMAB 2MG/ML INJ EXTERNAL 12/17/96 J0130 J0130 J0130 028 0636 5012
13710008 ABACAVIR 300MG TAB EXTERNAL 05/28/02 028 0251 5012
13710009 ABACAVIR 100MG/5ML ORAL SOLUTI EXTERNAL 05/28/02 028 0251 5012
13710043 ACETAMINOPHEN 80MG - 1 BOX(30) EXTERNAL 02/21/95 028 0250 5012
13710046 ACETAMINOPHEN 160MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13710049 ACETAMINOPHEN 325MG - 1 BOX(10 EXTERNAL 02/21/95 028 0251 5012
13710051 ACETAMINOPHEN 325MG BLISTER - EXTERNAL 10/19/93 028 0250 5012
13710052 ACETAMINOPHEN 650MG (2X325MG) EXTERNAL 10/19/93 028 0251 5012
13710053 ACETAMINOPHEN 1000MG (2X500MG) EXTERNAL 10/19/93 028 0251 5012
13710079 ACETAMINOPHEN 500MG - 1 BOX(10 EXTERNAL 03/22/88 028 0251 5012
13710080 ACETAMINOPHEN 32MG/ML SUSPENSI EXTERNAL 07/01/84 028 0250 5012
13710100 ACETAMINOPHEN 160MG SUSPENSION EXTERNAL 10/19/93 028 0250 5012
13710104 ACETAMINOPHEN 25MG SUSPENSION EXTERNAL 03/04/95 028 0251 5012
13710105 ACETAMINOPHEN 40MG SUSPENSION EXTERNAL 03/04/95 028 0251 5012
13710106 ACETAMINOPHEN 60MG SUSPENSION EXTERNAL 03/04/95 028 0251 5012
13710107 ACETAMINOPHEN 80MG SUSPENSION EXTERNAL 03/04/95 028 0251 5012
13710108 ACETAMINOPHEN 120MG SUSPENSION EXTERNAL 03/04/95 028 0251 5012
13710109 ACETAMINOPHEN 240MG SUSPENSION EXTERNAL 03/04/95 028 0251 5012
13710110 ACETAMINOPHEN 325MG SUSPENSION EXTERNAL 10/19/93 028 0250 5012
13710119 ACETAMINOPHEN 30MG SUSPENSION EXTERNAL 12/18/01 028 0251 5012
13710120 ACETAMINOPHEN 100MG SUSPENSION EXTERNAL 12/18/01 028 0251 5012
13710121 ACETAMINOPHEN 500MG SUSPENSION EXTERNAL 12/18/01 028 0251 5012
13710123 ACETAMINOPHEN 650MG SUSPENSION EXTERNAL 10/19/93 028 0250 5012
13710124 ACETAMINOPHEN 40MG SUPP EXTERNAL 01/25/05 028 0251 5012
13710125 ACETAMINOPHEN 20MG SUSPENSION EXTERNAL 12/21/04 028 0251 5012
13710140 ACETAMINOPHEN 120MG SUPP EXTERNAL 10/19/93 028 0250 5012
13710141 ACETAMINOPHEN 120MG SUPP-1 BOX EXTERNAL 10/19/93 028 0250 5012
13710142 ACETAMINOPHEN 80MG SUPP INFANT EXTERNAL 10/19/93 028 0251 5012
13710143 ACETAMINOPHEN 80MG SUPP EXTERNAL 10/19/93 028 0251 5012
13710144 ACETAMINOPHEN 20MG SUPP EXTERNAL 12/22/04 028 0251 5012
13710145 ACETAMINOPHEN 40MG SUPP EXTERNAL 12/22/04 028 0251 5012
13710146 ACETAMINOPHEN 30MG SUPP EXTERNAL 12/21/04 028 0251 5012
13710147 ACETAMINOPHEN 60MG SUPP EXTERNAL 12/21/04 028 0251 5012
13710149 ACETAMINOPHEN 325MG SUPP-1 BOX EXTERNAL 10/19/93 028 0251 5012
13710150 ACETAMINOPHEN 325MG SUPP EXTERNAL 10/19/93 028 0250 5012
13710151 ACETAMINOPHEN 650MG SUPP EXTERNAL 10/19/93 028 0250 5012
13710152 ACETAMINOPHEN 650MG SUPP-1 BOX EXTERNAL 10/19/93 028 0250 5012
13710153 ACETAMINOPHEN 975MG (325 MG X EXTERNAL 01/23/08 028 0251 5012
13710165 ACETAMINOPHEN-CODEINE 300MG/30 EXTERNAL 10/19/93 028 0250 5012
13710167 ACETAMINOPHEN-CODEINE 300MG/60 EXTERNAL 10/19/93 028 0250 5012
13710180 ACETAZOLAMIDE 250MG TAB EXTERNAL 10/19/93 028 0250 5012
13710200 ACETAZOLAMIDE 500MG DS CAP EXTERNAL 10/19/93 028 0250 5012
13710210 ACETAZOLAMIDE INJECTION 500MG EXTERNAL 10/19/93 J1120 J1120 J1120 028 0251 5012
13710231 ACETIC ACID 0.25% IRRIG SOLN EXTERNAL 07/01/84 028 0250 5012
13710240 TOPIRAMATE 15 MG CAP EXTERNAL 02/01/10 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 203
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13710241 TOPIRAMATE 25 MG TAB EXTERNAL 02/01/10 028 0251 5012
13710242 TOPIRAMATE 50 MG TAB EXTERNAL 02/01/10 028 0251 5012
13710243 TOPIRAMATE 100MG TAB EXTERNAL 02/01/10 028 0251 5012
13710290 ACETYLCHOLINE 1% OPHTH SOLN EXTERNAL 10/19/93 028 0250 5012
13710291 ACETYLCYSTEINE 200 MG/ML SOLN EXTERNAL 12/22/04 028 0251 5012
13710292 ACETYLCYSTEINE 200 MG/ML SOLN EXTERNAL 12/22/04 028 0251 5012
13710299 ACETYLCYSTEINE 20% SOLN 2ML EXTERNAL 12/22/04 028 0251 5012
13710300 ACETYLCYSTEINE 20% SOLN 4ML EXTERNAL 10/19/93 028 0251 5012
13710303 ACETYLCYSTEINE 10% SOLN EXTERNAL 03/26/02 028 0636 5012
13710304 N-ACETYL-L CYSTEINE 20% SVN 1M EXTERNAL 10/19/93 J7608 J7608 J7608 028 0250 5012
13710305 ACETYLCYSTEINE 20% SOLN 30ML EXTERNAL 10/19/93 028 0250 5012
13710306 N-ACETYL-L-CYSTEINE 20% SVN 1. EXTERNAL 03/06/96 J7608 J7608 J7608 028 0636 5012
13710309 ACETYLCYSTEINE 20% 600 MG SOLN EXTERNAL 12/22/04 028 0251 5012
13710311 ACYCLOVIR 25MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710312 ACYCLOVIR 30MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710313 ACYCLOVIR 35MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710314 ACYCLOVIR 50MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710315 ACYCLOVIR 60MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710316 ACYCLOVIR 70MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710317 ACYCLOVIR 80MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710318 ACYCLOVIR 100MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710319 ACYCLOVIR 120MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710321 ACYCLOVIR 150MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710322 ACYCLOVIR 180MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710323 ACYCLOVIR 240MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 028 0251 5012
13710324 ACYCLOVIR 300MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710325 ACYCLOVIR 600MG ORAL SUSP EXTERNAL 12/18/01 J0133 J0133 J0133 028 0251 5012
13710332 ACTIFED - 1 BOX EXTERNAL 10/19/93 028 0251 5012
13710342 ACYCLOVIR 200MG ORAL SUSP EXTERNAL 09/27/01 J0133 J0133 J0133 028 0251 5012
13710344 ACYCLOVIR 800MG ORAL SUSP EXTERNAL 09/27/01 J0133 J0133 J0133 028 0251 5012
13710347 ACYCLOVIR 40MG/ML ORAL SUSP EXTERNAL 10/19/93 J0133 J0133 J0133 028 0636 5012
13710348 ACYCLOVIR 50MG/ML INJ EXTERNAL 10/19/93 J0133 J0133 J0133 028 0636 5012
13710349 ACTIFED SYRUP - 120ML BOTTLE EXTERNAL 10/19/93 028 0250 5012
13710353 ACYCLOVIR SUSP 200MG/5ML 480ML EXTERNAL 10/19/93 028 0251 5012
13710354 ACYCLOVIR 200MG - 1 BOX EXTERNAL 10/19/93 028 0251 5012
13710355 ACYCLOVIR 5% OINT 15GM EXTERNAL 10/19/93 028 0250 5012
13710356 ACYCLOVIR INJECTION 500MG VIAL EXTERNAL 10/19/93 J0133 J0133 J0133 028 0250 5012
13710357 ACYCLOVIR 200MG CAPSULE EXTERNAL 10/19/93 J0133 J0133 028 0636 5012
13710359 ADENOSINE 3MG/ML INJ EXTERNAL 10/19/93 J0150 J0150 J0150 028 0636 5012
13710363 ACYCLOVIR 800MG TABLET EXTERNAL 10/19/93 J0133 J0133 J0133 028 0636 5012
13710364 ACYCLOVIR 800MG U.D. EXTERNAL 10/19/93 J0133 J0133 J0133 028 0251 5012
13710365 ACYCLOVIR 400MG TABLET EXTERNAL 10/19/93 J0133 J0133 028 0250 5012
13710366 ACYCLOVIR 400MG TABLET EXTERNAL 10/19/93 J0133 J0133 J0133 028 0251 5012
13710376 ACYCLOVIR 5MG/ML PEDS INJ EXTERNAL 01/04/01 J0133 J0133 J0133 028 0636 5012
13710380 FACTOR IX COMPLEX INJ EXTERNAL 03/26/02 J7194 J7194 028 0636 5012
13710383 AHF FACTOR 8/VON WILLEBRAND FA EXTERNAL 09/23/04 028 0258 5012
13710384 AHF FACTOR 8/VON WILLEBRAND FA EXTERNAL 11/10/98 028 0258 5012
13710386 ANTIHEMOPHILIC FACTOR VIII MON EXTERNAL 10/19/93 J7190 J7190 J7190 028 0636 5012
13710387 ANTIHEMOPHILIC FACTOR VIII REC EXTERNAL 10/19/93 J7192 J7192 J7192 028 0636 5012
13710388 ALBUMIN 25% INJ 100ML EXTERNAL 03/26/02 028 0250 5012
13710389 ALBUMIN 5% INJ 50ML EXTERNAL 03/26/02 028 0250 5012
13710390 ALBUMIN 5% INJ 250ML EXTERNAL 03/26/02 P9045 P9045 P9045 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 204
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13710391 ALBUMIN 25% INJ 20ML EXTERNAL 03/26/02 028 0251 5012
13710393 ALBUMIN 5% INJ 250ML EXTERNAL 05/06/04 P9045 P9045 P9045 028 0636 5012
13710400 ALBUMIN 25% INJ 50ML EXTERNAL 03/26/02 P9047 P9047 P9047 028 0636 5012
13710404 ALBUTEROL SYRUP 2MG/5ML 480ML EXTERNAL 10/19/93 028 0251 5012
13710405 ALBUTEROL MDI 17GM EXTERNAL 03/26/02 028 0250 5012
13710406 ALBUTEROL 0.083% SOLN 3ML (2.5 EXTERNAL 03/26/02 028 0258 5012
13710407 ALBUTEROL SOLUTION - RESP THER EXTERNAL 03/26/02 J7620 J7620 J7620 028 0251 5012
13710408 ALBUTEROL 5MG/ML SOLUTION 20ML EXTERNAL 03/26/02 028 0250 5012
13710412 ALBUTEROL 0.5% FOR NEBULIZER 0 EXTERNAL 03/26/02 J7620 J7620 J7620 028 0250 5012
13710413 ALBUTEROL 0.5% FOR NEBULIZER 0 EXTERNAL 03/26/02 J7620 J7620 J7620 028 0250 5012
13710418 ALBUTEROL 0.083% SOLN 1.5ML (2 EXTERNAL 12/05/08 028 0251 5012
13710419 ALBUTEROL 0.5% NEB SOLUTION 1. EXTERNAL 04/20/07 028 0251 5012
13710420 ALCOHOL ABSOLUTE INJ 1ML EXTERNAL 10/19/93 028 0251 5012
13710425 ALCOHOL DEHYDRATED INJ 5ML EXTERNAL 10/24/94 028 0251 5012
13710427 HCTZ-SPIRONOLACTONE 1MG SUSP EXTERNAL 10/19/93 028 0251 5012
13710428 HCTZ-SPIRONOLACTONE 1.5MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710429 HCTZ-SPIRONOLACTONE 2MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710431 HCTZ-SPIRONOLACTONE 12.5/12.5M EXTERNAL 10/24/94 028 0251 5012
13710432 HCTZ-SPIRONOLACTONE 3MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710433 HCTZ-SPIRONOLACTONE 4MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710434 HCTZ-SPIRONOLACTONE 5MG/ML SUS EXTERNAL 03/04/95 028 0251 5012
13710435 HCTZ-SPIRONOLACTONE 6MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710436 HCTZ-SPIRONOLACTONE 7MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710437 HCTZ-SPIRONOLACTONE 8MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710438 HCTZ-SPIRONOLACTONE 9MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710439 HCTZ-SPIRONOLACTONE 0.8MG SUSP EXTERNAL 11/18/92 028 0251 5012
13710441 HCTZ-SPIRONOLACTONE 25MG/25MG EXTERNAL 10/24/94 028 0250 5012
13710442 ALDACTAZIDE - 1 BOX UD EXTERNAL 10/24/94 028 0251 5012
13710447 HCTZ-SPIRONOLACTONE 10MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710448 HCTZ-SPIRONOLACTONE 12MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710449 HCTZ-SPIRONOLACTONE 15MG SUSP EXTERNAL 03/04/95 028 0251 5012
13710451 HCTZ-SPIRONOLACTONE 20MG SUSP EXTERNAL 07/01/84 028 0251 5012
13710452 ALBUTEROL 5 MG/ML 0.5 ML VIAL EXTERNAL 04/20/07 028 0251 5012
13710453 ALLOPURINOL 50MG (1/2 X 100MG) EXTERNAL 01/25/08 028 0251 5012
13710454 ALLOPURINOL 100MG - 1 BOX UD EXTERNAL 10/24/94 028 0251 5012
13710457 AMLODIPINE 1 MG/ML ORAL SUSP EXTERNAL 02/13/08 028 0251 5012
13710458 ATENOLOL 2 MG/ML ORAL SUSP EXTERNAL 02/13/08 028 0251 5012
13710459 ALLOPURINOL 200 MG (2 X 100MG) EXTERNAL 01/25/08 028 0251 5012
13710464 HCTZ-SPIRONOLACTONE 0.5MG SUSP EXTERNAL 11/12/98 028 0251 5012
13710465 HCTZ-SPIRONOLACTONE 0.6MG SUSP EXTERNAL 12/18/01 028 0251 5012
13710466 HCTZ-SPIRONOLACTONE 0.7MG SUSP EXTERNAL 12/18/01 028 0251 5012
13710467 HCTZ-SPIRONOLACTONE 0.9MG SUSP EXTERNAL 12/18/01 028 0251 5012
13710468 HCTZ-SPIRONOLACTONE 1.25MG SUS EXTERNAL 12/18/01 028 0251 5012
13710469 HCTZ-SPIRONOLACTONE 3.25MG SUS EXTERNAL 12/18/01 028 0251 5012
13710470 ALPHA CHYMOTRYPSIN 0.02%OPHTH EXTERNAL 10/24/94 028 0250 5012
13710471 ALBUTEROL 0.5MG SYRUP EXTERNAL 03/26/02 028 0251 5012
13710472 ALBUTEROL 0.75MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13710473 ALBUTEROL 1MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13710474 ALBUTEROL 1.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13710475 ALBUTEROL 2MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13710476 HCTZ-SPIRONOLACTONE 7.5MG SUSP EXTERNAL 12/18/01 028 0251 5012
13710477 HCTZ-SPIRONOLACTONE 12.5MG SUS EXTERNAL 12/18/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 205
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13710478 HCTZ-SPIRONOLACTONE 17.5MG SUS EXTERNAL 12/18/01 028 0251 5012
13710479 ALPRAZOLAM 2MG (1 MG X 2) TAB EXTERNAL 01/25/08 028 0251 5012
13710480 ALPHA KERI BATH OIL 240ML EXTERNAL 10/24/94 028 0250 5012
13710490 ALPROSTADIL 500MCG/ML INJ EXTERNAL 07/13/94 J0270 J0270 028 0636 5012
13710491 ALPRAZOLAM 0.125 MG TAB EXTERNAL 10/26/06 028 0251 5012
13710492 AMLODPINE 0.2 MG ORAL SUSP EXTERNAL 05/06/08 028 0251 5012
13710493 AMLODPINE 0.3 MG ORAL SUSP EXTERNAL 05/06/08 028 0251 5012
13710494 AMLODPINE 0.5 MG ORAL SUSP EXTERNAL 05/06/08 028 0251 5012
13710495 ALPROSTADIL 300MCG FOR 30 ML I EXTERNAL 03/06/08 028 0258 5012
13710496 AMLODPINE 1.5 MG ORAL SUSP EXTERNAL 05/06/08 028 0251 5012
13710497 AMLODPINE 2 MG ORAL SUSP EXTERNAL 05/06/08 028 0251 5012
13710498 AMLODPINE 3 MG ORAL SUSP EXTERNAL 05/06/08 028 0251 5012
13710540 ACETIC ACID-ALUM ACET OTIC SOL EXTERNAL 07/13/94 028 0250 5012
13710548 ALENDRONATE 35MG TAB EXTERNAL 04/19/06 028 0251 5012
13710561 ATENOLOL 2.5 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13710562 ATENOLOL 5 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13710563 ATENOLOL 10 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13710564 ATENOLOL 15 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13710600 ALUMINUM HYDROXIDE 320MG/5ML - EXTERNAL 07/13/94 028 0251 5012
13710602 ALUMINUM HYDROXIDE 2.5ML SUSP EXTERNAL 03/06/96 028 0251 5012
13710603 ALUMINUM HYDROXIDE 5ML SUSP EXTERNAL 03/06/96 028 0251 5012
13710604 ALUMINUM HYDROXIDE 10ML SUSP EXTERNAL 03/06/96 028 0251 5012
13710605 ALUMINUM HYDROXIDE SUSP 60MG/5 EXTERNAL 07/13/94 028 0251 5012
13710607 ALUMINUM HYDROXIDE 15ML LIQ CO EXTERNAL 03/06/96 028 0251 5012
13710608 ALUMINUM HYDROXIDE 15ML SUSP EXTERNAL 03/06/96 028 0251 5012
13710609 ALUMINUM HYDROXIDE 30ML LIQ CO EXTERNAL 03/06/96 028 0251 5012
13710610 ALUMINUM HYDROXIDE 30ML SUSP EXTERNAL 07/13/94 028 0250 5012
13710611 ALUMINUM HYDROXIDE 360ML LIQ C EXTERNAL 07/19/95 028 0251 5012
13710612 ALUMINUM HYDROXIDE 64 MG/ML (E EXTERNAL 12/27/04 028 0251 5012
13710613 ALUMINUM HYDROXIDE 120 MG/ML C EXTERNAL 04/29/08 028 0251 5012
13710625 ALUMINUM SULFATE/CALCIUM ACETA EXTERNAL 01/26/04 028 0251 5012
13710642 AMIFOSTINE 50MG/ML INJ EXTERNAL 05/22/98 J0207 J0207 028 0636 5012
13710643 AMIFOSTINE 500MG 10ML EXTERNAL 05/22/98 J0207 J0207 028 0636 5012
13710644 AMIFOSTINE 200 MG/ML INJ FOR S EXTERNAL 12/27/04 J0207 J0207 028 0636 5012
13710664 AMIKACIN 500MG/D5W 100ML EXTERNAL 03/06/96 028 0258 5012
13710673 AMIKACIN 250MG/ML INJ EXTERNAL 08/05/94 028 0250 5012
13710674 AMINO ACID 8.5% SOLN 500ML BOT EXTERNAL 07/01/84 028 0258 5012
13710677 AMIKACIN 250MG/D5W 100ML EXTERNAL 03/06/96 J0207 J0207 J0207 028 0258 5012
13710678 AMIODARONE 50MG/ML EXTERNAL 02/07/96 J0282 028 0636 5012
13710679 AMIODARONE 50MG/ML 3ML VIAL EXTERNAL 02/07/96 J0282 J0282 J0282 028 0258 5012
13710680 AMINOCAPROIC ACID 500MG TAB EXTERNAL 08/05/94 028 0250 5012
13710681 AMINOCAPROIC ACID INJ***MG EXTERNAL 08/05/94 028 0250 5012
13710690 AMINOCAPROIC ACID 1.25GM SYRUP EXTERNAL 08/05/94 028 0250 5012
13710691 AMINOCAPROIC ACID SYRUP 480ML EXTERNAL 08/05/94 028 0250 5012
13710700 AMINOCAPROIC ACID 250MG/ML INJ EXTERNAL 08/05/94 028 0250 5012
13710707 AMINOPHYLLINE 210MG SOLN EXTERNAL 08/05/94 028 0251 5012
13710709 AMINOPHYLLINE 500MG SOLN EXTERNAL 08/05/94 028 0251 5012
13710723 AMINOPHYLLINE 1MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
13710724 AMINOPHYLLINE 1.2MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
13710725 AMINOPHYLLINE 1.5MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
13710726 AMINOPHYLLINE 2MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710727 AMINOPHYLLINE 2.5MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 206
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13710728 AMINOPHYLLINE 3MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710729 AMINOPHYLLINE 3.5MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710756 AMINOPHYLLINE 4MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710757 AMINOPHYLLINE 4.5MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710764 AMINOPHYLLINE 15MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
13710765 AMINOPHYLLINE 20MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710766 AMINOPHYLLINE 25MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
13710767 AMINOPHYLLINE 30MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710768 AMINOPHYLLINE 35MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710769 AMINOPHYLLINE 40MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710770 AMINOPHYLLINE 25MG/ML INJ EXTERNAL 03/13/95 J0280 J0280 J0280 028 0636 5012
13710772 AMINOPHYLLINE 0.8MG INJ EXTERNAL 03/13/95 J0280 J0280 J0280 028 0636 5012
13710773 AMINOPHYLLINE 5MG/ML PEDS INJ EXTERNAL 03/13/95 J0280 J0280 028 0636 5012
13710774 AMINOPHYLLINE 45MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710776 AMINOPHYLLINE 50MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710777 AMINOPHYLLINE 55MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710778 AMINOPHYLLINE 60MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710779 AMINOPHYLLINE 5MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710783 AMINOPHYLLINE 6MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710784 AMINOPHYLLINE 7MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710785 AMINOPHYLLINE 8MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710786 AMINOPHYLLINE 9MG INJ EXTERNAL 03/06/96 J0280 J0280 028 0636 5012
13710787 AMINOPHYLLINE 10MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
13710788 AMINOPHYLLINE 12MG INJ EXTERNAL 03/06/96 J0280 J0280 J0280 028 0636 5012
13710790 AMIODARONE 200MG TAB EXTERNAL 03/13/95 028 0251 5012
13710791 AMIODARONE 200MG - 1 BOX EXTERNAL 03/13/95 028 0251 5012
13710792 AMIODARONE 100 MG (1/2 X 200 M EXTERNAL 01/25/08 240400 028 0251 5012
13710793 AMIODARONE 400MG (200 MG X 2) EXTERNAL 01/25/08 028 0251 5012
13710794 AMIODARONE 450MG FOR 250 ML LV EXTERNAL 03/06/08 028 0258 5012
13710795 AMIODARONE 150MG FOR 100 ML LV EXTERNAL 11/12/08 028 0258 5012
13710824 AMITRIPTYLINE 10MG TAB UD - 10 EXTERNAL 03/13/95 028 0251 5012
13710826 AMITRIPTYLINE 10MG TAB EXTERNAL 03/13/95 028 0251 5012
13710828 AMITRIPTYLINE 50MG - 1 BOX EXTERNAL 03/13/95 028 0251 5012
13710829 AMITRIPTYLINE 25MG - 1 BOX EXTERNAL 03/13/95 028 0251 5012
13710830 AMITRIPTYLINE 25MG TAB EXTERNAL 03/13/95 028 0250 5012
13710832 AMITRIPTYLINE 50MG TAB EXTERNAL 03/13/95 028 0250 5012
13710833 AMITRIPTYLINE 100MG TAB EXTERNAL 03/13/95 028 0250 5012
13710834 AMITRIPTYLINE 100MG - 1 BOTTLE EXTERNAL 03/13/95 028 0251 5012
13710835 AMLODIPINE 10 MG TABLET EXTERNAL 04/19/05 028 0251 5012
13710836 AMLODIPINE 5 MG TABLET EXTERNAL 04/19/05 028 0251 5012
13710837 AMLODIPINE 2.5 MG TABLET EXTERNAL 04/19/05 028 0251 5012
13710838 AMLODIPINE 1.25 MG (1/2 X 2.5 EXTERNAL 04/19/05 028 0251 5012
13710840 AMMONIA AROMATIC 0.33ML EXTERNAL 03/13/95 028 0250 5012
13710845 AMMONIA, AROMATIC 0.4ML AMP-12 EXTERNAL 03/13/95 028 0251 5012
13710880 AMMONIUM CHLORIDE 5MEQ/ML INJ EXTERNAL 03/13/95 028 0250 5012
13710881 AMOBARBITAL 500 MG VIAL EXTERNAL 06/07/01 028 0251 5012
13710882 AMOBARBITAL 0.5 GM INJ EXTERNAL 06/07/01 028 0251 5012
13710904 AMOXICILLIN 500MG SUSPENSION EXTERNAL 03/13/95 028 0250 5012
13710905 AMOXICILLIN SUSPENSION 150ML B EXTERNAL 03/13/95 028 0250 5012
13710906 AMOXICILLIN 125MG SUSPENSION EXTERNAL 03/13/95 028 0250 5012
13710907 AMOXICILLIN 50MG/ML SUSPENSION EXTERNAL 03/13/95 028 0250 5012
13710908 AMOXICILLIN 250MG SUSPENSION EXTERNAL 03/13/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 207
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13710916 AMOXICILLIN 1000 MG (2 X 500 M EXTERNAL 01/25/08 028 0251 5012
13710921 AMOXICILLIN-CLAVULANATE 875MG EXTERNAL 02/04/98 028 0251 5012
13710923 AMOXICILLIN 37.5MG SUSPENSION EXTERNAL 07/18/97 028 0251 5012
13710924 AMOXICILLIN 62.5MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710925 AMOXICILLIN 75MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710926 AMOXICILLIN 100 MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710927 AMOXICILLIN 150 MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710928 AMOXICILLIN 175 MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710929 AMOXICILLIN 200 MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710930 AMOXICILLIN 300 MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710931 AMOXICILLIN 400 MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13710940 AMPHOTERICIN B INJECTION 50MG EXTERNAL 03/13/95 J0285 J0285 J0285 028 0250 5012
13710941 AMPHOTERICIN B CONV 5MG/ML INJ EXTERNAL 08/01/94 J0285 J0285 028 0636 5012
13710942 AMPHOTERICIN B CONV 50MG BLAD EXTERNAL 07/01/84 J0285 J0285 028 0636 5012
13710943 AMPHOTERICIN B LIPID COMPLEX 2 EXTERNAL 09/23/96 J0287 J0287 028 0636 5012
13710944 AMPHOTERICIN B LIPID COMPLEX 5 EXTERNAL 09/23/96 J0287 J0287 028 0636 5012
13710945 AMPHOTERICIN B CONV 8.3MG/ML I EXTERNAL 06/09/98 J0285 J0285 028 0636 5012
13710946 AMPHO B 10MG/SWF IRR 1000ML EXTERNAL 02/15/01 028 0258 5012
13710947 AMPHOTERICIN B CONV 0.1MG/ML O EXTERNAL 11/02/01 J0285 J0285 J0285 028 0258 5012
13710948 AMPHOTERICIN B LIPID COMPLEX 1 EXTERNAL 12/27/04 J0290 J0290 028 0636 5012
13711060 AMPICILLIN INJECTION 125MG VIA EXTERNAL 03/13/95 J0290 J0290 028 0636 5012
13711064 UNASYN 1.5 GM INJ EXTERNAL 08/08/06 028 0258 5012
13711065 UNASYN 3.0 GM INJ EXTERNAL 08/08/06 028 0258 5012
13711066 UNASYN 375 MG/ML INJ EXTERNAL 04/08/08 028 0258 5012
13711067 UNASYN 30 MG AMPICILLIN/ML PED EXTERNAL 04/08/08 028 0258 5012
13711070 AMPICILLIN INJECTION 250MG VIA EXTERNAL 03/13/95 J0290 J0290 028 0636 5012
13711071 AMPICILLIN 150MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711072 AMPICILLIN 200MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711073 AMPICILLIN 250MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711079 AMPICILLIN 300MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711080 AMPICILLIN INJECTION 500MG VIA EXTERNAL 07/13/94 J0290 J0290 028 0636 5012
13711083 AMPICILLIN 400MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711084 AMPICILLIN 500MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711085 AMPICILLIN 500MG/NS 50ML EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711089 AMPICILLIN 300MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711090 AMPICILLIN INJECTION 500MG VIA EXTERNAL 07/13/94 J0290 J0290 028 0636 5012
13711093 AMPICILLIN 350MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711094 AMPICILLIN 400MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711095 AMPICILLIN 450MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711096 AMPICILLIN 500MG INJ EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711097 AMPICILLIN 500MG/NS 50ML EXTERNAL 03/06/96 J0290 J0290 028 0636 5012
13711098 AMPICILLIN 1.00GM EXTERNAL 03/07/96 028 0258 5012
13711100 AMPICILLIN 0.1GM/ML INJ EXTERNAL 07/13/94 J0290 J0290 028 0636 5012
13711101 AMPICILLIN 500MG/NS 25 ML EXTERNAL 03/07/96 J0290 J0290 028 0636 5012
13711110 AMYL NITRITE 0.3ML AMP EXTERNAL 07/13/94 028 0250 5012
13711120 ANALGESIC BALM 30GM EXTERNAL 07/13/94 028 0250 5012
13711135 ANDRODERM 5 MG/DAY PATCH EXTERNAL 05/12/03 028 0251 5012
13711171 ATGAM 50MG/ML INJ EXTERNAL 01/01/03 J7504 J7504 028 0636 5012
13711172 THYMOGLOBULIN 25MG/ML INJ EXTERNAL 01/01/03 J7504 J7504 028 0636 5012
13711173 ANTITHYMOCYTE GLOBULIN, RABBIT EXTERNAL 01/01/03 028 0251 5012
13711184 APROTININ INJ 1.4 MG/ML EXTERNAL 11/16/94 028 0251 5012
13711186 APREPITANT 125 MG CAPSULE EXTERNAL 12/27/04 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 208
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13711187 APREPITANT 80 MG CAPSULE EXTERNAL 12/27/04 028 0251 5012
13711241 AQUAPHOR OINT 16OZ EXTERNAL 07/13/94 028 0250 5012
13711242 AQUAPHOR OINT 50GM EXTERNAL 01/17/96 028 0251 5012
13711243 ARGATROBAN 100 MG/ML INJ EXTERNAL 06/14/04 028 0258 5012
13711244 ARGATROBAN 250 MG FOR 250 ML L EXTERNAL 12/27/04 028 0258 5012
13711251 ARGININE 10% INJ 300ML EXTERNAL 07/13/94 028 0250 5012
13711252 ARIPIPRAZOLE 10MG TAB EXTERNAL 05/22/03 028 0251 5012
13711253 ARIPIPRAZOLE 15MG TAB EXTERNAL 05/22/03 028 0251 5012
13711254 ARIPIPRAZOLE 5 MG (1/2 10 MG T EXTERNAL 12/27/04 028 0251 5012
13711255 ARIPIPRAZOLE 2.5 MG (1/4 10 MG EXTERNAL 12/27/04 028 0251 5012
13711256 ARIPIPRAZOLE 7.5MG/ML 1.3 ML V EXTERNAL 07/09/07 028 0258 5012
13711257 ARIPIPRAZOLE 20MG (2 X 10 MG) EXTERNAL 01/26/09 028 0251 5012
13711258 ARIPIPRAZOLE 30MG (2 X 15 MG) EXTERNAL 12/27/04 028 0251 5012
13711280 ASCORBIC ACID INJECTION 500MG EXTERNAL 07/13/94 028 0251 5012
13711300 ASCORBIC ACID 100MG TAB EXTERNAL 07/13/94 028 0250 5012
13711345 ASCORBIC ACID SOLN 58MG/ML 50M EXTERNAL 07/13/94 028 0250 5012
13711351 ASCORBIC ACID 100MG/ML SOLN EXTERNAL 07/13/94 028 0250 5012
13711418 ASPIRIN EC 81 MG BULK EXTERNAL 10/12/95 028 0251 5012
13711420 ASPIRIN 300MG SUPP EXTERNAL 07/13/94 028 0250 5012
13711421 ASPIRIN 300MG SUPPOSITORY 1BOX EXTERNAL 07/13/94 028 0250 5012
13711423 ASPIRIN/DIPYRIDAMOLE 25 MG/200 EXTERNAL 12/02/04 028 0251 5012
13711440 ASPIRIN 600MG SUPP EXTERNAL 07/13/94 028 0250 5012
13711441 ASPIRIN 600MG SUPPOSITORY-1 BO EXTERNAL 07/13/94 028 0250 5012
13711457 ATORVASTATIN 80 MG TABLET EXTERNAL 08/15/08 028 0251 5012
13711490 ATROPINE SULFATE 0.25MG/0.25ML EXTERNAL 07/13/94 J0461 J0461 028 0636 5012
13711491 ATROPINE 0.5% 1MG/0.5ML SVN EXTERNAL 11/30/90 028 0251 5012
13711492 ATROPINE 0.5% 1.5MG/0.75ML SVN EXTERNAL 03/12/96 028 0251 5012
13711493 ATROPINE 0.5% 2.5MG/1.25ML SVN EXTERNAL 03/12/96 028 0251 5012
13711498 ATAZANAVIR 300MG CAPSULE EXTERNAL 02/25/08 028 0251 5012
13711500 ATROPINE SULFATE 0.2MG VIAL EXTERNAL 07/13/94 J0461 J0461 J0461 028 0250 5012
13711503 ATROPINE SULFATE 0.4MG/ML INJ EXTERNAL 07/01/84 J0461 J0461 J0461 028 0636 5012
13711505 ATROPINE SULFATE 0.25MG/2.5ML EXTERNAL 07/13/94 J0461 J0461 J0461 028 0636 5012
13711530 ATROPINE SULFATE 1% OPTH OINT EXTERNAL 07/13/94 028 0250 5012
13711540 ATROPINE SULF 0.5% OPTH OINT EXTERNAL 07/13/94 028 0250 5012
13711550 ATROPINE SULF 1% OPTH SOLN 1ML EXTERNAL 07/13/94 028 0250 5012
13711551 ATROPINE SULF 1% OPTH SOLN 2ML EXTERNAL 07/13/94 028 0250 5012
13711560 ATROPINE SULF 1% OPTH SOLN 5ML EXTERNAL 07/01/84 028 0251 5012
13711570 ATROPINE SULF 1% OPTH SOLN 15M EXTERNAL 07/01/84 028 0251 5012
13711606 AMOXICILLIN-CLAVULANATE 500MG EXTERNAL 07/13/94 028 0251 5012
13711609 AMOXICILLIN-CLAVULANATE 125MG EXTERNAL 07/13/94 028 0251 5012
13711612 AMOXICILLIN-CLAVULANATE 250MG EXTERNAL 07/13/94 028 0251 5012
13711613 AMOXICILLIN-CLAVULANATE 50MG/M EXTERNAL 07/13/94 028 0251 5012
13711615 AMOXICILLIN-CLAVULANATE 500MG EXTERNAL 07/13/94 028 0251 5012
13711616 AMOXICILLIN-CLAVULANATE 62.5MG EXTERNAL 05/01/95 028 0251 5012
13711617 AMOXICILLIN-CLAVULANATE 37.5MG EXTERNAL 11/30/98 028 0251 5012
13711618 AMOXICILLIN-CLAVULANATE 75MG S EXTERNAL 06/26/03 028 0251 5012
13711619 AMOXICILLIN-CLAVULANATE 100MG EXTERNAL 06/26/03 028 0251 5012
13711620 AMOXICILLIN-CLAVULANATE 150MG EXTERNAL 06/26/03 028 0251 5012
13711621 AMOXICILLIN-CLAVULANATE 175MG EXTERNAL 06/26/03 028 0251 5012
13711622 AMOXICILLIN-CLAVULANATE 200MG EXTERNAL 06/26/03 028 0251 5012
13711623 AMOXICILLIN-CLAVULANATE 275MG EXTERNAL 06/26/03 028 0251 5012
13711624 AMOXICILLIN-CLAVULANATE 300MG EXTERNAL 06/26/03 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 209
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13711625 AMOXICILLIN-CLAVULANATE 400MG EXTERNAL 06/26/03 028 0251 5012
13711626 AMOXICILLIN-CLAVULANATE 400 MG EXTERNAL 12/27/04 028 0251 5012
13711630 ANTIPYRENE-BENZOCAINE OTIC SOL EXTERNAL 07/13/94 028 0250 5012
13711654 AZITHROMYCIN 1000MG ORAL SUSP EXTERNAL 05/28/02 Q0144 Q0144 Q0144 028 0251 5012
13711655 AZTREONAN 1 GM FROZEN INJECTIO EXTERNAL 03/24/05 028 0258 5012
13711656 AZTREONAN 2 GM FROZEN INJECTIO EXTERNAL 03/24/05 028 0258 5012
13711657 AZTREONAN 0.333G/ML EXTERNAL 03/24/05 028 0258 5012
13711658 AZATHIOPRINE 500 MG INJ EXTERNAL 12/27/04 J0456 J0456 J0456 028 0636 5012
13711662 AZATHIOPRINE 50MG UD - 100/BOX EXTERNAL 08/19/92 028 0251 5012
13711663 AZATHIOPRINE 25MG (PER 1/2 TAB EXTERNAL 07/13/94 J7500 J7500 028 0636 5012
13711664 AZATHIOPRINE 50MG/ML ORAL SOLN EXTERNAL 11/08/01 J7500 J7500 028 0636 5012
13711665 AZTREONAN 20 MG/ML PEDS INJ EXTERNAL 01/11/05 028 0258 5012
13711667 AZTREONAN 500 MG FROZEN INJEC EXTERNAL 03/24/05 028 0258 5012
13711670 AZATHIOPRINE INJ 100MG VIAL EXTERNAL 07/13/94 J7501 J7501 J7501 028 0258 5012
13711671 PREDNISONE 1MG TAB EXTERNAL 09/04/01 J7506 J7506 J7506 028 0636 5012
13711672 PREDNISONE 5MG + 2.5MG TAB EXTERNAL 04/07/94 J7506 J7506 J7506 028 0636 5012
13711674 PREDNISONE 5MG TAB EXTERNAL 04/07/94 J7506 J7506 J7506 028 0251 5012
13711675 PREDNISONE 1X20 MG + 1X5 MG TA EXTERNAL 04/07/94 J7506 J7506 J7506 028 0636 5012
13711678 PREDNISONE 5MG TAB EXTERNAL 04/08/94 J7506 J7506 J7506 028 0637 5012
13711679 PREDNISONE 2X20 MG + 1X5 MG TA EXTERNAL 04/08/94 J7506 J7506 J7506 028 0637 5012
13711682 PREDNISONE 5MG TABS EXTERNAL 04/08/94 J7506 J7506 J7506 028 0636 5012
13711696 PREMASOL 10% INJECTION EXTERNAL 06/29/01 028 0258 5012
13711697 PREGNANCY KIT EXTERNAL 06/01/10 028 0251 5012
13711716 AZITHROMYCIN 1GM ORAL SUSP EXTERNAL 03/26/02 Q0144 Q0144 Q0144 028 0636 5012
13711728 AZATHIOPRINE 225MG (4 1/2 X 50 EXTERNAL 07/13/94 J7500 J7500 J7500 028 0636 5012
13711760 BACITRACIN OINT 30GM EXTERNAL 07/13/94 028 0251 5012
13711761 BACITRACIN 0.09 GM OINT UD PKT EXTERNAL 02/25/08 028 0251 5012
13711762 BACITRACIN 15G OINT EXTERNAL 01/21/09 028 0251 5012
13711765 BACITRACIN OPHTH OINT 3.5GM EXTERNAL 07/13/94 028 0250 5012
13711770 BACITRACIN 50,000 UNITS INJ EXTERNAL 07/13/94 028 0250 5012
13711779 BACLOFEN 20MG (2 X 10 MG) TAB EXTERNAL 01/25/08 028 0251 5012
13711780 BACLOFEN 50MCG/ML TEST DOSE IN EXTERNAL 01/24/00 J0475 J0475 J0475 028 0636 5012
13711782 BACLOFEN 10MG/20ML (500MCG) EXTERNAL 01/24/00 028 0258 5012
13711783 BACLOFEN INTRATHECAL KIT 2000M EXTERNAL 01/01/03 J0476 J0476 J0476 028 0636 5012
13711784 BACLOFEN 2.5 MG (1/4 X 10 MG) EXTERNAL 06/08/06 028 0251 5012
13711785 BACLOFEN 10 MG/ML ORAL SUSP EXTERNAL 02/13/08 028 0251 5012
13711786 BACLOFEN 2.5MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13711787 BACLOFEN 5 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13711830 BALANCED SALT OPHTH SOLN 15ML EXTERNAL 07/01/84 028 0250 5012
13711831 BALANCED SALT OPTH SOLN 500ML EXTERNAL 07/01/84 028 0250 5012
13711864 BECLOMETHASONE AQ NASAL SOLN 2 EXTERNAL 07/14/94 028 0251 5012
13711865 BECLOMETHASONE NASAL INHALER 1 EXTERNAL 07/14/94 J7622 028 0250 5012
13711960 BENZOCAINE 20% SPRAY 60ML EXTERNAL 07/14/94 028 0250 5012
13711995 CALCIUM CHLORIDE 0.1GM/ML INJ EXTERNAL 05/14/02 028 0258 5012
13712069 BENZOYL PEROXIDE 2.5% GEL 60GM EXTERNAL 07/14/94 028 0250 5012
13712070 BENZOYL PEROXIDE 5% GEL 45GM EXTERNAL 07/14/94 028 0250 5012
13712080 BENZOYL PEROXIDE 10% GEL 90GM EXTERNAL 07/14/94 028 0250 5012
13712115 BERACTANT 25MG/ML SUSP 8 ML EXTERNAL 07/14/94 028 0251 5012
13712116 BERACTANT 25MG/ML SUSP 4ML EXTERNAL 05/25/00 028 0251 5012
13712121 BENZTROPINE MESYLATE 0.5MG - 1 EXTERNAL 01/25/95 028 0251 5012
13712122 BENZTROPINE 0.25MG (1/2 X 0.5M EXTERNAL 05/10/07 028 0251 5012
13712141 BENZTROPINE 1MG/ML INJ EXTERNAL 07/14/94 J0515 J0515 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 210
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13712142 BENZTROPINE MESYLATE 1MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13712191 BETAMETHASONE DIPRO 0.05% OINT EXTERNAL 03/26/02 028 0251 5012
13712192 BETAMETHASONE DIPRO 0.05% OINT EXTERNAL 03/26/02 028 0251 5012
13712193 BETAMETHASONE DIPRO 0.05%CRM 4 EXTERNAL 03/26/02 028 0251 5012
13712194 BETAMETHASONE DIPRO 0.05% CRM EXTERNAL 03/26/02 028 0251 5012
13712195 BETAMETHASONE VAL 0.1% CRM 45G EXTERNAL 03/26/02 028 0251 5012
13712196 BETAMETHASONE 3MG INJ EXTERNAL 07/17/97 J0702 J0702 028 0636 5012
13712200 BETAMETHASONE VAL 0.1% OINT 15 EXTERNAL 03/26/02 028 0251 5012
13712210 BETAMETHASONE VAL 0.1% OINT 45 EXTERNAL 03/26/02 028 0251 5012
13712301 CITRIC ACID-NA CITRATE 1ML ORA EXTERNAL 05/01/95 028 0251 5012
13712302 CITRIC ACID-NA CITRATE 1.5ML O EXTERNAL 05/01/95 028 0251 5012
13712303 CITRIC ACID-NA CITRATE 2ML ORA EXTERNAL 05/01/95 028 0251 5012
13712304 CITRIC ACID-NA CITRATE 2.5ML O EXTERNAL 05/01/95 028 0251 5012
13712308 CITRIC ACID-NA CITRATE 7.5ML O EXTERNAL 05/01/95 028 0251 5012
13712310 CITRIC ACID-NA CITRATE 20ML OR EXTERNAL 05/01/95 028 0250 5012
13712312 CITRIC ACID-NA CITRATE 0.5ML O EXTERNAL 12/18/01 028 0251 5012
13712340 BICITRA SOLUTION 480MG BOTTLE EXTERNAL 07/01/84 028 0250 5012
13712341 CITRIC ACID-NA CITRATE 15ML OR EXTERNAL 07/14/94 028 0251 5012
13712342 CITRIC ACID-NA CITRATE 30ML OR EXTERNAL 07/14/94 028 0251 5012
13712351 CITRIC ACID-NA CITRATE 5ML ORA EXTERNAL 05/01/95 028 0251 5012
13712352 CITRIC ACID-NA CITRATE 10ML OR EXTERNAL 05/01/95 028 0251 5012
13712353 CITRIC ACID-NA CITRATE 45ML OR EXTERNAL 05/01/95 028 0251 5012
13712354 CITRIC ACID-NA CITRATE 60ML OR EXTERNAL 05/01/95 028 0251 5012
13712356 CITRIC ACID-NA CITRATE 120ML O EXTERNAL 05/01/95 028 0251 5012
13712360 BISACODYL 5MG EC TAB EXTERNAL 07/14/94 028 0250 5012
13712361 BISACODYL 5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13712365 BISACODYL 10 MG (2 X 5 MG) EC EXTERNAL 01/29/08 028 0251 5012
13712370 BISACODYL 10MG SUPP EXTERNAL 07/14/94 028 0250 5012
13712371 BISACODYL 10MG SUPPOSITORY-1BO EXTERNAL 01/25/95 028 0251 5012
13712372 BISACODYL 5MG SUPP EXTERNAL 07/14/94 028 0251 5012
13712373 BIVALIRUDIN 250 MG INJ EXTERNAL 06/14/04 J0583 J0583 028 0636 5012
13712374 BIVALIRUDIN 250 MG FOR 100 ML EXTERNAL 06/14/04 J0583 J0583 028 0636 5012
13712390 BLEOMYCIN 15 MG/ML INJ EXTERNAL 07/14/94 J9040 J9040 J9040 028 0636 5012
13712399 BORTEZOMIB 3.5 MG INJ EXTERNAL 06/01/10 028 0258 5012
13712400 BOTULINUM TOXIN TYPE A INJ EXTERNAL 07/14/94 J0585 J0585 J0585 028 0636 5012
13712463 BRIMONIDINE 0.15% OPHTH SOLN 1 EXTERNAL 12/18/01 028 0251 5012
13712465 BROMOCRIPTINE 2.5MG TAB EXTERNAL 07/14/94 028 0250 5012
13712467 BIMATOPROST 0.03% OPTH SOL EXTERNAL 04/05/02 028 0251 5012
13712468 BROMOCRIPTINE 1.25MG TAB (1/2 EXTERNAL 06/08/06 028 0251 5012
13712483 BUDESONIDE 200MCG/INH MDI EXTERNAL 01/01/08 028 0250 5012
13712484 BUDESONIDE AQ 32 MCG SPRAY 8.6 EXTERNAL 03/27/03 028 0250 5012
13712485 BUDESONIDE 0.25 MG/2 ML NEB SU EXTERNAL 01/01/08 028 0251 5012
13712486 BUDESONIDE-FORMOTEROL 80-4.5 M EXTERNAL 09/25/09 028 0251 5012
13712487 BUDESONIDE-FORMOTEROL 160-4.5 EXTERNAL 09/25/09 028 0251 5012
13712539 BUPIVACAINE 0.75% SPINAL INJ EXTERNAL 07/14/94 028 0251 5012
13712541 BUPIVACAINE 0.25% INJ EXTERNAL 07/14/94 028 0250 5012
13712551 BUPIVACAINE 0.5% W/EPI INJ EXTERNAL 07/14/94 028 0251 5012
13712562 BUPIVACAINE 150MG VIAL EXTERNAL 10/19/90 028 0250 5012
13712570 BUPIVACAINE 250MG VIAL EXTERNAL 07/01/84 028 0250 5012
13712571 BUPIVACAINE 0.5% INJ EXTERNAL 07/14/94 028 0250 5012
13712572 BUPIVACAINE 0.0625% IN NACL 0. EXTERNAL 12/28/04 028 0258 5012
13712580 BUPIVACAINE 0.75% INJ EXTERNAL 07/14/94 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 211
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13712582 BUPIV 0.05%-EPI 1:2000 AMP EXTERNAL 10/19/90 028 0250 5012
13712583 BUPIVACAINE 0.25% W/EPI INJ EXTERNAL 01/28/93 028 0251 5012
13712594 BUPROPION 150MG SR TABLET- 1 B EXTERNAL 12/22/97 028 0251 5012
13712595 BUPROPION 150MG SR TAB EXTERNAL 12/22/97 028 0251 5012
13712596 BUPROPION 100MG SA TABLET- 1 B EXTERNAL 12/22/97 028 0251 5012
13712597 BUPROPION 100MG SR TAB EXTERNAL 12/22/97 028 0251 5012
13712621 BUSPIRONE 5MG - 1 BOX EXTERNAL 03/22/91 028 0251 5012
13712622 BUSPIRONE 5MG TAB EXTERNAL 07/14/94 028 0251 5012
13712624 BUSPIRONE 10MG - 1 BOX EXTERNAL 03/22/91 028 0251 5012
13712625 BUSPIRONE 10MG TAB EXTERNAL 07/14/94 028 0251 5012
13712629 BUSPIRONE 2.5MG TAB EXTERNAL 06/16/06 028 0251 5012
13712642 CAFFEINE CITRATE 7MG/0.35 ML S EXTERNAL 06/12/06 028 0251 5012
13712643 CAFFEINE CITRATE 5MG/0.25 ML S EXTERNAL 04/12/06 028 0251 5012
13712644 CAFFEINE CITRATE 6MG/0.3 ML SO EXTERNAL 04/12/06 028 0251 5012
13712645 CAFFEINE CITRATE 10MG/0.5 ML S EXTERNAL 04/12/06 028 0251 5012
13712646 CAFFEINE CITRATE 4MG/0.2 ML SO EXTERNAL 04/12/06 028 0251 5012
13712647 CAFFEINE CITRATE 8MG/0.4 ML SO EXTERNAL 04/12/06 028 0251 5012
13712648 CAFFEINE CITRATE 12MG/0.6 ML S EXTERNAL 04/12/06 028 0251 5012
13712650 BUSULFAN 2MG TAB EXTERNAL 07/14/94 J8510 J8510 028 0636 5012
13712651 BUSULFAN 2MG - 1 BOTTLE EXTERNAL 01/25/95 J8510 J8510 028 0636 5012
13712670 CAFFEINE-ERGOTAMINE 100MG/1MG EXTERNAL 07/14/94 028 0250 5012
13712671 ERGOTAMINE/CAFFEINE - 1 PACK EXTERNAL 01/25/95 028 0251 5012
13712672 CAFFEINE CITRATE 20 MG/ML INJ EXTERNAL 01/26/04 J0706 J0706 028 0636 5012
13712673 CAFFEINE CITRATE 20MG/ML SOLUT EXTERNAL 03/01/04 028 0251 5012
13712674 CAFFEINE CITRATE 10 MG/ML PEDS EXTERNAL 12/28/04 J0706 J0706 028 0636 5012
13712675 CAFFIENE BENZOATE 250 MG/ML IN EXTERNAL 02/08/08 028 0258 5012
13712716 CALCITRIOL 0.2 MCG ORAL SOLUTI EXTERNAL 12/28/04 028 0251 5012
13712717 CALCITRIOL 0.1 MCG ORAL SOLUTI EXTERNAL 12/28/04 028 0251 5012
13712718 CALCITRIOL 0.25 MCG ORAL SOLUT EXTERNAL 12/28/04 028 0251 5012
13712719 CALAMINE LOTION 120ML EXTERNAL 07/14/94 028 0250 5012
13712721 CALCITRIOL 0.5 MCG ORAL SOLUTI EXTERNAL 12/28/04 028 0251 5012
13712722 CALCITRIOL 0.75 MCG ORAL SOLUT EXTERNAL 12/28/04 028 0251 5012
13712723 CALCITRIOL ORAL SOLUTION 1 MCG EXTERNAL 08/03/00 028 0251 5012
13712724 CALCIUM CARBONATE 50MG SUSPENS EXTERNAL 12/18/01 028 0251 5012
13712725 CALCITRIOL 0.25MCG CAP EXTERNAL 07/14/94 028 0251 5012
13712726 CALCITRIOL 0.25MCG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13712728 CALCITRIOL 0.50MCG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13712729 CALCIUM CARBONATE 75MG SUSPENS EXTERNAL 12/18/01 028 0251 5012
13712730 CALCITONIN INJECTION 400 UNIT EXTERNAL 07/01/84 J0630 J0630 028 0636 5012
13712732 CALCITONIN 200UNITS/ML INJ EXTERNAL 07/14/94 J0630 J0630 028 0636 5012
13712734 CALCIUM CARBONATE 150MG SUSPEN EXTERNAL 12/18/01 028 0251 5012
13712735 CALCIUM CARBONATE 325MG SUSPEN EXTERNAL 12/18/01 028 0251 5012
13712736 CALCIUM CARBONATE 600MG SUSPEN EXTERNAL 12/18/01 028 0251 5012
13712737 CALCIUM CARBONATE 800MG SUSPEN EXTERNAL 12/18/01 028 0251 5012
13712738 CALCIUM CARBONATE 1250MG SUSP EXTERNAL 01/01/95 028 0251 5012
13712740 CALCIUM CARBONATE (OYSTER SHEL EXTERNAL 01/01/95 028 0250 5012
13712742 CALCIUM CARBONATE SUSPENSION 5 EXTERNAL 01/01/95 028 0251 5012
13712743 CALCIUM CARBONATE 1000MG SUSP EXTERNAL 01/01/95 028 0250 5012
13712744 CALCIUM CARBONATE 500MG SUSP EXTERNAL 01/01/95 028 0250 5012
13712745 CALCIUM CARBONATE 250MG/ML SUS EXTERNAL 11/01/94 028 0251 5012
13712746 CALCIUM CARBONATE 125MG SUSP EXTERNAL 05/01/95 028 0251 5012
13712748 CALCIUM CARBONATE 375MG SUSP EXTERNAL 05/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 212
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13712749 CALCIUM CARBONATE 750MG SUSP EXTERNAL 05/01/95 028 0251 5012
13712752 CALCIUM CARBONATE 1500MG SUSP EXTERNAL 05/01/95 028 0251 5012
13712753 CALCIUM CARBONATE 200MG SUSP EXTERNAL 05/01/95 028 0251 5012
13712755 CALCIUM CHLORIDE 10% INJ 1GM V EXTERNAL 01/01/95 028 0250 5012
13712758 CALCIUM CARBONATE 2500MG (2 X EXTERNAL 05/01/08 028 0251 5012
13712759 CALCIUM CARBONATE 2500 MG(2 X EXTERNAL 01/29/08 028 0251 5012
13712760 CALCIUM CHLORIDE 10% INJ 1GM S EXTERNAL 01/01/95 028 0250 5012
13712765 CALCIUM CARBONATE 625 MG(1/2 X EXTERNAL 01/29/08 028 0251 5012
13712790 EDETATE CALCIUM DISODIUM 200MG EXTERNAL 01/01/95 J0600 J0600 028 0636 5012
13712828 CALCIUM GLUCONATE 10% 50ML VIA EXTERNAL 10/23/08 J0610 J0610 J0610 028 0258 5012
13712829 CALCIUM GLUCONATE 10% - 200ML EXTERNAL 04/09/04 J0610 J0610 J0610 028 0258 5012
13712830 CALCIUM GLUCONATE 0.1GM/ML INJ EXTERNAL 01/01/95 J0610 J0610 028 0636 5012
13712831 CALCIUM GLUCONATE 10% INJ 1GM EXTERNAL 01/01/95 J0610 028 0636 5012
13712834 CALCIUM GLUCONATE 1GM/D5W 50ML EXTERNAL 01/16/03 J0610 J0610 028 0636 5012
13712835 CALCIUM GLUCONATE 200MG/D5W 10 EXTERNAL 01/16/03 J0610 J0610 028 0636 5012
13712885 LEUCOVORIN CALCIUM 10MG/ML INJ EXTERNAL 07/01/84 J0640 J0640 028 0636 5012
13712887 LEUCOVORIN CALCIUM 25MG TAB EXTERNAL 01/01/95 028 0250 5012
13712892 LEUCOVORIN CALCIUM 5MG TAB EXTERNAL 12/28/93 028 0251 5012
13712894 LEUCOVORIN CALCIUM 15 MG (3 X EXTERNAL 02/08/08 028 0251 5012
13712940 CANDIDA ALBICANS 1:1000 SKIN T EXTERNAL 07/01/84 028 0251 5012
13712950 CANTHARONE 0.7% TOPICAL SOLUTI EXTERNAL 01/01/95 028 0250 5012
13712980 CARBACHOL 3% 15ML OPTH SOLN EXTERNAL 01/01/95 028 0250 5012
13712993 CARBAMAZEPINE SR 100MG (BOX) EXTERNAL 12/17/96 028 0251 5012
13712996 CARBAMAZEPINE 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13713002 CARBAMAZEPINE 200MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13713003 CARBAMAZEPINE 100MG (1/2 X 200 EXTERNAL 01/01/95 028 0251 5012
13713004 CARBAMAZEPINE 300MG (100 MG X EXTERNAL 12/28/04 028 0251 5012
13713005 CARBAMAZEPINE 400MG (200 MG X EXTERNAL 01/29/08 028 0251 5012
13713006 CARBAMAZEPINE 100MG/5ML SUSP 4 EXTERNAL 07/07/88 028 0251 5012
13713007 CARBAMAZEPINE 50MG CHEW TAB EXTERNAL 06/16/06 028 0251 5012
13713008 CARBAMAZEPINE 1200 MG (400 MG EXTERNAL 12/28/04 028 0251 5012
13713010 CARBAMAZEPINE SR 200MG (BOX) EXTERNAL 12/17/96 028 0251 5012
13713013 CARBAMAZEPINE SR 400MG (BOX) EXTERNAL 12/17/96 028 0251 5012
13713055 CARBOPROST TROMETHAMINE 250MCG EXTERNAL 01/01/95 028 0251 5012
13713063 INDOCYANINE GREEN 5MG/ML INJ EXTERNAL 01/01/95 028 0251 5012
13713106 CARMUSTINE WAFERS BOX EXTERNAL 11/04/99 028 0251 5012
13713107 CARMUSTINE 7.7MG WAFER [8 PACK EXTERNAL 11/04/99 028 0258 5012
13713116 L-CARNITINE 330MG - 1 BOX EXTERNAL 05/31/90 028 0251 5012
13713117 LEVOCARNITINE 330MG TAB EXTERNAL 01/01/95 028 0251 5012
13713118 LEVOCARNITINE 500MG/5ML 120ML EXTERNAL 05/31/90 028 0251 5012
13713119 LEVOCARNITINE 300MG DOSE EXTERNAL 10/08/01 028 0251 5012
13713120 LEVOCARNITINE 100MG/ML SOLN EXTERNAL 03/12/96 028 0251 5012
13713129 CARVEDILOL 0.1 MG/ML ORAL SUSP EXTERNAL 02/13/08 028 0251 5012
13713131 CARVEDILOL 0.2 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13713132 CARVEDILOL 0.3 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13713133 CARVEDILOL 0.5 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13713134 CARVEDILOL 0.6 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13713135 CEFAZOLIN 500MG/D5W 50ML EXTERNAL 11/02/99 J0690 J0690 J0690 028 0258 5012
13713136 CARVEDILOL 1 MG ORAL SUSP EXTERNAL 05/07/08 028 0251 5012
13713141 CEFPODOXIME 50MG/5ML SUSP EXTERNAL 04/05/94 028 0251 5012
13713142 CEFPODXIME 20MG/ML SUSP EXTERNAL 01/01/95 028 0251 5012
13713144 CEFPODOXIME 100MG BOTTLE EXTERNAL 04/05/94 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 213
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13713147 CEFPODOXIME 200MG BOTTLE 100 EXTERNAL 04/05/94 028 0251 5012
13713151 CASPOFUNGIN 50 MG EXTERNAL 07/22/04 J0637 J0637 028 0636 5012
13713152 CASPOFUNGIN 70 MG EXTERNAL 07/22/04 J0637 J0637 028 0636 5012
13713153 CASPOFUNGIN 35 MG/NS 250 ML EXTERNAL 07/22/04 J0637 J0637 028 0636 5012
13713154 CASPOFUNGIN 50 MG/NS 250 ML EXTERNAL 07/22/04 J0637 J0637 028 0636 5012
13713155 CASPOFUNGIN 70 MG/NS 250 ML EXTERNAL 07/22/04 J0637 J0637 028 0636 5012
13713165 CEFOXITIN 1 GRAM EXTERNAL 01/01/95 J0694 J0694 J0694 028 0251 5012
13713166 CEFOXITIN 2 GRAMS EXTERNAL 01/01/95 J0694 J0694 J0694 028 0251 5012
13713167 CEFOXITIN 2GM/D5W 50ML EXTERNAL 05/09/94 J0694 J0694 028 0636 5012
13713169 CEFOXITIN 500MG/D5W 50ML EXTERNAL 06/29/93 J0694 J0694 028 0636 5012
13713171 CEFAZOLIN INJECTION 500MG VIAL EXTERNAL 01/01/95 J0690 J0690 028 0636 5012
13713172 CEFAZOLIN INJECTION 500MG SYRI EXTERNAL 01/01/95 J0690 J0690 028 0636 5012
13713173 CEFOXITIN 1GM/D5W 50ML EXTERNAL 06/29/93 J0694 J0694 028 0636 5012
13713174 CEFOXITIN 2 GRAMS IN 50ML D5W EXTERNAL 06/29/93 028 0251 5012
13713178 CEFAZOLIN 500MG/D5W 50ML EXTERNAL 03/07/96 J0690 J0690 028 0636 5012
13713179 CEFAZOLIN 1 GM/D5W 50ML EXTERNAL 12/18/92 J0690 J0690 028 0636 5012
13713180 CEFAZOLIN INJECTION 500MG VIA EXTERNAL 12/18/92 J0690 J0690 028 0636 5012
13713181 CEFAZOLIN INJECTION 500MG VIAL EXTERNAL 07/01/84 J0690 J0690 028 0636 5012
13713183 CEFOTAXIME INJECTION 1GRAM VIA EXTERNAL 12/18/92 J0694 J0694 028 0636 5012
13713184 CEFOTAXIME INJECTION 1GRAM VIA EXTERNAL 12/18/92 J0694 J0694 028 0636 5012
13713189 CEFTRIAXONE INJECTION 1 GM VI EXTERNAL 12/18/92 J0696 J0696 028 0636 5012
13713190 CEPACOL ANESTHETIC THROAT LOZE EXTERNAL 12/18/92 028 0250 5012
13713192 CEFTRIAXONE INJECTION 250MG VI EXTERNAL 07/01/84 J0696 J0696 028 0636 5012
13713198 CEFOTAXIME 1GM/D5W 50ML EXTERNAL 03/07/96 J0698 J0698 028 0636 5012
13713199 CEFOTAXIME 1GM/D5W 100ML EXTERNAL 03/07/96 J0698 J0698 028 0636 5012
13713201 CEFTAZADINE INJECTION 500MG VI EXTERNAL 12/18/92 J0713 J0713 028 0636 5012
13713202 CEFTAZADINE INJECTION 500MG VI EXTERNAL 12/18/92 J0713 J0713 028 0636 5012
13713203 CEFTAZADIME INJ***MG EXTERNAL 12/18/92 J0713 J0713 028 0636 5012
13713204 CEFTAZIDIME 500MG/D5W 50ML EXTERNAL 12/18/92 J0713 028 0636 5012
13713205 CEFTAZIDIME 500MG/D5W 50ML EXTERNAL 12/18/92 J0713 028 0636 5012
13713221 CEPHALEXIN 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13713231 CEFEPIME 0.1GM/ML INJ EXTERNAL 01/31/97 J0692 J0692 028 0636 5012
13713233 CEFEPIME 100MG/ML INJ EXTERNAL 03/14/97 J0692 J0692 028 0636 5012
13713234 CEFEPIME 1 GM/D5W 50 ML EXTERNAL 12/03/98 J0692 J0692 J0692 028 0636 5012
13713235 CEFEPIME 2 GM/D5W 50 ML EXTERNAL 11/24/03 J0692 J0692 028 0636 5012
13713251 CEPHALEXIN SUSPENSION 62.5MG EXTERNAL 12/18/92 028 0250 5012
13713260 CEPHALEXIN 125MG SUSPENSION EXTERNAL 12/18/92 028 0250 5012
13713263 CEPHALEXIN 37.5MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713265 CEPHALEXIN 75MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713266 CEPHALEXIN 100MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713267 CEPHALEXIN 150MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713268 CEPHALEXIN 175MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713269 CEPHALEXIN 200MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713270 CEPHALEXIN 50MG/ML SUSPENSION EXTERNAL 07/01/84 028 0250 5012
13713271 CEPHALEXIN 300MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713272 CEPHALEXIN 350MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713273 CEPHALEXIN 420MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13713280 CEPHALEXIN 250MG SUSPENSION EXTERNAL 12/18/92 028 0250 5012
13713281 CEPHALEXIN 500MG SUSPENSION EXTERNAL 12/18/92 028 0250 5012
13713282 CEFIXIME 20 MG/ML 50 ML VIAL EXTERNAL 01/07/08 028 0258 5012
13713307 CEFUROXIME 1500 MG/D5W 50 ML I EXTERNAL 11/14/08 028 0258 5012
13713313 CEFUROXIME AXETIL 125MG UD 100 EXTERNAL 05/30/92 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 214
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13713315 CEFUROXIME AXETIL 250MG UD-100 EXTERNAL 05/30/92 028 0251 5012
13713317 CEFUROXIME AXETIL 500MG UD-50/ EXTERNAL 05/30/92 028 0251 5012
13713319 CEFUROXIME 750MG INJECTION EXTERNAL 12/18/92 028 0251 5012
13713320 CEFUROXIME 220MG/ML (LIDO) INJ EXTERNAL 12/18/92 J0697 J0697 028 0636 5012
13713326 EXACTACAIN 60 GM SPRAY EXTERNAL 12/18/92 028 0250 5012
13713328 CETAPHIL LOTION 240ML EXTERNAL 12/18/92 028 0250 5012
13713333 CHARCOAL ACTIVATED 25GM EXTERNAL 03/04/96 028 0251 5012
13713334 CHARCOAL ACTIVATED 0.2GM/ML SU EXTERNAL 12/18/92 028 0250 5012
13713335 CHARCOAL ACTIVATED 50GRAM/240M EXTERNAL 12/18/92 028 0251 5012
13713336 CHARCOAL ACTIVATED 15GM/75ML S EXTERNAL 12/18/92 028 0251 5012
13713391 CHLORAL HYDRATE 500MG/5ML 480M EXTERNAL 07/01/84 028 0250 5012
13713410 CHLORAL HYDRATE 325MG SUPP 12 EXTERNAL 11/25/91 028 0251 5012
13713411 CHLORAL HYDRATE 325MG SUPP EXTERNAL 12/18/92 028 0251 5012
13713440 CHLORAMPHENICOL 250MG - 1 BOTT EXTERNAL 07/01/84 028 0250 5012
13713450 CHLORAMPHENICOL 250MG CAP EXTERNAL 07/01/84 028 0250 5012
13713452 CHLORAMPHENICOL 500MG/D5W 50ML EXTERNAL 03/08/96 J0720 J0720 028 0636 5012
13713453 CHLORAMPHENICOL 1GM/D5W 50ML EXTERNAL 03/08/96 J0720 J0720 028 0636 5012
13713510 CHLORAMPHENICOL 0.1GM/ML INJ EXTERNAL 12/18/92 J0720 J0720 028 0636 5012
13713520 CHLORHEXIDINE GLUCO 0.12% MOUT EXTERNAL 12/18/92 028 0251 5012
13713640 CHLOROPROCAINE MPF 2% INJ 30ML EXTERNAL 12/18/92 J2400 J2400 028 0636 5012
13713650 CHLOROPROCAINE MPF 3% INJ - 1 EXTERNAL 07/01/84 J2400 J2400 028 0636 5012
13713651 CHLOROPROCAINE 3% INJ EXTERNAL 12/18/92 J2400 028 0636 5012
13713663 CHLOROTHIAZIDE 28MG/ML INJ EXTERNAL 01/31/97 J1205 J1205 028 0636 5012
13713849 CHLORPROMAZINE 12.5 MG TAB EXTERNAL 01/22/07 028 0251 5012
13713850 CHLORPROMAZINE 25MG TAB EXTERNAL 12/18/92 Q0172 028 0637 5012
13713851 CHLORPROMAZINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13713855 CHLORPROMAZINE 50MG (25 MG X 2 EXTERNAL 01/29/08 028 0251 5012
13713890 CHLORPROMAZINE 25MG TAB EXTERNAL 12/18/92 028 0250 5012
13713891 CHLORPROMAZINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13713906 GENTAMICIN 60MG/NS 50ML EXTERNAL 11/02/99 J1580 J1580 J1580 028 0258 5012
13713907 GENTAMICIN 80MG/NS 50ML EXTERNAL 11/02/99 J1580 J1580 J1580 028 0258 5012
13713910 CHLORPROMAZINE 200 MG TAB EXTERNAL 12/18/92 028 0251 5012
13713912 GENTAMICIN 50MG/NS 25ML EXTERNAL 11/02/99 J1580 J1580 J1580 028 0258 5012
13713918 AMPICILLIN 500MG/25ML NS IVPB EXTERNAL 11/02/99 028 0258 5012
13713919 VANCOMYCIN 500MG D5W 125ML BAG EXTERNAL 11/02/99 J3370 J3370 028 0636 5012
13713920 LEVOFLOXACIN 500MG IV PREMIX B EXTERNAL 11/02/99 J1956 J1956 028 0258 5012
13713924 NAFCILLIN 2GM/D5W 100ML EXTERNAL 11/02/99 028 0258 5012
13713928 CEFTRIAXONE INJECTION 250MG D EXTERNAL 11/02/99 J0696 J0696 J0696 028 0258 5012
13713944 ERYTHROMYCIN 500MG/100ML NS EXTERNAL 11/02/99 J1364 J1364 J1364 028 0258 5012
13713951 CHLORPROMAZINE 12.5MG LIQ CONC EXTERNAL 11/02/01 028 0251 5012
13713952 CHLORPROMAZINE 25MG LIQ CONC EXTERNAL 11/02/01 028 0251 5012
13713953 CHLORPROMAZINE 25MG LIQ CONC EXTERNAL 11/02/01 028 0251 5012
13713960 CHLORPROMAZINE 25MG/ML INJ EXTERNAL 12/18/92 J3230 J3230 028 0636 5012
13713961 CHLORPROMAZINE 50 MG INJ EXTERNAL 12/28/04 J3230 J3230 028 0636 5012
13713970 CHLORPROMAZINE INJECTION 50MG EXTERNAL 12/18/92 J3230 J3230 J3230 028 0636 5012
13713991 CHLORPROMAZINE CONC 30MG/ML 12 EXTERNAL 07/01/84 028 0636 5012
13714000 CLINDAMYCIN SUSPENSION 150MG EXTERNAL 10/01/01 028 0251 5012
13714059 CHLORTHALIDONE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13714070 CHLORTHALIDONE 50MG TAB EXTERNAL 12/18/92 028 0250 5012
13714071 CHLORTHALIDONE 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13714100 CHLORTHALIDONE 100MG TAB EXTERNAL 12/18/92 028 0250 5012
13714101 CHLORTHALIDONE 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 215
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13714123 CISATRACURIUM 2MG/ML EXTERNAL 01/01/01 028 0258 5012
13714124 CISATRACURIUM 10MG/ML EXTERNAL 06/11/03 028 0258 5012
13714126 CISATRACURIUM 1MG/ML EXTERNAL 06/11/03 028 0258 5012
13714127 CHOLESTYRAMINE 4GM PKT (EXTEMP EXTERNAL 04/24/08 028 0251 5012
13714129 CHOLESTYRAMINE -1 BOX OF 60 PA EXTERNAL 01/25/95 028 0251 5012
13714130 CHOLESTYRAMINE 4GM PKT EXTERNAL 12/18/92 028 0250 5012
13714131 SALSALATE 500MG TAB EXTERNAL 12/18/92 028 0250 5012
13714132 SALSALATE 750MG TAB EXTERNAL 12/18/92 028 0250 5012
13714140 CHORIONIC GONADOTROPIN 500U/ML EXTERNAL 12/18/92 J0725 J0725 028 0636 5012
13714144 CISPLATIN-DOXORUBICIN INJ EXTERNAL 07/29/05 028 0258 5012
13714145 CISPLATIN-MANNITOL INJ EXTERNAL 12/09/05 028 0258 5012
13714146 ACETAMINOPHEN 30MG SUPP EXTERNAL 12/21/04 028 0251 5012
13714161 CIMETIDINE 400MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13714164 CIMETIDINE 400MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13714166 CIMETIDINE 300MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13714167 CIMETIDINE 200MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13714191 CLINDAMYCIN 150MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13714193 CLINDAMYCIN 450MG (150 MG X 3) EXTERNAL 01/29/08 028 0251 5012
13714194 CLINDAMYCIN 600MG (300 MG X 2) EXTERNAL 01/29/08 028 0251 5012
13714201 CLINDAMYCIN SUSP 75MG/5ML 100M EXTERNAL 07/01/84 028 0250 5012
13714210 CLINDAMYCIN INJECTION 300MG DO EXTERNAL 12/18/92 028 0250 5012
13714213 CLINDAMYCIN -T 1% TOP GEL 30ML EXTERNAL 12/18/92 028 0251 5012
13714221 CLINDAMYCIN 600MG/D5W 100ML EXTERNAL 12/18/92 028 0251 5012
13714222 CLINDAMYCIN INJECTION 900MG VI EXTERNAL 12/18/92 028 0250 5012
13714223 CLINDAMYCIN 900MG/D5W 50ML EXTERNAL 12/18/92 028 0251 5012
13714225 CLINDAMYCIN 1% 30ML TOP GEL EXTERNAL 12/18/92 028 0250 5012
13714230 CLINDAMYCIN 600MG/D5W 50ML EXTERNAL 12/18/92 028 0251 5012
13714242 CLOMIPHENE CITRATE 50MG-1 BOX( EXTERNAL 01/25/95 028 0251 5012
13714243 CLONAZEPAM 0.25MG PER 1/2 TAB EXTERNAL 07/01/84 028 0250 5012
13714255 CLONAZEPAM 0.1MG/ML SUSPENSION EXTERNAL 11/08/01 028 0251 5012
13714256 CLONAZEPAM 0.01MG ORAL SUSP EXTERNAL 12/19/01 028 0251 5012
13714257 CLONAZEPAM 0.02MG ORAL SUSP EXTERNAL 12/19/01 028 0251 5012
13714259 CLONAZEPAM 0.04MG ORAL SUSP EXTERNAL 12/19/01 028 0251 5012
13714261 CLONIDINE 0.2MG TABLET EXTERNAL 12/18/92 028 0250 5012
13714262 CLONIDINE 0.2MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13714264 CLONIDINE 100MCG/ML EXTERNAL 12/18/01 J0735 J0735 J0735 028 0258 5012
13714265 CLONIDINE 0.4MG (0.2 MG X 2) T EXTERNAL 01/31/08 028 0251 5012
13714269 CLONIDINE 0.3MG - 1 BOX EXTERNAL 05/25/89 028 0251 5012
13714280 CLOPIDOGREL 75MG TAB EXTERNAL 01/03/00 028 0251 5012
13714281 CLOPIDOGREL 75MG TAB BULK EXTERNAL 01/03/00 028 0251 5012
13714285 CLOPIDOGREL 300 MG (75 MG X 4) EXTERNAL 12/30/04 028 0251 5012
13714310 CYCLOPHOSPHAMIDE-MESNA INJ EXTERNAL 12/09/05 028 0258 5012
13714311 HYDROCORTISONE-METHOTREXATE IN EXTERNAL 01/26/06 028 0258 5012
13714312 CYTARABINE-HYDROCORTISONE-METH EXTERNAL 01/26/06 028 0258 5012
13714313 DEXAMETHASONE-ONDANSETRON INJ EXTERNAL 01/26/06 028 0258 5012
13714314 IFOSFAMIDE-MESNA INJ EXTERNAL 01/26/06 028 0258 5012
13714325 CLOTRIMAZOLE 1% CREAM 45GM EXTERNAL 12/18/92 028 0250 5012
13714326 CLOTRIMAZOLE 1% TOPICAL SOLN EXTERNAL 12/18/92 028 0250 5012
13714327 CLOTRIMAZOLE 10MG LOZENGE EXTERNAL 12/18/92 028 0250 5012
13714328 CLOTRIMAZOLE 10MG TROCHE - 1 B EXTERNAL 01/25/95 028 0251 5012
13714380 CMV IMM GLOBULIN 0.05 GM/ML IN EXTERNAL 05/31/95 J0850 J0850 028 0636 5012
13714383 CLOZAPINE 75MG (25 MG X 3) EXTERNAL 01/31/08 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 216
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13714385 CLOZAPINE 25MG EXTERNAL 11/04/99 028 0251 5012
13714386 CLOZAPINE 25MG TAB EXTERNAL 11/04/99 028 0251 5012
13714387 CLOZAPINE 100MG EXTERNAL 11/04/99 028 0251 5012
13714388 CLOZAPINE 12.5 MG (1/2 X 25MG) EXTERNAL 07/20/06 028 0251 5012
13714389 CLOZAPINE 100MG TAB EXTERNAL 11/04/99 028 0251 5012
13714407 FACTOR VIIA INJ 1MG/1ML EXTERNAL 08/29/08 J7189 J7189 J7189 028 0258 5012
13714420 T-GEL SHAMPOO 2% 132ML EXTERNAL 12/18/92 028 0250 5012
13714480 COCAINE 4% TOP SOLN 4ML EXTERNAL 12/18/92 028 0250 5012
13714482 COCAINE 4% TOP SOLN 10ML EXTERNAL 11/03/09 028 0251 5012
13714490 COCAINE 10% TOP SOLN 4ML EXTERNAL 12/18/92 028 0250 5012
13714608 MORPHINE 0.1MG/ML PEDS INJ EXTERNAL 06/27/01 J2270 J2270 028 0636 5012
13714609 MORPHINE 0.2MG/ML PEDS INJ EXTERNAL 06/27/01 J2270 J2270 028 0636 5012
13714623 PIPERACILLIN 2GM/D5W 50ML EXTERNAL 05/14/02 028 0258 5012
13714624 PIPERACILLIN 3GM/D5W 50ML EXTERNAL 05/14/02 028 0258 5012
13714625 PIPERACILLIN 4GM/D5W 100ML EXTERNAL 05/14/02 028 0258 5012
13714630 CODEINE PHOSPHATE 30MG/2ML SYR EXTERNAL 12/18/92 J0745 J0745 028 0636 5012
13714634 CODEINE PHOSPHATE 15MG/ML INJE EXTERNAL 11/14/08 028 0251 5012
13714637 CODEINE PHOSPHATE 30MG INJECTI EXTERNAL 11/14/08 028 0251 5012
13714640 CODEINE PHOSPHATE 60MG/2ML SYR EXTERNAL 12/18/92 J0745 J0745 028 0636 5012
13714680 CODEINE SULFATE 15MG TAB EXTERNAL 12/18/92 028 0250 5012
13714681 CODEINE SULFATE 15MG - 1 BOX ( EXTERNAL 01/25/95 028 0251 5012
13714687 CALCIUM GLUCONATE 50MG/ML PEDS EXTERNAL 06/07/01 J0610 J0610 028 0636 5012
13714693 AMPHOTERICIN B CONV 0.5MG/ML P EXTERNAL 11/14/08 028 0258 5012
13714694 AMPHOTERICIN B CONV 0.1MG/ML P EXTERNAL 06/27/01 J0285 J0285 028 0636 5012
13714695 AMPHOTERICIN B CONV 0.05MG/ML EXTERNAL 06/27/01 J0285 J0285 028 0636 5012
13714696 CEFAZOLIN 100 MG/ML PEDS INJ EXTERNAL 06/27/01 J0690 J0690 028 0636 5012
13714698 CEFAZOLIN 50 MG/ML PEDS INJ EXTERNAL 06/27/01 J0690 J0690 028 0636 5012
13714699 CEFTAZADIME 100MG/ML PEDS INJ EXTERNAL 06/27/01 J0713 J0713 028 0636 5012
13714704 CLINDAMYCIN 5MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13714705 CLINDAMYCIN 10MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13714706 DEXAMETHASONE 0.2MG/ML PEDS IN EXTERNAL 06/27/01 J1100 J1100 028 0636 5012
13714708 DEXAMETHASONE 4MG/ML PEDS INJ EXTERNAL 06/27/01 J1100 J1100 028 0636 5012
13714710 COLCHICINE 0.6MG TABLET EXTERNAL 12/18/92 028 0250 5012
13714711 COLCHICINE 0.65MG - 1 BULK BOT EXTERNAL 01/25/95 028 0251 5012
13714712 DIGOXIN 5 MCG/ML PEDS INJ EXTERNAL 06/27/01 J1160 J1160 028 0636 5012
13714713 COLLAGENASE OINT 15 GM EXTERNAL 06/01/10 028 0251 5012
13714714 DIGOXIN 100 MCG/ML PEDS INJ EXTERNAL 06/27/01 J1160 028 0636 5012
13714716 DIGOXIN 10MCG/ML PEDS INJ EXTERNAL 06/27/01 J1160 J1160 028 0636 5012
13714717 DIGOXIN 250 MCG/ML INJ EXTERNAL 06/27/01 J1160 J1160 028 0636 5012
13714719 FUROSEMIDE 2MG/ML PEDS INJ EXTERNAL 06/27/01 J1940 J1940 028 0636 5012
13714722 EPOETIN ALPHA 1000 U/ML EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13714723 EPOETIN ALPHA 100 UNITS/ML INJ EXTERNAL 01/01/07 Q4081 Q4081 Q4081 028 0634 5012
13714724 GENTAMICIN 2MG/ML PEDS INJ EXTERNAL 06/27/01 J1580 J1580 028 0636 5012
13714729 CEFTRIAXONE 40MG/ML PEDS INJ EXTERNAL 06/27/01 J0696 J0696 028 0636 5012
13714730 CEFTRIAXONE 350MG/ML (LIDO) IN EXTERNAL 07/01/84 J0696 J0696 028 0636 5012
13714731 HYDRALAZINE 0.4MG/ML PEDS INJ EXTERNAL 06/27/01 J0360 J0360 028 0636 5012
13714732 CEFTRIAXONE 0.35GM/ML (LIDO) I EXTERNAL 06/27/01 J0696 J0696 028 0636 5012
13714733 HYDRALAZINE 2MG/ML PEDS INJ EXTERNAL 06/27/01 J0360 J0360 028 0636 5012
13714735 LORAZEPAM 0.1MG/ML PEDS INJ EXTERNAL 06/27/01 J2060 J2060 028 0636 5012
13714736 LORAZEPAM 0.2MG/ML PEDS INJ EXTERNAL 06/27/01 J2060 J2060 028 0636 5012
13714737 LORAZEPAM 0.4MG/ML PEDS INJ EXTERNAL 06/27/01 J2060 J2060 028 0636 5012
13714738 LORAZEPAM 1MG/ML PEDS INJ EXTERNAL 06/27/01 J2060 J2060 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 217
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13714739 MORPHINE 0.4MG/ML PEDS INJ EXTERNAL 06/27/01 J2275 J2275 028 0636 5012
13714742 PANCURONIUM 0.4MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13714743 NAFCILLIN 20MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13714744 FOSPHENYTOIN 10MGPE/ML PEDS IN EXTERNAL 06/27/01 Q2009 Q2009 028 0636 5012
13714745 FOSPHENYTOIN 100 MG IVPB EXTERNAL 06/27/01 Q2009 Q2009 028 0636 5012
13714746 FOSPHENYTOIN 250 MG IVPB EXTERNAL 08/12/03 Q2009 Q2009 028 0636 5012
13714747 FOSPHENYTOIN 200 MG IVPB EXTERNAL 08/12/03 Q2009 Q2009 028 0636 5012
13714748 FOSPHENYTOIN 1000 MG PE/NS 50M EXTERNAL 08/12/03 Q2009 Q2009 028 0636 5012
13714749 PHENYTOIN 5MG/ML PEDS INJ EXTERNAL 06/27/01 J1165 J1165 028 0636 5012
13714751 POTASSIUM CHL 0.2MEQ/ML PEDS I EXTERNAL 06/27/01 J3480 J3480 028 0636 5012
13714752 AMINOPHYLLINE 2.5MG/ML PEDS IN EXTERNAL 06/27/01 J0280 J0280 J0280 028 0636 5012
13714758 FUROSEMIDE 10MG/ML PEDS INJ EXTERNAL 06/27/01 J1940 J1940 028 0636 5012
13714761 METHYLPREDNISOLONE 8MG/ML PEDS EXTERNAL 07/01/84 J2920 J2920 028 0636 5012
13714770 ACETAZOLAMIDE 100MG/ML INJ EXTERNAL 12/18/92 J1120 J1120 J1120 028 0636 5012
13714773 PENICILLIN GK 250000 U/ML PEDS EXTERNAL 06/27/01 J2540 J2540 028 0636 5012
13714777 PENICILLIN GK 20000 U/ML PEDS EXTERNAL 06/27/01 J2540 J2540 028 0636 5012
13714779 PENICILLIN GK 100000 U/ML PEDS EXTERNAL 06/27/01 J2540 J2540 028 0636 5012
13714780 ESTROGENS CONJUGATED .9MG TB-1 EXTERNAL 07/29/92 028 0251 5012
13714783 FOSPHENYTOIN 25MGPE/ML PEDS IN EXTERNAL 06/27/01 Q2009 Q2009 028 0636 5012
13714785 ESTROGENS CONJUGATED .9MG TABL EXTERNAL 12/18/92 028 0251 5012
13714786 CEFOTAXIME 100MG/1ML PEDS INJ EXTERNAL 06/27/01 J0698 J0698 028 0636 5012
13714787 CEFOTAXIME 50MG/ML PEDS INJ (D EXTERNAL 04/22/02 J0698 J0698 028 0636 5012
13714798 PHENOBARBITAL 6.0MG/ML PEDS IN EXTERNAL 06/27/01 J2560 J2560 028 0636 5012
13714799 PHENOBARBITAL 6.5MG/ML PEDS IN EXTERNAL 06/27/01 J2560 J2560 028 0636 5012
13714802 CORN OIL EMULSION ***ML EXTERNAL 12/18/92 028 0250 5012
13714803 PHENOBARBITAL 130MG/ML PEDS IN EXTERNAL 06/27/01 J2560 J2560 028 0636 5012
13714812 HYDRALAZINE 20MG/ML PEDS INJ EXTERNAL 06/27/01 J0360 J0360 028 0636 5012
13714816 INDOMETHACIN 0.2MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13714824 PANCURONIUM 2MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13714834 CLOZAPINE 50MG (25 MG X 2) EXTERNAL 01/31/08 028 0251 5012
13714836 CEFTAZADIME 50MG/ML PEDS INJ EXTERNAL 06/27/01 J0713 J0713 028 0636 5012
13714840 CORTICOTROPIN INJECTION 40UNIT EXTERNAL 07/21/94 J0800 J0800 028 0636 5012
13714842 HYDROCORTISONE 1.0% LOTION 60M EXTERNAL 07/01/84 028 0250 5012
13714843 HYDROCORTISONE 2.5% CREAM 30GM EXTERNAL 07/21/94 028 0250 5012
13714844 HYDROCORTISONE 2.5% OINT 30GM EXTERNAL 07/21/94 028 0250 5012
13714849 HYDROCORTISONE ACETATE 10% FOA EXTERNAL 07/21/94 028 0250 5012
13714854 HYDROCORTISONE 1.0% CREAM 120G EXTERNAL 07/21/94 028 0250 5012
13714855 HYDROCORTISONE 10MG TAB EXTERNAL 07/21/94 028 0250 5012
13714856 HYDROCORTISONE 20MG TAB EXTERNAL 07/21/94 028 0250 5012
13714859 HYDROCORTISONE 1.0% CREAM 454G EXTERNAL 01/25/95 028 0251 5012
13714860 HYDROCORTISONE 1.0% OINT 480GM EXTERNAL 07/01/84 028 0250 5012
13714861 HYDROCORTISONE SOD SUCC 100MG EXTERNAL 07/21/94 J1720 J1720 J1720 028 0251 5012
13714863 HYDROCORTISONE SOD SUCC 100MG EXTERNAL 07/21/94 J1720 J1720 J1720 028 0251 5012
13714864 HYDROCORTISONE SOD SUCC 50MG/M EXTERNAL 07/21/94 J1720 J1720 028 0636 5012
13714867 HYDROCORTISONE 1.0% OINT 30GM EXTERNAL 07/21/94 028 0251 5012
13714868 HYDROCORTISONE 1.0% CREAM 30GM EXTERNAL 07/21/94 028 0251 5012
13714871 CORTISONE ACETATE 5MG-1 BTL ( EXTERNAL 01/25/95 028 0251 5012
13714873 HYDROCORTISONE PRAMOXINE ANALP EXTERNAL 05/30/08 028 0251 5012
13714878 MAGNESIUM SULF 100MG/ML PEDS I EXTERNAL 06/27/01 J3475 J3475 028 0636 5012
13714879 CORTISONE 12.5MG (1/2 X 25MG) EXTERNAL 05/09/96 028 0251 5012
13714880 CORTISONE 25MG TAB EXTERNAL 07/21/94 028 0250 5012
13714881 CORTISONE ACETATE 25MG - 1 BOT EXTERNAL 01/25/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 218
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13714885 HYDROCORTISONE 5MG (1/2 X 10MG EXTERNAL 06/08/06 028 0251 5012
13714886 HYDROCORTISONE 2.5MG (1/4X10MG EXTERNAL 07/20/06 028 0251 5012
13714895 PHENOBARBITAL 13MG/ML PEDS INJ EXTERNAL 06/27/01 J2560 J2560 028 0636 5012
13714896 PHENOBARBITAL 12MG/ML PEDS INJ EXTERNAL 06/27/01 J2560 J2560 028 0636 5012
13714900 CORTISPORIN OTIC SOLN 10ML EXTERNAL 07/21/94 028 0250 5012
13714901 CORTISPORIN OTIC SUSP 10ML EXTERNAL 08/10/01 028 0251 5012
13714908 PENICILLIN GK 50000 U/ML PEDS EXTERNAL 06/27/01 J2540 J2540 028 0636 5012
13714909 PENICILLIN GK 5000000U/ML PEDS EXTERNAL 06/27/01 J2540 J2540 028 0636 5012
13714910 CORTISPORIN OTIC SUSPENSION 10 EXTERNAL 07/21/94 028 0250 5012
13714911 COTRIMOXAZOLE INJ 15ML D5W 250 EXTERNAL 03/08/96 028 0258 5012
13714912 COTRIMOXAZOLE INJ 20ML D5W 300 EXTERNAL 03/08/96 028 0258 5012
13714914 COTRIMOXAZOLE INJ 5ML D5W 100M EXTERNAL 10/28/98 028 0258 5012
13714915 COTRIMOXAZOLE INJ 10 ML D5W 25 EXTERNAL 12/12/03 028 0258 5012
13714916 PIPERCILLIN 200MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13714920 COSYNTROPIN INJECTION 0.25MG V EXTERNAL 07/21/94 J0835 J0835 028 0636 5012
13714921 COSYNTROPIN 0.25MG/ML INJ EXTERNAL 07/21/94 J0833 J0833 028 0636 5012
13714922 COTRIMOXAZOLE DS 160/800 - 1 B EXTERNAL 01/25/95 028 0251 5012
13714923 COTRIMOXAZOLE 20ML SUSPENSION EXTERNAL 07/21/94 028 0250 5012
13714924 COTRIMOXAZOLE INJECTION 10ML V EXTERNAL 07/01/84 028 0251 5012
13714926 COTRIMOXAZOLE TABLET EXTERNAL 07/21/94 028 0250 5012
13714929 COTRIMOXAZOLE 10ML SUSPENSION EXTERNAL 07/21/94 028 0250 5012
13714930 COTRIMOXAZOLE SUSPENSION 480ML EXTERNAL 07/01/84 028 0250 5012
13714931 COTRIMOXAZOLE INJ 30ML EXTERNAL 07/21/94 028 0251 5012
13714937 COTRIMOXAZOLE REG STRENGTH - 1 EXTERNAL 01/25/95 028 0251 5012
13714938 COTRIMOXAZOLE 5ML SUSPENSION EXTERNAL 07/21/94 028 0251 5012
13714939 COTRIMOXAZOLE 15ML SUSPENSION EXTERNAL 07/21/94 028 0251 5012
13714941 CROMOLYN 4% OPHTH SOLN 10ML EXTERNAL 07/21/94 028 0250 5012
13714943 CROMOLYN 10MG/ML SOLN INHL EXTERNAL 03/26/02 J7631 J7631 028 0636 5012
13714944 CROMOLYN SODIUM MDI 14.2GM EXTERNAL 03/26/02 J7631 J7631 028 0636 5012
13714951 COTRIMOXAZOLE 2.5ML SUSPENSION EXTERNAL 03/08/96 028 0251 5012
13714952 COTRIMOXAZOLE 3ML SUSPENSION EXTERNAL 10/01/01 028 0251 5012
13714953 COTRIMOXAZOLE 1.25ML SUSPENSIO EXTERNAL 12/19/01 028 0251 5012
13714954 COTRIMOXAZOLE 1.5ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714955 COTRIMOXAZOLE 2ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714956 COTRIMOXAZOLE 3.6ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714957 COTRIMOXAZOLE 4ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714958 COTRIMOXAZOLE 6ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714959 COTRIMOXAZOLE 7.5ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714962 COTRIMOXAZOLE 12ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714963 COTRIMOXAZOLE 18ML SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13714976 METHYLPRED SOD SUCC 125MG/NS 1 EXTERNAL 05/14/02 J2930 J2930 028 0636 5012
13714987 THROMBIN 20,000 UNITS SPRAY KI EXTERNAL 02/14/01 028 0251 5012
13714990 CYANIDE ANTIDOTE KIT EXTERNAL 07/21/94 028 0250 5012
13714991 COTRIMOXAZOLE 1/2 SS TAB EXTERNAL 06/12/06 028 0251 5012
13715001 CYANOCOBALAMIN 50MCG - 1 BOTTL EXTERNAL 01/25/95 028 0251 5012
13715002 CYANOCOBALAMIN 250MCG TAB (1/2 EXTERNAL 07/20/06 028 0251 5012
13715020 CYANOCOBALAMIN 1000MCG/ML INJ EXTERNAL 08/08/94 028 0258 5012
13715022 CYANOCOBALAMIN 100MCG/ML INJ EXTERNAL 08/08/94 028 0258 5012
13715025 CYANOCOBALAMIN 100MCG TAB EXTERNAL 08/01/95 028 0251 5012
13715050 CYANOCOBALAMIN INJ 1000MCG SYR EXTERNAL 08/08/94 028 0251 5012
13715055 CYCLOPENTO-PHENYLEPHRINE OPHTH EXTERNAL 08/08/94 028 0250 5012
13715060 CYCLOPENTOLATE 0.5% OPTH SOLN EXTERNAL 08/08/94 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 219
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13715070 CYCLOPENTOLATE 1% OPHTH SOLN 2 EXTERNAL 08/08/94 028 0250 5012
13715071 CYCLOPENTOLATE 2% OPHTH SOL 15 EXTERNAL 06/08/93 028 0251 5012
13715080 CYCLOPENTOLATE 1% OPHTH SOLN 1 EXTERNAL 07/01/84 028 0251 5012
13715101 CYCLOPHOSPHAMIDE 25MG - 1 BOTT EXTERNAL 01/25/95 028 0251 5012
13715111 CYCLOPHOSPHAMIDE 50MG TAB EXTERNAL 08/08/94 028 0251 5012
13715112 CYCLOPHOSPHAMIDE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715113 CYCLOPHOSPHAMIDE 25MG TAB EXTERNAL 01/31/08 028 0251 5012
13715115 CYCLOPHOSPHAMIDE 100 MG ( 50 M EXTERNAL 08/18/97 028 0251 5012
13715116 CYCLOPHOSPHAMIDE 150 MG ( 50 M EXTERNAL 08/18/97 028 0251 5012
13715120 CYCLOPHOSPHAMIDE INJ 200MG VIA EXTERNAL 08/08/94 J9070 J9070 028 0251 5012
13715130 CYCLOPHOSPHAMIDE INJ 500MG VIA EXTERNAL 08/08/94 J9090 J9090 J9090 028 0251 5012
13715131 CYCLOPHOSPHAMIDE INJ 1GRAM VIA EXTERNAL 08/08/94 J9091 J9091 J9091 028 0251 5012
13715135 CYCLOSPORINE* 50MG/ML INJ EXTERNAL 03/26/02 J7516 J7516 028 0636 5012
13715136 CYCLOSPORINE* 100MG/ML SOLN EXTERNAL 01/01/95 J7502 J7502 028 0636 5012
13715139 CYCLOSPORIN 100MG - 1 BOX EXTERNAL 11/17/90 028 0251 5012
13715156 L-CYSTEINE INJECTION 500MG VIA EXTERNAL 01/01/87 028 0250 5012
13715160 CYTARABINE INJECTION 100MG VIA EXTERNAL 07/01/84 028 0251 5012
13715170 CYTARABINE INJECTION 500MG VIA EXTERNAL 08/01/94 J9070 J9070 J9070 028 0251 5012
13715171 CYTARABINE INJECTION 500MG VIA EXTERNAL 01/01/95 028 0251 5012
13715172 CYTARABINE INJECTION 500MG VIA EXTERNAL 01/01/95 028 0251 5012
13715174 CYCLOSPORINE* 100MG CAP EXTERNAL 11/19/95 J7502 J7502 028 0636 5012
13715175 CYCLOSPORINE* 25MG CAP EXTERNAL 11/19/95 J7515 J7515 J7515 028 0636 5012
13715176 CYCLOSPORIN 25MG CAPSULE - BOX EXTERNAL 11/19/95 028 0251 5012
13715177 CYCLOSPORIN 100MG/ML 50ML EXTERNAL 11/22/95 028 0251 5012
13715179 CYCLOSPORINE* 200MG (100 MG X EXTERNAL 11/19/08 028 0251 5012
13715182 CYCLOSPORINE* 25MG CAP EXTERNAL 07/31/01 J7515 J7515 J7515 028 0251 5012
13715183 CYCLOSPORINE* 2X100 MG + 2X25 EXTERNAL 07/31/01 028 0251 5012
13715184 CYCLOSPORINE* 25MG CAP EXTERNAL 08/13/02 J7515 J7515 J7515 028 0251 5012
13715185 CYCLOSPORINE* 25MG CAP EXTERNAL 11/05/02 J7515 J7515 J7515 028 0636 5012
13715186 CYCLOSPORINE* 300MG (100 MG X EXTERNAL 11/19/08 028 0251 5012
13715187 CYCLOSPORINE* 75MG (25 MG X 3) EXTERNAL 01/31/08 028 0251 5012
13715188 CYCLOSPORINE* 50MG (25 MG X 2) EXTERNAL 01/31/08 028 0251 5012
13715200 DACTINOMYCIN INJECTION 500MCG EXTERNAL 11/02/93 J9120 J9120 J9120 028 0251 5012
13715201 DAKIN'S SOLUTION 1/4 STRENGTH EXTERNAL 07/01/84 028 0250 5012
13715202 DAKIN'S SOLUTION 1/2 STRENGTH EXTERNAL 07/01/84 028 0250 5012
13715203 DAKIN'S SOLUTION FULL STRENGTH EXTERNAL 07/01/84 028 0250 5012
13715204 DACLIZUMAB 5 MG/ML, 5 ML EXTERNAL 01/26/04 J7513 J7513 028 0636 5012
13715208 DANAZOL 200MG CAP EXTERNAL 08/09/94 028 0250 5012
13715209 DANOCRINE 200MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13715210 DANTROLENE SODIUM 25MG - 1 BO EXTERNAL 07/01/84 028 0250 5012
13715230 DANTROLENE 25MG CAP EXTERNAL 08/09/94 028 0250 5012
13715245 DANTROLENE SODIUM INJ 20MG VIA EXTERNAL 01/01/95 028 0250 5012
13715252 DAPTOMYCIN EXTERNAL 07/22/04 J0878 J0878 028 0636 5012
13715253 POTASSIUM CHL 0.067MEQ/ML PEDS EXTERNAL 06/27/01 J3480 J3480 028 0636 5012
13715261 DAPSONE 100MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13715262 DALTEPARIN 2,500 UNITS/0.2ML EXTERNAL 01/21/09 J1645 J1645 J1645 028 0258 5012
13715263 DALTEPARIN 5,000 UNITS/0.2ML EXTERNAL 01/21/09 J1645 J1645 J1645 028 0258 5012
13715264 DALTEPARIN 7,500 UNITS/0.3ML EXTERNAL 01/21/09 J1645 J1645 J1645 028 0636 5012
13715265 DALTEPARIN 10,000 UNITS/1ML EXTERNAL 01/21/09 J1645 J1645 J1645 028 0636 5012
13715266 DALTEPARIN 12,500 UNITS/0.5ML EXTERNAL 01/21/09 J1645 J1645 J1645 028 0636 5012
13715267 DALTEPARIN 15,000 UNITS/0.6ML EXTERNAL 01/21/09 J1645 J1645 J1645 028 0636 5012
13715268 DALTEPARIN 18,000 UNITS/0.72ML EXTERNAL 01/21/09 J1645 J1645 J1645 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 220
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13715269 DALTEPARIN 2,500 UNITS/ML PEDS EXTERNAL 02/23/09 028 0258 5012
13715270 DALTEPARIN 25,000 UNITS/ML EXTERNAL 01/21/09 028 0258 5012
13715302 ACETAMINO-PROPOXYPHENE 650MG/1 EXTERNAL 01/01/95 028 0250 5012
13715303 DARVOCET-N 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715307 DESMOPRESSIN NASAL SOLN 2.5ML EXTERNAL 01/01/95 028 0250 5012
13715310 DERMABOND SKIN ADHESIVE FOR ER EXTERNAL 07/02/01 028 0251 5012
13715311 DARBEPOETIN 200 MCG INJ EXTERNAL 01/01/06 J0882 J0882 J0882 028 0636 5012
13715312 DARBEPOETIN 100 MCG INJ EXTERNAL 06/14/04 J0882 J0882 J0882 028 0636 5012
13715313 DARBEPOETIN 25 MCG INJ EXTERNAL 01/03/05 J0882 J0882 J0882 028 0636 5012
13715314 DARBEPOETIN INJ 1MCG EXTERNAL 01/01/06 J0881 J0881 J0881 028 0636 5012
13715315 DARBEPOETIN 60 MCG INJ EXTERNAL 01/01/06 J0882 J0882 028 0636 5012
13715316 DARBEPOETIN 125 MCG INJ EXTERNAL 03/03/06 J0882 J0882 J0882 028 0258 5012
13715317 DARUNAVIR 300 MG TABLET EXTERNAL 02/25/08 028 0251 5012
13715325 CARBAMIDE PEROXIDE 6.5% OTIC S EXTERNAL 01/01/95 028 0250 5012
13715326 NON-ESRD DARBEPOETIN 100 MCG I EXTERNAL 03/10/08 J0881 J0881 J0881 028 0636 5012
13715327 NON-ESRD DARBEPETIN 125 MCG IN EXTERNAL 03/03/06 J0881 J0881 J0881 028 0258 5012
13715328 NON-ESRD DARBEPOETIN 200 MCG I EXTERNAL 03/10/08 J0881 J0881 J0881 028 0258 5012
13715329 NON-ESRD DARBEPOETIN 25 MCG IN EXTERNAL 04/29/05 J0881 J0881 J0881 028 0258 5012
13715330 NON-ESRD DARBEPOETIN 60 MCG IN EXTERNAL 03/10/08 J0881 J0881 J0881 028 0258 5012
13715331 NON-ESRD DARBEPOETIN INJ EXTERNAL 04/29/05 J0881 J0881 J0881 028 0258 5012
13715340 DEFEROXAMINE 250MG/ML INJ EXTERNAL 07/01/84 J0895 J0895 028 0636 5012
13715411 DESIPRAMINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715412 DERMOPLAST 20% SPRAY 60GM EXTERNAL 01/01/95 028 0250 5012
13715413 DESIPRAMINE 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715415 DESIPRAMINE 25MG TAB EXTERNAL 01/01/95 028 0250 5012
13715416 DESIPRAMINE 50MG TAB EXTERNAL 01/01/95 028 0250 5012
13715417 DESIPRAMINE 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13715419 DESIPRAMINE 100MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13715429 DESMOPRESSIN ACETATE 4MCG/ML I EXTERNAL 01/01/95 J2597 J2597 028 0636 5012
13715445 DESFLURANE 240ML EXTERNAL 03/17/93 028 0251 5012
13715453 DESMOPRESSIN 0.2MG TABLET EXTERNAL 03/02/07 028 0251 5012
13715455 DESMOPRESSIN 50 MCG TAB EXTERNAL 01/31/08 028 0251 5012
13715456 DESMOPRESSIN 100 MCG TAB EXTERNAL 01/31/08 028 0251 5012
13715460 DEXAMETHASONE 0.5MG TAB EXTERNAL 01/01/95 028 0250 5012
13715461 DEXAMETHASONE 0.5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715480 DEXAMETHASONE 0.75MG TAB EXTERNAL 01/01/95 028 0250 5012
13715481 DEXAMETHASONE 0.75MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715500 DEXAMETHASONE 1.5MG TAB EXTERNAL 01/01/95 028 0250 5012
13715501 DEXAMETHASONE 1.5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715506 DEXAMETHASONE 2MG TAB EXTERNAL 01/01/95 028 0250 5012
13715507 DEXAMETHASONE 2MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715511 DEXAMETHASONE 6MG (2 MG X 3) T EXTERNAL 01/31/08 028 0251 5012
13715512 DEXAMETHASONE 20 MG (4 MG X 5) EXTERNAL 01/31/08 028 0251 5012
13715513 DEXAMETHASONE 40 MG (4 MG X 10 EXTERNAL 01/31/08 028 0251 5012
13715514 DEXAMETHASONE 8 MG (4 MG X 2) EXTERNAL 01/31/08 028 0251 5012
13715520 DEXAMETHASONE 4MG TAB EXTERNAL 01/01/95 028 0250 5012
13715522 DEXAMETHASONE 4MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13715531 DEXAMETHASONE 0.5MG/5ML ELIXIR EXTERNAL 07/01/84 028 0250 5012
13715532 DEXAMETHASONE 0.05MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715533 0EXAMETHASONE SOLUTTION 1MG/ML EXTERNAL 07/01/84 028 0250 5012
13715535 DEXAMETHASONE 0.10MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715536 DEXAMETHASONE 0.12MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 221
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13715537 DEXAMETHASONE 0.15MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715538 DEXAMETHASONE 0.2MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715539 DEXAMETHASONE 0.25MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715540 DEXAMETHASONE INJECTION 4MG VI EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715541 DEXAMETHASONE 0.3MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715542 DEXAMETHASONE 0.4MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715543 DEXAMETHASONE 0.5MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715544 DEXAMETHASONE 0.6MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715545 DEXAMETHASONE 0.8MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715547 DEXAMETHASONE 1.2MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715548 DEXAMETHASONE 1.5MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715549 DEXAMETHASONE 2.0MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715550 DEXAMETHASONE 4MG/ML INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715552 DEXAMETHASONE 3.0MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13715554 DEXAMETHASONE 0.05MG INJ EXTERNAL 02/21/92 J1100 J1100 028 0636 5012
13715555 DEXAMETHASONE 0.10MG INJ EXTERNAL 02/21/92 J1100 J1100 028 0636 5012
13715556 DEXAMETHASONE 0.12MG INJ EXTERNAL 02/21/92 J1100 J1100 028 0636 5012
13715557 DEXAMETHASONE 0.15MG INJ EXTERNAL 02/21/92 J1100 J1100 028 0636 5012
13715558 DEXAMETHASONE 0.20MG INJ EXTERNAL 02/21/92 J1100 J1100 028 0636 5012
13715559 DEXAMETHASONE 4MG/1ML INJ EXTERNAL 07/01/84 J1100 J1100 028 0636 5012
13715560 DEXAMETHASONE INJECTION 4MG VI EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715561 DEXAMETHASONE 10MG/ML INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715562 DEXAMETHASONE INJECTION 10MG D EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715563 DEXAMETHASONE 0.25MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715564 DEXAMETHASONE 0.30MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715566 DEXAMETHASONE 0.50MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715567 DEXAMETHASONE 0.60MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715568 DEXAMETHASONE 0.80MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715571 DEXAMETHASONE 1.20MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715572 DEXAMETHASONE 1.50MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715573 DEXAMETHASONE 1.00MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715574 DEXAMETHASONE 3MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715575 BETAMETHASONE VAL 0.1% CRM 15G EXTERNAL 03/26/02 028 0251 5012
13715576 DEXAMETHASONE 1.00MG INJ EXTERNAL 01/01/95 J1100 J1100 028 0636 5012
13715577 DEXAMETHASONE 1MG TAB (2X.5MG) EXTERNAL 01/01/95 028 0251 5012
13715578 DEXAMETHASONE 3MG (2X1.5MG) TA EXTERNAL 01/01/95 028 0251 5012
13715579 DEXAMETHASONE 1MG/D5W 50ML EXTERNAL 03/08/96 J1100 J1100 028 0636 5012
13715580 DEXAMETHASONE 0.1% OPHTH SUSP EXTERNAL 01/01/95 028 0251 5012
13715582 DEXAMETHASONE 0.07MG ORAL SOLN EXTERNAL 03/14/95 028 0251 5012
13715591 DEXAMETHASONE 0.04MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13715592 DEXAMETHASONE 0.08MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13715593 DEXAMETHASONE 0.75MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13715594 DEXAMETHASONE 4MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13715595 DEXAMETHASONE 6MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13715597 DEXAMETHASONE 10MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13715630 DEXTRAN-40 (10% IN D5) 500ML EXTERNAL 07/01/84 J7100 J7100 028 0636 5012
13715640 DEXTRAN-40 (10% IN NS) 500ML EXTERNAL 07/01/84 J7100 J7100 028 0636 5012
13715780 DEXTROSE 5%/LACTATED RINGERS EXTERNAL 07/01/84 028 0258 5012
13715790 D5%/LR 1000ML EXTERNAL 07/01/84 028 0258 5012
13715840 D5%/NACL 0.9%500ML EXTERNAL 07/01/84 J7042 J7042 028 0636 5012
13715850 D5%/NACL 0.9% 500ML EXTERNAL 07/01/84 J7042 J7042 028 0636 5012
13715856 DEXTROSE 5%/NS/20MEQ KCL EXTERNAL 07/07/88 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 222
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13715865 DEXTROSE 5%/NACL 0.45%/20MEQ K EXTERNAL 07/01/84 028 0251 5012
13715875 DEXTROSE 25% INJ EXTERNAL 01/01/95 028 0251 5012
13715900 D5%/NACL 0.2% 500ML EXTERNAL 07/01/84 028 0251 5012
13715910 DEXTROSE 5%/NACL 0.2% 1000ML EXTERNAL 07/01/84 028 0251 5012
13715950 DEXTROSE 5%/NACL 0.45% 500ML EXTERNAL 01/01/95 028 0258 5012
13715960 DEXTROSE 5%/NACL 0.45% 1000ML EXTERNAL 07/01/84 J7120 J7120 028 0636 5012
13716010 D5% IN WATER 50ML EXTERNAL 01/01/95 J7060 J7060 028 0636 5012
13716020 D5% IN WATER 100ML EXTERNAL 01/01/95 J7060 J7060 028 0636 5012
13716021 D5% IN WATER 100ML (GLASS) EXTERNAL 07/27/01 J7060 J7060 J7060 028 0258 5012
13716022 D5% IN WATER 500ML (GLASS) EXTERNAL 05/14/02 J7060 J7060 J7060 028 0258 5012
13716023 D5% IN WATER 500ML (GLASS) EXTERNAL 05/14/02 J7060 J7060 J7060 028 0258 5012
13716030 D5% IN WATER 150ML EXTERNAL 01/01/95 J7060 J7060 028 0636 5012
13716031 DEXTROSE 5% WATER LOCK FLUSH EXTERNAL 05/09/94 028 0251 5012
13716040 D5% IN WATER 250ML EXTERNAL 01/01/95 J7060 J7060 028 0636 5012
13716041 D5% IN WATER 250ML (GLASS) EXTERNAL 10/19/90 J7060 J7060 028 0636 5012
13716042 DEXTROSE 3%-25% FOR COMPOUNDIN EXTERNAL 06/27/01 028 0258 5012
13716043 DEXTROSE 20% 500 ML EXTERNAL 11/04/09 028 0258 5012
13716050 D5% IN WATER 500ML EXTERNAL 01/01/95 J7060 J7060 028 0636 5012
13716060 D5% IN WATER 500ML EXTERNAL 01/01/95 J7060 J7060 028 0636 5012
13716100 D10%/NACL 0.9% 1000ML EXTERNAL 07/01/84 028 0258 5012
13716141 D10% IN WATER 1000ML EXTERNAL 07/01/84 028 0258 5012
13716143 D10%/NACL 0.45% 1000 ML EXTERNAL 08/19/97 028 0258 5012
13716144 D10%/NACL 0.45% 500 ML EXTERNAL 03/23/04 028 0258 5012
13716150 D10% IN WATER 500ML EXTERNAL 07/01/84 028 0258 5012
13716170 DEXTROSE 20% IN WATER 500ML EXTERNAL 07/01/84 028 0258 5012
13716180 DEXTROSE 50% IN WATER EXTERNAL 07/01/84 028 0258 5012
13716186 D70% IN WATER 2000ML EXTERNAL 07/01/84 028 0258 5012
13716195 DEXTROSE 10% INJ 5ML EXTERNAL 01/01/95 028 0250 5012
13716200 DEXTROSE 50% INJECTION 50ML VI EXTERNAL 01/01/95 028 0250 5012
13716210 DEXTROSE 50% INJ 50ML SYR EXTERNAL 01/01/95 028 0250 5012
13716211 DEXTROSE 50% INJ EXTERNAL 01/01/95 028 0250 5012
13716230 DEXTROSE SOLUTION 100GM BOTTLE EXTERNAL 07/01/84 028 0250 5012
13716249 DIATRIZOATE (MD-GASTROVIEW SOL EXTERNAL 02/22/06 028 0251 5012
13716250 DIAZEPAM 2.5MG PER 1/2 TAB EXTERNAL 07/01/84 028 0251 5012
13716252 DIAZEPAM 0.5MG ORAL SOLN EXTERNAL 10/01/01 028 0251 5012
13716253 DIAZEPAM 1MG PER 1/2 TAB EXTERNAL 10/01/01 028 0251 5012
13716254 DIAZEPAM 2MG ORAL SOLN EXTERNAL 10/01/01 028 0251 5012
13716255 DIAZEPAM 5MG ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13716257 DIAZEPAM 1MG/ML ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13716260 DIAZEPAM 2.5MG PER 1/2 TAB EXTERNAL 07/01/84 028 0251 5012
13716280 DIAZEPAM 2MG TABLET EXTERNAL 01/01/95 028 0251 5012
13716281 DIAZEPAM 2MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716282 DIAZEPAM 0.15MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716283 DIAZEPAM 0.25MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716284 DIAZEPAM 0.3MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716285 DIAZEPAM 0.7MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716286 DIAZEPAM 1.3MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716287 DIAZEPAM 1.5MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716288 DIAZEPAM 3MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716289 DIAZEPAM 4MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716290 DIAZEPAM 5MG TABLET EXTERNAL 01/01/95 028 0250 5012
13716291 DIAZEPAM 5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 223
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13716292 DIAZEPAM 10MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13716300 DIAZEPAM 10MG TABLET EXTERNAL 01/01/95 028 0251 5012
13716301 DIAZEPAM 10MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716310 DICLOXACILLIN 125MG CAP EXTERNAL 03/08/96 028 0251 5012
13716341 DIAZEPAM 5MG/ML INJ EXTERNAL 01/01/95 J3360 J3360 028 0636 5012
13716342 DIAZEPAM 5MG/ML PEDS INJ EXTERNAL 05/19/09 028 0258 5012
13716350 DIAZEPAM INJECTION 10MG SYRING EXTERNAL 01/01/95 J3360 028 0636 5012
13716370 DIBUCAINE 1% OINT 30GM EXTERNAL 01/01/95 028 0250 5012
13716375 DICLOFENAC 25MG CR TAB EXTERNAL 01/01/95 028 0251 5012
13716376 DICLOFENAC 25MG - 1 BOX EXTERNAL 01/23/90 028 0251 5012
13716378 DICLOFENAC 50MG CR TAB EXTERNAL 01/01/95 028 0251 5012
13716379 DICLOFENAC 50MG - 1 BOX EXTERNAL 01/23/90 028 0251 5012
13716381 DICLOFENAC 75MG CR TAB EXTERNAL 01/01/95 028 0251 5012
13716382 DICLOFENAC 75MG - 1 BOX EXTERNAL 01/23/90 028 0251 5012
13716390 DICYCLOMINE 10MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13716391 DICYCLOMINE 20MG VIAL EXTERNAL 01/01/95 028 0251 5012
13716395 DICYCLOMINE 10MG CAP EXTERNAL 07/01/84 028 0250 5012
13716400 DICYCLOMINE 20MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13716405 DICYCLOMINE 20MG TAB EXTERNAL 07/01/84 028 0250 5012
13716410 DIDANOSINE 25MG TAB - 60/BTL EXTERNAL 01/28/92 028 0251 5012
13716415 DIDANOSINE 50MG TAB - 60/BTL EXTERNAL 01/28/92 028 0251 5012
13716417 DIDANOSINE 200MG CHEW TAB EXTERNAL 11/25/02 028 0251 5012
13716418 DIDANOSINE 125MG ENTERIC-COATE EXTERNAL 11/25/02 028 0251 5012
13716419 DIDANOSINE 200MG ENTERIC-COATE EXTERNAL 11/25/02 028 0251 5012
13716420 DIDANOSINE 100MG TAB - 60/BTL EXTERNAL 01/28/92 028 0251 5012
13716422 DIDANOSINE 250MG ENTERIC-COATE EXTERNAL 11/25/02 028 0251 5012
13716423 DIDANOSINE 400MG ENTERIC-COATE EXTERNAL 11/25/02 028 0251 5012
13716425 DIDANOSINE 150MG TAB - 60/BTL EXTERNAL 01/28/92 028 0251 5012
13716426 DIDANOSINE 150MG CHEW TAB EXTERNAL 01/01/95 028 0251 5012
13716429 DIDANOSINE 20MG/ML SUSPENSION EXTERNAL 12/19/96 028 0251 5012
13716430 DIDANOSINE 20MG/ML 100ML PED O EXTERNAL 01/01/95 028 0251 5012
13716433 DIDANOSINE 375MG POWDER - 30/B EXTERNAL 01/29/92 028 0251 5012
13716434 DIDANOSINE 250MG POWDER EXTERNAL 01/01/95 028 0251 5012
13716435 DIDANOSINE 250MG POWDER - 30/B EXTERNAL 01/29/92 028 0251 5012
13716436 DIDANOSINE 167MG POWDER EXTERNAL 01/01/95 028 0251 5012
13716437 DIDANOSINE 167MG POWDER - 30/B EXTERNAL 01/29/92 028 0251 5012
13716438 DIDANOSINE 100MG POWDER EXTERNAL 01/01/95 028 0251 5012
13716439 DIDANOSINE 100MG POWDER - 30/B EXTERNAL 01/29/92 028 0251 5012
13716440 DIDANOSINE 10MG/ML SUSPENSION EXTERNAL 11/05/01 028 0251 5012
13716559 FLOCONAZOLE 200MG TAB UD - 100 EXTERNAL 03/26/92 028 0251 5012
13716561 FLUCONAZOLE 200MG TAB EXTERNAL 01/01/95 028 0251 5012
13716564 FLUCONAZOLE 40MG/ML SUSPENSION EXTERNAL 06/02/97 028 0251 5012
13716566 FLUCONAZOLE 100MG SUSPENSION EXTERNAL 10/02/01 028 0251 5012
13716567 FLUCONAZOLE 400MG (200 MG X 2) EXTERNAL 02/05/08 028 0251 5012
13716569 D5% IN WATER 120ML EXTERNAL 09/23/03 J7060 J7060 028 0636 5012
13716570 D5% IN WATER 240ML EXTERNAL 09/23/03 J7060 J7060 028 0636 5012
13716678 DIGOXIN IMMUNE FAB FRAG ***VIA EXTERNAL 01/01/95 J1162 J1162 J1162 028 0636 5012
13716679 DIGOXIN IMMUNE FAB 10MG/ML INJ EXTERNAL 10/19/90 J1162 J1162 J1162 028 0636 5012
13716702 DIGOXIN 2.5MCG ELIXIR EXTERNAL 10/01/01 028 0251 5012
13716703 DIGOXIN 62.5 MCG TAB (1/2 X 12 EXTERNAL 06/21/06 028 0251 5012
13716709 DIGOXIN 375MCG (3X125MCG) TAB EXTERNAL 01/01/95 028 0251 5012
13716710 DIGOXIN 125MCG TAB EXTERNAL 01/01/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 224
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13716711 DIGOXIN 0.125MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716712 DIGOXIN 10MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716713 DIGOXIN 12.5MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716714 DIGOXIN 4MCG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13716715 DIGOXIN 6.5MCG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13716716 DIGOXIN 18MCG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13716717 DIGOXIN 62.5MCG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13716718 DIGOXIN 80MCG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13716719 DIGOXIN 180MCG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13716720 DIGOXIN 250MCG TAB EXTERNAL 01/01/95 028 0251 5012
13716721 DIGOXIN 0.25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716722 DIGOXIN 5MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716723 DIGOXIN 6MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716724 DIGOXIN 7.5MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716727 DIGOXIN 15MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716729 DIGOXIN 25MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716731 DIGOXIN EXLIR 50MC/ML 60ML BTL EXTERNAL 07/01/84 028 0251 5012
13716734 DIGOXIN 30MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716735 DIGOXIN 35MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716736 DIGOXIN 40MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716738 DIGOXIN 45MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716739 DIGOXIN ELIXIR 50MCG EXTERNAL 03/08/96 028 0251 5012
13716740 DIGOXIN INJECTION 100MCG AMPUL EXTERNAL 01/01/95 J1160 J1160 028 0636 5012
13716750 DIGOXIN INJECTION 500MCG AMPUL EXTERNAL 01/01/95 J7060 J7060 J7060 028 0251 5012
13716752 DIGOXIN INJECTION 250MCG TUBEX EXTERNAL 01/01/95 J1160 J1160 J1160 028 0251 5012
13716753 DIGOXIN 125MCG INJ EXTERNAL 07/01/84 J1160 J1160 028 0636 5012
13716754 DIGOXIN 125MCG ELIXIR EXTERNAL 01/01/95 028 0251 5012
13716756 DIGOXIN 60MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716757 DIGOXIN 75MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716758 DIGOXIN 100MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716759 DIGOXIN ELIXIR 125MCG EXTERNAL 03/08/96 028 0251 5012
13716760 DIGOXIN 150MCG ELIXIR EXTERNAL 03/08/96 028 0251 5012
13716770 DIHYDROERGOTAMINE 1MG INJ EXTERNAL 07/01/84 J1110 J1110 028 0636 5012
13716780 DILTIAZEM 240MG CAP - BOX EXTERNAL 04/04/94 028 0251 5012
13716781 DILTIAZEM 360 MG CD CAP EXTERNAL 09/12/00 028 0251 5012
13716787 DILTIAZEM 120MG CD CAP EXTERNAL 08/10/01 028 0251 5012
13716789 DILTIAZEM CR 180MG CAP - BOX EXTERNAL 04/04/94 028 0251 5012
13716790 DILTIAZEM 180MG CAP UD - 100/B EXTERNAL 09/15/92 028 0251 5012
13716791 DILTIAZEM CR 240MG CAP - 100/B EXTERNAL 09/15/92 028 0251 5012
13716792 DILTIAZEM CD 300MG CAP - 100/B EXTERNAL 09/15/92 028 0251 5012
13716794 DILTIAZEM 180MG CD CAP EXTERNAL 01/01/95 028 0251 5012
13716796 DILTIAZEM 240MG CD CAP EXTERNAL 01/01/95 028 0251 5012
13716798 DILTIAZEM 300MG CD CAP EXTERNAL 01/01/95 028 0251 5012
13716800 DILTIAZEM SR 60MG - 1 BOX EXTERNAL 09/22/90 028 0251 5012
13716801 DILTIAZEM 60MG SR CAP EXTERNAL 01/01/95 028 0251 5012
13716803 DILTIAZEM SR 90MG - 1 BOX EXTERNAL 09/22/90 028 0251 5012
13716804 DILTIAZEM 90MG SR CAP EXTERNAL 01/01/95 028 0251 5012
13716806 DILTIAZEM SR 120MG - 1 BOX EXTERNAL 09/22/90 028 0251 5012
13716807 DILTIAZEM 120MG SR CAP EXTERNAL 01/01/95 028 0251 5012
13716808 DILTIAZEM 120MG - 1 BOX EXTERNAL 09/09/88 028 0251 5012
13716809 DILTIAZEM 90MG - 1 BOX EXTERNAL 09/09/88 028 0251 5012
13716811 DILTIAZEM 90MG TAB EXTERNAL 01/01/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 225
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13716812 DILTIAZEM TAB 120MG - 1 BOTTLE EXTERNAL 01/01/87 028 0251 5012
13716813 DILTIAZEM TAB 120MG EXTERNAL 01/01/95 028 0251 5012
13716814 DILTIAZEM 60MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716815 DILTIAZEM 30MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716816 DILTIAZEM 30MG TAB EXTERNAL 01/01/95 028 0250 5012
13716819 DILTIAZEM 60MG TAB EXTERNAL 01/01/95 028 0250 5012
13716820 DILTIAZEM 15 MG EXTERNAL 07/01/84 028 0251 5012
13716823 DEMECLOCYCLINE 150MG TAB EXTERNAL 01/01/95 028 0251 5012
13716825 DEMECLOCYCLINE 300MG TAB EXTERNAL 01/01/95 028 0251 5012
13716827 DIMERCAPROL 100MG/ML INJ EXTERNAL 12/17/96 J0470 J0470 028 0636 5012
13716829 DINOPROSTONE 10MG VAG INSERT EXTERNAL 01/18/01 028 0251 5012
13716833 DILTIAZEM SR 120MG CAP EXTERNAL 11/16/94 028 0251 5012
13716841 DILTIAZEM 5MG/ML INJ EXTERNAL 09/24/97 028 0251 5012
13716842 DILTIAZEM 50MG INJ EXTERNAL 09/24/97 028 0258 5012
13716850 DOCUSATE SOD 50MG CAPSULE EXTERNAL 01/01/95 028 0250 5012
13716851 DOCUSATE SODIUM 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716862 DIPH-TET-ACELL-PERTUSSIS 0.5ML EXTERNAL 03/24/98 028 0258 5012
13716863 DIPH-TET-ACELL-PERTUSSIS 0.5ML EXTERNAL 11/11/09 028 0258 5012
13716870 DOCUSATE SOD 100MG CAPSULE EXTERNAL 01/01/95 028 0250 5012
13716871 DOCUSATE SODIUM 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716872 DOCUSATE SOD 200MG (100 MG X 2 EXTERNAL 02/05/08 028 0251 5012
13716879 DOCUSATE 5MG SYRUP EXTERNAL 10/01/01 028 0251 5012
13716883 DOCUSATE 30MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13716884 DOCUSATE 40MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13716885 DOCUSATE SODIUM SYRUP 50MG EXTERNAL 10/01/01 028 0251 5012
13716887 DOCUSATE 200MG SYRUP EXTERNAL 10/01/01 028 0251 5012
13716897 DOCUSATE SODIUM 50MG/5ML - 1 B EXTERNAL 07/01/84 028 0250 5012
13716899 DOCUSATE SOD 200MG (100 MG X 2 EXTERNAL 05/02/08 028 0251 5012
13716900 DOCUSATE SOD 100MG LIQUID EXTERNAL 01/01/95 028 0250 5012
13716901 DOCUSATE 10MG SYRUP EXTERNAL 07/01/84 028 0250 5012
13716902 DOCUSATE SODIUM - 1 BOTTLE EXTERNAL 11/03/98 028 0251 5012
13716910 DOCUSATE 250MG SYRUP EXTERNAL 01/01/95 028 0250 5012
13716932 DICYCLOMINE 10MG/ML INJ EXTERNAL 01/01/95 J0500 J0500 028 0636 5012
13716950 DIPH TETANUS TOX ABSORBED PED EXTERNAL 01/01/95 028 0250 5012
13716951 DIPH TETANUS TOX ABSORBED PED EXTERNAL 10/19/90 028 0250 5012
13716955 TETANUS/DIPH T ADULT 0.5ML EXTERNAL 01/01/95 028 0250 5012
13716956 DIPH TETANUS TOX ABSORBED ADUL EXTERNAL 10/19/90 028 0250 5012
13716990 DIPHENHYDRAMINE 25MG CAP EXTERNAL 01/01/95 Q0163 Q0163 Q0163 028 0636 5012
13716991 DIPHENHYDRAMINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13716992 DIPHENHYDRAMINE 12.5MG ELIXIR EXTERNAL 01/01/95 028 0637 5012
13716993 DIPHENHYDRAMINE 25MG ELIXIR EXTERNAL 01/01/95 Q0163 Q0163 028 0636 5012
13716994 DIPHENHYDRAMINE 6.25MG ELIXIR EXTERNAL 10/01/01 Q0163 Q0163 028 0636 5012
13717010 DIPHENHYDRAMINE 50MG CAP EXTERNAL 01/01/95 028 0250 5012
13717011 DIPHENHYDRAMINE 50MG - 1 BOX EXTERNAL 01/25/95 Q0163 Q0163 028 0251 5012
13717021 DIPHENHYDRAMINE ELIXIR - 12.5M EXTERNAL 07/01/84 Q0163 Q0163 Q0163 028 0251 5012
13717022 DIPHENHYDRAMINE ELIXIR 25MG DO EXTERNAL 01/01/95 Q0163 Q0163 Q0163 028 0251 5012
13717040 DIPHENHYDRAMINE INJECTION 50MG EXTERNAL 01/01/95 J1200 J1200 028 0636 5012
13717049 DIPHENHYDRAMINE 50MG/ML INJ EXTERNAL 01/04/05 J1200 J1200 028 0636 5012
13717050 DIPHENHYDRAMINE 50MG/ML VIAL EXTERNAL 08/01/94 J1200 J1200 J1200 028 0636 5012
13717090 DONEPEZIL 5 MG 100UD/BOX EXTERNAL 03/19/97 028 0251 5012
13717091 DONEPEZIL 5 MG TAB EXTERNAL 03/19/97 028 0251 5012
13717093 DONEPEZIL 10MG 100UD/BOX EXTERNAL 03/19/97 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 226
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13717094 DONEPEZIL 10MG TAB EXTERNAL 03/19/97 028 0251 5012
13717100 DOFETILIDE 125 MCG TABLET EXTERNAL 02/08/08 028 0251 5012
13717101 DOFETILIDE 250 MCG TABLET EXTERNAL 02/08/08 028 0251 5012
13717102 DOFETILIDE 500 MCG TABLET EXTERNAL 02/08/08 028 0251 5012
13717158 DIPYRIDAMOLE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13717159 DIPYRIDAMOLE 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13717161 DIPYRIDAMOLE 25MG TAB EXTERNAL 01/01/95 028 0250 5012
13717163 DIPYRIDAMOLE 50MG TAB EXTERNAL 01/01/95 028 0250 5012
13717165 DIPYRIDAMOLE 75MG TAB EXTERNAL 01/01/95 028 0250 5012
13717166 DIPYRIDAMOLE 75MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13717170 DISODIUM EDETATE INJECTION *** EXTERNAL 07/01/84 028 0250 5012
13717189 DIVALPROEX 1250MG TAB(2X500+1X EXTERNAL 07/31/01 028 0251 5012
13717190 DIVALPROEX 125MG CAPSULE - 1 B EXTERNAL 07/01/84 028 0250 5012
13717191 DIVALPROEX 125MG SPRINKLE CAP EXTERNAL 01/01/95 028 0251 5012
13717192 DIVALPROEX 250MG TAB EXTERNAL 01/01/95 028 0250 5012
13717193 DIVALPROEX 500MG TAB EXTERNAL 01/01/95 028 0250 5012
13717194 DIVALPROEX SODIUM 250MG - 1 BO EXTERNAL 01/01/87 028 0250 5012
13717195 DOBUTAMINE 12.5MG/1ML INJ EXTERNAL 01/01/95 J1250 J1250 028 0636 5012
13717196 DIVALPROEX SODIUM 500MG - 1 BO EXTERNAL 01/25/95 028 0251 5012
13717197 DIVALPROEX 125MG TAB EXTERNAL 01/01/95 028 0250 5012
13717201 DOBUTAMINE 250MG/250ML D5W EXTERNAL 03/16/94 J1250 J1250 J1250 028 0636 5012
13717202 DOBUTAMINE 250MG/125ML D5W EXTERNAL 03/16/94 J1250 J1250 J1250 028 0636 5012
13717203 DOBUTAMINE 250MG/250ML D5W EXTERNAL 03/16/94 J1250 J1250 J1250 028 0636 5012
13717204 DOBUTAMINE 30 MG FOR 30 ML IV EXTERNAL 03/11/08 028 0258 5012
13717205 DOBUTAMINE 60 MG FOR 30 ML IV EXTERNAL 03/11/08 028 0258 5012
13717206 DOBUTAMINE 120 MG FOR 30 ML IV EXTERNAL 03/11/08 028 0258 5012
13717210 ATROPINE-HYOSCYAMINE-PB-SCOPOL EXTERNAL 07/01/84 028 0250 5012
13717211 DONNATAL - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13717228 DONNATAL ELIXIR 1ML EXTERNAL 03/14/02 028 0251 5012
13717229 ATROP-HYOSCYAMINE-PB-SCOPOLAMI EXTERNAL 10/01/01 028 0251 5012
13717230 ATROP-HYOSCYAMINE-PB-SCOPOLAMI EXTERNAL 01/01/95 028 0250 5012
13717231 DONNATAL 480ML - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13717235 DOPAMINE 200MG/D5W 250ML BAG EXTERNAL 01/01/95 J1265 J1265 J1265 028 0251 5012
13717236 DOPAMINE 400MG/D5W 250ML BAG EXTERNAL 01/01/95 J1265 J1265 J1265 028 0251 5012
13717237 DOPAMINE 800MG/D5W 250ML BAG EXTERNAL 01/01/95 J1265 J1265 J1265 028 0251 5012
13717240 DOPAMINE 40MG/ML INJ EXTERNAL 01/01/95 J1265 J1265 J1265 028 0636 5012
13717243 DOPAMINE 48 MG FOR 30 ML IV EXTERNAL 03/11/08 028 0258 5012
13717244 DOPAMINE 96 MG FOR 30 ML IV EXTERNAL 03/11/08 028 0258 5012
13717245 DOPAMINE 200MG FOR 250ML LVP EXTERNAL 01/01/95 J1265 J1265 J1265 028 0250 5012
13717247 DOPAMINE 400MG FOR 250ML LVP EXTERNAL 01/01/95 J1265 J1265 J1265 028 0636 5012
13717250 DOXAPRAM 20MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13717254 DORZOLAMIDE 2% OPHTH SOLN EXTERNAL 07/21/95 028 0251 5012
13717263 DOXAZOSIN 1 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717264 DOXAZOSIN 1 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717265 DOXAZOSIN 2 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717266 DOXAZOSIN 2 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717268 DOXAZOSIN 4 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717269 DOXAZOSIN 4 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717272 DOXAZOSIN 8 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717273 DOXAZOSIN 8 MG TAB EXTERNAL 09/25/97 028 0251 5012
13717335 DOXORUBICIN 2MG/ML INJ EXTERNAL 01/01/95 J9000 J9000 028 0636 5012
13717360 DOXYCYCLINE 50MG CAP EXTERNAL 01/01/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 227
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13717361 DOXYCYCLINE 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13717370 DOXYCYCLINE 100MG CAP EXTERNAL 01/01/95 028 0250 5012
13717371 DOXYCYCLINE 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13717380 DOXYCYCLINE INJECTION 100MG VI EXTERNAL 01/01/95 028 0251 5012
13717382 DOXYCYCLINE 10MG/1ML INJ EXTERNAL 01/01/95 028 0250 5012
13717383 DEFERASIROX 125 MG TABLET (FOR EXTERNAL 03/18/05 028 0251 5012
13717384 DEFERASIROX 500 MG TABLET (FOR EXTERNAL 01/07/08 028 0251 5012
13717385 DULOXETINE 20 MG CAPSULE EXTERNAL 01/07/08 028 0251 5012
13717386 DULOXETINE 30 MG CAPSULE EXTERNAL 01/07/08 028 0251 5012
13717390 DOXYCYCLINE 100MG/D5W 100ML EXTERNAL 01/13/96 028 0258 5012
13717392 DRONEDARONE 400 MG TABLET EXTERNAL 01/16/10 028 0251 5012
13717406 DROTRECOGIN ALFA 15 MG FOR 250 EXTERNAL 01/04/05 028 0258 5012
13717409 DROTRECOGIN ALFA 2MG/ML EXTERNAL 04/05/02 028 0258 5012
13717412 HCTZ-TRIAMTERENE 25MG/37.5MG EXTERNAL 01/01/95 028 0251 5012
13717413 DYAZIDE CAPSULE - 1 BOTTLE EXTERNAL 10/24/89 028 0251 5012
13717420 SALICYLIC ACID COLLOD 16.7% EXTERNAL 07/01/84 028 0250 5012
13717422 LIDOCAINE 4% INJECTION LARYNGO EXTERNAL 01/01/95 J2001 J2001 028 0251 5012
13717430 EPINEPH-PILOCARPINE 1%/2% OPHT EXTERNAL 01/01/95 028 0250 5012
13717485 EDETATE DISODIUM 150MG/ML INJ EXTERNAL 10/19/90 J3520 J3520 028 0636 5012
13717490 EDROPHONIUM 10MG/ML INJ EXTERNAL 01/01/95 028 0251 5012
13717501 EPAVIRENZ 600MG TAB EXTERNAL 05/28/02 028 0251 5012
13717502 EMTRICITABINE 200 MG CAPSULE EXTERNAL 02/25/08 028 0251 5012
13717503 EMTRICITABINE/TENOFOVIR TABLET EXTERNAL 02/25/08 028 0251 5012
13717549 ENALAPRIL 15 MG (5 MG X 3) TAB EXTERNAL 02/05/08 028 0251 5012
13717550 ENALAPRIL 10MG - 1 BOX EXTERNAL 11/17/90 028 0251 5012
13717551 ENALAPRIL 20MG - 1 BOX EXTERNAL 11/17/90 028 0251 5012
13717552 ENALAPRIL 1.25MG (1/2 X 2.5MG) EXTERNAL 04/08/94 028 0251 5012
13717553 EFAVIRENZ 50MG CAPSULE EXTERNAL 11/25/02 028 0251 5012
13717554 EFAVIRENZ 100MG CAPSULE EXTERNAL 11/25/02 028 0251 5012
13717556 EFAVIRENZ 200MG CAPSULE EXTERNAL 11/25/02 028 0251 5012
13717649 ENOXAPARIN 70 MG INJ EXTERNAL 11/07/08 028 0258 5012
13717651 ENOXAPARIN 100MG/ML INJ EXTERNAL 11/07/08 028 0258 5012
13717652 ENOXAPARIN 120 MG INJ EXTERNAL 11/07/08 028 0258 5012
13717653 ENOXAPARIN 20MG/ML PEDS INJ EXTERNAL 11/29/01 J1650 J1650 028 0636 5012
13717654 ENOXAPARIN 80MG SYR EXTERNAL 06/12/00 J1650 J1650 028 0636 5012
13717655 ENOXAPARIN 30MG SYR EXTERNAL 01/01/95 J1650 J1650 028 0636 5012
13717657 ENOXAPARIN 100MG SYR EXTERNAL 02/18/00 J1650 J1650 028 0636 5012
13717658 ENOXAPARIN 40MG SYR EXTERNAL 04/26/00 J1650 J1650 028 0636 5012
13717659 ENOXAPARIN 60MG SYR EXTERNAL 04/26/00 J1650 J1650 028 0636 5012
13717660 EPHEDRINE 25MG CAP EXTERNAL 01/01/95 028 0250 5012
13717661 EPHEDRINE SULFATE 25MG - 1 BOT EXTERNAL 01/25/95 028 0251 5012
13717665 ENOXAPARIN 120MG SYR EXTERNAL 02/15/02 028 0258 5012
13717670 EPHEDRINE SULFATE INJ 50MG AMP EXTERNAL 01/01/95 028 0250 5012
13717671 EPHEDRINE 50MG/ML INJ EXTERNAL 07/01/84 028 0251 5012
13717676 ENTACAPONE 200MG TAB EXTERNAL 05/11/00 028 0251 5012
13717677 ENTACAPONE 200MG BULK EXTERNAL 05/11/00 028 0251 5012
13717680 MEPIVACAINE 1.5% W/EPINEPHRINE EXTERNAL 05/21/92 J0670 J0670 028 0636 5012
13717690 EPINEPHRINE INJECTION 1MG AMPU EXTERNAL 01/01/95 J0170 J0170 028 0636 5012
13717692 EPINEPHRINE 1 MG/ML INJ AMP EXTERNAL 01/01/95 J0170 J0170 028 0636 5012
13717695 EPINEPHRINE 0.96 MG FOR 30 ML EXTERNAL 11/26/08 028 0258 5012
13717696 EPINEPHRINE 1.92 MG FOR 30 ML EXTERNAL 11/26/08 028 0258 5012
13717700 EPINEPHRINE INJECTION 1MG/ML EXTERNAL 01/01/95 J0170 J0170 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 228
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13717740 EPTIFIBATIDE 2MG/ML INJ EXTERNAL 11/24/98 J1327 J1327 028 0636 5012
13717742 EPTIFIBATIDE 0.75MG INJ EXTERNAL 11/24/98 J1327 J1327 028 0636 5012
13717760 EPINEPHRINE 1:10000 INJECTION EXTERNAL 07/01/84 J0170 J0170 028 0636 5012
13717770 EPINEPHRINE 1MG/10ML INJ SYRI EXTERNAL 01/01/95 J0170 J0170 J0170 028 0251 5012
13717780 EPINEPHRINE 1MG INJ - 21GX1.5" EXTERNAL 01/01/95 J0170 J0170 028 0636 5012
13717789 EPINEPHRINE RACEMIC SOLUTION 0 EXTERNAL 04/05/02 028 0251 5012
13717790 EPINEPHRINE RACEMIC 2.25% SOLN EXTERNAL 03/26/02 028 0250 5012
13717793 EPINEPHRINE RACEMIC 2.25% SVN EXTERNAL 03/26/02 028 0250 5012
13717794 EPINEPHRINE RACEMIC 2.25% SVN EXTERNAL 03/26/02 028 0636 5012
13717810 EPINEPHRYL BORATE 1% OPTH SOLN EXTERNAL 07/01/84 028 0250 5012
13717814 EPHEDRINE SULFATE 25 MG CAP EXTERNAL 05/12/03 028 0251 5012
13717815 EPLERENONE 25 MG TABLET EXTERNAL 06/14/04 028 0251 5012
13717830 ERGOCALCIFEROL 200U/DROP(8000U EXTERNAL 07/01/84 028 0250 5012
13717833 ERGOCALCIFEROL 8000UNITS/ML SO EXTERNAL 01/01/95 028 0250 5012
13717834 ERGOCALCIFEROL 400UNITS SOLUTI EXTERNAL 10/01/01 028 0251 5012
13717835 ERGOCALCIFEROL 800UNITS SOLUTI EXTERNAL 11/18/05 028 0251 5012
13717859 ERGOTAMINE 2MG SL TAB EXTERNAL 01/01/95 028 0250 5012
13717860 ERGOTAMINE TARTRATE 2MG-1 BTL EXTERNAL 01/25/95 028 0251 5012
13717890 ERYTHROMYCIN 250MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13717900 ERYTHROMYCIN 250MG TAB EXTERNAL 01/01/95 028 0250 5012
13717901 ERYTHROMYCIN 333MG EC TAB EXTERNAL 01/01/95 028 0250 5012
13717902 ERYTHROMYCIN 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13717905 ERYTHROMCYIN 333MG TABLET - 1 EXTERNAL 05/25/89 028 0251 5012
13717907 ERYTHROMYCIN 500MG EC TAB EXTERNAL 01/01/95 028 0251 5012
13717908 ERYTHROMYCIN 500MG TAB UD - 10 EXTERNAL 03/26/92 028 0251 5012
13717910 ERYTHROMYCIN 0.5% OPHTH OINT 3 EXTERNAL 01/01/95 028 0250 5012
13717911 ERYTHROMYCIN 2% TOPICAL SUSP 1 EXTERNAL 01/01/95 028 0250 5012
13717915 ERYTHROMYCIN 2% TOP SOLN 60ML EXTERNAL 01/01/95 028 0251 5012
13717918 ERYTHROMYCIN 500MG/NS 100ML EXTERNAL 08/08/92 J1364 J1364 028 0636 5012
13717920 ERYTHROMYCIN 200MG SUSPENSION EXTERNAL 01/01/95 028 0250 5012
13717921 ERYTHROMYCIN SUSP(40MG/ML) - 1 EXTERNAL 01/01/95 028 0250 5012
13717922 ERYTHROMYCIN 250MG SUSPENSION EXTERNAL 11/05/01 028 0251 5012
13717924 ERYTHROMYCIN 10MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13717925 ERYTHROMYCIN 20MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13717926 ERYTHROMYCIN 60MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13717927 ERYTHROMYCIN 120MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13717939 ERYTHROMYCIN 400MG SUSPENSION EXTERNAL 05/14/02 028 0251 5012
13717941 ERYTHROMYCIN SUSP(80MG/ML) - 1 EXTERNAL 07/01/84 028 0250 5012
13717943 ERYTHROMYCIN 50MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13717944 ERYTHROMYCIN 100MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13717945 EPOETIN ALPHA 130 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717947 EPOETIN ALPHA 170 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717948 EPOETIN ALPHA 200 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0258 5012
13717949 EPOETIN ALPHA 220 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717950 EPOETIN ALPHA 250 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717951 EPOETIN ALPHA 300 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717952 EPOETIN ALPHA 350 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717953 EPOETIN ALPHA 400 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717954 EPOETIN ALPHA 60 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0636 5012
13717955 EPOETIN ALPHA 80 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717956 EPOETIN ALPHA 100 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717957 EPOETIN ALPHA 120 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 229
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13717958 EPOETIN ALPHA 160 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0636 5012
13717960 ERYTHROMYCIN INJECTION 500MG V EXTERNAL 01/01/95 J1364 J1364 028 0636 5012
13717961 ERYTHROMYCIN 1GM/NS 250ML EXTERNAL 03/12/96 J1364 J1364 028 0636 5012
13717962 ERYTHROMYCIN LAC 0.05GM/ML INJ EXTERNAL 03/12/96 J1364 J1364 028 0636 5012
13717963 EPOETIN ALPHA 5000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13717966 EPOETIN ALPHA 4000 UNITS/ML IN EXTERNAL 11/21/89 J0886 J0886 J0886 028 0636 5012
13717967 EPOETIN ALPHA 1000 UNITS/ML I EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0636 5012
13717969 HEPATITIS B IMMUNE GLOBULIN 31 EXTERNAL 01/17/05 028 0258 5012
13717973 ESMOLOL 10MG/ML INJ EXTERNAL 09/01/94 028 0251 5012
13717974 NON-ESRD EPOETIN ALPHA 100 UNI EXTERNAL 01/01/09 J0885 J0885 J0885 028 0258 5012
13717975 NON-ESRD EPOETIN ALPHA 100 UNI EXTERNAL 01/01/95 J0885 J0885 J0885 028 0258 5012
13717976 NON-ESRD EPOETIN ALPHA 1000 U/ EXTERNAL 08/09/01 J0885 J0885 J0885 028 0258 5012
13717977 NON-ESRD EPOETIN ALPHA 1000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717978 NON-ESRD EPOETIN ALPHA 12,000 EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717979 NON-ESRD EPOETIN ALPHA 120 UNI EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717980 NON-ESRD EPOETIN ALPHA 13,000 EXTERNAL 07/01/84 J0885 J0885 J0885 028 0258 5012
13717981 NON-ESRD EPOETIN ALPHA 130 UNI EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717982 NON-ESRD EPOETIN ALPHA 15,000 EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717983 NON-ESRD EPOETIN ALPHA 160 UNI EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717984 NON-ESRD EPOETIN ALPHA 170 UNI EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717985 NON-ESRD EPOETIN ALPHA 20,000 EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717986 NON-ESRD EPOETIN ALPHA 200 UNI EXTERNAL 11/19/08 J0885 J0885 J0885 028 0258 5012
13717987 NON-ESRD EPOETIN ALPHA 2000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717988 NON-ESRD EPOETIN ALPHA 220 UNI EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717989 NON-ESRD EPOETIN ALPHA 250 NIT EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717990 ESTROGENS CONJ 0.625MG TAB EXTERNAL 01/01/95 028 0251 5012
13717991 ESTROGENS CONJUGATED 0.625MG-1 EXTERNAL 01/25/95 028 0251 5012
13717992 NON-ESRD EPOETIN ALPHA 300 UNI EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717993 NON-ESRD EPOETIN ALPHA 3000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717994 NON-ESRD EPOETIN ALPHA 350 UNI EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717995 NON-ESRD EPOETIN ALPHA 400 UNI EXTERNAL 11/19/08 J0885 J0885 J0885 028 0258 5012
13717996 NON-ESRD EPOETIN ALPHA 4000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717997 NON-ESRD EPOETIN ALPHA 4000 UN EXTERNAL 09/12/00 J0885 J0885 J0885 028 0258 5012
13717998 NON-ESRD EPOETIN ALPHA 5000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13717999 NON-ESRD EPOETIN ALPHA 60 UNIT EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13718000 NON-ESRD EPOETIN ALPHA 6000 UN EXTERNAL 07/01/84 J0885 J0885 J0885 028 0258 5012
13718001 NON-ESRD EPOETIN ALPHA 7000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13718002 NON-ESRD EPOETIN ALPHA 80 UNIT EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13718003 NON-ESRD EPOETIN ALPHA 8000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13718004 NON-ESRD EPOETIN ALPHA 9000 UN EXTERNAL 03/14/08 J0885 J0885 J0885 028 0258 5012
13718005 EPOETIN ALPHA 200 UNITS/ML INJ EXTERNAL 11/19/08 028 0258 5012
13718006 EPOETIN ALPHA 400 UNITS/ML INJ EXTERNAL 11/19/08 028 0258 5012
13718010 ESTROGENS CONJ 1.25MG TAB EXTERNAL 01/01/95 028 0251 5012
13718011 ESTROGENS CONJUGATED 1.25MG - EXTERNAL 01/25/95 028 0251 5012
13718020 ESTROGENS CONJ 2.5MG TAB EXTERNAL 01/01/95 028 0251 5012
13718021 ESTROGENS CONJUGATED 2.5MG - 1 EXTERNAL 03/26/02 028 0251 5012
13718030 ESTROGENS CONJ 0.3MG TAB EXTERNAL 01/01/95 028 0251 5012
13718031 ESTROGENS CONJUGATED 0.3MG - 1 EXTERNAL 01/25/95 J1410 J1410 028 0636 5012
13718037 ESTROGENS CONJ 25 MG/NS 100 ML EXTERNAL 09/12/00 J1410 J1410 028 0636 5012
13718040 ESTROGENS CONJ 5MG/ML INJ EXTERNAL 01/01/95 J1410 J1410 028 0636 5012
13718044 ESTRADIOL 0.1MG/DAY PATCH EXTERNAL 01/01/95 028 0636 5012
13718045 ESTRADIOL 0.05MG/DAY PATCH EXTERNAL 01/01/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 230
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13718046 ESTROGENS CONJ 25 MG/NS 100 ML EXTERNAL 11/12/08 028 0258 5012
13718050 ESTROGENS CONJ 0.625% VAG CRM EXTERNAL 01/01/95 028 0250 5012
13718060 ETHAMBUTOL 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13718061 ETHAMBUTOL 100MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13718069 ETHAMBUTAL 200MG (2 X100MG) TA EXTERNAL 01/01/95 028 0251 5012
13718070 ETHAMBUTOL 400MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13718072 ETHAMBUTOL 400MG TAB EXTERNAL 01/01/95 028 0250 5012
13718073 ETHAMBUTOL 400MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13718076 ETHANOLAMINE OLEATE 5% AMPULE EXTERNAL 01/01/95 028 0251 5012
13718077 ETHANOLAMINE OLEATE 50MG/ML IN EXTERNAL 01/01/95 028 0251 5012
13718090 ETHIODIZED OIL EXTERNAL 08/18/05 028 0258 5012
13718124 FLUCONAZOLE 2MG/ML INJ EXTERNAL 12/29/03 J1450 J1450 028 0636 5012
13718171 ETOPOSIDE INJECTION 100MG VIAL EXTERNAL 03/26/02 J9181 J9181 J9181 028 0258 5012
13718172 EXACTACAINE SPRAY EXTERNAL 04/03/06 028 0251 5012
13718174 ETOPOSIDE 0.02GM/ML INJ EXTERNAL 05/14/02 J9182 J9182 028 0636 5012
13718175 ETOPOSIDE *PHOS* 20MG/ML INJ EXTERNAL 03/17/97 J9182 J9182 028 0636 5012
13718176 ETOPOSIDE 50MG - 1 BOTTLE EXTERNAL 09/09/88 028 0258 5012
13718177 ETOPOSIDE 50MG CAP EXTERNAL 01/01/95 028 0258 5012
13718179 ETOPOSIDE INJECTION 20MG/ML 5M EXTERNAL 01/01/95 J9181 J9181 J9181 028 0258 5012
13718180 ETIDRONATE 200MG - 1 BOTTLE (6 EXTERNAL 01/25/95 028 0251 5012
13718182 ETOMIDATE 2MG/ML INJ EXTERNAL 10/01/94 028 0251 5012
13718184 EZETIMIBE 10MG TAB EXTERNAL 05/22/03 028 0251 5012
13718186 HYDROCERIN CREAM 120GM EXTERNAL 06/27/96 028 0251 5012
13718187 EZETIMIBE/SIMVASTATIN 10 MG/40 EXTERNAL 05/22/03 028 0251 5012
13718188 FAMOTIDINE 4 MG/ML INJ EXTERNAL 07/25/02 028 0251 5012
13718189 FAMOTIDINE 10 MG/ML INJ EXTERNAL 07/25/02 028 0251 5012
13718191 FAMOTIDINE 10 MG (1/2 X 20 MG EXTERNAL 07/01/84 028 0251 5012
13718192 FAMOTIDINE 10MG/4ML EXTERNAL 07/25/02 028 0258 5012
13718193 FAMOTIDINE 8 MG/ML ORAL SUSP EXTERNAL 07/25/02 028 0251 5012
13718194 FAMOTIDINE 20MG/2.5 ML ORAL SU EXTERNAL 07/25/02 028 0251 5012
13718196 FAMOTIDINE 40MG/5ML SUSP EXTERNAL 07/25/02 028 0251 5012
13718197 FAMOTIDINE 20MG/50ML EXTERNAL 07/25/02 028 0258 5012
13718198 FAMOTIDINE 10MG/2ML EXTERNAL 07/25/02 028 0258 5012
13718199 FAMOTIDINE 10MG/20ML EXTERNAL 07/25/02 028 0258 5012
13718201 FAT EMULSION 20% INJ 5ML SYR EXTERNAL 12/11/97 028 0258 5012
13718202 FAT EMULSION 20% INJ 10ML SYR EXTERNAL 12/11/97 028 0258 5012
13718203 FAT EMULSION 20% INJ 25ML SYR EXTERNAL 12/11/97 028 0258 5012
13718204 FAT EMULSION 20% INJ 50ML SYR EXTERNAL 12/11/97 028 0258 5012
13718208 FAT EMULSION 20% INJ 15ML SYR EXTERNAL 12/11/98 028 0258 5012
13718210 BALANCED SALT OPTH SOLN 30ML EXTERNAL 01/01/95 028 0250 5012
13718214 FAT EMULSION 10% INJ 500ML EXTERNAL 07/01/84 028 0258 5012
13718215 FAT EMULSION 20% INJ 500ML EXTERNAL 08/01/94 028 0258 5012
13718216 FAT EMULSION 20% INJ 100ML EXTERNAL 07/01/84 028 0258 5012
13718219 FENTANYL/BUPIVACAINE 2 MCG/0.1 EXTERNAL 03/02/09 028 0251 5012
13718220 FENTANYL 50 MCG/ML INJ 2 ML AM EXTERNAL 01/01/95 J3010 J3010 028 0636 5012
13718230 FENTANYL CITRATE 0.05MG/ML INJ EXTERNAL 01/01/95 J3010 J3010 028 0636 5012
13718233 FENTANYL 100MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718239 FENTANYL 100MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718242 FUROSEMIDE 0.5MG ORAL SOLN EXTERNAL 10/02/01 028 0251 5012
13718243 FENTANYL CLINICIAN DOSE PCA EXTERNAL 07/22/09 028 0251 5012
13718245 FERROUS SULFATE 2.5MG/0.1ML DR EXTERNAL 03/13/95 028 0251 5012
13718246 FERROUS SULFATE 5MG/0.2ML DROP EXTERNAL 03/13/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 231
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13718247 FERROUS SULFATE DROPS 7.5/0.3M EXTERNAL 03/13/95 028 0251 5012
13718248 FUROSEMIDE 1MG ORAL SOLN EXTERNAL 03/13/95 028 0251 5012
13718249 FUROSEMIDE 1.5MG ORAL SOLN EXTERNAL 03/13/95 028 0251 5012
13718250 FUROSEMIDE 2MG ORAL SOLN EXTERNAL 03/13/95 028 0251 5012
13718251 FUROSEMIDE 3MG ORAL SOLN EXTERNAL 03/13/95 028 0251 5012
13718253 FENTANYL 25MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718254 FENTANYL 25MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718255 FENTANYL 75MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718256 FENTANYL 75MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718257 FENTANYL 50MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718258 FENTANYL 50MCG/HR PATCH EXTERNAL 04/05/96 028 0251 5012
13718259 FENTANYL/BUPIVACAINE 2 MCG/0.1 EXTERNAL 03/02/09 028 0251 5012
13718262 FERROUS SULFATE 15MG/0.6ML DRO EXTERNAL 03/12/96 028 0251 5012
13718263 FERROUS SULFATE 20MG/0.8ML DRO EXTERNAL 03/12/96 028 0251 5012
13718265 FERROUS SULFATE 30MG/1.2ML DRO EXTERNAL 07/21/97 028 0251 5012
13718266 FUROSEMIDE 5MG ORAL SOLN EXTERNAL 03/12/96 028 0251 5012
13718268 FUROSEMIDE 7MG ORAL SOLN EXTERNAL 03/12/96 028 0251 5012
13718269 FUROSEMIDE 8MG ORAL SOLN EXTERNAL 03/12/96 028 0251 5012
13718270 FERROUS SULFATE 325MG TAB EXTERNAL 01/01/95 028 0250 5012
13718271 FERROUS SULFATE 300MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13718273 FUROSEMIDE 15MG ORAL SOLN EXTERNAL 03/12/96 028 0251 5012
13718276 FERROUS SULFATE 975MG (325 MG EXTERNAL 02/05/08 028 0251 5012
13718281 FERROUS SULFATE 220ML/5 ELX -4 EXTERNAL 07/01/84 028 0250 5012
13718282 FERROUS SULFATE 3MG DROPS EXTERNAL 12/19/01 028 0251 5012
13718284 FERROUS SULFATE 12.5MG DROPS EXTERNAL 12/19/01 028 0251 5012
13718285 FERROUS SULFATE 18MG DROPS EXTERNAL 12/19/01 028 0251 5012
13718286 FERROUS SULFATE 35MG DROPS EXTERNAL 12/19/01 028 0251 5012
13718288 FERROUS SULFATE 75MG DROPS EXTERNAL 12/19/01 028 0251 5012
13718290 FERROUS SULFATE 300MG/5ML LIQ EXTERNAL 01/01/95 028 0250 5012
13718300 FUROSEMIDE 0.6MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13718301 FUROSEMIDE 1.8MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13718302 FUROSEMIDE 7.5MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13718303 FUROSEMIDE 25MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13718304 FUROSEMIDE 30MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13718310 FERROUS SULFATE 125MG/ML 50ML EXTERNAL 07/01/84 028 0250 5012
13718312 FLUDARABINE 25MG/ML INJ EXTERNAL 03/24/98 J9185 J9185 J9185 028 0636 5012
13718320 FLECAINIDE 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13718321 FLECAINIDE 100MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13718325 FLECAINIDE 50MG (100 MG X 1/2( EXTERNAL 02/05/08 028 0251 5012
13718331 FLUCONAZOLE 150MG 12/BOTTLE EXTERNAL 11/22/95 028 0251 5012
13718332 FLUCONAZOLE 150MG TAB EXTERNAL 11/22/95 028 0251 5012
13718335 FLUCONAZOLE 200MG/NS 100ML EXTERNAL 01/01/95 028 0250 5012
13718336 FLUCONAZOLE 100MG - 1 BOTTLE ( EXTERNAL 05/31/90 028 0251 5012
13718337 FLUCONAZOLE 100MG TAB EXTERNAL 11/01/94 028 0251 5012
13718338 FLUCONAZOLE 50MG - 1 BOTTLE (3 EXTERNAL 05/31/90 028 0251 5012
13718339 FLUCONAZOLE 50MG TAB EXTERNAL 01/01/95 028 0251 5012
13718340 FLUOXETINE 20MG - 1 BOTTLE EXTERNAL 11/21/89 028 0251 5012
13718341 FLUCONAZOLE 200MG/NS 100ML EXTERNAL 09/11/01 028 0250 5012
13718342 FLUOXETINE 20MG CAPSULE EXTERNAL 01/01/95 028 0251 5012
13718343 FLUOXETINE 20MG/5ML - 120ML BT EXTERNAL 03/24/92 028 0251 5012
13718344 FLUOXETINE 4MG/ML SOLUTION EXTERNAL 01/01/95 028 0251 5012
13718345 FLUOXETINE 20MG SOLUTION EXTERNAL 01/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 232
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13718346 FLUOXETINE 10MG CAP EXTERNAL 03/01/93 028 0251 5012
13718347 FLUOXETINE 10MG CAPSULE EXTERNAL 01/01/95 028 0251 5012
13718348 FLUOXETINE 50MG SOLUTION EXTERNAL 10/02/01 028 0251 5012
13718349 FLUOXETINE 40MG (20 MG X 2) CA EXTERNAL 02/07/08 028 0251 5012
13718351 FLUOXETINE 60MG (20 MG X 3) CA EXTERNAL 02/07/08 028 0251 5012
13718361 FLOXURIDINE 100MG/ML INJ EXTERNAL 01/01/95 J9200 J9200 J9200 028 0636 5012
13718370 FLUCYTOSINE 250MG CAP EXTERNAL 01/01/95 028 0250 5012
13718372 FLUCYTOSINE 250MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13718380 FLUCYTOSINE 500MG CAP EXTERNAL 01/01/95 028 0250 5012
13718381 FLUCYTOSINE 500MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13718390 FLUDROCORTISONE 0.1MG TAB EXTERNAL 01/01/95 028 0250 5012
13718393 FLUDROCORTISONE 0.05 MG (1/2 X EXTERNAL 06/22/06 028 0251 5012
13718405 FLUMAZENIL 0.1MG/ML INJ 5ML VI EXTERNAL 01/01/95 028 0251 5012
13718410 FLUMAZENIL 0.1MG/ML INJ - 10ML EXTERNAL 01/01/95 028 0251 5012
13718480 FLUOCINOLONE ACETATE 0.01% LOT EXTERNAL 01/01/95 028 0250 5012
13718486 FLUORESCEIN SODIUM STRIP EXTERNAL 01/01/95 028 0251 5012
13718500 FLUORESCEIN SODIUM 10% INJ EXTERNAL 01/01/95 028 0250 5012
13718510 FLUORESCEIN SODIUM 25% INJ EXTERNAL 01/01/95 028 0251 5012
13718540 FLUORESCEIN SODIUM 2% OPHTH SO EXTERNAL 01/01/95 028 0251 5012
13718575 FLUOROMETHOLONE ACETATE 0.1% S EXTERNAL 01/01/95 028 0251 5012
13718580 FLUOROMETHALONE 0.1% OPTH SUSP EXTERNAL 07/01/84 028 0251 5012
13718581 FLUOROMETHOLONE 0.1% OPHTH OIN EXTERNAL 01/01/95 028 0250 5012
13718590 FLUOROURACIL 0.05GM/ML SYR INJ EXTERNAL 01/01/95 J9190 J9190 J9190 028 0636 5012
13718610 FLUOROURACIL 5% CREAM 25GM EXTERNAL 01/01/95 028 0250 5012
13718630 FLUOROURACIL 2% TOPICAL SOLN 1 EXTERNAL 01/01/96 028 0250 5012
13718640 FLUOROURACIL 5% SOLN 10ML EXTERNAL 01/01/95 028 0250 5012
13718660 FLUOXYMESTRONE 10MG TAB EXTERNAL 01/01/95 028 0250 5012
13718661 FLUOXYMESTRONE 10MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13718670 FLUPHENAZINE DECANOATE 25MG/ML EXTERNAL 07/01/84 028 0251 5012
13718671 FLUPHENAZINE HCL 2.5MG/ML INJ EXTERNAL 01/01/95 028 0251 5012
13718680 FLUPHENAZINE 1MG TAB EXTERNAL 01/01/95 028 0251 5012
13718681 FLUPHENAZINE 1MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13718700 FLUPHENAZINE 5MG TAB EXTERNAL 01/01/95 028 0251 5012
13718701 FLUPHENAZINE 5MG - 1 BOTTLE (1 EXTERNAL 01/25/95 028 0251 5012
13718702 FLUPHENAZINE 10MG TAB EXTERNAL 01/01/95 028 0251 5012
13718704 FLUPHENAZINE 10MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13718800 FLURBIPROFEN 0.03% OPHTH SOLN EXTERNAL 01/01/95 028 0250 5012
13718810 FLUORESCEIN OPHTH 5ML SOLN EXTERNAL 01/01/95 028 0250 5012
13718824 FLUTICASONE HFA 220MCG/DOSE MD EXTERNAL 12/11/98 028 0251 5012
13718828 FLUTICASONE HFA 44MCG/DOSE MDI EXTERNAL 12/11/98 028 0251 5012
13718829 FLUTICASONE HFA 110MCG/DOSE MD EXTERNAL 12/11/98 028 0251 5012
13718831 FLUTICASONE 110MCG/DOSE MDI 13 EXTERNAL 09/25/97 028 0251 5012
13718832 FLUTICASONE 220MCG/DOSE MDI 13 EXTERNAL 09/25/97 028 0251 5012
13718833 FLUTICASONE 44MCG/DOSE MDI 13G EXTERNAL 09/25/97 028 0251 5012
13718834 FLUTICASONE/SALMETEROL 100/50M EXTERNAL 04/05/02 028 0251 5012
13718835 FLUTICASONE/SALMETEROL 250/50M EXTERNAL 04/05/02 028 0251 5012
13718836 FLUTICASONE/SALMETEROL 500/50M EXTERNAL 04/05/02 028 0251 5012
13718837 FLUTICASONE 110MCG/DOSE INST 6 EXTERNAL 12/11/98 028 0251 5012
13718838 FLUTICASONE 220MCG/DOSE INST 6 EXTERNAL 06/23/03 028 0251 5012
13718839 FLUTICASONE 110MCG/DOSE INST 6 EXTERNAL 06/23/03 028 0251 5012
13718840 FOLIC ACID 1MG TAB EXTERNAL 01/01/95 028 0250 5012
13718841 FOLIC ACID 1MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 233
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13718842 FOLIC ACID 0.5 MG (1/2 X 1MG) EXTERNAL 07/20/06 028 0251 5012
13718843 FOLIC ACID 500 MCG/ML ORAL SUS EXTERNAL 02/13/08 028 0251 5012
13718844 FOLIC ACID 0.05 MG ORAL SUSP EXTERNAL 05/08/08 028 0251 5012
13718849 FOLIC ACID 1000MCG/ML ORAL SOL EXTERNAL 04/22/02 028 0251 5012
13718850 FOLIC ACID INJ 1MG DOSE EXTERNAL 01/01/95 028 0250 5012
13718851 FOLIC ACID INJECTION 50MG VIAL EXTERNAL 07/01/84 028 0250 5012
13718854 FOMEPIZOLE 1 GM/ML 1.5ML EXTERNAL 07/14/08 028 0258 5012
13718855 FOMEPIZOLE 1000 MG/ML ORAL SOL EXTERNAL 07/14/08 028 0258 5012
13718860 FONDAPARINUX 2.5MG/0.5ML SYRIN EXTERNAL 07/25/02 J1652 J1652 028 0636 5012
13718861 FONDAPARINUX 10MG/0.8ML SYRING EXTERNAL 02/11/09 028 0258 5012
13718862 FONDAPARINUX 7.5MG/0.6ML SYRIN EXTERNAL 02/18/09 028 0258 5012
13718863 FONDAPARINUX 5MG/0.4ML SYRINGE EXTERNAL 02/18/09 028 0258 5012
13718869 FOSAMPRENAVIR 700 MG TABLET EXTERNAL 02/25/08 028 0251 5012
13718871 FOSPHENYTOIN 50MGPE/ML INJ FOR EXTERNAL 12/17/96 Q2009 Q2009 028 0636 5012
13718873 FOSPHENYTOIN 50MGPE/ML INJ EXTERNAL 12/17/96 Q2009 Q2009 028 0636 5012
13718920 FENTANYL 100 MCG INJ EXTERNAL 01/07/05 J3010 J3010 028 0636 5012
13718921 FENTANYL 25 MCG INJ EXTERNAL 01/07/05 J3010 J3010 028 0636 5012
13718922 FENTANYL 50 MCG INJ EXTERNAL 01/07/05 J3010 J3010 028 0636 5012
13718923 FENTANYL 75 MCG INJ EXTERNAL 01/07/05 J3010 J3010 028 0636 5012
13718924 FENTANYL 125 MCG FOR LVP EXTERNAL 01/07/05 J3010 J3010 028 0636 5012
13718925 FENTANYL 250 MCG FOR 100 ML LV EXTERNAL 01/07/05 J3010 J3010 028 0636 5012
13718926 FENTANYL 500 MCG FOR 100 ML LV EXTERNAL 01/07/05 J3010 J3010 028 0636 5012
13718927 FENTANYL 1000 MCG FOR 100 ML L EXTERNAL 09/25/03 J3010 J3010 028 0636 5012
13718971 FUROSEMIDE 20MG TAB EXTERNAL 01/01/95 028 0250 5012
13718972 FUROSEMIDE 20MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13718978 FUROSEMIDE 10MG/ML SVN 1ML EXTERNAL 01/01/95 028 0251 5012
13718981 FUROSEMIDE 10MG (1/2 X 20MG) T EXTERNAL 01/01/95 028 0251 5012
13718982 FUROSEMIDE 60 MG (3 X 20MG) TA EXTERNAL 01/01/95 028 0251 5012
13718990 FUROSEMIDE 40MG TAB EXTERNAL 01/01/95 028 0250 5012
13718992 FUROSEMIDE 80MG TAB EXTERNAL 01/01/95 028 0250 5012
13718993 FUROSEMIDE 80MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13718994 FUROSEMIDE 40MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13718996 FUROSEMIDE ORAL SOLUTION 10MG/ EXTERNAL 01/01/95 028 0251 5012
13718997 FUROSEMIDE 120 (40 MG X 3) TAB EXTERNAL 02/07/08 028 0251 5012
13719000 FUROSEMIDE INJECTION 20MG VIAL EXTERNAL 01/01/95 J1940 J1940 028 0636 5012
13719001 FUROSEMIDE 40MG INJ EXTERNAL 01/01/95 J1940 J1940 028 0636 5012
13719002 FUROSEMIDE 60MG SYR (1X40MG +1 EXTERNAL 10/05/94 J1940 J1940 028 0636 5012
13719003 FUROSEMIDE 120MG SYR EXTERNAL 01/01/95 J1940 J1940 028 0636 5012
13719010 FUROSEMIDE 20MG SYRINGE EXTERNAL 10/01/94 J1940 J1940 028 0636 5012
13719012 FUROSEMIDE 20 MG/2 ML VIAL EXTERNAL 01/11/05 J1940 J1940 028 0636 5012
13719015 FUROSEMIDE INJECTION 20MG SYRI EXTERNAL 01/01/95 J1940 J1940 028 0636 5012
13719016 FUROSEMIDE 20MG INJ SYR EXTERNAL 01/01/95 J1940 J1940 028 0636 5012
13719017 FUROSEMIDE 10MG/ML INJ EXTERNAL 11/15/94 J1940 J1940 028 0636 5012
13719018 FUROSEMIDE 10MG/ML VIAL EXTERNAL 01/11/05 J1940 J1940 028 0636 5012
13719019 FUROSEMIDE 100 MG INJ SYR EXTERNAL 11/19/08 028 0258 5012
13719020 GABAPENTIN 100MG CAP - BULK BT EXTERNAL 05/26/94 028 0251 5012
13719021 GABAPENTIN ORAL SUSPENSION (10 EXTERNAL 11/14/01 028 0251 5012
13719022 GABAPENTIN 800MG (400 MG X 2) EXTERNAL 02/07/08 028 0251 5012
13719023 GABAPENTIN 600MG (300 MG X 2) EXTERNAL 02/07/08 028 0251 5012
13719024 GABAPENTIN 100MG CAP EXTERNAL 01/01/95 028 0251 5012
13719025 GABAPENTIN 300MG U.D. BOX EXTERNAL 05/27/94 028 0251 5012
13719026 GABAPENTIN 300MG CAP EXTERNAL 01/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 234
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13719027 GABAPENTIN 200MG (100 MG X 2) EXTERNAL 02/07/08 028 0251 5012
13719028 GABAPENTIN 400MG CAP EXTERNAL 01/01/95 028 0251 5012
13719029 GABAPENTIN 900MG (300 MG X 3) EXTERNAL 02/07/08 028 0251 5012
13719030 GANCICLOVIR 250MG CAPSULES EXTERNAL 11/05/95 028 0251 5012
13719031 GANCICLOVIR 250MG CAP EXTERNAL 11/05/95 028 0251 5012
13719032 GANCICLOVIR 10MG/ML SYR INJ EXTERNAL 11/05/95 J1570 J1570 028 0636 5012
13719034 GALANTAMINE 4 MG TAB EXTERNAL 03/11/04 028 0251 5012
13719035 GALANTAMINE 8 MG TAB EXTERNAL 03/11/04 028 0251 5012
13719041 GAVISCON - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13719043 GATAFLOXACIN 0.3% OPHTH SOLN 5 EXTERNAL 02/07/05 028 0251 5012
13719045 GASTROVIEW 36 ML BOTTLE EXTERNAL 06/29/05 028 0251 5012
13719051 GELATIN OPHTH DRESSING EXTERNAL 01/01/95 028 0251 5012
13719060 GELATIN TOPICAL STRIP EXTERNAL 01/01/95 028 0250 5012
13719080 GELFOAM DENTAL SPONGE EXTERNAL 07/01/84 028 0250 5012
13719100 GELFOAM SPONGE SIZE 12.7 - 1 B EXTERNAL 07/01/84 028 0250 5012
13719101 GELATIN POWDER EXTERNAL 01/01/95 028 0251 5012
13719111 GEMCITABINE 38MG/ML INJ EXTERNAL 01/01/03 J9201 J9201 028 0636 5012
13719112 GEMCITABINE 200MG VIAL EXTERNAL 06/09/98 028 0258 5012
13719113 GEMCITABINE 1000 MG VIAL EXTERNAL 07/01/03 028 0258 5012
13719161 GEMFIBROZIL 300MG (1/2X 600MG) EXTERNAL 07/20/06 028 0251 5012
13719162 GEMFIBROZIL 600MG TAB EXTERNAL 01/01/95 028 0250 5012
13719163 GEMFIBROZIL 600MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13719166 GENTAMICIN INJ 60MG.NS 50ML EXTERNAL 01/01/95 J1580 J1580 028 0636 5012
13719167 GENTAMICIN 80MG/NS 50ML EXTERNAL 01/01/95 J1580 J1580 028 0636 5012
13719168 GENTAMICIN 50MG/NS 25ML EXTERNAL 01/01/95 J1580 J1580 028 0636 5012
13719169 GENTAMICIN 120MG/100ML BAG EXTERNAL 01/01/95 J1580 J1580 028 0636 5012
13719170 GENTAMICIN 40MG/ML INJ EXTERNAL 01/01/95 J1580 J1580 028 0636 5012
13719176 GENTAMICIN 70MG/NS 50ML EXTERNAL 08/10/01 J1580 J1580 028 0636 5012
13719180 GENTAMICIN INJECTION 60MG SYRI EXTERNAL 01/01/95 J1580 J1580 028 0636 5012
13719200 GENTAMICIN 10MG/ML INJ EXTERNAL 01/01/95 J1364 J1364 J1364 028 0636 5012
13719205 GENTAMICIN INJECTION 40MG/ML I EXTERNAL 01/01/95 J1580 J1580 028 0636 5012
13719230 GENTAMICIN 0.3% OPTH OINT EXTERNAL 01/01/95 028 0251 5012
13719240 GENTAMICIN 0.3% OPTH SOL 5ML EXTERNAL 01/01/95 028 0251 5012
13719309 IMMUNE SERUM GLOBULIN 10 GM VI EXTERNAL 01/04/01 028 0258 5012
13719311 IMMUNE GLOBULIN 50MG/ML INJ EXTERNAL 01/01/08 J1569 J1569 J1569 028 0636 5012
13719320 GLUCAGON INJECTION 1MG VIAL EXTERNAL 01/01/95 J1610 J1610 028 0636 5012
13719329 GLATIRAMER 20MG/1.1ML INJ EXTERNAL 04/15/99 J1595 J1595 028 0636 5012
13719330 GLARGINE INSULIN 100UNITS/ML 1 EXTERNAL 05/22/03 J1815 J1815 J1815 028 0636 5012
13719332 GLARGINE INSULIN 15 UNITS EXTERNAL 01/24/05 J1815 J1815 028 0636 5012
13719333 GLARGINE INSULIN 20 UNITS EXTERNAL 01/24/05 J1815 J1815 028 0636 5012
13719334 GLARGINE INSULIN 25 UNITS EXTERNAL 01/24/05 J1815 J1815 028 0636 5012
13719335 GLARGINE INSULIN 30 UNITS EXTERNAL 01/24/05 J1815 J1815 028 0636 5012
13719336 GLARGINE INSULIN 35 UNITS EXTERNAL 01/24/05 J1815 J1815 028 0636 5012
13719337 GLARGINE INSULIN 40 UNITS EXTERNAL 01/24/05 J1815 J1815 J1815 028 0250 5012
13719338 GLUCOSE MONITOR EXTERNAL 06/07/04 028 0251 5012
13719339 GLYBURIDE 7.5MG TAB(1X5 + 1X2. EXTERNAL 07/31/01 028 0251 5012
13719341 GLUCOSE 40% GEL 112.5GM TUBE EXTERNAL 01/01/95 028 0250 5012
13719342 GLYBURIDE 2.5 MG - 1 BOX EXTERNAL 05/25/89 028 0251 5012
13719343 GLYBURIDE 1.25MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13719344 GLYBURIDE 1.25MG TAB EXTERNAL 01/01/95 028 0250 5012
13719345 GLYBURIDE 2.5MG TAB EXTERNAL 01/01/95 028 0250 5012
13719347 GLYBURIDE 5MG TAB EXTERNAL 01/01/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 235
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13719348 GLYBURIDE 5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719352 GLIPIZIDE 5 MG TABLET EXTERNAL 11/17/05 028 0251 5012
13719353 GLIPIZIDE 10 MG TABLET EXTERNAL 11/17/05 028 0251 5012
13719354 EZETIMIBE-SIMVASTATIN 10MG/40M EXTERNAL 02/19/07 028 0251 5012
13719355 GLYBURIDE 10 MG ( 5 MG X 2) TA EXTERNAL 02/07/08 028 0251 5012
13719356 GLYBURIDE 15 MG (5 MG X 3) TAB EXTERNAL 02/07/08 028 0251 5012
13719357 GLIPIZIDE 2.5 MG (5 MG X 1/2) EXTERNAL 02/07/08 028 0251 5012
13719360 GLYCERIN 50% SOLUTION 220ML BO EXTERNAL 07/01/84 028 0251 5012
13719381 GLYCERIN ADULT SUPP EXTERNAL 01/01/95 028 0250 5012
13719390 GLYCERIN INFANT SUPP EXTERNAL 01/01/95 028 0250 5012
13719392 GLYCERIN INFANT 1/2 SUPP EXTERNAL 01/17/05 028 0251 5012
13719400 GUAIFENESIN 100MG/5ML - 1 BOTT EXTERNAL 07/01/84 028 0250 5012
13719410 GUAIFENESIN 100MG SYRUP EXTERNAL 01/01/95 028 0250 5012
13719420 GUAIFENESIN 200MG SYRUP EXTERNAL 01/01/95 028 0250 5012
13719422 GUAIFENESIN 600MG ER TAB EXTERNAL 01/12/99 028 0251 5012
13719430 GUAIFENESIN 300MG SYRUP EXTERNAL 01/01/95 028 0250 5012
13719432 CODEINE-GUAIFENESIN 2ML SYRUP EXTERNAL 10/02/01 028 0251 5012
13719440 GUAIFENESIN 600MG SYRUP EXTERNAL 01/01/95 028 0250 5012
13719441 GUAIFENESIN 20MG/ML SYRUP EXTERNAL 01/01/95 028 0250 5012
13719442 CODEINE-GUAIFENESIN 5ML SYRUP EXTERNAL 01/01/95 028 0250 5012
13719445 GUAIFENESIN/DEXTROMETHORPHAN S EXTERNAL 07/01/84 028 0250 5012
13719446 DEXTROMETHORPHAN-GUAIFENESIN L EXTERNAL 01/01/95 028 0250 5012
13719447 DEXTROMETHORPHAN-GUAIFENESIN L EXTERNAL 01/01/95 028 0250 5012
13719450 GLYCOPYRROLATE 0.2MG VIAL EXTERNAL 10/01/94 028 0258 5012
13719452 GLYCOPYRROLATE 0.2MG/ML SVN (2 EXTERNAL 03/12/96 J7643 J7643 028 0636 5012
13719453 GLYCOPYRROLATE 0.2MG/ML SVN (1 EXTERNAL 03/12/96 J7643 J7643 028 0636 5012
13719460 DEXTROAMPHETAMINE 5 MG TAB EXTERNAL 05/12/03 028 0251 5012
13719470 GLYCOPYRROLATE INJECTION 4MG V EXTERNAL 01/01/95 028 0250 5012
13719471 HYDRALAZINE 10MG/ML ORAL SOLN EXTERNAL 11/14/01 028 0251 5012
13719472 HYDRALAZINE 0.5MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719473 HYDRALAZINE 1.5MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719474 HYDRALAZINE 2MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719475 HYDRALAZINE 2.5MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719476 HYDRALAZINE 4MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719477 HYDRALAZINE 5MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719478 HYDRALAZINE 7.5MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719479 HYDRALAZINE 8MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13719508 GRISEOFULVIN 165MG TAB EXTERNAL 01/01/95 028 0250 5012
13719510 GRISEOFULVIN 330MG TAB EXTERNAL 01/01/95 028 0250 5012
13719511 GRISEOFULVIN 330MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13719512 GRISEOFULVIN 165MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13719520 GRISEOFULVIN SUSPENSION - 1 BO EXTERNAL 07/01/84 028 0250 5012
13719521 METFROMIN 850MG TABLET (BOX) EXTERNAL 10/16/96 028 0251 5012
13719523 METFORMIN 500MG TABLET (BOX) EXTERNAL 10/16/96 028 0251 5012
13719524 METFORMIN 500MG TABLET EXTERNAL 10/16/96 028 0251 5012
13719554 HAEMOPHILUS B CONJ VACCINE 1 V EXTERNAL 01/01/95 028 0251 5012
13719555 HAEMOPHILUS B CONJ VACCINE EXTERNAL 01/01/95 028 0251 5012
13719556 HAEMOPHILUS B CONJ VACCINE EXTERNAL 06/07/01 028 0258 5012
13719557 PEDIARIX EXTERNAL 09/29/05 028 0258 5012
13719558 PEDIARIX VFC EXTERNAL 01/12/10 028 0258 5012
13719559 HAEMOPHILUS B CONJ VACCINE VFC EXTERNAL 01/12/10 028 0258 5012
13719561 HALOPERIDOL 0.5MG TAB EXTERNAL 01/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 236
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13719562 HALOPERIDOL 0.5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719571 HALOPERIDOL 1MG TAB EXTERNAL 01/01/95 028 0251 5012
13719572 HALOPERIDOL 1MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719581 HALOPERIDOL 2MG TAB EXTERNAL 01/01/95 028 0251 5012
13719582 HALOPERIDOL 2MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719590 HALOPERIDOL 5MG TAB EXTERNAL 01/01/95 028 0251 5012
13719593 HALOPERIDOL 10MG TAB EXTERNAL 01/01/95 028 0251 5012
13719594 HALOPERIDOL 10MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719596 HALOPERIDOL 5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719597 HALOPERIDOL 2.5 MG (1/2 X 5 MG EXTERNAL 06/18/08 028 0251 5012
13719599 HALOPERIDOL 15 (5 MG X 3) TAB EXTERNAL 02/07/08 028 0251 5012
13719610 HALOPERIDOL SOLUTION - 1 BOTTL EXTERNAL 07/01/84 J1610 J1610 028 0636 5012
13719620 HALOPERIDOL INJECTION 5MG VIAL EXTERNAL 07/01/84 J1630 J1630 028 0636 5012
13719621 HALOPERIDOL 5MG/ML INJ EXTERNAL 01/01/95 J1630 J1630 028 0636 5012
13719625 HALOPERIDOL INJECTION 50MG VIA EXTERNAL 01/01/95 J1630 J1630 028 0636 5012
13719626 HALOPERIDOL DECANOATE 100MG/ML EXTERNAL 01/01/95 J1631 J1631 J1631 028 0636 5012
13719630 HALOTHANE - 1 BOTTLE EXTERNAL 07/01/84 028 0251 5012
13719650 HEPARIN SODIUM 1000U/D5W 10ML EXTERNAL 01/01/95 J1644 J1644 028 0636 5012
13719651 HEPARIN 1000U/0.3ML PEDS DIALY EXTERNAL 03/18/03 J1644 J1644 028 0636 5012
13719652 HEPARIN 332U/ML 25ML PEDS DIAL EXTERNAL 03/18/03 028 0258 5012
13719653 HEPARIN 1:1000/2ML PEDS DIALY EXTERNAL 03/18/03 J1644 J1644 028 0636 5012
13719654 HEPARIN 1:1000/30ML PEDS DIAL EXTERNAL 03/18/03 J1644 J1644 028 0636 5012
13719656 HEPARIN SODIUM 1000U/.45%NS 10 EXTERNAL 01/01/95 J1644 J1644 028 0636 5012
13719657 HEPARIN 750UNITS/ML 30ML VIAL EXTERNAL 03/18/03 028 0258 5012
13719658 HEPARIN 750 UNITS /ML 10ML VIA EXTERNAL 03/18/03 028 0258 5012
13719690 HEPARIN SODIUM 1000U/ML INJ EXTERNAL 01/01/95 J1642 J1642 028 0636 5012
13719700 HEPARIN LOCK FLUSH ***ML EXTERNAL 01/01/95 J1644 J1644 028 0636 5012
13719710 HEPARIN SODIUM 1,000UNIT SYR EXTERNAL 09/01/94 J1644 J1644 028 0636 5012
13719711 HEPARIN SODIUM 1,000UNIT VIAL EXTERNAL 07/01/84 J1644 J1644 028 0636 5012
13719716 HEPARIN 1000 UNITS/NACL 0.9% 5 EXTERNAL 07/08/08 J1644 J1644 028 0258 5012
13719717 HEPARIN 2000 UNITS/NACL 0.9% 1 EXTERNAL 07/08/08 J1644 J1644 J1644 028 0258 5012
13719718 HEPARIN 2000 UNITS/NACL 0.9% 1 EXTERNAL 09/24/08 028 0258 5012
13719719 HEPARIN 1000 UNITS/NACL 0.9% 5 EXTERNAL 09/24/08 028 0258 5012
13719749 HEPARIN SODIUM 5,000 UNITS INJ EXTERNAL 01/17/05 J1644 J1644 028 0636 5012
13719750 HEPARIN SODIUM 1000 UNITS/ML I EXTERNAL 01/01/95 J1644 J1644 028 0636 5012
13719752 HEPARIN LOCK FLUSH PF - 100U/M EXTERNAL 05/14/02 J1642 J1642 028 0258 5012
13719753 HEPARIN LOCK FLUSH-PF 10 U/ML EXTERNAL 02/13/97 J1642 J1642 J1642 028 0636 5012
13719756 HEPARIN LOCK FLUSH 10 U/ML INJ EXTERNAL 03/12/96 J1642 J1642 028 0636 5012
13719757 HEPARIN LOCK FLUSH 10 U/ML INJ EXTERNAL 03/12/96 J1642 J1642 028 0636 5012
13719758 HEPARIN LOCK FLUSH 10 U/ML INJ EXTERNAL 07/01/84 J1642 J1642 028 0636 5012
13719759 HEPARIN LOCK FLUSH 1ML VIAL EXTERNAL 01/01/95 J1642 J1642 028 0636 5012
13719761 HEPARIN LOCK FLUSH 100 U/ML IN EXTERNAL 01/01/95 J1642 J1642 028 0636 5012
13719762 HEPARIN LOCK FLUSH 1ML VIAL-NO EXTERNAL 01/01/95 J1642 J1642 028 0258 5012
13719763 HEPARIN LOCK FLUSH 5ML VIAL-NO EXTERNAL 01/01/95 J1642 J1642 028 0258 5012
13719764 HEPARIN LOCK FLUSH-PF 10 U/ML EXTERNAL 02/13/97 J1642 J1642 028 0636 5012
13719766 HEPARIN LOCK FLUSH 100 UNITS/1 EXTERNAL 01/17/05 J1642 J1642 028 0636 5012
13719768 HEPARIN LOCK FLUSH-PF 10 U/ML EXTERNAL 12/14/98 J1642 J1642 028 0636 5012
13719779 HEPATITIS B VAC RECOMB (PEDS) EXTERNAL 03/31/88 90744 90744 90744 028 0636 5012
13719780 HEPATITIS B IMMUNE GLOBULIN EXTERNAL 01/01/03 90371 90371 90371 028 0636 5012
13719782 HEPATITIS B VAC RECOMB (ADULT) EXTERNAL 03/02/87 90746 90746 90746 028 0636 5012
13719785 HETASTARCH 6%/NACL 0.9% 500ML EXTERNAL 07/01/84 028 0258 5012
13719787 HEPATITIS B IMMUNE GLOBULIN EXTERNAL 06/16/03 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 237
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13719790 HEXACHLOROPHENE 3% LOTION 150M EXTERNAL 07/01/84 028 0251 5012
13719797 HEPATITIS B VAC REC PEDS (VFC EXTERNAL 01/17/05 028 0258 5012
13719860 HISTAMINE PHOSPHATE 2.75MG AMP EXTERNAL 01/01/95 028 0251 5012
13719870 HISTADINE-TRYPTOPHN-KETOGLUTAR EXTERNAL 03/25/03 028 0251 5012
13719879 HOMATROPINE 2% OPHTH SOLN 5ML EXTERNAL 01/01/95 028 0251 5012
13719880 HOMATROPINE 5% OPHTH SOLN 1ML EXTERNAL 01/01/95 028 0251 5012
13719890 HOMATROPINE 5% OPHTH SOLN 5ML EXTERNAL 07/01/84 028 0251 5012
13719900 HOMATROPINE 5% OPTH SOLN 15ML EXTERNAL 07/01/84 028 0251 5012
13719922 HEALON 10MG/ML 0.55ML SYR EXTERNAL 01/01/95 028 0251 5012
13719923 HEALON 10MG/ML 0.4ML SYR EXTERNAL 08/31/88 028 0251 5012
13719924 HEALON 10MG/ML 0.85ML SYR EXTERNAL 01/01/95 028 0251 5012
13719925 PROVISC 0.85ML SYR EXTERNAL 11/02/94 028 0251 5012
13719926 PROVISC 0.55ML SYR EXTERNAL 11/02/94 028 0251 5012
13719928 HEALON GV 14 MG/ML 0.85 ML SYR EXTERNAL 11/03/94 028 0251 5012
13719929 PROVISC 10MG/ML 0.4ML SYR EXTERNAL 08/01/01 028 0258 5012
13719930 DUOVISC 0.5ML/0.55ML SYR EXTERNAL 08/01/01 028 0258 5012
13719931 DUOVISC 0.35ML/0.4ML SYR EXTERNAL 08/01/01 028 0258 5012
13719938 HYDRALAZINE 2.5MG TAB EXTERNAL 08/21/01 028 0251 5012
13719939 HYDRALAZINE 5MG TAB EXTERNAL 08/21/01 028 0251 5012
13719940 HYDRALAZINE 10MG TAB EXTERNAL 01/01/95 028 0258 5012
13719951 HYDRALAZINE 25MG TAB EXTERNAL 01/01/95 028 0251 5012
13719952 HYDRALAZINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719953 HYDRALAZINE 10MG U.D. 100'S EXTERNAL 11/23/94 028 0251 5012
13719954 HYPAQUE 60% 50 ML BTL EXTERNAL 03/15/06 028 0258 5012
13719955 HYPAQUE-CYSTO 30% 250 ML BTL EXTERNAL 03/15/06 028 0258 5012
13719956 HYDRALAZINE 12.5 MG (1/2 X 25 EXTERNAL 06/22/06 028 0251 5012
13719961 HYDRALAZINE 50MG TAB EXTERNAL 01/01/95 028 0250 5012
13719962 HYDRALAZINE 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13719968 HYDRALAZINE 75MG (3X25MG) TAB EXTERNAL 01/01/95 028 0251 5012
13719969 HYDRALAZINE 100MG - 1 BOX EXTERNAL 05/25/89 028 0251 5012
13719970 HYDRALAZINE 100MG TAB EXTERNAL 01/01/95 028 0251 5012
13719980 HYDRALAZINE 20MG INJ EXTERNAL 01/01/95 J0360 J0360 028 0636 5012
13719983 HYDRALAZINE 20 MG/ML INJ EXTERNAL 01/17/05 J0360 J0360 028 0636 5012
13719984 HYDRALAZINE 10 MG/0.5 ML INJ EXTERNAL 03/18/08 028 0258 5012
13719999 HYDROCHLOROTHIAZIDE 6.25 MG TA EXTERNAL 07/20/06 028 0251 5012
13720000 HYDROCHLOROTHIAZIDE 25MG TAB EXTERNAL 01/01/95 028 0250 5012
13720001 HYDROCHLOROTHIAZIDE 25MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13720002 HYDROCHLOROTHIAZIDE 12.5MG CAP EXTERNAL 01/29/01 028 0251 5012
13720030 HYDROCHLOROTHIAZIDE 50MG TAB EXTERNAL 01/01/95 028 0250 5012
13720031 HYDROCHLOROTHIAZIDE 50MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13720041 HYDROCHLOROTHIAZIDE 50MG SOLN EXTERNAL 01/01/95 028 0250 5012
13720042 HYDROCHLOROTHIAZIDE SOLN 0.5MG EXTERNAL 10/02/01 028 0251 5012
13720043 HYDROCHLOROTHIAZIDE SOLN 2.5MG EXTERNAL 10/02/01 028 0251 5012
13720044 HYDROCHLOROTHIAZIDE SOLN 6.25M EXTERNAL 10/02/01 028 0251 5012
13720045 HYDROCHLOROTHIAZIDE 0.75MG SOL EXTERNAL 12/19/01 028 0251 5012
13720046 HYDROCHLOROTHIAZIDE 1MG SOLN EXTERNAL 12/19/01 028 0251 5012
13720047 HYDROCHLOROTHIAZIDE 1.5MG SOLN EXTERNAL 12/19/01 028 0251 5012
13720048 HYDROCHLOROTHIAZIDE 2MG SOLN EXTERNAL 12/19/01 028 0251 5012
13720049 HYDROCHLOROTHIAZIDE 4MG SOLN EXTERNAL 12/19/01 028 0251 5012
13720051 HYDROCORISONE 2MG/ML SUSP EXTERNAL 07/01/84 J1720 028 0636 5012
13720052 HYDROCHLOROTHIAZIDE 5MG SOLN EXTERNAL 12/19/01 028 0251 5012
13720053 HYDROCHLOROTHIAZIDE 7.5MG SOLN EXTERNAL 12/19/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 238
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13720054 HYDROCHLOROTHIAZIDE 12.5MG SOL EXTERNAL 12/19/01 028 0251 5012
13720055 HYDROCHLOROTHIAZIDE 25MG SOLN EXTERNAL 12/19/01 028 0251 5012
13720065 HYDROCHLOROTHIAZIDE 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13720066 HYDROCHLOROTHIAZIDE 100MG - 1 EXTERNAL 01/25/95 028 0251 5012
13720068 HYDROCHLOROTHIAZIDE SOLUTION EXTERNAL 07/01/84 028 0250 5012
13720089 HYDROCODENE/ACETA 5/500 UD - 1 EXTERNAL 03/26/92 028 0251 5012
13720091 ACETAMINOPHEN-HYDROCODONE 500M EXTERNAL 01/01/95 028 0251 5012
13720092 ACETAMINOPHEN-HYDROCODONE 325M EXTERNAL 08/08/06 028 0251 5012
13720093 ACETAMINOPHEN-HYDROCODONE 500M EXTERNAL 12/22/04 028 0251 5012
13720094 ACETAMIN-HYDROCODONE (500MG/5M EXTERNAL 12/22/04 028 0251 5012
13720100 HYDROCORTISONE 50MG/D5W 50ML EXTERNAL 03/12/96 J1720 J1720 028 0636 5012
13720105 HYDROCORTISONE 100MG/D5W 100ML EXTERNAL 03/12/96 J1720 J1720 028 0636 5012
13720241 HYDROCORTISONE 1MG/ML PEDS INJ EXTERNAL 04/04/02 J1720 J1720 028 0636 5012
13720318 HYDROMORPHONE 2MG - 1 BOX (100 EXTERNAL 01/25/95 J1170 J1170 028 0636 5012
13720319 HYDROMORPHONE 1MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13720321 HYDROMORPHONE 2MG TAB EXTERNAL 01/01/95 028 0250 5012
13720323 HYDROMORPHONE 4MG TAB EXTERNAL 01/01/95 028 0250 5012
13720324 HYDROMORPHONE 4MG - 1 BOX (100 EXTERNAL 01/25/95 028 0251 5012
13720325 HYDROMORPHONE CLINICIAN DOSE P EXTERNAL 07/22/09 028 0251 5012
13720330 HYDROMORPHONE 2MG INJ EXTERNAL 01/01/95 J1170 J1170 028 0636 5012
13720331 HYDROMORPHONE 1 MG INJ EXTERNAL 01/24/05 J1170 J1170 028 0636 5012
13720332 HYDROMORPHONE 4MG INJ EXTERNAL 02/12/09 028 0251 5012
13720334 HYDROMORPHONE 4MG (2 MG X 2) S EXTERNAL 01/24/05 028 0251 5012
13720336 HYDROMORPHONE 0.4 MG/ML INJ EXTERNAL 01/24/05 028 0251 5012
13720357 ADENOSINE 540 MG/180 ML EXTERNAL 12/22/04 J0152 J0152 028 0636 5012
13720358 ADENOSINE 360 MG/120 ML EXTERNAL 12/22/04 J0152 J0152 028 0636 5012
13720359 ADENOSINE 0.3 MG/ML PEDS INJ EXTERNAL 12/22/04 J0150 J0150 028 0636 5012
13720360 HYDROXYCHLOROQUINE 200MG TAB EXTERNAL 01/01/95 028 0250 5012
13720361 HYDROXYCHLOROQUINE 200MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13720362 HYDROXYCHLOROQUINE 100MG (1/2 EXTERNAL 06/22/06 028 0251 5012
13720369 HYDROXYPROPYL CELLULOSE - BOX EXTERNAL 07/01/84 028 0250 5012
13720370 HYDROXYPROPYLMETHYLCELLULOSE 0 EXTERNAL 01/01/95 028 0250 5012
13720371 HYDROXYPROPYLMETHYLCELLULOSE 2 EXTERNAL 01/01/95 028 0250 5012
13720387 HYDROXYUREA 2000 MG (500 MG X EXTERNAL 02/07/08 028 0251 5012
13720388 HYDROXYUREA 1500 MG (500 MG X EXTERNAL 02/07/08 028 0251 5012
13720389 HYDROXYUREA 1000 MG (500 MG X EXTERNAL 02/07/08 028 0251 5012
13720390 HYDROXYUREA 500MG CAP EXTERNAL 01/01/95 028 0251 5012
13720391 HYDROXYUREA 500MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13720393 HYOSCYAMINE 0.125MG BULK EXTERNAL 10/11/94 028 0251 5012
13720395 HYOSCYAMINE 0.375MG SR CAP EXTERNAL 10/11/94 028 0251 5012
13720396 HYOSCYAMINE 0.375MG BULK EXTERNAL 10/11/94 028 0251 5012
13720400 HYDROXYZINE HCL 10MG TAB EXTERNAL 01/01/95 028 0251 5012
13720401 HYDROXYZINE 10MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13720420 HYDROXYZINE INJECTION 100MG VI EXTERNAL 01/01/95 J3410 J3410 028 0636 5012
13720430 HYDROXYZINE HCL 25MG INJ EXTERNAL 01/01/95 J3410 J3410 028 0636 5012
13720441 HYDROXYZINE HCL 50MG/ML INJ EXTERNAL 01/01/95 J3410 028 0636 5012
13720443 HYDROXYZINE HCL 50MG/ML INJ EXTERNAL 12/05/08 028 0258 5012
13720451 HYDROXYZINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13720460 HYDROXYZINE HCL 25MG TAB EXTERNAL 01/01/95 028 0258 5012
13720461 HYDROXYZINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13720462 HYDROXYZINE 12.5 MG (1/2 X 25 EXTERNAL 07/20/06 028 0251 5012
13720480 HYDROXYZINE HCL 50MG TAB EXTERNAL 01/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 239
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13720490 HYDROXYZINE HCL 10MG SYRUP EXTERNAL 01/01/95 028 0251 5012
13720491 0YDROXYZINE SYRUP 10MG/5ML - 4 EXTERNAL 07/01/84 028 0251 5012
13720492 HYDROXYZINE SYRUP 25MG EXTERNAL 10/02/01 028 0251 5012
13720501 HYDROXYZINE PAMOATE SUSP 25ML EXTERNAL 07/01/84 028 0250 5012
13720507 IBUTILIDE 0.1 MG/ML 10 ML VIAL EXTERNAL 02/08/08 J1742 J1742 J1742 028 0258 5012
13720522 IBUPROFEN 30MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720523 IBUPROFEN 40MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720524 IBUPROFEN 50MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720526 IBUPROFEN 75MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720527 IBUPROFEN 100MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720528 IBUPROFEN 125MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720529 IBUPROFEN 150MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720531 IBUPROFEN 400MG TAB EXTERNAL 01/01/95 028 0250 5012
13720533 IBUPROFEN 400MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13720534 IBUPROFEN 200MG - 1 BOTTLE(500 EXTERNAL 01/25/95 028 0251 5012
13720535 IBUPROFEN 200MG TAB EXTERNAL 01/01/95 028 0250 5012
13720536 IBUPROFEN 200MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720537 IBUPROFEN 400MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720538 IBUPROFEN 600MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720539 IBUPROFEN 800MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720542 IBUPROFEN 1200MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13720545 IBUPROFEN 600MG TAB EXTERNAL 01/01/95 028 0250 5012
13720546 IBUPROFEN 800MG TABLET EXTERNAL 01/01/95 028 0250 5012
13720547 IBUPROFEN 600MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13720549 IBUPROFEN 800MG - 1 BOX EXTERNAL 05/25/89 028 0251 5012
13720550 IBUPROFEN 20MG/ML SUSPENSION EXTERNAL 11/21/89 028 0251 5012
13720552 IBUPROFEN SUSP 100MG/5ML****MG EXTERNAL 01/01/95 028 0251 5012
13720553 IBUPROFEN 25MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13720555 IBUPROFEN 120MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13720556 IBUPROFEN 180MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13720563 IDARUBICIN 1MG/ML INJ EXTERNAL 05/09/94 J9211 J9211 J9211 028 0636 5012
13720566 IBUPROFEN 240MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13720567 IBUPROFEN 300MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13720568 IMIPENEM-CILASTATIN 5MG/ML PED EXTERNAL 05/14/02 J0743 J0743 028 0636 5012
13720571 IMIPENEM-CILASTATIN 250MG/NS 1 EXTERNAL 12/17/96 J0743 J0743 028 0636 5012
13720573 IMIPENEM-CILASTATIN 50MG/ML IN EXTERNAL 12/17/96 J0743 J0743 028 0636 5012
13720574 IMIPENEM-CILASTATIN 0.05GM/ML EXTERNAL 05/14/02 J0743 J0743 028 0636 5012
13720575 IMIPENEM-CILASTATIN 500MG/NS 1 EXTERNAL 05/14/02 J0743 J0743 028 0636 5012
13720582 TAMSULOSIN 0.4MG CAPSULE EXTERNAL 01/11/05 028 0251 5012
13720583 FINASTERIDE 5MG TABLET EXTERNAL 01/11/05 028 0251 5012
13720584 TACROLIMUS 5 MG/ML EXTERNAL 08/18/05 J7507 J7507 J7507 028 0258 5012
13720585 SODIUM CHLORIDE 23.4% EXTERNAL 01/31/05 028 0258 5012
13720619 IMIPRAMINE 10MG TAB EXTERNAL 08/08/01 028 0251 5012
13720630 IMIPRAMINE 50MG TAB EXTERNAL 01/01/95 028 0250 5012
13720631 IMIPRAMINE 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13720700 INDIGO CARMINE INJECTION 40MG EXTERNAL 01/01/95 028 0251 5012
13720701 INDIGO CARMINE 8MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13720705 INDIAVIR 400MG CAPSULE EXTERNAL 02/04/98 028 0251 5012
13720706 INDIAVIR 400MG CAP EXTERNAL 02/04/98 028 0251 5012
13720707 INDIAVIR 200MG CAPSULE EXTERNAL 02/04/98 028 0251 5012
13720708 INDIAVIR 200MG CAP EXTERNAL 02/04/98 028 0251 5012
13720709 INDINAVIR 800 MG (400 MG X 2) EXTERNAL 02/07/08 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 240
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13720729 INDOMETHACIN 1MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13720740 INDOMETHACIN 25MG CAP EXTERNAL 01/01/95 028 0250 5012
13720741 INDOMETHACIN 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13720760 INDOMETHACIN 50MG CAP EXTERNAL 01/01/95 028 0250 5012
13720761 INDOMETHACIN 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13720762 INDOMETHACIN 75MG SR CAP EXTERNAL 01/01/95 028 0250 5012
13720763 INDOMETHACIN SR 75MG - 1 BTL(6 EXTERNAL 01/25/95 028 0251 5012
13720771 INFLUENZA VACCINE (ADULT) 5ML EXTERNAL 07/01/84 028 0250 5012
13720781 INFLUENZA VACCINE 0.25 ML INJ EXTERNAL 10/02/09 028 0258 5012
13720782 INFLUENZA VACCINE 0.5ML INJ EXTERNAL 01/01/95 028 0250 5012
13720783 SAQUINAVIR 200MG HARD GEL CAP EXTERNAL 11/25/02 028 0251 5012
13720784 INDINAVIR 333MG CAPSULE EXTERNAL 11/25/02 028 0251 5012
13720787 LAMIVUDINE-ZIDOVUDINE 150MG/30 EXTERNAL 11/25/02 028 0251 5012
13720788 TRIZIVIR (ZIDOVUDINE/LAMIVUDIN EXTERNAL 11/25/02 028 0251 5012
13720789 INFLUENZA VACCINE FLUVIRIN INJ EXTERNAL 12/20/06 028 0258 5012
13720790 DROPERIDOL-FENTANYL 2ML INJ EXTERNAL 07/01/84 J1810 028 0250 5012
13720791 INFLUENZA VACCINE AFLURIA INJ EXTERNAL 01/15/08 028 0258 5012
13720792 INFLUENZA VACCINE H1N1 INJ EXTERNAL 11/17/09 028 0258 5012
13720807 INSULIN DETEMIR 100 UNITS/ML 1 EXTERNAL 02/08/08 028 0258 5012
13720815 INSULIN HUMAN NPH 100 UNITS/ML EXTERNAL 01/01/95 J1815 J1815 028 0636 5012
13720816 INSULIN HUMAN REGULAR 5UNITS/M EXTERNAL 01/01/95 J1815 J1815 028 0636 5012
13720828 INSULIN HUMAN REG 6 UNITS FOR EXTERNAL 01/24/05 028 0258 5012
13720829 INSULIN HUMAN REG 15 UNITS FOR EXTERNAL 01/24/05 028 0258 5012
13720831 INSULIN HUMAN REG 30 UNITS FOR EXTERNAL 01/24/05 028 0258 5012
13720832 INSULIN REGULAR 1 UNIT/ML (1:1 EXTERNAL 08/17/09 028 0258 5012
13720833 INSULIN ASPART 1 UNIT/ML (1:10 EXTERNAL 08/17/09 028 0258 5012
13720834 INSULIN HUMAN 100 UNITS FOR 10 EXTERNAL 01/24/05 028 0251 5012
13720889 INSULIN ASPART 100 UNITS/ML EXTERNAL 03/11/04 J1815 028 0636 5012
13720893 INSULIN DRIP OR EXTERNAL 10/12/95 028 0636 5012
13720901 INVESTIGATIONAL STUDY DRUG N/C 06/30/10 028 0251 5012
13720902 INVESTIGAIONAL IV SOLUTION N/C 06/30/10 028 0258 5012
13720903 INVESTIGATIONAL LVP ADDITIVE # N/C 06/30/10 028 0258 5012
13720904 INVESTIGATIONAL LVP ADDITIVE # N/C 06/30/10 028 0258 5012
13720905 INVESTIGATIONAL LVP ADDITIVE # EXTERNAL 08/20/04 028 0258 5012
13720906 INVESTIGATIONAL INTERMITTENT N/C 06/30/10 028 0258 5012
13720916 0Z READY EXTERNAL 03/06/96 028 0251 5012
13720919 INSULIN HUMAN 70/30 10ML VIAL EXTERNAL 01/01/95 J1815 J1815 028 0636 5012
13720945 INTERFERON ALFA 2B 1MU/0.33ML EXTERNAL 01/01/95 J9214 J9214 J9214 028 0636 5012
13720946 INTERFERON ALFA 2B 1MU/ML INJ EXTERNAL 01/01/95 J9214 J9214 J9214 028 0636 5012
13720947 INTERFERON ALFA 2B 1MU/ML INJ EXTERNAL 01/01/95 J9214 J9214 J9214 028 0636 5012
13720949 INTERFERON ALFA 2B 1MU/ML INJ EXTERNAL 01/01/95 J9214 J9214 J9214 028 0636 5012
13720955 INTERFERON BETA-1A 30MCG/ML IN EXTERNAL 05/23/97 J1825 J1825 028 0636 5012
13721040 IPECAC 30ML SYRUP EXTERNAL 01/01/95 028 0250 5012
13721042 ALBUTEROL-IPRATROPIUM MDI 14.7 EXTERNAL 09/24/97 028 0251 5012
13721050 IPECAC 15ML SYRUP EXTERNAL 01/01/95 028 0250 5012
13721060 IPRATROPIUM BROMIDE MDI 14GM EXTERNAL 01/01/87 028 0250 5012
13721063 IPRATROPIUM 0.02% SVN 1.25ML EXTERNAL 03/12/96 J7644 J7644 028 0636 5012
13721066 IRINOTECAN 20MG/ML 5ML VIAL EXTERNAL 03/24/98 J7644 J7644 J7644 028 0251 5012
13721067 IRINOTECAN 20MG/ML INJ EXTERNAL 03/24/98 J9206 J9206 J9206 028 0636 5012
13721070 IRON DEXTRAN INJECTION 100MG A EXTERNAL 01/01/95 J1750 J1750 J1750 028 0258 5012
13721098 ISOFLURANE 100ML SOLN EXTERNAL 01/01/95 028 0250 5012
13721119 ISONIAZID 50MG TAB EXTERNAL 01/22/07 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 241
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13721120 ISONIAZID 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13721121 ISONIAZID 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721131 ISONIAZIDE SYRUP 10MG/ML EXTERNAL 01/01/95 028 0250 5012
13721140 ISONIAZID 300MG TAB EXTERNAL 01/01/95 028 0250 5012
13721141 ISONIAZID 300MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721160 ISONIAZID INJECTION 1GM VIAL EXTERNAL 07/01/84 028 0250 5012
13721161 ISONIAZID SYRUP 480ML BOTTLE EXTERNAL 07/01/84 028 0250 5012
13721163 ISONIAZID 150MG/RIFAMPIN 300MG EXTERNAL 12/17/87 028 0251 5012
13721225 LEVOFLOXACIN 5 MG/ML INJ EXTERNAL 11/13/08 028 0251 5012
13721226 LEVOFLOXACIN 250MG SUSPENSION EXTERNAL 01/21/09 028 0251 5012
13721227 LEVOFLOXACIN 25 MG/ML ORAL SOL EXTERNAL 02/13/08 028 0251 5012
13721228 LEVOFLOXACIN 750 MG TAB EXTERNAL 01/25/05 028 0251 5012
13721229 LEVOFLOXACIN 750MG IV PREMIX B EXTERNAL 09/13/00 J1956 J1956 028 0636 5012
13721231 LEVOFLOXACIN 250MG TABLETS EXTERNAL 07/08/98 028 0251 5012
13721232 LEVOFLOXACIN 250MG TAB EXTERNAL 07/08/98 028 0251 5012
13721233 LEVOFLOXACIN 500MG TABLETS EXTERNAL 07/08/98 028 0251 5012
13721234 LEVOFLOXACIN 500MG TAB EXTERNAL 07/08/98 028 0251 5012
13721235 LEVOFLOXACIN 25MG/ML INJ EXTERNAL 07/08/98 J1956 J1956 028 0636 5012
13721237 LEVOFLOXACIN 250MG/D5W 50ML EXTERNAL 07/08/98 J1956 J1956 028 0636 5012
13721240 LEVOFLOXACIN 250MG IV PREMIX B EXTERNAL 04/05/02 J1956 J1956 028 0636 5012
13721241 ISOSORBIDE MONO 60MG SR - BOX EXTERNAL 01/25/95 J1956 J1956 028 0636 5012
13721242 ISOSORBIDE MONO 60MG ER TAB EXTERNAL 01/01/95 028 0251 5012
13721243 ISOSORBIDE MONO 120 MG (60 MG EXTERNAL 02/07/08 028 0251 5012
13721244 ISOSORBIDE MONO 90MG (30 MG X EXTERNAL 02/07/08 028 0251 5012
13721260 ISOPROTERENOL 200MCG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13721265 ISOPROTERENOL 8 MG FOR 250 ML EXTERNAL 01/25/05 028 0258 5012
13721270 ISOPROTERENOL 0.2MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13721272 ISOPROTERENOL 1MG INJ SYR EXTERNAL 01/01/95 028 0250 5012
13721276 ISOSORBIDE MONO 30MG ER TAB EXTERNAL 08/07/95 028 0251 5012
13721277 ISOSORBIDE MONO 15MG ER (1/2X3 EXTERNAL 07/20/06 028 0251 5012
13721353 ISOSORBIDE DINITRATE 5MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13721356 ISOSORBIDE DINITRATE 5MG TAB EXTERNAL 01/01/95 028 0250 5012
13721358 ISOSORBIDE DINITRATE 10MG TAB EXTERNAL 01/01/95 028 0250 5012
13721360 ISOSORBIDE DINITRATE 20MG TAB EXTERNAL 01/01/95 028 0250 5012
13721362 ISOSORBIDE DINITRATE 40MG SR T EXTERNAL 01/01/95 028 0250 5012
13721363 ISOSORBIDE DINITRATE 40MG SR - EXTERNAL 01/25/95 028 0251 5012
13721364 ISOSORBIDE DINITRATE 10MG - 1 EXTERNAL 01/25/95 028 0251 5012
13721366 ISOSORBIDE DINITRATE 20MG - 1 EXTERNAL 01/25/95 028 0251 5012
13721390 KANAMYCIN 0.333GM/ML INJ EXTERNAL 01/01/95 J1840 J1840 028 0636 5012
13721397 ITRACONAZOLE 100MG U.D. BOX EXTERNAL 01/01/95 028 0251 5012
13721398 ITRACONAZOLE 100MG CAP EXTERNAL 04/21/94 028 0251 5012
13721404 J-TIP SYRINGE EXTERNAL 03/22/02 028 0251 5012
13721406 ITRACONAZOLE ORAL SOLN 100MG/1 EXTERNAL 04/15/99 028 0251 5012
13721407 ITRACONAZOLE 10MG/ML ORAL SOLN EXTERNAL 04/15/99 028 0251 5012
13721408 ITRACONAZOLE ORAL 100MG EXTERNAL 10/02/01 028 0251 5012
13721409 ITRACONAZOLE ORAL 200MG EXTERNAL 10/02/01 028 0251 5012
13721411 KANAMYCIN 333MG/ML INJ EXTERNAL 01/01/95 J1840 J1840 028 0636 5012
13721475 0ODIUM POLYSTYRENE SULF - 480M EXTERNAL 07/01/84 028 0250 5012
13721480 KETAMINE 100MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13721481 KETAMINE INJECTION 200MG VIAL EXTERNAL 01/01/95 028 0250 5012
13721483 KETAMINE 10MG/ML INJ 20ML VIAL EXTERNAL 01/07/98 028 0258 5012
13721484 KETAMINE 500 MG FOR 500 ML LVP EXTERNAL 03/19/08 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 242
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13721491 KETOROLAC 0.5% OPHTH SOL 5ML EXTERNAL 01/01/95 028 0251 5012
13721492 KETOROLAC 0.5% OPHTH SOL 0.4ML EXTERNAL 01/23/08 028 0251 5012
13721496 KETOCONAZOLE 200MG TAB EXTERNAL 01/01/95 028 0250 5012
13721498 KETOCONAZOLE 200MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721499 KETOROLAC 15MG/ML INJ EXTERNAL 01/01/95 J1885 J1885 028 0636 5012
13721500 KETOROLAC 15MG/ML INJ EXTERNAL 09/01/94 J1885 J1885 028 0636 5012
13721501 KETOROLAC 60MG SYR EXTERNAL 09/01/94 J1885 J1885 028 0636 5012
13721503 KETOROLAC 15 MG SYR EXTERNAL 01/25/05 J1885 J1885 028 0636 5012
13721504 KETOROLAC 30 MG SYR EXTERNAL 01/25/05 J1885 J1885 J1885 028 0636 5012
13721510 KIDNEY PRESERVATION SOLN EXTERNAL 07/01/84 028 0258 5012
13721515 KIT PREGNANCY EXTERNAL 07/02/01 028 0251 5012
13721516 LABETOLOL 10 MG/ML ORAL SUSPEN EXTERNAL 01/25/05 028 0251 5012
13721517 LABETOLOL ORAL SUSPENSION 20MG EXTERNAL 11/14/01 028 0251 5012
13721518 LABETOLOL ORAL SUSPENSION 40MG EXTERNAL 11/14/01 028 0251 5012
13721519 LABETOLOL 50MG (1/2 X 100MG) T EXTERNAL 01/01/95 028 0251 5012
13721522 LABETOLOL 200MG TAB EXTERNAL 01/01/95 028 0250 5012
13721524 LABETOLOL 300MG TAB EXTERNAL 01/01/95 028 0250 5012
13721526 LABETOLOL 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13721527 LABETOLOL 200MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721528 LABETOLOL 300MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721529 LABETOLOL 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721534 LABETOLOL 400MG (200 MG X 2) T EXTERNAL 02/07/08 028 0251 5012
13721535 LABETOLOL 25MG (1/4 X 100 MG) EXTERNAL 07/20/06 028 0251 5012
13721536 LABETOLOL 600MG (300 MG X 2) T EXTERNAL 02/07/08 028 0251 5012
13721566 LAMIVUDINE 300MG (150 MG X 2) EXTERNAL 01/25/05 028 0251 5012
13721567 LAMIVUDINE 25MG ORAL SOLUTION EXTERNAL 10/08/01 028 0251 5012
13721568 LAMIVUDINE 90MG ORAL SOLUTION EXTERNAL 10/08/01 028 0251 5012
13721569 LAMIVUDINE 100MG ORAL SOLUTION EXTERNAL 10/08/01 028 0251 5012
13721570 LACTOSE POWDER EXTERNAL 07/01/84 028 0250 5012
13721572 LAMIVUDINE 10MG/ML ORAL SOLN EXTERNAL 10/03/96 028 0251 5012
13721573 LAMIVUDINE 100MG TAB EXTERNAL 10/16/96 028 0251 5012
13721574 LACTULOSE 237ML SYRUP EXTERNAL 07/01/84 028 0250 5012
13721575 LAMIVUDINE 150MG TABLET BULK B EXTERNAL 10/16/96 028 0251 5012
13721576 LACTULOSE 15ML SYRUP EXTERNAL 01/01/95 028 0251 5012
13721577 LACTULOSE 300ML/STERILE WATER EXTERNAL 08/21/96 028 0251 5012
13721578 LACTULOSE SYRUP 5ML DOSE EXTERNAL 10/08/01 028 0251 5012
13721579 LACTULOSE SYRUP 2.5ML DOSE EXTERNAL 10/08/01 028 0251 5012
13721580 LACTULOSE 30ML SYRUP EXTERNAL 01/01/95 028 0250 5012
13721581 LAMOTRIGINE 25MG TAB EXTERNAL 05/01/95 028 0251 5012
13721582 LAMOTRIGINE 100MG 100'S EXTERNAL 05/01/95 028 0251 5012
13721583 LAMOTRIGINE 100MG TAB EXTERNAL 05/01/95 028 0251 5012
13721584 LAMOTRIGINE 150MG 60'S EXTERNAL 05/01/95 028 0251 5012
13721585 LAMOTRIGINE 150MG TAB EXTERNAL 05/01/95 028 0251 5012
13721586 LAMOTRIGINE 200MG 60'S EXTERNAL 05/01/95 028 0251 5012
13721587 LAMOTRIGINE 200MG TAB EXTERNAL 05/01/95 028 0251 5012
13721588 LAMOTRIGINE 25MG TAB BTL(100) EXTERNAL 05/01/95 028 0251 5012
13721592 LANSOPRAZOLE 30MG U.D. 100'S EXTERNAL 02/07/96 028 0251 5012
13721593 LANSOPRAZOLE 30MG CAP EXTERNAL 02/07/96 028 0251 5012
13721595 LANSOPRAZOLE 15MG CAP EXTERNAL 02/07/96 028 0251 5012
13721597 LANSOPRAZOLE 15MG BOTTLE 30'S EXTERNAL 02/07/96 028 0251 5012
13721598 LANSOPRAZOLE ORAL SUSPENSION 7 EXTERNAL 11/14/01 028 0251 5012
13721599 LANSOPRAZOLE ORAL SUSPENSION 1 EXTERNAL 11/14/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 243
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13721600 OPTHALAMIC IRRIGATING SOLN EXTERNAL 07/01/84 028 0250 5012
13721601 LANSOPRAZOLE ORAL SUSPENSION 3 EXTERNAL 11/14/01 028 0251 5012
13721602 LANSOPRAZOLE ORAL 3MG/ML ORAL EXTERNAL 03/14/02 028 0251 5012
13721605 LATANOPROST 0.005% OPHTH SOLN EXTERNAL 12/02/96 028 0251 5012
13721616 LEVETIRACETAM 250MG TABLET EXTERNAL 06/08/01 028 0251 5012
13721617 LEVETIRACETAM 500MG TABLET EXTERNAL 06/08/01 028 0251 5012
13721618 LEVETIRACETAM 750MG TABLET EXTERNAL 01/19/02 028 0251 5012
13721619 LEVETIRACETAM 1000MG TABLET (5 EXTERNAL 08/12/02 028 0251 5012
13721620 NOREPINEPHRINE 1MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13721622 LEVETIRACETAM 100 MG/ML ORAL S EXTERNAL 08/12/02 028 0251 5012
13721623 LEVETIRACETAM 250 MG SOLUTION EXTERNAL 01/25/05 028 0251 5012
13721624 LEVETIRACETAM 500 MG SOLUTION EXTERNAL 01/25/05 028 0251 5012
13721626 LEVETIRACETAM 1000MG SOLUTION EXTERNAL 11/01/06 028 0251 5012
13721627 LEVETIRACETAM 100MG/ML 5 ML VI EXTERNAL 12/27/06 J1953 J1953 J1953 028 0258 5012
13721628 LEVETIRACETAM 500MG/D5W 100 ML EXTERNAL 12/27/06 J1953 J1953 J1953 028 0258 5012
13721629 LEVETIRACETAM 125MG (250 MG X EXTERNAL 01/25/05 028 0251 5012
13721630 LATEX ALLERGY KIT EXTERNAL 02/28/06 028 0258 5012
13721631 LEVETIRACETAM 1500 MG (750 MG EXTERNAL 01/25/05 028 0251 5012
13721632 LEVETIRACETAM 10MG/ML INJ EXTERNAL 10/30/08 028 0258 5012
13721664 LEVONORGESTREL TABLET EXTERNAL 09/13/00 028 0251 5012
13721669 LEVOTHYROXINE 25MCG/ML ORAL SU EXTERNAL 11/14/01 028 0251 5012
13721670 LEVOTHYROXINE 25MCG TAB EXTERNAL 07/14/94 028 0250 5012
13721671 LEVOTHYROXINE 75MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721672 LEVOTHYROXINE 75MCG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721673 LEVOTHYROXINE 175MCG - 1 BOTTL EXTERNAL 07/01/84 028 0250 5012
13721674 LEVOTHYROXINE 175MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721675 LEVOTHYROXINE 25MCG - 1 BTL EXTERNAL 01/25/95 028 0251 5012
13721676 EXTERNAL 01/25/95 028 0251 5012
13721678 LEVOTHYROXINE 112MCG TAB EXTERNAL 11/17/94 028 0251 5012
13721679 LEVOTHYROXINE 12.5 MCG (1/2 X EXTERNAL 06/22/06 028 0251 5012
13721681 LEVOTHYROXINE 37.5 (1/2 X 75 M EXTERNAL 02/14/08 028 0251 5012
13721690 LEVOTHYROXINE 50MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721692 LEVOTHYROXINE 50MCG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721710 LEVOTHYROXINE 100MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721711 LEVOTHYROXINE 100MCG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721715 LEVOTHYROXINE 125MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721716 LEVOTHYROXINE 125MCG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721720 LEVOTHYROXINE 150MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721721 LEVOTHYROXINE 150MCG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721723 LEVOTHYROXINE 88MCG TAB EXTERNAL 08/08/01 028 0251 5012
13721740 LEVOTHYROXINE 200MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721741 LEVOTHYROXINE 200MCG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13721750 LEVOTHYROXINE 300MCG TAB EXTERNAL 01/01/95 028 0250 5012
13721751 LEVOTHYROXINE 300MCG - 1 BOTTL EXTERNAL 01/25/95 028 0251 5012
13721770 LIDOCAINE 5% OINT 35GM EXTERNAL 01/01/95 028 0251 5012
13721775 LIDOCAINE 4% TOP SOLN LARYNGO EXTERNAL 01/01/95 028 0251 5012
13721776 LIDOCAINE 4% TOP SOLN 50 ML EXTERNAL 01/26/05 028 0251 5012
13721777 LIDOCAINE 1GM/D5W 250ML BAG EXTERNAL 07/01/84 J2001 J2001 J2001 028 0251 5012
13721780 LIDOCAINE 0.5% INJ (ML) EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721781 LIDOCAINE 1% BUFFERED 3ML EXTERNAL 11/14/94 028 0251 5012
13721782 LIDOCAINE/EPI 1% 10ML VIAL EXTERNAL 01/01/95 028 0251 5012
13721783 BUMETANIDE 0.25 MG/ML 4 ML VIA EXTERNAL 03/14/07 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 244
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13721784 BUMETANIDE 0.025 MG/ML INJ EXTERNAL 03/06/08 028 0251 5012
13721785 BUMETANIDE 0.05 MG/ML INJ EXTERNAL 03/06/08 028 0251 5012
13721786 BUMETANIDE 10 MG INJECTION EXTERNAL 02/02/10 028 0251 5012
13721788 LIDOCAINE 1% INJ PF (ML) EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721789 LIDOCAINE 1% INJ (ML) EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721791 LIDOCAINE 1% INJECTION -20ML EXTERNAL 09/01/94 J2001 J2001 J2001 028 0251 5012
13721800 LIDOCAINE 1% INJECTION -50ML EXTERNAL 01/01/95 J2001 J2001 J2001 028 0251 5012
13721810 LIDOCAINE 1% W/EPINEPH (ML) EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721811 LIDOCAINE W/EPINEPH 2% -20ML EXTERNAL 01/01/95 J2001 J2001 028 0251 5012
13721830 LIDOCAINE 2% INJECTION -5ML A EXTERNAL 01/01/95 J2001 J2001 J2001 028 0251 5012
13721840 LIDOCAINE 2% INJ (ML) EXTERNAL 01/01/95 J2001 J2001 J2001 028 0636 5012
13721841 LIDOCAINE-PRILOCAINE 2.5%/2.5% EXTERNAL 01/01/95 028 0251 5012
13721842 LIDOCAINE-PRILOCAINE 2.5%/2.5% EXTERNAL 01/01/95 028 0251 5012
13721847 LIDOCAINE 20MG/ML INJ EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721850 LIDOCAINE 2% INJECTION -50ML EXTERNAL 01/01/95 J2001 J2001 J2001 028 0636 5012
13721870 LIDOCAINE 4% INJ (ML) EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721873 LIDOCAINE 5% W/GLUCOSE 7.5% SP EXTERNAL 01/01/95 028 0251 5012
13721880 LIDOCAINE 2% INJ 100MG SYR EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721890 LIDOCAINE 20% INJ 1GM SYRINGE EXTERNAL 07/01/84 028 0251 5012
13721900 LIDOCAINE 2% JELLY 30ML EXTERNAL 01/01/95 028 0251 5012
13721901 LIDOCAINE 2% JELLY 10ML URO-JE EXTERNAL 01/01/95 028 0251 5012
13721925 LIDOCAINE 2% VISCOUS SOLN (EXT EXTERNAL 05/06/08 028 0251 5012
13721930 LIDOCAINE 2% VISCOUS SOLN 100M EXTERNAL 01/01/95 028 0251 5012
13721931 LIDOCAINE 2% VISCOUS SOLN 15ML EXTERNAL 01/01/95 028 0251 5012
13721932 LIDOCAINE 2% VISCOUS SOLN 5ML EXTERNAL 03/12/96 028 0251 5012
13721933 LIDOCAINE VISCOUS SOLN 2% ___M EXTERNAL 03/14/96 028 0251 5012
13721934 LINEZOLID 600 MG SUSP EXTERNAL 08/30/06 028 0251 5012
13721935 LINEZOLID* 20MG/ML SUSP EXTERNAL 01/01/03 028 0251 5012
13721936 LINEZOLID 100MG/5ML 150ML EXTERNAL 01/01/06 J2020 J2020 J2020 028 0251 5012
13721937 LINEZOLID 600MG TAB EXTERNAL 01/26/01 028 0251 5012
13721938 LINEZOLID* 2MG/ML INJ EXTERNAL 01/01/03 J2020 J2020 028 0636 5012
13721939 LINEZOLID* 200MG/D5W 100ML EXTERNAL 01/01/03 J2020 J2020 028 0636 5012
13721940 LIDOCAINE 0.5% W/EPINEPH INJ ( EXTERNAL 01/01/95 028 0251 5012
13721941 LIDOCAINE/EPINEPHRINE/TETRACAI EXTERNAL 06/01/95 J2001 J2001 J2001 028 0251 5012
13721960 LIDOCAINE 2% W/EPINEPH INJ (ML EXTERNAL 01/01/95 J2001 J2001 028 0636 5012
13721965 LIDOCAINE 2% JELLY 5ML TUBE EXTERNAL 05/01/95 028 0251 5012
13721968 LIOTHYRONINE 10 MCG/ML INJ EXTERNAL 01/26/05 028 0258 5012
13721969 LIOTHYRONINE 5MCG TAB EXTERNAL 01/26/05 028 0251 5012
13721970 LIOTHYRONINE 25MCG - 1 BOTTLE EXTERNAL 08/05/88 028 0251 5012
13721971 LIOTHYRONINE 25MCG TAB EXTERNAL 01/01/95 028 0251 5012
13721972 LISINOPRIL 5 MG TAB EXTERNAL 07/23/03 028 0251 5012
13721973 LISINOPRIL 10MG TAB EXTERNAL 07/23/03 028 0251 5012
13721974 LISINOPRIL 20MG TAB EXTERNAL 07/23/03 028 0251 5012
13721975 LISINOPRIL 2.5 MG (1/2 OF 5 MG EXTERNAL 07/23/03 028 0251 5012
13721997 RETISERT IMPLANT (FLUONCINOLON EXTERNAL 01/19/07 J7311 J7311 J7311 028 0636 5012
13722001 LITHIUM CARBONATE 300MG ER TAB EXTERNAL 04/19/07 028 0251 5012
13722003 LORAZEPAM 0.25 MG TAB EXTERNAL 09/13/00 028 0251 5012
13722009 LORAZEPAM 0.16MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13722010 LITHIUM CARBONATE 300MG CAP EXTERNAL 01/01/95 028 0250 5012
13722011 LITHIUM CARBONATE 300MG - 1 BO EXTERNAL 01/25/95 028 0251 5012
13722012 LITHIUM CARBONATE 450MG SR TAB EXTERNAL 07/14/93 028 0251 5012
13722013 LITHIUM CARBONATE 450MG SR TAB EXTERNAL 01/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 245
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13722014 LORAZEPAM 0.2MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13722015 LORAZEPAM 0.25MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13722016 LORAZEPAM 0.3MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13722017 LORAZEPAM SOLUTION 0.1MG EXTERNAL 10/07/01 028 0251 5012
13722018 LORAZEPAM SOLUTION 0.125MG LIQ EXTERNAL 10/07/01 028 0251 5012
13722019 LORAZEPAM SOLUTION 0.5MG LIQ EXTERNAL 10/07/01 028 0251 5012
13722020 LITHIUM CITRATE* 300MG/5ML SYR EXTERNAL 07/01/84 028 0250 5012
13722024 LITHIUM CITRATE SYRUP 75MG DOS EXTERNAL 10/08/01 028 0251 5012
13722028 LOPERAMIDE 1MG ORAL SOL DOSE EXTERNAL 10/08/01 028 0251 5012
13722035 LOPERAMIDE 2MG LIQUID EXTERNAL 01/01/95 028 0251 5012
13722036 LORAZEPAM 0.5MG TABLET - BOX EXTERNAL 01/01/95 028 0251 5012
13722037 LORAZEPAM 0.5MG TAB EXTERNAL 01/01/95 028 0251 5012
13722039 LOPERAMIDE 4MG (2 MG X 2) CAPS EXTERNAL 02/14/08 028 0251 5012
13722040 ATROPINE-DIPHENOXYLATE 25MCG/2 EXTERNAL 01/01/95 028 0250 5012
13722041 LOMOTIL - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13722042 LOPERAMIDE 2MG CAPSULE 100/BOX EXTERNAL 01/30/93 028 0251 5012
13722043 LOPERAMIDE 2MG CAP EXTERNAL 01/01/95 028 0251 5012
13722045 LOPERAMIDE 1MG/5ML LIQUID BTL EXTERNAL 01/30/93 028 0251 5012
13722046 LOPERAMIDE 0.2MG/ML LIQ EXTERNAL 01/01/95 028 0251 5012
13722048 LORAZEPAM SOLUTION 1MG EXTERNAL 01/01/95 028 0251 5012
13722049 ATROPINE-DIPHENOXYLATE 10ML SO EXTERNAL 01/01/95 028 0250 5012
13722050 ATROPINE-DIPHENOXYLATE 5ML SOL EXTERNAL 07/01/84 028 0250 5012
13722053 LORAZEPAM 2MG/ML ORAL SOLN EXTERNAL 01/01/95 028 0251 5012
13722054 LORAZEPAM 2MG - 1 BOX(100/BX) EXTERNAL 01/25/95 028 0251 5012
13722055 LORAZEPAM 1MG - 1BOX(100) EXTERNAL 01/25/95 028 0251 5012
13722058 LORAZEPAM 1MG TAB EXTERNAL 01/01/95 028 0250 5012
13722060 LORAZEPAM 2MG TAB EXTERNAL 01/01/95 028 0250 5012
13722061 LORAZEPAM 2MG/ML INJ EXTERNAL 07/01/84 J2060 J2060 028 0636 5012
13722062 LORAZEPAM 2MG/0.5ML INJ EXTERNAL 07/01/84 J2060 J2060 028 0636 5012
13722063 LORAZEPAM 2MG INJ SYR EXTERNAL 08/01/94 J2060 J2060 028 0636 5012
13722064 LORAZEPAM 2MG INJ SYR EXTERNAL 01/01/95 J2060 J2060 028 0636 5012
13722065 LORAZEPAM INJECTION ***MG EXTERNAL 10/01/94 J2060 J2060 028 0636 5012
13722072 LORAZEPAM 1MG INJ EXTERNAL 01/26/05 J2060 J2060 028 0636 5012
13722073 LORAZEPAM 4MG (2 MG X 2) TABLE EXTERNAL 02/14/08 028 0251 5012
13722084 LORAZEPAM 2MG/12ML D5W EXTERNAL 10/26/94 J2060 J2060 J2060 028 0251 5012
13722086 LORATADINE 10MG TAB EXTERNAL 09/23/96 028 0251 5012
13722087 LORATADINE 5MG TAB EXTERNAL 02/14/08 028 0251 5012
13722092 LORAZEPAM 24MG FOR 120ML LVP EXTERNAL 09/10/03 J2060 J2060 028 0636 5012
13722093 LORAZEPAM 48MG FOR 240ML LVP EXTERNAL 09/10/03 J2060 J2060 028 0636 5012
13722117 LOPINAVIR/RITONAVIR ORAL SOLN EXTERNAL 05/28/02 028 0251 5012
13722119 LOPINAVIR-RITONAVIR 200MG/50MG EXTERNAL 02/02/06 028 0251 5012
13722160 MAALOX SUSPENSION 150ML BOTTLE EXTERNAL 01/01/95 028 0250 5012
13722161 MAALOX 150ML SUSP EXTERNAL 01/01/95 028 0250 5012
13722162 MAALOX SUSPENSION 6OZ BOTTLE EXTERNAL 03/12/96 028 0251 5012
13722163 ALUM MAGNESIUM HYDROXIDE SUSP EXTERNAL 12/27/04 028 0251 5012
13722170 MAALOX 15ML SUSP EXTERNAL 01/01/95 028 0250 5012
13722180 MAALOX 30ML SUSP EXTERNAL 01/01/95 028 0250 5012
13722181 ALVIMOPAN 12 MG TABLET EXTERNAL 03/11/09 028 0251 5012
13722244 MAGNESIUM OXIDE 200 MG (1/2 X EXTERNAL 07/20/06 028 0251 5012
13722246 MAGNESIUM OXIDE 400MG TAB EXTERNAL 01/01/95 028 0250 5012
13722247 MAGNESIUM OXIDE 400MG TAB U.D. EXTERNAL 11/23/94 028 0251 5012
13722248 MAGNESIUM OXIDE 800MG (400 MG EXTERNAL 02/14/08 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 246
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13722293 SENNA 8.6 MG TAB EXTERNAL 02/24/06 028 0251 5012
13722302 MAGNESIUM SULFATE 500MG/ D5W 5 EXTERNAL 01/01/95 J3475 J3475 028 0636 5012
13722303 MAGNESIUM SULFATE 40GM/L RTU EXTERNAL 01/01/95 J3475 J3475 J3475 028 0250 5012
13722304 MAGNESIUM SULFATE 500MG/ D5W 5 EXTERNAL 07/31/01 J3475 J3475 028 0636 5012
13722305 MAGNESIUM SULFATE 500MG/50ML S EXTERNAL 01/01/95 J3475 J3475 028 0636 5012
13722306 MAGNESIUM SULFATE 25GM/250ML D EXTERNAL 10/31/92 J3475 J3475 J3475 028 0258 5012
13722307 MAGNESIUM SULFATE 40 GM/80 ML EXTERNAL 01/26/05 J3475 J3475 028 0636 5012
13722308 MAGNESIUM SULFATE MG/KG PEDS-N EXTERNAL 05/14/02 J3475 J3475 028 0636 5012
13722309 MAGNESIUM SULFATE 500MG/ML INJ EXTERNAL 05/14/02 J3475 J3475 028 0636 5012
13722310 MAGNESIUM SULFATE 0.5GM/ML INJ EXTERNAL 01/01/95 J3475 J3475 028 0250 5012
13722320 MAGNESIUM SULFATE 50% INJECTIO EXTERNAL 01/01/95 J3475 J3475 028 0250 5012
13722321 MAGNESIUM SULFATE 4MEG/ML INJ EXTERNAL 09/25/92 J3475 J3475 028 0636 5012
13722322 MAGNESIUM SULFATE 500MG/D5% 25 EXTERNAL 10/16/01 J3475 028 0636 5012
13722323 MAGNESIUM SULFATE MEG/KG EXTERNAL 03/28/08 028 0258 5012
13722330 MAGNESIUM CITRATE 300ML EXTERNAL 01/01/95 028 0251 5012
13722340 MANNITOL 20% INJECTION ***GM EXTERNAL 01/01/95 028 0636 5012
13722341 MANNITOL 25% INJ EXTERNAL 01/01/95 028 0636 5012
13722380 MANNITOL 20% 250ML EXTERNAL 07/01/84 028 0258 5012
13722430 DEXAMETH-NEO-POLYMYXIN B OPHTH EXTERNAL 01/01/95 028 0250 5012
13722432 MD GASTROVIEW 120 ML BTL EXTERNAL 03/15/06 028 0251 5012
13722443 MAXZIDE(75/50) - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13722444 MAXZIDE (37.5/25) - 1 BOTTLE EXTERNAL 08/31/88 028 0251 5012
13722451 MEASLES-MUMPS-RUBELLA INJ 0.5M EXTERNAL 01/01/95 028 0250 5012
13722452 MEASLES-MUMPS-RUBELLA INJ 0.5M EXTERNAL 01/12/10 028 0258 5012
13722460 MEBENDAZOLE 100MG CHEW TAB EXTERNAL 01/01/95 028 0250 5012
13722461 MEBENDAZOLE 100MG - 1 BOX (12) EXTERNAL 01/25/95 028 0251 5012
13722480 MECHLORETHAMINE 1MG/ML INJ EXTERNAL 07/01/84 J9230 J9230 J9230 028 0636 5012
13722489 MECLIZINE 12.5MG TAB EXTERNAL 01/01/95 028 0251 5012
13722491 MECLIZINE 25MG TAB EXTERNAL 01/01/95 028 0251 5012
13722492 MECLIZINE 12.5MG-1 BOX EXTERNAL 01/25/95 028 0251 5012
13722493 MECLIZINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13722495 MEDFUSION PUMP CHARGE EXTERNAL 07/01/99 028 0251 4520
13722501 MEDROXYPROGESTERONE 10MG TAB EXTERNAL 01/01/95 028 0250 5012
13722502 MEDROXYPROGESTERONE ACET 10MG EXTERNAL 01/25/95 028 0251 5012
13722503 MEDROXYPROGESTERONE 2.5 MG TAB EXTERNAL 01/01/95 028 0251 5012
13722504 MEDROXYPROGESTERONE 2.5MG - 1 EXTERNAL 08/31/88 028 0251 5012
13722506 MEDROXYPROGESTERONE 150MG/ML I EXTERNAL 01/01/95 J1055 J1055 028 0636 5012
13722535 MEFLOQUINE 250MG - 1 BOX EXTERNAL 11/19/90 028 0251 5012
13722536 MEFLOQUINE 250MG TAB EXTERNAL 01/01/95 028 0251 5012
13722540 MEGESTROL 20MG TAB EXTERNAL 01/01/95 028 0251 5012
13722543 MEGESTROL 40MG/ML SUSP EXTERNAL 04/21/94 028 0251 5012
13722545 MEGESTROL 800MG SUSP EXTERNAL 08/27/01 028 0251 5012
13722547 MEGESTROL 80MG ORAL DOSE EXTERNAL 10/09/01 028 0251 5012
13722548 MEGESTROL 200MG ORAL DOSE EXTERNAL 10/09/01 028 0251 5012
13722549 MEGESTROL 400MG ORAL DOSE EXTERNAL 10/09/01 028 0251 5012
13722550 MEGESTROL 40MG TAB EXTERNAL 01/01/95 028 0250 5012
13722680 MELPHALAN 2MG TAB EXTERNAL 01/01/95 028 0251 5012
13722681 MELPHALAN 2MG - 1 BOTTLE(50) EXTERNAL 01/25/95 028 0251 5012
13722682 MELPHALAN 5MG/ML INJ EXTERNAL 05/03/93 J9245 J9245 028 0636 5012
13722690 MENINGOCOCCAL VACCINE INJ EXTERNAL 01/01/95 028 0251 5012
13722692 MENINGOCOCCAL VACCINE INJ VFC EXTERNAL 01/12/10 028 0258 5012
13722700 MEMANTINE 5 MG TABLET EXTERNAL 06/27/05 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 247
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13722810 MEPERIDINE 25MG INJ SYR EXTERNAL 01/01/95 J2175 J2175 028 0636 5012
13722820 MEPERIDINE 50MG INJ SYR EXTERNAL 09/01/94 J2175 J2175 028 0636 5012
13722830 MEPERIDINE 75MG INJ SYR EXTERNAL 08/01/94 J2175 J2175 028 0636 5012
13722840 MEPERIDINE 100MG INJ SYR EXTERNAL 10/01/94 J2175 J2175 028 0636 5012
13722861 EXTERNAL 01/25/95 028 0251 5012
13722881 MEPHOBARBITAL 100MG - 1BOTTLE EXTERNAL 01/25/95 028 0251 5012
13722900 MEPIVACAINE 1% INJ(ML) EXTERNAL 01/01/95 J0670 J0670 028 0636 5012
13722920 MEPIVACAINE 1.5% INJ (ML) EXTERNAL 01/01/95 J0670 J0670 028 0636 5012
13722930 MEPIVACAINE 2% INJ (ML) EXTERNAL 01/01/95 J0670 J0670 028 0636 5012
13723000 MERCAPTOPURINE 50MG TAB EXTERNAL 01/01/95 028 0251 5012
13723002 MERCAPTOPURINE 25MG (1/2X 50MG EXTERNAL 07/20/06 028 0251 5012
13723011 IFOSFAMIDE 0.05GM/ML INJ EXTERNAL 07/30/97 J9208 J9208 028 0636 5012
13723019 PSYLLIUM 6GM POWDER PACKET (E EXTERNAL 04/24/08 028 0251 5012
13723020 PSYLLIUM EFF 6GM POWDER PACKET EXTERNAL 01/01/95 028 0250 5012
13723022 MESALAMINE 250MG U.D. BOX EXTERNAL 03/08/94 028 0251 5012
13723023 MESALAMINE 250MG ER CAP EXTERNAL 01/01/95 028 0251 5012
13723025 MESALAMINE 500MG (250 MG X 2) EXTERNAL 10/03/00 028 0251 5012
13723026 MESALAMINE 1000MG (250 MG X 4) EXTERNAL 10/03/00 028 0251 5012
13723027 MESALAMINE 750MG (250 MG X 3) EXTERNAL 10/03/00 028 0251 5012
13723050 METHACHOLINE CHLORIDE INHL EXTERNAL 07/01/84 028 0251 5012
13723052 METFORMIN 500MG TAB EXTERNAL 06/19/96 028 0251 5012
13723053 METFORMIN 850MG TABLET EXTERNAL 06/19/96 028 0251 5012
13723054 METFORMIN 850MG TAB EXTERNAL 06/19/96 028 0251 5012
13723055 METFORMIN 500MG TABLET EXTERNAL 06/19/96 028 0251 5012
13723056 METFORMIN 250MG (1/2 X 500 MG EXTERNAL 07/20/06 028 0251 5012
13723057 METFORMIN 1000 MG (500 MG X 2) EXTERNAL 02/14/08 028 0251 5012
13723081 METHADONE 4MG/4ML ORAL SOLN EXTERNAL 06/07/01 028 0251 5012
13723082 METHADONE 0.3 MG/0.3 ML ORAL S EXTERNAL 06/07/01 028 0251 5012
13723083 METHADONE 0.2 MG/0.2 ML ORAL S EXTERNAL 06/07/01 028 0251 5012
13723084 METHADONE 0.6 MG/0.6 ML ORAL S EXTERNAL 06/07/01 028 0251 5012
13723085 METHADONE 0.7 MG/0.7 ML ORAL S EXTERNAL 06/07/01 028 0251 5012
13723086 METHADONE 0.8 MG/0.8 ML ORAL S EXTERNAL 06/07/01 028 0251 5012
13723087 METHADONE 0.9 MG/0.9 ML ORAL S EXTERNAL 06/07/01 028 0251 5012
13723088 METHADONE 1 MG/1 ML ORAL SOLN EXTERNAL 06/07/01 028 0251 5012
13723089 METHADONE 5MG - 1 BOX(100) EXTERNAL 01/25/95 028 0251 5012
13723091 METHADONE 5MG TAB EXTERNAL 01/01/95 028 0250 5012
13723093 METHADONE 1 MG/1 ML ORAL SOLN EXTERNAL 06/07/01 028 0251 5012
13723094 METHADONE 10 MG/1 ML INJ 20 ML EXTERNAL 06/07/01 J1230 J1230 J1230 028 0251 5012
13723095 METHADONE 90 MG ORAL SOLUTION EXTERNAL 10/08/01 028 0251 5012
13723096 METHADONE 2.5 MG (1/2 X 5 MG) EXTERNAL 12/19/07 028 0251 5012
13723101 METHADONE 10MG TAB EXTERNAL 01/01/95 028 0250 5012
13723102 METHADONE 10MG - 1 BOX(100) EXTERNAL 01/25/95 028 0251 5012
13723107 METHADONE 0.1MG ORAL SOLUTION EXTERNAL 10/08/01 028 0251 5012
13723108 METHADONE 0.5MG ORAL SOLUTION EXTERNAL 10/08/01 028 0251 5012
13723111 METHADONE 5MG ORAL SOLUTION DO EXTERNAL 10/08/01 028 0251 5012
13723112 METHADONE 10MG ORAL SOLUTION D EXTERNAL 10/08/01 028 0251 5012
13723113 METHADONE 20MG ORAL SOLUTION D EXTERNAL 10/08/01 028 0251 5012
13723114 METHADONE 50MG ORAL SOLUTION D EXTERNAL 10/08/01 028 0251 5012
13723115 METHADONE 100MG ORAL SOLUTION EXTERNAL 10/08/01 028 0251 5012
13723116 METHADONE 0.25MG ORAL SOLN EXTERNAL 12/19/01 028 0251 5012
13723119 METHADONE 1MG/ML PEDS INJ EXTERNAL 01/30/02 J1230 J1230 028 0636 5012
13723130 METHAZOLAMIDE 50MG TAB EXTERNAL 01/01/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 248
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13723220 METHIMAZOLE 5MG TAB EXTERNAL 01/01/95 028 0250 5012
13723221 METHIMAZOLE 5MG - 1BOTTLE EXTERNAL 01/25/95 028 0251 5012
13723222 METHIMAZOLE 10MG - 1 BOTTLE EXTERNAL 11/16/89 028 0251 5012
13723223 METHIMAZOLE 10MG TAB EXTERNAL 01/01/95 028 0251 5012
13723232 OXYCODONE SR 80 MG TAB EXTERNAL 06/07/01 028 0251 5012
13723312 METHOHEXITAL 10MG/ML INJ EXTERNAL 01/01/95 028 0251 5012
13723314 METHOHEXITAL 0.01GM/ML INJ EXTERNAL 05/14/02 028 0258 5012
13723320 METHOTREXATE 2.5MG TAB EXTERNAL 01/01/95 J8610 J8610 J8610 028 0636 5012
13723322 METHOTREXATE 2.5MG U.D. 100'S EXTERNAL 11/23/94 028 0251 5012
13723330 METHOTREXATE INJECTION 5MG VI EXTERNAL 07/01/84 J9260 J9260 J9260 028 0636 5012
13723331 METHOTREXATE 25MG/ML INJ EXTERNAL 10/20/92 J9250 J9250 028 0636 5012
13723332 METHOTREXATE 50MG/ML INJ EXTERNAL 05/16/02 J9260 J9260 028 0636 5012
13723333 METHOTREXATE 0.05GM/ML INJ EXTERNAL 05/16/02 J9260 J9260 028 0636 5012
13723341 PF METHOTREXATE 25MG/ML INJ EXTERNAL 01/01/95 J9260 J9260 028 0636 5012
13723360 METHOTREXATE INJ 50MG VIAL EXTERNAL 01/01/95 J9260 J9260 J9260 028 0251 5012
13723410 METHYLDOPA 500MG SUSP EXTERNAL 01/01/95 028 0250 5012
13723420 METHYLDOPA 125MG TAB EXTERNAL 01/01/95 028 0250 5012
13723421 METHYLDOPA 125MG - 1 BOTTLE EXTERNAL 01/01/87 028 0250 5012
13723450 METHYLDOPA 250MG TAB EXTERNAL 01/01/95 028 0250 5012
13723451 METHYLDOPA 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723460 METHYLDOPA 500MG - 1 BOTTLE(10 EXTERNAL 07/01/84 028 0250 5012
13723465 METHYLDOPA 500MG/D5W 100ML EXTERNAL 03/12/96 J0210 J0210 028 0636 5012
13723470 METHYLDOPA 500MG TAB EXTERNAL 01/01/95 028 0250 5012
13723471 METHYLDOPA 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723472 METHYLDOPA 2.5MG/ML INJ (1:20 EXTERNAL 10/03/00 028 0258 5012
13723480 METHYLDOPA INJECTION 250MG VIA EXTERNAL 01/01/95 028 0258 5012
13723481 METHYLDOPA 50MG/ML INJ EXTERNAL 01/01/95 J0210 J0210 028 0636 5012
13723482 METHYLDOPA 250MG/D5W 50ML EXTERNAL 03/12/96 J0210 J0210 028 0636 5012
13723484 METHYLDOPA SUSPENSION 50MG/ML EXTERNAL 03/14/02 028 0251 5012
13723486 METHYLDOPA 250MG SUSP EXTERNAL 01/01/95 028 0250 5012
13723500 METHYLENE BLUE 1% INJ 10ML EXTERNAL 01/01/95 028 0250 5012
13723502 METHYLENE BLUE 1% INJ 1ML EXTERNAL 01/01/95 028 0251 5012
13723503 METHYLENE BLUE 10 MG/ML SOLN 1 EXTERNAL 10/15/02 028 0258 5012
13723520 METHYLERGONOVINE 0.2MG/ML INJ EXTERNAL 01/01/95 J2210 J2210 028 0636 5012
13723539 METHYLPHENIDATE 2.5MG TABLET EXTERNAL 05/16/02 028 0251 5012
13723540 METHYLPHENIDATE 5MG TAB EXTERNAL 01/01/95 028 0250 5012
13723541 METHYLPHENIDATE 5MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13723542 METHYLPHENIDATE 18MG ER TAB EXTERNAL 12/17/98 028 0251 5012
13723543 METHYLPHENIDATE 18MG ER TAB EXTERNAL 12/17/98 028 0251 5012
13723550 METHYLPHENIDATE 10MG TAB EXTERNAL 01/01/95 028 0250 5012
13723551 METHYLPHENIDATE 10MG - 1 BOTTL EXTERNAL 01/25/95 028 0251 5012
13723570 METHYLPHENIDATE 20MG TABLET EXTERNAL 01/01/95 028 0250 5012
13723571 METHYLPHENIDATE 20MG - 1 BOTTL EXTERNAL 01/25/95 028 0251 5012
13723575 METHYLPHENIDATE 20MG SR TAB-10 EXTERNAL 07/29/92 028 0251 5012
13723576 METHYLPHENIDATE 20MG SR TAB EXTERNAL 01/01/95 028 0251 5012
13723579 METRONIDAZOLE 0.75% VAG. GEL 7 EXTERNAL 01/01/95 028 0251 5012
13723600 METHYLPRED ACETATE 40MG/ML IM EXTERNAL 01/01/95 J1030 J1030 028 0636 5012
13723610 METHYLPREDNISOLONE ACET 40MG V EXTERNAL 07/01/84 J1030 J1030 J1030 028 0258 5012
13723620 METHYLPREDNISOLONE ACET 80MG EXTERNAL 01/01/95 J1040 J1040 J1040 028 0258 5012
13723630 METHYLPREDNISOLONE ACET 400MG EXTERNAL 07/01/84 028 0258 5012
13723631 METHYLPRED ACETATE 80MG/ML IM EXTERNAL 01/01/95 J1040 J1040 028 0636 5012
13723640 METHYLPREDNISOLONE SUCC 40MG V EXTERNAL 01/01/95 J2920 J2920 J2920 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 249
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13723641 METHYLPREDNISOLONE SUCC 40MG I EXTERNAL 01/01/95 J2920 028 0636 5012
13723645 METHYLPREDNISOLONE SUCC 125MG EXTERNAL 03/12/96 J2930 028 0636 5012
13723650 METHYLPREDNISOLONE SUCC 125MG EXTERNAL 01/01/95 J2930 J2930 J2930 028 0258 5012
13723654 METHYLPREDNISOLONE 250MG/NS 10 EXTERNAL 10/03/00 J2930 J2930 028 0636 5012
13723655 METHYLPREDNISOLONE 125MG/NS 10 EXTERNAL 03/12/96 J2930 J2930 028 0636 5012
13723660 ZETHYLPREDNISOLONE SUCC 500MG EXTERNAL 01/01/95 028 0258 5012
13723670 METHYLPREDNISOLONE SUCC 250MG EXTERNAL 01/01/95 J2930 J2930 028 0636 5012
13723690 METOCLOPRAMIDE 0.15MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13723692 METOCLOPRAMIDE 0.6MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13723698 METOCLOPRAMIDE 15MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13723700 METOCLOPRAMIDE 5MG TAB EXTERNAL 01/01/95 028 0251 5012
13723701 METOCLOPRAMIDE 0.1MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723702 METOCLOPRAMIDE 0.2MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723703 METOCLOPRAMIDE 0.3MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723704 METOCLOPRAMIDE 0.4MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723705 METOCLOPRAMIDE 0.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723706 METOCLOPRAMIDE 0.8G SYRUP EXTERNAL 05/01/95 028 0251 5012
13723707 METOCLOPRAMIDE 1MG DOSE EXTERNAL 05/01/95 028 0251 5012
13723708 METOCLOPRAMIDE 1.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723709 METOCLOPRAMIDE 2MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723710 METOPROLOL 25MG (PER 1/2) TAB EXTERNAL 01/01/95 028 0251 5012
13723711 METOCLOPRAMIDE 2.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723712 METOCLOPRAMIDE 3.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13723714 METOCLOPRAMIDE 5 MG INJ VIAL EXTERNAL 01/28/05 J2765 J2765 028 0636 5012
13723715 MISOPROSTOL 100MCG TAB EXTERNAL 01/01/95 028 0251 5012
13723716 MISOPROSTOL 25MCG TAB EXTERNAL 06/07/00 028 0251 5012
13723718 METOCLOPRAMIDE 10MG/D5W 50ML EXTERNAL 03/26/02 J2765 J2765 028 0636 5012
13723719 METOCLOPRAMIDE 10MG/2ML INJ VI EXTERNAL 03/12/96 J2765 J2765 028 0636 5012
13723721 METOCLOPRAMIDE 2.5MG (1/2 X 5M EXTERNAL 07/20/06 028 0251 5012
13723723 METOCLOPRAMIDE INJECTION 50MG EXTERNAL 07/01/84 028 0258 5012
13723724 METOCLOPRAMIDE 5MG/ML INJ EXTERNAL 11/15/94 J2765 J2765 028 0636 5012
13723726 METOCLOPRAMIDE 10MG TAB EXTERNAL 01/01/95 028 0250 5012
13723727 METOCLOPRAMIDE SYRUP 480ML BOT EXTERNAL 07/01/84 028 0251 5012
13723729 METOCLOPRAMIDE 10MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723731 METOLAZONE 2.5MG TAB EXTERNAL 01/01/95 028 0250 5012
13723732 METOLAZONE 5MG TAB EXTERNAL 01/01/95 028 0250 5012
13723733 METOLAZONE 10MG TAB EXTERNAL 01/01/95 028 0250 5012
13723739 METOLAZONE 5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723741 METRONIDAZOLE 250MG TAB EXTERNAL 01/01/95 028 0250 5012
13723742 METOLAZONE 10MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723743 METOLAZONE 2.5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723745 METRONIDAZOLE 500MG TAB EXTERNAL 01/01/95 028 0251 5012
13723746 METRONIDAZOLE 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723747 METRONIDAZOLE 500MG - BOX EXTERNAL 01/25/95 028 0251 5012
13723748 METRONIDAZOLE 250MG/RTU 50ML EXTERNAL 01/01/95 028 0251 5012
13723749 METRONIDAZOLE 500MG/RTU 100ML EXTERNAL 08/01/94 028 0250 5012
13723751 METOPROLOL 50MG TAB EXTERNAL 01/01/95 028 0250 5012
13723753 METOPROLOL 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13723754 METOPROLOL TARTRATE 1MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13723755 METOPROLOL TARTRATE 50MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13723756 METOPROLOL TARTRATE 100MG - 1 EXTERNAL 01/25/95 028 0251 5012
13723757 METRONIDAZOLE 0.75% GEL 30GM EXTERNAL 01/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 250
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13723763 METOPROLOL 75MG TAB(1X50+1X25) EXTERNAL 07/31/01 028 0251 5012
13723764 METOPROLOL 10MG/ML ORAL SUSP EXTERNAL 09/13/01 028 0251 5012
13723765 METHYLPREDNISOLONE 125MG RIDER EXTERNAL 05/21/92 J2930 J2930 J2930 028 0251 5012
13723766 METOPROLOL 25MG XL TAB EXTERNAL 08/23/01 028 0251 5012
13723767 METOPROLOL 50MG XL TAB EXTERNAL 08/23/01 028 0251 5012
13723768 METOPROLOL 100MG XL TAB EXTERNAL 08/23/01 028 0251 5012
13723769 METOPROLOL 200MG XL TAB EXTERNAL 08/23/01 028 0251 5012
13723775 MIDAZOLAM 2MG/ML SYRUP EXTERNAL 11/11/98 028 0251 5012
13723780 MICONAZOLE NITRATE 2% CREAM 30 EXTERNAL 01/01/95 028 0250 5012
13723786 MICONAZOLE-7 VAGINAL 2% CREAM EXTERNAL 05/31/95 028 0250 5012
13723787 MICONAZOLE 7 VAG SUPP 7/BOX EXTERNAL 05/31/95 028 0251 5012
13723788 MICONAZOLE 7 VAG SUPP EXTERNAL 05/31/95 028 0251 5012
13723789 MICONAZOLE 3 VAG SUPPOSITORY EXTERNAL 05/31/95 028 0251 5012
13723792 MIDAZOLAM 5MG/ML 10ML EXTERNAL 01/01/95 028 0251 5012
13723793 MIDAZOLAM 1MG/ML INJ 1ML VIAL EXTERNAL 01/01/95 J2250 J2250 028 0636 5012
13723794 MIDAZOLAM 1MG/ML INJ 1ML VIAL EXTERNAL 01/01/95 J2250 J2250 028 0636 5012
13723796 MICROFIBRILLAR COLLAGEN HEMOST EXTERNAL 01/01/95 028 0250 5012
13723797 MICONAZOLE 3 VAG SUPP 200MG EXTERNAL 05/31/95 028 0251 5012
13723799 MIDAZOLAM SYRUP 20MG DOSE EXTERNAL 10/08/01 028 0251 5012
13723800 MILK OF MAGNESIA 15ML EXTERNAL 01/01/95 028 0250 5012
13723801 METOPROLOL 12.5MG (PER 1/2) TA EXTERNAL 12/17/98 028 0251 5012
13723802 METOPROLOL ORAL SUSPENSION 6.2 EXTERNAL 11/14/01 028 0251 5012
13723803 METRONIDAZOLE ORAL SUSPENSION EXTERNAL 11/14/01 028 0251 5012
13723804 METRONIDAZOLE ORAL SUSPENSION EXTERNAL 11/14/01 028 0251 5012
13723805 METRONIDAZOLE ORAL SUSPENSION EXTERNAL 11/14/01 028 0251 5012
13723806 METRONIDAZOLE ORAL SUSPENSION EXTERNAL 11/14/01 028 0251 5012
13723807 METRONIDAZOLE ORAL SUSPENSION EXTERNAL 11/14/01 028 0251 5012
13723808 METRONIDAZOLE ORAL SUSPENSION EXTERNAL 11/14/01 028 0251 5012
13723809 METOLAZONE SUSPENSION (1MG/ML) EXTERNAL 11/14/01 028 0251 5012
13723810 MILK OF MAGNESIA 30ML EXTERNAL 01/01/95 028 0250 5012
13723813 METOPROLOL TARTRATE 10 MG INJ EXTERNAL 01/31/05 028 0258 5012
13723814 METOPROLOL TARTRATE 2.5 MG INJ EXTERNAL 01/31/05 028 0258 5012
13723815 MILK OF MAGNESIA 180ML BTL. EXTERNAL 01/01/95 028 0251 5012
13723816 MILK OF MAGNESIA (EXTEMP) EXTERNAL 05/06/08 028 0251 5012
13723818 METOPROLOL 12.5 MG XL (1/2 X 2 EXTERNAL 07/20/06 028 0251 5012
13723819 MICAFUNGIN 10MG/ML INJECTION EXTERNAL 02/25/08 028 0258 5012
13723820 MILK OF MAGNESIA 480ML BOTTLE EXTERNAL 01/01/95 028 0251 5012
13723824 MICAFUNGIN 100MG/NS 100 ML EXTERNAL 03/24/08 028 0258 5012
13723830 MINERAL OIL 30ML EXTERNAL 01/01/95 028 0250 5012
13723831 MILRINONE 1MG/ML 5ML EXTERNAL 05/01/95 J2260 J2260 J2260 028 0636 5012
13723833 MILRINONE 1MG/ML INJ EXTERNAL 05/01/95 J2260 J2260 J2260 028 0636 5012
13723834 MILRINONE 20 MG/100 ML D5W, RT EXTERNAL 01/31/05 J2260 J2260 J2260 028 0251 5012
13723835 MILRINONE 6 MG FOR 30 ML IV EXTERNAL 04/03/08 028 0251 5012
13723842 MINERAL OIL 10ML EXTERNAL 10/08/01 028 0251 5012
13723843 MINERAL OIL 15ML EXTERNAL 10/08/01 028 0251 5012
13723850 MINERAL OIL 480ML BTL EXTERNAL 07/01/84 028 0250 5012
13723865 MINERAL OIL RETENTION ENEMA 13 EXTERNAL 03/12/96 028 0251 5012
13723871 MIRTAZAPINE 30MG EXTERNAL 11/04/99 028 0251 5012
13723872 MIRTAZAPINE 30MG TAB EXTERNAL 11/04/99 028 0251 5012
13723874 MIRTAZAPINE 15MG TAB EXTERNAL 11/04/99 028 0251 5012
13723875 MIRTAZAPINE 15MG EXTERNAL 11/04/99 028 0251 5012
13723876 MIRTAZAPINE 7.5 MG TAB EXTERNAL 01/29/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 251
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13723877 MINOXIDIL 2.5 MG TAB EXTERNAL 07/23/03 028 0251 5012
13723878 MINOXIDIL 10 MG TAB EXTERNAL 07/23/03 028 0251 5012
13723879 MINOXIDIL 5 MG (2.5 MG X 2) TA EXTERNAL 02/14/08 028 0251 5012
13723880 MINERAL OIL STERILE 10ML VIAL EXTERNAL 01/01/95 028 0250 5012
13723896 MINOCYCLINE 50MG CAP EXTERNAL 01/01/95 028 0251 5012
13723897 MINOCYCLINE 50MG CAP UD - 100/ EXTERNAL 07/29/92 028 0251 5012
13723900 MINOCYCLINE 100MG CAP EXTERNAL 01/01/95 028 0250 5012
13723901 MINOCYCLINE 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723921 MISOPROSTOL 200MCG TAB EXTERNAL 01/01/95 028 0251 5012
13723922 MISOPROSTOL 200MCG TAB - 1 BOX EXTERNAL 03/26/90 028 0251 5012
13723926 MITOXANTRONE INJECTION 5MG VIA EXTERNAL 08/05/88 J9293 J9293 028 0636 5012
13723927 MITOXANTRONE 2MG/ML INJ EXTERNAL 08/05/88 J9293 J9293 028 0636 5012
13723930 MITOMYCIN 0.5MG/ML INJ EXTERNAL 01/01/95 J9280 J9280 028 0636 5012
13723935 MITOMYCIN INJECTION 20MG VIAL EXTERNAL 01/01/95 J9290 J9290 J9290 028 0636 5012
13723936 MODAFINAL 100 MG TAB EXTERNAL 05/12/03 028 0251 5012
13723939 MODAFINAL 200 MG TAB EXTERNAL 05/12/03 028 0251 5012
13723940 MODURETIC 5/50 - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13723947 MORPHINE PF 1MG/2ML INJ EXTERNAL 01/01/95 J2275 J2275 J2275 028 0636 5012
13723950 MORPHINE 30MG/1.5 ML ORAL LIQ EXTERNAL 01/01/95 028 0251 5012
13723952 MORPHINE 10MG/0.5ML ORAL LIQ EXTERNAL 01/01/95 028 0251 5012
13723953 MORPHINE 15MG/0.75ML ORAL LIQ EXTERNAL 06/27/01 028 0251 5012
13723955 MORPHINE PF 5MG/10ML EXTERNAL 01/31/05 J2275 J2275 J2275 028 0251 5012
13723962 MORPHINE 1MG ORAL DOSE EXTERNAL 10/09/01 028 0251 5012
13723963 MORPHINE 2.5MG/0.125ML ORAL LI EXTERNAL 10/09/01 028 0251 5012
13723964 MORPHINE 5MG/0.25 ML ORAL LIQ EXTERNAL 10/09/01 028 0251 5012
13723969 MORPHINE 60MG SR TAB EXTERNAL 01/01/95 028 0251 5012
13723971 MORPHINE 15MG/ML INJ 20 ML EXTERNAL 01/01/95 J2271 J2271 028 0636 5012
13723972 MORPHINE SR 60MG - 1 BOTTLE EXTERNAL 07/15/88 028 0251 5012
13723973 MORPHINE 30MG SR TAB EXTERNAL 01/01/95 028 0250 5012
13723976 MORPHINE 30MG SR - (250/BLT) EXTERNAL 08/30/91 028 0251 5012
13723979 MORPHINE 20MG SUPPOSITORY-1 BO EXTERNAL 01/25/95 028 0251 5012
13723983 MORPHINE 10MG SUPPOSITORY-1 BO EXTERNAL 01/25/95 028 0251 5012
13723984 MORPHINE 5MG SUPPOSITORY-1 BO EXTERNAL 01/25/95 028 0251 5012
13723985 MORPHINE SULFATE IR 15MG - 1 B EXTERNAL 03/22/91 028 0251 5012
13723986 MORPHINE 15MG TAB EXTERNAL 01/01/95 028 0250 5012
13723987 MORPHINE 3 MG FOR 30 ML IV EXTERNAL 11/25/08 028 0258 5012
13723988 MORPHINE SULFATE IR 30MG - 1 B EXTERNAL 03/22/91 028 0251 5012
13723989 MORPHINE 30MG TAB EXTERNAL 01/01/95 028 0251 5012
13723990 MORPHINE 15MG SR TAB EXTERNAL 08/28/01 028 0251 5012
13723991 MORPHINE 100MG SR TAB EXTERNAL 08/28/01 028 0251 5012
13723992 MORPHINE 7MG ORAL DOSE EXTERNAL 10/09/01 028 0251 5012
13723993 MORPHINE 9MG ORAL DOSE EXTERNAL 10/09/01 028 0251 5012
13723994 MORPHINE 3MG ORAL DOSE EXTERNAL 10/09/01 028 0251 5012
13723996 MORPHINE 0.2 MG/0.1 ML ORAL SO EXTERNAL 06/07/01 028 0251 5012
13723997 MORPHINE 6 MG FOR 30 ML IV EXTERNAL 11/25/08 028 0258 5012
13724000 MORPHINE 2 MG/1 ML ORAL SOLN EXTERNAL 06/07/01 028 0251 5012
13724001 MORPHINE 6 MG/0.3 ML ORAL SOLN EXTERNAL 06/07/01 028 0251 5012
13724002 MORPHINE 5 MG/2.5 ML ORAL SOLN EXTERNAL 06/07/01 028 0251 5012
13724005 MORPHINE 1MG INJ EXTERNAL 01/01/95 J2270 J2270 028 0636 5012
13724006 MORPHINE 7.5 MG 1/2 TABLET IR EXTERNAL 10/09/01 028 0251 5012
13724007 MORPHINE 2 MG INJ SYRINGE EXTERNAL 01/31/05 J2270 J2270 028 0636 5012
13724008 MORPHINE 4MG INJ SYR EXTERNAL 01/01/95 J2270 J2270 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 252
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13724009 MORPHINE 2 MG/ML PEDS INJ EXTERNAL 01/31/05 J2270 J2270 028 0636 5012
13724010 MORPHINE 8MG INJ SYR EXTERNAL 01/01/95 J2270 J2270 028 0636 5012
13724011 MORPHINE 1MG/ML 1:2 DILUTION EXTERNAL 11/20/06 J2270 J2270 J2270 028 0251 5012
13724020 MORPHINE 10MG INJ SYR EXTERNAL 01/01/95 J2270 J2270 028 0636 5012
13724022 MORPHINE CLINICIAN DOSE FOR P EXTERNAL 07/22/09 028 0251 5012
13724032 MORPHINE INJECTION 5MG AMP (N EXTERNAL 01/01/95 J2270 J2270 028 0636 5012
13724039 MULTI-VITAMIN - 1 BOX EXTERNAL 05/25/89 028 0251 5012
13724050 MUMPS SKIN TEST ANTIGEN INJ EXTERNAL 01/01/95 028 0250 5012
13724055 PHENOBARBITAL 1.5MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724056 PHENOBARBITAL 2.0MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724057 PHENOBARBITAL 2.5MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724058 PHENOBARBITAL 3.0MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724059 PHENOBARBITAL 3.5MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724061 PHENOBARBITAL 5.0MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724062 PHENOBARBITAL 6.0MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724063 PHENOBARBITAL 7.0MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724064 PHENOBARBITAL 8.0MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724065 PHENOBARBITAL 10MG ELIXIR EXTERNAL 03/14/95 028 0251 5012
13724066 PHENOBARBITAL 12.0MG ELIXIR EXTERNAL 03/26/02 028 0251 5012
13724067 PHENOBARBITAL ELIXIR 100MG EXTERNAL 10/08/01 028 0251 5012
13724068 PHENOBARBITAL ELIXIR 200MG EXTERNAL 10/08/01 028 0251 5012
13724073 PHENOBARBITAL 4.5MG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13724075 PHENOBARBITAL 7.5MG ELIXER EXTERNAL 12/19/01 028 0251 5012
13724078 PHENOBARBITAL 16MG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13724080 MVI-12 INJECTION 10ML VIAL EXTERNAL 01/01/95 028 0251 5012
13724086 PHENOBARBITAL 85MG ELIXIR EXTERNAL 12/19/01 028 0251 5012
13724087 PHENOBARBITAL 97.2 MG TAB EXTERNAL 10/24/00 028 0251 5012
13724090 NYSTATIN-TRIAMCINOLONE II OINT EXTERNAL 01/01/95 028 0250 5012
13724091 MYCOPHENOLATE MOFETIL 500MG EXTERNAL 02/14/08 028 0251 5012
13724092 MYCOPHENOLATE MOFETIL 250MG CA EXTERNAL 12/18/01 J7517 J7517 J7517 028 0636 5012
13724093 MYCOPHENOLATE MOFETIL 250MG EXTERNAL 12/18/01 J7517 J7517 J7517 028 0636 5012
13724094 MYCOPHENOLATE 250MG TAB EXTERNAL 08/12/02 J7517 J7517 028 0636 5012
13724095 MYCOPHENOLATE ORAL SUSPENSION EXTERNAL 12/18/01 J7517 J7517 028 0636 5012
13724096 MYCOPHENOLATE 500 MG SUSP EXTERNAL 08/30/06 J7517 J7517 J7517 028 0251 5012
13724097 MYCOPHENOLATE 1000 MG SUSP EXTERNAL 08/30/06 J7517 J7517 J7517 028 0251 5012
13724098 MYCOPHENOLATE 250 MG SUSP EXTERNAL 08/31/06 J7517 J7517 J7517 028 0251 5012
13724099 MYCOPHENOLATE MOFETIL 1000MG ( EXTERNAL 02/14/08 028 0251 5012
13724100 NYSTATIN-TRIAMCINOLONE II CREA EXTERNAL 01/01/95 028 0250 5012
13724101 MYCOPHENOLATE MOFETIL 1500MG ( EXTERNAL 02/14/08 028 0251 5012
13724102 MYCOPHENOLIC ACID 180 MG (MYFO EXTERNAL 06/29/10 028 0251 5012
13724103 MYCOPHENOLIC ACID 360 MG (MYFO EXTERNAL 06/29/10 028 0251 5012
13724106 RIFABUTIN 150MG CAP EXTERNAL 01/01/95 028 0251 5012
13724110 MYLANTA DS 360ML SUSP EXTERNAL 07/01/84 028 0251 5012
13724112 MYLANTA DS 360ML ORAL SUSP (EX EXTERNAL 10/03/00 028 0251 5012
13724120 MYLANTA I SUSP 15ML EXTERNAL 01/01/95 028 0250 5012
13724121 MYLANTA DS 30ML SUSP EXTERNAL 01/01/95 028 0250 5012
13724122 MYLANTA DS 15ML SUSP EXTERNAL 08/31/06 028 0251 5012
13724124 NEFAZODONE 300MG (100 MG X 3) EXTERNAL 10/09/00 028 0251 5012
13724125 NEFAZODONE 50MG EXTERNAL 11/04/99 028 0251 5012
13724126 NEFAZODONE 50MG TAB EXTERNAL 11/04/99 028 0251 5012
13724127 NEFAZODONE 200MG (100 MG X 2) EXTERNAL 11/04/99 028 0251 5012
13724128 NEFAZODONE 100MG TAB EXTERNAL 11/04/99 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 253
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13724129 NESIRITIDE 0.1MG INJ EXTERNAL 05/28/02 J2325 J2325 J2325 028 0636 5012
13724130 NESIRITIDE 0.3MG/ML INJ EXTERNAL 02/03/05 J2325 J2325 J2325 028 0636 5012
13724131 NESIRITIDE 6 MCG/ML FROM BAG F EXTERNAL 02/03/05 J2325 J2325 J2325 028 0636 5012
13724149 NELFINAVIR 1250 MG (250 MG X 5 EXTERNAL 02/03/05 028 0251 5012
13724151 NELFINAVIR 250MG TAB BULK EXTERNAL 02/04/98 028 0251 5012
13724152 NELFINAVIR 250MG TAB EXTERNAL 02/04/98 028 0251 5012
13724155 NEVIRAPINE 200MG EXTERNAL 02/05/98 028 0251 5012
13724156 NEVIRAPINE 200MG TAB EXTERNAL 02/05/98 028 0251 5012
13724158 NEVIRAPINE ORAL SUSPENSION 200 EXTERNAL 11/05/01 028 0251 5012
13724159 NEVIRAPINE 10MG/ML ORAL SUSP EXTERNAL 03/14/02 028 0251 5012
13724160 NAFCILLIN 0.25 GM/ML INJ EXTERNAL 01/01/95 028 0251 5012
13724161 NAFCILLIN 1GM/D5W 50ML EXTERNAL 01/01/95 028 0251 5012
13724162 NAFCILLIN 1GM/D5W 50ML BAG EXTERNAL 01/01/95 028 0251 5012
13724166 NEVIRAPINE 10 MG/ML 240 ML ORA EXTERNAL 04/20/07 028 0251 5012
13724170 NAFCILLIN INJECTION 2GM VIAL EXTERNAL 01/01/95 028 0250 5012
13724172 NAFCILLIN 2GM/D5W 100ML BAG EXTERNAL 01/01/95 028 0251 5012
13724175 NAFCILLIN INJECTION 10GM VIAL EXTERNAL 07/01/84 028 0250 5012
13724178 NAFCILLIN 500MG/D5W 50ML EXTERNAL 03/12/96 028 0258 5012
13724181 NANDROLONE 100 MG/ML INJ EXTERNAL 05/12/03 J2321 J2321 J2321 028 0258 5012
13724182 NIACIN 500MG TAB - 100/BTL EXTERNAL 09/04/92 028 0251 5012
13724183 NIACIN 500MG TAB EXTERNAL 01/01/95 028 0251 5012
13724185 NIACIN 100MG TAB EXTERNAL 01/01/95 028 0251 5012
13724186 NIACIN 100MG TAB UD - 100/PACK EXTERNAL 09/04/92 028 0251 5012
13724190 NALOXONE 0.4MG INJ AMP EXTERNAL 01/01/95 J2310 J2310 028 0636 5012
13724191 NALOXONE INJECTION 0.4MG SYRIN EXTERNAL 01/01/95 J2310 J2310 028 0636 5012
13724201 NALOXONE 1MG/ML INJ AMP EXTERNAL 01/01/95 J2310 J2310 J2310 028 0251 5012
13724203 NALOXONE 4 MG FOR 500 ML LVP EXTERNAL 11/19/08 028 0258 5012
13724225 NAPHAZOLINE-PHENIRAMINE OPHTH EXTERNAL 01/01/95 028 0250 5012
13724231 NAPROXEN 500MG TAB UD 100/BOX EXTERNAL 10/16/92 028 0251 5012
13724233 NAPROXEN 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13724234 NAPROXEN 375MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13724235 NAPROXEN 250MG TAB EXTERNAL 01/01/95 028 0250 5012
13724237 NAPROXEN 375MG TAB EXTERNAL 01/01/95 028 0250 5012
13724238 NAPROXEN 500MG TAB EXTERNAL 01/01/95 028 0250 5012
13724240 NATEGLINIDE 60 MG TABLET EXTERNAL 11/17/05 028 0251 5012
13724241 NATEGLINIDE 120 MG TABLET EXTERNAL 11/17/05 028 0251 5012
13724242 NAPROXEN 125MG (1/2 X 250MG) T EXTERNAL 07/20/06 028 0251 5012
13724243 NATEGLINIDE 30 MG (1/2 X 60 MG EXTERNAL 07/20/06 028 0251 5012
13724270 EPOETIN ALPHA 9000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13724271 EPOETIN ALPHA 8000 UNITS INJ EXTERNAL 01/01/06 Q4081 Q4081 Q4081 028 0636 5012
13724272 EPOETIN ALPHA 12,000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0635 5012
13724273 EPOETIN ALPHA 13,000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0635 5012
13724275 EPOETIN ALPHA 20,000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13724276 EPOETIN ALPHA 3000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13724277 EPOETIN ALPHA 4000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13724278 EPOETIN ALPHA 6000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0636 5012
13724279 EPOETIN ALPHA 7000 UNITS INJ EXTERNAL 01/01/08 Q4081 Q4081 Q4081 028 0634 5012
13724281 NALBUPHINE 10MG/ML INJ AMP EXTERNAL 01/01/95 J2300 J2300 J2300 028 0636 5012
13724282 NALBUPHINE INJECTION 10MG VIAL EXTERNAL 01/01/95 J2300 J2300 028 0636 5012
13724283 NALBUPHINE 10MG/0.5ML INJ AMP EXTERNAL 11/29/94 J2300 J2300 028 0636 5012
13724284 NALBUPHINE 10MG/ML AMP EXTERNAL 01/31/05 J2300 J2300 J2300 028 0258 5012
13724300 NEOMYCIN SULFATE 0.5% OINT EXTERNAL 01/01/95 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 254
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13724311 NEOMYCIN 25MG/ML ORAL SOLN EXTERNAL 01/01/95 028 0250 5012
13724312 NEOMYCIN 62.5MG ORAL SOLN EXTERNAL 05/16/02 028 0251 5012
13724319 NEOMYCIN SULFATE 1000MG (500 M EXTERNAL 02/14/08 028 0251 5012
13724320 NEOMYCIN SULFATE 500MG TAB EXTERNAL 01/01/95 028 0250 5012
13724321 NEOMYCIN SULFATE 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13724325 NEOMYCIN ORAL SOLUTION 480ML B EXTERNAL 07/01/84 028 0250 5012
13724331 NEOMYCIN SULFATE 1GM ENEMA EXTERNAL 07/01/84 028 0250 5012
13724360 BACITRACIN-NEOMYCIN-POLYMYXIN EXTERNAL 01/01/95 028 0250 5012
13724390 BACITRACIN-NEO-POLYMYXIN B OPH EXTERNAL 01/01/95 028 0250 5012
13724410 NEOMYCIN-POLYMYXIN B GU IRRIGA EXTERNAL 01/01/95 028 0250 5012
13724422 NIACIN EXT REL 375/500/1000 MG EXTERNAL 01/12/99 028 0251 5012
13724423 NIACIN 500MG SR TAB EXTERNAL 06/01/00 028 0251 5012
13724424 NIACIN 750MG SR TAB EXTERNAL 06/01/00 028 0251 5012
13724430 NEOSTIGMINE BR TAB 15MG EXTERNAL 01/01/95 028 0250 5012
13724431 NEOSTIGMINE BROMIDE 15MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13724460 NEOSTIGMINE 1MG/ML INJ EXTERNAL 01/01/95 J2710 J2710 028 0636 5012
13724465 NEOSTIGMINE METHYLSULFATE .5MG EXTERNAL 01/01/95 028 0250 5012
13724472 NEPHRO-VITE RX - 100/BTL EXTERNAL 01/25/92 028 0251 5012
13724473 MULTIVITAMIN RENAL TAB EXTERNAL 01/01/95 028 0251 5012
13724481 NICARDIPINE 2.5MG/ML INJ 10ML EXTERNAL 11/15/94 028 0636 5012
13724484 NICARDIPINE 50 MG FOR 100 ML L EXTERNAL 06/28/01 028 0258 5012
13724533 NICOTINE 21MG TRANSDERMAL PATC EXTERNAL 03/10/95 028 0251 5012
13724534 NICOTINE 21MG PATCH (BOX) EXTERNAL 03/10/95 028 0251 5012
13724535 NICOTINE 14MG TRANSDERMAL PATC EXTERNAL 03/07/95 028 0251 5012
13724536 NICOTINE 14MG PATCH EXTERNAL 03/13/95 028 0251 5012
13724537 NICOTINE 7MG TRANSDERMAL PATCH EXTERNAL 03/13/95 028 0251 5012
13724546 NIFEDIPINE 10MG CAP EXTERNAL 01/01/95 028 0250 5012
13724547 NIFEDIPINE 10MG - 1 BOX EXTERNAL 01/01/87 028 0250 5012
13724548 NIFEDIPINE 20MG - 1 BOX EXTERNAL 01/01/87 028 0250 5012
13724549 NIFEDIPINE 20MG CAP EXTERNAL 01/01/95 028 0250 5012
13724551 NIFEDIPINE 30MG TAB XL U.D. EXTERNAL 01/04/93 028 0251 5012
13724552 NIFEDIPINE XL 30MG - 1 TABLET EXTERNAL 01/01/95 028 0251 5012
13724554 NIFEDIPINE 60MG TAB XL U.D. EXTERNAL 01/04/93 028 0251 5012
13724555 NIFEDIPINE XL 60MG - 1 TABLET EXTERNAL 01/01/95 028 0251 5012
13724559 NIFEDIPINE XL 90MG - BOX EXTERNAL 02/17/94 028 0251 5012
13724570 NIMODIPINE 30MG CAP EXTERNAL 01/01/95 028 0251 5012
13724571 NIMODIPINE 30MG - 1 BOX EXTERNAL 01/12/90 028 0251 5012
13724572 NIMODIPINE 60MG ( 30MG X 2) CA EXTERNAL 01/01/95 028 0251 5012
13724585 NIFEDIPINE 30MG ER TAB EXTERNAL 01/01/95 028 0251 5012
13724586 NIFEDIPINE ER 30MG TAB (ADALAT EXTERNAL 11/16/94 028 0251 5012
13724588 NIFEDIPINE 60MG ER TAB EXTERNAL 01/01/95 028 0251 5012
13724589 NIFEDIPINE ER 60MG TAB (ADALAT EXTERNAL 11/16/94 028 0251 5012
13724590 NIFEDIPINE ER 60MG (ADALAT CC- EXTERNAL 11/16/94 028 0251 5012
13724591 NIFEDIPINE 90MG ER TAB EXTERNAL 01/01/95 028 0251 5012
13724592 NIFEDIPINE ER 90MG TAB (ADALAT EXTERNAL 11/16/94 028 0251 5012
13724594 NIFEDIPINE 1 MG/ML ORAL SOLUTI EXTERNAL 07/26/04 028 0251 5012
13724595 NITRIC OXIDE GAS EXTERNAL 08/04/00 J3490 J3490 J3490 028 0636 5012
13724640 NITROFURANTOIN 25MG SUSP EXTERNAL 01/01/95 028 0250 5012
13724676 NITROGLYCERIN 1MG SR - 1 BTL EXTERNAL 01/01/95 028 0251 5012
13724678 NITROGLYCERIN 2MG SR - 1 BOTTL EXTERNAL 01/01/95 028 0251 5012
13724679 NITROGLYCERIN 0.1MG/HR PATCH EXTERNAL 07/01/84 028 0250 5012
13724680 NITROGLYCERIN 0.2MG/HR PATCH EXTERNAL 07/01/84 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 255
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13724681 NITROGLYCERIN 0.4MG/HR PATCH EXTERNAL 07/01/84 028 0250 5012
13724684 NITROGLYCERIN 0.3MG/HR PATCH EXTERNAL 09/02/88 028 0251 5012
13724685 NITROGLYCERIN 25MG/BTL 250ML EXTERNAL 02/15/91 028 0251 5012
13724686 NITROGLYCERIN 50MG/250ML BTL EXTERNAL 02/15/91 028 0251 5012
13724694 NITROGLYCERIN 5MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13724695 NITROGLYCERIN INJECTION 50MG V EXTERNAL 01/01/95 028 0250 5012
13724700 NITROGLYCERIN 2% OINT 30GM EXTERNAL 01/01/95 028 0250 5012
13724705 NITROGLYCERIN 2% OINT 60GM EXTERNAL 01/01/95 028 0250 5012
13724706 NITROGLYCERIN OINT PACKETS - 1 EXTERNAL 07/01/84 028 0250 5012
13724707 NITROGLYCERIN 2% OINT PKT EXTERNAL 02/29/96 028 0251 5012
13724720 NITROGLYCERIN 0.4MG SL TAB BTL EXTERNAL 01/01/95 028 0250 5012
13724721 NITROGLYCERIN 0.3MG SL TAB BTL EXTERNAL 02/14/08 028 0251 5012
13724725 NITROGLYCERIN .4MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13724863 NORTRIPTYLINE 75MG BOX EXTERNAL 04/05/96 028 0251 5012
13724866 NORTRIPTYLINE 25MG CAP EXTERNAL 01/01/95 028 0250 5012
13724867 NORTRIPTYLINE 75MG CAP EXTERNAL 01/01/95 028 0250 5012
13724868 NORTRIPTYLINE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13724910 NYSTATIN CREAM 15GM EXTERNAL 01/01/95 028 0250 5012
13724920 NYSTATIN POWDER 15GM EXTERNAL 01/01/95 028 0250 5012
13724930 NYSTATIN 15GM OINT EXTERNAL 01/01/95 028 0250 5012
13724935 NYSTATIN SUSPENSION 480ML BOTT EXTERNAL 07/01/84 028 0250 5012
13724936 NYSTATIN 1,000,000 UNITS POPSI EXTERNAL 01/01/95 028 0250 5012
13724938 NYSTATIN 10ML ORAL SUSP EXTERNAL 01/01/95 028 0251 5012
13724941 NYSTATIN 1ML ORAL SUSP EXTERNAL 01/01/95 028 0250 5012
13724942 NYSTATIN 5ML ORAL SUSP EXTERNAL 01/01/95 028 0250 5012
13724943 NYSTATIN SUSPENSION 0.5ML DOSE EXTERNAL 10/08/01 028 0251 5012
13724944 NYSTATIN SUSPENSION 2ML DOSE EXTERNAL 10/08/01 028 0251 5012
13724980 NYSTATIN 100,000 UNITS - 1 BOX EXTERNAL 07/01/84 028 0250 5012
13724999 OCTREOTIDE 5 MCG/ML PEDS INJ EXTERNAL 10/09/00 J2354 J2354 028 0636 5012
13725000 OATMEAL COLLOIDAL PKT EXTERNAL 01/01/95 028 0250 5012
13725003 OCTREOTIDE 100MCG/ML INJ EXTERNAL 03/20/97 J2354 J2354 028 0636 5012
13725006 OCTREOTIDE 500MCG/ML INJ EXTERNAL 07/23/01 J2354 J2354 028 0636 5012
13725007 OCTREOTIDE 25MCG/ML PEDS INJ EXTERNAL 04/23/02 J2354 J2354 028 0636 5012
13725008 OCTREOTIDE 75 MCG INJ EXTERNAL 10/09/00 J2354 J2354 028 0636 5012
13725009 OCTREOTIDE 150 MCG INJ EXTERNAL 10/09/00 J2354 J2354 028 0636 5012
13725011 OCTREOTIDE 50MCG/ML INJ EXTERNAL 01/01/95 J2354 J2354 028 0636 5012
13725013 OMEPRAZOLE 10MG CAPSULE - BULK EXTERNAL 07/10/96 028 0251 5012
13725018 OMEPRAZOLE 20MG - 1 BTL(30) EXTERNAL 01/23/90 028 0251 5012
13725021 SURG ONC MOUTHWASH 120ML EXTERNAL 04/16/87 028 0250 5012
13725025 ONDANSETRON 1MG EXTERNAL 01/01/95 J2405 J2405 028 0636 5012
13725026 ONDANSETRON INJ***MG EXTERNAL 01/01/95 J2405 J2405 J2405 028 0636 5012
13725037 ONDANSETRON 4MG/5ML ORAL SOLN EXTERNAL 09/30/98 Q0179 Q0179 028 0636 5012
13725039 ONDANSETRON 24MG TAB EXTERNAL 06/25/02 Q0179 Q0179 028 0636 5012
13725041 OFLOXACIN 0.3% OPHTH SOLN 5ML EXTERNAL 09/24/97 028 0251 5012
13725042 OFLOXACIN 0.3% OTIC SOLN 5ML EXTERNAL 07/25/02 028 0251 5012
13725043 ONDANSETRON 4MG/2ML VIAL EXTERNAL 09/10/02 J2405 J2405 028 0636 5012
13725045 ONDANSETRON 8MG/D5W 50 ML EXTERNAL 09/10/02 J2405 J2405 028 0636 5012
13725046 ONDANSETRON 32 MG/D5W 50 ML EXTERNAL 12/17/04 J2405 J2405 028 0636 5012
13725047 ONDANSETRON 8MG ORAL DISSOLVIN EXTERNAL 04/21/06 Q0179 Q0179 Q0179 028 0636 5012
13725048 ONDANSETRON 24MG (8MGX3) ODT EXTERNAL 04/21/06 Q0179 Q0179 Q0179 028 0251 5012
13725049 ONDANSETRON 8 MG (BOX 30'S) EXTERNAL 06/02/06 028 0251 5012
13725052 ONDANSETRON 4 MG (BOX 30'S) EXTERNAL 06/02/06 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 256
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13725053 ONDANSETRON 2MG/ML INJ EXTERNAL 04/03/08 028 0258 5012
13725054 ONDANSETRON 2MG/ML VIAL EXTERNAL 04/03/08 028 0258 5012
13725055 ONDANSETRON 2MG/2.5ML ORAL SOL EXTERNAL 01/31/07 Q0179 Q0179 Q0179 028 0251 5012
13725059 BELLADONNA-OPIUM SUPP 1/2 SUPP EXTERNAL 12/28/04 028 0251 5012
13725060 BELLADONNA-OPIUM SUPP EXTERNAL 01/01/95 028 0250 5012
13725061 OPIUM/BELLADONNA - 1 BOX(12) EXTERNAL 01/25/95 028 0251 5012
13725066 OPIUM TINCTURE EXTERNAL 05/12/03 028 0251 5012
13725074 ETH EST & NORETH (ORTHO-NOVUM EXTERNAL 01/01/95 028 0250 5012
13725076 OLANZAPINE 10MG TABLET- 1 BOTT EXTERNAL 12/22/97 028 0251 5012
13725080 OLANZAPINE 7.5MG TABLET- 1 BOT EXTERNAL 12/22/97 028 0251 5012
13725081 OLANZAPINE 7.5MG TAB EXTERNAL 12/22/97 028 0251 5012
13725084 OLANZAPINE 5MG TABLET- 1 BOTTL EXTERNAL 12/22/97 028 0251 5012
13725085 OLANZAPINE 5MG TAB EXTERNAL 12/22/97 028 0251 5012
13725088 OLANZAPINE 2.5MG TABLET- 1 BOT EXTERNAL 12/22/97 028 0251 5012
13725089 OLANZAPINE 2.5MG TAB EXTERNAL 12/22/97 028 0251 5012
13725090 OVRAL-28 TABS EXTERNAL 01/01/95 028 0250 5012
13725091 OLANZAPINE 10MG TAB EXTERNAL 12/22/97 028 0251 5012
13725092 OLANZAPINE 15 MG (5 MG X 3) TA EXTERNAL 02/14/08 028 0251 5012
13725093 OLANZAPINE 20MG TAB (10 MG X 2 EXTERNAL 01/26/09 028 0251 5012
13725099 ETH EST & NORGESTIMATE (SPRINT EXTERNAL 06/15/09 028 0251 5012
13725101 ETH EST & NORGES (ORTHO TRICYC EXTERNAL 06/02/06 028 0251 5012
13725102 ORTHO EVRA PATCH EXTERNAL 06/02/06 028 0251 5012
13725103 ETH EST & ETONOG (NUVARING) EXTERNAL 06/02/06 028 0251 5012
13725106 ORTHO EVRA PATCH BOX OF 18 EXTERNAL 06/12/06 028 0251 5012
13725108 OSELTAMIVIR 75 MG CAPSULE -FRE EXTERNAL 04/30/09 028 0251 5012
13725109 OSELTAMIVIR 12 MG/ML ORAL LIQU EXTERNAL 04/30/09 028 0251 5012
13725111 OSELTAMIVIR 45 MG CAPSULE EXTERNAL 04/30/09 028 0251 5012
13725112 OSELTAMIVIR 30 MG CAPSULE EXTERNAL 04/30/09 028 0251 5012
13725115 OSELTAMIVIR 75 MG CAPSULE -UIM EXTERNAL 10/27/09 028 0251 5012
13725117 OSELTAMIVIR 30 MG CAPSULE -UIM EXTERNAL 11/19/09 401200 028 0251 5012
13725118 OSELTAMIVIR 45MG CAP -UIMC STO EXTERNAL 11/19/09 028 0251 5012
13725130 DICLOXACILLIN 250MG CAP EXTERNAL 01/01/95 028 0250 5012
13725150 DICLOXACILLIN 500MG CAP EXTERNAL 01/01/95 028 0250 5012
13725160 DICLOXACILLIN SUSPENSION 100ML EXTERNAL 07/01/84 028 0250 5012
13725161 DICLOXACILLIN 12.5MG/ML SUSP EXTERNAL 01/01/95 028 0250 5012
13725170 DICLOXACILLIN 250MG SUSP EXTERNAL 01/01/95 028 0250 5012
13725209 OXCARBAZEPINE 300MG/5ML ORAL S EXTERNAL 10/21/09 028 0251 5012
13725210 OXCARBAZEPINE 600 MG (300 MG X EXTERNAL 02/09/05 028 0251 5012
13725211 OXCARBAZEPINE 75 MG (1/2 X 150 EXTERNAL 07/20/06 028 0251 5012
13725212 OXCARBAZEPINE (TRILEPTAL) 150 EXTERNAL 07/22/04 028 0251 5012
13725213 OXCARBAZEPINE (TRILEPTAL) 300 EXTERNAL 07/22/04 028 0251 5012
13725214 OXYBUTYNIN SYRUP 1MG/ML EXTERNAL 03/14/02 028 0251 5012
13725216 OXYBUTYNIN 5MG - BOX EXTERNAL 01/25/95 028 0251 5012
13725217 OXYBUTYNIN 5MG TAB EXTERNAL 01/01/95 028 0250 5012
13725218 OXYBUTYNIN 2.5MG (1/2 X 5MG) T EXTERNAL 01/01/95 028 0251 5012
13725219 OXYBUTYNIN SYRUP 5MG DOSE EXTERNAL 11/15/01 028 0251 5012
13725225 OXANDROLONE 2.5 MG TAB EXTERNAL 06/07/01 028 0251 5012
13725226 OXAZEPAM 10 MG TAB EXTERNAL 06/07/01 028 0251 5012
13725227 OXAZEPAM 30 MG TAB EXTERNAL 06/07/01 028 0251 5012
13725228 OXYCODONE IR 5 MG CAP EXTERNAL 06/07/01 028 0251 5012
13725229 OXYCODONE SR 10 MG TAB EXTERNAL 06/07/01 028 0251 5012
13725230 OXYCODONE SR 20 MG TAB EXTERNAL 06/07/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 257
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13725231 OXYCODONE SR 40 MG TAB EXTERNAL 06/07/01 028 0251 5012
13725232 OXYCODONE SR 80 MG TAB EXTERNAL 06/07/01 028 0251 5012
13725290 OXYMETAZOLINE NASAL SPRAY 15ML EXTERNAL 01/01/95 028 0250 5012
13725300 OXYTOCIN INJECTION 10UNIT AMPU EXTERNAL 01/01/95 J2590 J2590 028 0636 5012
13725304 PANCREALIPASE MT-10 CAP EXTERNAL 01/01/95 028 0251 5012
13725306 OXYTOCIN INJ 10UNITS/ML EXTERNAL 06/29/93 J2590 J2590 028 0636 5012
13725307 OXYTOCIN 10U/ 0.45% NS 167ML EXTERNAL 09/09/96 J2590 J2590 028 0636 5012
13725308 OXYTOCIN 30 UNITS INJ EXTERNAL 10/28/03 J2590 J2590 028 0636 5012
13725310 PAMIDRONATE 30MG INJ EXTERNAL 06/08/93 J2430 J2430 J2430 028 0636 5012
13725313 PAMIDRONATE 30MG INJ EXTERNAL 01/06/96 J2430 J2430 J2430 028 0636 5012
13725314 PAMIDRONATE 60MG IVPB EXTERNAL 07/22/09 028 0251 5012
13725315 PACLITAXEL 6MG/ML INJ EXTERNAL 01/01/95 J9265 J9265 J9265 028 0636 5012
13725318 PANCREASE MT-16 CAP EXTERNAL 02/08/01 028 0251 5012
13725321 PANCRELIPASE 325MG - 1 BOTTLE( EXTERNAL 01/25/95 028 0251 5012
13725326 PANCRELIPASE MT-4 CAP EXTERNAL 01/01/95 028 0251 5012
13725327 PANCRELIPASE MT-4 - 1 BOTTLE EXTERNAL 09/09/88 028 0251 5012
13725329 ZENPEP CAP 5000 UNITS EXTERNAL 07/21/10 028 0251 5012
13725332 ZENPEP CAP 10000 UNITS EXTERNAL 07/21/10 028 0251 5012
13725333 ZENPEP CAP 15000 UNITS EXTERNAL 07/21/10 028 0251 5012
13725342 PANCRELIPASE ENTERIC COATED - EXTERNAL 01/25/95 028 0251 5012
13725350 PALIVIZUMAB 100MG/ML INJ EXTERNAL 01/01/03 028 0251 5012
13725352 PALIVIZUMAB 100MG/ML INJ EXTERNAL 01/01/03 90378 90378 90378 028 0258 5012
13725360 PANCURONIUM BROMIDE INJ 4MG V EXTERNAL 01/01/95 028 0250 5012
13725370 PANCURONIUM 2MG/ML INJ EXTERNAL 12/01/93 028 0250 5012
13725371 PANCURONIUM 125MG FOR 250 ML L EXTERNAL 09/17/03 028 0258 5012
13725421 PAPAVERINE 30MG/ML 10ML INJ EXTERNAL 03/13/95 J2440 028 0636 5012
13725461 CHLORZOXAZONE 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13725462 CHLORZOXAZONE 250MG (1/2 X 500 EXTERNAL 06/19/06 028 0251 5012
13725537 PAROXETINE 20MG TAB EXTERNAL 02/14/08 028 0251 5012
13725538 PAROXETINE 40MG (20MG X 2) TAB EXTERNAL 02/14/08 028 0251 5012
13725539 PAROXETINE 10MG (PER 1/2) TAB EXTERNAL 01/01/95 028 0251 5012
13725540 PAROXETINE 20MG TABLET 100'S EXTERNAL 01/01/95 028 0251 5012
13725542 PAROXETINE 20MG TABLET 30'S EXTERNAL 01/01/95 028 0251 5012
13725543 PAROXETINE 60MG (30MG X 2) TAB EXTERNAL 06/08/93 028 0251 5012
13725544 PAROXETINE 30MG TAB 30'S EXTERNAL 06/08/93 028 0251 5012
13725545 PAROXETINE 30MG TAB EXTERNAL 01/01/95 028 0251 5012
13725546 PAROXETINE 5MG (1/2 X 10MG) TA EXTERNAL 07/20/06 028 0251 5012
13725551 PAREGORIC ELIXIR EXTERNAL 01/01/95 028 0250 5012
13725552 PAREGORIC 2MG/5ML LIQ EXTERNAL 01/01/95 028 0250 5012
13725554 PEGASPARGASE 750UNITS/ML 5ML V EXTERNAL 07/21/95 J9266 J9266 J9266 028 0636 5012
13725556 PAREGORIC BULK EXTERNAL 10/24/00 028 0251 5012
13725557 PAREGORIC 1 ML EXTERNAL 10/24/00 028 0251 5012
13725558 PAREGORIC 5 ML EXTERNAL 10/24/00 028 0251 5012
13725559 PAREGORIC 10 ML EXTERNAL 10/24/00 028 0251 5012
13725565 PEDIAZOLE SUSPENSION 100ML BOT EXTERNAL 07/01/84 028 0250 5012
13725567 PAREGORIC 2 ML EXTERNAL 11/18/05 028 0251 5012
13725568 PAREGORIC 3 ML EXTERNAL 11/18/05 028 0251 5012
13725575 BENZYLPENICILLOYL-POLYLYSINE S EXTERNAL 01/01/95 028 0250 5012
13725576 PEN G BENZ W/PROC PEN 600,000 EXTERNAL 01/01/95 J0559 J0559 J0559 028 0636 5012
13725577 PEN G BENZ W/PROCAINE PEN 1.2M EXTERNAL 01/01/95 J0559 J0559 J0559 028 0636 5012
13725578 PEN G BENZATHINE 600,000 UNITS EXTERNAL 01/01/95 J0560 J0560 028 0636 5012
13725579 PEN G BENZATHINE 1.2MU INJ EXTERNAL 01/01/95 J0570 J0580 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 258
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13725651 PENICILLIN SKIN TEST 0.1ML SYR EXTERNAL 07/01/84 028 0250 5012
13725670 PENICILLIN GK 200,000 UNITS IN EXTERNAL 01/01/95 J2540 J2540 J2540 028 0250 5012
13725680 PENICILLIN GK 500,000 UNITS/ML EXTERNAL 01/01/95 J2540 J2540 028 0636 5012
13725690 PEN G POTASSIUM 500,000 UNIT V EXTERNAL 07/01/84 J2540 J2540 J2540 028 0251 5012
13725693 PENICILLIN GK 2MU/D5W 50ML EXTERNAL 10/19/90 J2540 028 0636 5012
13725694 PENICILLIN GK 500,000 UNITS/D5 EXTERNAL 10/19/90 J2540 J2540 028 0636 5012
13725695 PENICILLIN GK 0.5MU/ML INJ EXTERNAL 01/01/87 J2540 J2540 028 0636 5012
13725697 PEN G POTASSIUM 600,000MU/D5W EXTERNAL 03/24/00 J2540 J2540 028 0636 5012
13725700 PEN G POTASSIUM 5 MILLION UNIT EXTERNAL 01/01/95 J2540 J2540 J2540 028 0258 5012
13725720 PEN G POTASSIUM 20MILLION UNIT EXTERNAL 07/01/84 J2540 J2540 J2540 028 0258 5012
13725750 PEN G PROCAINE 600,000 UNIT IN EXTERNAL 01/01/95 J2510 J2510 028 0636 5012
13725760 PEN G PROCAINE 600,000 UINTS I EXTERNAL 01/01/95 J2510 J2510 028 0636 5012
13725770 PEN G PROCAINE 2.4 MIL UNIT SY EXTERNAL 01/01/95 J2510 J2510 028 0636 5012
13725775 PEN G PROCAINE AND PROBENECID EXTERNAL 07/01/84 028 0258 5012
13725780 PEN G SODIUM 500000 UNITS/ML I EXTERNAL 01/01/95 028 0258 5012
13725781 PEN G SODIUM 1 MU/D5W 50 ML EXTERNAL 03/16/04 028 0258 5012
13725782 PEN G SODIUM 2 MU/D5W 50 ML EXTERNAL 03/16/04 028 0258 5012
13725783 PEN G SODIUM 2.5 MU/D5W 100 ML EXTERNAL 03/16/04 028 0258 5012
13725784 PEN G SODIUM 3 MU/D5W 50 ML EXTERNAL 03/16/04 028 0258 5012
13725785 PEN G SODIUM 50000 UNITS/ML IN EXTERNAL 03/16/04 028 0258 5012
13725786 PEN G SODIUM 100000 UNITS/ML I EXTERNAL 03/16/04 028 0258 5012
13725787 PEN G SODIUM 250000 UNITS/ML I EXTERNAL 03/16/04 028 0258 5012
13725790 PEN G SODIUM 0.5 MU/ML INJ EXTERNAL 01/01/95 028 0258 5012
13725830 PEN V POTASSIUM 250MG TAB EXTERNAL 01/01/95 028 0250 5012
13725831 PEN V POTASSIUM 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13725850 PEN V POTASSIUM 500MG TAB EXTERNAL 01/01/95 028 0250 5012
13725851 PEN V POTASSIUM 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13725860 PEN V POTASSIUM SUSP 100ML BOT EXTERNAL 07/01/84 028 0250 5012
13725870 PEN V POTASSIUM SUSP 200ML BOT EXTERNAL 07/01/84 028 0250 5012
13725876 PEN G SODIUM 100000 UNITS/ML I EXTERNAL 03/16/04 028 0258 5012
13725880 PEN V POTASSIUM 125MG SUSP EXTERNAL 01/01/95 028 0250 5012
13725881 PEN V POTASSIUM 500MG SUSP EXTERNAL 01/01/95 028 0250 5012
13725882 PEN V POTASSIUM 62.5MG SUSP EXTERNAL 01/01/95 028 0250 5012
13725883 PEN V POTASSIUM 12.5MG SUSP EXTERNAL 12/21/01 028 0251 5012
13725885 PEN V POTASSIUM 37.5MG SUSP EXTERNAL 12/21/01 028 0251 5012
13725886 PEN V POTASSIUM 75MG SUSP EXTERNAL 12/21/01 028 0251 5012
13725887 PEN V POTASSIUM 100MG SUSP EXTERNAL 12/21/01 028 0251 5012
13725888 PEN V POTASSIUM 150MG SUSP EXTERNAL 12/21/01 028 0251 5012
13725889 PEN V POTASSIUM 175MG SUSP EXTERNAL 12/21/01 028 0251 5012
13725890 PEN V POTASSIUM SYRUP 250MG/5M EXTERNAL 07/01/84 028 0250 5012
13725891 PEN V POTASSIUM 200MG SUSP EXTERNAL 12/21/01 028 0251 5012
13725900 PEN V POTASSIUM SUSP 200ML BOT EXTERNAL 07/01/84 028 0250 5012
13725910 PEN V POTASSIUM 250MG SUSP EXTERNAL 01/01/95 028 0250 5012
13725911 PEN V POTASSIUM 50MG/ML EXTERNAL 05/16/02 028 0251 5012
13725915 PENICILLAMINE 125MG CAP EXTERNAL 01/01/95 028 0250 5012
13725916 PENICILLAMINE 125MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13725917 PENICILLAMINE 250MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13725920 PENICILLAMINE 250MG CAP EXTERNAL 01/01/95 028 0250 5012
13725963 PENTAMIDINE INHL 50 MG/ML SOLN EXTERNAL 01/01/95 028 0258 5012
13725965 PENTAMIDINE 50 MG/ML INJ EXTERNAL 01/01/95 028 0250 5012
13726030 PENTOBARBITAL 1MG/ML INJ 1ML EXTERNAL 07/01/84 J2515 J2515 028 0636 5012
13726031 PENTOBARBITAL 500 MG FOR 500 M EXTERNAL 09/18/03 J2515 J2515 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 259
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13726053 PERFLUTREN LIPID MICROSPHERE I EXTERNAL 01/26/05 028 0258 5012
13726054 PERFLUTREN PROTEIN-TYPE A MICR EXTERNAL 01/26/05 028 0258 5012
13726058 PENTOXIFYLLINE 400MG SR TAB EXTERNAL 01/01/95 028 0250 5012
13726059 PENTOXIFYLLINE 400MG - 1 BOTTL EXTERNAL 01/25/95 028 0251 5012
13726064 PERGOLIDE 0.25MG BULK EXTERNAL 05/11/00 028 0251 5012
13726066 PERGOLIDE 1MG BULK EXTERNAL 05/11/00 028 0251 5012
13726067 PERITONEAL DIALYSIS D1.5% 200 EXTERNAL 07/29/96 028 0258 5012
13726068 PERITONEAL DIALYSIS D2.5% 200 EXTERNAL 07/31/03 028 0258 5012
13726069 PERITONEAL DIALYSIS D4.25% 20 EXTERNAL 07/31/03 028 0258 5012
13726070 PERITONEAL DIALYSIS D1.5% 500 EXTERNAL 07/31/03 028 0258 5012
13726071 PERITONEAL DIALYSIS D2.5% 500 EXTERNAL 07/31/03 028 0258 5012
13726072 PERITONEAL DIALYSIS D4.25% 50 EXTERNAL 07/31/03 028 0258 5012
13726073 PERITONEAL DIALYSIS D1.5% 600 EXTERNAL 07/31/03 028 0258 5012
13726074 PERITONEAL DIALYSIS D2.5% 600 EXTERNAL 07/31/03 028 0258 5012
13726075 PERITONEAL DIALYSIS D4.25% 60 EXTERNAL 07/31/03 028 0258 5012
13726076 PERI DIALYSIS D1.5% LOW CAL 1 EXTERNAL 07/31/03 028 0258 5012
13726077 PERI DIALYSIS D1.5% LOW CAL 2 EXTERNAL 07/31/03 028 0258 5012
13726078 PERI DIALYSIS D2.5% LOW CAL 2 EXTERNAL 07/31/03 028 0258 5012
13726079 PERI DIALYSIS D2.5% LOW CAL 1 EXTERNAL 07/31/03 028 0258 5012
13726080 PERI DIALYSIS D4.25% LOW CAL EXTERNAL 07/31/03 028 0258 5012
13726081 PERI DIALYSIS D4.25% LOW CAL EXTERNAL 07/31/03 028 0258 5012
13726082 PERITONEAL DIALYSIS 1.5% 1500M EXTERNAL 07/31/03 028 0258 5012
13726083 PERITONEAL DIALYSIS 1.5% 2000M EXTERNAL 07/31/03 028 0258 5012
13726084 PERITONEAL DIALYSIS 2.5% 1500M EXTERNAL 07/31/03 028 0258 5012
13726085 PERITONEAL DIALYSIS 2.5% 2000M EXTERNAL 07/31/03 028 0258 5012
13726086 PERITONEAL DIALYSIS 4.25% 1500 EXTERNAL 07/31/03 028 0258 5012
13726087 PERITONEAL DIALYSIS 4.25% 2000 EXTERNAL 07/31/03 028 0258 5012
13726088 PRISMASOL 0/2.5 SOLUTION EXTERNAL 05/20/09 028 0258 5012
13726089 PRISMASOL 2/3.5 SOLUTION EXTERNAL 05/20/09 028 0258 5012
13726090 PRISMASOL 4/2.5 SOLUTION EXTERNAL 05/20/09 028 0258 5012
13726110 PEPPERMINT OIL 30ML BTL EXTERNAL 07/01/84 028 0250 5012
13726122 PERCOCET - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13726198 PERMETHRIN 5% CREAM 60GM EXTERNAL 01/01/95 028 0251 5012
13726199 PERMETHRIN EMULSION 1% 60ML EXTERNAL 01/01/95 028 0250 5012
13726200 PERPHENAZINE 4MG TAB EXTERNAL 01/01/95 Q0175 028 0636 5012
13726202 PERPHENAZINE 4MG - 1 BOTTLE EXTERNAL 01/25/95 028 0636 5012
13726240 OCULAR LUBRICANT OINT 3.5GM EXTERNAL 01/01/95 028 0250 5012
13726250 PETROLATUM WHITE OINT 30GM EXTERNAL 01/01/95 028 0250 5012
13726260 PETROLATUM WHITE OINTMENT 454G EXTERNAL 07/01/84 028 0250 5012
13726320 PHENAZOPYRIDINE 100MG TAB EXTERNAL 07/01/84 028 0250 5012
13726460 PHENOBARBITAL 15MG TAB EXTERNAL 01/01/95 028 0250 5012
13726461 PHENOBARBITAL 15MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13726463 PHENOBARBITAL 15MG TAB (1/2 TA EXTERNAL 02/21/05 028 0251 5012
13726470 PHENOBARBITAL 32.4MG TAB EXTERNAL 07/01/84 028 0251 5012
13726480 PHENOBARBITAL 30MG TAB EXTERNAL 01/01/95 028 0250 5012
13726481 PHENOBARBITAL 30MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13726490 PHENOBARBITAL 64.8MG EXTERNAL 07/01/84 028 0251 5012
13726500 PHENOBARBITAL 60MG TAB EXTERNAL 01/01/95 028 0250 5012
13726501 PHENOBARBITAL 60MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13726520 PHENOBARBITAL 100MG TAB EXTERNAL 01/01/95 028 0250 5012
13726521 PHENOBARBITAL 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13726560 PHENOBARBITAL 130MG/ML INJ EXTERNAL 07/01/84 J2560 J2560 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 260
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13726578 PHENOBARBITAL 65MG/ML INJ EXTERNAL 08/02/01 J2560 J2560 028 0636 5012
13726580 PHENOBARBITAL 60MG/ML INJ EXTERNAL 01/01/95 J2560 J2560 028 0636 5012
13726645 PHENOXYBENZAMINE 10MG CAP EXTERNAL 01/01/95 028 0250 5012
13726660 PHENTOLAMINE 5MG/ML INJ EXTERNAL 01/01/95 J2760 J2760 028 0636 5012
13726680 PHENYLEPHRINE 10MG/ML INJ EXTERNAL 01/01/95 J2370 J2370 028 0636 5012
13726700 PHENYLEPHRINE 1% NASAL SOLN EXTERNAL 01/01/95 028 0250 5012
13726705 PHENYLEPHRINE 2.5% OPHTH SOLN EXTERNAL 07/01/84 028 0251 5012
13726707 PHENYLEPHRINE 2.5% OPTH SOLN 2 EXTERNAL 01/01/95 028 0250 5012
13726710 PHENYLEPHRINE 2.5% OPTH SOLN 1 EXTERNAL 07/01/84 028 0251 5012
13726721 PHENYLEPHRINE 10% OPTH SOLN EXTERNAL 01/01/95 028 0250 5012
13726725 PHENYLEPHRINE DRIP - OR EXTERNAL 05/21/92 J2370 J2370 J2370 028 0258 5012
13726730 PHENYLEPHRINE 0.25% NASAL SPRA EXTERNAL 07/01/84 028 0250 5012
13726740 PHENYLEPHRINE 0.5% NASAL SPRA EXTERNAL 07/01/84 028 0250 5012
13726744 PHENYTOIN 400MG (100 MG X 4) E EXTERNAL 02/14/08 028 0251 5012
13726745 PHENYTOIN 200MG (100 MG X 2) E EXTERNAL 02/14/08 028 0251 5012
13726746 PHENYTOIN 300MG (100 MG X 3) E EXTERNAL 02/14/08 028 0251 5012
13726747 PHENYTOIN 25 MG (50 MG X 1/2) EXTERNAL 02/21/05 028 0251 5012
13726748 PHENYTOIN 150 MG (50 MG X 3) C EXTERNAL 02/21/05 028 0251 5012
13726749 PHENYTOIN 100 MG (50 MG X 2) C EXTERNAL 02/21/05 028 0251 5012
13726752 PHENYTOIN* 330MG ERCAP (3X100+ EXTERNAL 07/31/01 028 0251 5012
13726753 PHENYTOIN* 360MG ERCAP (3X100+ EXTERNAL 07/31/01 028 0251 5012
13726754 PHENYTOIN 100MG/100ML NS IVPB EXTERNAL 03/12/96 J1165 028 0258 5012
13726757 PHENYTOIN 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13726758 PHENYTOIN 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13726759 PHENYTOIN 30MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13726761 PHENYTOIN 30MG ER CAPSULE EXTERNAL 07/01/84 028 0251 5012
13726763 PHENYTOIN 50MG CHEW TAB EXTERNAL 07/01/84 028 0251 5012
13726765 PHENYTOIN 100MG ER CAPSULE EXTERNAL 07/01/84 028 0258 5012
13726766 PHENYTOIN SUSPENSION 240ML BOT EXTERNAL 07/01/84 028 0258 5012
13726767 PHENYTOIN* 300MG (100 MG X 3) EXTERNAL 07/01/84 028 0258 5012
13726774 PHENYTOIN* 50 MG/ML INJ EXTERNAL 07/01/84 J1165 J1165 028 0636 5012
13726776 PHENYTOIN 200MG SUSPENSION EXTERNAL 06/28/94 028 0251 5012
13726778 PHENYTOIN 1GM/NS250 ML IVPB EXTERNAL 05/01/95 J1165 028 0258 5012
13726791 NEUTRA-PHOS PACKETS 100/BOX EXTERNAL 10/16/96 028 0251 5012
13726792 NEUTRA-PHOS PACKET EXTERNAL 10/16/96 028 0251 5012
13726793 PHOSPHOROUS/POTASSIUM REPLACEM EXTERNAL 01/12/99 028 0251 5012
13726794 NEUTRA PHOS K+ PACKET EXTERNAL 01/12/99 028 0251 5012
13726795 NEUTRA PHOS K+ PACKET (2 PACKE EXTERNAL 01/12/99 028 0251 5012
13726796 NEUTRA PHOS K+ PACKET (2 PACKE EXTERNAL 01/12/99 028 0251 5012
13726812 SODIUM BIPHOSPHATE-SODIUM PHOS EXTERNAL 07/01/84 028 0250 5012
13726814 SODIUM BIPHOSPHATE-SODIUM PHOS EXTERNAL 04/05/94 028 0251 5012
13726815 SODIUM BIPHOSPHATE-SODIUM PHOS EXTERNAL 04/05/94 028 0251 5012
13726816 SODIUM BIPHOSPHATE-SODIUM PHOS EXTERNAL 04/05/94 028 0251 5012
13726817 PHOSPHO-SODA 20ML U.D. EXTERNAL 10/10/01 028 0251 5012
13726818 SODIUM BIPHOSPHATE-SODIUM PHOS EXTERNAL 12/21/01 028 0251 5012
13726820 PHYSOSTIGMINE SALICYLATE INJEC EXTERNAL 07/01/84 028 0250 5012
13726821 PHYSOSTIGMINE 1MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13726830 PHYSOSTIGMINE 0.25% OPHTH OINT EXTERNAL 07/01/84 028 0250 5012
13726850 PHYTONADIONE 10MG/ML INJ EXTERNAL 07/01/84 J3430 J3430 028 0636 5012
13726852 PHYTONADIONE 1MG INJ AMP EXTERNAL 07/01/84 J3430 J3430 028 0636 5012
13726853 PHYTONADIONE 10MG IVPB EXTERNAL 03/18/08 J3430 J3430 J3430 028 0258 5012
13726859 PHYTONADIONE 0.2 MG/ML PEDS IN EXTERNAL 10/24/00 J3430 J3430 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 261
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13726860 PHYTONADIONE 2MG/ML INJ 0.5ML EXTERNAL 07/01/84 J3430 J3430 028 0636 5012
13726862 PHYTONADIONE 2MG/ML FOR DILN N EXTERNAL 05/14/02 J3430 J3430 J3430 028 0258 5012
13726863 PHYTONADIONE 10MG/ML FOR DILN EXTERNAL 05/14/02 J3430 J3430 J3430 028 0258 5012
13726864 PHYTONADIONE 1MG/0.5ML SYRINGE EXTERNAL 12/03/08 028 0258 5012
13726870 PHYTONADIONE INJECTION 1MG VIA EXTERNAL 07/01/84 J3430 J3430 028 0636 5012
13726880 PHYTONADIONE 5MG TAB EXTERNAL 07/01/84 028 0250 5012
13726881 PHYTONADIONE 5MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13726882 PHYTONADIONE 2.5 MG (1/2 X 5MG EXTERNAL 07/20/06 028 0251 5012
13726883 PHYTONADIONE 10 MG (5MG X 2) T EXTERNAL 03/07/05 028 0251 5012
13726912 PILOCARPINE 5MG TAB EXTERNAL 03/25/98 028 0251 5012
13726920 PILOCARPINE 1% OPTH SOLN 15ML EXTERNAL 07/01/84 028 0250 5012
13726940 PILOCARPINE 2% OPTH SOLN 15ML EXTERNAL 07/01/84 028 0251 5012
13726960 PILOCARPINE 2% OPTH SOLN 1ML EXTERNAL 07/01/84 028 0251 5012
13726965 PILOCARPINE 4% OPTH GEL 3.5GM EXTERNAL 07/01/84 028 0250 5012
13726970 PILOCARPINE 4% OPTH SOLN 15ML EXTERNAL 07/01/84 028 0251 5012
13726980 PILOCARPINE 4% OPTH SOLN 30ML EXTERNAL 07/01/84 028 0250 5012
13726991 PILOCARPINE 4% OPTH SOLN 1ML EXTERNAL 07/01/84 028 0251 5012
13726992 PILOCARPINE 6% OPTH SOLN 15ML EXTERNAL 07/01/84 028 0250 5012
13726993 PILOCARPINE 8% OPTH SOLN 15ML EXTERNAL 07/01/84 028 0250 5012
13726994 PIPERACILLIN INJECTION 2GM VIA EXTERNAL 02/02/87 028 0251 5012
13726995 PIPERACILLIN INJECTION 4GM VIA EXTERNAL 07/01/84 028 0250 5012
13726997 PINDOLOL 5MG TAB EXTERNAL 07/01/84 028 0250 5012
13727001 PIPERACILLIN 400MG/ML INJ EXTERNAL 10/26/00 028 0258 5012
13727004 PIPERACILLIN 0.4GM/ML INJ EXTERNAL 01/28/92 028 0251 5012
13727005 PIPERACILLIN INJECTION 3GM VIA EXTERNAL 01/28/92 028 0251 5012
13727007 ZOSYN 225 MG/ML INJ EXTERNAL 12/17/02 J2543 J2543 J2543 028 0258 5012
13727010 ZOSYN 0.225 GM/ML INJ EXTERNAL 12/17/02 J2543 J2543 028 0636 5012
13727011 PIP/TAZOBAC RTU (ZOSYN 3.375GM EXTERNAL 01/02/03 J2543 028 0636 5012
13727012 PIPERCILLIN/TAZOBACT RTU (ZOSY EXTERNAL 01/02/03 J2543 J2543 028 0636 5012
13727013 ZOSYN 67.5 MG/ML PEDS INJ EXTERNAL 01/06/03 J2543 J2543 028 0636 5012
13727014 PIP/TAZOBAC RTU (ZOSYN 3.375GM EXTERNAL 04/03/08 028 0258 5012
13727015 PIP/TAZOBAC RTU (ZOSYN 4.5GM/D EXTERNAL 04/03/08 028 0258 5012
13727041 EXTERNAL 01/25/95 028 0251 5012
13727053 PLASMALYTE A 1000ML EXTERNAL 07/01/84 028 0258 5012
13727065 PNEUMOCOCCAL VAC 0.5ML INJ EXTERNAL 07/01/84 028 0250 5012
13727066 PNEUMOCOCCOL VACCINE - 5 DOSE EXTERNAL 10/19/90 028 0250 5012
13727080 POLIOMYELIITIS VAC 0.5ML SYR EXTERNAL 07/01/84 028 0250 5012
13727081 POLIOMYELIITIS VAC 0.5ML VFC EXTERNAL 01/12/10 028 0258 5012
13727096 PEG 3350 MIRALAX **GM POWDER EXTERNAL 12/02/09 028 0251 5012
13727098 PEG LAVAGE SOLN/COLON PREP 400 EXTERNAL 05/28/92 028 0251 5012
13727099 PEG 3350 MIRALAX 17 GM POWDER EXTERNAL 05/06/08 028 0251 5012
13727100 MULTIVITAMIN CHEW TAB EXTERNAL 07/01/84 028 0251 5012
13727101 MULTIVITAMIN - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13727105 MULTIVITAMINS W/ IRON 50ML EXTERNAL 03/24/92 028 0251 5012
13727106 MULTIVITAMINS W/IRON 0.5ML DRO EXTERNAL 06/25/92 028 0251 5012
13727107 MULTIVITAMINS W/IRON 1ML DROPS EXTERNAL 06/25/92 028 0251 5012
13727110 MULTIVITAMIN DROPS 50ML BOTTLE EXTERNAL 01/25/95 028 0251 5012
13727111 MULTIVITAMIN 0.5ML DROPS EXTERNAL 07/01/84 028 0251 5012
13727120 POLYMYXIN B SULFATE 5MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13727125 PNEUMOCOCCAL CONJ. VAC 0.5ML I EXTERNAL 01/01/01 028 0258 5012
13727126 PNEUMOCOCCAL CONJ. VAC 0.5ML V EXTERNAL 01/12/10 028 0258 5012
13727127 PNEUMOCOCCAL 13 VACC 0.5 ML IN EXTERNAL 06/24/10 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 262
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13727130 NEO-POLYMIXIN B-PREDNISOLONE O EXTERNAL 02/03/05 028 0251 5012
13727131 NEO-POLY B DEXAMETHASONE OPHTH EXTERNAL 07/01/84 028 0250 5012
13727150 BACITRACIN-POLYMYXIN B OINT 30 EXTERNAL 07/01/84 028 0250 5012
13727160 POLYSPORIN OINTMENT PACKETS - EXTERNAL 07/01/84 028 0250 5012
13727170 BACITRACIN-POLYMYXIN B OPHTH O EXTERNAL 07/01/84 028 0250 5012
13727200 OCULAR LUBRICANT SOLN 30ML EXTERNAL 07/01/84 028 0250 5012
13727207 POTASIUM CHLORIDE RIDER - OR EXTERNAL 05/21/92 028 0258 5012
13727208 POTASSIUM ACETATE 0.2 MEQ/ML P EXTERNAL 10/26/00 028 0258 5012
13727209 POTASSIUM ACETATE 0.067 MEQ/ML EXTERNAL 10/26/00 028 0258 5012
13727211 POTASSIUM ACETATE INJ 40MEQ VI EXTERNAL 07/01/84 028 0250 5012
13727212 POTASSIUM ACETATE 2MEQ/ML INJ EXTERNAL 11/24/90 028 0251 5012
13727213 POTASSIUM ACETATE NEO MEQ/KG EXTERNAL 10/26/00 028 0258 5012
13727214 POTASSIUM CL 2MEQ/D5W 10ML EXTERNAL 02/20/90 J3480 J3480 J3480 028 0636 5012
13727216 POTASSIUM CHLORIDE 20MEQ - 1 B EXTERNAL 01/01/87 028 0250 5012
13727218 POTASSIUM CHLORIDE 20MEQ SR TA EXTERNAL 01/01/87 028 0250 5012
13727220 POTASSIUM CHLORIDE INJ 2MEQ VI EXTERNAL 07/01/84 028 0258 5012
13727224 POTASSIUM CHLORIDE 50MEQ LIQ EXTERNAL 05/25/95 028 0250 5012
13727226 POTASSIUM CHLORIDE SOLN - 1 BT EXTERNAL 07/01/84 028 0250 5012
13727227 POTASSIUM CHLORIDE 15MEQ LIQ EXTERNAL 07/01/84 028 0250 5012
13727228 POTASSIUM CHLORIDE 20MEQ LIQ EXTERNAL 07/01/84 028 0250 5012
13727229 POTASSIUM CHLORIDE 30MEQ LIQ EXTERNAL 07/01/84 028 0250 5012
13727230 POTASSIUM CHLORIDE 40MEQ LIQ EXTERNAL 07/01/84 028 0250 5012
13727231 POTASSIUM CHLORIDE INJ 2MEQ VI EXTERNAL 07/01/84 J3480 J3480 028 0636 5012
13727232 POTASSIUM CHLORIDE INJ 2MEQ VI EXTERNAL 07/01/84 J3480 J3480 028 0636 5012
13727233 POTASSIUM CHLORIDE 2MEQ/ML INJ EXTERNAL 07/01/84 J3480 J3480 028 0636 5012
13727235 POTASSIUM CHLORIDE INJ 2MEQ VI EXTERNAL 07/01/84 J3480 J3480 028 0636 5012
13727239 POTASSIUM CHLORIDE 10 MEQ INJ EXTERNAL 11/16/98 028 0258 5012
13727240 POTASSIUM CHLORIDE INJ 2MEQ VI EXTERNAL 07/01/84 J3480 J3480 028 0636 5012
13727241 POTASSIUM CHLORIDE 10MEQ CAP EXTERNAL 03/21/94 028 0251 5012
13727242 POTASSIUM CHLORIDE 10MEQ LIQ EXTERNAL 04/08/94 028 0251 5012
13727243 POTASSIUM CHLORIDE 5MEQ LIQ EXTERNAL 04/08/94 028 0251 5012
13727244 POTASSIUM CHLORIDE 15 MEQ INJ EXTERNAL 11/16/98 J3480 J3480 028 0636 5012
13727246 POTASSIUM CHLORIDE 0.5MEQ LIQ EXTERNAL 05/01/95 028 0251 5012
13727247 POTASSIUM CHLORIDE 1.0MEQ LIQ EXTERNAL 05/01/95 028 0251 5012
13727248 POTASSIUM CHLORIDE 2.0MEQ LIQ EXTERNAL 05/01/95 028 0251 5012
13727249 POTASSIUM CHLORIDE 3.0MEQ LIQ EXTERNAL 05/01/95 028 0251 5012
13727251 POTASSIUM CHLORIDE 7.5MEQ LIQ EXTERNAL 05/01/95 028 0251 5012
13727253 POTASSIUM CHLORIDE 45MEQ LIQ EXTERNAL 12/21/01 028 0251 5012
13727254 POTASSIUM PHOSPHATE 40MEQ IN D EXTERNAL 01/03/03 028 0258 5012
13727255 POTASSIUM PHOSPHATE 30MMOLE IN EXTERNAL 01/03/03 028 0258 5012
13727256 POTASSIUM ACETATE 40MEQ IN D5W EXTERNAL 01/03/03 028 0258 5012
13727257 SODIUM PHOSPHATE 30MMOLE IN D5 EXTERNAL 01/03/03 028 0258 5012
13727259 POTASSIUM CHLORIDE 30 MEQ INJ EXTERNAL 11/16/98 J3480 J3480 028 0636 5012
13727260 POTASSIUM CHLORIDE 40 MEQ INJ EXTERNAL 11/16/98 J3480 J3480 J3480 028 0636 5012
13727261 POTASSIUM CHLORIDE 60 MEQ INJ EXTERNAL 11/16/98 J3480 J3480 028 0636 5012
13727262 POTASSIUM CHLORIDE 80 MEQ INJ EXTERNAL 11/16/98 J3480 J3480 028 0636 5012
13727263 POTASSIUM CHLORIDE NEO MEQ/KG EXTERNAL 11/16/98 J3480 J3480 028 0636 5012
13727264 POTASSIUM CHLR 40MEQ (20 MEQ X EXTERNAL 02/14/08 028 0251 5012
13727265 POTASSIUM CHLR 60MEQ (20 MEQ X EXTERNAL 02/14/08 028 0251 5012
13727270 POTASSIUM IODIDE SOLN 30ML BOT EXTERNAL 07/01/84 028 0250 5012
13727272 POTASSIUM IODIDE 1000MG/ML SOL EXTERNAL 07/01/84 028 0250 5012
13727274 POTASSIUM IODIDE 20 GTT/ML ORA EXTERNAL 03/07/05 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 263
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13727329 POTASSIUM PHOSPHATE 15ML VIAL EXTERNAL 07/01/84 028 0251 5012
13727380 POVIDONE IODINE 30GM OINT EXTERNAL 07/01/84 028 0250 5012
13727424 PRAMIPEXOLE 0.125MG TAB EXTERNAL 05/11/00 028 0251 5012
13727425 PRAMIPEXOLE 0.125MG BULK EXTERNAL 05/11/00 028 0251 5012
13727426 PRAMIPEXOLE 0.25MG TAB EXTERNAL 05/11/00 028 0251 5012
13727427 PRAMIPEXOLE 0.25MG BULK EXTERNAL 05/11/00 028 0251 5012
13727428 PRAMIPEXOLE 0.5MG TAB EXTERNAL 05/11/00 028 0251 5012
13727429 PRAMIPEXOLE 0.5MG BULK EXTERNAL 05/11/00 028 0251 5012
13727431 PRAMIPEXOLE 1MG TAB EXTERNAL 05/11/00 028 0251 5012
13727432 PRAMIPEXOLE 1MG BULK EXTERNAL 05/11/00 028 0251 5012
13727433 PRAMIPEXOLE 1.5MG TAB EXTERNAL 05/11/00 028 0251 5012
13727434 PRAMIPEXOLE 1.5MG BULK EXTERNAL 05/11/00 028 0251 5012
13727440 PRASUGREL 10 MG TABLET EXTERNAL 02/01/10 028 0251 5012
13727446 PRAVASTATIN 10 MG TABLET EXTERNAL 04/08/10 028 0251 5012
13727447 PRAVASTATIN 20 MG TABLET EXTERNAL 08/15/08 028 0251 5012
13727448 PRAVASTATIN 40 MG TABLET EXTERNAL 08/15/08 028 0251 5012
13727450 PRALIDOXIME 50MG/ML INJ EXTERNAL 07/01/84 J2730 J2730 028 0636 5012
13727460 PREDNISOLONE 5MG TAB EXTERNAL 07/01/84 J7510 J7510 028 0636 5012
13727461 PREDNISOLONE 5MG - 1 BOX EXTERNAL 07/01/84 028 0258 5012
13727471 PREDNISOLONE 0.5MG ORAL DOSE EXTERNAL 10/10/01 J7510 J7510 028 0636 5012
13727473 PREDNISOLONE 4MG ORAL DOSE EXTERNAL 10/10/01 J7510 J7510 028 0636 5012
13727476 PREDNISOLONE 5MG ORAL DOSE EXTERNAL 10/10/01 J7510 J7510 028 0636 5012
13727477 PREDNISOLONE 2MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727478 PREDNISOLONE 2.5MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727480 PREDNISOLONE ACE 0.12% OPHTH S EXTERNAL 07/01/84 028 0250 5012
13727481 PREDNISOLONE 3.5MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727482 PREDNISOLONE 4.5MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727483 PREDNISOLONE 3MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727484 PREDNISOLONE 3.5MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727485 PREDNISOLONE 3.75MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727486 PREDNISOLONE 4MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727487 PREDNISOLONE 5MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727488 PREDNISOLONE 15MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727489 PREDNISOLONE 25MG LIQUID EXTERNAL 12/21/01 J7510 J7510 028 0636 5012
13727490 PREDNISOLONE ACE 1% OPHTH SUSP EXTERNAL 07/01/84 028 0251 5012
13727491 PREDNISOLONE ACE 1% OPHTH SUSP EXTERNAL 07/01/84 028 0251 5012
13727493 PREDNISOLONE 3 MG/ML LIQUID EXTERNAL 03/08/05 J7510 J7510 J7510 028 0251 5012
13727535 PREDNISONE 2.5MG - 1 BOX EXTERNAL 07/01/84 028 0250 5012
13727542 PREDNISOLONE 5MG LIQUID EXTERNAL 05/12/94 J7506 J7506 J7506 028 0636 5012
13727547 PREDNISONE 40 MG (20 MG X 2) T EXTERNAL 02/14/08 028 0251 5012
13727548 PREDNISONE 60 MG (20 MG X 3) T EXTERNAL 02/14/08 028 0251 5012
13727549 PREDNISONE 15 MG (5 MG X 3) TA EXTERNAL 02/14/08 028 0251 5012
13727550 PREDNISONE 5MG TAB EXTERNAL 07/01/84 J7506 J7506 J7506 028 0636 5012
13727551 PREDNISONE 5MG - 1 BOX EXTERNAL 01/25/95 028 0250 5012
13727552 PREDNISONE 5MG U.D. 100'S TAB EXTERNAL 11/23/94 028 0250 5012
13727553 PREDNISONE TAB 10MG EXTERNAL 10/11/00 J7506 J7506 028 0636 5012
13727570 PREDNISONE 20MG TAB EXTERNAL 07/01/84 J7506 J7506 028 0636 5012
13727571 PREDNISONE 5MG - 1 BOX EXTERNAL 01/25/95 028 0250 5012
13727590 PREDNISONE 5MG TAB EXTERNAL 07/01/84 J7506 J7506 028 0636 5012
13727592 PREDNISONE 5MG - 1 BOX EXTERNAL 01/25/95 J7506 J7506 028 0636 5012
13727601 PREDNISONE 2.5MG TAB EXTERNAL 07/01/84 J7506 J7506 028 0636 5012
13727610 PRIMAQUINE PHOSPHATE 26.3MG TA EXTERNAL 07/01/84 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 264
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13727611 PRIMAQUINE PHOSPHATE 26.3MG - EXTERNAL 01/25/95 028 0251 5012
13727620 PRIMIDONE 50MG TAB EXTERNAL 07/01/84 028 0250 5012
13727621 PRIMIDONE 50MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13727631 PRIMIDONE 50MG/ML SUSP EXTERNAL 07/01/84 028 0251 5012
13727640 PRIMIDONE 250MG TAB EXTERNAL 07/01/84 028 0250 5012
13727641 PRIMIDONE 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13727642 PRIMIDONE 125MG (1/2 X 250MG) EXTERNAL 04/08/94 028 0251 5012
13727670 PROBENECID 500MG TAB EXTERNAL 07/01/84 028 0250 5012
13727671 PROBENECID 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13727695 PROCAINIMDE 1000MG ER TAB 60/B EXTERNAL 10/03/96 028 0251 5012
13727705 PROCAINAMIDE 500MG ER TAB 100U EXTERNAL 10/03/96 028 0251 5012
13727708 PROCAINAMIDE 1.0GM TAB 100UD/B EXTERNAL 10/03/96 028 0251 5012
13727712 PROCAINAMIDE 250MG SR TAB EXTERNAL 07/01/84 028 0251 5012
13727714 PROCAINAMIDE 500MG SR TAB EXTERNAL 07/01/84 028 0250 5012
13727716 PROCAINAMIDE 750MG SR TAB EXTERNAL 07/01/84 028 0250 5012
13727717 PROCAINAMIDE SR 750MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13727718 PROCAINAMIDE SR 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13727719 PROCAINAMIDE SR 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13727720 PROCAINAMIDE INJECTION 1GM VIA EXTERNAL 07/01/84 J2690 J2690 028 0636 5012
13727722 PROCAINAMIDE 375MG CAP EXTERNAL 07/27/01 028 0251 5012
13727723 PROCAINAMIDE INJECTION 1GM VIA EXTERNAL 02/04/87 J2690 J2690 028 0636 5012
13727725 PROCAINAMIDE 250MG CAP EXTERNAL 05/16/97 028 0251 5012
13727727 PROCAINAMIDE 50 MG/ML ORAL SOL EXTERNAL 03/08/05 028 0251 5012
13727728 RINGERS2 TEST EXTERNAL 09/03/09 028 0258 5012
13727730 PROCAINAMIDE 100MG/ML INJ EXTERNAL 07/01/84 J2690 J2690 028 0636 5012
13727731 PROCAINAMIDE 0.1GM/ML INJ EXTERNAL 10/26/00 J2690 J2690 028 0636 5012
13727810 PROCARBAZINE 50MG CAP EXTERNAL 07/01/84 028 0251 5012
13727811 PROCARBAZINE 50MG - 1 BOTTLE EXTERNAL 01/25/95 028 0250 5012
13727830 PROCHLORPERAZINE 5MG TAB EXTERNAL 07/01/84 Q0164 Q0164 Q0164 028 0636 5012
13727831 PROCHLORPERAZINE 5MG - 1 BOX EXTERNAL 01/25/95 Q0164 Q0164 028 0636 5012
13727850 PROCHLORPERAZINE 10MG TAB EXTERNAL 07/01/84 Q0165 Q0165 Q0165 028 0250 5012
13727851 PROCHLORPERAZINE 10MG - 1 BOX EXTERNAL 01/25/95 Q0164 Q0164 028 0636 5012
13727901 PROCHLORPERAZINE SYRUP 12ML BO EXTERNAL 07/01/84 028 0636 5012
13727902 PROCHLORPERAZINE 5MG ORAL DOSE EXTERNAL 10/10/01 Q0164 028 0636 5012
13727903 PROCHLORPERAZINE 10MG ORAL DOS EXTERNAL 10/10/01 Q0165 028 0636 5012
13727911 PROCHLORPERAZINE SUPP 5MG - 1 EXTERNAL 01/25/95 028 0636 5012
13727920 PROCHLORPERAZINE 25MG SUPP EXTERNAL 07/01/84 028 0250 5012
13727921 PROCHLORPERAZINE SUPP 25MG - 1 EXTERNAL 01/25/95 028 0250 5012
13727930 PROCHLORPERAZINE INJ 10MG VIAL EXTERNAL 07/01/84 J0780 J0780 028 0636 5012
13727931 PROCHLORPERAZINE 5MG/ML INJ EXTERNAL 07/01/84 J0780 J0780 028 0636 5012
13727932 PROCHLORPERAZINE 10 MG/2 ML IN EXTERNAL 08/13/03 J0780 J0780 028 0636 5012
13727935 PROCHLORPERAZINE 5MG/ML INJ VI EXTERNAL 07/01/84 J0780 J0780 028 0636 5012
13727937 PROCTOFOAM HC 1% AEROSOL FOAM EXTERNAL 07/01/84 028 0250 5012
13727950 PROMETHAZINE 12.5MG - 1 BOTTLE EXTERNAL 07/01/84 028 0251 5012
13727951 PROGESTERONE 50MG/ML INJ EXTERNAL 03/26/02 J2675 J2675 028 0636 5012
13727952 PROGESTIN ORAL 0.35MG-PACK EXTERNAL 01/12/99 028 0251 5012
13727960 PROMETHAZINE 12.5MG TAB EXTERNAL 07/01/84 Q0169 Q0169 028 0251 5012
13727965 PROMETHAZINE 25 MG TAB EXTERNAL 02/14/08 028 0251 5012
13727980 PROMETHAZINE 25MG/ML INJ EXTERNAL 07/01/84 J2550 J2550 028 0636 5012
13727991 PROMETHAZINE 12.5MG SUPP EXTERNAL 07/01/84 028 0251 5012
13727992 PROMETHAZINE 25MG SUPP EXTERNAL 07/01/84 028 0251 5012
13727993 PROMETHAZINE SUPP 12.5MG - 1 B EXTERNAL 01/25/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 265
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13727994 PROMETHAZINE SUPP 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728050 PROPARACAINE 0.5% OPTH SOLUTIO EXTERNAL 07/01/84 028 0251 5012
13728051 PROPARACAINE 0.5% OPHTH SOLN EXTERNAL 07/01/84 028 0250 5012
13728100 PROPOFOL 10MG/ML INJ 20ML EXTERNAL 01/12/90 028 0251 5012
13728101 PROPOFOL 10MG/ML 50ML EXTERNAL 01/28/93 028 0251 5012
13728102 PROPOFOL 10MG/ML 100ML EXTERNAL 05/01/95 028 0258 5012
13728105 PROPOFOL 10MG/ML INJ 50ML EXTERNAL 11/22/95 028 0258 5012
13728106 PROPOFOL 10MG/ML INJ 100ML EXTERNAL 11/22/95 028 0258 5012
13728159 PROPRANOLOL 5MG (1/2 X 10MG) T EXTERNAL 03/21/94 028 0251 5012
13728160 PROPRANOLOL 10MG TAB EXTERNAL 07/01/84 028 0251 5012
13728162 PROPRANOLOL 20MG TAB EXTERNAL 07/01/84 028 0250 5012
13728163 PROPRANOLOL 10MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728164 PROPRANOLOL 20MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728165 PROPRANOLOL 4MG/ML ORAL SOLN EXTERNAL 03/26/88 028 0251 5012
13728166 PROPRANOLOL SOLUTION 500ML BOT EXTERNAL 09/10/88 028 0251 5012
13728167 PROPRANOLOL 10MG ORAL DOSE EXTERNAL 10/10/01 028 0251 5012
13728168 PROPRANOLOL 15MG ORAL DOSE EXTERNAL 10/10/01 028 0251 5012
13728169 PROPRANOLOL 20MG ORAL DOSE EXTERNAL 10/10/01 028 0251 5012
13728171 PROPRANOLOL 160MG (2X80MG) TAB EXTERNAL 04/08/94 028 0251 5012
13728172 PROPRANOLOL 240MG (3X80MG) TAB EXTERNAL 04/08/94 028 0251 5012
13728173 PROPRANOLOL 320MG (4X80MG) TAB EXTERNAL 04/08/94 028 0251 5012
13728180 PROPRANOLOL 40MG TAB EXTERNAL 07/01/84 028 0251 5012
13728181 PROPRANOLOL 40MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728184 PROPRANOLOL 60MG TAB EXTERNAL 07/01/84 028 0250 5012
13728185 PROPRANOLOL 60MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728186 PROPRANOLOL SR 60MG - 1 BOX EXTERNAL 08/05/88 028 0251 5012
13728187 PROPRANOLOL LA 60MG - 1 BOTTLE EXTERNAL 08/05/88 028 0251 5012
13728188 PROPRANOLOL 60MG LA CAP EXTERNAL 08/05/88 028 0251 5012
13728199 PROPRANOLOL 80MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728200 PROPRANOLOL 80MG TAB EXTERNAL 07/01/84 028 0251 5012
13728202 PROPRANOLOL 80MG LA CAP EXTERNAL 07/01/84 028 0251 5012
13728204 PROPRANOLOL 120MG LA CAP EXTERNAL 07/01/84 028 0251 5012
13728205 PROPRANOLOL LA 160MG - 1 BOX EXTERNAL 07/01/84 028 0251 5012
13728206 PROPRANOLOL 160MG LA CAP EXTERNAL 07/01/84 028 0251 5012
13728207 PROPRANOLOL LA 120MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728209 PROPRANOLOL LA 80MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728210 PROPRANOLOL 1MG/ML INJ EXTERNAL 07/01/84 J1800 J1800 J1800 028 0636 5012
13728250 PROPYLTHIOURACIL 50MG - 1 BTL( EXTERNAL 07/01/84 028 0250 5012
13728259 PROPYLTHIOURACIL 25MG (1/2 X 5 EXTERNAL 07/20/06 028 0251 5012
13728260 PROPYLTHIOURACIL 50MG TAB EXTERNAL 07/01/84 028 0250 5012
13728262 PROPYLTHIOURACIL 5MG/ML ORAL S EXTERNAL 11/08/01 028 0251 5012
13728300 PIOGLITAZONE 15MG TABLET EXTERNAL 06/28/07 028 0251 5012
13728301 PIOGLITAZONE 30MG TABLET EXTERNAL 06/28/07 028 0251 5012
13728340 PROTAMINE SULFATE 10MG AMPULE EXTERNAL 07/01/84 J2720 J2720 028 0636 5012
13728342 PROTAMINE SULF 10MG/ML INJ EXTERNAL 07/01/84 J2720 J2720 028 0636 5012
13728391 PSEUDOEPHEDRINE 30MG TAB EXTERNAL 07/01/84 028 0250 5012
13728392 PSEUDOEPHEDRINE 30MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728400 PSEUDOEPHEDRINE 60MG TAB EXTERNAL 07/01/84 028 0250 5012
13728402 PSEUDOEPHEDRINE 60MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728409 PSEUDOEPHEDRINE 15MG SYRUP EXTERNAL 10/10/01 028 0251 5012
13728410 PSEUDOEPHEDRINE 30MG SYRUP EXTERNAL 07/01/84 028 0250 5012
13728411 PSEUDOEPHEDRINE SYRUP 6MG/ML 1 EXTERNAL 07/01/84 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 266
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13728420 HYDROCORTISONE/POLYMIXIN B OTI EXTERNAL 07/01/84 028 0250 5012
13728421 DORNASE ALFA 2.5MG/2.5ML AMPUL EXTERNAL 11/22/95 028 0251 5012
13728422 DORNASE ALFA 2.5MG/2.5ML SVN F EXTERNAL 11/22/95 J7639 J7639 028 0636 5012
13728430 PYRIDOSTIGMINE BR 60MG TAB EXTERNAL 07/01/84 028 0250 5012
13728431 PYRIDOSTIGMINE 60MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13728435 PYRIDOSTIGMINE 30MG (1/2 X 60M EXTERNAL 04/08/94 028 0251 5012
13728440 PYRIDOSTIGMINE 180MG SR TAB EXTERNAL 07/01/84 028 0250 5012
13728441 PYRIDOSTIGMINE 180MG - 1 BOTTL EXTERNAL 01/25/95 028 0251 5012
13728450 PYRIDOSTIGMINE 60MG SYRUP EXTERNAL 07/01/84 028 0250 5012
13728460 PYRIDOSTIGMINE 5MG/1ML INJ EXTERNAL 07/01/84 028 0250 5012
13728481 PYRIDOXINE 50MG TAB EXTERNAL 07/01/84 J3415 J3415 028 0250 5012
13728482 PYRIDOXINE 50MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13728483 PYRIDOXINE 25MG TAB EXTERNAL 01/29/01 J3415 J3415 J3415 028 0251 5012
13728485 PYRIDOXINE 100MG/ML INJ EXTERNAL 07/01/84 J3415 J3415 028 0636 5012
13728490 PYRIMETHAMINE 25MG TAB EXTERNAL 07/01/84 028 0250 5012
13728491 PYRIMETHAMINE 25MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13728496 PYRAZINAMIDE 500MG TAB EXTERNAL 07/01/84 028 0250 5012
13728497 PYRAZINAMIDE 500MG U.D BOX EXTERNAL 02/17/94 028 0251 5012
13728498 PYRAZINAMIDE 250MG (1/2 X 500M EXTERNAL 04/08/94 028 0251 5012
13728500 QUETIAPINE 25MG EXTERNAL 11/04/99 028 0251 5012
13728501 QUETIAPINE 25MG TABLET EXTERNAL 11/04/99 028 0251 5012
13728502 QUETIAPINE 100MG EXTERNAL 11/04/99 028 0251 5012
13728503 QUETIAPINE 100MG TABLET EXTERNAL 11/04/99 028 0251 5012
13728504 QUETIAPINE 200MG TABLET EXTERNAL 01/03/02 028 0251 5012
13728505 QUETIAPINE 300MG TABLET EXTERNAL 03/10/05 028 0251 5012
13728506 QUETIAPINE 12.5MG TABLET EXTERNAL 05/23/06 028 0251 5012
13728510 QUETIAPINE 50 MG (25 MG X 2) EXTERNAL 02/15/08 028 0251 5012
13728513 QUETIAPINE 75 MG (25 MG X 3) EXTERNAL 02/15/08 028 0251 5012
13728516 QUETIAPINE 400MG (200 MG X 2) EXTERNAL 02/15/08 028 0251 5012
13728519 QUETIAPINE 600MG (300 MG X 2) EXTERNAL 02/15/08 028 0251 5012
13728601 QUINIDINE SULFATE 200MG - 1 BO EXTERNAL 01/25/95 028 0251 5012
13728604 QUINIDINE SULFATE 300MG - 1 BO EXTERNAL 01/25/95 028 0251 5012
13728608 RANITIDINE 0.75MG ORAL LIQ EXTERNAL 10/10/01 028 0251 5012
13728609 RANITIDINE 3MG ORAL LIQ EXTERNAL 10/10/01 028 0251 5012
13728610 QUININE SULFATE 200MG CAP EXTERNAL 07/01/84 028 0250 5012
13728611 QUININE SULFATE 200MG - 1 BOTT EXTERNAL 01/25/95 028 0251 5012
13728612 RANITIDINE 5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728613 RANITIDINE 7.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728614 RANITIDINE 10MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728615 RANITIDINE 15MG ORAL LIQ EXTERNAL 05/01/95 028 0251 5012
13728616 RANITIDINE 20MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728617 RANITIDINE 30MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728618 RANITIDINE 40MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728619 RANITIDINE 50MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728620 QUININE SULFATE 325MG CAP EXTERNAL 07/01/84 028 0250 5012
13728621 QUININE SULFATE 325MG - 1 BOTT EXTERNAL 01/25/95 028 0251 5012
13728622 RANITIDINE 75MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728623 RANITIDINE 100MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13728624 RANITIDINE 300MG SYRUP EXTERNAL 07/19/95 028 0251 5012
13728625 RANITIDINE 25MG/ML INJ EXTERNAL 04/01/94 J2780 J2780 028 0636 5012
13728626 RANITIDINE 2.5MG/ML PEDS INJ EXTERNAL 06/27/01 J2780 028 0636 5012
13728629 RANITIDINE 25MG ORAL LIQ EXTERNAL 11/30/00 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 267
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13728630 RANITIDINE 150MG SYRUP EXTERNAL 11/19/90 028 0251 5012
13728633 RANITIDINE SYRUP - 1 BOTTLE EXTERNAL 11/02/89 028 0251 5012
13728639 RANITIDINE INJECTION 25MG VIA EXTERNAL 07/01/84 J2780 J2780 J2780 028 0250 5012
13728640 RABIES VACCINE INJ EXTERNAL 07/01/84 028 0250 5012
13728641 RANITIDINE INJECTION 50MG VIAL EXTERNAL 07/01/84 J2780 J2780 J2780 028 0250 5012
13728645 RABIES IMM GLOB 150UNITS/ML IN EXTERNAL 07/01/84 028 0250 5012
13728647 RENALTAB - 1 TABLET EXTERNAL 07/01/84 028 0250 5012
13728648 RENALTAB - 1 BOTTLE (120) EXTERNAL 01/25/95 028 0251 5012
13728649 RANITIDINE 25MG/NACL 0.45% 25M EXTERNAL 03/10/88 J2780 J2780 028 0636 5012
13728652 RABIES IMMUNE GLOBULIN 2ML EXTERNAL 07/14/94 028 0251 5012
13728656 RIBAVIRIN 20MG/ML RESP EXTERNAL 12/11/97 028 0251 5012
13728666 RANITIDINE 1.5MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13728667 RANITIDINE 2MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13728668 RANITIDINE 2.5MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13728669 RANITIDINE 4MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13728671 RANITIDINE 12MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13728672 RANITIDINE 37.5MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13728673 RANITIDINE 60MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13728689 RITONAVIR 400MG ORAL DOSE EXTERNAL 10/10/01 028 0251 5012
13728751 RIFAMPIN 600MG (2X300MG) CAP EXTERNAL 04/05/94 028 0251 5012
13728756 RAFAMPIN/ISONIAZID/PYRAZINAMID EXTERNAL 05/31/95 028 0251 5012
13728760 RIFAMPIN 300MG CAP EXTERNAL 07/01/84 028 0250 5012
13728762 RIFAMPIN 300MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13728763 RIFAMPIN 150MG - 1 BOTTLE(30) EXTERNAL 03/26/88 028 0251 5012
13728764 RIFAMPIN 150MG CAP EXTERNAL 04/01/88 028 0251 5012
13728765 RIFAMPIN INJECTION ***MG EXTERNAL 05/31/90 028 0251 5012
13728766 RIFAMPIN 60MG/ML INJ EXTERNAL 10/07/91 028 0251 5012
13728767 RIFAXIMIN 550 MG TABLET EXTERNAL 06/01/41 028 0251 5012
13728850 LACTATED RINGERS 500ML EXTERNAL 07/01/84 J7120 J7120 028 0636 5012
13728860 LACTATED RINGERS 1000ML EXTERNAL 07/01/84 J1720 J1720 J1720 028 0636 5012
13728865 RITONAVIR 100MG BULK EXTERNAL 02/05/98 028 0251 5012
13728866 RITONAVIR 100MG CAP EXTERNAL 02/05/98 028 0251 5012
13728868 RITONAVIR ORAL SOLN 80MG/ML EXTERNAL 02/05/98 028 0251 5012
13728875 SODIUM CHLORIDE 3.5MEQ ORAL SO EXTERNAL 03/14/05 028 0251 5012
13728896 RISPERIDONE 2MG ORAL DISSOLV T EXTERNAL 02/15/08 028 0251 5012
13728898 RISPERIDONE 3MG ORAL DISSOLV T EXTERNAL 02/15/08 028 0251 5012
13728901 RISPERIDONE 3MG TAB EXTERNAL 08/12/02 028 0251 5012
13728902 RISPERIDONE 4MG TAB EXTERNAL 08/12/02 028 0251 5012
13728903 RISPERIDONE 1MG ORAL DISSOLVIN EXTERNAL 11/07/00 028 0251 5012
13728906 RITODRINE 10MG - 1 BOTTLE(60) EXTERNAL 01/25/95 028 0251 5012
13728907 RISPERIDONE 0.5MG TAB EXTERNAL 01/29/01 028 0251 5012
13728908 RISPERIDONE 1MG/ML EXTERNAL 01/06/03 028 0251 5012
13728909 RISPERIDONE 1MG/ML 30ML ORAL S EXTERNAL 04/05/02 028 0251 5012
13728913 RISPERIDONE 3MG BULK TABLET EXTERNAL 06/01/94 028 0251 5012
13728914 RISPERIDONE 4MG BULK TABLET EXTERNAL 06/01/94 028 0251 5012
13728915 RISPERIDONE 1MG U.D. 100 EXTERNAL 06/01/94 028 0251 5012
13728916 RISPERIDONE 1MG TAB EXTERNAL 06/01/94 028 0251 5012
13728917 RISPERIDONE 2MG BULK EXTERNAL 06/01/94 028 0251 5012
13728918 RISPERIDONE 2MG TAB EXTERNAL 06/01/94 028 0251 5012
13728919 ROCURONIUM 10MG/ML 5ML EXTERNAL 01/01/94 028 0251 5012
13728921 ROPIVACINE 7.5MG/ML INJ EXTERNAL 06/02/97 J2795 J2795 028 0636 5012
13728923 ROPIVACINE 5MG/ML INJ EXTERNAL 06/02/97 J2795 J2795 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 268
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13728924 ROPIVACINE 2MG/ML INJ EXTERNAL 06/02/97 J2795 J2795 028 0636 5012
13728925 ROPIVACINE 10MG/ML INJ EXTERNAL 06/02/97 J2795 J2795 028 0636 5012
13728927 RITUXIMAB 100MG/10ML VIAL EXTERNAL 06/02/97 J9310 J9310 028 0636 5012
13728928 RITUXIMAB 500MG/50ML VIAL EXTERNAL 03/25/03 J9310 J9310 028 0636 5012
13728929 ROPIVACINE 2MG/ML INJ EXTERNAL 04/19/05 J2795 J2795 J2795 028 0258 5012
13728932 ROCURONIUM OR 10ML VIAL EXTERNAL 11/04/95 028 0258 5012
13728933 ROCURONIUM 10MG/ML INJ EXTERNAL 08/24/94 028 0251 5012
13728934 ROFECOXIB 12.5 MG TAB EXTERNAL 06/08/01 028 0251 5012
13728935 ROFECOXIB 25MG TAB EXTERNAL 06/08/01 028 0251 5012
13728936 ROFECOXIB 50MG TABLET EXTERNAL 06/08/01 028 0251 5012
13728937 ROFECOXIB 2.5MG/ML SUSP EXTERNAL 10/02/01 028 0251 5012
13728938 ROFECOXIB 5MG/ML SUSP EXTERNAL 06/08/01 028 0251 5012
13728950 RONDEC DM DROPS 0.75ML DOSE EXTERNAL 07/01/84 028 0250 5012
13728971 ROPINIROLE 0.25MG TAB EXTERNAL 05/11/00 028 0251 5012
13728972 ROPINIROLE 0.25MG BULK EXTERNAL 05/11/00 028 0251 5012
13728973 ROPINIROLE 0.5MG TAB EXTERNAL 05/11/00 028 0251 5012
13728974 ROPINIROLE 0.5MG BULK EXTERNAL 05/11/00 028 0251 5012
13728975 ROPINIROLE 1MG TAB EXTERNAL 05/11/00 028 0251 5012
13728976 ROPINIROLE 1MG BULK EXTERNAL 05/11/00 028 0251 5012
13728977 ROPINIROLE 2MG TAB EXTERNAL 05/11/00 028 0251 5012
13728978 ROPINIROLE 2MG BULK EXTERNAL 05/11/00 028 0251 5012
13728982 ROSIGLITAZONE 2 MG BULK EXTERNAL 05/11/00 028 0251 5012
13728984 ROSIGLITAZONE 4 MG BULK EXTERNAL 05/11/00 028 0251 5012
13728986 ROSIGLITAZONE 8 MG BULK EXTERNAL 05/11/00 028 0251 5012
13728989 ROTOVIRUS VACCINE EXTERNAL 06/17/09 028 0251 5012
13728990 RUBELLA VACCINE LIVE EXTERNAL 07/01/84 028 0250 5012
13728999 RISPERIDONE 0.25MG TAB EXTERNAL 06/08/06 028 0251 5012
13729004 SALMETEROL XINAFOATE DISKS I/P EXTERNAL 06/12/00 028 0251 5012
13729007 SALT AND SODA MOUTHWASH EXTERNAL 07/02/98 028 0251 5012
13729012 SAQUINIVIR 200MG SOFT GEL CAP EXTERNAL 01/12/99 028 0251 5012
13729014 SAQUINIVIR 200MG SOFT GEL CAP EXTERNAL 06/19/06 028 0251 5012
13729016 SAQUINIVIR 500MG TAB EXTERNAL 06/19/06 028 0251 5012
13729050 SALICYLIC ACID 40% PLASTER EXTERNAL 10/19/90 028 0250 5012
13729051 CISPLAT-DOXORUB-MITOMYC-IODOXA EXTERNAL 07/29/05 028 0258 5012
13729055 CISPLAT-DOXORUB-VISIPAQ-LC BEA EXTERNAL 03/23/09 028 0258 5012
13729056 CISPLAT-MITOMYCIN-OMNIPAQUE 35 EXTERNAL 01/26/10 028 0258 5012
13729057 DOXORUB-QUADRASPHERE-OMNIPA 35 EXTERNAL 01/26/10 028 0258 5012
13729075 SALIVA SUBSTITUTE 120ML BTL EXTERNAL 07/01/84 028 0250 5012
13729078 SALSALATE 500MG - 1 BOTTLE(100 EXTERNAL 07/01/84 028 0250 5012
13729079 SALSALATE 750MG - 1 BOTTLE(100 EXTERNAL 07/01/84 028 0250 5012
13729080 EXTERNAL 07/01/84 028 0251 5012
13729081 RIVASTIGMINE 3 MG CAPSULE EXTERNAL 03/11/04 028 0251 5012
13729083 RIVASTIGMINE 1.5 MG CAPSULE EXTERNAL 03/11/04 028 0251 5012
13729084 RIVASTIGMINE 2 MG/ML SOLUTION EXTERNAL 03/11/04 028 0251 5012
13729086 RIVASTIGMINE 3 MG ORAL SOLUTIO EXTERNAL 03/11/04 028 0251 5012
13729087 RIVASTIGMINE 1.5 MG ORAL SOLUT EXTERNAL 03/11/04 028 0251 5012
13729135 SCOPOLAMINE 0.25% OPHTH SOLN 5 EXTERNAL 07/01/84 028 0250 5012
13729140 SCOPOLAMINE 0.25% OPHTH SOLN 1 EXTERNAL 07/01/84 028 0251 5012
13729141 SCOPOLAMINE 0.4MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13729144 SCOPOLAMINE 1.5 MG PATCH EXTERNAL 11/19/98 028 0251 5012
13729239 VECURONIUM NEO DRIP 10 MG EXTERNAL 06/28/01 028 0258 5012
13729240 VECURONIUM 1MG/ML INJ EXTERNAL 11/25/08 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 269
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13729286 SELEGILINE 5MG TABLET EXTERNAL 03/22/91 028 0251 5012
13729289 SERTRALINE 150MG TAB (50X3) EXTERNAL 08/12/02 028 0251 5012
13729290 SELENIUM 2.5% SHAMPOO 120ML EXTERNAL 07/01/84 028 0250 5012
13729291 SELENIUM 40MCG/ML INJ EXTERNAL 01/01/87 028 0250 5012
13729296 SERTRALINE 25MG TAB EXTERNAL 06/12/00 028 0251 5012
13729299 SERTRALINE 25 MG (50 MG X 1/2) EXTERNAL 02/19/08 028 0251 5012
13729300 SERTRALINE 50MG TAB BOX EXTERNAL 03/08/94 028 0251 5012
13729301 SERTRALINE 50MG TAB EXTERNAL 03/08/94 028 0250 5012
13729302 SERTRALINE 100MG TABLET BOX EXTERNAL 03/08/94 028 0251 5012
13729303 SERTRALINE 100MG TAB EXTERNAL 03/08/94 028 0251 5012
13729306 SEVELAMER 800 MG TABLET EXTERNAL 05/25/07 028 0251 5012
13729307 SEVOFLURANE SOLN 250ML EXTERNAL 07/16/96 028 0251 5012
13729308 SILDENAFIL 20 MG TAB EXTERNAL 03/17/05 028 0251 5012
13729309 SILDENAFIL 10MG TAB (1/2 X 20M EXTERNAL 06/18/07 028 0251 5012
13729312 SEVELAMER 400 MG TABLET EXTERNAL 05/25/07 028 0251 5012
13729313 SILDENAFIL 2.5 MG/ML ORAL SUSP EXTERNAL 02/13/08 028 0251 5012
13729314 SILDENAFIL 1 MG ORAL SUSP EXTERNAL 05/08/08 028 0251 5012
13729315 SILDENAFIL 1.5 MG ORAL SUSP EXTERNAL 05/08/08 028 0251 5012
13729316 SILDENAFIL 2 MG ORAL SUSP EXTERNAL 05/08/08 028 0251 5012
13729317 SILDENAFIL 2.5 MG ORAL SUSP EXTERNAL 05/08/08 028 0251 5012
13729318 SILDENAFIL 3 MG ORAL SUSP EXTERNAL 05/08/08 028 0251 5012
13729319 SILDENAFIL 4 MG ORAL SUSP EXTERNAL 05/08/08 028 0251 5012
13729360 SILVER NITRATE STICKS - 1 BOX EXTERNAL 07/01/84 028 0250 5012
13729365 SILVER NITRATE TOPICAL STICK EXTERNAL 06/03/92 028 0251 5012
13729370 SIMETHICONE BULK LIQUID LIQUID EXTERNAL 07/01/84 028 0250 5012
13729372 SIMETHICONE DROPS 20MG DOSE EXTERNAL 10/11/01 028 0251 5012
13729378 SIMETHICONE 40MG (PER 1/2) CHE EXTERNAL 07/01/84 028 0250 5012
13729379 SIMETHICONE 40MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13729389 CARBIDOPA-LEVODOPA 12.5/50MG ( EXTERNAL 07/20/06 028 0251 5012
13729390 SIMETHICONE 80MG CHEW TAB EXTERNAL 07/01/84 028 0250 5012
13729391 SIMETHICONE 80MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13729392 SIMVASTIN 5MG TABLET 100/BOX EXTERNAL 09/24/96 028 0251 5012
13729393 SIMVASTIN 5MG TAB EXTERNAL 09/24/96 028 0251 5012
13729395 SINCALIDE INJECTION 5MCG VIAL EXTERNAL 07/01/84 028 0250 5012
13729396 SINCALIDE 1MCG/ML INJ EXTERNAL 01/01/95 028 0258 5012
13729397 SIMVASTIN 10MG TABLET 100/BOX EXTERNAL 09/24/96 028 0251 5012
13729398 SIMVASTIN 10MG TAB EXTERNAL 09/24/96 028 0251 5012
13729401 CARBIDOPA-LEVODOPA 10MG/100MG EXTERNAL 07/01/84 028 0250 5012
13729402 SINEMET 10/100 - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13729403 SIMVASTIN 20MG TABLET 60/BOTTL EXTERNAL 09/24/96 028 0251 5012
13729404 SIMVASTIN 20MG TAB EXTERNAL 09/24/96 028 0251 5012
13729406 SIMVASTIN 40MG TABLET 60/BOTTL EXTERNAL 09/24/96 028 0251 5012
13729407 SIMVASTIN 40MG TAB EXTERNAL 09/24/96 028 0251 5012
13729408 CARBIDOPA-LEVODOPA 25MG/100MG EXTERNAL 07/01/84 028 0250 5012
13729409 SINEMET 25/100 - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13729410 SINEMET 25/250 - 1 BOX EXTERNAL 07/01/84 028 0250 5012
13729412 SIMVASTIN 80MG (40MG X 2) TAB EXTERNAL 02/19/08 028 0251 5012
13729413 CARBIDOPA-LEVODOPA 5MG/50MG TA EXTERNAL 01/23/08 028 0251 5012
13729415 CARBIDOPA-LEVODOPA 25MG/250MG EXTERNAL 07/01/84 028 0250 5012
13729420 SINOGRAFIN 10ML INJ EXTERNAL 07/01/84 028 0250 5012
13729422 NITROFURNTION MACROCRYSTALS MO EXTERNAL 07/23/03 028 0251 5012
13729424 MONTELUKAST 5MG TAB EXTERNAL 09/30/98 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 270
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13729425 MONTELUKAST 5MG CHEW TAB EXTERNAL 09/30/98 028 0251 5012
13729426 MONTELUKAST 10 MG TAB EXTERNAL 09/30/98 028 0251 5012
13729427 MONTELUKAST 10MG TAB EXTERNAL 09/30/98 028 0251 5012
13729430 SIROLIMUS* 1MG ORAL SOLN EXTERNAL 06/27/01 J7520 J7520 J7520 028 0636 5012
13729431 SIROLIMUS* 1MG ORAL SOLN EXTERNAL 06/26/01 J7520 J7520 028 0636 5012
13729432 SIROLIMUS .25MG/ML 1ML SOL EXTERNAL 02/12/01 J7520 J7520 028 0636 5012
13729434 SIROLIMUS 1MG/ML ORAL SOLN EXTERNAL 06/26/01 J7520 J7520 028 0636 5012
13729435 SIROLIMUS 1MG TAB EXTERNAL 10/05/01 J7520 J7520 028 0636 5012
13729436 SIROLIMUS 2MG TAB EXTERNAL 04/19/07 J7520 J7520 J7520 028 0636 5012
13729438 SIROLIMUS 3MG (1 MG X 3) TAB EXTERNAL 11/19/08 028 0251 5012
13729440 SIROLIMUS 4MG (2 MG X 2) TAB EXTERNAL 11/19/08 028 0251 5012
13729500 SODIUM BICARBONATE 325MG TAB EXTERNAL 07/01/84 028 0250 5012
13729501 SODIUM BICARBONATE 325MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13729504 SODIUM ACETATE NEO MEQ/KG EXTERNAL 06/12/00 028 0251 5012
13729505 SODIUM ACETATE 2MEQ/ML INJ EXTERNAL 08/24/94 028 0251 5012
13729520 SODIUM BICARBONATE 650MG TAB EXTERNAL 07/01/84 028 0250 5012
13729521 SODIUM BICARBONATE 650MG - 1 B EXTERNAL 01/25/95 028 0251 5012
13729525 SODIUM BICARBONATE 1250 MG (65 EXTERNAL 02/19/08 028 0251 5012
13729529 SODIUM BICARBONATE 4.2% 5ML SY EXTERNAL 10/04/90 028 0251 5012
13729532 SODIUM BICARBONATE 5MEQ DOSE EXTERNAL 11/15/01 028 0251 5012
13729533 SODIUM BICARBONATE 10MEQ DOSE EXTERNAL 11/15/01 028 0251 5012
13729534 SODIUM BICARBONATE 15MEQ DOSE EXTERNAL 11/15/01 028 0251 5012
13729535 SODIUM BICARBONATE 30MEQ DOSE EXTERNAL 11/15/01 028 0251 5012
13729540 SODIUM BICARBONATE 50MEQ SYRIN EXTERNAL 07/01/84 028 0250 5012
13729541 SODIUM BICARBONATE 8.4% 50MEQ EXTERNAL 07/01/84 028 0250 5012
13729543 SODIUM BICARBONATE 8.4% 50MEQ EXTERNAL 11/14/08 028 0258 5012
13729545 SODIUM BICARBONATE 50MEQ VIAL EXTERNAL 07/01/84 028 0250 5012
13729550 SODIUM BICARBONATE 10MEQ SYRIN EXTERNAL 07/01/84 028 0251 5012
13729560 SODIUM BICARBONATE 5% 500ML EXTERNAL 07/01/84 028 0258 5012
13729591 SODIUM CHLORIDE 1 GRAM TABLETS EXTERNAL 01/12/99 028 0251 5012
13729592 SODIUM BICARBONATE 4.2% - 5ML EXTERNAL 11/21/89 028 0251 5012
13729593 SODIUM BICARBONATE 4.2% INJ 5M EXTERNAL 08/22/91 028 0251 5012
13729594 SODIUM CHLORIDE 1 GM TAB EXTERNAL 01/12/99 028 0251 5012
13729595 SODIUM CHLORIDE 500 MG (1/2 X EXTERNAL 07/20/06 028 0251 5012
13729596 SODIUM CHLORIDE 2 GM (1 GM X 2 EXTERNAL 02/19/08 028 0251 5012
13729597 SODIUM CHLORIDE 3 GM (1 GM X 3 EXTERNAL 02/19/08 028 0251 5012
13729620 SODIUM CHLORIDE 5% OPHTH OINT EXTERNAL 07/01/84 028 0250 5012
13729630 SODIUM CHLORIDE 5% OPHTH SOLN EXTERNAL 07/01/84 028 0250 5012
13729649 NACL 3% NEO DRIP EXTERNAL 08/09/96 J7050 J7050 J7050 028 0258 5012
13729650 NACL 3% 500ML EXTERNAL 07/01/84 J7050 J7050 J7050 028 0251 5012
13729651 SODIUM CHLORIDE 3% SOLN (RESP) EXTERNAL 01/23/95 028 0251 5012
13729652 SODIUM CHLORIDE 0.9% (RESP) 3 EXTERNAL 05/06/08 028 0251 5012
13729653 SODIUM CHLORIDE 0.45% (RESP) I EXTERNAL 05/06/08 028 0251 5012
13729656 SODIUM CHLORIDE (PF) RESP 3ML EXTERNAL 01/01/07 028 0250 5012
13729670 SODIUM CHLORIDE (PF) RESP 5ML EXTERNAL 01/01/07 028 0250 5012
13729680 SODIUM CHLORIDE 0.9% (PF) INJ EXTERNAL 07/01/84 028 0250 5012
13729682 NACL 0.45% 50ML EXTERNAL 04/06/98 J7050 J7050 J7050 028 0258 5012
13729683 SODIUM CHLORIDE 023.4 % INJ EXTERNAL 07/25/05 028 0258 5012
13729691 NACL 0.9% 100ML (GLASS) EXTERNAL 07/27/01 J7050 J7050 J7050 028 0258 5012
13729695 NACL 0.9% INJ 250ML EXTERNAL 01/25/95 J7050 J7050 028 0636 5012
13729696 NACL 0.9% 500ML (GLASS) EXTERNAL 07/27/01 J7050 J7050 J7050 028 0258 5012
13729702 SODIUM CHLORIDE ORAL SOLUTION EXTERNAL 01/01/07 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 271
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13729705 SODIUM CHLORIDE 0.75MEQ ORAL S EXTERNAL 01/01/07 028 0250 5012
13729706 SODIUM CHLORIDE 1.5MEQ ORAL SO EXTERNAL 01/01/07 028 0250 5012
13729707 SODIUM CHLORIDE 4.5MEQ ORAL SO EXTERNAL 01/01/07 028 0250 5012
13729708 SODIUM CHLORIDE 5MEQ ORAL SOLN EXTERNAL 01/01/07 028 0250 5012
13729709 SODIUM CHLORIDE 8MEQ ORAL SOLN EXTERNAL 01/01/07 028 0251 5012
13729711 SODIUM CHLORIDE 10MEQ ORAL SOL EXTERNAL 01/01/07 028 0250 5012
13729712 SODIUM CHLORIDE 2.5MEQ ORAL SO EXTERNAL 01/01/07 028 0250 5012
13729713 SODIUM CHLORIDE 2.5MEQ/ML ORAL EXTERNAL 07/19/07 028 0251 5012
13729714 SODIUM CHLORIDE 2.5MEQ/ML ORAL EXTERNAL 03/14/05 028 0251 5012
13729720 SODIUM CHLORIDE 2.5MEQ/ML INJ EXTERNAL 01/01/07 028 0250 5012
13729731 SODIUM CHLORIDE NOSE SPRAY 45M EXTERNAL 07/01/84 028 0250 5012
13729765 NACL 0.9% IRRIGATION 500ML EXTERNAL 07/01/84 J7040 J7040 028 0636 5012
13729775 NACL 0.9% IRRIGATION 1000 ML B EXTERNAL 07/01/84 J7040 J7040 028 0636 5012
13729776 NACL 0.9% IRRIGATION 1000 ML B EXTERNAL 05/14/02 J7040 J7040 028 0636 5012
13729777 NACL 1.5% 1000 ML BAG EXTERNAL 05/02/08 J7050 J7050 J7050 028 0251 5012
13729790 NACL 0.9% IRRIGATION 4000ML EXTERNAL 07/01/84 J7040 028 0258 5012
13729860 NACL 0.45% 250 ML EXTERNAL 01/31/05 J7050 J7050 J7050 028 0258 5012
13729864 NACL 0.45% 1000ML EXTERNAL 12/17/96 J7050 J7050 J7050 028 0636 5012
13729865 NACL 0.45% 500ML EXTERNAL 07/01/84 J7050 J7050 J7050 028 0258 5012
13729867 SODIUM CHLORIDE SOLUTION EXTERNAL 07/01/84 028 0258 5012
13729870 NACL 0.9% 50ML EXTERNAL 07/01/84 J7050 J7050 028 0636 5012
13729871 SODIUM CHLORIDE 1MEQ ORAL SOLN EXTERNAL 01/01/07 028 0250 5012
13729872 SODIUM CHLORIDE 2MEQ ORAL SOLN EXTERNAL 01/01/07 028 0250 5012
13729873 SODIUM CHLORIDE 3MEQ ORAL SOLN EXTERNAL 01/01/07 028 0250 5012
13729874 SODIUM CHLORIDE 4MEQ ORAL SOLN EXTERNAL 01/01/07 028 0250 5012
13729880 NACL 0.9% 100ML EXTERNAL 07/01/84 J7050 J7050 028 0636 5012
13729890 NACL 0.9% 150ML EXTERNAL 07/01/84 J7050 J7050 028 0636 5012
13729891 NACL 0.45% 100 ML EXTERNAL 01/31/05 J7050 J7050 J7050 028 0258 5012
13729900 NACL 0.9% 250ML EXTERNAL 07/01/84 J7050 J7050 028 0636 5012
13729901 NACL 0.9% 250ML (GLASS) EXTERNAL 06/21/88 J7050 J7050 028 0636 5012
13729910 NACL 0.9% 500ML EXTERNAL 07/01/84 J7030 J7030 028 0636 5012
13729920 NACL 0.9% 1000ML EXTERNAL 07/01/84 J7050 J7050 J7050 028 0636 5012
13729925 SODIUM CHLORIDE .9%/KCL 20MEQ/ EXTERNAL 08/05/88 028 0251 5012
13729926 SODIUM CHLORIDE .9%/KCL 40MEQ/ EXTERNAL 08/05/88 028 0251 5012
13729941 CITRIC ACID-NA CITRATR 473ML S EXTERNAL 01/01/87 028 0250 5012
13729942 CITRIC ACID-NA CITRATE (EXTEMP EXTERNAL 05/01/08 028 0251 5012
13730002 BYETTA 5 MCG PEN EXTERNAL 06/01/06 028 0258 5012
13730003 BYETTA 10 MCG PEN EXTERNAL 06/01/06 028 0258 5012
13730021 SODIUM LACTATE 5MEQ/ML INJ EXTERNAL 07/01/84 028 0250 5012
13730031 SODIUM PHENYLBUTYRATE 250 GRAM EXTERNAL 03/17/97 028 0251 5012
13730032 SODIUM PHENYLBUTYRATE POWDER EXTERNAL 03/17/97 028 0251 5012
13730040 NITROPRUSSIDE INJECTION 50MG V EXTERNAL 07/01/84 028 0251 5012
13730042 SOD POLYSTYRENE SULF 10GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730043 SOD POLYSTYRENE SULF 12.5GM SU EXTERNAL 05/01/95 028 0251 5012
13730044 SOD POLYSTYRENE SULF 15GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730045 SOD POLYSTYRENE SULF 1.5GM SUS EXTERNAL 05/01/95 028 0251 5012
13730046 SOD POLYSTYRENE SULF 30GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730047 SOD POLYSTYRENE SULF 45GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730048 SOD POLYSTYRENE SULF 50GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730049 SOD POLYSTYRENE SULF 60GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730050 SOD POLYSTYRENE SULF 0.5GM SUS EXTERNAL 05/01/95 028 0251 5012
13730051 SOD POLYSTYRENE SULF 0.75GM SU EXTERNAL 05/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 272
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13730052 SOD POLYSTYRENE SULF 250MG/1ML EXTERNAL 05/01/95 028 0251 5012
13730053 SOD POLYSTYRENE SULF 2GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730054 SOD POLYSTYRENE SULF 3GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730055 SOD POLYSTYRENE SULF 4GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730056 SOD POLYSTYRENE SULF 5GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730057 SOD POLYSTYRENE SULF 6GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730058 SOD POLYSTYRENE SULF 7GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730059 SOD POLYSTYRENE SULF 8GM SUSP EXTERNAL 05/01/95 028 0251 5012
13730061 SODIUM PHOSPHATE 15MMOL/5ML IN EXTERNAL 02/08/08 028 0258 5012
13730064 SODIUM PHOSPHATE MMOL/KG PEDS- EXTERNAL 05/14/02 028 0258 5012
13730066 SODIUM PHOSPHATE 4 MEQ/ML INJ EXTERNAL 08/12/96 028 0258 5012
13730067 SODIUM PHOSPHATE MEQ/KG PEDS-N EXTERNAL 05/14/02 028 0258 5012
13730068 SODIUM POLYSTYRENE SULF15GM/60 EXTERNAL 09/04/92 028 0251 5012
13730069 SODIUM PHOSPHATE 3MMOL/ML ORAL EXTERNAL 03/18/02 028 0251 5012
13730070 SODIUM PHOSPHATE 150MMOLE VIAL EXTERNAL 11/24/90 028 0251 5012
13730071 SODIUM PHOSPHATE 3MMOL/ML INJ EXTERNAL 07/01/84 028 0258 5012
13730073 SODIUM PHOSPHATE ORAL SOL 0.5M EXTERNAL 11/15/01 028 0251 5012
13730075 SODIUM POLYSTYRENE SULF 7.5GM EXTERNAL 12/21/01 028 0251 5012
13730079 SODIUM POLYSTYRENE SULF SUSP 2 EXTERNAL 10/11/01 028 0251 5012
13730083 SODIUM POLYSTYRENE SULF SUSP 1 EXTERNAL 03/06/96 028 0251 5012
13730084 SOD POLYSTYRENE SULF 20GM SUSP EXTERNAL 03/06/96 028 0251 5012
13730085 SOD POLYSTYRENE SULF 25GM SUSP EXTERNAL 03/06/96 028 0251 5012
13730086 SODIUM POLYSTYRENE SULF SUSP 3 EXTERNAL 03/06/96 028 0251 5012
13730087 SOD POLYSTYRENE SULF 40GM SUSP EXTERNAL 03/06/96 028 0251 5012
13730089 SODIUM PHOSPHATE 15MMOLE IN D5 EXTERNAL 01/03/03 028 0258 5012
13730170 SODIUM SULFACETAMIDE 10% OPHTH EXTERNAL 07/01/84 028 0250 5012
13730182 Y DELETED EXTERNAL 12/02/91 028 0251 5012
13730189 SODIUM THIOSULFATE 250MG/ML IN EXTERNAL 07/01/84 028 0250 5012
13730191 SODIUM THIOSULFATE 100MG/ML IN EXTERNAL 07/01/84 028 0250 5012
13730193 SOMATROPIN 1MG/ML INJ EXTERNAL 03/26/02 J2941 J2941 J2941 028 0258 5012
13730194 SOMATROPIN 1MG/ML INJ EXTERNAL 04/22/02 J2941 J2941 028 0636 5012
13730196 SOMATROPIN 5MG (TEV-TROPIN) EXTERNAL 03/05/06 J2941 J2941 J2941 028 0258 5012
13730250 SORBITOL 70% SOLUTION 480ML EXTERNAL 07/01/84 028 0250 5012
13730252 SORBITOL 70% SOLN EXTERNAL 07/01/84 028 0250 5012
13730253 SORBITOL 70% 30ML SOLN EXTERNAL 04/05/94 028 0251 5012
13730254 SORBITOL 70% SOLUTION 15ML DOS EXTERNAL 10/11/01 028 0251 5012
13730261 SOTALOL 120MG TAB EXTERNAL 07/20/06 028 0251 5012
13730262 SOTALOL 40MG (1/2 X80MG) TAB EXTERNAL 05/12/94 028 0251 5012
13730263 SOTALOL 240MG 100'S EXTERNAL 06/09/93 028 0251 5012
13730265 SOTALOL 160MG 100'S EXTERNAL 06/09/93 028 0251 5012
13730266 SOTALOL 160MG TAB EXTERNAL 06/08/93 028 0251 5012
13730267 SOTALOL 80MG 100'S EXTERNAL 06/09/93 028 0251 5012
13730268 SOTALOL 80MG TAB EXTERNAL 06/08/93 028 0251 5012
13730270 SPECTINOMYCIN INJECTION 2GM VI EXTERNAL 07/01/84 J3320 J3320 J3320 028 0258 5012
13730315 SPIRONOLACTONE 200MG (100 MG X EXTERNAL 02/19/08 028 0251 5012
13730317 SPIRONOLACTONE 12.5 MG (25 MG EXTERNAL 02/19/08 028 0251 5012
13730319 SPIRONOLACTONE 50MG TAB EXTERNAL 07/19/95 028 0251 5012
13730321 SPIRONOLACTONE 25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13730326 SPIRONOLACTONE 100MG - 1 BOTTL EXTERNAL 01/25/95 028 0251 5012
13730331 SPIRONOLACTONE SUSPENSION 2MG EXTERNAL 11/15/01 028 0251 5012
13730332 SPIRONOLACTONE SUSPENSION 2.5M EXTERNAL 11/15/01 028 0251 5012
13730334 SPIRONOLACTONE SUSPENSION 6MG EXTERNAL 11/15/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 273
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13730335 SPIRONOLACTONE SUSPENSION 10MG EXTERNAL 11/15/01 028 0251 5012
13730336 SPIRONOLACTONE SUSPENSION 15MG EXTERNAL 11/15/01 028 0251 5012
13730337 SPIRONOLACTONE 0.5MG SUSPENSIO EXTERNAL 12/21/01 J3320 J3320 J3320 028 0251 5012
13730338 SPIRONOLACTONE 1MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13730339 SPIRONOLACTONE 1.5MG SUSPENSIO EXTERNAL 12/21/01 028 0251 5012
13730340 SPIRONOLACTONE 9MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13730341 SPIRONOLACTONE 12.5MG SUSPENSI EXTERNAL 12/21/01 028 0251 5012
13730342 SPIRONOLACTONE 25MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13730375 STAVUDINE 15MG (BULK) EXTERNAL 11/05/95 028 0251 5012
13730376 STAVUDINE 15MG CAP EXTERNAL 11/05/95 028 0251 5012
13730377 STAVUDINE 20MG (BULK) EXTERNAL 11/05/95 028 0251 5012
13730378 STAVUDINE 20MG CAP EXTERNAL 11/05/95 028 0251 5012
13730379 STAVUDINE 30MG (BULK) EXTERNAL 11/05/95 028 0251 5012
13730380 STAVUDINE 30MG CAP EXTERNAL 11/05/95 028 0251 5012
13730381 STAVUDINE 40MG (BULK) EXTERNAL 11/05/95 028 0251 5012
13730382 STAVUDINE 40MG CAP EXTERNAL 11/05/95 028 0251 5012
13730415 STREP ID KIT EXTERNAL 01/25/95 028 0251 5012
13730416 STERILE TALC 5 GM/100ML SLURRY EXTERNAL 02/25/08 028 0251 5012
13730430 STREPTOMYCIN 400MG/ML INJ EXTERNAL 07/01/84 J3000 J3000 028 0636 5012
13730437 STREPTOMYCIN 400MG/ML FOR IVPB EXTERNAL 04/08/08 028 0258 5012
13730466 SUCCIMER 100MG CAP EXTERNAL 10/02/91 028 0251 5012
13730480 SUCCINYLCHOLINE 20MG/ML INJ EXTERNAL 07/01/84 J0330 J0330 028 0636 5012
13730482 SUCCINYLCHOLINE 50MG/ML INJ EXTERNAL 07/01/84 J0330 J0330 028 0636 5012
13730483 SUCCINYLCHOLINE DRIP - 20ML BA EXTERNAL 07/01/84 028 0258 5012
13730489 SUCRALFATE 100 MG/ML SUSP (EXT EXTERNAL 05/06/08 028 0251 5012
13730492 SUCRALFATE 1GM - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13730493 SUCRALFATE 1GM SUSP EXTERNAL 09/07/90 028 0251 5012
13730494 SUCRALFATE SUSP 150MG DOSE EXTERNAL 10/11/01 028 0251 5012
13730495 SUCRALFATE SUSP 200MG DOSE EXTERNAL 10/11/01 028 0251 5012
13730497 SUCROSE 24% ORAL SOLUTION (ML) EXTERNAL 01/26/04 028 0251 5012
13730498 SUCRALFATE SUSP 500 MG EXTERNAL 10/11/01 028 0251 5012
13730499 SUCROSE 24% ORAL SOLUTION (GTT EXTERNAL 11/19/08 028 0251 5012
13730511 SUFENTANIL CITRATE 50MCG/ML IN EXTERNAL 07/01/84 028 0250 5012
13730512 SUFENTANIL CITRATE 100MCG AMPU EXTERNAL 07/01/84 028 0250 5012
13730515 SODIUM SULFACETAMIDE-SULFUR LO EXTERNAL 07/01/84 028 0250 5012
13730525 SILVER SULFADIAZINE 1% CREAM 2 EXTERNAL 07/01/84 028 0250 5012
13730530 SILVER SULFADIAZINE 1% CREAM 5 EXTERNAL 07/01/84 028 0250 5012
13730540 SILVER SULFADIAZINE 1% CREAM 4 EXTERNAL 07/01/84 028 0250 5012
13730587 SULFASALAZINE 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13730704 SURGIFOAM SPONGE SIZE 12 X 7 - EXTERNAL 05/07/01 028 0251 5012
13730709 SUNSCREEN LOTION 120ML EXTERNAL 01/25/95 028 0251 5012
13730711 SURGICEL 1/2"X2" REAGENT - 1 V EXTERNAL 02/04/87 028 0250 5012
13730712 SUMATRIPTAN 6MG INJ KIT EXTERNAL 05/24/93 J3030 J3030 J3030 028 0258 5012
13730713 SUMATRIPTAN 6MG/0.5ML INJ EXTERNAL 06/08/93 J3030 J3030 028 0636 5012
13730714 SUMATRIPTAN 6MG/.5ML SDV EXTERNAL 06/08/93 J3030 J3030 J3030 028 0251 5012
13730750 SIMPLE SYRUP EXTERNAL 07/01/84 028 0251 5012
13730752 TACROLIMUS 0.5 MG/ML ORAL SUSP EXTERNAL 02/13/08 J7507 J7507 J7507 028 0251 5012
13730772 TACROLIMUS CAPS 1 MG (PER BTL) EXTERNAL 01/31/97 J7507 J7507 J7507 028 0251 5012
13730773 TACROLIMUS* 1MG CAP EXTERNAL 01/31/97 J7507 J7507 J7507 028 0636 5012
13730774 TACROLIMUS CAPS 1 MG (5 X 1MG EXTERNAL 01/31/97 J7507 J7507 J7507 028 0251 5012
13730775 TACROLIMUS* 5MG CAP EXTERNAL 01/31/97 J7507 J7507 J7507 028 0636 5012
13730776 TACROLIMUS* 6 MG (1 MG X 6) CA EXTERNAL 07/31/01 J7507 J7507 J7507 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 274
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13730777 TACROLIMUS* 7 MG (1 MG X 7) CA EXTERNAL 07/31/01 J7507 J7507 J7507 028 0636 5012
13730778 TACROLIMUS* 8 MG (1 MG X 8) CA EXTERNAL 07/31/01 J7507 J7507 J7507 028 0636 5012
13730779 TACROLIMUS* 9 MG (1 MG X 9) CA EXTERNAL 07/31/01 J7507 J7507 J7507 028 0636 5012
13730780 TACROLIMUS 0.5MG CAP EXTERNAL 04/25/02 J7507 J7507 J7507 028 0251 5012
13730781 TACROLIMUS* 2MG (1 MG X 2) EXTERNAL 08/12/02 J7507 J7507 J7507 028 0636 5012
13730782 TACROLIMUS 3 MG ( 1 MG X 3) CA EXTERNAL 08/12/02 J7507 J7507 J7507 028 0636 5012
13730783 TACROLIMUS* 4MG (1 MG X 4) CAP EXTERNAL 08/12/02 J7507 J7507 J7507 028 0636 5012
13730784 TACROLIMUS 0.5MG CAP EXTERNAL 12/04/02 J7507 J7507 028 0636 5012
13730785 TALC (STERILE) EXTERNAL 03/11/04 028 0251 5012
13730786 TACROLIMUS 5 MG/ML INJ EXTERNAL 03/15/05 J7507 J7507 J7507 028 0258 5012
13730787 TACROLIMUS 0.25 MG ORAL SUSP EXTERNAL 05/06/08 J7507 J7507 J7507 028 0251 5012
13730788 TACROLIMUS 0.75 MG ORAL SUSP EXTERNAL 05/06/08 J7507 J7507 J7507 028 0251 5012
13730789 TAMOXIFEN 5MG (1/2 X 10 MG) TA EXTERNAL 07/20/06 028 0251 5012
13730791 TAMOXIFEN CITRATE 10MG - 1 BTL EXTERNAL 01/25/95 028 0251 5012
13730792 TACROLIMUS 1.25 MG ORAL SUSP EXTERNAL 05/06/08 J7507 J7507 J7507 028 0251 5012
13730800 TAMSULOSIN 0.4 MG CAPSULE EXTERNAL 07/25/05 028 0251 5012
13730801 ARTIFICIAL TEARS SOLN 30ML BOT EXTERNAL 07/01/84 028 0250 5012
13730805 TELMISARTAN 40 MG TABLET EXTERNAL 03/18/05 028 0251 5012
13730806 TELMISARTAN 80 MG TABLET EXTERNAL 06/27/05 028 0251 5012
13730807 TELMISARTAN 20 MG (1/2 X 40MG) EXTERNAL 07/20/06 028 0251 5012
13730820 TENOFOVIR 300 MG TABLET EXTERNAL 01/26/04 028 0251 5012
13730853 TEMAZEPAM 15MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13730861 TERBUTALINE SULFATE 2.5MG TAB EXTERNAL 07/01/84 028 0250 5012
13730862 TERBUTALINE SULFATE 2.5MG - 1 EXTERNAL 01/25/95 J3105 J3105 028 0636 5012
13730879 TERBUTALINE SULFATE 5MG - 1 BO EXTERNAL 01/25/95 028 0251 5012
13730880 TERBUTALINE SULFATE 5MG TAB EXTERNAL 07/01/84 028 0250 5012
13730881 TERBUTALINE SULFATE 1MG/ML INJ EXTERNAL 07/01/84 J3105 J3105 028 0636 5012
13730894 TERBUTALINE 1MG/ML FOR NEBULIZ EXTERNAL 12/03/97 J7681 J7681 028 0636 5012
13730941 TESTOSTERONE CYPIONATE 100MG/M EXTERNAL 07/01/84 J1070 J1070 J1070 028 0636 5012
13730942 TESTOSTERONE CYPIONATE 200MG/M EXTERNAL 11/20/98 J1080 J1080 J1080 028 0636 5012
13730960 TESTOSTERONE ENANTHATE 200MG/M EXTERNAL 07/01/84 J3130 J3130 028 0636 5012
13731000 SODIUM PHOSPHATE 0.16MEQ/ML PE EXTERNAL 04/30/03 028 0258 5012
13731001 SODIUM PHOSPHATE 0.12MMOL/ML P EXTERNAL 04/30/03 028 0258 5012
13731002 SODIUM PHOSPHATE 0.067MEQ/ML P EXTERNAL 04/30/03 028 0258 5012
13731003 SODIUM PHOSPHATE 0.05MMOL/ML P EXTERNAL 04/30/03 028 0258 5012
13731030 TETANUS IMMUNE GLOBULIN 250UNI EXTERNAL 07/01/84 J1670 J1670 028 0636 5012
13731040 TETANUS TOXOID ADSORBED 5.0 ML EXTERNAL 07/01/84 028 0250 5012
13731041 TETANUS DIPHTHERIA ACELLULAR P EXTERNAL 05/25/07 028 0258 5012
13731043 TETANUS DIPHTHERIA ACELLULAR P EXTERNAL 01/12/10 028 0258 5012
13731051 DIPH-TETANUS-TOX ADS PEDS 0.5M EXTERNAL 07/01/84 028 0250 5012
13731060 TETANUS TOXOID FLUID 0.5ML SYR EXTERNAL 07/01/84 028 0250 5012
13731090 TETRACAINE 2% SOLUTION 120ML B EXTERNAL 07/01/84 028 0250 5012
13731091 TETRACAINE 2% SOLN 30ML EXTERNAL 07/01/84 028 0250 5012
13731100 TETRACAINE 0.5% OPHTH SOLN 2ML EXTERNAL 07/01/84 028 0250 5012
13731101 TETRACAINE 0.5% OPHTH SOLN 15 EXTERNAL 01/23/08 028 0251 5012
13731140 TETRACYCLINE 250MG CAP EXTERNAL 07/01/84 028 0250 5012
13731141 TETRACYCLINE 250MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13731151 TETRACYCLINE 500MG CAP EXTERNAL 07/01/84 028 0250 5012
13731152 TETRACYCLINE 500MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13731244 THEOPHYLLINE 300MG CAP - 1 BOX EXTERNAL 10/14/92 028 0251 5012
13731248 THEOPHYLLIN GYROCAPS EXTERNAL 07/01/84 028 0250 5012
13731250 THEOPHYLLINE ELIXIR 480ML (1 P EXTERNAL 07/01/84 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 275
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13731252 THEOPHYLLINE 5.33MG/ML ELIXIR EXTERNAL 07/01/84 028 0250 5012
13731254 THEOPHYLLINE 300MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13731260 THEOPHYLLINE 30MG ELIXIR EXTERNAL 07/01/84 028 0251 5012
13731265 THEOPHYLLINE 15MG ELIXIR EXTERNAL 07/01/84 028 0251 5012
13731269 THEOPHYLLINE SR 450MG - 1 BOTT EXTERNAL 07/01/84 028 0251 5012
13731270 THEOPHYLLINE 450MG SR TAB EXTERNAL 07/01/84 028 0250 5012
13731272 THEOPHYLLINE 100MG SR TAB EXTERNAL 07/01/84 028 0250 5012
13731277 THEOPHYLLINE SR 200MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13731278 THEOPHYLLINE SR 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13731280 THEOPHYLLINE 300MG SR TAB EXTERNAL 07/01/84 028 0250 5012
13731281 THEOPHYLLINE SR 300MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13731282 THEOPHYLLINE 40MG/D5W 500ML B EXTERNAL 07/01/84 J2810 J2810 028 0636 5012
13731284 THEOPHYLLINE 40MG FOR 250ML LV EXTERNAL 12/16/98 J2810 J2810 J2810 028 0258 5012
13731286 THEOPHYLLINE 150MG (1/2 X 300M EXTERNAL 04/08/94 028 0251 5012
13731290 MULTIVITAMIN THERAPEUTIC TAB EXTERNAL 07/01/84 028 0251 5012
13731302 VORICONAZOLE 200MG/20ML EXTERNAL 02/13/04 J3465 J3465 028 0636 5012
13731339 THIAMINE 50MG (1/2 X 100 MG) T EXTERNAL 07/20/06 028 0251 5012
13731340 THIAMINE HCL 100MG TAB EXTERNAL 07/01/84 028 0250 5012
13731341 THIAMINE HCL 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13731349 THEOPHYLLINE ELIXIR 100MG DOSE EXTERNAL 10/11/01 028 0251 5012
13731351 THEOPHYLLINE 1MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731352 THEOPHYLLINE 1.3MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731353 THEOPHYLLINE 1.6MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731354 THEOPHYLLINE 2.1MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731355 THEOPHYLLINE 2.6MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731356 THEOPHYLLINE 3.2MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731357 THEOPHYLLINE 4.2MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731358 THEOPHYLLINE 5.5MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731359 THEOPHYLLINE 7MG ELIXER EXTERNAL 05/27/98 028 0251 5012
13731360 THEOPHYLLINE 8.5MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731361 THEOPHYLLINE 10.5MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731362 THEOPHYLLINE 13 MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731363 THEOPHYLLINE 16MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731364 THEOPHYLLINE 21MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731365 THEOPHYLLINE 26MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731366 THEOPHYLLINE 32MG ELIXER EXTERNAL 05/27/98 028 0251 5012
13731367 THEOPHYLLINE 40MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731368 THEOPHYLLINE 50MG ELIXIR EXTERNAL 05/27/98 028 0251 5012
13731369 THEOPHYLLINE 64MG ELIXER EXTERNAL 05/27/98 028 0251 5012
13731370 THIAMINE 100MG INJ EXTERNAL 07/01/84 J3411 J3411 028 0636 5012
13731371 THEOPHYLLINE 3MG ELIXIR EXTERNAL 12/21/01 028 0251 5012
13731372 THEOPHYLLINE 5MG ELIXER EXTERNAL 12/21/01 028 0251 5012
13731373 THEOPHYLLINE 6.5MG ELIXER EXTERNAL 12/21/01 028 0251 5012
13731374 THEOPHYLLINE 8MG ELIXER EXTERNAL 12/21/01 028 0251 5012
13731377 THEOPHYLLINE 80MG ELIXER EXTERNAL 12/21/01 028 0251 5012
13731380 THIAMINE HCL INJECTION 100MG S EXTERNAL 07/01/84 028 0250 5012
13731381 THIAMINE 100 MG/ML INJ EXTERNAL 08/13/96 J3411 J3411 028 0636 5012
13731400 THIOGUANINE 40MG TAB EXTERNAL 07/01/84 J8999 J8999 028 0636 5012
13731401 THIOGUANINE 40MG - 1 BTTLE(25) EXTERNAL 01/25/95 028 0250 5012
13731421 THIOPENTAL SODIUM 25MG/ML INJ EXTERNAL 07/01/84 028 0251 5012
13731423 THIOPENTAL SODIUM 25MG/ML BULK EXTERNAL 11/20/98 028 0258 5012
13731510 THIOTEPA 10MG/ML INJ EXTERNAL 07/01/84 J9340 J9340 J9340 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 276
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13731566 THROMBIN-JMI EPISTAXIS KIT EXTERNAL 09/24/08 028 0251 5012
13731567 THROMBIN 5000 UNIT KIT EXTERNAL 01/01/87 028 0250 5012
13731570 THROMBIN 5000 UNITS POWDER EXTERNAL 07/01/84 028 0250 5012
13731583 THROMBIN 20,000 UNITS SPRAY KI EXTERNAL 06/27/01 028 0251 5012
13731601 FIBRIN SEALANT (TISSEAL) 5 ML EXTERNAL 04/13/06 028 0251 5012
13731718 TICARCILLIN INJ***MG EXTERNAL 01/07/87 028 0250 5012
13731724 TICARCILLIN 3GM/D5W 50ML BAG EXTERNAL 07/01/84 028 0251 5012
13731725 TIMOLOL 0.25% OPHTH SOLN 5ML EXTERNAL 07/01/84 028 0251 5012
13731727 TIMOLOL 0.5% OPHTH SOLN 5ML EXTERNAL 07/01/84 028 0251 5012
13731728 TIMOLOL 0.5% OPHTH SOLN 15ML EXTERNAL 07/01/84 028 0251 5012
13731729 POLYMYXIN B-TRIMETHOPRIM OPHTH EXTERNAL 06/08/93 028 0251 5012
13731730 ALTEPLASE RECOMBINANT INJ 1MG EXTERNAL 03/22/88 J2997 J2997 J2997 028 0636 5012
13731734 ALTEPLASE, RECOMBINANT 1MG EXTERNAL 03/08/93 J2997 J2997 J2997 028 0636 5012
13731736 ALTEPLASE RECOMB 1MG/ML INJ EXTERNAL 09/04/92 J2997 J2997 J2997 028 0636 5012
13731737 GENTAMICIN-PREDNISOLONE OPHTH EXTERNAL 09/24/89 028 0251 5012
13731738 GENTAMICIN-PREDNISOLONE OPHTH EXTERNAL 09/27/89 028 0251 5012
13731739 PHYSIOLOGIC IRRIG SOLN 1000ML EXTERNAL 07/01/84 028 0250 5012
13731742 TIMOLOL XE 0.25% OPHTH GEL 5ML EXTERNAL 10/24/94 028 0251 5012
13731743 TIMOLOL XE 0.5% OPHTH GEL 5ML EXTERNAL 10/24/94 028 0251 5012
13731745 DEXAMETHASONE-TOBRAMYCIN OPHTH EXTERNAL 03/06/96 028 0251 5012
13731746 DEXAMETHASONE-TOBRAMYCIN OPHTH EXTERNAL 01/03/05 028 0251 5012
13731747 DORZOLAMIDE-TIMOLOL 2%/ 0.5% EXTERNAL 09/30/98 028 0251 5012
13731751 ALTEPLASE 1MG/1ML SYRINGE EXTERNAL 05/01/01 J2997 J2997 J2997 028 0258 5012
13731752 ALTEPLASE 1MG VIAL (CATHFLOACT EXTERNAL 04/09/02 J2997 J2997 J2997 028 0258 5012
13731761 TIOTROPIUM POWDER FOR INHALATI EXTERNAL 12/22/04 028 0251 5012
13731769 TOBRAMYCIN 10 MG/ML INJECTION EXTERNAL 08/21/07 028 0258 5012
13731773 TOCAINIDE 400MG - 1 BOX EXTERNAL 01/01/87 028 0250 5012
13731774 TOBRAMYCIN 40 MG/ML INJECTION EXTERNAL 02/21/08 028 0258 5012
13731791 VITAMIN E DROPS 50U/ML 12ML BT EXTERNAL 07/01/84 028 0251 5012
13731798 VITAMIN E 800 IU (400 INTL UNI EXTERNAL 11/25/08 028 0251 5012
13731817 DEXMEDETOMIDINE 100 MCG/ML EXTERNAL 01/23/09 028 0258 5012
13731881 TOLMETIN 200MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13731884 CTR0{CSMT S HMNUA21 EXTERNAL 02/07/90 028 0251 5012
13731886 TOPOTECAN 1MG/ML INJ EXTERNAL 03/24/98 J9350 J9350 028 0636 5012
13731892 TRACE ELEMENT MIXTURE 3ML VIAL EXTERNAL 10/19/90 028 0250 5012
13731981 TRAMADOL 25 MG TAB EXTERNAL 01/22/07 028 0251 5012
13731982 TRAMADOL 50 MG TAB EXTERNAL 08/24/06 028 0251 5012
13732093 TRIAMCINOLONE ACET 0.1% CRM 80 EXTERNAL 06/08/89 028 0250 5012
13732094 TRIAMCINOLONE ACET 0.025% OINT EXTERNAL 06/08/89 028 0250 5012
13732095 TRIAMCINOLONE ACET 0.025% CRM EXTERNAL 06/08/89 028 0250 5012
13732130 TRIAMCINOLONE ACET 0.1% OINT EXTERNAL 07/01/84 028 0251 5012
13732131 TRIAMCINOLONE ACET 0.1% OINT 4 EXTERNAL 10/02/01 028 0251 5012
13732132 TRIAMCINOLONE ACET 0.1% CRM 45 EXTERNAL 10/02/01 028 0251 5012
13732133 TRIAMCINOLONE ACET 0.1% OINT 8 EXTERNAL 10/02/01 028 0251 5012
13732134 TRIAMCINOLONE ACET 0.025% CRM EXTERNAL 10/02/01 028 0251 5012
13732135 TRIAMCINOLONE ACET 0.025% OINT EXTERNAL 10/02/01 028 0251 5012
13732150 TRIAMCINOLONE ACET 0.1% LOTION EXTERNAL 07/01/84 028 0251 5012
13732180 TRIAMCINOLONE ACET 10MG/ML INJ EXTERNAL 07/01/84 J3301 J3301 028 0636 5012
13732190 TRIAMCINOLONE ACET INJ 10MG VI EXTERNAL 07/01/84 J3301 J3301 028 0636 5012
13732280 TRIAMCINOLONE ACET 0.1% DENTAL EXTERNAL 07/01/84 028 0251 5012
13732301 TRIAMTERENE 100MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13732319 TRIAZOLAM 0.25MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 277
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13732325 TRICHOPHYTON 1:1000 SKIN TEST EXTERNAL 07/01/84 028 0250 5012
13732402 OMNISCAN 10ML PFS - 1 CASE EXTERNAL 08/23/07 028 0251 5012
13732403 OMNISCAN 15ML PFS - 1 CASE EXTERNAL 08/23/07 028 0251 5012
13732404 OMNISCAN 20ML VIAL- 1 CASE EXTERNAL 06/04/08 028 0251 5012
13732405 OMNISCAN 50ML VIAL- 1 CASE EXTERNAL 08/23/07 028 0251 5012
13732406 MULTIHANCE 10ML-1CASE EXTERNAL 08/23/07 028 0251 5012
13732407 MULTIHANCE 15ML-1CASE EXTERNAL 08/23/07 028 0251 5012
13732408 MULTIHANCE 20ML-1CASE EXTERNAL 08/23/07 028 0251 5012
13732686 TRIPLE SULFA - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13732691 TROMETHAMINE 36MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13732695 TRYPSIN, BALSAM PERU, CASTOR O EXTERNAL 07/06/06 028 0251 5012
13732710 TROPICAMIDE 0.5% OPHTH SOLN 15 EXTERNAL 07/01/84 028 0250 5012
13732721 TROPICAMIDE 1% OPHTH SOLN 2ML EXTERNAL 07/01/84 028 0250 5012
13732760 TUBERCULIN PPD 5TU/0.1ML INJ EXTERNAL 07/01/84 028 0250 5012
13732770 TUBERCULIN PPD INJECTION (1TU) EXTERNAL 07/01/84 028 0250 5012
13732775 TRYPAN BLUE 0.06% OPHTH SOLN EXTERNAL 04/19/05 028 0251 5012
13732782 TYPHOID VACCINE EC CAP EXTERNAL 11/19/90 028 0251 5012
13732875 TYROPANOATE SODIUM - 1 PACK EXTERNAL 07/01/84 028 0250 5012
13732901 URSODIOL 100 MG SUSPENSION EXTERNAL 10/24/97 028 0251 5012
13732902 URSODIOL 150 MG SUSPENSION EXTERNAL 06/26/03 028 0251 5012
13732905 UREA 20% CREAM 480GM EXTERNAL 07/01/84 028 0250 5012
13732907 URSODIOL 7.5MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13732918 URSODIOL 300MG - 1 BOTTLE EXTERNAL 04/12/89 028 0251 5012
13732919 URSODIOL ORAL SUSPENSION 20MG EXTERNAL 11/15/01 028 0251 5012
13732921 VALPROIC ACID 250MG SYRUP EXTERNAL 07/01/84 028 0250 5012
13732922 VALPROIC ACID SYRUP 480ML BOTT EXTERNAL 07/01/84 028 0251 5012
13732924 URSODIOL ORAL SUSPENSION 35MG EXTERNAL 11/15/01 028 0251 5012
13732927 URSODIOL 50MG SUSPENSION EXTERNAL 10/24/97 028 0251 5012
13732928 URSODIOL 75MG SUSPENSION EXTERNAL 10/24/97 028 0251 5012
13732930 VANCOMYCIN 50MG/ML INJ EXTERNAL 07/01/84 J3370 J3370 J3370 028 0636 5012
13732932 VANCOMYCIN 0.05GM/ML INJ EXTERNAL 01/01/87 J3370 J3370 028 0636 5012
13732933 VANCOMYCIN 500 MG / D5W 100ML EXTERNAL 03/26/88 J3370 J3370 028 0636 5012
13732934 VANCOMYCIN 1000MG/D5W 200ML EXTERNAL 02/06/89 J3370 J3370 J3370 028 0636 5012
13732937 VANCOMYCIN ORAL SOLUTION 100MG EXTERNAL 11/05/01 028 0251 5012
13732938 VANCOMYCIN ORAL SOLUTION 125MG EXTERNAL 11/05/01 028 0251 5012
13732939 VANCOMYCIN ORAL SOLUTION 500MG EXTERNAL 11/05/01 028 0251 5012
13732940 VALPROIC ACID 100MG/ML INJ EXTERNAL 01/24/00 028 0258 5012
13732943 URSODIOL ORAL SUSPENSION 250MG EXTERNAL 11/15/01 028 0251 5012
13732944 URSODIOL ORAL SUSPENSION 300MG EXTERNAL 11/15/01 028 0251 5012
13732945 URSODIOL 10MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13732946 URSODIOL 15MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13732947 URSODIOL 25MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13732948 URSODIOL 30MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13732949 URSODIOL 200MG SUSPENSION EXTERNAL 12/21/01 028 0251 5012
13732950 VANCOMYCIN 50MG/ML ORAL SOLUTI EXTERNAL 03/18/02 028 0251 5012
13732951 VANCOMYCIN 10MG/ML INTRA-VENTR EXTERNAL 11/23/98 J3370 J3370 J3370 028 0258 5012
13732952 VANCOMYCIN 5 MG/ML PEDS INJ EXTERNAL 11/23/98 J3370 J3370 J3370 028 0636 5012
13732953 VANCOMYCIN 750MG/D5W 150ML EXTERNAL 08/11/97 J3370 J3370 J3370 028 0636 5012
13732954 VANCOMYCIN 1250MG/D5W 250ML EXTERNAL 08/11/97 J3370 J3370 J3370 028 0636 5012
13732970 VARICELLA VACCINE VFC EXTERNAL 01/12/10 028 0258 5012
13732976 OMNIPAQUE 350MG/ML 500 ML - 1 EXTERNAL 11/16/09 028 0251 5012
13732977 TPN ADDITIVE EXTERNAL 02/10/06 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 278
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13732978 OMNIPAQUE 9 MG/ML 1000 ML EXTERNAL 11/12/08 028 0251 5012
13732979 OMNIPAQUE 240 MG/ML 20 ML - 1 EXTERNAL 06/09/08 028 0251 5012
13732980 OMNIPAQUE 300MG/ML 50 ML - 1 C EXTERNAL 05/11/06 028 0251 5012
13732981 OMNIPAQUE 300MG/ML 100 ML - 1 EXTERNAL 05/11/06 028 0251 5012
13732982 OMNIPAQUE 300MG/ML 150 ML - 1 EXTERNAL 05/11/06 028 0251 5012
13732983 OMNIPAQUE 300MG/ML 500 ML - 1 EXTERNAL 05/11/06 028 0251 5012
13732984 OMNIPAQUE 350MG/ML 50 ML - 1 C EXTERNAL 05/11/06 028 0251 5012
13732985 OMNIPAQUE 350MG/ML 200 ML - 1 EXTERNAL 05/11/06 028 0251 5012
13732986 VISIPAQUE 320MG/ML 50 ML - 1 C EXTERNAL 05/11/06 028 0251 5012
13732987 VISIPAQUE 320MG/ML 100 ML - 1 EXTERNAL 05/11/06 028 0251 5012
13732988 VISIPAQUE 320MG/ML 150 ML - 1 EXTERNAL 05/11/06 028 0251 5012
13732989 HYPAQUE 60% 50 ML - 1 CASE (25 EXTERNAL 06/07/06 028 0251 5012
13732990 OMNISCAN 287MG/ML PFS 20 ML- 1 EXTERNAL 06/07/06 028 0251 5012
13732991 OMNIPAQUE 180 MG/ML 20 ML - 1 EXTERNAL 06/12/06 028 0251 5012
13732992 OMNIPAQUE 240 MG/ML 10 ML - 1 EXTERNAL 06/12/06 028 0251 5012
13732993 OMNIPAQUE 300 MG/ML 30ML - 1CA EXTERNAL 06/12/06 028 0251 5012
13732994 SINOGRAFIN 38% - 1CASE EXTERNAL 06/12/06 028 0251 5012
13732995 HEXABRIX 320 MG/ML - 1 CASE (2 EXTERNAL 06/07/06 028 0251 5012
13732996 HYPAQUE 60% 50 ML - 1 VIAL EXTERNAL 06/12/06 028 0251 5012
13732997 ISOVUE 300-61% INJECTION-1 CAS EXTERNAL 06/12/06 028 0251 5012
13732998 OMNIPAQUE 350 MG/ML 100 ML - 1 EXTERNAL 04/16/08 028 0258 5012
13732999 OMNIPAQUE 240 MG/ML 50 ML - 1 EXTERNAL 06/04/08 028 0251 5012
13733000 ETANERCEPT 25MG - 1 BOX EXTERNAL 06/01/06 028 0258 5012
13733001 TACROLIMUS 0.5MG CAPS (PER BOT EXTERNAL 06/01/06 J7507 J7507 J7507 028 0251 5012
13733002 HEXABRIX 320 MG/ML - 1 BTL EXTERNAL 08/10/06 028 0251 5012
13733003 HYPAQUE 60% 50 ML - 1 UNIT EXTERNAL 08/10/06 028 0251 5012
13733004 OMNIPAQUE 180 MG/ML 20 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733005 OMNIPAQUE 240 MG/ML 10 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733006 OMNIPAQUE 300 MG/ML 30ML- 1 UN EXTERNAL 08/10/06 028 0251 5012
13733007 OMNIPAQUE 300MG/ML 50 ML - 1 U EXTERNAL 08/10/06 028 0251 5012
13733008 OMNIPAQUE 300MG/ML 100 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733009 OMNIPAQUE 300MG/ML 150 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733010 OMNIPAQUE 300MG/ML 500 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733011 OMNIPAQUE 350MG/ML 50 ML - 1 U EXTERNAL 08/10/06 028 0251 5012
13733012 OMNIPAQUE 350MG/ML 200 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733013 OMNISCAN 287MG/ML PFS 20 ML - EXTERNAL 08/10/06 028 0251 5012
13733014 SINOGRAFIN 38% - 1 EACH EXTERNAL 08/10/06 028 0251 5012
13733015 VISIPAQUE 320MG/ML 50 ML - 1 U EXTERNAL 08/10/06 028 0251 5012
13733016 VISIPAQUE 320MG/ML 100 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733017 VISIPAQUE 320MG/ML 150 ML - 1 EXTERNAL 08/10/06 028 0251 5012
13733018 OMNIPAQUE 240 MG/ML - 50 ML 1 EXTERNAL 08/10/06 028 0251 5012
13733019 OMNIPAQUE 26ML/1000 ML WATER EXTERNAL 04/10/07 028 0251 5012
13733022 VARICELLA VACCINE INJ EXTERNAL 02/07/96 028 0258 5012
13733024 OMNIPAQUE 350 MG/ML 24ML CUP EXTERNAL 04/30/08 028 0251 5012
13733025 OMNISCAN 10ML PFS 1-EACH EXTERNAL 08/23/07 028 0251 5012
13733026 OMNISCAN 15ML PFS - 1 EACH EXTERNAL 08/23/07 028 0251 5012
13733027 OMNIPAQUE 350MG/ML 500 ML - 1 EXTERNAL 11/16/09 028 0251 5012
13733028 OMNISCAN 50ML VIAL - 1 EACH EXTERNAL 08/23/07 028 0251 5012
13733029 MULTIHANCE 10ML-1 EACH EXTERNAL 08/23/07 028 0251 5012
13733030 MULTIHANCE 15ML-1 EACH EXTERNAL 08/23/07 028 0251 5012
13733031 MULTIHANCE 20ML-1 EACH EXTERNAL 08/23/07 028 0251 5012
13733032 OMNISCAN 20ML VIAL EXTERNAL 06/04/08 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 279
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13733033 OMNIPAQUE 240 MG/ML 20 ML - 1 EXTERNAL 06/10/08 028 0251 5012
13733042 VENLAFAXINE 25MG U.D. 100'S EXTERNAL 11/25/94 028 0251 5012
13733045 VENLAFAXINE 37.5MG U.D. 100'S EXTERNAL 11/25/94 028 0251 5012
13733048 VENLAFAXINE 50MG U.D. 100'S EXTERNAL 11/25/94 028 0251 5012
13733051 VENLAFAXINE 75MG U.D. 100'S EXTERNAL 11/25/94 028 0251 5012
13733054 VENLAFAXINE 100MG U.D. 100'S EXTERNAL 11/25/94 028 0251 5012
13733065 VANCOMYCIN 1.5GM IVPB EXTERNAL 11/23/98 J3370 J3370 028 0636 5012
13733067 VENLAFAXINE 225 MG (75 MG X 3) EXTERNAL 02/19/08 028 0251 5012
13733070 NAPHAZOLINE 0.1% OPHTH SOLN 15 EXTERNAL 07/01/84 028 0250 5012
13733080 VASOPRESSIN 20UNITS/ML INJ EXTERNAL 07/01/84 028 0250 5012
13733083 VASOPRESSIN 100 UNITS FOR 250 EXTERNAL 11/24/98 028 0258 5012
13733084 VASOPRESSIN 20 UNITS FOR 50 ML EXTERNAL 04/08/08 028 0258 5012
13733085 VASOPRESSIN 20 UNITS/ML (ADULT EXTERNAL 04/08/08 028 0258 5012
13733087 VERAPAMIL 80MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13733088 VERAPAMIL 120MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13733089 VECURONIUM 1MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13733093 VERAPAMIL INJECTION 10MG VIAL EXTERNAL 07/01/84 028 0250 5012
13733094 VERAPAMIL 2.5MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13733102 VERAPAMIL SR 240MG - 1 BOTTLE EXTERNAL 08/05/88 028 0251 5012
13733104 VERAPAMIL 60MG (1/2 X 120MG) T EXTERNAL 05/12/94 028 0251 5012
13733107 VERAPAMIL SR 180MG - 1 BOX EXTERNAL 05/31/90 028 0251 5012
13733109 VERAPAMIL 40MG (1/2 X 80MG) TA EXTERNAL 04/08/94 028 0251 5012
13733111 VERAPAMIL 50 MG/ML ORAL SUSP EXTERNAL 02/13/08 028 0251 5012
13733150 VINBLASTINE 1MG/ML SYR INJ EXTERNAL 07/01/84 J9360 J9360 028 0636 5012
13733161 VINCRISTINE 1MG/ML INJ EXTERNAL 01/01/87 J9370 J9370 028 0636 5012
13733188 MULTIVITAMIN 5ML THERAPEUTIC L EXTERNAL 03/31/88 028 0251 5012
13733201 ACETIC ACID-HYDROCORTISONE OTI EXTERNAL 07/01/84 028 0250 5012
13733221 WARFARIN 2MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13733222 WARFARIN 0.50MG (1/2 OF 1MG) T EXTERNAL 08/15/96 028 0251 5012
13733230 WARFARIN 2MG - 1 BOX EXTERNAL 07/01/84 028 0250 5012
13733240 WARFARIN 2.5MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13733251 WARFARIN 2.5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13733257 WARFARIN 4MG U.D. BOX EXTERNAL 02/21/00 028 0251 5012
13733259 WARFARIN 4MG (2 X 2MG) EXTERNAL 05/12/94 028 0251 5012
13733260 WARFARIN 5MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13733265 WARFARIN 8 MG (4 MG X 2) TAB EXTERNAL 02/21/08 028 0251 5012
13733271 WARFARIN 5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13733280 WARFARIN 7.5MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13733291 WARFARIN 7.5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13733300 WARFARIN 10MG - 1 BOTTLE EXTERNAL 07/01/84 028 0250 5012
13733311 WARFARIN 10MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13733314 WARFARIN 12.5MG (10MG + 2.5MG) EXTERNAL 04/08/94 028 0251 5012
13733315 WARFARIN SOD EXTERNAL 07/01/84 028 0250 5012
13733360 WATER FOR INJECTION (NP) 10ML EXTERNAL 07/01/84 028 0250 5012
13733361 WATER FOR INJECTION 50ML VIA EXTERNAL 07/01/84 028 0250 5012
13733380 WATER FOR INJECTION 30ML VIA EXTERNAL 07/01/84 028 0250 5012
13733460 WATER FOR IRRG 1000ML BTL EXTERNAL 01/25/95 028 0251 5012
13733480 WATER FOR IRRIG 1000ML BAG EXTERNAL 07/01/84 028 0250 5012
13733560 HEMORRHOIDAL SUPP. EXTERNAL 07/01/84 028 0251 5012
13733565 X-PREP 74ML SOLN EXTERNAL 07/01/84 028 0250 5012
13733580 D(+) XYLOSE POWDER 25GM EXTERNAL 07/01/84 028 0250 5012
13733590 YELLOW FEVER VACCINE EXTERNAL 07/01/84 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 280
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13733603 ZANAMIVIR 5 MG POWDER EXTERNAL 04/30/09 028 0251 5012
13733620 ZINC OXIDE OINT 4 OZ EXTERNAL 07/01/84 028 0250 5012
13733621 ZINC OXIDE OINTMENT 30GM EXTERNAL 07/01/84 028 0250 5012
13733640 ZOLPIDEM 5MG EXTERNAL 11/04/99 028 0251 5012
13733642 ZOLPIDEM 10MG EXTERNAL 11/04/99 028 0251 5012
13733658 ZIPRASIDONE 10 MG INJ EXTERNAL 11/12/03 J3486 J3486 028 0636 5012
13733659 ZIPRASIDONE 20 MG/ML 1 ML VIAL EXTERNAL 11/12/03 J3486 J3486 028 0636 5012
13733660 ZINC SULFATE INJECTION 10MG VI EXTERNAL 07/01/84 028 0250 5012
13733668 ZINC SULFATE ORAL SOLN 1MG/ML EXTERNAL 06/26/03 028 0251 5012
13733672 ZINC SULFATE ORAL SOLN 44 MG/M EXTERNAL 06/26/03 028 0251 5012
13733678 ZIDOVUDINE 300MG - 1 BOTTLE EXTERNAL 12/22/97 028 0251 5012
13733680 ZIDOVUDINE 10MG/ML SYRUP EXTERNAL 11/25/98 028 0251 5012
13733700 ZIDOVUDINE 100MG - 1 BOTTLE EXTERNAL 03/26/88 028 0251 5012
13733703 ZIDOVUDINE 10MG/ML INJ EXTERNAL 04/21/94 J3485 028 0636 5012
13733709 ZIDOVUDINE 600 MG FOR D5W 150 EXTERNAL 11/12/08 028 0251 5012
13733710 ZIDOVUDINE 2MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733711 ZIDOVUDINE 2.2MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733712 ZIDOVUDINE 2.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733713 ZIDOVUDINE 3.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733714 ZIDOVUDINE 3.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733715 ZIDOVUDINE 4.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733716 ZIDOVUDINE 4.5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733717 ZIDOVUDINE 5.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733718 ZIDOVUDINE 6.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733719 ZIDOVUDINE 7.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733720 ZIDOVUDINE 8.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733722 ZIDOVUDINE 12.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733723 ZIDOVUDINE 15.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733724 ZIDOVUDINE 20.0MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13733727 ZIDOVUDINE 1.5MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13733728 ZIDOVUDINE 1.7MG SYRUP EXTERNAL 12/19/01 028 0251 5012
13733729 ZIDOVUDINE 2.3MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733730 ZIDOVUDINE 2.7MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733731 ZIDOVUDINE 5.5MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733732 ZIDOVUDINE 12.5MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733733 ZIDOVUDINE 17MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733734 ZIDOVUDINE 22MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733735 ZIDOVUDINE 25MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733736 ZIDOVUDINE 30MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733737 ZIDOVUDINE 35MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733738 ZIDOVUDINE 40MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733739 ZIDOVUDINE 45MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733740 ZIDOVUDINE 50MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733741 ZIDOVUDINE 55MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733742 ZIDOVUDINE 60MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733743 ZIDOVUDINE 70MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733744 ZIDOVUDINE 80MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13733793 MIDAZOLAM 3MG/3 ML INJ (5 ML V EXTERNAL 01/31/05 J2250 J2250 028 0636 5012
13733794 MIDAZOLAM 4MG/4 ML INJ (5 ML V EXTERNAL 01/31/05 J2250 J2250 028 0636 5012
13733795 MIDAZOLAM 2MG/2 ML INJ EXTERNAL 01/31/05 J2250 J2250 028 0636 5012
13734110 AMINOCAPROIC ACID SYRUP 1GM/4M EXTERNAL 07/01/84 028 0250 5012
13734111 AMINOCAPROIC ACID 250MG/ML SYR EXTERNAL 07/07/00 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 281
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13734140 AMINOPHYLLINE 105MG ORAL SOLN EXTERNAL 07/01/84 J0280 J0280 J0280 028 0636 5012
13734310 COTRIMOXAZOLE SUSPENSION EXTERNAL 07/01/84 028 0250 5012
13734430 BLEOMYCIN 15 UNITS/ML INJ EXTERNAL 07/01/84 J9040 J9040 028 0636 5012
13734470 CALCIUM CHLORIDE 10% 100MG/ML EXTERNAL 07/01/84 028 0250 5012
13734473 CALCIUM CHLORIDE 10% 1.36 MEQ/ EXTERNAL 12/05/08 028 0258 5012
13734505 CARBAMAZEPINE 10MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13734507 CARBAMAZEPINE 30MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13734508 CARBAMAZEPINE 45MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13734509 CARBAMAZEPINE 250MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13734510 CARBAMAZEPINE 20MG/ML SUSPENSI EXTERNAL 07/07/88 028 0251 5012
13734511 CARBAMAZEPINE 300MG SUSPENSION EXTERNAL 05/12/94 028 0251 5012
13734512 CARBAMAZEPINE 400MG SUSPENSION EXTERNAL 05/12/94 028 0251 5012
13734515 CARBAMAZEPINE 200MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734516 CARBAMAZEPINE 100MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734517 CARBAMAZEPINE 450MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734518 CARBAMAZEPINE 15MG SUSPENSION EXTERNAL 09/27/01 028 0251 5012
13734519 CARBAMAZEPINE 25MG SUSPENSION EXTERNAL 09/27/01 028 0251 5012
13734521 CARBAMAZEPINE 50MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734522 CARBAMAZEPINE 60MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734523 CARBAMAZEPINE 75MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734525 CARBAMAZEPINE 125MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734526 CARBAMAZEPINE 150MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734527 CARBAMAZEPINE 175MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13734570 CEFAZOLIN 2GM/D5W 100ML EXTERNAL 07/01/84 J0690 J0690 028 0636 5012
13734571 CEFAZOLIN 0.1GM/ML INJ EXTERNAL 05/16/02 J0690 J0690 028 0636 5012
13734660 CHLORPROMAZINE 30MG/ML LIQ CON EXTERNAL 07/01/84 028 0251 5012
13735050 DEXAMETHASONE 1MG/ML ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13735100 DIGOXIN 50MCG/ML ELIXIR EXTERNAL 07/01/84 028 0251 5012
13735130 DIPHENHYDRAMINE 2.5MG/ML ELIXI EXTERNAL 07/01/84 Q0163 Q0163 028 0636 5012
13735230 ERYTHROMYCIN 40MG/ML SUSPENSIO EXTERNAL 07/01/84 028 0250 5012
13735350 FERROUS SULFATE 25MG/ML DROPS EXTERNAL 07/01/84 028 0250 5012
13735353 FERROUS SULFATE 15 MG/0.6 ML D EXTERNAL 05/02/08 028 0251 5012
13735367 FERRIC GLUCONATE 125 MG/NS 100 EXTERNAL 10/22/03 J2916 J2916 J2916 028 0636 5012
13735368 FERRIC GLUCONATE 12.5MG ELEM I EXTERNAL 10/22/03 J2916 J2916 028 0636 5012
13735370 FERROUS SULFATE 10MG/0.4ML DRO EXTERNAL 07/01/84 028 0250 5012
13735374 MORPHINE 20MG/ML ORAL LIQ EXTERNAL 06/07/01 028 0251 5012
13735376 MULTIVITAMINS DROPS* EXTERNAL 06/07/01 028 0251 5012
13735377 NAPROXEN 25MG/ML SUSP EXTERNAL 06/07/01 028 0251 5012
13735378 NYSTATIN ORAL SUSP EXTERNAL 06/07/01 028 0251 5012
13735379 RANTIDINE 15MG/ML SYRUP EXTERNAL 06/07/01 028 0251 5012
13735380 THIORIDAZINE 20MG/ML SUSP EXTERNAL 06/07/01 028 0251 5012
13735381 MULTIVITAMIN THERAPEUTIC LIQ EXTERNAL 06/07/01 028 0251 5012
13735382 PHENOL/NACL TOPICAL SOLN EXTERNAL 06/27/01 028 0251 5012
13735384 CEFOTAXIME 100MG/ML INJ EXTERNAL 06/07/01 J0698 J0698 028 0636 5012
13735385 CEFTRIAXONE 2GM D5W 50ML EXTERNAL 06/07/01 J0696 J0696 028 0636 5012
13735386 CEFTAZIDIME 280 MG/ML (LIDO) I EXTERNAL 06/07/01 J0713 J0713 028 0636 5012
13735391 CEFTRIAXONE 100MG/ML INJ EXTERNAL 06/07/01 J0696 J0696 028 0636 5012
13735392 CEFTAZIDIME 100MG/ML INJ EXTERNAL 06/07/01 J0713 J0713 028 0636 5012
13735400 MORPHINE 50MG FOR 50ML LVP EXTERNAL 09/10/03 J2271 J2271 028 0636 5012
13735401 MORPHINE 100MG FOR 100ML LVP EXTERNAL 09/10/03 J2271 J2271 028 0636 5012
13735540 GLUCAGON 1MG INJ EXTERNAL 07/01/84 J1610 J1610 028 0636 5012
13735570 GLYCOPYRROLATE 0.2MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 282
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13735580 GOLD SODIUM THIOMALATE 50MG DO EXTERNAL 07/01/84 J1600 J1600 J1600 028 0258 5012
13735650 HALOPERIDOL 2MG/ML ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13735653 HALOPERIDOL 2MG ORAL SOLN EXTERNAL 05/02/08 028 0251 5012
13735740 HYDROCORTISONE SOD SUCC 125MG/ EXTERNAL 07/01/84 J1720 J1720 028 0636 5012
13735750 HYDROXYZINE HCL 2MG/ML SYRUP EXTERNAL 07/01/84 028 0250 5012
13735891 REMIFENTANIL 1 MG/1ML VIAL EXTERNAL 03/19/97 028 0251 5012
13735892 REMIFENTANIL 1MG/3ML INJ EXTERNAL 03/19/97 028 0251 5012
13735893 REMIFENTANIL 2 MG/2ML VIAL EXTERNAL 03/19/97 028 0251 5012
13735894 REMIFENTANIL 2MG/5ML INJ EXTERNAL 03/19/97 028 0251 5012
13735896 REMIFENTANIL 5 MG/10ML EXTERNAL 03/19/97 028 0251 5012
13735898 RETISERT EXTERNAL 12/01/05 J7311 J7311 J7311 028 0636 5012
13735960 IRON DEXTRAN 50MG/ML INJ EXTERNAL 07/01/84 J1750 J1750 J1750 028 0636 5012
13736000 ACCUSOL HVVD 5B9249 SOLUTION EXTERNAL 12/14/07 028 0251 5012
13736001 ACCUSOL HVVD 5B9250 SOLUTION EXTERNAL 12/14/07 028 0251 5012
13736060 SOD POLYSTYRENE SULF 1GM/4ML S EXTERNAL 07/01/84 028 0250 5012
13736080 LACTULOSE SYRUP (ML) EXTERNAL 07/01/84 028 0250 5012
13736220 ATROPINE-DIPHENOXYLATE ORAL SO EXTERNAL 07/01/84 028 0250 5012
13736420 METHADONE 10MG/ML INJ EXTERNAL 07/01/84 J1230 J1230 028 0636 5012
13736421 METHADONE 0.4MG/ML PEDS INJ EXTERNAL 09/12/03 J1230 J1230 028 0636 5012
13736500 METHYLPRE SOD SUCC (GM)INJ*FOR EXTERNAL 07/01/84 J2920 J2920 028 0636 5012
13736501 METHYLPREDNISOLONE 4MG/ML PEDS EXTERNAL 07/23/01 J2920 J2920 J2920 028 0258 5012
13736505 METHYLPRE SOD SUCC (GM)INJ*FOR EXTERNAL 01/28/05 028 0258 5012
13736730 NITROFURANTOIN 5MG/ML SUSP EXTERNAL 07/01/84 028 0250 5012
13736893 PENICILLIN GK 2.5MU/D5W 100ML EXTERNAL 12/29/98 J2540 J2540 028 0636 5012
13737100 PHENYTOIN SUSPENSION 100MG EXTERNAL 07/01/84 028 0258 5012
13737105 PHENYTOIN SUSP 200MG (100MG X EXTERNAL 05/06/08 028 0251 5012
13737110 PHENYTOIN* 25MG/ML SUSPENSION EXTERNAL 07/01/84 028 0258 5012
13737290 POTASSIUM CHLORIDE 1.33MEQ/ML EXTERNAL 07/01/84 028 0250 5012
13737470 PROCHLORPERAZINE 1MG/ML SYRUP EXTERNAL 07/01/84 Q0165 Q0165 028 0250 5012
13737550 PSEUDOEPHEDRINE 6MG/ML SYRUP EXTERNAL 07/01/84 028 0250 5012
13737770 NITROPRUSSIDE 25MG/ML INJ EXTERNAL 07/01/84 028 0251 5012
13737810 SPECTINOMYCIN 0.4GM/ML INJ EXTERNAL 07/01/84 J3320 J3320 028 0636 5012
13737811 SPECTINOMYCIN 400MG/ML INJ EXTERNAL 05/14/02 J3320 J3320 J3320 028 0636 5012
13738190 TICARCILLIN INJ***GM EXTERNAL 07/01/84 028 0250 5012
13738220 VITAMIN E 50UNITS/ML DROPS EXTERNAL 07/01/84 028 0251 5012
13738221 VITAMIN E DROPS 100UNITS DOSE EXTERNAL 10/11/01 028 0251 5012
13738222 VITAMIN E DROPS 400UNITS DOSE EXTERNAL 10/11/01 028 0251 5012
13738223 VITAMIN E DROPS 25UNITS DOSE EXTERNAL 10/11/01 028 0251 5012
13738560 CALCIUM GLUCONATE 100MG/ML INJ EXTERNAL 07/01/84 J0610 J0610 028 0636 5012
13738563 CALCIUM GLUCONATE 0.465 MEQ/ML EXTERNAL 03/06/08 028 0258 5012
13738800 CEFAZOLIN INJECTION 250MG DOSE EXTERNAL 07/01/84 J0690 J0690 028 0636 5012
13738810 CEFAZOLIN 100MG/ML INJ EXTERNAL 07/01/84 J0690 J0690 028 0636 5012
13738820 DIPHENHYDRAMINE 50MG (25 MG X EXTERNAL 07/01/84 J1200 J1200 028 0636 5012
13738830 DIPHENHYDRAMINE 50MG/1ML INJ V EXTERNAL 07/01/84 J1200 J1200 J1200 028 0636 5012
13738920 CHLORAMPHENICOL 100MG/ML EXTERNAL 07/01/84 J0720 J0720 028 0636 5012
13738950 CLINDAMYCIN 150MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13738960 CLINDAMYCIN 12 MG/ML PEDS INJ EXTERNAL 12/30/04 028 0258 5012
13738980 DOCUSATE 4MG/ML SYRUP EXTERNAL 07/01/84 028 0250 5012
13738985 DOCUSATE 50MG SYRUP EXTERNAL 05/12/94 028 0251 5012
13739110 GRISEOFULVIN 25MG/ML SUSP EXTERNAL 07/01/84 028 0250 5012
13739190 ERYTHROMYCIN INJECTION 250MG D EXTERNAL 07/01/84 J1364 J1364 028 0258 5012
13739200 ERYTHROMYCIN LAC 50MG/ML INJ EXTERNAL 07/01/84 J1364 J1364 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 283
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13739240 FUROSEMIDE 20MG ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13739250 FUROSEMIDE 40MG ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13739260 FUROSEMIDE 10MG/ML ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13739261 FUROSEMIDE 10MG ORAL SOLN EXTERNAL 08/31/06 028 0251 5012
13739270 HALOPERIDOL 0.5MG SOLN EXTERNAL 07/01/84 028 0258 5012
13739271 HALOPERIDOL SOLUTION 2.5MG EXTERNAL 10/02/01 028 0251 5012
13739280 HALOPERIDOL 1MG SOLN EXTERNAL 07/01/84 028 0250 5012
13739290 HALOPERIDOL 5MG SOLN EXTERNAL 07/01/84 028 0250 5012
13739300 HALOPERIDOL 10MG SOLN EXTERNAL 07/01/84 028 0250 5012
13739311 LEVOTHYROXINE 20MCG/ML PEDS IN EXTERNAL 11/17/01 028 0258 5012
13739312 LEVOTHYROXINE 40MCG/ML PEDS IN EXTERNAL 11/17/01 028 0258 5012
13739313 LEVOTHYROXINE 100MCG/ML PEDS I EXTERNAL 11/17/01 028 0258 5012
13739330 ISONIAZID 100MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13739400 PROMETHAZINE 12.5MG INJ EXTERNAL 07/01/84 J2550 J2550 J2550 028 0636 5012
13739410 PSEUDOEPHEDRINE 60MG SYRUP EXTERNAL 07/01/84 028 0250 5012
13739470 NAFCILLIN 250MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13739520 PHENOBARBITAL 20MG ELIXIR EXTERNAL 07/01/84 028 0250 5012
13739521 PHENOBARBITAL 25MG ELIXIR EXTERNAL 03/12/96 028 0251 5012
13739523 PHENOBARBITAL 35MG ELIXIR EXTERNAL 03/12/96 028 0251 5012
13739525 PHENOBARBITAL 50MG ELIXIR EXTERNAL 03/12/96 028 0251 5012
13739526 PHENOBARBITAL 60MG ELIXIR EXTERNAL 03/12/96 028 0251 5012
13739530 PHENOBARBITAL ELIXIR 15MG DOSE EXTERNAL 07/01/84 028 0250 5012
13739540 PHENOBARBITAL 30MG ELIXIR EXTERNAL 07/01/84 028 0250 5012
13739560 PHENOBARBITAL 4MG/ML ELIXIR EXTERNAL 07/01/84 028 0250 5012
13739690 SODIUM BICARB 1MEQ/ML ORAL SOL EXTERNAL 07/01/84 028 0250 5012
13739751 GLYCOPYRROLATE 1MG TAB EXTERNAL 03/21/92 028 0251 5012
13739752 GLYCOPYRROLATE 200MCG ORAL SOL EXTERNAL 11/14/01 028 0251 5012
13739753 GLYCOPYRROLATE 400MCG ORAL SOL EXTERNAL 11/14/01 028 0251 5012
13739754 GLYCOPYRROLATE 600MCG ORAL SOL EXTERNAL 12/19/01 028 0251 5012
13739830 DANTROLENE 0.333MG/ML INJ EXTERNAL 07/01/84 028 0250 5012
13739990 TRICHLOROACETIC ACID TOP SOLN EXTERNAL 07/01/84 028 0251 5012
13740130 D10%/NACL 0.2% 1000ML EXTERNAL 07/01/84 028 0258 5012
13740140 D10/NACL 0.2% 500ML EXTERNAL 07/01/84 028 0258 5012
13740601 POTASSIUM PHOS 0.12MMOL/ML PED EXTERNAL 01/30/02 028 0258 5012
13740602 POTASSIUM PHOS 0.05MMOL/ML PED EXTERNAL 01/30/02 028 0258 5012
13740603 POTASSIUM PHOS 0.176MEQ/ML PED EXTERNAL 01/30/02 028 0258 5012
13740604 POTASSIUM PHOS 0.073MEQ/ML PED EXTERNAL 01/30/02 028 0258 5012
13740605 POT PHOS ORAL SOLN 2MEQ/0.45ML EXTERNAL 01/03/03 028 0251 5012
13740606 POT PHOS ORAL SOLN 0.5MMOL/0.1 EXTERNAL 06/26/03 028 0251 5012
13740710 LIDOCAINE 0.02GM/ML INJ EXTERNAL 07/01/84 J2001 J2001 028 0636 5012
13740970 NYSTATIN 15ML ORAL SUSP EXTERNAL 07/01/84 028 0250 5012
13741150 PENICILLIN GK 5MU/D5W 100ML EXTERNAL 07/01/84 J2540 J2540 028 0636 5012
13741263 HYDROMORPHONE PCA 10MG/50ML EXTERNAL 02/25/03 028 0251 5012
13741264 HYDROMORPHONE 2.5 MG INJ EXTERNAL 07/21/09 028 0251 5012
13741265 HYDROMORPHONE PCA 50MG/250ML EXTERNAL 12/02/09 028 0251 5012
13741420 DEXTROMETHORPHAN-GUAIFENESIN 1 EXTERNAL 07/01/84 028 0250 5012
13741450 CODEINE-GUAIFENESIN SYRUP EXTERNAL 07/01/84 028 0250 5012
13741600 PLACEBO (NS) INJ 1ML EXTERNAL 07/01/84 028 0251 5012
13741640 MORPHINE 50MG/50ML PCA EXTERNAL 01/31/05 028 0251 5012
13741641 MORPHINE 100MG/100ML PCA EXTERNAL 12/02/09 028 0251 5012
13741650 MORPHINE 2MG/ML ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13741910 SODIUM BICARBONATE 8.4% 10MEQ EXTERNAL 07/01/84 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 284
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13741920 SODIUM BICARBONATE 1MEQ/ML INJ EXTERNAL 07/01/84 028 0251 5012
13741921 SODIUM BICARBONATE NEO DRIP ME EXTERNAL 06/12/00 028 0258 5012
13741922 SODIUM BICARBONATE 100 MEQ FOR EXTERNAL 06/12/00 028 0258 5012
13741923 SODIUM BICARBONATE 100 MEQ INJ EXTERNAL 06/12/00 028 0258 5012
13741924 SODIUM BICARBONATE 150 MEQ FOR EXTERNAL 06/12/00 028 0258 5012
13741925 SODIUM BICARBONATE 300 MEQ FOR EXTERNAL 06/12/00 028 0258 5012
13741926 SODIUM BICARBONATE 25 MEQ FOR EXTERNAL 11/19/08 028 0258 5012
13741927 SODIUM BICARBONATE 75 MEQ FOR EXTERNAL 11/19/08 028 0258 5012
13742070 CEFOXITIN 0.1GM/ML INJ EXTERNAL 07/01/84 J0694 J0694 028 0636 5012
13742180 SODIUM BIPHOSPHATE-SODIUM PHOS EXTERNAL 07/01/84 028 0250 5012
13742643 DIGOXIN 55MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742645 DIGOXIN 65MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742646 DIGOXIN 70MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742648 DIGOXIN 80MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742649 DIGOXIN 90MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742651 DIGOXIN 100MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742654 DIGOXIN 6MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742655 DIGOXIN INJ 7.5MCG EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742656 DIGOXIN 10MCG INJ EXTERNAL 03/08/96 J1160 J1160 028 0636 5012
13742657 DIGOXIN 12.5MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742658 DIGOXIN 15MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742659 DIGOXIN 20MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742660 ERYTHROMYCIN 25MG SUSPENSION EXTERNAL 07/01/84 028 0251 5012
13742661 DIGOXIN 25MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742662 DIGOXIN 30MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742663 DIGOXIN 35MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742664 DIGOXIN 40MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742665 DIGOXIN 45MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742666 DIGOXIN 50MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742667 DIGOXIN 60MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742668 DIGOXIN 75MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742670 FUROSEMIDE 4MG ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13742671 DIGOXIN 150MCG INJ EXTERNAL 03/12/96 J1160 J1160 028 0636 5012
13742710 GENTAMICIN 2.5MG INJ EXTERNAL 07/01/84 J1580 J1580 028 0636 5012
13742711 GENTAMICIN 5MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742712 GENTAMICIN 7MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742713 GENTAMICIN 8MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742714 GENTAMICIN 9MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742715 GENTAMICIN 10MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742716 GENTAMICIN 12MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742717 GENTAMICIN 15MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742718 GENTAMICIN 17MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742719 GENTAMICIN 20MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742720 GENTAMICIN 25MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742723 GENTAMICIN 30MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742724 GENTAMICIN 35MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742725 GENTAMICIN 40MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742726 GENTAMICIN 45MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742727 GENTAMICIN 50MG INJ EXTERNAL 03/12/96 J1580 J1580 028 0636 5012
13742831 PENICILLIN GK 30000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0636 5012
13742832 PENICILLIN GK 40000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
13742834 PENICILLIN GK 65000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 285
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13742835 PENICILLIN GK 75000 UNITS INJ EXTERNAL 03/06/96 J2540 028 0258 5012
13742837 PENICILLIN GK 120000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
13742838 PENICILLIN GK 150000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
13742839 PENICILLIN GK 170000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
13742842 PENICILLIN GK 300000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
13742843 PENICILLIN GK 400000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
13742845 PENICILLIN GK 375000 UNITS INJ EXTERNAL 03/06/96 J2540 J2540 J2540 028 0258 5012
13742899 PHENYTOIN* 2.5MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13742900 PHENYTOIN* 5MG SUSPENSION EXTERNAL 07/01/84 028 0636 5012
13742901 PHENYTOIN 150MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742902 PHENYTOIN 125MG SUSPENSION EXTERNAL 08/26/01 028 0251 5012
13742903 PHENYTOIN SUSENSION 12.5MG EXTERNAL 08/26/01 028 0251 5012
13742906 PHENYTOIN 6MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742907 PHENYTOIN* 7MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742908 PHENYTOIN* 8MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742909 PHENYTOIN* 7.5MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13742910 PHENYTOIN* 10MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742912 PHENYTOIN* 12MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742913 PHENYTOIN SUSENSION 125MG EXTERNAL 08/21/01 028 0251 5012
13742915 PHENYTOIN* 15MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742918 PHENYTOIN* 18MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742920 PHENYTOIN* 20MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742923 PHENYTOIN SUSENSION 250MG EXTERNAL 10/09/01 028 0251 5012
13742925 PHENYTOIN* 25MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742930 PHENYTOIN* 30MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742935 PHENYTOIN* 35MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742940 PHENYTOIN* 40MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742945 PHENYTOIN* 45MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742950 PHENYTOIN* 50MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742955 PHENYTOIN* 70MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742960 PHENYTOIN* 60MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742961 PHENYTOIN* 65MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13742962 PHENYTOIN* 120MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13742963 PHENYTOIN* 175MG SUSPENSION EXTERNAL 12/19/01 028 0251 5012
13742966 VALGANCICLOVIR 900 MG (450 MG EXTERNAL 02/19/08 028 0251 5012
13742967 VALGANCICLOVIR 50 MG/ML ORAL S EXTERNAL 03/24/10 028 0251 5012
13742970 VALPROIC ACID 15MG SYRUP EXTERNAL 07/01/84 028 0250 5012
13742971 VALPROIC ACID 25MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742972 VALPROIC ACID 50MG/ML SYRUP EXTERNAL 03/12/96 028 0251 5012
13742973 VALPROIC ACID 75MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742974 VALPROIC ACID 100MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742975 PHENYTOIN* 75MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742976 VALPROIC ACID 125MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742977 VALPROIC ACID 150MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742978 VALPROIC ACID 175MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742979 VALPROIC ACID 200MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742981 VALPROIC ACID 225MG SYRUP EXTERNAL 03/12/96 028 0251 5012
13742983 VALPROIC ACID 350MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13742984 VALPROIC ACID 375MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13742985 PHENYTOIN* 80MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13742986 VALPROIC ACID 750MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13742987 VALPROIC ACID 1000MG SYRUP EXTERNAL 12/21/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 286
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13742988 VALPROIC ACID 1250MG SYRUP EXTERNAL 12/21/01 028 0251 5012
13742989 VALPROIC ACID 500MG/D5W 50 ML EXTERNAL 03/18/05 028 0258 5012
13742991 VALPROIC ACID 750MG/D5W 50 ML EXTERNAL 03/18/05 028 0258 5012
13742992 VALPROIC ACID 1000MG/D5W 50 ML EXTERNAL 10/27/05 028 0258 5012
13742995 PHENYTOIN* 90MG SUSPENSION EXTERNAL 03/12/96 028 0251 5012
13743022 VALSARTAN 40 MG TABLET EXTERNAL 06/27/05 028 0251 5012
13743023 VALSARTAN 20 MG (1/2 X 40MG) T EXTERNAL 07/20/06 028 0251 5012
13743100 SIMETHICONE 40MG/0.6ML LIQUID EXTERNAL 07/01/84 028 0250 5012
13743110 VITAMIN E 15 UNITS ORAL DROPS EXTERNAL 07/01/84 028 0251 5012
13743120 SILVER NITRATE 1/8% TOP SOLN ( EXTERNAL 07/01/84 028 0250 5012
13743420 ACETAMINOPHEN 240MG SUPP EXTERNAL 07/01/84 028 0250 5012
13743430 ACETAMINOPHEN 15MG SUSPENSION EXTERNAL 07/01/84 028 0250 5012
13743520 GENTAMICIN FORT OPHTH SOLN 7ML EXTERNAL 07/01/84 028 0250 5012
13743521 MIDODRINE 5MG TAB EXTERNAL 05/11/06 028 0251 5012
13743522 MIDODRINE 2.5 MG (1/2 X 5MG) T EXTERNAL 07/20/06 028 0251 5012
13744350 HYDROMORPHONE 1MG PER 1/2 TAB EXTERNAL 07/01/84 028 0250 5012
13744390 METHADONE 1MG/ML ORAL SOLN EXTERNAL 07/01/84 028 0250 5012
13744391 METHADONE 0.05 MG ORAL SOLN EXTERNAL 01/26/05 028 0251 5012
13744392 METHADONE 0.15 MG ORAL SOLN EXTERNAL 01/26/05 028 0251 5012
13744393 METHADONE 0.35 MG ORAL SOLN EXTERNAL 01/26/05 028 0251 5012
13744394 METHADONE 0.4 MG ORAL SOLN EXTERNAL 01/26/05 028 0251 5012
13744990 POTASSIUM CHLORIDE 1.5MEQ LIQ EXTERNAL 03/06/96 028 0251 5012
13744996 POTASSIUM CHLORIDE 4MEQ LIQ EXTERNAL 03/06/96 028 0251 5012
13745000 POTASSIUM CHLORIDE 7MEQ LIQ EXTERNAL 03/06/96 028 0251 5012
13745031 AMOXICILLIN 35MG SUSPENSION EXTERNAL 05/01/95 028 0251 5012
13745240 CEFOTAXIME 0.1GM/ML INJ EXTERNAL 07/01/84 J0698 J0698 028 0636 5012
13745350 ERYTHROMYCIN-SULFISOXAZOLE 2.5 EXTERNAL 07/01/84 028 0250 5012
13745360 ERYTHROMYCIN-SULFISOXAZOLE 5ML EXTERNAL 07/01/84 028 0250 5012
13745370 ERYTHROMYCIN-SULFISOXAZOLE 7.5 EXTERNAL 07/01/84 028 0250 5012
13745371 ERYTHROMYCIN-SULFISOXAZOLE SUS EXTERNAL 06/07/01 028 0251 5012
13745380 ERYTHROMYCIN-SULFISOXAZOLE 10M EXTERNAL 07/01/84 028 0250 5012
13745450 PEDS PD EXTERNAL 07/01/84 028 0258 5012
13745530 FILGRASTIM 300MCG/ML - 1ML VIA EXTERNAL 03/24/92 J1440 J1440 028 0636 5012
13745531 FILGRASTIM 300MCG/ML INJ EXTERNAL 03/24/92 J1440 J1440 J1440 028 0636 5012
13745535 FILGRASTIM 300MCG/1ML - 1.6ML EXTERNAL 03/24/92 J1440 J1440 J1440 028 0636 5012
13745538 FILGRASTIM 30MCG/ML PEDS INJ EXTERNAL 11/17/01 J1440 J1440 J1440 028 0636 5012
13745539 FILGRASTIM 15 MCG/ML PEDS INJ EXTERNAL 01/07/05 J1440 J1440 J1440 028 0258 5012
13745540 FINASTERIDE 5 MG TAB EXTERNAL 07/25/05 028 0251 5012
13745630 METOCLOPRAMIDE 10MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13745631 METOCLOPRAMIDE 5MG SYRUP EXTERNAL 05/01/95 028 0251 5012
13745632 METOCLOPRAMIDE 0.1MG/ML PEDS I EXTERNAL 06/28/01 J2765 J2765 028 0636 5012
13745640 METOCLOPRAMIDE 1MG/ML SYRUP EXTERNAL 07/01/84 J2765 J2765 028 0636 5012
13745790 CEFOXITIN 100MG/ML INJ EXTERNAL 07/01/84 J0694 J0694 028 0636 5012
13745890 HYDROCHLOROTHIAZIDE 10MG/ML SO EXTERNAL 07/01/84 028 0250 5012
13746381 SECRETIN 2MCG/ML INJ EXTERNAL 12/17/02 028 0258 5012
13746382 SECRETIN INJ TEST DOSE EXTERNAL 01/02/03 028 0258 5012
13746550 MICONAZOLE VAG SUPP 200MG EXTERNAL 07/01/84 028 0250 5012
13746721 CEFTRIAXONE IM****MG EXTERNAL 03/08/95 028 0636 5012
13746722 CEFTRIAXONE 1 GM/D5W 50ML EXTERNAL 07/31/95 J0696 028 0636 5012
13746723 CEFTRIAXONE 250MG/D5W 50ML EXTERNAL 03/08/96 J0696 028 0636 5012
13747220 GRISEOFULVIN 62.5MG SUSP EXTERNAL 05/01/95 028 0250 5012
13747221 GRISEOFULVIN 90MG SUSP EXTERNAL 05/01/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 287
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13747222 GRISEOFULVIN 187.5MG SUSP EXTERNAL 05/01/95 028 0251 5012
13747223 GRISEOFULVIN 250MG SUSP EXTERNAL 05/01/95 028 0251 5012
13747230 GRISEOFULVIN 125MG SUSP EXTERNAL 07/01/84 028 0250 5012
13747260 NEOMYCIN SULF 125MG SOLN EXTERNAL 07/01/84 028 0250 5012
13747270 NEOMYCIN SULF 250MG SOLN EXTERNAL 07/01/84 028 0250 5012
13747290 DICLOXACILLIN 500MG SUSP EXTERNAL 07/01/84 028 0250 5012
13747392 ENALAPRIL 7.5MG TAB(1X5 + 1X2. EXTERNAL 07/31/01 028 0251 5012
13747394 ENALAPRIL 2.5MG TAB UD - 100/B EXTERNAL 03/26/92 028 0251 5012
13747396 ENALAPRIL 2.5MG TAB EXTERNAL 03/21/92 028 0251 5012
13747397 ENALAPRIL 12.5MG TAB(1X10+1X2. EXTERNAL 07/31/01 028 0251 5012
13747398 MIDAZOLAM 10MG SYRUP EXTERNAL 09/18/92 028 0251 5012
13747400 CEFAZOLIN FORT OPHTH DROPS 10M EXTERNAL 07/01/84 028 0251 5012
13747401 MIDAZOLAM 5MG/ML INJ EXTERNAL 01/01/87 J2250 J2250 028 0636 5012
13747406 LABETALOL 5MG/ML INJ EXTERNAL 01/01/87 028 0251 5012
13747409 LEVOBUNOLOL 0.5% OPHTH SOLN 5M EXTERNAL 07/01/84 028 0250 5012
13747413 ENALAPRIL 5MG - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13747414 ENALAPRIL 10MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13747415 ENALAPRIL 20MG - 1 BOTTLE EXTERNAL 01/25/95 028 0251 5012
13747417 ENALAPRILAT 1.25MG/ML INJ 2ML EXTERNAL 08/31/88 028 0251 5012
13747419 ENALAPRIL 5MG TAB EXTERNAL 07/01/84 028 0250 5012
13747420 ENALAPRIL 10MG TAB EXTERNAL 07/01/84 028 0250 5012
13747421 ENALAPRIL 20MG TAB EXTERNAL 07/01/84 028 0250 5012
13747434 QUINIDINE GLUCONATE 324MG TAB EXTERNAL 07/01/84 028 0250 5012
13747435 QUINIDINE GLUCONATE 324MG - 1 EXTERNAL 01/25/95 028 0251 5012
13747436 CLONIDINE 0.1MG/24HRS PATCH EXTERNAL 07/01/84 028 0250 5012
13747437 CLONIDINE 100MCG PATCH(TTS-1)- EXTERNAL 01/25/95 028 0251 5012
13747438 CLONIDINE 0.2MG/24HRS PATCH EXTERNAL 07/01/84 028 0250 5012
13747439 CLONIDINE 200MCG PATCH(TTS-2)1 EXTERNAL 01/25/95 028 0251 5012
13747440 CLONIDINE 0.3MG/24HRS PATCH EXTERNAL 07/01/84 028 0250 5012
13747441 CLONIDINE 300MCG PATCH(TTS-3)- EXTERNAL 01/25/95 028 0251 5012
13747443 LABETOLOL INJ 200MG VIAL EXTERNAL 01/01/87 028 0250 5012
13747444 MIDAZOLAM 5MG SYRUP EXTERNAL 10/19/90 028 0250 5012
13747447 EPIFOAM 1% SPRAY 10GM EXTERNAL 07/01/84 028 0250 5012
13747462 ENALAPRIL 1MG/ML ORAL SUSPENSI EXTERNAL 11/14/01 028 0251 5012
13747470 MIDAZOLAM 20 MG INJ EXTERNAL 01/31/05 J2250 J2250 028 0636 5012
13747471 MIDAZOLAM 40 MG INJ EXTERNAL 01/31/05 J2250 J2250 028 0636 5012
13747472 MIDAZOLAM 80 MG FOR 100 ML LVP EXTERNAL 01/31/05 J2250 J2250 028 0636 5012
13747480 LABETALOL 5 MG INJ EXTERNAL 01/25/05 028 0258 5012
13747481 LABETALOL 10 MG INJ EXTERNAL 01/25/05 028 0258 5012
13751000 ALLOPURINOL 150MG (1/2 X 300 M EXTERNAL 01/25/08 028 0251 5012
13751010 ALBUTEROL 0.4 MG/ML SYRUP (EXT EXTERNAL 12/22/04 028 0251 5012
13751020 AZITHROMYCIN 1200 MG (2 X 600 EXTERNAL 01/25/08 028 0251 5012
13751025 AZITHROMYCIN 100 MG/ML INJ EXTERNAL 03/24/05 081212 028 0258 5012
13751030 AZITHROMYCIN 500 MG/NS 250 ML EXTERNAL 03/24/05 028 0258 5012
13751035 AZITHROMYCIN 2 MG/ML INJ EXTERNAL 03/24/05 028 0258 5012
13751050 CISPLATIN-DOXORUBICIN-MITOMYCI EXTERNAL 03/23/09 028 0258 5012
13751060 HYDROCORTISONE 50MG (10 MG X 5 EXTERNAL 02/07/08 028 0251 5012
13751070 DIVALPROEX 750MG (250 MG X 3) EXTERNAL 02/05/08 028 0251 5012
13751075 DIVALPROEX 1000 MG (500 MG X 2 EXTERNAL 02/05/08 028 0251 5012
13751080 DIVALPROEX 1500 MG (500 MG X 3 EXTERNAL 02/05/08 028 0251 5012
13751088 FAMOTIDINE 8 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751089 FAMOTIDINE 4 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 288
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13751090 FAMOTIDINE 2 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751091 FAMOTIDINE 10 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751092 FAMOTIDINE 3 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751093 FAMOTIDINE 12 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751094 FAMOTIDINE 5 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751095 FAMOTIDINE 16 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751096 FAMOTIDINE 6 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751097 FAMOTIDINE 24 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751098 FAMOTIDINE 28 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751099 FAMOTIDINE 32 MG ORAL SUSP EXTERNAL 11/25/08 028 0251 5012
13751110 ALTEPLASE 5 MG FOR 10 ML IV EXTERNAL 01/23/09 028 0258 5012
13751115 ALTEPLASE 7.5 MG FOR 15 ML IV EXTERNAL 01/23/09 028 0258 5012
13751120 ALTEPLASE 10 MG FOR 20 ML IV EXTERNAL 01/23/09 028 0258 5012
13751130 VECURONIUM 15 MG FOR 30 ML IV EXTERNAL 11/25/08 028 0258 5012
13751135 VECURONIUM 30 MG FOR 30 ML IV EXTERNAL 11/25/08 028 0258 5012
13751150 MIDAZOLAM 6 MG FOR 30 ML IV EXTERNAL 04/03/08 028 0258 5012
13751155 MIDAZOLAM 12 MG FOR 30 ML IV EXTERNAL 04/03/08 028 0258 5012
13751160 MIDAZOLAM 24 MG FOR 30 ML IV EXTERNAL 04/03/08 028 0258 5012
13751170 E-Z-CAT (BARIUM SULFATE) 4.9% EXTERNAL 08/28/06 028 0251 5012
13751180 METRONIDAZOLE 5MG/ML PEDS INJ EXTERNAL 06/28/01 028 0258 5012
13751190 METRONIDAZOLE 125MG TAB EXTERNAL 02/14/08 028 0251 5012
13751200 AZATHIOPRINE 100 MG (2 X 50 MG EXTERNAL 01/25/08 028 0251 5012
13751205 AZATHIOPRINE 150 MG (3 X 50 MG EXTERNAL 01/25/08 028 0251 5012
13751220 NIFEDIPINE ER 120 MG (60 MG X EXTERNAL 10/09/00 028 0251 5012
13752010 FENTANYL 75 MCG FOR 30 ML IV EXTERNAL 11/19/08 028 0251 5012
13752011 FENTANYL 150 MCG FOR 30 ML IV EXTERNAL 11/19/08 028 0251 5012
13752012 FENTANYL 300 MCG FOR 30 ML IV EXTERNAL 11/19/08 028 0251 5012
13752015 FENTANYL CITRATE 500 MCG AMP EXTERNAL 12/04/08 028 0251 5012
13752020 FENTANYL CITRATE 500MCG/50ML P EXTERNAL 01/07/05 028 0258 5012
13752040 METOPROLOL 150 MG (50 MG X 3) EXTERNAL 02/14/08 028 0251 5012
13752696 CRASH CART CHARGE EXTERNAL 01/07/87 028 0258 5012
13755350 EMPTY VIAFLEX CONTAINER 150ML EXTERNAL 01/25/95 028 0251 5012
13755360 EMPTY VIAFLEX CONTAINER 250ML EXTERNAL 01/25/95 028 0251 5012
13755825 KOLD KAP EXTERNAL 01/25/95 028 0251 5012
13755830 LAMINARIA STICK 3+60 MEDIUM EXTERNAL 07/01/84 028 0250 5012
13755831 LAMINARIA TENTS 3 + 60 THIN EXTERNAL 03/27/88 028 0250 5012
13755832 LAMINARIA STICK 5+60 THICK EXTERNAL 01/19/90 028 0251 5012
13755833 LAMINARIA TENTS 2 + 60 EXTRA T EXTERNAL 09/15/95 028 0251 5012
13755834 LAMINARIA TENTS 6 + 60 EXTRA T EXTERNAL 09/15/95 028 0251 5012
13756000 NONFORMULARY INJECTION EXTERNAL 05/06/97 028 0251 5012
13756245 AMIN-AID PWD PKT EXTERNAL 01/25/95 028 0251 5012
13756248 ENRICH 8OZ CASE EXTERNAL 01/25/95 028 0251 5012
13756249 ENSURE HN CASE EXTERNAL 01/25/95 028 0251 5012
13756250 ENSURE PLUS HN CASE EXTERNAL 01/25/95 028 0251 5012
13756257 OSMOLITE 8OZ CASE EXTERNAL 01/25/95 028 0251 5012
13756258 OSMOLITE HN 8OZ CASE EXTERNAL 01/25/95 028 0251 5012
13756259 POLYCOSE LIQ 4OZ CASE EXTERNAL 01/25/95 028 0251 5012
13756260 POLYCOSE PWD 14OZ CASE EXTERNAL 01/25/95 028 0251 5012
13756262 VITAL HN PWD CASE EXTERNAL 01/25/95 028 0251 5012
13756268 EXTERNAL 01/25/95 028 0251 5012
13756269 EXTERNAL 01/25/95 028 0251 5012
13756270 EXTERNAL 01/25/95 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 289
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13756271 EXTERNAL 01/25/95 028 0251 5012
13756272 EXTERNAL 01/25/95 028 0251 5012
13756273 EXTERNAL 01/25/95 028 0251 5012
13756274 EXTERNAL 01/25/95 028 0251 5012
13756275 EXTERNAL 01/25/95 028 0251 5012
13756276 EXTERNAL 01/25/95 028 0251 5012
13756277 EXTERNAL 01/25/95 028 0251 5012
13756278 EXTERNAL 01/25/95 028 0251 5012
13756279 EXTERNAL 01/25/95 028 0251 5012
13756280 EXTERNAL 01/25/95 028 0251 5012
13756295 EXTERNAL 01/25/95 028 0251 5012
13757000 NONFORMULARY IV SOLUTION EXTERNAL 06/11/96 028 0250 5012
13758000 NONFORMULARY MEDICATION EXTERNAL 01/01/90 028 0251 5012
13759000 NON-FORMULARY MFG INJECTION UD EXTERNAL 01/01/90 960000 028 0258 5012
13760009 MICROFIBRILLAR COLLAGEN HEMOST EXTERNAL 12/09/92 028 0251 5012
13761000 EXTERNAL 11/02/95 028 0251 5012
13761001 EXTERNAL 11/18/95 028 0251 5012
13761002 EXTERNAL 11/18/95 028 0251 5012
13761003 EXTERNAL 11/18/95 028 0251 5012
13761004 EXTERNAL 11/18/95 028 0251 5012
13761005 EXTERNAL 11/18/95 028 0251 5012
13761006 EXTERNAL 11/18/95 028 0251 5012
13761007 EXTERNAL 11/18/95 028 0251 5012
13761008 EXTERNAL 11/18/95 028 0251 5012
13762021 MARAX TABS EXTERNAL 07/07/92 028 0251 5012
13762024 BROMPHENIRAMINE 12MG TAB EXTERNAL 07/07/92 028 0251 5012
13762043 DESIPRAMINE 10MG TAB EXTERNAL 07/07/92 028 0251 5012
13762048 LISINOPRIL 40MG (20 MG X 2) TA EXTERNAL 07/07/92 028 0251 5012
13762053 METHANDROSTENOLONE 5MG TAB EXTERNAL 07/07/92 028 0251 5012
13762061 MENADIOL 5MG TAB EXTERNAL 07/07/92 028 0251 5012
13762092 DISOPYRAMIDE 150MG CAPSULES EXTERNAL 07/08/92 028 0251 5012
13762105 FAMOTIDINE 40MG (20MG X 2) TAB EXTERNAL 07/08/92 028 0251 5012
13762123 NADOLOL 40MG TABLET EXTERNAL 07/08/92 028 0251 5012
13762125 INDAPAMIDE 2.5MG TABLET (NF) EXTERNAL 07/08/92 028 0251 5012
13762132 DRONABINOL 5MG CAPSULE (NF) EXTERNAL 07/08/92 Q0168 Q0168 Q0168 028 0251 5012
13762140 PERCOCET TABLETS - 1 BOTTLE EXTERNAL 07/08/92 028 0251 5012
13762148 FAMOTIDINE 20MG TABLET (NF) EXTERNAL 07/08/92 028 0251 5012
13762149 CARBOPLATIN 50MG/5ML EXTERNAL 07/08/92 J9045 J9045 028 0636 5012
13762150 FAMOTIDINE 40MG (20 MG X 2) TA EXTERNAL 07/08/92 028 0251 5012
13762158 FLURAZEPAM 30MG CAPSULE EXTERNAL 07/08/92 028 0251 5012
13762159 FLURAZEPAM 15MG CAPSULE EXTERNAL 07/08/92 028 0251 5012
13762161 FANSIDAR TABLET (NF) EXTERNAL 07/08/92 028 0251 5012
13762170 NIACIN 100NG TABLET (NF) EXTERNAL 07/08/92 028 0251 5012
13762186 FIORINAL YABLET (NF) EXTERNAL 07/08/92 028 0251 5012
13762205 THIETHYLPERAZINE 10MG SUPP EXTERNAL 07/08/92 028 0251 5012
13762206 THIETHYLPERAZINE 10MG TABLET EXTERNAL 07/08/92 028 0250 5012
13762221 E.E.S. CHEWABLE 200MG TAB EXTERNAL 07/08/92 028 0251 5012
13762225 LITHIUM CARBONATE 450MG TAB EXTERNAL 07/08/92 028 0251 5012
13762262 PSEUDOEPHEDRINE 120MG CAP EXTERNAL 07/08/92 028 0251 5012
13762289 GENTAMICIN FORT. DROPS 7ML EXTERNAL 07/08/92 028 0251 5012
13762347 POLARAMINE 2MG TAB EXTERNAL 07/10/92 028 0251 5012
13762351 INSULIN HUMAN 70/30 - 10ML EXTERNAL 07/10/92 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 290
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13762353 LIBRAX CAPSULE EXTERNAL 07/10/92 028 0251 5012
13762354 SENOKOT TAB EXTERNAL 07/10/92 028 0251 5012
13762357 HYDROPHILIC OINTMENT EXTERNAL 07/10/92 028 0251 5012
13762358 TERFENADINE 60MG TAB EXTERNAL 07/10/92 028 0251 5012
13762360 NAPROXEN NA 275MG TAB EXTERNAL 07/10/92 028 0251 5012
13762361 ESTRAMUSTINE 140MG CAP - 100/B EXTERNAL 07/10/92 028 0251 5012
13762363 ANUSOL HC RECTAL SUPP EXTERNAL 07/10/92 028 0251 5012
13762364 TRIAMCINOLONE 0.1% CREAM - 15G EXTERNAL 07/10/92 028 0251 5012
13762365 1/4% SILVER NITRATE SOLUTION EXTERNAL 07/10/92 028 0251 5012
13762366 METHOCARBAMOL 750MG TAB EXTERNAL 07/10/92 028 0251 5012
13762378 TRIPELENNAMINE 100MG - 1 BTL EXTERNAL 07/10/92 028 0251 5012
13762404 ISOCARBOXAZID 10MG TABLET EXTERNAL 06/30/92 028 0251 5012
13762409 PHENYLBUTAZONE 100MG TAB EXTERNAL 06/30/92 028 0251 5012
13762413 FINASTERIDE 5GM TAB - 100/BTL EXTERNAL 06/30/92 028 0251 5012
13762414 VANCOMYCIN 500MG/100ML D5W FRZ EXTERNAL 06/30/92 J3370 J3370 J3370 028 0251 5012
13762418 TRIMETHADIONE 150MG - 1 BTL EXTERNAL 06/30/92 028 0251 5012
13762432 MISOPROSTOL 100MCG TABLETS (NF EXTERNAL 06/30/92 028 0251 5012
13762441 LAMPRENE 100MG CAPSULE (D) EXTERNAL 06/30/92 028 0251 5012
13762445 PROBUCOL 250MG TABLETS EXTERNAL 06/30/92 028 0251 5012
13762462 ACTIFED TABLET EXTERNAL 06/30/92 028 0251 5012
13762481 SPIRONOLACTONE 5MG/ML SUSPENSI EXTERNAL 06/30/92 028 0251 5012
13762502 CARBOPLATIN 50MG/VIAL EXTERNAL 07/07/92 J9045 J9045 J9045 028 0258 5012
13762514 ZIDOVUDINE 50MG/5ML 240ML EXTERNAL 07/07/92 028 0251 5012
13762531 TEGRETOL 100MG CHEWABLE SAMPLE EXTERNAL 07/10/92 028 0251 5012
13762575 PROPAFENONE 150MG TAB EXTERNAL 07/11/92 028 0251 5012
13762588 CLOZAPINE 100MG TAB EXTERNAL 07/11/92 028 0251 5012
13762594 LISINOPRIL 10MG TAB - 100/BTL EXTERNAL 07/11/92 028 0251 5012
13762595 CLEMASTINE 1.34/PHENYLPRO 75MG EXTERNAL 07/11/92 028 0251 5012
13762596 LONITEN 10MG TAB EXTERNAL 07/11/92 028 0251 5012
13762601 MESNA 100MG/ML 10ML EXTERNAL 07/11/92 J9209 J9209 J9209 028 0258 5012
13762602 MESNA 0.1GM/ML INJ EXTERNAL 07/11/92 J9209 J9209 028 0636 5012
13762609 BENZONATATE 100MG TAB EXTERNAL 07/11/92 028 0251 5012
13762615 GANCYCLOVIR 500MG/VIAL EXTERNAL 07/11/92 J1570 J1570 J1570 028 0258 5012
13762627 NABUMETONE 500MG TAB EXTERNAL 07/14/92 028 0251 5012
13762628 TRIMETHOPRIM 100MG - 1 BTL EXTERNAL 07/14/92 028 0251 5012
13762843 OTC Q-TEST PREGNANCY EXTERNAL 07/15/92 028 0251 5012
13762912 RED RUBBER CATHETER 16FR EXTERNAL 07/14/92 028 0251 5012
13762917 CHLORPROPRAMIDE 100MG TAB EXTERNAL 07/14/92 028 0251 5012
13762941 VANCOMYCIN OPT 50MG/CC 10CC VI EXTERNAL 07/14/92 J3370 J3370 J3370 028 0251 5012
13762978 INSULIN REGULAR - 5ML VIAL EXTERNAL 07/28/92 J1815 J1815 J1815 028 0258 5012
13762990 HEPATITIS B VAC 20MCG/VIAL 1ML EXTERNAL 09/22/92 028 0251 5012
13762999 CARBOPLATIN 50MG VIAL EXTERNAL 07/16/93 J9045 J9045 028 0258 5012
13763049 ZIDOVUDINE 100MG SYRUP EXTERNAL 05/09/94 028 0251 5012
13763050 NANDROLONE DECONATE INJ 100MG/ EXTERNAL 10/30/03 J2321 J2321 J2321 028 0251 5012
13763051 CLORAZEPATE 7.5MG TAB EXTERNAL 10/30/03 028 0251 5012
13763052 FIORINAL CAPSUEL EXTERNAL 10/30/03 028 0251 5012
13763054 TESTOSTERONE TRANSDERMAL PATCH EXTERNAL 10/30/03 028 0251 5012
13763135 EXTERNAL 03/10/93 028 0251 5012
13763139 BENZOYL PEROXIDE 10% GEL 45GM EXTERNAL 03/30/93 028 0251 5012
13763174 CHONDRO SU A/HYALUR SOD (VISCO EXTERNAL 02/23/01 028 0258 5012
13763176 CHONDRO SU A/HYALUR SOD (DUOVI EXTERNAL 12/11/98 028 0258 5012
13763201 PHENELZINE* 15MG TAB EXTERNAL 04/01/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 291
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13763202 ISOCARBOXAZID 10MG TAB EXTERNAL 04/01/01 028 0251 5012
13763203 SELEGILINE 5MG TAB EXTERNAL 06/06/01 028 0251 5012
13770031 FLUOCINOLONE ACETONE EXTERNAL 01/25/95 028 0251 5012
13770034 ANUSOL HC SUPPOSITORY - 1 BOX EXTERNAL 01/25/95 028 0251 5012
13770071 PHOSPHATE MMOL TPN EXTERNAL 05/10/01 028 0258 5012
13770212 ACETATE MEQ *TPN* EXTERNAL 05/10/01 028 0258 5012
13770360 POTASSIUM MEQ TPN EXTERNAL 05/10/01 J3480 J3480 028 0636 5012
13770662 ADULT TPN EXTERNAL 07/15/03 028 0258 5012
13770663 PEDS/NEO TPN EXTERNAL 07/15/03 028 0258 5012
13772002 TENOFOVIR 300 MG TABLET EXTERNAL 11/21/02 028 0251 5012
13772003 DELAVIRDINE MESYLATE 100MG EXTERNAL 11/21/02 028 0251 5012
13772004 DELAVIRDINE MESYLATE 200MG EXTERNAL 11/21/02 028 0251 5012
13772006 AGENERASE 150MG CAPSULE EXTERNAL 11/21/02 028 0251 5012
13773360 WATER ML TPN EXTERNAL 05/10/01 028 0258 5012
13773660 ZINC (AS SULFATE) MG TPN EXTERNAL 05/10/01 028 0251 5012
13776200 DEXTROSE % TPN EXTERNAL 05/10/01 028 0258 5012
13777233 CHLORIDE MEQ TPN EXTERNAL 05/10/01 028 0258 5012
13780001 SILICONE OIL EXTERNAL 12/17/96 028 0258 5012
13780002 ACETYLCYSTEINE 10% 30 ML VIAL EXTERNAL 12/05/05 028 0251 5012
13780004 ANTICOAGULANT CITRATE PHOSPHAT EXTERNAL 12/15/05 028 0258 5012
13780005 ACCUCHEK II BLOOD MONITOR EXTERNAL 05/07/01 028 0251 5012
13780006 TRUFILL LIQUID EMBOLIC SYSTEM EXTERNAL 12/19/05 028 0258 5012
13780007 CUSTODIAL SOLUTION 1 L EXTERNAL 01/02/07 028 0258 5012
13780008 ANTICOAGULANT SODIUM CITRATE S EXTERNAL 04/16/08 028 0258 5012
13780009 AVITENE WEB EXTERNAL 05/07/01 028 0251 5012
13780010 STRONG IODIDE SOLUTION (LUGOLS EXTERNAL 04/16/08 028 0251 5012
13780091 HYDROCODONE/ACETAMINOPHEN TAB EXTERNAL 05/07/01 028 0251 5012
13780101 ANESTHESIA TRAY 54.00 06/30/10 028 0258 5012
13780117 BUPIVICAINE 0.5% INJ ****MG EXTERNAL 05/07/01 028 0258 5012
13780120 BUPIVICAINE 0.75% 312MG INJECT EXTERNAL 05/07/01 028 0258 5012
13780121 BUPIVICAINE 0.125% IN 0.9% NAC EXTERNAL 05/22/02 028 0258 5012
13780140 ACETAMINOPHEN SUPPOSITORY 120M EXTERNAL 05/07/01 028 0251 5012
13780150 ACETAMINOPHEN SUPPOSITORY EXTERNAL 05/07/01 028 0251 5012
13780164 VANCOMYCIN 500MG INJ EXTERNAL 05/07/01 028 0258 5012
13780180 ACETAZOLAMIDE-OR EXTERNAL 05/07/01 028 0251 5012
13780231 ACETIC ACID 3% 8 OZ. EXTERNAL 04/03/04 028 0251 5012
13780251 GENTAMICIN 5MG/ML INHL (DOSE>6 EXTERNAL 06/28/01 028 0251 5012
13780252 GENTAMICIN 5MG/ML INHL (DOSE<6 EXTERNAL 06/28/01 028 0251 5012
13780253 ONDANSETRON 1MG/ML PEDS INJ EXTERNAL 06/27/01 J2405 J2405 028 0636 5012
13780254 CHLORPROMAZINE 1MG/ML PEDS INJ EXTERNAL 06/27/01 J3230 J3230 028 0636 5012
13780290 ACETYLCHOLINE 1% OPTH SOLUTION EXTERNAL 05/07/01 028 0251 5012
13780330 HYDROMORPHONE 2MG INJ EXTERNAL 06/08/08 J1170 J1170 J1170 028 0636 5012
13780370 GONIOSOL OPHTH SOL 15ML EXTERNAL 05/07/01 028 0251 5012
13780392 ALBUMIN 5% 250ML-OR EXTERNAL 05/07/01 P9045 P9045 P9045 028 0636 5012
13780400 ALBUMIN 25% 50ML VIAL EXTERNAL 05/10/01 028 0258 5012
13780404 SODIUM BICARBONATE INJ***MEQ EXTERNAL 05/07/01 028 0258 5012
13780405 ALBUTEROL - INHALER EXTERNAL 05/07/01 028 0251 5012
13780406 ALBUTEROL 0.083% SOLN 3ML (2.5 EXTERNAL 07/18/97 J7620 J7620 J7620 028 0251 5012
13780420 HYDROXYZINE INJECTION EXTERNAL 05/07/01 J3410 J3410 028 0636 5012
13780421 ALCOHOL ABSOLUTE INJ 1ML EXTERNAL 08/11/97 028 0258 5012
13780480 SUCCINYLCHOLINE CHLORIDE 20MG EXTERNAL 05/07/01 028 0258 5012
13780481 SUCCINYLCHOLINE PHARMEDIUM SYR EXTERNAL 08/26/09 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 292
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13780492 HEPARIN PF 1 UNIT/ML *TPN* EXTERNAL 06/29/01 028 0258 5012
13780512 SUFENTANIL INJ 2ML EXTERNAL 05/07/01 028 0258 5012
13780513 SUFENTANIL INJ 5ML EXTERNAL 05/07/01 028 0258 5012
13780514 SUFENTANIL 250MCG/250ML IV SOL EXTERNAL 08/25/09 028 0258 5012
13780541 IBUPROFEN TAB - OR EXTERNAL 05/07/01 028 0251 5012
13780560 IDARUBICIN INJECTION 5MG VIAL EXTERNAL 05/14/01 J9211 J9211 028 0636 5012
13780561 IDARUBICIN INJECTION 5MG VIAL EXTERNAL 05/14/01 J9211 J9211 028 0636 5012
13780643 AMIFOSTINE 500MG 10ML EXTERNAL 05/14/01 J0207 J0207 028 0636 5012
13780700 INDIGO CARMINE INJ 5ML AMP EXTERNAL 05/07/01 028 0258 5012
13780721 SURGICEL 14"X2" REAGENT - 1 V EXTERNAL 05/07/01 028 0251 5012
13780735 LIDOCAINE EPID 20ML SYR EXTERNAL 05/07/01 J2001 J2001 028 0258 5012
13780738 LO-SODIUM PREP EZM BOWEL KIT EXTERNAL 05/10/07 028 0251 5012
13780740 SURGICEL 4X8 EXTERNAL 05/07/01 028 0251 5012
13780741 NUKNIT SURGICEL 3 X 4 EXTERNAL 04/03/04 028 0251 5012
13780742 NUKNIT SURGICEL 6 X 9 EXTERNAL 04/03/04 028 0251 5012
13780743 SURGICEL 2X3 EXTERNAL 08/23/06 028 0251 5012
13780744 SURGICEL 5X2 EXTERNAL 08/23/06 028 0251 5012
13780745 FIBRILLAR 1X2 EXTERNAL 08/23/06 028 0251 5012
13780746 SURGICEL 4X4 EXTERNAL 07/11/05 028 0251 5012
13780747 FIBRILLAR 2X4 EXTERNAL 08/23/06 028 0251 5012
13780748 FIBRILLAR 4X4 EXTERNAL 08/23/06 028 0251 5012
13780749 NU-KNIT 1X1 EXTERNAL 08/23/06 028 0251 5012
13780750 NU-KNIT 1X3.5 EXTERNAL 08/23/06 028 0251 5012
13780751 SURGIFOAM 50 EXTERNAL 08/23/06 028 0251 5012
13780752 SURGIFOAM 100 EXTERNAL 08/23/06 028 0251 5012
13780753 SURGIFOAM 100 C EXTERNAL 08/23/06 028 0251 5012
13780754 SURGIFOAM HEMORRHOIDECOMY SPON EXTERNAL 08/23/06 028 0251 5012
13780755 SURGIFOAM POWDER 1 GM EXTERNAL 08/23/06 028 0251 5012
13780756 POWDER KIT 1 GM EXTERNAL 08/23/06 028 0251 5012
13780757 SURGIFLO HEMOSTATIC MATRIX EXTERNAL 08/23/06 028 0251 5012
13780758 ENDOSCOPIC APPLICATOR EXTERNAL 08/23/06 028 0251 5012
13780759 INSTAT 1X2 EXTERNAL 08/23/06 028 0251 5012
13780760 INSTAT 3X4 EXTERNAL 08/23/06 028 0251 5012
13780761 INSTAT MCH 0.5 GM EXTERNAL 08/23/06 028 0251 5012
13780762 INSTAT MCH 1 GM EXTERNAL 08/23/06 028 0251 5012
13780763 CROSSEAL FIBRIN SEALANT HUMAN EXTERNAL 08/23/06 028 0251 5012
13780764 CROSSEAL FIBRIN SEALANT HUMAN EXTERNAL 08/23/06 028 0251 5012
13780765 CROSSEAL FIBRIN SEALANT HUMAN EXTERNAL 08/23/06 028 0251 5012
13780766 CROSS FIB SEAL KIT HUMAN 5 ML EXTERNAL 08/23/06 028 0251 5012
13780767 PRESSURE REGULATOR EXTERNAL 08/23/06 028 0251 5012
13780770 AMINOPHYLLINE 250MG INJ EXTERNAL 12/10/03 J0280 J0280 028 0636 5012
13780801 ARTIFICIAL TEARS SOLN 30ML BOT EXTERNAL 05/07/01 028 0251 5012
13780804 CLINDAMYCIN IRRIG 500ML EXTERNAL 05/07/01 028 0258 5012
13780816 INSULIN HUMAN REGULAR 5U/ML EXTERNAL 05/07/01 J1815 J1815 J1815 028 0637 5012
13780820 GELFOAM SIZE 100 EXTERNAL 05/07/01 028 0251 5012
13780821 METHYLENE BLUE 10ML EXTERNAL 05/07/01 028 0258 5012
13780824 FENTANYL INJ 50MCG/ML 2ML EXTERNAL 05/07/01 J3010 J3010 028 0636 5012
13780826 TETRACAINE 2% 10ML EXTERNAL 05/07/01 028 0258 5012
13780827 LIDOCAINE (1%-2%) INJ EXTERNAL 05/07/01 028 0258 5012
13780829 BUPIVACAINE OR EXTERNAL 05/07/01 028 0258 5012
13780830 PROPOFOL OR EXTERNAL 05/07/01 028 0258 5012
13780831 SUFENTANIL SYR EXTERNAL 05/07/01 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 293
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13780832 PROPOFOL 1% 10 MG/ML 50 ML VIA EXTERNAL 08/25/09 028 0258 5012
13780833 PROPOFOL 1% 10 MG/ML 100ML VIA EXTERNAL 08/25/09 028 0258 5012
13780836 CEFAZOLIN IRRIGATION - OR EXTERNAL 05/07/01 J0690 J0690 J0690 028 0258 5012
13780837 TRANSPLANT ANTIBIOTIC IRRIG 1L EXTERNAL 04/17/03 028 0258 5012
13780946 AMPHOTERICIN B LIPID COMPLEX * EXTERNAL 05/07/01 028 0636 5012
13781010 CITRIC ACID/NA CIT SOLN 30ML EXTERNAL 05/07/01 028 0251 5012
13781015 AMPICILLIN 2GM VIAL EXTERNAL 05/07/01 J0290 J0290 028 0636 5012
13781016 AMPICILLIN INJECTION 500MG EXTERNAL 04/17/03 028 0258 5012
13781017 AMPICILLIN RIDER EXTERNAL 03/21/04 J0290 J0290 028 0636 5012
13781060 IPRATROPIUM BROMIDE MDI 14GM EXTERNAL 09/07/00 J7644 J7644 028 0251 5012
13781061 IPRATROPIUM 0.02% SVN 2.5ML EXTERNAL 09/07/00 J7644 J7644 J7644 028 0251 5012
13781066 UNASYN 1500 MG/NS 50 ML IVPB EXTERNAL 07/03/08 028 0258 5012
13781067 UNASYN 3000 MG/NS 100 ML IVPB EXTERNAL 07/03/08 028 0258 5012
13781070 AMINOCAPROIC ACID INJ 5GM VIA EXTERNAL 05/07/01 028 0258 5012
13781088 TETRACAINE 20MG SPINAL SYR - O EXTERNAL 05/07/01 028 0258 5012
13781090 AMPICILLIN INJECTION 500MG VIA EXTERNAL 04/16/03 028 0258 5012
13781091 TETRACAINE 1% OPHTH SOLN 10ML EXTERNAL 05/07/01 028 0251 5012
13781100 TETRACAINE 0.5% OPTH SOLN 2ML EXTERNAL 05/07/01 028 0251 5012
13781110 AMPICILLIN INJECTION 500MG VIA EXTERNAL 05/07/01 J0290 J0290 028 0636 5012
13781130 BUFFERED LIDOCAINE EXTERNAL 05/01/03 028 0258 5012
13781172 THYMOGLOBULIN 25MG/NS 50 ML I EXTERNAL 07/03/08 028 0258 5012
13781174 BACITRACIN IRRIG - OR EXTERNAL 05/07/01 028 0258 5012
13781175 THYMOGLOBULIN 50MG/NS 100 ML EXTERNAL 07/03/08 028 0258 5012
13781176 BACITRACIN 50,000 UNITS/NS 500 EXTERNAL 12/30/09 028 0258 5012
13781177 EPINEPHRINE 0.8MG/NACL 0.9% 25 EXTERNAL 12/30/09 028 0258 5012
13781181 APRACLONIDINE OPHTH SOL 1PKT EXTERNAL 05/07/01 028 0251 5012
13781183 APROTININ 200ML EXTERNAL 05/07/01 J0365 J0365 J0365 028 0636 5012
13781201 ISOPROPYL ALCOHOL 70% 30ML BOT EXTERNAL 05/07/01 028 0251 5012
13781237 LEVOFLOXACIN RIDER EXTERNAL 05/07/01 J1956 J1956 028 0636 5012
13781239 BLEOMYCIN INJECTION 15 UNIT AM EXTERNAL 09/19/01 J9040 J9040 028 0636 5012
13781273 ISOPROTERENOL DRIP EXTERNAL 05/07/01 028 0258 5012
13781316 CEFAZOLIN INJECTION 500MG EXTERNAL 05/07/01 J0690 J0690 028 0636 5012
13781365 ASPARAGINASE 10,000 UNIT VIAL EXTERNAL 05/14/01 J9020 J9020 028 0636 5012
13781380 D5W 50ML EXTERNAL 05/07/01 J7060 J7060 028 0636 5012
13781386 IRRIGATION SOLUTION WITH ADDIT EXTERNAL 05/07/01 028 0258 5012
13781416 CISPLATIN INJECTION 50MG VIAL EXTERNAL 05/14/01 J9062 J9062 028 0636 5012
13781420 ASPIRIN 300MG SUPP EXTERNAL 07/03/08 028 0251 5012
13781421 THIOPENTAL INJ 20 ML SYR EXTERNAL 05/07/01 028 0258 5012
13781422 THIOPENTAL PEDIACTIC SYR EXTERNAL 05/07/01 028 0258 5012
13781483 KETAMINE ***MG INJECTION EXTERNAL 05/07/01 028 0258 5012
13781491 KETOROLAC 0.5% OPHTH SOL (ACUL EXTERNAL 12/10/03 028 0251 5012
13781499 KETOROLAC INJ 15MG EXTERNAL 04/16/03 028 0258 5012
13781500 KETOROLAC INJ 15MG EXTERNAL 04/16/03 028 0258 5012
13781501 ATROPINE SULFATE 0.4MG VIAL EXTERNAL 01/01/10 J0461 J0461 028 0636 5012
13781502 KETOROLAC INJ EXTERNAL 05/07/01 J1885 J1885 028 0636 5012
13781503 KETOROLAC INJ 15MG EXTERNAL 04/16/03 028 0258 5012
13781510 KIDNEY PRESERVATION SOLUTION EXTERNAL 05/07/01 028 0258 5012
13781530 LACRILUBE OPHTH OINT EXTERNAL 05/07/01 028 0251 5012
13781550 ATROPINE SULF 1% OPTH SOLUTION EXTERNAL 05/07/01 028 0251 5012
13781568 THROMBIN 10,000U SPRAY KIT EXTERNAL 05/07/01 028 0251 5012
13781570 THROMBIN POWDER 5,000UNIT VIAL EXTERNAL 10/25/06 028 0251 5012
13781580 THROMBIN POWDER 10,000UNIT VIA EXTERNAL 05/07/01 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 294
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13781601 FIBRIN SEALANT (TISSEAL) 10 ML EXTERNAL 04/13/06 028 0251 5012
13781602 FIBRIN SEALANT (TISSEAL) 2 ML EXTERNAL 04/12/10 028 0251 5012
13781603 FIBRIN SEALANT (TISSEAL) 4 ML EXTERNAL 04/12/10 028 0251 5012
13781605 LATANOPROST 0.005% OPHTH SOLN EXTERNAL 09/13/00 028 0251 5012
13781670 AZATHIOPRINE INJ 100MG VIAL EXTERNAL 05/14/01 J7501 J7501 028 0636 5012
13781700 BASILIXIMAB 20MG VIAL EXTERNAL 05/07/01 J0480 J0480 J0480 028 0258 5012
13781727 TIMOLOL 0.5% OPTH SOLUTION 5M EXTERNAL 05/07/01 028 0251 5012
13781737 PRED-G OPHTH OINT 3.5GM TUBE EXTERNAL 05/07/01 028 0251 5012
13781739 TIS-U-SOL 1000ML EXTERNAL 05/07/01 028 0251 5012
13781744 TOBRAMYCIN 1.2GRAMS PMMA BONE EXTERNAL 05/07/01 028 0258 5012
13781745 TOBRADEX OPTH OINT 3.5GM EXTERNAL 05/07/01 028 0251 5012
13781749 VANCOMYCIN POWDER 500MG EXTERNAL 12/17/02 J3370 J3370 J3370 028 0636 5012
13781750 BACITRACIN INJ***UNITS EXTERNAL 05/07/01 028 0258 5012
13781760 BACITRACIN OINTMENT PACKET EXTERNAL 05/07/01 028 0251 5012
13781765 BACITRACIN OPHTH OINT 3.5GM EXTERNAL 08/02/03 028 0251 5012
13781767 LIDOCAINE 5% OINT 35GM EXTERNAL 07/03/08 028 0251 5012
13781768 BACITRACIN 50TU/GENTAMICIN 80 EXTERNAL 05/07/01 028 0258 5012
13781769 BACITRACIN 100TU/GENTAMICIN 16 EXTERNAL 05/07/01 028 0258 5012
13781771 BACITRACIN U/GENTAMICIN MG/IRR EXTERNAL 12/17/02 028 0258 5012
13781775 LIDOCAINE 4% TOP SOLN LARYNGO EXTERNAL 12/27/06 028 0251 5012
13781777 LIDOCAINE DRIP EXTERNAL 05/07/01 J2001 J2001 028 0636 5012
13781810 LIDOCAINE W/EPI (0.5-2%) EXTERNAL 05/07/01 J2001 J2001 028 0636 5012
13781830 BALANCED SALT OPTH SOLN 15ML B EXTERNAL 05/07/01 028 0251 5012
13781831 BALANCED SALT OPTH SOLN 500ML EXTERNAL 05/07/01 028 0251 5012
13781832 BALANCED SALT SOLN + VITRECTOM EXTERNAL 05/07/01 028 0251 5012
13781842 EMLA CREAM 5GM EXTERNAL 05/07/01 028 0251 5012
13781870 LIDOCAINE 4% INJ (ML) EXTERNAL 12/17/02 J2001 J2001 028 0636 5012
13781871 LIDOCAINE CARDIAC PFS EXTERNAL 09/09/09 028 0258 5012
13781893 LIDOCAINE INJ 100MG SYR EXTERNAL 01/01/05 J2001 J2001 028 0636 5012
13781900 LIDOCAINE 2% JELLY - 30GM TUBE EXTERNAL 05/07/01 J2001 J2001 028 0636 5012
13781901 LIDOCAINE 2% JELLY 30GM EXTERNAL 05/07/01 028 0251 5012
13781940 LIDOCAINE W/ EPI (0.5-2%) EXTERNAL 04/16/03 028 0258 5012
13781941 LIDOCAINE PF 2% 10ML AMPULE OF EXTERNAL 04/18/06 J2001 J2001 028 0251 5012
13781960 LIDOCAINE 2% W/EPI EXTERNAL 05/07/01 J2001 J2001 028 0636 5012
13781997 RETISERT IMPLANT (FLUONCINOLON EXTERNAL 01/19/07 J7311 J7311 J7311 028 0258 5012
13781998 VITRASERT IMPLANT (GANCICLOVIR EXTERNAL 11/12/08 J7310 J7310 J7310 028 0258 5012
13782003 PERFLUTREN (DEFINITY) 2 ML VIA EXTERNAL 03/31/10 028 0258 5012
13782063 LORAZEPAM INJECTION 2MG SYRING EXTERNAL 05/07/01 J2060 J2060 028 0636 5012
13782127 MESNA 100MG/ML 4ML AMPULE EXTERNAL 05/14/01 J9209 J9209 028 0636 5012
13782150 METOCOPRAMIDE INJ 5MG/ML 2ML EXTERNAL 05/07/01 J2765 J2765 028 0636 5012
13782191 KENALOG INJ EXTERNAL 05/07/01 J3301 J3301 028 0636 5012
13782192 BETAMETHASONE OINT .05% - 15GM EXTERNAL 05/07/01 028 0251 5012
13782251 TRIAMCINOLONE DIAC OPHTH INJ EXTERNAL 05/07/01 028 0258 5012
13782307 NUPERCAINAL OINT 30GM EXTERNAL 05/07/01 028 0251 5012
13782320 MAGNESIUM SULFATE 50% INJECTIO EXTERNAL 05/07/01 J3475 J3475 028 0636 5012
13782336 METHOTREXATE INJ 50MG VIAL EXTERNAL 05/14/01 J9260 J9260 J9260 028 0636 5012
13782341 MANNITOL 25% INJECTION 50ML BO EXTERNAL 05/07/01 J2150 J2150 J2150 028 0636 5012
13782342 MANNITOL 12.5GM SYR EXTERNAL 04/16/03 028 0258 5012
13782380 MANNITOL 20% 250ML EXTERNAL 07/03/08 028 0258 5012
13782390 MANNITOL 20% IV SOLUTION 500ML EXTERNAL 05/07/01 028 0636 5012
13782400 MARCAINE #1 SOLN EXTERNAL 05/07/01 028 0258 5012
13782401 MARCAINE "A" SOLN EXTERNAL 05/07/01 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 295
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13782403 MARCAINE "C" SOLN EXTERNAL 05/07/01 028 0258 5012
13782430 MAXITROL OPTH OINMENT 3.5GM TU EXTERNAL 05/07/01 028 0251 5012
13782432 MD GASTROVIEW 120 ML BTL EXTERNAL 03/15/06 028 0251 5012
13782433 MD GASTROVIEW 120 ML - 1 CASE EXTERNAL 12/31/08 028 0251 5012
13782463 BRIMONIDINE 0.15% OPHTH SOLN 1 EXTERNAL 08/02/03 028 0251 5012
13782480 MECHLORETHAMINE INJECTION 10MG EXTERNAL 05/14/01 J9230 J9230 J9230 028 0636 5012
13782542 BUPIVACAINE 0.25% INJ***ML EXTERNAL 05/07/01 028 0258 5012
13782550 BUPIVACAINE EPIDURAL PL/IMED/T EXTERNAL 05/07/01 028 0258 5012
13782551 BUPIVICAINE .5% W/EPI ***ML EXTERNAL 05/07/01 028 0258 5012
13782583 BUPIVACAINE 0.25% W/EPI 30ML EXTERNAL 05/07/01 028 0251 5012
13782600 FLUCONAZOLE 200 MG IVPB EXTERNAL 08/25/09 028 0258 5012
13782601 MESNA 100MG/ML 10ML EXTERNAL 05/14/01 J9209 J9209 028 0636 5012
13782667 PHENYLEPHRINE INJ EXTERNAL 04/16/03 J2370 J2370 J2370 028 0258 5012
13782668 PHENYLEPHERINE INJ 10MG EXTERNAL 05/07/01 J2370 J2370 028 0636 5012
13782669 PHENYLEPHERINE 40 MCG/ML 5 ML EXTERNAL 10/26/06 J2370 J2370 J2370 028 0258 5012
13782682 MELPHALAN 50MG VIAL EXTERNAL 05/14/01 J9245 028 0636 5012
13782690 TROMETHAMINE 0.3M 500ML (THAM) EXTERNAL 05/10/01 028 0258 5012
13782705 PLASMALYTE 1LITER EXTERNAL 05/07/01 028 0258 5012
13782721 TROPICAMIDE 1% OPTH SOLUTION EXTERNAL 05/07/01 028 0251 5012
13782760 CALCIUM CHLORIDE 10% INJ 1GM S EXTERNAL 05/07/01 028 0258 5012
13782761 CALCIUM GLUCONATE INJ OR EXTERNAL 05/07/01 J0610 J0610 028 0258 5012
13782762 CALCIUM CHLORIDE INJ OR EXTERNAL 05/07/01 028 0258 5012
13782775 TRYPAN BLUE 0.06% OPHTH SOLN EXTERNAL 12/27/05 028 0251 5012
13782810 MEPERIDINE INJECTION EXTERNAL 05/07/01 J2175 J2175 028 0636 5012
13782811 MEPERIDINE INJ EXTERNAL 04/16/03 J2175 J2175 J2175 028 0251 5012
13782812 MEPERIDINE SYR EXTERNAL 04/16/03 028 0251 5012
13782925 VANCOMYCIN RIDER EXTERNAL 05/07/01 J3370 J3370 J3370 028 0636 5012
13782980 CARBACHOL (MIOSTAT) 0.01% 1.5 EXTERNAL 04/20/06 028 0251 5012
13783002 HEXABRIX 320 MG/ML - 1 BTL EXTERNAL 08/21/06 028 0251 5012
13783003 HYPAQUE 60% 50 ML - 1 UNIT EXTERNAL 08/21/06 028 0251 5012
13783004 OMNIPAQUE 180 MG/ML - 1 UNIT EXTERNAL 08/21/06 028 0251 5012
13783005 OMNIPAQUE 240 MG/ML - 1 UNIT EXTERNAL 08/21/06 028 0251 5012
13783006 OMNIPAQUE 300 MG/ML 30ML- 1 UN EXTERNAL 08/21/06 028 0251 5012
13783007 OMNIPAQUE 300MG/ML 50 ML - 1 U EXTERNAL 08/21/06 028 0251 5012
13783008 OMNIPAQUE 300MG/ML 100 ML - 1 EXTERNAL 08/21/06 028 0251 5012
13783009 OMNIPAQUE 300MG/ML 150 ML - 1 EXTERNAL 08/21/06 028 0251 5012
13783010 OMNIPAQUE 300MG/ML 500 ML - 1 EXTERNAL 08/21/06 028 0251 5012
13783011 IFOSFAMIDE 1GRAM EXTERNAL 05/14/01 J9208 J9208 028 0636 5012
13783012 IFOSFAMIDE 1 GRAM VIAL EXTERNAL 05/14/01 J9208 J9208 028 0636 5012
13783013 OMNISCAN 287MG/ML - 1 EACH EXTERNAL 08/21/06 028 0251 5012
13783014 SINOGRAFIN 38% - 1 EACH EXTERNAL 08/21/06 028 0251 5012
13783015 VISIPAQUE 320MG/ML 50 ML - 1 U EXTERNAL 08/21/06 028 0251 5012
13783016 VISIPAQUE 320MG/ML 100 ML - 1 EXTERNAL 08/21/06 028 0251 5012
13783017 VISIPAQUE 320MG/ML 150 ML - 1 EXTERNAL 08/21/06 028 0251 5012
13783018 E-Z-CAT (BARIUM SULFATE) 4.9% EXTERNAL 08/28/06 028 0251 5012
13783019 MAXIBAR (BARIUM SULFATE) 210% EXTERNAL 08/28/06 028 0251 5012
13783020 E-Z-PAQUE (BARIUM SULFATE) 60% EXTERNAL 12/22/06 028 0251 5012
13783021 OMNIPAQUE 240 MG/ML - 1 UNIT 5 EXTERNAL 01/23/07 028 0251 5012
13783022 LIQUID POLIBAR PLUS 105% 1900 EXTERNAL 06/04/08 028 0251 5012
13783023 E-Z PASTE ESOPHEGEAL CREAM 454 EXTERNAL 06/04/08 028 0251 5012
13783024 BARICON SULFATE SUSPENSION EXTERNAL 09/25/08 028 0251 5012
13783025 OMNISCAN 10ML - 1 EACH EXTERNAL 04/16/08 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 296
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13783026 OMNISCAN 15ML - 1 EACH EXTERNAL 04/16/08 028 0251 5012
13783028 OMNISCAN 50ML - 1 EACH EXTERNAL 04/16/08 028 0251 5012
13783029 E-Z-CAT (BARIUM SULFATE) 4.9% EXTERNAL 06/04/08 028 0251 5012
13783030 MAXIBAR (BARIUM SULFATE) 210% EXTERNAL 06/04/08 028 0251 5012
13783031 E-Z-PAQUE(BARIUM SULFATE) 60% EXTERNAL 06/04/08 028 0251 5012
13783032 LIQUID POLIBAR PLUS 105% 1900 EXTERNAL 06/04/08 028 0251 5012
13783033 E-Z PASTE ESOPHEGEAL CREAM 454 EXTERNAL 06/04/08 028 0251 5012
13783034 E-Z-HD SUSP (BARIUM) - 1 CASE EXTERNAL 12/31/08 028 0251 5012
13783035 E-Z GAS II EFFERVECENT - 1 BOX EXTERNAL 12/31/08 028 0251 5012
13783037 GADOXETATE (EOVIST) 1 VIAL EXTERNAL 07/09/10 028 0251 5012
13783038 GADOXETATE (EOVIST) 1 BOX EXTERNAL 07/09/10 028 0251 5012
13783041 FOSCARNET 6GM VIAL EXTERNAL 05/14/01 J1455 J1455 028 0636 5012
13783053 CARBOPLATIN INJ 150MG EXTERNAL 05/14/01 J9045 J9045 028 0636 5012
13783056 CARBOPLATIN INJ 450MG EXTERNAL 05/14/01 J9045 J9045 J9045 028 0636 5012
13783057 CARBOPLATIN INJ 50MG EXTERNAL 05/14/01 J9045 J9045 J9045 028 0636 5012
13783059 CARDIOPLEGIA A SOLUTION EXTERNAL 05/07/01 028 0258 5012
13783060 CARDIOPLEGIC B SOLUTION EXTERNAL 04/16/03 028 0258 5012
13783061 CARDIOPLEGIC C SOLUTION EXTERNAL 04/16/03 028 0258 5012
13783063 INDOCYANINE GREEN (CARDIO-GREE EXTERNAL 05/07/01 028 0258 5012
13783075 VASOPRESSIN SYR - OR EXTERNAL 05/07/01 028 0258 5012
13783080 METHADONE INJECTION 10MG AMPUL EXTERNAL 02/01/01 J1230 J1230 028 0636 5012
13783083 METHADONE INJECTION 10MG AMPUL EXTERNAL 07/24/01 J1230 J1230 J1230 028 0251 5012
13783089 VECURONIUM INJECTION 10MG VIAL EXTERNAL 05/07/01 028 0258 5012
13783090 VECURONIUM PHARMEDIUM SYR EXTERNAL 08/25/09 028 0258 5012
13783092 VERAPAMIL INJ 5MG SYRINGE EXTERNAL 05/07/01 028 0251 5012
13783094 VERAPAMIL 25MG/NACL 0.9% 250 M EXTERNAL 05/07/07 028 0258 5012
13783105 CARMUSTINE INJECTION 100MG VIA EXTERNAL 05/14/01 J9050 J9050 028 0636 5012
13783107 PHENYTOIN DRIP OR EXTERNAL 05/07/01 J1165 J1165 028 0636 5012
13783108 THROMBIN 20,000 UNITS SPRAY KI EXTERNAL 05/07/01 028 0251 5012
13783111 OMNIPAQUE 350MG/ML 50 ML - 1 U EXTERNAL 08/21/06 028 0251 5012
13783112 OMNIPAQUE 350MG/ML 200 ML - 1 EXTERNAL 08/21/06 028 0251 5012
13783150 VINBLASTINE INJECTION 1MG VIAL EXTERNAL 05/14/01 J9360 J9360 028 0636 5012
13783151 THIOTEPA INJECTION 15MG VIAL EXTERNAL 05/14/01 J9340 J9340 028 0636 5012
13783162 VINCRISTINE INJECTION 2MG SYRI EXTERNAL 05/14/01 J9375 J9375 028 0636 5012
13783163 VISIPAQUE 320 MG/ML 100 ML BTL EXTERNAL 03/15/06 028 0258 5012
13783167 CEFOXITIN 2GRAM IN D5W 50ML PM EXTERNAL 05/07/01 J0694 J0694 028 0636 5012
13783172 CEFAZOLIN INJ 500MG SUBCONJ EXTERNAL 05/07/01 J0690 J0690 028 0636 5012
13783173 CAFFEINE CITRATE 20 MG/ML EXTERNAL 01/01/03 J0706 J0706 028 0636 5012
13783174 CHONDRO SU A/HYALUR SOD (VISCO EXTERNAL 05/07/01 028 0258 5012
13783175 PERFLUORO-N-OCTAINE (PERFLORON EXTERNAL 05/07/01 028 0258 5012
13783176 CHONDRO SU A/HYALUR SOD (DUOVI EXTERNAL 05/07/01 028 0258 5012
13783177 CEFAZOLIN RIDER - OR EXTERNAL 05/07/01 J0690 J0690 028 0636 5012
13783178 CEFOXITIN 1 GRAM RIDER EXTERNAL 06/27/01 J0694 J0694 028 0636 5012
13783180 CEFAZOLIN INJECTION 500MG VIA EXTERNAL 05/07/01 J0690 J0690 J0690 028 0258 5012
13783312 METHOHEXITAL SYR (4) EXTERNAL 05/07/01 028 0258 5012
13783320 CEFUROXIME ***MG INJECTION EXTERNAL 05/07/01 J0697 J0697 028 0636 5012
13783326 CETACAINE AEROSOL SPRAY 56GRAM EXTERNAL 05/07/01 028 0251 5012
13783331 METHOTREXATE 50MG VIAL EXTERNAL 05/14/01 J9260 J9260 028 0636 5012
13783335 METHOTREXATE 20MG VIAL EXTERNAL 05/14/01 J9250 J9250 028 0636 5012
13783340 METHOTREXATE INJECTION 50MG VI EXTERNAL 05/14/01 J9260 J9260 028 0636 5012
13783341 METHOTREXATE 50MG VIAL PF EXTERNAL 05/14/01 J9260 J9260 028 0636 5012
13783345 METHOTREXATE 50MG VIAL PF EXTERNAL 05/14/01 J9260 J9260 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 297
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13783346 DACLIZUMAB IVPB (25MG/ML VIAL) EXTERNAL 08/25/09 028 0258 5012
13783360 WATER FOR INJECTION (NP) 10ML EXTERNAL 05/07/01 028 0258 5012
13783365 THROMBIN 50,000 UNITS EXTERNAL 05/07/01 028 0258 5012
13783460 WATER FOR IRRIG POUR 1000ML BO EXTERNAL 05/14/01 028 0251 5012
13783502 METHYLENE BLUE 1% INJ 1ML EXTERNAL 12/17/02 028 0258 5012
13783520 METHERGINE SYR EXTERNAL 05/07/01 J2210 J2210 028 0636 5012
13783600 METHYLPREDNISOLONE ACET 40MG EXTERNAL 05/07/01 J1030 J1030 028 0636 5012
13783601 DEPO-MEDROL INJ 40MG/ML EXTERNAL 04/16/03 J1030 J1030 J1030 028 0258 5012
13783651 CHLOROPROCAINE EPID SYR EXTERNAL 05/07/01 J2400 J2400 028 0636 5012
13783758 METRONIDAZOLE 500MG RIDER OR EXTERNAL 05/07/01 028 0258 5012
13783775 MIDAZOLAM ORAL EXTERNAL 05/18/01 028 0258 5012
13783794 MIDAZOLAM INJ 1MG EXTERNAL 04/17/03 J2250 J2250 J2250 028 0258 5012
13783795 AVITENE POWDER 1GM JAR EXTERNAL 05/07/01 028 0251 5012
13783796 AVITENE POWDER 5GM JAR EXTERNAL 05/07/01 028 0251 5012
13783797 AVITENE NON WOVEN WEB EXTERNAL 07/29/05 028 0251 5012
13783833 MILRINONE 1MG/ML 20ML EXTERNAL 05/07/01 J2260 J2260 028 0636 5012
13783920 PLICAMYCIN 2.5 MG VIAL EXTERNAL 05/14/01 J9270 J9270 028 0636 5012
13783925 MITOXANTRONE INJECTION 5MG VIA EXTERNAL 05/14/01 J9293 J9293 028 0636 5012
13783926 MITOXANTRONE INJECTION 25MG VI EXTERNAL 05/14/01 J9293 J9293 028 0636 5012
13783927 MITOXANTRONE INJECTION 20 MG EXTERNAL 05/14/01 J9293 J9293 028 0636 5012
13783930 MITOMYCIN INJECTION 5MG VIAL EXTERNAL 05/14/01 J9280 J9280 028 0636 5012
13783935 MITOMYCIN INJECTION 20MG VIAL EXTERNAL 05/14/01 J9290 J9290 028 0636 5012
13783949 MORPHINE INJ - OR EXTERNAL 05/07/01 J2270 J2270 J2270 028 0636 5012
13783966 MORPHINE VIAL INJECTOR (PCA 5M EXTERNAL 05/07/01 J2270 J2270 028 0636 5012
13784005 MORPHINE INJ 2MG EXTERNAL 04/17/03 J2270 J2270 J2270 028 0251 5012
13784008 MORPHINE INJ 4MG EXTERNAL 04/17/03 J2270 J2270 J2270 028 0251 5012
13784020 MORPHINE 10MG INJ SYR EXTERNAL 04/17/03 J2270 J2270 J2270 028 0258 5012
13784034 MORPHINE EPIDURAL BAG-PAIN/I-M EXTERNAL 05/07/01 J2275 J2275 J2275 028 0636 5012
13784035 MORPHINE PF 0.5MG/ML INJ EXTERNAL 10/03/00 J2275 J2275 J2275 028 0636 5012
13784045 ALGLUCOSIDASE (MYOZYME) 50MG P EXTERNAL 01/01/08 J0220 J0220 J0220 028 0636 5012
13784125 TSAI SOLN 500ML EXTERNAL 05/07/01 028 0258 5012
13784160 NAFCILLIN INJ EXTERNAL 05/07/01 028 0258 5012
13784168 NAFCILLIN RIDER - OR EXTERNAL 05/07/01 028 0258 5012
13784170 NAFCILLIN INJECTION 2GM VIAL EXTERNAL 04/16/03 028 0258 5012
13784195 CLINDAMYCIN RIDER - OR EXTERNAL 05/07/01 028 0258 5012
13784211 CLINDAMYCIN INJ EXTERNAL 05/07/01 028 0258 5012
13784220 CLINDAMYCIN INJ 600MG EXTERNAL 04/17/03 028 0251 5012
13784222 CLINDAMYCIN INJ 900MG EXTERNAL 04/17/03 028 0258 5012
13784223 CLINDAMYCIN SUBCONJ EXTERNAL 04/17/03 028 0258 5012
13784281 NALBUPHINE 10MG/ML INJ AMP EXTERNAL 07/03/08 J2300 J2300 J2300 028 0258 5012
13784360 NEOSPORIN OINTMENT 30GM TUBE EXTERNAL 05/07/01 028 0251 5012
13784411 NEOSPORIN GU IRRIG 1000ML EXTERNAL 05/07/01 028 0258 5012
13784463 REVERSAL SYR EXTERNAL 05/07/01 J2710 J2710 028 0636 5012
13784465 NEOSTIGMINE METHYLSULFATE .5MG EXTERNAL 05/07/01 J2710 J2710 028 0636 5012
13784480 COCAINE 4% TOPICAL SOLUTION EXTERNAL 05/07/01 028 0251 5012
13784481 NICARDIPINE 25MG/10ML EXTERNAL 05/07/01 028 0258 5012
13784546 NIFEDIPINE 10MG CAPSULE EXTERNAL 05/07/01 028 0251 5012
13784630 CODEINE INJ 30MG EXTERNAL 05/07/01 J0745 J0745 028 0636 5012
13784690 NITROGLYCERIN DRIP - OR EXTERNAL 05/07/01 028 0258 5012
13784692 NITROGLYCERIN 25 MG/D5 250 ML EXTERNAL 07/13/05 028 0258 5012
13784694 NITROGLYCERIN 50MG/10ML EXTERNAL 12/10/03 028 0258 5012
13784699 CEFTAZADIME OR EXTERNAL 06/27/01 J0713 J0713 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 298
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13784707 NITROGLYCERIN OINTMENT 1/2INCH EXTERNAL 05/18/01 028 0251 5012
13784720 NITROGLYCERIN TABS 0.4MG EXTERNAL 05/07/01 028 0251 5012
13784738 NITROPRUSSIDE DRIP - OR EXTERNAL 05/07/01 028 0258 5012
13784775 COHEN SOLUTION EXTERNAL 12/03/02 028 0258 5012
13784776 COLLODION FLEXIBLE EXTERNAL 05/07/01 028 0258 5012
13784777 DAW SOLUTION EXTERNAL 12/03/02 028 0258 5012
13784778 GREVIOUS SOLUTION EXTERNAL 12/03/02 028 0258 5012
13784861 HYDROCORTISONE SOD SUCC 100MG EXTERNAL 05/14/01 J1720 J1720 028 0636 5012
13784864 HYDROCORTISONE SOD SUCC 100MG EXTERNAL 05/07/01 J1720 J1720 028 0636 5012
13784910 CORTISPORIN OTIC SUSPENSION 10 EXTERNAL 05/07/01 028 0251 5012
13785003 OCTREOTIDE 100MCG/ML EXTERNAL 05/07/01 J2353 J2353 028 0636 5012
13785005 OCTREOTIDE 500MCG/ML EXTERNAL 05/07/01 J2354 J2354 028 0636 5012
13785026 ONDANSETRON INJ EXTERNAL 05/07/01 J2405 J2405 028 0636 5012
13785027 ONDANSETRON INJ 1MG EXTERNAL 04/16/03 J2405 J2405 J2405 028 0258 5012
13785041 OFLOXACIN 0.3% OPHTH DROPS EXTERNAL 05/07/01 028 0251 5012
13785042 OFLOXACIN 0.3% OTIC SOLN 5ML EXTERNAL 07/25/02 028 0251 5012
13785043 OFLOXACIN 0.3% OTIC SOLN 0.25M EXTERNAL 12/13/06 028 0251 5012
13785068 OMNIPAQUE 350 MG/ML 100 ML BTL EXTERNAL 03/15/06 028 0258 5012
13785070 CYCLOPENTOLATE 1.0% OPTH SOLUT EXTERNAL 05/07/01 028 0251 5012
13785120 CYCLOPHOSPHAMIDE INJ 200MG VIA EXTERNAL 05/14/01 J9070 J9070 028 0636 5012
13785130 CYCLOPHOSPHAMIDE INJ 500MG VIA EXTERNAL 05/14/01 J9090 J9090 028 0636 5012
13785131 CYCLOPHOSPHAMIDE INJ 1GRAM VIA EXTERNAL 05/14/01 J9091 J9091 028 0636 5012
13785161 CYTARABINE INJECTION 100MG VIA EXTERNAL 05/14/01 J9100 J9100 028 0636 5012
13785170 CYTARABINE INJECTION 500MG VIA EXTERNAL 05/14/01 J9110 J9110 028 0636 5012
13785171 CYTARABINE INJECTION 1 GM VIAL EXTERNAL 05/14/01 J9110 J9110 028 0636 5012
13785172 CYTARABINE INJECTION 2 GM VIAL EXTERNAL 05/14/01 J9110 J9110 028 0636 5012
13785191 DACARBAZINE INJECTION 200MG VI EXTERNAL 05/14/01 J9140 J9140 028 0636 5012
13785200 DACTINOMYCIN INJECTION 500MCG EXTERNAL 05/14/01 J9120 J9120 028 0636 5012
13785217 OXYBUTYNIN 5MG TABLET EXTERNAL 05/07/01 028 0251 5012
13785241 ALCOHOL ABSOLUTE INJ 1ML EXTERNAL 08/11/97 028 0258 5012
13785290 OXYMETAZOLINE NOSE SPRAY 15ML EXTERNAL 05/07/01 028 0251 5012
13785305 OXYTOCIN SYRINGE EXTERNAL 05/07/01 J2590 J2590 028 0636 5012
13785306 DAUNORUBICINE INJECTION 10MG V EXTERNAL 05/14/01 J9150 J9150 028 0636 5012
13785315 PACLITAXEL 30MG VIAL EXTERNAL 05/14/01 J9265 J9265 028 0636 5012
13785317 PACLITAXEL 100MG VIAL EXTERNAL 05/14/01 J9265 J9265 028 0636 5012
13785370 PANCURONIUM 10MG SYRINGE EXTERNAL 05/07/01 028 0258 5012
13785420 PAPAVERINE INJECTION 30MG/ML 1 EXTERNAL 05/07/01 028 0250 5012
13785421 PAPAVERINE INJ 60MG + 38ML NAC EXTERNAL 12/17/02 J2440 J2440 028 0636 5012
13785470 FUROSEMIDE INJ 20MG VIAL EXTERNAL 05/07/01 J1940 J1940 028 0636 5012
13785505 OCTREOTIDE 500MCG/ML EXTERNAL 07/24/01 028 0258 5012
13785523 0.22 MICRON FILTER EXTERNAL 05/07/01 028 0258 5012
13785540 GLUCAGON INJECTION 1MG EXTERNAL 05/07/01 J1610 J1610 028 0636 5012
13785551 DEXAMETHASONE SYR 4MG EXTERNAL 05/07/01 J1100 J1100 J1100 028 0636 5012
13785554 PEGASAPARGASE 750IU/ML 5ML VIA EXTERNAL 05/14/01 J9266 J9266 028 0636 5012
13785562 DEXAMETHASONE INJ 1MG/0.1ML 0. EXTERNAL 05/07/01 J1100 J1100 J1100 028 0636 5012
13785590 PENICILLIN RIDER EXTERNAL 05/07/01 J2540 J2540 028 0636 5012
13785627 DEXMEDETOMIDINE 200 MCG IN 50 EXTERNAL 01/23/09 028 0258 5012
13785628 DEXMEDETOMIDINE 4MCG/ML FROM B EXTERNAL 10/02/08 028 0258 5012
13785629 DEXMEDETOMIDINE 100 MCG/ML EXTERNAL 11/13/03 028 0258 5012
13785630 DEXTRAN-40/D5W 500ML BOTTLE EXTERNAL 05/07/01 J7100 J7100 028 0636 5012
13785631 DEXMEDETOMIDINE 400 MCG IN 100 EXTERNAL 07/21/09 028 0258 5012
13785662 VIASPAN (UW SOLUTION) 1000ML EXTERNAL 01/13/03 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 299
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13785663 LOW POTASSIUM DEXTRAN SOLUTION EXTERNAL 01/13/03 028 0258 5012
13785696 PENICILLIN INJ 1MU EXTERNAL 06/27/01 J2540 J2540 028 0636 5012
13785892 REMIFENTANIL ***MG EXTERNAL 05/07/01 028 0258 5012
13785894 REMIFENTANIL INJ 2MG EXTERNAL 05/07/01 028 0251 5012
13785897 REMIFENTANIL INJ 1MG EXTERNAL 05/07/01 028 0258 5012
13785900 D5%/NACL 0.2% 500ML EXTERNAL 04/17/03 028 0258 5012
13786000 CLONIDINE VIAL EXTERNAL 05/07/01 J0735 J0735 028 0636 5012
13786001 SILICONE 5000 OIL EXTERNAL 05/07/01 028 0258 5012
13786010 DEXTROSE 5% IN WATER - 50ML EXTERNAL 05/14/01 J7060 J7060 J7060 028 0258 5012
13786031 NOREPINEPHRINE DRIP - OR EXTERNAL 05/07/01 028 0258 5012
13786040 DEXTROSE 5% IN WATER - 250ML EXTERNAL 05/14/01 J7060 J7060 J7060 028 0258 5012
13786110 PEPPERMINT OIL 30ML BOTTLE EXTERNAL 05/07/01 028 0251 5012
13786210 DEXTROSE 50% INJ 50ML SYRINGE EXTERNAL 05/07/01 028 0258 5012
13786290 DIAZEPAM TABLET EXTERNAL 05/07/01 028 0251 5012
13786370 DIBUCAINE 1% OINTMENT 30GM TUB EXTERNAL 05/07/01 028 0251 5012
13786500 METHYLPREDNISOLONE SUCC ***MG EXTERNAL 05/07/01 J2920 J2920 028 0636 5012
13786501 METHYLPRED SOD SUCC 0.125GM/ML EXTERNAL 08/02/03 J2930 J2930 028 0636 5012
13786630 MITOMYCIN C EXTERNAL 05/07/01 J9280 J9280 028 0636 5012
13786660 PHENTOLAMINE 5MG/ML INJ EXTERNAL 07/03/08 028 0251 5012
13786670 PHENYLEPHRINE PHARMEDIUM SYR EXTERNAL 08/26/09 028 0258 5012
13786680 NALOXONE INJ 0.4MG AMP EXTERNAL 05/07/01 J2310 J2310 J2310 028 0636 5012
13786681 PHENYLEPHRINE INJ EXTERNAL 12/09/03 J2370 J2370 028 0636 5012
13786690 PHENYLEPHRINE 0.25% NOSE DROPS EXTERNAL 05/07/01 028 0251 5012
13786707 PHENYLEPHRINE 2.5% OPTH SOLUTI EXTERNAL 05/07/01 028 0251 5012
13786720 PHENYLEPHRINE OPTH SOLUTION EXTERNAL 05/07/01 028 0251 5012
13786721 CEFTRIAXONE 1GM/2GM RIDER EXTERNAL 05/07/01 J0696 J0696 028 0636 5012
13786725 PHENYLEPHRINE DRIP - OR EXTERNAL 05/07/01 J2370 J2370 028 0636 5012
13786740 PHENYLEPHRINE 0.5% NASAL SPRA EXTERNAL 05/07/01 028 0251 5012
13786750 DIGOXIN INJECTION 500MCG AMPUL EXTERNAL 05/07/01 J1160 J1160 028 0636 5012
13786820 PHYSOSTIGMINE INJ 2MG/2ML EXTERNAL 05/07/01 028 0258 5012
13786841 DILTIAZEM DRIP EXTERNAL 05/07/01 028 0251 5012
13786960 PILOCARPINE 2% OPTH SOLN 1ML EXTERNAL 05/07/01 028 0251 5012
13786991 PILOCARPINE 4% OPTH SOLN 1ML EXTERNAL 08/02/03 028 0251 5012
13787002 ZOSYN RIDER EXTERNAL 05/07/01 J2543 J2543 028 0636 5012
13787050 DIPHENHYDRAMINE INJECTION 50MG EXTERNAL 05/07/01 J1200 J1200 028 0636 5012
13787051 HEP PLASMALYTE 1LITER EXTERNAL 05/07/01 028 0258 5012
13787052 HEPARIN LR 100U/1000ML EXTERNAL 12/17/02 028 0258 5012
13787130 PHENYTOIN SYR EXTERNAL 05/07/01 J1165 J1165 028 0636 5012
13787144 TRANSDERM SCOPALAMINE 1.5 MG EXTERNAL 04/01/04 028 0251 5012
13787145 CELECOXIB 200MG CAPSULE EXTERNAL 09/26/06 028 0251 5012
13787146 METOPROLOL 5MG AMPULE EXTERNAL 09/26/06 028 0251 5012
13787200 ULTRATEAR EXTERNAL 05/07/01 028 0251 5012
13787207 POTASSIUM CHLORIDE RIDER - OR EXTERNAL 05/07/01 J3480 J3480 028 0636 5012
13787208 CISATRACURIUM 2MG/ML EXTERNAL 06/14/01 028 0258 5012
13787220 DOBUTAMINE DRIP - OR EXTERNAL 05/07/01 J1250 J1250 028 0636 5012
13787235 POTASSIUM CHLORIDE INJ 40MEQ V EXTERNAL 05/14/01 J3480 J3480 028 0636 5012
13787241 DOXAPRAM INJECTION ***MG EXTERNAL 05/07/01 028 0258 5012
13787245 POTASSIUM/MAGNESIUM RIDER - OR EXTERNAL 05/07/01 J3480 J3480 028 0636 5012
13787249 DOPAMINE DRIP - OR EXTERNAL 05/07/01 J1265 J1265 J1265 028 0636 5012
13787254 DORZOLAMIDE 2% OPHTH SOLUTION EXTERNAL 05/07/01 028 0251 5012
13787320 DOXORUBICIN INJECTION 10MG VIA EXTERNAL 05/14/01 J9000 J9000 J9000 028 0636 5012
13787335 DOXORUBICIN HCL 2MG/ML 100ML V EXTERNAL 05/14/01 J9000 J9000 J9000 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 300
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13787380 POVIDONE IODINE OINTMENT 30GM EXTERNAL 05/07/01 028 0251 5012
13787400 CEFAZOLIN OPTH DROPS 10ML EXTERNAL 05/07/01 J0690 J0690 J0690 028 0251 5012
13787401 MIDAZOLAM INJECTION EXTERNAL 05/07/01 J2250 J2250 028 0636 5012
13787406 LABETOLOL INJ 20 MG EXTERNAL 05/07/01 028 0258 5012
13787407 LABETOLOL INJ EXTERNAL 04/17/03 028 0258 5012
13787408 DROPERIDOL INJECTION 2.5MG AMP EXTERNAL 05/07/01 J1790 J1790 028 0636 5012
13787485 EDETATE DISODIUM 150MG/ML INJ EXTERNAL 01/04/05 028 0251 5012
13787486 FERRIC SUBSULFATE (ASTRINGYN) EXTERNAL 03/29/06 028 0251 5012
13787491 PREDNISOLONE ACETATE 1% OPTH S EXTERNAL 05/07/01 028 0251 5012
13787655 ENOXAPARIN 30MG SYR EXTERNAL 07/03/08 J1650 J1650 J1650 028 0258 5012
13787658 ENOXAPARIN 40MG SYR EXTERNAL 07/03/08 J1650 J1650 J1650 028 0258 5012
13787670 EPHEDRINE 50 MG AMPULE EXTERNAL 05/07/01 028 0258 5012
13787671 EPHEDRINE INJ 5MG/ML EXTERNAL 05/07/01 028 0258 5012
13787672 EPHEDRINE PHARMEDIUM SYRINGE EXTERNAL 08/25/09 028 0258 5012
13787680 MEPIVACAINE SYR - OR EXTERNAL 05/07/01 J0670 J0670 028 0636 5012
13787685 EPINEPHERINE DRIP-OR EXTERNAL 05/07/01 J0170 028 0636 5012
13787692 EPINEPHRINE 1:1000 1ML SYR OR EXTERNAL 05/07/01 028 0258 5012
13787710 EPINEPHRINE 0.1% OPTH SOLUTION EXTERNAL 05/07/01 028 0258 5012
13787770 NITROPRUSSIDE 50MG VIAL EXTERNAL 12/10/03 028 0258 5012
13787785 EPINEPHRINE 1:200000 INJ EXTERNAL 05/07/01 J0170 J0170 028 0636 5012
13787795 EPINEPHRINE RACEMIC 2.25% **** EXTERNAL 05/07/01 J3535 028 0636 5012
13787800 NITROGLYCERIN OINT PKT EXTERNAL 05/07/01 028 0251 5012
13787910 ERYTHROMYCIN 0.5% OPTH OINTMEN EXTERNAL 05/07/01 028 0251 5012
13787911 ERYTHROMYCIN 0.5% OPTH OINTMEN EXTERNAL 08/26/09 028 0251 5012
13787935 PROCHLORPERAZINE INJ 10MG SYRI EXTERNAL 05/07/01 028 0258 5012
13787973 ESMOLOL 100MG SYRINGE EXTERNAL 05/07/01 028 0258 5012
13787974 ESCITALOPRAM 2.5MG TAB EXTERNAL 01/22/07 028 0251 5012
13787975 ESMOLOL DRIP - OR EXTERNAL 05/07/01 028 0258 5012
13787976 ESCITALOPRAM 10 MG TAB EXTERNAL 07/23/03 028 0251 5012
13787977 ESCITALOPRAM 20 MG TAB EXTERNAL 07/23/03 028 0251 5012
13787978 ESCITALOPRAM 5 MG TAB (1/2 OF EXTERNAL 01/07/05 028 0251 5012
13787979 ESCITALOPRAM 30 MG (10 MG X 3) EXTERNAL 02/05/08 028 0251 5012
13787980 PROMETHAZINE INJECTION 25MG AM EXTERNAL 05/07/01 J2550 028 0636 5012
13788000 MONSEL'S SOLUTION EXTERNAL 05/07/01 028 0251 5012
13788028 GABAPENTIN 400MG CAP EXTERNAL 09/11/00 028 0251 5012
13788170 ETOPOSIDE 1GM VIAL EXTERNAL 05/14/01 J9182 J9182 028 0636 5012
13788171 ETOPOSIDE 100MG VIAL EXTERNAL 05/14/01 J9182 J9182 028 0636 5012
13788179 ETOPOSIDE 100MG VIAL EXTERNAL 05/14/01 J9182 J9182 028 0636 5012
13788182 ETOMIDATE 20MG SYRINGE EXTERNAL 05/07/01 028 0258 5012
13788197 FAMOTIDINE 20MG RIDER EXTERNAL 12/10/03 028 0258 5012
13788210 BALANCED SALT OPTH SOLN 30ML B EXTERNAL 05/07/01 028 0251 5012
13788211 PROPRANOLOL INJ 1MG EXTERNAL 05/07/01 J1800 J1800 028 0636 5012
13788212 PROPRANOLOL INJ 1MG VIAL EXTERNAL 04/17/03 J1800 J1800 J1800 028 0258 5012
13788213 ZOSYN 4.5 GM VIAL EXTERNAL 05/15/06 J2543 J2543 J2543 028 0258 5012
13788214 VANCOMYCIN 500 MG VIAL EXTERNAL 05/15/06 J3370 J3370 J3370 028 0258 5012
13788215 LIDOCAINE 1% 50 ML VIAL EXTERNAL 05/15/06 J2001 J2001 J2001 028 0636 5012
13788216 MAGNESIUM SULFATE 5 GM 10 ML V EXTERNAL 05/15/06 J3475 J3475 J3475 028 0258 5012
13788217 TOBRADEX OPTHALMIC SUSPENSION EXTERNAL 09/29/05 028 0251 5012
13788218 DOCUSATE SODIUM 10MG/ML 473 ML EXTERNAL 05/16/06 028 0251 5012
13788219 LIDOCAINE-EPI 2% 1:200,000 20 EXTERNAL 05/15/06 028 0258 5012
13788220 CORTISPORIN OTIC SOLN 10ML EXTERNAL 05/17/06 028 0251 5012
13788221 ORA SWEET SYRUP VEHICLE EXTERNAL 05/17/06 028 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 301
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13788222 ORA PLUS SUSPENDING VEHICLE EXTERNAL 05/17/06 028 0251 5012
13788223 SURGIFOAM SPONGE SIZE 12 X 8.5 EXTERNAL 05/17/06 028 0251 5012
13788224 ALTEPLASE 100MG/100ML INJ EXTERNAL 05/30/06 J2997 J2997 J2997 028 0251 5012
13788225 SIMPLE SYRUP 473 ML EXTERNAL 05/30/06 028 0251 5012
13788226 POTASSIUM ACETATE 100 MEQ VIAL EXTERNAL 05/30/06 028 0251 5012
13788227 CHLOROPROCAINE 400MG/20ML VIAL EXTERNAL 05/30/06 J2400 J2400 J2400 028 0251 5012
13788228 VANCOMYCIN 5 GM VIAL EXTERNAL 05/30/06 J3370 J3370 J3370 028 0251 5012
13788229 CEFTAZIDIME 2GM VIAL EXTERNAL 05/30/06 J0713 J0713 J0713 028 0251 5012
13788231 HYDROCERIN 480 GM CREAM EXTERNAL 05/31/06 028 0251 5012
13788232 HEPARIN LOCK FLUSH PF 10 UNITS EXTERNAL 06/01/06 J1642 J1642 J1642 028 0258 5012
13788233 HEPARIN LOCK FLUSH PF 100 UNIT EXTERNAL 06/01/06 J1642 J1642 J1642 028 0258 5012
13788234 HEPARIN LOCK FLUSH 10 UNITS/ML EXTERNAL 06/01/06 J1642 J1642 J1642 028 0258 5012
13788252 FENTANYL/BUPIVACAINE 2 MCG/0.0 EXTERNAL 01/09/05 028 0251 5012
13788312 FLUDARABINE 50MG VIAL EXTERNAL 05/14/01 J9185 J9185 028 0636 5012
13788315 FIBRIN GLUE (TISSEEL) EXTERNAL 05/07/01 028 0251 5012
13788320 FIORINAL CAPSULE EXTERNAL 06/07/01 028 0251 5012
13788340 PROTAMINE SULFATE 10MG AMPULE EXTERNAL 05/07/01 028 0258 5012
13788360 FLOXURIDINE 500MG VIAL EXTERNAL 05/14/01 J9200 J9200 J9200 028 0636 5012
13788405 FLUMAZENIL 0.1MG/ML INJ - 5ML EXTERNAL 05/07/01 028 0258 5012
13788410 FLUMAZENIL 0.1MG/ML INJ - 10ML EXTERNAL 05/07/01 028 0258 5012
13788486 FLUORESCEIN OPHTH STRIPS EXTERNAL 05/07/01 028 0251 5012
13788500 FLUORESCEIN 10% INJ EXTERNAL 05/07/01 028 0258 5012
13788540 FLUORESCEIN 2% OPHTH SOLN 1ML EXTERNAL 05/07/01 028 0251 5012
13788590 FLUOROURACIL 500MG VIAL EXTERNAL 05/14/01 J9190 J9190 028 0636 5012
13788628 RANITIDINE RIDER - OR EXTERNAL 05/07/01 J2780 J2780 028 0636 5012
13788638 RANITIDINE INJECTION 25MG VIA EXTERNAL 05/07/01 J2780 J2780 028 0636 5012
13788800 FLURBIPROFEN 0.03% OPHTH SOLN EXTERNAL 05/07/01 028 0251 5012
13788810 RINGERS IV SOLUTION 1000ML BAG EXTERNAL 05/07/01 J7120 J7120 028 0636 5012
13788860 RINGERS LACTATED IV SOLN 1000M EXTERNAL 05/07/01 J7120 J7120 028 0636 5012
13788871 FOSPHENYTOIN 10ML VIAL EXTERNAL 05/07/01 Q2009 Q2009 028 0636 5012
13788918 ROPIVACAINE 0.2% 200 ML INJ EXTERNAL 08/25/09 028 0258 5012
13788919 ROCURONIUM INJ 5ML EXTERNAL 11/07/00 028 0258 5012
13788920 FENTANYL 1000 MCG/20ML AMPULE EXTERNAL 04/19/06 028 0251 5012
13788922 ROPIVACAINE INJ EXTERNAL 05/07/01 028 0250 5012
13788923 FENTANYL 100 MCG/2ML INJ EXTERNAL 08/25/09 028 0251 5012
13788924 FENTANYL 250 MCG/5ML INJ EXTERNAL 08/25/09 028 0251 5012
13788925 FENTANYL 500 MCG/10ML INJ EXTERNAL 08/25/09 028 0251 5012
13788932 ROCURONIUM INJ 5ML EXTERNAL 05/07/01 028 0258 5012
13788936 ROFECOXIB 50MG TABLET EXTERNAL 06/08/01 028 0251 5012
13789000 ETOPOSIDE PHOS 10MG/ML INJ EXTERNAL 06/13/02 J9181 J9181 J9181 028 0258 5012
13789001 ETOPOSIDE PHOS 10MG/ML SYR INJ EXTERNAL 06/13/02 J9181 J9181 J9181 028 0258 5012
13789003 AMMONIUM CHLORIDE 0.2MEQ/ML PE EXTERNAL 06/27/01 028 0258 5012
13789004 AMMONIUM CHLORIDE 0.4MEQ/ML PE EXTERNAL 06/27/01 028 0258 5012
13789005 CALCIUM CHL 20MG/ML PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13789006 CEFEPIME 40MG/ML PEDS INJ EXTERNAL 06/27/01 J0692 J0692 028 0636 5012
13789007 CEFOXITIN 100MG/1ML PEDS INJ EXTERNAL 06/27/01 J0694 J0694 028 0636 5012
13789008 CHLORAMPHENICOL 100MG/1ML PEDS EXTERNAL 06/27/01 J0720 J0720 028 0636 5012
13789009 CHLOROTHIAZIDE 28MG/ML PEDS IN EXTERNAL 06/27/01 J1205 J1205 028 0636 5012
13789010 CHLOROTHIAZIDE 2.8MG/ML PEDS I EXTERNAL 06/27/01 J1205 J1205 028 0636 5012
13789011 CHLOROTHIAZIDE 5.6MG/ML PEDS I EXTERNAL 06/27/01 J1205 028 0636 5012
13789012 COTRIMOXAZOLE 1:25 PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13789013 COTRIMOXAZOLE 1:20 PEDS INJ EXTERNAL 06/27/01 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 302
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13789014 COTRIMOXAZOLE 1:15 PEDS INJ EXTERNAL 06/27/01 028 0258 5012
13789015 CYCLOSPORINE 2MG/ML PEDS INJ EXTERNAL 06/28/01 J7516 J7516 028 0636 5012
13789016 DESMOPRESSIN ACE 0.5MCG/ML PED EXTERNAL 06/28/01 J2597 J2597 J2597 028 0636 5012
13789017 DIPHENHYDRAMINE 25MG/ML PEDS I EXTERNAL 05/16/02 J1200 J1200 028 0636 5012
13789018 ENALAPRILAT 0.125MG/ML PEDS IN EXTERNAL 06/28/01 028 0258 5012
13789019 ENALAPRILAT 0.05MG/ML PEDS INJ EXTERNAL 06/28/01 028 0258 5012
13789020 ENALAPRILAT 0.025MG/ML PEDS IN EXTERNAL 06/28/01 028 0258 5012
13789021 ERYTHROMYCIN 5MG/ML PEDS INJ EXTERNAL 06/28/01 J1364 J1364 028 0636 5012
13789022 FENTANYL 5MCG/ML PEDS INJ EXTERNAL 06/28/01 J3010 J3010 J3010 028 0636 5012
13789023 FILFGRASTIM 150MCG/ML PEDS INJ EXTERNAL 06/28/01 J1440 J1440 J1440 028 0636 5012
13789024 GLYCOPRROLATE 200MCG/ML PEDS I EXTERNAL 06/28/01 028 0258 5012
13789025 GLYCOPRROLATE 20MCG/ML PEDS IN EXTERNAL 06/28/01 028 0258 5012
13789027 HYDROCORTISONE 5MG/ML PEDS INJ EXTERNAL 06/28/01 J1720 028 0636 5012
13789029 INSULIN HUMAN REG 10 UNITS/ML EXTERNAL 06/28/01 028 0258 5012
13789030 INSULIN HUMAN NPH 10 UNITS/ML EXTERNAL 06/28/01 028 0258 5012
13789031 INSULIN LISPRO 10 UNITS/ML PED EXTERNAL 06/28/01 J1815 J1815 028 0636 5012
13789032 GANCICLOVIR 500MG VIAL EXTERNAL 05/14/01 J1570 J1570 028 0636 5012
13789033 LEUCOVORIN CA 10MG/ML PEDS INJ EXTERNAL 06/28/01 J0640 J0640 028 0636 5012
13789034 LEUCOVORIN CA 5MG/ML PEDS INJ EXTERNAL 06/28/01 J0640 J0640 028 0636 5012
13789035 METOCLOPRAMIDE 1MG/ML PEDS INJ EXTERNAL 06/28/01 J2765 J2765 028 0636 5012
13789036 SODIUM BICARB 0.5MEQ/ML PEDS I EXTERNAL 06/28/01 028 0258 5012
13789037 VECURONIUM 1MG/ML PEDS INJ EXTERNAL 06/28/01 028 0258 5012
13789038 ENALAPRILAT 1.25MG/ML PEDS INJ EXTERNAL 06/28/01 028 0258 5012
13789039 ALTEPLASE 1MG/ML ADULT CATH CL EXTERNAL 06/29/01 J2997 J2997 028 0636 5012
13789040 ALTEPLASE 0.5MG/ML PEDS CATH C EXTERNAL 06/29/01 J2997 J2997 028 0636 5012
13789041 ALTEPLASE 4MG/ML INTRA-VENTRIC EXTERNAL 06/29/01 J2997 J2997 028 0636 5012
13789042 SODIUM CHL 0.9% PF INTRA-VENTR EXTERNAL 06/28/01 028 0250 5012
13789043 SODIUM CHL 0.9% PF INTRA-THECA EXTERNAL 06/28/01 028 0250 5012
13789044 IMMUNE GLOBULIN 50MG/ML INJ EXTERNAL 06/28/01 028 0250 5012
13789045 ATGAM 1:1000 TEST DOSE INTRA-D EXTERNAL 01/01/03 J7511 J7511 J7511 028 0636 5012
13789046 CMV IMM GLOBULIN 50MG/ML INJ EXTERNAL 06/28/01 J0850 J0850 028 0636 5012
13789047 HEPATITIS B IMM GLOB IVPB EXTERNAL 01/01/03 028 0258 5012
13789048 AMIFOSTINE 5MG/ML IVP INJ EXTERNAL 06/28/01 J0207 J0207 J0207 028 0636 5012
13789049 LABETOLOL 5MG/ML PEDS INJ EXTERNAL 06/28/01 028 0258 5012
13789050 ASPARAGINASE 2000 U/ML IVP INJ EXTERNAL 06/26/01 J9020 J9020 028 0636 5012
13789051 GELFILM (ANY SIZE) EXTERNAL 05/07/01 028 0251 5012
13789052 ASPARAGINASE INJECTION 2000 U/ EXTERNAL 06/26/01 J9020 J9020 028 0636 5012
13789053 ASPARAGINASE INJ 20 U/ML ID TE EXTERNAL 06/26/01 J9020 J9020 028 0636 5012
13789054 AZATHIOPRINE INJ 10MG/ML IVPB EXTERNAL 06/28/01 J7501 J7501 028 0636 5012
13789055 AZATHIOPRINE INJ 10MG/ML IVP I EXTERNAL 06/28/01 J7501 J7501 028 0636 5012
13789056 BLEOMYCIN 3 UNITS/ML TEST DOSE EXTERNAL 06/28/01 J9040 J9040 028 0636 5012
13789057 BLEOMYCIN 3 UNITS/ML IVP INJ EXTERNAL 06/28/01 J9040 J9040 028 0636 5012
13789058 BLEOMYCIN 15UNITS/ML IM/SC INJ EXTERNAL 06/28/01 J9040 J9040 028 0636 5012
13789059 BLEOMYCIN 3 UNITS/ML INJ EXTERNAL 06/28/01 J9040 J9040 028 0636 5012
13789060 BLEOMYCIN 3 MG/ML TEST DOSE IN EXTERNAL 06/28/01 J9040 J9040 028 0636 5012
13789061 GATIFLOXACIN 0.3% OPTH SOLN 5 EXTERNAL 02/03/06 028 0251 5012
13789062 BLEOMYCIN 15MG/ML IM/SC INJ EXTERNAL 06/28/01 J9040 J9040 028 0636 5012
13789063 BLEOMYCIN 3 MG/ML INJ EXTERNAL 06/28/01 J9040 J9040 028 0636 5012
13789064 CARBOPLATIN 10MG/ML IVP INJ EXTERNAL 06/28/01 J9045 J9045 J9045 028 0636 5012
13789065 CARMUSTINE 3.3MG/ML INJ EXTERNAL 06/28/01 J9050 J9050 028 0636 5012
13789067 CISPLATIN 1MG/ML INJ EXTERNAL 06/27/01 J9060 J9060 028 0636 5012
13789068 CYCLOPHOSPHAMIDE 20MG/ML IVP I EXTERNAL 06/28/01 J9080 J9080 028 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 303
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13789069 CYCLOPHOSPHAMIDE 20MG/ML INJ EXTERNAL 06/28/01 J9080 J9080 028 0636 5012
13789070 CYCLOPHOSPHAMIDE 0.02GM/ML IVP EXTERNAL 06/28/01 J9080 J9080 028 0636 5012
13789071 CYCLOPHOSPHAMIDE 0.02GM/ML INJ EXTERNAL 06/28/01 J9080 J9080 028 0636 5012
13789072 CYTARABINE 20MG/ML SYR INJ EXTERNAL 06/28/01 J9110 J9110 028 0636 5012
13789073 CYTARABINE 50MG/ML SYR INJ EXTERNAL 06/28/01 J9100 J9100 028 0636 5012
13789074 CYTARABINE 100MG/ML SYR INJ EXTERNAL 06/28/01 J9110 J9110 028 0636 5012
13789075 CYTARABINE 100MG/ML INJ EXTERNAL 06/28/01 J9100 J9100 028 0636 5012
13789076 CYTARABINE 0.1GM/ML SYR INJ EXTERNAL 06/28/01 J9110 J9110 028 0636 5012
13789077 CYTARABINE 0.1GM/ML INJ EXTERNAL 06/28/01 J9110 J9110 028 0636 5012
13789078 DACARBAZINE 10MG/ML IVP INJ EXTERNAL 06/28/01 J9140 J9140 028 0636 5012
13789079 DACARBAZINE 10MG/ML INJ EXTERNAL 06/28/01 J9130 J9130 028 0636 5012
13789080 DACTINOMYCIN INJ 500MCG/ML IVP EXTERNAL 06/28/01 J9120 J9120 028 0636 5012
13789081 DACTINOMYCIN INJ 500MCG/ML INJ EXTERNAL 06/28/01 J9120 J9120 028 0636 5012
13789082 DACTINOMYCIN 0.5MG/ML IVP INJ EXTERNAL 06/28/01 J9120 J9120 028 0636 5012
13789083 DACTINOMYCIN 0.5MG/ML INJ EXTERNAL 06/28/01 J9120 J9120 028 0636 5012
13789084 DAUNORUBICIN HCL 2MG/ML IVP IN EXTERNAL 06/28/01 J9150 J9150 028 0636 5012
13789085 DAUNORUBICIN HCL 5MG/ML IVP IN EXTERNAL 06/28/01 J9150 J9150 028 0636 5012
13789086 DOXORUBICIN 2MG/ML IVP INJ EXTERNAL 06/27/01 J9000 J9000 028 0636 5012
13789088 DOPAMINE NEO DRIP MCG/KG/MIN EXTERNAL 06/28/01 J1265 J1265 J1265 028 0636 5012
13789089 DOBUTAMINE NEO DRIP MCG/KG/MIN EXTERNAL 06/28/01 J1250 028 0258 5012
13789090 BETAMETHASONE ACET/PHOS INJ*** EXTERNAL 05/07/01 J0702 J0702 028 0636 5012
13789091 ALPROSTADIL PEDS/NEO EXTERNAL 06/28/01 J0270 028 0636 5012
13789092 EPINEPHRINE NEO DRIP MCG/KG/MI EXTERNAL 06/28/01 J0170 J0170 028 0636 5012
13789093 ISOPROTERENOL PEDS/NEO EXTERNAL 06/28/01 028 0258 5012
13789094 GELFOAM 100 COMPRESSED EXTERNAL 05/07/01 028 0251 5012
13789095 PHENYLEPHRINE PEDS/NEO EXTERNAL 06/28/01 J2370 J2370 J2370 028 0258 5012
13789096 VECURONIUM PEDS/NEO EXTERNAL 06/28/01 028 0258 5012
13789097 NOREPINEPHRINE PEDS/NEO EXTERNAL 06/28/01 028 0258 5012
13789098 NITROPRUSSIDE PEDS/NEO EXTERNAL 06/28/01 028 0258 5012
13789099 GELFOAM SPONGE (12X7) EXTERNAL 05/07/01 028 0251 5012
13789100 MILRINONE PEDS/NEO EXTERNAL 06/28/01 J2260 J2260 028 0636 5012
13789101 TERBUTALINE PEDS/NEO EXTERNAL 06/28/01 J3105 J3105 J3105 028 0258 5012
13789102 MORPHINE NEO DRIP MCG/KG/HR EXTERNAL 06/28/01 J2275 J2275 028 0636 5012
13789103 FENTANYL PEDS/NEO EXTERNAL 06/28/01 J3010 J3010 J3010 028 0258 5012
13789104 INSULIN HUMAN REGULAR PEDS/NEO EXTERNAL 06/28/01 J1815 J1815 028 0636 5012
13789105 ETOPOSIDE 10MG/ML INJ EXTERNAL 06/28/01 J9181 J9181 J9181 028 0636 5012
13789106 FLUOROURACIL 50MG/ML INJ EXTERNAL 06/28/01 J9190 J9190 028 0636 5012
13789107 FLUOROURACIL 50MG/ML SYR INJ ( EXTERNAL 06/28/01 J9190 J9190 028 0636 5012
13789108 FLUOROURACIL 0.05GM/ML SYR INJ EXTERNAL 06/28/01 J9190 J9190 028 0636 5012
13789109 GANCICLOVIR 50MG/ML INJ EXTERNAL 06/28/01 J1570 J1570 028 0636 5012
13789110 IDARUBICIN 1MG/ML SYR INJ EXTERNAL 06/28/01 J9211 J9211 028 0636 5012
13789111 IFOSFAMIDE 50MG/ML INJ EXTERNAL 06/28/01 J9208 J9208 028 0636 5012
13789112 MECHLORETHAMINE 1MG/ML SYR INJ EXTERNAL 06/28/01 J9230 J9230 028 0636 5012
13789113 MELPHALAN 5MG/ML SYR INJ EXTERNAL 06/28/01 J9245 J9245 028 0636 5012
13789114 MESNA 100MG/ML INJ EXTERNAL 06/28/01 J9209 J9209 028 0636 5012
13789115 THIOTEPA 10MG/ML SYR INJ EXTERNAL 06/28/01 J9340 J9340 J9340 028 0636 5012
13789116 THIOTEPA 1MG/ML SYR INJ EXTERNAL 06/28/01 J9340 J9340 028 0636 5012
13789117 VINCRISTINE 1MG/ML SYR INJ EXTERNAL 06/28/01 J9370 J9370 028 0636 5012
13789119 ETOPOSIDE PHOS 10MG/0.5ML SYR EXTERNAL 06/28/01 J9182 J9182 J9182 028 0636 5012
13789120 ZIDOVUDINE 1MG/ML PEDS INJ EXTERNAL 06/28/01 J3485 J3485 028 0636 5012
13789121 METRONIDAZOLE 5MG/ML INJ EXTERNAL 06/28/01 028 0258 5012
13789122 AMIKACIN 5MG/ML PEDS INJ EXTERNAL 06/28/01 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 304
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13789123 CEFUROXIME 100MG/ML PEDS INJ EXTERNAL 06/28/01 J0697 J0697 028 0636 5012
13789124 FLUCONAZOLE 2MG/ML INJ EXTERNAL 06/28/01 J1450 J1450 028 0636 5012
13789125 ALPROSTADIL 500MCG FOR 250ML L EXTERNAL 06/28/01 J0270 J0270 028 0636 5012
13789126 AMIODARONE 150MG FOR 100 ML LV EXTERNAL 06/28/01 J0282 J0282 028 0636 5012
13789127 AMIODARONE 450MG FOR 250 ML LV EXTERNAL 06/28/01 J0282 J0282 J0282 028 0258 5012
13789128 AMIODARONE 30MG FOR 10 ML LVP EXTERNAL 06/28/01 J0282 J0282 J0282 028 0636 5012
13789131 DILTIAZEM 50MG FOR 100ML LVP EXTERNAL 06/28/01 028 0258 5012
13789132 DILTIAZEM 100MG FOR 100ML LVP EXTERNAL 06/28/01 028 0258 5012
13789133 EPINEPHRINE 1MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789134 EPINEPHRINE 2MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789135 EPINEPHRINE 4MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789136 EPINEPHRINE 8MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789137 EPINEPHRINE 16MG FOR 250ML LVP EXTERNAL 06/28/01 J0170 J0170 028 0636 5012
13789138 EPINEPHRINE 32MG FOR 250ML LVP EXTERNAL 06/28/01 J0170 J0170 028 0636 5012
13789139 ESMOLOL 2500MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789140 FUROSEMIDE 20MG FOR 20ML LVP EXTERNAL 06/28/01 J1940 J1940 J1940 028 0258 5012
13789141 SCOPOLAMINE 0.4MG VIAL EXTERNAL 05/07/01 028 0258 5012
13789142 FUROSEMIDE 500 NG/250 ML NS EXTERNAL 06/28/01 J1940 J1940 J1940 028 0258 5012
13789143 HEPARIN 1000 U/NS 10ML EXTERNAL 06/28/01 J1644 J1644 028 0636 5012
13789144 INSULIN HUMAN 5 UNITS FOR 100M EXTERNAL 06/28/01 J1815 J1815 J1815 028 0251 5012
13789145 INSULIN HUMAN 100 UNITS FOR 10 EXTERNAL 06/28/01 J1815 J1815 028 0636 5012
13789146 ISOPROTERENOL 1MG FOR 250ML LV EXTERNAL 06/28/01 028 0258 5012
13789147 ISOPROTERENOL 2MG FOR 250ML LV EXTERNAL 06/28/01 028 0258 5012
13789148 ISOPROTERENOL 4MG FOR 250ML LV EXTERNAL 06/28/01 028 0258 5012
13789149 LABETOLOL 1000MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789150 LABETOLOL 250MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789151 LABETOLOL 500MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
13789152 LIDOCAINE 1000MG FOR 250ML LVP EXTERNAL 06/28/01 J2001 J2001 028 0636 5012
13789153 LIDOCAINE 2000MG FOR 250ML LVP EXTERNAL 06/28/01 J2001 J2001 028 0258 5012
13789154 MIDAZOLAM 25MG FOR 100ML LVP EXTERNAL 06/28/01 J2250 J2250 J2250 028 0258 5012
13789155 MIDAZOLAM 1MG FOR 20ML LVP EXTERNAL 06/28/01 028 0258 5012
13789156 MIDAZOLAM 1MG FOR 1ML LVP EXTERNAL 06/28/01 028 0258 5012
13789157 MILRINONE 5MG FOR 100ML LVP EXTERNAL 06/07/01 J2260 J2260 028 0636 5012
13789159 MULTIVITAMIN PEDIATRIC ML EXTERNAL 12/28/98 028 0258 5012
13789160 MULTIVITAMINS ADDITIVE PEDS ML EXTERNAL 12/28/98 028 0258 5012
13789162 HEPARIN UNITS/ML *TPN* EXTERNAL 06/07/01 028 0258 5012
13789167 NOREPINEPHRINE 16MG FOR 250ML EXTERNAL 06/28/01 028 0258 5012
13789169 NOREPINEPHRINE 64MG FOR 250ML EXTERNAL 06/28/01 028 0258 5012
13789170 GENTAMICIN INJ 80MG/2ML VIAL EXTERNAL 05/07/01 J1580 J1580 028 0636 5012
13789171 OCTREOTIDE 500MCG FOR 100 ML L EXTERNAL 06/28/01 J2354 J2354 028 0636 5012
13789172 PHENYLEPHRINE 10MG FOR 250ML L EXTERNAL 06/28/01 J2370 J2370 J2370 028 0258 5012
13789173 PHENYLEPHRINE 20MG FOR 250ML L EXTERNAL 06/28/01 J2370 J2370 J2370 028 0258 5012
13789174 PHENYLEPHRINE 40MG FOR 250ML L EXTERNAL 06/28/01 J2370 J2370 J2370 028 0258 5012
13789175 PHENYLEPHRINE 80MG FOR 250ML L EXTERNAL 06/28/01 J2370 J2370 J2370 028 0258 5012
13789176 PHENYLEPHRINE 100MG FOR 250ML EXTERNAL 06/28/01 J2370 J2370 028 0636 5012
13789177 PHENYLEPHRINE 200MG FOR 250ML EXTERNAL 06/28/01 J2370 J2370 J2370 028 0258 5012
13789178 PROCAINAMIDE 1GM FOR 250ML LVP EXTERNAL 06/28/01 J2690 J2690 028 0636 5012
13789179 PROCAINAMIDE 2GM FOR 250ML LVP EXTERNAL 06/28/01 J2690 J2690 J2690 028 0258 5012
13789180 VECURONIUM 20MG FOR 100 ML LVP EXTERNAL 06/28/01 028 0258 5012
13789181 VECURONIUM 80MG FOR 100 ML LVP EXTERNAL 06/28/01 028 0258 5012
13789182 VECURONIUM 100MG FOR 100 ML LV EXTERNAL 06/28/01 028 0258 5012
13789183 NICARDIPINE 25MG FOR 250ML LVP EXTERNAL 06/28/01 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 305
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13789184 THEOPHYLLINE 40MG FOR 500ML LV EXTERNAL 08/02/01 J2810 J2810 028 0636 5012
13789185 GENTAMICIN RIDER - OR EXTERNAL 05/07/01 J1580 J1580 028 0636 5012
13789186 FUROSEMIDE 250MG FOR 250ML LVP EXTERNAL 06/28/01 J1940 J1940 J1940 028 0636 5012
13789187 NOREPINEPHRINE 4MG FOR 250ML L EXTERNAL 06/28/01 028 0258 5012
13789189 NITROGLYCERIN 25MG FOR 250ML L EXTERNAL 06/28/01 028 0258 5012
13789190 NITROGLYCERIN 50MG FOR 250ML L EXTERNAL 06/28/01 028 0258 5012
13789191 NITROGLYCERIN 100MG FOR 250ML EXTERNAL 06/28/01 028 0258 5012
13789192 NITROPRUSSIDE 50MG FOR 250ML L EXTERNAL 06/28/01 028 0258 5012
13789193 NITROPRUSSIDE 100MG FOR 250ML EXTERNAL 06/28/01 028 0258 5012
13789194 NITROPRUSSIDE 150MG FOR 250ML EXTERNAL 06/28/01 028 0258 5012
13789195 NITROPRUSSIDE 200MG FOR 250ML EXTERNAL 06/28/01 028 0258 5012
13789196 NOREPINEPHRINE 8MG FOR 250ML L EXTERNAL 06/28/01 028 0258 5012
13789197 OCTREOTIDE 100MCG FOR 100 ML L EXTERNAL 06/28/01 028 0258 5012
13789198 NACL 0.9% FOR NEO X MLS EXTERNAL 01/01/07 J7050 J7050 J7050 028 0250 5012
13789199 SODIUM CHLORIDE 0.45% FOR NEO EXTERNAL 08/10/01 028 0258 5012
13789201 NACL 0.2% FOR NEO X MLS EXTERNAL 08/10/01 028 0258 5012
13789202 GENTAMICIN SYR - OR EXTERNAL 05/07/01 J1580 J1580 028 0636 5012
13789203 CEFUROXIME 0.1GM/ML EXTERNAL 07/05/01 J0697 028 0636 5012
13789205 CEFUROXIME 1500 MG/D5W 50 ML I EXTERNAL 05/16/02 J0697 J0697 028 0636 5012
13789206 FUROSEMIDE 500MG FOR 250ML LVP EXTERNAL 01/11/05 028 0258 5012
13789207 VECURONIUM 200MG FOR 100 ML LV EXTERNAL 07/21/09 028 0258 5012
13789208 FUROSEMIDE 100 MG IV INFUSION EXTERNAL 08/25/09 028 0258 5012
13789230 GENTAMICIN 0.3% OPTH OINTMENT EXTERNAL 05/07/01 028 0251 5012
13789234 CISATRACURIUM 200MG FOR 250ML EXTERNAL 09/22/03 028 0258 5012
13789237 VECURONIUM 0.5 MG/ML PEDS INJ EXTERNAL 06/28/01 028 0258 5012
13789238 VECURONIUM NEO DRIP 10 MG EXTERNAL 06/28/01 028 0258 5012
13789239 VECURONIUM NEO DRIP 5 MG EXTERNAL 06/28/01 028 0258 5012
13789240 GENTAMICIN 0.3% OPTH SOL 5ML EXTERNAL 05/07/01 028 0251 5012
13789241 FLUOCINOLONE ACETONIDE INTRAVI EXTERNAL 09/29/05 J7311 J7311 J7311 028 0636 5012
13789245 GASTROVIEW 36 ML BOTTLE EXTERNAL 08/21/06 028 0251 5012
13789303 MIDAZOLAM 50MG FOR 50ML LVP EXTERNAL 09/22/03 J2250 J2250 028 0636 5012
13789370 GLYCERIN OPTH SOLUTION 7.5ML B EXTERNAL 05/07/01 028 0251 5012
13789409 ASPARAGINASE 5000 U/ML IM INJ EXTERNAL 06/28/01 J9020 J9020 028 0636 5012
13789450 GLYCOPYRROLATE 0.2MG VIAL EXTERNAL 05/07/01 028 0250 5012
13789451 GLYCOPYRROLATE 0.2MG/ML 5 ML V EXTERNAL 05/15/06 028 0258 5012
13789506 SODIUM ACETATE 100 MEQ VIAL EXTERNAL 03/25/08 028 0251 5012
13789520 SOD BICARB-SIMETHICONE (E-Z-GA EXTERNAL 04/21/06 028 0251 5012
13789605 CARBOPLATIN 10MG/ML INJ EXTERNAL 06/28/01 J9045 J9045 J9045 028 0636 5012
13789620 SODIUM CHLORIDE OPHTH OINTMENT EXTERNAL 05/07/01 028 0251 5012
13789645 HEPARINIZED SALINE CELL SAVER EXTERNAL 05/07/01 J1644 J1644 028 0636 5012
13789651 NACL 5% 500ML EXTERNAL 12/17/02 J7042 J7042 028 0636 5012
13789656 SODIUM CHLORIDE RESP (PF) 3ML EXTERNAL 05/07/01 028 0251 5012
13789670 SODIUM CHLORIDE FOR INHALATION EXTERNAL 01/01/07 028 0250 5012
13789677 EPINEPHRINE SYR - OR EXTERNAL 05/07/01 J0170 J0170 028 0636 5012
13789678 NORMAL SALINE 1L BAG EXTERNAL 05/07/01 028 0250 5012
13789680 SODIUM CHLORIDE INJ 10ML VIAL EXTERNAL 05/07/01 028 0250 5012
13789682 HEPARIN INJ EXTERNAL 05/07/01 J1644 J1644 028 0636 5012
13789683 HEPARININ DRIP EXTERNAL 12/17/02 J1644 J1644 028 0636 5012
13789684 HEPARIN SALINE BAG EXTERNAL 04/17/03 J1644 J1644 028 0636 5012
13789685 HEPARIN DRIP OR SYR EXTERNAL 04/17/03 J1644 J1644 J1644 028 0258 5012
13789686 TRIAMCINOLONE PF (TRIESENCE) 4 EXTERNAL 01/18/08 028 0251 5012
13789687 HEPARIN W/ NS 500 ML (PHOTOPHE EXTERNAL 11/18/09 028 0258 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 306
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13789706 ALTEPLASE 1MG/ML FOR IVPV OCCL EXTERNAL 10/03/02 J2997 J2997 028 0636 5012
13789707 ALTEPLASE 4MG/ML INTRA-VENTRIC EXTERNAL 10/03/02 J2997 J2997 028 0636 5012
13789708 ALTEPLASE 1MG FOR IV PV OCCLUS EXTERNAL 10/03/02 J2997 J2997 J2997 028 0258 5012
13789709 ALTEPLASE 1MG FOR IV PV OCCLUS EXTERNAL 10/03/02 J2997 J2997 J2997 028 0258 5012
13789710 ALTEPLASE 1MG FOR IV PV OCCLUS EXTERNAL 10/03/02 J2997 J2997 J2997 028 0258 5012
13789712 ALTEPLASE 2MG/ML INTRA-VENTRIC EXTERNAL 10/03/02 J2997 J2997 028 0636 5012
13789713 ALTEPLASE 1MG/ML INTRA-VENTRIC EXTERNAL 08/27/03 J2997 J2997 028 0636 5012
13789763 HEPARIN 500U/LR 1L (DAWOOD'S S EXTERNAL 05/07/01 J1644 J1644 028 0636 5012
13789785 HETASTARCH 6%/NACL 500ML BAG EXTERNAL 05/07/01 028 0258 5012
13789790 SODIUM CHLORIDE 4000ML UROMATI EXTERNAL 05/07/01 J7030 J7030 028 0636 5012
13789870 NACL 0.9% 50ML EXTERNAL 05/14/01 J7050 J7050 J7050 028 0258 5012
13789880 HOMATROPINE 5% OPTH SOLN 1ML D EXTERNAL 05/07/01 028 0251 5012
13789920 NORMAL SALINE 1L BAG EXTERNAL 05/14/01 028 0258 5012
13789921 HYALURONIDASE INJ 150U SYR EXTERNAL 05/07/01 J3470 J3470 J3470 028 0636 5012
13789922 IV SOLUTION 1000ML EXTERNAL 04/16/03 028 0258 5012
13789923 IV SOLUTION 250ML EXTERNAL 04/16/03 028 0258 5012
13789924 IV SOLUTION 500ML EXTERNAL 04/16/03 028 0258 5012
13789925 SODIUM HYALURONATE 0.85ML (PRO EXTERNAL 05/07/01 028 0258 5012
13789926 SODIUM HYALURONATE 0.55ML (PRO EXTERNAL 05/07/01 028 0250 5012
13789927 IV SOLUTION 2000ML EXTERNAL 04/16/03 028 0258 5012
13789928 SODIUM HYALURONATE INJ 0.4ML(P EXTERNAL 01/01/10 J7325 J7325 J7325 028 0636 5012
13789929 HEALON GV 14 MG/ML 0.85 ML SYR EXTERNAL 08/02/03 028 0258 5012
13789931 HYALURONIDASE HUMAN 150UNIT SY EXTERNAL 02/17/10 028 0258 5012
13789932 HYALURONIDASE OVINE 200 UNIT/M EXTERNAL 06/03/10 028 0258 5012
13789940 ISOTONIC RTU 1000 ML EXTERNAL 04/16/03 028 0258 5012
13789945 ISOTONIC RTU 250 ML EXTERNAL 04/16/03 028 0258 5012
13789950 ISOTONIC RTU 500 ML EXTERNAL 04/16/03 028 0258 5012
13789952 SODIUM HYALURONATE 0.85ML SYRI EXTERNAL 05/07/01 028 0258 5012
13789954 SODIUM HYALURONATE INJ 0.4ML S EXTERNAL 01/01/10 J7325 J7325 J7325 028 0636 5012
13789955 HYPAQUE-CYSTO 30% 250 ML BTL EXTERNAL 03/15/06 028 0258 5012
13789980 HYDRALAZINE INJECTION 20MG VIA EXTERNAL 05/07/01 J0360 J0360 028 0636 5012
13789981 SODIUM CHLORIDE MEQ/KG PEDS-NE EXTERNAL 01/01/07 028 0250 5012
13790092 ACETAMIN-HYDROCODONE 500MG/5MG EXTERNAL 08/08/06 028 0251 5012
13799999 TECHNICON TESTING EXTERNAL 01/25/95 028 0251 5012
17120741 TISSUE PLASMINOGEN ACT 1ML EXTERNAL 11/01/06 J2997 J2997 J2997 028 0636 0582
17120744 FOSCARNET PER 1000MG 98.00 06/30/10 J1455 J1455 J1455 028 0636 0582
17120747 GANCYCLOVIR, 500MG 89.00 06/30/10 J1570 J1570 J1570 028 0636 0582
17120753 METHOTREXATE 5MG 98.00 06/30/10 J9250 J9250 J9250 028 0636 0582
17122045 TRIESENCE SUSPENSION - 1MG 98.00 06/30/10 J3300 J3300 J3300 028 0636 0582
17130923 FOSCARNET PER 1000 MG 98.00 06/30/10 J1455 J1455 J1455 028 0636 0583
17130926 GANCYCLOVIR, 500MG 89.00 06/30/10 J1570 J1570 J1570 028 0636 0583
17130929 TRIESENCE SUSPENSION 334.00 06/30/10 J3490 J3490 J3490 028 0636 0583
17201370 PORFIMER SODIUM,75MG 2476.00 06/30/10 J9600 J9600 J9600 028 0636 0634
40101901 SECRITIN INJ 75UNIT VIAL 838.00 06/30/10 028 0254 3309
40101902 ETHANOLAMINE OLEATE 5% AMP 148.00 06/30/10 028 0251 3309
40101903 BOTULINUM TOXIN TYPE A /UNIT 17.00 06/30/10 J0585 J0585 028 0636 3309
40101904 ALBUMIN 25% 50ML 569.00 06/30/10 P9047 P9047 P9047 028 0636 3309
40101907 EPINEPHRINE 1MG/1ML VIAL 108.00 06/30/10 028 0250 3309
40101908 KENOVAC VIAL 56.00 06/30/10 028 0254 3309
40101909 GLUCAGON 1MG/1 UNIT 85.00 06/30/10 J1610 028 0636 3309
40101911 FENTANYL 0.1MG 14.00 06/30/10 J3010 J3010 J3010 028 0636 3309
40101912 TRIAMCINOLONE 4MG/ML(5ML VIAL) 22.00 06/30/10 028 0254 3309
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 307
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40101917 MIDAZOLAM PER 1 MG 14.00 06/30/10 J2250 J2250 J2250 028 0636 3309
40101920 ZOFRAN INJ 4MG/2ML 61.00 06/30/10 028 0250 3309
40101926 ZOFRAN TAB 8MG 109.00 06/30/10 Q0179 Q0179 Q0179 028 0636 3309
40101929 METHYLENE BL INJ 1% 100MG/10ML 16.00 06/30/10 028 0250 3309
40101932 FLUMAZENIL 0.5MG/5ML 236.00 06/30/10 028 0250 3309
40101935 NARCAN 0.4MG/ML 9.00 06/30/10 028 0250 3309
40520001 FLU VAC-NO PRESERV,6-35M,IM 55.00 06/30/10 90655 90655 90655 028 0636 5011
40520004 FLU VACC NO PRESERV 3 YO &>,IM 58.00 06/30/10 90656 90656 90656 028 0636 5011
40520007 PNEUMOCOCCAL VACCINE 109.00 06/30/10 90732 90732 90732 028 0636 5011
40520010 HEPB VACC, ILL PAT 3 DOSE IM 381.00 06/30/10 90740 90740 90740 028 0636 5011
40520013 INJ CALCITRIOL PER 0.1 MCG 3.00 06/30/10 J0636 J0636 J0636 028 0636 5011
40520016 CEFOXITIN SODIUM INJ-1 GM 29.00 06/30/10 J0694 J0694 J0694 028 0636 5011
40520019 CEFTRIAXONE SODIUM INJECTION 6.00 06/30/10 J0696 J0696 J0696 028 0636 5011
40520022 INJ CEFTAZIDIME PER 500 MG 13.00 06/30/10 J0713 J0713 J0713 028 0636 5011
40520025 DARBEPETIN ALFA, ESRD USE 1MCG 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
40520028 INJ 1MCG, DOXERCALCIFEROL 11.00 06/30/10 J1270 J1270 J1270 028 0636 5011
40520031 GARAMYCIN GENTAMICIN INJ 80MG 6.00 06/30/10 J1580 J1580 J1580 028 0636 5011
40520034 IRON SUCROSE INJECTION-1MG 3.00 06/30/10 J1756 J1756 J1756 028 0636 5011
40520037 NANDROLONE DECANOATE 50 MG 16.00 06/30/10 J2320 J2320 J2320 028 0636 5011
40520040 NANDROLONE DECANOATE 100 MG 25.00 06/30/10 J2321 J2321 J2321 028 0636 5011
40520043 NANDROLONE DECANOATE 200 MG 63.00 06/30/10 J2322 J2322 J2322 028 0636 5011
40520046 PARICALCITOL 1MCG 14.00 06/30/10 J2501 J2501 J2501 028 0636 5011
40520049 PIPERACILLIN/TAZOBACTAM 18.00 06/30/10 J2543 J2543 J2543 028 0636 5011
40520052 NA FERRIC GLUCONATE COMPLEX 17.00 06/30/10 J2916 J2916 J2916 028 0636 5011
40520055 ALTEPLASE RECOMBINANT 108.00 06/30/10 J2997 J2997 J2997 028 0636 5011
40520058 VANCOMYCIN HCL INJECTION 12.00 06/30/10 J3370 J3370 J3370 028 0636 5011
40520061 ADMIN/INFLUENZA VACCINE 59.00 06/30/10 G0008 G0008 G0008 028 0771 3324
40520070 CEFAZOLIN SODIUM INJECTION 4.00 06/30/10 J0690 J0690 J0690 028 0636 5011
40520073 FLU VACCINE AGE 3YO & OVER,IM 45.00 06/30/10 90658 90658 90658 028 0636 5011
40520076 INJECTION,THIAMINE HCL,100MG 9.00 06/30/10 J3411 J3411 J3411 028 0636 5011
40520078 AMIKACIN SULFATE INJ-100MG 2.00 06/30/10 J0278 J0278 J0278 028 0636 5011
40520080 LEVOCARNITINE 1 GM INJ 23.00 06/30/10 J1955 J1955 J1955 028 0636 5011
40520090 ASCORBIC ACID 250MG 7.00 06/30/10 J3490 J3490 J3490 028 0636 5011
40520092 INJ,DAPTOMYCIN 1MG 5.00 06/30/10 J0878 J0878 J0878 028 0636 5011
40520093 HEP VAC,ILL PAT 4 DOSE,IM 376.00 06/30/10 90747 90747 90747 028 0636 5011
40520095 INJ,FERUMOXYTOL 1MG(ESRD) 9.00 06/30/10 Q0139 Q0139 Q0139 028 0636 5011
40520096 LINEZOLID 200MG INJECTION 96.00 06/30/10 J2020 J2020 J2020 028 0636 5011
40620001 FLU VACC NO PRESERV 6-35M,IM 55.00 06/30/10 90655 90655 90655 028 0636 5011
40620004 FLU VACC NO PRSRV 3 YO &>,IM 58.00 06/30/10 90656 90656 90656 028 0636 5011
40620007 PNEUMOCOCCAL VACCINE 109.00 06/30/10 90732 90732 90732 028 0636 5011
40620010 HEPB VACC, ILL PAT 3 DOSE IM 381.00 06/30/10 90740 90740 90740 028 0636 5011
40620013 INJ CALCITRIOL PER 0.1 MCG 3.00 06/30/10 J0636 J0636 J0636 028 0636 5011
40620016 CEFOXITIN SODIUM INJECTION 29.00 06/30/10 J0694 J0694 J0694 028 0636 5011
40620019 CEFTRIAXONE SODIUM INJECTION 6.00 06/30/10 J0696 J0696 J0696 028 0636 5011
40620022 INJ CEFTAZIDIME PER 500 MG 13.00 06/30/10 J0713 J0713 J0713 028 0636 5011
40620025 DARBEPOETIN ALFA, ESRD USE 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
40620028 DOXERCALCIFEROL INJ 11.00 06/30/10 J1270 J1270 J1270 028 0636 5011
40620031 GARAMYCIN GENTAMICIN INJ 6.00 06/30/10 J1580 J1580 J1580 028 0636 5011
40620034 IRON SUCROSE INJECTION 3.00 06/30/10 J1756 J1756 J1756 028 0636 5011
40620037 NANDROLONE DECANOATE 50 MG 16.00 06/30/10 J2320 J2320 J2320 028 0636 5011
40620040 NANDROLONE DECANOATE 100 MG 25.00 06/30/10 J2321 J2321 J2321 028 0636 5011
40620043 NANDROLONE DECANOATE 200 MG 63.00 06/30/10 J2322 J2322 J2322 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 308
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40620046 PARICALCITOL 11.00 06/30/10 J2501 J2501 J2501 028 0636 5011
40620049 PIPERACILLIN/TAZOBACTAM 17.00 06/30/10 J2543 J2543 J2543 028 0636 5011
40620052 NA FERRIC GLUCONATE COMPLEX 17.00 06/30/10 J2916 J2916 J2916 028 0636 5011
40620055 ALTEPLASE RECOMBINANT 108.00 06/30/10 J2997 J2997 J2997 028 0636 5011
40620058 VANCOMYCIN HCL INJECTION 12.00 06/30/10 J3370 J3370 J3370 028 0636 5011
40620061 ADMIN/INFLUENZA VACCINE 59.00 06/30/10 G0008 G0008 G0008 028 0771 3500
40620064 ADMIN/PNEUMOCOCCAL VACCINE 69.00 06/30/10 G0009 G0009 G0009 028 0771 3500
40620065 LEVOCARNITINE 1 GM INJ 23.00 06/30/10 J1955 J1955 J1955 028 0636 5011
40620067 ADMIN/HEPATITIS B VACCINE 84.00 06/30/10 G0010 G0010 G0010 028 0771 3500
40620070 CEFAZOLIN SODIUM INJECTION 4.00 06/30/10 J0690 J0690 J0690 028 0636 5011
40620073 FLU VACCINE AGE 3YO & OVER,IM 45.00 06/30/10 90658 90658 90658 028 0636 5011
40620075 ASCORBIC ACID 250MG 7.00 06/30/10 J3490 J3490 J3490 028 0636 5011
40620078 AMIKACIN SULFATE INJ-100MG 2.00 06/30/10 028 0636 5011
40620080 EPOETIN ALFA,100U ESRD/DIALYSI 5.00 06/30/10 Q4081 Q4081 Q4081 028 0634 5011
40620083 INJECTION,THIAMINE HCL,100MG 9.00 06/30/10 J3411 J3411 J3411 028 0636 5011
40620086 HEP VACCINE, 40MCG IM 376.00 06/30/10 90747 90747 90747 028 0636 5011
40620089 LINEZOLID 200MG INJECTION 96.00 06/30/10 J2020 J2020 J2020 028 0636 5011
40620092 INJ,DAPTOMYCIN 1MG 5.00 06/30/10 J0878 J0878 J0878 028 0636 5011
40620095 INJ, FERUMOXYTOL IMG (ESRD) 9.00 06/30/10 Q0139 Q0139 Q0139 028 0636 5011
40620100 INFLUENZA A(H1N1) IMMUNE ADMIN 66.00 06/30/10 G9141 G9141 G9141 028 0771 3500
44012001 CATHETER ALL PURPOSE 14FR EXTERNAL 07/01/03 028 0270 5011
44014256 NORMAL,LOW,HI CALIB SOLN/CHIP EXTERNAL 08/01/00 A4256 A4256 A4256 028 0270 5011
44014420 MEDTRONIC REFILL KIT EXTERNAL 07/01/03 028 0270 5011
44016438 ACE BANDAGE EXTERNAL 02/01/05 028 0270 5011
44019563 SOD PHOS P-32,THERA,PER MILCUR EXTERNAL 01/01/07 A9563 A9563 A9563 028 0344 5011
44020003 CENOLATE-500MG/ML ASCRBC ACID EXTERNAL 03/01/06 028 0250 5011
44031084 DENILEUKIN DIFTITOX 300MCG EXTERNAL 03/26/02 J9160 J9160 J9160 028 0636 5011
44031086 TEMOZOLMIDE 5MG ORAL EXTERNAL 03/26/02 J8700 J8700 J8700 028 0636 5011
44031166 CYTARABINE LIPOSOME 10MG EXTERNAL 07/01/02 028 0636 5011
44031167 EPIRUBICIN HYDRO INJ 2MG EXTERNAL 07/01/02 028 0636 5011
44031178 BUSULFAN (BUSLEX IV) INJ 6MG EXTERNAL 01/01/07 J0594 J0594 J0594 028 0636 5011
44031203 VERTEPORFIN INJECTION 15MG IV EXTERNAL 03/26/02 J3396 J3396 J3396 028 0636 5011
44031207 OCTREOTIDE ACETATE 1MG SC EXTERNAL 01/01/03 028 0250 5011
44031305 APLIGRAF PER SQ CENTIMETER EXTERNAL 01/01/09 Q4101 Q4101 Q4101 028 0636 5011
44031774 ARANESP 1MCG EXTERNAL 08/01/00 J0881 J0881 J0881 028 0636 5011
44038890 PERFLUORON /2ML EXTERNAL 03/26/02 028 0250 5011
44038891 PERFLUORON /5 OR 7ML VIAL EXTERNAL 03/26/02 028 0250 5011
44039001 LINEZOLID INJECTION /200MG EXTERNAL 03/26/02 J2020 J2020 J2020 028 0636 5011
44039002 TENECTEPLASE PER 50MG VIAL IV EXTERNAL 01/01/09 J3101 J3101 J3101 028 0636 5011
44039003 PALIVIZUMAB-RSV-IGM/50MG EXTERNAL 01/01/08 90378 90378 90378 028 0636 5011
44039004 GEMTUZUMAB OZOGRA INJ 5MG EXTERNAL 03/26/02 J9300 J9300 J9300 028 0636 5011
44039005 RETEPLASE, INJECTION 18.8 MG EXTERNAL 03/26/02 J2993 J2993 J2993 028 0636 5011
44039006 TACROLIMUS,INJ PER 5MG(1 AMP) EXTERNAL 03/26/02 J7525 J7525 J7525 028 0636 5011
44039007 BACLOFEN INTRACATHECAL TRIAL EXTERNAL 01/01/07 J0476 J0476 J0476 028 0636 5011
44039008 BACLOFEN 10 MG INJECTION EXTERNAL 01/01/07 J0475 J0475 J0475 028 0636 5011
44039009 BACLOFEN REFILL KIT / 2000 MCG EXTERNAL 01/01/07 J0475 J0475 J0475 028 0636 5011
44039010 BACLOFEN IT REFILL-KT /4000MCG EXTERNAL 08/01/00 028 0250 5011
44039011 CAFFEINE CITRATE INJECT /1MG EXTERNAL 03/26/02 J0706 J0706 J0706 028 0636 5011
44039104 LYMPH IMM GLOB /25MG EXTERNAL 03/26/02 028 0250 5011
44039105 H-BIG / PER 1ML EXTERNAL 08/01/00 90371 90371 90371 028 0636 5011
44039107 TINZAPARIN SODIUM INJ PER 2MG EXTERNAL 03/26/02 J1655 J1655 J1655 028 0636 5011
44039109 TIROFIBAN HCL 6.25 MG EXTERNAL 01/01/07 J3246 J3246 J3246 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 309
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44039110 ALEMTUZUMAB AMP 3ML DS 3 EXTERNAL 01/01/03 J9010 J9010 J9010 028 0636 5011
44039116 INVANZ VIAL 1GM EXTERNAL 07/01/05 028 0250 5011
44039119 PEGFILGRASTIM 6MG PREFILL SYR EXTERNAL 08/01/00 J2505 J2505 J2505 028 0636 5011
44039120 FASLODEX PER 25MG EXTERNAL 08/01/03 J9395 J9395 J9395 028 0636 5011
44039121 ARGATROBAN, INJ EXTERNAL 01/01/06 C9121 C9121 C9121 028 0636 5011
44039127 ABRAXANE 1MG EXTERNAL 04/01/05 J9264 J9264 J9264 028 0636 5011
44039207 VELCADE INJ PER 0.1 MG EXTERNAL 01/01/05 J9041 J9041 028 0636 5011
44039210 PALONOSETRON PER 25MCG EXTERNAL 01/01/05 J2469 J2469 J2469 028 0636 5011
44039213 INJECTION PERMETREXED,PER 10MG EXTERNAL 01/01/05 J9305 J9305 J9305 028 0636 5011
44039214 INJECTION,BEVACIZUMAB,PER 10MG EXTERNAL 01/01/05 J9035 J9035 J9035 028 0636 5011
44039215 INJECTION, CETUXIMAB,PER 10MG EXTERNAL 01/01/05 J9055 J9055 J9055 028 0636 5011
44039216 ABARELIX,FOR INJ.SUSP.,PER10MG EXTERNAL 01/01/05 J0128 J0128 J0128 028 0636 5011
44039217 INJECTION, OMALIZUMAB, PER 5MG EXTERNAL 01/01/05 J2357 J2357 J2357 028 0636 5011
44039218 AZACITIDINE INJ EXTERNAL 10/01/04 J9025 J9025 J9025 028 0636 5011
44039220 ORTHOVISC INJ PER DOSE EXTERNAL 01/01/08 J7324 J7324 J7324 028 0636 5011
44039230 INJECTION, ABATACEPT EXTERNAL 08/01/06 J0129 J0129 J0129 028 0636 5011
44039231 DACOGEN (DECITABINE) PER 1MG EXTERNAL 01/01/08 J0894 J0894 J0894 028 0636 5011
44039235 VECTIBIX INJ 10MG EXTERNAL 01/01/08 J0220 J0220 J0220 028 0636 5011
44039245 N-PLATE, ROMIPLOSTIM,10MG EXTERNAL 01/01/09 J2796 J2796 J2796 028 0636 5011
44039252 MOZOBIL 1MG (PLERIXAFOR) EXTERNAL 07/01/09 028 0636 5011
44039398 MYOZYME PER 50MG EXTERNAL 01/01/07 C9399 C9399 C9399 028 0636 5011
44039399 LUMIZYME 50MG EXTERNAL 01/01/04 C9399 C9399 C9399 028 0636 5011
44039430 LEUPROLIDE ACT 1MG(LUPRON) EXTERNAL 01/01/05 028 0636 5011
44040779 ECLIPSE PUMP, PORTABLE EXTERNAL 04/01/08 99.25 028 0270 5011
44050120 TETRACYCLINE<=250 MG IM,IV EXTERNAL 08/01/00 J0120 J0120 J0120 028 0636 5011
44050128 ABARELIX,FOR INJ.SUSP.,PER10MG EXTERNAL 01/01/05 J0128 J0128 J0128 028 0636 5011
44050129 INJECTION,ORENCIA-10MG EXTERNAL 07/01/07 J0129 J0129 J0129 028 0636 5011
44050130 ABCIXIMAB 10MG EXTERNAL 08/01/00 J0130 J0130 J0130 028 0636 5011
44050133 ACYCOVIR INJ, 5MG EXTERNAL 05/01/06 J0133 J0133 J0133 028 0636 5011
44050150 ADENOSINE 6MG IV EXTERNAL 08/01/00 J0150 J0150 J0150 028 0636 5011
44050152 ADENOSINE INJ 30MG EXTERNAL 01/01/06 J0152 J0152 J0152 028 0636 5011
44050170 ADRENALIN, EPIN <=1ML AMP EXTERNAL 08/01/00 J0170 J0170 J0170 028 0636 5011
44050190 BIPERIDEN LACTATE /5MG EXTERNAL 08/01/00 J0190 J0190 J0190 028 0636 5011
44050205 ALGUCERASE/10 UNITS IV EXTERNAL 08/01/00 J0205 J0205 J0205 028 0636 5011
44050207 AMIFOSTINE 500MG IV,INJ EXTERNAL 07/01/02 J0207 J0207 J0207 028 0636 5011
44050210 METHYLDOPATE HCL <=250MG EXTERNAL 08/01/00 J0210 J0210 J0210 028 0636 5011
44050220 MYOZYME 10MG EXTERNAL 02/01/08 J0220 J0220 J0220 028 0636 5011
44050256 ALPHA 1-PROT INHIB,HUMAN/10MG EXTERNAL 08/01/00 J0256 J0256 J0256 028 0636 5011
44050270 ALPROSTADIL /1.25MCG EXTERNAL 08/01/00 J0270 J0270 J0270 028 0636 5011
44050275 ALPROSTADIL,URETHRA SUPPOSITOR EXTERNAL 08/01/00 J0275 J0275 J0275 028 0636 5011
44050280 AMINOPHYLLINE -LLIN <=250MG IV EXTERNAL 08/01/00 J0280 J0280 J0280 028 0636 5011
44050285 AMPHOTERICIN B, 50MG EXTERNAL 08/01/00 J0285 J0285 J0285 028 0636 5011
44050286 AMPHOTERICIN B 50MG EXTERNAL 08/01/00 J0285 J0285 J0285 028 0636 5011
44050287 AMPHOTERICIN LIPID B CPLX 10MG EXTERNAL 01/01/03 J0287 J0287 J0287 028 0636 5011
44050288 AMPHOTER B CHOL SULF CPLX,10MG EXTERNAL 01/01/03 J0288 J0288 J0288 028 0636 5011
44050289 AMPHOTERICIN B LIPOSOME, 10MG EXTERNAL 01/01/03 J0289 J0289 J0289 028 0636 5011
44050290 AMPICILLIN SODIUM 500MG EXTERNAL 08/01/00 J0290 J0290 J0290 028 0636 5011
44050295 AMPICLLN SOD/SUBATAM SOD 1.5GM EXTERNAL 08/01/00 J0295 J0295 J0295 028 0636 5011
44050300 AMOBARBITAL <=125MG EXTERNAL 08/01/00 J0300 J0300 J0300 028 0636 5011
44050330 SUCCINYLCHOLINE CHLORID <=20MG EXTERNAL 08/01/00 J0330 J0330 J0330 028 0636 5011
44050340 NANDROLONE PHENPRPNA <=50MG EXTERNAL 03/26/02 028 0636 5011
44050350 ANISTREPLASE/30 UNITS EXTERNAL 08/01/00 J0350 J0350 J0350 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 310
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44050360 HYDRALAZINE HCL <=20 MG EXTERNAL 08/01/00 J0360 J0360 J0360 028 0636 5011
44050380 METARAMINOL BITARTRATE/10MG EXTERNAL 08/01/00 J0380 J0380 J0380 028 0636 5011
44050390 CHLOROQUINE HCL <=250MG EXTERNAL 08/01/00 J0390 J0390 J0390 028 0636 5011
44050395 ARBUTAMINE HCL 1MG EXTERNAL 08/01/00 J0395 J0395 J0395 028 0636 5011
44050400 TRIMETHAPHAN CAMSYLATE<=500MG EXTERNAL 08/01/00 028 0250 5011
44050456 AZITHROMYCIN 500MG EXTERNAL 08/01/00 J0456 J0456 J0456 028 0636 5011
44050460 ATROPINE SULFATE <=0.3 MG EXTERNAL 07/01/02 J0461 J0461 J0461 028 0636 5011
44050461 INJ ATROPINE SULFATE 0.01MG EXTERNAL 01/01/10 J0461 J0461 J0461 028 0636 5011
44050470 DIMERCAPROL /100MG EXTERNAL 08/01/00 J0470 J0470 J0470 028 0636 5011
44050475 BACLOFEN 10MG EXTERNAL 08/01/00 J0475 J0475 J0475 028 0636 5011
44050476 BACLOFEN 50MG EXTERNAL 08/01/00 J0476 J0476 J0476 028 0636 5011
44050500 DICYCLOMINE HCL <=20MG IM EXTERNAL 08/01/00 J0500 J0500 J0500 028 0636 5011
44050510 BENZQUINAMIDE HCL <=50MG EXTERNAL 03/26/02 028 0636 5011
44050515 BENZTROPINE MESYLATE /1MG EXTERNAL 08/01/00 J0515 J0515 J0515 028 0636 5011
44050518 IPRA BRO INHAL SOL UNT/MG EXTERNAL 03/26/02 028 0250 5011
44050520 BETHANECHOL CHLORIDE <=5MG EXTERNAL 08/01/00 J0520 J0520 J0520 028 0636 5011
44050530 PENICIL G BEN&PRO <=600K EXTERNAL 01/01/10 J0559 J0559 J0559 028 0636 5011
44050540 PENICIL G BEN&PRO <=1200K EXTERNAL 08/01/00 J0559 J0559 J0559 028 0636 5011
44050550 PENICIL G BEN&PRO <=2400K EXTERNAL 08/01/00 J0550 J0550 J0550 028 0636 5011
44050559 PENCIL G BEN&PRO 2500 UNITS EXTERNAL 01/01/10 J0559 J0559 J0559 028 0636 5011
44050560 PENICILLN G BEN <=600K EXTERNAL 08/01/00 J0560 J0560 J0560 028 0636 5011
44050570 PENICILLIN G BEN <=1200K EXTERNAL 08/01/00 J0570 J0570 J0570 028 0636 5011
44050580 PENICILLIN G BEN <=2400K EXTERNAL 08/01/00 J0580 J0580 J0580 028 0636 5011
44050585 BOTULINUM TOXIN TYPE A /UNIT EXTERNAL 08/01/00 J0585 J0585 J0585 028 0636 5011
44050587 BOTULINUM TOXIN TYPE B,100U EXTERNAL 01/01/06 J0587 J0587 J0587 028 0636 5011
44050590 ETHYLNOREPINEPHRINE HCL 1ML EXTERNAL 03/26/02 028 0636 5011
44050592 BUPRENOPHRINE HCL,0.1 MG INJ EXTERNAL 01/01/03 J0592 J0592 J0592 028 0636 5011
44050600 EDETATE CALCIUM DISOD<=1000MG EXTERNAL 08/01/00 J0600 J0600 J0600 028 0636 5011
44050610 CALCIUM GLU SDV 10% 10ML 25 EXTERNAL 08/01/00 J0610 J0610 J0610 028 0636 5011
44050620 CAL GLYCER/PHOS & CAL LAC/10ML EXTERNAL 08/01/00 J0620 J0620 J0620 028 0636 5011
44050630 CALCITONIN-SALMON <=400 UNITS EXTERNAL 08/01/00 J0630 J0630 J0630 028 0636 5011
44050635 INJ,CALCITRIOL 0.1 MCG EXTERNAL 08/01/00 J0636 J0636 J0636 028 0636 5011
44050636 CALCITRIOL 0.1MCG INJ EXTERNAL 01/01/03 J0636 J0636 J0636 028 0636 5011
44050637 CASPOFUNGIN ACETATE, 5MG INJ EXTERNAL 01/01/06 J0637 J0637 J0637 028 0636 5011
44050640 LEUCOVORIN CALCIUM /50 MG EXTERNAL 07/01/02 J0640 J0640 J0640 028 0636 5011
44050670 MEPIVACAINE PER 10ML VAR EXTERNAL 08/01/00 J0670 J0670 J0670 028 0636 5011
44050690 CEFAZOLIN SODIUM 500MG EXTERNAL 08/01/00 J0690 J0690 J0690 028 0636 5011
44050692 CEFEPIME 500MG EXTERNAL 10/01/04 J0692 J0692 J0692 028 0636 5011
44050694 CEFOXITIN SODIUM 1G EXTERNAL 08/01/00 J0694 J0694 J0694 028 0636 5011
44050695 CEFONICID SODIUM 1G EXTERNAL 08/01/00 028 0250 5011
44050696 CEFTRIAXONE SODIUM /250MG EXTERNAL 07/01/02 J0696 J0696 J0696 028 0636 5011
44050697 CEFUROXIME SOD, STERILE /750MG EXTERNAL 08/01/00 J0697 J0697 J0697 028 0636 5011
44050698 CEFOTAXIME SODIUM /1G EXTERNAL 08/01/00 J0698 J0698 J0698 028 0636 5011
44050702 BETA ACE & BETA SOD PHOS 3MG EXTERNAL 08/01/00 J0702 J0702 J0702 028 0636 5011
44050704 BETAMETHASONE SOD PHOSPHAT 4MG EXTERNAL 08/01/00 J0704 J0704 J0704 028 0636 5011
44050710 CEPHAPIRIN SODIUM <=1G EXTERNAL 08/01/00 J0710 J0710 J0710 028 0636 5011
44050713 CEFTAZIDIME /500MG EXTERNAL 08/01/00 J0713 J0713 J0713 028 0636 5011
44050715 CEFTIZOXIME SODIUM /500MG EXTERNAL 08/01/00 J0715 J0715 J0715 028 0636 5011
44050720 CHLORAMPHE SOD SUCCINATE <=1G EXTERNAL 08/01/00 J0720 J0720 J0720 028 0636 5011
44050725 CHORIONIC GON/1K USP UNIT EXTERNAL 08/01/00 J0725 J0725 J0725 028 0636 5011
44050730 CHLORPHENIRAMINE MALEATE /10MG EXTERNAL 03/26/02 028 0636 5011
44050735 CLONIDINE HCL 1MG ORAL EXTERNAL 08/01/00 J0735 J0735 J0735 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 311
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44050740 CIDOFOVIR 375MG EXTERNAL 08/01/00 J0740 J0740 J0740 028 0636 5011
44050743 CILASTATIN SOD,IMIPENEM /250MG EXTERNAL 07/01/02 J0743 J0743 J0743 028 0636 5011
44050744 CIPROFLAXACIN 500MG TAB EXTERNAL 01/01/07 028 0636 5011
44050745 CODEINE PHOSPHATE /30MG EXTERNAL 08/01/00 J0745 J0745 J0745 028 0636 5011
44050760 COLCHICINE / 1 MG EXTERNAL 08/01/00 J0760 J0760 J0760 028 0636 5011
44050770 COLISTIMETHATE SODIUM <=150MG EXTERNAL 08/01/00 J0770 J0770 J0770 028 0636 5011
44050780 PROCHLORPERAZINE <= 10MG/IM,IV EXTERNAL 07/01/02 J0780 J0780 J0780 028 0636 5011
44050800 CORTICOTROPIN <=40 UNITS EXTERNAL 08/01/00 J0800 J0800 J0800 028 0636 5011
44050810 CORTISONE <=50MG EXTERNAL 03/26/02 028 0636 5011
44050835 COSYNTROPIN /0.25MG EXTERNAL 01/01/10 J0834 J0834 J0834 028 0636 5011
44050850 CYTOMEG IMM GLOB IV/VIAL EXTERNAL 08/01/00 J0850 J0850 J0850 028 0636 5011
44050880 DARBEPOETIN ALFA, 5MCG INJ EXTERNAL 01/01/03 J0881 J0881 J0881 028 0636 5011
44050881 DARBEPOETIN ALFA,NON-ESRD EXTERNAL 01/01/06 J0881 J0881 J0881 028 0636 5011
44050885 EPOETIN ALFA,NON-ESRD EXTERNAL 01/01/06 J0885 J0885 J0885 028 0636 5011
44050886 10000U EPOETIN ALFA,ESRD EXTERNAL 10/01/06 J0886 J0886 J0886 028 0635 5011
44050894 DACOGEN 1MG EXTERNAL 01/01/07 J0894 J0894 J0894 028 0636 5011
44050895 DEFEROX MESYLATE 500MG/5CC EXTERNAL 07/01/02 J0895 J0895 J0895 028 0636 5011
44050900 TESTOST ENANTH&ESTRAD VAL<=1CC EXTERNAL 08/01/00 J0900 J0900 J0900 028 0636 5011
44050945 BROMPHENIRAMINE MALEATE /10MG EXTERNAL 08/01/00 J0945 J0945 J0945 028 0636 5011
44050970 ESTRADIOL VALERATE <=40MG EXTERNAL 08/01/00 J0970 J0970 J0970 028 0636 5011
44051000 DEPO-ESTRADIOL CYPIONATE<=5MG EXTERNAL 08/01/00 J1000 J1000 J1000 028 0636 5011
44051020 METHYLPRDNSOLN ACTAE/20MG EXTERNAL 08/01/00 J1020 J1020 J1020 028 0636 5011
44051030 METHYLPRDNSOLN ACTAE/40MG EXTERNAL 08/01/00 J1030 J1030 J1030 028 0636 5011
44051040 METHYLPRDNSOLN ACTAE/80MG EXTERNAL 08/01/00 J1040 J1040 J1040 028 0636 5011
44051050 MEDROXYPROGESTRN ACE 100 MG EXTERNAL 07/01/02 J1051 J1051 J1051 028 0636 5011
44051051 MEDROXYPROGESTERONE 50MG INJ EXTERNAL 01/01/03 J1051 J1051 J1051 028 0636 5011
44051060 TESTOSTE&ESTRAD CYPIONAT<= 1ML EXTERNAL 08/01/00 J1060 J1060 J1060 028 0636 5011
44051070 TESTOSTERONE CYPIONAT<=100 MG EXTERNAL 08/01/00 J1070 J1070 J1070 028 0636 5011
44051080 TESTOSTERON CYPIONAT 1CC,200MG EXTERNAL 08/01/00 J1080 J1080 J1080 028 0636 5011
44051090 TESTOSTERONE CYPIONAT 1CC,50MG EXTERNAL 03/26/02 028 0636 5011
44051094 DEXAMETHASOME ACET 1MG INJ EXTERNAL 04/01/03 J1094 J1094 J1094 028 0636 5011
44051095 DEXAMETHASONE ACETATE 8MG/ML EXTERNAL 08/01/00 J1094 J1094 J1094 028 0636 5011
44051100 DEXAMETHASONE SOD PHOSP /1MG EXTERNAL 07/01/02 J1100 J1100 J1100 028 0636 5011
44051110 DIHYDROERGOTAMINE MESY /1ML EXTERNAL 07/01/02 J1110 J1110 J1110 028 0636 5011
44051120 ACETAZOLAMIDE SOD <=500MG EXTERNAL 08/01/00 J1120 J1120 J1120 028 0636 5011
44051160 DIGOXIN <=0.5MG IM,IV EXTERNAL 08/01/00 J1160 J1160 J1160 028 0636 5011
44051165 PHENYTOIN SODIUM /50MG EXTERNAL 08/01/00 J1165 J1165 J1165 028 0636 5011
44051170 HYDROMORPHONE HCL <=4 MG EXTERNAL 07/01/02 J1170 J1170 J1170 028 0636 5011
44051180 DYPHYLLINE <=500MG EXTERNAL 08/01/00 J1180 J1180 J1180 028 0636 5011
44051190 DEXRAZOXANE HCL/250MG EXTERNAL 08/01/00 J1190 J1190 J1190 028 0636 5011
44051200 DIPHENHYDRAMINE HCL <=50MG EXTERNAL 07/01/02 J1200 J1200 J1200 028 0636 5011
44051205 CHLOROTHIAZIDE SODIUM /500MG EXTERNAL 08/01/00 J1205 J1205 J1205 028 0636 5011
44051212 DMSO DIMETHYL SULFOXID 50%50ML EXTERNAL 08/01/00 J1212 J1212 J1212 028 0636 5011
44051230 METHADONE HCL <= 10MG EXTERNAL 08/01/00 J1230 J1230 J1230 028 0636 5011
44051240 DIMENHYDRINATE <=50MG EXTERNAL 08/01/00 J1240 J1240 J1240 028 0636 5011
44051245 DIPYRIDAMOLE /10ML EXTERNAL 08/01/00 J1245 J1245 J1245 028 0636 5011
44051250 DOBUTAMINE HCL /250MG IV EXTERNAL 08/01/00 J1250 J1250 J1250 028 0636 5011
44051260 DOLASETRON MESYLATE INJ 10MG EXTERNAL 08/01/00 J1260 J1260 J1260 028 0636 5011
44051320 AMITRIPTYLINE HCL <=20MG EXTERNAL 08/01/00 J1320 J1320 J1320 028 0636 5011
44051325 EPOPROSTENOL 0.5MG EXTERNAL 08/01/00 J1325 J1325 J1325 028 0636 5011
44051327 EPTIFIBATIDE 5MG EXTERNAL 08/01/00 J1327 J1327 J1327 028 0636 5011
44051330 ERGONOVINE MALEATE <=0.2MG EXTERNAL 08/01/00 J1330 J1330 J1330 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 312
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44051335 ERTAPENEM SOD (INVANZ) 500MG EXTERNAL 01/01/09 J1335 J1335 J1335 028 0636 5011
44051362 ERYTHROMYCIN GLUCEPTATE 250MG EXTERNAL 03/26/02 028 0636 5011
44051364 ERYTHROMYCIN LACTO 500MG EXTERNAL 08/01/00 J1364 J1364 J1364 028 0636 5011
44051380 ESTRADIOL VALERATE <=10MG EXTERNAL 08/01/00 J1380 J1380 J1380 028 0636 5011
44051390 ESTRADIOL VALERATE <=20MG EXTERNAL 08/01/00 J1390 J1390 J1390 028 0636 5011
44051410 ESTROGEN CONJUGATED /25MG EXTERNAL 08/01/00 J1410 J1410 J1410 028 0636 5011
44051435 ESTRONE /1MG EXTERNAL 08/01/00 J1435 J1435 J1435 028 0636 5011
44051436 ETIDRONATE DISODIUM /300MG EXTERNAL 08/01/00 J1436 J1436 J1436 028 0636 5011
44051438 ETANERCEPT 25MG EXTERNAL 08/01/00 J1438 J1438 J1438 028 0636 5011
44051440 FILGRASTIM (G-CSF)300MCG EXTERNAL 07/01/02 J1440 J1440 J1440 028 0636 5011
44051441 FILGRASTIM (G-CSF)480MCG EXTERNAL 07/01/02 J1441 J1441 J1441 028 0636 5011
44051450 FLUCONAZOLE 200 MG EXTERNAL 08/01/00 J1450 J1450 J1450 028 0636 5011
44051453 EMEND 1MG IV EXTERNAL 01/01/09 J1453 J1453 J1453 028 0636 5011
44051455 FOSCARNET SODIUM /1000 MG EXTERNAL 08/01/00 J1455 J1455 J1455 028 0636 5011
44051460 GAMMA GLOBULIN 1 CC EXTERNAL 08/01/00 J1460 J1460 J1460 028 0636 5011
44051470 GAMMA GLOBULIN 2 CC EXTERNAL 08/01/00 J1470 J1470 J1470 028 0636 5011
44051480 GAMMA GLOBULIN 3 CC EXTERNAL 08/01/00 J1480 J1480 J1480 028 0636 5011
44051490 GAMMA GLOBULIN 4 CC EXTERNAL 08/01/00 J1490 J1490 J1490 028 0636 5011
44051500 GAMMA GLOBULIN 5 CC EXTERNAL 08/01/00 J1500 J1500 J1500 028 0636 5011
44051510 GAMMA GLOBULIN 6 CC EXTERNAL 08/01/00 J1510 J1510 J1510 028 0636 5011
44051520 GAMMA GLOBULIN 7 CC EXTERNAL 08/01/00 J1520 J1520 J1520 028 0636 5011
44051530 GAMMA GLOBULIN 8 CC EXTERNAL 08/01/00 J1530 J1530 J1530 028 0636 5011
44051540 GAMMA GLOBULIN 9 CC EXTERNAL 08/01/00 J1540 J1540 J1540 028 0636 5011
44051550 GAMMA GLOBULIN 10 CC EXTERNAL 08/01/00 J1550 J1550 J1550 028 0636 5011
44051560 GAMMA GLOBULIN >10 CC EXTERNAL 08/01/00 J1560 J1560 J1560 028 0636 5011
44051561 IMMUNE GLOBULIN PER 500 MG EXTERNAL 07/01/02 J1561 J1561 J1561 028 0636 5011
44051564 IMMUNE GLOB-LIQUID INJ, 500MG EXTERNAL 01/01/08 J1561 J1561 J1561 028 0636 5011
44051565 RESP SYN VIR IMM GLOB 50MG IV EXTERNAL 08/01/00 028 0250 5011
44051566 IMMUNE GLOBLIN,POWDER EXTERNAL 12/01/05 J1566 J1566 J1566 028 0636 5011
44051567 IMMUNE GLOBLIN,LIQUID EXTERNAL 01/01/08 J1561 J1561 J1561 028 0636 5011
44051569 GAMMAGARD 500MG INJ EXTERNAL 02/01/08 J1569 J1569 J1569 028 0636 5011
44051570 GANCICLOVIR SODIUM 500 MG EXTERNAL 08/01/00 J1570 J1570 J1570 028 0636 5011
44051571 HEPAGAM B IM INJ EXTERNAL 02/01/08 J1571 J1571 J1571 028 0636 5011
44051572 FLEBOGAMMA 500MG EXTERNAL 02/01/08 J1572 J1572 J1572 028 0636 5011
44051573 HEPAGAM B, INTRAVEN,PER 0.5ML EXTERNAL 01/01/08 J1573 J1573 J1573 028 0636 5011
44051580 GARAMYCIN, GENTAMIC<=80MG EXTERNAL 08/01/00 J1580 J1580 J1580 028 0636 5011
44051600 GOLD SODIUM THIO <= 50 MG EXTERNAL 08/01/00 J1600 J1600 J1600 028 0636 5011
44051610 GLUCAGON HCL / 1 MG EXTERNAL 08/01/00 J1610 J1610 J1610 028 0636 5011
44051620 GONADORELIN HCL / 100 MCG EXTERNAL 08/01/00 J1620 J1620 J1620 028 0636 5011
44051626 GRANISETRON HCL 100 MCG EXTERNAL 08/01/00 J1626 J1626 J1626 028 0636 5011
44051630 HALOPERIDOL < = 5 MG EXTERNAL 08/01/00 J1630 J1630 J1630 028 0636 5011
44051631 HALOPERIDOL DECAN / 50 MG EXTERNAL 08/01/00 J1631 J1631 J1631 028 0636 5011
44051642 HEP SOD HEP LO FLU 10UNIT EXTERNAL 07/01/02 J1642 J1642 J1642 028 0636 5011
44051644 HEPARIN SODIUM 1,000 UNIT EXTERNAL 07/01/02 028 0250 5011
44051645 DALTEPARIN SOD /2500IU EXTERNAL 08/01/00 J1645 J1645 J1645 028 0636 5011
44051650 ENOXAPARIN SODIUM 10MG EXTERNAL 08/01/00 J1650 J1650 J1650 028 0636 5011
44051652 FONDAPARINIX SODIUM 0.5 MG EXTERNAL 01/01/03 J1652 J1652 J1652 028 0636 5011
44051670 TETANU IMM GLOB,HUMAN<=250UNIT EXTERNAL 08/01/00 J1670 J1670 J1670 028 0636 5011
44051690 PREDNISOLON TEBUTAT<=20MG VAR EXTERNAL 03/26/02 028 0636 5011
44051700 HYDROCOR ACETATE <=25 MG EXTERNAL 08/01/00 J1700 J1700 J1700 028 0636 5011
44051710 HYDROCORT SOD PHOSP<=50MG EXTERNAL 07/01/02 J1710 J1710 J1710 028 0636 5011
44051720 HYDROCORT SUC SOD <=100MG EXTERNAL 08/01/00 J1720 J1720 J1720 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 313
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44051730 DIAZOXIDE <=300MG IV EXTERNAL 08/01/00 J1730 J1730 J1730 028 0636 5011
44051739 HYDROPROGES CAPR 25MG/ML EXTERNAL 03/26/02 028 0636 5011
44051740 BONIVA INJ 3MG/3ML EXTERNAL 08/01/07 J1740 J1740 J1740 028 0636 5011
44051741 HYDROPROGES CAPR 250MG/ML EXTERNAL 03/26/02 028 0636 5011
44051742 IBUTILIDE FUMARATE 1 MG EXTERNAL 08/01/00 J1742 J1742 J1742 028 0636 5011
44051745 INFLIXIMAB 10MG EXTERNAL 08/01/00 J1745 J1745 J1745 028 0636 5011
44051750 IRON DEXTRAN 50 MG EXTERNAL 01/01/07 J1750 J1750 J1750 028 0636 5011
44051751 IRON DEXTRAN 165 INJECTION EXTERNAL 01/01/09 J1750 J1750 J1750 028 0636 5011
44051752 IRON DEXTRAN 267 INJECTION EXTERNAL 01/01/09 J1750 J1750 J1750 028 0636 5011
44051756 IRON SUCROSE, 1 MG INJ EXTERNAL 01/01/03 J1756 J1756 J1756 028 0636 5011
44051785 IMIGLUCERASE PER UNIT EXTERNAL 08/01/00 J1785 J1785 J1785 028 0636 5011
44051790 DROPERIDOL <=5MG EXTERNAL 08/01/00 J1790 J1790 J1790 028 0636 5011
44051800 PROPRANOLOL HCL <=1MG IV EXTERNAL 08/01/00 J1800 J1800 J1800 028 0636 5011
44051810 DROPERIDOL & FENT CIT <=2ML EXTERNAL 08/01/00 J1810 J1810 J1810 028 0636 5011
44051815 INJ, INSULIN, PER 5 UNIT INJ EXTERNAL 01/01/03 J1815 J1815 J1815 028 0636 5011
44051817 INSULIN FOR PUMP(DME)PER 50 UN EXTERNAL 01/01/03 J1817 J1817 J1817 028 0636 5011
44051820 INSULIN <= 100 UNITS EXTERNAL 08/01/00 J1815 J1815 J1815 028 0636 5011
44051825 INTERFERON BETA 1A 33 MCG EXTERNAL 07/01/02 J1825 J1825 J1825 028 0636 5011
44051830 INTERFERON BETA-1B0.25MG EXTERNAL 08/01/00 J1830 J1830 J1830 028 0636 5011
44051840 KANAMYCIN SULFATE <=500MG EXTERNAL 08/01/00 J1840 J1840 J1840 028 0636 5011
44051850 KANAMYCIN SULFATE <=75 MG EXTERNAL 08/01/00 J1850 J1850 J1850 028 0636 5011
44051885 KETOROLAC TROMETHAM /15MG EXTERNAL 08/01/00 J1885 J1885 J1885 028 0636 5011
44051890 CEPHALOTHIN SODIUM <=1G EXTERNAL 08/01/00 J1890 J1890 J1890 028 0636 5011
44051930 PROPLOMAZINE HCL<=20MG IV,IM EXTERNAL 03/26/02 028 0636 5011
44051931 LARONIDASE 0.1 MG EXTERNAL 01/01/06 J1931 J1931 J1931 028 0636 5011
44051940 FUROSEMIDE < = 20 MG EXTERNAL 07/01/02 J1940 J1940 J1940 028 0636 5011
44051950 LEUPROLIDE ACETATE 3.75MG EXTERNAL 08/01/00 J1950 J1950 J1950 028 0636 5011
44051955 LEVOCARNITINE /1GM EXTERNAL 08/01/00 J1955 J1955 J1955 028 0636 5011
44051956 LEVOFLOXACIN 250MG EXTERNAL 08/01/00 J1956 J1956 J1956 028 0636 5011
44051960 LEVORPHANOL TARTRATE <2MG EXTERNAL 08/01/00 J1960 J1960 J1960 028 0636 5011
44051970 METHOTRIMEPRAZINE <=20MG EXTERNAL 03/26/02 028 0636 5011
44051980 HYOSCYAMINE SULFA<=0.25MG EXTERNAL 08/01/00 J1980 J1980 J1980 028 0636 5011
44051990 CHLORDIAZEPOXIDE HCL <=100MG EXTERNAL 08/01/00 J1990 J1990 J1990 028 0636 5011
44052000 LIDOCAINE HCL 10MG EXTERNAL 08/01/00 J2001 J2001 J2001 028 0636 5011
44052010 LINCOMYCIN HCL <=300MG EXTERNAL 08/01/00 J2010 J2010 J2010 028 0636 5011
44052020 LINEZOLID INJ, 200MG EXTERNAL 01/01/06 J2020 J2020 J2020 028 0636 5011
44052060 LORAZEPAM 2MG EXTERNAL 07/01/02 J2060 J2060 J2060 028 0636 5011
44052150 MANNITOL 25% IN 50ML EXTERNAL 08/01/00 J2150 J2150 J2150 028 0636 5011
44052175 MEPERIDINE HCL PER 100MG EXTERNAL 07/01/02 J2175 J2175 J2175 028 0636 5011
44052180 MEPERDNE&PROTHAZNE HCL <=50MG EXTERNAL 08/01/00 J2180 J2180 J2180 028 0636 5011
44052210 METHYLERGVN MALATE <=0.2MG EXTERNAL 08/01/00 J2210 J2210 J2210 028 0636 5011
44052240 METOCURINE IODIDE <=2MG EXTERNAL 03/26/02 028 0636 5011
44052250 MIDAZOLAM HCL PER 1MG EXTERNAL 08/01/00 J2250 J2250 J2250 028 0636 5011
44052260 MILRINONE LACTATE/5MG EXTERNAL 08/01/00 J2260 J2260 J2260 028 0636 5011
44052270 MORPHINE SULFATE/10MG EXTERNAL 07/01/02 J2270 J2270 J2270 028 0636 5011
44052271 MORPHINE SULFATE/100MG EXTERNAL 08/01/00 J2271 J2271 J2271 028 0636 5011
44052275 MORPHINE SULFA PSV-FR/10MG EXTERNAL 08/01/00 J2275 J2275 J2275 028 0636 5011
44052300 NALBUPHINE HCL/10MG IM IV EXTERNAL 08/01/00 J2300 J2300 J2300 028 0636 5011
44052310 NALOXONE HCL PER 1MG EXTERNAL 08/01/00 J2310 J2310 J2310 028 0636 5011
44052320 NANDROLONE DECANOATE <=50MG EXTERNAL 08/01/00 J2320 J2320 J2320 028 0636 5011
44052321 NANDROLONE DECANATE <=100MG EXTERNAL 08/01/00 J2321 J2321 J2321 028 0636 5011
44052322 NANDROLONE DECANATE <=200MG EXTERNAL 08/01/00 J2322 J2322 J2322 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 314
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44052323 TYSABRI, 1MG EXTERNAL 02/01/10 J2323 J2323 J2323 028 0636 5011
44052324 NESIRITIDE INJECTION EXTERNAL 01/01/03 J2325 J2325 J2325 028 0636 5011
44052330 THIOTHIXENE<=4 MG IM EXTERNAL 03/26/02 028 0636 5011
44052350 NIACINAMIDE NIACIN <=100MG EXTERNAL 03/26/02 028 0636 5011
44052352 OCTREOTIDE ACETATE 1MG INJ EXTERNAL 07/01/02 028 0250 5011
44052353 OCTREOTIDE DEPOT IM PER 1MG EXTERNAL 01/01/04 J2353 J2353 J2353 028 0636 5011
44052354 OCTREOTIDE NON-DEPOT PER 25MCG EXTERNAL 01/01/04 J2354 J2354 J2354 028 0636 5011
44052355 OPRELVEKIN 5MG INJ EXTERNAL 08/01/00 J2355 J2355 J2355 028 0636 5011
44052357 INJECTION, OMALIZUMAB, PER 5MG EXTERNAL 01/01/05 J2357 J2357 J2357 028 0636 5011
44052360 ORPHENADRINE CITRATE <=60MG EXTERNAL 08/01/00 J2360 J2360 J2360 028 0636 5011
44052370 PHENYLEPHRINE HCL <=1ML EXTERNAL 08/01/00 J2370 J2370 J2370 028 0636 5011
44052400 CHLOROPROCAINE HCL /30ML EXTERNAL 08/01/00 J2400 J2400 J2400 028 0636 5011
44052405 ODANSETRON HCL 1MG IV EXTERNAL 07/01/02 J2405 J2405 J2405 028 0636 5011
44052410 OXYMORPHONE HCL <=1MG EXTERNAL 08/01/00 J2410 J2410 J2410 028 0636 5011
44052425 KEPIVANCE SDV 6.25MG D/S CT6 EXTERNAL 01/01/06 J2425 J2425 J2425 028 0636 5011
44052430 PAMIDRONATE DISODIUM/30MG EXTERNAL 07/01/02 J2430 J2430 J2430 028 0636 5011
44052440 PAPAVERINE HCL <=60MG EXTERNAL 08/01/00 J2440 J2440 J2440 028 0636 5011
44052460 OXYTETRACYCLINE HCL <=50MG EXTERNAL 08/01/00 J2460 J2460 J2460 028 0636 5011
44052469 ALOXI INJ.-25MCG EXTERNAL 01/01/05 J2469 J2469 J2469 028 0636 5011
44052480 HYDROCH OF OPI ALK <=20MG EXTERNAL 03/26/02 028 0636 5011
44052500 PARICALCITROL 5 MCG INJ EXTERNAL 08/01/00 J2501 J2501 J2501 028 0636 5011
44052501 PARICALCITROL 1MCG INJ EXTERNAL 01/01/03 J2501 J2501 J2501 028 0636 5011
44052505 NEULASTA INJ PER 6 MG EXTERNAL 01/01/06 J2505 J2505 J2505 028 0636 5011
44052510 PENICIL G PROC ACQ <=600K EXTERNAL 08/01/00 J2510 J2510 J2510 028 0636 5011
44052512 PENTAGASTRIN PER 2ML SC EXTERNAL 03/26/02 028 0636 5011
44052515 PENTOBARBITAL SODIUM/50MG EXTERNAL 08/01/00 J2515 J2515 J2515 028 0636 5011
44052540 PENICIL G POTASI <=600K EXTERNAL 08/01/00 J2540 J2540 J2540 028 0636 5011
44052543 PIPERACILN SOD/TAZO SOD 1.125G EXTERNAL 08/01/00 J2543 J2543 J2543 028 0636 5011
44052550 PROMETHAZINE HCL <=50MG IM,IV EXTERNAL 08/01/00 J2550 J2550 J2550 028 0636 5011
44052560 LUMINAL SODIUM <120MG EXTERNAL 08/01/00 J2560 J2560 J2560 028 0636 5011
44052562 MOZOBIL (PLERIXAFOR), 1MG EXTERNAL 01/01/10 J2562 J2562 J2562 028 0636 5011
44052590 OXYTOCIN UP TO 10 UNITS EXTERNAL 08/01/00 J2590 J2590 J2590 028 0636 5011
44052597 DESMOPRESSIN ACETATE 1MCG EXTERNAL 07/01/02 J2597 J2597 J2597 028 0636 5011
44052640 PREDNISOLONE SOD PHOSP <= 20MG EXTERNAL 03/26/02 028 0636 5011
44052650 PREDNISOLONE ACETATE <=1ML IM EXTERNAL 08/01/00 J2650 J2650 J2650 028 0636 5011
44052670 TOLAZOLINE HCL<= 25 MG IV EXTERNAL 08/01/00 J2670 J2670 J2670 028 0636 5011
44052675 PROGESTERONE PER 50MG IM EXTERNAL 03/26/02 028 0636 5011
44052680 FLUPHENAZINE DEC <=25MG EXTERNAL 08/01/00 J2680 J2680 J2680 028 0636 5011
44052690 PROCAINAMIDE HCL <=1G IM,IV EXTERNAL 08/01/00 J2690 J2690 J2690 028 0636 5011
44052700 OXACILLIN SODIUM <=250MG EXTERNAL 08/01/00 J2700 J2700 J2700 028 0636 5011
44052710 NEOSTIGMN METHYSLFA <=0.5MG EXTERNAL 08/01/00 J2710 J2710 J2710 028 0636 5011
44052720 PROTAMINE SULFATE PER 10MG IV EXTERNAL 08/01/00 J2720 J2720 J2720 028 0636 5011
44052725 PROTIRELIN PER 250MCG IV EXTERNAL 08/01/00 J2725 J2725 J2725 028 0636 5011
44052730 PRALIDOXIME CHLORIDE <= 1G EXTERNAL 08/01/00 J2730 J2730 J2730 028 0636 5011
44052760 PHENTOLAMINE MESYLATE <=5MG EXTERNAL 08/01/00 J2760 J2760 J2760 028 0636 5011
44052765 METOCLOPRAMIDE HCL <=10MG EXTERNAL 08/01/00 J2765 J2765 J2765 028 0636 5011
44052780 RANTIDINE HCL 25MG INJ EXTERNAL 07/01/02 J2780 J2780 J2780 028 0636 5011
44052783 RASBURICASE EXTERNAL 01/01/06 J2783 J2783 J2783 028 0636 5011
44052788 RHO D IMMUNE GLOBULIN 50MCG EXTERNAL 01/01/03 J2788 J2788 J2788 028 0636 5011
44052790 RHO(D)IMMUN GLOBU,HUMAN 1 DOSE EXTERNAL 08/01/00 J2790 J2790 J2790 028 0636 5011
44052791 RHO(D) 100 IU IV OR IM EXTERNAL 02/01/08 J2791 J2791 J2791 028 0636 5011
44052792 RHO(D) IMMUNE GLOBULIN 100 IU EXTERNAL 01/01/06 J2792 J2792 J2792 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 315
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44052794 RISPERIDONE LA,0.5MG EXTERNAL 01/01/06 J2794 J2794 J2794 028 0636 5011
44052796 N-PLATE, ROMIPLOSTIM,10MG EXTERNAL 04/01/10 J2796 J2796 J2796 028 0636 5011
44052800 METHOCARBAMOL UP TO 10ML EXTERNAL 08/01/00 J2800 J2800 J2800 028 0636 5011
44052810 THEOPHYLLINE PER 40 MG IV EXTERNAL 08/01/00 J2810 J2810 J2810 028 0636 5011
44052820 SARGRAMOSTIM (GM-CSF) 50MCG EXTERNAL 08/01/00 J2820 J2820 J2820 028 0636 5011
44052850 SECRETIN, SYNTHETIC HUMAN 1MCG EXTERNAL 04/01/06 J2850 J2850 J2850 028 0636 5011
44052860 SECOBARBITAL SODIUM <=250MG EXTERNAL 03/26/02 028 0636 5011
44052910 AUROTHIOGLUCOSE <=50MG EXTERNAL 08/01/00 J2910 J2910 J2910 028 0636 5011
44052912 SODIUM CHLORIDE,0.9% PER 2ML EXTERNAL 01/01/07 028 0250 5011
44052915 SODIUM FERR GLUC IN SUC 62.5MG EXTERNAL 08/01/00 028 0250 5011
44052916 SOD FERR GLUC COMPL 12.5MG INJ EXTERNAL 01/01/03 J2916 J2916 J2916 028 0636 5011
44052920 METHYLPRDSLN SOD SUC <=40MG EXTERNAL 07/01/02 J2920 J2920 J2920 028 0636 5011
44052930 METHYLPRDSLN SOD SU <=125MG EXTERNAL 08/01/00 J2930 J2930 J2930 028 0636 5011
44052941 SOMATROPIN INJ,1 MG EXTERNAL 01/01/06 J2941 J2941 J2941 028 0636 5011
44052950 PROMAZINE HCL <=25MG IM EXTERNAL 08/01/00 J2950 J2950 J2950 028 0636 5011
44052970 METHICILLIN SODIUM <=1G EXTERNAL 03/26/02 028 0636 5011
44052993 RETEPLASE INJ,18.1 MG EXTERNAL 01/01/06 J2993 J2993 J2993 028 0636 5011
44052994 RETEPLASE 37.6 MG IV EXTERNAL 08/01/00 028 0250 5011
44052995 STREPTOKINASE PER 250,000 IU EXTERNAL 08/01/00 J2995 J2995 J2995 028 0636 5011
44052996 ALTEPLASE RECOMBINANT /10MG EXTERNAL 07/01/02 J2997 J2997 J2997 028 0636 5011
44052997 ALTEPLASE RECOMBINANT 1 MG EXTERNAL 08/01/00 J2997 J2997 J2997 028 0636 5011
44053000 STREPTOMYCIN <=1G IM EXTERNAL 08/01/00 J3000 J3000 J3000 028 0636 5011
44053010 FENTANYL CITRATE <=2ML EXTERNAL 08/01/00 J3010 J3010 J3010 028 0636 5011
44053030 SUMATRIPTAN SUCCINATE 6MG SC EXTERNAL 08/01/00 J3030 J3030 J3030 028 0636 5011
44053070 PENTAZOCINE HCL <=30MG EXTERNAL 08/01/00 J3070 J3070 J3070 028 0636 5011
44053080 CHLORPROTHIXENE <=50 MG EXTERNAL 03/26/02 028 0636 5011
44053100 TENECTPLASE INJ, 50MG EXTERNAL 01/01/06 J3100 J3100 J3100 028 0636 5011
44053105 TERBUTALINE SULFATE <= 1MG SC EXTERNAL 08/01/00 J3105 J3105 J3105 028 0636 5011
44053120 TESTOSTERONE ENANTHATE<=100MG EXTERNAL 08/01/00 J3120 J3120 J3120 028 0636 5011
44053130 TESTOSTERONE ENANTHATE<=200 MG EXTERNAL 08/01/00 J3130 J3130 J3130 028 0636 5011
44053140 TESTOSTERONE SUSPENSION<=50MG EXTERNAL 08/01/00 J3140 J3140 J3140 028 0636 5011
44053150 TESTOSTERONE PROPIONATE<=100MG EXTERNAL 08/01/00 J3150 J3150 J3150 028 0636 5011
44053230 CHLORPROMAZINE <=50MG IM IV EXTERNAL 08/01/00 J3230 J3230 J3230 028 0636 5011
44053240 THYROTROPIN ALPHA INJECT 0.9MG EXTERNAL 08/01/00 J3240 J3240 J3240 028 0636 5011
44053245 TIROFIBAN HCI 12.5 MG INJ EXTERNAL 01/01/05 028 0636 5011
44053246 TIROFIBAN HCL 0.25 INJ EXTERNAL 01/01/06 J3246 J3246 J3246 028 0636 5011
44053250 TRIMETHOBENZAMIDE HCL<=200MG EXTERNAL 08/01/00 J3250 J3250 J3250 028 0636 5011
44053260 TOBRAMYCIN SULFATE<=80MG IM,IV EXTERNAL 08/01/00 J3260 J3260 J3260 028 0636 5011
44053265 TORSEMIDE 10MG/ML IV EXTERNAL 08/01/00 J3265 J3265 J3265 028 0636 5011
44053270 IMIPRAMINE HCL <= 25MG EXTERNAL 03/26/02 028 0636 5011
44053280 THIETHYLPERAZINE MALEATE<=10MG EXTERNAL 08/01/00 J3280 J3280 J3280 028 0636 5011
44053301 TRIAMCINOLONE ACETON PER 10MG EXTERNAL 08/01/00 J3301 J3301 J3301 028 0636 5011
44053302 TRIAMCINOLONE DIACETAT PER 5MG EXTERNAL 08/01/00 J3302 J3302 J3302 028 0636 5011
44053303 TRIAMCINOLONE HEXACETO PER 5MG EXTERNAL 08/01/00 J3303 J3303 J3303 028 0636 5011
44053305 TRIMETREXATE GLUCURONA /25MG EXTERNAL 07/01/02 J3305 J3305 J3305 028 0636 5011
44053310 PERPHENAZINE <=5MG EXTERNAL 08/01/00 J3310 J3310 J3310 028 0636 5011
44053315 TRIPTORELIN PAMOATE 3.75MG INJ EXTERNAL 01/01/03 J3315 J3315 J3315 028 0636 5011
44053320 SPECTINOMYCIN HCL<=2G IM EXTERNAL 08/01/00 J3320 J3320 J3320 028 0636 5011
44053350 UREA <=40G IV EXTERNAL 08/01/00 J3350 J3350 J3350 028 0636 5011
44053360 DIAZEPAM <=5MG IM, IV EXTERNAL 08/01/00 J3360 J3360 J3360 028 0636 5011
44053364 UROKINASE 5,000 IU VIAL IV EXTERNAL 08/01/00 J3364 J3364 J3364 028 0636 5011
44053365 UROKINASE 250,000 IU VIAL IV EXTERNAL 08/01/00 J3365 J3365 J3365 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 316
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44053370 VANCOMYCIN HCL 500MG IV,IM EXTERNAL 07/01/02 J3370 J3370 J3370 028 0636 5011
44053390 METHOXAMINE HCL <=20MG EXTERNAL 03/26/02 028 0636 5011
44053396 VERTEPORFIN, 0.1MG EXTERNAL 01/01/06 J3396 J3396 J3396 028 0636 5011
44053400 TRIFLUPROMAZINE HCL<=20 MG EXTERNAL 08/01/00 J3400 J3400 J3400 028 0636 5011
44053410 HYDROXYZINE HCL <=25 MG EXTERNAL 08/01/00 J3410 J3410 J3410 028 0636 5011
44053420 VIT B-12 CYANOCOBAL<=1,000 MCG EXTERNAL 07/01/02 J3420 J3420 J3420 028 0636 5011
44053430 PHYTONADIONE /1MG EXTERNAL 07/01/02 J3430 J3430 J3430 028 0636 5011
44053450 MEPHENTRMNE SULF <=30MG EXTERNAL 03/26/02 028 0250 5011
44053470 HYALURONIDASE <=150 UNITS EXTERNAL 08/01/00 J3470 J3470 J3470 028 0636 5011
44053475 MAGNESIUM SULFATE 500MG EXTERNAL 08/01/00 J3475 J3475 J3475 028 0636 5011
44053480 POTASSIUM CHLORIDE PER 2MEQ IV EXTERNAL 07/01/02 J3480 J3480 J3480 028 0636 5011
44053487 ZOLEDRONIC ACID 1MG INJ EXTERNAL 08/01/00 J3487 J3487 J3487 028 0636 5011
44053488 RECLAST 5MG INJ EXTERNAL 01/01/08 J3488 J3488 J3488 028 0636 5011
44053493 PLENAXIS(ABARELIX) 100MG EXTERNAL 07/01/04 J3490 J3490 J3490 028 0636 5011
44053494 VIDAZA(AZACITIDINE) 100MG EXTERNAL 07/01/04 C9399 C9399 C9399 028 0636 5011
44053520 ENDRATE ETHYLENEDIAMINE EXTERNAL 08/01/00 J3520 J3520 J3520 028 0636 5011
44053530 NASAL VACCINE INHALATION EXTERNAL 08/01/00 J3530 J3530 J3530 028 0636 5011
44053570 LACTRILE AMYGDA VITA B-17 EXTERNAL 08/01/00 J3570 J3570 J3570 028 0636 5011
44053590 UNCLASSIFIED BIOLOGICS EXTERNAL 01/01/03 J3590 J3590 J3590 028 0636 5011
44057030 SALINE SOLUT INFUSION,1000CC EXTERNAL 07/01/02 J7030 J7030 J7030 028 0636 5011
44057040 SALINE SOLU,STERIL,500ML=1UNIT EXTERNAL 07/01/02 J7040 J7040 J7040 028 0636 5011
44057042 DEXTROSE NORMAL NA CL 5% 500ML EXTERNAL 08/01/00 J7042 J7042 J7042 028 0636 5011
44057050 SALINE SOLUTION INFUSION,250CC EXTERNAL 07/01/02 J7050 J7050 J7050 028 0636 5011
44057051 SALINE SOLU,STERIL<=5CC IV,OTH EXTERNAL 07/01/02 028 0250 5011
44057060 DEXTROSE/WATER 5% 500ML EXTERNAL 07/01/02 028 0250 5011
44057070 D-5-W, INFUSION 1000CC EXTERNAL 07/01/02 J7070 J7070 J7070 028 0636 5011
44057100 DEXTRAN 40 500ML EXTERNAL 08/01/00 J7100 J7100 J7100 028 0636 5011
44057110 DEXTRAN 75 500ML EXTERNAL 08/01/00 J7110 J7110 J7110 028 0636 5011
44057120 RINGERS LACTATE INFU<=1,000CC EXTERNAL 08/01/00 J7120 J7120 J7120 028 0636 5011
44057188 VON WILLEBRAND FACTOR IU,INJ EXTERNAL 01/01/06 J7187 J7187 J7187 028 0636 5011
44057189 FACTOR VIIA EXTERNAL 01/01/06 J7189 J7189 J7189 028 0636 5011
44057190 FACTOR VIII /IU EXTERNAL 08/01/00 J7190 J7190 J7190 028 0636 5011
44057191 FACTOR VIII(PORCINE) /IU EXTERNAL 08/01/00 J7191 J7191 J7191 028 0636 5011
44057192 FACTOR VIII RECOMB /IU EXTERNAL 08/01/00 J7192 J7192 J7192 028 0636 5011
44057193 FACTOR IX NON-RECOMBINANT EXTERNAL 01/01/06 J7193 J7193 J7193 028 0636 5011
44057194 FACTOR IX COMPLEX /IU EXTERNAL 08/01/00 J7194 J7194 J7194 028 0636 5011
44057195 FACTOR IX RECOMBINANT EXTERNAL 01/01/06 J7195 J7195 J7195 028 0636 5011
44057196 HEMOPHILIA CLOTTING / 1U EXTERNAL 03/26/02 028 0636 5011
44057197 ANTITHROMBIN III (HUMAN)/IU EXTERNAL 08/01/00 J7197 J7197 J7197 028 0636 5011
44057198 ANTI-INHIBITOR /IU EXTERNAL 08/01/00 J7198 J7198 J7198 028 0636 5011
44057199 HEMOPHILIA CLOTTING FACTOR EXTERNAL 08/01/00 J7199 J7199 J7199 028 0636 5011
44057300 COPPER CONTRACEPTIVE, INTRAUTE EXTERNAL 08/01/00 J7300 J7300 J7300 028 0270 5011
44057310 GANCICLOVIR 4.5 MG EXTERNAL 08/01/00 J7310 J7310 J7310 028 0636 5011
44057316 SUPARTZ 25MG SYRINGES EXTERNAL 08/01/00 028 0250 5011
44057317 SOD HYALURONATE INJ 20-25MG EXTERNAL 01/01/08 J7321 J7321 J7321 028 0636 5011
44057320 HYLAN G-F 20 16 MG EXTERNAL 01/01/08 J7322 J7322 J7322 028 0636 5011
44057325 HYALURONAN(SYNVISC)INJ, 1MG EXTERNAL 12/01/09 J7325 J7325 J7325 028 0636 5011
44057500 AZATHIOPRINE, ORAL, 50MG EXTERNAL 01/01/03 J7500 J7500 J7500 028 0636 5011
44057501 AZATHIOPRINE, PARENTERAL 100MG EXTERNAL 08/01/00 J7501 J7501 J7501 028 0636 5011
44057502 CYCLOSPORINE, ORAL 100MG EXTERNAL 01/01/03 J7502 J7502 J7502 028 0636 5011
44057504 LYMPH IMM GLOB 50MG/ML 5ML EA EXTERNAL 08/01/00 J7504 J7504 J7504 028 0636 5011
44057505 MONOCLONAL ANTBDY PAR/5MG EXTERNAL 08/01/00 J7505 J7505 J7505 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 317
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44057506 PREDNISONE ORAL PER 5 MG EXTERNAL 01/01/03 J7506 J7506 J7506 028 0636 5011
44057507 TACROLIMUS,ORAL PER 1 MG EXTERNAL 01/01/03 J7507 J7507 J7507 028 0636 5011
44057508 TACROLIMUS,PO 5 MG (CONV 1MG) EXTERNAL 08/01/00 J7507 J7507 J7507 028 0636 5011
44057509 METHYLPRDNSOLN ORAL/4MG EXTERNAL 08/01/00 J7509 J7509 J7509 028 0636 5011
44057510 PREDNISOLONE 5MG ORAL EXTERNAL 08/01/00 J7510 J7510 J7510 028 0636 5011
44057511 ANTITHYMOCYTE GLOBULIN RABB EXTERNAL 01/01/06 J7511 J7511 J7511 028 0636 5011
44057513 DACLIZUMAB, PARENTERAL 25MG EXTERNAL 01/01/03 J7513 J7513 J7513 028 0636 5011
44057515 CYCLOSPORINE, ORAL 25MG EXTERNAL 08/01/00 J7515 J7515 J7515 028 0636 5011
44057516 CYCLOSPORINE, PARENTERAL 250MG EXTERNAL 08/01/00 J7516 J7516 J7516 028 0636 5011
44057517 MYCOPHENOLA MOF 250MG ORAL EXTERNAL 01/01/03 J7517 J7517 J7517 028 0636 5011
44057518 MYCOPHENOLIC ACID PO 180MG EXTERNAL 01/01/05 J7518 J7518 J7518 028 0636 5011
44057520 SIROLIMUS ORAL /1 MG EXTERNAL 08/01/00 J7520 J7520 J7520 028 0636 5011
44057525 TACROLIMUS,PARENTERAL 5MG IV EXTERNAL 08/01/00 J7525 J7525 J7525 028 0636 5011
44057599 IMMUNOSUPPRESSIVE DRUG, NOC EXTERNAL 08/01/04 J7599 J7599 J7599 028 0636 5011
44057602 ALBUTEROL, NONCOMP CONC FORM EXTERNAL 05/01/08 J7602 J7602 028 0636 5011
44057603 ALBUTEROL NONCOMPED UNIT DOSE EXTERNAL 05/01/08 J7603 J7603 028 0636 5011
44057608 ACETYLCYSTEINE SOL/GM INH EXTERNAL 08/01/00 J7608 J7608 J7608 028 0636 5011
44057609 ALBUTERL,INH SOL UNIT DOSE 1MG EXTERNAL 07/01/07 J7609 J7609 J7609 028 0636 5011
44057610 ALBTERL,INH SL,COMP'D CONC 1MG EXTERNAL 03/26/02 J7610 J7610 J7610 028 0636 5011
44057611 ALBUTEROL,INH SL,CONC FORM,1MG EXTERNAL 04/01/08 J7611 J7611 J7611 028 0636 5011
44057612 LVBUTERL,INH SL,CNC FRM,0.5MG EXTERNAL 01/01/08 J7612 J7612 J7612 028 0636 5011
44057613 ALBUTEROL,INH SOL,UNIT DSE,1MG EXTERNAL 01/01/08 J7613 J7613 J7613 028 0636 5011
44057614 LEVABUTERL,INH SL,UNT DOS,1MG EXTERNAL 01/01/08 J7614 J7614 J7614 028 0636 5011
44057615 ACETYLCYSTEINE 20%/ML INH EXTERNAL 01/01/08 028 0250 5011
44057618 ALBUTEROL CONCENT/1MG EXTERNAL 01/01/09 J7611 J7611 J7611 028 0250 5011
44057619 ALBUTEROL UNIT DOSE/1MG EXTERNAL 01/01/09 J7611 J7611 J7611 028 0250 5011
44057625 ALBUTEROL, SULFAT .5%/ML EXTERNAL 03/26/02 028 0636 5011
44057626 PULMICORT RESPS,UNIT DSE,0.5MG EXTERNAL 10/01/06 J7626 J7626 J7626 028 0636 5011
44057627 BUDESONDE,INH SL,UNT DSE,0.5MG EXTERNAL 03/26/02 J7627 J7627 J7627 028 0636 5011
44057628 BITO MESY, INH SOL, CONCEN /MG EXTERNAL 08/01/00 J7628 J7628 J7628 028 0636 5011
44057629 BITOL MESY,INH SOL, UN DO /MG EXTERNAL 08/01/00 J7629 J7629 J7629 028 0636 5011
44057630 CROMOLYN SODIUM /20MG EXTERNAL 03/26/02 028 0636 5011
44057631 CROMOLYN SOD INH SOL 10MG EXTERNAL 08/01/00 J7631 J7631 J7631 028 0636 5011
44057633 BUDESONIDE INH SOL PER 0.25MG EXTERNAL 01/01/03 J7633 J7633 J7633 028 0636 5011
44057635 ATROPINE INH-SOL CONC FORM /MG EXTERNAL 08/01/00 J7635 J7635 J7635 028 0636 5011
44057636 ATROPINE INH-SOL UNT DOSE FRM EXTERNAL 08/01/00 J7636 J7636 J7636 028 0636 5011
44057637 DEXAMETHASONE INH SOL/MG EXTERNAL 08/01/00 J7637 J7637 J7637 028 0636 5011
44057638 DEXAMETH INH SOL UNT DOSE/MG EXTERNAL 08/01/00 J7638 J7638 J7638 028 0636 5011
44057639 DORNASE ALPHA INH SOL/MG EXTERNAL 08/01/00 J7639 J7639 J7639 028 0636 5011
44057640 FORMOTEROL,INH SL,UNT DSE12MCG EXTERNAL 03/26/02 028 0636 5011
44057641 FLUNISOLIDE, INH SOL, UNIT DOS EXTERNAL 07/01/07 J7641 J7641 J7641 028 0636 5011
44057642 GLYCOPYRROLATE,INH SL,CON/MG EXTERNAL 08/01/00 J7642 J7642 J7642 028 0636 5011
44057643 GLYCPYRRLTE,INH SOL,U-DOS/MG EXTERNAL 08/01/00 J7643 J7643 J7643 028 0636 5011
44057644 IPRATROPIUM INHAL SOL PER MG EXTERNAL 08/01/03 J7644 J7644 J7644 028 0636 5011
44057645 IPRATROPIUM BROM, INH COMP /MG EXTERNAL 03/26/02 028 0636 5011
44057648 ISOETHARINE HCL,INH SL,CONC/MG EXTERNAL 08/01/00 J7648 J7648 J7648 028 0636 5011
44057649 ISOETHARNE HCL,INH SOL,UNIT/MG EXTERNAL 08/01/00 J7649 J7649 J7649 028 0636 5011
44057650 ISOETHARNE HCL,INH SOL,COMP/MG EXTERNAL 03/26/02 J7650 J7650 J7650 028 0636 5011
44057651 ISOETHARINE HCL 0.125%/ML EXTERNAL 03/26/02 028 0636 5011
44057652 ISOETHARINE HCL0.167% /ML EXTERNAL 03/26/02 028 0636 5011
44057653 ISOETHARINE HCL 0.2% / ML EXTERNAL 03/26/02 028 0636 5011
44057654 ISOETHARINE HCL 0.25% /ML EXTERNAL 03/26/02 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 318
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44057655 ISOETHARINE HCL 1.0% /ML EXTERNAL 03/26/02 028 0636 5011
44057658 ISO HCL INHAL SOL CONC/MG EXTERNAL 08/01/00 J7658 J7658 J7658 028 0636 5011
44057659 ISO HCL INHAL SOL UNT /MG EXTERNAL 08/01/00 J7659 J7659 J7659 028 0636 5011
44057660 ISOPRTRNL HCL,INH SOL,COMP/MG EXTERNAL 03/26/02 J7660 J7660 J7660 028 0636 5011
44057665 ISOPROTERENOL HCL 1.0%/ML EXTERNAL 03/26/02 028 0636 5011
44057667 METPRTRENOL,INH SOL,COMP/10MG EXTERNAL 07/01/07 J7667 J7667 J7667 028 0636 5011
44057668 METPRTERENL,INH SOL,CONC/10MG EXTERNAL 08/01/00 J7668 J7668 J7668 028 0636 5011
44057669 METPRTRENL,INH SOL,UNT DS/10MG EXTERNAL 08/01/00 J7669 J7669 J7669 028 0636 5011
44057670 METPRTRNOL,INH SL,COM UNT/10MG EXTERNAL 03/26/02 J7670 J7670 J7670 028 0636 5011
44057672 METAPRTNL SULFT 0.6%/2.5 ML EXTERNAL 03/26/02 028 0636 5011
44057674 METHACHOLINE CL, INH SOL, /MG EXTERNAL 07/01/07 028 0636 5011
44057680 TERBUTALIN SULF INH SOL PER MG EXTERNAL 08/01/00 J7680 J7680 J7680 028 0636 5011
44057681 TERBUTALIN SULF,INH UDF PER MG EXTERNAL 08/01/00 J7681 J7681 J7681 028 0636 5011
44057682 TOBRAMYCN,INH SL,UNT DSE/300MG EXTERNAL 01/01/06 J7682 J7682 J7682 028 0250 5011
44057683 TRIAMCINOLONE INH SOLU PER MG EXTERNAL 08/01/00 J7683 J7683 J7683 028 0636 5011
44057684 TRIAMCINOLON INH SOL UNIT /MG EXTERNAL 08/01/00 J7684 J7684 J7684 028 0636 5011
44058499 PRESCRIPT DRUG,ORAL,NONCHEMO EXTERNAL 11/01/04 028 0636 5011
44058501 EMEND PER 5MG EXTERNAL 04/01/05 J8501 J8501 J8501 028 0636 5011
44058510 BUSULFAN, ORAL EXTERNAL 08/01/00 J8510 J8510 J8510 028 0636 5011
44058520 CAPECITABINE 150MG EXTERNAL 08/01/00 J8520 J8520 J8520 028 0636 5011
44058521 CAPECITABINE 500MG EXTERNAL 08/01/00 J8521 J8521 J8521 028 0636 5011
44058530 CYCLOPHOSPHAMIDE, ORAL 25MG EXTERNAL 08/01/00 J8530 J8530 J8530 028 0636 5011
44058540 DEXAMETHASONE, ORAL, 0.25MG EXTERNAL 01/01/06 J8540 J8540 J8540 028 0636 5011
44058560 ETOPOSIDE ORAL 50MG EXTERNAL 08/01/00 J8560 J8560 J8560 028 0636 5011
44058597 ANTIEMETIC DRUG, ORAL, N.O.S. EXTERNAL 07/01/07 J8597 J8597 J8597 028 0636 5011
44058600 MELPHALAN, ORAL 2MG EXTERNAL 08/01/00 J8600 J8600 J8600 028 0636 5011
44058610 METHOTREXATE, ORAL 2.5MG EXTERNAL 08/01/00 J8610 J8610 J8610 028 0636 5011
44058999 PRESCRIPTION DRUG, ORAL,CHEMO EXTERNAL 08/01/00 J8999 J8999 J8999 028 0636 5011
44059000 DOXORUBICIN HCL 10MG EXTERNAL 07/01/02 J9000 J9000 J9000 028 0636 5011
44059001 DOXORUB HCL, ALL LIP FORM 10MG EXTERNAL 07/01/02 J9001 J9001 J9001 028 0636 5011
44059010 ALEMTUZUMAB, 10MG EXTERNAL 01/01/03 J9010 J9010 J9010 028 0636 5011
44059015 ALDESLEUKIN/SINGLE USE VIAL EXTERNAL 07/01/02 J9015 J9015 J9015 028 0636 5011
44059017 TRISENOX1MG (ARSENIC TRIOXIDE) EXTERNAL 08/01/00 J9017 J9017 J9017 028 0636 5011
44059020 ASPARAGINASE 10,000 UNITS EXTERNAL 07/01/02 J9020 J9020 J9020 028 0636 5011
44059025 AZACITIDINE INJ,(VIDIZA) EXTERNAL 01/01/06 J9025 J9025 J9025 028 0636 5011
44059027 CLOFARBINE INJ,(CLOLAR) EXTERNAL 01/01/06 J9027 J9027 J9027 028 0636 5011
44059031 BCG (BAC CAL AND GUERIN) /VIAL EXTERNAL 07/01/02 J9031 J9031 J9031 028 0636 5011
44059033 BENDAMISTINE(TREANDA).1MG EXTERNAL 01/01/09 J9033 J9033 J9033 028 0636 5011
44059035 BEVACIZAMIB(AVASTIN)INJ,10MG EXTERNAL 01/01/05 J9035 J9035 J9035 028 0636 5011
44059040 BLEOMYCIN SULFATE 15 UNITS EXTERNAL 07/01/02 J9040 J9040 J9040 028 0636 5011
44059041 VELCADE, 0.1MG INJECTION EXTERNAL 01/01/05 J9041 J9041 J9041 028 0636 5011
44059045 CARBOPLATIN 50MG EXTERNAL 07/01/02 J9045 J9045 J9045 028 0636 5011
44059050 CARMUSTINE 100MG EXTERNAL 07/01/02 J9050 J9050 J9050 028 0636 5011
44059055 CETUXIMAB(ERBITUX)INJ,10MG EXTERNAL 01/01/05 J9055 J9055 J9055 028 0636 5011
44059062 CISPLATIN 50MG EXTERNAL 08/01/00 J9062 J9062 J9062 028 0636 5011
44059065 CLADRIBINE /MG EXTERNAL 07/01/02 J9065 J9065 J9065 028 0636 5011
44059070 CYCLOPHOSPHAMIDE 100MG EXTERNAL 07/01/02 J9070 J9070 J9070 028 0636 5011
44059080 CYCLOPHOSPHAMIDE 200MG EXTERNAL 08/01/00 J9080 J9080 J9080 028 0636 5011
44059090 CYCLOPHOSPHAMIDE 500MG EXTERNAL 08/01/00 J9090 J9090 J9090 028 0636 5011
44059091 CYCLOPHOSPHAMIDE 1G EXTERNAL 08/01/00 J9091 J9091 J9091 028 0636 5011
44059092 CYCLOPHOSPHAMIDE 2G EXTERNAL 08/01/00 J9092 J9092 J9092 028 0636 5011
44059093 CYCLOPHOSP, LYOPHILIZED 100MG EXTERNAL 07/01/02 J9093 J9093 J9093 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 319
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44059094 CYCLOPHOSP, LYOPHILIZED 200MG EXTERNAL 08/01/00 J9094 J9094 J9094 028 0636 5011
44059095 CYCLOPHOSP, LYOPHILIZED 500MG EXTERNAL 08/01/00 J9095 J9095 J9095 028 0636 5011
44059096 CYCLOPHOSP, LYOPHILIZED 1G EXTERNAL 08/01/00 J9096 J9096 J9096 028 0636 5011
44059097 CYCLOPHOSP, LYOPHILIZED 2G EXTERNAL 08/01/00 J9097 J9097 J9097 028 0636 5011
44059098 CYTARABINE LIPOSOME, PER 10 MG EXTERNAL 10/01/04 J9098 J9098 J9098 028 0636 5011
44059100 CYTARABINE 100MG EXTERNAL 07/01/02 J9100 J9100 J9100 028 0636 5011
44059110 CYTARABINE 500MG EXTERNAL 08/01/00 J9110 J9110 J9110 028 0636 5011
44059120 DACTINOMYCIN 0.5MG EXTERNAL 08/01/00 J9120 J9120 J9120 028 0636 5011
44059130 DACARBAZINE 100MG EXTERNAL 07/01/02 J9130 J9130 J9130 028 0636 5011
44059140 DACARBAZINE 200MG EXTERNAL 08/01/00 J9140 J9140 J9140 028 0636 5011
44059150 DAUNORUBICIN HCL 10MG EXTERNAL 08/01/00 J9150 J9150 J9150 028 0636 5011
44059151 DAUNORUBICIN CITRATE 10MG EXTERNAL 08/01/00 J9151 J9151 J9151 028 0636 5011
44059160 DENILEUKIN DIFITOX,300MCG EXTERNAL 01/01/06 J9160 J9160 J9160 028 0636 5011
44059165 DIETHYL DIPHOSP <=250MG EXTERNAL 08/01/00 J9165 J9165 J9165 028 0636 5011
44059170 DOCETAXEL 20MG EXTERNAL 01/01/10 J9171 J9171 J9171 028 0636 5011
44059171 DOCETAXEL, 1MG EXTERNAL 01/01/10 J9171 J9171 J9171 028 0636 5011
44059178 EPIRUBICIN HCL 2MG INJ EXTERNAL 01/01/05 J9178 J9178 J9178 028 0636 5011
44059181 ETOPOSIDE 10MG EXTERNAL 07/01/02 J9181 J9181 J9181 028 0636 5011
44059182 ETOPOSIDE 100MG EXTERNAL 08/01/00 J9182 J9182 J9182 028 0636 5011
44059185 FLUDARABINE PHOSPH 50 MG EXTERNAL 07/01/02 J9185 J9185 J9185 028 0636 5011
44059190 FLUOROURACIL 500 MG EXTERNAL 07/01/02 J9190 J9190 J9190 028 0636 5011
44059200 FLOXURIDINE 500 MG EXTERNAL 07/01/02 J9200 J9200 J9200 028 0636 5011
44059201 GEMCITABINE HCL 200 MG EXTERNAL 07/01/02 J9201 J9201 J9201 028 0636 5011
44059202 GOSERELIN ACET IMP /3.6MG EXTERNAL 08/01/00 J9202 J9202 J9202 028 0636 5011
44059206 IRINOTECAN 20 MG EXTERNAL 07/01/02 J9206 J9206 J9206 028 0636 5011
44059207 IXABEPILONE 1MG EXTERNAL 06/01/09 J9207 J9207 J9207 028 0636 5011
44059208 IFOSFAMIDE / 1 G EXTERNAL 07/01/02 J9208 J9208 J9208 028 0636 5011
44059209 MESNA 200MG IV EXTERNAL 07/01/02 J9209 J9209 J9209 028 0636 5011
44059211 IDARUBICIN HCL 5 MG EXTERNAL 08/01/00 J9211 J9211 J9211 028 0636 5011
44059212 INTERFERON ALFACO-1 RECOM 1MCG EXTERNAL 08/01/00 J9212 J9212 J9212 028 0636 5011
44059213 INTERFERON ALFA-2A RECOMB 3 MU EXTERNAL 07/01/02 J9213 J9213 J9213 028 0636 5011
44059214 INTERFERON ALFA-2B RECOMB 1MU EXTERNAL 08/01/00 J9214 J9214 J9214 028 0636 5011
44059215 INTERF ALFA3 HU LEUK 250,000IU EXTERNAL 08/01/00 J9215 J9215 J9215 028 0636 5011
44059216 INTERFERON GAMMA-1B 3MILL EXTERNAL 08/01/00 J9216 J9216 J9216 028 0636 5011
44059217 LEUPROLIDE ACETATE 7.5MG IM EXTERNAL 07/01/02 J9217 J9217 J9217 028 0636 5011
44059218 LEUPROLIDE ACETATE /1MG EXTERNAL 08/01/00 J9218 J9218 J9218 028 0636 5011
44059219 LEUPROLIDE ACETATE IMPLANT EXTERNAL 01/01/06 J9219 J9219 J9219 028 0636 5011
44059230 MECHLORETHAMINE HCL 10MG EXTERNAL 08/01/00 J9230 J9230 J9230 028 0636 5011
44059245 MELPHALAN HCL 50MG IV EXTERNAL 08/01/00 J9245 J9245 J9245 028 0636 5011
44059250 METHOTREXATE SODIUM 5MG EXTERNAL 07/01/02 J9250 J9250 J9250 028 0636 5011
44059260 METHOTREXATE 250MG/10ML VIAL EXTERNAL 08/01/04 J9260 J9260 J9260 028 0636 5011
44059261 ARRANON 50MG EXTERNAL 01/01/09 J9261 J9261 J9261 028 0636 5011
44059263 ELOXATIN INJ PER 0.5 EXTERNAL 01/01/04 J9263 J9263 J9263 028 0636 5011
44059264 PACLITAXEL INJ,1MG(ABRAXANE) EXTERNAL 01/01/06 J9264 J9264 J9264 028 0636 5011
44059265 PACLITAXEL 30MG IV EXTERNAL 07/01/02 J9265 J9265 J9265 028 0636 5011
44059266 PEGASPARGASE/DOSE VIAL-IV EXTERNAL 08/01/00 J9266 J9266 J9266 028 0636 5011
44059268 PENTOSTATIN /10MG EXTERNAL 08/01/00 J9268 J9268 J9268 028 0636 5011
44059270 PLICAMYCIN 2,500 MCG IV EXTERNAL 08/01/00 J9270 J9270 J9270 028 0636 5011
44059280 MITOMYCIN 5 MG IV EXTERNAL 08/01/00 J9280 J9280 J9280 028 0636 5011
44059290 MITOMYCIN 20MG IV EXTERNAL 08/01/00 J9290 J9290 J9290 028 0636 5011
44059291 MITOMYCIN 40 MG IV EXTERNAL 08/01/00 J9291 J9291 J9291 028 0636 5011
44059293 MITOXANTRONE HCL/5MG IV EXTERNAL 07/01/02 J9293 J9293 J9293 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 320
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44059300 GEMTUZUMAB OZUG, INJ 5MG EXTERNAL 08/01/00 J9300 J9300 J9300 028 0636 5011
44059303 VECTIBIX 10MG EXTERNAL 02/01/08 J9303 J9303 J9303 028 0636 5011
44059305 PERMEXTRED,INJ(ALTIMA)10MG EXTERNAL 01/01/05 J9305 J9305 J9305 028 0636 5011
44059310 RITUXIMAB 100MG EXTERNAL 07/01/02 J9310 J9310 J9310 028 0636 5011
44059320 STREPTOZOCIN 1GM IV EXTERNAL 08/01/00 J9320 J9320 J9320 028 0636 5011
44059330 TORISEL, 1MG EXTERNAL 10/01/09 J9330 J9330 J9330 028 0636 5011
44059340 THIOTEPA 15MG IV EXTERNAL 08/01/00 J9340 J9340 J9340 028 0636 5011
44059350 TOPOTECAN 4MG EXTERNAL 08/01/00 J9350 J9350 J9350 028 0636 5011
44059355 TRASTUZUMAB 10MG EXTERNAL 07/01/02 J9355 J9355 J9355 028 0636 5011
44059357 VALRUBICIN 200MG INTRAVESICAL EXTERNAL 08/01/00 J9357 J9357 J9357 028 0636 5011
44059360 VINBLASTINE SULFATE 1MG IV EXTERNAL 07/01/02 J9360 J9360 J9360 028 0636 5011
44059370 VINCRISTINE SULFATE 1MG IV EXTERNAL 07/01/02 J9370 J9370 J9370 028 0636 5011
44059375 VINCRISTINE SULFATE 2MG IV EXTERNAL 08/01/00 J9375 J9375 J9375 028 0636 5011
44059380 VINCRISTINE SULFATE 5MG IV EXTERNAL 08/01/00 J9380 J9380 J9380 028 0636 5011
44059390 VINORELBINE TARTRATE /10MG EXTERNAL 07/01/02 J9390 J9390 J9390 028 0636 5011
44059395 FASLODEX INJ PER 25 MG EXTERNAL 01/01/04 J9395 J9395 J9395 028 0636 5011
44059600 PORFIMER SODIUM 75 MG EXTERNAL 08/01/00 J9600 J9600 J9600 028 0636 5011
44059999 NOC, ANTINEOPLASTIC DRUG EXTERNAL 12/01/04 J9999 J9999 J9999 028 0636 5011
44060119 AZATHIOPRINE 50MG EXTERNAL 03/26/02 028 0636 5011
44060120 AZATHIOPRINE, PARENTERAL 100MG EXTERNAL 03/26/02 028 0636 5011
44060121 CYCLOSPORINE, ORAL 25MG EXTERNAL 03/26/02 028 0636 5011
44060123 LYMPH IMM GLOB 250MG EXTERNAL 03/26/02 028 0636 5011
44060125 PREDNISONE TAB 5MG ORAL EXTERNAL 03/26/02 028 0250 5011
44060418 CYCLOSPORINE, ORAL /100MG EXTERNAL 08/01/00 028 0636 5011
44080034 FLUZONE SYRINGE 2003-20 EXTERNAL 08/01/03 90658 90658 90658 028 0636 5011
44080136 EPO NON ESRD/1000 UNITS EXTERNAL 01/01/08 028 0636 5011
44080137 ARANESP INJ PER 1 MCG EXTERNAL 01/01/04 J0881 J0881 J0881 028 0636 5011
44080156 ALBUMIN HUMAN 5% 250ML IV EXTERNAL 03/26/02 P9045 P9045 P9045 028 0636 5011
44080157 ALBUMIN HUMAN 25% 50ML IV EXTERNAL 03/26/02 P9047 P9047 P9047 028 0636 5011
44080160 FACTOR IX NON RECOMB /IU EXTERNAL 03/26/02 J7193 J7193 J7193 028 0636 5011
44080161 FACTOR IX RECOMB /IU EXTERNAL 03/26/02 J7195 J7195 J7195 028 0636 5011
44080163 DIPHENHYDRAMINE 50MG ORAL EXTERNAL 08/01/00 Q0163 Q0163 Q0163 028 0636 5011
44080164 PROCHLOPERAZ MALEAT 5MG ORAL EXTERNAL 07/01/02 Q0164 Q0164 Q0164 028 0636 5011
44080165 PROCHLORPERAZ MALEAT 10MG ORAL EXTERNAL 08/01/00 Q0165 Q0165 Q0165 028 0636 5011
44080166 GRANISETRON HCL 1MG ORAL EXTERNAL 08/01/00 Q0166 Q0166 Q0166 028 0636 5011
44080167 DRONABINOL 2.5 MG ORAL EXTERNAL 08/01/00 Q0167 Q0167 Q0167 028 0636 5011
44080168 DRONABINOL 5 MG ORAL EXTERNAL 08/01/00 Q0168 Q0168 Q0168 028 0636 5011
44080169 PROMETHAZINE HCL 12.5MG ORAL EXTERNAL 08/01/00 Q0169 Q0169 Q0169 028 0636 5011
44080170 PROMETHAZINE HCL 25MG ORAL EXTERNAL 08/01/00 Q0170 Q0170 Q0170 028 0636 5011
44080171 CHLORPROMAZINE 10MG ORAL EXTERNAL 07/01/02 Q0171 Q0171 Q0171 028 0636 5011
44080172 CHLORPROMAZINE 25MG ORAL EXTERNAL 08/01/00 Q0172 Q0172 Q0172 028 0636 5011
44080173 TRIMETHOBENZAMI HCL 250MG ORAL EXTERNAL 08/01/00 Q0173 Q0173 Q0173 028 0636 5011
44080174 THIETHYLPERAZINE 10MG ORAL EXTERNAL 08/01/00 Q0174 Q0174 Q0174 028 0636 5011
44080175 PERPHENAZINE <=4MG ORAL EXTERNAL 08/01/00 Q0175 Q0175 Q0175 028 0636 5011
44080176 PERPHENAZINE <=8MG ORAL EXTERNAL 08/01/00 Q0176 Q0176 Q0176 028 0636 5011
44080177 HYDROXYZINE PAMOT 25MG ORAL EXTERNAL 08/01/00 Q0177 Q0177 Q0177 028 0636 5011
44080178 HYDROXYZINE PAMOT 50 MG ORAL EXTERNAL 08/01/00 Q0178 Q0178 Q0178 028 0636 5011
44080179 ONDANSETRON HCL 8MG ORAL EXTERNAL 07/01/02 Q0179 Q0179 Q0179 028 0636 5011
44080180 DOLASETRON MESYLATE 100MG ORAL EXTERNAL 08/01/00 Q0180 Q0180 Q0180 028 0636 5011
44080181 UNSPECIFIED ORAL ANTI-EMETIC EXTERNAL 10/01/04 Q0181 Q0181 Q0181 028 0636 5011
44080187 FACTOR VIIIA(COAG-FACTR)/1.2MG EXTERNAL 08/01/00 J7189 J7189 J7189 028 0636 5011
44082002 ELLIOT'S B SOLUTION/ML EXTERNAL 01/01/07 J9175 J9175 J9175 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 321
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44082006 DIGOXIN IMMUNE FAB(OVINE)/40MG EXTERNAL 01/01/07 J1162 J1162 J1162 028 0636 5011
44082007 ETHANOLAMINE OLEATE, 100 MG EXTERNAL 01/01/07 J1430 J1430 J1430 028 0636 5011
44082008 FOMEPIZOLE, 15 MG EXTERNAL 01/01/07 J1451 J1451 J1451 028 0636 5011
44082009 FOSPHENYTOIN, 50 MG EXTERNAL 08/01/00 Q2009 Q2009 Q2009 028 0636 5011
44082010 GLATIRAMER ACETATE, 20 MG EXTERNAL 08/01/00 J1595 J1595 J1595 028 0636 5011
44082011 HEMIN, 1 MG EXTERNAL 08/01/00 J1640 J1640 J1640 028 0636 5011
44082012 PEGADEMASE BOVINE INJ 25 IU EXTERNAL 08/01/00 J2504 J2504 J2504 028 0636 5011
44082013 PENTASTARCH 10% INJ, 100 ML EXTERNAL 08/01/00 J2513 J2513 J2513 028 0636 5011
44082014 SERMORELIN ACETATE, 0.5 MG EXTERNAL 08/01/00 J0515 J0515 J0515 028 0636 5011
44082015 SOMATREM INJECTION 5MG IM EXTERNAL 03/26/02 028 0636 5011
44082016 SOMATROPIN,INJECTION 1MG SC,IM EXTERNAL 03/26/02 028 0636 5011
44082017 TENIPOSIDE, 50 MG EXTERNAL 08/01/00 Q2017 Q2017 Q2017 028 0636 5011
44082019 BASILIXIMAB, 20 MG EXTERNAL 01/01/03 J0480 J0480 J0480 028 0636 5011
44082020 HISTRELIN ACETATE, 0.5 MG EXTERNAL 08/01/00 J1675 J1675 J1675 028 0636 5011
44082021 LEPIRDIN, 50 MG EXTERNAL 08/01/00 J1945 J1945 J1945 028 0636 5011
44082022 VON WILLEBRAND FACTOR,PER IU EXTERNAL 01/01/07 J7187 J7187 J7187 028 0636 5011
44083021 RECOMBIVAX-HB VL 40MCG EXTERNAL 01/01/03 90740 90740 90740 028 0636 5011
44083022 ENGERIX-B 20MCG/ML EXTERNAL 08/01/03 90746 90746 90746 028 0636 5011
44083023 RECOMBIVAX-HB VL 40MCG PF EXTERNAL 01/01/03 90740 90740 90740 028 0636 5011
44083025 INTERFERON BETA 1-A, IM INJ. EXTERNAL 01/01/06 Q3025 Q3025 Q3025 028 0636 5011
44083130 DELASTRYL 200MG/ML INJ EXTERNAL 06/01/04 J3130 J3130 J3130 028 0636 5011
44083425 INTERFERON BETA-1A, 11MCG IM EXTERNAL 04/01/04 Q3025 Q3025 Q3025 028 0636 5011
44084052 OCTREOTIDE DEPOT IM INJ/PR 1MG EXTERNAL 07/01/03 J2353 J2353 J2353 028 0636 5011
44084053 PEGFILGRASTRIM INJ, PER 1MG EXTERNAL 07/01/03 028 0250 5011
44084054 ARANESP PER 1 MCG (FOR ESRD) EXTERNAL 01/01/06 J0882 J0882 J0882 028 0636 5011
44084079 NATALIZUMAB,1MG EXTERNAL 01/01/06 J2323 J2323 J2323 028 0636 5011
44084083 HYALGAN (SUPARTZ) INJ, PER DOS EXTERNAL 01/01/09 Q4083 Q4083 Q4083 028 0636 5011
44084087 OCTAGAM INJ EXTERNAL 07/01/07 J1568 J1568 J1568 028 0636 5011
44084088 GAMMAGARD LIQUID INJ 500MG EXTERNAL 01/01/08 J1569 J1569 J1569 028 0636 5011
44084089 RHOPHYLAC INJECTION 500MG EXTERNAL 01/01/08 J2791 J2791 J2791 028 0636 5011
44084090 HEPAGAM B INJ, INTAMUSC 500MG EXTERNAL 01/01/08 J1571 J1571 J1571 028 0636 5011
44084091 FLEBOGAMMA 500UNITS EXTERNAL 01/01/08 J1572 J1572 J1572 028 0636 5011
44084092 GAMMUNEX INJ 500MG EXTERNAL 01/01/08 J1561 J1561 J1561 028 0636 5011
44084095 INJ,ZOLEDRONIC ACD(RECLAST)1MG EXTERNAL 01/01/08 J3488 J3488 J3488 028 0636 5011
44089920 EPO/1000 UNIT PT HCT<=20 EXTERNAL 08/01/00 J0886 J0886 J0886 028 0636 5011
44089921 EPO/1000 UNITS PT HCT=21 EXTERNAL 01/01/07 J0886 028 0636 5011
44089922 EPO/1000 UNITS PT HCT=22 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089923 EPO/1000 UNITS PT HCT=23 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089924 EPO/1000 UNITS PT HCT=24 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089925 EPO/1000 UNITS PT HCT=25 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089927 EPO/1000 UNITS PT HCT=27 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089928 EPO/1000 UNITS PT HCT=28 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089929 EPO/1000 UNITS PT HCT=29 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089930 EPO/1000 UNITS PT HCT=30 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089931 EPO/1000 UNITS PT HCT=31 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089932 EPO/1000 UNITS PT HCT=32 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089933 EPO/1000 UNITS PT HCT=33 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089934 IVIG NON-LVOPHIL 1 GM EXTERNAL 01/01/08 J1561 J1561 J1561 028 0636 5011
44089935 EPO/1000 UNITS PT HCT=35 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089936 EPO/1000 UNITS PT HCT=36 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089937 EPO/1000 UNITS PT HCT=37 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089938 EPO/1000 UNITS PT HCT=38 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 322
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44089939 EPO/1000 UNITS PT HCT=39 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089940 EPO/1000 UNITS PT HCT>=40 EXTERNAL 01/01/07 J0886 J0886 J0886 028 0636 5011
44089942 IVIG LYOPHIL PER 10MG EXTERNAL 03/01/05 028 0636 5011
44089943 IVIG NON-LYOPHIL 1 GM EXTERNAL 01/01/08 J1561 J1561 J1561 028 0636 5011
44089944 IVIG NON-LYOPHIL 10MG EXTERNAL 01/01/08 J1561 J1561 J1561 028 0636 5011
44089956 EPO/1000 UNITS PT HCT=26 EXTERNAL 03/26/02 028 0636 5011
44090371 HEP-B IG, IM EXTERNAL 01/01/06 90371 90371 90371 028 0636 5011
44090396 VARICELLA-ZOSTER IMMUNE GLOB EXTERNAL 03/01/06 90396 90396 90396 028 0636 5011
44090585 BCG VACCINE, PERCUT EXTERNAL 01/01/06 90585 90585 90585 028 0636 5011
44090636 HEP-A/HEP-B VACCINE,ADULT IM EXTERNAL 01/01/06 90636 90636 90636 028 0636 5011
44090649 HPV VACCINE QUADRAVALENT EXTERNAL 03/01/08 90649 90649 90649 028 0636 5011
44090650 HPV VACCINE BIVALENT EXTERNAL 03/01/08 90650 90650 90650 028 0636 5011
44090658 INFLUENZA VACCINE-SPLIT VIRUS EXTERNAL 01/01/04 90658 90658 90658 028 0636 5011
44090675 RABIES VACCINE,IM EXTERNAL 01/01/06 90675 90675 90675 028 0636 5011
44090676 RABIES VACCINE.ID EXTERNAL 01/01/06 90676 90676 90676 028 0636 5011
44090700 ACTHIB VACCINE(HAEMOPHILIUS B) EXTERNAL 04/01/08 90700 90700 90700 028 0636 5011
44090743 RECOMBINAX-HB 10MCG 1ML EXTERNAL 03/01/06 90743 90743 90743 028 0636 5011
44093022 RECOMBIVAX 10MCG ADULT HEP B EXTERNAL 02/01/05 90740 90740 90740 028 0636 5011
44100001 ARANESP 25MCG/0.4ML (PFS) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100004 ARANESP 40MCG/0.4ML (PFS) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100007 ARANESP 60MCG/0.3ML (PFS) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100010 ARANESP 100MCG/0.5ML (PFS) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100013 ARANESP 150MCG/0.3ML (PFS) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100016 ARANESP 200MCG/0.4ML (PFS) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100020 ARANESP 25MCG/ML 1ML (SDV) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100023 ARANESP 100MCG/ML 1ML (SDV) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100026 ARANESP 150MCG/0.75ML (SDV) 11.00 06/30/10 J0882 J0882 J0882 028 0636 5011
44100030 EPOGEN 10MU/1ML SDV 5.00 06/30/10 Q4081 Q4081 Q4081 028 0634 5011
44100033 EPOGEN 40MU/1ML SDV 5.00 06/30/10 Q4081 Q4081 Q4081 028 0634 5011
44100036 PROCRIT 2000U/1ML SDV 5.00 06/30/10 Q4081 Q4081 Q4081 028 0634 5011
44100039 PROCRIT 10000U/1ML SDV 5.00 06/30/10 Q4081 Q4081 Q4081 028 0634 5011
44100042 GENTAMICIN 60MG 6.00 06/30/10 J1580 J1580 J1580 028 0636 5011
44100045 GENTAMICIN 80MG 6.00 06/30/10 J1580 J1580 J1580 028 0636 5011
44100048 GENTAMICIN 100MG 6.00 06/30/10 J1580 J1580 J1580 028 0636 5011
44100051 GENTAMICIN 120MG 6.00 06/30/10 J1580 J1580 J1580 028 0636 5011
44100060 VANCOMYCIN HCL INJECTION 12.00 06/30/10 J3370 J3370 J3370 028 0636 5011
44100063 VANCOMYCIN HCL 500MG IV,IM 12.00 06/30/10 J3370 J3370 J3370 028 0636 5011
44210147 INJ, ALGLUCOSIDASE ALFA,20MG EXTERNAL 03/01/07 J0220 J0220 J0220 028 0636 5011
44229727 ARICEPT 5MG TAB EXTERNAL 01/01/07 028 0250 5011
44229745 TRUVADA TABLETS EXTERNAL 06/01/06 028 0250 5011
44229746 APTIVUS CAP 250MG EXTERNAL 06/01/06 028 0250 5011
44229747 NORVIR SOFTGEL CAP 100MG EXTERNAL 06/01/06 028 0250 5011
44229749 NORVIR SOFTGEL CAP 100MG EXTERNAL 06/01/06 028 0250 5011
44229755 CARB/LEVO 25-100MG EXTERNAL 09/01/06 028 0250 5011
44229757 HYDROCORTSINE/NEOMYCIN SUPP EXTERNAL 11/01/06 028 0250 5011
44229765 CARB/LEVO 25-100MG EXTERNAL 09/01/06 028 0250 5011
44229840 GLIPIZIDE TAB 5MG EXTERNAL 01/20/10 028 0250 5011
44229852 EUCERIN CREAM UNSCENTED 4OZ EXTERNAL 04/01/10 028 0250 5011
44229853 POLYETHYLENE GLYCOL POWDER EXTERNAL 04/01/10 028 0250 5011
44229864 HYDROCO/APAP 7.5MG/325MG EXTERNAL 07/01/10 028 0250 5011
44250882 ARANESP,1MCG ESRD W/GS MOD EXTERNAL 04/01/06 J0882GS J0882GS J0882GS 028 0636 5011
44250886 10,000U EPOETIN ALFA, ESRD EXTERNAL 01/01/07 J0886 J0886 J0886 028 0634 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 323
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44253370 VANCOMYCIN/HEPLOCK EXTERNAL 05/01/06 J3370 J3370 J3370 028 0636 5011
44253491 ALIMTA(PREMEDTREXED) 500MG EXTERNAL 04/01/04 J3490 J3490 J3490 028 0636 5011
44262543 CYCLOBENZAPRINE HCL TABS 10MG EXTERNAL 05/01/01 028 0250 5011
44295568 VELCADE 3.5MG INJ EXTERNAL 07/01/03 J3590 J3590 J3590 028 0636 5011
01201001 LOWER EXTREMITY ARTERIAL EVAL 748.00 06/30/10 93923 93923 93923 032 0921 2725
01201003 LOWER EXTREM ARTER STRESS TEST 1058.00 06/30/10 93924 93924 93924 032 0921 2725
01201005 UPPER EXTREMITY ARTERIAL EVAL 748.00 06/30/10 93923 93923 93923 032 0921 2725
01201006 UPPER EXTREM EVAL W/REAC HYPER 986.00 06/30/10 93923 93923 93923 032 0921 2725
01201007 UPPER EXTRM THORAC OUTLET EVAL 748.00 06/30/10 93923 93923 93923 032 0921 2725
01203115 LOWER EXTREMITY DIGITAL EXAM 387.00 06/30/10 93922 93922 93922 032 0921 2725
01203120 UPPER EXTREMITY DIGITAL EXAM 387.00 06/30/10 93922 93922 93922 032 0921 2725
01203125 PENILE PLETHYSMOGRAPHY 212.00 06/30/10 54240 54240 54240 032 0921 2725
01203130 DIGITAL COLD IMMERSION 485.00 06/30/10 93740 93740 93740 032 0921 2725
01203140 FEMORAL ARTERY PRES MEASUREMNT 693.00 06/30/10 36620 36620 36620 032 0360 2725
01203160 UPPER EXTREMITY VENOUS EXAM N/C 06/30/10 032 0921 2725
01203165 LOWER EXTREMITY VENOUS EXAM N/C 06/30/10 032 0921 2725
01203170 AMBULATORY VENOUS PRES MEASURE 775.00 06/30/10 93925 93925 93925 032 0921 2725
01203175 VENOUS PHOTO PLETHYSMOGRAPHY 363.00 06/30/10 93965 93965 93965 032 0921 2725
01203185 CAROTID DUPLEX SCAN 1412.00 06/30/10 93880 93880 93880 032 0921 2725
01203191 VASC CAROTID DUPLEX SCAN - OCC N/C 06/30/10 93880 93880 93880 032 0921 2725
01203195 LIMITED DUPLEX ABDOMINAL SCAN 718.00 06/30/10 93976 93976 93976 032 0921 2725
01203200 UPPER EXTREM PERIPH ART DUPLEX 1026.00 06/30/10 93924 93924 93924 032 0921 2725
01203205 LOWER EXTREM PERIPH ART DUPLEX 1254.00 06/30/10 93925 93925 93925 032 0921 2725
01203210 DEEP VENOUS DUPLEX IMAGING N/C 06/30/10 032 0921 2725
01203215 SUPERFICIAL VEIN MAPPING LTD 722.00 06/30/10 93971 93971 93971 032 0921 2725
01203220 THORACIC OUTLET EXAM 1058.00 06/30/10 93923 93923 93923 032 0921 2725
01203228 DOPPLER LOWER EXTREMITY VENOUS 272.00 06/30/10 93965 93965 93965 032 0921 2725
01203230 RENAL VESSEL DUPLEX 1046.00 06/30/10 93975 93975 93975 032 0921 2725
01203235 PELVIC VESSEL DUPLEX 1046.00 06/30/10 93975 93975 93975 032 0921 2725
01203240 A-V FISTULA DUPLEX 758.00 06/30/10 93930 93930 93990 032 0921 2725
01203245 A-V MALFORMATION DUPLEX 927.00 06/30/10 93930 93930 93930 032 0921 2725
01203247 BRACHIAL ART.FMV 100.00 06/30/10 93931 93931 93931 032 0921 2725
01203250 SUPERIOR MESENTONIC ART DUPLEX 1046.00 06/30/10 93975 93975 93975 032 0921 2725
01203255 VISCERAL ARTERY DUPLEX 1046.00 06/30/10 93975 93975 93975 032 0921 2725
01203260 BEDSIDE EXAM 155.00 06/30/10 99060 99060 99060 032 0510 2725
01203265 TRANSCRANIAL DOPPLER; COMPLETE 756.00 06/30/10 93886 93886 93886 032 0921 2725
01203270 AIR PLETHYMOGRAPH 750.00 06/30/10 93965 93965 93965 032 0921 2725
01203271 LIMITED ARTERIAL EXAM 387.00 06/30/10 93922 93922 93922 032 0921 2725
01203273 TRANSCRANIAL DOPPLER STUDY LTD 553.00 06/30/10 93888 93888 93888 032 0921 2725
01203274 LTD CAROTID ARTERY DUPLEX SCAN 574.00 06/30/10 93882 93882 93882 032 0921 2725
01203275 DUPLEX GUIDED COMPRESSION 1465.00 06/30/10 76936 76936 76936 032 0402 2725
01203276 LIMITED UE ARTERIAL DUPLX SCAN 765.00 06/30/10 93931 93931 93931 032 0921 2725
01203277 LIMITED LE ARTERIAL DUPLX SCAN 771.00 06/30/10 93926 93926 93926 032 0921 2725
01203278 UPPER EXTREMITY VENOUS DUPLEX 784.00 06/30/10 93970 93970 93970 032 0921 2725
01203279 LOWER EXTREMITY VENOUS DUPLEX 784.00 06/30/10 93970 93970 93970 032 0921 2725
01203280 UPP-LOWR EXTRM DPLX SCAN-BILAT 1409.00 06/30/10 93970 93970 93970 032 0921 2725
01204000 SEGMENTAL DOPPLER WAVEFORM LES 748.00 06/30/10 93923 93923 93923 032 0921 2725
01204001 SEGMENT DOPPLER PRESSURES LES 748.00 06/30/10 93923 93923 93923 032 0921 2725
01204002 DIGITAL PLETHYSMOGRAPHY LES 748.00 06/30/10 93923 93923 93923 032 0921 2725
01204003 LOWER EXTR TREADMILL EXER ONLY 697.00 06/30/10 93924 93924 93924 032 0921 2725
01204030 LOWER EXTREMITY VENOUS DUPLEX 784.00 06/30/10 93970 93970 93970 032 0921 2725
01204033 LIMITED UE VENOUS DUPLEX 666.00 06/30/10 93971 93971 93971 032 0921 2725
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 324
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

01204036 LIMITED LE VENOUS DUPLEX 666.00 06/30/10 93971 93971 93971 032 0921 2725
01204039 BILAT SUPERFICIAL VEIN MAPPING 816.00 06/30/10 93970 93970 93970 032 0921 2725
01204042 TCD VASOREACTIVITY STUDY 831.00 06/30/10 93890 93890 93890 032 0921 2725
01204045 EMBOLI DETECT W/O MICROBUBBLE 831.00 06/30/10 93892 93892 93892 032 0921 2725
01204048 EMBOLI DETECT W/ MICROBUBBLE 905.00 06/30/10 93893 93893 93893 032 0921 2725
01204051 PERFORATOR MAPPING 1196.00 06/30/10 93970 93970 93970 032 0921 2725
01204054 LIMITED PERFORATOR MAPPING 913.00 06/30/10 93971 93971 93971 032 0921 2725
01204060 US GUID,INTRAOP 371.00 06/30/10 76998TC 76998 76998 032 0402 2725
01204063 US GUID,INTRAOP 738.00 06/30/10 76998TC 76998 76998 032 0402 2725
01204066 CIMT STUDY 398.00 06/30/10 0126T 0126T 0126T 032 0921 2725
03710744 EXERCISE TEST-CHILD 886.00 06/30/10 93017 93017 93017 89.44 032 0482 4601
03722483 EXER STRESS TEST TREADML/BICYC 886.00 06/30/10 93017 93017 93017 89.44 032 0482 3334
03750815 RT-HEART CATH; ONLY (INC CS) 3640.00 06/30/10 93530 93530 93530 37.21 032 0481 3330
03750823 COMB RT/LT HEART CATH COMBINED 6373.00 06/30/10 93531 93531 93531 37.23 032 0481 3330
03750894 RT-HEART CATH; SWAN-GANZ CATH 1024.00 06/30/10 93503 93503 93503 89.64 032 0481 3330
03773190 ECHOCARDIO 2D M-MODE TRNSESOPH 1740.00 06/30/10 93315 93315 93315 88.72 032 0480 3331
03773191 ECHOCARDIO PORTABLE TRANSESOPH 1913.00 06/30/10 93315 93315 93315 88.72 032 0480 3331
03773192 PLACE TRANSESOPHAGL PROBE ONLY 766.00 06/30/10 93316 93316 93316 88.72 032 0480 3331
03773193 IMAGE ACQUIS INTERPRET/REPORT 1351.00 06/30/10 93317 93317 93317 88.72 032 0480 3331
03773194 ECHOCARDIOGRAPHY 2D W/EXERCISE 1573.00 06/30/10 93350 93350 93350 88.72 032 0480 3331
03773195 DOPPLER COLOR FLOW VEL MAPPING 205.00 06/30/10 93325 93325 93325 88.72 032 0480 3331
03773196 DOPPLER ECHOCARDIO LTD OR F/U 456.00 06/30/10 93321 93321 93321 88.72 032 0480 3331
03773197 ECHOCARDIO DOPPLER, COMPLETE 687.00 06/30/10 93320 93320 93320 88.72 032 0480 3331
03773198 ECHOCARDIO 2D; LIMITED 549.00 06/30/10 93304 93304 93304 88.72 032 0480 3331
03773208 ECHOCARDIO, FETAL HEART 1239.00 06/30/10 76825 76825 76825 88.79 032 0402 3331
03773210 DOPPLER ECHOCARDIOGRAPHY FETAL 723.00 06/30/10 76827 76827 76827 88.79 032 0402 3331
03773218 STRESS TEST, DOBUTAMINE 859.00 06/30/10 93017 93017 93017 89.44 032 0482 3331
03780719 INDUCTION ARRYTHMIA BY PACING 2857.00 06/30/10 93618 93618 93618 37.29 032 0480 3331
03781059 O2-UPTAKE, FICK 757.00 06/30/10 94680 94680 94680 89.38 032 0460 4601
03781398 ECHOCARDIO 2D; COMPLETE 1073.00 06/30/10 93303 93303 93303 88.72 032 0480 3331
03790360 SURGICAL PROCEDURE-TECHNICAL 3155.00 06/30/10 032 0360 9999
06750027 TRANSCRAN DOPP STUDY LTD-HOSP 491.00 06/30/10 93888 93888 93888 032 0921 0663
06750028 TRANSCRAN DOPPLER STDY LTD-M.D 70.00 $ 06/30/09 93888 93888 93888 032 0920 0663
06750055 CAROTID DUPLEX SCAN-HOSP 251.00 06/30/10 93880 93880 93880 032 0921 0663
06750056 CAROTID DUPLEX SCAN-M.D. 67.00 $ 06/30/09 93880 93880 93880 032 0920 0663
12300307 CHEMO IV INFUS:INIT UP TO 1HR 720.00 06/30/10 96413 96413 96413 032 0940 0523
13300400 ECHO-FETAL,CARDIO SYSTEM-HOSP 1309.00 06/30/10 76825 76825 76825 032 0402 0648
13300401 ECHO-FETAL,CARDIO SYSTEM-M.D. 176.00 $ 06/30/09 76825 7682526 7682526 032 0972 0648
13300406 ECHO-FETAL,F/UP-RPT STUDY-HOSP 556.00 06/30/10 76826 76826 76826 032 0402 0648
13300407 ECHO-FETAL,F/UP-RPT STUDY-M.D. 86.00 $ 06/30/09 76826 7682626 7682626 032 0972 0648
13300412 DOP ECHO,FETAL COMPLETE-HOSP 763.00 06/30/10 76827 76827 76827 032 0402 0648
13300413 DOP ECHO,FETAL COMPLETE-M.D. 60.00 $ 06/30/09 76827 7682726 7682726 032 0972 0648
13300416 DOP ECHO,FETAL,F/UP-RPT-HOSP 421.00 06/30/10 76828 76828 76828 032 0402 0648
13300417 DOP ECHO,FETAL,F/UP-RPT-M.D. 60.00 $ 06/30/09 76828 7682826 7682826 032 0972 0648
13300440 ECHOCARDIO PORTABLE;COMPL-HOSP 502.00 06/30/10 93307 93307 93307 032 0480 0648
13300441 ECHOCARDIO PORTABLE;COMPL-M.D. 106.00 $ 06/30/09 9330726 9330726 9330726 032 0985 0648
13300444 ECHOCARD 2D M-MODE;LIMIT-HOSP 250.00 06/30/10 93308 93308 93308 032 0480 0648
13300445 ECHOCARD 2D M-MODE;LIMIT-M.D. 62.00 $ 06/30/09 9330826 9330826 9330826 032 0985 0648
13300446 ECHOCARDIO COMPL;CONGENIT-HOSP 586.00 06/30/10 9330326 9330326 9330326 032 0480 0648
13300447 ECHOCARDIO COMPL;CONGENIT-M.D. 146.00 $ 06/30/09 93303 93303 93303 032 0985 0648
13300450 DOPPLER ECHOCARDIOGRAPHY-HOSP 290.00 06/30/10 93320 93320 93320 032 0480 0648
13300451 DOPPLER ECHOCARDIOGRAPHY-M.D. 44.00 $ 06/30/09 9332026 9332026 9332026 032 0985 0648
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 325
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13300454 DOPPLER ECHO;F/U OR LIMIT-HOSP 220.00 06/30/10 93321 93321 93321 032 0480 0648
13300455 DOPPLER ECHO;F/U OR LIMIT-M.D. 18.00 $ 06/30/10 9332126 9332126 9332126 032 0985 0648
13300460 DOPPL COLOR FLOW VEL MAPP-HOSP 232.00 06/30/10 93325 93325 93325 032 0480 0648
13300461 DOPPL COLOR FLOW VEL MAPP-M.D. 9.00 $ 06/30/09 9332526 9332526 9332526 032 0985 0648
40400431 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 38.93 38.93 032 0300 3320
41010001 ARTERIAL CATH; PERCUTANEOUS 618.00 06/30/10 36620 36620 36620 38.91 38.91 032 0360 3330
41010005 CARDIAC CINE &/OR FLUOROSCOPY 985.00 06/30/10 76120 76120 76120 88.45 032 0320 3330
41010007 RIGHT HEART CATHETERIZATION 3527.00 06/30/10 93501 93501 93501 37.21 032 0481 3330
41010008 INSERT/PLACEMNT SWAN-GANZ CATH 3183.00 06/30/10 93503 93503 93503 89.64 032 0481 3330
41010009 LEFT HEART CATH; PERCUTANEOUS 5238.00 06/30/10 93510 93510 93510 37.22 032 0481 3330
41010010 LEFT HEART CATH; BY CUTDOWN 4556.00 06/30/10 93511 93511 93511 37.22 032 0481 3330
41010015 CORONARY GRAFT VISUALIZATION 1374.00 06/30/10 93540 93540 93540 88.57 032 0481 3330
41010016 RIGHT/LEFT HEART CATH 4860.00 06/30/10 93526 93526 93526 37.23 032 0481 3330
41010017 RIGHT/TRANSSEPT/LT HEART CATH 8101.00 06/30/10 93527 93527 93527 37.23 032 0481 3330
41010018 LEFT HEART CATH/TRANSSEPTAL 4025.00 06/30/10 93524 93524 93524 37.22 032 0481 3330
41010019 RT/LT HEART CATH/CORON ANGIOGR 7537.00 06/30/10 93529 93529 93529 37.23 032 0481 3330
41010023 PULMON ANGIO INJ DURING CATH 1678.00 06/30/10 93541 93541 93541 88.52 032 0481 3330
41010024 RV/RA ANGIO INJ DURING CATH 1597.00 06/30/10 93542 93542 93542 88.52 032 0481 3330
41010025 LA/LV ANGIO INJ DURING CATH 1474.00 06/30/10 93543 93543 93543 88.53 032 0481 3330
41010026 AORTOGRAM INJ DURING CATH 1602.00 06/30/10 93544 93544 93544 88.42 032 0481 3330
41010027 INTERNAL MAMMARY ANGIOGRAPHY 1344.00 06/30/10 93539 93539 93539 88.49 032 0481 3330
41010028 CORONARY ARTERY ANGIOGRAPHY 1729.00 06/30/10 93545 93545 93545 88.57 032 0481 3330
41010029 IMAG SUPERV-PA/CORON/AO ANGIOS 956.00 06/30/10 93556 93556 93556 89.04 032 0481 3330
41010030 IMAG SUPERV-LV/RV/LA/RA ANGIOS 899.00 06/30/10 93555 93555 93555 89.04 032 0481 3330
41010031 CATH PLCMNT ART. GRAFT W/O LHC 3950.00 06/30/10 93508 93508 93508 37.22 032 0481 3330
41010041 ENDOMYOCARDIAL BIOPSY 4200.00 06/30/10 93505 93505 93505 37.25 032 0481 3330
41010042 INTRACORON ULTRASND ONE VESSEL 2905.00 06/30/10 92978 92978 92978 88.79 032 0480 3330
41010043 INTRACORON ULTRASND ADD VESSEL 2122.00 06/30/10 92979 92979 92979 88.79 032 0480 3330
41010044 PERIPHERAL U/S ONE VESSEL 4161.00 06/30/10 37250 37250 37250 88.77 88.77 032 0360 3330
41010045 PERIPHERAL U/S ADDL VESSEL 3028.00 06/30/10 37251 37251 37251 88.77 88.77 032 0360 3330
41010046 CARDIOASSIST METHOD-INTERNAL 4352.00 06/30/10 92970 92970 92970 032 0360 3330
41010047 INTRAVASCULAR DOPPLER VELOCITY 3435.00 06/30/10 93571 93571 93571 032 0480 3330
41010049 INTRAVASC DOPP VELOC ADD VESL 3891.00 06/30/10 93572 93572 93572 032 0480 3330
41010051 TRANSCATHETER EMB OCCLUSION 6439.00 06/30/10 37204 37204 37204 39.53 032 0360 3330
41010053 I & S TRANSCATHETER OCCLUSION 4905.00 06/30/10 75894 75894 75894 89.04 032 0323 3330
41010055 TRNSCATH PLACE NON CORON STET 4794.00 06/30/10 37205 37205 37205 39.50 032 0360 3330
41010056 TRANCATH PLCE AD NON COR STENT 6713.00 06/30/10 37206 37206 37206 39.50 032 0360 3330
41010058 I & S STENT NON CORONARY 3378.00 06/30/10 75960 75960 75960 38.93 032 0323 3330
41010060 TRANSCATH RETRIEVAL FOR BODY 2100.00 06/30/10 37203 37203 37203 38.00 032 0360 3330
41010062 PULMONARY ARTERY PTA SNG VESSL 6691.00 06/30/10 92997 92997 92997 36.02 032 0481 3330
41010064 PULMONARY ARTERY PTA ADD VESSL 6691.00 06/30/10 92998 92998 92998 36.02 032 0481 3330
41010068 CARDIOVASC STRESS TEST-BICYCLE 380.00 06/30/10 93017 93017 93017 89.44 032 0482 3330
41010076 THERML DILUTION CARDIAC OUTPUT 897.00 06/30/10 93561 93561 93561 37.29 032 0481 3330
41010077 MEASURED O2 CONSUMP; REST/EXER 682.00 06/30/10 94680 94680 94680 89.38 032 0460 3330
41010078 MEASURED O2 CONSUMPTION; REST 682.00 06/30/10 94680 94680 94680 89.38 032 0460 3330
41010079 PULSE OXIMETRY; MULT DETERMIN 188.00 06/30/10 94761 94761 94761 89.38 032 0460 3330
41010091 PHLEBOTOMY, THERAPEUTIC 222.00 06/30/10 99195 99195 99195 89.04 032 0940 3330
41010095 VENOUS PTA I/S 3023.00 06/30/10 75978 75978 75978 89.04 032 0323 3330
41010099 VENOUS PTA PROCEDURE 4455.00 06/30/10 35476 35476 35476 39.59 032 0360 3330
41010100 PLCEMNT OF RADIATION DEL CATH 7115.00 06/30/10 92974 92974 92974 92.27 032 0481 3330
41010105 EMER CARDIAC CINE &/OR FLUOROS 2953.00 06/30/10 76120 76120 76120 88.45 032 0320 3330
41010110 ANGIO VIA EXST CTH F/U STDY-TX 964.00 06/30/10 75898 75898 75898 032 0320 3330
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 326
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41010114 EMER RHC 3527.00 06/30/10 93501 93501 93501 37.21 032 0481 3330
41010115 EMER LHC 5238.00 06/30/10 93510 93510 93510 37.22 032 0481 3330
41010116 EMER RIGHT/LEFT HEART CATH 4860.00 06/30/10 93526 93526 93526 37.23 032 0481 3330
41010117 EMER LA/LV ANG INJ DURING CATH 1474.00 06/30/10 93543 93543 93543 88.53 032 0481 3330
41010118 EMER CORONARY ARTERY ANGIO 1729.00 06/30/10 93545 93545 93545 88.57 032 0481 3330
41010119 EMER SUPERV/PA/CORON/AO ANGIOS 956.00 06/30/10 93556 93556 93556 89.04 032 0481 3330
41010120 EMER SUPERV/LV/RV/LA/RA ANGIOS 899.00 06/30/10 93555 93555 93555 89.04 032 0481 3330
41010130 CONSCIOUS SEDATION 428.00 06/30/10 99144 4 99144 99144 89.68 032 0370 3330
41010133 SELECTIVE VENOUS CATH/ANGIO 761.00 06/30/10 36011 36011 36011 38.93 032 0361 3330
41010136 SELECTIVE VENOUS CATH I & S 852.00 06/30/10 75820 75820 75820 88.66 032 0320 3330
41010139 IVC FILTER REMOVAL 3343.00 06/30/10 37203 37203 37203 032 0361 3330
41010142 IVC FILTER REMOVAL I&S 3872.00 06/30/10 75961 75961 75961 032 0320 3330
41010145 IVC FILTER REMOVAL DEVICE EXTERNAL 01/01/09 C1880 C1880 C1880 032 0278 3330
41010204 TRANSCATH CLOSURE ASD 10169.00 06/30/10 93580 93580 93580 032 0481 3330
41010208 TRANSCATH CLOSURE VSD 10169.00 06/30/10 93581 93581 93581 032 0481 3330
41010211 EXCHANGE EXIST CATH THROMB F/U 2124.00 06/30/10 37209 37209 37209 032 0481 3330
41010214 EXCH EXST CATH THROMB F/U S&I 4917.00 06/30/10 75900 75900 75900 032 0361 3330
41010220 ARTERIAL MECH THROMBECTOMY 5964.00 07/15/10 37184 37184 37184 032 0361 3330
41010223 VENOUS MECHANICAL THROMBECTOMY 5964.00 07/15/10 37187 37187 37187 032 0361 3330
41010226 VEN MECH THROMBECTMY(SUBS DY) 5964.00 07/15/10 37188 37188 37188 032 0361 3330
41020001 CORON ANGIOPLASTY; ONE VESSEL 6721.00 06/30/10 92982 92982 92982 36.01 032 0481 3330
41020002 CORON ANGIOPLAS EA ADDL VESSEL 4154.00 06/30/10 92984 92984 92984 86.05 032 0481 3330
41020003 CORON ATHERECTOMY; ONE VESSEL 6439.00 06/30/10 92995 92995 92995 36.09 032 0481 3330
41020004 CORON ATHERECTMY EA ADD VESSEL 5963.00 06/30/10 92996 92996 92996 36.09 032 0481 3330
41020005 INSERT INTRA-AORT BALLOON CATH 5519.00 06/30/10 33967 33967 33967 37.61 032 0481 3330
41020007 CATH EVAL IV INFUSION THERAPY 833.00 06/30/10 96365 96365 96365 032 0260 3330
41020008 IV INTRACATHETER INSERTION 155.00 06/30/10 36000 36000 36000 38.93 38.93 032 0360 3330
41020009 CENTRAL VEN CATH PLACEMNT PERC 1949.00 06/30/10 36556 36556 36556 38.95 38.95 032 0360 3330
41020012 PERICARDIOCENTESIS; INITIAL 3144.00 06/30/10 33010 33010 33010 37.0 37.0 032 0360 3330
41020013 PERICARDIOCENTESIS; W/DRAINAGE 3927.00 06/30/10 33015 33015 33015 37.12 37.12 032 0360 3330
41020015 THORACENTESIS W/TUBE 383.00 06/30/10 32421 32421 32421 34.91 34.91 032 0360 3330
41020017 THROMBOLYSIS BY INTRACOR INFUS 3470.00 06/30/10 92975 92975 92975 88.57 032 0481 3330
41020018 THROMBOLYSIS BY IV INFUSION 3470.00 06/30/10 92977 92977 92977 99.29 032 0481 3330
41020020 VALVULOPLASTY; MITRAL VALVE 6705.00 06/30/10 33420 33420 33420 35.12 35.12 032 0360 3330
41020022 VALVULOPLASTY; AORTIC VALVE 8883.00 06/30/10 92986 92986 92986 35.96 032 0481 3330
41020023 VALVULOPLASTY; PULMONARY VALVE 8883.00 06/30/10 92990 92990 92990 35.96 032 0481 3330
41020024 VALVULOPLASTY, TRICUSPID 6705.00 06/30/10 93799 93799 93799 35.14 032 0480 3330
41020026 PLACE INTRACOR STENT(S)-SINGLE EXTERNAL 10/25/95 92980 92980 92980 36.06 032 0481 3330
41020027 PLACE INTRACOR STENT(S)-EA ADD EXTERNAL 10/25/95 92981 92981 92981 36.06 032 0481 3330
41020030 ATRIAL SEPTOSTOMY BLADE METHOD 10136.00 06/30/10 92993 92993 92993 35.41 032 0481 3330
41020031 ATRIAL SEPTOSTOMY BALLOON METH 9653.00 06/30/10 92992 92992 92992 35.41 032 0481 3330
41020035 CARDIOPULMONARY RESUSCITATION 1681.00 06/30/10 92950 92950 92950 99.60 032 0481 3330
41020036 CARDIOVERSION, ELECTIVE 593.00 06/30/10 92960 92960 92960 99.62 032 0481 3330
41020037 INTRA-ATRIAL PACING 745.00 06/30/10 93610 93610 93610 37.29 032 0480 3330
41020038 INTRAVENTRICULAR PACING 745.00 06/30/10 93612 93612 93612 37.29 032 0480 3330
41020101 EMER CORON ANGIOPL; ONE VESSEL 5902.00 06/30/10 92982 92982 92982 36.01 032 0481 3330
41020102 EMER CORON ANGIOPL ADDL VESSEL 3052.00 06/30/10 92984 92984 92984 86.05 032 0481 3330
41020112 EMER PERICARDIOCENTESIS; INIT 3144.00 06/30/10 33010 33010 33010 37.0 37.0 032 0360 3330
41020113 EMER PERICARDIOCENT W/DRAINAGE 3927.00 06/30/10 33015 33015 33015 37.12 37.12 032 0360 3330
41020116 VENOGRAPHY SUBCLAVIAN AUTO 636.00 06/30/10 36011 36011 36011 38.93 032 0360 3330
41020119 VENOGRAPHY SUBCLAVIAN UNIL I&S 707.00 06/30/10 75820 75820 75820 88.66 032 0320 3330
41020122 VENOGRAPHY CAVAL SUPERIOR 1962.00 06/30/10 75827 75827 75827 032 0320 3330
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 327
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41020125 SEL CATH PLCMT VNOUS #2 ORD LT 897.00 06/30/10 36012LT 36012LT 36012LT 032 0361 3330
41020128 VENOGRAPHY SINUS/JUG CATH 2026.00 06/30/10 75860 75860 75860 032 0320 3330
41020131 INTRO CATH SVC I & S 1974.00 06/30/10 75827 75827 75827 032 0320 3330
41020134 3D RECONSTRUCT POST PROCESSING 472.00 06/30/10 76377 76377 76377 032 0320 3330
41020137 INFUSE LYS/INFUS NON-CORON S&I 4306.00 06/30/10 75896 75896 75896TC 032 0323 3330
41020140 EXIST CATH ANGIO LYS/INFUS S&I 964.00 06/30/10 75898 75898 75898TC 032 0323 3330
41020143 ABD W/BILAT ILEOFEM LE 2513.00 06/30/10 75630 75630 75630TC 032 0323 3330
41020146 IVC FILTER PLACEMENT 3107.00 06/30/10 37620 37620 37620 032 0361 3330
41020149 IVC FILTER PLACEMENT S&I 2862.00 06/30/10 75940 75940 75940TC 032 0320 3330
41020152 TRANCATH OCCLUDPERQ NONCNS 6179.00 06/30/10 37204 37204 37204 032 0361 3330
41020155 TRANSCATH TX EMBOLIZ ANY METH 4905.00 06/30/10 75894 75894 75894 032 0320 3330
41020158 AMPLATZER PLUG 1987.00 06/30/10 032 0278 3330
41020161 ARTERIAL PUNCTURE 95.00 06/30/10 36600 36600 36600 032 0361 3330
41020173 PICC LINE PLACEMENT-ADULT 1128.00 06/30/10 36569 36569 36569 032 0361 3330
41020176 FLUOROSCOPIC GUIDANCE 351.00 06/30/10 77001 77001 77001TC 032 0320 3330
41021120 PERC TRNSMECH THRMBCTMY VEIN 6906.00 05/01/10 37187 37187 37187 032 0361 3330
41030001 CARDIAC CATH LAB USAGE 2456.00 06/30/10 032 0481 3330
41030023 OMNIPAQUE 50CC 55.00 06/30/10 Q9963 Q9963 Q9963 032 0636 3330
41030026 OMNIPAQUE 100CC 89.00 06/30/10 Q9963 Q9963 Q9963 032 0636 3330
41030029 OMNIPAQUE 200CC 195.00 06/30/10 Q9963 Q9963 Q9963 032 0636 3330
41030032 VISIPAQUE 50CC 110.00 06/30/10 Q9962 Q9962 Q9962 032 0636 3330
41030035 VISIPAQUE 100CC 260.00 06/30/10 Q9962 Q9962 Q9962 032 0636 3330
41030038 VISIPAQUE 150CC 232.00 06/30/10 Q9962 Q9962 Q9962 032 0636 3330
41030053 NON-IONIC CONTRAST MEDIA 125ML 430.00 06/30/10 032 0254 3330
41030054 NON-IONIC CONTRAST 50ML 81.00 06/30/10 032 0254 3330
41030055 NON-IONIC CONTRAST 100ML 177.00 06/30/10 032 0254 3330
41030056 NON-IONIC CONTRAST 200ML 274.00 06/30/10 032 0254 3330
41030065 TRNSCTH PLC/INTRVSC STNT-P/I/V 6713.00 06/30/10 37205 37205 37205 39.50 39.50 032 0360 3330
41030066 TRNSCTH PLMT/STENT/EA ADD VESS 6713.00 06/30/10 37206 37206 37206 39.50 39.50 032 0360 3330
41030067 TRNSCTH PLT/EA ADD INTRVSC ST EXTERNAL 10/01/99 37206 37206 37206 39.50 39.50 032 0360 3330
41030068 PTA-TIBIOPERNL ART&BRNCHES(LE) 3497.00 06/30/10 35470 35470 35470 39.59 39.59 032 0360 3330
41030069 RENAL PTA (RIGHT) 5268.00 06/30/10 35471 35471 35471 39.59 39.59 032 0360 3330
41030070 PTA-AORTA 7328.00 06/30/10 35472 35472 35472 39.59 39.59 032 0360 3330
41030071 PTA-ILLIAC (RIGHT) 3937.00 06/30/10 35473 35473 35473 39.59 39.59 032 0360 3330
41030072 FEMORAL,POPLITL,TIB-FIB PTA(R) 3497.00 06/30/10 35474 35474 35474 39.59 39.59 032 0360 3330
41030073 ANGIO RENAL UNLAT SEL W/AOFLS 6468.00 06/30/10 75722 75722 75722 88.45 032 0323 3330
41030074 ANGIO RENAL BILAT SEL W/AO FLS 3425.00 06/30/10 75724 75724 75724 88.45 032 0323 3330
41030075 ABDOMEN/PELVIS ANGIO 926.00 06/30/10 36200 36200 36200 38.91 38.91 032 0360 3330
41030076 ABDOMEN/PELVIS/LOW EXT 1ST ORD 1399.00 06/30/10 36245 36245 36245 38.91 38.91 032 0360 3330
41030077 ABDOMEN/PELVIS/LOW EXT 2ND ORD 1350.00 06/30/10 36246 36246 36246 38.91 38.91 032 0360 3330
41030078 SEL RENL ANGIO 1ST ORD(L)ANGIO 1399.00 06/30/10 36245 36245 36245 38.91 032 0360 3330
41030079 AB/PEL(BIL ILC/RNL)NON SEL ANG 1602.00 06/30/10 93544 93544 93544 88.42 032 0481 3330
41030080 EXTERNAL CAROTID UNILATERAL 4007.00 06/30/10 75660 75660 75660 88.41 032 0323 3330
41030081 EXTERNAL CAROTID BILATERAL 3020.00 06/30/10 75662 75662 75662 88.41 032 0323 3330
41030082 CAROTID UNILATERAL 3622.00 06/30/10 75665 75665 75665 88.41 032 0323 3330
41030083 CAROTID BILATERAL 4007.00 06/30/10 75671 75671 75671 88.49 032 0323 3330
41030084 ILIAC PTA (LEFT) 3937.00 06/30/10 35473 35473 35473 39.59 032 0360 3330
41030085 FEMORL,POPLTEAL,TIB-FIB PTA(L) 3497.00 06/30/10 35474 35474 35474 39.59 032 0360 3330
41030089 RENAL PTA (LEFT) 5268.00 06/30/10 35471 35471 35471 39.59 032 0360 3330
41030100 COMMON CAROTID UNILATERAL I&S 3973.00 06/30/10 75676 75676 75676 88.41 032 0323 3330
41030102 VERT RT I&S 3128.00 06/30/10 75685RT 75685RT 75685TC 032 0321 3330
41030105 COMMON CAROTID BILATERAL I&S 4007.00 06/30/10 75680 75680 75680 88.41 032 0323 3330
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 328
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41030110 COMMON CAROT 1ST ORD(L) ANGIO 942.00 06/30/10 36215 36215 36215 38.91 032 0360 3330
41030115 COMMON CAROT 1ST ORD(R) ANGIO 942.00 06/30/10 36215 36215 36215 38.91 032 0360 3330
41030120 SUBCLAVIAN BILATERAL I&S 1921.00 06/30/10 75716 75716 75716 88.49 032 0323 3330
41030125 SUBCLAVIAN UNILATERAL I&S 2595.00 06/30/10 75710 75710 75710 88.49 032 0323 3330
41030127 CONTR VENOGRAPHY VIA IV CATH 334.00 06/30/10 36005 36005 36005 38.93 032 0360 3330
41030130 SUBCLAVIAN 1ST ORDER(L) ANGIO 942.00 06/30/10 36215 36215 36215 38.91 032 0360 3330
41030135 BRACHLCPH(R)SUBCLV 1ST ORD-ANG 942.00 06/30/10 36215 36215 36215 38.91 032 0360 3330
41030140 ABD/PELV(B/ILI/RNLS)NON SL.I&S 3277.00 06/30/10 75600 75600 75600 88.49 032 0323 3330
41030145 ABD/PELV SEL. ILIAC UNILAT I&S 2595.00 06/30/10 75710 75710 75710 88.49 032 0323 3330
41030150 AB/PELV SEL. ILIAC BILAT I&S 3193.00 06/30/10 75716 75716 75716 88.49 032 0323 3330
41030152 ADDITIONAL 3RD ORDER VESSEL 1552.00 06/30/10 36218RT 36218RT 36218RT 032 0361 3330
41030155 AB/PELV 2ND ORD(R) ILIAC ANGIO 1350.00 06/30/10 36246 36246 36246 38.91 032 0360 3330
41030160 AB/PELV 2ND ORD(L) ILIAC ANGIO 1350.00 06/30/10 36246 36246 36246 38.91 032 0360 3330
41030165 AB/PELVIS 3RD ORD(R)FEM ANGIO 1569.00 06/30/10 36247 36247 36247 38.91 032 0360 3330
41030170 AB/PELV 3RD ORD(L)FEMRAL ANGIO 1569.00 06/30/10 36247 36247 36247 38.91 032 0360 3330
41030171 AB/PLVS 3RD ORD BEY. FEM ANGIO 479.00 06/30/10 36248 36248 36248 38.91 032 0360 3330
41030175 SELCT PTA VESS I&S(CAR,SC,RNL) 2430.00 06/30/10 75966 75966 75966 89.04 032 0323 3330
41030180 ADD'L PTA VESSEL I&S(C,S,R) 3126.00 06/30/10 75968 75968 75968 89.04 032 0323 3330
41030182 TRANSCATH RETRVL FOR BODY I&S 3872.00 06/30/10 75961 75961 75961 032 0323 3330
41030185 LOWER EXTREMITY PTA I&S(I,F,T) 1953.00 06/30/10 75962 75962 75962 89.04 032 0323 3330
41030190 LOWER EXTREM ADD'L PTA I&S 1488.00 06/30/10 75964 75964 75964 89.04 032 0323 3330
41030193 PTA TOBIOPERITONEAL TRUNK/BRAN 3497.00 06/30/10 35470 35470 35470 032 0323 3330
41030195 CAROTID PTA (RIGHT) 4455.00 06/30/10 35475 35475 35475 39.59 032 0360 3330
41030200 CAROTID PTA (LEFT) 4455.00 06/30/10 35475 35475 35475 39.59 032 0360 3330
41030205 SUBCLAVIAN PTA (RIGHT) 3497.00 06/30/10 35472 35472 35472 39.59 032 0360 3330
41030210 SUBCLAVIAN PTA (LEFT) 3497.00 06/30/10 35472 35472 35472 39.59 032 0360 3330
41030215 INTRO CATH SUPER&INFER VEN CAV 1146.00 06/30/10 36010 36010 36010 38.93 032 0360 3330
41030220 VENOGRPHY SUPER&INFR ANG W/I&S 2009.00 06/30/10 75825 75825 75825 88.51 032 0323 3330
41030225 INTRACARDIAC ECHOCARDIOGRAPHY 4212.00 06/30/10 93662 93662 93662 032 0480 3330
41030230 DES PLACEMENT SNGL VESL EXTERNAL 10/01/04 92980 G0290 G0290 032 0481 3330
41030235 DES PLACEMENT ADD'L VESL EXTERNAL 03/01/05 G0291 032 0481 3330
41030238 IVC FILTER DEVICE 3244.00 06/30/10 C1880 C1880 C1880 032 0270 3330
41030241 VISION STENT EXTERNAL 07/01/08 C1876 C1876 C1876 032 0278 3330
41030525 CATH,INTRACARD ECHOCARDIOGRAPH EXTERNAL 06/30/08 C1759 C1759 C1759 032 0272 3330
41030531 GLIDESHEATH 107.00 06/30/10 C1894 C1894 C1894 032 0270 3330
41030546 CLOSURE DEVICE(PERCLOSE) 1177.00 06/30/10 032 0270 3330
41030548 CLOSURE DEVICE(ANGIOSEAL) 813.00 06/30/10 032 0270 3330
41030552 BALLOON CATH (CUTTING) 3588.00 06/30/10 032 0270 3330
41030555 DISTAL PROTECTION DEVICE 4002.00 06/30/10 C1884 C1884 C1884 032 0272 3330
41030558 THROMBO CATH EXTRCTN EXTERNAL 01/01/05 C1757 C1757 C1757 032 0272 3330
41030561 DES CYPHER IMPLANT STENT EXTERNAL 07/01/07 C1874 C1874 C1874 032 0278 3330
41030564 DES TAXUS IMPLANT STENT EXTERNAL 10/01/04 C1874 C1874 C1874 032 0278 3330
41030567 BM GUIDANT MULTILINK STENT EXTERNAL 03/01/05 C1876 C1876 C1876 032 0278 3330
41030570 BM SCI-MED EXPRESS EXTERNAL 03/01/05 C1877 C1877 C1877 032 0278 3330
41030573 WIRE CONTROL CATHETER 2009.00 06/30/10 C1887 C1887 C1887 032 0272 3330
41030576 BOOMERANG CLOSURE DEVICE 604.00 06/30/10 032 0270 3330
41030579 C-CLAMP COMPRESSION DISK 32.00 06/30/10 032 0270 3330
41030582 V-PAD HEMOSTASIS DISK 172.00 06/30/10 032 0270 3330
41030585 TAXUS STENT EXTERNAL 07/01/07 C1874 C1874 C1874 032 0278 3330
41030588 TAXUS STENT, ADD'L 6272.00 06/30/10 C1874 C1874 C1874 032 0278 3330
41030591 BALLOON CATH, BOSTON SCIENTFIC EXTERNAL 01/15/10 C1725 C1725 C1725 032 0272 3330
41030595 OUTBACK CATHETER 6272.00 06/30/10 032 0270 3330
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 329
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41030599 FRONTRUNNER CATHETER 3248.00 06/30/10 032 0270 3330
41030603 MICROGUIDE CATHETER 774.00 06/30/10 032 0270 3330
41030606 PROXIS PROTECTION DEVICE 4484.00 06/30/10 032 0278 3330
41030609 INFUSION CATHETER 901.00 06/30/10 032 0278 3330
41030612 ABBOTT STAINLESS STEEL STENT EXTERNAL 05/01/08 C1876 C1876 C1876 032 0278 3330
41030615 DES MEDTRONIC ENDEAVOR STENT EXTERNAL 05/01/08 C1874 C1874 C1874 032 0278 3330
41030618 MEDTRONIC SPRINTER BALLOON EXTERNAL 05/01/08 C1725 C1725 C1725 032 0272 3330
41030621 DES BOSTON SCI PROMUS STENT 8094.00 06/30/10 C1874 C1874 C1874 032 0278 3330
41030627 XIENCE CORONARY STENT 6347.00 06/30/10 C1874 C1874 C1874 032 0278 3330
41030660 IMPELLA PERC. HEART ASSIST DEV 75561.00 06/30/10 032 0278 3330
41030666 BM BSTN SCIEN VRIFLX BARE STNT 1889.00 06/30/10 C1876 C1876 C1876 032 0278 3330
41030669 BM MEDTRONIC DRIVER STENT 2101.00 06/30/10 C1876 C1876 C1876 032 0278 3330
41040203 I & S ANGIO VISCERAL SELECTIVE 3576.00 06/30/10 75726 75726 75726TC 032 0320 3330
41040206 I&S ANGIO SELECT-ADD'L VESSEL 2493.00 06/30/10 75774 75774 75774TC 032 0320 3330
41120000 ECHOCARDIOGRAPHY-COMPLETE N/C 06/30/10 032 0483 3331
41120001 ECHOCARDIO 2D M-MODE; COMPLETE 1043.00 06/30/10 93307 93307 93307 88.72 032 0480 3331
41120002 DOPPLER ECHOCARDIO; COMPLETE 687.00 06/30/10 93320 93320 93320 88.72 032 0480 3331
41120003 DOPPLER COLOR FLOW VEL MAPPING 213.00 06/30/10 93325 93325 93325 88.72 032 0480 3331
41120010 ECHOCARDIO PORTABLE-COMPLETE N/C 06/30/10 032 0483 3331
41120011 ECHOCARDIO PORTABLE; COMPLETE 1043.00 06/30/10 93307 93307 93307 88.72 032 0480 3331
41120012 DOPPLER ECHOCARDIOGRAPHY 687.00 06/30/10 93320 93320 93320 88.72 032 0480 3331
41120013 DOPPLER COLOR FLOW VEL MAPPING 251.00 06/30/10 93325 93325 93325 88.72 032 0480 3331
41120020 ECHOCARDIOGRAPHY TRANSESOPHAGL N/C 06/30/10 032 3331
41120021 ECHOCARDIO 2D M-MODE TRNSESOPH 1740.00 06/30/10 93312 93312 93312 88.72 032 0480 3331
41120022 DOPPLER ECHOCARDIOGRAPHY 687.00 06/30/10 93320 93320 93320 88.72 032 0480 3331
41120023 DOPPLER COLOR FLOW VEL MAPPING 213.00 06/30/10 93325 93325 93325 88.72 032 0480 3331
41120030 ECHO PORTABLE-TRANSESOPHAGEAL N/C 06/30/10 032 3331
41120031 ECHOCARDIO PORTABLE TRANSESOPH 1913.00 06/30/10 93312 93312 93312 88.72 032 0480 3331
41120032 DOPPLER ECHOCARDIOGRAPHY 687.00 06/30/10 93320 93320 93320 88.72 032 0480 3331
41120033 DOPPLER COLOR FLOW VEL MAPPING 251.00 06/30/10 93325 93325 93325 88.72 032 0480 3331
41120101 ECHOCARDIO 2D M-MODE; LIMITED 390.00 06/30/10 93308 93308 93308 88.72 032 0480 3331
41120102 DOPPLER ECHOCAR;F/U OR LIMITED 456.00 06/30/10 93321 93321 93321 88.72 032 0480 3331
41120107 ECHOCARDIO DURING STRESS TEST 1317.00 06/30/10 93350 93350 93350 88.72 032 0480 3331
41120108 STRESS DOBUTAMINE 1317.00 06/30/10 93350 93350 93350 88.72 032 0480 3331
41120109 CARDIOVASCULAR STRESS TEST 680.00 06/30/10 93017 93017 93017 89.44 032 0482 3331
41120111 PULSE OXIMETRY; MULT DETERMIN 188.00 06/30/10 94761 94761 94761 89.38 032 0460 3331
41120115 IV INSERTION 155.00 06/30/10 36000 36000 36000 38.93 38.93 032 0360 3331
41120120 CONSCIOUS SEDATION 428.00 06/30/10 99144 99144 99144 89.68 032 0370 3331
41120180 CONTRAST INJ OPTISON/PER ML 155.00 06/30/10 Q9956 Q9956 Q9956 032 0636 3331
41120185 DEFINITY INJ, 1ML 321.00 06/30/10 Q9957 Q9957 Q9957 032 0636 3331
41120214 FETAL 2D LIMITED 526.00 06/30/10 76826 76826 76826 032 0402 3331
41120217 FETAL DOPPLER LIMITED 400.00 06/30/10 76828 76828 76828 032 0402 3331
41120220 CARDIOVERSION, ELECTIVE 2171.00 06/30/10 92960 92960 92960 032 0480 3331
41120223 ECHO TTE COMPLETE 1317.00 06/30/10 93306 93306 93306 032 0483 3331
41120226 ECHO TTE COMPLETE PORTABLE 1317.00 06/30/10 93306 93306 93306 032 0483 3331
41210001 CT CORONARY CALCIFICATN STUDY 246.00 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210002 CARDIAC CT WITHOUT CONTRAST 1602.00 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210003 CARDIAC CT WITH CONTRAST 1606.00 06/30/10 71260 71260 71260 87.41 032 0352 3332
41210004 HCA CORONARY CALCIFICATN STUDY EXTERNAL 11/01/96 71250 71250 71250 87.41 032 0352 3332
41210007 CINE RADIOGRAPHY 73.00 06/30/10 76125 76125 76125 88.45 032 0320 3332
41210008 CARDIOVASC STRESS TEST-BICYCLE 150.00 06/30/10 93017 93017 93017 89.44 032 0482 3332
41210009 ORGAN BLOOD FLOW STUDY 82.00 06/30/10 76499 76499 76499 88.39 032 0320 3332
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 330
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41210010 CT HEAD OR BRAIN W/O CONTRAST 846.00 06/30/10 70450 70450 70450 87.03 032 0351 3332
41210011 CT HEAD OR BRAIN WITH CONTRAST 825.00 06/30/10 70460 70460 70460 87.03 032 0351 3332
41210012 CT ABDOMEN; WITHOUT CONTRAST 228.00 06/30/10 74150 74150 74150 88.01 032 0352 3332
41210013 CT ABDOMEN; WITH CONTRAST 1477.00 06/30/10 74160 74160 74160 88.01 032 0352 3332
41210014 CT LUNG W/O AND W/CONTRAST 1634.00 06/30/10 71270 71270 71270 87.41 032 0350 3332
41210015 CT PELVIS W/O AND W/CONTRAST 1538.00 06/30/10 74170 74170 74170 88.01 032 0350 3332
41210016 LUNG SCAN 549.00 06/30/10 71250 71250 71250 87.41 032 0350 3332
41210017 LUNG/HEART SCREEN 678.00 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210020 PULSE OXIMETRY; MULT DETERMIN 62.00 06/30/10 94761 94761 94761 89.38 032 0460 3332
41210021 ISOVUE (150 ML) 446.00 06/30/10 032 0254 3332
41210022 ISOVUE (50 ML) 165.00 06/30/10 032 0254 3332
41210030 IV INSERTION 48.00 06/30/10 36000 36000 36000 38.93 38.93 032 0360 3332
41210031 CT HEART CALCIUM STUDY 383.00 06/30/10 75571 75571 75571TC 032 0352 3332
41210032 CT LUNG SCREEN 487.00 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210033 CT LUNG SCREEN/HEART 709.00 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210034 CT BONE DENSITY,AXIAL 147.00 06/30/10 77078 77078 77078 88.38 032 0320 3332
41210035 CT BODY SCREEN N/C E 06/30/10 032 0352 3332
41210036 CT THORAX 264.00 C 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210037 CT ABDOMEN 216.00 C 06/30/10 74150 74150 74150 87.41 032 0352 3332
41210038 CT PELVIS 216.00 C 06/30/10 72192 72192 72192 88.38 032 0350 3332
41210039 CT BODY SCREEN/HEART N/C E 06/30/10 032 0352 3332
41210040 CT THORAX 383.00 C 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210041 CT ABDOMEN 200.00 C 06/30/10 74150 74150 74150 88.01 032 0352 3332
41210042 CT PELVIS 200.00 C 06/30/10 72192 72192 72192 88.38 032 0350 3332
41210043 CT BODY/HEART/BONE DENSITY N/C E 06/30/10 032 0352 3332
41210044 CT THORAX 383.00 C 06/30/10 71250 71250 71250 87.41 032 0352 3332
41210045 CT ABDOMEN 200.00 C 06/30/10 74150 74150 74150 88.01 032 0352 3332
41210046 CT PELVIS 200.00 C 06/30/10 72192 72192 72192 88.38 032 0350 3332
41210047 CT BONE DENSITY,AXIAL 108.00 C 06/30/10 77078 77078 77078 88.38 032 0320 3332
41210060 MEDICARE CT HEART CALCIUM HCA 503.00 06/30/10 75571 75571 75571TC 032 0359 3332
41210061 MDCRE CT BONE DNSITY HCA-AXIAL 168.00 06/30/10 77078 77078 77078 88.38 032 0359 3332
41210062 MEDICARE CT LUNG SCREEN HCA 549.00 06/30/10 71250 71250 71250 87.41 032 0359 3332
41210063 MEDICARE CT BODY SCREEN HCA N/C E 06/30/10 032 0359 3332
41210064 MEDICARE CT THORAX HCA 315.00 C 06/30/10 71250 71250 71250 87.41 032 0359 3332
41210065 MEDICARE CT ABDOMEN HCA 257.00 C 06/30/10 74150 74150 74150 88.01 032 0359 3332
41210066 MEDICARE CT PELVIS HCA 228.00 C 06/30/10 72192 72192 72192 88.38 032 0359 3332
41210067 MEDICARE CT/HEART LUNG HCA N/C E 06/30/10 032 0359 3332
41210068 MEDICARE CT HEART CALCIUM HCA 415.00 C 06/30/10 75571 75571 75571TC 032 0359 3332
41210069 MEDICARE CT THORAX SCREEN 452.00 C 06/30/10 71250 71250 71250 87.41 032 0359 3332
41210070 MEDICARE BODY/HEART SCREEN HCA N/C E 06/30/10 032 0359 3332
41210071 MEDICARE CT HEART CALCIUM HCA 256.00 C 06/30/10 75571 75571 75571TC 032 0359 3332
41210072 MEDICARE CT THORAX SCREEN HCA 278.00 C 06/30/10 71250 71250 71250 87.41 032 0359 3332
41210073 MEDICARE CT ABDOMEN SCREEN HCA 228.00 C 06/30/10 74150 74150 74150 88.01 032 0359 3332
41210074 MEDICARE CT PELVIS SCREEN HCA 228.00 C 06/30/10 72192 72192 72192 88.38 032 0359 3332
41210075 MEDICARE CT HEART/BDY/BONE DEN N/C E 06/30/10 032 0359 3332
41210076 MEDICARE CT HEART CALCIUM HCA 256.00 C 06/30/10 75571 75571 75571TC 88.39 032 0359 3332
41210077 MEDICARE CT THORAX SCREEN HCA 278.00 C 06/30/10 71250 71250 71250 87.41 032 0359 3332
41210078 MEDICARE CT ABDOMEN SCREEN HCA 228.00 C 06/30/10 74150 74150 74150 88.41 032 0359 3332
41210079 MEDICARE CT PELVIS SCREEN HCA 228.00 C 06/30/10 72192 72192 72192 88.38 032 0359 3332
41210080 MDCRE CT BONE DNS,AXIAL-HCA 130.00 C 06/30/10 77078 77078 77078 88.38 032 0359 3332
41210082 MEDICARE CT HRT/VIRT COLONSPY N/C E 06/30/10 032 0359 3332
41210083 MEDICARE CT HEART CALCIUM 316.00 C 06/30/10 76499 76499 76499 88.39 032 0359 3332
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 331
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41210090 CONSCIOUS SEDATION 312.00 06/30/10 99144 99144 99144 89.68 032 0370 3332
41210094 MULTIPLANAR 3D RECONSTRUCTION 500.00 06/30/10 76376 76376 76376 032 0350 3332
41210100 MEDICARE HRT/BDY/BONE DENSITY N/C E 06/30/10 032 0359 3332
41210101 MEDICARE CT HEART CALCIUM 271.00 C 06/30/10 76499 76499 76499 88.39 032 0359 3332
41210102 MEDICARE THORAX HCA 366.00 C 06/30/10 71250 71250 71250 87.41 032 0359 3332
41210103 MEDICARE ABDOMEN HCA 150.00 C 06/30/10 74150 74150 74150 87.41 032 0359 3332
41210104 MEDICARE PELVIS HCA 150.00 C 06/30/10 72192 72192 72192 88.38 032 0359 3332
41210105 MDCRE CT BONE DNSITY HCA-AXIAL 136.00 C 06/30/10 77078 77078 77078 88.38 032 0359 3332
41210110 MED CT HRT/BDY VIRT COLONSCPY N/C E 06/30/10 032 0359 3332
41210111 MEDICARE CT HEART CALCIUM 271.00 C 06/30/10 76499 76499 76499 88.39 032 0359 3332
41210112 MEDICARE THORAX HCA 366.00 C 06/30/10 71250 71250 71250 87.41 032 0359 3332
41210113 MEDICARE ABDOMEN HCA 150.00 C 06/30/10 74150 74150 74150 87.41 032 0359 3332
41210114 MEDICARE PELVIS HCA 150.00 C 06/30/10 72192 72192 72192 88.38 032 0359 3332
41210200 OMNIPAQUE 50CC 41.00 06/30/10 Q9963 Q9963 Q9963 032 0636 3332
41210203 OMNIPAQUE 100CC 79.00 06/30/10 Q9963 Q9963 Q9963 032 0636 3332
41210206 OMNIPAQUE 200CC 139.00 06/30/10 Q9963 Q9963 Q9963 032 0254 3332
41210210 VISIPAQUE 50CC 96.00 06/30/10 Q9962 Q9962 Q9962 032 0636 3332
41210213 VISIPAQUE 100CC 179.00 06/30/10 Q9962 Q9962 Q9962 032 0636 3332
41210216 VISIPAQUE 200CC 266.00 06/30/10 Q9962 Q9962 Q9962 032 0636 3332
41210300 ADIPOSE SLICE MEASUREMENT 172.00 06/30/10 74150 74150 74150 032 0359 3332
41310001 EPS ARTERIAL CATH PERCUTANEOUS 618.00 06/30/10 36620 36620 36620 38.91 38.91 032 0360 3330
41310002 EP EVAL RT HT W ARRHYTH INDUCT 9373.00 06/30/10 93620 93620 93620 37.26 032 0480 3333
41310004 COMPREHEN EPS STUDY; LV RECORD 7624.00 06/30/10 93622 93622 93622 37.26 032 0480 3333
41310005 INTRA-ATRIAL PACING 2323.00 06/30/10 93610 93610 93610 37.29 032 0480 3333
41310006 INTRA-ATRIAL RECORDING 2323.00 06/30/10 93602 93602 93602 37.29 032 0480 3333
41310007 INTRAVENTRICULAR PACING 2323.00 06/30/10 93612 93612 93612 37.29 032 0480 3333
41310008 RIGHT VENTRICULAR RECORDING 2323.00 06/30/10 93603 93603 93603 37.29 032 0480 3333
41310009 LEFT VENTRICULAR RECORDING 2323.00 06/30/10 93622 93622 93622 37.29 032 0480 3333
41310010 BUNDLE OF HIS RECORDING 2323.00 06/30/10 93600 93600 93600 37.29 032 0480 3333
41310011 INTRO OF ARRHYTHMIA W PACING 3467.00 06/30/10 93618 93618 93618 37.29 032 0480 3333
41310012 TACHYCARDIA MAPPING 7732.00 06/30/10 93609 93609 93609 37.29 032 0480 3333
41310013 INTRA-OPER CARDIAC PACING/MAP 4642.00 06/30/10 93631 93631 93631 37.29 032 0480 3333
41310014 ESOPHAGEAL RECORD ATRIAL/VENT 2694.00 06/30/10 93615 93615 93615 37.29 032 0480 3333
41310015 ESOPH REC ATRIAL/VENT W/PACING 2694.00 06/30/10 93616 93616 93616 37.29 032 0480 3333
41310016 EPS AICD LEADS EVAL (O.R.) 7259.00 06/30/10 93640 93640 93640 37.26 032 0480 3333
41310017 EPS AICD GENERATOR EVAL (O.R.) 4592.00 06/30/10 93641 93641 93641 37.29 032 0480 3333
41310018 TILT TABLE EVALUATION 1917.00 06/30/10 93660 93660 93660 37.29 032 0480 3333
41310019 AICD ANALYSIS W/O REPROGRAMMNG 269.00 06/30/10 93289 93289 93289 89.45 032 0921 3333
41310020 AICD ANALYSIS W/ REPROGRAMMING 768.00 06/30/10 93282 93282 93282 89.45 032 0921 3333
41310021 EPS AICD EVAL W/O REP(BEDSIDE) 269.00 06/30/10 93289 93289 93289 89.45 032 0921 3333
41310022 EPS AICD EVAL. W/PROG(BEDSIDE) 421.00 06/30/10 93282 93282 93282 89.45 032 0921 3333
41310030 EP EVAL RT HT W/O ARRHYTH IND 9269.00 06/30/10 93619 93619 93619 37.29 032 0480 3333
41310031 EP EVAL LT HT-COR SIN/LT ATRM 7584.00 06/30/10 93621 93621 93621 37.29 032 0480 3333
41310032 EP EVAL LT HT-LT VENTRICULAR 7584.00 06/30/10 93622 93622 93622 37.29 032 0480 3333
41310079 PULSE OXIMETRY; MULT DETERMIN 188.00 06/30/10 94761 94761 94761 89.38 032 0460 3333
41310540 LONG GUIDING SHEATH 875.00 06/30/10 032 0270 3330
41310544 SHEATH (NON-GUIDING) 55.00 06/30/10 032 0270 3330
41310548 CLOSURE DEVICE(VASOSEAL) 625.00 06/30/10 032 0270 3330
41310550 GUIDE WIRE (DIAGNOSTIC) 64.00 06/30/10 C1769 C1769 C1769 032 0272 3330
41310552 IVUS CATHETER 1779.00 06/30/10 C1753 032 0272 3330
41310556 GUIDEWIRE (SPECIALTY) 319.00 06/30/10 C1769 C1769 C1769 032 0272 3330
41310560 GUIDING CATHETER 240.00 06/30/10 C1887 C1887 C1887 032 0272 3330
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 332
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41310564 STENT COATED W/DELIVERY 3973.00 06/30/10 032 0270 3330
41310568 STENT COATED W/O DELIVERY 8095.00 06/30/10 032 0270 3330
41310572 STENT NON-COATED W/DELIVERY 3605.00 06/30/10 C1876 C1876 C1876 032 0278 3330
41310576 STENT NON-COATED W/O DELIVERY 1754.00 06/30/10 032 0270 3330
41310580 BALLON CATH 878.00 06/30/10 C1725 C1725 C1725 032 0272 3330
41310584 CATHETER THROMBOLECTMY(POSSIS) 4619.00 06/30/10 032 0270 3330
41310588 DIRECTIONAL ATHERECTOMY CATH 4016.00 06/30/10 032 0270 3330
41310595 ROTATIONAL ATHERECTOMY CATH 2705.00 06/30/10 C1724 C1724 C1724 032 0270 3330
41310599 RETRIEVAL DEVICE 664.00 06/30/10 032 0270 3330
41310601 BRACHYTHPY SD NON H/D IRID192 EXTERNAL 01/01/03 032 0270 3330
41310603 BRACHYTHERPY SEED H/D IRID 192 EXTERNAL 01/01/03 032 0270 3330
41310605 SEPTAL DEFECT IMPLANT 24024.00 06/30/10 032 0278 3330
41310697 GUIDEWIRE(RADI) 2743.00 06/30/10 032 0270 3330
41320001 EP EVAL AFTER DRUG INFUS-ACUTE 1778.00 06/30/10 93623 93623 93623 37.29 032 0480 3333
41320002 EP EVAL F/U DRUG THER-CHRONIC 6250.00 06/30/10 93624 93624 93624 37.26 032 0480 3333
41320004 ABLATION AVN FOR HEART BLOCK 11225.00 06/30/10 93650 93650 93650 37.34 032 0480 3333
41320005 ABLATION SVT, WPW & AVNRT 12742.00 06/30/10 93651 93651 93651 37.34 032 0480 3333
41320006 ABLATION VENTRICULAR TACHYCARD 15216.00 06/30/10 93652 93652 93652 37.34 032 0480 3333
41320020 CARDIOVERSION, ELECTIVE 2171.00 06/30/10 92960 92960 92960 99.62 032 0480 3333
41320021 INSERT AICD/LEADS 14503.00 06/30/10 33249 33249 33249 37.96 37.96 032 0360 3333
41320022 AICD/LEADS TEST AT INSERTION 4592.00 06/30/10 93641 93641 93641 37.29 032 0480 3333
41320023 INSERTION OF AICD 14923.00 06/30/10 33240 33240 33240 37.96 37.96 032 0360 3333
41320024 REMOVAL OF AICD/LEADS 4732.00 06/30/10 33244 33244 33244 37.99 37.99 032 0360 3333
41320027 REMOVAL OF ICD GENERATOR 4226.00 06/30/10 33241 33241 33241 032 0360 3333
41320031 INSRT/REPL TEMP PACEMAKER CATH 4435.00 06/30/10 33210 33210 33210 37.78 37.78 032 0360 3333
41320032 INS/REPL PERM PACEMAKER-ATRIAL 11008.00 06/30/10 33206 33206 33206 37.73 37.73 032 0360 3333
41320033 INS/REPL PERM PACEMAKR-VENTRIC 11008.00 06/30/10 33207 33207 33207 37.71 37.71 032 0360 3333
41320034 INS/REPL PERM PACEMKR-ATR&VENT 13132.00 06/30/10 33208 33208 33208 37.72 37.72 032 0360 3333
41320035 INS/REPL PACEMKR GEN-ATR/VENTR 8702.00 06/30/10 33212 33212 33212 37.85 37.85 032 0360 3333
41320037 INS/REPL PMKR GEN-DUAL CHAMBER 11008.00 06/30/10 33213 33213 33213 37.85 37.85 032 0360 3333
41320038 REP PACEMAKER LEAD-ATRIAL/VENT 8309.00 06/30/10 33218 33218 33218 37.75 37.75 032 0360 3333
41320039 INS/REPL/REPOS ATRL/VENTR LEAD 5838.00 06/30/10 33216 33216 33216 37.75 37.75 032 0360 3333
41320040 INS/REPL/REPOS DUAL CHMB LEADS 4910.00 06/30/10 33217 33217 33217 37.75 37.75 032 0360 3333
41320041 REV/RELOC POCKET FOR PACEMAKER 4635.00 06/30/10 33222 33222 33222 37.79 37.79 032 0360 3333
41320042 REMOVE PERM PACEMAKR GENERATOR 5279.00 06/30/10 33233 33233 33233 37.89 37.89 032 0360 3333
41320043 REMOVE ATRIAL OR VENTRIC LEADS 4791.00 06/30/10 33234 33234 33234 37.77 37.77 032 0360 3333
41320044 REMOVAL OF DUAL CHAMBER LEADS 4789.00 06/30/10 33235 33235 33235 37.77 37.77 032 0360 3333
41320047 INITIAL IMPLANT CARD RECORDER 11668.00 06/30/10 33282 33282 33282 032 0480 3333
41320050 REMOVAL OF CARD RECORDER 2166.00 06/30/10 33284 33284 33284 032 0480 3333
41320054 INTRACARD ECHO 4212.00 06/30/10 93662 93662 93662 032 0480 3333
41320060 SNGL CHMB PMKR EVAL W/O REPROG 264.00 06/30/10 93279 93279 93279 89.45 032 0921 3333
41320061 SNGL CHAMBR PMKR EVAL W REPROG 325.00 06/30/10 93286 93286 93286 89.45 032 0921 3333
41320063 DUAL CHAMBR PMKR EVAL W REPROG 379.00 06/30/10 93280 93280 93280 89.45 032 0921 3333
41320064 TRNSTELEPH EVAL SNGL CHMB PMKR 93.00 06/30/10 93293 93293 93293 89.46 032 0921 3333
41320065 TRNSTELEPH EVAL DUAL CHMB PMKR 123.00 06/30/10 93293 93293 93293 89.46 032 0921 3333
41320067 PMKR INSERT S&I 370.00 06/30/10 71090 71090 71090TC 032 0320 3333
41320070 VENOGRAPHY CORONARY SINUS 2313.00 06/30/10 75860 75860 75860 88.61 032 0323 3333
41320090 CONSCIOUS SEDATION 428.00 06/30/10 99144 99144 99144 89.68 032 0370 3333
41320100 INSERT AICD SNGL CHMB GEN 13629.00 06/30/10 33240 33240 33240 032 0360 3333
41320104 INSERT AICD DUAL CHAMB GEN 13629.00 06/30/10 33240 33240 33240 032 0360 3333
41320112 INSERT AICD DUAL CHMB & LEADS 21492.00 06/30/10 33249 33249 33249 032 0360 3333
41320230 AICD/LEADS EXTERNAL 08/19/96 032 0278 3333
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 333
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

41320231 AICD EXTERNAL 05/12/97 032 0278 3333
41320232 PACEMAKER LEAD(S) EXTERNAL 04/20/98 032 0278 3333
41320233 PERMANENT PACEMAKER GENERATOR EXTERNAL 04/20/98 032 0278 3333
41320247 INTRACARD ECHO CATHETER 10572.00 06/30/10 C1759 C1759 C1759 032 0272 3333
41320248 SUBCUTANEOUS ARRAY LEAD 7934.00 06/30/10 032 0275 3333
41320250 PACEMAKER LEAD EXTERNAL 01/01/03 C1898 C1898 C1898 032 0275 3333
41320254 SNGLE CHAMBER PACEMAKER GEN EXTERNAL 01/01/03 C1786 C1786 C1786 032 0275 3333
41320258 DUAL CHAMBER PACEMAKER GENRTR EXTERNAL 01/01/03 C1785 C1785 C1785 032 0275 3333
41320259 PACEMAKER LEAD EXTERNAL 01/01/03 032 0275 3333
41320262 AICD DUAL CHAMBER GENERATOR EXTERNAL 01/01/03 C1721 C1721 C1721 032 0275 3333
41320264 AICD SINGLE CHAMBER GENERATOR EXTERNAL 01/01/03 C1722 C1722 C1722 032 0275 3333
41320268 AICD/PACER LEAD COMBINATION EXTERNAL 01/01/03 032 0275 3333
41320269 BIVENT AICD GENERATOR EXTERNAL 05/01/03 C1882 C1882 C1882 032 0275 3333
41320270 LV CORONARY SINUS LEAD EXTERNAL 05/01/03 C1900 C1900 C1900 032 0275 3333
41320272 EP CATH DIAG(19 OR<ELECT) 2662.00 06/30/10 C1730 032 0272 3333
41320276 EP CATH DIAG(20OR<ELECT) 4696.00 06/30/10 C1731 032 0272 3333
41320280 EP DEFLECTABLE TIP DIAG CATH 2667.00 06/30/10 C1732 032 0272 3333
41320284 EP TEMPERATURE CONTROLLED CATH 8490.00 06/30/10 C2630 032 0272 3333
41320288 LONG GUIDING SHEATH 641.00 06/30/10 032 0270 3333
41320292 SHEATH (NON GUIDING) 69.00 06/30/10 032 0270 3333
41320296 CLOSURE DEVICE (VASOSEAL) 1013.00 06/30/10 032 0270 3333
41320298 AICD VENTR LEAD EXTERNAL 01/01/03 C1895 C1895 C1895 032 0275 3333
41320302 AICD ATRIAL LEAD EXTERNAL 01/01/03 032 0275 3333
41320306 CHILLI CATHETER EXTERNAL 01/01/03 032 0270 3333
41320310 ARRAY CATHETER 11664.00 06/30/10 C1732 C1732 C1732 032 0272 3333
41320315 EPS ENSITE PATCHES EXTERNAL 05/01/08 032 0270 3333
41320325 CARDIAC LOOP RECORDER DEVICE EXTERNAL 02/01/09 E0616 E0616 E0616 032 0275 3333
41320346 SHEATH(PEEL-AWAY) 129.00 06/30/10 C1892 C1892 C1892 032 0272 3333
41320350 DEVICE EP PACK 415.00 06/30/10 032 0275 3333
41320355 INSERT OF SUBCUT ARRAY LEAD 5838.00 06/30/10 33216 33216 33216 032 0360 3333
41321000 INSRT SGL CHMB PMKR GEN&ATR LD 13420.00 06/30/10 33206 33206 33206 37.73 032 0360 3333
41321005 INSRT SNGL PMKER GEN & VENT LD 13420.00 06/30/10 33207 33207 33207 37.71 032 0360 3333
41321010 INST DUAL CHMB PMKR GN W/LEADS 15971.00 06/30/10 66308 33208 33208 37.72 032 0360 3333
41321015 3-D MAPPING 7825.00 06/30/10 93613 93613 93613 032 0480 3333
41330001 EPS LAB USAGE 2338.00 06/30/10 032 0480 3333
41410001 CARDIOVASC STRESS TEST-BICYCLE 886.00 06/30/10 93017 93017 93017 89.44 032 0482 3334
41410002 CARDIOVAS STRESS TEST-TREADMLL 886.00 06/30/10 93017 93017 93017 89.44 032 0482 3334
41410005 OXYGEN UPTAKE; EXERCISE 391.00 06/30/10 94680 94680 94680 89.38 032 0460 3334
41410010 PULSE OXIMETRY; MULT DETERMIN 188.00 06/30/10 94761 94761 94761 89.38 032 0460 3334
41410015 IV INSERTION 155.00 06/30/10 36000 36000 36000 38.93 38.93 032 0360 3334
41410020 BIOLELECTRIC IMPEDANCE MEASURE 57.00 06/30/10 93799 93799 93799 032 0480 3334
41410025 PULMONARY STRESS TEST-COMPLEX 770.00 06/30/10 94621 94621 94621 032 0460 3334
03779343 LIVE KIDNEY ACQUISITION 82578.00 06/30/10 034 0811 1905
03779624 CADAVER DONOR-KIDNEY ACQUIS 82578.00 06/30/10 034 0812 1905
03779626 TRANSPORTATION FEE-KIDNEY EXTERNAL 10/01/02 034 0812 1905
12050396 NEUR AGNT,CERV/THOR,SING-M.D. 462.00 $ 06/30/09 64626 64626 64626 035 0975 2815
12700767 CT LIMITED/LOCALIZED F/UP 407.00 06/30/10 76380 76380 76380 035 0350 0622
02250021 CATHETERIZATN, URETHRA; SIMPLE 101.00 06/30/10 51701 51701 51701 57.94 57.94 036 0360 2825
02250023 COMPLEX CYSTOMETROGRAM 537.00 06/30/10 51726 51726 51726 89.22 89.22 036 0490 2825
02250024 SIMPLE UROFLOWMETRY 59.00 06/30/10 51736 51736 51736 89.24 89.24 036 0920 2825
02250025 COMPLEX UROFLOWMETRY 44.00 06/30/10 51741 51741 51741 89.24 89.24 036 0920 2825
02250026 EMG OF URETHRAL SPHINCTER 487.00 06/30/10 51785 51785 51785 89.23 89.23 036 0490 2825
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 334
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

02250027 BLADDER VOIDING PRESSURE 582.00 06/30/10 51728 51728 51728 036 0920 2825
02250028 INTRA-ABDOMINAL VOIDING PRESS 442.00 06/30/10 51797 51797 51797 89.29 89.29 036 0920 2825
02250035 BLOOD; OCCULT FECES SCREENING 38.00 06/30/10 82270 82270 82270 036 0301 2825
02250036 URINALYSIS; W/O MICROSCOPY 40.00 06/30/10 81002 81002 81002 036 0300 2825
02250037 URINALYSIS; BACTERIURIA SCREEN 41.00 06/30/10 81007 81007 81007 036 0300 2825
03704144 FACIAL NERVE FUNCTION STUDIES 252.00 06/30/10 92516 92516 92516 036 0471 4310
03704148 BASIC VESTIBULAR EVALUATION 259.00 06/30/10 92540 92540 92540 036 0471 4310
03704150 SPONTANEOUS NYSTAGMUS TEST 164.00 06/30/10 92541 92541 92541 036 0471 4310
03704168 POSITIONAL NYSTAGMUS TEST 164.00 06/30/10 92542 92542 92542 036 0471 4310
03704176 CALORIC VESTIBULAR TEST 259.00 06/30/10 92543 92543 92543 036 0471 4310
03704184 OPTOKINETIC NYSTAGMUS TEST 186.00 06/30/10 92544 92544 92544 036 0471 4310
03704192 OSCILLATING TRACKING TEST 164.00 06/30/10 92545 92545 92545 036 0471 4310
03704196 USE OF VERTICAL ELECTRODES 117.00 06/30/10 92547 92547 92547 036 0471 4310
03704198 COMPUTRIZED DYNMIC POSTUROGRPH 287.00 06/30/10 92548 92548 92548 036 0471 4310
03762992 VIS EVOK RSP ELECTROCULGR 442.00 06/30/10 92275 92275 92275 036 0920 4509
03775952 ELECTRORET VER CO 442.00 06/30/10 92275 92275 92275 036 0920 4509
03777008 VIS EVOKED RESP 215.00 06/30/10 95930 95930 95930 036 0922 4509
03779871 ELECTRORETINOGRAM 270.00 06/30/10 92275 92275 92275 036 0920 4509
03779889 ELECTRO-OCCULOGRAM 270.00 06/30/10 92270 92270 92270 036 0920 4509
03779897 ELECTRORET-OCULO CO 442.00 06/30/10 92275 92275 92275 036 0920 4509
03780176 DOLOR VISION TEST 123.00 06/30/10 92283 92283 92283 036 0920 4509
03780184 DARK ADAPTATION 204.00 06/30/10 92284 92284 92284 036 0920 4509
04010770 FRAGILE X SYNDROME N/C E 06/30/10 036 0301 2608
04010771 ISOLATION (PCR) 83.00 C 06/30/10 83891 83891 83891 036 0301 2608
04010772 ISOLATION/EXTRACTION 83.00 C 06/30/10 8389191 8389191 8389191 036 0301 2608
04010773 ENZYMATIC DIGESTION, EACH 83.00 C 06/30/10 83892 83892 83892 036 0301 2608
04010774 ENZYMATIC DIGESTION, EACH 83.00 C 06/30/10 8389291 8389291 8389291 036 0301 2608
04010775 GEL SEPARATION 83.00 C 06/30/10 83894 83894 83894 036 0301 2608
04010776 CAPILLARY ELECTROPHORESIS 83.00 C 06/30/10 83894 83894 83894 036 0301 2608
04010777 NUCLEIC ACID PROBE, EACH 83.00 C 06/30/10 83896 83896 83896 036 0301 2608
04010778 NUCLEIC ACID TRANSFER 83.00 C 06/30/10 83897 83897 83897 036 0301 2608
04010779 AMPLIFICATION, EACH 83.00 C 06/30/10 83898 83898 83898 036 0301 2608
04082001 ANGELMAN SYND METHYLAT PCR N/C 06/30/10 036 0301 2608
04082330 BCL2/IGH N/C E 06/30/10 036 0301 2651
04082331 BCL2 ISOLATION/EXTRACTION 149.00 C 06/30/10 83891 83891 838912H 036 0301 2651
04082332 BCL2 SEPARATION GEL ELECT#1 174.00 C 06/30/10 83894 83894 838942H 036 0301 2651
04082333 BCL2 SEPARATION GEL ELECT#2 174.00 C 06/30/10 8389491 8389491 838942H 036 0301 2651
04082334 BCL2 AMPLI NUCLEIC ACID #1 148.00 C 06/30/10 83898 83898 838982H 036 0301 2651
04082335 BCL2 AMPLI NUCLEIC ACID #2 148.00 C 06/30/10 8389891 8389891 838982H 036 0301 2651
04082336 BCL2 AMPLI NUCLEIC ACID #3 148.00 C 06/30/10 8389891 8389891 838982H 036 0301 2651
04082337 BCL2 AMPLI NUCLEIC ACID #4 148.00 C 06/30/10 8389891 8389891 838982H 036 0301 2651
04082338 BCL2 AMPLI NUCLEIC ACID #5 148.00 C 06/30/10 8389891 8389891 838982H 036 0301 2651
04082340 BCR/ABL P190 N/C E 06/30/10 036 0301 2651
04082341 P190 ISOLATION/EXTRACTION 152.00 C 06/30/10 83891 83891 838912B 036 0301 2651
04082342 P190 REVERSE TRANSCRIPTION 120.00 C 06/30/10 83902 83902 839022B 036 0301 2651
04082343 P190 SEPARATION GEL ELECT#1 178.00 C 06/30/10 83894 83894 838942B 036 0301 2651
04082344 P190 SEPARATION GEL ELECT#2 178.00 C 06/30/10 8389491 8389491 838942B 036 0301 2651
04082345 P190 AMPLI NUCLEIC ACID #1 152.00 C 06/30/10 83898 83898 838982B 036 0301 2651
04082346 P190 AMPLI NUCLEIC ACID #2 152.00 C 06/30/10 8389891 8389891 838982B 036 0301 2651
04082347 P190 AMPLI NUCLEIC ACID #3 152.00 C 06/30/10 8389891 8389891 838982B 036 0301 2651
04082350 BCR/ABL P210 N/C E 06/30/10 036 0301 2651
04082351 P210 ISOLATION/EXTRACTION 152.00 C 06/30/10 83891 83891 838912B 036 0301 2651
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 335
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04082352 P210 REVERSE TRANSCRIPTION 120.00 C 06/30/10 83902 83902 839022B 036 0301 2651
04082353 P210 SEPARATION GEL ELECT #1 178.00 C 06/30/10 83894 83894 838942B 036 0301 2651
04082354 P210 SEPARATION GEL ELECT #2 178.00 C 06/30/10 8389491 8389491 838942B 036 0301 2651
04082355 P210 AMPLI NUCLEIC ACID #1 152.00 C 06/30/10 83898 83898 83898 036 0301 2651
04082356 P210 AMPLI NUCLEIC ACID #2 152.00 C 06/30/10 8389891 8389891 838982B 036 0301 2651
04082357 P210 AMPLI NUCLEIC ACID #3 152.00 C 06/30/10 8389891 8389891 838982B 036 0301 2651
04082360 PML/RAR ALPHA N/C E 06/30/10 036 0301 2651
04082361 PML ISOLATION/EXTRACTION 152.00 C 06/30/10 83891 83891 838912F 036 0301 2651
04082362 PML REVERSE TRANSCRIPTION 120.00 C 06/30/10 83902 83902 839022F 036 0301 2651
04082363 PML SEPARATION GEL ELECT#1 178.00 C 06/30/10 83894 83894 838942F 036 0301 2651
04082364 PML SEPARATION GEL ELECT#2 178.00 C 06/30/10 8389491 8389491 838942F 036 0301 2651
04082365 PML AMPLI NUCLEIC ACID #1 152.00 C 06/30/10 83898 83898 838982F 036 0301 2651
04082366 PML AMPLI NUCLEIC ACID #2 152.00 C 06/30/10 8389891 8389891 838982F 036 0301 2651
04082367 PML AMPLI NUCLEIC ACID #3 152.00 C 06/30/10 8389891 8389891 838982F 036 0301 2651
04082370 AML1/ETO N/C E 06/30/10 036 0301 2651
04082371 AML1 ISOLATION/EXTRACTION 152.00 C 06/30/10 83891 83891 838912A 036 0301 2651
04082372 AML REVERSE TRANSCRIPTION 120.00 C 06/30/10 83902 83902 839022A 036 0301 2651
04082373 AML SEPARATION GEL ELECT#1 178.00 C 06/30/10 83894 83894 838942A 036 0301 2651
04082374 AML SEPARATION GEL ELECT#2 178.00 C 06/30/10 8389491 8389491 838942A 036 0301 2651
04082375 AML1 AMPLI NUCLEIC ACID#1 152.00 C 06/30/10 83898 83898 838982A 036 0301 2651
04082376 AML1 AMPLI NUCLEIC ACID#2 152.00 C 06/30/10 8389891 8389891 838982A 036 0301 2651
04082377 AML1 AMPLI NUCLEIC ACID#3 152.00 C 06/30/10 8389891 8389891 838982A 036 0301 2651
04082380 CBF BETA/MYH11 N/C E 06/30/10 036 0301 2651
04082381 CBF ISOLATION/EXTRACTION 152.00 C 06/30/10 83891 83891 838912D 036 0301 2651
04082382 CBF REVERSE TRANSCRIPTION 120.00 C 06/30/10 83902 83902 839022D 036 0301 2651
04082383 CBF SEPARATION GEL ELECT#1 178.00 C 06/30/10 83894 83894 838942D 036 0301 2651
04082384 CBF SEPARATION GEL ELECT#2 178.00 C 06/30/10 8389491 8389491 838942D 036 0301 2651
04082385 CBF AMPLI NUCLEIC ACID#1 152.00 C 06/30/10 83898 83898 838982D 036 0301 2651
04082386 CBF AMPLI NUCLEIC ACID#2 152.00 C 06/30/10 8389891 8389891 838982D 036 0301 2651
04082387 CBF AMPLI NUCLEIC ACID#3 152.00 C 06/30/10 8389891 8389891 838982D 036 0301 2651
04082450 FACTOR V LEIDEN MUTATION N/C E 06/30/10 036 0301 2651
04082451 FVL-ISOLATION/EXTRACTION 220.00 C 06/30/10 83891 83891 83891 036 0301 2651
04082452 FVL-AMPLIFICATION, EACH 248.00 C 06/30/10 83898 83898 83898 036 0301 2651
04082453 FVL-MUT ID BY ASPE 73.00 C 06/30/10 83914 83914 83914 036 0301 2651
04082454 FVL-NUCLEIC ACID PROBE #2 89.00 06/30/10 8389691 8389691 83896 036 0301 2651
04082455 FVL-MUTATION SCANNING #1 101.00 06/30/10 83903 83903 83903 036 0301 2651
04082456 FVL-MUTATION SCANNING #2 101.00 06/30/10 8390391 8390391 83903 036 0301 2651
04082460 PROTHROMBIN G20210A MUTATION N/C E 06/30/10 036 0301 2651
04082461 G2-ISOLATION/EXTRACTION 217.00 C 06/30/10 83891 83891 83891 036 0301 2651
04082462 G2-AMPLIFICATION, EACH 246.00 C 06/30/10 83898 83898 83898 036 0301 2651
04082463 G2-MUT ID BY ASPE 73.00 C 06/30/10 83914 83914 83914 036 0301 2651
04082464 G2-NUCLEIC ACID PROBE #2 89.00 06/30/10 8389691 8389691 83896 036 0301 2651
04082465 G2-MUTATION SCANNING #1 101.00 06/30/10 83903 83903 83903 036 0301 2651
04082466 G2-MUTATION SCANNING #2 101.00 06/30/10 8390391 8390391 83903 036 0301 2651
04082470 THERMOLABILE MTHFR(C677T) N/C E 06/30/10 036 0301 2651
04082471 MTH-ISOLATION/EXTRACTION 145.00 C 06/30/10 83891 83891 838913F 036 0301 2651
04082472 MTH-ENZYMATIC DIGESTION 96.00 C 06/30/10 83892 83892 838923F 036 0301 2651
04082473 MTH-NUCLEIC ACID PROBE #1 89.00 C 06/30/10 83896 83896 838963F 036 0301 2651
04082474 MTH-NUCLEIC ACID PROBE #2 89.00 C 06/30/10 8389691 8389691 838963F 036 0301 2651
04082475 MTH-MUTATION SCANNING #1 101.00 C 06/30/10 83903 83903 839033F 036 0301 2651
04082476 MTH-MUTATION SCANNING #2 101.00 C 06/30/10 8390391 8390391 839033F 036 0301 2651
04082500 THERMOLABILE MTHR(A1298C) N/C E 06/30/10 036 0301 2651
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 336
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

04082501 MTH-ISOLATION/EXTRACTION 145.00 C 06/30/10 83891 83891 838913F 036 0301 2651
04082502 MTH-ENZYMATIC DIGESTION 93.00 C 06/30/10 83892 83892 838923F 036 0301 2651
04082503 MTH-NUCLEIC ACID PROBE#1 89.00 C 06/30/10 83896 83896 838963F 036 0301 2651
04082504 MTH-NUCLEIC ACID PROBE#2 89.00 C 06/30/10 8389691 8389691 838963F 036 0301 2651
04082505 MTH-MUTATION SCANNING#1 101.00 C 06/30/10 83903 83903 839033F 036 0301 2651
04082506 MTH MUTATION SCANNING#2 101.00 C 06/30/10 8390391 8390391 839033F 036 0301 2651
04082510 HBV RNA QUANT BY BDNA 589.00 06/30/10 87517 87517 87517 036 0306 2651
04082514 HCV QUAL 343.00 06/30/10 87521 87521 87521 036 0306 2608
04082520 RESP VIRUS MULTIPLEX PCR N/C 06/30/10 036 0301 2651
04082750 JAK2(V617F) MUTATION PCR N/C E 06/30/10 036 0301 2651
04082751 ISOLATION/EXTRACTION 136.00 C 06/30/10 83891 83891 83891 036 0301 2651
04082752 NUCLEIC ACID PROBE, EACH 135.00 C 06/30/10 83896 83896 83896 036 0301 2651
04082753 NUCLEIC ACID PROBE,EACH 135.00 C 06/30/10 8389691 8389691 8389691 036 0301 2651
04082754 AMPLIFICATION,MULTIPLEX,FIRST2 196.00 C 06/30/10 83900 83900 83900 036 0301 2651
04082770 MTHFR (C677T,A1298C) N/C E 06/30/10 036 0301 2651
04082771 MTHFR-ISOLATION/EXTRACTION 164.00 C 06/30/10 83891 83891 83891 036 0301 2651
04082772 MTHFR-AMPLIFICATION,1ST 2 162.00 C 06/30/10 83900 83900 83900 036 0301 2651
04082773 MTHFR-MUT ID BY ASPE, 1 162.00 C 06/30/10 83914 83914 83914 036 0301 2651
04082774 MTHFR-MUT ID BY ASPE, 2 162.00 C 06/30/10 8391491 8391491 8391491 036 0301 2651
04088858 QUANTIFERON-TB GOLD 156.00 06/30/10 86480 86480 86480 036 0301 2639
06750052 PHYS PERF TEST-EA 15MIN-M.D. 62.00 $ 06/30/09 97750 97750GP 97750GP 036 0977 0663
07230111 CIRCUMCISION; NEWBORN 256.00 06/30/10 54150 54150 54150 64.0 64.0 036 0360 0292
07230114 TRANSCUTANEOUS BILIRUBIN TEST 29.00 06/30/10 88720 88720 88720 036 0301 0292
11700032 PULSE OXIMETRY - SINGLE 99.00 06/30/10 94760 94760 94760 036 0460 3400
11700035 PULSE OXIMETRY - MULT 151.00 06/30/10 94761 94761 94761 036 0460 3400
11873445 NOCTURNAL PENILE TUMESCENCE 729.00 06/30/10 54250 54250 54250 64.19 64.19 036 0920 0518
11873452 POLYSOMNOGRAPHY/8-12 CHANNELS 2022.00 06/30/10 95810 95810 95810 89.17 036 0740 0518
11873460 POLYSOMNOGRAPHY;CPAP/BIPAP 2310.00 06/30/10 95811 95811 95811 89.17 036 0740 0518
11873465 PULSE OXIMETRY NONINVAS (CONT) 281.00 06/30/10 94762 94762 94762 89.38 036 0460 0518
11875036 MULTIPLE SLEEP LATENCY TEST 1262.00 06/30/10 95805 95805 95805 89.17 036 0740 0518
12000152 ECG W/INTERPRETATION&RPT-M.D. 46.00 $ 06/30/09 93000 93000 93000 036 0985 0520
12000153 ECG W/TRACING ONLY 207.00 06/30/10 93005 93005 93005 036 0730 0520
12000158 CARDIOVASCULAR STRESS TST-M.D. 222.00 $ 06/30/09 93015 93015 93015 036 0983 0520
12000160 CARD STRESS TST-PHY SUPER-M.D. 52.00 $ 06/30/09 93016 93016 93016 036 0985 0520
12000166 RHYTHM ECG, 1-3 LEADS-M.D. 29.00 $ 06/30/09 93040 93040 93040 036 0985 0520
12000172 ELECTROCARDIO MONITORING-M.D. 271.00 $ 06/30/09 93224 93224 93224 036 0985 0520
12000179 VITAL CAPACITY, TOTAL-HOSP 74.00 06/30/10 94150 94150 94150 036 0460 0520
12000180 VITAL CAPACITY, TOTAL-M.D. 9.00 $ 06/30/09 94150 94150 94150 036 0976 0520
12000189 PULM STRESS TESTING-SIMP-HOSP. 147.00 06/30/10 94620 94620 94620 036 0460 0520
12000190 PULM STRESS TESTING-SIMP.-M.D. 161.00 $ 09/01/09 94620 9462026 9462026 036 0976 0520
12000195 O2 UPTAKE/GAS ANALYSIS-HOSP 452.00 06/30/10 94680 94680 94680 036 0460 0520
12000196 O2 UPTAKE/GAS ANALYSIS-M.D. 26.00 $ 06/30/09 94680 9468026 9468026 036 0976 0520
12000197 END TIDAL CO2 MONITORING-HOSP 614.00 06/30/10 94681 94681 94681 036 0460 0520
12000198 END TIDAL CO2 MONITORING-M.D. 20.00 $ 06/30/09 94681 9468126 9468126 036 0976 0520
12000199 O2 UPTAKE/REST,INDIRECT-HOSP 199.00 06/30/10 94690 94690 94690 036 0460 0520
12000200 O2 UPTAKE/REST,INDIRECT-M.D. 8.00 $ 06/30/09 94690 9469026 9469026 036 0976 0520
12000203 PULSE OXIMETRY - SINGLE 99.00 06/30/10 94760 94760 94760 036 0460 0520
12000205 PULSE OXIMETRY - MULT 151.00 06/30/10 94761 94761 94761 036 0460 0520
12000229 MUSCLE TESTING (EX HAND)-HOSP 76.00 06/30/10 95831 95831 95831 036 0920 0520
12000230 MUSCLE TESTING (EX HAND)-M.D. 30.00 $ 06/30/09 95831 95831 95831 036 0983 0520
12000231 MUSCLE TESTING-(HAND)-HOSP 80.00 06/30/10 95832 95832 95832 036 0920 0520
12000233 MUSC TEST TOT EVAL-EX HND-HOSP 183.00 06/30/10 95833 95833 95833 036 0920 0520
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 337
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12000234 MUSC TEST TOT EVAL-EX HND-M.D. 50.00 $ 06/30/09 95833 95833 95833 036 0983 0520
12000235 MUSC TST TOT EVAL-INC HND-HOSP 205.00 06/30/10 95834 95834 95834 036 0920 0520
12000236 MUSC TST TOT EVAL-INC HND-M.D. 63.00 $ 06/30/09 95834 95834 95834 036 0983 0520
12000237 MOTION MEASURE-EX HAND-HOSP 71.00 06/30/10 95851 95851 95851 036 0920 0520
12000238 MOTION MEASURE-EX HAND-M.D. 17.00 $ 06/30/10 95851 95851 95851 036 0983 0520
12000239 MOTION MEASURE-(HAND)-HOSP 71.00 06/30/10 95852 95852 95852 036 0920 0520
12000240 MOTION MEASURE-(HAND)-M.D. 13.00 $ 06/30/09 95852 95852 95852 036 0983 0520
12000243 NEEDLE ELECTRO,1 EXTREM-HOSP 324.00 06/30/10 95860 95860 95860 036 0922 0520
12000244 NEEDLE ELECTRO,1 EXTREM-M.D. 105.00 $ 06/30/09 95860 9586026 9586026 036 0983 0520
12000245 NEEDLE ELECTRO,2 EXTREM-HOSP 477.00 06/30/10 95861 95861 95861 036 0922 0520
12000246 NEEDLE ELECTRO,2 EXTREM-M.D. 167.00 $ 06/30/09 95861 9586126 9586126 036 0983 0520
12000247 NEEDLE ELECTRO,3 EXTREM-HOSP 641.00 06/30/10 95863 95863 95863 036 0922 0520
12000248 NEEDLE ELECTRO,3 EXTREM-M.D. 201.00 $ 06/30/09 95863 9586326 9586326 036 0983 0520
12000249 NEEDLE ELECTRO,4 EXTREM-HOSP 1147.00 06/30/10 95864 95864 95864 036 0922 0520
12000250 NEEDLE ELECTRO,4 EXTREM-M.D. 214.00 $ 06/30/09 95864 9586426 9586426 036 0983 0520
12000252 NDLE ELECTRO,UNILAT,CRAN-M.D. 84.00 $ 06/30/09 95867 9586726 9586726 036 0983 0520
12000253 NDLE ELECTRO,BILAT,CRAN.-HOSP. 896.00 06/30/10 95868 95868 95868 036 0922 0520
12000254 NDLE ELECTRO,BILAT,CRAN.-M.D. 126.00 $ 06/30/09 95868 9586826 9586826 036 0983 0520
12000255 NEEDLE ELECTRO,LTD STUDY-HOSP 254.00 06/30/10 95869 95869 95869 036 0922 0520
12000256 NEEDLE ELECTRO,LTD STUDY-M.D. 40.00 $ 06/30/09 95869 9586926 9586926 036 0983 0520
12000261 ISCHEMIC LIMB EXERCISE-HOSP 126.00 06/30/10 95875 95875 95875 036 0922 0520
12000262 ISCHEMIC LIMB EXERCISE-M.D. 117.00 $ 06/30/09 95875 9587526 9587526 036 0983 0520
12000263 NRVE CONDUCT W/OUT F-WAVE-HOSP 55.00 06/30/10 95900 95900 95900 036 0922 0520
12000264 NRVE CONDUCT W/OUT F-WAVE-M.D. 46.00 $ 06/30/09 95900 9590026 9590026 036 0983 0520
12000265 NRVE CONDUCT WITH F-WAVE-HOSP 321.00 06/30/10 95903 95903 95903 036 0922 0520
12000266 NRVE CONDUCT WITH F-WAVE-M.D. 64.00 $ 06/30/09 95903 9590326 9590326 036 0983 0520
12000267 NRVE CONDUCTION-SENSORY-HOSP 244.00 06/30/10 95904 95904 95904 036 0922 0520
12000268 NRVE CONDUCTION-SENSORY-M.D. 37.00 $ 06/30/09 95904 9590426 9590426 036 0983 0520
12000283 BLINK REFLEX-HOSP 308.00 06/30/10 95933 95933 95933 036 0920 0520
12000284 BLINK REFLEX-M.D. 65.00 $ 06/30/10 95933 9593326 9593326 036 0986 0520
12000285 H-RFLX STDY-GASTROCNEMIUS-HOSP 239.00 06/30/10 95934 95934 95934 036 0922 0520
12000286 H-RFLX STDY-GASTROCNEMIUS-M.D. 55.00 $ 06/30/09 95934 9593426 9593426 036 0986 0520
12000287 H-RFLX OTHR THAN GASTRO-HOSP. 273.00 06/30/10 95936 95936 95936 036 0922 0520
12000288 H-RFLX OTHR THAN GASTRO-M.D. 60.00 $ 06/30/09 95936 9593626 9593626 036 0986 0520
12000289 NEUROMUSCULAR JUNCT TEST-HOSP 277.00 06/30/10 95937 95937 95937 036 0922 0520
12000290 NEUROMUSCULAR JUNCT TEST-M.D. 76.00 $ 06/30/09 95937 9593726 9593726 036 0986 0520
12000302 APP SURF NEUROSTIMULATOR-M.D. 19.00 $ 06/30/09 64550 64550 64550 036 0975 0520
12000329 STIM EVOKED RESP URIN-HOSP 513.00 06/30/10 51792 51792 51792 036 0920 0520
12000330 STIM EVOKED RESP URIN-M.D. 124.00 $ 06/30/09 5179226 5179226 5179226 036 0982 0520
12000350 APP OF MOD-HOT/COLD PACKS-M.D. 11.00 $ 06/30/09 97010 97010GP 97010GP 036 0977 0520
12000360 APP OF MOD-ELECTR STIM-M.D. 35.00 $ 06/30/09 97032 97032GP 97032GP 036 0977 0520
12000369 PHYS MED EXERC EA 15 MIN-HOSP 42.00 06/30/10 97110 97110GP 97110GP 036 0420 0520
12000370 PHYS MED EXERC EA 15 MIN-M.D. 60.00 $ 08/10/08 97110 97110GP 97110GP 036 0977 0520
12000372 NEUROMUSCULAR REEDUCATION-M.D. 61.00 $ 06/30/09 97112 97112GP 97112GP 036 0977 0520
12000374 AQUATIC THERAPY-M.D. 73.00 $ 06/30/09 97113 97113GP 97113GP 036 0977 0520
12000375 GAIT TRAINING-HOSP 33.00 06/30/10 97116 97116GP 97116GP 036 0420 0520
12000376 GAIT TRAINING-M.D. 52.00 $ 06/30/09 97116 97116GP 97116GP 036 0977 0520
12000389 ORTHOTICS TRNING-EA 15MIN-HOSP 86.00 06/30/10 97760 97760GP 97760GP 036 0977 0520
12000390 ORTHOTICS TRNING-EA 15MIN-M.D. 69.00 $ 06/30/09 97760 97760GP 97760GP 036 0977 0520
12000393 THERAPEUTIC ACTIVITIES-HOSP 40.00 06/30/10 97530 97530GP 97530GP 036 0420 0520
12000394 THERAPEUTIC ACTIVITIES-M.D. 63.00 $ 06/30/09 97530 97530GP 97530GP 036 0977 0520
12000396 SELF CARE/HOME MANAGEMNT-M.D. 63.00 $ 06/30/09 97535 97535GP 97535GP 036 0977 0520
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 338
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12000398 COMMUNITY/WORK REINTEGRAT-M.D. 56.00 $ 06/30/09 97537 97537GO 97537GO 036 0978 0520
12000400 WHEELCHAIR MANAGEMENT-M.D. 57.00 $ 06/30/09 97542 97542GP 97542GP 036 0977 0520
12000401 WORK CONDITIONING;INIT 2HRS 384.00 06/30/10 97545 97545GP 97545GP 036 0420 0520
12000403 WORK CONDITION;EA ADD HR 155.00 06/30/10 97546 97546GP 97546GP 036 0420 0520
12000405 ORTHO/PROSTH CHECKOUT-HOSP 38.00 06/30/10 97762 97762GP 97762GP 036 0420 0520
12000406 ORTHO/PROSTH CHECKOUT-M.D. 72.00 $ 06/30/09 97762 97762GP 97762GP 036 0977 0520
12000408 PHYS PERF TEST-EA 15MIN-M.D. 62.00 $ 06/30/09 97750 97750GP 97750GP 036 0977 0520
12000410 DEVELOP COGNITIVE SKILLS-M.D. 51.00 $ 06/30/09 97532 97532 97532 036 0977 0520
12000415 OMT; 1-2 BODY REGIONS-HOSP 47.00 06/30/10 98925 98925 98925 036 0530 0520
12000416 OMT; 1-2 BODY REGIONS-M.D. 46.00 $ 06/30/09 98925 98925 98925 036 0983 0520
12000417 OMT; 3-4 BODY REGIONS-HOSP 68.00 06/30/10 98926 98926 98926 036 0530 0520
12000418 OMT; 3-4 BODY REGIONS-M.D. 68.00 $ 06/30/09 98926 98926 98926 036 0530 0520
12000419 OMT; 5-6 BODY REGIONS-HOSP 71.00 06/30/10 98927 98927 98927 036 0530 0520
12000420 OMT; 5-6 BODY REGIONS-M.D. 88.00 $ 06/30/09 98927 98927 98927 036 0530 0520
12000421 OMT; 7-8 BODY REGIONS-HOSP 74.00 06/30/10 98928 98928 98928 036 0530 0520
12000422 OMT; 7-8 BODY REGIONS-M.D. 104.00 $ 06/30/09 98928 98928 98928 036 0530 0520
12000423 OMT; 9-10 BODY REGIONS-HOSP 72.00 06/30/10 98929 98929 98929 036 0530 0520
12000424 OMT; 9-10 BODY REGIONS-M.D. 121.00 $ 06/30/09 98929 98929 98929 036 0530 0520
12000499 INJECTION, LIGAMENT-HOSP 186.00 06/30/10 20550 20550 20550 036 0360 0520
12000500 INJECTION, LIGAMENT-M.D. 89.00 $ 06/30/09 20550 20550 20550 036 0975 0520
12000501 ARTHROCENTESIS-SMALL JNT-HOSP 144.00 06/30/10 20600 20600 20600 036 0360 0520
12000502 ARTHROCENTESIS-SMALL JNT-M.D. 85.00 $ 06/30/09 20600 20600 20600 036 0975 0520
12000503 ARTHROCENTESIS,INTERMED-HOSP 133.00 06/30/10 20605 20605 20605 036 0360 0520
12000504 ARTHROCENTESIS,INTERMED-M.D. 88.00 $ 06/30/09 20605 20605 20605 036 0975 0520
12000505 ARTHROCENTESIS,MAJOR-HOSP 440.00 06/30/10 20610 20610 20610 036 0360 0520
12000506 ARTHROCENTESIS,MAJOR-M.D. 107.00 $ 06/30/09 20610 20610 20610 036 0975 0520
12000549 NEUROPLASTY; HAND OR FOOT-HOSP 1754.00 06/30/10 64704 64704 64704 036 0360 0520
12000550 NEUROPLASTY; HAND OR FOOT-M.D. 690.00 $ 06/30/09 64704 64704 64704 036 0975 0520
12000605 SYNVISC INJ 1 MG. 1116.00 06/30/10 J7325 J7325 J7325 036 0636 0520
12000611 BLOOD GLUCOSE 44.00 06/30/10 82962 82962 82962 036 0301 0520
12000625 LACTIC ACID 94.00 06/30/10 83605 83605 83605 036 0301 0520
12000630 ARISTOSPAN 20MG/ML,PER 5MG 25.00 06/30/10 J3303 036 0636 0520
12000633 ARISTOCORT 40MG/ML,PER 5MG 15.00 06/30/10 J3302 036 0636 0520
12000636 LIDOCAINE 1% OR 2% 7.00 06/30/10 036 0250 0520
12000639 MEPIVICAINE HCL 10ML 10.00 06/30/10 J0670 036 0636 0520
12000642 METHYLPREDNISOLONE 20MG 10.00 06/30/10 J1020 036 0636 0520
12000701 PSYCH DIAG INTERVIEW EXAM-HOSP 142.00 06/30/10 90801 90801 90801 036 0914 0520
12000702 PSYCH DIAG INTERVIEW EXAM-M.D. 269.00 $ 06/30/09 90801 90801 90801 036 0961 0520
12000707 IND PSYCH W/E&M 20-30MIN-HOSP 85.00 06/30/10 90805 90805 90805 036 0914 0520
12000708 IND PSYCH W/E&M 20-30MIN-M.D. 128.00 $ 06/30/09 90805 90805 90805 036 0961 0520
12000711 IND PSYCH W/E&M 45-50MIN-HOSP 114.00 06/30/10 90807 90807 90807 036 0914 0520
12000712 IND PSYCH W/E&M 45-50MIN-M.D. 190.00 $ 06/30/09 90807 90807 90807 036 0961 0520
12000715 FAMILY MED PSYCHOTHERAPY-HOSP 98.00 06/30/10 90846 90846 90846 036 0916 0520
12000716 FAMILY MED PSYCHOTHERAPY-M.D. 179.00 $ 06/30/09 90846 90846 90846 036 0961 0520
12000721 GROUP MED PSYCHOTHERAPY-HOSP 73.00 06/30/10 90853 90853 90853 036 0915 0520
12000722 GROUP MED PSYCHOTHERAPY-M.D. 61.00 $ 06/30/09 90853 90853 90853 036 0961 0520
12000745 DEVELOPMENTAL TESTING 310.00 06/30/10 96110 96110 96110 036 0918 0520
12000749 NEURO BEHAVIORAL EXAM 778.00 06/30/10 96116 96116 96116 036 0918 0520
12000761 PSYCH TEST BY PSYCH-PHYS 159.00 06/30/10 96101 96101 96101 036 0918 0520
12000763 PSYCH TEST BY TECHNICIAN 476.00 06/30/10 96102 96102 96102 036 0918 0520
12000765 PSYCH TST ADMIN BY COMPUT 176.00 06/30/10 96103 96103 96103 036 0918 0520
12000767 NEUROPSY TST -PSYC-PHYS PER HR 200.00 06/30/10 96118 96118 96118 036 0918 0520
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 339
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12000769 NEUROPSY TST -TECHN PER HR 475.00 06/30/10 96119 96119 96119 036 0918 0520
12000771 NEUROPSY TST ADMIN W/COMP 176.00 06/30/10 96120 96120 96120 036 0918 0520
12050101 LUMBAR PUNCTURE/DIAG-HOSP 257.00 06/30/10 62270 62270 62270 036 0360 2815
12050102 LUMBAR PUNCTURE/DIAG-M.D. 158.00 $ 06/30/09 62270 62270 62270 036 0975 2815
12050309 SINGLE EPID INJ-CERV/THOR-HOSP 682.00 06/30/10 62310 62310 62310 036 0360 2815
12050310 SINGLE EPID INJ.-CERV/THOR-M.D 206.00 $ 06/30/09 62310 62310 62310 036 0975 2815
12050311 SINGLE EPID INJ-LUMB/SACR-HOSP 676.00 06/30/10 62311 62311 62311 036 0360 2815
12050312 SINGLE EPI INJ-LUMB/SACRO-M.D. 170.00 $ 06/30/09 62311 62311 62311 036 0975 2815
12050317 EPIDURAL CATH-CERV/THORA-HOSP. 776.00 06/30/10 62318 62318 62318 036 0360 2815
12050318 EPIDURAL CATH-CERV/THORA-M.D. 206.00 $ 06/30/09 62318 62318 62318 036 0975 2815
12050321 EPIDURAL CATH-LUMB/SACRAL-HOSP 542.00 06/30/10 62319 62319 62319 036 0360 2815
12050322 EPIDURAL CATH-LUMBO/SACRAL-M.D 193.00 $ 06/30/09 62319 62319 62319 036 0975 2815
12050325 STELLATE GANG BLK-CERV-HOSP 768.00 06/30/10 64510 64510 64510 036 0360 2815
12050326 STELLATE GANG BLK-CERV-M.D. 136.00 $ 06/30/09 64510 64510 64510 036 0975 2815
12050327 LUMB/THOR PARAVERT BLOCK-HOSP 605.00 06/30/10 64520 64520 64520 036 0360 2815
12050328 LUMB/THOR PARAVERT BLOCK-M.D. 154.00 $ 06/30/09 64520 64520 64520 036 0975 2815
12050329 CELIAC PLEXUS BLOCK-HOSP 795.00 06/30/10 64530 64530 64530 036 0360 2815
12050330 CELIAC PLEXUS BLOCK-M.D. 182.00 $ 06/30/09 64530 64530 64530 036 0975 2815
12050333 ANALYSIS PUMP W/O R-PROG-HOSP 225.00 06/30/10 62367 62367 62367 036 0360 2815
12050334 ANALYSIS PUMP W/O R-PROG-M.D. 49.00 $ 06/30/09 62367 62367 62367 036 0975 2815
12050335 ANALYSIS PUMP W/ PROG-HOSP 325.00 06/30/10 62368 62368 62368 036 0360 2815
12050336 ANALYSIS PUMP W/ PROG-M.D. 78.00 $ 06/30/09 62368 62368 62368 036 0975 2815
12050345 GREATER OCCIPITAL NRV BLK-HOSP 257.00 06/30/10 64405 64405 64405 036 0360 2815
12050346 GREATER OCCIPITAL NRV BLK-M.D. 148.00 $ 06/30/09 64405 64405 64405 036 0975 2815
12050349 PHRENIC NERVE BLOCK-HOSP 276.00 06/30/10 64410 64410 64410 036 0360 2815
12050350 PHRENIC NERVE BLOCK-M.D. 159.00 $ 06/30/09 64410 64410 64410 036 0975 2815
12050355 BRACHIAL PLEXUS BLOCK-HOSP 257.00 06/30/10 64415 64415 64415 036 0360 2815
12050356 BRACHIAL PLEXUS BLOCK-M.D. 149.00 $ 06/30/09 64415 64415 64415 036 0975 2815
12050357 AXILLARY BLOCK-HOSP 264.00 06/30/10 64417 64417 64417 036 0360 2815
12050358 AXILLARY BLOCK-M.D. 150.00 $ 06/30/09 64417 64417 64417 036 0975 2815
12050359 SUPRASCAPULAR NRV BLK-HOSP 257.00 06/30/10 64418 64418 64418 036 0360 2815
12050360 SUPRASCAPULAR NRV BLK-M.D. 146.00 $ 06/30/09 64418 64418 64418 036 0975 2815
12050361 INTERCOST NRV BLK, SING-HOSP 299.00 06/30/10 64420 64420 64420 036 0360 2815
12050362 INTERCOST NRV BLK, SING-M.D. 134.00 $ 06/30/09 64420 64420 64420 036 0975 2815
12050363 INTERCOST NRV BLK, MULT-HOSP 497.00 06/30/10 64421 64421 64421 036 0360 2815
12050364 INTERCOST NRV BLK, MULT-M.D. 182.00 $ 06/30/09 64421 64421 64421 036 0975 2815
12050365 ILLOINGUIN/ILLOHY NRV BLK-HOSP 294.00 06/30/10 64425 64425 64425 036 0360 2815
12050366 ILLOINGUIN/ILLOHY NRV BLK-M.D. 190.00 $ 06/30/09 64425 64425 64425 036 0975 2815
12050381 INJ OTHR PERIP NRV/BRANCH-HOSP 195.00 06/30/10 64450 64450 64450 036 0360 2815
12050382 INJ OTHR PERIP NRV/BRANCH-M.D. 150.00 $ 06/30/09 64450 64450 64450 036 0975 2815
12050383 INJ-ANE,PR FCT JT,CERV(1)-HOSP 309.00 06/30/10 64490 64490 64490 036 0360 2815
12050384 INJ-ANE,PR FCT JT,CERV(1)-M.D. 234.00 $ 01/01/10 64490 64490 64490 036 0975 2815
12050385 INJ-AN/STR-PR JT,CRV-ADDL-HOSP 168.00 06/30/10 64491 64491 64491 036 0360 2815
12050386 INJ-AN/STR-PR JT,CRV-ADDL-M.D. 134.00 $ 06/30/10 64491 64491 64491 036 0975 2815
12050387 INJ-ANE/STR-PR JT-LUMB(1)-HOSP 265.00 06/30/10 64493 64493 64493 036 0360 2815
12050388 INJ-ANE/STR-PR JT-LUMB(1)-M.D. 198.00 $ 01/01/10 64493 64493 64493 036 0975 2815
12050389 INJ-AN/STR-PR JT-LUMB-ADL-HOSP 392.00 06/30/10 64494 64494 64494 036 0360 2815
12050390 INJ-AN/STR-PR JT-LUMB-ADL-M.D. 114.00 $ 01/01/10 64494 64494 64494 036 0975 2815
12050391 NEUR AGT,LUMB/SACR,SING-HOSP 694.00 06/30/10 64622 64622 64622 036 0360 2815
12050392 NEUR AGT,LUMB/SACR,SING-M.D. 352.00 $ 06/30/09 64622 64622 64622 036 0975 2815
12050393 NEUR,LUMB/SACR,EA ADD LVL-HOSP 694.00 06/30/10 64623 64623 64623 036 0360 2815
12050394 NEUR,LUMB/SACR,EA ADD LVL-M.D. 100.00 $ 06/30/09 64623 64623 64623 036 0975 2815
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 340
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12050395 NEUR AGNT,CERV/THOR,SING-HOSP 497.00 06/30/10 64626 64626 64626 036 0360 2815
12050397 NEUR AG,RV/THOR,EA ADD LV-HOSP 205.00 06/30/10 64627 64627 64627 036 0360 2815
12050398 NEUR AG,CRV/THOR,EA ADD LVL-MD 117.00 $ 06/30/09 64627 64627 64627 036 0975 2815
12050417 DEST NEU AGNT-NECK MUSCL-HOSP 856.00 06/30/10 64613 64613 64613 036 0360 2815
12050418 DEST NEU AGNT-NECK MUSCL-M.D. 253.00 $ 06/30/09 64613 64613 64613 036 0975 2815
12050423 INTERCOSTAL-HOSP 311.00 06/30/10 64620 64620 64620 036 0360 2815
12050424 INTERCOSTAL-M.D. 334.00 $ 06/30/09 64620 64620 64620 036 0975 2815
12050425 DEST NEU AGNT-EXTR/TRNK-HOSP 708.00 06/30/10 64614 64614 64614 036 0360 2815
12050426 DEST NEU AGNT-EXTR/TRNK-M.D. 279.00 $ 06/30/09 64614 64614 64614 036 0975 2815
12050431 PERIPHERAL-HOSP 355.00 06/30/10 64640 64640 64640 036 0360 2815
12050432 PERIPHERAL-M.D. 365.00 $ 06/30/09 64640 64640 64640 036 0975 2815
12050433 DESTRCT CELIAC PLEXUS-HOSP 534.00 06/30/10 64680 64680 64680 036 0360 2815
12050434 DESTRUCT CELIAC PLEXUS-M.D. 324.00 $ 06/30/09 64680 64680 64680 036 0975 2815
12050441 BLOOD OR CLOT PATCH-HOSP 606.00 06/30/10 62273 62273 62273 036 0360 2815
12050442 BLOOD OR CLOT PATCH-M.D. 226.00 $ 06/30/09 62273 62273 62273 036 0975 2815
12050460 INJ TRAN EPID CRV/THR (1)-HOSP 847.00 06/30/10 64479 64479 64479 036 0360 2815
12050461 INJ TRAN EPID CRV/THR (1)-M.D. 246.00 $ 06/30/09 64479 64479 64479 036 0975 2815
12050462 INJ TRAN EPID CRV/THR-ADD-HOSP 1016.00 06/30/10 64480 64480 64480 036 0360 2815
12050463 INJ TRAN EPID CRV/THR-ADD-M.D. 162.00 $ 06/30/09 64480 64480 64480 036 0975 2815
12050464 INJ TRAN EPID LUMB/SAC(1)-HOSP 829.00 06/30/10 64483 64483 64483 036 0360 2815
12050465 INJ TRAN EPID LUMB/SAC(1)-M.D. 217.00 $ 06/30/09 64483 64483 64483 036 0975 2815
12050466 INJ TRAN EPI LUMB/SAC-ADD-HOSP 832.00 06/30/10 64484 64484 64484 036 0360 2815
12050467 INJ TRAN EPI LUMB/SAC-ADD-M.D. 138.00 $ 06/30/09 64484 64484 64484 036 0975 2815
12050480 IMPLANT DEEPWAVE DEVICE - M.D 375.00 $ 08/10/08 64999 64999 64999 036 0960 2815
12050484 DEEPWAVE DEVICE & ACCESSORIES 3332.00 06/30/10 64999 64999 64999 036 0360 2815
12050488 DEEPWAVE PEA'S 176.00 06/30/10 64999 64999 64999 036 0360 2815
12050490 BIOWAVE TREATMENT - HOSP 210.00 06/30/10 64999 64999 64999 036 0360 2815
12050491 BIOWAVE TREATMENT - M.D. 100.00 $ 08/10/08 64999 64999 64999 036 0975 2815
12050501 INJ/INF NEUROLYTIC-HOSP 491.00 06/30/10 62280 62280 62280 036 0360 2815
12050502 INJ/INF NEUROLYTIC SUB-M.D. 322.00 $ 06/30/09 62280 62280 62280 036 0975 2815
12050505 PERCUTANEOUS DISKECTOMY-HOSP 4731.00 06/30/10 62287 62287 62287 036 0360 2815
12050506 PERCUTANEOUS DISKECTOMY-M.D. 1104.00 $ 06/30/09 62287 62287 62287 036 0975 2815
12050511 FLUOROGUIDE FOR SPINE INJ-HOSP 637.00 06/30/10 77003 77003 77003 036 0320 2815
12050512 FLUOROGUIDE FOR SPINE INJ-M.D. 60.00 $ 06/30/09 77003 7700326 7700326 036 0972 2815
12050515 DISKOGRAPHY(LUMBAR)-HOSP 849.00 06/30/10 62290 62290 62290 036 0360 2815
12050516 DISKOGRAPHY(LUMBAR)-M.D. 351.00 $ 06/30/09 62290 62290 62290 036 0975 2815
12050521 PERC IMPLNT ELECTR,EPIDUR-HOSP 6475.00 06/30/10 63650 63650 63650 036 0360 2815
12050522 PERC IMPLNT ELECTR,EPIDUR-M.D. 823.00 $ 06/30/09 63650 63650 63650 036 0975 2815
12050527 RMVL ELECTR PERC ARRAY(S)-HOSP 2897.00 06/30/10 63661 63661 63661 036 0360 2815
12050535 CATHETER, INTRADISCAL 2913.00 06/30/10 036 0270 2815
12050543 GANGLION IMPAR BLOCK-HOSP 593.00 06/30/10 64412 64412 64412 036 0360 2815
12050544 GANGLION IMPAR BLOCK-M.D. 142.00 $ 06/30/09 64412 64412 64412 036 0975 2815
12050550 IMPL/REV CATH,PMP,W/O LAM-HOSP 5422.00 06/30/10 62350 62350 62350 036 0360 2815
12050551 IMPL/REV CATH,PMP,W/O LAM-M.D. 827.00 $ 06/30/09 62350 62350 62350 036 0975 2815
12050556 IMPL/REPL DRG INF;SUB RES-HOSP 5422.00 06/30/10 62360 62360 62360 036 0360 2815
12050557 IMPL/REPL DRG INF;SUB RES-M.D. 563.00 $ 06/30/09 62360 62360 62360 036 0975 2815
12050560 PROG PUMP;PREP;+/- PROG-HOSP 27488.00 06/30/10 62362 62362 62362 036 0360 2815
12050561 PROG PUMP;PREP;+/- PROG-M.D. 880.00 $ 06/30/09 62362 62362 62362 036 0975 2815
12050570 INCIS/SUB PLCMNT PULS GEN-HOSP 47682.00 06/30/10 63685 63685 63685 036 0360 2815
12050571 INCIS/SUB PLCMNT PULS GEN-M.D. 841.00 $ 06/30/09 63685 63685 63685 036 0975 2815
12050576 REV/RMV SPINAL PULSE GEN-HOSP 5145.00 06/30/10 63688 63688 63688 036 0360 2815
12050577 REV/RMV SPINAL PULSE GEN-M.D. 750.00 $ 06/30/09 63688 63688 63688 036 0975 2815
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 341
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12050580 ANLY PUL GEN COMP 1ST HR-HOSP 229.00 06/30/10 95972 95972 95972 036 0740 2815
12050581 ANLY PUL GEN COMP 1ST HR-M.D. 167.00 $ 06/30/09 95972 95972 95972 036 0920 2815
12050582 ANLY PUL GEN COMP ADD 30M-HOSP 229.00 06/30/10 95973 95973 95973 036 0740 2815
12050583 ANLY PUL GEN COMP ADD 30M-M.D. 98.00 $ 06/30/09 95973 95973 95973 036 0920 2815
12050586 SCIATIC NRV,CONT CATH INF-HOSP 2508.00 06/30/10 64446 64446 64446 036 0360 2815
12050587 SCIATIC NRV,CONT CATH INF-M.D. 195.00 $ 06/30/09 64446 64446 64446 036 0975 2815
12050590 PATIENT PROGRAMMER 3363.00 06/30/10 036 0272 2815
12050593 GEN NEUROSTIM/CHARGE SYST 36844.00 06/30/10 C1820 C1820 C1820 036 0278 2815
12050596 ORTH/PROSTH SUPPLY ACC-PT.B 940.00 06/30/10 L9900 L9900 L9900 036 0274 2815
12050601 PERC-D WAND 2057.00 06/30/10 036 0270 2815
12050711 ARTHROCENT MAJ JNT/BURSA-HOSP 440.00 06/30/10 20610 20610 20610 036 0360 2815
12050712 ARTHROCENT MAJ JNT/BURSA-M.D. 107.00 $ 06/30/09 20610 20610 20610 036 0975 2815
12050745 SACROILIAC JOINT INJECT-HOSP. 497.00 06/30/10 27096 G0260 27096 036 0360 2815
12050746 SACROILIAC JOINT INJECTION-M.D 142.00 $ 06/30/09 27096 27096 27096 036 0975 2815
12050751 TRIGGER POINT INJ-HOSP 186.00 06/30/10 20550 20550 20550 036 0360 2815
12050752 TRIGGER POINT INJ-M.D. 89.00 $ 06/30/09 20550 20550 20550 036 0975 2815
12050762 LIDOCAINE HCL FOR IV INF 10 MG 9.00 06/30/10 J2001 J2001 J2001 036 0250 2815
12050771 BUPIVACAINE 33.00 06/30/10 036 0250 2815
12050773 S/B BOTULINUM TYPE A PER UNIT 15.00 06/30/10 J0585 J0585 J0585 036 0636 2815
12050775 S/B BOTUL TYPE B PER 100 UNITS 25.00 06/30/10 J0587 J0587 J0587 036 0636 2815
12050777 ELECTRODE PLACEMENT 485.00 06/30/10 L8680 L8680 L8680 036 0278 2815
12050780 STIM REPRO SIMP SC/PERIPH-HOSP 295.00 06/30/10 95971 95971 95971 036 0740 2815
12050781 STIM REPRO SIMP SC/PERIPH-M.D. 88.00 $ 06/30/09 95971 95971 95971 036 0920 2815
12050785 PUMP REFILL,ADMN BY PHYS-HOSP 384.00 06/30/10 95991 95991 95991 036 0510 2815
12050786 PUMP REFILL,ADMN BY PHYS-M.D. 79.00 $ 06/30/09 95991 95991 95991 036 0983 2815
12050795 REG IV ANES-UP/LOW EXTREM-HOSP 469.00 06/30/10 96373 96373 96373 036 0940 2815
12050796 REG IV ANES-UP/LOW EXTREM-M.D. 40.00 $ 06/30/09 96373 96373 96373 036 0361 2815
12050800 CONSC MOD SEDATION>5YRS-30MIN 275.00 06/30/10 99144 99144 99144 036 0370 2815
12050801 CONSC MOD SEDATION ADD 15 MIN 70.00 06/30/10 99145 99145 99145 036 0370 2815
12050804 LD NEUROSTIM TEST KIT(IMPLANT) EXTERNAL 11/01/07 C1897 C1897 L8686 036 0278 2815
12050807 LEAD NEUROSTIMULATOR IMPLANT EXTERNAL 11/01/07 C1897 C1897 C1897 036 0278 2815
12050811 INJ SG/MLT TRG PT,1-2 MUS-HOSP 475.00 06/30/10 20552 20552 20552 036 0360 2815
12050812 INJ SG/MLT TRG PT,1-2 MUS-M.D. 75.00 $ 06/30/09 20552 20552 20552 036 0975 2815
12050813 INJ SG/MLT TRG PT,3->MUS-HOSP 468.00 06/30/10 20553 20553 20553 036 0360 2815
12050814 INJ SG/MLT TRG PT,3->MUS-M.D. 81.00 $ 06/30/09 20553 20553 20553 036 0975 2815
12050821 KENALOG, PER 10 MG 10.00 06/30/10 J3301 J3301 J3301 036 0636 2815
12050823 ROPIVACAINE HCL, 1MG 7.00 06/30/10 J2795 J2795 J2795 036 0636 2815
12050831 LOW OS CON,400 OR>MG/ML,PER ML 66.00 06/30/10 Q9951 Q9951 Q9951 036 0636 2815
12050833 INJ,IRON MAG RES CON,PER ML 84.00 06/30/10 Q9953 Q9953 Q9953 036 0636 2815
12050834 ORAL MAG RES AGNT,PER 100 ML 27.00 06/30/10 Q9954 Q9954 Q9954 036 0636 2815
12050835 INJ,PERFLEX LIP MICRO,PER ML 135.00 06/30/10 Q9955 Q9955 Q9955 036 0636 2815
12050836 INJ,OCTAFLUORO MICRO,PER ML 111.00 06/30/10 Q9956 Q9956 Q9956 036 0636 2815
12050837 INJ PERFLUT LIP MICRO,PER ML 196.00 06/30/10 Q9957 Q9957 Q9957 036 0636 2815
12050838 HI OSM CON,</= 149MG/ML,PER ML 8.00 06/30/10 Q9958 Q9958 Q9958 036 0636 2815
12050839 HI OS CON,150-199 MG/ML,PER ML 59.00 06/30/10 Q9959 Q9959 Q9959 036 0636 2815
12050840 HI OS CON,200-249 MG/ML,PER ML 5.00 06/30/10 Q9960 Q9960 Q9960 036 0636 2815
12050841 HI OS CON,250-299 MG/ML,PER ML 5.00 06/30/10 Q9961 Q9961 Q9961 036 0636 2815
12050842 HI OS CON,300-349 MG/ML,PER ML 6.00 06/30/10 Q9962 Q9962 Q9962 036 0636 2815
12050843 HI OS CON,350-399 MG/ML,PER ML 5.00 06/30/10 Q9963 Q9963 Q9963 036 0636 2815
12050844 HI OS CON,400 OR> MG/ML,PER ML 5.00 06/30/10 Q9964 Q9964 Q9964 036 0636 2815
12050845 LOW OS CN,100-199 MG/ML,PER ML 7.00 06/30/10 Q9965 Q9965 Q9965 036 0636 2815
12050846 LOW OS CN,200-299 MG/ML,PER ML 5.00 06/30/10 Q9966 Q9966 Q9966 036 0636 2815
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 342
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12050847 LOW OS CN,300-399 MG/ML,PER ML 5.00 06/30/10 Q9967 Q9967 Q9967 036 0636 2815
12050861 BRACH PL CONT CATH INFUS-HOSP 1180.00 06/30/10 64416 64416 64416 036 0360 2815
12050862 BRACH PL CONT CATH INFUS-M.D. 205.00 $ 06/30/09 64416 64416 64416 036 0975 2815
12050871 SCIAT NRV CATH INFUS-SING-HOSP 709.00 06/30/10 64445 64445 64445 036 0360 2815
12050872 SCIAT NRV CONT CATH INFUS-M.D. 163.00 $ 06/30/09 64445 64445 64445 036 0960 2815
12050875 FEMORAL NERVE, SING-HOSP 709.00 06/30/10 64447 64447 64447 036 0360 2815
12050876 FEMORAL NERVE, SING-M.D. 142.00 $ 06/30/09 64447 64447 64447 036 0960 2815
12050877 FEM NRV,CONT CATH INFUS-HOSP 709.00 06/30/10 64448 64448 64448 036 0360 2815
12050878 FEM NRV,CONT CATH INFUS-M.D. 173.00 $ 06/30/09 64448 64448 64448 036 0960 2815
12050879 LUMBAR PLEXUS-HOSP 1222.00 06/30/10 64449 64449 64449 036 0360 2815
12050880 LUMBAR PLEXUS-M.D. 189.00 $ 06/30/09 64449 64449 64449 036 0960 2815
12050885 INJ SUP HYPOGAST PLEXUS-HOSP 1397.00 06/30/10 64517 64517 64517 036 0360 2815
12050886 INJ SUP HYPOGAST PLEXUS-M.D. 237.00 $ 06/30/09 64517 64517 64517 036 0960 2815
12050891 INJ CELIAC PLEXUS-HOSP 1397.00 06/30/10 64530 64530 64530 036 0360 2815
12050892 INJ CELIAC PLEXUS-M.D. 182.00 $ 06/30/09 64530 64530 64530 036 0960 2815
12050901 DEST SUP HYPOGAST PLEXUS-HOSP 2280.00 06/30/10 64681 64681 64681 036 0360 2815
12050902 DEST SUP HYPOGAST PLEXUS-M.D. 438.00 $ 06/30/09 64681 64681 64681 036 0960 2815
12050919 ELEC ANAL-NO CHNG IN PROG-HOSP 260.00 06/30/10 95970 95970 95970 036 0510 2815
12050920 ELEC ANAL-NO CHNG IN PROG-M.D. 48.00 $ 06/30/09 95970 95970 95970 036 0920 2815
12050930 INTRADISC ELECTO, SING-HOSP 3031.00 06/30/10 22899 22899 22899 036 0360 2815
12050931 INTRADISC ELECTO, SING-M.D. 2507.00 $ 01/01/10 22899 22899 22899 036 0960 2815
12050932 INTRADISC ELECTO,EA ADD-HOSP 3031.00 06/30/10 22899 22899 22899 036 0360 2815
12050933 INTRADISC ELECTO,EA ADD-M.D. 2507.00 $ 01/01/10 22899 22899 22899 036 0960 2815
12050940 CLEOCIN PHOSPHATE 300 MG/ML 22.00 06/30/10 036 0250 2815
12050943 INJ SI JOINT ARTHOGRAM-HOSP 1448.00 06/30/10 27096 27096 27096 036 0361 2815
12050944 INJ SI JOINT ARTHOGRAM-M.D. 142.00 $ 06/30/09 27096 27096 27096 036 0975 2815
12050945 SCIATIC BLOCK-HOSP 218.00 06/30/10 64445 64445 64445 036 0360 2815
12050946 SCIATIC BLOCK-M.D. 349.00 06/30/09 64445 64445 64445 036 0975 2815
12050949 PUDENDAL BLOCK-HOSP 315.00 06/30/10 64430 64430 64430 036 0360 2815
12050950 PUDENDAL BLOCK-M.D. 180.00 $ 06/30/09 64430 64430 64430 036 0975 2815
12050953 LUMBAR PUNCT/THERAPEUT-HOSP 519.00 06/30/10 62272 62272 62272 036 0360 2815
12050954 LUMBAR PUNCT/THERAPEUT-M.D. 176.00 $ 06/30/09 62272 62272 62272 036 0975 2815
12050957 PERC LYSIS-EPID ADHS-MULT-HOSP 1093.00 06/30/10 62263 62263 62263 036 0360 2815
12050958 PERC LYSIS-EPID ADHS-MULT-M.D. 762.00 $ 06/30/09 62263 62263 62263 036 0975 2815
12050961 PRC LYS-EP ADHS W/SOL INJ-HOSP 2187.00 06/30/10 62264 62264 62264 036 0390 2815
12050962 PERC LYS-EP ADHS W/SOL INJ-M.D 465.00 $ 06/30/09 62264 62264 62264 036 0975 2815
12050965 DISCOGRAPHY INJ,CERV/THOR-HOSP 1503.00 06/30/10 62291 62291 62291 036 0360 2815
12050966 DISCOGRAPHY INJ,CERV/THOR-M.D. 343.00 $ 06/30/09 62291 62291 62291 036 0975 2815
12050969 CHEMO NUCLYOSIS INJ DISCO-HOSP 1145.00 06/30/10 62292 62292 62292 036 0360 2815
12050970 CHEMO NUCLYOSIS INJ DISCO-M.D. 1014.00 $ 06/30/09 62292 62292 62292 036 0975 2815
12050980 ACUPUNCT W/O ELEC INIT 15 MIN 109.00 06/30/10 97810 97810 97810 036 0510 2815
12050982 ACPCT W/O ELE-15MIN-NO CHARGE N/C 06/30/10 97810 97810 97810 036 0510 2815
12050984 ACUPUNCT W/O ELE EA ADD 15 MIN 57.00 06/30/10 97811 97811 97811 036 0510 2815
12050986 ACPCT W/O EL-ADD 15MIN-NO CHRG N/C 06/30/10 97811 97811 97811 036 0510 2815
12340017 IV INF THER/PROPH/DIAG:INIT 491.00 06/30/10 96365 96365 96365 036 0260 0524
12340025 THERAP INJECTION IM/SUB 86.00 06/30/10 96372 96372 96372 036 0940 0524
12340029 REFILL/MAINT PORTABLE PUMP 402.00 06/30/10 96521 96521 96521 036 0940 0524
12340067 APPLICATION UNNA BOOT-HOSP 117.00 06/30/10 29580 29580 29580 036 0360 0524
12340068 APPLICATION UNNA BOOT-M.D. 77.00 $ 06/30/09 29580 29580 29580 036 0975 0524
12340077 SURGICAL TRAY 122.00 06/30/10 A4550 A4550 A4550 036 0270 0524
12340081 HYDROGEL DRESS=OR<16 SQ IN 15.00 06/30/10 A6231 A6231 A6231 036 0270 0524
12340085 HYDROGEL DRESS>16<48 SQ IN 15.00 06/30/10 A6231 A6231 A6231 036 0270 0524
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 343
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12340089 HYDROGEL DRESSING>48 SQ IN 20.00 06/30/10 A6232 A6232 A6232 036 0270 0524
12340091 INTERMITT URINARY CATH-W/SUPP 13.00 06/30/10 036 0270 0524
12340093 SALINE 1000 CC. 50.00 06/30/10 J7030 J7030 J7030 036 0636 0524
12340097 SALINE 500 CC. 48.00 06/30/10 J7040 J7040 J7040 036 0636 0524
12340101 TRACHEOST CARE KIT NEW TRACHEO 14.00 06/30/10 A4625 A4625 A4625 036 0270 0524
12340111 VACCINE ADMIN,SINGLE VAC 110.00 06/30/10 90471 90471 90471 036 0771 0524
12340115 VACCINE ADMIN,EACH ADD'L VAC 82.00 06/30/10 90472 90472 90472 036 0771 0524
12340123 B-12 INJECTION 86.00 06/30/10 96372 96372 96372 036 0940 0524
12340127 INFLUNZA SPLIT VIRUS 3+YRS OLD 36.00 06/30/10 90658 90658 90658 036 0636 0524
12340141 SCREEN-PAP,PREP&CONVEY-HOSP 72.00 06/30/10 Q0091 Q0091 Q0091 036 0923 0524
12340142 SCREEN-PAP,PREP&CONVEY-M.D. 39.00 $ 06/30/09 Q0091 Q0091 Q0091 036 0983 0524
12340147 ACCUCHECK 44.00 06/30/10 82962 82962 82962 036 0301 0524
12340175 THERAPEUTIC LP FOR CHEMO-HOSP 519.00 06/30/10 62272 62272 62272 036 0360 0524
12340176 THERAPEUTIC LP FOR CHEMO-M.D. 176.00 $ 06/30/09 62272 62272 62272 036 0975 0524
12340221 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 036 0510 0524
13300108 DTAP - < 7 YEARS 98.00 06/30/10 90700 90700 90700 036 0636 0648
13300146 HEPATITIS B PED/ADOLESCENT 105.00 06/30/10 90744 90744 90744 036 0636 0648
13300170 INFLUENZA VACCINE-INTRANASAL 38.00 06/30/10 90660 90660 90660 036 0636 0648
13300200 OPV 69.00 06/30/10 90712 90712 90712 036 0636 0648
13300238 AEROSOL INHALATION, 1ST HR. 170.00 06/30/10 94644 94644 94644 036 0460 0648
13300300 PULSE OX. - SING. 99.00 06/30/10 94760 94760 94760 036 0460 0648
13300306 PULSE OX. - MULTI. 143.00 06/30/10 94761 94761 94761 036 0460 0648
13300342 ALLERGY TST-DRUG SPEC#______ 64.00 06/30/10 95010 95010 95010 036 0924 0648
13300346 ALLERGY TST-IMMED TYPE,SPC#___ 86.00 06/30/10 95024 95024 95024 036 0924 0648
13300350 ALLRGN IMMN, SINGLE ANTIGEN 82.00 06/30/10 95120 95120 95120 036 0510 0648
13300354 ALLRGN IMMUN, MULT ANTIGENS 84.00 06/30/10 95125 95125 95125 036 0510 0648
13300362 SINGLE INSECT VENOM 111.00 06/30/10 95130 95130 95130 036 0510 0648
13300366 TWO INSECT VENOM 142.00 06/30/10 95131 95131 95131 036 0510 0648
13300370 THREE INSECT VENOM 172.00 06/30/10 95132 95132 95132 036 0510 0648
13300374 FOUR INSECT VENOM 206.00 06/30/10 95133 95133 95133 036 0510 0648
13300378 FIVE INSECT VENOM 246.00 06/30/10 95134 95134 95134 036 0510 0648
13300382 SPIROMETRY, SINGLE - HOSP 220.00 06/30/10 94010 94010 94010 036 0460 0648
13300383 SPIROMETRY, SINGLE - M.D. 18.00 $ 06/30/09 94010 9401026 9401026 036 0976 0648
13300388 SPIROMETRY,PRE/POST BD-HOSP 341.00 06/30/10 94060 94060 94060 036 0460 0648
13300389 SPIROMETRY,PRE/POST BD-M.D. 31.00 $ 06/30/09 94060 9406026 9406026 036 0976 0648
13300394 MULTI SPIRO W/ADMIN AGNTS-HOSP 594.00 06/30/10 94070 94070 94070 036 0460 0648
13300395 MULTI SPIRO W/ADMIN AGNTS-M.D. 61.00 $ 06/30/09 94070 9407026 9407026 036 0976 0648
13300494 ALLERGY TST-DRUG/VEN/BIO-HOSP 30.00 06/30/10 95015 95015 95015 036 0924 0648
13300495 ALLERGY TST-DRUG/VEN/BIO-M.D. 27.00 $ 06/30/09 95015 95015 95015 036 0983 0648
13300500 ALLERGY PANEL,ID(SPEC#______) 74.00 06/30/10 95028 95028 95028 036 0924 0648
13300508 ALLERGY PATCH TEST(SPEC#_____) 64.00 06/30/10 95044 95044 95044 036 0924 0648
13300516 ALLER MIX,SING DOSE ADMIN-HOSP 48.00 06/30/10 95144 95144 95144 036 0510 0648
13300517 ALLER MIX,SING DOSE ADMIN-M.D. 7.00 $ 06/30/09 95144 95144 95144 036 0983 0648
13300520 ALLER MIX,SING INSECT VEN-HOSP 130.00 06/30/10 95145 95145 95145 036 0510 0648
13300521 ALLER MIX,SING INSECT VEN-M.D. 7.00 $ 06/30/09 95145 95145 95145 036 0983 0648
13300524 ALLER MIX,2 SING INSC VEN-HOSP 55.00 06/30/10 95146 95146 95146 036 0510 0648
13300525 ALLER MIX,2 SING INSC VEN-M.D. 7.00 $ 06/30/09 95146 95146 95146 036 0983 0648
13300528 ALLER MIX,3 SING INSC VEN-HOSP 55.00 06/30/10 95147 95147 95147 036 0510 0648
13300529 ALLER MIX,3 SING INSC VEN-M.D. 7.00 $ 06/30/09 95147 95147 95147 036 0983 0648
13300532 ALLER MIX,4 SING INSC VEN-HOSP 48.00 06/30/10 95148 95148 95148 036 0510 0648
13300533 ALLER MIX,4 SING INSC VEN-M.D. 7.00 $ 06/30/09 95148 95148 95148 036 0983 0648
13300536 ALLER MIX,5 SING INSC VEN-HOSP 48.00 06/30/10 95149 95149 95149 036 0510 0648
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 344
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13300537 ALLER MIX,5 SING INSC VEN-M.D. 7.00 $ 06/30/09 95149 95149 95149 036 0983 0648
13300548 ALLER MIX WHOL BDY EXTRCT-HOSP 48.00 06/30/10 95170 95170 95170 036 0510 0648
13300549 ALLER MIX WHOL BDY EXTRCT-M.D. 7.00 $ 06/30/09 95170 95170 95170 036 0983 0648
13300564 BLOOD OCCT. FECAL SCREEN 34.00 06/30/10 82270 82270 82270 036 0301 0648
13300690 FOOD INGEST CHALLENGE-HOSP 712.00 06/30/10 95075 95075 95075 036 0924 0648
13300691 FOOD INGEST CHALLENGE-M.D. 125.00 $ 10/01/07 95075 95075 95075 036 0982 0648
13300746 IMMUNOTHERAPY SING INJ 27.00 06/30/10 95115 95115 95115 036 0924 0648
13300750 IMMUNOTHERAPY MULT INJ 81.00 06/30/10 95117 95117 95117 036 0924 0648
13300844 PEAK FLOW MONITOR 108.00 06/30/10 94799 94799 94799 036 0460 0648
13300874 SWEAT TEST 273.00 06/30/10 89230 89230 89230 036 0300 0648
13900240 CT HEAD OR BRAIN W/O CONT 1112.00 06/30/10 70450 70450 70450 036 0351 0621
13900241 CT HEAD OR BRAIN W/O CONT-M.D. 93.00 $ 06/30/09 70450 70450 70450 036 0972 0621
13900250 CT ORBT SELL EAR W/O CONT 1605.00 06/30/10 70480 70480 70480 036 0350 0621
13900251 CT ORBT SELL EAR W/O CONT-M.D. 140.00 $ 06/30/09 70480 70480 70480 036 0972 0621
13900260 CT MAXILLO W/O CONTRAST 2431.00 06/30/10 70486 70486 70486 036 0350 0621
13900261 CT MAXILLO W/O CONTRAST-M.D. 544.00 $ 06/01/10 7048626 7048626 7048626 036 0972 0621
13911001 OFFC CONSULT LVL1-DOCTOR 72.00 $ 06/30/09 99241 99241 99241 036 0983 0621
13911002 OFFC CONSULT LVL2-DOCTOR 152.00 $ 06/30/09 99242 99242 99242 036 0983 0621
13911003 OFFC CONSULT LVL3-DOCTOR 95.00 $ 06/30/09 99213 99213 99213 036 0983 0621
13911004 OFFC CONSULT LVL4-DOCTOR 331.00 $ 06/30/09 99244 99244 99244 036 0983 0621
13911005 OFFC CONSULT LVL5-DOCTOR 413.00 $ 06/30/09 99245 99245 99245 036 0983 0621
13911011 INPAT CONSULT 20 MIN-DOCTOR 104.00 $ 06/30/09 99251 99251 99251 036 0987 0621
13911012 INPAT CONSULT 40 MIN-DOCTOR 163.00 $ 06/30/09 99252 99252 99252 036 0987 0621
13911013 INPAT CONSULT 55 MIN-DOCTOR 246.00 $ 06/30/09 99253 99253 99253 036 0988 0621
13911014 INPAT CONSULT 80 MIN-DOCTOR 353.00 $ 06/30/09 99254 99254 99254 036 0988 0621
13911015 INPAT CONSULT 110 MIN-DOCTOR 432.00 $ 06/30/09 99255 99255 99255 036 0988 0621
13911021 SUB HOSP CARE E&M 15 MIN M.D. 79.00 $ 06/30/09 99231 99231 99231 036 0987 0621
13911022 SUB HOSP CARE E&M 25 MIN M.D. 141.00 $ 06/30/09 99232 99232 99232 036 0987 0621
13911023 SUB HOSP CARE E&M 35 MIN M.D. 59.00 06/30/09 99233 99233 99233 036 0987 0621
13920010 POSTOP F/U VST INCL GLBAL SRVC N/C 06/30/10 99024 99024 99024 036 0983 0617
13920014 ORTHOPANTOGRAM 396.00 06/30/10 70355 70355 70355 036 0320 0617
13920018 CEPHALOGRAM ORTHODONTIC 242.00 06/30/10 70350 70350 70350 036 0320 0617
13920040 CT ORBT SELL EAR W/O CONT 1605.00 06/30/10 70480 70480 70480 036 0350 0617
13920041 CT ORBT SELL EAR W/O CONT-M.D. 140.00 $ 06/30/09 70480 70480 70480 036 0972 0617
13920046 CT MAXILLO W/O CONTRAST 2506.00 06/30/10 70486 70486 70486 036 0350 0617
13920047 CT MAXILLO W/O CONTRAST-M.D. 124.00 $ 06/30/09 70486 70486 70486 036 0972 0617
13920050 CT HEAD OR BRAIN W/O CONT 1112.00 06/30/10 70450 70450 70450 036 0351 0617
13920051 CT HEAD OR BRAIN W/O CONT-M.D. 93.00 $ 06/30/09 70450 70450 70450 036 0972 0617
13920070 SPEECH &LANGUAGE EVALUATION 593.00 06/30/10 92506 92506 92506 036 0444 0617
13920074 S/L/H W/CONTIN MED SUPERVIS 208.00 06/30/10 92507 92507 92507 036 0440 0617
13920078 SPEECH & LANG THER INDIVIDUAL 186.00 06/30/10 92508 92508 92508 036 0440 0617
13920082 SPEECH & LANG THER GROUP 214.00 06/30/10 92511 92511 92511 036 0440 0617
13920086 NASAL FUNCTION STUDIES 232.00 06/30/10 92512 92512 92512 036 0440 0617
13920090 LARYNGEAL FUNCTION STUDIES 177.00 06/30/10 92520 92520 92520 036 0440 0617
13920094 SPEC REPORT>USUAL MED FORM 92.00 06/30/10 99080 99080 99080 036 0960 0617
13920098 ORTHODONTIA 311.00 06/30/10 99070 99070 99070 036 0270 0617
13920150 PURE TONE AUDIOMETRY AIR &BONE 287.00 06/30/10 92553 92553 92553 036 0471 0617
13920154 COMP AUDIOMETRY THRESHOLD EVAL 369.00 06/30/10 92557 92557 92557 036 0471 0617
13920158 STENGER TEST PURE TONE 116.00 06/30/10 92565 92565 92565 036 0471 0617
13920162 TYMPANOMETRY 159.00 06/30/10 92567 92567 92567 036 0471 0617
13920166 ACOUSTIC REFLEX TESTING 165.00 06/30/10 92568 92568 92568 036 0471 0617
13920170 ACOUSTIC REFLEX DECAY TEST 89.00 06/30/10 92570 92570 92570 036 0471 0617
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 345
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13920174 CONDITIONING PLAY AUDIOMETRY 315.00 06/30/10 92582 92582 92582 036 0471 0617
13920178 SELECT PICTURE AUDIOMETRY 308.00 06/30/10 92583 92583 92583 036 0471 0617
13920182 ELECTROCOCHLEOGRAPHY 391.00 06/30/10 92584 92584 92584 036 0471 0617
13920186 EVOKD POTNT &/TEST CNS COMP 331.00 06/30/10 92585 92585 92585 036 0471 0617
13920190 EVOKED OTOACOUSTIC EMSSNS LTD 192.00 06/30/10 92587 92587 92587 036 0471 0617
13920202 VISUAL REINFRCMNT AUDIOMETRY 315.00 06/30/10 92579 92579 92579 036 0471 0617
13920222 BONE ANCHORED HEARING AID 3237.00 06/30/10 E1399 E1399 E1399 036 0292 0617
13920260 PSYC DX INTERVIEW EXAMINATION 259.00 06/30/10 90801 90801 90801 036 0513 0617
13920264 PSYCHOTX INTERACT 20-30MIN 104.00 06/30/10 90810 90810 90810 036 0900 0617
13920268 PSYCHOTX INTERACT 45-50MIN 175.00 06/30/10 90812 90812 90812 036 0900 0617
13920272 PSYCHOTX INTERACT 75-80MIN 208.00 06/30/10 90814 90814 90814 036 0903 0617
13920276 PSYCHOLOGICAL TST W/I&R/HR 268.00 06/30/10 96102 96102 96102 036 0918 0617
13920280 DVLPMENTL TST LTD W/I&R 496.00 06/30/10 96110 96110 96110 036 0918 0617
13920284 DEVELOP TESTING,EXTENDED 419.00 06/30/10 96111 96111 96111 036 0440 0617
13920288 NEUROBEHVIRL STS EXAM W/I&R-HR 220.00 06/30/10 96116 96116 96116 036 0918 0617
13920292 NEUROPSY TEST BATTERY W/I&R-HR 419.00 06/30/10 96119 96119 96119 036 0918 0617
13920296 PLACEMNT OF HEALING CAP EXTERNAL 02/01/08 L7510 L7510 L7510 036 0274 0617
13920300 LTD ORTH TREAT-PRIM DENTITION EXTERNAL 02/01/09 D8010 D8010 D8010 036 0510 0617
13920305 LTD ORTH TREAT-TRANS DENTITION EXTERNAL 02/01/09 D8020 D8020 D8020 036 0510 0617
13920310 LTD ORTH TREAT-ADOL DENTITION EXTERNAL 02/01/09 D8030 D8030 D8030 036 0510 0617
13920315 LTD ORTH TREAT-ADULT DENTITION EXTERNAL 02/01/09 D8040 D8040 D8040 036 0510 0617
13920320 INTER ORTH TREAT-PRIM DENTIT EXTERNAL 02/01/09 D8050 D8050 D8050 036 0510 0617
13920325 INTER ORTH TRT-TRANS DENTITION EXTERNAL 02/01/09 D8060 D8060 D8060 036 0510 0617
13920330 COMP ORTH TRT-TRANS DENTITION EXTERNAL 02/01/09 D8070 D8070 D8070 036 0510 0617
13920335 COMP ORTH TRT-ADOLES DENTITION EXTERNAL 02/01/09 D8080 D8080 D8080 036 0510 0617
13920340 COMP ORTH TRT-ADLT DENTITION EXTERNAL 02/01/09 D8090 D8090 D8090 036 0510 0617
13920360 REMOVABLE APPLIANCE THERAPY EXTERNAL 02/01/09 D8210 D8210 D8210 036 0510 0617
13920365 FIXED APPLIANCE THERAPY EXTERNAL 02/01/09 D8220 D8220 D8220 036 0510 0617
13920370 PRE-ORTHODONTIC TREATMNT VISIT EXTERNAL 02/01/09 D8660 D8660 D8660 036 0510 0617
13920375 PERIOD ORTHODONTIC TRTMNT VST EXTERNAL 02/01/09 D8670 D8670 D8670 036 0510 0617
13920380 ORTHODONTIC RETENTION EXTERNAL 02/01/09 D8680 D8680 D8680 036 0510 0617
13920385 ORTHODONTIC TREATMENT EXTERNAL 02/01/09 D8690 D8690 D8690 036 0510 0617
13920387 REPAIR ORTHODONTIC APPLIANCE EXTERNAL 02/01/09 D8691 D8691 D8691 036 0510 0617
13920389 REPLACE LOST/BROKEN RETAINER EXTERNAL 02/01/09 D8692 D8692 D8692 036 0510 0617
13920400 UNSPEC ORTHODONTIC PROCEDURE EXTERNAL 02/01/09 D8999 D8999 D8999 036 0510 0617
14600002 VOID EXTERNAL 07/01/07 036 0983 9999
14699001 OFFICE VISIT ESTAB LEVEL 1 100.00 06/30/10 99211 99211 99211 036 0510 4606
14699003 OFFICE VISIT ESTAB LEVEL 2 120.00 06/30/10 99212 99212 99212 036 0510 4606
14699005 OFFICE VISIT ESTAB LEVEL 3 155.00 06/30/10 99213 99213 99213 036 0510 4606
14699007 OFFICE VISIT ESTAB LEVEL 4 197.00 06/30/10 99214 99214 99214 036 0510 4606
14699009 OFFICE VISIT LEVEL 5 225.00 06/30/10 99215 99215 99215 036 0510 4606
14699020 INJECTION IV THERAPEUTIC 65.00 06/30/10 96374 96374 96374 036 0940 4606
14699024 THERAPEUTIC INJ, IM OR SUBQ 90.00 06/30/10 96372 96372 96372 036 0940 4606
14699030 GTT DIRECT - 3 SPECIMENS 87.00 06/30/10 82951 82951 82951 036 0301 4606
14699034 GTT DIRECT EA ADDL AFTER 3 31.00 06/30/10 82952 82952 82952 036 0301 4606
14699038 ACCUCHECK 49.00 06/30/10 82962 82962 82962 036 0301 4606
14699042 URINE DIPSTICK W/O MICRO 35.00 06/30/10 81007 81007 81007 036 0300 4606
14699046 VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 036 0510 4606
14699050 GLUCAGON TOLERANCE TEST 83.00 06/30/10 82946 82946 82946 036 0301 4606
14699054 HEMATOCRIT 37.00 06/30/10 85014 85014 85014 036 0305 4606
14699070 PSG FOR RESEARCH 1300.00 06/30/10 95810 95810 95810 036 0740 4606
16101054 VOID N/C 06/30/10 036 0971 9998
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 346
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

16320105 SPCH LANG INITIAL EVAL 60MIN 427.00 06/30/10 92506GN 92506GN 92506GN 89.04 036 0444 4306
16320108 SPCH LANG INITIAL EVAL 90MIN 742.00 06/30/10 92506GN 92506GN 92506GN 89.04 036 0444 4306
16320111 SPCH LANG INITIAL EVAL 120MIN 794.00 06/30/10 92506GN 92506GN 92506GN 89.04 036 0444 4306
16320114 SPCH LANG F/U CONSULT 60MIN 742.00 06/30/10 92506GN 92506GN 92506GN 89.04 036 0444 4306
16320117 SPCH LANG F/U CONSULT 90MIN 794.00 06/30/10 92506GN 92506GN 92506GN 89.04 036 0444 4306
16320125 SPEECH&LANG THER INDIV 30MIN 175.00 06/30/10 92507GN 92507GN 92507GN 93.75 036 0440 4306
16320126 SPEECH&LANG THER INDIV 45MIN 207.00 06/30/10 92507GN 92507GN 92507GN 93.75 036 0440 4306
16320128 SPEECH&LANG THER INDIV 60MIN 346.00 06/30/10 92507GN 92507GN 92507GN 93.75 036 0440 4306
16320131 SPEECH&LANG THER GROUP 30MIN 114.00 06/30/10 92508GN 92508GN 92508GN 93.75 036 0440 4306
16320132 SPEECH&LANG THER GROUP 45MIN 120.00 06/30/10 92508GN 92508GN 92508GN 93.75 036 0440 4306
16320134 SPEECH&LANG THER GROUP 60MIN 200.00 06/30/10 92508GN 92508GN 92508GN 93.75 036 0440 4306
16320140 NASAL FUNC STUDY 293.00 06/30/10 92512GN 92512GN 92512GN 89.12 036 0440 4306
16320145 LARYN FUNC STUDY 30MIN 244.00 06/30/10 92520GN 92520GN 92520GN 93.75 036 0440 4306
16320150 LARYN FUNC STUDY 60MIN 326.00 06/30/10 92520GN 92520GN 92520GN 93.75 036 0440 4306
16320163 DYSPHAG/FEED THER INDIV 30MIN 165.00 06/30/10 92526GN 92526GN 92526GN 93.75 036 0440 4306
16320166 DYSPHAG/FEED THER INDIV 60MIN 325.00 06/30/10 92526GN 92526GN 92526GN 93.75 036 0440 4306
16320168 DYSPHAG/FEED THER INDIV 120MIN 514.00 06/30/10 92526GN 92526GN 92526GN 93.75 036 0440 4306
16320175 EVAL/FITTING VOICE PROS 30MIN 225.00 06/30/10 92597GN 92597GN 92597GN 93.23 93.23 036 0440 4306
16320178 EVAL/FITTING VOICE PROS 60MIN 340.00 06/30/10 92597GN 92597GN 92597GN 93.23 93.23 036 0440 4306
16320181 EVAL/FITTING VOICE PROS 90MIN 509.00 06/30/10 92597GN 92597GN 92597GN 93.23 93.23 036 0440 4306
16320200 DYSPHAG/FEEDING EVAL 30MIN 150.00 06/30/10 92610GN 92610GN 92610GN 93.24 93.24 036 0444 4306
16320203 DYSPHAG/FEEDING EVAL 60MIN 299.00 06/30/10 92610GN 92610GN 92610GN 93.24 93.24 036 0444 4306
16320206 DYSPHAG/FEEDING EVAL 90MIN 448.00 06/30/10 92610GN 92610GN 92610GN 93.24 93.24 036 0444 4306
16320212 VIDEOSWALLOW STUDY 75MIN 599.00 06/30/10 92611GN 92611GN 92611GN 93.20 036 0440 4306
16320218 VIDEOSWALLOW STUDY 105MIN 787.00 06/30/10 92611GN 92611GN 92611GN 93.20 036 0440 4306
16320225 MOD VOICE PROS/AUG DEVICE30MN 231.00 06/30/10 92507GN 92507GN 92507GN 93.24 93.24 036 0440 4306
16320228 MOD VOICE PROS/AUG DEVICE 60MN 460.00 06/30/10 92507GN 92507GN 92507GN 93.24 93.24 036 0440 4306
16320231 MOD VOICE PROS/AUG DEVICE 90MN 690.00 06/30/10 92507GN 92507GN 92507GN 93.24 93.24 036 0440 4306
16320240 SPEAKING VALVE 272.00 06/30/10 L8501 L8501 L8501 036 0274 4306
16320245 VOICE EVALUATION 60MIN 427.00 06/30/10 92506GN 92506GN 92506GN 93.75 036 0444 4306
16320248 VOICE EVALUATION 90MIN 742.00 06/30/10 92506GN 92506GN 92506GN 93.75 036 0444 4306
16320251 VOICE THERAPY INDIVIDUAL 30MIN 175.00 06/30/10 92507GN 92507GN 92507GN 93.75 036 0440 4306
16320254 VOICE THERAPY INDIVIDUAL 60MIN 346.00 06/30/10 92507GN 92507GN 92507GN 93.75 036 0440 4306
16320261 VOICE THERAPY GROUP 30MIN 114.00 06/30/10 92508GN 92508GN 92508GN 93.75 036 0440 4306
16320264 VOICE THERAPY GROUP 60MIN 200.00 06/30/10 92508GN 92508GN 92508GN 93.75 036 0440 4306
16320271 DEVELOMNTL INITIAL EVAL 60MIN 487.00 06/30/10 96111GN 96111GN 96111GN 93.75 036 0444 4306
16320274 DEVELOMNTL INITIAL EVAL 90MIN 725.00 06/30/10 96111GN 96111GN 96111GN 93.75 036 0444 4306
16320281 DEVELOMNTL F/U TESTING 60MIN 487.00 06/30/10 96111GN 96111GN 96111GN 93.75 036 0444 4306
16320284 DEVELOMNTL F/U TESTING 90MIN 725.00 06/30/10 96111GN 96111GN 96111GN 93.75 036 0444 4306
16320290 SPCH THRPY/H KIDS 1/4HR DPA 87.00 06/30/10 92507GN 036 0440 4306
16320293 SPCH THRPY INITL TRT DPA 87.00 06/30/10 92506GN 036 0440 4306
16320299 SPCH EVALUATION KIDS DPA 250.00 06/30/10 W7968 036 0444 4306
16320305 ST/60 DAY HOSP DISCH 1/4 DPA 87.00 06/30/10 92507GN 036 0440 4306
16325001 TREATMENT SWALLOW 91.00 06/30/10 92526 92526 92526 036 0441 4306
16325004 EVALUATION SWALLOW 277.00 06/30/10 92610 92610 92610 036 0440 4306
16325007 FLUOROSCOPIC EVAL SWALLOW 469.00 06/30/10 92611 92611 92611 036 0440 4306
16325010 FLEX FIBERENDO EVAL SWALLOW 363.00 06/30/10 92612 92612 92612 036 0400 4306
16325013 WITH MD INTERP AND REPORT 69.00 06/30/10 92613 92613 92613 036 0440 4306
16325016 FEE LARY SENSORY TEST 289.00 06/30/10 92614 92614 92614 036 0440 4306
16325019 WITH MD INTERP AND REPORT 429.00 06/30/10 92615 92615 92615 036 0440 4306
16325022 EVAL SPEECH,LANG, VOICE 372.00 06/30/10 92506 92506 92506 036 0440 4306
16325025 TREAT OF SPEECH,LANG, VOICE 240.00 06/30/10 92507 92507 92507 036 0440 4306
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 347
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

16325028 GROUP,TWO OR MORE 200.00 06/30/10 92508 92508 92508 036 0440 4306
16325031 TREAT COGNITIVE:EACH 15 103.00 06/30/10 97532 97532 97532 036 0440 4306
16325034 TREAT SENS INTEGRATIVE:EA 15M 95.00 06/30/10 97533 97533 97533 036 0440 4306
16325037 LARYNGEAL FUNCTION STUDIES 281.00 06/30/10 92520 92520 92520 036 0440 4306
16325040 EVAL AUD REHAB, IST HOUR 383.00 06/30/10 92626 92626 92626 036 0440 4306
16325043 EVAL AUD REHAB, EA ADD'L 15MIN 97.00 06/30/10 92627 92627 92627 036 0440 4306
16325046 AUD REHAB;PRE-LINGUAL 383.00 06/30/10 92630 92630 92630 036 0440 4306
16325049 AUD REHAB;POST-LINGUAL 383.00 06/30/10 92633 92633 92633 036 0440 4306
16325052 EVAL APHASIA WITH INTERP;PER H 389.00 06/30/10 96105 96105 96105 036 0440 4306
16325055 DEVELOP TESTING;LIMITED 349.00 06/30/10 96110 96110 96110 036 0440 4306
16325058 EXTENDED,W INTERP,PER HOUR 843.00 06/30/10 96111 96111 96111 036 0440 4306
16325061 STANDARD COG EVAL,PER HOUR- 389.00 06/30/10 96125 96125 96125 036 0440 4306
16325064 EVAL VOICE PROSHETIC DEVICE 395.00 06/30/10 92597 92597 92597 036 0440 4306
16325067 EVAL NON SPEECH AUG 383.00 06/30/10 92605 92605 92605 036 0440 4306
16325070 TREAT NON-SPEECH AUG COMM 313.00 06/30/10 92606 92606 92606 036 0440 4306
16325073 EVAL SPEECH AUG COMM, 1ST HOUR 313.00 06/30/10 92607 92607 92607 036 0440 4306
16325076 EACH ADD'L 30 MIN 200.00 06/30/10 92608 92608 92608 036 0440 4306
16325079 TREAT SPEECH DEVICE 275.00 06/30/10 92609 92609 92609 036 0440 4306
16325082 REPAIR/MOD AAC 108.00 06/30/10 V5336 V5336 V5336 036 0270 4306
16325085 ONLINE ASSESSMENT 82.00 06/30/10 98969 98969 98969 036 0440 4306
16325088 TEAM CONF W PATIENT/FAM, 30MIN 84.00 06/30/10 99366 99366 99366 036 0440 4306
16325091 TEAM CONF 30 MIN 89.00 06/30/10 99368 99368 99368 036 0440 4306
16430002 PURE TONE AUDIO(THRESH)AIR&BNE 81.00 06/30/10 92552 92552 92552 95.43 036 0471 4308
16430003 BEDSIDE AUDIO EXAM 325.00 06/30/10 92557 92557 92557 95.41 036 0471 4308
16430004 SPEECH AUDIO AND DISCRIM 114.00 06/30/10 92556 92556 92556 95.41 036 0471 4308
16430006 TYMPANOMETRY 86.00 06/30/10 92567 92567 92567 95.46 036 0471 4308
16430008 ACOUSTIC REFLEX TESTING 143.00 06/30/10 92568 92568 92568 95.46 036 0471 4308
16430010 ACOUSTIC REFLEX DECAY 108.00 06/30/10 92570 92570 92570 95.46 036 0471 4308
16430011 STENGER TEST, PURE TONE 105.00 06/30/10 92565 92565 92565 95.46 036 0471 4308
16430012 EVOKED RESPONSE AUDIOMETRY 537.00 06/30/10 92585 92585 92585 95.41 036 0471 4308
16430013 ELECTROCOCHLEOGRAPHY 790.00 06/30/10 92584 92584 92584 20.31 036 0471 4308
16430014 PED HEARING CONSULT/PER 15 MIN 128.00 06/30/10 92507 92507 92507 95.42 95.42 036 0440 4308
16430015 MED HEARING CONSULT/PER 15 MIN 174.00 06/30/10 92506 92506 92506 95.42 95.42 036 0470 4308
16430016 HEARING THERAPY & CONSULT/ HR 245.00 06/30/10 92507 92507 92507 95.42 95.42 036 0440 4308
16430018 SELCT PIC AUDIOMTRY(2 1/2-6YR) 177.00 06/30/10 92583 92583 92583 95.41 036 0471 4308
16430025 SOUNDFIELD/COND PLAY AUDIOMTY 281.00 06/30/10 92582 92582 92582 95.41 036 0471 4308
16430026 TINNITUS COUNSELING 219.00 06/30/10 92625 92625 92625 95.42 95.42 036 0470 4308
16430027 TINNITUS CHARACTERIZATION 81.00 06/30/10 92552 92552 92552 95.43 036 0471 4308
16430031 AUDIOLOGY SPECIAL REPORTS 81.00 06/30/10 99080 99080 99080 89.15 036 0510 4308
16430032 COCHLEAR IMPLANT COUNSEL /HR 534.00 06/30/10 92626 92626 92626 95.42 95.42 036 0470 4308
16430033 MAC BATTERY & SPEECH TEST /HR 407.00 06/30/10 92620 92620 92620 95.46 036 0471 4308
16430036 TRT OF SPEECH,LANG AUD DISORDR 845.00 06/30/10 92626 92626GN 92626 93.24 036 0440 4308
16430040 STENGER TEST, SPEECH 139.00 06/30/10 92577 92577 92577 95.46 036 0471 4308
16430041 CENTRAL AUDITORY FUNC TEST/HR 474.00 06/30/10 92620 92620 92620 95.46 036 0471 4308
16430042 CENT AUD FUNC TEST-EA ADD 15MN 122.00 06/30/10 92621 92621 92621 036 0471 4308
16430046 LIONS EARMOLD IMPRESSN-PER EAR 30.00 06/30/10 92700 92700 92700 95.49 036 0471 4308
16430047 BASIC COMPREHENSIVE AUDIOMETRY 325.00 06/30/10 92557 92557 92557 95.41 036 0471 4308
16430048 BASIC COMPREHEN AUDIO-REDUCED 53.00 06/30/10 92557 92557 92557 95.41 036 0471 4308
16430049 OTOACOUSTIC EMISSION-LIMITED 156.00 06/30/10 92587 92587 92587 95.49 036 0471 4308
16430050 OTOACOUSTIC EMISSION-EXTENDED 370.00 06/30/10 92588 92588 92588 95.49 036 0471 4308
16430051 MIDDLE LATENCY RESPONSE TEST 718.00 06/30/10 92700 92700 92700 95.41 036 0471 4308
16430052 P-300 TEST 718.00 06/30/10 92700 92700 92700 95.41 036 0471 4308
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 348
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

16430053 VIS REINFORCE AUDIOMETRY(VRA) 244.00 06/30/10 92579 92579 92579 95.41 036 0471 4308
16430056 DIAG ANALYSIS-COCH IMPLNT<7YRS 426.00 06/30/10 92601 92601 92601 95.49 036 0471 4308
16430059 SUBSQ RE-ANLYSIS COCH IMP<7YRS 429.00 06/30/10 92602 92602 92602 95.49 036 0471 4308
16430062 DIAG ANALYSIS COCH IMPL>7YRS 308.00 06/30/10 92603 92603 92603 95.49 036 0471 4308
16430065 SUBSQ RE-ANLYSIS COCH IMP>7YRS 386.00 06/30/10 92604 92604 92604 95.49 036 0471 4308
16430066 1RT-SPCH,LNG,VCE COMM &/OR A/D 72.00 06/30/10 92507 92507 92507 95.42 95.42 036 0470 4308
16430067 CENT AUDIT FUNC TST ADD'L 15MN 50.00 06/30/10 92621GN 92621GN 92621GN 036 0471 4306
16430068 PROG/DIAG ANALYS OF ABI,PER HR 233.00 06/30/10 92640 92640 92640 036 0471 4308
16500001 PURE TONE AUDIO(THRESH)AIR&BNE 81.00 06/30/10 92552 92552 92552 036 0471 0642
16500003 SPEECH AUDIO THRESHOLD 89.00 06/30/10 92555 92555 92555 036 0471 0642
16500004 BEDSIDE AUDIO EXAM 325.00 06/30/10 92557 92557 92557 036 0471 0642
16500007 SPEECH AUDIO AND DISCRIM 114.00 06/30/10 92567 92567 92567 036 0471 0642
16500010 TYMANOMETRY 86.00 06/30/10 92567 92567 92567 036 0471 0642
16500013 ACOUSTIC REFLEX TESTING 143.00 06/30/10 92568 92568 92568 036 0471 0642
16500016 ACOUSTIC REFLEX DECAY 108.00 06/30/10 92570 92570 92570 036 0471 0642
16500019 STENGER TEST, PURE TONE 120.00 06/30/10 92585 92585 92585 036 0471 0642
16500022 EVOKED RESPONSE AUDIOMETRY 537.00 06/30/10 92585 92585 92585 036 0471 0642
16500023 AUDIT BRAINSTM EVKD RESP (LTD) 182.00 06/30/10 92586 92586 92586 036 0471 0642
16500025 ELECTROCOCHLEOGRAPHY 790.00 06/30/10 92584 92584 92584 036 0471 0642
16500028 PED HEARING CONSULT/PER 15 MIN 128.00 06/30/10 92507 92507 92507 036 0440 0642
16500031 MED HEARING CONSULT/PER 15 MIN 174.00 06/30/10 92506 92506 92506 036 0470 0642
16500034 HEARING THERAPY & CONSULT/ HR 245.00 06/30/10 92507 92507 92507 036 0440 0642
16500040 SELCT PIC AUDIOMTRY(2 1/2-6YR) 177.00 06/30/10 92583 92583 92583 036 0471 0642
16500049 SOUNDFIELD/COND PLAY AUDIOMTY 281.00 06/30/10 92582 92582 92582 036 0471 0642
16500052 TINNITUS COUNSELING 219.00 06/30/10 92625 92625 92625 036 0470 0642
16500055 TINNITUS CHARACTERIZATION 81.00 06/30/10 92552 92552 92552 036 0471 0642
16500064 AUDIOLOGY SPECIAL REPORTS 81.00 06/30/10 99080 99080 99080 036 0510 0642
16500067 COCHLEAR IMPLANT COUNSEL /HR 534.00 06/30/10 92626 92626 92626 036 0470 0642
16500068 CNSL/AURAL REHAB-EA ADD 15 MIN 141.00 06/30/10 92627 92627 92627 036 0471 0642
16500070 MAC BATTERY & SPEECH TEST /HR 407.00 06/30/10 92620 92620 92620 036 0471 0642
16500073 TRT OF SPEECH,LANG AUD DISORDR 845.00 06/30/10 92626 92626GN 92626 036 0440 0642
16500079 STENGER TEST, SPEECH 139.00 06/30/10 92577 92577 92577 036 0471 0642
16500082 CENTRAL AUDITORY FUNC TEST/HR 474.00 06/30/10 92620 92620 92620 036 0471 0642
16500085 CENT AUD FUNC TEST-EA ADD 15MN 122.00 06/30/10 92621 92621 92621 036 0471 0642
16500094 LIONS EARMOLD IMPRESSN-PER EAR 33.00 06/30/10 92700 92700 92700 036 0471 0642
16500097 BASIC COMPREHENSIVE AUDIOMETRY 325.00 06/30/10 92557 92557 92557 036 0471 0642
16500100 BASIC COMPREHEN AUDIO-REDUCED 53.00 06/30/10 92557 92557 92557 036 0471 0642
16500103 OTOACOUSTIC EMISSION-LIMITED 156.00 06/30/10 92587 92587 92587 036 0471 0642
16500106 OTOACOUSTIC EMISSION-EXTENDED 370.00 06/30/10 92588 92588 92588 036 0471 0642
16500109 MIDDLE LATENCY RESPONSE TEST 718.00 06/30/10 92700 92700 92700 036 0471 0642
16500112 P-300 TEST 718.00 06/30/10 92700 92700 92700 036 0471 0642
16500115 VIS REINFORCE AUDIOMETRY 244.00 06/30/10 92579 92579 92579 036 0471 0642
16500118 DIAG ANALYSIS-COCH IMPLNT<7YRS 426.00 06/30/10 92601 92601 92601 036 0471 0642
16500121 SUBSQ RE-ANLYSIS COCH IMP<7YRS 429.00 06/30/10 92602 92602 92602 036 0471 0642
16500124 DIAG ANALYSIS COCH IMPL>7YRS 308.00 06/30/10 92603 92603 92603 036 0471 0642
16500127 SUBSQ RE-ANLYSIS COCH IMP>7YRS 386.00 06/30/10 92604 92604 92604 036 0471 0642
16500130 1RT-SPCH,LNG,VCE COMM &/OR A/D 72.00 06/30/10 92507 92507 92507 036 0470 0642
16500133 SPONT NYSTAGAMUS TESTING 47.00 06/30/10 92541 92541 92541 036 0471 0642
16500143 FACIAL NRVE FUNCT STUDIES 252.00 06/30/10 92516 92516 92516 036 0471 0642
16500147 TYMPAN/REFLEX THRESH MEASURING 81.00 06/30/10 92550 92550 92550 036 0471 0642
16500151 PURE TONE AUDIO, AIR AND BONE 208.00 06/30/10 92553 92553 92553 036 0471 0642
16500157 BEKESY AUDIOMETRY; SCREENING 96.00 06/30/10 92560 92560 92560 036 0471 0642
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 349
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

16500161 LOUDNESS BALANCE TEST 93.00 06/30/10 92562 92562 92562 036 0471 0642
16500170 PROG/DIAG ANALYS OF ABI,PER HR 233.00 06/30/10 92640 92640 92640 036 0471 0642
16500178 BASIC VESTIBULAR EVALUATION 259.00 06/30/10 92540 92540 92540 036 0471 0642
16500180 SPONTAN NYSTAGMUS TEST 164.00 06/30/10 92541 92541 92541 036 0471 0642
16500182 POSITIONAL NYSTAGMUS TEST 164.00 06/30/10 92542 92542 92542 036 0471 0642
16500184 CALORIC VESTIBULAR TEST 259.00 06/30/10 92543 92543 92543 036 0471 0642
16500186 OPTOKINET NYSTAGMUS TEST 186.00 06/30/10 92544 92544 92544 036 0471 0642
16500188 OSCILLATING TRACKING TEST 164.00 06/30/10 92545 92545 92545 036 0471 0642
16500192 USE OF VERTICAL ELECTRODES 117.00 06/30/10 92547 92547 92547 036 0471 0642
16500194 COMPUT DYNMIC POSTUR 287.00 06/30/10 92548 92548 92548 036 0471 0642
16500241 AUDITORY EVOKED POT CMPLT 331.00 06/30/10 92585 92585 92585 036 0471 0642
16500253 PT RE-EVALUATION -ONR 105.00 06/30/10 97002 97002 97002 036 0420 0642
16500300 AUD OSSEO DEV,EXT SND PRO,REPL 8025.00 06/30/10 L8691 L8691 L8691 036 0270 0642
17130273 FOCAL CHOROID 1181.00 06/30/10 67220 67220 67220 036 0360 0583
17200832 LARYNSPY FLX/RGD-W/STROBO-M.D. 291.00 $ 06/30/09 31579 31579 31579 036 0975 0641
17201000 I&D OF ABSCESS SIMPLE OR SINGL 254.00 06/30/10 10060 10060 10060 036 0360 0634
17201002 FINE NEEDLE ASPIRATION BIOP 355.00 06/30/10 10021 10021 10021 036 0360 0634
17201003 I&D ABSCESS COMPLICATED/MULTPL 269.00 06/30/10 10061 10061 10061 036 0360 0634
17201006 I&D HEMATOMA SEROMA/FL COLLECT 1160.00 06/30/10 10140 10140 10140 036 0360 0634
17201009 PUNCT ASP ABCES HEMA BULLA/CYS 100.00 06/30/10 10160 10160 10160 036 0360 0634
17201012 I&D CMPLX POSTOP WOUND INF 1339.00 06/30/10 10180 10180 10180 036 0360 0634
17201015 BX SKIN&/SUBQ TIS-SEP PRO 1LES 165.00 06/30/10 11100 11100 11100 036 0360 0634
17201018 BX SKIN&/SUBQ TIS-SEP PROEA AD 130.00 06/30/10 11101 11101 11101 036 0360 0634
17201021 REMOVE SKIN TAGS UP TO 15 166.00 06/30/10 11200 11200 11200 036 0360 0634
17201024 REMOVE SKIN TAGS EACH ADDTL 10 202.00 06/30/10 11201 11201 11201 036 0360 0634
17201027 EXC BENIGN LESION NECK TO 0.5C 841.00 06/30/10 11420 11420 11420 036 0360 0634
17201030 EXC BN LES FC ERS EYLD NSE.5CM 619.00 06/30/10 11440 11440 11440 036 0360 0634
17201033 EXC BN LES FCE ERS EYLD.6-1.CM 857.00 06/30/10 11441 11441 11441 036 0360 0634
17201036 EX MAL LES FCE ERS EYLD NSE.5< 929.00 06/30/10 11640 11640 11640 036 0360 0634
17201039 SIMPL REPR FACE&/MUCOUS <2.5CM 267.00 06/30/10 12011 12011 12011 036 0360 0634
17201042 LAYER CLOS FACE&/LIPS;<2.5CM 368.00 06/30/10 12051 12051 12051 036 0360 0634
17201045 BIOPSY SOFT TISSUE NECK 715.00 06/30/10 20206 20206 20206 036 0360 0634
17201048 CHEM CAUTERIZ OF GRANULAN TISS 120.00 06/30/10 17250 17250 17250 036 0360 0634
17201051 CLOS TX NASL BN FX W/O STBL 124.00 06/30/10 21315 21315 21315 036 0360 0634
17201054 CLOS TX NASL BONE FX W/STBL 124.00 06/30/10 21320 21320 21320 036 0360 0634
17201055 I&D NASAL ABSCESS/HEMATOMA 322.00 06/30/10 30000 30000 30000 036 0360 0634
17201056 I&D SEPTAL ABSCESS/HEMATOMA 322.00 06/30/10 30020 30020 30020 036 0360 0634
17201057 RMVAL FOR BODY,INTRANASAL 115.00 06/30/10 30300 30300 30300 036 0360 0634
17201060 LYSIS INTRANASAL SYNECHIA 236.00 06/30/10 30560 30560 30560 036 0360 0634
17201063 NOSE BLEED CAUTERIZATION 270.00 06/30/10 30901 30901 30901 036 0360 0634
17201066 CNTRL NASL HEMOR ANT CMPLX MET 268.00 06/30/10 30903 30903 30903 036 0360 0634
17201069 NASAL PACKING, POSTERIOR 649.00 06/30/10 30905 30905 30905 036 0360 0634
17201072 LAVAGE CANNULTION MAXLARY SINU 236.00 06/30/10 31000 31000 31000 036 0360 0634
17201075 NASAL ENDO DX UNI/BIL SEP PROC 666.00 06/30/10 31231 31231 31231 036 0360 0634
17201078 NASL/SINUS ENDOSURG W/BX SEPPR 3168.00 06/30/10 31237 31237 31237 036 0360 0634
17201081 TRACHEOTOMY TUBE CHANGE 368.00 06/30/10 31502 31502 31502 036 0360 0634
17201084 LARYNGOSCOPY INDIRECT SEP PROC 131.00 06/30/10 31505 31505 31505 036 0360 0634
17201087 LARYNGSCPY FLXIBLE FIBEROPTC D 282.00 06/30/10 31575 31575 31575 036 0360 0634
17201090 LARYNGSCPY FLEX/RIGID W/STROBO 765.00 06/30/10 31579 31579 31579 036 0360 0634
17201093 LARYNGEAL FUNCTION STUDIES 252.00 06/30/10 92520 92520 92520 036 0440 0634
17201096 NASOPHARYNGOSCOPY 188.00 06/30/10 92511 92511 92511 036 0471 0634
17201099 ACCOUSTIC RHINOMETRY 156.00 06/30/10 92512 92512 92512 036 0510 0634
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 350
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17201102 LIP BIOPSY 180.00 06/30/10 036 0360 0634
17201105 DRAINAGE OF ABSCESS MOUTH SMPL 233.00 06/30/10 40800 40800 40800 036 0360 0634
17201108 FOREGIN BODY REMVAL MOUTH/THRT 330.00 06/30/10 40804 40804 40804 036 0360 0634
17201111 BIOPSY OF TONGUE;ANTERIOR 2/3 1430.00 06/30/10 41100 41100 41100 036 0360 0634
17201114 BIOPSY FLOOR OF MOUTH 1017.00 06/30/10 41108 41108 41108 036 0360 0634
17201115 FRENECTOMY 1522.00 06/30/10 41115 41115 41115 036 0360 0634
17201117 BIOPSY OF PALATE, UVULA 940.00 06/30/10 42100 42100 42100 036 0360 0634
17201120 DRAINAGE OF ABCES PAROTID SMPL 1762.00 06/30/10 42300 42300 42300 036 0360 0634
17201123 DRAIN ABSC;SUBMAX/SUBL INTRAOR 236.00 06/30/10 42310 42310 42310 036 0360 0634
17201126 DRAINAGE ABSC; SUBMAX EXTERNAL 236.00 06/30/10 42320 42320 42320 036 0360 0634
17201129 BIOPSY OF SALIVARY GLAND NEEDL 421.00 06/30/10 42400 42400 42400 036 0360 0634
17201132 I&D ABSCESS PERITONSILLAR 359.00 06/30/10 42700 42700 42700 036 0360 0634
17201135 DILAT ESOPH BALLOON/DILAT RETR 731.00 06/30/10 43456 43456 43456 036 0360 0634
17201138 DRAIN EXT EAR ABSC/HEMA SIMPLE 223.00 06/30/10 69000 69000 69000 036 0360 0634
17201141 DRAIN EXT EAR ABSC/HEMA COMPLE 1619.00 06/30/10 69005 69005 69005 036 0360 0634
17201144 DRAIN EX AUDIT CANAL ABSC 223.00 06/30/10 69020 69020 69020 036 0360 0634
17201147 EXTERNAL EAR BIOPSY 712.00 06/30/10 69100 69100 69100 036 0360 0634
17201150 FOREIGN BODY REMOVAL-EAR 196.00 06/30/10 69200 69200 69200 036 0360 0634
17201153 WAX REMOVAL 90.00 06/30/10 69210 69210 69210 036 0360 0634
17201154 WAX REMOVAL SAME DATE FUNC TST 82.00 06/30/10 G0268 G0268 G0268 036 0510 0634
17201156 DEBRIDE MASTOIDECTOMY CAV-SMPL 136.00 06/30/10 69220 69220 69220 036 0360 0634
17201159 DEBRIDE MASTOIDECTOMY CAV-CMPL 2357.00 06/30/10 69222 69222 69222 036 0360 0634
17201162 MYRINGOTOMY-NO ANESTHESIA 565.00 06/30/10 69420 69420 69420 036 0360 0634
17201165 VENT TUBE RMVAL-INSRT ANTHER 1147.00 06/30/10 69424 69424 69424 036 0360 0634
17201168 PE TUBES 832.00 06/30/10 69433 69433 69433 036 0360 0634
17201171 SKIN TEST TB INTRADERMAL 40.00 06/30/10 86580 86580 86850 036 0300 0634
17201174 IMMUNIZATION ADMIN 1 VACCINE 110.00 06/30/10 90471 90471 90471 036 0771 0634
17201177 FLU VAC-SPLIT,=/>3 YR IM/JET 36.00 06/30/10 90658 90658 90658 036 0636 0634
17201180 FLU VACC-WHOLE VIRUS IM/JET 33.00 06/30/10 90658 90658 90658 036 0636 0634
17201183 THERAPTIC PROPH/DX INJ SUBQ/IM 86.00 06/30/10 96372 96372 96372 036 0940 0634
17201186 THERAPEUTIC PROPH/DX INJ,IV 236.00 06/30/10 96374 96374 96374 036 0940 0634
17201189 INTRAMSCLAR INJECT ANTIBIOTIC 110.00 06/30/10 96372 96372 96372 036 0940 0634
17201192 DESTROY NERVE FACIAL MUSCLE 547.00 06/30/10 64612 64612 64612 036 0360 0634
17201195 BOTULINUM TOXIN TYPE A PER UNI 31.00 06/30/10 J0585 J0585 J0585 036 0636 0634
17201198 INJ INTRALES; UP TO&INCL 7 LES 90.00 06/30/10 11900 11900 11900 036 0360 0634
17201199 INJ INTRALES> 7 LESIONS 135.00 06/30/10 11901 11901 11901 036 0360 0634
17201201 KENALOG PER 5 MG 10.00 06/30/10 J3301 J3301 J3301 036 0636 0634
17201204 SPONTANEOUS NYSTAGMUS TEST 139.00 06/30/10 92541 92541 92541 036 0471 0634
17201207 POSITIONAL NYSTAGMUS TEST 139.00 06/30/10 92542 92542 92542 036 0471 0634
17201210 CALORIC VESTIBULAR TEST 204.00 06/30/10 92543 92543 92543 036 0471 0634
17201213 OPTOKINETIC NYSTAGMUS TEST 139.00 06/30/10 92544 92544 92544 036 0510 0634
17201216 OSCILLATING TRACKING TEST 139.00 06/30/10 92545 92545 92545 036 0471 0634
17201219 SINUSOIDAL VRT AXS ROTATION TS 252.00 06/30/10 92546 92546 92546 036 0471 0634
17201222 USE OF VERTICAL ELECTRODES 117.00 06/30/10 92547 92547 92547 036 0471 0634
17201225 COMPUTRIZED DYNMIC POSTUROGRPH 287.00 06/30/10 92548 92548 92548 036 0471 0634
17201227 SKIN END POINT TITRATION 129.00 06/30/10 95027 95027 95027 036 0924 0634
17201228 FACIAL NERVE FUNCTION STUDIES 252.00 06/30/10 92516 92516 92546 036 0471 0634
17201229 IMMUNTOX W/O EXT 1 INJ 30.00 06/30/10 95115 95115 95115 036 0510 0634
17201230 IMMUNOTX W/O EXT 2/>INJ 81.00 06/30/10 95117 95117 95117 036 0924 0634
17201231 PULSE OXIMETRY MULT DETERMIN 151.00 06/30/10 94761 94761 94761 036 0460 0634
17201232 PREP & PRVS 1/MX ANTIG 125.00 06/30/10 95165 95165 95165 036 0510 0634
17201234 HILGER NERVE STIMULATION 84.00 06/30/10 95900 95900 95900 036 0922 0634
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 351
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17201240 TRACHEOSTOMY TUBE -PORTEX 82.00 06/30/10 036 0270 0634
17201243 ADM FLU VAC NO FEE SCH SAME DA 25.00 06/30/10 G0008 G0008 G0008 036 0771 0634
17201246 CMPLX DYNMIC PHRYNGEAL & SPCH 379.00 06/30/10 70371 70371 70371 036 0320 0634
17201249 BINOCULAR MICROSCOPY 71.00 06/30/10 92504 92504 92504 036 0471 0634
17201252 EPLEY MANEUVER 23.00 06/30/10 97140 97140 97140 036 0420 0634
17201255 NDLE ELECTRO,BILAT,CRAN 805.00 06/30/10 95868 95868 95868 036 0922 0634
17201258 NDLE ELECTRO,UNILAT,CRAN 415.00 06/30/10 95867 95867 95867 036 0510 0634
17201261 UVULECTOMY EXCIS OF UVULA 560.00 06/30/10 42140 42140 42140 036 0360 0634
17201264 CHEMODENERV MUSCLE-EXTREM 524.00 06/30/10 64614 64614 64614 036 0360 0634
17201267 NASAL BIOPSY 1017.00 06/30/10 30100 30100 30100 036 0360 0634
17201270 METHYLPRDNSOLN ACTAE/80MG 66.00 06/30/10 J1040 J1040 J1040 036 0636 0634
17201275 AUDITORY EVOKED POT CMPLT 331.00 06/30/10 92585 92585 92585 036 0471 0634
17201278 TRACHEO THRU TRACH INCL 1506.00 06/30/10 31615 31615 31615 036 0360 0634
17201281 TRACH CANNULA D.I.C. 7.00 06/30/10 036 0270 0634
17201284 TRACH CAP 6.00 06/30/10 A7527 A7527 036 0270 0634
17201290 NEEDLE ELECTROMYO; LARYNX 141.00 06/30/10 95865 95865 95865 036 0922 0634
17201293 SMKE/TOBACCO CNSL 3-10MIN 12.00 06/30/10 99406 99406 99406 036 0942 0634
17201296 SMK/TOBACCO CNSL 10-20MIN 12.00 06/30/10 99407 99407 99407 036 0510 0634
17201299 DEST NEU AGNT-NECK MUSCLE 1046.00 06/30/10 64613 64613 64613 036 0360 0634
17201310 OTOACOUSTIC EMISSION-LIMITED 156.00 06/30/10 92587 92587 92587 036 0471 0634
17201312 OTOACOUSTIC EMISSION-EXTENDED 370.00 06/30/10 92588 92588 92588 036 0471 0634
17201320 PT EVALUATION-ADULT OP 208.00 06/30/10 97001GP 97001GP 97001GP 036 0420 0634
17201322 PT RE-EVALUATION -ONR 105.00 06/30/10 97002 97002 97002GP 036 0420 0634
17201328 THER EXER-ADULT OP-PER 15 MIN 124.00 06/30/10 97110GP 97110GP 97110GP 036 0420 0634
17201334 MOTOR RETRAIN-ADULT OP/15 MIN 120.00 06/30/10 97112GP 97112GP 97112GP 036 0420 0634
17201340 MANUAL LYMPH DRAINAGE/15 MIN 122.00 06/30/10 97140GP 97140GP 97140GP 036 0420 0634
17201350 FUNCT. PERF. TRAIN/PER 15 MIN 109.00 06/30/10 97530GP 97530GP 97530GP 036 0420 0634
17201358 SELF CARE/HOME MANAGE/PER 15MI 100.00 06/30/10 97535GP 97535GP 97535GP 036 0420 0634
17201364 PHYSICAL PERF TEST/PER 15 MIN. 108.00 06/30/10 97750GP 97750GP 97750GP 036 0420 0634
17201372 BAHA HEALING CAPS 87.00 06/30/10 L7510 L7510 L7510 036 0270 0634
17201374 DEXAMETHASONE 1 MG 5.00 06/30/10 J1100 J1100 J1100 036 0636 0634
17201376 GENTAMICIN UP TO 80MG 6.00 06/30/10 J1580 J1580 J1580 036 0636 0634
17201380 SINGLE AGENT IV PUSH 394.00 06/30/10 96409 96409 96409 036 0335 0634
17201385 INJECT IV CLOTTING FACTOR 80.00 06/30/10 96374 96374 96374 036 0940 0634
17201387 PROSTHETIC IMPLANT, RADIENCE 953.00 06/30/10 L8699 L8699 L8699 036 0270 0634
17201390 COLLAGEN INJ 1CC OR LESS 265.00 06/30/10 11950 11950 11950 036 0360 0634
17201392 COLLAGEN INJ 1.1-5.0CC 335.00 06/30/10 11951 11951 11951 036 0360 0634
17201394 COLLAGEN INJ 5.1-10.0CC 419.00 06/30/10 11952 11952 11952 036 0360 0634
17201396 COLLAGEN INJ OVER 10.0CC 494.00 06/30/10 11954 11954 11954 036 0360 0634
17201398 INTRACUT TESTS-ALLERG-IMMED 86.00 06/30/10 95024 95024 95024 036 0924 0634
17201400 BASIC VESTIBULAR EVALUATION 259.00 06/30/10 92540 92540 92540 036 0471 0634
17291102 LIP BIOPSY 270.00 06/30/10 40490 40490 40490 036 0360 0634
19900191 INI PRV PHY EXM-1ST 12MTH-HOSP 228.00 06/30/10 G0402 G0402 G0402 036 0510 0599
19900192 INI PRV PHY EXM-1ST 12MTH-M.D. 201.00 $ 08/01/09 G0402 G0402 G0402 036 0983 0599
19900195 ECG 12 LD W/O INTRP&REPRT-HOSP 66.00 06/30/10 G0404 G0404 G0404 036 0730 0599
19900196 ECG 12 LD W/O INTRP&REPRT-M.D. 31.00 $ 08/01/09 G0404 G0404 G0404 036 0985 0599
19920101 OFFC VST NEW LVL1-HOSPITL 100.00 06/30/10 99201 99201 99201 036 0510 0599
19920102 OFFC VST NEW LVL1-DOCTOR 51.00 $ 06/30/09 99201 99201 99201 036 0983 0599
19920201 OFFC VST NEW LVL2-HOSPITL 120.00 06/30/10 99202 99202 99202 036 0510 0599
19920202 OFFC VST NEW LVL2-DOCTOR 97.00 $ 06/30/09 99202 99202 99202 036 0983 0599
19920301 OFFC VST NEW LVL3-HOSPITL 155.00 06/30/10 99203 99203 99203 036 0510 0599
19920302 OFFC VST NEW LVL3-DOCTOR 148.00 $ 06/30/09 99203 99203 99203 036 0983 0599
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 352
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

19920401 OFFC VST NEW LVL4-HOSPITL 197.00 06/30/10 99204 99204 99204 036 0510 0599
19920402 OFFC VST NEW LVL4-DOCTOR 245.00 $ 06/30/09 99204 99204 99204 036 0983 0599
19920501 OFFC VST NEW LVL5-HOSPITL 225.00 06/30/10 99205 99205 99205 036 0510 0599
19920502 OFFC VST NEW LVL5-DOCTOR 318.00 $ 06/30/09 99205 99205 99205 036 0983 0599
19921101 OFFC VST EST LVL1-HOSPITL 100.00 06/30/10 99211 99211 99211 036 0510 0599
19921102 OFFC VST EST LVL1-DOCTOR 19.00 $ 06/30/09 99211 99211 99211 036 0983 0599
19921201 OFFC VST EST LVL2-HOSPITL 120.00 06/30/10 99212 99212 99212 036 0510 0599
19921202 OFFC VST EST LVL2-DOCTOR 50.00 $ 06/30/09 99212 99212 99212 036 0983 0599
19921301 OFFC VST EST LVL3-HOSPITL 155.00 06/30/10 99213 99213 99213 036 0510 0599
19921302 OFFC VST EST LVL3-DOCTOR 95.00 $ 06/30/09 99213 99213 99213 036 0983 0599
19921401 OFFC VST EST LVL4-HOSPITL 197.00 06/30/10 99214 99214 99214 036 0510 0599
19921402 OFFC VST EST LVL4-DOCTOR 147.00 $ 06/30/09 99214 99214 99214 036 0983 0599
19921501 OFFC VST EST LVL5-HOSPITL 225.00 06/30/10 99215 99215 99215 036 0510 0599
19921502 OFFC VST EST LVL5-DOCTOR 210.00 $ 06/30/09 99215 99215 99215 036 0983 0599
19924102 OFFC CONSULT LVL1-DOCTOR 72.00 $ 06/30/09 99241 99241 99241 036 0983 0599
19924202 OFFC CONSULT LVL2-DOCTOR 152.00 $ 06/30/09 99242 99242 99242 036 0983 0599
19924302 OFFC CONSULT LVL3-DOCTOR 211.00 $ 06/30/09 99243 99243 99243 036 0983 0599
19924502 OFFC CONSULT LVL5-DOCTOR 413.00 $ 06/30/09 99245 99245 99245 036 0983 0599
19924609 PREV MED NEW PT-18-39 YRS-HOSP 193.00 06/30/10 99385 99385 99385 036 0510 0599
19924610 PREV MED NEW PT-18-39 YRS-M.D. 163.00 $ 06/30/09 99385 99385 99385 036 0983 0599
19924611 PREV MED NEW PT-40-64 YRS-HOSP 152.00 06/30/10 99386 99386 99386 036 0510 0599
19924612 PREV MED NEW PT-40-64 YRS-M.D. 199.00 $ 06/30/09 99386 99386 99386 036 0983 0599
19924613 PREV MED NEW PT-65+ YRS-HOSP 169.00 06/30/10 99387 99387 99387 036 0510 0599
19924614 PREV MED NEW PT-65+ YRS-M.D. 218.00 $ 06/30/09 99387 99387 99387 036 0983 0599
19924629 PREV MED EST PT 18-39 YRS-HOSP 161.00 06/30/10 99395 99395 99395 036 0510 0599
19924630 PREV MED EST PT 18-39 YRS-M.D. 144.00 $ 06/30/09 99395 99395 99395 036 0983 0599
19924631 PREV MED EST PT 40-64 YRS-HOSP 127.00 06/30/10 99396 99396 99396 036 0510 0599
19924632 PREV MED EST PT 40-64 YRS-M.D. 163.00 $ 06/30/09 99396 99396 99396 036 0983 0599
19924633 PREV MED EST PT 65+ YRS-HOSP 143.00 06/30/10 99397 99397 99397 036 0510 0599
19924634 PREV MED EST PT 65+ YRS-M.D. 182.00 $ 06/30/10 99397 99397 99397 036 0983 0599
19980061 LIPID PROFILE 202.00 06/30/10 80061QW 80061QW 80061QW 036 0300 0599
19981000 URINE DIPSTICK W/MICROSCOPY 38.00 06/30/10 81000 81000 81000 036 0300 0599
19981002 URINE DIPSTICK W/O MICROSCOPY 35.00 06/30/10 81002 81002 81002 036 0300 0599
19981003 UA W/O MICRO NON-AUTOMATED 45.00 06/30/10 81003QW 81003QW 81003QW 036 0300 0599
19981025 PREGNANCY TEST, URINE HCG 90.00 06/30/10 81025 81025 81025 036 0300 0599
19982270 BLOOD OCCT. FECAL SCREEN 34.00 06/30/10 82270 82270 82270 036 0301 0599
19982947 QUAN GLUCOSE DETERMINATION 41.00 06/30/10 82947 82947 82947 036 0301 0599
19982948 BLOOD GLUCOSE-STRIP METHOD 41.00 06/30/10 82948 82948 82948 036 0301 0599
19983036 HEMOGLOBIN, GLYCOSLATED 165.00 06/30/10 83036QW 83036QW 83036QW 036 0301 0599
19983986 PH,BODY FLUID,EXCEPT BLOOD 38.00 06/30/10 83986QW 83986QW 83986QW 036 0301 0599
19985018 HEMOGLOBIN 37.00 06/30/10 85018QW 85018QW 85018QW 036 0305 0599
19985610 PROTHROMBIN TIME 51.00 06/30/10 85610QW 85610QW 85610QW 036 0305 0599
19987880 STREP A 83.00 06/30/10 87880QW 87880QW 87880QW 036 0300 0599
19990698 DIPTH,TETAN,PERTUSSIS,HIB,IPV 19.00 06/30/10 90698 90698 90698 036 0636 0599
19997802 MED NUTRITION THRPY-EA 15 MIN 75.00 06/30/10 97802 97802 97802 036 0510 0599
19997803 MED NUTR,RE-ASS/INT EA 15MIN 41.00 06/30/10 97803 97803 97803 036 0510 0599
19997804 MED NUTR THRPY-GROUP-EA 30 MIN 85.00 06/30/10 97804 97804 97804 036 0510 0599
40400003 OFFICE VISIT NEW LEVEL 2 120.00 06/30/10 99202 99202 99202 036 0510 3320
40400005 OFFICE VISIT NEW LEVEL 3 155.00 06/30/10 99203 99203 99203 036 0510 3320
40400007 OFFICE VISIT NEW LEVEL 4 197.00 06/30/10 99204 99204 99204 036 0510 3320
40400009 OFFICE VISIT NEW LEVEL 5 225.00 06/30/10 99205 99205 99205 036 0510 3320
40400011 OFFICE VISIT EST LEVEL 1 100.00 06/30/10 99211 99211 99211 036 0510 3320
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 353
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

40400013 OFFICE VISIT EST LEVEL 2 120.00 06/30/10 99212 99212 99212 036 0510 3320
40400015 OFFICE VISIT EST LEVEL 3 155.00 06/30/10 99213 99213 99213 036 0510 3320
40400017 OFFICE VISIT EST LEVEL 4 197.00 06/30/10 99214 99214 99214 036 0510 3320
40400019 OFFICE VISIT EST LEVEL 5 225.00 06/30/10 99215 99215 99215 036 0510 3320
40400021 OFFICE CONSULT LEVEL 1 157.00 06/30/10 99241 99241 99241 036 0510 3320
40400023 OFFICE CONSULT LEVEL 2 207.00 06/30/10 99242 99242 99242 036 0510 3320
40400027 OFFICE CONSULT LEVEL 4 347.00 06/30/10 99244 99244 99244 036 0510 3320
40400029 OFFICE CONSULT LEVEL 5 356.00 06/30/10 99245 99245 99245 036 0510 3320
40400031 CONFIRMATORY CONSULT LEVEL 1 188.00 06/30/10 99241 99241 99241 036 0510 3320
40400033 CONFIRMATORY CONSULT LEVEL 2 211.00 06/30/10 99242 99242 99242 036 0510 3320
40400037 CONFIRMATORY CONSULT LEVEL 4 306.00 06/30/10 99244 99244 99244 036 0510 3320
40400039 CONFIRMATORY CONSULT LEVEL 5 406.00 06/30/10 99245 99245 99245 036 0510 3320
40400105 DIPHTHERIA/TETANUS TOXOID (DT) 52.00 06/30/10 90702 90702 90702 99.36 036 0636 3320
40400107 TETANUS TOX ABSORBD FOR IMUSE 42.00 06/30/10 90703 90703 90703 99.38 036 0636 3320
40400131 VARICELLA(CHICKEN POX) VACCINE 271.00 06/30/10 90716 90716 90716 99.59 036 0636 3320
40400135 TD ADSORB-INDIV 7 YRS/OLDER-IM 18.00 06/30/10 90718 90718 90718 99.36 036 0636 3320
40400143 FLU VIR VAC-SPLT 6-35MO IM USE 22.00 06/30/10 90657 90657 90657 99.52 036 0636 3320
40400155 PNEUMOCOCCAL VACCINE 41.00 06/30/10 90732 90732 90732 99.55 036 0636 3320
40400161 HEMOPHILUS INFLUENZA B 68.00 06/30/10 90748 90748 90748 99.52 036 0636 3320
40400171 HEPATITIS B VACCINE; 20 YRS 103.00 06/30/10 90746 90746 90746 99.55 036 0636 3320
40400201 IV INFUSION; UP TO ONE HR 87.00 06/30/10 96365 96365 96365 036 0260 3320
40400203 IV INFUSION; EA ADDITIONAL HR 181.00 06/30/10 96366 96366 96366 036 0260 3320
40400209 INJECTION; INTRAVENOUS 89.00 06/30/10 96374 96374 96374 036 0940 3320
40400261 PULSE OXIMETRY, SINGLE 115.00 06/30/10 94760 94760 94760 89.38 036 0460 3320
40400309 CHEMOTHER ADMIN INFUSION 1 HR 418.00 06/30/10 96413 96413 96413 99.25 036 0335 3320
40400311 CHEMOTHER ADM INFUS 1-8 HRS EA 183.00 06/30/10 96415 96415 96415 99.25 036 0335 3320
40400911 BLOOD, OCCULT FECES SCREEN 1-3 38.00 06/30/10 82270 82270 82270 036 0301 3320
40400985 SKIN TEST; CANDIDA 88.00 06/30/10 86485 86485 86485 036 0302 3320
40400987 SKIN TEST; TB, INTRADERMAL 52.00 06/30/10 86580 86580 86580 036 0302 3320
40400989 SKIN TEST TRICHOPHYTON 80.00 06/30/10 86486 86486 86486 036 0302 3320
40401021 SKIN TEST MUMPS 75.00 06/30/10 86735 86735 86735 036 0302 3320
41320116 INSERT LV CORONARY SINUS LEAD 6351.00 06/30/10 33225 33225 33225 036 0360 3333
99999999 DIAGNOSIS, ADMIN TRANSACTN N/C N/C 06/30/10 037 0940 9999
03799281 EMER DEPT VISIT LEVEL 1 123.00 06/30/10 99281 99281 99281 038 0451 6812
03799282 EMER DEPT VISIT LEVEL 2 352.00 06/30/10 99282 99282 99282 038 0450 6812
03799283 EMER DEPT VISIT LEVEL 3 453.00 06/30/10 99283 99283 99283 038 0450 6812
03799284 EMER DEPT VISIT LEVEL 4 877.00 06/30/10 99284 99284 99284 038 0450 6812
03799285 EMER DEPT VISIT LEVEL 5 1425.00 06/30/10 99285 99285 99285 038 0450 6812
07121001 EMERGENCY VISIT OB,LEVEL 1 123.00 06/30/10 99281 99281 99281 038 0450 0846
07121002 EMERGENCY VISIT OB, LEVEL 2 352.00 06/30/10 99282 99282 99282 038 0450 0846
07121003 EMERGENCY VISIT OB, LEVEL 3 453.00 06/30/10 99283 99283 99283 038 0450 0846
07121004 EMERGENCY VISIT OB, LEVEL 4 877.00 06/30/10 99284 99284 99284 038 0450 0846
07121005 EMERGENCY VISIT OB, LEVEL 5 1425.00 06/30/10 99285 99285 99285 038 0450 0846
08900001 EMER DEPT VISIT LEVEL 1 123.00 06/30/10 99281 99281 99281 038 0450 6812
08900002 EMER DEPT VISIT LEVEL 2 352.00 06/30/10 99282 99282 99282 038 0450 6812
08900003 EMER DEPT VISIT LEVEL 3 453.00 06/30/10 99283 99283 99283 038 0450 6812
08900004 EMER DEPT VISIT LEVEL 4 877.00 06/30/10 99284 99284 99284 038 0450 6812
08900005 EMER DEPT VISIT LEVEL 5 1425.00 06/30/10 99285 99285 99285 038 0450 6812
08900006 EMER DEPT VISIT LEVEL 6 1538.00 06/30/10 99285 99285 99285 038 0450 6812
08900024 VITAL CAPACITY SCREENING TESTS 82.00 06/30/10 94150 94150 94150 038 0460 6812
08900027 TRANSFUSION BLOOD/BLD COMPS 776.00 06/30/10 36430 36430 36430 038 0391 6812
08900033 INTRO NDLE/INTRACATHETER VEIN 94.00 06/30/10 36000 36000 36000 038 0260 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 354
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08900036 PORT ACCESS 250.00 06/30/10 36591 36591 36591 038 0260 6812
08900039 ART PUNCT WITHDRAW BLD DX 117.00 06/30/10 36600 36600 36600 038 0450 6812
08900042 CATHETR URETH SIMPLE(STR CATH) 61.00 06/30/10 51701 51701 51701 038 0450 6812
08900045 CATHETER URETHRA; COMPL 309.00 06/30/10 51703 51703 51703 038 0450 6812
08900048 TD ADSRB-7 YRS/OLDR-IM/JET INJ 31.00 06/30/10 96373 96373 96373 038 0450 6812
08900051 DIPTHERIA TOXOID-INTRAMUSC 146.00 06/30/10 90719 90719 90719 038 0636 6812
08900054 THERAP PROPH/DX INJ; SUBQ/IM 88.00 06/30/10 96372 96372 96372 038 0940 6812
08900057 THERAP PROPH/DX INJ; INTRA-ART 194.00 06/30/10 96373 96373 96373 038 0450 6812
08900060 THERAPUTIC PROPH/DX INJECT; IV 194.00 06/30/10 96374 96374 96374 038 0940 6812
08900063 OFC/OUTPT E&M NEW MINOR 10 MIN 100.00 06/30/10 99201 99201 99201 038 0456 6812
08900066 OFC/OTPT E&M NEW LOW-MD 20 MIN 86.00 06/30/10 99202 99202 99202 038 0983 6812
08900069 CRITCAL CARE E&M;1ST 30-74 MIN 1271.00 06/30/10 99291QW 99291QW 99291QW 038 0450 6812
08900075 URINE DIP 69.00 06/30/10 81003 81003 81003 038 0300 6812
08900078 ATTEND DEL&INIT STABILZATON NB 63.00 06/30/10 99464 99464 99464 038 0410 6812
08900081 HEMOGLOBIN; URINE 58.00 06/30/10 81001 81001 81001 038 0300 6812
08900084 PREGNANCY TEST - URINE 71.00 06/30/10 81025 81025 81025 038 0300 6812
08900087 INT TX 1ST DEG BURN NO >LOC TX 111.00 06/30/10 16000 16000 16000 038 0450 6812
08900090 INTR HEMSTATC AGT VAG-SEP PRC 244.00 06/30/10 57180 57180 57180 038 0450 6812
08900093 I & D - ABSCESS 242.00 06/30/10 10060 10060 10060 038 0450 6812
08900096 TEMP TRANSCUTANEOUS PACING 289.00 06/30/10 92953 92953 92953 038 0450 6812
08900099 CHANGE GASTROSTOMY TUBE 337.00 06/30/10 43760 43760 43760 038 0450 6812
08900102 PRESS OR NON PRESS INHALE TRTM 156.00 06/30/10 94640 94640 94640 038 0412 6812
08900105 CONTINUOUS NEBULIZER-1ST HR 170.00 06/30/10 94644 94644 94644 038 0410 6812
08900108 CONT NEBULIZER EA ADD'L HR 115.00 06/30/10 94645 94645 94645 038 0410 6812
08900203 SPINAL PUNCTURE,LUMBAR,DIAGNOS 351.00 06/30/10 62270 62270 62270 038 0361 6812
08901003 PULSE OXIMETRY 108.00 06/30/10 94760 94760 94760 038 0460 6812
08901006 PULSE OXIMETRY FOR 02 SAT MULT 179.00 06/30/10 94761 94761 94761 038 0460 6812
08910001 REMV FB EXT EYE;CORNL W/O LAMP 255.00 06/30/10 65220 65220 65220 038 0450 6812
08910004 REMV FB EXT EYE; CONJUNCT SUP 255.00 06/30/10 65205 65205 65205 038 0450 6812
08910007 REMV FB-EXT AUD CANAL;W/O ANES 193.00 06/30/10 69200 69200 69200 038 0450 6812
08910010 ALCOHOL; BREATH 61.00 06/30/10 82075 82075 82075 038 0300 6812
08910013 REMV IMPCT CERUMEN 1/BTH EARS 194.00 06/30/10 69210 69210 69210 038 0450 6812
08910100 I&D ABSCESS; COMPLICATED/MULT 273.00 06/30/10 10061 10061 10061 038 0450 6812
08910103 I&D OF PILONIDAL CYST; COMPLEX 871.00 06/30/10 10081 10081 10081 038 0450 6812
08910106 INCISI&REMVL FBSUBQTISS; SMPL 193.00 06/30/10 10120 10120 10120 038 0450 6812
08910109 PUNC ASPR ABSC HEMA BLLA/CYST 100.00 06/30/10 10160 10160 10160 038 0450 6812
08910112 DEBRIDE; SKIN PARTIAL THICK 204.00 06/30/10 11040 11040 11040 038 0450 6812
08910115 SIMPL REPR SCLP&TRUNK < 2.5 CM 173.00 06/30/10 12001 12001 12001 038 0450 6812
08910118 SIMPL REPR SCLP&TRNK 2.6-7.5CM 279.00 06/30/10 12002 12002 12002 038 0450 6812
08910121 SIMP REP SCLP&TRNK; 7.6-12.5CM 407.00 06/30/10 12004 12004 12004 038 0450 6812
08910124 SIMP REP SCLP&TRNK;12.6-20.0CM 601.00 06/30/10 12005 12005 12005 038 0450 6812
08910127 SIMP REPR SCLP&TRUNK;>30.0CM 859.00 06/30/10 12007 12007 12007 038 0450 6812
08910130 SIMPL REPR FACE&/MUC < 2.5 CM 173.00 06/30/10 12011 12011 12011 038 0450 6812
08910133 SIMPL REPR FACE&MUC 2.6-5.0 CM 244.00 06/30/10 12013 12013 12013 038 0450 6812
08910136 SIMPL REPR FACE&MUC 5.1-7.5 CM 279.00 06/30/10 12014 12014 12014 038 0450 6812
08910139 SIMPL REPR FACE&MUC7.6-12.5 CM 407.00 06/30/10 12015 12015 12015 038 0450 6812
08910142 SIMPL REPR FACE&MUC12.6-20. CM 748.00 06/30/10 12016 12016 12016 038 0450 6812
08910145 SIMPL REPR FACE&MUC;20.1-30CM 1195.00 06/30/10 12017 12017 12017 038 0450 6812
08910148 SIMPL REPR FACE&MUC >30CM 1793.00 06/30/10 12018 12018 12018 038 0450 6812
08910151 LAYER CLOS SCLP&TRNK 2.6-7.5CM 466.00 06/30/10 12032 12032 12032 038 0450 6812
08910154 LAYER CLS SCLP&TRNK 7.6-12.5CM 407.00 06/30/10 12034 12034 12034 038 0450 6812
08910157 LAYER CLS SCLP&TRNK 12.6-20CM 601.00 06/30/10 12035 12035 12035 038 0450 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 355
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08910160 LAYER CLS SCLP&TRNK 20.1-30CM 859.00 06/30/10 12036 12036 12036 038 0450 6812
08910163 LAYER CLOS SCLP&TRUNK > 30CM 1117.00 06/30/10 12037 12037 12037 038 0450 6812
08910166 LAYER CLS NCK FT&GENIT < 2.5CM 165.00 06/30/10 12041 12041 12041 038 0450 6812
08910169 LAYER CLS NECK&GENIT;2.6-7.5CM 279.00 06/30/10 12042 12042 12042 038 0450 6812
08910172 LAYER CLS NCK&GENIT;7.6-12.5CM 407.00 06/30/10 12044 12044 12044 038 0450 6812
08910175 LAYER CLS NCK&GENIT; 12.6-20CM 601.00 06/30/10 12045 12045 12045 038 0450 6812
08910178 LAYER CLS NCK&GENIT; 20.1-30CM 859.00 06/30/10 12046 12046 12046 038 0450 6812
08910181 LAYER CLOS NECK&GENIT; > 30CM 1117.00 06/30/10 12047 12047 12047 038 0450 6812
08910184 LAYER CLOS FACE&LIPS; < 2.5 CM 152.00 06/30/10 12051 12051 12051 038 0450 6812
08910187 LAYER CLOS FACE&LIPS;2.6-5.0CM 244.00 06/30/10 12052 12052 12052 038 0450 6812
08910190 LAYER CLOS FACE&LIPS;5.1-7.5CM 279.00 06/30/10 12053 12053 12053 038 0450 6812
08910193 LAYER CLS FACE&LIPS 7.6-12.5CM 407.00 06/30/10 12054 12054 12054 038 0450 6812
08910196 LAYER CLS FACE&LIPS; 12.6-20CM 601.00 06/30/10 12055 12055 12055 038 0450 6812
08910199 LAYER CLS FACE&LIPS; 20.1-30CM 859.00 06/30/10 12056 12056 12056 038 0450 6812
08910202 LAYER CLOS FACE&LIPS;>30.0 CM 1117.00 06/30/10 12057 12057 12057 038 0450 6812
08910205 REPAIR COMPLX TRUNK; 1.1-2.5CM 256.00 06/30/10 13100 13100 13100 038 0450 6812
08910208 REPAIR COMPLX TRUNK;2.6-7.5CM 354.00 06/30/10 13101 13101 13101 038 0450 6812
08910211 REP CMPLX TRNK; EA AD 5CM/LESS 256.00 06/30/10 13102 13102 13102 038 0450 6812
08910214 RP CPLX SCLP ARM&LEG;1.1-2.5CM 225.00 06/30/10 13120 13120 13120 038 0450 6812
08910217 RP CPLX SCLP ARM&LEG;2.6-7.5CM 263.00 06/30/10 13121 13121 13121 038 0450 6812
08910220 RP CPLX SCLP ARM&/LEG;EA AD5CM 225.00 06/30/10 13122 13122 13122 038 0450 6812
08910501 REP CPLX FORHEAD&\FT;1.1-2.5CM 225.00 06/30/10 13131 13131 13131 038 0450 6812
08910504 REP CPLX FORHEAD&/FT;2.6-7.5CM 306.00 06/30/10 13132 13132 13132 038 0450 6812
08910507 REP CPLX FORHEAD&/FT;EA ADD5CM 77.00 06/30/10 13133 13133 13133 038 0450 6812
08910510 REPR CMPLX EYELD&/LIPS<1.0CM 1622.00 06/30/10 13150 13150 13150 038 0450 6812
08910513 REP CPLX EYELD&/LIPS;1.1-2.5CM 1654.00 06/30/10 13151 13151 13151 038 0450 6812
08910516 REP CPLX EYELD&/LIPS;2.6-7.5CM 1016.00 06/30/10 13152 13152 13152 038 0450 6812
08910519 REP CPLX EYELD&/LPS;EA ADD 5CM 225.00 06/30/10 13153 13153 13153 038 0450 6812
08910522 DRESS/DEBRIDEMENT-SMALL 164.00 06/30/10 16020 16020 16020 038 0450 6812
08910525 DRESS/DEBRIDEMENT-MEDIUM 111.00 06/30/10 16025 16025 16025 038 0450 6812
08910528 DRESS/DEBRIDEMENT-LARGE 166.00 06/30/10 16030 16030 16030 038 0450 6812
08910531 ARTHROCENT ASPIR&INJ;SM JT 278.00 06/30/10 20600 20600 20600 038 0450 6812
08910534 ARTHRCEN ASPR&/INJ INTRMED JNT 245.00 06/30/10 20605 20605 20605 038 0450 6812
08910537 ARTHROCENT ASP&/INJ;MAJ JNT 179.00 06/30/10 20610 20610 20610 038 0450 6812
08910540 ASPIRATION&INJ TX BONE CYST 308.00 06/30/10 20615 20615 20615 038 0360 6812
08910543 I&D UPPER ARM OR ELBOW-BURSA 390.00 06/30/10 23931 23931 23931 038 0450 6812
08910546 I&D DP ABS BURS/HEMAT THGH/KN 1339.00 06/30/10 27301 27301 27301 038 0450 6812
08910549 I&D LEG OR ANK;INFECTED BURSA 1519.00 06/30/10 27604 27604 27604 038 0450 6812
08910552 INCIS&DRAINAGE,BURSA, FOOT 1061.00 06/30/10 28001 28001 28001 038 0450 6812
08910555 PNEUMOCENT PUNC LUNG ASP 590.00 06/30/10 32420 32420 32420 038 0450 6812
08910558 DRAIN ABSC VESTIBLE MOUTH SMPL 237.00 06/30/10 40800 40800 40800 038 0450 6812
08910561 I&D ABSCESS,PERITONSILLAR 267.00 06/30/10 42700 42700 42700 038 0450 6812
08910564 REMVL FORGN BODY FRM PHARNYX 115.00 06/30/10 42809 42809 42809 038 0450 6812
08910567 PRCTSIGIDSCPY RIGID;W/REMV FB 402.00 06/30/10 45307 45307 45307 038 0450 6812
08910570 PUNCT SHUNT TUBE/RESERVOIR-ASP 440.00 06/30/10 61070 61070 61070 038 0450 6812
08930001 IMMUNIZATION ADMIN; 1 VACCINE 108.00 06/30/10 90471 90471 90471 038 0450 6812
08930004 IMMUNIZATION ADMIN; EA ADD VAC 80.00 06/30/10 90472 90472 90472 038 0450 6812
08930007 IMMU ADMN INTRANASL/ORL;1 VAC 96.00 06/30/10 90473 90473 90473 038 0450 6812
08930010 IMMU ADM INTRANASL/ORL;ADD VAC 96.00 06/30/10 90474 90474 90474 038 0450 6812
08930013 MAX BREATH CAPAC MAX VOL VENT 130.00 06/30/10 94200 94200 94200 038 0460 6812
08930016 ROUTINE VENIPUNCT CLCT SPECI 24.00 06/30/10 36415 36415 36415 038 0450 6812
08930019 IV INFUSIN THER/DIAG EA 1ST HR 271.00 06/30/10 96365 96365 96365 038 0260 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 356
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08930022 IV INFUSIN THER/DIAG EA ADD HR 271.00 06/30/10 96366 96366 96366 038 0260 6812
08930025 ECG-12 LEADS-PEDIATRIC 197.00 06/30/10 93005 93005 93005 038 0730 6812
08930028 VENPUNCT CUTDWN; AGE 1 & OVER 88.00 06/30/10 36425 36425 36425 038 0450 6812
08930031 IV HYDR,INIT TO 1 HR 402.00 06/30/10 96360 96360 96360 038 0260 6812
08930034 IV HYDR EA ADD HR UP TO 8 244.00 06/30/10 96361 96361 96361 038 0260 6812
08930040 IV INJ IVP, INIT 236.00 06/30/10 96374 96374 96374 038 0260 6812
08930041 IV INJECT IVP,ADD'L 125.00 06/30/10 96375 96375 96375 038 0260 6812
08940001 INTUBE ENDOTRACH EMRG PROC 77.00 06/30/10 31500 31500 31500 038 0450 6812
08940007 TRCHEOST EMRG PRC; TRNSTRCH 579.00 06/30/10 31603 31603 31603 038 0450 6812
08940010 TRCHEOST EMG; CRICOTHYRD MMB 1196.00 06/30/10 31605 31605 31605 038 0450 6812
08940013 THORACENTESIS ASPIR INIT/SUBS 598.00 06/30/10 32421 32421 32421 038 0450 6812
08940016 TUBE THORACOSTOMY SEP PROC 598.00 06/30/10 32551 32551 32551 038 0450 6812
08940019 INTRO CATHR SUP/INF VENA CAVA 552.00 06/30/10 36010 36010 36010 038 0450 6812
08940022 PLCMNT NDLE INTRAOSSUS INFUS 300.00 06/30/10 36680 36680 36680 038 0450 6812
08940025 PERITONEOCENTESIS; INIT 683.00 06/30/10 49080 49080 49080 038 0450 6812
08940028 GASTRIC INTUBAT&ASPIR/LAVGE TX 317.00 06/30/10 91105 91105 91105 038 0450 6812
08940031 CARDIOPULMNARY RESUSCTATION 587.00 06/30/10 92950 92950 92950 038 0450 6812
08940034 CLOS TX SKULL FX W/O OPERATION 1196.00 06/30/10 038 0450 6812
08940037 TRANSFUSION BLOOD/BLD COMPS 776.00 06/30/10 36430 36430 36430 038 0391 6812
08940040 ECG 12 LEADS - ADULT 197.00 06/30/10 93005 93005 93005 038 0730 6812
08940543 I&D UPPER ARM OR ELBOW-BURSA 390.00 06/30/10 23931 23931 23931 038 0450 6812
08950001 CLOS TX RIB FRCT UNCOMP EA 395.00 06/30/10 21800 21800 21800 038 0450 6812
08950004 CLOSED TRTMNT STERNUM FRACT 246.00 06/30/10 21820 21820 21820 038 0450 6812
08950007 CLOS TX VERTEBRL PRCESS FRACT 395.00 06/30/10 22305 22305 22305 038 0450 6812
08950010 CLOS TX CLAVICULAR FX;W/O MANP 395.00 06/30/10 23500 23500 23500 038 0450 6812
08950013 CLOS TX CMC DISLC THMB W/MAN 395.00 06/30/10 26641 26641 26641 038 0450 6812
08950016 CLOS TX STERNCLV DISLC;W MANP 331.00 06/30/10 23525 23525 23525 038 0450 6812
08950019 CLOS TX STRNCLV DISLC;W/O MANP 331.00 06/30/10 23520 23520 23520 038 0450 6812
08950022 CLOS TX AC DISLOC; W/O MANIP 246.00 06/30/10 23540 23540 23540 038 0450 6812
08950025 CLOS TX AC DISLOC; W/MANIP 395.00 06/30/10 23545 23545 23545 038 0450 6812
08950028 CLOS TX SCAP FX; W/O MANIP 395.00 06/30/10 23570 23570 23570 038 0450 6812
08950031 CLS TX SCP FX; W/MANP W/WO TRC 331.00 06/30/10 23575 23575 23575 038 0450 6812
08950034 CLOS TX PRX HMERL FX; W/O MANP 246.00 06/30/10 23600 23600 23600 038 0450 6812
08950037 CLS TX PROX HMERAL FX; W/MANIP 371.00 06/30/10 23605 23605 23605 038 0450 6812
08950040 CLOS TX GT HUM TBERS FX;WO MNP 246.00 06/30/10 23620 23620 23620 038 0450 6812
08950043 CLOS TX GT HUM TBERS FX; W/MNP 371.00 06/30/10 23625 23625 23625 038 0450 6812
08950046 CLS TX SHLDR DISLC W/MNP;WO AN 395.00 06/30/10 23650 23650 23650 038 0450 6812
08950049 CLS TX SHLDR DISLC W/MNP;W/ANS 1133.00 06/30/10 23655 23655 23655 038 0361 6812
08950052 CLS TX SHLDR DISLC W/FX GT HUM 331.00 06/30/10 23665 23665 23665 038 0450 6812
08950055 CLS TX SHLDR DISLC W/FX SRG NK 246.00 06/30/10 23675 23675 23675 038 0450 6812
08950058 CLOS TX HUM SHAFT FX; W/O MANP 246.00 06/30/10 24500 24500 24500 038 0450 6812
08950061 CLOS TX HUM FX; W/MNP WWO TRC 246.00 06/30/10 24505 24505 24505 038 0450 6812
08950064 CLS TX SPRCOND HUM FX; WO MNP 246.00 06/30/10 24530 24530 24530 038 0450 6812
08950067 CLS TX SPRCOND HUM FX; W/MNP 331.00 06/30/10 24535 24535 24535 038 0450 6812
08950070 CLOS TX HUM EPICND FX; W/O MNP 246.00 06/30/10 24560 24560 24560 038 0450 6812
08950073 CLOS TX HUM EPICOND FX; W/MNP 246.00 06/30/10 24565 24565 24565 038 0450 6812
08950076 CLS TX HUM CONDYLR FX; WO MNP 246.00 06/30/10 24576 24576 24576 038 0450 6812
08950079 CLOS TX HUM CONDYLAR FX; W/MNP 331.00 06/30/10 24577 24577 24577 038 0450 6812
08950082 TX CLOS ELB DISLOC; W/O ANES 246.00 06/30/10 24600 24600 24600 038 0450 6812
08950085 CLS TX MONTEGGIA FX ELBO W/MNP 371.00 06/30/10 24620 24620 24620 038 0450 6812
08950088 CLOS TX RDIAL HD/NCK FX;WO MNP 246.00 06/30/10 24650 24650 24650 038 0450 6812
08950091 CLOS TX RADIAL HD/NCK FX;W/MNP 331.00 06/30/10 24655 24655 24655 038 0450 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 357
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08950094 CLOS TX ULNR FX PRX END;WO MNP 246.00 06/30/10 24670 24670 24670 038 0450 6812
08950097 CLOS TX ULNR FX PRX END; W/MNP 246.00 06/30/10 24675 24675 24675 038 0450 6812
08950098 CLOS TX MED MALLOUS FX; W/MNP 371.00 06/30/10 27762 27762 27762 038 0450 6812
08950100 CLOS TX RADIAL SHAFT FX;WO MNP 331.00 06/30/10 25505 25505 25505 038 0450 6812
08950103 CLOS TX RADIAL SHAFT FX;W/MANP 331.00 06/30/10 25505 25505 25505 038 0450 6812
08950106 CLOS TX RADL FX&DISLC RADULNR 331.00 06/30/10 25520 25520 25520 038 0450 6812
08950109 CLOS TX ULNAR SHAFT FX;W/O MNP 246.00 06/30/10 25530 25530 25530 038 0450 6812
08950112 CLOS TX ULNAR SHAFT FX; W/MANP 246.00 06/30/10 25535 25535 25535 038 0450 6812
08950115 CLOS TX RADL & ULNA FX; WO MNP 246.00 06/30/10 25560 25560 25560 038 0450 6812
08950118 CLOS TX RADIAL & ULNA FX;W/MNP 331.00 06/30/10 25565 25565 25565 038 0450 6812
08950121 CLOS TX DIST RADIAL FX;W/O MNP 246.00 06/30/10 25600 25600 25600 038 0450 6812
08950124 CLOS TX DIST RADIAL FX;REQ MNP 371.00 06/30/10 25605 25605 25605 038 0450 6812
08950126 CLS TX CARP SCPHOID FX;WO MNP 246.00 06/30/10 25622 25622 25622 038 0450 6812
08950127 CLOS TX CARP SCPHOID FX; W/MNP 331.00 06/30/10 25624 25624 25624 038 0450 6812
08950130 CLOS TX CARP BNE FX; WO MNP EA 246.00 06/30/10 25630 25630 25630 038 0450 6812
08950133 CLOS TX CARP BNE FX; W/MNP EA 331.00 06/30/10 25635 25635 25635 038 0450 6812
08950136 CLOSED TX ULNAR STYLOID FRACT 246.00 06/30/10 25650 25650 25650 038 0450 6812
08950139 CLOS TX RADIOCARPL DISLC W/MNP 246.00 06/30/10 25660 25660 25660 038 0450 6812
08950142 CLOS TX RADIOULNR DISLC W/MNP 246.00 06/30/10 25675 25675 25675 038 0450 6812
08950145 CLOS TX TRNS-SCPHRLNR W/MNP 246.00 06/30/10 25680 25680 25680 038 0450 6812
08950148 CLOS TX LUNATE DISLOC W/MANIP 371.00 06/30/10 25690 25690 25690 038 0450 6812
08950151 CLOS TX DST EXT TND WWO PIN 1176.00 06/30/10 26432 26432 26432 038 0450 6812
08950154 CLOS TX MC FX 1;W/O MANP EA BN 246.00 06/30/10 26600 26600 26600 038 0450 6812
08950157 CLOS TX MC FX SGLE;W/MNP EA BN 246.00 06/30/10 26605 26605 26605 038 0450 6812
08950160 CLS TX MC FX W/MNP W/EXT FX EA 371.00 06/30/10 26607 26607 26607 038 0450 6812
08950163 CLOS TX CMC DISLC THUMB W/MNP 246.00 06/30/10 26641 26641 26641 038 0450 6812
08950166 CLS TX CMC FX DISLC THMB W/MNP 331.00 06/30/10 26645 26645 26645 038 0450 6812
08950169 CLS TX CMC DISLC W/MNP;WO ANS 246.00 06/30/10 26670 26670 26670 038 0450 6812
08950172 CLS TX CMC DISLC W/MNP;RQR ANS 331.00 06/30/10 26675 26675 26675 038 0361 6812
08950175 CLS TX MCP DISLC 1 W/MN;WO ANE 395.00 06/30/10 26700 26700 26700 038 0450 6812
08950178 CLS TX MCP DISLC 1 W/MNP;W/ANS 246.00 06/30/10 26705 26705 26705 038 0361 6812
08950181 CLOS TX PHALANGL FX;WO MNP EA 395.00 06/30/10 26720 26720 26720 038 0450 6812
08950184 CLOS TX PHALANGL FX;W/WO TRAC 395.00 06/30/10 26725 26725 26725 038 0450 6812
08950187 CLS TX ARTC FX MCPI JNT;WO MNP 395.00 06/30/10 26740 26740 26740 038 0450 6812
08950190 CLS TX ARTIC FX MCP/IP JT;W/MN 246.00 06/30/10 26742 26742 26742 038 0450 6812
08950193 CLOS TX DIST PHALANG FX;WO MNP 395.00 06/30/10 26750 26750 26750 038 0450 6812
08950196 CLOS TX DIST PHALANG FX; W/MNP 395.00 06/30/10 26755 26755 26755 038 0450 6812
08950199 CLOS TX IP DISLOC W/MNP;WO ANS 405.00 06/30/10 26770 26770 26770 038 0450 6812
08950202 CLOS TX IP DISLC W/MANIP;W/ANS 1133.00 06/30/10 26775 26775 26775 038 0361 6812
08950205 CLOS TX PELVIC RING FX;W/O MNP 246.00 06/30/10 27193 27193 27193 038 0450 6812
08950208 CLOS TX PLVC RING FX;W/MNP-ANS 1133.00 06/30/10 27194 27194 27194 038 0450 6812
08950211 CLOS TRMNT COCCYGEAL FRACT 246.00 06/30/10 27200 27200 27200 038 0450 6812
08950214 CLOS TX ACETAB FX; W/O MANP 246.00 06/30/10 27220 27220 27220 038 0450 6812
08950217 CLS TX ACTAB FX;W/MNP WWO TRC 607.00 06/30/10 27222 27222 27222 038 0450 6812
08950220 CLOS TX FEM FX PRX END; WO MNP 246.00 06/30/10 27230 27230 27230 038 0450 6812
08950223 CLS TX FEM FX PRX END NCK;W/MN 577.00 06/30/10 27232 27232 27232 038 0450 6812
08950226 CLS TX INTRTRCH FEM FX; WO MNP 331.00 06/30/10 27238 27238 27238 038 0450 6812
08950229 CLOS INTRTRCH FEM FX; W/MNP 646.00 06/30/10 27240 27240 27240 038 0450 6812
08950232 CLOS TX GT TROCH FX W/O MANIP 395.00 06/30/10 27246 27246 27246 038 0450 6812
08950235 CLOS TX HIP DISLC TRAUM;WO ANS 246.00 06/30/10 27250 27250 27250 038 0450 6812
08950238 CLS TX HP ARTHPLST DSLC;WO ANS 246.00 06/30/10 27265 27265 27265 038 0450 6812
08950241 CLOS TX FEM SHAFT FX W/O MANIP 331.00 06/30/10 27500 27500 27500 038 0450 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 358
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08950244 CLOS TX SPRCOND FEM FX WO MNP 246.00 06/30/10 27501 27501 27501 038 0450 6812
08950247 CLS TX FEM FX W/MANIP W/WO TRC 371.00 06/30/10 27502 27502 27502 038 0450 6812
08950250 CLOS TX SPRCOND FEM FX W/MANIP 246.00 06/30/10 27503 27503 27503 038 0450 6812
08950253 CLS TX FEM FX DIST END W/O MNP 246.00 06/30/10 27508 27508 27508 038 0450 6812
08950256 CLOS TX FEM FX DIST END W/MANP 331.00 06/30/10 27510 27510 27510 038 0450 6812
08950259 CLS TX FM EPPHYSEL SEP;WO MNP 246.00 06/30/10 27516 27516 27516 038 0450 6812
08950262 CLOS TX FEM EPIPHYSL SEP;W/MNP 395.00 06/30/10 27517 27517 27517 038 0450 6812
08950265 CLOS TX PATELLAR FX WO MANIP 246.00 06/30/10 27520 27520 27520 038 0450 6812
08950268 CLS TX TIBIAL FX PROX;W/O MANP 246.00 06/30/10 27530 27530 27530 038 0450 6812
08950271 CLS TX TIB FX;W/WO MNIP W/TRAC 371.00 06/30/10 27532 27532 27532 038 0450 6812
08950274 CLS TX INTRCND FX KNE WWO MNP 395.00 06/30/10 27538 27538 27538 038 0450 6812
08950277 CLOS TX KNEE DISLOC;W/O ANEST 246.00 06/30/10 27550 27550 27550 038 0450 6812
08950280 CLOS TX KNEE DISLOC; RQR ANES 1133.00 06/30/10 27552 27552 27552 038 0361 6812
08950283 CLOS TX PATR DISLOC; W/O ANEST 246.00 06/30/10 27560 27560 27560 038 0450 6812
08950286 CLOS TX PATR DISLOC; RQR ANEST 1133.00 06/30/10 27562 27562 27562 038 0361 6812
08950289 CLS TX TIBL SHAFT FX;W/O MANIP 246.00 06/30/10 27750 27750 27750 038 0450 6812
08950292 CLS TX TIB FX; W/MANP W/WO TRC 371.00 06/30/10 27752 27752 27752 038 0450 6812
08950295 CLS TX MED MLLEOLS FX; W/O MNP 246.00 06/30/10 27760 27760 27760 038 0450 6812
08950301 CLOS TX PRX FIB/SHFT FX;WO MNP 246.00 06/30/10 27780 27780 27780 038 0450 6812
08950304 CLOS TX PROX FIB/SHFT FX;W/MNP 371.00 06/30/10 27781 27781 27781 038 0450 6812
08950307 CLOS TX DIST FIBR FX; W/O MANP 246.00 06/30/10 27786 27786 27786 038 0450 6812
08950310 CLOS TX DIST FIBR FX; W/MANIP 246.00 06/30/10 27788 27788 27788 038 0450 6812
08950313 CLS TX BIMALLELR ANK FX;WO MNP 246.00 06/30/10 27808 27808 27808 038 0450 6812
08950316 CLS TX BIMALLELR ANK FX; W/MNP 331.00 06/30/10 27810 27810 27810 038 0450 6812
08950319 CLS TX TRMALLELR ANK FX;WO MNP 246.00 06/30/10 27816 27816 27816 038 0450 6812
08950322 CLS TX TRIMALLELR ANK FX;W/MNP 331.00 06/30/10 27818 27818 27818 038 0450 6812
08950325 CLS TX FX ARTC DIST TIB;WO ANS 246.00 06/30/10 27824 27824 27824 038 0450 6812
08950328 CLS TX FX DIST TIB;W/TRC&/MANP 371.00 06/30/10 27825 27825 27825 038 0450 6812
08950331 CLS TX PRX TIBIFIB DISL;WO ANS 246.00 06/30/10 27830 27830 27830 038 0450 6812
08950334 CLS TX ANK DISLOC;W/O ANESTH 331.00 06/30/10 27840 27840 27840 038 0450 6812
08950337 CLS TX ARTC FX MCP/IPJNT;W/MNP 1133.00 06/30/10 27842 27842 27842 038 0361 6812
08950340 CLOS TX CALCAN FX;WO MANIPLTN 246.00 06/30/10 28400 28400 28400 038 0450 6812
08950343 CLOS TX CALCAN FX;W/MANIPUL 371.00 06/30/10 28405 28405 28405 038 0450 6812
08950346 CLOS TX TALUS FX; W/O MANIP 246.00 06/30/10 28430 28430 28430 038 0450 6812
08950349 CLOS TX TALUS FX; W/MANIP 246.00 06/30/10 28435 28435 28435 038 0450 6812
08950352 TX TARSAL BN FX; W/O MANIP EA 246.00 06/30/10 28450 28450 28450 038 0450 6812
08950355 CLOS TX MT FX; W/O MANIP EA 258.00 06/30/10 28470 28470 28470 038 0450 6812
08950358 CLS TX MT FX;W/MANIPULATION EA 246.00 06/30/10 28475 28475 28475 038 0450 6812
08950361 CLOS TX FX GT TOE PALNX;WO MNP 246.00 06/30/10 28490 28490 28490 038 0450 6812
08950364 CLOS TX FX GT TOE PHLNX;W/MNP 246.00 06/30/10 28495 28495 28495 038 0450 6812
08950367 CLS TX FX PHLN EX GT TOE;WO MP 246.00 06/30/10 28510 28510 28510 038 0450 6812
08950370 CLS TX FX PHLNX EX GT TOE;W/MP 395.00 06/30/10 28515 28515 28515 038 0450 6812
08950373 CLOS TREATMT SESAMOID FRACT 246.00 06/30/10 28530 28530 28530 038 0450 6812
08950376 CLS TX TARSL BNE DISLC;WO ANS 246.00 06/30/10 28540 28540 28540 038 0450 6812
08950379 CLOS TX TARSAL BNE DISLC;W/ANS 1706.00 06/30/10 28545 28545 28545 038 0361 6812
08950382 CLOS TX TALOTRSL DISLC;W/O ANS 331.00 06/30/10 28570 28570 28570 038 0450 6812
08950385 CLS TX TARSMT JNT DISLC;WO ANS 246.00 06/30/10 28600 28600 28600 038 0450 6812
08950388 CLS TX MTP JNT DISLOC;W/O ANES 246.00 06/30/10 28630 28630 28630 038 0450 6812
08950391 CLS TX MTP JNT DISLOC; W/ANES 1133.00 06/30/10 28635 28635 28635 038 0361 6812
08950394 CLS TX IP JNT DISLOC; W/O ANES 395.00 06/30/10 28660 28660 28660 038 0450 6812
08950397 APPLIC CAST; ELBOW TO FINGER 213.00 06/30/10 29075 29075 29075 038 0450 6812
08950400 APPLIC CAST; HAND&LOW FOREARM 188.00 06/30/10 29085 29085 29085 038 0450 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 359
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

08950403 APPLICATION OF LONG ARM SPLINT 213.00 06/30/10 29105 29105 29105 038 0450 6812
08950406 APPLIC SHORT ARM SPLINT;STATIC 213.00 06/30/10 29125 29125 29125 038 0450 6812
08950409 APPLIC FINGER SPLINT; STATIC 188.00 06/30/10 29130 29130 29130 038 0450 6812
08950412 APPLICATION OF SHORT LEG CAST; 213.00 06/30/10 29405 29405 29405 038 0450 6812
08950415 APPLICATION OF LONG LEG SPLINT 199.00 06/30/10 29505 29505 29505 038 0450 6812
08950416 SHORT LEG SPLINT (CALF) 202.00 06/30/10 29515 29515 29515 038 0450 6812
08950418 ER CAST ARM-LONG 276.00 06/30/10 29065 29065 29065 038 0450 6812
08950421 CLOS TX RDIAL HEAD SUBLX CHILD 246.00 06/30/10 24640 24640 24640 038 0450 6812
08960031 CLOS TX MAND FX;W/MANIPULATION 579.00 06/30/10 21451 21451 21451 038 0450 6812
08960034 CLOS TX MAND FX W/INTRDNTL FIX 2966.00 06/30/10 21453 21453 21453 038 0450 6812
08960037 CLOS TX TM DISLOC; INIT/SUBSQT 1196.00 06/30/10 21480 21480 21480 038 0450 6812
08960040 CLS TX TM DISLC;COMP INT/SBSQT 1196.00 06/30/10 21485 21485 21485 038 0450 6812
08960049 RMVL FB INTRANSL; OFC TYPE PRC 115.00 06/30/10 30300 30300 30300 038 0450 6812
08960052 CTRL NSL HEMR ANT SMPL ANY MTH 261.00 06/30/10 30901 30901 30901 038 0450 6812
08960055 CNTRL NSL HEMORR ANT CPLX MTH 230.00 06/30/10 30903 30903 30903 038 0450 6812
08960058 CNTRL NASL HEMR PCKS&/CAU;INT 230.00 06/30/10 30905 30905 30905 038 0450 6812
00249901 OBSERVATION UNDER 1 HOUR 43.00 06/30/10 G0378 040 0762 0499
00249902 OBSERVATION 1-6 HOURS /EACH HR 43.00 06/30/10 G0378 040 0762 0499
00249903 OBSERVATION 7-12 HRS /EACH HR 43.00 06/30/10 G0378 040 0762 0499
00249904 OBSERVATION 13 HRS/OVER /EA HR 43.00 06/30/10 G0378 040 0762 0499
00249920 DIRECT ADMIT TO OBSERVATION 65.00 06/30/10 G0379 G0379 G0379 040 0762 0499
00249921 OBSERVATION -UNDER 1 HOUR 278.00 06/30/10 G0378 040 0762 0499
00249922 OBSERV-FIRST HR 278.00 06/30/10 G0378 040 0762 0499
00249923 OBSERV-ADDL HRS 72.00 06/30/10 G0378 040 0762 0499
00249950 RECOVERY,EXTENDED,O/P 301.00 06/30/10 040 0710 0499
03700805 PICC INSERTION 1039.00 06/30/10 36010 36010 36010 38.93 38.93 040 0920 0495
03700807 MIDLINE CATHETER INSERTION 356.00 06/30/10 36100 36100 36100 38.91 38.91 040 0360 0495
03700809 PERIPHERAL IV SETUP ACCESS 98.00 06/30/10 040 0260 0495
03700815 MIDLINE/PICC DRESSING CHANGE 100.00 06/30/10 99211 99211 99211 040 0940 0495
03700817 PERIPHERAL IV DRESSING CHANGE 100.00 06/30/10 99211 99211 99211 040 0940 0495
03700821 IV DECLOTTING-UROKINASE 448.00 06/30/10 36860 36860 36860 39.49 39.49 040 0360 0495
03700825 VENIPUNCT >3 YR W/MD SKILL-SEP 102.00 06/30/10 36410 36410 36410 38.93 39.93 040 0360 0495
30010999 CHARGE TRANSFER/RELOCAT-ANCILL VARIABLE 07/01/85 040 0324
10900206 THERAPEUTIC INJ,IM OR SUB 86.00 06/30/10 96372 96372 96372 058 0940 0609
10900208 IM INJECTION ANTIBIOTICS 110.00 06/30/10 96372 96372 96372 058 0940 0609
10900501 ACNE SURGERY-HOSP 61.00 06/30/10 10040 10040 10040 058 0360 0609
10900502 ACNE SURGERY-M.D. 169.00 $ 06/30/09 10040 10040 10040 058 0975 0609
10900503 INCIS/DRAIN,ABSCESS;SIMP-HOSP 164.00 06/30/10 10060 10060 10060 058 0360 0609
10900504 INCIS/DRAIN,ABSCESS;SIMP-M.D. 186.00 $ 06/30/09 10060 10060 10060 058 0975 0609
10900505 I&D MULTIPLE - HOSP 269.00 06/30/10 10061 10061 10061 058 0360 0609
10900506 I&D MULTIPLE - M.D. 332.00 $ 06/30/09 10061 10061 10061 058 0975 0609
10900541 SKIN BIOP,SINGLE LESION-HOSP 165.00 06/30/10 11100 11100 11100 058 0360 0609
10900542 SKIN BIOP,SINGLE LESION-M.D. 95.00 $ 06/30/09 11100 11100 11100 058 0975 0609
10900543 BIOPSY ADDL SUBCUT TISSUE-HOSP 130.00 06/30/10 11101 11101 11101 058 0360 0609
10900544 BIOPSY ADDL SUBCUT TISSUE-M.D. 49.00 $ 06/30/09 11101 11101 11101 058 0975 0609
10900545 EXCISION OF LESION-HOSP 172.00 06/30/10 11200 11200 11200 058 0360 0609
10900546 EXCISION OF LESION-M.D. 132.00 $ 06/30/09 11200 11200 11200 058 0975 0609
10900547 EXC,SKIN TAGS-EA ADD 10 - HOSP 129.00 06/30/10 11201 11201 11201 058 0360 0609
10900548 EXC,SKIN TAGS-EA ADD 10 - M.D. 34.00 $ 06/30/09 11201 11201 11201 058 0975 0609
10900549 SHAVING OF LESN 0.5 CM - HOSP 173.00 06/30/10 11300 11300 11300 058 0360 0609
10900550 SHAVING OF LESN 0.5 CM - M.D. 59.00 $ 06/30/09 11300 11300 11300 058 0975 0609
10900551 SHAVING LESN 0.6-1.0 CM - HOSP 190.00 06/30/10 11301 11301 11301 058 0360 0609
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 360
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

10900552 SHAVING LESN 0.6-1.0 CM - M.D. 100.00 $ 06/30/09 11301 11301 11301 058 0975 0609
10900557 SHAVING OF LESN 0.5 CM - HOSP 167.00 06/30/10 11305 11305 11305 058 0360 0609
10900558 SHAVING OF LESN 0.5 CM - M.D. 77.00 $ 06/30/09 11305 11305 11305 058 0975 0609
10900559 SHAVING OF LESN 0.6-1.0 - HOSP 197.00 06/30/10 11306 11306 11306 058 0360 0609
10900560 SHAVING OF LESN 0.6-1.0 - M.D. 114.00 $ 06/30/09 11306 11306 11306 058 0360 0609
10900565 SHAVING OF LESN 0.5 CM - HOSP 207.00 06/30/10 11310 11310 11310 058 0360 0609
10900566 SHAVING OF LESN 0.5 CM - M.D. 85.00 $ 06/30/09 11310 11310 11310 058 0975 0609
10900567 SHAVING OF LESN 0.6-1.0 - HOSP 233.00 06/30/10 11311 11311 11311 058 0360 0609
10900568 SHAVING OF LESN 0.6-1.0CM-M.D. 124.00 $ 06/30/09 11311 11311 11311 058 0975 0609
10900689 INTRALESIONAL INJ UP TO 7-HOSP 90.00 06/30/10 11900 11900 11900 058 0360 0609
10900690 INTRALESIONAL INJ UP TO 7-M.D. 61.00 $ 06/30/09 11900 11900 11900 058 0975 0609
10900691 INTRALESIONAL INJ >7 - HOSP 135.00 06/30/10 11901 11901 11901 058 0360 0609
10900692 INTRALESIONAL INJ >7 - M.D. 95.00 $ 06/30/09 11901 11901 11901 058 0975 0609
10900801 DESTRUCTION OF LESIONS -HOSP 127.00 06/30/10 17000 17000 17000 058 0360 0609
10900802 DESTRUCTION OF LESIONS -M.D. 105.00 $ 06/30/09 17000 17000 17000 058 0975 0609
10900803 DESTRUC 2ND-14 LESIONS-HOSP 69.00 06/30/10 17003 17003 17003 058 0360 0609
10900804 DESTRUC 2ND-14 LESIONS-M.D. 10.00 $ 06/30/09 17003 17003 17003 058 0975 0609
10900807 DESTRUC 15/MORE LESIONS-HOSP 143.00 06/30/10 17004 17004 17004 058 0360 0609
10900808 DESTRUC 15/MORE LESIONS-M.D. 264.00 $ 06/30/09 17004 17004 17004 058 0975 0609
10900812 DESTRUC BEN SKIN LESN ONE-M.D. 105.00 $ 06/30/09 17000 17000 17000 058 0975 0609
10900814 DESTRUC 2ND-14 LESIONS-M.D. 10.00 $ 06/30/09 17003 17003 17003 058 0975 0609
10900827 DESTR,ANY MTH,UPTO14WARTS-HOSP 125.00 06/30/10 17110 17110 17110 058 0360 0609
10900828 DES,ANY METH,UP TO 14WARTS-M.D 132.00 $ 06/30/09 17110 17110 17110 058 0975 0609
10900829 RMVL OF SKIN TAGS UP TO 15-HSP 172.00 06/30/10 11200 11200 11200 058 0360 0609
10900830 RMVL OF SKIN TAGS UP TO 15-M.D 132.00 $ 06/30/09 11200 11200 11200 058 0975 0609
10900831 ELECT SKIN TAGS ADDL 10 - HOSP 151.00 06/30/10 11201 11201 11201 058 0360 0609
10900832 ELECT SKIN TAGS ADDL 10 - M.D. 34.00 $ 06/30/09 11201 11201 11201 058 0975 0609
10900862 MOHS',1 STAGE,H/N/HF/G-HOSP 807.00 06/30/10 17311 17311 17311 058 0360 0609
10900863 MOHS',1 STAGE,H/N/HF/G-M.D. 746.00 $ 06/30/09 17311 17311 17311 058 0975 0609
10900864 MOHS'CHEMO: ADD'L STAGE-HOSP 554.00 06/30/10 17312 17312 17312 058 0360 0609
10900865 MOHS'CHEMO: ADD'L STAGE-M.D. 397.00 $ 06/30/09 17312 17312 17312 058 0975 0609
10900866 MOHS' CHEMO: 3RD STAGE-HOSP 637.00 06/30/10 17312 17312 17312 058 0360 0609
10900867 MOHS' CHEMO: 3RD STAGE-M.D. 397.00 $ 06/30/09 17312 17312 17312 058 0975 0609
10900868 MOHS' CHEMO: ADD'L STAGES-HOSP 540.00 06/30/10 17314 17314 17314 058 0360 0609
10900869 MOHS'CHEMO:ADD'L STAGE-M.D 368.00 $ 06/30/09 17314 17314 17314 058 0975 0609
10900870 MOHS' CHEMO: ADDL BLOCK-HOSP 68.00 06/30/10 17315 17315 17315 058 0360 0609
10900871 MOHS' CHEMO: ADDL BLOCK-M.D. 104.00 $ 06/30/09 17315 17315 17315 058 0975 0609
10900875 FULL THK GRFT,UP TO 20SQ 2602.00 06/30/10 15260 15260 15260 058 0360 0609
10900921 STRAPPING; UNNA BOOT - HOSP 117.00 06/30/10 29580 29580 29580 058 0360 0609
10900922 STRAPPING; UNNA BOOT - M.D. 77.00 $ 06/30/09 29580 29580 29580 058 0975 0609
10901049 DARKFIELD EXAM 120.00 06/30/10 87164 87164 87164 058 0306 0609
10901050 DARKFIELD EXAM - M.D. N/C 06/15/99 87164 87164 87164 058 0306 0609
10901065 SMEAR, PRIMARY SOURCE 50.00 06/30/10 87205 87205 87205 058 0306 0609
10901066 SMEAR, PRIMARY SOURCE - M.D. N/C 06/15/99 87205 87205 87205 058 0306 0609
10901068 IMMUNOCYTOCHEMISTRY 86.00 06/30/10 88313 88313 88313 058 0310 0609
10901070 TRANZK SMEAR - M.D. N/C 06/15/99 87207 87207 87207 058 0306 0609
10901072 SPECIAL STAINS GROUP 1 130.00 06/30/10 88312 88312 88312 058 0300 0609
10901074 SPECIAL STAINS GROUP 2 35.00 06/30/10 88313 88313 88313 058 0300 0609
10901077 TISSUE EXAM FOR FUNGI 52.00 06/30/10 87220 87220 87220 058 0306 0609
10901078 TISSUE EXAM FOR FUNGI - M.D. N/C 06/15/99 87220 87220 87220 058 0306 0609
10901092 SMALL SPEC GROSS&MICRO LVL3 135.00 06/30/10 88304 88304 88304 058 0310 0609
10901094 SM SPEC GROSS&MICRO LVL4 146.00 06/30/10 88304 88304 88304 058 0300 0609
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 361
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

10901098 DIRECT IMMUNO STUDY 91.00 06/30/10 88346 88346 88346 058 0300 0609
10901099 INDIRECT METHOD 141.00 06/30/10 88347 88347 88347 058 0300 0609
10901133 PATCH TESTS #____________ 64.00 06/30/10 95044 95044 95044 058 0924 0609
10901134 PATCH TESTS #_______ - M.D. N/C 06/15/99 95044 95044 95044 058 0924 0609
10901136 PATCH TESTS 11-20 - M.D. N/C 06/15/99 95044 95044 95044 058 0924 0609
10901138 PATCH TESTS 21-30 - M.D. N/C 06/15/99 95044 95044 95044 058 0924 0609
10901140 PATCH TESTS >30 - M.D. N/C 06/15/99 95044 95044 95044 058 0924 0609
10901142 PHOTO PATCH TEST UP TO 10-M.D. N/C 06/15/99 95052 95052 95052 058 0924 0609
10901144 PHOTO PATCH TESTS >10 - M.D. N/C 06/15/99 95052 95052 95052 058 0924 0609
10901146 PHOTO TESTS - M.D. N/C 06/15/99 95056 95056 95056 058 0924 0609
10901200 PHOTO THERAPY, UVB 135.00 06/30/10 96900 96900 96900 058 0940 0609
10901204 PHOTOCHEMO THERAPY PUVA 169.00 06/30/10 96912 96912 96912 058 0940 0609
10901221 INIT VISIT W/PROCEDURE-HOSP 107.00 06/30/10 058 0510 0609
10901222 INIT VISIT W/PROCEDURE - M.D. 79.00 $ 08/10/08 058 0983 0609
10910401 TRUNK- 1.1 - 2.5CM 396.00 06/30/10 13100 13100 13100 058 0360 0609
10910403 TRUNK- 2.6 - 7.5CM 605.00 06/30/10 13101 13101 13101 058 0360 0609
10910404 TRUNK - EA ADD 5CM OR < 320.00 06/30/10 13102 13102 13102 058 0360 0609
10910405 S/A/L - 1.1CM - 2.5CM 610.00 06/30/10 13120 13120 13120 058 0360 0609
10910407 S/A/L - 2.6CM - 7.5CM 719.00 06/30/10 13121 13121 13121 058 0360 0609
10910408 S/A/L - EA ADD 5CM OR < 402.00 06/30/10 13122 13122 13122 058 0360 0609
10910409 HD/NK/GN/HN/FT- 1.1 - 2.5CM 613.00 06/30/10 13131 13131 13131 058 0360 0609
10910411 HD/NK/GN/HN/FT- 2.6CM - 7.5CM 812.00 06/30/10 13132 13132 13132 058 0360 0609
10910412 HD/NK/GN/FT - EA ADD 5CM OR < 579.00 06/30/10 13133 13133 13133 058 0360 0609
10910413 FACE - 1.0CM OR LESS 936.00 06/30/10 13150 13150 13150 058 0360 0609
10910415 FACE - 1.1 - 2.5CM 995.00 06/30/10 13151 13151 13151 058 0360 0609
10910417 FACE - 2.6 - 7.5CM 1179.00 06/30/10 13152 13152 13152 058 0360 0609
10910418 FACE - EA ADD 5CM OR < 915.00 06/30/10 13153 13153 13153 058 0360 0609
10910419 SECONDARY CLOSE SURG WOUND 1594.00 06/30/10 13160 13160 13160 058 0360 0609
10910423 DESTRCT,BENIGN LES,1ST LES 127.00 06/30/10 17000 17000 17000 058 0360 0609
10910425 DESTRCT, 2ND THROUGH 14 LESION 70.00 06/30/10 17003 17003 17003 058 0360 0609
10910427 DESTRUCT, 15 OR MORE LESIONS 147.00 06/30/10 17004 17004 17004 058 0360 0609
10910429 INTRALES. INJ. UP TO & INCL 7 90.00 06/30/10 11900 11900 11900 058 0360 0609
10910431 INTRALESIONAL INJ. MORE THAN 7 135.00 06/30/10 11901 11901 11901 058 0360 0609
10910433 MOHS,1 STAGE H/N/HF/G 832.00 06/30/10 17311 17311 17311 058 0360 0609
10910435 MOHS ADDL STAGE 572.00 06/30/10 17312 17312 17312 058 0360 0609
10910437 MOHS' ADDL STAGE 612.00 06/30/10 17312 17312 17312 058 0360 0609
10910439 MOHS' CHEMO: ADDITIONAL STAGE 556.00 06/30/10 17314 17314 17314 058 0360 0609
10910441 MOHS' SURG,ADDL BLOCK 68.00 06/30/10 17315 17315 17315 058 0360 0609
10910443 PATCH OR APPL TEST(S) 64.00 06/30/10 95044 95044 95044 058 0924 0609
10910445 PHOTO PATCH TEST(S) 133.00 06/30/10 95052 95052 95052 058 0924 0609
10910447 ACTINOTHERAPY, UVP 135.00 06/30/10 96900 96900 96900 058 0940 0609
10910451 DEST FLAT WARTS UP TO 14 125.00 06/30/10 17110 17110 17110 058 0361 0609
10910452 DEST FLAT WARTS UP TO 15 N/C 06/30/10 17110 17110 17110 058 0975 0609
10910453 DEST FLAT WARTS 15 OR> 142.00 06/30/10 17111 17111 17111 058 0360 0609
10910501 ACNE SURGERY 61.00 06/30/10 10040 10040 10040 058 0360 0609
10910507 ABCESS 139.00 06/30/10 10080 10080 10080 058 0360 0609
10910509 COMPLICATED OR MULTIPLE 593.00 06/30/10 10081 10081 10081 058 0360 0609
10910511 REM OF FOREIGN BODY,SIMPLE 193.00 06/30/10 10120 10120 10120 058 0360 0609
10910513 REM OF FOREIGN BODY COMPL 1022.00 06/30/10 10121 10121 10121 058 0360 0609
10910515 INCIS & DRANGE HEMATOMA SIMP 300.00 06/30/10 10140 10140 10140 058 0360 0609
10910517 PUNC ASP ABSCESS HEMATOMA 100.00 06/30/10 10160 10160 10160 058 0360 0609
10910519 COMPLEX POST-OP WOUND INFECT 940.00 06/30/10 10180 10180 10180 058 0360 0609
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 362
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

10910535 BEN HYPERK SKIN LES SINGLE 88.00 06/30/10 11055 11055 11055 058 0360 0609
10910537 2-4 LESIONS 112.00 06/30/10 11056 11056 11056 058 0360 0609
10910539 > 4 LESIONS 154.00 06/30/10 11057 11057 11057 058 0360 0609
10910541 BIOPSY OF SKIN SINGLE 165.00 06/30/10 11100 11100 11100 058 0360 0609
10910543 -EA ADDL LESION 130.00 06/30/10 11101 11101 11101 058 0360 0609
10910545 REM SKIN TAGS-UP TO 15 LES 172.00 06/30/10 11200 11200 11200 058 0360 0609
10910547 -EA ADDL 10 LESIONS 129.00 06/30/10 11201 11201 11201 058 0360 0609
10910549 TR/LG 0.5CM OR LESS 173.00 06/30/10 11300 11300 11300 058 0360 0609
10910551 TR/AR/LG 0.6-1.0CM 190.00 06/30/10 11301 11301 11301 058 0360 0609
10910553 TR/AR/LG 1.1-2.0CM 208.00 06/30/10 11302 11302 11302 058 0360 0609
10910555 TR/AR/LG OVER 2.0CM 317.00 06/30/10 11303 11303 11303 058 0360 0609
10910557 SC/NK/HD/FT/GN 0.5CM OR LESS 167.00 06/30/10 11305 11305 11305 058 0360 0609
10910559 SC/NK/HD/FT/GN 0.6-1.0CM 197.00 06/30/10 11306 11306 11306 058 0360 0609
10910561 SC/NK/HD/FT/GN 1.1-2.0CM 240.00 06/30/10 11307 11307 11307 058 0360 0609
10910563 SC/NK/HD/FT/GN OVER 2.0CM 292.00 06/30/10 11308 11308 11308 058 0360 0609
10910565 FACE 0.5CM OR LESS 207.00 06/30/10 11310 11310 11310 058 0360 0609
10910567 FACE 0.6-1.0CM 233.00 06/30/10 11311 11311 11311 058 0360 0609
10910569 FACE 1.1-2.0CM 280.00 06/30/10 11312 11312 11312 058 0360 0609
10910571 FACE OVER 2.0CM 317.00 06/30/10 11313 11313 11313 058 0360 0609
10910573 TR/AR/LG/0.5CM OR LESS 254.00 06/30/10 11400 11400 11400 058 0360 0609
10910575 TR/AR/LG 0.6-1.0CM 300.00 06/30/10 11401 11401 11401 058 0360 0609
10910577 TR/AR/LG 1.1-2.0CM 393.00 06/30/10 11402 11402 11402 058 0360 0609
10910579 TR/AR/LG 2.1-3.0CM 516.00 06/30/10 11403 11403 11403 058 0360 0609
10910581 TR/AR/LG 3.1-4.0CM 762.00 06/30/10 11404 11404 11404 058 0360 0609
10910583 TR/AR/LG OVER 4.0CM 2657.00 06/30/10 11406 11406 11406 058 0360 0609
10910585 SC/NK/HD/FT/GN 0.5CM 287.00 06/30/10 11420 11420 11420 058 0360 0609
10910587 SC/NK/HD/FT/GN 0.6-1.0CM 495.00 06/30/10 11421 11421 11421 058 0360 0609
10910589 SC/NK/HD/FT/GN 1.1-2.0CM 488.00 06/30/10 11422 11422 11422 058 0360 0609
10910591 SC/NK/HD/FT/GN 2.1-3.0CM 893.00 06/30/10 11423 11423 11423 058 0360 0609
10910593 SC/NK/HD/FT/GN 3.1-4.0CM 742.00 06/30/10 11424 11424 11424 058 0360 0609
10910595 SC/NK/HD FT/GN OVER 4.0CM 1769.00 06/30/10 11426 11426 11426 058 0360 0609
10910597 FACE 0.5CM OR LESS 344.00 06/30/10 11440 11440 11440 058 0360 0609
10910599 FACE 0.6-1.0CM 857.00 06/30/10 11441 11441 11441 058 0360 0609
10910601 FACE 1.1-2.0CM 566.00 06/30/10 11442 11442 11442 058 0360 0609
10910603 FACE 2.1-3.0CM 758.00 06/30/10 11443 11443 11443 058 0360 0609
10910605 FACE 3.1-4.0CM 969.00 06/30/10 11444 11444 11444 058 0360 0609
10910607 FACE OVER 4.0CM 1352.00 06/30/10 11446 11446 11446 058 0360 0609
10910621 TR/AR/LG 0.5CM OR LESS 482.00 06/30/10 11600 11600 11600 058 0360 0609
10910623 TR/AR/LG 0.6-1.0CM 398.00 06/30/10 11601 11601 11601 058 0360 0609
10910625 TR/AR/LG 1.1-2.0CM 663.00 06/30/10 11602 11602 11602 058 0360 0609
10910627 TR/AR/LG 2.1-3.0CM 903.00 06/30/10 11603 11603 11603 058 0360 0609
10910629 TR/AR/LG 3.1-4.0CM 1004.00 06/30/10 11604 11604 11604 058 0360 0609
10910631 TR/AR/LG OVER 4.0CM 1707.00 06/30/10 11606 11606 11606 058 0360 0609
10910633 SC/NK/HD/FT/GN 0.5CM OR LESS 566.00 06/30/10 11620 11620 11620 058 0360 0609
10910635 SC/NK/HD/FT/GN 0.6-1.0CM 675.00 06/30/10 11621 11621 11621 058 0360 0609
10910637 SC/NK/HD/FT/GN 1.1-2.0CM 764.00 06/30/10 11622 11622 11622 058 0360 0609
10910639 SC/NK/HD/FT/GN 2.1-3.0CM 965.00 06/30/10 11623 11623 11623 058 0360 0609
10910641 SC/NK/HD/FT/GN 3.1-4.0CM 1207.00 06/30/10 11624 11624 11624 058 0360 0609
10910643 SC/NK/HD/FT/GN OVER 4.0CM 3232.00 06/30/10 11626 11626 11626 058 0360 0609
10910645 FACE 0.5CM OR LESS 688.00 06/30/10 11640 11640 11640 058 0360 0609
10910647 FACE 0.6-1.0CM 831.00 06/30/10 11641 11641 11641 058 0360 0609
10910649 FACE 1.1-2.0CM 1042.00 06/30/10 11642 11642 11642 058 0360 0609
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 363
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

10910651 FACE 2.1-3.0CM 1993.00 06/30/10 11643 11643 11643 058 0360 0609
10910653 FACE 3.1-4.0CM 1495.00 06/30/10 11644 11644 11644 058 0360 0609
10910655 FACE OVER 4.0CM 2169.00 06/30/10 11646 11646 11646 058 0360 0609
10910665 AVULSION OF NAIL PLATE;SING 209.00 06/30/10 11730 11730 11730 058 0360 0609
10910669 -EA ADDL NAIL PLATE 88.00 06/30/10 11732 11732 11732 058 0360 0609
10910671 EVAC SUBUNGUAL HEMATOM 74.00 06/30/10 11740 11740 11740 058 0360 0609
10910673 EXCIS NAIL/MATRIX-PART/COM 531.00 06/30/10 11750 11750 11750 058 0360 0609
10910675 EXCIS W/AMP TUFT DISTAL PHA 911.00 06/30/10 11752 11752 11752 058 0360 0609
10910677 BIOPSY NAIL UNIT ANY METHOD 318.00 06/30/10 11755 11755 11755 058 0360 0609
10910679 REPAIR NAIL BED 661.00 06/30/10 11760 11760 11760 058 0360 0609
10910681 RECONSTR NAIL BED W/GRAFT 1097.00 06/30/10 11762 11762 11762 058 0360 0609
10910683 WEDGE EXCIS SKIN/NAIL FOLD 358.00 06/30/10 11765 11765 11765 058 0360 0609
10910689 INJECT INTRALES UP TO 7 LESION 90.00 06/30/10 11900 11900 11900 058 0360 0609
10910691 INJECT INTRALES > 7 LESIONS 135.00 06/30/10 11901 11901 11901 058 0360 0609
10910699 SUBCUT INJECT 1CC OR LESS 494.00 06/30/10 11950 11950 11950 058 0360 0609
10910701 SUBCUT INJECT 1.1-5.0CC 484.00 06/30/10 11951 11951 11951 058 0360 0609
10910703 SUBCUT INJECT 5.1-10.0CC 468.00 06/30/10 11952 11952 11952 058 0360 0609
10910705 SUBCUT INJECT OVER 10.0CC 503.00 06/30/10 11954 11954 11954 058 0360 0609
10910707 INSERT TISS EXPAND(NT BREAST) 3925.00 06/30/10 11960 11960 11960 058 0360 0609
10910709 REPL TISS EXPAND W/PERM PROSTH 3278.00 06/30/10 11970 11970 11970 058 0360 0609
10910711 REM TISS EXPAND W/O PROSTH 1314.00 06/30/10 11971 11971 11971 058 0360 0609
10910719 S/N/H/G/T/A/L/F 2.5CM OR LESS 226.00 06/30/10 12001 12001 12001 058 0360 0609
10910721 S/N/H/G/T/A/L/F 2.6-7.5CM 373.00 06/30/10 12002 12002 12002 058 0360 0609
10910723 S/N/H/G/T/A/L/F 7.6-12.5CM 545.00 06/30/10 12004 12004 12004 058 0360 0609
10910725 S/N/H/G/T/A/L/F 12.6-20.0CM 667.00 06/30/10 12005 12005 12005 058 0360 0609
10910727 S/N/H/G/T/A/L/F 20.1-30.0CM 567.00 06/30/10 12006 12006 12006 058 0360 0609
10910729 S/N/H/G/T/A/L/F OVER 30.0CM 662.00 06/30/10 12007 12007 12007 058 0360 0609
10910731 FACE 2.5CM OR LESS 270.00 06/30/10 12011 12011 12011 058 0360 0609
10910733 FACE 2.6-5.0CM 332.00 06/30/10 12013 12013 12013 058 0360 0609
10910735 FACE 5.1-7.5CM 311.00 06/30/10 12014 12014 12014 058 0360 0609
10910737 FACE 7.6-12.5CM 399.00 06/30/10 12015 12015 12015 058 0360 0609
10910739 FACE 12.6-20.0CM 772.00 06/30/10 12016 12016 12016 058 0360 0609
10910741 FACE 20.1-30.0CM 1693.00 06/30/10 12017 12017 12017 058 0360 0609
10910743 FACE OVER 30.0CM 2388.00 06/30/10 12018 12018 12018 058 0360 0609
10910745 SUPERFIC WOUND DEHISCHENCE 419.00 06/30/10 12020 12020 12020 058 0360 0609
10910747 -WITH PACKING 456.00 06/30/10 12021 12021 12021 058 0360 0609
10910749 SC/TR/EXTREM: 2.5CM OR LESS 252.00 06/30/10 12031 12031 12031 058 0360 0609
10910751 SC/TR/EXTREM: 2.6 - 7.5CM 466.00 06/30/10 12032 12032 12032 058 0360 0609
10910753 SC/TR/EXTREM: 7.6 - 12.5CM 442.00 06/30/10 12034 12034 12034 058 0360 0609
10910755 SC/TR/EXTREM: 12.6 - 20.0CM 546.00 06/30/10 12035 12035 12035 058 0360 0609
10910757 SC/TR/EXTREM: 20.1 -30.0CM 831.00 06/30/10 12036 12036 12036 058 0360 0609
10910759 SC/TR/EXTREM: OVER 30.0CM 1231.00 06/30/10 12037 12037 12037 058 0360 0609
10910761 N/H/F/G: 2.5CM OR LESS 319.00 06/30/10 12041 12041 12041 058 0360 0609
10910763 N/H/F/G: 2.6 - 7.5CM 295.00 06/30/10 12042 12042 12042 058 0360 0609
10910765 N/H/F/G: 7.6 - 12.5CM 705.00 06/30/10 12044 12044 12044 058 0360 0609
10910767 N/H/F/G: 12.6 - 20.0CM 961.00 06/30/10 12045 12045 12045 058 0360 0609
10910769 N/H/F/G: 20.1 - 30.0CM 1314.00 06/30/10 12046 12046 12046 058 0360 0609
10910771 N/H/F/G: OVER 30.0CM 1697.00 06/30/10 12047 12047 12047 058 0360 0609
10910773 FACE 2.5CM OR LESS 368.00 06/30/10 12051 12051 12051 058 0360 0609
10910775 FACE 2.6 - 5.0CM 270.00 06/30/10 12052 12052 12052 058 0360 0609
10910777 FACE 5.1 - 7.5CM 747.00 06/30/10 12053 12053 12053 058 0360 0609
10910779 FACE 7.6 - 12.5CM 1272.00 06/30/10 12054 12054 12054 058 0360 0609
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 364
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

10910781 FACE 12.6 - 20.0CM 1637.00 06/30/10 12055 12055 12055 058 0360 0609
10910783 FACE 20.1 - 30.0CM 2254.00 06/30/10 12056 12056 12056 058 0360 0609
10910785 FACE OVER 30.0CM 3013.00 06/30/10 12057 12057 12057 058 0360 0609
10910801 ONE LESION OF FACE 127.00 06/30/10 17000 17000 17000 058 0360 0609
10910807 DESTRUCTION 15 OR MORE LESIONS 143.00 06/30/10 17004 17004 17004 058 0360 0609
10910811 ONE LESION, NOT FACE 127.00 06/30/10 17000 17000 17000 058 0360 0609
10910813 DESTRUCTION 2ND-14 LESIONS, EA 69.00 06/30/10 17003 17003 17003 058 0360 0609
10910817 DESTRUCTION 15 OR MORE LESIONS 143.00 06/30/10 17004 17004 17004 058 0360 0609
10910821 VASCULAR <10 SQ CM 176.00 06/30/10 17106 17106 17106 058 0360 0609
10910823 VASCULAR 10.0 - 50 SQ CM 176.00 06/30/10 17107 17107 17107 058 0360 0609
10910825 VASCULAR OVER 50 SQ CM 176.00 06/30/10 17108 17108 17108 058 0360 0609
10910827 >15 LES-FLAT WARTS, MOLL, MILI 125.00 06/30/10 17110 17110 17110 058 0360 0609
10910829 >15 LES-MULTI FIBROCUT TAGS 172.00 06/30/10 11200 11200 11200 058 0360 0609
10910831 BENIGN EA ADDL. 10 LESIONS 154.00 06/30/10 11201 11201 11201 058 0360 0609
10910833 CHEM CAUTERIZ OF GRANULAN TISS 120.00 06/30/10 17250 17250 17250 058 0360 0609
10910835 TRK/ARM/LEG 0.5CM OR LESS 379.00 06/30/10 17260 17260 17260 058 0360 0609
10910837 TRK/ARM/LEG 0.6 - 1.0CM 232.00 06/30/10 17261 17261 17261 058 0360 0609
10910839 TRK/ARM/LEG 1.1 - 2.0CM 154.00 06/30/10 17262 17262 17262 058 0360 0609
10910841 TRK/ARM/LEG 2.1 - 3.0CM 154.00 06/30/10 17263 17263 17263 058 0360 0609
10910843 TRK/ARM/LEG 3.1 - 4.0CM 154.00 06/30/10 17264 17264 17264 058 0360 0609
10910845 TRK/ARM/LEG OVER 4.0CM 176.00 06/30/10 17266 17266 17266 058 0360 0609
10910847 SC/NK/HD/FT/GEN 0.5CM OR LESS 126.00 06/30/10 17270 17270 17270 058 0360 0609
10910849 SC/NK/HD/FT/GEN 0.6 - 1.0CM 126.00 06/30/10 17271 17271 17271 058 0360 0609
10910851 SC/NK/HD/FT/GEN 1.1 - 2.0CM 126.00 06/30/10 17272 17272 17272 058 0360 0609
10910853 SC/NK/HD/FT/GEN 2.1 - 3.0CM 143.00 06/30/10 17273 17273 17273 058 0360 0609
10910855 SC/NK/HD/FT/GEN 3.1 - 4.0CM 143.00 06/30/10 17274 17274 17274 058 0360 0609
10910857 SC/NK/HD/FT/GEN >4.0CM 143.00 06/30/10 17276 17276 17276 058 0360 0609
10910859 MALIGNANT FACE O.5CM OR LESS 270.00 06/30/10 17280 17280 17280 058 0360 0609
10910861 FACE 0.6 - 1.0CM 311.00 06/30/10 17281 17281 17281 058 0360 0609
10910863 FACE 1.1 - 2.0CM 143.00 06/30/10 17282 17282 17282 058 0360 0609
10910865 FACE 2.1 - 3.0CM 143.00 06/30/10 17283 17283 17283 058 0360 0609
10910867 FACE 3.1 - 4.0CM 143.00 06/30/10 17284 17284 17284 058 0360 0609
10910869 FACE OVER 4.0CM 143.00 06/30/10 17286 17286 17286 058 0360 0609
10910871 CRYOTHER C02 SLUSH LIQ N2 ACNE 64.00 06/30/10 17340 17340 17340 058 0360 0609
10910873 CHEMICAL EXFOLIATION (ACNE) 61.00 06/30/10 17360 17360 17360 058 0360 0609
10910875 ELECTRO EPILATION EA 1/2 HR 91.00 06/30/10 17380 17380 17380 058 0360 0609
10910949 DEST ANAL LES;SIMP,CRYOSURGERY 295.00 06/30/10 46916 46916 46916 058 0360 0609
10910951 ANUS, DEST., LASER SURGERY 143.00 06/30/10 46917 46917 46917 058 0360 0609
10910953 ANUS, DEST., EXTENSIVE 143.00 06/30/10 46924 46924 46924 058 0360 0609
10910971 PENIS, DEST., LASER SURGERY 519.00 06/30/10 54057 54057 54057 058 0360 0609
10910973 PENIS, DEST., EXTENSIVE 176.00 06/30/10 54065 54065 54065 058 0360 0609
10910993 VULVA, DEST., SIMPLE 143.00 06/30/10 56501 56501 56501 058 0360 0609
10910995 VULVA, DEST., EXTENSIVE 143.00 06/30/10 56515 56515 56515 058 0360 0609
10911200 PHOTOCHEMOTHERAPY, UVB 135.00 06/30/10 96900 96900 96900 058 0940 0609
10911204 PHOTOCHEMO THERAPY PUVA 169.00 06/30/10 96912 96912 96912 058 0940 0609
10911801 TATTOO DESTRUCTION 127.00 06/30/10 17000 17000 17000 058 0360 0609
10912001 BIOPSY - LIP 273.00 06/30/10 40490 40490 40490 058 0360 0609
10912003 BIOPSY - NAIL 672.00 06/30/10 11755 11755 11755 058 0360 0609
10912005 BIOPSY - EXTERNAL EAR 712.00 06/30/10 69100 69100 69100 058 0360 0609
10912007 BIOPSY OF PENIS 3453.00 06/30/10 54100 54100 54100 058 0360 0609
10912009 BIOPSY OF VULVA, 1 LESION 627.00 06/30/10 56605 56605 56605 058 0360 0609
10912011 BIOPSY OF VULVA, EA ADD'L LE 551.00 06/30/10 56606 56606 56606 058 0360 0609
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 365
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

10912013 DEST VASC LES <10 SQ CM 522.00 06/30/10 17106 17106 17106 058 0360 0609
10912015 DEST VASC LES 10-50 SQ CM 934.00 06/30/10 17107 17107 17107 058 0360 0609
10912017 DEST VASC LES >50 SQ CM 1872.00 06/30/10 17108 17108 17108 058 0360 0609
10912019 DEST LES, PENIS-CHEMICAL 194.00 06/30/10 54050 54050 54050 058 0360 0609
10912021 DEST LES, PENIS-ELECTRO 2811.00 06/30/10 54055 54055 54055 058 0360 0609
10912023 DEST LES, PENIS-CRYOSURG 248.00 06/30/10 54056 54056 54056 058 0360 0609
10912025 DEST LES, PENIS-LASER SURG 2811.00 06/30/10 54057 54057 54057 058 0360 0609
10912027 DEST LES, PENIS-SURG EXCIS 3891.00 06/30/10 54060 54060 54060 058 0360 0609
10912029 DEST LES, PENIS-EXTENSIVE 3319.00 06/30/10 54065 54065 54065 058 0360 0609
10912031 DEST OF LESION,VULVA, SIMPLE 1737.00 06/30/10 56501 56501 56501 058 0360 0609
10912033 DEST OF LESION, VULVA, EXTENSI 2049.00 06/30/10 56515 56515 56515 058 0360 0609
10912035 TRK/ARM/LEG 0.5CM OR LESS 232.00 06/30/10 17260 17260 17260 058 0360 0609
10912037 TRK/ARM/LEG 0.6 - 1.0CM 232.00 06/30/10 17261 17261 17261 058 0360 0609
10912039 TRK/ARM/LEG 1.1 - 2.0CM 300.00 06/30/10 17262 17262 17262 058 0360 0609
10912041 TRK/ARM/LEG 2.1 - 3.0CM 348.00 06/30/10 17263 17263 17263 058 0360 0609
10912043 TRK/ARM/LEG 3.1 - 4.0CM 403.00 06/30/10 17264 17264 17264 058 0360 0609
10912045 TRK/ARM/LEG OVER 4.0CM 553.00 06/30/10 17266 17266 17266 058 0360 0609
10912047 SC/NK/HD/FT/GEN 0.5CM OR LES 235.00 06/30/10 17270 17270 17270 058 0360 0609
10912049 SC/NK/HD/FT/GEN 0.6-1.0CM 225.00 06/30/10 17271 17271 17271 058 0360 0609
10912051 SC/NK/HD/FT/GEN 1.1-2.0CM 276.00 06/30/10 17272 17272 17272 058 0360 0609
10912053 SC/NK/HD/FT/GEN 2.1-3.0CM 331.00 06/30/10 17273 17273 17273 058 0360 0609
10912055 SC/NK/HD/FT/GEN 3.1-4.0CM 382.00 06/30/10 17274 17274 17274 058 0360 0609
10912057 SC/NK/HD/FT/GEN >4.0CM 452.00 06/30/10 17276 17276 17276 058 0360 0609
10912059 FACE 0.5CM OR LESS 270.00 06/30/10 17280 17280 17280 058 0360 0609
10912061 FACE 0.6 - 1.0CM 299.00 06/30/10 17281 17281 17281 058 0360 0609
10912063 FACE 1.1 -2.0CM 478.00 06/30/10 17282 17282 17282 058 0360 0609
10912065 FACE 2.1 - 3.0CM 597.00 06/30/10 17283 17283 17283 058 0360 0609
10912067 FACE 3.1 - 4.0CM 718.00 06/30/10 17284 17284 17284 058 0360 0609
10912069 FACE OVER 4.0CM 444.00 06/30/10 17286 17286 17286 058 0360 0609
10912071 THERAP/DIAG INJ SUBQ/IM 86.00 06/30/10 96372 96372 96372 058 0510 0609
10912073 TRUNK 10 S CM OR < 2240.00 06/30/10 14000 14000 14000 058 0360 0609
10912075 TRUNK 10.1 TO 30 S CM 2556.00 06/30/10 14001 14001 14001 058 0360 0609
10912077 SC/ARM/LEGS 10 S CM OR < 2254.00 06/30/10 14020 14020 14020 058 0360 0609
10912079 SC/ARM/LEGS 10.1 TO 30 S CM 2704.00 06/30/10 14021 14021 14021 058 0360 0609
10912081 FHD/MTH/GEN/FT 10 S CM OR< 2192.00 06/30/10 14040 14040 14040 058 0360 0609
10912083 FHD/MTH/GEN/FT 10.1-30 S CM 2223.00 06/30/10 14041 14041 14041 058 0360 0609
10912085 EYE/NOSE/EAR 10 S CM OR < 2715.00 06/30/10 14060 14060 14060 058 0360 0609
10912087 EYE/NOSE/EAR 10.1-30 S CM 2813.00 06/30/10 14061 14061 14061 058 0360 0609
10912089 30-60 SQ CM, COMPL, ANY AREA 2285.00 06/30/10 14301 14301 14301 058 0360 0609
10912091 FING/TOE, INCL PREP OF REC 2213.00 06/30/10 14350 14350 14350 058 0360 0609
10912101 KOH - WET MOUNT 52.00 06/30/10 87220 87220 87220 058 0306 0609
10912103 DERMABRASION; TOTAL FACE 1908.00 06/30/10 15780 15780 15780 058 0360 0609
10912105 DERMABRASION; SEG FACE 1908.00 06/30/10 15781 15781 15781 058 0360 0609
10912107 DERMA REG, OTHER THAN FACE 1908.00 06/30/10 15782 15782 15782 058 0360 0609
10912109 DERMABRAS SUPER, ANY SITE 288.00 06/30/10 15783 15783 15783 058 0360 0609
10912111 ABRASION; SING LESION 120.00 06/30/10 15786 15786 15786 058 0360 0609
10912113 CHEM PEEL, FACIAL EPIDERM 88.00 06/30/10 15788 15788 15788 058 0360 0609
10912115 CHEM PEEL, FACIAL DERMAL 171.00 06/30/10 15789 15789 15789 058 0360 0609
10912117 CHEM PEEL, NONFACIAL EPID 106.00 06/30/10 15792 15792 15792 058 0360 0609
10912119 CHEM PEEL, NONFAC DERMAL 120.00 06/30/10 15793 15793 15793 058 0360 0609
10912126 CHEMDNRV ECC GLND BTH AXI 216.00 06/30/10 64650 64650 64650 058 0360 0609
10912150 PHOTOCHEMOTHERAPY WITH UV-B 91.00 06/01/10 96910 96910 96910 058 0361 0609
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 366
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

10912160 LASER TRT INFL SKIN-<250 SQ CM 139.00 06/30/10 96920 96920 96920 058 0361 0609
10912161 LASER TRT SKN-250-500 SQ CM 108.00 06/30/10 96921 96921 96921 058 0361 0609
10912162 LASER TRT INFL SKIN->500 SQ CM 108.00 06/30/10 96922 96922 96922 058 0361 0609
10912170 FULL THCK SKN GRFT-HEAD/FACE 1794.00 06/30/10 15240 15240 15240 058 0490 0609
10912175 DERMAL AUTOGRAFT, 100CM 2362.00 06/30/10 15135 15135 15135 058 0360 0609
10912177 DERMAL AUTOCRAFT,ADD'L 100 CM 2362.00 06/30/10 15136 15136 15136 058 0360 0609
03790510 CLINIC SERVICE-TECHNICAL EXTERNAL 04/01/03 059 0510 9999
03790983 CLINIC SERVICE PROFESSIONAL EXTERNAL 04/01/03 059 0983 9999
10801102 VOID EXTERNAL 04/01/07 059 0983 9999
03610081 OFFC VST NEW LVL1-HOSPITL 100.00 06/30/10 99201 99201 99201 060 0510 9998
03762260 IM INJECTION ANTIBIOTIC 112.00 06/30/10 96372 96372 96372 060 0510 0605
03762265 LUMBAR PUNCTURE/DIAG-HOSP 351.00 06/30/10 62270 62270 62270 060 0360 0605
03762281 LUMBAR PUNCTURE/THERAPEUT-HOSP 519.00 06/30/10 62272 62272 62272 060 0360 0605
03783857 TENSILON TESTS - HOSP 141.00 06/30/10 95857 95857 95857 060 0920 0605
03783860 TRANSCRANIAL DOPPLER - HOSP 244.00 06/30/10 93886 93886 93886 060 0921 0605
03783863 ASSESS HIGHR CORDIAL FUNC-HOSP 55.00 06/30/10 96116 96116 96116 060 0900 0605
03783873 TAP SHUNTS - HOSP 440.00 06/30/10 61070 61070 61070 060 0360 0605
03783881 DEST NEU AGNT-FACIAL NRVE-HOSP 547.00 06/30/10 64612 64612 64612 060 0360 0605
03783882 DEST NEU AGNT-NECK MUSCL-HOSP 897.00 06/30/10 64613 64613 64613 060 0360 0605
03783883 DEST NEUR AGNT-PERIPH NVE-HOSP 372.00 06/30/10 64640 64640 64640 060 0360 0605
03783884 BOTOX TYPE A-PER UNIT 864.00 06/30/10 J0585 J0585 J0585 060 0636 0605
03783885 BOTOX TYPE B-2500 U/.5 ML 453.00 06/30/10 J0587 J0587 J0587 060 0636 0605
03783890 DES NEU AGNT-EXTREMITY(S)-HOSP 549.00 06/30/10 64614 64614 64614 060 0360 0605
03788039 THERAPEUTIC/DIAG INJ SUBQ/IM 86.00 06/30/10 96372 96372 96372 060 0510 0605
03788041 THERAPEUTIC/DIAG INJ IV HOSP 80.00 06/30/10 96374 96374 96374 060 0510 0605
03788054 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 060 0510 0605
03788057 NEUROSTIM ANALY W/O REPRO-HOSP 125.00 06/30/10 95970 95970 95970 060 0740 0605
03788060 STIM COMPL CRN,1ST HR-HOSP 478.00 06/30/10 95974 95974 95974 060 0920 0605
03788063 STIM COMPL CRN,ADD 30MIN-HOSP 250.00 06/30/10 95975 95975 95975 060 0740 0605
03788066 INCI IMPLNT ELEC;CRAN NRV-HOSP 12480.00 06/30/10 64573 64573 64573 060 0360 0605
03788069 INSRT/RPL CRAN NEUR;1 ARR-HOSP 14247.00 06/30/10 61885 61885 61885 060 0360 0605
03788072 REV/RMVL PERIPH NEUR ELEC-HOSP 1355.00 06/30/10 64585 64585 64585 060 0360 0605
03788076 REV/RMVL CRAN NEUROST GEN-HOSP 2832.00 06/30/10 61888 61888 61888 060 0360 0605
03788080 SPIROMETRY-HOSP 220.00 06/30/10 94010 94010 94010 060 0460 0605
06680001 DUP SCAN EXTRACRAN COMPLETE 647.00 06/30/10 93880 93880 93880 060 0921 0555
06680005 DUP SCAN EXTRACRAN LIMITED 564.00 06/30/10 93882 93882 93882 060 0921 0555
06680013 TRANSCRANIAL DOPPLER COMPLETE 815.00 06/30/10 93886 93886 93886 060 0921 0555
06680017 TRANSCRANIAL DOPPLER LIMITED 491.00 06/30/10 93888 93888 93888 060 0921 0555
06680031 TRANCRAN DOP-EMBOLI DT W/BUB 596.00 06/30/10 93893 93893 93893 060 0921 0555
06750001 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 060 0510 0663
06750015 THERAPEUTIC/DIAG INJ IV HOSP 57.00 06/30/10 96374 96374 96374 060 0510 0663
06750016 THERAPEUTIC/DIAG INJ SUBQ/IM 79.00 06/30/10 96372 96372 96372 060 0510 0663
06750019 DUP SCAN EXTRACRAN ART-HOSP 647.00 06/30/10 93880 93880 93880 060 0921 0663
06750020 DUP SCAN EXTRACRAN ART-M.D. 67.00 $ 06/30/09 93880 9388026 9388026 060 0920 0663
06750021 DUP SCAN EXTRACRAN LTD-HOSP 564.00 06/30/10 93882 93882 93882 060 0921 0663
06750022 DUP SCAN EXTRACRAN LTD-M.D. 45.00 $ 06/30/09 93882 93882 93882 060 0920 0663
06750023 TRANSCRANIAL DOPPLER - HOSP 815.00 06/30/10 93886 93886 93886 060 0921 0663
06750024 TRANSCRANIAL DOPPLER - M.D. 102.00 $ 06/30/09 93886 9388626 9388626 060 0920 0663
06750031 TRCRN DOP-EMBOLI DT W/BUB-HOSP 596.00 06/30/10 93893 93893 93893 060 0921 0663
06750032 TRCRN DOP-EMBOLI DT W/BUB-M.D. 123.00 $ 06/30/09 93893 93893 93893 060 0921 0663
06750059 ASSESS HIGHR CORDIAL FUNC-HOSP 58.00 06/30/10 96116 96116 96116 060 0918 0663
06750060 ASSESS HIGHR CORDIAL FUNC-M.D. 199.00 $ 06/30/09 96116 96116 96116 060 0900 0663
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 367
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

06750061 TRNSCRN BUB STDY/FULL TCD-HOSP 159.00 06/30/10 93886 93886 93886 060 0921 0663
06750062 TRNSCRN BUB STDY/FULL TCD-M.D. 102.00 $ 06/30/09 93886 93886 93886 060 0920 0663
12666441 SMRT-DOP SING LVL BI STDY-HOSP 158.00 06/30/10 93922 93922 93922 060 0921 0602
12666442 SMRT-DOP SING LVL BI STDY-M.D. 28.00 $ 06/30/09 93922 9392226 9392226 060 0921 0602
93610081 VOID EXTERNAL 12/31/03 060 0983 9998
93610084 OFFC VST NEW LVL4-DOCTOR 245.00 $ 06/30/09 99204 99204 99204 060 0983 0605
93610085 OFFC VST NEW LVL5-DOCTOR 318.00 $ 06/30/09 99205 99205 99205 060 0983 0605
93610086 OFFC VST EST LVL1-DOCTOR 19.00 $ 06/30/09 99211 99211 99211 060 0983 0605
93610087 OFFC VST EST LVL2-DOCTOR 50.00 $ 06/30/09 99212 99212 99212 060 0983 0605
93610088 OFFC VST EST LVL3-DOCTOR 95.00 $ 06/30/09 99213 99213 99213 060 0983 0605
93762265 LUMBAR PUNCTURE/DIAG-M.D. 158.00 $ 06/30/09 62270 62270 62270 060 0975 0605
93762281 LUMBAR PUNCTURE/THERAPEUT-M.D. 176.00 $ 06/30/09 62272 62272 62272 060 0975 0605
93783857 TENSILON TESTS-M.D. 57.00 $ 06/30/09 95857 95857 95857 060 0983 0605
93783860 TRANSCRANIAL DOPPLER - M.D. 102.00 $ 06/30/09 93886 9388626 9388626 060 0983 0605
93783863 ASSESS HIGHR CORDIAL FUNC-M.D. 199.00 $ 06/30/09 96116 96116 96116 060 0916 0605
93783873 TAP SHUNTS - M.D. 174.00 $ 06/30/09 61070 61070 61070 060 0975 0605
93783881 DEST NEU AGNT-FACIAL NRVE-M.D. 268.00 $ 06/30/09 64612 64612 64612 060 0975 0605
93783882 DEST NEU AGNT-NECK MUSCL-M.D. 253.00 $ 06/30/09 64613 64613 64613 060 0975 0605
93783883 DEST NEUR AGNT-PERIPH NVE-M.D. 365.00 $ 06/30/09 64640 64640 64640 060 0975 0605
93783890 DES NEU AGENT EXTEMITY(S)-HOSP 279.00 $ 06/30/09 64614 64614 64614 060 0975 0605
93788041 THERAPEUTIC/DIAG INJ IV M.D. 119.00 $ 06/30/09 96374 96374 96374 060 0983 0605
93788057 NEUROSTIM ANALY W/O REPRO-M.D. 48.00 $ 06/30/09 95970 95970 95970 060 0983 0605
93788060 STIM COMPL CRN,1ST HR-M.D. 317.00 $ 06/30/09 95974 95974 95974 060 0983 0605
93788063 STIM COMPL CRN,ADD 30MIN-M.D. 185.00 $ 06/30/09 95975 95975 95975 060 0920 0605
93788066 INCI IMPLNT ELEC;CRAN NRV-M.D. 1240.00 $ 06/30/09 64573 64573 64573 060 0975 0605
93788069 INSRT/RPL CRAN NEUR;1 ARR-M.D. 1303.00 $ 06/30/09 61885 61885 61885 060 0975 0605
93788072 REV/RMVL PERIPH NEUR ELEC-M.D. 328.00 $ 06/30/09 64585 64585 64585 060 0975 0605
93788076 REV/RMVL CRAN NEUROST GEN-M.D. 849.00 $ 06/30/09 61888 61888 61888 060 0975 0605
93788080 SPIROMETRY-M.D. 18.00 $ 06/30/09 9401026 9401026 9401026 060 0983 0605
02230005 MTHLY RENTAL PERINEOMETER EMG 392.00 06/30/10 E0746 E0746 E0746 062 0270 2825
03783876 MED TEAM CONF(30 MIN)-HOSP 128.00 06/30/10 99367 99367 99367 062 0510 0605
03783878 MED TEAM CONF(1 HR.)-HOSP. 218.00 06/30/10 99367 99367 99367 062 0510 0605
03785738 SOFT SPHERE-HOSP 29.00 06/30/10 92314 92314 92314 062 0510 4502
03785740 SOFT TORIC-HOSP 41.00 06/30/10 92314 92314 92314 062 0510 4502
03785741 EXTENDED WEAR EVALUATION-HOSP 50.00 06/30/10 92314 92314 92314 062 0510 4502
03785742 RGP - HOSP 41.00 06/30/10 92314 92314 92314 062 0510 4502
03785748 SOFT BIFOCAL-HOSP 41.00 06/30/10 92314 92314 92314 062 0510 4502
03785753 RGP BIFOCAL - HOSP 43.00 06/30/10 92314 92314 92314 062 0510 4502
07230100 PURE TONE SCREENING INFANT 378.00 06/30/10 92551 92551 92551 95.49 062 0471 0292
07230105 AUDITORY EVOKED POTENTIALS 266.00 06/30/10 92586 92586 92586 062 0470 0292
09001040 ACETAMIN W/CODEINE #3 TAB 21.00 06/30/10 062 0250 6812
09001171 AMOXICILLIN 250MG CAP 13.00 06/30/10 062 0250 6812
09001235 ASPIRIN 325MG TAB 14.00 06/30/10 062 0250 6812
09001240 ASPIRIN 81MG CHEW TAB 14.00 06/30/10 062 0250 6812
09001293 AZITHROMYCIN250MG TABLET 29.00 06/30/10 062 0250 6812
09001296 AZITHROMYCIN500MG TABLET 46.00 06/30/10 062 0250 6812
09001429 CAPTOPRIL 25MG TABLET 13.00 06/30/10 062 0250 6812
09001455 CEFPODOXIME 200MG TAB 21.00 06/30/10 062 0250 6812
09001500 CEPHALEXIN 250MG CAP 16.00 06/30/10 062 0250 6812
09001545 CHLORL HYDRATE 500 MG ORAL LIQ 13.00 06/30/10 062 0250 6812
09001589 CLINDAMYCIN 150MG CAP 17.00 06/30/10 062 0250 6812
09001595 CLONIDINE 0.1 MG TAB 11.00 06/30/10 062 0250 6812
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 368
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

09001635 COTRIMOXAZOLE (BACTRIM) TAB 10.00 06/30/10 062 0250 6812
09002590 INSULIN NPH HUMULIN 100U/ML 5.00 06/30/10 062 0636 6812
09002595 INSULIN REG HUMULIN 100U/ML 5.00 06/30/10 062 0250 6812
09004495 THEOPHYLLINE SR 300MG TAB 10.00 06/30/10 062 0250 6812
09004541 THIAMINE 100MG TAB 10.00 06/30/10 062 0250 6812
09004785 VIOXX 25MG TAB 10.00 06/30/10 062 0250 6812
11050109 IUD INSERTION-HOSP 301.00 06/30/10 58300 58300 58300 062 0360 0612
11050110 IUD INSERTION-M.D. 119.00 $ 06/30/09 58300 58300 58300 062 0975 0612
11050131 NORPLANT INSERTION-HOSP 309.00 06/30/10 11975 11975 11975 062 0360 0612
11050132 NORPLANT INSERTION-M.D. 174.00 $ 06/30/09 11975 11975 11975 062 0975 0612
11050139 NORPLANT REMOVAL&REINSERT-HOSP 337.00 06/30/10 11977 11977 11977 062 0360 0612
11050140 NORPLANT REMOVAL&REINSERT-M.D. 385.00 $ 06/30/09 11977 11977 11977 062 0975 0612
11050317 PREV MED CNSL-15MIN-HOSP 46.00 06/30/10 99401 99401 99401 062 0510 0612
11050318 PREV MED CNSL-15MIN-M.D. 44.00 06/30/09 99401 99401 99401 062 0983 0612
11050321 PREV MED CNSL-30MIN-HOSP 86.00 06/30/10 99402 99402 99402 062 0510 0612
11050322 PREV MED CNSL-30MIN-M.D. 61.00 06/30/09 99402 99402 99402 062 0983 0612
11050325 PREV MED CNSL-45MIN-HOSP 128.00 06/30/10 99403 99403 99403 062 0510 0612
11050326 PREV MED CNSL-45MIN-M.D. 94.00 06/30/09 99403 99403 99403 062 0983 0612
11050329 PREV MED CNSL-60MIN-HOSP 167.00 06/30/10 99404 99404 99404 062 0510 0612
11050330 PREV MED CNSL-60MIN-M.D. 149.00 06/30/09 99404 99404 99404 062 0983 0612
11050505 PREV MED VST NEW-AGE18-39 HOSP 193.00 06/30/10 99385 99385 99385 062 0510 0612
11050506 PREV MED VST NEW-AGE18-39-M.D. 163.00 $ 06/30/09 99385 99385 99385 062 0983 0612
11050509 PREV MED VST,NEW-AGE 40-64HOSP 152.00 06/30/10 99386 99386 99386 062 0510 0612
11050510 PREV MED VST,NEW-AGE 40-64M.D. 199.00 $ 06/30/09 99386 99386 99386 062 0983 0612
11050513 REV MED VST NEW-AGE 65+-HOSP 169.00 06/30/10 99387 99387 99387 062 0510 0612
11050514 PREV MED VST NEW-AGE65+ M.D. 218.00 $ 06/30/09 99387 99387 99387 062 0983 0612
11050521 PREV MED VST EST-AGE18-39 HOSP 161.00 06/30/10 99395 99395 99395 062 0510 0612
11050522 PREV MED VST EST-AGE 18-39M.D. 144.00 $ 06/30/09 99395 99395 99395 062 0983 0612
11050525 PREV MED VST EST AGE40-64-HOSP 127.00 06/30/10 99396 99396 99396 062 0510 0612
11050526 PREV MED VST EST AGE40-64 M.D. 163.00 $ 06/30/09 99396 99396 99396 062 0983 0612
11050529 PREV MED VST EST AGE65+-HOSP 143.00 06/30/10 99397 99397 99397 062 0510 0612
11050530 PREV MED VST EST AGE65+-M.D. 182.00 $ 06/30/09 99397 99397 99397 062 0983 0612
11050535 MULTIFETAL PREG REDUCTION-HOSP 235.00 06/30/10 59866 59866 59866 062 0360 0612
11050536 MULTIFETAL PREG REDUCTION-M.D. 543.00 $ 06/30/09 59866 59866 59866 062 0975 0612
11050541 NUCHAL TRANSLUC SCRN,SING-HOSP 249.00 06/30/10 76813TC 76813 76813 062 0402 0612
11050542 NUCHAL TRANSLUC SCRN,SING-M.D. 122.00 $ 06/30/09 7681326 7681326 7681326 062 0972 0612
11050545 NUCHAL TRNS SCRN,EA ADD'L-HOSP 159.00 06/30/10 76814TC 76814 76814 062 0402 0612
11050546 NUCHAL TRANS SCRN,EA ADD'L-M.D 104.00 $ 06/30/09 76814TC 76814 76814 062 0972 0612
11060109 IUD INSERTION 301.00 06/30/10 58300 58300 58300 062 0360 0612
11060131 NORPLANT INSERTION 309.00 06/30/10 11975 11975 11975 062 0360 0612
11060139 NORPLANT REMOVAL & REINSERT 337.00 06/30/10 11977 11977 11977 062 0360 0612
11060317 PREV MED CNSL-15 MIN 46.00 06/30/10 99401 99401 99401 062 0510 0612
11060321 PREV MED CNSL-30 MIN 86.00 06/30/10 99402 99402 99402 062 0510 0612
11060325 PREV MED CNSL-45 MIN 128.00 06/30/10 99403 99403 99403 062 0510 0612
11060329 PREV MED CNSL-60 MIN 167.00 06/30/10 99404 99404 99404 062 0510 0612
11060505 PREV MED VST NEW-AGE 18-39 193.00 06/30/10 99385 99385 99385 062 0510 0612
11060509 PREV MED VST NEW-AGE 40-64 152.00 06/30/10 99386 99386 99386 062 0510 0612
11060513 PREV MED VST NEW-AGE 65+ 169.00 06/30/10 99387 99387 99387 062 0510 0612
11060521 PREV MED VST EST-AGE 18-39 161.00 06/30/10 99395 99395 99395 062 0510 0612
11060525 PREV MED VST EST AGE 40-64 127.00 06/30/10 99396 99396 99396 062 0510 0612
11060529 PREV MED VST EST AGE 65+ 143.00 06/30/10 99397 99397 99397 062 0510 0612
11060535 MULTIFETAL PREG REDUCTION 235.00 06/30/10 59866 59866 59866 062 0360 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 369
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11060541 NUCHAL TRANSLUC SCRN,SING 249.00 06/30/10 76813TC 76813 76813 062 0402 0612
11060545 NUCHAL TRNS SCRN,EA ADD'L 159.00 06/30/10 76814TC 76814 76814 062 0402 0612
11100654 VOID 293.00 06/30/10 58300 58300 58300 062 0975 9999
11910066 ENVIRON INTERVENT-MED MGMT 79.00 06/30/10 90882 90882 90882 062 0900 0517
11910101 MEDICAL CONFERENCE - 30 MIN 101.00 06/30/10 99367 99367 99367 062 0510 0517
11910106 MEDICAL CONFERENCE - 60 MIN 101.00 06/30/10 99367 99367 99367 062 0510 0517
12340045 CHEMO,ANTO-NEOPL,SQ/IM 136.00 06/30/10 96401 96401 96401 062 0331 0524
12666269 DEPO PROVERA 150 MG 100.00 06/30/10 J1055 J1055 J1055 062 0636 0602
12666370 HEARING SCREENING 85.00 06/30/10 92551 92551 92551 062 0471 0602
12666915 PREV MED CNSL-30MIN-HOSP 86.00 06/30/10 99402 99402 99402 062 0510 0602
12666916 PREV MED CNSL-30MIN-M.D. 102.00 $ 06/30/09 99402 99402 99402 062 0983 0602
12666919 PREV MED CNSL-45MIN-HOSP 128.00 06/30/10 99403 99403 99403 062 0510 0602
12666920 PREV MED CNSL-45MIN-M.D. 153.00 $ 06/30/09 99403 99403 99403 062 0983 0602
12666923 PREV MED CNSL-60MIN-HOSP 167.00 06/30/10 99404 99404 99404 062 0510 0602
12666924 PREV MED CNSL-60MIN-M.D. 204.00 $ 06/30/09 99404 99404 99404 062 0983 0602
13300048 PREV MED NEW PT-18-39 YRS-HOSP 193.00 06/30/10 99385 99385 99385 062 0510 0648
13300049 PREV MED NEW PT-18-39 YRS-M.D. 163.00 $ 06/30/09 99385 99385 99385 062 0983 0648
13300058 PREV MED EST PT 18-39 YRS-HOSP 161.00 06/30/10 99395 99395 99395 062 0510 0648
13300059 PREV MED EST PT 18-39 YRS-M.D. 144.00 $ 06/30/09 99395 99395 99395 062 0983 0648
13300060 PREV MED CNSL 30MIN - HOSP 86.00 06/30/10 99402 99402 99402 062 0510 0648
13300061 PREV MED CNSL 30MIN - M.D. 102.00 $ 06/30/09 99402 99402 99402 062 0983 0648
13300062 PREV MED CNSL 45MIN-HOSP 128.00 06/30/10 99403 99403 99403 062 0510 0648
13300063 PREV MED CNSL 45MIN-M.D. 153.00 $ 06/30/09 99403 99403 99403 062 0983 0648
13300064 PREV MED CNSL 60MIN-HOSP 167.00 06/30/10 99404 99404 99404 062 0510 0648
13300065 PREV MED CNSL 60MIN-M.D. 204.00 $ 06/30/09 99404 99404 99404 062 0983 0648
13300130 HEALTH RISK ASSESSMENT-HOSP 70.00 06/30/10 99420 99420 99420 062 0510 0648
13300131 HEALTH RISK ASSESSMENT-M.D. 64.00 $ 12/01/09 99420 99420 99420 062 0983 0648
13300278 HEARING SCREENING 85.00 06/30/10 92551 92551 92551 062 0471 0648
13301008 PREV MED NEW PT 18-39 YRS-HOSP 193.00 06/30/10 99385 99385 99385 062 0510 0648
13301009 PREV MED NEW PT 18-39 YRS-M.D. 163.00 $ 06/30/09 99385 99385 99385 062 0983 0648
13301025 PREV MED EST PT 5-11 YRS-M.D. 127.00 $ 06/30/09 99393 99393 99393 062 0983 0648
13301028 PREV MED EST PT 18-39 YRS-HOSP 161.00 06/30/10 99395 99395 99395 062 0510 0648
13301029 PREV MED EST PT 18-39 YRS-M.D. 144.00 $ 06/30/09 99395 99395 99395 062 0983 0648
13710042 ACETAMINOPHEN 80MG CHEW TAB EXTERNAL 03/02/87 062 0250 5012
13710045 ACETAMINOPHEN 160MG CHEW TAB EXTERNAL 07/01/84 062 0250 5012
13710050 ACETAMINOPHEN 325MG TAB EXTERNAL 10/19/93 062 0250 5012
13710077 ACETAMINOPHEN 500MG TAB EXTERNAL 10/19/93 062 0250 5012
13710101 ACETAMINOPHEN-CODEINE 1ML ELIX EXTERNAL 12/18/01 062 0251 5012
13710102 ACETAMINOPHEN-CODEINE 1.5ML EL EXTERNAL 12/18/01 062 0251 5012
13710103 ACETAMINOPHEN-CODEINE 3ML ELIX EXTERNAL 12/18/01 062 0251 5012
13710130 ACETAMINOPHEN DROPS 15ML BOTTL EXTERNAL 10/19/93 062 0250 5012
13710157 ACETAMINOPHEN-CODEINE 25ML ELI EXTERNAL 05/25/95 062 0250 5012
13710158 ACETAMINOPHEN-CODEINE 5ML ELIX EXTERNAL 10/19/93 062 0250 5012
13710159 ACETAMINOPHEN-CODEINE 10ML ELI EXTERNAL 10/19/93 062 0250 5012
13710160 ACETAMINOPHEN-CODEINE 15ML ELI EXTERNAL 10/19/93 062 0250 5012
13710163 ACETAMINOPHEN-CODEINE 12.5ML E EXTERNAL 10/19/93 062 0250 5012
13710168 ACETAMINOPHEN/COD #3 - 1 BOX EXTERNAL 10/19/93 062 0251 5012
13710169 ACETAMINOPHEN/COD #4 - 1 BOX EXTERNAL 10/19/93 062 0251 5012
13710170 ACETAZOLAMIDE 125MG TAB EXTERNAL 10/19/93 062 0250 5012
13710171 ACETAZOLAMIDE 125MG - 1 BOTTLE EXTERNAL 10/19/93 062 0251 5012
13710172 ACETAMINOPHEN-CODEINE 2.5ML EL EXTERNAL 05/01/95 062 0251 5012
13710173 ACETAMINOPHEN-CODEINE 4ML ELIX EXTERNAL 05/01/95 062 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 370
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13710174 ACETAMINOPHEN-CODEINE 7.5ML EL EXTERNAL 05/01/95 062 0251 5012
13710181 ACETAZOLAMIDE 250MG - 1 BOX EXTERNAL 10/19/93 062 0251 5012
13710183 ACETAZOLAMIDE 50 MG/ML ORAL SU EXTERNAL 12/22/04 062 0251 5012
13710202 ACETAZOLAMIDE 500MG - BOTTLE EXTERNAL 10/19/93 062 0251 5012
13710377 ADDERALL TAB 2.5 MG HALF TABLE EXTERNAL 06/07/01 062 0251 5012
13710378 ADDERALL TAB 5 MG EXTERNAL 06/07/01 062 0251 5012
13710379 ADDERALL TAB 10 MG EXTERNAL 06/07/01 062 0251 5012
13710382 ADDERALL TAB 10 MG XR EXTERNAL 06/07/01 062 0251 5012
13710455 ALLOPURINOL 100MG TAB EXTERNAL 10/24/94 062 0250 5012
13710461 ALLOPURINOL 300MG TAB EXTERNAL 10/24/94 062 0250 5012
13710462 ALLOPURINOL 300MG - 1 BOX EXTERNAL 10/24/94 062 0251 5012
13710481 ALPRAZOLAM 0.250MG - 1 BOX EXTERNAL 07/13/94 062 0251 5012
13710482 ALPRAZOLAM 0.125MG PER 1/2 TAB EXTERNAL 07/13/94 062 0251 5012
13710483 ALPRAZOLAM 0.25MG TAB EXTERNAL 07/13/94 062 0250 5012
13710485 ALPRAZOLAM 0.5MG TAB EXTERNAL 07/13/94 062 0250 5012
13710487 ALPRAZOLAM 1MG TAB EXTERNAL 07/13/94 062 0250 5012
13710488 ALPRAZOLAM 0.500MG - 1 BOX EXTERNAL 07/13/94 062 0251 5012
13710489 ALPRAZOLAM 1MG - 1 BOX EXTERNAL 07/13/94 062 0251 5012
13710542 ALENDRONATE 40MG TABLETS EXTERNAL 04/05/96 062 0251 5012
13710543 ALENDRONATE 10MG TAB EXTERNAL 04/05/96 062 0251 5012
13710544 ALENDRONATE 70MG TAB EXTERNAL 07/25/02 062 0251 5012
13710546 ALENDRONATE 10MG TABLETS EXTERNAL 04/05/96 062 0251 5012
13710650 AMANTADINE 100MG CAP EXTERNAL 08/05/94 062 0250 5012
13710651 AMAMTADINE 100MG - 1 BOX EXTERNAL 08/05/94 062 0251 5012
13710655 AMANTADINE SYRUP 480ML BOTTLE EXTERNAL 08/05/94 062 0250 5012
13710656 AMANTADINE 50MG SYRUP EXTERNAL 08/05/94 062 0250 5012
13710708 AMINOPHYLLINE 300MG ORAL SOLN EXTERNAL 08/05/94 062 0251 5012
13710711 AMINOPHYLLINE 100MG TAB EXTERNAL 08/05/94 062 0251 5012
13710712 AMINOPHYLLINE 100MG - 1 BOX EXTERNAL 08/05/94 062 0251 5012
13710721 AMINOPHYLLINE 200MG TAB EXTERNAL 08/05/94 062 0251 5012
13710722 AMINOPHYLLINE 200MG - 1 BOX EXTERNAL 08/05/94 062 0251 5012
13710731 AMINOPHYLLINE 1.2MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710732 AMINOPHYLLINE 1.5MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710733 AMINOPHYLLINE 2MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710734 AMINOPHYLLINE 2.5MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710735 AMINOPHYLLINE 3MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710736 AMINOPHYLLINE 3.5MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710737 AMINOPHYLLINE 4MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710738 AMINOPHYLLINE 4.5MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710739 AMINOPHYLLINE 5MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710740 AMINOPHYLLINE 6MG ORAL SOLN EXTERNAL 03/13/95 062 0251 5012
13710741 AMINOPHYLLINE 7MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710742 AMINOPHYLLINE 8MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710743 AMINOPHYLLINE 9MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710744 AMINOPHYLLINE 10MG ORAL SOLN EXTERNAL 03/06/96 J0280 J0280 J0280 062 0251 5012
13710745 AMINOPHYLLINE 12MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710746 AMINOPHYLLINE 15MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710747 AMINOPHYLLINE 20MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710748 AMINOPHYLLINE 25MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710749 AMINOPHYLLINE 30MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710750 AMINOPHYLLINE 35MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710751 AMINOPHYLLINE 40MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 371
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13710752 AMINOPHYLLINE 45MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710753 AMINOPHYLLINE 50MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710754 AMINOPHYLLINE 55MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710755 AMINOPHYLLINE 60MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13710910 AMOXICILLIN 250MG CAPSULE EXTERNAL 03/13/95 062 0250 5012
13710912 AMOXICILLIN 500MG CAPSULE EXTERNAL 03/13/95 062 0250 5012
13710913 AMOXICILLIN 500MG - 1 BOX EXTERNAL 03/13/95 062 0251 5012
13710914 AMOXICILLIN 250MG - 1 BOX EXTERNAL 03/13/95 062 0251 5012
13710920 AUGMENTIN 875MG TABLETS EXTERNAL 02/04/98 062 0251 5012
13710970 AMPICILLIN 250MG CAPSULE EXTERNAL 03/13/95 062 0251 5012
13710971 AMPICILLIN 250MG - 1 BOX EXTERNAL 03/13/95 062 0251 5012
13710990 AMPICILLIN 500MG CAPSULE EXTERNAL 03/13/95 062 0251 5012
13710991 AMPICILLIN 500MG - 1 BOX EXTERNAL 03/13/95 062 0251 5012
13711001 AMPICILLIN 125MG ORAL SUSP EXTERNAL 03/13/95 062 0251 5012
13711011 AMPICILLIN 500MG ORAL SUSP EXTERNAL 03/13/95 062 0251 5012
13711012 AMPICILLIN 250MG ORAL SUSP EXTERNAL 03/13/95 062 0251 5012
13711022 AMPICILLIN 50MG/ML ORAL SUSP EXTERNAL 06/27/01 062 0251 5012
13711050 AMPICILLIN SUSPENSION 200ML BO EXTERNAL 03/13/95 062 0251 5012
13711310 ASCORBIC ACID 250MG - 1 BOTTLE EXTERNAL 07/13/94 062 0251 5012
13711311 ASCORBIC ACID 250MG TAB EXTERNAL 07/13/94 062 0251 5012
13711340 ASCORBIC ACID 500MG TAB EXTERNAL 07/13/94 062 0250 5012
13711341 ASCORBIC ACID 500MG - 1 BOX EXTERNAL 07/13/94 062 0251 5012
13711380 ASPIRIN 325MG TAB EXTERNAL 07/13/94 062 0637 5012
13711382 ASPIRIN 325MG - 1 BOX EXTERNAL 07/13/94 062 0251 5012
13711419 ASPIRIN 81MG EC TAB EXTERNAL 10/12/95 062 0251 5012
13711422 ASPIRIN 40.5MG TAB EXTERNAL 01/29/01 062 0251 5012
13711450 ASPIRIN 81MG CHEW TABLET EXTERNAL 07/13/94 062 0250 5012
13711451 ASPIRIN 75MG - 1 BOTTLE (36) EXTERNAL 07/13/94 062 0251 5012
13711461 ASPIRIN 325MG EC TAB EXTERNAL 07/13/94 062 0250 5012
13711462 ASPIRIN 325MG EC - 1 BOX EXTERNAL 07/13/94 062 0251 5012
13711467 ASPIRIN 650MG EC - 1 BOX EXTERNAL 07/13/94 062 0251 5012
13711471 ASPIRIN 650MG EC TAB EXTERNAL 07/13/94 062 0250 5012
13711476 ATENOLOL 50MG TAB EXTERNAL 07/13/94 062 0250 5012
13711478 ATENOLOL 100MG TAB EXTERNAL 07/13/94 062 0250 5012
13711479 ATENOLOL 100MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13711482 ATENOLOL 50MG - 1 BOX EXTERNAL 01/01/87 062 0250 5012
13711485 ATENOLOL 25MG TAB EXTERNAL 04/06/94 062 0251 5012
13711497 ATENOLOL 12.5MG TAB EXTERNAL 08/10/01 062 0251 5012
13711602 AUGMENTIN 125MG - 1 BTL(30 CHW EXTERNAL 01/12/90 062 0251 5012
13711607 AUGMENTIN 500MG - 1 BOX EXTERNAL 01/12/90 062 0251 5012
13711652 AZITHROMYCIN 600MG TAB EXTERNAL 06/12/00 Q0144 Q0144 Q0144 062 0637 5012
13711653 AZITHROMYCIN 600MG TAB BULK EXTERNAL 06/12/00 062 0251 5012
13711660 AZATHIOPRINE 50MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
13711677 PREDNISONE (2X20 MG + 3X15 MG EXTERNAL 04/08/94 J7506 J7506 J7506 062 0637 5012
13711711 AZITHROMYCIN 500 MG TAB EXTERNAL 12/27/04 Q0144 Q0144 Q0144 062 0636 5012
13711712 AZITHROMYCIN 250 MG TAB EXTERNAL 12/27/04 Q0144 Q0144 Q0144 062 0251 5012
13711713 AZITHROMYCIN 200 ML/5 ML ORAL EXTERNAL 05/28/02 Q0144 Q0144 Q0144 062 0251 5012
13711722 AZATHIOPRINE 75MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
13711723 AZATHIOPRINE 50MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
13711724 AZATHIOPRINE 50MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
13711725 AZATHIOPRINE 50MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
13711726 AZATHIOPRINE 50MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 372
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13711727 AZATHIOPRINE 50MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
13711729 AZATHIOPRINE 50MG TAB EXTERNAL 07/13/94 J7500 J7500 J7500 062 0636 5012
13711776 BACLOFEN 5MG (PER 1/2) TAB EXTERNAL 07/13/94 062 0251 5012
13711777 BACLOFEN 10MG TAB EXTERNAL 07/13/94 062 0250 5012
13711778 BACLOFEN 10MG - 1 BOX EXTERNAL 07/13/94 062 0636 5012
13712110 BENZTROPINE 2MG TAB EXTERNAL 07/14/94 062 0250 5012
13712120 BENZTROPINE 0.5MG TAB EXTERNAL 07/14/94 062 0250 5012
13712140 BENZTROPINE 1MG TAB EXTERNAL 07/14/94 062 0250 5012
13712250 BETHANECHOL 10MG TAB EXTERNAL 07/14/94 062 0250 5012
13712251 BETHANECHOL 10MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13712270 BETHANECHOL 25MG TAB EXTERNAL 07/14/94 062 0250 5012
13712271 BETHANECHOL 25MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13712727 CALCITRIOL 0.50MCG CAP EXTERNAL 07/14/94 S0161 062 0250 5012
13712739 CALCIUM CARBONATE 500MG - 1 BO EXTERNAL 05/25/89 062 0251 5012
13712794 CALCIUM GLUBIONATE 360MG/ML SY EXTERNAL 03/19/02 062 0251 5012
13712795 CALCIUM GLUBIONATE SYRUP 480ML EXTERNAL 07/01/84 062 0250 5012
13712800 CALCIUM GLUBIONATE 250MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13712801 CALCIUM GLUBIONATE 350MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13712802 CALCIUM GLUBIONATE 400MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13712803 CALCIUM GLUBIONATE 500MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13712804 CALCIUM GLUBIONATE 100MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13712805 CALCIUM GLUBIONATE 150MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13712806 CALCIUM GLUBIONATE 200MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13712808 CALCIUM GLUBIONATE 125MG SYRUP EXTERNAL 09/27/01 062 0251 5012
13712809 CALCIUM GLUBIONATE 180MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712810 CALCIUM GLUBIONATE 210MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712811 CALCIUM GLUBIONATE 300MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712812 CALCIUM GLUBIONATE 375MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712813 CALCIUM GLUBIONATE 450MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712814 CALCIUM GLUBIONATE 540MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712815 CALCIUM GLUBIONATE 650MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712816 CALCIUM GLUBIONATE 750MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712817 CALCIUM GLUBIONATE 900MG SYRUP EXTERNAL 12/18/01 062 0251 5012
13712818 CALCIUM GLUBIONATE 1000MG SYRU EXTERNAL 12/18/01 062 0251 5012
13712819 CALCIUM GLUBIONATE 1250MG SYRU EXTERNAL 12/18/01 062 0251 5012
13712824 CALCIUM GLUBIONATE 1500MG SYRU EXTERNAL 12/18/01 062 0251 5012
13712891 CALCIUM LEUCOVORIN 25MG TAB U. EXTERNAL 12/28/93 062 0251 5012
13712895 CALCIUM LEUCOVORIN 5MG TAB EXTERNAL 01/01/95 062 0251 5012
13712941 CAPTOPRIL 6.25MG (PER 1/2) TAB EXTERNAL 01/01/95 062 0251 5012
13712945 CAPTOPRIL 100MG-1 BOX EXTERNAL 01/25/95 062 0251 5012
13712946 CAPTOPRIL 25MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13712947 CAPTOPRIL 50MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13712948 CAPTOPRIL 12.5MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13712952 CAPTOPRIL 25MG TAB EXTERNAL 01/01/95 062 0250 5012
13712954 CAPTOPRIL 50MG TAB EXTERNAL 01/01/95 062 0250 5012
13712956 CAPTOPRIL 100MG TAB EXTERNAL 01/01/95 062 0250 5012
13712958 CAPTOPRIL 12.5MG - 1 BOTTLE EXTERNAL 07/01/84 062 0250 5012
13712959 CAPTOPRIL 12.5MG TAB EXTERNAL 01/01/95 062 0250 5012
13712962 CAPTOPRIL 37.5MG TAB EXTERNAL 04/06/94 062 0251 5012
13712963 CAPTOPRIL 0.025MG ORAL SUSP EXTERNAL 09/27/01 062 0251 5012
13712964 CAPTOPRIL 0.05MG ORAL SUSP EXTERNAL 09/27/01 062 0251 5012
13712965 CAPTOPRIL 0.1MG ORAL SUSP EXTERNAL 09/27/01 062 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 373
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13712966 CAPTOPRIL 0.25MG ORAL SUSP EXTERNAL 09/27/01 062 0251 5012
13712967 CAPTOPRIL 12.5MG ORAL SUSP EXTERNAL 09/27/01 062 0251 5012
13712968 CAPTOPRIL 10MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13712971 CAPTOPRIL 0.5MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712972 CAPTOPRIL 1.0MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712973 CAPTOPRIL 1.5MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712974 CAPTOPRIL 2MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712975 CAPTOPRIL 2.5MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712976 CAPTOPRIL 3.0MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712977 CAPTOPRIL 4.0MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712978 CAPTOPRIL 5.0MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712979 CAPTOPRIL 8.0MG ORAL SUSP EXTERNAL 05/01/95 062 0251 5012
13712982 CAPTOPRIL 0.075MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13712983 CAPTOPRIL 0.13MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13712984 CAPTOPRIL 0.2MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13712985 CAPTOPRIL 0.75MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13712987 CAPTOPRIL 3.5MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13712988 CAPTOPRIL 5.0MG ORAL SUSPENSIO EXTERNAL 05/01/95 062 0251 5012
13712989 CAPTOPRIL 6.25MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13712994 CARBAMAZEPINE 100MG XR TAB EXTERNAL 12/17/96 062 0251 5012
13712999 CARBAMAZEPINE 100MG CHEW TAB EXTERNAL 01/01/95 062 0250 5012
13713001 CARBAMAZEPINE 200MG TAB EXTERNAL 01/01/95 062 0250 5012
13713011 CARBAMAZEPINE 200MG XR TAB EXTERNAL 12/17/96 062 0251 5012
13713014 CARBAMAZEPINE 400MG XR TAB EXTERNAL 12/17/96 062 0251 5012
13713121 CARVEDILOL 6.25MG TABLET EXTERNAL 09/25/97 062 0251 5012
13713122 CARVEDILOL 6.25MG TAB EXTERNAL 09/25/97 062 0251 5012
13713123 CARVEDILOL 3.125MG TABLET EXTERNAL 09/25/97 062 0251 5012
13713124 CARVEDILOL 3.125MG TAB EXTERNAL 09/25/97 062 0251 5012
13713125 CARVEDILOL 25.0MG TABLET EXTERNAL 09/25/97 062 0251 5012
13713126 CARVEDILOL 25MG TAB EXTERNAL 09/25/97 062 0251 5012
13713127 CARVEDILOL 12.5MG TABLET EXTERNAL 09/25/97 062 0251 5012
13713128 CARVEDILOL 12.5MG TAB EXTERNAL 09/25/97 062 0251 5012
13713140 CASCARA SAGRADA 5ML ELIXER EXTERNAL 01/01/95 062 0250 5012
13713145 CEFPODOXIME 100MG TAB EXTERNAL 01/01/95 062 0251 5012
13713146 CEFPODOXIME 100MG TAB BOTTLE 1 EXTERNAL 04/05/94 062 0251 5012
13713148 CEFPODOXIME 200MG TAB EXTERNAL 01/01/95 062 0251 5012
13713187 CEFIXIME 400MG TABLET 1 BOX EXTERNAL 07/01/84 062 0251 5012
13713188 CEFIXIME 400MG TAB EXTERNAL 07/01/84 062 0251 5012
13713207 CEFIXIME 200MG TABLET EXTERNAL 03/17/93 062 0251 5012
13713208 CEFIXIME 200MG TAB EXTERNAL 03/17/93 062 0251 5012
13713220 CEPHALEXIN 250MG CAPSULE EXTERNAL 12/18/92 062 0250 5012
13713240 CEPHALEXIN 500MG CAPSULE EXTERNAL 12/18/92 062 0250 5012
13713241 CEPHALEXIN 500MG CAP - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13713314 CEFUROXIME 125MG TAB EXTERNAL 05/30/92 062 0251 5012
13713316 CEFUROXIME 250MG TAB EXTERNAL 05/30/92 062 0251 5012
13713318 CEFUROXIME 500MG TAB EXTERNAL 05/30/92 062 0251 5012
13713343 CELECOXIB 100 MG CAP EXTERNAL 06/08/01 062 0251 5012
13713344 CELECOXIB 200 MG CAP EXTERNAL 01/24/05 062 0251 5012
13713400 CHLORAL HYDRATE 500MG SYRUP EXTERNAL 12/18/92 062 0250 5012
13713402 CHLORAL HYDRATE 250MG SYRUP EXTERNAL 12/18/92 062 0250 5012
13713403 CHLORAL HYDRATE 25MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713404 CHLORAL HYDRATE 35MG SYRUP EXTERNAL 05/01/95 062 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 374
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13713405 CHLORAL HYDRATE 50MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713406 CHLORAL HYDRATE 65MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713407 CHLORAL HYDRATE 80MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713409 CHLORAL HYDRATE 125MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713412 CHLORAL HYDRATE 150MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713413 CHLORAL HYDRATE 200MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713414 CHLORAL HYDRATE 300MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713415 CHLORAL HYDRATE 400MG SYRUP EXTERNAL 05/01/95 062 0251 5012
13713416 CHLORAL HYDRATE BULK SYRUP EXTERNAL 10/24/00 062 0251 5012
13713420 CHLORAMBUCIL 2MG TAB EXTERNAL 12/18/92 062 0251 5012
13713455 CHLORDIAZEPOXIDE 10 MG CAP EXTERNAL 01/31/05 062 0251 5012
13713660 CHLOROQUINE 500MG TAB EXTERNAL 12/18/92 062 0250 5012
13714001 CLINDAMYCIN 300MG ORAL SUSP EXTERNAL 10/01/01 062 0251 5012
13714002 CLINDAMYCIN 450MG ORAL SUSP EXTERNAL 10/01/01 062 0251 5012
13714058 CHLORTHALIDONE 25MG TAB EXTERNAL 12/18/92 062 0250 5012
13714141 CIMETIDINE 800MG TAB UD - 100/ EXTERNAL 03/26/92 062 0251 5012
13714173 CIPROFLOXACIN 500MG - 1 BOX EXTERNAL 08/05/88 062 0251 5012
13714176 CIPROFLOXACIN 500MG TAB EXTERNAL 12/18/92 062 0251 5012
13714183 CLINDAMYCIN 300MG CAP U.D. EXTERNAL 12/18/92 062 0251 5012
13714185 CLINDAMYCIN 300MG CAPSULE EXTERNAL 10/28/88 062 0251 5012
13714190 CLINDAMYCIN 150MG CAPSULE EXTERNAL 12/18/92 062 0250 5012
13714200 CLINDAMYCIN 75MG ORAL SUSP EXTERNAL 12/18/92 062 0250 5012
13714226 CLOFAZIMINE 50MG CAPSULE EXTERNAL 02/02/87 062 0251 5012
13714234 CLOFAZIMINE 100MG CAPSULE EXTERNAL 03/28/93 062 0251 5012
13714236 CLONAZEPAM 0.5MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13714238 CLONAZEPAM 1.0MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13714239 CLONAZEPAM 2.0MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13714241 CLOMIPHENE CITRATE 50MG TAB EXTERNAL 12/18/92 062 0250 5012
13714244 CLONAZEPAM 0.5MG TABLET EXTERNAL 12/18/92 062 0250 5012
13714246 CLONAZEPAM 1.0MG TABLET EXTERNAL 12/18/92 062 0250 5012
13714248 CLONAZEPAM 2.0MG TABLET EXTERNAL 12/18/92 062 0250 5012
13714250 CLONIDINE 0.1MG - 1 BOTTLE EXTERNAL 07/01/84 062 0250 5012
13714251 CLONIDINE 0.1MG TABLET EXTERNAL 12/18/92 062 0250 5012
13714253 CLONIDINE 0.1MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13714254 CLONIDINE 0.05MG TAB EXTERNAL 01/29/01 062 0251 5012
13714258 CLONAZEPAM 0.03MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13714263 CLONAZEPAM 0.05MG ORAL SUSP EXTERNAL 12/19/01 062 0251 5012
13714270 CLONIDINE 0.3MG TABLET EXTERNAL 12/18/92 062 0250 5012
13714278 CLONIDINE 0.15MG TABLET EXTERNAL 01/29/01 062 0251 5012
13714322 CLOTRIMAZOLE VAG TABLETS - 1 P EXTERNAL 01/25/95 062 0251 5012
13714340 CLORAZEPATE 7.5 MG TAB EXTERNAL 06/07/01 062 0251 5012
13714690 CODEINE SULFATE 30MG TAB EXTERNAL 12/18/92 062 0250 5012
13714691 CODEINE SULFATE 30MG - 1 BOX ( EXTERNAL 01/25/95 062 0251 5012
13714701 CODEINE SULFATE 60MG TAB EXTERNAL 07/01/84 062 0250 5012
13714702 CODEINE SULFATE 60MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13714882 CORTISONE ACETATE 10MG TAB EXTERNAL 02/26/93 062 0251 5012
13714928 COTRIMOXAZOLE DS TAB EXTERNAL 07/21/94 062 0250 5012
13715000 CYANOCOBALAMIN 50MCG TAB EXTERNAL 07/21/94 062 0250 5012
13715026 CYANOCOBALAMIN 500MCG TAB EXTERNAL 11/22/02 062 0251 5012
13715250 DAPSONE 25MG TAB EXTERNAL 01/01/95 062 0250 5012
13715251 DAPSONE 25MG - 1 BOTTLE EXTERNAL 01/25/95 062 0251 5012
13715260 DAPSONE 100MG TAB EXTERNAL 01/01/95 062 0250 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 375
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13717820 VITAMIN D 50,000 UNIT CAP EXTERNAL 01/01/95 062 0250 5012
13718195 FAMOTIDINE 20MG TABLET EXTERNAL 07/25/02 062 0251 5012
13719324 TROGLITAZONE 300MG TABLET- 1 B EXTERNAL 12/26/97 062 0251 5012
13719326 TROGLITAZONE 400MG TABLET-1 BO EXTERNAL 12/26/97 062 0251 5012
13719431 CODEINE-GUAIFENESIN 0.5ML SYRU EXTERNAL 10/02/01 062 0251 5012
13719434 CODEINE-GUAIFENESIN 1ML SYRUP EXTERNAL 10/02/01 062 0251 5012
13719435 CODEINE-GUAIFENESIN 1.5ML SYRU EXTERNAL 10/02/01 062 0251 5012
13719444 CODEINE-GUAIFENESIN 10ML SYRUP EXTERNAL 01/01/95 062 0250 5012
13719449 CODEINE-GUAIFENESIN 15ML SYRUP EXTERNAL 10/02/01 062 0251 5012
13720786 AMPRENAVIR 50MG CAP EXTERNAL 11/25/02 062 0251 5012
13724040 MULTIPLE VITAMIN TAB EXTERNAL 01/01/95 062 0251 5012
13725460 CHLORZOXAZONE 500MG TAB EXTERNAL 01/01/95 062 0250 5012
13727605 VITAMINS PRENATAL TAB EXTERNAL 07/01/84 062 0251 5012
13730320 SPIRONOLACTONE 25MG TAB EXTERNAL 07/01/84 062 0250 5012
13730325 SPIRONOLACTONE 100MG TAB EXTERNAL 07/01/84 062 0250 5012
13730383 STAVUDINE ORAL SOLUTION 10MG D EXTERNAL 11/05/01 062 0251 5012
13730384 STAVUDINE ORAL SOLUTION 20MG D EXTERNAL 11/05/01 062 0251 5012
13730385 STAVUDINE ORAL SOLUTION 30MG D EXTERNAL 11/05/01 062 0251 5012
13730465 SUCCIMER 100MG CAP (100/BTL) EXTERNAL 10/02/91 062 0251 5012
13730491 SUCRALFATE 1GM TAB EXTERNAL 07/01/84 062 0250 5012
13730545 SULFADIAZINE 500MG TAB EXTERNAL 01/25/92 062 0251 5012
13730583 SULFASALAZINE 500MG EC TAB EXTERNAL 04/12/89 062 0251 5012
13730716 SUMATRIPTAN 50MG TAB EXTERNAL 04/05/96 062 0251 5012
13730717 SUMATRIPTAN 50MG TABLETS EXTERNAL 04/05/96 062 0251 5012
13730718 SUMATRIPTAN 25MG TAB EXTERNAL 04/05/96 062 0251 5012
13730719 SUMATRIPTAN 25MG TABLETS EXTERNAL 04/05/96 062 0251 5012
13730790 TAMOXIFEN 10MG TAB EXTERNAL 07/01/84 062 0250 5012
13730810 TEMEZEPAM 15 MG TAB EXTERNAL 06/07/01 062 0251 5012
13731245 THEOPHYLLINE 400MG SR TAB EXTERNAL 12/04/91 062 0251 5012
13731246 THEOPHYLLINE 400MG SR TABLET B EXTERNAL 12/04/91 062 0251 5012
13731262 THEOPHYLLINE 200MG CAP - 1 BOX EXTERNAL 10/14/92 062 0251 5012
13731276 THEOPHYLLINE 200MG SR TAB EXTERNAL 07/01/84 062 0250 5012
13731291 VITAMINS THERAPEUTIC - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13731303 VORICONAZOLE 200MG TAB EXTERNAL 02/13/04 062 0251 5012
13731304 VORICONAZOLE 50 MG TAB EXTERNAL 05/27/04 J3465 J3465 J3465 062 0251 5012
13731305 VORICONAZOLE (VFEND) ORAL SUSP EXTERNAL 07/22/04 J3465 J3465 J3465 062 0251 5012
13731777 TOCAINIDE 400MG TAB EXTERNAL 07/01/84 062 0250 5012
13731782 VITAMIN E 50 UNIT CAPSULE EXTERNAL 01/25/95 062 0251 5012
13731796 VITAMIN E 400IU CAPSULE EXTERNAL 10/08/03 062 0251 5012
13731797 VITAMIN E 100IU CAPSULE EXTERNAL 06/13/00 062 0251 5012
13731880 TOLMETIN 200MG TAB EXTERNAL 07/01/84 062 0250 5012
13731883 TOLMETIN 400MG CAP EXTERNAL 02/07/90 062 0251 5012
13731931 TRAZODONE 150MG TAB EXTERNAL 05/14/93 062 0251 5012
13731932 TRAZODONE 50MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13731933 TRAZODONE 100MG - 1 BOX EXTERNAL 01/25/95 062 0251 5012
13731934 TRAZODONE 50MG TAB EXTERNAL 07/01/84 062 0250 5012
13731936 TRAZODONE 100MG TAB EXTERNAL 07/01/84 062 0250 5012
13731937 TRAZODONE 25 MG TAB EXTERNAL 01/29/01 062 0251 5012
13732810 ACETAMINOPHEN-CODEINE ELIXIR EXTERNAL 07/01/84 062 0250 5012
13732917 URSODIOL 300MG CAPSULE EXTERNAL 04/12/89 062 0251 5012
13733043 VENLAFAXINE 25MG TAB EXTERNAL 11/25/94 062 0251 5012
13733046 VENLAFAXINE 37.5MG TAB EXTERNAL 11/25/94 062 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 376
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13733049 VENLAFAXINE 50MG TAB EXTERNAL 11/25/94 062 0251 5012
13733052 VENLAFAXINE 75MG TAB EXTERNAL 11/25/94 062 0251 5012
13733055 VENLAFAXINE 100MG TAB EXTERNAL 11/25/94 062 0251 5012
13733056 VENLAFAXINE 37.5MG XR CAPSULE- EXTERNAL 07/29/97 062 0251 5012
13733057 VENLAFAXINE 37.5MG XR CAPSULE EXTERNAL 07/29/97 062 0251 5012
13733059 VENLAFAXINE 75MG XR CAPSULE-BO EXTERNAL 07/29/97 062 0251 5012
13733060 VENLAFAXINE 75MG XR CAP EXTERNAL 07/29/97 062 0251 5012
13733062 VENLAFAXINE 150MG XR CAPSULE-B EXTERNAL 07/29/97 062 0251 5012
13733063 VENLAFAXINE 150MG XR CAP EXTERNAL 07/29/97 062 0251 5012
13733071 VERAPAMIL SR 120MG TAB EXTERNAL 04/05/94 062 0251 5012
13733097 VERAPAMIL 80MG TAB EXTERNAL 07/01/84 062 0250 5012
13733099 VERAPAMIL 120MG TAB EXTERNAL 07/01/84 062 0250 5012
13733103 VERAPAMIL 240MG SR TAB EXTERNAL 07/02/88 062 0251 5012
13733108 VERAPAMIL 180MG SR TAB EXTERNAL 05/31/90 062 0251 5012
13733191 VITAMIN A 50000 UNITS - 1 BOTT EXTERNAL 01/25/95 062 0251 5012
13733194 VITAMIN A 10,000 UNIT CAP EXTERNAL 09/28/00 062 0251 5012
13733219 WARFARIN 1MG TAB EXTERNAL 04/05/94 062 0251 5012
13733220 WARFARIN 2MG TAB EXTERNAL 07/01/84 062 0250 5012
13733250 WARFARIN 2.5MG TAB EXTERNAL 07/01/84 062 0250 5012
13733252 WARFARIN 3MG TAB EXTERNAL 05/12/94 062 0251 5012
13733258 WARFARIN 4MG TAB EXTERNAL 02/21/00 062 0251 5012
13733270 WARFARIN 5MG TAB EXTERNAL 07/01/84 062 0250 5012
13733272 WARFARIN 6MG TAB EXTERNAL 07/31/01 062 0251 5012
13733290 WARFARIN 7.5MG TAB EXTERNAL 07/01/84 062 0250 5012
13733310 WARFARIN 10MG TAB EXTERNAL 07/01/84 062 0250 5012
13733602 ZALEPON 10 MG CAPSULE EXTERNAL 06/07/01 062 0251 5012
13733641 ZOLPIDEM 5MG TAB EXTERNAL 11/04/99 062 0251 5012
13733643 ZOLPIDEM 10MG TAB EXTERNAL 11/04/99 062 0251 5012
13733661 ZOLPIDEM 2.5MG PER 1/2 TAB EXTERNAL 09/22/90 062 0251 5012
13733662 ZINC SULFATE 220MG CAP EXTERNAL 09/22/90 062 0251 5012
13733663 ZIPRASIDONE 80MG CAP EXTERNAL 11/17/01 J3486 J3486 J3486 062 0251 5012
13733664 ZIPRASIDONE 60MG (20 MG X 3) C EXTERNAL 11/17/01 J3486 J3486 J3486 062 0251 5012
13733665 ZIPRASIDONE 20MG CAP EXTERNAL 11/17/01 J3486 J3486 J3486 062 0251 5012
13733666 ZIPRASIDONE 40MG CAP EXTERNAL 11/17/01 J3486 J3486 J3486 062 0251 5012
13733669 ZINC SULFATE ORAL SOLN 5 MG EXTERNAL 06/26/03 062 0251 5012
13733671 ZINC SULFATE ORAL SOLN 5 MG EXTERNAL 06/26/03 062 0251 5012
13733679 ZIDOVUDINE 300MG TAB EXTERNAL 12/22/97 062 0251 5012
13733701 ZIDOVUDINE 100MG CAP EXTERNAL 04/01/88 062 0251 5012
13733725 ZIDOVUDINE 200MG ORAL LIQUID EXTERNAL 11/05/01 062 0251 5012
13733726 ZIDOVUDINE 300MG ORAL LIQUID EXTERNAL 11/05/01 062 0251 5012
13734630 CHLORAL HYDRATE 100MG/ML SYRUP EXTERNAL 07/01/84 062 0250 5012
13734631 CHLORAL HYDRATE 75MG/ML SYRUP EXTERNAL 09/27/01 062 0251 5012
13734760 CLINDAMYCIN 15MG/ML ORAL SUSP EXTERNAL 07/01/84 062 0250 5012
13735884 INSULIN HUMAN REGULAR SLIDING EXTERNAL 07/01/84 J1815 J1815 J1815 062 0636 5012
13737920 AMANTADINE 10MG/ML SYRUP EXTERNAL 06/07/01 062 0251 5012
13738940 CLINDAMYCIN 150MG ORAL SUSP EXTERNAL 07/01/84 062 0250 5012
13739421 CALCIUM GLUBIONATE 50MG SYRUP EXTERNAL 03/06/96 062 0251 5012
13741580 ASCORBIC ACID 35MG ORAL SOLN EXTERNAL 07/01/84 062 0250 5012
13741590 ASCORBIC ACID 40MG ORAL SOLN EXTERNAL 07/01/84 062 0250 5012
13742451 AMINOPHYLLINE 0.8MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13742452 AMINOPHYLLINE 1MG ORAL SOLN EXTERNAL 03/06/96 062 0251 5012
13742965 VALGANCICLOVIR 450 MG TABLET EXTERNAL 01/26/04 062 0251 5012
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 377
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13743020 VALSARTAN 80 MG TABLET EXTERNAL 03/18/05 062 0251 5012
13743021 VALSARTAN 160 MG TABLET EXTERNAL 06/27/05 062 0251 5012
13762017 ALKA SELTSER ORIGINAL TAB EXTERNAL 07/07/92 062 0251 5012
13762070 ASCORBIC ACID 100MG TAB EXTERNAL 07/08/92 062 0251 5012
13762130 CEFADROXIL 500MG CAP EXTERNAL 07/08/92 062 0251 5012
13762153 TRIPLE SULFA TABLET EXTERNAL 07/08/92 062 0251 5012
13762231 DAPSONE 100MG TAB EXTERNAL 07/08/92 062 0251 5012
13762244 TOLMENTIN 600MG TAB EXTERNAL 07/08/92 062 0251 5012
13762375 CALCIUM ACETATE 667MG TAB EXTERNAL 07/10/92 062 0251 5012
13762457 CEFTIXIME 400MG TABLET EEI STU EXTERNAL 06/30/92 062 0251 5012
13762587 CLOZAPINE 25MG TAB EXTERNAL 07/11/92 062 0251 5012
13762916 ALLOPURINOL 100MG TAB EXTERNAL 07/14/92 062 0251 5012
13763053 ZALEPLON CAPSUEL EXTERNAL 10/30/03 062 0251 5012
13763200 TRANYLCYPROMINE 10MG TAB EXTERNAL 04/01/01 062 0251 5012
13772000 ZALCITABINE 0.375MG TAB EXTERNAL 11/21/02 062 0251 5012
13772001 ZALCITABINE 0.75MG TAB EXTERNAL 11/21/02 062 0251 5012
13780050 ACETAMINOPHEN TAB 325MG EXTERNAL 05/07/01 062 0251 5012
13780077 ACETAMINOPHEN 500MG TABLET EXTERNAL 05/07/01 062 0251 5012
13780100 ACETAMINOPHEN ELIXIR 160MG CUP EXTERNAL 05/07/01 062 0251 5012
13780165 ACETAMINOPHEN/COD #3 - 1 TABLE EXTERNAL 05/07/01 062 0251 5012
13783281 ACETAMINOPHEN/COD ELIXIR EXTERNAL 05/07/01 062 0251 5012
13910021 INTRAORAL-COMPLETE SERIES 77.00 06/01/10 D0210 D0210 D0210 062 0320 0621
13910022 INTRAORAL-PERIAPICAL-1ST FILM 25.00 06/01/10 D0220 D0220 D0220 062 0510 0621
13910023 INTRAORAL-PERIAPICAL ADD FILM 15.00 06/01/10 D0230 D0230 D0230 062 0510 0621
13910033 PANORAMIC FILM 115.00 01/01/10 70355 70355 70355 062 0320 0621
13910071 PROPHYLAXIS-ADULT 115.00 06/01/10 D1110 D1110 D1110 062 0510 0621
13910211 AMALGAM-1-SURFACE, PERMANENT EXTERNAL 12/12/94 D2140 D2140 D2140 062 0510 0621
13910212 AMALGAM-2-SURFACES, PERMANENT 350.00 06/01/10 D2150 D2150 D2150 062 0510 0621
13910213 AMALGAM-3-SURFACES, PERMAMENT 450.00 06/01/10 D2160 D2160 D2160 062 0510 0621
13910231 RESIN-1 SURFACE, ANTERIOR 250.00 06/01/10 D2330 D2330 D2330 062 0510 0621
13910232 RESIN-2 SURFACES, ANTERIOR 350.00 06/01/10 D2331 D2331 D2331 062 0510 0621
13910233 RESIN-3 SURFACES, ANTERIOR 450.00 06/01/10 D2332 D2332 D2332 062 0510 0621
13910234 RESIN-4 OR > SURFACES ANTERIOR 815.00 06/01/10 D2335 D2335 D2335 062 0510 0621
13910235 RESIN-1-SURFACE,POSTERIOR-PERM 250.00 06/01/10 D2391 D2391 D2391 062 0510 0621
13910236 RESIN-2-SURFACES, POSTER-PERM 350.00 06/01/10 D2392 D2392 D2392 062 0510 0621
13910237 RESIN-3 OR > SURF POSTER-PERM 450.00 06/01/10 D2393 D2393 D2393 062 0510 0621
13910275 CROWN-PORCEL FUSES H-N METAL 1300.00 06/01/10 D2750 D2750 D2750 062 0510 0621
13910277 CROWN-FULL CAST H-N METAL EXTERNAL 12/12/94 D2790 D2790 D2790 062 0510 0621
13910295 CAST POST&CORE IN ADD TO CROWN 650.00 06/01/10 D2954 D2954 D2954 062 0510 0621
13910296 PREFAB POST&CORE ADD TO CROWN 500.00 06/01/10 D2954 D2954 D2954 062 0510 0621
13910298 LABIAL VENEER 1000.00 06/01/10 D2962 D2962 D2962 062 0510 0621
13910301 ROOT CANAL, ANTERIOR EXTERNAL 01/01/06 D3310 D3310 D3310 062 0510 0621
13910304 ROOT CANAL, PREMOLAR EXTERNAL 01/01/06 D3320 D3320 D3320 062 0510 0621
13910307 ROOT CANAL, MOLAR EXTERNAL 01/01/06 D3330 D3330 D3330 062 0510 0621
13910313 RT PLAN&SCALING PER QUAD EXTERNAL 02/16/98 D4341 D4341 D4341 062 0510 0621
13910331 COMPLETE UPPER 2000.00 06/01/10 D5110 D5110 D5110 062 0360 0621
13910332 COMPLETE LOWER 2000.00 06/01/10 D5120 D5120 D5120 062 0360 0621
13910333 IMMEDIATE UPPER 3500.00 06/01/10 D5130 D5130 D5130 062 0510 0621
13910334 IMMEDIATE LOWER EXTERNAL 12/12/94 D5140 D5140 D5140 062 0510 0621
13910351 UPPER PARTIAL-RESIN BASE 1750.00 06/01/10 D5211 D5211 D5211 062 0510 0621
13910352 LOWER PARTIAL-RESIN BASE EXTERNAL 12/12/94 D5212 D5212 D5212 062 0510 0621
13910353 UPPER PARTIAL-CAST METAL BASE EXTERNAL 12/12/94 D5213 D5213 D5213 062 0510 0621
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 378
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13910354 LOWER PARTIAL-CAST METAL BASE 2250.00 06/01/10 D5214 D5214 D5214 062 0510 0621
13910412 REPAIR CAST FRAMEWORK EXTERNAL 12/12/94 D5620 D5620 D5620 062 0510 0621
13910414 REPLACE BROKEN TEETH-PER-TOOTH EXTERNAL 12/12/94 D5520 D5520 D5520 062 0510 0621
13910415 ADD TOOTH EXIST PART DENTURE EXTERNAL 12/12/94 D5650 D5650 D5650 062 0510 0621
13910435 RELINE COMPL UP DENTURE (LAB) 350.00 06/01/10 D5750 D5750 D5750 062 0274 0621
13910436 RELINE COMPL LOW DENTURE (LAB) 350.00 06/01/10 D5751 D5751 D5751 062 0274 0621
13910437 RELINE UPPER PART DENTURE(LAB) 350.00 06/01/10 D5760 D5760 D5760 062 0510 0621
13910451 INTERIM COMPL DENTURE (UPPER) EXTERNAL 12/12/94 D5810 D5810 D5810 062 0274 0621
13910452 INTERIM COMPL DENTURE (LOWER) EXTERNAL 12/12/94 D5811 D5811 D5811 062 0274 0621
13910457 TISSUE COND,UPPER/DENTURE UNIT 250.00 06/01/10 D5850 D5850 D5850 062 0510 0621
13910458 TISSUE COND,LOWER/DENTURE UNIT 250.00 06/01/10 D5851 D5851 D5851 062 0510 0621
13910461 PRECISION ATTACHMENT,BY REPORT 600.00 06/01/10 D5862 D5862 D5862 062 0510 0621
13910511 FLOURIDE GEL CARRIER 350.00 06/01/10 D5986 D5986 D5986 062 0510 0621
13910531 IMPLANT CONNECTING BAR 1500.00 06/01/10 D6055 D6055 D6055 062 0360 0621
13910535 IMPLANT MAINTENANCE PROCEDURES 375.00 06/01/10 D6080 D6080 D6080 062 0510 0621
13910536 REPAIR IMPLANT EXTERNAL 12/12/94 D6090 D6090 D6090 062 0510 0621
13910551 PONTIC-CAST HIGH NOBLE METAL EXTERNAL 12/12/94 D6210 D6210 D6210 062 0510 0621
13910555 PONTIC-PORCEL FUSED H-N METAL 1300.00 06/01/10 D6240 D6240 D6240 062 0510 0621
13910601 CROWN RESIN W/HIGH NOBLE METAL EXTERNAL 12/12/94 D6545 D6545 D6545 062 0510 0621
13910609 CROWN-FULL CAST H-N METAL 1500.00 06/01/10 D6750 D6750 D6750 062 0510 0621
13910615 UNSPEC MAXILLO PROST,BY REPORT EXTERNAL 07/01/07 D5999 D5999 D5999 062 0274 0621
13910616 PALATAL LIFT PROSTHESIS, MODIF EXTERNAL 07/01/07 D5959 D5959 D5959 062 0274 0621
13910617 SPEECH AID PROSTHESIS, MODIFIC EXTERNAL 07/01/07 D5960 D5960 D5960 062 0274 0621
13910620 ADJUST COMPLETE DENTURE-MAXILL EXTERNAL 07/01/07 D5410 D5410 D5410 062 0274 0621
13910621 ADJUST COMPLETE DENTURE-MANDIB EXTERNAL 07/01/07 D5411 D5411 D5411 062 0274 0621
13910628 ADJUST PARTIAL DENTURE-MAXILL EXTERNAL 07/01/07 D5421 D5421 D5421 062 0274 0621
13910629 ADJUST PARTIAL DENTURE-MANDIBU EXTERNAL 07/01/07 D5422 D5422 D5422 062 0274 0621
13910649 IMPLANT CROWN 1500.00 06/01/10 D6999 D6999 D6999 062 0274 0621
13910720 SINGLE TOOTH EXTRACTION 110.00 06/01/10 D7110 D7110 D7110 062 0360 0621
13910760 LTD ORTH TREAT-PRIM DENTITION EXTERNAL 02/01/09 D8010 D8010 D8010 062 0510 0621
13910765 LTD ORTH TREAT-TRANS DENTITION EXTERNAL 02/01/09 D8020 D8020 D8020 062 0510 0621
13910770 LTD ORTH TREAT-ADOL DENTITION EXTERNAL 02/01/09 D8030 D8030 D8030 062 0510 0621
13910775 LTD ORTH TREAT-ADULT DENTITION EXTERNAL 02/01/09 D8040 D8040 D8040 062 0510 0621
13910780 INTER ORTH TREAT-PRIM DENTIT EXTERNAL 02/01/09 D8050 D8050 D8050 062 0510 0621
13910785 INTER ORTH TRT-TRANS DENTITION EXTERNAL 02/01/09 D8060 D8060 D8060 062 0510 0621
13910790 COMP ORTH TRT-TRANS DENTITION EXTERNAL 02/01/09 D8070 D8070 D8070 062 0510 0621
13910795 COMP ORTH TRT-ADOLES DENTITION EXTERNAL 02/01/09 D8080 D8080 D8080 062 0510 0621
13910800 COMP ORTH TRT-ADLT DENTITION EXTERNAL 02/01/09 D8090 D8090 D8090 062 0510 0621
13910810 PROSTHETIC SERVICES EXTERNAL 07/01/10 062 0510 0621
13910820 REMOVABLE APPLIANCE THERAPY EXTERNAL 02/01/09 D8210 D8210 D8210 062 0510 0621
13910825 FIXED APPLIANCE THERAPY EXTERNAL 02/01/09 D8220 D8220 D8220 062 0510 0621
13910830 PRE-ORTHODONTIC TREATMNT VISIT EXTERNAL 02/01/09 D8660 D8660 D8660 062 0510 0621
13910835 PERIOD ORTHODONTIC TRTMNT VST EXTERNAL 02/01/09 D8670 D8670 D8670 062 0510 0621
13910840 ORTHODONTIC RETENTION EXTERNAL 02/01/09 D8680 D8680 D8680 062 0510 0621
13910845 ORTHODONTIC TREATMENT EXTERNAL 02/01/09 D8690 D8690 D8690 062 0510 0621
13910847 REPAIR ORTHODONTIC APPLIANCE EXTERNAL 02/01/09 D8691 D8691 D8691 062 0510 0621
13910849 REPLACE LOST/BROKEN RETAINER EXTERNAL 02/01/09 D8692 D8692 D8692 062 0510 0621
13910870 UNSPEC ORTHODONTIC PROCEDURE EXTERNAL 02/01/09 D8999 D8999 D8999 062 0510 0621
13920194 HEARING AID EXAM&SEL MONAURAL 235.00 06/30/10 92590 92590 92590 062 0471 0617
13920198 HEARING AID EXAM&SEL BINAURAL 357.00 06/30/10 92591 92591 92591 062 0471 0617
13920206 ASSESSMENT FOR HEARING AID 298.00 06/30/10 V5010 V5010 V5010 062 0471 0617
13920209 DISPENSING FEE, BINAURAL 1510.00 06/30/10 V5160 V5160 V5160 062 0273 0617
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 379
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13920212 DISP FEE,MONAUR HEAR AID 940.00 06/30/10 V5241 V5241 V5241 062 0279 0617
13920215 EAR MLD/INSRT,NOT DISPOS 133.00 06/30/10 V5264 V5264 V5264 062 0279 0617
13920218 BATTERY-HEARING DEVICE 36.00 06/30/10 V5266 V5266 V5266 062 0270 0617
16430017 HEAR AID SELECT,MON/BINAURAL 398.00 06/30/10 92590 V5090 92590 95.48 062 0270 4308
16430021 HEARING AID CHECK(MON) 157.00 06/30/10 92592 V5011 92592 95.49 95.49 062 0471 4308
16430022 HEARING AID CHECK(BIN) 307.00 06/30/10 92593 V5011 92593 95.49 95.49 062 0471 4308
16430028 TINNITUS MASKER SELECTION(MON) 307.00 06/30/10 92590 92590 92590 95.42 95.42 062 0471 4308
16430029 TINNITUS MASKER SELECTION(BIN) 605.00 06/30/10 92591 92591 92591 95.42 95.42 062 0471 4308
16430039 NICU PURE TONE SCREEN INFANT 439.00 06/30/10 92551 92551 92551 95.49 062 0471 4308
16430044 LIONS HEARING AID SELECT(MON) 75.00 06/30/10 92590 92590 92590 95.48 062 0471 4308
16430045 LIONS HEARING AID SELECT(BIN) 149.00 06/30/10 92591 92591 92591 95.48 062 0471 4308
16500037 HEAR AID SELECT,MON/BINAURAL 398.00 06/30/10 92590 92590 92590 062 0471 0642
16500043 HEARING AID CHECK(MON) 127.00 06/30/10 92592 92511 92592 062 0471 0642
16500046 HEARING AID CHECK(BIN) 307.00 06/30/10 92593 V5011 92593 062 0471 0642
16500058 TINNITUS MASKER SELECTION(MON) 307.00 06/30/10 92590 92590 92590 062 0471 0642
16500061 TINNITUS MASKER SELECTION(BIN) 605.00 06/30/10 92591 92591 92591 062 0471 0642
16500076 PURE TONE HEARING TEST, AIR 439.00 06/30/10 92551 92551 92551 062 0471 0642
16500088 LIONS HEARING AID SELECT(MON) 79.00 06/30/10 92590 92590 92590 062 0471 0642
16500091 LIONS HEARING AID SELECT(BIN) 207.00 06/30/10 92551 92551 92551 062 0471 0642
17120051 REFRACTION-HOSP 23.00 06/30/10 92015 92015GY 92015 062 0510 0582
17120052 REFRACTION-M.D. 40.00 $ 06/30/09 92015 92015GY 92015 062 0983 0582
41210018 CT VIRTUAL COLONOSCOPY 856.00 06/30/10 74263 74263 74263TC 88.39 062 0352 3332
41210081 MEDICARE CT VIRT COLONOSCOPY 856.00 06/30/10 74263 74263 74263TC 88.39 062 0359 3332
41210084 MEDICARE VIRTUAL COLONOSCOPY 811.00 C 06/30/10 74263 74263 74263TC 88.39 062 0359 3332
41210087 CT VIRT COLONOSCOPY-DIAGNOSTIC 814.00 06/30/10 74262 74262 74262TC 062 0352 3332
41210096 MEDICARE CT VRT COLONSCPY-DIAG 814.00 06/30/10 74262 74262 74262TC 062 0359 3332
41210106 MEDICARE CT VIRT COLONOSCOPY 586.00 C 06/30/10 74263 74263 74263TC 88.39 062 0359 3332
41210115 MEDICARE CT VIRT COLONOSCOPY 586.00 C 06/30/10 74263 74263 74263TC 88.39 062 0359 3332
44051055 MEDROXYPROGESTRN ACE 150MG EXTERNAL 08/01/00 J1055 J1055 J1055 062 0636 5011
44080144 AZITHROMYCIN DIHY, CAP/POWD 1G EXTERNAL 03/26/02 062 0636 5011
44210075 ACETAMINOPHEN TABS 325MG EXTERNAL 08/01/00 062 0250 5011
44210079 TYLENOL EX STR CAPLETS 500MG/ EXTERNAL 08/01/00 062 0250 5011
44210450 ALLOPURINOL TABS 100MG EXTERNAL 08/01/00 062 0250 5011
44210920 AUGMENTIN 875/125MG TAB/ EXTERNAL 08/01/00 062 0250 5011
44211475 ATENOLOL TABS 50MG EXTERNAL 08/01/00 062 0250 5011
44211716 ZITHROMAX 250MG TABLETS EXTERNAL 08/01/00 062 0250 5011
44211777 BACLOFEN 10MG TAB EXTERNAL 08/01/00 062 0250 5011
44212595 WELLBUTRIN TABS SR 150MG EXTERNAL 08/01/00 062 0250 5011
44212910 BIAXIN TABS 250MG EXTERNAL 08/01/00 062 0250 5011
44212951 CAPTOPRIL TABS 25MG/ EXTERNAL 08/01/00 062 0250 5011
44212999 TEGRETOL TABS CHEW 100MG/NOVA EXTERNAL 08/01/00 062 0250 5011
44214168 CIMETIDINE TABS 300MG EXTERNAL 08/01/00 062 0250 5011
44214245 CLONAZEPAM TABS 1MG/TEVA USA EXTERNAL 08/01/00 062 0250 5011
44214271 CLONIDINE HCL TABS 0.3MG/ EXTERNAL 08/01/00 062 0250 5011
44214922 SULFATRIM DS TABS 800-160MG/S EXTERNAL 08/01/00 062 0250 5011
44216421 VIDEX EC 400MG CAP EXTERNAL 08/01/00 062 0250 5011
44216434 VIDEX EC 250MG CAP EXTERNAL 08/01/00 062 0250 5011
44221680 SYNTHROID TABS 50MCG/BOOTS-FL EXTERNAL 08/01/00 062 0250 5011
44224152 VIRACEPT TABS 250MG EXTERNAL 08/01/00 062 0250 5011
44225091 ZYPREXA TABS 10MG/LILLY EXTERNAL 08/01/00 062 0250 5011
44229707 SULFATRIM SS 400MG/80MG TAB EXTERNAL 01/01/04 062 0250 5011
44229955 CELEBREX 200MG CAP EXTERNAL 06/01/03 062 0250 5011
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 380
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

44230379 ZERIT CAPS 30MG/SQUIBB EXTERNAL 08/01/00 062 0250 5011
44230381 ZERIT CAPS 40MG/ EXTERNAL 08/01/00 062 0250 5011
44231450 THIORIDAZINE HCL TABS 25MG/ EXTERNAL 08/01/00 062 0250 5011
44231470 THIORIDAZINE HCL TABS 50MG/ EXTERNAL 08/01/00 062 0250 5011
44232290 TRIAMTERENE/HCTZ TABS 75-50MG EXTERNAL 08/01/00 062 0250 5011
44232301 TRIAMTERENE/HCTZ CAPS 50-25MG EXTERNAL 08/01/00 062 0250 5011
44232917 URSODIOL 300MG CAP EXTERNAL 08/01/00 062 0250 5011
44233098 VERAPAMIL HCL TABS CR 120MG/ EXTERNAL 08/01/00 062 0250 5011
44233300 COUMADIN TABS 10MG/ EXTERNAL 08/01/00 062 0250 5011
44233641 AMBIEN TABS 5MG EXTERNAL 08/01/00 062 0250 5011
44237550 ALLEGRA-D TABS 60/120/ EXTERNAL 08/01/00 062 0250 5011
44239217 URSODIAL 300MG CAP EXTERNAL 08/01/00 062 0250 5011
44246600 ALTACE CAPS 10MG/ EXTERNAL 08/01/00 062 0250 5011
44262062 COUMADIN TABS 5MG EXTERNAL 08/01/00 062 0250 5011
44262090 BIAXIN TABS 500MG EXTERNAL 08/01/00 062 0250 5011
44262130 CEFADROXIL 500MG CAP EXTERNAL 08/01/00 062 0250 5011
44262262 SUDAFED 12 HOUR(120MG) CAPS EXTERNAL 08/01/00 062 0250 5011
44262272 ULTRAM TABS 50MG EXTERNAL 08/01/00 062 0250 5011
44262456 AUGMENTIN 500TABS 550-125MG/ EXTERNAL 08/01/00 062 0250 5011
44262468 ATENOLOL TABS 25MG EXTERNAL 08/01/00 062 0250 5011
44262594 ZESTRIL TABS 10MG EXTERNAL 08/01/00 062 0250 5011
44280014 CELEBREX 100MG CAPSULE/ EXTERNAL 08/01/00 062 0250 5011
44280018 VIOXX 25MG TABLET EXTERNAL 08/01/00 062 0250 5011
44299910 SPIRONOLACT 100MG TAB EXTERNAL 08/01/00 062 0250 5011
44299913 VIREAD 300MG TABLETS EXTERNAL 08/01/00 062 0250 5011
44299917 VALCYTE 450MG TAB EXTERNAL 08/01/00 062 0250 5011
44299975 BEXTRA 10MG TABLETS EXTERNAL 08/01/00 062 0250 5011
44299978 CRIXIVAN 200MG CAP EXTERNAL 08/01/00 062 0250 5011
44299993 XELODA 500MG TAB EXTERNAL 08/01/01 062 0250 5011
93783876 MED TEAM CONF(30 MIN)-M.D. 117.00 $ 06/30/09 99367 99367 99367 062 0983 0605
93783878 MED TEAM CONF-(1 HR)-M.D. 117.00 $ 06/30/09 99367 99367 99367 062 0983 0605
93785738 SOFT SPHERE-DOCTOR 71.00 $ 06/30/09 92314 92314 92314 062 0983 4502
93785740 SOFT TORIC-DOCTOR 71.00 $ 06/30/09 92314 92314 92314 062 0983 4502
93785741 EXTENDED WEAR EVALUATION-DR 71.00 $ 06/30/09 92314 92314 92314 062 0983 4502
93785742 RGP - DOCTOR 71.00 $ 06/30/09 92314 92314 92314 062 0983 4502
93785748 SOFT BIFOCAL-DOCTOR 71.00 $ 06/30/09 92314 92314 92314 062 0983 4502
93785753 RGP BIFOCAL-DOCTOR 71.00 $ 06/30/09 92314 92314 92314 062 0983 4502
03703665 POST-OP FOLLOW UP N/C 06/30/10 99024 99024 99024 063 0983 0622
04006602 INFLUENZA B DFA 69.00 C 06/30/10 87275 87275 87275 063 0306 2639
04011800 CHLORPROMAZINE, SERUM 96.00 06/30/10 82415 82415 82415 063 0301 2608
04323660 PV VACUUM BOTTLE 267.00 06/30/10 063 0272 2030
06750051 PHYS PERF TEST-EA-15MIN-HOSP 47.00 06/30/10 97750 97750 97750 063 0430 0663
12050537 FLURO GUIDE NEEDL PLCEMNT-HOSP 396.00 06/30/10 77002TC 77002 77002 063 0320 2815
12050538 FLURO GUIDE NEEDL PLCEMNT-M.D. 57.00 $ 06/30/09 7700226 7700226 7700226 063 0972 2815
12340005 CHEMO IV INFUSION: EA ADDL HR 425.00 06/30/10 96415 96415 96415 063 0335 0524
12340119 INFLUENZA VACCINE,WHOLE VIRUS 33.00 06/30/10 90658 90658 90658 063 0636 0524
12340181 ABDOMINAL PARACENT,INIT-HOSP 293.00 06/30/10 49080 49080 49080 063 0360 0524
12340182 ABDOMINAL PARACENT,INIT-M.D. 151.00 $ 06/30/09 49080 49080 49080 063 0975 0524
12340225 ASPIRATION OF BREAST CYST-HOSP 322.00 06/30/10 19000 19000 19000 063 0360 0524
12340226 ASPIRATION OF BREAST CYST-M.D. 97.00 $ 06/30/09 19000 19000 19000 063 0975 0524
12340231 BIOPSY BREAST,NEEDLE-HOSP 251.00 06/30/10 19100 19100 19100 063 0360 0524
12340232 BIOPSY BREAST,NEEDLE-M.D. 145.00 $ 06/30/09 19100 19100 19100 063 0975 0524
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 381
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12340237 BIOPSY OF VULVA-HOSP 428.00 06/30/10 56605 56605 56605 063 0360 0524
12340238 BIOPSY OF VULVA-M.D. 130.00 $ 06/30/09 56605 56605 56605 063 0975 0524
12340249 BIOPSY VAGINAL MUCOSA-HOSP 484.00 06/30/10 57100 57100 57100 063 0360 0524
12340250 BIOPSY VAGINAL MUCOSA-M.D. 140.00 $ 06/30/09 57100 57100 57100 063 0975 0524
12340253 VAGINAL CURETTAGE - HOSP 606.00 06/30/10 57420 57420 57420 063 0360 0524
12340254 VAGINAL CURETTAGE - M.D. 192.00 $ 06/30/09 57420 57420 57420 063 0975 0524
12340255 COLOSCOPY (VAGINOSCOPY) 433.00 06/30/10 57452 57452 57452 063 0360 0524
12340256 COLOSCOPY (VAGINOSCOPY)-M.D. 195.00 $ 06/30/09 57452 57452 57452 063 0975 0524
12340261 COLOSCOPY W/BIOP.,CERVIX-HOSP 715.00 06/30/10 57454 57454 57454 063 0360 0524
12340262 COLOSCOPY W/BIOP.,CERVIX-M.D. 292.00 $ 06/30/09 57454 57454 57454 063 0975 0524
12340267 ENDOCERVICAL CURRETTAGE-HOSP 440.00 06/30/10 57505 57505 57505 063 0360 0524
12340268 ENDOCERVICAL CURRETTAGE-M.D. 190.00 $ 06/30/09 57505 57505 57505 063 0975 0524
12340273 ENDOMETRIAL BIOPSY-HOSP 414.00 06/30/10 58100 58100 58100 063 0360 0524
12340274 ENDOMETRIAL BIOPSY-M.D. 187.00 $ 06/30/09 58100 58100 58100 063 0975 0524
12340279 EXAM/BIOPSY:VULVA W/SCOPE-HOSP 354.00 06/30/10 56821 56821 56821 063 0360 0524
12340280 EXAM/BIOPSY:VULVA W/SCOPE-M.D. 247.00 $ 06/30/09 56821 56821 56821 063 0975 0524
12340290 DECLOTT OF PORT DEVICE 329.00 06/30/10 36593 36593 36593 063 0360 0524
12340293 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 063 0510 0524
12340371 I&D VULVAR ABSCESS-HOSP 339.00 06/30/10 56405 56405 56405 063 0360 0524
12340372 I&D VULVAR ABSCESS-M.D. 222.00 $ 06/30/09 56405 56405 56405 063 0975 0524
12700000 POST-OP FOLLOW UP N/C 06/30/10 99024 99024 99024 063 0983 0622
12700001 ARISTOCORT 40MG/ML 22.00 06/30/10 J3302 J3302 J3302 063 0636 0622
12700004 ARISTOSPAN 20MG/ML 32.00 06/30/10 J3303 J3303 J3303 063 0636 0622
12700007 INCIS/DRAIN,ABSCESS;SIMP-HOSP 164.00 06/30/10 10060 10060 10060 063 0360 0622
12700008 INCIS/DRAIN,ABSCESS;SIMP-M.D. 186.00 $ 06/30/09 10060 10060 10060 063 0975 0622
12700011 INCIS/DRAIN,ABSCESS;COMP-HOSP 279.00 06/30/10 10061 10061 10061 063 0360 0622
12700012 INCIS/DRAIN,ABSCESS;COMP-M.D. 332.00 $ 06/30/09 10061 10061 10061 063 0975 0622
12700015 INCIS/REMOV FOR BODY SIMP-HOSP 193.00 06/30/10 10120 10120 10120 063 0360 0622
12700016 INCIS/REMOV FOR BODY SIMP-M.D. 182.00 $ 06/30/09 10120 10120 10120 063 0975 0622
12700019 INCIS/RMVL FOR/BODY SIMP-HOSP 1022.00 06/30/10 10121 10121 10121 063 0360 0622
12700020 INCIS/RMVL FOR/BODY SIMP-M.D. 377.00 $ 06/30/09 10121 10121 10121 063 0975 0622
12700023 I&D-COMP,P/OP WND INFECT-HOSP 940.00 06/30/10 10180 10180 10180 063 0360 0622
12700024 I&D-COMP,P/OP WND INFECT-M.D. 362.00 $ 06/30/09 10180 10180 10180 063 0975 0622
12700027 SKIN DEBRIDE 10% OF BODY-HOSP 109.00 06/30/10 11000 11000 11000 063 0360 0622
12700028 SKIN DEBRIDE 10% OF BODY-M.D. 68.00 $ 06/30/09 11000 11000 11000 063 0975 0622
12700031 DEBRIDE SKIN & SUBCUT TIS-HOSP 571.00 06/30/10 11042 11042 11042 063 0360 0622
12700032 DEBRIDE SKIN & SUBCUT TIS-M.D. 101.00 $ 06/30/09 11042 11042 11042 063 0975 0622
12700035 PAR/CUR SKIN LESION-SNGLE-HOSP 88.00 06/30/10 11055 11055 11055 063 0360 0622
12700036 PAR/CUR SKIN LESION-SNGLE-M.D. 49.00 $ 06/30/09 11055 11055 11055 063 0975 0622
12700039 PAR/CUR SKIN LES.(2-4)-HOSP 92.00 06/30/10 11056 11056 11056 063 0360 0622
12700040 PAR/CUR SKIN LES.(2-4)-M.D. 69.00 $ 06/30/09 11056 11056 11056 063 0975 0622
12700043 PAR/CUR SKIN LESION>4-HOSP 126.00 06/30/10 11057 11057 11057 063 0360 0622
12700044 PAR/CUR SKIN LESION>4-M.D. 90.00 $ 06/30/09 11057 11057 11057 063 0975 0622
12700047 EXCIS BENIGN LESION<.5 CM-HOSP 287.00 06/30/10 11420 11420 11420 063 0360 0622
12700048 EXCIS BENIGN LESION<.5 CM-M.D. 159.00 $ 06/30/09 11420 11420 11420 063 0975 0622
12700051 EXCIS BENIGN LES .6-1CM-HOSP 494.00 06/30/10 11421 11421 11421 063 0360 0622
12700052 EXCIS BENIGN LES .6-1CM-M.D. 215.00 $ 06/30/09 11421 11421 11421 063 0975 0622
12700055 NAIL DEBRIDEMNT;1-5 NAILS-HOSP 71.00 06/30/10 11720 11720 11720 063 0360 0622
12700056 NAIL DEBRIDEMENT;1-5 NAILS-M.D 36.00 $ 06/30/09 11720 11720 11720 063 0975 0622
12700059 NAIL DEBRIDEMENT;6+ NAILS-HOSP 108.00 06/30/10 11721 11721 11721 063 0360 0622
12700060 NAIL DEBRIDEMENT;6+ NAILS-M.D. 62.00 $ 06/30/09 11721 11721 11721 063 0975 0622
12700063 AVULS NAIL PLATE,SIMP-HOSP 141.00 06/30/10 11730 11730 11730 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 382
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12700064 AVULS NAIL PLATE,SIMP-M.D. 126.00 $ 06/30/09 11730 11730 11730 063 0975 0622
12700067 EA ADD'L NAIL PLATE AVUL-HOSP 90.00 06/30/10 11732 11732 11732 063 0360 0622
12700068 EA ADD'L NAIL PLATE AVUL-M.D. 65.00 $ 08/10/08 11732 11732 11732 063 0975 0622
12700071 EXCISION OF NAIL-HOSP 531.00 06/30/10 11750 11750 11750 063 0360 0622
12700072 EXCISION OF NAIL-M.D. 350.00 $ 06/30/09 11750 11750 11750 063 0975 0622
12700075 REPAIR NAIL BED-HOSP 661.00 06/30/10 11760 11760 11760 063 0360 0622
12700076 REPAIR NAIL BED-M.D. 266.00 $ 06/30/09 11760 11760 11760 063 0975 0622
12700079 RECONS NAIL BED W/GRAFT-HOSP 221.00 06/30/10 11762 11762 11762 063 0360 0622
12700080 RECONS NAIL BED W/GRAFT-M.D. 410.00 $ 06/30/09 11762 11762 11762 063 0975 0622
12700083 REPR LACERAT-2.5CM OR <-HOSP 226.00 06/30/10 12001 12001 12001 063 0360 0622
12700084 REPR LACERAT-2.5CM OR <-M.D. 206.00 $ 06/30/09 12001 12001 12001 063 0975 0622
12700087 REM FR BDY-MUS.TEN SHEATH-HOSP 363.00 06/30/10 20520 20520 20520 063 0360 0622
12700088 REM FR BDY-MUS.TEN SHEATH-M.D. 287.00 $ 06/30/09 20520 20520 20520 063 0975 0622
12700091 INJ. TEND SHEATH LIG TRIG-HOSP 186.00 06/30/10 20550 20550 20550 063 0360 0622
12700092 INJ. TEND SHEATH LIG TRIG-M.D. 89.00 $ 06/30/09 20550 20550 20550 063 0975 0622
12700095 INJ,TENDON ORIGIN/INSERT-HOSP 307.00 06/30/10 20551 20551 20551 063 0360 0622
12700096 INJ,TENDON ORIGIN/INSERT-M.D. 90.00 $ 06/30/09 20551 20551 20551 063 0975 0622
12700099 INJ SNG/MULTI TRIGGER PTS-HOSP 475.00 06/30/10 20552 20552 20552 063 0360 0622
12700100 INJ SING/MULTI TRIGGER PTS-M.D 75.00 $ 06/30/09 20552 20552 20552 063 0975 0622
12700103 ARTHROCENTESIS-SMALL JT-HOSP 144.00 06/30/10 20600 20600 20600 063 0360 0622
12700104 ARTHROCENTESIS-SMALL JT-M.D. 85.00 $ 06/30/09 20600 20600 20600 063 0975 0622
12700107 ARTHROCENTESIS,INTERMED-HOSP 147.00 06/30/10 20605 20605 20605 063 0360 0622
12700108 ARTHROCENTESIS,INTERMED-M.D. 88.00 $ 06/30/09 20605 20605 20605 063 0975 0622
12700111 ARTHROCENT MAJ JNT/BURSA-HOSP 513.00 06/30/10 20610 20610 20610 063 0360 0622
12700112 ARTHROCENT MAJ JNT/BURSA-M.D. 107.00 $ 06/30/09 20610 20610 20610 063 0975 0622
12700115 INSRT PN/WIRE W/SKEL TRCT-HOSP 703.00 06/30/10 20650 20650 20650 063 0360 0622
12700116 INSRT PIN/WIRE W/SKEL TRCT-M.D 325.00 $ 06/30/09 20650 20650 20650 063 0975 0622
12700119 RMVL IMPLANT-SUPERFICIAL-HOSP 647.00 06/30/10 20670 20670 20670 063 0360 0622
12700120 RMVL IMPLANT-SUPERFICIAL-M.D. 308.00 $ 06/30/09 20670 20670 20670 063 0975 0622
12700123 REMOVAL OF IMPLANT-DEEP-HOSP 1762.00 06/30/10 20680 20680 20680 063 0360 0622
12700124 REMOVAL OF IMPLANT-DEEP-M.D. 829.00 $ 06/30/09 20680 20680 20680 063 0975 0622
12700127 INTERSTITIAL FLUID PRESS-HOSP 336.00 06/30/10 20950 20950 20950 063 0360 0622
12700128 INTERSTITIAL FLUID PRESS-M.D. 191.00 $ 06/30/09 20950 20950 20950 063 0975 0622
12700131 CLOS TX RIB FRCT UNCMP EA-HOSP 203.00 06/30/10 21800 21800 21800 063 0360 0622
12700132 CLOS TX RIB FRCT UNCMP EA-M.D. 193.00 $ 06/30/09 21800 21800 21800 063 0975 0622
12700135 CLOS TRTMT STERNUM FRACT-HOSP 203.00 06/30/10 21820 21820 21820 063 0360 0622
12700136 CLOS TRTMT STERNUM FRACT-M.D. 259.00 $ 06/30/09 21820 21820 21820 063 0975 0622
12700139 CLOS TRTMT VRT PRO FRACT-HOSP 203.00 06/30/10 22305 22305 22305 063 0360 0622
12700140 CLOS TRTMT VRT PRO FRACT-M.D. 352.00 $ 06/30/09 22305 22305 22305 063 0975 0622
12700143 CLOS TRT BDY FRCT W/O MAN-HOSP 306.00 06/30/10 22310 22310 22310 063 0360 0622
12700144 CLOS TRT BDY FRCT W/O MAN-M.D. 539.00 $ 06/30/09 22310 22310 22310 063 0975 0622
12700147 CLS TRT VT FRCT CAST/BRCE-HOSP 306.00 06/30/10 22315 22315 22315 063 0360 0622
12700148 CLS TRT VT FRCT CAST/BRCE-M.D. 1575.00 $ 06/30/09 22315 22315 22315 063 0975 0622
12700151 CLS TRTCLAV FRCT W/O MAN-HOSP 203.00 06/30/10 23500 23500 23500 063 0360 0622
12700152 CLS TRTCLAV FRCT W/O MAN-M.D. 407.00 $ 06/30/09 23500 23500 23500 063 0975 0622
12700155 CLS TX STRNV DIS W/O MAN-HOSP 306.00 06/30/10 23520 23520 23520 063 0360 0622
12700156 CLS TX STRNV DIS W/O MAN-M.D. 429.00 $ 06/30/09 23520 23520 23520 063 0975 0622
12700159 CLS TX STRNV DIS W/MANI-HOSP 306.00 06/30/10 23525 23525 23525 063 0360 0622
12700160 CLS TX STRNV DIS W/MANI-M.D. 616.00 $ 08/10/08 23525 23525 23525 063 0975 0622
12700163 CLS TX ACROM DIS W/O MANI-HOSP 203.00 06/30/10 23540 23540 23540 063 0360 0622
12700164 CLS TX ACROM DIS W/O MANI-M.D. 412.00 $ 06/30/09 23540 23540 23540 063 0975 0622
12700167 CLS TX SCAP FRCT W/O MANI-HOSP 203.00 06/30/10 23570 23570 23570 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 383
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12700168 CLS TX SCAP FRCT W/O MANI-M.D 446.00 $ 06/30/09 23570 23570 23570 063 0975 0622
12700171 CLS TX PRO HUM FX W/O MAN-HOSP 203.00 06/30/10 23600 23600 23600 063 0360 0622
12700172 CLS TX PRO HUM FX W/O MAN-M.D. 572.00 $ 06/30/09 23600 23600 23600 063 0975 0622
12700175 CLS TX HUM TUBER W/O MAN-HOSP 203.00 06/30/10 23620 23620 23620 063 0360 0622
12700176 CLS TX HUM TUBER W/O MAN-M.D. 480.00 $ 06/30/09 23620 23620 23620 063 0975 0622
12700179 CLS TX SHLDR DISLOC W/MAN-HOSP 203.00 06/30/10 23650 23650 23650 063 0360 0622
12700180 CLS TX SHLDR DISLOC W/MAN-M.D 511.00 $ 06/30/09 23650 23650 23650 063 0975 0622
12700183 CLS TX SHLD DIS W/FX& MAN-HOSP 306.00 06/30/10 23665 23665 23665 063 0360 0622
12700184 CLS TX SHLD DIS W/FX& MAN-M.D. 779.00 $ 06/30/09 23665 23665 23665 063 0975 0622
12700187 CLS TX SHD DIS W/SURG&MAN-HOSP 203.00 06/30/10 23675 23675 23675 063 0360 0622
12700188 CLS TX SHD DIS W/SURG&MAN-M.D 1009.00 $ 06/30/09 23675 23675 23675 063 0975 0622
12700191 CLS TX HU SHFT FX W/O MAN-HOSP 203.00 06/30/10 24500 24500 24500 063 0360 0622
12700192 TX HU SHFT FX W/O MAN-M.D. 608.00 $ 06/30/09 24500 24500 24500 063 0975 0622
12700195 CLS TX HUM SHAFT FX W/MAN-HOSP 203.00 06/30/10 24505 24505 24505 063 0360 0622
12700196 CLS TX HUM SHAFT FX W/MAN-M.D. 905.00 $ 06/30/09 24505 24505 24505 063 0975 0622
12700199 CLS TX SUP/TR HUM W/O MAN-HOSP 203.00 06/30/10 24530 24530 24530 063 0360 0622
12700200 CLS TX SUP/TR HUM W/O MAN-M.D 658.00 $ 06/30/09 24530 24530 24530 063 0975 0622
12700203 CLS TX SUP/TRAN HUM W/MAN-HOSP 306.00 06/30/10 24535 24535 24535 063 0360 0622
12700204 CLS TX SUP/TRAN HUM W/MAN-M.D 1157.00 $ 06/30/09 24535 24535 24535 063 0975 0622
12700207 CLS TX HUM EPI FX W/O MAN-HOSP 203.00 06/30/10 24560 24560 24560 063 0360 0622
12700208 CLS TX HUM EPI FX W/O MAN-M.D 536.00 $ 06/30/09 24560 24560 24560 063 0975 0622
12700211 CLS TX HUM CON FX W/O MAN-HOSP 203.00 06/30/10 24576 24576 24576 063 0360 0622
12700212 CLS TX HUM CON FX W/O MAN-M.D. 570.00 $ 06/30/09 24576 24576 24576 063 0975 0622
12700215 CLS TX HUM CON FX W/MAN-HOSP 306.00 06/30/10 24577 24577 24577 063 0360 0622
12700216 CLS TX HUM CON FX W/MAN-M.D. 976.00 $ 06/30/09 24577 24577 24577 063 0975 0622
12700219 CLS TX MONT FX DISLOC ELB-HOSP 306.00 06/30/10 24620 24620 24620 063 0360 0622
12700220 CLS TX MONT FX DISLOC ELB-M.D 1119.00 $ 06/30/09 24620 24620 24620 063 0975 0622
12700223 CLS TX HD SUB CHLD,NU ELB-HOSP 203.00 06/30/10 24640 24640 24640 063 0360 0622
12700224 CLS TX HD SUB CHLD,NU ELB-M.D. 169.00 $ 06/30/09 24640 24640 24640 063 0975 0622
12700227 CLS TX HD/NK FX,W/O MAN-HOSP 203.00 06/30/10 24650 24650 24650 063 0360 0622
12700228 CLS TX HD/NK FX,W/O MAN-M.D. 442.00 $ 06/30/09 24650 24650 24650 063 0975 0622
12700231 CLS TX ULNAR FX W/O MAN-HOSP 203.00 06/30/10 24670 24670 24670 063 0360 0622
12700232 CLS TX ULNAR FX W/O MAN-M.D. 495.00 $ 06/30/09 24670 24670 24670 063 0975 0622
12700235 CLS TX RD SHFT FX W/O MAN-HOSP 228.00 06/30/10 25500 25500 25500 063 0360 0622
12700236 CLS TX RD SHFT FX W/O MAN-M.D. 455.00 $ 06/30/09 25500 25500 25500 063 0975 0622
12700239 CLS TX RAD SHFT FX W/MAN-HOSP 306.00 06/30/10 25505 25505 25505 063 0360 0622
12700240 CLS TX RAD SHFT FX W/MAN-M.D. 918.00 $ 06/30/09 25505 25505 25505 063 0975 0622
12700243 CLS TX RD SHFT/DIS RADIOU-HOSP 306.00 06/30/10 25520 25520 25520 063 0360 0622
12700244 CLS TX RD SHFT/DIS RADIOU-M.D 1048.00 $ 06/30/09 25520 25520 25520 063 0975 0622
12700247 CLS TX ULNAR SHFT W/O MAN-HOSP 203.00 06/30/10 25530 25530 25530 063 0360 0622
12700248 CLS TX ULNAR SHFT W/O MAN-M.D. 436.00 $ 06/30/09 25530 25530 25530 063 0975 0622
12700251 CLS TX ULNAR SHAFT W/MAN-HOSP 203.00 06/30/10 25535 25535 25535 063 0360 0622
12700252 CLS TX ULNAR SHAFT W/MAN-M.D. 903.00 $ 06/30/09 25535 25535 25535 063 0975 0622
12700255 CLS TX RD/UL SHFT W/O MAN-HOSP 203.00 06/30/10 25560 25560 25560 063 0360 0622
12700256 CLS TX RD/UL SHFT W/O MAN-M.D. 453.00 $ 06/30/09 25560 25560 25560 063 0975 0622
12700259 CLS TX RAD/ULN SHFT W/MAN-HOSP 306.00 06/30/10 25565 25565 25565 063 0360 0622
12700260 CLS TX RAD/ULN SHFT W/MAN-M.D. 952.00 $ 06/30/09 25565 25565 25565 063 0975 0622
12700263 CLS TX DIS RD/EPI W/O MAN-HOSP 203.00 06/30/10 25600 25600 25600 063 0360 0622
12700264 CLS TX DIS RD/EPI W/O MAN-M.D. 502.00 $ 06/30/09 25600 25600 25600 063 0975 0622
12700267 CLS TX DIS RD/EPI W/MAN-HOSP 306.00 06/30/10 25605 25605 25605 063 0360 0622
12700268 CLS TX DIS RD/EPI W/MAN-M.D. 1144.00 $ 06/30/09 25605 25605 25605 063 0975 0622
12700271 CLS TX NAVIC FX W/O MAN-HOSP 203.00 06/30/10 25622 25622 25622 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 384
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12700272 CLS TX NAVIC FX W/O MAN-M.D 511.00 $ 06/30/09 25622 25622 25622 063 0975 0622
12700275 CLS TX CRP BONE W/O MAN-HOSP 203.00 06/30/10 25630 25630 25630 063 0360 0622
12700276 CLS TX CRP BONE W/O MAN-M.D. 527.00 $ 06/30/09 25630 25630 25630 063 0975 0622
12700279 CLS TX CRP BONE W/MAN-HOSP 306.00 06/30/10 25635 25635 25635 063 0360 0622
12700280 CLS TX CRP BONE W/MAN-M.D 769.00 $ 06/30/09 25635 25635 25635 063 0975 0622
12700283 CLS TX ULNAR STYLOID FX-HOSP 203.00 06/30/10 25650 25650 25650 063 0360 0622
12700284 CLS TX ULNAR STYLOID FX-M.D. 558.00 $ 06/30/09 25650 25650 25650 063 0975 0622
12700287 CLS TX RD CARP DIS W/MAN-HOSP 203.00 06/30/10 25660 25660 25660 063 0360 0622
12700288 CLS TX RD CARP DIS W/MAN-M.D. 784.00 $ 06/30/09 25660 25660 25660 063 0975 0622
12700291 CLS TX DIST RAD DIS W/MAN-HOSP 203.00 06/30/10 25675 25675 25675 063 0360 0622
12700292 CLS TX DIST RAD DIS W/MAN-M.D. 769.00 $ 06/30/09 25675 25675 25675 063 0975 0622
12700295 CLS TX TRN-SCAP FX W/MAN-HOSP 203.00 06/30/10 25680 25680 25680 063 0360 0622
12700296 CLS TX TRN-SCAP FX W/MAN-M.D. 913.00 $ 06/30/09 25680 25680 25680 063 0975 0622
12700299 CLS TX LUNATE DIS W/MANIP-HOSP 306.00 06/30/10 25690 25690 25690 063 0360 0622
12700300 CLS TX LUNATE DIS W/MANIP-M.D. 934.00 $ 06/30/09 25690 25690 25690 063 0975 0622
12700303 CLS TX DIS EXT TEND INSRT-HOSP 1578.00 06/30/10 26432 26432 26432 063 0360 0622
12700304 CLS TX DIS EXT TEND INSRT-M.D. 986.00 $ 06/30/09 26432 26432 26432 063 0975 0622
12700307 CLS TX METACAR FX W/O MAN-HOSP 203.00 06/30/10 26600 26600 26600 063 0360 0622
12700308 CLS TX METACAR FX W/O MAN-M.D 481.00 $ 06/30/09 26600 26600 26600 063 0975 0622
12700311 CLS TX MET FX SING W/MAN-HOSP 203.00 06/30/10 26605 26605 26605 063 0360 0622
12700312 CLS TX MET FX SING W/MAN-M.D 561.00 $ 06/30/09 26605 26605 26605 063 0975 0622
12700315 CLS TX MET FX EXT W/MAN-HOSP 306.00 06/30/10 26607 26607 26607 063 0360 0622
12700316 CLS TX MET FX EXT W/MAN-M.D 887.00 $ 06/30/09 26607 26607 26607 063 0975 0622
12700319 CLS TX CAR DIS THMB W/MAN-HOSP 203.00 06/30/10 26641 26641 26641 063 0360 0622
12700320 CLS TX CAR DIS THMB W/MAN-M.D. 628.00 $ 06/30/09 26641 26641 26641 063 0975 0622
12700323 CLS TX CARPO FX DIS THUMB-HOSP 306.00 06/30/10 26645 26645 26645 063 0360 0622
12700324 CLS TX CARPO FX DIS THUMB-M.D. 744.00 $ 06/30/09 26645 26645 26645 063 0975 0622
12700327 CLS TX CARPO DIS W/MAN-HOSP 203.00 06/30/10 26670 26670 26670 063 0360 0622
12700328 CLS TX CARPO DIS W/MAN-M.D. 562.00 $ 06/30/09 26670 26670 26670 063 0975 0622
12700331 CLS TX METCARP DIS W/MAN-HOSP 203.00 06/30/10 26700 26700 26700 063 0360 0622
12700332 CLS TX METCARP DIS W/MAN-M.D. 551.00 $ 06/30/09 26700 26700 26700 063 0975 0622
12700335 TEN,PERC-ACH TEND,LOC ANE-HOSP 203.00 06/30/10 26705 26705 26705 063 0360 0622
12700336 TEN,PERC-ACH TEND,LOC ANE-M.D. 726.00 $ 06/30/09 26705 26705 26705 063 0975 0622
12700339 CLS TX PHAL SHFT W/O MAN-HOSP 203.00 06/30/10 26720 26720 26720 063 0360 0622
12700340 CLS TX PHAL SHFT W/O MAN-M.D. 333.00 $ 06/30/09 26720 26720 26720 063 0975 0622
12700343 CLS TX PHAL SHFT W/MAN-HOSP 203.00 06/30/10 26725 26725 26725 063 0360 0622
12700344 CLS TX PHAL SHFT W/MAN-M.D. 593.00 $ 06/30/09 26725 26725 26725 063 0975 0622
12700347 CLS TX ART FX JNT W/O MAN-HOSP 203.00 06/30/10 26740 26740 26740 063 0360 0622
12700348 CLS TX ART FX JNT W/O MAN-M.D. 400.00 $ 06/30/09 26740 26740 26740 063 0975 0622
12700351 CLS TX ART FX JNT W/MAN-HOSP 203.00 06/30/10 26742 26742 26742 063 0360 0622
12700352 CLS TX ART FX JNT W/MAN-M.D. 656.00 $ 06/30/09 26742 26742 26742 063 0975 0622
12700355 CLS TX PHAL W/O MAN-HOSP 203.00 06/30/10 26750 26750 26750 063 0360 0622
12700356 CLS TX DIST PHAL W/O MAN-M.D. 329.00 $ 06/30/09 26750 26750 26750 063 0975 0622
12700359 CLS TX DIST PHAL W/MAN-HOSP 203.00 06/30/10 26755 26755 26755 063 0360 0622
12700360 CLS TX DIST PHAL W/MAN-M.D. 523.00 $ 06/30/09 26755 26755 26755 063 0975 0622
12700363 CLS TX INTPHAL DISL W/MAN-HOSP 203.00 06/30/10 26770 26770 26770 063 0360 0622
12700364 CLS TX INTPHAL DISL W/MAN-M.D. 457.00 $ 06/30/09 26770 26770 26770 063 0975 0622
12700367 CLS TX PELV RNG FX,DISLOC-HOSP 203.00 06/30/10 27193 27193 27193 063 0360 0622
12700368 CLS TX PELV RNG FX,DISLOC-M.D. 961.00 $ 06/30/09 27193 27193 27193 063 0975 0622
12700371 CLS TX OF COCCYGEAL FX-HOSP 203.00 06/30/10 27200 27200 27200 063 0360 0622
12700372 CLS TX OF COCCYGEAL FX-M.D. 348.00 $ 06/30/09 27200 27200 27200 063 0975 0622
12700375 CLS TX ACETABUL FX W/O MAN-HOS 203.00 06/30/10 27220 27220 27220 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 385
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12700376 CLS TX ACETABUL FX W/O MAN-M.D 1066.00 $ 06/30/09 27220 27220 27220 063 0975 0622
12700379 CLS TX FEM FX PROX END NK-HOSP 203.00 06/30/10 27230 27230 27230 063 0360 0622
12700380 CLS TX FEM PROX END NK-M.D. 944.00 $ 06/30/09 27230 27230 27230 063 0975 0622
12700383 CLS TX INT/PER/SUBCHN FEM-HOSP 306.00 06/30/10 27238 27238 27238 063 0360 0622
12700384 CLS TX INT/PER/SUBCHN FEM-M.D. 921.00 $ 06/30/09 27238 27238 27238 063 0975 0622
12700387 CLS TX TROCHN FX W/O MAN-HOSP 306.00 06/30/10 27246 27246 27246 063 0360 0622
12700388 CLS TX TROCHN FX W/O MAN-M.D. 786.00 $ 06/30/09 27246 27246 27246 063 0975 0622
12700391 TX SPNT HIP DIS ABDUC SPL-HOSP 203.00 06/30/10 27256 27256 27256 063 0360 0622
12700392 TX SPNT HIP DIS ABDUC SPL-M.D. 502.00 $ 06/30/09 27256 27256 27256 063 0975 0622
12700395 CLS TX HIP ARTH DISLO-HOSP 203.00 06/30/10 27265 27265 27265 063 0360 0622
12700396 CLS TX HIP PST ARTH DISLO-M.D. 785.00 $ 06/30/09 27265 27265 27265 063 0975 0622
12700399 CLS TX FEM SHFT W/O MAN-HOSP 306.00 06/30/10 27500 27500 27500 063 0360 0622
12700400 CLS TX FEM SHFT W/O MAN-M.D. 975.00 $ 06/30/09 27500 27500 27500 063 0975 0622
12700403 CLS TX CONDY FEM W/O MAN-HOSP 203.00 06/30/10 27501 27501 27501 063 0360 0622
12700404 CLS TX CONDY FEM W/O MAN-M.D 1013.00 $ 06/30/09 27501 27501 27501 063 0975 0622
12700407 CLS TX FEM SHFT FX W/MAN-HOSP 306.00 06/30/10 27502 27502 27502 063 0360 0622
12700408 CLS TX FEM SHFT FX W/MAN-M.D. 1647.00 $ 06/30/09 27502 27502 27502 063 0975 0622
12700411 CLS TX CONDY FEM FX W/MAN-HOSP 203.00 06/30/10 27503 27503 27503 063 0360 0622
12700412 CLS TX CONDY FEM FX W/MAN-M.D. 1680.00 $ 06/30/09 27503 27503 27503 063 0975 0622
12700415 CLS TX FM DIS CON W/O MAN-HOSP 203.00 06/30/10 27508 27508 27508 063 0360 0622
12700416 CLS TX FM DIS CON W/O MAN-M.D. 992.00 $ 06/30/09 27508 27508 27508 063 0975 0622
12700419 CLS TX FEM DIST CON W/MAN-HOSP 306.00 06/30/10 27510 27510 27510 063 0360 0622
12700420 CLS TX FEM DIST CON W/MAN-M.D. 1452.00 $ 06/30/09 27510 27510 27510 063 0975 0622
12700423 CLS TX FM EPI SEP W/O MAN-HOSP 203.00 06/30/10 27516 27516 27516 063 0360 0622
12700424 CLS TX FM EPI SEP W/O MAN-M.D. 920.00 $ 06/30/09 27516 27516 27516 063 0975 0622
12700427 CLS TX FM EPI SEP W/MAN-HOSP 203.00 06/30/10 27517 27517 27517 063 0360 0622
12700428 CLS TX FM EPI SEP W/MAN-M.D. 1372.00 $ 06/30/09 27517 27517 27517 063 0975 0622
12700431 CLS TX PATELL FX W/O MAN-HOSP 203.00 06/30/10 27520 27520 27520 063 0360 0622
12700432 CLS TX PATELL FX W/O MAN-M.D. 556.00 $ 06/30/09 27520 27520 27520 063 0975 0622
12700435 CLS TX TIB PROX W/O MAN-HOSP 203.00 06/30/10 27530 27530 27530 063 0360 0622
12700436 CLS TX TIB PROX W/O MAN-M.D. 721.00 $ 06/30/09 27530 27530 27530 063 0975 0622
12700439 CLS TX COND SPI/TUB KNEE-HOSP 203.00 06/30/10 27538 27538 27538 063 0360 0622
12700440 CLS TX COND SPI/TUB KNEE-M.D. 874.00 $ 06/30/09 27538 27538 27538 063 0975 0622
12700443 CLS TX OF KNEE DISLOCAT-HOSP 203.00 06/30/10 27550 27550 27550 063 0360 0622
12700444 CLS TX OF KNEE DISLOCAT-M.D. 905.00 $ 06/30/09 27550 27550 27550 063 0975 0622
12700447 CLS TX PATELL DISLOCAT-HOSP 203.00 06/30/10 27560 27560 27560 063 0360 0622
12700448 CLS TX PATELL DISLOCAT-M.D. 633.00 $ 06/30/09 27560 27560 27560 063 0975 0622
12700451 INJ-ACHIL TENO W/LOC ANES-HOSP 1986.00 06/30/10 27605 27605 27605 063 0360 0622
12700452 INJ-ACHIL TENO W/LOC ANES-M.D. 420.00 $ 06/30/09 27605 27605 27605 063 0975 0622
12700455 CLS TX SHFT W/O MAN-HOSP 203.00 06/30/10 27750 27750 27750 063 0360 0622
12700456 CLS TX TIB SHFT W/O MAN-M.D. 612.00 $ 06/30/09 27750 27750 27750 063 0975 0622
12700459 CLS TX TIB SHFT W/MAN-HOSP 306.00 06/30/10 27752 27752 27752 063 0360 0622
12700460 CLS TX SHFT W/MAN-M.D. 1010.00 $ 06/30/09 27752 27752 27752 063 0975 0622
12700463 CLS TX MED MALL W/O MAN-HOSP 203.00 06/30/10 27760 27760 27760 063 0360 0622
12700464 CLS TX MED MALL W/O MAN-M.D. 579.00 $ 06/30/09 27760 27760 27760 063 0975 0622
12700467 CLS TX MED MALL W/MANIP-HOSP 306.00 06/30/10 27762 27762 27762 063 0360 0622
12700468 CLS TX MED MALL W/MANIP-M.D. 892.00 $ 06/30/09 27762 27762 27762 063 0975 0622
12700471 CLS TX PROX FIB W/O MAN-HOSP 203.00 06/30/10 27780 27780 27780 063 0360 0622
12700472 CLS TX PROX FIB W/O MAN-M.D. 516.00 $ 06/30/09 27780 27780 27780 063 0975 0622
12700475 CLS TX PROX FIB W/MAN-HOSP 306.00 06/30/10 27781 27781 27781 063 0360 0622
12700476 CLS TX PROX FIB W/MAN-M.D. 779.00 $ 06/30/09 27781 27781 27781 063 0975 0622
12700479 CLS TX DIST FIB W/O MAN-HOSP 203.00 06/30/10 27786 27786 27786 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 386
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12700480 CLS TX DIST FIB W/O MAN-M.D. 545.00 $ 06/30/09 27786 27786 27786 063 0975 0622
12700483 CLS TX DIST FIB W/MAN-HOSP 203.00 06/30/10 27788 27788 27788 063 0360 0622
12700484 CLS TIX DIST FIB W/MAN-M.D. 777.00 $ 06/30/09 27788 27788 27788 063 0975 0622
12700487 CLS TX BIMALL ANK W/O MAN-HOSP 203.00 06/30/10 27808 27808 27808 063 0360 0622
12700488 CLS TX BIMALL ANK W/O MAN M.D. 568.00 $ 06/30/09 27808 27808 27808 063 0975 0622
12700491 CLS TX BIMALL ANK W/MAN-HOSP 306.00 06/30/10 27810 27810 27810 063 0360 0622
12700492 CLS TX BIMALL ANK W/MAN-M.D. 868.00 $ 06/30/09 27810 27810 27810 063 0975 0622
12700495 CLS TX TRIMAL ANK W/O MAN-HOSP 203.00 06/30/10 27816 27816 27816 063 0360 0622
12700496 CLS TX TRIMAL ANK W/O MAN-M.D. 538.00 $ 06/30/09 27816 27816 27816 063 0975 0622
12700499 CLS TX TRIAML ANK W/MAN-HOSP 306.00 06/30/10 27818 27818 27818 063 0360 0622
12700500 CLS TX TRIAML ANK W/MAN-M.D. 885.00 $ 08/10/08 27818 27818 27818 063 0975 0622
12700503 CLA TX FX DIST TIBA W/MAN-HOSP 306.00 06/30/10 27825 27825 27825 063 0360 0622
12700504 CLA TX FX DIST TIBIA W/MAN-M.D 1022.00 $ 06/30/09 27825 27825 27825 063 0975 0622
12700507 CLS TX PRX TIB JNT DISLOC-HOSP 203.00 06/30/10 27830 27830 27830 063 0360 0622
12700508 CLS TX PRX TIB JNT DISLOC-M.D. 654.00 $ 06/30/09 27830 27830 27830 063 0975 0622
12700511 CLS TX OF ANK DISLOCATION-HOSP 306.00 06/30/10 27840 27840 27840 063 0360 0622
12700512 CLS TX OF ANK DISLOCATION-M.D. 689.00 $ 06/30/09 27840 27840 27840 063 0975 0622
12700515 INC/DRN-INFECT FOOT BURSA-HOSP 1028.00 06/30/10 28001 28001 28001 063 0360 0622
12700516 INC/DRN-INFECT FOOT BURSA-M.D. 380.00 $ 06/30/09 28001 28001 28001 063 0975 0622
12700519 INC/DRN INF FT BEL FASCIA-HOSP 1915.00 06/30/10 28002 28002 28002 063 0360 0622
12700520 INC/DRN INF FT BEL FASCIA-M.D. 795.00 $ 06/30/09 28002 28002 28002 063 0975 0622
12700523 INC/DRN INF FT MULT AREAS-HOSP 1700.00 06/30/10 28003 28003 28003 063 0360 0622
12700524 INC/DRN INF FT MULT AREAS-M.D. 1189.00 $ 06/30/09 28003 28003 28003 063 0975 0622
12700527 TENOTOMY,PERC-SING TENDON-HOSP 1625.00 06/30/10 28010 28010 28010 063 0360 0622
12700528 TENOTOMY,PERC-SING TENDON-M.D. 445.00 $ 06/30/09 28010 28010 28010 063 0975 0622
12700531 TEN,PERC-TOE-MULT TENDONS-HOSP 1625.00 06/30/10 28011 28011 28011 063 0360 0622
12700532 TEN,PERC-TOE-MULT TENDONS-M.D. 700.00 06/30/09 28011 28011 28011 063 0975 0622
12700535 EXC LES-TEN/SHEATH CAP-FT-HOSP 1625.00 06/30/10 28090 28090 28090 063 0360 0622
12700536 EXC LES-TEN/SHEATH CAP-FT-M.D. 663.00 $ 06/30/09 28090 28090 28090 063 0975 0622
12700539 EXCISE LESION-TENDON-TOE-HOSP 1625.00 06/30/10 28092 28092 28092 063 0360 0622
12700540 EXCISE LESION-TENDON-TOE-M.D. 581.00 $ 06/30/09 28092 28092 28092 063 0975 0622
12700543 CLS TX CALCA FX,W/O MANIP-HOSP 187.00 06/30/10 28400 28400 28400 063 0360 0622
12700544 CLS TX CALCA FX,W/O MANIP-M.D. 441.00 $ 06/30/09 28400 28400 28400 063 0975 0622
12700547 CLS TX CALC FX,W/MANIP-HOSP 251.00 06/30/10 28405 28405 28405 063 0360 0622
12700548 CLS TX CALC FX,W/MANIP-M.D. 744.00 $ 06/30/09 28405 28405 28405 063 0975 0622
12700551 CLS TX TALUS FX,W/O MANIP-HOSP 167.00 06/30/10 28430 28430 28430 063 0360 0622
12700552 CLS TX TALUS FX,W/O MANIP-M.D. 399.00 $ 06/30/10 28430 28430 28430 063 0975 0622
12700555 CLS TX TALUS FX,W/MANIP-HOSP 167.00 06/30/10 28435 28435 28435 063 0360 0622
12700556 CLS TX TALUS FX.W/MANIP-M.D. 593.00 $ 06/30/09 28435 28435 28435 063 0975 0622
12700559 CLS TX METAT FX-W/O MANIP-HOSP 206.00 06/30/10 28470 28470 28470 063 0360 0622
12700560 CLS TX METAT FX-W/O MANIP-M.D. 374.00 $ 06/30/09 28470 28470 28470 063 0975 0622
12700563 CLS TX METAT FX,WMANIP-HOSP 167.00 06/30/10 28475 28475 28475 063 0360 0622
12700564 CLS TX METAT FX,W/MANIP-M.D. 489.00 $ 06/30/09 28475 28475 28475 063 0975 0622
12700567 CLS TX TOE PHAL W/O MANIP-HOSP 167.00 06/30/10 28490 28490 28490 063 0360 0622
12700568 CLS TX TOE PHAL W/O MANIP-M.D. 230.00 $ 06/30/09 28490 28490 28490 063 0975 0622
12700571 CLS TX TOE PHAL W/MANIP-HOSP 167.00 06/30/10 28495 28495 28495 063 0360 0622
12700572 CLS TX TOE PHAL W/MANIP-M.D. 296.00 $ 06/30/09 28495 28495 28495 063 0975 0622
12700575 CLS TX OF PHAL FX W/O MAN-HOSP 188.00 06/30/10 28510 28510 28510 063 0360 0622
12700576 CLS TX OF PHAL FX W/O MAN-M.D. 224.00 $ 06/30/09 28510 28510 28510 063 0975 0622
12700579 CLS TX OF PHAL FX W/MAN-HOSP 207.00 06/30/10 28515 28515 28515 063 0360 0622
12700580 CLS TX PHAL FX W/MAN-M.D. 277.00 $ 06/30/09 28515 28515 28515 063 0975 0622
12700583 CLS TX OF SESAMOID FX-HOSP 167.00 06/30/10 28530 28530 28530 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 387
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12700584 CLS TX OF SESAMOID FX-M.D. 205.00 $ 06/30/09 28530 28530 28530 063 0975 0622
12700587 CLS TX TARSAL BONE DISLOC-HOSP 167.00 06/30/10 28540 28540 28540 063 0360 0622
12700588 CLS TX TARSAL BONE DISLOC-M.D. 367.00 $ 06/30/09 28540 28540 28540 063 0975 0622
12700591 CLS TX TALOTAR JNT DISLOC-HOSP 251.00 06/30/10 28570 28570 28570 063 0360 0622
12700592 CLS TX TALOTAR JNT DISLOC-M.D. 307.00 $ 06/30/10 28570 28570 28570 063 0975 0622
12700595 CLS TX TARSOMET JNT DISLO-HOSP 167.00 06/30/10 28600 28600 28600 063 0360 0622
12700596 CLS TX TARSOMET JNT DISLO-M.D. 370.00 $ 06/30/09 28600 28600 28600 063 0975 0622
12700599 CLS TX METATAR JNT DISLOC-HOSP 187.00 06/30/10 28630 28630 28630 063 0360 0622
12700600 CLS TX METATAR JNT DISLOC-M.D. 228.00 $ 06/30/09 28630 28630 28630 063 0975 0622
12700603 CLS TX INTERPHA JNT DISLO-HOSP 167.00 06/30/10 28660 28660 28660 063 0360 0622
12700604 CLS TX INTERPHA JNT DISLO-M.D. 172.00 $ 06/30/09 28660 28660 28660 063 0360 0622
12700607 SHOULDER SPICA CA-HOSP 493.00 06/30/10 29055 29055 29055 063 0360 0622
12700608 SHOULDER SPICA CA-M.D. 282.00 $ 06/30/09 29055 29055 29055 063 0975 0622
12700611 APPLIC LONG ARM CAST-HOSP 276.00 06/30/10 29065 29065 29065 063 0360 0622
12700612 APPLIC LONG ARM CAST-M.D. 141.00 $ 06/30/09 29065 29065 29065 063 0975 0622
12700615 APPLIC SHORT ARM CAST-HOSP 233.00 06/30/10 29075 29075 29075 063 0360 0622
12700616 APPLIC SHORT ARM CAST-M.D. 127.00 $ 06/30/10 29075 29075 29075 063 0975 0622
12700619 APPLIC HAN/LOWER FOREARM-HOSP 180.00 06/30/10 29085 29085 29085 063 0360 0622
12700620 APPLIC HAND/LOWER FOREARM-M.D. 137.00 $ 06/30/10 29085 29085 29085 063 0975 0622
12700621 APPLICATION, CAST-FINGER-HOSP 173.00 06/30/10 29086 29086 29086 063 0360 0622
12700622 APPLICATION, CAST-FINGER-M.D. 98.00 $ 06/30/09 29086 29086 29086 063 0975 0622
12700623 APPLIC LONG ARM SPLINT-HOSP 200.00 06/30/10 29105 29105 29105 063 0360 0622
12700624 APPLIC LONG ARM SPLINT-M.D. 122.00 $ 06/30/09 29105 29105 29105 063 0975 0622
12700627 APPLIC SHORT ARM SPLINT-HOSP 129.00 06/30/10 29125 29125 29125 063 0360 0622
12700628 APPLIC SHORT ARM SPLINT-M.D. 86.00 $ 06/30/09 29125 29125 29125 063 0975 0622
12700631 SHORT ARM SPLINT-HOSP 142.00 06/30/10 29129 29126 29126 063 0360 0622
12700632 SHORT ARM SPLINT-M.D. 104.00 $ 06/30/09 29126 29126 29126 063 0975 0622
12700635 APPLIC STATIC FING SPLINT-HOSP 73.00 06/30/10 29130 29130 29130 063 0360 0622
12700636 APPLIC STATIC FING SPLINT-M.D. 60.00 $ 06/30/09 29130 29130 29130 063 0975 0622
12700639 SPICA - HIP-HOSP 339.00 06/30/10 29305 29305 29305 063 0360 0622
12700640 SPICA - HIP-M.D. 329.00 $ 06/30/09 29305 29305 29305 063 0975 0622
12700643 APP LNG CAST-THIGH TO TOE-HOSP 343.00 06/30/10 29345 29345 29345 063 0360 0622
12700644 APP LNG CAST-THIGH TO TOE-M.D. 214.00 $ 06/30/09 29345 29345 29345 063 0975 0622
12700647 APP LONG LEG CAST,WALKER-HOSP 144.00 06/30/10 29355 29355 29355 063 0360 0622
12700648 APP LONG LEG CAST,WALKER-M.D. 228.00 $ 06/30/09 29355 29355 29355 063 0975 0622
12700651 LONG LEG CAST BRACE-HOSP 661.00 06/30/10 29358 29358 29358 063 0360 0622
12700652 LONG LEG CAST BRACE-M.D. 219.00 $ 06/30/09 29358 29358 29358 063 0975 0622
12700655 APP CYLI CAST-THIGH-ANKLE-HOSP 312.00 06/30/10 29365 29365 29365 063 0360 0622
12700656 APP CYLI CAST-THIGH-ANKLE-M.D. 185.00 $ 06/30/09 29365 29365 29365 063 0975 0622
12700659 APP BELOW KNEE CAST-HOSP 334.00 06/30/10 29405 29405 29405 063 0360 0622
12700660 APP BELOW KNEE CAST-M.D. 135.00 $ 06/30/09 29405 29405 29405 063 0975 0622
12700663 APP SHORT LEG CAST,WALK-HOSP 157.00 06/30/10 29425 29425 29425 063 0360 0622
12700664 APP SHORT LEG CAST,WALK-M.D. 149.00 $ 08/10/08 29425 29425 29425 063 0975 0622
12700667 APP OF PTB CAST-HOSP 413.00 06/30/10 29435 29435 29435 063 0360 0622
12700668 APP OF PTB CAST-M.D. 315.00 $ 06/30/09 29435 29435 29435 063 0975 0622
12700671 CASTBOOT-ADD WALK TO CAST-HOSP 94.00 06/30/10 29440 29440 29440 063 0360 0622
12700672 CASTBOOT-ADD WALK TO CAST-M.D. 181.00 $ 06/30/09 29440 29440 29440 063 0975 0622
12700675 CLUBFOOT CAST W/MOLDING-HOSP 181.00 06/30/10 29450 29450 29450 063 0360 0622
12700676 CLUBFOOT CAST W/MOLDING-M.D. 264.00 $ 06/30/09 29450 29450 29450 063 0975 0622
12700679 APP LNG LG SPLNT-THGH/ANK-HOSP 230.00 06/30/10 29505 29505 29505 063 0360 0622
12700680 APP LNG LG SPLNT-THGH/ANK-M.D. 97.00 $ 06/30/09 29505 29505 29505 063 0975 0622
12700683 SHORT LEG SPLINT-HOSP 157.00 06/30/10 29515 29515 29515 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 388
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12700684 SHORT LEG SPLINT-M.D. 102.00 $ 06/30/09 29515 29515 29515 063 0975 0622
12700687 APPLICATION; UNNA BOOT - HOSP 120.00 06/30/10 29580 29580 29580 063 0360 0622
12700688 APPLICATION; UNNA BOOT - M.D. 77.00 $ 06/30/09 29580 29580 29580 063 0975 0622
12700689 RMVL/BIVALVING GAUNTLET-HOSP 132.00 06/30/10 29700 29700 29700 063 0360 0622
12700690 RMVL/BIVALVING GAUNTLET-M.D. 74.00 $ 06/30/09 29700 29700 29700 063 0975 0622
12700691 FULL ARM/LEG CAST-REMVL-HOSP 125.00 06/30/10 29705 29705 29705 063 0360 0622
12700692 FULL ARM/LEG CAST-REMVL-M.D. 104.00 $ 06/30/09 29705 29705 29705 063 0975 0622
12700695 SHOULDER/HIP CAST-REMVL-HOSP 162.00 06/30/10 29710 29710 29710 063 0360 0622
12700696 SHOULDER/HIP CAST-REMVL-M.D. 176.00 $ 06/30/09 29710 29710 29710 063 0975 0622
12700699 RPR-SPICA/BDY CAST/JACKET-HOSP 68.00 06/30/10 29720 29720 29720 063 0360 0622
12700700 RPR-SPICA/BDY CAST/JACKET-M.D. 96.00 $ 06/30/09 29720 29720 29720 063 0975 0622
12700703 WINDOWING OF CAST-HOSP 73.00 06/30/10 29730 29730 29730 063 0360 0622
12700704 WINDOWING OF CAST-M.D. 100.00 $ 06/30/09 29730 29730 29730 063 0975 0622
12700707 WEDGING OF CAST-HOSP 74.00 06/30/10 29740 29740 29740 063 0360 0622
12700708 WEDGING OF CAST-M.D. 145.00 $ 06/30/09 29740 29740 29740 063 0975 0622
12700711 WEDGING OF CLUBFOOT CAST-HOSP 96.00 06/30/10 29750 29750 29750 063 0360 0622
12700712 WEDGING OF CLUBFOOT CAST-M.D. 167.00 $ 06/30/09 29750 29750 29750 063 0975 0622
12700715 FLUOROSCOPY UP TO 1 HR - HOSP 238.00 06/30/10 76000 76000 76000 063 0320 0622
12700716 FLUOROSCOPY UP TO 1 HR - M.D. 19.00 $ 01/28/10 7600026 7600026 7600026 063 0972 0622
12700719 NDLE LOCALIZATION BY XRAY-HOSP 436.00 06/30/10 77002 77002 77002 063 0320 0622
12700720 FLURO GUID NEEDL PLACEMNT-M.D. 57.00 $ 06/30/09 77002 77002 77002 063 0972 0622
12700725 UNLIST CAST/STRAPPING-HOSP 108.00 06/30/10 29799 29799 29799 063 0510 0622
12700726 UNLIST CAST/STRAPPING-M.D. 155.00 $ 08/10/08 29799 29799 29799 063 0983 0622
12700730 POST-OP FOLLOW UP N/C 06/30/10 99024 99024 99024 063 0983 0622
12700733 WK RELAT/DIS EXM-TREAT MD-HOSP 228.00 06/30/10 99455 99455 99455 063 0510 0622
12700734 WK RELAT/DIS EXM-TREAT MD-M.D. 216.00 $ 08/10/08 99455 99455 99455 063 0983 0622
12700737 WK REL/DIS EXM-NON TRT MD-HOSP 277.00 06/30/10 99456 99456 99456 063 0510 0622
12700738 WK REL/DIS EXM-NON TRT MD-M.D. 240.00 $ 08/10/08 99456 99456 99456 063 0983 0622
12700751 CT SCAN FOR NEEDLE BIOPSY 1608.00 06/30/10 77012 77012 77012 063 0350 0622
12700752 CT SCAN FOR NEEDLE BIOPSY-M.D. 127.00 $ 10/01/09 77012 77012 77012 063 0972 0622
12700759 3D PROC W/O INDP W/STN 426.00 06/30/10 76376 76376 76376 063 0350 0622
12700760 3D PROC W/O INDP W/STN-M.D. 24.00 $ 10/01/09 76376 76376 76376 063 0972 0622
12700768 CT LIMITED/LOCALIZED F/UP-M.D. 106.00 $ 10/01/09 76380 76380 76380 063 0972 0622
12700771 CT UP EXTREM W/O CONTRST 713.00 06/30/10 73200 73200 73200 063 0350 0622
12700772 CT UP EXTREM W/O CONTRST-M.D. 119.00 $ 10/01/09 73200 73200 73200 063 0972 0622
12700781 CT LOW EXTREM W/O CNTRST 713.00 06/30/10 73700 73700 73700 063 0350 0622
12700782 CT LOW EXTREM W/O CNTRST-M.D. 119.00 $ 10/01/09 73700 73700 73700 063 0972 0622
12701000 THERAPEUTIC INJ,IM OR SUB 86.00 06/30/10 96372 96372 96372 063 0940 0622
12701003 CAST SHOE-NON-ELASTIC 59.00 06/30/10 A4465 A4465 A4465 063 0274 0622
12701006 SURGICAL TRAY 122.00 06/30/10 A4550 A4550 A4550 063 0272 0622
12701009 SLING 51.00 06/30/10 063 0270 0622
12701012 SPLINT 29.00 06/30/10 063 0270 0622
12701015 PLASTER CASTER 35.00 06/30/10 063 0270 0622
12701018 CAST SUPPLY (FIBERGLASS) 62.00 06/30/10 063 0270 0622
12701021 MEPIVICAINE HCL 10ML 9.00 06/30/10 J0670 J0670 J0670 063 0636 0622
12701024 METHYLPREDISOLONE 20MG 10.00 06/30/10 J1020 J1020 J1020 063 0636 0622
12701027 LIDOCAINE 1% OR 2% - 50CC 10.00 06/30/10 063 0250 0622
12701036 SYNVISC INJ 1 MG. 1243.00 06/30/10 J7325 J7325 J7325 063 0636 0622
12701039 KENALOG 10MG 18.00 06/30/10 J3301 J3301 J3301 063 0636 0622
12701043 ASP/INJ GANGLION CYST(S)-HOSP 254.00 06/30/10 20612 20612 20612 063 0360 0622
12701044 ASP/INJ GANGLION CYST(S)-M.D. 92.00 $ 06/30/09 20612 20612 20612 063 0975 0622
12710000 EXCIS BENIGN LES<.5CM 2168.00 06/30/10 11420 11420 11420 063 0360 0622
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 389
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12710004 EXCIS BENIGN LES 1.1-2CM 2464.00 06/30/10 11422 11422 11422 063 0360 0622
12710008 NAIL DEBRIDEMENT; 6+ NAILS 108.00 06/30/10 11721 11721 11721 063 0360 0622
12710012 REMOVAL OF NAIL PLATE 212.00 06/30/10 11730 11730 11730 063 0360 0622
12710020 REMOVAL OF NAIL BED 1074.00 06/30/10 11750 11750 11750 063 0360 0622
12710030 SKIN TISSUE PROCEDURE 57.00 06/30/10 17999 17999 17999 063 0360 0622
12710040 BONE BIOP, TROCAR/NEEDLE 2464.00 06/30/10 20225 20225 20225 063 0360 0622
12710050 REMOVAL OF FOREIGN BODY 3977.00 06/30/10 20525 20525 20525 063 0360 0622
12710060 INJ TENDON ORIGIN/INSRT 580.00 06/30/10 20551 20551 20551 063 0360 0622
12710070 INJ TRIG POINT, 1/2 MUSCL 475.00 06/30/10 20552 20552 20552 063 0360 0622
12710080 RMVL OF SUPPORT IMPLANT 5268.00 06/30/10 20680 20680 20680 063 0360 0622
12710090 DRAIN LOWER LEG LESION 3452.00 06/30/10 27603 27603 27603 063 0360 0622
12710100 EXCIS OF FOOT LESION 3923.00 06/30/10 28045 28045 28045 063 0360 0622
12710110 INCIS OF FOOT TENDON(S) 3923.00 06/30/10 28230 28230 28230 063 0360 0622
12710120 TREAT SESAMOID BONE FRACT 4927.00 06/30/10 28531 28531 28531 063 0360 0622
12710130 PARTIAL AMPUTATION OF TOE 3923.00 06/30/10 28825 28825 28825 063 0360 0622
12710140 FOOT/TOES SURG PROCEDURE 334.00 06/30/10 28899 28899 28899 063 0360 0622
12710150 APPLY SHORT LEG CAST 650.00 06/30/10 29405 29405 29405 063 0360 0622
12710160 ADDIT OF WALKER TO CAST 206.00 06/30/10 29440 29440 29440 063 0360 0622
12710170 APPLIC LOWER LEG SPLINT 311.00 06/30/10 29515 29515 29515 063 0360 0622
12710200 FLUOROSCOPE EXAM 378.00 06/30/10 76000 76000 76000 063 0320 0622
12710210 PAR/CUR SKIN LESION (2-4) 92.00 06/30/10 11056 11056 11056 063 0360 0622
12710301 CT SCAN FOR NEEDLE BIOPSY 1608.00 06/30/10 77012 77012 77012 063 0350 0622
12710309 3D PROC W/O INDP W/STN 426.00 06/30/10 76376 76376 76376 063 0350 0622
12710317 CT LIMITED/LOCALIZED F/UP 458.00 06/30/10 76380 76380 76380 063 0350 0622
12710321 CT UP EXTREM W/O CONTRST 713.00 06/30/10 73200 73200 73200 063 0350 0622
12710331 CT LOW EXTREM W/O CNTRST 713.00 06/30/10 73700 73700 73700 063 0350 0622
12710341 DEBRIDE SKIN & SUBCUT TIS 571.00 08/01/10 11042 11042 11042 063 0360 0622
12710351 PAR/CUR SKIN LESION SINGLE 88.00 08/01/10 11055 11055 11055 063 0360 0622
93785912 VOID EXTERNAL 04/01/07 063 0977 9999
01205001 APPLIGRAPH-LE 2964.00 06/30/10 L5999 L5999 L5999 064 0274 2725
02250063 HEMORRHOIDEC BY SMPL LIGATURE 421.00 06/30/10 46221 46221 46221 064 0360 2825
02500100 POST OP FOLLOW-UP VISIT-M.D. N/C 06/30/10 99024 99024 99024 064 0983 1910
02500110 INCIS/DRAIN,ABSCESS,SIMP-HOSP 164.00 06/30/10 10060 10060 10060 064 0360 1910
02500111 INCIS/DRAIN,ABSCESS,SIMP-M.D. 186.00 $ 06/30/09 10060 10060 10060 064 0975 1910
02500112 INCIS/DRAIN,ABSCESS,COMP-HOSP 269.00 06/30/10 10061 10061 10061 064 0360 1910
02500113 INCIS/DRAIN,ABSCESS,COMP-M.D. 332.00 $ 06/30/09 10061 10061 10061 064 0975 1910
02500130 DRAINAGE OF SEROMA-HOSP 300.00 06/30/10 10140 10140 10140 064 0360 1910
02500131 DRAINAGE OF SEROMA-M.D. 241.00 $ 06/30/09 10140 10140 10140 064 0975 1910
02500140 ASPIR ABSCESS,HEMA CYST-HOSP 100.00 06/30/10 10160 10160 10160 064 0360 1910
02500141 ASPIR ABSCESS,HEMA CYST-M.D. 193.00 $ 06/30/09 10160 10160 10160 064 0975 1910
02500150 SKIN DEBRIDE 10% OF BODY-HOSP 106.00 06/30/10 11000 11000 11000 064 0360 1910
02500151 SKIN DEBRIDE 10% OF BODY-M.D. 68.00 $ 06/30/09 11000 11000 11000 064 0975 1910
02500160 DEBRIDE SKIN PART THICK-HOSP 147.00 06/30/10 11040 11040 11040 064 0360 1910
02500162 DEBRIDE SKIN,FULL THICK-HOSP 301.00 06/30/10 11041 11041 11041 064 0360 1910
02500163 DEBRIDE SKIN,FULL THICK-M.D. 76.00 $ 06/30/09 11041 11041 11041 064 0975 1910
02500170 SKIN BIOP,SINGLE LESION-HOSP 165.00 06/30/10 11100 11100 11100 064 0360 1910
02500171 SKIN BIOP,SINGLE LESION-M.D. 95.00 $ 06/30/09 11100 11100 11100 064 0975 1910
02500210 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 064 0510 1910
02500220 CVC PLACEMENT>2YRS OLD-HOSP 770.00 06/30/10 36555 36555 36555 064 0360 1910
02500221 CVC PLACEMENT>2YRS OLD-M.D. 266.00 $ 06/30/09 36555 36555 36555 064 0975 1910
02500222 PLACE CNT VENS CATH AGE>5-HOSP 1082.00 06/30/10 36556 36556 36556 064 0360 1910
02500223 PLACE CNT VENS CATH AGE>5-M.D. 260.00 $ 06/30/09 36556 36556 36556 064 0975 1910
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 390
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

02500230 REMOVAL CENTRAL LINE-HOSP 737.00 06/30/10 36589 36589 36589 064 0360 1910
02500231 REMOVAL CENTRAL LINE-M.D. 303.00 $ 06/30/09 36589 36589 36589 064 0975 1910
02500240 INSERT OF CANNULA-HOSP 2415.00 06/30/10 36800 36800 36800 064 0360 1910
02500241 INSERT OF CANNULA-M.D. 341.00 $ 06/30/09 36800 36800 36800 064 0975 1910
02500250 CANNULA DECLOT W/O BALLN-HOSP 730.00 06/30/10 36860 36860 36860 064 0360 1910
02500251 CANNULA DECLOT W/O BALLN-M.D. 217.00 $ 06/30/09 36860 36860 36860 064 0975 1910
02500260 ABDOMINAL PARACEN-INITIAL-HOSP 293.00 06/30/10 49080 49080 49080 064 0360 1910
02500261 ABDOMINAL PARACEN-INITIAL-M.D. 151.00 $ 06/30/09 49080 49080 49080 064 0975 1910
02500262 PARACENTESIS,SUBSEQUENT-HOSP 293.00 06/30/10 49081 49081 49081 064 0360 1910
02500263 PARACENTESIS,SUBSEQUENT-M.D. 143.00 $ 06/30/09 49081 49081 49081 064 0975 1910
02500290 SPINAL PUNCTURE,LUMBAR-HOSP 351.00 06/30/10 62270 62270 62270 064 0360 1910
02500291 SPINAL PUNCTURE,LUMBAR-M.D. 158.00 $ 06/30/09 62270 62270 62270 064 0975 1910
02500300 ECHO ABDOMINAL;COMPLETE-HOSP 689.00 06/30/10 7670026 7670026 7670026 064 0402 1910
02500301 ECHO ABDOMINAL;COMPLETE-M.D. 88.00 $ 06/30/09 76700 76700 76700 064 0972 1910
02500310 ECHO ABDOMINAL;LIMITED-HOSP 684.00 06/30/10 76705 76705 76705 064 0402 1910
02500311 ECHO ABDOMINAL;LIMITED-M.D. 65.00 $ 06/30/09 76705 76705 76705 064 0972 1910
02500340 ULTRASON GUIDANCE NEEDLE BIOP 754.00 07/27/10 76942 76942 76942 064 0402 1910
02500360 URINE DIPSTICK W/O MICRO 35.00 06/30/10 81002 81002 81002 064 0300 1910
02500370 BLOOD OCCULT DIAGNOSTIC 34.00 06/30/10 82270 82270 82270 064 0301 1910
02500400 AUTOMATIC BLOOD PRESSR MONITOR 191.00 06/30/10 93784 93784 93784 064 0730 1910
02500405 DUPLEX SCAN-HEMODIALYSIS ACCES 342.00 06/30/10 93990 93990 93990 064 0929 1910
03790975 SURGL PROCEDURE-PROFESSIONAL 223.00 $ 06/30/09 44385 44385 44385 064 0975 9999
06830001 POST-OP FOLLOW UP VISIT N/C 06/30/10 99024 99024 99024 064 0360 0683
06831001 ACEL DRM PL 1ST 100 SQ/CM-HOSP 793.00 06/30/10 15170 15170 15170 064 0360 0683
06831002 ACEL DRM PL 1ST 100 SQ/CM-M.D. 731.00 $ 06/30/10 15170 15170 15170 064 0975 0683
06831005 ACEL GRFT T/ARM/LG ADD ON-HOSP 217.00 06/30/10 15171 15171 15171 064 0360 0683
06831006 ACEL GRFT T/ARM/LG ADD ON-M.D. 185.00 $ 06/30/09 15171 15171 15171 064 0975 0683
06831009 ACELLULAR GRAFT F/N/HF/G-HOSP 677.00 06/30/10 15175 15175 15175 064 0360 0683
06831010 ACELLULAR GRAFT F/N/HF/G-M.D. 974.00 $ 06/30/09 15175 15175 15175 064 0975 0683
06831017 ALLOGRFT SKN ADD 100SQ CM-HOSP 897.00 06/30/10 15301 15301 15301 064 0360 0683
06831018 ALLOGRFT SKN ADD 100SQ CM-M.D. 122.00 $ 06/30/09 15301 15301 15301 064 0975 0683
06831021 ALGFT NOT T/A/L 1ST 100CM-HOSP 897.00 06/30/10 15320 15320 15320 064 0360 0683
06831022 ALGFT NOT T/A/L 1ST 100CM-M.D. 666.00 $ 06/30/09 15320 15320 15320 064 0975 0683
06831025 ALLOGRFT T/A/L 1ST 100CM-HOSP 897.00 06/30/10 15300 15300 15300 064 0360 0683
06831026 ALLOGRFT T/A/L 1ST 100CM-M.D. 587.00 $ 06/30/09 15300 15300 15300 064 0975 0683
06831029 APLIGRAF -PER SQ CENTIMETER 51.00 06/30/10 Q4101 Q4101 Q4101 064 0636 0683
06831033 APP 1ST 25CM BILAMIN SKN-HOSP 418.00 06/30/10 15340 15340 15340 064 0360 0683
06831034 APP 1ST 25CM BILAMIN SKN-M.D. 543.00 $ 06/30/09 15340 15340 15340 064 0975 0683
06831037 APP 2ND 25SQ CM BILAM SKN-HOSP 418.00 06/30/10 15341 15341 15341 064 0360 0683
06831038 APP 2ND 25SQ CM BILAM SKN-M.D. 58.00 $ 06/30/09 15341 15341 15341 064 0975 0683
06831049 APPLY RIGID CAST TO LEG-HOSP 454.00 06/30/10 29445 29445 29445 064 0360 0683
06831050 APPLY RIGID CAST TO LEG-M.D. 240.00 $ 06/30/09 29445 29445 29445 064 0975 0683
06831053 APP WND VAC INC ASS<50CM-HOSP 119.00 06/30/10 97605 97605 97605 064 0420 0683
06831054 APP WND VAC INC ASS<50CM-M.D. 55.00 $ 06/30/09 97605 97605 97605 064 0983 0683
06831057 APP WND VAC INC ASS>50CM-HOSP 219.00 06/30/10 97606 97606 97606 064 0420 0683
06831058 APP WND VAC INC ASS>50CM-M.D. 61.00 $ 06/30/09 97606 97606 97606 064 0983 0683
06831061 BIOP,BONE,TROCAR/NDLE,SUP-HOSP 1721.00 06/30/10 20220 20220 20220 064 0360 0683
06831062 BIOP,BONE,TROCAR/NDLE,SUP-M.D. 162.00 $ 06/30/09 20220 20220 20220 064 0975 0683
06831065 BIOP SFT TISS FORARM SUP-HOSP 1299.00 06/30/10 25065 25065 25065 064 0360 0683
06831066 BIOP SFT TISS FORARM SUP-M.D. 322.00 $ 06/30/09 25065 25065 25065 064 0975 0683
06831069 BIOP SFT TISS FORARM DEE-HOSP 3155.00 06/30/10 25066 25066 25066 064 0360 0683
06831070 BIOP SFT TISS FORARM DEE-M.D. 763.00 $ 06/30/09 25066 25066 25066 064 0975 0683
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 391
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

06831073 BURN DEBRID SM UNDER ANES-HOSP 119.00 06/30/10 16000 16000 16000 064 0360 0683
06831074 BURN DEBRID SM UNDER ANES-M.D. 96.00 $ 06/30/09 16000 16000 16000 064 0975 0683
06831077 BURN DEBRID MED/LRG ANEST-HOSP 119.00 06/30/10 16000 16000 16000 064 0360 0683
06831078 BURN DEBRID MED/LRG ANEST-M.D. 96.00 $ 06/30/09 16000 16000 16000 064 0975 0683
06831081 BURN/DEBRI SMALL/NO ANEST-HOSP 326.00 06/30/10 16020 16020 16020 064 0360 0683
06831082 BURN/DEBRI SMALL/NO ANEST-M.D. 114.00 $ 06/30/09 16020 16020 16020 064 0975 0683
06831085 BURN/DEBRID MED/NO ANEST-HOSP 398.00 06/30/10 16025 16025 16025 064 0360 0683
06831086 BURN/DEBRID MED/NO ANEST-M.D. 234.00 $ 06/30/09 16025 16025 16025 064 0975 0683
06831089 BURN DEBRID LRG/NO ANEST-HOSP 398.00 06/30/10 16030 16030 16030 064 0360 0683
06831090 BURN DEBRID LRG/NO ANEST-M.D. 268.00 $ 06/30/09 16030 16030 16030 064 0975 0683
06831093 CALLOUS DEBRIDEMENT 1-HOSP 158.00 06/30/10 11055 11055 11055 064 0360 0683
06831094 CALLOUS DEBRIDEMENT 1-M.D. 49.00 $ 06/30/09 11055 11055 11055 064 0975 0683
06831097 CALLOUS DEBRIDEMENT 2-4-HOSP 158.00 06/30/10 11056 11056 11056 064 0360 0683
06831098 CALLOUS DEBRIDEMENT 2-4-M.D. 69.00 $ 06/30/09 11056 11056 11056 064 0975 0683
06831101 CALLOUS DEBRIDEMENT 5+-HOSP 291.00 06/30/10 11057 11057 11057 064 0360 0683
06831102 CALLOUS DEBRIDEMENT 5+-M.D. 90.00 $ 06/30/09 11057 11057 11057 064 0975 0683
06831105 CHEMICAL CAUTER,GRNL TISS-HOSP 233.00 06/30/10 17250 17250 17250 064 0360 0683
06831106 CHEMICAL CAUTER,GRNL TISS-M.D. 74.00 $ 06/30/09 17250 17250 17250 064 0975 0683
06831109 DEBR EXT ECZM/INF SKN<10%-HOSP 158.00 06/30/10 11000 11000 11000 064 0360 0683
06831110 DEBR EXT ECZM/INF SKN<10%-M.D. 68.00 $ 06/30/09 11000 11000 11000 064 0975 0683
06831113 DEBRI(NO-PHYS)W/PUL<20SCM-HOSP 219.00 06/30/10 97597 97597 97597 064 0420 0683
06831114 DEBRI(NO-PHYS)W/PUL<20SCM-M.D. 70.00 $ 06/30/09 97597 97597 97597 064 0983 0683
06831117 DEBRI(NO-PHYS)W/PUL>20SCM-HOSP 219.00 06/30/10 97598 97598 97598 064 0420 0683
06831118 DEBRI(NO-PHYS)W/PUL>20SCM-M.D. 92.00 $ 06/30/09 97598 97598 97598 064 0983 0683
06831121 DEBRIDE SKIN FULL THICK-HOSP 291.00 06/30/10 11041 11041 11041 064 0360 0683
06831122 DEBRIDE SKIN FULL THICK-M.D. 76.00 $ 06/30/09 11041 11041 11041 064 0975 0683
06831125 DEBRIDE SKIN PART THICK-HOSP 330.00 06/30/10 11040 11040 11040 064 0360 0683
06831126 DEBRIDE SKIN PART THICK-M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0683
06831129 DEBRIDE SKIN & SUB Q TISS-HOSP 599.00 06/30/10 11042 11042 11042 064 0360 0683
06831130 DEBRIDE SKIN & SUB Q TISS-M.D. 101.00 $ 06/30/09 11042 11042 11042 064 0975 0683
06831131 DEBRI SKN&SUB Q TISS MUSC-HOSP 527.00 06/30/10 11043 11043 11043 064 0360 0683
06831132 DEBRI SKN&SUB Q TISS MUSC-M.D. 471.00 $ 06/30/09 11043 11043 11043 064 0975 0683
06831135 DEB SK SUB Q TIS MUS&BONE-HOSP 1363.00 06/30/10 11044 11044 11044 064 0360 0683
06831136 DEB SK SUB Q TIS MUS&BONE-M.D. 648.00 $ 06/30/09 11044 11044 11044 064 0975 0683
06831139 DEBRIDEMENT OF NAIL 1-5-HOSP 158.00 06/30/10 11720 11720 11720 064 0360 0683
06831140 DEBRIDEMENT OF NAIL 1-5-M.D. 36.00 $ 06/30/09 11720 11720 11720 064 0975 0683
06831143 DEBRIDEMENT OF NAIL >6-HOSP 158.00 06/30/10 11721 11721 11721 064 0360 0683
06831144 DEBRIDEMENT OF NAIL >6-M.D. 62.00 $ 06/30/09 11721 11721 11721 064 0975 0683
06831147 DERMAGRAFT PER 37.5 SQ CM 86.00 06/30/10 J7342 J7342 J7342 064 0636 0683
06831151 EXC TUMOR FRARM/WRST DEEP-HOSP 3155.00 06/30/10 25076 25076 25076 064 0360 0683
06831152 EXC TUMOR FRARM/WRST DEEP-M.D. 901.00 $ 06/30/09 25076 25076 25076 064 0975 0683
06831155 EXC TUMOR FRARM/WRST SUPE-HOSP 2407.00 06/30/10 25075 25075 25075 064 0360 0683
06831156 EXC TUMOR FRARM/WRST SUPE-M.D. 667.00 $ 06/30/09 25075 25075 25075 064 0975 0683
06831159 EXPLORATION OF FOOT JOINT-HOSP 3114.00 06/30/10 28020 28020 28020 064 0360 0683
06831160 EXPLORATION OF FOOT JOINT-M.D. 763.00 $ 06/30/09 28020 28020 28020 064 0975 0683
06831165 WND PREP,CH/INF,F/N/HF/G-HOSP 568.00 06/30/10 15004 15004 15004 064 0360 0683
06831166 WND PREP,CH/INF,F/N/HF/G-M.D. 592.00 $ 06/30/09 15004 15004 15004 064 0975 0683
06831171 INCIS&DRAIN ABSCESS COMPL-HOSP 269.00 06/30/10 10061 10061 10061 064 0360 0683
06831172 INCIS&DRAIN ABSCESS COMPL-M.D. 332.00 $ 06/30/09 10061 10061 10061 064 0975 0683
06831175 INCIS&DRAIN ABSCESS SIMPL-HOSP 164.00 06/30/10 10060 10060 10060 064 0360 0683
06831176 INCIS&DRAIN ABSCESS SIMPL-M.D. 186.00 $ 06/30/09 10060 10060 10060 064 0975 0683
06831179 INCISION/DRAIN HEMATOMA-HOSP 300.00 06/30/10 10140 10140 10140 064 0360 0683
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 392
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

06831180 INCISION/DRAIN HEMATOMA-M.D. 241.00 $ 06/30/09 10140 10140 10140 064 0975 0683
06831183 INCIS/DRN POST-OP WND INF-HOSP 940.00 06/30/10 10180 10180 10180 064 0360 0683
06831184 INCIS/DRN POST-OP WND INF-M.D. 362.00 $ 06/30/09 10180 10180 10180 064 0975 0683
06831187 INCIS/RMVL FOREIGN BODY-HOSP 193.00 06/30/10 10120 10120 10120 064 0360 0683
06831188 INCIS/RMVL FOREIGN BODY-M.D. 182.00 $ 06/30/09 10120 10120 10120 064 0975 0683
06831191 MYRINGOTOMY W/O GEN ANEST-HOSP 509.00 06/30/10 69420 69420 69420 064 0360 0683
06831192 MYRINGOTOMY W/O GEN ANEST-M.D. 238.00 $ 06/30/09 69420 69420 69420 064 0975 0683
06831203 NEG PRESS WND THER>50SQCM-HOSP 219.00 06/30/10 97606 97606 97606 064 0420 0683
06831204 NEG PRESS WND THER>50SQCM-M.D. 61.00 $ 06/30/09 97606 97606 97606 064 0983 0683
06831207 NEG PRES WND THER<=50SQCM-HOSP 219.00 06/30/10 97605 97605 97605 064 0420 0683
06831208 NEG PRES WND THER<=50SQCM-M.D. 55.00 $ 06/30/09 97605 97605 97605 064 0983 0683
06831219 OASIS BIOLOGIC 10.00 06/30/10 Q4103 Q4103 Q4103 064 0250 0683
06831223 OASIS SKN GRFT<100 SQ CM-HOSP 1166.00 06/30/10 15430 15430 15430 064 0360 0683
06831224 OASIS SKN GRFT<100 SQ CM-M.D. 997.00 $ 06/30/09 15430 15430 15430 064 0975 0683
06831227 OASIS GRAFT EA ADD 100CM-HOSP 1166.00 06/30/10 15431 15431 15431 064 0360 0683
06831228 OASIS GRAFT EA ADD 100CM-M.D. 440.00 $ 09/01/08 15431 15431 15431 064 0975 0683
06831231 PARING/CUR SKN LES-SING-HOSP 158.00 06/30/10 11055 11055 11055 064 0360 0683
06831232 PARING/CUR SKN LES-SING-M.D. 49.00 $ 06/30/09 11055 11055 11055 064 0975 0683
06831235 PARING/CUR SKN LES 2-4-HOSP 158.00 06/30/10 11056 11056 11056 064 0360 0683
06831236 PARING/CUR SKN LES 2-4-M.D. 69.00 $ 06/30/09 11056 11056 11056 064 0975 0683
06831239 PARING/CUR SKN LES >4-HOSP 291.00 06/30/10 11057 11057 11057 064 0360 0683
06831240 PARING/CUR SKN LES >4-M.D. 90.00 $ 06/30/09 11057 11057 11057 064 0975 0683
06831243 PUNCH BIOPSY-HOSP 158.00 06/30/10 11100 11100 11100 064 0360 0683
06831244 PUNCH BIOPSY - M.D. 95.00 $ 06/30/09 11100 11100 11100 064 0975 0683
06831245 BIOPSY ADDL SUBCUT TISSUE-HOSP 130.00 06/30/10 11101 11101 11101 064 0360 0683
06831246 BIOPSY ADDL SUBCUT TISSUE-M.D. 49.00 $ 06/30/09 11101 11101 11101 064 0975 0683
06831247 RMVL OF DEVIT TIS>20SQ CM-HOSP 219.00 06/30/10 97598 97598 97598 064 0420 0683
06831248 RMVL OF DEVIT TIS>20SQ CM-M.D. 92.00 $ 06/30/09 97598 97598 97598 064 0983 0683
06831251 RMVL DEVIT TISS<=20SQ CM-HOSP 219.00 06/30/10 97597 97597 97597 064 0420 0683
06831252 RMVL DEVIT TISS<=20SQ CM-M.D. 70.00 $ 06/30/09 97597 97597 97597 064 0983 0683
06831255 RMVL IMPACT CERUMEN EARS-HOSP 126.00 06/30/10 69210 69210 69210 064 0360 0683
06831256 RMVL IMPACT CERUMEN EARS-M.D. 67.00 $ 06/30/09 69210 69210 69210 064 0975 0683
06831259 REMOVE INGROWN TOENAIL-HOSP 291.00 06/30/10 11765 11765 11765 064 0360 0683
06831260 REMOVE INGROWN TOENAIL-M.D. 135.00 $ 06/30/09 11765 11765 11765 064 0975 0683
06831263 REPAIR NAIL BED-HOSP 418.00 06/30/10 11760 11760 11760 064 0360 0683
06831264 REPAIR NAIL BED-M.D. 266.00 $ 06/30/09 11760 11760 11760 064 0975 0683
06831267 STRAPPING ANKLE-HOSP 216.00 06/30/10 29540 29540 29540 064 0360 0683
06831268 STRAPPING ANKLE-M.D. 69.00 $ 06/30/09 29540 29540 29540 064 0975 0683
06831271 SURG PREP 1ST 100CM T/A/L-HOSP 677.00 06/30/10 15002 15002 15002 064 0360 0683
06831272 SURG PREP 1ST 100CM T/A/L-M.D. 473.00 $ 06/30/09 15002 15002 15002 064 0975 0683
06831275 TCOMS 2-20 SITES 461.00 06/30/10 93923 93923 93923 064 0920 0683
06831279 TCOMS ONE SITE 305.00 06/30/10 93922 93922 93922 064 0920 0683
06831287 TRIM NAILS-HOSP 147.00 06/30/10 11719 11719 11719 064 0360 0683
06831288 TRIM NAILS-M.D. 19.00 $ 06/30/09 11719 11719 11719 064 0975 0683
06831291 TYMPANOMETRY 89.00 06/30/10 92567 92567 92567 064 0471 0683
06831295 UNNA BOOT APPLICATION 216.00 06/30/10 29580 29580 29580 064 0360 0683
06831296 UNNA BOOT APPLICATION-M.D. 77.00 $ 06/30/09 29580 29580 29580 064 0975 0683
06831299 XENO NOT T/A/L 1ST 100CM-HOSP 677.00 06/30/10 15420 15420 15420 064 0360 0683
06831300 XENO NOT T/A/L 1ST 100CM-M.D. 779.00 $ 06/30/09 15420 15420 15420 064 0975 0683
06831303 XENOGRFT T/A/L 1ST 100CM-HOSP 677.00 06/30/10 15400 15400 15400 064 0360 0683
06831304 XENOGRFT T/A/L 1ST 100CM-M.D. 703.00 $ 06/30/09 15400 15400 15400 064 0975 0683
06831307 WOUND CARE W/O DEBRIDE-HOSP 330.00 06/30/10 11040 11040 11040 064 0360 0683
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 393
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

06831308 WOUND CARE W/O DEBRIDE-M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0683
06831313 EXC BEN LES T,A,L 1.1-2CM-HOSP 393.00 06/30/10 11402 11402 11402 064 0360 0683
06831314 EXC BEN LES T,A,L 1.1-2CM-M.D. 217.00 $ 06/30/09 11402 11402 11402 064 0975 0683
06831319 SKN SUB, DERMAGRAFT, PER SQ CM 112.00 06/30/10 Q4106 Q4106 Q4106 064 0636 0683
06831321 DERMAL SUBSTIT 100 SQ CM-HOSP 661.00 06/30/10 15365 15365 15365 064 0360 0683
06831322 DERMAL SUBSTIT 100 SQ CM-M.D. 611.00 $ 11/01/09 15365 15365 15365 064 0975 0683
12050809 QUTENZA PATCH 28.00 07/01/10 C9268 C9268 C9268 064 0636 2815
12310443 INFUSION PUMP RMVL-HOSP 811.00 06/30/10 36590 36590 36590 064 0360 0524
12310444 INFUSION PUMP RMVL-M.D. 438.00 $ 06/30/09 36590 36590 36590 064 0975 0524
12310466 DEST,MALIG LES 1.1CM-2CM-M.D. 247.00 $ 06/30/09 17272 17272 17272 064 0975 0524
12340312 INJECTION SUBQ/IM CHEMO DRUG 440.00 06/30/10 96401 96401 96401 064 0331 0524
13000503 INCS/DRAIN,ABSCESS,SIMPLE-HOSP 164.00 06/30/10 10060 10060 10060 064 0360 0625
13000504 INCIS/DRAIN,ABSCESS-SIMP-M.D. 186.00 $ 06/30/09 10060 10060 10060 064 0975 0625
13000507 I&D PILONIDL ABSCESS SIMP-HOSP 135.00 06/30/10 10080 10080 10080 064 0360 0625
13000508 I&D PILONIDL ABSCESS SMPL-M.D. 189.00 $ 06/30/09 10080 10080 10080 064 0975 0625
13000509 I&D PILONIDL ABSCESS COMP-HOSP 577.00 06/30/10 10081 10081 10081 064 0360 0625
13000510 I&D PILONIDL ABSCESS COMP-M.D. 332.00 $ 06/30/09 10081 10081 10081 064 0975 0625
13000511 RMVL FOREIGN BODY-SIMPLE-HOSP 193.00 06/30/10 10120 10120 10120 064 0360 0625
13000512 RMVL FOREIGN BODY-SIMPLE-M.D. 182.00 $ 06/30/09 10120 10120 10120 064 0975 0625
13000513 RMVL FOREIGN BODY-COMP-HOSP 1022.00 06/30/10 10121 10121 10121 064 0360 0625
13000514 RMVL FOREIGN BODY-COMP-M.D. 377.00 $ 06/30/09 10121 10121 10121 064 0975 0625
13000515 DRAINAGE OF SEROMA-HOSP 300.00 06/30/10 10140 10140 10140 064 0360 0625
13000516 DRAINAGE OF SEROMA-M.D. 241.00 $ 06/30/09 10140 10140 10140 064 0975 0625
13000517 ASP ABSCESS HEMATOMA CYST-HOSP 100.00 06/30/10 10160 10160 10160 064 0360 0625
13000518 ASP ABSCESS HEMATOMA CYST-M.D. 193.00 $ 06/30/09 10160 10160 10160 064 0975 0625
13000525 DEBRIDE SKIN PART THICK-HOSP 147.00 06/30/10 11040 11040 11040 064 0360 0625
13000526 DEBRIDE SKIN PART THICK-M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0625
13000527 DEBRIDE SKIN FULL THICK-HOSP 301.00 06/30/10 11041 11041 11041 064 0360 0625
13000528 DEBRIDE SKIN FULL THICK-M.D. 76.00 $ 06/30/09 11041 11041 11041 064 0975 0625
13000529 DEBRIDE SKIN & SUBCUT TIS-HOSP 571.00 06/30/10 11042 11042 11042 064 0360 0625
13000530 DEBRIDE SKIN & SUBCUT TIS-M.D. 101.00 $ 06/30/09 11042 11042 11042 064 0975 0625
13000531 DEBRIDE SKIN SUB TIS/MUS-HOSP 1224.00 06/30/10 11043 11043 11043 064 0360 0625
13000532 DEBRIDE SKIN SUB TIS/MUS-M.D. 471.00 $ 06/30/09 11043 11043 11043 064 0975 0625
13000541 SKIN BIOP,SINGLE LESION-HOSP. 165.00 06/30/10 11100 11100 11100 064 0360 0625
13000542 SKIN BIOP. SINGLE LESION-M.D. 95.00 $ 06/30/09 11100 11100 11100 064 0975 0625
13000551 INFUSION PUMP RMVL-HOSP 811.00 06/30/10 36590 36590 36590 064 0360 0625
13000552 INFUSION PUMP RMVL-M.D. 438.00 $ 06/30/09 36590 36590 36590 064 0975 0625
13000573 EXCIS B LES T,A,L 0.5CM-HOSP 254.00 06/30/10 11400 11400 11400 064 0360 0625
13000574 EXCIS B LES T,A,L 0.5CM-M.D. 145.00 $ 06/30/09 11400 11400 11400 064 0975 0625
13000575 EXCIS B LES T,A,L 0.6-1CM-HOSP 299.00 06/30/10 11401 11401 11401 064 0360 0625
13000576 EXCIS B LES T,A,L 0.6-1CM-M.D. 194.00 $ 06/30/09 11401 11401 11401 064 0975 0625
13000577 EXCIS B LES T,A,L 1.1-2CM-HOSP 393.00 06/30/10 11402 11402 11402 064 0360 0625
13000578 EXCIS B LES T,A,L 1.1-2CM-M.D. 217.00 $ 06/30/09 11402 11402 11402 064 0975 0625
13000579 EXCIS B LES T,A,L 2.1-3CM-HOSP 516.00 06/30/10 11403 11403 11403 064 0360 0625
13000580 EXCIS B LES T,A,L 2.1-3CM-M.D. 276.00 $ 06/30/09 11403 11403 11403 064 0975 0625
13000581 EXCIS B LES T,A,L 3.1-4CM-HOSP 762.00 06/30/10 11404 11404 11404 064 0360 0625
13000582 EXCIS B LES T,A,L 3.1-4CM-M.D. 309.00 $ 06/30/09 11404 11404 11404 064 0975 0625
13000583 EXCIS B LESION T,A,L >4CM-HOSP 2657.00 06/30/10 11406 11406 11406 064 0360 0625
13000584 EXCIS B LESION T,A,L >4CM-M.D. 459.00 $ 06/30/09 11406 11406 11406 064 0975 0625
13000591 EX B LES-SC,NK,HD,FT<.5CM-HOSP 287.00 06/30/10 11420 11420 11420 064 0360 0625
13000592 EX B LES-SC,NK,HD,FT<.5CM-M.D. 159.00 $ 06/30/09 11420 11420 11420 064 0975 0625
13000595 EX B LES-SC,NK,FT-.6-1CM-HOSP 494.00 06/30/10 11421 11421 11421 064 0360 0625
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 394
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13000596 EX B LES-SC,NK,FT-.6-1CM-M.D. 215.00 $ 06/30/09 11421 11421 11421 064 0975 0625
13000597 EX B LES SC,NK,FT 1.1-2CM-HOSP 488.00 06/30/10 11422 11422 11422 064 0360 0625
13000598 EX B LES SC,NK,FT 1.1-2CM-M.D. 260.00 $ 06/30/09 11422 11422 11422 064 0975 0625
13000601 EX B LES SC,NK,FT 2.1-3CM-HOSP 893.00 06/30/10 11423 11423 11423 064 0360 0625
13000602 EX B LES SC,NK,FT 2.1-3CM-M.D. 304.00 $ 06/30/09 11423 11423 11423 064 0975 0625
13000603 EX B LES FACE,EAR <.5 CM-HOSP 296.00 06/30/10 11440 11440 11440 064 0360 0625
13000604 EX B LES FACE,EAR <.5 CM-M.D. 189.00 $ 06/30/09 11440 11440 11440 064 0975 0625
13000605 EX B LES FACE,EAR,.6-1CM-HOSP 857.00 06/30/10 11441 11441 11441 064 0360 0625
13000606 EX B LES FACE,EAR,.6-1CM-M.D. 250.00 $ 06/30/09 11441 11441 11441 064 0975 0625
13000607 EX B LES FACE,EAR,1.1-2CM-HOSP 566.00 06/30/10 11442 11442 11442 064 0360 0625
13000608 EX B LES FACE,EAR,1.1-2CM-M.D. 280.00 $ 06/30/09 11442 11442 11442 064 0975 0625
13000609 EX B LES FACE,EAR,2.1-3CM-HOSP 758.00 06/30/10 11443 11443 11443 064 0360 0625
13000610 EX B LES FACE,EAR,2.1-3CM-M.D. 346.00 $ 06/30/09 11443 11443 11443 064 0975 0625
13000611 EX MAL LES FACE,EAR,<.5CM-HOSP 688.00 06/30/10 11640 11640 11640 064 0360 0625
13000612 EX MAL LES FACE,EAR,<.5CM-M.D. 233.00 $ 06/30/09 11640 11640 11640 064 0975 0625
13000613 EX MAL LES FACE,<.6-1CM-HOSP 755.00 06/30/10 11641 11641 11641 064 0360 0625
13000614 EX MAL LES FACE,<.6-1CM-M.D. 306.00 $ 06/30/09 11641 11641 11641 064 0975 0625
13000615 EX MAL LES FACE,1.1-2CM-HOSP 1042.00 06/30/10 11642 11642 11642 064 0360 0625
13000616 EX MAL LES FACE,1.1-2CM-M.D. 361.00 $ 06/30/09 11642 11642 11642 064 0975 0625
13000617 EX MAL LES SC,NK,HD,<.5CM-HOSP 296.00 06/30/10 11620 11620 11620 064 0360 0625
13000618 EX MAL LES SC,NK,HD,<.5CM-M.D. 220.00 $ 06/30/09 11620 11620 11620 064 0975 0625
13000619 EX MAL LES SC,NK,HD.6-1CM-HOSP 675.00 06/30/10 11621 11621 11621 064 0360 0625
13000620 EX MAL LES SC,NK,HD.6-1CM-M.D. 284.00 $ 06/30/09 11621 11621 11621 064 0975 0625
13000621 EX MAL LES SC,NK, 1.1-2CM-HOSP 764.00 06/30/10 11622 11622 11622 064 0360 0625
13000622 EX MAL LES SC,NK,1.1-2-CM-M.D. 327.00 $ 06/30/09 11622 11622 11622 064 0975 0625
13000623 EX MAL LES SC,NK 2.1-3CM-HOSP 936.00 06/30/10 11623 11623 11623 064 0360 0625
13000624 EX MAL LES SC,NK 2.1-3CM-M.D. 405.00 $ 06/30/09 11623 11623 11623 064 0975 0625
13000651 WND PRP,CH/INF,TRK/ARM/LG-HOSP 517.00 06/30/10 15002 15002 15002 064 0360 0625
13000652 WND PRP,CH/INF,TRK/ARM/LG-M.D. 473.00 $ 06/30/09 15002 15002 15002 064 0975 0625
13000653 OASIS SKIN GRAFT<100SQ CM-HOSP 1166.00 06/30/10 15430 15430 15430 064 0360 0625
13000654 OASIS SKIN GRAFT<100SQ CM-M.D. 997.00 $ 06/30/09 15430 15430 15430 064 0975 0625
13000657 OASIS GRAFT EA ADD 100 CM-HOSP 1166.00 06/30/10 15431 15431 15431 064 0360 0625
13000658 OASIS GRAFT EA ADD 100 CM-M.D. 440.00 $ 08/10/08 15431 15431 15431 064 0975 0625
13000701 BIOPSY BREAST,NEEDLE-HOSP. 251.00 06/30/10 19100 19100 19100 064 0360 0625
13000702 BIOPSY BREAST,NEEDLE-M.D 145.00 $ 06/30/09 19100 19100 19100 064 0975 0625
13000703 BIOSPY BREAST INCISIONAL -HOSP 1498.00 06/30/10 19101 19101 19101 064 0360 0625
13000704 BIOPSY BREAST INCISIONAL -M.D. 435.00 $ 06/30/09 19101 19101 19101 064 0975 0625
13000715 BIOPSY,MUSCLE;SUPERFICIAL-HOSP 710.00 06/30/10 20200 20200 20200 064 0360 0625
13000716 BIOPSY,MUSCLE;SUPERFICIAL-M.D. 197.00 $ 06/30/09 20200 20200 20200 064 0975 0625
13000867 PROCTOSIGMOIDOSCOPY; DIAG-HOSP 303.00 06/30/10 45300 45300 45300 064 0360 0625
13000868 PROCTOSIGMOIDOSCOPY; DIAG-M.D. 97.00 $ 06/30/09 45300 45300 45300 064 0975 0625
13000879 FLEXIBLE SIGMOIDOSCOPY - HOSP 554.00 06/30/10 45330 45330 45330 064 0360 0625
13000880 FLEXIBLE SIGMOIDOSCOPY - M.D. 129.00 $ 06/30/09 45330 45330 45330 064 0975 0625
13000931 HEMORRHOIDECTOMY,LIGATURE-HOSP 421.00 06/30/10 46221 46221 46221 064 0360 0625
13000932 HEMORRHOIDECTOMY,LIGATURE-M.D. 354.00 $ 06/30/09 46221 46221 46221 064 0975 0625
13001175 PLACEMENT CENTRL VEN CATH-HOSP 1082.00 06/30/10 36556 36556 36556 064 0360 0625
13001176 PLACEMENT CENTRL VEN CATH-M.D. 260.00 $ 06/30/09 36556 36556 36556 064 0975 0625
13001191 RMVL CENTRAL VENOUS CATH-HOSP 660.00 06/30/10 36589 36589 36589 064 0360 0625
13001192 RMVL CENTRAL VENOUS CATH-M.D. 303.00 $ 06/30/09 36589 36589 36589 064 0975 0625
13001211 FINE NEEDLE BIO-LYM NODE-HOSP. 685.00 06/30/10 38505 38505 38505 064 0360 0625
13001212 FINE NEEDLE BIO. LYM NODE-M.D. 157.00 $ 06/30/09 38505 38505 38505 064 0975 0625
13001237 GASTROSTOMY TUBE REPLACE-HOSP 312.00 06/30/10 43760 43760 43760 064 0360 0625
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 395
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13001238 GASTROSTOMY TUBE REPLACE-M.D. 108.00 $ 06/30/09 43760 43760 43760 064 0975 0625
13001277 PROCTOSIGMOIDOSCOP/BIOPSY-HOSP 618.00 06/30/10 45305 45305 45305 064 0360 0625
13001278 PROCTOSIGMOIDOSCOP/BIOPSY-M.D. 154.00 $ 06/30/09 45305 45305 45305 064 0975 0625
13001283 FINE NEEDLE ASPIR.-BREAST-HOSP 355.00 06/30/10 10021 10021 10021 064 0360 0625
13001284 FINE NEEDLE ASPIR.-BREAST-M.D. 141.00 $ 06/30/09 10021 10021 10021 064 0975 0625
13001293 I&D PERIRECTAL ABSCESS-HOSP 1157.00 06/30/10 46040 46040 46040 064 0360 0625
13001294 I&D PERIRECTAL ABSCESS-M.D. 780.00 $ 06/30/09 46040 46040 46040 064 0975 0625
13001295 I&D PERINEAL ABSCESS-HOSP 556.00 06/30/10 46050 46050 46050 064 0360 0625
13001296 I&D PERINEAL ABSCESS-M.D. 182.00 $ 06/30/10 46050 46050 46050 064 0975 0625
13001303 EXCIS THROMB HEMORRHOIDS-HOSP 456.00 06/30/10 46320 46320 46320 064 0360 0625
13001304 EXCIS THROMB HEMORRHOIDS-M.D. 214.00 $ 06/30/09 46320 46320 46320 064 0975 0625
13001305 INJ OF SCLEROSING SOLUT-HOSP 98.00 06/30/10 46500 46500 46500 064 0360 0625
13001306 INJ OF SCLEROSING SOLUT-M.D. 240.00 $ 06/30/09 46500 46500 46500 064 0975 0625
13001307 ANOSCOPY,DIAGNOSTIC-HOSP. 109.00 06/30/10 46600 46600 46600 064 0360 0625
13001308 ANOSCOPY,DIAGNOSTIC-M.D. 76.00 $ 06/30/09 46600 46600 46600 064 0975 0625
13001311 ANOSCOPY W/BIOPSY-HOSP 182.00 06/30/10 46606 46606 46606 064 0360 0625
13001312 ANOSCOPY W/BIOPSY-M.D. 145.00 $ 06/30/09 46606 46606 46606 064 0975 0625
13001611 SWALLOW FUNC PHAR/ESOPH W/VID 269.00 06/30/10 74230 74230 74230 064 0320 0625
13001631 ECHO COMPLETE ABDOMEN-HOSP 684.00 06/30/10 76705 76705 76705 064 0402 0625
13001632 ECHO COMPLETE ABDOMEN-M.D. 65.00 $ 06/30/09 76705 7670526 7670526 064 0972 0625
13001663 US GUID NDLE PLMT IMG S&I-HOSP 754.00 07/27/10 76942 76942 76942 064 0402 0625
13001664 US GUID NDLE PLMT IMG S&I-M.D. 73.00 $ 06/30/09 76942 7694226 7694226 064 0972 0625
13001671 FLURO GUIDE NEEDLE PLACEMENT 396.00 06/30/10 77002 77002 77002 064 0320 0625
13001725 GI TRAC CAPSULE ENDOSCOPY-HOSP 1559.00 06/30/10 91110 91110 91110 064 0750 0625
13001726 GI TRAC CAPSULE ENDOSCOPY-M.D. 409.00 $ 06/30/09 91110 91110 91110 064 0983 0625
13001730 ADJ GASTRIC BAND-SUBC PRT 378.00 06/30/10 S2083 S2083 S2083 064 0360 0625
13001731 ADJ GASTRIC BAND-SUBC PRT-M.D. 350.00 $ 08/10/08 S2083 S2083 S2083 064 0983 0625
13001734 LAP BAND ADJUSTMENT 130.00 06/30/10 064 0360 0625
13010042 POSTOP FOLLOW-UP VISIT-M.D. N/C 07/01/95 99024 99024 99024 064 0983 0626
13010503 INCIS/DRAIN,ABSCESS,SIMP-HOSP. 164.00 06/30/10 10060 10060 10060 064 0360 0626
13010504 INCIS/DRAIN,ABSCESS,SIMP-M.D. 186.00 $ 06/30/09 10060 10060 10060 064 0975 0626
13010505 INCIS/DRAIN,ABSCESS,COMP-HOSP. 279.00 06/30/10 10061 10061 10061 064 0360 0626
13010506 INCIS/DRAIN,ABSCESS,COMP-M.D. 332.00 $ 06/30/09 10061 10061 10061 064 0975 0626
13010511 ASPIR ABSCESS, HEMA CYST-HOSP. 100.00 06/30/10 10160 10160 10160 064 0360 0626
13010512 ASPIR ABSCESS,HEMA CYST-M.D. 193.00 $ 06/30/09 10160 10160 10160 064 0975 0626
13010515 DRAINAGE OF SEROMA-HOSP. 300.00 06/30/10 10140 10140 10140 064 0360 0626
13010516 DRAINAGE OF SEROMA-M.D. 241.00 $ 06/30/09 10140 10140 10140 064 0975 0626
13010521 SKIN DEBRIDE 10% OF BODY-HOSP 106.00 06/30/10 11000 11000 11000 064 0360 0626
13010522 SKIN DEBRIDE 10% OF BODY-M.D. 68.00 $ 06/30/09 11000 11000 11000 064 0975 0626
13010525 DEBRDE SKIN PRT THICKNESS-HOSP 147.00 06/30/10 11040 11040 11040 064 0360 0626
13010526 DEBRIDE SKIN PRT THICKNSS-M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0626
13010527 DEBRIDE SKIN, FULL THICK-HOSP. 301.00 06/30/10 11041 11041 11041 064 0360 0626
13010528 DEBRIDE SKIN FULL THICK-M.D. 76.00 $ 06/30/09 11041 11041 11041 064 0975 0626
13010529 DEBRIDE; SKIN PART THICK-HOSP 404.00 06/30/10 11040 11040 11040 064 0360 0626
13010530 DEBRIDE; SKIN PART THICK-M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0626
13010531 SKIN BIOP,SINGLE LESION-HOSP. 165.00 06/30/10 11100 11100 11100 064 0360 0626
13010532 SKIN BIOP, SINGLE LESION-M.D. 95.00 $ 06/30/09 11100 11100 11100 064 0975 0626
13010601 SUB HORMONE PELLET IMPLNT-HOSP 115.00 06/30/10 11980 11980 11980 064 0360 0626
13010602 SUB HORMONE PELLET IMPLNT-M.D. 167.00 $ 06/30/09 11980 11980 11980 064 0975 0626
13010605 RMVL,NON-BIO DRUG DELIV - HOSP 115.00 06/30/10 11982 11982 11982 064 0360 0626
13010606 RMVL,NON-BIO DRUG DELIV - M.D. 216.00 $ 01/01/10 11982 11982 11982 064 0975 0626
13010775 PLACE CNT VENS CATH AGE>2-HOSP 1008.00 06/30/10 36556 36556 36556 064 0360 0626
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 396
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13010776 PLACE CNT VENS CATH AGE>2-M.D. 266.00 $ 06/30/09 36555 36555 36555 064 0975 0626
13010778 PLACE BY CUTDOWN AGE > 2 -M.D. 266.00 $ 06/30/09 36555 36555 36555 064 0975 0626
13010783 REMOVAL CENTRAL LINE-HOSP 660.00 06/30/10 36589 36589 36589 064 0360 0626
13010784 REMOVAL CENTRAL LINE-M.D. 303.00 $ 06/30/09 36589 36589 36589 064 0975 0626
13010787 INSERT OF CANNULA-HOSP 2415.00 06/30/10 36800 36800 36800 064 0360 0626
13010788 INSERT CANNULA -M.D. 341.00 $ 06/30/09 36800 36800 36800 064 0975 0626
13010799 CANNULA DECLOT W/O BALLN-HOSP 730.00 06/30/10 36860 36860 36860 064 0360 0626
13010800 CANNULA DECLOT W/O BALLN-M.D. 217.00 $ 06/30/09 36860 36860 36860 064 0975 0626
13010807 ABDOMINAL PARACEN-INITIAL-HOSP 293.00 06/30/10 49080 49080 49080 064 0360 0626
13010808 ABDOMINAL PARACEN-INITIAL-M.D. 151.00 $ 06/30/09 49080 49080 49080 064 0975 0626
13010811 PARACENTESIS,SUBSEQUENT-HOSP 293.00 06/30/10 49081 49081 49081 064 0360 0626
13010812 PARACENTESIS,SUBSEQUENT-M.D. 143.00 $ 06/30/09 49081 49081 49081 064 0975 0626
13010815 SPINAL PUNCTURE,LUMBAR-HOSP 351.00 06/30/10 62270 62270 62270 064 0360 0626
13010816 SPINAL PUNCTURE,LUMBAR-M.D. 158.00 $ 06/30/09 62270 62270 62270 064 0975 0626
13010820 URINE DIPSTICK W/O MICRO 35.00 06/30/10 81002 81002 81002 064 0300 0626
13010824 BLOOD OCCULT DIAGNOSTIC 34.00 06/30/10 82270 82270 82270 064 0301 0626
13010829 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 064 0510 0626
13010831 THERAPEUTIC INJ,IV 237.00 06/30/10 96372 96372 96372 064 0940 0626
13010840 THERPETC PROPH/DX INJ; SUBQ/IM 86.00 06/30/10 96372 96372 96372 064 0510 0626
13010845 THERAPTIC PROPH/DX INJECT; IV 236.00 06/30/10 96374 96374 96374 064 0510 0626
13011631 ECHO ABDOMINAL; LIMITED - HOSP 684.00 06/30/10 76705 76705 76705 064 0402 0626
13011632 ECHO ABDOMINAL; LIMITED-M.D. 65.00 $ 06/30/09 76705 7670526 7670526 064 0972 0626
13020042 POSTOP FOLLOW-UP VISIT-M.D. N/C 06/13/94 99024 99024 99024 064 0983 0627
13020525 DEBRIDE SKIN PART THICK-HOSP 147.00 06/30/10 11040 11040 11040 064 0360 0627
13020526 DEBRIDE SKIN PART THICK-M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0627
13020527 DEBRIDE SKIN FULL THICK-HOSP 301.00 06/30/10 11041 11041 11041 064 0360 0627
13020528 DEBRIDE SKIN FULL THICK-M.D. 76.00 $ 06/30/09 11041 11041 11041 064 0975 0627
13020529 DEBRIDE SKIN/SUBCUT TISS-HOSP 571.00 06/30/10 11042 11042 11042 064 0360 0627
13020530 DEBRIDE SKIN/SUBCUT TISS-M.D. 101.00 $ 06/30/09 11042 11042 11042 064 0975 0627
13020531 DEBRIDE SKN SUBQ TIS/MUS-HOSP 1224.00 06/30/10 11043 11043 11043 064 0360 0627
13020532 DEBRIDE SKN SUBQ TISS/MUS-M.D. 471.00 $ 06/30/09 11043 11043 11043 064 0975 0627
13020533 DEBRIDE SUBQ TIS/MUS/BONE-HOSP 1594.00 06/30/10 11044 11044 11044 064 0360 0627
13020534 DEBRIDE SUBQ TIS/MUS/BONE-M.D. 648.00 $ 06/30/09 11044 11044 11044 064 0975 0627
13020535 PAR/CUR SKIN LESION-SNGLE-HOSP 88.00 06/30/10 11055 11055 11055 064 0360 0627
13020536 PAR/CUR SKIN LESION-SNGLE-M.D. 49.00 $ 06/30/09 11055 11055 11055 064 0975 0627
13020537 PARE/CUR SKIN LES.(2-4)-HOSP. 92.00 06/30/10 11056 11056 11056 064 0360 0627
13020538 PAR/CUR SKIN LESIONS (2-4)-M.D 69.00 $ 06/30/09 11056 11056 11056 064 0975 0627
13020539 PAR/CUR SKIN LESION>4-HOSP 126.00 06/30/10 11057 11057 11057 064 0360 0627
13020540 PAR/CUR SKIN LESION >4-M.D. 90.00 $ 06/30/09 11057 11057 11057 064 0975 0627
13020591 APP SKIN GRFT-25 CM(MEDI)-HOSP 617.00 06/30/10 15340 15340 15340 064 0360 0627
13020592 APP SKN GRFT-25 CM(MEDI)-M.D. 543.00 $ 06/30/09 15340 15340 15340 064 0975 0627
13020593 APP SK GFT-ADD 25CM(MEDI)-HOSP 2290.00 06/30/10 15341 15341 15341 064 0360 0627
13020594 APP SK GFT-ADD 25CM(MEDI)-M.D. 58.00 $ 06/30/09 15341 15341 15341 064 0975 0627
13020595 APLIGRAPH PER SQ CENTIMETER 51.00 06/30/10 J7340 J7340 J7340 064 0636 0627
13020601 WND PRP,CH/INF,TRK/ARM/LG-HOSP 465.00 06/30/10 15002 15002 15002 064 0360 0627
13020602 WND PRP,CH/INF,TRK/ARM/LG-M.D. 473.00 $ 06/30/09 15002 15002 15002 064 0975 0627
13020603 OASIS SKIN GRAFT<100SQ CM-HOSP 1166.00 06/30/10 15430 15430 15430 064 0360 0627
13020604 OASIS SKIN GRAFT<100SQ CM-M.D. 997.00 $ 06/30/09 15430 15430 15430 064 0975 0627
13020607 OASIS GRAFT EA ADD 100 CM-HOSP 1166.00 06/30/10 15431 15431 15431 064 0360 0627
13020608 OASIS GRAFT EA ADD 100 CM-M.D. 440.00 $ 08/10/08 15431 15431 15431 064 0975 0627
13020610 SKIN SPLIT GRAFT-HOSP. 1730.00 06/30/10 15100 15100 15100 064 0360 0627
13020611 SKIN SPLIT GRAFT-M.D. 1450.00 $ 06/30/09 15100 15100 15100 064 0975 0627
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 397
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13020651 LEG OR ANKLE SUPERFICIAL-HOSP. 566.00 06/30/10 27613 27613 27613 064 0360 0627
13020652 LEG OR ANKLE SUPERFICIAL-M.D. 332.00 $ 06/30/09 27613 27613 27613 064 0975 0627
13020653 LEG OR ANKLE DEEP-HOSP. 1541.00 06/30/10 27614 27614 27614 064 0360 0627
13020654 LEG OR ANKLE DEEP-M.D. 846.00 $ 06/30/09 27614 27614 27614 064 0975 0627
13020711 APPLICATION; UNNA BOOT 216.00 06/30/10 29580 29580 29580 064 0360 0627
13020712 APPLICATION; UNNA BOOT - M.D. 77.00 $ 06/30/09 29580 29580 29580 064 0975 0627
13020765 SING/MLT INJ SPIDER VEINS-HOSP 456.00 06/30/10 36468 36468 36468 064 0360 0627
13020766 SING/MLT INJ SPIDER VEINS-M.D. 614.00 $ 08/10/08 36468 36468 36468 064 0975 0627
13020769 SINGLE VEIN-HOSP. 159.00 06/30/10 36470 36470 36470 064 0360 0627
13020770 SINGLE VEIN-M.D 150.00 $ 06/30/09 36470 36470 36470 064 0975 0627
13020771 MULTIPLE VEIN SAME LEG-HOSP. 342.00 06/30/10 36471 36471 36471 064 0360 0627
13020772 MULTIPLE VEIN,SAME LEG-M.D. 212.00 $ 06/30/09 36471 36471 36471 064 0975 0627
13020773 ENDOVEN RADIO FREQ 1ST VN-HOSP 7748.00 07/01/10 36475 36475 36475 064 0360 0627
13020774 ENDOVEN RADIO FREQ 1ST VN-M.D. 838.00 $ 07/01/10 36475 36475 36475 064 0975 0627
13020775 ENDOVEN RADIO FREQ VN ADD-HOSP 4572.00 07/01/10 36476 36476 36476 064 0360 0627
13020776 ENDOVEN RADIO FREQ VN ADD-M.D. 413.00 $ 07/01/10 36476 36476 36476 064 0975 0627
13020777 ENDOVENOUS LASER 1ST VEIN-HOSP 4572.00 07/01/10 36478 36478 36478 064 0360 0627
13020778 ENDOVENOUS LASER 1ST VEIN-M.D. 833.00 $ 07/01/10 36478 36478 36478 064 0975 0627
13020779 ENDOVEN LASER VEIN ADDON-HOSP 4572.00 07/01/10 36479 36479 36479 064 0360 0627
13020780 ENDOVEN LASER VEIN ADDON-M.D. 408.00 $ 07/01/10 36479 36479 36479 064 0975 0627
13020791 LIGATION/BIOP TEMP ARTERY-HOSP 1207.00 06/30/10 37609 37609 37609 064 0360 0627
13020792 LIGATION/BIOP TEMP ARTERY-M.D. 421.00 $ 06/30/09 37609 37609 37609 064 0975 0627
13020795 US GUID NEEDLE PLACEMENT-HOSP 754.00 07/01/10 76942 76942 76942 064 0402 0627
13020796 US GUID NEEDLE PLACEMENT-M.D. 400.00 $ 07/01/10 76942 76942 76942 064 0972 0627
13020801 URINE DIPSTICK W/O MICRO 35.00 06/30/10 81002 81002 81002 064 0300 0627
13020805 BLOOD OCCULT DIAGNOSTIC 34.00 06/30/10 82270 82270 82270 064 0301 0627
13020821 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 064 0510 0627
13020825 THERA PROPH/DX INJ; SUBQ/IM 86.00 06/30/10 96372 96372 96372 064 0510 0627
13020831 THERAPEUTIC/DIAGNOSTIC INJ IV 236.00 06/30/10 96374 96374 96374 064 0510 0627
13029953 SIMPLE PROCEDURE / 1ST HR 235.00 06/30/10 064 0360 0627
13029954 COMPLEX PROCEDURE / 1ST HR 351.00 06/30/10 064 0360 0627
13029956 PROCEDRE RM/-1/2 HR(INC ADD'L) 81.00 06/30/10 064 0360 0627
13029957 LIG DIV &/OR EX RECURRENT-HOSP 1544.00 06/30/10 37785 37785 37785 064 0360 0627
13029958 LIG DIV &/OR EX RECURRENT-M.D. 567.00 $ 06/30/09 37785 37785 37785 064 0975 0627
13030042 POSTOP FOLLOW-UP VISIT-M.D. N/C 07/15/99 99024 99024 99024 064 0983 0611
13030521 DEBRIDE OF ECZE/INF SKIN-HOSP 106.00 06/30/10 11000 11000 11000 064 0360 0611
13030522 DEBRIDE OF ECZE/INF SKIN-M.D. 68.00 $ 06/30/09 11000 11000 11000 064 0975 0611
13030527 DEBRIDEMENT; SKIN, PT THK-HOSP 404.00 06/30/10 11040 11040 11040 064 0360 0611
13030528 DEBRIDEMENT;SKIN ,PT THICK M.D 59.00 $ 06/30/09 11040 11040 11040 064 0975 0611
13030861 BIOP ANORECTAL WALL ANAL-HOSP 1036.00 06/30/10 45100 45100 45100 064 0360 0611
13030862 BIOP ANORECTAL WALL ANAL-M.D. 568.00 $ 06/30/09 45100 45100 45100 064 0975 0611
13030867 PROCTOSIGMOIDOSCOPY; DIAG-HOSP 243.00 06/30/10 45300 45300 45300 064 0360 0611
13030868 PROCTOSIGMOIDOSCOPY; DIAG-M.D. 97.00 $ 06/30/09 45300 45300 45300 064 0975 0611
13030871 PROCTOSIGMOIDOSCOP W/BIOP-HOSP 638.00 06/30/10 45305 45305 45305 064 0360 0611
13030872 PROCTOSIGMOIDOSCOP W/BIOP-M.D. 154.00 $ 06/30/09 45305 45305 45305 064 0975 0611
13030879 SIGMOIDOSCOPY FLEX DIAG-HOSP 781.00 06/30/10 45330 45330 45330 064 0360 0611
13030880 SIGMOIDOSCOPY FLEX DIAG-M.D. 129.00 $ 06/30/09 45330 45330 45330 064 0975 0611
13030881 SIGMO W/BIOPSY & OR SPEC-HOSP 726.00 06/30/10 45331 45331 45331 064 0360 0611
13030882 SIGMO W/BIOPSY & OR SPEC-M.D. 156.00 $ 06/30/09 45331 45331 45331 064 0975 0611
13030913 I&D OF ISCHIORECT ABSCESS-HOSP 1157.00 06/30/10 46040 46040 46040 064 0360 0611
13030914 I&D OF ISCHIORECT ABSCESS-M.D. 780.00 $ 06/30/09 46040 46040 46040 064 0975 0611
13030915 I&D OF INTRAMURAL ABSCESS-HOSP 1390.00 06/30/10 46045 46045 46045 064 0360 0611
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 398
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13030916 I&D OF INTRAMURAL ABSCESS-M.D. 793.00 $ 06/30/09 46045 46045 46045 064 0975 0611
13030923 I&D PERINEAL ABSCESS-HOSP 556.00 06/30/10 46050 46050 46050 064 0360 0611
13030924 I&D PERINAL ABSCESS-M.D. 182.00 $ 06/30/09 46050 46050 46050 064 0975 0611
13030931 HEMORRHOIDEC BY SMPL LIG-HOSP 421.00 06/30/10 46221 46221 46221 064 0360 0611
13030932 HEMORRHOIDEC BY SMPL LIG-M.D. 354.00 $ 06/30/09 46221 46221 46221 064 0975 0611
13030943 FISTULOTOMY; SUBCUTANEOUS-HOSP 1654.00 06/30/10 46270 46270 46270 064 0360 0611
13030944 FISTULOTOMY; SUBCUTANEOUS-M.D. 705.00 $ 06/30/09 46270 46270 46270 064 0975 0611
13030949 ENUCLEAT/EXCIS EXT HEMORR-HOSP 456.00 06/30/10 46320 46320 46320 064 0360 0611
13030950 ENUCLEAT/EXCIS EXT HEMORR-M.D. 214.00 $ 06/30/09 46320 46320 46320 064 0975 0611
13030951 INJECTION SCLEROS SOLUTN-HOSP 98.00 06/30/10 46500 46500 46500 064 0360 0611
13030952 INJECTION SCLEROS SOLUTN-M.D. 240.00 $ 06/30/09 46500 46500 46500 064 0975 0611
13030953 ANOSCOPY DIAGNOSTIC-HOSP 109.00 06/30/10 46600 46600 46600 064 0360 0611
13030954 ANOSCOPY DIAGNOSTIC-M.D. 76.00 $ 06/30/09 46600 46600 46600 064 0975 0611
13030957 ANOSCOPY DIAG FOR BIOPSY-HOSP 182.00 06/30/10 46606 46606 46606 064 0360 0611
13030958 ANOSCOPY DIAG FOR BIOPSY-M.D. 145.00 $ 06/30/09 46606 46606 46606 064 0975 0611
13030965 RPR ANAL FIST W/FIBR GLUE-HOSP 628.00 06/30/10 46706 46706 46706 064 0360 0611
13030966 RPR ANAL FIST W/FBR GLUE MD 331.00 $ 06/30/09 46706 46706 46706 064 0975 0611
13030975 DESTRUCT OF LESIONS, ANUS-HOSP 137.00 06/30/10 46900 46900 46900 064 0360 0611
13030976 DESTRUCT OF LESIONS, ANUS-M.D 269.00 $ 06/30/09 46900 46900 46900 064 0975 0611
13030981 DESTRUCT OF LESIONS EXCIS-HOSP 641.00 06/30/10 46922 46922 46922 064 0360 0611
13030982 DESTRUCT OF LESIONS EXCIS-M.D. 262.00 $ 06/30/09 46922 46922 46922 064 0975 0611
13030990 EMG STDY ANAL/URETH SPHNC-HOSP 204.00 06/30/10 51784 51784 51784 064 0490 0611
13030991 EMG STDY ANAL/URETH SPHNC-M.D. 174.00 $ 06/01/09 51784 51784 51784 064 0960 0611
13031001 INJECT TREATMENT OF NERVE-HOSP 355.00 06/30/10 64640 64640 64640 064 0360 0611
13031002 INJECT TREATMENT OF NERVE-M.D. 365.00 $ 06/30/09 64640 64640 64640 064 0975 0611
13031200 BOTOX TYPE A-100 UNITS/VIAL 824.00 06/30/10 J0585 064 0636 0611
13031651 ECHO TRANSRECTAL ULTRASND-HOSP 590.00 06/30/10 76872 76872 76872 064 0402 0611
13031652 ECHO TRANSRECTAL ULTRASND-M.D. 78.00 $ 06/30/09 76872 7687226 76872 064 0972 0611
13031680 URINE DIPSTICK W/O MICRO 35.00 06/30/10 81002 81002 81002 064 0300 0611
13031685 THERAPEU PROPH/DX INJ; SUBQ/IM 86.00 06/30/10 96372 96372 96372 064 0510 0611
13031693 BLOOD OCCT. FECAL SCREEN 34.00 06/30/10 82270 82270 82270 064 0301 0611
13031711 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 064 0510 0611
13031715 THERAPEUTIC INJ, IV 236.00 06/30/10 96374 96374 96374 064 0510 0611
13031718 ANAL PAP SMEAR 38.00 06/30/10 88161 88161 88161 064 0311 0611
13031730 RECT SENS,TONE/COMPL TEST-HOSP 365.00 06/30/10 91120 91120 91120 064 0750 0611
13031731 RECT SENS,TONE/COMPL TEST-M.D. 106.00 $ 06/01/09 91120 91120 91120 064 0960 0611
13031736 ANORECTAL MANOMETRY-HOSP 826.00 06/30/10 91122 91122 91122 064 0750 0611
13031737 ANORECTAL MANOMETRY-M.D. 197.00 $ 06/30/10 91122 91122 91122 064 0960 0611
13040042 POSTOPERATIVE FOLLOW-UP VISIT N/C 06/30/10 99024 99024 99024 064 0510 0628
13040100 APPL SKN GRFT-25SQ CM-HOSP. 424.00 06/30/10 15340 15340 15340 064 0360 0628
13040101 APPL SKN GRFT-25SQ CM-M.D. 543.00 $ 06/30/09 15340 15340 15340 064 0975 0628
13040102 APPL SK GFT-EA ADD25SQ CM-HOSP 617.00 06/30/10 15341 15341 15341 064 0360 0628
13040103 APP SK GFT-EA AD 25 SQ CM-M.D. 333.00 06/30/09 15341 15341 15341 064 0975 9999
13040105 APLIGRAF PER SQ CENTIMETER 51.00 06/30/10 Q4101 Q4101 Q4101 064 0636 0628
13040503 I & D ABSCESS; SIMPLE - HOSP 164.00 06/30/10 10060 10060 10060 064 0360 0628
13040504 I & D ABSCESS; SIMPLE - M.D. 186.00 $ 06/30/09 10060 10060 10060 064 0975 0628
13040511 INCIS/REMOV FOR BODY SIMP-HOSP 193.00 06/30/10 10120 10120 10120 064 0360 0628
13040512 INCIS/REMOV FOR/BODY SIMP-M.D. 182.00 $ 06/30/09 10120 10120 10120 064 0975 0628
13040517 PUNC ASPIR ABS HEMA/CYST -HOSP 100.00 06/30/10 10160 10160 10160 064 0360 0628
13040518 PUNC ASPIR ABS HEMA/CYST -M.D. 193.00 $ 06/30/09 10160 10160 10160 064 0975 0628
13040525 DEBRIDE SKIN PART THICK - HOSP 147.00 06/30/10 11040 11040 11040 064 0360 0628
13040526 DEBRIDE SKIN PART THICK - M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0628
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 399
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13040527 DEBRIDE SKIN FULL THICK-HOSP 301.00 06/30/10 11041 11041 11041 064 0360 0628
13040528 DEBRIDE SKIN FULL THICK-M.D. 76.00 $ 06/30/09 11041 11041 11041 064 0975 0628
13040529 DEBRIDE SKIN SUBCUT TISS-HOSP 571.00 06/30/10 11042 11042 11042 064 0360 0628
13040530 DEBRIDE SKIN SUBCUT TISS-M.D. 101.00 $ 06/30/09 11042 11042 11042 064 0975 0628
13040531 DEBRIDE SKIN SUB TIS/MUS-HOSP 1224.00 06/30/10 11043 11043 11043 064 0360 0628
13040532 DEBRIDE SKIN SUB TIS/MUS-M.D. 471.00 $ 06/30/09 11043 11043 11043 064 0975 0628
13040535 CURET/CAUT BEN SKIN LES 1-HOSP 88.00 06/30/10 11055 11055 11055 064 0360 0628
13040536 CURET/CAUT BEN SKIN LES 1-M.D. 49.00 $ 06/30/09 11055 11055 11055 064 0975 0628
13040541 BIOPSY NAIL BED-HOSP 295.00 06/30/10 11755 11755 11755 064 0360 0628
13040542 BIOPSY NAIL BED-M.D. 176.00 $ 06/30/09 11755 11755 11755 064 0975 0628
13040545 REMOVE SKIN TAGS; <15-HOSP 172.00 06/30/10 11200 11200 11200 064 0360 0628
13040546 REMOVE SKIN TAGS; <15-M.D. 132.00 $ 06/30/09 11200 11200 11200 064 0975 0628
13040549 SHAVE LESION <.5CM-HOSP 173.00 06/30/10 11300 11300 11300 064 0360 0628
13040550 SHAVE LESION <.5CM- M.D. 59.00 $ 06/30/09 11300 11300 11300 064 0975 0628
13040551 SHAVE LESION .6-1CM-HOSP 190.00 06/30/10 11301 11301 11301 064 0360 0628
13040552 SHAVE LESION .6-1CM-M.D. 100.00 $ 06/30/09 11301 11301 11301 064 0975 0628
13040557 SHAVE LESION <.5CM-HOSP 167.00 06/30/10 11305 11305 11305 064 0360 0628
13040558 SHAVE LESION <.5CM-M.D. 77.00 $ 06/30/09 11305 11305 11305 064 0975 0628
13040559 SHAVE LESION <.6-1CM-HOSP 197.00 06/30/10 11306 11306 11306 064 0360 0628
13040560 SHAVE LESION <.6-1CM-M.D. 114.00 $ 06/30/09 11306 11306 11306 064 0975 0628
13040565 SHAVE LESION <.5CM-HOSP 207.00 06/30/10 11310 11310 11310 064 0360 0628
13040566 SHAVE LESION <.5CM-M.D. 85.00 $ 06/30/09 11310 11310 11310 064 0975 0628
13040567 SHAVE LESION .6-1CM-HOSP 233.00 06/30/10 11311 11311 11311 064 0360 0628
13040568 SHAVE LESION .6-1CM-M.D. 124.00 $ 06/30/09 11311 11311 11311 064 0975 0628
13040573 EXCIS BEN LES <.5CM-HOSP 254.00 06/30/10 11400 11400 11400 064 0360 0628
13040574 EXCIS BEN LES <.5CM-M.D. 145.00 $ 06/30/09 11400 11400 11400 064 0975 0628
13040575 EXCIS BEN LES .6-1CM-HOSP 299.00 06/30/10 11401 11401 11401 064 0360 0628
13040576 EXCIS BEN LES .6-1CM-M.D. 194.00 $ 06/30/09 11401 11401 11401 064 0975 0628
13040577 EXCIS BEN LES 1.1-2CM-HOSP 393.00 06/30/10 11402 11402 11402 064 0360 0628
13040578 EXCIS BEN LES 1.1-2CM-M.D. 217.00 $ 06/30/09 11402 11402 11402 064 0975 0628
13040579 EXCIS BEN LES 2.1-3CM-HOSP 516.00 06/30/10 11403 11403 11403 064 0360 0628
13040580 EXCIS BEN LES 2.1-3CM-M.D. 276.00 $ 06/30/09 11403 11403 11403 064 0975 0628
13040581 EXCIS BENIGN LES 3.1-4CM-HOSP 762.00 06/30/10 11404 11404 11404 064 0360 0628
13040582 EXCIS BENIGN LES 3.1-4CM-M.D. 309.00 $ 06/30/09 11404 11404 11404 064 0975 0628
13040585 EXCIS BEN LES <.5CM-HOSP 287.00 06/30/10 11420 11420 11420 064 0360 0628
13040586 EXCIS BEN LES <.5CM-M.D. 159.00 $ 06/30/09 11420 11420 11420 064 0975 0628
13040587 EXCIS BEN LES .6-1CM-HOSP 494.00 06/30/10 11421 11421 11421 064 0360 0628
13040588 EXCIS BEN LES .6-1CM-M.D. 215.00 $ 06/30/09 11421 11421 11421 064 0975 0628
13040589 EXCIS BEN LES 1.1-2CM-HOSP 488.00 06/30/10 11422 11422 11422 064 0360 0628
13040590 EXCIS BEN LES 1.1-2CM-M.D. 260.00 $ 06/30/09 11422 11422 11422 064 0975 0628
13040591 EXCIS BEN LES 2.1-3CM-HOSP 893.00 06/30/10 11423 11423 11423 064 0360 0628
13040592 EXCIS BEN LES 2.1-3CM-M.D. 304.00 $ 06/30/09 11423 11423 11423 064 0975 0628
13040595 REPAIR NAIL BED-HOSP 661.00 06/30/10 11760 11760 11760 064 0360 0628
13040596 REPAIR NAIL BED-M.D. 266.00 $ 06/30/09 11760 11760 11760 064 0975 0628
13040597 EXCIS BEN LES <.5CM-HOSP 344.00 06/30/10 11440 11440 11440 064 0360 0628
13040598 EXCIS BEN LES <.5CM-M.D. 189.00 $ 06/30/09 11440 11440 11440 064 0975 0628
13040599 EXCIS BEN LES .6-1CM-HOSP 857.00 06/30/10 11441 11441 11441 064 0360 0628
13040600 EXCIS BEN LES .6-1CM-M.D. 250.00 $ 06/30/09 11441 11441 11441 064 0975 0628
13040601 EXCIS BEN LES 1.1-2CM-HOSP 566.00 06/30/10 11442 11442 11442 064 0360 0628
13040602 EXCIS BEN LES 1.1-2CM-M.D. 280.00 $ 06/30/09 11442 11442 11442 064 0975 0628
13040603 EXCIS BEN LES 2.1-3CM-HOSP 758.00 06/30/10 11443 11443 11443 064 0360 0628
13040604 EXCIS BEN LES 2.1-3CM-M.D. 346.00 $ 06/30/09 11443 11443 11443 064 0975 0628
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 400
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13040615 DERMABRASION SUPERFL ANY HOSP 299.00 06/30/10 15783 15783 15783 064 0360 0628
13040616 DERMABRASION SUPERFL ANY MD 719.00 $ 06/30/09 15783 15783 15783 064 0975 0628
13040621 EXCIS MALIG LES <.5CM-HOSP 455.00 06/30/10 11600 11600 11600 064 0360 0628
13040622 EXCIS MALIG LES <.5CM-M.D. 217.00 $ 06/30/09 11600 11600 11600 064 0975 0628
13040623 EXCIS MALIG LES .6-1CM-HOSP 398.00 06/30/10 11601 11601 11601 064 0360 0628
13040624 EXCIS MALIG LES .6-1CM-M.D. 281.00 $ 06/30/09 11601 11601 11601 064 0975 0628
13040625 EXCIS MALIG LES 1.1 - 2CM-HOSP 663.00 06/30/10 11602 11602 11602 064 0360 0628
13040626 EXCIS MALIG LES 1.1 - 2CM-M.D. 308.00 $ 06/30/09 11602 11602 11602 064 0975 0628
13040629 EXCIS MALIG LES 2.1 - 3CM-HOSP 734.00 06/30/10 11603 11603 11603 064 0360 0628
13040630 EXCIS MALIG LES 2.1 - 3CM-M.D. 367.00 $ 06/30/09 11603 11603 11603 064 0975 0628
13040631 EXCIS MALIG LES 3.1-4CM-HOSP 1004.00 06/30/10 11604 11604 11604 064 0360 0628
13040632 EXCIS MALIG LESION 3.1-4CM-M.D 404.00 $ 06/30/09 11604 11604 11604 064 0975 0628
13040633 EXCIS MALIG LES > 4.0CM-HOSP 3348.00 06/30/10 11606 11606 11606 064 0360 0628
13040634 EXCIS MALIG LES > 4.0CM-M.D. 602.00 $ 06/30/09 11606 11606 11606 064 0975 0628
13040635 EXCIS MALIG LES <.5CM-HOSP 308.00 06/30/10 11620 11620 11620 064 0360 0628
13040636 EXCIS MALIG LES <.5CM-M.D. 220.00 $ 06/30/09 11620 11620 11620 064 0975 0628
13040637 EXCIS MALIG LES .6 - 1CM-HOSP 675.00 06/30/10 11621 11621 11621 064 0360 0628
13040638 EXCIS MALIG LES .6 - 1CM-M.D. 284.00 $ 06/30/09 11621 11621 11621 064 0975 0628
13040639 EXCIS MALIG LES 1.1 - 2CM-HOSP 764.00 06/30/10 11622 11622 11622 064 0360 0628
13040640 EXCIS MALIG LES 1.1 - 2CM-M.D. 327.00 $ 06/30/09 11622 11622 11622 064 0975 0628
13040641 EXCIS MALIG LES 2.1 - 3CM-HOSP 936.00 06/30/10 11623 11623 11623 064 0360 0628
13040642 EXCIS MALIG LES 2.1 - 3CM-M.D. 405.00 $ 06/30/09 11623 11623 11623 064 0975 0628
13040647 EXCIS MALIG LES <.5CM-HOSP 688.00 06/30/10 11640 11640 11640 064 0360 0628
13040648 EXCIS MALIG LES <.5CM-M.D. 233.00 $ 06/30/09 11640 11640 11640 064 0975 0628
13040649 EXCIS MALIG LES .6 - 1CM-HOSP 786.00 06/30/10 11641 11641 11641 064 0360 0628
13040650 EXCIS MALIG LES .6 - 1CM-M.D. 306.00 $ 06/30/09 11641 11641 11641 064 0975 0628
13040651 EXCIS MALIG LES 1.1 - 2CM-HOSP 1042.00 06/30/10 11642 11642 11642 064 0360 0628
13040652 EXCIS MALIG LES 1.1 -2CM-M.D. 361.00 $ 06/30/09 11642 11642 11642 064 0975 0628
13040660 RMVL TISS EXPAND W/O PROS-HOSP 3155.00 06/30/10 11971 11971 11971 064 0360 0628
13040661 RMVL TISS EXPAND W/O PROS-M.D. 588.00 $ 06/30/09 11971 11971 11971 064 0975 0628
13040697 TATTOO 6 SQ CM OR LESS-HOSP 1109.00 06/30/10 11920 11920 11920 064 0360 0628
13040698 TATTOO 6 SQ CM OR LESS-M.D. 240.00 $ 06/30/09 11920 11920 11920 064 0975 0628
13040699 TATTOO 6.1-20 SQ CM-HOSP 2224.00 06/30/10 11921 11921 11921 064 0360 0628
13040700 TATTOO 6.1-20 SQ CM-M.D. 283.00 $ 06/30/09 11921 11921 11921 064 0975 0628
13040701 TATTOO EACH ADDL 20 SQ CM-HOSP 1130.00 06/30/10 11922 11922 11922 064 0360 0628
13040702 TATTOO EACH ADDL 20 SQ CM-M.D. 64.00 $ 06/30/09 11922 11922 11922 064 0975 0628
13040703 COLLAGEN INJ 1CC OR LESS-HOSP 265.00 06/30/10 11950 11950 11950 064 0360 0628
13040704 COLLAGEN INJ 1CC OR LESS-M.D. 102.00 $ 06/30/09 11950 11950 11950 064 0975 0628
13040705 COLLAGEN INJ 1.1 - 5.OCC-HOSP 335.00 06/30/10 11951 11951 11951 064 0360 0628
13040706 COLLAGEN INJ 1.1 - 5.OCC-M.D. 144.00 $ 06/30/09 11951 11951 11951 064 0975 0628
13040707 COLLAGEN INJ 5.1 - 10.0CC-HOSP 419.00 06/30/10 11952 11952 11952 064 0360 0628
13040708 COLLAGEN INJ 5.1 - 10.0CC-M.D. 208.00 $ 06/30/09 11952 11952 11952 064 0975 0628
13040709 COLLAGEN INJ OVER 10.0CC-HOSP 494.00 06/30/10 11954 11954 11954 064 0360 0628
13040710 COLLAGEN INJ OVER 10.0CC-M.D. 240.00 $ 06/30/09 11954 11954 11954 064 0975 0628
13040711 KENALOG INJ 1-7 LESIONS-HOSP 90.00 06/30/10 11900 11900 11900 064 0360 0628
13040712 KENALOG INJ 1-7 LESIONS-M.D. 61.00 $ 06/30/09 11900 11900 11900 064 0975 0628
13040713 KENALOG INJ> 7 LESIONS-HOSP 135.00 06/30/10 11901 11901 11901 064 0360 0628
13040714 KENALOG INJ >7 LESIONS-M.D. 95.00 $ 06/30/09 11901 11901 11901 064 0975 0628
13040715 INIT TRTMNT,1ST DEG BURN-HOSP 61.00 06/30/10 16000 16000 16000 064 0360 0628
13040716 INIT TRTMENT,1ST DEG BURN-M.D. 96.00 $ 06/30/09 16000 16000 16000 064 0975 0628
13040717 DRESS/DEBRIDEMENT-SMALL-HOSP 98.00 06/30/10 16020 16020 16020 064 0360 0628
13040718 DRESS/DEBRIDEMENT-SMALL-M.D. 114.00 $ 06/30/09 16020 16020 16020 064 0975 0628
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 401
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13040719 DRESS/DEBRIDEMENT-MED-HOSP 113.00 06/30/10 16025 16025 16025 064 0360 0628
13040720 DRESS/DEBRIDEMENT-MED.-M.D. 234.00 $ 06/30/09 16025 16025 16025 064 0975 0628
13040721 DRESS/DEBRIDEMENT-LARGE-HOSP 242.00 06/30/10 16030 16030 16030 064 0360 0628
13040722 DRESS/DEBRIDEMENT-LARGE-M.D.. 268.00 $ 06/30/09 16030 16030 16030 064 0975 0628
13040723 SIMP HAND REPAIR 2.5CM-HOSP 226.00 06/30/10 12001 12001 12001 064 0360 0628
13040724 SIMP HAND REPAIR 2.5CM-M.D. 206.00 $ 06/30/09 12001 12001 12001 064 0975 0628
13040725 SIMPLE HAND REP 2.6 - 7CM-HOSP 373.00 06/30/10 12002 12002 12002 064 0360 0628
13040726 SIMPLE HAND REP 2.6-7CM-M.D. 229.00 $ 06/30/09 12002 12002 12002 064 0975 0628
13040735 SPLIT EAR-LOBE REPAIR-HOSP 267.00 06/30/10 12011 12011 12011 064 0360 0628
13040736 SPLIT EAR-LOBE REPAIR-M.D. 213.00 $ 06/30/09 12011 12011 12011 064 0975 0628
13040751 RPR,WND-SC/TR/EX:2.5CM OR<HOSP 252.00 06/30/10 12031 12031 12031 064 0360 0628
13040752 RPR,WND-SC/TR/EX:2.5CM OR<M.D. 310.00 $ 06/30/09 12031 12031 12031 064 0975 0628
13040765 INTERMD HAND RPR 2.5CM OR-HOSP 319.00 06/30/10 12041 12041 12041 064 0360 0628
13040766 INTERMD HAND RPR 2.5CM OR-M.D. 332.00 $ 06/30/09 12041 12041 12041 064 0975 0628
13040767 INTERMD HND RPR 2.6-7.5CM-HOSP 295.00 06/30/10 12042 12042 12042 064 0360 0628
13040768 INTERMD HND RPR 2.6-7.5CM-M.D. 384.00 $ 06/30/09 12042 12042 12042 064 0975 0628
13040769 LAY CLOS,FACE 2.5 CM OR <-HOSP 301.00 06/30/10 12051 12051 12051 064 0360 0628
13040770 LAY CLOS,FACE 2.5 CM OR <-M.D. 355.00 $ 06/30/09 12051 12051 12051 064 0975 0628
13040771 WND PREP,CH/INF,F/N/HF/G-HOSP 568.00 06/30/10 15004 15004 15004 064 0360 0628
13040772 WND PREP,CH/INF,F/N/HF/G-M.D. 592.00 $ 06/30/09 15004 15004 15004 064 0975 0628
13040773 OASIS SKIN GRAFT<100SQ CM-HOSP 1166.00 06/30/10 15430 15430 15430 064 0360 0628
13040774 OASIS SKIN GRAFT<100SQ CM-M.D. 997.00 $ 06/30/10 15430 15430 15430 064 0975 0628
13040777 OASIS GRAFT EA ADD 100 CM-HOSP 1166.00 06/30/10 15431 15431 15431 064 0360 0628
13040778 OASIS GRAFT EA ADD 100 CM-M.D. 440.00 $ 08/10/08 15431 15431 15431 064 0975 0628
13040798 TISS TRNSFR-CHKS-10 CM OR<HOSP 2979.00 06/30/10 14040 14040 14040 064 0360 0628
13040799 TISS TRNSFR-CHKS-10 CM OR<M.D. 1270.00 $ 06/30/09 14040 14040 14040 064 0975 0628
13040801 TIS TRAN-NK 10.1-30 SQCM-HOSP 2830.00 06/30/10 14041 14041 14041 064 0360 0628
13040802 TIS TRAN-NK 10.1-30 SQCM-M.D. 1564.00 $ 06/30/09 14041 14041 14041 064 0975 0628
13040819 TIS TRAN-LIP 10SQ CM OR <-HOSP 2715.00 06/30/10 14060 14060 14060 064 0360 0628
13040820 TIS TRAN-LIP 10SQ CM OR <-M.D. 1342.00 $ 06/30/09 14060 14060 14060 064 0975 0628
13040821 TIS TRAN-EYE 10.1-30SQ CM-HOSP 2813.00 06/30/10 14061 14061 14061 064 0360 0628
13040822 TIS TRAN-EYE 10.1-30SQ CM-M.D. 1667.00 $ 06/30/09 14061 14061 14061 064 0975 0628
13040881 MASTOPEXY-HOSP 4978.00 06/30/10 19316 19316 19316 064 0360 0628
13040882 MASTOPEXY-M.D. 1597.00 $ 06/30/09 19316 19316 19316 064 0975 0628
13040891 NIPPLE/AEROLA RECONSTRUCT-HOSP 4126.00 06/30/10 19350 19350 19350 064 0360 0628
13040892 NIPPLE/AEROLA RECONSTRUCT-M.D. 1392.00 $ 11/01/09 19350 19350 19350 064 0975 0628
13040901 INCIS SFT TISS ABSC,SUPER-HOSP 138.00 06/30/10 20000 20000 20000 064 0360 0628
13040902 INCIS SFT TISS ABSC,SUPER-M.D. 316.00 $ 06/30/09 20000 20000 20000 064 0975 0628
13040911 REM FR BDY-MUS/TEN SHEATH-HOSP 322.00 06/30/10 20520 20520 20520 064 0360 0628
13040912 REM FR BDY-MUS/TEN SHEATH-M.D. 287.00 $ 06/30/09 20520 20520 20520 064 0975 0628
13040919 RMVL IMPL/DEEP(WRE,PN,SCRW)HSP 1614.00 06/30/10 20680 20680 20680 064 0360 0628
13040920 RMVL IMPL/DEEP(WRE,PN,SCRW)-MD 829.00 $ 06/30/10 20680 20680 20680 064 0975 0628
13041051 APPLIC LONG ARM CAST-HOSP 276.00 06/30/10 29065 29065 29065 064 0360 0628
13041052 APPLIC LONG ARM CAST-M.D. 141.00 $ 06/30/09 29065 29065 29065 064 0975 0628
13041053 APPLIC SHORT ARM CAST-HOSP 233.00 06/30/10 29075 29075 29075 064 0360 0628
13041054 APPLIC SHORT ARM CAST-M.D. 127.00 $ 06/30/09 29075 29075 29075 064 0975 0628
13041055 APPLIC HAND/LOWER FOREARM-HOSP 180.00 06/30/10 29085 29085 29085 064 0360 0628
13041056 APPLIC HAND/LOWER FOREARM-M.D. 137.00 $ 06/30/09 29085 29085 29085 064 0975 0628
13041057 APPLIC LONG ARM SPLINT-HOSP 151.00 06/30/10 29105 29105 29105 064 0360 0628
13041058 APPLIC LONG ARM SPLINT-M.D. 122.00 $ 06/30/09 29105 29105 29105 064 0975 0628
13041059 APPLIC SHORT ARM SPLINT-HOSP 129.00 06/30/10 29125 29125 29125 064 0360 0628
13041060 APPLIC SHORT ARM SPLINT-M.D. 86.00 $ 06/30/09 29125 29125 29125 064 0975 0628
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 402
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13041061 APPLIC STATIC FING SPLINT-HOSP 73.00 06/30/10 29130 29130 29130 064 0360 0628
13041062 APPLIC STATIC FING SPLINT-M.D. 60.00 $ 06/30/09 29130 29130 29130 064 0975 0628
13041081 UNNA BOOT STRAPPING 216.00 06/30/10 29580 29580 29580 064 0360 0628
13041082 UNNA BOOT STRAPPING-M.D. 77.00 $ 06/30/09 29580 29580 29580 064 0975 0628
13041091 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 064 0510 0628
13041093 THERAPEUTIC/DIAGNOSTIC INJ, IV 236.00 06/30/10 96374 96374 96374 064 0510 0628
13041100 THERAPEUTIC PROPH/DX INJ; SUBQ 86.00 06/30/10 96372 96372 96372 064 0510 0628
13041110 RMVL/BIVALVING GAUNTLET-HOSP 106.00 06/30/10 29700 29700 29700 064 0360 0628
13041111 RMVL/BIVALVING GAUNTLET-M.D. 74.00 $ 06/30/09 29700 29700 29700 064 0975 0628
13041120 FULL ARM/LEG CAST-REMVL-HOSP 113.00 06/30/10 29705 29705 29705 064 0360 0628
13041121 FULL ARM/LEG CAST-REMVL-M.D. 104.00 $ 06/30/09 29705 29705 29705 064 0975 0628
13041651 SING/MLT INJ SPIDER VEINS-HOSP 456.00 06/30/10 36468 36468 36468 064 0360 0628
13041652 SING/MLT INJ SPIDER VEINS-M.D. 614.00 $ 08/10/08 36468 36468 36468 064 0975 0628
13041655 SINGLE VEIN-HOSP 159.00 06/30/10 36470 36470 36470 064 0360 0628
13041656 SINGLE VEIN-M.D 150.00 $ 06/30/09 36470 36470 36470 064 0975 0628
13041659 MULTIPLE VEIN SAME LEG-HOSP. 342.00 06/30/10 36471 36471 36471 064 0360 0628
13041660 MULTIPLE VEIN,SAME LEG-M.D 212.00 $ 06/30/09 36471 36471 36471 064 0982 0628
13049900 KENALOG, PER 10 MG 35.00 06/30/10 J3301 J3301 J3301 064 0636 0628
13049910 SPLINT 18.00 06/30/10 064 0270 0628
13049915 PLASTER CASTER 27.00 06/30/10 A4580 A4580 A4580 064 0274 0628
13049920 CAST SUPPLY (FIBERGLASS) 48.00 06/30/10 064 0270 0628
13049950 LIPOSUCTION/ FIRST HR 360.00 06/30/10 064 0360 0628
13049951 LASER-SIMPLE/ FIRST HOUR 181.00 06/30/10 064 0360 0628
13049952 LASER-COMPLEX/ FIRST HOUR 360.00 06/30/10 064 0360 0628
13049953 PROCEDURE-SIMPLE- 1ST HOUR 181.00 06/30/10 064 0360 0628
13049954 PROCEDURE-COMPLEX -1ST HOUR 360.00 06/30/10 064 0360 0628
13049956 PROCEDURE ROOM ADD'L 1/2 HOUR 61.00 06/30/10 064 0360 0628
13049959 PLASTIC SURGERY PROCEDURE: N/C 06/30/10 064 0360 0628
13049990 SURG PROCEDRE-SPECIAL SUPPLIES EXTERNAL 12/09/96 064 0270 0628
13051505 CYSTOMETROGRAM-SIMPLE-HOSP. 399.00 06/30/10 51725 51725 51725 064 0360 0624
13051506 CYSTOMETROGRAM-SIMPLE M.D. 173.00 $ 08/01/09 5172526 5172526 5172526 064 0982 0624
13051775 URINE DIPSTICK W/ MICRO 38.00 06/30/10 81000 81000 81000 064 0300 0624
13060041 POST-OP FOLLOW-UP -M.D. N/C 06/30/10 99024 99024 99024 064 0510 0623
13060517 DRAINAGE OF WOUND - HOSP 1045.00 06/30/10 10180 10180 10180 064 0360 0623
13060518 DRAINAGE OF WOUND - M.D. 362.00 $ 06/30/09 10180 10180 10180 064 0975 0623
13060525 SKIN PARTIAL THICKNESS - HOSP 164.00 06/30/10 11040 11040 11040 064 0360 0623
13060526 SKIN PARTIAL THICKNESS - M.D. 59.00 $ 06/30/09 11040 11040 11040 064 0975 0623
13060527 DEBRDEMNT,SKIN,FULL THICK-HOSP 301.00 06/30/10 11041 11041 11041 064 0360 0623
13060528 DEBRDEMNT,SKIN FULL THICK-M.D. 76.00 $ 06/30/09 11041 11041 11041 064 0975 0623
13060529 DEBRIDEMENT OF WOUND-HOSP 571.00 06/30/10 11042 11042 11042 064 0360 0623
13060530 DEBRIDEMENT OF WOUND-M.D. 101.00 $ 06/30/09 11042 11042 11042 064 0975 0623
13060531 SKIN & SUB Q TISS/MUSCLE-HOSP 1224.00 06/30/10 11043 11043 11043 064 0360 0623
13060532 SKIN & SUB Q TISS/MUSCLE-M.D. 471.00 $ 06/30/09 11043 11043 11043 064 0975 0623
13060533 SKIN & SUB Q TIS/MUS/BONE-HOSP 1607.00 06/30/10 11044 11044 11044 064 0360 0623
13060534 SKIN & SUB Q TIS/MUS/BONE-M.D. 648.00 $ 06/30/09 11044 11044 11044 064 0975 0623
13060541 RMVL CENTRAL VENOUS CATH-HOSP 726.00 04/01/10 36589 36589 36589 064 0360 0623
13060542 RMVL CENTRAL VENOUS CATH-M.D. 303.00 $ 04/01/10 36589 36589 36589 064 0975 0623
13060775 THORACENTESIS - HOSP 373.00 06/30/10 32421 32421 32421 064 0360 0623
13060776 THORACENTESIS - M.D. 164.00 $ 06/30/09 32421 32421 32421 064 0975 0623
13060779 TUBE THORACOSTOMY - HOSP 1309.00 06/30/10 32551 32551 32551 064 0360 0623
13060780 TUBE THORACOSTOMY - M.D. 391.00 $ 06/30/09 32551 32551 32551 064 0975 0623
13060783 URINE DIPSTICK W/O MICOSCOPY 35.00 06/30/10 81002 81002 81002 064 0300 0623
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 403
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13060785 BLOOD OCCT. FECAL SCREEN 34.00 06/30/10 82270 82270 82270 064 0301 0623
13060794 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 064 0510 0623
13060797 THERAPEUTIC INJECTION,IV 236.00 06/30/10 96374 96374 96374 064 0510 0623
13060800 THERA PROPH/DX INJ; SUBQ/IM 86.00 06/30/10 96372 96372 96372 064 0510 0623
13060803 THERA PROPH/DX INJ; SUBQ/IM 86.00 06/30/10 96372 96372 96372 064 0510 0623
13301060 PH MONITORING-CATH BASED-HOSP 699.00 06/30/10 91034 91034 91034 064 0750 0648
13301061 PH MONITORING-CATH BASED-M.D. 112.00 $ 06/30/09 91034 91034 91034 064 0960 0648
17121065 LIGATION/BIOP TEMP ARTERY-HOSP 1213.00 06/30/10 37609 37609 37609 064 0360 0582
17121066 LIGATION/BIOP TEMP ARTERY-M.D. 421.00 $ 06/30/09 37609 37609 37609 064 0975 0582
17130554 LIGATION/BIOP TEMP ARTERY 1213.00 06/30/10 37609 37609 37609 064 0360 0583
17200821 EXCIS BEN LES .6-1CM -HOSP 857.00 06/30/10 11441 11441 11441 064 0360 0641
17200822 EXCIS BEN LES .6-1CM-M.D. 250.00 $ 06/30/09 11441 11441 11441 064 0975 0641
19920100 POST OP FOLLOW-UP VISIT-M.D. N/C 01/01/06 99024 99024 99024 064 0983 0599
12400042 POST OP FOLLOW-UP VISIT-M.D. N/C 01/17/94 99024 99024 99024 065 0983 0620
12400206 THERAPEUTIC INJ IM OR SUB 86.00 06/30/10 96372 96372 96372 065 0940 0620
12400210 THERA PROPH/DX INJ; SUBQ/IM 86.00 06/30/10 96372 96372 96372 065 0510 0620
12400215 INJ IM ANTIBIOTIC 110.00 06/30/10 96372 96372 96372 065 0510 0620
12400356 CHEMOTHERAPY-IV PUSH 387.00 06/30/10 96409 96409 96409 065 0510 0620
12400501 DEBRIDEMNT;SKIN PAR THICK-HOSP 404.00 06/30/10 11040 11040 11040 065 0360 0620
12400502 DEBRIDEMNT;SKIN PAR THICK M.D. 59.00 $ 06/30/09 11040 11040 11040 065 0975 0620
12400509 FRENOPLASTY - HOSP 1114.00 06/30/10 41520 41520 41520 065 0360 0620
12400510 FRENOPLASTY - M.D. 503.00 $ 06/30/09 41520 41520 41520 065 0975 0620
12400515 INSRT NON-INDWL BLAD CATH-HOSP 86.00 06/30/10 51701 51701 51701 065 0510 0620
12400516 INSRT NON-INDWLL BLAD CATH-M.D 61.00 $ 06/30/09 51701 51701 51701 065 0983 0620
12400517 INST TEMP BLAD CATH-SIMP-HOSP 98.00 06/30/10 51702 51702 51702 065 0510 0620
12400518 INSRT TMP BLD CATH;SIMP-M.D. 68.00 $ 06/30/09 51702 51702 51702 065 0983 0620
12400519 INSRT TMP BLAD CATH;COMP-HOSP 144.00 06/30/10 51703 51703 51703 065 0510 0620
12400520 INSRT TMP BLAD CATH;COMP-M.D. 183.00 $ 06/30/09 51703 51703 51703 065 0983 0620
12400523 CATH,URETHA - SIMPLE-HOSP. 86.00 06/30/10 51701 51701 51701 065 0510 0620
12400524 CATH,URETHA - SIMPLE-M.D. 105.00 06/30/09 51701 51701 51701 065 0983 0620
12400530 BLADDER INSTILLATION-HOSP. 183.00 06/30/10 51720 51720 51720 065 0360 0620
12400531 BLADDER INSTILLATION-M.D. 190.00 $ 06/30/09 51720 51720 51720 065 0975 0620
12400532 CYSTOMETROGRAM, SIMPLE-HOSP 399.00 06/30/10 51725 51725 51725 065 0360 0620
12400533 CYSTOMETROGRAM-SIMPLE-M.D. 173.00 $ 06/30/09 5172526 5172526 5172526 065 0982 0620
12400534 CYSTOMETROGRAM, COMPLEX-HOSP 524.00 06/30/10 51726 51726 51726 065 0920 0620
12400535 CYSTOMETROGRAM, COMPLEX-M.D. 196.00 $ 06/30/09 5172626 5172626 5172626 065 0982 0620
12400540 UROFLOWMETRY, COMPLEX-HOSP 187.00 06/30/10 51741 51741 51741 065 0920 0620
12400541 UROFLOWMETRY, COMPLEX-M.D. 132.00 $ 06/30/09 5174126 5174126 5174126 065 0982 0620
12400543 EMG ANAL/URETHRL SPHINCTR-HOSP 326.00 06/30/10 51785 51785 51785 065 0360 0620
12400544 EMG ANAL/URETHRL SPHINCTR-M.D. 174.00 $ 06/30/09 5178526 5178526 5178526 065 0982 0620
12400547 EMG ANAL/URETH SPHIN-HOSP ONLY 326.00 06/30/10 51785 51785 51785 065 0490 0620
12400560 CYSTOSCOPY-HOSP 995.00 06/30/10 52000 52000 52000 065 0360 0620
12400561 CYSTOSCOPY - M.D. 280.00 $ 06/30/09 52000 52000 52000 065 0975 0620
12400568 CYSTOSCOPY,BLADDER BIOPSY-HOSP 1158.00 06/30/10 52204 52204 52204 065 0360 0620
12400569 CYSTOSCOPY, BLADDER BIOPSY-M.D 318.00 $ 06/30/09 52204 52204 52204 065 0975 0620
12400572 CYSTO W/DILATION-HOSP 2385.00 06/30/10 52281 52281 52281 065 0360 0620
12400573 CYSTO W/DILATION-M.D. 351.00 $ 06/30/09 52281 52281 52281 065 0975 0620
12400582 CYSTOSCPY REMVE URE/STENT-HOSP 1175.00 06/30/10 52310 52310 52310 065 0360 0620
12400583 CYSTSCPY,REMV OF URE STENT-M.D 345.00 $ 06/30/09 52310 52310 52310 065 0975 0620
12400601 DILATION URETH STRICT S/D-HOSP 127.00 06/30/10 53600 53600 53600 065 0360 0620
12400602 DILATION URETH STRICT S/D-M.D. 146.00 $ 06/30/09 53600 53600 53600 065 0975 0620
12400607 DILATION URETH STRICT F&F-HOSP 183.00 06/30/10 53620 53620 53620 065 0360 0620
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 404
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12400608 DILATION URETH STRICT F&F-M.D. 198.00 $ 06/30/09 53620 53620 53620 065 0975 0620
12400621 DILAT FEMALE URETH INIT-HOSP 150.00 06/30/10 53660 53660 53660 065 0360 0620
12400622 DILAT FEMALE URETH INIT-M.D. 93.00 $ 06/30/09 53660 53660 53660 065 0975 0620
12400649 FULG PENILE CONDYLOMA,EXT-HOSP 355.00 06/30/10 54055 54055 54055 065 0360 0620
12400650 FULG PENILE CONDYLOMA,EXT-M.D. 192.00 $ 06/30/09 54055 54055 54055 065 0975 0620
12400653 DEST LES,PENIS,SIMP:LASER-HOSP 3942.00 06/30/10 54057 54057 54057 065 0360 0620
12400654 DEST LES,PENIS,SIMP:LASER-M.D. 202.00 $ 06/30/09 54057 54057 54057 065 0975 0620
12400673 SNAP GAUGE TEST - HOSP 1398.00 06/30/10 54250 54250 54250 065 0920 0620
12400674 SNAP GAUGE TEST - M.D. 257.00 $ 06/30/09 54250 54250 5425026 065 0982 0620
12400684 VASECTOMY-HOSP 1255.00 06/30/10 55250 55250 55250 065 0360 0620
12400685 VASECTOMY- M.D. 506.00 $ 06/30/09 55250 55250 55250 065 0975 0620
12400690 BIOPSY PROSTA NEEDLE PNCH-HOSP 858.00 06/30/10 55700 55700 55700 065 0360 0620
12400691 BIOPSY PROSTA NEEDLE PUNCH-M.D 301.00 $ 06/30/09 55700 55700 55700 065 0975 0620
12400697 EEJ (ELECTROEJACULATION)-HOSP 451.00 06/30/10 55870 55870 55870 065 0360 0620
12400698 EEJ(ELECTROEJACULATION)-M.D. 323.00 $ 06/30/09 55870 55870 55870 065 0975 0620
12400705 PLACEMENT INTERTITIAL DEV-HOSP 783.00 06/30/10 55876 55876 55876 065 0360 0620
12400706 PLACEMENT INTERTITIAL DEV-M.D. 253.00 $ 06/30/09 55876 55876 55876 065 0975 0620
12400711 BLADDER SCAN-HOSP 115.00 06/30/10 51798 51798 51798 065 0402 0620
12400712 BLADDER SCAN-M.D. 52.00 $ 06/30/09 51798 51798 51798 065 0983 0620
12400747 U/S, VARIOCELE-SCROTUM-HOSP 427.00 06/30/10 76870 76870 76870 065 0402 0620
12400748 U/S,VARIOCELE-SCROTUM -M.D. 70.00 $ 06/30/09 7687026 7687026 7687026 065 0972 0620
12400750 ECHO,TRANSRECT,ULTRASND-HOSP 592.00 06/30/10 76872 76872 76872 065 0402 0620
12400751 ECHO,TRANSRECT,ULTRASND-M.D. 78.00 $ 06/30/09 7687226 7687226 7687226 065 0972 0620
12400760 US GUID NDLE PLMT IMG S&I-HOSP 754.00 07/27/10 76942 76942 76942 065 0402 0620
12400761 US GUID NDLE PLMT IMG S&I-M.D. 73.00 $ 06/30/09 7694226 7694226 7694226 065 0972 0620
12400780 SOFT TISSUE MARKERS (SET OF 3) 501.00 06/30/10 C1879 C1879 C1879 065 0278 0620
12400781 SOFT TISSUE MARKERS (SET OF 4) 667.00 06/30/10 C1879 C1879 C1879 065 0278 0620
12400871 VOID N/C 06/30/10 065 0302 9998
12400897 (CAP)INSRT NON-INDLL BLAD CATH 86.00 06/30/10 51701 51701 51701 065 0510 0620
12400898 (CAP)INSRT TEMP BLAD CATH-SIMP 104.00 06/30/10 51702 51702 51702 065 0510 0620
12400899 (CAP)INSRT TEMP BLAD CATH-COMP 246.00 06/30/10 51703 51703 51703 065 0510 0620
12400901 (CAPITATED)BIOP,PROST,NDLE PUN 858.00 06/30/10 55700 55700 55700 065 0360 0620
12400903 (CAPITATED) CYSTOSCOPY 492.00 06/30/10 52000 52000 52000 065 0360 0620
12400905 (CAPITATED)CYSTOSCOP BLAD BIOP 1158.00 06/30/10 52204 52204 52204 065 0360 0620
12400907 (CAPITATED)CYSTO,RMV URE STENT 1175.00 06/30/10 52310 52310 52310 065 0360 0620
12400909 (CAPITATED)ECHO,TRNSRCT,ULTRAS 210.00 06/30/10 76872 76872 76872 065 0402 0620
12400911 (CAPITATED)CYSTOMETRAGRM-CMPLX 524.00 06/30/10 51726 51726 51726 065 0920 0620
12400912 (CAP)CYSTOSCPY,RMV OF URE STNT 1175.00 06/30/10 52310 52310 52310 065 0360 0620
12400914 (CAP)DILAT. URETH STRICT(F&F) 183.00 06/30/10 53620 53620 53620 065 0360 0620
12400916 (CAP)DILAT. URETH STRICT(S/D) 127.00 06/30/10 53600 53600 53600 065 0360 0620
12400917 (CAP)FULG PENILE CONDYLOMA EXT 355.00 06/30/10 54055 54055 54055 065 0360 0620
12400918 (CAPITATED)THERA INJ,IM OR SUB 86.00 06/30/10 96372 96372 96372 065 0510 0620
12400919 (CAP)INJECT CORPORA CAVERNOSA 168.00 06/30/10 54235 54235 54235 065 0360 0620
12400920 (CAPITATED)UROFLOWMETRY,COMPLX 187.00 06/30/10 51741 51741 51741 065 0920 0620
12400921 (CAPITATED)VASECTOMY 1255.00 06/30/10 55250 55250 55250 065 0360 0620
12400922 (CAPITATED)BLADDER SCAN 115.00 06/30/10 51798 51798 51798 065 0402 0620
12400924 (CAPITATED)CATH,BLADDER,SIMPLE 445.00 06/30/10 51720 51720 51720 065 0360 0620
12400925 (CAP)CORP CAVERN IRRIG-PRIAP. 294.00 06/30/10 54220 54220 54220 065 0360 0620
12400927 BLADDER IRRIG,LAVAGE-HOSP 211.00 06/30/10 51700 51700 51700 065 0360 0620
12400928 BLADDER IRRIG,LAVAGE-M.D. 100.00 $ 06/30/09 51700 51700 51700 065 0975 0620
12400929 CYSTO,W/INSRT URETER CATH-HOSP 2542.00 06/30/10 51045 51045 51045 065 0360 0620
12400930 CYSTO,W/INSRT URETER CATH-M.D. 1032.00 $ 06/30/09 51045 51045 51045 065 0975 0620
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 405
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12400933 CHANGE CYSTO TUBE,SIMPLE-HOSP 219.00 06/30/10 51705 51705 51705 065 0360 0620
12400934 CHANGE CYSTO TUBE,SIMP-M.D. 149.00 $ 06/30/09 51705 51705 51705 065 0975 0620
12400941 INJECT CORPORA CAVERNOSA-HOSP 194.00 06/30/10 54235 54235 54235 065 0360 0620
12400942 INJECT CORPORA CAVERNOSA-M.D 165.00 $ 06/30/09 54235 54235 54235 065 0975 0620
12400951 CORP CAVERN IRRIG PRIAP-HOSP 294.00 06/30/10 54220 54220 54220 065 0360 0620
12400952 CORP CAVERN IRRIG PRIAP-M.D. 303.00 $ 06/30/09 54220 54220 54220 065 0975 0620
12401001 URINE DIPSTICK W/O MICRO 35.00 06/30/10 81002 81002 81002 065 0300 0620
12401004 URINE DIPSTICK W/ MICRO 38.00 06/30/10 81000 81000 81000 065 0300 0620
12401008 BLOOD OCCT. FECAL SCREEN 34.00 06/30/10 82270 82270 82270 065 0301 0620
12401015 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 065 0510 0620
12401017 THERAPEUTIC INJ, IV 236.00 06/30/10 96374 96374 96374 065 0510 0620
12401019 IV INF THER/PROPH/DIAG:INIT 285.00 06/30/10 96365 96365 96365 065 0260 0620
12403001 LUPRON 7.5MG 929.00 06/30/10 J9217 065 0636 0620
12666381 PREV MED NEW PT 5-11-HOSP 128.00 06/30/10 99383 99383 065 0510 0602
12666385 PREV MED NEW PT 12-17 HOSP 136.00 06/30/10 99384 99384 065 0510 0602
12666386 PREV MED NEW PT 12-17 M.D. 163.00 $ 06/30/09 99384 99384 065 0983 0602
12666391 PREV MED EST PT 5-11-HOSP 106.00 06/30/10 99393 99393 065 0510 0602
12666393 PREV MED EST PT 12-17 HOSP 113.00 06/30/10 99394 99394 065 0510 0602
12666394 PREV MED EST PT 12-17-M.D. 144.00 $ 06/30/09 99394 99394 065 0983 0602
12500547 VOIDING PRESSURE STUDIES -HOSP 582.00 06/30/10 51728 51728 51728 066 0920 0620
12500548 VOIDING PRESSURE STUDIES -M.D. 629.00 $ 01/01/10 5172826 5172826 5172826 066 0982 0620
12500614 VOID N/C 06/30/10 066 0975 9998
11110652 VOID 825.00 06/30/10 58120 58120 58120 69.09 69.09 067 0975 9999
11700504 VOID 306.00 06/30/10 11976 11976 11976 86.05 86.05 067 0975 9999
03734042 POSTOP FOLLOW-UP VISIT-M.D. N/C 06/30/10 99024 99024 99024 068 0983 0618
03734108 TENSILON TESTS - HOSP 135.00 06/30/10 95857 95857 95857 068 0922 0618
03734116 TAP SHUNTS - HOSP 440.00 06/30/10 61070 61070 61070 068 0360 0618
03762295 REMOVAL OF HALO VEST - HOSP 211.00 06/30/10 20665 20665 20665 068 0360 0618
03762307 LUMBAR PUNCT. DIAGNOSTIC-HOSP 351.00 06/30/10 62270 62270 62270 068 0360 0618
03762323 LUMBAR PUNCT.THERAPEUTIC-HOSP 519.00 06/30/10 62272 62272 62272 068 0360 0618
03762325 TRIG BRANCH BLOCK-HOSP 172.00 06/30/10 64400 64400 64400 068 0360 0618
03762327 GR OCCIPITAL BLOCK-HOSP 257.00 06/30/10 64405 64405 64405 068 0360 0618
03762333 CERVICAL PLEXUS BLOCK-HOSP 257.00 06/30/10 64413 64413 64413 068 0360 0618
03762335 BRACHIAL PLEXUS BLOCK-HOSP 256.00 06/30/10 64415 64415 64415 068 0360 0618
03762337 AXILLARY BLOCK-HOSP 264.00 06/30/10 64417 64417 64417 068 0360 0618
03762339 EPID CERV/THOR INJECT-HOSP 682.00 06/30/10 62310 62310 62310 068 0360 0618
03762341 EPID LUMB/SACR INJ-HOSP 676.00 06/30/10 62311 62311 62311 068 0360 0618
03762345 SI JOINT INJECTION-HOSP 366.00 06/30/10 27096 27096 27096 068 0360 0618
03762347 DIAGNOSTIC LP-HOSP 351.00 06/30/10 62270 62270 62270 068 0360 0618
03762348 THERAPEUTIC LP-HOSP 519.00 06/30/10 62272 62272 62272 068 0360 0618
03762350 EPIDUR BLOOD PATCH-HOSP 606.00 06/30/10 62273 62273 62273 068 0360 0618
03762367 ANALYSIS PUMP W/O PROGRAM-HOSP 225.00 06/30/10 62367 62367 62367 068 0360 0618
03762368 ANALYSIS PUMP W/ PROG-HOSP 325.00 06/30/10 62368 62368 62368 068 0360 0618
03762369 REPROG PROGRAM CSF SHUNT-HOSP 399.00 06/30/10 62252 62252 62252 068 0360 0618
03762418 SUPRASCAPULAR BLOC-HOSP 257.00 06/30/10 64418 64418 64418 068 0360 0618
03762420 INTERCOSTAL NERVE,SINGLE-HOSP 299.00 06/30/10 64420 64420 64420 068 0360 0618
03762421 INTERCOSTAL NERVE,MULT-HOSP 480.00 06/30/10 64421 64421 64421 068 0360 0618
03762425 ILIONG/ILIOHYPOG BLOCK-HOSP 268.00 06/30/10 64425 64425 64425 068 0360 0618
03762430 PUDENDAL BLOCK-HOSP 315.00 06/30/10 64430 64430 64430 068 0360 0618
03762445 SCIATIC BLOCK-HOSP 218.00 06/30/10 64445 64445 64445 068 0360 0618
03762450 OTHER PER NERVE BLOCK-HOSP 195.00 06/30/10 64450 64450 64450 068 0360 0618
03762470 CERV/THOR FACET BLOCK-HOSP 1191.00 06/30/10 64490 64490 64490 068 0360 0618
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 406
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03762472 INJ-AN/STR-PR JT,CRV-ADDL-HOSP 419.00 06/30/10 64491 64491 64491 068 0360 0618
03762475 LUMB/SACR FACET BLOCK-HOSP 1194.00 06/30/10 64493 64493 64493 068 0360 0618
03762476 INJ-AN/STR-PR JT-LUMB-ADL-HOSP 392.00 06/30/10 64494 64494 64494 068 0360 0618
03762505 SPHENOPALAT BLOCK-HOSP 176.00 06/30/10 64505 64505 64505 068 0360 0618
03762510 STELLATE BLOCK-HOSP 768.00 06/30/10 64510 64510 64510 068 0360 0618
03762520 THOR/LUMB SYMP BLOCK-HOSP 551.00 06/30/10 64520 64520 64520 068 0360 0618
03762530 PUMP REFILL, ADMN BY PHYS-HOSP 384.00 06/30/10 95991 95991 95991 068 0510 0618
03762540 NEUROSTIM ANALY W/O REPRO-HOSP 148.00 06/30/10 95970 95970 95970 068 0740 0618
03762542 STIM REPRO SIMP SC/PERIPH-HOSP 295.00 06/30/10 95971 95971 95971 068 0740 0618
03762544 STIM COMPL SC/PN,1ST HR-HOSP 303.00 06/30/10 95972 95972 95972 068 0740 0618
03762546 STIM COMPL SC/PN,ADD 30M-HOSP 147.00 06/30/10 95973 95973 95973 068 0740 0618
03762550 STIM COMPL CRN,1ST HR-HOSP 573.00 06/30/10 95974 95974 95974 068 0740 0618
03762600 NEUROLYTIC INJ TRG BRANCH-HOSP 560.00 06/30/10 64600 64600 64600 068 0360 0618
03788082 STIM COMPL SC/PN,1ST HR-HOSP 288.00 06/30/10 95972 95972 95972 068 0740 0605
03788084 STIM COMPL SC/PN,ADD 30MN-HOSP 147.00 06/30/10 95973 95973 95973 068 0740 0605
03788682 THERAPEUTIC INJ,IM OR SUBCUT 86.00 06/30/10 96372 96372 96372 068 0940 0618
03788690 INJ IM, ANTIBIOTIC 110.00 06/30/10 96372 96372 96372 068 0510 0618
03788708 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 068 0510 0618
06700001 POSTOP FOLLOW-UP VISIT-M.D. N/C 12/01/03 99024 99024 99024 068 0983 0662
06700015 TAP SHUNTS - HOSP 440.00 06/30/10 61070 61070 61070 068 0360 0662
06700016 TAP SHUNTS - M.D. 174.00 $ 06/30/09 61070 61070 61070 068 0975 0662
06700031 REPROG PROGRAM CSF SHUNT-HOSP 334.00 06/30/10 62252 62252 62252 068 0360 0662
06700032 REPROG PROGRAM CSF SHUNT-M.D. 105.00 $ 06/30/09 62252 62252 6225226 068 0975 0662
06750065 LUMBAR PUNCT DIAGNOSTIC-HOSP 351.00 06/30/10 62270 62270 62270 068 0360 0663
06750066 LUMBAR PUNCT DIAGNOSTIC-M.D. 158.00 $ 06/30/09 62270 62270 62270 068 0975 0663
55000001 INPAT-OUT OF HOSPITAL SVCS EXTERNAL 11/01/08 068 0920 9999
93734108 TENSILON TEST -M.D. 57.00 $ 06/30/09 95857 95857 95857 068 0983 0618
93734116 TAP SHUNTS - M.D. 174.00 $ 06/30/09 61070 61070 61070 068 0975 0618
93762295 REMOVAL OF HALO VEST - M.D. 209.00 $ 06/30/09 20665 20665 20665 068 0975 0618
93762297 DEBRIDEMNT;SKIN PAR THICK-M.D. 59.00 $ 06/30/09 11040 11040 11040 068 0975 0618
93762307 LUMBAR PUNCT,DIAGNOSTIC-M.D. 158.00 $ 06/30/09 62270 62270 62270 068 0975 0618
93762323 LUMBAR PUNCT, THERAPEUTIC-M.D. 176.00 $ 06/30/09 62272 62272 62272 068 0975 0618
93762325 TRIG BRANCH BLOCK-M.D. 127.00 $ 06/30/09 64400 64400 64400 068 0975 0618
93762327 GR OCCIPITAL BLOCK-M.D 148.00 $ 06/30/09 64405 64405 64405 068 0975 0618
93762333 CERVICAL PLEXUS BLOCK-M.D. 154.00 $ 06/30/09 64413 64413 64413 068 0975 0618
93762335 BRACHIAL PLEXUS BLOCK-M.D. 149.00 $ 06/30/09 64415 64415 64415 068 0975 0618
93762337 AXILLARY BLOCK-M.D. 150.00 $ 06/30/09 64417 64417 64417 068 0975 0618
93762339 EPID CERV/THOR INJECT-M.D. 206.00 $ 06/30/09 62310 62310 62310 068 0975 0618
93762341 EPID LUMB/SACR INJECT-M.D. 170.00 $ 06/30/09 62311 62311 62311 068 0975 0618
93762345 SI JOINT INJECTION-M.D. 142.00 $ 06/30/09 27096 27096 27096 068 0975 0618
93762347 DIAGNOSTIC LP-M.D. 158.00 $ 06/30/09 62270 62270 62270 068 0975 0618
93762348 THERAPEUTIC LP-M.D. 176.00 $ 06/30/09 62272 62272 62272 068 0975 0618
93762350 EPIDUR BLOOD PATCH-M.D. 226.00 $ 06/30/09 62273 62273 62273 068 0975 0618
93762367 ANALYSIS PUMP W/O REPROG-M.D. 49.00 $ 06/30/09 62367 62367 6236726 068 0975 0618
93762368 ANALYSIS PUMP W/ PROGRAM-M.D. 78.00 $ 06/30/09 62368 62368 6236826 068 0975 0618
93762369 REPROG PROGRAM CSF SHUNT-M.D. 105.00 $ 06/30/09 62252 62252 6225226 068 0975 0618
93762418 SUPRASCAPULAR BLOC-M.D. 146.00 $ 06/30/09 64418 64418 64418 068 0975 0618
93762420 INTERCOSTAL NERVE,SINGLE-M.D. 134.00 $ 06/30/09 64420 64420 64420 068 0975 0618
93762421 INTERCOSTAL NERVE, MULTI-M.D. 182.00 $ 06/30/09 64421 64421 64421 068 0975 0618
93762425 ILIONG/ILIOHYPOG BLOCK-M.D. 190.00 $ 06/30/09 64425 64425 64425 068 0975 0618
93762430 PUDENDAL BLOCK-M.D. 180.00 $ 06/30/09 64430 64430 64430 068 0975 0618
93762445 SCIATIC BLOCK-M.D. 163.00 $ 06/30/09 64445 64445 64445 068 0975 0618
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 407
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

93762450 OTHER PER NERVE BLOCK-M.D. 150.00 $ 06/30/09 64450 64450 64450 068 0975 0618
93762470 CERV/THOR NERVE BLOCK-M.D. 234.00 $ 01/01/10 64490 64490 64490 068 0975 0618
93762472 INJ-AN/STR-PR JT,CRV-ADDL-M.D. 134.00 $ 01/01/10 64491 64491 64491 068 0975 0618
93762475 LUMB/SACR FACET BLOCK-M.D. 198.00 $ 01/01/10 64493 64493 64493 068 0975 0618
93762476 INJ-AN/STR-PR JT-LUMB-ADL-M.D. 114.00 $ 01/01/10 64494 64494 64494 068 0975 0618
93762505 SPHENOPALAT BLOCK-M.D. 171.00 $ 06/30/09 64505 64505 64505 068 0975 0618
93762510 STELLATE BLOCK-M.D. 136.00 $ 06/30/09 64510 64510 64510 068 0975 0618
93762520 THOR/LUMB SYMP BLOCK-M.D. 154.00 $ 06/30/09 64520 64520 64520 068 0975 0618
93762530 PUMP REFILL, ADMN BY PHYS-M.D. 79.00 $ 06/30/09 95991 95991 95991 068 0983 0618
93762540 NEUROSTIM ANALY W/O REPRO-M.D. 48.00 $ 06/30/09 95970 95970 95970 068 0983 0618
93762542 STIM REPRO SIMP SC/PERIPH-M.D. 88.00 $ 06/30/09 95971 95971 95971 068 0920 0618
93762544 STIM COMPL SC/PN,1ST HR-M.D. 167.00 $ 06/30/09 95972 95972 95972 068 0920 0618
93762546 STIM COMPL SC/PN,1ST HR-M.D. 98.00 $ 06/30/09 95973 95973 95973 068 0920 0618
93762550 STIM COMPL CRN,1ST HR-M.D. 317.00 $ 06/30/09 95974 95974 95974 068 0920 0618
93762552 STIM COMPL CRN,ADD 30MIN-M.D. 185.00 $ 06/30/09 95975 95975 95975 068 0920 0618
93762600 NEUROLYTIC INJ TRIG BRANCH-M.D 437.00 $ 06/30/09 64600 64600 64600 068 0975 0618
93788082 STIM COMPL SC/ PN1ST HR-M.D. 167.00 $ 06/30/09 95972 95972 95972 068 0920 0605
93788084 STIM COMPL SC/PN,ADD 30MN-M.D. 98.00 $ 06/30/09 95973 95973 95973 068 0920 0605
03762552 STIM COMPL CRN,ADD 30M-HOSP 300.00 06/30/10 95975 95975 95975 069 0740 0618
19900100 INJECTION SUBQ/IM CHEMO DRUG 440.00 06/30/10 96401 96401 96401 069 0331 0599
19900103 INJECT SUBQ/IM HORMONAL DRUG 431.00 06/30/10 96402 96402 96402 069 0260 0599
19900104 CHEMO ADM-INTRALES-UP TO 7 267.00 06/30/10 96405 96405 96405 069 0510 0599
19900106 IV PUSH, CHEMOTHERAPY, INITIAL 399.00 06/30/10 96409 96409 96409 069 0335 0599
19900109 IV PUSH, CHEMOTHERAPY, ADDL 265.00 06/30/10 96411 96411 96411 069 0335 0599
19900112 CHEMO IV INFUS:INIT UP TO 1HR 720.00 06/30/10 96413 96413 96413 069 0335 0599
19900118 CHEMOTHERAPY PUMP INFUSION 510.00 06/30/10 96416 96416 96416 069 0335 0599
19900121 CHEMO IV INFUSE EACH ADDL SEQ 694.00 06/30/10 96417 96417 96417 069 0335 0599
19900124 CHEMO INTRA-ARTERIAL PUSH 413.00 06/30/10 96420 96420 96420 069 0335 0599
19900127 INTRA-ART CHEMO INFUS,1ST HR 720.00 06/30/10 96422 96422 96422 069 0335 0599
19900130 INTRA-ART CHEMO INFUS,ADDL HR 694.00 06/30/10 96423 96423 96423 069 0335 0599
19900133 PUMP INFUSION>8HRS,NON-CHEMO 833.00 06/30/10 96425 96425 96425 069 0335 0599
19900136 CHEMOTHERAPY/THORACENTESIS 519.00 06/30/10 96440 96440 96440 069 0940 0599
19900139 CHEMOTHERAPY/PERITONEAL CAVITY 519.00 06/30/10 96445 96445 96445 069 0940 0599
19900142 CHEMOTHERAPY/INTRATHECAL-HOSP 587.00 06/30/10 96450 96450 96450 069 0331 0599
19900145 IRRIG OF VENOUS ACCESS DEVICE 90.00 06/30/10 96523 96523 96523 069 0260 0599
19900148 CHEMO INJECTION VIA RESERVOIR 417.00 06/30/10 96542 96542 96542 069 0331 0599
10020125 INFLUENZA WHOLE VIRUS 26.00 06/30/10 90660 G0008 90660 99.52 070 0636 0500
90020031 VOID EXTERNAL 12/31/03 070 0918 9998
93713429 VOID 90.00 06/30/09 070 0971 9999
93732369 VOID EXTERNAL 09/25/95 070 0971 9999
93785901 VOID EXTERNAL 04/01/07 070 0973 9999
11700026 BLOOD/PLATELET TRANSFUSION 763.00 06/30/10 36430 36430 36430 071 0391 3400
12300203 IV HYDRA INFUSION EACH ADDL HR 151.00 06/30/10 96361 96361 96361 071 0260 0523
12300205 THERAPEUTIC INJ,IM OR SUB 86.00 06/30/10 96372 96372 96372 071 0940 0523
12300301 INJECTION SUBQ/IM CHEMO DRUG 440.00 06/30/10 96401 96401 96401 071 0331 0523
12300303 INJECT SUBQ/IM HORMONAL DRUG 431.00 06/30/10 96402 96402 96402 071 0331 0523
12300305 IV PUSH, CHEMOTHERAPY, INITIAL 399.00 06/30/10 96409 96409 96409 071 0335 0523
12300309 CHEMO IV INFUSION: EA ADDL HR 425.00 06/30/10 96415 96415 96415 071 0940 0523
12300311 CHEMO IV INFUSION: EA ADDL HR 510.00 06/30/10 96415 96415 96415 071 0335 0523
12300353 CHEMO INFUSION IV M AG PUSH 387.00 06/30/10 96409 96409 96409 071 0335 0523
12300355 CHEMO INFUSION IV S AG PUSH 387.00 06/30/10 96409 96409 96409 071 0335 0523
12300357 CHEMO IV INFUS:INIT UP TO 1HR 720.00 06/30/10 96413 96413 96413 071 0335 0523
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 408
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12300359 CHEMO IV INFUSION: EA ADDL HR 299.00 06/30/10 96415 96415 96415 071 0335 0523
12300363 IV INFUSION,>8 HRS W/PUMP 510.00 06/30/10 96416 96416 96416 071 0335 0523
12300401 VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 071 0510 0523
12300405 BLOOD/PLATELET TRANSFUSION 763.00 06/30/10 36430 36430 36430 071 0391 0523
12300420 VOID 76.00 06/30/10 36410 36410 36410 071 0975 9999
12310201 IV INFUSION, TO 1 HR 402.00 06/30/10 90765 90765 Q0081 071 0260 0524
12310203 IV HYDRA INFUSION EACH ADDL HR 244.00 06/30/10 96361 96361 96361 071 0260 0524
12310205 THERAPEUTIC INJ,IM OR SUB 86.00 06/30/10 96372 96372 96372 071 0940 0524
12310210 SKIN TEST, TB,INTRADERMAL 46.00 06/30/10 86580 86580 86580 071 0302 0524
12310217 THERAPEUTIC INJ,IV 80.00 06/30/10 96374 96374 96374 071 0940 0524
12310353 CHEMO INFUS IV M AG PUSH 394.00 06/30/10 96409 96409 96409 071 0335 0524
12310355 CHEMO INFUS IV S AG PUSH 394.00 06/30/10 96409 96409 96409 071 0335 0524
12310361 IV INFUSION,>8 HRS W/PUMP 348.00 06/30/10 96416 96416 96416 071 0335 0524
12310371 CHEMO ADMIN-INTRAPLEURAL-HOSP 390.00 06/30/10 96440 96440 071 0280 0524
12310372 CHEMO ADMIN-INTRAPLEURAL-M.D. 287.00 $ 06/30/09 96440 96440 071 0983 0524
12310373 CHEMO ADMN-PERITON CAVITY-HOSP 267.00 06/30/10 96445 96445 071 0335 0524
12310374 CHEMO ADMN-PERITON CAVITY-M.D. 252.00 $ 06/30/09 96445 96445 071 0983 0524
12310375 INTRATHECAL (INCLUDES LP)-HOSP 252.00 06/30/10 96450 96450 Q0083 071 0331 0524
12310376 INTRATHECAL (INCLUDES LP)-M.D. 190.00 $ 06/30/09 96450 96450 071 0983 0524
12310377 REFILL/MAINTENANCE PORT PUMP 402.00 06/30/10 96521 96521 96521 071 0940 0524
12310379 REFILL/MAINTEN IMPLANT PUMP 402.00 06/30/10 96522 96522 96522 071 0510 0524
12310395 PHLEBOTOMY 157.00 06/30/10 99195 99195 99195 071 0940 0524
12310401 VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 071 0510 0524
12310405 BLOOD/PLATELET TRANSFUSION 763.00 06/30/10 36430 36430 36430 071 0391 0524
12310407 VENIPUNCTURE-UNDER 1 YEAR-HOSP 192.00 06/30/10 36420 36420 36420 071 0360 0524
12310408 VENIPUNCTURE-UNDER 1 YEAR-M.D. 104.00 $ 06/30/09 36420 36420 36420 071 0975 0524
12310409 VENIPUNCTURE-AGE 1 OR OVR-HOSP 108.00 06/30/10 36425 36425 36425 071 0360 0524
12310410 VENIPUNCTURE-AGE 1 OR OVR-M.D. 83.00 $ 06/30/09 36425 36425 36425 071 0975 0524
12310411 EX TRANSFU,OTR THAN NWBRN-HOSP 1111.00 06/30/10 36455 36455 36455 071 0360 0524
12310412 EX TRANSFU,OTR THAN NWBRN-M.D. 273.00 $ 06/30/09 36455 36455 36455 071 0975 0524
12310425 CVC PLACEMENT >2YRS OLD-HOSP 770.00 06/30/10 36555 36555 36555 071 0360 0524
12310426 CVC PLACEMENT >2YRS OLD-M.D. 266.00 $ 06/30/09 36555 36555 36555 071 0975 0524
12310430 DECLOTT OF PORT 329.00 06/30/10 36593 36593 36593 071 0360 0524
12310433 SPEC FROM PORT/CENT LINE 124.00 06/30/10 36591 36591 36591 071 0361 0524
12310436 PV BLOOD SPEC-CENTRAL LINE 134.00 06/30/10 36592 36592 36592 071 0361 0524
12310439 ARTERIAL PUNCTURE-HOSP 95.00 06/30/10 36600 36600 36600 071 0360 0524
12310440 ARTERIAL PUNCTURE-M.D. 33.00 $ 06/30/09 36600 36600 36600 071 0975 0524
12310461 DEST,MALIG LES .5CM OR <-HOSP 149.00 06/30/10 17270 17270 17270 071 0360 0524
12310462 DEST,MALIG LES .5CM OR <-M.D. 189.00 $ 06/30/09 17270 17270 17270 071 0975 0524
12310463 DEST,MALIG LES .6CM-1CM-HOSP 196.00 06/30/10 17271 17271 17271 071 0360 0524
12310464 DEST,MALIG LES .6CM-1CM-M.D. 213.00 $ 06/30/09 17271 17271 17271 071 0975 0524
12310465 DEST,MALIG LES 1.1CM-2CM-HOSP 238.00 06/30/10 17272 17272 17272 071 0360 0524
12310467 DEST,MALIG LES 2.1CM-3CM-HOSP 285.00 06/30/10 17273 17273 17273 071 0360 0524
12310468 DEST,MALIG LES 2.1CM-3CM-M.D. 278.00 $ 06/30/09 17273 17273 17273 071 0975 0524
12310469 DEST,MALIG LES 3.1-4CM-HOSP 343.00 06/30/10 17274 17274 17274 071 0360 0524
12310470 DEST,MALIG LES 3.1-4.1CM-M.D. 341.00 $ 06/30/09 17274 17274 17274 071 0975 0524
12310471 DEST,MALIG LES OVER 4CM-HOSP 339.00 06/30/10 17276 17276 17276 071 0360 0524
12310472 DEST,MALIG LES OVER 4 CM-M.D. 413.00 $ 06/30/09 17276 17276 17276 071 0975 0524
12310509 ARTH,ASPIR/INJ-SMALL JNT-HOSP. 144.00 06/30/10 20600 20600 20600 071 0360 0524
12310510 ARTH,ASPIR/INJ-SMALL JNT-M.D. 85.00 $ 06/30/09 20600 20600 20600 071 0975 0524
12310511 INTERMEDIATE JOINT/BURSA-HOSP. 133.00 06/30/10 20605 20605 20605 071 0360 0524
12310512 INTERMEDIATE JOINT/BURSA-M.D. 88.00 $ 06/30/09 20605 20605 20605 071 0975 0524
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 409
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12310513 ARTH,ASPIR/INJ-MJR JOINT-HOSP. 440.00 06/30/10 20610 20610 20610 071 0360 0524
12310514 ARTH/ASPIR/INJ-MJR JOINT-M.D. 107.00 $ 06/30/09 20610 20610 20610 071 0975 0524
12310541 THORACENTESIS-HOSP 373.00 06/30/10 32421 32421 32421 071 0360 0524
12310542 THORACENTESIS-M.D. 164.00 $ 06/30/09 32421 32421 32421 071 0975 0524
12310601 PROCTOSIGMOIDOSCOPY-HOSP 272.00 06/30/10 45300 45300 45300 071 0360 0524
12310602 PROCTOSIGMOIDOSCOPY-M.D. 97.00 $ 06/30/09 45300 45300 45300 071 0975 0524
12310605 PROCTOSIGMOIDOSCPY W/BIOP-HOSP 556.00 06/30/10 45305 45305 45305 071 0360 0524
12310606 PROCTOSIGMOIDOSCPY W/BIOP-M.D. 154.00 $ 06/30/09 45305 45305 45305 071 0975 0524
12310651 ABDOMINAL PARACENT,INIT.-HOSP 293.00 06/30/10 49080 49080 49080 071 0360 0524
12310652 ABDOMINAL PARACENTESIS-M.D. 151.00 $ 06/30/09 49080 49080 49080 071 0975 0524
12310653 PARACENTESIS, SUBSEQUENT-HOSP 293.00 06/30/10 49081 49081 49081 071 0360 0524
12310654 PARACENTESIS, SUBSEQUENT-M.D. 143.00 $ 06/30/09 49081 49081 49081 071 0975 0524
12310661 RMV PERM INTRAP CANN/CATH-HOSP 1665.00 06/30/10 49422 49422 49422 071 0490 0524
12310662 RMV PERM INTRAP CANN/CATH-M.D. 795.00 $ 06/30/09 49422 49422 49422 071 0975 0524
12310701 SPINAL PUNCTURE, LUMBAR-HOSP 351.00 06/30/10 62270 62270 62270 071 0360 0524
12310702 SPINAL PUNCTURE, LUMBAR-M.D. 158.00 $ 06/30/09 62270 62270 62270 071 0975 0524
12310705 PERCUTANEOUS DISKECTOMY-HOSP 4731.00 06/30/10 62287 62287 62287 071 0360 0524
12310706 PERCUTANEOUS DISKECTOMY-M.D. 1104.00 $ 06/30/09 62287 62287 62287 071 0975 0524
12310818 BLOOD OCCULT,SINGLE SPECIMEN 38.00 06/30/10 82272 82272 82272 071 0301 0524
12310821 BLEEDING TIME TEST 60.00 06/30/10 85002 85002 85002 071 0305 0524
12310823 BLOOD COUNT,MAN DIFF WBC 45.00 06/30/10 85007 85007 85007 071 0305 0524
12310843 BONE MARROW ASPIRAT ONLY-HOSP 297.00 06/30/10 38220 38220 38220 071 0361 0524
12310844 BONE MARROW ASPIR ONLY-M.D. 126.00 $ 06/30/09 38220 38220 38220 071 0983 0524
12310845 INTERPRETATION OF SMEAR-HOSP 116.00 06/30/10 85097 85097 85097 071 0305 0524
12310846 INTERPRETATION OF SMEAR-M.D. 99.00 $ 06/30/09 85097 85097 85097 071 0971 0524
12310847 BONE MARROW BIOPSY-HOSP 242.00 06/30/10 38221 38221 38221 071 0361 0524
12310848 BONE MARROW BIOPSY-M.D. 160.00 $ 06/30/09 38221 38221 38221 071 0975 0524
12310851 WET MOUNT/GRAM STAIN 46.00 06/30/10 87210 87210 87210 071 0306 0524
12310891 TISSUE CULTURE, BONE MARROW 636.00 06/30/10 88237 88237 88237 071 0310 0524
12310895 CYTOPATH,CERV/VAG INTERP-HOSP 68.00 06/30/10 88141 88141 88141 071 0311 0524
12310896 CYTOPATH,CERV/VAG INTERP-M.D. 58.00 $ 06/30/09 88141 88141 88141 071 0971 0524
12331011 FINE NEEDLE ASPIR-BREAST 355.00 06/30/10 10021 10021 10021 071 0361 0523
12331013 FINE NDL ASP WITH IMAGING 336.00 06/30/10 10022 10022 10022 071 0361 0523
12331017 INCS/DRAIN,ABCESS,SIMPLE 164.00 06/30/10 10060 10060 10060 071 0360 0523
12331018 I & D MULTIPLE 269.00 06/30/10 10061 10061 10061 071 0360 0523
12331023 DRAINAGE OF SEROMA 323.00 06/30/10 10140 10140 10140 071 0360 0523
12331029 ASP ABSCESS HEMATOMA CYST 159.00 06/30/10 10160 10160 10160 071 0360 0523
12331032 SKIN DEBRIDE 10% OF BODY 106.00 06/30/10 11000 11000 11000 071 0360 0523
12331035 SKIN BIOP, SINGLE LESION 201.00 06/30/10 11100 11100 11100 071 0360 0523
12331041 BIOPSY ADDL SUBCUT TISSUE 151.00 06/30/10 11101 11101 11101 071 0360 0523
12331047 EXCISION OF LESION 172.00 06/30/10 11200 11200 11200 071 0360 0523
12331053 EXCIS B LES T,A,L 0.5CM 254.00 06/30/10 11400 11400 11400 071 0360 0523
12331059 EXCIS B LES T,A,L 0.6-1CM 299.00 06/30/10 11401 11401 11401 071 0360 0523
12331065 EXCIS B LES T,A,L 1.1-2CM 422.00 06/30/10 11402 11402 11402 071 0360 0523
12331071 EXCIS B LES T,A,L 2.1-3CM 516.00 06/30/10 11403 11403 11403 071 0360 0523
12331077 EXCIS B LES T,A,L 3.1-4CM 762.00 06/30/10 11404 11404 11404 071 0360 0523
12331079 EXC BEN LES TRK,ARM,LEG>4.0CM 2657.00 06/30/10 11406 11406 11406 071 0360 0523
12331082 EXC BEN LES SC HD FT GN 0.5 309.00 06/30/10 11420 11420 11420 071 0360 0523
12331083 EXC B LES SCLP,NCK,HND 1.1-2CM 488.00 06/30/10 11422 11422 11422 071 0360 0523
12331089 EXC B LES SCLP,NK,HD F 2.1-3CM 893.00 06/30/10 11423 11423 11423 071 0360 0523
12331091 REPR LACERAT-2.5CM OR < 226.00 06/30/10 12001 12001 12001 071 0360 0523
12331093 SIMP RPR SC/TRK;20.1-30CM 464.00 06/30/10 12006 12006 12006 071 0360 0523
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 410
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12331095 EXC B LES SCLP,NK,HD,FT<.5CM. 301.00 06/30/10 11440 11440 11440 071 0360 0523
12331101 EXC B LES SCP,NK,HD,FT .6-1CM 510.00 06/30/10 11441 11441 11441 071 0360 0523
12331103 EXCIS BENIGN LES 2.1-3 CM 758.00 06/30/10 11443 11443 11443 071 0360 0523
12331105 EXCIS BENIGN LES .6-1CM 531.00 06/30/10 11421 11421 11421 071 0360 0523
12331107 EXC MAL LES T,A,L <.5CM 482.00 06/30/10 11600 11600 11600 071 0360 0523
12331113 RMVL SKIN LES T,A,L 0.6-1.0CM 398.00 06/30/10 11601 11601 11601 071 0360 0523
12331119 EXC MAL LES T,A,L 1.1-2CM 729.00 06/30/10 11602 11602 11602 071 0360 0523
12331125 EXC MAL LES T,A,L 2.1-3CM 1071.00 06/30/10 11603 11603 11603 071 0360 0523
12331126 EXC MAL LES T,A,L 2.1-3CM-M.D. 367.00 $ 06/30/10 11603 11603 11603 071 0960 0523
12331131 EXC MAL LES T,A,L 3.1-4CM 1004.00 06/30/10 11604 11604 11604 071 0360 0523
12331137 RMVL SKIN LES T,A,L >4.0CM 1707.00 06/30/10 11606 11606 11606 071 0360 0523
12331143 EXC MAL LES SCLP,NK,HD,FT<.5CM 326.00 06/30/10 11620 11620 11620 071 0360 0523
12331149 EXC MAL LES SCP,NK,HD,F .6-1CM 825.00 06/30/10 11621 11621 11621 071 0360 0523
12331155 EXC MAL LES S,N,H,F 1.1-2CM 764.00 06/30/10 11622 11622 11622 071 0360 0523
12331161 RMVL SKN LES S,N,H,F 2.1-3.0CM 936.00 06/30/10 11623 11623 11623 071 0360 0523
12331167 SC/NK/HD/FT/GN 3.1-4.0CM 3453.00 06/30/10 11624 11624 11624 071 0360 0523
12331173 SC/NK/HD/FT/GN OVER 4.0CM 3232.00 06/30/10 11626 11626 11626 071 0360 0523
12331179 EXCIS MALIG LES FACE<.5CM. 688.00 06/30/10 11640 11640 11640 071 0360 0523
12331185 RMVL SKIN LES FACE 1.1-2.0CM 1042.00 06/30/10 11642 11642 11642 071 0360 0523
12331191 REM MALG LES LIDS-2.1-3CM 1993.00 06/30/10 11643 11643 11643 071 0360 0523
12331197 SC/TR/EXTREM: 2.5CM OR LESS 286.00 06/30/10 12031 12031 12031 071 0360 0523
12331203 SC/TR/EXTREM: 2.6-7.5CM 678.00 06/30/10 12032 12032 12032 071 0360 0523
12331204 SC/TR/EXTREM: 2.6-7.5CM-M.D. 378.00 $ 06/30/10 12032 12032 12032 071 0960 0523
12331209 SC/TR/EXTREM: 7.6-12.5CM 539.00 06/30/10 12034 12034 12034 071 0360 0523
12331211 SC/TR/EXTREM: 12.6-20.0 CM 233.00 06/01/10 12035 12035 12035 071 0360 0523
12331215 INTERMED HAND REP 2.5CM 319.00 06/30/10 12041 12041 12041 071 0360 0523
12331221 INTER HAND REP 2.6-7.5CM 295.00 06/30/10 12042 12042 12042 071 0360 0523
12331227 LAY CLOS,FACE 2.5CM OR< 301.00 06/30/10 12051 12051 12051 071 0360 0523
12331233 LAYER CLOSURE OF WOUND(S) 270.00 06/30/10 12052 12052 12052 071 0360 0523
12331235 ADJ TRAN SC/ARM/LG; 10CM/< 1845.00 06/30/10 14020 14020 14020 071 0360 0523
12331236 INFUSION PUMP RMVL 1246.00 06/30/10 36590 36590 36590 071 0360 0523
12331239 ASPIRATION OF BREAST CYST 476.00 06/30/10 19000 19000 19000 071 0360 0523
12331245 DRAIN BREAST LESION ADD-ON 301.00 06/30/10 19001 19001 19001 071 0360 0523
12331251 BIOPSY BREAST, NEEDLE 270.00 06/30/10 19100 19100 19100 071 0360 0523
12331253 U/S BIOP BREAST NEEDLE CORE 1409.00 06/30/10 19102 19102 19102 071 0360 0523
12331254 AUTO VAC ASSISTED BIOPSY 1126.00 06/30/10 19103 19103 19103 071 0360 0523
12331257 REMOVAL OF BREAST LESION 2088.00 06/30/10 19120 19120 19120 071 0360 0523
12331263 EXCISION, BREAST LESION 1708.00 06/30/10 19125 19125 19125 071 0360 0523
12331269 EXCISION, ADDL BREAST LESION 632.00 06/30/10 19126 19126 19126 071 0360 0523
12331270 TISSUE MARKER PLACEMENT 334.00 06/30/10 19295 19295 19295 071 0360 0523
12331272 PLCMNT RADTHER BALLN CATH 7724.00 06/30/10 19296 19296 19296 071 0360 0523
12331275 NEEDLE BIOPSY, MUSCLE 873.00 06/30/10 20206 20206 20206 071 0360 0523
12331277 EXC TUMOR,NECK/THORAX,SUB-M.D. 658.00 $ 05/01/10 21555 21555 21555 071 0975 0523
12331278 EXC TUMOR, NECK/THORAX, SUBCUT 5104.00 06/30/10 21555 21555 21555 071 0360 0523
12331279 EXC TUMOR,NECK/THORAX,DEEP 3155.00 06/30/10 21556 21556 21556 071 0360 0523
12331281 BIOPSY SHOULDER TISSUES 628.00 06/30/10 23066 23066 23066 071 0360 0523
12331282 EXC,TUMOR,FOREARM/WRIST;DEEP 3313.00 06/30/10 25076 25076 25076 071 0360 0523
12331283 EXC,TUMOR,PELVIS/HIP;DEEP,IM 3313.00 06/30/10 27048 27048 27048 071 0360 0523
12331285 EXC,TUMOR-ARM/ELBOW SUBCUT 2528.00 06/30/10 24075 24075 24075 071 0360 0523
12331287 BIOPSY, THIGH SOFT TISSUES 674.00 06/30/10 27324 27324 27324 071 0360 0523
12331290 EXC,TUMOR,THIGH/KNEE-SUBC 3313.00 06/30/10 27327 27327 27327 071 0360 0523
12331293 EXCISION OF FOOT LESION 536.00 06/30/10 28043 28043 28043 071 0360 0523
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 411
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12331295 EXC TUMOR FOREARM/WRIST SUBCUT 2407.00 06/30/10 25075 25075 25075 071 0360 0523
12331296 EX TUMOR FORARM/WRIST SUB-M.D. 682.00 $ 05/01/10 25075 25075 25075 071 0975 0523
12331299 DIAGNOSTIC LARYNGOSCOPY 106.00 06/30/10 31505 31505 31505 071 0360 0523
12331301 LARYN DIR W/WO TRACHEO DIAG 2672.00 06/30/10 31525 31525 31525 071 0360 0523
12331303 LARYN DIR W/WO TRACH-ASPIRAT 3364.00 06/30/10 31515 31515 31515 071 0360 0523
12331305 SUCTIONING, NASOTRACHEAL 158.00 06/30/10 31720 31720 31720 071 0360 0523
12331311 INSERTION OF CATHETER, VEIN 974.00 06/30/10 36556 36556 36556 071 0360 0523
12331317 INSERTION OF ACCESS DEVICE 2012.00 06/30/10 071 0360 0523
12331323 RMVL CENTRAL VENOUS CATH 660.00 06/30/10 36589 36589 36589 071 0360 0523
12331326 INFUSION PUMP REMOVAL 1246.00 06/30/10 36590 36590 36590 071 0360 0523
12331329 DECLOT VASCULAR DEVICE 329.00 06/30/10 36593 36593 36593 071 0360 0523
12331335 BIOPSY/REMOVAL, LYMPH NODES 1296.00 06/30/10 38500 38500 38500 071 0360 0523
12331341 NEEDLE BIOPSY, LYMPH NODES 754.00 06/30/10 38505 38505 38505 071 0360 0523
12331347 BIOPSY/REMOVAL, LYMPH NODES 2583.00 06/30/10 38510 38510 38510 071 0360 0523
12331350 BIOPSY, VESTIBULE OF MOUTH 374.00 06/30/10 40808 40808 40808 071 0360 0523
12331353 EXCISE/REPAIR MOUTH LESION 558.00 06/30/10 40814 40814 40814 071 0360 0523
12331359 BIOPSY OF TONGUE 1430.00 06/30/10 41100 41100 41100 071 0360 0523
12331365 BIOPSY OF THROAT 801.00 06/30/10 42800 42800 42800 071 0360 0523
12331369 CHANGE GASTRONOMY TUBE 312.00 06/30/10 43760 43760 43760 071 0360 0523
12331370 CHANGE GASTRONOMY TUBE-M.D. 137.00 $ 06/01/10 43760 43760 43760 071 0960 0523
12331371 PROCTOSIGMOIDOSCOPY 272.00 06/30/10 45300 45300 45300 071 0360 0523
12331373 RECTAL BIOPSY 1036.00 06/30/10 45100 45100 45100 071 0360 0523
12331377 ABDOMINAL PARACENT, INIT. 293.00 06/30/10 49080 49080 49080 071 0360 0523
12331381 REPLACE DUOD/JEJ TUBE PERC 1099.00 05/01/10 49451 49451 49451 071 0361 0523
12331383 CATH, URETHRA, SIMPLE. 86.00 06/30/10 51701 51701 51701 071 0360 0523
12331389 TUMOR IMAGING, LIMITED AREA 1468.00 06/30/10 78800 78800 78800 071 0341 0523
12331391 EXC,TUMOR,LEG/ANK;SUBCUT 2332.00 06/30/10 27618 27618 27618 071 0360 0523
12331395 NASOPHARYNGOSCOPY 169.00 06/30/10 92511 92511 92511 071 0471 0523
12331399 EXC,TUMOR,SOFT TISS BACK/FLANK 3155.00 06/30/10 21930 21930 21930 071 0360 0523
12331400 EX,TUMOR,SFT TIS BCK/FLNK-M.D. 774.00 $ 05/01/10 21930 21930 21930 071 0975 0523
12331401 ECHO BREAST UNI/BILATERAL 397.00 06/30/10 76645 76645 76645 071 0402 0523
12331404 ECHO SOFT TISS-HEAD/NECK 427.00 06/30/10 76536 76536 76536 071 0402 0523
12331407 ECHO ABDOMINAL COMPLETE 689.00 06/30/10 76700 76700 76700 071 0402 0523
12331408 ECHO ABDOMINAL; LIMITED 684.00 06/30/10 76705 76705 76705 071 0402 0523
12331410 ECHOGRAPHY EXTREMITY 350.00 06/30/10 76880 76880 76880 071 0402 0523
12331413 U/S GUIDE NEEDLE PLACEMENT 754.00 07/27/10 76942 76942 76942 071 0402 0523
12331420 DIGITAL MOLE MAP(FAM)FULL 716.00 06/30/10 96904 96904 96904 071 0920 0523
12331423 DIGITAL MOLE MAP(FAM)PARTIAL 271.00 06/30/10 96904 96904 96904 071 0920 0523
12331426 DIGITAL MOLE MAP (PERSNAL)FULL 875.00 06/30/10 96904 96904 96904 071 0920 0523
12331429 DIGITAL MOLE MAP(PERSONAL)PART 271.00 06/30/10 9690452 9690452 9690452 071 0920 0523
12340001 CHEMO IV INFUS:INIT UP TO 1HR 720.00 06/30/10 96413 96413 96413 071 0335 0524
12340009 CHEMO INFUS IV MAG PUSH 387.00 06/30/10 96409 96409 96409 071 0335 0524
12340013 CHEMO INFUS IV S AG PUSH 387.00 06/30/10 96409 96409 96409 071 0335 0524
12340033 REFILL/MAINTEN IMPLANT PUMP 402.00 06/30/10 96522 96522 96522 071 0510 0524
12340037 IV INFUSION,>8HRS W/PUMP 510.00 06/30/10 96416 96416 96416 071 0335 0524
12340041 THERAPEUTIC INJ,IV 80.00 06/30/10 96374 96374 96374 071 0940 0524
12340049 CHEMO ADMIN-INTRAPLEURAL-HOSP 390.00 06/30/10 96440 96440 96440 071 0280 0524
12340050 CHEMO ADMIN-INTRAPLEURAL-M.D. 287.00 $ 06/30/09 96440 96440 96440 071 0983 0524
12340055 CHEMO ADMIN-PERITON CAVITY-HOS 354.00 06/30/10 96445 96445 96445 071 0280 0524
12340056 CHEMO ADMIN-PERITON CAVITY-M.D 252.00 $ 06/30/09 96445 96445 96445 071 0983 0524
12340061 INTRATHECAL (INCLUDES LP)-HOSP 252.00 06/30/10 96450 96450 Q0083 071 0331 0524
12340062 INTRATHECAL (INCLUDES LP)-M.D. 190.00 $ 06/30/09 96450 96450 96450 071 0983 0524
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 412
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12340133 BLOOD OCCULT FECAL SCREEN 34.00 06/30/10 82270 82270 82270 071 0301 0524
12340137 SKIN TEST,TB,INTRADERMAL 46.00 06/30/10 86580 86580 86580 071 0302 0524
12340151 BONE MARROW ASPIRAT ONLY-HOSP 297.00 06/30/10 38220 38220 38220 071 0510 0524
12340152 BONE MARROW ASPIRAT ONLY-M.D. 126.00 $ 06/30/09 38220 38220 38220 071 0983 0524
12340157 BONE MARROW BIOPSY-HOSP 242.00 06/30/10 38221 38221 38221 071 0510 0524
12340158 BONE MARROW BIOPSY-M.D. 160.00 $ 06/30/09 38221 38221 38221 071 0983 0524
12340163 INTERPRETATION OF SMEAR-HOSP 116.00 06/30/10 85097 85097 85097 071 0305 0524
12340164 INTERPRETATION OF SMEAR-M.D. 99.00 $ 06/30/09 85097 85097 85097 071 0971 0524
12340169 SPINAL PUNCTURE,LUMBAR-HOSP 351.00 06/30/10 62270 62270 62270 071 0360 0524
12340170 SPINAL PUNCTURE,LUMBAR-M.D. 158.00 $ 06/30/09 62270 62270 62270 071 0975 0524
12340187 PARACENTESIS,SUBSEQUENT-HOSP 293.00 06/30/10 49081 49081 49081 071 0360 0524
12340188 PARACENTESIS,SUBSEQUENT-M.D. 143.00 $ 06/30/09 49081 49081 49081 071 0975 0524
12340193 THORACENTESIS-HOSP 373.00 06/30/10 32421 32421 32421 071 0360 0524
12340194 THORACENTESIS-M.D. 164.00 $ 06/30/09 32421 32421 32421 071 0975 0524
12340199 CVC PLACEMENT>2YRS OLD-HOSP 770.00 06/30/10 36555 36555 36555 071 0360 0524
12340200 CVC PLACEMENT>2YRS OLD-M.D. 266.00 $ 06/30/09 36555 36555 36555 071 0975 0524
12340205 BLOOD/PLATELET TRANSFUSION 763.00 06/30/10 36430 36430 36430 071 0391 0524
12340209 SKIN BIOP,SINGLE LESION-HOSP 201.00 06/30/10 11100 11100 11100 071 0360 0524
12340210 SKIN BIOP,SINGLE LESION-M.D. 95.00 $ 06/30/09 11100 11100 11100 071 0975 0524
12340215 ARTERIAL PUNCTURE-HOSP 95.00 06/30/10 36600 36600 36600 071 0360 0524
12340216 ARTERIAL PUNCTURE-M.D. 33.00 $ 06/30/09 36600 36600 36600 071 0975 0524
12340235 INSRT TMP INDWLL BLD CATH-HOSP 98.00 06/30/10 51702 51702 51702 071 0360 0524
12340236 INSRT TMP INDWLL BLD CATH-M.D. 68.00 $ 06/30/09 51702 51702 51702 071 0975 0524
12340300 BCG VACCINE, PERCUTANEOUS 186.00 06/30/10 90585 90585 90585 071 0636 0524
12340310 HEP A,HEP B VACC,ADLT IM 133.00 06/30/10 90636 90636 90636 071 0636 0524
12340314 INJECT SUBQ/IM HORMONAL DRUG 431.00 06/30/10 96402 96402 96402 071 0510 0524
12340316 IV PUSH, CHEMOTHERAPY, INITIAL 399.00 06/30/10 96409 96409 96409 071 0335 0524
12340318 IV PUSH, CHEMOTHERAPY, ADDL 265.00 06/30/10 96411 96411 96411 071 0335 0524
12340324 CHEMO IV INFUSION: EA ADDL HR 510.00 06/30/10 96415 96415 96415 071 0335 0524
12340326 ADDL INFUSION OF DRUG W/PUMP 694.00 06/30/10 96417 96417 96417 071 0335 0524
12340328 CHEMO INTRA-ARTERIAL PUSH 337.00 06/30/10 96420 96420 96420 071 0335 0524
12340330 INTRA-ART CHEMO INFUS,1ST HR 589.00 06/30/10 96422 96422 96422 071 0335 0524
12340332 INTRA-ART CHEMO INFUS,ADDL HR 569.00 06/30/10 96423 96423 96423 071 0335 0524
12340334 PUMP INFUSION >8HRS,NON-CHEMO 833.00 06/30/10 96425 96425 96425 071 0335 0524
12340336 CHEMOTHERAPY/THORACENTESIS 426.00 06/30/10 96440 96440 96440 071 0280 0524
12340338 CHEMOTHERAPY/PERITONEAL CAVITY 519.00 06/30/10 96445 96445 96445 071 0280 0524
12340340 CHEMOTHERAPY/INTRATHECAL 587.00 06/30/10 96450 96450 96450 071 0331 0524
12340342 IRRIG OF VENOUS ACCESS DEVICE 90.00 06/30/10 96523 96523 96523 071 0510 0524
12340344 CHEMO INJECTION VIA RESERVOIR 417.00 06/30/10 96542 96542 96542 071 0940 0524
12340346 PATIENT MANAGEMENT EA 30 MIN 34.00 06/30/10 98960 98960 98960 071 0942 0524
12340348 IVIG ENCOUNTER CHARGE 183.00 06/30/10 J1568 J1568 J1568 071 0510 0524
12340351 BONE MARROW ASPIRATION-HOSP 133.00 06/30/10 G0364 G0364 G0364 071 0360 0524
12340352 BONE MARROW ASPIRATION-M.D. 23.00 $ 06/30/09 G0364 G0364 G0364 071 0361 0524
12340360 NON-COV PROC,CLINIC TRIAL 94.00 06/30/10 G0294 G0294 G0294 071 0940 0524
12340381 PICC LINE 5YRS OR OLDER-HOSP 1434.00 06/30/10 36569 36569 36569 071 0361 0524
12340382 PICC LINE 5YRS OR OLDER-M.D. 215.00 $ 06/30/09 36569 36569 36569 071 0975 0524
12340387 RMVL CENTRAL VENOUS CATH-HOSP 660.00 06/30/10 36589 36589 36589 071 0360 0524
12340388 RMVL CENTRAL VENOUS CATH-M.D. 303.00 $ 06/30/09 36589 36589 36589 071 0975 0524
12350001 CYSTO, W/INSRT URETER CATH 2542.00 06/30/10 51045 51045 51045 071 0360 0524
12350005 BLADDER IRRIG, LAVAGE 211.00 06/30/10 51700 51700 51700 071 0360 0524
12350007 STRAIGHT CATH, URETHA 86.00 06/30/10 51701 51701 51701 071 0360 0524
12350009 INSRT BLAD CATH (FOLEY) 98.00 06/30/10 51702 51702 51702 071 0360 0524
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 413
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12350011 SUPER PUBIC CATH 144.00 06/30/10 51703 51703 51703 071 0510 0524
12350015 CHANGE CYSTO TUBE, SIMP 219.00 06/30/10 51705 51705 51705 071 0360 0524
12350027 BLADDER INSTILLATION 183.00 06/30/10 51720 51720 51720 071 0360 0524
12350033 CYSTOMETROGRAM-SIMPLE 399.00 06/30/10 51725 51725 51725 071 0360 0524
12350035 CYSTOMETROGRAM-COMPLEX 524.00 06/30/10 51726 51726 51726 071 0510 0524
12350045 UROFLOWMETRY, COMPLEX 187.00 06/30/10 51741 51741 51741 071 0920 0524
12350051 EMG ANAL OR URETH SPHINCT 326.00 06/30/10 51785 51785 51785 071 0490 0524
12350057 VOIDING PRESSURE STUDIES 582.00 06/30/10 51729 51729 51729 071 0920 0524
12350059 VOIDING & URETH PRESS STUDIES 582.00 06/30/10 51729 51729 51729 071 0920 0524
12350063 CYSTOSCOPY 995.00 06/30/10 52000 52000 52000 071 0360 0524
12350071 CYSTOSCOPY, BLADDER BIOP 1158.00 06/30/10 52204 52204 52204 071 0360 0524
12350083 CYSTO W/DILATION 2385.00 06/30/10 52281 52281 52281 071 0360 0524
12350095 CYSTOSCOPY, REM URE STENT 1175.00 06/30/10 52310 52310 52310 071 0360 0524
12350101 DILAT URETH STRICT (S&D) 127.00 06/30/10 53600 53600 53600 071 0360 0524
12350111 DILAT URETH STRICT (F&F) 183.00 06/30/10 53620 53620 53620 071 0360 0524
12350117 DILAT FEMALE URETH INIT 150.00 06/30/10 53660 53660 53660 071 0360 0524
12350123 FULG PENILE CONDYLOMA, EXT 355.00 06/30/10 54055 54055 54055 071 0360 0524
12350131 DEST LES,PENIS,SIMP:LASER 3942.00 06/30/10 54057 54057 54057 071 0360 0524
12350137 CORP CAVERN IRRIG PRIAP 294.00 06/30/10 54220 54220 54220 071 0360 0524
12350149 INJECT CORPORA CAVERNOSA 194.00 06/30/10 54235 54235 54235 071 0360 0524
12350153 BIOPSY OF PENIS 3453.00 06/30/10 54100 54100 54100 071 0360 0524
12350157 VASECTOMY 1255.00 06/30/10 55250 55250 55250 071 0360 0524
12350169 BIOPSY,PROST,NEEDLE PUNCH 858.00 06/30/10 55700 55700 55700 071 0360 0524
12350177 BLADDER SCAN 109.00 06/30/10 76705 76705 76705 071 0402 0524
12350189 ECHO TRANSRECT,ULTRASOUND 210.00 06/30/10 76872 76872 76872 071 0402 0524
12350197 US GUID NDLE PLMT IMG S&I 754.00 07/27/10 76942 76942 76942 071 0402 0524
12351001 INCIS/DRAIN,ABSCESS;SIMP 164.00 06/30/10 10060 10060 10060 071 0360 0524
12351003 LIP BIOPSY 321.00 06/30/10 40490 40490 40490 071 0360 0524
12351005 BIOPSY OF PALATE,UVULVA 591.00 06/30/10 42100 42100 42100 071 0360 0524
12351007 BIOPSY OF SALIVARY GLAND NEEDL 421.00 06/30/10 42400 42400 42400 071 0360 0524
12351009 BIOP OF TONGUE-ANTERIOR 2/3 1447.00 06/30/10 41100 41100 41100 071 0360 0524
12351011 BIOP OF TONGUE-POSTERIOR 1/3 3311.00 06/30/10 41105 41105 41105 071 0360 0524
12351013 BIOPSY SOFT TISSUE NECK 715.00 06/30/10 20206 20206 20206 071 0360 0524
12351015 BIOPSY FLOOR OF MOUTH 1017.00 06/30/10 41108 41108 41108 071 0360 0524
12351017 CHEM CAUTERIZ GRANULAT TISS 120.00 06/30/10 17250 17250 17250 071 0360 0524
12351019 DILAT ESOPH BALLOON/DILAT RETR 731.00 06/30/10 43456 43456 43456 071 0360 0524
12351021 DRAINAGE ABSC; SUBMAX EXTERNAL 236.00 06/30/10 42320 42320 42320 071 0360 0524
12351023 DRAINAGE OF ABCES PAROTID SMPL 1762.00 06/30/10 42300 42300 42300 071 0360 0524
12351025 DRAIN ABSCESS MOUTH SMPL 194.00 06/30/10 40800 40800 40800 071 0360 0524
12351027 EX MAL LES FCE;ERS;EYLD;<.5CM 688.00 06/30/10 11640 11640 11640 071 0360 0524
12351029 EX BEN LES NECK TO .5 CM 287.00 06/30/10 11420 11420 11420 071 0360 0524
12351031 EX BEN LES FCE;ERS;EYLD;<.5CM 296.00 06/30/10 11440 11440 11440 071 0360 0524
12351033 EX BEN LES FCE;ERS;EYLD;.6-1CM 857.00 06/30/10 11441 11441 11441 071 0360 0524
12351035 FOR BDY REM-MOUTH/THROAT 330.00 06/30/10 40804 40804 40804 071 0360 0524
12351037 I&D ABSCESS COMPLICATED/MULTPL 269.00 06/30/10 10061 10061 10061 071 0360 0524
12351039 I&D ABSC PERITONSILLAR 359.00 06/30/10 42700 42700 42700 071 0360 0524
12351041 INCIS/DRN POST-OP WND INF 940.00 06/30/10 10180 10180 10180 071 0360 0524
12351043 I&D OF HEMATOMA/SEROMA 300.00 06/30/10 10140 10140 10140 071 0360 0524
12351045 LARYNGSCPY FLEX FIBEROPTIC 184.00 06/30/10 31575 31575 31575 071 0360 0524
12351047 LAY CLOS,FACE/LIPS 2.5CM OR < 301.00 06/30/10 12051 12051 12051 071 0360 0524
12351049 NASAL ENDO DX UNI/BIL SEP PROC 332.00 06/30/10 31231 31231 31231 071 0360 0524
12351051 PUNCT ASP ABCES HEMA BULLA/CYS 100.00 06/30/10 10160 10160 10160 071 0360 0524
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 414
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12351053 RMVL OF SKIN TAGS UP TO 15 172.00 06/30/10 11200 11200 11200 071 0360 0524
12351055 RMV SKIN TAGS EACH ADDL 10 129.00 06/30/10 11201 11201 11201 071 0360 0524
12351057 SIMPL REPR FACE&/MUCOUS <2.5CM 267.00 06/30/10 12011 12011 12011 071 0360 0524
12351059 SKIN BIOP,SINGLE LESION 165.00 06/30/10 11100 11100 11100 071 0360 0524
12351061 BIOPSY ADDL SUBCUT TISSUE 130.00 06/30/10 11101 11101 11101 071 0360 0524
12351063 TRACHEOTOMY TUBE CHANGE 368.00 06/30/10 31502 31502 31502 071 0360 0524
12351065 NASO/ORO GASTR TUBE PLACE 219.00 06/30/10 43752 43752 43752 071 0360 0524
12351067 LARYNGOSCOPY FOR ASPIRATION 3733.00 05/01/10 31515 31515 31515 071 0360 0524
12351069 NASOPHARYNGOSCOPY 242.00 04/01/10 92511 92511 92511 071 0471 0524
17200815 THERAPEUTIC INJ,IV 57.00 06/30/10 96374 96374 96374 071 0940 0641
19900143 CHEMOTHERAPY/INTRATHECAL-M.D. 190.00 $ 06/30/09 96450 96450 96450 071 0983 0599
19900160 REFILL/MAINTENANCE PORT PUMP 402.00 06/30/10 96521 96521 96521 071 0940 0599
19900165 REFILL/MAINTEN IMPLANT PUMP 402.00 06/30/10 96522 96522 96522 071 0510 0599
13300070 PROLNG DIR EVAL 30-74MIN-HOSP 238.00 06/30/10 99354 99354 99354 073 0510 0648
13300071 PROLNG DIR EVAL 30-74MIN-M.D. 186.00 $ 06/30/09 99354 99354 99354 073 0983 0648
13300072 PROLNG DIR EVAL EA 30MIN-HOSP 120.00 06/30/10 99355 99355 99355 073 0510 0648
13300073 PROLNG DIR EVAL EA 30MIN-M.D. 183.00 $ 06/30/09 99355 99355 99355 073 0983 0648
14300002 VOIDED N/C 06/01/01 073 0983 9998
14300404 VOID EXTERNAL 04/01/07 073 0975 9999
14300586 VOID EXTERNAL 04/01/07 073 0972 9999
12510001 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 074 0510 0636
12510010 LIPID PROFILE 202.00 06/30/10 80061QW 80061QW 80061QW 074 0300 0636
12510020 GLUCOSE FINGERSTICK 41.00 06/30/10 82948 82948 82948 074 0301 0636
12510030 PROTHROMBIN TIME 51.00 06/30/10 85610QW 85610QW 85610QW 074 0305 0636
12510040 EKG TRACING & INTERPRET-HOSP 207.00 06/30/10 93005 93005 93005 074 0730 0636
12510041 EKG TRACING & INTERPRET-M.D. 19.00 $ 06/30/09 93010 93010 93010 074 0985 0636
12510047 CARD STRES TST-PHYS SUPER-M.D. 52.00 $ 06/30/09 93016 93016 93016 074 0985 0636
12510048 EXR STRSS TST TRDML/BICYC-HOSP 761.00 06/30/10 93017 93017 93017 074 0482 0636
12510049 CARD STRES TST-INTRP/RPT-M.D. 34.00 $ 06/30/09 93018 93018 93018 074 0985 0636
12510060 HOLTER MONITOR TEST-24HR 562.00 06/30/10 93225 93225 93225 074 0731 0636
12510062 HOLTER MONITOR WITH SCAN 866.00 06/30/10 93226 93226 93226 074 0731 0636
12510064 HOLTER MONITOR W/PHY INT-M.D. 61.00 $ 06/30/09 93227 93227 93227 074 0985 0636
12510070 EVENT MONITOR HOOK-UP 386.00 06/30/10 93270 93270 93270 074 0730 0636
12510072 EVNT MONITOR W/SCAN-ANALY 438.00 06/30/10 93271 93271 93271 074 0730 0636
12510075 EVNT MON PHYS REV/INTERPR.M.D. 58.00 $ 06/30/09 93272 93272 93272 074 0985 0636
12510080 PPM PRGRM EVAL W/ADJ-SING 71.00 06/30/10 93279 93279 93279 074 0480 0636
12510082 PPM PRGRM EVAL W/ADJ-SING-M.D. 77.00 $ 06/30/09 9327926 9327926 9327926 074 0983 0636
12510084 PPM PRGRM EVAL W/ADJ-DUAL 71.00 06/30/10 93280 93280 93280 074 0480 0636
12510086 PPM PRGRM EVAL W/ADJ-DUAL-M.D. 92.00 $ 06/30/09 9328026 9328026 9328026 074 0983 0636
12510088 PPM PRGRM EVAL W/ADJ-MULT 71.00 06/30/10 93281 93281 93281 074 0480 0636
12510090 PPM PRGRM EVAL W/ADJ-MULT-M.D. 107.00 $ 06/30/09 93281 93281 93281 074 0983 0636
12510092 ICD PROG EVL W/ADJST-SING 120.00 06/30/10 93282 93282 93282 074 0480 0636
12510094 ICD PROG EVL W/ADJST-SING-M.D. 101.00 $ 06/30/09 9328226 9328226 9328226 074 0983 0636
12510096 ICD PROG EVL W/ADJST-DUAL 120.00 06/30/10 93283 93283 93283 074 0480 0636
12510098 ICD PROG EVL W/ADJST-DUAL-M.D. 127.00 $ 06/30/09 9328326 9328326 9328326 074 0921 0636
12510100 ICD PROG EVL W/ADJST-MULT 120.00 06/30/10 93284 93284 93284 074 0480 0636
12510102 ICD PROG EVL W/ADJST-MULT-M.D. 150.00 $ 06/30/09 93284 93284 93284 074 0983 0636
12510108 PPM INTEROG:SING/DUAL/MUL 71.00 06/30/10 93288 93288 93288 074 0480 0636
12510110 PPM INTEROG:SING/DUAL/MUL-M.D. 51.00 $ 06/30/09 9328826 9328826 9328826 074 0983 0636
12510112 ICD INTEROG:SING/DUAL/MUL 120.00 06/30/10 93289 93289 93289 074 0480 0636
12510114 ICD INTEROG:SING/DUAL/MUL-M.D. 92.00 $ 06/30/09 9328926 9328926 9328926 074 0983 0636
12510120 PPM PHONE CHECK - HOSP 91.00 06/30/10 93293 93293 93293 074 0480 0636
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 415
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12510121 PPM PHONE CHECK - M.D. 37.00 $ 06/30/09 93293 93293 93293 074 0983 0636
12510130 ECHO COMPLETE - HOSP 1317.00 06/30/10 93306 93306 93306 074 0480 0636
12510131 ECHO COMPLETE - M.D. 152.00 $ 06/30/09 9330626 9330626 9330626 074 0983 0636
12510134 ECHOCARDIO 2D M-MODEL;LTD-HOSP 390.00 06/30/10 93308 93308 93308 074 0480 0636
12510135 ECHOCARDIO 2D M-MODEL;LTD-M.D. 62.00 $ 06/30/09 93308 93308 93308 074 0960 0636
12510144 ECHO DURING REST & STRESS-HOSP 1237.00 06/30/10 93350 93350 93350 074 0480 0636
12510145 ECHO DURING REST & STRESS-M.D. 171.00 $ 06/30/09 9335026 9335026 9335026 074 0985 0636
12510150 USE OF CTST AGT STRS ECHO-M.D. 85.00 $ 06/30/09 93352 93352 93352 074 0983 0636
12510160 SMRT-DOP SING LVL BI STDY 158.00 06/30/10 93922 93922 93922 074 0921 0636
12510162 SMRT-DOP MULT LVL BI STDY 219.00 06/30/10 93923 93923 93923 074 0921 0636
12510164 LOWER EXTREM ARTER STRESS TEST 219.00 06/30/10 93924 93924 93924 074 0921 0636
12510170 PULM STRESS TESTING-SIMP-HOSP 147.00 06/30/10 94620 94620 94620 074 0460 0636
12510171 PULM STRESS TESTING-SIMP-M.D. 161.00 $ 09/01/09 94620 94620 94620 074 0976 0636
12510172 PULM STRESS TESTING-COMP-HOSP 641.00 06/30/10 94621 94621 94621 074 0460 0636
12510173 PULM STRESS TESTING-COMP-M.D. 352.00 $ 09/01/09 94621 94621 94621 074 0976 0636
12510180 PULSE OXIMETRY - SING 99.00 06/30/10 94760 94760 94760 074 0460 0636
12510200 NORMAL SALINE SOL. 1000CC 50.00 06/30/10 J7030 J7030 J7030 074 0636 0636
12510206 NORMAL SALINE SOL. 500ML 48.00 06/30/10 J7040 J7040 J7040 074 0636 0636
12510220 DEFINITY INJ, 1ML 302.00 06/30/10 Q9957 Q9957 Q9957 074 0636 0636
13300248 ARTERIAL PUNCTURE - HOSP 108.00 06/30/10 36600 36600 36600 074 0360 0648
13300249 ARTERIAL PUNCTURE - M.D. 33.00 $ 06/30/10 36600 36600 36600 074 0975 0648
13300310 PULSE OX.- CONTINUOUS 264.00 06/30/10 94762 94762 94762 074 0460 0648
13300420 ECG 12 LEAD TRACE-HOSP 207.00 06/30/10 93005 93005 93005 074 0730 0648
13300421 ECG 12 LEAD TRACE-M.D. 19.00 $ 06/30/09 93010 93010 93010 074 0985 0648
13300424 DEFIB ANALYSIS W/REPROG-HOSP 249.00 08/10/08 93742 93742 93742 074 0921 0648
13300425 DEFIB ANALYSIS W/REPROG-M.D. 135.00 06/30/10 93742 9374226 9374226 074 0983 0648
13300428 DEFIB ANALYSIS W/O REPROG-HOSP 194.00 08/10/08 93743 93743 93743 074 0921 0648
13300429 DEFIB ANALYSIS W/O REPROG-M.D. 68.00 08/10/08 93743 9374326 9374326 074 0983 0648
13300432 ECG RHYTHM STRP INTERPRET-HOSP 53.00 06/30/10 93042 93042 93042 074 0985 0648
13300433 ECG RHYTHM STRP INTERPRET-M.D. 17.00 $ 06/30/09 93042 93042 93042 074 0985 0648
13300436 ECG 12/24 HR TAPE-HOSP 363.00 06/30/10 93227 93227 93227 074 0985 0648
13300437 ECG 12/24 HR TAPE-M.D. 61.00 $ 06/30/09 93227 93227 93227 074 0985 0648
13300638 DEFIB ANALYSIS W/REPROG-HOSP 229.00 08/10/08 93742 93742 93742 074 0921 0648
13300639 DEFIB ANALYSIS W/REPROG-M.D. 108.00 08/10/08 93742 93742 93742 074 0983 0648
13300644 DEFIB ANALYSIS W/O REPROG-HOSP 194.00 08/10/08 93743 93743 93743 074 0921 0648
13300645 DEFIB ANALYSIS W/O REPROG-M.D. 171.00 08/10/08 93743 93743 93743 074 0983 0648
13300836 PPM INTEROG:SING/DUAL/MUL-HOSP 71.00 06/30/10 93288 93288 93288 074 0480 0648
13300837 PPM INTEROG:SING/DUAL/MUL-M.D. 51.00 $ 06/30/09 93288 93288 93288 074 0983 0648
13300840 PPM PRGRM EVAL W/ADJ-SING-HOSP 71.00 06/30/10 93279 93279 93279 074 0480 0648
13300841 PPM PRGRM EVAL W/ADJ-SING-M.D. 77.00 $ 06/30/09 93279 93279 93279 074 0983 0648
93722503 VOID EXTERNAL 04/01/07 074 0982 9999
12666935 DXA WHOLE BODY COMP-HOSP 312.00 06/30/10 76499 76499 76499 075 0320 0602
03701945 T/B PANEL 238.00 06/30/10 88182 88182 88182 076 0311 3313
03773557 POST OPERATIVE FOLLOW UP VISIT N/C 06/30/10 99024 99024 99024 076 0510 0668
12666564 SCREEN-PAP,PREP & CONVEY-M.D. 39.00 $ 06/30/09 Q0091 Q0091 Q0091 076 0983 0602
41320108 INSERT AICD SNGL CHMB & LEAD 17560.00 06/30/10 33249 33249 33249 076 0360 3333
02500181 INTRO-NDLE/INTRACATH,VEIN-HOSP 135.00 06/30/10 36000 36000 36000 078 0510 1910
02500182 INTRO-NDLE/INTRACATH,VEIN-M.D. 20.00 $ 06/30/09 36000 36000 36000 078 0975 1910
02500185 TRANFUS BLOOD/BLD COMPS 775.00 06/30/10 36430 36430 36430 078 0391 1910
02500270 RENAL BIOP,PERC,TROC/NDL-HOSP 667.00 06/30/10 50200 50200 50200 078 0361 1910
02500271 RENAL BIOP,PERC,TROC/NDL-M.D. 316.00 $ 06/30/09 50200 50200 50200 078 0975 1910
02500280 BLADDER SCAN-DIAG U/S-HOSP 115.00 06/30/10 51798 51798 51798 078 0402 1910
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 416
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

02500281 BLADDER SCAN-DIAG U/S-M.D. 52.00 $ 06/30/09 5179826 5179826 5179826 078 0983 1910
02500320 US RETROPERIT B-SCAN;CMPL-HOSP 190.00 06/30/10 76770 76770 76770 078 0402 1910
02500321 US RETROPERIT B-SCAN;CMPL-M.D. 80.00 $ 06/30/09 76770 76770 76770 078 0972 1910
02500330 US RETROPERIT B-SCAN;LMTD-HOSP 212.00 06/30/10 76775 76775 76775 078 0402 1910
02500331 US RETROPERIT B-SCAN;LMTD-M.D. 65.00 $ 06/30/09 7677526 7677526 7677526 078 0972 1910
02500332 US EXAM K TRANSPL W/DOPP-HOSP 210.00 06/30/10 76776 76776 76776 078 0402 1910
02500333 US EXAM K TRANSPL W/DOPP-M.D. 82.00 $ 06/30/09 76776 76776 76776 078 0972 1910
02500380 HEPATITIS B 226.00 06/30/10 90746 90746 90746 078 0636 1910
02500395 EPO ADMIN LAB CT: EXTERNAL 01/01/09 96372 96372 96372 078 0940 1910
06750035 SPIROMETRY-HOSP 220.00 06/30/10 94010 94010 94010 078 0460 0663
06750036 SPIROMETRY-M.D. 18.00 $ 06/30/09 94010 94010 94010 078 0983 0663
08900061 THERA,DX OR PROPHY INJ,INITIAL 125.00 06/30/10 96374 96374 96374 078 0940 6812
08900062 THERAP INJ,IV-EA ADDL 125.00 06/30/10 96375 96375 96375 078 0940 6812
11700001 IV HYDRA,INIT UP TO 1 HR 402.00 06/30/10 96360 96360 96360 078 0260 3400
11700002 IV HYDR EA ADD HR UP TO 8 244.00 06/30/10 96361 96361 96361 078 0260 3400
11700005 VACCINE FLU SPLIT 3YR+ IM/JET 33.00 06/30/10 90658 90658 90658 078 0636 3400
11700008 ADMN INFLU VIRUS VACCINE 36.00 06/30/10 90471 G0008 90471 078 0771 3400
11700011 VACCINE PNEUMO 2YR/> SUBQ/JET 50.00 06/30/10 90732 90732 90732 078 0636 3400
11700014 ADMN PNEUMOC VACCINE 43.00 06/30/10 90471 G0009 90471 078 0771 3400
11700017 IV THER INFUSION, UP TO ONE HR 491.00 06/30/10 96365 96365 96365 078 0260 3400
11700020 THERAPEUTIC INJ,IV 236.00 06/30/10 96374 96374 96374 078 0940 3400
11700023 THERAPEUTIC INJ,IM OR SUB 86.00 06/30/10 96372 96372 96372 078 0940 3400
11700038 THERAP INFUSION-EA ADD'L HR 296.00 06/30/10 96366 96366 96366 078 0260 3400
11700042 THERAP INJ,IVP-EA ADDL 125.00 06/30/10 96375 96375 96375 078 0260 3400
11700045 DIRECT ADMIT FOR OBS CARE 532.00 06/30/10 G0379 G0379 G0379 078 0762 3400
11700047 SPEC FROM PORT/CENT LINE 228.00 06/30/10 36591 36591 36591 078 0260 3400
11700049 PV BLOOD SPEC-CENTRAL LINE 134.00 06/30/10 36592 36592 36592 078 0360 3400
12666001 NASO GAST. - HOSP 64.00 06/30/10 91055 91055 91055 078 0750 0602
12666002 NASO GAST.- M.D. 129.00 $ 06/30/10 91055 9105526 9105526 078 0940 0602
12666003 SKIN TEST-READING 64.00 06/30/10 95010 95010 95010 078 0924 0602
12666004 SKIN TEST-READING-M.D. 37.00 $ 06/30/09 95010 95010 95010 078 0983 0602
12666005 SM JOINT,BURSA OR GANLON-HOSP 144.00 06/30/10 20600 20600 20600 078 0360 0602
12666006 SM JOINT,BURSA OR GANGLION-M.D 85.00 $ 06/30/09 20600 20600 20600 078 0975 0602
12666007 INJ,TENDON SHEATH,LIGMENT-HOSP 186.00 06/30/10 20550 20550 20550 078 0360 0602
12666008 INJ,TENDON SHEATH,LIGAMENT-M.D 89.00 $ 06/30/09 20550 20550 20550 078 0975 0602
12666010 BLOOD GLUCOSE,GLUCOMETER 44.00 06/30/10 82962 82962 82962 078 0301 0602
12666011 CRYSTAL IDENTIFICATION 98.00 06/30/10 89060 89060 89060 078 0300 0602
12666012 IV INF THER/PROPH/DIAG:INIT 264.00 06/30/10 96365 96365 96365 078 0260 0602
12666013 IMMUNIZATION; DPT 18.00 06/30/10 90701 90701 90701 078 0636 0602
12666014 IMMUNIZATION; MEASLES 27.00 06/30/10 90705 90705 90705 078 0636 0602
12666015 IMMUNIZATION; RUBELLA 18.00 06/30/10 90706 90706 90706 078 0636 0602
12666018 TETANUS TOXOID ABSORB,IM 38.00 06/30/10 90703 90703 90703 078 0636 0602
12666020 CHEMO IV INFUS:INIT UP TO 1HR 498.00 06/30/10 96413 96413 96413 078 0335 0602
12666023 PSYCH DIAG INTERVIEW EXAM-HOSP 127.00 06/30/10 90801 90801 90801 078 0510 0602
12666024 PSYCH DIAG INTERVIEW EXAM-M.D. 269.00 $ 06/30/09 90801 90801 90801 078 0961 0602
12666027 SIMPLE UROFLOWMETRY - HOSP 236.00 06/30/10 51736 51736 51736 078 0920 0602
12666028 SIMPLE UROFLOWMETRY - M.D. 71.00 $ 06/30/09 5173626 5173626 51736 078 0982 0602
12666030 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 078 0510 0602
12666033 ARTHROCENT INT JNT/BURSA-HOSP 133.00 06/30/10 20605 20605 20605 078 0360 0602
12666034 ARTHROCENT INT JNT/BURSA-M.D. 88.00 $ 06/30/09 20605 20605 20605 078 0975 0602
12666035 ARTHROCENT MAJ JNT/BURSA-HOSP 440.00 06/30/10 20610 20610 20610 078 0360 0602
12666036 ARTHROCENT MAJ JNT/BURSA-MD 107.00 $ 06/30/09 20610 20610 20610 078 0975 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 417
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666039 ASPIRAT/INJ FOR BONE CYST-HOSP 416.00 06/30/10 20615 20615 20615 078 0360 0602
12666040 ASPIRAT/INJ FOR BONE CYST-M.D. 320.00 $ 06/30/09 20615 20615 20615 078 0975 0602
12666043 PUNC ASP ABSCESS HEMATOMA-HOSP 100.00 06/30/10 10160 10160 10160 078 0360 0602
12666044 PUNC ASP ABSCESS HEMATOMA-M.D. 193.00 $ 06/30/09 10160 10160 10160 078 0975 0602
12666047 BIOPSY MUSCLE SUPERFICAL HOSP 641.00 06/30/10 20200 20200 20200 078 0360 0602
12666048 BIOPSY MUSCLE SUPERFICIAL-M.D. 197.00 $ 06/30/09 20200 20200 20200 078 0975 0602
12666051 BIOPSY BONE TROCAR-SUPER-HOSP 637.00 06/30/10 20220 20220 20220 078 0360 0602
12666052 BIOPSY BONE TROCAR-SUPER-M.D. 162.00 $ 06/30/09 20220 20220 20220 078 0975 0602
12666055 OSTEO MANIP TRTMNT 1-2-HOSP 47.00 06/30/10 98925 98925 98925 078 0530 0602
12666056 OSTEO MANIP TRTMNT 1-2-M.D. 46.00 $ 06/30/09 98925 98925 98925 078 0983 0602
12666058 ADULT DT 40.00 06/30/10 90718 90718 90718 078 0636 0602
12666060 VACCINE,ADMIN,SINGLE VAC 110.00 06/30/10 90471 90471 90471 078 0771 0602
12666061 VACCINE,ADMIN,EACH ADDL 82.00 06/30/10 90472 90472 90472 078 0771 0602
12666065 PULSE OXIMETRY-SING 99.00 06/30/10 94760 94760 94760 078 0460 0602
12666066 PULSE OXIMETRY-MULT 143.00 06/30/10 94761 94761 94761 078 0460 0602
12666072 SKIN TEST; TB TINE 43.00 06/30/10 86580 86580 86580 078 0302 0602
12666075 ANERGY BATTERY-HOSP 61.00 06/30/10 86486 86486 86486 078 0302 0602
12666076 ANERGY BATTERY-M.D. 12.00 $ 06/30/09 86486 86486 86486 078 0971 0602
12666079 SPIROMETRY-HOSP 220.00 06/30/10 94010 94010 94010 078 0460 0602
12666080 SPIROMETRY-M.D. 18.00 $ 06/30/09 94010 9401026 9401026 078 0983 0602
12666083 VITAL CAPACITY, TOTAL 74.00 06/30/10 9415026 94150 94150 078 0460 0602
12666084 VITAL CAPACITY, TOTAL-M.D. 60.00 06/30/09 9415026 9415026 9415026 078 0976 0602
12666086 PERCUTANEOUS TEST (PER TEST) 64.00 06/30/10 95004 95004 95004 078 0924 0602
12666087 INTRACUT TESTS-ALLERG-IMMED 86.00 06/30/10 95024 95024 95024 078 0924 0602
12666088 INTRACUT TESTS-DELAYED 74.00 06/30/10 95028 95028 95028 078 0924 0602
12666090 MMR 180.00 06/30/10 90707 90707 90707 078 0636 0602
12666093 THORACENTESIS-HOSP 373.00 06/30/10 32421 32421 32421 078 0360 0602
12666094 THORACENTESIS-M.D. 164.00 $ 06/30/09 32421 32421 32421 078 0975 0602
12666097 ABDOMINAL PARACEN-INITIAL-HOSP 293.00 06/30/10 49080 49080 49080 078 0360 0602
12666098 ABDOMINAL PARACEN-INITIAL-M.D. 151.00 $ 06/30/09 49080 49080 49080 078 0975 0602
12666101 ABDOMINAL PARACEN-SUBSEQ-HOSP 293.00 06/30/10 49081 49081 49081 078 0360 0602
12666102 ABDOMINAL PARACEN-SUBSEQ-M.D. 143.00 $ 06/30/09 49081 49081 49081 078 0975 0602
12666103 BLADDER SCAN-DIAG U/S-HOSP 99.00 06/30/10 51798 51798 51798 078 0402 0602
12666104 BLADDER SCAN-DIAG U/S-M.D. 52.00 $ 06/30/09 51798 51798 51798 078 0983 0602
12666105 COLPSOCOPY(VAGINASCOPY)-HOSP 330.00 06/30/10 57452 57452 57452 078 0360 0602
12666106 COLPOSCOPY(VAGINASCOPY)-M.D. 195.00 $ 06/30/09 57452 57452 57452 078 0975 0602
12666109 COLPOSCOPY WITH BIOPSY-HOSP 545.00 06/30/10 57454 57454 57454 078 0360 0602
12666110 COLPOSCOPY WITH BIOPSY-M.D. 292.00 $ 06/30/09 57454 57454 57454 078 0975 0602
12666113 ENDOCERVICAL CURETTAGE-HOSP 335.00 06/30/10 57505 57505 57505 078 0360 0602
12666114 ENDOCERVICAL CURETTAGE-M.D. 190.00 $ 06/30/09 57505 57505 57505 078 0975 0602
12666117 NST COMPLETE-HOSP 193.00 06/30/10 59025 59025 59025 078 0920 0602
12666118 NST COMPLETE-M.D. 71.00 $ 06/30/09 59025 59025 5902526 078 0983 0602
12666121 LUMBAR PUNCTURE-HOSP 333.00 06/30/10 62270 62270 62270 078 0360 0602
12666122 LUMBAR PUNCTURE-M.D. 158.00 $ 06/30/09 62270 62270 62270 078 0975 0602
12666125 EXAM DRK FIELD ANY SOURCE-HOSP 46.00 06/30/10 87164 87164 87164 078 0306 0602
12666126 EXAM DRK FIELD ANY SOURCE-M.D. 38.00 $ 06/30/09 87164 8716426 8716426 078 0971 0602
12666135 HEMATOCRIT 39.00 06/30/10 85013 85013 85013 078 0305 0602
12666137 VISION SCREENING-HOSP 21.00 06/30/10 92002 92002 92002 078 0920 0602
12666139 VISION SCREENING-M.D. 91.00 $ 06/30/09 92002 92002 92002 078 0983 0602
12666140 DEVELOP TESTING,EXTENDED 37.00 06/30/10 96111 96111 96111 078 0918 0602
12666149 DEVELPMNTL SCRN TESTS 37.00 06/30/10 96110 96110 96110 078 0918 0602
12666155 DTP/HIB CONJUGATE 14.00 06/30/10 90720 90720 90720 078 0636 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 418
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666156 DPT-1 18.00 06/30/10 90701 90701 90701 078 0636 0602
12666157 DPT-2 18.00 06/30/10 90701 90701 90701 078 0636 0602
12666158 DPT-3 18.00 06/30/10 90701 90701 90701 078 0636 0602
12666159 DPT B-1 18.00 06/30/10 90701 90701 90701 078 0636 0602
12666161 DPT B-2 18.00 06/30/10 90701 90701 90701 078 0636 0602
12666162 DT-1 21.00 06/30/10 90718 90718 90718 078 0636 0602
12666163 DT-2 21.00 06/30/10 90718 90718 90718 078 0636 0602
12666164 DT-3 21.00 06/30/10 90718 90718 90718 078 0636 0602
12666165 DT B-1 21.00 06/30/10 90718 90718 90718 078 0636 0602
12666166 DT B-2 21.00 06/30/10 90718 90718 90718 078 0636 0602
12666168 MMR 14.00 06/30/10 90707 90707 90707 078 0636 0602
12666169 HEPATITIS B VACCINE 14.00 06/30/10 90744 90744 90744 078 0636 0602
12666171 INCIS/DRAIN,ABSCESS;SIMP-HOSP 164.00 06/30/10 10060 10060 10060 078 0360 0602
12666172 INCIS/DRAIN,ABSCESS;SIMP-M.D. 186.00 $ 06/30/09 10060 10060 10060 078 0975 0602
12666175 SUTURING, SIMPLE-HOSP 226.00 06/30/10 12001 12001 12001 078 0360 0602
12666176 SUTURING, SIMPLE-M.D. 206.00 $ 06/30/09 12001 12001 12001 078 0975 0602
12666179 CATHETER IRRIG (BLADDER)-HOSP 211.00 06/30/10 51700 51700 51700 078 0360 0602
12666180 CATHETER IRRIG (BLADDER)-M.D. 100.00 $ 06/30/09 51700 51700 51700 078 0975 0602
12666182 PREGNANCY TEST URINE 90.00 06/30/10 81025 81025 81025 078 0300 0602
12666184 CANDIDA 61.00 06/30/10 86485 86485 86485 078 0302 0602
12666186 SKIN TEST,TB, INTRADERMAL 46.00 06/30/10 86580 86580 86580 078 0302 0602
12666189 IV INFUS THER/PROPH:EA ADDL HR 235.00 06/30/10 96366 96366 96366 078 0260 0602
12666191 NAIL DEBRDEMENT;1-5 NAILS-HOSP 71.00 06/30/10 11720 11720 11720 078 0360 0602
12666192 NAIL DEBRIDEMENT;1-5 NAILS-M.D 36.00 $ 06/30/09 11720 11720 11720 078 0975 0602
12666193 NAIL DEBRIDEMENT;6+ NAILS-HOSP 108.00 06/30/10 11721 11721 11721 078 0360 0602
12666194 NAIL DEBRIDEMENT;6+ NAILS-M.D. 62.00 $ 06/30/09 11721 11721 11721 078 0975 0602
12666197 THYROID ULTRASOUND-HOSP 427.00 06/30/10 76536 76536 76536 078 0402 0602
12666198 THYROID ULTRASOUND-M.D. 59.00 $ 06/30/09 76536 7653626 7653626 078 0972 0602
12666201 HEMOGLOBIN, GLYCOSLATED 165.00 06/30/10 83036QW 83036QW 83036QW 078 0301 0602
12666205 SPIROMETRY PRE/POST BD-HOSP 341.00 06/30/10 94060 94060 94060 078 0460 0602
12666206 SPIROMETRY PRE/POST BD-M.D. 31.00 $ 06/30/09 94060 9406026 9406026 078 0976 0602
12666209 ACCU-CHECK/GLU-URIN 37.00 06/30/10 82948 82948 82948 078 0301 0602
12666211 IV HYDRA INFUSION EACH ADDL HR 244.00 06/30/10 96361 96361 96361 078 0260 0602
12666213 ADMIN PNEUMOC VACCINE 28.00 06/30/10 G0009 G0009 G0009 078 0771 0602
12666214 IMMUNIZATION; HIB 28.00 06/30/10 90646 90646 90646 078 0636 0602
12666215 IMMUNIZ; HEP B IMMUNE GLOBULIN 41.00 06/30/10 90371 90371 078 0636 0602
12666217 VACCINE ADMIN,EA ADDL VAC 82.00 06/30/10 90472 90472 90472 078 0771 0602
12666220 CHEMO IV INFUSION: EA ADDL HR 299.00 06/30/10 96415 96415 96415 078 0335 0602
12666223 INSRT NONINDWLL BLAD CATH-HOSP 86.00 06/30/10 51701 51701 51701 078 0510 0602
12666224 INSRT NONINDWLL BLAD CATH-M.D. 61.00 $ 06/30/09 51701 51701 51701 078 0975 0602
12666225 INSRT TMP INDWLL BLD CATH-HOSP 98.00 06/30/10 51702 51702 51702 078 0510 0602
12666226 INSRT TEMP INDWLL BLD CATH-M.D 68.00 $ 06/30/09 51702 51702 51702 078 0975 0602
12666227 EMG OF URETHRAL SPHINCTER-HOSP 237.00 06/30/10 51785 51785 51785 078 0922 0602
12666228 EMG OF URETHRAL SPHINCTER-M.D. 174.00 $ 06/30/09 5178526 5178526 5178526 078 0982 0602
12666231 CERUMEN REMOVAL-HOSP 108.00 06/30/10 69210 69210 69210 078 0360 0602
12666232 CERUMEN REMOVAL-M.D. 67.00 $ 06/30/09 69210 69210 69210 078 0975 0602
12666235 DEBRIDE SKIN PART THICK-HOSP 147.00 06/30/10 11040 11040 11040 078 0360 0602
12666236 DEBRIDE SKIN PART THICK - M.D. 59.00 $ 06/30/09 11040 11040 11040 078 0975 0602
12666239 DEBRIDE SKIN FULL THICK - HOSP 301.00 06/30/10 11041 11041 11041 078 0360 0602
12666240 DEBRIDE SKIN FULL THICK - M.D. 76.00 $ 06/30/09 11041 11041 11041 078 0975 0602
12666241 DEBRIDEMENT OF WOUND-HOSP 571.00 06/30/10 11042 11042 11042 078 0360 0602
12666242 DEBRIDEMENT OF WOUND-M.D. 101.00 $ 06/30/09 11042 11042 11042 078 0975 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 419
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666245 INJECT SUBCUT/INTRAMUSC 86.00 06/30/10 96372 96372 96372 078 0940 0602
12666246 INFLUENZA SPLIT VIRUS 3+ YRS 36.00 06/30/10 90658 90658 90658 078 0636 0602
12666247 THERAPEUTIC INJ, INTRA-ART 228.00 06/30/10 96373 96373 96373 078 0510 0602
12666250 GLUCOSE FINGERSTICK 41.00 06/30/10 82948 82948 82948 078 0301 0602
12666256 IMMUNOTHER, SINGLE ANTIGEN 50.00 06/30/10 95115 95115 95115 078 0924 0602
12666257 IMMUNOTHER, MULTIPLE ANTIGENS 68.00 06/30/10 95165 95165 95165 078 0924 0602
12666258 STINGING INSECT ANTIGEN 130.00 06/30/10 95145 95145 95145 078 0924 0602
12666259 SING INSECT ANTIGEN MULT VIALS 130.00 06/30/10 95145 95145 95145 078 0924 0602
12666265 S INSECT ANTIGEN MULT VLS-HOSP 130.00 06/30/10 95145 95145 95145 078 0924 0602
12666266 S INSECT ANTIGEN MULT VLS-M.D. 7.00 $ 06/30/09 95145 95145 95145 078 0983 0602
12666275 AEROSOL PENTAMIDINE 124.00 06/30/10 94642 94642 94642 078 0410 0602
12666277 INFLUENZA VACCINE 36.00 06/30/10 90658 90658 90658 078 0636 0602
12666279 HIB VACCINE 42.00 06/30/10 90647 90647 90647 078 0636 0602
12666280 OPV-1 14.00 06/30/10 90712 90712 90712 078 0636 0602
12666281 OPV-2 14.00 06/30/10 90712 90712 90712 078 0636 0602
12666282 OPV-3 14.00 06/30/10 90712 90712 90712 078 0636 0602
12666283 OPV B-1 14.00 06/30/10 90712 90712 90712 078 0636 0602
12666284 OPV B-2 14.00 06/30/10 90712 90712 90712 078 0636 0602
12666287 HIB VACCINE - HMHK 21.00 06/30/10 90647 90647 90647 078 0636 0602
12666293 EKG TRACING & INTERPRET-HOSP 207.00 06/30/10 93005 93005 93005 078 0730 0602
12666294 EKG TRACING & INTERPRET-M.D. 19.00 $ 06/30/09 93010 93010 93010 078 0985 0602
12666296 NEBULIZED MEDICATION 156.00 06/30/10 94640 94640 94640 078 0410 0602
12666298 ADMIN HEPATITIS B VACCINE 51.00 06/30/10 90471 90471 90471 078 0771 0602
12666300 INJECTION,ANTIBIOTIC(IM) 110.00 06/30/10 96372 96372 96372 078 0510 0602
12666301 NASO GAST. - HOSP 64.00 06/30/10 91055 91055 91055 078 0750 0602
12666303 HEPATITIS A 158.00 06/30/10 90632 90632 90632 078 0636 0602
12666304 HEPATITIS B 226.00 06/30/10 90746 90746 90746 078 0636 0602
12666306 URINE, DIPSTICK 35.00 06/30/10 81002 81002 81002 078 0300 0602
12666309 HEMOCCULT, DIAGNOSTIC 34.00 06/30/10 82270 82270 82270 078 0301 0602
12666311 WET MOUNT/GRAMSTAIN 48.00 06/30/10 87210 Q0112 Q0112 078 0306 0602
12666315 DEPOPROVERA 50 MG 35.00 06/30/10 J1051 J1051 J1051 078 0636 0602
12666318 BLOOD GLUCOSE-STRIP METHOD 41.00 06/30/10 82948 82948 82948 078 0301 0602
12666321 CONT. GLUCOSE MONITOR SYSTEM 750.00 06/30/10 95250 95250 95250 078 0920 0602
12666323 CONT.GLUCOSE MON. INT/RPT-M.D. 84.00 $ 06/30/09 95251 95251 95251 078 0920 0602
12666325 FINE NEEDLE ASPIR BIOPSY-HOSP 355.00 06/30/10 10021 10021 10021 078 0360 0602
12666326 FINE NEEDLE ASPIR BIOPSY-M.D. 141.00 $ 06/30/09 10021 10021 10021 078 0983 0602
12666328 AEROSOL INHAL INITIAL 89.00 06/30/10 94664 94664 94664 078 0410 0602
12666329 AEROSOL INHALATION-SUBSEQ 107.00 06/30/10 94664 94664 94664 078 0410 0602
12666332 VACCINE ADMIN,EA ADDL VAC 82.00 06/30/10 90472 90472 90472 078 0771 0602
12666335 MARSUP BRTHOLNS GLND CYST HOSP 1850.00 06/30/10 56440 56440 56440 078 0360 0602
12666336 MARSUP BRTHOLNS GLND CYST-MD 386.00 $ 06/30/09 56440 56440 56440 078 0975 0602
12666339 UA DIPSTK/TBLT NONAUTO W/MICRO 38.00 06/30/10 81000 81000 81000 078 0300 0602
12666341 UA DPSTK/TBLT WO MCRO NON-AUTO 35.00 06/30/10 81002 81002 81002 078 0300 0602
12666343 THERAPEUTIC PROPH/DX INJECT IV 236.00 06/30/10 96374 96374 96374 078 0940 0602
12666345 OCCULT BLOOD,FECES 52.00 06/30/10 82270 82270 82270 078 0300 0602
12666347 DIABETES COUNSEL INDIVD/30 MIN 102.00 06/30/10 G0108 G0108 078 0942 0602
12666349 DIABETES COUNSEL GRP /30MIN 101.00 06/30/10 G0109 G0109 078 0942 0602
12666351 NORPLANT REMOVAL-HOSP 301.00 06/30/10 11976 11976 11976 078 0360 0602
12666352 NORPLANT REMOVAL-M.D. 204.00 $ 06/30/09 11976 11976 11976 078 0975 0602
12666355 ENDOMETRIAL BIOPSY CLOSED-HOSP 316.00 06/30/10 58100 58100 58100 078 0360 0602
12666356 ENDOMETRIAL BIOPSY CLOSED-M.D. 187.00 $ 06/30/09 58100 58100 58100 078 0975 0602
12666361 SUCTIONING, NASOTRACHEAL-HOSP 158.00 06/30/10 31720 31720 31720 078 0360 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 420
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666362 SUCTIONING, NASOTRACHEAL-M.D. 111.00 $ 06/30/09 31720 31720 31720 078 0975 0602
12666365 ARTERIAL PUNCTURE-HOSP 95.00 06/30/10 36600 36600 36600 078 0510 0602
12666366 ARTERIAL PUNCTURE - M.D. 33.00 $ 06/30/09 36600 36600 36600 078 0983 0602
12666373 PREV MED NEW PT-18-39 YRS-HOSP 193.00 06/30/10 99385 99385 99385 078 0510 0602
12666374 PREV MED NEW PT-18-39 YRS-M.D. 163.00 $ 06/30/09 99385 99385 99385 078 0983 0602
12666395 PREV MED EST PT.18-39 YRS-HOSP 161.00 06/30/10 99395 99395 99395 078 0510 0602
12666396 PREV MED EST PT.18-39 YRS-M.D. 144.00 $ 06/30/09 99395 99395 99395 078 0983 0602
12666403 DT 16.00 06/30/10 90702 90702 90702 078 0636 0602
12666406 DTAP 98.00 06/30/10 90700 90700 90700 078 0636 0602
12666409 DTAP/HIB 136.00 06/30/10 90721 90721 90721 078 0636 0602
12666412 HE/HIB 188.00 06/30/10 90748 90748 90748 078 0636 0602
12666415 HIB 98.00 06/30/10 90645 90645 90645 078 0636 0602
12666421 IPV 108.00 06/30/10 90713 90713 90713 078 0636 0602
12666424 ADMN INFLU VIRUS VACCINE 63.00 06/30/10 G0008 G0008 G0008 078 0771 0602
12666430 ADMN 1 VACC-NOT FLU OR PNEU 110.00 06/30/10 90471 90471 90471 078 0771 0602
12666433 VACCINE FLU WHOLE VIRUS IM/JET 21.00 06/30/10 90658 90658 90658 078 0636 0602
12666436 VACCINE PNEUMO 2YR/>SUBQ/JET 124.00 06/30/10 90732 90732 90732 078 0636 0602
12666445 SPONT NYSTAGAMUS TESTING-HOSP 47.00 06/30/10 92541 92541 92541 078 0471 0602
12666449 PSTN NYSTAGMUS TST 6 PSTN-HOSP 47.00 06/30/10 92542 92542 92542 078 0471 0602
12666450 PSTN NYSTAGMUS TST 6 PSTN-M.D. 35.00 $ 06/30/09 92542 9254226 92542 078 0983 0602
12666453 CALORIC VESTIBULAR TEST-HOSP 246.00 06/30/10 92543 92543 92543 078 0471 0602
12666457 OPTOKINETIC NYST TESTING-HOSP 35.00 06/30/10 92544 92544 92544 078 0471 0602
12666461 OSCILLATING TRACKING TEST-HOSP 35.00 06/30/10 92545 92545 92545 078 0471 0602
12666462 OSCILLATING TRACKING TEST-M.D. 25.00 $ 06/30/09 92545 9254526 9254526 078 0983 0602
12666465 SINUSOIDAL ROTATION TEST-HOSP 246.00 06/30/10 92546 92546 92546 078 0471 0602
12666466 SINUSOIDAL ROTATION TEST-M.D. 31.00 $ 06/30/09 92546 9254626 9254626 078 0983 0602
12666469 USE OF VERTICAL ELECTRO-HOSP 111.00 06/30/10 92547 92547 92547 078 0471 0602
12666470 USE OF VERTICAL ELECTRO-M.D. 16.00 $ 06/30/09 92547 92547 92547 078 0920 0602
12666480 PULM STRESS TESTING-SIMP-HOSP 147.00 06/30/10 94620 94620 94620 078 0460 0602
12666481 PULM STRESS TESTING-SIMP-M.D. 161.00 $ 09/01/09 94620 94620 94620 078 0976 0602
12666497 NEUROMUSC RE-ED,EA 15 MIN-HOSP 94.00 06/30/10 97112 97112 97112 078 0430 0602
12666498 NEUROMUSC RE-ED,EA 15 MIN-M.D. 61.00 $ 06/30/09 97112 97112 97112 078 0977 0602
12666500 FLUTTER DEVICE 173.00 06/30/10 S8185 078 0271 0602
12666503 PHYS PERF TEST-EA-15MIN-HOSP 47.00 06/30/10 97750 97750GO 97750GO 078 0430 0602
12666504 PHYS PERF TEST-EA-15MIN-M.D. 62.00 $ 06/30/09 97750GO 97750GO 97750GO 078 0977 0602
12666507 ALLER IMMUN INJ PREP/PROV-HOSP 125.00 06/30/10 95165 95165 95165 078 0510 0602
12666508 ALLER IMMUN INJ PREP/PROV-M.D. 7.00 $ 06/30/09 95165 95165 95165 078 0983 0602
12666511 MCV 4 166.00 06/30/10 90734 90734 90734 078 0636 0602
12666514 PREVNAR 148.00 06/30/10 90669 90669 90669 078 0636 0602
12666517 KENALOG-40 VIAL 40MG 1ML 31.00 06/30/10 J3301 J3301 J3301 078 0636 0602
12666520 KENALOG-40 VIAL 40MG 5ML 113.00 06/30/10 J3301 J3301 J3301 078 0636 0602
12666523 DTAP-HEP B-IPV VACCINE-IM 90.00 06/30/10 90723 90723 90723 078 0636 0602
12666531 US RETROPERIT B-SCAN;CMPL-HOSP 190.00 06/30/10 76770 76770 76770 078 0402 0602
12666532 US RETROPERIT B-SCAN;CMPL-M.D. 80.00 $ 06/30/09 7677026 7677026 7677026 078 0972 0602
12666534 PV PICCLINE MIDLINE 336.00 06/30/10 C1751 C1751 C1751 078 0272 0602
12666535 US RETROPERIT B-SCAN;LMTD-HOSP 212.00 06/30/10 76775 76775 76775 078 0402 0602
12666536 US RETROPERIT B-SCAN;LMTD-M.D. 65.00 $ 06/30/09 7677526 7677526 7677526 078 0972 0602
12666539 US EXAM K TRANSPL W/DOPP-HOSP 210.00 06/30/10 76776 76776 76776 078 0402 0602
12666540 US EXAM K TRANSPL W/DOPP-M.D. 82.00 $ 06/30/09 76776 76776 76776 078 0972 0602
12666543 RENAL BIOP,PERC,TROC/NDL-HOSP 667.00 06/30/10 50200 50200 50200 078 0361 0602
12666544 RENAL BIOP,PERC,TROC/NDL-M.D. 316.00 $ 06/30/09 50200 50200 50200 078 0975 0602
12666547 SPUTUM CULTURE 56.00 06/30/10 87206 87206 87206 078 0306 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 421
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666551 TREAT SUPER WND W/PKING-HOSP 456.00 06/30/10 12021 12021 12021 078 0360 0602
12666552 TREAT SUPER WND W/PKING-M.D. 276.00 $ 06/30/09 12021 12021 12021 078 0975 0602
12666555 I&D-COMP,P/OP WND INFECT-HOSP 940.00 06/30/10 10180 10180 10180 078 0360 0602
12666556 I&D-COMP,P/OP WND INFECT-M.D. 362.00 $ 06/30/09 10180 10180 10180 078 0975 0602
12666559 BREAST/CERV CANCER SCRN-HOSP 77.00 06/30/10 G0101 G0101 G0101 078 0510 0602
12666560 BREAST/CERV CANCER SCRN-M.D. 74.00 $ 06/30/09 G0101 G0101 G0101 078 0983 0602
12666563 SCREEN-PAP,PREP & CONVEY-HOSP 72.00 06/30/10 Q0091 Q0091 Q0091 078 0923 0602
12666567 EXR STRSS TST TRDML/BICYC-HOSP 761.00 06/30/10 93017 93017 93017 078 0482 0602
12666570 DEFINITY INJ, 1ML 302.00 06/30/10 Q9957 Q9957 Q9957 078 0636 0602
12666573 DXA BONE DENSITY,VERT FX-HOSP 161.00 06/30/10 77082 77082 77082 078 0320 0602
12666574 DXA BONE DENSITY,VERT FX-M.D. 18.00 $ 06/30/09 77082 77082 77082 078 0972 0602
12666577 DEBRIDEMENT,SKIN-HOSP 106.00 06/30/10 11000 11000 11000 078 0360 0602
12666578 DEBRIDEMENT,SKIN-M.D. 68.00 $ 06/30/09 11000 11000 11000 078 0975 0602
12666581 WOUND CARE-HOSP 301.00 06/30/10 11041 11041 11041 078 0360 0602
12666582 WOUND CARE-M.D. 76.00 $ 06/30/09 11041 11041 11041 078 0975 0602
12666585 BIOPSY,SYNOVIAL,CLOSED-HOSP 1632.00 06/30/10 26100 26100 26100 078 0360 0602
12666586 BIOPSY,SYNOVIAL,CLOSED-M.D. 641.00 $ 06/30/09 26100 26100 26100 078 0975 0602
12666589 SACROILIAC JOINT INJECT 345.00 06/30/10 27096 G0260 27096 078 0360 0602
12666590 VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 078 0510 0602
12666593 SPEC FROM PORT/CENT LINE 228.00 06/30/10 36591 36591 36591 078 0360 0602
12666596 THROMBOLYSIS CENTRAL LINE 329.00 06/30/10 36593 36593 36593 078 0360 0602
12666599 INSRT TUNNL CVC;5YR/>-HOSP 1748.00 06/30/10 36558 36558 36558 078 0361 0602
12666600 INSRT TUNNL CVC;5YR/>-M.D. 631.00 $ 06/30/09 36558 36558 36558 078 0975 0602
12666603 REP CV ACSS CATH W/O PORT-HOSP 440.00 06/30/10 36575 36575 36575 078 0361 0602
12666604 REP CV ACSS CATH W/O PORT-M.D. 97.00 $ 06/30/09 36575 36575 36575 078 0975 0602
12666607 REPL TUNN CVC W/O PORT-HOSP 1500.00 06/30/10 36581 36581 36581 078 0361 0602
12666608 REPL TUNN CVC W/O PORT-M.D. 427.00 $ 06/30/09 36581 36581 36581 078 0975 0602
12666609 RMVL CENTRAL VENOUS CATH-HOSP 660.00 06/30/10 36589 36589 36589 078 0360 0602
12666610 RMVL CENTRAL VENOUS CATH-M.D. 303.00 $ 06/30/09 36589 36589 36589 078 0975 0602
12666613 CHANGE GASTRONOMY TUBE-HOSP 312.00 06/30/10 43760 43760 43760 078 0360 0602
12666614 CHANGE GASTRONOMY TUBE-M.D. 108.00 $ 06/30/09 43760 43760 43760 078 0975 0602
12666617 ANOSCOPY;DIAGNOSTIC-HOSP 109.00 06/30/10 46600 46600 46600 078 0360 0602
12666618 ANOSCOPY;DIAGNOSTIC-M.D. 76.00 $ 06/30/09 46600 46600 46600 078 0975 0602
12666621 ANOSOSCOPY;W/BIO,SGL/MULT-HOSP 182.00 06/30/10 46606 46606 46606 078 0360 0602
12666622 ANOSCOPY;W/BIOP,SINGL/MULT-M.D 145.00 $ 06/30/09 46606 46606 46606 078 0975 0602
12666625 LIVER BIOP;PERCUTAN NDLE-HOSP 1471.00 06/30/10 47000 47000 47000 078 0360 0602
12666626 LIVER BIOPSY;PERCUTAN NDLE-M.D 214.00 $ 06/30/09 47000 47000 47000 078 0975 0602
12666629 PARACENTESIS, INIT.-HOSP 593.00 06/30/10 49080 49080 49080 078 0360 0602
12666630 PARACENTESIS, INIT.-M.D. 151.00 $ 06/30/09 49080 49080 49080 078 0975 0602
12666633 PARACENTESIS; SUBS. SESS-HOSP. 521.00 06/30/10 49081 49081 49081 078 0360 0602
12666634 PARACENTESIS; SUBS. SESS.-M.D. 143.00 $ 06/30/09 49081 49081 49081 078 0975 0602
12666637 PERITONEOSCOPY - HOSP 2842.00 06/30/10 49320 49320 49320 078 0360 0602
12666638 PERITONEOSCOPY - M.D. 666.00 $ 06/30/09 49320 49320 49320 078 0975 0602
12666641 INJ AIR/CNTRST PERIT CAV-HOSP 134.00 06/30/10 49400 49400 49400 078 0361 0602
12666642 INJ AIR/CNTRST PERIT CAV-M.D. 213.00 $ 06/30/09 49400 49400 49400 078 0975 0602
12666645 INSRT INTRAPER CANN;PERM-HOSP 2345.00 06/30/10 49421 49421 49421 078 0361 0602
12666646 INSRT INTRAPER CANN;PERM-M.D. 787.00 $ 06/30/09 49421 49421 49421 078 0975 0602
12666653 SINGLE EPID INJ-LUMB/SACR-HOSP 497.00 06/30/10 62311 62311 62311 078 0360 0602
12666654 SINGL EPID INJ-LUMB/SAC-M.D. 170.00 $ 06/30/09 62311 62311 62311 078 0983 0602
12666663 APP SURF NEUROSTIMULATOR-HOSP 37.00 06/30/10 64550 64550 64550 078 0975 0602
12666664 APP SURF NEUROSTIMULATOR-M.D 18.00 06/30/09 64450 64450 64450 078 0975 0602
12666667 FLUOROGUIDE FOR VEIN DEV-HOSP 141.00 06/30/10 77001 77001 77001 078 0320 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 422
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666668 FLUOROGUIDE FOR VEIN DEV-M.D. 40.00 $ 06/30/09 77001 77001 77001 078 0972 0602
12666671 FLUOROGUIDE FOR SPINE INJ-HOSP 553.00 06/30/10 77003 77003 77003 078 0320 0602
12666672 FLUOROGUIDE FOR SPINE INJ-M.D. 60.00 $ 06/30/09 7700326 7700326 7700326 078 0972 0602
12666675 DXA BONE DENSITY, AXIAL-HOSP 389.00 06/30/10 77080 77080 77080 078 0320 0602
12666676 DXA BONE DENSITY, AXIAL-M.D. 22.00 $ 06/30/09 77080 7708026 7708026 078 0972 0602
12666679 DXA BONE DENSITY/PERIPH-HOSP 324.00 06/30/10 77081 77081 77081 078 0320 0602
12666680 DXA BONE DENSITY/PERIPH-M.D. 23.00 $ 06/30/09 77081 7708126 7708126 078 0972 0602
12666684 DXA BONE DENSITY,VERT FX-M.D. 18.00 $ 06/30/09 7708226 7708226 77082TC 078 0972 0602
12666687 U/S ABDOMINAL,COMPLETE-HOSP 689.00 06/30/10 76700 76700 76700 078 0402 0602
12666688 U/S ABDOMINAL,COMPLETE-M.D. 88.00 $ 06/30/09 76700 7670026 7670026 078 0972 0602
12666691 U/S ABDOMINAL,LIMITED-HOSP 684.00 06/30/10 76705 76705 76705 078 0402 0602
12666692 U/S ABDOMINAL,LIMITED-M.D. 65.00 $ 06/30/09 76705 7670526 7670526 078 0972 0602
12666695 U/S EXTREM,B-SCN W/IMAGE-HOSP 186.00 06/30/10 76880 76880 76880 078 0402 0602
12666696 U/S EXTREM,B-SCN W/IMAGE-M.D. 63.00 $ 06/30/09 76880 76880 76880 078 0972 0602
12666699 US GUID VASCULAR ACCESS-HOSP 264.00 06/30/10 76937 76937 76937 078 0402 0602
12666700 US GUID VASCULAR ACCESS-M.D. 35.00 $ 06/30/09 7693726 7693726 7693726 078 0972 0602
12666703 US GUID NEEDLE PLACEMENT-HOSP 754.00 07/27/10 76942 76942 76942 078 0402 0602
12666704 US GUID NEEDLE PLACEMENT-M.D. 73.00 $ 06/30/09 7694226 7694226 7694226 078 0972 0602
12666707 LIPID PROFILE 202.00 06/30/10 80061QW 80061QW 80061QW 078 0300 0602
12666713 BLOOD OCCULT FECAL SCREEN 34.00 06/30/10 82270 82270 82270 078 0301 0602
12666716 PROTHROMBIN TIME 51.00 06/30/10 85610QW 85610QW 85610QW 078 0305 0602
12666719 HEP A,ADULT DOSAGE 249.00 06/30/10 90632 90632 90632 078 0636 0602
12666722 HEP A,HEP B VACC,ADLT IM 142.00 06/30/10 90636 90636 90636 078 0636 0602
12666725 GROUP TREATMENT-HOSP 67.00 06/30/10 90853 90853 90853 078 0915 0602
12666726 GROUP TREATMENT-M.D. 61.00 $ 06/30/09 90853 90853 90853 078 0961 0602
12666729 BREATH HYDROGEN TEST-HOSP 228.00 06/30/10 91065 91065 91065 078 0750 0602
12666730 BREATH HYDROGEN TEST-M.D. 22.00 $ 06/30/09 91065 91065 91065 078 0940 0602
12666735 ECHO COMPLETE - HOSP 1317.00 06/30/10 93306 93306 93306 078 0480 0602
12666736 ECHO COMPLETE - M.D. 152.00 $ 06/30/09 9330626 9330626 9330626 078 0983 0602
12666737 ECHOCARDIOGRAPHY 2D M-MODE 805.00 08/10/08 93307 93307 93307 078 0480 0602
12666740 DOPPLER ECHOCARDIOGRAPHY 477.00 08/10/08 93320 93320 93320 078 0480 0602
12666743 DOPPLER COLOR FLOW VEL MAPPING 326.00 08/10/08 93325 93325 93325 078 0480 0602
12666745 ECHO DURING REST & STRESS-HOSP 1237.00 06/30/10 93350 93350 93350 078 0480 0602
12666746 ECHO DURING REST & STRESS-M.D. 171.00 $ 06/30/09 9335026 9335026 9335026 078 0985 0602
12666749 BIOIMPEDENCE ANALYSIS-HOSP 426.00 06/30/10 93721 93721 93721 078 0921 0602
12666750 BIOIMPEDENCE ANALYSIS - M.D. 86.00 $ 06/30/09 93721 9372126 9372126 078 0920 0602
12666753 PPM INTEROG:SING/DUAL/MUL 71.00 06/30/10 93288 93288 93288 078 0480 0602
12666754 PPM INTEROG:SING/DUAL/MUL-M.D. 51.00 $ 06/30/09 93288 9328826 9328826 078 0983 0602
12666757 PPM PRGRM EVAL W/ADJ-DUAL 71.00 06/30/10 93280 93280 93280 078 0480 0602
12666758 PPM PRGRM EVAL W/ADJ-DUAL-M.D. 92.00 $ 06/30/09 93280 9328026 9328026 078 0983 0602
12666759 PPM PRGRM EVAL W/ADJ-MULT 71.00 06/30/10 93281 93281 93281 078 0480 0602
12666760 PPM PRGRM EVAL W/ADJ-MULT-M.D. 107.00 $ 06/30/09 93281 93281 93281 078 0983 0602
12666761 PPM PRGRM EVAL W/ADJ-SING 71.00 06/30/10 93279 93279 93279 078 0480 0602
12666762 PPM PRGRM EVAL W/ADJ-SING-M.D. 77.00 $ 06/30/09 93279 9327926 9327926 078 0983 0602
12666769 ICD INTEROG:SING/DUAL/MUL 120.00 06/30/10 93289 93289 93289 078 0480 0602
12666770 ICD INTEROG:SING/DUAL/MUL-M.D. 92.00 $ 06/30/09 93289 9328926 9328926 078 0983 0602
12666773 ICD PROG EVL W/ADJST-SING 120.00 06/30/10 93282 93282 93282 078 0480 0602
12666774 ICD PROG EVL W/ADJST-SING-M.D. 101.00 $ 06/30/09 93282 9328226 9328226 078 0983 0602
12666777 ICD PROG EVL W/ADJST-DUAL 120.00 06/30/10 93283 93283 93283 078 0480 0602
12666778 ICD PROG EVL W/ADJST-DUAL-M.D. 127.00 $ 06/30/09 9328326 9328326 9328326 078 0921 0602
12666779 ICD PROG EVL W/ADJST-MULT 120.00 06/30/10 93284TC 93284 93284 078 0480 0602
12666780 ICD PROG EVL W/ADJST-MULT-M.D. 150.00 $ 06/30/09 9328426 9328426 9328426 078 0983 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 423
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666785 CPAP VENT INIT & MANAGE - HOSP 123.00 06/30/10 94660 94660 94660 078 0412 0602
12666786 CPAP VENT INIT & MANAGE-M.D. 77.00 $ 06/30/09 94660 94660 94660 078 0460 0602
12666789 INDIRECT CALORIMETRY - HOSP 199.00 06/30/10 94690 94690 94690 078 0460 0602
12666790 INDIRECT CALORIMETRY - M.D. 8.00 $ 06/30/09 94690 9469026 9469026 078 0976 0602
12666797 APP OF MOD-ELECTR STIM - HOSP 25.00 06/30/10 97032 97032 97032 078 0420 0602
12666798 APP OF MOD-ELECTR STIM-M.D. 35.00 $ 06/30/09 97032 97032 97032 078 0977 0602
12666801 WOUND CARE W/O DEBRIDEMENT 120.00 06/30/10 97602 97602 97602 078 0510 0602
12666802 ECHOCARDIO 2D M-MODE;LTD-M.D 62.00 $ 06/30/09 93308 93308 93308 078 0960 0602
12666803 ECHOCARDIO 2D M-MODE;LTD-HOSP 390.00 06/30/10 93308 93308 93308 078 0480 0602
12666804 POST OPERATIVE FOLLOW UP N/C 06/30/10 99024 99024 99024 078 0510 0602
12666807 PROLONGED SERVICE 1ST HR-HOSP 238.00 06/30/10 99354 99354 99354 078 0510 0602
12666808 PROLONGED SERVICE 1ST HR-M.D. 186.00 $ 06/30/09 99354 99354 99354 078 0983 0602
12666811 PROLONGED SVC-ADDL 30 MIN-HOSP 120.00 06/30/10 99355 99355 99355 078 0510 0602
12666812 PROLONGED SVC-ADDL 30 MIN-M.D. 183.00 $ 06/30/09 99355 99355 99355 078 0983 0602
12666815 SMKE/TOBACCO CNSL 3-10MIN 53.00 06/30/10 99406 99406 99406 078 0942 0602
12666818 SMKE/TOBACCO CNSL >10MIN 53.00 06/30/10 99407 99407 99407 078 0942 0602
12666821 SOD HYALURONATE INJ 20-25MG 259.00 06/30/10 J7321 J7321 J7321 078 0636 0602
12666824 ALBUMIN(HUMAN),5%,250ML 144.00 06/30/10 P9045 P9045 P9045 078 0636 0602
12666827 ALBUMIN(HUMAN),25%,50ML 111.00 06/30/10 P9047 P9047 P9047 078 0636 0602
12666841 GI TRAC CAPSULE ENDOSCOPY-HOSP 1404.00 06/30/10 91110 91110 91110 078 0750 0602
12666842 GI TRAC CAPSULE ENDOSCOPY M.D. 409.00 $ 06/30/09 91110 91110 91110 078 0983 0602
12666845 SPECIAL REPORTS 95.00 06/30/10 99080 99080 99080 078 0510 0602
12666850 REPEAT ULTRASOUND-SAME DAY 172.00 06/30/10 76970 76970 76970 078 0402 0602
12666853 ASP/INJECT THYROID CYST-HOSP 254.00 06/30/10 60300 60300 60300 078 0361 0602
12666854 ASP/INJECT THYROID CYST-M.D. 107.00 $ 06/30/09 60300 60300 60300 078 0975 0602
12666857 FINE NDL ASP WITH IMAGING-HOSP 336.00 06/30/10 10022 10022 10022 078 0361 0602
12666858 FINE NDL ASP WITH IMAGING -M.D 139.00 $ 06/30/09 10022 10022 10022 078 0975 0602
12666861 HEALTH RISK ASSESSMENT-HOSP 23.00 06/30/10 99420 99420 99420 078 0510 0602
12666862 HEALTH RISK ASSESSMENT-M.D. 21.00 $ 08/10/08 99420 99420 99420 078 0983 0602
12666865 PICC LINE 5YRS OR OLDER-HOSP 1434.00 06/30/10 36569 36569 36569 078 0361 0602
12666866 PICC LINE 5YRS OR OLDER-M.D. 215.00 $ 06/30/09 36569 36569 36569 078 0975 0602
12666870 TRANFUS BLOOD/BLD COMPS 775.00 06/30/10 36430 36430 36430 078 0391 0602
12666873 UGI ENDO SIMPLE PRIM EXAM-HOSP 1028.00 06/30/10 43234 43234 43234 078 0360 0602
12666874 UGI ENDO SIMPLE PRIM EXAM-M.D. 250.00 $ 06/30/09 43234 43234 43234 078 0975 0602
12666877 ESOPH MOTILITY STUDY-HOSP 699.00 06/30/10 91010 91010 91010 078 0750 0602
12666878 ESOPH MOTILITY STUDY-M.D. 143.00 $ 06/30/09 91010 91010 91010 078 0750 0602
12666880 PH MONITORING-CATH BASED-HOSP 699.00 06/30/10 91034 91034 91034 078 0750 0602
12666881 PH MONITORING-CATH BASED-M.D. 112.00 $ 06/30/09 91034 91034 91034 078 0960 0602
12666882 PH MONITORING-TELEMETRY-HOSP 911.00 06/30/10 91035 91035 91035 078 0750 0602
12666883 PH MONITORING-TELEMETRY-M.D. 180.00 $ 06/30/09 91035 91035 91035 078 0960 0602
12666884 ESOPH FUNCT TST-NASL CATH-HOSP 802.00 06/30/10 91037 91037 91037 078 0750 0602
12666885 ESOPH FUNCT TST-NASL CATH-M.D. 114.00 $ 06/30/09 91037 91037 91037 078 0960 0602
12666886 ESOPH FUNCT TST-PROLONGED-HOSP 802.00 06/30/10 91038 91038 91038 078 0750 0602
12666887 ESOPH FUNCT TST-PROLONGED-M.D. 128.00 $ 06/30/09 91038 91038 91038 078 0960 0602
12666888 ESOPHAG BALL PROVOC STUDY-HOSP 305.00 06/30/10 91040 91040 91040 078 0750 0602
12666889 ESOPHAG BALL PROVOC STUDY-M.D. 117.00 $ 06/30/09 91040 91040 91040 078 0960 0602
12666891 INJ EPIDUR LUMB/SAC 1 LVL-HOSP 829.00 06/30/10 64483 64483 64483 078 0360 0602
12666892 INJ EPIDUR LUMB/SAC 1 LVL -M.D 217.00 $ 06/30/09 64483 64483 64483 078 0975 0602
12666895 INJ EPID LUMB/SAC EA ADD-HOSP 832.00 06/30/10 64484 64484 64484 078 0360 0602
12666896 INJ EPID LUMB/SAC EA ADD-M.D. 138.00 $ 06/30/09 64484 64484 64484 078 0975 0602
12666899 FLURO GUID NEEDL PLACEMNT-HOSP 396.00 06/30/10 77002TC 77002 77002 078 0320 0602
12666900 FLURO GUID NEEDL PLACEMNT-M.D. 57.00 $ 06/30/09 77002TC 77002 77002 078 0972 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 424
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666936 DXA WHOLE BODY COMP-M.D. 43.00 $ 01/01/09 76499 76499 76499 078 0975 0602
12666944 USE OF CTST AGT STRS ECHO-M.D. 85.00 $ 06/30/09 93352 93352 93352 078 0983 0602
12666960 HOLTER MONITER TEST-24HR 562.00 06/30/10 93225 93225 93225 078 0731 0602
12666962 HOLTER MONITOR WITH SCAN 866.00 06/30/10 93226 93226 93226 078 0731 0602
12666964 HOLTER MONITOR W/PHY INT-M.D. 61.00 $ 06/30/09 93227 93227 93227 078 0985 0602
12666970 EVENT MONITOR HOOK-UP 386.00 06/30/10 93270 93270 93270 078 0730 0602
12666972 EVNT MONITOR W/SCAN-ANAL 438.00 06/30/10 93271 93271 93271 078 0730 0602
12666974 EVNT MON PHYS REV/INTERPR-M.D. 58.00 $ 06/30/09 93272 93272 93272 078 0985 0602
12666980 IMMUNOTX W/O EXT 2/> INJ 81.00 06/30/10 95117 95117 95117 078 0924 0602
12666990 ALLER MIX,2 SING INSC VEN 222.00 06/30/10 95146 95146 95146 078 0510 0602
12666991 ALLER MIX,2 SING INSC VEN-M.D. 7.00 $ 02/01/10 95146 95146 95146 078 0983 0602
12666992 ALLER MIX,3 SING INSC VEN 222.00 06/30/10 95147 95147 95147 078 0510 0602
12666993 ALLER MIX,3 SING INSC VEN-M.D. 7.00 $ 02/01/10 95147 95147 95147 078 0983 0602
12666994 ALLER MIX,4 SING INSC VEN 110.00 06/30/10 95148 95148 95148 078 0510 0602
12666995 ALLER MIX,4 SING INSC VEN-M.D. 7.00 $ 02/01/10 95148 95148 95148 078 0983 0602
12667527 HEPATITIS A VACCINE 146.00 06/30/10 90633 90633 90633 078 0636 0602
12667610 TYPHOID VAC, LIVE, ORAL 139.00 06/30/10 90690 90690 90690 078 0250 0602
12667611 TYPHOID VAC,(VICP),INTRAMUSCUL 206.00 06/30/10 90691 90691 90691 078 0250 0602
12667612 TYPHOID VAC, HEAT, SUBCUT 139.00 06/30/10 90692 90692 90692 078 0250 0602
12667620 PATCH OR APPL TEST(S) 64.00 06/30/10 95044 95044 95044 078 0924 0602
12667628 RECT SENS,TONE/COMPL TEST-HOSP 365.00 06/30/10 91120 91120 91120 078 0750 0602
12667629 RECT SENS,TONE/COMPL TEST-M.D. 106.00 $ 06/30/09 91120 91120 91120 078 0960 0602
12667650 PPM PHONE CHECK - HOSP 91.00 06/30/10 93293 93293 93293 078 0480 0602
12667651 PPM PHONE CHECK - M.D. 37.00 $ 06/30/09 93293 93293 93293 078 0983 0602
12667656 CARD STRES TST-INTRP/RPT-M.D. 34.00 $ 06/30/09 93018 93018 93018 078 0985 0602
12667660 ADMIN BRONCHOPROV AGNT-HOSP 452.00 06/30/10 95070 95070 95070 078 0460 0602
12667661 ADMIN BRONCHOPROV AGNT-M.D. 93.00 $ 10/01/09 95070 95070 95070 078 0976 0602
12667670 CYSTOSCOPY - HOSP 995.00 06/30/10 52000 52000 52000 078 0360 0602
12667671 CYSTOSCOPY - M.D. 280.00 $ 10/01/09 52000 52000 52000 078 0975 0602
12667672 CYSTOSCOPY, BLADDER BIOP-HOSP 1158.00 06/30/10 52204 52204 52204 078 0360 0602
12667673 CYSTOSCOPY, BLADDER BIOP-M.D. 318.00 $ 10/01/09 52204 52204 52204 078 0975 0602
12667676 CYSTOSCOPY,REM URE STENT-HOSP 1175.00 06/30/10 52310 52310 52310 078 0360 0602
12667677 CYSTOSCOPY,REM URE STENT-M.D. 345.00 $ 10/01/09 52310 52310 52310 078 0975 0602
12667680 DEST LES,PENIS-SURG EXC-HOSP 3891.00 06/30/10 54060 54060 54060 078 0360 0602
12667681 DEST LES,PENIS-SURG EXC-M.D. 282.00 $ 10/01/09 54060 54060 54060 078 0975 0602
12667684 DILAT FEMALE URETH INIT-HOSP 150.00 06/30/10 53660 53660 53660 078 0360 0602
12667685 DILAT FEMALE URETH INIT-M.D. 93.00 $ 10/01/09 53660 53660 53660 078 0975 0602
12667686 DILAT URETH STRICT (F&F)-HOSP 183.00 06/30/10 53620 53620 53620 078 0360 0602
12667687 DILAT URETH STRICT (F&F)-M.D. 198.00 $ 10/01/09 53620 53620 53620 078 0975 0602
12667690 DILAT URETH STRICT (S&D)-HOSP 127.00 06/30/10 53600 53600 53600 078 0360 0602
12667691 DILAT URETH STRICT (S&D)-M.D. 146.00 $ 10/01/09 53600 53600 53600 078 0975 0602
12667694 BLADDER IRRIG, LAVAGE 211.00 06/30/10 51700 51700 51700 078 0360 0602
12667695 BLADDER IRRIG, LAVAGE - M.D. 100.00 $ 10/01/09 51700 51700 51700 078 0975 0602
12667698 VASECTOMY - HOSP 1255.00 06/30/10 55250 55250 55250 078 0360 0602
12667699 VASECTOMY - M.D. 506.00 $ 10/01/09 55250 55250 55250 078 0975 0602
12668001 IDOC -ONLINE E&M (INFECT DIS) VARIABLE 10/01/09 99444 99444 99444 078 0960 0602
12668004 IDOC-TELEPH CALL 11-20 MIN(ID) VARIABLE 10/01/09 99442 99442 99442 078 0960 0602
12668007 IDOC-TELEPHN CALL 20-30MN(IF) VARIABLE 10/01/09 99443 99443 99443 078 0960 0602
12668011 IDOC -ONLINE E&M (LIVER CTR) VARIABLE 10/01/09 99444 99444 99444 078 0960 0602
12668014 DOC-TELEPHONE CALL 11-20MN(LC) VARIABLE 10/01/09 99442 99442 99442 078 0960 0602
12668017 IDOC-TELEPH CALL 21-30MN(LC) 92.00 06/30/10 99443 99443 99443 078 0960 0602
12668032 IDOC-OFFC VST NEW LVL 1-M.D. N/C 10/01/09 99201 99201 99201 078 0983 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 425
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12668034 IDOC-OFFC VST NEW LVL 2-M.D. N/C 10/01/09 99202 99202 99202 078 0983 0602
12668036 IDOC-OFFC VST NEW LVL 3-M.D. N/C 10/01/09 99203 99203 99203 078 0983 0602
12668038 IDOC-OFFC VST NEW LVL 4-M.D. N/C 10/01/09 99204 99204 99204 078 0983 0602
12668040 IDOC-OFFC VST NEW LVL 5-M.D. N/C 10/01/09 99205 99205 99205 078 0983 0602
12668042 IDOC-OFFC VST EST LVL 1-M.D. N/C 10/01/09 99211 99211 99211 078 0983 0602
12668044 IDOC-OFFC VST EST LVL 2-M.D. N/C 10/01/09 99212 99212 99212 078 0983 0602
12668046 IDOC-OFFC VST EST LVL 3-M.D. N/C 10/01/09 99213 99213 99213 078 0983 0602
12668048 IDOC-OFFC VST EST LVL 4-M.D. N/C 10/01/09 99214 99214 99214 078 0983 0602
12668050 IDOC-OFFC VST EST LVL 5-M.D. N/C 10/01/09 99215 99215 99215 078 0983 0602
12800001 LAPBAND BARIATRIC SURGERY 603.00 06/30/10 43999 43999 43999 078 0360 0675
12800005 THERAPEUTIC INJECTION =SALINE 64.00 06/30/10 96372 96372 96372 078 0260 0675
13300488 AIRWAYS RESISTANCE (RAW)-HOSP 95.00 06/30/10 94360 94360 94360TC 078 0460 0648
13300489 AIRWAYS RESISTANCE (RAW)-M.D. 26.00 $ 06/30/09 94360 94360 9436026 078 0976 0648
13300774 MAX VOLUNTARY VENT-HOSP 122.00 06/30/10 94200 94200 94200 078 0410 0648
13300775 MAX VOLUNTARY VENT-M.D. 50.00 $ 06/30/10 94200 94200 94200 078 0976 0648
13301100 RESPIRATORY FLOW VOL LOOP-HOSP 170.00 06/30/10 94375 94375 94375 078 0460 0648
13301101 RESPIRATORY FLOW VOL LOOP-M.D. 80.00 $ 09/01/09 94375 94375 94375 078 0976 0648
13301106 CARBON MONOXIDE DIFF CAP-HOSP 409.00 06/30/10 94720 94720 94720 078 0460 0648
13301107 CARBON MONOXIDE DIFF CAP-M.D. 114.00 $ 09/01/09 94720 94720 94720 078 0976 0648
13301112 MALDISTRIB OF VENTILATION-HOSP 160.00 06/30/10 94350 94350 94350 078 0460 0648
13301113 MALDISTRIB OF VENTILATION-M.D. 77.00 $ 09/01/09 94350 94350 94350 078 0976 0648
13301118 PULM STRESS TESTING-SIMP-HOSP 147.00 06/30/10 94620 94620 94620 078 0460 0648
13301119 PULM STRESS TESTING-SIMP-M.D. 161.00 $ 09/01/09 94620 94620 94620 078 0976 0648
13301122 MEMBRANE DIFFUS CAPACITY-HOSP 160.00 06/30/10 94725 94725 94725 078 0460 0648
13301123 MEMBRANE DIFFUS CAPACITY-M.D. 151.00 $ 09/01/09 94725 94725 94725 078 0976 0648
13301128 PULM STRESS TESTING-COMP-HOSP 641.00 06/30/10 94621 94621 94621 078 0460 0648
13301129 PULM STRESS TESTING-COMP-M.D. 352.00 $ 09/01/09 94621 94621 94621 078 0976 0648
13301136 ADMIN BRONCHOPROV AGNT-HOSP 452.00 06/30/10 95070 95070 95070 078 0460 0648
13301137 ADMIN BRONCHOPROV AGNT-M.D. 93.00 $ 09/01/09 95070 95070 95070 078 0976 0648
13400001 CANDIDA 61.00 06/30/10 86485 86485 86485 078 0302 0664
13400004 INSRT TMP INDWLL BLD CATH 98.00 06/30/10 51702 51702 51702 078 0510 0664
13400007 CATHETER IRRIG (BLADDER) 211.00 06/30/10 51700 51700 51700 078 0360 0664
13400010 CYSTOSCOPY 995.00 06/30/10 52000 52000 52000 078 0360 0664
13400013 CYSTOSCOPY, BLADDER BIOP 1158.00 06/30/10 52204 52204 52204 078 0360 0664
13400016 CYSTOSCOPY,REM URE STENT 1175.00 06/30/10 52310 52310 52310 078 0360 0664
13400019 DILAT FEMALE URETH INIT 150.00 06/30/10 53660 53660 53660 078 0360 0664
13400025 DILAT URETH STRICT (S&D) 127.00 06/30/10 53600 53600 53600 078 0360 0664
13400028 INSRT NONINDWLL BLAD CATH 86.00 06/30/10 51701 51701 51701 078 0510 0664
13400031 INSRT TMP INDWLL BLD CATH 98.00 06/30/10 51702 51702 51702 078 0510 0664
13400034 BLADDER IRRIG, LAVAGE 211.00 06/30/10 51700 51700 51700 078 0360 0664
13400037 INCIS/DRAIN,ABSCESS;SIMP 164.00 06/30/10 10060 10060 10060 078 0360 0664
13400040 VASECTOMY 1255.00 06/30/10 55250 55250 55250 078 0360 0664
13400046 SPEC FROM PORT/CENT LINE 228.00 06/30/10 36591 36591 36591 078 0360 0664
13400049 PULSE OXIMETRY-SING 99.00 06/30/10 94760 94760 94760 078 0460 0664
13400052 SKIN TEST; TB TINE 46.00 06/30/10 86580 86580 86580 078 0302 0664
13400055 SUTURING, SIMPLE- 226.00 06/30/10 12001 12001 12001 078 0360 0664
17200810 ADMN INFLU VIRUS VACCINE 77.00 06/30/10 90471 G0008 90471 078 0771 0641
17200812 VACCINE FLU WHOLE VIRUS IM/JET 21.00 06/30/10 90658 90658 90658 078 0636 0641
19101200 INCIS/RMVL FRGN BDY-SIMP-HOSP 193.00 06/30/10 10120 10120 10120 078 0360 0599
19101201 INCIS/RMVL FRGN BDY-SIMP-M.D. 182.00 $ 06/30/09 10120 10120 10120 078 0975 0599
19205520 INJ SG/MLT TRG PT,1-2 MUS-HOSP 475.00 06/30/10 20552 20552 20552 078 0360 0599
19205521 INJ SG/MLT TRG PT,1-2 MUS-M.D. 75.00 $ 10/01/09 20552 20552 20552 078 0975 0599
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 426
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

19900007 IPV 108.00 06/30/10 90713 90713 90713 078 0636 0599
19900009 TDAP 7 YRS OR >;IM 95.00 06/30/10 90715 90715 90715 078 0636 0599
19900011 ADMN INFLU VIRUS VACCINE 36.00 06/30/10 90471 G0008 90471 078 0771 0599
19900015 ADMN PNEUMOC VACCINE 43.00 06/30/10 90471 G0009 90471 078 0771 0599
19900017 ADMIN H1N1 IMMUNIZATION 51.00 06/30/10 G9141 G9141 G9141 078 0771 0599
19900020 ADMIN 1 VACC-NOT FLU OR PNEU 51.00 06/30/10 90471 90471 90471 078 0771 0599
19900023 VACCINE FLU SPLT 6-35MO IM/JET 26.00 06/30/10 90657 90657 90657 078 0636 0599
19900024 VACCINE FLU SPLIT 3YR+ IM/JET 33.00 06/30/10 90658 90658 90658 078 0636 0599
19900025 VACCINE FLU WHOLE VIRUS IM/JET 30.00 06/30/10 90658 90658 90658 078 0636 0599
19900030 VACCINE PNEUMO 2YR/> SUBQ/JET 50.00 06/30/10 90732 90732 90732 078 0636 0599
19900032 ADMN INFLU VIRUS VAC-EA ADDL 36.00 06/30/10 90472 G0008 90472 078 0771 0599
19900034 ADMN PNEUMOC VAC-EA ADDL 43.00 06/30/10 90472 G0009 90472 078 0771 0599
19900036 ADMN 1 VAC-NOT FLU/PNEU-EA ADD 38.00 06/30/10 90472 90472 90472 078 0771 0599
19900037 IMMUNE ADMIN ORAL/NASAL 14.00 06/30/10 90473 90473 90473 078 0771 0599
19900041 IMM ADM ORAL/NASAL-EA ADD- 14.00 06/30/10 90474 90474 90474 078 0771 0599
19900043 HPV VACCINE 493.00 06/30/10 90649 90649 90649 078 0636 0599
19900045 IV HYDRA INFUS:INIT UP TO 1 HR 402.00 06/30/10 96360 96360 96360 078 0260 0599
19900049 IV HYDRA INFUSION EACH ADDL HR 244.00 06/30/10 96361 96361 96361 078 0260 0599
19900051 IV INFUSION, UP TO ONE HR 491.00 06/30/10 96365 96365 96365 078 0260 0599
19900055 IV INFUS THER/PROPH:EA ADDL HR 296.00 06/30/10 96366 96366 96366 078 0260 0599
19900059 ADD SQ IV INFS,UP TO 1HR 296.00 06/30/10 96367 96367 96367 078 0260 0599
19900063 CONCURRENT IV INFUSION 296.00 06/30/10 96368 96368 96368 078 0260 0599
19900067 THERAPEUTIC INJ,IM OR SUB 86.00 06/30/10 96372 96372 96372 078 0940 0599
19900071 THERAPEUTIC INJ,INTRA-ART 228.00 06/30/10 96373 96373 96373 078 0940 0599
19900075 THERAPEUTIC INJ,IV 236.00 06/30/10 96374 96374 96374 078 0940 0599
19900079 THERAP INJ,IV-EA ADDL 125.00 06/30/10 96375 96375 96375 078 0940 0599
19900161 SUBCUT INFUS THER UP TO 1HR 303.00 06/30/10 96369 96369 96369 078 0260 0599
19900186 SUBCUT FOR THER EA ADD'L HR 66.00 06/30/10 96370 96370 96370 078 0260 0599
19900189 SUBCUT INFUS(ADD'L INFUS SITE) 135.00 06/30/10 96371 96371 96371 078 0260 0599
19936000 INTRO-NDLE/INTRACATH,VEIN 125.00 06/30/09 36000 36000 36000 078 0260 0599
19936415 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 078 0510 0599
19990670 PCV13 VACCINE 378.00 04/15/10 90670 90670 90670 078 0636 0599
93705033 VOID EXTERNAL 04/01/07 078 0975 9999
93705074 VOID EXTERNAL 04/01/07 078 0975 9999
93705173 VOID EXTERNAL 04/01/07 078 0971 9999
93705314 VOID EXTERNAL 04/01/07 078 0975 9999
93705363 VOID EXTERNAL 04/01/07 078 0985 9999
11300340 VOID N/C 06/30/10 080 0983 9998
11310838 VOID 320.00 06/30/10 76812 7681226 76812 88.78 88.78 080 0972 9999
13300150 HEPATITIS B VACCINE ADULT DOSE 226.00 06/30/10 90746 90746 90746 081 0636 0648
13300262 CHANGE GASTRONOMY TUBE-HOSP 312.00 06/30/10 43760 43760 43760 081 0360 0648
13300263 CHANGE GASTRONOMY TUBE-M.D. 108.00 $ 06/30/10 43760 43760 43760 081 0975 0648
13300000 FINGER, HEEL AND EAR STICK 26.00 06/30/10 36416 36416 36416 082 0360 0648
13300020 INTRO-NDLE/INTRACATH,VEIN 161.00 06/30/10 36000 36000 36000 082 0360 0648
13300042 PREV MED NEW PT 1-4 YRS-HOSP 130.00 06/30/10 99382 99382 99382 082 0510 0648
13300043 PREV MED NEW PT 1-4 YRS-M.D. 144.00 $ 06/30/09 99382 99382 99382 082 0983 0648
13300044 PREV MED NEW PT 5-11 YRS-HOSP 138.00 06/30/10 99383 99383 99383 082 0510 0648
13300045 PREV MED NEW PT 5-11 YRS-M.D. 144.00 $ 06/30/09 99383 99383 99383 082 0983 0648
13300078 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 082 0300 0648
13300082 SPEC FROM PORT/CENT LINE 228.00 06/30/10 36591 36591 36591 082 0260 0648
13300086 THROMBOLYSIS CENTRAL LINE 329.00 06/30/10 36593 36593 36593 082 0360 0648
13300100 VACCINE ADMIN-VFC PROGRAM ONLY 16.79 07/01/10 082 0510 0648
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 427
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13300102 DT VACCINE 16.00 06/30/10 90702 90702 90702 082 0636 0648
13300144 HEPATITIS A VACCINE-PEDS 146.00 06/30/10 90633 90633 90633 082 0636 0648
13300154 HIB VACCINE 98.00 06/30/10 90645 90645 90645 082 0636 0648
13300172 KINRIX 183.00 06/30/10 90696 90696 90696 082 0250 0648
13300180 IPV 108.00 06/30/10 90713 90713 90713 082 0636 0648
13300190 MMR 180.00 06/30/10 90707 90707 90707 082 0636 0648
13300204 PNEUMOCCAL CONJUGATE VACCINE 148.00 06/30/10 90669 90669 90669 082 0636 0648
13300228 VARICELLA 272.00 06/30/10 90716 90716 90716 082 0636 0648
13300232 AEROSOL INHALATION, ACUTE 156.00 06/30/10 94640 94640 94640 082 0460 0648
13300252 STRAIGHT CATHETERIZATION 86.00 06/30/10 51701 51701 51701 082 0360 0648
13300254 INSRT TEMP CATH-FOLEY 98.00 06/30/10 51702 51702 51702 082 0510 0648
13300288 I&D OF ABSCESS-COMP/MULT-HOSP 279.00 06/30/10 10061 10061 10061 082 0360 0648
13300289 I&D OF ABSCESS-COMP/MULT-M.D. 332.00 $ 06/30/09 10061 10061 10061 082 0975 0648
13300330 URINE DIPSTICK-NON-AUTOMATED 38.00 06/30/10 81000 81000 81000 082 0300 0648
13300336 UA W/O MICRO-NON-AUTOMATD 45.00 06/30/10 81003QW 81003QW 81003QW 082 0300 0648
13300594 CHANGE OF CYSTO TUBE SIMP-HOSP 219.00 06/30/10 51705 51705 51705 082 0360 0648
13300595 CHANGE OF CYSTO TUBE SIMP-M.D. 149.00 $ 06/30/09 51705 51705 51705 082 0975 0648
13300616 CNSLT:O.P. RPTS/SLDS REV 50.00 06/30/10 87205 87205 87205 082 0306 0648
13300656 DEVLP TEST;LTD-DENVER 310.00 06/30/10 96110 96110 96110 082 0918 0648
13300660 DEVELOP TESTING,EXTENDED 843.00 06/30/10 96111 96111 96111 082 0918 0648
13300680 FAM THERAPY W/PAT PRESENT-HOSP 117.00 06/30/10 90847 90847 90847 082 0916 0648
13300681 FAM THERAPY W/PAT PRESENT-M.D. 215.00 $ 06/30/09 90847 90847 90847 082 0961 0648
13300722 I&D OF HEMATOMA/SEROMA-HOSP 300.00 06/30/10 10140 10140 10140 082 0360 0648
13300723 I&D OF HEMATOMA/SEROMA-M.D. 241.00 $ 06/30/09 10140 10140 10140 082 0975 0648
13300754 INCIS/RMVL FRGN BDY SIMP-HOSP 193.00 06/30/10 10120 10120 10120 082 0360 0648
13300755 INCIS/RMVL FRGN BDY SIMP-M.D. 182.00 $ 06/30/09 10120 10120 10120 082 0975 0648
13300848 PHLEBOTOMY, THERAPEUT HLA 157.00 06/30/10 99195 99195 99195 082 0940 0648
13300860 PUNCT ASP-ABSC HEMATOMA-HOSP 100.00 06/30/10 10160 10160 10160 082 0360 0648
13300861 PUNCT ASP-ABSC HEMATOMA-M.D. 193.00 $ 06/30/09 10160 10160 10160 082 0975 0648
13300890 TREAT OF SUPERFICIAL WND-HOSP 419.00 06/30/10 12020 12020 12020 082 0360 0648
13300891 TREAT OF SUPERFICIAL WND-M.D. 377.00 $ 06/30/09 12020 12020 12020 082 0975 0648
13300894 TREAT SUPER WND W/PKING-HOSP 456.00 06/30/10 12021 12021 12021 082 0360 0648
13300895 TREAT SUPER WND W/PKING-M.D. 276.00 $ 06/30/09 12021 12021 12021 082 0975 0648
13301002 PREV MED NEW PT 1-4 YRS-HOSP 130.00 06/30/10 99382 99382 99382 082 0510 0648
13301003 PREV MED NEW PT 1-4 YRS-M.D. 144.00 $ 06/30/09 99382 99382 99382 082 0983 0648
13301004 PREV MED NEW PT 5-11 YRS-HOSP 138.00 06/30/10 99383 99383 99383 082 0510 0648
13301005 PREV MED NEW PT 5-11 YRS-M.D. 144.00 $ 06/30/09 99383 99383 99383 082 0983 0648
13301070 CIRCUMCISION-HOSP 2370.00 06/30/10 54150 54150 54150 082 0360 0648
13301071 CIRCUMCISION-M.D. 221.00 $ 07/01/09 54150 54150 54150 082 0960 0648
93610521 VOID 52.00 06/30/09 99201 99201 99201 082 0983 9998
93755879 VOID EXTERNAL 06/30/08 51701 51701 51701 082 0975 9998
03758834 SPIROMETRY-HOSP 224.00 06/30/10 94010 94010 94010 083 0460 0648
03772815 PULMONARY FUNCTION TEST-HOSP 55.00 06/30/10 94620 94620 94620 083 0460 0648
03799812 ESTAB PT - 1-4 YRS - HOSP. 112.00 06/30/10 99392 99392 083 0510 0648
03799911 EST PT <1 YR-HOSP 109.00 06/30/10 99391 99391 99391 083 0510 0648
03799912 EST PT 1-4 YRS-HOSP 112.00 06/30/10 99392 99392 99392 083 0510 0648
03799913 EST PT 5-11 YRS-HOSP 116.00 06/30/10 99393 99393 99393 083 0510 0648
12666368 PREV MED VST,NEW-AGE40-64 HOSP 152.00 06/30/10 99386 99386 99386 083 0510 0602
12666369 PREV MED VST,NEW-AGE40-64 M.D. 199.00 $ 06/30/09 99386 99386 99386 083 0983 0602
12666371 PREV MED VST,NEW-AGE 65+ HOSP 169.00 06/30/10 99387 99387 99387 083 0510 0602
12666372 PREV MED VST,NEW-AGE 65+ M.D. 218.00 $ 06/30/09 99387 99387 99387 083 0983 0602
12666375 PREV MED NEW PT<1 YR-HOSP 136.00 06/30/10 99381 99381 99381 083 0510 0602
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 428
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

12666376 PREV MED NEW PT<1 YR-M.D. 127.00 $ 06/30/09 99381 99381 99381 083 0983 0602
12666379 PREV MED NEW PT 1-4 YRS-HOSP 130.00 06/30/10 99382 99382 083 0510 0602
12666380 PREV MED NEW PT 1-4 YRS-M.D. 144.00 $ 06/30/09 99382 99382 083 0983 0602
12666382 PREV MED NEW PT 5-11-M.D. 144.00 $ 06/30/09 99383 99383 083 0983 0602
12666387 PREV MED EST PT <1YR-HOSP 109.00 06/30/10 99391 99391 083 0510 0602
12666388 PREV MED EST PT <1YR-M.D. 108.00 $ 06/30/09 99391 99391 083 0983 0602
12666389 PREV MED EST PT 1-4YRS-HOSP 112.00 06/30/10 99392 99392 083 0510 0602
12666390 PREV MED EST PT 1-4 YRS-M.D. 127.00 $ 06/30/09 99392 99392 083 0983 0602
12666392 PREV MED EST PT 5-11-M.D. 127.00 $ 06/30/09 99393 99393 083 0983 0602
12666397 PREV MED VST EST AGE40-64-HOSP 127.00 06/30/10 99396 99396 99396 083 0510 0602
12666398 PREV MED VST EST AGE40-64-M.D. 163.00 $ 06/30/09 99396 99396 99396 083 0983 0602
12666400 VARICELLA 272.00 06/30/10 90716 90716 90716 083 0636 0602
12666401 PREV MED VST EST AGE65+-HOSP 143.00 06/30/10 99397 99397 99397 083 0510 0602
12666402 PREV MED VST EST AGE65+-M.D. 182.00 $ 06/30/09 99397 99397 99397 083 0983 0602
12666903 TDAP 7 YRS OR >;IM 95.00 06/30/10 90715 90715 90715 083 0636 0602
12666906 MMRV 408.00 06/30/10 90710 90710 90710 083 0636 0602
12666909 ROTAVIRUS VACCINATION 233.00 06/30/10 90680 90680 90680 083 0636 0602
12666912 HPV VACCINE 493.00 06/30/10 90649 90649 90649 083 0636 0602
12666930 ZOSTAVAX(ZOSTER VACCINE) 539.00 06/30/10 083 0250 0602
12667638 PREV MED RST PT 18-39 YRS-HOSP 161.00 06/30/10 99395 99395 99395 083 0510 0602
12667639 PREV MED RST PT 18-39 YRS-M.D. 144.00 $ 06/30/10 99395 99395 99395 083 0983 0602
13300010 HEMATOCRIT - HEMOGLOBIN 37.00 06/30/10 85018QW 85018QW 85018QW 083 0305 0648
13300040 PREV MED NEW PAT-<1 YR-HOSP 136.00 06/30/10 99381 99381 99381 083 0510 0648
13300041 PREV MED NEW PAT-<1 YR-M.D. 127.00 $ 06/30/09 99381 99381 99381 083 0983 0648
13300046 PREV MED NEW PT 12-17 YRS-HOSP 136.00 06/30/10 99384 99384 99384 083 0510 0648
13300047 PREV MED NEW PT 12-17 YRS-M.D. 163.00 $ 06/30/09 99384 99384 99384 083 0983 0648
13300050 PREV MED EST PT <1 YR-HOSP 109.00 06/30/10 99391 99391 99391 083 0510 0648
13300051 PREV MED EST PT <1 YR-M.D. 108.00 $ 06/30/09 99391 99391 99391 083 0983 0648
13300052 PREV MED EST PT 1-4 YRS-HOSP 112.00 06/30/10 99392 99392 99392 083 0510 0648
13300053 PREV MED EST PT 1-4 YRS-M.D. 127.00 $ 06/30/09 99392 99392 99392 083 0983 0648
13300054 PREV MED EST PT 5-11 YRS-HOSP 116.00 06/30/10 99393 99393 99393 083 0510 0648
13300055 PREV MED EST PT 5-11 YRS-M.D. 127.00 $ 06/30/09 99393 99393 99393 083 0983 0648
13300056 PREV MED EST PT 12-17 YRS-HOSP 125.00 06/30/10 99394 99394 99394 083 0510 0648
13300057 PREV MED EST PT 12-17 YRS-M.D. 144.00 $ 06/30/09 99394 99394 99394 083 0983 0648
13300090 TRANSFUSE BLOOD/PRODUCTS 763.00 06/30/10 36430 36430 36430 083 0391 0648
13300118 DTAP-HEP B-IPV VACCINE,IM 90.00 06/30/10 90723 90723 90723 083 0636 0648
13300126 FLOURIDE VARNISHING - HOSP 27.00 06/30/10 D1203 D1203 083 0510 0648
13300127 FLOURIDE VARNISHING - M.D. 107.00 $ 12/01/09 D1203 D1203 083 0982 0648
13300140 HEP/HIB 47.00 06/30/10 90748 90748 90748 083 0636 0648
13300158 HPV VACCINE 493.00 06/30/10 90649 90649 90649 083 0636 0648
13300184 MENINGOCOCCAL VACCINE 166.00 06/30/10 90734 90734 90734 083 0636 0648
13300194 MMRV 408.00 06/30/10 90710 90710 90710 083 0636 0648
13300208 ROTAVIRUS VACCINATION 233.00 06/30/10 90680 90680 90680 083 0636 0648
13300216 TDAP 7 YRS OR >; IM 95.00 06/30/10 90715 90715 90715 083 0636 0648
13300268 CRYOTHERAPY OF SKIN-HOSP 64.00 06/30/10 17340 17340 17340 083 0360 0648
13300269 CRYOTHERAPY OF SKIN-M.D. 92.00 $ 06/30/09 17340 17340 17340 083 0975 0648
13300274 GLUCOSE FINGER STICK 41.00 06/30/10 82948 82948 82948 083 0301 0648
13300286 I&D OF ABSCESS - HOSP 164.00 06/30/10 10060 10060 10060 083 0360 0648
13300287 I&D OF ABSCESS - M.D. 186.00 $ 06/30/09 10060 10060 10060 083 0975 0648
13300292 LUMBAR PUNCTURE - HOSP 351.00 06/30/10 62270 62270 62270 083 0360 0648
13300293 LUMBAR PUNCTURE - M.D. 158.00 $ 06/30/09 62270 62270 62270 083 0975 0648
13300296 PREGNANCY TEST, URINE HCG 90.00 06/30/10 81025 81025 81025 083 0300 0648
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 429
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13300316 REMOVAL IMPACTED CERUMEN-HOSP 108.00 06/30/10 69210 69210 69210 083 0360 0648
13300317 REMOVAL IMPACTED CERUMEN-M.D. 67.00 $ 06/30/09 69210 69210 69210 083 0975 0648
13300322 STREPTOCOCCUS GROUP A TEST 79.00 06/30/10 87430QW 87430QW 87430QW 083 0306 0648
13300326 TYMPANOMETRY 81.00 06/30/10 92567 92567 92567 083 0471 0648
13300338 WET MOUNT 46.00 06/30/10 87210 87210 87210 083 0306 0648
13300358 PRICK TST W/ALLER EXT SPEC#___ 64.00 06/30/10 95004 95004 95004 083 0924 0648
13300542 ALLER MIX MULT VIAL-HOSP 125.00 06/30/10 95165 95165 95165 083 0510 0648
13300543 ALLER MIX MULT VIAL-M.D. 7.00 $ 06/30/09 95165 95165 95165 083 0983 0648
13300664 DIAGNOSTIC INTERVIEW - HOSP 134.00 06/30/10 90801 90801 90801 083 0900 0648
13300665 DIAGNOSTIC INTERVIEW - M.D. 269.00 $ 06/30/09 90801 90801 90801 083 0961 0648
13300670 DEVELOPMENTAL SCREEN 265.00 06/30/10 96110 96110 96110 083 0918 0648
13300671 DEVELOPMENTAL SCREEN - M.D. 39.00 $ 12/01/09 96110 96110 96110 083 0961 0648
13300730 IM ADM<8 YR;M.D.CNSL;1 IN-HOSP 89.00 06/30/10 90465 90465 90465 083 0771 0648
13300731 IM ADM<8 YR;M.D.CNSL;1 IN-M.D. 45.00 $ 06/30/09 90465 90465 90465 083 0771 0648
13300734 IM ADM<8 YR;M.D.CSL;EA AD-HOSP 89.00 06/30/10 90466 90466 90466 083 0771 0648
13300735 IM ADM<8 YR;M.D.CSL;EA AD-M.D. 17.00 $ 06/30/09 90466 90466 90466 083 0771 0648
13300738 IM ADM<8 YR;INT/ORL;1/DAY-HOSP 89.00 06/30/10 90467 90467 90467 083 0771 0648
13300739 IM ADM<8 YR;INT/ORL;1/DAY-M.D. 20.00 $ 06/30/09 90467 90467 90467 083 0771 0648
13300742 IM ADM<8 YR;INT/ORL;EA AD-HOSP 89.00 06/30/10 90468 90468 90468 083 0771 0648
13300743 IM ADM<8 YR;INT/ORL;EA AD-M.D. 16.00 $ 06/30/09 90468 90468 90468 083 0771 0648
13300764 LACERATION,REPAIR-SIMPLE-HOSP 226.00 06/30/10 12001 12001 12001 083 0360 0648
13300765 LACERATION,REPAIR-SIMPLE-M.D. 206.00 $ 06/30/09 12001 12001 12001 083 0975 0648
13300930 VISION SCREEN TEST, BILAT 32.00 06/30/10 99173 99173 99173 083 0510 0648
13300936 BILIRUBIN,TOTAL,TRANSCUTANEOUS 29.00 06/30/10 88720 88720 88720 083 0301 0648
13301000 PREV MED NEW PAT-<1 YR-HOSP 136.00 06/30/10 99381 99381 99381 083 0510 0648
13301001 PREV MED NEW PAT-<1 YR-M.D. 127.00 $ 06/30/09 99381 99381 99381 083 0983 0648
13301006 PREV MED NEW PT 12-17 YRS-HOSP 136.00 06/30/10 99384 99384 99384 083 0510 0648
13301007 PREV MED NEW PT 12-17 YRS-M.D. 163.00 $ 06/30/09 99384 99384 99384 083 0983 0648
13301020 PREV MED EST PT <1 YR-HOSP 109.00 06/30/10 99391 99391 99391 083 0510 0648
13301021 PREV MED EST PT <1 YR-M.D. 108.00 $ 06/30/09 99391 99391 99391 083 0983 0648
13301022 PREV MED EST PT 1-4 YRS-HOSP 112.00 06/30/10 99392 99392 99392 083 0510 0648
13301023 PREV MED EST PT 1-4 YRS-M.D. 127.00 $ 06/30/09 99392 99392 99392 083 0983 0648
13301024 PREV MED EST PT 5-11 YRS-HOSP 116.00 06/30/10 99393 99393 99393 083 0510 0648
13301026 PREV MED EST PT 12-17 YRS-HOSP 125.00 06/30/10 99394 99394 99394 083 0510 0648
13301027 PREV MED EST PT 12-17 YRS-M.D. 144.00 $ 06/30/09 99394 99394 99394 083 0983 0648
13301040 MED GENETIC CNSL SVC-EA 30 MIN 101.00 06/30/10 96040 96040 96040 083 0510 0648
13510339 MMRV 450.00 06/30/08 90710 90710 90710 083 0510 0606
93758586 NULL AND VOID EXTERNAL 06/30/08 51701 51701 51701 083 0975 0648
93758834 NULL 45.00 06/30/09 94010 9401026 9401026 89.37 083 0971 9998
93759105 VOIDED EXTERNAL 06/30/08 99173 99173 95.09 083 0982 9998
93772815 VOID 648 N/C 06/30/08 083 0971 9998
93799801 NEW PT-<1 YR- M.D. 128.00 06/30/09 99381 99381 083 0983 0648
93799812 ESTAB PT - 1-4 YRS - M.D. 65.00 06/30/09 99392 99392 083 0983 0648
93799911 EST PT <1 YR-M.D. 66.00 06/30/09 99391 99391 99391 083 0983 0648
93799912 EST PT 1-4 YRS-M.D. 65.00 06/30/09 99392 99392 99392 083 0983 0648
93799913 EST PT 5-11 YRS-M.D. 70.00 06/30/09 99393 99393 99393 083 0983 0648
11010733 VOID EXTERNAL 04/01/07 084 0972 9999
11050001 BIOPSY VAG MUCOSA SIMPLE-HOSP 369.00 06/30/10 57100 57100 57100 084 0360 0612
11050002 BIOPSY VAG MUCOSA SIMPLE-M.D. 140.00 $ 06/30/09 57100 57100 57100 084 0975 0612
11050005 BIOPSY EXCIS CERVICAL LES-HOSP 416.00 06/30/10 57500 57500 57500 084 0360 0612
11050006 BIOPSY EXCIS CERVICAL LES-M.D. 156.00 $ 06/30/09 57500 57500 57500 084 0975 0612
11050009 BIOPSY ENDOMETRIAL-HOSP 316.00 06/30/10 58100 58100 58100 084 0360 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 430
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11050010 BIOPSY ENDOMETRIAL-M.D. 187.00 $ 06/30/09 58100 58100 58100 084 0975 0612
11050013 BIOPSY VULVA-HOSP 361.00 06/30/10 56605 56605 56605 084 0360 0612
11050014 BIOPSY VULVA-M.D. 130.00 $ 06/30/09 56605 56605 56605 084 0975 0612
11050017 CATHETER IRRIG (BLADDER)-HOSP 211.00 06/30/10 51700 51700 51700 084 0360 0612
11050018 CATHETER IRRIG (BLADDER)-M.D. 100.00 $ 06/30/09 51700 51700 51700 084 0975 0612
11050021 CATHETERIZ URETHRA-SIMP-HOSP 86.00 06/30/10 51701 51701 51701 084 0360 0612
11050022 CATHETERIZ URETHRA SIMP-M.D. 61.00 $ 06/30/09 51701 51701 51701 084 0975 0612
11050025 CAUTERIZATION,CERVIX-HOSP 408.00 06/30/10 57510 57510 57510 084 0360 0612
11050026 CAUTERIZATION,CERVIX-M.D. 247.00 $ 06/30/09 57510 57510 57510 084 0975 0612
11050029 COMPLEX CYSTOMETROGRAM-HOSP 524.00 06/30/10 51726 51726 51726 084 0490 0612
11050030 COMPLEX CYSTOMETROGRAM-M.D. 196.00 $ 06/30/09 5172626 5172626 5172626 084 0982 0612
11050033 SIMPLE CYSTOMETROGRAM-HOSP 399.00 06/30/10 51725 51725 51725 084 0360 0612
11050034 SIMPLE CYSTOMETROGRAM-M.D. 173.00 $ 06/30/09 5172526 5172526 5172526 084 0982 0612
11050037 COLPOCENTESIS-HOSP 402.00 06/30/10 57020 57020 57020 084 0360 0612
11050038 COLPOCENTESIS-M.D. 175.00 $ 06/30/09 57020 57020 57020 084 0975 0612
11050041 COLPOSCOPY-HOSP 330.00 06/30/10 57452 57452 57452 084 0360 0612
11050042 COLPOSCOPY-M.D. 195.00 $ 06/30/09 57452 57452 57452 084 0975 0612
11050045 COLPOSCOPY W/CERVICAL BIO-HOSP 545.00 06/30/10 57454 57454 57454 084 0360 0612
11050046 COLPOSCOPY W/CERVICAL BIO-M.D. 292.00 $ 06/30/09 57454 57454 57454 084 0975 0612
11050049 UROFLOWMETRY,COMPLEX-HOSP 187.00 06/30/10 51741 51741 51741 084 0920 0612
11050050 UROFLOWMETRY,COMPLEX-M.D. 132.00 $ 06/30/09 5174126 5174126 5174126 084 0982 0612
11050053 CRYOTHERAPY OF SKIN-ACNE-HOSP 64.00 06/30/10 17340 17340 17340 084 0360 0612
11050054 CRYOTHERAPY OF SKIN-ACNE-M.D. 92.00 $ 06/30/09 17340 17340 17340 084 0975 0612
11050057 CYSTOSCOPY-HOSP 492.00 06/30/10 52000 52000 52000 084 0360 0612
11050058 CYSTOSCOPY-M.D. 280.00 $ 06/30/09 52000 52000 52000 084 0975 0612
11050061 DESTRUCT OF LESIONS 2-14-HOSP 69.00 06/30/10 17003 17003 17003 084 0360 0612
11050062 DESTRUCT OF LESIONS 2-14-M.D. 10.00 $ 06/30/09 17003 17003 17003 084 0975 0612
11050065 DIAPHRAGM/CERV CAP FIT-HOSP 79.00 06/30/10 57170 57170 57170 084 0510 0612
11050066 DIAPHRAGM/CERV CAP FIT-M.D. 104.00 $ 06/30/09 57170 57170 57170 084 0983 0612
11050069 ENDOCERVICAL CURETTAGE-HOSP 335.00 06/30/10 57505 57505 57505 084 0360 0612
11050070 ENDOCERVICAL CURETTAGE-M.D. 190.00 $ 06/30/09 57505 57505 57505 084 0975 0612
11050073 BIOPSY ENDOMETRIAL-HOSP 316.00 06/30/10 58100 58100 58100 084 0360 0612
11050074 BIOPSY ENDOMETRIAL-M.D. 187.00 $ 06/30/09 58100 58100 58100 084 0975 0612
11050077 CERV MUCUS PENETRATION TEST 257.00 06/30/10 89330 89330 89330 084 0300 0612
11050081 FINE NEEDLE ASP,BREAST-HOSP 355.00 06/30/10 10021 10021 10021 084 0361 0612
11050082 FINE NEEDLE ASP,BREAST-M.D. 141.00 $ 06/30/09 10021 10021 10021 084 0983 0612
11050085 HYSTERO RMVL FOREIGN BODY-HOSP 1899.00 06/30/10 58562 58562 58562 084 0360 0612
11050086 HYSTERO RMVL FOREIGN BODY-M.D. 627.00 $ 06/30/09 58562 58562 58562 084 0975 0612
11050089 HYSTEROSCOPY W/BIOPSY-HOSP 1693.00 06/30/10 58558 58558 58558 084 0360 0612
11050090 HYSTEROSCOPY W/BIOPSY-M.D. 574.00 $ 06/30/09 58558 58558 58558 084 0975 0612
11050093 HYSTEROSCOPY,DIAG-HOSP 1559.00 06/30/10 58555 58555 58555 084 0360 0612
11050094 HYSTEROSCOPY,DIAG-M.D. 407.00 $ 06/30/09 58555 58555 58555 084 0975 0612
11050097 I&D BARTHOLIN CYST-HOSP 384.00 06/30/10 56420 56420 56420 084 0360 0612
11050098 I&D BARTHOLIN CYST-M.D. 193.00 $ 06/30/09 56420 56420 56420 084 0975 0612
11050101 I&D VULVAR ABSCESS-HOSP 339.00 06/30/10 56405 56405 56405 084 0360 0612
11050102 I&D VULVAR ABSCESS-M.D. 222.00 $ 06/30/09 56405 56405 56405 084 0975 0612
11050105 INJECTION IM ANTIBIOTIC 110.00 06/30/10 96372 96372 96372 084 0940 0612
11050113 IUD REMOVAL-HOSP 105.00 06/30/10 58301 58301 58301 084 0360 0612
11050114 IUD REMOVAL-M.D. 146.00 $ 06/30/09 58301 58301 58301 084 0975 0612
11050117 INJ IM THERAPEUTIC 86.00 06/30/10 96372 96372 96372 084 0940 0612
11050120 INJ IV THERAPEUTIC 80.00 06/30/10 96374 96374 96374 084 0940 0612
11050123 INSERTION PESSARY-HOSP 112.00 06/30/10 57160 57160 57160 084 0360 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 431
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11050124 INSERTION PESSARY-M.D. 102.00 $ 06/30/09 57160 57160 57160 084 0975 0612
11050127 LOOP EXCISION CERVIX-HOSP 1483.00 06/30/10 57460 57460 57460 084 0360 0612
11050128 LOOP EXCISION CERVIX-M.D. 350.00 $ 06/30/09 57460 57460 57460 084 0975 0612
11050135 NORPLANT REMOVAL-HOSP 301.00 06/30/10 11976 11976 11976 084 0360 0612
11050136 NORPLANT REMOVAL-M.D. 204.00 $ 06/30/09 11976 11976 11976 084 0975 0612
11050143 SIS-HOSP 282.00 06/30/10 58340 58340 58340 084 0360 0612
11050144 SIS-M.D. 124.00 $ 06/30/09 58340 58340 58340 084 0975 0612
11050147 SIMPLE UROFLOWMETRY-HOSP 236.00 06/30/10 51736 51736 51736 084 0920 0612
11050148 SIMPLE UROFLOWMETRY-M.D. 71.00 $ 06/30/09 5173626 5173626 5173626 084 0982 0612
11050151 ACTIVE WOUND CARE/20CM OR < 106.00 06/30/10 97597 97597 97597 084 0510 0612
11050155 ECHO COMPLETE ABDOMINAL-HOSP 689.00 06/30/10 76700 76700 76700 084 0402 0612
11050156 ECHO COMPLETE ABDOMINAL-M.D. 88.00 $ 06/30/09 7670026 7670026 7670026 084 0402 0612
11050159 U/S TRANSVAGINAL,NON OB 358.00 06/30/10 76830 76830 76830 084 0402 0612
11050160 U/S TRANSVAGINAL,NON OB-M.D. 74.00 $ 06/30/09 7683026 7683026 7683026 084 0402 0612
11050163 ECHO PELVIS NON OB-HOSP 412.00 06/30/10 76856 76856 76856 084 0402 0612
11050164 ECHO PELVIS NON OB-M.D. 75.00 $ 06/30/09 7685626 7685626 7685626 084 0972 0612
11050167 ACCUCHECK 44.00 06/30/10 82962 82962 82962 084 0301 0612
11050170 HEMAGLOBIN 29.00 06/30/10 85018QW 85018QW 85018QW 084 0305 0612
11050173 BLOOD OCCLT FECAL SCREEN 34.00 06/30/10 82270 82270 82270 084 0301 0612
11050176 KOH WET MOUNT 52.00 06/30/10 87220 87220 87220 084 0306 0612
11050179 PREGNANCY TEST 90.00 06/30/10 81025 81025 81025 084 0300 0612
11050182 TB SKIN TEST 46.00 06/30/10 86580 86580 86580 084 0302 0612
11050185 URINALYSIS DIPSTICK 35.00 06/30/10 81007 81007 81007 084 0300 0612
11050188 HEMATOCRIT-HEMOGLOBIN 48.00 06/30/10 85014 85014 85014 084 0305 0612
11050191 QUAN GLUCOSE DETERMINATION 41.00 06/30/10 82947 82947 82947 084 0301 0612
11050194 GLUCOSE POST DOSE 53.00 06/30/10 82950 82950 82950 084 0301 0612
11050197 PH,BODY FLUID,EXCEPT BLOOD 38.00 06/30/10 83986QW 83986QW 83986QW 084 0301 0612
11050201 AMINES,VAG FLUID,QUAL-HOSP 65.00 06/30/10 82120 82120 82120 084 0301 0612
11050202 AMINES, VAG FLUID,QUAL-M.D. 23.00 $ 08/10/08 82120 82120 82120 084 0971 0612
11050205 DEPO PROVERA 150MG 66.00 06/30/10 J1055 J1055 J1055 084 0636 0612
11050208 PESSARY 125.00 06/30/10 A4561 A4561 A4561 084 0270 0612
11050211 PARAGARD IUD 578.00 06/30/10 J7300 J7300 J7300 084 0270 0612
11050214 MIRENA IUD 833.00 06/30/10 J7302 J7302 J7302 084 0270 0612
11050217 LUPRON 3.75 MG 881.00 06/30/10 J1950 J1950 J1950 084 0636 0612
11050220 DPT 18.00 06/30/10 90701 90701 90701 084 0636 0612
11050223 DT 16.00 06/30/10 90702 90702 90702 084 0636 0612
11050229 MUMPS 74.00 06/30/10 90704 90704 90704 084 0636 0612
11050232 RUBELLA 90.00 06/30/10 90706 90706 90706 084 0636 0612
11050235 MMR 180.00 06/30/10 90707 90707 90707 084 0636 0612
11050238 ORAL POLIO 69.00 06/30/10 90712 90712 90712 084 0636 0612
11050241 ADULT DIPHTHERIA & (TD) 40.00 06/30/10 90718 90718 90718 084 0636 0612
11050244 HEPATITIS B PED/ADOLESCNT 105.00 06/30/10 90744 90744 90744 084 0636 0612
11050247 HEPATITIS B ADULT DOSAGE 226.00 06/30/10 90746 90746 90746 084 0636 0612
11050250 PNEUMOCOCCAL POLYSAC VAC 30.00 06/30/10 90732 90732 90732 084 0636 0612
11050253 HEP A, ADULT DOSAGE 249.00 06/30/10 90632 90632 90632 084 0636 0612
11050256 HIB, PRP-D 81.00 06/30/10 90646 90646 90646 084 0636 0612
11050259 INFLUENZA VAC, WHOLE VIRUS 33.00 06/30/10 90658 90658 90658 084 0636 0612
11050263 BREAST/CERV CANCER SCRN-HOSP 77.00 06/30/10 G0101 G0101 G0101 084 0510 0612
11050264 BREAST/CERV CANCER SCRN-M.D. 74.00 $ 06/30/09 G0101 G0101 G0101 084 0983 0612
11050267 SCREEN-PAP,PREP & CONVEY-HOSP 72.00 06/30/10 Q0091 Q0091 Q0091 084 0510 0612
11050268 SCREEN-PAP,PREP & CONVEY-M.D. 39.00 $ 06/30/10 Q0091 Q0091 Q0091 084 0983 0612
11050271 ROCEPHIN 250MG 41.00 06/30/10 J0696 J0696 J0696 084 0636 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 432
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11050274 BICILLIN L-A 23.00 06/30/10 J0570 J0570 J0570 084 0636 0612
11050277 ANTPRT ONLY;INIT VISIT-HOSP 120.00 06/30/10 0500F 59425 0500F 084 0510 0612
11050278 ANTPRT ONLY;INIT VISIT-M.D. 761.00 $ 06/30/09 0500F 59425 0500F 084 0983 0612
11050281 ANTPRT ONLY SUBSQ VISIT-HOSP 118.00 06/30/10 0502F 59426 59426 084 0510 0612
11050282 ANTPRT ONLY SUBSQ VISIT-M.D. 87.00 $ 06/30/09 59426 59426 0502F 084 0983 0612
11050285 FETAL BPP W/NST- HOSP 760.00 06/30/10 76818 76818 76818 084 0402 0612
11050286 FETAL BPP W/NST-M.D. 111.00 $ 06/30/09 7681826 7681826 7681826 084 0402 0612
11050289 U/S BASIC>14 WKS,SINGLE/1ST 563.00 06/30/10 76805 76805 76805 084 0402 0612
11050290 U/S BASIC>14 WKS,SINGLE/1ST-MD 105.00 $ 06/30/09 7680526 7680526 7680526 084 0972 0612
11050293 U/S FOLLOW-UP,PER FETUS 319.00 06/30/10 76816 76816 76816 084 0402 0612
11050294 U/S FOLLOW-UP,PER FETUS-M.D. 90.00 $ 06/30/09 7681626 7681626 7681626 084 0972 0612
11050297 U/S BAS>14 WKS,E ADD GEST-HOSP 980.00 06/30/10 76810 76810 76810 084 0402 0612
11050298 U/S BASIC>14 WKS,E ADD GEST-MD 104.00 $ 06/30/09 7681026 7681026 7681026 084 0972 0612
11050301 NST FETAL-HOSP 363.00 06/30/10 59025 59025 59025 084 0920 0612
11050302 NST FETAL-M.D. 71.00 $ 06/30/09 5902526 5902526 5902526 084 0983 0612
11050305 U/S LIMITED, ALL FETUSES-HOSP 511.00 06/30/10 76815 76815 76815 084 0402 0612
11050306 U/S LIMITED,ALL FETUSES-M.D. 69.00 $ 06/30/09 76815 7681526 7681526 084 0972 0612
11050309 PRENATAL RISK ASSESSMENT-HOSP 100.00 06/30/10 W7359 99211 99211 084 0510 0612
11050310 PRENATAL RISK ASSESSMENT-M.D. 19.00 $ 06/30/09 99211 99211 99211 084 0983 0612
11050313 URINE DIPSTICK 35.00 06/30/10 81002 81002 81002 084 0300 0612
11050314 U/S GUIDANCE OF AMNIOCENT-M.D. 40.00 $ 06/30/09 76946 7694626 7694626 084 0972 0612
11050333 DOP ECHO,FETAL COMPLETE-HOSP 763.00 06/30/10 76827 76827 76827 084 0402 0612
11050334 DOP ECHO,FETAL COMPLETE-M.D. 60.00 $ 06/30/09 7682726 7682726 7682726 084 0972 0612
11050337 DOP ECHO,FETAL,F/UP-RPT-HOSP 421.00 06/30/10 76828 76828 76828 084 0402 0612
11050338 DOP ECHO,FETAL,F/UP-RPT-M.D. 60.00 $ 06/30/09 76828 7682826 7682826 084 0972 0612
11050341 DOP ECHO,COLOR MAPPING-HOSP 414.00 06/30/10 93325 93325 93325 084 0480 0612
11050342 DOP ECHO,COLOR MAPPING-M.D. 9.00 $ 06/30/09 9332526 9332526 9332526 084 0985 0612
11050345 FETAL BIOPHYS PRO W/O NST-HOSP 200.00 06/30/10 76819 76819 76819 084 0402 0612
11050346 FETAL BIOPHYS PRO W/O NST-M.D. 81.00 $ 06/30/09 76819 76819 76819 084 0972 0612
11050349 FETAL ECHOCARDIOGRAPHY-HOSP. 263.00 06/30/10 76825 76825 76825 084 0402 0612
11050350 FETAL ECHOCARDIOGRAPHY-M.D. 176.00 $ 06/30/09 7682526 7682526 7682526 084 0972 0612
11050353 ECHO-FETAL,F/UP-RPT STUDY-HOSP 556.00 06/30/10 76826 76826 76826 084 0402 0612
11050354 ECHO-FETAL,F/UP-RPT STUDY-M.D. 86.00 $ 06/30/09 76826 7682626 7682626 084 0972 0612
11050357 SURGICAL TRAY 122.00 06/30/10 A4550 A4550 A4550 084 0272 0612
11050359 U/S,DETAILED SING/1ST-HOSP 353.00 06/30/10 76811 76811 76811 084 0402 0612
11050360 U/S, DETAILED SING/1ST-M.D. 201.00 $ 06/30/09 7681126 7681126 7681126 084 0972 0612
11050363 U/S, DETAILED EA ADD GEST-HOSP 224.00 06/30/10 76812 76812 76812 084 0402 0612
11050364 U/S,DETAILED EA ADD GEST-M.D. 187.00 $ 06/30/09 76812 7681226 7681226 084 0972 0612
11050367 U/S<14WKS SING/1ST-HOSP 137.00 06/30/10 76801 76801 76801 084 0402 0612
11050368 U/S<14WKS SING/1ST-M.D. 106.00 $ 06/30/09 7680126 7680126 7680126 084 0972 0612
11050371 U/S<14WKS EA ADDL GEST-HOSP 120.00 06/30/10 76802 76802 76802 084 0402 0612
11050372 U/S<14WKS EA ADDL GEST-M.D. 89.00 $ 06/30/09 7680226 7680226 7680226 084 0972 0612
11050375 U/S TRANSVAGINAL,OB-HOSP 159.00 06/30/10 76817 76817 76817 084 0402 0612
11050376 U/S TRANSVAGINAL,OB-M.D. 79.00 $ 06/30/09 76817 7681726 7681726 084 0972 0612
11050379 CELESTONE 4MG(CODEX3 FOR 12MG) 73.00 06/30/10 J0704 J0704 J0704 084 0636 0612
11050382 WET MOUNT/GRAMSTAIN 46.00 06/30/10 87210 87210 87210 084 0306 0612
11050385 PNEUMOCCAL CONJUGATE VACCINE 138.00 06/30/10 90669 90669 084 0636 0612
11050388 INFLUENZA VAC WHOLE VIRUS 38.00 06/30/10 90660 90660 90660 084 0636 0612
11050389 INFLUENZA VAC WHOLE VIRUS 47.00 06/30/10 90660 90660 084 0636 0612
11050399 AMINO THER AMNIOTIC FL RDC-HSP 509.00 06/30/10 59001 59001 59001 084 0361 0612
11050400 AMINO THERP AMNIOTC FL RDC-M.D 424.00 $ 06/30/09 59001 59001 59001 084 0982 0612
11050403 CVS-HOSP 588.00 06/30/10 59015 59015 59015 084 0361 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 433
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11050404 CVS-M.D 305.00 $ 06/30/09 59015 59015 59015 084 0982 0612
11050407 EXT CEPHALIC VERSION-HOSP 391.00 06/30/10 59412 59412 59412 084 0360 0612
11050408 EXT CEPHALIC VERSION-M.D. 237.00 $ 06/30/09 59412 59412 59412 084 0975 0612
11050409 U/S GUIDANCE OF CVS-HOSP 591.00 06/30/10 76945 76945 76945 084 0402 0612
11050410 U/S GUIDANCE OF CVS-M.D. 71.00 $ 06/30/09 76945 7694526 7694526 084 0972 0612
11050413 AMNIOCENTESIS,DIAG-HOSP 509.00 06/30/10 59000 59000 59000 084 0361 0612
11050414 AMNIOCENTESIS,DIAG-M.D. 185.00 $ 06/30/09 59000 59000 59000 084 0982 0612
11050417 FETAL CONTRAC STRESS TEST-HOSP 377.00 06/30/10 59020 59020 59020 084 0920 0612
11050418 FETAL CONTRAC STRESS TEST-M.D. 88.00 $ 06/30/09 59020 59020 5902026 084 0920 0612
11050421 U/S GUIDANCE OF AMNIOCENT-HOSP 718.00 06/30/10 76946 76946 76946 084 0402 0612
11050422 U/S GUIDANCE OF AMNIOCENT-M.D. 40.00 $ 06/30/09 76946 7694626 7694626 084 0972 0612
11050425 DOPPLER ECHOCARDIOGRAPHY-HOSP 547.00 06/30/10 93320 93320 93320 084 0480 0612
11050426 DOPPLER ECHOCARDIOGRAPHY-M.D. 44.00 $ 06/30/09 9332026 9332026 9332026 084 0985 0612
11050429 UMBILICAL ARTERY DOPPLER-HOSP 194.00 06/30/10 76820 76820 76820 084 0402 0612
11050430 UMBILICAL ARTERY DOPPLER-M.D. 54.00 $ 06/30/09 7682026 7682026 7682026 084 0972 0612
11050433 MIDDLE CEREBRAL ART DPPL-HOSP 225.00 06/30/10 76821 76821 76821 084 0402 0612
11050434 MIDDLE CEREBRAL ART DPPL-M.D. 74.00 $ 06/30/09 76821 76821 76821 084 0972 0612
11050437 URETHRAL PROFILE STUDY-HOSP 159.00 06/30/10 51727 51727 51727 084 0360 0612
11050438 URETHRAL PROFILE STUDY-M.D. 631.00 $ 01/01/10 5172726 5172726 5172726 084 0982 0612
11050441 INTRAL ABDOM PRESS MNGMNT-HOSP 194.00 06/30/10 51797 51797 51797 084 0920 0612
11050442 INTRAL ABDOM PRESS MNGMNT-M.D. 105.00 $ 06/30/09 5179726 5179726 5179726 084 0982 0612
11050445 VOIDING PRESSURE STUDIES -HOSP 582.00 06/30/10 51728 51728 51728 084 0920 0612
11050446 VOIDING PRESSURE STUDIES -M.D. 629.00 $ 01/01/10 5172826 5172826 5172826 084 0982 0612
11050447 VOID&URETH PRESS STUDIES-HOSP 582.00 06/30/10 51729 51729 51729 084 0920 0612
11050448 VOID&URETH PRESS STUDIES-M.D. 675.00 $ 03/01/10 51729 51729 51729 084 0982 0612
11050449 POST VOID RESIDUAL VOLUME-HOSP 115.00 06/30/10 51798 51798 51798 084 0402 0612
11050450 POST VOID RESIDUAL VOLUME-M.D. 52.00 $ 06/30/09 5179826 5179826 5179826 084 0983 0612
11050453 CRYOSURGERY-HOSP 1225.00 06/30/10 57061 57061 57061 084 0360 0612
11050454 CRYOSURGERY-M.D. 202.00 $ 06/30/09 57061 57061 57061 084 0975 0612
11050457 DILATION CERVICAL CANAL-HOSP 259.00 06/30/10 57800 57800 57800 084 0360 0612
11050458 DILATION CERVICAL CANAL-M.D. 103.00 $ 06/30/09 57800 57800 57800 084 0975 0612
11050461 SIS INTERPRETATION-HOSP 672.00 06/30/10 76831 76831 76831 084 0402 0612
11050462 SIS INTERPRETATION-M.D. 75.00 $ 06/30/09 7683126 7683126 7683126 084 0972 0612
11050465 HEALTH RISK ASSESSMENT 23.00 06/30/10 99420 99420 99420 084 0510 0612
11050501 PREV VST NEW AGE 12-17-HOSP 155.00 06/30/10 99384 99384 99384 084 0510 0612
11050502 PREV VST NEW AGE 12-17-M.D. 163.00 $ 06/30/09 99384 99384 99384 084 0983 0612
11050517 PREV MED VST EST-AGE 12-17HOSP 125.00 06/30/10 99394 99394 99394 084 0510 0612
11050518 PREV MED VST EST-AGE 12-17 M.D 144.00 $ 06/30/09 99394 99394 99394 084 0983 0612
11050539 EMG STDY ANAL/URETH SPHNC 204.00 06/30/10 51784 51784 51784 084 0490 0612
11050561 INSRT,NON-BIO DRUG DELIV-HOSP 115.00 06/30/10 11981 11981 11981 084 0360 0612
11050562 INSRT,NON-BIO DRUG DELIV-M.D. 175.00 $ 06/30/09 11981 11981 11981 084 0975 0612
11050563 RMVL,NON-BIO DRUG DELIV-HOSP 115.00 06/30/10 11982 11982 11982 084 0360 0612
11050564 RMVL,NON-BIO DRUG DELIV-M.D. 216.00 $ 06/30/09 11982 11982 11982 084 0975 0612
11050565 REMV W/INSRT,NON-BIO DRUG-HOSP 115.00 06/30/10 11983 11983 11983 084 0360 0612
11050566 REMV W/INSRT,NON-BIO DRUG-M.D. 388.00 $ 06/30/09 11983 11983 11983 084 0975 0612
11050571 DEST VAG LESIONS-EXTEN-HOSP 2390.00 06/30/10 57065 57065 57065 084 0360 0612
11050572 DEST VAG LESIONS-EXTEN-M.D. 359.00 $ 06/30/09 57065 57065 57065 084 0975 0612
11050581 POST PARTUM CARE ONLY-HOSP 100.00 06/30/10 59430 99211 59430 084 0510 0612
11050582 POST PARTUM CARE ONLY-M.D. 289.00 $ 06/30/09 59430 99211 59430 084 0983 0612
11050585 3D PROC W/O INDP W/STN-HOSP 426.00 06/30/10 76376 76376 76376 084 0350 0612
11050586 3D PROC W/O INDP W/STN-M.D. 24.00 $ 06/30/09 76376 76376 76376TC 084 0972 0612
11050589 3D PROC W INDP W/STN-HOSP 588.00 06/30/10 76377 76377 76377TC 084 0320 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 434
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11060001 BIOPSY VAG MUCOSA SIMPLE 369.00 06/30/10 57100 57100 57100 084 0360 0612
11060005 BIOPSY EXCIS CERVICAL LES 416.00 06/30/10 57500 57500 57500 084 0360 0612
11060009 BIOPSY ENDOMETRIAL 316.00 06/30/10 58100 58100 58100 084 0360 0612
11060013 BIOPSY VULVA 361.00 06/30/10 56605 56605 56605 084 0360 0612
11060017 CATHETER IRRIG (BLADDER) 211.00 06/30/10 51700 51700 51700 084 0360 0612
11060021 CATHETERIZ URETHRA-SIMP 86.00 06/30/10 51701 51701 51701 084 0360 0612
11060025 CAUTERIZATION, CERVIX 408.00 06/30/10 57510 57510 57510 084 0360 0612
11060029 COMPLEX CYSTOMETROGRAM 524.00 06/30/10 51726 51726 51726 084 0490 0612
11060033 SIMPLE CYSTOMETROGRAM 399.00 06/30/10 51725 51725 51725 084 0360 0612
11060037 COLPOCENTESIS 402.00 06/30/10 57020 57020 57020 084 0360 0612
11060041 COLPOSCOPY 330.00 06/30/10 57452 57452 57452 084 0360 0612
11060045 COLPOSCOPY W/CERVICAL BIO 545.00 06/30/10 57454 57454 57454 084 0360 0612
11060049 UROFLOWMETRY, COMPLEX 187.00 06/30/10 51741 51741 51741 084 0920 0612
11060053 CRYOTHERAPY OF SKIN-ACNE 64.00 06/30/10 17340 17340 17340 084 0360 0612
11060057 CYSTOSCOPY 492.00 06/30/10 52000 52000 52000 084 0360 0612
11060061 DESTRUCT OF LESIONS 2-14 69.00 06/30/10 17003 17003 17003 084 0360 0612
11060065 DIAPHRAGM/CERV CAP FIT 79.00 06/30/10 57170 57170 57170 084 0510 0612
11060069 ENDOCERVICAL CURETTAGE 335.00 06/30/10 57505 57505 57505 084 0360 0612
11060073 BIOPSY ENDOMETRIAL 316.00 06/30/10 58100 58100 58100 084 0360 0612
11060077 CERV MUCUS PENETRATION TEST 257.00 06/30/10 89330 89330 89330 084 0300 0612
11060081 FINE NEEDLE ASP, BREAST 355.00 06/30/10 10021 10021 10021 084 0361 0612
11060085 HYSTERO RMVL FOREIGN BODY 1899.00 06/30/10 58562 58562 58562 084 0360 0612
11060089 HYSTEROSCOPY W/BIOPSY 1693.00 06/30/10 58558 58558 58558 084 0360 0612
11060093 HYSTEROSCOPY, DIAG 1559.00 06/30/10 58555 58555 58555 084 0360 0612
11060097 I&D BARTHOLIN CYST 384.00 06/30/10 56420 56420 56420 084 0360 0612
11060101 I&D VULVAR ABSCESS 339.00 06/30/10 56405 56405 56405 084 0360 0612
11060113 IUD REMOVAL 105.00 06/30/10 58301 58301 58301 084 0360 0612
11060123 INSERTION PESSARY 112.00 06/30/10 57160 57160 57160 084 0360 0612
11060127 LOOP EXCISION CERVIX 1483.00 06/30/10 57460 57460 57460 084 0360 0612
11060135 NORPLANT REMOVAL 301.00 06/30/10 11976 11976 11976 084 0360 0612
11060143 SIS 282.00 06/30/10 58340 58340 58340 084 0360 0612
11060147 SIMPLE UROFLOWMETRY 236.00 06/30/10 51736 51736 51736 084 0920 0612
11060151 ACTIVE WOUND CARE/20CM OR < 106.00 06/30/10 97597 97597 97597 084 0510 0612
11060155 ECHO COMPLETE ABDOMINAL 689.00 06/30/10 76700 76700 76700 084 0402 0612
11060159 U/S TRANSVAGINAL, NON OB 358.00 06/30/10 76830 76830 76830 084 0402 0612
11060163 ECHO PELVIS NON OB 412.00 06/30/10 76856 76856 76856 084 0402 0612
11060167 ACCUCHECK 44.00 06/30/10 82962 82962 82962 084 0301 0612
11060170 HEMAGLOBIN 29.00 06/30/10 85018QW 85018QW 85018QW 084 0305 0612
11060173 BLOOD OCCLT FECAL SCREEN 34.00 06/30/10 82270 82270 82270 084 0301 0612
11060176 KOH WET MOUNT 52.00 06/30/10 87220 87220 87220 084 0306 0612
11060179 PREGNANCY TEST 90.00 06/30/10 81025 81025 81025 084 0300 0612
11060182 TB SKIN TEST 46.00 06/30/10 86580 86580 86580 084 0302 0612
11060185 URINALYSIS DIPSTICK 35.00 06/30/10 81007 81007 81007 084 0300 0612
11060188 HEMATOCRIT-HEMOGLOBIN 48.00 06/30/10 85014 85014 85014 084 0305 0612
11060191 QUAN GLUCOSE DETERMINATION 41.00 06/30/10 82947 82947 82947 084 0301 0612
11060194 GLUCOSE POST DOSE 53.00 06/30/10 82950 82950 82950 084 0301 0612
11060197 PH,BODY FLUID, QUAL 38.00 06/30/10 83986QW 83986QW 83986QW 084 0301 0612
11060201 AMINES, VAG FLUID, QUAL 65.00 06/30/10 82120 82120 82120 084 0301 0612
11060205 DEPO PROVERA 150MG 66.00 06/30/10 J1055 J1055 J1055 084 0636 0612
11060208 PESSARY 166.00 06/30/10 084 0270 0612
11060211 PARAGARD IUD 578.00 06/30/10 J7300 J7300 J7300 084 0270 0612
11060214 MIRENA IUD 833.00 06/30/10 J7302 J7302 J7302 084 0270 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 435
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11060217 LUPRON 3.75 MG 881.00 06/30/10 J1950 J1950 J1950 084 0636 0612
11060220 DPT 18.00 06/30/10 90701 90701 90701 084 0636 0612
11060223 DT 16.00 06/30/10 90702 90702 90702 084 0636 0612
11060229 MUMPS 74.00 06/30/10 90704 90704 90704 084 0636 0612
11060232 RUBELLA 90.00 06/30/10 90706 90706 90706 084 0636 0612
11060235 MMR 180.00 06/30/10 90707 90707 90707 084 0636 0612
11060238 ORAL POLIO 69.00 06/30/10 90712 90712 90712 084 0636 0612
11060241 ADULT DIPHTHERIA & (TD) 40.00 06/30/10 90718 90718 90718 084 0636 0612
11060244 HEPATITIS B PED/ADOLESCNT 105.00 06/30/10 90744 90744 90744 084 0636 0612
11060247 HEPATITIS B ADULT DOSAGE 226.00 06/30/10 90746 90746 90746 084 0636 0612
11060253 HEP A, ADULT DOSAGE 249.00 06/30/10 90632 90632 90632 084 0636 0612
11060256 HIB, PRP-D 81.00 06/30/10 90646 90646 90646 084 0636 0612
11060263 BREAST/CERV CANCER SCRN 77.00 06/30/10 G0101 G0101 G0101 084 0510 0612
11060267 SCREEN-PAP,PREP & CONVEY 72.00 06/30/10 Q0091 Q0091 Q0091 084 0923 0612
11060271 ROCEPHIN 250MG 41.00 06/30/10 J0696 J0696 J0696 084 0636 0612
11060274 BICILLIN L-A 23.00 06/30/10 J0570 J0570 J0570 084 0636 0612
11060277 ANTPRT ONLY;INIT VISIT 120.00 06/30/10 59425 59425 084 0510 0612
11060281 ANTPRT ONLY SUBSQ VISIT 118.00 06/30/10 59426 59426 084 0510 0612
11060285 FETAL BPP W/NST 760.00 06/30/10 76818 76818 76818 084 0402 0612
11060289 U/S BASIC>14 WKS,SING/1ST 563.00 06/30/10 76805 76805 76805 084 0402 0612
11060293 U/S FOLLOW-UP,PER FETUS 319.00 06/30/10 76816 76816 76816 084 0402 0612
11060297 U/S BASIC>14 WKS,EA ADD GEST 980.00 06/30/10 76810 76810 76810 084 0402 0612
11060301 NST FETAL 363.00 06/30/10 59025 59025 59025 084 0920 0612
11060305 U/S LIMITED, ALL FETUSES 511.00 06/30/10 76815 76815 76815 084 0402 0612
11060309 PRENATAL RISK ASSESSMENT 100.00 06/30/10 99211 99211 084 0510 0612
11060333 DOP ECHO,FETAL COMPLETE 763.00 06/30/10 76827 76827 76827 084 0402 0612
11060337 DOP ECHO,FETAL,F/UP-RPT 421.00 06/30/10 76828 76828 76828 084 0402 0612
11060341 DOP ECHO,COLOR MAPPING 414.00 06/30/10 93325 93325 93325 084 0480 0612
11060345 FETAL BIOPHYS PRO W/O NST 200.00 06/30/10 76819 76819 76819 084 0402 0612
11060349 FETAL ECHOCARDIOGRAPHY 263.00 06/30/10 76825 76825 76825 084 0402 0612
11060353 ECHO-FETAL,F/UP-RPT STUDY 556.00 06/30/10 76826 76826 76826 084 0402 0612
11060357 SURGICAL TRAY 122.00 06/30/10 A4550 A4550 A4550 084 0272 0612
11060359 U/S,DETAILED SING/1ST 353.00 06/30/10 76811 76811 76811 084 0402 0612
11060363 U/S, DETAILED EA ADD GEST 224.00 06/30/10 76812 76812 76812 084 0402 0612
11060367 U/S<14WKS SING/1ST 137.00 06/30/10 76801 76801 76801 084 0402 0612
11060371 U/S<14WKS EA ADDL GEST 120.00 06/30/10 76802 76802 76802 084 0402 0612
11060375 U/S TRANSVAGINAL, OB 159.00 06/30/10 76817 76817 76817 084 0402 0612
11060379 CELESTONE 4MG(CODEX3 FOR 12MG) 73.00 06/30/10 J0704 J0704 J0704 084 0636 0612
11060382 WET MOUNT/GRAMSTAIN 46.00 06/30/10 87210 87210 87210 084 0306 0612
11060385 PNEUMOCCAL CONJUGATE VACCINE 138.00 06/30/10 90669 90669 084 0636 0612
11060388 INFLUENZA VAC WHOLE VIRUS 38.00 06/30/10 90660 90660 90660 084 0636 0612
11060399 AMINO THER AMNIOTIC FL RDC 509.00 06/30/10 59001 59001 59001 084 0361 0612
11060403 CVS 588.00 06/30/10 59015 59015 59015 084 0361 0612
11060409 U/S GUIDANCE OF CVS 591.00 06/30/10 76945 76945 76945 084 0402 0612
11060413 AMNIOCENTESIS, DIAG 509.00 06/30/10 59000 59000 59000 084 0361 0612
11060417 FETAL CONTRAC STRESS TEST 377.00 06/30/10 59020 59020 59020 084 0920 0612
11060421 U/S GUIDANCE OF AMNIOCENT 718.00 06/30/10 76946 76946 76946 084 0402 0612
11060425 DOPPLER ECHOCARDIOGRAPHY 547.00 06/30/10 93320 93320 93320 084 0480 0612
11060429 UMBILICAL ARTERY DOPPLER 194.00 06/30/10 76820 76820 76820 084 0400 0612
11060433 MIDDLE CEREBRAL ART DPPL 225.00 06/30/10 76821 76821 76821 084 0402 0612
11060437 URETHRAL PROFILE STUDY 159.00 06/30/10 51727 51727 51727 084 0490 0612
11060441 INTRAL ABDOM PRESS MNGMNT 194.00 06/30/10 51797 51797 51797 084 0920 0612
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 436
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

11060445 VOIDING PRESSURE STUDIES 582.00 06/30/10 51728 51728 51728 084 0920 0612
11060447 VOIDING & URETH PRESS STUDIES 582.00 06/30/10 51729 51729 51729 084 0920 0612
11060449 POST VOID RESIDUAL VOLUME 115.00 06/30/10 51798 51798 51798 084 0402 0612
11060453 CRYOSURGERY 1225.00 06/30/10 57061 57061 57061 084 0360 0612
11060457 DILATION CERVICAL CANAL 259.00 06/30/10 57800 57800 57800 084 0360 0612
11060461 SIS INTERPRETATION 672.00 06/30/10 76831 76831 76831 084 0402 0612
11060501 PREV VST NEW AGE 12-17 155.00 06/30/10 99384 99384 99384 084 0510 0612
11060517 PREV MED VST EST-AGE 12-17 125.00 06/30/10 99394 99394 99394 084 0510 0612
11060539 EMG STDY ANAL/URETH SPHNC 204.00 06/30/10 51784 51784 51784 084 0490 0612
11060561 INSRT,NON-BIO DRUG DELIV 115.00 06/30/10 11981 11981 11981 084 0360 0612
11060563 RMVL,NON-BIO DRUG DELIV 115.00 06/30/10 11982 11982 11982 084 0360 0612
11060565 REMV W/INSRT,NON-BIO DRUG 115.00 06/30/10 11983 11983 11983 084 0360 0612
11060571 DEST VAG LESIONS-EXTEN 2390.00 06/30/10 57065 57065 57065 084 0360 0612
11060581 POST PARTUM CARE ONLY 140.00 06/30/10 59430 59430 59430 084 0510 0612
12340283 BIOPSY EXCIS CERVICAL LES-HOSP 416.00 06/30/10 57500 57500 57500 084 0360 0524
12340284 BIOPSY EXCIS CERVICAL LES-M.D. 156.00 $ 06/30/09 57500 57500 57500 084 0975 0524
17120001 OFFC VST NEW LVL1-HOSPITL 100.00 06/30/10 99201 99201 99201 085 0510 0582
17120002 OFFC VST NEW LVL1-DOCTOR 51.00 $ 06/30/09 99201 99201 99201 085 0983 0582
17120003 OFFC VST NEW LVL2-HOSPITL 120.00 06/30/10 99202 99202 99202 085 0510 0582
17120004 OFFC VST NEW LVL2-DOCTOR 97.00 $ 06/30/09 99202 99202 99202 085 0983 0582
17120005 OFFC VST NEW LVL3-HOSPITL 155.00 06/30/10 99203 99203 99203 085 0510 0582
17120006 OFFC VST NEW LVL3-DOCTOR 148.00 $ 06/30/09 99203 99203 99203 085 0983 0582
17120008 OFFC VST NEW LVL4-DOCTOR 245.00 $ 06/30/09 99204 99204 99204 085 0983 0582
17120010 OFFC VST NEW LVL5-DOCTOR 318.00 $ 06/30/09 99205 99205 99205 085 0983 0582
17120012 OFFC VST EST LVL1-DOCTOR 19.00 $ 06/30/09 99211 99211 99211 085 0983 0582
17120014 OFFC VST EST LVL2-DOCTOR 50.00 $ 06/30/09 99212 99212 99212 085 0983 0582
17120016 OFFC VST EST LVL3-DOCTOR 95.00 $ 06/30/09 99213 99213 99213 085 0983 0582
17120018 OFFC VST EST LVL4-DOCTOR 147.00 $ 06/30/09 99214 99214 99214 085 0983 0582
17120020 OFFC VST EST LVL5-DOCTOR 210.00 $ 06/30/09 99215 99215 99215 085 0983 0582
17120022 OFFC CONSULT LVL1-DOCTOR 72.00 $ 06/30/09 99241 99241 99241 085 0983 0582
17120024 OFFC CONSULT LVL2-DOCTOR 152.00 $ 06/30/09 99242 99242 99242 085 0510 0582
17120026 OFFC CONSULT LVL3-DOCTOR 211.00 $ 06/30/09 99243 99243 99243 085 0983 0582
17120028 OFFC CONSULT LVL4-DOCTOR 331.00 $ 06/30/09 99244 99244 99244 085 0983 0582
17120030 OFFC CONSULT LVL5-DOCTOR 413.00 $ 06/30/09 99245 99245 99245 085 0983 0582
17120033 VOID 92.00 06/30/09 085 0510 0582
17120041 POSTOPERATIVE FOLLOW-UP VISIT N/C 06/30/10 99024 99024 99024 085 0510 0582
17120043 OPHTHAL NEW INTERMEDIATE-HOSP 69.00 06/30/10 92002 92002 92002 085 0510 0582
17120044 OPHTHAL NEW INTERMEDIATE-M.D. 91.00 $ 06/30/09 92002 92002 92002 085 0983 0582
17120045 OPHTHAL NEW COMPREHENSIVE-HOSP 70.00 06/30/10 92004 92004 92004 085 0510 0582
17120046 OPHTHAL NEW COMPREHENSIVE-M.D. 189.00 $ 06/30/09 92004 92004 92004 085 0983 0582
17120047 OPHTHAL EST INTERMEDIATE-HOSP 77.00 06/30/10 92012 92012 92012 085 0510 0582
17120048 OPHTHAL EST INTERMEDIATE-M.D. 97.00 $ 06/30/09 92012 92012 92012 085 0962 0582
17120049 OPHTHAL EST COMPREHENSIVE-HOSP 78.00 06/30/10 92014 92014 92014 085 0510 0582
17120050 OPHTHAL EST COMPREHENSIVE-M.D. 148.00 $ 06/30/09 92014 92014 92014 085 0983 0582
17120053 COMPREHENSIVE EUA-HOSPITAL 195.00 06/30/10 92018 92018 92018 085 0510 0582
17120054 COMPREHENSIVE EUA-DOCTOR 270.00 $ 06/30/09 92018 92018 92018 085 0983 0582
17120055 LIMITED EUA-HOSPITAL 82.00 06/30/10 92019 92019 92019 085 0510 0582
17120056 LIMITED EUA-DOCTOR 134.00 $ 06/30/09 92019 92019 92019 085 0983 0582
17120057 GONIOSCOPY HOSPITAL 59.00 06/30/10 92020 92020 92020 085 0920 0582
17120058 GONIOSCOPY-DOCTOR 40.00 $ 06/30/09 92020 92020 92020 085 0962 0582
17120059 SENSORIMOTOR EXAM-HOSPITAL 101.00 06/30/10 92060 92060 92060TC 085 0920 0582
17120060 SENSORIMOTOR EXAM-DOCTOR 74.00 $ 06/30/09 92060 9206026 9206026 085 0962 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 437
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17120061 ORTHOPTIC TRAINING-HOSPITAL 49.00 06/30/10 92065 92065 92065 085 0920 0582
17120062 ORTHOPTIC TRAINING-DOCTOR 37.00 $ 06/30/09 92065 9206526 9206526 085 0962 0582
17120065 LMTD VF EXAM(TANGENT)-HOSPITAL 110.00 06/30/10 92081 92081 92081 085 0920 0582
17120066 LMTD VF EXAM(TANGENT)-DOCTOR 38.00 $ 06/30/09 92081 9208126 9208126 085 0962 0582
17120067 SUPRATHRES HVF/2 ISOP GVF-HOSP 159.00 06/30/10 92082 92082 92082 085 0920 0582
17120068 SUPRATHRES HVF/2 ISOP GVF-M.D. 46.00 $ 06/30/09 92082 9208226 9208226 085 0962 0582
17120069 THRESH HVF/3 OR >ISOP GVF-HOSP 216.00 06/30/10 92083 92083 92083TC 085 0920 0582
17120070 THRESH HVF/3 OR >ISOP GVF-M.D. 53.00 $ 06/30/09 92083 9208326 9208326 085 0983 0582
17120071 DIURNAL CURVE-HOSPITAL 35.00 06/30/10 92100 92100 92100 085 0920 0582
17120072 DIURNAL CURVE-DOCTOR 96.00 $ 06/30/09 92100 92100 92100 085 0983 0582
17120073 TONOGRAPHY-HOSPITAL 39.00 06/30/10 92120 92120 92120 085 0920 0582
17120074 TONOGRAPHY-DOCTOR 85.00 $ 06/30/09 92120 92120 92120 085 0983 0582
17120079 INDRT OPTHALMSCPY(INTL)-HOSP 81.00 06/30/10 92225 92225 92225 085 0920 0582
17120080 INDRT OPTHALSCOPY(INTL)-DCTR 40.00 $ 06/30/09 92225 92225 92225 085 0983 0582
17120081 INDRT OPTHALMSCPY(SUB)-HOSP 70.00 06/30/10 92226 92226 92226 085 0920 0582
17120082 INDRT OPTHALSCPY(SUB)-DCTR 36.00 $ 06/30/09 92226 92226 92226 085 0983 0582
17120085 FLUORESCEIN ANGIO UNILAT-HOSP 469.00 06/30/10 92235 92235 92235TC 085 0920 0582
17120086 FLOUROSCEIN ANGIO UNILAT-M.D. 88.00 $ 06/30/09 92235 9223526 92235TC 085 0983 0582
17120087 INDOCYANINE GRN ANGIGRAPHY-HOS 406.00 06/30/10 92240 92240 92240 085 0920 0582
17120088 INDOCYANINE GRN ANGIOGRPHY-DR 121.00 $ 06/30/09 92240 9224026 9224026 085 0983 0582
17120089 FUNDUS PHOTOGRAPHY-HOSP 112.00 06/30/10 92250TC 92250 92250TC 085 0920 0582
17120090 FUNDUS PHOTOGRAPHY-DOCTOR 46.00 $ 06/30/09 92250 92250 9225026 085 0983 0582
17120091 SCOI - UNILAT-HOSP 135.00 06/30/10 92135 92135 92135 085 0920 0582
17120092 SCOI - UNILAT-M.D. 38.00 $ 06/30/09 92135 9213526 9213526 085 0983 0582
17120099 SLIT LAMP PHOTOGRAPHY-HOSP 124.00 06/30/10 92285 92285 92285 085 0920 0582
17120100 SLIT LAMP PHOTOGRAPHY-DOCTOR 22.00 $ 06/30/09 92285 9228526 9228526 085 0983 0582
17120101 PHOTOKERASCOPY-HOSPITAL 141.00 06/30/10 92285 92285 92285 085 0920 0582
17120102 PHOTOKERASCOPY-DOCTOR 22.00 $ 06/30/09 92285 9228526 9228526 085 0983 0582
17120105 ENDOTHELIAL PHOTOGRAPHY-HOSP 515.00 06/30/10 92286 92286 92286 085 0920 0582
17120106 ENDOTHELIAL PHOTOGRAPHY-DOCTOR 71.00 $ 06/30/09 92286 9228626 9228626 085 0983 0582
17120109 VISUAL EVOKED POTENTIAL-HOSP 214.00 06/30/10 95930 95930 95930 085 0920 0582
17120110 VISUAL EVOKED POTENTIAL-M.D. 38.00 $ 06/30/09 95930 9593026 9593026 085 0920 0582
17120120 OPHTHAL NEW INTERMED-TECH ONLY 69.00 06/30/10 92002 92002 92002 085 0510 0582
17120122 OPHTHAL NEW COMPREH-TECH ONLY 70.00 06/30/10 92004 92004 92004 085 0510 0582
17120124 OPHTHAL EST INTERMED-TECH ONLY 77.00 06/30/10 92012 92012 92012 085 0510 0582
17120126 OPHTHAL EST COMPREH-TECH ONLY 78.00 06/30/10 92014 92014 92014 085 0510 0582
17120201 *THERAPEU/DIAG INJ SUBQ/IM 94.00 06/30/10 96372 96372 96372 085 0510 0582
17120205 IV HYDRA INFUS:INIT UP TO 1 HR 285.00 06/30/10 96360 96360 96360 085 0260 0582
17120209 *THERAPEITIC/DIAGNOSTIC INJ IV 236.00 06/30/10 96374 96374 96374 085 0510 0582
17120301 REMOVE CONJ FB (EXTERNAL)-HOSP 70.00 06/30/10 65205 65205 65205 085 0360 0582
17120302 REMOVE CONJ FB (EXTERNAL)-M.D. 82.00 $ 06/30/09 65205 65205 65205 085 0975 0582
17120303 REMOVE EMBEDDED CONJ FB-HOSP 84.00 06/30/10 65210 65210 65210 085 0360 0582
17120304 REMOVE EMBEDDED CONJ FB-M.D. 99.00 $ 06/30/09 65210 65210 65210 085 0975 0582
17120305 REM CORN FB W/O SLIT LAMP-HOSP 100.00 06/30/10 65220 65220 65220 085 0360 0582
17120306 REM CORN FB W/O SLIT LAMP-M.D. 82.00 $ 06/30/09 65220 65220 65220 085 0975 0582
17120307 RMVE CORN FB W/SLIT LAMP-HOSP 114.00 06/30/10 65222 65222 65222 085 0360 0582
17120308 RMVE CORN FB W/SLIT LAMP-M.D. 108.00 $ 06/30/09 65222 65222 65222 085 0975 0582
17120315 PTERYGIUM (W/O GRAFT)-HOSP 1328.00 06/30/10 65420 65420 65420 085 0360 0582
17120316 PTERYGIUM (W/O GRAFT)-M.D. 668.00 $ 06/30/09 65420 65420 65420 085 0975 0582
17120317 PTERYGIUM (W/GRAFT)-HOSP 1749.00 06/30/10 65426 65426 65426 085 0360 0582
17120318 PTERYGIUM (W/GRAFT)-M.D. 847.00 $ 06/30/09 65426 65426 65426 085 0975 0582
17120319 SCRAPPING CORN/DIAG SMEAR-HOSP 79.00 06/30/10 65430 65430 65430 085 0360 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 438
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17120320 SCRAPPING CORN/DIAG SMEAR-M.D. 190.00 $ 06/30/09 65430 65430 65430 085 0975 0582
17120323 PARACENTESIS OF AC-HOSP 255.00 06/30/10 65800 65800 65800 085 0360 0582
17120324 PARACENTESIS OF AC-M.D. 240.00 $ 06/30/09 65800 65800 65800 085 0975 0582
17120325 PARACENTESIS THERAPEUTIC-HOSP 217.00 06/30/10 65805 65805 65805 085 0360 0582
17120326 PARACENTESIS THERAPEUTIC-M.D. 240.00 $ 06/30/09 65805 65805 65805 085 0975 0582
17120327 PARA W/WO IRRIG &/OR AIR-HOSP 1630.00 06/30/10 65815 65815 65815 085 0360 0582
17120328 PARA W/WO IRRIG &/OR AIR-M.D. 839.00 $ 06/30/09 65815 65815 65815 085 0975 0582
17120331 ARG LASER TRABECULOPLASTY-HOSP 1391.00 06/30/10 65855 65855 65855 085 0360 0582
17120332 ARG LASER TRABECULOPLASTY-M.D. 536.00 $ 06/30/09 65855 65855 65855 085 0975 0582
17120341 INJECT AIR/LIQUID INTO AC-HOSP 373.00 06/30/10 66020 66020 66020 085 0360 0582
17120342 INJECT AIR/LIQUID INTO AC-M.D. 235.00 $ 06/30/09 66020 66020 66020 085 0975 0582
17120343 INJ ANTIFIB AGNT/CHAMB-HOSP 235.00 06/30/10 66030 66030 66030 085 0360 0582
17120344 INJ ANTIFIB AGNT/CHAMB-M.D. 197.00 $ 06/30/09 66030 66030 66030 085 0975 0582
17120349 BLEB NEEDLING (REVISION)-HOSP 1940.00 06/30/10 66250 66250 66250 085 0360 0582
17120350 BLEB NEEDLING (REVISION)-M.D. 980.00 $ 06/30/09 66250 66250 66250 085 0975 0582
17120351 REVISE OPERATIVE WOUND-HOSP 2072.00 06/30/10 66250 66250 66250 085 0360 0582
17120352 REVISE OPERATIVE WOUND-DOCTOR 980.00 $ 06/30/09 66250 66250 66250 085 0975 0582
17120353 CYCLODIATH (YAG TRANSCL)-HOSP 1931.00 06/30/10 66700 66700 66700 085 0360 0582
17120354 CYCLODIATH (YAG TRANSCL)-M.D. 704.00 $ 06/30/09 66700 66700 66700 085 0975 0582
17120355 CYCLOTH (YAG/CONTACT YAG)-HOSP 2198.00 06/30/10 66710 66710 66710 085 0360 0582
17120356 CYCLOTH (YAG/CONTACT YAG)-M.D. 701.00 $ 06/30/09 66710 66710 66710 085 0975 0582
17120357 TRANSPUPILLIARY YAG-HOSPITAL 1908.00 06/30/10 66710 66710 66710 085 0360 0582
17120358 TRANSPUPILLIARY YAG-DOCTOR 701.00 $ 06/30/09 66710 66710 66710 085 0975 0582
17120361 IRIDOTOMY (YAG/ARGON)-HOSP 1278.00 06/30/10 66761 66761 66761 085 0360 0582
17120362 IRIDOTOMY (YAG/ARGON)-M.D. 725.00 $ 06/30/09 66761 66761 66761 085 0975 0582
17120363 GONIOPLASTY-HOSP 965.00 06/30/10 66762 66762 66762 085 0360 0582
17120364 GONIOPLASTY-M.D. 751.00 $ 06/30/09 66762 66762 66762 085 0975 0582
17120369 DISCISSION-SECONDARY MEMB-HOSP 1286.00 06/30/10 66821 66821 66821 085 0360 0582
17120370 DISCISSION-SECONDARY MEMB-M.D. 537.00 $ 06/30/09 66821 66821 66821 085 0975 0582
17120381 INTRAVITREAL INJECTION-HOSP 649.00 06/30/10 67028 67028 67028 085 0361 0582
17120382 INTRAVITREAL INJECTION-M.D. 309.00 $ 06/30/09 67028 67028 67028 085 0975 0582
17120385 REPAIR RD (CRYO)-HOSP 2010.00 06/30/10 67101 67101 67101 085 0360 0582
17120386 REPAIR RD (CRYO)-M.D. 1191.00 $ 06/30/09 67101 67101 67101 085 0975 0582
17120387 REP RET DET W/DRAIN ARGON-HOSP 1646.00 06/30/10 67105 67105 67105 085 0360 0582
17120388 REP RET DET W/DRAIN ARGON -DR 1143.00 $ 06/30/09 67105 67105 67105 085 0975 0582
17120393 PNEUMATIC RETINOPEXY-HOSP 2748.00 06/30/10 67110 67110 67110 085 0360 0582
17120394 PNEUMATIC RETINOPEXY-M.D. 1372.00 $ 06/30/09 67110 67110 67110 085 0975 0582
17120399 CRYOPEXY-HOSPITAL 1544.00 06/30/10 67141 67141 67141 085 0360 0582
17120400 CRYOPEXY-DOCTOR 857.00 $ 06/30/09 67141 67141 67141 085 0975 0582
17120401 PROPHYLAXIS RET DET ARG-HOSP 1507.00 06/30/10 67145 67145 67145 085 0360 0582
17120402 PROPHYLAXIS RET DETACH ARG-MD 876.00 $ 06/30/09 67145 67145 67145 085 0975 0582
17120405 FOCAL PHOTO/ARGON-HOSP 1255.00 06/30/10 67210 67210 67210 085 0360 0582
17120406 FOCAL PHOTO/ARGON-DOCTOR 1203.00 $ 06/30/09 67210 67210 67210 085 0975 0582
17120409 DEST LOCAL LESION CHOROID-HOSP 1185.00 06/30/10 67220 67220 67220 085 0360 0582
17120410 DEST LOCAL LESION CHOROID-M.D. 1820.00 $ 06/30/09 67220 67220 67220 085 0975 0582
17120413 PAN RETIN PHOTCOAGULATION-HOSP 1436.00 06/30/10 67228 67228 67228 085 0360 0582
17120414 PAN RETIN PHOTCOAGULATION-M.D. 1886.00 $ 06/30/09 67228 67228 67228 085 0975 0582
17120431 RETROBULBAR INJECTION-HOSP 172.00 06/30/10 67500 67500 67500 085 0360 0582
17120432 RETROBULBAR INJECTION-M.D. 147.00 $ 06/30/09 67500 67500 67500 085 0975 0582
17120433 ALCOHOL INJECTION-HOSP 239.00 06/30/10 67505 67505 67505 085 0360 0582
17120434 ALCOHOL INJECTION-M.D. 143.00 $ 06/30/09 67505 67505 67505 085 0975 0582
17120435 INJ INTO TENON'S CAPSULE-HOSP 169.00 06/30/10 67515 67515 67515 085 0360 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 439
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17120436 INJ INTO TENON'S CAPSULE-M.D. 154.00 $ 06/30/09 67515 67515 67515 085 0975 0582
17120443 BLEPH,DRAIN EYELID ABSC-HOSP 95.00 06/30/10 67700 67700 67700 085 0360 0582
17120444 BLEPH,DRAIN EYELID ABSC-M.D. 206.00 $ 06/30/09 67700 67700 67700 085 0975 0582
17120447 CHALAZION-HOSP 205.00 06/30/10 67800 67800 67800 085 0360 0582
17120448 CHALAZION-M.D. 188.00 $ 06/30/09 67800 67800 67800 085 0975 0582
17120449 MULT CHALAZ EXC(SAME LID)-HOSP 280.00 06/30/10 67801 67801 67801 085 0360 0582
17120450 MULT CHALAZ EXC(SAME LID)-M.D. 243.00 $ 06/30/09 67801 67801 67801 085 0975 0582
17120451 MULT CHALAZ EXC(DIFF LID)-HOSP 223.00 06/30/10 67805 67805 67805 085 0360 0582
17120452 MULT CHALAZ EXC(DIFF LID)-M.D. 299.00 $ 06/30/09 67805 67805 67805 085 0975 0582
17120453 EYELID BIOPSY-HOSP 230.00 06/30/10 67810 67810 67810 085 0360 0582
17120454 EYELID BIOPSY-M.D. 174.00 $ 06/30/09 67810 67810 67810 085 0975 0582
17120455 EPILATION - MANUAL-HOSP 75.00 06/30/10 67820 67820 67820 085 0360 0582
17120456 EPILATION - MANUAL-M.D. 99.00 $ 06/30/09 67820 67820 67820 085 0975 0582
17120457 EPILATION - ELECTRO-HOSP 245.00 06/30/10 67825 67825 67825 085 0360 0582
17120458 EPILATION - ELECTRO-M.D. 217.00 $ 06/30/09 67825 67825 67825 085 0975 0582
17120459 EPILATION W/LID MARG INCI-HOSP 299.00 06/30/10 67830 67830 67830 085 0360 0582
17120460 EPILATION W/LID MARG INCI-M.D. 247.00 $ 06/30/09 67830 67830 67830 085 0975 0582
17120467 TARSORRHAPHY, SUTURE-HOSP 564.00 06/30/10 67875 67875 67875 085 0360 0582
17120468 TARSORRHAPHY, SUTURE-M.D. 179.00 $ 06/30/09 67875 67875 67875 085 0975 0582
17120469 TARSORRHAPHY, MEDIAN- HOSP 954.00 06/30/10 67880 67880 67880 085 0360 0582
17120470 TARSORRHAPHY, MEDIAN-M.D. 648.00 $ 06/30/09 67880 67880 67880 085 0975 0582
17120471 TARSORRHAPHY, W/TRAN TARS-HOSP 1253.00 06/30/10 67882 67882 67882 085 0360 0582
17120472 TARSORRHAPHY, W/TRANSPOS-M.D. 834.00 $ 06/30/09 67882 67882 67882 085 0975 0582
17120487 SUTURE EYELID-FULL THICK-HOSP 867.00 06/30/10 67935 67935 67935 085 0360 0582
17120488 SUTURE EYELID-FULL THICK-M.D. 825.00 $ 06/30/09 67935 67935 67935 085 0975 0582
17120491 CANTHOPLASTY - HOSP 2800.00 06/30/10 67950 67950 67950 085 0360 0582
17120492 CANTHOPLASTY - M.D. 852.00 $ 06/30/09 67950 67950 67950 085 0975 0582
17120493 EXCIS & REPAIR EYELID-HOSP 2021.00 06/30/10 67961 67961 67961 085 0360 0582
17120494 EXCIS & REPAIR EYELID-M.D. 830.00 $ 06/30/09 67961 67961 67961 085 0975 0582
17120511 SUBCONJUNCTIVAL INJECTION-HOSP 119.00 06/30/10 68200 68200 68200 085 0360 0582
17120512 SUBCONJUNCTIVAL INJECTION-M.D. 63.00 $ 06/30/09 68200 68200 68200 085 0975 0582
17120515 PLASTIC RPR OF CANALUCULI-HOSP 1926.00 06/30/10 68700 68700 68700 085 0360 0582
17120516 PLASTIC RPR OF CANALICULI-M.D. 1068.00 $ 06/30/09 68700 68700 68700 085 0975 0582
17120535 PUNCTUM CAUTERY LASER-HOSP 213.00 06/30/10 68760 68760 68760 085 0360 0582
17120536 PUNCTUM CAUTERY LASER-M.D. 262.00 $ 06/30/09 68760 68760 68760 085 0975 0582
17120537 PUNCTAL PLUG INSRT PR EYE-HOSP 216.00 06/30/10 68761 68761 68761 085 0360 0582
17120538 PUNCTAL PLG INSERT PER EYE -DR 212.00 $ 06/30/09 68761 68761 68761 085 0975 0582
17120539 PUNCTUM DIL/IRIG-HOSP 120.00 06/30/10 68801 68801 68801 085 0360 0582
17120540 PUNCTUM DIL/IRIG-M.D. 190.00 $ 06/30/09 68801 68801 68801 085 0975 0582
17120541 NLD PROBING-HOSP 223.00 06/30/10 68810 68810 68810 085 0360 0582
17120542 NLD PROBIND-M.D. 340.00 $ 06/30/09 68810 68810 68810 085 0975 0582
17120545 PUNCTAL OCCLUSION-HOSP 124.00 06/30/10 68840 68840 68840 085 0360 0582
17120546 PUNCTAL OCCLUSION-M.D. 200.00 $ 06/30/09 68840 68840 68840 085 0975 0582
17120548 FRESNELL PRISM 35.00 06/30/10 V2718 V2718 V2718 085 0274 0582
17120550 PUNCTAL PLUG PER EYE 334.00 06/30/10 085 0270 0582
17120555 KENALOG, PER 10MG 13.00 06/30/10 J3301 085 0636 0582
17120558 AVASTIN - 10 MG 161.00 06/30/10 J9035 J9035 J9035 085 0636 0582
17120559 BOTOX TYPE A-PER UNIT 15.00 06/30/10 J0585 J0585 J0585 085 0636 0582
17120570 ARISTICORT, PER 5MG 8.00 06/30/10 J3303 J3303 J3303 085 0636 0582
17120573 LUCENTIS-VIAL & SYRINGE .1 MG 1262.00 06/30/10 J2778 J2778 J2778 085 0636 0582
17120577 GENENTECH ACC PROG-LUCENT-.1MG N/C 06/30/10 J2778 J2778 J2778 085 0636 0582
17120603 *RMVL SKIN TAGS=<15 LESION HSP 185.00 06/30/10 11200 11200 11200 085 0360 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 440
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17120604 *RMVL SKIN TAGS=<15 LESION MD 132.00 $ 06/30/09 11200 11200 11200 085 0975 0582
17120605 RMVL SKIN TAGS/ADD 10LSNS HOSP 69.00 06/30/10 11201 11201 11201 085 0360 0582
17120606 RMVL SKIN TAGS/ADD 10 LSNS MD 34.00 $ 06/30/09 11201 11201 11201 085 0975 0582
17120607 SHV SKIN LES-5CM OR LESS-HOSP 207.00 06/30/10 11310 11310 11310 085 0360 0582
17120608 SHAVE SKN LES-.5CM OR LESS-M.D 85.00 $ 06/30/09 11310 11310 11310 085 0975 0582
17120609 SHAVE SKN LES-.6-1.0CM-HOSP 233.00 06/30/10 11311 11311 11311 085 0360 0582
17120610 SHAVE SKN LES-.6-1.0CM-M.D. 124.00 $ 06/30/09 11311 11311 11311 085 0975 0582
17120611 DEBRIDE SKIN;PARTIAL THCK-HOSP 394.00 06/30/10 11040 11040 11040 085 0360 0582
17120612 DEBRIDE SKIN;PARTIAL THCK-M.D. 59.00 $ 06/30/09 11040 11040 11040 085 0975 0582
17120613 EXCIS BNGNLES-0.5 CM OR<-HOSP 280.00 06/30/10 11440 11440 11440 085 0360 0582
17120614 EXCIS BNGNLES-0.5 CM OR<-M.D. 189.00 $ 06/30/09 11440 11440 11440 085 0975 0582
17120615 EXC BNGN LES,FACE .6-1CM-HOSP 857.00 06/30/10 11441 11441 11441 085 0360 0582
17120616 EXC BNGN LES,FACE .6-1CM-M.D. 250.00 $ 06/30/09 11441 11441 11441 085 0975 0582
17120617 EXC BNGN LES,FACE 1.1-2CM-HOSP 566.00 06/30/10 11442 11442 11442 085 0360 0582
17120618 EXC BNGN LES,FACE 1.1-2CM-M.D. 280.00 $ 06/30/09 11442 11442 11442 085 0975 0582
17120621 REMVL OF SKN LES-2.1-3CM-HOSP 758.00 06/30/10 11443 11443 11443 085 0360 0582
17120622 REMVL OF SKN LES-2.1-3CM-M.D. 346.00 $ 06/30/09 11443 11443 11443 085 0975 0582
17120623 EXCIS BNGN LES,FACE >4CM-HOSP 1188.00 06/30/10 11446 11446 11446 085 0360 0582
17120624 EXCIS BNGN LES,FACE >4CM-M.D. 628.00 $ 06/30/09 11446 11446 11446 085 0975 0582
17120625 EXCISE MALIG LES.6-1.0CM HOSP 398.00 06/30/10 11601 11601 11601 085 0360 0582
17120626 EXCISE MALIG LES.6-1.0CM MD 281.00 $ 06/30/09 11601 11601 11601 085 0975 0582
17120627 REM MALGN LES LIDS-.6-1CM-HOSP 680.00 06/30/10 11641 11641 11641 085 0360 0582
17120628 REM MALIG LES LIDS-.6-1CM-M.D. 306.00 $ 06/30/09 11641 11641 11641 085 0975 0582
17120629 REM MALGN LES LDS-1.1-2CM-HOSP 1042.00 06/30/10 11642 11642 11642 085 0360 0582
17120630 REM MALGN LES LID-1.1-2CM-M.D. 361.00 $ 06/30/09 11642 11642 11642 085 0975 0582
17120631 REM MALG LES LIDS-2.1-3CM-HOSP 1993.00 06/30/10 11643 11643 11643 085 0360 0582
17120632 REM MALG LES LIDS-2.1-3CM-M.D. 451.00 $ 06/30/09 11643 11643 11643 085 0975 0582
17120633 REM MALIG LES LIDS->4CM-HOSP 1336.00 06/30/10 11646 11646 11646 085 0360 0582
17120634 REM MALIG LES LIDS->4CM-M.D. 803.00 $ 06/30/09 11646 11646 11646 085 0975 0582
17120635 SIMP RPR,FACE 2.5CM OR<-HOSP 267.00 06/30/10 12011 12011 12011 085 0360 0582
17120636 SIMP RPR,FACE 2.5CM OR<-M.D. 213.00 $ 06/30/09 12011 12011 12011 085 0975 0582
17120637 SIMP RPR,FACE 2.6-5CM-HOSP 332.00 06/30/10 12013 12013 12013 085 0360 0582
17120638 SIMP RPR,FACE 2.6-5CM-M.D. 243.00 $ 06/30/09 12013 12013 12013 085 0975 0582
17120639 SIMP RPR,FACE 5.-7.5CM-HOSP 311.00 06/30/10 12014 12014 12014 085 0360 0582
17120640 SIMP RPR,FACE 5.-7.5CM-M.D. 293.00 $ 06/30/09 12014 12014 12014 085 0975 0582
17120641 SIMP RPR,FACE 7.6-12.5 CM-HOSP 326.00 06/30/10 12015 12015 12015 085 0360 0582
17120642 SIMP RPR,FACE 7.6-12.5 CM-M.D. 368.00 $ 06/30/09 12015 12015 12015 085 0975 0582
17120643 SIMP RPR FACE 12.6-20CM-HOSP 418.00 06/30/10 12016 12016 12016 085 0360 0582
17120644 SIMP RPR FACE 12.6-20 CM-M.D. 450.00 $ 06/30/09 12016 12016 12016 085 0975 0582
17120647 INJECT SKIN KESIONS-HOSP 104.00 06/30/10 11900 11900 11900 085 0360 0582
17120648 INJECT SKIN LESIONS-M.D. 61.00 $ 06/30/09 11900 11900 11900 085 0975 0582
17120649 REPAIR SUPRF WND 2.6-7.5CM HOS 373.00 06/30/10 12002 12002 12002 085 0360 0582
17120650 REPAIR SUPERF WND 2.6-7.5CM MD 229.00 $ 06/30/09 12002 12002 12002 085 0975 0582
17120651 LAY CLOS,FACE 2.5CM OR <-HOSP 301.00 06/30/10 12051 12051 12051 085 0360 0582
17120652 LAY CLOS,FACE 2.5CM OR <-M.D. 355.00 $ 06/30/09 12051 12051 12051 085 0975 0582
17120653 LAY CLOS,FACE 2.6CM-5CM-HOSP 270.00 06/30/10 12052 12052 12052 085 0360 0582
17120654 LAY CLOS,FACE 2.6CM-5CM-M.D. 412.00 $ 08/10/08 12052 12052 12052 085 0975 0582
17120655 LAY CLOS,FACE 5.1CM-7.5CM-HOSP 611.00 06/30/10 12053 12053 12053 085 0360 0582
17120656 LAY CLOS,FACE 5.1CM-7.5CM-M.D. 422.00 $ 06/30/09 12053 12053 12053 085 0975 0582
17120657 LAY CLOS,FACE 7.6-12.5CM-HOSP 690.00 06/30/10 12054 12054 12054 085 0360 0582
17120658 LAY CLOS,FACE 7.6-12.5CM-M.D. 452.00 $ 06/30/09 12054 12054 12054 085 0975 0582
17120661 TIS TRAN-LIP 10SQ CM OR <-HOSP 2715.00 06/30/10 14060 14060 14060 085 0360 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 441
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17120662 TIS TRAN-LIP 10SQ CM OR <-M.D. 1342.00 $ 06/30/09 14060 14060 14060 085 0975 0582
17120663 TIS TRAN-EYE 10.1-30SQ CM-HOSP 2813.00 06/30/10 14061 14061 14061 085 0360 0582
17120664 TIS TRAN-EYE 10.1-30SQ CM-M.D. 1667.00 $ 06/30/09 14061 14061 14061 085 0975 0582
17120677 SUTURE RMVL-SAME SURGN-HOSP 120.00 06/30/10 15850 15850 15850 085 0360 0582
17120678 SUTURE RMVL-SAME SURGN-DCTR 86.00 $ 06/30/09 15850 15850 15850 085 0975 0582
17120679 SUTURE RMVL-OTHR SURGN-HOSP 124.00 06/30/10 15851 15851 15851 085 0360 0582
17120680 SUTURE RMVL-OTHR SURGN-DOCTR 92.00 $ 06/30/09 15851 15851 15851 085 0975 0582
17120681 DESTROY PREMALIG LESION-HOSP 127.00 06/30/10 17000 17000 17000 085 0360 0582
17120682 DESTROY PREMALIG LESION-M.D. 105.00 $ 06/30/09 17000 17000 17000 085 0975 0582
17120683 DESTROY BENIGN LES 2-14-HOSP 69.00 06/30/10 17003 17003 17003 085 0360 0582
17120684 DESTROY BENIGN LES 2-14-M.D. 105.00 $ 06/30/09 17000 17000 17000 085 0975 0582
17120685 DESTROY WARTS 1-14 -HOSP 125.00 06/30/10 17110 17110 17110 085 0360 0582
17120686 DESTROY WARTS 1-14 -M.D. 132.00 $ 06/30/09 17110 17110 17110 085 0975 0582
17120711 QUANTITATIVE A-SCAN-HOSP 620.00 06/30/10 76511 76511 76511 085 0402 0582
17120712 QUANTITATIVE A-SCAN -M.D. 103.00 $ 06/30/09 76511 7651126 7651126 085 0402 0582
17120713 QUANTITATIVE B-SCAN -HOSP 475.00 06/30/10 76512 76512 76512 085 0402 0582
17120714 QUANTITATIVE B-SCAN -M.D. 102.00 $ 06/30/09 76512 7651226 7651226 085 0972 0582
17120715 IMMERSION B-SCAN-HOSPITAL 678.00 06/30/10 76513 76513 76513 085 0402 0582
17120716 IMMERSION B-SCAN-DOCTOR 70.00 $ 06/30/09 76513 7651326 7651326 085 0972 0582
17120719 A-SCAN W/IOL CALC-HOSP 391.00 06/30/10 76519 76519 76519 085 0402 0582
17120720 A-SCAN W/IOL CALC DOCTOR 58.00 $ 06/30/09 76519 7651926 7651926 085 0972 0582
17120721 FOREIGN BODY ULTRASOUND-HOSP 488.00 06/30/10 76529 76529 76529 085 0402 0582
17120722 FOREIGN BODY ULTRASOUND-DCTR 62.00 $ 06/30/09 76529 7652926 7652926 085 0972 0582
17120735 VISUDYNE 0.1 MG 26.00 06/30/10 J3396 J3396 J3396 085 0636 0582
17120738 MACUGEN 0.3MG 1766.00 06/30/10 J2503 J2503 J2503 085 0636 0582
17120750 EYE MINOR TREATMENT 158.00 06/30/10 085 0360 0582
17120761 INJECT FOR NERVE BLOCK-HOSP 237.00 06/30/10 64402 64402 64402 085 0360 0582
17120762 INJECT FOR NERVE BLOCK-M.D. 146.00 $ 06/30/09 64402 64402 64402 085 0975 0582
17120763 INJECT TRTMNT FOR NERVE-HOSP 273.00 06/30/10 64640 64640 64640 085 0975 0582
17120764 INJECT TRTMNT FOR NERVE-M.D. 365.00 $ 06/30/09 64640 64640 64640 085 0975 0582
17120769 REPAIR EYE LACERATION-HOSP 228.00 06/30/10 65270 65270 65270 085 0360 0582
17120770 REPAIR EYE LACERATION-M.D. 254.00 $ 06/30/09 65270 65270 65270 085 0975 0582
17120775 REPAIR CONJ LACERATION-HOSP 319.00 06/30/10 65272 65272 65272 085 0360 0582
17120776 REPAIR CONJ LACERATION-M.D. 616.00 $ 06/30/09 65272 65272 65272 085 0975 0582
17120781 GLUE CORNEA OR SCLERA-HOSP 733.00 06/30/10 65286 65286 65286 085 0360 0582
17120782 GLUE CORNEA OR SCLERA-M.D. 873.00 $ 06/30/09 65286 65286 65286 085 0975 0582
17120787 REPAIR OF EYE SOCKT WOUND-HOSP 1619.00 06/30/10 65290 65290 65290 085 0360 0582
17120788 REPAIR OF EYE SOCKT WOUND-M.D. 876.00 $ 06/30/09 65290 65290 65290 085 0975 0582
17120793 CURRETTE CORNEA-HOSP 189.00 06/30/10 65435 65435 65435 085 0360 0582
17120794 CURRETTE CORNEA-M.D. 127.00 $ 06/30/09 65435 65435 65435 085 0975 0582
17120795 EDTA-HOSP 1950.00 06/30/10 65436 65436 65436 085 0360 0582
17120796 EDTA-M.D. 659.00 $ 06/30/09 65436 65436 65436 085 0975 0582
17120801 DESTR CILIARY BODY-CRYO-HOSP 1579.00 06/30/10 66720 66720 66720 085 0360 0582
17120802 DESTR CILIARY BODY-CRYO-M.D. 746.00 $ 06/30/09 66720 66720 66720 085 0975 0582
17120811 DESTR LOC LES-CRYO/DIATH-HOSP 1453.00 06/30/10 67208 67208 67208 085 0360 0582
17120812 DESTR LOC LES-CRYO/DIATH-M.D. 1026.00 $ 06/30/09 67208 67208 67208 085 0975 0582
17120821 DESTR PROG RET-CYRO/DIATH-HOSP 1809.00 06/30/10 67227 67227 67227 085 0360 0582
17120822 DESTR PROG RET CYRO/DIATH-M.D. 1014.00 $ 06/30/09 67227 67227 67227 085 0975 0582
17120831 SEVERING TARSORRHAPHY HOSP 148.00 06/30/10 67710 67710 67710 085 0360 0582
17120832 SEVERING TARSORRHAPHY MD 172.00 $ 06/30/09 67710 67710 67710 085 0975 0582
17120835 CANTHOTOMY HOSP 226.00 06/30/10 67715 67715 67715 085 0360 0582
17120836 CANTHOTOMY MD 194.00 $ 06/30/09 67715 67715 67715 085 0975 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 442
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17120841 DES LES LID MARGIN<=1CM-HOSP 304.00 06/30/10 67850 67850 67850 085 0360 0582
17120842 DES LES LID MARGIN<=1CM-M.D. 256.00 $ 06/30/09 67850 67850 67850 085 0975 0582
17120847 REPAIR EYELID DEFECT-HOSP 878.00 06/30/10 67921 67921 67921 085 0360 0582
17120848 REPAIR EYELID DEFECT-M.D. 489.00 $ 06/30/09 67921 67921 67921 085 0975 0582
17120851 REP EYELD WND-PART THICK-HOSP 516.00 06/30/10 67930 67930 67930 085 0360 0582
17120852 REP EYELD WOUND-PART THICK-M.D 448.00 $ 06/30/09 67930 67930 67930 085 0975 0582
17120853 RMV FOREIGN BODY-EYELID-HOSP 135.00 06/30/10 67938 67938 67938 085 0360 0582
17120854 RMV FOREIGN BODY-EYELID-M.D. 206.00 $ 06/30/09 67938 67938 67938 085 0975 0582
17120855 EXC CONJ LESION UP TO 1CM-HOSP 369.00 06/30/10 68110 68110 68110 085 0360 0582
17120856 EXC CONJ LESION UP TO 1CM-M.D. 266.00 $ 06/30/09 68110 68110 68110 085 0975 0582
17120857 EXCISION OF CONJ LES >1CM-HOSP 3899.00 06/30/10 68115 68115 68115 085 0360 0582
17120858 EXCISION OF CONJ LES >1CM-M.D. 332.00 $ 06/30/09 68115 68115 68115 085 0975 0582
17120861 DESTR LESION CONJUNCTIVA-HOSP 190.00 06/30/10 68135 68135 68135 085 0360 0582
17120862 DESTR LESION CONJUNCTIVA-M.D. 272.00 $ 06/30/09 68135 68135 68135 085 0975 0582
17120867 SEPARATE EYELID LESIONS-HOSP 1253.00 06/30/10 68340 68340 68340 085 0360 0582
17120868 SEPARATE EYELID LESIONS-M.D. 701.00 $ 06/30/09 68340 68340 68340 085 0975 0582
17120871 INCISE/DRAIN TEAR GLAND-HOSP 267.00 06/30/10 68400 68400 68400 085 0360 0582
17120872 INCISE/DRAIN TEAR GLAND-M.D. 246.00 $ 06/30/09 68400 68400 68400 085 0975 0582
17120875 CLEARANCE OF TEAR DUCT-HOSP 760.00 06/30/10 68530 68530 68530 085 0360 0582
17120876 CLEARANCE OF TEAR DUCT-M.D. 477.00 $ 06/30/09 68530 68530 68530 085 0975 0582
17120881 CORRECT EVERTD PUNCT CAUT HOSP 213.00 06/30/10 68705 68705 68705 085 0360 0582
17120882 CORRECT EVERTED PUNCT CAUT MD 299.00 $ 06/30/09 68705 68705 68705 085 0975 0582
17120885 DESTRUCT BY NEURO AGAENT-HOSP 547.00 06/30/10 64612 64612 64612 085 0360 0582
17120886 DESTRUCT BY NEURO AGENT-M.D. 268.00 $ 06/30/09 64612 64612 64612 085 0975 0582
17120891 BIOPSY OF CORNEA-HOSP 313.00 06/30/10 65410 65410 65410 085 0360 0582
17120892 BIOPSY OF CORNEA-M.D. 190.00 $ 06/30/09 65410 65410 65410 085 0975 0582
17120897 FOCAL CHOROID-HOSP 1181.00 06/30/10 67220 67220 67220 085 0360 0582
17120898 FOCAL CHOROID-M.D. 1820.00 $ 06/30/09 67220 67220 67220 085 0975 0582
17120901 PDT - HOSP 1653.00 06/30/10 67221 67221 67221 085 0360 0582
17120902 PDT-M.D. 406.00 $ 06/30/09 67221 67221 67221 085 0975 0582
17120905 PDT 2ND EYE-SAME DAY-HOSP 1597.00 06/30/10 67225 67225 67225 085 0510 0582
17120906 PDT 2ND EYE-SAME DAY-M.D. 52.00 $ 06/30/09 67225 67225 67225 085 0983 0582
17120909 TTT - HOSP 2941.00 06/30/10 0016T 0016T 0016T 085 0510 0582
17120910 TTT - M.D. 1875.00 $ 08/10/08 0016T 0016T 0016T 085 0983 0582
17120911 FEED VESSEL TECHNIQUE-HOSP 1741.00 06/30/10 G0186 G0186 G0186 085 0510 0582
17120912 FEED VESSEL TECHNIQUE-M.D. 2045.00 $ 08/10/08 G0186 G0186 G0186 085 0983 0582
17120914 DESTRUCT MAC DRUSEN-M.D. 2031.00 06/30/09 085 0983 0582
17120917 GLAUCOMA SCREENING-HOSP 48.00 06/30/10 G0117 G0117 G0117 085 0510 0582
17120918 GLAUCOMA SCREENING-M.D. 93.00 $ 06/30/09 G0117 G0117 G0117 085 0983 0582
17120921 CHEMODENEVATION EOM-HOSP 378.00 06/30/10 67345 67345 67345 085 0360 0582
17120922 CHEMODEVERVATION EOM-M.D. 387.00 $ 06/30/09 67345 67345 67345 085 0975 0582
17120925 BIOPSY EYELID-HOSP 152.00 06/30/10 67810 67810 67810 085 0360 0582
17120926 BIOPSY EYELID-M.D. 174.00 $ 06/30/09 67810 67810 67810 085 0975 0582
17120931 REMVE LID LES(NOT CHALAZ)-HOSP 282.00 06/30/10 67840 67840 67840 085 0360 0582
17120932 REMVE LID LES(NOT CHALAZ)-M.D. 287.00 $ 06/30/09 67840 67840 67840 085 0975 0582
17120935 REP EYELID WND FULL THICK-HOSP 1058.00 06/30/10 67935 67935 67935 085 0360 0582
17120936 REPR EYELID WND FULL THICK M.D 825.00 $ 06/30/09 67935 67935 67935 085 0975 0582
17120941 INCISE TEAR DUCT OPENING-HOSP 181.00 06/30/10 68440 68440 68440 085 0360 0582
17120942 INCISE TEAR DUCT OPENING-M.D. 173.00 $ 06/30/09 68440 68440 68440 085 0975 0582
17120951 NLD PROBE W/TUBE OR STENT-HOSP 490.00 06/30/10 68815 68815 68815 085 0360 0582
17120952 NLD PROBE W/TUBE OR STENT-M.D. 466.00 $ 06/30/10 68815 68815 68815 085 0975 0582
17120957 SCOI - BILAT-HOSP 225.00 06/30/10 9213550 9213550 92135TC 085 0920 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 443
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17120958 SCOI - BILAT-M.D. 76.00 $ 06/30/09 9213550 9213550 9213550 085 0983 0582
17120961 FLUORESCEIN ANGIO-BILAT-HOSP 937.00 06/30/10 9223550 9223550 9223550 085 0920 0582
17120962 FLUORESCEIN ANGIO-BILAT-M.D. 88.00 $ 06/30/09 9223526 9223526 9223526 085 0983 0582
17120971 OPTHALMODYNAMOTRY-HOSP 79.00 06/30/10 92260 92260 92260 085 0920 0582
17120972 OPTHALMODYNAMOTRY-M.D 22.00 $ 06/30/09 92260 92260 92260 085 0983 0582
17120975 NEEDLE ELECTROMYO-HOSP 223.00 06/30/10 92265 92265 92265 085 0920 0582
17120976 NEEDLE ELECTROMYO-M.D. 85.00 $ 06/30/09 92265 9226526 9226526 085 0983 0582
17120981 EOG-HOSP 219.00 06/30/10 92270 92270 92270 085 0920 0582
17120982 EOG-M.D. 85.00 $ 06/30/09 92270 9227026 9227026 085 0920 0582
17120987 ERG-HOSP 191.00 06/30/10 92275 92275 92275 085 0920 0582
17120988 ERG-M.D 110.00 $ 06/30/09 92275 9227526 9227526 085 0983 0582
17120991 COLOR VISION TESTING-HOSP 111.00 06/30/10 92283 92283 92283 085 0920 0582
17120992 COLOR VISION TESTING-M.D. 19.00 $ 06/30/09 92283 9228326 9228326 085 0983 0582
17120993 DARK ADAPTATION-HOSP 143.00 06/30/10 92284 92284 92284 085 0920 0582
17120994 DARK ADAPTATION-M.D. 25.00 $ 06/30/09 92284 9228426 9228426 085 0920 0582
17121025 PACHYMETRY - HOSP 187.00 06/30/10 76514 76514 76514 085 0402 0582
17121026 PACHYMETRY - M.D. 19.00 $ 06/30/09 76514 7651426 7651426 085 0972 0582
17121052 EXAM OUTSIDE REG OFFICE HRS 27.00 $ 06/30/10 99050 99050 99050 085 0983 0582
17121060 OFFICE EMERG-M.D. 28.00 $ 08/10/08 99058 99058 99058 085 0983 0582
17121063 CORNEAL TATTOO-HOSP 1737.00 06/30/10 65600 65600 65600 085 0360 0582
17121064 CORNEAL TATTOO-M.D. 596.00 $ 06/30/09 65600 65600 65600 085 0975 0582
17121071 CORNEAL RELAX INCS-ASTIG-HOSP 1169.00 06/30/10 65772 65772 65772 085 0360 0582
17121072 CORNEAL RELAX INCS-ASTIG-M.D. 714.00 $ 06/30/09 65772 65772 65772 085 0975 0582
17121076 OCULAR SURF RECONST,AMNIO-HOSP 3851.00 06/30/10 65780 65780 65780 085 0360 0582
17121077 OCULAR SURF RECONST,AMNIO-M.D. 1573.00 $ 12/01/09 65780 65780 65780 085 0975 0582
17121081 RECON LID TRANF 2ND STG-HOSP 1514.00 06/30/10 67975 67975 67975 085 0360 0582
17121082 RECON LID TRANF 2ND STG-M.D. 1252.00 $ 06/30/09 67975 67975 67975 085 0975 0582
17121085 PARACENT-EYE,RMV VITR-HOSP 2466.00 06/30/10 65810 65810 65810 085 0360 0582
17121086 PARACENT-EYE,RMV VITR-M.D. 828.00 $ 06/30/09 65810 65810 65810 085 0975 0582
17121089 SCLERAL BUCKLE REMOVAL-HOSP 1621.00 06/30/10 67115 67115 67115 085 0360 0582
17121090 SCLERAL BUCKLE REMOVAL-M.D. 872.00 $ 06/30/09 67115 67115 67115 085 0975 0582
17121095 INCIS,DRAIN-LACRIMAL SAC-HOSP 3355.00 06/30/10 68420 68420 68420 085 0360 0582
17121096 INCIS,DRAIN-LACRIMAL SAC-M.D. 315.00 $ 06/30/09 68420 68420 68420 085 0975 0582
17121583 BIOPSY OF CONJUNCTIVA-HOSP 295.00 06/30/10 68100 68100 68100 085 0360 0582
17121853 BIOPSY OF CONJUNCTIVA-HOSP 189.00 06/30/10 68100 68100 68100 085 0360 0582
17121854 BIOPSY OF CONJUNCTIVA-M.D. 181.00 $ 06/30/09 68100 68100 68100 085 0975 0582
17121857 FITTING FEE/P EYE-DIS-HOSP 46.00 06/30/10 92070 92070 92070 085 0510 0582
17121858 FITTING FEE PER EYE,DIS-DOCTOR 75.00 $ 06/30/09 92070 92070 92070 085 0983 0582
17121861 COMPUTERIZED CORNEAL TOP-HOSP 122.00 06/30/10 92025 92025 92025 085 0510 0582
17121862 COMPUTERZED CORNEAL TOP-M.D. 37.00 $ 06/30/09 92025 92025 92025 085 0983 0582
17121865 REPAIR-BLEPHTOSIS W/SUT-HOSP 3899.00 06/30/10 67901 67901 67901 085 0360 0582
17121866 REPAIR BLEPHTOSIS W/SUTURE-M.D 1054.00 $ 06/30/09 67901 67901 67901 085 0975 0582
17121870 RPR SYMBLPHA W/WO CONTACT LENS 2800.00 06/30/10 68340 68340 68340 085 0360 0582
17121871 RPR SYMBL W/WO CNTCT LENS-M.D. 701.00 $ 10/01/09 68340 68340 68340 085 0975 0582
17121900 GLAUCOMA SCREENING 74.00 06/30/10 G0117 G0117 G0117 085 0510 0582
17121903 CORRECT OF LID RETRACTION-HOSP 2352.00 06/30/10 67911 67911 67911 085 0360 0582
17121904 CORRECT OF LID RETRACTION-M.D. 990.00 $ 06/30/09 67911 67911 67911 085 0975 0582
17121907 OPTH U/S,B SCAN & A SCAN-HOSP 252.00 06/30/10 76510 76510 76510 085 0402 0582
17121908 OPTH U/S,B SCAN & A SCAN-M.D. 168.00 $ 06/30/09 76510 76510 76510 085 0972 0582
17121911 ORBITOTOMY W/O BONE FLAP-HOSP 3047.00 06/30/10 67400 67400 67400 085 0361 0582
17121912 ORBITOTOMY W/O BONE FLAP-M.D. 1677.00 $ 06/30/09 67400 67400 67400 085 0975 0582
17121915 BLPHRPLSTY,UP EYE,EX SKIN-HOSP 2417.00 06/30/10 15823 15823 15823 085 0360 0582
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 444
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17121916 BLEPHARPLSTY,UP EYELID-M.D. 1167.00 $ 06/30/09 15823 15823 15823 085 0982 0582
17121920 SEVER VIT STRNDS 1OR>STGS-HOSP 1601.00 06/30/10 67031 67031 67031 085 0360 0582
17121921 SEVER VIT STRNDS 1OR>STGS-M.D. 625.00 $ 08/01/09 67031 67031 67031 085 0960 0582
17121924 RPR BLEPH;CONJ-TARSO-MULL-HOSP 3651.00 06/30/10 67908 67908 67908 085 0360 0582
17121925 RPR BLEPH;CONJ-TARSO-MULL-M.D. 778.00 $ 11/01/09 67908 67908 67908 085 0975 0582
17121930 REPAIR OF ECTROPION;SUTRE-HOSP 3528.00 06/30/10 67914 67914 67914 085 0360 0582
17121931 REPAIR OF ECTROPION;SUTRE-M.D. 785.00 $ 06/01/09 67914 67914 67914 085 0975 0582
17121940 RMVAL FOR BODY,INTRANASAL-HOSP 113.00 06/30/10 30300 30300 30300 085 0360 0582
17121941 RMVAL FOR BODY,INTRANASAL-M.D. 236.00 $ 12/01/09 30300 30300 30300 085 0975 0582
17121960 NASAL ENDO DX UNI/BIL SEP-HOSP 169.00 06/30/10 31231 31231 31231 085 0360 0582
17121961 NASAL ENDO DX UNI/BIL SEP-M.D. 157.00 $ 12/01/09 31231 31231 31231 085 0975 0582
17122000 CNTC LENS PMMA SPHERICAL EXTERNAL 06/01/04 V2500 V2500 V2500 085 0274 0582
17122003 CT LENS PMMA TORIC/PRISM EXTERNAL 06/01/04 V2501 V2501 V2501 085 0274 0582
17122006 CNTC LENS PMMA BIFOCAL EXTERNAL 06/01/04 V2502 V2502 V2502 085 0274 0582
17122009 CT LENS PMMA COLOR VIS DEF EXTERNAL 06/01/04 V2503 V2503 V2503 085 0274 0582
17122012 CT LENS GAS PERM SPHER EXTERNAL 06/01/04 V2510 V2510 V2510 085 0274 0582
17122015 CT LENS GAS PER PRSM BLST EXTERNAL 06/01/04 V2511 V2511 V2511 085 0274 0582
17122018 CNTC LENS GAS PERM BIFOCL EXTERNAL 06/01/04 V2512 V2512 V2512 085 0274 0582
17122021 CT LENS GAS PERM EXT WEAR EXTERNAL 06/01/04 V2513 V2513 V2513 085 0274 0582
17122024 CNTC LENS HYDROPHIL SPHER EXTERNAL 06/01/04 V2520 V2520 V2520 085 0274 0582
17122027 CT LENS HYDRO/PRISM BLLST EXTERNAL 06/01/04 V2521 V2521 V2521 085 0274 0582
17122030 CNTC LENS HYDROP BIFOCAL EXTERNAL 06/01/04 V2522 V2522 V2522 085 0274 0582
17122033 CNTC LENS HYDRO EXT WEAR EXTERNAL 06/01/04 V2523 V2523 V2523 085 0274 0582
17122036 CT LENS SCLER GAS IMPERM EXTERNAL 06/01/04 V2530 V2530 V2530 085 0274 0582
17122039 CT LENS SCLERL GAS PERM EXTERNAL 06/01/04 V2531 V2531 V2531 085 0274 0582
17122042 CONTACT LENS OTHER TYPE EXTERNAL 06/01/04 V2599 V2599 V2599 085 0274 0582
17122047 OZURDEX - .1MG 471.00 06/30/10 J3490 J3490 J3490 085 0636 0582
17129622 REMOVL OF SKN LES-2.1-3CM-M.D. 346.00 $ 06/30/10 11443 11443 11443 085 0975 0582
17130031 EXCISE SKIN TAGS 178.00 06/30/10 11200 11200 11200 085 0360 0583
17130033 SHV SKIN LES - .5 CM OR LESS 207.00 06/30/10 11310 11310 11310 085 0360 0583
17130034 DEBRIDEMENT SKIN;PARTIAL THICK 394.00 06/30/10 11040 11040 11040 085 0360 0583
17130035 EXCIS BNGNLES-0.5 CM OR< 216.00 06/30/10 11440 11440 11440 085 0360 0583
17130037 EXC BNGNLES,FACE .6-1CM 857.00 06/30/10 11441 11441 11441 085 0360 0583
17130039 EXC BNGN LES,FACE>4CM 566.00 06/30/10 11442 11442 11442 085 0360 0583
17130045 EXCIS BNGN LES,FACE>4CM 733.00 06/30/10 11446 11446 11446 085 0360 0583
17130075 SIMP RPR,FACE 2.5CM OR< 267.00 06/30/10 12011 12011 12011 085 0360 0583
17130077 SIMP RPR,FACE 2.6-5CM 536.00 06/30/10 12013 12013 12013 085 0360 0583
17130079 SIMP RPR,FACE 5.-7.5CM 311.00 06/30/10 12014 12014 12014 085 0360 0583
17130081 SIMP RPR,FACE 7.6-12.5 CM 326.00 06/30/10 12015 12015 12015 085 0360 0583
17130083 SIMP RPR FACE 12.6-20CM 418.00 06/30/10 12016 12016 12016 085 0360 0583
17130101 LAY CLOS,FACE 2.5CM OR < 301.00 06/30/10 12051 12051 12051 085 0360 0583
17130103 LAY CLOS,FACE 2.6CM-5CM 270.00 06/30/10 12052 12052 12052 085 0360 0583
17130105 LAY CLOS,FACE 5.1CM-7.5CM 611.00 06/30/10 12053 12053 12053 085 0360 0583
17130107 LAY CLOS,FACE 7.6-12.5CM 690.00 06/30/10 12054 12054 12054 085 0360 0583
17130115 REMOVE CONJ FB (EXTERNAL) 69.00 06/30/10 65205 65205 65205 085 0360 0583
17130117 REMOVE EMBEDDED CONJ FB 84.00 06/30/10 65210 65210 65210 085 0360 0583
17130119 RMVE CORN FB W/O SLIT LAMP 82.00 06/30/10 65220 65220 65220 085 0360 0583
17130121 RMVE CORN FB W/ SLIT LAMP 113.00 06/30/10 65222 65222 65222 085 0360 0583
17130129 BIOPSY OF CORNEA 313.00 06/30/10 65410 65410 65410 085 0360 0583
17130132 EXCIS OF LESION,CORNEA 1250.00 06/30/10 65400 65400 65400 085 0360 0583
17130135 PTERYGIUM (W/O GRAFT) 1328.00 06/30/10 65420 65420 65420 085 0360 0583
17130141 PTERYGIUM (W/GRAFT) 1826.00 06/30/10 65426 65426 65426 085 0360 0583
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 445
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17130143 SCRAPING CORN/DIAG SMEAR 106.00 06/30/10 65430 65430 65430 085 0360 0583
17130183 PARACENTESIS OF AC 255.00 06/30/10 65800 65800 65800 085 0360 0583
17130185 PARACENTESIS THERAPEUTIC 217.00 06/30/10 65805 65805 65805 085 0360 0583
17130186 PARACENT-EYE,RMV VITR 2466.00 06/30/10 65810 65810 65810 085 0360 0583
17130187 PARA W/WO IRRIG &/OR AIR 1630.00 06/30/10 65815 65815 65815 085 0360 0583
17130191 ARG0N LASER TRABECULAPLASTY 1391.00 06/30/10 65855 65855 65855 085 0360 0583
17130195 PARACENT-EYE,RMV VITR 2466.00 06/30/10 65810 65810 65810 085 0360 0583
17130201 INJECT AIR/LIQUID INTO AC 373.00 06/30/10 66020 66020 66020 085 0360 0583
17130203 INJ ANTIFIB AGNT/ANT CHAMB 243.00 06/30/10 66030 66030 66030 085 0360 0583
17130221 REVISE OPERATIVE WOUND 2434.00 06/30/10 66250 66250 66250 085 0360 0583
17130227 CYCLODIATH (YAG TRANSCL) 1931.00 06/30/10 66700 66700 66700 085 0360 0583
17130229 TRANSPUPILLIARY YAG 2122.00 06/30/10 66710 66710 66710 085 0360 0583
17130231 ARGON IRIDOTOMY 299.00 06/30/10 66761 66761 66761 085 0360 0583
17130233 YAG IRIDOTOMY 299.00 06/30/10 66761 66761 66761 085 0360 0583
17130234 IRIDOTOMY (YAG/ARGON) 1278.00 06/30/10 66761 66761 66761 085 0360 0583
17130235 GONIOPLASTY 965.00 06/30/10 66762 66762 66762 085 0360 0583
17130239 YAG-DISCISSIONSECNDRY-MEMBRANE 1286.00 06/30/10 66821 66821 66821 085 0360 0583
17130251 INTRAVITREAL INJECTION 649.00 06/30/10 67028 67028 67028 085 0360 0583
17130255 SEVER VIT STRNDS 1 OR > STAGES 1601.00 06/30/10 67031 67031 67031 085 0360 0583
17130259 REPAIR RET. DET. CRYO 2010.00 06/30/10 67101 67101 67101 085 0360 0583
17130261 REPAIR RET. DET. W/DRAIN ARGON 2011.00 06/30/10 67105 67105 67105 085 0360 0583
17130263 PNEUMATIC RETINOPLEXY 2748.00 06/30/10 67110 67110 67110 085 0360 0583
17130266 SCLERAL BUCKLE REMOVAL 1621.00 06/30/10 67115 67115 67115 085 0360 0583
17130269 CRYOPLEXY 1544.00 06/30/10 67141 67141 67141 085 0360 0583
17130271 PROPHYLAXIS RET. DETACH. ARGON 1507.00 06/30/10 67145 67145 67145 085 0360 0583
17130275 FOCAL PHOTO/ARGON/DYE 1255.00 06/30/10 67210 67210 67210 085 0360 0583
17130279 PAN RETINAL PHOTOCOAGULATION 1436.00 06/30/10 67228 67228 67228 085 0360 0583
17130289 RETROBULBAR INJECTION 172.00 06/30/10 67500 67500 67500 085 0360 0583
17130291 ALCOHOL INJECTION 293.00 06/30/10 67505 67505 67505 085 0360 0583
17130293 INJECTION INTO TENON'S CAPSULE 169.00 06/30/10 67515 67515 67515 085 0360 0583
17130299 BLEPH,DRAIN EYELID ABSC 95.00 06/30/10 67700 67700 67700 085 0360 0583
17130305 CHALAZION 211.00 06/30/10 67800 67800 67800 085 0360 0583
17130307 MULT CHALAZ EXC(SAME LID) 350.00 06/30/10 67801 67801 67801 085 0360 0583
17130309 MULT CHALAZ EXC (DIFF LID) 223.00 06/30/10 67805 67805 67805 085 0360 0583
17130311 EYELID BIOPSY 152.00 06/30/10 67810 67810 67810 085 0360 0583
17130313 EPILATION - MANUAL 74.00 06/30/10 67820 67820 67820 085 0360 0583
17130315 EPILATION- ELECTRO 216.00 06/30/10 67825 67825 67825 085 0360 0583
17130317 EPILATION W/LID MARG INCI 365.00 06/30/10 67830 67830 67830 085 0360 0583
17130319 REPAIR OF ECTROPION; SUTURE 3528.00 06/30/10 67914 67914 67914 085 0360 0583
17130321 TARSORRAPHY, SUTURE 559.00 06/30/10 67875 67875 67875 085 0360 0583
17130323 TARSORRHAPHY, MEDIAN 954.00 06/30/10 67880 67880 67880 085 0360 0583
17130325 TARSORRHAPHY,W/TRANSPOS TARSOL 1253.00 06/30/10 67882 67882 67882 085 0360 0583
17130330 BLEPHARTOSIS REPAIR 3505.00 06/30/10 67904 67904 67904 085 0360 0583
17130333 LID RETRACTION 2352.00 06/30/10 67911 67911 67911 085 0360 0583
17130335 REPAIR ENTROPION SUTURE 1253.00 06/30/10 67921 67921 67921 085 0360 0583
17130338 REPR EYELID WND-PART THICK 516.00 06/30/10 67930 67930 67930 085 0360 0583
17130341 SUTURE EYELID-FULL THICK 867.00 06/30/10 67935 67935 67935 085 0360 0583
17130344 RMV FOREIGN BODY-EYELID 126.00 06/30/10 67938 67938 67938 085 0360 0583
17130347 EXCIS & REPAIR EYELID 2021.00 06/30/10 67961 67961 67961 085 0360 0583
17130350 EXC CONJ LESION UP TO 1CM 369.00 06/30/10 68110 68110 68110 085 0360 0583
17130352 EXCISION OF CONJ LES >1CM 3899.00 06/30/10 68115 68115 68115 085 0360 0583
17130353 DESTR LESION CNJUNCTIVA 190.00 06/30/10 68135 68135 68135 085 0360 0583
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 446
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17130357 SUBCONJUNCTIVAL INJECTION 133.00 06/30/10 68200 68200 68200 085 0360 0583
17130360 CORRECT EVERTD PUNCT CAUT 213.00 06/30/10 68705 68705 68705 085 0360 0583
17130362 PLASTIC RPR OF CANALICULI 1926.00 06/30/10 68700 68700 68700 085 0360 0583
17130367 PUNCTUM CAUTERY LASER 240.00 06/30/10 68760 68760 68760 085 0360 0583
17130373 PUNCTAL PLUG INSERT PER EYE 215.00 06/30/10 68761 68761 68761 085 0360 0583
17130375 PUNCTUM DIL/IRIG 125.00 06/30/10 68801 68801 68801 085 0360 0583
17130377 NLD PROBING 223.00 06/30/10 68810 68810 68810 085 0360 0583
17130380 CORNEAL RELAX INCS-ASTIG 1169.00 06/30/10 65772 65772 65772 085 0360 0583
17130383 PUNCTAL OCCLUSION 118.00 06/30/10 68840 68840 68840 085 0360 0583
17130387 RPR SYMBLPHA W/WO CONTACT LENS 2800.00 06/30/10 68340 68340 68340 085 0360 0583
17130390 COMPREHENSIVE EUA 195.00 06/30/10 92018 92018 92018 085 0920 0583
17130391 LIMITED EUA 82.00 06/30/10 92019 92019 92019 085 0920 0583
17130401 QUANTITATIVE A-SCAN 487.00 06/30/10 76511 76511 76511 085 0402 0583
17130403 QUANTITATIVE B-SCAN 475.00 06/30/10 76512 76512 76512 085 0402 0583
17130405 IMMERSION B-SCAN 580.00 06/30/10 76513 76513 76513 085 0402 0583
17130407 A-SCAN W/IOL CALC 431.00 06/30/10 76519 76519 76519 085 0402 0583
17130409 FOREIGN BODY ULTRASOUND 462.00 06/30/10 76529 76529 76529 085 0402 0583
17130411 REFRACTION 23.00 06/30/10 92015 92015 92015 085 0510 0583
17130412 COMPUTERIZED CORNEAL TOPOGRPHY 113.00 06/30/10 92025 92025 92025 085 0510 0583
17130413 GONIOSCOPY 42.00 06/30/10 92020 92020 92020 085 0920 0583
17130415 SENSORIMOTOR EXAM 101.00 06/30/10 92060 92060 92060 085 0920 0583
17130417 ORTHOPTIC TRAINING 49.00 06/30/10 92065 92065 92065 085 0920 0583
17130419 LIMITED VF EXAM (TANGENT) 76.00 06/30/10 92081 92081 92081 085 0920 0583
17130421 SUPRATHRES HVF/2 ISOP GVF 125.00 06/30/10 92082 92082 92082 085 0920 0583
17130423 THRESH HVF/3 OR>ISOP GVF 216.00 06/30/10 92083 92083 92083 085 0920 0583
17130425 DIURNAL CURVE 29.00 06/30/10 92100 92100 92100 085 0920 0583
17130427 TONOGRAPHY 34.00 06/30/10 92120 92120 92120 085 0920 0583
17130429 INDIRECT OPTHALMOSCOPY(INIT) 81.00 06/30/10 92225 92225 92225 085 0920 0583
17130431 INDIRECT OPHTHALMOSCOPY(SUBSQ) 70.00 06/30/10 92226 92226 92226 085 0920 0583
17130433 FLUORESCEIN ANGIOGRAPHY 469.00 06/30/10 92235 92235 92235 085 0920 0583
17130435 INDOCYANINE GREEN ANGIOGRAPHY 406.00 06/30/10 92240 92240 92240 085 0920 0583
17130437 FUNDUS PHOTOGRAPHY 112.00 06/30/10 92250 92250 92250 085 0920 0583
17130439 CONFOCAL SCAN OPTH 135.00 06/30/10 92135 92135 92135 085 0920 0583
17130441 SLIT LAMP-PHOTOGRAPHY 124.00 06/30/10 92285 92285 92285 085 0920 0583
17130443 PHOTOKERATOSCOPY 124.00 06/30/10 92285 92285 92285 085 0920 0583
17130445 ENDOTHELIAL PHOTOGRAPHY 490.00 06/30/10 92286 92286 92286 085 0920 0583
17130447 VISUAL EVOKED POTENTIAL 266.00 06/30/10 95930 95930 95930 085 0920 0583
17130450 VISUDYNE 0.1 MG 26.00 06/30/10 J3396 J3396 J3396 085 0636 0583
17130453 DESTRUCT BY NEURO AGENT 547.00 06/30/10 64612 64612 64612 085 0360 0583
17130460 RECON LID TRANSF 2ND STG 1514.00 06/30/10 67975 67975 67975 085 0360 0583
17130465 TARSO LEV RES INTERN APPR 2150.00 06/30/10 67903 67903 67903 085 0360 0583
17130470 RPR BLEPH;CONJ-TARSO-MULLER'S 3651.00 06/30/10 67908 67908 67908 085 0360 0583
17130474 PDT 1653.00 06/30/10 67221 67221 67221 085 0360 0583
17130477 PDT SECOND EYE-SAME DAY 1952.00 06/30/10 67225 67225 67225 085 0510 0583
17130480 TTT 2941.00 06/30/10 0016T 0016T 0016T 085 0510 0583
17130483 FENDER VESSEL TECHNIQUE 1741.00 06/30/10 G0186 G0186 G0186 085 0510 0583
17130486 DESTRUCT MAC DRUSEN 1314.00 06/30/10 0017T 0017T 085 0360 0583
17130489 CHEMODENERVATION EOM 378.00 06/30/10 67345 67345 67345 085 0360 0583
17130501 REMOVE LID LESION(NOT CHALAZ) 230.00 06/30/10 67840 67840 67840 085 0360 0583
17130504 INCISE TEAR DUCT OPENING 150.00 06/30/10 67840 67840 67840 085 0360 0583
17130506 BIOPSY OF CONJUNCTIVA 189.00 06/30/10 68100 68100 68100 085 0360 0583
17130507 NLD PROBE W/TUBE OR STENT 490.00 06/30/10 68815 68815 68815 085 0360 0583
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 447
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17130509 BOTOX TYPE A-PER UNIT 8.00 06/30/10 J0585 J0585 J0585 085 0636 0583
17130510 INJECTION-SUB Q OR IM 86.00 06/30/10 96372 96372 96372 085 0510 0583
17130512 KENALOG, PER 10 MG 10.00 06/30/10 J3301 J3301 J3301 085 0636 0583
17130513 INJECTION-IV 236.00 06/30/10 96374 96374 96374 085 0510 0583
17130515 ARISTICORT,PER 5MG 8.00 06/30/10 J3303 J3303 J3303 085 0636 0583
17130516 OPHTHALMODYNAMOMETRY 79.00 06/30/10 92260 92260 92260 085 0920 0583
17130519 NEEDLE ELECTROMYO 223.00 06/30/10 92265 92265 92265 085 0920 0583
17130522 EOG 219.00 06/30/10 92270 92270 92270 085 0920 0583
17130525 ERG 191.00 06/30/10 92275 92275 92275 085 0920 0583
17130528 COLOR VISION TESTING 111.00 06/30/10 92283 92283 92283 085 0920 0583
17130531 DARK ADAPTATION 117.00 06/30/10 92284 92284 92284 085 0920 0583
17130534 FRESNELL PRISM 35.00 06/30/10 V2718 V2718 V2718 085 0274 0583
17130538 CURRETTE CORNEA 140.00 06/30/10 65435 65435 65435 085 0360 0583
17130542 PACHYMETRY 151.00 06/30/10 76514 76514 76514 085 0402 0583
17130546 PUNCTAL PLUG PER EYE 168.00 06/30/10 A4263 A4263 A4263 085 0274 0583
17130550 DESTR PROG RET-CYRO/DIATH 1644.00 06/30/10 67227 67227 67227 085 0360 0583
17130558 CORNEAL RELAX INCS-ASTIG 1169.00 06/30/10 65772 65772 65772 085 0360 0583
17130562 CORNEAL TATTOO 1737.00 06/30/10 65600 65600 65600 085 0360 0583
17130566 EDTA 1950.00 06/30/10 65436 65436 65436 085 0360 0583
17130569 GLUE CORNEA OR SCLERA 895.00 06/30/10 65286 65286 65286 085 0360 0583
17130572 EXCIS BENIGN LESION<.5 CM 287.00 06/30/10 11420 11420 11420 085 0360 0583
17130575 INCIS OF CONJUNCT,DRAIN CYST 1414.00 06/30/10 68020 68020 68020 085 0361 0583
17130578 SECONDARY CLOS-SURGICAL WOUND 2335.00 06/30/10 13160 13160 13160 085 0361 0583
17130914 LUCENTIS-VIAL & SYRGINGE .1 MG 1262.00 06/30/10 J2778 J2778 J2778 085 0636 0583
17130917 GLAUCOMA SCREENING 48.00 06/30/10 G0117 G0117 G0117 085 0510 0583
17130920 FITTING FEE/P EYE-DIS 46.00 06/30/10 92070 92070 92070 085 0510 0583
17130932 OPTH U/S,B SCAN & A SCAN 252.00 06/30/10 76510 76510 76510 085 0402 0583
17130935 REP OF BLEPHAROPTOSIS W SUTURE 3899.00 06/30/10 67901 67901 67901 085 0360 0583
17130940 FULL THK GRFT,UP TO 20SQ 2602.00 06/30/10 15260 15260 15260 085 0360 0583
17130945 REM MALG LES LIDS-2.1-3CM 1993.00 06/30/10 11643 11643 11643 085 0360 0583
17132000 CNTC LENS PMMA SPHERICAL EXTERNAL 06/01/04 V2500 V2500 V2500 085 0274 0583
17132003 CT LENS PMMA TORIC/PRISM EXTERNAL 06/01/04 V2501 V2501 V2501 085 0274 0583
17132006 CNTC LENS PMMA BIFOCAL EXTERNAL 06/01/04 V2502 V2502 V2502 085 0274 0583
17132009 CT LENS PMMA COLR VIS DEF EXTERNAL 06/01/04 V2503 V2503 V2503 085 0274 0583
17132012 CT LENS GAS PERM SPHER EXTERNAL 06/01/04 V2510 V2510 V2510 085 0274 0583
17132015 CT LENS GAS PER PRSM BLST EXTERNAL 06/01/04 V2511 V2511 V2511 085 0274 0583
17132018 CNTC LENS GAS PERM BIFOCL EXTERNAL 06/01/04 V2512 V2512 V2512 085 0274 0583
17132021 CT LENS GAS PERM EXT WEAR EXTERNAL 06/01/04 V2513 V2513 V2513 085 0274 0583
17132024 CNTC LENS HYDROPHIL SPHER EXTERNAL 06/01/04 V2520 V2520 V2520 085 0274 0583
17132027 CT LENS HYDRO/PRISM BLLST EXTERNAL 06/01/04 V2521 V2521 V2521 085 0274 0583
17132030 CNTC LENS HYDROP BIFOCAL EXTERNAL 06/01/04 V2522 V2522 V2522 085 0274 0583
17132033 CNTC LENS HYDRO EXT WEAR EXTERNAL 06/01/04 V2523 V2523 V2523 085 0274 0583
17132036 CT LENS SCLER GAS PERM EXTERNAL 06/01/04 V2530 V2530 V2530 085 0274 0583
17132039 CT LENS SCLERL GAS PERM EXTERNAL 06/01/04 V2531 V2531 V2531 085 0274 0583
17132042 CONTACT LENS OTHER TYPE EXTERNAL 06/01/04 V2599 V2599 V2599 085 0274 0583
17139500 ORBITOTOMY W/O BONE FLAP 3047.00 06/30/10 67400 67400 67400 085 0361 0583
17139502 INCISION,DRAINAGE-LACRIMAL SAC 3355.00 06/30/10 68420 68420 68420 085 0360 0583
17139504 INCISE TEAR DUCT OPENING 150.00 06/30/10 68440 68440 68440 085 0360 0583
17139507 INCIS OF CONJUN/PLC OF IMPLA 211.00 06/30/10 68399 68399 68399 085 0361 0583
17139510 INCISION AND RMVL OF FB-SIMPLE 193.00 06/30/10 10120 10120 10120 085 0361 0583
17139513 RMVL OF IMPLANT MAT-ANTERIOR 2100.00 06/30/10 65920 65920 65920 085 0361 0583
17139516 ORBIOTOMY W/DRAINANGE ONLY 2305.00 06/30/10 67405 67405 67405 085 0361 0583
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 448
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17139519 EXCISION/REPAIR OVER 1/4TH LID 2082.00 06/30/10 67966 67966 67966 085 0361 0583
17139522 PARTIAL CONJ FLAP 2100.00 06/30/10 68360 68360 68360 085 0361 0583
17139526 REDUCTION OVER CORRECT-PTOSIS 1572.00 06/30/10 67909 67909 67909 085 0361 0583
17139530 CANTHOPLASTY 2800.00 06/30/10 67950 67950 67950 085 0360 0583
17139533 BLEPAROPLSTY,UP EYE,EXESS SKIN 2417.00 06/30/10 15823 15823 15823 085 0360 0583
17139540 TIS TRAN-LIP 10SQ CM OR < 2715.00 06/30/10 14060 14060 14060 085 0360 0583
17139542 TIS TRAN-EYE 10.1-30SQ CM 2813.00 06/30/10 14061 14061 14061 085 0360 0583
17139544 RPR LACERATION;CORN,PERF W/REP 4427.00 06/30/10 65285 65285 65285 085 0360 0583
17139546 RMVL FRGN BODY INTRANASAL 113.00 06/30/10 30300 30300 30300 085 0360 0583
17139548 OCULAR SURF RECON,AMNIO MEM TR 3851.00 06/30/10 65780 65780 65780 085 0360 0582
17139550 NASAL ENDO DX UNI/BIL SEP PROC 169.00 06/30/10 31231 31231 31231 085 0360 0583
17200825 LAY CLOS,FACE 2.5CM OR <-HOSP 206.00 06/30/10 12051 12051 12051 085 0360 0641
17200826 LAY CLOS,FACE 2.5CM OR <M.D. 355.00 $ 06/30/09 12051 12051 12051 085 0975 0641
17200831 LARYNSPY FLX/RGD-W/STROBO-HOSP 614.00 06/30/10 31579 31579 31579 085 0360 0641
16500137 PSTN NYSTAGMUS TST 6 PSTN 47.00 06/30/10 92542 92542 92542 087 0471 0642
16500141 AUDITORY EVOKED POT CMPLT 331.00 06/30/10 92585 92585 92585 087 0471 0642
16500244 PT RE-EVALUATION - OP 105.00 06/30/10 97002 97002 97002 087 0420 0642
16500247 PT EVALUATION - OP 208.00 06/30/10 97001 97001 97001 087 0420 0642
17200041 POST OPERATIVE VISIT N/C 06/30/10 99024 99024 99024 087 0510 0641
17200049 BINOCULAR MICROSCOPY-HOSP 64.00 06/30/10 92504 92504 92504 087 0471 0641
17200050 BINOCULAR MICROSCOPY-M.D. 20.00 $ 06/30/09 92504 92504 92504 087 0983 0641
17200055 NASOPHARYNGOSCOPY-HOSP 169.00 06/30/10 92511 92511 92511 087 0471 0641
17200056 NASOPHARYNGOSCOPY-M.D. 121.00 $ 06/30/09 92511 92511 92511 087 0983 0641
17200057 ACOUSTIC RHINOMETRY-HOSP 156.00 06/30/10 92512 92512 92512 087 0471 0641
17200058 ACOUSTIC RHINOMETRY-M.D. 58.00 $ 06/30/09 92512 92512 92512 087 0983 0641
17200059 FACIAL NRVE FUNCT STUDIES-HOSP 252.00 06/30/10 92516 92516 92516 087 0471 0641
17200060 FACIAL NRVE FUNCT STUDIES-M.D. 46.00 $ 06/30/09 92516 92516 92516 087 0979 0641
17200070 TYPANOMETRY 72.00 06/30/10 92567 92567 92567 087 0471 0641
17200080 SPONT NYSTAGAMUS TESTING-HOSP 47.00 06/30/10 92541 92541 92541 087 0471 0641
17200081 SPONT NYSTAGAMUS TESTING-M.D. 43.00 $ 06/30/09 92541 9254126 9254126 087 0983 0641
17200082 PSTN NYSTAGMUS TST 6 PSTN-HOSP 47.00 06/30/10 92542 92542 92542 087 0471 0641
17200083 PSTN NYSTAGMUS TST 6 PSTN-M.D. 35.00 $ 06/30/09 92542 9254226 92542 087 0983 0641
17200088 AUDITORY EVOKED POT CMPLT-HOSP 331.00 06/30/10 92585 92585 92585 087 0471 0641
17200089 AUDITORY EVOKED POT CMPLT-M.D. 55.00 $ 06/30/09 92585 92585 92585 087 0983 0641
17200107 THERAPEUTIC INJECTION 86.00 06/30/10 96372 96372 96372 087 0940 0641
17200109 INTRAVENOUS INJECTION 80.00 06/30/10 96374 96374 96374 087 0940 0641
17200201 INCIS/DRAIN,ABSCESS;SIMP-HOSP. 164.00 06/30/10 10060 10060 10060 087 0360 0641
17200202 INCIS/DRAIN,ABSCESS;SIMP-M.D. 186.00 $ 06/30/09 10060 10060 10060 087 0975 0641
17200227 SKIN BIOP,SINGLE LESION-HOSP. 165.00 06/30/10 11100 11100 11100 087 0360 0641
17200228 SKIN BIOP,SINGLE LESION-M.D. 95.00 $ 06/30/09 11100 11100 11100 087 0975 0641
17200231 EXCISION OF LESION-HOSP 172.00 06/30/10 11200 11200 11200 087 0360 0641
17200232 EXCISION OF LESION-M.D. 132.00 $ 06/30/09 11200 11200 11200 087 0975 0641
17200241 EAR LOBE CLEFT REPAIR-HOSP 267.00 06/30/10 12011 12011 12011 087 0360 0641
17200242 EAR LOBE CLEFT BIOPSY-M.D. 213.00 $ 06/30/09 12011 12011 12011 087 0975 0641
17200291 RMVAL OF SUTURES W/ANES-HOSP 114.00 06/30/10 15850 15850 15850 087 0360 0641
17200292 RMVAL OF SUTURES W/ANES-M.D. 86.00 $ 06/30/09 15850 15850 15850 087 0975 0641
17200311 CAUTERIZ GRANULATION TISS-HOSP 120.00 06/30/10 17250 17250 17250 087 0360 0641
17200312 CAUTERIZ GRANULATION TISS-M.D. 74.00 $ 06/30/09 17250 17250 17250 087 0975 0641
17200401 NOSE BIOPSY-HOSP 1017.00 06/30/10 30100 30100 30100 087 0360 0641
17200402 NOSE BIOPSY-M.D. 140.00 $ 06/30/09 30100 30100 30100 087 0975 0641
17200415 RMVAL FOR BODY,INTRANASAL-HOSP 115.00 06/30/10 30300 30300 30300 087 0360 0641
17200416 RMVL FRGN BDY INTRANASAL-M.D. 235.00 $ 06/30/09 30300 30300 30300 087 0975 0641
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 449
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17200423 NOSE BLEED CAUTERIZATION-HOSP 270.00 06/30/10 30901 30901 30901 087 0360 0641
17200424 NOSE BLEED CAUTERIZATION-M.D. 130.00 $ 06/30/09 30901 30901 30901 087 0975 0641
17200427 NASAL PACKING,POSTERIOR-HOSP. 649.00 06/30/10 30905 30905 30905 087 0360 0641
17200428 NASAL PACKING,POSTERIOR-M.D. 216.00 $ 06/30/09 30905 30905 30905 087 0360 0641
17200435 SINUS TAP/IRRIGATION-HOSP 236.00 06/30/10 31000 31000 31000 087 0360 0641
17200436 SINUS TAP/IRRIGATION-M.D. 205.00 $ 06/30/09 31000 31000 31000 087 0975 0641
17200445 NASAL ENDOSCOPY-HOSP 369.00 06/30/10 31231 31231 31231 087 0360 0641
17200446 NASAL ENDOSCOPY-M.D. 157.00 $ 06/30/09 31231 31231 31231 087 0975 0641
17200449 DEBRIDE,NASAL CAVITY-HOSP 3168.00 06/30/10 31237 31237 31237 087 0360 0641
17200450 DEBRIDE,NASAL CAVITY-M.D. 381.00 $ 06/30/09 31237 31237 31237 087 0975 0641
17200457 TRACHEOTOMY TUBE-BIVONA 757.00 06/30/10 087 0270 0641
17200461 TRACHEOTOMY TUBE CHANGE-HOSP 368.00 06/30/10 31502 31502 31502 087 0360 0641
17200462 TRACHEOTOMY TUBE CHANGE-M.D. 74.00 $ 06/30/09 31502 31502 31502 087 0975 0641
17200485 LARYNGOSCOPY;DIAGNOSTIC-HOSP. 184.00 06/30/10 31575 31575 31575 087 0360 0641
17200486 LARYNGOSCOPY;DIAGNOSTIC-M.D. 157.00 $ 06/30/09 31575 31575 31575 087 0975 0641
17200501 LIP BIOPSY-HOSP 321.00 06/30/10 40490 40490 40490 087 0360 0641
17200502 LIP BIOPSY-M.D. 146.00 $ 06/30/09 40490 40490 40490 087 0975 0641
17200515 FOR BDY REM-MOUTH/THROAT-HOSP 330.00 06/30/10 40804 40804 40804 087 0360 0641
17200516 FOR BDY REM-MOUTH/THROAT-M.D. 252.00 $ 06/30/09 40804 40804 40804 087 0975 0641
17200535 ORAL CAVITY BIOPSY-HOSP 1017.00 06/30/10 41108 41108 41108 087 0360 0641
17200536 ORAL CAVITY BIOPSY-M.D. 179.00 $ 06/30/09 41108 41108 41108 087 0975 0641
17200555 I&D ABSC PERITONSILLAR-HOSP 359.00 06/30/10 42700 42700 42700 087 0360 0641
17200556 I&D ABSC PERITONSILLAR-M.D. 270.00 $ 06/30/09 42700 42700 42700 087 0975 0641
17200565 DILATION OF ESOPHAGUS-HOSPITL 731.00 06/30/10 43456 43456 43456 087 0360 0641
17200566 DILATION OF ESOPHAGUS-M.D. 326.00 $ 06/30/09 43456 43456 43456 087 0975 0641
17200601 DRAIN EXT EAR ABSC/HEMA-HOSP 223.00 06/30/10 69000 69000 69000 087 0360 0641
17200602 DRAIN EXT EAR ABSC/HEMA-M.D. 231.00 $ 06/30/09 69000 69000 69000 087 0975 0641
17200603 DRAIN EX AUDIT CANAL ABSC-HOSP 223.00 06/30/10 69020 69020 69020 087 0360 0641
17200604 DRAIN EX AUDIT CANAL ABSC-M.D. 280.00 $ 06/30/09 69020 69020 69020 087 0975 0641
17200607 EXTERNAL EAR BIOPSY-HOSP 302.00 06/30/10 69100 69100 69100 087 0360 0641
17200608 EXTERNAL EAR BIOPSY-M.D. 96.00 $ 06/30/09 69100 69100 69100 087 0975 0641
17200617 FOREIGN BODY REMOVAL-EAR-HOSP 196.00 06/30/10 69200 69200 69200 087 0360 0641
17200618 FOREIGN BODY REMOVAL-EAR -M.D. 112.00 $ 06/30/09 69200 69200 69200 087 0975 0641
17200621 WAX REMOVAL-HOSP 108.00 06/30/10 69210 69210 69210 087 0360 0641
17200622 WAX REMOVAL-M.D. 67.00 $ 06/30/09 69210 69210 69210 087 0975 0641
17200623 DEBRIDE MASTOIDECTOMY CAV-HOSP 136.00 06/30/10 69220 69220 69220 087 0360 0641
17200624 DEBRIDE MASTOIDECTOMY CAV-M.D. 126.00 $ 06/30/09 69220 69220 69220 087 0975 0641
17200625 PE TUBES-HOSP 832.00 06/30/10 69433 69433 69433 087 0360 0641
17200626 PE TUBES-M.D. 257.00 $ 06/30/09 69433 69433 69433 087 0975 0641
17200631 MYRINGOTOMY-NO ANESTHESIA-HOSP 509.00 06/30/10 69420 69420 69420 087 0360 0641
17200632 MYRINGOTOMY-NO ANESTHESIA-M.D. 238.00 $ 06/30/09 69420 69420 69420 087 0975 0641
17200633 DEBRIDE MASTOID CAV - COMP-HOS 2015.00 06/30/10 69222 69222 69222 087 0360 0641
17200634 DEBRIDE MASTOID CAV COMP-M.D. 273.00 $ 06/30/09 69222 69222 69222 087 0975 0641
17200661 TYMPANIC MEMBRANE REPAIR-HOSP 3199.00 06/30/10 69601 69601 69601 087 0360 0641
17200662 TYMPANIC MEMBRANE REPAIR-M.D. 2088.00 $ 06/30/09 69601 69601 69601 087 0975 0641
17200711 SKIN TEST,TB,INTRADERMAL 46.00 06/30/10 86580 86580 86580 087 0302 0641
17200723 THROAT CULTURE 132.00 06/30/10 87071 87071 87071 087 0306 0641
17200739 FINE NEEDLE ASPIRATION-HOSP 355.00 06/30/10 10021 10021 10021 087 0361 0641
17200740 FINE NEEDLE ASPIRATION-M.D. 141.00 $ 06/30/09 10021 10021 10021 087 0983 0641
17200781 PULSE OXIMETRY; MULT DETERMIN 151.00 06/30/10 94761 94761 94761 087 0460 0641
17200783 SPEECH & LANG EVAL-HOSP 130.00 06/30/10 92506 92506 92506 087 0444 0641
17200784 SPEECH & LANG EVAL-M.D. 93.00 $ 06/30/09 92506 92506 92506 087 0979 0641
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 450
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

17200787 TREATMENT S/L/H;INDIV-HOSP 36.00 06/30/10 92507 92507 92507 087 0440 0641
17200788 TREATMENT S/L/H;INDIV-M.D. 55.00 $ 06/30/09 92507GN 92507GN 92507GN 087 0979 0641
17200791 HILGER NERVE STIMULATION-HOSP 48.00 06/30/10 95900 95900 95900 087 0922 0641
17200792 HILGER NERVE STIMULATION-M.D. 46.00 $ 06/30/09 95900 9590026 9590026 087 0983 0641
17200801 MINOR OR PROCEDURE ENT 235.00 06/30/10 087 0360 0641
17200835 TRACHEO THRU TRACH INCL-HOSP. 1506.00 06/30/10 31615 31615 31615 087 0360 0641
17200836 TRACHEO THRU TRACH INCL-M.D. 263.00 $ 06/30/09 31615 31615 31615 087 0975 0641
17200841 DRAIN ABSCESS MOUTH SMPL-HOSP 194.00 06/30/10 40800 40800 40800 087 0360 0641
17200842 DRAIN ABSCESS MOUTH SMPL-M.D. 251.00 $ 06/30/09 40800 40800 40800 087 0975 0641
17200847 BIOPSY OF TONGUE-HOSP 588.00 06/30/10 41100 41100 41100 087 0360 0641
17200848 BIOPSY OF TONGUE-M.D. 221.00 $ 06/30/09 41100 41100 41100 087 0975 0641
17200851 BIOPSY OF PALATE,UVULA-HOSP. 591.00 06/30/10 42100 42100 42100 087 0360 0641
17200852 BIOPSY OF PALATE,UVULA-M.D. 218.00 $ 06/30/09 42100 42100 42100 087 0975 0641
17200861 MYRINGOTOMY-NO ANESTHESIA-HOSP 236.00 06/30/10 69420 69420 69420 087 0360 0641
17200862 MYRINGOTOMY-NO ANESTHESIA-M.D. 238.00 $ 06/30/09 69420 69420 69420 087 0975 0641
17200871 CAUT/ABLAT MUCOS TURB;SUP-HOSP 739.00 06/30/10 30801 30801 30801 087 0360 0641
17200872 CAUT/ABLAT MUCOS TURB;SUP-M.D. 257.00 $ 06/30/09 30801 30801 30801 087 0975 0641
17200878 TRACH CAP 6.00 06/30/10 A7527 A7527 A7527 087 0270 0641
17200885 NEEDLE ELECTROMYO; LARYNX-HOSP 141.00 06/30/10 95865 95865 95865 087 0922 0641
17200886 NEEDLE ELECTROMYO; LARYNX-M.D. 173.00 $ 06/30/09 95865 95865 95865 087 0983 0641
17200889 SMKE/TOBACCO CNSL 3-10MIN-HOSP 12.00 06/30/10 99406 99406 99406 087 0510 0641
17200890 SMKE/TOBACCO CNSL 3-10MIN-MD. 25.00 $ 08/10/08 99406 99406 99406 087 0970 0641
17200893 SMK/TOBACCO CNSL 10-20MIN-HOSP 12.00 06/30/10 99407 99407 99407 087 0510 0641
17200894 SMK/TOBACCO CNSL 10-20MIN-PRO 50.00 $ 06/30/09 99407 99407 99407 087 0970 0641
17200897 LARYNG INDIRECT SEP PROC-HOSP 131.00 06/30/10 31505 31505 31505 087 0360 0641
17200898 LARYNG INDIRECT SEP PROC-PRO 99.00 $ 06/30/09 31505 31505 31505 087 0975 0641
17200901 PT EVALUATION - OP 208.00 06/30/10 97001 97001 97001 087 0420 0641
17200903 PT RE-EVALUATION - OP 105.00 06/30/10 97002 97002 97002 087 0420 0641
17200907 INTRALESIONAL INJ UP TO 7-HOSP 90.00 06/30/10 11900 11900 11900 087 0360 0641
17200908 INTRALESIONAL INJ UP TO 7-M.D. 61.00 $ 08/01/09 11900 11900 11900 087 0975 0641
17200910 INTRACUT TESTS-ALLERG-IMMED 86.00 06/30/10 95024 95024 95024 087 0924 0641
17200916 SKIN END POINT TITRATION 129.00 06/30/10 95027 95027 95027 087 0924 0641
17200920 IMMUNTOX W/O EXT 1 INJ 30.00 06/30/10 95115 95115 95115 087 0510 0641
17200924 IMMUNTOX W/O EXT 2/> INJ 81.00 06/30/10 95117 95117 95117 087 0924 0641
17200936 PREP & PRVS 1/MX ANTIG 125.00 06/30/10 95165 95165 95165 087 0510 0641
13900002 OFFC VST NEW LVL1-DOCTOR 51.00 $ 06/30/09 99201 99201 088 0983 0621
13900101 ADHESIVE 45.00 06/01/10 99070 99070 088 0270 0621
13900103 ADJUSTMNT OF OCULAR PROSTHESIS 450.00 06/01/10 V2626 V2626 V2626 088 0274 0621
13900105 AURICULAR PROTHESIS 7414.00 06/01/10 21086 21086 21086 088 0360 0621
13900107 BUILD-UP OF PROSTHESIS 1087.00 06/01/10 V2625 V2625 V2625 088 0274 0621
13900109 CUSTOM CONFORMER 686.00 06/01/10 V2628 V2628 V2628 088 0274 0621
13900111 FACIAL PROTHESIS EXTERNAL 03/21/94 21088 21088 21088 088 0360 0621
13900113 HND RESTOR-MULT FINGERS REMAIN 4353.00 06/01/10 L6905 L6905 L6905 088 0274 0621
13900115 HND RESTOR-1 FINGER REMAIN 4398.00 06/01/10 L6900 L6900 L6900 088 0274 0621
13900117 HND RESTOR-NO FINGERS REMAIN EXTERNAL 03/21/94 L6910 L6910 L6910 088 0274 0621
13900119 HND RESTOR-REPLACEMENT GLOVE EXTERNAL 03/21/94 L6915 L6915 L6915 088 0274 0621
13900121 INSERTION PALATAL PROSTHESIS 2965.00 06/01/10 42281 42281 42281 088 0360 0621
13900123 LOWER EXTREMITY PROSTHESIS EXTERNAL 03/21/94 L5970 L5970 L5970 088 0274 0621
13900125 MANDIB RESECT PROSTH 7414.00 06/01/10 21081 21081 21081 088 0360 0621
13900127 MANDIB RESECT PROSTH W/O GUIDE EXTERNAL 03/21/94 21081 21081 21081 088 0360 0621
13900129 MAXILLARY IMPRESS PALATAL PROS 591.00 06/01/10 42280 42280 42280 088 0360 0621
13900131 NASAL PROSTHESIS 7414.00 06/01/10 21087 21087 21087 088 0360 0621
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 451
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13900133 NASAL SEPTAL PROSTHESIS EXTERNAL 03/21/94 30220 30220 30220 088 0360 0621
13900135 NO OTHERWISE CLASSIFICATION EXTERNAL 03/21/94 V2629 V2629 V2629 088 0274 0621
13900137 OBTURATOR PROSTHES, DEFINITIVE 7414.00 06/01/10 21080 21080 21080 088 0360 0621
13900139 OBTURATOR PROSTHESIS, INTERIM 7414.00 06/01/10 21079 21079 21079 088 0360 0621
13900141 OBTURATOR PROSTHESIS, SURGICAL 4306.00 06/01/10 21076 21076 21076 088 0360 0621
13900145 OCULAR PROSTHESIS, INTERIM EXTERNAL 01/01/06 088 0940 0621
13900147 OCULAR PROTHESIS, CUST PLASTIC 2123.00 06/01/10 V2623 V2623 V2623 088 0274 0621
13900153 ORBITAL PROSTHESIS 7414.00 06/01/10 21077 21077 21077 088 0360 0621
13900155 PALATAL AUGMENTATN PROSTHESIS 7414.00 06/01/10 21082 21082 21082 088 0360 0621
13900157 PALATAL LIFT PROSTHESIS, DEFIN EXTERNAL 03/21/94 21083 21083 21083 088 0360 0621
13900159 PALATAL LIFT PROSTHES, INTERIM 7414.00 06/01/10 21083 21083 21083 088 0360 0621
13900161 PART FOOT, SHOE INSERT W/ARCH EXTERNAL 03/21/94 L5000 L5000 L5000 088 0274 0621
13900163 PART HAND, NO FINGERS REMAIN EXTERNAL 03/21/94 L6020 L6020 L6020 088 0274 0621
13900165 PART HAND LITTLE/RING FING REM EXTERNAL 03/21/94 L6010 L6010 L6010 088 0274 0621
13900167 PARTIAL HAND, THUMB REMAINING EXTERNAL 03/21/94 L6000 L6000 L6000 088 0274 0621
13900169 POLISHING OF PROSTHESIS 137.00 06/01/10 V2624 V2624 V2624 088 0274 0621
13900171 RECALL VISIT-NO CHARGE N/C 06/30/10 99024 99024 99024 088 0960 0621
13900173 SCLERAL PRE-SHELL EXTERNAL 03/21/94 V2630 V2630 V2630 088 0276 0621
13900175 SCLERAL SHELL PROSTHESIS 3225.00 06/01/10 V2627 V2627 V2627 088 0274 0621
13900177 SKIN BARRIER WIPES, PER 50 EXTERNAL 03/21/94 99070 99070 99070 088 0270 0621
13900179 SPEECH AID PROSTHESIS; ADULT EXTERNAL 03/21/94 21084 21084 21084 088 0360 0621
13900181 SPEECH AID PROSTHESIS; PEDS EXTERNAL 03/21/94 21084 21084 21084 088 0360 0621
13900183 SURGICAL SPLINT 2965.00 06/01/10 21085 21085 21085 088 0360 0621
13900184 SURG SPLINT-OFF SITE-M.D. 1191.00 $ 06/30/09 21085 21085 21085 088 0960 0621
13900185 SURGICAL STENT EXTERNAL 03/21/94 21085 21085 21085 088 0360 0621
13900186 SURGICAL STENT-OFF-SITE-M.D. 1191.00 $ 06/30/09 21085 21085 21085 088 0960 0621
13900187 TAPE, ALL TYPES AND SIZES EXTERNAL 03/21/94 99070 99070 99070 088 0270 0621
13900189 TERMINAL DEVICE, HAND, PASSIVE EXTERNAL 03/21/94 088 0274 0621
13900191 TERMINAL DEV, HAND, CHILD MITT EXTERNAL 03/21/94 088 0274 0621
13900193 TERM DEV GLOVE FOR ABOVE HANDS EXTERNAL 03/21/94 L6895 L6895 L6895 088 0274 0621
13900195 UNLIST MAXILLOFAC PROSTH PROC 199.00 06/01/10 21089 21089 21089 088 0274 0621
13900197 UNLIST PROC FOR LE PROSTHESIS EXTERNAL 03/21/94 L5999 L5999 L5999 088 0274 0621
13900199 UNLIST PROC FOR UE PROSTHESIS EXTERNAL 03/21/94 L7499 L7499 L7499 088 0274 0621
13900201 UNLIST PROC MISCEL PROSTH SERV EXTERNAL 03/21/94 L8499 L8499 L8499 088 0274 0621
13900203 X-RAY EXAM, TEETH; SING VIEW 77.00 06/01/10 70300 70300 70300 088 0320 0621
13900205 X-RAY;PARTIAL EXAM <FULL MOUTH 77.00 06/01/10 70310 70310 70310 088 0320 0621
13900207 X-RAY; COMPLETE, FULL MOUTH 77.00 06/01/10 70320 70320 70320 088 0320 0621
13900215 OSTEOPLASTY, FACIAL BONE AUG EXTERNAL 05/11/98 21208 21208 21208 088 0360 0621
13900216 OST,FAC BONE AUG-OFF-SITE-M.D. 1655.00 $ 06/30/09 21208 21208 21208 088 0960 0621
13900217 RECONSTRUCT MD/MAX, PARTIAL EXTERNAL 05/11/98 21248 21248 21248 088 0360 0621
13900218 RECON MD/MAX PRT-OFF SITE-M.D. 1795.00 $ 06/30/09 21248 21248 21248 088 0960 0621
13900219 RECONSTRUCT MD/MAX, COMP EXTERNAL 05/11/98 21249 21249 21249 088 0360 0621
13900220 RECN MD/MAX/COMP-OFF-SITE-M.D. 2567.00 $ 06/30/09 21249 21249 21249 088 0960 0621
13900221 REMOVAL OF IMPLANT (WIRE) 3018.00 06/01/10 20670 20670 20670 088 0360 0621
13900230 PLACEMNT OF HEALING CAP EXTERNAL 02/01/08 L7510 L7510 L7510 088 0274 0621
13910001 INITIAL ORAL EXAM EXTERNAL 06/01/10 D0150 D0150 D0150 088 0510 0621
13910002 PERIODIC ORAL EXAM EXTERNAL 06/01/10 D0120 D0120 D0120 088 0510 0621
13910003 EMERGENCY ORAL EXAMINATION EXTERNAL 12/12/94 088 0510 0621
13910024 INTRAORAL-OCCLUSAL FILM EXTERNAL 12/12/94 088 0510 0621
13910027 BITEWINGS-SINGLE FILM EXTERNAL 12/12/94 088 0510 0621
13910028 BITEWINGS-TWO FILMS EXTERNAL 12/12/94 088 0510 0621
13910030 BITEWINGS-FOUR FILMS EXTERNAL 12/12/94 088 0510 0621
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 452
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13910051 DIAGNOSTIC CASTS EXTERNAL 12/12/94 088 0510 0621
13910052 DIAGNOSTIC PHOTOGRAPHS EXTERNAL 12/12/94 088 0510 0621
13910072 PROPHYLAXIS-CHILD 75.00 06/01/10 D1120 D1120 D1120 088 0510 0621
13910081 ORAL HYGIENE INSTRUCTION EXTERNAL 12/12/94 088 0510 0621
13910214 AMALGAM-4 OR MORE SURF, PERM 815.00 06/01/10 D2161 D2161 D2161 088 0510 0621
13910251 ONLAY-METALLIC-PER TOOTH EXTERNAL 12/12/94 088 0510 0621
13910254 INLAY-PORCELAIN/CERAMIC-1 SURF EXTERNAL 12/12/94 088 0510 0621
13910255 INLAY-PORCELAIN/CERAMIC-2 SURF EXTERNAL 12/12/94 088 0510 0621
13910256 INLAY-PORCELAIN/CERAMIC-3 SURF EXTERNAL 12/12/94 088 0510 0621
13910259 ONLAY-PORCEL/CERAMIC/TOOTH EXTERNAL 12/12/94 088 0510 0621
13910271 CROWN-RESIN (LABORATORY) EXTERNAL 12/12/94 088 0510 0621
13910272 CROWN-RESIN W/HIGH NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910273 CROWN-RESIN WITH NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910274 CROWN-PORCEL/CERAMIC SUBSTRATE EXTERNAL 12/12/94 088 0510 0621
13910276 CROWN-PORCEL FUSED NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910278 CROWN-FULL CAST NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910291 RECEMENT CROWN EXTERNAL 12/12/94 D2910 D2910 D2910 088 0510 0621
13910294 CORE BUILDUP, INCLUDING PINS 500.00 06/01/10 D2950 D2950 D2950 088 0510 0621
13910311 PROVIS SPLINTING-INTRACORONAL EXTERNAL 12/12/94 088 0510 0621
13910321 PERIDONTAL MAINTENANCE PROCED EXTERNAL 12/12/94 088 0510 0621
13910371 ADJUST COMPLETE DENTURE-UPPER EXTERNAL 12/12/94 088 0510 0621
13910372 ADJUST COMPLETE DENTURE-LOWER EXTERNAL 12/12/94 088 0510 0621
13910373 ADJUST PARTIAL DENTURE-UPPER EXTERNAL 12/12/94 088 0510 0621
13910374 ADJUST PARTIAL DENTURE-LOWER EXTERNAL 12/12/94 088 0510 0621
13910391 REPAIR BROKE COMP DENTURE BASE EXTERNAL 12/12/94 088 0510 0621
13910392 REPLACE MISS/BROKEN TEETH COMP 250.00 06/01/10 D5640 D5640 D5640 088 0510 0621
13910411 REPAIR RESIN SADDLE OR BASE 450.00 06/01/10 V2626 V2626 V2626 088 0274 0621
13910413 REPAIR OR REPLACE BROKEN CLASP EXTERNAL 12/12/94 088 0510 0621
13910416 ADD CLASP EXIST PART DENTURE EXTERNAL 12/12/94 088 0510 0621
13910431 RELINE COMPL UP DENT(CHRSIDE) EXTERNAL 12/12/94 088 0510 0621
13910432 RELINE COML LOW DENT (CHRSIDE) EXTERNAL 12/12/94 088 0510 0621
13910433 RELINE UP PART DENT(CHAIRSIDE) EXTERNAL 12/12/94 088 0510 0621
13910434 RELINE LOW PART DENT (CHRSIDE) EXTERNAL 12/12/94 088 0510 0621
13910438 RELINE LOWER PART DENTURE(LAB) EXTERNAL 12/12/94 088 0510 0621
13910453 INTERIM PART DENTURE (UPPER) EXTERNAL 12/12/94 088 0510 0621
13910454 INTERIM PART DENTURE (LOWER) EXTERNAL 12/12/94 088 0510 0621
13910460 OVERDENTURE-COMPLETE,BY REPORT EXTERNAL 12/12/94 088 0510 0621
13910471 ADHESIVE EXTERNAL 12/12/94 088 0510 0621
13910472 ADHESIVE REMOVER EXTERNAL 12/12/94 088 0510 0621
13910476 FACIAL MOULAGE (SECTIONAL) EXTERNAL 12/12/94 088 0510 0621
13910477 FACIAL MOULAGE (COMPLETE) EXTERNAL 12/12/94 088 0510 0621
13910478 NASAL PROSTHESIS EXTERNAL 12/12/94 088 0510 0621
13910479 AURICULAR PROSTHESIS EXTERNAL 12/12/94 088 0510 0621
13910480 ORBITAL PROSTHESIS EXTERNAL 12/12/94 088 0510 0621
13910481 OCULAR PROSTHESIS EXTERNAL 12/12/94 088 0510 0621
13910482 FACIAL PROSTHESIS EXTERNAL 12/12/94 088 0510 0621
13910483 OCULAR PROSTHESIS, INTERIM EXTERNAL 12/12/94 088 0510 0621
13910484 CRANIAL PROSTHESIS EXTERNAL 12/12/94 088 0510 0621
13910485 FACIAL AUGMENT IMPLANT PROSTH EXTERNAL 12/12/94 088 0510 0621
13910486 NASAL PROSTHESIS, REPLACEMENT EXTERNAL 12/12/94 088 0510 0621
13910487 AURICULAR PROSTH, REPLACEMENT EXTERNAL 12/12/94 088 0510 0621
13910488 ORBITAL PROSTHESIS,REPLACEMENT EXTERNAL 12/12/94 088 0510 0621
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 453
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

13910489 FACIAL PROSTHESIS, REPLACEMENT EXTERNAL 12/12/94 088 0510 0621
13910491 ORBTURATOR PROSTHESIS,SURGICAL EXTERNAL 12/12/94 088 0510 0621
13910492 ORBTURATOR PROSTH,DEFINITIVE EXTERNAL 12/12/94 088 0510 0621
13910493 ORBTURATOR PROSTH,MODIFICATION EXTERNAL 12/12/94 088 0510 0621
13910494 MANDI PROSTH W/GUIDE FLANGE EXTERNAL 12/12/94 088 0510 0621
13910495 MANDI PROSTH W/O GUIDE FLANGE EXTERNAL 12/12/94 088 0510 0621
13910496 OBTURATOR PROSTHESIS, INTERIM EXTERNAL 12/12/94 088 0510 0621
13910500 SPEECH AID PROSTH, PEDIATRIC EXTERNAL 12/12/94 088 0510 0621
13910501 SPEECH AID PROSTHESIS, ADULT EXTERNAL 12/12/94 088 0510 0621
13910502 PALATAL AUGMENTATION PROSTH EXTERNAL 12/12/94 088 0510 0621
13910503 PALATAL LIFT PROSTH,DEFINITIVE EXTERNAL 12/12/94 088 0510 0621
13910505 PALATAL LIFT PROSTH, INTERIM EXTERNAL 12/12/94 088 0510 0621
13910506 PALATAL LIFT PROSTHESIS, MODIF EXTERNAL 12/12/94 088 0510 0621
13910507 SPEECH AID PROSTHESIS, MODIF EXTERNAL 12/12/94 088 0510 0621
13910508 SURGICAL STENT EXTERNAL 12/12/94 088 0510 0621
13910509 RADIATION CARRIER EXTERNAL 12/12/94 D5983 D5983 D5983 088 0510 0621
13910510 RADIATION SHEILD 1781.00 06/01/10 D5984 D5984 D5984 088 0510 0621
13910512 FLOURIDE GEL 15.00 06/01/10 088 0270 0621
13910513 COMMISSURE SPLINT EXTERNAL 12/12/94 D5987 D5987 D5987 088 0510 0621
13910514 SURGICAL SPLINT EXTERNAL 12/12/94 088 0270 0621
13910542 IMPLANT ABUTMENT 375.00 06/01/10 21299 21299 21299 088 0360 0621
13910552 PONTIC-CAST NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910556 PONTIC-PORCEL FUSED PREDOMIN EXTERNAL 12/12/94 088 0510 0621
13910557 PONTIC-PORCEL FUSED N-METAL EXTERNAL 12/12/94 088 0510 0621
13910559 PONTIC-RESIN W/H-N METAL EXTERNAL 12/12/94 088 0510 0621
13910560 PONTIC-RESIN W/NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910581 RETAINER CAST METAL EXTERNAL 12/12/94 088 0510 0621
13910602 CROWN RESIN W/NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910605 CROWN-PORCEL FUSED H-N METAL EXTERNAL 12/12/94 088 0510 0621
13910606 CROWN-PORCEL FUSED NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910610 CROWN-FULL CAST NOBLE METAL EXTERNAL 12/12/94 088 0510 0621
13910631 RECEMENT BRIDGE EXTERNAL 12/12/94 088 0510 0621
13910632 STRESS BREAKER EXTERNAL 12/12/94 088 0510 0621
13910633 PRECISION ATTACHMENT EXTERNAL 12/12/94 088 0510 0621
13910635 CAST POST & CORE ADD BRIDGE EXTERNAL 12/12/94 088 0510 0621
13910636 PREFAB POST/CORE ADD BRIDGE EXTERNAL 12/12/94 088 0510 0621
13910637 CORE BUILD UP FOR RETAINER EXTERNAL 12/12/94 088 0510 0621
13910638 COPING-METAL EXTERNAL 12/12/94 088 0510 0621
13910639 BRIDGE REPAIR, BY REPORT EXTERNAL 12/12/94 088 0510 0621
13910701 OFFICE VISIT FOR OBSERVATION N/C 06/30/10 088 0510 0621
13910741 APPL OF DESENSIT MEDICAMENTS EXTERNAL 12/12/94 088 0510 0621
13910745 OCCLUSAL GUARD 1781.00 06/01/10 D9940 D9940 D9940 088 0510 0621
13910748 OCCLUSAL ANALYSIS-MOUNTED CASE EXTERNAL 12/12/94 088 0510 0621
13910749 OCCLUSAL ADJUSTMENT-LIMITED EXTERNAL 12/12/94 088 0510 0621
13910750 OCCLUSAL ADJUSTMENT-COMPLETE EXTERNAL 12/12/94 088 0510 0621
44059060 CISPLATIN, POWDR OR SOL /10MG EXTERNAL 07/01/02 J9060 J9060 J9060 089 0636 5011
07110009 OFFICE VISIT EST, LEVEL 1 100.00 06/30/10 99211 99211 99211 73.21 73.21 090 0510 0846
07110010 OFFICE VISIT EST, LEVEL 2 120.00 06/30/10 99212 99212 99212 73.21 73.21 090 0510 0846
07110011 OFFICE VISIT EST, LEVEL 3 155.00 06/30/10 99213 99213 99213 73.21 73.21 090 0510 0846
07110012 OFFICE VISIT EST, LEVEL 4 197.00 06/30/10 99214 99214 99214 73.21 73.21 090 0510 0846
07110013 OFFICE VISIT EST, LEVEL 5 225.00 06/30/10 99215 99215 99215 73.21 73.21 090 0510 0846
07110021 TRANSFUSION, BLOOD/BLD COMPON 98.00 06/30/10 99.07 99.07 090 0391 0846
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 454
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

07110078 THERAPEUTIC INJECTN OF RHOGAM 61.00 06/30/10 090 0250 0846
07110100 CHRONIC VILLUS SAMPL ANY METH 235.00 06/30/10 59015 59015 59015 090 0360 0846
07110103 FETAL BIOPHYS PRFILE W/NONSTRS 816.00 06/30/10 76818 76818 76818 090 0402 0846
07110106 FETAL CONTRACTION STRESS TEST 358.00 06/30/10 59020 59020 59020 090 0720 0846
07110109 FETAL MONIT-LBOR-CNSLT MD S&I 180.00 06/30/10 59050 59050 59050 090 0720 0846
07110112 FETAL NON-STRESS TEST 286.00 06/30/10 59025 59025 59025 090 0720 0846
07110115 FETL BIPHYS PROFIL W/O NST 812.00 06/30/10 76819 76819 76819 090 0402 0846
07110118 US PG UTERUS BSCAN W/IMG CMPL 207.00 06/30/10 76805 76805 76805 090 0402 0846
07110121 US PG UTRUS B-SCAN W/IMG LTD 591.00 06/30/10 76815 76815 76815 090 0402 0846
07110124 US PG UTRUS BSCAN; CMPL MX GST 1385.00 06/30/10 76810 76810 76810 090 0402 0846
07110127 US PG UTRUS B-SCAN F/U/REPT 370.00 06/30/10 76816 76816 76816 090 0402 0846
07122022 CATHETERIZATION URETHRA SIMPLE 101.00 06/30/10 51701 51701 51701 57.94 57.94 090 0360 0846
07122023 TREATMENT OF MISSED ABORTION 839.00 06/30/10 59820 59820 59820 69.02 090 0360 0846
07122025 GASTRIC INTUBATION 107.00 06/30/10 96.34 96.34 090 0750 0846
07122049 FETAL BIOPHYSICAL PROFILE 410.00 06/30/10 76818 76818 76818 88.79 090 0402 0847
07122062 AUTOMATIC BLOOD PRESSR MONITOR 92.00 06/30/10 93784 93784 93784 89.59 89.59 090 0730 0846
07122064 PLACEMNT CENT VEN CATH; >AGE 5 1128.00 06/30/10 36558 36558 36558 38.95 090 0360 0846
07122074 MEDICATIONS, P.O. 14.00 06/30/10 090 0250 0846
07122076 I-MED/I-MED CASSETTE 124.00 06/30/10 090 0270 0846
07122077 SUPPOSITORIES 11.00 06/30/10 090 0637 0846
07122091 CHICAGO FIRE DEPT SUPPLIES 131.00 06/30/10 090 0270 0846
07122092 HOT PACK 11.00 06/30/10 090 0270 0846
07122093 COLD PACK 14.00 06/30/10 090 0270 0846
07122094 STERI STRIPS 14.00 06/30/10 090 0270 0846
07110001 OFFICE VISIT NEW, LEVEL 1 100.00 06/30/10 99201 99201 99201 091 0510 0846
07110002 OFFICE VISIT NEW, LEVEL 2 120.00 06/30/10 99202 99202 99202 091 0510 0846
07110003 OFFICE VISIT NEW, LEVEL 3 155.00 06/30/10 99203 99203 99203 091 0510 0846
07110004 OFFICE VISIT NEW, LEVEL 4 197.00 06/30/10 99204 99204 99204 091 0510 0846
07110005 OFFICE VISIT NEW, LEVEL 5 225.00 06/30/10 99205 99205 99205 091 0510 0846
02180465 OFFICE VISIT, UP TO 10 MIN 100.00 06/30/10 99211 99211 99211 092 0510 2820
02180467 OFFICE VISIT, 11 TO 30 MIN 100.00 06/30/10 99211 99211 99211 092 0510 2820
02180469 OFFICE VISIT, OVER 30 MIN 100.00 06/30/10 99211 99211 99211 092 0510 2820
02180507 URETHRAL INTRACATHETER 155.00 06/30/10 36000 36000 36000 38.93 38.93 092 0360 2820
02180515 DIABETIC GLUCOSE MONITOR 48.00 06/30/10 82947 82947 82947 092 0301 2820
02180523 HYPERTENSION MONITOR 71.00 06/30/10 93799 93799 93799 89.59 092 0510 2820
02180529 THER/PROPH/DIAG IV INF,INIT HR 196.00 06/30/10 96365 96365 96365 092 0260 2820
02180530 IV HYDRA INFUSION EACH ADDL HR 181.00 06/30/10 96361 96361 96361 092 0260 2820
02180531 THER/PROPH/DIAG INJ,SC/IM 47.00 06/30/10 96372 96372 96372 092 0940 2820
02180598 ROUTINE VENIPUNCTURE 24.00 06/30/10 36415 36415 36415 38.93 38.93 092 0510 2820
02180606 DEBRIDEMENT SKIN PARTIAL THICK 164.00 06/30/10 11040 11040 11040 86.22 86.22 092 0360 2820
43010134 MOTOR EVKED POTENT-UPPER EXTRM 431.00 06/30/10 95928 95928 95928 092 0922 3701
43010137 MOTOR EVKED POTENT-LOWER EXTRM 467.00 06/30/10 9592926 9592926 9592926 092 0922 3701
03780821 OPTHAL NEW INTERMEDIATE-HOSP 79.00 06/30/10 92002 92002 92002 093 0510 4502
03780822 OPTHAL NEW COMPREHENSIVE-HOSP 90.00 06/30/10 92004 92004 92004 093 0510 4502
03780823 OPTHAL EST INTERMEDIATE-HOSP 65.00 06/30/10 92012 92012 92012 093 0510 4502
03780824 OPTHAL EST COMPREHENSIVE-HOSP 92.00 06/30/10 92014 92014 92014 093 0510 4502
03780831 EXAM OUTSIDE REG OFF HRS-HOSP 12.00 06/30/10 99050 99050 99050 093 0510 4502
03780834 OFFICE EMERGENCY-HOSP 15.00 06/30/10 99058 99058 99058 093 0510 4502
03780846 EXAMINATION UNDER ANESTHESIA 601.00 06/30/10 92018 92018 92018 093 0920 4502
03780847 CORNEAL TOPOGRAPHY-HOSP 39.00 06/30/10 92285 92285 92285 093 0920 4502
03780861 GONOISCOPY 118.00 06/30/10 92020 92020 92020 093 0920 4502
03780879 SPECULAR MICROSCOPY 68.00 06/30/10 92286 92286 92286 093 0920 4502
1 UI-HP011BC UIC MED CENTER 08/22/10 PAGE 455
CHARGE DESCRIPTION MASTER LIST PRINT 08/23/10 04:39
SEQUENCE: INS COV CODE
DEPARTMENT: ALL DEPARTMENTS

CDM UNIT PRO P/ EFFECT (BC1) (BC2) (BC3) (BC7) (BC8) INS REV
CODE STATEMENT/BILL DESCRIPTION PRICE FEE E DATE IDPA HCPCS CPT-4 IDPA ICD-9 COV UB92 DEPT

03781307 PERIMETRY-EXTENDED 184.00 06/30/10 92083 92083 92083 093 0920 4502
03781315 PERIMETRY-INTERMEDIATE 114.00 06/30/10 92082 92082 92082 093 0920 4502
03781316 PUNCTAL PLUG INSERT PER EYE 476.00 06/30/10 68761 68761 68761 093 0360 4502
03781317 PUNCTAL PLUG PER EYE 130.00 06/30/10 A4263 A4263 A4263 093 0274 4502
03784376 CONTRACT VISIT-NO CHARGE N/C 06/30/10 093 0510 4502
03785736 PRESCR/FIT CORNEOSCLERAL LENS 175.00 06/30/10 92313 92313 92313 093 0510 4502
03785746 FTTNG FEE/PER EYE/APHAKIA-HOSP 49.00 06/30/10 92311 92311 92311 093 0510 4502
03785754 COMPUTER CORNL TOPOGRPHY-HOSP 113.00 06/30/10 92025 92025 92025 093 0510 4502
03785761 FITTING FEE/P EYE-DIS-HOSP 63.00 06/30/10 92070 92070 92070 093 0510 4502
03785779 CONTACT LENS DISPENSING-HOSP 100.00 06/30/10 99211 99211 99211 093 0510 4502
03785787 CONTACT LENS MATERIALS EXTERNAL 01/01/01 V2512 V2512 V2512 093 0270 4502
03785795 BANDAGE CONTACT LENS-HOSP 40.00 06/30/10 92070 92070 92070 093 0510 4502
03785829 OCULAR PROSTHETICS EXTERNAL 01/01/01 093 0270 4502
03785835 ORTHOKERATOLOGY-HOSP 342.00 06/30/10 92499 92499 92499 093 0510 4502
03785838 LOW VISION AIDS EXTERNAL 01/01/01 093 0270 4502
03785850 CNTC LENS PMMA SPHERICAL EXTERNAL 04/01/08 V2500 V2500 V2500 093 0274 4502
03785852 CT LENS PMMA TORIC/PRISM EXTERNAL 04/01/08 V2501 V2501 V2501 093 0274 4502
03785854 CNTC LENS PMMA BIFOCAL EXTERNAL 04/01/08 V2502 V2502 V2502 093 0274 4502
03785856 CT LENS PMMA COLR VIS DEF EXTERNAL 04/01/08 V2503 V2503 V2503 093 0274 4502
03785858 CT LENS GAS PERM SPHER EXTERNAL 04/01/08 V2510 V2510 V2510 093 0274 4502
03785860 CT LENS GAS PER PRSM BLST EXTERNAL 04/01/08 V2511 V2511 V2511 093 0274 4502
03785862 CNTC LENS GAS PERM BIFOCL EXTERNAL 04/01/08 V2512 V2512 V2512 093 0274 4502
03785864 CT LENS GAS PERM EXT WEAR EXTERNAL 04/01/08 V2513 V2513 V2513 093 0274 4502
03785866 CNTC LENS HYDROPHIL SPHER EXTERNAL 04/01/08 V2520 V2520 V2520 093 0274 4502
03785868 CT LENS HYDRO/PRISM BLLST EXTERNAL 04/01/08 V2521 V2521 V2521 093 0274 4502
03785870 CNTC LENS HYDROP BIFOCAL EXTERNAL 04/01/08 V2522 V2522 V2522 093 0274 4502
03785872 CNTC LENS HYDRO EXT WEAR EXTERNAL 04/01/08 V2523 V2523 V2523 093 0274 4502
03785874 CT LENS SCLER GAS PERM EXTERNAL 04/01/08 V2530 V2530 V2530 093 0274 4502
03785876 CT LENS SCLERL GAS PERM EXTERNAL 04/01/08 V2531 V2531 V2531 093 0274 4502
03785878 CONTACT LENS OTHER TYPE EXTERNAL 04/01/08 V2599 V2599 V2599 093 0274 4502
93780821 OPTHAL NEW INTERMEDIATE-DR. 91.00 $ 06/30/09 92002 92002 92002 093 0983 4502
93780822 OPTHAL NEW COMPREHENSIVE-DR 189.00 $ 06/30/09 92004 92004 92004 093 0983 4502
93780823 OPTHAL EST INTERMEDIATE-DR 97.00 $ 06/30/09 92012 92012 92012 093 0983 4502
93780824 OPTHAL EST COMPREHENSIVE-DR 148.00 $ 06/30/09 92014 92014 92014 093 0983 4502
93780831 EXAM OUTSIDE REG OFF HRS-M.D. 18.00 $ 08/10/08 99050 99050 99050 093 0983 4502
93780832 EMERGENCY-11PM-8AM - DR 18.00 06/30/09 093 0982 4502
93780847 CORNEAL TOPOGRAPHY-DOCTOR 22.00 $ 06/30/09 92285 9228526 9228526 093 0983 4502
93785746 FITTING FEE,PER EYE,APHAKIA-DR 111.00 $ 06/30/09 92311 92311 92311 093 0983 4502
93785754 CMPUTER CRNEL TOPOGRPHY-M.D. 37.00 $ 06/30/09 92025 92025 92025 093 0983 4502
93785761 FITTING FEE PER EYE,DIS-DOCTOR 75.00 $ 06/30/09 92070 92070 92070 093 0983 4502
93785779 CONTACT LENS DISPENSING-DOCTOR 19.00 $ 06/30/09 99211 99211 99211 093 0983 4502
93785795 BANDAGE CONTACT LENS-DOCTOR 75.00 $ 06/30/09 92070 92070 92070 093 0983 4502
93785835 ORTHOKERATOLOGY-DOCTOR 1500.00 $ 08/10/08 92499 92499 92499 093 0983 4502