| Code | Description | Amount |
|---|---|---|
| 01411 | CRITICAL CARE (ICU) - 1ST DAY | $335.77 |
| 01412 | VENTILATORY SUPPORT (ICU) - 1ST DAY | $292.76 |
| 01413 | COMPREHENSIVE CARE (ICU) - 1ST DAY | $503.76 |
| 01421 | CRITICAL CARE (ICU) - 2ND TO 7TH DAY (INCL.) | $171.27 |
| 01422 | VENTILATORY SUPPORT (ICU) - 2ND TO 7TH DAY (INCL.) | $151.13 |
| 01423 | COMPREHENSIVE CARE (ICU) - 2ND TO 7TH DAY (INCL.) | $254.70 |
| 01431 | CRITICAL CARE (ICU) - 8TH TO 30TH DAY | $113.84 |
| 01432 | VENTILATORY SUPPORT (ICU) - 8TH TO 30TH DAY | $118.88 |
| 01433 | COMPREHENSIVE CARE (ICU) - 8TH TO 30TH DAY | $141.05 |
| 01441 | CRITICAL CARE (ICU) - 31ST DAY ONWARD | $53.34 |
| 01442 | VENTILATORY SUPPORT (ICU) - 31ST DAY ONWARD | $70.49 |
| 01443 | COMPREHENSIVE CARE (ICU) - 31ST DAY ONWARD | $80.60 |
| Code | Description | Amount |
|---|---|---|
| 01511 | NEONATAL ICU - LEVEL A - DAY 1 | $628.74 |
| 01512 | NEONATAL ICU - LEVEL B - DAY 1 | $461.12 |
| 01513 | NEONATAL ICU - LEVEL C - DAY 1 | $398.21 |
| 01521 | NEONATAL ICU - LEVEL A - DAY 2 - 10 | $251.47 |
| 01522 | NEONATAL ICU - LEVEL B - DAY 2 - 10 | $167.69 |
| 01523 | NEONATAL ICU - LEVEL C - DAY 2 - 10 | $123.07 |
| 01531 | NEONATAL ICU - LEVEL A - DAY 11 ONWARD | $167.69 |
| 01532 | NEONATAL ICU - LEVEL B - DAY 11 ONWARD | $124.60 |
| 01533 | NEONATAL ICU - LEVEL C - DAY 11 ONWARD | $98.73 |