| Code | Description | Amount |
|---|---|---|
| 01411 | CRITICAL CARE (ICU) - 1ST DAY | $340.05 |
| 01412 | VENTILATORY SUPPORT (ICU) - 1ST DAY | $294.96 |
| 01413 | COMPREHENSIVE CARE (ICU) - 1ST DAY | $507.54 |
| 01421 | CRITICAL CARE (ICU) - 2ND TO 7TH DAY (INCL.) | $172.55 |
| 01422 | VENTILATORY SUPPORT (ICU) - 2ND TO 7TH DAY (INCL.) | $152.26 |
| 01423 | COMPREHENSIVE CARE (ICU) - 2ND TO 7TH DAY (INCL.) | $256.61 |
| 01431 | CRITICAL CARE (ICU) - 8TH TO 30TH DAY | $117.75 |
| 01432 | VENTILATORY SUPPORT (ICU) - 8TH TO 30TH DAY | $123.38 |
| 01433 | COMPREHENSIVE CARE (ICU) - 8TH TO 30TH DAY | $142.11 |
| 01441 | CRITICAL CARE (ICU) - 31ST DAY ONWARD | $135.47 |
| 01442 | VENTILATORY SUPPORT (ICU) - 31ST DAY ONWARD | $110.89 |
| 01443 | COMPREHENSIVE CARE (ICU) - 31ST DAY ONWARD | $147.80 |
| Code | Description | Amount |
|---|---|---|
| 01511 | NEONATAL ICU - LEVEL A - DAY 1 | $633.46 |
| 01512 | NEONATAL ICU - LEVEL B - DAY 1 | $464.58 |
| 01513 | NEONATAL ICU - LEVEL C - DAY 1 | $401.20 |
| 01521 | NEONATAL ICU - LEVEL A - DAY 2 - 10 | $253.36 |
| 01522 | NEONATAL ICU - LEVEL B - DAY 2 - 10 | $168.95 |
| 01523 | NEONATAL ICU - LEVEL C - DAY 2 - 10 | $123.99 |
| 01531 | NEONATAL ICU - LEVEL A - DAY 11 ONWARD | $168.95 |
| 01532 | NEONATAL ICU - LEVEL B - DAY 11 ONWARD | $125.53 |
| 01533 | NEONATAL ICU - LEVEL C - DAY 11 ONWARD | $99.47 |