| Code | Description | Amount |
|---|---|---|
| 01411 | CRITICAL CARE (ICU) - 1ST DAY | $33,577.00 |
| 01412 | VENTILATORY SUPPORT (ICU) - 1ST DAY | $29,276.00 |
| 01413 | COMPREHENSIVE CARE (ICU) - 1ST DAY | $50,376.00 |
| 01421 | CRITICAL CARE (ICU) - 2ND TO 7TH DAY (INCL.) | $17,127.00 |
| 01422 | VENTILATORY SUPPORT (ICU) - 2ND TO 7TH DAY (INCL.) | $15,113.00 |
| 01423 | COMPREHENSIVE CARE (ICU) - 2ND TO 7TH DAY (INCL.) | $25,470.00 |
| 01431 | CRITICAL CARE (ICU) - 8TH TO 30TH DAY | $11,384.00 |
| 01432 | VENTILATORY SUPPORT (ICU) - 8TH TO 30TH DAY | $11,888.00 |
| 01433 | COMPREHENSIVE CARE (ICU) - 8TH TO 30TH DAY | $14,105.00 |
| 01441 | CRITICAL CARE (ICU) - 31ST DAY ONWARD | $5,334.00 |
| 01442 | VENTILATORY SUPPORT (ICU) - 31ST DAY ONWARD | $7,049.00 |
| 01443 | COMPREHENSIVE CARE (ICU) - 31ST DAY ONWARD | $8,060.00 |
| 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 |