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Usual and Customary Charges for Select Services*

Pricing: 2010


DESCRIPTION CPT CHARGE EFFECTIVE 01/02/10
EMERGENCY ROOM
EMERG. DEPT VISIT - LEVEL 1    99281 $165.47
EMERG. DEPT VISIT - LEVEL 2    99282 $339.70
EMERG. DEPT VISIT - LEVEL 3    99283 $719.86
EMERG. DEPT VISIT - LEVEL 4    99284 $813.97
EMERG. DEPT VISIT - LEVEL 5    99285 $1,167.53
LABORATORY 
BASIC METABOLIC PANEL          80048 $41.47
BUN - VENOUS SAMPLE            84520 $27.48
CBC PLATELET AUTO DIFF         85025 $45.49
CK MB (CREATINE KINASE MB FRACTION)                         82553 $100.93
COMP METABOLIC PANEL           80053 $62.72
CREATINE KINASE (CK)           82550 $40.78
CREATININE BLD                 82565 $40.84
CULTURE BLOOD                  87040 $111.12
CULTURE URINE W CC             87086 $55.95
CYTO PAP TLP MAN SCR           88142 $94.49
HEMATOCRIT                     85014 $14.81
HEMOGLOBIN                     85018 $14.81
HEMOGLOBIN  A1C GLYCOHGB                 83036 $69.44
CBC AUTO                       85027 $40.47
HEPATIC PANEL                  80076 $41.58
LIPID PANEL                    80061 $88.19
LYTES PANEL                    80051 $33.08
MAGNESIUM BLD                  83735 $42.09
MYOGLOBIN BLD                  83874 $80.53
PROTIME (PROTHROMBIN TIME)                    85610 $27.30
PROSTATE SPECIFIC ANTIGEN(PSA) 84153 $90.97
PTT (PARTIAL THROMBOPLASTIN TIME)                          85730 $41.58
SEDIMENTATION RATE MANUAL                85651 $28.66
SENSITIVITY MICRO               87186 $48.26
SURGICAL PATHOLOGY LEVEL 4              88305 $383.00
TROPONIN QUANT                 84484 $61.49
TSH  (THYROID STIMULATING HORMONE)                         84443 $84.48
URINALYSIS WITH MICRO AUTO                81001 $25.99
URINALYSIS WITHOUT MICRO AUTO              81003 $22.10
VENIPUNCTURE                   36415 $13.67
PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY
BLOOD GASES                    82803 $159.05
INHALATION TREATMENT-ACUTE OBSTRUCTION 94640 $71.58
OCCUPATIONAL THERAPY EVALUATION                  97003 $156.66
OCCUPATIONAL MANUAL THERAPY 15 MINUTES                97140 $102.78
PHYSICAL THERAPY EVALUATION                  97001 $156.66
THERAPEUTIC EXERCISE 15 MIN 97110 $100.39
PT GAIT TRAINING 15 MINUTES 97116 $81.69
ROOM & BOARD CHARGES
LABOR/DEL/REC                         $2,517.66
R & B MED/SURG/GYN        $891.88
R & B SEMIPVT-MED/SURG         $891.88
R & B SURGICAL INTENSIVE CARE         $1,974.87
R & B MEDICAL INTENSIVE CARE        $1,974.87
OPERATING ROOM
OR 1 1ST 30 MINS                     $1,528.32
OR 1 ADDL 15                         $463.13
OR 2 1ST 30 MINS                     $2,222.86
OR 2 ADDL 15                         $648.41
OR 3 1ST 30 MINS                     $2,778.56
OR 3 ADDL 15                         $648.41
OR 4 1ST 30 MINS                     $3,754.82
OR 4 ADDL 15                         $826.14
POST-OP 1 0-30 MINS                  $285.14
POST-OP 1 ADDL 15                    $92.71
POST-OP 2 0-30 MINS                  $484.69
POST-OP 2 ADDL 15                    $121.22
POST-OP 3 0-30 MINS                  $597.80
POST-OP 3 ADDL 15                    $131.92
RADIOLOGY
ABDOMEN 3 VIEWS                74020 $278.38
ABDOMEN W CON                  74160 $1,926.01
ANKLE COMP. MINIMUM 3 VWS.  73610 $327.68
BONE DENSITY STUDY             77080 $324.91
BRAIN WITH & WITHOUT CONTRAST 70553 $4,513.51
CERVICAL SP AP & LAT OR 2 VIEWS 72040 $343.10
CERVICAL SPINE W OBLIQUES      72050 $489.95
CHEST 1 VIEW - FRONTAL         71010 $194.94
CHEST PA/AP & LATERAL          71020 $230.02
COMPLETE ABDOMINAL SERIES WITH CHEST 74022 $630.69
ELBOW MINIMUM 3 VIEWS 73080 $317.11
FINGER(S) LT 73140 $214.17
FINGER(S) RT 73140 $214.17
FOOT  MINIMUM 3 VIEWS 73630 $327.68
HAND COMPLETE UNILATERAL 73130 $285.92
HEAD/BRAIN W & WO CON          70470 $1,482.84
HEAD/BRAIN WO CON              70450 $1,134.56
HIP COMPLETE UNILATERAL 73510 $330.10
KNEE COMPLETE (4+ VIEW) UNILATERAL 73564 $428.67
LUMBAR SPINE 1 VIEW 72020 $254.66
LUMBAR SPINE 3 VIEWS           72100 $391.17
LUMBAR SPINE W OBLIQUES        72110 $596.51
MAMMOGRAPHY BILAT (DX) 77056 $266.30
MAMMOGRAPHY SCREENING 77057 $153.64
MODIFIED BARIUM SWALLOW 74230 $290.54
PELVIS WITH CONTRAST 72193 $990.29
SHOULDER UNILATERAL 73030 $332.70
SINUSES/FACIAL WITHOUT CONTRAST 70486 $1,466.93
THORACIC SPINE 3 VIEWS 72072 $468.11
THORAX WITH CONTRAST 71260 $1,902.60
WRIST MINIMUM 3  VIEWS 73110 $327.68

* In accordance with Ohio Revised Code, Section 3727.42
Professional fees are not billed by the hospital and are not included in these charges. Prices/charges may be updated at any time without notice. The patient/guarantor may be responsible for any amount different than those prices listed here.

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