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Usual and Customary Charges for Select Services*

Pricing: 2008


CPT Code Procedure Name Cost
  EMERGENCY ROOM SERVICES  
99281 Emergency Dept Visit - Level 1 $143.27
99282 Emergency Dept Visit - Level 2 $294.11
99283 Emergency Dept Visit - Level 3 $623.26
99294 Emergency Dept Visit - Level 4 $704.73
99285 Emergency Dept Visit - Level 5 $1,002.19
  LABORATORY PROCEDURES  
80048 BASIC METABOLIC PANEL $35.90
84520 BUN - VENOUS SAMPLE (UREA NITROGEN) $23.79
85025 CBC PLATELET AUTO DIFF $39.38
82553 CK MB (CREATINE KINASE MB FRACTION) $87.38
80053 COMP METABOLIC PANEL $54.30
82550 CREATINE KINASE (CK) $35.30
82565 CREATININE BLD $35.36
87040 CULTURE BLOOD $96.21
87086 CULTURE URINE W CC $48.44
G0123 CYTO PAP TLP MAN SCR $81.81
85014 HEMATOCRIT $12.82
85018 HEMOGLOBIN $12.82
83036 HEMOGLOBIN AIC GLYCOHGB $60.12
85027 CBC AUTO $35.04
80076 HEPATIC PANEL $36.00
80061 LIPID PANEL $76.35
80051 ELECTROLYTES PANEL $28.64
83735 MAGNESIUM BLD $36.44
83874 MYOGLOBIN BLD $69.72
84153 PROS SPEC AG (PSA) $78.76
85610 PROTIME (PROTHROMBIN TIME) $23.64
85730 PTT (PARTIAL THROMBOPLASTIN TIME) $36.00
85651 SEDIMENTATION RATE MANUAL $24.81
87186 SENSITIVITY MICRO $41.78
88305 SURGICAL PATHOLOGY LEVEL 4 $331.60
84484 TROPONIN QUANT $53.24
84443 TSH (THYROID STIMULATING HORMONE) $73.14
81001 URINALYSIS WITH MICRO AUTO $22.50
81003 URINALYSIS WITHOUT MICRO AUTO $19.13
36415 VENIPUNCTURE $11.84
  PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY
82803 GASES, BLOOD $137.70
94640 INHALATION TX-ACUTE OBSTRUCTION $61.97
97003 OCCUPATIONAL THERAPY EVALUATION $135.64
97140 OT MANUAL THERAPY - 15 MIN $88.99
97001 PHYSICAL THERAPY EVALUATION $135.64
97110 PT THERAPEUTIC EXERCISE - 15 MIN $86.91
97116 PT GAIT TRAINING 15 MIN $70.72
  ROOM & BOARD CHARGES  
  LABOR/DEL/REC $2,179.79
  OB/GYN - 2OB $772.19
  Medical/Surgical Semi-Private - 5B $772.19
  Surgical ICU $1,709.85
  Medical ICU $1,709.85
  OPERATING ROOM  
  OR Level 1 - 1st 30 MIN $1,323.22
  OR Level 1 - EA ADDITIONAL 15 MIN $400.98
  OR Level 2 - 1st 30 MIN $1,924.55
  OR Level 2 - EA ADDITIONAL 15 MIN $561.39
  OR Level 3 - 1st 30 MIN $2,405.68
  OR Level 3 - EA ADDITIONAL 15 MIN $561.39
  OR Level 4 - 1st 30 MIN $3,250.92
  OR Level 4 - EA ADDITIONAL 15 MIN $715.28
  POST OP Level 1 - 00-30 MIN $246.88
  POST OP Level 1 - ADDITIONAL 15 MIN $80.27
  POST OP Level 2 - 00-30 MIN $419.65
  POST OP Level 2 - ADDITIONAL 15 MIN $104.95
  POST OP Level 3 - 00-30 MIN $517.57
  POST OP Level 3 - ADDITIONAL 15 MIN $114.22
  RADIOLOGY  
74020 ABDOMEN 3 VIEWS $241.02
74160 ABDOMEN W CON $1,667.54
73610 ANKLE COMP MIN 3 VIEWS $283.70
77080 BONE DENSITY STUDY $281.30
70553 BRAIN WITH & WITHOUT CONTRAST $3,907.80
72040 CERVICAL SP AP & LAT OR 2 VWS; $297.06
72050 CERVICAL SPINE W/OBLIQUES $424.20
71010 CHEST 1 VIEW - FRONTAL $168.78
71020 CHEST PA/AP & LATERAL $199.15
74022 COMPLETE ABD SERIES W/ 1VW CHEST $546.05
73080 ELBOW MINIMUM 3 VIEWS $274.55
73140 FINGER(S) UNILATERAL $185.43
73630 FOOT COMP. MINIMUM 3 VWS $283.70
73130 HAND COMPLETE (unilateral) $247.55
70470 HEAD/BRAIN W & WO CON $1,283.85
70450 HEAD/BRAIN WO CONTRAST $982.30
73510 HIP COMPLETE (unilateral) $285.80
73564 KNEE COMPLETE (4+VIEW) $371.14
72020 LUMBAR SPINE 1 VIEW $220.49
72100 LUMBAR SPINE 3 VIEWS $338.68
72110 LUMBAR SPINE W/OBLIQUES $516.46
77056 MAMMOGRAPHY BILAT (DX) $230.56
77057 MAMMOGRAPHY SCREENING $133.02
74230 MODIFIED BARIUM SWALLOW $251.55
72193 PELVIS W/ CONTRAST $857.39
73030 SHOULDER (unilateral) $288.05
70486 SINUSES/FACIAL W/O CONTRAST $1,270.07
72072 THORACIC SPINE 3 VIEWS $405.29
71260 THORAX WITH CONTRAST $1,647.28
73110 WRIST MINIMUM 3 VWS. $283.70

* 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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