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Usual and Customary Charges for Select Services*

Pricing: 2012


DESCRIPTION CPT CHARGE EFFECTIVE 01/02/12
EMERGENCY ROOM
EMERG. DEPT VISIT - LEVEL 1    99281 $193.01
EMERG. DEPT VISIT - LEVEL 2    99282 $396.23
EMERG. DEPT VISIT - LEVEL 3    99283 $839.65
EMERG. DEPT VISIT - LEVEL 4    99284 $949.42
EMERG. DEPT VISIT - LEVEL 5    99285 $1,350.14
LABORATORY 
BASIC METABOLIC PANEL          80048 $73.16
BUN - VENOUS SAMPLE            84520 $32.05
CBC PLATELET AUTO DIFF         85025 $53.06
CK MB (CREATINE KINASE MB FRACTION)                         82553 $117.72
COMP METABOLIC PANEL           80053 $67.74
CREATINE KINASE (CK)           82550 $47.64
CREATININE BLD                 82565 $44.11
CULTURE BLOOD                  87040 $129.61
CULTURE URINE W CC             87086 $65.26
CYTO PAP TLP MAN SCR           88142 $110.21
HEMATOCRIT                     85014 $17.27
HEMOGLOBIN                     85018 $17.27
HEMOGLOBIN  A1C GLYCOHGB                 83036 $75.00
CBC AUTO                       85027 $47.21
HEPATIC PANEL                  80076 $44.91
LIPID PANEL                    80061 $102.87
LYTES PANEL                    80051 $38.59
MAGNESIUM BLD                  83735 $49.10
MYOGLOBIN BLD                  83874 $93.93
PROTIME (PROTHROMBIN TIME)                    85610 $31.84
PROSTATE SPECIFIC ANTIGEN(PSA) 84153 $98.25
PTT (PARTIAL THROMBOPLASTIN TIME)                          85730 $48.50
SEDIMENTATION RATE MANUAL                85651 $33.43
SENSITIVITY MICRO               87186 $97.98
SURGICAL PATHOLOGY LEVEL 4              88305 $446.73
TROPONIN QUANT                 84484 $71.72
TSH  (THYROID STIMULATING HORMONE)                         84443 $98.54
URINALYSIS WITH MICRO AUTO                81001 $30.32
URINALYSIS WITHOUT MICRO AUTO              81003 $25.78
VENIPUNCTURE                   36415 $15.94
PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY
BLOOD GASES                    82803 $185.51
INHALATION TREATMENT-ACUTE OBSTRUCTION 94640 $83.49
OCCUPATIONAL THERAPY EVALUATION                  97003 $182.73
OCCUPATIONAL MANUAL THERAPY 15 MINUTES                97140 $119.88
PHYSICAL THERAPY EVALUATION                  97001 $182.73
THERAPEUTIC EXERCISE 15 MIN 97110 $117.09
PT GAIT TRAINING 15 MINUTES 97116 $95.29
ROOM & BOARD CHARGES
LABOR/DEL/REC                         $2,936.60
R & B MEDICAL SURGICAL        $1,350
R & B MED/SURG ORTHO        $1,350
R & B INTERM ICU - IMCU (STEPDOWN)        $2,106
R & B M S TELE 3NO          $1,728
R & B SURGICAL INTENSIVE CARE         $2,700.00
R & B MEDICAL INTENSIVE CARE        $2,916
OPERATING ROOM
OR 1 1ST 30 MINS                     $1,782.64
OR 1 ADDL 15                         $540.19
OR 2 1ST 30 MINS                     $2,592.75
OR 2 ADDL 15                         $756.30
OR 3 1ST 30 MINS                     $3,240.91
OR 3 ADDL 15                         $756.30
OR 4 1ST 30 MINS                     $4,379.63
OR 4 ADDL 15                         $963.61
POST-OP 1 0-30 MINS                  $332.59
POST-OP 1 ADDL 15                    $108.14
POST-OP 2 0-30 MINS                  $565.30
POST-OP 2 ADDL 15                    $141.39
POST-OP 3 0-30 MINS                  $697.27
POST-OP 3 ADDL 15                    $153.87
RADIOLOGY
ABDOMEN 3 VIEWS                74020 $324.70
ABDOMEN W CON                  74160 $2246.50
ANKLE COMP. MINIMUM 3 VWS.  73610 $382.20
BONE DENSITY STUDY             77080 $378.97
BRAIN WITH & WITHOUT CONTRAST 70553 $5,264.56
CAD W/ SCRN MAMMO 70552 $49.42
CERVICAL SP AP & LAT OR 2 VIEWS 72040 $400.19
CERVICAL SPINE W OBLIQUES      72050 $571.48
CHEST 1 VIEW - FRONTAL         71010 $227.38
CHEST PA/AP & LATERAL          71020 $268.29
COMPLETE ABDOMINAL SERIES WITH CHEST 74022 $735.64
DX MAMMO DIRECT UNI ALL 77055 $306.12
DX DIAG W SCR SAME DAY BI 77056 $391.63
ELBOW MINIMUM 3 VIEWS 73080 $369.88
FINGER(S) 73140 $249.80
FOOT  MINIMUM 3 VIEWS 73630 $382.20
HAND COMPLETE UNILATERAL 73130 $333.49
HEAD/BRAIN W & WO CON          70470 $1,323.35
HEAD/BRAIN WO CON              70450 $1,729.59
HIP COMPLETE UNILATERAL 73510 $385.03
KNEE COMPLETE (4+ VIEW) UNILATERAL 73564 $500.00
LUMBAR SPINE 1 VIEW 72020 $297.03
LUMBAR SPINE 3 VIEWS           72100 $546.00
LUMBAR SPINE W OBLIQUES        72110 $695.77
MODIFIED BARIUM SWALLOW 74230 $338.88
PELVIS WITH CONTRAST 72193 $1,155.07
SHOULDER UNILATERAL 73030 $388.07
SINUSES/FACIAL WITHOUT CONTRAST 70486 $1,711.02
THORACIC SPINE 3 VIEWS 72072 $505.56
THORAX WITH CONTRAST 71260 $2,219.19
WRIST MINIMUM 3  VIEWS 73110 $382.20

* 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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