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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