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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