Usual and Customary Charges for Select Services*

Pricing: 2011

DESCRIPTION	CPT	CHARGE EFFECTIVE 01/02/11
EMERGENCY ROOM
EMERG. DEPT VISIT - LEVEL 1	99281	$178.71
EMERG. DEPT VISIT - LEVEL 2	99282	$366.88
EMERG. DEPT VISIT - LEVEL 3	99283	$777.45
EMERG. DEPT VISIT - LEVEL 4	99284	$879.09
EMERG. DEPT VISIT - LEVEL 5	99285	$1,250.13
LABORATORY
BASIC METABOLIC PANEL	80048	$44.79
BUN - VENOUS SAMPLE	84520	$29.68
CBC PLATELET AUTO DIFF	85025	$49.13
CK MB (CREATINE KINASE MB FRACTION)	82553	$109.00
COMP METABOLIC PANEL	80053	$67.74
CREATINE KINASE (CK)	82550	$44.04
CREATININE BLD	82565	$44.11
CULTURE BLOOD	87040	$120.01
CULTURE URINE W CC	87086	$60.43
CYTO PAP TLP MAN SCR	88142	$102.05
HEMATOCRIT	85014	$15.99
HEMOGLOBIN	85018	$15.99
HEMOGLOBIN  A1C GLYCOHGB	83036	$75.00
CBC AUTO	85027	$43.71
HEPATIC PANEL	80076	$44.91
LIPID PANEL	80061	$95.25
LYTES PANEL	80051	$35.73
MAGNESIUM BLD	83735	$45.46
MYOGLOBIN BLD	83874	$86.97
PROTIME (PROTHROMBIN TIME)	85610	$29.48
PROSTATE SPECIFIC ANTIGEN(PSA)	84153	$98.25
PTT (PARTIAL THROMBOPLASTIN TIME)	85730	$44.91
SEDIMENTATION RATE MANUAL	85651	$30.95
SENSITIVITY MICRO	87186	$90.72
SURGICAL PATHOLOGY LEVEL 4	88305	$413.64
TROPONIN QUANT	84484	$66.41
TSH  (THYROID STIMULATING HORMONE)	84443	$91.24
URINALYSIS WITH MICRO AUTO	81001	$28.07
URINALYSIS WITHOUT MICRO AUTO	81003	$23.87
VENIPUNCTURE	36415	$14.76
PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY
BLOOD GASES	82803	$171.77
INHALATION TREATMENT-ACUTE OBSTRUCTION	94640	$77.31
OCCUPATIONAL THERAPY EVALUATION	97003	$169.19
OCCUPATIONAL MANUAL THERAPY 15 MINUTES	97140	$111.00
PHYSICAL THERAPY EVALUATION	97001	$169.19
THERAPEUTIC EXERCISE 15 MIN	97110	$108.42
PT GAIT TRAINING 15 MINUTES	97116	$88.23
ROOM & BOARD CHARGES
LABOR/DEL/REC		$2,719.07
R & B MEDICAL SURGICAL		$1,250.00
R & B MED/SURG ORTHO		$1,250.00
R & B INTERM ICU - IMCU (STEPDOWN)		$1,950.00
R & B M S TELE 3NO		$1,600.00
R & B SURGICAL INTENSIVE CARE		$2,700.00
R & B MEDICAL INTENSIVE CARE		$2,700.00
OPERATING ROOM
OR 1 1ST 30 MINS		$1,650.59
OR 1 ADDL 15		$500.18
OR 2 1ST 30 MINS		$2,400.69
OR 2 ADDL 15		$700.28
OR 3 1ST 30 MINS		$3,000.84
OR 3 ADDL 15		$700.28
OR 4 1ST 30 MINS		$4,055.21
OR 4 ADDL 15		$892.23
POST-OP 1 0-30 MINS		$307.95
POST-OP 1 ADDL 15		$100.13
POST-OP 2 0-30 MINS		$523.47
POST-OP 2 ADDL 15		$130.92
POST-OP 3 0-30 MINS		$645.62
POST-OP 3 ADDL 15		$142.47
RADIOLOGY
ABDOMEN 3 VIEWS	74020	$300.65
ABDOMEN W CON	74160	$2,080.09
ANKLE COMP. MINIMUM 3 VWS.	73610	$353.89
BONE DENSITY STUDY	77080	$350.90
BRAIN WITH & WITHOUT CONTRAST	70553	$4,874.59
CAD W/ SCRN MAMMO	70552	$45.76
CERVICAL SP AP & LAT OR 2 VIEWS	72040	$370.55
CERVICAL SPINE W OBLIQUES	72050	$529.15
CHEST 1 VIEW - FRONTAL	71010	$210.54
CHEST PA/AP & LATERAL	71020	$248.42
COMPLETE ABDOMINAL SERIES WITH CHEST	74022	$681.15
ELBOW MINIMUM 3 VIEWS	73080	$342.48
FINGER(S) LT	73140	$231.30
FINGER(S) RT	73140	$231.30
FOOT  MINIMUM 3 VIEWS	73630	$353.89
HAND COMPLETE UNILATERAL	73130	$308.79
HEAD/BRAIN W & WO CON	70470	$1,601.47
HEAD/BRAIN WO CON	70450	$1,225.32
HIP COMPLETE UNILATERAL	73510	$356.51
KNEE COMPLETE (4+ VIEW) UNILATERAL	73564	$462.96
LUMBAR SPINE 1 VIEW	72020	$275.03
LUMBAR SPINE 3 VIEWS	72100	$422.46
LUMBAR SPINE W OBLIQUES	72110	$644.23
MODIFIED BARIUM SWALLOW	74230	$313.78
PELVIS WITH CONTRAST	72193	$1,069.51
SHOULDER UNILATERAL	73030	$359.32
SINUSES/FACIAL WITHOUT CONTRAST	70486	$1,584.28
THORACIC SPINE 3 VIEWS	72072	$505.56
THORAX WITH CONTRAST	71260	$2,054.81
WRIST MINIMUM 3  VIEWS	73110	$353.89

* 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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