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Usual and Customary Charges for Select Services*

Pricing: 2014


MNEMONIC DESCRIPTION MC HCPCS CPT CHARGE EFFECTIVE JAN 2014
EMERGENCY ROOM
EDMV090001 EMERG. DEPT VISIT - LEVEL 1    99281 99281 $221.00
EDMV090002 EMERG. DEPT VISIT - LEVEL 2    99282 99282 $454.00
EDMV090003 EMERG. DEPT VISIT - LEVEL 3    99283 99283 $962.00
EDMV090004 EMERG. DEPT VISIT - LEVEL 4    99284 99284 $1,087.00
EDMV090005 EMERG. DEPT VISIT - LEVEL 5    99285 99285 $1,546.00
LABORATORY
LAB0957230 BASIC METABOLIC PANEL 80048 80048 $55.12
LAB0950457 BUN - VENOUS SAMPLE 84520 84520 $37.10
LAB0951013 CBC AUTO 85027 85027 $54.06
LAB0951012 CBC PLATELET AUTO DIFF 85025 85025 $60.42
LAB0950205 CK MB (CREATINE KINASE MB FRACTION) 82553 82553 $134.62
LAB0957231 COMP METABOLIC PANEL 80053 80053 $83.74
LAB0950203 CREATINE KINASE (CK) 82550 82550 $54.06
LAB0950207 CREATININE BLD 82565 82565 $54.06
LAB0954003 CULTURE BLOOD 87040 87040 $148.40
LAB0954018 CULTURE URINE W CC 87086 87086 $74.20
LAB0957206 CYTO PAP TLP MAN SCR  G0123 88142 $126.14
LAB0951006 HEMATOCRIT 85014 85014 $20.14
LAB0951007 HEMOGLOBIN 85018 85018 $20.14
LAB0950291 HEMOGLOBIN A1C GLYCOHGB 83036 83036 $92.22
LAB0957232 HEPATIC PANEL 80076 80076 $55.12
LAB0950006 LIPID PANEL 80061 80061 $117.66
LAB0950002 LYTES PANEL 80051 80051 $44.52
LAB0950336 MAGNESIUM BLD 83735 83735 $56.18
LAB0950348 MYOGLOBIN BLD                  83874 83874 $107.06
LAB0950402 PROSTATE SPECIFIC ANTIGEN(PSA) G0103 84153 $121.90
LAB0951083 PROTIME (PROTHROMBIN TIME) 85610 85610 $36.04
LAB0951093 PTT (PARTIAL THROMBOPLASTIN TIME) 85730 85730 $55.12
LAB0951088 SEDIMENTATION RATE MANUAL 85651 85651 $38.16
LAB0954040 SENSITIVITY MICRO 87186 87186 $112.36
LAB0956003 SURGICAL PATHOLOGY LEVEL 4 88305 88305 $510.92
LAB0950456 TROPONIN QUANT 84484 84484 $81.62
LAB0950445 TSH(THYROID STIMULATING HORMONE) 84443 84443 $112.36
LAB0950102 URINALYSIS WITH MICRO AUTO 81001 81001 $34.98
LAB0950104 URINALYSIS WITHOUT MICRO AUTO 81003 81003 $29.68
LAB0957019 VENIPUNCTURE 36415 36415 $18.00
PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY
RTG0520120 BLOOD GASES 82803 82803 $212.00
RTG0520122 INHALATION TREATMENT-ACUTE OBSTRUCTION 94640 94640 $96.00
ROT0640020 OCCUPATIONAL THERAPY EVALUATION 97003 97003 $214.00
ROT0640016 OCCUPATIONAL MANUAL THERAPY 15 MINUTES 97140 97140 $137.00
RPT0660046 PHYSICAL THERAPY EVALUATION 97001 97001 $214.00
RPT0660056 THERAPEUTIC EXERCISE 15 MIN 97110 97110 $134.00
RPT0660054 PT GAIT TRAINING 15 MINUTES 97116 97116 $109.00
ROOM & BOARD CHARGES
LD00260059 LABOR/DEL/REC     $3,114.00
RMB0990108 R & B MEDICAL SURGICAL     $1,546.00
RMB0990201 R & B MED/SURG  ORTHO     $1,546.00
RMB0990208 R&B INTERM ICU - IMCU (STEPDOWN)     $2,411.00
RMB0990129 R & B M S TELE 3NO     $1,978.00
RMB0990147 R & B SURGICAL ICU     $3,338.00
RMB0990148 R & B MEDICAL ICU     $3,338.00
OPERATING ROOM
ORI0780005 OR 1 1ST 30 MINS     $2,041.00
ORI0780000 OR 1 ADDL 15     $618.00
ORI0780001 OR 2 1ST 30 MINS     $2,968.00
ORI0780002 OR 2 ADDL 15     $867.00
ORI0780003 OR 3 1ST 30 MINS     $3,710.00
ORI0780004 OR 3 ADDL 15     $867.00
ORI0780006 OR 4 1ST 30 MINS     $5,014.00
ORI0780007 OR 4 ADDL 15     $1,104.00
         
PAC0250020 POST-OP 1 0-30 MINS     $381.00
PAC0250021 POST-OP 1 ADDL 15     $124.00
PAC0250022 POST-OP 2 0-30 MINS     $648.00
PAC0250023 POST-OP 2 ADDL 15     $163.00
PAC0250005 POST-OP 3 0-30 MINS     $799.00
PAC0250019 POST-OP 3 ADDL 15     $176.00
RADIOLOGY
RDC0720002 HEAD/BRAIN WO CON 70450 70450 $1,556.00
RDC0720003 HEAD/BRAIN W & WO CON 70470 70470 $1,981.00
RDC0720026 SINUSES/FACIAL WITHOUT CONTRAST 70486 70486 $1,959.00
RDM0740022 BRAIN WITH & WITHOUT CONTRAST 70553 70553 $5,581.00
RDD0690029 CHEST 1 VIEW - FRONTAL 71010 71010 $261.00
RDD0690030 CHEST PA/AP & LATERAL 71020 71020 $308.00
RDC0720012 THORAX WITH CONTRAST 71260 71260 $2,541.00
RDD0690199 LUMBAR SPINE 1 VIEW 72020 72020 $341.00
RDD0690042 CERVICAL SP AP & LAT OR 2 VIEWS 72040 72040 $458.00
RDD0690043 CERVICAL SPINE W OBLIQUES 72050 72050 $655.00
RDD0690388 THORACIC SPINE 3 VIEWS 72072 72072 $626.00
RDD0690047 LUMBAR SPINE 3 VIEWS 72100 72100 $523.00
RDD0690048 LUMBAR SPINE W OBLIQUES 72110 72110 $797.00
RDC0720018 PELVIS WITH CONTRAST 72193 72193 $1,322.00
RDD0692063 SHOULDER UNILATERAL 73030 73030 $445.00
RDD0692067 ELBOW MINIMUM 3 VIEWS 73080 73080 $424.00
RDD0692070 WRIST MINIMUM 3 VIEWS 73110 73110 $438.00
RDD0692072 HAND COMPLETE UNILATERAL 73130 73130 $382.00
RDD0692642 FINGER(S) 73140 73140 $287.00
RDD0692076 HIP COMPLETE UNILATERAL 73510 73510 $441.00
RDD0692082 KNEE COMPLETE (4+ VIEW) UNILATERAL 73564 73564 $573.00
RDD0692085 ANKLE COMP. MINIMUM 3 VWS. 73610 73610 $438.00
RDD0692087 FOOT MINIMUM 3 VIEWS 73630 73630 $438.00
RDD0690092 ABDOMEN 3 VIEWS 74020 74020 $373.00
RDD0690448 COMPLETE ABDOMINAL SERIES WITH CHEST 74022 74022 $842.00
RDC0720015 ABDOMEN W CON 74160 74160 $2,572.00
RDD0690449 MODIFIED BARIUM SWALLOW 74230 74230 $388.00
BHSP000018 CAD W/SCRN MAMMO 77052 77052 $56.00
BHSP000019 DX MAMMO DIRECT UNI ALL  G0206 77055 $351.00
BHSP000023 DX DIAG W SCR SAME DAY BI G0204 77056 $416.00
BHSP000025 BONE DENSITY STUDY 77080 77080 $434.00
         

* 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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