Charges for Select Hospital Services

Pricing: 2008

CPT Code	Procedure Name	Cost
	EMERGENCY ROOM SERVICES
99281	Emergency Dept Visit - Level 1	$155.66
99282	Emergency Dept Visit - Level 2	$232.86
99283	Emergency Dept Visit - Level 3	$475.29
99294	Emergency Dept Visit - Level 4	$609.92
99285	Emergency Dept Visit - Level 5	$947.29
	LABORATORY PROCEDURES
80048	BASIC METABOLIC PANEL	$28.45
84520	BUN - VENOUS SAMPLE (UREA NITROGEN)	$17.78
85027	CBC AUTO (COMPLETE BLOOD COUNT)	$29.13
85025	CBC PLATELET AUTO DIFF	$34.95
82553	CK MB (CREATINE KINASE MB FRACTION)	$40.90
80053	COMPLETE METABOLIC PANEL	$40.65
82550	CREATINE KINASE (CK)	$29.31
82565	CREATININE BLOOD	$18.40
87040	CULTURE BLOOD	$46.49
87086	CULTURE URINE W CC	$36.33
G0123	CYTO PAP TLP MAN SCR	$71.57
85014	HEMATOCRIT	$10.66
85018	HEMOGLOBIN	$10.66
83036	HEMOGLOBIN A1C GLYCOHGB	$43.69
80076	HEPATIC PANEL	$20.37
80061	LIPID PANEL	$57.20
80051	ELECTROLYTES PANEL	$20.37
83735	MAGNESIUM BLD	$25.97
83874	MYOGLOBIN BLD	$58.06
84153	PROS SPEC AG (PSA)	$82.72
85610	PROTIME (PROTHROMBIN TIME)	$17.66
85730	PTT (PARTIAL THROMBOPLASTIN TIME)	$27.02
85651	SEDIMENTATION RATE MANUAL	$16.00
87186	SENSITIVITY MICRO	$34.76
88305	SURGICAL PATHOLOGY LEVEL 4	$174.39
84484	TROPONIN QUANT	$44.24
84443	TSH (THYROID STIMULATING HORMONE)	$75.54
81001	URINALYSIS WITH MICRO AUTO	$14.25
81003	URINALYSIS WITHOUT MICRO AUTO	$10.11
36415	VENIPUNCTURE	$9.80
	PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY
82803	GASES, BLOOD	$154.58
94640	INHALATION TX-ACUTE OBST	$92.50
97003	OCCUPATIONAL THERAPY EVALUATION	$182.57
97140	OT MANUAL THERAPY - 15 MIN	$76.70
97001	PHYSICAL THERAPY EVALUATION	$182.57
97116	PT GAIT TRAINING 15 MIN	$64.51
97110	PT THERAPEUTIC EXERCISE - 15 MIN	$86.82
	ROOM & BOARD CHARGES
	Medical/Surgical Private Room	$1,013.14
	Medical/Surgical Semi-Private - 5B	$953.54
	Surgical ICU	$1,996.47
	Medical ICU	$1,996.47
	OPERATING ROOM
	OR Level 1 - 1st 30 MIN	$1,004.13
	OR Level 1 - EA ADDITIONAL 15 MIN	$456.43
	OR Level 2 - 1st 30 MIN	$1,460.56
	OR Level 2 - EA ADDITIONAL 15 MIN	$586.81
	OR Level 3 - 1st 30 MIN	$2,751.57
	OR Level 3 - EA ADDITIONAL 15 MIN	$750.56
	OR Level 4 - 1st 30 MIN	$3,042.83
	OR Level 4 - EA ADDITIONAL 15 MIN	$669.42
	POST-OP Level 1 - 00-30 MIN	$243.43
	POST-OP Level 1 - ADDITIONAL 15 MIN	$79.12
	POST-OP Level 2 - 00-30 MIN	$413.82
	POST-OP Level 2 - ADDITIONAL 15 MIN	$91.28
	POST-OP Level 3 - 00-30 MIN	$510.37
	POST-OP Level 3 - ADDITIONAL 15 MIN	$127.59
	RADIOLOGY
74020	ABDOMEN 3 VIEWS	$289.29
74160	ABDOMEN W CONTRAST	$1,411.94
74022	ABDOMEN SERIES WITH CHEST	$531.29
73610	ANKLE COMP MINIMUM 3 VIEWS	$276.03
77080	BONE DENSITY STUDY	$276.11
70553	BRAIN W & WO CON	$2,867.14
72040	CERVICAL SP AP & LAT OR 2 VWS	$284.56
72050	CERVICAL SPINE W/OBLIQUES	$344.34
71010	CHEST 1 VIEW - FRONTAL	$169.12
71020	CHEST PA/AP & LATERAL	$215.50
73080	ELBOW MINIMUM 3 VIEWS	$223.81
73140	FINGER(S) UNILATERAL	$158.64
73630	FOOT COMP MINIMUM 3 VWS	$223.81
73130	HAND COMPLETE (UNILATERAL)	$189.40
70470	HEAD/BRAIN W & WO CON	$1,401.94
70450	HEAD/BRAIN WO CONTRAST	$1,065.79
73510	HIP COMPLETE (UNILATERAL)	$221.37
73564	KNEE COMPLETE (4+ VIEW)	$292.79
72020	LUMBAR SPINE 1 VIEW	$218.71
72100	LUMBAR SPINE 3 VIEWS	$274.07
72110	LUMBAR SPINE W/OBLIQUES	$409.00
77056	MAMMOGRAPHY BILAT (DX)	$197.47
77057	MAMMOGRAPHY SCREENING	$132.25
74230	MODIFIED BARIUM SWALLOW	$312.32
72193	PELVIS WITH CONTRAST	$1,327.37
73030	SHOULDER (UNILATERAL)	$223.81
70486	SINUSES/FACIAL WITHOUT CONTRAST	$1,921.02
72072	THORACIC SPINE 3 VIEWS	$384.22
71260	THORAX WITH CONTRAST	$1,321.76
73110	WRIST COMPLETE	$223.81

* 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.