Charges for Select Hospital Services
Pricing: 2010
| DESCRIPTION |
CPT |
CHARGE $
EFCTV January 2010 |
| EMERGENCY ROOM SERVICES |
| EMERG. DEPT VISIT - LEVEL 1 |
99281 |
$159.00 |
| EMERG. DEPT VISIT - LEVEL 2 |
99282 |
$293.00 |
| EMERG. DEPT VISIT - LEVEL 3 |
99283 |
$461.00 |
| EMERG. DEPT VISIT - LEVEL 4 |
99284 |
$714.00 |
| EMERG. DEPT VISIT - LEVEL 5 |
99285 |
$1,164.00 |
| LABORATORY |
| BASIC METABOLIC PANEL |
80048 |
$64.00 |
| BUN - VENOUS SAMPLE |
84520 |
$27.00 |
| CBC PLATELET AUTO DIFF |
85025 |
$71.00 |
| CK MB (CREATINE KINASE MB FRACTION) |
82553 |
$71.00 |
| COMP METABOLIC PANEL |
80053 |
$110.00 |
| CREATINE KINASE (CK) |
82550 |
$37.00 |
| CREATININE BLD |
82565 |
$33.00 |
| CULTURE BLOOD |
87040 |
$103.00 |
| CULTURE URINE W CC |
87086 |
$54.00 |
| CYTO PAP TLP MAN SCR |
88142 |
$75.00 |
| HEMATOCRIT |
85014 |
$15.00 |
| HEMOGLOBIN |
85018 |
$17.00 |
| HEMOGLOBIN A1C GLYCOHGB |
83036 |
$6.00 |
| CBC AUTO |
85027 |
$61.00 |
| HEPATIC PANEL |
80076 |
$79.00 |
| LIPID PANEL |
80061 |
$79.00 |
| LYTES PANEL |
80051 |
$50.00 |
| MAGNESIUM BLD |
83735 |
$47.00 |
| MYOGLOBIN BLD |
83874 |
$149.00 |
| PROTIME (PROTHROMBIN TIME) |
85610 |
$35.00 |
| PTT (PARTIAL THROMBOPLASTIN TIME) |
85730 |
$43.00 |
| PROS SPEC AG (PSA) |
84153 |
$87.00 |
| SED RATE MANUAL |
85651 |
$33.00 |
| SENSITIVITY MICRO |
87186 |
$62.00 |
| SURGICAL PATHOLOGY LEVEL 4 |
88305 |
$267.00 |
| TROPONIN QUANT |
84484 |
$123.00 |
| TSH (THYROID STIMULATING HORMONE) |
84443 |
$103.00 |
| URINALYSIS WITH MICRO AUTO |
81001 |
$33.00 |
| URINALYSIS WITHOUT MICRO AUTO |
81003 |
$21.00 |
| VENIPUNCTURE |
36415 |
$1.00 |
| PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY |
| GASES BLOOD |
82803 |
$197.00 |
| INHALATION TREATMENT-ACUTE OBSTRUCTION |
94640 |
$119.00 |
| OCCUPATIONAL THERAPY EVALUATION |
97003 |
$214.00 |
| OCCUPATIONAL MANUAL THERAPY 15 MINUTES |
97140 |
$93.00 |
| PHYSICAL THERAPY EVALUATION |
97001 |
$204.00 |
| PHYSICIAL THERAPEUTIC EXERCISE 15 MINUTES |
97110 |
$130.00 |
| GAIT TRAINING 15 MINUTES |
97116 |
$89.00 |
| ROOM & BOARD CHARGES |
| R & B MED SURG PRIVATE |
|
$1,150.00 |
| R & B MED/SURG SEMIPVT |
|
$1,125.00 |
| R & B SURGICAL ICU |
|
$1,900.00 |
| R & B MEDICAL ICU |
|
$1,900.00 |
| OPERATING ROOM |
| OR 1 1ST 30 MINS |
|
$1,085.97 |
| OR 1 ADDL 15 |
|
$850.00 |
| OR 2 1ST 30 MINS |
|
$1,800.00 |
| OR 2 ADDL 15 |
|
$750.00 |
| OR 3 1ST 30 MINS |
|
$2,100.00 |
| OR 3 ADDL 15 |
|
$850.00 |
| OR 4 1ST 30 MINS |
|
$2,400.00 |
| OR 4 ADDL 15 |
|
$950.00 |
| POST-OP 1 0-30 MINS |
|
$263.27 |
| POST-OP 1 ADDL 15 |
|
$85.57 |
| POST-OP 2 0-30 MINS |
|
$447.55 |
| POST-OP 2 ADDL 15 |
|
$98.72 |
| POST-OP 3 0-30 MINS |
|
$551.97 |
| POST-OP 3 ADDL 15 |
|
$137.99 |
| RADIOLOGY |
| ABDOMEN 3 VIEWS |
74020 |
$312.00 |
| ABDOMEN WITHCONTRAST |
74160 |
$1,729.00 |
| ANKLE COMP. MINIMUM 3 VWS. |
73610 |
$214.00 |
| BONE DENSITY STUDY |
77080 |
$378.00 |
| BRAIN WITH & WITHOUT CONTRAST |
70553 |
$4,665.00 |
| CERVICAL SP AP & LAT OR 2 VWS. |
72040 |
$265.00 |
| CERVICAL SPINE W OBLIQUES |
72050 |
$350.00 |
| CHEST 1 VIEW - FRONTAL |
71010 |
$209.00 |
| CHEST PA/AP & LATERAL |
71020 |
$224.00 |
| COMPLETE ABDOMINAL SERIES WITH CHEST |
74022 |
$406.00 |
| ELBOW MINIMUM 3 VIEWS |
73080 |
$214.00 |
| FINGER THUMB |
73140 |
$148.00 |
| FOOT MINIMUM 3 VIEWS |
73630 |
$231.00 |
| HAND COMPLETE UNILATERAL |
73130 |
$206.00 |
| HEAD/BRAIN W & WO CON |
70470 |
$1,704.00 |
| HEAD/BRAIN WO CON |
70450 |
$1,120.00 |
| HIP COMPLETE UNILATERAL |
73510 |
$281.00 |
| KNEE COMPLETE (4+ VIEW) UNILATERAL |
73564 |
$311.00 |
| LUMBAR SPINE 1 VIEW |
72020 |
$207.00 |
| LUMBAR SPINE 3 VIEWS |
72100 |
$317.00 |
| LUMBAR SPINE W OBLIQUES |
72110 |
$520.00 |
| MAMMOGRAPHY BILAT (DX) |
77056 |
$253.00 |
| MAMMOGRAPHY SCREENING |
77057 |
$143.03 |
| MODIFIED BARIUM SWALLOW |
74230 |
$516.00 |
| PELVIS WITH CONTRAST |
72193 |
$1,584.00 |
| SHOULDER UNILATERAL |
73030 |
$238.00 |
| SINUSES/FACIAL WITHOUT CONTRAST |
70486 |
$1,263.00 |
| THORACIC SPINE 3 VIEWS |
72072 |
$284.00 |
| THORAX W CON |
71260 |
$1,425.00 |
| WRIST COMP. MINIMUM 3 VWS. LT |
73110 |
$215.00 |
* 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.