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Usual and Customary Charges for Select Services*

Pricing: 2016

In compliance with state law, St John Medical Center is providing this list which reflects selected charges for room and board, the emergency department, the operating and recovery room , labor and delivery, physical, occupational and respiratory therapy, lab and radiology services. The hospital’s charges are the same for all patients however the patient’s financial responsibility will vary depending on the payment plans negotiated with individual health insurers. Uninsured or underinsured patients should consult with our Financial Counselors or billing staff to determine whether they qualify for a discount under the Financial Assistance Policy. The prices below are correct as of January 1, 2016.


MNEMONICDESCRIPTION MC HCPCS CPT CHARGE EFFECTIVE JAN 2016
EMERGENCY ROOM
EMERG. DEPT VISIT - LEVEL 1    99281 99281 $245.00
EMERG. DEPT VISIT - LEVEL 2    99282 99282 $501.00
EMERG. DEPT VISIT - LEVEL 3    99283 99283 $1,062.00
EMERG. DEPT VISIT - LEVEL 4    99284 99284 $1,200.00
EMERG. DEPT VISIT - LEVEL 5    99285 99285 $1,706.00
LABORATORY
BASIC METABOLIC PANEL 80048 80048 $61.00
BUN - VENOUS SAMPLE 84520 84520 $41.00
CBC AUTO 85027 85027 $60.00
CBC PLATELET AUTO DIFF 85025 85025 $67.00
CK MB (CREATINE KINASE MB FRACTION) 82553 82553 $150.00
COMP METABOLIC PANEL 80053 80053 $94.00
CREATINE KINASE (CK) 82550 82550 $60.00
CREATININE BLD 82565 82565 $60.00
CULTURE BLOOD 87040 87040 $164.00
CULTURE URINE W CC 87086 87086 $82.00
CYTO PAP TLP MAN SCR  G0123 88142 $140.00
HEMATOCRIT 85014 85014 $23.00
HEMOGLOBIN 85018 85018 $23.00
HEMOGLOBIN A1C GLYCOHGB 83036 83036 $102.00
HEPATIC PANEL 80076 80076 $61.00
LIPID PANEL 80061 80061 $131.00
LYTES PANEL 80051 80051 $51.00
MAGNESIUM BLD 83735 83735 $62.00
MYOGLOBIN BLD                  83874 83874 $119.00
PROSTATE SPECIFIC ANTIGEN(PSA) G0103 84153 $136.00
PROTIME (PROTHROMBIN TIME) 85610 85610 $40.00
PTT (PARTIAL THROMBOPLASTIN TIME) 85730 85730 $61.00
SEDIMENTATION RATE MANUAL 85651 85651 $42.00
SENSITIVITY MICRO 87186 87186 $124.00
SURGICAL PATHOLOGY LEVEL 4 88305 88305 $537.00
TROPONIN QUANT 84484 84484 $92.00
TSH(THYROID STIMULATING HORMONE) 84443 84443 $124.00
URINALYSIS WITH MICRO AUTO 81001 81001 $39.00
URINALYSIS WITHOUT MICRO AUTO 81003 81003 $34.00
VENIPUNCTURE 36415 36415 $20.00
PHYSICAL, OCCUPATIONAL, PULMONARY THERAPY
BLOOD GASES 82803 82803 $235.00
INHALATION TREATMENT-ACUTE OBSTRUCTION 94640 94640 $286.00
OCCUPATIONAL THERAPY EVALUATION 97003 97003 $259.00
OCCUPATIONAL MANUAL THERAPY 15 MINUTES 97140 97140 $152.00
PHYSICAL THERAPY EVALUATION 97001 97001 $259.00
THERAPEUTIC EXERCISE 15 MIN 97110 97110 $149.00
PT GAIT TRAINING 15 MINUTES 97116 97116 $121.00
ROOM & BOARD CHARGES
LABOR/DEL/REC     $3,434.00
R & B MEDICAL SURGICAL     $1,706.00
R & B MED/SURG  ORTHO     $1,706.00
R&B INTERM ICU - IMCU (STEPDOWN)     $2,659.00
R & B M S TELE 3NO     $2,181.00
R & B SURGICAL ICU     $3,681.00
R & B MEDICAL ICU     $3,681.00
OPERATING ROOM
OR 1 1ST 30 MINS     $2,252.00
OR 1 ADDL 15     $682.00
OR 2 1ST 30 MINS     $3,273.00
OR 2 ADDL 15     $957.00
OR 3 1ST 30 MINS     $4,091.00
OR 3 ADDL 15     $957.00
OR 4 1ST 30 MINS     $5,529.00
OR 4 ADDL 15     $1,218.00
         
POST-OP 1 0-30 MINS     $422.00
POST-OP 1 ADDL 15     $138.00
POST-OP 2 0-30 MINS     $716.00
POST-OP 2 ADDL 15     $181.00
POST-OP 3 0-30 MINS     $881.00
POST-OP 3 ADDL 15     $195.00
RADIOLOGY
HEAD/BRAIN WO CON 70450 70450 $1,591.00
HEAD/BRAIN W & WO CON 70470 70470 $2,186.00
SINUSES/FACIAL WITHOUT CONTRAST 70486 70486 $2,057.00
BRAIN WITH & WITHOUT CONTRAST 70553 70553 $4,982.00
CHEST 1 VIEW - FRONTAL 71010 71010 $289.00
CHEST PA/AP & LATERAL 71020 71020 $341.00
THORAX WITH CONTRAST 71260 71260 $2,803.00
LUMBAR SPINE 1 VIEW 72020 72020 $377.00
CERVICAL SP AP & LAT OR 2 VIEWS 72040 72040 $506.00
CERVICAL SPINE W OBLIQUES 72050 72050 $723.00
THORACIC SPINE 3 VIEWS 72072 72072 $691.00
LUMBAR SPINE 3 VIEWS 72100 72100 $578.00
LUMBAR SPINE W OBLIQUES 72110 72110 $879.00
PELVIS WITH CONTRAST 72193 72193 $1,459.00
SHOULDER UNILATERAL 73030 73030 $468.00
ELBOW MINIMUM 3 VIEWS 73080 73080 $446.00
WRIST MINIMUM 3 VIEWS 73110 73110 $460.00
HAND COMPLETE UNILATERAL 73130 73130 $402.00
FINGER(S) 73140 73140 $318.00
HIP COMPLETE UNILATERAL 73510 73510 $488.00
KNEE COMPLETE (4+ VIEW) UNILATERAL 73564 73564 $602.00
ANKLE COMP. MINIMUM 3 VWS. 73610 73610 $460.00
FOOT MINIMUM 3 VIEWS 73630 73630 $460.00
ABDOMEN 3 VIEWS 74020 74020 $412.00
COMPLETE ABDOMINAL SERIES WITH CHEST 74022 74022 $930.00
ABDOMEN W CON 74160 74160 $2,837.00
MODIFIED BARIUM SWALLOW 74230 74230 $429.00
CAD W/SCRN MAMMO 77052 77052 $62.00
DX MAMMO DIRECT UNI ALL  G0206 77055 $388.00
DX DIAG W SCR SAME DAY BI G0204 77056 $459.00
BONE DENSITY STUDY 77080 77080 $479.00
         

* 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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