Common Charges
June 1, 2011
| Evaluation & Management Services | CPT Code | Facility Charge |
|---|---|---|
| Emergency Room Visit, Level 2 (low to moderate severity) |
99282 | $160.00 |
| Emergency Room Visit, Level 3 (moderate severity) |
99283 | $230.00 |
| Emergency Room Visit, Level 4 (high severity) |
99284 | $630.00 |
| Outpatient Visit, established patient, 15 minutes | 99213 | $55.00 |
| Laboratory & Pathology Services | ||
| Basic Metabolic Panel | 80048 | $164.00 |
| Blood Gas Analysis, including 02 saturation | 82805 | $354.00 |
| Complete Blood Count, automated | 85027 | $76.00 |
| Complete Blood Count, with differential WBC, automated | 85025 | $104.00 |
| Comprehensive Metabolic Panel | 80053 | $251.00 |
| Creatine Kinase (CK), (CPK), Total | 82550 | $83.00 |
| Lipid Panel | 80061 | $135.00 |
| Partial Thromboplastin Time | 85730 | $59.00 |
| Prothrombin Time | 85610 | $48.00 |
| Thyroid Stimulating Hormone | 84443 | $171.00 |
| Troponin, Quantitative | 84484 | $103.00 |
| Urinalysis, without microscopy | 81003 | $31.00 |
| Urinalysis, with microscopy | 81001 | $61.00 |
| Radiology Services | ||
| CT Scan, Abdomen, with contrast | 74160 | $1,206.40 |
| CT Scan, Head or Brain, without contrast | 70450 | $750.75 |
| CT Scan, Pelvis, with contrast | 72193 | $1,108.90 |
| Mammography, Screening, Bilateral | 77057 | $230.10 |
| MRI, Head or Brain, without contrast, followed by contrast | 70553 | $2,861.95 |
| Ultrasound, Abdomen, Complete | 76700 | $878.80 |
| Ultrasound, OB, 14 weeks or more, transabdominal | 76805 | $651.30 |
| X-Ray, Lower Back, four views | 72110 | $490.10 |
| X-Ray, Chest, two views | 71020 | $309.40 |
The charge information in this document is made available for your inspection based on Chapter 2 of Division 2, commencing with Section 1339.50 of the California Health and Safety Code, also known as the Payers Bill of Rights.
The charge information contained in this document is specific to Contra Costa Health Services and does not include fees for professional services. Descriptions and charges contained in this document will vary from facility to facility.
The physician orders, based on his/her examination and treatment of the patient, are the key components in determining which services and procedures are charged to an individual patient. There are many components that comprise a hospital bill. For example, a short hospital inpatient stay could include surgical procedures, treatment in the emergency department, supplies, pharmaceuticals, room and board, numerous tests (i.e., x-rays, laboratory), and respiratory and physical therapy (all based on a physician's orders). Therefore, this document should not be used to accurately estimate the final patient cost of a given hospital stay or outpatient visit. It is provided for information only.