AB 1045 - List of 25 Common

Outpatient Procedures for 2007

Hospital Name: Dameron Hospital Association
OSHPD Facility No: 106390846
Effective Date of Charges: June 1, 2007

In response to requests from hospitals and the public, OSHPD has developed this form to assist hospitals in collecting
and submitting the average charge for 25 common outpatient procedures performed by hospitals, as required by AB
1045 (Chapter 532, Statutes of 2005). In developing this form, OSHPD compiled the outpatient procedures reported by
hospitals in 2006, analyzed 2005 hospital ambulatory surgery data collected by OSHPD, and compared outpatient data
obtained from CMS and DHS. Use of the OSHPD form is voluntary, but highly encouraged, as it allows hospitals to
report and the public to compare uniform information regarding common outpatient procedures.
2007 CPT Code
Evaluation & Management Services (CPT Codes 99201-99499)
Average Charge
99282
Emergency Room Visit, Level 2 (low to moderate severity)
$579.15
99283
Emergency Room Visit, Level 3 (moderate severity)
$910.91
99284
Emergency Room Visit, Level 4 (high severity)
$1,350.00
99213
Outpatient Visit, established patient, 15 minutes
$288.75
2007 CPT Code
Laboratory & Pathology Services (CPT Codes 80048-89356)
Average Charge
80048
Basic Metabolic Panel
$251.05
82805
Blood Gas Analysis, including 02 saturation
$503.15
85027
Complete Blood Count, automated
$121.25
85025
Complete Blood Count, with differential WBC, automated
$130.15
80053
Comprehensive Metabolic Panel
$310.30
82550
Creatine Kinase (CK), (CPK), Total
$177.75
80061
Lipid Panel
$283.20
85730
Partial Thromboplastin Time
$110.60
85610
Prothrombin Time
$85.90
84443
Thyroid Stimulating Hormone
$243.03
84484
Troponin, Quantitative
$211.30
Urinalysis, without microscopy
81002 or 81003
$46.38
Urinalysis, with microscopy
81000 or 81001
$80.52
2007 CPT Code
Radiology Services (CPT Codes 70010-79999)
Average Charge
74160
CT Scan, Abdomen, with contrast
$3,300.00
70450
CT Scan, Head or Brain, without contrast
$2,717.00
72193
CT Scan, Pelvis, with contrast
$3,300.00
77056
Mammography, Screening, Bilateral
n/a
70553
MRI, Head or Brain, without contrast, followed by contrast
n/a
76700
Ultrasound, Abdomen, Complete
$1,295.25
76805
Ultrasound, OB, 14 weeks or more, transabdominal
$869.00
X-Ray, Lower Back, four views
72110
$965.25
71020
X-Ray, Chest, two views
$497.08
2007 CPT Code
Medicine Services (CPT Codes 90281-99602)
Average Charge
93510
Cardiac Catheterization, Left Heart, percutaneous
$22,810.91
93307
Echocardiography, complete
$996.20
93000
Electrocardiogram, routine, with interpretation and report
$329.04
94640
Inhalation Treatment, pressurized or nonpressurized
$582.06
97001
Physical Therapy, Evaluation
$192.10
97116
Physical Therapy, Gait Training
$78.25
97110
Physical Therapy, Therapeutic Exercise
$75.44

Office of Statewide Health Planning and Development

AB 1045 (May 2007)

AB 1045 - List of 25 Common

Outpatient Procedures for 2007
Hospital Name: Dameron Hospital Association
OSHPD Facility No: 106390846
Effective Date of Charges: June 1, 2007
Surgery Services (CPT Codes 10021-69990)
Arthroscopy, Knee, with meniscectomy (medial or lateral)
Arthroscopy, Shoulder, with partial acromioplasty
Carpal Tunnel Surgery
Cataract Removal with Insertion of Intraocular Lens, 1 Stage
Colonoscopy, diagnostic
Colonoscopy, with biopsy
Colonoscopy, with lesion removal, by snare technique
Discission, secondary membranous cataract, laser surgery
Endoscopy, Upper GI, with biopsy
Endoscopy, Upper GI, diagnostic
Excision, Breast Lesion
Hernia Repair, Inguinal, 5 years and older
Injection, Diagnostic or Therapeutic substance, epidural
Injection, Anesthetic or Steroid, transforaminal epidural
Laparoscopic Cholecystectomy
Tympanostomy (insert ventilating tube, general anesthesia)
Tonsillectomy with Adenoidectomy, less than 12 years old
Other Common Outpatient Procedures (list as needed)

2007 CPT Code

Average Charge
29881
$9,878.47
29826
$12,723.61
64721
$7,889.16
66984
$9,986.04
45378
$2,968.89
45380
$3,238.29
45385
$4,134.19
66821
n/a
43239
$3,913.25
43235
$3,338.45
19120
$8,898.03
49505
$13,581.04
62311
$7,555.73
64483
$7,771.83
47562
$21,985.76
69436
$5,401.49
42820
$9,632.31
2007 CPT Code
Average Charge

Count of Reported Procedures (minimum 25 required)

Instructions for Completing AB 1045 Common Outpatient Procedure Form
1. Enter Hospital Name and OSHPD Facility Number. Revise Effective Date of Charges, if necessary.
2. Enter Average Charge for at least 25 commonly performed outpatient procedures. For Evaluation & Management
Services, do not include related ancillary charges. For all other procedures, include related ancillary charges.
NOTE: The CPT codes are included on this form to help identify the listed procedures based on the principal
procedure appearing on the patient's medical record. The average charge for all related services and procedures
(e.g., supplies, drugs, lab, use of operating room, etc.) should be included in the average charge for that procedure.
3. Do not change procedure descriptions or CPT code references. Use "Other Common Outpatient Procedures"
(rows 62-71) if you are unable to select procedures from list.
4. Submit completed form as Excel (.xls) file, along with chargemaster and percent change in gross revenue
calculation, by e-mail to chargemaster@oshpd.ca.gov or by standard mail on CD.

Office of Statewide Health Planning and Development

AB 1045 (May 2007)