Patient Price Information List

As of February 1, 2017

1. All charges noted do not include medications or supplies that may be used during your  stay at Community Hospitals and Wellness Centers.

1.1 Hospital based Pathology or Pathologist charges are included in the CHWC hospital bill.

1.2 Emergency Department Physician charges are not included in the CHWC hospital bills.

Information can be obtained by contacting:

For Bryan & Montpelier Emergency Departments:
Samaritan
SymMetricBilling@SymMetricRS.com
866 603-4198

1.3 Radiologist, FWRadiology, services are not included in the CHWC hospital bills.

Information can be obtained by contacting:
FWRadiology
3707 New Vision Dr.
Fort Wayne, IN 46845
260-484-0850 or 800-758-0292

1.4 Non Hospital Based Anesthesia services provided by Anesthesia Associates of Fort Wayne

(AAFW) are not included in the CHWC hospital bills. Information can be obtained by contacting:
AAFW – CIPROMS
Suite 400, 3600 Woodview Trace
Indianapolis, IN 46268
888-802-6903

1.5 Pain Management Physician charges are not included in the CHWC hospital bills.

Information can be obtained by contacting:
For: Dr. Tom Kindl
Pain Management Specialists
1900 S Main Street
Middleburg Heights, Ohio 44130
Findlay, OH 45840
419-423-5310

1.6 Radiation Oncology Physician charges are not included in the CHWC hospital bills.
Information can be obtained by contacting:
Toledo Radiation Oncology
3000 Regency Court, Suite 207
Toledo, OH 43623
419-473 2636 or 800-223-0311

1.7 University of Toledo Physicians LLC charges are not included in the CHWC hospital bills.
Information can be obtained by contacting:
University of Toledo Physicians
3355 Glendale Ave., 3rd Floor
Toledo, OH 43614
419-383-7100

1.8 Parkview Physician Group charges are not included in the CHWC hospital bills
Information can be obtained by contacting:
Parkview Physicians Group
PO Box 10416
Des Moines, Iowa 50306
260-266-6700 or 855-814-0012
Fax – 260-458-5685

2. Room and Board – Per Day Charges

Charges

CAH Swing Bed Room Rate

1,570.00

Intensive Care Room Rate

1,930.00

Medical/Surgical Room Rate

1,170.00

Nursery Room Rate

630.00

OB Room Rate

1,080.00

Pediatrics Room Rate

1,270.00

Telemetry Room Rate

1,350.00

3. Labor and Delivery Charges

Charges

Labor and Delivery

$ 1,280.00

Cesarean Section Delivery

See Major Surgery

4. Emergency Department Charges

Charges

Level 1

$ 169.00

Level 2

280.00

Level 3

470.00

Level 4

810.00

Level 5

1,250.00

5. Operating Room Charges

Initial

Addt’l 15

Half Hr

Min Chrg

Minor Surgery

$ 1,390.00

$ 330.00

Major Surgery

1,790.00

390.00

Recovery Room

813.00

84.00

6. Occupational Therapy Charges – most common services

Charges

Addt’l Home Ins-Ast Development 15 MIN

$

85.00

Develope Cognitive Skill 15 MIN

65.00

Fluidotherapy

70.00

Orthotic Fitting & Training 15 MIN

96.00

OT Evaluation

206.00

Paraffin Bath

27.00

Physical Capacity 15 MIN

80.00

Therapeutic Activity 15 MIN

84.00

Therapeutic Exercise 15 MIN

78.00

Work Condition Exrcs/Job Stimulation 1 hr

118.00

7. Physical Therapy Charges – most common services

Charges

Aquatic Therapy 15 MIN

$ 103.00

Electrical Stimulate PT Assisted

47.00

Electrical Stimulate Unattended

35.00

Gait (Walking) Training 15 MIN

69.00

Infrared Therapy

48.00

Iontophoresis 15 MIN

78.00

Manual Therapy Tech 15 MIN

72.00

Massage 15 MIN

63.00

Neuromuscle Facilitation 15 MIN

82.00

PT Evaluation

183.00

PT Evaluation Vestibula (Balance)

183.00

TENS – Transcutaneous Elect Nerve Stim

24.00

Therapeutic Activity 15 MIN

84.00

Therapeutic Exercise 15 MIN

78.00

Therapeutic Exercise in a Group

51.00

Traction Mechanical

39.00

Ultrasound 15 MIN

31.00

Vestibular Ex 15 MIN

82.00

8. Pulmonary Therapy Charges – most common services

Charges

Aerosol All Treatments after Initial

$

75.00

Aerosol Initial Treatment

175.00

Arterial Blood Gas

105.00

Atrovent with normal saline

12.00

Diffusion Carbon Dioxide Across Capilary Mem

200.00

Disposable Incentive Spirometry

157.00

Duoneb Inhalation

9.00

EKG

96.00

PFT – Spirometry Brnch/Dilt/ADM

550.00

Proventil normal saline

7.00

Xopenex 1.25 MG normal saline0

12.00

9. X-Ray and Radiological Charges – 30 most common services

Charges

Abdomen: AP, UP CXR 3 views

$ 400.00

Ankle: 3 views

240.00

Cervical Spine: 2-3 views

400.00

Chest: AP/PA 1 view

240.00

Chest with Lateral: 2 views

240.00

CT Abdomen: W/O contrast

450.00

CT Abdomen: with contrast

950.00

CT Brain: W/O contrast

450.00

CT Chest: with contrast

950.00

CT Pelvis: with contrast

950.00

CT Abdomen Pelvis W/O contrast

900.00

CT Abdomen Pelvis with contrast

1,400.00

Foot: Min 3 views

240.00

Hand: Min 3 views

240.00

K.U.B.: 1 view

240.00

Knee: 3 views

240.00

Lumbar Spine: 2-3 views

400.00

Lumbar Spine: 5 views

400.00

MRI Brain: W/ & W/O contrast

1,820.00

MRI Brain: W/O contrast

1,090.00

MRI Cervical Spine: W/O contrast

1,090.00

MRI Low Extrm W JT: W/O contrast

1,090.00

MRI Lumbar Spine: W/O contrast

1,090.00

MRI Up Extrm W JT: W/O contrast

1,090.00

Nuclear Med Bone Scan: Complete

1,330.00

Nuc Med Cardolite Treadmill Stress

7,069.00

Shoulder: 2 views

240.00

ECHO Full Study

1,670.00

Ultrasound both Carotid Arteries

610.00

Ultrasound Pelvic

610.00

10. Laboratory Charges – 30 most common

Charges

ALT SGPT

$

28.00

Amylase

35.00

Basic Profile

40.00

Blood Culture

56.00

BNP

185.00

Urine Culture

44.00

CBC with BC Differential

42.00

CKMB

50.00

Comprehensive Profile

57.00

CPK

35.00

Electrolyte Profile

25.00

Hemoglobin A1C

53.00

Liver Profile

34.00

Hemoglobin

13.00

Level IV Gross & Micro

220.00

Lipase

38.00

Lipid Profile

69.00

Magnesium

31.00

Myoglobin

70.00

Organism ID

44.00

Phosphorus

26.00

PKU Newborn Screening

150.00

Protime

21.00

PTT

33.00

SED Rate

19.00

Sensitivity

42.00

PSA Screening or Total

100.00

Troponin 1

54.00

TSH

91.00

Urinalysis

12.00

11. Hospital Billing Policy

All accounts with health insurance will be billed to the insurance. Secondary insurance plans are billed following completed processing of the claim by the primary insurance plan. The billing office will follow up with the health insurance until a payment is received or until the claim has completed processing by the insurance. The account will be held if a payment date is provided by the health insurance. If the insurance is holding the claim for additional information from the patient, a letter will be sent asking the policy holder to contact the insurance with the requested information and notify the hospital within 10 days. If no response is received, the first statement will be sent to the guarantor.

Under the ‘Patient Services’ tab, and ‘financial assistance’, the hospital ‘Financial Assistance Policy’ and the ‘Financial Collection Policy’ can be viewed to obtain information explaining CHWC’s patient billing process and financial assistance options.