Usual & Customary Charges

Usual & Customary Charges

Community Memorial Hospital
Patient Price Information List
Effective January 1, 2012

In compliance with state law, Community Memorial Hospital is providing this price list containing our charges for room and board, emergency department, operating room, delivery, physical therapy, and other procedures. Hospital charges are the same for all patients, but a patient's responsibility may vary depending on payment plans negotiated with individual health insurers. Underinsured patients should consult with our admitting and billing staff to determine whether they qualify for discounts.

 

Room and Board–Per Day Charges

  U&C Charges
Semi Private $1,234.00
Swing Bed $550.00
MBU/ICU $2,000.00
Obstetrics $784.00
Newborn $598.00

 

Labor and Delivery

The following list does not include charges for anesthesia, drugs, or supplies required for a particular procedure performed in the OB department. Fees for physician services or anesthesia administration are also not reflected, and will be billed separately by the physician.

  U&C Charges
Vaginal Delivery $2,320.00
Cesarean Delivery OR Time
OB Observation 1st hour $33.00
OB Observation addn'l hour $33.00
Circumcision $143.00

 

Emergency Department

Emergency department charges are based on the level of emergency care provided to our patients. The levels, with level 1 representing basic emergency care, reflect the type of accommodations needed, the personnel resources, the intensity of care, and the amount of time needed to provide treatment. The following charges do not include fees for drugs, supplies, or additional ancillary procedures that may be required for a particular emergency treatment. Emergency department physician fees are billed separately as shown below.

Emergency Department:

  U&C Charges
Basic $125.00
Moderate $193.00
Complex $391.00
Severe $454.00
Comprehensive $793.00

 

Emergency Department Physician:

  U&C Charges
Basic $127.00
Moderate $204.00
Complex $282.00
Severe $339.00
Comprehensive $514.00

 

Surgery

Surgery charges are based on time in the operating room. These charges include set up charges and most supply charges. There will be additional charges for orthopedic implants. These charges do not include preoperative testing or additional charges for further studies. Anesthesia is an additional charge billed by the hospital. 

  U&C Charges
Surgery initial half hour $1,914.00
Surgery each added 1/4 hour $734.00
Special Procedure Room $1,690.00
CRNA per unit $179.00

 

Laboratory

The following charges reflect the most common services offered by our Laboratory Department. Patients may have additional charges depending on the services performed.

  U&C Charges
Prothrombin Time $45.00
Blood Count Complete $70.00
Venipuncture $24.00
Basic Metabolic Panel $112.00
Creatinine-Blood $50.00
Lipid Panel $125.00
Thyroid Stimulating Hormone $100.00
Comprehensive Metabolic Panel $137.00
Electrolyte Panel $65.00
Renal Function $100.00
Urea Nitrogen, Quantitative $59.00
Hemoglobin; A1C $112.00
Digoxin $157.00
Culture MIC $80.00
Creatine Kinase: Total $126.00
AST (SGOT) $50.00
Cult Bacterial $73.00
UA Dipstick $45.00
Hepatic Function Panel $100.00
LDH $50.00
Troponin $84.00
Potassium Serum $45.00
Thyroxin; Total $65.00
Thyroid Hormone Uptake $65.00
Glucose, Quantitative $30.00
Indentification Organism $33.00
Vitamin B12 $90.00
Tacrolimus $247.00
Phenytoin $112.00

 

Diagnostic Imaging

The following charges reflect the most common services offered by our Diagnostic Imaging Department. Patients may have additional charges depending on the services performed.  These charges do not reflect the physician charge for reading the results.

  U&C Charges
CT Abdomen w contrast $1,438.00
CT Head/Brain w/o contrast $1,258.00
CT Pelvis w contrast $1,464.00
CT Chest w contrast $1,372.00
CT Abdomen w/o contrast  $1,266.00
CT Cervical Spine w/o contrast $1,178.00
Chest 2 Views $150.00
Screening Mammography $144.00
Bone Density Study $364.00
Hip 2 Views $199.00
Shoulder Complete $213.00
Chest Single View $86.00
Spine, Lumbar 4 Views $293.00
Knee 3 Views $222.00
Abdomen Acute Series $349.00 
MRI Lumbar Spine $2,167.00
MRI Any Joint Lower Ext $1,647.00
MRI Brain $1,974.00
MRI Any Joint Upper Ext $1,647.00
US Retroperitoneal $632.00
US Abdomen $649.00

 

Respiratory Therapy

The following charges reflect the most common services offered by our Respiratory Therapy Department. Patients may have additional charges depending on the services performed.

  U&C Charges
Pulse Ox Single $65.00
Overnight Sat Study $167.00
CO2 Monitor $94.00
CPR $284.00
Aerosol Treatment $73.00
Breath Alcohol Test $87.00
Bi PAP Daily $219.00
Incentive Spirometer $33.00
Intubation $425.00
Arterial Blood Gas $276.00

 

Physical Therapy

The following charges reflect the most common services offered by our Physical Therapy Department. Patients may have additional charges depending on the services performed.

  U&C Charges
Evaluation $233.00
Exercise 15 minutes $92.00
Gait Training $72.00
Gait Training Each $72.00
Debridement Large $179.00
Debridement Small $150.00
Whirlpool $110.00
Ultrasound $109.00
Electrical Stimulation $87.00

 

Occupational Therapy

The following charges reflect the most common services offered by our Occupational Therapy Department. Patients may have additional charges depending on the services performed.   

  U&C Charges
Evaluation $327.00
Orthotic Fit/Training - 15 min $66.00
Group Therapy $93.00
Work Reconditioning - 2 hours $286.00
Therapeutic Exercise $87.00
Cognitive/Perceptual - 15 min $79.00
Wheelchair Management $62.00
Iontophoresis - 15 min $87.00

 

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208 N. Columbus | Hicksville, OH 43526 | (419) 542-6692

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