Summa Akron City, St. Thomas and Barberton Hospitals

Summa Akron City, St. Thomas and Barberton Hospitals Usual and Customary Charges for Selected Procedures Patient Price List

In compliance with state law, Summa Akron City and St. Thomas Hospitals publishes charges for room and board, emergency department, labor and delivery, operating room, lab, radiology and other procedures. This publication is available upon request when visiting the hospital and may be found at http://summahealth.org/patientvisitor/InsuranceandBilling/patientpricereports. The hospital charges are consistent for all patients. The patient’s responsibility may vary, however, depending on insurance contracts with individual health insurers. Summa Health System offers financial assistance through the Ohio Hospital Care Assurance Program, Summa’s Charity and Uninsured Patient Charity Programs. For information contact Patient Financial Services at 234.312.5700.

These prices are correct as of January 1, 2016. Room and Board per Day Charges

Medical/Surgical Semi-Private $2,610.50 Nursery 1,997.75 Chemical Dependency/Detox/Psychiatry 2,610.50 Perinatal 3,810.50 Oncology 2,652.50 Telemetry 5,651.75 ICU Step Down 9,105.75 Medical/Surgical Private 2,700.00 Coronary/Intensive Care 12,907.25

Labor and Delivery Charges

The following list does not include charges for anesthesia, drugs or supplies required for a particular delivery room procedure. Fees for physician services or anesthesia administration are also not reflected and will be billed separately by your physician. Labor Room First Hr 521.50 OB OR Level 1: First 30 Min 2,620.00 Labor Room each additional Hr 261.25 OB OR Level 2: First 30 Min 5,088.25 Labor/Delivery Unit 537.75 OB OR Level 3: First 30 Min 7,509.25 Birthing Room First Hr 4,591.50 OB OR Level 1 or 2: each additional 15 Min 266.75 Birthing Room High Risk First 30 Min 5,141.50 OB OR Level 3: each additional 15 Min 413.75 Birthing Room High Risk each additional 15 Min 102.00 OB PACU First 30 Min 473.00 Delivery Room First 30 Min 4,851.75 OB PACU each additional 15 Min 105.50 Delivery Room each additional 15 Min 102.00 Circumcision w/Regional Block 435.00 Fetal Non-Stress 597.75

Emergency Department Charges Emergency Department charges are based on the level of emergency care provided to patients. There may be other hospital charges related to the emergency room visit (drugs, ancillary services, testing, anesthesia, etc.) Services provided by Emergency physicians will be billed by the physicians.

Level 1 Emergency Exam 401.25 Critical Care First Hour 4,930.25 Level 2 Emergency Exam 579.50 Critical Care Addl 30 Min 1,569.00 Level 3 Emergency Exam 1,138.00 Pre-Notify Trauma Eval w/CC 6,051.75 Level 4 Emergency Exam 1,788.00 Pre-Notify Trauma Act w/CC 9,738.75 Level 5 Emergency Exam 2,640.00

of 5 Summa Akron City, St. Thomas and Barberton Hospitals Usual and Customary Charges for Selected Procedures Patient Price List

Operating Room Charges Operating Room Room Open Per Minute Level 1 1,961.00 41.25 Level 2 4,319.50 43.50 Level 3 5,618.00 51.00 Level 4 12,031.00 82.75

Anesthesia charges are a function of the type of anesthesia and the level of risk for the patient based on the patient’s overall health and risk for complications. Fees for anesthesia administration are not reflected and will be billed separately by your physician.

Epidural ASA 1 First 30 Min 785.50 MAC ASA 4 First 30 Min 461.75 Epidural ASA 2 First 30 Min 864.00 MAC ASA 5 First 30 Min 507.75 Epidural ASA 3 First 30 Min 950.75 Regional ASA 1 First 30 Min 514.25 Epidural ASA 4 First 30 Min 1,045.75 Regional ASA 2 First 30 Min 565.75 Epidural ASA 5 First 30 Min 1,150.25 Regional ASA 3 First 30 Min 622.00 General ASA 1 First 30 Min 986.00 Regional ASA 4 First 30 Min 684.50 General ASA 2 First 30 Min 1,085.00 Regional ASA 5 First 30 Min 752.50 General ASA 3 First 30 Min 1,193.25 Spinal ASA 1 First 30 Min 630.00 General ASA 4 First 30 Min 1,315.50 Spinal ASA 2 First 30 Min 692.25 General ASA 5 First 30 Min 1,443.50 Spinal ASA 3 First 30 Min 762.00 MAC ASA 1 First 30 Min 347.25 Spinal ASA 4 First 30 Min 838.00 MAC ASA 2 First 30 Min 381.50 Spinal ASA 5 First 30 Min 922.25 MAC ASA 3 First 30 Min 420.25 each additional 15 Min all anesthesia 65.25

X-Ray and Radiological Charges The following charges reflect the hospital’s 30 most common Radiological procedures (in alphabetical order)

Bone and or Jt Imag Whole Body 2,876.75 Mammog Scr-Bil w/Dig Image 373.25 CT Abd/Pelv w cont 4,638.75 Myocard Perf Image Spect Mx 5,223.50 CT Abd/Pelv wo cont 3,744.50 PET CT Skull Thigh 9,006.00 CT Cerv Spine wo cont 2,735.00 Ultrasound ABD w Image Doc Complt 1,732.00 CT Head/Brain wo cont 2,735.00 Ultrasound ABD w Image Doc Ltd 1,229.50 CT Thorax w contr 3,115.50 Ultrasound Breast Limited 633.00 CTA Chest w/wo cont 4,569.50 Ultrasound Guid Needle Plcmt 1,538.25 Digital Diag Mammography 464.50 Ultrasound Pelvic w/Docum Complt 869.50 DXA Bone Density 1+ Sites Axial 1,183.25 Ultrasound Preg 1st Trim TA APP Sing 763.00 ECG Stress 1,633.00 Ultrasound Preg Transvaginal 1,168.00 Fluoro Guide Needle Plcmt 1,253.00 Ultrasound Transvaginal 1,326.50 Hepatobili Duct Image incl GB 2,715.00 XR Abd Complt Incl Decubitus 962.00 MRA Head wo cont 3,899.25 XR Abdomen Single AP View 465.00 MRI Any Jt Low Ext w cont 4,835.00 XR Chest 1 View Front 547.00 MRI Brain w/wo cont 6,735.75 XR Chest PA and Lateral 647.25

Laboratory

The following charges reflect the hospital’s 30 most common laboratory procedures (in alphabetical order).

Alerg SP-IGE Quan or SemiQuan 28.75 Hepatic Function 182.00 APTT 125.75 Iron 116.00 Autom Urinalysis WO Micro 74.00 Lipase 192.25 Bact Cult-Urine Quan Count 209.50 Lipid Panel 223.75 Page 3 of 5 Summa Akron City, St. Thomas and Barberton Hospitals Usual and Customary Charges for Selected Procedures Patient Price List

Basic Metabolic Panel 185.25 Magnesium 107.00 Blood Typing ABO 117.25 Neisseria Amplif NA Probe 241.00 Blood Typing RH 110.25 Prothrombin Time 87.75 Chlam Trach Amp Probe 241.00 RBC AB Scrn Ea Techiq 238.00 Compl Autom CBC W Plt 119.25 Surgical Path Level IV 362.75 Pl CBC W Plt W Autom Diff 119.25 Troponin Quant 263.50 Drug Screen Class List A 251.00 Thyroid Stimulating Hormone (TSH) 169.50 Comprehensive Metabolic Panel 348.00 Urinalysis Complete 25.00 Ferritin 218.50 Urinalysis Microscopic Only 33.25 Glucose by Meter 104.75 Urine Pregnancy Visual color 214.25 Hemoglobin A-1-C 182.00 Vitamin B-12 Level 260.25

Occupational or Physical Therapy The following charges reflect the most common services offered by our Occupational Therapy and Physical Therapy departments. Patients may have additional charges, depending on the services performed.

Apply Finger Splint – Static 307.25 PT Evaluation and Report 499.75 Apply Short Arm Splint 707.75 PT Re-Eval 499.75 OT Evaluation and Report 524.50 PT Tx Active Funct per 15 Min 289.75 OT Re-Eval 436.00 PT Tx Man Ther Tech per 15 Min 241.25 OT Tx Man Ther per 15 Min 241.25 PT Tx Proc Neuro per 15 Min 227.75 OT Tx Proc per Min 251.25 PT Tx Proc per 15 Min 251.25 OT Whirlpool Therapy 342.25 PT Tract Mech 228.75 PT E Stim Unat 146.50 PT US per 15 Min 241.25

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

Arterial Puncture Blood for DX 921.75 Hast w/ Report 226.50 Behav Chng Smoking 3-10 min 77.75 Intubation Emerg Proc 2,013.75 Behavior Chng Smoking > 10 min 104.00 Pos Airway Pressure CPAP 1,259.50

Blood Gas Mixed WO O2 Sat 370.25 Potassium 79.50 Bronchoprovocation 3,268.25 Pulm Funct Tst by Gas FRC/RV 1,065.75 Bronchospasm-Pre & Post BD 1,042.00 Pulm Funct Tst Pleth/FRC/RV 816.25 Chest Pt; Subsequent 210.00 Pulse OX Multi Det with Exercise 192.25 CO Diffuse Capacity 791.75 Pulse OX Sgl w/Procedure Only 315.25 CO Expired Gas by IR 676.25 Spirometry 664.25 Evaluate Pt Use of Inhaler 313.25 Vent Mgmt Inpt Init or Obs 1st Day 3,263.00 Flow Volume Loop 1,065.75 Vent Mgmt Inpat Subq Day 1,949.25

Hospital Billing Policies Your insurance providers, including Medicare, Medicaid, other primary insurance providers and secondary insurance providers are billed by Summa hospitals before a bill is sent to you. Interest will not be charged on any balance due after insurance payments are received. If you are not able to pay the amount you owe in full, please contact Patient Financial Services at the phone number noted on your bill to apply for financial assistance or arrange for a payment plan.

Emergency services are neither delayed nor withheld on the basis of a patient’s ability to pay. You may also find helpful consumer information at http://www.ohiohealthcareguide.org/.