2021 SELF-PAY PACKAGE PRICING - IHEALTHSPOT
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2021 Self-Pay Package Pricing
The package prices are discounted
in exchange for prompt payment,
the day of service.
Discounts
Do Not Apply to Packaged
Prices Below
■2
5% discount if paid on the
date of the hospital statement
(approximately 7-10 days
after the date of service).
■2
0% discount if paid
in 30 days
The package prices are discounted in exchange for prompt payment, the day of service.
2021 SELF-PAY PACKAGE PRICING
Wooster ENT Drs. A. Mathur, K. Mathur, & Wartmann 330.264.9699
ENT Procedures CPT Code(s) Price
Bilateral ear tubes (myringotomy) 69436 $1,390
Tonsillectomy - 12 yrs old 42826 $1,842
Tonsillectomy & myringotomy - 12 yrs old 69436 & 42826 $2,123
Tonsillectomy & adenoidectomy (T&A) - 12 yrs old 42821 $1,869
T&A including myringotomy - 12 yrs old 69436 & 42821 $2,482
Adenoidectomy - 12 yrs old 42831 $1,664
Adenoidectomy & myringotomy - 12 yrs old 69436 & 42831 $2,747
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon. Cash payment must be made the day of the procedure.
Fee assumes procedure is performed without complications.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
North Central Ohio Ear Nose & Throat Surgeons, Inc. Dr. Grimes 330.621.8013
ENT Procedures CPT Code(s) Price
Bilateral ear tubes (myringotomy) 69436 $1,214
Tonsillectomy - 12 yrs old 42826 $1,591
Tonsillectomy & myringotomy - 12 yrs old 69436 & 42826 $1,873
Tonsillectomy & adenoidectomy (T&A) - 12 yrs old 42821 $1,678
T&A including myringotomy - 12 yrs old 69436 & 42821 $2,120
Adenoidectomy - 12 yrs old 42831 $1,557
Adenoidectomy & myringotomy - 12 yrs old 69436 & 42831 $2,203
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon. Cash payment must be made the day of the procedure.
Fee assumes procedure is performed without complications.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
1 1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org
2021 SELF-PAY PACKAGE PRICING
Bloomington Women’s Care Drs. Marcanthony & Prokop 330.202.5662
OB/GYN Procedures CPT Code(s) Price
Cerclage of cervix/revision of cervix 59320 $3,233
Vaginal/laparoscopic hysterectomy, 250Gm LAVH/BSO 58554 $11,363
Vaginal/laparoscopic hysterectomy, 250Gm LAVH Only 58553 $11,135
Hysteroscopy biopsy, with or without D&C 58558 $3,332
D&C (dilation & curettage) 58120 $3,282
Miscarriage, 1st trimester, suction D&E 59820 $3,497
Miscarriage, 2nd trimester, suction D&E 59821 $3,495
Laparoscopy with tubal block 58670 $6,235
Anterior repair, vagina & bladder 57240 $6,229
Posterior repair, rectum & vagina 57250 $6,234
Anterior & posterior repair, vagina 57260 $6,438
Repair of enterocele (bowel bulge), vaginal 57268 $3,968
(1) C-section DRG 766 59510 $8,471
Tubal w/C-section DRG 766 59510 $8,571
(2) Vaginal delivery DRG 775 59400 $6,755
Vaginal birth after cesearean (VBAC) DRG 775 59610 $6,894
Total abdominal hysterectomy (inpatient) DRG 742 58150 $14,209
Total vaginal hysterectomy 58260 $6,713
Total vaginal hysterectomy w/BSO 58262 $6,826
Bladder suspension/TVT/TVTO 57288 $6,424
Hysterosalpingography 58340 $381
74740 $312
Salingo-oophorectomy (complete or partial/unilat or bilat) laparoscopic 58661 $7,559
Total vaginal hysterectomy with AP repair 58270 $6,361
Tubal ligation w/epidural 58671 $7,051
Scheduled NST 59025 $244
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon. Procedures must be done by the listed physicians.
(1) C-section Includes: 1st ultrasound (done in office), prenatal office visits, six-week postpartum/post-op follow up,
and 72 hours length of stay for mom and infant.
(2) Vaginal delivery Includes: 1st ultrasound (done in office), prenatal office visits, six-week postpartum follow up, and 48
hours length of stay for mom and infant.
(1&2) Requires monthly payment. Delivery packages be paid by 32 weeks. For questions please call: 330.202.5662.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org 2
2021 SELF-PAY PACKAGE PRICING
Wooster OB/GYN Drs. Holmes Mason, C. Miller, J. Miller & Weeman 330.345.2229
OB/GYN Procedures CPT Code(s) Price
Cerclage of cervix/revision of cervix 59320 $3,791
Vaginal/laparoscopic hysterectomy, 250Gm LAVH/BSO 58554 $13,141
Vaginal/laparoscopic hysterectomy, 250Gm LAVH Only 58553 $13,253
Hysteroscopy biopsy, with or without D&C 58558 $4,104
D&C (dilation & curettage) 58120 $3,903
Miscarriage, 1st trimester, suction D&E 59820 $4,127
Miscarriage, 2nd trimester, suction D&E 59821 $4,133
Laparoscopy with tubal block 58670 $7,218
Anterior repair, vagina & bladder 57240 $7,102
Posterior repair, rectum & vagina 57250 $7,107
Anterior & posterior repair, vagina 57260 $7,339
Repair of enterocele (bowel bulge), vaginal 57268 $6,906
(1) C-section DRG 766 59510 $8,843
Tubal w/C-section DRG 766 58611 $9,039
(2) Vaginal delivery DRG 775 59400 $7,079
Vaginal birth after cesearean (VBAC) DRG 775 59610 $7,411
Total abdominal hysterectomy (inpatient) DRG 742 58150 $15,545
Total vaginal hysterectomy 58260 $7,430
Total vaginal hysterectomy w/BSO 58262 $7,430
Bladder suspension/TVT/TVTO 57288 $7,010
Hysterosalpingography 58340 & 74740 $551
Salingo-oophorectomy (complete or partial/unilat or bilat) laparoscopic 58661 $7,808
Total vaginal hysterectomy with AP repair 58270 $7,730
Tubal ligation w/epidural 58671 $7,136
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon. Procedures must be done by the listed physicians.
(1) C-section Includes: 1st ultrasound (done in office), prenatal office visits, six-week postpartum/post-op follow up,
and 72 hours length of stay for mom and infant.
(2) Vaginal delivery Includes: 1st ultrasound (done in office), prenatal office visits, six-week postpartum follow up, and 48 hours
length of stay for mom and infant.
(1&2) Requires monthly payment. Payment is required in full by week 32. For questions please call: 330.345.2229.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
3 1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org
2021 SELF-PAY PACKAGE PRICING
WCH Surgical Associates Drs. Calabretta, Cebul & Robotham 330.287.2595
Wooster Plastic & Reconstructive Surgery Dr. Slaby 330.202.3350
General Surgery Procedures CPT Code(s) Price
**Procedure performed by Dr. Slaby
* = Inpatient only
Inguinal hernia repair, w/o mesh (unilateral) 49505 $5,000
Inguinal hernia repair, w/mesh (unilateral) 49505 & 49568 $5,332
Inguinal hernia repair, laparoscopic, w/o mesh (unilateral) 49650 $7,208
Laparoscopic inguinal hernia repair w/mesh (unilateral) 49650 & 49568 $7,620
Laparoscopic inguinal hernia repair w/mesh (bilateral) 49650 & 49568 $7,700
Laparoscopic cholecystectomy w/o cholangiography 47562 $7,573
Laparoscopic cholecystectomy w/cholangiography 47563 $7,645
Laparo cholecystectomy/explr 47564 $8,135
Open cholecystectomy w/o cholangiography* DRG 416 47600 $12,650
Open cholecystectomy w/cholangiography* DRG 413 47605 $14,797
Screening colonoscopy (Cebul) 45378 $1,218
Diagnostic colonoscopy (Cebul) 45380 $1,549
Screening Colonoscopy with general anesthesia 45378 $1,461
Diagnostic Colonoscopy with general anesthesia 45380 $1,793
Debridement & possible skin graft 15002 $5,901
Debridement 15002
Skin graft 15100
Open umbilical hernia repair, w/o mesh 49585 $4,906
Open umbilical hernia repair, w/mesh 49585 & 49568 $5,238
Modified radical mastectomy 19307 $14,271
Lymph node biopsy 38525
Sentinel lymph node tracer 38792
49650, 49568 &
Laparoscopic unilateral inguinal hernia w/mesh + umbilical hernia repairs $12,207
49585
49650, 49568 &
Laparoscopic bilateral inguinal hernia w/mesh + umbilical hernia repairs $12,287
49585
49650, 49568 &
Laparoscopic bilateral inguinal hernia w/mesh + umbilical hernia repairs $12,327
49585
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon (not included in colonoscopy packages).
Services must be performed by the above listed physicians. Cash payment must be made the day of the procedure.
Fee assumes procedure is performed without complications.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org 42021 SELF-PAY PACKAGE PRICING
WCH Surgical Associates Drs. Calabretta, Cebul & Robotham 330.287.2595
Wooster Plastic & Reconstructive Surgery Dr. Slaby 330.202.3350
General Surgery Procedures CPT Code(s) Price
**Procedure performed by Dr. Slaby
* = Inpatient only
EGD (upper endoscopy) 43235 $1,530
EGD (upper endoscopy) 43239 $1,549
Litholaplaxy 52318 $4,702
Removal of hydrocele 55040 $4,569
Endovenous laser 1st vein 36478 $4,065
Endovenous laser vein addon 36479 $169
Dilate urethra stricture 53620 $949
Probe nasolacrimal duct 68811 $2,873
Cystoscopy & ureter catheter 52005 $2,703
Cysto/uretero w/lithotripsy 52356 $6,207
Fragmenting of kidney stone 50590 $5,053
Cystoscopy and treatment 52332 $4,232
Exc neck tum deep < 5 cm 21556 $3,851
Debride skin musc at fx site 11011 $1,159
Deb skin bone at fx site 11012 $3,524
Laparoscopy appendectomy 44970 $7,381
Repair vagina/perineum 57210 $3,830
Removal of nose polyp(s) 30115 $4,246
Laparoscopy pyeloplasty 50544 $13,214
Lithotripsy/stent 52356 $6,367
Excision, malignant lesion, face 11644 $2,325
Insertion of port 36561, 77001 & $4,333
76937
Thyroidectomy uni 60220 $7,618
Thyroidectomy total 60240 $7,881
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon (not included in colonoscopy packages).
Services must be performed by the above listed physicians. Cash payment must be made the day of the procedure.
Fee assumes procedure is performed without complications.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
5 1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org2021 SELF-PAY PACKAGE PRICING
Ohio State Medical Center Sports Medicine Orthopaedics
Dr. Chicorelli
330.202.3420
Bloomington Orthopedic Specialists
Drs. Borruso & Newton
Elective Surgery Procedures CPT Code(s) Price
**Procedure performed by Dr. Slaby
**Carpal tunnel - unilateral (open) 64721 $3,177
**Carpal tunnel - bilateral (open) - bilateral 64721 $3,257
Total hip replacement DRG 470 27130 $18,026
Revision of total hip arthroplasty, both components DRG 468 27134 $25,637
Revision of total hip arthroplasty, acetabular component only DRG 468 27137 $24,746
Revision of total hip arthroplasty, femoral component only DRG 468 27138 $24,817
Total hip, anterior 27130 $18,106
Shoulder rotator cuff arthroscopy 29827 $8,498
Shoulder arthroscopy 29824 & 29826 $4,903
Total shoulder replacement DRG 483 23472 $23,164
Total knee replacement, unilateral DRG 470 INPATIENT 27447 $18,044
Total knee replacement, bilateral DRG 462 INPATIENT 27447 $28,018
Total knee replacement, unilateral, OUTPATIENT 27447 $18,224
Revision of knee joint, unicompartmental DRG 468 27446 $24,242
Knee revision, with or without allograft, one component DRG 468 27486 $24,624
Knee revision, femoral & entire tibial component DRG 468 27487 $25,055
Arthroscopic ACL knee with allograft 29888 $9,791
Knee arthroscopy 29880 $4,823
Knee arthroscopy 29881 $4,798
Knee arthroscopy 29882 $4,983
Knee arthroscopy 29883 $5,163
Knee arthroscopy 29877 $4,895
Knee arthroscopy 29874 $4,795
below knee amputation DRG 240 27880 $23,995
Above knee amputation DRG 240 27590 $23,854
repair of kneecap tendon 27380 $9,024
Treatment of ankle fracture 27792 $9,074
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon.
Services must be performed by the above listed physicians. Cash payment must be made the day of the procedure.
Fee assumes procedure is performed without complications.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org 62021 SELF-PAY PACKAGE PRICING
Ohio State Medical Center Sports Medicine Orthopaedics
Dr. Chicorelli
330.202.3420
Bloomington Orthopedic Specialists
Drs. Borruso & Newton
Orthopedic Procedures CPT Code(s) Price
ORIF, ankle 27814 $9,220
ORIF, wrist 25574 $9,104
Wrist fracture 25606 $4,873
labral tear 29807 $9,545
treat heel fracture 28415 $9,684
N block other peripheral 64450 $864
pin finger fracture each 26756 $4,059
treat fx rad intra-articul 25608 $8,767
Microdiscectomy lumbar, 1 level 63030 $9,650
S1 Fusion 1 level 27279 $22,321
Lumbar laminectomy 1 level 63047 $9,819
Anterior cervical discectomy and fusion, 1 level 22551, 22845 & $19,536
20931
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon.
Services must be performed by the above listed physicians. Cash payment must be made the day of the procedure.
Fee assumes procedure is performed without complications.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
7 1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org2021 SELF-PAY PACKAGE PRICING
Wooster Orthopaedic & Sports Medicine Center
330.804.9712
Drs. Knapic, Miller, Watts & Widmer
Orthopedic Procedures CPT Code(s) Price
Total knee replacement, unilateral DRG 470 27447 $18,325
Total knee replacement, bilateral DRG 462 27447 $29,873
Total knee, unilateral, unicompartmental, OUTPATIENT 27447 $18,325
Revision of knee joint, unicompartmental DRG 468 27446 $24,433
Knee revision, with or without allograft, one component 27486 $24,848
Knee revision, femoral & entire tibial component 27487 $25,323
Total hip replacement 27130 $18,425
Total hip replacement OUTPATIENT 27130 $18,365
Revision of total hip arthroplasty, both components 27134 $25,701
Revision of total hip arthroplasty, acetabular component only 27137 $25,099
Revision of total hip arthroplasty, femoral component only 27138 $25,178
Total hip, anterior 27130 $18,446
Total shoulder replacement DRG 483 23472 $22,031
Below Knee Amputation 27880 $23,587
Above knee Amputation 27590 $23,427
Microdiscectomy lumbar, 1 level 63030 $9,650
Spinal cord stimulator trial 63650 $8,927
Spinal cord stimulator permanent 63685 $38,745
S1 Fusion 1 level 27279 $22,321
Lumbar laminectomy 1 level 63047 $9,819
Anterior cervical discectomy and fusion, 1 level 22551, 22845 $19,536
& 20931
Fee includes: hospital, surgeon and anesthesiologist,
1 pre-operative and 1 post-operative office visit with the surgeon.
Services must be performed by the above listed physicians. Cash payment must be made the day of the procedure.
Fee assumes procedure is performed without complications.
Prices for all services do NOT include pathology for 2021
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org 82021 SELF-PAY PACKAGE PRICING
Wooster Heart Group - Drs. Ofori, Moodispaw, & Nagajothi 330.202.5700
Cardiovascular Procedures CPT Code(s) Price
Nuclear stress test with exercise 93016, 93018 $1,745
& 78456
Nuclear stress test without exercise (with Regadenoson) 93016, 93018 & $1,789
Add drug charge 78456
Cardioversion 92960 $828
Echocardiogram, complete 93306 $694
Stress test 93017 & 93350 $1,021
Left heart cath 93458 $3,994
PCTA/stent (drug eluting) 92928 $13,609
Calcium Scoring 76380 & 75571 $263
Regional Vascular & Vein Institute - Dr. Butler 330.588.8900
Cardiovascular Procedures CPT Code(s) Price
Carotid Complete 93880 $361
93882 $183
Venous Complete - Bilateral 93970 $354
Venous Limited (1-leg) 93971 $178
Arterial duplex 93925 $361
93926 $183
Arterial Complete 93923 $213
Arterial with Exercise 93924 $217
Ankle brachial index 93922 $200
Upper extremity arterial study 93923 $213
Renal duplex 93975 $387
Aorta 93978 $361
AV Fistula 93990 $182
93985 $361
Surgical Specialists of Wayne County - Dr. Stern 330.264.5347
Cardiovascular Procedures CPT Code(s) Price
Carotid Complete 93880 $361
Venous Complete - Bilateral 93970 $354
Venous Limited (1-leg) 93971 $178
Arterial Complete 93923 $213
Arterial with Exercise 93924 $217
Fee includes: hospital, and interpreting physician fee. Cash payment must be made the day of the procedure. There have been
no arrangement made with Cleveland Clinic to date.
Fee assumes procedure is performed without complications.
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
9 1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org2021 SELF-PAY PACKAGE PRICING
WCH Business Office:
Wooster Community Hospital Imaging Services
330.263.8158
MRI
Test CPT code Pricing
To schedule a MRI please
MRI w/o contrast, per exam $510 call 330.263.8660
MRI w/contrast, per exam $701 Physicians order required
MRI w/o & w/contrast, per exam $870
MRI, breast $362
Fee includes: hospital and radiologist interpretation. Cash payment must be made the day of the procedure.
Imaging Tests
Test CPT code Pricing
PET scan 78815 $2,019 To schedule an
Chest x-ray & all plain films $127 imaging test please call
Mammogram $140 330.263.8660
Ultrasound (basic) $222 Physicians order required
Breast Ultrasound $145
Bone Density $146
Low-dose lung screening $201
Computerized Tomography Scan
Test CPT code Pricing
To schedule a CT scan
CT with contrast 74177 $526 please call 330.263.8660
CT without contrast 74176 $360 Physicians order required
CT with and without contrast 74178 $526
CTA $526
Fee includes: hospital and radiologist interpretation. Cash payment must be made the day of the procedure.
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org 102021 SELF-PAY PACKAGE PRICING
Dr. Mary Catherine Sementi 330.263.8416
WCH Inpatient Rehabilitation CPT Code(s) Price
Day Inpatient Rehab Stay $1,535 per day
Fee includes: All services provided at Wooster Community Hospital. Payment for the anticipated number of days is
expected at the time of admission.
Sleep Disorders Center 330.263.8400
CPT Code(s) Price
Sleep study first night 95810 $1,240
Sleep study second night 95811 $1,244
Multiple sleep latency test (MSLT) 95805 $1,181
Sleep study, unattended 95806 $207
Fee includes: All services provided at Wooster Community Hospital. Payment is expected at the time of testing and includes the
physician interpretation fee.
Pulmonary Medicine of Wooster
Drs. Brown and Arthur
330.462.7001
CPT Code(s) Price
6 minute walk 94618 $164
Complete PFT 94060, 94729, $727
94726
EKG 93005 $76
Fee includes: All services provided at Wooster Community Hospital. Payment for the anticipated number of days is
expected at the time of admission.
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
11 1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org2021 SELF-PAY PACKAGE PRICING
HealthPoint Rehab Outpatient Services
330.202.3300
Occupational Therapy, Physical Therapy and Speech Therapy
CPT Code(s) Price
Physical Therapy Evaluation $125
Physical Therapy Treatment $95
Occupational Therapy Evaluation $125
Occupational Therapy Treatment $95
Speech Therapy Evaluation $125
Speech Therapy Treatment $85
The package prices stated are for scheduled and pre-arranged services only.
Complications are not covered under the stated package prices.
Prices are subject to change, for the most up to date pricing, please refer to the website.
1761 Beall Avenue I Wooster, OH 44691 I 330.263.8158 I www.woosterhospital.org 12Hospital Call Center
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