Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
Fee Schedule
Low
$4
Average
$42
Median
$45
High
$191
Each hospital's average Molina rate, under the methodology and billing class chosen below.
25 hospitals; the 90th percentile is 14.4× the 10th. Each bar is a price range and its height is how many hospitals fall in it. Hover a bar, or a row in the ladder, for details.
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25 hospital rates
iThe hospitals that file a Molina rate for this code, one row per hospital and set of terms (billing class, payment method, setting). Rates under different terms are never blended, so the terms are shown under each hospital’s name. Figures are the hospital’s averages across its plans.| # | Plans | |||||||
|---|---|---|---|---|---|---|---|---|
| 1 | AKRON GENERAL MEDICAL CENTER Akron, OH facility · case rate · outpatient | 1 | $46 | $46 | — | — | — | $46 – $46 |
| 2 | CLEVELAND CLINIC AVON HOSPITAL Avon, OH facility · case rate · outpatient | 1 | $44 | $44 | — | — | — | $44 – $44 |
| 3 | CLEVELAND CLINIC CHILDREN'S HOSPITAL FOR REHABILITATION Cleveland, OH facility · case rate · outpatient | 1 | $80 | $80 | — | — | — | $80 – $80 |
| 4 | CLEVELAND CLINIC HEALTH SYSTEM - EAST REGION Mentor, OH facility · case rate · outpatient | 1 | $49 | $49 | — | — | — | $49 – $49 |
| 5 | CLEVELAND CLINIC HEALTH SYSTEM - EAST REGION Euclid, OH facility · case rate · outpatient | 1 | $50 | $50 | — | — | — | $50 – $50 |
| 6 | CLEVELAND CLINIC HEALTH SYSTEM - EAST REGION Warrensville Heights, OH facility · case rate · outpatient | 1 | $52 | $52 | — | — | — | $52 – $52 |
| 7 | Cleveland Clinic Mercy Hospital Canton, OH facility · case rate · outpatient | 1 | $45 | $45 | — | — | — | $45 – $45 |
| 8 | Fairview Hospital Cleveland, OH facility · case rate · outpatient | 1 | $47 | $47 | — | — | — | $47 – $47 |
| 9 | Fisher-Titus Medical Center Norwalk, OH facility · case rate · outpatient | 1 | $33 | $33 | — | — | — | $33 – $33 |
| 10 | Henry Ford Health System West Bloomfield, MI facility · percent of total billed charges · outpatientfrom % of charges | 1 | $5 | $5 | $3 | 68% | — | $2 – $8 |
| 11 | Henry Ford Health System Plymouth, MI facility · percent of total billed charges · outpatientfrom % of charges | 1 | $5 | $5 | $3 | 68% | — | $2 – $8 |
| 12 | Henry Ford Macomb Hospital Corporation Clinton Twp, MI facility · percent of total billed charges · outpatientfrom % of charges | 1 | $5 | $5 | $3 | 68% | — | $2 – $8 |
| 13 | Henry Ford Wyandotte Hospital Brownstown Charter Twp., MI facility · percent of total billed charges · outpatientfrom % of charges | 1 | $5 | $5 | $3 | 68% | — | $2 – $8 |
| 14 | Kalkaska Memorial Health Center Kalkaska, MI facility · percent of total billed charges · outpatientfrom % of charges | 1 | $32 | $32 | — | — | — | $32 – $32 |
| 15 | LODI COMMUNITY HOSPITAL Lodi, OH facility · case rate · outpatient | 1 | $77 | $77 | — | — | — | $77 – $77 |
| 16 | LUTHERAN HOSPITAL Cleveland, OH facility · case rate · outpatient | 1 | $45 | $45 | — | — | — | $45 – $45 |
| 17 | MARYMOUNT HOSPITAL INC Garfield Heights, OH facility · case rate · outpatient | 1 | $44 | $44 | — | — | — | $44 – $44 |
| 18 | MEDICAL CITY ARLINGTON GRAND PRAIRIE, TX percent of total billed charges · outpatientfrom % of charges | 1 | $16 | $16 | $8 | 50% | — | $8 – $24 |
| 19 | MEDICAL CITY FORT WORTH FORT WORTH, TX percent of total billed charges · outpatientfrom % of charges | 1 | $191 | $191 | $95 | 50% | — | $95 – $286 |
| 20 | MEDICAL CITY LAS COLINAS Irving, TX percent of total billed charges · outpatientfrom % of charges | 1 | $4 | $4 | $2 | 50% | — | $2 – $5 |
| 21 | MEDINA HOSPITAL Medina, OH facility · case rate · outpatient | 1 | $46 | $46 | — | — | — | $46 – $46 |
| 22 | THE UNION HOSPITAL ASSOCIATION Dover, OH facility · case rate · outpatient | 1 | $59 | $59 | — | — | — | $59 – $59 |
| 23 | The Cleveland Clinic Foundation Brunswick, OH facility · case rate · outpatient | 1 | $58 | $58 | — | — | — | $58 – $58 |
| 24 | United Memorial Medical Center Batavia, NY facility · fee schedule · outpatient | 1 | $5 | $5 | — | — | — | $5 – $5 |
| 25 | WA Foote Memorial Hospital Jackson, MI facility · percent of total billed charges · outpatientfrom % of charges | 1 | $5 | $5 | $3 | 68% | — | $2 – $8 |
← Payers reporting HCPCS S0030 · Snapshot 20261112T181611Z-3fa9fb76