Patient Price Information List

Disclaimer: Forks Community Hospital determines its standard charges for patient items and services through the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient’s bill. These are the baseline rates for items and services provided at the Hospital. The chargemaster is similar in concept to the manufacturer’s suggested retail price (“MSRP”) on a particular product or good. The charges listed provide only a general starting point in determining the potential costs of an individual patient’s care at the Hospital. This list does not reflect the actual out-of-pocket costs that may be paid by a patient for any particular service, it is not binding, and the actual charges for items and services may vary.

Many factors may influence the actual cost of an item or service, including insurance coverage, rates negotiated with payors, and so on. Government payors, such as Medicare and Medicaid for example, do not pay the chargemaster rates, but rather have their own set rates that hospitals are obligated to accept. Commercial insurance payments are based on contract negotiations with payors and may or may not reflect the standard charges. The cost of treatment also may be impacted by variables involved in a patient’s actual care, such as specific equipment or supplies required, the length of time spent in surgery or recovery, additional tests, or any changes in care or unexpected conditions or complications that arise. Moreover, the foregoing list of charges for services only includes charges from the Hospital. It does not reflect the charges for physicians, such as the surgeon, anesthesiologist, radiologist, pathologist, or other physician specialists or providers who may be involved in providing particular services to a patient. These charges are billed separately.

Individuals with questions about their out-of-pocket costs of service and other financial information should contact the hospital or consider contacting their insurers for further information.

LOCAL MARKET HOSPITALS

In order to present a meaningful comparison, Forks Community Hospital has partnered with Hospital Pricing Specialists LLC to analyze current charges, based off CMS adjudicated claims through 3/31/18. Forks Community Hospital charges are displayed and compared with the local market charge, consisting of the following hospitals:

Hospital Name
Location

Capital Medical Center

Olympia

WA

Evergreen Health Monroe

Monroe

WA

Grays Harbor Community Hospital

Aberdeen

WA

Harrison Medical Center

Bremerton

WA

Island Hospital

Anacortes

WA

Jefferson Healthcare

Port Townsend

WA

Mason General Hospital

Shelton

WA

Morton General Hospital

Morton

WA

Multicare Tacoma General Hospital

Tacoma

WA

Olympic Medical Center

Port Angeles

WA

Providence Centralia Hospital

Centralia

WA

Providence St Peter Hospital

Olympia

WA

Summit Pacific Medical Center

Elma

WA

Whidbey General Hospital

Coupville

WA

INPATIENT ROOM AND BOARD DAILY CHARGES

Description

Our Charge
Market Charge

Variance

Private Room

$2,476
$2,553

3% lower than market

Semi-Private Room

$2,476
$2,375

4% higher than market

OUTPATIENT EMERGENCY DEPARTMENT CHARGES

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. They also do not include fees for Emergency Department physicians, who will bill separately for their services.

Description

Our Charge
Market Charge

Variance

Emergency Critical Care, Each Additional 30 Minutes

$888
$2,467

64% lower than market

Emergency Critical Care, First 30 Minutes

$1,839
$5,904

69% lower than market

Emergency Department Visit - Level 1

$200
$306

35% lower than market

Emergency Department Visit - Level 2

$360
$389

8% lower than market

Emergency Department Visit - Level 3

$570
$868

34% lower than market

Emergency Department Visit - Level 4

$504
$1,288

61% lower than market

OUTPATIENT PHYSICAL THERAPY CHARGES

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

Description

Our Charge
Market Charge

Variance

Application of Electrical Stimulation - 15 Minutes

$142
$107

33% higher than market

Physical Therapy, complex evaluation

$428
$346

24% higher than market

PT Evaluation - Moderate Complexity

$428
$321

33% higher than market

Physical Therapy, re-evaluation

$192
$172

12% higher than market

OUTPATIENT CLINIC CHARGES

Description

Our Charge
Market Charge

Variance

Established patient assisted living visit, typically 25 minutes

$196
$196

Approximately equal to market

Established patient office or other outpatient visit, typically 10 minutes

$204
$172

18% higher than market

Established patient office visit, comprehensive visit

$345
$347

1% lower than market

OUTPATIENT OCCUPATIONAL THERAPY CHARGES

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

Description

Our Charge
Market Charge

Variance

Occupational Therapy, complex evaluation

$394
$411

4% lower than market

Occupational Therapy Evaluation - Moderate Complexity

$394
$312

26% higher than market

Self Care - Home Management Training - 15 Minutes

$160
$142

13% higher than market

OUTPATIENT PULMONARY THERAPY CHARGES

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

Description

Our Charge
Market Charge

Variance

Holter Testing - 48-Hour EKG

$173
$508

66% lower than market

Routine EKG - Minimum 12 Leads

$234
$224

4% higher than market

Spirometry - breathing test

$128
$319

60% lower than market

Spirometry - medicated breathing procedure

$207
$558

63% lower than market

Stress Test

$346
$908

62% lower than market

OUTPATIENT LABORATORY AND PATHOLOGY CHARGES

The following charges reflect our most common laboratory procedures. For all lab specimens collected via blood draw, the venipuncture will be charged separately.

Description

Our Charge
Market Charge

Variance

Adrenocorticotropic hormone (ACTH) level

$219
$249

12% lower than market

Albumin Level

$70
$52

36% higher than market

Alpha-Fetoprotein (AFP) Level, Serum

$102
$103

1% lower than market

Ammonia Level

$212
$155

37% higher than market

Antibody; Epstein-Barr (EB) virus, nuclear antigen (EBNA)

$184
$165

12% higher than market

Analysis for antibody to Herpes simplex virus, type 2

$124
$111

11% higher than market

Arterial Blood Gases Measurement

$354
$259

37% higher than market

Bacterial Blood Culture

$212
$228

7% lower than market

Blood Potassium Level

$80
$60

33% higher than market

Blood Sodium Level

$80
$77

4% higher than market

Blood Typing, ABO

$68
$100

32% lower than market

Blood Typing, Rh (D)

$83
$60

38% higher than market

Blood Unit Compatibility Test; Antiglobulin Technique

$233
$208

12% higher than market

Carcinoembryonic Antigen (CEA) Protein Level

$149
$200

25% lower than market

Coagulation Function Measurement; D-dimer; quantitative

$203
$176

15% higher than market

Creatine Kinase

$74
$87

15% lower than market

Creatine Kinase Level

$256
$189

36% higher than market

Creatinine clearance measurement to test for kidney function

$128
$126

1% higher than market

Culture for acid-fast bacilli

$110
$111

1% lower than market

Cyanocobalamin (Vitamin B-12)

$84
$120

30% lower than market

Detection Test for Chlamydia; Amplified Probe Technique

$124
$181

32% lower than market

Detection Test for Hepatitis B

$102
$84

22% higher than market

Detection Test for Hepatitis C Virus; Includes Reverse Transcription

$438
$424

3% higher than market

Detection Test for Neisseria Gonorrhoeae

$124
$164

24% lower than market

Immunoassay for infectious agent antibody, quantitative, not otherwise specified

$96
$279

66% lower than market

Detection test for HIV-1 and HIV-2

$184
$182

1% higher than market

Detection test for clostridium difficile

$229
$169

35% higher than market

Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reve

$825
$897

8% lower than market

Drug Test(s) by Chemistry Analyzer

$340
$517

34% lower than market

Drug test(s) presumptive, any number of drug classes, includes sample validation when performed

$85
$137

38% lower than market

Ferritin

$71
$115

38% lower than market

Folic Acid Level

$76
$110

31% lower than market

Folic acid level

$106
$96

10% higher than market

Fungal culture (mold or yeast)

$86
$151

43% lower than market

Gammaglobulin Measurement

$108
$82

31% higher than market

Glutamyltransferase Level

$57
$60

5% lower than market

Gonadotropin Analysis

$142
$106

34% higher than market

Gonadotropin, chorionic (reproductive hormone) level

$169
$179

5% lower than market

Hepatitis B Antibody Measurement

$77
$86

11% lower than market

Hepatitis B Surface Antibody Measurement

$69
$71

2% lower than market

Hepatitis C Antibody Measurement

$77
$118

35% lower than market

HLA typing; A, B, or C (eg, A10, B7, B27), single antigen

$196
$158

24% higher than market

Immunologic Analysis for Detection of Tumor Antigen; Immunoassay - Quantitative CA 19-9

$204
$162

26% higher than market

Infectious agent detection by nucleic acid (DNA or RNA); 12-25 targets

$825
$985

16% lower than market

Iron Binding Capacity

$72
$54

33% higher than market

Iron Level

$65
$55

17% higher than market

Lactic Acid

$124
$160

22% lower than market

Levetiracetam level

$102
$84

21% higher than market

Lipase

$143
$121

18% higher than market

Manual urinalysis test with examination using microscope

$99
$99

Approximately equal to market

Measurement high sensitivity C-reactive protein

$86
$112

23% lower than market

Measurement of Antibody for Assessment of Autoimmune Disorder

$116
$111

4% higher than market

Measurement of Hepatitis A antibody

$68
$107

37% lower than market

Microsomal Antibodies Measurement

$103
$77

33% higher than market

Organic acid level

$160
$149

8% higher than market

PSA Measurement; Free

$112
$146

23% lower than market

Pap test; screening by automated system and manual review

$86
$110

22% lower than market

Parathormone

$255
$218

17% higher than market

Phosphatase (enzyme) level; alkaline

$69
$53

30% higher than market

Protein Measurement, Serum

$134
$108

24% higher than market

Qualitative or semiquantitative detection test for helicobacter pylori in stool, multiple-step metho

$157
$137

14% higher than market

Quantitation of therapeutic drug

$200
$332

40% lower than market

Red Blood Cell Concentration Measurement

$53
$39

35% higher than market

Screening Test for Autoimmune Disorder

$102
$86

19% higher than market

Screening Test for Red Blood Cell Antibodies

$136
$111

22% higher than market

Screening test for antibody to noninfectious agent

$77
$95

19% lower than market

Sex hormone binding globulin (protein) level

$142
$102

39% higher than market

Smear for Parasites

$107
$113

6% lower than market

Special stain for parasites

$107
$80

33% higher than market

Stool analysis for blood

$90
$90

1% higher than market

Surgical Pathology, Intermediate Complexity

$50
$341

85% lower than market

Syphilis Detection Test

$37
$31

20% higher than market

Test for Influenza Virus

$128
$183

30% lower than market

Testosterone Level; Free

$138
$142

3% lower than market

Testosterone Level; Total

$138
$172

20% lower than market

Thyroid Stimulating Hormone (TSH)

$158
$126

26% higher than market

Total Protein Level, Blood

$43
$71

40% lower than market

Troponin

$231
$184

25% higher than market

Urine Osmolality Measurement

$93
$79

18% higher than market

Valproic acid level

$223
$223

Approximately equal to market

Vancomycin Level

$223
$178

25% higher than market

OUTPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

Determination of lung volumes using gas dilution or washout

$153
$221

31% lower than market

External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; review and interpretation by a physician or other qualified health care professional

$97
$97

Approximately equal to market

Hydration Infusion into a Vein

$167
$191

13% lower than market

Hydration Infusion into a Vein - 31 Minutes to 1 Hour

$323
$588

45% lower than market

Infusion (Additional) for Therapy, Diagnosis or Prevention

$22
$245

91% lower than market

Infusion into a Vein for Therapy, Diagnosis, or Prevention

$22
$198

89% lower than market

Infusion of Drug or Substance into Vein for Therapy or Diagnosis

$380
$744

49% lower than market

Injection Beneath the Skin for Therapy, Diagnosis, or Prevention

$72
$207

65% lower than market

Injection of Same Drug into Vein for Therapy or Diagnosis

$22
$177

88% lower than market

Sleep Monitoring with CPAP

$4,477
$5,654

21% lower than market

Sleep monitoring of patient (6 years or older) in sleep lab

$4,223
$4,919

14% lower than market

Training in use of orthotics (supports, braces, or splints) for arms, legs and/or trunk each 15 minu

$138
$163

16% lower than market

VITAL CAPACITY TOTAL SEPARATE PROCEDURE

$102
$247

59% lower than market

Wheelchair management, each 15 minutes

$131
$105

25% higher than market

OUTPATIENT OBSERVATION CHARGES

Description

Our Charge
Market Charge

Variance

Hospital observation care typically 50 minutes

$349
$361

3% lower than market

Hospital observation care typically 70 minutes per day

$527
$460

15% higher than market

Hospital observation or inpatient care high severity, 55 minutes per day

$1,143
$1,143

Approximately equal to market

Subsequent observation care, typically 15 minutes per day

$157
$245

36% lower than market

OUTPATIENT OTHER CHARGES

Description

Our Charge
Market Charge

Variance

Anesthesia for middle or incisional abdominal hernia repair

$48
$48

Approximately equal to market

Anesthesia for open or endoscopic procedure on knee including

$48
$48

Approximately equal to market

Anesthesia for procedure on nerves, muscles, tendons, fascia, and bursae of forearm, wrist, and hand

$48
$48

Approximately equal to market

Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified

$48
$48

Approximately equal to market

Diabetes outpatient self-management training services, individual, per 30 minutes

$130
$158

18% lower than market

Electric Stimulation for Therapy

$124
$105

18% higher than market

Hospital Observation per Hour

$92
$140

34% lower than market

Injection, clindamycin phosphate, 300 mg

$50
$50

Approximately equal to market

Injection, pantoprazole sodium, 40 mg

$31
$31

Approximately equal to market

Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure)

$9,260
$7,610

22% higher than market

OUTPATIENT PHARMACY AND DRUG ADMINISTRATION CHARGES

Description

Our Charge
Market Charge

Variance

Injection of Drug or Substance into Vein for Therapy or Diagnosis

$139
$446

69% lower than market

Injection of New Drug into Vein for Therapy or Diagnosis

$22
$229

90% lower than market

Atezolizumab - 1200 mg

$9
$13

30% lower than market

Injection, Azithromycin, 500 mg

$27
$100

73% lower than market

Injection, Cefazolin Sodium, 500 mg

$50
$52

3% lower than market

Injection, Ceftriaxone Sodium, per 250 mg

$55
$58

6% lower than market

Injection, Dexamethasone Sodium Phosphate, 1 mg

$12
$11

10% higher than market

Injection, Diphenhydramine HCL, up to 50 mg

$10
$58

84% lower than market

Injection, Fentanyl Citrate, 0.1 mg

$11
$85

88% lower than market

Injection, Furosemide, up to 20 mg

$24
$37

35% lower than market

Injection, Hydromorphone, Up to 4 mg

$16
$68

76% lower than market

Injection, Ketorolac Tromethamine, per 15 mg

$15
$61

75% lower than market

Injection, Levofloxacin, 250 mg

$64
$55

17% higher than market

Injection, Lorazepam, 2 mg

$9
$72

87% lower than market

Injection, Methylprednisolone Sodium Succinate, up to 125 mg

$34
$88

62% lower than market

Injection, Metoclopramide HCL, Up to 10mg

$11
$80

86% lower than market

Injection, Midazolam Hydrochloride, per 1 mg

$10
$51

81% lower than market

Injection, Morphine Sulfate, up to 10 mg

$15
$88

83% lower than market

Injection, Ondansetron Hydrochloride, per 1 mg

$15
$28

45% lower than market

Injection, Promethazine HCL, up to 50 mg

$10
$75

87% lower than market

Injection, Vancomycin HCL, 500 mg

$67
$53

26% higher than market

Injection, cefepime hydrochloride, 500 mg

$22
$59

63% lower than market

Injection, digoxin, up to 0.5 mg

$36
$42

14% lower than market

Injection, ertapenem sodium, 500 mg

$108
$282

62% lower than market

Injection, glucagon hydrochloride, per 1 mg

$549
$783

30% lower than market

Injection, haloperidol, up to 5 mg

$55
$68

19% lower than market

Injection, naloxone hydrochloride, per 1 mg

$73
$118

38% lower than market

Injection, sincalide, 5 micrograms

$269
$458

41% lower than market

Injection, terbutaline sulfate, up to 1 mg

$27
$27

Approximately equal to market

Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg

$48
$49

3% lower than market

OUTPATIENT RESPIRATORY THERAPY CHARGES

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

Description

Our Charge
Market Charge

Variance

CO Diffusion Capacity

$244
$261

6% lower than market

Nebulizer Treatment

$139
$269

48% lower than market

Pulse Oximetry

$43
$109

61% lower than market

OUTPATIENT SURGICAL SERVICES CHARGES

Description

Our Charge
Market Charge

Variance

Biopsy of breast accessed throught the skin with ultrasound guidance; first lesion

$2,836
$2,627

8% higher than market

Control Nose Bleed - Simple Case

$469
$514

9% lower than market

Drainage of Abscess

$407
$606

33% lower than market

Insertion of Needle into Vein to Collect Blood

$29
$30

5% lower than market

Release and/or relocation of median nerve of hand

$6,351
$6,105

4% higher than market

Removal of foreign body from ear canal

$511
$376

36% higher than market

Removal of foreign body in anus using an endoscope

$618
$618

Approximately equal to market

Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral

$9,000
$9,000

Approximately equal to market

Repair of Wound (2.6 to 7.5 centimeters)

$732
$671

9% higher than market

Repair of Wound (7.6 to 12.5 cm)

$864
$716

21% higher than market

Simple wound repair of scalp, neck, external genitalia; 2.5 cm or less

$624
$633

1% lower than market

OUTPATIENT TRANSPORTATION CHARGES

Description

Our Charge
Market Charge

Variance

Ambulance service, basic life support, emergency transport (bls-emergency)

$811
$741

9% higher than market

Ground mileage, per statute mile

$38
$28

35% higher than market

OUTPATIENT X-RAY AND RADIOLOGICAL CHARGES

The following charges reflect our most common x-ray and radiological procedures. For all exams requiring contrast, the contrast will be charged separately.

Description

Our Charge
Market Charge

Variance

Ultrasound Heart

$2,045
$2,008

2% higher than market

Ultrasound Veins of Both Arms or Legs

$1,691
$1,542

10% higher than market

Ultrasound Veins of One Arm or Leg

$850
$924

8% lower than market

Bone Density Scan (DEXA Scan)

$569
$430

32% higher than market

Breast Ultrasound - Limited

$398
$323

23% higher than market

CT Abdomen & Pelvis with Contrast

$4,034
$3,845

5% higher than market

CT Abdomen & Pelvis with and without Contrast

$4,834
$4,013

20% higher than market

CT Abdomen & Pelvis without Contrast

$3,504
$3,788

7% lower than market

CT Abdomen with and without Contrast

$2,521
$2,418

4% higher than market

CT Abdomen without Contrast

$1,829
$1,838

Approximately equal to market

CT Angiogram Chest with and without Contrast

$3,072
$3,770

19% lower than market

CT Arm without Contrast

$1,539
$1,413

9% higher than market

CT Chest with Contrast

$2,260
$2,127

6% higher than market

CT Chest without Contrast

$1,965
$1,629

21% higher than market

CT Face without Contrast

$1,680
$1,658

1% higher than market

CT Head Brain with and without Contrast

$2,193
$2,462

11% lower than market

CT Head Brain without Contrast

$1,591
$1,955

19% lower than market

CT Leg with Contrast

$1,599
$2,755

42% lower than market

CT Leg without Contrast

$1,389
$1,494

7% lower than market

CT Neck with Contrast

$1,988
$1,884

6% higher than market

CT Pelvis without Contrast

$1,680
$2,310

27% lower than market

CT Spine Cervical without Contrast

$2,009
$2,553

21% lower than market

CT Spine Lumbar without Contrast

$2,009
$2,253

11% lower than market

Cardiac Nuclear Stress Testing

$3,709
$4,544

18% lower than market

Chest X-Ray; 2 Views

$537
$390

38% higher than market

Chest X-Ray; Single View

$345
$315

9% higher than market

Diagnostic mammography, bilateral

$611
$489

25% higher than market

Imaging of Abdomen and Chest

$662
$605

9% higher than market

Imaging of Abdomen; 2 Views

$502
$456

10% higher than market

Imaging of Liver and Bile Duct System with Use of Drugs

$1,567
$2,244

30% lower than market

MRI Arm without Contrast

$2,922
$2,266

29% higher than market

Screening Mammography, Bilateral

$530
$423

25% higher than market

Ultrasound Abdomen - Limited

$720
$617

17% higher than market

Ultrasound Behind Abdominal Cavity - Limited

$405
$607

33% lower than market

Ultrasound Pelvis through Vagina

$778
$634

23% higher than market

Whole Body Bone Scan

$1,484
$1,545

4% lower than market

X-Ray Both Hips and Pelvis, 2 Views

$570
$555

3% higher than market

X-Ray Elbow, 3 Views

$502
$371

35% higher than market

X-Ray Esophagus

$693
$616

13% higher than market

X-Ray Femus, 2 Views

$502
$365

38% higher than market

X-Ray Fingers, 2 Views

$311
$262

18% higher than market

X-Ray Foot, 2 Views

$399
$302

32% higher than market

X-Ray Forearm, 2 Views

$473
$371

27% higher than market

X-Ray Heel, 2 Views

$345
$328

5% higher than market

X-Ray Hip and Pelvis, 2 Views

$502
$381

32% higher than market

X-Ray Knee, 1-2 Views

$473
$384

23% higher than market

X-Ray Knee, 4 or More Views

$537
$507

6% higher than market

X-Ray Lower Sacral Spine, 2-3 Views

$570
$414

38% higher than market

X-Ray Pelvis, 1-2 Views

$473
$397

19% higher than market

X-ray Ribs One Side, Minimum 3 Views

$570
$438

30% higher than market

X-ray lower and sacral spine including bending views 2 or 3 views

$570
$515

11% higher than market

INPATIENT CARDIOLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Abnormal or Irregular Heartbeat with complications

$6,911
$26,631

74% lower than market

Abnormal or Irregular Heartbeat without complications

$19,070
$18,487

3% higher than market

Acute myocardial infarction, discharged alive with complications

$17,420
$36,656

52% lower than market

Acute myocardial infarction, discharged alive with major complications

$7,219
$50,800

86% lower than market

Acute myocardial infarction, discharged alive without complications

$12,417
$29,715

58% lower than market

Angina pectoris

$9,426
$17,954

47% lower than market

Cardiac arrhythmia & conduction disorders with major complications

$28,135
$37,010

24% lower than market

Heart Failure with complications

$16,519
$28,379

42% lower than market

Heart Failure with major complications

$16,128
$44,261

64% lower than market

Heart failure & shock without complications

$9,610
$22,027

56% lower than market

Other circulatory system diagnoses with major complications

$15,525
$70,032

78% lower than market

Peripheral vascular disorders with complications

$23,048
$30,344

24% lower than market

INPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

Blood Infection with major complications

$9,007
$54,441

83% lower than market

Blood infection without major complications

$14,864
$34,720

57% lower than market

Cellulitis with major complications

$22,178
$36,650

39% lower than market

Complications of treatment with major complications

$24,387
$54,905

56% lower than market

Diabetes with complications

$13,780
$26,090

47% lower than market

Disorders of liver except malignancy with complications

$14,520
$29,242

50% lower than market

Disorders of pancreas except malignancy with complications

$11,815
$26,662

56% lower than market

Disorders of pancreas except malignancy with major complications

$9,063
$72,092

87% lower than market

Endocrine disorders with major complications

$19,189
$51,113

62% lower than market

Esophagitis, gastroent & misc digest disorders with major complications

$24,704
$39,708

38% lower than market

G.I. hemorrhage with major complications

$13,427
$56,852

76% lower than market

G.I. hemorrhage without complications

$15,859
$19,449

18% lower than market

G.I. obstruction with complications

$9,177
$26,734

66% lower than market

General symptoms of illness such as fever, pain, shortness of breath

$10,548
$21,270

50% lower than market

Infection of the skin

$15,457
$27,405

44% lower than market

Major gastrointestinal disorders & peritoneal infections with complications

$27,785
$30,622

9% lower than market

Major skin disorders without major complications

$19,025
$19,214

1% lower than market

Nutritional or Metabolic Disorders without major complications

$11,080
$22,727

51% lower than market

Other digestive system diagnoses without complications

$3,416
$23,385

85% lower than market

Signs & symptoms with major complications

$15,772
$34,905

55% lower than market

Stomach Disorder without complications

$15,613
$26,537

41% lower than market

INPATIENT NEUROLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Degenerative nervous system disorders with major complications

$10,366
$70,876

85% lower than market

Degenerative nervous system disorders without complications

$5,775
$46,918

88% lower than market

Stroke with complications

$15,564
$35,328

56% lower than market

Stroke with major complications

$30,269
$55,740

46% lower than market

INPATIENT ONCOLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Other myeloprolif dis or poorly diff neopl diag with complications

$13,437
$41,537

68% lower than market

Respiratory neoplasms with complications

$17,898
$39,810

55% lower than market

Respiratory neoplasms with major complications

$17,094
$55,903

69% lower than market

INPATIENT ORTHOPEDIC SURGERY CHARGES

Description

Our Charge
Market Charge

Variance

Knee or Hip replacement without major complications

$69,876
$73,673

5% lower than market

Lower extrem & humer proc except hip,foot,femur without complications

$48,400
$63,804

24% lower than market

INPATIENT ORTHOPEDICS CHARGES

Description

Our Charge
Market Charge

Variance

Aftercare, musculoskeletal system & connective tissue without complications

$15,139
$21,376

29% lower than market

Bone diseases & arthropathies without major complications

$12,895
$17,080

24% lower than market

Fractures of hip, pelvis & thigh without major complications

$14,428
$24,879

42% lower than market

Medical back problems without major complications

$13,916
$33,203

58% lower than market

INPATIENT PSYCHIATRY CHARGES

Description

Our Charge
Market Charge

Variance

Mental disturbances and retardation

$23,008
$54,491

58% lower than market

INPATIENT PULMONOLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Bronchitis & asthma with major complications

$9,982
$28,568

65% lower than market

Chronic Lung Disease with complications

$15,695
$27,960

44% lower than market

Chronic Lung Disease with major complications

$23,363
$36,787

36% lower than market

Chronic Lung Disease without complications

$18,431
$20,137

8% lower than market

Interstitial lung disease with complications

$13,536
$28,388

52% lower than market

Other respiratory system diagnoses without major complications

$26,977
$25,905

4% higher than market

Pneumonia with complications

$16,081
$25,828

38% lower than market

Pneumonia with major complications

$25,952
$34,398

25% lower than market

Pneumonia without complications

$19,943
$17,561

14% higher than market

Respiratory infections & inflammations without complications

$18,816
$20,818

10% lower than market

Respiratory infections and inflammations with major complications

$22,403
$49,034

54% lower than market

INPATIENT UROLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Kidney failure with complications

$15,050
$28,389

47% lower than market

Kidney & urinary Infection with major complications

$8,093
$29,745

73% lower than market

Kidney & urinary Infection without complications

$15,677
$22,479

30% lower than market

Other kidney & urinary tract diagnoses with complications

$10,957
$30,389

64% lower than market

Urinary stones without lithotripsy and without major complications

$20,838
$31,448

34% lower than market

BILLING PROCESS AND INFORMATION

How You Can Help

Thank you for choosing Forks Community Hospital for your healthcare needs. At Forks Community Hospital, we are committed to making the billing process as patient-friendly as possible. Here are some ways you can help the billing process go smoothly.

• Please give us complete health insurance information.

In addition to your health insurance card, we may ask for a photo ID. If you have been seen at Forks Community Hospital, let us know if your personal information or insurance information has changed since your last visit.

• Please understand and follow the requirements of your health plan.

Be sure to know your benefits, obtain proper authorization for services and submit referral claim forms if necessary. Many insurance plans require patients to pay a co-payment or deductible amount. You are responsible for paying co-payments required by your insurance provider and Forks Community Hospital is responsible for collecting co-payments. Please come to your appointment prepared to make your co-payment.

• Please respond promptly to any requests from your insurance provider.

You may receive multiple bills for your hospital visit, including your family doctor, specialists, physicians to read x-rays, give anesthesia, or do blood work. Insurance benefits are the result of your contract with your insurance company. We are a third-party to those benefits and may need your help with your insurance. If your insurance plan does not pay the bill within 90 days after billing, or your claim is denied, you will receive a statement from Forks Community Hospital indicating the bill is now your responsibility. All bills sent to you are due upon receipt.

Questions about Price and Billing Information

Our goal is for each of our patients and their families to have the best healthcare experience possible. Part of our commitment is to provide you with information that helps you make well informed decisions about your own care.

To ask questions or get more information about a bill for services you've received, please contact our Customer Call Center at 360-374-6271.

If you need more information about the price of a future service, please contact our Price Hotline at 360-374-6271. A CPT code is strongly encouraged when you call. You can obtain the CPT code from the ordering physician.

Online Payment, Registration, & Scheduling

For the convenience of our patients, a number of online services are available at https://www.forkshospital.org/. Forks Community Hospital offers secure online payment.

Forks Community Hospital also offers pre-registration and appointment requests through a secure online form at https://www.forkshospital.org/. Patients may pre-register for surgeries, admissions, outpatient procedures and tests at least three business days in advance. Patients may also pre-register for maternity services up to three months prior to their expected delivery date.

Financial Assistance

We are pleased to offer financial assistance to patients with limited resources and inadequate medical insurance coverage. Eligibility is determined by total family income/assets. The patient must agree to apply for other assistance available to pay hospital charges (Medicaid, Medicare, private insurance) before being discharged.

Forks Community Hospital's Charity Care Policy

Forks Community Hospital provides high quality care to everyone, regardless of their ability to pay.

Forks Community Hospital's charity care policy includes:

• Substantial charity care guidelines that provide free care for individuals and families who earn less than 200 percent of the federal poverty level.

• Sliding scale fees to provide substantially discounted care for individuals and families who are between 200 and 400 percent of the federal poverty level.

• Hardship policy for those patients who would not otherwise qualify for charity care but have unique circumstances.

In many cases, Forks Community Hospital offers interest free loans for up to one year to assist patients.

For more information, please contact our Customer Call Center at 360-374-6271.