Patient Price Information List

Disclaimer: Memorial Hospital of Converse County 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, Memorial Hospital of Converse County has partnered with Hospital Pricing Specialists LLC to analyze current charges, based off CMS adjudicated claims through 3/31/2020. Memorial Hospital of Converse County's charges are displayed and compared with the local market charge, consisting of the following hospitals:

Hospital Name
Location

Campbell County Memorial Hospital

Gillette

WY

Cheyenne Regional Medical Cener

Cheyenne

WY

Community Hospital

Torrington

WY

Ivinson Memorial Hospital

Laramie

WY

Memorial Hospital of Carbon County

Rawlins

WY

Mountain View Regional Medical Hospital

Casper

WY

North Colorado Medical Center - Banner Health

Greeley

CO

Platte County Memorial Hospital

Wheatland

WY

SageWest Health Care at Riverton

Riverton

WY

UCHealth Medical Center of the Rockies

Loveland

CO

UCHealth Poudre Valley Hospital

Fort Collins

CO

UCHealth University of Colorado Hospital

Aurora

CO

Wyoming Medical Center

Casper

WY

INPATIENT ROOM AND BOARD DAILY CHARGES

Description

Our Charge
Market Charge

Variance

Private Room

$1,934
$2,332

17% lower than market

Semi-Private Room

$1,934
$2,282

15% lower than market

Intensive Care Unit

$3,958
$4,186

5% lower than market

Coronary Care Unit

$2,817
$1,776

59% 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 Department Visit - Level 1

$236
$268

12% lower than market

Emergency Department Visit - Level 2

$452
$481

6% lower than market

Emergency Department Visit - Level 3

$521
$805

35% lower than market

Emergency Department Visit - Level 4

$993
$1,401

29% lower than market

Emergency Department Visit - Level 5

$1,448
$2,192

34% lower than market

Emergency Critical Care, Each Additional 30 Minutes

$733
$1,891

61% lower than market

Emergency Critical Care, First 30 Minutes

$1,929
$3,581

46% lower than market

Initial hospital inpatient care, typically 70 minutes per day

$561
$507

11% higher 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

Gait Training - 15 Minutes

$68
$112

39% lower than market

PT Evaluation - Moderate Complexity

$183
$293

38% lower than market

PT to Re-Educate Brain to Muscle Function (15 min)

$68
$120

43% lower than market

Physical Therapy 1 or More Regions (15 min)

$71
$128

44% lower than market

Physical Therapy Exercise, 15 Minutes

$68
$113

40% lower than market

Physical Therapy, complex evaluation

$208
$339

39% lower than market

Physical Therapy, standard evaluation - 20 minutes

$166
$256

35% lower than market

OUTPATIENT CLINIC CHARGES

Description

Our Charge
Market Charge

Variance

Established patient office visit, comprehensive visit

$147
$443

67% lower than market

Hospital Outpatient Clinic Visit for Assessment and Management of a Patient

$79
$191

59% lower than market

New patient office or other outpatient visit, typically 20 minutes

$77
$88

13% lower than market

New patient office or other outpatient visit, typically 45 min

$170
$257

34% lower than market

New patient office visit, comprehensive visit

$210
$564

63% lower than market

New patient office visit, standard

$45
$61

27% 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 Evaluation - Moderate Complexity

$214
$305

30% lower than market

Occupational Therapy, complex evaluation

$257
$395

35% lower than market

Occupational Therapy, standard evaluation - 30 minutes

$171
$266

36% lower than market

Self Care - Home Management Training - 15 Minutes

$83
$124

33% lower than market

Therapeutic Activities Involving Functional Activities (15 min)

$68
$113

40% lower 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

Routine EKG - Minimum 12 Leads

$221
$305

28% lower than market

Spirometry - medicated breathing procedure

$458
$648

29% lower than market

Stress Test with EKG tracing

$1,143
$1,144

Approximately equal to market

OUTPATIENT SPEECH THERAPY CHARGES

Description

Our Charge
Market Charge

Variance

Swallow Evaluation

$170
$325

48% 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

Acute hepatitis panel

$75
$343

78% lower than market

Arterial Blood Gases Measurement

$312
$303

3% higher than market

Bacterial Blood Culture

$209
$247

16% lower than market

Bacterial Culture for Aerobic Isolates

$77
$104

26% lower than market

Bacterial Culture, Any Source Blood

$129
$170

24% lower than market

Bacterial Culture, Any Source Except Urine, Blood, or Stool

$143
$196

27% lower than market

Bilirubin level (Total)

$17
$54

68% lower than market

Blood Typing, ABO

$39
$85

54% lower than market

Blood Typing, Rh (D)

$39
$65

40% lower than market

Blood Unit Compatibility Test; Antiglobulin Technique

$158
$203

22% lower than market

Blood glucose (sugar) measurement using reagent strip

$27
$34

21% lower than market

Blood test, basic group of blood chemicals

$161
$118

37% higher than market

Blood test, clotting time

$58
$48

20% higher than market

Blood test, comprehensive group of blood chemicals

$213
$163

31% higher than market

Blood test, lipids (cholesterol and triglycerides)

$150
$130

15% higher than market

Blood test, thyroid stimulating hormone (TSH)

$161
$152

6% higher than market

Carcinoembryonic antigen (CEA) protein level

$37
$172

78% lower than market

Complete blood cell count - automated differential WBC count

$117
$102

14% higher than market

Complete blood cell count - automated test with out Differential

$72
$80

10% lower than market

Creatinine level to test for kidney function or muscle injury

$72
$79

9% lower than market

Cyanocobalamin (vitamin B-12) level

$53
$162

67% lower than market

Detection test for Mycoplasma pneumoniae (bacteria)

$155
$251

38% lower than market

Detection test for Staphylococcus aureus, methicillin resistant (MRSA bacteria)

$151
$164

8% lower than market

Detection test for multiple types influenza virus

$175
$255

31% lower than market

Detection test for organism; amplified probe technique

$155
$346

55% lower than market

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

$79
$101

22% lower than market

Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker

$31
$112

72% lower than market

Folic acid; serum

$138
$141

2% lower than market

Gammaglobulin Measurement

$53
$114

53% lower than market

Hemoglobin A1C level

$111
$104

7% higher than market

Hemoglobin Measurement

$41
$54

25% lower than market

Hepatitis C Antibody Measurement

$32
$136

77% lower than market

Immunologic Analysis for Detection of Tumor Antigen; Immunoassay - Quantitative CA 15-3

$42
$145

71% lower than market

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

$42
$170

75% lower than market

Iron Binding Capacity

$30
$105

72% lower than market

Iron level

$30
$89

66% lower than market

Kidney Function Blood Test Panel

$110
$139

21% lower than market

Lactate dehydrogenase (enzyme) level

$82
$87

5% lower than market

Lipase (fat enzyme) level

$137
$165

17% lower than market

Liver enzyme (SGOT), level

$17
$66

74% lower than market

Liver enzyme (SGPT), level

$58
$59

2% lower than market

Liver function blood test panel

$194
$125

55% higher than market

Magnesium Level

$91
$86

6% higher than market

Measurement C-reactive protein

$97
$96

1% higher than market

Measurement of antibody (IgE) to allergic substance

$19
$38

51% lower than market

Measurement of antibody for rheumatoid arthritis assessment

$27
$113

76% lower than market

Microscopic Examination of White Blood Cells with Manual Count

$56
$68

17% lower than market

Natriuretic peptide (heart and blood vessel protein) level

$306
$318

4% lower than market

Organic acid level

$58
$277

79% lower than market

Other closed skull fracture without mention of intracranial injury, with loss of consciousness of unspecified duration

$75
$338

78% lower than market

PSA (prostate specific antigen) measurement

$167
$168

1% lower than market

PSA Measurement; Free

$27
$138

80% lower than market

Parathormone

$72
$238

70% lower than market

Coagulation assessment blood test

$109
$89

22% higher than market

Pathology examination of tissue using a microscope, intermediate complexity

$216
$275

21% lower than market

Pathology examination of tissue using a microscope, moderately low complexity

$174
$222

21% lower than market

Phosphatase (enzyme) level

$17
$57

70% lower than market

Prostate Cancer Screening Test

$167
$164

2% higher than market

Red Blood Cell Concentration Measurement

$44
$58

25% lower than market

Rheumatoid factor level

$70
$72

2% lower than market

Screening Test for Red Blood Cell Antibodies

$39
$123

68% lower than market

Special Stain for Microorganism; Gram or Glemsa Stain

$72
$71

2% higher than market

Special stained specimen slides to examine tissue

$69
$168

59% lower than market

Strep Test

$65
$75

13% lower than market

Tacrolimus Level

$251
$295

15% lower than market

Testosterone (hormone) level

$133
$190

30% lower than market

Thyroid Hormone, T3 Measurement, Free

$78
$179

57% lower than market

Total protein level, blood

$16
$72

78% lower than market

Troponin (protein) analysis

$236
$219

8% higher than market

Uric acid level, blood

$70
$64

9% higher than market

Urinalysis with Examination, using Microscope

$81
$63

29% higher than market

Urinalysis, Automated Test

$59
$49

20% higher than market

Urinalysis, Manual Test

$32
$33

4% lower than market

Vitamin D-3 Level

$109
$230

53% lower than market

OUTPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

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

$3,643
$4,253

14% lower than market

OUTPATIENT OBSERVATION CHARGES

Description

Our Charge
Market Charge

Variance

Hospital Observation per Hour

$74
$131

44% lower than market

Hospital observation care discharge

$73
$118

38% lower than market

Hospital observation care typically 30 minutes

$100
$276

64% lower than market

Subsequent observation care, typically 25 minutes per day

$72
$137

47% 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

Arterial Puncture

$58
$105

45% lower than market

OUTPATIENT SUPPLIES CHARGES

Description

Our Charge
Market Charge

Variance

Technetium tc-99m sestamibi, diagnostic, per study dose

$772
$1,004

23% lower than market

OUTPATIENT SURGICAL SERVICES CHARGES

Description

Our Charge
Market Charge

Variance

Amputation of finger or thumb; with direct closure

$4,136
$8,430

51% lower than market

Amputation, toe; metatarsophalangeal joint

$4,493
$6,137

27% lower than market

Application of Short Arm Splint

$262
$391

33% lower than market

Application of Short Leg Splint (Calf to Foot)

$333
$390

15% lower than market

Application of cast, elbow to finger (short arm)

$153
$399

62% lower than market

Application of cast, shoulder to hand (long arm)

$213
$706

70% lower than market

Application of long arm splint (shoulder to hand)

$109
$399

73% lower than market

Application of short leg cast (below knee to toes)

$161
$420

62% lower than market

Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device

$4,034
$18,595

78% lower than market

Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)

$6,313
$17,413

64% lower than market

Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))

$8,175
$15,900

49% lower than market

Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each

$4,648
$10,247

55% lower than market

Aspiration of abscess, blood accumulation, blister, or cyst

$728
$683

7% higher than market

Avulsion of nail plate, partial or complete, simple; single

$147
$463

68% lower than market

Biopsy and/or removal of polyp of the uterus using an endoscope

$2,810
$6,732

58% lower than market

Biopsy of Large Bowel, Using an Endoscope

$2,277
$3,069

26% lower than market

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

$1,091
$2,701

60% lower than market

Biopsy of the Esophagus, Stomach, Using an Endoscope

$370
$2,765

87% lower than market

Biopsy of uterine lining

$465
$843

45% lower than market

Biopsy of voice box using an endoscope with operating microscope or telescope

$4,527
$9,689

53% lower than market

Biopsy or removal of nasal polyp or tissue using an endoscope

$1,266
$4,541

72% lower than market

Bunionectomy

$7,617
$9,928

23% lower than market

Carpal Tunnel Release

$2,940
$4,877

40% lower than market

Carpectomy; 1 bone

$3,465
$3,123

11% higher than market

Closed treatment of broken ankle with manipulation, trimalleolar ankle fracture

$2,949
$2,681

10% higher than market

Closed treatment of broken great toe with manipulation

$752
$1,205

38% lower than market

Colonoscopy on High Cancer Risk Patient

$2,544
$3,388

25% lower than market

Colonscopy

$424
$2,781

85% lower than market

Complex control of nose bleed

$324
$662

51% lower than market

Control Nose Bleed - Simple Case

$501
$495

1% higher than market

Control of nose bleed and insertion of packing

$686
$753

9% lower than market

Correction of deformity of first long bone at toe joint

$5,088
$6,701

24% lower than market

Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double osteotomy, any method

$4,716
$10,116

53% lower than market

Crushing of stone in urinary duct (ureter) with stent using an endoscope

$5,339
$10,840

51% lower than market

Destruction of benign lesions; 15 or more lesions

$139
$604

77% lower than market

Destruction of lower or sacral spinal facet joint nerves using imaging guidance

$4,305
$4,405

2% lower than market

Destruction of malignant growth (2.1 to 3.0 centimeters) of trunk, arms, or legs

$532
$898

41% lower than market

Destruction of skin growth

$91
$132

31% lower than market

Destruction of up to 14 skin growths

$117
$288

59% lower than market

Diagnostic Examination of Esophagus, Stomach, and/or Upper Small Bowel with Endoscope

$4,610
$2,019

128% higher than market

Diagnostic examination of voice box using flexible endoscope

$436
$563

23% lower than market

Drainage of Abscess

$121
$498

76% lower than market

Exploration, drainage, or removal of foreign body in knee joint

$4,874
$5,597

13% lower than market

Removal of cataract with insertion of lens

$2,597
$4,099

37% lower than market

Fine needle aspiration; without imaging guidance

$159
$676

76% lower than market

Gallbladder Removal Using an Endoscope

$6,342
$12,968

51% lower than market

Hammer Toe Correction

$1,874
$6,016

69% lower than market

Implantation of spinal neurostimulator electrodes

$5,160
$8,383

38% lower than market

Implantation of spinal neurostimulator electrodes, accessed through the skin

$4,670
$8,860

47% lower than market

Incision and removal of foreign body, subcutaneous tissues; simple

$224
$745

70% lower than market

Incision of penile foreskin

$3,143
$3,874

19% lower than market

Incision of should joint capsule using an endoscope

$7,949
$12,169

35% lower than market

Incision of tendon located from elbow to shoulder, open procedure

$3,678
$4,756

23% lower than market

Incision to release foot tendon, open procedure

$1,525
$3,946

61% lower than market

Incision to repair tendon covering at wrist; deQuervains disease

$3,867
$3,901

1% lower than market

Injection of radioactive dye for X-ray identification of lymph node

$244
$495

51% lower than market

Injection of anesthetic and/or steroid into lower spine nerve root using imaging

$1,464
$2,912

50% lower than market

Injection of substance into spinal canal or lower back using imaging

$1,464
$5,227

72% lower than market

Injections of anesthetic and/or steroid drug into nerve of foot

$455
$717

36% lower than market

Injections of tendon sheath, ligament, or muscle membrane

$158
$650

76% lower than market

Insertion of Breathing Tube Using an Endoscope

$941
$1,041

10% lower than market

Insertion of Central Venous Catheter

$3,926
$7,191

45% lower than market

Insertion of Central Venous Catheter for Infusion

$1,738
$2,200

21% lower than market

Insertion of Needle into Vein to Collect Blood

$28
$38

26% lower than market

Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level

$5,091
$16,667

69% lower than market

Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older

$1,859
$2,402

23% lower than market

Insertion of spinal neurostimulator pulse generator or receiver

$2,894
$11,418

75% lower than market

Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older

$3,194
$6,495

51% lower than market

Removal of one knee cartilage using an endoscope

$5,376
$9,030

40% lower than market

Lumbar Joint Injection

$1,464
$2,691

46% lower than market

Lumbar Kyphoplasty

$11,402
$17,379

34% lower than market

Manipulation of shoulder joint under anesthesia

$2,497
$3,586

30% lower than market

Open treatment of broken foot bone, metatarsal

$4,493
$5,860

23% lower than market

Open treatment of broken of lower forearm or growth plate separation with insertion of hardware 3 or

$6,228
$12,562

50% lower than market

Open treatment of broken of lower forearm or growth plate separation with insertion of hardware of 2

$4,956
$10,070

51% lower than market

Open treatment of knee cap fracture with insertion of hardware and/or removal of knee cap

$5,132
$10,913

53% lower than market

Open treatment of ligament tear at ankle joint

$3,252
$4,933

34% lower than market

Open treatment of metacarpal fracture, single

$6,228
$11,042

44% lower than market

Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, when performed

$3,632
$10,710

66% lower than market

Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus

$2,877
$5,269

45% lower than market

Partial removal of bone with release of spinal cord or spinal nerves of 1 interspace in lower spine

$7,937
$13,539

41% lower than market

Partial removal of breast

$4,658
$9,085

49% lower than market

Partial removal of collar bone at shoulder using an endoscope

$4,826
$6,798

29% lower than market

Partial removal of external female genitals, simple

$2,604
$7,620

66% lower than market

Partial removal of knee joint lining using an endoscope

$4,840
$5,203

7% lower than market

Partial removal of toe bone

$4,138
$3,859

7% higher than market

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inc

$7,958
$8,306

4% lower than market

Release of lower spinal cord and/or nerves

$14,148
$13,006

9% higher than market

Release of shoulder biceps tendon using an endoscope

$6,384
$7,060

10% lower than market

Removal (3 centimeters or greater) tissue growth beneath the skin of upper arm or elbow

$3,194
$10,179

69% lower than market

Removal (less than 3 centimeters) tissue growth beneath the skin of upper arm or elbow

$4,648
$8,144

43% lower than market

Removal impacted cerumen using irrigation/lavage, unilateral

$65
$193

66% lower than market

Removal of (less than 3 centimeters) tissue growth beneath the skin of neck or front of chest

$1,943
$9,765

80% lower than market

Removal of 1 or more breast growth, open procedure

$3,926
$7,225

46% lower than market

Colonoscopy with removal of polyp(s)

$568
$3,329

83% lower than market

Removal of bone joints between wrist and fingers

$5,429
$9,750

44% lower than market

Removal of both knee cartilages using an endoscope

$5,956
$8,873

33% lower than market

Removal of cyst at wrist (dorsal or volar); primary

$4,648
$4,644

Approximately equal to market

Removal of dead or infected ankle joint tissue using an endoscope

$4,740
$5,297

11% lower than market

Removal of deep bone implant

$2,652
$9,179

71% lower than market

Removal of fluid accumulation in one testicle and sperm reservoir

$3,875
$8,101

52% lower than market

Removal of fluid from chest cavity with imaging guidance

$1,371
$2,077

34% lower than market

Removal of fluid-filled sac (bursa) or calcium deposit of pelvis

$4,835
$5,116

5% lower than market

Removal of foreign bodies of esophagus, stomach, and/or upper small bowel using an endoscope

$2,156
$2,728

21% lower than market

Removal of foreign body from ear canal

$208
$228

9% lower than market

Removal of gallbladder with X-ray study of bile ducts using endoscope

$5,627
$17,593

68% lower than market

Removal of growth of tendon covering or joint capsule of foot

$2,486
$9,084

73% lower than market

Removal of growth of tendon finger or hand

$1,888
$6,126

69% lower than market

Removal of heel bone

$2,854
$7,562

62% lower than market

Removal of impact ear wax, one ear

$82
$189

56% lower than market

Removal of joint lining from two or more knee joint compartments using an endoscope

$5,621
$5,714

2% lower than market

Removal of multiple wrist bones

$4,764
$5,826

18% lower than market

Removal of nail

$285
$1,374

79% lower than market

Removal of peripheral venous catheter for infusion

$834
$3,001

72% lower than market

Removal of shoulder joint tissue using an endoscope

$4,292
$9,868

56% lower than market

Removal of tissue and/or bone at elbow with tendon repair, open procedure

$2,919
$5,140

43% lower than market

Removal of tissue from 6 or more finger or toe nails

$58
$218

73% lower than market

Repair of Wound (2.6 to 7.5 centimeters)

$532
$516

3% higher than market

Repair of Wound (7.6 to 12.5 cm)

$528
$556

5% lower than market

Repair of groin hernia patient age 5 years or older

$3,738
$12,665

70% lower than market

Repair of muscle group above knee joint

$5,429
$13,233

59% lower than market

Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

$6,357
$7,911

20% lower than market

Repair of shoulder socket cartilage using an endoscope

$7,964
$8,029

1% lower than market

Repair of wound (2.6 to 5.0 centimeters) of face, ears, eyelids, nose, lips, and/or mouth

$864
$797

8% higher than market

Repair of wound (2.6 to 7.5 centimeters) of the scalp, underarms, trunk, arms, and/or legs

$321
$818

61% lower than market

Repair, flexor tendon, leg; primary, without graft, each tendon

$4,758
$8,054

41% lower than market

Reprogramming of programmable brain and spinal fluid shunt

$701
$815

14% lower than market

Rotator Cuff Repair

$8,185
$10,989

26% lower than market

Second repair of surgical wound

$4,835
$5,013

4% lower than market

Shaving of shoulder bone using an endoscope

$4,609
$8,758

47% lower than market

Shoulder scope with debridement

$5,243
$9,491

45% lower than market

Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

$2,277
$3,116

27% lower than market

Simple wound repair of face, including ears; 2.5 cm or less

$480
$509

6% lower than market

Simple wound repair of face, including ears; 2.6 cm to 5.0 cm

$575
$549

5% higher than market

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

$389
$506

23% lower than market

Suture of ruptured muscle of thigh; primary

$4,742
$11,202

58% lower than market

Total knee repair

$6,834
$19,233

64% lower than market

Trigger Finger Release

$3,867
$3,812

1% higher than market

Trimming of fingernails or toenails

$46
$119

61% lower than market

Ulnar Nerve Release

$4,027
$5,890

32% lower than market

OUTPATIENT TRANSPORTATION CHARGES

Description

Our Charge
Market Charge

Variance

Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency)

$1,544
$1,740

11% lower than market

Ambulance service, advanced life support, non-emergency transport, level 1 (als 1)

$993
$1,318

25% lower than market

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

$801
$993

19% lower than market

Ground mileage, per statute mile

$26
$34

23% lower 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

Breast Ultrasound - Complete

$529
$533

1% lower than market

CT Abdomen & Pelvis with Contrast

$4,916
$4,622

6% higher than market

CT Abdomen with Contrast

$2,551
$2,749

7% lower than market

CT Abdomen with and without Contrast

$3,165
$3,108

2% higher than market

CT Abdomen without Contrast

$2,340
$2,323

1% higher than market

CT Angiogram Abdomen with and without Contrast

$3,223
$3,168

2% higher than market

CT Angiogram Chest with and without Contrast

$2,789
$2,798

Approximately equal to market

CT Angiogram Head with and without Contrast

$2,610
$2,514

4% higher than market

CT Angiogram Neck with and without Contrast

$2,803
$2,638

6% higher than market

CT Arm with Contrast

$2,342
$2,390

2% lower than market

CT Chest with Contrast

$2,524
$2,497

1% higher than market

CT Chest with and without Contrast

$3,118
$2,975

5% higher than market

CT Chest without Contrast

$2,016
$1,996

1% higher than market

CT Cranial Cavity without Contrast

$2,043
$2,092

2% lower than market

CT Face without Contrast

$1,871
$1,758

6% higher than market

CT Head Brain with Contrast

$2,223
$2,257

1% lower than market

CT Head Brain with and without Contrast

$2,896
$2,664

9% higher than market

CT Head Brain without Contrast

$1,910
$1,845

4% higher than market

CT Leg with Contrast

$2,173
$2,552

15% lower than market

CT Leg without Contrast

$2,134
$1,939

10% higher than market

CT Neck with Contrast

$2,494
$2,331

7% higher than market

CT Neck without Contrast

$2,192
$2,052

7% higher than market

CT Pelvis with Contrast

$2,445
$2,486

2% lower than market

CT Spine Cervical without Contrast

$2,547
$2,357

8% higher than market

CT scan of heart with evaluation of blood vessel calcium

$133
$307

57% lower than market

Chest X-Ray; 2 Views

$385
$387

Approximately equal to market

Chest X-Ray; Single View

$284
$311

9% lower than market

Diagnostic mammography, bilateral

$527
$516

2% higher than market

Diagnostic mammography, unilateral

$437
$376

16% higher than market

Fluoroscopic guidance for spine or spinal canal injection

$578
$935

38% lower than market

Imaging guidance for procedure, up to 1 hour

$696
$878

21% lower than market

Imaging of Abdomen and Chest

$609
$575

6% higher than market

Imaging of Abdomen; Single View

$348
$326

7% higher than market

Imaging of Liver and Bile Duct System with Use of Drugs

$1,094
$2,509

56% lower than market

Imaging of Liver and Bile Duct System without Use of Drugs

$980
$2,303

57% lower than market

Imaging of lymphatic tissue and lymph node

$1,624
$1,959

17% lower than market

Imaging of parathyroid with nuclear medicine study

$991
$1,237

20% lower than market

Low dose ct scan (ldct) for lung cancer screening

$368
$1,677

78% lower than market

MRA Head without Contrast

$2,642
$3,063

14% lower than market

MRA Neck without Contrast

$2,656
$3,229

18% lower than market

MRI Abdomen with and without Contrast

$3,451
$3,370

2% higher than market

MRI Arm Join with Contrast

$2,426
$3,022

20% lower than market

MRI Arm Joint without Contrast

$2,819
$2,677

5% higher than market

MRI Arm with and without Contrast

$2,864
$3,798

25% lower than market

MRI Arm without Contrast

$2,276
$2,122

7% higher than market

MRI Brain with and without Conrast

$4,213
$3,956

6% higher than market

MRI Leg Joint with and without Contrast

$3,296
$3,816

14% lower than market

MRI Leg Joint without Contrast

$2,527
$2,371

7% higher than market

MRI Leg with and without Contrast

$3,622
$3,790

4% lower than market

MRI Leg without Contrast

$2,358
$2,144

10% higher than market

MRI Orbit, Face, Neck with and without Contrast

$3,413
$4,040

16% lower than market

MRI Pelvis with and without Contrast

$4,240
$4,408

4% lower than market

MRI Pelvis without Contrast

$2,751
$2,991

8% lower than market

MRI Spine Cervical with and without Contrast

$3,169
$3,841

17% lower than market

MRI Spine Cervical without Contrast

$2,753
$2,737

1% higher than market

MRI Spine Lumbar with and without Contrast

$3,859
$3,935

2% lower than market

MRI Spine Lumbar without Contrast

$3,033
$2,849

6% higher than market

MRI Spine Thoracic without Contrast

$2,977
$2,912

2% higher than market

MRI scan of leg joint with contrast

$2,433
$2,806

13% lower than market

MRI scan of lower spinal canal with contrast

$3,421
$4,500

24% lower than market

Myocardial Perfusion, Tomographic

$4,770
$4,387

9% higher than market

Nuclear Medicine Study of Lung Ventilation and Blood Circulation in the Lungs

$1,724
$2,229

23% lower than market

Nuclear medicine study of bone and/or joint

$2,112
$1,935

9% higher than market

Radiologic exam, spine, entire thoracic and lumbar, including skull, cervical and sacral spine; 2 or 3 views

$477
$477

Approximately equal to market

Radiologic examination, abdomen; 3 or more views

$416
$383

9% higher than market

Radiological supervision and interpretation X-ray of bile and/or pancreatic ducts during surgery

$681
$848

20% lower than market

Radiological supervision and interpretation X-ray of shoulder joint

$981
$1,377

29% lower than market

Screening Mammography, Bilateral, with CAD

$527
$415

27% higher than market

Stomach emptying study

$1,657
$2,504

34% lower than market

Ultrasound Abdomen - Complete

$1,134
$1,012

12% higher than market

Ultrasound Behind Abdominal Cavity - Complete

$931
$848

10% higher than market

Ultrasound Behind Abdominal Cavity - Limited

$599
$579

3% higher than market

Ultrasound Blood Flow Outside the Brain

$1,292
$1,263

2% higher than market

Ultrasound Heart

$2,596
$2,554

2% higher than market

Ultrasound Joint Soft Tissue - Limited

$440
$540

18% lower than market

Ultrasound Pelvis NonOB

$848
$824

3% higher than market

Ultrasound Pelvis through Vagina

$789
$697

13% higher than market

Ultrasound Pleural Effusion Chest

$566
$574

1% lower than market

Ultrasound Scrotum

$734
$777

6% lower than market

Ultrasound Veins of Both Arms or Legs

$1,495
$1,704

12% lower than market

Ultrasound Veins of One Arm or Leg

$1,076
$1,079

Approximately equal to market

Ultrasound guidance for accessing into blood vessel

$510
$706

28% lower than market

Ultrasound scan of abdominal, pelvic, and/or scrotal arterial inflow and venous outflow

$937
$1,074

13% lower than market

Whole Body Bone Scan

$2,644
$2,403

10% higher than market

X-Ray Collar Bone

$341
$337

1% higher than market

X-Ray Esophagus

$698
$708

1% lower than market

X-Ray Fingers, 2 Views

$266
$290

8% lower than market

X-Ray Foot, 2 Views

$302
$325

7% lower than market

X-Ray Foot, 3 Views

$384
$365

5% higher than market

X-Ray Forearm, 2 Views

$353
$333

6% higher than market

X-Ray Hand, 3 Views

$388
$370

5% higher than market

X-Ray Heel, 2 Views

$285
$318

11% lower than market

X-Ray Hip and Pelvis, 2 Views

$407
$388

5% higher than market

X-Ray Knee, 1-2 Views

$357
$333

7% higher than market

X-Ray Knee, 4 or More Views

$480
$436

10% higher than market

X-Ray Lower Sacral Spine, 2-3 Views

$499
$469

6% higher than market

X-Ray Lower Sacral Spine, 4 or More Views

$719
$615

17% higher than market

X-Ray Neck Spine, 2-3 Views

$437
$395

11% higher than market

X-Ray Pelvis, 2 Views

$377
$372

1% higher than market

X-Ray Pelvis, 3 Views

$457
$431

6% higher than market

X-Ray Shoulder, 2 Views

$406
$378

7% higher than market

X-Ray Toes, 2 Views

$284
$291

2% lower than market

X-Ray Upper Arm, 2 Views

$338
$324

4% higher than market

X-Ray Upper Digestive Tract without Contrast

$811
$894

9% lower than market

X-Ray Upper Spine, 4-5 Views

$562
$556

1% higher than market

X-Ray Wrist, 3 Views

$380
$368

3% higher than market

X-ray Ribs One Side, Minimum 3 Views

$491
$465

6% higher than market

X-ray lower and sacral spine including bending views minimum 6 views

$549
$608

10% lower than market

X-ray of bones

$461
$603

23% lower than market

X-ray of mandible, minimum of 4 views

$301
$509

41% lower than market

X-ray of upper digestive tract with contrast

$1,080
$1,054

3% higher than market

INPATIENT ORTHOPEDIC SURGERY CHARGES

Description

Our Charge
Market Charge

Variance

Cervical spinal fusion without complications

$52,305
$82,410

37% lower than market

Spinal fusion other than the neck without major complications

$165,024
$123,996

33% higher than market

Total Knee or Hip Replacement

$56,787
$70,511

19% lower than market

BILLING PROCESS AND INFORMATION

How You Can Help

Thank you for choosing Memorial Hospital of Converse County for your healthcare needs. As part of our commitment to delivering EXCELLENT service, we want to make understanding and paying your bill as easy as possible. Here are some ways you can help us as we work to make 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 Memorial Hospital of Converse County, 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 Memorial Hospital of Converse County 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 Memorial Hospital of Converse County 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 307-358-2122.

If you need more information about the price of a future service, please contact our Price Hotline at 307-358-2122. A CPT code is strongly encouraged when you call. You can obtain the CPT code from the ordering physician.

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.

Memorial Hospital of Converse County's Charity Care Policy

Memorial Hospital of Converse County provides high quality care to everyone, regardless of their ability to pay.

Memorial Hospital of Converse County'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, Memorial Hospital of Converse County offers interest free loans for up to one year to assist patients.

For more information, please contact our Customer Call Center at 307-358-2122.