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 9/30/2019. 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

Medical Center of the Rockies

Loveland

CO

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

Poudre Valley Hospital

Fort Collins

CO

Riverton Memorial Hospital

Riverton

WY

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

$1,753
$2,100

17% lower than market

Semi-Private Room

$1,753
$2,083

16% lower than market

Intensive Care Unit

$3,589
$3,536

2% higher than market

Coronary Care Unit

$2,554
$2,622

3% lower 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 2

$350
$484

28% lower than market

Emergency Department Visit - Level 3

$634
$796

20% lower than market

Emergency Department Visit - Level 4

$945
$1,358

30% lower than market

Emergency Department Visit - Level 5

$1,364
$2,141

36% lower than market

Emergency Critical Care, First 30 Minutes

$1,837
$3,795

52% 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

Gait Training - 15 Minutes

$68
$107

37% lower than market

PT Evaluation - Moderate Complexity

$166
$271

39% lower than market

Physical Therapy Exercise, 15 Minutes

$68
$116

41% lower than market

OUTPATIENT CLINIC CHARGES

Description

Our Charge
Market Charge

Variance

Established patient office or other outpatient visit, typically 10 minutes

$45
$49

8% lower than market

Established patient office or other outpatient, visit typically 25 minutes

$110
$145

24% lower than market

Established patient office visit, complex

$75
$88

15% lower than market

Established patient office visit, comprehensive visit

$147
$222

34% lower than market

Hospital Outpatient Clinic Visit for Assessment and Management of a Patient

$79
$176

55% 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
$265

36% lower than market

New patient office visit, complex

$111
$169

34% lower than market

New patient office visit, comprehensive visit

$210
$434

52% lower than market

New patient office visit, standard

$45
$106

57% 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
$289

26% lower than market

Self Care - Home Management Training - 15 Minutes

$68
$122

44% lower than market

Therapeutic Activities Involving Functional Activities (15 min)

$68
$110

38% 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

$210
$323

35% lower than market

Spirometry - medicated breathing procedure

$436
$659

34% lower than market

Stress Test with EKG tracing

$1,088
$1,191

9% 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

$71
$339

79% lower than market

Alcohols

$193
$176

9% higher than market

Ammonia level

$154
$156

1% lower than market

Analysis of Substance Using Immunoassay Technique

$93
$96

3% lower than market

Arterial Blood Gases Measurement

$297
$281

6% higher than market

Bacterial Blood Culture

$199
$256

22% lower than market

Bacterial Culture for Aerobic Isolates

$73
$95

23% lower than market

Bacterial Culture, Any Source Blood

$122
$170

28% lower than market

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

$136
$193

30% lower than market

Bilirubin level (Total)

$16
$58

72% lower than market

Blood Typing, ABO

$37
$69

47% lower than market

Blood Typing, Rh (D)

$37
$62

40% lower than market

Blood Unit Compatibility Test; Antiglobulin Technique

$150
$205

27% lower than market

Blood glucose (sugar) measurement using reagent strip

$25
$39

35% lower than market

Blood potassium level

$70
$66

7% higher than market

Blood test, basic group of blood chemicals

$153
$123

25% higher than market

Blood test, clotting time

$59
$47

26% higher than market

Blood test, comprehensive group of blood chemicals

$202
$162

25% higher than market

Blood test, lipids (cholesterol and triglycerides)

$142
$130

9% higher than market

Blood test, thyroid stimulating hormone (TSH)

$153
$160

4% lower than market

Carcinoembryonic antigen (CEA) protein level

$35
$172

80% lower than market

Complete blood cell count - automated differential WBC count

$111
$106

4% higher than market

Complete blood cell count - automated test with out Differential

$68
$78

13% lower than market

Creatine kinase Level (cardiac enzyme) - Total

$94
$94

Approximately equal to market

Creatine kinase level (cardiac enzyme) - Muscle/Brain

$207
$194

7% higher than market

Creatinine level to test for kidney function or muscle injury

$68
$78

13% lower than market

Culture, typing; identification by nucleic acid (DNA or RNA) probe, amplified probe technique, per culture or isolate, each organism probed

$200
$414

52% lower than market

Cyanocobalamin (vitamin B-12) level

$50
$159

69% lower than market

Detection test for Chlamydia pneumoniae

$155
$175

11% lower than market

Detection test for Mycoplasma pneumoniae (bacteria)

$155
$161

4% lower than market

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

$143
$161

11% lower than market

Detection test for candida species (yeast); direct probe technique

$42
$143

71% lower than market

Detection test for clostridium difficile

$158
$194

18% lower than market

Detection test for gardnerella vaginalis (bacteria); direct probe technique

$42
$143

71% lower than market

Detection test for multiple types influenza virus

$167
$311

47% lower than market

Detection test for organism; amplified probe technique

$155
$244

37% lower than market

Detection test for organism; quantification, each organism

$360
$560

36% lower than market

Detection test for trichomonas vaginalis (genital parasite); direct probe technique

$42
$143

71% lower than market

Digoxin level

$157
$147

7% higher than market

Dihydroxyvitamin D, 1, 25 level

$55
$210

74% lower than market

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

$159
$169

6% lower than market

Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral); enzyme detection

$46
$58

20% lower than market

Folic acid; serum

$49
$127

62% lower than market

Gammaglobulin Measurement

$50
$104

52% lower than market

Glutamyltransferase (liver enzyme) level

$16
$65

76% lower than market

Gonadotropin (reproductive hormone) analysis

$92
$154

40% lower than market

HLA class II typing low resolution one locus

$89
$285

69% lower than market

Hemoglobin A1C level

$105
$105

Approximately equal to market

Hemoglobin Measurement

$39
$46

16% lower than market

Hepatitis C Antibody Measurement

$30
$123

76% lower than market

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

$40
$144

72% lower than market

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

$775
$1,206

36% lower than market

Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique

$80
$132

39% lower than market

Iron Binding Capacity

$28
$107

74% lower than market

Iron level

$28
$90

69% lower than market

Kidney Function Blood Test Panel

$105
$151

31% lower than market

Lactate dehydrogenase (enzyme) level

$78
$92

15% lower than market

Lactic acid level

$189
$176

7% higher than market

Lipase (fat enzyme) level

$130
$164

21% lower than market

Liver enzyme (SGOT), level

$16
$70

77% lower than market

Liver enzyme (SGPT), level

$55
$66

16% lower than market

Liver function blood test panel

$184
$135

37% higher than market

Magnesium Level

$86
$93

7% lower than market

Measurement C-reactive protein

$92
$98

6% lower than market

Measurement of Antibody for Assessment of Autoimmune Disorder

$85
$124

32% lower than market

Measurement of antibody (IgE) to allergic substance

$50
$103

52% lower than market

Measurement of antibody for rheumatoid arthritis assessment

$25
$118

79% lower than market

Microscopic Examination of White Blood Cells with Manual Count

$53
$65

19% lower than market

Natriuretic peptide (heart and blood vessel protein) level

$291
$319

9% lower than market

Organic acid level

$55
$260

79% lower than market

PSA (prostate specific antigen) measurement

$159
$160

1% lower than market

PSA Measurement; Free

$25
$138

82% lower than market

Parathormone

$68
$223

69% lower than market

Coagulation assessment blood test

$103
$94

10% higher than market

Pathology examination of tissue during surgery

$57
$222

74% lower than market

Pathology examination of tissue using a microscope, intermediate complexity

$205
$268

23% lower than market

Pathology examination of tissue using a microscope, moderately low complexity

$166
$219

25% lower than market

Phosphatase (enzyme) level

$16
$49

67% lower than market

Prostate Cancer Screening Test

$159
$160

1% lower than market

Red Blood Cell Concentration Measurement

$41
$57

28% lower than market

Red Blood Cells, Leukocytes Reduced, Each Unit

$575
$607

5% lower than market

Rheumatoid factor level

$66
$70

6% lower than market

Screening Test for Red Blood Cell Antibodies

$116
$120

4% lower than market

Special Stain for Microorganism; Gram or Glemsa Stain

$68
$78

13% lower than market

Special stained specimen slides to examine tissue

$66
$171

62% lower than market

Special stained specimen slides to examine tissue including interpretation and report

$136
$151

10% lower than market

Stool Analysis for Blood

$43
$39

9% higher than market

Strep Test

$61
$69

12% lower than market

Streptoccus

$144
$134

7% higher than market

Tacrolimus Level

$239
$288

17% lower than market

Testosterone (hormone) level

$126
$209

40% lower than market

Testosterone Level; Free

$30
$150

80% lower than market

Thyroid Hormone, T3 Measurement, Free

$74
$154

52% lower than market

Thyroxine (thyroid chemical) measurement - Free Thyroxine

$136
$142

4% lower than market

Total protein level, blood

$15
$67

78% lower than market

Troponin (protein) analysis

$224
$225

1% lower than market

Uric acid level, blood

$66
$68

3% lower than market

Urinalysis with Examination, using Microscope

$77
$67

15% higher than market

Urinalysis, Automated Test

$56
$46

21% higher than market

Urinalysis, Manual Test

$30
$41

26% lower than market

Vitamin D-3 Level

$104
$200

48% lower than market

OUTPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

Heart rhythm analysis, interpretation and report of 48-hour EKG

$610
$641

5% lower than market

Hydration Infusion into a Vein

$155
$175

11% lower than market

Hydration Infusion into a Vein - 31 Minutes to 1 Hour

$369
$419

12% lower than market

Infusion into a Vein for Therapy, Diagnosis, or Prevention

$177
$169

5% higher than market

Infusion of Drug or Substance into Vein for Therapy or Diagnosis

$425
$463

8% lower than market

Injection of allergenic extracts into skin, accessed through the skin

$12
$31

61% lower than market

Multiple measurements of oxygen saturation in blood using ear or finger device

$224
$259

14% lower than market

Overnight measurement of oxygen saturation in blood using ear or finger device

$204
$514

60% lower than market

Physical performance test or measurement with report, each 15 minutes

$170
$156

9% higher than market

Physician services for outpatient heart rehabilitation with continuous EKG monitoring per session

$184
$283

35% lower than market

Routine electrocardiogram (EKG) using at least 12 leads with interpretation and report

$110
$181

39% lower than market

Sleep Monitoring with CPAP

$4,149
$4,640

11% lower than market

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

$3,469
$4,146

16% lower than market

Therapeutic removal of whole blood to correct blood level imbalance

$175
$215

19% lower than market

Vaccine for influenza administered into muscle, quadrivalent (IIV4) split virus, preservative free, 0.5 mL dosage

$34
$73

53% lower than market

OUTPATIENT OBSERVATION CHARGES

Description

Our Charge
Market Charge

Variance

Hospital Observation per Hour

$70
$125

44% lower than market

Hospital observation care discharge

$73
$118

38% lower than market

Hospital observation care typically 50 minutes

$136
$239

43% lower than market

Subsequent observation care, typically 25 minutes per day

$72
$126

43% lower than market

OUTPATIENT OTHER CHARGES

Description

Our Charge
Market Charge

Variance

Anesthesia for closed procedure in chest

$31
$138

77% lower than market

Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

$114
$273

58% lower than market

Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit

$174
$267

35% lower than market

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

$104
$153

32% lower than market

Injection, pantoprazole sodium, per vial

$45
$118

62% lower than market

OUTPATIENT PHARMACY AND DRUG ADMINISTRATION CHARGES

Description

Our Charge
Market Charge

Variance

Injection of New Drug into Vein for Therapy or Diagnosis

$166
$163

2% higher than market

Injection, Cefazolin Sodium, 500 mg

$18
$45

61% lower than market

Injection, Ceftriaxone Sodium, per 250 mg

$9
$21

55% lower than market

Injection, Dexamethasone Sodium Phosphate, 1 mg

$4
$10

55% lower than market

Injection, Enoxaparin Sodium, 10 mg

$13
$23

45% lower than market

Injection, Furosemide, up to 20 mg

$22
$27

19% lower than market

Injection, Heparin Sodium, per 1000 Units

$9
$24

63% lower than market

Injection, Magnesium Sulfate, per 500 mg

$14
$55

74% lower than market

Injection, Ondansetron Hydrochloride, per 1 mg

$11
$13

12% lower than market

Injection, Vancomycin HCL, 500 mg

$29
$69

59% lower than market

Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)

$126
$382

67% lower than market

Injection, alteplase recombinant, 1 mg

$95
$378

75% lower than market

Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg

$30
$88

66% lower than market

Injection, calcium gluconate, per 10 ml

$45
$57

22% lower than market

Injection, cefepime hydrochloride, 500 mg

$58
$77

25% lower than market

Injection, cefoxitin sodium, 1 gm

$38
$92

58% lower than market

Injection, ertapenem sodium, 500 mg

$288
$394

27% lower than market

Injection, infliximab, excludes biosimilar, 10 mg

$350
$318

10% higher than market

Injection, insulin, per 5 units

$9
$11

16% lower than market

Injection, iron sucrose, 1 mg

$3
$3

3% higher than market

Injection, lidocaine hcl for intravenous infusion, 10 mg

$4
$10

57% lower than market

Injection, medroxyprogesterone acetate, 1 mg

$2
$2

6% lower than market

Injection, methylprednisolone acetate, 40 mg

$63
$72

13% lower than market

Injection, penicillin g benzathine, 100,000 units

$30
$142

79% lower than market

Injection, phytonadione (vitamin k), per 1 mg

$28
$68

59% lower than market

Injection, propofol, 10 mg

$2
$3

32% lower than market

Injection, regadenoson, 0.1 mg

$230
$352

35% lower than market

Injection, rituximab, 100 mg

$2,679
$3,653

27% lower than market

Injection, succinylcholine chloride, up to 20 mg

$12
$37

67% lower than market

Injection, thiamine hcl, 100 mg

$38
$36

5% higher than market

Injection, tocilizumab, 1 mg

$16
$16

2% higher than market

Injection, triamcinolone acetonide, not otherwise specified, 10 mg

$9
$21

57% lower than market

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

$37
$51

27% lower than market

Niacinamide/niacin injection

$108
$141

23% lower than market

Prednisone, immediate release or delayed release, oral, 1 mg

$1
$3

60% 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

Nebulizer Treatment

$207
$190

9% higher than market

OUTPATIENT SUPPLIES CHARGES

Description

Our Charge
Market Charge

Variance

Epifix or epicord, per square centimeter

$368
$1,150

68% lower than market

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

$642
$963

33% lower than market

OUTPATIENT SURGICAL SERVICES CHARGES

Description

Our Charge
Market Charge

Variance

Application of Short Arm Splint

$249
$368

32% lower than market

Application of skin substitute (wound surface up to 100 sq cm) to face, scalp, eyelids, mouth, neck; first 25 sq cm

$321
$1,137

72% lower than market

Aspiration and/or injection: intermediate joint/bursa

$172
$869

80% lower than market

Aspiration and/or injection: small joint/bursa

$366
$1,071

66% lower than market

Biopsy of Large Bowel, Using an Endoscope

$504
$3,442

85% lower than market

Biopsy of the Esophagus, Stomach, Using an Endoscope

$2,002
$2,762

28% lower than market

Carpal Tunnel Release

$3,441
$4,305

20% lower than market

Colonscopy

$424
$3,221

87% lower than market

Colorectal Cancer Screening; Colonoscopy on Non-High Risk Patient

$2,422
$3,585

32% lower than market

Control Nose Bleed - Simple Case

$477
$431

11% higher than market

Correction of deformity of first long bone at toe joint

$4,845
$4,739

2% higher than market

Destruction of skin growth

$91
$136

33% lower than market

Destruction of up to 14 skin growths

$117
$371

68% lower than market

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

$4,482
$2,199

104% higher than market

Diagnostic examination of nasal passages using an endoscope

$217
$726

70% lower than market

Diagnostic examination of voice box using flexible endoscope

$436
$1,319

67% lower than market

Drainage of Abscess

$162
$717

77% lower than market

Epidural Injection Thoracic

$1,393
$2,016

31% lower than market

Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)

$2,156
$2,185

1% lower than market

Removal of cataract with insertion of lens

$2,473
$3,753

34% lower than market

Gallbladder Removal Using an Endoscope

$6,040
$16,465

63% lower than market

Implantation of spinal neurostimulator electrodes

$4,914
$11,453

57% lower than market

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

$1,393
$3,105

55% lower than market

Injection of substance into spinal canal or lower back using imaging

$1,393
$1,437

3% lower than market

Insertion of Central Venous Catheter

$3,737
$6,274

40% lower than market

Insertion of Needle into Vein to Collect Blood

$26
$36

29% lower than market

Insertion of spinal neurostimulator pulse generator or receiver

$2,756
$9,965

72% lower than market

Removal of one knee cartilage using an endoscope

$4,311
$9,341

54% lower than market

Lumbar Joint Injection

$2,090
$2,815

26% 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
$3,731

23% lower than market

Partial removal of collar bone

$2,418
$5,331

55% lower than market

Partial removal of collar bone at shoulder using an endoscope

$4,596
$4,986

8% lower than market

Release of shoulder biceps tendon using an endoscope

$6,080
$6,186

2% lower than market

Removal impacted cerumen using irrigation/lavage, unilateral

$65
$180

64% lower than market

Removal of Polyps in Large Bowel, Using an Endoscope

$568
$3,696

85% lower than market

Removal of both knee cartilages using an endoscope

$5,672
$9,984

43% lower than market

Removal of deep bone implant

$5,721
$8,445

32% lower than market

Removal of foreign body from ear canal

$208
$246

15% lower than market

Removal of impact ear wax, one ear

$137
$223

39% lower than market

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

$4,311
$6,370

32% lower than market

Removal of shoulder joint tissue using an endoscope

$4,087
$10,117

60% lower than market

Removal of tissue from 6 or more finger or toe nails

$46
$219

79% lower than market

Repair of Wound (2.6 to 7.5 centimeters)

$506
$546

7% lower than market

Repair of groin hernia patient age 5 years or older

$3,738
$8,894

58% lower than market

Rotator Cuff Repair

$7,795
$10,097

23% lower than market

Shaving of shoulder bone using an endoscope

$4,389
$5,776

24% lower than market

Shoulder scope with debridement

$4,993
$6,016

17% lower than market

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

$575
$582

1% lower than market

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

$370
$500

26% lower than market

OUTPATIENT TRANSPORTATION CHARGES

Description

Our Charge
Market Charge

Variance

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

$1,470
$1,733

15% lower than market

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

$945
$1,246

24% lower than market

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

$762
$1,071

29% lower than market

Ground mileage, per statute mile

$26
$32

19% 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

$503
$604

17% lower than market

CT Abdomen & Pelvis with Contrast

$4,681
$4,738

1% lower than market

CT Abdomen & Pelvis with and without Contrast

$5,485
$5,165

6% higher than market

CT Abdomen & Pelvis without Contrast

$4,125
$4,083

1% higher than market

CT Angiogram Chest with and without Contrast

$2,656
$3,018

12% lower than market

CT Chest with Contrast

$2,403
$2,484

3% lower than market

CT Chest without Contrast

$1,920
$2,043

6% lower than market

CT Face without Contrast

$1,781
$1,849

4% lower than market

CT Head Brain without Contrast

$1,819
$1,829

1% lower than market

CT Leg without Contrast

$2,032
$1,929

5% higher than market

CT Pelvis with Contrast

$2,445
$2,446

Approximately equal to market

CT Pelvis without Contrast

$2,329
$2,172

7% higher than market

CT Spine Cervical without Contrast

$2,425
$2,338

4% higher than market

CT scan bone mineral density study 1 or more sites

$569
$567

Approximately equal to market

CT scan of heart with evaluation of blood vessel calcium

$126
$284

56% lower than market

Chest X-Ray; 2 Views

$366
$378

3% lower than market

Chest X-Ray; Single View

$270
$306

12% lower than market

Diagnostic mammography, bilateral

$501
$485

3% higher than market

Diagnostic mammography, unilateral

$416
$376

11% higher than market

Imaging guidance for procedure, more than 1 hour

$886
$1,537

42% lower than market

Imaging guidance for procedure, up to 1 hour

$696
$877

21% lower than market

Imaging of Abdomen; Single View

$331
$331

Approximately equal to market

MRI Arm Joint without Contrast

$2,684
$2,505

7% higher than market

MRI Brain with and without Conrast

$4,012
$3,952

2% higher than market

MRI Leg Joint without Contrast

$2,406
$2,451

2% lower than market

MRI Spine Cervical without Contrast

$2,621
$2,743

4% lower than market

MRI Spine Lumbar without Contrast

$2,888
$2,872

1% higher than market

MRI Spine Thoracic without Contrast

$2,835
$2,832

Approximately equal to market

Myocardial Perfusion, Tomographic

$4,543
$4,541

Approximately equal to market

Nuclear medicine study of bone and/or joint

$2,011
$1,841

9% higher than market

Radiologic examination, abdomen; 3 or more views

$396
$357

11% higher than market

Screening Mammography, Bilateral, with CAD

$501
$421

19% higher than market

Ultrasound Abdomen - Complete

$1,080
$1,018

6% higher than market

Ultrasound Behind Abdominal Cavity - Complete

$886
$828

7% higher than market

Ultrasound Blood Flow Outside the Brain

$1,230
$1,146

7% higher than market

Ultrasound Head Neck

$750
$711

5% higher than market

Ultrasound Heart

$2,472
$2,638

6% lower than market

Ultrasound Joint Soft Tissue - Limited

$419
$545

23% lower than market

Ultrasound Pelvis through Vagina

$751
$713

5% higher than market

Ultrasound Veins of Both Arms or Legs

$1,423
$1,587

10% lower than market

Ultrasound Veins of One Arm or Leg

$1,024
$1,035

1% lower than market

X-Ray Elbow, 2 Views

$332
$303

10% higher than market

X-Ray Elbow, 3 Views

$394
$377

5% higher than market

X-Ray Esophagus

$664
$713

7% lower than market

X-Ray Fingers, 2 Views

$253
$286

12% lower than market

X-Ray Foot, 3 Views

$365
$362

1% higher than market

X-Ray Forearm, 2 Views

$336
$341

2% lower than market

X-Ray Hand, 3 Views

$369
$376

2% lower than market

X-Ray Hip and Pelvis, 2 Views

$387
$394

2% lower than market

X-Ray Knee, 1-2 Views

$340
$335

1% higher than market

X-Ray Knee, 3 Views

$457
$419

9% higher than market

X-Ray Knee, 4 or More Views

$457
$457

Approximately equal to market

X-Ray Lower Leg, 2 Views

$375
$345

9% higher than market

X-Ray Lower Sacral Spine, 2-3 Views

$475
$462

3% higher than market

X-Ray Lower Sacral Spine, 4 or More Views

$684
$622

10% higher than market

X-Ray Middle Spine, 3 Views

$444
$416

7% higher than market

X-Ray Neck Spine, 2-3 Views

$416
$396

5% higher than market

X-Ray Shoulder, 2 Views

$386
$362

7% higher than market

X-Ray Toes, 2 Views

$270
$293

8% lower than market

X-Ray Upper Arm, 2 Views

$321
$331

3% lower than market

X-Ray Upper Spine, 4-5 Views

$535
$559

4% lower than market

X-Ray Wrist, 3 Views

$361
$374

3% lower than market

X-Ray of Middle Spine; 3 Views

$517
$466

11% higher than market

X-ray Ribs One Side, Minimum 3 Views

$467
$461

1% higher than market

INPATIENT GYNECOLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Uterus or Ovary Surgery Not Related to Cancer without complications

$35,914
$38,384

6% lower than market

INPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

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

$10,602
$22,188

52% lower than market

INPATIENT ORTHOPEDIC SURGERY CHARGES

Description

Our Charge
Market Charge

Variance

Cervical spinal fusion without complications

$55,067
$83,936

34% lower than market

Spinal fusion other than the neck without major complications

$119,845
$125,852

5% lower than market

Total Knee or Hip Replacement

$66,870
$66,603

Approximately equal to market

INPATIENT PULMONOLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Chronic Lung Disease without complications

$14,857
$16,571

10% lower than market

Pneumonia without complications

$16,389
$20,162

19% lower than market

INPATIENT UROLOGY CHARGES

Description

Our Charge
Market Charge

Variance

Kidney & urinary Infection without complications

$11,992
$19,965

40% 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.