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 6/30/18. 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
$2,039

14% lower than market

Semi-Private Room

$1,753
$1,920

9% lower than market

Intensive Care Unit

$3,589
$3,739

4% 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
$449

22% lower than market

Emergency Department Visit - Level 3

$526
$751

30% lower than market

Emergency Department Visit - Level 4

$900
$1,267

29% lower than market

Emergency Department Visit - Level 5

$1,313
$2,046

36% lower than market

Emergency Critical Care, First 30 Minutes

$1,749
$3,394

48% lower than market

OUTPATIENT CLINIC CHARGES

Description

Our Charge
Market Charge

Variance

Established patient office or other outpatient visit, typically 10 minutes

$45
$66

32% lower than market

Established patient office or other outpatient, visit typically 25 minutes

$110
$182

40% lower than market

Established patient office visit, complex

$75
$112

33% lower than market

Established patient office visit, comprehensive visit

$147
$258

43% lower than market

Hospital Outpatient Clinic Visit for Assessment and Management of a Patient

$79
$170

54% lower than market

New patient office or other outpatient visit, typically 20 minutes

$77
$116

34% lower than market

New patient ofice visit, comprehensive visit

$210
$583

64% lower than market

New patient ofice visit, standard

$45
$73

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

Holter Testing - 48-Hour EKG

$482
$437

10% higher than market

Routine EKG - Minimum 12 Leads

$199
$292

32% lower than market

Stress Test with EKG tracing

$1,036
$1,086

5% 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
$349

80% lower than market

Albumin (protein) level

$66
$52

28% higher than market

Ammonia level

$154
$145

6% higher than market

Amylase (enzyme) level

$126
$123

3% higher than market

Antibody Screen

$277
$261

6% higher than market

Bilirubin level (Direct)

$68
$74

9% lower than market

Bilirubin level (Total)

$16
$58

72% lower than market

Blood Typing, ABO

$37
$59

37% lower than market

Blood Typing, Rh (D)

$37
$57

35% lower than market

Blood Unit Compatibility Test, Antiglobulin Technique

$150
$200

25% lower than market

Blood glucose (sugar) level

$66
$62

8% higher than market

Blood glucose (sugar) measurement using reagent strip

$25
$32

21% lower than market

Blood potassium level

$70
$63

11% higher than market

Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)

$105
$98

7% higher than market

Blood test, basic group of blood chemicals

$153
$119

28% higher than market

Blood test, clotting time

$58
$49

18% higher than market

Blood test, lipids (cholesterol and triglycerides)

$142
$118

20% higher than market

Blood test, thyroid stimulating hormone (TSH)

$153
$149

3% higher than market

Body fluid cell count with cell identification

$104
$157

34% lower than market

Carbamazepine level

$152
$173

12% lower than market

Cell examination of specimen

$132
$170

22% lower than market

Chemistry procedures

$31
$366

92% lower than market

Cholesterol level

$16
$34

54% lower than market

Complete blood cell count - automated differential WBC count

$111
$100

11% higher than market

Complete blood cell count - automated test with out Differential

$68
$73

7% lower than market

Creatine kinase Level (cardiac enzyme) - Total

$94
$86

10% higher than market

Creatine kinase level (cardiac enzyme) - Muscle/Brain

$207
$170

22% higher than market

Creatinine clearance measurement to test for kidney function

$122
$104

17% higher than market

Cyanocobalamin (vitamin B-12) level

$50
$149

67% lower than market

Digoxin level

$157
$137

14% higher than market

Drug Test(s) by Chemistry Analyzer

$185
$205

10% lower than market

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

$159
$188

15% lower than market

Drug test(s), includes specimen validity testing, per day, 8-14 drug class(es)

$193
$211

9% lower than market

Evaluation of antimicrobial drug (antibiotic, antifungal, antiviral), disk method

$53
$107

51% lower than market

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

$46
$52

11% lower than market

Evaluation of fine needle aspirate with interpretation and report

$230
$171

35% higher than market

Fat or lipids, feces, quantitative

$81
$272

70% lower than market

Ferritin (blood protein) level

$170
$128

33% higher than market

Folic acid, serum

$49
$130

62% lower than market

Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit

$283
$308

8% lower than market

Glucose Level on Body Fluid

$81
$89

9% lower than market

Glutamyltransferase (liver enzyme) level

$16
$73

79% lower than market

Gonadotropin (reproductive hormone) analysis

$92
$147

37% lower than market

Gonadotropin, luteinizing (reproductive hormone) level

$30
$145

79% lower than market

HDL cholesterol level

$16
$82

81% lower than market

Hemoglobin A1C level

$105
$95

11% higher than market

Hemoglobin Measurement

$35
$43

19% lower than market

Hemoglobin fractionation and quantitation, chromatography (eg, A2, S, C, and/or F)

$28
$171

83% lower than market

Hemoglobin fractionation and quantitation, electrophoresis (eg, A2, S, C, and/or F)

$68
$189

64% lower than market

Hepatitis B Antibody Measurement

$53
$110

52% lower than market

Hepatitis B core antibody (IgM) measurement

$24
$142

83% lower than market

Hepatitis B surface antibody measurement

$34
$117

71% lower than market

Immunologic analysis for detection of tumor antigen (CA 125)

$40
$176

77% lower than market

Ionized Calcium

$30
$128

76% lower than market

Iron level

$28
$82

65% lower than market

Islet cell (pancreas) antibody measurement

$139
$188

26% lower than market

Ketone bodies analysis, qualtitative

$75
$76

1% lower than market

Kidney Function Blood Test Panel

$105
$159

34% lower than market

Lactate dehydrogenase (enzyme) level

$78
$84

7% lower than market

Lactic acid level

$189
$167

13% higher than market

Lipase (fat enzyme) level

$130
$150

13% lower than market

Liver enzyme (SGOT), level

$16
$66

76% lower than market

Liver enzyme (SGPT), level

$55
$62

12% lower than market

Liver function blood test panel

$184
$122

51% higher than market

Magnesium Level

$86
$90

4% lower than market

Measurement of Hepatitis A antibody (IgM)

$24
$143

83% lower than market

Natriuretic peptide (heart and blood vessel protein) level

$291
$300

3% lower than market

PSA (prostate specific antigen) measurement

$159
$155

2% higher than market

Partial Thromblostatin Time, Activated

$103
$87

18% higher than market

Pathology examination of tissue using a microscope, intermediate complexity

$205
$249

18% lower than market

Pathology examination of tissue using a microscope, moderately high complexity

$342
$488

30% lower than market

Pathology examination of tissue using a microscope, moderately low complexity

$166
$205

19% lower than market

Phosphatase (enzyme) level

$16
$43

63% lower than market

Red blood cell sedimentation rate, to detect inflammation

$88
$57

54% higher than market

Red blood count, automated test

$106
$80

32% higher than market

Testosterone (hormone) level

$126
$202

38% lower than market

Thyroid Hormone, T3 Measurement, Free

$74
$154

52% lower than market

Thyroxine (thyroid chemical) measurement - Free Thyroxine

$136
$133

2% higher than market

Total protein level, blood

$15
$56

73% lower than market

Triglycerides level

$83
$72

16% higher than market

Troponin (protein) analysis

$224
$204

10% higher than market

Urea nitrogen level to assess kidney function

$70
$50

39% higher than market

Uric acid level, blood

$66
$59

12% higher than market

Urinalysis with Examination, using Microscope

$77
$63

22% higher than market

Urinalysis with Microscopy

$55
$32

74% higher than market

Urinalysis, Automated Test

$56
$38

47% higher than market

Urine microalbumin (protein) level

$126
$91

39% higher than market

Valproic acid level

$30
$172

83% lower than market

OUTPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

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

$581
$610

5% lower than market

Hydration Infusion into a Vein

$147
$176

17% lower than market

Hydration Infusion into a Vein - 31 Minutes to 1 Hour

$351
$423

17% lower than market

Infusion into a Vein for Therapy, Diagnosis, or Prevention

$168
$166

1% higher than market

Infusion of Drug or Substance into Vein for Therapy or Diagnosis

$404
$460

12% lower than market

Injection Beneath the Skin for Therapy, Diagnosis, or Prevention

$126
$124

2% higher than market

Injection of Same Drug into Vein for Therapy or Diagnosis

$133
$109

21% higher than market

Respiratory inhaled aerosol treatment to relieve airway obstruction, first hour

$150
$386

61% lower than market

Sleep Monitoring with CPAP

$4,149
$4,108

1% higher than market

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

$3,469
$3,935

12% lower than market

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

$34
$93

63% lower than market

Vein Infusion for Therapy, Prevention or Diagnosis, Concurrent with Another Infusion

$198
$182

9% higher than market

Ventilation assist and management, hospital inpatient/observation, each subsequent day

$1,200
$1,560

23% lower than market

OUTPATIENT OBSERVATION CHARGES

Description

Our Charge
Market Charge

Variance

Hospital Observation per Hour

$106
$116

8% lower than market

Hospital observation care discharge

$73
$136

46% lower than market

Hospital observation care typically 50 minutes

$136
$260

48% lower than market

Hospital observation care typically 70 minutes per day

$186
$374

50% lower than market

Hospital observation or inpatient care moderate severity, 50 minutes per day

$169
$341

50% lower than market

Subsequent observation care, typically 15 minutes per day

$40
$77

48% lower than market

Subsequent observation care, typically 25 minutes per day

$72
$139

48% lower than market

Subsequent observation care, typically 35 minutes per day

$104
$200

48% lower than market

OUTPATIENT OTHER CHARGES

Description

Our Charge
Market Charge

Variance

Diagnostic mammography, including computer-aided detection (cad) when performed, bilateral

$477
$474

1% higher than market

Diagnostic mammography, including computer-aided detection (cad) when performed, unilateral

$396
$355

11% higher than market

Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (cad) when performed

$477
$384

24% higher than market

X-ray of abdomen, single view

$315
$304

3% higher than market

X-ray of chest, 1 view, front

$257
$265

3% lower than market

X-ray of chest, 2 views, front and side

$348
$328

6% higher than market

OUTPATIENT PHARMACY AND DRUG ADMINISTRATION CHARGES

Description

Our Charge
Market Charge

Variance

Administration of Influenza Virus Vaccine

$79
$68

16% higher than market

Administration of Pneumococcal Vaccine

$79
$82

4% 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

$197
$197

Approximately equal to market

OUTPATIENT SURGICAL SERVICES CHARGES

Description

Our Charge
Market Charge

Variance

Aspiration and/or injection: large joint/bursa

$63
$503

88% lower than market

Aspiration and/or injection: small joint/bursa

$49
$1,552

97% lower than market

Biopsy of Large Bowel, Using an Endoscope

$504
$3,340

85% lower than market

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

$989
$2,294

57% lower than market

Biopsy of external female genitals, 1 lesion

$262
$884

70% lower than market

Biopsy of the Esophagus, Stomach, Using an Endoscope

$370
$2,839

87% lower than market

Colonscopy

$424
$2,934

86% lower than market

Drainage of Abscess

$297
$911

67% lower than market

Extracapsular cataract removal with insertion of intraocular lens prosthesis

$2,353
$3,537

33% 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

$479
$500

4% lower than market

CT Abdomen & Pelvis with Contrast

$4,458
$4,324

3% higher than market

CT Abdomen & Pelvis with and without Contrast

$5,224
$4,770

10% higher than market

CT Abdomen & Pelvis without Contrast

$3,929
$3,786

4% higher than market

CT Abdomen with Contrast

$2,313
$2,577

10% lower than market

CT Abdomen with and without Contrast

$2,870
$2,944

3% lower than market

CT Abdomen without Contrast

$2,122
$2,310

8% lower than market

CT Angiogram Chest with and without Contrast

$2,529
$2,831

11% lower than market

CT Angiogram Head with and without Contrast

$2,367
$2,398

1% lower than market

CT Angiogram Neck with and without Contrast

$2,542
$2,411

5% higher than market

CT Head Brain with and without Contrast

$2,626
$2,546

3% higher than market

CT Head Brain without Contrast

$1,732
$1,686

3% higher than market

Chest X-Ray, 2 Views

$348
$332

5% higher than market

Chest X-Ray, Single View

$257
$285

10% lower than market

Diagnostic mammography, bilateral

$477
$459

4% higher than market

Diagnostic mammography, unilateral

$396
$352

13% higher than market

Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries

$598
$474

26% higher than market

MRA Head without Contrast

$2,396
$2,761

13% lower than market

MRI Brain with and without Conrast

$3,821
$3,962

4% lower than market

MRI Brain without Contrast

$2,854
$2,671

7% higher than market

Myocardial Perfusion, Tomographic

$4,543
$4,293

6% higher than market

Screening Mammography, Bilateral, with CAD

$477
$386

24% higher than market

Ultrasound Abdomen - Limited

$765
$674

13% higher than market

Ultrasound Behind Abdominal Cavity - Complete

$843
$753

12% higher than market

Ultrasound Blood Flow Outside the Brain

$1,171
$1,021

15% higher than market

Ultrasound Head Neck

$714
$668

7% higher than market

Ultrasound Heart

$2,354
$2,394

2% lower than market

Ultrasound Pelvis NonOB

$769
$790

3% lower than market

Ultrasound Veins of Both Arms or Legs

$1,355
$1,502

10% lower than market

Ultrasound Veins of One Arm or Leg

$975
$985

1% lower than market

X-Ray Ankle, 3 Views

$448
$332

35% higher than market

X-Ray Foot, 3 Views

$347
$335

3% higher than market

X-Ray Hand, 3 Views

$351
$358

2% lower than market

X-Ray Hip and Pelvis, 2 Views

$368
$341

8% higher than market

X-Ray Knee, 1-2 Views

$323
$302

7% higher than market

X-Ray Knee, 4 or More Views

$435
$405

7% higher than market

X-Ray Lower Sacral Spine, 2-3 Views

$452
$429

5% higher than market

INPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

Stomach Disorder without complications

$16,012
$20,452

22% 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.