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Patient Price Information List

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

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

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

LOCAL MARKET HOSPITALS

In order to present a meaningful comparison, Adams Memorial Hospital has partnered with Hospital Pricing Specialists LLC to analyze current charges, based off CMS adjudicated claims through 3/31/2021. Adams Memorial Hospital's charges are displayed and compared with the local market charge, consisting of the following hospitals:

Hospital Name
Location

Bluffton Regional Medical Center

Bluffton

IN

IU Health Blackford Hospital

Hartford City

IN

IU Health Jay Hospital

Portland

IN

Lutheran Hospital

Fort Wayne

IN

Parkview Regional Medical Center

Fort Wayne

IN

Van Wert County Hospital

Van Wert

OH

INPATIENT ROOM AND BOARD DAILY CHARGES

Description

Our Charge
Market Charge

Variance

Semi-Private Room

$1,561
$1,798

13% lower than market

CMS SHOPPABLE SERVICE

Description

Our Charge
Market Charge

Variance

Abdominal and pelvic CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74177]

$2,100
$3,839

45% lower than market

Abdominal ultrasound (complete) [HCPCS 76700]

$575
$1,747

67% lower than market

Anesthetic agent and/or steroid injection into lower or sacral spine nerve root with imaging guidance (single level) [HCPCS 64483]

$2,974
$4,501

34% lower than market

Cataract removal involving removal of the front part of the capsule and the central part of the lens with lens prosthesis insertion [HCPCS 66984]

$3,741
$19,756

81% lower than market

Colon (large bowel) examination and biopsy with endoscope [HCPCS 45380]

$4,489
$8,385

46% lower than market

Colon (large bowel) examination and polyps or tumors removal by snare technique with endoscope [HCPCS 45385]

$4,582
$10,875

58% lower than market

Colon (large bowel) examination with endoscope for diagnosis (high risk) [HCPCS 45378]

$3,971
$11,482

65% lower than market

Esophagus, stomach, and/or upper small bowel examination and biopsy with endoscope [HCPCS 43239]

$3,337
$7,277

54% lower than market

Gallbladder removal with an endoscope [HCPCS 47562]

$10,338
$35,547

71% lower than market

Groin hernia repair for patient 5 years of age or older (herniated tissue that is not trapped) [HCPCS 49505]

$6,107
$26,167

77% lower than market

Head or brain CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70450]

$1,025
$1,304

21% lower than market

Imaging of brain by MRI without contrast, followed by contrast [HCPCS 70553]

$2,600
$2,237

16% higher than market

Imaging of leg joint by MRI without contrast [HCPCS 73721]

$1,800
$1,903

5% lower than market

Imaging of lower spinal canal by MRI without contrast [HCPCS 72148]

$1,700
$1,555

9% higher than market

Imaging of pelvis by ultrasound through vagina [HCPCS 76830]

$630
$809

22% lower than market

Lab analysis of urine specimen by dipstick with microscope (automated) [HCPCS 81001]

$13
$56

77% lower than market

Lab analysis of urine specimen by dipstick without microscope (automated) [HCPCS 81003]

$11
$43

74% lower than market

Lab analysis of urine specimen by dipstick without microscope (non-automated) [HCPCS 81002]

$19
$113

83% lower than market

Lab analysis to evaluate kidney function via a blood test panel [HCPCS 80069]

$129
$160

19% lower than market

Lab analysis to evaluate the clotting time in plasma specimen and monitor drug effectiveness [HCPCS 85610]

$18
$45

60% lower than market

Lab analysis to identify the thyroid stimulating hormone (tsh) in blood specimen [HCPCS 84443]

$80
$134

40% lower than market

Lab analysis to measure coagulation in plasma or whole blood specimen [HCPCS 85730]

$25
$97

74% lower than market

Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test [HCPCS 85027]

$44
$70

37% lower than market

Lab analysis to measure complete blood cell count (red cells, white blood cell, and platelets), automated test and automated differential white blood cell count [HCPCS 85025]

$53
$59

10% lower than market

Lab analysis to measure the amount of albumin, total and direct bilirubin, alkaline phosphatase, total protein, alanine amino transferase, and asparate amino transferase in blood specimen to evaluate liver function [HCPCS 800

$121
$119

2% higher than market

Lab analysis to measure the amount of free PSA (prostate specific antigen) in serum specimen [HCPCS 84154]

$74
$157

53% lower than market

Lab analysis to measure the amount of lipids (cholesterol and triglycerides) in blood specimen [HCPCS 80061]

$198
$109

81% higher than market

Lab analysis to measure the amount of total calcium, carbon dioxide (bicarbonate), chloride, creatinine, glucose, potassium, sodium, and urea nitrogen (BUN) in blood specimen [HCPCS 80048]

$125
$88

42% higher than market

Lab analysis to measure the amount of total PSA (prostate specific antigen) in serum specimen [HCPCS 84153]

$74
$161

54% lower than market

Lab analysis via blood test to measure a comprehensive group of blood chemicals [HCPCS 80053]

$156
$180

13% lower than market

Mammography of both breasts (screening exam) [HCPCS 77067]

$319
$552

42% lower than market

Mammography of both breasts for diagnosis [HCPCS 77066]

$319
$547

42% lower than market

Mammography of one breast for diagnosis [HCPCS 77065]

$160
$445

64% lower than market

Pelvis CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 72193]

$1,175
$2,081

44% lower than market

Physical therapy exercise to develop strength, endurance, range of motion, and flexibility (each 15 minutes) [HCPCS 97110]

$101
$111

9% lower than market

Sleep pattern monitoring of patient in sleep lab, sleep staging with 4 or more parameters of sleep (6 years of age or older) [HCPCS 95810]

$2,562
$5,324

52% lower than market

Spinal canal injection of substance into lower back or sacrum with imaging guidance [HCPCS 62323]

$3,144
$3,661

14% lower than market

Spinal x-ray of lower and sacral spine (minimum of 4 views) [HCPCS 72110]

$358
$918

61% lower than market

Total Knee or Hip Replacement

$39,270
$100,040

61% lower than market

OUTPATIENT EMERGENCY DEPARTMENT

Description

Our Charge
Market Charge

Variance

Critical care delivery to critically ill or injured patient (first 30-74 minutes) [HCPCS 99291]

$2,319
$4,439

48% lower than market

Emergency department visit for problem of high severity [HCPCS 99284]

$800
$1,884

58% lower than market

Emergency department visit for problem of low to moderate severity [HCPCS 99282]

$400
$659

39% lower than market

Emergency department visit for problem of moderate severity [HCPCS 99283]

$600
$1,212

51% lower than market

Emergency department visit for problem with significant threat to life [HCPCS 99285]

$1,000
$2,905

66% lower than market

OUTPATIENT LABORATORY AND PATHOLOGY

Description

Our Charge
Market Charge

Variance

Hopd covid-19 spec collect [HCPCS C9803]

$26
$49

47% lower than market

Lab analysis by immunoassay (ELISA) to identify bacteria toxin (shiga-like toxin) [HCPCS 87427]

$48
$72

33% lower than market

Lab analysis by nucleic acid (DNA or RNA) to identify HPV (human papillomavirus) (high-risk types) [HCPCS 87624]

$141
$161

13% lower than market

Lab analysis by nucleic acid (DNA or RNA) to identify multiple types of the influenza virus (first 2 types or sub-types) [HCPCS 87502]

$258
$257

Approximately equal to market

Lab analysis by nucleic acid (DNA or RNA) to identify Staphylococcus aureus (bacteria) by amplified probe technique [HCPCS 87640]

$141
$168

16% lower than market

Lab analysis by nucleic acid (DNA or RNA) to identify Staphylococcus aureus, methicillin resistant (MRSA bacteria) by amplified probe technique [HCPCS 87641]

$141
$182

23% lower than market

Lab analysis of any culture (except blood) to identify aerobic isolates (each isolate) [HCPCS 87077]

$33
$77

57% lower than market

Lab analysis of any culture (except urine, blood, or stool) to identify bacteria [HCPCS 87070]

$35
$163

79% lower than market

Lab analysis of blood culture to identify bacteria [HCPCS 87040]

$42
$178

76% lower than market

Lab analysis of complex special stain to identify parasites [HCPCS 87209]

$72
$253

72% lower than market

Lab analysis of smear to identify and measre the amount of parasites in culture [HCPCS 87177]

$36
$203

82% lower than market

Lab analysis of special gram or Giemsa stain to idenitfy microorganisms [HCPCS 87205]

$18
$93

81% lower than market

Lab analysis of stool culture to identify bacteria [HCPCS 87045]

$38
$95

60% lower than market

Lab analysis of urine culture to measure the amount of bacteria [HCPCS 87086]

$33
$99

67% lower than market

Lab analysis of wet mount to identify bacteria, fungi, or parasites [HCPCS 87210]

$24
$94

74% lower than market

Lab analysis to evaluate an antimicrobial drug (antibiotic, antifungal, antiviral) by microdilution or agar dilution (each multi-antimicrobial, per plate) [HCPCS 87186]

$35
$125

72% lower than market

Lab analysis to identify antibodies for autoimmune disorder assessment (any method) [HCPCS 86235]

$72
$118

39% lower than market

Lab analysis to identify antibodies to native or double stranded DNA [HCPCS 86225]

$55
$121

55% lower than market

Lab analysis to identify antibodies to severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 86769]

$47
$163

71% lower than market

Lab analysis to identify antibody IgE to allergic substance (each crude allergen extract) [HCPCS 86003]

$21
$28

24% lower than market

Lab analysis to identify antibody to noninfectious agents [HCPCS 86256]

$49
$85

42% lower than market

Lab analysis to identify Hepatitis C antibodies [HCPCS 86803]

$58
$189

69% lower than market

Lab analysis to identify substances by immunoassay technique (multiple step method) [HCPCS 83516]

$47
$144

67% lower than market

Lab analysis to identify total thyroxine (thyroid chemical) function in serum specimen for screening [HCPCS 84436]

$28
$138

80% lower than market

Lab analysis to identify tumor antigens by immunoassay (quantitative, CA 125) [HCPCS 86304]

$84
$257

67% lower than market

Lab analysis to identify tumor antigens by immunoassay (quantitative, CA 15-3) [HCPCS 86300]

$84
$173

51% lower than market

Lab analysis to measure blood count (hemoglobin) [HCPCS 85018]

$12
$51

76% lower than market

Lab analysis to measure coagulation function measurement of D-dimer (quantitative) [HCPCS 85379]

$41
$131

69% lower than market

Lab analysis to measure free testosterone (hormone) level in serum specimen [HCPCS 84402]

$102
$188

46% lower than market

Lab analysis to measure free thyroxine (thyroid chemical) in serum specimen [HCPCS 84439]

$49
$182

73% lower than market

Lab analysis to measure red blood cell concentration [HCPCS 85014]

$12
$43

72% lower than market

Lab analysis to measure red blood cell sedimentation rate to detect inflammation (automated) [HCPCS 85652]

$13
$49

74% lower than market

Lab analysis to measure red blood count with additional calculations (automated test) [HCPCS 85046]

$23
$52

56% lower than market

Lab analysis to measure the albumin (protein) level in blood, serum, or plasma specimen [HCPCS 82040]

$20
$68

70% lower than market

Lab analysis to measure the ammonia level [HCPCS 82140]

$59
$186

68% lower than market

Lab analysis to measure the amount of blood gases [HCPCS 82803]

$105
$242

57% lower than market

Lab analysis to measure the amount of blood gases with oxygen saturation [HCPCS 82805]

$316
$328

4% lower than market

Lab analysis to measure the amount of carbon dioxide, chloride, potassium, and sodium in blood specimen [HCPCS 80051]

$104
$123

16% lower than market

Lab analysis to measure the amount of C-reactive protein in serum to identify infection or inflammation [HCPCS 86140]

$47
$148

68% lower than market

Lab analysis to measure the amount of free thyroid hormone, T3 in serum specimen [HCPCS 84481]

$68
$205

67% lower than market

Lab analysis to measure the amount of gammaglobulin (immune system protein) [HCPCS 82784]

$38
$57

33% lower than market

Lab analysis to measure the amount of glucose (sugar) in blood specimen with reagent strip [HCPCS 82948]

$21
$19

13% higher than market

Lab analysis to measure the amount of immune system protein (complement) antigens (each component) [HCPCS 86160]

$48
$76

37% lower than market

Lab analysis to measure the amount of ketone bodies in blood, serum, or plasma specimen [HCPCS 82010]

$33
$394

92% lower than market

Lab analysis to measure the amount of levetiracetam in blood specimen [HCPCS 80177]

$53
$351

85% lower than market

Lab analysis to measure the amount of microsomal antibodies (autoantibody) [HCPCS 86376]

$59
$294

80% lower than market

Lab analysis to measure the amount of phenobarbital in serum or plasma specimen [HCPCS 80184]

$62
$259

76% lower than market

Lab analysis to measure the amount of protein in serum specimen [HCPCS 84165]

$43
$92

53% lower than market

Lab analysis to measure the amount of substance by radioimmunoassay [HCPCS 83519]

$74
$372

80% lower than market

Lab analysis to measure the amount of tacrolimus in blood specimen [HCPCS 80197]

$55
$492

89% lower than market

Lab analysis to measure the amount of total cortisol (hormone) [HCPCS 82533]

$66
$176

62% lower than market

Lab analysis to measure the amount of total digoxin in blood specimen [HCPCS 80162]

$54
$189

71% lower than market

Lab analysis to measure the amount of total phenytoin in blood specimen [HCPCS 80185]

$53
$195

73% lower than market

Lab analysis to measure the amount of total thyroid hormone, T3 in serum specimen [HCPCS 84480]

$57
$174

67% lower than market

Lab analysis to measure the amount of total valproic acid in blood specimen [HCPCS 80164]

$55
$223

75% lower than market

Lab analysis to measure the amount of troponin (protein) in serum specimen [HCPCS 84484]

$50
$198

75% lower than market

Lab analysis to measure the amylase (enzyme) level in serum specimen [HCPCS 82150]

$26
$112

77% lower than market

Lab analysis to measure the blood potassium level in blood specimen [HCPCS 84132]

$20
$49

59% lower than market

Lab analysis to measure the carcinoembryonic antigen (cea) protein level [HCPCS 82378]

$76
$205

63% lower than market

Lab analysis to measure the cholesterol level in blood specimen [HCPCS 82465]

$18
$65

72% lower than market

Lab analysis to measure the c-peptide (protein) level in urine specimen [HCPCS 84681]

$84
$255

67% lower than market

Lab analysis to measure the creatine kinase (cardiac enzyme) level (MB fraction only) [HCPCS 82553]

$47
$178

74% lower than market

Lab analysis to measure the creatinine level to test for kidney function or muscle injury (other than blood specimen) [HCPCS 82570]

$21
$107

80% lower than market

Lab analysis to measure the cyanocobalamin (vitamin b-12) level [HCPCS 82607]

$61
$146

58% lower than market

Lab analysis to measure the direct bilirubin level [HCPCS 82248]

$21
$58

64% lower than market

Lab analysis to measure the ferritin (blood protein) level [HCPCS 82728]

$55
$181

70% lower than market

Lab analysis to measure the folic acid level in serum specimen [HCPCS 82746]

$59
$161

63% lower than market

Lab analysis to measure the glutamyltransferase (liver enzyme) level [HCPCS 82977]

$29
$87

67% lower than market

Lab analysis to measure the hemoglobin A1C level in blood specimen [HCPCS 83036]

$39
$84

54% lower than market

Lab analysis to measure the ionized calcium level in blood specimen [HCPCS 82330]

$55
$121

54% lower than market

Lab analysis to measure the iron binding capacity [HCPCS 83550]

$35
$123

72% lower than market

Lab analysis to measure the iron level [HCPCS 83540]

$26
$118

78% lower than market

Lab analysis to measure the lactate dehydrogenase (enzyme) level [HCPCS 83615]

$25
$89

72% lower than market

Lab analysis to measure the lactic acid level in blood, plasma, or cerbrospinal fluid specimen [HCPCS 83605]

$47
$157

70% lower than market

Lab analysis to measure the LDL cholesterol level [HCPCS 83721]

$42
$145

71% lower than market

Lab analysis to measure the lipase (fat enzyme) level [HCPCS 83690]

$28
$133

79% lower than market

Lab analysis to measure the liver enzyme (sgot), level in serum or plasma specimen [HCPCS 84450]

$21
$68

69% lower than market

Lab analysis to measure the liver enzyme (sgpt), level in serum or plasma specimen [HCPCS 84460]

$22
$57

61% lower than market

Lab analysis to measure the magnesium level in body fluids and cells [HCPCS 83735]

$27
$93

71% lower than market

Lab analysis to measure the microalbumin (protein) level in urine specimen [HCPCS 82043]

$24
$82

71% lower than market

Lab analysis to measure the natriuretic peptide (heart and blood vessel protein) level in plasma specimen [HCPCS 83880]

$158
$279

43% lower than market

Lab analysis to measure the parathormone (parathyroid hormone) level [HCPCS 83970]

$166
$441

62% lower than market

Lab analysis to measure the phosphate level [HCPCS 84100]

$19
$66

71% lower than market

Lab analysis to measure the prealbumin (protein) level in urine specimen [HCPCS 84134]

$59
$119

50% lower than market

Lab analysis to measure the procalcitonin (hormone) level in serum or plasma specimen [HCPCS 84145]

$109
$290

62% lower than market

Lab analysis to measure the total calcium level in blood specimen [HCPCS 82310]

$21
$70

70% lower than market

Lab analysis to measure the total protein level in blood specimen [HCPCS 84155]

$15
$63

76% lower than market

Lab analysis to measure the total protein level in urine specimen [HCPCS 84156]

$15
$101

85% lower than market

Lab analysis to measure the uric acid level in blood specimen [HCPCS 84550]

$19
$65

71% lower than market

Lab analysis to measure the vitamin D-3 level in serum or plasma specimen [HCPCS 82306]

$119
$164

28% lower than market

Lab analysis to measure total testosterone (hormone) level in serum specimen [HCPCS 84403]

$104
$225

54% lower than market

Lab analysis to measure urea nitrogen level in serum or plasma specimen to assess kidney function (quantitative) [HCPCS 84520]

$16
$52

69% lower than market

Lab analysis to screen for autoimmune disorders [HCPCS 86038]

$49
$209

77% lower than market

Lab blood analysis to confirm blood unit compatibility with computer check (electronic) [HCPCS 86923]

$165
$329

50% lower than market

Lab blood analysis to identify antigens on red blood cell surface and determine the patient's blood group type (ABO) [HCPCS 86900]

$22
$326

93% lower than market

Lab blood analysis to identify antigens on red blood cell surface and determine the patient's Rh (D) type (Rh positive or Rh negative) [HCPCS 86901]

$22
$112

80% lower than market

Lab blood analysis to screen for antibodies to red blood cell antigens (each serum technique) [HCPCS 86850]

$40
$188

79% lower than market

Pathology lab analysis of special stained specimen slides to examine tissue (each additional procedure) [HCPCS 88341]

$128
$209

39% lower than market

Pathology lab analysis of special stained specimen slides to examine tissue (initial procedure) [HCPCS 88342]

$139
$697

80% lower than market

Pathology lab analysis of tissue with microscope (intermediate complexity) [HCPCS 88305]

$122
$407

70% lower than market

Pathology lab analysis of tissue with microscope (moderately low complexity) [HCPCS 88304]

$110
$309

64% lower than market

Psa screening [HCPCS G0103]

$156
$158

2% lower than market

Rbc leukocytes reduced [HCPCS P9016]

$292
$864

66% lower than market

OUTPATIENT MEDICINE

Description

Our Charge
Market Charge

Variance

Drug administration beneath the skin or into muscle by injection for therapy, diagnosis, or prevention [HCPCS 96372]

$94
$176

46% lower than market

Drug administration into vein by infusion for therapy, prevention, or diagnosis (each additional hour) [HCPCS 96366]

$61
$124

51% lower than market

Drug administration into vein by infusion for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96365]

$309
$1,201

74% lower than market

Drug administration into vein by infusion of additional sequential infusion of new drug for therapy, prevention, or diagnosis (up to 1 hour) [HCPCS 96367]

$94
$250

62% lower than market

Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of same drug) [HCPCS 96376]

$61
$194

69% lower than market

External 48-hour EKG heart rhythm tracing, analysis, and interpretation with scanning analysis and report [HCPCS 93226]

$282
$1,194

76% lower than market

Hydration administration into vein by infusion (31 minutes to 1 hour) [HCPCS 96360]

$402
$1,192

66% lower than market

Hydration administration into vein by infusion (each additional hour) [HCPCS 96361]

$92
$106

13% lower than market

Immunization administration of vaccine into, between, or beneath the skin or into muscle (single vaccine) [HCPCS 90471]

$87
$148

41% lower than market

Influenza vaccine for injection into muscle (0.5 ml dosage, quadrivalent, preservation free) [HCPCS 90686]

$32
$85

62% lower than market

Mechanical traction application to 1 or more areas [HCPCS 97012]

$51
$161

68% lower than market

Medical nutrition therapy assessment and intervention (each 15 minutes) [HCPCS 97802]

$80
$80

Approximately equal to market

Oxygen saturation measurement in blood by ear or finger device (multiple determinations) [HCPCS 94761]

$71
$402

82% lower than market

Physician services for outpatient heart rehab with continuous EKG monitoring (per session) [HCPCS 93798]

$292
$442

34% lower than market

Pneumococcal conjugate, 13 valent vaccine for injection into muscle [HCPCS 90670]

$231
$1,283

82% lower than market

Pneumococcal polysaccharide vaccine for injection beneath the skin or into muscle (2 years of age or older) [HCPCS 90732]

$126
$523

76% lower than market

Sleep pattern monitoring of patient in sleep lab with continued pressured respiratory assistance by mask or breathing tube (6 years of age or older) [HCPCS 95811]

$3,616
$6,397

43% lower than market

OUTPATIENT OTHER

Description

Our Charge
Market Charge

Variance

Oth resp proc, group [HCPCS G0239]

$80
$494

84% lower than market

OUTPATIENT PHARMACY AND DRUG ADMINISTRATION

Description

Our Charge
Market Charge

Variance

Admin influenza virus vac [HCPCS G0008]

$87
$103

15% lower than market

Admin pneumococcal vaccine [HCPCS G0009]

$87
$104

16% lower than market

Adrenalin epinephrine inject [HCPCS J0171]

$3
$75

96% lower than market

Betamethasone acet&sod phosp [HCPCS J0702]

$4
$89

96% lower than market

Cefazolin sodium injection [HCPCS J0690]

$4
$7

39% lower than market

Drug administration into vein by push technique for therapy, diagnosis, or prevention (each additional push of new drug) [HCPCS 96375]

$61
$220

72% lower than market

Drug administration into vein by push technique for therapy, diagnosis, or prevention (initial drug) [HCPCS 96374]

$309
$417

26% lower than market

Drugs unclassified injection [HCPCS J3490]

$4
$337

99% lower than market

Fentanyl citrate injection [HCPCS J3010]

$17
$54

69% lower than market

Furosemide injection [HCPCS J1940]

$17
$39

57% lower than market

Garamycin gentamicin inj [HCPCS J1580]

$2
$61

96% lower than market

Hydromorphone injection [HCPCS J1170]

$17
$61

73% lower than market

Inj magnesium sulfate [HCPCS J3475]

$2
$12

83% lower than market

Inj midazolam hydrochloride [HCPCS J2250]

$3
$13

76% lower than market

Inj pantoprazole sodium, via [HCPCS C9113]

$59
$101

41% lower than market

Ketorolac tromethamine inj [HCPCS J1885]

$8
$40

79% lower than market

Levofloxacin injection [HCPCS J1956]

$6
$18

63% lower than market

Lorazepam injection [HCPCS J2060]

$12
$53

76% lower than market

Methylprednisolone 20 mg inj [HCPCS J1020]

$15
$29

46% lower than market

Methylprednisolone 40 mg inj [HCPCS J1030]

$15
$84

83% lower than market

Methylprednisolone 80 mg inj [HCPCS J1040]

$50
$114

56% lower than market

Methylprednisolone injection [HCPCS J2930]

$62
$122

49% lower than market

Metoclopramide hcl injection [HCPCS J2765]

$17
$55

69% lower than market

Morphine sulfate injection [HCPCS J2270]

$17
$76

77% lower than market

Neostigmine methylslfte inj [HCPCS J2710]

$3
$10

73% lower than market

Normal saline solution infus [HCPCS J7030]

$60
$180

67% lower than market

Normal saline solution infus [HCPCS J7040]

$61
$176

66% lower than market

Normal saline solution infus [HCPCS J7050]

$18
$127

86% lower than market

Oral dexamethasone [HCPCS J8540]

$1
$1

27% lower than market

Phenylephrine hcl injection [HCPCS J2370]

$61
$75

19% lower than market

Promethazine hcl injection [HCPCS J2550]

$17
$60

72% lower than market

Regadenoson injection [HCPCS J2785]

$34
$206

84% lower than market

Ringers lactate infusion [HCPCS J7120]

$60
$72

17% lower than market

Succinycholine chloride inj [HCPCS J0330]

$3
$12

72% lower than market

Tc99m sestamibi [HCPCS A9500]

$249
$286

13% lower than market

Tetanus, diphtheria toxoids and acellular pertussis (whooping cough) vaccine for injection into muscle (7 years of age or older) [HCPCS 90715]

$188
$324

42% lower than market

Triamcinolone acet inj nos [HCPCS J3301]

$2
$5

63% lower than market

Vancomycin hcl injection [HCPCS J3370]

$14
$16

10% lower than market

Vitamin b12 injection [HCPCS J3420]

$10
$106

91% lower than market

Vitamin k phytonadione inj [HCPCS J3430]

$3
$21

84% lower than market

Zoledronic acid 1mg [HCPCS J3489]

$29
$63

55% lower than market

OUTPATIENT PHYSICAL/OCCUPATIONAL/SPEECH THERAPY

Description

Our Charge
Market Charge

Variance

Function improvement activities with one-on-one contact between patient and provider (each 15 minutes) [HCPCS 97530]

$110
$138

21% lower than market

Occupational therapy evaluation (typically 45 minutes) [HCPCS 97166]

$329
$424

22% lower than market

Physcial therapy exercise of walking training to 1 or more areas (each 15 minutes) [HCPCS 97116]

$89
$157

43% lower than market

Physical therapy evaluation (typically 20 minutes) [HCPCS 97161]

$294
$388

24% lower than market

Physical therapy evaluation (typically 30 minutes) [HCPCS 97162]

$331
$415

20% lower than market

Physical therapy evaluation (typically 45 minutes) [HCPCS 97163]

$369
$440

16% lower than market

Physical therapy techniques to 1 or more regions (each 15 minutes) [HCPCS 97140]

$94
$143

34% lower than market

Speech, language, voice, communication, and/or hearing processing disorder treatment [HCPCS 92507]

$341
$389

12% lower than market

Swallowing and/or oral feeding function treatment [HCPCS 92526]

$189
$281

33% lower than market

Training activities for home and self-care management (each 15 minutes) [HCPCS 97535]

$109
$128

15% lower than market

OUTPATIENT PULMONARY THERAPY

Description

Our Charge
Market Charge

Variance

Amount and speed of breathed air measurement and graphic recording before and after medication administration [HCPCS 94060]

$823
$1,548

47% lower than market

External 48-hour EKG heart rhythm tracing, analysis, and interpretation with recording [HCPCS 93225]

$282
$1,398

80% lower than market

Heart and blood vessel stress test with EKG tracing and monitoring (exercise or drug-induced) [HCPCS 93017]

$666
$1,491

55% lower than market

Pulmonary rehab w exer [HCPCS G0424]

$147
$452

68% lower than market

Routine EKG (electrocardiogram) tracing using at least 12 wires [HCPCS 93005]

$140
$326

57% lower than market

Total and timed exhaled air capacity measurement and graphic recording [HCPCS 94010]

$435
$1,054

59% lower than market

OUTPATIENT RESPIRATORY THERAPY

Description

Our Charge
Market Charge

Variance

Airway inhalation treatment to relieve airway obstruction or for sputum collection (inhaled pressure or nonpressure treatment) [HCPCS 94640]

$188
$223

16% lower than market

Lung diffusing capacity measurement [HCPCS 94729]

$476
$651

27% lower than market

Lung volumes measurement by plethysmography [HCPCS 94726]

$667
$929

28% lower than market

Oxygen saturation measurement in blood by ear or finger device (single determination) [HCPCS 94760]

$45
$99

55% lower than market

OUTPATIENT SURGICAL SERVICES

Description

Our Charge
Market Charge

Variance

Blood specimen collection from a completely implantable venous access device [HCPCS 36591]

$112
$5,227

98% lower than market

Collection of blood specimen from arterial puncture for diagnosis [HCPCS 36600]

$120
$6,356

98% lower than market

Large joint or joint capsule fluid removal and/or injection with needle [HCPCS 20610]

$1,070
$5,202

79% lower than market

Large joint or joint capsule fluid removal and/or injection with needle and ultrasound guidance including recording and reporting [HCPCS 20611]

$923
$1,310

30% lower than market

Lower or sacral spinal facet joint nerves destruction with imaging guidance (single facet joint) [HCPCS 64635]

$1,896
$8,587

78% lower than market

Lower or sacral spine facet joint injections with imaging guidance (first level) [HCPCS 64493]

$2,233
$4,775

53% lower than market

Measurement of bladder capacity after voiding by ultrasound [HCPCS 51798]

$4,170
$4,486

7% lower than market

Medium joint or joint capsule fluid removal and/or injection with needle [HCPCS 20605]

$510
$2,020

75% lower than market

Needle insertion into vein for collection of blood sample [HCPCS 36415]

$23
$35

35% lower than market

Small joint or joint capsule fluid removal and/or injection with needle [HCPCS 20600]

$853
$1,996

57% lower than market

Strapping application of unna boot [HCPCS 29580]

$283
$1,099

74% lower than market

Tendon sheath, ligament, or muscle membrane injections [HCPCS 20550]

$317
$341

7% lower than market

Trigger points injection into 1 or 2 muscles [HCPCS 20552]

$524
$2,822

81% lower than market

Vein wound compression system application to lower leg below knee including ankle and foot [HCPCS 29581]

$753
$1,149

34% lower than market

OUTPATIENT TRANSPORTATION SERVICES

Description

Our Charge
Market Charge

Variance

Als 1 [HCPCS A0426]

$425
$2,529

83% lower than market

Als1-emergency [HCPCS A0427]

$728
$2,795

74% lower than market

Bls [HCPCS A0428]

$354
$1,670

79% lower than market

Bls-emergency [HCPCS A0429]

$566
$2,144

74% lower than market

Ground mileage [HCPCS A0425]

$16
$21

23% lower than market

OUTPATIENT X-RAY AND RADIOLOGICAL

Description

Our Charge
Market Charge

Variance

Abdominal and pelvic CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 74176]

$1,400
$3,105

55% lower than market

Abdominal ultrasound (limited) [HCPCS 76705]

$433
$859

50% lower than market

Abdominal x-ray (2 views) [HCPCS 74019]

$241
$613

61% lower than market

Abdominal x-ray (single view) [HCPCS 74018]

$205
$445

54% lower than market

Abdominal x-ray, complete study including 2 or more views of abdomen and single view of chest [HCPCS 74022]

$322
$852

62% lower than market

Ankle x-ray (minimum of 3 views) [HCPCS 73610]

$264
$453

42% lower than market

Arms or legs veins ultrasound with assessment of compression and functional maneuvers (complete, both arms or legs) [HCPCS 93970]

$1,044
$2,334

55% lower than market

Arms or legs veins ultrasound with assessment of compression and functional maneuvers (limited, one arm or leg) [HCPCS 93971]

$495
$1,780

72% lower than market

Blood flow (outside of the brain) ultrasound on both sides of head and neck [HCPCS 93880]

$579
$1,741

67% lower than market

Bone density measurement of the axial skeleton (hips, pelvis, spine) [HCPCS 77080]

$226
$581

61% lower than market

Breast ultrasound (one breast, limited) [HCPCS 76642]

$379
$496

24% lower than market

Chest x-ray (2 views) [HCPCS 71046]

$215
$441

51% lower than market

Chest x-ray (single view) [HCPCS 71045]

$205
$333

38% lower than market

CTA scan of chest blood vessels with contrast to examine injury, foreign bodies, or tumors [HCPCS 71275]

$1,700
$1,978

14% lower than market

Elbow x-ray, complete study (minimum of 3 views) [HCPCS 73080]

$222
$449

51% lower than market

Facial CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 70486]

$1,025
$1,521

33% lower than market

Finger(s) x-ray (minimum of 2 views) [HCPCS 73140]

$287
$310

7% lower than market

Foot x-ray, complete study (minimum of 3 views) [HCPCS 73630]

$245
$467

47% lower than market

Hand x-ray (minimum of 2 views) [HCPCS 73130]

$261
$452

42% lower than market

Head and neck ultrasound [HCPCS 76536]

$618
$832

26% lower than market

Heart ultrasound including color-depicted blood flow rate, direction, and valve function [HCPCS 93306]

$2,817
$3,267

14% lower than market

Hip x-ray of both hips with pelvis (2 views) [HCPCS 73521]

$283
$647

56% lower than market

Hip x-ray of both hips with pelvis (3 to 4 views) [HCPCS 73522]

$367
$983

63% lower than market

Hip x-ray of hip with pelvis (2 to 3 views) [HCPCS 73502]

$335
$440

24% lower than market

Imaging of arm joint by MRI without contrast [HCPCS 73221]

$1,800
$1,862

3% lower than market

Imaging of heart vessels with SPECT tomography and drugs or exercise (multiple studies) [HCPCS 78452]

$3,221
$6,615

51% lower than market

Imaging of upper spinal canal by MRI without contrast [HCPCS 72141]

$1,700
$1,788

5% lower than market

Knee x-ray (1 or 2 views) [HCPCS 73560]

$269
$420

36% lower than market

Knee x-ray (3 views) [HCPCS 73562]

$293
$470

38% lower than market

Knee x-ray (4 or more views) [HCPCS 73564]

$329
$558

41% lower than market

Leg ultrasound of arteries and arterial grafts of both legs (complete study) [HCPCS 93925]

$1,044
$2,183

52% lower than market

Liver and bile duct system imaging with the use of oral medication [HCPCS 78227]

$1,199
$2,725

56% lower than market

Lower leg x-ray (2 views) [HCPCS 73590]

$269
$451

40% lower than market

Neck CT scan of the soft tissue of the neck with contrast to examine injury, foreign bodies, or tumors [HCPCS 70491]

$1,175
$1,497

21% lower than market

Pelvis CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 72192]

$1,025
$1,560

34% lower than market

Pelvis ultrasound, not pregrnancy related (complete) [HCPCS 76856]

$530
$898

41% lower than market

Pelvis x-ray (1 or 2 views) [HCPCS 72170]

$205
$557

63% lower than market

Rib cage x-ray of ribs on one side of body including chest (minimum of 3 views) [HCPCS 71101]

$274
$640

57% lower than market

Shoulder x-ray, complete study (minimum of 2 views) [HCPCS 73030]

$235
$496

53% lower than market

Spinal CT scan of lower spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72131]

$1,025
$2,160

53% lower than market

Spinal CT scan of upper spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72125]

$1,025
$2,064

50% lower than market

Spinal x-ray of lower and sacral spine (2 or 3 views) [HCPCS 72100]

$270
$702

62% lower than market

Spinal x-ray of middle spine (3 views) [HCPCS 72072]

$264
$719

63% lower than market

Spinal x-ray of upper spine (2 or 3 views) [HCPCS 72040]

$267
$522

49% lower than market

Spinal x-ray of upper spine (4 or 5 views) [HCPCS 72050]

$371
$761

51% lower than market

Thighbone x-ray (minimum of 2 views) [HCPCS 73552]

$248
$454

45% lower than market

Ultrasound application to 1 or more areas (each 15 minutes) [HCPCS 97035]

$40
$139

71% lower than market

Ultrasound of area behind abdominal cavity (complete) [HCPCS 76770]

$535
$919

42% lower than market

Ultrasound of area behind abdominal cavity (limited) [HCPCS 76775]

$275
$671

59% lower than market

Wrist x-ray, complete study (minimum of 3 views) [HCPCS 73110]

$300
$428

30% lower than market

INPATIENT CARDIOLOGY

Description

Our Charge
Market Charge

Variance

Heart Failure with major complications

$20,457
$29,222

30% lower than market

INPATIENT MEDICINE

Description

Our Charge
Market Charge

Variance

Blood Infection with major complications

$24,929
$43,190

42% lower than market

Blood infection without major complications

$16,066
$26,720

40% lower than market

INPATIENT PULMONOLOGY

Description

Our Charge
Market Charge

Variance

Respiratory infections and inflammations with major complications

$30,195
$45,015

33% lower than market

INPATIENT UROLOGY

Description

Our Charge
Market Charge

Variance

Kidney & urinary Infection without complications

$8,123
$19,084

57% lower than market

BILLING PROCESS AND INFORMATION

How You Can Help

Thank you for choosing Adams Memorial Hospital for your healthcare needs. 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 Adams Memorial Hospital, let us know if your personal information or insurance information has changed since your last visit.

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

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

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

You may receive multiple bills from your hospital visit, including your family doctor, specialists, physicians that read x-rays, providers that give anesthesia, or physicians that interpret 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 Adams Memorial Hospital indicating the bill is now your responsibility. All bills sent to you are due upon receipt.

Questions about Price and Billing Information

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

To ask questions or get more information about a bill for services you've received, please contact our Billing Department at 260-724-2145.

If you need more information about the price of a future service, please contact our Customer Service at 260-724-2145. A physician’s order or CPT code is strongly encouraged when you call to assist us in providing you with the most accurate estimate. You can obtain the CPT code from the ordering physician.