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Patient Price Information List

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

Hospital Name
Location

Alleghany Memorial Hospital

Sparta

NC

Charles A. Cannon, Jr. Memorial Hospital

Linville

NC

Chatham Hospital

Siler City

NC

Novant Health Forsyth Medical Center

Winston-Salem

NC

Wake Forest Baptist Health - Wilkes Medical Center

North Wilkesboro

NC

Watauga Medical Center

Boone

NC

INPATIENT ROOM AND BOARD DAILY CHARGES

Description

Our Charge
Market Charge

Variance

Semi-Private Room

$616
$1,698

64% lower than market

Intensive Care Unit

$723
$1,858

61% 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]

$3,975
$4,427

10% lower than market

Abdominal ultrasound (complete) [HCPCS 76700]

$773
$834

7% 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]

$5,816
$9,337

38% lower than market

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

$3,620
$7,763

53% lower than market

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

$3,936
$7,783

49% lower than market

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

$3,236
$6,352

49% lower than market

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

$4,079
$10,356

61% lower than market

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

$9,053
$9,122

1% lower than market

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

$1,352
$1,554

13% lower than market

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

$3,165
$4,043

22% lower than market

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

$2,305
$2,495

8% lower than market

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

$2,375
$2,588

8% lower than market

Imaging of pelvis by ultrasound through vagina [HCPCS 76830]

$520
$593

12% lower than market

Knee cartilage removal with endoscope (one knee) [HCPCS 29881]

$5,474
$15,444

65% lower than market

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

$41
$56

26% lower than market

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

$30
$31

5% lower than market

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

$46
$119

62% lower than market

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

$40
$35

14% higher than market

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

$105
$96

9% higher than market

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

$77
$81

5% lower than market

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

$55
$54

2% higher 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]

$94
$87

8% higher 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

$80
$65

24% higher than market

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

$105
$85

23% 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]

$46
$79

43% lower than market

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

$116
$89

30% higher than market

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

$93
$179

48% lower than market

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

$195
$303

36% lower than market

Mammography of both breasts for diagnosis [HCPCS 77066]

$245
$535

54% lower than market

Mammography of one breast for diagnosis [HCPCS 77065]

$215
$387

44% lower than market

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

$1,980
$2,697

27% lower than market

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

$118
$99

19% higher than market

Recurring cataract removal in lens capsule by laser [HCPCS 66821]

$731
$1,205

39% lower than market

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

$380
$414

8% lower than market

Total Knee or Hip Replacement

$38,324
$55,669

31% lower than market

OUTPATIENT EMERGENCY DEPARTMENT

Description

Our Charge
Market Charge

Variance

Critical care delivery to critically ill or injured patient (each additional 30 minutes) [HCPCS 99292]

$326
$345

6% lower than market

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

$1,535
$1,847

17% lower than market

Emergency department visit for minor problem [HCPCS 99281]

$46
$203

77% lower than market

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

$624
$988

37% lower than market

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

$250
$335

25% lower than market

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

$397
$556

29% lower than market

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

$903
$1,399

35% lower than market

OUTPATIENT LABORATORY AND PATHOLOGY

Description

Our Charge
Market Charge

Variance

Lab analysis by immunoassay (ELISA) to identify infectious organism antigen (multiple-step method, each organism) [HCPCS 87449]

$70
$115

39% lower than market

Lab analysis by immunoassay to identify Strep (streptococcus) [HCPCS 87880]

$78
$70

11% higher than market

Lab analysis by nucleic acid (DNA or RNA) to identify antigen of severe acute respiratory syndrome coronavirus 2 (Covid-19) [HCPCS 87635]

$400
$150

166% higher 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]

$155
$281

45% lower than market

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

$55
$88

38% lower than market

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

$100
$113

11% lower than market

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

$98
$210

53% 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]

$55
$127

57% lower than market

Lab analysis to measure blood glucose (sugar) level with hand-held instrument [HCPCS 82962]

$11
$28

61% lower than market

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

$75
$87

14% lower than market

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

$11
$18

40% lower than market

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

$125
$172

27% lower than market

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

$57
$71

20% lower than market

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

$100
$151

34% lower than market

Lab analysis to measure the creatinine level in blood specimen to test for kidney function or muscle injury [HCPCS 82565]

$43
$68

37% lower than market

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

$40
$46

12% lower than market

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

$75
$92

18% lower than market

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

$39
$61

37% lower than market

Lab analysis to measure the iron level [HCPCS 83540]

$27
$45

41% lower than market

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

$100
$113

12% lower than market

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

$48
$69

30% lower than market

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

$185
$212

13% lower than market

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

$139
$242

43% lower than market

Lab analysis to measure the total creatine kinase (cardiac enzyme) level in blood specimen [HCPCS 82550]

$65
$79

18% lower than market

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

$172
$191

10% lower than market

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

$195
$169

16% higher than market

Lab blood analysis to confirm blood unit compatibility by immediate spin technique [HCPCS 86920]

$46
$171

73% 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]

$35
$83

58% 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]

$35
$52

34% lower than market

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

$99
$196

50% lower than market

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

$105
$168

37% lower than market

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

$105
$277

62% lower than market

Platelet pheres leukoreduced [HCPCS P9035]

$961
$1,753

45% lower than market

Rbc leukocytes reduced [HCPCS P9016]

$212
$524

59% lower than market

Unlisted lab analysis by immunoassay for identification of organism [HCPCS 87899]

$37
$63

41% lower than market

OUTPATIENT MEDICINE

Description

Our Charge
Market Charge

Variance

Chemotherapy administration beneath the skin or into muscle (hormonal, anti-cancer) [HCPCS 96402]

$104
$114

8% lower than market

Chemotherapy administration beneath the skin or into muscle (non-hormonal, anti-cancer) [HCPCS 96401]

$190
$175

8% higher than market

Chemotherapy administration into vein by infusion (each additional hour) [HCPCS 96415]

$58
$148

61% lower than market

Chemotherapy administration into vein by push technique (single drug) [HCPCS 96409]

$351
$292

20% higher than market

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

$49
$127

62% lower than market

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

$94
$143

35% lower than market

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

$252
$466

46% 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]

$130
$252

48% lower than market

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

$112
$162

31% lower than market

Heart and lungs restart (attempt) [HCPCS 92950]

$234
$586

60% lower than market

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

$252
$384

35% lower than market

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

$89
$142

38% lower than market

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

$80
$86

7% lower than market

Implanted venous access drug delivery device irrigation [HCPCS 96523]

$85
$96

12% lower than market

Influenza vaccine for injection into muscle (preservation free) [HCPCS 90662]

$179
$280

36% lower than market

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

$94
$124

25% lower than market

Medication application by electic current through skin (each 15 minutes) [HCPCS 97033]

$106
$150

29% lower than market

Oxygen saturation measurement in blood by ear or finger device (continuous overnight monitoring) [HCPCS 94762]

$112
$144

22% lower than market

Physical performance test or measurement with report (each 15 minutes) [HCPCS 97750]

$124
$189

34% lower than market

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

$135
$253

47% lower than market

Rabies vaccine for injection into muscle [HCPCS 90675]

$805
$1,466

45% lower than market

Thought processing testing, interpretation, and report (standardized test, per hour) [HCPCS 96125]

$189
$245

23% lower than market

Voice and resonance bhavioral and qualitative analysis [HCPCS 92524]

$280
$286

2% lower than market

Whole blood removal by needle to correct blood level imbalance [HCPCS 99195]

$98
$226

57% lower than market

OUTPATIENT OBSERVATION

Description

Our Charge
Market Charge

Variance

Hospital observation care on discharge date [HCPCS 99217]

$171
$215

20% lower than market

Hospital observation or inpatient care provided to patients admitted and discharged on the same date of service for problem(s) of moderate severity (50 minutes per day) [HCPCS 99235]

$435
$499

13% lower than market

Hospital observation per hr [HCPCS G0378]

$2
$71

97% lower than market

Initial observation care (typically 70 minutes) [HCPCS 99220]

$381
$548

30% lower than market

Subsequent observation care (typically 25 minutes per day) [HCPCS 99225]

$162
$216

25% lower than market

OUTPATIENT OTHER

Description

Our Charge
Market Charge

Variance

Non-covered item or service [HCPCS A9270]

$5
$10

44% lower than market

Oth resp proc, group [HCPCS G0239]

$92
$123

25% lower than market

Telehealth facility fee [HCPCS Q3014]

$77
$100

23% lower than market

OUTPATIENT PHARMACY AND DRUG ADMINISTRATION

Description

Our Charge
Market Charge

Variance

Admin influenza virus vac [HCPCS G0008]

$32
$64

50% lower than market

Alteplase recombinant [HCPCS J2997]

$1
$195

99% lower than market

Amiodarone hcl [HCPCS J0282]

$10
$19

49% lower than market

Atropine sulfate injection [HCPCS J0461]

$50
$2

2576% higher than market

Cefoxitin sodium injection [HCPCS J0694]

$37
$36

3% higher than market

Chemotherapy administration into vein by infusion (up to 1 hour, single drug) [HCPCS 96413]

$506
$624

19% lower than market

Diazepam injection [HCPCS J3360]

$22
$107

80% lower than market

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

$54
$189

71% lower than market

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

$109
$260

58% lower than market

Ertapenem injection [HCPCS J1335]

$98
$178

45% lower than market

Furosemide injection [HCPCS J1940]

$12
$17

26% lower than market

Hydralazine hcl injection [HCPCS J0360]

$50
$76

35% lower than market

Inj enoxaparin sodium [HCPCS J1650]

$3
$11

71% lower than market

Inj magnesium sulfate [HCPCS J3475]

$6
$14

54% lower than market

Ketorolac tromethamine inj [HCPCS J1885]

$50
$29

69% higher than market

Lidocaine injection [HCPCS J2001]

$50
$15

220% higher than market

Methylprednisolone injection [HCPCS J2920]

$99
$58

72% higher than market

Methylprednisolone injection [HCPCS J2930]

$50
$77

36% lower than market

Piperacillin/tazobactam [HCPCS J2543]

$18
$21

13% lower than market

Prochlorperazine injection [HCPCS J0780]

$50
$136

64% lower than market

Sincalide injection [HCPCS J2805]

$194
$601

68% lower than market

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

$120
$212

43% lower than market

Triamcinolone acet inj nos [HCPCS J3301]

$12
$6

107% higher than market

Vancomycin hcl injection [HCPCS J3370]

$12
$19

35% lower than market

Zoledronic acid 1mg [HCPCS J3489]

$56
$24

136% higher than market

OUTPATIENT PHYSICAL/OCCUPATIONAL/SPEECH THERAPY

Description

Our Charge
Market Charge

Variance

Elec stim other than wound [HCPCS G0283]

$70
$96

27% lower than market

Electrical stimulation application to 1 or more areas (each 15 minutes) [HCPCS 97032]

$98
$114

14% lower than market

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

$185
$264

30% lower than market

Occupational therapy re-evaluation with established plan of care (typically 30 minutes) [HCPCS 97168]

$126
$121

4% higher than market

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

$160
$265

40% lower than market

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

$181
$258

30% lower than market

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

$268
$262

3% higher than market

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

$111
$132

16% lower than market

Speech sound production evaluation with evaluation of language comprehension and expression [HCPCS 92523]

$218
$442

51% lower than market

OUTPATIENT PULMONARY THERAPY

Description

Our Charge
Market Charge

Variance

Aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device demonstration and/or evaluation for patient use [HCPCS 94664]

$95
$185

49% lower than market

CPAP (continuous positive airway pressure) mask or breathing tube initiation and management for night time respiratory muscle rest [HCPCS 94660]

$476
$507

6% 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]

$89
$258

65% lower than market

OUTPATIENT SURGICAL SERVICES

Description

Our Charge
Market Charge

Variance

Abdominal cavity fluid drainage with imaging guidance [HCPCS 49083]

$1,455
$4,683

69% lower than market

Abscess incision and drainage (simple procedure or single abscess) [HCPCS 10060]

$167
$2,833

94% lower than market

Blood or blood products transfusion [HCPCS 36430]

$1,976
$4,776

59% lower than market

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

$538
$2,231

76% lower than market

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

$3,247
$5,533

41% lower than market

Fluid removal from chest cavity with imaging guidance [HCPCS 32555]

$1,958
$3,261

40% lower than market

Gallbladder removal with x-ray study of bile ducts with endoscope [HCPCS 47563]

$11,559
$15,079

23% lower than market

Indwelling bladder catheter insertion (simple) [HCPCS 51702]

$2,713
$5,189

48% lower than market

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

$1,511
$6,235

76% lower than market

Short arm splint application forearm to hand (non-moveable) [HCPCS 29125]

$1,564
$3,491

55% lower than market

Simple repair of wound of face, ears, eyelids, nose, lips and/or mouth (2.5 cm or less) [HCPCS 12011]

$2,280
$4,140

45% lower than market

Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.5 cm or less) [HCPCS 12001]

$1,697
$2,341

27% lower than market

Simple repair of wound of scalp, neck, underarms, genitalia, trunk, arms, and/or legs (2.6 to 7.5 cm) [HCPCS 12002]

$2,252
$2,754

18% lower than market

Tunneled central venous catheter insertion for infusion with implanted port beneath the skin (5 years of age or older) [HCPCS 36561]

$3,310
$16,615

80% 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]

$3,034
$3,444

12% lower than market

Abdominal and pelvic CT scan without contrast, followed by contrast for injury, foreign bodies, or tumors [HCPCS 74178]

$4,121
$4,903

16% lower than market

Abdominal aorta ultrasound for screening of abdominal aortic aneurysm [HCPCS 76706]

$271
$370

27% lower than market

Abdominal CT scan with contrast for injury, foreign bodies, or tumors [HCPCS 74160]

$2,225
$2,309

4% lower than market

Abdominal ultrasound (limited) [HCPCS 76705]

$610
$632

3% lower than market

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

$265
$303

12% lower than market

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

$205
$212

3% lower than market

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

$335
$420

20% lower than market

Ankle x-ray (2 views) [HCPCS 73600]

$220
$271

19% lower than market

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

$275
$330

17% lower than market

Arm CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73200]

$1,425
$1,713

17% lower than market

Arm x-ray of forearm (2 views) [HCPCS 73090]

$235
$296

21% lower than market

Arm x-ray of upper arm (minimum of 2 views) [HCPCS 73060]

$198
$264

25% lower than market

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

$1,008
$1,057

5% lower than market

Arteries and arterial grafts ultrasound of one leg (limited study) [HCPCS 93926]

$473
$529

11% lower than market

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

$344
$407

15% lower than market

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

$235
$309

24% lower than market

Chest CT scan with contrast to examine injury, foreign bodies, or tumors [HCPCS 71260]

$1,642
$2,314

29% lower than market

Chest CT scan without contrast to examine injury, foreign bodies, or tumors [HCPCS 71250]

$1,372
$1,619

15% lower than market

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

$159
$249

36% lower than market

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

$160
$244

35% lower than market

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

$2,845
$3,241

12% lower than market

CTA scan of head blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70496]

$2,845
$3,332

15% lower than market

CTA scan of neck blood vessels with contrast to examine blood clots or aneurysms [HCPCS 70498]

$2,845
$3,486

18% lower than market

Elbow x-ray (2 views) [HCPCS 73070]

$130
$247

47% lower than market

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

$245
$316

22% lower than market

Esophagus x-ray with barium swallow (single contrast material swallowed) [HCPCS 74220]

$410
$475

14% lower than market

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

$1,268
$1,816

30% lower than market

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

$200
$260

23% lower than market

Fluoroscopic guidance for needle placement [HCPCS 77002]

$406
$481

16% lower than market

Fluoroscopy imaging guidance for procedure (up to 1 hour) [HCPCS 76000]

$180
$472

62% lower than market

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

$245
$251

3% lower than market

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

$240
$281

15% lower than market

Head and neck ultrasound [HCPCS 76536]

$545
$593

8% lower than market

Head or brain CT scan without contrast, followed by contrast to examine injury, foreign bodies, or tumors [HCPCS 70470]

$2,095
$2,301

9% lower than market

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

$252
$256

2% lower than market

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

$2,017
$2,415

16% lower than market

Imaging of bone and/or joint (whole body) [HCPCS 78306]

$1,360
$1,825

25% lower than market

Imaging of brain by MRI without contrast [HCPCS 70551]

$2,164
$2,710

20% lower than market

Imaging of lower spinal canal by MRI without contrast, followed by contrast [HCPCS 72158]

$4,247
$4,127

3% higher than market

Imaging of scrotum by ultrasound [HCPCS 76870]

$506
$571

11% lower than market

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

$2,619
$2,778

6% lower than market

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

$225
$252

11% lower than market

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

$305
$324

6% lower than market

Leg CT scan without contrast for injury, foreign bodies, or tumors [HCPCS 73700]

$1,287
$1,609

20% lower than market

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

$941
$897

5% higher than market

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

$1,208
$1,997

39% lower than market

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

$245
$316

23% lower than market

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

$1,920
$2,269

15% lower than market

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

$1,463
$1,725

15% lower than market

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

$580
$685

15% lower than market

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

$180
$256

30% lower than market

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

$280
$323

13% lower than market

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

$250
$314

20% lower than market

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

$1,491
$1,873

20% lower than market

Spinal CT scan of middle spine without contrast to examine injury, foreign bodies, or tumors [HCPCS 72128]

$1,372
$1,916

28% lower than market

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

$1,372
$2,024

32% lower than market

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

$340
$346

2% lower than market

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

$385
$438

12% lower than market

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

$305
$299

2% higher than market

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

$405
$488

17% lower than market

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

$170
$283

40% lower than market

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

$70
$109

36% lower than market

Wrist x-ray (2 views) [HCPCS 73100]

$134
$232

42% lower than market

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

$184
$317

42% lower than market

X-ray of sacrum and tailbone (minimum of 2 views) [HCPCS 72220]

$240
$229

5% higher than market

INPATIENT CARDIOLOGY

Description

Our Charge
Market Charge

Variance

Abnormal or Irregular Heartbeat with complications

$12,513
$14,672

15% lower than market

Abnormal or Irregular Heartbeat without complications

$5,210
$11,298

54% lower than market

Acute myocardial infarction, discharged alive with major complications

$9,127
$26,932

66% lower than market

Angina pectoris

$7,844
$34,085

77% lower than market

Cardiac arrhythmia & conduction disorders with major complications

$5,906
$25,210

77% lower than market

Heart failure & shock without complications

$2,988
$11,100

73% lower than market

Heart Failure with complications

$9,286
$16,468

44% lower than market

Heart Failure with major complications

$10,616
$19,603

46% lower than market

Hypertension without major complications

$5,373
$11,027

51% lower than market

Peripheral vascular disorders with complications

$8,492
$20,935

59% lower than market

Syncope & collapse

$3,516
$17,408

80% lower than market

INPATIENT GENERAL SURGERY

Description

Our Charge
Market Charge

Variance

Laparoscopic cholecystectomy with complications

$16,058
$45,616

65% lower than market

Major small & large bowel procedures with complications

$32,327
$75,600

57% lower than market

Major small & large bowel procedures without complications

$26,065
$44,119

41% lower than market

Peritoneal adhesiolysis with complications

$29,136
$69,602

58% lower than market

INPATIENT MEDICINE

Description

Our Charge
Market Charge

Variance

Anemia or other red blood cell disorders without complications

$5,800
$17,750

67% lower than market

Blood Infection with major complications

$21,362
$31,412

32% lower than market

Blood infection without major complications

$12,667
$20,268

37% lower than market

Cirrhosis & alcoholic hepatitis with complications

$2,307
$25,579

91% lower than market

Diabetes with complications

$5,566
$13,141

58% lower than market

Digestive System Bleeding with complications

$8,476
$22,639

63% lower than market

Disorders of pancreas except malignancy with complications

$5,967
$17,889

67% lower than market

Disorders of pancreas except malignancy without complications

$6,352
$12,804

50% lower than market

Dysequilibrium

$2,234
$16,133

86% lower than market

G.I. hemorrhage with major complications

$15,600
$47,841

67% lower than market

G.I. hemorrhage without complications

$8,894
$24,211

63% lower than market

G.I. obstruction with complications

$3,134
$14,929

79% lower than market

G.I. obstruction without complications

$2,743
$16,041

83% lower than market

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

$5,630
$16,887

67% lower than market

Infection of the skin

$9,664
$13,831

30% lower than market

Major gastrointestinal disorders & peritoneal infections with complications

$8,676
$19,512

56% lower than market

Nutritional or Metabolic Disorders without major complications

$9,204
$11,434

20% lower than market

Other digestive system diagnoses with complications

$4,166
$17,689

76% lower than market

Other digestive system diagnoses with major complications

$16,528
$24,106

31% lower than market

Other disorders of the eye without major complications

$9,189
$15,215

40% lower than market

Signs & symptoms with major complications

$23,418
$25,877

9% lower than market

Stomach Disorder without complications

$5,417
$13,846

61% lower than market

INPATIENT NEUROLOGY

Description

Our Charge
Market Charge

Variance

Degenerative nervous system disorders without complications

$6,309
$23,295

73% lower than market

Intracranial hemorrhage or cerebral infarction without complications

$12,150
$17,637

31% lower than market

Nonspecific cerebrovascular disorders with complications

$3,182
$20,851

85% lower than market

Nonspecific cerebrovascular disorders with major complications

$7,227
$24,589

71% lower than market

Other disorders of nervous system with complications

$20,889
$18,357

14% higher than market

Other disorders of nervous system with major complications

$9,771
$35,789

73% lower than market

Stroke with complications

$9,101
$19,771

54% lower than market

Stroke with major complications

$12,747
$28,035

55% lower than market

Transient ischemia

$3,810
$23,486

84% lower than market

INPATIENT ONCOLOGY

Description

Our Charge
Market Charge

Variance

Respiratory neoplasms with complications

$7,969
$18,870

58% lower than market

Respiratory neoplasms with major complications

$27,751
$30,245

8% lower than market

INPATIENT ORTHOPEDIC SURGERY

Description

Our Charge
Market Charge

Variance

Hip & femur procedures except major joint with complications

$50,922
$49,970

2% higher than market

Total Ankle Replacement

$41,878
$73,802

43% lower than market

INPATIENT ORTHOPEDICS

Description

Our Charge
Market Charge

Variance

Fractures of hip & pelvis without major complications

$4,995
$11,373

56% lower than market

Fractures of hip, pelvis & thigh without major complications

$6,633
$14,685

55% lower than market

Medical back problems without major complications

$5,673
$18,463

69% lower than market

Pathological fractures & musculoskelet & conn tiss malig with compications

$7,442
$19,036

61% lower than market

Tendonitis, myositis & bursitis without major complications

$11,849
$18,023

34% lower than market

INPATIENT PHYSICIAN SERVICES

Description

Our Charge
Market Charge

Variance

Initial hospital inpatient care (typically 70 minutes per day) [HCPCS 99223]

$408
$599

32% lower than market

INPATIENT PSYCHIATRY

Description

Our Charge
Market Charge

Variance

Alcohol or Drug Abuse without rehab or major complications

$7,555
$18,042

58% lower than market

Mental disturbances and retardation

$2,953
$22,978

87% lower than market

INPATIENT PULMONOLOGY

Description

Our Charge
Market Charge

Variance

Chronic Lung Disease with complications

$11,553
$11,489

1% higher than market

Chronic Lung Disease with major complications

$12,016
$19,963

40% lower than market

Chronic Lung Disease without complications

$8,250
$9,516

13% lower than market

Major chest trauma with complications

$3,628
$27,722

87% lower than market

Pleural effusion with complications

$7,148
$18,474

61% lower than market

Pneumonia with complications

$13,233
$13,566

2% lower than market

Pneumonia with major complications

$15,265
$23,927

36% lower than market

Pneumonia without complications

$5,042
$14,326

65% lower than market

Pulmonary embolism without major complications

$2,301
$14,480

84% lower than market

Respiratory Failure

$8,720
$21,975

60% lower than market

Respiratory infections & inflammations without complications

$9,381
$21,280

56% lower than market

Respiratory infections and inflammations with major complications

$19,129
$32,649

41% lower than market

Respiratory signs & symptoms

$1,606
$27,370

94% lower than market

Ventilator support for 4 days or less

$23,613
$57,717

59% lower than market

INPATIENT UROLOGY

Description

Our Charge
Market Charge

Variance

Kidney & urinary Infection with major complications

$8,687
$15,196

43% lower than market

Kidney & urinary Infection without complications

$6,033
$14,120

57% lower than market

Kidney failure with complications

$7,483
$15,459

52% lower than market

Kidney failure with major complications

$10,942
$28,222

61% lower than market

Other kidney & urinary tract diagnoses with complications

$11,920
$17,181

31% lower than market

Other kidney & urinary tract diagnoses with major complications

$80,378
$34,348

134% higher than market

Renal failure without complications

$7,809
$12,836

39% lower than market

BILLING PROCESS AND INFORMATION

How You Can Help

Thank you for choosing Ashe 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 Ashe 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 Ashe 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 Ashe 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 336-846-7101.

If you need more information about the price of a future service, please contact our Customer Service at 336-846-7101. 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.