CONSUMER PRICE GUIDE

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1 1 CONSUMER PRICE GUIDE Revised January 1 st 2017

2 General Information Memorial Hospital abides by all state and federal charging and billing regulations for hospital based healthcare services. The following information is published in accordance with Ohio House Bill No. 197 to allow consumers the opportunity to review hospital charges for selected medical services. Although the information provides basic charge information it is not all inclusive of the potential charges for a given service. It does not include items such as nonroutine supplies and medications that can vary significantly among patients. If more detailed or additional information is needed for specific services, please contact us at or (937) This hospital published charge information includes the following: Cardiac Cath Lab Services Delivery Room Services Emergency Department Services Laboratory Services Occupational Therapy Services Operating Room Services Pain Management Services Physical Therapy Services Radiological/x-ray Services Respiratory Therapy Services Sleep Lab Services Wound Care Services Inpatient Room and Board rates & Observation Room rates Memorial Hospital makes every effort to ensure that hospital bills are complete and accurate and is willing to provide financial assistance to those patients who are experiencing difficulty in paying their bills. The hospital participates in the Hospital Care Assurance Program (HCAP) that provides a sliding scale discount based on income and household size. Interest is not charged on unpaid, billed accounts. For more information on payment assistance please contact the hospital via at or by phone at (937) The information contained here does not include detail on physician charges for radiology, laboratory, surgical, cardiology or emergency services. For physician charge information, please contact the following businesses. Emergency Department Physicians TEAMHealth: (877) Radiologists (X-ray readings) Mid-Ohio Radiology: (614) or (800) Pathology and Cardiology (pathology and EKG readings) OSU Physicians: (614) or (888) Anesthesia Rural Anesthesia Management: (859)

3 Cardiac Cath Lab s Estimated Insertion/replacement of permanent implantable defibrillator system... 58, Removal/replacement of pacemaker pulse generator dual lead system , Estimated Removal/replacement of pacemaker pulse generator single lead system.. 17, Estimated charge for Implantation of patient-activated cardiac event recorder... 13, Cardioversion, elective, electrical conversion of arrhythmia; external , Estimated Tilt Table , Estimated charge for Left Heart Artery / Ventricle Angiography , Estimated charge for Left Heart Artery / Graft Angiography , Estimated charge for Right & Left Heart Artery/Ventricle Angiography , Labor & Delivery Room s Monitor-Fetal Heart-Per Hour $ Monitor-Neonatal Delivery Room Amniocentesis Laboring Epidural per Hour Laboring Monitoring per Hour OB Recovery 1st Hour OB Recovery Room/15 Minutes Additional Labor & Delivery Room s continued OB C-Section 1st 15 Minutes , OB C-Section Each Additional 15 Minutes Average Total Delivery s Median Normal Vaginal Delivery Hospital (Includes all medications, supplies and hospital services) $7, Median Uncomplicated C-Section Delivery Hospital (Includes all medications, supplies and hospital services) $18,

4 Emergency Department s ED Levels of Care Emergency Room Level $ Emergency Room Level Emergency Room Level Emergency Room Level , Emergency Room Level , Emergency Room Level Critical , ED Procedures Arterial Puncture Arthrocentesis of Joint, Needle Aspiration or Injection Avulsion of Nail Plate, Partial or Complete Blood Product Transfusion , Central Vein IV Line Insertion , Chest Tube Insertion , Ear Wax Impaction Removal EKG 12 Lead Tracing only Electrocardioversion of Heart , Endotracheal Intubation - Breathing Tube Insertion Epidural Blood Patch Spinal Injection , Incision & Drainage Hematoma/Fluid , Foley Catheter Insertion Lab Draw ER Staff Injection, IV push, initial Injection, each additional sequential IV push of a new substance/drug Injection, Subcutaneous or intramuscular IV Hydration, initial, up to one hour IV Hydration, each additional hour IV Infusion Therapy, Additional Sequential, Up to 1 Hour IV Infusion Therapy, Concurrent IV Infusion Therapy, Initial, Up To One Hour IV Infusion Therapy, each additional hour Therapeutic, prophylactic, or diagnostic injection; IV push initial Therapeutic, prophylactic, or diagnostic injection; ea. add l IV push new drug Dermabond Lumbar Puncture/Spinal Tap Moderate Sedation Over 5 Years Old First 30 Minutes Nasal Packing/Cautery Emergency Department s Continued 3

5 PICC Insertion (Peripheral Central IV Line) , Straight Catheter Insertion for Urine Trans Cutaneous Pacing of Heart Immunization Administration through 18 years of age 1 st Component Immunization Administration through 18 years of age Additional Component Vaccine Administration Adult Laboratory s Complete Blood Count (CBC) with Auto Differential $55.00 Complete Blood Count (CBC) Without Auto Differential Basic Metabolic Panel F Comprehensive Metabolic Panel Lipid Panel Ha 1C Marysville Glucose Cholesterol Prothrombin Time Creatinine Serum BUN B Electrolyte Panel Troponin-I Urinalysis - Dipstick Only Urinalysis; Auto with Microscopy Culture - Urine PTT TSH-High Sensitivity TSH-Reflex Magnesium Gross & Micro / Level IV Lipase Potassium Sensitivity Venipuncture Occupational Therapy s 4

6 Activities of Daily Living Mobility - 15 Minutes $97.00 Aquatic Therapy Exercises Each 15 minutes Dynamic Functional Activity - 15 Minutes Fluidotherapy - Whirlpool Therapy Joint Mobilization - 15 Minutes Manual Therapy Each 15 Minutes Massage Therapy -15 Minutes Myofascial Release -15 Minutes Occupational Therapy Evaluation Occupational Therapy Re Evaluation Paraffin - One Area -15 Minutes Patient Education/Instruction - 15 Minutes Sensory Integrative Techniques Therapeutic Exercise - Limited - 15 Minutes Therapeutic Procedure Group - 2 or More Ultrasound Attended - 15 Minutes Whirlpool Therapy Operating Room s Eye Minor - 1st 15 Minutes $1, Eye Major - 1st 15 Minutes , Minor - 1st 15 Minutes $2, Intermediate - 1st 15 Minutes , Major - 1st 15 Minutes , Minor - Additional 15 Minutes Intermediate - Additional 15 Minutes Major - Additional 15 Minutes Pain Management s Office/Outpatient Visit New Level

7 Office/Outpatient Visit New Level Office/Outpatient Visit New Level Office/Outpatient Visit New Level Office/Outpatient Visit New Level Office/Outpatient Visit Established Level Office/Outpatient Visit Established Level Office/Outpatient Visit Established Level Office/Outpatient Visit Established Level Office/Outpatient Visit Established Level EMG 1 Extremity EMG 2 Extremities EMG 3 Extremities EMG 4 Extremities Motor and/or Nerve Conduction Test Nerve Conduction Studies Nerve Conduction Studies Nerve Conduction Studies Nerve Conduction Studies Nerve Conduction Studies Nerve Conduction Studies Nerve Conduction Studies 13 or more Destroy Lumbar/Sacral Facet Joint , Destroy Lumbar/Sacral Joint each additional Facet Joint , Destroy Cervical/Thoracic Facet Joint , Inject Foramen Epidural Lumbar/Sacral Bilateral procedure , Inject Foramen Epidural Lumbar/Sacral , Inject Foramen Epidural ea. add l level. 1, Inject Paravertebral Facet Joint Lumbar/Sacral 1 Level Bilateral procedure , Inject Paravertebral Facet Joint Lumbar/Sacral 2 Level Bilateral procedure , Physical Therapy s Aquatic Therapy with Therapeutic Exercise - 15 Minutes

8 Dynamic Functional Activities - 15 Minutes EMS - Electrical Stimulation - Unattended Exercise-Therapeutic - 15 Minutes Gait Training - 15 Minutes Myofascial Release - 15 Minutes Neuromuscular Re-Education - 15 Minutes Patient Education Instruction - Additional 15 Minutes Physical Therapy Evaluation Physical Therapy Re-Evaluation Physical Performance test - per 15 Minutes Sports Performance Evaluation / Consult Sports Performance Evaluation / Consult / Nutrition Therapeutic Activities - Group - 15 Minutes Therapeutic Activities - Includes Function Performance - 15 Minutes Traction - Mechanical - Supervised Traction-Manual Therapy - 15 Minutes Ultrasound Therapy - 15 Minutes Vasopneumatic Device Therapy 1 + areas Whirlpool Therapy Work Conditioning per hour Radiology s X-Rays Abdomen and Posterior, Anterior Chest $ Cervical 5 view/oblique Chest Posterior, Anterior and Lateral Chest Posterior, Anterior Only Portable Chest Posterior, Anterior Only $ Cross Fire Abdomen DexaScan Foot, 3 views Hand X-Rays Continued Hip Knee X-Ray, 1-2 views Ankle Lumbar Spine-AP & Lateral/Oblique, 4views Mammography Diagnostic Bilateral Mammography Screening Bilateral Shoulder,

9 Upper GI Tract with Double Contrast Wrist CT Scans CT Abdomen with Contrast $1, CT Angiography Chest with Contrast , CT Cervical without Contrast , CT Head without Contrast , CT Head with and without Contrast , CT Pelvis with Contrast , CT Thorax without Contrast , CT Thorax / Chest with Contrast , CT Stone Study , MRI MRI Brain, with and without Contrast $1, MRI Brain, without Contrast $1, MRI Cervical Spine, Without Contrast , MRI Lower Extremity Joint Only without Contrast , MRI Lumbar Spine, Without Contrast , MRI Upper Extremity Joint Only without Contrast , Ultrasound Ultrasound Abdominal/Complete Ultrasound Abdominal/Limited Ultrasound Pelvis/Complete Ultrasound Renal/Limited/No Bladder Ultrasound Renal and Bladder Complete Ultrasound Thyroid and or Neck Respiratory Therapy s Bronchoscopy with Local Anesthetic $1, Bronchoscopy with Sedation , Bronchodilator Response Pre and Post Dilator Administration

10 Nebulizer Therapy Breathing Exercise Instruction Cool Aerosol/Initial Treatment EEG (Electroencephalogram) Awake & Asleep , EEG Extended Monitoring, minutes , EKG Standard 12 Lead (initial) Holter Monitor up to 48 hours Holter Analysis with report Sputum Induction Ventilator Assistance & Mgmt, Initial Day Ventilator Subsequent Days Infant Apnea Monitor management-inpatient Only CPAP Ventilation Initiation and Management Arterial Puncture Oximetry, Multiple Determinations Oximetry, Single Determination Spirometry Nocturnal Oximetry Sat Study Respiratory Medication Inhalation Medication Oxygen Daily Sleep Lab s Sleep Study Unattended Multi Sleep Latency Test / Maintenance of Wakefulness Testing...3, Sleep Polysomnography, w/4 +Parameters (limited study)...3, Sleep Polysomnography w/4 + Parameters..5, Sleep Polysomnography w/ CPAP / BIPAP... 5, Wound Care s Office/Outpatient Visit New Patient Level 1...$ Office/Outpatient Visit New Patient Level Office/Outpatient Visit New Patient Level Office/Outpatient Visit New Patient Level

11 Office/Outpatient Visit New Patient Level Office/Outpatient Visit Established Patient Level Office/Outpatient Visit Established Patient Level Office/Outpatient Visit Established Patient Level Office/Outpatient Visit Established Patient Level Office/Outpatient Visit Established Patient Level Hyperbaric Oxygen Therapy...2, Skin Substitute Graft Trunk/Arm/Leg..6, Skin Substitute Graft Face/Neck/Hand/Foot.....4, Debridement, subcutaneous first 20 square cm or less...1, Debridement, subcutaneous each additional 20 square cm... 1, Negative Pressure Wound Therapy less than or equal to 50 square cm Negative Pressure Wound Therapy greater than 50 square cm Selective Wound Debridement 20 square cm or less Inpatient Room and Board Rates Intensive Care , Intermediate Care , Medical on ICU , Medical/Surgical (Morey Center) Nursery Obstetrics Telemetry (Morey Center) Observation Room s Intensive Care (per hour rate) Medical on ICU (per hour rate) Intermediate Care (per hour rate) Medical on Stepdown (per hour rate)

12 Medical/Surgical Morey Center (per hour rate) Medical/Surgical Telemetry Morey Center (per hour rate) Obstetrics (per hour rate) Average Total s (inclusive of all charges) The 5 Most Common Inpatient Surgical Procedures Total Abdominal Hysterectomy $24, Laparoscopic Cholecystectomy (Gallbladder removal) , Closed Reduction Internal Fixation of Femur Fracture , Total Knee Replacement , Total Hip Replacement , The 5 Most Common Outpatient Surgical Procedures Colonoscopy with Biopsy $3, Esophagogastroduodenoscopy (Upper GI Scope) With Biopsy , Colonoscopy , Colonoscopy with Polypectomy , Esophagogastroduodenoscopy (Upper GI Scope) ,

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