Hospital Charge Information Listing These charges are estimated as of 10/01/2017 and are subject to change. To better inform our patients, Day Kimball Hospital is providing a current list of charges which reflect the most commonly performed tests, services or procedures here at Day Kimball Hospital. Please note that charges do not always represent what a patient will owe. A patient's financial responsibility can vary widely depending upon several factors: Hospitals Contracted Rates with each Insurance Carrier o Through negotiations, the hospital and insurance companies agree contractually to fees that will be paid (or allowed ) for each service. An example: hospital charges $230 for an x-ray of the ankle, but insurance carrier A has contractually agreed to (or only allows) $100 to be paid to the hospital for this x-ray as payment in full. Employer Health Insurance Benefit Design o An employer will decide its employees responsibilities for any deductibles, coinsurance or copayments based upon the insurance plan chosen. Using the x-ray example above, the health insurance benefit design determines how much of that $100 is paid by the patient and how much is paid by the insurance company. Deductible example: the patient must pay $100 directly to the hospital if the yearly deductible that has not yet been met. Coinsurance example: if there is no deductible (or if it has been met for the year) but the patient has a 20% coinsurance requirement, the insurance company would pay the hospital $80 and the patient would pay the hospital $20, (or 20% of $100). Personal Health Insurance Benefit Design through an Insurance Plan purchased on the Exchange or Marketplace o A patient s plan selection through the Exchange or Marketplace will define any deductibles, coinsurance or copayments required. Payments due to the hospital will follow the same example as shown above for Employer Health Insurance Benefit Design BILLING POLICIES Day Kimball Healthcare wants to ensure that its patients receive the full benefits of all insurance coverage as well as consideration under our financial assistance programs. Before you are billed, we submit your claims to all active insurance carriers based upon the information that is provided to us at the time of service. In addition to your hospital bill, you may receive separate bills for physician or other professional service providers involved in your hospital care. Financial Assistance is available for those who qualify. If you are not able to pay the amount you owe in full, you may contact our financial counseling team at (860) 963-6337 option 2 to apply for financial assistance or to determine a payment plan that fits your needs. Emergent services will never be delayed or withheld on the basis of your ability to pay.
Y SURGER AL GENER EMERGENCY SERVICES- Emergency Department charges are based on the level of emergency care provided to our patients. Each level reflects the intensity of services, and amount of resources required to provide treatment. Each Emergency Room Visit is unique; therefore, there may be supplies; drugs, testing, or additional procedures which may be required for a particular emergency treatment. Such services or procedures are above and beyond the average charges listed below. Additionally; the average charges listed do not include fees for Emergency Department Physicians; Radiologist, or other consulting Physicians who will bill separately for their services. LEVEL OF SERVICE AVERAGE CHARGE per EMERGENCY ROOM VISIT LEVEL 1 $295 LEVEL 2 $402 LEVEL 3 $1,114 LEVEL 4 $2,658 LEVEL 5 $3,494 CRITICAL CARE, INITIAL CARE $6,283 INPATIENT CARE- Inpatient Care charges are based on the length of stay; level of acuity of the patient, and services provided during the patients stay. Each Inpatient stay is unique; therefore, there may be supplies; drugs, testing, or additional procedures which may be required for a particular Inpatient Care. Such services are above and beyond the average charges listed below. Additionally, the average charges listed do not include fees for Emergency Department physicians; Radiologists, Anesthesiologists, and consulting Physicians who will bill separately for their services. INPATIENT CARE CLASSIFICATION AVERAGE CHARGE per Hospital Admission INTENSIVE CARE $24,158 MEDICAL $18,045 PEDIATRIC $5,768 PSYCHIATRY $15,849 TELEMETRY $18,654 NON-MATERNITY OBSTETRICAL $13,058 MATERNITY SERVICES AVERAGE CHARGE per Admission VAGINAL DELIVERY (SINGLE BIRTH) $9,810 CESAREAN DELIVERY (SINGLE BIRTH) $16,983 NEWBORN $8,434 SURGICAL PROCEDURES- Operating Room The following charges are for some of our most common procedures. Because each patient surgery is unique, there may be additional resources that may be required which could increase the charges for a surgical case. In addition, the listed average charges do not include professional fees for surgeons, physicians or anesthesiologists who will bill separately for their services. GENERAL SURGERY ABDOMINAL HERNIA REPAIR W/ MESH $8,485 APPENDECTOMY $15,558
ORTHOPEDIC SURGERY ENT SURGERY OB/GYN SURGERY CARDIAC SURGERY Y EYE SURGER CYSTOSCOPY W/ BIOPSY(S) $9,942 EXCISION -BREAST LESION $9,053 INGUINAL HERNIA REPAIR W/ MESH $6,317 INSERTION OF TUNNELED CATHETER IN CHEST $7,033 LAPAROSCOPIC CHOLECYSTECTOMY $10,214 LAPAROSCOPY APPENDECTOMY $14,528 REPAIR OF RECTUM/REMOVE SIGMOID COLON $34,514 REPAIR UMBILICAL HERNIA $6,653 ORTHOPEDIC SURGERY BUNIONECTOMY $6,775 CARPAL TUNNEL SURGERY $4,779 CERVICAL DISCECTOMY $58,260 KNEE ARTHROSCOPY/SURGERY $6,560 LUMBRAL DISCECTOMY $29,263 RELEASE HAND/FINGER TENDON $4,495 SHOULDER ARTHROSCOPY/SURGERY $18,149 TOTAL KNEE ARTHROPLASTY $33,629 EAR NOSE AND THROAT SURGERY CREATE EARDRUM OPENING $4,343 IRRIGATION MAXILLARY SINUS $7,662 REMOVAL OF ADENOIDS $5,012 REMOVAL OF TONSILS $5,558 OBSTETRIC AND GYNOCOLOGICAL SURGERY DILATION AND CURETTAGE (D &C) $7,373 ENDOSCOPIC DESTRUCTION OF FALLOPIAN TUBES $5,674 HYSTEROSCOPY BIOPSY $9,311 LAPAROSCOPIC HYSTERECTOMY $14,970 CARDIAC SURGERY INSERTION OF PACEMAKER, DUAL LEADS $27,194 REMOVAL OF PACEMAKER GENERATOR $17,365 CORRECTIVE EYE SURGERY CATARACT SURGERY W/ IOL 1 STAGE $5,005 CLINICAL LABORATORY The following charges represent the Hospital s most common laboratory tests and their associated prices. LAB EXAM ACETOMINOPHEN $127 ALBUMIN (BLOOD) $18 ALCOHOL $127 ANTIBODY SCREEN $136 ANTINUCLEAR ANTIBODIES, IFA $69 BABESIA, AMPLIFIED PROBE TECHNIQUE $195 BETA STREP GROUPING $33 BETA STREP SCREEN $26 BILIRUBIN, CONJUGATED $22 BLOOD CULTURE $55 BLOOD TYPING ABO $136
BUN $19 CALCITROL(1,25 DI-OH VITD) $220 CALCIUM $20 CAMPY STOOL CULT $42 CANDIDA SPECIES $165 CBC/AUTO DIFF $44 CEA $74 CHLAMYDIA DNA $195 CPK $36 CREATININE $22 CREATININE RANDOM URINE $33 CROSSMATCH, IMMEDIATE SPIN $223 CRP,HIGH SENSITIVITY $58 DEFINITIVE ID AER 1 $31 DIGOXIN $55 FERRITIN $77 FIBRINOGEN $36 FOLIC ACID $57 FREE K + L LT CHAINS, QUANTITATIVE SERUM $78 GARDNERELLA $165 GC DNA $195 GLUCOSE 1HR,NF $22 GLUCOSE FASTING $17 GLYCOHEMOGLOBIN W/EAG $55 GROUP B STREP SCREEN $26 GRAM STAIN $18 HEPATITIS B SURFACE ANTIGEN SCREEN $59 HCG BETA SUBUNIT $69 HIGH DENSITY LIPID PANEL $78 HEMOGLOBIN $12 HEPATITIS A (REFLEX TO IGM) $71 HEPATITIS B CORE ANTIBODY, TOTAL $103 HEPATITIS B SURFACE ANTIBODY $92 HEPATITIS C ANTIBODY W/REFLEX QUANTITATIVE AB BY PCR $82 HEPATIC FUNCTION PANEL $58 HPV DNA HIGH RISK $111 IGA $78 IMMUNOGLOBULIN, QN $80 INFLUENZA A $39 IRON $25 LACTOFERRIN $67 LDH $28 LEAD, BLOOD, PEDI CAPILLARY $104 LIPASE $32 ELECTROLYTES $38 MAGNESIUM $28 MYCOPLASMA IGM $97 NT BNP $196 OCCULT BLOOD FECES $22 PHOSPHOROUS $19 PREG MONOCLONAL URINE $71 PROLACTIN $86 PROTHROMBIN TIME $18 PROSTATE SPECIFIC ANTIGEN FREE (PSA FREE) $105 PROSTATE SPECIFIC ANTIGEN SCREEN (PSA SCREENING ) $79 PROSTATE SPECIFIC ANTIGEN TOTAL (PSA DIAGNOSTIC) $105 PARATHYROID HORMONE, INTACT (PTH, INTACT) $236 PARTIAL PROTHOMBIN TIME (PTT) $26 RA FACTOR,QUANT $41
ALLERGEN PANELS XRAY- RADIOLOGICAL IMAGING RAPID GROUP A STREP $96 RESPIRATORY CULTURE $37 RETICULOCYTES $18 RH (BLOOD ANTIGEN) $136 RPR $38 RUBELLA SCREEN $103 SALICYLATE $127 SALM/SHIG STOOL CULTURE $42 SENSITIVITY,MIC $34 SGOT $47 SHIGA TOXIN, STOOL $106 T3 UPTAKE $29 T4 (THYROXINE) $34 THROAT CULTURE $38 THROAT SCREEN PEDS $26 TRICHOMONAS $165 TROPONIN LAB $44 TSH $75 URIC ACID $18 URINALYSIS $28 URINE CULTURE $31 URINE DRUG SCREEN $91 VALPROIC ACID $55 VITAMIN B12 $67 VITAMIN D, 25 HYDROXY $169 WOUND CULTURE $49 CLINICAL LABORATORY-ALLERGEN TESTING COMMON ALLERGEN PANELS ALLERGEN PROFILE, CITRUS $149 ALLERGEN PROFILE, SHELLFISH $179 HYMENOPTERA PROFILE $179 ALLERGEN PROFILE, FISH $209 ALLERGENS(7) NUTS $209 ALLERGENS (9) NUTS $269 ALLERGEN PROFILE, BASIC FOOD $319 SEASONAL ALLERGENS, SPRING TREE $358 ALLERGENS, ZONE 1 $866 ALLERGENS (39) (CUSTOM FOR DR. CHARON) $1,164 RADIOLOGY The following charges represent the Hospital s most common radiological procedures. These charges do not include the cost of any contrast agent or isotope, if required. All interpretations of these exams will be billed separately by the radiologist. XRAY- RADIOLOGICAL IMAGING ABDOMEN $230 ANKLE $230 BARIUM SWALLOW $247 BONE DENSITY (DEXA) $479 CERVICAL SPINE $237 CERVICAL SPINE - W/OBLIQUES $237 CHEST X-RAY 2 VIEW FRONTAL & LATERAL $148 DORSAL SPINE $237
MAMMOGRAPHY IMAGING- XRAY/ULTRASOUND /MRI ULTRASOUND IMAGING CT SCAN IMAGING ELBOW $144 FINGER, SINGLE $144 FOOT $144 FOREARM $144 HAND $144 HIP $144 KNEE $230 LOWER LEG $144 LUMBAR SPINE ROUTINE $237 LUMBAR SPINE W OBLIQUES MINIMUM- 4 VIEW $230 PELVIS 1 OR 2 VIEWS $237 RIBS ONE SIDE $237 SHOULDER $230 WRIST $144 MAMMOGRAPHY XRAY/ULTRASOUND/MRI MAMMOGRAM SCREEN DIGITAL $418 MAMMOGRAM DIAGNOSTIC DIGITAL $652 MAMMOGRAM DIAGNOSTIC DIGITAL (1 BREAST) $279 MAMMOGRAM DIAGNOSTIC EXTRA VIEWS $279 BREAST ULTRASOUND BILATERAL $276 BREAST ULTRASOUND UNILATERAL $224 MRI-BREASTS W/WO CONTRAST $4,222 ULTRASOUND ABDOMINAL AORTA ULTRASOUND $351 ABDOMINAL ULTRASOUND $343 CAROTID DUPLEX W C/F $420 DOBUTAMINE-STRESS ECHOCARDIOGRAM $876 HEAD OR NECK ULTRASOUND $307 PELVIC ULTRASOUND $297 PELVIC-NON OBSTETRICAL TRANSVAGINAL $294 PERIVASCULAR-LEG-UNILATERAL $287 PERIVASCULAR-LEG-BILATERAL $647 RENAL ULTRASOUND $343 STRESS & REST ECHOCARDIOGRAM $941 THYROID ULTRASOUND $302 CT SCAN ANGIO ABDOMEN & PELVIS WITH AND WITHOUT CONTRAST $2,794 CT ABDOMEN $1,385 CT ABDOMEN AND PELVIS $1,575 CT CHEST $1,274 CT EXTREMITY $966 CT FACE/MANDIBLE $939 CT HEAD $921 CT LUMBAR $1,144 CT NECK $1,085 CT ORBITS $980 CT PELVIS $1,227 CT SINUS $919 CT SPINE $1,143 LOW DOSE CT OF THE CHEST $1,128 LUNG CANCER SCREENING $1,125
MRI IMAGING PET SCAN CARDIOLOGY SERVICES MRI IMAGING MRI ABDOMEN $4,557 MRI ANKLE $2,365 MRI C SPINE $2,508 MRI D SPINE $3,240 MRI ELBOW $2,467 MRI FACE $3,432 MRI HEAD $4,054 MRI HIP $2,483 MRI IAC $4,775 MRI KNEE $2,217 MRI LOWER EXTREMITY $3,170 MRI LOWER SPINE $2,769 MRI NECK $4,444 MRI ORBITS $4,299 MRI PELVIS $4,297 MRI SHOULDER $2,188 MRI UPPER EXTREMITY $3,246 MRI UPPER EXTREMITY - JOINT $2,782 MRI WRIST $2,611 MRI-CHEST W/WO CONTRAST $4,706 MRI-MRCP $1,617 MRI-PIT/SELLA W/WO CONTRAST $4,809 MRI-TMJ BILATERAL $2,164 PET SCAN PET/CT SKULL TO THIGH INITIAL $10,007 PET/CT SKULL TO THIGH SUBSEQUENT $9,714 CARDIOLOGY The following charges reflect the Hospital s most commonly offered Cardiology services. The following charges do not include fees for drugs or supplies. All interpretations of these services will be billed separately by the cardiologist and/or Day Kimball Hospital on behalf of the cardiologist. CARDIOLOGY SERVICES AMBULATORY BLOOD PRESSURE MONITORING $140 CARDIOVERSION PROCEDURE $2,679 DOBUTAMINE STRESS $557 ECG HOLTER MONITOR CONNECT RECORD $577 ECG HOLTER MONITOR-TRANSMIT&ANALYZE $275 ECG LOOP MONITOR CONNECT RECORD $581 ECG LOOP MONITOR-TRANSMIT&ANALYZE $280 EKG $239 EKG REPEAT SAME DAY $249 EKG RHYTHM STRIP $137 EXERCISE OR DRUG INDUCED STRESS TEST $566 INSERT TEMPORARY PACEMAKER $10,225 LEXISCAN STRESS TEST $568 PERSANTINE STRESS TEST $557 RESPIRATORY THERAPY AND PULMONARY FUNCTION CHARGES The following charges reflect the most common services offered by our Respiratory and Pulmonary departments. Patients may have additional charges depending on the services performed. The following charges do not include fees for physicians who may bill separately for the interpretation of certain tests performed.
RESPIRATORY AND PULMONARY FUNCTION PHYSICAL THERAPY OCCUPATI ONAL THERAPY RESPIRATORY AND PULMONARY SERVICES AEROSOL INITIAL TREATMENT $198 AEROSOL SUBSEQUENT TREATMENT $74 ARTERIAL PUNCTURE $243 BIPAP/CPAP $159 DLCO- MEMBRANE DIFFUSE CAPACITY $621 INDUCED SPUTUM TREATMENT $221 INHALATION TEACH & EVALUATE $194 LUNG VOLUME $390 METHACHOLINE EVALUATION $2,109 NONINVASIVE EAR/PULSE OX OVERNIGHT $265 PLETHYSOMOGRAPHY $211 PULSE OXIMETRY WITH EXERCISE $222 PULSE OXIMETRY OVERNIGHT $83 SIX MINUTE PULMONARY STRESS TEST $251 SMOKING CESSATION EDUCATION $63 SPIROMETRY $179 SPRIOMETRY W/BRONCHODILATOR $282 VITAL CAPACITY $261 PHYSICAL THERAPY The following charges reflect the most common services offered by our Physical Therapy department. Patients may have additional charges depending on the services performed. The following charges do not include fees for supplies or additional resources that may be required. PHYSICAL THERAPY FLUIDOTHERAPY $43 VASOPNEUMATIC DEVICE $33 THERAPEUTIC ACTIVITY PER 15 MIN $126 PROSTHETIC TRAINING PER 15 MIN $303 MANUAL THERAPY TECHNIQUE PER 15 MIN $72 NEURO-MUSCULAR RE-EDUCATION PER 15 MIN $86 MECHANICAL TRACTION $36 ADULT DAILY SELF CARE TRAINING MGMT-PER 15 MIN $121 E-STIM INTER UNATTENDED $123 E-STIM MANUAL ATTEND PER 15 MIN $60 PARAFIN PROCEDURE $19 ULTRASOUND PER 15 MIN $30 THERAPEUTIC EXERCISE PER 15 MIN $117 GAIT TRAINING PER 15 MIN $69 PT RE-EVALUATION ESTABLISHED CARE PLAN $135 PT Evaluation HIGH Complexity 45 MIN $203 PT Evaluation MODERATE Complexity 30 MIN $198 PT Evaluation LOW Complexity 20 MIN $198 OCCUPATIONAL THERAPY The following charges reflect the most common services offered by our Occupational Therapy department. Patients may have additional charges depending on the services performed. OCCUPATIONAL THERAPY FLUIDOTHERAPY $43 VASOPNEUMATIC DEVICE $33 ORTHOTIC FIT & TRAIN PER 15 MIN $193
SPEECH THERAPY SPEECH THERAPY MANUAL THERAPY TECH PER 15 MIN $87 NEURO-MUSCULAR RE-EDUCATION PER 15 MIN $123 ADULT DAILY SELF CARE TRAINING MGMT-PER 15 MIN $155 E-STIM INTER UNATTENDED $123 E-STIM MANUAL ATTENDED PER 15 MIN $46 PARAFIN PROCEDURE $19 ULTRASOUND PER 15 MIN $30 THERAPEUTIC ACTIVITY PER 15 MIN $118 THERAPEUTIC EXERCISE PER 15 MIN $109 OT RE-EVALUATION ESTABLISHED CARE PLAN $128 OT Evaluation HIGH Complexity 45 MIN $194 OT Evaluation MODERATE Complexity 30 MIN $193 OT Evaluation LOW Complexity 20 MIN $191 The following charges reflect the most common services offered by our Speech Therapy department. Patients may have additional charges depending on the services performed. SPEECH THERAPY EVALUATION OF SPEECH FLUENCY $456 DEVELOPMENT COGNITIVE SKILLS- PER 15 MIN $173 VIDEO FLUORO EVALUATION $555 AAC EVALUATION SPEECH GENERAL- 1ST HR $486 EVALUATE RECEPTIVE/EXPRESSIVE LANGUAGE $491 SPEECH SOUND LANGUAGE COMPREHENSION $456 SWALLOW TREATMENT $303 SWALLOW EVALUATION $441 SPEECH & LANGUAGE TREATMENT $323