2011 SRMC Pricing Disclosure.xlsx
2011 SRMC Pricing Disclosure.xlsx
2011 SRMC Pricing Disclosure.xlsx
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Patient Price Information List<br />
In compliance with state law, St. Rita's Medical Center is providing this price list containing our charges for room and board, emergency<br />
department, operating room, delivery, physical therapy and other procedures. The hospital's charges are the same for all patients, but a<br />
patient's responsibility may vary, depending on payment plans negotiated with individual health insurers. Uninsured or underinsured<br />
patients should consult with our admitting and billing staff to determine whether they qualify for discounts. These prices are correct as of<br />
January 1, <strong>2011</strong>.<br />
Room and Board -- Per Day Charges<br />
Charges<br />
MEDICAL/SURGICAL $ 1,061.00<br />
ICU $ 2,366.00<br />
ICU STEP DOWN $ 1,235.00<br />
CCU $ 2,099.00<br />
CCU STEP DOWN $ 1,248.00<br />
PEDIATRICS $ 1,292.00<br />
LABOR/DELIVERY $ 1,635.00<br />
PHYSICAL REHAB $ 999.00<br />
ADULT PSYCHIATRIC $ 1,197.00<br />
TRANSITIONAL CARE $ 866.00<br />
NURSERY $ 975.00<br />
ONCOLOGY $ 1,096.00<br />
Labor and Delivery Charges<br />
The following list does not include charges for anesthesia, drugs, or supplies required for a particular delivery room procedure. Fees for physician services or anesthesia<br />
administration are also not reflected, and will be billed separately by your physician.<br />
Charges<br />
LD&R $7,292.96<br />
LABOR PER HR $54.92<br />
Emergency Department Charges<br />
Emergency Department charges are based on the level of emergency care provided to our patients. The levels, with level 1 representing basic emergency care, reflect<br />
the type of accommodations needed, the personnel resources, the intensity of care and the amount of time needed to provide treatment. The following charges do not<br />
include fees for drugs, supplies or additional ancillary procedures that may be required for a particular emergency treatment. They also do not include fees for<br />
Emergency Department physicians, who will bill separately for their services.<br />
Charges<br />
VISIT LEVEL #1 ED $156.98 99281<br />
VISIT LEVEL #2 ED $231.84 99282<br />
VISIT LEVEL #3 ED $423.84 99283<br />
VISIT LEVEL #4 ED $769.19 99284<br />
VISIT LEVEL #5 ED $1,068.65 99285<br />
CRITICAL VISIT EA HR $1,930.95 99291<br />
CPT
Operating Room Charges<br />
Operating Room charges are based on the complexity level, with level 1 being the most basic, for a particular operation There is an initial, set-up charge as well as an<br />
additional charge for each minute while the operation is being performed.<br />
Charges<br />
ACUITY LEVEL 1- INITIAL 30 MIN $3,730.27<br />
ACUITY LEVEL 1- EACH ADDITIONAL 30 MIN $272.55<br />
ACUITY LEVEL 3- INITIAL 30 MIN $4,874.45<br />
ACUITY LEVEL 3- EACH ADDITIONAL 30 MIN $585.49<br />
ACUITY LEVEL 4- INITIAL 30 MIN $6,069.40<br />
ACUITY LEVEL 4- EACH ADDITIONAL 30 MIN $660.49<br />
ACUITY LEVEL 5- INITIAL 30 MIN $7,675.46<br />
ACUITY LEVEL 5- EACH ADDITIONAL 30 MIN $1,147.09<br />
ACUITY LEVEL 6- INITIAL 30 MIN $9,082.40<br />
ACUITY LEVEL 6- EACH ADDITIONAL 30 MIN $1,414.53<br />
ACUITY LEVEL 7- INITIAL 30 MIN $9,561.31<br />
ACUITY LEVEL 7- EACH ADDITIONAL 30 MIN $1,594.50<br />
ACUITY LEVEL 8- INITIAL 30 MIN $9,260.16<br />
ACUITY LEVEL 8- EACH ADDITIONAL 30 MIN $1,583.30<br />
ACUITY LEVEL 9- INITIAL 30 MIN $18,360.56<br />
ACUITY LEVEL 9- EACH ADDITIONAL 30 MIN $1,557.54<br />
Physical Therapy Charges<br />
The following charges reflect the most common services offered by our Physical Therapy department. Patients may have additional charges, depending on the services<br />
performed.<br />
Charges<br />
EVAL BY PT (41-60 MIN) $192.05 97001<br />
GROUP THERAPY PT 30 MIN $42.83 97150<br />
THER EXER W/PT 15 MIN $84.79 97110<br />
GAIT TRAINING 15 MIN $43.07 97116<br />
NEURO EXER W/PT 15 MIN $92.86 97112<br />
ULTRASOUND 15 MIN $82.10 97035<br />
CPT<br />
Occupational Therapy Charges<br />
The following charges reflect the most common services offered by our Occupational Therapy department. Patients may have additional charges, depending on the<br />
services performed.<br />
Charges<br />
EVAL BY OT (41-60 MIN) $295.91 97003<br />
GROUP THERAPY, OT 30 MIN $42.83 97150<br />
THER EXER W/OT 15 MIN $82.48 97110<br />
ADL TRAINING 15 MIN $56.29 97535<br />
AQUATIC THERAPY 15 MIN $88.83 97113<br />
CPT
Cardiopulmonary Charges<br />
The following charges reflect the most common services offered by our Pulmonary Therapy department. Patients may have additional charges, depending on the<br />
services performed.<br />
Charges<br />
ECHOCARDIOGRAM 2D SECTOR $1,097.36 93303<br />
EKG STRESS TEST $693.05 93017<br />
ELECTROCARDIOGRAM---ADULT $149.00 93005<br />
MONITOR HOLTER ANALYSIS/REPORT $621.14 93226<br />
MONITOR HOLTER HOOK UP/RECORDING 24 HR $624.59 93225<br />
OXIMETRY EVAL $54.88 94760<br />
OXYGEN THERAPY (DAILY) $160.04 -<br />
PUL FUN GAS DIFFUSION $172.47 94720<br />
BODY PLETHYSMOGRAPHY $325.68 93721<br />
TREAT AEROSOL $51.39 94640<br />
METERED DRUG ADMIN INIT $51.39 94640<br />
CPT<br />
X-Ray and Radiological Charges<br />
The following charges reflect the hospital's 30 most common x-ray and radiological procedures.Charges do not include the services of the Radiologist or contrast<br />
material. Please contact Lima Radiological Associates to obtain the charges of the Radiologist.<br />
Charges<br />
ABDOMEN 2V AP/UP/DE/LA $341.63 74020<br />
ABDOMEN ACUTE $505.43 74022<br />
ABDOMEN SUPINE $253.89 74000<br />
ANKLE MIN 3 VIEWS $279.00 73610<br />
C SPINE 1 VIEW $200.58 72020<br />
CERV SPINE 2 OR 3 VIEWS $276.11 72040<br />
C SPINE WITH OBLIQUES $475.44 72050<br />
CHEST PA & LAT $244.49 71020<br />
CHEST SINGLE $122.40 71010<br />
FLUORO-LESS THAN 1 HR $473.53 76000<br />
FLUORO-MORE THAN 1 HR $733.47 76001<br />
FOOT MIN 3 VIEW $292.28 73630<br />
GI TRACT; UPPER $635.29 74240<br />
HAND MIN 3 VIEW $299.63 73130<br />
HIP $219.16 73510<br />
KNEE 1-2 VIEWS $273.72 73560<br />
KNEE COMP 4/MORE VIEWS $364.01 73564<br />
LUMBAR SPINE 1 VIEW $200.58 72020<br />
LUMBAR SPINE 2OR 3 VIEWS $276.11 72100<br />
BARIUM ENEMA SINGLE $658.70 74270<br />
PELVIS $193.15 72170<br />
SHOULDER $346.68 73030<br />
SOFT TISSUE NECK $253.89 70360<br />
TEETH SINGLE VIEW $64.39 70300<br />
THORACIC SPINE: 3 VIEW $283.54 72072<br />
TIBIA/FIBULA $279.81 73590<br />
UROGRAM WITH NEPHROTOMOGR $855.25 74400<br />
WRIST $283.83 73110<br />
BONE DENSITY DEXA SCAN $390.01 77080<br />
DIGITAL BREAST SCREEN BIL $172.55 77057<br />
CAD W SCREENING MAMM $33.70 77052<br />
CPT
CT, MRI, Nuclear Medicine, & Ultrasound Charges<br />
The following charges reflect the hospital's most common CT, MRI, Nuclear Medicine, and Ultrasound procedures.Charges do not include the services of the Radiologist<br />
or contrast material. Please contact Lima Radiological Associates to obtain the charges of the Radiologist.<br />
Charges<br />
CT-ABDOMEN-W/CONTRAST $1,495.56 74160<br />
CT HEAD $1,127.37 70450<br />
CT HEAD WO&W CONTRAST $1,363.97 70470<br />
CT-PELVIS-W/CONTRAST $1,927.02 72193<br />
CT-SIMPLE SINUSES $805.98 70486<br />
CT-THORAX-LUNGS-W/WO $1,666.37 71270<br />
MRI ANY JT UPPER EXTREMITY W/CO $3,653.22 73222<br />
MRI BRAIN/B-STEM W/O&W CON $2,816.64 70553<br />
MRI C SPINE CANAL&CONT W/O $3,436.99 72141<br />
NM PULMONARY PERFUSION $797.13 78580<br />
NM BONE SCAN-WHOLE BODY $1,432.41 78306<br />
NM SPECT CARDIOLITE STR & REST $4,603.16 -<br />
NM PET CT WHOLE BODY $4,057.64 78816<br />
NM MYOCARD PERF W/WALL STUDY $4,303.16 -<br />
US GALL BLADDER $804.92 76705<br />
US KIDNEY $569.85 76775<br />
US PELVIC - LMTD (NON-OB) $457.84 76857<br />
CPT
Laboratory Charges<br />
The following charges reflect the hospital's 30 most common laboratory procedures.<br />
Charges<br />
ALBUMIN $22.87 82040<br />
ALKALINE PHOSPHATASE $22.87 84075<br />
AMYLASE $150.08 82150<br />
APTT $49.64 85730<br />
BILIRUBIN, TOTAL $22.87 82247<br />
BUN $22.87 84520<br />
CBC W AUTO DIFF $91.57 85025<br />
CHOLESTEROL $28.27 82465<br />
CK MB I $84.32 82553<br />
CO2 $22.87 82374<br />
CPK $50.02 82550<br />
CREATININE $22.87 82565<br />
CULTURE BLOOD $97.18 87040<br />
CULTURE URINE $78.61 87086<br />
GLUCOSE $22.87 82947<br />
GRAM STAIN SMEAR $41.45 87205<br />
HEMATOCRIT $33.09 85014<br />
HEMOGLOBIN $31.72 85018<br />
LIPASE $71.47 83690<br />
MAGNESIUM $51.46 83735<br />
POTASSIUM $22.87 84132<br />
PROTHROMBIN TIME $28.96 85610<br />
SURGICAL PATH IV $227.25 88305<br />
T4 FREE $142.93 84439<br />
TRIGLYCERIDES $28.59 84478<br />
TROPONIN-I, SERUM $87.19 84484<br />
TSH THYROID STIM HORM $164.37 84443<br />
URINALYSIS $42.75 81000<br />
URINALYSIS W/MICROSCOPY $48.60 81001<br />
VENIPUNCTURE $13.80 36415<br />
CPT
Hospital Billing Policies<br />
Billing Information<br />
St. Rita's Medical Center billing and collection policies are consistent with our mission and values. When you receive a bill from St. Rita's, it covers the services you<br />
received at one of our healthcare delivery facilities. You may receive separate bills from your personal physician, surgeon, pathologist or other healthcare professional.<br />
To make a payment by telephone or to speak with a customer service representative, please call 419-226-9136 or 1-800-537-0058. You may do the following by<br />
telephone:<br />
• Make a payment on your account using a credit card.<br />
• Request an itemized statement.<br />
• Provide insurance information.<br />
• Update your address and telephone number.<br />
• Obtain information on our financial assistance programs and more.<br />
If you have specific questions about your account, our Customer Service Representatives are available Monday through Friday, 8:30 a.m. to 12:30 p.m. and 1:30 p.m. to<br />
4:20 p.m. Spanish speaking representatives are also available.<br />
We repeatedly offer patients access to financial help during their hospital stay and after, as well as with each billing notice. We do not charge interest to patients on their<br />
bills. We send bills to collection as a last resort, only:<br />
• When patients have the ability to pay some portion of their healthcare expenses but refuse to do so<br />
• When patients refuse to work with us to determine if they qualify for free or discounted care via federal, state, local or hospital assistance programs<br />
• When we are unable to locate the patient or the person responsible for the bill<br />
Consumers can access a number of government and private Websites, which provide additional information on hospitals' charges and quality. For a complete listing of<br />
available online resources, please visit the Consumer's Guide to Quality Health Care in Ohio at www.ohanet.org/portal.
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