Patient Pricing
Below represents hospital charge information effective January 1, 2015. These charges do not include charges for
physician services that occur during a visit to the Hospital. If you need information on a specific charge procedure please
called Patient Financial Services at (315)349-5532.
Emergency Department Charges - The following represents the hospital charges for each level of emergency care
provided to patients. The charges below do not include the fees for drugs, supplies or additional procedures that may be
rendered during the emergency department visit such as laboratory and radiology.
Description
ER VISIT SIMPLE DX
ER VISIT EXP PROB FO
ER VISIT URGENT
ER VISIT EMERGENT
ED VISIT COMPLEX
Charge CPT Code
$ 152.20
99281
$ 268.80
99282
$ 379.50
99283
$ 562.20
99284
$ 590.80
99285
The average total charges for patients in the Emergency department were $1,060 in 2014.
Urgent Care Clinic Charges - The following represents the hospital charges for each level of urgent care clinic services
provided to patients. These services range from level 1 (lowest level) to level 5 (highest level). The charges below do not
include the fees for drugs, supplies or additional procedures that may be rendered during the urgent care clinic visit such
as laboratory and radiology.
Description
Charge CPT Code
URGENT CARE NEW PATIENT LEVEL 1 $ 87.40
99201
URGENT CARE NEW PATIENT LEVEL 2 $ 99.50
99202
URGENT CARE NEW PATIENT LEVEL 3 $ 133.30
99203
URGENT CARE NEW PATIENT LEVEL 4 $ 166.10
99204
URGENT CARE NEW PATIENT LEVEL 5 $ 277.50
99205
URGENT CARE EXIST PATIENT LEVEL 1 $ 75.40
99211
URGENT CARE EXIST PATIENT LEVEL 2 $ 92.90
99212
URGENT CARE EXIST PATIENT LEVEL 3 $ 109.20
99213
URGENT CARE EXIST PATIENT LEVEL 4 $ 144.70
99214
URGENT CARE EXIST PATIENT LEVEL 5 $ 185.70
99215
The average total charges for patients in the Urgent Care clinic were $242 in 2014.
Behavioral Health Clinic Charges – The following represents the hospital charges for services provided in the outpatient
behavioral health clinic. The charges below do not include the fees for drugs or supplies that may be rendered during the
clinic visit.
Description
Charge CPT Code
PSYCH DIAG EVAL
$ 227.00
90791
MD PSYCH DIAG EVALUATION
$ 141.00
90792
PSYCHOTHERAPY 30 MINS
$ 128.00
90832
PSYCHOTHERAPY 45 MINS
$ 243.56
90834
CRISIS VISIT
$ 139.00
90839
FAMILY PSYCHOTHERAPY
$ 242.20
90846
FAMILY PSYCHOTHERAPY
$ 159.00
90847
FAM THER MD W/PT
$ 219.00
90847
MULTI FAMILY GROUP THERAPY
$ 85.00
90849
GROUP THERAPY
$ 85.00
90853
PSYCHOLOGICAL TESTING
$ 216.00
96101
THERAPEUTIC INJECTION
$ 92.85
96372
RN/LPN THERAPEUT INJECTION
$ 92.85
96372
AFTER HRS & WEEKENDS
$ 30.00
99051
E/M NEW PT STRAIGHTFORWARD $ 122.00
99202
E/M NEW PT LOW COMPLEX
$ 171.00
99203
E/M NEW PT MODERATE
$ 260.00
99204
E/M NEW PT HIGH COMP
$ 172.00
99205
E/M EST PT STRAIGHTFORWARD
$ 97.00
99212
E/M EST PT LOW COMPL
$ 122.00
99213
E/M EST PT MODERATE
$ 172.00
99214
E/M EST PT HIGH COMP
$ 239.00
99215
Operating Room Charges - The following represents the hospital charges for each level of surgery that is provided at our
hospital. The following list does not include charges for anesthesia, drugs, supplies or implants/devices for services
rendered.
The following represents average total charges for outpatient surgery by specialty for 2014:
Specialty
ENT
GASTROENTEROLOGY
GENERAL SURGERY
OB/GYN
OPTHOMOLOGY
ORTHOPEDIC
PODIATRY
UROLOGY
Average Charge
$ 4,815.52
$ 4,045.81
$ 6,791.66
$ 6,574.91
$ 5,261.65
$ 6,687.46
$ 6,545.65
$ 7,614.94
Radiology Charges - The following charges represent the hospital's top 40 most common radiology procedures.
Description
CT HEAD OR BRAIN WO CONT
MR BRAIN WO CONTRAST
XR CHEST FRONTAL SINGLE VIEW
CHEST X-RAY 2 VIEWS FR&LAT
CT CHEST WO CONTRAST
CT CHEST W CONTRAST
MAGNEVIST 20 ML
XR SPINE CERVICAL MIN >=4V
XR SPINE LUMBAR 2-3 VIEWS
XR SPINE LUMBAR COMP W OBL
CT SPINE CERVICAL WO CONTRAS
MR SPINE LUMBAR WO CONTRAST
XR PELVIS 1 TO 2 VIEWS
X-RAY EXAM OF SHOULDER 1 VIE
XR SHOULDER COM >=2V LEFT
XR HAND MIN >=3 VIEWS RIGHT
X-RAY EXAM KNEE >=4 VIEWS
XR KNEE >=4V OR MORE LEFT
XR ANKLE >=3V MIN COMP RIGH
XR ANKLE >=3V MIN COMP LEFT
XR FOOT 2V MIN COMP RIGHT
XR FOOT >=3V MIN COMP LEFT
XR ABDOMEN KUB 1 VIEW
XR ABD SURGICAL WITH PA CHES
CT ABD & PELVIS WO CONT
CT ABD & PELVIS W CONT
US THYROID
US ABDOMINAL LIMITED
US RENAL COMPLETE
US TRANSVAGINAL NON OB
MG CAD MAMMOGRAM SCREENING
SCN MAMMO DIGITAL 2 VIEWS BI
XR DEXA HIPS PELVIS SPINE
CD ECHOCARDIOGRAM COMPLETE
CD CARDIO DUPLEX DOPPLER COM
CD DOPPLER COLOR FLOW VELOCI
CD STRESS ECHO COMPLETE
US CAROTID DUPLEX SCAN; BILA
EXTREMITY VENOUS DUPLEX BIL
US EXTREMITY VENOUS DOP LEFT
Charge CPT Code
$ 938.20
70450
$ 1,866.20
70551
$ 121.40
71010
$ 217.20
71020
$ 938.20
71250
$ 1,094.50
71260
$ 2,006.00
71555
$ 236.50
72050
$ 203.00
72100
$ 373.40
72110
$ 938.20
72125
$ 1,905.10
72148
$ 206.80
72170
$ 188.10
73020
$ 188.10
73030
$ 158.90
73130
$ 189.90
73564
$ 189.90
73564
$ 163.00
73610
$ 163.00
73610
$ 189.90
73620
$ 189.90
73630
$ 123.40
74000
$ 261.10
74022
$ 1,876.40
74176
$ 2,188.90
74177
$ 428.80
76536
$ 279.70
76705
$ 373.00
76770
$ 466.10
76830
$ 52.80
77052
$ 382.80
77057
$ 423.90
77080
$ 694.60
93306
$ 441.30
93320
$ 122.10
93325
$ 694.60
93351
$ 726.10
93880
$ 454.00
93970
$ 299.50
93971
Laboratory Charges - The following charges represent the hospital's top 40 most common radiology procedures.
Description
ROUTINE VENIPUNCTURE
METABOLIC PANEL TOTAL Ca
COMPREHENSIVE METABOLIC PANEL
LIPID PANEL
HEPATIC FUNCTION PANEL
DRUG SCREEN NON TLC DEVICES
AUTOM URINE DIP W MICRO
URINE AUTOMATED W/O MICRO
MICROALBUMIN; URINE QUAN
AMYLASE SERUM
DIRECT BILIRUBIN
VITAMIN D 25 HYDROXY
CPK; TOTAL
VITAMIN B-12 LEVEL
FERRITIN LEVEL
GLYCOSYLATED HEMOGLOBIN TEST
IRON SERUM
IBC
LIPASE
MAGNESIUM SERUM
BRAIN NATRIURETIC PEPTIDE
PSA - COMPLEXED SCREENING
PTT; PLASMA OR WHOLE BLOOD
T4 SERUM THYROXINE TOTAL
FREE THYROXINE
THYROID STIMULATING HORMONE
TROPONIN QUAN
URIC ACID; BLOOD
BETA HCG (QUALITATIVE)
BL SMEAR W/DIFF WBC COUNT
CBC PLATELETS W/AUTO DIFF
PROTHROMBIN TIME;
AUTOM ERYTHROCYTE SED RATE
C-REACTIVE PROTEIN
AEROB BACTERIAL BLOOD CULTURE
CULTURE URINE COUNT QUANT
MICROBE SUSCEPTIBLE MIC
CHLAMYDIA T AMPLIF NA PROBE
NEISSERIA AMPLIF NA PROBE
HPV HIGH-RISK TYPES
Charge
CPT Code
$ 21.60
36415
$ 98.40
80048
$ 128.00
80053
$ 102.90
80061
$ 61.10
80076
$ 95.40
80300
$ 42.70
81001
$ 381.80
81207
$ 15.78
82043
$ 79.60
82150
$ 28.60
82248
$ 114.50
82306
$ 17.76
82550
$ 138.00
82607
$ 144.00
82728
$ 67.20
83036
$ 47.00
83540
$ 55.20
83550
$ 57.20
83690
$ 61.10
83735
$ 206.10
83880
$ 99.70
84152
$ 9.98
84157
$ 79.60
84436
$ 71.00
84439
$ 134.30
84443
$ 99.70
84484
$ 40.90
84550
$ 40.90
84703
$ 91.50
85007
$ 78.20
85025
$ 40.90
85610
$ 42.60
85652
$ 51.00
86140
$ 59.20
87081
$ 102.60
87086
$ 77.30
87186
$ 95.52
87491
$ 95.52
87591
$ 87.40
87624