Hospital Charge Information List
To better inform our patients, Day Kimball Hospital is providing a current list of charges which reflect the most commonly
performed tests or services here at Day Kimball Hospital. A patient's financial responsibility or the ultimate portion owed as a
percentage of these charges may vary widely depending on rates negotiated with individual insurance carriers as well as your
benefit plan design and any deductible and coinsurance requirements you may be obligated to meet.
These charges are estimated as of 10/01/2014 and are subject to change.
INPATIENT CARE
INPATIENT TYPE
Average Charge Per Inpatient
Hospital Admission
Intensive Care
$19,852
Medical
$17,074
Newborn
$5,328
Obstetrical
$10,814
Pediatric
$13,753
Psychiatric
$15,218
Telemetry
$15,900
EMERGENCY SERVICES
Emergency Department charges are based on the level of emergency care provided to our patients. Each level reflects the
intensity of services, amount of resources required and time needed to provide treatment. Each Emergency Room Visit is unique,
therefore there may be supplies, drugs, testing or additional procedures that may be required for a particular emergency
treatment which are above and beyond the average charges listed below. Additionally, the average charges listed do not include
fees for Emergency Department physicians or other consulting physicians who will bill separately for their services.
Level of Service / CPT
Average Charge per Emergency Room
Visit
Level 1 (99281)
$268
Level 2 (99282)
$399
Level 3 (99283)
$840
Level 4 (99284)
$2,074
Level 5 (99285)
$2,756
Critical Care, Initial Care (99291)
$3,605
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.
Type of Surgery
Average Charge Per Case
APPENDECTOMY
$14,577
BLADDER LESION
$7,710
BUNIONECTOMY/OSTEOTOMY
$6,520
CARPAL TUNNEL RELEASE
$4,366
CATARACT SURGERY
$4,659
DILATION & CUTTERAGE
$5,139
EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) STONE
TREATMENT
$8,664
EXCISION OF SEMILUNAR CARTILAGE OF KNEE
$5,470
EXPLORATION OF TENDON SHEATH-HAND
$3,802
INGUINAL HERNIA REPAIR
$6,129
INSERT VASCULAR ACCESS DEVICE
$6,068
LAPAROSCOPIC TOTAL ABDOMINAL HYSTERECTOMY
$14,103
LAPAROSCOPIC CHOLECYSTECTOMY
$9,491
LOCAL EXCISION BREAST LESION
$6,549
MYRINGOTOMY WITH INSERTION OF TUBES
$4,060
OPEN REDUCTION OF FRACTURE W/INTERNAL FIXATION TIBULA/FIBULA
$14,511
ROTATOR CUFF REPAIR
$13,824
SHOULDER ARTHROPLASTY
$11,111
TONSILLECTOMY
$5,307
TONSILLECTOMY/ADENOIDECTOMY
$5,188
TOTAL KNEE REPLACEMENT
$29,628
UMBILICAL HERNIA REPAIR
$6,644
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DELIVERY ROOM
The following list is for delivering mothers only. Newborn charges can be found within the inpatient type section. Because each
delivery is unique, there may be additional resources that may increase the charges listed below for a delivery. In addition, the
charges below do not include professional fees for physicians or anesthesiologists, who will bill separately for their services.
Type of Delivery
Average Charge per Delivery
VAGINAL DELIVERY (single birth)
$8,418
CESAREAN SECTION DELIVERY (single birth)
$13,210
LABORATORY
The following charges represent the Hospital’s most common laboratory tests and their associated prices.
Lab Test
Average Charge per Test
A PHAGOCYTOPHILUM, AMP PROBE TECH
$184
ACETOMINOPHEN
$74
ALANINE AMINO (SGPT)
$19
ALBUMIN (BLOOD)
$17
ALCOHOL
$43
ALLERGY TESTING, EACH ALLERGEN
$28
AMMONIA (BLOOD)
$53
AMYLASE
$28
ANA SCREEN
$44
ANAEROBIC ISOLATION
$39
ANTIBODY SCREEN
$27
ANTINUCLEAR ANTIBODIES, IFA
$65
ASSAY IGA/IGD/IGG/IGM EACH
$73
ASSAY OF GGT
$30
BABESIA, AMPLIFIED PROBE
$184
BASIC METABOLIC PANEL
$51
BETA STREP GROUPING
$31
BETA STREP GROUPING
$31
BETA STREP SCREEN
$24
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BILIRUBIN
$21
BILIRUBIN TOTAL
$21
BILIRUBIN, CONJUGATED
$21
BLOOD CULTURE
$51
BLOOD DRAW FEE (VENIPUNCTURE)
$16
BLOOD GASES
$71
BLOOD TYPING ABO
$17
BLOOD TYPING, RH
$15
BUN, UREA NITROGEN
$18
C DIFF TOXIN B
$196
C REACTIVE PROTEIN
$29
CALCITROL(1,25 DI-OH VITD)
$207
CALCIUM
$19
CAMPY STOOL CULT
$39
CANDIDA SPECIES
$156
CARCINOEMBRYONIC ANTIGEN,CEA
$69
CHLAMYDIA DNA
$183
CKMB
$56
CLADOSPORIUM HERBARU, IGE
$35
COMPLETE BLOOD COUNT/AUTO
$42
COMPLETE BLOOD COUNT/MANUAL DIFF
$62
COMPREHENSIVE METABOLIC PANEL
$57
CORD BLOOD TYPING
$49
CORTISOL AM
$88
C-REACTIVE PROTEIN HS
$54
CREATINE KINASE
$34
CREATININE
$21
CREATININE RANDOM UR
$31
CROSSMATCH, COMPATIBILITY TEST SPIN
$31
CULTURE AEROBIC IDENTIFY
$30
CYSTIC FIBROSIS PROFILE
$124
CYTO PAP THINPREP DIAG
$93
CYTO PAP THINPREP SCREEN
$93
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CYTO URINE
$230
D-DIMER
$96
DECALCIFICATION
$193
DEFINITIVE ID AER.2, CULTURE AEROBIC IDENTIFY
$30
DHEA-SULFATE
$120
DIGOXIN
$52
DILANTIN
$60
DRUG SCREEN SINGLE, EACH DRUG CLASS
$23
EPSTEIN BARR CAPSID VCA
$98
FERRITIN
$73
FIBRINOGEN
$34
FOLIC ACID
$54
FREE T4
$49
GARDNERELLA
$156
GLUCOSE 1HR
$20
GLUCOSE FASTING OR RANDOM
$16
GLYCOHEMOGLOBIN
$36
GONADOTROPIN (FSH)SERUM
$78
GONORRHOEAE DNA
$183
GP.B STREP SCREEN
$24
GROSS/MICRO PATHOLOGY
$129
H PYLORI
$52
HCG BETA SUBUNIT
$65
HCV AB W/RFLX
$77
HDL PANEL
$57
HEMATOCRIT
$11
HEMOGLOBIN
$11
HEMOGLOBIN CHROMOTOGRAPHY
$97
HEMOGRAM
$35
HEPATITIS A (RFLX TO IGM)
$67
HEPATITIS B CORE AB, TOTAL
$97
HEPATITIS B SURFACE AB
$87
HEPATITIS C AB
$141
HEPATITIS C W/REFLEX QUANT PCR
$77
HIV 1 & 2
$52
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HOMOCYST(E)INE, PLASMA
$136
HPV DNA HIGH RISK
$103
IGG IMMUNOBLOT
$78
IGM
$73
IGM/IGG/IGA ANTIBODY CAPTURE
$78
IMMUNOASSAY NONANTIBODY, GLIADIN IGG/IGA
$62
IMMUNOHISTOCHEMISTRY
$78
INFLUENZA
$36
INSULIN
$93
IRON BINDING TEST
$36
LACTATE (LD) (LDH) ENZYME
$26
LDL, BLOOD LIPOPROTEIN, ASSAY
$37
LEAD, BLOOD, PEDIATRIC
$98
LEAD-CHILD
$24
LEVEL 3 GROSS/MICRO PATHOLOGY
$76
LEVEL 5 GROSS/MICRO PATHOLOGY
$174
LIPASE
$30
LITHIUM LEVEL
$30
LUTEINIZING HORMONE
$78
LYTES
$36
MAGNESIUM
$26
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA)
$24
METHYLMALONIC ACID, SERUM
$89
MICROALBUMIN, RANDOM
$28
MICROBE SUSCEPTIBILITY
$25
MONONUCLEOSIS TEST
$47
MUMPS ANTIBODIES, IGG
$70
NATRIURETIC PEPTIDENT (BNP) ASSAY
$185
NEPHELOMETRY, FREE K, SERUM
$73
OCCULT BLOOD FECES
$21
OVA AND PARASITE SMEARS
$48
PARATHORMONE, ASSAY, PTH, INTACT
$223
PHOSPHOROUS
$18
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POTASSIUM (K),SERUM
$25
PREG MONOCLONAL URINE
$67
PROLACTIN
$81
PROTEIN 24HR URINE
$28
PROTEIN ELECTRO SERUM
$58
PROTEIN UR RANDOM
$19
PROTEIN, TOTAL, SERUM
$20
PROTHROMBIN TIME
$17
PSA DIAGNOSTIC OR SCREENING
$74
PTT, THROMBOPLASTIN TIME PARTIAL
$24
RA FACTOR,QUANT
$39
RAPID GROUP A STREP
$24
RESPIRATORY CULTURE
$35
RESPIRATORY SYNCYTIAL VIRUS (RSV)
$51
RETICULOCYTES
$17
RETROVIRAL SEROLOGY
$46
REVERSE T3, SERUM
$85
RH CHECK
$15
RPR, SYPHILIS TEST
$36
RUBELLA SCREEN
$97
RUBEOLA ANTIBODIES, IGG
$69
SALICYLATE
$40
SED RATE WESTERGREN
$22
SENSITIVITY,MIC
$32
SICKLE CELL TEST
$28
SMEAR COMPLEX STAIN
$67
SMEAR GRAM STAIN
$17
SPECIAL STAIN GP I
$112
SPECIAL STAIN GP II
$119
STOOL CULTURE
$39
TACROLIMUS BLOOD
$74
TEGRETOL
$63
TESTERONE FREE
$137
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TESTOSTERONE
$201
TESTOSTERONE TOTAL
$139
THROAT CULTURE
$36
THROAT SCREEN PEDIATRIC
$24
THYROID (T3 OR T4) ASSAY
$28
THYROID STIMULATING HORMONE
$71
THYROXINE, T4
$32
TRANSFERASE (SGOT)
$44
TRICHOMONAS
$156
TRIIODOTHYRONINE, FREE, SERUM
$91
TROPONIN LAB
$41
T-TRANSGLUTAMINASE(TTG)IGA
$62
TUMOR CA 15-3, IMMUNOASSAY
$112
TYPE CHECK
$17
URIC ACID
$17
URINALYSIS
$26
URINALYSIS VOLUME MEASURE
$17
URINE COLONY COUNT
$32
URINE CULTURE
$30
URINE DRUG SCREEN, MULTIPLE CLASS
$171
VALPROIC ACID
$52
VANCOMYCIN TROUGH
$58
VARICELLA-ZOSTER V AB, IGG
$69
VITAMIN B12
$63
VITAMIN D
$85
VITAMIN D, 25 HYDROXY
$160
WOUND CULTURE
$46
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 needed. All interpretations of these exams will be billed separately by the radiologist.
X Ray
Average Charge per Exam
ABDOMEN
$112
ANKLE
$136
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BARIUM SWALLOW
$267
BONE DENSITY (DEXA)
$455
CERVICAL SPINE
$161
CERVICAL SPINE - W/OBLIQUES
$185
CHEST X-RAY 2VIEW FRONTAL & LATERAL
$148
DORSAL SPINE
$112
ELBOW
$112
FINGER,SINGLE
$112
FOOT
$112
FOREARM
$122
HAND
$112
HIP
$112
KNEE
$112
LOWER LEG
$136
LUMBAR SPINE ROUTINE
$112
LUMBAR SPINE W OBLIQUES MIN 4 VIEW
$147
MAMMOGRAM DIAGNOSTIC DIGITAL
$551
MAMMOGRAM DIAGNOSTIC DIGITAL (1 BREAST)
$253
MAMMOGRAM DIAGNOSTIC EXTRA VIEWS
$252
MAMMOGRAM SCREEN DIGITAL
$409
PELVIS 1 OR 2 VIEWS
$112
RIBS ONE SIDE
$172
SHOULDER
$112
WRIST
$112
Ultrasound
Average Charge per Exam
ABD AORTA ULTRASOUND
$360
ABDOMINAL ULTRASOUND
$455
BREAST ULTRASOUND BILATERAL
$292
BREAST ULTRASOUND UNILATERAL
$190
CAROTID DUPLEX
$480
DOPPLER ECHOCARDIOGRAM
$1,570
ECHO EXAM OF ABDOMEN
$455
PELVIC ULTRASOUND
$341
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PELVIC-NON OBSTETRICAL TRANSVAGINAL
$297
PERIVASCULAR LEG-BILATERAL
$715
PERIVASCULAR LEG-UNILATERAL
$315
RENAL ULTRASOUND
$360
STRESS & REST ECHOCARDIOGRAM
$1,495
THYROID ULTRASOUND
$585
PET Scan
Average Charge per Exam
PET/CT SKULL TO THIGH
$6,901
PET/CT WHOLE BODY
$7,956
PET/CT BRAIN-METABOLIC EVALUATION
$3,844
MRI
Average Charge per Exam
MRI-ABDOMEN
$4,652
MRI-BREASTS
$4,139
MRI-CERVICAL SPINE
$3,143
MRI-ELBOW
$3,094
MRI-HEAD
$3,143
MRI-INTERNAL AUDITORY CANALS (IAC'S)
$3,143
MRI-KNEE
$3,094
MRI-LUMBAR SPINE
$3,143
MRI-NECK
$3,094
MRI-SHOULDER
$3,094
MRI-WRIST
$3,094
CT Scan
Average Charge per Exam
CT ABDOMEN AND PELVIS
$3,038
CT ABDOMEN
$1,584
CT ANGIOGRAPHY ABDOMEN & PELVIS
$1,919
CT CERVICAL SPINE
$1,119
CT CHEST
$1,338
CT FACIAL/MANDIBLE
$1,215
CT HEAD
$1,519
CT LOWER EXTREMITY
$1,215
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CT LUMBAR SPINE
$1,119
CT NECK
$1,215
CT ORBITS (EYE SOCKETS)
$1,215
CT SINUS
$1,215
CT ANGIOGRAPHY CHEST
$1,214
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 Service
Average Charge per Service
AMBULATORY BLOOD PRESSURE MONITOR
$136
DOBUTAMINE STRESS TEST
$695
EKG
$266
EKG RHYTHM STRIP
$59
EXERCISE OR DRUG INDUCED STRESS TEST
$643
PERSANTINE STRESS TEST
$695
RESPIRATORY THERAPY AND PULMONARY FUNCTION
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.
Services
Average Charges Per Service
AIRWAY INHALATION TREATMENT INITIAL/SUBSEQUENT TREATMENT
$59
ARTERIAL PUNCTURE
$42
MEMBRANE DIFFUSE CAPACITY (DLCO)
$644
FLUTTER VALVE INITIAL / SUBSEQUENT
$133
INHALATION TEACH & EVALUATE
$73
LUNG VOLUME
$402
METHACHOLINE EVALUALTION
$1,163
PLETHYSOMOGRAPHY
$220
PULSE OXIMETRY WITH EXERCISE (OXYGEN SATURATION)
$313
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SIX MINUTE PULMONARY STRESS TEST
$243
SMOKING CESSATION
$73
SPIROMETRY
$205
SPRIOMETRY WITH BRONCHODILATOR
$295
VITAL CAPACITY
$64
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.
Service
Average Charge Per Service
CONTINUOUS PASSIVE MOTION RENTAL PER DAY (CPM)
$27
CONTINUOUS PASSIVE MOTION SET UP (CPM)
$125
ELECTRICAL STIMULATION, UNATTENDED
$119
ELECTRICAL STIMULATION, MANUAL PER 15 MINUTES
$45
EVALUATION
$178
GAIT TRAINING PER 15 MINUTES
$60
MANUAL THERAPY TECHNIQUE PER 15 MINUTES
$65
MECHANICAL TRACTION
$35
NEURO-MUSCULAR RE-EDUCATION PER 15 MINUTES
$73
PARAFIN
$18
RE-EVALUATION
$95
TENS
$33
THERAPEUTIC ACTIVITY PER 15 MINUTES
$87
THERAPEUTIC EXERCISE PER 15 MINUTES
$70
ULTRASOUND PER 15 MINUTES
$29
VASOPNEUMATIC DEVICE
$32
WHEELCHAIR MANAGEMENT TRAINING PER 15 MINUTES
$65
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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.
Service
Average Charge Per Service
OT SELF CARE MANAGEMENT TRAINING (ADL) PER 15 MINUTES
$78
OT COGNITIVE SKILLS DEVELOPMENT PER 15 MINUTES
$59
OT ESTIM,MANUAL ATT PER 15 MINUTES
$45
OT EVALUATION
$185
OT EXERCISE PER 15 MINUTES
$70
OT IONTOPHORESIS PER 15 MINUTES
$38
OT MANUAL THER TECH PER 15 MINUTES
$65
OT NEUROMUSCULAR RE-EDUCATION PER 15 MINUTES
$73
OT PARAFIN
$18
OT THERAPEUTIC ACTIVITY PER 15 MINUTES
$87
OT ULTRASOUND PER 15 MINUTES
$29
OT VASOPNEUMATIC DEVICE
$32
SPEECH THERAPY
The following charges reflect the most common services offered by our Speech Therapy department. Patients may have
additional charges depending on the services performed.
Services
Average Charge Per Service
DEVELOPMENT, COGNITIVE SKILL PER 15 MINUTES
$59
EVALUATE RECEPTIVE/EXPRESSIVE LANGUAGE
$476
EVALUATE SPEECH & LANGUAGE
$443
SPEECH & LANGUAGE TREATMENT
$313
SPEECH DEVICE SERVICE
$310
SPEECH SOUND LANGUAGE COMPREHENSION
$443
SWALLOW EVALUATION
$428
SWALLOW TREATMENT
$293
VIDEO FLUORO EVALUATION
$539
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BILLING POLICIES
Day Kimball Healthcare wants to ensure that patients receive the full benefits of their insurance coverage as well as
consideration under our financial assistance programs. Before you are billed, we submit your claims to all active insurance
carriers 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. 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.
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