Patient Price Information List

Disclaimer: Sidney Regional Medical Center determines its standard charges for patient items and services through the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient’s bill. These are the baseline rates for items and services provided at the Hospital. The chargemaster is similar in concept to the manufacturer’s suggested retail price (“MSRP”) on a particular product or good. The charges listed provide only a general starting point in determining the potential costs of an individual patient’s care at the Hospital. This list does not reflect the actual out-of-pocket costs that may be paid by a patient for any particular service, it is not binding, and the actual charges for items and services may vary.

Many factors may influence the actual cost of an item or service, including insurance coverage, rates negotiated with payors, and so on. Government payors, such as Medicare and Medicaid for example, do not pay the chargemaster rates, but rather have their own set rates that hospitals are obligated to accept. Commercial insurance payments are based on contract negotiations with payors and may or may not reflect the standard charges. The cost of treatment also may be impacted by variables involved in a patient’s actual care, such as specific equipment or supplies required, the length of time spent in surgery or recovery, additional tests, or any changes in care or unexpected conditions or complications that arise. Moreover, the foregoing list of charges for services only includes charges from the Hospital. It does not reflect the charges for physicians, such as the surgeon, anesthesiologist, radiologist, pathologist, or other physician specialists or providers who may be involved in providing particular services to a patient. These charges are billed separately.

Individuals with questions about their out-of-pocket costs of service and other financial information should contact the hospital or consider contacting their insurers for further information.

LOCAL MARKET HOSPITALS

In order to present a meaningful comparison, Sidney Regional Medical Center has partnered with Hospital Pricing Specialists LLC to analyze current charges, based off CMS adjudicated claims through 9/30/2019. Sidney Regional Medical Center's charges are displayed and compared with the local market charge, consisting of the following hospitals:

Hospital Name
Location

Box Butte General Hospital

Alliance

NE

Cheyenne Regional Medical Center

Cheyenne

WY

Great Plains Regional Med Ctr

North Platte

NE

Kimball Health Services

Kimball

NE

Medical Center of the Rockies

Loveland

CO

Morrill County Community Hosp

Bridgeport

NE

Ogallala Community Hospital

Ogallala

NE

Perkins County Health Services

Grant

NE

Phelps Memorial Health Center

Holdrege

NE

Regional West Garden County Hospital

Oshkosh

NE

Regional West Medical Center

Scottsbluff

NE

Sterling Regional MedCenter

Sterling

CO

INPATIENT ROOM AND BOARD DAILY CHARGES

Note: SRMC’s Private Room rate includes most supplies and equipment usage charges. Market comparison hospitals shown above may or may not include this in their Private Room rate.

Description

Our Charge
Market Charge

Variance

Private Room

$1,721
$1,487

16% higher than market

Intensive Care Unit

$2,840
$2,891

2% lower than market

Coronary Care Unit

$2,840
$2,993

5% lower than market

OUTPATIENT EMERGENCY DEPARTMENT CHARGES

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 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 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 Emergency Department physicians, who will bill separately for their services.

Description

Our Charge
Market Charge

Variance

CPT 99281 - Emergency Department Visit - Level 1

$203
$205

1% lower than market

CPT 99285 - Emergency Department Visit - Level 5

$1,653
$1,653

Approximately equal to market

OUTPATIENT PHYSICAL THERAPY CHARGES

The following charges reflect the most common services offered by our Physical Therapy department. Patients may have additional charges, depending on the services performed.

Description

Our Charge
Market Charge

Variance

CPT 97032 - Application of Electrical Stimulation - 15 Minutes

$92
$92

Approximately equal to market

CPT 97162 - PT Evaluation - Moderate Complexity

$185
$186

1% lower than market

CPT 97112 - PT to Re-Educate Brain to Muscle Function (15 min)

$91
$91

Approximately equal to market

CPT 97140 - Physical Therapy 1 or More Regions (15 min)

$99
$99

Approximately equal to market

CPT 97110 - Physical Therapy Exercise, 15 Minutes

$100
$99

1% higher than market

CPT 97163 - Physical Therapy, complex evaluation

$255
$257

1% lower than market

CPT 97164 - Physical Therapy, re-evaluation

$130
$130

Approximately equal to market

CPT 97161 - Physical Therapy, standard evaluation - 20 minutes

$158
$159

1% lower than market

OUTPATIENT CLINIC CHARGES

Description

Our Charge
Market Charge

Variance

CPT 99212 - Established patient office or other outpatient visit, typically 10 minutes

$82
$83

1% lower than market

CPT 99211 - Established patient office visit, standard

$58
$58

Approximately equal to market

CPT 99204 - New patient office or other outpatient visit, typically 45 min

$220
$277

21% lower than market

OUTPATIENT OCCUPATIONAL THERAPY CHARGES

The following charges reflect the most common services offered by our Occupational Therapy department. Patients may have additional charges, depending on the services performed.

Description

Our Charge
Market Charge

Variance

CPT 97166 - Occupational Therapy Evaluation - Moderate Complexity

$198
$200

1% lower than market

CPT 97168 - Occupational Therapy, re-evaluation

$136
$136

Approximately equal to market

CPT 97165 - Occupational Therapy, standard evaluation - 30 minutes

$172
$174

1% lower than market

OUTPATIENT PULMONARY THERAPY CHARGES

The following charges reflect the most common services offered by our Pulmonary Therapy department. Patients may have additional charges, depending on the services performed.

Description

Our Charge
Market Charge

Variance

CPT 93225 - Holter Testing - 48-Hour EKG

$480
$464

3% higher than market

CPT 94010 - Spirometry - breathing test

$323
$326

1% lower than market

CPT 94060 - Spirometry - medicated breathing procedure

$660
$666

1% lower than market

CPT 93017 - Stress Test with EKG tracing

$1,104
$1,115

1% lower than market

OUTPATIENT LABORATORY AND PATHOLOGY CHARGES

The following charges reflect our most common laboratory procedures. For all lab specimens collected via blood draw, the venipuncture will be charged separately.

Description

Our Charge
Market Charge

Variance

CPT 82140 - Ammonia level

$158
$159

1% lower than market

CPT 86703 - Analysis for antibody to HIV-1 and HIV-2 virus

$121
$149

19% lower than market

CPT 86870 - Antibody Screen

$280
$282

1% lower than market

CPT 82803 - Arterial Blood Gases Measurement

$252
$254

1% lower than market

CPT 87040 - Bacterial Blood Culture

$190
$191

1% lower than market

CPT 87075 - Bacterial Culture, Any Source Blood

$128
$128

Approximately equal to market

CPT 87070 - Bacterial Culture, Any Source Except Urine, Blood, or Stool

$142
$143

1% lower than market

CPT 82248 - Bilirubin level (Direct)

$64
$64

Approximately equal to market

CPT 86900 - Blood Typing, ABO

$84
$90

6% lower than market

CPT 82947 - Blood glucose (sugar) level

$52
$52

1% lower than market

CPT 83930 - Blood osmolality (concentration) measurement

$108
$109

1% lower than market

CPT 84132 - Blood potassium level

$59
$59

Approximately equal to market

CPT 80047 - Blood test, basic group of blood chemicals

$115
$157

27% lower than market

CPT 80048 - Blood test, basic group of blood chemicals

$114
$105

8% higher than market

CPT 85610 - Blood test, clotting time

$51
$51

Approximately equal to market

CPT 80053 - Blood test, comprehensive group of blood chemicals

$143
$144

1% lower than market

CPT 80061 - Blood test, lipids (cholesterol and triglycerides)

$123
$123

Approximately equal to market

CPT 84443 - Blood test, thyroid stimulating hormone (TSH)

$111
$112

1% lower than market

CPT 89051 - Body fluid cell count with cell identification

$125
$159

21% lower than market

CPT 85210 - Clotting factor II prothrombin, measurement

$102
$180

43% lower than market

CPT 85379 - Coagulation Function Measurement; D-dimer; quantitative

$182
$183

1% lower than market

CPT 85025 - Complete blood cell count - automated differential WBC count

$82
$83

1% lower than market

CPT 85027 - Complete blood cell count - automated test with out Differential

$64
$64

Approximately equal to market

CPT 87015 - Concentration of specimen for infectious agents

$68
$69

1% lower than market

CPT 89060 - Crystal identification from tissue or body fluid

$71
$71

Approximately equal to market

CPT 80158 - Cyclosporine level

$120
$163

26% lower than market

CPT 87491 - Detection Test for Chlamydia; Amplified Probe Technique

$129
$130

1% lower than market

CPT 87340 - Detection Test for Hepatitis B

$107
$107

Approximately equal to market

CPT 87522 - Detection Test for Hepatitis C Virus; Includes Reverse Transcription

$275
$277

1% lower than market

CPT 87591 - Detection Test for Neisseria Gonorrhoeae

$138
$139

1% lower than market

CPT 87480 - Detection test for candida species (yeast); direct probe technique

$54
$86

37% lower than market

CPT 87510 - Detection test for gardnerella vaginalis (bacteria); direct probe technique

$54
$86

37% lower than market

CPT 87502 - Detection test for multiple types influenza virus

$243
$245

1% lower than market

CPT 87798 - Detection test for organism; amplified probe technique

$191
$240

20% lower than market

CPT 87660 - Detection test for trichomonas vaginalis (genital parasite); direct probe technique

$54
$86

37% lower than market

CPT 80162 - Digoxin level

$128
$128

Approximately equal to market

CPT 82746 - Folic acid; serum

$141
$142

1% lower than market

CPT P9017 - Fresh frozen plasma (single donor), frozen within 8 hours of collection, each unit

$272
$301

10% lower than market

CPT 81240 - Gene analysis (prothrombin, coagulation factor II) A variant

$251
$365

31% lower than market

CPT 82945 - Glucose Level on Body Fluid

$82
$83

1% lower than market

CPT 84703 - Gonadotropin (reproductive hormone) analysis

$125
$126

1% lower than market

CPT 84702 - Gonadotropin, chorionic (reproductive hormone) level

$137
$138

1% lower than market

CPT 83036 - Hemoglobin A1C level

$84
$85

1% lower than market

CPT 85018 - Hemoglobin Measurement

$40
$40

Approximately equal to market

CPT 83021 - Hemoglobin fractionation and quantitation; chromatography (eg, A2, S, C, and/or F)

$196
$197

1% lower than market

CPT 83020 - Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F)

$126
$213

41% lower than market

CPT 83520 - Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified

$72
$159

55% lower than market

CPT 87449 - Immunologic analysis for detection of organism; qualitative or semiquantitative; multiple-step method

$132
$133

1% lower than market

CPT 87507 - Infectious agent detection by nucleic acid (DNA or RNA); 12-25 targets

$833
$841

1% lower than market

CPT 87631 - Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (3-5 targets)

$320
$322

1% lower than market

CPT 87633 - Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (6-11 targets)

$670
$739

9% lower than market

CPT 80069 - Kidney Function Blood Test Panel

$130
$131

1% lower than market

CPT 83605 - Lactic acid level

$178
$180

1% lower than market

CPT 83690 - Lipase (fat enzyme) level

$138
$139

1% lower than market

CPT 80076 - Liver function blood test panel

$122
$122

Approximately equal to market

CPT 83789 - Mass spectrometry and tandem mass spectrometry (eg, MS, MS/ MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen

$136
$156

13% lower than market

CPT 86060 - Measurement for Strep antibody (strep throat)

$63
$63

Approximately equal to market

CPT 86160 - Measurement of Complement (Immune System Proteins)

$110
$110

Approximately equal to market

CPT 86200 - Measurement of antibody for rheumatoid arthritis assessment

$121
$122

1% lower than market

CPT 85007 - Microscopic Examination of White Blood Cells with Manual Count

$65
$65

Approximately equal to market

CPT 88360 - Microscopic genetic analysis of tumor; each single antibody stain procedure

$382
$385

1% lower than market

CPT 80306 - Other closed skull fracture without mention of intracranial injury, with loss of consciousness of unspecified duration

$297
$338

12% lower than market

CPT 80183 - Oxcarbazepine level

$109
$149

27% lower than market

CPT 84153 - PSA (prostate specific antigen) measurement

$136
$136

Approximately equal to market

CPT 84154 - PSA Measurement; Free

$122
$123

1% lower than market

CPT 85730 - Coagulation assessment blood test

$86
$86

Approximately equal to market

CPT 88302 - Pathology examination of tissue using a microscope

$123
$152

19% lower than market

CPT 88305 - Pathology examination of tissue using a microscope, intermediate complexity

$220
$222

1% lower than market

CPT 88307 - Pathology examination of tissue using a microscope, moderately high complexity

$463
$467

1% lower than market

CPT 88304 - Pathology examination of tissue using a microscope, moderately low complexity

$186
$187

1% lower than market

CPT P9035 - Platelets, pheresis, leukocytes reduced, each unit

$1,529
$1,645

7% lower than market

CPT 88311 - Preparation of tissue for examination by removing any calcium present

$57
$57

Approximately equal to market

CPT 84145 - Procalcitonin (hormone) level

$199
$200

1% lower than market

CPT 84166 - Protein measurement, body fluid

$131
$159

17% lower than market

CPT 85014 - Red Blood Cell Concentration Measurement

$47
$47

Approximately equal to market

CPT 85652 - Red blood cell sedimentation rate, to detect inflammation

$38
$38

1% lower than market

CPT 86850 - Screening Test for Red Blood Cell Antibodies

$117
$117

Approximately equal to market

CPT 87081 - Screening test for Pathogenic Organisms

$80
$79

1% higher than market

CPT 87205 - Special Stain for Microorganism; Gram or Glemsa Stain

$64
$64

Approximately equal to market

CPT 87209 - Special stain for parasites

$105
$105

Approximately equal to market

CPT 88313 - Special stained specimen slides to examine tissue including interpretation and report

$146
$147

1% lower than market

CPT 88312 - Special stained specimen slides to identify organisms including interpretation and report

$126
$44

186% higher than market

CPT 82705 - Stool fat analysis

$90
$90

Approximately equal to market

CPT 87880 - Strep Test

$66
$67

1% lower than market

CPT 80197 - Tacrolimus Level

$177
$210

16% lower than market

CPT 84436 - Thyroxine (thyroid chemical) measurement - Total

$86
$87

1% lower than market

CPT 87253 - Tissue culture for virus isolation

$62
$63

1% lower than market

CPT 88342 - Tissue or Cell Analysis by Immunologic Technique

$288
$290

1% lower than market

CPT 84157 - Total Protein Level, Body Fluid

$61
$90

32% lower than market

CPT 84155 - Total protein level, blood

$59
$60

1% lower than market

CPT 84478 - Triglycerides level

$44
$44

1% lower than market

CPT 84484 - Troponin (protein) analysis

$215
$216

1% lower than market

CPT 81001 - Urinalysis with Examination, using Microscope

$54
$54

Approximately equal to market

CPT 81015 - Urinalysis with Microscopy

$35
$35

Approximately equal to market

CPT 81003 - Urinalysis, Automated Test

$39
$39

Approximately equal to market

CPT 81025 - Urine Pregnancy Test

$92
$101

9% lower than market

CPT 81050 - Urine Volume Measurement

$32
$32

Approximately equal to market

CPT 82340 - Urine calcium level

$79
$79

Approximately equal to market

CPT 82043 - Urine microalbumin (protein) level

$95
$96

1% lower than market

CPT 84300 - Urine sodium level

$73
$74

1% lower than market

CPT 84630 - Zinc level

$79
$80

1% lower than market

OUTPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

CPT 90472 - Administration of vaccine

$50
$50

Approximately equal to market

CPT 97012 - Application of mechanical traction to 1 or more areas

$84
$84

Approximately equal to market

CPT 97597 - Debridement, open wound; first 20 cm2 or less

$285
$860

67% lower than market

CPT 97598 - Debridement, open wound; each additional 20cm2 or part thereof

$288
$291

1% lower than market

CPT 93288 - Evaluation of parameters of single, dual, or multiple lead pacemaker including device connection, re

$103
$104

1% lower than market

CPT 92611 - Fluoroscopic and video recorded motion evaluation of swallowing function

$378
$381

1% lower than market

CPT 93226 - Heart rhythm analysis, interpretation and report of 48-hour EKG

$507
$512

1% lower than market

CPT 93270 - Heart rhythm symptom-related tracing of 24-hour EKG monitoring up to 30 days

$310
$312

1% lower than market

CPT 96402 - Hormonal anti-neoplastic chemotherapy administration beneath the skin or into muscle

$210
$212

1% lower than market

CPT 96361 - Hydration Infusion into a Vein

$151
$152

1% lower than market

CPT 96360 - Hydration Infusion into a Vein - 31 Minutes to 1 Hour

$384
$387

1% lower than market

CPT 96367 - Infusion (Additional) for Therapy, Diagnosis or Prevention

$168
$169

1% lower than market

CPT 96366 - Infusion into a Vein for Therapy, Diagnosis, or Prevention

$144
$145

1% lower than market

CPT 96365 - Infusion of Drug or Substance into Vein for Therapy or Diagnosis

$386
$389

1% lower than market

CPT 96415 - Infusion of chemotherapy into a vein

$200
$202

1% lower than market

CPT 96411 - Infusion of different chemotherapy drug or substance into a vein

$214
$216

1% lower than market

CPT 96417 - Infusion of different chemotherapy drug or substance into a vein up to 1 hour

$232
$234

1% lower than market

CPT 96376 - Injection of Same Drug into Vein for Therapy or Diagnosis

$135
$136

1% lower than market

CPT 96523 - Irrigation of implanted venous access drug delivery device

$166
$167

1% lower than market

CPT 95861 - Needle measurement and recording of electrical activity of muscles of arms or legs

$726
$733

1% lower than market

CPT 97605 - Negative pressure wound therapy for ongoing care, per session

$246
$636

61% lower than market

CPT 97607 - Negative pressure wound therapy; total wound(s) surface area less than or equal to 50 square centimeters

$496
$501

1% lower than market

CPT 96401 - Non-hormonal anti-neoplastic chemotherapy beneath the skin or into muscle

$243
$243

Approximately equal to market

CPT 97763 - Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

$102
$103

1% lower than market

CPT 94762 - Overnight measurement of oxygen saturation in blood using ear or finger device

$487
$555

12% lower than market

CPT 94618 - Pulmonary stress testing, including measurement of heart rate, oximetry and oxygen titration

$455
$459

1% lower than market

CPT 95810 - Sleep monitoring of patient (6 years or older) in sleep lab

$3,736
$3,889

4% lower than market

CPT 99195 - Therapeutic removal of whole blood to correct blood level imbalance

$165
$171

4% lower than market

OUTPATIENT OTHER CHARGES

Description

Our Charge
Market Charge

Variance

CPT 0297T - Analysis and report of external EKG recording for more than 48 hours up to 21 days

$262
$265

1% lower than market

CPT 64640 - Destruction of peripheral nerve or branch

$1,802
$1,819

1% lower than market

CPT G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes

$113
$114

1% lower than market

OUTPATIENT PHARMACY AND DRUG ADMINISTRATION CHARGES

Description

Our Charge
Market Charge

Variance

CPT 90471 - Administration of 1 Vaccine

$90
$90

Approximately equal to market

OUTPATIENT RESPIRATORY THERAPY CHARGES

The following charges reflect the most common services offered by our Respiratory Therapy department. Patients may have additional charges, depending on the services performed.

Description

Our Charge
Market Charge

Variance

CPT 36600 - Arterial Puncture

$195
$196

1% lower than market

CPT 94640 - Nebulizer Treatment

$185
$186

1% lower than market

OUTPATIENT SUPPLIES CHARGES

Description

Our Charge
Market Charge

Variance

CPT A9500 - Technetium tc-99m sestamibi, diagnostic, per study dose

$854
$612

40% higher than market

OUTPATIENT SURGICAL SERVICES CHARGES

Description

Our Charge
Market Charge

Variance

CPT 27570 - Alignment of knee joint under anesthesia

$2,311
$2,334

1% lower than market

CPT 29125 - Application of Short Arm Splint

$241
$243

1% lower than market

CPT 29075 - Application of cast, elbow to finger (short arm)

$295
$298

1% lower than market

CPT 17250 - Application of chemical agent to excessive wound tissue

$285
$287

1% lower than market

CPT 29581 - Application of vein wound compression system lower leg below knee including ankle and foot

$279
$281

1% lower than market

CPT 20610 - Aspiration and/or injection: large joint/bursa

$577
$582

1% lower than market

CPT 20600 - Aspiration and/or injection: small joint/bursa

$725
$1,054

31% lower than market

CPT 11730 - Avulsion of nail plate, partial or complete, simple; single

$373
$377

1% lower than market

CPT 45380 - Biopsy of Large Bowel, Using an Endoscope

$2,413
$2,437

1% lower than market

CPT 55700 - Biopsy of prostate gland

$1,722
$3,050

44% lower than market

CPT 51700 - Bladder irrigation and/or instillation

$276
$278

1% lower than market

CPT 36591 - Collection of blood specimen from a completely implantable venous access device

$163
$164

1% lower than market

CPT 45378 - Colonscopy

$2,295
$2,317

1% lower than market

CPT 30901 - Control Nose Bleed - Simple Case

$341
$344

1% lower than market

CPT 30905 - Control of nose bleed and insertion of packing

$392
$395

1% lower than market

CPT 17000 - Destruction of skin growth

$139
$140

1% lower than market

CPT 43235 - Diagnostic Examination of Esophagus, Stomach, and/or Upper Small Bowel with Endoscope

$2,074
$2,094

1% lower than market

CPT 52000 - Diagnostic examination of the bladder and bladder canal (urethra) using an endoscope

$1,988
$2,720

27% lower than market

CPT 31575 - Diagnostic examination of voice box using flexible endoscope

$330
$333

1% lower than market

CPT 43450 - Dilation of esophagus, by unguided sound or bougie, single or multiple passes

$1,770
$1,787

1% lower than market

CPT 26010 - Drainage of finger abscess; simple

$426
$430

1% lower than market

CPT 49083 - Drainage of fluid from abdominal cavity using imaging guidance

$1,177
$1,415

17% lower than market

CPT 62321 - Epidural Injection Lumbar

$1,492
$2,021

26% lower than market

CPT 62323 - Epidural Injection Thoracic

$1,702
$1,906

11% lower than market

CPT 66984 - Removal of cataract with insertion of lens

$2,950
$3,529

16% lower than market

CPT 47562 - Gallbladder Removal Using an Endoscope

$7,482
$9,237

19% lower than market

CPT 64483 - Injection of anesthetic and/or steroid into lower spine nerve root using imaging

$2,340
$2,355

1% lower than market

CPT 20551 - Injections of tendon attachment to bone

$570
$2,139

73% lower than market

CPT 20552 - Injections of trigger points in 1 or 2 muscles

$309
$495

38% lower than market

CPT 36569 - Insertion of Central Venous Catheter for Infusion

$1,958
$1,978

1% lower than market

CPT 51702 - Insertion of Indwelling Bladder Catheter

$189
$191

1% lower than market

CPT 36415 - Insertion of Needle into Vein to Collect Blood

$29
$29

Approximately equal to market

CPT 29881 - Removal of one knee cartilage using an endoscope

$5,596
$6,487

14% lower than market

CPT 50200 - Needle biopsy of kidney, accessed through the skin

$2,534
$2,781

9% lower than market

CPT 19120 - Removal of 1 or more breast growth, open procedure

$4,304
$5,984

28% lower than market

CPT 45385 - Colonoscopy with removal of polyp(s)

$2,484
$2,317

7% higher than market

CPT 32555 - Removal of fluid from chest cavity with imaging guidance

$1,602
$1,818

12% lower than market

CPT 69200 - Removal of foreign body from ear canal

$223
$225

1% lower than market

CPT 11400 - Removal of growth (0.5 centimeters or less) of the trunk, arms or legs

$3,107
$6,299

51% lower than market

CPT 11404 - Removal of growth (3.1 to 4.0 centimeters) of the trunk, arms, or legs

$1,971
$3,484

43% lower than market

CPT 69210 - Removal of impact ear wax, one ear

$414
$418

1% lower than market

CPT 11646 - Removal of malignant growth (over 4.0 centimeters) of the face, ears, eyelids, nose, or lips

$1,981
$3,862

49% lower than market

CPT 36590 - Removal of peripheral venous catheter for infusion

$2,574
$3,212

20% lower than market

CPT 11042 - Removal of skin and tissue first 20 sq cm or less

$1,425
$1,779

20% lower than market

CPT 12002 - Repair of Wound (2.6 to 7.5 centimeters)

$421
$424

1% lower than market

CPT 12004 - Repair of Wound (7.6 to 12.5 cm)

$483
$488

1% lower than market

CPT 49505 - Repair of groin hernia patient age 5 years or older

$4,356
$7,825

44% lower than market

CPT 12005 - Repair of wound (12.6 to 20.0 centimeters) of the scalp, neck, underarms, genitals, trunk, arms and/

$450
$454

1% lower than market

CPT 29826 - Shaving of shoulder bone using an endoscope

$1,441
$6,373

77% lower than market

CPT 12011 - Simple wound repair of face, including ears; 2.5 cm or less

$406
$409

1% lower than market

CPT 12013 - Simple wound repair of face, including ears; 2.6 cm to 5.0 cm

$437
$441

1% lower than market

CPT 12001 - Simple wound repair of scalp, neck, external genitalia; 2.5 cm or less

$394
$397

1% lower than market

CPT 29580 - Strapping, Unna boot

$272
$274

1% lower than market

CPT 36430 - Transfusion of Blood or Blood Products

$748
$914

18% lower than market

CPT 51798 - Ultrasound measurement of bladder capacity after voiding

$221
$223

1% lower than market

OUTPATIENT X-RAY AND RADIOLOGICAL CHARGES

The following charges reflect our most common x-ray and radiological procedures. For all exams requiring contrast, the contrast will be charged separately.

Description

Our Charge
Market Charge

Variance

CPT 76642 - Breast Ultrasound - Limited

$428
$432

1% lower than market

CPT 74177 - CT Abdomen & Pelvis with Contrast

$4,382
$4,426

1% lower than market

CPT 74178 - CT Abdomen & Pelvis with and without Contrast

$4,923
$4,973

1% lower than market

CPT 74160 - CT Abdomen with Contrast

$2,729
$2,756

1% lower than market

CPT 74170 - CT Abdomen with and without Contrast

$3,132
$3,164

1% lower than market

CPT 74150 - CT Abdomen without Contrast

$2,246
$2,268

1% lower than market

CPT 71275 - CT Angiogram Chest with and without Contrast

$3,077
$3,108

1% lower than market

CPT 70496 - CT Angiogram Head with and without Contrast

$2,939
$2,969

1% lower than market

CPT 70498 - CT Angiogram Neck with and without Contrast

$2,852
$2,881

1% lower than market

CPT 73201 - CT Arm with Contrast

$2,497
$2,521

1% lower than market

CPT 73200 - CT Arm without Contrast

$1,914
$1,933

1% lower than market

CPT 71260 - CT Chest with Contrast

$2,561
$2,586

1% lower than market

CPT 70470 - CT Head Brain with and without Contrast

$2,740
$2,767

1% lower than market

CPT 70450 - CT Head Brain without Contrast

$1,926
$1,945

1% lower than market

CPT 73700 - CT Leg without Contrast

$1,943
$1,962

1% lower than market

CPT 70491 - CT Neck with Contrast

$2,603
$2,628

1% lower than market

CPT 72193 - CT Pelvis with Contrast

$2,711
$2,733

1% lower than market

CPT 75635 - CT Scan of Abdominal Aorta and Both Leg Arteries with Contrast

$2,931
$2,960

1% lower than market

CPT 72126 - CT Spine Cervical with Contrast

$2,654
$2,758

4% lower than market

CPT 93325 - Cardiac testing - doppler color flow, add on

$414
$542

24% lower than market

CPT 93320 - Cardiac testing - electrocardiogram, doppler

$473
$595

20% lower than market

CPT 71046 - Chest X-Ray; 2 Views

$337
$340

1% lower than market

CPT 71045 - Chest X-Ray; Single View

$275
$278

1% lower than market

CPT 77066 - Diagnostic mammography, bilateral

$414
$418

1% lower than market

CPT 77065 - Diagnostic mammography, unilateral

$330
$333

1% lower than market

CPT 77003 - Fluoroscopic guidance for spine or spinal canal injection

$875
$884

1% lower than market

CPT 93321 - Follow-up or limited heart doppler ultrasound study of heart blood flow, valves, and chambers

$278
$427

35% lower than market

CPT 93308 - Follow-up or limited ultrasound examination of heart

$758
$765

1% lower than market

CPT 74230 - Imaging for Evaluation of Swalling Function

$603
$608

1% lower than market

CPT 76000 - Imaging guidance for procedure, up to 1 hour

$611
$617

1% lower than market

CPT 74022 - Imaging of Abdomen and Chest

$574
$580

1% lower than market

CPT 74019 - Imaging of Abdomen; 2 Views

$388
$392

1% lower than market

CPT 74018 - Imaging of Abdomen; Single View

$306
$309

1% lower than market

CPT 93312 - Insertion of probe in esophagus for heart ultrasound examination including interpretation and report

$2,312
$2,335

1% lower than market

CPT 70549 - MRA Neck with and without Contrast

$4,335
$4,659

7% lower than market

CPT 70553 - MRI Brain with and without Conrast

$4,078
$4,181

2% lower than market

CPT 73721 - MRI Leg Joint without Contrast

$2,680
$2,707

1% lower than market

CPT 70543 - MRI Orbit, Face, Neck with and without Contrast

$4,274
$4,412

3% lower than market

CPT 72197 - MRI Pelvis with and without Contrast

$3,891
$4,118

6% lower than market

CPT 72148 - MRI Spine Lumbar without Contrast

$3,188
$3,219

1% lower than market

CPT 72149 - MRI scan of lower spinal canal with contrast

$4,045
$4,085

1% lower than market

CPT 78582 - Nuclear Medicine Study of Lung Ventilation and Blood Circulation in the Lungs

$2,294
$2,317

1% lower than market

CPT 78070 - Parathyroid Planar Imaging

$1,446
$1,460

1% lower than market

CPT 97035 - Physical Therapy, ultrasound therapy - 15 minutes

$80
$80

Approximately equal to market

CPT 74021 - Radiologic examination, abdomen; 3 or more views

$384
$387

1% lower than market

CPT 77012 - Radiological supervision and interpretation of CT guidance for needle insertion

$2,077
$2,253

8% lower than market

CPT 77067 - Screening Mammography, Bilateral, with CAD

$356
$359

1% lower than market

CPT 76700 - Ultrasound Abdomen - Complete

$866
$875

1% lower than market

CPT 76705 - Ultrasound Abdomen - Limited

$683
$689

1% lower than market

CPT 76770 - Ultrasound Behind Abdominal Cavity - Complete

$756
$763

1% lower than market

CPT 76942 - Ultrasound Guidance for Insertion of Needle

$668
$674

1% lower than market

CPT 76536 - Ultrasound Head Neck

$657
$663

1% lower than market

CPT 76881 - Ultrasound Joint Soft Tissue - Complete

$731
$738

1% lower than market

CPT 76856 - Ultrasound Pelvis NonOB

$784
$791

1% lower than market

CPT 76805 - Ultrasound Pregnant Uterus > 14 Weeks Pregnant

$790
$790

Approximately equal to market

CPT 76870 - Ultrasound Scrotum

$675
$681

1% lower than market

CPT 93970 - Ultrasound Veins of Both Arms or Legs

$1,462
$1,477

1% lower than market

CPT 93971 - Ultrasound Veins of One Arm or Leg

$960
$969

1% lower than market

CPT 93976 - Ultrasound limited scan of abdominal, pelvic, and/or scrotal arterial inflow and venous outflow

$979
$989

1% lower than market

CPT 73600 - X-Ray Ankle, 2 Views

$279
$282

1% lower than market

CPT 73610 - X-Ray Ankle, 3 Views

$334
$336

1% lower than market

CPT 73000 - X-Ray Collar Bone

$310
$313

1% lower than market

CPT 73070 - X-Ray Elbow, 2 Views

$284
$287

1% lower than market

CPT 73080 - X-Ray Elbow, 3 Views

$335
$338

1% lower than market

CPT 74220 - X-Ray Esophagus

$713
$719

1% lower than market

CPT 73140 - X-Ray Fingers, 2 Views

$243
$245

1% lower than market

CPT 73620 - X-Ray Foot, 2 Views

$279
$281

1% lower than market

CPT 73630 - X-Ray Foot, 3 Views

$334
$337

1% lower than market

CPT 73090 - X-Ray Forearm, 2 Views

$287
$289

1% lower than market

CPT 73120 - X-Ray Hand, 2 Views

$309
$311

1% lower than market

CPT 73130 - X-Ray Hand, 3 Views

$330
$333

1% lower than market

CPT 73502 - X-Ray Hip and Pelvis, 2 Views

$318
$321

1% lower than market

CPT 73560 - X-Ray Knee, 1-2 Views

$312
$315

1% lower than market

CPT 73562 - X-Ray Knee, 3 Views

$376
$379

1% lower than market

CPT 73564 - X-Ray Knee, 4 or More Views

$425
$429

1% lower than market

CPT 73590 - X-Ray Lower Leg, 2 Views

$315
$317

1% lower than market

CPT 72100 - X-Ray Lower Sacral Spine, 2-3 Views

$405
$409

1% lower than market

CPT 72110 - X-Ray Lower Sacral Spine, 4 or More Views

$581
$586

1% lower than market

CPT 72070 - X-Ray Middle Spine, 3 Views

$357
$361

1% lower than market

CPT 70360 - X-Ray Neck Soft Tissue

$320
$323

1% lower than market

CPT 72040 - X-Ray Neck Spine, 2-3 Views

$357
$360

1% lower than market

CPT 72170 - X-Ray Pelvis, 1-2 Views

$334
$337

1% lower than market

CPT 72220 - X-Ray Pelvis, 2 Views

$329
$332

1% lower than market

CPT 71100 - X-Ray Ribs One Side, 2 Views

$337
$340

1% lower than market

CPT 73020 - X-Ray Shoulder, 1 View

$280
$282

1% lower than market

CPT 73030 - X-Ray Shoulder, 2 Views

$353
$356

1% lower than market

CPT 74250 - X-Ray Small Intestine without Contrast

$670
$731

8% lower than market

CPT 73660 - X-Ray Toes, 2 Views

$247
$249

1% lower than market

CPT 73060 - X-Ray Upper Arm, 2 Views

$316
$319

1% lower than market

CPT 72050 - X-Ray Upper Spine, 4-5 Views

$490
$495

1% lower than market

CPT 73100 - X-Ray Wrist, 2 Views

$280
$282

1% lower than market

CPT 73110 - X-Ray Wrist, 3 Views

$335
$338

1% lower than market

CPT 71110 - X-ray of both sides of the ribs, 3 views

$453
$457

1% lower than market

CPT 71120 - X-ray of breast bone, minimum of 2 views

$332
$335

1% lower than market

INPATIENT ORTHOPEDIC SURGERY CHARGES

Description

Our Charge
Market Charge

Variance

DRG 473 - Cervical spinal fusion without complications

$59,822
$71,361

16% lower than market

DRG 460 - Spinal fusion other than the neck without major complications

$92,475
$114,664

19% lower than market

DRG 470 - Total Knee or Hip Replacement

$65,323
$52,379

25% higher than market

BILLING PROCESS AND INFORMATION

How You Can Help

Thank you for choosing Sidney Regional Medical Center for your healthcare needs. We want to make understanding and paying your bill as easy as possible. Here are some ways you can help us as we work to make the billing process go smoothly.

• Please give us complete health insurance information.

In addition to your health insurance card, we may ask for a photo ID. If you have been seen at Sidney Regional Medical Center, let us know if your personal information or insurance information has changed since your last visit.

• Please understand and follow the requirements of your health plan.

Be sure to know your benefits, obtain proper authorization for services and submit referral claim forms if necessary. Many insurance plans require patients to pay a co-payment or deductible amount. You are responsible for paying co-payments required by your insurance provider and Sidney Regional Medical Center is responsible for collecting co-payments. Please come to your appointment prepared to make your co-payment.

• Please respond promptly to any requests from your insurance provider.

You may receive multiple bills from your hospital visit, including your family doctor, specialists, physicians that read x-rays, providers that give anesthesia, or physicians that interpret blood work. Insurance benefits are the result of your contract with your insurance company. We are a third-party to those benefits and may need your help with your insurance. If your insurance plan does not pay the bill within 90 days after billing, or your claim is denied, you will receive a statement from Sidney Regional Medical Center indicating the bill is now your responsibility. All bills sent to you are due upon receipt.

Questions about Price and Billing Information

Our goal is for each of our patients and their families to have the best healthcare experience possible. Part of our commitment is to provide you with information that helps you make well informed decisions about your own care.

To ask questions or get more information about a bill for services you've received, please contact our Billing Department at 308-254-8778.

If you need more information about the price of a future service, please contact our Customer Service at 308-254-8778. A physician’s order or CPT code is strongly encouraged when you call to assist us in providing you with the most accurate estimate. You can obtain the CPT code from the ordering physician.