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Patient Price Information List (Effective 1/1/2015)

Inpatient Nursing Care

Room Charge per Day    
Routine Care $538.00  
Intensive/Coronary Care 1,193.00  
Rehabilitation Care 725.00  
Transitional Care 387.00 Semi-private
  418.00 Private

In addition to the Room Charge per day, a daily Nursing Care Level is charged to patients receiving Routine Care and Intensive/Coronary Care. No Nursing Care Level is charged to Rehabilitation and Transitional Care Patients due to the nature of the service provided. Patients are assessed on a daily basis and a care level is assigned based upon the amount of resources that are utilized and the intensity of care for the patient. These resources include, but are not limited to, the amount of nursing time that is involved in caring for the patient, IV and PCA pumps, cardiac monitoring, glucose meters, routine supplies and other technologies.

Nursing Care Levels per Day    
Routine    
Low $296.00  
High 708.00  
Average 414.00  
Intensive/Coronary Care    
Low $472.00  
High 925.00  
Average 617.00  

Birthing Center Charges

The following list does not include charges for anesthesia, anesthesia administration drugs, or supplies required for a particular delivery room procedure. This list also does not include charges for any diagnostic testing or physician services performed during a labor and delivery stay.

Normal Delivery $3,561.00  
Cesarean Section Delivery    
Operating Room Charge - 1st 30 minutes 5,062.00  
Each Additional Minute 37.00  
Recovery Room Charge - 1st 30 minutes 1,092.00  
Each Additional 15 Minutes 89.00  
Respiratory Support 223.00  
OB Room Charge 543.00  
OB Nursing Care Levels    
Low 306.00  
High 1,123.00  
Average 628.00  
Newborn Care per Day 698.00  
Neonatal Care per Day 1,262.00  
Ultrasound Amniocentesis 842.00  
Fetal Monitor charges are included in the delivery charge.    
Labor Room charges are included in the delivery charge.    

Emergency Center Charges

Emergency Center charges are based upon 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 levels of care do not include fees for drugs, supplies, or additional ancillary procedures that may be required for emergency treatment. The Hospital also bills for the emergency room physician allowing the patient to receive one bill. We also offer Urgent Care Services during select after hours and weekends in St. Marys at the Emergency Center. We triage patients coming in to both the Emergency Center and Urgent Care Center to ensure that they are seen in the appropriate setting for the care the patient needs.

Facility Charges    
Level 1 $123.00  
Level 2 227.00  
Level 3 355.00  
Level 4 682.00  
Level 5 1,031.00  
Critical care 1,713.00  
Physician Charges    
Level 1 $80.00  
Level 2 124.00  
Level 3 185.00  
Level 4 330.00  
Level 5 584.00  
Critical care - 1st hour 719.00  
Each additional 30 minutes 298.00  

Urgent Care Charges

JTDMH offers Urgent Care services in St. Marys at the Emergency. The following levels of care do not include fees for drugs, supplies, or additional ancillary procedures that may be required for urgent care treatment. We triage patients coming in to both the Emergency Center and Urgent Care Center to ensure that they are seen in the appropriate setting for the care the patient needs. This aids the patient both financially and clinically. The Hospital also bills for the urgent care physician allowing the patient to receive one bill.

Facility Charges    
Level 1 $87.00  
Level 2 107.00  
Level 3 141.00  
Physician Charges    
Level 1 $16.00  
Level 2 37.00  
Level 3 52.00  

Surgical Center Charges

Surgical classification charges are by specialty and classified by the type of procedure, equipment, instrumentation, supplies and staffing that are unique to each class. There is an initial charge, which includes the first 30 minutes of surgery, as well as a charge for each additional minute until the operation is complete. The following charges do not include charges for anesthesia, recovery room, medications, implants, pathology and patient-specific supplies used during the procedure.

Minor Surgery    
Level 1 $670.00  
General Surgery    
Level 1 $3,195.00  
Level 2 3,411.00  
Level 3 4,109.00  
Level 4 5,342.00  
Level 5 5,455.00  
Each Additional Minute 37.00  
Ear/Nose/Throat    
Level 1 $3,020.00  
Level 2 3,762.00  
Level 3 4,087.00  
Level 4 4,677.00  
Each Additional Minute 37.00  
Gynecological    
Level 1 $2,833.00  
Level 2 3,454.00  
Level 3 4,349.00  
Level 4 4,853.00  
Level 5 5,062.00  
Each Additional Minute 37.00  
Neurological    
Level 1 $2,872.00  
Level 2 3,644.00  
Level 3 3,817.00  
Level 4 5,489.00  
Level 5 5,601.00  
Each Additional Minute 37.00  
Ophthalmology    
Level 1 $2,502.00  
Level 2 3,032.00  
Level 3 3,334.00  
Level 4 3,787.00  
Each Additional Minute 37.00  
Orthopaedic    
Level 1 $2,700.00  
Level 2 3,841.00  
Level 3 4,538.00  
Level 4 4,788.00  
Level 5 5,921.00  
Level 6 6,306.00  
Each Additional Minute 37.00  
Thoracic    
Level 1 ( Thoracentesis/Paracentesis)   $2,435.00  
Level 2 2,796.00  
Level 3 4,440.00  
Level 4 4,518.00  
Each Additional Minute 37.00  
Urological    
Level 1 $3,318.00  
Level 2 3,697.00  
Level 3 3,846.00  
Level 4 4,410.00  
Level 5 10,726.00  
Level 6 12,491.00  
Each Additional Minute 37.00  
Vascular    
Level 1 $2,511.00  
Level 2 2,849.00  
Level 3 3,481.00  
Level 4 3,878.00  
Each Additional Minute 37.00  

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.

Physical Therapy Evaluation $140.00  
Therapeutic Exercise - 15 minutes 70.00  
Therapeutic Activity - 15 minutes 55.00  
Electrical Stimulation - Unattended 64.00  
Gait Training - Ambulation - 15 minutes 53.00  
Ultrasound - 15 minutes 66.00  
Whirlpool 92.00  

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.

Occupational Therapy Evaluation $140.00  
Therapeutic Exercise - 15 minutes 70.00  
Therapeutic Activity - 15 minutes 55.00  
Massage - 15 minutes 66.00  
Occupational Therapy-Activities of Daily Living - 15 minutes 61.00  
Ultrasound - 15 minutes 66.00  

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.

Aerosol Treatment $61.00  
Arterial Blood Gas 174.00  
Arterial Blood Gas Puncture 55.00  
Multidose Inhaler 61.00  
Oxygen Administration - per Shift 90.00  
Pulse Ox Check 61.00  

Medical Imaging (Radiology) Charges

The following charges reflect the most common services offered by our Medical Imaging department. Patients may have additional charges, depending on the services performed. These charges do not include services provided by a physician/radiologist for the interpretation of these studies. A radiologist from Columbus Radiology will perform the medical imaging interpretation and you will receive a separate bill for this service.

Abdomen - Kidneys Ureter and Bladder Xray (Single View) $227.00  
Ankle Xray Complete 234.00  
Cervical Spine Xray with Obliques 382.00  
Chest Xray - Posterior, Anterior & Lateral 291.00  
Chest Xray - Posterior & Anterior 233.00  
CT Scan Abdomen with Contrast 1,720.00  
CT Scan Abdomen with/without contrast 2,340.00  
CT Scan Abdomen without contrast 1,708.00  
CT Scan Head without contrast 1,359.00  
CT Scan Pelvis with contrast 1,720.00  
CT Scan Pelvis without contrast 1,708.00  
CT Scan Chest with contrast 1,867.00  
Dual Energy Xray Absorptiometry (DXA) Scan Spine/Hip 499.00  
Foot Xray - 3 or more views 234.00  
Hand Xray - 3 or more views 234.00  
Hip Xray- Posterior, Anterior & Lateral 263.00  
Lumbar Spine with Obliques Xray 353.00  
Mammography Digital Diagnostic 251.00  
Mammography Digital Screening 210.00  
Mammography CAD Diagnostic 48.00  
Mammography CAD Screening 48.00  
MRI Scan Brain without contrast 2,371.00  
MRI Scan Lumbar Spine w/o contrast 2,575.00  
MRI Cervical Spine w/o contrast 2,618.00  
MRI Knee w/o contrast 2,290.00  
MRI Shoulder w/o contrast 2,290.00  
MRI Lumbar Spine w/w/o contrast 3,226.00  
MRI Ankle w/o contrast 2,290.00  
Obstructive Xray Series 440.00  
Pelvis Xray - Anterior & Posterior 234.00  
Shoulder Xray Complete 304.00  
Ultrasound Abdomen Limited - Follow Up 613.00  
Ultrasound Carotid Artery Complete 764.00  
Ultrasound OB - Complete after 1st Single 1,110.00  
Ultrasound Pelvis 734.00  
MRI is a Magnetic Resonance Imaging Scan    
CT is a Computed Tomography Scan.    

Laboratory Charges

The following charges reflect the 30 most common services offered by our Laboratory Department.

Our Hospital Description Alternate Description  
Albumin, Serum Albumin $25.00  
ALK PHOS ALP 24.00  
ALT (SGPT)   24.00  
AST (SGOT)   24.00  
Basic Metabolic Panel BMP 216.00  
Bilirubin, Total   37.00  
Blood Collection, Venous   19.00  
Calcium   26.00  
CBC Manual Diff if Indicated CBC 64.00  
Chloride CL 23.00  
Cholesterol   42.00  
CKMB with MB Index   85.00  
CO2   17.00  
Comprehensive Metabolic Panel CMP 369.00  
Creatinine Creat 29.00  
Glucose Blood Sugar 31.00  
Glucose POC Monitoring   28.00  
HDL   54.00  
Hemoglobin A1C Hb A1c 81.00  
Lipid Profile   128.00  
Potassium K 34.00  
Protein Serum, Total   19.00  
Prothrombin Time PT or Pro Time 35.00  
Sodium Na 27.00  
T4 Free   93.00  
Triglycerides Tgl 32.00  
Troponin   101.00  
TSH, Ultrasensitive   113.00  
U/A - Micro if Indicated Urinalysis, Urine Microscopic if Indicated 34.00  
Urea Nitrogen BUN 29.00  

For information regarding lab testing and what tests mean, please visit: http://www.labtestsonline.org The laboratory has a menu of specific tests that patients may order for themselves (direct access testing). These tests are general health screening tests such as would be found at a health fair. Health panels, Liver, Kidney and Thyroid function panels, as well as Lipid, Iron and Diabetes assessment profiles are among the tests offered. Like health fair tests, these tests are offered at a considerable discount, but must be paid for prior to blood draw. Print off a copy of the order form or pick up a form at the Outpatient Registration desk at the hospital. The results of these tests will be reported back to you. To learn more about your tests, go to http://www.labtestsonline.org/.

Hospital Billing Policies

When you arrive at JTDMH, you will need to be registered into the hospital’s information system. During registration, you will need to provide information regarding yourself and your insurance coverage; if you do have insurance coverage, please be sure to bring your insurance card(s) with you. An account number will be assigned by the hospital’s information system for your visit and the information you provide during registration will be stored in the system. You will also need to sign a form regarding Consent for Treatment and Conditions for Admission. This form provides information regarding authorization for medical treatment and disclosure of information, patient rights and responsibilities, and financial responsibility. Ultimately, patients are financially responsible for the healthcare services they are provided. In the event that insurance information is provided, JTDMH will file a claim to the insurance company on the patient’s behalf for the benefits assigned to it. Once the insurance company has finished processing the claim, or if the claim is not processed timely, a statement will be sent to the patient for the balance due. An itemized bill showing the detail of all services provided will be issued to the patient upon request. Individuals without insurance will automatically receive an itemized bill showing the detail of all services provided to them. A statement will also be sent to the patient for the balance due. A prompt pay discount of 5% is available to all self-pay patients who do not have insurance and pay their bill timely for the services they were provided. Please contact the Patient Accounts Department at 419-394-9521, for more information. Individuals who are not able to pay the balance of their account in full should contact the Patient Accounts Department at 419-394-9521, to set up an acceptable payment plan. Individuals who are uninsured or underinsured, and are not able to pay on their account should contact the Patient Accounts Department at 419-394-9521 to inquire about free or discounted care based upon the Federal Poverty Level Guidelines and guidelines issued by the State of Ohio. Patient Account Representatives are available Monday through Friday, 8:00am – 4:30pm to assist with questions and completion of necessary forms for financial assistance. Please note that delinquent accounts are referred to an outside agency for collection when payment on the account is overdue or appropriate payment plans have not been arranged. To help facilitate patients in paying for their healthcare services, JTDMH has consolidated the billing of many physician services that are rendered during a hospital visit. Physician charges for Anesthesiology, Emergency Room, the Hospitalist, Pain Management, Pathology, and Urgent Care are combined with the hospital bill. Patients will receive a separate bill for physician services provided for Cardiology, Radiology, and any services performed by a surgeon or family physician, as these services are not billed by the hospital.

consumers-guide-to-quanlity-health-care-in-ohioConsumers can access a number of government and private Websites, which provide additional information on hospitals' charges and quality. For a complete listing of available online resources, please visit the Consumer's Guide to Quality Healthcare in Ohio at www.ohanet.org/portal.