Patient Price Information List
In compliance WITH state law, Mount Carmel Health System is providing this price list for its four hospitals – Mount Carmel East, Mount
Carmel West, Mount Carmel St. Ann’s and Mount Carmel New Albany – containing our charges for room and board, emergency department,
operating room, delivery services, physical therapy and other procedures. Mount Carmel Health System charges the same for all patients, but
a patient’s responsibility may vary, depending on payment plans negotiated WITH individual health insurers. Uninsured or underinsured
patients should consult WITH our admitting and billing staff to determine whether they qualify for discounts. These prices are correct as of July
1, 2016.
As mentioned above our hospitals charge the same for all patients, however, a patient’s share of the payment may vary depending on the type
of coverage they have WITH their insurance company. To get an estimate of the costs of services for a particular insurance plan, please call
614-234-6074 and request an estimate of the patient’s portion of the payment. We are committed to providing care for all of our patients,
regardless of their ability to pay; therefore, patients who do not have insurance or are considered underinsured should call 614-234-8888 to
determine if they are eligible for our financial assistance programs. Financial Counselors are available weekdays between 8am & 5pm to
provide cost estimates as well as discuss options for financial assistance.
Room and Board -- Per Day Charges
The following list included per day charges for inpatients only. Observation rates are not reflected and will be billed in addition to the per day
rates, if the patient was in observation status at anytime during their stay.
GENERAL MED/SURG
Routine care
$ 2,040.00 $ 1,944.00
31011368
u
Intermediate Care
$ 3,864.00 $ 2,568.00
31511336
u
Critical/Intensive Care
Palliative Care
NURSERY/NEWBORN
u
Nursery
u
Neonatal Intensive Care
MENTAL HEALTH

Adult Psychiatric
u
u

$ 4,248.00
$ 2,040.00
$ 3,792.00
$ 1,944.00
32011337
31011368
$ 1,944.00
$ 4,368.00
$ 2,568.00
$ 3,792.00
35011347
35011350
$ 1,690.00
East, West & St. Ann’s only
West only
Labor and Delivery Charges
The following list does not include charges for anesthesia, drugs, or supplies required for a particular delivery room procedure nor does it
include room charges. Fees for physician services or anesthesia administration are also not reflected, and will be billed separately by your
physician.
NORMAL DELIVERY
u
22507393
Level I
Routine
$ 2,704.00
22507393
u
22522225
Level II
Complicated
$ 5,516.00
22522225
.
CESAREAN SECTION DELIVERY
.
u
22503147
Level I
Routine
$ 4,921.00
22503147
u
22528420
Level II
Complicated
$ 8,707.00
22528420
u
East, West & St. Ann’s only
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 care, reflect the type of accommodations needed, personnel resources, intensity of care and 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 services.
22004649
22004650
22004651
22004652
22004653
22003116
22003117
22018619
u
u
u
u
u
u
u
u
ER Visit - Level 1
ER Visit - Level 2
ER Visit - Level 3
ER Visit - Level 4
ER Visit - Level 5
ER Visit - Critical Care First 31-74 Minutes
Critical Care Additional 30 Minutes
Trauma Activation Fee
East, West, Grove City & St. Ann’s only
$
$
$
$
$
$
$
$
294.00
682.00
1,352.00
2,195.00
3,045.00
4,250.00
301.00
5,085.00
$
$
$
$
$
$
$
$
267.00
620.00
1,288.00
1,995.00
2,768.00
3,864.00
274.00
5,085.00
22004649
22004650
22004651
22004652
22004653
22003116
22003117
Patient Price Information List
Operating Room Charges
Operating Room charges are based on a per minute room and per minute labor charge. Recovery time is charged by a per hour complexity
level. Additional charges will be made for the supplies used in the course of the surgery.
MINOR
per 15 mins
u
u
u
u
u
u
v
v
v
v
v
u
u
u
CARDIOTHORACIC
Initial
Additional
EAR/NOSE/THROAT
Initial
Additional
EYE
Initial
Additional
GENERAL
Initial
Additional
GYN
Initial
Additional
MAX FACIAL
Initial
Additional
NEURO
Initial
Additional
ORTHO
Initial
Additional
PLASTIC
Initial
Additional
ROBOTICS
Initial
Additional
SPINE
Initial
Additional
TRAUMA
Initial
Additional
UROLOGY
Initial
Additional
VASCULAR
Initial
Additional
u
v
MAJOR
per 30 mins
COMPLEX
per 30 mins
26001970
26001971
$
$
5,431.00
559.00
26001968
26001969
$
$
8,995.00
1,610.00
26001966
26001967
$ 11,013.00
$ 2,459.00
26004525
26004526
$
$
5,277.00
617.00
26004516
26004517
$ 10,089.00
$ 1,876.00
26004488
26004489
$ 11,717.00
$ 3,073.00
26004918
26004919
$
$
4,321.00
185.00
26004916
26004917
$
$
5,369.00
1,568.00
26004910
26004911
$ 7,101.00
$ 1,522.00
26005531
26005532
$
$
7,086.00
474.00
26005529
26005530
$ 10,881.00
$ 1,959.00
26005526
26005527
$ 12,597.00
$ 2,893.00
26005861
26005862
$
$
5,939.00
432.00
26005859
26005860
$
$
7,761.00
2,951.00
26005857
26005858
$ 10,441.00
$ 3,353.00
26007830
26007831
$
$
5,601.00
531.00
26007828
26007829
$ 11,827.00
$ 1,225.00
26007826
26007827
$ 12,123.00
$ 2,297.00
26008925
26008926
$
$
6,269.00
562.00
26008923
26008924
$ 10,115.00
$ 2,023.00
26008921
26008922
$ 10,547.00
$ 2,834.00
26009319
26009320
$
$
3,439.00
1,835.00
26009317
26009318
$
$
5,182.00
3,994.00
26009315
26009316
$ 5,204.00
$ 4,783.00
26009981
26009982
$
$
6,339.00
403.00
26009979
26009980
$
$
8,336.00
714.00
26009977
26009978
$ 8,994.00
$ 1,609.00
26023018
26023019
$ 15,000.00
$ 4,500.00
26023016
26023017
$ 17,000.00
$ 5,500.00
26012474
26012475
$
$
7,492.00
683.00
26012472
26012473
$
$
9,320.00
1,415.00
26012470
26012471
$ 10,312.00
$ 2,972.00
26023014
26023015
$
$
4,268.00
2,277.00
26023012
26023013
$
$
5,182.00
3,996.00
26023010
26023011
$ 5,204.00
$ 4,781.00
26014004
26014005
$
$
5,321.00
216.00
26014002
26014003
$
$
8,381.00
2,204.00
26014000
26014001
$ 14,328.00
$ 3,695.00
26014149
26014150
$
$
7,107.00
967.00
26014147
26014148
$ 10,589.00
$ 2,518.00
26014145
26014146
$ 12,912.00
$ 3,075.00
East, West, & St. Ann’s only
East, West, New Albany & St. Ann’s only
Patient Price Information List
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.
11016867
11011192
11011197
11011203
11011188
11011210
11011171
11011220
11011189
11011223
ELECTRICAL STIMULATION UNATTENDED-15 MIN
GAIT TRAINING-15 MIN
MANUAL THERAPY TECHNIQUE-15 MIN
NEUROMUSCULAR RE-EDUCATION-15 MIN
PHYSICAL THERAPY EVALUATION-BASIC
PHYSICAL THERAPY RE-EVALUATION
SELF-CARE MANAGEMENT TRAINING OF DAILY LIVING-15 MIN
THERAPEUTIC ACTIVITIES-15 MIN
THERAPEUTIC EXERCISES-15 M
ULTRASOUND THERAPY-15 MIN
$
$
$
$
$
$
$
$
$
$
38.00
61.00
83.00
92.00
173.00
80.00
70.00
75.00
88.00
36.00
02/10/16-Per RT remove PT and Pulmonary
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.
11209380
COGNITIVE SKILLS TRAINING-15 MIN
$
75.00
11209398
MANUAL THERAPY-15 MIN
$
83.00
11209400
NEUROMUSCULAR RE-EDUCATION-15 MIN
$
92.00
11209386
OCCUPATIONAL THERAPY EVALUATION
$
190.00
11209404
PERFORMANCE TEST-15 MIN
$
93.00
11209370
SELF-CARE MANAGEMENT TRAINING OF DAILY LIVING - 15 MIN
$
70.00
11209410
11209414
11209390
11209415
SENSORY INTEGRATION-15 MIN
THERAPEUTIC ACTIVITY-15 MIN
THERAPEUTIC EXERCISES-15 M
THERAPEUTIC PROCEDURE(S) GROUP
u
$
$
$
$
82.00
75.00
88.00
57.00
East, West & St. Ann’s only
Pulmonary Therapy ChargesŒ
Œ
The following charges reflect the most common services offered by our Pulmonary Therapy department. Patients may have additional charges,
depending on the services performed.
12521109
12521110
12502464
12503097
12509471
12509122
12511268
12514179
12514177
BIPAP NONINVASIVE VENT INITIAL DAY
BIPAP NONINVASIVE VENT SUBSEQUENT DAY
CHEST PHYSIOTHERAPY SUBSEQUENT
CPAP INITIATION & MANAGEMENT DAILY
OXYGEN PER DAY
PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT
PUNCTURE ARTERIAL
VENTILATOR EACH SUBSEQUENT DAY
VENTILATOR INITIAL DAY
$
$
$
$
$
$
$
$
$
238.00
238.00
57.00
238.00
20.00
153.00
46.00
401.00
401.00
02/10/16-Per RT remove PT and Pulmonary
Patient Price Information List
X-Ray and Radiological Charges
The following charges reflect the hospital's 30 most common x-ray and radiological procedures. There may be additional supply and contrast
media charges depending on the procedure. This does not include any physician related expenses related to interpretation/reading of image
results.
15601473
15127441
15127440
15103157
15103161
15103172
15103202
15704251
15704253
15704245
15516471
15617258
15617261
15616687
15616485
15408457
15408458
15214008
15217753
15231571
15231572
15214038
15214042
15214044
15214050
15014496
15014536
15014537
15014618
15014674
15616485
BONE DENSITY STUDY DXA(dual-energy x-ray absorptiometry) AXIAL SKELETON
70450 $
CAT SCAN ABDOMEN AND PELVIS WITH CONTRAST
CAT SCAN ABDOMEN AND PELVIS WITHOUT CONTTRAST
CAT SCAN CHEST WITHOUT CONTRAST
CAT SCAN CERVICAL SPINE WITHOUT CONTRAST
CAT HEAD WITHOUT CONTRAST
CTA CHEST WITH AND OR WITHOUT CONTRAST
DUPLX EXTREMITY VENOUS COMPLEX BILATERAL
DUPLX EXTREMITY VENOUS UNILATERAL LIMITED
DUPLX EXTRACRANIAL ARTERIAL COMPELX BILATERAL
70551
70553
71010
71020
71101
71250
71260
71275
72020
INSERT PICC CATHETER WIITHOUT SUBCUTANEOUS PORT OR PUMP >=5 yrs of age
MAMMOGRAM DIGITAL DIAGNOSTIC BILATERAL
MAMMOGRAM DIGITAL SCREENING BILATERAL
MAMMOGRAM DIAGNOSTIC CAD(computer aided detection)
MAMMOGRAM SCREENING CAD(computer aided detection)
15014588 MRI BRAIN WITH AND OR WITHOUT CONTRAST
15014593 MRI BRAIN WITHOUT CONTRAST
ULTRASOUND ABDOMEN LIMITED
15014615 ULTRASOUND BLADDER RESIDUAL URINE
15014502 ULTRASOUND BREAST UNILATERAL LIMITED LEFT
15014586 ULTRASOUND BREAST UNILATERAL LIMITED RIGHT
ULTRASOUND PELVIS NON-OBSTETRIC COMPLETE
ULTRASOUND PREG FOLLOW-UP PER FETUS
ULTRASOUND RETROPERITIONEAL COMPLETE
ULTRASOUND TRANSVAGINAL
XRAY ABDOMEN 1 VIEW
XRAY CHEST 1 VIEW
XRAY CHEST 2 VIEWS
XRAY L-SPINE 2-3 VIEWS
XRAY SHOULDER 2 OR MORE VIEWS RIGHT SIDE
72100
72125
72170
73030
73090
73130
73510
73564
73610
73630
74000
74176
74177
76705
76770
76830
76856
78452
G0202
77052
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
513.00
1,520.00
1,483.00
1,150.00
1,150.00
1,150.00
1,315.00
672.00
672.00
672.00
920.00
240.00
119.00
40.00
35.00
2,130.00
1,476.00
564.00
119.00
311.00
311.00
658.00
480.00
695.00
660.00
178.00
267.00
267.00
285.00
285.00
72050
15617258
15617261
15616687
15616485
Patient Price Information List
Laboratory Charges
The following charges reflect the hospital's 30 most common laboratory procedures.
19000412
19001817
19002401
19002404
19002478
19002594
19003146
19003203
19003208
19003209
19003241
19003244
19003966
19004635
19004636
19004638
19004639
19027488
19005409
19005417
19005592
19005627
19005644
19005900
19005902
19005987
19005988
19006072
19006079
19006443
19006518
19006701
19007341
19007705
19007750
19008537
19009934
19010689
19012213
19005458
AMIODARONE THERAPEUTIC DRUG ASSAY
CALCIUM QUANTITATIVE URINE TIMED
CELL COUNT BODY FLUID
CELL COUNT WITH DIFFERENTIAL BODY FLUID
CHLAMYDIA TRACHOMATIS NUCLEIC ACID AMPLIFIED
CHOLESTEROL
CRYSTAL ID LIGHT MICROSCOPY
CULTURE AEROBIC ADD DEFIN EA
CULTURE BLOOD
CULTURE BODY FLUID
CULTURE SCR STREP GROUP B
CULTURE SPUTUM
DNA AB DOUBLE STRAND
EPSTEIN BARR EARLY AG AB
EPSTEIN BARR EBNA AB
EPSTEIN BARR VCA AB IGG
EPSTEIN BARR VCA AB IGM
FLU DNA AMP PROB > 2 EA ADDL
FOLIC ACID
FOLLICLE STIM HORMONE
GGT (GAMMA GLUTAMYL TRANSPEP)
GLUCOSE
GLUCOSE URINE
HCG QL
HCG QN
HEPATIC FUNCTION PANEL
HEPATITIS A (HAAB) AB IGM
HIV 1 AB
HIV-1 QN NAP
IGG SUBCLASSES EACH
IMMUNOFIXATION ELECTROPHOR UR
INFECTIOUS AGENT NAP AMPLIFIED
LACTATE DEHYDROGENASE (LDH)
LUTEINIZING HORMONE (LH)
MAGNESIUM
MUMPS AB IGG
PINWORM EXAM
PROCAINAMIDE W/NAPA TDA
TB SKIN TEST INTRADERMAL
TREPONEMA PALLIDUM
80048
82248
82805
85027
85025
87491
80053
82553
82550
82565
87040
87086
85007
80051
83036
87205
85018
80076
83605
83690
80061
83735
87591
85730
84100
85610
84443
84484
81001
81003
81002
84520
82607
82306
83880
G0434
88305
86850
86900
86901
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
58.00
33.00
21.00
30.00
96.00
24.00
39.00
44.00
57.00
24.00
36.00
24.00
76.00
72.00
76.00
76.00
76.00
114.00
81.00
102.00
40.00
22.00
22.00
41.00
41.00
35.00
62.00
24.00
468.00
44.00
161.00
193.00
33.00
102.00
32.00
72.00
23.00
92.00
31.00
73.00
Patient Price Information List
Hospital Billing Policies
Mount Carmel Health System is committed to providing the highest quality health care to every patient, regardless of the ability to pay. We offer
the information contained here to help you understand your hospital bill, health insurance requirements and financial assistance options.
Patients may also call (614) 234-8888 or (800) 346-1009 to speak to a representative for assistance.
Patients With Health Insurance
Mount Carmel Health System accepts Medicare, Medicaid, managed care, commercial, and work-related insurance plans. Payment of your
financial obligation is required at the time of service. Mount Carmel Health System will bill your primary insurance company for you. If you have
secondary insurance coverage, Mount Carmel Health System will bill that company, after your primary insurance benefits are processed. As a
patient, you assume responsibility for paying any charges that your insurance company denies or does not pay. If you have questions about
your financial obligation, or about other benefits, call your insurance company directly.
Patients Without Health Insurance
Patients who wish to schedule elective medical and/or maternity services are required to pay in full prior to coming in for the service. A Patient
Financial Specialist will contact you prior to your scheduled service to arrange for payment of your bill. You may make an acceptable payment
plan to resolve the account balance and any other outstanding obligations at that time.
Payment Options
You may pay for services online at www.mountcarmelhealth.com, via “check by phone,” or by personal check, credit card, bank loan, or cash.
You may also make arrangements to pay an acceptable monthly amount. There will be a fee charged for checks returned unpaid. Mount
Carmel Health System does not charge interest for financial obligations that are paid within the regular Mount Carmel Health System billing
cycle or through a mutually acceptable payment arrangement. Financial counselors are available for consultation while you are a patient at
Mount Carmel East, West, St. Ann’s or New Albany to help you resolve your hospital bill. If you have any questions, contact your Patient
Financial Specialist, who can provide financial counseling services.
Health Insurance Exchange
Everyone deserves access to affordable healthcare. If you would like more a more affordable health plan or are presently uninsured, please
call (614) 334-4093 for a representative at My Health Quoter (myhealthquoter.com) or call (866) 227-7117 for a representative at Insurance
Spark to answer your questions.
Financial Assistance
If you cannot pay the balance of your bill in full, contact Mount Carmel Health System. Two options are available for financial assistance.
Medically unnecessary procedures may not qualify.
Option 1: Hospital Care Assurance Program (HCAP)
The Hospital Care Assurance Program (HCAP) is available to patients:
• who are Ohio residents
• who are not currently receiving Medicaid benefits
• whose personal/family income is at or below federal poverty income guidelines
If you apply and are eligible for this program, you will not be billed for hospital services. You will be responsible for
paying your physicians’ bills. For more information, call 614-234-8796.
Option 2: Mount Carmel Financial Assistance Programs
Provides financial assistance programs based upon a patient’s income, expenses, and other circumstances.
Other Bills for Your Treatment
Your bill from Mount Carmel Health System is only for hospital services. Depending on the services you received, you may be billed by your
personal physician, other physicians who were involved in your care, and/or physicians who administered/interpreted your test results,
including, but not limited to, bills for such services as emergency care, radiology, pathology, and anesthesiology. If you have questions about
any bill you receive other than a bill from Mount Carmel Health System, you should call the office that sent the bill directly.
Price Information
A phone line is available for patients to request non-published pricing information for patients on a case-by-case basis. That number is (614)
234-6074.
Automated Touch-Tone Service
Mount Carmel Health System’s Automated Touch-Tone Service offers quick answers to many common questions about your account. You
must have your account number ready when you call. It can be found on the statement that you received from Mount Carmel Health System.
Access to this service is available 24-hours-a-day.
Patient Financial Services: (614) 234-8888 or (800) 346-1009 Regular Business Hours 8 a.m. - 4:45 p.m. Monday - Friday
30011366
35011347
32511326
30011366
R&B/Obs Descr.
Current
% Increase
Proposed
35011347 R&B NSY LVL II CONTINUING CARE
3216 0.2
3864
31511336 R&B ICU SEMIPVT STEPDOWN INTRM 3216 0.2
3864
31029002
35011350
32011328
31029002 R&B SEMI PRIVATE INTERMED OB
29590665 OBSV/HR/TELE SAME DATE DCH
3216
134
0.2
0.2
3864
161
2015
Minor chg
dollar difference Major chg
$ 4,797.00
$ 561.00
$
$
626.00
112.00
$ 9,172.00
$ 1,705.00
$ 6,442.00
$ 431.00
$
$
840.00
86.00
$ 9,892.00
$ 1,781.00
$ 5,399.00
$ 393.00
$
$
704.00
79.00
$ 7,055.00
$ 2,683.00
$ 4,837.00
$ 196.00
$
$
631.00
39.00
$ 7,619.00
$ 2,004.00
$ 6,461.00
$ 879.00
$
$
843.00
176.00
$ 9,626.00
$ 2,289.00
T remove PT and Pulmonary site designations.
T remove PT and Pulmonary site designations.
G0204
G0202
77051
77052
G0204
G0202
77051
77052
77056
77057
77051
77052
$240
$119
$40
$35