Operating Budget

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Patient Price List at Rumford Hospital

Inpatient Charges

Room Charges Daily Rate

Intensive Care $2,968 Medical/Surgical $1,204 Maternity $1,058 Newborn Care Fee $621

Level Professional Fee

Hospital New Patient Consult Level 1 $90.50 Level 2 $131.00 Level 3 $180.00 Level 4 $218.50 Level 5 $278.75 Duration Professional Fee

Initial Hospital Care/Day 30 Minutes $166.75 30 Minutes $231.50 40 Minutes $287.50 Duration Professional Fee

Subsequent Hospital Care/Day 20 Minutes $86.00 40 Minutes $117.75 55 Minutes $176.25

DAILY ROOM RATES

HOSPITAL CARE

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Level Facility Charge

ED Level 1 $107.00 ED Level 2 $178.25 ED Level 3 $365.50 ED Level 4 $667.25 ED Level 5 $1,082.50 Critical Care – 1st Hour $1,783.00 Critical Care – Each Additional ½ Hour $445.75

Emergency Department Charges

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

MS DRG Description Average Charges

795 NORMAL NEWBORN $2,150.72 948 SIGNS SYMPTOMS W/O MCC $18,425.85 775 VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES $6,955.92 194 SIMPLE PNEUMONIA PLEURISY W CC $20,317.05 603 CELLULITIS W/O MCC $13,585.45 195 SIMPLE PNEUMONIA PLEURISY W/O CC/MCC $15,319.19 189 PULMONARY EDEMA RESPIRATORY FAILURE $12,916.14 192 CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC $13,310.99 690 KIDNEY URINARY TRACT INFECTIONS W/O MCC $11,893.45 392 ESOPHAGITIS GASTROENT MISC DIGEST DISORDERS W/O MCC $15,384.01 292 HEART FAILURE SHOCK W CC $12,724.42 794 NEONATE W OTHER SIGNIFICANT PROBLEMS $3,007.88 191 CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC $13,647.37 947 SIGNS SYMPTOMS W MCC $24,515.20

561 AFTERCARE MUSCULOSKELETAL SYSTEM CONNECTIVE TISSUE W/O CC/MCC

$26,221.92

641 MISC DISORDERS OF NUTRITIONMETABOLISM- FLUIDS/ELECTROLYTES W/O MCC

$14,191.79

440 DISORDERS OF PANCREAS EXCEPT MALIGNANCY W/O CC/MCC $10,063.85 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV >96 HOURS W/O MCC $14,734.51

066 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W/O CC/MCC

$16,600.94

683 RENAL FAILURE W CC $16,916.56

Top 20 MS-DRGS

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Provider Based Practice Charges

Level Professional Fee Facility Fee

Office Visits Level 1 $59.25 $56.25 Level 2 $100.75 $77.00 Level 3 $148.75 $77.00 Level 4 $188.25 $98.75 Level 5 $247.50 $136.25

Level Professional Fee Facility Fee

Office Visits Level 1 $33.25 $56.25 Level 2 $58.25 $77.00 Level 3 $72.75 $77.00 Level 4 $134.25 $98.75 Level 5 $191.25 $136.25

Age Professional Fee

Physicals Age 0-1 $197.25 Age 1-4 $211.00 Age 5-11 $207.00 Age 12-17 $213.50 Age 18-39 $209.00 Age 40-64 $240.00 Age 64+ $260.00

Age Professional Fee

Physicals Age 0-1 $160.50 Age 1-4 $180.50 Age 5-11 $180.50 Age 12-17 $178.25 Age 18-39 $177.25 Age 40-64 $206.00 Age 64+ $223.75

NEW PATIENTS

ESTABLISHED PATIENTS

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Provider Based Practice Charges, continued

Level Professional Fee

Outpatient Hospital Consult Level 1 $118.50 Level 2 $154.00 Level 3 $218.50 Level 4 $267.25 Level 5 $333.75 Duration Professional Fee

Initial Inpatient Consult 20 Minutes $128.50 40 Minutes $170.75 55 Minutes $215.50 80 Minutes $277.00 110 Minutes $349.25 Duration Professional Fee

Office Consult 30 Minutes $118.50 30 Minutes $173.75 40 Minutes $226.75 60 Minutes $298.50

80 Minutes $376.50

CONSULTS

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Radiology Charges

CPT Description BH

70250 XR Skull 1-3 Views $219.00 70260 XR Skull Complete 4 Views $346.50 70450 CT Head wo Contrast $1,217.25 70470 CT Head w+wo Contrast $1,813.50 70480 CT Orbit wo Contrast $1,058.75 70486 CT Axial or Coronol Face wo Contrast $881.00 70540 MRI Orbit and or Face wo Contrast $1,191.50 70542 MRI Orbit and or Face w Contrast $1,445.50 70551 MRI Brain wo Contrast $1,191.50 70552 MRI Brain w Contrast $1,445.50 71020 XR Chest PA+Lateral $177.75 71101 XR Ribs Right w PA Chest $344.50 72040 XR Cervical Spine $182.25 72100 XR Lumbar Spine AP + Lateral $254.75 72141 MRI Cervical Spine wo Contrast $1,191.50 72192 CT Pelvis wo Contrast $1,351.00 72193 CT Pelvis w Contrast $1,472.50 72194 CT Pelvis w+wo Contrast $2,025.50 73706 CT Angio Low Ext Bilat w+wo Contrast $1,279.25

CT Angio Lower Ext LT w+wo Contrast $1,279.25

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Radiology Charges, continued

CPT Description BH

CT Angio Lower Ext RT w+wo Contrast $1,279.25 73718 MRI lower extremity w/o dye $1,191.50 73721 MRI Knee Left wo Contrast $1,191.50 73722 MRI Knee Left w Contrast $1,445.50 73723 MRI Knee Left w+wo Contrast $1,824.50 74240 XR UGI Series wo KUB $468.00 76642 US Breasts Limited $291.75 76706 US AAA Screening $393.00 76770 US Retroperitoneal Complete $537.75 76881 US Left Ext Comp $319.00 76881 US Right Ext Comp $319.00 76882 US Left Ext Ltd $206.75 76882 US Right Ext Ltd $206.75 77073 CT Bone Length Study $450.50 78803 NM Tumor Imaging SPECT $761.25 78804 NM Tumor Imaging WB Multi $2,110.00 93017 Cardiovascular Stress Test Tracing $462.00

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Lab Charges

CPT Description BH

80048 $ Basic Metabolic 80048 $132.75 80061 Coronary Risk Panel $120.75 80156 Carbamazepine Level $135.75 81002 Urine Test $35.00 81003 Urnls Dip Stick $41.75 81025 Pregnancy Test $49.00 82270 Hemoccult $32.50 82274 Occult Blood FIT, Stool $60.50 82803 Mixed Blood Gas $251.50 82947 Glucose Test $43.00 83001 Follicle Stimulating Hormone $155.50 83516 Anti Mullerian Hormone $284.00 83520 GM1 Antibody Panel $116.00 84144 Progesterone Level $164.50 84403 Testosterone Level $180.00 84520 Blood Urea Nitrogen $39.50 86706 Hepatitis B surface Antibody $66.00 86762 Rubella IgG Ab $51.25 86765 Rubeola IgG Ab $29.00 86787 Varicella IgG Ab $71.75 87088 Urine Culture $77.75 87491 Chlamydia $47.50 87535 HIV $414.00 87591 Gonorrhea $63.00 87624 HPV High Risk Screen by TMA $93.50 87880 Strep Test $58.00 88341 Immunio Stain 2+ $177.00

Reimbursement to the hospital (and the patient’s financial responsibility) will also vary based on the term of any insurance coverage, contractual reimbursement rates, deductible, copay, and coinsurance.

The above 2016 charge estimates are based on rates as of 07/01/2016. Charges for specific patients will depend on many factors including the physician, the condition of the patient, unexpected complications, or additional procedures required. These charges are to be considered estimates only and are not a guarantee of final costs. These are hospital charges only except where indicated. Other fees and charges are not included such as surgeon or other physician fees, radiologist, and other non-facility fees.

If you have any questions please contact our billing office at 207-795-2237

Glossary

AMI Acute Myocardial Infarction

Bilat Bilateral

BX Biopsy

CC Complications and Comorbidities

CV Central Venous

DRG Diagnosis Related Group

ED Emergency Department

EGD Upper Endoscopy

ENDOS Endoscopy

ESWL Extracorporeal Shock Wave Lithotripsy

EXCIS Excision

FB Foreign Body

FB/DEVCE SK Foreign Body/Device Skin

GU Genitourinary System

I&D Incision and drainage

IN Insertion

LAP ASST Laparoscopy Assisted

MCC Major Complications and Comorbidities

MV Mechanical Ventilation

NEC Not Elsewhere Classified

NICU Neonatal Intensive Care Unit

OCC Occlusion

PERC Pulmonary Emboli Rule out Criteria

SubQ Subcutaneous

VAS ACC Vascular Access