Patient Price Information List

In compliance with state law, Pomerene Hospital is providing this price list containing our charges for room and board, emergency department, operating room, delivery, physical therapy and other procedures. The hospital's charges are 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 January 1, 2008.

Labor and Delivery
The following list does not include charges for anesthesia, drugs, or supplies required for a particular delivery room procedure. Fees for physician services or anesthesia administration are also not reflected and will be billed separately by your physician.

Normal Delivery	$1848.00
Cesarean Section Delivery	$5,335.77
Amniocentesis
Fetal Non-Stress Test	$144.00
Labor Room per hour	$43.00

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.

Level 1	$101.00
Level 2	$140.00
Level 3	$195.00
Level 4	$398.00
Level 5	$582.00
Critical Care
First Hour	$756.00
Additional 1/2 Hr.	$343.00

Operating Room Charges
Operating Room charges are based on the complexity level, with level 1 being the most basic, for a particular operation. There is an initial set-up charge as well as an additional charge for each 15 minutes while the operation is being performed.

Minor
Setup Charge	$994.00
Additional 15 Min.	$151.00
Major
Setup Charge	$1,612.25
Additional 15 Min.	$202.50

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.

Therapeutic Exercise per 15 min	$64.75
Ultrasound per 15 min	$38.75
Mobilization per 15 min	$65.25
Aquatic Therapy per 15 min	$66.50
Gait Training per 15 min	$59.25
Massage per 15 min	$41.75
Evaluation	$119.50
Traction	$37.00
Electrical Stimulation per 15 min	$37.00

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.

Therapeutic Exercise per 15 min	$64.75
Therapeutic Activities per 15 min	$64.75
Activity of Daily Living	$49.50
Evaluation	$114.50
Neuromuscular Re-education	$61.75
Orthotic Training	$171.00

Respiratory 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.

Arterial Blood Gas	$82.00
Acapella Device	$125.00
BiPap	$205.00
Medication Nebulizer Initial	$56.00
Medication Nebulizer Sub	$44.00
Incentive Spirometer	$62.00
Oxygen Per Hour	$6.50
Oxygen set up	$21.50
Pulmonary Function Test Complete	$429.00
Sleep Study	$1,390.00
Sleep Study w CPAP trial	$1,621.00
Venilator Management 1st day	$336.00
Venilator Management Subsequent	$460.00

EKG
EKG	$98.00
Cardiac Event Moniter	$370.00
Holter Moniter	$447.00

X-Ray and Radiological Charges
The following charges reflect the hospital's 30 most common x-ray and radiological procedures.

Diagnostic
Chest One View	$117.00
Chest Two View	$139.00
Screening Mammogram	$101.00
KUB Multiple Views	$147.00
Lumbosacral Complete Min 4 Views	$210.00
Pelvis AP	$126.00
Bone Density Dexa Axial Skeleton	$189.00
Cervical Spine Complete	$210.00
Ankle Unilateral	$139.00
Foot Unilateral Min 3 Views	$139.00
Knee Complete Unilateral Min 4 Views	$157.00
Hipp Complete Unilateral Min 2 Views	$167.00
Wrist Complete Unilateral Min 3 Views	$122.00

Ultrasound
Abdomen Limited	$296.00
Pelvis	$326.00
Breast	$179.00
Both Kidneys	$303.00
Soft Tissue Head and Neck	$174.00
Needle Placement	$470.00

Nuclear Medicine
Myocardial w Ejection Fraction	$258.00
Myocardial w Wall	$260.00
Spect Cardiac	$909.00
Bone/Whole Body	$717.00
Hepatobiliary	$829.00
Thyroid Uptake and Scan	$462.00

CT
Brain without contrast	$707.00
Pelvis w contrast	$1064.00
Abdomen w contrast	$1109.00
Limited or Localized Follow Up	$586.00
Coronal Sagittal Rec	$265.00

MRI
Lumbar Spine	$1,108.00
Any Joint Lower	$1,108.00
Brain	$1,182.00
Any Joint Upper	$1,108.00
Brain w & w/o contrast	$1,305.00
Cervical	$1,276.00

Vascular Ultrasound
Peripheral Venous Unilateral Study	$331.00
Carotid	$466.00
Venous Bilateral	$481.00
Arterial	$515.00

Cardiac Ultrasound
Echocardiogram	$466.00

Laboratory Charges
The following charges reflect the hospital's 30 most common laboratory procedures.

Complete Blood Count	$33.00
Basic Metabolic Panel	$31.50
Comprehensive Metabolic Panel	$82.00
Urinalysis	$15.50
Glucose Bedside	$23.50
Lipid Panel	$41.00
Thyroid Stimulatin Hormone (TSH)	$56.00
Urine Culture	$35.50
Hemoglobin Glycosylated (HGB A1C)	$60.00
Natriuretic Peptide (BNP)	$147.00
Troponin	$159.00
Hepatic Panel	$57.00
CPK	$34.00
Creatine Kinase MB Fraction (CKMB)	$88.00
Hemoglobin	$10.50
Culture Blood	$45.00
Thromboplastin Time Partial (APTT)	$44.00
Electrolytes Panel 4	$38.00
Creatine Kinase (CK)	$34.00
Potassium	$23.00
Depakene	$91.00
Dilantin	$69.00
C Reactive Protein	$51.00
BUN	$32.50
Sedimentation Rate	$15.25
Occult Blood Stool	$15.50
Amylase	$42.00
Magnesium	$37.25
PSA	$84.00
Glucose	$23.50

Hospital Billing Policies:
Financial Assistance

Pomerene Hospital has two (2) Charity Care Programs in place to assist you.

1. Hospital Care Assurance Program (HCAP). The government of the State of Ohio, in collaboration with the United States federal government, has sponsored, funded, and implemented an Expanded Hospital Care Assurance Program, which was effective May 22, 1992. Pomerene Hospital provides, without charge to the individual patient, basic, medically necessary, hospital-level services to individuals who are residents of this State, are not recipients of the Medicaid program, and whose income is at or below the federal poverty line.”

2. Pomerene Hospital Charity Care Program (PHCC). Pomerene Hospital is also concerned with the health of our community and will provide a reasonable amount of care either at no charge or at a reduced charge to individuals who are residents of Holmes County and eligible under the Pomerene Hospital Charity Care Program.

If you are interested in having us determine your eligibility for these programs for any services rendered, please call (330) 674-1584, extension 1750, to make an application appointment. We will be happy to analyze your application and give you a written response within ten (10) working days after its receipt. If you qualify, your charges could be reduced or eliminated. You must reapply for these programs each time you incur charges at Pomerene Hospital

Prompt Pay Discounts

Pomerene Hospital patients without insurance may take advantage of our Prompt Pay Discount Program. Patients able to pay an account in full within 15 days of the initial billing date will receive a 17% discount. Please contact us at (330) 674-1584 extension 1750.

Payment Arrangements

In the event you can not pay you account in full, you may contact one of our Patient Financial Counselors to set up a monthly (no interest) payment arrangement. Please contact us at (330) 674-1584 extension 1750 for more information


Consumers can access a number of government and private Web sites, 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 Health Care in Ohio at www.ohanet.org/portal.