Covenant Health is an innovative, Catholic regional delivery network and a leader in values based, not-for-profit health and elder care. We sponsor hospitals, nursing homes, assisted living residences and other health and elder care organizations throughout New England.
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Estimated Charges for Selected Procedures

2017 Estimated Charges for Selected Procedures

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

       
  Inpatient (Top 15 Admissions)
(Basic Per Diem Med Surg Bed Charge: $1,499.00)
   
       
MS DRG Procedure Median Charge Uninsured Self
Pay Charge
Childbirth Related
775 Normal Vaginal Delivery (Mother) $7,619 $2,895
774 Normal Vaginal Delivery (w/ complicating diagnosis) $9,582 $3,641
766 Normal Cesarean Section (Mother) $13,521 $5,138
765 Cesarean Section when there are complications $14,250 $5,415
794 Neonate with other significant problems $4,121 $1,566
795 Normal Newborn (Baby) $4,046 $1,537
       
Medical/Other
101 Seizures w/out Major Complications $16,700 $6,346
189 Pulmonary Edema Respiratory Failure $19,265 $7,321
194 Simply Pneumonia Pleurisy w/CC $14,601 $5,548
291 Heart Failure and Shock w/ MCC $21,500 $8,170
392 Esophagitis, Gastroenteritis & Misc Digestive Disorders w/ Complications (age 17 or older) $16,001 $6,080
470 Major Joint Replacement or Reattachment $47,060 $17,883
603 Cellulitis w/o MCC $15,440 $5,867
871 Septicemia or Severe Sepsis w/o MV 96+ Hours w/MCC $28,271 $10,743
872 Septicemia or Severe Sepsis w/o MV 96+ Hours w/o MCC $22,817 $8,670
       
Psychoses or Drug Related
881 Depressive Neuroses $10,513 $3,995
882 Neuroses except Depressive $9,775 $3,715
885 Psychoses/td> $12,364 $4,698
895 Alcohol/Drug Abuse or Dependence with Rehabiliation Therapy $12,410 $4,716
897 Alcohol/Drug Abuse or Dependency $7,888 $2,997
       
 

Top 20 Outpatient Services

   
  Description of Service Median Charge Uninsured Self Pay Median Charge
  Cardiac Catheterization-Left Heart Cardiac Catheterization $14,900 $5,662
  Cataract Removal $9,200 $3,496
  Closed [Endoscopic] Biopsy of Large Intestine $3,210 $1,220
  Colonoscopy $2,820 $1,072
  Cystometrogram $3,150 $1,197
  Dilation and Curettage of Uterus (D&C) $10,560 $4,013
  Dilation of Esophagus $5,190 $1,972
  Endoscopic Bronchial Biopsy (Closed) $4,600 $1,748
  Endoscopic Gall Bladder Removal (Laparoscopic Cholecystectomy) $21,300 $8,094
  Endoscopic Polypectomy of Large Intestine $5,050 $1,919
  Endoscopic Polypectomy of Rectum $4,890 $1,858
  Esophagogastroduodenoscopy (EGD) with Closed Biopsy $3,920 $1,490
  Excision of Semilunar Cartilage of Knee $11,750 $4,465
  Extracorporeal Shockwave Lithotripsy [ESWL] of the Kidney, Ureter and/or Bladder $6,020 $2,288
  Fetal Monitoring $460 $175
  Insertion of Totally Implantable Vascular Device $9,970 $3,789
  Local Destruction of Lesion or Tissue of Skin/Subcutaneous Tissue $1,830 $695
  Tonsillectomy w/ Adenoidectomy $10,200 $3,876
  Transurethral Excision or Destruction of Lesion or Tissue of Bladder $12,400 $4,712
  Upper Eye Lid Rhytidectomy $9,150 $3,477
  Other Miscellaneous Outpatient Services    
  Cat Scan (CT) of the Abdomen and Pelvis w/out Contrast $2,851 $1,084
  Cat Scan (CT) of the Head w/out Contrast $1,235 $469
  Chest X-Ray (PA & Lateral) $295 $112
  Digital Mammography (Mammogram) Screening $312 $118
  MRI-Brain /out Contrast $2,311 $878
  MRI-Extrimity w/out Contrast $2,311 $878
  MRI-Lumbar w/out Contrast $2,311 $878
       

Emergency Room (includes physician fee)*

   
  Procedure Charges* Uninsured Self Pay Charge*
  Level 1 (least critical) $198 $75
  Level 2 $294 $112
  Level 3 $545 $207
  Level 4 $1,001 $380
  Level 5 (most critical) $1,721 $654
       
*Charges shown are for basic facility and professional fees and do not include any additional services that may be performed in the Emergency Department.
       

Provider Based Primary Care Physician Practices

   
  Procedure Insured and Uninsured Charges**
99201 New Patient Level 1 $79
99202 New Patient Level 2 $136
99203 New Patient Level 3 $195
99204 New Patient Level 4 $302
99205 New Patient Level 5 $380
99211 Established Patient Level 1 $39
99212 Established Patient Level 2 $78
99213 Established Patient Level 3 $132
99214 Established Patient Level 4 $197
99215 Established Patient Level 5 $266
99241 Primary Care Physician Consult Level 1 $147
99242 Primary Care Physician Consult Level 2 $233
99243 Primary Care Physician Consult Level 3 $302
99244 Primary Care Physician Consult Level 4 $424
99245 Primary Care Physician Consult Level 5 $571
       
**Charges shown are for basic facility and professional fees and do not include any additional services that may be performed in the facility, practice or in any other non primary care physician practice.
       

The above 2017 charge estimates are based on rates as of 01/01/2017. 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.

St. Mary's Health System • 93 Campus Avenue • Lewiston, ME 04240