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Fees -As of 6 12 2019.Xls • Timed charges: Some charges such as anesthesia are based on a units of time, so the charges may vary based on the units charged. • Drugs and implants: Drugs, implants and supplies are priced individually based on the cost loaded into our information systems at the time of charging, so they do not have individual prices listed. The typical methodology will take the cost in place at the time, multiplied by a markup percentage. • Estimated Total Charges of Procedure/Stays/Visits etc can be obtained by contacting -AJ Karpinski at 218-546-2507. All charges are then subject to Insurance contract payer reductions. To get any accurate representation of patient final cost, I would strongly encourage contacting us to accurately predict final price -costs of services State Mandated Clinic Price Transparency – Average. Charge Medicare Medicaid Cuyuna Regional Medical Center - Clinic Commecial Reim. Office/outpatient visit new Level 1 $190 $76 $45 $34 Office/outpatient visit new Level 2 $396 $130 $75 $57 Office/outpatient visit new Level 3 $574 $186 $107 $82 Office/outpatient visit new Level 4 $708 $283 $163 $126 Office/outpatient visit est Level 1 $96 $36 $22 $16 Office/outpatient visit est Level 2 $187 $76 $44 $34 Office/outpatient visit est Level 3 $424 $127 $73 $56 Office/outpatient visit est Level 4 $549 $187 $108 $83 Office/outpatient visit est Level 5 $624 $245 $145 $112 Per pm reeval est pat infant $300 $176 Non-cov. $77 Prev visit est age 1-4 $347 $184 Non-cov. $82 Prev visit est age 18-39 $432 $205 Non-cov. $91 Prev visit est age 40-64 $408 $219 Non-cov. $97 Per pm reeval est pat 65+ yr $478 $236 Non-cov. $105 Init pm e/m new pat infant $342 $192 Non-cov. $85 Init pm e/m new pat 1-4 yrs $374 $201 Non-cov. $89 rev visit new age 18-39 $401 $229 Non-cov. $102 Prev visit new age 40-64 $470 $265 Non-cov. $118 Init pm e/m new pat 65+ yrs $514 $287 Non-cov. $128 VENIPUNCTURE/Lab Draw $46 $15 $3 $3 Seasonal Influenza $139 $39 $39 $53 Immunization admin $80 $28 $20 $16 Vaccine Admin $28 $25 $10 $16 PR SUBSEQUENT ANNUAL WELLNESS VISIT $289 $165 $117 $83 Transitional Care Management <14 days post dc. $526 $285 $165 $127 • ATTENTION: The amounts posted above DO NOT reflect the amount(s) each clinic patient will pay for • The Minnesota Legislature passed a law that requires certain clinics to report amounts for their 25 the services listed. For specific information about the amount you will owe for the services you receive, most frequent services that cost more than $25.00. The services listed here do not reflect all the services please contact your insurer. provided at this clinic. • Patients with government-sponsored health coverage, such as Medicare or Medical Assistance: The For more information, please contact AJ Karpinski, Director Managed Care Contracting, at 218- payment rates listed above reflect amounts set by Medicare or Medical Assistance, not by this clinic. 546-2507 These listed rates do not reflect the amount you might owe as a co-payment. NOTICE: Cuyuna Regional Medical Center - Crosby is a provider based facility. This clinic is a part of a • Patients covered by commercial health insurance or a Medicare Advantage plan: Your health insurance hospital and the patient may receive a separate charge or billing for the facility component of the service. company has likely negotiated a discount or contracted rate for each service. Your health insurance This may result in a higher out of pocket expense. company’s negotiated price might be higher or lower than the average commercial payment amount listed above. To learn more about your health insurance company’s negotiated price or how much you will owe under the term of your specific health policy, please contact your health insurance company. Fee Schedule Procedure Name UNIT_Charge ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID SCIATIC NERVE 1,518.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID SCIATIC NERVE CONT INFUS 32.00 ANES FAC FEE PR ANES SKIN SURG THORAX EXTR 10.00 ANES FAC FEE PR ANES REPAIR UPPER ABD HERNIA NOS 10.00 ANES FAC FEE PR ANES BICEPS TENDON REPAIR 10.00 ANES FAC FEE PR ANES UPPER GI ENDOSCOPY 10.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID BRACHIAL PLEXUS 175.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID INTERCOST NERVE EA ADDL LVL 219.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID FEMORAL NERVE 81.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID FEMORAL NERVE CONT INFUS 174.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID OTH PERIPH NERVE/BRANCH 225.00 ANES FAC FEE PR HEART/LUNG RESUSCITATION (CPR) 342.00 ANES FAC FEE PR ANES CORRECT HEART RHYTHM 10.00 ANES FAC FEE PR ANES CARDIOVERTER DEFIB 10.00 ANES FAC FEE PR ANES EXTERNALCEPHALIC VERSION PRC 10.00 ANES FAC FEE PR INSERT NON TUNNEL CVCATH OVER 5 YRS 395.00 ANES FAC FEE HCHG ANES FACILITY TIMED CUY ONLY 10.00 ANES FAC FEE PR INJ TRIGGER POINTS 3 OR > MUSCLES 58.00 ANES FAC FEE PR INJ LUMBAR EPIDUR BLOOD/CLOT PATCH 204.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID AXILLARY NERVE 181.00 ANES FAC FEE PR ANES DX ARTHROSCOPIC PROC KNEE JOINT 10.00 ANES FAC FEE PR ANES KNEE JOINT CASTING 10.00 ANES FAC FEE PR ANES ACHILLES TENDON SURG 10.00 ANES FAC FEE PR FLUOROSCOPIC GUIDE FOR NEEDLE PLACEMENT 953.00 ANES FAC FEE HCHG NITROUS OXIDE PER 15 MIN 64.00 ANES FAC FEE HCHG MODERATE SED SAME PROVIDER > 5 YRS 1ST 15 MINUTES 210.00 ANES FAC FEE HCHG GENERAL ANESTHESIA 10.00 ANES FAC FEE PR INJ TRIGGER POINT 1 OR 2 MUSCLES 58.00 ANES FAC FEE PR VENIPUNC <3 YEARS FEMORAL JUGULAR MD SKILL 23.00 ANES FAC FEE PR WITHDRAWAL OF ARTERIAL BLOOD 58.00 ANES FAC FEE PR ANES SURG LOWER IP ABDOMEN 10.00 ANES FAC FEE PR ANES SURG LOW ABDEXTRAPERINTONEAL 10.00 ANES FAC FEE PR ANES KNEE AREA SURGERY 10.00 ANES FAC FEE PR ANES TOTAL KNEE ARTHROPLASTY 10.00 ANES FAC FEE PR ANES LOWER ARM SURGERY 10.00 ANES FAC FEE HCHG MODERATE SED DIFF PROVIDER EACH ADDL 15 MINUTES 162.00 ANES FAC FEE PR VENIPUNCTURE > 3 MD SKILL DX OR TX PURP 23.00 ANES FAC FEE PR ANES FOR LENS SURGERY 10.00 ANES FAC FEE PR ANES SKIN SURG HEAD/NECK 10.00 ANES FAC FEE PR ANES REPAIR LO ABD HERNIA NOS 10.00 ANES FAC FEE PR ANES RADICAL REMOVE TESTIS INGUINAL 10.00 ANES FAC FEE PR ANES UPPER LEG SURG 10.00 ANES FAC FEE PR ANES SURGERY OF SHOULDER 10.00 ANES FAC FEE PR ANES OPEN OR ARTHROSCOPIC LOWER ARM SURGERY 10.00 ANES FAC FEE PR NEURAXIAL LABOR ANAL/ANES PLAN VAG DEL 368.00 ANES FAC FEE PR CATH PLCMT INJ/INFUSE EPI OR SUBA LUMB SACRAL WO GUIDE 337.00 ANES FAC FEE PR ULTRASOUND GUIDED NEEDLE PLCMT 509.00 ANES FAC FEE PR ANES LOWER GI ENDOSCOPY SCREENING COLONOSCOPY 10.00 ANES FAC FEE PR SPINAL PUNCTURE THERAPEUTIC DRAINAGE 218.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID BRACHIAL PLEXUS CONTINOUS 175.00 ANES FAC FEE PR ANES BONE MARROW ASP/BX ILIAC CRST 10.00 ANES FAC FEE PR ANES TOTAL HIP ARTHROPLASTY 10.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID LUMBAR PLEXUS CONT INFUS 56.00 ANES FAC FEE HCHG MONITORED ANESTHESIA CARE 10.00 ANES FAC FEE PR INSERT EMERGENCY ENDOTRACH AIRWAY 154.00 ANES FAC FEE PR INJ(S) ANES AGENT AND/OR STEROID INTERCOSTAL NERVE SGL LVL 170.00 ANES FAC FEE PR INJ FORAMEN L/S 1 LEVEL WITH FLUORO OR CT 217.00 ANES FAC FEE PR ANES CES DEL FOL NEURAXIAL ANAL/ANES 10.00 ANES FAC FEE PR ANES NERVE BLOCKS/INJ NOT PRONE 10.00 ANES FAC FEE PR DAILY MGMT EPIDUR/SUBARACH CONT 538.00 ANES FAC FEE PR INSERT NON TUNNEL CVCATH UNDER 5 YRS 357.00 ANES FAC FEE HCHG SEVOFLURANE PER 15 MIN 19.00 ANES FAC FEE HCHG CATH PLCMT INJ/INFUSE EPI OR SUBA LUMB SACRAL WO GUIDE 210.00 ANES FAC FEE HCHG MODERATE SED SAME PROVIDER EACH ADDL 15 MINUTES 162.00 ANES FAC FEE PR ANES LOWER GI ENDOSCOPY 10.00 ANES FAC FEE PR INSERT CATH ART PERCUT SHORT TERM 58.00 ANES FAC FEE PR ANES REPAIR UP HERNIA LUMBAR/VENTR 10.00 ANES FAC FEE PR ANES SURG UPPER IP ABDOMEN 10.00 ANES FAC FEE PR ANES ABD WALL LOWER ANTSURG 10.00 ANES FAC FEE PR ANES ELBOW AREA SURGERY 10.00 ANES FAC FEE PR ANES ELBOW REPLACEMENT 10.00 ANES FAC FEE HCHG MODERATE SED DIFF PROVIDER > 5 YRS 1ST 15 MINUTES 210.00 ANES FAC FEE HCHG ANES US GUIDE 3,464.00 CRNA PR VENIPUNC <3 YEARS FEMORAL JUGULAR MD SKILL 21.00 CRNA PR INJ(S) ANES AGENT AND/OR STEROID INTERCOST NERVE EA ADDL LVL 137.00 CRNA PR INJ(S) ANES AGENT AND/OR STEROID FEMORAL NERVE 56.00 CRNA PR CRITICAL CARE EA ADDL 30 MIN 404.00 CRNA PR ANES FOR LENS SURGERY 21.00 CRNA PR ANES INTRAORAL PROCEDURE NOS 21.00 CRNA PR ANES REPAIR LO HERNIA VENTR/INCIS 21.00 CRNA PR ANES ANORECTAL SURGERY 21.00 CRNA PR ANES RADICAL REMOVE TESTIS INGUINAL 21.00 CRNA PR ANES VAGINAL PROCEDURES 21.00 CRNA PR ANES HYSTEROSCOPY/VAG BX 21.00 CRNA PR ANES ELBOW REPLACEMENT 21.00 CRNA PR ANES CESAREAN DELIVERY ONLY 21.00 CRNA PR ANES NERVE BLOCKS/INJ NOT PRONE 21.00 CRNA PR DAILY MGMT EPIDUR/SUBARACH CONT 368.00 CRNA PR ANES PERC IMG TX SPINE PROC 21.00 CRNA PR NEWBORN RESUSCITATION 375.00 CRNA PR INSERT EMERGENCY ENDOTRACH AIRWAY 82.00 CRNA PR WITHDRAWAL OF ARTERIAL BLOOD 108.00 CRNA PR INJ(S) ANES AGENT AND/OR STEROID INTERCOSTAL NERVE SGL LVL 100.00 CRNA PR ANES NECK VESSEL SURG SIMPL LIGAT 21.00 CRNA PR ANES REPAIR UPPER ABD HERNIA NOS 21.00 CRNA PR ANES GASTRIC RESTRICT MORBID OBESITY 21.00 CRNA PR ANES OPEN PROC UPPER 2/3 FEMUR 21.00 CRNA PR ANES AMPUTATION LEG ABOVE KNEE 21.00 CRNA PR ANES UPPER LEG SURG 21.00 CRNA PR ANES TIB/FIB/PATELLA OPEN PROCEDURE 21.00 CRNA PR ANES TOTAL KNEE ARTHROPLASTY 21.00 CRNA PR ANES ARTHROSCIC OPEN SHOULDER JOINT 21.00 CRNA PR ANES LOWER ARM SURGERY 21.00 CRNA PR INSERT NON TUNNEL CVCATH OVER 5 YRS 395.00 CRNA PR VENT MGMT INPAT SUBQ DAY 194.00 CRNA PR FLUOROSCOPIC GUIDE FOR NEEDLE PLACEMENT 508.00
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