Patient Price Information List
In compliance with state law, Gov. Juan F. Luis 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. These prices are correct as of January 1, 2021.
Emergency Department Charge
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.
| DESCRIPTION |
CPT/HCPCS |
PRICE |
| Level-ED TRIAGE ONLY |
|
$85.00 |
| Level I ED |
99281 |
$131.41 |
| Level II ED |
99282 |
$244.46 |
| Level III ED |
99283 |
$428.81 |
| Level IV ED |
99284 |
$667.82 |
| Level V ED |
99285 |
$959.20 |
Labor and Delivery Charges
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.
| DESCRIPTION |
CPT/HCPCS |
PRICE |
| OB CARE ANTEPAR VAG DLVRY & POST PARTUM |
59400 |
$4,262.67 |
| OB CARE VAG DLVRY ONLY |
59409 |
$4,948.02 |
| OB ANTEPAR CARE CESAREAN DLVRY & POST PARTUM |
59510 |
$4,716.33 |
| CESAREAN DLVRY ONLY W/ POST PARTUM CARE |
59515 |
$2,316.95 |
Physical Therapy Charges
| DESCRIPTION |
CPT/HCPCS |
PRICE |
| Physical Therapy Evaluation Low Complex 20min |
97161 |
$473.10 |
| Physical Therapy Evaluation Moderate Complex 30min |
97162 |
$536.18 |
| Physical Therapy Evaluation High Complex 45min |
97163 |
$639.92 |
| Physical Therapy Re-Evaluation Est. Care 20min |
97164 |
$316.26 |
Pulmonary Therapy Charges
| DESCRIPTION |
CPT/HCPS |
PRICE |
| Exhaled Air Analysis |
94680 |
$254.50 |
| Airway Inhalation Treatment |
94640 |
$335.13 |
| Spirometry Up to 2 Years Old |
94011 |
$254.50 |
ESRD Dialysis CHARGES
| DESCRIPTION |
CPT/HCPCS |
PRICE |
| ESRD SRV 2-3 VISITS PMO 20+ |
90961 |
$798.00 |
| ESRD SRV 1 VISIT PMO 20+ |
90962 |
$950.00 |
| ESRD SRV 4 VISITS PMO 20+ |
90960 |
$950.00 |
| ESRD SRV PER DAY PT 20+ |
90970 |
$960.00 |
| UNLISTED DIALYSIS PROCEDURE |
90999 |
$375.00 |
Laboratory Charges
| DESCRIPTION |
CPT/HCPCS |
PRICE |
| Antibody ID, EA, RBC |
86850 |
$152.00 |
| Basic Metabolic Panel |
80048 |
$119.00 |
| Complete Blood Count |
85027 |
$89.00 |
| Glucose; Blood |
82947 |
$18.00 |
| Hemoglobin |
85018 |
$75.00 |
| Magnesium Level |
83735 |
$52.00 |
| Troponin Qual |
84484 |
$90.00 |
| Urinalysis |
81003 |
$72.00 |
Popular Surgery Charges
The following charges do not include fees for drugs, supplies, or additional ancillary procedures that may be required for a particular surgery treatment. They also do not include fees for physicians.
| DESCRIPTION |
CPT/HCPCS |
PRICE |
| Endo Cholangiopancreatograph |
43262 |
$5,706.21 |
| Colonoscopy w/Lesion Removal |
45385 |
$1,895.10 |
| EGD Bio Single/Multiple |
43261 |
$5,706.21 |
| ERCP Remove Duct Calculi |
43264 |
$5,706.21 |
| Carpel Tunnel Surg |
64721 |
$3,145.66 |
| Cystouretero w/ Lithotrispsy |
52353 |
$8,228.82 |
| ABD Paracentesis w/o Guidance |
49082 |
$1,444.65 |
| Artery-Vein Nonautograft |
36830 |
$8,994.58 |
| Laparoscopic Cholecystectomy |
47562 |
$2,875.00 |
| Laparoscopy Appendectomy |
44970 |
$9,121.27 |
