Top 40 services provided by GOOD SAMARITAN HOSPITAL
Services CPT Price Est. Cash Price
MRI scan of the brain with and without contrast 70553 $5,500.00 $3,850.00
X-ray of the chest, 2 views 71046 $675.00 $472.50
X-ray of the lower spine with 4 or more views 72110 $860.00 $602.00
CT scan of the pelvis with contrast or dye 72193 $4,700.00 $3,290.00
CT scan of the abdomen with contrast or dye 74160 $4,700.00 $3,290.00
Ultrasound of the abdomen 76700 $2,050.00 $1,435.00
Ultrasound for pregnancy after 1st trimester or after 14 weeks for a single baby or first baby for multiples 76805 $2,050.00 $1,435.00
Mammogram of both breasts 77067 $647.00 $452.90
Basic Metabolic Panel 80048 $625.00 $437.50
Comprehensive Metabolic Panel 80053 $675.00 $472.50
Lipid Panel 80061 $195.00 $136.50
Urinalysis, by dipstick or tablet reagent not automated without a microscope 81001 $180.00 $126.00
Blood test that measures the amount of thyroid stimulating hormone (TSH). It helps determine how well your thyroid is functioning. 84443 $195.00 $136.50
Blood test used to test Troponin levels in the blood; generally used to diagnose heart attacks 84484 $187.00 $130.90
Complete blood cell count (red cells, white blood cell, platelets), automated test 85025 $309.00 $216.30
Blood test for the amount of time it takes to form clots; called a Prothrombin Time (PT) test. 85610 $121.00 $84.70
Routine electrocardiogram (EKG) with tracing using at least 12 leads 93005 $675.00 $472.50
Treatment to relieve airway obstruction or for sputum specimen; used to relieve conditions of COPD 94640 $349.00 $244.30
Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes 97110 $182.00 $127.40
Training for walking to 1 or more areas for 15 minutes 97116 $185.00 $129.50
Physical therapy evaluation session for 20 minutes 97161 $225.00 $157.50
Office visit for an established patient (moderate severity) typically 15 minutes 99213 $195.00 $136.50
Emergency department visit facility fees for a visit of moderate severity 99283 $642.00 $449.40
Emergency department visit facility fees for a visit of high to moderate severity 99284 $800.00 $560.00