Prices Posted and Effective on 12-22-2020

Grace Cottage Hospital - Price List for Shoppable Services

Prices Posted and Effective as of 12-22-2020

Disclaimer: The Hospital determines its standard charges for patient items and services through the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient’s bill. These are the baseline rates for items and services provided at the Hospital. The chargemaster is similar in concept to the manufacturer’s suggested retail price (“MSRP”) on a particular product or good. The charges listed provide only a general starting point in determining the potential costs of an individual patient’s care at the Hospital. This list does not reflect the actual out-of-pocket costs that may be paid by a patient for any particular service, it is not binding, and the actual charges for items and services may vary. Individuals with questions about their out-of-pocket costs of service and other financial information should contact the hospital or consider contacting their insurers for further information. The cost of treatment also may be impacted by variables involved in a patient’s actual care, such as specific equipment or supplies required, the length of time spent in surgery or recovery, additional tests, or any changes in care or unexpected conditions or complications that arise.

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Service DescriptionService CodeCash PriceRates
Service DescriptionService CodeCash PriceRates
CT Scan
3d render w/intrp postprocesCPT 76376$334
CT scanCPT 70450$1,678
CT scan of abdomen and pelvis with contrastCPT 74177$3,338
CT scan of pelvis with contrastCPT 72193$2,171
Ct abd & pelv 1/> regnsCPT 74178$4,005
Ct abd & pelvis w/o contrastCPT 74176$2,742
Ct abdomen w/dyeCPT 74160$2,215
Ct abdomen w/o & w/dyeCPT 74170$2,330
Ct abdomen w/o dyeCPT 74150$1,923
Ct angio abd&pelv w/o&w/dyeCPT 74174$3,338
Ct angio abdominal arteriesCPT 75635$2,497
Ct angiography chestCPT 71275$2,885
Ct angiography headCPT 70496$2,407
Ct angiography neckCPT 70498$2,885
Ct chest spine w/o dyeCPT 72128$1,933
Ct head/brain w/o & w/dyeCPT 70470$2,326
Ct lower extremity w/o dyeCPT 73700$1,700
Ct lumbar spine w/dyeCPT 72132$2,307
Ct lumbar spine w/o dyeCPT 72131$1,933
Ct maxillofacial w/dyeCPT 70487$1,957
Ct maxillofacial w/o dyeCPT 70486$1,659
Ct neck spine w/o dyeCPT 72125$1,933
Ct pelvis w/o dyeCPT 72192$1,955
Ct soft tissue neck w/dyeCPT 70491$1,941
Ct thorax dx c+CPT 71260$2,314
Ct thorax dx c-CPT 71250$1,933
Ct thorax dx c-/c+CPT 71270$2,768
Ct upper extremity w/o dyeCPT 73200$1,702
Clinic
Advncd care plan 30 minCPT 99497$218
Application of paste bootCPT 29580$102
Behav chng smoking 3-10 minCPT 99406$28
Behavior counsel obesity 15mHCPCS G0447$43
Comm svcs by rhc/fqhc 5 minHCPCS G0071$37
Destruct b9 lesion 1-14CPT 17110$206
Developmental screen w/scoreCPT 96110$36
Dis site tele svcs rhc/fqhcHCPCS G2025$132
Domicil/r-home visit est patCPT 99335$182
Drain/inj joint/bursa w/o usCPT 20610$143
Home visit est patientCPT 99347$104
Immunotherapy one injectionCPT 95115$19
Init pm e/m new pat 1-4 yrsCPT 99382$343
Init pm e/m new pat infantCPT 99381$318
Initial new patient preventative medicine evaluation (18-3...CPT 99385$362
Initial new patient preventative medicine evaluation (40-6...CPT 99386$429
Inj tendon sheath/ligamentCPT 20550$106
Med nutrition indiv subseqCPT 97803$46
Medical nutrition indiv inCPT 97802$46
New patient office or other outpatient visit, 30 minCPT 99203$195
New patient office or other outpatient visit, 45 minCPT 99204$298
New patient office or other outpatient visit, 60 minCPT 99205$369
Observ/hosp same dateCPT 99234$249
Observation care dischargeCPT 99217$133
Obtaining screen pap smearHCPCS Q0091$73
Office o/p est low 20-29 minCPT 99213$130
Office o/p est minimal probCPT 99211$40
Office o/p est sf 10-19 minCPT 99212$81
Office o/p new sf 15-29 minCPT 99202$130
Patient office consultation, 40 minCPT 99243$224
Patient office consultation, 60 minCPT 99244$330
Per pm reeval est pat 65+ yrCPT 99397$362
Per pm reeval est pat infantCPT 99391$242
Phone e/m phys/qhp 21-30 minCPT 99443$138
Phone e/m phys/qhp 5-10 minCPT 99441$57
Ppps, subseq visitHCPCS G0439$362
Prev visit est age 1-4CPT 99392$271
Prev visit est age 12-17CPT 99394$294
Prev visit est age 18-39CPT 99395$298
Prev visit est age 40-64CPT 99396$330
Prev visit est age 5-11CPT 99393$271
Prev visit new age 5-11CPT 99383$334
Preventive counseling indivCPT 99402$169
Preventive counseling indivCPT 99401$84
Preventive counseling indivCPT 99403$234
Program intake assessmentHCPCS T1023$61
Psytx w pt w e/m 30 minCPT 90833$58
Psytx w pt w e/m 45 minCPT 90836$94
Punch bx skin single lesionCPT 11104$158
Remove impacted ear wax uniCPT 69209$36
Remove impacted ear wax uniCPT 69210$97
Tangntl bx skin single lesCPT 11102$126
Trans care mgmt 14 day dischCPT 99495$289
Trans care mgmt 7 day dischCPT 99496$396
Work related disability examCPT 99455$160
EEG
Sleep study (Not Offered)CPT 95810--
EKG
0298T Zio Patch- External electrocardiographic recording f...CPT 0298T$80
Electrocardiogram, routine, with interpretation and reportCPT 93000$270
Emergency Room
Critical care addl 30 minCPT 99292$582
Critical care first hourCPT 99291$1,355
Drain/inj joint/bursa w/o usCPT 20605$449
Emergency Room Visit - Level 1 (Facility Fee Only)CPT 99281$201
Emergency Room Visit - Level 2 (Facility Fee Only)CPT 99282$310
Emergency Room Visit - Level 3 (Facility Fee Only)CPT 99283$574
Emergency Room Visit - Level 4 (Facility Fee Only)CPT 99284$882
Emergency Room Visit - Level 5 (Facility Fee Only)CPT 99285$1,234
Rpr s/n/ax/gen/trnk2.6-7.5cmCPT 12002$320
Ther/diag concurrent infCPT 96368$42
IV Therapy
Hydrate iv infusion add-onCPT 96361$134
Hydration iv infusion initCPT 96360$140
Irrig drug delivery deviceCPT 96523$151
Ther/proph/diag inj iv pushCPT 96374$93
Ther/proph/diag iv inf addonCPT 96366$110
Ther/proph/diag iv inf initCPT 96365$224
Tx/pro/dx inj new drug addonCPT 96375$134
Tx/pro/dx inj same drug adonCPT 96376$134
Tx/proph/dg addl seq iv infCPT 96367$125
Imaging
Abdomial ultrasound of pregnant uterus (Not Offered)CPT 76805--
Echo exam of abdomenCPT 76705$530
Extremity studyCPT 93970$915
Mammography of both breasts (Not Offered)CPT 77066--
Mammography of one breast (Not Offered)CPT 77065--
Mammography, screening, bilateral (Not Offered)CPT 77067--
Ultrasound of abdomenCPT 76700$699
Ultrasound pelvis through vaginaCPT 76830$716
Us abdl aorta screen aaaCPT 76706$537
Us exam abdo back wall compCPT 76770$691
Us exam abdo back wall limCPT 76775$537
Us exam of head and neckCPT 76536$666
Us exam pelvic completeCPT 76856$507
Us exam pelvic limitedCPT 76857$480
Us exam scrotumCPT 76870$494
Us lmtd jt/nonvasc xtr struxCPT 76882$509
Inpatient Procedures
Cardiac valve or cardiothoracic procedure with cardiac cat... (Not Offered)DRG 216--
Cervical spinal fusion without CC or MCC (Not Offered)DRG 473--
Major joint replacement or reattachment of lower extremity... (Not Offered)DRG 470--
Spinal fusion except cervical without MCC (Not Offered)DRG 460--
Uterine and adnexa procedures for non-malignancy without C... (Not Offered)DRG 743--
Laboratory
Alanine amino (alt) (sgpt)CPT 84460$43
Allg spec ige crude xtrc eaCPT 86003$40
Antinuclear antibodiesCPT 86038$94
Aspergillus antibodyCPT 86606$132
Assay carbamazepine totalCPT 80156$106
Assay dipropylacetic acd totCPT 80164$106
Assay glucose blood quantCPT 82947$31
Assay iga/igd/igg/igm eachCPT 82784$115
Assay of ammoniaCPT 82140$108
Assay of amylaseCPT 82150$53
Assay of blood chlorideCPT 82435$31
Assay of blood/uric acidCPT 84550$40
Assay of c-peptideCPT 84681$197
Assay of calciumCPT 82310$34
Assay of calcium in urineCPT 82340$47
Assay of ck (cpk)CPT 82550$73
Assay of creatinineCPT 82565$31
Assay of digoxin totalCPT 80162$106
Assay of ferritinCPT 82728$86
Assay of folic acid serumCPT 82746$108
Assay of free thyroxineCPT 84439$84
Assay of ggtCPT 82977$58
Assay of gonadotropin (fsh)CPT 83001$228
Assay of gonadotropin (lh)CPT 83002$130
Assay of homocystineCPT 83090$210
Assay of insulinCPT 83525$106
Assay of ironCPT 83540$53
Assay of lactic acidCPT 83605$106
Assay of leadCPT 83655$94
Assay of lipaseCPT 83690$44
Assay of lithiumCPT 80178$66
Assay of magnesiumCPT 83735$66
Assay of natriuretic peptideCPT 83880$208
Assay of parathormoneCPT 83970$322
Assay of phenytoin totalCPT 80185$106
Assay of phosphorusCPT 84100$40
Assay of prealbuminCPT 84134$126
Assay of progesteroneCPT 84144$150
Assay of prolactinCPT 84146$164
Assay of protein serumCPT 84155$40
Assay of protein urineCPT 84156$40
Assay of serum albuminCPT 82040$31
Assay of serum potassiumCPT 84132$31
Assay of serum sodiumCPT 84295$43
Assay of total estradiolCPT 82670$228
Assay of total testosteroneCPT 84403$213
Assay of total thyroxineCPT 84436$66
Assay of transferrinCPT 84466$100
Assay of troponin quantCPT 84484$113
Assay of urea nitrogenCPT 84520$31
Assay of urine creatinineCPT 82570$49
Assay of urine osmolalityCPT 83935$68
Assay of urine sodiumCPT 84300$52
Assay of vancomycinCPT 80202$169
Assay of vitamin aCPT 84590$188
Assay of zincCPT 84630$126
Assay test for blood fecalCPT 82274$118
Assay triiodothyronine (t3)CPT 84480$125
Automated reticulocyte countCPT 85045$86
Basic metabolic panelCPT 80048$113
Bilirubin directCPT 82248$44
Bl smear w/diff wbc countCPT 85007$39
Blood culture for bacteriaCPT 87040$116
Blood gases any combinationCPT 82803$338
Blood test, clotting timeCPT 85610$47
Blood test, comprehensive group of blood chemicalsCPT 80053$129
Blood test, lipidsCPT 80061$108
Blood test, thyroid stimulating hormone (TSH)CPT 84443$148
Blood typing serologic aboCPT 86900$55
Blood typing serologic rh(d)CPT 86901$55
Body fluid cell countCPT 89050$64
C-reactive proteinCPT 86140$57
C-reactive protein hsCPT 86141$117
Carcinoembryonic antigenCPT 82378$134
Ccp antibodyCPT 86200$143
Chorionic gonadotropin assayCPT 84703$86
Chorionic gonadotropin testCPT 84702$212
Chylmd trach dna amp probeCPT 87491$124
Clostridium ag iaCPT 87324$102
Cmv antibodyCPT 86644$135
Cmv antibody igmCPT 86645$135
Coagulation assessment blood testCPT 85730$48
Compatibility test spinCPT 86920$80
Complement antigenCPT 86160$218
Complete blood cell count (CBC), automatedCPT 85027$62
Complete blood cell count (CBC), with differential white b...CPT 85025$60
Cov-19 amp prb hgh thruputHCPCS U0003$85
Cryptosporidium ag ifCPT 87272$150
Culture aerobic identifyCPT 87077$73
Culture othr specimn aerobicCPT 87070$100
Culture screen onlyCPT 87081$60
Cytopath c/v auto fluid redoCPT 88175$77
Detect agent nos dna ampCPT 87798$637
Drug test prsmv dir opt obsCPT 80305$18
Ehrlichia antibodyCPT 86666$180
Electrophoretic testCPT 82664$248
Epstein-barr capsid vcaCPT 86665$125
Epstein-barr nuclear antigenCPT 86664$169
Fibrin degradation quantCPT 85379$94
Free assay (ft-3)CPT 84481$157
Giardia ag ifCPT 87269$93
Glycosylated hemoglobin testCPT 83036$86
HematocritCPT 85014$28
HemoglobinCPT 85018$28
Hep b core antibody igmCPT 86705$96
Hep b surface antibodyCPT 86706$119
Hepatitis a antibodyCPT 86708$96
Hepatitis b surface ag iaCPT 87340$133
Hepatitis c ab testCPT 86803$155
Hepatitis c revrs trnscrpjCPT 87522$652
Herpes simplex type 1 testCPT 86695$106
Herpes simplex type 2 testCPT 86696$140
Heterophile antibody screenCPT 86308$50
Hiv-1/hiv-2 1 result antbdyCPT 86703$108
Hla ii typing 1 locus lrCPT 81376$167
Hpv high-risk typesCPT 87624$72
Hpylori stool ag iaCPT 87338$103
Hsv dna amp probeCPT 87529$48
Immunfix e-phorsis/urine/csfCPT 86335$206
Immunoassay nonantibodyCPT 83516$114
Immunoassay tumor ca 125CPT 86304$143
Immunoassay tumor ca 15-3CPT 86300$185
Immunoassay tumor ca 19-9CPT 86301$185
Immunofix e-phoresis serumCPT 86334$152
Influenza assay w/opticCPT 87804$93
Iron binding testCPT 83550$64
Kidney function panel testCPT 80069$129
Lactate (ld) (ldh) enzymeCPT 83615$66
Lactoferrin fecal (qual)CPT 83630$165
Liver function blood testCPT 80076$129
Lyme disease antibodyCPT 86618$118
Microbe susceptible diskCPT 87184$90
Microscopic exam of urineCPT 81015$44
Microsomal antibody eachCPT 86376$118
N.gonorrhoeae dna amp probCPT 87591$140
Nfct agent detection giCPT 87505$159
Nos each organism ag iaCPT 87449$102
Nuclear antigen antibodyCPT 86235$74
Obstetric blood test panel (Not Offered)CPT 80055--
Organic acid single quantCPT 83921$335
Protein e-phoresis serumCPT 84165$94
Protein e-phoresis/urine/csfCPT 84166$130
Protozoa antibody nosCPT 86753$180
Psa screeningHCPCS G0103$132
Rbc antibody screenCPT 86850$110
Rbc sed rate nonautomatedCPT 85651$44
Reagent strip/blood glucoseCPT 82948$32
Rheumatoid factor quantCPT 86431$65
Routine venipunctureCPT 36415$23
Rubella antibodyCPT 86762$136
Rubeola antibodyCPT 86765$135
Smear complex stainCPT 87209$146
Smear fluorescent/acid staiCPT 87206$53
Specimen collect covid-19HCPCS G2023$32
Specimen infect agnt concntjCPT 87015$90
Strep a assay w/opticCPT 87880$81
Tb intradermal testCPT 86580$39
Tb test cell immun measureCPT 86480$490
Thyroglobulin antibodyCPT 86800$102
Tissue exam by pathologistCPT 88305$53
Total cortisolCPT 82533$129
Total prostate-specific antigen (PSA) testCPT 84153$132
Total prostate-specific antigen (PSA) testCPT 84154$139
Transferase (ast) (sgot)CPT 84450$34
Treponema pallidumCPT 86780$96
Ur albumin quantitativeCPT 82043$51
Urinalysis testCPT 81003$30
Urinalysis test (Not Offered)CPT 81002--
Urinalysis test using microscopeCPT 81001$57
Urinalysis test using microscopeCPT 81000$57
Urine culture/colony countCPT 87086$62
Urine pregnancy testCPT 81025$22
Vaginitis Exam FAHCCPT 1-872$42
Varicella-zoster antibodyCPT 86787$128
Vitamin b-12CPT 82607$94
Vitamin d 25 hydroxyCPT 82306$238
MRI
MRI Scan (Not Offered)CPT 70553--
MRI scan of leg joint (Not Offered)CPT 73721--
MRI scan of lower spinal canal (Not Offered)CPT 72148--
Other Diagnostic
Extremity studyCPT 93971$832
Pure tone hearing test airCPT 92551$51
Other Procedures and Observation
Hospital observation per hrHCPCS G0378$66
Us urine capacity measureCPT 51798$90
Pharmacy
Methylprednisolone 80 mg injHCPCS J1040$47
Psychiatric
Family psychotherapy, including patient, 50 min (Not Offered)CPT 90847--
Family psychotherapy, not including patient, 50 min (Not Offered)CPT 90846--
Group psychotherapy (Not Offered)CPT 90853--
Psych diag eval w/med srvcsCPT 90792$292
Psychotherapy, 30 minCPT 90832$124
Psychotherapy, 45 minCPT 90834$162
Psychotherapy, 60 min (Not Offered)CPT 90837--
Radiology
Dxa bone density axialCPT 77080$484
X-Ray of lower backCPT 72110$435
X-ray exam abdomen 1 viewCPT 74018$234
X-ray exam abdomen 2 viewsCPT 74019$334
X-ray exam chest 1 viewCPT 71045$188
X-ray exam chest 2 viewsCPT 71046$282
X-ray exam complete abdomenCPT 74022$338
X-ray exam hip uni 2-3 viewsCPT 73502$310
X-ray exam hips bi 2 viewsCPT 73521$494
X-ray exam hips bi 3-4 viewsCPT 73522$520
X-ray exam knee 4 or moreCPT 73564$363
X-ray exam l-s spine 2/3 vwsCPT 72100$298
X-ray exam l-s spine bendingCPT 72114$428
X-ray exam neck spine 2-3 vwCPT 72040$266
X-ray exam neck spine 4/5vwsCPT 72050$274
X-ray exam of ankleCPT 73610$274
X-ray exam of ankleCPT 73600$257
X-ray exam of collar boneCPT 73000$256
X-ray exam of elbowCPT 73080$274
X-ray exam of elbowCPT 73070$237
X-ray exam of femur 2/>CPT 73552$274
X-ray exam of finger(s)CPT 73140$190
X-ray exam of footCPT 73630$274
X-ray exam of footCPT 73620$262
X-ray exam of forearmCPT 73090$198
X-ray exam of handCPT 73130$274
X-ray exam of handCPT 73120$266
X-ray exam of humerusCPT 73060$274
X-ray exam of knee 1 or 2CPT 73560$244
X-ray exam of kneesCPT 73565$150
X-ray exam of lower legCPT 73590$237
X-ray exam of neckCPT 70360$184
X-ray exam of pelvisCPT 72170$270
X-ray exam of pelvisCPT 72190$354
X-ray exam of shoulderCPT 73030$274
X-ray exam of toe(s)CPT 73660$194
X-ray exam of wristCPT 73110$256
X-ray exam of wristCPT 73100$246
X-ray exam ribs uni 2 viewsCPT 71100$274
X-ray exam sacrum tailboneCPT 72220$274
X-ray exam si joints 3/> vwsCPT 72202$354
X-ray exam thorac spine 2vwsCPT 72070$262
X-ray exam thorac spine 3vwsCPT 72072$354
X-ray exam thoracolmb 2/> vwCPT 72080$290
X-ray exam unilat ribs/chestCPT 71101$448
Surgical Procedures
Biopsy exam of esophagus, stomach or small bowel using an ... (Not Offered)CPT 43239--
Biopsy exam of large bowel using an endoscope (Not Offered)CPT 45380--
Biopsy of prostate gland (Not Offered)CPT 55700--
Diagnostic exam of esophagus, stomach or small bowel using... (Not Offered)CPT 43235--
Diagnostic exam of large bowel using an endoscope (Not Offered)CPT 45378--
Injection(s) of anesthetic into lower spine using imaging ... (Not Offered)CPT 64483--
Injection(s) of therapeutic substance (Not Offered)CPT 62322--
Injection(s) of therapeutic substance (Not Offered)CPT 62323--
Insertion of catheter into left heart for diagnosis (Not Offered)CPT 93452--
Obstetric care, planned cesarean delivery (Not Offered)CPT 59510--
Obstetric care, planned vaginal delivery (Not Offered)CPT 59400--
Obstetric care, planned vaginal delivery (post delivery by... (Not Offered)CPT 59610--
Removal of cataract with insertion of lens (Not Offered)CPT 66984--
Removal of gallbladder using an endoscope (Not Offered)CPT 47562--
Removal of one knee cartilage using an endoscope (Not Offered)CPT 29881--
Removal of one or more breast growth, open procedure (Not Offered)CPT 19120--
Removal of polyps or growths of large bowel using an endos... (Not Offered)CPT 45385--
Removal of recurring cataract in lens capsule using laser (Not Offered)CPT 66821--
Removal of tonsils and adenoid glands, patient younger tha... (Not Offered)CPT 42820--
Repair of groin hernia patient age 5 years or older (Not Offered)CPT 49505--
Shaving of shoulder bone using endoscope (Not Offered)CPT 29826--
Surgical removal of prostate and surrounding lymph nodes u... (Not Offered)CPT 55866--
Ultrasound examination of lower large bowel using an endos... (Not Offered)CPT 45391--
Therapy
Physical therapy, therapeutic exerciseCPT 97110$86
Uncategorized
Immunization adminCPT 90471$21
Immunization admin each addCPT 90472$30
Remove intrauterine deviceCPT 58301$174
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