Southeast Colorado Hospital District - Price List for Shoppable Services

Prices Posted and Effective as of 12-30-2020

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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.

Service Description	Service Code	Cash Price	Rates
CT Scan
CT scan	CPT 70450	$889
CT scan of abdomen and pelvis with contrast	CPT 74177	$1,453
CT scan of pelvis with contrast	CPT 72193	$1,038
Ct angiograph pelv w/o&w/dye	CPT 72191	$1,372
Ct head/brain w/dye	CPT 70460	$846
Cardiology
Doppler color flow add-on	CPT 93325	$113
Doppler echo exam heart	CPT 93321	$85
Stress tte complete	CPT 93351	$770
Tte w/doppler complete	CPT 93306	$765
Clinic
Initial new patient preventative medicine evaluation (18-3... (Not Offered)	CPT 99385	-	-
Initial new patient preventative medicine evaluation (40-6... (Not Offered)	CPT 99386	-	-
New patient office or other outpatient visit, 30 min	CPT 99203	$164
New patient office or other outpatient visit, 45 min	CPT 99204	$222
New patient office or other outpatient visit, 60 min	CPT 99205	$315
Patient office consultation, 40 min (Not Offered)	CPT 99243	-	-
Patient office consultation, 60 min (Not Offered)	CPT 99244	-	-
EEG
Sleep study	CPT 95810	$1,818
EKG
Ecg monit/reprt up to 48 hrs	CPT 93225	$262
Electrocardiogram tracing	CPT 93005	$132
Electrocardiogram, routine, with interpretation and report (Not Offered)	CPT 93000	-	-
Emergency Room
Application of long arm cast	CPT 29065	$184
Blood transfusion service	CPT 36430	$931
Remove foreign body from eye	CPT 65220	$291
Strep a ag ia	CPT 87430	$54
Ther/proph/diag inj iv push	CPT 96374	$147
Treat shoulder dislocation	CPT 23650	$518
Tx/pro/dx inj same drug adon	CPT 96376	$116
Tx/proph/dg addl seq iv inf	CPT 96367	$73
Wound closure by adhesive	HCPCS G0168	$76
Imaging
Abdomial ultrasound of pregnant uterus (Not Offered)	CPT 76805	-	-
Mammography of both breasts (Not Offered)	CPT 77066	-	-
Mammography of one breast (Not Offered)	CPT 77065	-	-
Mammography, screening, bilateral (Not Offered)	CPT 77067	-	-
Ob us follow-up per fetus	CPT 76816	$269
Ultrasound breast complete	CPT 76641	$422
Ultrasound of abdomen	CPT 76700	$607
Ultrasound pelvis through vagina	CPT 76830	$531
Us exam pelvic limited	CPT 76857	$269
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
Acute hepatitis panel	CPT 80074	$105
Alanine amino (alt) (sgpt)	CPT 84460	$81
Allg spec ige crude xtrc ea	CPT 86003	$18
Alpha-fetoprotein serum	CPT 82105	$146
Analgesics non-opioid 1 or 2	CPT 80329	$82
Androstanediol glucuronide	CPT 82154	$66
Antinuclear antibodies	CPT 86038	$58
Antistreptolysin o titer	CPT 86060	$49
Antithrombin iii activity	CPT 85300	$34
Assay activated protein c	CPT 85307	$114
Assay alkaline phosphatases	CPT 84080	$29
Assay bld/serum cholesterol	CPT 82465	$58
Assay glucose blood quant	CPT 82947	$58
Assay iga/igd/igg/igm each	CPT 82784	$37
Assay nephelometry not spec	CPT 83883	$168
Assay of acth	CPT 82024	$50
Assay of aldosterone	CPT 82088	$85
Assay of ammonia	CPT 82140	$28
Assay of amylase	CPT 82150	$96
Assay of blood/uric acid	CPT 84550	$28
Assay of c-peptide	CPT 84681	$277
Assay of calcium	CPT 82330	$78
Assay of calcium in urine	CPT 82340	$47
Assay of ceruloplasmin	CPT 82390	$43
Assay of ck (cpk)	CPT 82550	$81
Assay of copper	CPT 82525	$146
Assay of creatinine	CPT 82565	$48
Assay of digoxin total	CPT 80162	$62
Assay of erythropoietin	CPT 82668	$101
Assay of estrogen	CPT 82672	$199
Assay of ferritin	CPT 82728	$123
Assay of folic acid serum	CPT 82746	$53
Assay of free testosterone	CPT 84402	$206
Assay of free thyroxine	CPT 84439	$54
Assay of ggt	CPT 82977	$28
Assay of gonadotropin (fsh)	CPT 83001	$209
Assay of gonadotropin (lh)	CPT 83002	$275
Assay of insulin	CPT 83525	$46
Assay of iron	CPT 83540	$59
Assay of lactic acid	CPT 83605	$54
Assay of lipase	CPT 83690	$96
Assay of lithium	CPT 80178	$36
Assay of magnesium	CPT 83735	$28
Assay of metanephrines	CPT 83835	$205
Assay of parathormone	CPT 83970	$74
Assay of phenytoin total	CPT 80185	$43
Assay of phosphorus	CPT 84100	$81
Assay of prealbumin	CPT 84134	$151
Assay of progesterone	CPT 84144	$62
Assay of proinsulin	CPT 84206	$342
Assay of prolactin	CPT 84146	$88
Assay of protein serum	CPT 84155	$71
Assay of protein urine	CPT 84156	$24
Assay of renin	CPT 84244	$83
Assay of serum albumin	CPT 82040	$36
Assay of serum potassium	CPT 84132	$81
Assay of sex hormone globul	CPT 84270	$147
Assay of sirolimus	CPT 80195	$130
Assay of tacrolimus	CPT 80197	$173
Assay of thyroglobulin	CPT 84432	$53
Assay of total estradiol	CPT 82670	$157
Assay of total testosterone	CPT 84403	$214
Assay of total thyroxine	CPT 84436	$86
Assay of troponin quant	CPT 84484	$79
Assay of urine creatinine	CPT 82570	$48
Assay of urine osmolality	CPT 83935	$48
Assay of urine potassium	CPT 84133	$28
Assay of urine sodium	CPT 84300	$48
Assay of vancomycin	CPT 80202	$50
Assay of vitamin a	CPT 84590	$47
Assay of zinc	CPT 84630	$113
Assay synovial fluid mucin	CPT 83872	$20
Assay test for blood fecal	CPT 82274	$45
Assay triiodothyronine (t3)	CPT 84480	$57
Automated reticulocyte count	CPT 85045	$24
Basic metabolic panel	CPT 80048	$179
Benzodiazepines1-12	CPT 80346	$161
Bilirubin direct	CPT 82248	$67
Bilirubin total	CPT 82247	$77
Blood culture for bacteria	CPT 87040	$62
Blood gases any combination	CPT 82803	$212
Blood smear interpretation	CPT 85060	$36
Blood test, clotting time	CPT 85610	$61
Blood test, comprehensive group of blood chemicals	CPT 80053	$334
Blood test, lipids	CPT 80061	$163
Blood test, thyroid stimulating hormone (TSH)	CPT 84443	$53
Blood typing serologic abo	CPT 86900	$51
Blood typing serologic rh(d)	CPT 86901	$39
Body fluid cell count	CPT 89051	$27
C diff amplified probe	CPT 87493	$238
C-reactive protein	CPT 86140	$60
Calculus spectroscopy	CPT 82365	$142
Capillary blood draw	CPT 36416	$34
Carcinoembryonic antigen	CPT 82378	$210
Ccp antibody	CPT 86200	$254
Chorionic gonadotropin assay	CPT 84703	$62
Chorionic gonadotropin test	CPT 84702	$62
Chylmd trach dna amp probe	CPT 87491	$106
Clot inhibit prot c activity	CPT 85303	$58
Clot inhibit prot s free	CPT 85306	$243
Coagulation assessment blood test	CPT 85730	$75
Col chromotography qual/quan	CPT 82542	$34
Collagen crosslinks	CPT 82523	$244
Collect blood from picc	CPT 36592	$87
Compatibility test antiglob	CPT 86922	$34
Compatibility test spin	CPT 86920	$67
Complete blood cell count (CBC), automated (Not Offered)	CPT 85027	-	-
Complete blood cell count (CBC), with differential white b...	CPT 85025	$96
Creatine mb fraction	CPT 82553	$128
Creatinine clearance test	CPT 82575	$137
Cultr bacteria except blood	CPT 87075	$58
Culture aerobic identify	CPT 87077	$86
Culture anaerobe ident each	CPT 87076	$86
Culture othr specimn aerobic	CPT 87070	$306
Culture screen only	CPT 87081	$174
Culture type immunologic	CPT 87147	$46
Cytogenetics dna probe	CPT 88271	$178
Cytomeg dna quant	CPT 87497	$255
Detect agent nos dna amp	CPT 87798	$156
Dna antibody native	CPT 86225	$48
Dna/rna amplified probe	CPT 87150	$37
Draw blood off venous device	CPT 36591	$87
Drug screen quantalcohols	CPT 80320	$200
Drug screening barbiturates	CPT 80345	$66
Drug screening buprenorphine	CPT 80348	$66
Drug screening cocaine	CPT 80353	$34
Drug scrn quan levetiracetam	CPT 80177	$154
Drug test prsmv chem anlyzr	CPT 80307	$319
Drug test prsmv dir opt obs	CPT 80305	$47
Epstein-barr capsid vca	CPT 86665	$66
Epstein-barr nuclear antigen	CPT 86664	$66
Exam synovial fluid crystals	CPT 89060	$58
F5 gene	CPT 81241	$218
Feces culture aerobic bact	CPT 87045	$23
Fibrin degradation quant	CPT 85379	$140
Genotype dna hiv reverse t	CPT 87901	$250
Genotype dna/rna hep c	CPT 87902	$302
Giardia ag ia	CPT 87329	$86
Glucose blood test	CPT 82962	$8
Glucose test	CPT 82950	$116
Glycosylated hemoglobin test	CPT 83036	$54
H pylori (c-13) breath	CPT 83013	$238
Helicobacter pylori antibody	CPT 86677	$79
Hemoglobin	CPT 85018	$8
Hep b core antibody total	CPT 86704	$51
Hep b surface antibody	CPT 86706	$49
Hepatitis a antibody	CPT 86708	$50
Hepatitis b surface ag ia	CPT 87340	$39
Hepatitis c ab test	CPT 86803	$49
Hepatitis c revrs trnscrpj	CPT 87522	$470
Herpes simplex type 1 test	CPT 86695	$30
Herpes simplex type 2 test	CPT 86696	$30
Heterophile antibody screen	CPT 86308	$49
Heterophile antibody titer	CPT 86309	$45
Hfe gene	CPT 81256	$322
Hiv-1 ag w/hiv-1&2 ab ag ia	CPT 87389	$94
Hiv-1 quant&revrse trnscrpj	CPT 87536	$280
Hla typing a b or c	CPT 86812	$61
Hpylori stool ag ia	CPT 87338	$69
Immunoassay infectious agent	CPT 86317	$22
Immunoassay nonantibody	CPT 83516	$179
Immunoassay tumor ca 125	CPT 86304	$148
Immunoassay tumor ca 15-3	CPT 86300	$133
Immunofix e-phoresis serum	CPT 86334	$38
Immunohisto antb 1st stain	CPT 88342	$235
Immunohisto antb addl slide	CPT 88341	$164
Influenza assay w/optic	CPT 87804	$46
Iron binding test	CPT 83550	$66
Jak2 gene	CPT 81270	$691
Kidney function panel test	CPT 80069	$139
Lactate (ld) (ldh) enzyme	CPT 83615	$230
Leukocyte assessment fecal	CPT 89055	$57
Liver function blood test	CPT 80076	$196
Mass spectrometry qual/quan	CPT 83789	$66
Microbe susceptible enzyme	CPT 87185	$57
Microbe susceptible mic	CPT 87186	$98
Microsomal antibody each	CPT 86376	$132
Mycoplasma antibody	CPT 86738	$45
N.gonorrhoeae dna amp prob	CPT 87591	$106
Nos each organism ag ia	CPT 87449	$46
Nuclear antigen antibody	CPT 86235	$47
Obstetric blood test panel (Not Offered)	CPT 80055	-	-
Opioids & opiate analogs 3/4	CPT 80363	$66
Ova and parasites smears	CPT 87177	$72
Particle agglut antbdy scrn	CPT 86403	$148
Phenotype infect agent drug	CPT 87900	$136
Procalcitonin (pct)	CPT 84145	$368
Protein e-phoresis serum	CPT 84165	$58
Q fever antibody	CPT 86638	$98
Quantitative assay drug	CPT 80299	$441
Rbc antibody screen	CPT 86850	$74
Rbc sed rate automated	CPT 85652	$67
Resp virus 12-25 targets	CPT 87633	$473
Respiratory virus antibody	CPT 86756	$101
Rheumatoid factor quant	CPT 86431	$51
Ria nonantibody	CPT 83519	$104
Rubella antibody	CPT 86762	$53
Rubeola antibody	CPT 86765	$49
Shiga-like toxin ag ia	CPT 87427	$28
Smear complex stain	CPT 87209	$286
Smear gram stain	CPT 87205	$205
Smear wet mount saline/ink	CPT 87210	$52
Special stains group 1	CPT 88312	$258
Stool cultr aerobic bact ea	CPT 87046	$23
Strep a dna amp probe	CPT 87651	$53
Syphilis test non-trep qual	CPT 86592	$52
T cell absolute count	CPT 86361	$86
Tb test cell immun measure	CPT 86480	$142
Test for acetone/ketones	CPT 82009	$46
Thyroglobulin antibody	CPT 86800	$53
Tissue exam by pathologist	CPT 88305	$175
Tissue exam by pathologist	CPT 88304	$139
Total cortisol	CPT 82533	$74
Total prostate-specific antigen (PSA) test	CPT 84153	$66
Total prostate-specific antigen (PSA) test	CPT 84154	$66
Transferase (ast) (sgot)	CPT 84450	$81
Ur albumin quantitative	CPT 82043	$40
Urinalysis test	CPT 81003	$43
Urinalysis test	CPT 81002	$25
Urinalysis test using microscope	CPT 81001	$58
Urinalysis test using microscope (Not Offered)	CPT 81000	-	-
Urinalysis volume measure	CPT 81050	$33
Urine culture/colony count	CPT 87086	$78
Urine pregnancy test	CPT 81025	$56
Varicella-zoster antibody	CPT 86787	$60
Vit d 1 25-dihydroxy	CPT 82652	$98
Vitamin b-12	CPT 82607	$53
Vitamin d 25 hydroxy	CPT 82306	$102
Wbc antibody identification	CPT 86021	$86
Withdrawal of arterial blood	CPT 36600	$87
Language Pathology
Evaluate swallowing function	CPT 92610	$319
Oral function therapy	CPT 92526	$126
Speech sound lang comprehen	CPT 92523	$307
Speech/hearing therapy	CPT 92507	$101
MRI
MRI Scan	CPT 70553	$1,525
MRI scan of leg joint	CPT 73721	$2,085
MRI scan of lower spinal canal	CPT 72148	$2,085
Mri pelvis w/o & w/dye	CPT 72197	$1,730
Medical and Surgical Supplies
Cast sup shrt leg fiberglass	HCPCS Q4038	$238
Other Procedures and Observation
Hospital observation per hr	HCPCS G0378	$49
Hydration iv infusion init	CPT 96360	$160
Ther/proph/diag inj sc/im	CPT 96372	$98
Ther/proph/diag iv inf addon	CPT 96366	$71
Other Therapeutic
Cardiac rehab/monitor	CPT 93798	$88
Medical nutrition indiv in	CPT 97802	$84
Peripheral vascular rehab	CPT 93668	$88
Phlebotomy	CPT 99195	$154
Pulmonary rehab w exer	HCPCS G0424	$132
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	-	-
Psychotherapy, 30 min (Not Offered)	CPT 90832	-	-
Psychotherapy, 45 min (Not Offered)	CPT 90834	-	-
Psychotherapy, 60 min (Not Offered)	CPT 90837	-	-
Pulmonary Function
Evaluation of wheezing	CPT 94060	$607
Measure blood oxygen level	CPT 94762	$222
Measure blood oxygen level	CPT 94761	$160
Measure blood oxygen level	CPT 94760	$77
Radiology
X-Ray of lower back	CPT 72110	$263
X-ray exam of heel	CPT 73650	$192
X-ray exam of jaw <4views	CPT 70100	$192
X-ray exam of nasal bones	CPT 70160	$192
X-ray exam of pelvis	CPT 72190	$262
X-ray exam of sinuses	CPT 70210	$192
Respiratory
Airway inhalation treatment	CPT 94640	$147
Cbt 1st hour	CPT 94644	$174
Chest wall manipulation	CPT 94668	$174
Chest wall manipulation	CPT 94667	$174
Evaluate pt use of inhaler	CPT 94664	$147
Mechanical chest wall oscill	CPT 94669	$147
Pos airway pressure cpap	CPT 94660	$294
Vent mgmt inpat subq day	CPT 94003	$372
Surgical Procedures
Biopsy exam of esophagus, stomach or small bowel using an ...	CPT 43239	$522
Biopsy exam of large bowel using an endoscope	CPT 45380	$1,607
Biopsy of prostate gland (Not Offered)	CPT 55700	-	-
Diagnostic exam of esophagus, stomach or small bowel using...	CPT 43235	$460
Diagnostic exam of large bowel using an endoscope	CPT 45378	$1,528
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	-	-
Mod sed oth phys/qhp <5 yrs	CPT 99155	$133
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	CPT 49505	$2,566
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
Apply multlay comprs lwr leg	CPT 29581	$107
Community/work reintegration	CPT 97537	$82
Elec stim other than wound	HCPCS G0283	$50
Electric stimulation therapy	CPT 97014	$74
Electrical stimulation	CPT 97032	$37
Gait training therapy	CPT 97116	$75
Manual therapy 1/> regions	CPT 97140	$76
Mechanical traction therapy	CPT 97012	$38
Neg press wnd tx <=50 sq cm	CPT 97607	$56
Neg press wound tx <=50 cm	CPT 97605	$65
Neg press wound tx >50 cm	CPT 97606	$70
Neuromuscular reeducation	CPT 97112	$88
Orthc/prostc mgmt sbsq enc	CPT 97763	$133
Orthotic mgmt&traing 1st enc	CPT 97760	$124
Ot eval high complex 60 min	CPT 97167	$271
Ot eval low complex 30 min	CPT 97165	$181
Ot eval mod complex 45 min	CPT 97166	$226
Paraffin bath therapy	CPT 97018	$15
Physical performance test	CPT 97750	$87
Physical therapy, therapeutic exercise	CPT 97110	$101
Pt eval high complex 45 min	CPT 97163	$256
Pt eval low complex 20 min	CPT 97161	$171
Pt eval mod complex 30 min	CPT 97162	$214
Pt re-eval est plan care	CPT 97164	$147
Rmvl devital tis 20 cm/<	CPT 97597	$91
Rmvl devital tis addl 20cm/<	CPT 97598	$64
Self care mngment training	CPT 97535	$86
Therapeutic activities	CPT 97530	$82
Ultrasound therapy	CPT 97035	$36
Vasopneumatic device therapy	CPT 97016	$30
Wheelchair mngment training	CPT 97542	$82
Wound(s) care non-selective	CPT 97602	$141
Uncategorized
Apply rigid leg cast	CPT 29445	$258
Bls-emergency	HCPCS A0429	$903
Cmplx rpr f/c/c/m/n/ax/g/h/f	CPT 13132	$643
Colon ca scrn not hi rsk ind	HCPCS G0121	$304
Ground mileage	HCPCS A0425	$19
Insert drug implant device	CPT 11981	$104
Treat fracture radius/ulna	CPT 25605	$687