Prices Posted and Effective on 12-30-2020

Southwest Health System - Price List for Shoppable Services

Prices Posted and Effective as of 12-30-2020

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
CT scanCPT 70450$954
CT scan of abdomen and pelvis with contrastCPT 74177$2,246
CT scan of pelvis with contrastCPT 72193$1,376
Ct angiography chestCPT 71275$1,798
Cancer Services
Chemo hormon antineopl sq/imCPT 96402$277
Clinic
Initial new patient preventative medicine evaluation (18-3...CPT 99385$199
Initial new patient preventative medicine evaluation (40-6...CPT 99386$221
New patient office or other outpatient visit, 30 minCPT 99203$158
New patient office or other outpatient visit, 45 minCPT 99204$255
New patient office or other outpatient visit, 60 minCPT 99205$278
Patient office consultation, 40 min (Not Offered)CPT 99243--
Patient office consultation, 60 min (Not Offered)CPT 99244--
EEG
Sleep studyCPT 95810$3,119
EKG
Ecg monit/reprt up to 48 hrsCPT 93225$326
Electrocardiogram tracingCPT 93005$330
Electrocardiogram, routine, with interpretation and reportCPT 93000$114
Emergency Room
Application long leg splintCPT 29505$335
Application lower leg splintCPT 29515$320
Application of finger splintCPT 29130$224
Application of forearm castCPT 29075$221
Application of paste bootCPT 29580$194
Apply forearm splintCPT 29125$224
Apply long arm splintCPT 29105$185
Apply short leg castCPT 29405$221
Control of nosebleedCPT 30901$206
Critical care addl 30 minCPT 99292$1,052
Critical care first hourCPT 99291$2,104
Deb subq tissue 20 sq cm/<CPT 11042$680
Debride nail 1-5CPT 11720$107
Debride nail 6 or moreCPT 11721$100
Drain/inj joint/bursa w/o usCPT 20610$355
Drain/inj joint/bursa w/o usCPT 20600$385
Drain/inj joint/bursa w/o usCPT 20605$463
Drainage of skin abscessCPT 10060$356
Emergency dept visitCPT 99283$538
Emergency dept visitCPT 99284$723
Emergency dept visitCPT 99285$1,230
Emergency dept visitCPT 99282$255
Emergency dept visitCPT 99281$205
Inj tendon sheath/ligamentCPT 20550$385
Insert emergency airwayCPT 31500$995
Insert temp bladder cathCPT 51702$146
Njx aa&/strd other pn/branchCPT 64450$442
Obstetrical careCPT 59409$3,269
Removal of nail bedCPT 11750$731
Removal/revision of castCPT 29705$221
Remove drug implant deviceCPT 11982$641
Remove impacted ear wax uniCPT 69209$121
Rpr f/e/e/n/l/m 2.6-5.0 cmCPT 12013$376
Rpr s/n/ax/gen/trnk2.6-7.5cmCPT 12002$376
Treat fracture radius/ulnaCPT 25605$1,941
Treat shoulder dislocationCPT 23650$663
Treat shoulder dislocationCPT 23655$2,363
IV Therapy
Hydrate iv infusion add-onCPT 96361$90
Hydration iv infusion initCPT 96360$458
Ther/diag concurrent infCPT 96368$77
Ther/proph/diag inj iv pushCPT 96374$191
Ther/proph/diag inj sc/imCPT 96372$83
Ther/proph/diag iv inf addonCPT 96366$117
Ther/proph/diag iv inf initCPT 96365$532
Tx/pro/dx inj new drug addonCPT 96375$117
Tx/pro/dx inj same drug adonCPT 96376$125
Tx/proph/dg addl seq iv infCPT 96367$179
Imaging
Abdomial ultrasound of pregnant uterusCPT 76805$486
Breast tomosynthesis biCPT 77063$136
Mammography of both breastsCPT 77066$361
Mammography of one breastCPT 77065$169
Mammography, screening, bilateralCPT 77067$286
Ultrasound breast completeCPT 76641$356
Ultrasound of abdomenCPT 76700$544
Ultrasound pelvis through vaginaCPT 76830$477
Us exam abdo back wall limCPT 76775$442
Inpatient Procedures
Cardiac valve or cardiothoracic procedure with cardiac cat... (Not Offered)DRG 216--
Cervical spinal fusion without CC or MCCDRG 473$14,575
Major joint replacement or reattachment of lower extremity...DRG 470$24,027
Spinal fusion except cervical without MCCDRG 460$13,271
Uterine and adnexa procedures for non-malignancy without C... (Not Offered)DRG 743--
Laboratory
Acute hepatitis panelCPT 80074$134
Alanine amino (alt) (sgpt)CPT 84460$59
Allg spec ige crude xtrc eaCPT 86003$11
Alpha-fetoprotein serumCPT 82105$62
Antinuclear antibodiesCPT 86038$59
Antinuclear antibodies (ana)CPT 86039$52
Assay dipropylacetic acd totCPT 80164$146
Assay for calprotectin fecalCPT 83993$259
Assay glucose blood quantCPT 82947$43
Assay iga/igd/igg/igm eachCPT 82784$29
Assay nephelometry not specCPT 83883$77
Assay of ammoniaCPT 82140$158
Assay of amylaseCPT 82150$70
Assay of biotinidaseCPT 82261$30
Assay of blood pkuCPT 84030$10
Assay of blood/uric acidCPT 84550$48
Assay of calciumCPT 82310$56
Assay of calcium in urineCPT 82340$20
Assay of ck (cpk)CPT 82550$21
Assay of creatinineCPT 82565$42
Assay of digoxin totalCPT 80162$25
Assay of estradiolCPT 82670$79
Assay of estriolCPT 82677$101
Assay of ferritinCPT 82728$66
Assay of folic acid rbcCPT 82747$62
Assay of folic acid serumCPT 82746$69
Assay of free testosteroneCPT 84402$81
Assay of free thyroxineCPT 84439$90
Assay of ggtCPT 82977$78
Assay of gonadotropin (fsh)CPT 83001$90
Assay of gonadotropin (lh)CPT 83002$90
Assay of homocystineCPT 83090$80
Assay of ironCPT 83540$70
Assay of lactic acidCPT 83605$15
Assay of lipaseCPT 83690$76
Assay of magnesiumCPT 83735$22
Assay of natriuretic peptideCPT 83880$193
Assay of neonatal thyroxineCPT 84437$11
Assay of parathormoneCPT 83970$93
Assay of phenytoin totalCPT 80185$144
Assay of phosphorusCPT 84100$50
Assay of progesteroneCPT 84144$112
Assay of progesterone 17-dCPT 83498$48
Assay of prolactinCPT 84146$92
Assay of protein serumCPT 84155$11
Assay of protein urineCPT 84156$17
Assay of serum albuminCPT 82040$54
Assay of serum potassiumCPT 84132$49
Assay of tacrolimusCPT 80197$90
Assay of total testosteroneCPT 84403$81
Assay of total thyroxineCPT 84436$75
Assay of triglyceridesCPT 84478$63
Assay of urea nitrogenCPT 84520$44
Assay of urine creatinineCPT 82570$15
Assay of urine sodiumCPT 84300$15
Assay of vancomycinCPT 80202$146
Assay of vitamin b-1CPT 84425$94
Assay of zincCPT 84630$48
Assay test for blood fecalCPT 82274$84
Assay triiodothyronine (t3)CPT 84480$67
Automated reticulocyte countCPT 85045$44
Basic metabolic panelCPT 80048$45
Bilirubin directCPT 82248$54
Bilirubin totalCPT 82247$54
Bilirubin total transcutCPT 88720$13
Bl smear w/diff wbc countCPT 85007$37
Bl smear w/o diff wbc countCPT 85008$27
Blood culture for bacteriaCPT 87040$111
Blood gases any combinationCPT 82803$159
Blood smear interpretationCPT 85060$13
Blood test, clotting timeCPT 85610$26
Blood test, comprehensive group of blood chemicalsCPT 80053$55
Blood test, lipidsCPT 80061$42
Blood test, thyroid stimulating hormone (TSH)CPT 84443$30
Blood typing serologic aboCPT 86900$151
Blood typing serologic rh(d)CPT 86901$34
Body fluid cell countCPT 89051$60
C-reactive proteinCPT 86140$56
C-reactive protein hsCPT 86141$35
Capillary blood drawCPT 36416$15
Carcinoembryonic antigenCPT 82378$90
Ccp antibodyCPT 86200$90
Cftr gene com variantsCPT 81220$795
Chorionic gonadotropin assayCPT 84703$76
Chorionic gonadotropin testCPT 84702$60
Chylmd trach dna amp probeCPT 87491$49
Clostridium ag iaCPT 87324$46
Coagulation assessment blood testCPT 85730$17
Compatibility test spinCPT 86920$186
Complement antigenCPT 86160$59
Complete blood cell count (CBC), automatedCPT 85027$31
Complete blood cell count (CBC), with differential white b...CPT 85025$36
Coombs test directCPT 86880$52
Culture aerobic identifyCPT 87077$34
Culture anaerobe ident eachCPT 87076$77
Culture othr specimn aerobicCPT 87070$94
Culture screen onlyCPT 87081$64
Cytomeg dna quantCPT 87497$165
Cytopath concentrate techCPT 88108$107
Detect agent nos dna quantCPT 87799$373
Drug screen quantalcoholsCPT 80320$55
Drug test def 1-7 classesHCPCS G0480$100
Drug test prsmv chem anlyzrCPT 80307$118
Drug test prsmv dir opt obsCPT 80305$134
Feces culture aerobic bactCPT 87045$103
Fibrin degradation quantCPT 85379$83
Free assay (ft-3)CPT 84481$81
Galactose transferase testCPT 82776$17
Giardia ag iaCPT 87329$131
Glucose blood testCPT 82962$25
Glucose testCPT 82950$50
Glycosylated hemoglobin testCPT 83036$106
H pylori (c-13) breathCPT 83013$131
HematocritCPT 85014$27
HemoglobinCPT 85018$27
Hemoglobin electrophoresisCPT 83020$23
Hep b core antibody totalCPT 86704$59
Hepatitis b surface ag iaCPT 87340$48
Hepatitis c ab testCPT 86803$67
Hepatitis c revrs trnscrpjCPT 87522$206
Heterophile antibody screenCPT 86308$56
Hiv-1 ag w/hiv-1 & hiv-2 abCPT 87389$76
Hpylori stool iaCPT 87338$131
Immunoassay infectious agentCPT 86317$50
Immunoassay nonantibodyCPT 83516$81
Immunoassay quant nos nonabCPT 83520$25
Immunoassay tumor ca 125CPT 86304$99
Immunoassay tumor ca 15-3CPT 86300$78
Immunoassay tumor ca 19-9CPT 86301$99
Immunofix e-phoresis serumCPT 86334$84
Immunohisto antb 1st stainCPT 88342$310
Influenza a/b ag iaCPT 87400$28
Inhibin aCPT 86336$50
Iron binding testCPT 83550$95
Kidney function panel testCPT 80069$95
Lactate (ld) (ldh) enzymeCPT 83615$66
Liver function blood testCPT 80076$67
Mass spectrometry qual/quanCPT 83789$34
Microbe susceptible enzymeCPT 87185$33
Microbe susceptible micCPT 87186$94
Microscopic exam of urineCPT 81015$31
Microsomal antibody eachCPT 86376$69
Mumps antibodyCPT 86735$50
Nuclear antigen antibodyCPT 86235$71
Obstetric blood test panelCPT 80055$220
Ova and parasites smearsCPT 87177$43
Protein e-phoresis serumCPT 84165$46
Psa screeningHCPCS G0103$124
Rbc antibody screenCPT 86850$78
Rbc sed rate automatedCPT 85652$30
Reagent strip/blood glucoseCPT 82948$12
Resp syncytial ag iaCPT 87420$131
Rheumatoid factor quantCPT 86431$15
Ria nonantibodyCPT 83519$229
Routine venipunctureCPT 36415$10
Rubella antibodyCPT 86762$46
Rubeola antibodyCPT 86765$52
Smear complex stainCPT 87209$39
Smear gram stainCPT 87205$47
Smear wet mount saline/inkCPT 87210$46
Special stains group 2CPT 88313$122
Stool cultr aerobic bact eaCPT 87046$45
Strep a assay w/opticCPT 87880$61
Surgical path grossCPT 88300$42
Syphilis test non-trep qualCPT 86592$19
Syphilis test non-trep quantCPT 86593$30
Tb test cell immun measureCPT 86480$230
Test for acetone/ketonesCPT 82009$48
Thyroglobulin antibodyCPT 86800$66
Tissue exam by pathologistCPT 88305$183
Tissue exam by pathologistCPT 88304$181
Total cortisolCPT 82533$50
Total prostate-specific antigen (PSA) testCPT 84153$54
Total prostate-specific antigen (PSA) testCPT 84154$54
Transferase (ast) (sgot)CPT 84450$56
Unlisted molecular pathologyCPT 81479$13
Ur albumin quantitativeCPT 82043$63
Urinalysis testCPT 81003$26
Urinalysis test (Not Offered)CPT 81002--
Urinalysis test using microscopeCPT 81001$50
Urinalysis test using microscope (Not Offered)CPT 81000--
Urine bacteria cultureCPT 87088$58
Urine pregnancy testCPT 81025$59
Varicella-zoster antibodyCPT 86787$61
Vitamin b-12CPT 82607$73
Vitamin d 25 hydroxyCPT 82306$215
Wbc antibody identificationCPT 86021$47
Withdrawal of arterial bloodCPT 36600$151
Language Pathology
Developmental screen w/scoreCPT 96110$20
Motion fluoroscopy/swallowCPT 92611$137
Speech/hearing therapyCPT 92507$122
MRI
MRI ScanCPT 70553$3,432
MRI scan of leg jointCPT 73721$2,255
MRI scan of lower spinal canalCPT 72148$1,890
Mri brain stem w/o dyeCPT 70551$2,391
Medical and Surgical Supplies
3DMAX MESH LEFT LIGHTHCPCS C1781$340
ALLOMATRIX INJECTABLE BONE PUTTY 3CCHCPCS C1713$934
Cath w/drainage 2-way silcneHCPCS A4315$36
Post chmbr intraocular lensHCPCS V2632$384
Nuclear Medicine
Tc99m disofeninHCPCS A9510$202
Tc99m tetrofosminHCPCS A9502$335
Other Diagnostic
Fetal non-stress testCPT 59025$368
Polysom 6/>yrs cpap 4/> parmCPT 95811$3,190
Sleep study unatt&resp efftCPT 95806$508
Other Procedures and Observation
Draw blood off venous deviceCPT 36591$78
Hospital observation per hrHCPCS G0378$45
Other Therapeutic
Blood transfusion serviceCPT 36430$1,098
Cardiac rehab/monitorCPT 93798$168
Diab manage trn per indivHCPCS G0108$40
Immunization admin each addCPT 90472$76
Immunotherapy injectionsCPT 95117$54
Immunotherapy one injectionCPT 95115$30
Irrig drug delivery deviceCPT 96523$118
Med nutrition indiv subseqCPT 97803$30
Medical nutrition indiv inCPT 97802$34
PhlebotomyCPT 99195$126
Rbc leukocytes reducedHCPCS P9016$302
Pharmacy
Abd paracentesis w/imagingCPT 49083$242
Hospital discharge dayCPT 99239$209
Hospital discharge dayCPT 99238$116
Initial hospital careCPT 99222$247
Initial hospital careCPT 99223$410
Initial hospital careCPT 99221$139
Initial observation careCPT 99219$308
Initial observation careCPT 99220$431
Inj trigger point 1/2 musclCPT 20552$71
Inject sacroiliac jointCPT 27096$125
Observation care dischargeCPT 99217$199
Office/outpatient visit estCPT 99213$90
Office/outpatient visit estCPT 99214$131
Office/outpatient visit estCPT 99212$68
Office/outpatient visit estCPT 99215$195
Office/outpatient visit newCPT 99202$113
Rpr f/e/e/n/l/m 2.5 cm/<CPT 12011$187
Rpr s/n/ax/gen/trnk 2.5cm/<CPT 12001$270
Strapping of shoulderCPT 29240$42
Subsequent hospital careCPT 99232$188
Subsequent hospital careCPT 99231$113
Subsequent hospital careCPT 99233$318
Subsequent observation careCPT 99225$143
Trim skin lesionCPT 11055$148
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
Breathing capacity testCPT 94010$166
Co/membane diffuse capacityCPT 94729$277
Evaluation of wheezingCPT 94060$463
Pulm function test by gasCPT 94727$277
Radiology
Fluoroscopy <1 hr phys/qhpCPT 76000$340
Needle localization by xrayCPT 77002$253
X-Ray of lower backCPT 72110$223
X-ray exam abdomen 1 viewCPT 74018$113
X-ray exam abdomen 2 viewsCPT 74019$153
X-ray exam chest 1 viewCPT 71045$87
X-ray exam chest 2 viewsCPT 71046$139
X-ray exam complete abdomenCPT 74022$197
X-ray exam hip uni 2-3 viewsCPT 73502$123
X-ray exam hip uni 4/> viewsCPT 73503$146
X-ray exam knee 4 or moreCPT 73564$162
X-ray exam l-s spine 2/3 vwsCPT 72100$162
X-ray exam l-s spine bendingCPT 72114$291
X-ray exam neck spine 2-3 vwCPT 72040$151
X-ray exam neck spine 4/5vwsCPT 72050$218
X-ray exam of ankleCPT 73610$94
X-ray exam of collar boneCPT 73000$115
X-ray exam of elbowCPT 73080$144
X-ray exam of elbowCPT 73070$113
X-ray exam of femur 2/>CPT 73552$104
X-ray exam of finger(s)CPT 73140$113
X-ray exam of footCPT 73630$88
X-ray exam of footCPT 73620$78
X-ray exam of forearmCPT 73090$115
X-ray exam of handCPT 73130$130
X-ray exam of handCPT 73120$113
X-ray exam of humerusCPT 73060$127
X-ray exam of knee 1 or 2CPT 73560$121
X-ray exam of knee 3CPT 73562$121
X-ray exam of kneesCPT 73565$109
X-ray exam of lower legCPT 73590$119
X-ray exam of pelvisCPT 72170$113
X-ray exam of shoulderCPT 73030$130
X-ray exam of toe(s)CPT 73660$85
X-ray exam of wristCPT 73110$139
X-ray exam of wristCPT 73100$119
X-ray exam ribs uni 2 viewsCPT 71100$139
X-ray exam sacrum tailboneCPT 72220$130
X-ray exam thorac spine 2vwsCPT 72070$144
X-ray exam unilat ribs/chestCPT 71101$167
Respiratory
Airway inhalation treatmentCPT 94640$268
Pos airway pressure cpapCPT 94660$316
Surgical Procedures
Biopsy exam of esophagus, stomach or small bowel using an ...CPT 43239$951
Biopsy exam of large bowel using an endoscopeCPT 45380$751
Biopsy of prostate gland (Not Offered)CPT 55700--
Circumcision w/regionl blockCPT 54150$2,439
Diagnostic exam of esophagus, stomach or small bowel using...CPT 43235$421
Diagnostic exam of large bowel using an endoscopeCPT 45378$1,056
Injection(s) of anesthetic into lower spine using imaging ...CPT 64483$1,234
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--
Nasal/orogastric w/tube plmtCPT 43752$129
Obstetric care, planned cesarean delivery (Not Offered)CPT 59510--
Obstetric care, planned vaginal deliveryCPT 59400$2,987
Obstetric care, planned vaginal delivery (post delivery by... (Not Offered)CPT 59610--
Removal of cataract with insertion of lensCPT 66984$1,181
Removal of gallbladder using an endoscopeCPT 47562$1,558
Removal of one knee cartilage using an endoscopeCPT 29881$6,141
Removal of one or more breast growth, open procedureCPT 19120$860
Removal of polyps or growths of large bowel using an endos...CPT 45385$1,418
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 olderCPT 49505$1,251
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
Elec stim other than woundHCPCS G0283$22
Gait training therapyCPT 97116$44
Group therapeutic proceduresCPT 97150$27
Manual therapy 1/> regionsCPT 97140$46
Neuromuscular reeducationCPT 97112$52
Ot eval low complex 30 minCPT 97165$132
Ot eval mod complex 45 minCPT 97166$132
Physical medicine procedureCPT 97139$14
Physical therapy, therapeutic exerciseCPT 97110$50
Pt eval low complex 20 minCPT 97161$117
Pt eval mod complex 30 minCPT 97162$117
Rmvl devital tis 20 cm/<CPT 97597$59
Self care mngment trainingCPT 97535$55
Therapeutic activitiesCPT 97530$55
Ultrasound therapyCPT 97035$20
Wound(s) care non-selectiveCPT 97602$25
Uncategorized
Als1-emergencyHCPCS A0427$1,268
Bls-emergencyHCPCS A0429$1,084
Ground mileageHCPCS A0425$27
Immunization adminCPT 90471$46
Trauma respons w/hosp critiHCPCS G0390$2,414
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