Southwest Health System - 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	$954
CT scan of abdomen and pelvis with contrast	CPT 74177	$2,246
CT scan of pelvis with contrast	CPT 72193	$1,376
Ct angiography chest	CPT 71275	$1,798
Cancer Services
Chemo hormon antineopl sq/im	CPT 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 min	CPT 99203	$158
New patient office or other outpatient visit, 45 min	CPT 99204	$255
New patient office or other outpatient visit, 60 min	CPT 99205	$278
Patient office consultation, 40 min (Not Offered)	CPT 99243	-	-
Patient office consultation, 60 min (Not Offered)	CPT 99244	-	-
EEG
Sleep study	CPT 95810	$3,119
EKG
Ecg monit/reprt up to 48 hrs	CPT 93225	$326
Electrocardiogram tracing	CPT 93005	$330
Electrocardiogram, routine, with interpretation and report	CPT 93000	$114
Emergency Room
Application long leg splint	CPT 29505	$335
Application lower leg splint	CPT 29515	$320
Application of finger splint	CPT 29130	$224
Application of forearm cast	CPT 29075	$221
Application of paste boot	CPT 29580	$194
Apply forearm splint	CPT 29125	$224
Apply long arm splint	CPT 29105	$185
Apply short leg cast	CPT 29405	$221
Control of nosebleed	CPT 30901	$206
Critical care addl 30 min	CPT 99292	$1,052
Critical care first hour	CPT 99291	$2,104
Deb subq tissue 20 sq cm/<	CPT 11042	$680
Debride nail 1-5	CPT 11720	$107
Debride nail 6 or more	CPT 11721	$100
Drain/inj joint/bursa w/o us	CPT 20610	$355
Drain/inj joint/bursa w/o us	CPT 20600	$385
Drain/inj joint/bursa w/o us	CPT 20605	$463
Drainage of skin abscess	CPT 10060	$356
Emergency dept visit	CPT 99283	$538
Emergency dept visit	CPT 99284	$723
Emergency dept visit	CPT 99285	$1,230
Emergency dept visit	CPT 99282	$255
Emergency dept visit	CPT 99281	$205
Inj tendon sheath/ligament	CPT 20550	$385
Insert emergency airway	CPT 31500	$995
Insert temp bladder cath	CPT 51702	$146
Njx aa&/strd other pn/branch	CPT 64450	$442
Obstetrical care	CPT 59409	$3,269
Removal of nail bed	CPT 11750	$731
Removal/revision of cast	CPT 29705	$221
Remove drug implant device	CPT 11982	$641
Remove impacted ear wax uni	CPT 69209	$121
Rpr f/e/e/n/l/m 2.6-5.0 cm	CPT 12013	$376
Rpr s/n/ax/gen/trnk2.6-7.5cm	CPT 12002	$376
Treat fracture radius/ulna	CPT 25605	$1,941
Treat shoulder dislocation	CPT 23650	$663
Treat shoulder dislocation	CPT 23655	$2,363
IV Therapy
Hydrate iv infusion add-on	CPT 96361	$90
Hydration iv infusion init	CPT 96360	$458
Ther/diag concurrent inf	CPT 96368	$77
Ther/proph/diag inj iv push	CPT 96374	$191
Ther/proph/diag inj sc/im	CPT 96372	$83
Ther/proph/diag iv inf addon	CPT 96366	$117
Ther/proph/diag iv inf init	CPT 96365	$532
Tx/pro/dx inj new drug addon	CPT 96375	$117
Tx/pro/dx inj same drug adon	CPT 96376	$125
Tx/proph/dg addl seq iv inf	CPT 96367	$179
Imaging
Abdomial ultrasound of pregnant uterus	CPT 76805	$486
Breast tomosynthesis bi	CPT 77063	$136
Mammography of both breasts	CPT 77066	$361
Mammography of one breast	CPT 77065	$169
Mammography, screening, bilateral	CPT 77067	$286
Ultrasound breast complete	CPT 76641	$356
Ultrasound of abdomen	CPT 76700	$544
Ultrasound pelvis through vagina	CPT 76830	$477
Us exam abdo back wall lim	CPT 76775	$442
Inpatient Procedures
Cardiac valve or cardiothoracic procedure with cardiac cat... (Not Offered)	DRG 216	-	-
Cervical spinal fusion without CC or MCC	DRG 473	$14,575
Major joint replacement or reattachment of lower extremity...	DRG 470	$24,027
Spinal fusion except cervical without MCC	DRG 460	$13,271
Uterine and adnexa procedures for non-malignancy without C... (Not Offered)	DRG 743	-	-
Laboratory
Acute hepatitis panel	CPT 80074	$134
Alanine amino (alt) (sgpt)	CPT 84460	$59
Allg spec ige crude xtrc ea	CPT 86003	$11
Alpha-fetoprotein serum	CPT 82105	$62
Antinuclear antibodies	CPT 86038	$59
Antinuclear antibodies (ana)	CPT 86039	$52
Assay dipropylacetic acd tot	CPT 80164	$146
Assay for calprotectin fecal	CPT 83993	$259
Assay glucose blood quant	CPT 82947	$43
Assay iga/igd/igg/igm each	CPT 82784	$29
Assay nephelometry not spec	CPT 83883	$77
Assay of ammonia	CPT 82140	$158
Assay of amylase	CPT 82150	$70
Assay of biotinidase	CPT 82261	$30
Assay of blood pku	CPT 84030	$10
Assay of blood/uric acid	CPT 84550	$48
Assay of calcium	CPT 82310	$56
Assay of calcium in urine	CPT 82340	$20
Assay of ck (cpk)	CPT 82550	$21
Assay of creatinine	CPT 82565	$42
Assay of digoxin total	CPT 80162	$25
Assay of estradiol	CPT 82670	$79
Assay of estriol	CPT 82677	$101
Assay of ferritin	CPT 82728	$66
Assay of folic acid rbc	CPT 82747	$62
Assay of folic acid serum	CPT 82746	$69
Assay of free testosterone	CPT 84402	$81
Assay of free thyroxine	CPT 84439	$90
Assay of ggt	CPT 82977	$78
Assay of gonadotropin (fsh)	CPT 83001	$90
Assay of gonadotropin (lh)	CPT 83002	$90
Assay of homocystine	CPT 83090	$80
Assay of iron	CPT 83540	$70
Assay of lactic acid	CPT 83605	$15
Assay of lipase	CPT 83690	$76
Assay of magnesium	CPT 83735	$22
Assay of natriuretic peptide	CPT 83880	$193
Assay of neonatal thyroxine	CPT 84437	$11
Assay of parathormone	CPT 83970	$93
Assay of phenytoin total	CPT 80185	$144
Assay of phosphorus	CPT 84100	$50
Assay of progesterone	CPT 84144	$112
Assay of progesterone 17-d	CPT 83498	$48
Assay of prolactin	CPT 84146	$92
Assay of protein serum	CPT 84155	$11
Assay of protein urine	CPT 84156	$17
Assay of serum albumin	CPT 82040	$54
Assay of serum potassium	CPT 84132	$49
Assay of tacrolimus	CPT 80197	$90
Assay of total testosterone	CPT 84403	$81
Assay of total thyroxine	CPT 84436	$75
Assay of triglycerides	CPT 84478	$63
Assay of urea nitrogen	CPT 84520	$44
Assay of urine creatinine	CPT 82570	$15
Assay of urine sodium	CPT 84300	$15
Assay of vancomycin	CPT 80202	$146
Assay of vitamin b-1	CPT 84425	$94
Assay of zinc	CPT 84630	$48
Assay test for blood fecal	CPT 82274	$84
Assay triiodothyronine (t3)	CPT 84480	$67
Automated reticulocyte count	CPT 85045	$44
Basic metabolic panel	CPT 80048	$45
Bilirubin direct	CPT 82248	$54
Bilirubin total	CPT 82247	$54
Bilirubin total transcut	CPT 88720	$13
Bl smear w/diff wbc count	CPT 85007	$37
Bl smear w/o diff wbc count	CPT 85008	$27
Blood culture for bacteria	CPT 87040	$111
Blood gases any combination	CPT 82803	$159
Blood smear interpretation	CPT 85060	$13
Blood test, clotting time	CPT 85610	$26
Blood test, comprehensive group of blood chemicals	CPT 80053	$55
Blood test, lipids	CPT 80061	$42
Blood test, thyroid stimulating hormone (TSH)	CPT 84443	$30
Blood typing serologic abo	CPT 86900	$151
Blood typing serologic rh(d)	CPT 86901	$34
Body fluid cell count	CPT 89051	$60
C-reactive protein	CPT 86140	$56
C-reactive protein hs	CPT 86141	$35
Capillary blood draw	CPT 36416	$15
Carcinoembryonic antigen	CPT 82378	$90
Ccp antibody	CPT 86200	$90
Cftr gene com variants	CPT 81220	$795
Chorionic gonadotropin assay	CPT 84703	$76
Chorionic gonadotropin test	CPT 84702	$60
Chylmd trach dna amp probe	CPT 87491	$49
Clostridium ag ia	CPT 87324	$46
Coagulation assessment blood test	CPT 85730	$17
Compatibility test spin	CPT 86920	$186
Complement antigen	CPT 86160	$59
Complete blood cell count (CBC), automated	CPT 85027	$31
Complete blood cell count (CBC), with differential white b...	CPT 85025	$36
Coombs test direct	CPT 86880	$52
Culture aerobic identify	CPT 87077	$34
Culture anaerobe ident each	CPT 87076	$77
Culture othr specimn aerobic	CPT 87070	$94
Culture screen only	CPT 87081	$64
Cytomeg dna quant	CPT 87497	$165
Cytopath concentrate tech	CPT 88108	$107
Detect agent nos dna quant	CPT 87799	$373
Drug screen quantalcohols	CPT 80320	$55
Drug test def 1-7 classes	HCPCS G0480	$100
Drug test prsmv chem anlyzr	CPT 80307	$118
Drug test prsmv dir opt obs	CPT 80305	$134
Feces culture aerobic bact	CPT 87045	$103
Fibrin degradation quant	CPT 85379	$83
Free assay (ft-3)	CPT 84481	$81
Galactose transferase test	CPT 82776	$17
Giardia ag ia	CPT 87329	$131
Glucose blood test	CPT 82962	$25
Glucose test	CPT 82950	$50
Glycosylated hemoglobin test	CPT 83036	$106
H pylori (c-13) breath	CPT 83013	$131
Hematocrit	CPT 85014	$27
Hemoglobin	CPT 85018	$27
Hemoglobin electrophoresis	CPT 83020	$23
Hep b core antibody total	CPT 86704	$59
Hepatitis b surface ag ia	CPT 87340	$48
Hepatitis c ab test	CPT 86803	$67
Hepatitis c revrs trnscrpj	CPT 87522	$206
Heterophile antibody screen	CPT 86308	$56
Hiv-1 ag w/hiv-1 & hiv-2 ab	CPT 87389	$76
Hpylori stool ia	CPT 87338	$131
Immunoassay infectious agent	CPT 86317	$50
Immunoassay nonantibody	CPT 83516	$81
Immunoassay quant nos nonab	CPT 83520	$25
Immunoassay tumor ca 125	CPT 86304	$99
Immunoassay tumor ca 15-3	CPT 86300	$78
Immunoassay tumor ca 19-9	CPT 86301	$99
Immunofix e-phoresis serum	CPT 86334	$84
Immunohisto antb 1st stain	CPT 88342	$310
Influenza a/b ag ia	CPT 87400	$28
Inhibin a	CPT 86336	$50
Iron binding test	CPT 83550	$95
Kidney function panel test	CPT 80069	$95
Lactate (ld) (ldh) enzyme	CPT 83615	$66
Liver function blood test	CPT 80076	$67
Mass spectrometry qual/quan	CPT 83789	$34
Microbe susceptible enzyme	CPT 87185	$33
Microbe susceptible mic	CPT 87186	$94
Microscopic exam of urine	CPT 81015	$31
Microsomal antibody each	CPT 86376	$69
Mumps antibody	CPT 86735	$50
Nuclear antigen antibody	CPT 86235	$71
Obstetric blood test panel	CPT 80055	$220
Ova and parasites smears	CPT 87177	$43
Protein e-phoresis serum	CPT 84165	$46
Psa screening	HCPCS G0103	$124
Rbc antibody screen	CPT 86850	$78
Rbc sed rate automated	CPT 85652	$30
Reagent strip/blood glucose	CPT 82948	$12
Resp syncytial ag ia	CPT 87420	$131
Rheumatoid factor quant	CPT 86431	$15
Ria nonantibody	CPT 83519	$229
Routine venipuncture	CPT 36415	$10
Rubella antibody	CPT 86762	$46
Rubeola antibody	CPT 86765	$52
Smear complex stain	CPT 87209	$39
Smear gram stain	CPT 87205	$47
Smear wet mount saline/ink	CPT 87210	$46
Special stains group 2	CPT 88313	$122
Stool cultr aerobic bact ea	CPT 87046	$45
Strep a assay w/optic	CPT 87880	$61
Surgical path gross	CPT 88300	$42
Syphilis test non-trep qual	CPT 86592	$19
Syphilis test non-trep quant	CPT 86593	$30
Tb test cell immun measure	CPT 86480	$230
Test for acetone/ketones	CPT 82009	$48
Thyroglobulin antibody	CPT 86800	$66
Tissue exam by pathologist	CPT 88305	$183
Tissue exam by pathologist	CPT 88304	$181
Total cortisol	CPT 82533	$50
Total prostate-specific antigen (PSA) test	CPT 84153	$54
Total prostate-specific antigen (PSA) test	CPT 84154	$54
Transferase (ast) (sgot)	CPT 84450	$56
Unlisted molecular pathology	CPT 81479	$13
Ur albumin quantitative	CPT 82043	$63
Urinalysis test	CPT 81003	$26
Urinalysis test (Not Offered)	CPT 81002	-	-
Urinalysis test using microscope	CPT 81001	$50
Urinalysis test using microscope (Not Offered)	CPT 81000	-	-
Urine bacteria culture	CPT 87088	$58
Urine pregnancy test	CPT 81025	$59
Varicella-zoster antibody	CPT 86787	$61
Vitamin b-12	CPT 82607	$73
Vitamin d 25 hydroxy	CPT 82306	$215
Wbc antibody identification	CPT 86021	$47
Withdrawal of arterial blood	CPT 36600	$151
Language Pathology
Developmental screen w/score	CPT 96110	$20
Motion fluoroscopy/swallow	CPT 92611	$137
Speech/hearing therapy	CPT 92507	$122
MRI
MRI Scan	CPT 70553	$3,432
MRI scan of leg joint	CPT 73721	$2,255
MRI scan of lower spinal canal	CPT 72148	$1,890
Mri brain stem w/o dye	CPT 70551	$2,391
Medical and Surgical Supplies
3DMAX MESH LEFT LIGHT	HCPCS C1781	$340
ALLOMATRIX INJECTABLE BONE PUTTY 3CC	HCPCS C1713	$934
Cath w/drainage 2-way silcne	HCPCS A4315	$36
Post chmbr intraocular lens	HCPCS V2632	$384
Nuclear Medicine
Tc99m disofenin	HCPCS A9510	$202
Tc99m tetrofosmin	HCPCS A9502	$335
Other Diagnostic
Fetal non-stress test	CPT 59025	$368
Polysom 6/>yrs cpap 4/> parm	CPT 95811	$3,190
Sleep study unatt&resp efft	CPT 95806	$508
Other Procedures and Observation
Draw blood off venous device	CPT 36591	$78
Hospital observation per hr	HCPCS G0378	$45
Other Therapeutic
Blood transfusion service	CPT 36430	$1,098
Cardiac rehab/monitor	CPT 93798	$168
Diab manage trn per indiv	HCPCS G0108	$40
Immunization admin each add	CPT 90472	$76
Immunotherapy injections	CPT 95117	$54
Immunotherapy one injection	CPT 95115	$30
Irrig drug delivery device	CPT 96523	$118
Med nutrition indiv subseq	CPT 97803	$30
Medical nutrition indiv in	CPT 97802	$34
Phlebotomy	CPT 99195	$126
Rbc leukocytes reduced	HCPCS P9016	$302
Pharmacy
Abd paracentesis w/imaging	CPT 49083	$242
Hospital discharge day	CPT 99239	$209
Hospital discharge day	CPT 99238	$116
Initial hospital care	CPT 99222	$247
Initial hospital care	CPT 99223	$410
Initial hospital care	CPT 99221	$139
Initial observation care	CPT 99219	$308
Initial observation care	CPT 99220	$431
Inj trigger point 1/2 muscl	CPT 20552	$71
Inject sacroiliac joint	CPT 27096	$125
Observation care discharge	CPT 99217	$199
Office/outpatient visit est	CPT 99213	$90
Office/outpatient visit est	CPT 99214	$131
Office/outpatient visit est	CPT 99212	$68
Office/outpatient visit est	CPT 99215	$195
Office/outpatient visit new	CPT 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 shoulder	CPT 29240	$42
Subsequent hospital care	CPT 99232	$188
Subsequent hospital care	CPT 99231	$113
Subsequent hospital care	CPT 99233	$318
Subsequent observation care	CPT 99225	$143
Trim skin lesion	CPT 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 test	CPT 94010	$166
Co/membane diffuse capacity	CPT 94729	$277
Evaluation of wheezing	CPT 94060	$463
Pulm function test by gas	CPT 94727	$277
Radiology
Fluoroscopy <1 hr phys/qhp	CPT 76000	$340
Needle localization by xray	CPT 77002	$253
X-Ray of lower back	CPT 72110	$223
X-ray exam abdomen 1 view	CPT 74018	$113
X-ray exam abdomen 2 views	CPT 74019	$153
X-ray exam chest 1 view	CPT 71045	$87
X-ray exam chest 2 views	CPT 71046	$139
X-ray exam complete abdomen	CPT 74022	$197
X-ray exam hip uni 2-3 views	CPT 73502	$123
X-ray exam hip uni 4/> views	CPT 73503	$146
X-ray exam knee 4 or more	CPT 73564	$162
X-ray exam l-s spine 2/3 vws	CPT 72100	$162
X-ray exam l-s spine bending	CPT 72114	$291
X-ray exam neck spine 2-3 vw	CPT 72040	$151
X-ray exam neck spine 4/5vws	CPT 72050	$218
X-ray exam of ankle	CPT 73610	$94
X-ray exam of collar bone	CPT 73000	$115
X-ray exam of elbow	CPT 73080	$144
X-ray exam of elbow	CPT 73070	$113
X-ray exam of femur 2/>	CPT 73552	$104
X-ray exam of finger(s)	CPT 73140	$113
X-ray exam of foot	CPT 73630	$88
X-ray exam of foot	CPT 73620	$78
X-ray exam of forearm	CPT 73090	$115
X-ray exam of hand	CPT 73130	$130
X-ray exam of hand	CPT 73120	$113
X-ray exam of humerus	CPT 73060	$127
X-ray exam of knee 1 or 2	CPT 73560	$121
X-ray exam of knee 3	CPT 73562	$121
X-ray exam of knees	CPT 73565	$109
X-ray exam of lower leg	CPT 73590	$119
X-ray exam of pelvis	CPT 72170	$113
X-ray exam of shoulder	CPT 73030	$130
X-ray exam of toe(s)	CPT 73660	$85
X-ray exam of wrist	CPT 73110	$139
X-ray exam of wrist	CPT 73100	$119
X-ray exam ribs uni 2 views	CPT 71100	$139
X-ray exam sacrum tailbone	CPT 72220	$130
X-ray exam thorac spine 2vws	CPT 72070	$144
X-ray exam unilat ribs/chest	CPT 71101	$167
Respiratory
Airway inhalation treatment	CPT 94640	$268
Pos airway pressure cpap	CPT 94660	$316
Surgical Procedures
Biopsy exam of esophagus, stomach or small bowel using an ...	CPT 43239	$951
Biopsy exam of large bowel using an endoscope	CPT 45380	$751
Biopsy of prostate gland (Not Offered)	CPT 55700	-	-
Circumcision w/regionl block	CPT 54150	$2,439
Diagnostic exam of esophagus, stomach or small bowel using...	CPT 43235	$421
Diagnostic exam of large bowel using an endoscope	CPT 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 plmt	CPT 43752	$129
Obstetric care, planned cesarean delivery (Not Offered)	CPT 59510	-	-
Obstetric care, planned vaginal delivery	CPT 59400	$2,987
Obstetric care, planned vaginal delivery (post delivery by... (Not Offered)	CPT 59610	-	-
Removal of cataract with insertion of lens	CPT 66984	$1,181
Removal of gallbladder using an endoscope	CPT 47562	$1,558
Removal of one knee cartilage using an endoscope	CPT 29881	$6,141
Removal of one or more breast growth, open procedure	CPT 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 older	CPT 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 wound	HCPCS G0283	$22
Gait training therapy	CPT 97116	$44
Group therapeutic procedures	CPT 97150	$27
Manual therapy 1/> regions	CPT 97140	$46
Neuromuscular reeducation	CPT 97112	$52
Ot eval low complex 30 min	CPT 97165	$132
Ot eval mod complex 45 min	CPT 97166	$132
Physical medicine procedure	CPT 97139	$14
Physical therapy, therapeutic exercise	CPT 97110	$50
Pt eval low complex 20 min	CPT 97161	$117
Pt eval mod complex 30 min	CPT 97162	$117
Rmvl devital tis 20 cm/<	CPT 97597	$59
Self care mngment training	CPT 97535	$55
Therapeutic activities	CPT 97530	$55
Ultrasound therapy	CPT 97035	$20
Wound(s) care non-selective	CPT 97602	$25
Uncategorized
Als1-emergency	HCPCS A0427	$1,268
Bls-emergency	HCPCS A0429	$1,084
Ground mileage	HCPCS A0425	$27
Immunization admin	CPT 90471	$46
Trauma respons w/hosp criti	HCPCS G0390	$2,414