Supplies, drugs & other prices at Intermountain Health Good Samaritan Hospital

Lafayette, CO · every code in this section with a posted price and a Medicare benchmark.

40 codes. Prices are the hospital's own posted facility charges.

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ProcedureCash priceGross charge× Medicare
Adm tocilizu covid-19 1st (M0249) $1,773.85
Admin hepatitis b vaccine (G0010) $21.17
Catheterize for urine spec (P9612) $74.40
Covid-19 lab test non-cdc (U0002) $168.54
Direct refer hospital observ (G0379) $1,579.40
Drug test def 1-7 classes (G0480) $412.35
Drug test def 15-21 classes (G0482) $478.85
Drug test def 22+ classes (G0483) $862.95
Drug test def 8-14 classes (G0481) $411.08
Eia hiv-1/hiv-2 screen (G0432) $288.74
Elisa hiv-1/hiv-2 screen (G0433) $309.35
Fecal microbiota prep instil (G0455) $7,606.65
Heart symp image plnr (0331T) $4,112.25
Hep c screen high risk/other (G0472) $422.32
Hepb screen high risk indiv (G0499) $146.38
Hospital outpt clinic visit (G0463) $419.10
Neuro csf prion prtn qual (0035U) $596.30
Oth resp proc, group (G0239) $207.50
Oth resp proc, indiv (G0238) $207.50
Pathogen test for platelets (P9100) $124.48
Perc d-e cor revasc chro sin (C9607) $41,207.04
Perq sac agmntj bi w/wo balo/mchnl dev 2/> ndls (0201T) $22,158.60
Perq sac agmntj uni w/wo balo/mchnl dev 1/> ndl (0200T) $21,195.20
Pet not otherwise specified (G0235) $3,816.40
Prostate biopsy, any mthd (G0416) $954.29
Psa screening (G0103) $242.30
Revasc intra lithotrip-ather (C9766) $49,497.45
Revasc intra lithotrip-stent (C9765) $49,497.45
Revasc intravasc lithotripsy (C9764) $30,588.15
Revasc lithotr-ather tib/per (C9774) $47,228.15
Revasc lithotrip tibi/perone (C9772) $31,770.70
Scr c/v cyto,thinlayer,rescr (G0145) $117.22
Screen cerv/vag thin layer (G0123) $89.65
Therapeutic procd strg endur (G0237) $207.50
Trauma respons w/hosp criti (G0390) $11,815.50
Trluml perip athrc abd aorta (0236T) $41,303.65
Trluml perip athrc brchiocph (0237T) $35,916.25
Trluml perip athrc iliac art (0238T) $46,237.50
Trluml perip athrc renal art (0234T) $41,303.65
Unsched dialysis esrd pt hos (G0257) $3,825.95