Visits & medical services prices at Intermountain Health Good Samaritan Hospital

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

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

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ProcedureCash priceGross charge× Medicare
Acoustic immitance testing (92570) $419.05
Administration of chemotherapy into artery using push technique (96420) $1,941.45
Administration of chemotherapy into fluid-filled space between the tissue that cover the brain and spinal cord (96450) $2,043.60
Aep hearing status deter broadband stimuli i&r (92651) $980.90
Aep neurodiagnostic interpretation and report (92653) $1,190.20
Aep threshold estimation mlt frequencies i&r (92652) $980.90
Aerosol inhalation pentamidine (94642) $689.75
Airway inhalation treatment (94640) $718.10
Appl on-body injector for timed subq injection (96377) $125.40
Application of a modality to 1 or more areas; contrast baths, each 15 minutes Other Outpatient (97034) $120.40
Application of a modality to 1 or more areas; diathermy (eg, microwave) Other Outpatient (97024) $56.25
Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Other Outpatient (97032) $171.20
Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes Other Outpatient (97036) $278.30
Application of a modality to 1 or more areas; iontophoresis, each 15 minutes Other Outpatient (97033) $191.95
Application of a modality to 1 or more areas; ultrasound, each 15 minutes Other Outpatient (97035) $147.85
Application of a modality to 1 or more areas; vasopneumatic devices Other Outpatient (97016) $78.20
Assessment of aphasia (96105) $916.65
Behavioral & qualit analysis voice and resonance (92524) $853.90
Bfb training ea addl 15 min (90913) $63.10
Biofeedback training by any modality Other Outpatient (90901) $219.70
Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when… (90912) $157.10
Biopsy of heart lining (93505) $8,823.40
Bipap initial day (94660) $789.40
Breath hydrogen/methane test (91065) $765
Breathing capacity test (94010) $646.75
Bronchial allergy tests (95070) $1,671.60
Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration (94060) $1,260.75
Bundle of his recording (93600) $36,612
C motor evoked lwr limbs (95929) $1,400.75
Canalith repositioning (95992) $229.95
Car seat/bed test inft thru 12 mo 60 min (94780) $174.05
Cardiopulmonary exercise testing (94621) $2,813.05
Cardiovascular procedure unlisted (93799) $4,191.40
Cardiovascular stress test (93017) $2,274.95
Cardioversion elective external (92960) $6,974.25
Caregiver training 1st 30 min (97550) $160.15
Caregiver training ea addl 15 (97551) $79.45
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary… (93460) $33,421.80
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary… (93459) $32,614.55
Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary… (93458) $28,009.70
Chemo anti-neopl sq/im (96401) $852.65
Chemo hormon antineopl sq/im (96402) $596.65
Chemo IV infus each addl seq (96417) $596.65
Chemo IV infusion addl hr (96415) $797.10
Chemo IV push addl drug (96411) $648.55
Chemother prolong infuse w/pump (96416) $2,576.85
Chemotherapy administration into pleural cavity, requiring and including thoracentesis (96440) $1,581.30
Chemotherapy administration into the peritoneal cavity via implanted port or catheter (96446) $1,581.30
Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug (96413) $2,228
Chemotherapy administration; intravenous, push technique, single or initial substance/drug (96409) $1,416.35
Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents (96542) $1,314.70
Chest physiotherapy initial (94667) $912.20
Color/duplex Doppler, complete (93975) $969.55
Color/duplex Doppler, limited (93976) $918.80
Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or… (97537) $281.15
Compre electrophysiologic w/o arrhyt induction (93619) $19,416.55
Compre ep eval abltj atr fib pulm vein isolation (93656) $101,492.45
Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with… (93620) $23,280.60
Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction… (93653) $84,819.90
Comprehensive electrophysiologic evaluation with insertion and repositioning of multiple electrode catheters, induction… (93654) $86,625
Comprehensive hearing test (92557) $1,172.50
Concurrent chemotherapy (96549) $349.95
Conditioning play audiometry (92582) $930.25
Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour (94644) $1,714.70
Coronary art/grft angio s&i (93455) $25,305.55
Coronary artery angio s&i (93454) $17,824.60
Cpr (92950) $2,895.85
Critical care ill/injured patient init 30-74 min (99291) $17,763.85
Ctr motr ep std transcrnl motr stim upr&low limb (95939) $3,365.55
Debridement open wound 20 sq cm< (97597) $624.40
Delivery/birthing room resuscitation (99465) $2,033.70
Developmental tst admin phys/qhp 1st hour (96112) $1,068.75
Dialysis one evaluation (90945) $1,319.55
Distrt prod evokd otoacoustic emsns comp/dx eval (92588) $821.70
Dup-scan artl infl&ven o/f pen vsl compl (93980) $1,517.10
Duplex hemodialysis access (93990) $929
Duplex scan artl infl&ven o/f hemo compl bi std (93985) $1,237.95
Duplex scan artl infl&ven o/f hemo compl uni std (93986) $444.50
Duplex scan of arterial inflow and venous outflow of penile vessels; follow-up or limited study Age Under 21 (93981) $1,100.35
Duplex scan of extracranial arteries; complete bilateral study Age Under 21 (93880) $1,597.80
Duplex scan of extracranial arteries; unilateral or limited study Age Under 21 (93882) $1,492.65
Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study Age… (93970) $3,438.70
Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study Age… (93971) $2,137.25
Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study Age Under 21 (93925) $2,357.70
Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study Age Under 21 (93926) $1,094.50
Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study Age Under 21 (93930) $3,180.55
Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study Age Under 21 (93931) $1,361.75
ECG monit/reprt up to 48 hrs (93226) $2,313.80
Echo transesophageal (93312) $6,784.76
Echo tthrc r-t 2d w/wo m-mode rest&strs cont ECG (93351) $3,118.77
EEG 41-60 minutes (95812) $2,909.85
EEG awake & asleep (95819) $2,909.85
EEG awake/drowsy (95816) $2,909.85
EEG coma or sleep only (95822) $2,909.85
EEG cont rec w/video by tech min 8 channels (95700) $1,462
EEG extended monitoring 61-119 minutes (95813) $2,909.85
EEG w/o vid by tech ea incr 12-26 hr intmt mntr (95709) $4,958.15
EEG w/o vid by tech ea incr 12-26hr unmonitored (95708) $4,958.15
EEG w/o vid tech ea incr 12-26 hr cont r-t mntr (95710) $4,958.15
EEG w/o video by tech 2-12 hr intermittent mntr (95706) $2,909.85
EEG w/o video by tech 2-12 hr unmonitored (95705) $2,909.85
EEG w/o video by tech 2-12hr continuous r-t mntr (95707) $2,909.85
EKG 12 lead tracing only (93005) $551.70
EKG rhythm strip (93041) $177.25
Elec alys implt brn npgt prgrmg 1st 15 min (95983) $327.55
Elec alys implt npgt phys/qhp w/o programming (95970) $550.30
Electrode stimulation brain (95961) $9,506.90
Electrophysiologic evaluation of single or dual chamber transvenous pacing cardioverter-defibrillator (includes… (93642) $6,339.35
Electrophysiologic follow-up study with pacing and recording to test effectiveness of therapy, including induction or… (93624) $36,612
Emergency department visit high mdm (99285) $10,353.05
Emergency department visit low mdm (99283) $4,774.75
Emergency department visit may not req phys/qhp (99281) $807.15
Emergency department visit moderate mdm (99284) $5,609.85
Emergency department visit straightforward mdm (99282) $1,815.10
EMG thoracic paraspinal (95869) $464.50
End tidal co2 mntrng (crbn dxde exp gas dtrmntn by infrared analyzer) (94799) $511.34
Endoscopy swallow (fees) vid (92612) $599.30
Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and… (91010) $2,310.25
Esophageal recording (93615) $6,180.90
Esophageal recording of atrial electrogram with or without ventricular electrogram(s); with pacing without Cardiac Cath (93616) $6,339.35
Eval of Oral and Pharyngeal Swallowing - Eval of Oral and Pharyngeal Swallowing Fx Chg (92610) $706.10
Evaluate pt use of inhaler (94664) $583.15
Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with… (92607) $1,105.40
Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face… (92605) $792
Evaluation of speech fluency (92521) $965.10
Evaluation of speech sound production articulate (92522) $892.15
Evoked auditory test limited (92587) $807
External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; recording (includes… (93225) $1,393.25
External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data… (93229) $2,100
Flexible ndsc eval swlng&laryn sens c/v rec (92616) $1,758.15
Fluidotherapy (97022) $151.45
Gas dilut/washout lung vol w/wo distrib vent&vol (94727) $1,645
Gastroesophag reflx test w/telemtry ph eltrd (91035) $1,442.50
Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), colon, with interpretation and report Age Under 21 (91113) $2,394.65
Gastrointestinal tract imaging, intraluminal (eg, capsule endoscopy), esophagus through ileum, with interpretation and… (91110) $2,973.40
Group caregiver training strategies & technique (97552) $73.25
Health behavior assessment/re-assessment (96156) $323.20
Health behavior ivntj fam w/pt f2f 1st 30 min (96167) $297.15
Health behavior ivntj indiv f2f 1st 30 min (96158) $299.80
Hemodialysis procedure w/ phys/qhp evaluation (90935) $7,317.15
Hot/cold pack (97010) $31.50
Hypoxia response curve (94450) $807
Im adm intransl/oral 1 vaccine (90473) $21.17
Imm admn sarscov2 vaccine single dose (90480) $59.64
Immunization administration (90471) $130.50
Induction of arrhythmia by electrical pacing without Cardiac Cath (93618) $6,339.35
Infrared therapy (97026) $58.65
Injection,Therap/Proph/Diagnost, IV Push, Ea Add, New Drug (96375) $256.75
Injection,Therap/Proph/Diagnost, IV Push, Initial Drug (96374) $595.85
Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes with Cardiac Cath (93503) $4,287.25
Interrogation vad in prson w/phys/qhp analysis (93750) $287.37
Intra-atrial pacing (93610) $36,612
Intra-atrial recording (93602) $36,612
Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete… (93650) $36,612
Intraventricular pacing (93612) $36,612
Irrigaj implntd venous access drug delivery syst (96523) $325.75
IV infusion hydration each additional hour (96361) $243.80
IV infusion hydration initial 31 min-1 hour (96360) $664.60
IV infusion ther proph addl sequential to 1 hr (96367) $263.90
IV infusion therapy/prophylaxis /dx 1st to 1 hr (96365) $666.80
IV tx, each additional hour (96366) $443.05
Lwr xtr vasc stdy bilat (93924) $2,360.05
Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent (94668) $401.50
Maximum voluntary ventilation (94200) $340.25
Measurement of brain wave activity (EEG) to evaluate brain death (95824) $4,958.15
Mechanical chest wall oscillation lung function (94669) $840.25
Mechanical traction therapy (97012) $127.05
Methacholine challenge (94070) $1,257
Motion fluoroscopic evaluation of swallowing function by cine or video recording Other Outpatient (92611) $851.70
Multiple sleep latency (95805) $4,958.15
Muscle test 3 limbs (95863) $564.30
Muscle test larynx (95865) $355.10
Nasopharyngoscopy (92511) $658
Ndl EMG 4 xtr w/wo related paraspinal areas (95864) $586.65
Needle electromyography 2 extremities with or without related paraspinal areas 95861 (95861) $464.20
Needle electromyography cranial nrv muscle uni (95867) $854.40
Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber… (95872) $443.65
Needle electromyography; 1 extremity with or without related paraspinal areas (95860) $373.50
Needle EMG lmtd std musc 1 xtr/non-limb uni/bi (95870) $400.70
Needle measurement of electrical activity in muscles on both sides of body (95868) $910.25
Neg pressure wound therapy non dme </= 50 sq cm (97607) $1,075
Neg pressure wound therapy non dme >50 sq cm (97608) $1,290
Negative pressure wound therapy dme </= 50 sq cm (97605) $624.40
Negative pressure wound therapy dme >50 sq cm (97606) $1,290
Nerve conduction studies 1-2 studies (95907) $419.05
Nerve conduction studies 11-12 studies (95912) $1,741.25
Nerve conduction studies 13/> studies (95913) $1,924.95
Nerve conduction studies 3-4 studies (95908) $1,008.75
Nerve conduction studies 5-6 studies (95909) $1,008.75
Nerve conduction studies 7-8 studies (95910) $1,155
Nerve conduction studies 9-10 studies (95911) $1,411.60
Neuromuscular junction test (95937) $421.40
Non-invasive physiologic study extremity 3 levels (93923) $1,196.15
Noninvasive ear/pulse oximetry overnight monitor (94762) $1,902.80
Occupational therapy eval high complex 60 mins (97167) $470.40
Occupational therapy eval low complex 30 mins (97165) $421.60
Occupational therapy eval mod complex 45 mins (97166) $442.35
Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording (92544) $693.40
Oral function therapy (92526) $834.10
Oral speech device eval (92597) $605.30
Orthc/prostc mgmt sbsq enc (97763) $218.15
Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper… (97760) $223.65
Osteopath manj 1-2 regions (98925) $77.85
Ot manual therapy ea 15 min (97140) $223.65
Ot neuromuscular re-education (97112) $206.35
Ot paraffin bath (97018) $45.60
Ot re-evaluation (97168) $358.35
OT Therapeutic Activities Charges (97530) $240.45
Ot wheelchair management (97542) $189.50
Outpatient cardiac rehab w/cont ECG monitoring (93798) $741.20
Outpatient cardiac rehab w/o cont ECG monitor (93797) $512.25
Oxygen uptake, expired gas analysis; rest, indirect (separate procedure) (94690) $985.75
Peripheral vascular rehab (93668) $356.15
Perq transcath closure pda (93582) $49,497.45
Phlebotomy therapeutic (99195) $664.05
Phy/qhp op pulm rhb w/mntr (94626) $618.50
Phy/qhp op pulm rhb w/o mntr (94625) $651.05
Physical therapy evaluation high complex 45 mins (97163) $444.70
Physical therapy evaluation low complex 20 mins (97161) $421.60
Physical therapy evaluation mod complex 30 mins (97162) $442.35
Polysom 6/>yrs sleep w/cpap 4/> addl param attnd (95811) $9,506.90
Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes Other… (97761) $344.45
Prq trluml coronary angio/atherect one art/brnch (92924) $31,811.68
Prq trluml coronary angioplasty one art/branch (92920) $20,388
Prq trluml coronary byp grft revasc one vessel (92937) $32,965.66
Prq trluml coronary stent w/angio one art/brnch (92928) $39,764.61
Prq trluml coronry chronic occlus revasc one vsl (92943) $41,207.04
Prq trluml coronry stent/ath/angio one art/brnch (92933) $51,477.35
Pt gait training 15 min (97116) $179.15
Pt physical performance test (97750) $131.95
Pt re-evaluation (97164) $358.35
Pulm funct tst plethysmograp (94726) $1,645
Pulmonary stress testing (94618) $886.95
R hrt art/grft angio (93457) $8,524.85
R hrt coronary artery angio (93456) $26,999.20
R&l hrt art/ventricle angio (93461) $8,524.85
R&l hrt cath w/ventriclgrphy (93453) $10,656.05
Refilling and maintenance of implantable pump or reservoir for drug delivery, spinal (intrathecal, epidural) or brain… (95990) $1,150.15
Refilling and maintenance of portable pump (96521) $960.75
Rem interrog scrms <30 d phys/qhp (93298) $117.50
Remote 30 day ECG rev/report (93270) $2,984.45
Respiratory flow volume loop (94375) $1,008.75
Right heart cath o2 saturation & cardiac output (93451) $11,324.30
Right ventricular recording (93603) $6,339.35
Select picture audiometry (92583) $198.75
Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation,… (97535) $204.75
Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands,… (97533) $289.80
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording… (95927) $811.50
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording… (95938) $1,783.55
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording… (95926) $811.50
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording… (95925) $811.50
Sleep study unattended (95806) $1,462
Speech audiometry threshold (92555) $163.60
Speech sound lang comprehen (92523) $1,207
Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording (92541) $693.40
Standardized cognitive performance testing (96125) $473.30
Stenger test pure tone (92565) $1,034.70
Stenger test speech (92577) $1,393
Stress tte only (93350) $3,348.20
Surfactant administration (94610) $662.15
Temp transcutaneous pacing (92953) $2,357.25
Test for ability to detect and repeat spoken words with speech recognition (92556) $293.30
Test for abnormal eye movement using a moving target that moves back and forth with recording (92545) $807
Test for hearing various pitches using earphone (92552) $401.50
Test for hearing various pitches using earphone and device placed against the bone (92553) $673.65
Test to assess defects in adaption to sounds (92563) $345.05
Test to assess middle ear muscle reflex (92568) $345.05
Test to measure resistance of the airways and lungs to differing frequencies (94728) $983.65
Testing autonomic nervous system function (95923) $404.20
Testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more… (95921) $421.40
Testing of autonomic nervous system function; vasomotor adrenergic innervation (sympathetic adrenergic function),… (95922) $404.20
Ther ivntj cog funcj cntct 1st 15 minutes (97129) $177.65
Ther ivntj cog funcj cntct ea addl 15 minutes (97130) $168.70
Therapeutic procedure(s), group (2 or more individuals) Other Outpatient (97150) $173.20
Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Other Outpatient (97113) $367.85
Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement… (97124) $81.90
Therapeutic prophylactic/dx injection subq/im (96372) $194.40
Therapeutic service(s) for the use of non-speech-generating device, including programming and modification (92606) $785.50
Therapeutic services for the use of speech-generating device, including programming and modification Other Outpatient (92609) $930.25
Tilt table evaluation (93660) $5,776.45
Tobacco use cessation intensive >10 minutes (99407) $172.80
Tobacco use cessation intermediate 3-10 minutes (99406) $118.20
Transcath closure of asd (93580) $58,925.55
Transcranial doppler stdy intracranial art compl (93886) $3,134
Transthoracic echocardiography for congenital cardiac anomalies; follow-up or limited study Age Under 21 (93304) $2,884.78
Tte congenital complete (93303) $3,059.37
Tte f-up or lmtd (93308) $2,462.60
Tte w/doppler complete (93306) $7,300.05
Tx of Speech/Lang/Voice/Comm/Auditory Chg (92507) $837.85
Tx speech language voice commj auditry 2/>indiv (92508) $194.35
Tympanometry (92567) $212.90
Unlisted noninvasive vascular diagnostic study (93998) $552.10
Upr/l xtremity art 2 levels (93922) $801.15
Valvuloplasty aortic valve (92986) $15,683.05
Veeg by tech 2-12 hours unmonitored (95711) $2,909.85
Veeg by tech 2-12 hr continuous r-t monitoring (95713) $4,958.15
Veeg by tech 2-12 hr intermittent monitoring (95712) $2,909.85
Veeg by tech ea incr 12-26 hr cont r-t mntr (95716) $9,506.90
Veeg by tech ea incr 12-26 hr intermittent mntr (95715) $4,958.15
Veeg by tech ea incr 12-26 hr unmonitored (95714) $4,958.15
Ventilation ip/obs initial day (94002) $5,550.90
Ventilator subsequent day (94003) $4,711.90
Visual ep testing cns except glaucoma w/i&r (95930) $988.65
Visual reinforcement audiometry (vra) (92579) $930.25
Vital capacity total (94150) $502.85
Wada activation test (95958) $9,506.90
Wound(s) care non-selective (97602) $628.50