Good Faith Estimate
You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost. Under the law, healthcare providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items or services.
Patient Rights
- You have the right to receive a Good Faith Estimate for the total of expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.
- Make sure that your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before the medical service or item. You can also ask your provider (and another provider you choose) for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Always retain a copy or picture of your specific Good Faith Estimate.
- If you have questions about your Good Faith Estimate please contact us at 801-475-3500 or use the link below.
Price Estimate Questions & Disputes
Self-Pay Prices
Actual cost of services may be higher or lower, depending on many factors such as changes to treatment choices, actual services provided, complications that may arise, and any other factors considered when determining charges. Estimates are based on information provided before your visit to Ogden Clinic. Estimates are not a guarantee of the actual cost for the services to be provided to you nor are they a contract for the actual amount to be paid.
Office Visit
New patient: $111 to $254
Existing patient: $83 to $182 (Varies by complexity)
Preventive Office Visit
New patient: $159 to $237
Existing patient: $142 to $195 (Varies by age)
Vaccinations
$25 to $350 (Varies by type)
IUD Devices
$900 to $1,100 for device
Lab Services, Radiology, Injectables
Refer to charts below
|
GENERAL XRAYS |
CPT Code |
Fee |
|
Chest ‐ 2 view |
71046 |
$59.00 |
|
Ribs / Chest |
71101 |
$71.00 |
|
Neck Spine 4 view |
72050 |
$90.00 |
|
Lumbar Spine ‐ 2/3 view |
72100 |
$72.00 |
|
Lumbar Spine ‐ 4 view |
72110 |
$92.00 |
|
Collar Bone |
73000 |
$52.00 |
|
Shoulder |
73030 |
$59.00 |
|
Elbow |
73080 |
$60.00 |
|
Forearm |
73090 |
$50.00 |
|
Wrist |
73110 |
$68.00 |
|
Hand |
73130 |
$59.00 |
|
Finger(s) |
73140 |
$61.00 |
|
Hip ‐ 2/3 view |
73502 |
$90.00 |
|
Knee ‐ 3 view |
73562 |
$73.00 |
|
Knee ‐ 4 view |
73564 |
$80.00 |
|
Lower Leg |
73590 |
$60.00 |
|
Ankle |
73610 |
$60.00 |
|
Foot |
73630 |
$57.00 |
|
Toe(s) |
73660 |
$55.00 |
|
Abdomen ‐ 1 view |
74018 |
$53.00 |
|
Abdomen ‐ 2 view |
74019 |
$64.00 |
|
Abdomen (complete) |
74022 |
$87.00 |
|
Urography Retrograde KUB |
74420 |
$282.00 |
|
COMMON LABS |
CPT Code |
Fee |
|
Antimicrobial Susceptibility Studies |
87186 |
$21.00 |
|
Bacterial Culture |
87070 |
$28.00 |
|
Basic Metabolic Panel |
80048 |
$21.00 |
|
Blood Iron Test |
83540 |
$16.00 |
|
Blood Type Pos+ or Neg‐ |
86901 |
$12.00 |
|
Blood Type (O, A, B, or AB) |
86900 |
$12.00 |
|
C‐Reactive Protein |
86140 |
$12.00 |
|
CBC (Complete Blood Count w/Auto Diffe |
85025 |
$14.00 |
|
Chlamydia Test |
87491 |
$67.00 |
|
Collection Fee for Helicobacter Pylori Ure |
83014 |
$20.00 |
|
Comp Metabolic Panel, CBC, TSH Level |
80050 |
$71.00 |
|
Comp Metabolic Panel |
80053 |
$27.00 |
|
COVID + Flu A and B |
87428 |
$100.00 |
|
Creatine Kinase Total |
82550 |
$17.00 |
|
Creatinine |
82570 |
$11.00 |
|
Culture Screening presumptive pathogenic |
87081 |
$15.00 |
|
Ferritin |
82728 |
$36.00 |
|
Flu A and B Rapid Antigen Test |
87804 |
$30.00 |
|
Glucose |
82950 |
$12.00 |
|
Glycosylated Hbg A1C |
83036 |
$24.00 |
|
Gonorroeae Test |
87591 |
$67.00 |
|
Helicobacter Pylori; Urea Breath Test |
83013 |
$152.00 |
|
Hepatic Function Panel (ALP, ALT, AST, Dire) |
80076 |
$21.00 |
|
HIV Testing |
87389 |
$41.00 |
|
Lipase |
83690 |
$17.00 |
|
Lipid Panel |
80061 |
$33.00 |
|
Magnesium |
83735 |
$23.00 |
|
Prostate Specific Antigen |
84153 |
$46.00 |
|
Prostate Specific Antigen Test |
G0103 |
$40.00 |
|
Prothrombin Time |
85610 |
$10.00 |
|
RBC Screening for RBC Antibodies |
86850 |
$45.00 |
|
RSV Antigen Test |
87280 |
$30.00 |
|
Rubella Antibodies |
86762 |
$36.00 |
|
Sedimentation rate, erythrocyte |
85651 |
$9.00 |
|
Streptococcus, group A Rapid Antigen Test |
87880 |
$30.00 |
|
Syphilis Antibody |
86780 |
$26.00 |
|
T4 Free (FT4) |
84439 |
$22.00 |
|
Thyroid Stimulating Hormone (TSH) |
84443 |
$42.00 |
|
Total Iron Binding Capacity |
83550 |
$22.00 |
|
Uric Acid Blood Test |
84550 |
$11.00 |
|
Urinalysis by dip stick - Automated |
81001 |
$8.00 |
|
Urinalysis by dip stick - Non‐Automated |
81002 |
$8.00 |
|
Urine Culture Colony count |
87086 |
$20.00 |
|
Urine Culture organisms ID |
87088 |
$18.00 |
|
Urine Microalbumin |
82043 |
$20.00 |
|
Urine Pregnancy Test |
81025 |
$16.00 |
|
Vaginosis Panel |
Multiple |
$120.00 |
|
Vitamin D; 25 Hydroxy |
82306 |
$73.00 |
|
Vitamin B12 |
82607 |
$39.00 |
|
ULTRASOUND |
CPT Code |
Fee |
|
Head and Neck |
76536 |
$236.00 |
|
Breast (complete) |
76641 |
$207.00 |
|
Abdomen (complete) |
76700 |
$239.00 |
|
Abdomen |
76705 |
$211.00 |
|
Retroperitoneal |
76770 |
$226.00 |
|
Limited Fetus OB |
76815 |
$176.00 |
|
Transvaginal OB |
76817 |
$199.00 |
|
Transvaginal Non‐OB |
76830 |
$214.00 |
|
Pelvic |
76856 |
$241.00 |
|
Scrotum |
76870 |
$201.00 |
|
Transrectal |
76872 |
$315.00 |
|
MAMMOGRAPHY |
CPT Code |
Fee |
|
Diagnostic, including CAD, unilateral |
77065 |
$227.00 |
|
Diagnostic, including CAD; bilateral |
77066 |
$287.00 |
|
Screening, including CAD; bilateral |
77067 |
$235.00 |
|
Computed Tomography (CT) |
CPT Code |
Fee |
|
Abdomen and Pelvis w contrast |
74177 |
$840.00 |
|
Head and Neck |
70486 |
$445.00 |
|
Abdomen and Pelvis w/o contrast |
74176 |
$407.00 |
|
Abdomen and Pelvis w/o & w contrast |
74178 |
$1,061.00 |
|
3D rendering w Interpretation |
76377 |
$226.00 |
|
Thorax w contrast |
71260 |
$564.00 |
| Magnetic Resonance Imaging(MRI) |
CPT Code |
Fee |
|
Brain Stem w/o contrast |
70551 |
$900.00 |
|
Brain Stem w/o & w contrast |
70553 |
$1,550.00 |
|
Neck Spine w/o contrast |
72141 |
$844.00 |
|
Lumbar Spine w/o contrast |
72148 |
$860.00 |
|
Upper Extremity w/o contrast |
73221 |
$860.00 |
|
Upper Extremity w contrast |
73222 |
$982.00 |
|
Lower Extremity w/o contrast |
73721 |
$875.00 |
|
Lower Extremity w contrast |
73722 |
$987.00 |
| OTHER DRUGS AND INJECTIBLES |
CPT Code |
Fee |
|
Botox A ‐ 200 Units |
J0585 |
$2,200.00 |
|
Denosumab/Prolia ‐ 60 mg dose |
J0897 |
$1,320.00 |
|
Leuprolide ‐ 22.5 mg dose |
J9217 |
$1,350.00 |
|
Synvisc One ‐ 48mg dose |
J7325 |
$1,392.00 |
|
Denosumab/Prolia ‐ 60 mg dose |
J0897 |
$1,320.00 |
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