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Pagosa Springs Medical Center Transparency in Pricing

All prices are applicable for uninsured patients (Self-pay) only.

Payment in full is required within thirty days of date of patients first statement

Emergency Department:

Test Description CPT Code Uninsured Patient Responsibility
Level One 99281 $231.70
Level Two 99282 $323.40
Level Three 99283 $507.50
Level Four 99284 $208.60
Level Five 99285 $1,105.30

Note: Above prices do not include Professional fee, any additional Ancillary Services or Procedures.

Laboratory:

Test Description CPT Code Uninsured Patient Responsibility Self-Ordered Labs (Payment required at time of service)
Basic Metabolic Panel 80048 $65.80 $25.00
CBC Auto Differential 85027 $59.50
CBC w/Manual Differential 85025 $59.50 $20.00
Comprehensive Metabolic Panel 80053 $86.80 $36.00
Creatine Kinase (CK) 82550 $50.40
Lipid Panel 80061 $93.80 $31.00
Partial Thromboplastin Time 85730 $47.60
Prothrombin Time 85610 $39.90 $22.00
Thyroid Stimulating Hormone 84443 $82.60 $31.00
Troponin, Quantitative 84484 $117.60

Radiology Services (Imaging)

(Does not include Professional Reading charge)

Test Description CPT Code Uninsured Patient Responsibility
CT Scan, Abdomen, with contrast 74160 $1,018.50
CT Scan, Head or Brain, without contrast 70450 $802.90
CT Scan, Pelvis, with contrast 72193 $1,018.50
Mammography, Screening, Bilateral 77067 $81.20
MRI, Head or Brain, Without Contrast 70553 $1,838.20
Ultrasound, Abdomen, Complete 76700 $373.80
Ultrasound, OB, 14 weeks or more, transabdominal 76805 $397.60
X-Ray, Chest, (2 view) 71020 $182.00

Note: Patients that have annual family income below 250 percent of Federal Poverty levels please refer to the hospitals Charity Care Program

All Uninsured patients receive a 15% discount and if payment is made in full within 30 days of their first statement, another 15% discount.

Both of these discounts have been applied in computing the prices shown above.

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