Does Three Rivers Hospital have an emergency room?

Yes. Medicare (CMS) data lists emergency services at Three Rivers Hospital. In a medical emergency, call 911.

Where is Three Rivers Hospital?

507 Hospital Way, Brewster, WA 98812, in Okanogan County, Washington.

What is the phone number of Three Rivers Hospital?

(509) 689-2517, as listed by Medicare (CMS).

What is the Medicare star rating of Three Rivers Hospital?

CMS does not show an overall star rating for this hospital. This is common, for example when a hospital reports too few quality measures or is not part of the rating program.

Three Rivers Hospital — Brewster, WA

Quick answers

Does Three Rivers Hospital have an emergency room?: Yes. Medicare (CMS) data lists emergency services at Three Rivers Hospital. In a medical emergency, call 911.
Where is Three Rivers Hospital?: 507 Hospital Way, Brewster, WA 98812, in Okanogan County, Washington.
What is the phone number of Three Rivers Hospital?: (509) 689-2517, as listed by Medicare (CMS).
What is the Medicare star rating of Three Rivers Hospital?: CMS does not show an overall star rating for this hospital. This is common, for example when a hospital reports too few quality measures or is not part of the rating program.

Specialties and care areas^[4]

Conditions treated^[12]

Diabetic foot ulcers
Venous ulcers
Pressure ulcers
Non-healing surgical wounds
Arterial/ischemic ulcers
Traumatic wounds
Infected wounds
Crush injuries

Treatments^[4][7][10]

Advanced wound care
CT scan
MRI
Digital fluoroscopy (X-ray)
Ultrasound
Echocardiogram
3D mammography
Complete blood count
Blood type and crossmatching

Programs and centers^{[4][5][9][11][12]}

Transitional Care / Swing Bed
Laboratory
Emergency department (24/7)
Stroke care via telestroke with Providence Health (Spokane)
Advanced wound care
Physical therapy

Emergency care (hospital website)^[5]

Emergency room	Yes
Open 24/7	Yes
Trauma designation	Level IV

Visiting and practical information

Interpreters and languages	Spanish spoken; language interpreting via 509-689-2517 ext. 3125^[4][11]
Patient portal	MyCareCorner

Doctors and clinicians (44)

44 doctors and other clinicians list Three Rivers Hospital as a hospital where they work, in Medicare's official clinician data (updated 2026-10-02). It is not a complete staff list.

Main specialties

And 20 more: the button below opens the full list.

Other emergency rooms nearby

Hospitals that list emergency services, by straight-line distance (not driving distance).

Lake Chelan Community Hospital21 mi · Chelan, WA · Critical Access Hospital
Mid Valley Hospital & Clinic23 mi · Omak, WA · Critical Access Hospital
Coulee Medical Center38 mi · Grand Coulee, WA · Critical Access Hospital
North Valley Hospital44 mi · Tonasket, WA · Critical Access Hospital
Confluence Health Hospital53 mi · Wenatchee, WA · Acute Care Hospital

Other hospitals nearby

Cascade Medical Center54 mi · Leavenworth, WA · Critical Access Hospital

Nursing homes, hospice, home health and dialysis nearby

Medicare-certified providers within 25 miles, by straight-line distance. Hospice and home health care is given at home: their address is the office.

Nursing homes

Regency Harmony House Rehab & Nursing0.2 mi · Brewster, WA · 5 of 5 stars

All nursing homes in the state →

Community care nearby

Health centers, clinics, urgent care and pharmacies closest to this hospital, by straight-line distance, from official HRSA, Medicare and NPI Registry data. In a medical emergency, call 911.

Community health centers

FHC Brewster Jay Avenue Medical Clinic0.5 mi · Brewster, WA · Community health center
FHC Brewster Dental Clinic0.5 mi · Brewster, WA · Community health center
FHC - Brewster School District0.9 mi · Brewster, WA · Community health center

Clinics and urgent care

Confluence Health Brewster Clinic2.0 mi · Brewster, WA · Rural health clinic
Three Rivers Family Medicine2.0 mi · Brewster, WA · Rural health clinic

Pharmacies

Family Health Centers2.0 mi · Brewster, WA · Clinic pharmacy
Quickrx LLC2.0 mi · Brewster, WA · Pharmacy

About the Medicare star rating

CMS (the federal Medicare agency) gives many hospitals an overall rating from 1 to 5 stars, based on measures of mortality, safety, readmissions, patient experience and timely care. It is one piece of information: ask your doctor what matters for your care. See the full Medicare profile →

Medicare quality data

What Three Rivers Hospital reported to Medicare (CMS), the federal agency that publishes these results for hospitals nationwide. These are averages for many patients, not a prediction for any one person: ask your doctor what matters for your care. In a medical emergency, call 911.

What patients said (patient survey)

What this means: Patients who stayed overnight answered a national survey (HCAHPS) about their stay. More stars mean patients reported a better experience than at other hospitals. The percentages show how often patients gave the best answer, next to the national average.

Not reported to Medicare

Source: Patient survey (HCAHPS) - Hospital — CMS, released July 22, 2026; patients discharged October 2024 to September 2025.

Infections caught in the hospital

What this means: CMS compares the number of infections patients caught in this hospital with the number expected for a hospital like it. The number shown is that ratio: below 1 means fewer infections than expected, above 1 means more. “Better” or “worse” is shown only when the difference is clear in the data.

Central line bloodstream infections (CLABSI)	Not reported to Medicare
Catheter-associated urinary tract infections (CAUTI)	Not reported to Medicare
Surgical site infections after colon surgery	Not reported to Medicare
Surgical site infections after abdominal hysterectomy	Not reported to Medicare
MRSA bloodstream infections	Not reported to Medicare
Clostridioides difficile (C. diff) intestinal infections	Not reported to Medicare

Source: Healthcare Associated Infections - Hospital — CMS, released July 22, 2026.

Complications and deaths

What this means: Death rates are the share of patients who died within 30 days of going into the hospital for that condition, adjusted for how sick they were. PSI-90 combines several serious complications (a lower number is better). “No different from the national rate” is the most common result and means the hospital is in line with hospitals nationwide.

Deaths within 30 days: heart attack patients	Not reported to Medicare
Deaths within 30 days: heart failure patients	Too few cases to report
Deaths within 30 days: pneumonia patients	Too few cases to report
Deaths within 30 days: COPD patients	Too few cases to report
Deaths within 30 days: stroke patients	Not reported to Medicare
Deaths within 30 days: coronary bypass surgery (CABG)	Not reported to Medicare
Serious complications (patient safety indicator PSI-90)	Not reported to Medicare
Complications after hip or knee replacement	Not reported to Medicare

Source: Complications and Deaths - Hospital — CMS, released September 10, 2026.

Return visits to the hospital (readmissions)

What this means: The share of patients who had to be admitted to a hospital again within 30 days after going home, adjusted for how sick they were. A lower percentage is better.

Returned to any hospital within 30 days (all patients)	Not reported to Medicare
Readmitted within 30 days: heart attack	Not reported to Medicare
Readmitted within 30 days: heart failure	Too few cases to report
Readmitted within 30 days: pneumonia	Too few cases to report
Readmitted within 30 days: COPD	Too few cases to report
Readmitted within 30 days: coronary bypass surgery	Not reported to Medicare
Readmitted within 30 days: hip or knee replacement	Not reported to Medicare

Source: Unplanned Hospital Visits - Hospital — CMS, released September 10, 2026.

Emergency room times and sepsis care

What this means: ER time is the middle (median) time from arriving at the emergency room to leaving it; busier ERs usually have longer times, so the ER volume is shown too. Leaving before being seen: a lower percentage is better. Sepsis is a life-threatening reaction to an infection; a higher percentage means more patients got every recommended early step.

Average (median) time patients spent in the emergency room before leaving (OP-18b)	Not reported to Medicare
Patients who left the emergency room before being seen (OP-22)	Not reported to Medicare
Sepsis patients who got all the recommended early care (SEP-1)	Not reported to Medicare

Source: Timely and Effective Care - Hospital — CMS, released July 22, 2026.

See every measure on Medicare Care Compare →

ER wait times and Medicare ratings nearby

How this hospital compares with others in the area, ranked only by official Medicare (CMS) numbers.

ER wait times in Washington Best hospitals in Washington

Prices

Every US hospital must publish its standard charges in a file that follows a federal (CMS) format. Below are 86 common services exactly as Three Rivers Hospital lists them in its file. This is not a quote: what you pay depends on your insurance and plan, the doctors involved and the care you actually receive. Prices change: ask the hospital for an estimate before you schedule care (if you are uninsured or paying yourself, you have the right to a written “good faith estimate”). In a medical emergency, call 911.

What the prices mean

Hospital charge: The hospital’s list price (“gross charge”) before any discount or insurance. Few people pay this amount.
Cash price: The price the hospital offers if you pay yourself, without insurance (“discounted cash price”).
Insurance rates: The lowest and highest amounts the hospital has agreed with any insurance plan for the service (“de-identified minimum and maximum”), and some of the rates it lists by insurer and plan. Your share depends on your deductible, copay and coinsurance.
Hospital and doctor fees: A service can have a hospital (facility) fee and a separate doctor (professional) fee; the total for your care can include both, plus other services.

How to use hospital prices: estimates, financial assistance and your rights →

Office and emergency visits

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
New patient office visit (about 30–44 minutes) CPT 99203 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OFFICE O/P NEW LOW 30 MIN	Not listed in the file	Not listed in the file	Not listed in the file
New patient office visit (about 30–44 minutes): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
New patient office visit (about 30–44 minutes) CPT 99203 · Inpatient or outpatient · Hospital (facility) fee · modifier CG In the file: OFFICE CALL NEW LIMITED	$242	$181.50	Not listed in the file
New patient office visit (about 30–44 minutes) CPT 99203 · Inpatient or outpatient · Hospital (facility) fee · modifier 95 In the file: TM-OFFICE CALL NEW LIMITED	$242	$181.50	Not listed in the file
New patient office visit (about 45–59 minutes) CPT 99204 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OFFICE O/P NEW MOD 45 MIN	Not listed in the file	Not listed in the file	Not listed in the file
New patient office visit (about 45–59 minutes): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
New patient office visit (about 45–59 minutes) CPT 99204 · Inpatient or outpatient · Hospital (facility) fee · modifier CG In the file: OFFICE CALL NEW EXTENDED	$315	$236.25	Not listed in the file
New patient office visit (about 45–59 minutes) CPT 99204 · Inpatient or outpatient · Hospital (facility) fee · modifier 95 In the file: TM-OFFICE CALL NEW EXTENDED	$315	$236.25	Not listed in the file
New patient office visit (about 60–74 minutes) CPT 99205 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OFFICE O/P NEW HI 60 MIN	Not listed in the file	Not listed in the file	Not listed in the file
New patient office visit (about 60–74 minutes): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
New patient office visit (about 60–74 minutes) CPT 99205 · Inpatient or outpatient · Hospital (facility) fee · modifier CG In the file: OFFICE CALL NEW COMPLEX	$368	$276	Not listed in the file
New patient office visit (about 60–74 minutes) CPT 99205 · Inpatient or outpatient · Hospital (facility) fee · modifier 95 In the file: TM-OFFICE CALL NEW COMPLEX	$368	$276	Not listed in the file
Established patient office visit (about 20–29 minutes) CPT 99213 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OFFICE O/P EST LOW 20 MIN	Not listed in the file	Not listed in the file	Not listed in the file
Established patient office visit (about 20–29 minutes): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Established patient office visit (about 20–29 minutes) CPT 99213 · Inpatient or outpatient · Hospital (facility) fee · modifier CG In the file: OFFICE CALL ESTABLISHED LIMITED	$174	$130.50	Not listed in the file
Established patient office visit (about 20–29 minutes) CPT 99213 · Inpatient or outpatient · Hospital (facility) fee · modifier 93 In the file: TELEMED AUDIO/VIDEO EST PT 20 MINUTES	$90	$67.50	Not listed in the file
Established patient office visit (about 30–39 minutes) CPT 99214 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OFFICE O/P EST MOD 30 MIN	Not listed in the file	Not listed in the file	Not listed in the file
Established patient office visit (about 30–39 minutes): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Established patient office visit (about 30–39 minutes) CPT 99214 · Inpatient or outpatient · Hospital (facility) fee · modifier CG In the file: OFFICE CALL ESTABLISHED EXTENDED	$215	$161.25	Not listed in the file
Established patient office visit (about 30–39 minutes) CPT 99214 · Inpatient or outpatient · Hospital (facility) fee · modifier 93 In the file: TELEMED AUDIO/VIDEO EST PT 30 MINUTES	$132	$99	Not listed in the file
Office consultation with a specialist (moderate) CPT 99243 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OFF/OP CNSLTJ NEW/EST LOW 30	Not listed in the file	Not listed in the file	Not listed in the file
Office consultation with a specialist (moderate): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Office consultation with a specialist (moderate to high) CPT 99244 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OFF/OP CNSLTJ NEW/EST MOD 40	Not listed in the file	Not listed in the file	Not listed in the file
Office consultation with a specialist (moderate to high): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Preventive checkup, new patient, age 18–39 CPT 99385 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PREV VISIT NEW AGE 18-39	Not listed in the file	Not listed in the file	Not listed in the file
Preventive checkup, new patient, age 18–39: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Preventive checkup, new patient, age 40–64 CPT 99386 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PREV VISIT NEW AGE 40-64	Not listed in the file	Not listed in the file	Not listed in the file
Preventive checkup, new patient, age 40–64: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Emergency room visit (moderate) CPT 99283 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: EMERGENCY DEPT VISIT LOW MDM	Not listed in the file	Not listed in the file	Not listed in the file
Emergency room visit (moderate): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Emergency room visit (moderately high) CPT 99284 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: EMERGENCY DEPT VISIT MOD MDM	Not listed in the file	Not listed in the file	Not listed in the file
Emergency room visit (moderately high): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Emergency room visit (high) CPT 99285 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: EMERGENCY DEPT VISIT HI MDM	Not listed in the file	Not listed in the file	Not listed in the file
Emergency room visit (high): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Lab tests

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Basic metabolic panel (blood test) CPT 80048 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: METABOLIC PANEL TOTAL CA	Not listed in the file	Not listed in the file	Not listed in the file
Basic metabolic panel (blood test): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Comprehensive metabolic panel (blood test) CPT 80053 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: COMPREHEN METABOLIC PANEL	Not listed in the file	Not listed in the file	Not listed in the file
Comprehensive metabolic panel (blood test): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Obstetric blood test panel CPT 80055 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OBSTETRIC PANEL	Not listed in the file	Not listed in the file	Not listed in the file
Obstetric blood test panel: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Cholesterol panel (lipid panel) CPT 80061 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: LIPID PANEL	Not listed in the file	Not listed in the file	Not listed in the file
Cholesterol panel (lipid panel): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Kidney function panel CPT 80069 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: RENAL FUNCTION PANEL	Not listed in the file	Not listed in the file	Not listed in the file
Kidney function panel: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Liver function panel CPT 80076 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: HEPATIC FUNCTION PANEL	Not listed in the file	Not listed in the file	Not listed in the file
Liver function panel: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Urine test (automated, with microscope) CPT 81001 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: URINALYSIS AUTO W/SCOPE	Not listed in the file	Not listed in the file	Not listed in the file
Urine test (automated, with microscope): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Urine test (manual, without microscope) CPT 81002 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: URINALYSIS NONAUTO W/O SCOPE	Not listed in the file	Not listed in the file	Not listed in the file
Urine test (manual, without microscope): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Urine test (automated, without microscope) CPT 81003 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: URINALYSIS AUTO W/O SCOPE	Not listed in the file	Not listed in the file	Not listed in the file
Urine test (automated, without microscope): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
PSA (prostate specific antigen) blood test CPT 84153 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: ASSAY OF PSA TOTAL	Not listed in the file	Not listed in the file	Not listed in the file
PSA (prostate specific antigen) blood test: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Thyroid stimulating hormone (TSH) test CPT 84443 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: ASSAY THYROID STIM HORMONE	Not listed in the file	Not listed in the file	Not listed in the file
Thyroid stimulating hormone (TSH) test: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Complete blood count (CBC) with differential CPT 85025 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: COMPLETE CBC W/AUTO DIFF WBC	Not listed in the file	Not listed in the file	Not listed in the file
Complete blood count (CBC) with differential: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Complete blood count (CBC), automated CPT 85027 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: COMPLETE CBC AUTOMATED	Not listed in the file	Not listed in the file	Not listed in the file
Complete blood count (CBC), automated: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Blood clotting time test (prothrombin time, PT) CPT 85610 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PROTHROMBIN TIME	Not listed in the file	Not listed in the file	Not listed in the file
Blood clotting time test (prothrombin time, PT): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Blood clotting test (partial thromboplastin time, PTT) CPT 85730 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: THROMBOPLASTIN TIME PARTIAL	Not listed in the file	Not listed in the file	Not listed in the file
Blood clotting test (partial thromboplastin time, PTT): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Imaging (X-ray, CT, MRI, ultrasound, mammogram)

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
CT scan of the head or brain, without contrast CPT 70450 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: CT HEAD/BRAIN W/O DYE	Not listed in the file	Not listed in the file	Not listed in the file
CT scan of the head or brain, without contrast: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
MRI of the brain, before and after contrast CPT 70553 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: MRI BRAIN STEM W/O & W/DYE	Not listed in the file	Not listed in the file	Not listed in the file
MRI of the brain, before and after contrast: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Chest X-ray, 2 views CPT 71046 · Inpatient or outpatient · Hospital (facility) fee In the file: PF-CHEST TWO VIEWS	$57	$42.75	$48.45 – $57
Chest X-ray, 2 views: 10 of 14 insurance plan rates Aetna — All: $57 Allegiance — All: $51.30 Amerigroup — All: $57 Coordinated Care — All: $57 First Choice Health — All: $51.30 Health Alliance — All: $57 Health Options — All: $57 Labor and Industries — All: $57 Medicare — Advantage: $57 Molina — All: $57
Chest X-ray, 2 views CPT 71046 · Inpatient or outpatient · Hospital (facility) fee In the file: PF-CJD-CHEST XRAY 2 V B-READ (ASBESTOS)	$57	$42.75	$48.45 – $57
Chest X-ray, 2 views: 10 of 14 insurance plan rates Aetna — All: $57 Allegiance — All: $51.30 Amerigroup — All: $57 Coordinated Care — All: $57 First Choice Health — All: $51.30 Health Alliance — All: $57 Health Options — All: $57 Labor and Industries — All: $57 Medicare — Advantage: $57 Molina — All: $57
X-ray of the lower spine, at least 4 views CPT 72110 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: X-RAY EXAM L-2 SPINE 4/>VWS	Not listed in the file	Not listed in the file	Not listed in the file
X-ray of the lower spine, at least 4 views: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
MRI of the lower back (lumbar spine), without contrast CPT 72148 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: MRI LUMBAR SPINE W/O DYE	Not listed in the file	Not listed in the file	Not listed in the file
MRI of the lower back (lumbar spine), without contrast: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
CT scan of the pelvis, with contrast CPT 72193 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: CT PELVIS W/DYE	Not listed in the file	Not listed in the file	Not listed in the file
CT scan of the pelvis, with contrast: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
MRI of a leg joint (such as the knee), without contrast CPT 73721 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: MRI JNT OF LWR EXTRE W/O DYE	Not listed in the file	Not listed in the file	Not listed in the file
MRI of a leg joint (such as the knee), without contrast: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
CT scan of the abdomen and pelvis, with contrast CPT 74177 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: CT ABD & PELV W/CONTRAST	Not listed in the file	Not listed in the file	Not listed in the file
CT scan of the abdomen and pelvis, with contrast: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Ultrasound of the abdomen, complete CPT 76700 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: US EXAM ABDOM COMPLETE	Not listed in the file	Not listed in the file	Not listed in the file
Ultrasound of the abdomen, complete: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Pregnancy ultrasound (after the first trimester) CPT 76805 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OB US >= 14 WKS SNGL FETUS	Not listed in the file	Not listed in the file	Not listed in the file
Pregnancy ultrasound (after the first trimester): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Transvaginal ultrasound CPT 76830 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: TRANSVAGINAL US NON-OB	Not listed in the file	Not listed in the file	Not listed in the file
Transvaginal ultrasound: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Diagnostic mammogram, one breast CPT 77065 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: DX MAMMO INCL CAD UNI	Not listed in the file	Not listed in the file	Not listed in the file
Diagnostic mammogram, one breast: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Diagnostic mammogram, both breasts CPT 77066 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: DX MAMMO INCL CAD BI	Not listed in the file	Not listed in the file	Not listed in the file
Diagnostic mammogram, both breasts: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Screening mammogram, both breasts CPT 77067 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: SCR MAMMO BI INCL CAD	Not listed in the file	Not listed in the file	Not listed in the file
Screening mammogram, both breasts: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Heart tests and sleep study

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Electrocardiogram (ECG/EKG) with reading CPT 93000 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: ELECTROCARDIOGRAM COMPLETE	Not listed in the file	Not listed in the file	Not listed in the file
Electrocardiogram (ECG/EKG) with reading: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Left heart catheterization (diagnostic) CPT 93452 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: LEFT HRT CATH W/VENTRCLGRPHY	Not listed in the file	Not listed in the file	Not listed in the file
Left heart catheterization (diagnostic): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Heart rhythm study (electrophysiology evaluation) CPT 93619 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: ELECTROPHYSIOLOGY EVALUATION	Not listed in the file	Not listed in the file	Not listed in the file
Heart rhythm study (electrophysiology evaluation): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Heart rhythm study with ablation for atrial fibrillation CPT 93656 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: COMPRE EP EVAL ABLTJ ATR FIB	Not listed in the file	Not listed in the file	Not listed in the file
Heart rhythm study with ablation for atrial fibrillation: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Sleep study (overnight, in a sleep lab) CPT 95810 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: POLYSOM 6/> YRS 4/> PARAM	Not listed in the file	Not listed in the file	Not listed in the file
Sleep study (overnight, in a sleep lab): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Physical therapy and mental health

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Physical therapy: therapeutic exercise (each 15 minutes) CPT 97110 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: THERAPEUTIC EXERCISES	Not listed in the file	Not listed in the file	Not listed in the file
Physical therapy: therapeutic exercise (each 15 minutes): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Physical therapy evaluation (low complexity) CPT 97161 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PT EVAL LOW COMPLEX 20 MIN	Not listed in the file	Not listed in the file	Not listed in the file
Physical therapy evaluation (low complexity): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Physical therapy evaluation (moderate complexity) CPT 97162 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PT EVAL MOD COMPLEX 30 MIN	Not listed in the file	Not listed in the file	Not listed in the file
Physical therapy evaluation (moderate complexity): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Physical therapy evaluation (high complexity) CPT 97163 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PT EVAL HIGH COMPLEX 45 MIN	Not listed in the file	Not listed in the file	Not listed in the file
Physical therapy evaluation (high complexity): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Psychotherapy, 30 minutes CPT 90832 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PSYTX W PT 30 MINUTES	Not listed in the file	Not listed in the file	Not listed in the file
Psychotherapy, 30 minutes: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Psychotherapy, 45 minutes CPT 90834 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PSYTX W PT 45 MINUTES	Not listed in the file	Not listed in the file	Not listed in the file
Psychotherapy, 45 minutes: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Psychotherapy, 60 minutes CPT 90837 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PSYTX W PT 60 MINUTES	Not listed in the file	Not listed in the file	Not listed in the file
Psychotherapy, 60 minutes: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Family psychotherapy, without the patient CPT 90846 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: FAMILY PSYTX W/O PT 50 MIN	Not listed in the file	Not listed in the file	Not listed in the file
Family psychotherapy, without the patient: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Family psychotherapy, with the patient CPT 90847 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: FAMILY PSYTX W/PT 50 MIN	Not listed in the file	Not listed in the file	Not listed in the file
Family psychotherapy, with the patient: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Group psychotherapy CPT 90853 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: GROUP PSYCHOTHERAPY	Not listed in the file	Not listed in the file	Not listed in the file
Group psychotherapy: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Procedures and surgery

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Removal of breast growth (open surgery) CPT 19120 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: REMOVAL OF BREAST LESION	Not listed in the file	Not listed in the file	Not listed in the file
Removal of breast growth (open surgery): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Total hip replacement CPT 27130 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: TOTAL HIP ARTHROPLASTY	Not listed in the file	Not listed in the file	Not listed in the file
Total hip replacement: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Total knee replacement CPT 27447 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: TOTAL KNEE ARTHROPLASTY	Not listed in the file	Not listed in the file	Not listed in the file
Total knee replacement: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Shoulder arthroscopy: shaving of shoulder bone CPT 29826 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: SHO ARTHRS SRG DECOMPRESSION	Not listed in the file	Not listed in the file	Not listed in the file
Shoulder arthroscopy: shaving of shoulder bone: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Knee arthroscopy: removal of torn cartilage (meniscus) CPT 29881 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: KNEE ARTHROSCOPY/SURGERY	Not listed in the file	Not listed in the file	Not listed in the file
Knee arthroscopy: removal of torn cartilage (meniscus): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Removal of tonsils and adenoids (under age 12) CPT 42820 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: REMOVE TONSILS AND ADENOIDS	Not listed in the file	Not listed in the file	Not listed in the file
Removal of tonsils and adenoids (under age 12): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Upper GI endoscopy (diagnostic) CPT 43235 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: EGD DIAGNOSTIC BRUSH WASH	Not listed in the file	Not listed in the file	Not listed in the file
Upper GI endoscopy (diagnostic): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Upper GI endoscopy with biopsy CPT 43239 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: EGD BIOPSY SINGLE/MULTIPLE	Not listed in the file	Not listed in the file	Not listed in the file
Upper GI endoscopy with biopsy: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Colonoscopy (diagnostic) CPT 45378 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: DIAGNOSTIC COLONOSCOPY	Not listed in the file	Not listed in the file	Not listed in the file
Colonoscopy (diagnostic): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Colonoscopy with biopsy CPT 45380 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: COLONOSCOPY AND BIOPSY	Not listed in the file	Not listed in the file	Not listed in the file
Colonoscopy with biopsy: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Colonoscopy with removal of polyps (snare) CPT 45385 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: COLONOSCOPY W/LESION REMOVAL	Not listed in the file	Not listed in the file	Not listed in the file
Colonoscopy with removal of polyps (snare): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Ultrasound of the lower bowel by endoscope CPT 45391 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: COLONOSCOPY W/ENDOSCOPE US	Not listed in the file	Not listed in the file	Not listed in the file
Ultrasound of the lower bowel by endoscope: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Screening colonoscopy (not high risk) HCPCS G0121 · Inpatient or outpatient · Hospital (facility) fee In the file: COLONOSCOPY FLEXIBLE WITH W/O BIOPSY	$640	$480	$544 – $640
Screening colonoscopy (not high risk): 10 of 14 insurance plan rates Aetna — All: $640 Allegiance — All: $576 Amerigroup — All: $640 Coordinated Care — All: $640 First Choice Health — All: $576 Health Alliance — All: $640 Health Options — All: $640 Labor and Industries — All: $640 Medicare — Advantage: $640 Molina — All: $640
Gallbladder removal by laparoscope CPT 47562 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: LAPAROSCOPIC CHOLECYSTECTOMY	Not listed in the file	Not listed in the file	Not listed in the file
Gallbladder removal by laparoscope: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Groin (inguinal) hernia repair, age 5 or older CPT 49505 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: PRP I/HERN INIT REDUC >5 YR	Not listed in the file	Not listed in the file	Not listed in the file
Groin (inguinal) hernia repair, age 5 or older: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Prostate biopsy CPT 55700 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: BIOPSY OF PROSTATE	Not listed in the file	Not listed in the file	Not listed in the file
Prostate biopsy: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Prostate removal by laparoscope (radical prostatectomy) CPT 55866 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: LAPS SURG PRST8ECT RPBIC RAD	Not listed in the file	Not listed in the file	Not listed in the file
Prostate removal by laparoscope (radical prostatectomy): 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Hysteroscopy with biopsy of the uterus lining CPT 58558 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: HYSTEROSCOPY BIOPSY	Not listed in the file	Not listed in the file	Not listed in the file
Hysteroscopy with biopsy of the uterus lining: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Spinal injection, lower back (epidural), with imaging guidance CPT 62323 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: NJX INTERLAMINAR LMBR/SAC	Not listed in the file	Not listed in the file	Not listed in the file
Spinal injection, lower back (epidural), with imaging guidance: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Nerve root injection, lower back, with imaging guidance CPT 64483 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: NJX AA&/STRD TFRM EPI L/S 1	Not listed in the file	Not listed in the file	Not listed in the file
Nerve root injection, lower back, with imaging guidance: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Carpal tunnel release CPT 64721 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: CARPAL TUNNEL SURGERY	Not listed in the file	Not listed in the file	Not listed in the file
Carpal tunnel release: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Laser treatment of clouding after cataract surgery CPT 66821 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: AFTER CATARACT LASER SURGERY	Not listed in the file	Not listed in the file	Not listed in the file
Laser treatment of clouding after cataract surgery: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Cataract removal with lens implant CPT 66984 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: XCAPSL CTRC RMVL W/O ECP	Not listed in the file	Not listed in the file	Not listed in the file
Cataract removal with lens implant: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Pregnancy and childbirth

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Vaginal delivery, with care before and after CPT 59400 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: OBSTETRICAL CARE	Not listed in the file	Not listed in the file	Not listed in the file
Vaginal delivery, with care before and after: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Cesarean delivery (C-section), with care before and after CPT 59510 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: CESAREAN DELIVERY	Not listed in the file	Not listed in the file	Not listed in the file
Cesarean delivery (C-section), with care before and after: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Vaginal delivery after a previous C-section, with care before and after CPT 59610 · Outpatient (no overnight stay) · Hospital (facility) fee In the file: VBAC DELIVERY	Not listed in the file	Not listed in the file	Not listed in the file
Vaginal delivery after a previous C-section, with care before and after: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Hospital stays (whole stay, MS-DRG)

Service	Hospital charge	Cash price	Insurance rates (lowest – highest)
Heart valve or major heart-chest surgery with heart catheterization, with major complications MS-DRG 216 · Inpatient (hospital stay) · Hospital (facility) fee In the file: CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC	Not listed in the file	Not listed in the file	Not listed in the file
Heart valve or major heart-chest surgery with heart catheterization, with major complications: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Hip or knee replacement (major joint of the leg), without major complications MS-DRG 470 · Inpatient (hospital stay) · Hospital (facility) fee In the file: MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC	Not listed in the file	Not listed in the file	Not listed in the file
Hip or knee replacement (major joint of the leg), without major complications: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Neck (cervical) spinal fusion, without complications MS-DRG 473 · Inpatient (hospital stay) · Hospital (facility) fee In the file: CERVICAL SPINAL FUSION WITHOUT CC/MCC	Not listed in the file	Not listed in the file	Not listed in the file
Neck (cervical) spinal fusion, without complications: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)
Uterus and ovary surgery (not for cancer), without complications MS-DRG 743 · Inpatient (hospital stay) · Hospital (facility) fee In the file: UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC	Not listed in the file	Not listed in the file	Not listed in the file
Uterus and ovary surgery (not for cancer), without complications: 10 of 14 insurance plan rates Aetna — All: 100% (a percentage in the contract, not a dollar amount) Allegiance — All: 90% (a percentage in the contract, not a dollar amount) Amerigroup — All: 100% (a percentage in the contract, not a dollar amount) Coordinated Care — All: 100% (a percentage in the contract, not a dollar amount) First Choice Health — All: 90% (a percentage in the contract, not a dollar amount) Health Alliance — All: 100% (a percentage in the contract, not a dollar amount) Health Options — All: 100% (a percentage in the contract, not a dollar amount) Labor and Industries — All: 100% (a percentage in the contract, not a dollar amount) Medicare — Advantage: 100% (a percentage in the contract, not a dollar amount) Molina — All: 100% (a percentage in the contract, not a dollar amount)

Source: Three Rivers Hospital’s standard charges file (trh.goredde.com, CSV, CMS template 3.0.0; it can be a very large file), last updated by the hospital on March 29, 2026; retrieved November 1, 2026. The hospital’s price transparency page →

Found through the hospital’s cms-hpt.txt file, as required by the federal hospital price transparency rule (CMS). We show a selection of common services; the file has every item and service.

Hospital information

Hospital type	Critical Access Hospital
Address	507 Hospital Way, Brewster, WA 98812
County	Okanogan County
State	Washington
Phone	(509) 689‑2517
Emergency services	Yes
Ownership	Government - Hospital District or Authority
Medicare overall rating	Not rated by CMS
CMS Certification Number	501324
Name in Medicare records	THREE RIVERS HOSPITAL
Profile level	Medicare data + hospital website
Official website	threerivershospital.net
Corrections	Report an error or suggest an update →

Sources

Hospital General Information — Centers for Medicare & Medicaid Services (CMS), data updated 2026-07-22, retrieved 2026-10-29
Medicare Care Compare — official Medicare profile of this hospital
U.S. Census Bureau Geocoder — map position used for distances

From the hospital’s website

Numbers match the citations above. Checked 2026-10-30.

Three Rivers Hospital — threerivershospital.net
Emergency Care — threerivershospital.net
Radiology - Three Rivers Hospital — threerivershospital.net
Patients and Visitors - Three Rivers Hospital - Brewster, WA — threerivershospital.net
Laboratory Services & Blood Draws - Three Rivers Hospital - Brewster, WA — threerivershospital.net
Services - Three Rivers Hospital — threerivershospital.net
Advanced Wound Care - Three Rivers Hospital - Brewster, WA — threerivershospital.net

Three Rivers Hospital

Summary

Profile from official sources

At a glance