Sutter Gould Medical Foundation
Charges for Frequently Used Doctor Services
The services below have drop-down menus that show charges for frequently used services provided by Sutter Gould Medical Foundation. The amounts you see are the most you would pay before any discounts that may be available to you. The charges also do not include any additional procedures that may be done as part of the visit.
Cost Estimator Tool
You can use our new online Cost Estimator tool to find out what medical care costs are for more than 225 most frequently used medical services. Select up to five services, and the location you would like to receive the service to see an estimate of your costs.
Online Cost Estimator Tool
Charges for Common Services
Charges for lab tests and vaccines do not include specimen collection fees or fees associated with administering vaccines.
Last updated: January 2016
If you can’t find the service you are looking for, please call (866) 961-8539.
- Doctor's Office Visit
Common Charges for Doctor's Office Visit Service Estimated Charge Doctor's Office Visit for a New Patient Nurse Visit $121 Low-to-Moderate Level Visit $205 Moderate Level Visit $295 Moderate-to-High Level Visit $447 High Level Visit $553 Doctor's Office Visit for an Established Patient Nurse Visit $69 Low-to-Moderate Level Visit $125 Moderate Level Visit $197 Moderate-to-High Level Visit $294 High Level Visit $393 Doctor's Office Visit for a Specialist Consultation Nurse Visit $125 Low-to-Moderate-Level $234 Moderate-Level $319 Moderate-to-High-Level $472 High-Level $576
- Eye Exams
Common Charges for Eye Exams Service Estimated Charge Eye Exams New Patient Intermediate Eye Exam $226 New Patient Comprehensive Eye Exam $412 Established Patient Intermediate Eye Exam $238 Established Patient Comprehensive Eye Exam $344 Eye Refraction for Vision Correction $45
- Physical/Occupational Therapy
Common Charges for Physical Therapy Service Estimated Charge Physical/Occupational Therapy Physical Therapy Evaluation $274 Physical Therapy Re-evaluation $187 Occupational Therapy Evaluation $265 Occupational Therapy Re-evaluation $176
- Allergy Injections
Common Charges for Allergy Injections Service Estimated Charge Allergy Injections Allergy shot - single injection $33 Allergy shot - two or more injections $38
- Diagnostic Imaging
Common Charges for Diagnostic Imaging Service Estimated Charge Diagnostic Imaging Abdomen CT Scan $622 Abdomen CT Scan with and without dye $1,133 Abdomen CT Scan, including dye $984 Abdomen X-ray $85 Abdomen/Pelvis CT scan $801 Abdomen/Pelvis CT scan with and without dye $1,423 Abdomen/Pelvis CT scan, including dye $1,215 Abdominal ultrasound $497 Abdominal ultrasound, limited $382 Ankle X-ray (3+ views) $120 Bone density scan (dexa scan) $175 Brain MRI with and without dye $1,992 Brain MRI without dye $1,526 Breast MRI with and without dye $2,190 Breathing Test $130 Bronchography $126 Cardiac Stress Test, complete $274 Cervical Spine MRI without dye $1,348 Cervical Spine X-ray, minimum 4-5 views $171 Chest CT scan $741 Chest CT scan, including dye $926 Chest X-ray (One views) $82 Chest x-ray (two views) $107 Digital Mammogram, bilateral $587 Digital Mammogram, unilateral $463 Digital Mammogram, screening $482 Elbow X-ray, complete $120 Electrocardiogram (ECG) $62 Femur X-ray (1 view) $132 Femur X-ray (2+ views) $154 Finger X-ray $122 Foot X-ray (complete) $113 Hand X-ray, complete $116 Head CT scan $582 Hearing Threshold Evaluation $126 Hearing Tone Screen $44 Hip X-ray (1 view) $140 Hip X-ray (2-3 views) $196 Hip X-ray (4+ views) $245 Knee MRI without dye $979 Knee X-ray 3 views $134 Knee X-ray one or two views $110 Knee X-ray, bilateral $128 Knee X-ray, complete, 4+ views $157 Lumbar Spine MRI without dye $1,331 Lumbar spine x-ray (two or three views) $127 Middle-Ear Function Test $48 Pelvic ultrasound exam, complete $440 Pelvis CT Scan $611 Pelvis CT Scan, including dye $968 Pelvis MRI $1,507 Pelvis X-ray, AP view only $102 Radiologic Stress Test $1,755 Scan of Extracranial Arteries $854 Shoulder X-ray complete $109 Sinus CT scan $805 Stress Test w/ Doppler $657 Stress Test w/ Echo $810 Toe X-ray, minimum 2 views $110 Transvaginal ultrasound $262 Ultrasound breast complete $374 Ultrasound breast limited $307 Upper Extremity Joint MRI without dye $979 Wrist X-ray, 2 views $114 Wrist X-ray, complete $136
- Pregnancy & Prenatal Tests
Common Charges for Pregnancy & Prenatal Tests Service Estimated Charge Pregnancy & Prenatal Tests Fetal non-stress test $163 Pregnancy ultrasound, first trimester $446 Pregnancy ultrasound, after first trimester $522 Obstetric ultrasound, Limited $318 Obstetric ultrasound - after first trimester $418 Obstetric ultrasound, transvaginal $360 Urine Pregnancy Test $13
- Lab Testing
Common Charges for Lab Testing Service Estimated Charge Lab Testing ABO Blood Typing Test $16 Acute Hepatitis Panel $262 Alkaline Phosphatase Test $28 Allergen-specific IgE Antibody Test $29 Alpha-Fetoprotein (AFP) Test $92 Amylase Test $36 Antinuclear Antibodies (ANA) Test $66 Bacterial Culture $47 Bacterial Culture, urine Test $44 Basic Metabolic Panel $47 Bilirubin Test $28 Blood Clot Test $22 Blood Folic Acid Test $81 Blood Serology (RPR) Test $23 Blood Sugar Test, monitoring $13 Calcium test $28 Carcinoembryonic Antigen Test (CEA) $104 Chickenpox Test $71 Chlamydia Test $193 Cholesterol Test $24 Chorionic Gonadotropin (hCG) Test $83 Complete Blood Count $43 Comprehensive Metabolic Panel $58 Cortisol Test $90 C-Reactive Protein (CRP) Test $28 Creatine Test $36 Creatinine Test $28 DHEA-S Test $122 Fecal Occult Blood Screening Test $18 Feces Bacteria Culture Test $52 Ferritin Test $75 Flu Test $51 Gamma Glutamyltransferase Test $40 Gammaglobulin IgE Test $91 Glucose Test $22 Gonorrhea Test $193 Hemoglobin A1c Test $53 Hemoglobin Test $13 Hepatitis B Antibody Test $59 Hepatitis B Antigen Test $57 Hepatitis C Antibody Test $78 Hepatitis C Test $236 High Sensitivity CRP Test $71 HIV-1/HIV-2 Test $75 Insulin Test $63 Iron Test $36 Lactate Dehydrogenase (LDH) Test $33 LDL Cholesterol Test $52 Lipase Test $38 Lipid Panel Test $74 Liver Function Panel $45 Magnesium Test $37 Pap Smear Test $111 Parathyroid Hormone Test $227 Phosphorus Test $26 Potassium Test $25 Prolactin Test $107 Prostate-Specific Antigen (PSA) Test $101 Protein, Urine Test $20 Rapid Strep Group A Test $51 Rheumatoid Arthritis Factor Test $31 Renal Function Panel $48 RH (D) Blood Typing Test $16 Screening Culture $36 Sedimentation Rate Test $20 Sodium Test $26 Testosterone Test $142 Thyroglobulin Test $87 Thyroid Peroxidase (TPO) Test $80 Thyroid Stimulating Hormone (TSH) Test $92 Thyroxine, free $50 Thyroxine, total $38 Transferase Alanine Amino (ALT) Test $29 Transferase Aspartate Amino (AST) Test $28 Triglycerides Test $32 Triidothyronine, free Test $93 Triidothyronine, total Test $78 Urea Nitrogen Test $22 Uric Acid Test $25 Urine Test $17 Urine Test, dipstick only $14 Vitamin B-12 Test $83
- Office Procedures
Common Charges for Office Procedures Service Estimated Charge Office Procedures Abscess Incision and Drainage $401 Apply Short-Arm Cast $302 Bronchodilation $224 Control Nosebleed, simple $330 Fluid Removal from Intermediate Joint $218 Fluid Removal from Major Joint $201 Fluid Removal from Small Joint $158 Impacted Earwax Removal $143 Inhalation Treatment $68 Injection, tendon or ligament $197 Skin Biopsy $291 Skin Lesion Destruction $193
Common Charges for Vaccines Service Estimated Charge Vaccines Chickenpox $178 Diphtheria, Tetanus, and Pertussis (DTaP) $46 Diphtheria, Tetanus, Pertussis, Hib and Polio (DTaP-Hib-IPV) $101 Flu $40 Flu - High Dose $50 Flu - Nasal Mist $40 Hepatitis A - Adult $120 Hepatitis A - Pediatric $53 Hepatitis B - Adult $96 Hepatitis B - Pediatric $76 HPV $254 Measles, Mumps, and Rubella (MMR) $100 Measles, Mumps, Rubella and Chickenpox (MMRV) $278 Meningitis $203 Pneumonia - 13 valent $259 Pneumonia - 23 valent $123 Polio (IPV) $49 Rotavirus $135 Shingles $313 Tetanus, Diphtheria, and Pertussis (Tdap) $73
New Patient Visit: A new patient is someone who has not been seen by this specialty at any Sutter Gould Medical Foundation location in the past three years.
Nurse Visit: Presenting problem is minor.
Low-to-Moderate Level Visit: Routine problem like a minor injury that may require an X-ray or a minor illness like a respiratory infection.
Moderate Level Visit: Several routine problems or a single problem, like abdominal pain, requiring multiple tests such as blood tests and X-rays.
Moderate-to-High Level Visit: Complicated problem or several problems requiring extensive exams and testing.
High Level Visit: One or more chronic illnesses with severe symptoms, a new problem requiring extensive testing or acute or chronic illness that may pose a threat to life or bodily function.
Ultrasound, limited: This test will only show fetal heart beat, placental location, fetal position, and/or amniotic fluid volume.
Please check with your health plan if you need help understanding your benefits for the service chosen. Uninsured patients may be eligible for discounts.