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    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
    Vaccines
    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

    Glossary

    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.



    Disclaimer
    Please check with your health plan if you need help understanding your benefits for the service chosen. Uninsured patients may be eligible for discounts.