Emergency visit, high (level 4) at Good Samaritan Hospital (GSH). CPT 99284.
What Good Samaritan Hospital (GSH) publishes for this service, straight from its standard-charges file, last updated April 1, 2026.
Outpatient / ER
$875cash price (self-pay)
$1,458list price
$97.50–$2,000range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Aetna | Medicaid | $97.50 |
| Anthem Pathways | Medicaid | $97.50 |
| Anthem | Medicaid | $104 |
| Caresource HIP | Medicaid | $104 |
| Caresource | Medicaid | $104 |
| Anthem HIP | HIP | $104 |
| BCBS | Medicare Advantage | $104 |
| Aetna | Medicare Advantage | $276 |
| Allwell | MCR ADV/PPO/HMO | $276 |
| Anthem MCR | MCR ADV/PPO/HMO | $276 |
| Anthem MCR | Medicare Advantage | $276 |
| Anthem | MCR ADV/PPO/HMO | $276 |
| Cigna | Medicare Advantage | $276 |
| Humana | Medicare Advantage | $276 |
| United Healthcare | Medicare Advantage | $276 |
| Alliance Coal | Commercial | $398 |
| CareSource | Commercial | $401 |
| Indiana University | MCR ADV/PPO/HMO | $441 |
| MHS Ambetter | Commercial | $441 |
| Hope Trust | Commercial | $553 |
| Aetna | Commercial | $582 |
| Encore Prime | Commercial | $707 |
| Amish | Commercial | $729 |
| Anthem | Exchange | $832 |
| United Healthcare | Commercial | $956 |
| Anthem | Trad/PPO/HMO | $1,040 |
| OneCare | Commercial | $1,111 |
| Indiana University | Commercial | $1,111 |
| Direct Health | Direct Health | $1,118 |
| SIHO | Commercial | $1,118 |
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