Emergency visit, high (level 4) at CHI Health Good Samaritan. CPT 99284.
What CHI Health Good Samaritan publishes for this service, straight from its standard-charges file, last updated February 28, 2026.
Outpatient / ER
$1,010cash price (self-pay)
$1,655list price
$230–$4,242range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Medica | Commercial|ACO | $230 |
| Amerigroup | Medicaid|All Plans | $347 |
| Centene | Medicaid|IA Total Care | $347 |
| United | Medicaid|Community Plan | $348 |
| Centene | Medicaid|NE Total Care | $351 |
| IAMolina | Medicaid|All Plans | $354 |
| BCBS - NE | Medicare|All Plans | $403 |
| Humana | Medicare|All Plans | $403 |
| Medica | Medicare|All Plans | $403 |
| PACE | Medicare|All Plans | $403 |
| United | Medicare|All Plans | $403 |
| Centene | Medicare|All Plans | $415 |
| Amerigroup | Medicare|All Plans | $423 |
| Great Plains | Medicare|All Plans | $423 |
| Creighton University Employees | Commercial|All Plans | $811 |
| AMPS | Commercial|All Plans | $895 |
| ELAP | Commercial|All Plans | $960 |
| Medica | Commercial|CHI Health | $1,035 |
| Medica | Commercial|All Other Plans | $1,215 |
| United | Commercial|All Plans | $1,258 |
| Medica | Commercial|Open Access | $1,291 |
| Midlands Choice | Commercial|Premier | $1,291 |
| Midlands Choice | Commercial|Standard | $1,523 |
| MultiPlan PHCS | Commercial|All Plans | $1,539 |
| Greater Omaha Packing | Commercial|Narrow Network | $3,688 |
| Millard Public Schools | Commercial|Narrow Network | $3,688 |
| One World | Commercial|Narrow Network | $3,688 |
| Greater Omaha Packing | Commercial|Broad Network | $4,242 |
| Millard Public Schools | Commercial|Broad Network | $4,242 |
| One World | Commercial|Broad Network | $4,242 |
Inpatient
$1,010cash price (self-pay)
$1,655list price
$811–$1,539range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Creighton University Employees | Commercial|All Plans | $811 |
| United | Commercial|All Plans | $1,258 |
| Medica | Commercial|Open Access | $1,291 |
| Midlands Choice | Commercial|Premier | $1,291 |
| Midlands Choice | Commercial|Standard | $1,523 |
| MultiPlan PHCS | Commercial|All Plans | $1,539 |
Billed more than this?
Scan my billSnap a photo of your bill. We compare every line with these prices and coding rules, free.