Emergency visit, high (level 4) at Good Samaritan Hospital. CPT 99284.
What Good Samaritan Hospital publishes for this service, straight from its standard-charges file, last updated June 29, 2026.
Outpatient / ER
$7,011cash price (self-pay)
$7,011list price
$193–$11,599range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Beacon Commercial | Beacon Commercial | $193 |
| Oxford Exchange | Oxford Exchange | $1,530 |
| UHC Exchange | UHC Exchange | $1,530 |
| Oxford Commercial | Oxford Commercial | $1,718 |
| UHC Commercial | UHC Commercial | $1,800 |
| UHC Empire | UHC Empire | $1,800 |
| Emblem Select Care (Exchange) | Emblem Select Care (Exchange) | $1,943 |
| Beacon Medicare | Beacon Medicare | $2,017 |
| Hamaspik (Mcr) | Hamaspik (Mcr) | $2,017 |
| Medicare Managed | Medicare Managed | $2,017 |
| Mvp Gold (Mcr) | Mvp Gold (Mcr) | $2,017 |
| World Trade Center Fdny | World Trade Center Fdny | $2,017 |
| World Trade Center Other | World Trade Center Other | $2,017 |
| Medicare | Medicare | $2,018 |
| Emblem Ghi/Hip Medicare | Emblem Ghi/Hip Medicare | $2,057 |
| SELF-PAY - CC 30% | SELF-PAY - CC 30 PerCent | $2,103 |
| Affinity By Molina Mcr | Affinity By Molina Mcr | $2,117 |
| Health First Medicare | Health First Medicare | $2,158 |
| Emblem Ghi/Hip HMO/EPO/POS | Emblem Ghi/Hip HMO/EPO/POS | $2,286 |
| Emblem Ghi/Hip PPO | Emblem Ghi/Hip PPO | $2,286 |
| Beacon Exchange | Beacon Exchange | $2,420 |
| Magnacare Preferred | Magnacare Preferred | $2,434 |
| Mvp Exchange | Mvp Exchange | $2,442 |
| Aetna HP Network | Aetna HP Network | $2,676 |
| Cdphp | Cdphp | $2,687 |
| Mvp HMO/PPO | Mvp HMO/PPO | $2,873 |
| Aetna | Aetna | $2,973 |
| Aetna Employee | Aetna Employee | $2,973 |
| Tricare | Tricare | $3,330 |
| Cigna PPO | Cigna PPO | $4,908 |
Inpatient
$7,011cash price (self-pay)
$7,011list price
$2,103–$4,908range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| SELF-PAY - CC 30% | SELF-PAY - CC 30 PerCent | $2,103 |
| Cdphp | Cdphp | $3,506 |
| Self-Pay - Cc 50% | Self-Pay - Cc 50 | $3,506 |
| Magnacare Standard | Magnacare Standard | $4,908 |
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