MRI lower back without contrast at Intermountain Health Good Samaritan Medical Center. CPT 72148.
What Intermountain Health Good Samaritan Medical Center publishes for this service, straight from its standard-charges file, last updated March 22, 2026.
Outpatient / ER
—cash price (self-pay)
$3,191list price
$240–$2,862range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $590 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $734 |
| Kaiser Perm HMO | Kaiser Out Of State | $734 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $734 |
| Allegiance | Cigna Sclhs Employees | $798 |
| Cigna Scl Employees | Cigna Sclhs Cdhp | $798 |
| Cigna | Cigna Co Public Option | $812 |
| Cigna | Cigna Connect Exchange | $812 |
| Cigna | Cigna Surefit | $812 |
| Aetna | Aetna Colorado Preferred | $1,187 |
| BCBS/Anthem | BCBS Co Federal | $1,270 |
| BCBS/Anthem | BCBS Co HMO | $1,270 |
| BCBS/Anthem | BCBS Co PPO | $1,270 |
| Aetna | Aetna HMO/EPO | $1,273 |
| Aetna | Aetna Indemnity | $1,273 |
| Aetna | Aetna Other | $1,273 |
| Aetna | Aetna POS/Qpos | $1,273 |
| Aetna | Aetna PPO | $1,273 |
| Aetna | Aetna Src | $1,273 |
| Geha | Geha-Asa | $1,273 |
| Preferred One | Preferred One | $1,273 |
| Choicecare Humana | Choicecare Humana HMO EPO | $1,340 |
| Choicecare Humana | Choicecare Humana PPO | $1,340 |
| Cigna | Cigna HMO | $1,827 |
| Cigna | Cigna Indemnity | $1,827 |
| Cigna | Cigna Local Plus | $1,827 |
| Cigna | Cigna Other | $1,827 |
| Cigna | Cigna POS/Qpos | $1,827 |
| Cigna | Cigna PPO | $1,827 |
| Cigna | Eighth Dist Elect Ben Pln | $1,827 |
Inpatient
—cash price (self-pay)
$3,191list price
$941–$3,191range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $941 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $1,344 |
| Kaiser Perm HMO | Kaiser Out Of State | $1,344 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $1,344 |
| Kaiser Self Funded | Kaiser Self Funded | $1,344 |
| Kaiser Perm PPO/POS | Kaiser Perm PPO/POS | $1,385 |
| Private Hlthcare Sys | Phcs Other | $2,393 |
| Private Hlthcare Sys | Phcs PPO | $2,393 |
| BCBS/Anthem | BCBS Co Indemnity | $2,686 |
| Multiplan Inc | Multiplan Inc Other | $2,712 |
| Multiplan Inc | Multiplan Inc PPO | $2,712 |
| Aetna | Aetna Nap | $2,862 |
| Cigna | Cigna HMO | $3,191 |
| Cigna | Cigna Indemnity | $3,191 |
| Cigna | Cigna Local Plus | $3,191 |
| Cigna | Cigna Other | $3,191 |
| Cigna | Cigna POS/Qpos | $3,191 |
| Cigna | Cigna PPO | $3,191 |
| Cigna | Eighth Dist Elect Ben Pln | $3,191 |
| Cigna | Health-Partners | $3,191 |
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All common services at Intermountain Health Good Samaritan Medical Center