Emergency visit, moderate (level 3) at Intermountain Health Good Samaritan Medical Center. CPT 99283.
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)
$4,775list price
$275–$4,283range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $883 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $1,098 |
| Kaiser Perm HMO | Kaiser Out Of State | $1,098 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $1,098 |
| Kaiser Self Funded | Kaiser Self Funded | $1,098 |
| Kaiser Perm PPO/POS | Kaiser Perm PPO/POS | $1,114 |
| Allegiance | Cigna Sclhs Employees | $1,194 |
| Aetna | Aetna Colorado Preferred | $1,776 |
| BCBS/Anthem | BCBS Co Federal | $1,900 |
| BCBS/Anthem | BCBS Co HMO | $1,900 |
| BCBS/Anthem | BCBS Co PPO | $1,900 |
| Aetna | Aetna HMO/EPO | $1,905 |
| Aetna | Aetna Indemnity | $1,905 |
| Aetna | Aetna Other | $1,905 |
| Aetna | Aetna POS/Qpos | $1,905 |
| Aetna | Aetna PPO | $1,905 |
| Aetna | Aetna Src | $1,905 |
| Choicecare Humana | Choicecare Humana HMO EPO | $2,005 |
| Choicecare Humana | Choicecare Humana PPO | $2,005 |
| Cigna | Cigna HMO | $2,734 |
| Cigna | Cigna Indemnity | $2,734 |
| Cigna | Cigna Local Plus | $2,734 |
| Cigna | Cigna Other | $2,734 |
| Cigna | Cigna POS/Qpos | $2,734 |
| Cigna | Cigna PPO | $2,734 |
| Cigna | Eighth Dist Elect Ben Pln | $2,734 |
| Cigna | Health-Partners | $2,734 |
| Geha | Geha | $2,769 |
| Geha | Geha Mcr Supplemental | $2,769 |
| United Healthcare | All Savers Alternative Funding | $2,769 |
Inpatient
—cash price (self-pay)
$4,775list price
$1,409–$4,775range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $1,409 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $2,012 |
| Kaiser Perm HMO | Kaiser Out Of State | $2,012 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $2,012 |
| Kaiser Self Funded | Kaiser Self Funded | $2,012 |
| Kaiser Perm PPO/POS | Kaiser Perm PPO/POS | $2,073 |
| Private Hlthcare Sys | Phcs Other | $3,581 |
| Private Hlthcare Sys | Phcs PPO | $3,581 |
| BCBS/Anthem | BCBS Co Indemnity | $4,019 |
| Multiplan Inc | Multiplan Inc Other | $4,059 |
| Multiplan Inc | Multiplan Inc PPO | $4,059 |
| Aetna | Aetna Nap | $4,283 |
| Cigna | Cigna HMO | $4,775 |
| Cigna | Cigna Indemnity | $4,775 |
| Cigna | Cigna Local Plus | $4,775 |
| Cigna | Cigna Other | $4,775 |
| Cigna | Cigna POS/Qpos | $4,775 |
| Cigna | Cigna PPO | $4,775 |
| Cigna | Eighth Dist Elect Ben Pln | $4,775 |
| Cigna | Health-Partners | $4,775 |
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All common services at Intermountain Health Good Samaritan Medical Center