Emergency visit, high (level 4) at Intermountain Health Good Samaritan Medical Center. CPT 99284.
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)
$5,610list price
$424–$5,032range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $1,038 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $1,290 |
| Kaiser Perm HMO | Kaiser Out Of State | $1,290 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $1,290 |
| Kaiser Self Funded | Kaiser Self Funded | $1,290 |
| Kaiser Perm PPO/POS | Kaiser Perm PPO/POS | $1,309 |
| Allegiance | Cigna Sclhs Employees | $1,402 |
| Aetna | Aetna Colorado Preferred | $2,087 |
| BCBS/Anthem | BCBS Co Federal | $2,232 |
| BCBS/Anthem | BCBS Co HMO | $2,232 |
| BCBS/Anthem | BCBS Co PPO | $2,232 |
| Aetna | Aetna HMO/EPO | $2,238 |
| Aetna | Aetna Indemnity | $2,238 |
| Aetna | Aetna Other | $2,238 |
| Aetna | Aetna POS/Qpos | $2,238 |
| Aetna | Aetna PPO | $2,238 |
| Aetna | Aetna Src | $2,238 |
| Choicecare Humana | Choicecare Humana HMO EPO | $2,356 |
| Choicecare Humana | Choicecare Humana PPO | $2,356 |
| Cigna | Cigna HMO | $3,212 |
| Cigna | Cigna Indemnity | $3,212 |
| Cigna | Cigna Local Plus | $3,212 |
| Cigna | Cigna Other | $3,212 |
| Cigna | Cigna POS/Qpos | $3,212 |
| Cigna | Cigna PPO | $3,212 |
| Cigna | Eighth Dist Elect Ben Pln | $3,212 |
| Cigna | Health-Partners | $3,212 |
| Geha | Geha | $3,254 |
| Geha | Geha Mcr Supplemental | $3,254 |
| United Healthcare | All Savers Alternative Funding | $3,254 |
Inpatient
—cash price (self-pay)
$5,610list price
$1,655–$5,610range insurers pay
| Insurance plan | Negotiated rate |
|---|---|
| Kaiser Perm HMO | Kp Select HMO | $1,655 |
| Kaiser Perm HMO | Kaiser HMO Exchange Plan | $2,363 |
| Kaiser Perm HMO | Kaiser Out Of State | $2,363 |
| Kaiser Perm HMO | Kaiser Permanente HMO | $2,363 |
| Kaiser Self Funded | Kaiser Self Funded | $2,363 |
| Kaiser Perm PPO/POS | Kaiser Perm PPO/POS | $2,435 |
| Private Hlthcare Sys | Phcs Other | $4,207 |
| Private Hlthcare Sys | Phcs PPO | $4,207 |
| BCBS/Anthem | BCBS Co Indemnity | $4,722 |
| Multiplan Inc | Multiplan Inc Other | $4,768 |
| Multiplan Inc | Multiplan Inc PPO | $4,768 |
| Aetna | Aetna Nap | $5,032 |
| Cigna | Cigna HMO | $5,610 |
| Cigna | Cigna Indemnity | $5,610 |
| Cigna | Cigna Local Plus | $5,610 |
| Cigna | Cigna Other | $5,610 |
| Cigna | Cigna POS/Qpos | $5,610 |
| Cigna | Cigna PPO | $5,610 |
| Cigna | Eighth Dist Elect Ben Pln | $5,610 |
| Cigna | Health-Partners | $5,610 |
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All common services at Intermountain Health Good Samaritan Medical Center