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Clinic Pricing

These rates show our standard fees for common procedures provided by our office.  We are happy to offer you a 20% cash discount if you don’t have insurance and if you pay in full at the time of service.

 If you have health insurance, these rates will be discounted according to our contract with your insurance company. If you have insurance and would like to get an estimate of your cost, please contact your insurance provider beforehand.

 If you have any questions or concerns with your bill, need to make payment arrangements or discuss assistance with resolving your debt, please call our billing office at 801-894-1335.

Office Visits

  • 99211 Established Patient Office Visit, Level 1 $38
  • 99212 Established Patient Office Visit, Level 2 $67
  • 99213 Established Patient Office Visit, Level 3 $114
  • 99214 Established Patient Office Visit, Level 4 $168
  • 99215 Established Patient Office Visit, Level 5 $227
  • 99051 Medical Services After Hours, Office $31
  • 99202 New Patient Office Visit, Level 2 $115
  • 99203 New Patient Office Visit, Level 3 $169
  • 99204 New Patient Office Visit, Level 4 $260
  • 99205 New Patient Office Visit, Level 5 $325

Fracture Care

  • 29075 Application of Forearm Cast $160
  • 27786 Closed Treat Distal Fibular Fracture $614
  • 25500 Closed Treatment, Distal Radial Fracture w/o manipulation $524
  • 26720 Closed Treatment, Finger/Thumb Fracture w/o manipulation $383
  • 26605 Closed Treatment, Metacarpal fracture w/o manipulation $660
  • 28470 Treat Metatarsal Fracture $429

Hospital Care

  • 99231 Follow-up Hospital Care, brief $65
  • 99232 Follow-up Hospital Care, moderate $96
  • 99233 Follow-up Hospital Care, extensive $138
  • 99238 Hospital Discharge, day care $108
  • 99460 Initial Care, normal newborn $208
  • 99222 Initial Hospital Care, moderate $184
  • 99223 Initial Hospital Care, high $271
  • 99479 Sub Intensive Care, ea day, low birth wgt $312

Immunizations

  • 90715 Adacel (TDaP) $75
  • 90716 Chicken Pox Vaccine $147
  • 90696 DTaP, Polio (Quadracel) $85
  • 90649 Gardasil (HPV) $284
  • 90648 Homphilus influenza B vaccine (HIB) $42
  • 90633 Hepatitis A Vaccine, pediatric/adolescent $108
  • 90632 Hepatitis A Vaccine, adult dose $121
  • 90746 Hepatitis B Vaccine, adult $121
  • 90744 Hepatitis B Vaccine, pediatric $57
  • 90471 Immunization admin 1 vaccine $33
  • 90472 Immunization admin ea additional vaccine, single/combo $22
  • 90473 Immunization administration intranasal/oral 1 vaccine $35
  • 90687 Influenza virus Vaccine, 6-35 months $23
  • 90686 Influenza virus Vaccine, 3 years and up $25
  • 90707 Measles Mumps Rubella (MMR) $85
  • 90734 Meningococcal Vaccine, IM $165
  • 90723 Pediarix – DTaP – HEP B – IPV $123
  • 90670 Pneumococcal (Prevnar), under 5 years $271
  • 90713 Poliomyelitis vaccine $56
  • 90681 Rotavirus vaccine, live, oral $116
  • 90750 Zoster vaccine RZV (Shingrix) $180
  • 90736 Zoster vaccine ZVL (Zostavax) $275

Injections

  • J2175 Demerol per 100 MG $20
  • J1055 Depo Provera 150 MG $112
  • J7321 Hyalgan Injection per dose $200
  • J0696 Rocephin Injection per 250 MG $10

Laboratory Tests

  • 86677 Antibody, Helicobacter Pylori $56
  • 84443 Assay thyroid stimulation hormone $46
  • 87804 Ingct Antigen, Influenza $45
  • 84154 Assay, PSA, total $50
  • 84479 Assay, thyroid hormone $14
  • 82043 Assay, albumin, urine microalbumin $39
  • 85025 Automated hemogram (CBC) $22
  • 36415 Blood draw (Venipuncture), finger/heel/ear $12
  • 87086 Culture, bacterial; quant colony urine $29
  • 82950 Glucose test $41
  • 83036 Glycosylated hemoglobin assay $31
  • 85018 Hemoglobin count, colorimetric $16
  • 80076 Hepatic Function Panel $30
  • 80061 Lipid profile $44
  • 80048 Metabolic Panel, basic $27
  • 80053 Metabolic Panel, comprehensive $44
  • 85610 Prothrombin time (Protime) $17
  • 85651 RBC Sedimentation rate, non-auto $18
  • 99000 Specimen handling/transport $20
  • 87880 Streptococcus, Group A $26
  • 81001 Urinalysis, automated w/ microscopy $15
  • 84439 Assay, Free Thyroxine $35
  • 82570 Assay, Creatinine, Other Sources $29
  • 82947 Assay Body Fluid, Glucose $17
  • 80305 Drug Test PRSMV Dir OPT OBS $51
  • 87491 Infct Antigen, Chlamydia Trac, Ampl $67
  • 87591 Infct Antigen, Neisseria Gon Ampl $67
  • 81025 Urine Pregnancy Test $34
  • 86580 TB Intradermal Test $19
  • 87804 Infct Antigen, Influenza $45

Lacerations

  • 12015 Repair superficial wounds, face $275
  • 12001 Repair superficial wounds, trunk $221

Obstetrics

  • 59426 Ante partum care only, 7+ visits $1,250
  • 59514 Caesarean delivery only $1,774
  • 80055 Obstetric Profile $85
  • 59400 Routine Obstetric Care $3,360
  • 59510 Routine care and caesarean delivery $3,780
  • 59610 VBAC delivery, routine obstetric care $3,400
  • 59409 Vaginal delivery only $1,460

Office Procedures

  • 90524 Allergy Skin Tests, Percutaneous $11 each
  • 93015 Cardiovascular stress test using Treadmill $274
  • 54150 Circumcision, clamp procedure, newborn $250
  • 17000 Destroy benign/premalignant lesion, 1st $116
  • 17110 Destroy flat wart, up to 14 lesions $189
  • 10060 Drain skin abscess, simple/single $205
  • 20605 Drain/inject intermediate joint/bursa $141
  • 20610 Drain/inject major joint or bursa $145
  • 93224 ECG Monitor/24 hrs, Complete (Holter Monitor) $274
  • 93000 EKG 12 Leads $44
  • 58100 Endometrial Biopsy, w/o Cervical DI $185
  • 59025 Fetal Non-Stress Test $109
  • 58300 Insert Intrauterine Device (IUD) $154
  • J7300 IUD copper Para Guard $938
  • J7298 IUD Mirena $1,089
  • 94640 Non Pressurized Inhalation Treatment $38
  • 11750 Permanent removal of nail bed $371
  • 69210 Removal of impacted cerumen $85
  • 58301 Remove Intrauterine Device (IUD) $162
  • 11200 Removal of skin tags, up to 15 $158
  • 95806 Sleep Study, Unattended $350
  • 94010 Spirometer $65
  • 55450 Vasectomy $925

Preventative Care

  • 99391 Preventive Checkup, established infant $143
  • 99392 Preventive Checkup, established 1-4 yrs $154
  • 99393 Preventive Checkup, established 5-11 yrs $164
  • 99394 Preventive Checkup, established 12-17 yrs $178
  • 99395 Preventive Checkup, established 18-39 yrs $185
  • 99396 Preventive Checkup, established 40-64 yrs $196
  • 99397 Preventive Checkup, established, 65+ $228
  • 99381 Preventive Checkup, new, infant $160
  • 99382 Preventive Checkup, new, 1-4 yrs $166
  • 99383 Preventive Checkup, new, 5-11 yrs $181
  • 99384 Preventive Checkup, new, 12-17 yrs $197
  • 99385 Preventive Checkup, new, 18-39 yrs $191
  • 99386 Preventive Checkup, new, 40-64 yrs $230
  • 99387 Preventive Checkup, new, 65+ $255

Surgeries

  • 29898 Arthscpy Ankle Debrid Extensive $1,200
  • 29826 Arthscpy Shldr Decompression $1,418
  • 57455 Colposcopy w/ biopsy of cervix $240
  • 58565 Hysteroscopy/sterilization $3,400
  • 58563 Hysteroscopy w/ endometrial ablation $3,695
  • 29880 Knee Arthscpy Mnsctmy Medial or Lat $1,400
  • 57288 Repair bladder defect $1,276
  • 24341 Repair Tendon/Muscle upper arm/elbow $1,475
  • 57260 Repair of vagina $1,460
  • 27130 Total Hip Arthroplasty & Prosthesis $3,800
  • 58150 Total hysterectomy $1,700
  • 58152 Total hysterectomy with suspension $2,114
  • 58260 Vaginal hysterectomy $2,050

Ultra Sounds

  • 76770 U/S abdomen (Renal U/S) $215
  • 76700 U/S abdomen, complete $281
  • 76801 U/S OB < 14 weeks single fetus $258
  • 76805 U/S OB complete, routine 20 weeks $280
  • 76856 U/S pelvic B scan complete $280
  • 76870 U/S testicle/scrotal $206

X-Rays

  • 74018 Abdomen, single AP View $61
  • 73610 Ankle, complete minimum 3 views $70
  • 71045 Chest 1 view AP $60
  • 71046 Chest AP and Lateral $71
  • 77080 Dexa Bone Density, Axial (hips, pelvis, spine) $190
  • 73620 Foot AP and Lateral views $68
  • 73630 Foot, complete minimum 3 views $70
  • 73120 Hand, 2 views $54
  • 73130 Hand, minimum of 3 views $66
  • 73562 Knee, complete 3 views $88
  • 72100 Spine lumbosacral AP and Lateral $79
  • 73590 Tibia and Fibula AP and Lateral $72
  • 73110 Wrist complete, minimum 3 views $76
Last updated October 22, 2018