Good Faith Estimate

You have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost. Under the law, healthcare providers need to give patients who don't have insurance or who are not using insurance an estimate of the bill for medical items or services.

Patient Rights

You have the right to receive a Good Faith Estimate for the total of expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment and hospital fees.
Make sure that your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before the medical service or item. You can also ask your provider (and another provider you choose) for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Always retain a copy or picture of your specific Good Faith Estimate.
If you have questions about your Good Faith Estimate please contact us at 801-475-3500 or use the link below.

Price Estimate Questions & Disputes

Self-Pay Prices

Actual cost of services may be higher or lower, depending on many factors such as changes to treatment choices, actual services provided, complications that may arise, and any other factors considered when determining charges. Estimates are based on information provided before your visit to Ogden Clinic. Estimates are not a guarantee of the actual cost for the services to be provided to you nor are they a contract for the actual amount to be paid.

Office Visit
New patient: $111 to $254
Existing patient: $83 to $182 (Varies by complexity)

Preventive Office Visit
New patient: $159 to $237
Existing patient: $142 to $195 (Varies by age)

Vaccinations
$25 to $350 (Varies by type)

IUD Devices
$900 to $1,100 for device

Lab Services, Radiology, Injectables
Refer to charts below

GENERAL XRAYS	CPT Code	Fee
Chest ‐ 2 view	71046	$59.00
Ribs / Chest	71101	$71.00
Neck Spine 4 view	72050	$90.00
Lumbar Spine ‐ 2/3 view	72100	$72.00
Lumbar Spine ‐ 4 view	72110	$92.00
Collar Bone	73000	$52.00
Shoulder	73030	$59.00
Elbow	73080	$60.00
Forearm	73090	$50.00
Wrist	73110	$68.00
Hand	73130	$59.00
Finger(s)	73140	$61.00
Hip ‐ 2/3 view	73502	$90.00
Knee ‐ 3 view	73562	$73.00
Knee ‐ 4 view	73564	$80.00
Lower Leg	73590	$60.00
Ankle	73610	$60.00
Foot	73630	$57.00
Toe(s)	73660	$55.00
Abdomen ‐ 1 view	74018	$53.00
Abdomen ‐ 2 view	74019	$64.00
Abdomen (complete)	74022	$87.00
Urography Retrograde KUB	74420	$282.00

COMMON LABS	CPT Code	Fee
Antimicrobial Susceptibility Studies	87186	$21.00
Bacterial Culture	87070	$28.00
Basic Metabolic Panel	80048	$21.00
Blood Iron Test	83540	$16.00
Blood Type Pos+ or Neg‐	86901	$12.00
Blood Type (O, A, B, or AB)	86900	$12.00
C‐Reactive Protein	86140	$12.00
CBC (Complete Blood Count w/Auto Diffe	85025	$14.00
Chlamydia Test	87491	$67.00
Collection Fee for Helicobacter Pylori Ure	83014	$20.00
Comp Metabolic Panel, CBC, TSH Level	80050	$71.00
Comp Metabolic Panel	80053	$27.00
COVID + Flu A and B	87428	$100.00
Creatine Kinase Total	82550	$17.00
Creatinine	82570	$11.00
Culture Screening presumptive pathogenic	87081	$15.00
Ferritin	82728	$36.00
Flu A and B Rapid Antigen Test	87804	$30.00
Glucose	82950	$12.00
Glycosylated Hbg A1C	83036	$24.00
Gonorroeae Test	87591	$67.00
Helicobacter Pylori; Urea Breath Test	83013	$152.00
Hepatic Function Panel (ALP, ALT, AST, Dire)	80076	$21.00
HIV Testing	87389	$41.00
Lipase	83690	$17.00
Lipid Panel	80061	$33.00
Magnesium	83735	$23.00
Prostate Specific Antigen	84153	$46.00
Prostate Specific Antigen Test	G0103	$40.00
Prothrombin Time	85610	$10.00
RBC Screening for RBC Antibodies	86850	$45.00
RSV Antigen Test	87280	$30.00
Rubella Antibodies	86762	$36.00
Sedimentation rate, erythrocyte	85651	$9.00
Streptococcus, group A Rapid Antigen Test	87880	$30.00
Syphilis Antibody	86780	$26.00
T4 Free (FT4)	84439	$22.00
Thyroid Stimulating Hormone (TSH)	84443	$42.00
Total Iron Binding Capacity	83550	$22.00
Uric Acid Blood Test	84550	$11.00
Urinalysis by dip stick - Automated	81001	$8.00
Urinalysis by dip stick - Non‐Automated	81002	$8.00
Urine Culture Colony count	87086	$20.00
Urine Culture organisms ID	87088	$18.00
Urine Microalbumin	82043	$20.00
Urine Pregnancy Test	81025	$16.00
Vaginosis Panel	Multiple	$120.00
Vitamin D; 25 Hydroxy	82306	$73.00
Vitamin B12	82607	$39.00

ULTRASOUND	CPT Code	Fee
Head and Neck	76536	$236.00
Breast (complete)	76641	$207.00
Abdomen (complete)	76700	$239.00
Abdomen	76705	$211.00
Retroperitoneal	76770	$226.00
Limited Fetus OB	76815	$176.00
Transvaginal OB	76817	$199.00
Transvaginal Non‐OB	76830	$214.00
Pelvic	76856	$241.00
Scrotum	76870	$201.00
Transrectal	76872	$315.00

MAMMOGRAPHY	CPT Code	Fee
Diagnostic, including CAD, unilateral	77065	$227.00
Diagnostic, including CAD; bilateral	77066	$287.00
Screening, including CAD; bilateral	77067	$235.00

Computed Tomography (CT)	CPT Code	Fee
Abdomen and Pelvis w contrast	74177	$840.00
Head and Neck	70486	$445.00
Abdomen and Pelvis w/o contrast	74176	$407.00
Abdomen and Pelvis w/o & w contrast	74178	$1,061.00
3D rendering w Interpretation	76377	$226.00
Thorax w contrast	71260	$564.00

Magnetic Resonance Imaging(MRI)	CPT Code	Fee
Brain Stem w/o contrast	70551	$900.00
Brain Stem w/o & w contrast	70553	$1,550.00
Neck Spine w/o contrast	72141	$844.00
Lumbar Spine w/o contrast	72148	$860.00
Upper Extremity w/o contrast	73221	$860.00
Upper Extremity w contrast	73222	$982.00
Lower Extremity w/o contrast	73721	$875.00
Lower Extremity w contrast	73722	$987.00

OTHER DRUGS AND INJECTIBLES	CPT Code	Fee
Botox A ‐ 200 Units	J0585	$2,200.00
Denosumab/Prolia ‐ 60 mg dose	J0897	$1,320.00
Leuprolide ‐ 22.5 mg dose	J9217	$1,350.00
Synvisc One ‐ 48mg dose	J7325	$1,392.00
Denosumab/Prolia ‐ 60 mg dose	J0897	$1,320.00