Sutter Gould Medical Foundation Charges for Frequently Used Doctor Services
The services below expand to show charges for frequently used services provided by Sutter Gould Medical Foundation. If you can’t find the service you are looking for, please call (866) 961-8539.
Doctor's Office Visit
| Service | Estimated Charge |
|---|---|
| Doctor's Office Visit for a New Patient | |
| Low-Level Visit | $128 |
| Low-to-Moderate Level Visit | $216 |
| Moderate Level Visit | $310 |
| Moderate-to-High Level Visit | $470 |
| High Level Visit | $581 |
| Doctor's Office Visit for an Established Patient | |
| Low-Level Visit | $73 |
| Low-to-Moderate Level Visit | $132 |
| Moderate Level Visit | $208 |
| Moderate-to-High Level Visit | $309 |
| High Level Visit | $414 |
| Doctor's Office Visit - Specialist Consultation | |
| Low-Level Visit | $132 |
| Low-to-Moderate Level Visit | $246 |
| Moderate Level Visit | $336 |
| Moderate-to-High Level Visit | $496 |
| High Level Visit | $605 |
Eye Exams
| Service | Estimated Charge |
|---|---|
| Eye Exams | |
| New Patient Intermediate Eye Exam | $238 |
| New Patient Comprehensive Eye Exam | $433 |
| Established Patient Intermediate Eye Exam | $251 |
| Established Patient Comprehensive Eye Exam | $361 |
| Eye Refraction for Vision Correction | $49 |
Physical/Occupational Therapy
| Service | Estimated Charge |
|---|---|
| Physical/Occupational Therapy | |
| Occupational Therapy Evaluation (Low Level Visit) | $279 |
| Occupational Therapy Evaluation (Moderate Level Visit) | $279 |
| Occupational Therapy Evaluation (High Level Visit) | $279 |
| Occupational Therapy Re-evaluation | $185 |
| Electric Stimulation Therapy, Treatment Only | $54 |
| Physical Therapy Evaluation (Low Level Visit) | $288 |
| Physical Therapy Evaluation (Moderate Level Visit) | $288 |
| Physical Therapy Evaluation (High Level Visit) | $288 |
| Physical Therapy Re-evaluation | $197 |
| Physical Therapy Exercises, Treatment Only | $105 |
| Physical Therapy Ultrasound, Treatment Only | $45 |
| Physical Therapy ‐ Manual therapy | $98 |
Allergy Injections
| Service | Estimated Charge |
|---|---|
| Allergy Injections | |
| Allergy shot ‐ single injection | $35 |
| Allergy shot ‐ two or more injections | $40 |
Diagnostic Imaging
| Service | Estimated Charge |
|---|---|
| Diagnostic Imaging | |
| Abdomen CT Scan | $653 |
| Abdomen CT Scan with and without dye | $1,189 |
| Abdomen CT Scan, including dye | $1,033 |
| Abdomen X-ray | $90 |
| Abdomen/Pelvis CT scan | $841 |
| Abdomen/Pelvis CT scan with and without dye | $1,493 |
| Abdomen/Pelvis CT scan, including dye | $1,275 |
| Abdominal ultrasound | $522 |
| Abdominal ultrasound, limited | $401 |
| Ankle X-ray (3+ views) | $127 |
| Auditory Threshold Evaluation | $133 |
| Bone density scan (dexa scan) | $185 |
| Brain MRI with and without dye | $2,089 |
| Brain MRI without dye | $1,602 |
| Breast MRI | $2,298 |
| Breast MRI with CAD | $2,384 |
| Breathing Test (spirometry) | $137 |
| Bronchography | $133 |
| Cardiac Stress Test, complete | $289 |
| Cervical Spine MRI without dye | $1,415 |
| Cervical Spine X-ray, minimum 4-5 views | $180 |
| Chest CT Scan | $778 |
| Chest CT scan, including dye | $972 |
| Chest X-ray (One views) | $87 |
| Chest X-ray (two views) | $114 |
| Diagnostic mammography, including CAD unilateral | $666 |
| Diagnostic mammography, including CAD bilateral | $845 |
| Doppler Color Flow, add-on | $73 |
| Duplex scan of Extracranial Arteries | $896 |
| Echocardiogram, doppler | $163 |
| Elbow X-ray, complete | $127 |
| Electrocardiogram (ECG) | $72 |
| Femur X-ray (1 view) | $139 |
| Femur X-ray (2+ views) | $163 |
| Finger X-ray | $129 |
| Foot X-ray, complete | $119 |
| Hand X-ray, complete | $122 |
| Head CT Scan | $611 |
| Hip X-ray (1 view) | $147 |
| Hip X-ray (2-3 views) | $207 |
| Hip X-ray (4+ views) | $258 |
| Knee MRI without dye | $1,028 |
| Knee X-ray 3 views | $142 |
| Knee X-ray one or two views | $116 |
| Knee X-ray, bilateral | $135 |
| Knee X-ray, complete, 4+ views | $166 |
| Lumbar Spine MRI without dye | $1,397 |
| Lumbar spine x-ray (two or three views) | $134 |
| Pelvic ultrasound exam, complete | $463 |
| Pelvis CT Scan | $642 |
| Pelvis CT Scan, including dye | $1,016 |
| Pelvis MRI | $1,581 |
| Pelvis X-ray, AP view only | $108 |
| Radiologic Stress Test | $1,841 |
| Screening mammography, bilateral including CAD | $684 |
| Shoulder X-ray, complete | $115 |
| Sinus CT Scan | $845 |
| Stress Test w/ Doppler, complete | $690 |
| Stress Test w/ Echocardiogram, real-time image | $850 |
| Toe X-ray, minimum 2 views | $116 |
| Tone Screening Test |
$48 |
| Transvaginal ultrasound | $276 |
| Tympanometry | $52 |
| Ultrasound breast, complete | $393 |
| Ultrasound breast, limited | $323 |
| Upper Extremity Joint MRI without dye | $1,028 |
| Wrist X-ray, 2 views | $120 |
| Wrist X-ray, complete | $144 |
Pregnancy & Prenatal Tests
| Service | Estimated Charge |
|---|---|
| Pregnancy & Prenatal Tests | |
| Fetal non-stress test | $172 |
| Pregnancy ultrasound, first trimester | $469 |
| Pregnancy ultrasound, after first trimester | $549 |
| Obstetric ultrasound, limited | $335 |
| Obstetric ultrasound, after first trimester | $439 |
| Obstetric ultrasound, transvaginal | $379 |
| Urine Pregnancy Test | $15 |
Lab Testing
| Service | Estimated Charge |
|---|---|
| Lab Testing | |
| ABO Blood Typing Test | $18 |
| Acute Hepatitis Panel | $276 |
| Alkaline Phosphatase, serum | $30 |
| Allergen-specific IgE Antibody Test | $31 |
| Alpha-Fetoprotein-Serum | $98 |
| Amylase Test, serum | $38 |
| Antinuclear Antibodies, direct | $70 |
| Assay of Calcium | $30 |
| Assay of Ferritin | $79 |
| Assay of Iron | $38 |
| Assay of Magnesium | $39 |
| Assay of Phosphorus | $28 |
| Assay of Testosterone, total | $150 |
| Assay of Thyroxine, total | $40 |
| Assay of Triidothyronine, total | $82 |
| Assay of Urea Nitrogen | $24 |
| Bacterial Culture, other source | $51 |
| Bacterial Culture, urine | $48 |
| Basic Metabolic Panel | $51 |
| Bilirubin Test, total | $30 |
| Blood Folic Acid Serum | $86 |
| Blood Serology, qualitative | $25 |
| Blood Sugar Test, monitoring | $15 |
| Carcinoembryonic Antigen | $110 |
| Chlamydia | $203 |
| Chorionic Gonadotropin Test | $88 |
| Complete Blood Count | $46 |
| Comprehensive Metabolic Panel | $62 |
| Cortisol, total | $96 |
| C-Reactive Protein | $30 |
| Creatine Kinase | $38 |
| Creatinine | $30 |
| Dehydrepiandrosterone Sulfate | $129 |
| Fecal Blood Occult | $20 |
| Feces Culture, bacteria | $56 |
| Gamma Glutamyltransferase | $43 |
| Gammaglobulin IgE | $97 |
| Glucose Test | $24 |
| Gonorrhea Test | $203 |
| Hemoglobin Test | $15 |
| Hemoglobin A1c Test | $57 |
| Hepatic Function Panel | $49 |
| Hepatitis B Surface Antibody Test | $63 |
| Hepatitis B Surface Antigen Test | $61 |
| Hepatitis C Antibody Test | $82 |
| Hepatitis C Test | $249 |
| High Sensitivity C-Reactive Protein Test | $75 |
| HIV-1/HIV-2 Single Assay Test | $79 |
| Influenza Test | $55 |
| Insulin Test, total | $67 |
| Lactate Dehydrogenase Test | $35 |
| LDL Cholesterol Test | $56 |
| Lipase Test | $40 |
| Lipid Panel Test | $78 |
| Pap Smear | $117 |
| Parathyroid Hormone, intact | $239 |
| Potassium Test | $27 |
| Prolactin Test | $113 |
| Prostate-Specific Antigen (PSA) Test | $107 |
| Prothrombin Time | $24 |
| Rheumatoid Arthritis Factor Test | $33 |
| Renal Function Panel | $52 |
| RH (D) Blood Typing Test | $18 |
| Screening Culture | $38 |
| Sedimentation Rate Test | $22 |
| Sodium, serum | $28 |
| Strep Group A | $55 |
| Thyroglobulin Antibody Test | $93 |
| Thyroid Peroxidase Antibody Test | $85 |
| Thyroid Stimulating Hormone Test | $98 |
| Thyroxine | $54 |
| Total Cholesterol Test | $26 |
| Total Protein, urine | $22 |
| Transferase Alanine Amino (ALT) Test | $31 |
| Transferase Aspartate Amino (AST) Test | $30 |
| Triglycerides Test | $34 |
| Triidothyronine, free | $99 |
| Uric Acid Test | $27 |
| Urinalysis | $19 |
| Urine Test | $19 |
| Urine Test, dipstick only | $16 |
| Urine Test, microanalysis only | $19 |
| Varicella-Zoster Antibody Test | $75 |
| Vitamin B-12 Test | $88 |
Office Procedures
| Service | Estimated Charge |
|---|---|
| Office Procedures | |
| Apply Short-Arm Cast | $317 |
| Arthrocentesis | $212 |
| Bronchodilation | $236 |
| Control Nosebleed, simple | $347 |
| Impacted Cerumen Removal | $151 |
| Incision and Drainage | $422 |
| Inhalation Treatment | $72 |
| Injection, tendon | $208 |
| Injection/Aspiration, intermediate joint/bursa | $230 |
| Injection/Aspiration, small joint/bursa | $167 |
| Tangential Skin Biopsy | $306 |
| Punch Skin Biopsy | $365 |
| Incisional Skin Biopsy | $442 |
| Skin Lesion Destruction | $203 |
Vaccines
| Service | Estimated Charge |
|---|---|
| Vaccines | |
| Diphtheria, Tetanus, and Pertussis (DTaP) | $50 |
| Diphtheria, Tetanus, and Pertussis (DTaP-Hib-IPV) | $107 |
| Flu | $20 |
| Flu - High Dose | $55 |
| Flu - Nasal Mist | $25 |
| H Papilloma Vaccine, 2 or 3 dose | $391 |
| Hepatitis A | $57 |
| Hepatitis A - Adult | $127 |
| Hepatitis B - Adult | $102 |
| Hepatitis B - Pediatric | $80 |
| Measles, Mumps, and Rubella (MMR) | $106 |
| Measles, Mumps, Rubella (MMRV) | $293 |
| Meningococcal | $214 |
| Pneumococcal, 13 valent | $272 |
| Pneumococcal, 23 valent | $219 |
| Polio | $53 |
| Rotavirus | $143 |
| Tetanus, Diphtheria, and Pertussis (TdaP) | $77 |
| Varicella Virus | $188 |
| Zoster | $330 |
Disclaimer
The amounts you see are the most you would pay before any discounts that may be available to you. The charges also do not include any additional procedures that may be done as part of the visit. Charges for lab tests and vaccines do not include specimen collection fees or fees associated with administering vaccines.