Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
Current percep threshold tst
Low
$65
Average
$413
Median
$400
High
$2.1k
Each hospital's average Aetna rate, under the methodology and billing class chosen below.
54 hospitals; the 90th percentile is 4.7× the 10th. Each bar is a price range and its height is how many hospitals fall in it. Hover a bar, or a row in the ladder, for details.
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56 hospital rates
iThe hospitals that file a Aetna rate for this code, one row per hospital and set of terms (billing class, payment method, setting). Rates under different terms are never blended, so the terms are shown under each hospital’s name. Figures are the hospital’s averages across its plans.| # | Plans | |||||||
|---|---|---|---|---|---|---|---|---|
| 1 | Acadia Hospital Bangor, ME professional · fee schedule · outpatient | 1 | $400 | $400 | — | — | — | $400 – $400 |
| 2 | Allen Memorial Hospital Corporation Waterloo, IA fee schedule · both | 2 | $541 | $541 | $5 | 1% | — | $536 – $547 |
| 3 | Alta Newport Hospital, LLC Tustin, CA facility · case rate · outpatient | 2 | $697 | $697 | $0 | 0% | — | $697 – $697 |
| 4 | Bethesda Hospital Inc. Lebanon, OH facility · fee schedule · outpatient | 1 | $139 | $139 | $1 | 1% | — | $138 – $140 |
| 5 | Blue Hill Memorial Hospital Hill, ME professional · fee schedule · outpatient | 1 | $400 | $400 | — | — | — | $400 – $400 |
| 6 | Boulder Community Health Lafayette, CO professional · fee schedule · both | 2 | $50 | $65 | $21 | 32% | — | $50 – $94 |
| 7 | COMMUNITY MEMORIAL HOSPITAL Hill, VA case rate · outpatient | 1 | $202 | $202 | — | — | — | $202 – $202 |
| 8 | Central Iowa Hospital Corporation Des Moines, IA fee schedule · both | 2 | $536 | $536 | — | — | — | $536 – $536 |
| 9 | Central Iowa Hospital Corporation West Des Moines, IA fee schedule · both | 2 | $536 | $536 | — | — | — | $536 – $536 |
| 10 | Charles A. Dean Memorial Hospital Greenville, ME professional · fee schedule · outpatient | 1 | $400 | $400 | — | — | — | $400 – $400 |
| 11 | Cheshire Medical Center Keene, NH professional · fee schedule · outpatient | 2 | $200 | $200 | $80 | 40% | — | $120 – $280 |
| 12 | Cleveland Clinic Weston Hospital Nonprofit Corporation Weston, FL facility · case rate · outpatient | 1 | $104 | $104 | — | — | — | $104 – $104 |
| 13 | Cleveland Clinic Weston Hospital Nonprofit Corporation Weston, FL facility · fee schedule · outpatient | 1 | $54 | $54 | — | — | — | $54 – $54 |
| 14 | Clinton Memorial Hospital Wilmington, OH fee schedule · outpatient | 1 | $139 | $139 | $1 | 1% | — | $138 – $140 |
| 15 | Conway Hospital, Inc. Conway, SC professional · fee schedule · outpatient | 1 | $475 | $475 | $61 | 13% | — | $414 – $536 |
| 16 | Covenant Medical Center Lubbock, TX fee schedule · outpatient | 1 | $2.1k | $2.1k | — | — | — | $2.1k – $2.1k |
| 17 | Doctors’ Hospital of Williamsburg Williamsburg, VA fee schedule · outpatient | 1 | $181 | $181 | — | — | — | $181 – $181 |
| 18 | ERIE COUNTY MEDICAL CENTER CORPORATION Buffalo, NY fee schedule · outpatient | 1 | $86 | $86 | — | — | — | $86 – $86 |
| 19 | East Cooper Medical Center LLC Mt Pleasant, SC fee schedule · outpatient | 1 | $400 | $400 | — | — | — | $400 – $400 |
| 20 | Eastern Maine Medical Center Bangor, ME facility · fee schedule · outpatient | 1 | $408 | $408 | — | — | — | $408 – $408 |
| 21 | Eastern Maine Medical Center Bangor, ME professional · fee schedule · outpatient | 2 | $280 | $267 | $115 | 43% | — | $120 – $400 |
| 22 | Garnet Health Medical Center Middletown, NY facility · fee schedule · outpatient | 1 | $1.0k | $1.0k | — | — | — | $1.0k – $1.0k |
| 23 | Garnet Health Medical Center Catskills Harris, NY facility · fee schedule · outpatient | 1 | $932 | $932 | — | — | — | $932 – $932 |
| 24 | Grinnell Regional Medical Center Grinnell, IA fee schedule · both | 2 | $536 | $536 | — | — | — | $536 – $536 |
| 25 | Hilton Head Medical Center LLC Hilton Head Island, SC fee schedule · outpatient | 1 | $400 | $400 | — | — | — | $400 – $400 |
← Payers reporting HCPCS G0255 · Snapshot 20261112T124536Z-e251e855