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
$29
Average
$318
Median
$403
High
$961
Each hospital's average Cigna rate, under the methodology and billing class chosen below.
19 hospitals; the 90th percentile is 20.2× 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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20 hospital rates
iThe hospitals that file a Cigna 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 | Alomere Health Alexandria, MN facility · fee schedule · outpatient | 1 | $242 | $242 | — | — | — | $242 – $242 |
| 2 | Cleveland Clinic Weston Hospital Nonprofit Corporation Weston, FL facility · fee schedule · outpatient | 3 | $448 | $458 | $17 | 4% | — | $444 – $481 |
| 3 | Fairview Maple Grove Surgery Center Maple Grove, MN fee schedule · both | 1 | $91 | $91 | $8 | 9% | — | $83 – $99 |
| 4 | Fairview Maple Grove Surgery Center Maple Grove, MN fee schedule · outpatient | 1 | $192 | $192 | $17 | 9% | — | $175 – $208 |
| 5 | Good Samaritan Hospital Puyallup, WA fee schedule · outpatient | 1 | $403 | $403 | — | — | — | $403 – $403 |
| 6 | INDIAN RIVER MEMORIAL HOSPITAL INC Vero Beach, FL facility · fee schedule · outpatient | 3 | $644 | $617 | $61 | 10% | — | $532 – $674 |
| 7 | MARTIN MEMORIAL MEDICAL CENTER INC Port St Lucie, FL facility · fee schedule · outpatient | 3 | $562 | $578 | $132 | 23% | — | $424 – $747 |
| 8 | Memorial Hospital of Laramie County Cheyenne, WY fee schedule · both | 1 | $86 | $86 | — | — | — | $86 – $86 |
| 9 | MultiCare Auburn Medical Center Auburn, WA fee schedule · outpatient | 1 | $403 | $403 | — | — | — | $403 – $403 |
| 10 | MultiCare Capital Medical Center Lacey, WA fee schedule · outpatient | 1 | $403 | $403 | — | — | — | $403 – $403 |
| 11 | MultiCare Covington Medical Center Covington, WA fee schedule · outpatient | 1 | $403 | $403 | — | — | — | $403 – $403 |
| 12 | MultiCare Deaconess Hospital Spokane, WA fee schedule · outpatient | 1 | $403 | $403 | — | — | — | $403 – $403 |
| 13 | MultiCare Valley Hospital Spokane Valley, WA fee schedule · outpatient | 1 | $403 | $403 | — | — | — | $403 – $403 |
| 14 | Munson Healthcare Cadillac Cadillac, MI facility · fee schedule · outpatient | 1 | $29 | $29 | — | — | — | $29 – $29 |
| 15 | Munson Healthcare Grayling Grayling, MI facility · fee schedule · outpatient | 1 | $29 | $29 | — | — | — | $29 – $29 |
| 16 | Munson Healthcare Manistee Hospital Manistee, MI facility · fee schedule · outpatient | 1 | $29 | $29 | — | — | — | $29 – $29 |
| 17 | Munson Healthcare Otsego Memorial Hospital Gaylord, MI facility · fee schedule · outpatient | 1 | $29 | $29 | — | — | — | $29 – $29 |
| 18 | Munson Medical Center Traverse City, MI facility · fee schedule · outpatient | 1 | $29 | $29 | — | — | — | $29 – $29 |
| 19 | Tacoma General Allenmore Hospital Bremerton, WA fee schedule · outpatient | 1 | $403 | $403 | — | — | — | $403 – $403 |
| 20 | Virginia Mason Medical Center Seattle, WA facility · fee schedule · outpatient | 2 | $961 | $961 | $61 | 6% | — | $900 – $1.0k |
← Payers reporting HCPCS G0255 · Snapshot 20261112T124536Z-e251e855