The case of the $517 chest x-ray
Part 1 in a Series. So the story goes like this: a patient of mine needed a chest x-ray, and he does not have insurance. He doesn't have health insurance, so rather than just give him a requisition and send him to the local hospital, I decided to do a little calling around on his behalf to find out what the damage would be.
Vendor #1: A well-known local hospital
I called up the radiology department and asked them how much a PA and Lateral Chest X-ray would cost. 'I don't know. We don't have that information' I was told by the clerk. The radiologist gave me the same answer. They both said I should just send the patient over and he would find out the cost when he received the bill.
That seemed a little dumb. Since when do we go into stores and buy things without knowing the price? So after 4 additional phone calls and about 2 hours, my assistant and I finally reached Bob who is in charge of uninsured patient billing. He was able to tell me the price: $517.
For cash paying patients who pay at the time of service and know to ask for the '20-20' discount by name, the price ends up being reduced to $310.20. But you have to know the secret code word. Time to receive report: 2-3 days.
Vendor #2: Free-Standing Private Radiology Office
I called up and the receptionist answered on the first ring. I asked how much for a PA and Lateral Chest x-ray. An immediate answer: $73. Time to receive report in my office: 1 hour. Quality: Just as Good.
So my question is this. How can the hospital be charging 4.25 times as much as the place down the street to cash-paying patients, for the same product and actually inferior response time? (Or 7 times as much without the secret code word.) I know, 'cost shifting' is a common refrain. But that just doesn't fly any more.
And what's more disturbing, how can it be so difficult to find out the price when you call up and ask? So many doctors just send their patients to the hospital x-ray department or lab without thinking that it may bankrupt them. And many doctors have no idea that the price spread can be so great.
It's time we developed some more price transparency in health care. Every entity should be required to have front-line staff know the prices for every service they offer. That way patients and doctors can make rational decisions about how to get each patient what they need.
Update, 2026
Everything above is a field report from August 2010 and stands as written. Three things have changed since. One has not.
Price transparency did become a federal requirement. Since January 2021 hospitals have had to publish a machine-readable file of their standard charges, plus either a consumer-facing display covering at least 300 shoppable services or a price estimator tool. Notice what that does and does not do. The ask in the paragraph above was that front-line staff know the price when you call. What arrived instead was a website obligation.
The spread held. The Health Care Cost Institute, analyzing commercial claims, finds hospital outpatient departments charging about 3.7 times physician-office prices for imaging of this class. That is close to the 4.25 times I measured by telephone in 2010, sixteen years earlier. Worth knowing where the number comes from: HCCI data is contributed by large commercial insurers, who have their own interest in the site-of-care argument. The direction is corroborated elsewhere, so treat 3.7 as one estimate rather than the estimate.
And here is what I have not done. I have not re-made these calls. Whether you can get a cash price for a chest x-ray by telephone today, from a hospital or from a free-standing office, is a question this update does not answer, and I would rather leave it open than guess at it. The published files exist. Whether the person who picks up the phone can quote you a number is a different question, and it was the actual subject of this post. If I re-run it, the results will appear here.
