Calculate Your Potential Costs While we can't always predict medical needs, you can use this worksheet to help you calculate the potential out-of-pocket costs you could incur during the plan year to help you choose the best plan for you and your family. YOU YOUR SPOUSE YOUR DEPENDENT(S) Primary Care Physician (PCP) office visit $____________________ $____________________ $____________________ Specialist office visit $____________________ $____________________ $____________________ Imaging (MRI, CT & PET Scan) $____________________ $____________________ $____________________ Outpatient Surgery $____________________ $____________________ $____________________ Prescription Drugs $____________________ $____________________ $____________________ Other Expenses $____________________ $____________________ $____________________ Total Estimated Expenses $__________________ $__________________ $__________________ The average cost of The average cost of an The national average The average sticker Average Costs: bloodwork without MRI can range anywhere cost for a colonoscopy price of giving birth in insurance is $432, but from $400 to $12,000, at inpatient facilities is Massachusetts hospitals the price can range from depending on the place $4,350, while the same is $14,063. $50 to upwards of of service. procedure at outpatient $1,000 depending on facilities averaged what tests are $2,550. performed.