Hospital Charges / Price Transparency

OVERVIEW 

In compliance with the Centers for Medicare and Medicaid Services (CMS), Muleshoe Area Medical Center is making available to the public a copy of its standard charges known as a “Charge Master,” “Charge Description Master” or “CDM”.

Since payment rates for hospital care provided to insured patients are either negotiated with health plans, set by the federal government for Medicare, or set by state governments for Medicaid enrollees, the payments hospitals receive for patient care do not necessarily reflect the prices reflected in the Charge Master.  A patient’s responsibility may vary depending on the payment plans negotiated with insurance companies as well as the patient’s individual and/or family deductibles and co-payments with their insurance plan.  Additionally, uninsured patients are not generally expected to pay the hospital’s standard charges as reflected in the CDM and may be eligible for financial assistance.

The information provided is based on information we have gathered from contracts with managed care commercial insurance plans.  This is not a guarantee of what you will be charged. Your actual charges may differ from the estimated charges for many reasons, including the seriousness of your medical condition, actual time the procedure takes and the services and supplies that you receive.

The charges listed here are for services from the Hospital.  They do not reflect the charges for physicians (such as surgeon, anesthesiologist, radiologist, pathologist, etc.) who may be involved in providing particular services to a patient. These charges are billed separately from the individual physician/physicians group.

Muleshoe Area Medical Center shall not be liable for any difference between charges listed in the price lists and the final bill for services.

AVAILABLE FILES 
There are two files regarding the hospital’s CDM for price transparency. 

The CSV file is a comprehensive, machine-readable file that makes public all standard charge information for all hospital items and services.  This can easily be imported into Microsoft Excel or similar software. This file contains the following information: 

  • Charge Code – specific charge code for each item or service
  • Description – description of each item or service
  • Department – department where item or service performed
  • Rev Code – corresponding department’s revenue code for item or service
  • CPT Code – corresponding CPT billing code for item or service (if applicable)
  • Gross Charge – corresponding gross charge for each individual item or service
  • Cash Price – corresponding discounted cash price that applies to each item or service
  • Payer-Specific Negotiated Charge – each column lists the negotiated charge with the name of each specific third-party payer as the column header
  • De-identified minimum negotiated charge that applies to each item or service
  • De-identified maximum negotiated charge that applies to each item or service

The PDF file is a searchable consumer-friendly format of payer-specific negotiated charge information of 300 “shoppable outpatient services” at the hospital.  The file contains the following information: 

  • Charge Code – specific charge code for each item or service
  • Description – description of each item or service
  • Department – department where item or service performed
  • Rev Code – corresponding department’s revenue code for item or service
  • CPT Code – corresponding CPT billing code for item or service (if applicable)
  • Gross Charge – corresponding gross charge for each individual item or service
  • Cash Price – corresponding discounted cash price that applies to each item or service
  • Payer-Specific Negotiated Charge – each column lists the negotiated charge with the name of each specific third-party payer as the column header
  • De-identified minimum negotiated charge that applies to each item or service
  • De-identified maximum negotiated charge that applies to each item or service

QUESTIONS?

If you have further questions about the Muleshoe Area Medical Center CDM, please contact our hospital business office at (806) 272-4524 or come by and speak to one of our business office representatives.  Thank you for choosing Muleshoe Area Medical Center for your health care needs! 

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Searchable Shoppable Services

Muleshoe Area Medical Center Shoppable Services as of 7/15/2023

CHARGE CODEDESCRIPTIONREV CODEDepartmentCPT CODERATECash PriceAetnaBCBS TraditionalBCBS PPOBCBS HMOBCBS Blue AdvCIGNACoventryFirstCareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
4420057CT HEAD W/O CONTRAST351CT Scan70450$ 927.00$ 602.55$ 741.60$ 409.09$ 409.09$ 368.74$ 196.14$ 602.55$ 741.60$ 648.90$ 741.60$ 196.14$ 741.60
4420007CT MAXILLOFACIAL W/O CM350CT Scan70486$ 796.00$ 517.40$ 636.80$ 409.09$ 409.09$ 368.74$ 196.14$ 517.40$ 636.80$ 557.20$ 636.80$ 196.14$ 636.80
4420055CT MAXILLOFACIAL W/CM350CT Scan70487$ 1,262.00$ 820.30$ 1,009.60$ 665.10$ 665.10$ 599.50$ 318.89$ 820.30$ 1,009.60$ 883.40$ 1,009.60$ 318.89$ 1,009.60
4420051CT SOFT TISS NECK W/O CM350CT Scan70490$ 796.00$ 517.40$ 636.80$ 409.09$ 409.09$ 368.74$ 196.14$ 517.40$ 636.80$ 557.20$ 636.80$ 196.14$ 636.80
4420019CT SOFT TISS NECK W/CM350CT Scan70491$ 1,313.00$ 853.45$ 1,050.40$ 665.10$ 665.10$ 599.50$ 318.89$ 853.45$ 1,050.40$ 919.10$ 1,050.40$ 318.89$ 1,050.40
4420009CT THORAX W/O C/M350CT Scan71250$ 927.00$ 602.55$ 741.60$ 409.09$ 409.09$ 368.74$ 196.14$ 602.55$ 741.60$ 648.90$ 741.60$ 196.14$ 741.60
4420063CT THORAX W/CM350CT Scan71260$ 1,262.00$ 820.30$ 1,009.60$ 665.10$ 665.10$ 599.50$ 318.89$ 820.30$ 1,009.60$ 883.40$ 1,009.60$ 318.89$ 1,009.60
4420061CT THORAX W&W/O CM350CT Scan71270$ 1,442.00$ 937.30$ 1,153.60$ 665.10$ 665.10$ 599.50$ 318.89$ 937.30$ 1,153.60$ 1,009.40$ 1,153.60$ 318.89$ 1,153.60
4420001CT CHEST W&W/O CM ANGIOGR350CT Scan71275$ 1,880.00$ 1,222.00$ 1,504.00$ 665.10$ 665.10$ 599.50$ 318.89$ 1,222.00$ 1,504.00$ 1,316.00$ 1,504.00$ 318.89$ 1,504.00
4420031CT SPINE CERV/W/O CM350CT Scan72125$ 927.00$ 602.55$ 741.60$ 409.09$ 409.09$ 368.74$ 196.14$ 602.55$ 741.60$ 648.90$ 741.60$ 196.14$ 741.60
4420033CT SPINE THOR W/O CM350CT Scan72128$ 850.00$ 552.50$ 680.00$ 409.09$ 409.09$ 368.74$ 196.14$ 552.50$ 680.00$ 595.00$ 680.00$ 196.14$ 680.00
4420035CT SPINE LUMB W/O CM350CT Scan72131$ 902.00$ 586.30$ 721.60$ 409.09$ 409.09$ 368.74$ 196.14$ 586.30$ 721.60$ 631.40$ 721.60$ 196.14$ 721.60
4420027CT PELVIS W/O CONTRAST350CT Scan72192$ 796.00$ 517.40$ 636.80$ 409.09$ 409.09$ 368.74$ 196.14$ 517.40$ 636.80$ 557.20$ 636.80$ 196.14$ 636.80
4420013CT UP EXTREM W/O CONTRAST350CT Scan73200$ 796.00$ 517.40$ 636.80$ 409.09$ 409.09$ 368.74$ 196.14$ 517.40$ 636.80$ 557.20$ 636.80$ 196.14$ 636.80
4420072CT upper extremity with contrast352CT Scan73201$ 1,400.00$ 910.00$ 1,120.00$ 1,393.75$ 1,393.75$ 1,256.29$ 668.24$ 910.00$ 1,120.00$ 980.00$ 1,120.00$ 668.24$ 1,393.75
4420047CT LOW EXTREM WO CONT350CT Scan73700$ 796.00$ 517.40$ 636.80$ 409.09$ 409.09$ 368.74$ 196.14$ 517.40$ 636.80$ 557.20$ 636.80$ 196.14$ 636.80
4420045CT ABD W/CONTRAST350CT Scan74160$ 1,262.00$ 820.30$ 1,009.60$ 665.10$ 665.10$ 599.50$ 318.89$ 820.30$ 1,009.60$ 883.40$ 1,009.60$ 318.89$ 1,009.60
4420069CT ABD/PELVIS WO CON350CT Scan74176$ 1,591.00$ 1,034.15$ 1,272.80$ 850.60$ 850.60$ 766.70$ 407.82$ 1,034.15$ 1,272.80$ 1,113.70$ 1,272.80$ 407.82$ 1,272.80
4420067CT ABD/PELVIS W/CON350CT Scan74177$ 1,931.00$ 1,255.15$ 1,544.80$ 1,393.75$ 1,393.75$ 1,256.29$ 668.24$ 1,255.15$ 1,544.80$ 1,351.70$ 1,544.80$ 668.24$ 1,544.80
4420065CT ABD/PELVIS W/WO350CT Scan74178$ 2,163.00$ 1,405.95$ 1,730.40$ 1,393.75$ 1,393.75$ 1,256.29$ 668.24$ 1,405.95$ 1,730.40$ 1,514.10$ 1,730.40$ 668.24$ 1,730.40
4340009EKG730EKG/ECG93005$ 175.00$ 113.75$ 140.00$ 153.48$ 153.48$ 114.42$ 55.01$ 113.75$ 140.00$ 122.50$ 140.00$ 55.01$ 153.48
4301551I-STAT BMP301Laboratory80047$ 81.00$ 52.65$ 64.80$ 48.06$ 48.06$ 43.25$ 24.03$ 52.65$ 64.80$ 52.65$ 64.80$ 24.03$ 64.80
4300027BASIC METABOLIC301Laboratory80048$ 81.00$ 52.65$ 64.80$ 29.61$ 29.61$ 26.65$ 14.81$ 52.65$ 64.80$ 52.65$ 64.80$ 14.81$ 64.80
4303634BMP Ref301Laboratory80048$ 81.00$ 52.65$ 64.80$ 29.61$ 29.61$ 26.65$ 14.81$ 52.65$ 64.80$ 52.65$ 64.80$ 14.81$ 64.80
4300049GENRL HEALTH PAN(NOT MCR)300Laboratory80050$ 306.00$ 198.90$ 244.80$ 123.62$ 123.62$ 111.26$ 61.81$ 198.90$ 244.80$ 198.90$ 244.80$ 61.81$ 244.80
4302243CMP Ref301Laboratory80053$ 132.00$ 85.80$ 105.60$ 36.96$ 36.96$ 33.26$ 18.48$ 85.80$ 105.60$ 85.80$ 105.60$ 18.48$ 105.60
4300021COMPLETE METABOLIC301Laboratory80053$ 124.00$ 80.60$ 99.20$ 36.96$ 36.96$ 33.26$ 18.48$ 80.60$ 99.20$ 80.60$ 99.20$ 18.48$ 99.20
4301217OB PROFILE LAB CHARGE300Laboratory80055$ 523.00$ 339.95$ 418.40$ 167.34$ 167.34$ 150.60$ 83.67$ 339.95$ 418.40$ 339.95$ 418.40$ 83.67$ 418.40
4303854Lipid Cov300Laboratory80061$ 106.00$ 68.90$ 84.80$ 46.87$ 46.87$ 42.18$ 23.43$ 68.90$ 84.80$ 68.90$ 84.80$ 23.43$ 84.80
4300031LIPID PROFILE301Laboratory80061$ 109.00$ 70.85$ 87.20$ 46.87$ 46.87$ 42.18$ 23.43$ 70.85$ 87.20$ 70.85$ 87.20$ 23.43$ 87.20
4301705LIPID-REF301Laboratory80061$ 109.00$ 70.85$ 87.20$ 46.87$ 46.87$ 42.18$ 23.43$ 70.85$ 87.20$ 70.85$ 87.20$ 23.43$ 87.20
4303837NMR Lipids300Laboratory80061$ 109.00$ 70.85$ 87.20$ 46.87$ 46.87$ 42.18$ 23.43$ 70.85$ 87.20$ 70.85$ 87.20$ 23.43$ 87.20
4300593RENAL FUNCTION PANEL301Laboratory80069$ 95.00$ 61.75$ 76.00$ 30.38$ 30.38$ 27.34$ 15.19$ 61.75$ 76.00$ 61.75$ 76.00$ 15.19$ 76.00
4303635RENAL REF301Laboratory80069$ 95.00$ 61.75$ 76.00$ 30.38$ 30.38$ 27.34$ 15.19$ 61.75$ 76.00$ 61.75$ 76.00$ 15.19$ 76.00
4300923HEPATITIS PANEL301Laboratory80074$ 394.00$ 256.10$ 315.20$ 166.71$ 166.71$ 150.03$ 83.35$ 256.10$ 315.20$ 256.10$ 315.20$ 83.35$ 315.20
4300025HEPATIC FUNCTION301Laboratory80076$ 84.00$ 54.60$ 67.20$ 28.60$ 28.60$ 25.74$ 14.30$ 54.60$ 67.20$ 54.60$ 67.20$ 14.30$ 67.20
4300357CARBAMAZEPINE (TEGRETOL)301Laboratory80156$ 122.00$ 79.30$ 97.60$ 51.00$ 51.00$ 45.90$ 25.50$ 79.30$ 97.60$ 79.30$ 97.60$ 25.50$ 97.60
4303826Digoxin New300Laboratory80162$ 124.00$ 80.60$ 99.20$ 46.48$ 46.48$ 41.83$ 23.24$ 80.60$ 99.20$ 80.60$ 99.20$ 23.24$ 99.20
4302231VALPORIC ACID-REF301Laboratory80164$ 110.00$ 71.50$ 88.00$ 47.39$ 47.39$ 42.65$ 23.70$ 71.50$ 88.00$ 71.50$ 88.00$ 23.70$ 88.00
4300457LEVETIRACETAM (KEPPRA)301Laboratory80177$ 115.00$ 74.75$ 92.00$ 46.38$ 46.38$ 41.74$ 23.19$ 74.75$ 92.00$ 74.75$ 92.00$ 23.19$ 92.00
4301743PHENOBARBITAL-I301Laboratory80184$ 109.00$ 70.85$ 87.20$ 53.55$ 53.55$ 48.20$ 26.78$ 70.85$ 87.20$ 70.85$ 87.20$ 26.78$ 87.20
4300041DILANTIN301Laboratory80185$ 109.00$ 70.85$ 87.20$ 46.38$ 46.38$ 41.74$ 23.19$ 70.85$ 87.20$ 70.85$ 87.20$ 23.19$ 87.20
4301279SIROLIMUS301Laboratory80195$ 135.00$ 87.75$ 108.00$ 48.06$ 48.06$ 43.25$ 24.03$ 87.75$ 108.00$ 87.75$ 108.00$ 24.03$ 108.00
4303856Tacrolimans LCMS300Laboratory80197$ 137.00$ 89.05$ 109.60$ 48.06$ 48.06$ 43.25$ 24.03$ 89.05$ 109.60$ 89.05$ 109.60$ 24.03$ 109.60
4303827Vancomycin Random300Laboratory80202$ 124.00$ 80.60$ 99.20$ 47.39$ 47.39$ 42.65$ 23.70$ 80.60$ 99.20$ 80.60$ 99.20$ 23.70$ 99.20
4303829Vancomycin Trogh300Laboratory80202$ 124.00$ 80.60$ 99.20$ 47.39$ 47.39$ 42.65$ 23.70$ 80.60$ 99.20$ 80.60$ 99.20$ 23.70$ 99.20
4300459LAMICTAL (LAMOTRIGINE)301Laboratory80299$ 137.00$ 89.05$ 109.60$ 65.24$ 65.24$ 58.72$ 32.62$ 89.05$ 109.60$ 89.05$ 109.60$ 32.62$ 109.60
4301501DRUG SCREEN COLLECTION #3301Laboratory80306$ 72.00$ 46.80$ 57.60$ 59.99$ 59.99$ 53.99$ 30.00$ 46.80$ 57.60$ 46.80$ 57.60$ 30.00$ 59.99
4301633URINE DRUG SCREEN301Laboratory80306$ 72.00$ 46.80$ 57.60$ 59.99$ 59.99$ 53.99$ 30.00$ 46.80$ 57.60$ 46.80$ 57.60$ 30.00$ 59.99
4301229UA W/MICRO (COMPLETE)307Laboratory81001$ 62.00$ 40.30$ 49.60$ 11.10$ 11.10$ 9.99$ 5.55$ 40.30$ 49.60$ 40.30$ 49.60$ 5.55$ 49.60
4300851UA DIPSTICK ONLY307Laboratory81003$ 47.00$ 30.55$ 37.60$ 7.88$ 7.88$ 7.09$ 3.94$ 30.55$ 37.60$ 30.55$ 37.60$ 3.94$ 37.60
4300531UA - MICROSCOPIC ONLY307Laboratory81015$ 47.00$ 30.55$ 37.60$ 10.68$ 10.68$ 9.61$ 5.34$ 30.55$ 37.60$ 30.55$ 37.60$ 5.34$ 37.60
4300599PREGNANCY TEST URINE307Laboratory81025$ 76.00$ 49.40$ 60.80$ 30.14$ 30.14$ 27.12$ 15.07$ 49.40$ 60.80$ 49.40$ 60.80$ 15.07$ 60.80
4300265KETONES, QUAITATIVE SERM301Laboratory82009$ 59.00$ 38.35$ 47.20$ 15.82$ 15.82$ 14.24$ 7.91$ 38.35$ 47.20$ 38.35$ 47.20$ 7.91$ 47.20
4301121MICROALBUMIN-REF301Laboratory82043$ 46.00$ 29.90$ 36.80$ 20.23$ 20.23$ 18.21$ 10.12$ 29.90$ 36.80$ 29.90$ 36.80$ 10.12$ 36.80
4301685MICROALBUMIN QUAL URINE301Laboratory82044$ 46.00$ 29.90$ 36.80$ 21.81$ 21.81$ 19.62$ 10.90$ 29.90$ 36.80$ 29.90$ 36.80$ 10.90$ 36.80
4300413AMMONIA; SERUM OR URINE301Laboratory82140$ 122.00$ 79.30$ 97.60$ 51.00$ 51.00$ 45.90$ 25.50$ 79.30$ 97.60$ 79.30$ 97.60$ 25.50$ 97.60
4301377AMYLASE301Laboratory82150$ 99.00$ 64.35$ 79.20$ 22.68$ 22.68$ 20.41$ 11.34$ 64.35$ 79.20$ 64.35$ 79.20$ 11.34$ 79.20
4301231BILI TOTAL301Laboratory82247$ 282.00$ 183.30$ 225.60$ 17.57$ 17.57$ 15.81$ 8.79$ 183.30$ 225.60$ 183.30$ 225.60$ 8.79$ 225.60
4301173BILI DIRECT301Laboratory82248$ 66.00$ 42.90$ 52.80$ 17.57$ 17.57$ 15.81$ 8.79$ 42.90$ 52.80$ 42.90$ 52.80$ 8.79$ 52.80
CHARGE CODEDESCRIPTIONREV CODEDepartmentCPT CODERATECash PriceAetnaBCBS TraditionalBCBS PPOBCBS HMOBCBS Blue AdvCIGNACoventryFirstCareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
4300463OCCULT BLOOD SCREENING301Laboratory82270$ 65.00$ 42.25$ 52.00$ 15.33$ 15.33$ 13.80$ 7.67$ 42.25$ 52.00$ 42.25$ 52.00$ 7.67$ 52.00
4301677OCCULT BLD DIAGONSTI-iFOB301Laboratory82274$ 65.00$ 42.25$ 52.00$ 55.72$ 55.72$ 50.15$ 27.86$ 42.25$ 52.00$ 42.25$ 52.00$ 27.86$ 55.72
4303668Vit D Total II MAMC300Laboratory82306$ 144.00$ 93.60$ 115.20$ 103.60$ 103.60$ 93.24$ 51.80$ 93.60$ 115.20$ 93.60$ 115.20$ 51.80$ 115.20
4301993CALCIUM-P301Laboratory82310$ 66.00$ 42.90$ 52.80$ 18.06$ 18.06$ 16.25$ 9.03$ 42.90$ 52.80$ 42.90$ 52.80$ 9.03$ 52.80
4301341CORTISOL BLOOD301Laboratory82533$ 156.00$ 101.40$ 124.80$ 57.05$ 57.05$ 51.35$ 28.53$ 101.40$ 124.80$ 101.40$ 124.80$ 28.53$ 124.80
4301459CPK#301Laboratory82550$ 66.00$ 42.90$ 52.80$ 22.79$ 22.79$ 20.51$ 11.39$ 42.90$ 52.80$ 42.90$ 52.80$ 11.39$ 52.80
4301569BIOSITE CKMB301Laboratory82553$ 112.00$ 72.80$ 89.60$ 40.43$ 40.43$ 36.38$ 20.21$ 72.80$ 89.60$ 72.80$ 89.60$ 20.21$ 89.60
4300719CREATININE, BLOOD#301Laboratory82565$ 66.00$ 42.90$ 52.80$ 17.92$ 17.92$ 16.13$ 8.96$ 42.90$ 52.80$ 42.90$ 52.80$ 8.96$ 52.80
4301687CREATININE QUAL-URINE301Laboratory82570$ 66.00$ 42.90$ 52.80$ 18.13$ 18.13$ 16.32$ 9.07$ 42.90$ 52.80$ 42.90$ 52.80$ 9.07$ 52.80
4300775CREATININE, URINE-REF301Laboratory82570$ 66.00$ 42.90$ 52.80$ 18.13$ 18.13$ 16.32$ 9.07$ 42.90$ 52.80$ 42.90$ 52.80$ 9.07$ 52.80
4300125CREAT CLEARANCE 24 HR UR301Laboratory82575$ 80.00$ 52.00$ 64.00$ 33.11$ 33.11$ 29.80$ 16.56$ 52.00$ 64.00$ 52.00$ 64.00$ 16.56$ 64.00
4301463B-12301Laboratory82607$ 129.00$ 83.85$ 103.20$ 52.78$ 52.78$ 47.50$ 26.39$ 83.85$ 103.20$ 83.85$ 103.20$ 26.39$ 103.20
4300315VITAMIN D, 1,25-DIHYDROXY301Laboratory82652$ 219.00$ 142.35$ 175.20$ 134.75$ 134.75$ 121.28$ 67.38$ 142.35$ 175.20$ 142.35$ 175.20$ 67.38$ 175.20
4300989ESTROGEN TOTAL301Laboratory82672$ 199.00$ 129.35$ 159.20$ 75.95$ 75.95$ 68.36$ 37.98$ 129.35$ 159.20$ 129.35$ 159.20$ 37.98$ 159.20
4301343FERRITIN301Laboratory82728$ 115.00$ 74.75$ 92.00$ 47.71$ 47.71$ 42.93$ 23.85$ 74.75$ 92.00$ 74.75$ 92.00$ 23.85$ 92.00
4300663FOLATE (FOLIC ACID)301Laboratory82746$ 122.00$ 79.30$ 97.60$ 51.45$ 51.45$ 46.31$ 25.73$ 79.30$ 97.60$ 79.30$ 97.60$ 25.73$ 97.60
4300723IMMUNOGLOBULIN IGA-P301Laboratory82784$ 170.00$ 110.50$ 136.00$ 32.55$ 32.55$ 29.30$ 16.28$ 110.50$ 136.00$ 110.50$ 136.00$ 16.28$ 136.00
4300721IMMUNOGLOBULIN IGG301Laboratory82784$ 170.00$ 110.50$ 136.00$ 32.55$ 32.55$ 29.30$ 16.28$ 110.50$ 136.00$ 110.50$ 136.00$ 16.28$ 136.00
4300725IMMUNOGLOBULIN IGM301Laboratory82784$ 170.00$ 110.50$ 136.00$ 32.55$ 32.55$ 29.30$ 16.28$ 110.50$ 136.00$ 110.50$ 136.00$ 16.28$ 136.00
4302151BLOOD GAS-ARTERIAL301Laboratory82803$ 187.00$ 121.55$ 149.60$ 91.25$ 91.25$ 82.12$ 45.62$ 121.55$ 149.60$ 121.55$ 149.60$ 45.62$ 149.60
4300991GLUCOSE BLOOD#301Laboratory82947$ 66.00$ 42.90$ 52.80$ 13.76$ 13.76$ 12.38$ 6.88$ 42.90$ 52.80$ 42.90$ 52.80$ 6.88$ 52.80
4300279GLUCOSE; O'SULLIVAN301Laboratory82950$ 81.00$ 52.65$ 64.80$ 16.63$ 16.63$ 14.96$ 8.31$ 52.65$ 64.80$ 52.65$ 64.80$ 8.31$ 64.80
4300859GTT UP TO 3 SPEC301Laboratory82951$ 137.00$ 89.05$ 109.60$ 45.05$ 45.05$ 40.54$ 22.52$ 89.05$ 109.60$ 89.05$ 109.60$ 22.52$ 109.60
4300317GTT EACH ADDITONAL SAMPLE301Laboratory82952$ 48.00$ 31.20$ 38.40$ 13.72$ 13.72$ 12.35$ 6.86$ 31.20$ 38.40$ 31.20$ 38.40$ 6.86$ 38.40
4301473FSH301Laboratory83001$ 178.00$ 115.70$ 142.40$ 65.03$ 65.03$ 58.53$ 32.52$ 115.70$ 142.40$ 115.70$ 142.40$ 32.52$ 142.40
4300007LH301Laboratory83002$ 178.00$ 115.70$ 142.40$ 64.82$ 64.82$ 58.34$ 32.41$ 115.70$ 142.40$ 115.70$ 142.40$ 32.41$ 142.40
4303608H PYLORI BREATH301Laboratory83013$ 330.00$ 214.50$ 264.00$ 235.76$ 235.76$ 212.18$ 117.88$ 214.50$ 264.00$ 214.50$ 264.00$ 117.88$ 264.00
4303609H PYLORI COLLECTION301Laboratory83014$ 38.00$ 24.70$ 30.40$ 27.51$ 27.51$ 24.76$ 13.76$ 24.70$ 30.40$ 24.70$ 30.40$ 13.76$ 30.40
4300469HBA1C (HEM A1C)301Laboratory83036$ 80.00$ 52.00$ 64.00$ 33.99$ 33.99$ 30.59$ 16.99$ 52.00$ 64.00$ 52.00$ 64.00$ 16.99$ 64.00
4300667HOMOCYSTEINE (BLOOD)301Laboratory83090$ 139.00$ 90.35$ 111.20$ 62.72$ 62.72$ 56.45$ 31.36$ 90.35$ 111.20$ 90.35$ 111.20$ 31.36$ 111.20
4303662Fe (iron)300Laboratory83540$ 180.00$ 117.00$ 144.00$ 22.65$ 22.65$ 20.38$ 11.32$ 117.00$ 144.00$ 117.00$ 144.00$ 11.32$ 144.00
4303663UIBC (Unsaturated Iron-Binding Capacity)300Laboratory83550$ 232.00$ 150.80$ 185.60$ 30.59$ 30.59$ 27.53$ 15.30$ 150.80$ 185.60$ 150.80$ 185.60$ 15.30$ 185.60
4302261Lactic Acid301Laboratory83605$ 87.00$ 56.55$ 69.60$ 40.50$ 40.50$ 36.45$ 20.25$ 56.55$ 69.60$ 56.55$ 69.60$ 20.25$ 69.60
4301475LDH301Laboratory83615$ 87.00$ 56.55$ 69.60$ 21.14$ 21.14$ 19.03$ 10.57$ 56.55$ 69.60$ 56.55$ 69.60$ 10.57$ 69.60
4302025STOOL WBC; LACTOFERRIN301Laboratory83630$ 98.00$ 63.70$ 78.40$ 68.95$ 68.95$ 62.06$ 34.48$ 63.70$ 78.40$ 63.70$ 78.40$ 34.48$ 78.40
4301423LIPASE301Laboratory83690$ 87.00$ 56.55$ 69.60$ 24.12$ 24.12$ 21.70$ 12.06$ 56.55$ 69.60$ 56.55$ 69.60$ 12.06$ 69.60
4303664LDL Direct300Laboratory83721$ 103.00$ 66.95$ 82.40$ 36.75$ 36.75$ 33.08$ 18.38$ 66.95$ 82.40$ 66.95$ 82.40$ 18.38$ 82.40
4301291MAGNESIUM301Laboratory83735$ 87.00$ 56.55$ 69.60$ 23.45$ 23.45$ 21.11$ 11.73$ 56.55$ 69.60$ 56.55$ 69.60$ 11.73$ 69.60
4300555B-NATRIURETIC PEPTIDE301Laboratory83880$ 246.00$ 159.90$ 196.80$ 137.41$ 137.41$ 123.67$ 68.71$ 159.90$ 196.80$ 159.90$ 196.80$ 68.71$ 196.80
4303823ProBNP300Laboratory83880$ 246.00$ 159.90$ 196.80$ 137.41$ 137.41$ 123.67$ 68.71$ 159.90$ 196.80$ 159.90$ 196.80$ 68.71$ 196.80
4302235KAPPA-LAMBDA RATIO301Laboratory83883$ 246.00$ 159.90$ 196.80$ 47.60$ 47.60$ 42.84$ 23.80$ 159.90$ 196.80$ 159.90$ 196.80$ 23.80$ 196.80
4300271METHYLMALONIC ACID SERUM301Laboratory83921$ 165.00$ 107.25$ 132.00$ 74.24$ 74.24$ 66.81$ 37.12$ 107.25$ 132.00$ 107.25$ 132.00$ 37.12$ 132.00
4300423PTH (PARATHORMONE, RIA)301Laboratory83970$ 303.00$ 196.95$ 242.40$ 144.48$ 144.48$ 130.03$ 72.24$ 196.95$ 242.40$ 196.95$ 242.40$ 72.24$ 242.40
4300787PHOSPHORUS (PO4)#301Laboratory84100$ 87.00$ 56.55$ 69.60$ 16.59$ 16.59$ 14.93$ 8.30$ 56.55$ 69.60$ 56.55$ 69.60$ 8.30$ 69.60
4300871POTASSIUM-BLOOD#301Laboratory84132$ 66.00$ 42.90$ 52.80$ 16.66$ 16.66$ 14.99$ 8.33$ 42.90$ 52.80$ 42.90$ 52.80$ 8.33$ 52.80
4301135PROGESTERONE301Laboratory84144$ 206.00$ 133.90$ 164.80$ 73.01$ 73.01$ 65.71$ 36.51$ 133.90$ 164.80$ 133.90$ 164.80$ 36.51$ 164.80
4303822Procalcitonin300Laboratory84145$ 309.00$ 200.85$ 247.20$ 95.27$ 95.27$ 85.74$ 47.64$ 200.85$ 247.20$ 200.85$ 247.20$ 47.64$ 247.20
4301003PROLACTIN, RIA301Laboratory84146$ 191.00$ 124.15$ 152.80$ 67.83$ 67.83$ 61.05$ 33.92$ 124.15$ 152.80$ 124.15$ 152.80$ 33.92$ 152.80
4301777PSA TOTAL-REF301Laboratory84153$ 109.00$ 70.85$ 87.20$ 64.37$ 64.37$ 57.93$ 32.18$ 70.85$ 87.20$ 70.85$ 87.20$ 32.18$ 87.20
4301251PSA, TOTAL301Laboratory84153$ 109.00$ 70.85$ 87.20$ 64.37$ 64.37$ 57.93$ 32.18$ 70.85$ 87.20$ 70.85$ 87.20$ 32.18$ 87.20
4301293PSA, FREE301Laboratory84154$ 178.00$ 115.70$ 142.40$ 64.37$ 64.37$ 57.93$ 32.18$ 115.70$ 142.40$ 115.70$ 142.40$ 32.18$ 142.40
4300565PROTEIN, URINE RANDOM301Laboratory84156$ 66.00$ 42.90$ 52.80$ 12.85$ 12.85$ 11.56$ 6.42$ 42.90$ 52.80$ 42.90$ 52.80$ 6.42$ 52.80
4300483TOTAL PROTEIN 24 HR UR301Laboratory84156$ 66.00$ 42.90$ 52.80$ 12.85$ 12.85$ 11.56$ 6.42$ 42.90$ 52.80$ 42.90$ 52.80$ 6.42$ 52.80
4300485PROTEIN, SERUM, ELECT.301Laboratory84165$ 94.00$ 61.10$ 75.20$ 37.59$ 37.59$ 33.83$ 18.80$ 61.10$ 75.20$ 61.10$ 75.20$ 18.80$ 75.20
4300231PROTEIN URINE ELECTROPHES301Laboratory84166$ 94.00$ 61.10$ 75.20$ 62.41$ 62.41$ 56.16$ 31.20$ 61.10$ 75.20$ 61.10$ 75.20$ 31.20$ 75.20
4301081SODIUM-BLOOD#301Laboratory84295$ 66.00$ 42.90$ 52.80$ 16.84$ 16.84$ 15.15$ 8.42$ 42.90$ 52.80$ 42.90$ 52.80$ 8.42$ 52.80
4300733TESTOSTERONE, FREE301Laboratory84402$ 246.00$ 159.90$ 196.80$ 89.15$ 89.15$ 80.23$ 44.57$ 159.90$ 196.80$ 159.90$ 196.80$ 44.57$ 196.80
4300735TESTOSTERONE-TOTAL301Laboratory84403$ 214.00$ 139.10$ 171.20$ 90.34$ 90.34$ 81.30$ 45.17$ 139.10$ 171.20$ 139.10$ 171.20$ 45.17$ 171.20
4301009T4 (THYROXINE)301Laboratory84436$ 69.00$ 44.85$ 55.20$ 24.05$ 24.05$ 21.64$ 12.02$ 44.85$ 55.20$ 44.85$ 55.20$ 12.02$ 55.20
4301355FREE T-4301Laboratory84439$ 109.00$ 70.85$ 87.20$ 31.57$ 31.57$ 28.41$ 15.79$ 70.85$ 87.20$ 70.85$ 87.20$ 15.79$ 87.20
CHARGE CODEDESCRIPTIONREV CODEDepartmentCPT CODERATECash PriceAetnaBCBS TraditionalBCBS PPOBCBS HMOBCBS Blue AdvCIGNACoventryFirstCareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
4300293THYROXINE BINDING GLOBUL301Laboratory84442$ 143.00$ 92.95$ 114.40$ 51.73$ 51.73$ 46.56$ 25.87$ 92.95$ 114.40$ 92.95$ 114.40$ 25.87$ 114.40
4302221TSH-REF301Laboratory84443$ 109.00$ 70.85$ 87.20$ 58.80$ 58.80$ 52.92$ 29.40$ 70.85$ 87.20$ 70.85$ 87.20$ 29.40$ 87.20
4300295TSH--THYROID STIM. HORMON301Laboratory84443$ 109.00$ 70.85$ 87.20$ 58.80$ 58.80$ 52.92$ 29.40$ 70.85$ 87.20$ 70.85$ 87.20$ 29.40$ 87.20
4301253T-3 UPTAKE301Laboratory84479$ 69.00$ 44.85$ 55.20$ 22.65$ 22.65$ 20.38$ 11.32$ 44.85$ 55.20$ 44.85$ 55.20$ 11.32$ 55.20
4301303TOTAL T-3301Laboratory84480$ 137.00$ 89.05$ 109.60$ 49.63$ 49.63$ 44.67$ 24.82$ 89.05$ 109.60$ 89.05$ 109.60$ 24.82$ 109.60
4301395T3 FREE301Laboratory84481$ 129.00$ 83.85$ 103.20$ 59.29$ 59.29$ 53.36$ 29.65$ 83.85$ 103.20$ 83.85$ 103.20$ 29.65$ 103.20
4301573BIOSITE TROPONIN301Laboratory84484$ 112.00$ 72.80$ 89.60$ 43.65$ 43.65$ 39.28$ 21.82$ 72.80$ 89.60$ 72.80$ 89.60$ 21.82$ 89.60
4303849Tro-Gen4300Laboratory84484$ 112.00$ 72.80$ 89.60$ 43.65$ 43.65$ 39.28$ 21.82$ 72.80$ 89.60$ 72.80$ 89.60$ 21.82$ 89.60
4303830Troponin T New300Laboratory84484$ 112.00$ 72.80$ 89.60$ 43.65$ 43.65$ 39.28$ 21.82$ 72.80$ 89.60$ 72.80$ 89.60$ 21.82$ 89.60
4300375BUN BLOOD-UREA-NITROGEN#301Laboratory84520$ 66.00$ 42.90$ 52.80$ 13.83$ 13.83$ 12.44$ 6.91$ 42.90$ 52.80$ 42.90$ 52.80$ 6.91$ 52.80
4300875URIC ACID-BLOOD#301Laboratory84550$ 87.00$ 56.55$ 69.60$ 15.82$ 15.82$ 14.24$ 7.91$ 56.55$ 69.60$ 56.55$ 69.60$ 7.91$ 69.60
4300957BETA HCG-QUANT.301Laboratory84702$ 123.00$ 79.95$ 98.40$ 52.68$ 52.68$ 47.41$ 26.34$ 79.95$ 98.40$ 79.95$ 98.40$ 26.34$ 98.40
4300615PREGNANCY TEST SERUM301Laboratory84703$ 76.00$ 49.40$ 60.80$ 26.32$ 26.32$ 23.69$ 13.16$ 49.40$ 60.80$ 49.40$ 60.80$ 13.16$ 60.80
4300711MANUAL DIFFERENTIAL305Laboratory85007$ 33.00$ 21.45$ 26.40$ 13.30$ 13.30$ 11.97$ 6.65$ 21.45$ 26.40$ 21.45$ 26.40$ 6.65$ 26.40
4301257HEMATOCRIT305Laboratory85014$ 33.00$ 21.45$ 26.40$ 8.30$ 8.30$ 7.47$ 4.15$ 21.45$ 26.40$ 21.45$ 26.40$ 4.15$ 26.40
4301259HEMOGLOBIN305Laboratory85018$ 33.00$ 21.45$ 26.40$ 8.30$ 8.30$ 7.47$ 4.15$ 21.45$ 26.40$ 21.45$ 26.40$ 4.15$ 26.40
4300959CBC W/AUTO DIFF305Laboratory85025$ 62.00$ 40.30$ 49.60$ 27.20$ 27.20$ 24.48$ 13.60$ 40.30$ 49.60$ 40.30$ 49.60$ 13.60$ 49.60
4300795CBC NO DIFF305Laboratory85027$ 66.00$ 42.90$ 52.80$ 22.65$ 22.65$ 20.38$ 11.32$ 42.90$ 52.80$ 42.90$ 52.80$ 11.32$ 52.80
4301113D-DIMER QUANT, BIOSITE305Laboratory85378$ 112.00$ 72.80$ 89.60$ 34.02$ 34.02$ 30.62$ 17.01$ 72.80$ 89.60$ 72.80$ 89.60$ 17.01$ 89.60
4301137PROTIME (PT)305Laboratory85610$ 76.00$ 49.40$ 60.80$ 15.02$ 15.02$ 13.51$ 7.51$ 49.40$ 60.80$ 49.40$ 60.80$ 7.51$ 60.80
4301933PT-REF-P305Laboratory85610$ 76.00$ 49.40$ 60.80$ 15.02$ 15.02$ 13.51$ 7.51$ 49.40$ 60.80$ 49.40$ 60.80$ 7.51$ 60.80
4300617SED RATE - AUTOMATED305Laboratory85652$ 82.00$ 53.30$ 65.60$ 9.45$ 9.45$ 8.51$ 4.73$ 53.30$ 65.60$ 53.30$ 65.60$ 4.73$ 65.60
4303713PASE APTT300Laboratory85730$ 180.00$ 117.00$ 144.00$ 21.04$ 21.04$ 18.93$ 10.52$ 117.00$ 144.00$ 117.00$ 144.00$ 10.52$ 144.00
4301479PTT305Laboratory85730$ 180.00$ 117.00$ 144.00$ 21.04$ 21.04$ 18.93$ 10.52$ 117.00$ 144.00$ 117.00$ 144.00$ 10.52$ 144.00
4301857PTT-REF305Laboratory85730$ 180.00$ 117.00$ 144.00$ 21.04$ 21.04$ 18.93$ 10.52$ 117.00$ 144.00$ 117.00$ 144.00$ 10.52$ 144.00
4301935PTT-REF-P305Laboratory85730$ 180.00$ 117.00$ 144.00$ 21.04$ 21.04$ 18.93$ 10.52$ 117.00$ 144.00$ 117.00$ 144.00$ 10.52$ 144.00
4303833Anxca Scr w/ Rweflex300Laboratory86021$ 75.00$ 48.75$ 60.00$ 52.68$ 52.68$ 47.41$ 26.34$ 48.75$ 60.00$ 48.75$ 60.00$ 26.34$ 60.00
4300813ANA; QUANTATATIVE302Laboratory86039$ 94.00$ 61.10$ 75.20$ 39.06$ 39.06$ 35.15$ 19.53$ 61.10$ 75.20$ 61.10$ 75.20$ 19.53$ 75.20
4300883ASO QUANTITATIVE302Laboratory86063$ 83.00$ 53.95$ 66.40$ 20.20$ 20.20$ 18.18$ 10.10$ 53.95$ 66.40$ 53.95$ 66.40$ 10.10$ 66.40
4303661CRP (inflammatory)302Laboratory86140$ 81.00$ 52.65$ 64.80$ 18.13$ 18.13$ 16.32$ 9.07$ 52.65$ 64.80$ 52.65$ 64.80$ 9.07$ 64.80
4301483C 3-I302Laboratory86160$ 99.00$ 64.35$ 79.20$ 42.00$ 42.00$ 37.80$ 21.00$ 64.35$ 79.20$ 64.35$ 79.20$ 21.00$ 79.20
4301361ANTI CCP302Laboratory86200$ 179.00$ 116.35$ 143.20$ 45.33$ 45.33$ 40.79$ 22.66$ 116.35$ 143.20$ 116.35$ 143.20$ 22.66$ 143.20
4301191MONO SCREEN302Laboratory86308$ 83.00$ 53.95$ 66.40$ 18.13$ 18.13$ 16.32$ 9.07$ 53.95$ 66.40$ 53.95$ 66.40$ 9.07$ 66.40
4301947PNEUMOCOCCAL TITER302Laboratory86317$ 95.00$ 61.75$ 76.00$ 52.47$ 52.47$ 47.22$ 26.23$ 61.75$ 76.00$ 61.75$ 76.00$ 26.23$ 76.00
4301321H. PYLORI302Laboratory86318$ 109.00$ 70.85$ 87.20$ 63.32$ 63.32$ 56.98$ 31.66$ 70.85$ 87.20$ 70.85$ 87.20$ 31.66$ 87.20
4300625IMMUNOFIXATION BLOOD302Laboratory86334$ 163.00$ 105.95$ 130.40$ 78.19$ 78.19$ 70.37$ 39.10$ 105.95$ 130.40$ 105.95$ 130.40$ 39.10$ 130.40
4300199THYROID PEROXID ANTIBDY302Laboratory86376$ 122.00$ 79.30$ 97.60$ 50.93$ 50.93$ 45.83$ 25.46$ 79.30$ 97.60$ 79.30$ 97.60$ 25.46$ 97.60
4300889RA FACTOR SCREEN302Laboratory86430$ 87.00$ 56.55$ 69.60$ 21.49$ 21.49$ 19.34$ 10.75$ 56.55$ 69.60$ 56.55$ 69.60$ 10.75$ 69.60
4303843QuantiFERON TB Gold Plus300Laboratory86480$ 294.00$ 191.10$ 235.20$ 216.93$ 216.93$ 195.24$ 108.47$ 191.10$ 235.20$ 191.10$ 235.20$ 108.47$ 235.20
4301093LYME TEST EIA302Laboratory86618$ 139.00$ 90.35$ 111.20$ 59.61$ 59.61$ 53.64$ 29.80$ 90.35$ 111.20$ 90.35$ 111.20$ 29.80$ 111.20
4300303HIV-1 & HIV-2 SINGL ASSAY302Laboratory86703$ 137.00$ 89.05$ 109.60$ 47.99$ 47.99$ 43.19$ 23.99$ 89.05$ 109.60$ 89.05$ 109.60$ 23.99$ 109.60
4302047HIV-EXPOSE PROTOCOL302Laboratory86703$ 137.00$ 89.05$ 109.60$ 47.99$ 47.99$ 43.19$ 23.99$ 89.05$ 109.60$ 89.05$ 109.60$ 23.99$ 109.60
4303780HBSAB EMP HEALTH300Laboratory86707$ 94.00$ 61.10$ 75.20$ 40.50$ 40.50$ 36.45$ 20.25$ 61.10$ 75.20$ 61.10$ 75.20$ 20.25$ 75.20
4300693MYCOPLASMA ANTIBODY302Laboratory86738$ 109.00$ 70.85$ 87.20$ 46.34$ 46.34$ 41.71$ 23.17$ 70.85$ 87.20$ 70.85$ 87.20$ 23.17$ 87.20
4300439TREPONEMA PALLIDUM, FTA302Laboratory86780$ 289.00$ 187.85$ 231.20$ 46.34$ 46.34$ 41.71$ 23.17$ 187.85$ 231.20$ 187.85$ 231.20$ 23.17$ 231.20
4302051HEP C-EXPOSE PROTOCOL302Laboratory86803$ 115.00$ 74.75$ 92.00$ 49.95$ 49.95$ 44.95$ 24.97$ 74.75$ 92.00$ 74.75$ 92.00$ 24.97$ 92.00
4300631HEPATITIS C ANTIBODY302Laboratory86803$ 115.00$ 74.75$ 92.00$ 49.95$ 49.95$ 44.95$ 24.97$ 74.75$ 92.00$ 74.75$ 92.00$ 24.97$ 92.00
4300249HLA TYP, A,B,OR C;SINGLE302Laboratory86812$ 252.00$ 163.80$ 201.60$ 90.34$ 90.34$ 81.30$ 45.17$ 163.80$ 201.60$ 163.80$ 201.60$ 45.17$ 201.60
4301021CULTURE, BLOOD306Laboratory87040$ 114.00$ 74.10$ 91.20$ 36.12$ 36.12$ 32.51$ 18.06$ 74.10$ 91.20$ 74.10$ 91.20$ 18.06$ 91.20
4300109CULTRE STOL SALM, SHIGELA306Laboratory87045$ 87.00$ 56.55$ 69.60$ 33.04$ 33.04$ 29.74$ 16.52$ 56.55$ 69.60$ 56.55$ 69.60$ 16.52$ 69.60
4301845CULT, WOUND-REF306Laboratory87070$ 112.00$ 72.80$ 89.60$ 30.17$ 30.17$ 27.15$ 15.09$ 72.80$ 89.60$ 72.80$ 89.60$ 15.09$ 89.60
4301873CULT, SPUTUM-REF306Laboratory87070$ 112.00$ 72.80$ 89.60$ 30.17$ 30.17$ 27.15$ 15.09$ 72.80$ 89.60$ 72.80$ 89.60$ 15.09$ 89.60
4301853CULT, THROAT-REF306Laboratory87070$ 112.00$ 72.80$ 89.60$ 30.17$ 30.17$ 27.15$ 15.09$ 72.80$ 89.60$ 72.80$ 89.60$ 15.09$ 89.60
4301881CULT ID ANAEROBIC306Laboratory87076$ 218.00$ 141.70$ 174.40$ 28.28$ 28.28$ 25.45$ 14.14$ 141.70$ 174.40$ 141.70$ 174.40$ 14.14$ 174.40
4301899CULT ID AEROBIC306Laboratory87077$ 180.00$ 117.00$ 144.00$ 28.28$ 28.28$ 25.45$ 14.14$ 117.00$ 144.00$ 117.00$ 144.00$ 14.14$ 144.00
4301851CULT, URINE-REF306Laboratory87086$ 76.00$ 49.40$ 60.80$ 28.25$ 28.25$ 25.42$ 14.12$ 49.40$ 60.80$ 49.40$ 60.80$ 14.12$ 60.80
4303649Culture Urine Quantitative Count306Laboratory87086$ 76.00$ 49.40$ 60.80$ 28.25$ 28.25$ 25.42$ 14.12$ 49.40$ 60.80$ 49.40$ 60.80$ 14.12$ 60.80
4301905CULT ID YEAST306Laboratory87106$ 175.00$ 113.75$ 140.00$ 36.12$ 36.12$ 32.51$ 18.06$ 113.75$ 140.00$ 113.75$ 140.00$ 18.06$ 140.00
4303601Culture Typing Immuno306Laboratory87147$ 79.00$ 51.35$ 63.20$ 18.13$ 18.13$ 16.32$ 9.07$ 51.35$ 63.20$ 51.35$ 63.20$ 9.07$ 63.20
4300903O&P DIRECT SMEAR306Laboratory87177$ 129.00$ 83.85$ 103.20$ 31.15$ 31.15$ 28.04$ 15.58$ 83.85$ 103.20$ 83.85$ 103.20$ 15.58$ 103.20
CHARGE CODEDESCRIPTIONREV CODEDepartmentCPT CODERATECash PriceAetnaBCBS TraditionalBCBS PPOBCBS HMOBCBS Blue AdvCIGNACoventryFirstCareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
4303901Cult Sens Gradient Ea300Laboratory87181$ 26.00$ 16.90$ 20.80$ 16.63$ 16.63$ 14.96$ 8.31$ 16.90$ 20.80$ 16.90$ 20.80$ 8.31$ 20.80
4301855CULT, SUSCEPTIBILITY-REF306Laboratory87186$ 196.00$ 127.40$ 156.80$ 30.28$ 30.28$ 27.25$ 15.14$ 127.40$ 156.80$ 127.40$ 156.80$ 15.14$ 156.80
4301849GRAM STAIN-REF306Laboratory87205$ 76.00$ 49.40$ 60.80$ 14.95$ 14.95$ 13.45$ 7.47$ 49.40$ 60.80$ 49.40$ 60.80$ 7.47$ 60.80
4300751O&P TRICHOME STAIN306Laboratory87209$ 129.00$ 83.85$ 103.20$ 62.93$ 62.93$ 56.64$ 31.47$ 83.85$ 103.20$ 83.85$ 103.20$ 31.47$ 103.20
4301327WET MOUNT306Laboratory87210$ 66.00$ 42.90$ 52.80$ 20.37$ 20.37$ 18.33$ 10.19$ 42.90$ 52.80$ 42.90$ 52.80$ 10.19$ 52.80
4300701O&P CRYPTOSPORIDIUM306Laboratory87328$ 76.00$ 49.40$ 60.80$ 48.37$ 48.37$ 43.53$ 24.19$ 49.40$ 60.80$ 49.40$ 60.80$ 24.19$ 60.80
4301199O&P GIARDIA306Laboratory87329$ 87.00$ 56.55$ 69.60$ 41.93$ 41.93$ 37.74$ 20.97$ 56.55$ 69.60$ 56.55$ 69.60$ 20.97$ 69.60
4302053HBSAG-EXPOSE PROTOCOL306Laboratory87340$ 87.00$ 56.55$ 69.60$ 36.16$ 36.16$ 32.54$ 18.08$ 56.55$ 69.60$ 56.55$ 69.60$ 18.08$ 69.60
4300255HEPATITIS B SURFACE ANTIG306Laboratory87340$ 87.00$ 56.55$ 69.60$ 36.16$ 36.16$ 32.54$ 18.08$ 56.55$ 69.60$ 56.55$ 69.60$ 18.08$ 69.60
4303825Legionella Ag MAMC300Laboratory87449$ 99.00$ 64.35$ 79.20$ 41.93$ 41.93$ 37.74$ 20.97$ 64.35$ 79.20$ 64.35$ 79.20$ 20.97$ 79.20
4303783Candidia DNA probe300Laboratory87480$ 98.00$ 63.70$ 78.40$ 70.18$ 70.18$ 63.16$ 35.09$ 63.70$ 78.40$ 63.70$ 78.40$ 35.09$ 78.40
4301665CHLAMYDIA URINE306Laboratory87491$ 124.00$ 80.60$ 99.20$ 122.82$ 122.82$ 110.53$ 61.41$ 80.60$ 99.20$ 80.60$ 99.20$ 61.41$ 122.82
4303674C Difficile amplified probe306Laboratory87493$ 175.00$ 113.75$ 140.00$ 130.45$ 130.45$ 117.40$ 65.22$ 113.75$ 140.00$ 113.75$ 140.00$ 65.22$ 140.00
4303858Enteric Pathogens Stool PCR300Laboratory87506$ 1,004.00$ 652.60$ 803.20$ 920.47$ 920.47$ 828.42$ 460.23$ 652.60$ 803.20$ 652.60$ 803.20$ 460.23$ 920.47
4303782Gardnerella DNA probe300Laboratory87510$ 98.00$ 63.70$ 78.40$ 70.18$ 70.18$ 63.16$ 35.09$ 63.70$ 78.40$ 63.70$ 78.40$ 35.09$ 78.40
4303676Mycoplasma DNA amplification306Laboratory87581$ 124.00$ 80.60$ 99.20$ 122.82$ 122.82$ 110.53$ 61.41$ 80.60$ 99.20$ 80.60$ 99.20$ 61.41$ 122.82
4301667N. GONORRHOEAE- URINE306Laboratory87591$ 124.00$ 80.60$ 99.20$ 122.82$ 122.82$ 110.53$ 61.41$ 80.60$ 99.20$ 80.60$ 99.20$ 61.41$ 122.82
4303878COVID-19 REFERENCE LAB300Laboratory87635$ 270.00$ 175.50$ 216.00$ 179.59$ 179.59$ 161.63$ 89.79$ 175.50$ 216.00$ 175.50$ 216.00$ 89.79$ 216.00
4303677Gp A Strep DNA amplification reflexed306Laboratory87651$ 134.00$ 87.10$ 107.20$ 122.82$ 122.82$ 110.53$ 61.41$ 87.10$ 107.20$ 87.10$ 107.20$ 61.41$ 122.82
4303678Group A Strep DNA only306Laboratory87651$ 139.00$ 90.35$ 111.20$ 122.82$ 122.82$ 110.53$ 61.41$ 90.35$ 111.20$ 90.35$ 111.20$ 61.41$ 122.82
4303784Trichomonas DNA probe300Laboratory87797$ 125.00$ 81.25$ 100.00$ 105.11$ 105.11$ 94.59$ 52.55$ 81.25$ 100.00$ 81.25$ 100.00$ 52.55$ 105.11
4301627PERTUSSIS DNA PCR306Laboratory87798$ 246.00$ 159.90$ 196.80$ 122.82$ 122.82$ 110.53$ 61.41$ 159.90$ 196.80$ 159.90$ 196.80$ 61.41$ 196.80
4300911INFLUENZA A & B306Laboratory87804$ 124.00$ 80.60$ 99.20$ 57.93$ 57.93$ 52.13$ 28.96$ 80.60$ 99.20$ 80.60$ 99.20$ 28.96$ 99.20
4301487RSV306Laboratory87807$ 109.00$ 70.85$ 87.20$ 45.85$ 45.85$ 41.27$ 22.93$ 70.85$ 87.20$ 70.85$ 87.20$ 22.93$ 87.20
4301201QUICK STREP306Laboratory87880$ 87.00$ 56.55$ 69.60$ 57.86$ 57.86$ 52.07$ 28.93$ 56.55$ 69.60$ 56.55$ 69.60$ 28.93$ 69.60
4301500DRUG SCR COLLECTION #2300Laboratory99000$ 45.00$ 29.25$ 36.00$ 42.88$ 42.88$ 38.59$ 21.44$ 29.25$ 36.00$ 29.25$ 36.00$ 21.44$ 42.88
4300037PSA SCREEN309LaboratoryG0103$ 109.00$ 70.85$ 87.20$ 67.59$ 67.59$ 60.83$ 33.79$ 70.85$ 87.20$ 70.85$ 87.20$ 33.79$ 87.20
4301675OCCULT BLD SCREEN-iFOB305LaboratoryG0328$ 65.00$ 42.25$ 52.00$ 63.18$ 63.18$ 56.86$ 31.59$ 42.25$ 52.00$ 42.25$ 52.00$ 31.59$ 63.18
4480007MRI - BRAIN W&WO CONT611MRI70553$ 2,652.00$ 1,723.80$ 2,121.60$ 1,393.75$ 1,393.75$ 1,256.29$ 668.24$ 1,723.80$ 2,121.60$ 1,856.40$ 2,121.60$ 668.24$ 2,121.60
4480043MRI SPINE LUMBAR W/O CM612MRI72148$ 1,648.00$ 1,071.20$ 1,318.40$ 850.60$ 850.60$ 766.70$ 407.82$ 1,071.20$ 1,318.40$ 1,153.60$ 1,318.40$ 407.82$ 1,318.40
4480047MRI LOW JOINT W/O CM610MRI73721$ 1,648.00$ 1,071.20$ 1,318.40$ 850.60$ 850.60$ 766.70$ 407.82$ 1,071.20$ 1,318.40$ 1,153.60$ 1,318.40$ 407.82$ 1,318.40
4600047ELECTRICAL STIM 15 MIN420Physical Therapy97014$ 73.00$ 47.45$ 58.40$ 42.24$ 42.24$ 31.49$ 15.14$ 47.45$ 58.40$ 51.10$ 58.40$ 15.14$ 58.40
4600071ULTRASOUND - 15 MIN420Physical Therapy97035$ 81.00$ 52.65$ 64.80$ 39.23$ 39.23$ 29.24$ 14.06$ 52.65$ 64.80$ 56.70$ 64.80$ 14.06$ 64.80
4600083EXERCISE - 15 MIN420Physical Therapy97110$ 103.00$ 66.95$ 82.40$ 87.47$ 87.47$ 65.21$ 31.35$ 66.95$ 82.40$ 72.10$ 82.40$ 31.35$ 87.47
4600095GAIT TRAINING420Physical Therapy97116$ 93.00$ 60.45$ 74.40$ 86.46$ 86.46$ 64.46$ 30.99$ 60.45$ 74.40$ 65.10$ 74.40$ 30.99$ 86.46
4600029MASSAGE - 15 MIN/PT420Physical Therapy97124$ 82.00$ 53.30$ 65.60$ 81.44$ 81.44$ 60.72$ 29.19$ 53.30$ 65.60$ 57.40$ 65.60$ 29.19$ 81.44
4600101EVALUATION424Physical Therapy97161$ 258.00$ 167.70$ 206.40$ 241.31$ 241.31$ 179.90$ 86.49$ 167.70$ 206.40$ 180.60$ 206.40$ 86.49$ 241.31
46097161PT EVAL; LOW COMPLEXITY424Physical Therapy97161$ 258.00$ 167.70$ 206.40$ 241.31$ 241.31$ 179.90$ 86.49$ 167.70$ 206.40$ 180.60$ 206.40$ 86.49$ 241.31
4600055KINETIC ACTIV THERAPEUTIC420Physical Therapy97530$ 125.00$ 81.25$ 100.00$ 113.61$ 113.61$ 84.70$ 40.72$ 81.25$ 100.00$ 87.50$ 100.00$ 40.72$ 113.61
4400031MANDLE;PART LESS THAN (4)320Radiology70100$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400083FACIAL BONES COMPL SERIES320Radiology70150$ 279.00$ 181.35$ 223.20$ 257.78$ 257.78$ 147.95$ 112.08$ 181.35$ 223.20$ 195.30$ 223.20$ 112.08$ 257.78
4400037NASAL BONES - XRAY320Radiology70160$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400073RADIOLOG EXM NEK SFT TISS320Radiology70360$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400043CHEST (1)324Radiology71045$ 232.00$ 150.80$ 185.60$ 183.56$ 183.56$ 105.35$ 79.81$ 150.80$ 185.60$ 162.40$ 185.60$ 79.81$ 185.60
4400141CHEST (1) WITH PORTABLE320Radiology71045$ 232.00$ 150.80$ 185.60$ 183.56$ 183.56$ 105.35$ 79.81$ 150.80$ 185.60$ 162.40$ 185.60$ 79.81$ 185.60
4400097CHEST,APICAL LORDOTI ONLY320Radiology71045$ 232.00$ 150.80$ 185.60$ 183.56$ 183.56$ 105.35$ 79.81$ 150.80$ 185.60$ 162.40$ 185.60$ 79.81$ 185.60
4400353CHEST (2)324Radiology71046$ 232.00$ 150.80$ 185.60$ 183.56$ 183.56$ 105.35$ 79.81$ 150.80$ 185.60$ 162.40$ 185.60$ 79.81$ 185.60
4400013RIBS (2) LEFT320Radiology71100$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400011RIBS (2) RIGHT320Radiology71100$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400107RIBS BILAT + PA CHEST 4WS320Radiology71111$ 279.00$ 181.35$ 223.20$ 257.78$ 257.78$ 147.95$ 112.08$ 181.35$ 223.20$ 195.30$ 223.20$ 112.08$ 257.78
4400169SPINE CERVICAL 2-3 VWS320Radiology72040$ 202.00$ 131.30$ 161.60$ 183.56$ 183.56$ 105.35$ 79.81$ 131.30$ 161.60$ 141.40$ 161.60$ 79.81$ 183.56
4400131SPINE CERVICAL MIN 4 VWS320Radiology72050$ 279.00$ 181.35$ 223.20$ 257.78$ 257.78$ 147.95$ 112.08$ 181.35$ 223.20$ 195.30$ 223.20$ 112.08$ 257.78
4400133SPINE, CERVICAL COMPLETE320Radiology72052$ 318.00$ 206.70$ 254.40$ 257.78$ 257.78$ 147.95$ 112.08$ 206.70$ 254.40$ 222.60$ 254.40$ 112.08$ 257.78
4400217SPINE, THORACIC (2)320Radiology72070$ 282.00$ 183.30$ 225.60$ 257.78$ 257.78$ 147.95$ 112.08$ 183.30$ 225.60$ 197.40$ 225.60$ 112.08$ 257.78
4400147SPINE, LUMBAR 2-3 VIEWS320Radiology72100$ 279.00$ 181.35$ 223.20$ 257.78$ 257.78$ 147.95$ 112.08$ 181.35$ 223.20$ 195.30$ 223.20$ 112.08$ 257.78
4400135SPINE, LUMBAR MIN OF (4)320Radiology72110$ 279.00$ 181.35$ 223.20$ 257.78$ 257.78$ 147.95$ 112.08$ 181.35$ 223.20$ 195.30$ 223.20$ 112.08$ 257.78
4400171SPINE, LUMBER COMPLETE320Radiology72114$ 318.00$ 206.70$ 254.40$ 257.78$ 257.78$ 147.95$ 112.08$ 206.70$ 254.40$ 222.60$ 254.40$ 112.08$ 257.78
4400149PELVIS (1) OR (2) VIEWS320Radiology72170$ 279.00$ 181.35$ 223.20$ 257.78$ 257.78$ 147.95$ 112.08$ 181.35$ 223.20$ 195.30$ 223.20$ 112.08$ 257.78
4400029SACRUM AND COCCYX320Radiology72220$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400249CLAVICLE COMPL LT320Radiology73000$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
CHARGE CODEDESCRIPTIONREV CODEDepartmentCPT CODERATECash PriceAetnaBCBS TraditionalBCBS PPOBCBS HMOBCBS Blue AdvCIGNACoventryFirstCareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
4400255SHOULDER (2) LEFT320Radiology73030$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400237SHOULDER (2) RIGHT320Radiology73030$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400263HUMERUS (2) LEFT320Radiology73060$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400257HUMERUS (2) RIGHT320Radiology73060$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400291ELBOW (2) LEFT320Radiology73070$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400277ELBOW (2) RIGHT320Radiology73070$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400354ELBOW 3 VIEWS LT320Radiology73080$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400323ELBOW 3 VIEWS RT320Radiology73080$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400265FOREARM (2) LEFT320Radiology73090$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400259FOREARM (2) RIGHT320Radiology73090$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400293WRIST (2) LEFT320Radiology73100$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400279WRIST (2) RIGHT320Radiology73100$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400025WRIST (3VW MIN) LEFT320Radiology73110$ 196.00$ 127.40$ 156.80$ 183.56$ 183.56$ 105.35$ 79.81$ 127.40$ 156.80$ 137.20$ 156.80$ 79.81$ 183.56
4400193WRIST (3VW MIN) RIGHT320Radiology73110$ 196.00$ 127.40$ 156.80$ 183.56$ 183.56$ 105.35$ 79.81$ 127.40$ 156.80$ 137.20$ 156.80$ 79.81$ 183.56
4400325HAND (2) LEFT320Radiology73120$ 275.00$ 178.75$ 220.00$ 257.78$ 257.78$ 147.95$ 112.08$ 178.75$ 220.00$ 192.50$ 220.00$ 112.08$ 257.78
4400295HAND (2) RIGHT320Radiology73120$ 275.00$ 178.75$ 220.00$ 257.78$ 257.78$ 147.95$ 112.08$ 178.75$ 220.00$ 192.50$ 220.00$ 112.08$ 257.78
4400327HAND (3) LEFT320Radiology73130$ 279.00$ 181.35$ 223.20$ 183.56$ 183.56$ 105.35$ 79.81$ 181.35$ 223.20$ 195.30$ 223.20$ 79.81$ 223.20
4400297HAND (3) RIGHT320Radiology73130$ 279.00$ 181.35$ 223.20$ 183.56$ 183.56$ 105.35$ 79.81$ 181.35$ 223.20$ 195.30$ 223.20$ 79.81$ 223.20
4400281FINGER (3) LEFT320Radiology73140$ 224.00$ 145.60$ 179.20$ 183.56$ 183.56$ 105.35$ 79.81$ 145.60$ 179.20$ 156.80$ 179.20$ 79.81$ 183.56
4400267FINGER (3) RIGHT320Radiology73140$ 224.00$ 145.60$ 179.20$ 183.56$ 183.56$ 105.35$ 79.81$ 145.60$ 179.20$ 156.80$ 179.20$ 79.81$ 183.56
4400343HIP (2) LEFT320Radiology73503$ 371.00$ 241.15$ 296.80$ 257.78$ 257.78$ 147.95$ 112.08$ 241.15$ 296.80$ 259.70$ 296.80$ 112.08$ 296.80
4400331HIP (2) RIGHT320Radiology73503$ 371.00$ 241.15$ 296.80$ 257.78$ 257.78$ 147.95$ 112.08$ 241.15$ 296.80$ 259.70$ 296.80$ 112.08$ 296.80
4400299FEMUR (2) LEFT320Radiology73552$ 227.00$ 147.55$ 181.60$ 183.56$ 183.56$ 105.35$ 79.81$ 147.55$ 181.60$ 158.90$ 181.60$ 79.81$ 183.56
4400283FEMUR (2) RIGHT320Radiology73552$ 227.00$ 147.55$ 181.60$ 183.56$ 183.56$ 105.35$ 79.81$ 147.55$ 181.60$ 158.90$ 181.60$ 79.81$ 183.56
4400333KNEE (2) LEFT320Radiology73560$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400301KNEE (2) RIGHT320Radiology73560$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400335KNEE (3) LEFT320Radiology73562$ 191.00$ 124.15$ 152.80$ 183.56$ 183.56$ 105.35$ 79.81$ 124.15$ 152.80$ 133.70$ 152.80$ 79.81$ 183.56
4400303KNEE (3) RIGHT320Radiology73562$ 191.00$ 124.15$ 152.80$ 183.56$ 183.56$ 105.35$ 79.81$ 124.15$ 152.80$ 133.70$ 152.80$ 79.81$ 183.56
4400205KNEES, (AP STANDING)320Radiology73565$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400345LEG (2) LEFT320Radiology73590$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400337LEG (2) RIGHT320Radiology73590$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400285ANKLE (2) RIGHT320Radiology73600$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400307ANKLE (3) LEFT320Radiology73610$ 185.00$ 120.25$ 148.00$ 183.56$ 183.56$ 105.35$ 79.81$ 120.25$ 148.00$ 129.50$ 148.00$ 79.81$ 183.56
4400287ANKLE (3) RIGHT320Radiology73610$ 185.00$ 120.25$ 148.00$ 183.56$ 183.56$ 105.35$ 79.81$ 120.25$ 148.00$ 129.50$ 148.00$ 79.81$ 183.56
4400309FOOT (2) LEFT320Radiology73620$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400311FOOT (2) RIGHT320Radiology73620$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400339FOOT (3) LEFT320Radiology73630$ 224.00$ 145.60$ 179.20$ 183.56$ 183.56$ 105.35$ 79.81$ 145.60$ 179.20$ 156.80$ 179.20$ 79.81$ 183.56
4400313FOOT (3) RIGHT320Radiology73630$ 224.00$ 145.60$ 179.20$ 183.56$ 183.56$ 105.35$ 79.81$ 145.60$ 179.20$ 156.80$ 179.20$ 79.81$ 183.56
4400017TOES, LEFT320Radiology73660$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4400351TOES, RIGHT320Radiology73660$ 200.00$ 130.00$ 160.00$ 183.56$ 183.56$ 105.35$ 79.81$ 130.00$ 160.00$ 140.00$ 160.00$ 79.81$ 183.56
4420073CT lower extremity with contrast352Radiology73701$ 1,288.00$ 837.20$ 1,030.40$ 665.10$ 665.10$ 599.50$ 318.89$ 837.20$ 1,030.40$ 901.60$ 1,030.40$ 318.89$ 1,030.40
4400261ABDOMEN 1 AP VIEW320Radiology74018$ 232.00$ 150.80$ 185.60$ 183.56$ 183.56$ 105.35$ 79.81$ 150.80$ 185.60$ 162.40$ 185.60$ 79.81$ 185.60
4400101ABD COMP INCL ERECT/DECUB320Radiology74019$ 438.00$ 284.70$ 350.40$ 257.78$ 257.78$ 147.95$ 112.08$ 284.70$ 350.40$ 306.60$ 350.40$ 112.08$ 350.40
4400093ABD ACUT SERIES PA CHEST320Radiology74021$ 438.00$ 284.70$ 350.40$ 257.78$ 257.78$ 147.95$ 112.08$ 284.70$ 350.40$ 306.60$ 350.40$ 112.08$ 350.40
4460001DEXASCAN -BONE DENSITY/ A320Radiology77080$ 318.00$ 206.70$ 254.40$ 70.45$ 70.45$ 40.43$ 30.63$ 206.70$ 254.40$ 222.60$ 254.40$ 30.63$ 254.40
99203OFFICE VISIT NEW PAT L3521Rural Health Clinic99203$ 180.00$ 117.00$ 85.85$ 115.41$ 115.41$ 115.41$ 113.22$ 85.85$ 85.85$ 85.85$ 85.85$ 85.85$ 115.41
99204OFFICE VISIT NEW PAT L4521Rural Health Clinic99204$ 245.00$ 159.25$ 184.98$ 175.20$ 175.20$ 175.20$ 171.87$ 184.98$ 184.98$ 184.98$ 184.98$ 171.87$ 184.98
99205OFFICE VISIT NEW PAT L5521Rural Health Clinic99205$ 305.00$ 198.25$ 191.85$ 220.23$ 220.23$ 220.23$ 216.04$ 191.85$ 191.85$ 191.85$ 191.85$ 191.85$ 220.23
99385PREVENTIVE CARE 18-39 YRS521Rural Health Clinic99385$ 150.00$ 97.50$ 113.07$ 140.76$ 140.76$ 140.76$ 138.09$ 113.07$ 113.07$ 113.07$ 113.07$ 113.07$ 140.76
99386PREVENTIVE CARE 40-64 YR521Rural Health Clinic99386$ 304.25$ 197.76$ 137.23$ 163.47$ 163.47$ 163.47$ 160.36$ 137.23$ 137.23$ 137.23$ 137.23$ 137.23$ 163.47
4440001US SOFT TISS HEADNECK THY402Ultrasound76536$ 361.00$ 234.65$ 288.80$ 257.78$ 257.78$ 147.95$ 112.08$ 234.65$ 288.80$ 252.70$ 288.80$ 112.08$ 288.80
4400211BILATERAL RENAL SONOGRAM402Ultrasound76700$ 615.00$ 399.75$ 492.00$ 257.78$ 257.78$ 147.95$ 112.08$ 399.75$ 492.00$ 430.50$ 492.00$ 112.08$ 492.00
32076700ULTRASOUND ABD COMPLETE402Ultrasound76700$ 615.00$ 399.75$ 492.00$ 257.78$ 257.78$ 147.95$ 112.08$ 399.75$ 492.00$ 430.50$ 492.00$ 112.08$ 492.00
4440007US ABD LTD - GALLBLADDER402Ultrasound76705$ 366.00$ 237.90$ 292.80$ 257.78$ 257.78$ 147.95$ 112.08$ 237.90$ 292.80$ 256.20$ 292.80$ 112.08$ 292.80
4440017US ABD LTD - LIVER402Ultrasound76705$ 366.00$ 237.90$ 292.80$ 257.78$ 257.78$ 147.95$ 112.08$ 237.90$ 292.80$ 256.20$ 292.80$ 112.08$ 292.80
4440003US ABD LTD SNGL ORG/QUAD402Ultrasound76705$ 366.00$ 237.90$ 292.80$ 257.78$ 257.78$ 147.95$ 112.08$ 237.90$ 292.80$ 256.20$ 292.80$ 112.08$ 292.80
4440029US PELVIS NON-OB COMPL402Ultrasound76856$ 366.00$ 237.90$ 292.80$ 257.78$ 257.78$ 147.95$ 112.08$ 237.90$ 292.80$ 256.20$ 292.80$ 112.08$ 292.80
4440035US PELVIS NON-OB LTD402Ultrasound76857$ 279.00$ 181.35$ 223.20$ 257.78$ 257.78$ 147.95$ 112.08$ 181.35$ 223.20$ 195.30$ 223.20$ 112.08$ 257.78
4440037US SCROTUM/TESTICLES402Ultrasound76870$ 366.00$ 237.90$ 292.80$ 257.78$ 257.78$ 147.95$ 112.08$ 237.90$ 292.80$ 256.20$ 292.80$ 112.08$ 292.80
4440019US SOFT TISSUE402Ultrasound76882$ 312.00$ 202.80$ 249.60$ 257.78$ 257.78$ 147.95$ 112.08$ 202.80$ 249.60$ 218.40$ 249.60$ 112.08$ 257.78

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.  This included related costs like medical test, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.  You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call {877-696-6775}