Hospital Charges - Muleshoe Area Medical Center

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 CODE	DESCRIPTION	REV CODE	Department	CPT CODE	RATE	Cash Price	Aetna	BCBS Traditional	BCBS PPO	BCBS HMO	BCBS Blue Adv	CIGNA	Coventry	FirstCare	United	Minimum Negotiated Charge	Maximum Negotiated Charge
4420057	CT HEAD W/O CONTRAST	351	CT Scan	70450	$ 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
4420007	CT MAXILLOFACIAL W/O CM	350	CT Scan	70486	$ 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
4420055	CT MAXILLOFACIAL W/CM	350	CT Scan	70487	$ 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
4420051	CT SOFT TISS NECK W/O CM	350	CT Scan	70490	$ 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
4420019	CT SOFT TISS NECK W/CM	350	CT Scan	70491	$ 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
4420009	CT THORAX W/O C/M	350	CT Scan	71250	$ 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
4420063	CT THORAX W/CM	350	CT Scan	71260	$ 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
4420061	CT THORAX W&W/O CM	350	CT Scan	71270	$ 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
4420001	CT CHEST W&W/O CM ANGIOGR	350	CT Scan	71275	$ 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
4420031	CT SPINE CERV/W/O CM	350	CT Scan	72125	$ 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
4420033	CT SPINE THOR W/O CM	350	CT Scan	72128	$ 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
4420035	CT SPINE LUMB W/O CM	350	CT Scan	72131	$ 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
4420027	CT PELVIS W/O CONTRAST	350	CT Scan	72192	$ 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
4420013	CT UP EXTREM W/O CONTRAST	350	CT Scan	73200	$ 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
4420072	CT upper extremity with contrast	352	CT Scan	73201	$ 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
4420047	CT LOW EXTREM WO CONT	350	CT Scan	73700	$ 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
4420045	CT ABD W/CONTRAST	350	CT Scan	74160	$ 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
4420069	CT ABD/PELVIS WO CON	350	CT Scan	74176	$ 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
4420067	CT ABD/PELVIS W/CON	350	CT Scan	74177	$ 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
4420065	CT ABD/PELVIS W/WO	350	CT Scan	74178	$ 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
4340009	EKG	730	EKG/ECG	93005	$ 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
4301551	I-STAT BMP	301	Laboratory	80047	$ 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
4300027	BASIC METABOLIC	301	Laboratory	80048	$ 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
4303634	BMP Ref	301	Laboratory	80048	$ 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
4300049	GENRL HEALTH PAN(NOT MCR)	300	Laboratory	80050	$ 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
4302243	CMP Ref	301	Laboratory	80053	$ 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
4300021	COMPLETE METABOLIC	301	Laboratory	80053	$ 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
4301217	OB PROFILE LAB CHARGE	300	Laboratory	80055	$ 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
4303854	Lipid Cov	300	Laboratory	80061	$ 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
4300031	LIPID PROFILE	301	Laboratory	80061	$ 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
4301705	LIPID-REF	301	Laboratory	80061	$ 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
4303837	NMR Lipids	300	Laboratory	80061	$ 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
4300593	RENAL FUNCTION PANEL	301	Laboratory	80069	$ 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
4303635	RENAL REF	301	Laboratory	80069	$ 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
4300923	HEPATITIS PANEL	301	Laboratory	80074	$ 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
4300025	HEPATIC FUNCTION	301	Laboratory	80076	$ 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
4300357	CARBAMAZEPINE (TEGRETOL)	301	Laboratory	80156	$ 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
4303826	Digoxin New	300	Laboratory	80162	$ 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
4302231	VALPORIC ACID-REF	301	Laboratory	80164	$ 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
4300457	LEVETIRACETAM (KEPPRA)	301	Laboratory	80177	$ 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
4301743	PHENOBARBITAL-I	301	Laboratory	80184	$ 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
4300041	DILANTIN	301	Laboratory	80185	$ 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
4301279	SIROLIMUS	301	Laboratory	80195	$ 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
4303856	Tacrolimans LCMS	300	Laboratory	80197	$ 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
4303827	Vancomycin Random	300	Laboratory	80202	$ 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
4303829	Vancomycin Trogh	300	Laboratory	80202	$ 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
4300459	LAMICTAL (LAMOTRIGINE)	301	Laboratory	80299	$ 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
4301501	DRUG SCREEN COLLECTION #3	301	Laboratory	80306	$ 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
4301633	URINE DRUG SCREEN	301	Laboratory	80306	$ 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
4301229	UA W/MICRO (COMPLETE)	307	Laboratory	81001	$ 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
4300851	UA DIPSTICK ONLY	307	Laboratory	81003	$ 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
4300531	UA - MICROSCOPIC ONLY	307	Laboratory	81015	$ 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
4300599	PREGNANCY TEST URINE	307	Laboratory	81025	$ 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
4300265	KETONES, QUAITATIVE SERM	301	Laboratory	82009	$ 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
4301121	MICROALBUMIN-REF	301	Laboratory	82043	$ 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
4301685	MICROALBUMIN QUAL URINE	301	Laboratory	82044	$ 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
4300413	AMMONIA; SERUM OR URINE	301	Laboratory	82140	$ 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
4301377	AMYLASE	301	Laboratory	82150	$ 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
4301231	BILI TOTAL	301	Laboratory	82247	$ 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
4301173	BILI DIRECT	301	Laboratory	82248	$ 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 CODE	DESCRIPTION	REV CODE	Department	CPT CODE	RATE	Cash Price	Aetna	BCBS Traditional	BCBS PPO	BCBS HMO	BCBS Blue Adv	CIGNA	Coventry	FirstCare	United	Minimum Negotiated Charge	Maximum Negotiated Charge
4300463	OCCULT BLOOD SCREENING	301	Laboratory	82270	$ 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
4301677	OCCULT BLD DIAGONSTI-iFOB	301	Laboratory	82274	$ 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
4303668	Vit D Total II MAMC	300	Laboratory	82306	$ 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
4301993	CALCIUM-P	301	Laboratory	82310	$ 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
4301341	CORTISOL BLOOD	301	Laboratory	82533	$ 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
4301459	CPK#	301	Laboratory	82550	$ 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
4301569	BIOSITE CKMB	301	Laboratory	82553	$ 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
4300719	CREATININE, BLOOD#	301	Laboratory	82565	$ 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
4301687	CREATININE QUAL-URINE	301	Laboratory	82570	$ 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
4300775	CREATININE, URINE-REF	301	Laboratory	82570	$ 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
4300125	CREAT CLEARANCE 24 HR UR	301	Laboratory	82575	$ 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
4301463	B-12	301	Laboratory	82607	$ 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
4300315	VITAMIN D, 1,25-DIHYDROXY	301	Laboratory	82652	$ 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
4300989	ESTROGEN TOTAL	301	Laboratory	82672	$ 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
4301343	FERRITIN	301	Laboratory	82728	$ 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
4300663	FOLATE (FOLIC ACID)	301	Laboratory	82746	$ 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
4300723	IMMUNOGLOBULIN IGA-P	301	Laboratory	82784	$ 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
4300721	IMMUNOGLOBULIN IGG	301	Laboratory	82784	$ 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
4300725	IMMUNOGLOBULIN IGM	301	Laboratory	82784	$ 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
4302151	BLOOD GAS-ARTERIAL	301	Laboratory	82803	$ 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
4300991	GLUCOSE BLOOD#	301	Laboratory	82947	$ 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
4300279	GLUCOSE; O'SULLIVAN	301	Laboratory	82950	$ 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
4300859	GTT UP TO 3 SPEC	301	Laboratory	82951	$ 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
4300317	GTT EACH ADDITONAL SAMPLE	301	Laboratory	82952	$ 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
4301473	FSH	301	Laboratory	83001	$ 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
4300007	LH	301	Laboratory	83002	$ 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
4303608	H PYLORI BREATH	301	Laboratory	83013	$ 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
4303609	H PYLORI COLLECTION	301	Laboratory	83014	$ 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
4300469	HBA1C (HEM A1C)	301	Laboratory	83036	$ 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
4300667	HOMOCYSTEINE (BLOOD)	301	Laboratory	83090	$ 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
4303662	Fe (iron)	300	Laboratory	83540	$ 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
4303663	UIBC (Unsaturated Iron-Binding Capacity)	300	Laboratory	83550	$ 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
4302261	Lactic Acid	301	Laboratory	83605	$ 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
4301475	LDH	301	Laboratory	83615	$ 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
4302025	STOOL WBC; LACTOFERRIN	301	Laboratory	83630	$ 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
4301423	LIPASE	301	Laboratory	83690	$ 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
4303664	LDL Direct	300	Laboratory	83721	$ 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
4301291	MAGNESIUM	301	Laboratory	83735	$ 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
4300555	B-NATRIURETIC PEPTIDE	301	Laboratory	83880	$ 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
4303823	ProBNP	300	Laboratory	83880	$ 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
4302235	KAPPA-LAMBDA RATIO	301	Laboratory	83883	$ 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
4300271	METHYLMALONIC ACID SERUM	301	Laboratory	83921	$ 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
4300423	PTH (PARATHORMONE, RIA)	301	Laboratory	83970	$ 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
4300787	PHOSPHORUS (PO4)#	301	Laboratory	84100	$ 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
4300871	POTASSIUM-BLOOD#	301	Laboratory	84132	$ 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
4301135	PROGESTERONE	301	Laboratory	84144	$ 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
4303822	Procalcitonin	300	Laboratory	84145	$ 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
4301003	PROLACTIN, RIA	301	Laboratory	84146	$ 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
4301777	PSA TOTAL-REF	301	Laboratory	84153	$ 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
4301251	PSA, TOTAL	301	Laboratory	84153	$ 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
4301293	PSA, FREE	301	Laboratory	84154	$ 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
4300565	PROTEIN, URINE RANDOM	301	Laboratory	84156	$ 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
4300483	TOTAL PROTEIN 24 HR UR	301	Laboratory	84156	$ 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
4300485	PROTEIN, SERUM, ELECT.	301	Laboratory	84165	$ 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
4300231	PROTEIN URINE ELECTROPHES	301	Laboratory	84166	$ 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
4301081	SODIUM-BLOOD#	301	Laboratory	84295	$ 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
4300733	TESTOSTERONE, FREE	301	Laboratory	84402	$ 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
4300735	TESTOSTERONE-TOTAL	301	Laboratory	84403	$ 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
4301009	T4 (THYROXINE)	301	Laboratory	84436	$ 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
4301355	FREE T-4	301	Laboratory	84439	$ 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 CODE	DESCRIPTION	REV CODE	Department	CPT CODE	RATE	Cash Price	Aetna	BCBS Traditional	BCBS PPO	BCBS HMO	BCBS Blue Adv	CIGNA	Coventry	FirstCare	United	Minimum Negotiated Charge	Maximum Negotiated Charge
4300293	THYROXINE BINDING GLOBUL	301	Laboratory	84442	$ 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
4302221	TSH-REF	301	Laboratory	84443	$ 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
4300295	TSH--THYROID STIM. HORMON	301	Laboratory	84443	$ 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
4301253	T-3 UPTAKE	301	Laboratory	84479	$ 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
4301303	TOTAL T-3	301	Laboratory	84480	$ 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
4301395	T3 FREE	301	Laboratory	84481	$ 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
4301573	BIOSITE TROPONIN	301	Laboratory	84484	$ 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
4303849	Tro-Gen4	300	Laboratory	84484	$ 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
4303830	Troponin T New	300	Laboratory	84484	$ 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
4300375	BUN BLOOD-UREA-NITROGEN#	301	Laboratory	84520	$ 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
4300875	URIC ACID-BLOOD#	301	Laboratory	84550	$ 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
4300957	BETA HCG-QUANT.	301	Laboratory	84702	$ 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
4300615	PREGNANCY TEST SERUM	301	Laboratory	84703	$ 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
4300711	MANUAL DIFFERENTIAL	305	Laboratory	85007	$ 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
4301257	HEMATOCRIT	305	Laboratory	85014	$ 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
4301259	HEMOGLOBIN	305	Laboratory	85018	$ 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
4300959	CBC W/AUTO DIFF	305	Laboratory	85025	$ 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
4300795	CBC NO DIFF	305	Laboratory	85027	$ 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
4301113	D-DIMER QUANT, BIOSITE	305	Laboratory	85378	$ 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
4301137	PROTIME (PT)	305	Laboratory	85610	$ 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
4301933	PT-REF-P	305	Laboratory	85610	$ 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
4300617	SED RATE - AUTOMATED	305	Laboratory	85652	$ 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
4303713	PASE APTT	300	Laboratory	85730	$ 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
4301479	PTT	305	Laboratory	85730	$ 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
4301857	PTT-REF	305	Laboratory	85730	$ 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
4301935	PTT-REF-P	305	Laboratory	85730	$ 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
4303833	Anxca Scr w/ Rweflex	300	Laboratory	86021	$ 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
4300813	ANA; QUANTATATIVE	302	Laboratory	86039	$ 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
4300883	ASO QUANTITATIVE	302	Laboratory	86063	$ 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
4303661	CRP (inflammatory)	302	Laboratory	86140	$ 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
4301483	C 3-I	302	Laboratory	86160	$ 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
4301361	ANTI CCP	302	Laboratory	86200	$ 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
4301191	MONO SCREEN	302	Laboratory	86308	$ 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
4301947	PNEUMOCOCCAL TITER	302	Laboratory	86317	$ 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
4301321	H. PYLORI	302	Laboratory	86318	$ 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
4300625	IMMUNOFIXATION BLOOD	302	Laboratory	86334	$ 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
4300199	THYROID PEROXID ANTIBDY	302	Laboratory	86376	$ 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
4300889	RA FACTOR SCREEN	302	Laboratory	86430	$ 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
4303843	QuantiFERON TB Gold Plus	300	Laboratory	86480	$ 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
4301093	LYME TEST EIA	302	Laboratory	86618	$ 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
4300303	HIV-1 & HIV-2 SINGL ASSAY	302	Laboratory	86703	$ 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
4302047	HIV-EXPOSE PROTOCOL	302	Laboratory	86703	$ 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
4303780	HBSAB EMP HEALTH	300	Laboratory	86707	$ 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
4300693	MYCOPLASMA ANTIBODY	302	Laboratory	86738	$ 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
4300439	TREPONEMA PALLIDUM, FTA	302	Laboratory	86780	$ 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
4302051	HEP C-EXPOSE PROTOCOL	302	Laboratory	86803	$ 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
4300631	HEPATITIS C ANTIBODY	302	Laboratory	86803	$ 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
4300249	HLA TYP, A,B,OR C;SINGLE	302	Laboratory	86812	$ 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
4301021	CULTURE, BLOOD	306	Laboratory	87040	$ 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
4300109	CULTRE STOL SALM, SHIGELA	306	Laboratory	87045	$ 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
4301845	CULT, WOUND-REF	306	Laboratory	87070	$ 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
4301873	CULT, SPUTUM-REF	306	Laboratory	87070	$ 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
4301853	CULT, THROAT-REF	306	Laboratory	87070	$ 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
4301881	CULT ID ANAEROBIC	306	Laboratory	87076	$ 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
4301899	CULT ID AEROBIC	306	Laboratory	87077	$ 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
4301851	CULT, URINE-REF	306	Laboratory	87086	$ 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
4303649	Culture Urine Quantitative Count	306	Laboratory	87086	$ 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
4301905	CULT ID YEAST	306	Laboratory	87106	$ 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
4303601	Culture Typing Immuno	306	Laboratory	87147	$ 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
4300903	O&P DIRECT SMEAR	306	Laboratory	87177	$ 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 CODE	DESCRIPTION	REV CODE	Department	CPT CODE	RATE	Cash Price	Aetna	BCBS Traditional	BCBS PPO	BCBS HMO	BCBS Blue Adv	CIGNA	Coventry	FirstCare	United	Minimum Negotiated Charge	Maximum Negotiated Charge
4303901	Cult Sens Gradient Ea	300	Laboratory	87181	$ 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
4301855	CULT, SUSCEPTIBILITY-REF	306	Laboratory	87186	$ 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
4301849	GRAM STAIN-REF	306	Laboratory	87205	$ 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
4300751	O&P TRICHOME STAIN	306	Laboratory	87209	$ 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
4301327	WET MOUNT	306	Laboratory	87210	$ 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
4300701	O&P CRYPTOSPORIDIUM	306	Laboratory	87328	$ 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
4301199	O&P GIARDIA	306	Laboratory	87329	$ 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
4302053	HBSAG-EXPOSE PROTOCOL	306	Laboratory	87340	$ 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
4300255	HEPATITIS B SURFACE ANTIG	306	Laboratory	87340	$ 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
4303825	Legionella Ag MAMC	300	Laboratory	87449	$ 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
4303783	Candidia DNA probe	300	Laboratory	87480	$ 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
4301665	CHLAMYDIA URINE	306	Laboratory	87491	$ 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
4303674	C Difficile amplified probe	306	Laboratory	87493	$ 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
4303858	Enteric Pathogens Stool PCR	300	Laboratory	87506	$ 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
4303782	Gardnerella DNA probe	300	Laboratory	87510	$ 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
4303676	Mycoplasma DNA amplification	306	Laboratory	87581	$ 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
4301667	N. GONORRHOEAE- URINE	306	Laboratory	87591	$ 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
4303878	COVID-19 REFERENCE LAB	300	Laboratory	87635	$ 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
4303677	Gp A Strep DNA amplification reflexed	306	Laboratory	87651	$ 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
4303678	Group A Strep DNA only	306	Laboratory	87651	$ 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
4303784	Trichomonas DNA probe	300	Laboratory	87797	$ 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
4301627	PERTUSSIS DNA PCR	306	Laboratory	87798	$ 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
4300911	INFLUENZA A & B	306	Laboratory	87804	$ 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
4301487	RSV	306	Laboratory	87807	$ 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
4301201	QUICK STREP	306	Laboratory	87880	$ 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
4301500	DRUG SCR COLLECTION #2	300	Laboratory	99000	$ 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
4300037	PSA SCREEN	309	Laboratory	G0103	$ 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
4301675	OCCULT BLD SCREEN-iFOB	305	Laboratory	G0328	$ 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
4480007	MRI - BRAIN W&WO CONT	611	MRI	70553	$ 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
4480043	MRI SPINE LUMBAR W/O CM	612	MRI	72148	$ 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
4480047	MRI LOW JOINT W/O CM	610	MRI	73721	$ 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
4600047	ELECTRICAL STIM 15 MIN	420	Physical Therapy	97014	$ 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
4600071	ULTRASOUND - 15 MIN	420	Physical Therapy	97035	$ 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
4600083	EXERCISE - 15 MIN	420	Physical Therapy	97110	$ 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
4600095	GAIT TRAINING	420	Physical Therapy	97116	$ 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
4600029	MASSAGE - 15 MIN/PT	420	Physical Therapy	97124	$ 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
4600101	EVALUATION	424	Physical Therapy	97161	$ 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
46097161	PT EVAL; LOW COMPLEXITY	424	Physical Therapy	97161	$ 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
4600055	KINETIC ACTIV THERAPEUTIC	420	Physical Therapy	97530	$ 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
4400031	MANDLE;PART LESS THAN (4)	320	Radiology	70100	$ 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
4400083	FACIAL BONES COMPL SERIES	320	Radiology	70150	$ 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
4400037	NASAL BONES - XRAY	320	Radiology	70160	$ 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
4400073	RADIOLOG EXM NEK SFT TISS	320	Radiology	70360	$ 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
4400043	CHEST (1)	324	Radiology	71045	$ 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
4400141	CHEST (1) WITH PORTABLE	320	Radiology	71045	$ 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
4400097	CHEST,APICAL LORDOTI ONLY	320	Radiology	71045	$ 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
4400353	CHEST (2)	324	Radiology	71046	$ 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
4400013	RIBS (2) LEFT	320	Radiology	71100	$ 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
4400011	RIBS (2) RIGHT	320	Radiology	71100	$ 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
4400107	RIBS BILAT + PA CHEST 4WS	320	Radiology	71111	$ 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
4400169	SPINE CERVICAL 2-3 VWS	320	Radiology	72040	$ 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
4400131	SPINE CERVICAL MIN 4 VWS	320	Radiology	72050	$ 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
4400133	SPINE, CERVICAL COMPLETE	320	Radiology	72052	$ 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
4400217	SPINE, THORACIC (2)	320	Radiology	72070	$ 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
4400147	SPINE, LUMBAR 2-3 VIEWS	320	Radiology	72100	$ 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
4400135	SPINE, LUMBAR MIN OF (4)	320	Radiology	72110	$ 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
4400171	SPINE, LUMBER COMPLETE	320	Radiology	72114	$ 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
4400149	PELVIS (1) OR (2) VIEWS	320	Radiology	72170	$ 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
4400029	SACRUM AND COCCYX	320	Radiology	72220	$ 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
4400249	CLAVICLE COMPL LT	320	Radiology	73000	$ 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 CODE	DESCRIPTION	REV CODE	Department	CPT CODE	RATE	Cash Price	Aetna	BCBS Traditional	BCBS PPO	BCBS HMO	BCBS Blue Adv	CIGNA	Coventry	FirstCare	United	Minimum Negotiated Charge	Maximum Negotiated Charge
4400255	SHOULDER (2) LEFT	320	Radiology	73030	$ 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
4400237	SHOULDER (2) RIGHT	320	Radiology	73030	$ 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
4400263	HUMERUS (2) LEFT	320	Radiology	73060	$ 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
4400257	HUMERUS (2) RIGHT	320	Radiology	73060	$ 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
4400291	ELBOW (2) LEFT	320	Radiology	73070	$ 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
4400277	ELBOW (2) RIGHT	320	Radiology	73070	$ 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
4400354	ELBOW 3 VIEWS LT	320	Radiology	73080	$ 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
4400323	ELBOW 3 VIEWS RT	320	Radiology	73080	$ 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
4400265	FOREARM (2) LEFT	320	Radiology	73090	$ 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
4400259	FOREARM (2) RIGHT	320	Radiology	73090	$ 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
4400293	WRIST (2) LEFT	320	Radiology	73100	$ 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
4400279	WRIST (2) RIGHT	320	Radiology	73100	$ 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
4400025	WRIST (3VW MIN) LEFT	320	Radiology	73110	$ 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
4400193	WRIST (3VW MIN) RIGHT	320	Radiology	73110	$ 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
4400325	HAND (2) LEFT	320	Radiology	73120	$ 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
4400295	HAND (2) RIGHT	320	Radiology	73120	$ 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
4400327	HAND (3) LEFT	320	Radiology	73130	$ 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
4400297	HAND (3) RIGHT	320	Radiology	73130	$ 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
4400281	FINGER (3) LEFT	320	Radiology	73140	$ 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
4400267	FINGER (3) RIGHT	320	Radiology	73140	$ 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
4400343	HIP (2) LEFT	320	Radiology	73503	$ 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
4400331	HIP (2) RIGHT	320	Radiology	73503	$ 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
4400299	FEMUR (2) LEFT	320	Radiology	73552	$ 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
4400283	FEMUR (2) RIGHT	320	Radiology	73552	$ 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
4400333	KNEE (2) LEFT	320	Radiology	73560	$ 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
4400301	KNEE (2) RIGHT	320	Radiology	73560	$ 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
4400335	KNEE (3) LEFT	320	Radiology	73562	$ 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
4400303	KNEE (3) RIGHT	320	Radiology	73562	$ 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
4400205	KNEES, (AP STANDING)	320	Radiology	73565	$ 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
4400345	LEG (2) LEFT	320	Radiology	73590	$ 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
4400337	LEG (2) RIGHT	320	Radiology	73590	$ 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
4400285	ANKLE (2) RIGHT	320	Radiology	73600	$ 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
4400307	ANKLE (3) LEFT	320	Radiology	73610	$ 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
4400287	ANKLE (3) RIGHT	320	Radiology	73610	$ 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
4400309	FOOT (2) LEFT	320	Radiology	73620	$ 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
4400311	FOOT (2) RIGHT	320	Radiology	73620	$ 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
4400339	FOOT (3) LEFT	320	Radiology	73630	$ 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
4400313	FOOT (3) RIGHT	320	Radiology	73630	$ 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
4400017	TOES, LEFT	320	Radiology	73660	$ 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
4400351	TOES, RIGHT	320	Radiology	73660	$ 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
4420073	CT lower extremity with contrast	352	Radiology	73701	$ 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
4400261	ABDOMEN 1 AP VIEW	320	Radiology	74018	$ 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
4400101	ABD COMP INCL ERECT/DECUB	320	Radiology	74019	$ 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
4400093	ABD ACUT SERIES PA CHEST	320	Radiology	74021	$ 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
4460001	DEXASCAN -BONE DENSITY/ A	320	Radiology	77080	$ 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
99203	OFFICE VISIT NEW PAT L3	521	Rural Health Clinic	99203	$ 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
99204	OFFICE VISIT NEW PAT L4	521	Rural Health Clinic	99204	$ 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
99205	OFFICE VISIT NEW PAT L5	521	Rural Health Clinic	99205	$ 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
99385	PREVENTIVE CARE 18-39 YRS	521	Rural Health Clinic	99385	$ 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
99386	PREVENTIVE CARE 40-64 YR	521	Rural Health Clinic	99386	$ 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
4440001	US SOFT TISS HEADNECK THY	402	Ultrasound	76536	$ 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
4400211	BILATERAL RENAL SONOGRAM	402	Ultrasound	76700	$ 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
32076700	ULTRASOUND ABD COMPLETE	402	Ultrasound	76700	$ 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
4440007	US ABD LTD - GALLBLADDER	402	Ultrasound	76705	$ 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
4440017	US ABD LTD - LIVER	402	Ultrasound	76705	$ 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
4440003	US ABD LTD SNGL ORG/QUAD	402	Ultrasound	76705	$ 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
4440029	US PELVIS NON-OB COMPL	402	Ultrasound	76856	$ 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
4440035	US PELVIS NON-OB LTD	402	Ultrasound	76857	$ 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
4440037	US SCROTUM/TESTICLES	402	Ultrasound	76870	$ 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
4440019	US SOFT TISSUE	402	Ultrasound	76882	$ 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}

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