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:
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:
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!
Muleshoe Area Medical Center Shoppable Services as of 7/15/2022
| CHARGE CODE | DESCRIPTION | REV CODE | Department | CPT CODE | RATE | Cash Price | Aetna | BCBS Blue Adv | BCBS PPO | BCBS Traditional | CIGNA | Coventry | FirstCare | United | Minimum Negotiated Charge | Maximum Negotiated Charge | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4420045 | CT ABD W/CONTRAST | 350 | CT Scan | 74160 | $1,225.00 | $796.25 | $980.00 | $300.57 | $965.74 | $1,054.88 | $796.25 | $980.00 | $857.50 | $980.00 | $300.57 | $1,054.88 | |
| 4420067 | CT ABD/PELVIS W/CON | 350 | CT Scan | 74177 | $1,875.00 | $1,218.75 | $1,500.00 | $581.04 | $1,568.39 | $1,713.16 | $1,218.75 | $1,500.00 | $1,312.50 | $1,500.00 | $581.04 | $1,713.16 | |
| 4420065 | CT ABD/PELVIS W/WO | 350 | CT Scan | 74178 | $2,100.00 | $1,365.00 | $1,680.00 | $581.04 | $1,568.39 | $1,713.16 | $1,365.00 | $1,680.00 | $1,470.00 | $1,680.00 | $581.04 | $1,713.16 | |
| 4420069 | CT ABD/PELVIS WO CON | 350 | CT Scan | 74176 | $1,545.00 | $1,004.25 | $1,236.00 | $405.60 | $994.66 | $1,086.48 | $1,004.25 | $1,236.00 | $1,081.50 | $1,236.00 | $405.60 | $1,236.00 | |
| 4420001 | CT CHEST W&W/O CM ANGIOGR | 350 | CT Scan | 71275 | $1,825.00 | $1,186.25 | $1,460.00 | $338.70 | $1,102.53 | $1,204.30 | $1,186.25 | $1,460.00 | $1,277.50 | $1,460.00 | $338.70 | $1,460.00 | |
| 4420057 | CT HEAD W/O CONTRAST | 351 | CT Scan | 70450 | $900.00 | $585.00 | $720.00 | $192.10 | $564.14 | $616.21 | $585.00 | $720.00 | $630.00 | $720.00 | $192.10 | $720.00 | |
| 4420047 | CT LOW EXTREM WO CONT | 350 | CT Scan | 73700 | $773.00 | $502.45 | $618.40 | $192.10 | $564.14 | $616.21 | $502.45 | $618.40 | $541.10 | $618.40 | $192.10 | $618.40 | |
| 4420055 | CT MAXILLOFACIAL W/CM | 350 | CT Scan | 70487 | $1,225.00 | $796.25 | $980.00 | $300.57 | $965.74 | $1,054.88 | $796.25 | $980.00 | $857.50 | $980.00 | $300.57 | $1,054.88 | |
| 4420007 | CT MAXILLOFACIAL W/O CM | 350 | CT Scan | 70486 | $773.00 | $502.45 | $618.40 | $192.10 | $564.14 | $616.21 | $502.45 | $618.40 | $541.10 | $618.40 | $192.10 | $618.40 | |
| 4420027 | CT PELVIS W/O CONTRAST | 350 | CT Scan | 72192 | $773.00 | $502.45 | $618.40 | $192.10 | $564.14 | $616.21 | $502.45 | $618.40 | $541.10 | $618.40 | $192.10 | $618.40 | |
| 4420019 | CT SOFT TISS NECK W/CM | 350 | CT Scan | 70491 | $1,275.00 | $828.75 | $1,020.00 | $300.57 | $965.74 | $1,054.88 | $828.75 | $1,020.00 | $892.50 | $1,020.00 | $300.57 | $1,054.88 | |
| 4420051 | CT SOFT TISS NECK W/O CM | 350 | CT Scan | 70490 | $773.00 | $502.45 | $618.40 | $192.10 | $564.14 | $616.21 | $502.45 | $618.40 | $541.10 | $618.40 | $192.10 | $618.40 | |
| 4420031 | CT SPINE CERV/W/O CM | 350 | CT Scan | 72125 | $900.00 | $585.00 | $720.00 | $192.10 | $564.14 | $616.21 | $585.00 | $720.00 | $630.00 | $720.00 | $192.10 | $720.00 | |
| 4420035 | CT SPINE LUMB W/O CM | 350 | CT Scan | 72131 | $876.00 | $569.40 | $700.80 | $192.10 | $564.14 | $616.21 | $569.40 | $700.80 | $613.20 | $700.80 | $192.10 | $700.80 | |
| 4420033 | CT SPINE THOR W/O CM | 350 | CT Scan | 72128 | $825.00 | $536.25 | $660.00 | $192.10 | $564.14 | $616.21 | $536.25 | $660.00 | $577.50 | $660.00 | $192.10 | $660.00 | |
| 4420061 | CT THORAX W&W/O CM | 350 | CT Scan | 71270 | $1,400.00 | $910.00 | $1,120.00 | $334.45 | $1,070.36 | $1,169.16 | $910.00 | $1,120.00 | $980.00 | $1,120.00 | $334.45 | $1,169.16 | |
| 4420063 | CT THORAX W/CM | 350 | CT Scan | 71260 | $1,225.00 | $796.25 | $980.00 | $300.57 | $965.74 | $1,054.88 | $796.25 | $980.00 | $857.50 | $980.00 | $300.57 | $1,054.88 | |
| 4420009 | CT THORAX W/O C/M | 350 | CT Scan | 71250 | $900.00 | $585.00 | $720.00 | $192.10 | $564.14 | $616.21 | $585.00 | $720.00 | $630.00 | $720.00 | $192.10 | $720.00 | |
| 4420013 | CT UP EXTREM W/O CONTRAST | 350 | CT Scan | 73200 | $773.00 | $502.45 | $618.40 | $192.10 | $564.14 | $616.21 | $502.45 | $618.40 | $541.10 | $618.40 | $192.10 | $618.40 | |
| 4340009 | EKG | 730 | EKG/ECG | 93005 | $140.00 | $91.00 | $112.00 | $10.53 | $28.02 | $31.08 | $91.00 | $112.00 | $98.00 | $112.00 | $10.53 | $112.00 | |
| 4320023 | AB SCRN INDRICT COOMBS | 302 | Laboratory | 86885 | $110.00 | $71.50 | $88.00 | $7.71 | $30.46 | $32.39 | $71.50 | $88.00 | $71.50 | $88.00 | $7.71 | $88.00 | |
| 4301057 | ACETAMINOPHEN | 301 | Laboratory | 80329 | $67.00 | $43.55 | $53.60 | $0.48 | $1.51 | $1.61 | $43.55 | $53.60 | $43.55 | $53.60 | $0.48 | $53.60 | |
| 4301061 | ALCOHOL BLOOD | 301 | Laboratory | 80320 | $106.00 | $68.90 | $84.80 | $4.11 | $12.95 | $13.77 | $68.90 | $84.80 | $68.90 | $84.80 | $4.11 | $84.80 | |
| 4300413 | AMMONIA; SERUM OR URINE | 301 | Laboratory | 82140 | $118.00 | $76.70 | $94.40 | $20.64 | $63.09 | $67.10 | $76.70 | $94.40 | $76.70 | $94.40 | $20.64 | $94.40 | |
| 4301377 | AMYLASE | 301 | Laboratory | 82150 | $96.00 | $62.40 | $76.80 | $9.18 | $25.01 | $26.60 | $62.40 | $76.80 | $62.40 | $76.80 | $9.18 | $76.80 | |
| 4300813 | ANA; QUANTATATIVE | 302 | Laboratory | 86039 | $91.00 | $59.15 | $72.80 | $15.81 | $48.35 | $51.42 | $59.15 | $72.80 | $59.15 | $72.80 | $15.81 | $72.80 | |
| 4301361 | ANTI CCP | 302 | Laboratory | 86200 | $174.00 | $113.10 | $139.20 | $18.34 | $56.07 | $59.63 | $113.10 | $139.20 | $113.10 | $139.20 | $18.34 | $139.20 | |
| 4303833 | Anxca Scr w/ Rweflex | 300 | Laboratory | 86021 | $73.00 | $47.45 | $58.40 | $21.33 | $65.21 | $69.35 | $47.45 | $58.40 | $47.45 | $58.40 | $21.33 | $69.35 | |
| 4300883 | ASO QUANTITATIVE | 302 | Laboratory | 86063 | $81.00 | $52.65 | $64.80 | $8.18 | $24.98 | $26.57 | $52.65 | $64.80 | $52.65 | $64.80 | $8.18 | $64.80 | |
| 4301463 | B-12 | 301 | Laboratory | 82607 | $125.00 | $81.25 | $100.00 | $21.35 | $45.14 | $48.01 | $81.25 | $100.00 | $81.25 | $100.00 | $21.35 | $100.00 | |
| 4300027 | BASIC METABOLIC | 301 | Laboratory | 80048 | $79.00 | $51.35 | $63.20 | $11.98 | $36.63 | $38.96 | $51.35 | $63.20 | $51.35 | $63.20 | $11.98 | $63.20 | |
| 4300957 | BETA HCG-QUANT. | 301 | Laboratory | 84702 | $119.00 | $77.35 | $95.20 | $12.37 | $65.21 | $69.35 | $77.35 | $95.20 | $77.35 | $95.20 | $12.37 | $95.20 | |
| 4301173 | BILI DIRECT | 301 | Laboratory | 82248 | $64.00 | $41.60 | $51.20 | $7.10 | $21.74 | $23.12 | $41.60 | $51.20 | $41.60 | $51.20 | $7.10 | $51.20 | |
| 4301231 | BILI TOTAL | 301 | Laboratory | 82247 | $274.00 | $178.10 | $219.20 | $7.10 | $21.74 | $23.12 | $178.10 | $219.20 | $178.10 | $219.20 | $7.10 | $219.20 | |
| 4301569 | BIOSITE CKMB | 301 | Laboratory | 82553 | $109.00 | $70.85 | $87.20 | $8.72 | $33.58 | $35.71 | $70.85 | $87.20 | $70.85 | $87.20 | $8.72 | $87.20 | |
| 4301573 | BIOSITE TROPONIN | 301 | Laboratory | 84484 | $109.00 | $70.85 | $87.20 | $13.94 | $42.62 | $45.33 | $70.85 | $87.20 | $70.85 | $87.20 | $13.94 | $87.20 | |
| 4302151 | BLOOD GAS-ARTERIAL | 301 | Laboratory | 82803 | $182.00 | $118.30 | $145.60 | $27.40 | $83.79 | $89.11 | $118.30 | $145.60 | $118.30 | $145.60 | $27.40 | $145.60 | |
| 4303634 | BMP Ref | 301 | Laboratory | 80048 | $79.00 | $51.35 | $63.20 | $11.98 | $36.63 | $38.96 | $51.35 | $63.20 | $51.35 | $63.20 | $11.98 | $63.20 | |
| 4300555 | B-NATRIURETIC PEPTIDE | 301 | Laboratory | 83880 | $239.00 | $155.35 | $191.20 | $48.08 | $146.98 | $156.31 | $155.35 | $191.20 | $155.35 | $191.20 | $48.08 | $191.20 | |
| 4300375 | BUN BLOOD-UREA-NITROGEN# | 301 | Laboratory | 84520 | $64.00 | $41.60 | $51.20 | $5.59 | $15.12 | $16.08 | $41.60 | $51.20 | $41.60 | $51.20 | $5.59 | $51.20 | |
| 4301483 | C 3-I | 302 | Laboratory | 86160 | $96.00 | $62.40 | $76.80 | $17.01 | $51.98 | $55.28 | $62.40 | $76.80 | $62.40 | $76.80 | $17.01 | $76.80 | |
| 4303674 | C Difficile amplified probe | 306 | Laboratory | 87493 | $170.00 | $110.50 | $136.00 | $49.71 | $112.80 | $119.96 | $110.50 | $136.00 | $110.50 | $136.00 | $49.71 | $136.00 | |
| 4301993 | CALCIUM-P | 301 | Laboratory | 82310 | $64.00 | $41.60 | $51.20 | $7.30 | $17.48 | $18.59 | $41.60 | $51.20 | $41.60 | $51.20 | $7.30 | $51.20 | |
| 4303783 | Candidia DNA probe | 300 | Laboratory | 87480 | $95.00 | $61.75 | $76.00 | $28.40 | $86.85 | $92.36 | $61.75 | $76.00 | $61.75 | $76.00 | $28.40 | $92.36 | |
| 4300357 | CARBAMAZEPINE (TEGRETOL) | 301 | Laboratory | 80156 | $118.00 | $76.70 | $94.40 | $20.62 | $63.06 | $67.07 | $76.70 | $94.40 | $76.70 | $94.40 | $20.62 | $94.40 | |
| 4300795 | CBC NO DIFF | 305 | Laboratory | 85027 | $64.00 | $41.60 | $51.20 | $9.17 | $28.00 | $29.78 | $41.60 | $51.20 | $41.60 | $51.20 | $9.17 | $51.20 | |
| 4300959 | CBC W/AUTO DIFF | 305 | Laboratory | 85025 | $60.00 | $39.00 | $48.00 | $11.02 | $33.67 | $35.81 | $39.00 | $48.00 | $39.00 | $48.00 | $11.02 | $48.00 | |
| 4301665 | CHLAMYDIA URINE | 306 | Laboratory | 87491 | $120.00 | $78.00 | $96.00 | $49.71 | $112.80 | $119.96 | $78.00 | $96.00 | $78.00 | $96.00 | $49.71 | $119.96 | |
| 4302243 | CMP Ref | 301 | Laboratory | 80053 | $128.00 | $83.20 | $102.40 | $14.97 | $45.77 | $48.68 | $83.20 | $102.40 | $83.20 | $102.40 | $14.97 | $102.40 | |
| 4300021 | COMPLETE METABOLIC | 301 | Laboratory | 80053 | $120.00 | $78.00 | $96.00 | $14.97 | $45.77 | $48.68 | $78.00 | $96.00 | $78.00 | $96.00 | $14.97 | $96.00 | |
| 4301341 | CORTISOL BLOOD | 301 | Laboratory | 82533 | $151.00 | $98.15 | $120.80 | $23.10 | $70.59 | $75.07 | $98.15 | $120.80 | $98.15 | $120.80 | $23.10 | $120.80 | |
| 4303878 | COVID-19 REFERENCE LAB | 300 | Laboratory | 87635 | $262.50 | $170.63 | $210.00 | $- | $- | $- | $170.63 | $210.00 | $170.63 | $210.00 | $- | $210.00 | |
| 4301459 | CPK# | 301 | Laboratory | 82550 | $64.00 | $41.60 | $51.20 | $9.23 | $28.19 | $29.98 | $41.60 | $51.20 | $41.60 | $51.20 | $9.23 | $51.20 | |
| 4300125 | CREAT CLEARANCE 24 HR UR | 301 | Laboratory | 82575 | $78.00 | $50.70 | $62.40 | $13.39 | $21.33 | $22.68 | $50.70 | $62.40 | $50.70 | $62.40 | $13.39 | $62.40 | |
| 4301687 | CREATININE QUAL-URINE | 301 | Laboratory | 82570 | $64.00 | $41.60 | $51.20 | $7.33 | $22.40 | $23.82 | $41.60 | $51.20 | $41.60 | $51.20 | $7.33 | $51.20 | |
| 4300719 | CREATININE, BLOOD# | 301 | Laboratory | 82565 | $64.00 | $41.60 | $51.20 | $7.26 | $22.18 | $23.58 | $41.60 | $51.20 | $41.60 | $51.20 | $7.26 | $51.20 | |
| 4300775 | CREATININE, URINE-REF | 301 | Laboratory | 82570 | $64.00 | $41.60 | $51.20 | $7.33 | $22.40 | $23.82 | $41.60 | $51.20 | $41.60 | $51.20 | $7.33 | $51.20 | |
| 4303661 | CRP (inflammatory) | 302 | Laboratory | 86140 | $79.00 | $51.35 | $63.20 | $7.33 | $14.96 | $15.91 | $51.35 | $63.20 | $51.35 | $63.20 | $7.33 | $63.20 | |
| 4301899 | CULT ID AEROBIC | 306 | Laboratory | 87077 | $65.00 | $42.25 | $52.00 | $11.45 | $35.00 | $37.22 | $42.25 | $52.00 | $42.25 | $52.00 | $11.45 | $52.00 | |
| 4301881 | CULT ID ANAEROBIC | 306 | Laboratory | 87076 | $212.00 | $137.80 | $169.60 | $11.45 | $35.00 | $37.22 | $137.80 | $169.60 | $137.80 | $169.60 | $11.45 | $169.60 | |
| 4301905 | CULT ID YEAST | 306 | Laboratory | 87106 | $170.00 | $110.50 | $136.00 | $14.62 | $44.70 | $47.54 | $110.50 | $136.00 | $110.50 | $136.00 | $14.62 | $136.00 | |
| 4303901 | Cult Sens Gradient Ea | 300 | Laboratory | 87181 | $25.00 | $16.25 | $20.00 | $6.73 | $4.82 | $5.13 | $16.25 | $20.00 | $16.25 | $20.00 | $4.82 | $20.00 | |
| 4301845 | CULT, WOUND-REF | 306 | Laboratory | 87070 | $109.00 | $70.85 | $87.20 | $12.20 | $37.30 | $39.66 | $70.85 | $87.20 | $70.85 | $87.20 | $12.20 | $87.20 | |
| 4301873 | CULT, SPUTUM-REF | 306 | Laboratory | 87070 | $109.00 | $70.85 | $87.20 | $12.20 | $37.30 | $39.66 | $70.85 | $87.20 | $70.85 | $87.20 | $12.20 | $87.20 | |
| 4301855 | CULT, SUSCEPTIBILITY-REF | 306 | Laboratory | 87186 | $73.00 | $47.45 | $58.40 | $12.25 | $37.42 | $39.80 | $47.45 | $58.40 | $47.45 | $58.40 | $12.25 | $58.40 | |
| 4301853 | CULT, THROAT-REF | 306 | Laboratory | 87070 | $109.00 | $70.85 | $87.20 | $12.20 | $37.30 | $39.66 | $70.85 | $87.20 | $70.85 | $87.20 | $12.20 | $87.20 | |
| 4301851 | CULT, URINE-REF | 306 | Laboratory | 87086 | $74.00 | $48.10 | $59.20 | $11.43 | $24.98 | $26.57 | $48.10 | $59.20 | $48.10 | $59.20 | $11.43 | $59.20 | |
| 4300109 | CULTRE STOL SALM, SHIGELA | 306 | Laboratory | 87045 | $84.00 | $54.60 | $67.20 | $13.36 | $40.86 | $43.45 | $54.60 | $67.20 | $54.60 | $67.20 | $13.36 | $67.20 | |
| 4303601 | Culture Typing Immuno | 306 | Laboratory | 87147 | $77.00 | $50.05 | $61.60 | $7.33 | $22.40 | $23.82 | $50.05 | $61.60 | $50.05 | $61.60 | $7.33 | $61.60 | |
| 4303649 | Culture Urine Quantitative Count | 306 | Laboratory | 87086 | $74.00 | $48.10 | $59.20 | $11.43 | $24.98 | $26.57 | $48.10 | $59.20 | $48.10 | $59.20 | $11.43 | $59.20 | |
| 4301021 | CULTURE, BLOOD | 306 | Laboratory | 87040 | $111.00 | $72.15 | $88.80 | $14.62 | $32.63 | $34.71 | $72.15 | $88.80 | $72.15 | $88.80 | $14.62 | $88.80 | |
| 4301113 | D-DIMER QUANT, BIOSITE | 305 | Laboratory | 85378 | $109.00 | $70.85 | $87.20 | $10.10 | $30.90 | $32.86 | $70.85 | $87.20 | $70.85 | $87.20 | $10.10 | $87.20 | |
| 4303826 | Digoxin New | 300 | Laboratory | 80162 | $120.00 | $78.00 | $96.00 | $18.80 | $57.49 | $61.14 | $78.00 | $96.00 | $78.00 | $96.00 | $18.80 | $96.00 | |
| 4300041 | DILANTIN | 301 | Laboratory | 80185 | $106.00 | $68.90 | $84.80 | $18.77 | $57.39 | $61.04 | $68.90 | $84.80 | $68.90 | $84.80 | $18.77 | $84.80 | |
| 4301500 | DRUG SCR COLLECTION #2 | 300 | Laboratory | 99000 | $20.00 | $13.00 | $16.00 | $20.00 | $20.00 | $20.00 | $13.00 | $16.00 | $13.00 | $16.00 | $13.00 | $20.00 | |
| 4301501 | DRUG SCREEN COLLECTION #3 | 301 | Laboratory | 80306 | $70.00 | $45.50 | $56.00 | $15.26 | $48.07 | $51.12 | $45.50 | $56.00 | $45.50 | $56.00 | $15.26 | $56.00 | |
| 4303858 | Enteric Pathogens Stool PCR | 300 | Laboratory | 87506 | $975.00 | $633.75 | $780.00 | $290.45 | $914.92 | $973.01 | $633.75 | $780.00 | $633.75 | $780.00 | $290.45 | $973.01 | |
| 4300989 | ESTROGEN TOTAL | 301 | Laboratory | 82672 | $193.00 | $125.45 | $154.40 | $12.39 | $86.18 | $91.66 | $125.45 | $154.40 | $125.45 | $154.40 | $12.39 | $154.40 | |
| 4303662 | Fe (iron) | 300 | Laboratory | 83540 | $57.00 | $37.05 | $45.60 | $9.18 | $28.04 | $29.82 | $37.05 | $45.60 | $37.05 | $45.60 | $9.18 | $45.60 | |
| 4301343 | FERRITIN | 301 | Laboratory | 82728 | $112.00 | $72.80 | $89.60 | $19.30 | $59.00 | $62.75 | $72.80 | $89.60 | $72.80 | $89.60 | $19.30 | $89.60 | |
| 4300663 | FOLATE (FOLIC ACID) | 301 | Laboratory | 82746 | $118.00 | $76.70 | $94.40 | $20.82 | $58.81 | $62.54 | $76.70 | $94.40 | $76.70 | $94.40 | $20.82 | $94.40 | |
| 4301355 | FREE T-4 | 301 | Laboratory | 84439 | $106.00 | $68.90 | $84.80 | $12.77 | $39.06 | $41.54 | $68.90 | $84.80 | $68.90 | $84.80 | $12.77 | $84.80 | |
| 4301473 | FSH | 301 | Laboratory | 83001 | $173.00 | $112.45 | $138.40 | $26.32 | $80.45 | $85.56 | $112.45 | $138.40 | $112.45 | $138.40 | $26.32 | $138.40 | |
| 4303782 | Gardnerella DNA probe | 300 | Laboratory | 87510 | $95.00 | $61.75 | $76.00 | $28.40 | $86.85 | $92.36 | $61.75 | $76.00 | $61.75 | $76.00 | $28.40 | $92.36 | |
| 4300049 | GENRL HEALTH PAN(NOT MCR) | 300 | Laboratory | 80050 | $297.00 | $193.05 | $237.60 | $33.30 | $104.90 | $111.56 | $193.05 | $237.60 | $193.05 | $237.60 | $33.30 | $237.60 | |
| 4300991 | GLUCOSE BLOOD# | 301 | Laboratory | 82947 | $64.00 | $41.60 | $51.20 | $5.56 | $16.98 | $18.06 | $41.60 | $51.20 | $41.60 | $51.20 | $5.56 | $51.20 | |
| 4300279 | GLUCOSE; O'SULLIVAN | 301 | Laboratory | 82950 | $79.00 | $51.35 | $63.20 | $6.73 | $20.57 | $21.88 | $51.35 | $63.20 | $51.35 | $63.20 | $6.73 | $63.20 | |
| 4303677 | Gp A Strep DNA amplification reflexed | 306 | Laboratory | 87651 | $130.00 | $84.50 | $104.00 | $49.71 | $112.80 | $119.96 | $84.50 | $104.00 | $84.50 | $104.00 | $49.71 | $119.96 | |
| 4301849 | GRAM STAIN-REF | 306 | Laboratory | 87205 | $74.00 | $48.10 | $59.20 | $6.05 | $18.49 | $19.66 | $48.10 | $59.20 | $48.10 | $59.20 | $6.05 | $59.20 | |
| 4303678 | Group A Strep DNA only | 306 | Laboratory | 87651 | $135.00 | $87.75 | $108.00 | $49.71 | $112.80 | $119.96 | $87.75 | $108.00 | $87.75 | $108.00 | $49.71 | $119.96 | |
| 4300317 | GTT EACH ADDITONAL SAMPLE | 301 | Laboratory | 82952 | $47.00 | $30.55 | $37.60 | $5.55 | $12.47 | $13.27 | $30.55 | $37.60 | $30.55 | $37.60 | $5.55 | $37.60 | |
| 4300859 | GTT UP TO 3 SPEC | 301 | Laboratory | 82951 | $133.00 | $86.45 | $106.40 | $18.23 | $55.72 | $59.26 | $86.45 | $106.40 | $86.45 | $106.40 | $18.23 | $106.40 | |
| 4303608 | H PYLORI BREATH | 301 | Laboratory | 83013 | $320.00 | $208.00 | $256.00 | $95.40 | $291.66 | $310.18 | $208.00 | $256.00 | $208.00 | $256.00 | $95.40 | $310.18 | |
| 4303609 | H PYLORI COLLECTION | 301 | Laboratory | 83014 | $37.00 | $24.05 | $29.60 | $11.14 | $34.05 | $36.21 | $24.05 | $29.60 | $24.05 | $29.60 | $11.14 | $36.21 | |
| 4301321 | H. PYLORI | 302 | Laboratory | 86318 | $106.00 | $68.90 | $84.80 | $18.34 | $56.07 | $59.63 | $68.90 | $84.80 | $68.90 | $84.80 | $18.34 | $84.80 | |
| 4300469 | HBA1C (HEM A1C) | 301 | Laboratory | 83036 | $78.00 | $50.70 | $62.40 | $13.75 | $42.02 | $44.69 | $50.70 | $62.40 | $50.70 | $62.40 | $13.75 | $62.40 | |
| 4303780 | HBSAB EMP HEALTH | 300 | Laboratory | 86707 | $91.00 | $59.15 | $72.80 | $16.38 | $50.09 | $53.27 | $59.15 | $72.80 | $59.15 | $72.80 | $16.38 | $72.80 | |
| 4302053 | HBSAG-EXPOSE PROTOCOL | 306 | Laboratory | 87340 | $84.00 | $54.60 | $67.20 | $14.63 | $44.73 | $47.57 | $54.60 | $67.20 | $54.60 | $67.20 | $14.63 | $67.20 | |
| 4301257 | HEMATOCRIT | 305 | Laboratory | 85014 | $32.00 | $20.80 | $25.60 | $3.35 | $10.27 | $10.92 | $20.80 | $25.60 | $20.80 | $25.60 | $3.35 | $25.60 | |
| 4301259 | HEMOGLOBIN | 305 | Laboratory | 85018 | $32.00 | $20.80 | $25.60 | $3.35 | $10.27 | $10.92 | $20.80 | $25.60 | $20.80 | $25.60 | $3.35 | $25.60 | |
| 4302051 | HEP C-EXPOSE PROTOCOL | 302 | Laboratory | 86803 | $112.00 | $72.80 | $89.60 | $20.22 | $57.61 | $61.27 | $72.80 | $89.60 | $72.80 | $89.60 | $20.22 | $89.60 | |
| 4300025 | HEPATIC FUNCTION | 301 | Laboratory | 80076 | $82.00 | $53.30 | $65.60 | $11.57 | $35.37 | $37.62 | $53.30 | $65.60 | $53.30 | $65.60 | $11.57 | $65.60 | |
| 4300255 | HEPATITIS B SURFACE ANTIG | 306 | Laboratory | 87340 | $84.00 | $54.60 | $67.20 | $14.63 | $44.73 | $47.57 | $54.60 | $67.20 | $54.60 | $67.20 | $14.63 | $67.20 | |
| 4300631 | HEPATITIS C ANTIBODY | 302 | Laboratory | 86803 | $112.00 | $72.80 | $89.60 | $20.22 | $57.61 | $61.27 | $72.80 | $89.60 | $72.80 | $89.60 | $20.22 | $89.60 | |
| 4300923 | HEPATITIS PANEL | 301 | Laboratory | 80074 | $383.00 | $248.95 | $306.40 | $67.47 | $202.04 | $214.87 | $248.95 | $306.40 | $248.95 | $306.40 | $67.47 | $306.40 | |
| 4300303 | HIV-1 & HIV-2 SINGL ASSAY | 302 | Laboratory | 86703 | $133.00 | $86.45 | $106.40 | $19.43 | $45.74 | $48.64 | $86.45 | $106.40 | $86.45 | $106.40 | $19.43 | $106.40 | |
| 4302047 | HIV-EXPOSE PROTOCOL | 302 | Laboratory | 86703 | $133.00 | $86.45 | $106.40 | $19.43 | $45.74 | $48.64 | $86.45 | $106.40 | $86.45 | $106.40 | $19.43 | $106.40 | |
| 4300249 | HLA TYP, A,B,OR C;SINGLE | 302 | Laboratory | 86812 | $245.00 | $159.25 | $196.00 | $36.56 | $111.76 | $118.86 | $159.25 | $196.00 | $159.25 | $196.00 | $36.56 | $196.00 | |
| 4300667 | HOMOCYSTEINE (BLOOD) | 301 | Laboratory | 83090 | $135.00 | $87.75 | $108.00 | $23.89 | $73.05 | $77.69 | $87.75 | $108.00 | $87.75 | $108.00 | $23.89 | $108.00 | |
| 4300625 | IMMUNOFIXATION BLOOD | 302 | Laboratory | 86334 | $158.00 | $102.70 | $126.40 | $31.64 | $96.74 | $102.88 | $102.70 | $126.40 | $102.70 | $126.40 | $31.64 | $126.40 | |
| 4300723 | IMMUNOGLOBULIN IGA-P | 301 | Laboratory | 82784 | $165.00 | $107.25 | $132.00 | $13.17 | $32.19 | $34.24 | $107.25 | $132.00 | $107.25 | $132.00 | $13.17 | $132.00 | |
| 4300721 | IMMUNOGLOBULIN IGG | 301 | Laboratory | 82784 | $165.00 | $107.25 | $132.00 | $13.17 | $32.19 | $34.24 | $107.25 | $132.00 | $107.25 | $132.00 | $13.17 | $132.00 | |
| 4300725 | IMMUNOGLOBULIN IGM | 301 | Laboratory | 82784 | $165.00 | $107.25 | $132.00 | $13.17 | $32.19 | $34.24 | $107.25 | $132.00 | $107.25 | $132.00 | $13.17 | $132.00 | |
| 4300911 | INFLUENZA A & B | 306 | Laboratory | 87804 | $120.00 | $78.00 | $96.00 | $16.99 | $49.58 | $52.73 | $78.00 | $96.00 | $78.00 | $96.00 | $16.99 | $96.00 | |
| 4301551 | I-STAT BMP | 301 | Laboratory | 80047 | $79.00 | $51.35 | $63.20 | $11.98 | $36.63 | $38.96 | $51.35 | $63.20 | $51.35 | $63.20 | $11.98 | $63.20 | |
| 4302235 | KAPPA-LAMBDA RATIO | 301 | Laboratory | 83883 | $239.00 | $155.35 | $191.20 | $19.25 | $49.17 | $52.29 | $155.35 | $191.20 | $155.35 | $191.20 | $19.25 | $191.20 | |
| 4300265 | KETONES, QUAITATIVE SERM | 301 | Laboratory | 82009 | $57.00 | $37.05 | $45.60 | $6.17 | $19.56 | $20.80 | $37.05 | $45.60 | $37.05 | $45.60 | $6.17 | $45.60 | |
| 4302261 | Lactic Acid | 301 | Laboratory | 83605 | $84.00 | $54.60 | $67.20 | $15.13 | $46.24 | $49.18 | $54.60 | $67.20 | $54.60 | $67.20 | $15.13 | $67.20 | |
| 4300459 | LAMICTAL (LAMOTRIGINE) | 301 | Laboratory | 80299 | $133.00 | $86.45 | $106.40 | $19.40 | $59.31 | $63.08 | $86.45 | $106.40 | $86.45 | $106.40 | $19.40 | $106.40 | |
| 4301475 | LDH | 301 | Laboratory | 83615 | $84.00 | $54.60 | $67.20 | $8.55 | $26.15 | $27.81 | $54.60 | $67.20 | $54.60 | $67.20 | $8.55 | $67.20 | |
| 4303664 | LDL Direct | 300 | Laboratory | 83721 | $100.00 | $65.00 | $80.00 | $13.51 | $39.72 | $42.24 | $65.00 | $80.00 | $65.00 | $80.00 | $13.51 | $80.00 | |
| 4303825 | Legionella Ag MAMC | 300 | Laboratory | 87449 | $96.00 | $62.40 | $76.80 | $16.99 | $49.58 | $52.73 | $62.40 | $76.80 | $62.40 | $76.80 | $16.99 | $76.80 | |
| 4300457 | LEVETIRACETAM (KEPPRA) | 301 | Laboratory | 80177 | $112.00 | $72.80 | $89.60 | $18.09 | $56.98 | $60.60 | $72.80 | $89.60 | $72.80 | $89.60 | $18.09 | $89.60 | |
| 4300007 | LH | 301 | Laboratory | 83002 | $173.00 | $112.45 | $138.40 | $26.23 | $76.99 | $81.87 | $112.45 | $138.40 | $112.45 | $138.40 | $26.23 | $138.40 | |
| 4301423 | LIPASE | 301 | Laboratory | 83690 | $84.00 | $54.60 | $67.20 | $9.76 | $20.13 | $21.41 | $54.60 | $67.20 | $54.60 | $67.20 | $9.76 | $67.20 | |
| 4300031 | LIPID PROFILE | 301 | Laboratory | 80061 | $106.00 | $68.90 | $84.80 | $18.97 | $47.53 | $50.55 | $68.90 | $84.80 | $68.90 | $84.80 | $18.97 | $84.80 | |
| 4301705 | LIPID-REF | 301 | Laboratory | 80061 | $106.00 | $68.90 | $84.80 | $18.97 | $47.53 | $50.55 | $68.90 | $84.80 | $68.90 | $84.80 | $18.97 | $84.80 | |
| 4301093 | LYME TEST EIA | 302 | Laboratory | 86618 | $135.00 | $87.75 | $108.00 | $24.12 | $61.87 | $65.79 | $87.75 | $108.00 | $87.75 | $108.00 | $24.12 | $108.00 | |
| 4301291 | MAGNESIUM | 301 | Laboratory | 83735 | $84.00 | $54.60 | $67.20 | $9.49 | $29.01 | $30.85 | $54.60 | $67.20 | $54.60 | $67.20 | $9.49 | $67.20 | |
| 4300711 | MANUAL DIFFERENTIAL | 305 | Laboratory | 85007 | $32.00 | $20.80 | $25.60 | $4.87 | $12.47 | $13.27 | $20.80 | $25.60 | $20.80 | $25.60 | $4.87 | $25.60 | |
| 4300271 | METHYLMALONIC ACID SERUM | 301 | Laboratory | 83921 | $160.00 | $104.00 | $128.00 | $23.31 | $71.25 | $75.78 | $104.00 | $128.00 | $104.00 | $128.00 | $23.31 | $128.00 | |
| 4301685 | MICROALBUMIN QUAL URINE | 301 | Laboratory | 82044 | $45.00 | $29.25 | $36.00 | $6.48 | $19.81 | $21.07 | $29.25 | $36.00 | $29.25 | $36.00 | $6.48 | $36.00 | |
| 4301121 | MICROALBUMIN-REF | 301 | Laboratory | 82043 | $45.00 | $29.25 | $36.00 | $7.89 | $23.40 | $24.89 | $29.25 | $36.00 | $29.25 | $36.00 | $7.89 | $36.00 | |
| 4301191 | MONO SCREEN | 302 | Laboratory | 86308 | $81.00 | $52.65 | $64.80 | $7.33 | $22.40 | $23.82 | $52.65 | $64.80 | $52.65 | $64.80 | $7.33 | $64.80 | |
| 4300693 | MYCOPLASMA ANTIBODY | 302 | Laboratory | 86738 | $106.00 | $68.90 | $84.80 | $18.76 | $45.20 | $48.07 | $68.90 | $84.80 | $68.90 | $84.80 | $18.76 | $84.80 | |
| 4303676 | Mycoplasma DNA amplification | 306 | Laboratory | 87581 | $120.00 | $78.00 | $96.00 | $49.71 | $112.80 | $119.96 | $78.00 | $96.00 | $78.00 | $96.00 | $49.71 | $119.96 | |
| 4301667 | N. GONORRHOEAE- URINE | 306 | Laboratory | 87591 | $120.00 | $78.00 | $96.00 | $49.71 | $112.80 | $119.96 | $78.00 | $96.00 | $78.00 | $96.00 | $49.71 | $119.96 | |
| 4303837 | NMR Lipids | 300 | Laboratory | 80061 | $106.00 | $68.90 | $84.80 | $18.97 | $47.53 | $50.55 | $68.90 | $84.80 | $68.90 | $84.80 | $18.97 | $84.80 | |
| 4300701 | O&P CRYPTOSPORIDIUM | 306 | Laboratory | 87328 | $74.00 | $48.10 | $59.20 | $16.99 | $49.58 | $52.73 | $48.10 | $59.20 | $48.10 | $59.20 | $16.99 | $59.20 | |
| 4300903 | O&P DIRECT SMEAR | 306 | Laboratory | 87177 | $125.00 | $81.25 | $100.00 | $12.39 | $38.52 | $40.97 | $81.25 | $100.00 | $81.25 | $100.00 | $12.39 | $100.00 | |
| 4301199 | O&P GIARDIA | 306 | Laboratory | 87329 | $84.00 | $54.60 | $67.20 | $16.99 | $49.58 | $52.73 | $54.60 | $67.20 | $54.60 | $67.20 | $16.99 | $67.20 | |
| 4300751 | O&P TRICHOME STAIN | 306 | Laboratory | 87209 | $125.00 | $81.25 | $100.00 | $25.46 | $77.84 | $82.78 | $81.25 | $100.00 | $81.25 | $100.00 | $25.46 | $100.00 | |
| 4301217 | OB PROFILE LAB CHARGE | 300 | Laboratory | 80055 | $508.00 | $330.20 | $406.40 | $36.69 | $115.57 | $122.91 | $330.20 | $406.40 | $330.20 | $406.40 | $36.69 | $406.40 | |
| 4301677 | OCCULT BLD DIAGONSTI-iFOB | 301 | Laboratory | 82274 | $63.00 | $40.95 | $50.40 | $22.53 | $52.32 | $55.64 | $40.95 | $50.40 | $40.95 | $50.40 | $22.53 | $55.64 | |
| 4301675 | OCCULT BLD SCREEN-iFOB | 305 | Laboratory | G0328 | $63.00 | $40.95 | $50.40 | $22.53 | $52.32 | $55.64 | $40.95 | $50.40 | $40.95 | $50.40 | $22.53 | $55.64 | |
| 4300463 | OCCULT BLOOD SCREENING | 301 | Laboratory | 82270 | $63.00 | $40.95 | $50.40 | $4.61 | $14.11 | $15.01 | $40.95 | $50.40 | $40.95 | $50.40 | $4.61 | $50.40 | |
| 4303713 | PASE APTT | 300 | Laboratory | 85730 | $74.00 | $48.10 | $59.20 | $8.50 | $25.99 | $27.64 | $48.10 | $59.20 | $48.10 | $59.20 | $8.50 | $59.20 | |
| 4301627 | PERTUSSIS DNA PCR | 306 | Laboratory | 87798 | $239.00 | $155.35 | $191.20 | $49.71 | $112.80 | $119.96 | $155.35 | $191.20 | $155.35 | $191.20 | $49.71 | $191.20 | |
| 4301743 | PHENOBARBITAL-I | 301 | Laboratory | 80184 | $106.00 | $68.90 | $84.80 | $16.22 | $49.58 | $52.73 | $68.90 | $84.80 | $68.90 | $84.80 | $16.22 | $84.80 | |
| 4300787 | PHOSPHORUS (PO4)# | 301 | Laboratory | 84100 | $84.00 | $54.60 | $67.20 | $6.72 | $20.54 | $21.84 | $54.60 | $67.20 | $54.60 | $67.20 | $6.72 | $67.20 | |
| 4301947 | PNEUMOCOCCAL TITER | 302 | Laboratory | 86317 | $92.00 | $59.80 | $73.60 | $21.24 | $64.92 | $69.04 | $59.80 | $73.60 | $59.80 | $73.60 | $21.24 | $73.60 | |
| 4300871 | POTASSIUM-BLOOD# | 301 | Laboratory | 84132 | $64.00 | $41.60 | $51.20 | $6.51 | $19.91 | $21.17 | $41.60 | $51.20 | $41.60 | $51.20 | $6.51 | $51.20 | |
| 4300615 | PREGNANCY TEST SERUM | 301 | Laboratory | 84703 | $74.00 | $48.10 | $59.20 | $10.64 | $32.54 | $34.61 | $48.10 | $59.20 | $48.10 | $59.20 | $10.64 | $59.20 | |
| 4300599 | PREGNANCY TEST URINE | 307 | Laboratory | 81025 | $74.00 | $48.10 | $59.20 | $8.96 | $27.41 | $29.15 | $48.10 | $59.20 | $48.10 | $59.20 | $8.96 | $59.20 | |
| 4303823 | ProBNP | 300 | Laboratory | 83880 | $239.00 | $155.35 | $191.20 | $48.08 | $146.98 | $156.31 | $155.35 | $191.20 | $155.35 | $191.20 | $48.08 | $191.20 | |
| 4303822 | Procalcitonin | 300 | Laboratory | 84145 | $300.00 | $195.00 | $240.00 | $37.93 | $115.98 | $123.35 | $195.00 | $240.00 | $195.00 | $240.00 | $37.93 | $240.00 | |
| 4301135 | PROGESTERONE | 301 | Laboratory | 84144 | $200.00 | $130.00 | $160.00 | $29.55 | $90.34 | $96.08 | $130.00 | $160.00 | $130.00 | $160.00 | $29.55 | $160.00 | |
| 4301003 | PROLACTIN, RIA | 301 | Laboratory | 84146 | $185.00 | $120.25 | $148.00 | $27.45 | $83.92 | $89.24 | $120.25 | $148.00 | $120.25 | $148.00 | $27.45 | $148.00 | |
| 4300231 | PROTEIN URINE ELECTROPHES | 301 | Laboratory | 84166 | $91.00 | $59.15 | $72.80 | $25.26 | $77.24 | $82.14 | $59.15 | $72.80 | $59.15 | $72.80 | $25.26 | $82.14 | |
| 4300485 | PROTEIN, SERUM, ELECT. | 301 | Laboratory | 84165 | $91.00 | $59.15 | $72.80 | $15.21 | $46.49 | $49.45 | $59.15 | $72.80 | $59.15 | $72.80 | $15.21 | $72.80 | |
| 4300565 | PROTEIN, URINE RANDOM | 301 | Laboratory | 84156 | $64.00 | $41.60 | $51.20 | $5.19 | $15.88 | $16.88 | $41.60 | $51.20 | $41.60 | $51.20 | $5.19 | $51.20 | |
| 4301137 | PROTIME (PT) | 305 | Laboratory | 85610 | $74.00 | $48.10 | $59.20 | $5.56 | $17.01 | $18.09 | $48.10 | $59.20 | $48.10 | $59.20 | $5.56 | $59.20 | |
| 4300037 | PSA SCREEN | 309 | Laboratory | G0103 | $106.00 | $68.90 | $84.80 | $26.06 | $79.66 | $84.72 | $68.90 | $84.80 | $68.90 | $84.80 | $26.06 | $84.80 | |
| 4301777 | PSA TOTAL-REF | 301 | Laboratory | 84153 | $106.00 | $68.90 | $84.80 | $26.06 | $79.66 | $84.72 | $68.90 | $84.80 | $68.90 | $84.80 | $26.06 | $84.80 | |
| 4301293 | PSA, FREE | 301 | Laboratory | 84154 | $173.00 | $112.45 | $138.40 | $26.06 | $79.66 | $84.72 | $112.45 | $138.40 | $112.45 | $138.40 | $26.06 | $138.40 | |
| 4301251 | PSA, TOTAL | 301 | Laboratory | 84153 | $106.00 | $68.90 | $84.80 | $26.06 | $79.66 | $84.72 | $68.90 | $84.80 | $68.90 | $84.80 | $26.06 | $84.80 | |
| 4300423 | PTH (PARATHORMONE, RIA) | 301 | Laboratory | 83970 | $294.00 | $191.10 | $235.20 | $58.46 | $178.73 | $190.08 | $191.10 | $235.20 | $191.10 | $235.20 | $58.46 | $235.20 | |
| 4303875 | PTH MAMC | 300 | Laboratory | 83970 | $294.00 | $191.10 | $235.20 | $58.46 | $178.73 | $190.08 | $191.10 | $235.20 | $191.10 | $235.20 | $58.46 | $235.20 | |
| 4301933 | PT-REF-P | 305 | Laboratory | 85610 | $74.00 | $48.10 | $59.20 | $5.56 | $17.01 | $18.09 | $48.10 | $59.20 | $48.10 | $59.20 | $5.56 | $59.20 | |
| 4301479 | PTT | 305 | Laboratory | 85730 | $74.00 | $48.10 | $59.20 | $8.50 | $25.99 | $27.64 | $48.10 | $59.20 | $48.10 | $59.20 | $8.50 | $59.20 | |
| 4301857 | PTT-REF | 305 | Laboratory | 85730 | $74.00 | $48.10 | $59.20 | $8.50 | $25.99 | $27.64 | $48.10 | $59.20 | $48.10 | $59.20 | $8.50 | $59.20 | |
| 4301935 | PTT-REF-P | 305 | Laboratory | 85730 | $74.00 | $48.10 | $59.20 | $8.50 | $25.99 | $27.64 | $48.10 | $59.20 | $48.10 | $59.20 | $8.50 | $59.20 | |
| 4303843 | QuantiFERON TB Gold Plus | 300 | Laboratory | 86480 | $285.00 | $185.25 | $228.00 | $87.79 | $263.91 | $280.66 | $185.25 | $228.00 | $185.25 | $228.00 | $87.79 | $280.66 | |
| 4301201 | QUICK STREP | 306 | Laboratory | 87880 | $84.00 | $54.60 | $67.20 | $16.99 | $49.58 | $52.73 | $54.60 | $67.20 | $54.60 | $67.20 | $16.99 | $67.20 | |
| 4300889 | RA FACTOR SCREEN | 302 | Laboratory | 86430 | $84.00 | $54.60 | $67.20 | $8.04 | $24.57 | $26.13 | $54.60 | $67.20 | $54.60 | $67.20 | $8.04 | $67.20 | |
| 4300593 | RENAL FUNCTION PANEL | 301 | Laboratory | 80069 | $92.00 | $59.80 | $73.60 | $12.30 | $37.61 | $40.00 | $59.80 | $73.60 | $59.80 | $73.60 | $12.30 | $73.60 | |
| 4303635 | RENAL REF | 301 | Laboratory | 80069 | $92.00 | $59.80 | $73.60 | $12.30 | $37.61 | $40.00 | $59.80 | $73.60 | $59.80 | $73.60 | $12.30 | $73.60 | |
| 4301487 | RSV | 306 | Laboratory | 87807 | $106.00 | $68.90 | $84.80 | $16.99 | $49.58 | $52.73 | $68.90 | $84.80 | $68.90 | $84.80 | $16.99 | $84.80 | |
| 4301223 | SALICYLATE | 301 | Laboratory | 80329 | $67.00 | $43.55 | $53.60 | $0.48 | $1.51 | $1.61 | $43.55 | $53.60 | $43.55 | $53.60 | $0.48 | $53.60 | |
| 4300617 | SED RATE - AUTOMATED | 305 | Laboratory | 85652 | $80.00 | $52.00 | $64.00 | $3.83 | $11.69 | $12.43 | $52.00 | $64.00 | $52.00 | $64.00 | $3.83 | $64.00 | |
| 4301279 | SIROLIMUS | 301 | Laboratory | 80195 | $131.00 | $85.15 | $104.80 | $19.45 | $31.59 | $33.60 | $85.15 | $104.80 | $85.15 | $104.80 | $19.45 | $104.80 | |
| 4301081 | SODIUM-BLOOD# | 301 | Laboratory | 84295 | $64.00 | $41.60 | $51.20 | $6.82 | $18.93 | $20.13 | $41.60 | $51.20 | $41.60 | $51.20 | $6.82 | $51.20 | |
| 4302025 | STOOL WBC; LACTOFERRIN | 301 | Laboratory | 83630 | $95.00 | $61.75 | $76.00 | $27.80 | $84.99 | $90.38 | $61.75 | $76.00 | $61.75 | $76.00 | $27.80 | $90.38 | |
| 4301395 | T3 FREE | 301 | Laboratory | 84481 | $125.00 | $81.25 | $100.00 | $24.00 | $73.36 | $78.02 | $81.25 | $100.00 | $81.25 | $100.00 | $24.00 | $100.00 | |
| 4301253 | T-3 UPTAKE | 301 | Laboratory | 84479 | $67.00 | $43.55 | $53.60 | $9.17 | $28.00 | $29.78 | $43.55 | $53.60 | $43.55 | $53.60 | $9.17 | $53.60 | |
| 4301009 | T4 (THYROXINE) | 301 | Laboratory | 84436 | $67.00 | $43.55 | $53.60 | $9.73 | $29.74 | $31.62 | $43.55 | $53.60 | $43.55 | $53.60 | $9.73 | $53.60 | |
| 4303856 | Tacrolimans LCMS | 300 | Laboratory | 80197 | $133.00 | $86.45 | $106.40 | $19.45 | $31.59 | $33.60 | $86.45 | $106.40 | $86.45 | $106.40 | $19.45 | $106.40 | |
| 4300733 | TESTOSTERONE, FREE | 301 | Laboratory | 84402 | $239.00 | $155.35 | $191.20 | $36.07 | $110.25 | $117.25 | $155.35 | $191.20 | $155.35 | $191.20 | $36.07 | $191.20 | |
| 4300735 | TESTOSTERONE-TOTAL | 301 | Laboratory | 84403 | $208.00 | $135.20 | $166.40 | $36.57 | $105.27 | $111.96 | $135.20 | $166.40 | $135.20 | $166.40 | $36.57 | $166.40 | |
| 4300199 | THYROID PEROXID ANTIBDY | 302 | Laboratory | 86376 | $118.00 | $76.70 | $94.40 | $20.61 | $62.97 | $66.97 | $76.70 | $94.40 | $76.70 | $94.40 | $20.61 | $94.40 | |
| 4300293 | THYROXINE BINDING GLOBUL | 301 | Laboratory | 84442 | $139.00 | $90.35 | $111.20 | $20.95 | $64.04 | $68.11 | $90.35 | $111.20 | $90.35 | $111.20 | $20.95 | $111.20 | |
| 4300483 | TOTAL PROTEIN 24 HR UR | 301 | Laboratory | 84156 | $64.00 | $41.60 | $51.20 | $5.19 | $15.88 | $16.88 | $41.60 | $51.20 | $41.60 | $51.20 | $5.19 | $51.20 | |
| 4301303 | TOTAL T-3 | 301 | Laboratory | 84480 | $133.00 | $86.45 | $106.40 | $20.08 | $61.39 | $65.29 | $86.45 | $106.40 | $86.45 | $106.40 | $20.08 | $106.40 | |
| 4300439 | TREPONEMA PALLIDUM, FTA | 302 | Laboratory | 86780 | $281.00 | $182.65 | $224.80 | $12.39 | $57.33 | $60.97 | $182.65 | $224.80 | $182.65 | $224.80 | $12.39 | $224.80 | |
| 4303784 | Trichomonas DNA probe | 300 | Laboratory | 87797 | $95.00 | $61.75 | $76.00 | $28.40 | $86.85 | $92.36 | $61.75 | $76.00 | $61.75 | $76.00 | $28.40 | $92.36 | |
| 4303849 | Tro-Gen4 | 300 | Laboratory | 84484 | $109.00 | $70.85 | $87.20 | $13.94 | $42.62 | $45.33 | $70.85 | $87.20 | $70.85 | $87.20 | $13.94 | $87.20 | |
| 4303830 | Troponin T New | 300 | Laboratory | 84484 | $109.00 | $70.85 | $87.20 | $13.94 | $42.62 | $45.33 | $70.85 | $87.20 | $70.85 | $87.20 | $13.94 | $87.20 | |
| 4302221 | TSH-REF | 301 | Laboratory | 84443 | $106.00 | $68.90 | $84.80 | $23.80 | $72.77 | $77.39 | $68.90 | $84.80 | $68.90 | $84.80 | $23.80 | $84.80 | |
| 4300295 | TSH--THYROID STIM. HORMON | 301 | Laboratory | 84443 | $106.00 | $68.90 | $84.80 | $23.80 | $72.77 | $77.39 | $68.90 | $84.80 | $68.90 | $84.80 | $23.80 | $84.80 | |
| 4300531 | UA - MICROSCOPIC ONLY | 307 | Laboratory | 81015 | $46.00 | $29.90 | $36.80 | $4.31 | $12.47 | $13.27 | $29.90 | $36.80 | $29.90 | $36.80 | $4.31 | $36.80 | |
| 4300851 | UA DIPSTICK ONLY | 307 | Laboratory | 81003 | $46.00 | $29.90 | $36.80 | $3.18 | $7.69 | $8.17 | $29.90 | $36.80 | $29.90 | $36.80 | $3.18 | $36.80 | |
| 4301229 | UA W/MICRO (COMPLETE) | 307 | Laboratory | 81001 | $60.00 | $39.00 | $48.00 | $4.48 | $13.70 | $14.57 | $39.00 | $48.00 | $39.00 | $48.00 | $4.48 | $48.00 | |
| 4303663 | UIBC (Unsaturated Iron-Binding Capacity) | 300 | Laboratory | 83550 | $73.00 | $47.45 | $58.40 | $12.38 | $37.86 | $40.27 | $47.45 | $58.40 | $47.45 | $58.40 | $12.38 | $58.40 | |
| 4300875 | URIC ACID-BLOOD# | 301 | Laboratory | 84550 | $84.00 | $54.60 | $67.20 | $6.40 | $19.56 | $20.80 | $54.60 | $67.20 | $54.60 | $67.20 | $6.40 | $67.20 | |
| 4301633 | URINE DRUG SCREEN | 301 | Laboratory | 80306 | $70.00 | $45.50 | $56.00 | $15.26 | $48.07 | $51.12 | $45.50 | $56.00 | $45.50 | $56.00 | $15.26 | $56.00 | |
| 4302231 | VALPORIC ACID-REF | 301 | Laboratory | 80164 | $107.00 | $69.55 | $85.60 | $19.19 | $58.68 | $62.41 | $69.55 | $85.60 | $69.55 | $85.60 | $19.19 | $85.60 | |
| 4303827 | Vancomycin Random | 300 | Laboratory | 80202 | $120.00 | $78.00 | $96.00 | $19.19 | $58.68 | $62.41 | $78.00 | $96.00 | $78.00 | $96.00 | $19.19 | $96.00 | |
| 4303829 | Vancomycin Trogh | 300 | Laboratory | 80202 | $120.00 | $78.00 | $96.00 | $19.19 | $58.68 | $62.41 | $78.00 | $96.00 | $78.00 | $96.00 | $19.19 | $96.00 | |
| 4300005 | VENIP (FINGER OR HEEL) | 300 | Laboratory | 36416 | $14.00 | $9.10 | $11.20 | $- | $- | $- | $9.10 | $11.20 | $9.10 | $11.20 | $- | $11.20 | |
| 4303668 | Vit D Total II MAMC | 300 | Laboratory | 82306 | $140.00 | $91.00 | $112.00 | $38.49 | $128.21 | $136.35 | $91.00 | $112.00 | $91.00 | $112.00 | $38.49 | $136.35 | |
| 4300315 | VITAMIN D, 1,25-DIHYDROXY | 301 | Laboratory | 82652 | $213.00 | $138.45 | $170.40 | $54.53 | $166.70 | $177.28 | $138.45 | $170.40 | $138.45 | $170.40 | $54.53 | $177.28 | |
| 4301327 | WET MOUNT | 306 | Laboratory | 87210 | $64.00 | $41.60 | $51.20 | $6.05 | $18.49 | $19.66 | $41.60 | $51.20 | $41.60 | $51.20 | $6.05 | $51.20 | |
| 4480007 | MRI - BRAIN W&WO CONT | 611 | MRI | 70553 | $2,575.00 | $1,673.75 | $2,060.00 | $534.55 | $1,785.78 | $1,950.62 | $1,673.75 | $2,060.00 | $1,802.50 | $2,060.00 | $534.55 | $2,060.00 | |
| 4480047 | MRI LOW JOINT W/O CM | 610 | MRI | 73721 | $1,600.00 | $1,040.00 | $1,280.00 | $338.74 | $1,100.09 | $1,201.64 | $1,040.00 | $1,280.00 | $1,120.00 | $1,280.00 | $338.74 | $1,280.00 | |
| 4480043 | MRI SPINE LUMBAR W/O CM | 612 | MRI | 72148 | $1,600.00 | $1,040.00 | $1,280.00 | $338.74 | $1,100.09 | $1,201.64 | $1,040.00 | $1,280.00 | $1,120.00 | $1,280.00 | $338.74 | $1,280.00 | |
| 4600047 | ELECTRICAL STIM 15 MIN | 420 | Physical Therapy | 97014 | $70.50 | $45.83 | $56.40 | $15.29 | $43.92 | $48.71 | $45.83 | $56.40 | $49.35 | $56.40 | $15.29 | $56.40 | |
| 4600101 | EVALUATION | 424 | Physical Therapy | 97161 | $250.00 | $162.50 | $200.00 | $81.52 | $224.18 | $248.64 | $162.50 | $200.00 | $175.00 | $200.00 | $81.52 | $248.64 | |
| 4600083 | EXERCISE - 15 MIN | 420 | Physical Therapy | 97110 | $100.00 | $65.00 | $80.00 | $30.58 | $87.84 | $97.42 | $65.00 | $80.00 | $70.00 | $80.00 | $30.58 | $97.42 | |
| 4600095 | GAIT TRAINING | 420 | Physical Therapy | 97116 | $90.00 | $58.50 | $72.00 | $27.18 | $77.55 | $86.01 | $58.50 | $72.00 | $63.00 | $72.00 | $27.18 | $86.01 | |
| 4600055 | KINETIC ACTIV THERAPEUTIC | 420 | Physical Therapy | 97530 | $110.00 | $71.50 | $88.00 | $33.64 | $96.25 | $106.75 | $71.50 | $88.00 | $77.00 | $88.00 | $33.64 | $106.75 | |
| 4600029 | MASSAGE - 15 MIN/PT | 420 | Physical Therapy | 97124 | $80.00 | $52.00 | $64.00 | $25.14 | $71.94 | $79.79 | $52.00 | $64.00 | $56.00 | $64.00 | $25.14 | $79.79 | |
| 46097161 | PT EVAL; LOW COMPLEXITY | 424 | Physical Therapy | 97161 | $250.00 | $162.50 | $200.00 | $81.52 | $224.18 | $248.64 | $162.50 | $200.00 | $175.00 | $200.00 | $81.52 | $248.64 | |
| 4600071 | ULTRASOUND - 15 MIN | 420 | Physical Therapy | 97035 | $78.25 | $50.86 | $62.60 | $12.23 | $34.57 | $38.34 | $50.86 | $62.60 | $54.78 | $62.60 | $12.23 | $62.60 | |
| 4400093 | ABD ACUT SERIES PA CHEST | 320 | Radiology | 74021 | $425.00 | $276.25 | $340.00 | $118.74 | $385.91 | $421.53 | $276.25 | $340.00 | $297.50 | $340.00 | $118.74 | $421.53 | |
| 4400101 | ABD COMP INCL ERECT/DECUB | 320 | Radiology | 74019 | $425.00 | $276.25 | $340.00 | $118.74 | $385.91 | $421.53 | $276.25 | $340.00 | $297.50 | $340.00 | $118.74 | $421.53 | |
| 4400261 | ABDOMEN 1 AP VIEW | 320 | Radiology | 74018 | $225.00 | $146.25 | $180.00 | $62.11 | $201.86 | $220.49 | $146.25 | $180.00 | $157.50 | $180.00 | $62.11 | $220.49 | |
| 4400285 | ANKLE (2) RIGHT | 320 | Radiology | 73600 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400307 | ANKLE (3) LEFT | 320 | Radiology | 73610 | $180.00 | $117.00 | $144.00 | $44.87 | $149.34 | $163.12 | $117.00 | $144.00 | $126.00 | $144.00 | $44.87 | $163.12 | |
| 4400287 | ANKLE (3) RIGHT | 320 | Radiology | 73610 | $180.00 | $117.00 | $144.00 | $44.87 | $149.34 | $163.12 | $117.00 | $144.00 | $126.00 | $144.00 | $44.87 | $163.12 | |
| 4400043 | CHEST (1) | 324 | Radiology | 71045 | $225.00 | $146.25 | $180.00 | $62.11 | $201.86 | $220.49 | $146.25 | $180.00 | $157.50 | $180.00 | $62.11 | $220.49 | |
| 4400141 | CHEST (1) WITH PORTABLE | 320 | Radiology | 71045 | $225.00 | $146.25 | $180.00 | $62.11 | $201.86 | $220.49 | $146.25 | $180.00 | $157.50 | $180.00 | $62.11 | $220.49 | |
| 4400353 | CHEST (2) | 324 | Radiology | 71046 | $225.00 | $146.25 | $180.00 | $62.11 | $201.86 | $220.49 | $146.25 | $180.00 | $157.50 | $180.00 | $62.11 | $220.49 | |
| 4400097 | CHEST,APICAL LORDOTI ONLY | 320 | Radiology | 71045 | $225.00 | $146.25 | $180.00 | $62.11 | $201.86 | $220.49 | $146.25 | $180.00 | $157.50 | $180.00 | $62.11 | $220.49 | |
| 4400249 | CLAVICLE COMPL LT | 320 | Radiology | 73000 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4420073 | CT lower extremity with contrast | 352 | Radiology | 73701 | $1,250.00 | $812.50 | $1,000.00 | $300.57 | $965.74 | $1,054.88 | $812.50 | $1,000.00 | $875.00 | $1,000.00 | $300.57 | $1,054.88 | |
| 4460001 | DEXASCAN -BONE DENSITY/ A | 320 | Radiology | 77080 | $309.00 | $200.85 | $247.20 | $46.89 | $131.40 | $143.53 | $200.85 | $247.20 | $216.30 | $247.20 | $46.89 | $247.20 | |
| 4400291 | ELBOW (2) LEFT | 320 | Radiology | 73070 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400277 | ELBOW (2) RIGHT | 320 | Radiology | 73070 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400354 | ELBOW 3 VIEWS LT | 320 | Radiology | 73080 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400323 | ELBOW 3 VIEWS RT | 320 | Radiology | 73080 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400083 | FACIAL BONES COMPL SERIES | 320 | Radiology | 70150 | $271.00 | $176.15 | $216.80 | $44.87 | $230.23 | $251.48 | $176.15 | $216.80 | $189.70 | $216.80 | $44.87 | $251.48 | |
| 4400299 | FEMUR (2) LEFT | 320 | Radiology | 73552 | $220.00 | $143.00 | $176.00 | $60.80 | $197.60 | $215.84 | $143.00 | $176.00 | $154.00 | $176.00 | $60.80 | $215.84 | |
| 4400283 | FEMUR (2) RIGHT | 320 | Radiology | 73552 | $220.00 | $143.00 | $176.00 | $60.80 | $197.60 | $215.84 | $143.00 | $176.00 | $154.00 | $176.00 | $60.80 | $215.84 | |
| 4400281 | FINGER (3) LEFT | 320 | Radiology | 73140 | $217.00 | $141.05 | $173.60 | $44.87 | $149.34 | $163.12 | $141.05 | $173.60 | $151.90 | $173.60 | $44.87 | $173.60 | |
| 4400267 | FINGER (3) RIGHT | 320 | Radiology | 73140 | $217.00 | $141.05 | $173.60 | $44.87 | $149.34 | $163.12 | $141.05 | $173.60 | $151.90 | $173.60 | $44.87 | $173.60 | |
| 4400309 | FOOT (2) LEFT | 320 | Radiology | 73620 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400311 | FOOT (2) RIGHT | 320 | Radiology | 73620 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400339 | FOOT (3) LEFT | 320 | Radiology | 73630 | $217.00 | $141.05 | $173.60 | $44.87 | $149.34 | $163.12 | $141.05 | $173.60 | $151.90 | $173.60 | $44.87 | $173.60 | |
| 4400313 | FOOT (3) RIGHT | 320 | Radiology | 73630 | $217.00 | $141.05 | $173.60 | $44.87 | $149.34 | $163.12 | $141.05 | $173.60 | $151.90 | $173.60 | $44.87 | $173.60 | |
| 4400265 | FOREARM (2) LEFT | 320 | Radiology | 73090 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400259 | FOREARM (2) RIGHT | 320 | Radiology | 73090 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400325 | HAND (2) LEFT | 320 | Radiology | 73120 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400295 | HAND (2) RIGHT | 320 | Radiology | 73120 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400327 | HAND (3) LEFT | 320 | Radiology | 73130 | $271.00 | $176.15 | $216.80 | $44.87 | $149.34 | $163.12 | $176.15 | $216.80 | $189.70 | $216.80 | $44.87 | $216.80 | |
| 4400297 | HAND (3) RIGHT | 320 | Radiology | 73130 | $271.00 | $176.15 | $216.80 | $44.87 | $149.34 | $163.12 | $176.15 | $216.80 | $189.70 | $216.80 | $44.87 | $216.80 | |
| 4400343 | HIP (2) LEFT | 320 | Radiology | 73503 | $360.00 | $234.00 | $288.00 | $100.69 | $327.24 | $357.45 | $234.00 | $288.00 | $252.00 | $288.00 | $100.69 | $357.45 | |
| 4400331 | HIP (2) RIGHT | 320 | Radiology | 73503 | $360.00 | $234.00 | $288.00 | $100.69 | $327.24 | $357.45 | $234.00 | $288.00 | $252.00 | $288.00 | $100.69 | $357.45 | |
| 4400263 | HUMERUS (2) LEFT | 320 | Radiology | 73060 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400257 | HUMERUS (2) RIGHT | 320 | Radiology | 73060 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400333 | KNEE (2) LEFT | 320 | Radiology | 73560 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400301 | KNEE (2) RIGHT | 320 | Radiology | 73560 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400335 | KNEE (3) LEFT | 320 | Radiology | 73562 | $185.00 | $120.25 | $148.00 | $44.87 | $149.34 | $163.12 | $120.25 | $148.00 | $129.50 | $148.00 | $44.87 | $163.12 | |
| 4400303 | KNEE (3) RIGHT | 320 | Radiology | 73562 | $185.00 | $120.25 | $148.00 | $44.87 | $149.34 | $163.12 | $120.25 | $148.00 | $129.50 | $148.00 | $44.87 | $163.12 | |
| 4400205 | KNEES, (AP STANDING) | 320 | Radiology | 73565 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400345 | LEG (2) LEFT | 320 | Radiology | 73590 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400337 | LEG (2) RIGHT | 320 | Radiology | 73590 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400031 | MANDLE;PART LESS THAN (4) | 320 | Radiology | 70100 | $175.00 | $113.75 | $140.00 | $44.87 | $149.34 | $163.12 | $113.75 | $140.00 | $122.50 | $140.00 | $44.87 | $163.12 | |
| 4400037 | NASAL BONES - XRAY | 320 | Radiology | 70160 | $175.00 | $113.75 | $140.00 | $44.87 | $149.34 | $163.12 | $113.75 | $140.00 | $122.50 | $140.00 | $44.87 | $163.12 | |
| 4400149 | PELVIS (1) OR (2) VIEWS | 320 | Radiology | 72170 | $271.00 | $176.15 | $216.80 | $44.87 | $149.34 | $163.12 | $176.15 | $216.80 | $189.70 | $216.80 | $44.87 | $216.80 | |
| 4400073 | RADIOLOG EXM NEK SFT TISS | 320 | Radiology | 70360 | $175.00 | $113.75 | $140.00 | $44.87 | $149.34 | $163.12 | $113.75 | $140.00 | $122.50 | $140.00 | $44.87 | $163.12 | |
| 4400013 | RIBS (2) LEFT | 320 | Radiology | 71100 | $175.00 | $113.75 | $140.00 | $44.87 | $149.34 | $163.12 | $113.75 | $140.00 | $122.50 | $140.00 | $44.87 | $163.12 | |
| 4400011 | RIBS (2) RIGHT | 320 | Radiology | 71100 | $175.00 | $113.75 | $140.00 | $44.87 | $149.34 | $163.12 | $113.75 | $140.00 | $122.50 | $140.00 | $44.87 | $163.12 | |
| 4400107 | RIBS BILAT + PA CHEST 4WS | 320 | Radiology | 71111 | $271.00 | $176.15 | $216.80 | $75.55 | $230.23 | $251.48 | $176.15 | $216.80 | $189.70 | $216.80 | $75.55 | $251.48 | |
| 4400029 | SACRUM AND COCCYX | 320 | Radiology | 72220 | $175.00 | $113.75 | $140.00 | $44.87 | $149.34 | $163.12 | $113.75 | $140.00 | $122.50 | $140.00 | $44.87 | $163.12 | |
| 4400255 | SHOULDER (2) LEFT | 320 | Radiology | 73030 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400237 | SHOULDER (2) RIGHT | 320 | Radiology | 73030 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400169 | SPINE CERVICAL 2-3 VWS | 320 | Radiology | 72040 | $196.00 | $127.40 | $156.80 | $44.87 | $149.34 | $163.12 | $127.40 | $156.80 | $137.20 | $156.80 | $44.87 | $163.12 | |
| 4400131 | SPINE CERVICAL MIN 4 VWS | 320 | Radiology | 72050 | $271.00 | $176.15 | $216.80 | $75.55 | $230.23 | $251.48 | $176.15 | $216.80 | $189.70 | $216.80 | $75.55 | $251.48 | |
| 4400133 | SPINE, CERVICAL COMPLETE | 320 | Radiology | 72052 | $309.00 | $200.85 | $247.20 | $75.55 | $230.23 | $251.48 | $200.85 | $247.20 | $216.30 | $247.20 | $75.55 | $251.48 | |
| 4400147 | SPINE, LUMBAR 2-3 VIEWS | 320 | Radiology | 72100 | $271.00 | $176.15 | $216.80 | $44.87 | $149.34 | $163.12 | $176.15 | $216.80 | $189.70 | $216.80 | $44.87 | $216.80 | |
| 4400135 | SPINE, LUMBAR MIN OF (4) | 320 | Radiology | 72110 | $271.00 | $176.15 | $216.80 | $75.55 | $230.23 | $251.48 | $176.15 | $216.80 | $189.70 | $216.80 | $75.55 | $251.48 | |
| 4400171 | SPINE, LUMBER COMPLETE | 320 | Radiology | 72114 | $309.00 | $200.85 | $247.20 | $75.55 | $230.23 | $251.48 | $200.85 | $247.20 | $216.30 | $247.20 | $75.55 | $251.48 | |
| 4400217 | SPINE, THORACIC (2) | 320 | Radiology | 72070 | $274.00 | $178.10 | $219.20 | $44.87 | $149.34 | $163.12 | $178.10 | $219.20 | $191.80 | $219.20 | $44.87 | $219.20 | |
| 4400017 | TOES, LEFT | 320 | Radiology | 73660 | $175.00 | $113.75 | $140.00 | $44.87 | $149.34 | $163.12 | $113.75 | $140.00 | $122.50 | $140.00 | $44.87 | $163.12 | |
| 4400351 | TOES, RIGHT | 320 | Radiology | 73660 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400293 | WRIST (2) LEFT | 320 | Radiology | 73100 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400279 | WRIST (2) RIGHT | 320 | Radiology | 73100 | $165.00 | $107.25 | $132.00 | $44.87 | $149.34 | $163.12 | $107.25 | $132.00 | $115.50 | $132.00 | $44.87 | $163.12 | |
| 4400025 | WRIST (3VW MIN) LEFT | 320 | Radiology | 73110 | $190.00 | $123.50 | $152.00 | $44.87 | $149.34 | $163.12 | $123.50 | $152.00 | $133.00 | $152.00 | $44.87 | $163.12 | |
| 4400193 | WRIST (3VW MIN) RIGHT | 320 | Radiology | 73110 | $190.00 | $123.50 | $152.00 | $44.87 | $149.34 | $163.12 | $123.50 | $152.00 | $133.00 | $152.00 | $44.87 | $163.12 | |
| 99203 | OFFICE VISIT NEW PAT L3 | 521 | Rural Health Clinic | 99203 | $180.00 | $117.00 | $85.85 | $113.22 | $115.41 | $115.41 | $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 | $171.87 | $175.20 | $175.20 | $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 | $216.04 | $220.23 | $220.23 | $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 | $138.09 | $140.76 | $140.76 | $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 | $160.36 | $163.47 | $163.47 | $137.23 | $137.23 | $137.23 | $137.23 | $137.23 | $163.47 | |
| 4400211 | BILATERAL RENAL SONOGRAM | 402 | Ultrasound | 76700 | $597.00 | $388.05 | $477.60 | $96.49 | $322.79 | $352.59 | $388.05 | $477.60 | $417.90 | $477.60 | $96.49 | $477.60 | |
| 32076700 | ULTRASOUND ABD COMPLETE | 402 | Ultrasound | 76700 | $597.00 | $388.05 | $477.60 | $96.49 | $322.79 | $352.59 | $388.05 | $477.60 | $417.90 | $477.60 | $96.49 | $477.60 | |
| 4440007 | US ABD LTD - GALLBLADDER | 402 | Ultrasound | 76705 | $355.00 | $230.75 | $284.00 | $96.49 | $322.79 | $352.59 | $230.75 | $284.00 | $248.50 | $284.00 | $96.49 | $352.59 | |
| 4440017 | US ABD LTD - LIVER | 402 | Ultrasound | 76705 | $355.00 | $230.75 | $284.00 | $96.49 | $322.79 | $352.59 | $230.75 | $284.00 | $248.50 | $284.00 | $96.49 | $352.59 | |
| 4440003 | US ABD LTD SNGL ORG/QUAD | 402 | Ultrasound | 76705 | $355.00 | $230.75 | $284.00 | $96.49 | $322.79 | $352.59 | $230.75 | $284.00 | $248.50 | $284.00 | $96.49 | $352.59 | |
| 4440029 | US PELVIS NON-OB COMPL | 402 | Ultrasound | 76856 | $355.00 | $230.75 | $284.00 | $96.49 | $322.79 | $352.59 | $230.75 | $284.00 | $248.50 | $284.00 | $96.49 | $352.59 | |
| 4440035 | US PELVIS NON-OB LTD | 402 | Ultrasound | 76857 | $271.00 | $176.15 | $216.80 | $62.94 | $209.85 | $229.22 | $176.15 | $216.80 | $189.70 | $216.80 | $62.94 | $229.22 | |
| 4440037 | US SCROTUM/TESTICLES | 402 | Ultrasound | 76870 | $355.00 | $230.75 | $284.00 | $96.49 | $322.79 | $352.59 | $230.75 | $284.00 | $248.50 | $284.00 | $96.49 | $352.59 | |
| 4440001 | US SOFT TISS HEADNECK THY | 402 | Ultrasound | 76536 | $350.00 | $227.50 | $280.00 | $95.81 | $319.12 | $348.57 | $227.50 | $280.00 | $245.00 | $280.00 | $95.81 | $348.57 | |
| 4440019 | US SOFT TISSUE | 402 | Ultrasound | 76882 | $303.00 | $196.95 | $242.40 | $10.87 | $37.54 | $41.00 | $196.95 | $242.40 | $212.10 | $242.40 | $10.87 | $242.40 |
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.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call {877-696-6775}
© Muleshoe Area Medical Center. All rights reserved.
