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 7/15/2023
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.
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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