OVERVIEW
In compliance with the Centers for Medicare and Medicaid Services (CMS), Kimble Hospital 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.
Kimble Hospital 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 Kimble Hospital CDM, please contact our hospital business office at (325) 446-3321 or come by and speak to one of our business office representatives. Thank you for choosing Kimble Hospital for your health care needs!
Kimble Hospital Shoppable Services as of 7/18/2022
CHARGE CODE | DESCRIPTION | DEPT | REV CODE | CPT CODE | Gross Charge | Cash Price | Aetna | BCBS - Blue Essentials HMO | BCBS - Traditional | BCBS - PPO | Cigna | Humana | Scott & White | Shannon | United | Minimum Negotiated Charge | Maximum Negotiated Charge | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Y533050A | EKG 12 LEAD TRACING ONLY | EKG/ECG | 730 | 93005 | $240.00 | $144.00 | $144.00 | $214.25 | $237.75 | $237.75 | $172.80 | $175.68 | $204.00 | $216.00 | $164.88 | $144.00 | $237.75 | |
90846 | FAMILY PSYCHOTHERAPY W/O PAT | Family therapy | 916 | 90846 | $285.00 | $171.00 | $171.00 | $- | $- | $- | $205.20 | $208.62 | $242.25 | $256.50 | $195.80 | $- | $256.50 | |
GRP1600 | PSYCH FAMILY THERAPY | Family therapy | 916 | 90847 | $310.00 | $186.00 | $186.00 | $164.28 | $165.35 | $165.35 | $223.20 | $226.92 | $263.50 | $279.00 | $212.97 | $164.28 | $279.00 | |
31645378 | COLONOSCOPY | Gastrointestinal | 750 | 45378 | $2,650.00 | $1,590.00 | $1,590.00 | $2,371.19 | $2,634.66 | $2,634.66 | $1,908.00 | $1,939.80 | $2,252.50 | $2,385.00 | $1,820.55 | $1,590.00 | $2,634.66 | |
316G0105 | COLONOSCOPY SCREEN HIGH RISK | Gastrointestinal | 750 | G0105 | $2,650.00 | $1,590.00 | $1,590.00 | $2,371.19 | $2,634.66 | $2,634.66 | $1,908.00 | $1,939.80 | $2,252.50 | $2,385.00 | $1,820.55 | $1,590.00 | $2,634.66 | |
316G0121 | COLONOSCOPY SCREEN NOT HI RSK | Gastrointestinal | 750 | G0121 | $2,650.00 | $1,590.00 | $1,590.00 | $2,371.19 | $2,634.66 | $2,634.66 | $1,908.00 | $1,939.80 | $2,252.50 | $2,385.00 | $1,820.55 | $1,590.00 | $2,634.66 | |
31645380 | COLONOSCOPY W BIOPSY(S) | Gastrointestinal | 750 | 45380 | $2,650.00 | $1,590.00 | $1,590.00 | $2,371.19 | $2,634.66 | $2,634.66 | $1,908.00 | $1,939.80 | $2,252.50 | $2,385.00 | $1,820.55 | $1,590.00 | $2,634.66 | |
31645385 | COLONOSCOPY W SNARE REMOVAL | Gastrointestinal | 750 | 45385 | $2,650.00 | $1,590.00 | $1,590.00 | $2,371.19 | $2,634.66 | $2,634.66 | $1,908.00 | $1,939.80 | $2,252.50 | $2,385.00 | $1,820.55 | $1,590.00 | $2,634.66 | |
31643249 | EGD W BALLOON DILATION ESOP | Gastrointestinal | 750 | 43249 | $3,850.00 | $2,310.00 | $2,310.00 | $3,427.20 | $3,808.00 | $3,808.00 | $2,772.00 | $2,818.20 | $3,272.50 | $3,465.00 | $2,644.95 | $2,310.00 | $3,808.00 | |
31643239 | EGD W BIOPSY | Gastrointestinal | 750 | 43239 | $2,610.00 | $1,566.00 | $1,566.00 | $2,347.88 | $2,608.76 | $2,608.76 | $1,879.20 | $1,910.52 | $2,218.50 | $2,349.00 | $1,793.07 | $1,566.00 | $2,608.76 | |
31643235 | EGD WITH OR WITHOUT SPECIMENS | Gastrointestinal | 750 | 43235 | $2,610.00 | $1,566.00 | $1,566.00 | $2,347.88 | $2,608.76 | $2,608.76 | $1,879.20 | $1,910.52 | $2,218.50 | $2,349.00 | $1,793.07 | $1,566.00 | $2,608.76 | |
GRP1400 | GRP PSYCH PROCESS INT W/OTHER | Group therapy | 915 | 90853 | $164.00 | $98.40 | $98.40 | $38.85 | $39.10 | $39.10 | $118.08 | $120.05 | $139.40 | $147.60 | $112.67 | $38.85 | $147.60 | |
GRP1000 | GRP PSYCH THERAPY PROCESS INIT | Group therapy | 915 | 90853 | $164.00 | $98.40 | $98.40 | $38.85 | $39.10 | $39.10 | $118.08 | $120.05 | $139.40 | $147.60 | $112.67 | $38.85 | $147.60 | |
GRP1200 | GRP PSYCH THRPY PRCSS SUBS HR | Group therapy | 915 | 90853 | $164.00 | $98.40 | $98.40 | $38.85 | $39.10 | $39.10 | $118.08 | $120.05 | $139.40 | $147.60 | $112.67 | $38.85 | $147.60 | |
90804 | INDIV PSYCHTHERAPY 16-37 MINS | Individual therapy | 914 | 90832 | $109.00 | $65.40 | $65.40 | $97.68 | $98.31 | $98.31 | $78.48 | $79.79 | $92.65 | $98.10 | $74.88 | $65.40 | $98.31 | |
90806 | INDIV PSYCHTHERAPY 38-52 MIN | Individual therapy | 914 | 90834 | $218.00 | $130.80 | $130.80 | $130.43 | $131.27 | $131.27 | $156.96 | $159.58 | $185.30 | $196.20 | $149.77 | $130.43 | $196.20 | |
86900 | ABO | Laboratory | 390 | 86900 | $230.00 | $138.00 | $138.00 | $205.30 | $228.24 | $228.24 | $165.60 | $168.36 | $195.50 | $207.00 | $158.01 | $138.00 | $228.24 | |
82009 | ACETONE | Laboratory | 301 | 82009 | $42.00 | $25.20 | $25.20 | $21.84 | $24.28 | $24.28 | $30.24 | $30.74 | $35.70 | $37.80 | $28.85 | $21.84 | $37.80 | |
3060001 | AEROBIC ISOLATE 1 | Laboratory | 306 | 87077 | $50.00 | $30.00 | $30.00 | $40.37 | $44.88 | $44.88 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $45.00 | |
82040 | ALBUMIN | Laboratory | 301 | 82040 | $31.00 | $18.60 | $18.60 | $24.74 | $27.50 | $27.50 | $22.32 | $22.69 | $26.35 | $27.90 | $21.30 | $18.60 | $27.90 | |
335231 | ALKALINE PHOSPHAT, ISOENZYMES | Laboratory | 301 | 84080 | $76.00 | $45.60 | $45.60 | $43.71 | $48.59 | $48.59 | $54.72 | $55.63 | $64.60 | $68.40 | $52.21 | $43.71 | $68.40 | |
84460 | ALT | Laboratory | 301 | 84460 | $31.00 | $18.60 | $18.60 | $26.50 | $29.46 | $29.46 | $22.32 | $22.69 | $26.35 | $27.90 | $21.30 | $18.60 | $29.46 | |
82140 | AMMONIA | Laboratory | 301 | 82140 | $140.00 | $84.00 | $84.00 | $72.85 | $80.99 | $80.99 | $100.80 | $102.48 | $119.00 | $126.00 | $96.18 | $72.85 | $126.00 | |
82150 | AMYLASE (SERUM/URINE) | Laboratory | 301 | 82150 | $80.00 | $48.00 | $48.00 | $32.41 | $36.03 | $36.03 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $32.41 | $72.00 | |
335249 | ANA | Laboratory | 302 | 86038 | $111.00 | $66.60 | $66.60 | $60.44 | $67.20 | $67.20 | $79.92 | $81.25 | $94.35 | $99.90 | $76.26 | $60.44 | $99.90 | |
3358472 | ANTI HCV HEP C ANTIBODY | Laboratory | 302 | 86803 | $80.00 | $48.00 | $48.00 | $71.34 | $79.32 | $79.32 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $79.32 | |
3355081 | ANTI TPO | Laboratory | 302 | 86376 | $90.00 | $54.00 | $54.00 | $72.74 | $80.87 | $80.87 | $64.80 | $65.88 | $76.50 | $81.00 | $61.83 | $54.00 | $81.00 | |
86850 | ANTIBODY SCREEN | Laboratory | 302 | 86850 | $195.00 | $117.00 | $117.00 | $175.24 | $194.82 | $194.82 | $140.40 | $142.74 | $165.75 | $175.50 | $133.97 | $117.00 | $194.82 | |
85730 | APTT | Laboratory | 305 | 85730 | $88.00 | $52.80 | $52.80 | $30.02 | $33.37 | $33.37 | $63.36 | $64.42 | $74.80 | $79.20 | $60.46 | $30.02 | $79.20 | |
82803 | ARTERIAL BLOOD GAS | Laboratory | 301 | 82803 | $259.00 | $155.40 | $155.40 | $96.74 | $107.55 | $107.55 | $186.48 | $189.59 | $220.15 | $233.10 | $177.93 | $96.74 | $233.10 | |
84450 | AST | Laboratory | 301 | 84450 | $30.00 | $18.00 | $18.00 | $25.87 | $28.76 | $28.76 | $21.60 | $21.96 | $25.50 | $27.00 | $20.61 | $18.00 | $28.76 | |
80048 | BASIC METABOLIC PANEL-CHEM 8 | Laboratory | 301 | 80048 | $175.00 | $105.00 | $105.00 | $42.28 | $47.00 | $47.00 | $126.00 | $128.10 | $148.75 | $157.50 | $120.23 | $42.28 | $157.50 | |
82247 | BILIRUBIN TOTAL | Laboratory | 301 | 82247 | $30.00 | $18.00 | $18.00 | $25.07 | $27.87 | $27.87 | $21.60 | $21.96 | $25.50 | $27.00 | $20.61 | $18.00 | $27.87 | |
GLM200 | BLOOD REAGENT STRIP | Laboratory | 300 | 82948 | $20.00 | $12.00 | $12.00 | $15.85 | $17.63 | $17.63 | $14.40 | $14.64 | $17.00 | $18.00 | $13.74 | $12.00 | $18.00 | |
83880 | B-TYPE NATRIUETIC PEPTIDE | Laboratory | 301 | 83880 | $275.00 | $116.40 | $116.40 | $169.70 | $188.66 | $188.66 | $139.68 | $142.01 | $164.90 | $174.60 | $133.28 | $116.40 | $188.66 | |
3358756 | C DIFF TOXIN A | Laboratory | 306 | 87324 | $166.00 | $99.60 | $99.60 | $59.93 | $66.63 | $66.63 | $119.52 | $121.51 | $141.10 | $149.40 | $114.04 | $59.93 | $149.40 | |
335372 | C PEPTIDE | Laboratory | 301 | 80432 | $760.00 | $456.00 | $456.00 | $675.39 | $750.84 | $750.84 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $750.84 | |
33529256 | CA 125 | Laboratory | 302 | 86316 | $132.00 | $79.20 | $79.20 | $104.04 | $115.67 | $115.67 | $95.04 | $96.62 | $112.20 | $118.80 | $90.68 | $79.20 | $118.80 | |
33529493 | CA 2729 | Laboratory | 300 | 86300 | $252.00 | $151.20 | $151.20 | $104.04 | $115.67 | $115.67 | $181.44 | $184.46 | $214.20 | $226.80 | $173.12 | $104.04 | $226.80 | |
82310 | CALCIUM | Laboratory | 301 | 82310 | $31.00 | $18.60 | $18.60 | $25.80 | $28.68 | $28.68 | $22.32 | $22.69 | $26.35 | $27.90 | $21.30 | $18.60 | $28.68 | |
33582340 | CALCIUM, 24 HR URINE | Laboratory | 301 | 82340 | $40.00 | $24.00 | $24.00 | $30.13 | $33.50 | $33.50 | $28.80 | $29.28 | $34.00 | $36.00 | $27.48 | $24.00 | $36.00 | |
82330 | CALCIUM, IONIZED | Laboratory | 301 | 82330 | $80.00 | $48.00 | $48.00 | $68.37 | $76.01 | $76.01 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $76.01 | |
85025 | CBC COMPLETE AUTO W AUTO DIFF# | Laboratory | 305 | 85025 | $71.00 | $42.60 | $42.60 | $38.87 | $43.21 | $43.21 | $51.12 | $51.97 | $60.35 | $63.90 | $48.78 | $38.87 | $63.90 | |
335978 | CEA | Laboratory | 301 | 82378 | $108.00 | $64.80 | $64.80 | $94.83 | $105.43 | $105.43 | $77.76 | $79.06 | $91.80 | $97.20 | $74.20 | $64.80 | $105.43 | |
3356919 | CHLAMYDIA AND GC GEN PROBE | Laboratory | 300 | 87491 | $200.00 | $120.00 | $120.00 | $175.43 | $195.02 | $195.02 | $144.00 | $146.40 | $170.00 | $180.00 | $137.40 | $120.00 | $195.02 | |
82553 | CKMB | Laboratory | 301 | 82553 | $181.00 | $108.60 | $108.60 | $30.79 | $34.23 | $34.23 | $130.32 | $132.49 | $153.85 | $162.90 | $124.35 | $30.79 | $162.90 | |
87077 | CLO TEST RAPID UREASE TEST | Laboratory | 301 | 87077 | $50.00 | $30.00 | $30.00 | $40.37 | $44.88 | $44.88 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $45.00 | |
80053 | COMPREHENSIVE METABOLIC PANEL | Laboratory | 301 | 80053 | $220.00 | $132.00 | $132.00 | $52.81 | $58.71 | $58.71 | $158.40 | $161.04 | $187.00 | $198.00 | $151.14 | $52.81 | $198.00 | |
3354212 | CORTISOL AM | Laboratory | 301 | 82533 | $100.00 | $60.00 | $60.00 | $81.51 | $90.62 | $90.62 | $72.00 | $73.20 | $85.00 | $90.00 | $68.70 | $60.00 | $90.62 | |
3350002 | COVID-19 REFERENCE LAB | Laboratory | 300 | 87635 | $250.00 | $132.00 | $132.00 | $188.38 | $209.43 | $209.43 | $158.40 | $161.04 | $187.00 | $198.00 | $151.14 | $132.00 | $209.43 | |
33586769 | COVID-19 Antibody test | Laboratory | 300 | 86769 | $130.00 | $78.00 | $78.00 | $47.27 | $52.55 | $52.55 | $93.60 | $95.16 | $110.50 | $117.00 | $89.31 | $47.27 | $117.00 | |
82550 | CPK | Laboratory | 301 | 82550 | $100.00 | $60.00 | $60.00 | $32.55 | $36.19 | $36.19 | $72.00 | $73.20 | $85.00 | $90.00 | $68.70 | $32.55 | $90.00 | |
86140 | C-REACTIVE PROTEIN | Laboratory | 302 | 86140 | $191.00 | $114.60 | $114.60 | $25.87 | $28.76 | $28.76 | $137.52 | $139.81 | $162.35 | $171.90 | $131.22 | $25.87 | $171.90 | |
3358459 | CREATANINE URINE RANDOM | Laboratory | 301 | 82570 | $36.00 | $21.60 | $21.60 | $25.87 | $28.76 | $28.76 | $25.92 | $26.35 | $30.60 | $32.40 | $24.73 | $21.60 | $32.40 | |
82565 | CREATININE | Laboratory | 301 | 82565 | $60.00 | $36.00 | $36.00 | $25.62 | $28.48 | $28.48 | $43.20 | $43.92 | $51.00 | $54.00 | $41.22 | $25.62 | $54.00 | |
3357943 | CREATININE CLEARANCE | Laboratory | 301 | 82575 | $131.00 | $78.60 | $78.60 | $47.27 | $52.55 | $52.55 | $94.32 | $95.89 | $111.35 | $117.90 | $90.00 | $47.27 | $117.90 | |
33521618 | CREATININE URINE RANDOM | Laboratory | 301 | 82570 | $36.00 | $21.60 | $21.60 | $25.87 | $28.76 | $28.76 | $25.92 | $26.35 | $30.60 | $32.40 | $24.73 | $21.60 | $32.40 | |
86904A | CROSSMATCH EA UNIT | Laboratory | 302 | 86904 | $125.00 | $75.00 | $75.00 | $111.97 | $124.48 | $124.48 | $90.00 | $91.50 | $106.25 | $112.50 | $85.88 | $75.00 | $124.48 | |
86141 | CRP High Sensitivity | Laboratory | 300 | 86141 | $80.00 | $48.00 | $48.00 | $64.70 | $71.93 | $71.93 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $72.00 | |
3354556 | CULTURE SPUTUM | Laboratory | 300 | 87070 | $80.00 | $30.00 | $30.00 | $43.09 | $47.90 | $47.90 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $47.90 | |
33510019 | CULTURE STOOL SALM/SHIG | Laboratory | 306 | 87045 | $62.00 | $37.20 | $37.20 | $47.20 | $52.47 | $52.47 | $44.64 | $45.38 | $52.70 | $55.80 | $42.59 | $37.20 | $55.80 | |
335394 | CULTURE THROAT | Laboratory | 306 | 87070 | $80.00 | $30.00 | $30.00 | $43.09 | $47.90 | $47.90 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $47.90 | |
87088 | CULTURE URINE W/ISOLATION | Laboratory | 306 | 87088 | $74.00 | $44.40 | $44.40 | $40.48 | $45.00 | $45.00 | $53.28 | $54.17 | $62.90 | $66.60 | $50.84 | $40.48 | $66.60 | |
3354550 | CULTURE, AEROBIC | Laboratory | 306 | 87070 | $80.00 | $30.00 | $30.00 | $43.09 | $47.90 | $47.90 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $47.90 | |
87070 | CULTURE, BACT ANY SOUCE | Laboratory | 306 | 87070 | $80.00 | $30.00 | $48.00 | $43.09 | $47.90 | $47.90 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $43.09 | $72.00 | |
335389 | CULTURE, BLOOD | Laboratory | 306 | 87040 | $60.00 | $36.00 | $36.00 | $51.64 | $57.41 | $57.41 | $43.20 | $43.92 | $51.00 | $54.00 | $41.22 | $36.00 | $57.41 | |
3354473 | CULTURE, BODY FLUID | Laboratory | 306 | 87070 | $80.00 | $30.00 | $30.00 | $43.09 | $47.90 | $47.90 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $47.90 | |
335349 | CULTURE, THROAT | Laboratory | 306 | 87081 | $40.00 | $24.00 | $24.00 | $33.14 | $36.84 | $36.84 | $28.80 | $29.28 | $34.00 | $36.00 | $27.48 | $24.00 | $36.84 | |
87086 | CULTURE, URINE | Laboratory | 306 | 87086 | $136.00 | $81.60 | $81.60 | $40.37 | $44.88 | $44.88 | $97.92 | $99.55 | $115.60 | $122.40 | $93.43 | $40.37 | $122.40 | |
335395 | CULTURE, URINE | Laboratory | 306 | 87088 | $74.00 | $44.40 | $44.40 | $40.48 | $45.00 | $45.00 | $53.28 | $54.17 | $62.90 | $66.60 | $50.84 | $40.48 | $66.60 | |
9621A | CULTURE, WOUND | Laboratory | 306 | 87070 | $80.00 | $30.00 | $48.00 | $43.09 | $47.90 | $47.90 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $43.09 | $72.00 | |
3353471 | CYTOLOGY, FLUID | Laboratory | 311 | 88104 | $125.00 | $75.00 | $75.00 | $111.97 | $124.48 | $124.48 | $90.00 | $91.50 | $106.25 | $112.50 | $85.88 | $75.00 | $124.48 | |
85379 | D-DIMER | Laboratory | 305 | 85379 | $173.00 | $103.80 | $103.80 | $46.54 | $51.73 | $51.73 | $124.56 | $126.64 | $147.05 | $155.70 | $118.85 | $46.54 | $155.70 | |
335402 | DHEA SULFATE | Laboratory | 301 | 82627 | $125.00 | $75.00 | $75.00 | $111.16 | $123.58 | $123.58 | $90.00 | $91.50 | $106.25 | $112.50 | $85.88 | $75.00 | $123.58 | |
85007 | DIFFERENTIAL (MANUAL) | Laboratory | 305 | 85007 | $32.00 | $19.20 | $19.20 | $17.18 | $19.09 | $19.09 | $23.04 | $23.42 | $27.20 | $28.80 | $21.98 | $17.18 | $28.80 | |
80162 | DIGOXIN | Laboratory | 301 | 80162 | $150.00 | $90.00 | $90.00 | $66.39 | $73.81 | $73.81 | $108.00 | $109.80 | $127.50 | $135.00 | $103.05 | $66.39 | $135.00 | |
80185 | DILANTIN | Laboratory | 301 | 80185 | $181.00 | $108.60 | $108.60 | $66.28 | $73.68 | $73.68 | $130.32 | $132.49 | $153.85 | $162.90 | $124.35 | $66.28 | $162.90 | |
335429 | ESTRADIOL | Laboratory | 301 | 82670 | $160.00 | $96.00 | $96.00 | $139.68 | $155.28 | $155.28 | $115.20 | $117.12 | $136.00 | $144.00 | $109.92 | $96.00 | $155.28 | |
335439 | ESTROGEN | Laboratory | 301 | 82672 | $81.00 | $48.60 | $48.60 | $43.71 | $48.59 | $48.59 | $58.32 | $59.29 | $68.85 | $72.90 | $55.65 | $43.71 | $72.90 | |
335457 | FERRITIN LEVEL | Laboratory | 301 | 82728 | $125.00 | $75.00 | $75.00 | $68.15 | $75.77 | $75.77 | $90.00 | $91.50 | $106.25 | $112.50 | $85.88 | $68.15 | $112.50 | |
335466 | FOLATE, SERUM | Laboratory | 301 | 82746 | $85.00 | $51.00 | $51.00 | $73.51 | $81.72 | $81.72 | $61.20 | $62.22 | $72.25 | $76.50 | $58.40 | $51.00 | $81.72 | |
335467 | FOLIC ACID | Laboratory | 301 | 82746 | $85.00 | $51.00 | $51.00 | $73.51 | $81.72 | $81.72 | $61.20 | $62.22 | $72.25 | $76.50 | $58.40 | $51.00 | $81.72 | |
84439 | FREE T4 | Laboratory | 301 | 84439 | $93.00 | $55.80 | $55.80 | $45.07 | $50.10 | $50.10 | $66.96 | $68.08 | $79.05 | $83.70 | $63.89 | $45.07 | $83.70 | |
335470 | FSH | Laboratory | 301 | 83001 | $105.00 | $63.00 | $63.00 | $92.89 | $103.26 | $103.26 | $75.60 | $76.86 | $89.25 | $94.50 | $72.14 | $63.00 | $103.26 | |
33534429 | FT3 | Laboratory | 301 | 84481 | $400.00 | $240.00 | $240.00 | $84.67 | $94.13 | $94.13 | $288.00 | $292.80 | $340.00 | $360.00 | $274.80 | $84.67 | $360.00 | |
A33515980 | GAMMAGLOBULIN IGA IGD IGM EA | Laboratory | 300 | 82784 | $138.00 | $82.80 | $82.80 | $46.50 | $51.69 | $51.69 | $99.36 | $101.02 | $117.30 | $124.20 | $94.81 | $46.50 | $124.20 | |
30080050 | General Health Panel (CBC,TSH,CMP) | Laboratory | 300 | 80050 | $300.00 | $180.00 | $180.00 | $128.78 | $143.17 | $143.17 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $128.78 | $270.00 | |
80170 | GENTAMICIN LEVEL, PLASMA | Laboratory | 309 | 80170 | $184.00 | $110.40 | $110.40 | $81.91 | $91.07 | $91.07 | $132.48 | $134.69 | $156.40 | $165.60 | $126.41 | $81.91 | $165.60 | |
335482 | GGT | Laboratory | 301 | 82977 | $45.00 | $27.00 | $27.00 | $36.00 | $40.02 | $40.02 | $32.40 | $32.94 | $38.25 | $40.50 | $30.92 | $27.00 | $40.50 | |
G82952 | GLUCOSE EACH ADDITIONAL SPEC | Laboratory | 300 | 82952 | $106.00 | $63.60 | $63.60 | $19.60 | $21.79 | $21.79 | $76.32 | $77.59 | $90.10 | $95.40 | $72.82 | $19.60 | $95.40 | |
G82951 | GLUCOSE TOLERANCE 3 SPECIMENS | Laboratory | 300 | 82951 | $106.00 | $63.60 | $63.60 | $64.34 | $71.52 | $71.52 | $76.32 | $77.59 | $90.10 | $95.40 | $72.82 | $63.60 | $95.40 | |
86677 | H. PYLORI ANTIBODY | Laboratory | 302 | 86677 | $50.00 | $30.00 | $30.00 | $40.88 | $45.45 | $45.45 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $45.45 | |
33534838 | H. PYLORI ANTIGEN, STOOL | Laboratory | 306 | 87338 | $94.00 | $56.40 | $56.40 | $71.90 | $79.93 | $79.93 | $67.68 | $68.81 | $79.90 | $84.60 | $64.58 | $56.40 | $84.60 | |
335499 | HBSAB | Laboratory | 302 | 86706 | $116.00 | $69.60 | $69.60 | $53.69 | $59.69 | $59.69 | $83.52 | $84.91 | $98.60 | $104.40 | $79.69 | $53.69 | $104.40 | |
335498 | HBSAG | Laboratory | 306 | 87340 | $116.00 | $69.60 | $69.60 | $51.64 | $57.41 | $57.41 | $83.52 | $84.91 | $98.60 | $104.40 | $79.69 | $51.64 | $104.40 | |
3358396 | HCG, QUANT | Laboratory | 300 | 84702 | $50.00 | $30.00 | $30.00 | $43.67 | $48.55 | $48.55 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $48.55 | |
85014 | HEMATOCRIT# | Laboratory | 300 | 85014 | $44.00 | $26.40 | $26.40 | $11.85 | $13.18 | $13.18 | $31.68 | $32.21 | $37.40 | $39.60 | $30.23 | $11.85 | $39.60 | |
85018 | HEMOGLOBIN# | Laboratory | 300 | 85018 | $37.00 | $22.20 | $22.20 | $11.85 | $13.18 | $13.18 | $26.64 | $27.08 | $31.45 | $33.30 | $25.42 | $11.85 | $33.30 | |
80076 | HEPATIC FUNCTION PANEL | Laboratory | 301 | 80076 | $200.00 | $120.00 | $120.00 | $40.85 | $45.41 | $45.41 | $144.00 | $146.40 | $170.00 | $180.00 | $137.40 | $40.85 | $180.00 | |
33510306 | HEPATITIS PANEL, ACUTE | Laboratory | 301 | 80074 | $270.00 | $162.00 | $162.00 | $238.15 | $264.75 | $264.75 | $194.40 | $197.64 | $229.50 | $243.00 | $185.49 | $162.00 | $264.75 | |
3358181 | HGB A1C | Laboratory | 301 | 83036 | $72.00 | $43.20 | $43.20 | $48.52 | $53.94 | $53.94 | $51.84 | $52.70 | $61.20 | $64.80 | $49.46 | $43.20 | $64.80 | |
309001 | HGB AIC | Laboratory | 301 | 83036 | $72.00 | $43.20 | $43.20 | $48.52 | $53.94 | $53.94 | $51.84 | $52.70 | $61.20 | $64.80 | $49.46 | $43.20 | $64.80 | |
33519728 | HIV 1 & 2 WITH REFLEX | Laboratory | 335 | 86703 | $80.00 | $48.00 | $48.00 | $68.52 | $76.17 | $76.17 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $76.17 | |
G0432 | HIV SCREENING | Laboratory | 300 | 86703 | $80.00 | $48.00 | $48.00 | $68.52 | $76.17 | $76.17 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $76.17 | |
3350001 | Hu Antibody screen w/ reflex | Laboratory | 300 | 86255 | $122.00 | $73.20 | $73.20 | $60.22 | $66.95 | $66.95 | $87.84 | $89.30 | $103.70 | $109.80 | $83.81 | $60.22 | $109.80 | |
3357083 | IMMUNOGLOBULINS | Laboratory | 301 | 82784 | $138.00 | $82.80 | $82.80 | $46.50 | $51.69 | $51.69 | $99.36 | $101.02 | $117.30 | $124.20 | $94.81 | $46.50 | $124.20 | |
B33515980 | INFECT AGENT ANTIGEN | Laboratory | 300 | 83516 | $69.00 | $41.40 | $41.40 | $57.66 | $64.10 | $64.10 | $49.68 | $50.51 | $58.65 | $62.10 | $47.40 | $41.40 | $64.10 | |
187804A | INFLUENZA | Laboratory | 306 | 87804 | $67.00 | $40.20 | $40.20 | $59.93 | $66.63 | $66.63 | $48.24 | $49.04 | $56.95 | $60.30 | $46.03 | $40.20 | $66.63 | |
86710 | INFLUENZA A&B | Laboratory | 302 | 86710 | $127.00 | $76.20 | $76.20 | $67.75 | $75.32 | $75.32 | $91.44 | $92.96 | $107.95 | $114.30 | $87.25 | $67.75 | $114.30 | |
3357573 | IRON AND TIBC | Laboratory | 300 | 83540 | $130.00 | $78.00 | $78.00 | $32.37 | $35.99 | $35.99 | $93.60 | $95.16 | $110.50 | $117.00 | $89.31 | $32.37 | $117.00 | |
335571 | IRON, TOTAL | Laboratory | 301 | 83540 | $130.00 | $78.00 | $78.00 | $32.37 | $35.99 | $35.99 | $93.60 | $95.16 | $110.50 | $117.00 | $89.31 | $32.37 | $117.00 | |
87220 | KOH PREP | Laboratory | 306 | 87205 | $38.00 | $22.80 | $22.80 | $21.36 | $23.75 | $23.75 | $27.36 | $27.82 | $32.30 | $34.20 | $26.11 | $21.36 | $34.20 | |
83605 | LACTIC ACID | Laboratory | 300 | 83605 | $60.00 | $36.00 | $36.00 | $53.40 | $59.36 | $59.36 | $43.20 | $43.92 | $51.00 | $54.00 | $41.22 | $36.00 | $59.36 | |
335593 | LDH | Laboratory | 300 | 83615 | $35.00 | $21.00 | $21.00 | $30.17 | $33.54 | $33.54 | $25.20 | $25.62 | $29.75 | $31.50 | $24.05 | $21.00 | $33.54 | |
83721 | LDL, DIRECT | Laboratory | 301 | 83721 | $60.00 | $36.00 | $36.00 | $47.71 | $53.04 | $53.04 | $43.20 | $43.92 | $51.00 | $54.00 | $41.22 | $36.00 | $54.00 | |
335599 | LEAD LEVEL | Laboratory | 301 | 83655 | $238.00 | $142.80 | $142.80 | $60.52 | $67.28 | $67.28 | $171.36 | $174.22 | $202.30 | $214.20 | $163.51 | $60.52 | $214.20 | |
335615 | LH | Laboratory | 301 | 83002 | $206.00 | $123.60 | $123.60 | $92.56 | $102.90 | $102.90 | $148.32 | $150.79 | $175.10 | $185.40 | $141.52 | $92.56 | $185.40 | |
83690 | LIPASE, SERUM | Laboratory | 300 | 83690 | $46.00 | $27.60 | $27.60 | $34.42 | $38.27 | $38.27 | $33.12 | $33.67 | $39.10 | $41.40 | $31.60 | $27.60 | $41.40 | |
80061 | LIPID PANEL | Laboratory | 301 | 80061 | $120.00 | $72.00 | $72.00 | $66.94 | $74.42 | $74.42 | $86.40 | $87.84 | $102.00 | $108.00 | $82.44 | $66.94 | $108.00 | |
335613 | LITHIUM LEVEL | Laboratory | 301 | 80178 | $40.00 | $24.00 | $24.00 | $33.07 | $36.76 | $36.76 | $28.80 | $29.28 | $34.00 | $36.00 | $27.48 | $24.00 | $36.76 | |
83735 | MAGNESIUM | Laboratory | 301 | 83735 | $40.00 | $24.00 | $24.00 | $33.47 | $37.21 | $37.21 | $28.80 | $29.28 | $34.00 | $36.00 | $27.48 | $24.00 | $37.21 | |
335964 | MEASLES (RUBEOLA) | Laboratory | 300 | 86765 | $90.00 | $54.00 | $54.00 | $64.41 | $71.60 | $71.60 | $64.80 | $65.88 | $76.50 | $81.00 | $61.83 | $54.00 | $81.00 | |
82044 | MICROALBUMIN | Laboratory | 301 | 82044 | $48.00 | $28.80 | $28.80 | $22.86 | $25.42 | $25.42 | $34.56 | $35.14 | $40.80 | $43.20 | $32.98 | $22.86 | $43.20 | |
86308 | MONOSPOT | Laboratory | 302 | 86308 | $104.00 | $62.40 | $62.40 | $25.87 | $28.76 | $28.76 | $74.88 | $76.13 | $88.40 | $93.60 | $71.45 | $25.87 | $93.60 | |
3358624 | MUMPS ANTIBODY | Laboratory | 300 | 86735 | $75.00 | $45.00 | $45.00 | $65.22 | $72.50 | $72.50 | $54.00 | $54.90 | $63.75 | $67.50 | $51.53 | $45.00 | $72.50 | |
33520210 | OBSTETRIC PANEL | Laboratory | 301 | 80055 | $272.00 | $163.20 | $163.20 | $238.99 | $265.69 | $265.69 | $195.84 | $199.10 | $231.20 | $244.80 | $186.86 | $163.20 | $265.69 | |
82270 | OCCULT BLOOD (STOOLX3) | Laboratory | 301 | 82270 | $46.00 | $27.60 | $27.60 | $16.26 | $18.07 | $18.07 | $33.12 | $33.67 | $39.10 | $41.40 | $31.60 | $16.26 | $41.40 | |
82272 | OCCULT BLOOD,FECAL,SINGLE COLL | Laboratory | 301 | 82272 | $26.00 | $15.60 | $15.60 | $16.26 | $18.07 | $18.07 | $18.72 | $19.03 | $22.10 | $23.40 | $17.86 | $15.60 | $23.40 | |
1UR | ORGANISM ID Aerobioc | Laboratory | 306 | 87077 | $50.00 | $30.00 | $30.00 | $40.37 | $44.88 | $44.88 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $45.00 | |
ORG ID 1 | ORGANISM ID Anaeriobic | Laboratory | 306 | 87076 | $50.00 | $30.00 | $30.00 | $40.37 | $44.88 | $44.88 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $45.00 | |
335681 | OVA AND PARASITE ONCE ONLY | Laboratory | 300 | 87177 | $80.00 | $48.00 | $48.00 | $43.71 | $48.59 | $48.59 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $43.71 | $72.00 | |
33588300 | Path Surgical Level 1 G&M | Laboratory | 300 | 88300 | $180.00 | $108.00 | $108.00 | $111.97 | $124.48 | $124.48 | $129.60 | $131.76 | $153.00 | $162.00 | $123.66 | $108.00 | $162.00 | |
84100 | PHOSPHOROUS | Laboratory | 301 | 84100 | $31.00 | $18.60 | $18.60 | $23.71 | $26.36 | $26.36 | $22.32 | $22.69 | $26.35 | $27.90 | $21.30 | $18.60 | $27.90 | |
84132 | POTASSIUM | Laboratory | 301 | 84132 | $70.00 | $42.00 | $42.00 | $22.97 | $25.54 | $25.54 | $50.40 | $51.24 | $59.50 | $63.00 | $48.09 | $22.97 | $63.00 | |
84703 | PREGNANCY TEST (SERUM) | Laboratory | 301 | 84703 | $93.00 | $55.80 | $55.80 | $37.58 | $41.78 | $41.78 | $66.96 | $68.08 | $79.05 | $83.70 | $63.89 | $37.58 | $83.70 | |
81025 | PREGNANCY/URINE | Laboratory | 307 | 81025 | $44.00 | $26.40 | $26.40 | $31.60 | $35.13 | $35.13 | $31.68 | $32.21 | $37.40 | $39.60 | $30.23 | $26.40 | $39.60 | |
335745 | PROGESTERONE LEVEL | Laboratory | 301 | 84144 | $120.00 | $72.00 | $72.00 | $104.30 | $115.95 | $115.95 | $86.40 | $87.84 | $102.00 | $108.00 | $82.44 | $72.00 | $115.95 | |
335746 | PROLACTIN LEVEL | Laboratory | 301 | 84146 | $110.00 | $66.00 | $66.00 | $96.89 | $107.71 | $107.71 | $79.20 | $80.52 | $93.50 | $99.00 | $75.57 | $66.00 | $107.71 | |
335747 | PROTEIN ELECTROPHORESIS | Laboratory | 301 | 84155 | $72.00 | $43.20 | $43.20 | $18.35 | $20.40 | $20.40 | $51.84 | $52.70 | $61.20 | $64.80 | $49.46 | $18.35 | $64.80 | |
185610 | PROTHROMBIN TIME FINGER | Laboratory | 301 | 85610 | $68.00 | $40.80 | $40.80 | $19.67 | $21.87 | $21.87 | $48.96 | $49.78 | $57.80 | $61.20 | $46.72 | $19.67 | $61.20 | |
85610 | PROTHROMBIN TIME/INR# | Laboratory | 300 | 85610 | $68.00 | $40.80 | $40.80 | $19.67 | $21.87 | $21.87 | $48.96 | $49.78 | $57.80 | $61.20 | $46.72 | $19.67 | $61.20 | |
G84154 | PSA FREE | Laboratory | 301 | 84154 | $110.00 | $66.00 | $66.00 | $91.97 | $102.24 | $102.24 | $79.20 | $80.52 | $93.50 | $99.00 | $75.57 | $66.00 | $102.24 | |
G84153 | PSA TOTAL | Laboratory | 301 | 84153 | $150.00 | $90.00 | $90.00 | $91.97 | $102.24 | $102.24 | $108.00 | $109.80 | $127.50 | $135.00 | $103.05 | $90.00 | $135.00 | |
84153 | PSA# | Laboratory | 301 | 84153 | $150.00 | $90.00 | $90.00 | $91.97 | $102.24 | $102.24 | $108.00 | $109.80 | $127.50 | $135.00 | $103.05 | $90.00 | $135.00 | |
3358446 | PTH INTACT | Laboratory | 301 | 83970 | $230.00 | $138.00 | $138.00 | $206.36 | $229.42 | $229.42 | $165.60 | $168.36 | $195.50 | $207.00 | $158.01 | $138.00 | $229.42 | |
80069 | RENAL FUNCTION PANEL | Laboratory | 301 | 80069 | $150.00 | $90.00 | $90.00 | $43.42 | $48.27 | $48.27 | $108.00 | $109.80 | $127.50 | $135.00 | $103.05 | $43.42 | $135.00 | |
335793 | RETICULOCYTE COUNT | Laboratory | 300 | 85045 | $45.00 | $27.00 | $27.00 | $20.00 | $22.24 | $22.24 | $32.40 | $32.94 | $38.25 | $40.50 | $30.92 | $20.00 | $40.50 | |
86901 | RH TYPE | Laboratory | 302 | 86901 | $125.00 | $75.00 | $75.00 | $111.97 | $124.48 | $124.48 | $90.00 | $91.50 | $106.25 | $112.50 | $85.88 | $75.00 | $124.48 | |
3354418 | RHEUMATOID FACTOR | Laboratory | 302 | 86431 | $162.00 | $97.20 | $97.20 | $28.37 | $31.54 | $31.54 | $116.64 | $118.58 | $137.70 | $145.80 | $111.29 | $28.37 | $145.80 | |
3351761 | RPR | Laboratory | 302 | 86592 | $70.00 | $42.00 | $42.00 | $21.36 | $23.75 | $23.75 | $50.40 | $51.24 | $59.50 | $63.00 | $48.09 | $21.36 | $63.00 | |
87420 | RSV ANTIGEN EIA | Laboratory | 306 | 87420 | $170.00 | $102.00 | $102.00 | $59.93 | $66.63 | $66.63 | $122.40 | $124.44 | $144.50 | $153.00 | $116.79 | $59.93 | $153.00 | |
335802 | RUBELLA IGG AB | Laboratory | 302 | 86762 | $85.00 | $51.00 | $51.00 | $71.97 | $80.01 | $80.01 | $61.20 | $62.22 | $72.25 | $76.50 | $58.40 | $51.00 | $80.01 | |
85651 | SEDIMENTATION RATE (ESR) | Laboratory | 305 | 85651 | $52.00 | $31.20 | $31.20 | $17.73 | $19.71 | $19.71 | $37.44 | $38.06 | $44.20 | $46.80 | $35.72 | $17.73 | $46.80 | |
86588 | STREP A | Laboratory | 306 | 87430 | $70.00 | $42.00 | $42.00 | $59.93 | $66.63 | $66.63 | $50.40 | $51.24 | $59.50 | $63.00 | $48.09 | $42.00 | $66.63 | |
87430 | STREPTOCOCCUS GRP A RAPID ANTI | Laboratory | 306 | 87430 | $70.00 | $42.00 | $42.00 | $59.93 | $66.63 | $66.63 | $50.40 | $51.24 | $59.50 | $63.00 | $48.09 | $42.00 | $66.63 | |
87186 | SUSCEPTIBILITY 1 | Laboratory | 306 | 87186 | $138.00 | $82.80 | $82.80 | $43.23 | $48.06 | $48.06 | $99.36 | $101.02 | $117.30 | $124.20 | $94.81 | $43.23 | $124.20 | |
87187 | SUSCEPTIBILITY 2 | Laboratory | 306 | 87187 | $136.00 | $81.60 | $81.60 | $51.82 | $57.61 | $57.61 | $97.92 | $99.55 | $115.60 | $122.40 | $93.43 | $51.82 | $122.40 | |
3351715 | T PROTEIN W/CREAT, RANDOM URNE | Laboratory | 301 | 84155 | $72.00 | $43.20 | $43.20 | $18.35 | $20.40 | $20.40 | $51.84 | $52.70 | $61.20 | $64.80 | $49.46 | $18.35 | $64.80 | |
335859 | T3, TOTAL | Laboratory | 301 | 84480 | $80.00 | $48.00 | $48.00 | $70.87 | $78.78 | $78.78 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $78.78 | |
335867 | T4, TOTAL | Laboratory | 301 | 84436 | $40.00 | $24.00 | $24.00 | $34.31 | $38.15 | $38.15 | $28.80 | $29.28 | $34.00 | $36.00 | $27.48 | $24.00 | $38.15 | |
33534482 | TACRILIMUS FK506 LEVEL | Laboratory | 301 | 80197 | $215.00 | $129.00 | $129.00 | $68.67 | $76.34 | $76.34 | $154.80 | $157.38 | $182.75 | $193.50 | $147.71 | $68.67 | $193.50 | |
G84402 | TESTOSTERONE FREE | Laboratory | 301 | 84402 | $145.00 | $87.00 | $87.00 | $127.31 | $141.54 | $141.54 | $104.40 | $106.14 | $123.25 | $130.50 | $99.62 | $87.00 | $141.54 | |
33536170 | TESTOSTERONE FREE & TOTAL | Laboratory | 301 | 84403 | $145.00 | $87.00 | $87.00 | $129.07 | $143.49 | $143.49 | $104.40 | $106.14 | $123.25 | $130.50 | $99.62 | $87.00 | $143.49 | |
G84403 | TESTOSTERONE TOTAL | Laboratory | 301 | 84403 | $145.00 | $87.00 | $87.00 | $129.07 | $143.49 | $143.49 | $104.40 | $106.14 | $123.25 | $130.50 | $99.62 | $87.00 | $143.49 | |
335873 | TESTOSTERONE, TOTAL | Laboratory | 301 | 84403 | $145.00 | $87.00 | $87.00 | $129.07 | $143.49 | $143.49 | $104.40 | $106.14 | $123.25 | $130.50 | $99.62 | $87.00 | $143.49 | |
80198 | THEOPHYLLINE | Laboratory | 301 | 80198 | $94.00 | $56.40 | $56.40 | $70.72 | $78.62 | $78.62 | $67.68 | $68.81 | $79.90 | $84.60 | $64.58 | $56.40 | $84.60 | |
33584425 | Thiamine (Vitamin B1) | Laboratory | 300 | 84425 | $48.00 | $28.80 | $28.80 | $33.98 | $37.78 | $37.78 | $34.56 | $35.14 | $40.80 | $43.20 | $32.98 | $28.80 | $43.20 | |
335891 | TRANSFERRIN | Laboratory | 301 | 84466 | $54.00 | $32.40 | $32.40 | $46.02 | $51.16 | $51.16 | $38.88 | $39.53 | $45.90 | $48.60 | $37.10 | $32.40 | $51.16 | |
84478 | TRIGLYCERIDES# | Laboratory | 301 | 84478 | $66.00 | $39.60 | $39.60 | $28.74 | $31.95 | $31.95 | $47.52 | $48.31 | $56.10 | $59.40 | $45.34 | $28.74 | $59.40 | |
84484 | TROPONIN | Laboratory | 301 | 84484 | $334.00 | $200.40 | $200.40 | $49.18 | $54.67 | $54.67 | $240.48 | $244.49 | $283.90 | $300.60 | $229.46 | $49.18 | $300.60 | |
84443 | TSH# | Laboratory | 301 | 84443 | $165.00 | $99.00 | $99.00 | $84.01 | $93.39 | $93.39 | $118.80 | $120.78 | $140.25 | $148.50 | $113.36 | $84.01 | $148.50 | |
84520 | UREA NITROGEN (BUN) | Laboratory | 301 | 84520 | $71.00 | $42.60 | $42.60 | $19.74 | $21.95 | $21.95 | $51.12 | $51.97 | $60.35 | $63.90 | $48.78 | $19.74 | $63.90 | |
84550 | URIC ACID | Laboratory | 301 | 84550 | $31.00 | $18.60 | $18.60 | $22.61 | $25.13 | $25.13 | $22.32 | $22.69 | $26.35 | $27.90 | $21.30 | $18.60 | $27.90 | |
R81002 | URINALYSIS-RURAL HEALTH | Laboratory | 307 | 81003 | $38.00 | $22.80 | $22.80 | $11.23 | $12.48 | $12.48 | $27.36 | $27.82 | $32.30 | $34.20 | $26.11 | $11.23 | $34.20 | |
80100 | URINE DRUG SCREEN | Laboratory | 301 | 80305 | $75.00 | $45.00 | $45.00 | $41.98 | $46.68 | $46.68 | $54.00 | $54.90 | $63.75 | $67.50 | $51.53 | $41.98 | $67.50 | |
81001 | URINE/WITH MICROSCOPY | Laboratory | 307 | 81001 | $60.00 | $36.00 | $36.00 | $15.85 | $17.63 | $17.63 | $43.20 | $43.92 | $51.00 | $54.00 | $41.22 | $15.85 | $54.00 | |
81003 | URINE/WITHOUT MICROSCOPY | Laboratory | 307 | 81003 | $38.00 | $22.80 | $22.80 | $11.23 | $12.48 | $12.48 | $27.36 | $27.82 | $32.30 | $34.20 | $26.11 | $11.23 | $34.20 | |
3359167 | VALPROIC ACID LEVEL | Laboratory | 301 | 80164 | $80.00 | $48.00 | $48.00 | $67.75 | $75.32 | $75.32 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $75.32 | |
80202 | VANCOMYCIN LEVEL, PLASMA | Laboratory | 309 | 80202 | $80.00 | $48.00 | $48.00 | $67.75 | $75.32 | $75.32 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $75.32 | |
3358579 | VANCOMYCIN, TROUGH | Laboratory | 301 | 80202 | $80.00 | $48.00 | $48.00 | $67.75 | $75.32 | $75.32 | $57.60 | $58.56 | $68.00 | $72.00 | $54.96 | $48.00 | $75.32 | |
3354439 | VARICELLA ZOSTER IG G AB | Laboratory | 302 | 86787 | $50.00 | $30.00 | $30.00 | $40.88 | $45.45 | $45.45 | $36.00 | $36.60 | $42.50 | $45.00 | $34.35 | $30.00 | $45.45 | |
3354729 | VIT D,1,25-DIHYDROXY | Laboratory | 301 | 82652 | $220.00 | $132.00 | $132.00 | $192.45 | $213.96 | $213.96 | $158.40 | $161.04 | $187.00 | $198.00 | $151.14 | $132.00 | $213.96 | |
335927 | VITAMIN B12 CHEMISTRY | Laboratory | 301 | 82607 | $150.00 | $90.00 | $90.00 | $75.38 | $83.80 | $83.80 | $108.00 | $109.80 | $127.50 | $135.00 | $103.05 | $75.38 | $135.00 | |
33517306 | VITAMIN D 25 HYDROXY | Laboratory | 300 | 82306 | $155.00 | $93.00 | $93.00 | $135.86 | $151.04 | $151.04 | $111.60 | $113.46 | $131.75 | $139.50 | $106.49 | $93.00 | $151.04 | |
87210 | WET MOUNT | Laboratory | 306 | 87210 | $24.00 | $14.40 | $14.40 | $21.36 | $23.75 | $23.75 | $17.28 | $17.57 | $20.40 | $21.60 | $16.49 | $14.40 | $23.75 | |
33897116 | GAIT TRAINING | Physical Therapy | 420 | 97116 | $125.00 | $75.00 | $75.00 | $109.69 | $121.72 | $121.72 | $90.00 | $91.50 | $106.25 | $112.50 | $85.88 | $75.00 | $121.72 | |
33897140 | MANUAL THERAPY | Physical Therapy | 420 | 97140 | $130.00 | $78.00 | $78.00 | $115.21 | $127.84 | $127.84 | $93.60 | $95.16 | $110.50 | $117.00 | $89.31 | $78.00 | $127.84 | |
33897012 | MECHANICAL TRACTION | Physical Therapy | 420 | 97012 | $70.00 | $42.00 | $42.00 | $61.70 | $68.47 | $68.47 | $50.40 | $51.24 | $59.50 | $63.00 | $48.09 | $42.00 | $68.47 | |
33897001 | PHYSICAL THERAPY EVALUATION | Physical Therapy | 424 | 97161 | $350.00 | $210.00 | $210.00 | $312.22 | $346.46 | $346.46 | $252.00 | $256.20 | $297.50 | $315.00 | $240.45 | $210.00 | $346.46 | |
33897002 | PHYSICAL THERAPY RE-EVALUATION | Physical Therapy | 424 | 97164 | $250.00 | $150.00 | $150.00 | $212.26 | $235.54 | $235.54 | $180.00 | $183.00 | $212.50 | $225.00 | $171.75 | $150.00 | $235.54 | |
97161 | PT EVAL; LOW COMPLEXITY | Physical Therapy | 420 | 97161 | $350.00 | $210.00 | $210.00 | $312.22 | $346.46 | $346.46 | $252.00 | $256.20 | $297.50 | $315.00 | $240.45 | $210.00 | $346.46 | |
97162 | PT EVAL; MODERATE COMPLEXITY | Physical Therapy | 420 | 97162 | $350.00 | $210.00 | $210.00 | $312.22 | $346.46 | $346.46 | $252.00 | $256.20 | $297.50 | $315.00 | $240.45 | $210.00 | $346.46 | |
33897110 | THERAPEUTIC EXERCISE | Physical Therapy | 420 | 97110 | $140.00 | $84.00 | $84.00 | $124.78 | $138.47 | $138.47 | $100.80 | $102.48 | $119.00 | $126.00 | $96.18 | $84.00 | $138.47 | |
33897035 | ULTRASOUND | Physical Therapy | 420 | 97035 | $55.00 | $33.00 | $33.00 | $49.37 | $54.78 | $54.78 | $39.60 | $40.26 | $46.75 | $49.50 | $37.79 | $33.00 | $54.78 | |
33897016 | VASOPNEUMATIC DEVICE | Physical Therapy | 420 | 97016 | $90.00 | $54.00 | $54.00 | $74.03 | $82.15 | $82.15 | $64.80 | $65.88 | $76.50 | $81.00 | $61.83 | $54.00 | $82.15 | |
74160 | ABDOMEN W/CONTRAST CT | Radiology Diagnostic | 352 | 74160 | $1,806.00 | $1,083.60 | $1,083.60 | $1,044.55 | $1,160.61 | $1,160.61 | $1,300.32 | $1,321.99 | $1,535.10 | $1,625.40 | $1,240.72 | $1,044.55 | $1,625.40 | |
74150 | ABDOMEN W/O CONTRAST CT | Radiology Diagnostic | 352 | 74150 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
74000 | ABDOMEN-1 VIEW | Radiology Diagnostic | 320 | 74018 | $310.00 | $186.00 | $186.00 | $273.91 | $304.34 | $304.34 | $223.20 | $226.92 | $263.50 | $279.00 | $212.97 | $186.00 | $304.34 | |
74020 | ABDOMEN-2 VIEWS | Radiology Diagnostic | 320 | 74019 | $590.00 | $354.00 | $354.00 | $523.64 | $581.83 | $581.83 | $424.80 | $431.88 | $501.50 | $531.00 | $405.33 | $354.00 | $581.83 | |
74022 | ABDOMEN-ACUTE | Radiology Diagnostic | 320 | 74022 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
93925 | BILATERAL ARTERIAL SCAN LOWER | Radiology Diagnostic | 921 | 93925 | $817.00 | $490.20 | $490.20 | $585.53 | $649.74 | $649.74 | $588.24 | $598.04 | $694.45 | $735.30 | $561.28 | $490.20 | $735.30 | |
73522 | Bilateral Hips xray w/ pelvis 3-4 views | Radiology Diagnostic | 320 | 73522 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
93880 | CAROTID DOPPLER BILATERAL | Radiology Diagnostic | 921 | 93880 | $878.00 | $526.80 | $526.80 | $586.91 | $651.27 | $651.27 | $632.16 | $642.70 | $746.30 | $790.20 | $603.19 | $526.80 | $790.20 | |
71260 | CHEST W/CONTRAST CT# | Radiology Diagnostic | 352 | 71260 | $1,806.00 | $1,083.60 | $1,083.60 | $1,044.55 | $1,160.61 | $1,160.61 | $1,300.32 | $1,321.99 | $1,535.10 | $1,625.40 | $1,240.72 | $1,044.55 | $1,625.40 | |
71270 | CHEST W/O & W/CONTRAST CT# | Radiology Diagnostic | 352 | 71270 | $1,710.00 | $1,026.00 | $1,026.00 | $1,533.45 | $1,703.83 | $1,703.83 | $1,231.20 | $1,251.72 | $1,453.50 | $1,539.00 | $1,174.77 | $1,026.00 | $1,703.83 | |
71250 | CHEST W/O CONTRAST CT# | Radiology Diagnostic | 352 | 71250 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
71010 | CHEST-1 VIEW | Radiology Diagnostic | 324 | 71045 | $310.00 | $186.00 | $186.00 | $273.91 | $304.34 | $304.34 | $223.20 | $226.92 | $263.50 | $279.00 | $212.97 | $186.00 | $304.34 | |
71020 | CHEST-2 VIEWS | Radiology Diagnostic | 324 | 71046 | $310.00 | $186.00 | $186.00 | $273.91 | $304.34 | $304.34 | $223.20 | $226.92 | $263.50 | $279.00 | $212.97 | $186.00 | $304.34 | |
74177 | CT ABDOMEN/PELVIS W/CONTRAST | Radiology Diagnostic | 352 | 74177 | $2,297.00 | $1,378.20 | $1,378.20 | $1,533.45 | $1,703.83 | $1,703.83 | $1,653.84 | $1,681.40 | $1,952.45 | $2,067.30 | $1,578.04 | $1,378.20 | $2,067.30 | |
74176 | CT ABDOMEN/PELVIS W/O CONTRAST | Radiology Diagnostic | 352 | 74176 | $2,037.00 | $1,222.20 | $1,222.20 | $846.59 | $940.65 | $940.65 | $1,466.64 | $1,491.08 | $1,731.45 | $1,833.30 | $1,399.42 | $846.59 | $1,833.30 | |
74178 | CT ABDOMEN/PELVIS W/WO CONTRST | Radiology Diagnostic | 352 | 74178 | $3,303.00 | $1,981.80 | $1,981.80 | $1,533.45 | $1,703.83 | $1,703.83 | $2,378.16 | $2,417.80 | $2,807.55 | $2,972.70 | $2,269.16 | $1,533.45 | $2,972.70 | |
70487 | FACIAL AREA W/CONTRAST CT | Radiology Diagnostic | 351 | 70487 | $1,170.00 | $702.00 | $702.00 | $1,044.55 | $1,160.61 | $1,160.61 | $842.40 | $856.44 | $994.50 | $1,053.00 | $803.79 | $702.00 | $1,160.61 | |
70486 | FACIAL AREA W/O CONTRAST | Radiology Diagnostic | 351 | 70486 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
70470 | HEAD W/O & W/CONTRAST CT# | Radiology Diagnostic | 351 | 70470 | $1,507.00 | $904.20 | $904.20 | $1,044.55 | $1,160.61 | $1,160.61 | $1,085.04 | $1,103.12 | $1,280.95 | $1,356.30 | $1,035.31 | $904.20 | $1,356.30 | |
70450 | HEAD W/O CONTRAST CT# | Radiology Diagnostic | 351 | 70450 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
76830 | IVT/TRANSVAGINAL PROBE | Radiology Diagnostic | 402 | 76830 | $440.00 | $264.00 | $264.00 | $390.02 | $433.36 | $433.36 | $316.80 | $322.08 | $374.00 | $396.00 | $302.28 | $264.00 | $433.36 | |
73600 | L ANKLE-2 VIEWS | Radiology Diagnostic | 320 | 73600 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73610 | L ANKLE-3 VIEWS | Radiology Diagnostic | 320 | 73610 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73000 | L CLAVICLE-2 VIEWS | Radiology Diagnostic | 320 | 73000 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73070 | L ELBOW 1-2 VIEWS | Radiology Diagnostic | 320 | 73070 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73080 | L ELBOW- 3-4 views | Radiology Diagnostic | 320 | 73080 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73700 | L EXT LOWER W/O CONTRAST CT | Radiology Diagnostic | 350 | 73700 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
73550 | L FEMUR-2 VIEW | Radiology Diagnostic | 320 | 73552 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73140 | L FINGER- 2 to 4 views | Radiology Diagnostic | 320 | 73140 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73630 | L FOOT-3 VIEWS | Radiology Diagnostic | 320 | 73630 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73090 | L FOREARM-2 VIEWS | Radiology Diagnostic | 320 | 73090 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73120 | L HAND 1-2 VIEWS | Radiology Diagnostic | 320 | 73120 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
73130 | L HAND 3-4 VIEWS | Radiology Diagnostic | 320 | 73130 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73502 | L Hip w/Pelvis - 2-3 views | Radiology Diagnostic | 320 | 73502 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73060 | L HUMERUS-2 VIEWS | Radiology Diagnostic | 320 | 73060 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73560 | L KNEE-1 to 2 views | Radiology Diagnostic | 320 | 73560 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73562 | L KNEE-3 VIEWS | Radiology Diagnostic | 320 | 73562 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73590 | L LEG-2 VIEWS | Radiology Diagnostic | 320 | 73590 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73650 | L OS CALCIS-2 VIEWS | Radiology Diagnostic | 320 | 73650 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73030 | L SHOULDER-2 VIEWS | Radiology Diagnostic | 320 | 73030 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73660 | L TOES 2 VIEWS | Radiology Diagnostic | 320 | 73660 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
71100 | L UNILAT RIBS 2-3 VIEW | Radiology Diagnostic | 320 | 71100 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73110 | L WRIST 3-4 VIEWS | Radiology Diagnostic | 320 | 73110 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
73100 | L WRIST-2 VIEWS | Radiology Diagnostic | 320 | 73100 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
70491 | NECK SFT TISS W/CONTRAST CT | Radiology Diagnostic | 351 | 70491 | $1,170.00 | $702.00 | $702.00 | $1,044.55 | $1,160.61 | $1,160.61 | $842.40 | $856.44 | $994.50 | $1,053.00 | $803.79 | $702.00 | $1,160.61 | |
70490 | NECK SFT TISS W/O CONTRAST CT | Radiology Diagnostic | 351 | 70490 | $780.00 | $468.00 | $468.00 | $496.08 | $551.20 | $551.20 | $561.60 | $570.96 | $663.00 | $702.00 | $535.86 | $468.00 | $702.00 | |
70360 | NECK-SOFT TISSUE | Radiology Diagnostic | 320 | 70360 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
72170 | PELVIS 1-2 VIEWS | Radiology Diagnostic | 320 | 72170 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
72193 | PELVIS W/CONTRAST CT | Radiology Diagnostic | 352 | 72193 | $1,806.00 | $1,083.60 | $1,083.60 | $1,044.55 | $1,160.61 | $1,160.61 | $1,300.32 | $1,321.99 | $1,535.10 | $1,625.40 | $1,240.72 | $1,044.55 | $1,625.40 | |
72192 | PELVIS, W/O CONTRAST CT | Radiology Diagnostic | 352 | 72192 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
173600 | R ANKLE 2 VIEWS | Radiology Diagnostic | 320 | 73600 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173610 | R ANKLE 3 VIEWS | Radiology Diagnostic | 320 | 73610 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173000 | R CLAVICLE 2 VIEWS | Radiology Diagnostic | 320 | 73000 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173080 | R ELBOW- 3 to 4 views | Radiology Diagnostic | 320 | 73080 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173070 | R ELBOW1- 2 VIEWS | Radiology Diagnostic | 320 | 73070 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173700 | R EXT LOWER W/O CONTRAST CT | Radiology Diagnostic | 350 | 73700 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
173200 | R EXT UPPER W/O CONTRAST CT | Radiology Diagnostic | 350 | 73200 | $1,710.00 | $1,026.00 | $1,026.00 | $496.08 | $551.20 | $551.20 | $1,231.20 | $1,251.72 | $1,453.50 | $1,539.00 | $1,174.77 | $496.08 | $1,539.00 | |
1735502 | R FEMUR 1 VIEW | Radiology Diagnostic | 320 | 73551 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173550 | R FEMUR 2 VIEW min | Radiology Diagnostic | 320 | 73552 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173140 | R FINGERS- 2 to 4 views | Radiology Diagnostic | 320 | 73140 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173630 | R FOOT 3 VIEWS | Radiology Diagnostic | 320 | 73630 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173090 | R FOREARM 2 VIEWS | Radiology Diagnostic | 320 | 73090 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173120 | R HAND 1-2 VIEWS | Radiology Diagnostic | 320 | 73120 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
173130 | R HAND 3-4 VIEWS | Radiology Diagnostic | 320 | 73130 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173500 | R HIP w/Pelvis 1 view | Radiology Diagnostic | 320 | 73501 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173510 | R HIP w/Pelvis 2-3 views | Radiology Diagnostic | 320 | 73502 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173060 | R HUMERUS 2 VIEWS | Radiology Diagnostic | 320 | 73060 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173560 | R KNEE - 1 to 2 views | Radiology Diagnostic | 320 | 73560 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173562 | R KNEE 3 VIEWS | Radiology Diagnostic | 320 | 73562 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173590 | R LEG 2 VIEWS | Radiology Diagnostic | 320 | 73590 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173650 | R OS CALLIS 2 VIEWS | Radiology Diagnostic | 320 | 73650 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173020 | R SHOULDER 1 VIEW | Radiology Diagnostic | 320 | 73020 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173030 | R SHOULDER 2 VIEWS | Radiology Diagnostic | 320 | 73030 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173660 | R TOES 2 VIEWS | Radiology Diagnostic | 320 | 73660 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
171100 | R UNILAT RIBS 2-3 VIEW | Radiology Diagnostic | 320 | 71100 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173100 | R WRIST 2 VIEWS | Radiology Diagnostic | 320 | 73100 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
173110 | R WRIST 3-4 VIEWS | Radiology Diagnostic | 320 | 73110 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
70220 | SINUSES-3 VIEWS | Radiology Diagnostic | 320 | 70220 | $300.00 | $180.00 | $180.00 | $268.13 | $297.92 | $297.92 | $216.00 | $219.60 | $255.00 | $270.00 | $206.10 | $180.00 | $297.92 | |
72040 | SPINE CERVICAL 2-3 VIEWS | Radiology Diagnostic | 320 | 72040 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
72125 | SPINE CERVICAL W/O CNTRST CT# | Radiology Diagnostic | 352 | 72125 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
72100 | SPINE LUMBAR 2-3 VIEWS | Radiology Diagnostic | 320 | 72100 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
72110 | SPINE LUMBAR 4-5 VIEWS | Radiology Diagnostic | 320 | 72110 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
72131 | SPINE LUMBAR W/O CONTRAST CT# | Radiology Diagnostic | 352 | 72131 | $1,468.00 | $880.80 | $880.80 | $496.08 | $551.20 | $551.20 | $1,056.96 | $1,074.58 | $1,247.80 | $1,321.20 | $1,008.52 | $496.08 | $1,321.20 | |
72070 | SPINE THORACIC 2 VIEWS | Radiology Diagnostic | 320 | 72070 | $500.00 | $300.00 | $300.00 | $444.04 | $493.38 | $493.38 | $360.00 | $366.00 | $425.00 | $450.00 | $343.50 | $300.00 | $493.38 | |
72128 | SPINE THORACIC W/O CNTRST CT# | Radiology Diagnostic | 352 | 72128 | $1,305.00 | $783.00 | $783.00 | $496.08 | $551.20 | $551.20 | $939.60 | $955.26 | $1,109.25 | $1,174.50 | $896.54 | $496.08 | $1,174.50 | |
G0389 | Ultrasound AAA Screening | Radiology Diagnostic | 402 | 76706 | $330.00 | $198.00 | $198.00 | $294.85 | $327.61 | $327.61 | $237.60 | $241.56 | $280.50 | $297.00 | $226.71 | $198.00 | $327.61 | |
76870 | ULTRASOUND TESTICULAR | Radiology Diagnostic | 402 | 76870 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
76770 | ULTRASOUND/ RENAL,BILATERAL | Radiology Diagnostic | 402 | 76770 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
76856 | ULTRASOUND-PELVIC COMPLETE | Radiology Diagnostic | 402 | 76856 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
76815 | US OB Limited | Radiology Diagnostic | 402 | 76815 | $869.00 | $521.40 | $521.40 | $677.29 | $752.54 | $752.54 | $625.68 | $636.11 | $738.65 | $782.10 | $597.00 | $521.40 | $782.10 | |
76817 | US OB TRANSVAGINAL | Radiology Diagnostic | 402 | 76817 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
767055 | US Soft Tissue Other | Radiology Diagnostic | 402 | 76705 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
76882 | US: EXTREMITY SOFT TISSUE | Radiology Diagnostic | 402 | 76882 | $525.00 | $315.00 | $315.00 | $406.03 | $451.14 | $451.14 | $378.00 | $384.30 | $446.25 | $472.50 | $360.68 | $315.00 | $472.50 | |
76801 | US: OB 1ST TRIMESTER | Radiology Diagnostic | 402 | 76801 | $370.00 | $222.00 | $222.00 | $325.28 | $361.42 | $361.42 | $266.40 | $270.84 | $314.50 | $333.00 | $254.19 | $222.00 | $361.42 | |
76805 | US: OB 2ND TRIMESTER | Radiology Diagnostic | 402 | 76805 | $460.00 | $276.00 | $276.00 | $408.94 | $454.38 | $454.38 | $331.20 | $336.72 | $391.00 | $414.00 | $316.02 | $276.00 | $454.38 | |
76857 | US: PELVIC LIMITED OR FOLLOWUP | Radiology Diagnostic | 402 | 76857 | $460.00 | $276.00 | $276.00 | $406.03 | $451.14 | $451.14 | $331.20 | $336.72 | $391.00 | $414.00 | $316.02 | $276.00 | $451.14 | |
76775 | US: RETROPERITONEAL LIMITED | Radiology Diagnostic | 402 | 76775 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
76536 | US: THYROID/PARATHYROID | Radiology Diagnostic | 402 | 76536 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
76700 | US:ABDOMEN COMPLETE | Radiology Diagnostic | 402 | 76700 | $900.00 | $540.00 | $540.00 | $677.29 | $752.54 | $752.54 | $648.00 | $658.80 | $765.00 | $810.00 | $618.30 | $540.00 | $810.00 | |
76705 | US:ABDOMEN LIMITED | Radiology Diagnostic | 402 | 76705 | $760.00 | $456.00 | $456.00 | $677.29 | $752.54 | $752.54 | $547.20 | $556.32 | $646.00 | $684.00 | $522.12 | $456.00 | $752.54 | |
93922 | VASCULAR STUDY UP/LOW EXT ART | Radiology Diagnostic | 921 | 93922 | $450.00 | $270.00 | $270.00 | $349.22 | $387.52 | $387.52 | $324.00 | $329.40 | $382.50 | $405.00 | $309.15 | $270.00 | $405.00 | |
93970 | VENOUS STUDY BILATERAL | Radiology Diagnostic | 921 | 93970 | $925.00 | $555.00 | $555.00 | $586.91 | $651.27 | $651.27 | $666.00 | $677.10 | $786.25 | $832.50 | $635.48 | $555.00 | $832.50 | |
93971 | VENOUS STUDY UNILATERAL | Radiology Diagnostic | 921 | 93971 | $600.00 | $360.00 | $360.00 | $382.58 | $424.53 | $424.53 | $432.00 | $439.20 | $510.00 | $540.00 | $412.20 | $360.00 | $540.00 | |
199203 | OFFICE VISIT NEW PATIENT L-3 | Rural Health Clinic | 521 | 99203 | $180.00 | $135.00 | $85.50 | $113.22 | $111.02 | $111.02 | $105.07 | $105.07 | $105.07 | $105.07 | $105.07 | $85.50 | $113.22 | |
199204 | OFFICE VISIT NEW PATIENT L-4 | Rural Health Clinic | 521 | 99204 | $245.00 | $183.75 | $130.31 | $171.87 | $168.53 | $168.53 | $160.85 | $160.85 | $160.85 | $160.85 | $160.85 | $130.31 | $171.87 | |
199205 | OFFICE VISIT NEW PATIENT L-5 | Rural Health Clinic | 521 | 99205 | $305.00 | $228.75 | $163.98 | $216.04 | $211.85 | $211.85 | $203.40 | $203.40 | $203.40 | $203.40 | $203.40 | $163.98 | $216.04 | |
199386 | PREVENTIVE, NEW PT AGE 40-64 | Rural Health Clinic | 521 | 99386 | $218.00 | $163.50 | $121.93 | $160.36 | $157.25 | $157.25 | $162.19 | $135.16 | $135.16 | $135.16 | $171.72 | $121.93 | $171.72 | |
199385 | PREVENTIVE, NEW PT, AGE 18-39 YRS | Rural Health Clinic | 521 | 99385 | $186.00 | $139.50 | $104.16 | $138.09 | $135.41 | $135.41 | $138.38 | $115.32 | $115.32 | $115.32 | $151.96 | $104.16 | $151.96 |
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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