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 7/15/2023
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 | $ 245.00 | $ 147.00 | $ 147.00 | $ 214.25 | $ 237.75 | $ 237.75 | $ 176.40 | $ 179.34 | $ 208.25 | $ 220.50 | $ 168.32 | $ 147.00 | $ 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 |
31643235 | EGD WITH OR WITHOUT SPECIMENS | Gastrointestinal Services | 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 |
31643239 | EGD W BIOPSY | Gastrointestinal Services | 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 |
31643249 | EGD W BALLOON DILATION ESOP | Gastrointestinal Services | 750 | 43249 | $ 3,927.00 | $ 2,356.20 | $ 2,356.20 | $ 3,427.20 | $ 3,808.00 | $ 3,808.00 | $ 2,827.44 | $ 2,874.56 | $ 3,337.95 | $ 3,534.30 | $ 2,697.85 | $ 2,356.20 | $ 3,808.00 |
31645378 | COLONOSCOPY | Gastrointestinal Services | 750 | 45378 | $ 2,703.00 | $ 1,621.80 | $ 1,621.80 | $ 2,371.19 | $ 2,634.66 | $ 2,634.66 | $ 1,946.16 | $ 1,978.60 | $ 2,297.55 | $ 2,432.70 | $ 1,856.96 | $ 1,621.80 | $ 2,634.66 |
31645380 | COLONOSCOPY W BIOPSY(S) | Gastrointestinal Services | 750 | 45380 | $ 2,703.00 | $ 1,621.80 | $ 1,621.80 | $ 2,371.19 | $ 2,634.66 | $ 2,634.66 | $ 1,946.16 | $ 1,978.60 | $ 2,297.55 | $ 2,432.70 | $ 1,856.96 | $ 1,621.80 | $ 2,634.66 |
31645385 | COLONOSCOPY W SNARE REMOVAL | Gastrointestinal Services | 750 | 45385 | $ 2,703.00 | $ 1,621.80 | $ 1,621.80 | $ 2,371.19 | $ 2,634.66 | $ 2,634.66 | $ 1,946.16 | $ 1,978.60 | $ 2,297.55 | $ 2,432.70 | $ 1,856.96 | $ 1,621.80 | $ 2,634.66 |
316G0105 | COLONOSCOPY SCREEN HIGH RISK | Gastrointestinal Services | 750 | G0105 | $ 2,703.00 | $ 1,621.80 | $ 1,621.80 | $ 2,371.19 | $ 2,634.66 | $ 2,634.66 | $ 1,946.16 | $ 1,978.60 | $ 2,297.55 | $ 2,432.70 | $ 1,856.96 | $ 1,621.80 | $ 2,634.66 |
316G0121 | COLONOSCOPY SCREEN NOT HI RSK | Gastrointestinal Services | 750 | G0121 | $ 2,703.00 | $ 1,621.80 | $ 1,621.80 | $ 2,371.19 | $ 2,634.66 | $ 2,634.66 | $ 1,946.16 | $ 1,978.60 | $ 2,297.55 | $ 2,432.70 | $ 1,856.96 | $ 1,621.80 | $ 2,634.66 |
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 |
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 |
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 |
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 |
80048 | BASIC METABOLIC PANEL-CHEM 8 | Laboratory | 301 | 80048 | $ 179.00 | $ 107.40 | $ 107.40 | $ 42.28 | $ 47.00 | $ 47.00 | $ 128.88 | $ 131.03 | $ 152.15 | $ 161.10 | $ 122.97 | $ 42.28 | $ 161.10 |
30080050 | General Health Panel (CBC,TSH,CMP) | Laboratory | 300 | 80050 | $ 306.00 | $ 183.60 | $ 183.60 | $ 128.78 | $ 143.17 | $ 143.17 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 128.78 | $ 275.40 |
80053 | COMPREHENSIVE METABOLIC PANEL | Laboratory | 301 | 80053 | $ 224.00 | $ 134.40 | $ 134.40 | $ 52.81 | $ 58.71 | $ 58.71 | $ 161.28 | $ 163.97 | $ 190.40 | $ 201.60 | $ 153.89 | $ 52.81 | $ 201.60 |
33520210 | OBSTETRIC PANEL | Laboratory | 301 | 80055 | $ 277.00 | $ 166.20 | $ 166.20 | $ 238.99 | $ 265.69 | $ 265.69 | $ 199.44 | $ 202.76 | $ 235.45 | $ 249.30 | $ 190.30 | $ 166.20 | $ 265.69 |
80061 | LIPID PANEL | Laboratory | 301 | 80061 | $ 122.00 | $ 73.20 | $ 73.20 | $ 66.94 | $ 74.42 | $ 74.42 | $ 87.84 | $ 89.30 | $ 103.70 | $ 109.80 | $ 83.81 | $ 66.94 | $ 109.80 |
80069 | RENAL FUNCTION PANEL | Laboratory | 301 | 80069 | $ 153.00 | $ 91.80 | $ 91.80 | $ 43.42 | $ 48.27 | $ 48.27 | $ 110.16 | $ 112.00 | $ 130.05 | $ 137.70 | $ 105.11 | $ 43.42 | $ 137.70 |
33510306 | HEPATITIS PANEL, ACUTE | Laboratory | 301 | 80074 | $ 275.00 | $ 165.00 | $ 165.00 | $ 238.15 | $ 264.75 | $ 264.75 | $ 198.00 | $ 201.30 | $ 233.75 | $ 247.50 | $ 188.93 | $ 165.00 | $ 264.75 |
80076 | HEPATIC FUNCTION PANEL | Laboratory | 301 | 80076 | $ 204.00 | $ 122.40 | $ 122.40 | $ 40.85 | $ 45.41 | $ 45.41 | $ 146.88 | $ 149.33 | $ 173.40 | $ 183.60 | $ 140.15 | $ 40.85 | $ 183.60 |
80162 | DIGOXIN | Laboratory | 301 | 80162 | $ 153.00 | $ 91.80 | $ 91.80 | $ 66.39 | $ 73.81 | $ 73.81 | $ 110.16 | $ 112.00 | $ 130.05 | $ 137.70 | $ 105.11 | $ 66.39 | $ 137.70 |
3359167 | VALPROIC ACID LEVEL | Laboratory | 301 | 80164 | $ 82.00 | $ 49.20 | $ 49.20 | $ 67.75 | $ 75.32 | $ 75.32 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 75.32 |
80170 | GENTAMICIN LEVEL, PLASMA | Laboratory | 309 | 80170 | $ 188.00 | $ 112.80 | $ 112.80 | $ 81.91 | $ 91.07 | $ 91.07 | $ 135.36 | $ 137.62 | $ 159.80 | $ 169.20 | $ 129.16 | $ 81.91 | $ 169.20 |
335613 | LITHIUM LEVEL | Laboratory | 301 | 80178 | $ 41.00 | $ 24.60 | $ 24.60 | $ 33.07 | $ 36.76 | $ 36.76 | $ 29.52 | $ 30.01 | $ 34.85 | $ 36.90 | $ 28.17 | $ 24.60 | $ 36.90 |
80185 | DILANTIN | Laboratory | 301 | 80185 | $ 185.00 | $ 111.00 | $ 111.00 | $ 66.28 | $ 73.68 | $ 73.68 | $ 133.20 | $ 135.42 | $ 157.25 | $ 166.50 | $ 127.10 | $ 66.28 | $ 166.50 |
33534482 | TACRILIMUS FK506 LEVEL | Laboratory | 301 | 80197 | $ 219.00 | $ 131.40 | $ 131.40 | $ 68.67 | $ 76.34 | $ 76.34 | $ 157.68 | $ 160.31 | $ 186.15 | $ 197.10 | $ 150.45 | $ 68.67 | $ 197.10 |
80198 | THEOPHYLLINE | Laboratory | 301 | 80198 | $ 96.00 | $ 57.60 | $ 57.60 | $ 70.72 | $ 78.62 | $ 78.62 | $ 69.12 | $ 70.27 | $ 81.60 | $ 86.40 | $ 65.95 | $ 57.60 | $ 86.40 |
3358579 | VANCOMYCIN, TROUGH | Laboratory | 301 | 80202 | $ 82.00 | $ 49.20 | $ 49.20 | $ 67.75 | $ 75.32 | $ 75.32 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 75.32 |
80202 | VANCOMYCIN LEVEL, PLASMA | Laboratory | 309 | 80202 | $ 82.00 | $ 49.20 | $ 49.20 | $ 67.75 | $ 75.32 | $ 75.32 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 75.32 |
80100 | URINE DRUG SCREEN | Laboratory | 301 | 80305 | $ 77.00 | $ 46.20 | $ 46.20 | $ 41.98 | $ 46.68 | $ 46.68 | $ 55.44 | $ 56.36 | $ 65.45 | $ 69.30 | $ 52.90 | $ 41.98 | $ 69.30 |
335372 | C PEPTIDE | Laboratory | 301 | 80432 | $ 775.00 | $ 465.00 | $ 465.00 | $ 675.39 | $ 750.84 | $ 750.84 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 750.84 |
81001 | URINE/WITH MICROSCOPY | Laboratory | 307 | 81001 | $ 61.00 | $ 36.60 | $ 36.60 | $ 15.85 | $ 17.63 | $ 17.63 | $ 43.92 | $ 44.65 | $ 51.85 | $ 54.90 | $ 41.91 | $ 15.85 | $ 54.90 |
81003 | URINE/WITHOUT MICROSCOPY | Laboratory | 307 | 81003 | $ 39.00 | $ 23.40 | $ 23.40 | $ 11.23 | $ 12.48 | $ 12.48 | $ 28.08 | $ 28.55 | $ 33.15 | $ 35.10 | $ 26.79 | $ 11.23 | $ 35.10 |
R81002 | URINALYSIS-RURAL HEALTH | Laboratory | 307 | 81003 | $ 39.00 | $ 23.40 | $ 23.40 | $ 11.23 | $ 12.48 | $ 12.48 | $ 28.08 | $ 28.55 | $ 33.15 | $ 35.10 | $ 26.79 | $ 11.23 | $ 35.10 |
81025 | PREGNANCY/URINE | Laboratory | 307 | 81025 | $ 45.00 | $ 27.00 | $ 27.00 | $ 31.60 | $ 35.13 | $ 35.13 | $ 32.40 | $ 32.94 | $ 38.25 | $ 40.50 | $ 30.92 | $ 27.00 | $ 40.50 |
82009 | ACETONE | Laboratory | 301 | 82009 | $ 43.00 | $ 25.80 | $ 25.80 | $ 21.84 | $ 24.28 | $ 24.28 | $ 30.96 | $ 31.48 | $ 36.55 | $ 38.70 | $ 29.54 | $ 21.84 | $ 38.70 |
82040 | ALBUMIN | Laboratory | 301 | 82040 | $ 32.00 | $ 19.20 | $ 19.20 | $ 24.74 | $ 27.50 | $ 27.50 | $ 23.04 | $ 23.42 | $ 27.20 | $ 28.80 | $ 21.98 | $ 19.20 | $ 28.80 |
82044 | MICROALBUMIN | Laboratory | 301 | 82044 | $ 49.00 | $ 29.40 | $ 29.40 | $ 22.86 | $ 25.42 | $ 25.42 | $ 35.28 | $ 35.87 | $ 41.65 | $ 44.10 | $ 33.66 | $ 22.86 | $ 44.10 |
82140 | AMMONIA | Laboratory | 301 | 82140 | $ 143.00 | $ 85.80 | $ 85.80 | $ 72.85 | $ 80.99 | $ 80.99 | $ 102.96 | $ 104.68 | $ 121.55 | $ 128.70 | $ 98.24 | $ 72.85 | $ 128.70 |
82150 | AMYLASE (SERUM/URINE) | Laboratory | 301 | 82150 | $ 82.00 | $ 49.20 | $ 49.20 | $ 32.41 | $ 36.03 | $ 36.03 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 32.41 | $ 73.80 |
82247 | BILIRUBIN TOTAL | Laboratory | 301 | 82247 | $ 31.00 | $ 18.60 | $ 18.60 | $ 25.07 | $ 27.87 | $ 27.87 | $ 22.32 | $ 22.69 | $ 26.35 | $ 27.90 | $ 21.30 | $ 18.60 | $ 27.90 |
82270 | OCCULT BLOOD (STOOLX3) | Laboratory | 301 | 82270 | $ 47.00 | $ 28.20 | $ 28.20 | $ 16.26 | $ 18.07 | $ 18.07 | $ 33.84 | $ 34.40 | $ 39.95 | $ 42.30 | $ 32.29 | $ 16.26 | $ 42.30 |
82272 | OCCULT BLOOD,FECAL,SINGLE COLL | Laboratory | 301 | 82272 | $ 27.00 | $ 16.20 | $ 16.20 | $ 16.26 | $ 18.07 | $ 18.07 | $ 19.44 | $ 19.76 | $ 22.95 | $ 24.30 | $ 18.55 | $ 16.20 | $ 24.30 |
33517306 | VITAMIN D 25 HYDROXY | Laboratory | 300 | 82306 | $ 158.00 | $ 94.80 | $ 94.80 | $ 135.86 | $ 151.04 | $ 151.04 | $ 113.76 | $ 115.66 | $ 134.30 | $ 142.20 | $ 108.55 | $ 94.80 | $ 151.04 |
82310 | CALCIUM | Laboratory | 301 | 82310 | $ 32.00 | $ 19.20 | $ 19.20 | $ 25.80 | $ 28.68 | $ 28.68 | $ 23.04 | $ 23.42 | $ 27.20 | $ 28.80 | $ 21.98 | $ 19.20 | $ 28.80 |
82330 | CALCIUM, IONIZED | Laboratory | 301 | 82330 | $ 82.00 | $ 49.20 | $ 49.20 | $ 68.37 | $ 76.01 | $ 76.01 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 76.01 |
33582340 | CALCIUM, 24 HR URINE | Laboratory | 301 | 82340 | $ 41.00 | $ 24.60 | $ 24.60 | $ 30.13 | $ 33.50 | $ 33.50 | $ 29.52 | $ 30.01 | $ 34.85 | $ 36.90 | $ 28.17 | $ 24.60 | $ 36.90 |
335978 | CEA | Laboratory | 301 | 82378 | $ 110.00 | $ 66.00 | $ 66.00 | $ 94.83 | $ 105.43 | $ 105.43 | $ 79.20 | $ 80.52 | $ 93.50 | $ 99.00 | $ 75.57 | $ 66.00 | $ 105.43 |
3354212 | CORTISOL AM | Laboratory | 301 | 82533 | $ 102.00 | $ 61.20 | $ 61.20 | $ 81.51 | $ 90.62 | $ 90.62 | $ 73.44 | $ 74.66 | $ 86.70 | $ 91.80 | $ 70.07 | $ 61.20 | $ 91.80 |
82550 | CPK | Laboratory | 301 | 82550 | $ 102.00 | $ 61.20 | $ 61.20 | $ 32.55 | $ 36.19 | $ 36.19 | $ 73.44 | $ 74.66 | $ 86.70 | $ 91.80 | $ 70.07 | $ 32.55 | $ 91.80 |
82553 | CKMB | Laboratory | 301 | 82553 | $ 185.00 | $ 111.00 | $ 111.00 | $ 30.79 | $ 34.23 | $ 34.23 | $ 133.20 | $ 135.42 | $ 157.25 | $ 166.50 | $ 127.10 | $ 30.79 | $ 166.50 |
82565 | CREATININE | Laboratory | 301 | 82565 | $ 61.00 | $ 36.60 | $ 36.60 | $ 25.62 | $ 28.48 | $ 28.48 | $ 43.92 | $ 44.65 | $ 51.85 | $ 54.90 | $ 41.91 | $ 25.62 | $ 54.90 |
3358459 | CREATANINE URINE RANDOM | Laboratory | 301 | 82570 | $ 37.00 | $ 22.20 | $ 22.20 | $ 25.87 | $ 28.76 | $ 28.76 | $ 26.64 | $ 27.08 | $ 31.45 | $ 33.30 | $ 25.42 | $ 22.20 | $ 33.30 |
33521618 | CREATININE URINE RANDOM | Laboratory | 301 | 82570 | $ 37.00 | $ 22.20 | $ 22.20 | $ 25.87 | $ 28.76 | $ 28.76 | $ 26.64 | $ 27.08 | $ 31.45 | $ 33.30 | $ 25.42 | $ 22.20 | $ 33.30 |
3357943 | CREATININE CLEARANCE | Laboratory | 301 | 82575 | $ 134.00 | $ 80.40 | $ 80.40 | $ 47.27 | $ 52.55 | $ 52.55 | $ 96.48 | $ 98.09 | $ 113.90 | $ 120.60 | $ 92.06 | $ 47.27 | $ 120.60 |
335927 | VITAMIN B12 CHEMISTRY | Laboratory | 301 | 82607 | $ 153.00 | $ 91.80 | $ 91.80 | $ 75.38 | $ 83.80 | $ 83.80 | $ 110.16 | $ 112.00 | $ 130.05 | $ 137.70 | $ 105.11 | $ 75.38 | $ 137.70 |
335402 | DHEA SULFATE | Laboratory | 301 | 82627 | $ 128.00 | $ 76.80 | $ 76.80 | $ 111.16 | $ 123.58 | $ 123.58 | $ 92.16 | $ 93.70 | $ 108.80 | $ 115.20 | $ 87.94 | $ 76.80 | $ 123.58 |
3354729 | VIT D,1,25-DIHYDROXY | Laboratory | 301 | 82652 | $ 224.00 | $ 134.40 | $ 134.40 | $ 192.45 | $ 213.96 | $ 213.96 | $ 161.28 | $ 163.97 | $ 190.40 | $ 201.60 | $ 153.89 | $ 134.40 | $ 213.96 |
335429 | ESTRADIOL | Laboratory | 301 | 82670 | $ 163.00 | $ 97.80 | $ 97.80 | $ 139.68 | $ 155.28 | $ 155.28 | $ 117.36 | $ 119.32 | $ 138.55 | $ 146.70 | $ 111.98 | $ 97.80 | $ 155.28 |
335439 | ESTROGEN | Laboratory | 301 | 82672 | $ 83.00 | $ 49.80 | $ 49.80 | $ 43.71 | $ 48.59 | $ 48.59 | $ 59.76 | $ 60.76 | $ 70.55 | $ 74.70 | $ 57.02 | $ 43.71 | $ 74.70 |
335457 | FERRITIN LEVEL | Laboratory | 301 | 82728 | $ 128.00 | $ 76.80 | $ 76.80 | $ 68.15 | $ 75.77 | $ 75.77 | $ 92.16 | $ 93.70 | $ 108.80 | $ 115.20 | $ 87.94 | $ 68.15 | $ 115.20 |
335466 | FOLATE, SERUM | Laboratory | 301 | 82746 | $ 87.00 | $ 52.20 | $ 52.20 | $ 73.51 | $ 81.72 | $ 81.72 | $ 62.64 | $ 63.68 | $ 73.95 | $ 78.30 | $ 59.77 | $ 52.20 | $ 81.72 |
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 | ||
335467 | FOLIC ACID | Laboratory | 301 | 82746 | $ 87.00 | $ 52.20 | $ 52.20 | $ 73.51 | $ 81.72 | $ 81.72 | $ 62.64 | $ 63.68 | $ 73.95 | $ 78.30 | $ 59.77 | $ 52.20 | $ 81.72 |
A33515980 | GAMMAGLOBULIN IGA IGD IGM EA | Laboratory | 300 | 82784 | $ 141.00 | $ 84.60 | $ 84.60 | $ 46.50 | $ 51.69 | $ 51.69 | $ 101.52 | $ 103.21 | $ 119.85 | $ 126.90 | $ 96.87 | $ 46.50 | $ 126.90 |
3357083 | IMMUNOGLOBULINS | Laboratory | 301 | 82784 | $ 141.00 | $ 84.60 | $ 84.60 | $ 46.50 | $ 51.69 | $ 51.69 | $ 101.52 | $ 103.21 | $ 119.85 | $ 126.90 | $ 96.87 | $ 46.50 | $ 126.90 |
82803 | ARTERIAL BLOOD GAS | Laboratory | 301 | 82803 | $ 264.00 | $ 158.40 | $ 158.40 | $ 96.74 | $ 107.55 | $ 107.55 | $ 190.08 | $ 193.25 | $ 224.40 | $ 237.60 | $ 181.37 | $ 96.74 | $ 237.60 |
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 |
G82951 | GLUCOSE TOLERANCE 3 SPECIMENS | Laboratory | 300 | 82951 | $ 108.00 | $ 64.80 | $ 64.80 | $ 64.34 | $ 71.52 | $ 71.52 | $ 77.76 | $ 79.06 | $ 91.80 | $ 97.20 | $ 74.20 | $ 64.34 | $ 97.20 |
G82952 | GLUCOSE EACH ADDITIONAL SPEC | Laboratory | 300 | 82952 | $ 108.00 | $ 64.80 | $ 64.80 | $ 19.60 | $ 21.79 | $ 21.79 | $ 77.76 | $ 79.06 | $ 91.80 | $ 97.20 | $ 74.20 | $ 19.60 | $ 97.20 |
335482 | GGT | Laboratory | 301 | 82977 | $ 46.00 | $ 27.60 | $ 27.60 | $ 36.00 | $ 40.02 | $ 40.02 | $ 33.12 | $ 33.67 | $ 39.10 | $ 41.40 | $ 31.60 | $ 27.60 | $ 41.40 |
335470 | FSH | Laboratory | 301 | 83001 | $ 107.00 | $ 64.20 | $ 64.20 | $ 92.89 | $ 103.26 | $ 103.26 | $ 77.04 | $ 78.32 | $ 90.95 | $ 96.30 | $ 73.51 | $ 64.20 | $ 103.26 |
335615 | LH | Laboratory | 301 | 83002 | $ 210.00 | $ 126.00 | $ 126.00 | $ 92.56 | $ 102.90 | $ 102.90 | $ 151.20 | $ 153.72 | $ 178.50 | $ 189.00 | $ 144.27 | $ 92.56 | $ 189.00 |
309001 | HGB AIC | Laboratory | 301 | 83036 | $ 73.00 | $ 43.80 | $ 43.80 | $ 48.52 | $ 53.94 | $ 53.94 | $ 52.56 | $ 53.44 | $ 62.05 | $ 65.70 | $ 50.15 | $ 43.80 | $ 65.70 |
B33515980 | INFECT AGENT ANTIGEN | Laboratory | 300 | 83516 | $ 70.00 | $ 42.00 | $ 42.00 | $ 57.66 | $ 64.10 | $ 64.10 | $ 50.40 | $ 51.24 | $ 59.50 | $ 63.00 | $ 48.09 | $ 42.00 | $ 64.10 |
3357573 | IRON AND TIBC | Laboratory | 300 | 83540 | $ 133.00 | $ 79.80 | $ 79.80 | $ 32.37 | $ 35.99 | $ 35.99 | $ 95.76 | $ 97.36 | $ 113.05 | $ 119.70 | $ 91.37 | $ 32.37 | $ 119.70 |
335571 | IRON, TOTAL | Laboratory | 301 | 83540 | $ 133.00 | $ 79.80 | $ 79.80 | $ 32.37 | $ 35.99 | $ 35.99 | $ 95.76 | $ 97.36 | $ 113.05 | $ 119.70 | $ 91.37 | $ 32.37 | $ 119.70 |
83605 | LACTIC ACID | Laboratory | 300 | 83605 | $ 61.00 | $ 36.60 | $ 36.60 | $ 53.40 | $ 59.36 | $ 59.36 | $ 43.92 | $ 44.65 | $ 51.85 | $ 54.90 | $ 41.91 | $ 36.60 | $ 59.36 |
335593 | LDH | Laboratory | 300 | 83615 | $ 36.00 | $ 21.60 | $ 21.60 | $ 30.17 | $ 33.54 | $ 33.54 | $ 25.92 | $ 26.35 | $ 30.60 | $ 32.40 | $ 24.73 | $ 21.60 | $ 33.54 |
335599 | LEAD LEVEL | Laboratory | 301 | 83655 | $ 243.00 | $ 145.80 | $ 145.80 | $ 60.52 | $ 67.28 | $ 67.28 | $ 174.96 | $ 177.88 | $ 206.55 | $ 218.70 | $ 166.94 | $ 60.52 | $ 218.70 |
83690 | LIPASE, SERUM | Laboratory | 300 | 83690 | $ 47.00 | $ 28.20 | $ 28.20 | $ 34.42 | $ 38.27 | $ 38.27 | $ 33.84 | $ 34.40 | $ 39.95 | $ 42.30 | $ 32.29 | $ 28.20 | $ 42.30 |
83721 | LDL, DIRECT | Laboratory | 301 | 83721 | $ 61.00 | $ 36.60 | $ 36.60 | $ 47.71 | $ 53.04 | $ 53.04 | $ 43.92 | $ 44.65 | $ 51.85 | $ 54.90 | $ 41.91 | $ 36.60 | $ 54.90 |
83735 | MAGNESIUM | Laboratory | 301 | 83735 | $ 300.00 | $ 180.00 | $ 180.00 | $ 33.47 | $ 37.21 | $ 37.21 | $ 216.00 | $ 219.60 | $ 255.00 | $ 270.00 | $ 206.10 | $ 33.47 | $ 270.00 |
83880 | B-TYPE NATRIUETIC PEPTIDE | Laboratory | 301 | 83880 | $ 281.00 | $ 168.60 | $ 168.60 | $ 169.70 | $ 188.66 | $ 188.66 | $ 202.32 | $ 205.69 | $ 238.85 | $ 252.90 | $ 193.05 | $ 168.60 | $ 252.90 |
3358446 | PTH INTACT | Laboratory | 301 | 83970 | $ 235.00 | $ 141.00 | $ 141.00 | $ 206.36 | $ 229.42 | $ 229.42 | $ 169.20 | $ 172.02 | $ 199.75 | $ 211.50 | $ 161.45 | $ 141.00 | $ 229.42 |
335231 | ALKALINE PHOSPHAT, ISOENZYMES | Laboratory | 301 | 84080 | $ 78.00 | $ 46.80 | $ 46.80 | $ 43.71 | $ 48.59 | $ 48.59 | $ 56.16 | $ 57.10 | $ 66.30 | $ 70.20 | $ 53.59 | $ 43.71 | $ 70.20 |
84100 | PHOSPHOROUS | Laboratory | 301 | 84100 | $ 32.00 | $ 19.20 | $ 19.20 | $ 23.71 | $ 26.36 | $ 26.36 | $ 23.04 | $ 23.42 | $ 27.20 | $ 28.80 | $ 21.98 | $ 19.20 | $ 28.80 |
84132 | POTASSIUM | Laboratory | 301 | 84132 | $ 71.00 | $ 42.60 | $ 42.60 | $ 22.97 | $ 25.54 | $ 25.54 | $ 51.12 | $ 51.97 | $ 60.35 | $ 63.90 | $ 48.78 | $ 22.97 | $ 63.90 |
335745 | PROGESTERONE LEVEL | Laboratory | 301 | 84144 | $ 122.00 | $ 73.20 | $ 73.20 | $ 104.30 | $ 115.95 | $ 115.95 | $ 87.84 | $ 89.30 | $ 103.70 | $ 109.80 | $ 83.81 | $ 73.20 | $ 115.95 |
335746 | PROLACTIN LEVEL | Laboratory | 301 | 84146 | $ 112.00 | $ 67.20 | $ 67.20 | $ 96.89 | $ 107.71 | $ 107.71 | $ 80.64 | $ 81.98 | $ 95.20 | $ 100.80 | $ 76.94 | $ 67.20 | $ 107.71 |
84153 | PSA# | Laboratory | 301 | 84153 | $ 153.00 | $ 91.80 | $ 91.80 | $ 91.97 | $ 102.24 | $ 102.24 | $ 110.16 | $ 112.00 | $ 130.05 | $ 137.70 | $ 105.11 | $ 91.80 | $ 137.70 |
G84153 | PSA TOTAL | Laboratory | 301 | 84153 | $ 153.00 | $ 91.80 | $ 91.80 | $ 91.97 | $ 102.24 | $ 102.24 | $ 110.16 | $ 112.00 | $ 130.05 | $ 137.70 | $ 105.11 | $ 91.80 | $ 137.70 |
G84154 | PSA FREE | Laboratory | 301 | 84154 | $ 112.00 | $ 67.20 | $ 67.20 | $ 91.97 | $ 102.24 | $ 102.24 | $ 80.64 | $ 81.98 | $ 95.20 | $ 100.80 | $ 76.94 | $ 67.20 | $ 102.24 |
3351715 | T PROTEIN W/CREAT, RANDOM URNE | Laboratory | 301 | 84155 | $ 73.00 | $ 43.80 | $ 43.80 | $ 18.35 | $ 20.40 | $ 20.40 | $ 52.56 | $ 53.44 | $ 62.05 | $ 65.70 | $ 50.15 | $ 18.35 | $ 65.70 |
335747 | PROTEIN ELECTROPHORESIS | Laboratory | 301 | 84155 | $ 73.00 | $ 43.80 | $ 43.80 | $ 18.35 | $ 20.40 | $ 20.40 | $ 52.56 | $ 53.44 | $ 62.05 | $ 65.70 | $ 50.15 | $ 18.35 | $ 65.70 |
G84402 | TESTOSTERONE FREE | Laboratory | 301 | 84402 | $ 148.00 | $ 88.80 | $ 88.80 | $ 127.31 | $ 141.54 | $ 141.54 | $ 106.56 | $ 108.34 | $ 125.80 | $ 133.20 | $ 101.68 | $ 88.80 | $ 141.54 |
G84403 | TESTOSTERONE TOTAL | Laboratory | 301 | 84403 | $ 148.00 | $ 88.80 | $ 88.80 | $ 129.07 | $ 143.49 | $ 143.49 | $ 106.56 | $ 108.34 | $ 125.80 | $ 133.20 | $ 101.68 | $ 88.80 | $ 143.49 |
335873 | TESTOSTERONE, TOTAL | Laboratory | 301 | 84403 | $ 148.00 | $ 88.80 | $ 88.80 | $ 129.07 | $ 143.49 | $ 143.49 | $ 106.56 | $ 108.34 | $ 125.80 | $ 133.20 | $ 101.68 | $ 88.80 | $ 143.49 |
33536170 | TESTOSTERONE FREE & TOTAL | Laboratory | 301 | 84403 | $ 148.00 | $ 88.80 | $ 88.80 | $ 129.07 | $ 143.49 | $ 143.49 | $ 106.56 | $ 108.34 | $ 125.80 | $ 133.20 | $ 101.68 | $ 88.80 | $ 143.49 |
33584425 | Thiamine (Vitamin B1) | Laboratory | 300 | 84425 | $ 49.00 | $ 29.40 | $ 29.40 | $ 33.98 | $ 37.78 | $ 37.78 | $ 35.28 | $ 35.87 | $ 41.65 | $ 44.10 | $ 33.66 | $ 29.40 | $ 44.10 |
335867 | T4, TOTAL | Laboratory | 301 | 84436 | $ 41.00 | $ 24.60 | $ 24.60 | $ 34.31 | $ 38.15 | $ 38.15 | $ 29.52 | $ 30.01 | $ 34.85 | $ 36.90 | $ 28.17 | $ 24.60 | $ 38.15 |
84439 | FREE T4 | Laboratory | 301 | 84439 | $ 95.00 | $ 57.00 | $ 57.00 | $ 45.07 | $ 50.10 | $ 50.10 | $ 68.40 | $ 69.54 | $ 80.75 | $ 85.50 | $ 65.27 | $ 45.07 | $ 85.50 |
84443 | TSH# | Laboratory | 301 | 84443 | $ 168.00 | $ 100.80 | $ 100.80 | $ 84.01 | $ 93.39 | $ 93.39 | $ 120.96 | $ 122.98 | $ 142.80 | $ 151.20 | $ 115.42 | $ 84.01 | $ 151.20 |
84450 | AST | Laboratory | 301 | 84450 | $ 31.00 | $ 18.60 | $ 18.60 | $ 25.87 | $ 28.76 | $ 28.76 | $ 22.32 | $ 22.69 | $ 26.35 | $ 27.90 | $ 21.30 | $ 18.60 | $ 28.76 |
84460 | ALT | Laboratory | 301 | 84460 | $ 32.00 | $ 19.20 | $ 19.20 | $ 26.50 | $ 29.46 | $ 29.46 | $ 23.04 | $ 23.42 | $ 27.20 | $ 28.80 | $ 21.98 | $ 19.20 | $ 29.46 |
335891 | TRANSFERRIN | Laboratory | 301 | 84466 | $ 55.00 | $ 33.00 | $ 33.00 | $ 46.02 | $ 51.16 | $ 51.16 | $ 39.60 | $ 40.26 | $ 46.75 | $ 49.50 | $ 37.79 | $ 33.00 | $ 51.16 |
84478 | TRIGLYCERIDES# | Laboratory | 301 | 84478 | $ 67.00 | $ 40.20 | $ 40.20 | $ 28.74 | $ 31.95 | $ 31.95 | $ 48.24 | $ 49.04 | $ 56.95 | $ 60.30 | $ 46.03 | $ 28.74 | $ 60.30 |
335859 | T3, TOTAL | Laboratory | 301 | 84480 | $ 82.00 | $ 49.20 | $ 49.20 | $ 70.87 | $ 78.78 | $ 78.78 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 78.78 |
33534429 | FT3 | Laboratory | 301 | 84481 | $ 408.00 | $ 244.80 | $ 244.80 | $ 84.67 | $ 94.13 | $ 94.13 | $ 293.76 | $ 298.66 | $ 346.80 | $ 367.20 | $ 280.30 | $ 84.67 | $ 367.20 |
84484 | TROPONIN | Laboratory | 301 | 84484 | $ 341.00 | $ 204.60 | $ 204.60 | $ 49.18 | $ 54.67 | $ 54.67 | $ 245.52 | $ 249.61 | $ 289.85 | $ 306.90 | $ 234.27 | $ 49.18 | $ 306.90 |
84520 | UREA NITROGEN (BUN) | Laboratory | 301 | 84520 | $ 72.00 | $ 43.20 | $ 43.20 | $ 19.74 | $ 21.95 | $ 21.95 | $ 51.84 | $ 52.70 | $ 61.20 | $ 64.80 | $ 49.46 | $ 19.74 | $ 64.80 |
84550 | URIC ACID | Laboratory | 301 | 84550 | $ 32.00 | $ 19.20 | $ 19.20 | $ 22.61 | $ 25.13 | $ 25.13 | $ 23.04 | $ 23.42 | $ 27.20 | $ 28.80 | $ 21.98 | $ 19.20 | $ 28.80 |
3358396 | HCG, QUANT | Laboratory | 300 | 84702 | $ 51.00 | $ 30.60 | $ 30.60 | $ 43.67 | $ 48.55 | $ 48.55 | $ 36.72 | $ 37.33 | $ 43.35 | $ 45.90 | $ 35.04 | $ 30.60 | $ 48.55 |
84703 | PREGNANCY TEST (SERUM) | Laboratory | 301 | 84703 | $ 95.00 | $ 57.00 | $ 57.00 | $ 37.58 | $ 41.78 | $ 41.78 | $ 68.40 | $ 69.54 | $ 80.75 | $ 85.50 | $ 65.27 | $ 37.58 | $ 85.50 |
85007 | DIFFERENTIAL (MANUAL) | Laboratory | 305 | 85007 | $ 33.00 | $ 19.80 | $ 19.80 | $ 17.18 | $ 19.09 | $ 19.09 | $ 23.76 | $ 24.16 | $ 28.05 | $ 29.70 | $ 22.67 | $ 17.18 | $ 29.70 |
85014 | HEMATOCRIT# | Laboratory | 300 | 85014 | $ 45.00 | $ 27.00 | $ 27.00 | $ 11.85 | $ 13.18 | $ 13.18 | $ 32.40 | $ 32.94 | $ 38.25 | $ 40.50 | $ 30.92 | $ 11.85 | $ 40.50 |
85018 | HEMOGLOBIN# | Laboratory | 300 | 85018 | $ 38.00 | $ 22.80 | $ 22.80 | $ 11.85 | $ 13.18 | $ 13.18 | $ 27.36 | $ 27.82 | $ 32.30 | $ 34.20 | $ 26.11 | $ 11.85 | $ 34.20 |
85025 | CBC COMPLETE AUTO W AUTO DIFF# | Laboratory | 305 | 85025 | $ 72.00 | $ 43.20 | $ 43.20 | $ 38.87 | $ 43.21 | $ 43.21 | $ 51.84 | $ 52.70 | $ 61.20 | $ 64.80 | $ 49.46 | $ 38.87 | $ 64.80 |
335793 | RETICULOCYTE COUNT | Laboratory | 300 | 85045 | $ 46.00 | $ 27.60 | $ 27.60 | $ 20.00 | $ 22.24 | $ 22.24 | $ 33.12 | $ 33.67 | $ 39.10 | $ 41.40 | $ 31.60 | $ 20.00 | $ 41.40 |
85379 | D-DIMER | Laboratory | 305 | 85379 | $ 176.00 | $ 105.60 | $ 105.60 | $ 46.54 | $ 51.73 | $ 51.73 | $ 126.72 | $ 128.83 | $ 149.60 | $ 158.40 | $ 120.91 | $ 46.54 | $ 158.40 |
85610 | PROTHROMBIN TIME/INR# | Laboratory | 300 | 85610 | $ 69.00 | $ 41.40 | $ 41.40 | $ 19.67 | $ 21.87 | $ 21.87 | $ 49.68 | $ 50.51 | $ 58.65 | $ 62.10 | $ 47.40 | $ 19.67 | $ 62.10 |
185610 | PROTHROMBIN TIME FINGER | Laboratory | 301 | 85610 | $ 69.00 | $ 41.40 | $ 41.40 | $ 19.67 | $ 21.87 | $ 21.87 | $ 49.68 | $ 50.51 | $ 58.65 | $ 62.10 | $ 47.40 | $ 19.67 | $ 62.10 |
85651 | SEDIMENTATION RATE (ESR) | Laboratory | 305 | 85651 | $ 53.00 | $ 31.80 | $ 31.80 | $ 17.73 | $ 19.71 | $ 19.71 | $ 38.16 | $ 38.80 | $ 45.05 | $ 47.70 | $ 36.41 | $ 17.73 | $ 47.70 |
85730 | APTT | Laboratory | 305 | 85730 | $ 90.00 | $ 54.00 | $ 54.00 | $ 30.02 | $ 33.37 | $ 33.37 | $ 64.80 | $ 65.88 | $ 76.50 | $ 81.00 | $ 61.83 | $ 30.02 | $ 81.00 |
335249 | ANA | Laboratory | 302 | 86038 | $ 113.00 | $ 67.80 | $ 67.80 | $ 60.44 | $ 67.20 | $ 67.20 | $ 81.36 | $ 82.72 | $ 96.05 | $ 101.70 | $ 77.63 | $ 60.44 | $ 101.70 |
86140 | C-REACTIVE PROTEIN | Laboratory | 302 | 86140 | $ 195.00 | $ 117.00 | $ 117.00 | $ 25.87 | $ 28.76 | $ 28.76 | $ 140.40 | $ 142.74 | $ 165.75 | $ 175.50 | $ 133.97 | $ 25.87 | $ 175.50 |
86141 | CRP High Sensitivity | Laboratory | 300 | 86141 | $ 82.00 | $ 49.20 | $ 49.20 | $ 64.70 | $ 71.93 | $ 71.93 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 73.80 |
3350001 | Hu Antibody screen w/ reflex | Laboratory | 300 | 86255 | $ 124.00 | $ 74.40 | $ 74.40 | $ 60.22 | $ 66.95 | $ 66.95 | $ 89.28 | $ 90.77 | $ 105.40 | $ 111.60 | $ 85.19 | $ 60.22 | $ 111.60 |
33529493 | CA 2729 | Laboratory | 300 | 86300 | $ 257.00 | $ 154.20 | $ 154.20 | $ 104.04 | $ 115.67 | $ 115.67 | $ 185.04 | $ 188.12 | $ 218.45 | $ 231.30 | $ 176.56 | $ 104.04 | $ 231.30 |
86308 | MONOSPOT | Laboratory | 302 | 86308 | $ 106.00 | $ 63.60 | $ 63.60 | $ 25.87 | $ 28.76 | $ 28.76 | $ 76.32 | $ 77.59 | $ 90.10 | $ 95.40 | $ 72.82 | $ 25.87 | $ 95.40 |
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 | ||
33529256 | CA 125 | Laboratory | 302 | 86316 | $ 135.00 | $ 81.00 | $ 81.00 | $ 104.04 | $ 115.67 | $ 115.67 | $ 97.20 | $ 98.82 | $ 114.75 | $ 121.50 | $ 92.75 | $ 81.00 | $ 121.50 |
3355081 | ANTI TPO | Laboratory | 302 | 86376 | $ 92.00 | $ 55.20 | $ 55.20 | $ 72.74 | $ 80.87 | $ 80.87 | $ 66.24 | $ 67.34 | $ 78.20 | $ 82.80 | $ 63.20 | $ 55.20 | $ 82.80 |
3354418 | RHEUMATOID FACTOR | Laboratory | 302 | 86431 | $ 165.00 | $ 99.00 | $ 99.00 | $ 28.37 | $ 31.54 | $ 31.54 | $ 118.80 | $ 120.78 | $ 140.25 | $ 148.50 | $ 113.36 | $ 28.37 | $ 148.50 |
3351761 | RPR | Laboratory | 302 | 86592 | $ 71.00 | $ 42.60 | $ 42.60 | $ 21.36 | $ 23.75 | $ 23.75 | $ 51.12 | $ 51.97 | $ 60.35 | $ 63.90 | $ 48.78 | $ 21.36 | $ 63.90 |
86677 | H. PYLORI ANTIBODY | Laboratory | 302 | 86677 | $ 51.00 | $ 30.60 | $ 30.60 | $ 40.88 | $ 45.45 | $ 45.45 | $ 36.72 | $ 37.33 | $ 43.35 | $ 45.90 | $ 35.04 | $ 30.60 | $ 45.90 |
G0432 | HIV SCREENING | Laboratory | 300 | 86703 | $ 82.00 | $ 49.20 | $ 49.20 | $ 68.52 | $ 76.17 | $ 76.17 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 76.17 |
33519728 | HIV 1 & 2 WITH REFLEX | Laboratory | 335 | 86703 | $ 82.00 | $ 49.20 | $ 49.20 | $ 68.52 | $ 76.17 | $ 76.17 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 76.17 |
335499 | HBSAB | Laboratory | 302 | 86706 | $ 118.00 | $ 70.80 | $ 70.80 | $ 53.69 | $ 59.69 | $ 59.69 | $ 84.96 | $ 86.38 | $ 100.30 | $ 106.20 | $ 81.07 | $ 53.69 | $ 106.20 |
86710 | INFLUENZA A&B | Laboratory | 302 | 86710 | $ 130.00 | $ 78.00 | $ 78.00 | $ 67.75 | $ 75.32 | $ 75.32 | $ 93.60 | $ 95.16 | $ 110.50 | $ 117.00 | $ 89.31 | $ 67.75 | $ 117.00 |
3358624 | MUMPS ANTIBODY | Laboratory | 300 | 86735 | $ 77.00 | $ 46.20 | $ 46.20 | $ 65.22 | $ 72.50 | $ 72.50 | $ 55.44 | $ 56.36 | $ 65.45 | $ 69.30 | $ 52.90 | $ 46.20 | $ 72.50 |
335802 | RUBELLA IGG AB | Laboratory | 302 | 86762 | $ 87.00 | $ 52.20 | $ 52.20 | $ 71.97 | $ 80.01 | $ 80.01 | $ 62.64 | $ 63.68 | $ 73.95 | $ 78.30 | $ 59.77 | $ 52.20 | $ 80.01 |
335964 | MEASLES (RUBEOLA) | Laboratory | 300 | 86765 | $ 92.00 | $ 55.20 | $ 55.20 | $ 64.41 | $ 71.60 | $ 71.60 | $ 66.24 | $ 67.34 | $ 78.20 | $ 82.80 | $ 63.20 | $ 55.20 | $ 82.80 |
33586769 | COVID-19 Antibody test | Laboratory | 300 | 86769 | $ 133.00 | $ 79.80 | $ 79.80 | $ 47.27 | $ 52.55 | $ 52.55 | $ 95.76 | $ 97.36 | $ 113.05 | $ 119.70 | $ 91.37 | $ 47.27 | $ 119.70 |
3354439 | VARICELLA ZOSTER IG G AB | Laboratory | 302 | 86787 | $ 175.00 | $ 105.00 | $ 105.00 | $ 40.88 | $ 45.45 | $ 45.45 | $ 126.00 | $ 128.10 | $ 148.75 | $ 157.50 | $ 120.23 | $ 40.88 | $ 157.50 |
3358472 | ANTI HCV HEP C ANTIBODY | Laboratory | 302 | 86803 | $ 82.00 | $ 49.20 | $ 49.20 | $ 71.34 | $ 79.32 | $ 79.32 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 49.20 | $ 79.32 |
86850 | ANTIBODY SCREEN | Laboratory | 302 | 86850 | $ 199.00 | $ 119.40 | $ 119.40 | $ 175.24 | $ 194.82 | $ 194.82 | $ 143.28 | $ 145.67 | $ 169.15 | $ 179.10 | $ 136.71 | $ 119.40 | $ 194.82 |
86900 | ABO | Laboratory | 390 | 86900 | $ 235.00 | $ 141.00 | $ 141.00 | $ 205.30 | $ 228.24 | $ 228.24 | $ 169.20 | $ 172.02 | $ 199.75 | $ 211.50 | $ 161.45 | $ 141.00 | $ 228.24 |
86901 | RH TYPE | Laboratory | 302 | 86901 | $ 128.00 | $ 76.80 | $ 76.80 | $ 111.97 | $ 124.48 | $ 124.48 | $ 92.16 | $ 93.70 | $ 108.80 | $ 115.20 | $ 87.94 | $ 76.80 | $ 124.48 |
86904A | CROSSMATCH EA UNIT | Laboratory | 302 | 86904 | $ 128.00 | $ 76.80 | $ 76.80 | $ 111.97 | $ 124.48 | $ 124.48 | $ 92.16 | $ 93.70 | $ 108.80 | $ 115.20 | $ 87.94 | $ 76.80 | $ 124.48 |
335389 | CULTURE, BLOOD | Laboratory | 306 | 87040 | $ 61.00 | $ 36.60 | $ 36.60 | $ 51.64 | $ 57.41 | $ 57.41 | $ 43.92 | $ 44.65 | $ 51.85 | $ 54.90 | $ 41.91 | $ 36.60 | $ 57.41 |
33510019 | CULTURE STOOL SALM/SHIG | Laboratory | 306 | 87045 | $ 63.00 | $ 37.80 | $ 37.80 | $ 47.20 | $ 52.47 | $ 52.47 | $ 45.36 | $ 46.12 | $ 53.55 | $ 56.70 | $ 43.28 | $ 37.80 | $ 56.70 |
87070 | CULTURE, BACT ANY SOUCE | Laboratory | 306 | 87070 | $ 125.00 | $ 75.00 | $ 75.00 | $ 43.09 | $ 47.90 | $ 47.90 | $ 90.00 | $ 91.50 | $ 106.25 | $ 112.50 | $ 85.88 | $ 43.09 | $ 112.50 |
9621A | CULTURE, WOUND | Laboratory | 306 | 87070 | $ 125.00 | $ 75.00 | $ 75.00 | $ 43.09 | $ 47.90 | $ 47.90 | $ 90.00 | $ 91.50 | $ 106.25 | $ 112.50 | $ 85.88 | $ 43.09 | $ 112.50 |
3354550 | CULTURE, AEROBIC | Laboratory | 306 | 87070 | $ 125.00 | $ 75.00 | $ 75.00 | $ 43.09 | $ 47.90 | $ 47.90 | $ 90.00 | $ 91.50 | $ 106.25 | $ 112.50 | $ 85.88 | $ 43.09 | $ 112.50 |
3354556 | CULTURE SPUTUM | Laboratory | 300 | 87070 | $ 125.00 | $ 75.00 | $ 75.00 | $ 43.09 | $ 47.90 | $ 47.90 | $ 90.00 | $ 91.50 | $ 106.25 | $ 112.50 | $ 85.88 | $ 43.09 | $ 112.50 |
335394 | CULTURE THROAT | Laboratory | 306 | 87070 | $ 125.00 | $ 75.00 | $ 75.00 | $ 43.09 | $ 47.90 | $ 47.90 | $ 90.00 | $ 91.50 | $ 106.25 | $ 112.50 | $ 85.88 | $ 43.09 | $ 112.50 |
3354473 | CULTURE, BODY FLUID | Laboratory | 306 | 87070 | $ 125.00 | $ 75.00 | $ 75.00 | $ 43.09 | $ 47.90 | $ 47.90 | $ 90.00 | $ 91.50 | $ 106.25 | $ 112.50 | $ 85.88 | $ 43.09 | $ 112.50 |
ORG ID 1 | ORGANISM ID Anaeriobic | Laboratory | 306 | 87076 | $ 51.00 | $ 30.60 | $ 30.60 | $ 40.37 | $ 44.88 | $ 44.88 | $ 36.72 | $ 37.33 | $ 43.35 | $ 45.90 | $ 35.04 | $ 30.60 | $ 45.90 |
87077 | CLO TEST RAPID UREASE TEST | Laboratory | 301 | 87077 | $ 51.00 | $ 30.60 | $ 30.60 | $ 40.37 | $ 44.88 | $ 44.88 | $ 36.72 | $ 37.33 | $ 43.35 | $ 45.90 | $ 35.04 | $ 30.60 | $ 45.90 |
3060001 | AEROBIC ISOLATE 1 | Laboratory | 306 | 87077 | $ 51.00 | $ 30.60 | $ 30.60 | $ 40.37 | $ 44.88 | $ 44.88 | $ 36.72 | $ 37.33 | $ 43.35 | $ 45.90 | $ 35.04 | $ 30.60 | $ 45.90 |
1UR | ORGANISM ID Aerobioc | Laboratory | 306 | 87077 | $ 51.00 | $ 30.60 | $ 30.60 | $ 40.37 | $ 44.88 | $ 44.88 | $ 36.72 | $ 37.33 | $ 43.35 | $ 45.90 | $ 35.04 | $ 30.60 | $ 45.90 |
335349 | CULTURE, THROAT | Laboratory | 306 | 87081 | $ 41.00 | $ 24.60 | $ 24.60 | $ 33.14 | $ 36.84 | $ 36.84 | $ 29.52 | $ 30.01 | $ 34.85 | $ 36.90 | $ 28.17 | $ 24.60 | $ 36.90 |
87086 | CULTURE, URINE | Laboratory | 306 | 87086 | $ 139.00 | $ 83.40 | $ 83.40 | $ 40.37 | $ 44.88 | $ 44.88 | $ 100.08 | $ 101.75 | $ 118.15 | $ 125.10 | $ 95.49 | $ 40.37 | $ 125.10 |
87088 | CULTURE URINE W/ISOLATION | Laboratory | 306 | 87088 | $ 75.00 | $ 45.00 | $ 45.00 | $ 40.48 | $ 45.00 | $ 45.00 | $ 54.00 | $ 54.90 | $ 63.75 | $ 67.50 | $ 51.53 | $ 40.48 | $ 67.50 |
335395 | CULTURE, URINE | Laboratory | 306 | 87088 | $ 75.00 | $ 45.00 | $ 45.00 | $ 40.48 | $ 45.00 | $ 45.00 | $ 54.00 | $ 54.90 | $ 63.75 | $ 67.50 | $ 51.53 | $ 40.48 | $ 67.50 |
335681 | OVA AND PARASITE ONCE ONLY | Laboratory | 300 | 87177 | $ 82.00 | $ 49.20 | $ 49.20 | $ 43.71 | $ 48.59 | $ 48.59 | $ 59.04 | $ 60.02 | $ 69.70 | $ 73.80 | $ 56.33 | $ 43.71 | $ 73.80 |
87186 | SUSCEPTIBILITY 1 | Laboratory | 306 | 87186 | $ 141.00 | $ 84.60 | $ 84.60 | $ 43.23 | $ 48.06 | $ 48.06 | $ 101.52 | $ 103.21 | $ 119.85 | $ 126.90 | $ 96.87 | $ 43.23 | $ 126.90 |
87187 | SUSCEPTIBILITY 2 | Laboratory | 306 | 87187 | $ 139.00 | $ 83.40 | $ 83.40 | $ 51.82 | $ 57.61 | $ 57.61 | $ 100.08 | $ 101.75 | $ 118.15 | $ 125.10 | $ 95.49 | $ 51.82 | $ 125.10 |
87220 | KOH PREP | Laboratory | 306 | 87205 | $ 39.00 | $ 23.40 | $ 23.40 | $ 21.36 | $ 23.75 | $ 23.75 | $ 28.08 | $ 28.55 | $ 33.15 | $ 35.10 | $ 26.79 | $ 21.36 | $ 35.10 |
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 |
3358756 | C DIFF TOXIN A | Laboratory | 306 | 87324 | $ 169.00 | $ 101.40 | $ 101.40 | $ 59.93 | $ 66.63 | $ 66.63 | $ 121.68 | $ 123.71 | $ 143.65 | $ 152.10 | $ 116.10 | $ 59.93 | $ 152.10 |
33534838 | H. PYLORI ANTIGEN, STOOL | Laboratory | 306 | 87338 | $ 150.00 | $ 90.00 | $ 90.00 | $ 71.90 | $ 79.93 | $ 79.93 | $ 108.00 | $ 109.80 | $ 127.50 | $ 135.00 | $ 103.05 | $ 71.90 | $ 135.00 |
335498 | HBSAG | Laboratory | 306 | 87340 | $ 118.00 | $ 70.80 | $ 70.80 | $ 51.64 | $ 57.41 | $ 57.41 | $ 84.96 | $ 86.38 | $ 100.30 | $ 106.20 | $ 81.07 | $ 51.64 | $ 106.20 |
87420 | RSV ANTIGEN EIA | Laboratory | 306 | 87420 | $ 173.00 | $ 103.80 | $ 103.80 | $ 59.93 | $ 66.63 | $ 66.63 | $ 124.56 | $ 126.64 | $ 147.05 | $ 155.70 | $ 118.85 | $ 59.93 | $ 155.70 |
86588 | STREP A | Laboratory | 306 | 87430 | $ 71.00 | $ 42.60 | $ 42.60 | $ 59.93 | $ 66.63 | $ 66.63 | $ 51.12 | $ 51.97 | $ 60.35 | $ 63.90 | $ 48.78 | $ 42.60 | $ 66.63 |
87430 | STREPTOCOCCUS GRP A RAPID ANTI | Laboratory | 306 | 87430 | $ 71.00 | $ 42.60 | $ 42.60 | $ 59.93 | $ 66.63 | $ 66.63 | $ 51.12 | $ 51.97 | $ 60.35 | $ 63.90 | $ 48.78 | $ 42.60 | $ 66.63 |
3356919 | CHLAMYDIA AND GC GEN PROBE | Laboratory | 300 | 87491 | $ 204.00 | $ 122.40 | $ 122.40 | $ 175.43 | $ 195.02 | $ 195.02 | $ 146.88 | $ 149.33 | $ 173.40 | $ 183.60 | $ 140.15 | $ 122.40 | $ 195.02 |
3350002 | COVID-19 REFERENCE LAB | Laboratory | 300 | 87635 | $ 255.00 | $ 153.00 | $ 153.00 | $ 188.38 | $ 209.43 | $ 209.43 | $ 183.60 | $ 186.66 | $ 216.75 | $ 229.50 | $ 175.19 | $ 153.00 | $ 229.50 |
187804A | INFLUENZA | Laboratory | 306 | 87804 | $ 68.00 | $ 40.80 | $ 40.80 | $ 59.93 | $ 66.63 | $ 66.63 | $ 48.96 | $ 49.78 | $ 57.80 | $ 61.20 | $ 46.72 | $ 40.80 | $ 66.63 |
3353471 | CYTOLOGY, FLUID | Laboratory | 311 | 88104 | $ 128.00 | $ 76.80 | $ 76.80 | $ 111.97 | $ 124.48 | $ 124.48 | $ 92.16 | $ 93.70 | $ 108.80 | $ 115.20 | $ 87.94 | $ 76.80 | $ 124.48 |
33588300 | Path Surgical Level 1 G&M | Laboratory | 300 | 88300 | $ 184.00 | $ 110.40 | $ 110.40 | $ 111.97 | $ 124.48 | $ 124.48 | $ 132.48 | $ 134.69 | $ 156.40 | $ 165.60 | $ 126.41 | $ 110.40 | $ 165.60 |
33897012 | MECHANICAL TRACTION | Physical Therapy | 420 | 97012 | $ 71.00 | $ 42.60 | $ 42.60 | $ 61.70 | $ 68.47 | $ 68.47 | $ 51.12 | $ 51.97 | $ 60.35 | $ 63.90 | $ 48.78 | $ 42.60 | $ 68.47 |
33897016 | VASOPNEUMATIC DEVICE | Physical Therapy | 420 | 97016 | $ 92.00 | $ 55.20 | $ 55.20 | $ 74.03 | $ 82.15 | $ 82.15 | $ 66.24 | $ 67.34 | $ 78.20 | $ 82.80 | $ 63.20 | $ 55.20 | $ 82.80 |
33897035 | ULTRASOUND | Physical Therapy | 420 | 97035 | $ 56.00 | $ 33.60 | $ 33.60 | $ 49.37 | $ 54.78 | $ 54.78 | $ 40.32 | $ 40.99 | $ 47.60 | $ 50.40 | $ 38.47 | $ 33.60 | $ 54.78 |
33897110 | THERAPEUTIC EXERCISE | Physical Therapy | 420 | 97110 | $ 143.00 | $ 85.80 | $ 85.80 | $ 124.78 | $ 138.47 | $ 138.47 | $ 102.96 | $ 104.68 | $ 121.55 | $ 128.70 | $ 98.24 | $ 85.80 | $ 138.47 |
33897116 | GAIT TRAINING | Physical Therapy | 420 | 97116 | $ 128.00 | $ 76.80 | $ 76.80 | $ 109.69 | $ 121.72 | $ 121.72 | $ 92.16 | $ 93.70 | $ 108.80 | $ 115.20 | $ 87.94 | $ 76.80 | $ 121.72 |
33897140 | MANUAL THERAPY | Physical Therapy | 420 | 97140 | $ 133.00 | $ 79.80 | $ 79.80 | $ 115.21 | $ 127.84 | $ 127.84 | $ 95.76 | $ 97.36 | $ 113.05 | $ 119.70 | $ 91.37 | $ 79.80 | $ 127.84 |
97161 | PT EVAL; LOW COMPLEXITY | Physical Therapy | 420 | 97161 | $ 357.00 | $ 214.20 | $ 214.20 | $ 312.22 | $ 346.46 | $ 346.46 | $ 257.04 | $ 261.32 | $ 303.45 | $ 321.30 | $ 245.26 | $ 214.20 | $ 346.46 |
33897001 | PHYSICAL THERAPY EVALUATION | Physical Therapy | 424 | 97161 | $ 357.00 | $ 214.20 | $ 214.20 | $ 312.22 | $ 346.46 | $ 346.46 | $ 257.04 | $ 261.32 | $ 303.45 | $ 321.30 | $ 245.26 | $ 214.20 | $ 346.46 |
97162 | PT EVAL; MODERATE COMPLEXITY | Physical Therapy | 420 | 97162 | $ 357.00 | $ 214.20 | $ 214.20 | $ 312.22 | $ 346.46 | $ 346.46 | $ 257.04 | $ 261.32 | $ 303.45 | $ 321.30 | $ 245.26 | $ 214.20 | $ 346.46 |
33897002 | PHYSICAL THERAPY RE-EVALUATION | Physical Therapy | 424 | 97164 | $ 255.00 | $ 153.00 | $ 153.00 | $ 212.26 | $ 235.54 | $ 235.54 | $ 183.60 | $ 186.66 | $ 216.75 | $ 229.50 | $ 175.19 | $ 153.00 | $ 235.54 |
70220 | SINUSES-3 VIEWS | Radiology Diagnostic | 320 | 70220 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
70360 | NECK-SOFT TISSUE | Radiology Diagnostic | 320 | 70360 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
70450 | HEAD W/O CONTRAST CT# | Radiology Diagnostic | 351 | 70450 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
70470 | HEAD W/O & W/CONTRAST CT# | Radiology Diagnostic | 351 | 70470 | $ 1,537.00 | $ 922.20 | $ 922.20 | $ 1,044.55 | $ 1,160.61 | $ 1,160.61 | $ 1,106.64 | $ 1,125.08 | $ 1,306.45 | $ 1,383.30 | $ 1,055.92 | $ 922.20 | $ 1,383.30 |
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 | ||
70486 | FACIAL AREA W/O CONTRAST | Radiology Diagnostic | 351 | 70486 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
70487 | FACIAL AREA W/CONTRAST CT | Radiology Diagnostic | 351 | 70487 | $ 1,193.00 | $ 715.80 | $ 715.80 | $ 1,044.55 | $ 1,160.61 | $ 1,160.61 | $ 858.96 | $ 873.28 | $ 1,014.05 | $ 1,073.70 | $ 819.59 | $ 715.80 | $ 1,160.61 |
70490 | NECK SFT TISS W/O CONTRAST CT | Radiology Diagnostic | 351 | 70490 | $ 796.00 | $ 477.60 | $ 477.60 | $ 496.08 | $ 551.20 | $ 551.20 | $ 573.12 | $ 582.67 | $ 676.60 | $ 716.40 | $ 546.85 | $ 477.60 | $ 716.40 |
70491 | NECK SFT TISS W/CONTRAST CT | Radiology Diagnostic | 351 | 70491 | $ 1,193.00 | $ 715.80 | $ 715.80 | $ 1,044.55 | $ 1,160.61 | $ 1,160.61 | $ 858.96 | $ 873.28 | $ 1,014.05 | $ 1,073.70 | $ 819.59 | $ 715.80 | $ 1,160.61 |
71010 | CHEST-1 VIEW | Radiology Diagnostic | 324 | 71045 | $ 316.00 | $ 189.60 | $ 189.60 | $ 273.91 | $ 304.34 | $ 304.34 | $ 227.52 | $ 231.31 | $ 268.60 | $ 284.40 | $ 217.09 | $ 189.60 | $ 304.34 |
71020 | CHEST-2 VIEWS | Radiology Diagnostic | 324 | 71046 | $ 316.00 | $ 189.60 | $ 189.60 | $ 273.91 | $ 304.34 | $ 304.34 | $ 227.52 | $ 231.31 | $ 268.60 | $ 284.40 | $ 217.09 | $ 189.60 | $ 304.34 |
171100 | R UNILAT RIBS 2-3 VIEW | Radiology Diagnostic | 320 | 71100 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
71100 | L UNILAT RIBS 2-3 VIEW | Radiology Diagnostic | 320 | 71100 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
71250 | CHEST W/O CONTRAST CT# | Radiology Diagnostic | 352 | 71250 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
71260 | CHEST W/CONTRAST CT# | Radiology Diagnostic | 352 | 71260 | $ 1,842.00 | $ 1,105.20 | $ 1,105.20 | $ 1,044.55 | $ 1,160.61 | $ 1,160.61 | $ 1,326.24 | $ 1,348.34 | $ 1,565.70 | $ 1,657.80 | $ 1,265.45 | $ 1,044.55 | $ 1,657.80 |
71270 | CHEST W/O & W/CONTRAST CT# | Radiology Diagnostic | 352 | 71270 | $ 1,744.00 | $ 1,046.40 | $ 1,046.40 | $ 1,533.45 | $ 1,703.83 | $ 1,703.83 | $ 1,255.68 | $ 1,276.61 | $ 1,482.40 | $ 1,569.60 | $ 1,198.13 | $ 1,046.40 | $ 1,703.83 |
72040 | SPINE CERVICAL 2-3 VIEWS | Radiology Diagnostic | 320 | 72040 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
72070 | SPINE THORACIC 2 VIEWS | Radiology Diagnostic | 320 | 72070 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
72100 | SPINE LUMBAR 2-3 VIEWS | Radiology Diagnostic | 320 | 72100 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
72110 | SPINE LUMBAR 4-5 VIEWS | Radiology Diagnostic | 320 | 72110 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
72125 | SPINE CERVICAL W/O CNTRST CT# | Radiology Diagnostic | 352 | 72125 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
72128 | SPINE THORACIC W/O CNTRST CT# | Radiology Diagnostic | 352 | 72128 | $ 1,331.00 | $ 798.60 | $ 798.60 | $ 496.08 | $ 551.20 | $ 551.20 | $ 958.32 | $ 974.29 | $ 1,131.35 | $ 1,197.90 | $ 914.40 | $ 496.08 | $ 1,197.90 |
72131 | SPINE LUMBAR W/O CONTRAST CT# | Radiology Diagnostic | 352 | 72131 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
72170 | PELVIS 1-2 VIEWS | Radiology Diagnostic | 320 | 72170 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
72192 | PELVIS, W/O CONTRAST CT | Radiology Diagnostic | 352 | 72192 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
72193 | PELVIS W/CONTRAST CT | Radiology Diagnostic | 352 | 72193 | $ 1,842.00 | $ 1,105.20 | $ 1,105.20 | $ 1,044.55 | $ 1,160.61 | $ 1,160.61 | $ 1,326.24 | $ 1,348.34 | $ 1,565.70 | $ 1,657.80 | $ 1,265.45 | $ 1,044.55 | $ 1,657.80 |
73000 | L CLAVICLE-2 VIEWS | Radiology Diagnostic | 320 | 73000 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173000 | R CLAVICLE 2 VIEWS | Radiology Diagnostic | 320 | 73000 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173020 | R SHOULDER 1 VIEW | Radiology Diagnostic | 320 | 73020 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173030 | R SHOULDER 2 VIEWS | Radiology Diagnostic | 320 | 73030 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73030 | L SHOULDER-2 VIEWS | Radiology Diagnostic | 320 | 73030 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173060 | R HUMERUS 2 VIEWS | Radiology Diagnostic | 320 | 73060 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73060 | L HUMERUS-2 VIEWS | Radiology Diagnostic | 320 | 73060 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73070 | L ELBOW 1-2 VIEWS | Radiology Diagnostic | 320 | 73070 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173070 | R ELBOW1- 2 VIEWS | Radiology Diagnostic | 320 | 73070 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173080 | R ELBOW- 3 to 4 views | Radiology Diagnostic | 320 | 73080 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73080 | L ELBOW- 3-4 views | Radiology Diagnostic | 320 | 73080 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73090 | L FOREARM-2 VIEWS | Radiology Diagnostic | 320 | 73090 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173090 | R FOREARM 2 VIEWS | Radiology Diagnostic | 320 | 73090 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73100 | L WRIST-2 VIEWS | Radiology Diagnostic | 320 | 73100 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173100 | R WRIST 2 VIEWS | Radiology Diagnostic | 320 | 73100 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173110 | R WRIST 3-4 VIEWS | Radiology Diagnostic | 320 | 73110 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73110 | L WRIST 3-4 VIEWS | Radiology Diagnostic | 320 | 73110 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173120 | R HAND 1-2 VIEWS | Radiology Diagnostic | 320 | 73120 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
73120 | L HAND 1-2 VIEWS | Radiology Diagnostic | 320 | 73120 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
173130 | R HAND 3-4 VIEWS | Radiology Diagnostic | 320 | 73130 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73130 | L HAND 3-4 VIEWS | Radiology Diagnostic | 320 | 73130 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173140 | R FINGERS- 2 to 4 views | Radiology Diagnostic | 320 | 73140 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73140 | L FINGER- 2 to 4 views | Radiology Diagnostic | 320 | 73140 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173200 | R EXT UPPER W/O CONTRAST CT | Radiology Diagnostic | 350 | 73200 | $ 1,744.00 | $ 1,046.40 | $ 1,046.40 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,255.68 | $ 1,276.61 | $ 1,482.40 | $ 1,569.60 | $ 1,198.13 | $ 496.08 | $ 1,569.60 |
173500 | R HIP w/Pelvis 1 view | Radiology Diagnostic | 320 | 73501 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73502 | L Hip w/Pelvis - 2-3 views | Radiology Diagnostic | 320 | 73502 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173510 | R HIP w/Pelvis 2-3 views | Radiology Diagnostic | 320 | 73502 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73522 | Bilateral Hips xray w/ pelvis 3-4 views | Radiology Diagnostic | 320 | 73522 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
1735502 | R FEMUR 1 VIEW | Radiology Diagnostic | 320 | 73551 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73550 | L FEMUR-2 VIEW | Radiology Diagnostic | 320 | 73552 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173550 | R FEMUR 2 VIEW min | Radiology Diagnostic | 320 | 73552 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173560 | R KNEE - 1 to 2 views | Radiology Diagnostic | 320 | 73560 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73560 | L KNEE-1 to 2 views | Radiology Diagnostic | 320 | 73560 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173562 | R KNEE 3 VIEWS | Radiology Diagnostic | 320 | 73562 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73562 | L KNEE-3 VIEWS | Radiology Diagnostic | 320 | 73562 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173590 | R LEG 2 VIEWS | Radiology Diagnostic | 320 | 73590 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73590 | L LEG-2 VIEWS | Radiology Diagnostic | 320 | 73590 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173600 | R ANKLE 2 VIEWS | Radiology Diagnostic | 320 | 73600 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73600 | L ANKLE-2 VIEWS | Radiology Diagnostic | 320 | 73600 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73610 | L ANKLE-3 VIEWS | Radiology Diagnostic | 320 | 73610 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173610 | R ANKLE 3 VIEWS | Radiology Diagnostic | 320 | 73610 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173630 | R FOOT 3 VIEWS | Radiology Diagnostic | 320 | 73630 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73630 | L FOOT-3 VIEWS | Radiology Diagnostic | 320 | 73630 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73650 | L OS CALCIS-2 VIEWS | Radiology Diagnostic | 320 | 73650 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
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 | ||
173650 | R OS CALLIS 2 VIEWS | Radiology Diagnostic | 320 | 73650 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173660 | R TOES 2 VIEWS | Radiology Diagnostic | 320 | 73660 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
73660 | L TOES 2 VIEWS | Radiology Diagnostic | 320 | 73660 | $ 306.00 | $ 183.60 | $ 183.60 | $ 268.13 | $ 297.92 | $ 297.92 | $ 220.32 | $ 223.99 | $ 260.10 | $ 275.40 | $ 210.22 | $ 183.60 | $ 297.92 |
173700 | R EXT LOWER W/O CONTRAST CT | Radiology Diagnostic | 350 | 73700 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
73700 | L EXT LOWER W/O CONTRAST CT | Radiology Diagnostic | 350 | 73700 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
74000 | ABDOMEN-1 VIEW | Radiology Diagnostic | 320 | 74018 | $ 316.00 | $ 189.60 | $ 189.60 | $ 273.91 | $ 304.34 | $ 304.34 | $ 227.52 | $ 231.31 | $ 268.60 | $ 284.40 | $ 217.09 | $ 189.60 | $ 304.34 |
74020 | ABDOMEN-2 VIEWS | Radiology Diagnostic | 320 | 74019 | $ 602.00 | $ 361.20 | $ 361.20 | $ 523.64 | $ 581.83 | $ 581.83 | $ 433.44 | $ 440.66 | $ 511.70 | $ 541.80 | $ 413.57 | $ 361.20 | $ 581.83 |
74022 | ABDOMEN-ACUTE | Radiology Diagnostic | 320 | 74022 | $ 510.00 | $ 306.00 | $ 306.00 | $ 444.04 | $ 493.38 | $ 493.38 | $ 367.20 | $ 373.32 | $ 433.50 | $ 459.00 | $ 350.37 | $ 306.00 | $ 493.38 |
74150 | ABDOMEN W/O CONTRAST CT | Radiology Diagnostic | 352 | 74150 | $ 1,497.00 | $ 898.20 | $ 898.20 | $ 496.08 | $ 551.20 | $ 551.20 | $ 1,077.84 | $ 1,095.80 | $ 1,272.45 | $ 1,347.30 | $ 1,028.44 | $ 496.08 | $ 1,347.30 |
74160 | ABDOMEN W/CONTRAST CT | Radiology Diagnostic | 352 | 74160 | $ 1,842.00 | $ 1,105.20 | $ 1,105.20 | $ 1,044.55 | $ 1,160.61 | $ 1,160.61 | $ 1,326.24 | $ 1,348.34 | $ 1,565.70 | $ 1,657.80 | $ 1,265.45 | $ 1,044.55 | $ 1,657.80 |
74176 | CT ABDOMEN/PELVIS W/O CONTRAST | Radiology Diagnostic | 352 | 74176 | $ 2,078.00 | $ 1,246.80 | $ 1,246.80 | $ 846.59 | $ 940.65 | $ 940.65 | $ 1,496.16 | $ 1,521.10 | $ 1,766.30 | $ 1,870.20 | $ 1,427.59 | $ 846.59 | $ 1,870.20 |
74177 | CT ABDOMEN/PELVIS W/CONTRAST | Radiology Diagnostic | 352 | 74177 | $ 2,343.00 | $ 1,405.80 | $ 1,405.80 | $ 1,533.45 | $ 1,703.83 | $ 1,703.83 | $ 1,686.96 | $ 1,715.08 | $ 1,991.55 | $ 2,108.70 | $ 1,609.64 | $ 1,405.80 | $ 2,108.70 |
74178 | CT ABDOMEN/PELVIS W/WO CONTRST | Radiology Diagnostic | 352 | 74178 | $ 3,369.00 | $ 2,021.40 | $ 2,021.40 | $ 1,533.45 | $ 1,703.83 | $ 1,703.83 | $ 2,425.68 | $ 2,466.11 | $ 2,863.65 | $ 3,032.10 | $ 2,314.50 | $ 1,533.45 | $ 3,032.10 |
76536 | US: THYROID/PARATHYROID | Radiology Diagnostic | 402 | 76536 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
76700 | US:ABDOMEN COMPLETE | Radiology Diagnostic | 402 | 76700 | $ 918.00 | $ 550.80 | $ 550.80 | $ 677.29 | $ 752.54 | $ 752.54 | $ 660.96 | $ 671.98 | $ 780.30 | $ 826.20 | $ 630.67 | $ 550.80 | $ 826.20 |
76705 | US:ABDOMEN LIMITED | Radiology Diagnostic | 402 | 76705 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
767055 | US Soft Tissue Other | Radiology Diagnostic | 402 | 76705 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
G0389 | Ultrasound AAA Screening | Radiology Diagnostic | 402 | 76706 | $ 337.00 | $ 202.20 | $ 202.20 | $ 294.85 | $ 327.61 | $ 327.61 | $ 242.64 | $ 246.68 | $ 286.45 | $ 303.30 | $ 231.52 | $ 202.20 | $ 327.61 |
76770 | ULTRASOUND/ RENAL,BILATERAL | Radiology Diagnostic | 402 | 76770 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
76775 | US: RETROPERITONEAL LIMITED | Radiology Diagnostic | 402 | 76775 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
76801 | US: OB 1ST TRIMESTER | Radiology Diagnostic | 402 | 76801 | $ 377.00 | $ 226.20 | $ 226.20 | $ 325.28 | $ 361.42 | $ 361.42 | $ 271.44 | $ 275.96 | $ 320.45 | $ 339.30 | $ 259.00 | $ 226.20 | $ 361.42 |
76805 | US: OB 2ND TRIMESTER | Radiology Diagnostic | 402 | 76805 | $ 469.00 | $ 281.40 | $ 281.40 | $ 408.94 | $ 454.38 | $ 454.38 | $ 337.68 | $ 343.31 | $ 398.65 | $ 422.10 | $ 322.20 | $ 281.40 | $ 454.38 |
76815 | US OB Limited | Radiology Diagnostic | 402 | 76815 | $ 886.00 | $ 531.60 | $ 531.60 | $ 677.29 | $ 752.54 | $ 752.54 | $ 637.92 | $ 648.55 | $ 753.10 | $ 797.40 | $ 608.68 | $ 531.60 | $ 797.40 |
76817 | US OB TRANSVAGINAL | Radiology Diagnostic | 402 | 76817 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
76830 | IVT/TRANSVAGINAL PROBE | Radiology Diagnostic | 402 | 76830 | $ 449.00 | $ 269.40 | $ 269.40 | $ 390.02 | $ 433.36 | $ 433.36 | $ 323.28 | $ 328.67 | $ 381.65 | $ 404.10 | $ 308.46 | $ 269.40 | $ 433.36 |
76856 | ULTRASOUND-PELVIC COMPLETE | Radiology Diagnostic | 402 | 76856 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
76857 | US: PELVIC LIMITED OR FOLLOWUP | Radiology Diagnostic | 402 | 76857 | $ 469.00 | $ 281.40 | $ 281.40 | $ 406.03 | $ 451.14 | $ 451.14 | $ 337.68 | $ 343.31 | $ 398.65 | $ 422.10 | $ 322.20 | $ 281.40 | $ 451.14 |
76870 | ULTRASOUND TESTICULAR | Radiology Diagnostic | 402 | 76870 | $ 775.00 | $ 465.00 | $ 465.00 | $ 677.29 | $ 752.54 | $ 752.54 | $ 558.00 | $ 567.30 | $ 658.75 | $ 697.50 | $ 532.43 | $ 465.00 | $ 752.54 |
76882 | US: EXTREMITY SOFT TISSUE | Radiology Diagnostic | 402 | 76882 | $ 536.00 | $ 321.60 | $ 321.60 | $ 406.03 | $ 451.14 | $ 451.14 | $ 385.92 | $ 392.35 | $ 455.60 | $ 482.40 | $ 368.23 | $ 321.60 | $ 482.40 |
93880 | CAROTID DOPPLER BILATERAL | Radiology Diagnostic | 921 | 93880 | $ 896.00 | $ 537.60 | $ 537.60 | $ 586.91 | $ 651.27 | $ 651.27 | $ 645.12 | $ 655.87 | $ 761.60 | $ 806.40 | $ 615.55 | $ 537.60 | $ 806.40 |
93922 | VASCULAR STUDY UP/LOW EXT ART | Radiology Diagnostic | 921 | 93922 | $ 459.00 | $ 275.40 | $ 275.40 | $ 349.22 | $ 387.52 | $ 387.52 | $ 330.48 | $ 335.99 | $ 390.15 | $ 413.10 | $ 315.33 | $ 275.40 | $ 413.10 |
93925 | BILATERAL ARTERIAL SCAN LOWER | Radiology Diagnostic | 921 | 93925 | $ 833.00 | $ 499.80 | $ 499.80 | $ 585.53 | $ 649.74 | $ 649.74 | $ 599.76 | $ 609.76 | $ 708.05 | $ 749.70 | $ 572.27 | $ 499.80 | $ 749.70 |
93970 | VENOUS STUDY BILATERAL | Radiology Diagnostic | 921 | 93970 | $ 944.00 | $ 566.40 | $ 566.40 | $ 586.91 | $ 651.27 | $ 651.27 | $ 679.68 | $ 691.01 | $ 802.40 | $ 849.60 | $ 648.53 | $ 566.40 | $ 849.60 |
93971 | VENOUS STUDY UNILATERAL | Radiology Diagnostic | 921 | 93971 | $ 612.00 | $ 367.20 | $ 367.20 | $ 382.58 | $ 424.53 | $ 424.53 | $ 440.64 | $ 447.98 | $ 520.20 | $ 550.80 | $ 420.44 | $ 367.20 | $ 550.80 |
199203 | OFFICE VISIT NEW PATIENT L-3 | Rural Health Clinic | 521 | 99203 | $ 180.00 | $ 135.00 | $ 85.50 | $ 113.22 | $ 111.02 | $ 111.02 | $ 85.50 | $ 85.50 | $ 85.50 | $ 85.50 | $ 85.50 | $ 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 | $ 130.31 | $ 130.31 | $ 130.31 | $ 130.31 | $ 130.31 | $ 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 | $ 163.98 | $ 163.98 | $ 163.98 | $ 163.98 | $ 163.98 | $ 163.98 | $ 216.04 |
199385 | PREVENTIVE, NEW PT, AGE 18-39 YRS | Rural Health Clinic | 521 | 99385 | $ 186.00 | $ 139.50 | $ 39.20 | $ 138.09 | $ 135.41 | $ 135.41 | $ 39.20 | $ 39.20 | $ 39.20 | $ 39.20 | $ 39.20 | $ 39.20 | $ 138.09 |
199386 | PREVENTIVE, NEW PT AGE 40-64 | Rural Health Clinic | 521 | 99386 | $ 218.00 | $ 163.50 | $ 121.93 | $ 160.36 | $ 157.25 | $ 157.25 | $ 121.93 | $ 121.93 | $ 121.93 | $ 121.93 | $ 121.93 | $ 121.93 | $ 160.36 |
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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