Price Transparency

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: 

  • Charge Code – specific charge code for each item or service
  • Description – description of each item or service
  • Department – department where item or service performed
  • Rev Code – corresponding department’s revenue code for item or service
  • CPT Code – corresponding CPT billing code for item or service (if applicable)
  • Gross Charge – corresponding gross charge for each individual item or service
  • Cash Price – corresponding discounted cash price that applies to each item or service
  • Payer-Specific Negotiated Charge – each column lists the negotiated charge with the name of each specific third-party payer as the column header
  • De-identified minimum negotiated charge that applies to each item or service
  • De-identified maximum negotiated charge that applies to each item or service

The PDF file is a searchable consumer-friendly format of payer-specific negotiated charge information of 300 “shoppable outpatient services” at the hospital.  The file contains the following information: 

  • Charge Code – specific charge code for each item or service
  • Description – description of each item or service
  • Department – department where item or service performed
  • Rev Code – corresponding department’s revenue code for item or service
  • CPT Code – corresponding CPT billing code for item or service (if applicable)
  • Gross Charge – corresponding gross charge for each individual item or service
  • Cash Price – corresponding discounted cash price that applies to each item or service
  • Payer-Specific Negotiated Charge – each column lists the negotiated charge with the name of each specific third-party payer as the column header
  • De-identified minimum negotiated charge that applies to each item or service
  • De-identified maximum negotiated charge that applies to each item or service

QUESTIONS?

If you have further questions about the 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! 

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Searchable Shoppable Services

Kimble Hospital Shoppable Services as of 7/15/2023

CHARGE CODE DESCRIPTION DEPTREV CODECPT CODEGross ChargeCash PriceAetnaBCBS - Blue Essentials HMOBCBS - TraditionalBCBS - PPOCignaHumanaScott & WhiteShannonUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
Y533050AEKG 12 LEAD TRACING ONLYEKG/ECG73093005$ 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
90846FAMILY PSYCHOTHERAPY W/O PATFamily therapy91690846$ 285.00$ 171.00$ 171.00$ -$ -$ -$ 205.20$ 208.62$ 242.25$ 256.50$ 195.80$ -$ 256.50
GRP1600PSYCH FAMILY THERAPYFamily therapy91690847$ 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
31643235EGD WITH OR WITHOUT SPECIMENSGastrointestinal Services75043235$ 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
31643239EGD W BIOPSYGastrointestinal Services75043239$ 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
31643249EGD W BALLOON DILATION ESOPGastrointestinal Services75043249$ 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
31645378COLONOSCOPYGastrointestinal Services75045378$ 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
31645380COLONOSCOPY W BIOPSY(S)Gastrointestinal Services75045380$ 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
31645385COLONOSCOPY W SNARE REMOVALGastrointestinal Services75045385$ 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
316G0105COLONOSCOPY SCREEN HIGH RISKGastrointestinal Services750G0105$ 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
316G0121COLONOSCOPY SCREEN NOT HI RSKGastrointestinal Services750G0121$ 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
GRP1200GRP PSYCH THRPY PRCSS SUBS HRGroup therapy91590853$ 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
GRP1000GRP PSYCH THERAPY PROCESS INITGroup therapy91590853$ 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
GRP1400GRP PSYCH PROCESS INT W/OTHERGroup therapy91590853$ 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
90804INDIV PSYCHTHERAPY 16-37 MINSIndividual therapy91490832$ 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
90806INDIV PSYCHTHERAPY 38-52 MINIndividual therapy91490834$ 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
80048BASIC METABOLIC PANEL-CHEM 8Laboratory30180048$ 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
30080050General Health Panel (CBC,TSH,CMP)Laboratory30080050$ 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
80053COMPREHENSIVE METABOLIC PANELLaboratory30180053$ 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
33520210OBSTETRIC PANELLaboratory30180055$ 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
80061LIPID PANELLaboratory30180061$ 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
80069RENAL FUNCTION PANELLaboratory30180069$ 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
33510306HEPATITIS PANEL, ACUTELaboratory30180074$ 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
80076HEPATIC FUNCTION PANELLaboratory30180076$ 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
80162DIGOXINLaboratory30180162$ 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
3359167VALPROIC ACID LEVELLaboratory30180164$ 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
80170GENTAMICIN LEVEL, PLASMALaboratory30980170$ 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
335613LITHIUM LEVELLaboratory30180178$ 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
80185DILANTINLaboratory30180185$ 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
33534482TACRILIMUS FK506 LEVELLaboratory30180197$ 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
80198THEOPHYLLINELaboratory30180198$ 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
3358579VANCOMYCIN, TROUGHLaboratory30180202$ 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
80202VANCOMYCIN LEVEL, PLASMALaboratory30980202$ 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
80100URINE DRUG SCREENLaboratory30180305$ 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
335372C PEPTIDELaboratory30180432$ 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
81001URINE/WITH MICROSCOPYLaboratory30781001$ 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
81003URINE/WITHOUT MICROSCOPYLaboratory30781003$ 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
R81002URINALYSIS-RURAL HEALTHLaboratory30781003$ 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
81025PREGNANCY/URINELaboratory30781025$ 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
82009ACETONELaboratory30182009$ 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
82040ALBUMINLaboratory30182040$ 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
82044MICROALBUMINLaboratory30182044$ 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
82140AMMONIALaboratory30182140$ 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
82150AMYLASE (SERUM/URINE)Laboratory30182150$ 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
82247BILIRUBIN TOTALLaboratory30182247$ 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
82270OCCULT BLOOD (STOOLX3)Laboratory30182270$ 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
82272OCCULT BLOOD,FECAL,SINGLE COLLLaboratory30182272$ 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
33517306VITAMIN D 25 HYDROXYLaboratory30082306$ 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
82310CALCIUMLaboratory30182310$ 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
82330CALCIUM, IONIZEDLaboratory30182330$ 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
33582340CALCIUM, 24 HR URINELaboratory30182340$ 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
335978CEALaboratory30182378$ 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
3354212CORTISOL AMLaboratory30182533$ 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
82550CPKLaboratory30182550$ 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
82553CKMBLaboratory30182553$ 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
82565CREATININELaboratory30182565$ 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
3358459CREATANINE URINE RANDOMLaboratory30182570$ 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
33521618CREATININE URINE RANDOMLaboratory30182570$ 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
3357943CREATININE CLEARANCELaboratory30182575$ 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
335927VITAMIN B12 CHEMISTRYLaboratory30182607$ 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
335402DHEA SULFATELaboratory30182627$ 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
3354729VIT D,1,25-DIHYDROXYLaboratory30182652$ 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
335429ESTRADIOLLaboratory30182670$ 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
335439ESTROGENLaboratory30182672$ 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
335457FERRITIN LEVELLaboratory30182728$ 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
335466FOLATE, SERUMLaboratory30182746$ 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 DEPTREV CODECPT CODEGross ChargeCash PriceAetnaBCBS - Blue Essentials HMOBCBS - TraditionalBCBS - PPOCignaHumanaScott & WhiteShannonUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
335467FOLIC ACIDLaboratory30182746$ 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
A33515980GAMMAGLOBULIN IGA IGD IGM EALaboratory30082784$ 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
3357083IMMUNOGLOBULINSLaboratory30182784$ 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
82803ARTERIAL BLOOD GASLaboratory30182803$ 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
GLM200BLOOD REAGENT STRIPLaboratory30082948$ 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
G82951GLUCOSE TOLERANCE 3 SPECIMENSLaboratory30082951$ 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
G82952GLUCOSE EACH ADDITIONAL SPECLaboratory30082952$ 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
335482GGTLaboratory30182977$ 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
335470FSHLaboratory30183001$ 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
335615LHLaboratory30183002$ 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
309001HGB AICLaboratory30183036$ 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
B33515980INFECT AGENT ANTIGENLaboratory30083516$ 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
3357573IRON AND TIBCLaboratory30083540$ 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
335571IRON, TOTALLaboratory30183540$ 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
83605LACTIC ACIDLaboratory30083605$ 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
335593LDHLaboratory30083615$ 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
335599LEAD LEVELLaboratory30183655$ 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
83690LIPASE, SERUMLaboratory30083690$ 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
83721LDL, DIRECTLaboratory30183721$ 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
83735MAGNESIUMLaboratory30183735$ 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
83880B-TYPE NATRIUETIC PEPTIDELaboratory30183880$ 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
3358446PTH INTACTLaboratory30183970$ 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
335231ALKALINE PHOSPHAT, ISOENZYMESLaboratory30184080$ 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
84100PHOSPHOROUSLaboratory30184100$ 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
84132POTASSIUMLaboratory30184132$ 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
335745PROGESTERONE LEVELLaboratory30184144$ 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
335746PROLACTIN LEVELLaboratory30184146$ 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
84153PSA#Laboratory30184153$ 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
G84153PSA TOTALLaboratory30184153$ 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
G84154PSA FREELaboratory30184154$ 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
3351715T PROTEIN W/CREAT, RANDOM URNELaboratory30184155$ 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
335747PROTEIN ELECTROPHORESISLaboratory30184155$ 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
G84402TESTOSTERONE FREELaboratory30184402$ 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
G84403TESTOSTERONE TOTALLaboratory30184403$ 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
335873TESTOSTERONE, TOTALLaboratory30184403$ 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
33536170TESTOSTERONE FREE & TOTALLaboratory30184403$ 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
33584425Thiamine (Vitamin B1)Laboratory30084425$ 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
335867T4, TOTALLaboratory30184436$ 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
84439FREE T4Laboratory30184439$ 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
84443TSH#Laboratory30184443$ 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
84450ASTLaboratory30184450$ 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
84460ALTLaboratory30184460$ 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
335891TRANSFERRINLaboratory30184466$ 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
84478TRIGLYCERIDES#Laboratory30184478$ 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
335859T3, TOTALLaboratory30184480$ 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
33534429FT3Laboratory30184481$ 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
84484TROPONINLaboratory30184484$ 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
84520UREA NITROGEN (BUN)Laboratory30184520$ 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
84550URIC ACIDLaboratory30184550$ 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
3358396HCG, QUANTLaboratory30084702$ 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
84703PREGNANCY TEST (SERUM)Laboratory30184703$ 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
85007DIFFERENTIAL (MANUAL)Laboratory30585007$ 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
85014HEMATOCRIT#Laboratory30085014$ 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
85018HEMOGLOBIN#Laboratory30085018$ 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
85025CBC COMPLETE AUTO W AUTO DIFF#Laboratory30585025$ 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
335793RETICULOCYTE COUNTLaboratory30085045$ 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
85379D-DIMERLaboratory30585379$ 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
85610PROTHROMBIN TIME/INR#Laboratory30085610$ 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
185610PROTHROMBIN TIME FINGERLaboratory30185610$ 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
85651SEDIMENTATION RATE (ESR)Laboratory30585651$ 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
85730APTTLaboratory30585730$ 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
335249ANALaboratory30286038$ 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
86140C-REACTIVE PROTEINLaboratory30286140$ 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
86141CRP High SensitivityLaboratory30086141$ 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
3350001Hu Antibody screen w/ reflexLaboratory30086255$ 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
33529493CA 2729Laboratory30086300$ 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
86308MONOSPOTLaboratory30286308$ 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 DEPTREV CODECPT CODEGross ChargeCash PriceAetnaBCBS - Blue Essentials HMOBCBS - TraditionalBCBS - PPOCignaHumanaScott & WhiteShannonUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
33529256CA 125Laboratory30286316$ 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
3355081ANTI TPOLaboratory30286376$ 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
3354418RHEUMATOID FACTORLaboratory30286431$ 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
3351761RPRLaboratory30286592$ 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
86677H. PYLORI ANTIBODYLaboratory30286677$ 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
G0432HIV SCREENINGLaboratory30086703$ 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
33519728HIV 1 & 2 WITH REFLEXLaboratory33586703$ 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
335499HBSABLaboratory30286706$ 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
86710INFLUENZA A&BLaboratory30286710$ 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
3358624MUMPS ANTIBODYLaboratory30086735$ 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
335802RUBELLA IGG ABLaboratory30286762$ 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
335964MEASLES (RUBEOLA)Laboratory30086765$ 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
33586769COVID-19 Antibody testLaboratory30086769$ 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
3354439VARICELLA ZOSTER IG G ABLaboratory30286787$ 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
3358472ANTI HCV HEP C ANTIBODYLaboratory30286803$ 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
86850ANTIBODY SCREENLaboratory30286850$ 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
86900ABOLaboratory39086900$ 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
86901RH TYPELaboratory30286901$ 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
86904ACROSSMATCH EA UNITLaboratory30286904$ 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
335389CULTURE, BLOODLaboratory30687040$ 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
33510019CULTURE STOOL SALM/SHIGLaboratory30687045$ 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
87070CULTURE, BACT ANY SOUCELaboratory30687070$ 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
9621ACULTURE, WOUNDLaboratory30687070$ 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
3354550CULTURE, AEROBICLaboratory30687070$ 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
3354556CULTURE SPUTUMLaboratory30087070$ 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
335394CULTURE THROATLaboratory30687070$ 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
3354473CULTURE, BODY FLUIDLaboratory30687070$ 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 1ORGANISM ID AnaeriobicLaboratory30687076$ 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
87077CLO TEST RAPID UREASE TESTLaboratory30187077$ 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
3060001AEROBIC ISOLATE 1Laboratory30687077$ 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
1URORGANISM ID AerobiocLaboratory30687077$ 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
335349CULTURE, THROATLaboratory30687081$ 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
87086CULTURE, URINELaboratory30687086$ 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
87088CULTURE URINE W/ISOLATIONLaboratory30687088$ 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
335395CULTURE, URINELaboratory30687088$ 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
335681OVA AND PARASITE ONCE ONLYLaboratory30087177$ 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
87186SUSCEPTIBILITY 1Laboratory30687186$ 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
87187SUSCEPTIBILITY 2Laboratory30687187$ 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
87220KOH PREPLaboratory30687205$ 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
87210WET MOUNTLaboratory30687210$ 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
3358756C DIFF TOXIN ALaboratory30687324$ 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
33534838H. PYLORI ANTIGEN, STOOLLaboratory30687338$ 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
335498HBSAGLaboratory30687340$ 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
87420RSV ANTIGEN EIALaboratory30687420$ 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
86588STREP ALaboratory30687430$ 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
87430STREPTOCOCCUS GRP A RAPID ANTILaboratory30687430$ 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
3356919CHLAMYDIA AND GC GEN PROBELaboratory30087491$ 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
3350002COVID-19 REFERENCE LABLaboratory30087635$ 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
187804AINFLUENZALaboratory30687804$ 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
3353471CYTOLOGY, FLUIDLaboratory31188104$ 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
33588300Path Surgical Level 1 G&MLaboratory30088300$ 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
33897012MECHANICAL TRACTIONPhysical Therapy42097012$ 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
33897016VASOPNEUMATIC DEVICEPhysical Therapy42097016$ 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
33897035ULTRASOUNDPhysical Therapy42097035$ 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
33897110THERAPEUTIC EXERCISEPhysical Therapy42097110$ 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
33897116GAIT TRAININGPhysical Therapy42097116$ 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
33897140MANUAL THERAPYPhysical Therapy42097140$ 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
97161PT EVAL; LOW COMPLEXITYPhysical Therapy42097161$ 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
33897001PHYSICAL THERAPY EVALUATIONPhysical Therapy42497161$ 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
97162PT EVAL; MODERATE COMPLEXITYPhysical Therapy42097162$ 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
33897002PHYSICAL THERAPY RE-EVALUATIONPhysical Therapy42497164$ 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
70220SINUSES-3 VIEWSRadiology Diagnostic32070220$ 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
70360NECK-SOFT TISSUERadiology Diagnostic32070360$ 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
70450HEAD W/O CONTRAST CT#Radiology Diagnostic35170450$ 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
70470HEAD W/O & W/CONTRAST CT#Radiology Diagnostic35170470$ 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 DEPTREV CODECPT CODEGross ChargeCash PriceAetnaBCBS - Blue Essentials HMOBCBS - TraditionalBCBS - PPOCignaHumanaScott & WhiteShannonUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
70486FACIAL AREA W/O CONTRASTRadiology Diagnostic35170486$ 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
70487FACIAL AREA W/CONTRAST CTRadiology Diagnostic35170487$ 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
70490NECK SFT TISS W/O CONTRAST CTRadiology Diagnostic35170490$ 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
70491NECK SFT TISS W/CONTRAST CTRadiology Diagnostic35170491$ 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
71010CHEST-1 VIEWRadiology Diagnostic32471045$ 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
71020CHEST-2 VIEWSRadiology Diagnostic32471046$ 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
171100R UNILAT RIBS 2-3 VIEWRadiology Diagnostic32071100$ 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
71100L UNILAT RIBS 2-3 VIEWRadiology Diagnostic32071100$ 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
71250CHEST W/O CONTRAST CT#Radiology Diagnostic35271250$ 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
71260CHEST W/CONTRAST CT#Radiology Diagnostic35271260$ 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
71270CHEST W/O & W/CONTRAST CT#Radiology Diagnostic35271270$ 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
72040SPINE CERVICAL 2-3 VIEWSRadiology Diagnostic32072040$ 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
72070SPINE THORACIC 2 VIEWSRadiology Diagnostic32072070$ 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
72100SPINE LUMBAR 2-3 VIEWSRadiology Diagnostic32072100$ 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
72110SPINE LUMBAR 4-5 VIEWSRadiology Diagnostic32072110$ 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
72125SPINE CERVICAL W/O CNTRST CT#Radiology Diagnostic35272125$ 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
72128SPINE THORACIC W/O CNTRST CT#Radiology Diagnostic35272128$ 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
72131SPINE LUMBAR W/O CONTRAST CT#Radiology Diagnostic35272131$ 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
72170PELVIS 1-2 VIEWSRadiology Diagnostic32072170$ 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
72192PELVIS, W/O CONTRAST CTRadiology Diagnostic35272192$ 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
72193PELVIS W/CONTRAST CTRadiology Diagnostic35272193$ 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
73000L CLAVICLE-2 VIEWSRadiology Diagnostic32073000$ 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
173000R CLAVICLE 2 VIEWSRadiology Diagnostic32073000$ 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
173020R SHOULDER 1 VIEWRadiology Diagnostic32073020$ 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
173030R SHOULDER 2 VIEWSRadiology Diagnostic32073030$ 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
73030L SHOULDER-2 VIEWSRadiology Diagnostic32073030$ 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
173060R HUMERUS 2 VIEWSRadiology Diagnostic32073060$ 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
73060L HUMERUS-2 VIEWSRadiology Diagnostic32073060$ 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
73070L ELBOW 1-2 VIEWSRadiology Diagnostic32073070$ 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
173070R ELBOW1- 2 VIEWSRadiology Diagnostic32073070$ 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
173080R ELBOW- 3 to 4 viewsRadiology Diagnostic32073080$ 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
73080L ELBOW- 3-4 viewsRadiology Diagnostic32073080$ 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
73090L FOREARM-2 VIEWSRadiology Diagnostic32073090$ 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
173090R FOREARM 2 VIEWSRadiology Diagnostic32073090$ 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
73100L WRIST-2 VIEWSRadiology Diagnostic32073100$ 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
173100R WRIST 2 VIEWSRadiology Diagnostic32073100$ 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
173110R WRIST 3-4 VIEWSRadiology Diagnostic32073110$ 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
73110L WRIST 3-4 VIEWSRadiology Diagnostic32073110$ 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
173120R HAND 1-2 VIEWSRadiology Diagnostic32073120$ 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
73120L HAND 1-2 VIEWSRadiology Diagnostic32073120$ 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
173130R HAND 3-4 VIEWSRadiology Diagnostic32073130$ 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
73130L HAND 3-4 VIEWSRadiology Diagnostic32073130$ 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
173140R FINGERS- 2 to 4 viewsRadiology Diagnostic32073140$ 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
73140L FINGER- 2 to 4 viewsRadiology Diagnostic32073140$ 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
173200R EXT UPPER W/O CONTRAST CTRadiology Diagnostic35073200$ 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
173500R HIP w/Pelvis 1 viewRadiology Diagnostic32073501$ 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
73502L Hip w/Pelvis - 2-3 viewsRadiology Diagnostic32073502$ 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
173510R HIP w/Pelvis 2-3 viewsRadiology Diagnostic32073502$ 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
73522Bilateral Hips xray w/ pelvis 3-4 viewsRadiology Diagnostic32073522$ 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
1735502R FEMUR 1 VIEWRadiology Diagnostic32073551$ 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
73550L FEMUR-2 VIEWRadiology Diagnostic32073552$ 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
173550R FEMUR 2 VIEW minRadiology Diagnostic32073552$ 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
173560R KNEE - 1 to 2 viewsRadiology Diagnostic32073560$ 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
73560L KNEE-1 to 2 viewsRadiology Diagnostic32073560$ 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
173562R KNEE 3 VIEWSRadiology Diagnostic32073562$ 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
73562L KNEE-3 VIEWSRadiology Diagnostic32073562$ 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
173590R LEG 2 VIEWSRadiology Diagnostic32073590$ 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
73590L LEG-2 VIEWSRadiology Diagnostic32073590$ 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
173600R ANKLE 2 VIEWSRadiology Diagnostic32073600$ 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
73600L ANKLE-2 VIEWSRadiology Diagnostic32073600$ 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
73610L ANKLE-3 VIEWSRadiology Diagnostic32073610$ 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
173610R ANKLE 3 VIEWSRadiology Diagnostic32073610$ 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
173630R FOOT 3 VIEWSRadiology Diagnostic32073630$ 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
73630L FOOT-3 VIEWSRadiology Diagnostic32073630$ 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
73650L OS CALCIS-2 VIEWSRadiology Diagnostic32073650$ 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 DEPTREV CODECPT CODEGross ChargeCash PriceAetnaBCBS - Blue Essentials HMOBCBS - TraditionalBCBS - PPOCignaHumanaScott & WhiteShannonUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
173650R OS CALLIS 2 VIEWSRadiology Diagnostic32073650$ 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
173660R TOES 2 VIEWSRadiology Diagnostic32073660$ 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
73660L TOES 2 VIEWSRadiology Diagnostic32073660$ 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
173700R EXT LOWER W/O CONTRAST CTRadiology Diagnostic35073700$ 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
73700L EXT LOWER W/O CONTRAST CTRadiology Diagnostic35073700$ 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
74000ABDOMEN-1 VIEWRadiology Diagnostic32074018$ 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
74020ABDOMEN-2 VIEWSRadiology Diagnostic32074019$ 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
74022ABDOMEN-ACUTERadiology Diagnostic32074022$ 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
74150ABDOMEN W/O CONTRAST CTRadiology Diagnostic35274150$ 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
74160ABDOMEN W/CONTRAST CTRadiology Diagnostic35274160$ 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
74176CT ABDOMEN/PELVIS W/O CONTRASTRadiology Diagnostic35274176$ 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
74177CT ABDOMEN/PELVIS W/CONTRASTRadiology Diagnostic35274177$ 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
74178CT ABDOMEN/PELVIS W/WO CONTRSTRadiology Diagnostic35274178$ 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
76536US: THYROID/PARATHYROIDRadiology Diagnostic40276536$ 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
76700US:ABDOMEN COMPLETERadiology Diagnostic40276700$ 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
76705US:ABDOMEN LIMITEDRadiology Diagnostic40276705$ 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
767055US Soft Tissue OtherRadiology Diagnostic40276705$ 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
G0389Ultrasound AAA ScreeningRadiology Diagnostic40276706$ 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
76770ULTRASOUND/ RENAL,BILATERALRadiology Diagnostic40276770$ 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
76775US: RETROPERITONEAL LIMITEDRadiology Diagnostic40276775$ 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
76801US: OB 1ST TRIMESTERRadiology Diagnostic40276801$ 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
76805US: OB 2ND TRIMESTERRadiology Diagnostic40276805$ 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
76815US OB LimitedRadiology Diagnostic40276815$ 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
76817US OB TRANSVAGINALRadiology Diagnostic40276817$ 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
76830IVT/TRANSVAGINAL PROBERadiology Diagnostic40276830$ 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
76856ULTRASOUND-PELVIC COMPLETERadiology Diagnostic40276856$ 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
76857US: PELVIC LIMITED OR FOLLOWUPRadiology Diagnostic40276857$ 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
76870ULTRASOUND TESTICULARRadiology Diagnostic40276870$ 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
76882US: EXTREMITY SOFT TISSUERadiology Diagnostic40276882$ 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
93880CAROTID DOPPLER BILATERALRadiology Diagnostic92193880$ 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
93922VASCULAR STUDY UP/LOW EXT ARTRadiology Diagnostic92193922$ 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
93925BILATERAL ARTERIAL SCAN LOWERRadiology Diagnostic92193925$ 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
93970VENOUS STUDY BILATERALRadiology Diagnostic92193970$ 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
93971VENOUS STUDY UNILATERALRadiology Diagnostic92193971$ 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
199203OFFICE VISIT NEW PATIENT L-3Rural Health Clinic52199203$ 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
199204OFFICE VISIT NEW PATIENT L-4Rural Health Clinic52199204$ 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
199205OFFICE VISIT NEW PATIENT L-5Rural Health Clinic52199205$ 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
199385PREVENTIVE, NEW PT, AGE 18-39 YRSRural Health Clinic52199385$ 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
199386PREVENTIVE, NEW PT AGE 40-64Rural Health Clinic52199386$ 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.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.  This included related costs like medical test, prescription drugs, equipment, and hospital fees.
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