OVERVIEW
In compliance with the Centers for Medicare and Medicaid Services (CMS), Schleicher County Medical Center is making available to the public a copy of its standard charges known as a “Charge Master,” “Charge Description Master” or “CDM”.
Since payment rates for hospital care provided to insured patients are either negotiated with health plans, set by the federal government for Medicare, or set by state governments for Medicaid enrollees, the payments hospitals receive for patient care do not necessarily reflect the prices reflected in the Charge Master. A patient’s responsibility may vary depending on the payment plans negotiated with insurance companies as well as the patient’s individual and/or family deductibles and co-payments with their insurance plan. Additionally, uninsured patients are not generally expected to pay the hospital’s standard charges as reflected in the CDM and may be eligible for financial assistance.
The information provided is based on information we have gathered from contracts with managed care commercial insurance plans. This is not a guarantee of what you will be charged. Your actual charges may differ from the estimated charges for many reasons, including the seriousness of your medical condition, actual time the procedure takes and the services and supplies that you receive.
The charges listed here are for services from the Hospital. They do not reflect the charges for physicians (such as surgeon, anesthesiologist, radiologist, pathologist, etc.) who may be involved in providing particular services to a patient. These charges are billed separately from the individual physician/physicians group.
Schleicher County Medical Center shall not be liable for any difference between charges listed in the price lists and the final bill for services.
AVAILABLE FILES
There are two files regarding the hospital’s CDM for price transparency.
The CSV file is a comprehensive, machine-readable file that makes public all standard charge information for all hospital items and services. This can easily be imported into Microsoft Excel or similar software. This file contains the following information:
The PDF file is a searchable consumer-friendly format of payer-specific negotiated charge information of 300 “shoppable outpatient services” at the hospital. The file contains the following information:
QUESTIONS?
If you have further questions about the Schleicher County Medical Center 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 Schleicher County Medical Center for your health care needs!
Schlecher County Medical Center Shoppable Services as of 7/15/2022
Charge Code | Charge Code Description | Dept # | Dept | Rev Code | CPT Code | Gross Charge | Discounted Cash Price | Aetna | BCBS - Blue Adv | BCBS - HMO | BCBS - PPO | BCBS - Trad | CIGNA | Scott & White | United | Minimum Negotiated Rate | Maximum Negotiated Rate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
73093000 | EKG ROUTINE 12 LEAD | 730 | EKG/ECG | 730 | 93000 | $152.00 | $98.80 | $98.80 | $141.36 | $129.20 | $129.20 | $129.20 | $115.52 | $129.20 | $115.52 | $98.80 | $141.36 |
730G0403 | EKG, 12 LEADS SCREENING INITIAL MCR PREV | 730 | EKG/ECG | 730 | G0403 | $103.00 | $66.95 | $66.95 | $95.79 | $87.55 | $87.55 | $87.55 | $78.28 | $87.55 | $78.28 | $66.95 | $95.79 |
73093005 | EKG,12 LEADS,TRACING ONLY | 730 | EKG/ECG | 730 | 93005 | $103.00 | $66.95 | $66.95 | $95.79 | $95.79 | $95.79 | $95.79 | $78.28 | $87.55 | $78.28 | $66.95 | $95.79 |
32093005 | EKG/12 LEADS TRCG ONLY WO IR | 730 | EKG/ECG | 730 | 93005 | $90.00 | $58.50 | $58.50 | $83.70 | $76.50 | $76.50 | $76.50 | $68.40 | $76.50 | $68.40 | $58.50 | $83.70 |
30082306 | 25-HYDROXYVITAMIN D2 & D3 | 300 | Laboratory | 300 | 82306 | $196.00 | $127.40 | $127.40 | $182.28 | $166.60 | $166.60 | $166.60 | $148.96 | $166.60 | $148.96 | $127.40 | $182.28 |
30086900 | ABO BLOOD TYPING | 300 | Laboratory | 390 | 86900 | $82.67 | $53.74 | $53.74 | $76.88 | $70.27 | $70.27 | $70.27 | $62.83 | $70.27 | $62.83 | $53.74 | $76.88 |
30082040 | ALBUMIN/SERUM | 300 | Laboratory | 300 | 82040 | $49.00 | $31.85 | $31.85 | $45.57 | $41.65 | $41.65 | $41.65 | $37.24 | $41.65 | $37.24 | $31.85 | $45.57 |
30082103 | ALPHA1-ANTITRYPSIN, TOTAL | 300 | Laboratory | 300 | 82103 | $506.00 | $328.90 | $328.90 | $470.58 | $430.10 | $430.10 | $430.10 | $384.56 | $430.10 | $384.56 | $328.90 | $470.58 |
30082105 | ALPHA-FETOPROTEIN | 300 | Laboratory | 300 | 82105 | $173.00 | $112.45 | $112.45 | $160.89 | $147.05 | $147.05 | $147.05 | $131.48 | $147.05 | $131.48 | $112.45 | $160.89 |
30084460 | ALT (SGPT) | 300 | Laboratory | 300 | 84460 | $94.00 | $61.10 | $61.10 | $87.42 | $79.90 | $79.90 | $79.90 | $71.44 | $79.90 | $71.44 | $61.10 | $87.42 |
30080335 | Amitriptyline, Serum | 300 | Laboratory | 300 | 80335 | $43.00 | $27.95 | $27.95 | $39.99 | $36.55 | $36.55 | $36.55 | $32.68 | $36.55 | $32.68 | $27.95 | $39.99 |
30082140 | AMMONIA | 300 | Laboratory | 300 | 82140 | $139.00 | $90.35 | $90.35 | $129.27 | $118.15 | $118.15 | $118.15 | $105.64 | $118.15 | $105.64 | $90.35 | $129.27 |
30082150 | AMYLASE/SERUM | 300 | Laboratory | 300 | 82150 | $88.00 | $57.20 | $57.20 | $81.84 | $74.80 | $74.80 | $74.80 | $66.88 | $74.80 | $66.88 | $57.20 | $81.84 |
30086038 | ANA | 300 | Laboratory | 300 | 86038 | $94.00 | $61.10 | $61.10 | $87.42 | $79.90 | $79.90 | $79.90 | $71.44 | $79.90 | $71.44 | $61.10 | $87.42 |
30086850 | ANTIBODY SCREEN RBC | 300 | Laboratory | 300 | 86850 | $39.00 | $25.35 | $25.35 | $36.27 | $33.15 | $33.15 | $33.15 | $29.64 | $33.15 | $29.64 | $25.35 | $36.27 |
30082180 | Asorbic acid (vitamin C) | 300 | Laboratory | 300 | 82180 | $30.00 | $19.50 | $19.50 | $27.90 | $25.50 | $25.50 | $25.50 | $22.80 | $25.50 | $22.80 | $19.50 | $27.90 |
30084305 | ASSAY OF SOMATOMEDIN | 300 | Laboratory | 300 | 84305 | $57.00 | $37.05 | $37.05 | $53.01 | $48.45 | $48.45 | $48.45 | $43.32 | $48.45 | $43.32 | $37.05 | $53.01 |
30084597 | ASSAY VITAMIN K | 300 | Laboratory | 300 | 84597 | $251.00 | $163.15 | $163.15 | $233.43 | $213.35 | $213.35 | $213.35 | $190.76 | $213.35 | $190.76 | $163.15 | $233.43 |
30084450 | AST (SGOT) | 300 | Laboratory | 300 | 84450 | $94.00 | $61.10 | $61.10 | $87.42 | $79.90 | $79.90 | $79.90 | $71.44 | $79.90 | $71.44 | $61.10 | $87.42 |
30080048 | BASIC METABOLIC PANEL | 300 | Laboratory | 300 | 80048 | $180.00 | $117.00 | $117.00 | $167.40 | $153.00 | $153.00 | $153.00 | $136.80 | $153.00 | $136.80 | $117.00 | $167.40 |
30082248 | BILIRUBIN/DIRECT | 300 | Laboratory | 300 | 82248 | $91.00 | $59.15 | $59.15 | $84.63 | $77.35 | $77.35 | $77.35 | $69.16 | $77.35 | $69.16 | $59.15 | $84.63 |
30082247 | BILIRUBIN/TOTAL | 300 | Laboratory | 300 | 82247 | $78.00 | $50.70 | $50.70 | $72.54 | $66.30 | $66.30 | $66.30 | $59.28 | $66.30 | $59.28 | $50.70 | $72.54 |
30087799 | BK Virus Quanti | 300 | Laboratory | 300 | 87799 | $375.00 | $243.75 | $243.75 | $348.75 | $318.75 | $318.75 | $318.75 | $285.00 | $318.75 | $285.00 | $243.75 | $348.75 |
30082310 | CALCIUM/TOTAL/BLOOD | 300 | Laboratory | 300 | 82310 | $72.00 | $46.80 | $46.80 | $66.96 | $61.20 | $61.20 | $61.20 | $54.72 | $61.20 | $54.72 | $46.80 | $66.96 |
30082360 | CALCULUS ASSAY QUANT | 300 | Laboratory | 300 | 82360 | $63.00 | $40.95 | $40.95 | $58.59 | $53.55 | $53.55 | $53.55 | $47.88 | $53.55 | $47.88 | $40.95 | $58.59 |
30086304 | CANCER ANTIGEN 125 | 300 | Laboratory | 300 | 86304 | $148.00 | $96.20 | $96.20 | $137.64 | $125.80 | $125.80 | $125.80 | $112.48 | $125.80 | $112.48 | $96.20 | $137.64 |
30086300 | CANCER ANTIGEN CA-15-3/2729 | 300 | Laboratory | 300 | 86300 | $173.00 | $112.45 | $112.45 | $160.89 | $147.05 | $147.05 | $147.05 | $131.48 | $147.05 | $131.48 | $112.45 | $160.89 |
30086147 | Cardiolipin Antibody Each IG Class | 300 | Laboratory | 300 | 86147 | $36.00 | $23.40 | $23.40 | $33.48 | $30.60 | $30.60 | $30.60 | $27.36 | $30.60 | $27.36 | $23.40 | $33.48 |
30087324 | C-DIFF | 300 | Laboratory | 300 | 87324 | $112.00 | $72.80 | $72.80 | $104.16 | $95.20 | $95.20 | $95.20 | $85.12 | $95.20 | $85.12 | $72.80 | $104.16 |
30089051 | CELL COUNT, W/DIFF COUNT | 300 | Laboratory | 300 | 89051 | $31.00 | $20.15 | $20.15 | $28.83 | $26.35 | $26.35 | $26.35 | $23.56 | $26.35 | $23.56 | $20.15 | $28.83 |
30088305 | CELL PATH GROSS & MICR- LEV 4 | 300 | Laboratory | 300 | 88305 | $271.00 | $176.15 | $176.15 | $252.03 | $230.35 | $230.35 | $230.35 | $205.96 | $230.35 | $205.96 | $176.15 | $252.03 |
30082390 | Ceruloplasmin | 300 | Laboratory | 300 | 82390 | $15.00 | $9.75 | $9.75 | $13.95 | $12.75 | $12.75 | $12.75 | $11.40 | $12.75 | $11.40 | $9.75 | $13.95 |
30087491 | CHLAMYDIA TRACHOMATIS, AMPLI | 300 | Laboratory | 300 | 87491 | $130.00 | $84.50 | $84.50 | $120.90 | $110.50 | $110.50 | $110.50 | $98.80 | $110.50 | $98.80 | $84.50 | $120.90 |
30082553 | CK MB FRACTION ONLY | 300 | Laboratory | 300 | 82553 | $183.00 | $118.95 | $118.95 | $170.19 | $155.55 | $155.55 | $155.55 | $139.08 | $155.55 | $139.08 | $118.95 | $170.19 |
30082550 | CK/CPK /TOTAL | 300 | Laboratory | 300 | 82550 | $110.00 | $71.50 | $71.50 | $102.30 | $93.50 | $93.50 | $93.50 | $83.60 | $93.50 | $83.60 | $71.50 | $102.30 |
30086635 | Coccidiodes Anitbody by comp fix | 300 | Laboratory | 300 | 86635 | $75.00 | $48.75 | $48.75 | $69.75 | $63.75 | $63.75 | $63.75 | $57.00 | $63.75 | $57.00 | $48.75 | $69.75 |
30082542 | COLUMN CHROMOTOGRAPHY QUANT | 300 | Laboratory | 300 | 82542 | $92.00 | $59.80 | $59.80 | $85.56 | $78.20 | $78.20 | $78.20 | $69.92 | $78.20 | $69.92 | $59.80 | $85.56 |
30086920 | COMP.TEST EACH UNIT | 300 | Laboratory | 300 | 86920 | $136.00 | $88.40 | $88.40 | $126.48 | $115.60 | $115.60 | $115.60 | $103.36 | $115.60 | $103.36 | $88.40 | $126.48 |
30086160 | COMPLEMENT;ANTIGEN, EACH COMP. | 300 | Laboratory | 300 | 86160 | $112.00 | $72.80 | $72.80 | $104.16 | $95.20 | $95.20 | $95.20 | $85.12 | $95.20 | $85.12 | $72.80 | $104.16 |
30085025 | COMPLETE CBC AUTO/AUTODIF | 300 | Laboratory | 300 | 85025 | $72.00 | $46.80 | $46.80 | $66.96 | $61.20 | $61.20 | $61.20 | $54.72 | $61.20 | $54.72 | $46.80 | $66.96 |
30085027 | COMPLETE CBC AUTOMATED | 300 | Laboratory | 300 | 85027 | $91.00 | $59.15 | $59.15 | $84.63 | $77.35 | $77.35 | $77.35 | $69.16 | $77.35 | $69.16 | $59.15 | $84.63 |
30080053 | COMPREHEN. METABOLIC PANE | 300 | Laboratory | 300 | 80053 | $261.00 | $169.65 | $169.65 | $242.73 | $221.85 | $221.85 | $221.85 | $198.36 | $221.85 | $198.36 | $169.65 | $242.73 |
30086140 | C-REACTIVE PROTEIN | 300 | Laboratory | 300 | 86140 | $78.00 | $50.70 | $50.70 | $72.54 | $66.30 | $66.30 | $66.30 | $59.28 | $66.30 | $59.28 | $50.70 | $72.54 |
30086141 | C-REACTIVE PROTEIN HS | 300 | Laboratory | 300 | 86141 | $61.00 | $39.65 | $39.65 | $56.73 | $51.85 | $51.85 | $51.85 | $46.36 | $51.85 | $46.36 | $39.65 | $56.73 |
30082570 | CREATININE (OTHER SOURCE) | 300 | Laboratory | 300 | 82570 | $72.00 | $46.80 | $46.80 | $66.96 | $61.20 | $61.20 | $61.20 | $54.72 | $61.20 | $54.72 | $46.80 | $66.96 |
30082565 | CREATININE/BLOOD | 300 | Laboratory | 300 | 82565 | $72.00 | $46.80 | $46.80 | $66.96 | $61.20 | $61.20 | $61.20 | $54.72 | $61.20 | $54.72 | $46.80 | $66.96 |
30089060 | CRYSTAL I.D. | 300 | Laboratory | 300 | 89060 | $62.00 | $40.30 | $40.30 | $57.66 | $52.70 | $52.70 | $52.70 | $47.12 | $52.70 | $47.12 | $40.30 | $57.66 |
30087077 | CULTURE, AEROBIC IDENTIFY | 300 | Laboratory | 300 | 87077 | $37.00 | $24.05 | $24.05 | $34.41 | $31.45 | $31.45 | $31.45 | $28.12 | $31.45 | $28.12 | $24.05 | $34.41 |
30087040 | CULTURE/BLOOD | 300 | Laboratory | 300 | 87040 | $165.00 | $107.25 | $107.25 | $153.45 | $140.25 | $140.25 | $140.25 | $125.40 | $140.25 | $125.40 | $107.25 | $153.45 |
30087070 | CULTURE/OTHER SOURCE | 300 | Laboratory | 300 | 87070 | $110.00 | $71.50 | $71.50 | $102.30 | $93.50 | $93.50 | $93.50 | $83.60 | $93.50 | $83.60 | $71.50 | $102.30 |
30087081 | CULTURE/SCREENING ONLY | 300 | Laboratory | 300 | 87081 | $135.00 | $87.75 | $87.75 | $125.55 | $114.75 | $114.75 | $114.75 | $102.60 | $114.75 | $102.60 | $87.75 | $125.55 |
30087045 | CULTURE/STOOL | 300 | Laboratory | 300 | 87045 | $105.00 | $68.25 | $68.25 | $97.65 | $89.25 | $89.25 | $89.25 | $79.80 | $89.25 | $79.80 | $68.25 | $97.65 |
30087046 | CULTURE/STOOL BACT ISOLATION | 300 | Laboratory | 300 | 87046 | $50.00 | $32.50 | $32.50 | $46.50 | $42.50 | $42.50 | $42.50 | $38.00 | $42.50 | $38.00 | $32.50 | $46.50 |
30087086 | CULTURE/URINE | 300 | Laboratory | 300 | 87086 | $110.00 | $71.50 | $71.50 | $102.30 | $93.50 | $93.50 | $93.50 | $83.60 | $93.50 | $83.60 | $71.50 | $102.30 |
30082607 | CYANOCOBALAMIN (B-12) | 300 | Laboratory | 300 | 82607 | $123.00 | $79.95 | $79.95 | $114.39 | $104.55 | $104.55 | $104.55 | $93.48 | $104.55 | $93.48 | $79.95 | $114.39 |
30085379 | D-DIMER, QUANTITATIVE | 300 | Laboratory | 300 | 85379 | $41.00 | $26.65 | $26.65 | $38.13 | $34.85 | $34.85 | $34.85 | $31.16 | $34.85 | $31.16 | $26.65 | $38.13 |
30082627 | DEHYDROEPLANDROSTERONE | 300 | Laboratory | 300 | 82627 | $60.00 | $39.00 | $39.00 | $55.80 | $51.00 | $51.00 | $51.00 | $45.60 | $51.00 | $45.60 | $39.00 | $55.80 |
30087800 | DETECT AGNTMULT DNA DIRECT | 300 | Laboratory | 300 | 87800 | $181.00 | $117.65 | $117.65 | $168.33 | $153.85 | $153.85 | $153.85 | $137.56 | $153.85 | $137.56 | $117.65 | $168.33 |
30080162 | DIGOXIN | 300 | Laboratory | 300 | 80162 | $167.00 | $108.55 | $108.55 | $155.31 | $141.95 | $141.95 | $141.95 | $126.92 | $141.95 | $126.92 | $108.55 | $155.31 |
30086225 | DNA ANTIBODY;NATIVE/DBL STRAND | 300 | Laboratory | 300 | 86225 | $200.00 | $130.00 | $130.00 | $186.00 | $170.00 | $170.00 | $170.00 | $152.00 | $170.00 | $152.00 | $130.00 | $186.00 |
30080307 | Drug Screen | 300 | Laboratory | 300 | 80307 | $64.00 | $41.60 | $41.60 | $59.52 | $54.40 | $54.40 | $54.40 | $48.64 | $54.40 | $48.64 | $41.60 | $59.52 |
30080100E | DRUG SCREEN INHOUSE- EMPLOYEE | 300 | Laboratory | 300 | 80307 | $64.00 | $41.60 | $41.60 | $59.52 | $54.40 | $54.40 | $54.40 | $48.64 | $54.40 | $48.64 | $41.60 | $59.52 |
30080100N | Drug Screen Nursing Home | 300 | Laboratory | 300 | 80307 | $64.00 | $41.60 | $41.60 | $59.52 | $54.40 | $54.40 | $54.40 | $48.64 | $54.40 | $48.64 | $41.60 | $59.52 |
30080195 | Drug Screen Quantitative Sirolimus | 300 | Laboratory | 300 | 80195 | $70.00 | $45.50 | $45.50 | $65.10 | $59.50 | $59.50 | $59.50 | $53.20 | $59.50 | $53.20 | $45.50 | $65.10 |
30080051 | ELECTROLYTE PANEL | 300 | Laboratory | 300 | 80051 | $118.00 | $76.70 | $76.70 | $109.74 | $100.30 | $100.30 | $100.30 | $89.68 | $100.30 | $89.68 | $76.70 | $109.74 |
30086664 | EPSTEIN BARR EBNA | 300 | Laboratory | 300 | 86664 | $94.00 | $61.10 | $61.10 | $87.42 | $79.90 | $79.90 | $79.90 | $71.44 | $79.90 | $71.44 | $61.10 | $87.42 |
30086665 | EPSTEIN BARR VCA X2 | 300 | Laboratory | 300 | 86665 | $184.00 | $119.60 | $119.60 | $171.12 | $156.40 | $156.40 | $156.40 | $139.84 | $156.40 | $139.84 | $119.60 | $171.12 |
30082670 | ESTRADIOL | 300 | Laboratory | 300 | 82670 | $329.00 | $213.85 | $213.85 | $305.97 | $279.65 | $279.65 | $279.65 | $250.04 | $279.65 | $250.04 | $213.85 | $305.97 |
30082672 | ESTROGENS/TOTAL | 300 | Laboratory | 300 | 82672 | $329.00 | $213.85 | $213.85 | $305.97 | $279.65 | $279.65 | $279.65 | $250.04 | $279.65 | $250.04 | $213.85 | $305.97 |
30080320 | ETOH/ANYSPEC.EXCP.BREATH (ALCOHOL) | 300 | Laboratory | 300 | 80320 | $113.00 | $73.45 | $73.45 | $105.09 | $96.05 | $96.05 | $96.05 | $85.88 | $96.05 | $85.88 | $73.45 | $105.09 |
30082705 | Fecal Fat Lipids | 300 | Laboratory | 300 | 82705 | $30.00 | $19.50 | $19.50 | $27.90 | $25.50 | $25.50 | $25.50 | $22.80 | $25.50 | $22.80 | $19.50 | $27.90 |
30082274 | FECAL OCCULT BLOOD | 300 | Laboratory | 300 | 82274 | $40.00 | $26.00 | $26.00 | $37.20 | $34.00 | $34.00 | $34.00 | $30.40 | $34.00 | $30.40 | $26.00 | $37.20 |
30082728 | FERRITIN | 300 | Laboratory | 300 | 82728 | $123.00 | $79.95 | $79.95 | $114.39 | $104.55 | $104.55 | $104.55 | $93.48 | $104.55 | $93.48 | $79.95 | $114.39 |
30082746 | FOLIC ACID/SERUM | 300 | Laboratory | 300 | 82746 | $119.00 | $77.35 | $77.35 | $110.67 | $101.15 | $101.15 | $101.15 | $90.44 | $101.15 | $90.44 | $77.35 | $110.67 |
30083001 | FSH | 300 | Laboratory | 300 | 83001 | $144.00 | $93.60 | $93.60 | $133.92 | $122.40 | $122.40 | $122.40 | $109.44 | $122.40 | $109.44 | $93.60 | $133.92 |
30086606 | Fungal Anitbodies by double immuno-diff | 300 | Laboratory | 300 | 86606 | $60.00 | $39.00 | $39.00 | $55.80 | $51.00 | $51.00 | $51.00 | $45.60 | $51.00 | $45.60 | $39.00 | $55.80 |
30082784 | GAMMA GLOBULIN | 300 | Laboratory | 300 | 82784 | $231.00 | $150.15 | $150.15 | $214.83 | $196.35 | $196.35 | $196.35 | $175.56 | $196.35 | $175.56 | $150.15 | $214.83 |
30087507 | Gastrointestinal Profile | 300 | Laboratory | 300 | 87507 | $1,300.00 | $845.00 | $845.00 | $1,209.00 | $1,105.00 | $1,105.00 | $1,105.00 | $988.00 | $1,105.00 | $988.00 | $845.00 | $1,209.00 |
30080050 | GENERAL HEALTH PANEL | 300 | Laboratory | 300 | 80050 | $500.00 | $325.00 | $325.00 | $465.00 | $425.00 | $425.00 | $425.00 | $380.00 | $425.00 | $380.00 | $325.00 | $465.00 |
30080170 | GENTAMICIN | 300 | Laboratory | 300 | 80170 | $249.00 | $161.85 | $161.85 | $231.57 | $211.65 | $211.65 | $211.65 | $189.24 | $211.65 | $189.24 | $161.85 | $231.57 |
30082977 | GGT | 300 | Laboratory | 300 | 82977 | $66.00 | $42.90 | $42.90 | $61.38 | $56.10 | $56.10 | $56.10 | $50.16 | $56.10 | $50.16 | $42.90 | $61.38 |
30082962 | GLUCOSE FINGERSTICK | 300 | Laboratory | 300 | 82962 | $44.00 | $28.60 | $28.60 | $40.92 | $37.40 | $37.40 | $37.40 | $33.44 | $37.40 | $33.44 | $28.60 | $40.92 |
30082947 | GLUCOSE SERUM/FLUID | 300 | Laboratory | 300 | 82947 | $71.00 | $46.15 | $46.15 | $66.03 | $60.35 | $60.35 | $60.35 | $53.96 | $60.35 | $53.96 | $46.15 | $66.03 |
30082945 | GLUCOSE, OTHER THAN BLOOD | 300 | Laboratory | 300 | 82945 | $30.00 | $19.50 | $19.50 | $27.90 | $25.50 | $25.50 | $25.50 | $22.80 | $25.50 | $22.80 | $19.50 | $27.90 |
30084703 | GONADOTROPIN,CHRIONIC;QUAL. | 300 | Laboratory | 300 | 84703 | $94.00 | $61.10 | $61.10 | $87.42 | $79.90 | $79.90 | $79.90 | $71.44 | $79.90 | $71.44 | $61.10 | $87.42 |
30087338 | H PYLORI STOOL | 300 | Laboratory | 300 | 87338 | $162.00 | $105.30 | $105.30 | $150.66 | $137.70 | $137.70 | $137.70 | $123.12 | $137.70 | $123.12 | $105.30 | $150.66 |
30086677 | H. PYLORI | 300 | Laboratory | 300 | 86677 | $144.00 | $93.60 | $93.60 | $133.92 | $122.40 | $122.40 | $122.40 | $109.44 | $122.40 | $109.44 | $93.60 | $133.92 |
30085014 | HEMATOCRIT | 300 | Laboratory | 300 | 85014 | $33.00 | $21.45 | $21.45 | $30.69 | $28.05 | $28.05 | $28.05 | $25.08 | $28.05 | $25.08 | $21.45 | $30.69 |
30085018 | HEMOGLOBIN | 300 | Laboratory | 300 | 85018 | $33.00 | $21.45 | $21.45 | $30.69 | $28.05 | $28.05 | $28.05 | $25.08 | $28.05 | $25.08 | $21.45 | $30.69 |
30083036 | HEMOGLOBIN A1C | 300 | Laboratory | 300 | 83036 | $73.00 | $47.45 | $47.45 | $67.89 | $62.05 | $62.05 | $62.05 | $55.48 | $62.05 | $55.48 | $47.45 | $67.89 |
30086706 | HEP.B SURFACE ANTOBODY | 300 | Laboratory | 300 | 86706 | $112.00 | $72.80 | $72.80 | $104.16 | $95.20 | $95.20 | $95.20 | $85.12 | $95.20 | $85.12 | $72.80 | $104.16 |
30080076 | HEPATIC FUNCTION PANEL | 300 | Laboratory | 300 | 80076 | $283.00 | $183.95 | $183.95 | $263.19 | $240.55 | $240.55 | $240.55 | $215.08 | $240.55 | $215.08 | $183.95 | $263.19 |
30086803 | HEPATITIS C ANTIBODY | 300 | Laboratory | 300 | 86803 | $112.00 | $72.80 | $72.80 | $104.16 | $95.20 | $95.20 | $95.20 | $85.12 | $95.20 | $85.12 | $72.80 | $104.16 |
30087522 | HEPATITIS C QUANTIFICATION | 300 | Laboratory | 300 | 87522 | $760.00 | $494.00 | $494.00 | $706.80 | $646.00 | $646.00 | $646.00 | $577.60 | $646.00 | $577.60 | $494.00 | $706.80 |
30080074 | HEPATITIS PANEL | 300 | Laboratory | 300 | 80074 | $404.00 | $262.60 | $262.60 | $375.72 | $343.40 | $343.40 | $343.40 | $307.04 | $343.40 | $307.04 | $262.60 | $375.72 |
30086694 | HERPES TITER ANTIBODY | 300 | Laboratory | 300 | 86694 | $206.00 | $133.90 | $133.90 | $191.58 | $175.10 | $175.10 | $175.10 | $156.56 | $175.10 | $156.56 | $133.90 | $191.58 |
30086308 | HETEROPHILE ANTIBODIES | 300 | Laboratory | 300 | 86308 | $66.00 | $42.90 | $42.90 | $61.38 | $56.10 | $56.10 | $56.10 | $50.16 | $56.10 | $50.16 | $42.90 | $61.38 |
30086703 | HIV-1 HIV-2 SINGLE ASSAY | 300 | Laboratory | 300 | 86703 | $136.00 | $88.40 | $88.40 | $126.48 | $115.60 | $115.60 | $115.60 | $103.36 | $115.60 | $103.36 | $88.40 | $126.48 |
30083789 | HOMOCYSTINE LEVEL | 300 | Laboratory | 300 | 83789 | $179.00 | $116.35 | $116.35 | $166.47 | $152.15 | $152.15 | $152.15 | $136.04 | $152.15 | $136.04 | $116.35 | $166.47 |
30087624 | HPV High Risk | 300 | Laboratory | 300 | 87624 | $121.00 | $78.65 | $78.65 | $112.53 | $102.85 | $102.85 | $102.85 | $91.96 | $102.85 | $91.96 | $78.65 | $112.53 |
30087497 | IADNA Cytomegalovirus Quantification | 300 | Laboratory | 300 | 87497 | $210.00 | $136.50 | $136.50 | $195.30 | $178.50 | $178.50 | $178.50 | $159.60 | $178.50 | $159.60 | $136.50 | $195.30 |
30083516 | IMMUNOASSAY NONANTIBODY | 300 | Laboratory | 300 | 83516 | $49.00 | $31.85 | $31.85 | $45.57 | $41.65 | $41.65 | $41.65 | $37.24 | $41.65 | $37.24 | $31.85 | $45.57 |
30087449 | INFECTIOUS AGENT ANTI DET | 300 | Laboratory | 300 | 87449 | $118.00 | $76.70 | $76.70 | $109.74 | $100.30 | $100.30 | $100.30 | $89.68 | $100.30 | $89.68 | $76.70 | $109.74 |
52387449 | INFECTIOUS AGENT ANTI DET-CLIA | 300 | Laboratory | 300 | 87449 | $118.00 | $76.70 | $76.70 | $109.74 | $100.30 | $100.30 | $100.30 | $89.68 | $100.30 | $89.68 | $76.70 | $109.74 |
30083525 | INSULIN/TOTAL | 300 | Laboratory | 300 | 83525 | $139.00 | $90.35 | $90.35 | $129.27 | $118.15 | $118.15 | $118.15 | $105.64 | $118.15 | $105.64 | $90.35 | $129.27 |
30083540 | IRON | 300 | Laboratory | 300 | 83540 | $46.00 | $29.90 | $29.90 | $42.78 | $39.10 | $39.10 | $39.10 | $34.96 | $39.10 | $34.96 | $29.90 | $42.78 |
30083550 | IRON BINDING | 300 | Laboratory | 300 | 83550 | $78.00 | $50.70 | $50.70 | $72.54 | $66.30 | $66.30 | $66.30 | $59.28 | $66.30 | $59.28 | $50.70 | $72.54 |
30083605 | LACTIC ACID | 300 | Laboratory | 300 | 83605 | $132.00 | $85.80 | $85.80 | $122.76 | $112.20 | $112.20 | $112.20 | $100.32 | $112.20 | $100.32 | $85.80 | $122.76 |
30083615 | LDH | 300 | Laboratory | 300 | 83615 | $102.00 | $66.30 | $66.30 | $94.86 | $86.70 | $86.70 | $86.70 | $77.52 | $86.70 | $77.52 | $66.30 | $94.86 |
30083721 | LDL CHOLESTEROL | 300 | Laboratory | 300 | 83721 | $26.00 | $16.90 | $16.90 | $24.18 | $22.10 | $22.10 | $22.10 | $19.76 | $22.10 | $19.76 | $16.90 | $24.18 |
30083655 | LEAD | 300 | Laboratory | 300 | 83655 | $110.00 | $71.50 | $71.50 | $102.30 | $93.50 | $93.50 | $93.50 | $83.60 | $93.50 | $83.60 | $71.50 | $102.30 |
30089055 | LEUKOCYTE, FECAL | 300 | Laboratory | 300 | 89055 | $50.00 | $32.50 | $32.50 | $46.50 | $42.50 | $42.50 | $42.50 | $38.00 | $42.50 | $38.00 | $32.50 | $46.50 |
30083002 | LH | 300 | Laboratory | 300 | 83002 | $144.00 | $93.60 | $93.60 | $133.92 | $122.40 | $122.40 | $122.40 | $109.44 | $122.40 | $109.44 | $93.60 | $133.92 |
30083690 | LIPASE | 300 | Laboratory | 300 | 83690 | $68.00 | $44.20 | $44.20 | $63.24 | $57.80 | $57.80 | $57.80 | $51.68 | $57.80 | $51.68 | $44.20 | $63.24 |
30080061 | LIPID PANEL | 300 | Laboratory | 300 | 80061 | $130.00 | $84.50 | $84.50 | $120.90 | $110.50 | $110.50 | $110.50 | $98.80 | $110.50 | $98.80 | $84.50 | $120.90 |
30086618 | LYME DISEASE AB | 300 | Laboratory | 300 | 86618 | $147.00 | $95.55 | $95.55 | $136.71 | $124.95 | $124.95 | $124.95 | $111.72 | $124.95 | $111.72 | $95.55 | $136.71 |
30083735 | MAGNESIUM | 300 | Laboratory | 300 | 83735 | $49.00 | $31.85 | $31.85 | $45.57 | $41.65 | $41.65 | $41.65 | $37.24 | $41.65 | $37.24 | $31.85 | $45.57 |
30082044 | MICROALBUMIN SEMIQUANT | 300 | Laboratory | 300 | 82044 | $39.00 | $25.35 | $25.35 | $36.27 | $33.15 | $33.15 | $33.15 | $29.64 | $33.15 | $29.64 | $25.35 | $36.27 |
30086376 | MICROSOMAL ANTIBODIES | 300 | Laboratory | 300 | 86376 | $45.00 | $29.25 | $29.25 | $41.85 | $38.25 | $38.25 | $38.25 | $34.20 | $38.25 | $34.20 | $29.25 | $41.85 |
30086735 | MUMPS ANTIBODY | 300 | Laboratory | 300 | 86735 | $319.00 | $207.35 | $207.35 | $296.67 | $271.15 | $271.15 | $271.15 | $242.44 | $271.15 | $242.44 | $207.35 | $296.67 |
30083880 | NATRIURETIC PEPTIDE | 300 | Laboratory | 300 | 83880 | $197.00 | $128.05 | $128.05 | $183.21 | $167.45 | $167.45 | $167.45 | $149.72 | $167.45 | $149.72 | $128.05 | $183.21 |
30087591 | NEISSERIA GONORRHEA, AMPLIFIED | 300 | Laboratory | 300 | 87591 | $153.00 | $99.45 | $99.45 | $142.29 | $130.05 | $130.05 | $130.05 | $116.28 | $130.05 | $116.28 | $99.45 | $142.29 |
30087177 | O & P COMPLETE | 300 | Laboratory | 300 | 87177 | $135.00 | $87.75 | $87.75 | $125.55 | $114.75 | $114.75 | $114.75 | $102.60 | $114.75 | $102.60 | $87.75 | $125.55 |
30082271 | OCCULT BLOOD OTHER SOURCE | 300 | Laboratory | 300 | 82271 | $44.00 | $28.60 | $28.60 | $40.92 | $37.40 | $37.40 | $37.40 | $33.44 | $37.40 | $33.44 | $28.60 | $40.92 |
30082656 | Pancreatic elast fecal | 300 | Laboratory | 300 | 82656 | $300.00 | $195.00 | $195.00 | $279.00 | $255.00 | $255.00 | $255.00 | $228.00 | $255.00 | $228.00 | $195.00 | $279.00 |
30088142 | PAP SMEAR - THIN LAYER | 300 | Laboratory | 300 | G0123 | $105.00 | $68.25 | $68.25 | $97.65 | $89.25 | $89.25 | $89.25 | $79.80 | $89.25 | $79.80 | $68.25 | $97.65 |
30083970 | PARATHYROID HORM. | 300 | Laboratory | 300 | 83970 | $293.00 | $190.45 | $190.45 | $272.49 | $249.05 | $249.05 | $249.05 | $222.68 | $249.05 | $222.68 | $190.45 | $272.49 |
30085730 | PART. PROTIME (PTT) | 300 | Laboratory | 300 | 85730 | $80.00 | $52.00 | $52.00 | $74.40 | $68.00 | $68.00 | $68.00 | $60.80 | $68.00 | $60.80 | $52.00 | $74.40 |
30082803 | PH, PCO2, PO2 SIM. | 300 | Laboratory | 300 | 82803 | $264.00 | $171.60 | $171.60 | $245.52 | $224.40 | $224.40 | $224.40 | $200.64 | $224.40 | $200.64 | $171.60 | $245.52 |
30080184 | PHENOBARBITAL LEVEL | 300 | Laboratory | 300 | 80184 | $100.00 | $65.00 | $65.00 | $93.00 | $85.00 | $85.00 | $85.00 | $76.00 | $85.00 | $76.00 | $65.00 | $93.00 |
30080185 | PHENYTOIN TOTAL | 300 | Laboratory | 300 | 80185 | $127.00 | $82.55 | $82.55 | $118.11 | $107.95 | $107.95 | $107.95 | $96.52 | $107.95 | $96.52 | $82.55 | $118.11 |
30084075 | PHOSPHATASE ALKALINE | 300 | Laboratory | 300 | 84075 | $73.00 | $47.45 | $47.45 | $67.89 | $62.05 | $62.05 | $62.05 | $55.48 | $62.05 | $55.48 | $47.45 | $67.89 |
30084100 | PHOSPHORUS | 300 | Laboratory | 300 | 84100 | $40.00 | $26.00 | $26.00 | $37.20 | $34.00 | $34.00 | $34.00 | $30.40 | $34.00 | $30.40 | $26.00 | $37.20 |
30085049 | PLATELET COUNT | 300 | Laboratory | 300 | 85049 | $34.00 | $22.10 | $22.10 | $31.62 | $28.90 | $28.90 | $28.90 | $25.84 | $28.90 | $25.84 | $22.10 | $31.62 |
30084132 | POTASSIUM (K)/SERUM | 300 | Laboratory | 300 | 84132 | $71.00 | $46.15 | $46.15 | $66.03 | $60.35 | $60.35 | $60.35 | $53.96 | $60.35 | $53.96 | $46.15 | $66.03 |
30084134 | PREALBUMIN | 300 | Laboratory | 300 | 84134 | $99.00 | $64.35 | $64.35 | $92.07 | $84.15 | $84.15 | $84.15 | $75.24 | $84.15 | $75.24 | $64.35 | $92.07 |
30081025 | PREGNANCY TEST, URINE | 300 | Laboratory | 300 | 81025 | $94.00 | $61.10 | $61.10 | $87.42 | $79.90 | $79.90 | $79.90 | $71.44 | $79.90 | $71.44 | $61.10 | $87.42 |
30084144 | PROGESTERONE | 300 | Laboratory | 300 | 84144 | $147.00 | $95.55 | $95.55 | $136.71 | $124.95 | $124.95 | $124.95 | $111.72 | $124.95 | $111.72 | $95.55 | $136.71 |
30084146 | PROLACTIN | 300 | Laboratory | 300 | 84146 | $190.00 | $123.50 | $123.50 | $176.70 | $161.50 | $161.50 | $161.50 | $144.40 | $161.50 | $144.40 | $123.50 | $176.70 |
30084157 | Protein Total Xcpt Refractometry Oth SRC | 300 | Laboratory | 300 | 84157 | $15.00 | $9.75 | $9.75 | $13.95 | $12.75 | $12.75 | $12.75 | $11.40 | $12.75 | $11.40 | $9.75 | $13.95 |
30084156 | PROTEIN, TOTAL URINE | 300 | Laboratory | 300 | 84156 | $387.00 | $251.55 | $251.55 | $359.91 | $328.95 | $328.95 | $328.95 | $294.12 | $328.95 | $294.12 | $251.55 | $359.91 |
30085610 | PROTIME (PT) | 300 | Laboratory | 300 | 85610 | $71.00 | $46.15 | $46.15 | $66.03 | $60.35 | $60.35 | $60.35 | $53.96 | $60.35 | $53.96 | $46.15 | $66.03 |
30084153 | PSA (PROSTATE S A ) | 300 | Laboratory | 300 | 84153 | $81.00 | $52.65 | $52.65 | $75.33 | $68.85 | $68.85 | $68.85 | $61.56 | $68.85 | $61.56 | $52.65 | $75.33 |
30084154 | PSA Specific Antigen, Free | 300 | Laboratory | 300 | 84154 | $43.00 | $27.95 | $27.95 | $39.99 | $36.55 | $36.55 | $36.55 | $32.68 | $36.55 | $32.68 | $27.95 | $39.99 |
30080069 | RENAL FUNCTION PANEL | 300 | Laboratory | 300 | 80069 | $206.00 | $133.90 | $133.90 | $191.58 | $175.10 | $175.10 | $175.10 | $156.56 | $175.10 | $156.56 | $133.90 | $191.58 |
30085045 | RETICULOCYTE, AUTOMATED | 300 | Laboratory | 300 | 85045 | $37.00 | $24.05 | $24.05 | $34.41 | $31.45 | $31.45 | $31.45 | $28.12 | $31.45 | $28.12 | $24.05 | $34.41 |
30086901 | RH BLOOD TYPING | 300 | Laboratory | 300 | 86901 | $52.00 | $33.80 | $33.80 | $48.36 | $44.20 | $44.20 | $44.20 | $39.52 | $44.20 | $39.52 | $33.80 | $48.36 |
30086431 | RHEUMATOID FACTOR/QUAN. | 300 | Laboratory | 300 | 86431 | $105.00 | $68.25 | $68.25 | $97.65 | $89.25 | $89.25 | $89.25 | $79.80 | $89.25 | $79.80 | $68.25 | $97.65 |
30087425 | ROTAVIRUS | 300 | Laboratory | 300 | 87425 | $132.00 | $85.80 | $85.80 | $122.76 | $112.20 | $112.20 | $112.20 | $100.32 | $112.20 | $100.32 | $85.80 | $122.76 |
30086592 | RPR/QUALITATIVE | 300 | Laboratory | 300 | 86592 | $61.00 | $39.65 | $39.65 | $56.73 | $51.85 | $51.85 | $51.85 | $46.36 | $51.85 | $46.36 | $39.65 | $56.73 |
30087420 | RSV | 300 | Laboratory | 300 | 87420 | $127.00 | $82.55 | $82.55 | $118.11 | $107.95 | $107.95 | $107.95 | $96.52 | $107.95 | $96.52 | $82.55 | $118.11 |
52387420 | RSV | 300 | Laboratory | 300 | 87420 | $127.00 | $82.55 | $82.55 | $118.11 | $107.95 | $107.95 | $107.95 | $96.52 | $107.95 | $96.52 | $82.55 | $118.11 |
30085651 | SED RATE (ESR) | 300 | Laboratory | 300 | 85651 | $52.00 | $33.80 | $33.80 | $48.36 | $44.20 | $44.20 | $44.20 | $39.52 | $44.20 | $39.52 | $33.80 | $48.36 |
30087186 | SENSITIVITY (MIC) | 300 | Laboratory | 300 | 87186 | $68.00 | $44.20 | $44.20 | $63.24 | $57.80 | $57.80 | $57.80 | $51.68 | $57.80 | $51.68 | $44.20 | $63.24 |
30084295 | SODIUM (NA)/BLOOD | 300 | Laboratory | 300 | 84295 | $73.00 | $47.45 | $47.45 | $67.89 | $62.05 | $62.05 | $62.05 | $55.48 | $62.05 | $55.48 | $47.45 | $67.89 |
30087880 | STREP SCREEN | 300 | Laboratory | 300 | 87880 | $61.00 | $39.65 | $39.65 | $56.73 | $51.85 | $51.85 | $51.85 | $46.36 | $51.85 | $46.36 | $39.65 | $56.73 |
52387880 | STREP SCREEN | 300 | Laboratory | 300 | 87880 | $61.00 | $39.65 | $39.65 | $56.73 | $51.85 | $51.85 | $51.85 | $46.36 | $51.85 | $46.36 | $39.65 | $56.73 |
30084480 | T3/TOTAL | 300 | Laboratory | 300 | 84480 | $156.00 | $101.40 | $101.40 | $145.08 | $132.60 | $132.60 | $132.60 | $118.56 | $132.60 | $118.56 | $101.40 | $145.08 |
30080197 | TACROLIMUS | 300 | Laboratory | 300 | 80197 | $312.00 | $202.80 | $202.80 | $290.16 | $265.20 | $265.20 | $265.20 | $237.12 | $265.20 | $237.12 | $202.80 | $290.16 |
30084402 | TESTOSTERONE ASSAY | 300 | Laboratory | 300 | 84402 | $40.00 | $26.00 | $26.00 | $37.20 | $34.00 | $34.00 | $34.00 | $30.40 | $34.00 | $30.40 | $26.00 | $37.20 |
30084403 | TESTOSTERONE TOTAL | 300 | Laboratory | 300 | 84403 | $247.00 | $160.55 | $160.55 | $229.71 | $209.95 | $209.95 | $209.95 | $187.72 | $209.95 | $187.72 | $160.55 | $229.71 |
30086800 | THYROGLOBULIN ANTIBODY | 300 | Laboratory | 300 | 86800 | $37.00 | $24.05 | $24.05 | $34.41 | $31.45 | $31.45 | $31.45 | $28.12 | $31.45 | $28.12 | $24.05 | $34.41 |
30084439 | THYROXINE/FREE-T4 | 300 | Laboratory | 300 | 84439 | $149.00 | $96.85 | $96.85 | $138.57 | $126.65 | $126.65 | $126.65 | $113.24 | $126.65 | $113.24 | $96.85 | $138.57 |
30084436 | THYROXINE/TOTAL-T4 | 300 | Laboratory | 300 | 84436 | $61.00 | $39.65 | $39.65 | $56.73 | $51.85 | $51.85 | $51.85 | $46.36 | $51.85 | $46.36 | $39.65 | $56.73 |
30084478 | TRIGLYCERIDES | 300 | Laboratory | 300 | 84478 | $118.00 | $76.70 | $76.70 | $109.74 | $100.30 | $100.30 | $100.30 | $89.68 | $100.30 | $89.68 | $76.70 | $109.74 |
30084481 | TRIIODOTHYRONINE T3; FREE | 300 | Laboratory | 300 | 84481 | $47.00 | $30.55 | $30.55 | $43.71 | $39.95 | $39.95 | $39.95 | $35.72 | $39.95 | $35.72 | $30.55 | $43.71 |
30084512 | TROPONIN QUALITIATIVE | 300 | Laboratory | 300 | 84512 | $196.00 | $127.40 | $127.40 | $182.28 | $166.60 | $166.60 | $166.60 | $148.96 | $166.60 | $148.96 | $127.40 | $182.28 |
30084484 | TROPONIN QUANTITATIVE | 300 | Laboratory | 300 | 84484 | $44.00 | $28.60 | $28.60 | $40.92 | $37.40 | $37.40 | $37.40 | $33.44 | $37.40 | $33.44 | $28.60 | $40.92 |
30084443 | TSH | 300 | Laboratory | 300 | 84443 | $167.00 | $108.55 | $108.55 | $155.31 | $141.95 | $141.95 | $141.95 | $126.92 | $141.95 | $126.92 | $108.55 | $155.31 |
30081001 | UA AUTOMATED, W/MICRO | 300 | Laboratory | 300 | 81001 | $68.00 | $44.20 | $44.20 | $63.24 | $57.80 | $57.80 | $57.80 | $51.68 | $57.80 | $51.68 | $44.20 | $63.24 |
30081003 | UA AUTOMATED, W/O MICRO | 300 | Laboratory | 300 | 81003 | $52.00 | $33.80 | $33.80 | $48.36 | $44.20 | $44.20 | $44.20 | $39.52 | $44.20 | $39.52 | $33.80 | $48.36 |
30084520 | UREA NITROGEN (BUN) | 300 | Laboratory | 300 | 84520 | $72.00 | $46.80 | $46.80 | $66.96 | $61.20 | $61.20 | $61.20 | $54.72 | $61.20 | $54.72 | $46.80 | $66.96 |
30084550 | URIC ACID/SERUM | 300 | Laboratory | 300 | 84550 | $71.00 | $46.15 | $46.15 | $66.03 | $60.35 | $60.35 | $60.35 | $53.96 | $60.35 | $53.96 | $46.15 | $66.03 |
30087088 | URINE BACTERIA CULT W/ISO | 300 | Laboratory | 300 | 87088 | $37.00 | $24.05 | $24.05 | $34.41 | $31.45 | $31.45 | $31.45 | $28.12 | $31.45 | $28.12 | $24.05 | $34.41 |
30080202 | VANCOMYCIN LEVEL | 300 | Laboratory | 300 | 80202 | $140.00 | $91.00 | $91.00 | $130.20 | $119.00 | $119.00 | $119.00 | $106.40 | $119.00 | $106.40 | $91.00 | $130.20 |
30086787 | VARICELLA TITER | 300 | Laboratory | 300 | 86787 | $118.00 | $76.70 | $76.70 | $109.74 | $100.30 | $100.30 | $100.30 | $89.68 | $100.30 | $89.68 | $76.70 | $109.74 |
30084425 | VITAMIN B 1 | 300 | Laboratory | 300 | 84425 | $245.00 | $159.25 | $159.25 | $227.85 | $208.25 | $208.25 | $208.25 | $186.20 | $208.25 | $186.20 | $159.25 | $227.85 |
42097032 | ELECTRICAL STIM EACH 15 MIN | 420 | Physical Therapy | 420 | 97032 | $49.00 | $31.85 | $31.85 | $45.57 | $41.65 | $41.65 | $41.65 | $37.24 | $41.65 | $37.24 | $31.85 | $45.57 |
42097014 | ES-UNATTENDED | 420 | Physical Therapy | 420 | 97014 | $54.00 | $35.10 | $35.10 | $50.22 | $45.90 | $45.90 | $45.90 | $41.04 | $45.90 | $41.04 | $35.10 | $50.22 |
420G0283 | ES-UNATTENDED | 420 | Physical Therapy | 420 | G0283 | $54.00 | $35.10 | $35.10 | $50.22 | $45.90 | $45.90 | $45.90 | $41.04 | $45.90 | $41.04 | $35.10 | $50.22 |
42097116 | GAIT TRAINING 0-15 | 420 | Physical Therapy | 420 | 97116 | $76.00 | $49.40 | $49.40 | $70.68 | $64.60 | $64.60 | $64.60 | $57.76 | $64.60 | $57.76 | $49.40 | $70.68 |
42097530 | KINETIC THER. | 420 | Physical Therapy | 420 | 97530 | $98.00 | $63.70 | $63.70 | $91.14 | $83.30 | $83.30 | $83.30 | $74.48 | $83.30 | $74.48 | $63.70 | $91.14 |
42097140 | MANUAL THERAPY 15 MINUTES | 420 | Physical Therapy | 420 | 97140 | $74.00 | $48.10 | $48.10 | $68.82 | $62.90 | $62.90 | $62.90 | $56.24 | $62.90 | $56.24 | $48.10 | $68.82 |
42097112 | NEURO MUS. RE ED | 420 | Physical Therapy | 420 | 97112 | $76.00 | $49.40 | $49.40 | $70.68 | $64.60 | $64.60 | $64.60 | $57.76 | $64.60 | $57.76 | $49.40 | $70.68 |
42097760 | ORTHOTIC MANAGEMENT & TRAINING | 420 | Physical Therapy | 420 | 97760 | $47.00 | $30.55 | $30.55 | $43.71 | $39.95 | $39.95 | $39.95 | $35.72 | $39.95 | $35.72 | $30.55 | $43.71 |
42097018 | PARAFFIN BATH | 420 | Physical Therapy | 420 | 97018 | $54.00 | $35.10 | $35.10 | $50.22 | $45.90 | $45.90 | $45.90 | $41.04 | $45.90 | $41.04 | $35.10 | $50.22 |
42097163 | PT EVAL; HIGH COMPLEXITY | 420 | Physical Therapy | 424 | 97163 | $200.00 | $130.00 | $130.00 | $186.00 | $170.00 | $170.00 | $170.00 | $152.00 | $170.00 | $152.00 | $130.00 | $186.00 |
42097161 | PT EVAL; LOW COMPLEXITY | 420 | Physical Therapy | 424 | 97161 | $160.00 | $104.00 | $104.00 | $148.80 | $136.00 | $136.00 | $136.00 | $121.60 | $136.00 | $121.60 | $104.00 | $148.80 |
42097162 | PT EVAL; MODERATE COMPLEXITY | 420 | Physical Therapy | 424 | 97162 | $180.00 | $117.00 | $117.00 | $167.40 | $153.00 | $153.00 | $153.00 | $136.80 | $153.00 | $136.80 | $117.00 | $167.40 |
42097002 | RE-EVALUATION | 420 | Physical Therapy | 420 | 97164 | $110.00 | $71.50 | $71.50 | $102.30 | $93.50 | $93.50 | $93.50 | $83.60 | $93.50 | $83.60 | $71.50 | $102.30 |
42097110 | THER EX 0-15 | 420 | Physical Therapy | 420 | 97110 | $90.00 | $58.50 | $58.50 | $83.70 | $76.50 | $76.50 | $76.50 | $68.40 | $76.50 | $68.40 | $58.50 | $83.70 |
42097012 | TRACTION/MECH. | 420 | Physical Therapy | 420 | 97012 | $54.00 | $35.10 | $35.10 | $50.22 | $45.90 | $45.90 | $45.90 | $41.04 | $45.90 | $41.04 | $35.10 | $50.22 |
42097035 | ULTRASOUND | 420 | Physical Therapy | 420 | 97035 | $70.00 | $45.50 | $45.50 | $65.10 | $59.50 | $59.50 | $59.50 | $53.20 | $59.50 | $53.20 | $45.50 | $65.10 |
42097542 | Wheelchair Management Training | 420 | Physical Therapy | 420 | 97542 | $101.00 | $65.65 | $65.65 | $93.93 | $85.85 | $85.85 | $85.85 | $76.76 | $85.85 | $76.76 | $65.65 | $93.93 |
42097602 | WOUND CARE NON-SELECTIVE | 420 | Physical Therapy | 420 | 97602 | $132.96 | $86.42 | $86.42 | $123.65 | $113.02 | $113.02 | $113.02 | $101.05 | $113.02 | $101.05 | $86.42 | $123.65 |
42097597 | WOUND CARE/20CM OR LESS | 420 | Physical Therapy | 420 | 97597 | $180.00 | $117.00 | $117.00 | $167.40 | $153.00 | $153.00 | $153.00 | $136.80 | $153.00 | $136.80 | $117.00 | $167.40 |
42097598 | WOUND CARE/GREATER THAN 20CM | 420 | Physical Therapy | 420 | 97598 | $209.00 | $135.85 | $135.85 | $194.37 | $177.65 | $177.65 | $177.65 | $158.84 | $177.65 | $158.84 | $135.85 | $194.37 |
32074000 | ABDOMEN 1V (KUB) | 320 | Radiology Diagnostic | 320 | 74018 | $173.00 | $112.45 | $112.45 | $160.89 | $147.05 | $147.05 | $147.05 | $131.48 | $147.05 | $131.48 | $112.45 | $160.89 |
32074020 | ABDOMEN COMPLETE | 320 | Radiology Diagnostic | 320 | 74021 | $218.00 | $141.70 | $141.70 | $202.74 | $185.30 | $185.30 | $185.30 | $165.68 | $185.30 | $165.68 | $141.70 | $202.74 |
32074010 | ABDOMEN/2 VIEWS | 320 | Radiology Diagnostic | 320 | 74019 | $188.00 | $122.20 | $122.20 | $174.84 | $159.80 | $159.80 | $159.80 | $142.88 | $159.80 | $142.88 | $122.20 | $174.84 |
32073050 | AC JOINTS BIL. W/OR W/O WEIGHT | 320 | Radiology Diagnostic | 320 | 73050 | $76.00 | $49.40 | $49.40 | $70.68 | $64.60 | $64.60 | $64.60 | $57.76 | $64.60 | $57.76 | $49.40 | $70.68 |
32073600 | ANKLE 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73600 | $182.00 | $118.30 | $118.30 | $169.26 | $154.70 | $154.70 | $154.70 | $138.32 | $154.70 | $138.32 | $118.30 | $169.26 |
32073610 | ANKLE COMP./M3V | 320 | Radiology Diagnostic | 320 | 73610 | $222.00 | $144.30 | $144.30 | $206.46 | $188.70 | $188.70 | $188.70 | $168.72 | $188.70 | $168.72 | $144.30 | $206.46 |
32076010 | BABY GRAM SINGLE VIEW | 320 | Radiology Diagnostic | 320 | 76010 | $199.00 | $129.35 | $129.35 | $185.07 | $169.15 | $169.15 | $169.15 | $151.24 | $169.15 | $151.24 | $129.35 | $185.07 |
32076020 | BONE AGE STUDY | 320 | Radiology Diagnostic | 320 | 77072 | $139.00 | $90.35 | $90.35 | $129.27 | $118.15 | $118.15 | $118.15 | $105.64 | $118.15 | $105.64 | $90.35 | $129.27 |
32073650 | CALCANEUS(HEEL)M2V | 320 | Radiology Diagnostic | 320 | 73650 | $158.00 | $102.70 | $102.70 | $146.94 | $134.30 | $134.30 | $134.30 | $120.08 | $134.30 | $120.08 | $102.70 | $146.94 |
32072052 | CERVICAL SPINE COMP. | 320 | Radiology Diagnostic | 320 | 72052 | $340.00 | $221.00 | $221.00 | $316.20 | $289.00 | $289.00 | $289.00 | $258.40 | $289.00 | $258.40 | $221.00 | $316.20 |
32072050 | CERVICAL SPINE, MIN 4 VIEWS | 320 | Radiology Diagnostic | 320 | 72050 | $382.00 | $248.30 | $248.30 | $355.26 | $324.70 | $324.70 | $324.70 | $290.32 | $324.70 | $290.32 | $248.30 | $355.26 |
32072040 | CERVICAL SPINE/2V OR 3V | 320 | Radiology Diagnostic | 320 | 72040 | $244.00 | $158.60 | $158.60 | $226.92 | $207.40 | $207.40 | $207.40 | $185.44 | $207.40 | $185.44 | $158.60 | $226.92 |
32071010 | CHEST/1 VIEW | 320 | Radiology Diagnostic | 320 | 71045 | $152.00 | $98.80 | $98.80 | $141.36 | $129.20 | $129.20 | $129.20 | $115.52 | $129.20 | $115.52 | $98.80 | $141.36 |
32071020 | CHEST/2 VIEW | 320 | Radiology Diagnostic | 320 | 71046 | $246.00 | $159.90 | $159.90 | $228.78 | $209.10 | $209.10 | $209.10 | $186.96 | $209.10 | $186.96 | $159.90 | $228.78 |
32071030 | CHEST/COMP. M4V | 320 | Radiology Diagnostic | 320 | 71030 | $215.00 | $139.75 | $139.75 | $199.95 | $182.75 | $182.75 | $182.75 | $163.40 | $182.75 | $163.40 | $139.75 | $199.95 |
32073000 | CLAVICLE COMPLETE | 320 | Radiology Diagnostic | 320 | 73000 | $208.00 | $135.20 | $135.20 | $193.44 | $176.80 | $176.80 | $176.80 | $158.08 | $176.80 | $158.08 | $135.20 | $193.44 |
35074178 | CT ABDOMEN & PELV W&W/O CNTRST | 320 | Radiology Diagnostic | 350 | 74178 | $1,714.00 | $1,114.10 | $1,114.10 | $1,594.02 | $1,456.90 | $1,456.90 | $1,456.90 | $1,302.64 | $1,456.90 | $1,302.64 | $1,114.10 | $1,594.02 |
35074176 | CT ABDOMEN & PELVIS | 320 | Radiology Diagnostic | 350 | 74176 | $1,500.00 | $975.00 | $975.00 | $1,395.00 | $1,275.00 | $1,275.00 | $1,275.00 | $1,140.00 | $1,275.00 | $1,140.00 | $975.00 | $1,395.00 |
35074177 | CT ABDOMEN & PELVIS W/CONTRAST | 320 | Radiology Diagnostic | 350 | 74177 | $1,607.00 | $1,044.55 | $1,044.55 | $1,494.51 | $1,365.95 | $1,365.95 | $1,365.95 | $1,221.32 | $1,365.95 | $1,221.32 | $1,044.55 | $1,494.51 |
35074150 | CT-ABDOMEN W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 74150 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35074170 | CT-ABDOMEN W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 74170 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35074160 | CT-ABDOMEN WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 74160 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35073200 | CT-ARM W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 73200 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35073201 | CT-ARM WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 73201 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35070450 | CT-BRAIN W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 70450 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35070470 | CT-BRAIN W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 70450 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35070460 | CT-BRAIN WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 70460 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35072125 | CT-C SPINE W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 72125 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35072127 | CT-C SPINE W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 72127 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35072126 | CT-C SPINE WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 72126 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35070480 | CT-EAR W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 70480 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35070482 | CT-EAR W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 70482 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35070481 | CT-EAR WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 70481 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35070486 | CT-FACE W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 70486 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35070488 | CT-FACE W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 70488 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35070487 | CT-FACE WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 70487 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35072131 | CT-L SPINE W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 72131 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35072133 | CT-L SPINE W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 72133 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35072132 | CT-L SPINE WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 72132 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35073700 | CT-LOWER EXTREMITY W/O CONT | 320 | Radiology Diagnostic | 350 | 73700 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35073702 | CT-LOWER EXTREMITY W/WO CONT | 320 | Radiology Diagnostic | 350 | 73702 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35073701 | CT-LOWER EXTREMITY WITH CONT | 320 | Radiology Diagnostic | 350 | 73701 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35070490 | CT-NECK W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 70490 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35070492 | CT-NECK W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 70492 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35070491 | CT-NECK WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 70491 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35072192 | CT-PELVIS W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 72192 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35072194 | CT-PELVIS W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 72194 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35072193 | CT-PELVIS WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 72193 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35072128 | CT-T SPINE W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 72128 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35072130 | CT-T SPINE W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 72130 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35072129 | CT-T SPINE WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 72129 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
35071250 | CT-THORAX,CHEST W/O CONTRAST | 320 | Radiology Diagnostic | 350 | 71250 | $1,526.00 | $991.90 | $991.90 | $1,419.18 | $1,297.10 | $1,297.10 | $1,297.10 | $1,159.76 | $1,297.10 | $1,159.76 | $991.90 | $1,419.18 |
35071270 | CT-THORAX,CHEST W/WO CONTRAST | 320 | Radiology Diagnostic | 350 | 71270 | $2,817.00 | $1,831.05 | $1,831.05 | $2,619.81 | $2,394.45 | $2,394.45 | $2,394.45 | $2,140.92 | $2,394.45 | $2,140.92 | $1,831.05 | $2,619.81 |
35071260 | CT-THORAX,CHEST WITH CONTRAST | 320 | Radiology Diagnostic | 350 | 71260 | $1,878.00 | $1,220.70 | $1,220.70 | $1,746.54 | $1,596.30 | $1,596.30 | $1,596.30 | $1,427.28 | $1,596.30 | $1,427.28 | $1,220.70 | $1,746.54 |
32077080 | DEXASCAN 1/MORE SITES AXIAL SK | 320 | Radiology Diagnostic | 320 | 77080 | $176.00 | $114.40 | $114.40 | $163.68 | $149.60 | $149.60 | $149.60 | $133.76 | $149.60 | $133.76 | $114.40 | $163.68 |
32073070 | ELBOW 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73070 | $172.00 | $111.80 | $111.80 | $159.96 | $146.20 | $146.20 | $146.20 | $130.72 | $146.20 | $130.72 | $111.80 | $159.96 |
32073080 | ELBOW SERIES/M3V | 320 | Radiology Diagnostic | 320 | 73080 | $176.00 | $114.40 | $114.40 | $163.68 | $149.60 | $149.60 | $149.60 | $133.76 | $149.60 | $133.76 | $114.40 | $163.68 |
32070150 | FACIAL BONES COMP/M3V | 320 | Radiology Diagnostic | 320 | 70150 | $295.00 | $191.75 | $191.75 | $274.35 | $250.75 | $250.75 | $250.75 | $224.20 | $250.75 | $224.20 | $191.75 | $274.35 |
32070140 | FACIAL BONES/LESS THAN 3V | 320 | Radiology Diagnostic | 320 | 70140 | $169.00 | $109.85 | $109.85 | $157.17 | $143.65 | $143.65 | $143.65 | $128.44 | $143.65 | $128.44 | $109.85 | $157.17 |
32073550 | FEMUR 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73552 | $216.00 | $140.40 | $140.40 | $200.88 | $183.60 | $183.60 | $183.60 | $164.16 | $183.60 | $164.16 | $140.40 | $200.88 |
32073140 | FINGER/FINGERS/M2V | 320 | Radiology Diagnostic | 320 | 73140 | $176.00 | $114.40 | $114.40 | $163.68 | $149.60 | $149.60 | $149.60 | $133.76 | $149.60 | $133.76 | $114.40 | $163.68 |
32073620 | FOOT 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73620 | $187.00 | $121.55 | $121.55 | $173.91 | $158.95 | $158.95 | $158.95 | $142.12 | $158.95 | $142.12 | $121.55 | $173.91 |
32073630 | FOOT COMP /M3V | 320 | Radiology Diagnostic | 320 | 73630 | $216.00 | $140.40 | $140.40 | $200.88 | $183.60 | $183.60 | $183.60 | $164.16 | $183.60 | $164.16 | $140.40 | $200.88 |
32073090 | FOREARM 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73090 | $192.00 | $124.80 | $124.80 | $178.56 | $163.20 | $163.20 | $163.20 | $145.92 | $163.20 | $145.92 | $124.80 | $178.56 |
32073120 | HAND 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73120 | $169.00 | $109.85 | $109.85 | $157.17 | $143.65 | $143.65 | $143.65 | $128.44 | $143.65 | $128.44 | $109.85 | $157.17 |
32073130 | HAND COMP./M3V | 320 | Radiology Diagnostic | 320 | 73130 | $195.00 | $126.75 | $126.75 | $181.35 | $165.75 | $165.75 | $165.75 | $148.20 | $165.75 | $148.20 | $126.75 | $181.35 |
32073500 | HIP 1 VIEW | 320 | Radiology Diagnostic | 320 | 73501 | $158.00 | $102.70 | $102.70 | $146.94 | $134.30 | $134.30 | $134.30 | $120.08 | $134.30 | $120.08 | $102.70 | $146.94 |
32073502 | HIP UNI 2-3 VIEWS | 320 | Radiology Diagnostic | 320 | 73502 | $219.00 | $142.35 | $142.35 | $203.67 | $186.15 | $186.15 | $186.15 | $166.44 | $186.15 | $166.44 | $142.35 | $203.67 |
32073520 | HIPS BI 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73521 | $264.00 | $171.60 | $171.60 | $245.52 | $224.40 | $224.40 | $224.40 | $200.64 | $224.40 | $200.64 | $171.60 | $245.52 |
32073060 | HUMERUS/M2V | 320 | Radiology Diagnostic | 320 | 73060 | $212.00 | $137.80 | $137.80 | $197.16 | $180.20 | $180.20 | $180.20 | $161.12 | $180.20 | $161.12 | $137.80 | $197.16 |
32073562 | KNEE /M3V | 320 | Radiology Diagnostic | 320 | 73562 | $190.00 | $123.50 | $123.50 | $176.70 | $161.50 | $161.50 | $161.50 | $144.40 | $161.50 | $144.40 | $123.50 | $176.70 |
32073560 | KNEE 1/2V | 320 | Radiology Diagnostic | 320 | 73560 | $176.00 | $114.40 | $114.40 | $163.68 | $149.60 | $149.60 | $149.60 | $133.76 | $149.60 | $133.76 | $114.40 | $163.68 |
32073564 | KNEE COMP. SERIES/M4V | 320 | Radiology Diagnostic | 320 | 73564 | $294.00 | $191.10 | $191.10 | $273.42 | $249.90 | $249.90 | $249.90 | $223.44 | $249.90 | $223.44 | $191.10 | $273.42 |
32073565 | KNEE XRAY-BOTH | 320 | Radiology Diagnostic | 320 | 73565 | $156.00 | $101.40 | $101.40 | $145.08 | $132.60 | $132.60 | $132.60 | $118.56 | $132.60 | $118.56 | $101.40 | $145.08 |
32072110 | L-S SPINE 5 VIEWS | 320 | Radiology Diagnostic | 320 | 72110 | $402.00 | $261.30 | $261.30 | $373.86 | $341.70 | $341.70 | $341.70 | $305.52 | $341.70 | $305.52 | $261.30 | $373.86 |
32072114 | L-S SPINE COMP/BEND | 320 | Radiology Diagnostic | 320 | 72114 | $310.00 | $201.50 | $201.50 | $288.30 | $263.50 | $263.50 | $263.50 | $235.60 | $263.50 | $235.60 | $201.50 | $288.30 |
32072100 | L-S SPINE/2 OR 3V | 320 | Radiology Diagnostic | 320 | 72100 | $238.00 | $154.70 | $154.70 | $221.34 | $202.30 | $202.30 | $202.30 | $180.88 | $202.30 | $180.88 | $154.70 | $221.34 |
32070100 | MANDIBLE/LESS THAN 4V | 320 | Radiology Diagnostic | 320 | 70100 | $242.00 | $157.30 | $157.30 | $225.06 | $205.70 | $205.70 | $205.70 | $183.92 | $205.70 | $183.92 | $157.30 | $225.06 |
32070160 | NASAL BONES COMP/M3V | 320 | Radiology Diagnostic | 320 | 70160 | $204.00 | $132.60 | $132.60 | $189.72 | $173.40 | $173.40 | $173.40 | $155.04 | $173.40 | $155.04 | $132.60 | $189.72 |
32070360 | NECK, SOFT TISSUE | 320 | Radiology Diagnostic | 320 | 70360 | $193.00 | $125.45 | $125.45 | $179.49 | $164.05 | $164.05 | $164.05 | $146.68 | $164.05 | $146.68 | $125.45 | $179.49 |
32070200 | ORBITS COMP/M4V | 320 | Radiology Diagnostic | 320 | 70200 | $205.00 | $133.25 | $133.25 | $190.65 | $174.25 | $174.25 | $174.25 | $155.80 | $174.25 | $155.80 | $133.25 | $190.65 |
32072170 | PELVIS/1 OR 2 VIEWS | 320 | Radiology Diagnostic | 320 | 72170 | $191.00 | $124.15 | $124.15 | $177.63 | $162.35 | $162.35 | $162.35 | $145.16 | $162.35 | $145.16 | $124.15 | $177.63 |
32073540 | PELVIS/HIP/M2V/CHILD | 320 | Radiology Diagnostic | 320 | 73540 | $123.00 | $79.95 | $79.95 | $114.39 | $104.55 | $104.55 | $104.55 | $93.48 | $104.55 | $93.48 | $79.95 | $114.39 |
32093041 | RHYTHM ECG | 320 | Radiology Diagnostic | 320 | 93041 | $99.00 | $64.35 | $64.35 | $92.07 | $84.15 | $84.15 | $84.15 | $75.24 | $84.15 | $75.24 | $64.35 | $92.07 |
32071110 | RIBS/BILATERAL/3V | 320 | Radiology Diagnostic | 320 | 71110 | $301.00 | $195.65 | $195.65 | $279.93 | $255.85 | $255.85 | $255.85 | $228.76 | $255.85 | $228.76 | $195.65 | $279.93 |
32071100 | RIBS/UNILAT/2V | 320 | Radiology Diagnostic | 320 | 71100 | $241.00 | $156.65 | $156.65 | $224.13 | $204.85 | $204.85 | $204.85 | $183.16 | $204.85 | $183.16 | $156.65 | $224.13 |
32072200 | SACROILIAC JTS./LESS 3V | 320 | Radiology Diagnostic | 320 | 72200 | $150.00 | $97.50 | $97.50 | $139.50 | $127.50 | $127.50 | $127.50 | $114.00 | $127.50 | $114.00 | $97.50 | $139.50 |
32072220 | SACRUM/COCCYX/M2V | 320 | Radiology Diagnostic | 320 | 72220 | $204.00 | $132.60 | $132.60 | $189.72 | $173.40 | $173.40 | $173.40 | $155.04 | $173.40 | $155.04 | $132.60 | $189.72 |
32073010 | SCAPULA COMPLETE | 320 | Radiology Diagnostic | 320 | 73010 | $199.00 | $129.35 | $129.35 | $185.07 | $169.15 | $169.15 | $169.15 | $151.24 | $169.15 | $151.24 | $129.35 | $185.07 |
32072090 | SCOLIOSIS STUDY | 320 | Radiology Diagnostic | 320 | 72082 | $90.08 | $58.55 | $58.55 | $83.77 | $76.57 | $76.57 | $76.57 | $68.46 | $76.57 | $68.46 | $58.55 | $83.77 |
32073020 | SHOULDER 1 VIEW | 320 | Radiology Diagnostic | 320 | 73020 | $159.00 | $103.35 | $103.35 | $147.87 | $135.15 | $135.15 | $135.15 | $120.84 | $135.15 | $120.84 | $103.35 | $147.87 |
32073030 | Shoulder comp/M2V | 320 | Radiology Diagnostic | 320 | 73030 | $230.00 | $149.50 | $149.50 | $213.90 | $195.50 | $195.50 | $195.50 | $174.80 | $195.50 | $174.80 | $149.50 | $213.90 |
32070220 | SINUSES COMP.SERIES/M3V | 320 | Radiology Diagnostic | 320 | 70220 | $280.00 | $182.00 | $182.00 | $260.40 | $238.00 | $238.00 | $238.00 | $212.80 | $238.00 | $212.80 | $182.00 | $260.40 |
32070210 | SINUSES/LESS THAN 3V | 320 | Radiology Diagnostic | 320 | 70210 | $127.00 | $82.55 | $82.55 | $118.11 | $107.95 | $107.95 | $107.95 | $96.52 | $107.95 | $96.52 | $82.55 | $118.11 |
32070260 | SKULL COMP.SERIES/M4V | 320 | Radiology Diagnostic | 320 | 70260 | $302.00 | $196.30 | $196.30 | $280.86 | $256.70 | $256.70 | $256.70 | $229.52 | $256.70 | $229.52 | $196.30 | $280.86 |
32070250 | SKULL/LESS THAN 4V | 320 | Radiology Diagnostic | 320 | 70250 | $216.00 | $140.40 | $140.40 | $200.88 | $183.60 | $183.60 | $183.60 | $164.16 | $183.60 | $164.16 | $140.40 | $200.88 |
32071120 | STERNUM/M2V | 320 | Radiology Diagnostic | 320 | 71120 | $163.00 | $105.95 | $105.95 | $151.59 | $138.55 | $138.55 | $138.55 | $123.88 | $138.55 | $123.88 | $105.95 | $151.59 |
32072070 | THORACIC SPINE/2V | 320 | Radiology Diagnostic | 320 | 72070 | $244.00 | $158.60 | $158.60 | $226.92 | $207.40 | $207.40 | $207.40 | $185.44 | $207.40 | $185.44 | $158.60 | $226.92 |
32072072 | THORACIC SPINE/3V | 320 | Radiology Diagnostic | 320 | 72072 | $307.00 | $199.55 | $199.55 | $285.51 | $260.95 | $260.95 | $260.95 | $233.32 | $260.95 | $233.32 | $199.55 | $285.51 |
32073592 | TIBIA/FIBULA/INFANT | 320 | Radiology Diagnostic | 320 | 73592 | $127.00 | $82.55 | $82.55 | $118.11 | $107.95 | $107.95 | $107.95 | $96.52 | $107.95 | $96.52 | $82.55 | $118.11 |
32073590 | TIBIA-FIBULA/2V | 320 | Radiology Diagnostic | 320 | 73590 | $216.00 | $140.40 | $140.40 | $200.88 | $183.60 | $183.60 | $183.60 | $164.16 | $183.60 | $164.16 | $140.40 | $200.88 |
32070328 | TMJ | 320 | Radiology Diagnostic | 320 | 70328 | $217.00 | $141.05 | $141.05 | $201.81 | $184.45 | $184.45 | $184.45 | $164.92 | $184.45 | $164.92 | $141.05 | $201.81 |
32070330 | TMJ/BILATERAL | 320 | Radiology Diagnostic | 320 | 70330 | $217.00 | $141.05 | $141.05 | $201.81 | $184.45 | $184.45 | $184.45 | $164.92 | $184.45 | $164.92 | $141.05 | $201.81 |
32073660 | TOE/TOES M2V | 320 | Radiology Diagnostic | 320 | 73660 | $164.00 | $106.60 | $106.60 | $152.52 | $139.40 | $139.40 | $139.40 | $124.64 | $139.40 | $124.64 | $106.60 | $152.52 |
32071101 | Unilateral Ribs/Chest min 3v | 320 | Radiology Diagnostic | 320 | 71101 | $389.00 | $252.85 | $252.85 | $361.77 | $330.65 | $330.65 | $330.65 | $295.64 | $330.65 | $295.64 | $252.85 | $361.77 |
32073100 | WRIST 2 VIEWS | 320 | Radiology Diagnostic | 320 | 73100 | $152.00 | $98.80 | $98.80 | $141.36 | $129.20 | $129.20 | $129.20 | $115.52 | $129.20 | $115.52 | $98.80 | $141.36 |
32073110 | WRIST COMP./M3V | 320 | Radiology Diagnostic | 320 | 73110 | $216.00 | $140.40 | $140.40 | $200.88 | $183.60 | $183.60 | $183.60 | $164.16 | $183.60 | $164.16 | $140.40 | $200.88 |
52199204 | COMPREHENSIVE EXAM NEW PATIENT | 521 | Rural Health Clinic | 521 | 99204 | $245.00 | $183.75 | $103.20 | $168.53 | $171.87 | $172.61 | $168.53 | $160.85 | $160.85 | $160.85 | $103.20 | $172.61 |
52199203 | DETAILED EXAM NEW PATIENT | 521 | Rural Health Clinic | 521 | 99203 | $180.00 | $135.00 | $60.86 | $111.02 | $113.22 | $113.70 | $111.02 | $105.07 | $105.07 | $105.07 | $60.86 | $113.70 |
52181002 | DIPSTICK UA | 521 | Rural Health Clinic | 521 | 81002 | $20.00 | $15.00 | $2.26 | $2.33 | $2.51 | $2.78 | $2.78 | $2.26 | $2.26 | $2.26 | $2.26 | $2.78 |
52199205 | HIGH COMPLEX EXAM NEW PATIENT | 521 | Rural Health Clinic | 521 | 99205 | $305.00 | $228.75 | $134.68 | $211.85 | $216.04 | $216.97 | $211.85 | $203.40 | $203.40 | $203.40 | $134.68 | $216.97 |
52199385 | PREV EXAM 18-39YRS NEW PT | 521 | Rural Health Clinic | 521 | 99385 | $228.00 | $171.00 | $79.56 | $135.41 | $138.09 | $138.68 | $135.41 | $79.56 | $79.56 | $79.56 | $79.56 | $138.68 |
52199386 | PREVENTATIVE 40-64YRS | 521 | Rural Health Clinic | 521 | 99386 | $245.00 | $183.75 | $96.82 | $157.25 | $160.36 | $161.05 | $157.25 | $96.82 | $96.82 | $96.82 | $96.82 | $161.05 |
52185610 | PROTIME (PT) | 521 | Rural Health Clinic | 521 | 85610 | $40.00 | $30.00 | $2.84 | $2.93 | $3.15 | $3.50 | $3.50 | $2.84 | $2.84 | $2.84 | $2.84 | $3.50 |
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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