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!
Schleicher County Medical Center Shoppable Services as of 7/15/2023
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
73093005 | EKG,12 LEADS,TRACING ONLY | 730 | EKG/ECG | 730 | 93005 | $ 105.00 | $ 68.25 | $ 68.25 | $ 97.65 | $ 97.65 | $ 97.65 | $ 97.65 | $ 79.80 | $ 89.25 | $ 79.80 | $ 68.25 | $ 97.65 |
73093000 | EKG ROUTINE 12 LEAD | 730 | EKG/ECG | 730 | 93000 | $ 155.00 | $ 100.75 | $ 100.75 | $ 144.15 | $ 131.75 | $ 131.75 | $ 131.75 | $ 117.80 | $ 131.75 | $ 117.80 | $ 100.75 | $ 144.15 |
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 |
730G0403 | EKG, 12 LEADS SCREENING INITIAL MCR PREV | 730 | EKG/ECG | 730 | G0403 | $ 105.00 | $ 68.25 | $ 68.25 | $ 97.65 | $ 89.25 | $ 89.25 | $ 89.25 | $ 79.80 | $ 89.25 | $ 79.80 | $ 68.25 | $ 97.65 |
30080048 | BASIC METABOLIC PANEL | 300 | Laboratory | 300 | 80048 | $ 184.00 | $ 119.60 | $ 119.60 | $ 171.12 | $ 156.40 | $ 156.40 | $ 156.40 | $ 139.84 | $ 156.40 | $ 139.84 | $ 119.60 | $ 171.12 |
30080050 | GENERAL HEALTH PANEL | 300 | Laboratory | 300 | 80050 | $ 510.00 | $ 331.50 | $ 331.50 | $ 474.30 | $ 433.50 | $ 433.50 | $ 433.50 | $ 387.60 | $ 433.50 | $ 387.60 | $ 331.50 | $ 474.30 |
30080051 | ELECTROLYTE PANEL | 300 | Laboratory | 300 | 80051 | $ 120.00 | $ 78.00 | $ 78.00 | $ 111.60 | $ 102.00 | $ 102.00 | $ 102.00 | $ 91.20 | $ 102.00 | $ 91.20 | $ 78.00 | $ 111.60 |
30080053 | COMPREHEN. METABOLIC PANE | 300 | Laboratory | 300 | 80053 | $ 266.00 | $ 172.90 | $ 172.90 | $ 247.38 | $ 226.10 | $ 226.10 | $ 226.10 | $ 202.16 | $ 226.10 | $ 202.16 | $ 172.90 | $ 247.38 |
30080061 | LIPID PANEL | 300 | Laboratory | 300 | 80061 | $ 133.00 | $ 86.45 | $ 86.45 | $ 123.69 | $ 113.05 | $ 113.05 | $ 113.05 | $ 101.08 | $ 113.05 | $ 101.08 | $ 86.45 | $ 123.69 |
30080069 | RENAL FUNCTION PANEL | 300 | Laboratory | 300 | 80069 | $ 210.00 | $ 136.50 | $ 136.50 | $ 195.30 | $ 178.50 | $ 178.50 | $ 178.50 | $ 159.60 | $ 178.50 | $ 159.60 | $ 136.50 | $ 195.30 |
30080074 | HEPATITIS PANEL | 300 | Laboratory | 300 | 80074 | $ 412.00 | $ 267.80 | $ 267.80 | $ 383.16 | $ 350.20 | $ 350.20 | $ 350.20 | $ 313.12 | $ 350.20 | $ 313.12 | $ 267.80 | $ 383.16 |
30080076 | HEPATIC FUNCTION PANEL | 300 | Laboratory | 300 | 80076 | $ 289.00 | $ 187.85 | $ 187.85 | $ 268.77 | $ 245.65 | $ 245.65 | $ 245.65 | $ 219.64 | $ 245.65 | $ 219.64 | $ 187.85 | $ 268.77 |
30080162 | DIGOXIN | 300 | Laboratory | 300 | 80162 | $ 170.00 | $ 110.50 | $ 110.50 | $ 158.10 | $ 144.50 | $ 144.50 | $ 144.50 | $ 129.20 | $ 144.50 | $ 129.20 | $ 110.50 | $ 158.10 |
30080170 | GENTAMICIN | 300 | Laboratory | 300 | 80170 | $ 254.00 | $ 165.10 | $ 165.10 | $ 236.22 | $ 215.90 | $ 215.90 | $ 215.90 | $ 193.04 | $ 215.90 | $ 193.04 | $ 165.10 | $ 236.22 |
30080184 | PHENOBARBITAL LEVEL | 300 | Laboratory | 300 | 80184 | $ 102.00 | $ 66.30 | $ 66.30 | $ 94.86 | $ 86.70 | $ 86.70 | $ 86.70 | $ 77.52 | $ 86.70 | $ 77.52 | $ 66.30 | $ 94.86 |
30080185 | PHENYTOIN TOTAL | 300 | Laboratory | 300 | 80185 | $ 130.00 | $ 84.50 | $ 84.50 | $ 120.90 | $ 110.50 | $ 110.50 | $ 110.50 | $ 98.80 | $ 110.50 | $ 98.80 | $ 84.50 | $ 120.90 |
30080195 | Drug Screen Quantitative Sirolimus | 300 | Laboratory | 300 | 80195 | $ 71.00 | $ 46.15 | $ 46.15 | $ 66.03 | $ 60.35 | $ 60.35 | $ 60.35 | $ 53.96 | $ 60.35 | $ 53.96 | $ 46.15 | $ 66.03 |
30080197 | TACROLIMUS | 300 | Laboratory | 300 | 80197 | $ 318.00 | $ 206.70 | $ 206.70 | $ 295.74 | $ 270.30 | $ 270.30 | $ 270.30 | $ 241.68 | $ 270.30 | $ 241.68 | $ 206.70 | $ 295.74 |
30080202 | VANCOMYCIN LEVEL | 300 | Laboratory | 300 | 80202 | $ 143.00 | $ 92.95 | $ 92.95 | $ 132.99 | $ 121.55 | $ 121.55 | $ 121.55 | $ 108.68 | $ 121.55 | $ 108.68 | $ 92.95 | $ 132.99 |
30080307 | Drug Screen | 300 | Laboratory | 300 | 80307 | $ 65.00 | $ 42.25 | $ 42.25 | $ 60.45 | $ 55.25 | $ 55.25 | $ 55.25 | $ 49.40 | $ 55.25 | $ 49.40 | $ 42.25 | $ 60.45 |
30080100E | DRUG SCREEN INHOUSE- EMPLOYEE | 300 | Laboratory | 300 | 80307 | $ 65.00 | $ 42.25 | $ 42.25 | $ 60.45 | $ 55.25 | $ 55.25 | $ 55.25 | $ 49.40 | $ 55.25 | $ 49.40 | $ 42.25 | $ 60.45 |
30080100N | Drug Screen Nursing Home | 300 | Laboratory | 300 | 80307 | $ 65.00 | $ 42.25 | $ 42.25 | $ 60.45 | $ 55.25 | $ 55.25 | $ 55.25 | $ 49.40 | $ 55.25 | $ 49.40 | $ 42.25 | $ 60.45 |
30080320 | ETOH/ANYSPEC.EXCP.BREATH (ALCOHOL) | 300 | Laboratory | 300 | 80320 | $ 115.00 | $ 74.75 | $ 74.75 | $ 106.95 | $ 97.75 | $ 97.75 | $ 97.75 | $ 87.40 | $ 97.75 | $ 87.40 | $ 74.75 | $ 106.95 |
30080335 | Amitriptyline, Serum | 300 | Laboratory | 300 | 80335 | $ 44.00 | $ 28.60 | $ 28.60 | $ 40.92 | $ 37.40 | $ 37.40 | $ 37.40 | $ 33.44 | $ 37.40 | $ 33.44 | $ 28.60 | $ 40.92 |
30081001 | UA AUTOMATED, W/MICRO | 300 | Laboratory | 300 | 81001 | $ 69.00 | $ 44.85 | $ 44.85 | $ 64.17 | $ 58.65 | $ 58.65 | $ 58.65 | $ 52.44 | $ 58.65 | $ 52.44 | $ 44.85 | $ 64.17 |
30081003 | UA AUTOMATED, W/O MICRO | 300 | Laboratory | 300 | 81003 | $ 53.00 | $ 34.45 | $ 34.45 | $ 49.29 | $ 45.05 | $ 45.05 | $ 45.05 | $ 40.28 | $ 45.05 | $ 40.28 | $ 34.45 | $ 49.29 |
30081025 | PREGNANCY TEST, URINE | 300 | Laboratory | 300 | 81025 | $ 96.00 | $ 62.40 | $ 62.40 | $ 89.28 | $ 81.60 | $ 81.60 | $ 81.60 | $ 72.96 | $ 81.60 | $ 72.96 | $ 62.40 | $ 89.28 |
30082040 | ALBUMIN/SERUM | 300 | Laboratory | 300 | 82040 | $ 50.00 | $ 32.50 | $ 32.50 | $ 46.50 | $ 42.50 | $ 42.50 | $ 42.50 | $ 38.00 | $ 42.50 | $ 38.00 | $ 32.50 | $ 46.50 |
30082044 | MICROALBUMIN SEMIQUANT | 300 | Laboratory | 300 | 82044 | $ 40.00 | $ 26.00 | $ 26.00 | $ 37.20 | $ 34.00 | $ 34.00 | $ 34.00 | $ 30.40 | $ 34.00 | $ 30.40 | $ 26.00 | $ 37.20 |
30082103 | ALPHA1-ANTITRYPSIN, TOTAL | 300 | Laboratory | 300 | 82103 | $ 516.00 | $ 335.40 | $ 335.40 | $ 479.88 | $ 438.60 | $ 438.60 | $ 438.60 | $ 392.16 | $ 438.60 | $ 392.16 | $ 335.40 | $ 479.88 |
30082105 | ALPHA-FETOPROTEIN | 300 | Laboratory | 300 | 82105 | $ 176.00 | $ 114.40 | $ 114.40 | $ 163.68 | $ 149.60 | $ 149.60 | $ 149.60 | $ 133.76 | $ 149.60 | $ 133.76 | $ 114.40 | $ 163.68 |
30082140 | AMMONIA | 300 | Laboratory | 300 | 82140 | $ 142.00 | $ 92.30 | $ 92.30 | $ 132.06 | $ 120.70 | $ 120.70 | $ 120.70 | $ 107.92 | $ 120.70 | $ 107.92 | $ 92.30 | $ 132.06 |
30082150 | AMYLASE/SERUM | 300 | Laboratory | 300 | 82150 | $ 90.00 | $ 58.50 | $ 58.50 | $ 83.70 | $ 76.50 | $ 76.50 | $ 76.50 | $ 68.40 | $ 76.50 | $ 68.40 | $ 58.50 | $ 83.70 |
30082180 | Asorbic acid (vitamin C) | 300 | Laboratory | 300 | 82180 | $ 31.00 | $ 20.15 | $ 20.15 | $ 28.83 | $ 26.35 | $ 26.35 | $ 26.35 | $ 23.56 | $ 26.35 | $ 23.56 | $ 20.15 | $ 28.83 |
30082247 | BILIRUBIN/TOTAL | 300 | Laboratory | 300 | 82247 | $ 80.00 | $ 52.00 | $ 52.00 | $ 74.40 | $ 68.00 | $ 68.00 | $ 68.00 | $ 60.80 | $ 68.00 | $ 60.80 | $ 52.00 | $ 74.40 |
30082248 | BILIRUBIN/DIRECT | 300 | Laboratory | 300 | 82248 | $ 93.00 | $ 60.45 | $ 60.45 | $ 86.49 | $ 79.05 | $ 79.05 | $ 79.05 | $ 70.68 | $ 79.05 | $ 70.68 | $ 60.45 | $ 86.49 |
30082271 | OCCULT BLOOD OTHER SOURCE | 300 | Laboratory | 300 | 82271 | $ 45.00 | $ 29.25 | $ 29.25 | $ 41.85 | $ 38.25 | $ 38.25 | $ 38.25 | $ 34.20 | $ 38.25 | $ 34.20 | $ 29.25 | $ 41.85 |
30082274 | FECAL OCCULT BLOOD | 300 | Laboratory | 300 | 82274 | $ 41.00 | $ 26.65 | $ 26.65 | $ 38.13 | $ 34.85 | $ 34.85 | $ 34.85 | $ 31.16 | $ 34.85 | $ 31.16 | $ 26.65 | $ 38.13 |
30082306 | 25-HYDROXYVITAMIN D2 & D3 | 300 | Laboratory | 300 | 82306 | $ 200.00 | $ 130.00 | $ 130.00 | $ 186.00 | $ 170.00 | $ 170.00 | $ 170.00 | $ 152.00 | $ 170.00 | $ 152.00 | $ 130.00 | $ 186.00 |
30082310 | CALCIUM/TOTAL/BLOOD | 300 | Laboratory | 300 | 82310 | $ 73.00 | $ 47.45 | $ 47.45 | $ 67.89 | $ 62.05 | $ 62.05 | $ 62.05 | $ 55.48 | $ 62.05 | $ 55.48 | $ 47.45 | $ 67.89 |
30082360 | CALCULUS ASSAY QUANT | 300 | Laboratory | 300 | 82360 | $ 64.00 | $ 41.60 | $ 41.60 | $ 59.52 | $ 54.40 | $ 54.40 | $ 54.40 | $ 48.64 | $ 54.40 | $ 48.64 | $ 41.60 | $ 59.52 |
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 |
30082542 | COLUMN CHROMOTOGRAPHY QUANT | 300 | Laboratory | 300 | 82542 | $ 94.00 | $ 61.10 | $ 61.10 | $ 87.42 | $ 79.90 | $ 79.90 | $ 79.90 | $ 71.44 | $ 79.90 | $ 71.44 | $ 61.10 | $ 87.42 |
30082550 | CK/CPK /TOTAL | 300 | Laboratory | 300 | 82550 | $ 112.00 | $ 72.80 | $ 72.80 | $ 104.16 | $ 95.20 | $ 95.20 | $ 95.20 | $ 85.12 | $ 95.20 | $ 85.12 | $ 72.80 | $ 104.16 |
30082553 | CK MB FRACTION ONLY | 300 | Laboratory | 300 | 82553 | $ 187.00 | $ 121.55 | $ 121.55 | $ 173.91 | $ 158.95 | $ 158.95 | $ 158.95 | $ 142.12 | $ 158.95 | $ 142.12 | $ 121.55 | $ 173.91 |
30082565 | CREATININE/BLOOD | 300 | Laboratory | 300 | 82565 | $ 73.00 | $ 47.45 | $ 47.45 | $ 67.89 | $ 62.05 | $ 62.05 | $ 62.05 | $ 55.48 | $ 62.05 | $ 55.48 | $ 47.45 | $ 67.89 |
30082570 | CREATININE (OTHER SOURCE) | 300 | Laboratory | 300 | 82570 | $ 73.00 | $ 47.45 | $ 47.45 | $ 67.89 | $ 62.05 | $ 62.05 | $ 62.05 | $ 55.48 | $ 62.05 | $ 55.48 | $ 47.45 | $ 67.89 |
30082607 | CYANOCOBALAMIN (B-12) | 300 | Laboratory | 300 | 82607 | $ 125.00 | $ 81.25 | $ 81.25 | $ 116.25 | $ 106.25 | $ 106.25 | $ 106.25 | $ 95.00 | $ 106.25 | $ 95.00 | $ 81.25 | $ 116.25 |
30082627 | DEHYDROEPLANDROSTERONE | 300 | Laboratory | 300 | 82627 | $ 61.00 | $ 39.65 | $ 39.65 | $ 56.73 | $ 51.85 | $ 51.85 | $ 51.85 | $ 46.36 | $ 51.85 | $ 46.36 | $ 39.65 | $ 56.73 |
30082656 | Pancreatic elast fecal | 300 | Laboratory | 300 | 82656 | $ 306.00 | $ 198.90 | $ 198.90 | $ 284.58 | $ 260.10 | $ 260.10 | $ 260.10 | $ 232.56 | $ 260.10 | $ 232.56 | $ 198.90 | $ 284.58 |
30082670 | ESTRADIOL | 300 | Laboratory | 300 | 82670 | $ 336.00 | $ 218.40 | $ 218.40 | $ 312.48 | $ 285.60 | $ 285.60 | $ 285.60 | $ 255.36 | $ 285.60 | $ 255.36 | $ 218.40 | $ 312.48 |
30082672 | ESTROGENS/TOTAL | 300 | Laboratory | 300 | 82672 | $ 336.00 | $ 218.40 | $ 218.40 | $ 312.48 | $ 285.60 | $ 285.60 | $ 285.60 | $ 255.36 | $ 285.60 | $ 255.36 | $ 218.40 | $ 312.48 |
30082705 | Fecal Fat Lipids | 300 | Laboratory | 300 | 82705 | $ 31.00 | $ 20.15 | $ 20.15 | $ 28.83 | $ 26.35 | $ 26.35 | $ 26.35 | $ 23.56 | $ 26.35 | $ 23.56 | $ 20.15 | $ 28.83 |
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 |
30082728 | FERRITIN | 300 | Laboratory | 300 | 82728 | $ 125.00 | $ 81.25 | $ 81.25 | $ 116.25 | $ 106.25 | $ 106.25 | $ 106.25 | $ 95.00 | $ 106.25 | $ 95.00 | $ 81.25 | $ 116.25 |
30082746 | FOLIC ACID/SERUM | 300 | Laboratory | 300 | 82746 | $ 121.00 | $ 78.65 | $ 78.65 | $ 112.53 | $ 102.85 | $ 102.85 | $ 102.85 | $ 91.96 | $ 102.85 | $ 91.96 | $ 78.65 | $ 112.53 |
30082784 | GAMMA GLOBULIN | 300 | Laboratory | 300 | 82784 | $ 236.00 | $ 153.40 | $ 153.40 | $ 219.48 | $ 200.60 | $ 200.60 | $ 200.60 | $ 179.36 | $ 200.60 | $ 179.36 | $ 153.40 | $ 219.48 |
30082803 | PH, PCO2, PO2 SIM. | 300 | Laboratory | 300 | 82803 | $ 269.00 | $ 174.85 | $ 174.85 | $ 250.17 | $ 228.65 | $ 228.65 | $ 228.65 | $ 204.44 | $ 228.65 | $ 204.44 | $ 174.85 | $ 250.17 |
30082945 | GLUCOSE, OTHER THAN BLOOD | 300 | Laboratory | 300 | 82945 | $ 31.00 | $ 20.15 | $ 20.15 | $ 28.83 | $ 26.35 | $ 26.35 | $ 26.35 | $ 23.56 | $ 26.35 | $ 23.56 | $ 20.15 | $ 28.83 |
30082947 | GLUCOSE SERUM/FLUID | 300 | Laboratory | 300 | 82947 | $ 72.00 | $ 46.80 | $ 46.80 | $ 66.96 | $ 61.20 | $ 61.20 | $ 61.20 | $ 54.72 | $ 61.20 | $ 54.72 | $ 46.80 | $ 66.96 |
30082962 | GLUCOSE FINGERSTICK | 300 | Laboratory | 300 | 82962 | $ 45.00 | $ 29.25 | $ 29.25 | $ 41.85 | $ 38.25 | $ 38.25 | $ 38.25 | $ 34.20 | $ 38.25 | $ 34.20 | $ 29.25 | $ 41.85 |
30082977 | GGT | 300 | Laboratory | 300 | 82977 | $ 67.00 | $ 43.55 | $ 43.55 | $ 62.31 | $ 56.95 | $ 56.95 | $ 56.95 | $ 50.92 | $ 56.95 | $ 50.92 | $ 43.55 | $ 62.31 |
30083001 | FSH | 300 | Laboratory | 300 | 83001 | $ 147.00 | $ 95.55 | $ 95.55 | $ 136.71 | $ 124.95 | $ 124.95 | $ 124.95 | $ 111.72 | $ 124.95 | $ 111.72 | $ 95.55 | $ 136.71 |
30083002 | LH | 300 | Laboratory | 300 | 83002 | $ 147.00 | $ 95.55 | $ 95.55 | $ 136.71 | $ 124.95 | $ 124.95 | $ 124.95 | $ 111.72 | $ 124.95 | $ 111.72 | $ 95.55 | $ 136.71 |
30083036 | HEMOGLOBIN A1C | 300 | Laboratory | 300 | 83036 | $ 74.00 | $ 48.10 | $ 48.10 | $ 68.82 | $ 62.90 | $ 62.90 | $ 62.90 | $ 56.24 | $ 62.90 | $ 56.24 | $ 48.10 | $ 68.82 |
30083516 | IMMUNOASSAY NONANTIBODY | 300 | Laboratory | 300 | 83516 | $ 50.00 | $ 32.50 | $ 32.50 | $ 46.50 | $ 42.50 | $ 42.50 | $ 42.50 | $ 38.00 | $ 42.50 | $ 38.00 | $ 32.50 | $ 46.50 |
30083525 | INSULIN/TOTAL | 300 | Laboratory | 300 | 83525 | $ 142.00 | $ 92.30 | $ 92.30 | $ 132.06 | $ 120.70 | $ 120.70 | $ 120.70 | $ 107.92 | $ 120.70 | $ 107.92 | $ 92.30 | $ 132.06 |
30083540 | IRON | 300 | Laboratory | 300 | 83540 | $ 47.00 | $ 30.55 | $ 30.55 | $ 43.71 | $ 39.95 | $ 39.95 | $ 39.95 | $ 35.72 | $ 39.95 | $ 35.72 | $ 30.55 | $ 43.71 |
30083550 | IRON BINDING | 300 | Laboratory | 300 | 83550 | $ 80.00 | $ 52.00 | $ 52.00 | $ 74.40 | $ 68.00 | $ 68.00 | $ 68.00 | $ 60.80 | $ 68.00 | $ 60.80 | $ 52.00 | $ 74.40 |
30083605 | LACTIC ACID | 300 | Laboratory | 300 | 83605 | $ 135.00 | $ 87.75 | $ 87.75 | $ 125.55 | $ 114.75 | $ 114.75 | $ 114.75 | $ 102.60 | $ 114.75 | $ 102.60 | $ 87.75 | $ 125.55 |
30083615 | LDH | 300 | Laboratory | 300 | 83615 | $ 104.00 | $ 67.60 | $ 67.60 | $ 96.72 | $ 88.40 | $ 88.40 | $ 88.40 | $ 79.04 | $ 88.40 | $ 79.04 | $ 67.60 | $ 96.72 |
30083655 | LEAD | 300 | Laboratory | 300 | 83655 | $ 112.00 | $ 72.80 | $ 72.80 | $ 104.16 | $ 95.20 | $ 95.20 | $ 95.20 | $ 85.12 | $ 95.20 | $ 85.12 | $ 72.80 | $ 104.16 |
30083690 | LIPASE | 300 | Laboratory | 300 | 83690 | $ 69.00 | $ 44.85 | $ 44.85 | $ 64.17 | $ 58.65 | $ 58.65 | $ 58.65 | $ 52.44 | $ 58.65 | $ 52.44 | $ 44.85 | $ 64.17 |
30083721 | LDL CHOLESTEROL | 300 | Laboratory | 300 | 83721 | $ 27.00 | $ 17.55 | $ 17.55 | $ 25.11 | $ 22.95 | $ 22.95 | $ 22.95 | $ 20.52 | $ 22.95 | $ 20.52 | $ 17.55 | $ 25.11 |
30083735 | MAGNESIUM | 300 | Laboratory | 300 | 83735 | $ 50.00 | $ 32.50 | $ 32.50 | $ 46.50 | $ 42.50 | $ 42.50 | $ 42.50 | $ 38.00 | $ 42.50 | $ 38.00 | $ 32.50 | $ 46.50 |
30083789 | HOMOCYSTINE LEVEL | 300 | Laboratory | 300 | 83789 | $ 183.00 | $ 118.95 | $ 118.95 | $ 170.19 | $ 155.55 | $ 155.55 | $ 155.55 | $ 139.08 | $ 155.55 | $ 139.08 | $ 118.95 | $ 170.19 |
30083880 | NATRIURETIC PEPTIDE | 300 | Laboratory | 300 | 83880 | $ 201.00 | $ 130.65 | $ 130.65 | $ 186.93 | $ 170.85 | $ 170.85 | $ 170.85 | $ 152.76 | $ 170.85 | $ 152.76 | $ 130.65 | $ 186.93 |
30083970 | PARATHYROID HORM. | 300 | Laboratory | 300 | 83970 | $ 299.00 | $ 194.35 | $ 194.35 | $ 278.07 | $ 254.15 | $ 254.15 | $ 254.15 | $ 227.24 | $ 254.15 | $ 227.24 | $ 194.35 | $ 278.07 |
30084075 | PHOSPHATASE ALKALINE | 300 | Laboratory | 300 | 84075 | $ 74.00 | $ 48.10 | $ 48.10 | $ 68.82 | $ 62.90 | $ 62.90 | $ 62.90 | $ 56.24 | $ 62.90 | $ 56.24 | $ 48.10 | $ 68.82 |
30084100 | PHOSPHORUS | 300 | Laboratory | 300 | 84100 | $ 41.00 | $ 26.65 | $ 26.65 | $ 38.13 | $ 34.85 | $ 34.85 | $ 34.85 | $ 31.16 | $ 34.85 | $ 31.16 | $ 26.65 | $ 38.13 |
30084132 | POTASSIUM (K)/SERUM | 300 | Laboratory | 300 | 84132 | $ 72.00 | $ 46.80 | $ 46.80 | $ 66.96 | $ 61.20 | $ 61.20 | $ 61.20 | $ 54.72 | $ 61.20 | $ 54.72 | $ 46.80 | $ 66.96 |
30084134 | PREALBUMIN | 300 | Laboratory | 300 | 84134 | $ 101.00 | $ 65.65 | $ 65.65 | $ 93.93 | $ 85.85 | $ 85.85 | $ 85.85 | $ 76.76 | $ 85.85 | $ 76.76 | $ 65.65 | $ 93.93 |
30084144 | PROGESTERONE | 300 | Laboratory | 300 | 84144 | $ 150.00 | $ 97.50 | $ 97.50 | $ 139.50 | $ 127.50 | $ 127.50 | $ 127.50 | $ 114.00 | $ 127.50 | $ 114.00 | $ 97.50 | $ 139.50 |
30084146 | PROLACTIN | 300 | Laboratory | 300 | 84146 | $ 194.00 | $ 126.10 | $ 126.10 | $ 180.42 | $ 164.90 | $ 164.90 | $ 164.90 | $ 147.44 | $ 164.90 | $ 147.44 | $ 126.10 | $ 180.42 |
30084153 | PSA (PROSTATE S A ) | 300 | Laboratory | 300 | 84153 | $ 83.00 | $ 53.95 | $ 53.95 | $ 77.19 | $ 70.55 | $ 70.55 | $ 70.55 | $ 63.08 | $ 70.55 | $ 63.08 | $ 53.95 | $ 77.19 |
30084154 | PSA Specific Antigen, Free | 300 | Laboratory | 300 | 84154 | $ 44.00 | $ 28.60 | $ 28.60 | $ 40.92 | $ 37.40 | $ 37.40 | $ 37.40 | $ 33.44 | $ 37.40 | $ 33.44 | $ 28.60 | $ 40.92 |
30084156 | PROTEIN, TOTAL URINE | 300 | Laboratory | 300 | 84156 | $ 395.00 | $ 256.75 | $ 256.75 | $ 367.35 | $ 335.75 | $ 335.75 | $ 335.75 | $ 300.20 | $ 335.75 | $ 300.20 | $ 256.75 | $ 367.35 |
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 |
30084295 | SODIUM (NA)/BLOOD | 300 | Laboratory | 300 | 84295 | $ 74.00 | $ 48.10 | $ 48.10 | $ 68.82 | $ 62.90 | $ 62.90 | $ 62.90 | $ 56.24 | $ 62.90 | $ 56.24 | $ 48.10 | $ 68.82 |
30084305 | ASSAY OF SOMATOMEDIN | 300 | Laboratory | 300 | 84305 | $ 58.00 | $ 37.70 | $ 37.70 | $ 53.94 | $ 49.30 | $ 49.30 | $ 49.30 | $ 44.08 | $ 49.30 | $ 44.08 | $ 37.70 | $ 53.94 |
30084402 | TESTOSTERONE ASSAY | 300 | Laboratory | 300 | 84402 | $ 41.00 | $ 26.65 | $ 26.65 | $ 38.13 | $ 34.85 | $ 34.85 | $ 34.85 | $ 31.16 | $ 34.85 | $ 31.16 | $ 26.65 | $ 38.13 |
30084403 | TESTOSTERONE TOTAL | 300 | Laboratory | 300 | 84403 | $ 252.00 | $ 163.80 | $ 163.80 | $ 234.36 | $ 214.20 | $ 214.20 | $ 214.20 | $ 191.52 | $ 214.20 | $ 191.52 | $ 163.80 | $ 234.36 |
30084425 | VITAMIN B 1 | 300 | Laboratory | 300 | 84425 | $ 250.00 | $ 162.50 | $ 162.50 | $ 232.50 | $ 212.50 | $ 212.50 | $ 212.50 | $ 190.00 | $ 212.50 | $ 190.00 | $ 162.50 | $ 232.50 |
30084436 | THYROXINE/TOTAL-T4 | 300 | Laboratory | 300 | 84436 | $ 62.00 | $ 40.30 | $ 40.30 | $ 57.66 | $ 52.70 | $ 52.70 | $ 52.70 | $ 47.12 | $ 52.70 | $ 47.12 | $ 40.30 | $ 57.66 |
30084439 | THYROXINE/FREE-T4 | 300 | Laboratory | 300 | 84439 | $ 152.00 | $ 98.80 | $ 98.80 | $ 141.36 | $ 129.20 | $ 129.20 | $ 129.20 | $ 115.52 | $ 129.20 | $ 115.52 | $ 98.80 | $ 141.36 |
30084443 | TSH | 300 | Laboratory | 300 | 84443 | $ 170.00 | $ 110.50 | $ 110.50 | $ 158.10 | $ 144.50 | $ 144.50 | $ 144.50 | $ 129.20 | $ 144.50 | $ 129.20 | $ 110.50 | $ 158.10 |
30084450 | AST (SGOT) | 300 | Laboratory | 300 | 84450 | $ 96.00 | $ 62.40 | $ 62.40 | $ 89.28 | $ 81.60 | $ 81.60 | $ 81.60 | $ 72.96 | $ 81.60 | $ 72.96 | $ 62.40 | $ 89.28 |
30084460 | ALT (SGPT) | 300 | Laboratory | 300 | 84460 | $ 96.00 | $ 62.40 | $ 62.40 | $ 89.28 | $ 81.60 | $ 81.60 | $ 81.60 | $ 72.96 | $ 81.60 | $ 72.96 | $ 62.40 | $ 89.28 |
30084478 | TRIGLYCERIDES | 300 | Laboratory | 300 | 84478 | $ 120.00 | $ 78.00 | $ 78.00 | $ 111.60 | $ 102.00 | $ 102.00 | $ 102.00 | $ 91.20 | $ 102.00 | $ 91.20 | $ 78.00 | $ 111.60 |
30084480 | T3/TOTAL | 300 | Laboratory | 300 | 84480 | $ 159.00 | $ 103.35 | $ 103.35 | $ 147.87 | $ 135.15 | $ 135.15 | $ 135.15 | $ 120.84 | $ 135.15 | $ 120.84 | $ 103.35 | $ 147.87 |
30084481 | TRIIODOTHYRONINE T3; FREE | 300 | Laboratory | 300 | 84481 | $ 48.00 | $ 31.20 | $ 31.20 | $ 44.64 | $ 40.80 | $ 40.80 | $ 40.80 | $ 36.48 | $ 40.80 | $ 36.48 | $ 31.20 | $ 44.64 |
30084484 | TROPONIN QUANTITATIVE | 300 | Laboratory | 300 | 84484 | $ 45.00 | $ 29.25 | $ 29.25 | $ 41.85 | $ 38.25 | $ 38.25 | $ 38.25 | $ 34.20 | $ 38.25 | $ 34.20 | $ 29.25 | $ 41.85 |
30084512 | TROPONIN QUALITIATIVE | 300 | Laboratory | 300 | 84512 | $ 200.00 | $ 130.00 | $ 130.00 | $ 186.00 | $ 170.00 | $ 170.00 | $ 170.00 | $ 152.00 | $ 170.00 | $ 152.00 | $ 130.00 | $ 186.00 |
30084520 | UREA NITROGEN (BUN) | 300 | Laboratory | 300 | 84520 | $ 73.00 | $ 47.45 | $ 47.45 | $ 67.89 | $ 62.05 | $ 62.05 | $ 62.05 | $ 55.48 | $ 62.05 | $ 55.48 | $ 47.45 | $ 67.89 |
30084550 | URIC ACID/SERUM | 300 | Laboratory | 300 | 84550 | $ 72.00 | $ 46.80 | $ 46.80 | $ 66.96 | $ 61.20 | $ 61.20 | $ 61.20 | $ 54.72 | $ 61.20 | $ 54.72 | $ 46.80 | $ 66.96 |
30084597 | ASSAY VITAMIN K | 300 | Laboratory | 300 | 84597 | $ 256.00 | $ 166.40 | $ 166.40 | $ 238.08 | $ 217.60 | $ 217.60 | $ 217.60 | $ 194.56 | $ 217.60 | $ 194.56 | $ 166.40 | $ 238.08 |
30084703 | GONADOTROPIN,CHRIONIC;QUAL. | 300 | Laboratory | 300 | 84703 | $ 96.00 | $ 62.40 | $ 62.40 | $ 89.28 | $ 81.60 | $ 81.60 | $ 81.60 | $ 72.96 | $ 81.60 | $ 72.96 | $ 62.40 | $ 89.28 |
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 |
30085014 | HEMATOCRIT | 300 | Laboratory | 300 | 85014 | $ 34.00 | $ 22.10 | $ 22.10 | $ 31.62 | $ 28.90 | $ 28.90 | $ 28.90 | $ 25.84 | $ 28.90 | $ 25.84 | $ 22.10 | $ 31.62 |
30085018 | HEMOGLOBIN | 300 | Laboratory | 300 | 85018 | $ 34.00 | $ 22.10 | $ 22.10 | $ 31.62 | $ 28.90 | $ 28.90 | $ 28.90 | $ 25.84 | $ 28.90 | $ 25.84 | $ 22.10 | $ 31.62 |
30085025 | COMPLETE CBC AUTO/AUTODIF | 300 | Laboratory | 300 | 85025 | $ 73.00 | $ 47.45 | $ 47.45 | $ 67.89 | $ 62.05 | $ 62.05 | $ 62.05 | $ 55.48 | $ 62.05 | $ 55.48 | $ 47.45 | $ 67.89 |
30085027 | COMPLETE CBC AUTOMATED | 300 | Laboratory | 300 | 85027 | $ 93.00 | $ 60.45 | $ 60.45 | $ 86.49 | $ 79.05 | $ 79.05 | $ 79.05 | $ 70.68 | $ 79.05 | $ 70.68 | $ 60.45 | $ 86.49 |
30085045 | RETICULOCYTE, AUTOMATED | 300 | Laboratory | 300 | 85045 | $ 38.00 | $ 24.70 | $ 24.70 | $ 35.34 | $ 32.30 | $ 32.30 | $ 32.30 | $ 28.88 | $ 32.30 | $ 28.88 | $ 24.70 | $ 35.34 |
30085049 | PLATELET COUNT | 300 | Laboratory | 300 | 85049 | $ 35.00 | $ 22.75 | $ 22.75 | $ 32.55 | $ 29.75 | $ 29.75 | $ 29.75 | $ 26.60 | $ 29.75 | $ 26.60 | $ 22.75 | $ 32.55 |
30085379 | D-DIMER, QUANTITATIVE | 300 | Laboratory | 300 | 85379 | $ 42.00 | $ 27.30 | $ 27.30 | $ 39.06 | $ 35.70 | $ 35.70 | $ 35.70 | $ 31.92 | $ 35.70 | $ 31.92 | $ 27.30 | $ 39.06 |
30085610 | PROTIME (PT) | 300 | Laboratory | 300 | 85610 | $ 72.00 | $ 46.80 | $ 46.80 | $ 66.96 | $ 61.20 | $ 61.20 | $ 61.20 | $ 54.72 | $ 61.20 | $ 54.72 | $ 46.80 | $ 66.96 |
30085651 | SED RATE (ESR) | 300 | Laboratory | 300 | 85651 | $ 53.00 | $ 34.45 | $ 34.45 | $ 49.29 | $ 45.05 | $ 45.05 | $ 45.05 | $ 40.28 | $ 45.05 | $ 40.28 | $ 34.45 | $ 49.29 |
30085730 | PART. PROTIME (PTT) | 300 | Laboratory | 300 | 85730 | $ 82.00 | $ 53.30 | $ 53.30 | $ 76.26 | $ 69.70 | $ 69.70 | $ 69.70 | $ 62.32 | $ 69.70 | $ 62.32 | $ 53.30 | $ 76.26 |
30086038 | ANA | 300 | Laboratory | 300 | 86038 | $ 96.00 | $ 62.40 | $ 62.40 | $ 89.28 | $ 81.60 | $ 81.60 | $ 81.60 | $ 72.96 | $ 81.60 | $ 72.96 | $ 62.40 | $ 89.28 |
30086140 | C-REACTIVE PROTEIN | 300 | Laboratory | 300 | 86140 | $ 80.00 | $ 52.00 | $ 52.00 | $ 74.40 | $ 68.00 | $ 68.00 | $ 68.00 | $ 60.80 | $ 68.00 | $ 60.80 | $ 52.00 | $ 74.40 |
30086141 | C-REACTIVE PROTEIN HS | 300 | Laboratory | 300 | 86141 | $ 62.00 | $ 40.30 | $ 40.30 | $ 57.66 | $ 52.70 | $ 52.70 | $ 52.70 | $ 47.12 | $ 52.70 | $ 47.12 | $ 40.30 | $ 57.66 |
30086147 | Cardiolipin Antibody Each IG Class | 300 | Laboratory | 300 | 86147 | $ 37.00 | $ 24.05 | $ 24.05 | $ 34.41 | $ 31.45 | $ 31.45 | $ 31.45 | $ 28.12 | $ 31.45 | $ 28.12 | $ 24.05 | $ 34.41 |
30086160 | COMPLEMENT;ANTIGEN, EACH COMP. | 300 | Laboratory | 300 | 86160 | $ 114.00 | $ 74.10 | $ 74.10 | $ 106.02 | $ 96.90 | $ 96.90 | $ 96.90 | $ 86.64 | $ 96.90 | $ 86.64 | $ 74.10 | $ 106.02 |
30086225 | DNA ANTIBODY;NATIVE/DBL STRAND | 300 | Laboratory | 300 | 86225 | $ 204.00 | $ 132.60 | $ 132.60 | $ 189.72 | $ 173.40 | $ 173.40 | $ 173.40 | $ 155.04 | $ 173.40 | $ 155.04 | $ 132.60 | $ 189.72 |
30086300 | CANCER ANTIGEN CA-15-3/2729 | 300 | Laboratory | 300 | 86300 | $ 176.00 | $ 114.40 | $ 114.40 | $ 163.68 | $ 149.60 | $ 149.60 | $ 149.60 | $ 133.76 | $ 149.60 | $ 133.76 | $ 114.40 | $ 163.68 |
30086304 | CANCER ANTIGEN 125 | 300 | Laboratory | 300 | 86304 | $ 151.00 | $ 98.15 | $ 98.15 | $ 140.43 | $ 128.35 | $ 128.35 | $ 128.35 | $ 114.76 | $ 128.35 | $ 114.76 | $ 98.15 | $ 140.43 |
30086308 | HETEROPHILE ANTIBODIES | 300 | Laboratory | 300 | 86308 | $ 67.00 | $ 43.55 | $ 43.55 | $ 62.31 | $ 56.95 | $ 56.95 | $ 56.95 | $ 50.92 | $ 56.95 | $ 50.92 | $ 43.55 | $ 62.31 |
30086376 | MICROSOMAL ANTIBODIES | 300 | Laboratory | 300 | 86376 | $ 46.00 | $ 29.90 | $ 29.90 | $ 42.78 | $ 39.10 | $ 39.10 | $ 39.10 | $ 34.96 | $ 39.10 | $ 34.96 | $ 29.90 | $ 42.78 |
30086431 | RHEUMATOID FACTOR/QUAN. | 300 | Laboratory | 300 | 86431 | $ 107.00 | $ 69.55 | $ 69.55 | $ 99.51 | $ 90.95 | $ 90.95 | $ 90.95 | $ 81.32 | $ 90.95 | $ 81.32 | $ 69.55 | $ 99.51 |
30086592 | RPR/QUALITATIVE | 300 | Laboratory | 300 | 86592 | $ 62.00 | $ 40.30 | $ 40.30 | $ 57.66 | $ 52.70 | $ 52.70 | $ 52.70 | $ 47.12 | $ 52.70 | $ 47.12 | $ 40.30 | $ 57.66 |
30086606 | Fungal Anitbodies by double immuno-diff | 300 | Laboratory | 300 | 86606 | $ 61.00 | $ 39.65 | $ 39.65 | $ 56.73 | $ 51.85 | $ 51.85 | $ 51.85 | $ 46.36 | $ 51.85 | $ 46.36 | $ 39.65 | $ 56.73 |
30086618 | LYME DISEASE AB | 300 | Laboratory | 300 | 86618 | $ 150.00 | $ 97.50 | $ 97.50 | $ 139.50 | $ 127.50 | $ 127.50 | $ 127.50 | $ 114.00 | $ 127.50 | $ 114.00 | $ 97.50 | $ 139.50 |
30086635 | Coccidiodes Anitbody by comp fix | 300 | Laboratory | 300 | 86635 | $ 77.00 | $ 50.05 | $ 50.05 | $ 71.61 | $ 65.45 | $ 65.45 | $ 65.45 | $ 58.52 | $ 65.45 | $ 58.52 | $ 50.05 | $ 71.61 |
30086664 | EPSTEIN BARR EBNA | 300 | Laboratory | 300 | 86664 | $ 96.00 | $ 62.40 | $ 62.40 | $ 89.28 | $ 81.60 | $ 81.60 | $ 81.60 | $ 72.96 | $ 81.60 | $ 72.96 | $ 62.40 | $ 89.28 |
30086665 | EPSTEIN BARR VCA X2 | 300 | Laboratory | 300 | 86665 | $ 188.00 | $ 122.20 | $ 122.20 | $ 174.84 | $ 159.80 | $ 159.80 | $ 159.80 | $ 142.88 | $ 159.80 | $ 142.88 | $ 122.20 | $ 174.84 |
30086677 | H. PYLORI | 300 | Laboratory | 300 | 86677 | $ 147.00 | $ 95.55 | $ 95.55 | $ 136.71 | $ 124.95 | $ 124.95 | $ 124.95 | $ 111.72 | $ 124.95 | $ 111.72 | $ 95.55 | $ 136.71 |
30086694 | HERPES TITER ANTIBODY | 300 | Laboratory | 300 | 86694 | $ 210.00 | $ 136.50 | $ 136.50 | $ 195.30 | $ 178.50 | $ 178.50 | $ 178.50 | $ 159.60 | $ 178.50 | $ 159.60 | $ 136.50 | $ 195.30 |
30086703 | HIV-1 HIV-2 SINGLE ASSAY | 300 | Laboratory | 300 | 86703 | $ 139.00 | $ 90.35 | $ 90.35 | $ 129.27 | $ 118.15 | $ 118.15 | $ 118.15 | $ 105.64 | $ 118.15 | $ 105.64 | $ 90.35 | $ 129.27 |
30086706 | HEP.B SURFACE ANTOBODY | 300 | Laboratory | 300 | 86706 | $ 114.00 | $ 74.10 | $ 74.10 | $ 106.02 | $ 96.90 | $ 96.90 | $ 96.90 | $ 86.64 | $ 96.90 | $ 86.64 | $ 74.10 | $ 106.02 |
30086735 | MUMPS ANTIBODY | 300 | Laboratory | 300 | 86735 | $ 325.00 | $ 211.25 | $ 211.25 | $ 302.25 | $ 276.25 | $ 276.25 | $ 276.25 | $ 247.00 | $ 276.25 | $ 247.00 | $ 211.25 | $ 302.25 |
30086787 | VARICELLA TITER | 300 | Laboratory | 300 | 86787 | $ 120.00 | $ 78.00 | $ 78.00 | $ 111.60 | $ 102.00 | $ 102.00 | $ 102.00 | $ 91.20 | $ 102.00 | $ 91.20 | $ 78.00 | $ 111.60 |
30086800 | THYROGLOBULIN ANTIBODY | 300 | Laboratory | 300 | 86800 | $ 38.00 | $ 24.70 | $ 24.70 | $ 35.34 | $ 32.30 | $ 32.30 | $ 32.30 | $ 28.88 | $ 32.30 | $ 28.88 | $ 24.70 | $ 35.34 |
30086803 | HEPATITIS C ANTIBODY | 300 | Laboratory | 300 | 86803 | $ 114.00 | $ 74.10 | $ 74.10 | $ 106.02 | $ 96.90 | $ 96.90 | $ 96.90 | $ 86.64 | $ 96.90 | $ 86.64 | $ 74.10 | $ 106.02 |
30086850 | ANTIBODY SCREEN RBC | 300 | Laboratory | 300 | 86850 | $ 40.00 | $ 26.00 | $ 26.00 | $ 37.20 | $ 34.00 | $ 34.00 | $ 34.00 | $ 30.40 | $ 34.00 | $ 30.40 | $ 26.00 | $ 37.20 |
30086900 | ABO BLOOD TYPING | 300 | Laboratory | 390 | 86900 | $ 84.00 | $ 54.60 | $ 54.60 | $ 78.12 | $ 71.40 | $ 71.40 | $ 71.40 | $ 63.84 | $ 71.40 | $ 63.84 | $ 54.60 | $ 78.12 |
30086901 | RH BLOOD TYPING | 300 | Laboratory | 300 | 86901 | $ 53.00 | $ 34.45 | $ 34.45 | $ 49.29 | $ 45.05 | $ 45.05 | $ 45.05 | $ 40.28 | $ 45.05 | $ 40.28 | $ 34.45 | $ 49.29 |
30086920 | COMP.TEST EACH UNIT | 300 | Laboratory | 300 | 86920 | $ 139.00 | $ 90.35 | $ 90.35 | $ 129.27 | $ 118.15 | $ 118.15 | $ 118.15 | $ 105.64 | $ 118.15 | $ 105.64 | $ 90.35 | $ 129.27 |
30087040 | CULTURE/BLOOD | 300 | Laboratory | 300 | 87040 | $ 168.00 | $ 109.20 | $ 109.20 | $ 156.24 | $ 142.80 | $ 142.80 | $ 142.80 | $ 127.68 | $ 142.80 | $ 127.68 | $ 109.20 | $ 156.24 |
30087045 | CULTURE/STOOL | 300 | Laboratory | 300 | 87045 | $ 107.00 | $ 69.55 | $ 69.55 | $ 99.51 | $ 90.95 | $ 90.95 | $ 90.95 | $ 81.32 | $ 90.95 | $ 81.32 | $ 69.55 | $ 99.51 |
30087046 | CULTURE/STOOL BACT ISOLATION | 300 | Laboratory | 300 | 87046 | $ 51.00 | $ 33.15 | $ 33.15 | $ 47.43 | $ 43.35 | $ 43.35 | $ 43.35 | $ 38.76 | $ 43.35 | $ 38.76 | $ 33.15 | $ 47.43 |
30087070 | CULTURE/OTHER SOURCE | 300 | Laboratory | 300 | 87070 | $ 112.00 | $ 72.80 | $ 72.80 | $ 104.16 | $ 95.20 | $ 95.20 | $ 95.20 | $ 85.12 | $ 95.20 | $ 85.12 | $ 72.80 | $ 104.16 |
30087077 | CULTURE, AEROBIC IDENTIFY | 300 | Laboratory | 300 | 87077 | $ 38.00 | $ 24.70 | $ 24.70 | $ 35.34 | $ 32.30 | $ 32.30 | $ 32.30 | $ 28.88 | $ 32.30 | $ 28.88 | $ 24.70 | $ 35.34 |
30087081 | CULTURE/SCREENING ONLY | 300 | Laboratory | 300 | 87081 | $ 138.00 | $ 89.70 | $ 89.70 | $ 128.34 | $ 117.30 | $ 117.30 | $ 117.30 | $ 104.88 | $ 117.30 | $ 104.88 | $ 89.70 | $ 128.34 |
30087086 | CULTURE/URINE | 300 | Laboratory | 300 | 87086 | $ 112.00 | $ 72.80 | $ 72.80 | $ 104.16 | $ 95.20 | $ 95.20 | $ 95.20 | $ 85.12 | $ 95.20 | $ 85.12 | $ 72.80 | $ 104.16 |
30087088 | URINE BACTERIA CULT W/ISO | 300 | Laboratory | 300 | 87088 | $ 38.00 | $ 24.70 | $ 24.70 | $ 35.34 | $ 32.30 | $ 32.30 | $ 32.30 | $ 28.88 | $ 32.30 | $ 28.88 | $ 24.70 | $ 35.34 |
30087177 | O & P COMPLETE | 300 | Laboratory | 300 | 87177 | $ 138.00 | $ 89.70 | $ 89.70 | $ 128.34 | $ 117.30 | $ 117.30 | $ 117.30 | $ 104.88 | $ 117.30 | $ 104.88 | $ 89.70 | $ 128.34 |
30087186 | SENSITIVITY (MIC) | 300 | Laboratory | 300 | 87186 | $ 69.00 | $ 44.85 | $ 44.85 | $ 64.17 | $ 58.65 | $ 58.65 | $ 58.65 | $ 52.44 | $ 58.65 | $ 52.44 | $ 44.85 | $ 64.17 |
30087324 | C-DIFF | 300 | Laboratory | 300 | 87324 | $ 114.00 | $ 74.10 | $ 74.10 | $ 106.02 | $ 96.90 | $ 96.90 | $ 96.90 | $ 86.64 | $ 96.90 | $ 86.64 | $ 74.10 | $ 106.02 |
30087338 | H PYLORI STOOL | 300 | Laboratory | 300 | 87338 | $ 165.00 | $ 107.25 | $ 107.25 | $ 153.45 | $ 140.25 | $ 140.25 | $ 140.25 | $ 125.40 | $ 140.25 | $ 125.40 | $ 107.25 | $ 153.45 |
30087420 | RSV | 300 | Laboratory | 300 | 87420 | $ 130.00 | $ 84.50 | $ 84.50 | $ 120.90 | $ 110.50 | $ 110.50 | $ 110.50 | $ 98.80 | $ 110.50 | $ 98.80 | $ 84.50 | $ 120.90 |
52387420 | RSV | 300 | Laboratory | 300 | 87420 | $ 130.00 | $ 84.50 | $ 84.50 | $ 120.90 | $ 110.50 | $ 110.50 | $ 110.50 | $ 98.80 | $ 110.50 | $ 98.80 | $ 84.50 | $ 120.90 |
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 |
30087425 | ROTAVIRUS | 300 | Laboratory | 300 | 87425 | $ 135.00 | $ 87.75 | $ 87.75 | $ 125.55 | $ 114.75 | $ 114.75 | $ 114.75 | $ 102.60 | $ 114.75 | $ 102.60 | $ 87.75 | $ 125.55 |
30087449 | INFECTIOUS AGENT ANTI DET | 300 | Laboratory | 300 | 87449 | $ 120.00 | $ 78.00 | $ 78.00 | $ 111.60 | $ 102.00 | $ 102.00 | $ 102.00 | $ 91.20 | $ 102.00 | $ 91.20 | $ 78.00 | $ 111.60 |
52387449 | INFECTIOUS AGENT ANTI DET-CLIA | 300 | Laboratory | 300 | 87449 | $ 120.00 | $ 78.00 | $ 78.00 | $ 111.60 | $ 102.00 | $ 102.00 | $ 102.00 | $ 91.20 | $ 102.00 | $ 91.20 | $ 78.00 | $ 111.60 |
30087491 | CHLAMYDIA TRACHOMATIS, AMPLI | 300 | Laboratory | 300 | 87491 | $ 133.00 | $ 86.45 | $ 86.45 | $ 123.69 | $ 113.05 | $ 113.05 | $ 113.05 | $ 101.08 | $ 113.05 | $ 101.08 | $ 86.45 | $ 123.69 |
30087497 | IADNA Cytomegalovirus Quantification | 300 | Laboratory | 300 | 87497 | $ 214.00 | $ 139.10 | $ 139.10 | $ 199.02 | $ 181.90 | $ 181.90 | $ 181.90 | $ 162.64 | $ 181.90 | $ 162.64 | $ 139.10 | $ 199.02 |
30087507 | Gastrointestinal Profile | 300 | Laboratory | 300 | 87507 | $ 1,326.00 | $ 861.90 | $ 861.90 | $ 1,233.18 | $ 1,127.10 | $ 1,127.10 | $ 1,127.10 | $ 1,007.76 | $ 1,127.10 | $ 1,007.76 | $ 861.90 | $ 1,233.18 |
30087522 | HEPATITIS C QUANTIFICATION | 300 | Laboratory | 300 | 87522 | $ 775.00 | $ 503.75 | $ 503.75 | $ 720.75 | $ 658.75 | $ 658.75 | $ 658.75 | $ 589.00 | $ 658.75 | $ 589.00 | $ 503.75 | $ 720.75 |
30087591 | NEISSERIA GONORRHEA, AMPLIFIED | 300 | Laboratory | 300 | 87591 | $ 156.00 | $ 101.40 | $ 101.40 | $ 145.08 | $ 132.60 | $ 132.60 | $ 132.60 | $ 118.56 | $ 132.60 | $ 118.56 | $ 101.40 | $ 145.08 |
30087624 | HPV High Risk | 300 | Laboratory | 300 | 87624 | $ 123.00 | $ 79.95 | $ 79.95 | $ 114.39 | $ 104.55 | $ 104.55 | $ 104.55 | $ 93.48 | $ 104.55 | $ 93.48 | $ 79.95 | $ 114.39 |
30087799 | BK Virus Quanti | 300 | Laboratory | 300 | 87799 | $ 383.00 | $ 248.95 | $ 248.95 | $ 356.19 | $ 325.55 | $ 325.55 | $ 325.55 | $ 291.08 | $ 325.55 | $ 291.08 | $ 248.95 | $ 356.19 |
30087800 | DETECT AGNTMULT DNA DIRECT | 300 | Laboratory | 300 | 87800 | $ 185.00 | $ 120.25 | $ 120.25 | $ 172.05 | $ 157.25 | $ 157.25 | $ 157.25 | $ 140.60 | $ 157.25 | $ 140.60 | $ 120.25 | $ 172.05 |
30087880 | STREP SCREEN | 300 | Laboratory | 300 | 87880 | $ 62.00 | $ 40.30 | $ 40.30 | $ 57.66 | $ 52.70 | $ 52.70 | $ 52.70 | $ 47.12 | $ 52.70 | $ 47.12 | $ 40.30 | $ 57.66 |
52387880 | STREP SCREEN | 300 | Laboratory | 300 | 87880 | $ 62.00 | $ 40.30 | $ 40.30 | $ 57.66 | $ 52.70 | $ 52.70 | $ 52.70 | $ 47.12 | $ 52.70 | $ 47.12 | $ 40.30 | $ 57.66 |
30088305 | CELL PATH GROSS & MICR- LEV 4 | 300 | Laboratory | 300 | 88305 | $ 276.00 | $ 179.40 | $ 179.40 | $ 256.68 | $ 234.60 | $ 234.60 | $ 234.60 | $ 209.76 | $ 234.60 | $ 209.76 | $ 179.40 | $ 256.68 |
30089051 | CELL COUNT, W/DIFF COUNT | 300 | Laboratory | 300 | 89051 | $ 32.00 | $ 20.80 | $ 20.80 | $ 29.76 | $ 27.20 | $ 27.20 | $ 27.20 | $ 24.32 | $ 27.20 | $ 24.32 | $ 20.80 | $ 29.76 |
30089055 | LEUKOCYTE, FECAL | 300 | Laboratory | 300 | 89055 | $ 51.00 | $ 33.15 | $ 33.15 | $ 47.43 | $ 43.35 | $ 43.35 | $ 43.35 | $ 38.76 | $ 43.35 | $ 38.76 | $ 33.15 | $ 47.43 |
30089060 | CRYSTAL I.D. | 300 | Laboratory | 300 | 89060 | $ 63.00 | $ 40.95 | $ 40.95 | $ 58.59 | $ 53.55 | $ 53.55 | $ 53.55 | $ 47.88 | $ 53.55 | $ 47.88 | $ 40.95 | $ 58.59 |
30088142 | PAP SMEAR - THIN LAYER | 300 | Laboratory | 300 | G0123 | $ 107.00 | $ 69.55 | $ 69.55 | $ 99.51 | $ 90.95 | $ 90.95 | $ 90.95 | $ 81.32 | $ 90.95 | $ 81.32 | $ 69.55 | $ 99.51 |
42097012 | TRACTION/MECH. | 420 | Physical Therapy | 420 | 97012 | $ 55.00 | $ 35.75 | $ 35.75 | $ 51.15 | $ 46.75 | $ 46.75 | $ 46.75 | $ 41.80 | $ 46.75 | $ 41.80 | $ 35.75 | $ 51.15 |
42097014 | ES-UNATTENDED | 420 | Physical Therapy | 420 | 97014 | $ 55.00 | $ 35.75 | $ 35.75 | $ 51.15 | $ 46.75 | $ 46.75 | $ 46.75 | $ 41.80 | $ 46.75 | $ 41.80 | $ 35.75 | $ 51.15 |
42097018 | PARAFFIN BATH | 420 | Physical Therapy | 420 | 97018 | $ 55.00 | $ 35.75 | $ 35.75 | $ 51.15 | $ 46.75 | $ 46.75 | $ 46.75 | $ 41.80 | $ 46.75 | $ 41.80 | $ 35.75 | $ 51.15 |
42097032 | ELECTRICAL STIM EACH 15 MIN | 420 | Physical Therapy | 420 | 97032 | $ 50.00 | $ 32.50 | $ 32.50 | $ 46.50 | $ 42.50 | $ 42.50 | $ 42.50 | $ 38.00 | $ 42.50 | $ 38.00 | $ 32.50 | $ 46.50 |
42097035 | ULTRASOUND | 420 | Physical Therapy | 420 | 97035 | $ 71.00 | $ 46.15 | $ 46.15 | $ 66.03 | $ 60.35 | $ 60.35 | $ 60.35 | $ 53.96 | $ 60.35 | $ 53.96 | $ 46.15 | $ 66.03 |
42097110 | THER EX 0-15 | 420 | Physical Therapy | 420 | 97110 | $ 92.00 | $ 59.80 | $ 59.80 | $ 85.56 | $ 78.20 | $ 78.20 | $ 78.20 | $ 69.92 | $ 78.20 | $ 69.92 | $ 59.80 | $ 85.56 |
42097112 | NEURO MUS. RE ED | 420 | Physical Therapy | 420 | 97112 | $ 78.00 | $ 50.70 | $ 50.70 | $ 72.54 | $ 66.30 | $ 66.30 | $ 66.30 | $ 59.28 | $ 66.30 | $ 59.28 | $ 50.70 | $ 72.54 |
42097116 | GAIT TRAINING 0-15 | 420 | Physical Therapy | 420 | 97116 | $ 78.00 | $ 50.70 | $ 50.70 | $ 72.54 | $ 66.30 | $ 66.30 | $ 66.30 | $ 59.28 | $ 66.30 | $ 59.28 | $ 50.70 | $ 72.54 |
42097140 | MANUAL THERAPY 15 MINUTES | 420 | Physical Therapy | 420 | 97140 | $ 75.00 | $ 48.75 | $ 48.75 | $ 69.75 | $ 63.75 | $ 63.75 | $ 63.75 | $ 57.00 | $ 63.75 | $ 57.00 | $ 48.75 | $ 69.75 |
42097161 | PT EVAL; LOW COMPLEXITY | 420 | Physical Therapy | 424 | 97161 | $ 163.00 | $ 105.95 | $ 105.95 | $ 151.59 | $ 138.55 | $ 138.55 | $ 138.55 | $ 123.88 | $ 138.55 | $ 123.88 | $ 105.95 | $ 151.59 |
42097162 | PT EVAL; MODERATE COMPLEXITY | 420 | Physical Therapy | 424 | 97162 | $ 184.00 | $ 119.60 | $ 119.60 | $ 171.12 | $ 156.40 | $ 156.40 | $ 156.40 | $ 139.84 | $ 156.40 | $ 139.84 | $ 119.60 | $ 171.12 |
42097163 | PT EVAL; HIGH COMPLEXITY | 420 | Physical Therapy | 424 | 97163 | $ 204.00 | $ 132.60 | $ 132.60 | $ 189.72 | $ 173.40 | $ 173.40 | $ 173.40 | $ 155.04 | $ 173.40 | $ 155.04 | $ 132.60 | $ 189.72 |
42097002 | RE-EVALUATION | 420 | Physical Therapy | 420 | 97164 | $ 112.00 | $ 72.80 | $ 72.80 | $ 104.16 | $ 95.20 | $ 95.20 | $ 95.20 | $ 85.12 | $ 95.20 | $ 85.12 | $ 72.80 | $ 104.16 |
42097530 | KINETIC THER. | 420 | Physical Therapy | 420 | 97530 | $ 100.00 | $ 65.00 | $ 65.00 | $ 93.00 | $ 85.00 | $ 85.00 | $ 85.00 | $ 76.00 | $ 85.00 | $ 76.00 | $ 65.00 | $ 93.00 |
42097542 | Wheelchair Management Training | 420 | Physical Therapy | 420 | 97542 | $ 103.00 | $ 66.95 | $ 66.95 | $ 95.79 | $ 87.55 | $ 87.55 | $ 87.55 | $ 78.28 | $ 87.55 | $ 78.28 | $ 66.95 | $ 95.79 |
42097597 | WOUND CARE/20CM OR LESS | 420 | Physical Therapy | 420 | 97597 | $ 184.00 | $ 119.60 | $ 119.60 | $ 171.12 | $ 156.40 | $ 156.40 | $ 156.40 | $ 139.84 | $ 156.40 | $ 139.84 | $ 119.60 | $ 171.12 |
42097598 | WOUND CARE/GREATER THAN 20CM | 420 | Physical Therapy | 420 | 97598 | $ 213.00 | $ 138.45 | $ 138.45 | $ 198.09 | $ 181.05 | $ 181.05 | $ 181.05 | $ 161.88 | $ 181.05 | $ 161.88 | $ 138.45 | $ 198.09 |
42097602 | WOUND CARE NON-SELECTIVE | 420 | Physical Therapy | 420 | 97602 | $ 136.00 | $ 88.40 | $ 88.40 | $ 126.48 | $ 115.60 | $ 115.60 | $ 115.60 | $ 103.36 | $ 115.60 | $ 103.36 | $ 88.40 | $ 126.48 |
42097760 | ORTHOTIC MANAGEMENT & TRAINING | 420 | Physical Therapy | 420 | 97760 | $ 48.00 | $ 31.20 | $ 31.20 | $ 44.64 | $ 40.80 | $ 40.80 | $ 40.80 | $ 36.48 | $ 40.80 | $ 36.48 | $ 31.20 | $ 44.64 |
420G0283 | ES-UNATTENDED | 420 | Physical Therapy | 420 | G0283 | $ 55.00 | $ 35.75 | $ 35.75 | $ 51.15 | $ 46.75 | $ 46.75 | $ 46.75 | $ 41.80 | $ 46.75 | $ 41.80 | $ 35.75 | $ 51.15 |
32070100 | MANDIBLE/LESS THAN 4V | 320 | Radiology | 320 | 70100 | $ 247.00 | $ 160.55 | $ 160.55 | $ 229.71 | $ 209.95 | $ 209.95 | $ 209.95 | $ 187.72 | $ 209.95 | $ 187.72 | $ 160.55 | $ 229.71 |
32070140 | FACIAL BONES/LESS THAN 3V | 320 | Radiology | 320 | 70140 | $ 172.00 | $ 111.80 | $ 111.80 | $ 159.96 | $ 146.20 | $ 146.20 | $ 146.20 | $ 130.72 | $ 146.20 | $ 130.72 | $ 111.80 | $ 159.96 |
32070150 | FACIAL BONES COMP/M3V | 320 | Radiology | 320 | 70150 | $ 301.00 | $ 195.65 | $ 195.65 | $ 279.93 | $ 255.85 | $ 255.85 | $ 255.85 | $ 228.76 | $ 255.85 | $ 228.76 | $ 195.65 | $ 279.93 |
32070160 | NASAL BONES COMP/M3V | 320 | Radiology | 320 | 70160 | $ 208.00 | $ 135.20 | $ 135.20 | $ 193.44 | $ 176.80 | $ 176.80 | $ 176.80 | $ 158.08 | $ 176.80 | $ 158.08 | $ 135.20 | $ 193.44 |
32070200 | ORBITS COMP/M4V | 320 | Radiology | 320 | 70200 | $ 209.00 | $ 135.85 | $ 135.85 | $ 194.37 | $ 177.65 | $ 177.65 | $ 177.65 | $ 158.84 | $ 177.65 | $ 158.84 | $ 135.85 | $ 194.37 |
32070210 | SINUSES/LESS THAN 3V | 320 | Radiology | 320 | 70210 | $ 130.00 | $ 84.50 | $ 84.50 | $ 120.90 | $ 110.50 | $ 110.50 | $ 110.50 | $ 98.80 | $ 110.50 | $ 98.80 | $ 84.50 | $ 120.90 |
32070220 | SINUSES COMP.SERIES/M3V | 320 | Radiology | 320 | 70220 | $ 286.00 | $ 185.90 | $ 185.90 | $ 265.98 | $ 243.10 | $ 243.10 | $ 243.10 | $ 217.36 | $ 243.10 | $ 217.36 | $ 185.90 | $ 265.98 |
32070250 | SKULL/LESS THAN 4V | 320 | Radiology | 320 | 70250 | $ 220.00 | $ 143.00 | $ 143.00 | $ 204.60 | $ 187.00 | $ 187.00 | $ 187.00 | $ 167.20 | $ 187.00 | $ 167.20 | $ 143.00 | $ 204.60 |
32070260 | SKULL COMP.SERIES/M4V | 320 | Radiology | 320 | 70260 | $ 308.00 | $ 200.20 | $ 200.20 | $ 286.44 | $ 261.80 | $ 261.80 | $ 261.80 | $ 234.08 | $ 261.80 | $ 234.08 | $ 200.20 | $ 286.44 |
32070328 | TMJ | 320 | Radiology | 320 | 70328 | $ 221.00 | $ 143.65 | $ 143.65 | $ 205.53 | $ 187.85 | $ 187.85 | $ 187.85 | $ 167.96 | $ 187.85 | $ 167.96 | $ 143.65 | $ 205.53 |
32070330 | TMJ/BILATERAL | 320 | Radiology | 320 | 70330 | $ 221.00 | $ 143.65 | $ 143.65 | $ 205.53 | $ 187.85 | $ 187.85 | $ 187.85 | $ 167.96 | $ 187.85 | $ 167.96 | $ 143.65 | $ 205.53 |
32070360 | NECK, SOFT TISSUE | 320 | Radiology | 320 | 70360 | $ 197.00 | $ 128.05 | $ 128.05 | $ 183.21 | $ 167.45 | $ 167.45 | $ 167.45 | $ 149.72 | $ 167.45 | $ 149.72 | $ 128.05 | $ 183.21 |
35070450 | CT-BRAIN W/O CONTRAST | 320 | Radiology | 350 | 70450 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35070470 | CT-BRAIN W/WO CONTRAST | 320 | Radiology | 350 | 70450 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
35070460 | CT-BRAIN WITH CONTRAST | 320 | Radiology | 350 | 70460 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
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 |
35070480 | CT-EAR W/O CONTRAST | 320 | Radiology | 350 | 70480 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35070481 | CT-EAR WITH CONTRAST | 320 | Radiology | 350 | 70481 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35070482 | CT-EAR W/WO CONTRAST | 320 | Radiology | 350 | 70482 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
35070486 | CT-FACE W/O CONTRAST | 320 | Radiology | 350 | 70486 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35070487 | CT-FACE WITH CONTRAST | 320 | Radiology | 350 | 70487 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35070488 | CT-FACE W/WO CONTRAST | 320 | Radiology | 350 | 70488 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
35070490 | CT-NECK W/O CONTRAST | 320 | Radiology | 350 | 70490 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35070491 | CT-NECK WITH CONTRAST | 320 | Radiology | 350 | 70491 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35070492 | CT-NECK W/WO CONTRAST | 320 | Radiology | 350 | 70492 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
32071030 | CHEST/COMP. M4V | 320 | Radiology | 320 | 71030 | $ 219.00 | $ 142.35 | $ 142.35 | $ 203.67 | $ 186.15 | $ 186.15 | $ 186.15 | $ 166.44 | $ 186.15 | $ 166.44 | $ 142.35 | $ 203.67 |
32071010 | CHEST/1 VIEW | 320 | Radiology | 320 | 71045 | $ 155.00 | $ 100.75 | $ 100.75 | $ 144.15 | $ 131.75 | $ 131.75 | $ 131.75 | $ 117.80 | $ 131.75 | $ 117.80 | $ 100.75 | $ 144.15 |
32071020 | CHEST/2 VIEW | 320 | Radiology | 320 | 71046 | $ 251.00 | $ 163.15 | $ 163.15 | $ 233.43 | $ 213.35 | $ 213.35 | $ 213.35 | $ 190.76 | $ 213.35 | $ 190.76 | $ 163.15 | $ 233.43 |
32071100 | RIBS/UNILAT/2V | 320 | Radiology | 320 | 71100 | $ 246.00 | $ 159.90 | $ 159.90 | $ 228.78 | $ 209.10 | $ 209.10 | $ 209.10 | $ 186.96 | $ 209.10 | $ 186.96 | $ 159.90 | $ 228.78 |
32071101 | Unilateral Ribs/Chest min 3v | 320 | Radiology | 320 | 71101 | $ 397.00 | $ 258.05 | $ 258.05 | $ 369.21 | $ 337.45 | $ 337.45 | $ 337.45 | $ 301.72 | $ 337.45 | $ 301.72 | $ 258.05 | $ 369.21 |
32071110 | RIBS/BILATERAL/3V | 320 | Radiology | 320 | 71110 | $ 307.00 | $ 199.55 | $ 199.55 | $ 285.51 | $ 260.95 | $ 260.95 | $ 260.95 | $ 233.32 | $ 260.95 | $ 233.32 | $ 199.55 | $ 285.51 |
32071120 | STERNUM/M2V | 320 | Radiology | 320 | 71120 | $ 166.00 | $ 107.90 | $ 107.90 | $ 154.38 | $ 141.10 | $ 141.10 | $ 141.10 | $ 126.16 | $ 141.10 | $ 126.16 | $ 107.90 | $ 154.38 |
35071250 | CT-THORAX,CHEST W/O CONTRAST | 320 | Radiology | 350 | 71250 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35071260 | CT-THORAX,CHEST WITH CONTRAST | 320 | Radiology | 350 | 71260 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35071270 | CT-THORAX,CHEST W/WO CONTRAST | 320 | Radiology | 350 | 71270 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
32072040 | CERVICAL SPINE/2V OR 3V | 320 | Radiology | 320 | 72040 | $ 249.00 | $ 161.85 | $ 161.85 | $ 231.57 | $ 211.65 | $ 211.65 | $ 211.65 | $ 189.24 | $ 211.65 | $ 189.24 | $ 161.85 | $ 231.57 |
32072050 | CERVICAL SPINE, MIN 4 VIEWS | 320 | Radiology | 320 | 72050 | $ 390.00 | $ 253.50 | $ 253.50 | $ 362.70 | $ 331.50 | $ 331.50 | $ 331.50 | $ 296.40 | $ 331.50 | $ 296.40 | $ 253.50 | $ 362.70 |
32072052 | CERVICAL SPINE COMP. | 320 | Radiology | 320 | 72052 | $ 347.00 | $ 225.55 | $ 225.55 | $ 322.71 | $ 294.95 | $ 294.95 | $ 294.95 | $ 263.72 | $ 294.95 | $ 263.72 | $ 225.55 | $ 322.71 |
32072070 | THORACIC SPINE/2V | 320 | Radiology | 320 | 72070 | $ 249.00 | $ 161.85 | $ 161.85 | $ 231.57 | $ 211.65 | $ 211.65 | $ 211.65 | $ 189.24 | $ 211.65 | $ 189.24 | $ 161.85 | $ 231.57 |
32072072 | THORACIC SPINE/3V | 320 | Radiology | 320 | 72072 | $ 313.00 | $ 203.45 | $ 203.45 | $ 291.09 | $ 266.05 | $ 266.05 | $ 266.05 | $ 237.88 | $ 266.05 | $ 237.88 | $ 203.45 | $ 291.09 |
32072090 | SCOLIOSIS STUDY | 320 | Radiology | 320 | 72082 | $ 92.00 | $ 59.80 | $ 59.80 | $ 85.56 | $ 78.20 | $ 78.20 | $ 78.20 | $ 69.92 | $ 78.20 | $ 69.92 | $ 59.80 | $ 85.56 |
32072100 | L-S SPINE/2 OR 3V | 320 | Radiology | 320 | 72100 | $ 243.00 | $ 157.95 | $ 157.95 | $ 225.99 | $ 206.55 | $ 206.55 | $ 206.55 | $ 184.68 | $ 206.55 | $ 184.68 | $ 157.95 | $ 225.99 |
32072110 | L-S SPINE 5 VIEWS | 320 | Radiology | 320 | 72110 | $ 410.00 | $ 266.50 | $ 266.50 | $ 381.30 | $ 348.50 | $ 348.50 | $ 348.50 | $ 311.60 | $ 348.50 | $ 311.60 | $ 266.50 | $ 381.30 |
32072114 | L-S SPINE COMP/BEND | 320 | Radiology | 320 | 72114 | $ 316.00 | $ 205.40 | $ 205.40 | $ 293.88 | $ 268.60 | $ 268.60 | $ 268.60 | $ 240.16 | $ 268.60 | $ 240.16 | $ 205.40 | $ 293.88 |
35072125 | CT-C SPINE W/O CONTRAST | 320 | Radiology | 350 | 72125 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35072126 | CT-C SPINE WITH CONTRAST | 320 | Radiology | 350 | 72126 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35072127 | CT-C SPINE W/WO CONTRAST | 320 | Radiology | 350 | 72127 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
35072128 | CT-T SPINE W/O CONTRAST | 320 | Radiology | 350 | 72128 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35072129 | CT-T SPINE WITH CONTRAST | 320 | Radiology | 350 | 72129 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35072130 | CT-T SPINE W/WO CONTRAST | 320 | Radiology | 350 | 72130 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
35072131 | CT-L SPINE W/O CONTRAST | 320 | Radiology | 350 | 72131 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35072132 | CT-L SPINE WITH CONTRAST | 320 | Radiology | 350 | 72132 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35072133 | CT-L SPINE W/WO CONTRAST | 320 | Radiology | 350 | 72133 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
32072170 | PELVIS/1 OR 2 VIEWS | 320 | Radiology | 320 | 72170 | $ 195.00 | $ 126.75 | $ 126.75 | $ 181.35 | $ 165.75 | $ 165.75 | $ 165.75 | $ 148.20 | $ 165.75 | $ 148.20 | $ 126.75 | $ 181.35 |
35072192 | CT-PELVIS W/O CONTRAST | 320 | Radiology | 350 | 72192 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35072193 | CT-PELVIS WITH CONTRAST | 320 | Radiology | 350 | 72193 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35072194 | CT-PELVIS W/WO CONTRAST | 320 | Radiology | 350 | 72194 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
32072200 | SACROILIAC JTS./LESS 3V | 320 | Radiology | 320 | 72200 | $ 153.00 | $ 99.45 | $ 99.45 | $ 142.29 | $ 130.05 | $ 130.05 | $ 130.05 | $ 116.28 | $ 130.05 | $ 116.28 | $ 99.45 | $ 142.29 |
32072220 | SACRUM/COCCYX/M2V | 320 | Radiology | 320 | 72220 | $ 208.00 | $ 135.20 | $ 135.20 | $ 193.44 | $ 176.80 | $ 176.80 | $ 176.80 | $ 158.08 | $ 176.80 | $ 158.08 | $ 135.20 | $ 193.44 |
32073000 | CLAVICLE COMPLETE | 320 | Radiology | 320 | 73000 | $ 212.00 | $ 137.80 | $ 137.80 | $ 197.16 | $ 180.20 | $ 180.20 | $ 180.20 | $ 161.12 | $ 180.20 | $ 161.12 | $ 137.80 | $ 197.16 |
32073010 | SCAPULA COMPLETE | 320 | Radiology | 320 | 73010 | $ 203.00 | $ 131.95 | $ 131.95 | $ 188.79 | $ 172.55 | $ 172.55 | $ 172.55 | $ 154.28 | $ 172.55 | $ 154.28 | $ 131.95 | $ 188.79 |
32073020 | SHOULDER 1 VIEW | 320 | Radiology | 320 | 73020 | $ 162.00 | $ 105.30 | $ 105.30 | $ 150.66 | $ 137.70 | $ 137.70 | $ 137.70 | $ 123.12 | $ 137.70 | $ 123.12 | $ 105.30 | $ 150.66 |
32073030 | Shoulder comp/M2V | 320 | Radiology | 320 | 73030 | $ 235.00 | $ 152.75 | $ 152.75 | $ 218.55 | $ 199.75 | $ 199.75 | $ 199.75 | $ 178.60 | $ 199.75 | $ 178.60 | $ 152.75 | $ 218.55 |
32073050 | AC JOINTS BIL. W/OR W/O WEIGHT | 320 | Radiology | 320 | 73050 | $ 78.00 | $ 50.70 | $ 50.70 | $ 72.54 | $ 66.30 | $ 66.30 | $ 66.30 | $ 59.28 | $ 66.30 | $ 59.28 | $ 50.70 | $ 72.54 |
32073060 | HUMERUS/M2V | 320 | Radiology | 320 | 73060 | $ 216.00 | $ 140.40 | $ 140.40 | $ 200.88 | $ 183.60 | $ 183.60 | $ 183.60 | $ 164.16 | $ 183.60 | $ 164.16 | $ 140.40 | $ 200.88 |
32073070 | ELBOW 2 VIEWS | 320 | Radiology | 320 | 73070 | $ 175.00 | $ 113.75 | $ 113.75 | $ 162.75 | $ 148.75 | $ 148.75 | $ 148.75 | $ 133.00 | $ 148.75 | $ 133.00 | $ 113.75 | $ 162.75 |
32073080 | ELBOW SERIES/M3V | 320 | Radiology | 320 | 73080 | $ 180.00 | $ 117.00 | $ 117.00 | $ 167.40 | $ 153.00 | $ 153.00 | $ 153.00 | $ 136.80 | $ 153.00 | $ 136.80 | $ 117.00 | $ 167.40 |
32073090 | FOREARM 2 VIEWS | 320 | Radiology | 320 | 73090 | $ 196.00 | $ 127.40 | $ 127.40 | $ 182.28 | $ 166.60 | $ 166.60 | $ 166.60 | $ 148.96 | $ 166.60 | $ 148.96 | $ 127.40 | $ 182.28 |
32073100 | WRIST 2 VIEWS | 320 | Radiology | 320 | 73100 | $ 155.00 | $ 100.75 | $ 100.75 | $ 144.15 | $ 131.75 | $ 131.75 | $ 131.75 | $ 117.80 | $ 131.75 | $ 117.80 | $ 100.75 | $ 144.15 |
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 |
32073110 | WRIST COMP./M3V | 320 | Radiology | 320 | 73110 | $ 220.00 | $ 143.00 | $ 143.00 | $ 204.60 | $ 187.00 | $ 187.00 | $ 187.00 | $ 167.20 | $ 187.00 | $ 167.20 | $ 143.00 | $ 204.60 |
32073120 | HAND 2 VIEWS | 320 | Radiology | 320 | 73120 | $ 172.00 | $ 111.80 | $ 111.80 | $ 159.96 | $ 146.20 | $ 146.20 | $ 146.20 | $ 130.72 | $ 146.20 | $ 130.72 | $ 111.80 | $ 159.96 |
32073130 | HAND COMP./M3V | 320 | Radiology | 320 | 73130 | $ 199.00 | $ 129.35 | $ 129.35 | $ 185.07 | $ 169.15 | $ 169.15 | $ 169.15 | $ 151.24 | $ 169.15 | $ 151.24 | $ 129.35 | $ 185.07 |
32073140 | FINGER/FINGERS/M2V | 320 | Radiology | 320 | 73140 | $ 180.00 | $ 117.00 | $ 117.00 | $ 167.40 | $ 153.00 | $ 153.00 | $ 153.00 | $ 136.80 | $ 153.00 | $ 136.80 | $ 117.00 | $ 167.40 |
35073200 | CT-ARM W/O CONTRAST | 320 | Radiology | 350 | 73200 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35073201 | CT-ARM WITH CONTRAST | 320 | Radiology | 350 | 73201 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
32073500 | HIP 1 VIEW | 320 | Radiology | 320 | 73501 | $ 161.00 | $ 104.65 | $ 104.65 | $ 149.73 | $ 136.85 | $ 136.85 | $ 136.85 | $ 122.36 | $ 136.85 | $ 122.36 | $ 104.65 | $ 149.73 |
32073502 | HIP UNI 2-3 VIEWS | 320 | Radiology | 320 | 73502 | $ 223.00 | $ 144.95 | $ 144.95 | $ 207.39 | $ 189.55 | $ 189.55 | $ 189.55 | $ 169.48 | $ 189.55 | $ 169.48 | $ 144.95 | $ 207.39 |
32073520 | HIPS BI 2 VIEWS | 320 | Radiology | 320 | 73521 | $ 269.00 | $ 174.85 | $ 174.85 | $ 250.17 | $ 228.65 | $ 228.65 | $ 228.65 | $ 204.44 | $ 228.65 | $ 204.44 | $ 174.85 | $ 250.17 |
32073540 | PELVIS/HIP/M2V/CHILD | 320 | Radiology | 320 | 73540 | $ 125.00 | $ 81.25 | $ 81.25 | $ 116.25 | $ 106.25 | $ 106.25 | $ 106.25 | $ 95.00 | $ 106.25 | $ 95.00 | $ 81.25 | $ 116.25 |
32073550 | FEMUR 2 VIEWS | 320 | Radiology | 320 | 73552 | $ 220.00 | $ 143.00 | $ 143.00 | $ 204.60 | $ 187.00 | $ 187.00 | $ 187.00 | $ 167.20 | $ 187.00 | $ 167.20 | $ 143.00 | $ 204.60 |
32073560 | KNEE 1/2V | 320 | Radiology | 320 | 73560 | $ 180.00 | $ 117.00 | $ 117.00 | $ 167.40 | $ 153.00 | $ 153.00 | $ 153.00 | $ 136.80 | $ 153.00 | $ 136.80 | $ 117.00 | $ 167.40 |
32073562 | KNEE /M3V | 320 | Radiology | 320 | 73562 | $ 194.00 | $ 126.10 | $ 126.10 | $ 180.42 | $ 164.90 | $ 164.90 | $ 164.90 | $ 147.44 | $ 164.90 | $ 147.44 | $ 126.10 | $ 180.42 |
32073564 | KNEE COMP. SERIES/M4V | 320 | Radiology | 320 | 73564 | $ 300.00 | $ 195.00 | $ 195.00 | $ 279.00 | $ 255.00 | $ 255.00 | $ 255.00 | $ 228.00 | $ 255.00 | $ 228.00 | $ 195.00 | $ 279.00 |
32073565 | KNEE XRAY-BOTH | 320 | Radiology | 320 | 73565 | $ 159.00 | $ 103.35 | $ 103.35 | $ 147.87 | $ 135.15 | $ 135.15 | $ 135.15 | $ 120.84 | $ 135.15 | $ 120.84 | $ 103.35 | $ 147.87 |
32073590 | TIBIA-FIBULA/2V | 320 | Radiology | 320 | 73590 | $ 220.00 | $ 143.00 | $ 143.00 | $ 204.60 | $ 187.00 | $ 187.00 | $ 187.00 | $ 167.20 | $ 187.00 | $ 167.20 | $ 143.00 | $ 204.60 |
32073592 | TIBIA/FIBULA/INFANT | 320 | Radiology | 320 | 73592 | $ 130.00 | $ 84.50 | $ 84.50 | $ 120.90 | $ 110.50 | $ 110.50 | $ 110.50 | $ 98.80 | $ 110.50 | $ 98.80 | $ 84.50 | $ 120.90 |
32073600 | ANKLE 2 VIEWS | 320 | Radiology | 320 | 73600 | $ 186.00 | $ 120.90 | $ 120.90 | $ 172.98 | $ 158.10 | $ 158.10 | $ 158.10 | $ 141.36 | $ 158.10 | $ 141.36 | $ 120.90 | $ 172.98 |
32073610 | ANKLE COMP./M3V | 320 | Radiology | 320 | 73610 | $ 226.00 | $ 146.90 | $ 146.90 | $ 210.18 | $ 192.10 | $ 192.10 | $ 192.10 | $ 171.76 | $ 192.10 | $ 171.76 | $ 146.90 | $ 210.18 |
32073620 | FOOT 2 VIEWS | 320 | Radiology | 320 | 73620 | $ 191.00 | $ 124.15 | $ 124.15 | $ 177.63 | $ 162.35 | $ 162.35 | $ 162.35 | $ 145.16 | $ 162.35 | $ 145.16 | $ 124.15 | $ 177.63 |
32073630 | FOOT COMP /M3V | 320 | Radiology | 320 | 73630 | $ 220.00 | $ 143.00 | $ 143.00 | $ 204.60 | $ 187.00 | $ 187.00 | $ 187.00 | $ 167.20 | $ 187.00 | $ 167.20 | $ 143.00 | $ 204.60 |
32073650 | CALCANEUS(HEEL)M2V | 320 | Radiology | 320 | 73650 | $ 161.00 | $ 104.65 | $ 104.65 | $ 149.73 | $ 136.85 | $ 136.85 | $ 136.85 | $ 122.36 | $ 136.85 | $ 122.36 | $ 104.65 | $ 149.73 |
32073660 | TOE/TOES M2V | 320 | Radiology | 320 | 73660 | $ 167.00 | $ 108.55 | $ 108.55 | $ 155.31 | $ 141.95 | $ 141.95 | $ 141.95 | $ 126.92 | $ 141.95 | $ 126.92 | $ 108.55 | $ 155.31 |
35073700 | CT-LOWER EXTREMITY W/O CONT | 320 | Radiology | 350 | 73700 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35073701 | CT-LOWER EXTREMITY WITH CONT | 320 | Radiology | 350 | 73701 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35073702 | CT-LOWER EXTREMITY W/WO CONT | 320 | Radiology | 350 | 73702 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
32074000 | ABDOMEN 1V (KUB) | 320 | Radiology | 320 | 74018 | $ 176.00 | $ 114.40 | $ 114.40 | $ 163.68 | $ 149.60 | $ 149.60 | $ 149.60 | $ 133.76 | $ 149.60 | $ 133.76 | $ 114.40 | $ 163.68 |
32074010 | ABDOMEN/2 VIEWS | 320 | Radiology | 320 | 74019 | $ 192.00 | $ 124.80 | $ 124.80 | $ 178.56 | $ 163.20 | $ 163.20 | $ 163.20 | $ 145.92 | $ 163.20 | $ 145.92 | $ 124.80 | $ 178.56 |
32074020 | ABDOMEN COMPLETE | 320 | Radiology | 320 | 74021 | $ 222.00 | $ 144.30 | $ 144.30 | $ 206.46 | $ 188.70 | $ 188.70 | $ 188.70 | $ 168.72 | $ 188.70 | $ 168.72 | $ 144.30 | $ 206.46 |
35074150 | CT-ABDOMEN W/O CONTRAST | 320 | Radiology | 350 | 74150 | $ 1,557.00 | $ 1,012.05 | $ 1,012.05 | $ 1,448.01 | $ 1,323.45 | $ 1,323.45 | $ 1,323.45 | $ 1,183.32 | $ 1,323.45 | $ 1,183.32 | $ 1,012.05 | $ 1,448.01 |
35074160 | CT-ABDOMEN WITH CONTRAST | 320 | Radiology | 350 | 74160 | $ 1,916.00 | $ 1,245.40 | $ 1,245.40 | $ 1,781.88 | $ 1,628.60 | $ 1,628.60 | $ 1,628.60 | $ 1,456.16 | $ 1,628.60 | $ 1,456.16 | $ 1,245.40 | $ 1,781.88 |
35074170 | CT-ABDOMEN W/WO CONTRAST | 320 | Radiology | 350 | 74170 | $ 2,873.00 | $ 1,867.45 | $ 1,867.45 | $ 2,671.89 | $ 2,442.05 | $ 2,442.05 | $ 2,442.05 | $ 2,183.48 | $ 2,442.05 | $ 2,183.48 | $ 1,867.45 | $ 2,671.89 |
35074176 | CT ABDOMEN & PELVIS | 320 | Radiology | 350 | 74176 | $ 1,530.00 | $ 994.50 | $ 994.50 | $ 1,422.90 | $ 1,300.50 | $ 1,300.50 | $ 1,300.50 | $ 1,162.80 | $ 1,300.50 | $ 1,162.80 | $ 994.50 | $ 1,422.90 |
35074177 | CT ABDOMEN & PELVIS W/CONTRAST | 320 | Radiology | 350 | 74177 | $ 1,639.00 | $ 1,065.35 | $ 1,065.35 | $ 1,524.27 | $ 1,393.15 | $ 1,393.15 | $ 1,393.15 | $ 1,245.64 | $ 1,393.15 | $ 1,245.64 | $ 1,065.35 | $ 1,524.27 |
35074178 | CT ABDOMEN & PELV W&W/O CNTRST | 320 | Radiology | 350 | 74178 | $ 1,748.00 | $ 1,136.20 | $ 1,136.20 | $ 1,625.64 | $ 1,485.80 | $ 1,485.80 | $ 1,485.80 | $ 1,328.48 | $ 1,485.80 | $ 1,328.48 | $ 1,136.20 | $ 1,625.64 |
32076010 | BABY GRAM SINGLE VIEW | 320 | Radiology | 320 | 76010 | $ 203.00 | $ 131.95 | $ 131.95 | $ 188.79 | $ 172.55 | $ 172.55 | $ 172.55 | $ 154.28 | $ 172.55 | $ 154.28 | $ 131.95 | $ 188.79 |
32076020 | BONE AGE STUDY | 320 | Radiology | 320 | 77072 | $ 142.00 | $ 92.30 | $ 92.30 | $ 132.06 | $ 120.70 | $ 120.70 | $ 120.70 | $ 107.92 | $ 120.70 | $ 107.92 | $ 92.30 | $ 132.06 |
32077080 | DEXASCAN 1/MORE SITES AXIAL SK | 320 | Radiology | 320 | 77080 | $ 180.00 | $ 117.00 | $ 117.00 | $ 167.40 | $ 153.00 | $ 153.00 | $ 153.00 | $ 136.80 | $ 153.00 | $ 136.80 | $ 117.00 | $ 167.40 |
32093041 | RHYTHM ECG | 320 | Radiology | 320 | 93041 | $ 101.00 | $ 65.65 | $ 65.65 | $ 93.93 | $ 85.85 | $ 85.85 | $ 85.85 | $ 76.76 | $ 85.85 | $ 76.76 | $ 65.65 | $ 93.93 |
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 |
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 |
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 |
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 |
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 |
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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