Hospital Charges - Schleicher County Medical Center

Hospital Charges / Price Transparency

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:

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

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

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

QUESTIONS?

If you have further questions about the 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!

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Searchable Shoppable Services

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.

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

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

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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