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 CodeCharge Code DescriptionDept #DeptRev CodeCPT CodeGross ChargeDiscounted Cash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TradCIGNAScott & WhiteUnitedMinimum Negotiated RateMaximum Negotiated Rate
73093005EKG,12 LEADS,TRACING ONLY730EKG/ECG73093005$ 105.00$ 68.25$ 68.25$ 97.65$ 97.65$ 97.65$ 97.65$ 79.80$ 89.25$ 79.80$ 68.25$ 97.65
73093000EKG ROUTINE 12 LEAD730EKG/ECG73093000$ 155.00$ 100.75$ 100.75$ 144.15$ 131.75$ 131.75$ 131.75$ 117.80$ 131.75$ 117.80$ 100.75$ 144.15
32093005EKG/12 LEADS TRCG ONLY WO IR730EKG/ECG73093005$ 90.00$ 58.50$ 58.50$ 83.70$ 76.50$ 76.50$ 76.50$ 68.40$ 76.50$ 68.40$ 58.50$ 83.70
730G0403EKG, 12 LEADS SCREENING INITIAL MCR PREV730EKG/ECG730G0403$ 105.00$ 68.25$ 68.25$ 97.65$ 89.25$ 89.25$ 89.25$ 79.80$ 89.25$ 79.80$ 68.25$ 97.65
30080048BASIC METABOLIC PANEL300Laboratory30080048$ 184.00$ 119.60$ 119.60$ 171.12$ 156.40$ 156.40$ 156.40$ 139.84$ 156.40$ 139.84$ 119.60$ 171.12
30080050GENERAL HEALTH PANEL300Laboratory30080050$ 510.00$ 331.50$ 331.50$ 474.30$ 433.50$ 433.50$ 433.50$ 387.60$ 433.50$ 387.60$ 331.50$ 474.30
30080051ELECTROLYTE PANEL300Laboratory30080051$ 120.00$ 78.00$ 78.00$ 111.60$ 102.00$ 102.00$ 102.00$ 91.20$ 102.00$ 91.20$ 78.00$ 111.60
30080053COMPREHEN. METABOLIC PANE300Laboratory30080053$ 266.00$ 172.90$ 172.90$ 247.38$ 226.10$ 226.10$ 226.10$ 202.16$ 226.10$ 202.16$ 172.90$ 247.38
30080061LIPID PANEL300Laboratory30080061$ 133.00$ 86.45$ 86.45$ 123.69$ 113.05$ 113.05$ 113.05$ 101.08$ 113.05$ 101.08$ 86.45$ 123.69
30080069RENAL FUNCTION PANEL300Laboratory30080069$ 210.00$ 136.50$ 136.50$ 195.30$ 178.50$ 178.50$ 178.50$ 159.60$ 178.50$ 159.60$ 136.50$ 195.30
30080074HEPATITIS PANEL300Laboratory30080074$ 412.00$ 267.80$ 267.80$ 383.16$ 350.20$ 350.20$ 350.20$ 313.12$ 350.20$ 313.12$ 267.80$ 383.16
30080076HEPATIC FUNCTION PANEL300Laboratory30080076$ 289.00$ 187.85$ 187.85$ 268.77$ 245.65$ 245.65$ 245.65$ 219.64$ 245.65$ 219.64$ 187.85$ 268.77
30080162DIGOXIN300Laboratory30080162$ 170.00$ 110.50$ 110.50$ 158.10$ 144.50$ 144.50$ 144.50$ 129.20$ 144.50$ 129.20$ 110.50$ 158.10
30080170GENTAMICIN300Laboratory30080170$ 254.00$ 165.10$ 165.10$ 236.22$ 215.90$ 215.90$ 215.90$ 193.04$ 215.90$ 193.04$ 165.10$ 236.22
30080184PHENOBARBITAL LEVEL300Laboratory30080184$ 102.00$ 66.30$ 66.30$ 94.86$ 86.70$ 86.70$ 86.70$ 77.52$ 86.70$ 77.52$ 66.30$ 94.86
30080185PHENYTOIN TOTAL300Laboratory30080185$ 130.00$ 84.50$ 84.50$ 120.90$ 110.50$ 110.50$ 110.50$ 98.80$ 110.50$ 98.80$ 84.50$ 120.90
30080195Drug Screen Quantitative Sirolimus300Laboratory30080195$ 71.00$ 46.15$ 46.15$ 66.03$ 60.35$ 60.35$ 60.35$ 53.96$ 60.35$ 53.96$ 46.15$ 66.03
30080197TACROLIMUS300Laboratory30080197$ 318.00$ 206.70$ 206.70$ 295.74$ 270.30$ 270.30$ 270.30$ 241.68$ 270.30$ 241.68$ 206.70$ 295.74
30080202VANCOMYCIN LEVEL300Laboratory30080202$ 143.00$ 92.95$ 92.95$ 132.99$ 121.55$ 121.55$ 121.55$ 108.68$ 121.55$ 108.68$ 92.95$ 132.99
30080307Drug Screen300Laboratory30080307$ 65.00$ 42.25$ 42.25$ 60.45$ 55.25$ 55.25$ 55.25$ 49.40$ 55.25$ 49.40$ 42.25$ 60.45
30080100EDRUG SCREEN INHOUSE- EMPLOYEE300Laboratory30080307$ 65.00$ 42.25$ 42.25$ 60.45$ 55.25$ 55.25$ 55.25$ 49.40$ 55.25$ 49.40$ 42.25$ 60.45
30080100NDrug Screen Nursing Home300Laboratory30080307$ 65.00$ 42.25$ 42.25$ 60.45$ 55.25$ 55.25$ 55.25$ 49.40$ 55.25$ 49.40$ 42.25$ 60.45
30080320ETOH/ANYSPEC.EXCP.BREATH (ALCOHOL)300Laboratory30080320$ 115.00$ 74.75$ 74.75$ 106.95$ 97.75$ 97.75$ 97.75$ 87.40$ 97.75$ 87.40$ 74.75$ 106.95
30080335Amitriptyline, Serum300Laboratory30080335$ 44.00$ 28.60$ 28.60$ 40.92$ 37.40$ 37.40$ 37.40$ 33.44$ 37.40$ 33.44$ 28.60$ 40.92
30081001UA AUTOMATED, W/MICRO300Laboratory30081001$ 69.00$ 44.85$ 44.85$ 64.17$ 58.65$ 58.65$ 58.65$ 52.44$ 58.65$ 52.44$ 44.85$ 64.17
30081003UA AUTOMATED, W/O MICRO300Laboratory30081003$ 53.00$ 34.45$ 34.45$ 49.29$ 45.05$ 45.05$ 45.05$ 40.28$ 45.05$ 40.28$ 34.45$ 49.29
30081025PREGNANCY TEST, URINE300Laboratory30081025$ 96.00$ 62.40$ 62.40$ 89.28$ 81.60$ 81.60$ 81.60$ 72.96$ 81.60$ 72.96$ 62.40$ 89.28
30082040ALBUMIN/SERUM300Laboratory30082040$ 50.00$ 32.50$ 32.50$ 46.50$ 42.50$ 42.50$ 42.50$ 38.00$ 42.50$ 38.00$ 32.50$ 46.50
30082044MICROALBUMIN SEMIQUANT300Laboratory30082044$ 40.00$ 26.00$ 26.00$ 37.20$ 34.00$ 34.00$ 34.00$ 30.40$ 34.00$ 30.40$ 26.00$ 37.20
30082103ALPHA1-ANTITRYPSIN, TOTAL300Laboratory30082103$ 516.00$ 335.40$ 335.40$ 479.88$ 438.60$ 438.60$ 438.60$ 392.16$ 438.60$ 392.16$ 335.40$ 479.88
30082105ALPHA-FETOPROTEIN300Laboratory30082105$ 176.00$ 114.40$ 114.40$ 163.68$ 149.60$ 149.60$ 149.60$ 133.76$ 149.60$ 133.76$ 114.40$ 163.68
30082140AMMONIA300Laboratory30082140$ 142.00$ 92.30$ 92.30$ 132.06$ 120.70$ 120.70$ 120.70$ 107.92$ 120.70$ 107.92$ 92.30$ 132.06
30082150AMYLASE/SERUM300Laboratory30082150$ 90.00$ 58.50$ 58.50$ 83.70$ 76.50$ 76.50$ 76.50$ 68.40$ 76.50$ 68.40$ 58.50$ 83.70
30082180Asorbic acid (vitamin C)300Laboratory30082180$ 31.00$ 20.15$ 20.15$ 28.83$ 26.35$ 26.35$ 26.35$ 23.56$ 26.35$ 23.56$ 20.15$ 28.83
30082247BILIRUBIN/TOTAL300Laboratory30082247$ 80.00$ 52.00$ 52.00$ 74.40$ 68.00$ 68.00$ 68.00$ 60.80$ 68.00$ 60.80$ 52.00$ 74.40
30082248BILIRUBIN/DIRECT300Laboratory30082248$ 93.00$ 60.45$ 60.45$ 86.49$ 79.05$ 79.05$ 79.05$ 70.68$ 79.05$ 70.68$ 60.45$ 86.49
30082271OCCULT BLOOD OTHER SOURCE300Laboratory30082271$ 45.00$ 29.25$ 29.25$ 41.85$ 38.25$ 38.25$ 38.25$ 34.20$ 38.25$ 34.20$ 29.25$ 41.85
30082274FECAL OCCULT BLOOD300Laboratory30082274$ 41.00$ 26.65$ 26.65$ 38.13$ 34.85$ 34.85$ 34.85$ 31.16$ 34.85$ 31.16$ 26.65$ 38.13
3008230625-HYDROXYVITAMIN D2 & D3300Laboratory30082306$ 200.00$ 130.00$ 130.00$ 186.00$ 170.00$ 170.00$ 170.00$ 152.00$ 170.00$ 152.00$ 130.00$ 186.00
30082310CALCIUM/TOTAL/BLOOD300Laboratory30082310$ 73.00$ 47.45$ 47.45$ 67.89$ 62.05$ 62.05$ 62.05$ 55.48$ 62.05$ 55.48$ 47.45$ 67.89
30082360CALCULUS ASSAY QUANT300Laboratory30082360$ 64.00$ 41.60$ 41.60$ 59.52$ 54.40$ 54.40$ 54.40$ 48.64$ 54.40$ 48.64$ 41.60$ 59.52
30082390Ceruloplasmin300Laboratory30082390$ 15.00$ 9.75$ 9.75$ 13.95$ 12.75$ 12.75$ 12.75$ 11.40$ 12.75$ 11.40$ 9.75$ 13.95
30082542COLUMN CHROMOTOGRAPHY QUANT300Laboratory30082542$ 94.00$ 61.10$ 61.10$ 87.42$ 79.90$ 79.90$ 79.90$ 71.44$ 79.90$ 71.44$ 61.10$ 87.42
30082550CK/CPK /TOTAL300Laboratory30082550$ 112.00$ 72.80$ 72.80$ 104.16$ 95.20$ 95.20$ 95.20$ 85.12$ 95.20$ 85.12$ 72.80$ 104.16
30082553CK MB FRACTION ONLY300Laboratory30082553$ 187.00$ 121.55$ 121.55$ 173.91$ 158.95$ 158.95$ 158.95$ 142.12$ 158.95$ 142.12$ 121.55$ 173.91
30082565CREATININE/BLOOD300Laboratory30082565$ 73.00$ 47.45$ 47.45$ 67.89$ 62.05$ 62.05$ 62.05$ 55.48$ 62.05$ 55.48$ 47.45$ 67.89
30082570CREATININE (OTHER SOURCE)300Laboratory30082570$ 73.00$ 47.45$ 47.45$ 67.89$ 62.05$ 62.05$ 62.05$ 55.48$ 62.05$ 55.48$ 47.45$ 67.89
30082607CYANOCOBALAMIN (B-12)300Laboratory30082607$ 125.00$ 81.25$ 81.25$ 116.25$ 106.25$ 106.25$ 106.25$ 95.00$ 106.25$ 95.00$ 81.25$ 116.25
30082627DEHYDROEPLANDROSTERONE300Laboratory30082627$ 61.00$ 39.65$ 39.65$ 56.73$ 51.85$ 51.85$ 51.85$ 46.36$ 51.85$ 46.36$ 39.65$ 56.73
30082656Pancreatic elast fecal300Laboratory30082656$ 306.00$ 198.90$ 198.90$ 284.58$ 260.10$ 260.10$ 260.10$ 232.56$ 260.10$ 232.56$ 198.90$ 284.58
30082670ESTRADIOL300Laboratory30082670$ 336.00$ 218.40$ 218.40$ 312.48$ 285.60$ 285.60$ 285.60$ 255.36$ 285.60$ 255.36$ 218.40$ 312.48
30082672ESTROGENS/TOTAL300Laboratory30082672$ 336.00$ 218.40$ 218.40$ 312.48$ 285.60$ 285.60$ 285.60$ 255.36$ 285.60$ 255.36$ 218.40$ 312.48
30082705Fecal Fat Lipids300Laboratory30082705$ 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 CodeCharge Code DescriptionDept #DeptRev CodeCPT CodeGross ChargeDiscounted Cash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TradCIGNAScott & WhiteUnitedMinimum Negotiated RateMaximum Negotiated Rate
30082728FERRITIN300Laboratory30082728$ 125.00$ 81.25$ 81.25$ 116.25$ 106.25$ 106.25$ 106.25$ 95.00$ 106.25$ 95.00$ 81.25$ 116.25
30082746FOLIC ACID/SERUM300Laboratory30082746$ 121.00$ 78.65$ 78.65$ 112.53$ 102.85$ 102.85$ 102.85$ 91.96$ 102.85$ 91.96$ 78.65$ 112.53
30082784GAMMA GLOBULIN300Laboratory30082784$ 236.00$ 153.40$ 153.40$ 219.48$ 200.60$ 200.60$ 200.60$ 179.36$ 200.60$ 179.36$ 153.40$ 219.48
30082803PH, PCO2, PO2 SIM.300Laboratory30082803$ 269.00$ 174.85$ 174.85$ 250.17$ 228.65$ 228.65$ 228.65$ 204.44$ 228.65$ 204.44$ 174.85$ 250.17
30082945GLUCOSE, OTHER THAN BLOOD300Laboratory30082945$ 31.00$ 20.15$ 20.15$ 28.83$ 26.35$ 26.35$ 26.35$ 23.56$ 26.35$ 23.56$ 20.15$ 28.83
30082947GLUCOSE SERUM/FLUID300Laboratory30082947$ 72.00$ 46.80$ 46.80$ 66.96$ 61.20$ 61.20$ 61.20$ 54.72$ 61.20$ 54.72$ 46.80$ 66.96
30082962GLUCOSE FINGERSTICK300Laboratory30082962$ 45.00$ 29.25$ 29.25$ 41.85$ 38.25$ 38.25$ 38.25$ 34.20$ 38.25$ 34.20$ 29.25$ 41.85
30082977GGT300Laboratory30082977$ 67.00$ 43.55$ 43.55$ 62.31$ 56.95$ 56.95$ 56.95$ 50.92$ 56.95$ 50.92$ 43.55$ 62.31
30083001FSH300Laboratory30083001$ 147.00$ 95.55$ 95.55$ 136.71$ 124.95$ 124.95$ 124.95$ 111.72$ 124.95$ 111.72$ 95.55$ 136.71
30083002LH300Laboratory30083002$ 147.00$ 95.55$ 95.55$ 136.71$ 124.95$ 124.95$ 124.95$ 111.72$ 124.95$ 111.72$ 95.55$ 136.71
30083036HEMOGLOBIN A1C300Laboratory30083036$ 74.00$ 48.10$ 48.10$ 68.82$ 62.90$ 62.90$ 62.90$ 56.24$ 62.90$ 56.24$ 48.10$ 68.82
30083516IMMUNOASSAY NONANTIBODY300Laboratory30083516$ 50.00$ 32.50$ 32.50$ 46.50$ 42.50$ 42.50$ 42.50$ 38.00$ 42.50$ 38.00$ 32.50$ 46.50
30083525INSULIN/TOTAL300Laboratory30083525$ 142.00$ 92.30$ 92.30$ 132.06$ 120.70$ 120.70$ 120.70$ 107.92$ 120.70$ 107.92$ 92.30$ 132.06
30083540IRON300Laboratory30083540$ 47.00$ 30.55$ 30.55$ 43.71$ 39.95$ 39.95$ 39.95$ 35.72$ 39.95$ 35.72$ 30.55$ 43.71
30083550IRON BINDING300Laboratory30083550$ 80.00$ 52.00$ 52.00$ 74.40$ 68.00$ 68.00$ 68.00$ 60.80$ 68.00$ 60.80$ 52.00$ 74.40
30083605LACTIC ACID300Laboratory30083605$ 135.00$ 87.75$ 87.75$ 125.55$ 114.75$ 114.75$ 114.75$ 102.60$ 114.75$ 102.60$ 87.75$ 125.55
30083615LDH300Laboratory30083615$ 104.00$ 67.60$ 67.60$ 96.72$ 88.40$ 88.40$ 88.40$ 79.04$ 88.40$ 79.04$ 67.60$ 96.72
30083655LEAD300Laboratory30083655$ 112.00$ 72.80$ 72.80$ 104.16$ 95.20$ 95.20$ 95.20$ 85.12$ 95.20$ 85.12$ 72.80$ 104.16
30083690LIPASE300Laboratory30083690$ 69.00$ 44.85$ 44.85$ 64.17$ 58.65$ 58.65$ 58.65$ 52.44$ 58.65$ 52.44$ 44.85$ 64.17
30083721LDL CHOLESTEROL300Laboratory30083721$ 27.00$ 17.55$ 17.55$ 25.11$ 22.95$ 22.95$ 22.95$ 20.52$ 22.95$ 20.52$ 17.55$ 25.11
30083735MAGNESIUM300Laboratory30083735$ 50.00$ 32.50$ 32.50$ 46.50$ 42.50$ 42.50$ 42.50$ 38.00$ 42.50$ 38.00$ 32.50$ 46.50
30083789HOMOCYSTINE LEVEL300Laboratory30083789$ 183.00$ 118.95$ 118.95$ 170.19$ 155.55$ 155.55$ 155.55$ 139.08$ 155.55$ 139.08$ 118.95$ 170.19
30083880NATRIURETIC PEPTIDE300Laboratory30083880$ 201.00$ 130.65$ 130.65$ 186.93$ 170.85$ 170.85$ 170.85$ 152.76$ 170.85$ 152.76$ 130.65$ 186.93
30083970PARATHYROID HORM.300Laboratory30083970$ 299.00$ 194.35$ 194.35$ 278.07$ 254.15$ 254.15$ 254.15$ 227.24$ 254.15$ 227.24$ 194.35$ 278.07
30084075PHOSPHATASE ALKALINE300Laboratory30084075$ 74.00$ 48.10$ 48.10$ 68.82$ 62.90$ 62.90$ 62.90$ 56.24$ 62.90$ 56.24$ 48.10$ 68.82
30084100PHOSPHORUS300Laboratory30084100$ 41.00$ 26.65$ 26.65$ 38.13$ 34.85$ 34.85$ 34.85$ 31.16$ 34.85$ 31.16$ 26.65$ 38.13
30084132POTASSIUM (K)/SERUM300Laboratory30084132$ 72.00$ 46.80$ 46.80$ 66.96$ 61.20$ 61.20$ 61.20$ 54.72$ 61.20$ 54.72$ 46.80$ 66.96
30084134PREALBUMIN300Laboratory30084134$ 101.00$ 65.65$ 65.65$ 93.93$ 85.85$ 85.85$ 85.85$ 76.76$ 85.85$ 76.76$ 65.65$ 93.93
30084144PROGESTERONE300Laboratory30084144$ 150.00$ 97.50$ 97.50$ 139.50$ 127.50$ 127.50$ 127.50$ 114.00$ 127.50$ 114.00$ 97.50$ 139.50
30084146PROLACTIN300Laboratory30084146$ 194.00$ 126.10$ 126.10$ 180.42$ 164.90$ 164.90$ 164.90$ 147.44$ 164.90$ 147.44$ 126.10$ 180.42
30084153PSA (PROSTATE S A )300Laboratory30084153$ 83.00$ 53.95$ 53.95$ 77.19$ 70.55$ 70.55$ 70.55$ 63.08$ 70.55$ 63.08$ 53.95$ 77.19
30084154PSA Specific Antigen, Free300Laboratory30084154$ 44.00$ 28.60$ 28.60$ 40.92$ 37.40$ 37.40$ 37.40$ 33.44$ 37.40$ 33.44$ 28.60$ 40.92
30084156PROTEIN, TOTAL URINE300Laboratory30084156$ 395.00$ 256.75$ 256.75$ 367.35$ 335.75$ 335.75$ 335.75$ 300.20$ 335.75$ 300.20$ 256.75$ 367.35
30084157Protein Total Xcpt Refractometry Oth SRC300Laboratory30084157$ 15.00$ 9.75$ 9.75$ 13.95$ 12.75$ 12.75$ 12.75$ 11.40$ 12.75$ 11.40$ 9.75$ 13.95
30084295SODIUM (NA)/BLOOD300Laboratory30084295$ 74.00$ 48.10$ 48.10$ 68.82$ 62.90$ 62.90$ 62.90$ 56.24$ 62.90$ 56.24$ 48.10$ 68.82
30084305ASSAY OF SOMATOMEDIN300Laboratory30084305$ 58.00$ 37.70$ 37.70$ 53.94$ 49.30$ 49.30$ 49.30$ 44.08$ 49.30$ 44.08$ 37.70$ 53.94
30084402TESTOSTERONE ASSAY300Laboratory30084402$ 41.00$ 26.65$ 26.65$ 38.13$ 34.85$ 34.85$ 34.85$ 31.16$ 34.85$ 31.16$ 26.65$ 38.13
30084403TESTOSTERONE TOTAL300Laboratory30084403$ 252.00$ 163.80$ 163.80$ 234.36$ 214.20$ 214.20$ 214.20$ 191.52$ 214.20$ 191.52$ 163.80$ 234.36
30084425VITAMIN B 1300Laboratory30084425$ 250.00$ 162.50$ 162.50$ 232.50$ 212.50$ 212.50$ 212.50$ 190.00$ 212.50$ 190.00$ 162.50$ 232.50
30084436THYROXINE/TOTAL-T4300Laboratory30084436$ 62.00$ 40.30$ 40.30$ 57.66$ 52.70$ 52.70$ 52.70$ 47.12$ 52.70$ 47.12$ 40.30$ 57.66
30084439THYROXINE/FREE-T4300Laboratory30084439$ 152.00$ 98.80$ 98.80$ 141.36$ 129.20$ 129.20$ 129.20$ 115.52$ 129.20$ 115.52$ 98.80$ 141.36
30084443TSH300Laboratory30084443$ 170.00$ 110.50$ 110.50$ 158.10$ 144.50$ 144.50$ 144.50$ 129.20$ 144.50$ 129.20$ 110.50$ 158.10
30084450AST (SGOT)300Laboratory30084450$ 96.00$ 62.40$ 62.40$ 89.28$ 81.60$ 81.60$ 81.60$ 72.96$ 81.60$ 72.96$ 62.40$ 89.28
30084460ALT (SGPT)300Laboratory30084460$ 96.00$ 62.40$ 62.40$ 89.28$ 81.60$ 81.60$ 81.60$ 72.96$ 81.60$ 72.96$ 62.40$ 89.28
30084478TRIGLYCERIDES300Laboratory30084478$ 120.00$ 78.00$ 78.00$ 111.60$ 102.00$ 102.00$ 102.00$ 91.20$ 102.00$ 91.20$ 78.00$ 111.60
30084480T3/TOTAL300Laboratory30084480$ 159.00$ 103.35$ 103.35$ 147.87$ 135.15$ 135.15$ 135.15$ 120.84$ 135.15$ 120.84$ 103.35$ 147.87
30084481TRIIODOTHYRONINE T3; FREE300Laboratory30084481$ 48.00$ 31.20$ 31.20$ 44.64$ 40.80$ 40.80$ 40.80$ 36.48$ 40.80$ 36.48$ 31.20$ 44.64
30084484TROPONIN QUANTITATIVE300Laboratory30084484$ 45.00$ 29.25$ 29.25$ 41.85$ 38.25$ 38.25$ 38.25$ 34.20$ 38.25$ 34.20$ 29.25$ 41.85
30084512TROPONIN QUALITIATIVE300Laboratory30084512$ 200.00$ 130.00$ 130.00$ 186.00$ 170.00$ 170.00$ 170.00$ 152.00$ 170.00$ 152.00$ 130.00$ 186.00
30084520UREA NITROGEN (BUN)300Laboratory30084520$ 73.00$ 47.45$ 47.45$ 67.89$ 62.05$ 62.05$ 62.05$ 55.48$ 62.05$ 55.48$ 47.45$ 67.89
30084550URIC ACID/SERUM300Laboratory30084550$ 72.00$ 46.80$ 46.80$ 66.96$ 61.20$ 61.20$ 61.20$ 54.72$ 61.20$ 54.72$ 46.80$ 66.96
30084597ASSAY VITAMIN K300Laboratory30084597$ 256.00$ 166.40$ 166.40$ 238.08$ 217.60$ 217.60$ 217.60$ 194.56$ 217.60$ 194.56$ 166.40$ 238.08
30084703GONADOTROPIN,CHRIONIC;QUAL.300Laboratory30084703$ 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 CodeCharge Code DescriptionDept #DeptRev CodeCPT CodeGross ChargeDiscounted Cash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TradCIGNAScott & WhiteUnitedMinimum Negotiated RateMaximum Negotiated Rate
30085014HEMATOCRIT300Laboratory30085014$ 34.00$ 22.10$ 22.10$ 31.62$ 28.90$ 28.90$ 28.90$ 25.84$ 28.90$ 25.84$ 22.10$ 31.62
30085018HEMOGLOBIN300Laboratory30085018$ 34.00$ 22.10$ 22.10$ 31.62$ 28.90$ 28.90$ 28.90$ 25.84$ 28.90$ 25.84$ 22.10$ 31.62
30085025COMPLETE CBC AUTO/AUTODIF300Laboratory30085025$ 73.00$ 47.45$ 47.45$ 67.89$ 62.05$ 62.05$ 62.05$ 55.48$ 62.05$ 55.48$ 47.45$ 67.89
30085027COMPLETE CBC AUTOMATED300Laboratory30085027$ 93.00$ 60.45$ 60.45$ 86.49$ 79.05$ 79.05$ 79.05$ 70.68$ 79.05$ 70.68$ 60.45$ 86.49
30085045RETICULOCYTE, AUTOMATED300Laboratory30085045$ 38.00$ 24.70$ 24.70$ 35.34$ 32.30$ 32.30$ 32.30$ 28.88$ 32.30$ 28.88$ 24.70$ 35.34
30085049PLATELET COUNT300Laboratory30085049$ 35.00$ 22.75$ 22.75$ 32.55$ 29.75$ 29.75$ 29.75$ 26.60$ 29.75$ 26.60$ 22.75$ 32.55
30085379D-DIMER, QUANTITATIVE300Laboratory30085379$ 42.00$ 27.30$ 27.30$ 39.06$ 35.70$ 35.70$ 35.70$ 31.92$ 35.70$ 31.92$ 27.30$ 39.06
30085610PROTIME (PT)300Laboratory30085610$ 72.00$ 46.80$ 46.80$ 66.96$ 61.20$ 61.20$ 61.20$ 54.72$ 61.20$ 54.72$ 46.80$ 66.96
30085651SED RATE (ESR)300Laboratory30085651$ 53.00$ 34.45$ 34.45$ 49.29$ 45.05$ 45.05$ 45.05$ 40.28$ 45.05$ 40.28$ 34.45$ 49.29
30085730PART. PROTIME (PTT)300Laboratory30085730$ 82.00$ 53.30$ 53.30$ 76.26$ 69.70$ 69.70$ 69.70$ 62.32$ 69.70$ 62.32$ 53.30$ 76.26
30086038ANA300Laboratory30086038$ 96.00$ 62.40$ 62.40$ 89.28$ 81.60$ 81.60$ 81.60$ 72.96$ 81.60$ 72.96$ 62.40$ 89.28
30086140C-REACTIVE PROTEIN300Laboratory30086140$ 80.00$ 52.00$ 52.00$ 74.40$ 68.00$ 68.00$ 68.00$ 60.80$ 68.00$ 60.80$ 52.00$ 74.40
30086141C-REACTIVE PROTEIN HS300Laboratory30086141$ 62.00$ 40.30$ 40.30$ 57.66$ 52.70$ 52.70$ 52.70$ 47.12$ 52.70$ 47.12$ 40.30$ 57.66
30086147Cardiolipin Antibody Each IG Class300Laboratory30086147$ 37.00$ 24.05$ 24.05$ 34.41$ 31.45$ 31.45$ 31.45$ 28.12$ 31.45$ 28.12$ 24.05$ 34.41
30086160COMPLEMENT;ANTIGEN, EACH COMP.300Laboratory30086160$ 114.00$ 74.10$ 74.10$ 106.02$ 96.90$ 96.90$ 96.90$ 86.64$ 96.90$ 86.64$ 74.10$ 106.02
30086225DNA ANTIBODY;NATIVE/DBL STRAND300Laboratory30086225$ 204.00$ 132.60$ 132.60$ 189.72$ 173.40$ 173.40$ 173.40$ 155.04$ 173.40$ 155.04$ 132.60$ 189.72
30086300CANCER ANTIGEN CA-15-3/2729300Laboratory30086300$ 176.00$ 114.40$ 114.40$ 163.68$ 149.60$ 149.60$ 149.60$ 133.76$ 149.60$ 133.76$ 114.40$ 163.68
30086304CANCER ANTIGEN 125300Laboratory30086304$ 151.00$ 98.15$ 98.15$ 140.43$ 128.35$ 128.35$ 128.35$ 114.76$ 128.35$ 114.76$ 98.15$ 140.43
30086308HETEROPHILE ANTIBODIES300Laboratory30086308$ 67.00$ 43.55$ 43.55$ 62.31$ 56.95$ 56.95$ 56.95$ 50.92$ 56.95$ 50.92$ 43.55$ 62.31
30086376MICROSOMAL ANTIBODIES300Laboratory30086376$ 46.00$ 29.90$ 29.90$ 42.78$ 39.10$ 39.10$ 39.10$ 34.96$ 39.10$ 34.96$ 29.90$ 42.78
30086431RHEUMATOID FACTOR/QUAN.300Laboratory30086431$ 107.00$ 69.55$ 69.55$ 99.51$ 90.95$ 90.95$ 90.95$ 81.32$ 90.95$ 81.32$ 69.55$ 99.51
30086592RPR/QUALITATIVE300Laboratory30086592$ 62.00$ 40.30$ 40.30$ 57.66$ 52.70$ 52.70$ 52.70$ 47.12$ 52.70$ 47.12$ 40.30$ 57.66
30086606Fungal Anitbodies by double immuno-diff300Laboratory30086606$ 61.00$ 39.65$ 39.65$ 56.73$ 51.85$ 51.85$ 51.85$ 46.36$ 51.85$ 46.36$ 39.65$ 56.73
30086618LYME DISEASE AB300Laboratory30086618$ 150.00$ 97.50$ 97.50$ 139.50$ 127.50$ 127.50$ 127.50$ 114.00$ 127.50$ 114.00$ 97.50$ 139.50
30086635Coccidiodes Anitbody by comp fix300Laboratory30086635$ 77.00$ 50.05$ 50.05$ 71.61$ 65.45$ 65.45$ 65.45$ 58.52$ 65.45$ 58.52$ 50.05$ 71.61
30086664EPSTEIN BARR EBNA300Laboratory30086664$ 96.00$ 62.40$ 62.40$ 89.28$ 81.60$ 81.60$ 81.60$ 72.96$ 81.60$ 72.96$ 62.40$ 89.28
30086665EPSTEIN BARR VCA X2300Laboratory30086665$ 188.00$ 122.20$ 122.20$ 174.84$ 159.80$ 159.80$ 159.80$ 142.88$ 159.80$ 142.88$ 122.20$ 174.84
30086677H. PYLORI300Laboratory30086677$ 147.00$ 95.55$ 95.55$ 136.71$ 124.95$ 124.95$ 124.95$ 111.72$ 124.95$ 111.72$ 95.55$ 136.71
30086694HERPES TITER ANTIBODY300Laboratory30086694$ 210.00$ 136.50$ 136.50$ 195.30$ 178.50$ 178.50$ 178.50$ 159.60$ 178.50$ 159.60$ 136.50$ 195.30
30086703HIV-1 HIV-2 SINGLE ASSAY300Laboratory30086703$ 139.00$ 90.35$ 90.35$ 129.27$ 118.15$ 118.15$ 118.15$ 105.64$ 118.15$ 105.64$ 90.35$ 129.27
30086706HEP.B SURFACE ANTOBODY300Laboratory30086706$ 114.00$ 74.10$ 74.10$ 106.02$ 96.90$ 96.90$ 96.90$ 86.64$ 96.90$ 86.64$ 74.10$ 106.02
30086735MUMPS ANTIBODY300Laboratory30086735$ 325.00$ 211.25$ 211.25$ 302.25$ 276.25$ 276.25$ 276.25$ 247.00$ 276.25$ 247.00$ 211.25$ 302.25
30086787VARICELLA TITER300Laboratory30086787$ 120.00$ 78.00$ 78.00$ 111.60$ 102.00$ 102.00$ 102.00$ 91.20$ 102.00$ 91.20$ 78.00$ 111.60
30086800THYROGLOBULIN ANTIBODY300Laboratory30086800$ 38.00$ 24.70$ 24.70$ 35.34$ 32.30$ 32.30$ 32.30$ 28.88$ 32.30$ 28.88$ 24.70$ 35.34
30086803HEPATITIS C ANTIBODY300Laboratory30086803$ 114.00$ 74.10$ 74.10$ 106.02$ 96.90$ 96.90$ 96.90$ 86.64$ 96.90$ 86.64$ 74.10$ 106.02
30086850ANTIBODY SCREEN RBC300Laboratory30086850$ 40.00$ 26.00$ 26.00$ 37.20$ 34.00$ 34.00$ 34.00$ 30.40$ 34.00$ 30.40$ 26.00$ 37.20
30086900ABO BLOOD TYPING300Laboratory39086900$ 84.00$ 54.60$ 54.60$ 78.12$ 71.40$ 71.40$ 71.40$ 63.84$ 71.40$ 63.84$ 54.60$ 78.12
30086901RH BLOOD TYPING300Laboratory30086901$ 53.00$ 34.45$ 34.45$ 49.29$ 45.05$ 45.05$ 45.05$ 40.28$ 45.05$ 40.28$ 34.45$ 49.29
30086920COMP.TEST EACH UNIT300Laboratory30086920$ 139.00$ 90.35$ 90.35$ 129.27$ 118.15$ 118.15$ 118.15$ 105.64$ 118.15$ 105.64$ 90.35$ 129.27
30087040CULTURE/BLOOD300Laboratory30087040$ 168.00$ 109.20$ 109.20$ 156.24$ 142.80$ 142.80$ 142.80$ 127.68$ 142.80$ 127.68$ 109.20$ 156.24
30087045CULTURE/STOOL300Laboratory30087045$ 107.00$ 69.55$ 69.55$ 99.51$ 90.95$ 90.95$ 90.95$ 81.32$ 90.95$ 81.32$ 69.55$ 99.51
30087046CULTURE/STOOL BACT ISOLATION300Laboratory30087046$ 51.00$ 33.15$ 33.15$ 47.43$ 43.35$ 43.35$ 43.35$ 38.76$ 43.35$ 38.76$ 33.15$ 47.43
30087070CULTURE/OTHER SOURCE300Laboratory30087070$ 112.00$ 72.80$ 72.80$ 104.16$ 95.20$ 95.20$ 95.20$ 85.12$ 95.20$ 85.12$ 72.80$ 104.16
30087077CULTURE, AEROBIC IDENTIFY300Laboratory30087077$ 38.00$ 24.70$ 24.70$ 35.34$ 32.30$ 32.30$ 32.30$ 28.88$ 32.30$ 28.88$ 24.70$ 35.34
30087081CULTURE/SCREENING ONLY300Laboratory30087081$ 138.00$ 89.70$ 89.70$ 128.34$ 117.30$ 117.30$ 117.30$ 104.88$ 117.30$ 104.88$ 89.70$ 128.34
30087086CULTURE/URINE300Laboratory30087086$ 112.00$ 72.80$ 72.80$ 104.16$ 95.20$ 95.20$ 95.20$ 85.12$ 95.20$ 85.12$ 72.80$ 104.16
30087088URINE BACTERIA CULT W/ISO300Laboratory30087088$ 38.00$ 24.70$ 24.70$ 35.34$ 32.30$ 32.30$ 32.30$ 28.88$ 32.30$ 28.88$ 24.70$ 35.34
30087177O & P COMPLETE300Laboratory30087177$ 138.00$ 89.70$ 89.70$ 128.34$ 117.30$ 117.30$ 117.30$ 104.88$ 117.30$ 104.88$ 89.70$ 128.34
30087186SENSITIVITY (MIC)300Laboratory30087186$ 69.00$ 44.85$ 44.85$ 64.17$ 58.65$ 58.65$ 58.65$ 52.44$ 58.65$ 52.44$ 44.85$ 64.17
30087324C-DIFF300Laboratory30087324$ 114.00$ 74.10$ 74.10$ 106.02$ 96.90$ 96.90$ 96.90$ 86.64$ 96.90$ 86.64$ 74.10$ 106.02
30087338H PYLORI STOOL300Laboratory30087338$ 165.00$ 107.25$ 107.25$ 153.45$ 140.25$ 140.25$ 140.25$ 125.40$ 140.25$ 125.40$ 107.25$ 153.45
30087420RSV300Laboratory30087420$ 130.00$ 84.50$ 84.50$ 120.90$ 110.50$ 110.50$ 110.50$ 98.80$ 110.50$ 98.80$ 84.50$ 120.90
52387420RSV300Laboratory30087420$ 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 CodeCharge Code DescriptionDept #DeptRev CodeCPT CodeGross ChargeDiscounted Cash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TradCIGNAScott & WhiteUnitedMinimum Negotiated RateMaximum Negotiated Rate
30087425ROTAVIRUS300Laboratory30087425$ 135.00$ 87.75$ 87.75$ 125.55$ 114.75$ 114.75$ 114.75$ 102.60$ 114.75$ 102.60$ 87.75$ 125.55
30087449INFECTIOUS AGENT ANTI DET300Laboratory30087449$ 120.00$ 78.00$ 78.00$ 111.60$ 102.00$ 102.00$ 102.00$ 91.20$ 102.00$ 91.20$ 78.00$ 111.60
52387449INFECTIOUS AGENT ANTI DET-CLIA300Laboratory30087449$ 120.00$ 78.00$ 78.00$ 111.60$ 102.00$ 102.00$ 102.00$ 91.20$ 102.00$ 91.20$ 78.00$ 111.60
30087491CHLAMYDIA TRACHOMATIS, AMPLI300Laboratory30087491$ 133.00$ 86.45$ 86.45$ 123.69$ 113.05$ 113.05$ 113.05$ 101.08$ 113.05$ 101.08$ 86.45$ 123.69
30087497IADNA Cytomegalovirus Quantification300Laboratory30087497$ 214.00$ 139.10$ 139.10$ 199.02$ 181.90$ 181.90$ 181.90$ 162.64$ 181.90$ 162.64$ 139.10$ 199.02
30087507Gastrointestinal Profile300Laboratory30087507$ 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
30087522HEPATITIS C QUANTIFICATION300Laboratory30087522$ 775.00$ 503.75$ 503.75$ 720.75$ 658.75$ 658.75$ 658.75$ 589.00$ 658.75$ 589.00$ 503.75$ 720.75
30087591NEISSERIA GONORRHEA, AMPLIFIED300Laboratory30087591$ 156.00$ 101.40$ 101.40$ 145.08$ 132.60$ 132.60$ 132.60$ 118.56$ 132.60$ 118.56$ 101.40$ 145.08
30087624HPV High Risk300Laboratory30087624$ 123.00$ 79.95$ 79.95$ 114.39$ 104.55$ 104.55$ 104.55$ 93.48$ 104.55$ 93.48$ 79.95$ 114.39
30087799BK Virus Quanti300Laboratory30087799$ 383.00$ 248.95$ 248.95$ 356.19$ 325.55$ 325.55$ 325.55$ 291.08$ 325.55$ 291.08$ 248.95$ 356.19
30087800DETECT AGNTMULT DNA DIRECT300Laboratory30087800$ 185.00$ 120.25$ 120.25$ 172.05$ 157.25$ 157.25$ 157.25$ 140.60$ 157.25$ 140.60$ 120.25$ 172.05
30087880STREP SCREEN300Laboratory30087880$ 62.00$ 40.30$ 40.30$ 57.66$ 52.70$ 52.70$ 52.70$ 47.12$ 52.70$ 47.12$ 40.30$ 57.66
52387880STREP SCREEN300Laboratory30087880$ 62.00$ 40.30$ 40.30$ 57.66$ 52.70$ 52.70$ 52.70$ 47.12$ 52.70$ 47.12$ 40.30$ 57.66
30088305CELL PATH GROSS & MICR- LEV 4300Laboratory30088305$ 276.00$ 179.40$ 179.40$ 256.68$ 234.60$ 234.60$ 234.60$ 209.76$ 234.60$ 209.76$ 179.40$ 256.68
30089051CELL COUNT, W/DIFF COUNT300Laboratory30089051$ 32.00$ 20.80$ 20.80$ 29.76$ 27.20$ 27.20$ 27.20$ 24.32$ 27.20$ 24.32$ 20.80$ 29.76
30089055LEUKOCYTE, FECAL300Laboratory30089055$ 51.00$ 33.15$ 33.15$ 47.43$ 43.35$ 43.35$ 43.35$ 38.76$ 43.35$ 38.76$ 33.15$ 47.43
30089060CRYSTAL I.D.300Laboratory30089060$ 63.00$ 40.95$ 40.95$ 58.59$ 53.55$ 53.55$ 53.55$ 47.88$ 53.55$ 47.88$ 40.95$ 58.59
30088142PAP SMEAR - THIN LAYER300Laboratory300G0123$ 107.00$ 69.55$ 69.55$ 99.51$ 90.95$ 90.95$ 90.95$ 81.32$ 90.95$ 81.32$ 69.55$ 99.51
42097012TRACTION/MECH.420Physical Therapy42097012$ 55.00$ 35.75$ 35.75$ 51.15$ 46.75$ 46.75$ 46.75$ 41.80$ 46.75$ 41.80$ 35.75$ 51.15
42097014ES-UNATTENDED420Physical Therapy42097014$ 55.00$ 35.75$ 35.75$ 51.15$ 46.75$ 46.75$ 46.75$ 41.80$ 46.75$ 41.80$ 35.75$ 51.15
42097018PARAFFIN BATH420Physical Therapy42097018$ 55.00$ 35.75$ 35.75$ 51.15$ 46.75$ 46.75$ 46.75$ 41.80$ 46.75$ 41.80$ 35.75$ 51.15
42097032ELECTRICAL STIM EACH 15 MIN420Physical Therapy42097032$ 50.00$ 32.50$ 32.50$ 46.50$ 42.50$ 42.50$ 42.50$ 38.00$ 42.50$ 38.00$ 32.50$ 46.50
42097035ULTRASOUND420Physical Therapy42097035$ 71.00$ 46.15$ 46.15$ 66.03$ 60.35$ 60.35$ 60.35$ 53.96$ 60.35$ 53.96$ 46.15$ 66.03
42097110THER EX 0-15420Physical Therapy42097110$ 92.00$ 59.80$ 59.80$ 85.56$ 78.20$ 78.20$ 78.20$ 69.92$ 78.20$ 69.92$ 59.80$ 85.56
42097112NEURO MUS. RE ED420Physical Therapy42097112$ 78.00$ 50.70$ 50.70$ 72.54$ 66.30$ 66.30$ 66.30$ 59.28$ 66.30$ 59.28$ 50.70$ 72.54
42097116GAIT TRAINING 0-15420Physical Therapy42097116$ 78.00$ 50.70$ 50.70$ 72.54$ 66.30$ 66.30$ 66.30$ 59.28$ 66.30$ 59.28$ 50.70$ 72.54
42097140MANUAL THERAPY 15 MINUTES420Physical Therapy42097140$ 75.00$ 48.75$ 48.75$ 69.75$ 63.75$ 63.75$ 63.75$ 57.00$ 63.75$ 57.00$ 48.75$ 69.75
42097161PT EVAL; LOW COMPLEXITY420Physical Therapy42497161$ 163.00$ 105.95$ 105.95$ 151.59$ 138.55$ 138.55$ 138.55$ 123.88$ 138.55$ 123.88$ 105.95$ 151.59
42097162PT EVAL; MODERATE COMPLEXITY420Physical Therapy42497162$ 184.00$ 119.60$ 119.60$ 171.12$ 156.40$ 156.40$ 156.40$ 139.84$ 156.40$ 139.84$ 119.60$ 171.12
42097163PT EVAL; HIGH COMPLEXITY420Physical Therapy42497163$ 204.00$ 132.60$ 132.60$ 189.72$ 173.40$ 173.40$ 173.40$ 155.04$ 173.40$ 155.04$ 132.60$ 189.72
42097002RE-EVALUATION420Physical Therapy42097164$ 112.00$ 72.80$ 72.80$ 104.16$ 95.20$ 95.20$ 95.20$ 85.12$ 95.20$ 85.12$ 72.80$ 104.16
42097530KINETIC THER.420Physical Therapy42097530$ 100.00$ 65.00$ 65.00$ 93.00$ 85.00$ 85.00$ 85.00$ 76.00$ 85.00$ 76.00$ 65.00$ 93.00
42097542Wheelchair Management Training420Physical Therapy42097542$ 103.00$ 66.95$ 66.95$ 95.79$ 87.55$ 87.55$ 87.55$ 78.28$ 87.55$ 78.28$ 66.95$ 95.79
42097597WOUND CARE/20CM OR LESS420Physical Therapy42097597$ 184.00$ 119.60$ 119.60$ 171.12$ 156.40$ 156.40$ 156.40$ 139.84$ 156.40$ 139.84$ 119.60$ 171.12
42097598WOUND CARE/GREATER THAN 20CM420Physical Therapy42097598$ 213.00$ 138.45$ 138.45$ 198.09$ 181.05$ 181.05$ 181.05$ 161.88$ 181.05$ 161.88$ 138.45$ 198.09
42097602WOUND CARE NON-SELECTIVE420Physical Therapy42097602$ 136.00$ 88.40$ 88.40$ 126.48$ 115.60$ 115.60$ 115.60$ 103.36$ 115.60$ 103.36$ 88.40$ 126.48
42097760ORTHOTIC MANAGEMENT & TRAINING420Physical Therapy42097760$ 48.00$ 31.20$ 31.20$ 44.64$ 40.80$ 40.80$ 40.80$ 36.48$ 40.80$ 36.48$ 31.20$ 44.64
420G0283ES-UNATTENDED420Physical Therapy420G0283$ 55.00$ 35.75$ 35.75$ 51.15$ 46.75$ 46.75$ 46.75$ 41.80$ 46.75$ 41.80$ 35.75$ 51.15
32070100MANDIBLE/LESS THAN 4V320Radiology32070100$ 247.00$ 160.55$ 160.55$ 229.71$ 209.95$ 209.95$ 209.95$ 187.72$ 209.95$ 187.72$ 160.55$ 229.71
32070140FACIAL BONES/LESS THAN 3V320Radiology32070140$ 172.00$ 111.80$ 111.80$ 159.96$ 146.20$ 146.20$ 146.20$ 130.72$ 146.20$ 130.72$ 111.80$ 159.96
32070150FACIAL BONES COMP/M3V320Radiology32070150$ 301.00$ 195.65$ 195.65$ 279.93$ 255.85$ 255.85$ 255.85$ 228.76$ 255.85$ 228.76$ 195.65$ 279.93
32070160NASAL BONES COMP/M3V320Radiology32070160$ 208.00$ 135.20$ 135.20$ 193.44$ 176.80$ 176.80$ 176.80$ 158.08$ 176.80$ 158.08$ 135.20$ 193.44
32070200ORBITS COMP/M4V320Radiology32070200$ 209.00$ 135.85$ 135.85$ 194.37$ 177.65$ 177.65$ 177.65$ 158.84$ 177.65$ 158.84$ 135.85$ 194.37
32070210SINUSES/LESS THAN 3V320Radiology32070210$ 130.00$ 84.50$ 84.50$ 120.90$ 110.50$ 110.50$ 110.50$ 98.80$ 110.50$ 98.80$ 84.50$ 120.90
32070220SINUSES COMP.SERIES/M3V320Radiology32070220$ 286.00$ 185.90$ 185.90$ 265.98$ 243.10$ 243.10$ 243.10$ 217.36$ 243.10$ 217.36$ 185.90$ 265.98
32070250SKULL/LESS THAN 4V320Radiology32070250$ 220.00$ 143.00$ 143.00$ 204.60$ 187.00$ 187.00$ 187.00$ 167.20$ 187.00$ 167.20$ 143.00$ 204.60
32070260SKULL COMP.SERIES/M4V320Radiology32070260$ 308.00$ 200.20$ 200.20$ 286.44$ 261.80$ 261.80$ 261.80$ 234.08$ 261.80$ 234.08$ 200.20$ 286.44
32070328TMJ320Radiology32070328$ 221.00$ 143.65$ 143.65$ 205.53$ 187.85$ 187.85$ 187.85$ 167.96$ 187.85$ 167.96$ 143.65$ 205.53
32070330TMJ/BILATERAL320Radiology32070330$ 221.00$ 143.65$ 143.65$ 205.53$ 187.85$ 187.85$ 187.85$ 167.96$ 187.85$ 167.96$ 143.65$ 205.53
32070360NECK, SOFT TISSUE320Radiology32070360$ 197.00$ 128.05$ 128.05$ 183.21$ 167.45$ 167.45$ 167.45$ 149.72$ 167.45$ 149.72$ 128.05$ 183.21
35070450CT-BRAIN W/O CONTRAST320Radiology35070450$ 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
35070470CT-BRAIN W/WO CONTRAST320Radiology35070450$ 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
35070460CT-BRAIN WITH CONTRAST320Radiology35070460$ 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 CodeCharge Code DescriptionDept #DeptRev CodeCPT CodeGross ChargeDiscounted Cash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TradCIGNAScott & WhiteUnitedMinimum Negotiated RateMaximum Negotiated Rate
35070480CT-EAR W/O CONTRAST320Radiology35070480$ 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
35070481CT-EAR WITH CONTRAST320Radiology35070481$ 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
35070482CT-EAR W/WO CONTRAST320Radiology35070482$ 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
35070486CT-FACE W/O CONTRAST320Radiology35070486$ 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
35070487CT-FACE WITH CONTRAST320Radiology35070487$ 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
35070488CT-FACE W/WO CONTRAST320Radiology35070488$ 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
35070490CT-NECK W/O CONTRAST320Radiology35070490$ 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
35070491CT-NECK WITH CONTRAST320Radiology35070491$ 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
35070492CT-NECK W/WO CONTRAST320Radiology35070492$ 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
32071030CHEST/COMP. M4V320Radiology32071030$ 219.00$ 142.35$ 142.35$ 203.67$ 186.15$ 186.15$ 186.15$ 166.44$ 186.15$ 166.44$ 142.35$ 203.67
32071010CHEST/1 VIEW320Radiology32071045$ 155.00$ 100.75$ 100.75$ 144.15$ 131.75$ 131.75$ 131.75$ 117.80$ 131.75$ 117.80$ 100.75$ 144.15
32071020CHEST/2 VIEW320Radiology32071046$ 251.00$ 163.15$ 163.15$ 233.43$ 213.35$ 213.35$ 213.35$ 190.76$ 213.35$ 190.76$ 163.15$ 233.43
32071100RIBS/UNILAT/2V320Radiology32071100$ 246.00$ 159.90$ 159.90$ 228.78$ 209.10$ 209.10$ 209.10$ 186.96$ 209.10$ 186.96$ 159.90$ 228.78
32071101Unilateral Ribs/Chest min 3v320Radiology32071101$ 397.00$ 258.05$ 258.05$ 369.21$ 337.45$ 337.45$ 337.45$ 301.72$ 337.45$ 301.72$ 258.05$ 369.21
32071110RIBS/BILATERAL/3V320Radiology32071110$ 307.00$ 199.55$ 199.55$ 285.51$ 260.95$ 260.95$ 260.95$ 233.32$ 260.95$ 233.32$ 199.55$ 285.51
32071120STERNUM/M2V320Radiology32071120$ 166.00$ 107.90$ 107.90$ 154.38$ 141.10$ 141.10$ 141.10$ 126.16$ 141.10$ 126.16$ 107.90$ 154.38
35071250CT-THORAX,CHEST W/O CONTRAST320Radiology35071250$ 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
35071260CT-THORAX,CHEST WITH CONTRAST320Radiology35071260$ 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
35071270CT-THORAX,CHEST W/WO CONTRAST320Radiology35071270$ 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
32072040CERVICAL SPINE/2V OR 3V320Radiology32072040$ 249.00$ 161.85$ 161.85$ 231.57$ 211.65$ 211.65$ 211.65$ 189.24$ 211.65$ 189.24$ 161.85$ 231.57
32072050CERVICAL SPINE, MIN 4 VIEWS320Radiology32072050$ 390.00$ 253.50$ 253.50$ 362.70$ 331.50$ 331.50$ 331.50$ 296.40$ 331.50$ 296.40$ 253.50$ 362.70
32072052CERVICAL SPINE COMP.320Radiology32072052$ 347.00$ 225.55$ 225.55$ 322.71$ 294.95$ 294.95$ 294.95$ 263.72$ 294.95$ 263.72$ 225.55$ 322.71
32072070THORACIC SPINE/2V320Radiology32072070$ 249.00$ 161.85$ 161.85$ 231.57$ 211.65$ 211.65$ 211.65$ 189.24$ 211.65$ 189.24$ 161.85$ 231.57
32072072THORACIC SPINE/3V320Radiology32072072$ 313.00$ 203.45$ 203.45$ 291.09$ 266.05$ 266.05$ 266.05$ 237.88$ 266.05$ 237.88$ 203.45$ 291.09
32072090SCOLIOSIS STUDY320Radiology32072082$ 92.00$ 59.80$ 59.80$ 85.56$ 78.20$ 78.20$ 78.20$ 69.92$ 78.20$ 69.92$ 59.80$ 85.56
32072100L-S SPINE/2 OR 3V320Radiology32072100$ 243.00$ 157.95$ 157.95$ 225.99$ 206.55$ 206.55$ 206.55$ 184.68$ 206.55$ 184.68$ 157.95$ 225.99
32072110L-S SPINE 5 VIEWS320Radiology32072110$ 410.00$ 266.50$ 266.50$ 381.30$ 348.50$ 348.50$ 348.50$ 311.60$ 348.50$ 311.60$ 266.50$ 381.30
32072114L-S SPINE COMP/BEND320Radiology32072114$ 316.00$ 205.40$ 205.40$ 293.88$ 268.60$ 268.60$ 268.60$ 240.16$ 268.60$ 240.16$ 205.40$ 293.88
35072125CT-C SPINE W/O CONTRAST320Radiology35072125$ 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
35072126CT-C SPINE WITH CONTRAST320Radiology35072126$ 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
35072127CT-C SPINE W/WO CONTRAST320Radiology35072127$ 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
35072128CT-T SPINE W/O CONTRAST320Radiology35072128$ 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
35072129CT-T SPINE WITH CONTRAST320Radiology35072129$ 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
35072130CT-T SPINE W/WO CONTRAST320Radiology35072130$ 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
35072131CT-L SPINE W/O CONTRAST320Radiology35072131$ 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
35072132CT-L SPINE WITH CONTRAST320Radiology35072132$ 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
35072133CT-L SPINE W/WO CONTRAST320Radiology35072133$ 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
32072170PELVIS/1 OR 2 VIEWS320Radiology32072170$ 195.00$ 126.75$ 126.75$ 181.35$ 165.75$ 165.75$ 165.75$ 148.20$ 165.75$ 148.20$ 126.75$ 181.35
35072192CT-PELVIS W/O CONTRAST320Radiology35072192$ 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
35072193CT-PELVIS WITH CONTRAST320Radiology35072193$ 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
35072194CT-PELVIS W/WO CONTRAST320Radiology35072194$ 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
32072200SACROILIAC JTS./LESS 3V320Radiology32072200$ 153.00$ 99.45$ 99.45$ 142.29$ 130.05$ 130.05$ 130.05$ 116.28$ 130.05$ 116.28$ 99.45$ 142.29
32072220SACRUM/COCCYX/M2V320Radiology32072220$ 208.00$ 135.20$ 135.20$ 193.44$ 176.80$ 176.80$ 176.80$ 158.08$ 176.80$ 158.08$ 135.20$ 193.44
32073000CLAVICLE COMPLETE320Radiology32073000$ 212.00$ 137.80$ 137.80$ 197.16$ 180.20$ 180.20$ 180.20$ 161.12$ 180.20$ 161.12$ 137.80$ 197.16
32073010SCAPULA COMPLETE320Radiology32073010$ 203.00$ 131.95$ 131.95$ 188.79$ 172.55$ 172.55$ 172.55$ 154.28$ 172.55$ 154.28$ 131.95$ 188.79
32073020SHOULDER 1 VIEW320Radiology32073020$ 162.00$ 105.30$ 105.30$ 150.66$ 137.70$ 137.70$ 137.70$ 123.12$ 137.70$ 123.12$ 105.30$ 150.66
32073030Shoulder comp/M2V320Radiology32073030$ 235.00$ 152.75$ 152.75$ 218.55$ 199.75$ 199.75$ 199.75$ 178.60$ 199.75$ 178.60$ 152.75$ 218.55
32073050AC JOINTS BIL. W/OR W/O WEIGHT320Radiology32073050$ 78.00$ 50.70$ 50.70$ 72.54$ 66.30$ 66.30$ 66.30$ 59.28$ 66.30$ 59.28$ 50.70$ 72.54
32073060HUMERUS/M2V320Radiology32073060$ 216.00$ 140.40$ 140.40$ 200.88$ 183.60$ 183.60$ 183.60$ 164.16$ 183.60$ 164.16$ 140.40$ 200.88
32073070ELBOW 2 VIEWS320Radiology32073070$ 175.00$ 113.75$ 113.75$ 162.75$ 148.75$ 148.75$ 148.75$ 133.00$ 148.75$ 133.00$ 113.75$ 162.75
32073080ELBOW SERIES/M3V320Radiology32073080$ 180.00$ 117.00$ 117.00$ 167.40$ 153.00$ 153.00$ 153.00$ 136.80$ 153.00$ 136.80$ 117.00$ 167.40
32073090FOREARM 2 VIEWS320Radiology32073090$ 196.00$ 127.40$ 127.40$ 182.28$ 166.60$ 166.60$ 166.60$ 148.96$ 166.60$ 148.96$ 127.40$ 182.28
32073100WRIST 2 VIEWS320Radiology32073100$ 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 CodeCharge Code DescriptionDept #DeptRev CodeCPT CodeGross ChargeDiscounted Cash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TradCIGNAScott & WhiteUnitedMinimum Negotiated RateMaximum Negotiated Rate
32073110WRIST COMP./M3V320Radiology32073110$ 220.00$ 143.00$ 143.00$ 204.60$ 187.00$ 187.00$ 187.00$ 167.20$ 187.00$ 167.20$ 143.00$ 204.60
32073120HAND 2 VIEWS320Radiology32073120$ 172.00$ 111.80$ 111.80$ 159.96$ 146.20$ 146.20$ 146.20$ 130.72$ 146.20$ 130.72$ 111.80$ 159.96
32073130HAND COMP./M3V320Radiology32073130$ 199.00$ 129.35$ 129.35$ 185.07$ 169.15$ 169.15$ 169.15$ 151.24$ 169.15$ 151.24$ 129.35$ 185.07
32073140FINGER/FINGERS/M2V320Radiology32073140$ 180.00$ 117.00$ 117.00$ 167.40$ 153.00$ 153.00$ 153.00$ 136.80$ 153.00$ 136.80$ 117.00$ 167.40
35073200CT-ARM W/O CONTRAST320Radiology35073200$ 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
35073201CT-ARM WITH CONTRAST320Radiology35073201$ 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
32073500HIP 1 VIEW320Radiology32073501$ 161.00$ 104.65$ 104.65$ 149.73$ 136.85$ 136.85$ 136.85$ 122.36$ 136.85$ 122.36$ 104.65$ 149.73
32073502HIP UNI 2-3 VIEWS320Radiology32073502$ 223.00$ 144.95$ 144.95$ 207.39$ 189.55$ 189.55$ 189.55$ 169.48$ 189.55$ 169.48$ 144.95$ 207.39
32073520HIPS BI 2 VIEWS320Radiology32073521$ 269.00$ 174.85$ 174.85$ 250.17$ 228.65$ 228.65$ 228.65$ 204.44$ 228.65$ 204.44$ 174.85$ 250.17
32073540PELVIS/HIP/M2V/CHILD320Radiology32073540$ 125.00$ 81.25$ 81.25$ 116.25$ 106.25$ 106.25$ 106.25$ 95.00$ 106.25$ 95.00$ 81.25$ 116.25
32073550FEMUR 2 VIEWS320Radiology32073552$ 220.00$ 143.00$ 143.00$ 204.60$ 187.00$ 187.00$ 187.00$ 167.20$ 187.00$ 167.20$ 143.00$ 204.60
32073560KNEE 1/2V320Radiology32073560$ 180.00$ 117.00$ 117.00$ 167.40$ 153.00$ 153.00$ 153.00$ 136.80$ 153.00$ 136.80$ 117.00$ 167.40
32073562KNEE /M3V320Radiology32073562$ 194.00$ 126.10$ 126.10$ 180.42$ 164.90$ 164.90$ 164.90$ 147.44$ 164.90$ 147.44$ 126.10$ 180.42
32073564KNEE COMP. SERIES/M4V320Radiology32073564$ 300.00$ 195.00$ 195.00$ 279.00$ 255.00$ 255.00$ 255.00$ 228.00$ 255.00$ 228.00$ 195.00$ 279.00
32073565KNEE XRAY-BOTH320Radiology32073565$ 159.00$ 103.35$ 103.35$ 147.87$ 135.15$ 135.15$ 135.15$ 120.84$ 135.15$ 120.84$ 103.35$ 147.87
32073590TIBIA-FIBULA/2V320Radiology32073590$ 220.00$ 143.00$ 143.00$ 204.60$ 187.00$ 187.00$ 187.00$ 167.20$ 187.00$ 167.20$ 143.00$ 204.60
32073592TIBIA/FIBULA/INFANT320Radiology32073592$ 130.00$ 84.50$ 84.50$ 120.90$ 110.50$ 110.50$ 110.50$ 98.80$ 110.50$ 98.80$ 84.50$ 120.90
32073600ANKLE 2 VIEWS320Radiology32073600$ 186.00$ 120.90$ 120.90$ 172.98$ 158.10$ 158.10$ 158.10$ 141.36$ 158.10$ 141.36$ 120.90$ 172.98
32073610ANKLE COMP./M3V320Radiology32073610$ 226.00$ 146.90$ 146.90$ 210.18$ 192.10$ 192.10$ 192.10$ 171.76$ 192.10$ 171.76$ 146.90$ 210.18
32073620FOOT 2 VIEWS320Radiology32073620$ 191.00$ 124.15$ 124.15$ 177.63$ 162.35$ 162.35$ 162.35$ 145.16$ 162.35$ 145.16$ 124.15$ 177.63
32073630FOOT COMP /M3V320Radiology32073630$ 220.00$ 143.00$ 143.00$ 204.60$ 187.00$ 187.00$ 187.00$ 167.20$ 187.00$ 167.20$ 143.00$ 204.60
32073650CALCANEUS(HEEL)M2V320Radiology32073650$ 161.00$ 104.65$ 104.65$ 149.73$ 136.85$ 136.85$ 136.85$ 122.36$ 136.85$ 122.36$ 104.65$ 149.73
32073660TOE/TOES M2V320Radiology32073660$ 167.00$ 108.55$ 108.55$ 155.31$ 141.95$ 141.95$ 141.95$ 126.92$ 141.95$ 126.92$ 108.55$ 155.31
35073700CT-LOWER EXTREMITY W/O CONT320Radiology35073700$ 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
35073701CT-LOWER EXTREMITY WITH CONT320Radiology35073701$ 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
35073702CT-LOWER EXTREMITY W/WO CONT320Radiology35073702$ 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
32074000ABDOMEN 1V (KUB)320Radiology32074018$ 176.00$ 114.40$ 114.40$ 163.68$ 149.60$ 149.60$ 149.60$ 133.76$ 149.60$ 133.76$ 114.40$ 163.68
32074010ABDOMEN/2 VIEWS320Radiology32074019$ 192.00$ 124.80$ 124.80$ 178.56$ 163.20$ 163.20$ 163.20$ 145.92$ 163.20$ 145.92$ 124.80$ 178.56
32074020ABDOMEN COMPLETE320Radiology32074021$ 222.00$ 144.30$ 144.30$ 206.46$ 188.70$ 188.70$ 188.70$ 168.72$ 188.70$ 168.72$ 144.30$ 206.46
35074150CT-ABDOMEN W/O CONTRAST320Radiology35074150$ 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
35074160CT-ABDOMEN WITH CONTRAST320Radiology35074160$ 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
35074170CT-ABDOMEN W/WO CONTRAST320Radiology35074170$ 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
35074176CT ABDOMEN & PELVIS320Radiology35074176$ 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
35074177CT ABDOMEN & PELVIS W/CONTRAST320Radiology35074177$ 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
35074178CT ABDOMEN & PELV W&W/O CNTRST320Radiology35074178$ 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
32076010BABY GRAM SINGLE VIEW320Radiology32076010$ 203.00$ 131.95$ 131.95$ 188.79$ 172.55$ 172.55$ 172.55$ 154.28$ 172.55$ 154.28$ 131.95$ 188.79
32076020BONE AGE STUDY320Radiology32077072$ 142.00$ 92.30$ 92.30$ 132.06$ 120.70$ 120.70$ 120.70$ 107.92$ 120.70$ 107.92$ 92.30$ 132.06
32077080DEXASCAN 1/MORE SITES AXIAL SK320Radiology32077080$ 180.00$ 117.00$ 117.00$ 167.40$ 153.00$ 153.00$ 153.00$ 136.80$ 153.00$ 136.80$ 117.00$ 167.40
32093041RHYTHM ECG320Radiology32093041$ 101.00$ 65.65$ 65.65$ 93.93$ 85.85$ 85.85$ 85.85$ 76.76$ 85.85$ 76.76$ 65.65$ 93.93
52181002DIPSTICK UA521Rural Health Clinic52181002$ 20.00$ 15.00$ 2.26$ 2.33$ 2.51$ 2.78$ 2.78$ 2.26$ 2.26$ 2.26$ 2.26$ 2.78
52185610PROTIME (PT)521Rural Health Clinic52185610$ 40.00$ 30.00$ 2.84$ 2.93$ 3.15$ 3.50$ 3.50$ 2.84$ 2.84$ 2.84$ 2.84$ 3.50
52199203DETAILED EXAM NEW PATIENT521Rural Health Clinic52199203$ 180.00$ 135.00$ 60.86$ 111.02$ 113.22$ 113.70$ 111.02$ 105.07$ 105.07$ 105.07$ 60.86$ 113.70
52199204COMPREHENSIVE EXAM NEW PATIENT521Rural Health Clinic52199204$ 245.00$ 183.75$ 103.20$ 168.53$ 171.87$ 172.61$ 168.53$ 160.85$ 160.85$ 160.85$ 103.20$ 172.61
52199205HIGH COMPLEX EXAM NEW PATIENT521Rural Health Clinic52199205$ 305.00$ 228.75$ 134.68$ 211.85$ 216.04$ 216.97$ 211.85$ 203.40$ 203.40$ 203.40$ 134.68$ 216.97
52199385PREV EXAM 18-39YRS NEW PT521Rural Health Clinic52199385$ 228.00$ 171.00$ 79.56$ 135.41$ 138.09$ 138.68$ 135.41$ 79.56$ 79.56$ 79.56$ 79.56$ 138.68
52199386PREVENTATIVE 40-64YRS521Rural Health Clinic52199386$ 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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