Hospital Charges / Price Transparency

OVERVIEW

In compliance with the Centers for Medicare and Medicaid Services (CMS), Collingsworth General Hospital is making available to the public a copy of its standard charges known as a “Charge Master,” “Charge Description Master” or “CDM”.

Since payment rates for hospital care provided to insured patients are either negotiated with health plans, set by the federal government for Medicare, or set by state governments for Medicaid enrollees, the payments hospitals receive for patient care do not necessarily reflect the prices reflected in the Charge Master. A patient’s responsibility may vary depending on the payment plans negotiated with insurance companies as well as the patient’s individual and/or family deductibles and co-payments with their insurance plan. Additionally, uninsured patients are not generally expected to pay the hospital’s standard charges as reflected in the CDM and may be eligible for financial assistance.

The information provided is based on information we have gathered from contracts with managed care commercial insurance plans. This is not a guarantee of what you will be charged. Your actual charges may differ from the estimated charges for many reasons, including the seriousness of your medical condition, actual time the procedure takes and the services and supplies that you receive.

The charges listed here are for services from the Hospital. They do not reflect the charges for physicians (such as surgeon, anesthesiologist, radiologist, pathologist, etc.) who may be involved in providing particular services to a patient. These charges are billed separately from the individual physician/physicians group.

Collingsworth General Hospital shall not be liable for any difference between charges listed in the price lists and the final bill for services.

AVAILABLE FILES
There are two files regarding the hospital’s CDM for price transparency.

The CSV file is a comprehensive, machine-readable file that makes public all standard charge information for all hospital items and services. This can easily be imported into Microsoft Excel or similar software. This file contains the following information:

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

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

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

QUESTIONS?

If you have further questions about the Collingsworth General Hospital CDM, please contact our hospital business office at (806) 447-2521 or come by and speak to one of our business office representatives. Thank you for choosing Collingsworth General Hospital for your health care needs!

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Searchable Shoppable Services

Collingsworth General Hospital Shoppable Services as of 7/21/2023

Charge Code	Charge Code Description	Dept #	Dept	RevCode	CPT Code	Current Price	Cash Price	Aetna	BCBS - Blue Adv	BCBS - HMO	BCBS - PPO	BCBS - Traditional	CIGNA	FirstCare - HMO	FirstCare - PPO	HealthSource	Humana	United	Minimum Negotiated Rate	Maximum Negotiated Rate
45036430	TRANSFUSION	380	Blood/Blood Products	391	36430	$ 900.00	$ 630.00	$ 765.00	$ -	$ -	$ -	$ -	$ 702.00	$ 63.33	$ 60.78	$ 675.00	$ 783.00	$ 648.90	$ -	$ 783.00
10006	EKG-Tracing only (with at least 12 leads	730	EKG/ECG	730	93005	$ 280.00	$ 196.00	$ 238.00	$ 242.04	$ 253.05	$ 275.05	$ 275.05	$ 218.40	$ 28.29	$ 31.65	$ 210.00	$ 243.60	$ 201.88	$ 28.29	$ 275.05
10009	HOLTER MONITOR 24-48 HOUR	730	EKG/ECG	731	93225	$ 520.00	$ 364.00	$ 442.00	$ 479.73	$ 501.54	$ 520.00	$ 520.00	$ 405.60	$ 76.00	$ 88.02	$ 390.00	$ 452.40	$ 374.92	$ 76.00	$ 520.00
8333	BASIC METABOLIC PANEL	300	Laboratory	301	80048	$ 60.00	$ 42.00	$ 51.00	$ 49.91	$ 52.11	$ 56.68	$ 56.68	$ 46.80	$ -	$ 21.06	$ 45.00	$ 52.20	$ 43.26	$ -	$ 56.68
8747	GENERAL HEALTH PANEL	300	Laboratory	310	80050	$ 240.00	$ 168.00	$ 204.00	$ 208.39	$ 217.57	$ 236.64	$ 236.64	$ 187.20	$ 48.56	$ -	$ 180.00	$ 208.80	$ 173.04	$ -	$ 236.64
8120	COMPREHENSIVE METABOLIC PANEL	300	Laboratory	301	80053	$ 125.00	$ 87.50	$ 106.25	$ 62.30	$ 65.05	$ 70.75	$ 70.75	$ 97.50	$ 10.34	$ 26.30	$ 93.75	$ 108.75	$ 90.13	$ 10.34	$ 108.75
8181	LIPID PANEL	300	Laboratory	301	80061	$ 91.00	$ 63.70	$ 77.35	$ 79.00	$ 82.48	$ 89.71	$ 89.71	$ 70.98	$ 13.10	$ 33.32	$ 68.25	$ 79.17	$ 65.61	$ 13.10	$ 89.71
8392	RENAL FUNCTION PANEL	300	Laboratory	301	80069	$ 78.00	$ 54.60	$ 66.30	$ 51.21	$ 53.47	$ 58.16	$ 58.16	$ 60.84	$ -	$ 21.60	$ 58.50	$ 67.86	$ 56.24	$ -	$ 67.86
8192	HEPATITIS PANEL	300	Laboratory	301	80074	$ 325.00	$ 227.50	$ 276.25	$ 281.02	$ 293.40	$ 319.12	$ 319.12	$ 253.50	$ -	$ 118.48	$ 243.75	$ 282.75	$ 234.33	$ -	$ 319.12
8125	HEPATIC FUNCTION PANEL	300	Laboratory	301	80076	$ 55.00	$ 38.50	$ 46.75	$ 48.20	$ 50.33	$ 54.74	$ 54.74	$ 42.90	$ -	$ 20.32	$ 41.25	$ 47.85	$ 39.66	$ -	$ 54.74
8070	CARBAMAZEPINE (TEGRETOL)	300	Laboratory	301	80156	$ 111.00	$ 77.70	$ 94.35	$ 85.96	$ 89.75	$ 97.62	$ 97.62	$ 86.58	$ -	$ 36.22	$ 83.25	$ 96.57	$ 80.03	$ -	$ 97.62
8034	DIGOXIN	300	Laboratory	301	80162	$ 170.00	$ 119.00	$ 144.50	$ 78.35	$ 81.80	$ 88.98	$ 88.98	$ 132.60	$ -	$ 33.03	$ 127.50	$ 147.90	$ 122.57	$ -	$ 147.90
8051	VALPROIC ACID (DEPAKENE)	300	Laboratory	301	80164	$ 131.00	$ 91.70	$ 111.35	$ 79.89	$ 83.41	$ 90.72	$ 90.72	$ 102.18	$ -	$ 33.70	$ 98.25	$ 113.97	$ 94.45	$ -	$ 113.97
8108	LITHIUM	300	Laboratory	301	80178	$ 54.00	$ 37.80	$ 45.90	$ 39.00	$ 40.72	$ 44.29	$ 44.29	$ 42.12	$ -	$ 16.43	$ 40.50	$ 46.98	$ 38.93	$ -	$ 46.98
8035	DILANTIN, PHENTOIN TOTAL	300	Laboratory	301	80185	$ 135.00	$ 94.50	$ 114.75	$ 78.18	$ 81.62	$ 88.78	$ 88.78	$ 105.30	$ -	$ 32.98	$ 101.25	$ 117.45	$ 97.34	$ -	$ 117.45
8225	VANCOMYCIN	300	Laboratory	301	80202	$ 131.00	$ 91.70	$ 111.35	$ 79.89	$ 83.41	$ 90.72	$ 90.72	$ 102.18	$ -	$ 33.70	$ 98.25	$ 113.97	$ 94.45	$ -	$ 113.97
8529	KEPPRA LEVEL	300	Laboratory	301	80299	$ 110.00	$ 77.00	$ 93.50	$ 109.98	$ 110.00	$ 110.00	$ 110.00	$ 85.80	$ -	$ 34.06	$ 82.50	$ 95.70	$ 79.31	$ -	$ 110.00
8798	AMDN	300	Laboratory	300	80299	$ 140.00	$ 98.00	$ 119.00	$ 109.98	$ 114.82	$ 124.89	$ 124.89	$ 109.20	$ -	$ 34.06	$ 105.00	$ 121.80	$ 100.94	$ -	$ 124.89
8634	Drug screen; comprehensive	300	Laboratory	301	80306	$ 115.00	$ 80.50	$ 97.75	$ 101.13	$ 105.58	$ 114.84	$ 114.84	$ 89.70	$ -	$ -	$ 86.25	$ 100.05	$ 82.92	$ -	$ 114.84
8634	TRIAGE UA DRUG SCREEN 9 PANEL	300	Laboratory	301	80306	$ 115.00	$ 80.50	$ 97.75	$ 101.13	$ 105.58	$ 114.84	$ 114.84	$ 89.70	$ -	$ -	$ 86.25	$ 100.05	$ 82.92	$ -	$ 114.84
8176	ALCOHOL (ETOH)	300	Laboratory	301	80320	$ 78.00	$ 54.60	$ 66.30	$ -	$ -	$ -	$ -	$ 60.84	$ -	$ -	$ 58.50	$ 67.86	$ 56.24	$ -	$ 67.86
8739	AMP/MAMP CONFIRMATION	300	Laboratory	301	80324	$ 133.00	$ 93.10	$ 113.05	$ -	$ -	$ -	$ -	$ 103.74	$ -	$ -	$ 99.75	$ 115.71	$ 95.89	$ -	$ 115.71
8193	ACETAMINOPHEN SERUM	300	Laboratory	301	80329	$ 232.00	$ 162.40	$ 197.20	$ -	$ -	$ -	$ -	$ 180.96	$ -	$ -	$ 174.00	$ 201.84	$ 167.27	$ -	$ 201.84
8065	SALICYLATES ANY SOURCE	300	Laboratory	301	80329	$ 232.00	$ 162.40	$ 197.20	$ -	$ -	$ -	$ -	$ 180.96	$ -	$ -	$ 174.00	$ 201.84	$ 167.27	$ -	$ 201.84
8077	URINALYSIS BY DIPSTICK	300	Laboratory	307	81000	$ 30.00	$ 21.00	$ 25.50	$ 23.72	$ 24.76	$ 26.93	$ 26.93	$ 23.40	$ 3.10	$ 7.87	$ 22.50	$ 26.10	$ 21.63	$ 3.10	$ 26.93
8806	Urinalysis, complete	300	Laboratory	300	81001	$ 80.00	$ 56.00	$ 68.00	$ 18.70	$ 19.53	$ 21.24	$ 21.24	$ 62.40	$ 3.10	$ 7.87	$ 60.00	$ 69.60	$ 57.68	$ 3.10	$ 69.60
8078	HCG URINE	300	Laboratory	307	81025	$ 45.00	$ 31.50	$ 38.25	$ 45.00	$ 45.00	$ 45.00	$ 45.00	$ 35.10	$ 6.19	$ 15.73	$ 33.75	$ 39.15	$ 32.45	$ 6.19	$ 45.00
8170	ALPHA FETOPROTEIN (TUMOR)	300	Laboratory	301	82105	$ 120.00	$ 84.00	$ 102.00	$ 98.94	$ 103.30	$ 112.36	$ 112.36	$ 93.60	$ -	$ 41.72	$ 90.00	$ 104.40	$ 86.52	$ -	$ 112.36
8082	AMMONIA	300	Laboratory	301	82140	$ 110.00	$ 77.00	$ 93.50	$ 85.96	$ 89.75	$ 97.62	$ 97.62	$ 85.80	$ -	$ 36.25	$ 82.50	$ 95.70	$ 79.31	$ -	$ 97.62
8003	AMYLASE	300	Laboratory	301	82150	$ 90.00	$ 63.00	$ 76.50	$ 38.23	$ 39.92	$ 43.42	$ 43.42	$ 70.20	$ -	$ 16.13	$ 67.50	$ 78.30	$ 64.89	$ -	$ 78.30
8048	OCCULT BLOOD, FECES (1-3)	300	Laboratory	301	82272	$ 45.00	$ 31.50	$ 38.25	$ 24.96	$ 26.06	$ 28.34	$ 28.34	$ 35.10	$ -	$ 5.90	$ 33.75	$ 39.15	$ 32.45	$ -	$ 39.15
8718	BLOOD OCCULT	300	Laboratory	300	82272	$ 45.00	$ 31.50	$ 38.25	$ 24.96	$ 26.06	$ 28.34	$ 28.34	$ 35.10	$ -	$ 5.90	$ 33.75	$ 39.15	$ 32.45	$ -	$ 39.15
8253	CALCIFEDIOL 25-OH VITAMIN D-3	300	Laboratory	301	82306	$ 200.00	$ 140.00	$ 170.00	$ 174.64	$ 182.34	$ 198.32	$ 198.32	$ 156.00	$ -	$ 67.59	$ 150.00	$ 174.00	$ 144.20	$ -	$ 198.32
8817	Vitamin D 3 level	300	Laboratory	300	82306	$ 225.00	$ 157.50	$ 191.25	$ 174.64	$ 182.34	$ 198.32	$ 198.32	$ 175.50	$ -	$ 67.59	$ 168.75	$ 195.75	$ 162.23	$ -	$ 198.32
8365	CALCIUM, IONIZED	300	Laboratory	301	82330	$ 95.00	$ 66.50	$ 80.75	$ 80.71	$ 84.27	$ 91.66	$ 91.66	$ 74.10	$ -	$ 33.98	$ 71.25	$ 82.65	$ 68.50	$ -	$ 91.66
8014	CEA LEVEL	300	Laboratory	301	82378	$ 131.00	$ 91.70	$ 111.35	$ 111.86	$ 116.79	$ 127.03	$ 127.03	$ 102.18	$ -	$ 47.20	$ 98.25	$ 113.97	$ 94.45	$ -	$ 127.03
8713	CERULOPLASMIN	300	Laboratory	301	82390	$ 72.00	$ 50.40	$ 61.20	$ 63.37	$ 66.16	$ 71.96	$ 71.96	$ 56.16	$ -	$ 26.71	$ 54.00	$ 62.64	$ 51.91	$ -	$ 71.96
8728	COPPER	300	Laboratory	310	82525	$ 85.00	$ 59.50	$ 72.25	$ 73.22	$ 76.45	$ 83.15	$ 83.15	$ 66.30	$ -	$ 30.87	$ 63.75	$ 73.95	$ 61.29	$ -	$ 83.15
8142	CORTISOL, SERUM	300	Laboratory	301	82533	$ 110.00	$ 77.00	$ 93.50	$ 96.17	$ 100.41	$ 109.21	$ 109.21	$ 85.80	$ -	$ 40.55	$ 82.50	$ 95.70	$ 79.31	$ -	$ 109.21
8489	24 URINE CREATINE	300	Laboratory	301	82540	$ 35.00	$ 24.50	$ 29.75	$ 27.38	$ 28.58	$ 31.09	$ 31.09	$ 27.30	$ -	$ 11.52	$ 26.25	$ 30.45	$ 25.24	$ -	$ 31.09
8022	CPK;TOTAL	300	Laboratory	301	82550	$ 45.00	$ 31.50	$ 38.25	$ 38.41	$ 40.10	$ 43.62	$ 43.62	$ 35.10	$ -	$ 16.22	$ 33.75	$ 39.15	$ 32.45	$ -	$ 43.62
8177	MB FRACTION ONLY	300	Laboratory	301	82553	$ 146.00	$ 102.20	$ 124.10	$ 68.15	$ 71.15	$ 77.39	$ 77.39	$ 113.88	$ -	$ 15.30	$ 109.50	$ 127.02	$ 105.27	$ -	$ 127.02
8023	CREATININE;BLOOD	300	Laboratory	301	82565	$ 43.00	$ 30.10	$ 36.55	$ 30.21	$ 31.54	$ 34.30	$ 34.30	$ 33.54	$ -	$ 12.73	$ 32.25	$ 37.41	$ 31.00	$ -	$ 37.41
8773	Urine Creatinine Reference	300	Laboratory	301	82570	$ 59.00	$ 41.30	$ 50.15	$ 30.56	$ 31.91	$ 34.71	$ 34.71	$ 46.02	$ -	$ 12.87	$ 44.25	$ 51.33	$ 42.54	$ -	$ 51.33
8773	Urine Creatinine Ref	300	Laboratory	301	82570	$ 59.00	$ 41.30	$ 50.15	$ 30.56	$ 31.91	$ 34.71	$ 34.71	$ 46.02	$ -	$ 12.87	$ 44.25	$ 51.33	$ 42.54	$ -	$ 51.33
8261	URINE CREATININE (24HR)	300	Laboratory	301	82570	$ 85.00	$ 59.50	$ 72.25	$ 30.56	$ 31.91	$ 34.71	$ 34.71	$ 66.30	$ -	$ 12.87	$ 63.75	$ 73.95	$ 61.29	$ -	$ 73.95
8115	CYANOCOBALAMIN (VITAMIN B-12)	300	Laboratory	301	82607	$ 105.00	$ 73.50	$ 89.25	$ 88.97	$ 92.89	$ 101.04	$ 101.04	$ 81.90	$ -	$ 37.49	$ 78.75	$ 91.35	$ 75.71	$ -	$ 101.04
8098	ESTRADIOL	300	Laboratory	301	82670	$ 192.00	$ 134.40	$ 163.20	$ 164.85	$ 172.11	$ 187.20	$ 187.20	$ 149.76	$ -	$ 69.52	$ 144.00	$ 167.04	$ 138.43	$ -	$ 187.20
8451	ESTROGEN TOTAL	300	Laboratory	301	82672	$ 150.00	$ 105.00	$ 127.50	$ 128.03	$ 133.67	$ 145.39	$ 145.39	$ 117.00	$ -	$ 21.76	$ 112.50	$ 130.50	$ 108.15	$ -	$ 145.39
8135	FERRITIN	300	Laboratory	301	82728	$ 117.00	$ 81.90	$ 99.45	$ 80.42	$ 83.96	$ 91.32	$ 91.32	$ 91.26	$ -	$ 33.89	$ 87.75	$ 101.79	$ 84.36	$ -	$ 101.79
8101	FOLIC ACID SERUM	300	Laboratory	301	82746	$ 122.00	$ 85.40	$ 103.70	$ 86.73	$ 90.55	$ 98.49	$ 98.49	$ 95.16	$ -	$ 36.58	$ 91.50	$ 106.14	$ 87.96	$ -	$ 106.14
8130	IGA QUAN SERUM OR CSF	300	Laboratory	301	82784	$ 77.00	$ 53.90	$ 65.45	$ 54.87	$ 57.29	$ 62.31	$ 62.31	$ 60.06	$ -	$ 23.13	$ 57.75	$ 66.99	$ 55.52	$ -	$ 66.99
8131	IGG QUAN SERUM OR CSF	300	Laboratory	301	82784	$ 77.00	$ 53.90	$ 65.45	$ 54.87	$ 57.29	$ 62.31	$ 62.31	$ 60.06	$ -	$ 23.13	$ 57.75	$ 66.99	$ 55.52	$ -	$ 66.99
8822	IFE Immunofixation, Serum	300	Laboratory	300	82784	$ 77.00	$ 53.90	$ 65.45	$ 54.87	$ 57.29	$ 62.31	$ 62.31	$ 60.06	$ -	$ 23.13	$ 57.75	$ 66.99	$ 55.52	$ -	$ 66.99
8122	GASES,ARTERIAL BLOOD	300	Laboratory	301	82803	$ 176.00	$ 123.20	$ 149.60	$ 153.81	$ 160.59	$ 174.67	$ 174.67	$ 137.28	$ -	$ 48.13	$ 132.00	$ 153.12	$ 126.90	$ -	$ 174.67
8037	GLUCOSE ALL BODY FLUIDS	300	Laboratory	301	82947	$ 63.00	$ 44.10	$ 53.55	$ 23.19	$ 24.21	$ 26.33	$ 26.33	$ 49.14	$ -	$ 9.76	$ 47.25	$ 54.81	$ 45.42	$ -	$ 54.81
8038	GLUCOSE TOLERANCE 3 SPECS	300	Laboratory	301	82951	$ 143.00	$ 100.10	$ 121.55	$ 75.93	$ 79.28	$ 86.23	$ 86.23	$ 111.54	$ -	$ 32.04	$ 107.25	$ 124.41	$ 103.10	$ -	$ 124.41
8038B	GTT EACH ADD'L SPEC > 3	300	Laboratory	301	82952	$ 63.00	$ 44.10	$ 53.55	$ 23.13	$ 24.15	$ 26.26	$ 26.26	$ 49.14	$ -	$ 9.76	$ 47.25	$ 54.81	$ 45.42	$ -	$ 54.81
8180	GGT	300	Laboratory	301	82977	$ 63.00	$ 44.10	$ 53.55	$ 42.48	$ 44.35	$ 48.24	$ 48.24	$ 49.14	$ 8.05	$ 17.91	$ 47.25	$ 54.81	$ 45.42	$ 8.05	$ 54.81
8231	FSH SERUM	300	Laboratory	301	83001	$ 139.00	$ 97.30	$ 118.15	$ 109.62	$ 114.45	$ 124.49	$ 124.49	$ 108.42	$ -	$ 46.24	$ 104.25	$ 120.93	$ 100.22	$ -	$ 124.49
8232	LH	300	Laboratory	301	83002	$ 141.00	$ 98.70	$ 119.85	$ 109.27	$ 114.08	$ 124.08	$ 124.08	$ 109.98	$ -	$ 46.08	$ 105.75	$ 122.67	$ 101.66	$ -	$ 124.08
8161	GLYCOSYLATED HGB (HGBA1C)	300	Laboratory	301	83036	$ 70.00	$ 49.00	$ 59.50	$ 57.29	$ 59.81	$ 65.06	$ 65.06	$ 54.60	$ 13.42	$ 24.16	$ 52.50	$ 60.90	$ 50.47	$ 13.42	$ 65.06
8167	5-HIAA 24 HOUR	300	Laboratory	301	83497	$ 250.00	$ 175.00	$ 212.50	$ 76.11	$ 79.46	$ 86.43	$ 86.43	$ 195.00	$ -	$ 11.57	$ 187.50	$ 217.50	$ 180.25	$ -	$ 217.50
8689	GLIADIN AB IGG	300	Laboratory	301	83516	$ 70.00	$ 49.00	$ 59.50	$ 60.00	$ 60.00	$ 60.00	$ 60.00	$ 54.60	$ -	$ 28.71	$ 52.50	$ 60.90	$ 50.47	$ -	$ 60.90
8197	INSULIN LEVELS	300	Laboratory	301	83525	$ 103.00	$ 72.10	$ 87.55	$ 67.44	$ 70.41	$ 76.58	$ 76.58	$ 80.34	$ -	$ 28.46	$ 77.25	$ 89.61	$ 74.26	$ -	$ 89.61
8102	IRON	300	Laboratory	301	83540	$ 55.00	$ 38.50	$ 46.75	$ 38.17	$ 39.86	$ 43.35	$ 43.35	$ 42.90	$ -	$ 16.11	$ 41.25	$ 47.85	$ 39.66	$ -	$ 47.85
8103	IRON BINDING CAPACITY	300	Laboratory	301	83550	$ 79.00	$ 55.30	$ 67.15	$ 51.57	$ 53.84	$ 58.56	$ 58.56	$ 61.62	$ -	$ 21.74	$ 59.25	$ 68.73	$ 56.96	$ -	$ 68.73
8387	LACTATE LEVELS	300	Laboratory	301	83605	$ 80.00	$ 56.00	$ 68.00	$ 68.26	$ 71.27	$ 77.52	$ 77.52	$ 62.40	$ -	$ 26.57	$ 60.00	$ 69.60	$ 57.68	$ -	$ 77.52
8044	LDH	300	Laboratory	301	83615	$ 43.00	$ 30.10	$ 36.55	$ 35.64	$ 37.21	$ 40.47	$ 40.47	$ 33.54	$ -	$ 15.03	$ 32.25	$ 37.41	$ 31.00	$ -	$ 40.47
8173	LIPASE	300	Laboratory	301	83690	$ 50.00	$ 35.00	$ 42.50	$ 40.65	$ 42.44	$ 46.16	$ 46.16	$ 39.00	$ -	$ 17.14	$ 37.50	$ 43.50	$ 36.05	$ -	$ 46.16
Charge Code	Charge Code Description	Dept #	Dept	RevCode	CPT Code	Current Price	Cash Price	Aetna	BCBS - Blue Adv	BCBS - HMO	BCBS - PPO	BCBS - Traditional	CIGNA	FirstCare - HMO	FirstCare - PPO	HealthSource	Humana	United	Minimum Negotiated Rate	Maximum Negotiated Rate
8045	MAGNESIUM (MG)	300	Laboratory	301	83735	$ 50.00	$ 35.00	$ 42.50	$ 39.53	$ 41.27	$ 44.89	$ 44.89	$ 39.00	$ -	$ 16.67	$ 37.50	$ 43.50	$ 36.05	$ -	$ 44.89
8813	NTBNP2	300	Laboratory	300	83880	$ 245.00	$ 171.50	$ 208.25	$ 231.63	$ 241.84	$ 245.00	$ 245.00	$ 191.10	$ -	$ 61.66	$ 183.75	$ 213.15	$ 176.65	$ -	$ 245.00
8424	B-TYPE NATRIURETIC PEPTID	300	Laboratory	301	83880	$ 265.00	$ 185.50	$ 225.25	$ 231.63	$ 241.84	$ 263.04	$ 263.04	$ 206.70	$ -	$ 61.66	$ 198.75	$ 230.55	$ 191.07	$ -	$ 263.04
8202	URINE OSMOLALITY	300	Laboratory	301	83935	$ 115.00	$ 80.50	$ 97.75	$ 40.24	$ 42.01	$ 45.69	$ 45.69	$ 89.70	$ -	$ 12.26	$ 86.25	$ 100.05	$ 82.92	$ -	$ 100.05
8347	PTH INTACT	300	Laboratory	301	83970	$ 306.00	$ 214.20	$ 260.10	$ 243.55	$ 254.28	$ 276.58	$ 276.58	$ 238.68	$ -	$ 102.67	$ 229.50	$ 266.22	$ 220.63	$ -	$ 276.58
8055	PHOSPHORUS INORGANIC(P04)	300	Laboratory	301	84100	$ 43.00	$ 30.10	$ 36.55	$ 27.97	$ 29.20	$ 31.76	$ 31.76	$ 33.54	$ -	$ 11.81	$ 32.25	$ 37.41	$ 31.00	$ -	$ 37.41
8058	POTASSIUM (K) SERUM	300	Laboratory	301	84132	$ 43.00	$ 30.10	$ 36.55	$ 28.08	$ 29.32	$ 31.89	$ 31.89	$ 33.54	$ -	$ 11.43	$ 32.25	$ 37.41	$ 31.00	$ -	$ 37.41
8337	URINE POTASSIUM	300	Laboratory	301	84133	$ 33.00	$ 23.10	$ 28.05	$ 27.91	$ 29.14	$ 31.69	$ 31.69	$ 25.74	$ -	$ 10.69	$ 24.75	$ 28.71	$ 23.79	$ -	$ 31.69
8234	PROGESTERONE	300	Laboratory	301	84144	$ 140.00	$ 98.00	$ 119.00	$ 123.07	$ 128.50	$ 139.76	$ 139.76	$ 109.20	$ -	$ 51.89	$ 105.00	$ 121.80	$ 100.94	$ -	$ 139.76
8749	PROCALCITONIN (PCT)	300	Laboratory	301	84145	$ 200.00	$ 140.00	$ 170.00	$ 160.60	$ 167.68	$ 182.37	$ 182.37	$ 156.00	$ -	$ -	$ 150.00	$ 174.00	$ 144.20	$ -	$ 182.37
8235	PROLACTIN	300	Laboratory	301	84146	$ 130.00	$ 91.00	$ 110.50	$ 114.34	$ 119.38	$ 129.85	$ 129.85	$ 101.40	$ -	$ 48.20	$ 97.50	$ 113.10	$ 93.73	$ -	$ 129.85
8036	PSA TOTAL	300	Laboratory	301	84153	$ 125.00	$ 87.50	$ 106.25	$ 108.50	$ 113.28	$ 123.21	$ 123.21	$ 97.50	$ 20.56	$ 45.76	$ 93.75	$ 108.75	$ 90.13	$ 20.56	$ 123.21
8834	PSA Total Reflex to Free	300	Laboratory	300	84153	$ 125.00	$ 87.50	$ 106.25	$ 108.50	$ 113.28	$ 123.21	$ 123.21	$ 97.50	$ 20.56	$ 45.76	$ 93.75	$ 108.75	$ 90.13	$ 20.56	$ 123.21
8835	Reflex to free on PSA free and total	300	Laboratory	300	84154	$ 98.00	$ 68.60	$ 83.30	$ 98.00	$ 98.00	$ 98.00	$ 98.00	$ 76.44	$ -	$ 45.76	$ 73.50	$ 85.26	$ 70.66	$ -	$ 98.00
8216	URINE PROTEIN 24 HOUR	300	Laboratory	301	84156	$ 42.00	$ 29.40	$ 35.70	$ 21.65	$ 22.61	$ 24.59	$ 24.59	$ 32.76	$ -	$ 6.66	$ 31.50	$ 36.54	$ 30.28	$ -	$ 36.54
8787	Urine Total Protein	300	Laboratory	301	84156	$ 42.00	$ 29.40	$ 35.70	$ 21.65	$ 22.61	$ 24.59	$ 24.59	$ 32.76	$ -	$ 6.66	$ 31.50	$ 36.54	$ 30.28	$ -	$ 36.54
8338	URINE SODIUM	300	Laboratory	301	84300	$ 35.00	$ 24.50	$ 29.75	$ 29.85	$ 31.17	$ 33.90	$ 33.90	$ 27.30	$ -	$ 12.10	$ 26.25	$ 30.45	$ 25.24	$ -	$ 33.90
8449	TESTOSTERONE LEVEL FREE	300	Laboratory	301	84402	$ 210.00	$ 147.00	$ 178.50	$ 150.27	$ 156.90	$ 170.65	$ 170.65	$ 163.80	$ -	$ 63.34	$ 157.50	$ 182.70	$ 151.41	$ -	$ 182.70
8450	TESTOSTERONE LEVEL TOTAL	300	Laboratory	301	84403	$ 175.00	$ 122.50	$ 148.75	$ 152.28	$ 158.99	$ 172.93	$ 172.93	$ 136.50	$ -	$ 64.22	$ 131.25	$ 152.25	$ 126.18	$ -	$ 172.93
8648	THIAMINE (VITAMIN B-1)	300	Laboratory	301	84425	$ 140.00	$ 98.00	$ 119.00	$ 125.26	$ 130.78	$ 140.00	$ 140.00	$ 109.20	$ -	$ 16.90	$ 105.00	$ 121.80	$ 100.94	$ -	$ 140.00
8239	T4 (TOTAL)	300	Laboratory	301	84436	$ 50.00	$ 35.00	$ 42.50	$ 40.53	$ 42.32	$ 46.03	$ 46.03	$ 39.00	$ -	$ 17.10	$ 37.50	$ 43.50	$ 36.05	$ -	$ 46.03
8408	T4 FREE	300	Laboratory	301	84439	$ 96.00	$ 67.20	$ 81.60	$ 53.22	$ 55.56	$ 60.43	$ 60.43	$ 74.88	$ -	$ 22.43	$ 72.00	$ 83.52	$ 69.22	$ -	$ 83.52
8137	TSH	300	Laboratory	301	84443	$ 115.00	$ 80.50	$ 97.75	$ 99.12	$ 103.49	$ 112.56	$ 112.56	$ 89.70	$ 16.43	$ 41.78	$ 86.25	$ 100.05	$ 82.92	$ 16.43	$ 112.56
8682	TRANSFERRIN	300	Laboratory	301	84466	$ 76.00	$ 53.20	$ 64.60	$ 75.28	$ 76.00	$ 76.00	$ 76.00	$ 59.28	$ -	$ 22.90	$ 57.00	$ 66.12	$ 54.80	$ -	$ 76.00
8229	T3 (TOTAL)	300	Laboratory	301	84480	$ 101.00	$ 70.70	$ 85.85	$ 83.66	$ 87.35	$ 95.01	$ 95.01	$ 78.78	$ -	$ 35.28	$ 75.75	$ 87.87	$ 72.82	$ -	$ 95.01
8362	T3 (FREE)	300	Laboratory	301	84481	$ 185.00	$ 129.50	$ 157.25	$ 99.95	$ 104.35	$ 113.50	$ 113.50	$ 144.30	$ -	$ 42.14	$ 138.75	$ 160.95	$ 133.39	$ -	$ 160.95
8399	TROPONIN I, QUALITATIVE	300	Laboratory	301	84484	$ 85.00	$ 59.50	$ 72.25	$ 73.57	$ 76.82	$ 83.55	$ 83.55	$ 66.30	$ -	$ 24.48	$ 63.75	$ 73.95	$ 61.29	$ -	$ 83.55
8076	URIC ACID SERUM	300	Laboratory	301	84550	$ 63.00	$ 44.10	$ 53.55	$ 26.67	$ 27.84	$ 30.28	$ 30.28	$ 49.14	$ -	$ 11.25	$ 47.25	$ 54.81	$ 45.42	$ -	$ 54.81
8729	ZINC	300	Laboratory	301	84630	$ 80.00	$ 56.00	$ 68.00	$ 67.20	$ 70.16	$ 76.31	$ 76.31	$ 62.40	$ -	$ 28.33	$ 60.00	$ 69.60	$ 57.68	$ -	$ 76.31
8305	HCG QUANTATIVE	300	Laboratory	301	84702	$ 131.00	$ 91.70	$ 111.35	$ 88.80	$ 92.71	$ 100.84	$ 100.84	$ 102.18	$ -	$ 21.73	$ 98.25	$ 113.97	$ 94.45	$ -	$ 113.97
8509	HCG SERUM	300	Laboratory	301	84703	$ 55.00	$ 38.50	$ 46.75	$ 44.37	$ 46.32	$ 50.38	$ 50.38	$ 42.90	$ 7.34	$ 18.68	$ 41.25	$ 47.85	$ 39.66	$ 7.34	$ 50.38
8019	(CBC) MANUEL DIFFERENTIAL	300	Laboratory	305	85007	$ 36.00	$ 25.20	$ 30.60	$ 22.42	$ 23.41	$ 25.46	$ 25.46	$ 28.08	$ -	$ 8.57	$ 27.00	$ 31.32	$ 25.96	$ -	$ 31.32
8041	HEMATOCRIT (HCT)	300	Laboratory	305	85014	$ 45.00	$ 31.50	$ 38.25	$ 13.98	$ 14.60	$ 15.88	$ 15.88	$ 35.10	$ -	$ 5.89	$ 33.75	$ 39.15	$ 32.45	$ -	$ 39.15
8042	HEMOGLOBIN (HGB)	300	Laboratory	305	85018	$ 34.00	$ 23.80	$ 28.90	$ 13.98	$ 14.60	$ 15.88	$ 15.88	$ 26.52	$ -	$ 5.89	$ 25.50	$ 29.58	$ 24.51	$ -	$ 29.58
8018	CBC AUTO DIFF	300	Laboratory	305	85025	$ 55.00	$ 38.50	$ 46.75	$ 45.84	$ 47.86	$ 52.06	$ 52.06	$ 42.90	$ 7.60	$ 19.33	$ 41.25	$ 47.85	$ 39.66	$ 7.60	$ 52.06
80192	(CBC) AUTOMATED HEMOGRAM	300	Laboratory	305	85027	$ 45.00	$ 31.50	$ 38.25	$ 38.17	$ 39.86	$ 43.35	$ 43.35	$ 35.10	$ -	$ 16.11	$ 33.75	$ 39.15	$ 32.45	$ -	$ 43.35
8062	RETICULOCYTE COUNT	300	Laboratory	305	85044	$ 41.00	$ 28.70	$ 34.85	$ 25.43	$ 26.55	$ 28.88	$ 28.88	$ 31.98	$ -	$ 10.69	$ 30.75	$ 35.67	$ 29.56	$ -	$ 35.67
8416	PATHOLOGY CONSULT	300	Laboratory	305	85060	$ 150.00	$ 105.00	$ 127.50	$ 150.00	$ 150.00	$ 150.00	$ 150.00	$ 117.00	$ -	$ 40.46	$ 112.50	$ 130.50	$ 108.15	$ -	$ 150.00
8363	D-DIMER (FSP)	300	Laboratory	305	85378	$ 91.00	$ 63.70	$ 77.35	$ 57.35	$ 59.88	$ 65.12	$ 65.12	$ 70.98	$ -	$ 17.75	$ 68.25	$ 79.17	$ 65.61	$ -	$ 79.17
8701	PROTHROMBIN TIME	300	Laboratory	305	85610	$ 72.00	$ 50.40	$ 61.20	$ 25.31	$ 26.43	$ 28.74	$ 28.74	$ 56.16	$ -	$ 9.77	$ 54.00	$ 62.64	$ 51.91	$ -	$ 62.64
8066	SEDIMENTATION RATE (ESR)	300	Laboratory	305	85651	$ 37.00	$ 25.90	$ 31.45	$ 25.19	$ 26.30	$ 28.61	$ 28.61	$ 28.86	$ -	$ 8.84	$ 27.75	$ 32.19	$ 26.68	$ -	$ 32.19
8054	THROMBOPLASTIN TIME PTT	300	Laboratory	305	85730	$ 91.00	$ 63.70	$ 77.35	$ 35.46	$ 37.02	$ 40.27	$ 40.27	$ 70.98	$ -	$ 14.94	$ 68.25	$ 79.17	$ 65.61	$ -	$ 79.17
8004	ANA	300	Laboratory	302	86038	$ 85.00	$ 59.50	$ 72.25	$ 71.33	$ 74.47	$ 81.00	$ 81.00	$ 66.30	$ -	$ 30.06	$ 63.75	$ 73.95	$ 61.29	$ -	$ 81.00
8147	C-REACTIVE PROTEIN	300	Laboratory	302	86140	$ 62.00	$ 43.40	$ 52.70	$ 30.56	$ 31.91	$ 34.71	$ 34.71	$ 48.36	$ -	$ 12.87	$ 46.50	$ 53.94	$ 44.70	$ -	$ 53.94
8031	C-3,COMPLEMENT	300	Laboratory	302	86160	$ 103.00	$ 72.10	$ 87.55	$ 70.80	$ 73.92	$ 80.40	$ 80.40	$ 80.34	$ -	$ 29.86	$ 77.25	$ 89.61	$ 74.26	$ -	$ 89.61
8032	C-4 COMPLEMENT	300	Laboratory	302	86160	$ 103.00	$ 72.10	$ 87.55	$ 70.80	$ 73.92	$ 80.40	$ 80.40	$ 80.34	$ -	$ 29.86	$ 77.25	$ 89.61	$ 74.26	$ -	$ 89.61
8423	ANTI-MITRO CHONDRIAL ANTI	300	Laboratory	300	86255	$ 160.00	$ 112.00	$ 136.00	$ 71.10	$ 74.23	$ 80.74	$ 80.74	$ 124.80	$ -	$ 29.99	$ 120.00	$ 139.20	$ 115.36	$ -	$ 139.20
8224	EPSTEIN BARR VIRUS PANEL	300	Laboratory	302	86256	$ 272.00	$ 190.40	$ 231.20	$ 71.10	$ 74.23	$ 80.74	$ 80.74	$ 212.16	$ -	$ 29.99	$ 204.00	$ 236.64	$ 196.11	$ -	$ 236.64
8630	H.PYLORI (SCREENING)	300	Laboratory	302	86318	$ 110.00	$ 77.00	$ 93.50	$ 106.73	$ 110.00	$ 110.00	$ 110.00	$ 85.80	$ 12.66	$ 32.20	$ 82.50	$ 95.70	$ 79.31	$ 12.66	$ 110.00
8163	MICROSOMAL ANTIBODIES	300	Laboratory	300	86376	$ 133.00	$ 93.10	$ 113.05	$ 85.85	$ 89.63	$ 97.49	$ 97.49	$ 103.74	$ -	$ 36.20	$ 99.75	$ 115.71	$ 95.89	$ -	$ 115.71
8340	RHEUMATOID FACTOR QUANIT	300	Laboratory	302	86431	$ 42.00	$ 29.40	$ 35.70	$ 33.45	$ 34.93	$ 37.99	$ 37.99	$ 32.76	$ -	$ 14.13	$ 31.50	$ 36.54	$ 30.28	$ -	$ 37.99
8218	HIV AB ELISA	300	Laboratory	302	86701	$ 99.00	$ 69.30	$ 84.15	$ 52.45	$ 54.76	$ 59.56	$ 59.56	$ 77.22	$ -	$ 22.10	$ 74.25	$ 86.13	$ 71.38	$ -	$ 86.13
8351	HEPATITIS B SURFACE AB	300	Laboratory	302	86706	$ 75.00	$ 52.50	$ 63.75	$ 63.37	$ 66.16	$ 71.96	$ 71.96	$ 58.50	$ -	$ 26.71	$ 56.25	$ 65.25	$ 54.08	$ -	$ 71.96
8463	MUMPS (MMR TITER)	300	Laboratory	302	86735	$ 150.00	$ 105.00	$ 127.50	$ 77.00	$ 80.39	$ 87.44	$ 87.44	$ 117.00	$ -	$ 32.45	$ 112.50	$ 130.50	$ 108.15	$ -	$ 130.50
8064	RUBELLA AB.	300	Laboratory	302	86762	$ 100.00	$ 70.00	$ 85.00	$ 84.90	$ 88.64	$ 96.41	$ 96.41	$ 78.00	$ -	$ 35.80	$ 75.00	$ 87.00	$ 72.10	$ -	$ 96.41
8465	RUBELLA (MMR TITER)	300	Laboratory	302	86762	$ 100.00	$ 70.00	$ 85.00	$ 84.90	$ 88.64	$ 96.41	$ 96.41	$ 78.00	$ -	$ 35.80	$ 75.00	$ 87.00	$ 72.10	$ -	$ 96.41
8464	RUBEOLA (MMR TITER)	300	Laboratory	302	86765	$ 90.00	$ 63.00	$ 76.50	$ 75.99	$ 79.34	$ 86.30	$ 86.30	$ 70.20	$ -	$ 32.06	$ 67.50	$ 78.30	$ 64.89	$ -	$ 86.30
8811	Covid-19 Antibody IgG	300	Laboratory	300	86769	$ 200.00	$ 140.00	$ 170.00	$ 200.00	$ 200.00	$ 200.00	$ 200.00	$ 156.00	$ -	$ -	$ 150.00	$ 174.00	$ 144.20	$ -	$ 200.00
8810	Covid-19 Antibody Total	300	Laboratory	300	86769	$ 200.00	$ 140.00	$ 170.00	$ 200.00	$ 200.00	$ 200.00	$ 200.00	$ 156.00	$ -	$ -	$ 150.00	$ 174.00	$ 144.20	$ -	$ 200.00
8497	VZV AB IGG	300	Laboratory	302	86787	$ 125.00	$ 87.50	$ 106.25	$ 75.99	$ 79.34	$ 86.30	$ 86.30	$ 97.50	$ -	$ 20.36	$ 93.75	$ 108.75	$ 90.13	$ -	$ 108.75
8162	THYROGLOBULIN ANTIBODY	300	Laboratory	302	86800	$ 135.00	$ 94.50	$ 114.75	$ 93.87	$ 98.01	$ 106.60	$ 106.60	$ 105.30	$ -	$ 39.56	$ 101.25	$ 117.45	$ 97.34	$ -	$ 117.45
8011	ANTIBODY SCREEN;RBC	300	Laboratory	302	86850	$ 210.00	$ 147.00	$ 178.50	$ 210.00	$ 210.00	$ 210.00	$ 210.00	$ 163.80	$ -	$ -	$ 157.50	$ 182.70	$ 151.41	$ -	$ 210.00
8009	BLOOD TYPING (ABO)	300	Laboratory	390	86900	$ 250.00	$ 175.00	$ 212.50	$ 250.00	$ 250.00	$ 250.00	$ 250.00	$ 195.00	$ -	$ 7.42	$ 187.50	$ 217.50	$ 180.25	$ -	$ 250.00
8010	RH (D)	300	Laboratory	300	86901	$ 195.00	$ 136.50	$ 165.75	$ 195.00	$ 195.00	$ 195.00	$ 195.00	$ 152.10	$ -	$ 6.26	$ 146.25	$ 169.65	$ 140.60	$ -	$ 195.00
8021	COMPATIBILITY TEST; ANTIGLOBUL	300	Laboratory	390	86922	$ 975.00	$ 682.50	$ 828.75	$ 846.65	$ 883.96	$ 961.45	$ 961.45	$ 760.50	$ -	$ -	$ 731.25	$ 848.25	$ 702.98	$ -	$ 961.45
8017	CULTURE,BACTERIAL; BLOOD	300	Laboratory	306	87040	$ 75.00	$ 52.50	$ 63.75	$ 60.89	$ 63.57	$ 69.14	$ 69.14	$ 58.50	$ -	$ 25.69	$ 56.25	$ 65.25	$ 54.08	$ -	$ 69.14
8028	CULTURE BACTERIAL STOOL	300	Laboratory	306	87045	$ 65.00	$ 45.50	$ 55.25	$ 55.70	$ 58.15	$ 63.25	$ 63.25	$ 55.00	$ -	$ 23.47	$ 48.75	$ 56.55	$ 46.87	$ -	$ 63.25
8057	CULTURE THROAT OR NOSE	300	Laboratory	306	87070	$ 112.00	$ 78.40	$ 95.20	$ 50.86	$ 53.10	$ 57.75	$ 57.75	$ 87.36	$ 9.62	$ 21.42	$ 84.00	$ 97.44	$ 80.75	$ 9.62	$ 97.44
8025	CULTURE, ANY OTHER SOUCE	300	Laboratory	306	87070	$ 112.00	$ 78.40	$ 95.20	$ 50.86	$ 53.10	$ 57.75	$ 57.75	$ 87.36	$ 9.62	$ 21.42	$ 84.00	$ 97.44	$ 80.75	$ 9.62	$ 97.44
8184	ANAEROBIC CULTURE WOUND	300	Laboratory	306	87075	$ 150.00	$ 105.00	$ 127.50	$ 55.87	$ 58.34	$ 63.45	$ 63.45	$ 117.00	$ -	$ 23.54	$ 112.50	$ 130.50	$ 108.15	$ -	$ 130.50
Charge Code	Charge Code Description	Dept #	Dept	RevCode	CPT Code	Current Price	Cash Price	Aetna	BCBS - Blue Adv	BCBS - HMO	BCBS - PPO	BCBS - Traditional	CIGNA	FirstCare - HMO	FirstCare - PPO	HealthSource	Humana	United	Minimum Negotiated Rate	Maximum Negotiated Rate
8090	CULTURE, AEROBIC ISOLATE	300	Laboratory	306	87077	$ 55.00	$ 38.50	$ 46.75	$ 47.67	$ 49.77	$ 54.14	$ 54.14	$ 42.90	$ -	$ 20.09	$ 41.25	$ 47.85	$ 39.66	$ -	$ 54.14
8013	CULTURE URINE ROUTINE	300	Laboratory	306	87086	$ 55.00	$ 38.50	$ 46.75	$ 47.61	$ 49.71	$ 54.07	$ 54.07	$ 42.90	$ -	$ 20.09	$ 41.25	$ 47.85	$ 39.66	$ -	$ 54.07
8049	OVA & PARASITES, STOOL	300	Laboratory	306	87177	$ 85.00	$ 59.50	$ 72.25	$ 52.51	$ 54.82	$ 59.63	$ 59.63	$ 66.30	$ -	$ 21.76	$ 63.75	$ 73.95	$ 61.29	$ -	$ 73.95
8050	SENSITIVITY 13 DISK	300	Laboratory	306	87184	$ 55.00	$ 38.50	$ 46.75	$ 44.13	$ 46.08	$ 50.12	$ 50.12	$ 42.90	$ 7.70	$ 17.15	$ 41.25	$ 47.85	$ 39.66	$ 7.70	$ 50.12
8191	CLOSTRIDIUM DIFF TOXIN B	300	Laboratory	306	87230	$ 146.00	$ 102.20	$ 124.10	$ 116.47	$ 121.60	$ 132.26	$ 132.26	$ 113.88	$ -	$ 49.10	$ 109.50	$ 127.02	$ 105.27	$ -	$ 132.26
8809	Rapid Covid-19 antigen test	300	Laboratory	300	87426	$ 150.00	$ 105.00	$ 127.50	$ 100.00	$ 100.00	$ 100.00	$ 100.00	$ 117.00	$ -	$ -	$ 112.50	$ 130.50	$ 108.15	$ -	$ 130.50
8550	C DIFF AG	300	Laboratory	306	87449	$ 70.00	$ 49.00	$ 59.50	$ 70.00	$ 70.00	$ 70.00	$ 70.00	$ 54.60	$ -	$ 29.84	$ 52.50	$ 60.90	$ 50.47	$ -	$ 70.00
8525	HEPATITIS C VIRUS RNA	300	Laboratory	306	87522	$ 634.00	$ 443.80	$ 538.90	$ 252.76	$ 263.89	$ 287.03	$ 287.03	$ 494.52	$ -	$ 70.60	$ 475.50	$ 551.58	$ 457.11	$ -	$ 551.58
8800	COVID-19 REFERENCE LAB	300	Laboratory	300	87635	$ 250.00	$ 175.00	$ 212.50	$ 250.00	$ 250.00	$ 250.00	$ 250.00	$ 195.00	$ -	$ -	$ 187.50	$ 217.50	$ 180.25	$ -	$ 250.00
30087636	COVID PCR & FLU	300	Laboratory	300	87636	$ 200.00	$ 140.00	$ 170.00	$ 200.00	$ 200.00	$ 200.00	$ 200.00	$ 156.00	$ -	$ -	$ 150.00	$ 174.00	$ 144.20	$ -	$ 200.00
30087637	COVID PCR, FLU, RSV	300	Laboratory	300	87637	$ 200.00	$ 140.00	$ 170.00	$ 200.00	$ 200.00	$ 200.00	$ 200.00	$ 156.00	$ -	$ -	$ 150.00	$ 174.00	$ 144.20	$ -	$ 200.00
8447	CHLAMYDIA/GC PROBE-NON AM	300	Laboratory	306	87800	$ 300.00	$ 210.00	$ 255.00	$ 257.65	$ 269.01	$ 292.59	$ 292.59	$ 234.00	$ -	$ 84.05	$ 225.00	$ 261.00	$ 216.30	$ -	$ 292.59
8454	INFLUENZA A&B	300	Laboratory	306	87804	$ 114.00	$ 79.80	$ 96.90	$ 97.65	$ 101.95	$ 110.89	$ 110.89	$ 88.92	$ -	$ 29.84	$ 85.50	$ 99.18	$ 82.19	$ -	$ 110.89
80471	RSV RAPID ANTIGEN (INHOUSE)	300	Laboratory	306	87807	$ 131.00	$ 91.70	$ 111.35	$ 77.29	$ 80.70	$ 87.77	$ 87.77	$ 102.18	$ 11.73	$ 21.79	$ 98.25	$ 113.97	$ 94.45	$ 11.73	$ 113.97
8812	Rapid Covid-19 Test	300	Laboratory	300	87811	$ 150.00	$ 105.00	$ 127.50	$ 150.00	$ 150.00	$ 150.00	$ 150.00	$ 117.00	$ -	$ -	$ 112.50	$ 130.50	$ 108.15	$ -	$ 150.00
8397	RAPID STREP TEST	300	Laboratory	306	87880	$ 90.00	$ 63.00	$ 76.50	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 70.20	$ -	$ 29.84	$ 67.50	$ 78.30	$ 64.89	$ -	$ 90.00
8145	CELL CNT W/DIFF BODY FLUD	300	Laboratory	305	89051	$ 67.00	$ 46.90	$ 56.95	$ 33.04	$ 34.50	$ 37.52	$ 37.52	$ 52.26	$ -	$ 13.70	$ 50.25	$ 58.29	$ 48.31	$ -	$ 58.29
28002	SPEECH TREATMENT	420	Physical Therapy	440	92507	$ 200.00	$ 140.00	$ 170.00	$ 200.00	$ 200.00	$ 200.00	$ 200.00	$ 156.00	$ 54.23	$ 118.87	$ 150.00	$ 174.00	$ 144.20	$ 54.23	$ 200.00
28005	TREAT. SWALLOWING/ORAL FU	420	Physical Therapy	440	92526	$ 215.00	$ 150.50	$ 182.75	$ 215.00	$ 215.00	$ 215.00	$ 215.00	$ 167.70	$ 62.80	$ 121.26	$ 161.25	$ 187.05	$ 155.02	$ 62.80	$ 215.00
2102	CLINICAL SWALLOWING EVALUATION	420	Physical Therapy	440	92610	$ 275.00	$ 192.50	$ 233.75	$ 275.00	$ 275.00	$ 275.00	$ 275.00	$ 214.50	$ -	$ 151.80	$ 206.25	$ 239.25	$ 198.28	$ -	$ 275.00
265062	HOT/COLD PACK APPLICATION	420	Physical Therapy	420	97010	$ 35.00	$ 24.50	$ 29.75	$ 28.56	$ 29.85	$ 32.45	$ 32.45	$ 27.30	$ 14.27	$ 6.51	$ 26.25	$ 30.45	$ 25.24	$ 6.51	$ 32.45
265060	PARAFFIN BATH	420	Physical Therapy	420	97018	$ 43.00	$ 30.10	$ 36.55	$ 31.72	$ 33.17	$ 36.05	$ 36.05	$ 33.54	$ 19.00	$ 10.97	$ 32.25	$ 37.41	$ 31.00	$ 10.97	$ 37.41
265023	ULTRASOUND	420	Physical Therapy	420	97035	$ 70.00	$ 49.00	$ 59.50	$ 61.86	$ 64.68	$ 70.00	$ 70.00	$ 54.60	$ 14.25	$ 17.91	$ 52.50	$ 60.90	$ 50.47	$ 14.25	$ 70.00
265006	THERAPEUTIC EXERCISE	420	Physical Therapy	420	97110	$ 115.00	$ 80.50	$ 97.75	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 89.70	$ 33.25	$ 43.29	$ 86.25	$ 100.05	$ 82.92	$ 33.25	$ 115.00
265010	NEUROMUSCULAR REEDUCATION	420	Physical Therapy	420	97112	$ 125.00	$ 87.50	$ 106.25	$ 125.00	$ 125.00	$ 125.00	$ 125.00	$ 97.50	$ 26.60	$ 44.91	$ 93.75	$ 108.75	$ 90.13	$ 26.60	$ 125.00
265009	AQUATIC THERAPY W THER EX	420	Physical Therapy	420	97113	$ 140.00	$ 98.00	$ 119.00	$ 140.00	$ 140.00	$ 140.00	$ 140.00	$ 109.20	$ 29.45	$ 47.13	$ 105.00	$ 121.80	$ 100.94	$ 29.45	$ 140.00
265001	GAIT TRAINING	420	Physical Therapy	420	97116	$ 115.00	$ 80.50	$ 97.75	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 89.70	$ 27.55	$ 37.39	$ 86.25	$ 100.05	$ 82.92	$ 27.55	$ 115.00
265068	MANUAL THERAPY TECHNIQUES	420	Physical Therapy	420	97140	$ 145.00	$ 101.50	$ 123.25	$ 125.27	$ 130.96	$ 142.35	$ 142.35	$ 113.10	$ 28.81	$ 40.34	$ 108.75	$ 126.15	$ 104.55	$ 28.81	$ 142.35
265011	THERAPEUTIC-GROUP	420	Physical Therapy	420	97150	$ 160.00	$ 112.00	$ 136.00	$ 82.46	$ 86.20	$ 93.70	$ 93.70	$ 124.80	$ 29.00	$ 28.88	$ 120.00	$ 139.20	$ 115.36	$ 28.88	$ 139.20
265052	P.T. EVALUATION LOW COMPLEXITY	420	Physical Therapy	424	97161	$ 325.00	$ 227.50	$ 276.25	$ 325.00	$ 325.00	$ 325.00	$ 325.00	$ 253.50	$ -	$ -	$ 243.75	$ 282.75	$ 234.33	$ -	$ 325.00
265054	PT EVAL MODERATE COMPLEXITY	420	Physical Therapy	424	97162	$ 350.00	$ 245.00	$ 297.50	$ 350.00	$ 350.00	$ 350.00	$ 350.00	$ 273.00	$ -	$ -	$ 262.50	$ 304.50	$ 252.35	$ -	$ 350.00
265051	P.T. RE-EVALUATION	420	Physical Therapy	420	97164	$ 150.00	$ 105.00	$ 127.50	$ 150.00	$ 150.00	$ 150.00	$ 150.00	$ 117.00	$ -	$ -	$ 112.50	$ 130.50	$ 108.15	$ -	$ 150.00
265045	THERAPEUTIC ACTIVITIES	420	Physical Therapy	420	97530	$ 140.00	$ 98.00	$ 119.00	$ 140.00	$ 140.00	$ 140.00	$ 140.00	$ 109.20	$ 36.10	$ 53.22	$ 105.00	$ 121.80	$ 100.94	$ 36.10	$ 140.00
265029	DEBRIDEMENT NECROTIC TISSUE	420	Physical Therapy	420	97597	$ 400.00	$ 280.00	$ 340.00	$ 107.84	$ 112.75	$ 122.55	$ 122.55	$ 312.00	$ 73.55	$ 61.23	$ 300.00	$ 348.00	$ 288.40	$ 61.23	$ 348.00
265053	DEBRIDEMENT, 15 MINUTES	420	Physical Therapy	420	97597	$ 400.00	$ 280.00	$ 340.00	$ 107.84	$ 112.75	$ 122.55	$ 122.55	$ 312.00	$ 73.55	$ 61.23	$ 300.00	$ 348.00	$ 288.40	$ 61.23	$ 348.00
11015	FACIAL BONES COMPLETE	320	Radiology Diagnostic	320	70150	$ 365.00	$ 255.50	$ 310.25	$ 365.00	$ 365.00	$ 365.00	$ 365.00	$ 284.70	$ 57.00	$ 67.06	$ 273.75	$ 317.55	$ 263.17	$ 57.00	$ 365.00
11057	SKULL SERIES	320	Radiology Diagnostic	320	70260	$ 535.00	$ 374.50	$ 454.75	$ 535.00	$ 535.00	$ 535.00	$ 535.00	$ 417.30	$ 68.22	$ 80.17	$ 401.25	$ 465.45	$ 385.74	$ 68.22	$ 535.00
11042	NECK SOFT TISSUES	320	Radiology Diagnostic	320	70360	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 32.96	$ 38.37	$ 165.00	$ 191.40	$ 158.62	$ 32.96	$ 220.00
19001	HEAD W/O CONTRAST	320	Radiology Diagnostic	350	70450	$ 755.00	$ 528.50	$ 641.75	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 588.90	$ 283.98	$ 343.11	$ 700.00	$ 656.85	$ 544.36	$ 283.98	$ 750.94
19007	MAXILLOFACIAL W/O CONT.	320	Radiology Diagnostic	350	70486	$ 800.00	$ 560.00	$ 680.00	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 624.00	$ 306.29	$ 367.72	$ 700.00	$ 696.00	$ 576.80	$ 306.29	$ 750.94
19009	MAXILLOFACIAL W/O & W/CON	320	Radiology Diagnostic	350	70488	$ 1,507.00	$ 1,054.90	$ 1,280.95	$ 1,075.10	$ 1,122.48	$1,220.87	$ 1,220.87	$ 1,175.46	$ 436.46	$ 525.78	$ 700.00	$ 1,311.09	$ 1,086.55	$ 436.46	$ 1,311.09
19010	SOFT TISSUE NECK W/O CONT	320	Radiology Diagnostic	350	70490	$ 950.00	$ 665.00	$ 807.50	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 741.00	$ 317.71	$ 380.02	$ 700.00	$ 826.50	$ 684.95	$ 317.71	$ 826.50
19011	SOFT TISSUE NECK W/CONT.	320	Radiology Diagnostic	350	70491	$ 1,384.00	$ 968.80	$ 1,176.40	$ 1,075.10	$ 1,122.48	$1,220.87	$ 1,220.87	$ 1,079.52	$ 368.01	$ 441.55	$ 700.00	$ 1,204.08	$ 997.86	$ 368.01	$ 1,220.87
2013	MRI BRAIN W/O & WITH	320	Radiology Diagnostic	611	70553	$ 3,454.00	$ 2,417.80	$ 2,935.90	$ 2,252.92	$ 2,352.20	$2,558.40	$ 2,558.40	$ 2,694.12	$ 1,328.69	$ 1,625.56	$ 950.00	$ 3,004.98	$ 2,490.33	$ 950.00	$ 3,004.98
11005	CHEST 1 VIEW	320	Radiology Diagnostic	320	71045	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ -	$ -	$ 165.00	$ 191.40	$ 158.62	$ -	$ 220.00
11035	CHEST PA & LAT PORTABLE	320	Radiology Diagnostic	320	71046	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ -	$ -	$ 165.00	$ 191.40	$ 158.62	$ -	$ 220.00
11047R	RIBS UNI MIN 3 VW	320	Radiology Diagnostic	320	71100	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 43.91	$ 51.88	$ 165.00	$ 191.40	$ 158.62	$ 43.91	$ 220.00
11047L	RIBS UNI MIN 3VW	320	Radiology Diagnostic	320	71100	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 43.91	$ 51.88	$ 165.00	$ 191.40	$ 158.62	$ 43.91	$ 220.00
19013	THORAX W/O CONTRAST	320	Radiology Diagnostic	350	71250	$ 950.00	$ 665.00	$ 807.50	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 741.00	$ 366.62	$ 437.45	$ 700.00	$ 826.50	$ 684.95	$ 366.62	$ 826.50
19014	THORAX W/CONTRAST	320	Radiology Diagnostic	350	71260	$ 1,250.00	$ 875.00	$ 1,062.50	$ 1,075.10	$ 1,122.48	$1,220.87	$ 1,220.87	$ 975.00	$ 421.94	$ 509.81	$ 700.00	$ 1,087.50	$ 901.25	$ 421.94	$ 1,220.87
19044	CT chest PEw/contrast	320	Radiology Diagnostic	350	71275	$ 1,225.00	$ 857.50	$ 1,041.25	$ 1,075.10	$ 1,122.48	$1,220.87	$ 1,220.87	$ 955.50	$ 465.50	$ 670.24	$ 700.00	$ 1,065.75	$ 883.23	$ 465.50	$ 1,220.87
11063	C SPINE 2 or 3 Views	320	Radiology Diagnostic	320	72040	$ 365.00	$ 255.50	$ 310.25	$ 365.00	$ 365.00	$ 365.00	$ 365.00	$ 284.70	$ 44.77	$ 53.60	$ 273.75	$ 317.55	$ 263.17	$ 44.77	$ 365.00
11138	C spine 4 or 5 views	320	Radiology Diagnostic	320	72050	$ 535.00	$ 374.50	$ 454.75	$ 535.00	$ 535.00	$ 535.00	$ 535.00	$ 417.30	$ 65.61	$ 78.34	$ 401.25	$ 465.45	$ 385.74	$ 65.61	$ 535.00
11065	T SPINE AP & LAT	320	Radiology Diagnostic	320	72070	$ 275.00	$ 192.50	$ 233.75	$ 275.00	$ 275.00	$ 275.00	$ 275.00	$ 214.50	$ 47.04	$ 56.47	$ 206.25	$ 239.25	$ 198.28	$ 47.04	$ 275.00
11067	L SPINE 2 or 3 VIEWS	320	Radiology Diagnostic	320	72100	$ 365.00	$ 255.50	$ 310.25	$ 365.00	$ 365.00	$ 365.00	$ 365.00	$ 284.70	$ 47.95	$ 57.67	$ 273.75	$ 317.55	$ 263.17	$ 47.95	$ 365.00
11068	L SPINE COMPLETE	320	Radiology Diagnostic	320	72110	$ 386.00	$ 270.20	$ 328.10	$ 386.00	$ 386.00	$ 386.00	$ 386.00	$ 301.08	$ 66.52	$ 79.48	$ 289.50	$ 335.82	$ 278.31	$ 66.52	$ 386.00
19016	C-SPINE W/O CONTRAST	320	Radiology Diagnostic	350	72125	$ 755.00	$ 528.50	$ 641.75	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 588.90	$ -	$ 437.45	$ 700.00	$ 656.85	$ 544.36	$ -	$ 750.94
19018	T-SPINE W/O CONTRAST	320	Radiology Diagnostic	350	72128	$ 1,305.00	$ 913.50	$ 1,109.25	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 1,017.90	$ 362.23	$ 437.45	$ 700.00	$ 1,135.35	$ 940.91	$ 362.23	$ 1,135.35
19020	L-SPINE W/O CONTRAST	320	Radiology Diagnostic	350	72131	$ 1,000.00	$ 700.00	$ 850.00	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 780.00	$ 332.93	$ 437.45	$ 700.00	$ 870.00	$ 721.00	$ 332.93	$ 870.00
2018	MRI SPINAL CANAL&CONTS CERVW/O	320	Radiology Diagnostic	612	72141	$ 1,805.00	$ 1,263.50	$ 1,534.25	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,407.90	$ 640.43	$ 777.69	$ 950.00	$ 1,570.35	$ 1,301.41	$ 640.43	$ 1,570.35
2019	MRI SPINAL CANAL&CONTS.CERV W	320	Radiology Diagnostic	612	72142	$ 2,200.00	$ 1,540.00	$ 1,870.00	$ 2,200.00	$ 2,200.00	$2,200.00	$ 2,200.00	$ 1,716.00	$ 768.20	$ 933.68	$ 950.00	$ 1,914.00	$ 1,586.20	$ 768.20	$ 2,200.00
2021	MRISPINAL CAN&CONTS.THORAC W/O	320	Radiology Diagnostic	612	72146	$ 1,805.00	$ 1,263.50	$ 1,534.25	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,407.90	$ 697.07	$ 847.84	$ 950.00	$ 1,570.35	$ 1,301.41	$ 697.07	$ 1,570.35
2024	MRISPINAL CAN&CONTS LUMBAR W/O	320	Radiology Diagnostic	612	72148	$ 1,700.00	$ 1,190.00	$ 1,445.00	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,326.00	$ 687.21	$ 837.99	$ 950.00	$ 1,479.00	$ 1,225.70	$ 687.21	$ 1,561.37
11043	PELVIS AP 1/2 VIEWS	320	Radiology Diagnostic	320	72170	$ 275.00	$ 192.50	$ 233.75	$ 275.00	$ 275.00	$ 275.00	$ 275.00	$ 214.50	$ 37.00	$ 44.67	$ 206.25	$ 239.25	$ 198.28	$ 37.00	$ 275.00
19022	PELVIS W/O CONTRAST	320	Radiology Diagnostic	350	72192	$ 1,044.00	$ 730.80	$ 887.40	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 814.32	$ 356.53	$ 431.33	$ 700.00	$ 908.28	$ 752.72	$ 356.53	$ 908.28
19023	PELVIS W/CONTRAST	320	Radiology Diagnostic	350	72193	$ 1,225.00	$ 857.50	$ 1,041.25	$ 1,075.10	$ 1,122.48	$1,220.87	$ 1,220.87	$ 955.50	$ -	$ 490.97	$ 700.00	$ 1,065.75	$ 883.23	$ -	$ 1,220.87
2028	MRI PELVIS W/O	320	Radiology Diagnostic	610	72195	$ 1,805.00	$ 1,263.50	$ 1,534.25	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,407.90	$ 742.69	$ 757.30	$ 950.00	$ 1,570.35	$ 1,301.41	$ 742.69	$ 1,570.35
11049	SCARUM & COCCYX MIN 2 VWS	320	Radiology Diagnostic	320	72220	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 39.77	$ 47.59	$ 165.00	$ 191.40	$ 158.62	$ 39.77	$ 220.00
11007R	CLAVICLE XRAY; RIGHT	320	Radiology Diagnostic	320	73000	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 36.47	$ 44.04	$ 165.00	$ 191.40	$ 158.62	$ 36.47	$ 220.00
11007	CLAVICLE COMPLETE; LEFT	320	Radiology Diagnostic	320	73000	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 36.47	$ 44.04	$ 165.00	$ 191.40	$ 158.62	$ 36.47	$ 220.00
Charge Code	Charge Code Description	Dept #	Dept	RevCode	CPT Code	Current Price	Cash Price	Aetna	BCBS - Blue Adv	BCBS - HMO	BCBS - PPO	BCBS - Traditional	CIGNA	FirstCare - HMO	FirstCare - PPO	HealthSource	Humana	United	Minimum Negotiated Rate	Maximum Negotiated Rate
11054L	SHOULDER LEFT MIN 2 VIEWS	320	Radiology Diagnostic	320	73030	$ 235.00	$ 164.50	$ 199.75	$ 235.00	$ 235.00	$ 235.00	$ 235.00	$ 183.30	$ 40.29	$ 48.22	$ 176.25	$ 204.45	$ 169.44	$ 40.29	$ 235.00
11054R	SHOULDER RT MIN 2 VIEWS	320	Radiology Diagnostic	320	73030	$ 235.00	$ 164.50	$ 199.75	$ 235.00	$ 235.00	$ 235.00	$ 235.00	$ 183.30	$ 40.29	$ 48.22	$ 176.25	$ 204.45	$ 169.44	$ 40.29	$ 235.00
11028L	HUMERUS 2 VIEWS	320	Radiology Diagnostic	320	73060	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 39.77	$ 47.59	$ 165.00	$ 191.40	$ 158.62	$ 39.77	$ 220.00
11028R	HUMERUS 2 VIEWS	320	Radiology Diagnostic	320	73060	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 39.77	$ 47.59	$ 165.00	$ 191.40	$ 158.62	$ 39.77	$ 220.00
11013L	ELBOW AP & LAT	320	Radiology Diagnostic	320	73070	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.96	$ 42.84	$ 165.00	$ 191.40	$ 158.62	$ 35.96	$ 220.00
11013R	ELBOW AP & LAT	320	Radiology Diagnostic	320	73070	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.96	$ 42.84	$ 165.00	$ 191.40	$ 158.62	$ 35.96	$ 220.00
11025L	ELBOW COMPLETE MIN 3 VWS	320	Radiology Diagnostic	320	73080	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 39.77	$ 47.59	$ 165.00	$ 191.40	$ 158.62	$ 39.77	$ 220.00
11025R	ELBOW COMPLETE MIN 3 VWS	320	Radiology Diagnostic	320	73080	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 39.77	$ 47.59	$ 165.00	$ 191.40	$ 158.62	$ 39.77	$ 220.00
11148	Forearm 1 View; Left	320	Radiology Diagnostic	320	73090	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 36.47	$ 44.04	$ 165.00	$ 191.40	$ 158.62	$ 36.47	$ 220.00
11149	Forearm 1 View; Right	320	Radiology Diagnostic	320	73090	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 36.47	$ 44.04	$ 165.00	$ 191.40	$ 158.62	$ 36.47	$ 220.00
11022L	FOREARM AP & LAT 2 VIEWS	320	Radiology Diagnostic	320	73090	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 36.47	$ 44.04	$ 165.00	$ 191.40	$ 158.62	$ 36.47	$ 220.00
11022R	FOREARM AP & LAT 2 VIEWS	320	Radiology Diagnostic	320	73090	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 36.47	$ 44.04	$ 165.00	$ 191.40	$ 158.62	$ 36.47	$ 220.00
11075L	WRIST COMPLETE MIN 3 VWS	320	Radiology Diagnostic	320	73110	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.96	$ 45.25	$ 165.00	$ 191.40	$ 158.62	$ 37.96	$ 220.00
11075R	WRIST COMPLETE MIN 3 VWS	320	Radiology Diagnostic	320	73110	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.96	$ 45.25	$ 165.00	$ 191.40	$ 158.62	$ 37.96	$ 220.00
73120	Hand 2 view Right	320	Radiology Diagnostic	320	73120	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.10	$ 42.32	$ 165.00	$ 191.40	$ 158.62	$ 35.10	$ 220.00
11024	HAND 2 VIEWS Left	320	Radiology Diagnostic	320	73120	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.10	$ 42.32	$ 165.00	$ 191.40	$ 158.62	$ 35.10	$ 220.00
11030R	HAND MIN 3 VIEW RIGHT	320	Radiology Diagnostic	320	73130	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.96	$ 45.25	$ 165.00	$ 191.40	$ 158.62	$ 37.96	$ 220.00
11030L	HAND MIN 3 VIEWS LEFT	320	Radiology Diagnostic	320	73130	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.96	$ 45.25	$ 165.00	$ 191.40	$ 158.62	$ 37.96	$ 220.00
11019L	FINGER SERIES MIN 2 VWS	320	Radiology Diagnostic	320	73140	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 29.84	$ 35.28	$ 165.00	$ 191.40	$ 158.62	$ 29.84	$ 220.00
11019R	FINGER SERIES MIN 2 VWS	320	Radiology Diagnostic	320	73140	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 29.84	$ 35.28	$ 165.00	$ 191.40	$ 158.62	$ 29.84	$ 220.00
19025R	UPPER EXT CT WO CONTRAST; RIGHT	320	Radiology Diagnostic	350	73200	$ 845.00	$ 591.50	$ 718.25	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 659.10	$ 368.42	$ 376.61	$ 700.00	$ 735.15	$ 609.25	$ 368.42	$ 750.94
19025	UPPER EXT CT W/O CONTRAST; LEFT	320	Radiology Diagnostic	350	73200	$ 845.00	$ 591.50	$ 718.25	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 659.10	$ 368.42	$ 376.61	$ 700.00	$ 735.15	$ 609.25	$ 368.42	$ 750.94
19026R	UPPER EXT CT W/ CONTRAST; RIGHT	320	Radiology Diagnostic	350	73201	$ 2,200.00	$ 1,540.00	$ 1,870.00	$ 2,200.00	$ 2,200.00	$2,200.00	$ 2,200.00	$ 1,716.00	$ 433.02	$ 437.45	$ 700.00	$ 1,914.00	$ 1,586.20	$ 433.02	$ 2,200.00
19026	UPPER EXT W/ CONTRAST; LEFT	320	Radiology Diagnostic	350	73201	$ 2,200.00	$ 1,540.00	$ 1,870.00	$ 2,200.00	$ 2,200.00	$2,200.00	$ 2,200.00	$ 1,716.00	$ 433.02	$ 437.45	$ 700.00	$ 1,914.00	$ 1,586.20	$ 433.02	$ 2,200.00
2035R	MRI UPPER EXT ANY JOINT WO CONT; RIGHT	320	Radiology Diagnostic	610	73221	$ 1,805.00	$ 1,263.50	$ 1,534.25	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,407.90	$ 616.63	$ 744.34	$ 950.00	$ 1,570.35	$ 1,301.41	$ 616.63	$ 1,570.35
2035	MRI UPPER EXT ANY JOINT WO CONT; LEFT	320	Radiology Diagnostic	610	73221	$ 1,805.00	$ 1,263.50	$ 1,534.25	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,407.90	$ 616.63	$ 744.34	$ 950.00	$ 1,570.35	$ 1,301.41	$ 616.63	$ 1,570.35
11027L	HIP COMP MIN 2 VIEWS LEFT	320	Radiology Diagnostic	320	73502	$ 225.00	$ 157.50	$ 191.25	$ 225.00	$ 225.00	$ 225.00	$ 225.00	$ 175.50	$ -	$ -	$ 168.75	$ 195.75	$ 162.23	$ -	$ 225.00
11027R	HIP COMP MIN 2 VIEW RIGHT	320	Radiology Diagnostic	320	73502	$ 235.00	$ 164.50	$ 199.75	$ 235.00	$ 235.00	$ 235.00	$ 235.00	$ 183.30	$ -	$ -	$ 176.25	$ 204.45	$ 169.44	$ -	$ 235.00
11137R	HIP RT W/ PELVIS	320	Radiology Diagnostic	320	73502	$ 395.00	$ 276.50	$ 335.75	$ 395.00	$ 395.00	$ 395.00	$ 395.00	$ 308.10	$ -	$ -	$ 296.25	$ 343.65	$ 284.80	$ -	$ 395.00
11137	Hip LEFT w/ pelvis	320	Radiology Diagnostic	320	73502	$ 395.00	$ 276.50	$ 335.75	$ 395.00	$ 395.00	$ 395.00	$ 395.00	$ 308.10	$ -	$ -	$ 296.25	$ 343.65	$ 284.80	$ -	$ 395.00
11133	BILATERAL HIPS	320	Radiology Diagnostic	320	73522	$ 535.00	$ 374.50	$ 454.75	$ 535.00	$ 535.00	$ 535.00	$ 535.00	$ 417.30	$ -	$ -	$ 401.25	$ 465.45	$ 385.74	$ -	$ 535.00
11017L	FEMUR AP & LAT	320	Radiology Diagnostic	320	73552	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ -	$ -	$ 165.00	$ 191.40	$ 158.62	$ -	$ 220.00
11017R	FEMUR AP & LAT	320	Radiology Diagnostic	320	73552	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ -	$ -	$ 165.00	$ 191.40	$ 158.62	$ -	$ 220.00
11029L	KNEE AP & LAT LEFT	320	Radiology Diagnostic	320	73560	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.00	$ 45.30	$ 165.00	$ 191.40	$ 158.62	$ 37.00	$ 220.00
11029R	KNEE AP & LAT RT	320	Radiology Diagnostic	320	73560	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.00	$ 45.30	$ 165.00	$ 191.40	$ 158.62	$ 37.00	$ 220.00
73561	Knee 3 Views Left	320	Radiology Diagnostic	320	73562	$ 250.00	$ 175.00	$ 212.50	$ 250.00	$ 250.00	$ 250.00	$ 250.00	$ 195.00	$ 40.81	$ 48.84	$ 187.50	$ 217.50	$ 180.25	$ 40.81	$ 250.00
73562	Knee 3 Views Right	320	Radiology Diagnostic	320	73562	$ 250.00	$ 175.00	$ 212.50	$ 250.00	$ 250.00	$ 250.00	$ 250.00	$ 195.00	$ 40.81	$ 48.84	$ 187.50	$ 217.50	$ 180.25	$ 40.81	$ 250.00
73601	Ankle 2 view Rt	320	Radiology Diagnostic	320	73600	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.10	$ 42.32	$ 165.00	$ 191.40	$ 158.62	$ 35.10	$ 220.00
73600	Ankle 2v AP & Lateral Lt	320	Radiology Diagnostic	320	73600	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.10	$ 42.32	$ 165.00	$ 191.40	$ 158.62	$ 35.10	$ 220.00
11004R	ANKLE COMPLETE MIN 3 VWS	320	Radiology Diagnostic	320	73610	$ 235.00	$ 164.50	$ 199.75	$ 235.00	$ 235.00	$ 235.00	$ 235.00	$ 183.30	$ 37.96	$ 45.25	$ 176.25	$ 204.45	$ 169.44	$ 37.96	$ 235.00
11004L	ANKLE COMPLETE MIN. 3 VWS	320	Radiology Diagnostic	320	73610	$ 235.00	$ 164.50	$ 199.75	$ 235.00	$ 235.00	$ 235.00	$ 235.00	$ 183.30	$ 37.96	$ 45.25	$ 176.25	$ 204.45	$ 169.44	$ 37.96	$ 235.00
11020L	FOOT AP & LAT 2 VIEWS	320	Radiology Diagnostic	320	73620	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.10	$ 42.32	$ 165.00	$ 191.40	$ 158.62	$ 35.10	$ 220.00
11020R	FOOT AP & LAT 2 VIEWS	320	Radiology Diagnostic	320	73620	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 35.10	$ 42.32	$ 165.00	$ 191.40	$ 158.62	$ 35.10	$ 220.00
11021L	FOOT COMPLETE MIN 3 VWS	320	Radiology Diagnostic	320	73630	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.96	$ 45.25	$ 165.00	$ 191.40	$ 158.62	$ 37.96	$ 220.00
11021R	FOOT COMPLETE MIN 3 VWS	320	Radiology Diagnostic	320	73630	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 37.96	$ 45.25	$ 165.00	$ 191.40	$ 158.62	$ 37.96	$ 220.00
11113R	TMJs UNILATERAL; RIGHT	320	Radiology Diagnostic	320	73660	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 29.84	$ 35.28	$ 165.00	$ 191.40	$ 158.62	$ 29.84	$ 220.00
11071R	TOES MIN 2 VIEW; RIGHT	320	Radiology Diagnostic	320	73660	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 29.84	$ 35.28	$ 165.00	$ 191.40	$ 158.62	$ 29.84	$ 220.00
11071	TOES MIN 2 VIEWS; LEFT	320	Radiology Diagnostic	320	73660	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ 29.84	$ 35.28	$ 165.00	$ 191.40	$ 158.62	$ 29.84	$ 220.00
19028R	LOWER EXT CT WO CONTRAST; RIGHT	320	Radiology Diagnostic	350	73700	$ 1,250.00	$ 875.00	$ 1,062.50	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 975.00	$ 313.04	$ 376.61	$ 700.00	$ 1,087.50	$ 901.25	$ 313.04	$ 1,087.50
19028	LOWER EXT. W/O CONTRAST; LEFT	320	Radiology Diagnostic	350	73700	$ 1,250.00	$ 875.00	$ 1,062.50	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 975.00	$ 313.04	$ 376.61	$ 700.00	$ 1,087.50	$ 901.25	$ 313.04	$ 1,087.50
2042R	MRI LOWER EXT ANY JOINT W/O CONT; RIGHT	320	Radiology Diagnostic	610	73721	$ 1,805.00	$ 1,263.50	$ 1,534.25	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,407.90	$ 616.63	$ 744.34	$ 950.00	$ 1,570.35	$ 1,301.41	$ 616.63	$ 1,570.35
2042	MRI LOWER EXT ANY JOINT W/O CONT; LEFT	320	Radiology Diagnostic	610	73721	$ 1,805.00	$ 1,263.50	$ 1,534.25	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,407.90	$ 616.63	$ 744.34	$ 950.00	$ 1,570.35	$ 1,301.41	$ 616.63	$ 1,570.35
11001	ABDOMEN (KUB) 1 VIEW	320	Radiology Diagnostic	320	74018	$ 220.00	$ 154.00	$ 187.00	$ 220.00	$ 220.00	$ 220.00	$ 220.00	$ 171.60	$ -	$ -	$ 165.00	$ 191.40	$ 158.62	$ -	$ 220.00
11002	ABDOMEN, UPRIGHT & SUPINE	320	Radiology Diagnostic	320	74019	$ 247.00	$ 172.90	$ 209.95	$ 247.00	$ 247.00	$ 247.00	$ 247.00	$ 192.66	$ -	$ -	$ 185.25	$ 214.89	$ 178.09	$ -	$ 247.00
19031	ABDOMEN W/O CONTRAST	320	Radiology Diagnostic	350	74150	$ 1,071.00	$ 749.70	$ 910.35	$ 661.27	$ 690.41	$ 750.94	$ 750.94	$ 835.38	$ 352.97	$ 425.53	$ 700.00	$ 931.77	$ 772.19	$ 352.97	$ 931.77
19032	ABDOMEN W/CONTRAST	320	Radiology Diagnostic	350	74160	$ 1,285.00	$ 899.50	$ 1,092.25	$ 1,075.10	$ 1,122.48	$1,220.87	$ 1,220.87	$ 1,002.30	$ 413.65	$ 500.23	$ 700.00	$ 1,117.95	$ 926.49	$ 413.65	$ 1,220.87
19045	CT Abdominal Aorta w/ contrast	320	Radiology Diagnostic	350	74174	$ 1,675.00	$ 1,172.50	$ 1,423.75	$ 1,675.00	$ 1,675.00	$1,675.00	$ 1,675.00	$ 1,306.50	$ -	$ -	$ 700.00	$ 1,457.25	$ 1,207.68	$ -	$ 1,675.00
19043	CT ABDOMEN/PELVIS W/O CONTRAST	320	Radiology Diagnostic	350	74176	$ 1,575.00	$ 1,102.50	$ 1,338.75	$ 1,374.94	$ 1,435.53	$1,561.37	$ 1,561.37	$ 1,228.50	$ -	$ -	$ 700.00	$ 1,370.25	$ 1,135.58	$ -	$ 1,561.37
19041	CT-ABDOMEN & PELVIS W/CONT	320	Radiology Diagnostic	350	74177	$ 2,200.00	$ 1,540.00	$ 1,870.00	$ 2,200.00	$ 2,200.00	$2,200.00	$ 2,200.00	$ 1,716.00	$ -	$ -	$ 700.00	$ 1,914.00	$ 1,586.20	$ -	$ 2,200.00
19042	CT ABDOMEN/PELVIS W W/O CNTRST	320	Radiology Diagnostic	350	74178	$ 2,472.00	$ 1,730.40	$ 2,101.20	$ 2,252.92	$ 2,352.20	$2,472.00	$ 2,472.00	$ 1,928.16	$ -	$ -	$ 700.00	$ 2,150.64	$ 1,782.31	$ -	$ 2,472.00
11083	SOFT TISSUE SONO HEAD/NEK	320	Radiology Diagnostic	402	76536	$ 650.00	$ 455.00	$ 552.50	$ 567.12	$ 592.90	$ 644.46	$ 644.46	$ 507.00	$ 109.88	$ 129.71	$ 487.50	$ 565.50	$ 468.65	$ 109.88	$ 644.46
11093	CHEST SONO	320	Radiology Diagnostic	402	76604	$ 550.00	$ 385.00	$ 467.50	$ 550.00	$ 550.00	$ 550.00	$ 550.00	$ 429.00	$ 103.90	$ 121.58	$ 412.50	$ 478.50	$ 396.55	$ 103.90	$ 550.00
11103R	BREAST ULTRASOUND; RIGHT	320	Radiology Diagnostic	402	76641	$ 440.00	$ 308.00	$ 374.00	$ 440.00	$ 440.00	$ 440.00	$ 440.00	$ 343.20	$ -	$ -	$ 330.00	$ 382.80	$ 317.24	$ -	$ 440.00
11103	BREAST ULTRASOUND; LEFT	320	Radiology Diagnostic	402	76641	$ 440.00	$ 308.00	$ 374.00	$ 440.00	$ 440.00	$ 440.00	$ 440.00	$ 343.20	$ -	$ -	$ 330.00	$ 382.80	$ 317.24	$ -	$ 440.00
11077	ABDOMEN SONOGRAM	320	Radiology Diagnostic	402	76700	$ 650.00	$ 455.00	$ 552.50	$ 567.12	$ 592.90	$ 644.46	$ 644.46	$ 507.00	$ 154.46	$ 182.34	$ 487.50	$ 565.50	$ 468.65	$ 154.46	$ 644.46
11078	AORTA SONOGRAM SCREENING	320	Radiology Diagnostic	402	76706	$ 525.00	$ 367.50	$ 446.25	$ 441.28	$ 461.34	$ 501.46	$ 501.46	$ 409.50	$ -	$ -	$ 393.75	$ 456.75	$ 378.53	$ -	$ 501.46
11080	RENAL SONOGRAM	320	Radiology Diagnostic	402	76770	$ 800.00	$ 560.00	$ 680.00	$ 567.12	$ 592.90	$ 644.46	$ 644.46	$ 624.00	$ 149.26	$ 176.16	$ 600.00	$ 696.00	$ 576.80	$ 149.26	$ 696.00
11084	OBSTETRICS SONOGRAM	320	Radiology Diagnostic	402	76805	$ 550.00	$ 385.00	$ 467.50	$ 463.19	$ 484.25	$ 526.36	$ 526.36	$ 429.00	$ 174.85	$ 205.76	$ 412.50	$ 478.50	$ 396.55	$ 174.85	$ 526.36
11115	TRANSVAGINAL ULTRASOUND	320	Radiology Diagnostic	402	76830	$ 600.00	$ 420.00	$ 510.00	$ 446.80	$ 467.11	$ 507.73	$ 507.73	$ 468.00	$ 125.22	$ 146.59	$ 450.00	$ 522.00	$ 432.60	$ 125.22	$ 522.00
11087	PELVIC MASS SONOGRAM	320	Radiology Diagnostic	402	76856	$ 650.00	$ 455.00	$ 552.50	$ 567.12	$ 592.90	$ 644.46	$ 644.46	$ 507.00	$ 125.22	$ 146.59	$ 487.50	$ 565.50	$ 468.65	$ 125.22	$ 644.46
Charge Code	Charge Code Description	Dept #	Dept	RevCode	CPT Code	Current Price	Cash Price	Aetna	BCBS - Blue Adv	BCBS - HMO	BCBS - PPO	BCBS - Traditional	CIGNA	FirstCare - HMO	FirstCare - PPO	HealthSource	Humana	United	Minimum Negotiated Rate	Maximum Negotiated Rate
11119	UPPER EXT ULTRASOUND; LEFT	320	Radiology Diagnostic	402	76881	$ 383.00	$ 268.10	$ 325.55	$ 293.58	$ 306.93	$ 333.62	$ 333.62	$ 298.74	$ -	$ -	$ 287.25	$ 333.21	$ 276.14	$ -	$ 333.62
11130	BONE DEXA SCAN	320	Radiology Diagnostic	320	77080	$ 225.00	$ 157.50	$ 191.25	$ 154.99	$ 162.03	$ 176.12	$ 176.12	$ 175.50	$ 159.14	$ 123.87	$ 168.75	$ 195.75	$ 162.23	$ 123.87	$ 195.75
11140	Bone Dexa Scan/Vert fracture assess	320	Radiology Diagnostic	320	77085	$ 535.00	$ 374.50	$ 454.75	$ 535.00	$ 535.00	$ 535.00	$ 535.00	$ 417.30	$ -	$ -	$ 401.25	$ 465.45	$ 385.74	$ -	$ 535.00
11104	ECHOCARDIOGRAM	320	Radiology Diagnostic	480	93306	$ 680.00	$ 476.00	$ 578.00	$ 596.24	$ 623.35	$ 677.55	$ 677.55	$ 530.40	$ 369.42	$ -	$ 510.00	$ 591.60	$ 490.28	$ -	$ 677.55
11099	DUPLEX SCAN EXTRACRANIAL	320	Radiology Diagnostic	921	93880	$ 825.00	$ 577.50	$ 701.25	$ 723.10	$ 755.96	$ 821.70	$ 821.70	$ 643.50	$ 228.00	$ 334.76	$ 618.75	$ 717.75	$ 594.83	$ 228.00	$ 821.70
11058	ANKLE BRACHIAL INDEX	320	Radiology Diagnostic	921	93922	$ 325.00	$ 227.50	$ 276.25	$ 325.00	$ 325.00	$ 325.00	$ 325.00	$ 253.50	$ 111.80	$ 111.81	$ 243.75	$ 282.75	$ 234.33	$ 111.80	$ 325.00
11124	BILATERAL ARTERIAL LOW EX	320	Radiology Diagnostic	921	93925	$ 750.00	$ 525.00	$ 637.50	$ 750.00	$ 750.00	$ 750.00	$ 750.00	$ 585.00	$ 228.00	$ 333.22	$ 562.50	$ 652.50	$ 540.75	$ 228.00	$ 750.00
11112	ARTERIAL DUPLEX SCAN LEFT	320	Radiology Diagnostic	921	93926	$ 480.00	$ 336.00	$ 408.00	$ 480.00	$ 480.00	$ 480.00	$ 480.00	$ 374.40	$ 148.20	$ 222.63	$ 360.00	$ 417.60	$ 346.08	$ 148.20	$ 480.00
11143	Arterial Duplex Scan Right	320	Radiology Diagnostic	921	93926	$ 480.00	$ 336.00	$ 408.00	$ 480.00	$ 480.00	$ 480.00	$ 480.00	$ 374.40	$ 148.20	$ 222.63	$ 360.00	$ 417.60	$ 346.08	$ 148.20	$ 480.00
11108	DUPLEX SCAN VENOUS SYSTEM	320	Radiology Diagnostic	921	93970	$ 750.00	$ 525.00	$ 637.50	$ 719.93	$ 719.93	$ 719.93	$ 719.93	$ 585.00	$ 223.25	$ 372.74	$ 562.50	$ 652.50	$ 540.75	$ 223.25	$ 719.93
11114R	VENOUS DUPLEX UNILATERAL; RIGHT	320	Radiology Diagnostic	921	93971	$ 494.00	$ 345.80	$ 419.90	$ 440.84	$ 460.87	$ 494.00	$ 494.00	$ 385.32	$ 144.40	$ 247.75	$ 370.50	$ 429.78	$ 356.17	$ 144.40	$ 494.00
11114	Venous Duplex Unilateral Left	320	Radiology Diagnostic	921	93971	$ 494.00	$ 345.80	$ 419.90	$ 440.84	$ 460.87	$ 494.00	$ 494.00	$ 385.32	$ 144.40	$ 247.75	$ 370.50	$ 429.78	$ 356.17	$ 144.40	$ 494.00
11048	RENAL ARTERY DOPPLER	320	Radiology Diagnostic	921	93975	$ 750.00	$ 525.00	$ 637.50	$ 750.00	$ 750.00	$ 750.00	$ 750.00	$ 585.00	$ 234.66	$ 531.62	$ 562.50	$ 652.50	$ 540.75	$ 234.66	$ 750.00
81002	URINALYSIS DIPSTICK	521	Rural Health Clinic	521	81002	$ 10.00	$ 7.00	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -
81003	URINE TEST AUTOMATED	521	Rural Health Clinic	521	81003	$ 10.00	$ 7.00	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -
93000	EKG 12 LEADS W/INTER & REPORT	521	Rural Health Clinic	521	93000	$ 80.00	$ 56.00	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59	$ 14.59
99202	NEW PAT-BRIEF	521	Rural Health Clinic	521	99202	$ 130.00	$ 91.00	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58	$ 74.58
99203	NEW PAT-LIMITED	521	Rural Health Clinic	521	99203	$ 180.00	$ 126.00	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19	$ 114.19
99204	NEW PAT-INTER	521	Rural Health Clinic	521	99204	$ 245.00	$ 171.50	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35	$ 170.35
99205	NEW PAT-COMP	521	Rural Health Clinic	521	99205	$ 305.00	$ 213.50	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26	$ 225.26
99212	EST.PAT BRIEF	521	Rural Health Clinic	521	99212	$ 75.00	$ 52.50	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84	$ 57.84
99213	EST.PAT.LIMITED	521	Rural Health Clinic	521	99213	$ 90.00	$ 63.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00	$ 90.00
99214	EST.PAT.INTER.	521	Rural Health Clinic	521	99214	$ 115.00	$ 80.50	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00	$ 115.00
99385	EPSDT NEW PATIENT 18-39 YEARS	521	Rural Health Clinic	521	99385	$ 186.00	$ 130.20	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01	$ 150.01

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}

1013 15th Street Wellington, Texas 79095

806-447-2521