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:
The PDF file is a searchable consumer-friendly format of payer-specific negotiated charge information of 300 “shoppable outpatient services” at the hospital. The file contains the following information:
QUESTIONS?
If you have further questions about the 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!
Collingsworth General Hospital Shoppable Services as of 7/19/2022
| Charge Code | Charge Code Description | Dept # | Dept | Rev Code | Proc 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/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 | $520.00 | $520.00 | $520.00 | $520.00 | $405.60 | $76.00 | $88.02 | $390.00 | $452.40 | $374.92 | $76.00 | $520.00 |
| 80192 | (CBC) AUTOMATED HEMOGRAM | 300 | Laboratory | 305 | 85027 | $40.00 | $28.00 | $34.00 | $38.17 | $39.86 | $40.00 | $40.00 | $31.20 | $- | $16.11 | $30.00 | $34.80 | $28.84 | $- | $40.00 |
| 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 |
| 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 |
| 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 |
| 8193 | ACETAMINOPHEN SERUM | 300 | Laboratory | 301 | 80329 | $232.00 | $162.40 | $197.20 | $- | $- | $- | $- | $180.96 | $- | $- | $174.00 | $201.84 | $167.27 | $- | $201.84 |
| 8176 | ALCOHOL (ETOH) | 300 | Laboratory | 301 | 80320 | $78.00 | $54.60 | $66.30 | $- | $- | $- | $- | $60.84 | $- | $- | $58.50 | $67.86 | $56.24 | $- | $67.86 |
| 8170 | ALPHA FETOPROTEIN (TUMOR) | 300 | Laboratory | 301 | 82105 | $100.00 | $70.00 | $85.00 | $98.94 | $100.00 | $100.00 | $100.00 | $78.00 | $- | $41.72 | $75.00 | $87.00 | $72.10 | $- | $100.00 |
| 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 |
| 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 |
| 8739 | AMP/MAMP CONFIRMATION | 300 | Laboratory | 301 | 80324 | $133.00 | $93.10 | $113.05 | $- | $- | $- | $- | $103.74 | $- | $- | $99.75 | $115.71 | $95.89 | $- | $115.71 |
| 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 |
| 8004 | ANA | 300 | Laboratory | 302 | 86038 | $80.00 | $56.00 | $68.00 | $71.33 | $74.47 | $80.00 | $80.00 | $62.40 | $- | $30.06 | $60.00 | $69.60 | $57.68 | $- | $80.00 |
| 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 |
| 8011 | ANTIBODY SCREEN;RBC | 300 | Laboratory | 302 | 86850 | $100.00 | $70.00 | $85.00 | $100.00 | $100.00 | $100.00 | $100.00 | $78.00 | $- | $- | $75.00 | $87.00 | $72.10 | $- | $100.00 |
| 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 |
| 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 |
| 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 |
| 8009 | BLOOD TYPING (ABO) | 300 | Laboratory | 390 | 86900 | $135.00 | $94.50 | $114.75 | $135.00 | $135.00 | $135.00 | $135.00 | $105.30 | $- | $7.42 | $101.25 | $117.45 | $97.34 | $- | $135.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8365 | CALCIUM, IONIZED | 300 | Laboratory | 301 | 82330 | $80.00 | $56.00 | $68.00 | $80.00 | $80.00 | $80.00 | $80.00 | $62.40 | $- | $33.98 | $60.00 | $69.60 | $57.68 | $- | $80.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8713 | CERULOPLASMIN | 300 | Laboratory | 301 | 82390 | $65.00 | $45.50 | $55.25 | $63.37 | $65.00 | $65.00 | $65.00 | $50.70 | $- | $26.71 | $48.75 | $56.55 | $46.87 | $- | $65.00 |
| 8447 | CHLAMYDIA/GC PROBE-NON AM | 300 | Laboratory | 306 | 87800 | $255.00 | $178.50 | $216.75 | $255.00 | $255.00 | $255.00 | $255.00 | $198.90 | $- | $84.05 | $191.25 | $221.85 | $183.86 | $- | $255.00 |
| 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 |
| 8021 | COMPATIBILITY TEST; ANTIGLOBUL | 300 | Laboratory | 390 | 86922 | $250.00 | $175.00 | $212.50 | $250.00 | $250.00 | $250.00 | $250.00 | $195.00 | $- | $- | $187.50 | $217.50 | $180.25 | $- | $250.00 |
| 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 |
| 8728 | COPPER | 300 | Laboratory | 310 | 82525 | $75.00 | $52.50 | $63.75 | $73.22 | $75.00 | $75.00 | $75.00 | $58.50 | $- | $30.87 | $56.25 | $65.25 | $54.08 | $- | $75.00 |
| 8142 | CORTISOL, SERUM | 300 | Laboratory | 301 | 82533 | $108.00 | $75.60 | $91.80 | $96.17 | $100.41 | $108.00 | $108.00 | $84.24 | $- | $40.55 | $81.00 | $93.96 | $77.87 | $- | $108.00 |
| 30087636 | COVID PCR & FLU | 300 | Laboratory | 300 | 87636 | $150.00 | $105.00 | $127.50 | $150.00 | $150.00 | $150.00 | $150.00 | $117.00 | $- | $- | $112.50 | $130.50 | $108.15 | $- | $150.00 |
| 30087637 | COVID PCR, FLU, RSV | 300 | Laboratory | 300 | 87637 | $150.00 | $105.00 | $127.50 | $150.00 | $150.00 | $150.00 | $150.00 | $117.00 | $- | $- | $112.50 | $130.50 | $108.15 | $- | $150.00 |
| 8811 | Covid-19 Antibody IgG | 300 | Laboratory | 300 | 86769 | $150.00 | $105.00 | $127.50 | $150.00 | $150.00 | $150.00 | $150.00 | $117.00 | $- | $- | $112.50 | $130.50 | $108.15 | $- | $150.00 |
| 8810 | Covid-19 Antibody Total | 300 | Laboratory | 300 | 86769 | $150.00 | $105.00 | $127.50 | $150.00 | $150.00 | $150.00 | $150.00 | $117.00 | $- | $- | $112.50 | $130.50 | $108.15 | $- | $150.00 |
| 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 |
| 8022 | CPK;TOTAL | 300 | Laboratory | 301 | 82550 | $38.00 | $26.60 | $32.30 | $38.00 | $38.00 | $38.00 | $38.00 | $29.64 | $- | $16.22 | $28.50 | $33.06 | $27.40 | $- | $38.00 |
| 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 |
| 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 |
| 8028 | CULTURE BACTERIAL STOOL | 300 | Laboratory | 306 | 87045 | $55.00 | $38.50 | $46.75 | $55.00 | $55.00 | $55.00 | $55.00 | $55.00 | $- | $23.47 | $41.25 | $47.85 | $39.66 | $- | $55.00 |
| 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 |
| 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 |
| 8090 | CULTURE, AEROBIC ISOLATE | 300 | Laboratory | 306 | 87077 | $50.00 | $35.00 | $42.50 | $47.67 | $49.77 | $50.00 | $50.00 | $39.00 | $- | $20.09 | $37.50 | $43.50 | $36.05 | $- | $50.00 |
| 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 |
| 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 |
| 8115 | CYANOCOBALAMIN (VITAMIN B-12) | 300 | Laboratory | 301 | 82607 | $101.00 | $70.70 | $85.85 | $88.97 | $92.89 | $101.00 | $101.00 | $78.78 | $- | $37.49 | $75.75 | $87.87 | $72.82 | $- | $101.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | $130.00 | $91.00 | $110.50 | $128.03 | $130.00 | $130.00 | $130.00 | $101.40 | $- | $21.76 | $97.50 | $113.10 | $93.73 | $- | $130.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8689 | GLIADIN AB IGG | 300 | Laboratory | 301 | 83516 | $70.00 | $49.00 | $59.50 | $68.03 | $70.00 | $70.00 | $70.00 | $54.60 | $- | $28.71 | $52.50 | $60.90 | $50.47 | $- | $70.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8509 | HCG SERUM | 300 | Laboratory | 301 | 84703 | $45.00 | $31.50 | $38.25 | $44.37 | $45.00 | $45.00 | $45.00 | $35.10 | $7.34 | $18.68 | $33.75 | $39.15 | $32.45 | $7.34 | $45.00 |
| 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 |
| 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 |
| 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 |
| 8125 | HEPATIC FUNCTION PANEL | 300 | Laboratory | 301 | 80076 | $50.00 | $35.00 | $42.50 | $48.20 | $50.00 | $50.00 | $50.00 | $39.00 | $- | $20.32 | $37.50 | $43.50 | $36.05 | $- | $50.00 |
| 8351 | HEPATITIS B SURFACE AB | 300 | Laboratory | 302 | 86706 | $65.00 | $45.50 | $55.25 | $63.37 | $65.00 | $65.00 | $65.00 | $50.70 | $- | $26.71 | $48.75 | $56.55 | $46.87 | $- | $65.00 |
| 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 |
| 8192 | HEPATITIS PANEL | 300 | Laboratory | 301 | 80074 | $275.00 | $192.50 | $233.75 | $275.00 | $275.00 | $275.00 | $275.00 | $214.50 | $- | $118.48 | $206.25 | $239.25 | $198.28 | $- | $275.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | $37.00 | $25.90 | $31.45 | $35.64 | $37.00 | $37.00 | $37.00 | $28.86 | $- | $15.03 | $27.75 | $32.19 | $26.68 | $- | $37.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8463 | MUMPS (MMR TITER) | 300 | Laboratory | 302 | 86735 | $80.00 | $56.00 | $68.00 | $77.00 | $80.00 | $80.00 | $80.00 | $62.40 | $- | $32.45 | $60.00 | $69.60 | $57.68 | $- | $80.00 |
| 8813 | NTBNP2 | 300 | Laboratory | 300 | 83880 | $230.00 | $161.00 | $195.50 | $230.00 | $230.00 | $230.00 | $230.00 | $179.40 | $- | $61.66 | $172.50 | $200.10 | $165.83 | $- | $230.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8234 | PROGESTERONE | 300 | Laboratory | 301 | 84144 | $139.00 | $97.30 | $118.15 | $123.07 | $128.50 | $139.00 | $139.00 | $108.42 | $- | $51.89 | $104.25 | $120.93 | $100.22 | $- | $139.00 |
| 8235 | PROLACTIN | 300 | Laboratory | 301 | 84146 | $115.00 | $80.50 | $97.75 | $114.34 | $115.00 | $115.00 | $115.00 | $89.70 | $- | $48.20 | $86.25 | $100.05 | $82.92 | $- | $115.00 |
| 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 |
| 8036 | PSA TOTAL | 300 | Laboratory | 301 | 84153 | $110.00 | $77.00 | $93.50 | $108.50 | $110.00 | $110.00 | $110.00 | $85.80 | $20.56 | $45.76 | $82.50 | $95.70 | $79.31 | $20.56 | $110.00 |
| 8834 | PSA Total Reflex to Free | 300 | Laboratory | 300 | 84153 | $120.00 | $84.00 | $102.00 | $108.50 | $113.28 | $120.00 | $120.00 | $93.60 | $20.56 | $45.76 | $90.00 | $104.40 | $86.52 | $20.56 | $120.00 |
| 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 |
| 8809 | Rapid Covid-19 antigen test | 300 | Laboratory | 300 | 87426 | $82.00 | $57.40 | $69.70 | $82.00 | $82.00 | $82.00 | $82.00 | $63.96 | $- | $- | $61.50 | $71.34 | $59.12 | $- | $82.00 |
| 8812 | Rapid Covid-19 Test | 300 | Laboratory | 300 | 87811 | $125.00 | $87.50 | $106.25 | $125.00 | $125.00 | $125.00 | $125.00 | $97.50 | $- | $- | $93.75 | $108.75 | $90.13 | $- | $125.00 |
| 8397 | RAPID STREP TEST | 300 | Laboratory | 306 | 87880 | $85.00 | $59.50 | $72.25 | $85.00 | $85.00 | $85.00 | $85.00 | $66.30 | $- | $29.84 | $63.75 | $73.95 | $61.29 | $- | $85.00 |
| 8835 | Reflex to free on PSA free and total | 300 | Laboratory | 300 | 84154 | $75.00 | $52.50 | $63.75 | $75.00 | $75.00 | $75.00 | $75.00 | $58.50 | $- | $45.76 | $56.25 | $65.25 | $54.08 | $- | $75.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8465 | RUBELLA (MMR TITER) | 300 | Laboratory | 302 | 86762 | $85.00 | $59.50 | $72.25 | $84.90 | $85.00 | $85.00 | $85.00 | $66.30 | $- | $35.80 | $63.75 | $73.95 | $61.29 | $- | $85.00 |
| 8064 | RUBELLA AB. | 300 | Laboratory | 302 | 86762 | $85.00 | $59.50 | $72.25 | $84.90 | $85.00 | $85.00 | $85.00 | $66.30 | $- | $35.80 | $63.75 | $73.95 | $61.29 | $- | $85.00 |
| 8464 | RUBEOLA (MMR TITER) | 300 | Laboratory | 302 | 86765 | $80.00 | $56.00 | $68.00 | $75.99 | $79.34 | $80.00 | $80.00 | $62.40 | $- | $32.06 | $60.00 | $69.60 | $57.68 | $- | $80.00 |
| 8065 | SALICYLATES ANY SOURCE | 300 | Laboratory | 301 | 80329 | $232.00 | $162.40 | $197.20 | $- | $- | $- | $- | $180.96 | $- | $- | $174.00 | $201.84 | $167.27 | $- | $201.84 |
| 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 |
| 8050 | SENSITIVITY 13 DISK | 300 | Laboratory | 306 | 87184 | $45.00 | $31.50 | $38.25 | $44.13 | $45.00 | $45.00 | $45.00 | $35.10 | $7.70 | $17.15 | $33.75 | $39.15 | $32.45 | $7.70 | $45.00 |
| 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 |
| 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 |
| 8239 | T4 (TOTAL) | 300 | Laboratory | 301 | 84436 | $40.00 | $28.00 | $34.00 | $40.00 | $40.00 | $40.00 | $40.00 | $31.20 | $- | $17.10 | $30.00 | $34.80 | $28.84 | $- | $40.00 |
| 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 |
| 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 | $125.00 | $87.50 | $106.25 | $125.00 | $125.00 | $125.00 | $125.00 | $97.50 | $- | $16.90 | $93.75 | $108.75 | $90.13 | $- | $125.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8338 | URINE SODIUM | 300 | Laboratory | 301 | 84300 | $33.00 | $23.10 | $28.05 | $29.85 | $31.17 | $33.00 | $33.00 | $25.74 | $- | $12.10 | $24.75 | $28.71 | $23.79 | $- | $33.00 |
| 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 |
| 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 |
| 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 |
| 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 |
| 8497 | VZV AB IGG | 300 | Laboratory | 302 | 86787 | $77.00 | $53.90 | $65.45 | $75.99 | $77.00 | $77.00 | $77.00 | $60.06 | $- | $20.36 | $57.75 | $66.99 | $55.52 | $- | $77.00 |
| 8729 | ZINC | 300 | Laboratory | 301 | 84630 | $70.00 | $49.00 | $59.50 | $67.20 | $70.00 | $70.00 | $70.00 | $54.60 | $- | $28.33 | $52.50 | $60.90 | $50.47 | $- | $70.00 |
| 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 |
| 2102 | CLINICAL SWALLOWING EVALUATION | 420 | Physical Therapy | 440 | 92610 | $270.00 | $189.00 | $229.50 | $270.00 | $270.00 | $270.00 | $270.00 | $210.60 | $- | $151.80 | $202.50 | $234.90 | $194.67 | $- | $270.00 |
| 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 |
| 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 |
| 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 |
| 265068 | MANUAL THERAPY TECHNIQUES | 420 | Physical Therapy | 420 | 97140 | $115.00 | $80.50 | $97.75 | $115.00 | $115.00 | $115.00 | $115.00 | $89.70 | $28.81 | $40.34 | $86.25 | $100.05 | $82.92 | $28.81 | $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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 28002 | SPEECH TREATMENT | 420 | Physical Therapy | 440 | 92507 | $185.00 | $129.50 | $157.25 | $185.00 | $185.00 | $185.00 | $185.00 | $144.30 | $54.23 | $118.87 | $138.75 | $160.95 | $133.39 | $54.23 | $185.00 |
| 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 |
| 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 |
| 265011 | THERAPEUTIC-GROUP | 420 | Physical Therapy | 420 | 97150 | $90.00 | $63.00 | $76.50 | $82.46 | $86.20 | $90.00 | $90.00 | $70.20 | $29.00 | $28.88 | $67.50 | $78.30 | $64.89 | $28.88 | $90.00 |
| 28005 | TREAT. SWALLOWING/ORAL FU | 420 | Physical Therapy | 440 | 92526 | $200.00 | $140.00 | $170.00 | $200.00 | $200.00 | $200.00 | $200.00 | $156.00 | $62.80 | $121.26 | $150.00 | $174.00 | $144.20 | $62.80 | $200.00 |
| 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 |
| 11001 | ABDOMEN (KUB) 1 VIEW | 320 | Radiology Diag | 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 |
| 11077 | ABDOMEN SONOGRAM | 320 | Radiology Diag | 402 | 76700 | $569.00 | $398.30 | $483.65 | $569.00 | $569.00 | $569.00 | $569.00 | $443.82 | $154.46 | $182.34 | $426.75 | $495.03 | $410.25 | $154.46 | $569.00 |
| 19032 | ABDOMEN W/CONTRAST | 320 | Radiology Diag | 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 |
| 19031 | ABDOMEN W/O CONTRAST | 320 | Radiology Diag | 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 |
| 11002 | ABDOMEN, UPRIGHT & SUPINE | 320 | Radiology Diag | 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 |
| 73601 | Ankle 2 view Rt | 320 | Radiology Diag | 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 Diag | 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 |
| 11058 | ANKLE BRACHIAL INDEX | 320 | Radiology Diag | 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 |
| 11004R | ANKLE COMPLETE MIN 3 VWS | 320 | Radiology Diag | 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 Diag | 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 |
| 11078 | AORTA SONOGRAM SCREENING | 320 | Radiology Diag | 402 | 76706 | $415.00 | $290.50 | $352.75 | $415.00 | $415.00 | $415.00 | $415.00 | $323.70 | $- | $- | $311.25 | $361.05 | $299.22 | $- | $415.00 |
| 11112 | ARTERIAL DUPLEX SCAN LEFT | 320 | Radiology Diag | 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 Diag | 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 |
| 11124 | BILATERAL ARTERIAL LOW EX | 320 | Radiology Diag | 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 |
| 11133 | BILATERAL HIPS | 320 | Radiology Diag | 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 |
| 11130 | BONE DEXA SCAN | 320 | Radiology Diag | 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 Diag | 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 |
| 11103 | BREAST ULTRASOUND; LEFT | 320 | Radiology Diag | 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 |
| 11103R | BREAST ULTRASOUND; RIGHT | 320 | Radiology Diag | 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 |
| 11063 | C SPINE 2 or 3 Views | 320 | Radiology Diag | 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 Diag | 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 |
| 11005 | CHEST 1 VIEW | 320 | Radiology Diag | 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 Diag | 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 |
| 11093 | CHEST SONO | 320 | Radiology Diag | 402 | 76604 | $535.00 | $374.50 | $454.75 | $535.00 | $535.00 | $535.00 | $535.00 | $417.30 | $103.90 | $121.58 | $401.25 | $465.45 | $385.74 | $103.90 | $535.00 |
| 11007 | CLAVICLE COMPLETE; LEFT | 320 | Radiology Diag | 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 |
| 11007R | CLAVICLE XRAY; RIGHT | 320 | Radiology Diag | 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 |
| 19016 | C-SPINE W/O CONTRAST | 320 | Radiology Diag | 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 |
| 19042 | CT ABDOMEN/PELVIS W W/O CNTRST | 320 | Radiology Diag | 350 | 74178 | $2,472.00 | $1,730.40 | $2,101.20 | $2,472.00 | $2,472.00 | $2,472.00 | $2,472.00 | $1,928.16 | $- | $- | $700.00 | $2,150.64 | $1,782.31 | $- | $2,472.00 |
| 19043 | CT ABDOMEN/PELVIS W/O CONTRAST | 320 | Radiology Diag | 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 |
| 19045 | CT Abdominal Aorta w/ contrast | 320 | Radiology Diag | 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 |
| 19044 | CT chest PEw/contrast | 320 | Radiology Diag | 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 |
| 19041 | CT-ABDOMEN & PELVIS W/CONT | 320 | Radiology Diag | 350 | 74177 | $2,000.00 | $1,400.00 | $1,700.00 | $2,000.00 | $2,000.00 | $2,000.00 | $2,000.00 | $1,560.00 | $- | $- | $700.00 | $1,740.00 | $1,442.00 | $- | $2,000.00 |
| 11099 | DUPLEX SCAN EXTRACRANIAL | 320 | Radiology Diag | 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 |
| 11108 | DUPLEX SCAN VENOUS SYSTEM | 320 | Radiology Diag | 921 | 93970 | $750.00 | $525.00 | $637.50 | $750.00 | $750.00 | $750.00 | $750.00 | $585.00 | $223.25 | $372.74 | $562.50 | $652.50 | $540.75 | $223.25 | $750.00 |
| 11104 | ECHOCARDIOGRAM | 320 | Radiology Diag | 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 |
| 11013L | ELBOW AP & LAT | 320 | Radiology Diag | 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 Diag | 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 Diag | 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 Diag | 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 |
| 11015 | FACIAL BONES COMPLETE | 320 | Radiology Diag | 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 |
| 11017L | FEMUR AP & LAT | 320 | Radiology Diag | 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 Diag | 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 |
| 11019L | FINGER SERIES MIN 2 VWS | 320 | Radiology Diag | 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 Diag | 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 |
| 11020L | FOOT AP & LAT 2 VIEWS | 320 | Radiology Diag | 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 Diag | 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 Diag | 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 Diag | 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 |
| 11148 | Forearm 1 View; Left | 320 | Radiology Diag | 320 | 73090 | $180.00 | $126.00 | $153.00 | $180.00 | $180.00 | $180.00 | $180.00 | $140.40 | $36.47 | $44.04 | $135.00 | $156.60 | $129.78 | $36.47 | $180.00 |
| 11149 | Forearm 1 View; Right | 320 | Radiology Diag | 320 | 73090 | $180.00 | $126.00 | $153.00 | $180.00 | $180.00 | $180.00 | $180.00 | $140.40 | $36.47 | $44.04 | $135.00 | $156.60 | $129.78 | $36.47 | $180.00 |
| 11022L | FOREARM AP & LAT 2 VIEWS | 320 | Radiology Diag | 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 Diag | 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 |
| 73120 | Hand 2 view Right | 320 | Radiology Diag | 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 Diag | 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 Diag | 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 Diag | 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 |
| 19001 | HEAD W/O CONTRAST | 320 | Radiology Diag | 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 |
| 11027R | HIP COMP MIN 2 VIEW RIGHT | 320 | Radiology Diag | 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 |
| 11027L | HIP COMP MIN 2 VIEWS LEFT | 320 | Radiology Diag | 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 |
| 11137 | Hip LEFT w/ pelvis | 320 | Radiology Diag | 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 |
| 11137R | HIP RT W/ PELVIS | 320 | Radiology Diag | 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 |
| 11028L | HUMERUS 2 VIEWS | 320 | Radiology Diag | 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 Diag | 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 |
| 73561 | Knee 3 Views Left | 320 | Radiology Diag | 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 Diag | 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 |
| 11029L | KNEE AP & LAT LEFT | 320 | Radiology Diag | 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 Diag | 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 |
| 11067 | L SPINE 2 or 3 VIEWS | 320 | Radiology Diag | 320 | 72100 | $350.00 | $245.00 | $297.50 | $350.00 | $350.00 | $350.00 | $350.00 | $273.00 | $47.95 | $57.67 | $262.50 | $304.50 | $252.35 | $47.95 | $350.00 |
| 11068 | L SPINE COMPLETE | 320 | Radiology Diag | 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 |
| 19028R | LOWER EXT CT WO CONTRAST; RIGHT | 320 | Radiology Diag | 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 Diag | 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 |
| 19020 | L-SPINE W/O CONTRAST | 320 | Radiology Diag | 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 |
| 19009 | MAXILLOFACIAL W/O & W/CON | 320 | Radiology Diag | 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 |
| 19007 | MAXILLOFACIAL W/O CONT. | 320 | Radiology Diag | 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 |
| 2013 | MRI BRAIN W/O & WITH | 320 | Radiology Diag | 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 |
| 2042 | MRI LOWER EXT ANY JOINT W/O CONT; LEFT | 320 | Radiology Diag | 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 |
| 2042R | MRI LOWER EXT ANY JOINT W/O CONT; RIGHT | 320 | Radiology Diag | 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 |
| 2028 | MRI PELVIS W/O | 320 | Radiology Diag | 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 |
| 2018 | MRI SPINAL CANAL&CONTS CERVW/O | 320 | Radiology Diag | 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 Diag | 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 |
| 2035 | MRI UPPER EXT ANY JOINT WO CONT; LEFT | 320 | Radiology Diag | 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 |
| 2035R | MRI UPPER EXT ANY JOINT WO CONT; RIGHT | 320 | Radiology Diag | 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 |
| 2024 | MRISPINAL CAN&CONTS LUMBAR W/O | 320 | Radiology Diag | 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 |
| 2021 | MRISPINAL CAN&CONTS.THORAC W/O | 320 | Radiology Diag | 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 |
| 11042 | NECK SOFT TISSUES | 320 | Radiology Diag | 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 |
| 11084 | OBSTETRICS SONOGRAM | 320 | Radiology Diag | 402 | 76805 | $435.00 | $304.50 | $369.75 | $435.00 | $435.00 | $435.00 | $435.00 | $339.30 | $174.85 | $205.76 | $326.25 | $378.45 | $313.64 | $174.85 | $435.00 |
| 11087 | PELVIC MASS SONOGRAM | 320 | Radiology Diag | 402 | 76856 | $535.00 | $374.50 | $454.75 | $535.00 | $535.00 | $535.00 | $535.00 | $417.30 | $125.22 | $146.59 | $401.25 | $465.45 | $385.74 | $125.22 | $535.00 |
| 11043 | PELVIS AP 1/2 VIEWS | 320 | Radiology Diag | 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 |
| 19023 | PELVIS W/CONTRAST | 320 | Radiology Diag | 350 | 72193 | $1,178.00 | $824.60 | $1,001.30 | $1,178.00 | $1,178.00 | $1,178.00 | $1,178.00 | $918.84 | $- | $490.97 | $700.00 | $1,024.86 | $849.34 | $- | $1,178.00 |
| 19022 | PELVIS W/O CONTRAST | 320 | Radiology Diag | 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 |
| 11048 | RENAL ARTERY DOPPLER | 320 | Radiology Diag | 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 |
| 11080 | RENAL SONOGRAM | 320 | Radiology Diag | 402 | 76770 | $535.00 | $374.50 | $454.75 | $535.00 | $535.00 | $535.00 | $535.00 | $417.30 | $149.26 | $176.16 | $401.25 | $465.45 | $385.74 | $149.26 | $535.00 |
| 11047R | RIBS UNI MIN 3 VW | 320 | Radiology Diag | 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 Diag | 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 |
| 11049 | SCARUM & COCCYX MIN 2 VWS | 320 | Radiology Diag | 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 |
| 11054L | SHOULDER LEFT MIN 2 VIEWS | 320 | Radiology Diag | 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 Diag | 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 |
| 11057 | SKULL SERIES | 320 | Radiology Diag | 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 |
| 19011 | SOFT TISSUE NECK W/CONT. | 320 | Radiology Diag | 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 |
| 19010 | SOFT TISSUE NECK W/O CONT | 320 | Radiology Diag | 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 |
| 11083 | SOFT TISSUE SONO HEAD/NEK | 320 | Radiology Diag | 402 | 76536 | $535.00 | $374.50 | $454.75 | $535.00 | $535.00 | $535.00 | $535.00 | $417.30 | $109.88 | $129.71 | $401.25 | $465.45 | $385.74 | $109.88 | $535.00 |
| 11065 | T SPINE AP & LAT | 320 | Radiology Diag | 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 |
| 19014 | THORAX W/CONTRAST | 320 | Radiology Diag | 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 |
| 19013 | THORAX W/O CONTRAST | 320 | Radiology Diag | 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 |
| 11113R | TMJs UNILATERAL; RIGHT | 320 | Radiology Diag | 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 Diag | 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 Diag | 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 |
| 11115 | TRANSVAGINAL ULTRASOUND | 320 | Radiology Diag | 402 | 76830 | $420.00 | $294.00 | $357.00 | $420.00 | $420.00 | $420.00 | $420.00 | $327.60 | $125.22 | $146.59 | $315.00 | $365.40 | $302.82 | $125.22 | $420.00 |
| 19018 | T-SPINE W/O CONTRAST | 320 | Radiology Diag | 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 |
| 19026 | UPPER EXT W/ CONTRAST; LEFT | 320 | Radiology Diag | 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 |
| 19026R | UPPER EXT CT W/ CONTRAST; RIGHT | 320 | Radiology Diag | 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 |
| 19025 | UPPER EXT CT W/O CONTRAST; LEFT | 320 | Radiology Diag | 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 |
| 19025R | UPPER EXT CT WO CONTRAST; RIGHT | 320 | Radiology Diag | 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 |
| 11119 | UPPER EXT ULTRASOUND; LEFT | 320 | Radiology Diag | 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 |
| 11114 | Venous Duplex Unilateral Left | 320 | Radiology Diag | 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 |
| 11114R | VENOUS DUPLEX UNILATERAL; RIGHT | 320 | Radiology Diag | 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 |
| 11075L | WRIST COMPLETE MIN 3 VWS | 320 | Radiology Diag | 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 Diag | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call {877-696-6775}
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