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 7/21/2023
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.
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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