Price Transparency

OVERVIEW 

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

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

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

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

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

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

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

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

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

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

QUESTIONS?

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

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Searchable Shoppable Services

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

Charge CodeCharge Code DescriptionDept #DeptRevCodeCPT CodeCurrent PriceCash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAFirstCare - HMOFirstCare - PPOHealthSourceHumanaUnitedMinimum Negotiated RateMaximum Negotiated Rate
45036430TRANSFUSION380Blood/Blood Products39136430$ 900.00$ 630.00$ 765.00$ -$ -$ -$ -$ 702.00$ 63.33$ 60.78$ 675.00$ 783.00$ 648.90$ -$ 783.00
10006EKG-Tracing only (with at least 12 leads730EKG/ECG73093005$ 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
10009HOLTER MONITOR 24-48 HOUR730EKG/ECG73193225$ 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
8333BASIC METABOLIC PANEL300Laboratory30180048$ 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
8747GENERAL HEALTH PANEL300Laboratory31080050$ 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
8120COMPREHENSIVE METABOLIC PANEL300Laboratory30180053$ 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
8181LIPID PANEL300Laboratory30180061$ 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
8392RENAL FUNCTION PANEL300Laboratory30180069$ 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
8192HEPATITIS PANEL300Laboratory30180074$ 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
8125HEPATIC FUNCTION PANEL300Laboratory30180076$ 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
8070CARBAMAZEPINE (TEGRETOL)300Laboratory30180156$ 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
8034DIGOXIN300Laboratory30180162$ 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
8051VALPROIC ACID (DEPAKENE)300Laboratory30180164$ 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
8108LITHIUM300Laboratory30180178$ 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
8035DILANTIN, PHENTOIN TOTAL300Laboratory30180185$ 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
8225VANCOMYCIN300Laboratory30180202$ 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
8529KEPPRA LEVEL300Laboratory30180299$ 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
8798AMDN300Laboratory30080299$ 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
8634Drug screen; comprehensive300Laboratory30180306$ 115.00$ 80.50$ 97.75$ 101.13$ 105.58$ 114.84$ 114.84$ 89.70$ -$ -$ 86.25$ 100.05$ 82.92$ -$ 114.84
8634TRIAGE UA DRUG SCREEN 9 PANEL300Laboratory30180306$ 115.00$ 80.50$ 97.75$ 101.13$ 105.58$ 114.84$ 114.84$ 89.70$ -$ -$ 86.25$ 100.05$ 82.92$ -$ 114.84
8176ALCOHOL (ETOH)300Laboratory30180320$ 78.00$ 54.60$ 66.30$ -$ -$ -$ -$ 60.84$ -$ -$ 58.50$ 67.86$ 56.24$ -$ 67.86
8739AMP/MAMP CONFIRMATION300Laboratory30180324$ 133.00$ 93.10$ 113.05$ -$ -$ -$ -$ 103.74$ -$ -$ 99.75$ 115.71$ 95.89$ -$ 115.71
8193ACETAMINOPHEN SERUM300Laboratory30180329$ 232.00$ 162.40$ 197.20$ -$ -$ -$ -$ 180.96$ -$ -$ 174.00$ 201.84$ 167.27$ -$ 201.84
8065SALICYLATES ANY SOURCE300Laboratory30180329$ 232.00$ 162.40$ 197.20$ -$ -$ -$ -$ 180.96$ -$ -$ 174.00$ 201.84$ 167.27$ -$ 201.84
8077URINALYSIS BY DIPSTICK300Laboratory30781000$ 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
8806Urinalysis, complete300Laboratory30081001$ 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
8078HCG URINE300Laboratory30781025$ 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
8170ALPHA FETOPROTEIN (TUMOR)300Laboratory30182105$ 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
8082AMMONIA300Laboratory30182140$ 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
8003AMYLASE300Laboratory30182150$ 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
8048OCCULT BLOOD, FECES (1-3)300Laboratory30182272$ 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
8718BLOOD OCCULT300Laboratory30082272$ 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
8253CALCIFEDIOL 25-OH VITAMIN D-3300Laboratory30182306$ 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
8817Vitamin D 3 level300Laboratory30082306$ 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
8365CALCIUM, IONIZED300Laboratory30182330$ 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
8014CEA LEVEL300Laboratory30182378$ 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
8713CERULOPLASMIN300Laboratory30182390$ 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
8728COPPER300Laboratory31082525$ 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
8142CORTISOL, SERUM300Laboratory30182533$ 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
848924 URINE CREATINE300Laboratory30182540$ 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
8022CPK;TOTAL300Laboratory30182550$ 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
8177MB FRACTION ONLY300Laboratory30182553$ 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
8023CREATININE;BLOOD300Laboratory30182565$ 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
8773Urine Creatinine Reference300Laboratory30182570$ 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
8773Urine Creatinine Ref300Laboratory30182570$ 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
8261URINE CREATININE (24HR)300Laboratory30182570$ 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
8115CYANOCOBALAMIN (VITAMIN B-12)300Laboratory30182607$ 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
8098ESTRADIOL300Laboratory30182670$ 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
8451ESTROGEN TOTAL300Laboratory30182672$ 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
8135FERRITIN300Laboratory30182728$ 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
8101FOLIC ACID SERUM300Laboratory30182746$ 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
8130IGA QUAN SERUM OR CSF300Laboratory30182784$ 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
8131IGG QUAN SERUM OR CSF300Laboratory30182784$ 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
8822IFE Immunofixation, Serum300Laboratory30082784$ 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
8122GASES,ARTERIAL BLOOD300Laboratory30182803$ 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
8037GLUCOSE ALL BODY FLUIDS300Laboratory30182947$ 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
8038GLUCOSE TOLERANCE 3 SPECS300Laboratory30182951$ 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
8038BGTT EACH ADD'L SPEC > 3300Laboratory30182952$ 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
8180GGT300Laboratory30182977$ 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
8231FSH SERUM300Laboratory30183001$ 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
8232LH300Laboratory30183002$ 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
8161GLYCOSYLATED HGB (HGBA1C)300Laboratory30183036$ 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
81675-HIAA 24 HOUR300Laboratory30183497$ 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
8689GLIADIN AB IGG300Laboratory30183516$ 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
8197INSULIN LEVELS300Laboratory30183525$ 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
8102IRON300Laboratory30183540$ 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
8103IRON BINDING CAPACITY300Laboratory30183550$ 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
8387LACTATE LEVELS300Laboratory30183605$ 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
8044LDH300Laboratory30183615$ 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
8173LIPASE300Laboratory30183690$ 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 CodeCharge Code DescriptionDept #DeptRevCodeCPT CodeCurrent PriceCash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAFirstCare - HMOFirstCare - PPOHealthSourceHumanaUnitedMinimum Negotiated RateMaximum Negotiated Rate
8045MAGNESIUM (MG)300Laboratory30183735$ 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
8813NTBNP2300Laboratory30083880$ 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
8424B-TYPE NATRIURETIC PEPTID300Laboratory30183880$ 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
8202URINE OSMOLALITY300Laboratory30183935$ 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
8347PTH INTACT300Laboratory30183970$ 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
8055PHOSPHORUS INORGANIC(P04)300Laboratory30184100$ 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
8058POTASSIUM (K) SERUM300Laboratory30184132$ 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
8337URINE POTASSIUM300Laboratory30184133$ 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
8234PROGESTERONE300Laboratory30184144$ 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
8749PROCALCITONIN (PCT)300Laboratory30184145$ 200.00$ 140.00$ 170.00$ 160.60$ 167.68$ 182.37$ 182.37$ 156.00$ -$ -$ 150.00$ 174.00$ 144.20$ -$ 182.37
8235PROLACTIN300Laboratory30184146$ 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
8036PSA TOTAL300Laboratory30184153$ 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
8834PSA Total Reflex to Free300Laboratory30084153$ 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
8835Reflex to free on PSA free and total300Laboratory30084154$ 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
8216URINE PROTEIN 24 HOUR300Laboratory30184156$ 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
8787Urine Total Protein300Laboratory30184156$ 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
8338URINE SODIUM300Laboratory30184300$ 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
8449TESTOSTERONE LEVEL FREE300Laboratory30184402$ 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
8450TESTOSTERONE LEVEL TOTAL300Laboratory30184403$ 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
8648THIAMINE (VITAMIN B-1)300Laboratory30184425$ 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
8239T4 (TOTAL)300Laboratory30184436$ 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
8408T4 FREE300Laboratory30184439$ 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
8137TSH300Laboratory30184443$ 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
8682TRANSFERRIN300Laboratory30184466$ 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
8229T3 (TOTAL)300Laboratory30184480$ 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
8362T3 (FREE)300Laboratory30184481$ 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
8399TROPONIN I, QUALITATIVE300Laboratory30184484$ 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
8076URIC ACID SERUM300Laboratory30184550$ 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
8729ZINC300Laboratory30184630$ 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
8305HCG QUANTATIVE300Laboratory30184702$ 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
8509HCG SERUM300Laboratory30184703$ 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 DIFFERENTIAL300Laboratory30585007$ 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
8041HEMATOCRIT (HCT)300Laboratory30585014$ 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
8042HEMOGLOBIN (HGB)300Laboratory30585018$ 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
8018CBC AUTO DIFF300Laboratory30585025$ 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 HEMOGRAM300Laboratory30585027$ 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
8062RETICULOCYTE COUNT300Laboratory30585044$ 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
8416PATHOLOGY CONSULT300Laboratory30585060$ 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
8363D-DIMER (FSP)300Laboratory30585378$ 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
8701PROTHROMBIN TIME300Laboratory30585610$ 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
8066SEDIMENTATION RATE (ESR)300Laboratory30585651$ 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
8054THROMBOPLASTIN TIME PTT300Laboratory30585730$ 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
8004ANA300Laboratory30286038$ 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
8147C-REACTIVE PROTEIN300Laboratory30286140$ 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
8031C-3,COMPLEMENT300Laboratory30286160$ 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
8032C-4 COMPLEMENT300Laboratory30286160$ 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
8423ANTI-MITRO CHONDRIAL ANTI300Laboratory30086255$ 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
8224EPSTEIN BARR VIRUS PANEL300Laboratory30286256$ 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
8630H.PYLORI (SCREENING)300Laboratory30286318$ 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
8163MICROSOMAL ANTIBODIES300Laboratory30086376$ 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
8340RHEUMATOID FACTOR QUANIT300Laboratory30286431$ 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
8218HIV AB ELISA300Laboratory30286701$ 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
8351HEPATITIS B SURFACE AB300Laboratory30286706$ 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
8463MUMPS (MMR TITER)300Laboratory30286735$ 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
8064RUBELLA AB.300Laboratory30286762$ 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
8465RUBELLA (MMR TITER)300Laboratory30286762$ 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
8464RUBEOLA (MMR TITER)300Laboratory30286765$ 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
8811Covid-19 Antibody IgG300Laboratory30086769$ 200.00$ 140.00$ 170.00$ 200.00$ 200.00$ 200.00$ 200.00$ 156.00$ -$ -$ 150.00$ 174.00$ 144.20$ -$ 200.00
8810Covid-19 Antibody Total300Laboratory30086769$ 200.00$ 140.00$ 170.00$ 200.00$ 200.00$ 200.00$ 200.00$ 156.00$ -$ -$ 150.00$ 174.00$ 144.20$ -$ 200.00
8497VZV AB IGG300Laboratory30286787$ 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
8162THYROGLOBULIN ANTIBODY300Laboratory30286800$ 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
8011ANTIBODY SCREEN;RBC300Laboratory30286850$ 210.00$ 147.00$ 178.50$ 210.00$ 210.00$ 210.00$ 210.00$ 163.80$ -$ -$ 157.50$ 182.70$ 151.41$ -$ 210.00
8009BLOOD TYPING (ABO)300Laboratory39086900$ 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
8010RH (D)300Laboratory30086901$ 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
8021COMPATIBILITY TEST; ANTIGLOBUL300Laboratory39086922$ 975.00$ 682.50$ 828.75$ 846.65$ 883.96$ 961.45$ 961.45$ 760.50$ -$ -$ 731.25$ 848.25$ 702.98$ -$ 961.45
8017CULTURE,BACTERIAL; BLOOD300Laboratory30687040$ 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
8028CULTURE BACTERIAL STOOL300Laboratory30687045$ 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
8057CULTURE THROAT OR NOSE300Laboratory30687070$ 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
8025CULTURE, ANY OTHER SOUCE300Laboratory30687070$ 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
8184ANAEROBIC CULTURE WOUND300Laboratory30687075$ 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 CodeCharge Code DescriptionDept #DeptRevCodeCPT CodeCurrent PriceCash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAFirstCare - HMOFirstCare - PPOHealthSourceHumanaUnitedMinimum Negotiated RateMaximum Negotiated Rate
8090CULTURE, AEROBIC ISOLATE300Laboratory30687077$ 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
8013CULTURE URINE ROUTINE300Laboratory30687086$ 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
8049OVA & PARASITES, STOOL300Laboratory30687177$ 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
8050SENSITIVITY 13 DISK300Laboratory30687184$ 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
8191CLOSTRIDIUM DIFF TOXIN B300Laboratory30687230$ 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
8809Rapid Covid-19 antigen test300Laboratory30087426$ 150.00$ 105.00$ 127.50$ 100.00$ 100.00$ 100.00$ 100.00$ 117.00$ -$ -$ 112.50$ 130.50$ 108.15$ -$ 130.50
8550C DIFF AG300Laboratory30687449$ 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
8525HEPATITIS C VIRUS RNA300Laboratory30687522$ 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
8800COVID-19 REFERENCE LAB300Laboratory30087635$ 250.00$ 175.00$ 212.50$ 250.00$ 250.00$ 250.00$ 250.00$ 195.00$ -$ -$ 187.50$ 217.50$ 180.25$ -$ 250.00
30087636COVID PCR & FLU300Laboratory30087636$ 200.00$ 140.00$ 170.00$ 200.00$ 200.00$ 200.00$ 200.00$ 156.00$ -$ -$ 150.00$ 174.00$ 144.20$ -$ 200.00
30087637COVID PCR, FLU, RSV300Laboratory30087637$ 200.00$ 140.00$ 170.00$ 200.00$ 200.00$ 200.00$ 200.00$ 156.00$ -$ -$ 150.00$ 174.00$ 144.20$ -$ 200.00
8447CHLAMYDIA/GC PROBE-NON AM300Laboratory30687800$ 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
8454INFLUENZA A&B300Laboratory30687804$ 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
80471RSV RAPID ANTIGEN (INHOUSE)300Laboratory30687807$ 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
8812Rapid Covid-19 Test300Laboratory30087811$ 150.00$ 105.00$ 127.50$ 150.00$ 150.00$ 150.00$ 150.00$ 117.00$ -$ -$ 112.50$ 130.50$ 108.15$ -$ 150.00
8397RAPID STREP TEST300Laboratory30687880$ 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
8145CELL CNT W/DIFF BODY FLUD300Laboratory30589051$ 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
28002SPEECH TREATMENT420Physical Therapy44092507$ 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
28005TREAT. SWALLOWING/ORAL FU420Physical Therapy44092526$ 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
2102CLINICAL SWALLOWING EVALUATION420Physical Therapy44092610$ 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
265062HOT/COLD PACK APPLICATION420Physical Therapy42097010$ 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
265060PARAFFIN BATH420Physical Therapy42097018$ 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
265023ULTRASOUND420Physical Therapy42097035$ 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
265006THERAPEUTIC EXERCISE420Physical Therapy42097110$ 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
265010NEUROMUSCULAR REEDUCATION420Physical Therapy42097112$ 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
265009AQUATIC THERAPY W THER EX420Physical Therapy42097113$ 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
265001GAIT TRAINING420Physical Therapy42097116$ 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
265068MANUAL THERAPY TECHNIQUES420Physical Therapy42097140$ 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
265011THERAPEUTIC-GROUP420Physical Therapy42097150$ 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
265052P.T. EVALUATION LOW COMPLEXITY420Physical Therapy42497161$ 325.00$ 227.50$ 276.25$ 325.00$ 325.00$ 325.00$ 325.00$ 253.50$ -$ -$ 243.75$ 282.75$ 234.33$ -$ 325.00
265054PT EVAL MODERATE COMPLEXITY420Physical Therapy42497162$ 350.00$ 245.00$ 297.50$ 350.00$ 350.00$ 350.00$ 350.00$ 273.00$ -$ -$ 262.50$ 304.50$ 252.35$ -$ 350.00
265051P.T. RE-EVALUATION420Physical Therapy42097164$ 150.00$ 105.00$ 127.50$ 150.00$ 150.00$ 150.00$ 150.00$ 117.00$ -$ -$ 112.50$ 130.50$ 108.15$ -$ 150.00
265045THERAPEUTIC ACTIVITIES420Physical Therapy42097530$ 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
265029DEBRIDEMENT NECROTIC TISSUE420Physical Therapy42097597$ 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
265053DEBRIDEMENT, 15 MINUTES420Physical Therapy42097597$ 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
11015FACIAL BONES COMPLETE320Radiology Diagnostic32070150$ 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
11057SKULL SERIES320Radiology Diagnostic32070260$ 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
11042NECK SOFT TISSUES320Radiology Diagnostic32070360$ 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
19001HEAD W/O CONTRAST320Radiology Diagnostic35070450$ 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
19007MAXILLOFACIAL W/O CONT.320Radiology Diagnostic35070486$ 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
19009MAXILLOFACIAL W/O & W/CON320Radiology Diagnostic35070488$ 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
19010SOFT TISSUE NECK W/O CONT320Radiology Diagnostic35070490$ 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
19011SOFT TISSUE NECK W/CONT.320Radiology Diagnostic35070491$ 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
2013MRI BRAIN W/O & WITH320Radiology Diagnostic61170553$ 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
11005CHEST 1 VIEW320Radiology Diagnostic32071045$ 220.00$ 154.00$ 187.00$ 220.00$ 220.00$ 220.00$ 220.00$ 171.60$ -$ -$ 165.00$ 191.40$ 158.62$ -$ 220.00
11035CHEST PA & LAT PORTABLE320Radiology Diagnostic32071046$ 220.00$ 154.00$ 187.00$ 220.00$ 220.00$ 220.00$ 220.00$ 171.60$ -$ -$ 165.00$ 191.40$ 158.62$ -$ 220.00
11047RRIBS UNI MIN 3 VW320Radiology Diagnostic32071100$ 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
11047LRIBS UNI MIN 3VW320Radiology Diagnostic32071100$ 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
19013THORAX W/O CONTRAST320Radiology Diagnostic35071250$ 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
19014THORAX W/CONTRAST320Radiology Diagnostic35071260$ 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
19044CT chest PEw/contrast320Radiology Diagnostic35071275$ 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
11063C SPINE 2 or 3 Views320Radiology Diagnostic32072040$ 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
11138C spine 4 or 5 views320Radiology Diagnostic32072050$ 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
11065T SPINE AP & LAT320Radiology Diagnostic32072070$ 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
11067L SPINE 2 or 3 VIEWS320Radiology Diagnostic32072100$ 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
11068L SPINE COMPLETE320Radiology Diagnostic32072110$ 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
19016C-SPINE W/O CONTRAST320Radiology Diagnostic35072125$ 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
19018T-SPINE W/O CONTRAST320Radiology Diagnostic35072128$ 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
19020L-SPINE W/O CONTRAST320Radiology Diagnostic35072131$ 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
2018MRI SPINAL CANAL&CONTS CERVW/O320Radiology Diagnostic61272141$ 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
2019MRI SPINAL CANAL&CONTS.CERV W320Radiology Diagnostic61272142$ 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
2021MRISPINAL CAN&CONTS.THORAC W/O320Radiology Diagnostic61272146$ 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
2024MRISPINAL CAN&CONTS LUMBAR W/O320Radiology Diagnostic61272148$ 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
11043PELVIS AP 1/2 VIEWS320Radiology Diagnostic32072170$ 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
19022PELVIS W/O CONTRAST320Radiology Diagnostic35072192$ 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
19023PELVIS W/CONTRAST320Radiology Diagnostic35072193$ 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
2028MRI PELVIS W/O320Radiology Diagnostic61072195$ 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
11049SCARUM & COCCYX MIN 2 VWS320Radiology Diagnostic32072220$ 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
11007RCLAVICLE XRAY; RIGHT320Radiology Diagnostic32073000$ 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
11007CLAVICLE COMPLETE; LEFT320Radiology Diagnostic32073000$ 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 CodeCharge Code DescriptionDept #DeptRevCodeCPT CodeCurrent PriceCash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAFirstCare - HMOFirstCare - PPOHealthSourceHumanaUnitedMinimum Negotiated RateMaximum Negotiated Rate
11054LSHOULDER LEFT MIN 2 VIEWS320Radiology Diagnostic32073030$ 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
11054RSHOULDER RT MIN 2 VIEWS320Radiology Diagnostic32073030$ 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
11028LHUMERUS 2 VIEWS320Radiology Diagnostic32073060$ 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
11028RHUMERUS 2 VIEWS320Radiology Diagnostic32073060$ 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
11013LELBOW AP & LAT320Radiology Diagnostic32073070$ 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
11013RELBOW AP & LAT320Radiology Diagnostic32073070$ 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
11025LELBOW COMPLETE MIN 3 VWS320Radiology Diagnostic32073080$ 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
11025RELBOW COMPLETE MIN 3 VWS320Radiology Diagnostic32073080$ 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
11148Forearm 1 View; Left320Radiology Diagnostic32073090$ 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
11149Forearm 1 View; Right320Radiology Diagnostic32073090$ 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
11022LFOREARM AP & LAT 2 VIEWS320Radiology Diagnostic32073090$ 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
11022RFOREARM AP & LAT 2 VIEWS320Radiology Diagnostic32073090$ 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
11075LWRIST COMPLETE MIN 3 VWS320Radiology Diagnostic32073110$ 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
11075RWRIST COMPLETE MIN 3 VWS320Radiology Diagnostic32073110$ 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
73120Hand 2 view Right320Radiology Diagnostic32073120$ 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
11024HAND 2 VIEWS Left320Radiology Diagnostic32073120$ 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
11030RHAND MIN 3 VIEW RIGHT320Radiology Diagnostic32073130$ 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
11030LHAND MIN 3 VIEWS LEFT320Radiology Diagnostic32073130$ 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
11019LFINGER SERIES MIN 2 VWS320Radiology Diagnostic32073140$ 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
11019RFINGER SERIES MIN 2 VWS320Radiology Diagnostic32073140$ 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
19025RUPPER EXT CT WO CONTRAST; RIGHT320Radiology Diagnostic35073200$ 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
19025UPPER EXT CT W/O CONTRAST; LEFT320Radiology Diagnostic35073200$ 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
19026RUPPER EXT CT W/ CONTRAST; RIGHT320Radiology Diagnostic35073201$ 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
19026UPPER EXT W/ CONTRAST; LEFT320Radiology Diagnostic35073201$ 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
2035RMRI UPPER EXT ANY JOINT WO CONT; RIGHT320Radiology Diagnostic61073221$ 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
2035MRI UPPER EXT ANY JOINT WO CONT; LEFT320Radiology Diagnostic61073221$ 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
11027LHIP COMP MIN 2 VIEWS LEFT320Radiology Diagnostic32073502$ 225.00$ 157.50$ 191.25$ 225.00$ 225.00$ 225.00$ 225.00$ 175.50$ -$ -$ 168.75$ 195.75$ 162.23$ -$ 225.00
11027RHIP COMP MIN 2 VIEW RIGHT320Radiology Diagnostic32073502$ 235.00$ 164.50$ 199.75$ 235.00$ 235.00$ 235.00$ 235.00$ 183.30$ -$ -$ 176.25$ 204.45$ 169.44$ -$ 235.00
11137RHIP RT W/ PELVIS320Radiology Diagnostic32073502$ 395.00$ 276.50$ 335.75$ 395.00$ 395.00$ 395.00$ 395.00$ 308.10$ -$ -$ 296.25$ 343.65$ 284.80$ -$ 395.00
11137Hip LEFT w/ pelvis320Radiology Diagnostic32073502$ 395.00$ 276.50$ 335.75$ 395.00$ 395.00$ 395.00$ 395.00$ 308.10$ -$ -$ 296.25$ 343.65$ 284.80$ -$ 395.00
11133BILATERAL HIPS320Radiology Diagnostic32073522$ 535.00$ 374.50$ 454.75$ 535.00$ 535.00$ 535.00$ 535.00$ 417.30$ -$ -$ 401.25$ 465.45$ 385.74$ -$ 535.00
11017LFEMUR AP & LAT320Radiology Diagnostic32073552$ 220.00$ 154.00$ 187.00$ 220.00$ 220.00$ 220.00$ 220.00$ 171.60$ -$ -$ 165.00$ 191.40$ 158.62$ -$ 220.00
11017RFEMUR AP & LAT320Radiology Diagnostic32073552$ 220.00$ 154.00$ 187.00$ 220.00$ 220.00$ 220.00$ 220.00$ 171.60$ -$ -$ 165.00$ 191.40$ 158.62$ -$ 220.00
11029LKNEE AP & LAT LEFT320Radiology Diagnostic32073560$ 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
11029RKNEE AP & LAT RT320Radiology Diagnostic32073560$ 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
73561Knee 3 Views Left320Radiology Diagnostic32073562$ 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
73562Knee 3 Views Right320Radiology Diagnostic32073562$ 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
73601Ankle 2 view Rt320Radiology Diagnostic32073600$ 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
73600Ankle 2v AP & Lateral Lt320Radiology Diagnostic32073600$ 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
11004RANKLE COMPLETE MIN 3 VWS320Radiology Diagnostic32073610$ 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
11004LANKLE COMPLETE MIN. 3 VWS320Radiology Diagnostic32073610$ 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
11020LFOOT AP & LAT 2 VIEWS320Radiology Diagnostic32073620$ 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
11020RFOOT AP & LAT 2 VIEWS320Radiology Diagnostic32073620$ 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
11021LFOOT COMPLETE MIN 3 VWS320Radiology Diagnostic32073630$ 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
11021RFOOT COMPLETE MIN 3 VWS320Radiology Diagnostic32073630$ 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
11113RTMJs UNILATERAL; RIGHT320Radiology Diagnostic32073660$ 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
11071RTOES MIN 2 VIEW; RIGHT320Radiology Diagnostic32073660$ 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
11071TOES MIN 2 VIEWS; LEFT320Radiology Diagnostic32073660$ 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
19028RLOWER EXT CT WO CONTRAST; RIGHT320Radiology Diagnostic35073700$ 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
19028LOWER EXT. W/O CONTRAST; LEFT320Radiology Diagnostic35073700$ 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
2042RMRI LOWER EXT ANY JOINT W/O CONT; RIGHT320Radiology Diagnostic61073721$ 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
2042MRI LOWER EXT ANY JOINT W/O CONT; LEFT320Radiology Diagnostic61073721$ 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
11001ABDOMEN (KUB) 1 VIEW320Radiology Diagnostic32074018$ 220.00$ 154.00$ 187.00$ 220.00$ 220.00$ 220.00$ 220.00$ 171.60$ -$ -$ 165.00$ 191.40$ 158.62$ -$ 220.00
11002ABDOMEN, UPRIGHT & SUPINE320Radiology Diagnostic32074019$ 247.00$ 172.90$ 209.95$ 247.00$ 247.00$ 247.00$ 247.00$ 192.66$ -$ -$ 185.25$ 214.89$ 178.09$ -$ 247.00
19031ABDOMEN W/O CONTRAST320Radiology Diagnostic35074150$ 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
19032ABDOMEN W/CONTRAST320Radiology Diagnostic35074160$ 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
19045CT Abdominal Aorta w/ contrast320Radiology Diagnostic35074174$ 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
19043CT ABDOMEN/PELVIS W/O CONTRAST320Radiology Diagnostic35074176$ 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
19041CT-ABDOMEN & PELVIS W/CONT320Radiology Diagnostic35074177$ 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
19042CT ABDOMEN/PELVIS W W/O CNTRST320Radiology Diagnostic35074178$ 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
11083SOFT TISSUE SONO HEAD/NEK320Radiology Diagnostic40276536$ 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
11093CHEST SONO320Radiology Diagnostic40276604$ 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
11103RBREAST ULTRASOUND; RIGHT320Radiology Diagnostic40276641$ 440.00$ 308.00$ 374.00$ 440.00$ 440.00$ 440.00$ 440.00$ 343.20$ -$ -$ 330.00$ 382.80$ 317.24$ -$ 440.00
11103BREAST ULTRASOUND; LEFT320Radiology Diagnostic40276641$ 440.00$ 308.00$ 374.00$ 440.00$ 440.00$ 440.00$ 440.00$ 343.20$ -$ -$ 330.00$ 382.80$ 317.24$ -$ 440.00
11077ABDOMEN SONOGRAM320Radiology Diagnostic40276700$ 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
11078AORTA SONOGRAM SCREENING320Radiology Diagnostic40276706$ 525.00$ 367.50$ 446.25$ 441.28$ 461.34$ 501.46$ 501.46$ 409.50$ -$ -$ 393.75$ 456.75$ 378.53$ -$ 501.46
11080RENAL SONOGRAM320Radiology Diagnostic40276770$ 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
11084OBSTETRICS SONOGRAM320Radiology Diagnostic40276805$ 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
11115TRANSVAGINAL ULTRASOUND320Radiology Diagnostic40276830$ 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
11087PELVIC MASS SONOGRAM320Radiology Diagnostic40276856$ 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 CodeCharge Code DescriptionDept #DeptRevCodeCPT CodeCurrent PriceCash PriceAetnaBCBS - Blue AdvBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAFirstCare - HMOFirstCare - PPOHealthSourceHumanaUnitedMinimum Negotiated RateMaximum Negotiated Rate
11119UPPER EXT ULTRASOUND; LEFT320Radiology Diagnostic40276881$ 383.00$ 268.10$ 325.55$ 293.58$ 306.93$ 333.62$ 333.62$ 298.74$ -$ -$ 287.25$ 333.21$ 276.14$ -$ 333.62
11130BONE DEXA SCAN320Radiology Diagnostic32077080$ 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
11140Bone Dexa Scan/Vert fracture assess320Radiology Diagnostic32077085$ 535.00$ 374.50$ 454.75$ 535.00$ 535.00$ 535.00$ 535.00$ 417.30$ -$ -$ 401.25$ 465.45$ 385.74$ -$ 535.00
11104ECHOCARDIOGRAM320Radiology Diagnostic48093306$ 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
11099DUPLEX SCAN EXTRACRANIAL320Radiology Diagnostic92193880$ 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
11058ANKLE BRACHIAL INDEX320Radiology Diagnostic92193922$ 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
11124BILATERAL ARTERIAL LOW EX320Radiology Diagnostic92193925$ 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
11112ARTERIAL DUPLEX SCAN LEFT320Radiology Diagnostic92193926$ 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
11143Arterial Duplex Scan Right320Radiology Diagnostic92193926$ 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
11108DUPLEX SCAN VENOUS SYSTEM320Radiology Diagnostic92193970$ 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
11114RVENOUS DUPLEX UNILATERAL; RIGHT320Radiology Diagnostic92193971$ 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
11114Venous Duplex Unilateral Left320Radiology Diagnostic92193971$ 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
11048RENAL ARTERY DOPPLER320Radiology Diagnostic92193975$ 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
81002URINALYSIS DIPSTICK521Rural Health Clinic52181002$ 10.00$ 7.00$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -
81003URINE TEST AUTOMATED521Rural Health Clinic52181003$ 10.00$ 7.00$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -
93000EKG 12 LEADS W/INTER & REPORT521Rural Health Clinic52193000$ 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
99202NEW PAT-BRIEF521Rural Health Clinic52199202$ 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
99203NEW PAT-LIMITED521Rural Health Clinic52199203$ 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
99204NEW PAT-INTER521Rural Health Clinic52199204$ 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
99205NEW PAT-COMP521Rural Health Clinic52199205$ 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
99212EST.PAT BRIEF521Rural Health Clinic52199212$ 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
99213EST.PAT.LIMITED521Rural Health Clinic52199213$ 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
99214EST.PAT.INTER.521Rural Health Clinic52199214$ 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
99385EPSDT NEW PATIENT 18-39 YEARS521Rural Health Clinic52199385$ 186.00$ 130.20$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01$ 150.01

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.  This included related costs like medical test, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.  You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call {877-696-6775}

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