OVERVIEW
In compliance with the Centers for Medicare and Medicaid Services (CMS), Coleman County Medical Center is making available to the public a copy of its standard charges known as a “Charge Master,” “Charge Description Master” or “CDM”.
Since payment rates for hospital care provided to insured patients are either negotiated with health plans, set by the federal government for Medicare, or set by state governments for Medicaid enrollees, the payments hospitals receive for patient care do not necessarily reflect the prices reflected in the Charge Master. A patient’s responsibility may vary depending on the payment plans negotiated with insurance companies as well as the patient’s individual and/or family deductibles and co-payments with their insurance plan. Additionally, uninsured patients are not generally expected to pay the hospital’s standard charges as reflected in the CDM and may be eligible for financial assistance.
The information provided is based on information we have gathered from contracts with managed care commercial insurance plans. This is not a guarantee of what you will be charged. Your actual charges may differ from the estimated charges for many reasons, including the seriousness of your medical condition, actual time the procedure takes and the services and supplies that you receive.
The charges listed here are for services from the Hospital. They do not reflect the charges for physicians (such as surgeon, anesthesiologist, radiologist, pathologist, etc.) who may be involved in providing particular services to a patient. These charges are billed separately from the individual physician/physicians group.
Coleman County Medical Center shall not be liable for any difference between charges listed in the price lists and the final bill for services.
AVAILABLE FILES
There are three 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 first 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
The second PDF file is a searchable consumer-friendly format of average charge per admission to the hospital. The file contains the following information:
• MS DRG – Diagnosis Related Group Code – specific DRG for Inpatient admission based on diagnosis
• DRG Description – description of admission based on diagnosis criteria
• DRG Weight – CMS’ weight assigned to corresponding DRG (diagnosis). The higher the DRG weight, the higher level of acuity/care the patient needs.
• Average Length of Stay – average length of stay of the patient based on the corresponding DRG code. Some average length of stay are larger than others due to patients being in the hospital’s Medicare Swing Bed unit.
• Average Charge per Admission – average total charges for a patient with the corresponding DRG code.
• Average Charge per Day – average charge per day incurred for a patient with the corresponding DRG code.
QUESTIONS?
If you have further questions about the Coleman County Medical Center CDM, please contact our hospital business office at (325) 625-2135 or come by and speak to one of our business office representatives.
Thank you for choosing Coleman County Medical Center for your health care needs!
Coleman County Medical Center Shoppable Services as of 7/20/2022
Charge Code | Charge Code Description | Dept | Dept Name | Rev Code | CPT Code | Gross Charge | Cash Price | Aetna - All Commercial Plans | BCBS TX - HMO | BCBS TX - Blue Advantage | BCBS TX - Traditional PAR | BCBS TX - PPO | CIGNA - All Commercial Plans | FirstCare - PPO | Scott & White - PPO | United - All Commercial Plans | Minimum Negotiated Price | Maximum Negotiated Rate |
3550010 | EKG 12 LEAD TRACING ONLY | 730 | EKG/ECG | 730 | 93005 | $167.00 | $83.50 | $133.60 | $79.21 | $55.01 | $88.02 | $88.02 | $120.24 | $141.95 | $141.95 | $141.95 | $55.01 | $141.95 |
4101096 | #CBC (SEND OUT/ABI) | 300 | Laboratory | 305 | 85025 | $123.00 | $61.50 | $98.40 | $23.08 | $15.54 | $25.64 | $25.64 | $88.56 | $104.55 | $104.55 | $22.00 | $15.54 | $104.55 |
4100063 | 24HR URINE, PROTEIN | 300 | Laboratory | 301 | 84156 | $81.00 | $40.50 | $64.80 | $10.90 | $7.34 | $12.11 | $12.11 | $58.32 | $68.85 | $68.85 | $22.00 | $7.34 | $68.85 |
4100065 | A N A ANTINUCLEAR ANTIBOD | 300 | Laboratory | 302 | 86038 | $144.00 | $72.00 | $115.20 | $35.91 | $24.18 | $39.90 | $39.90 | $103.68 | $122.40 | $122.40 | $22.00 | $22.00 | $122.40 |
4100121 | ABG | 300 | Laboratory | 301 | 82803 | $402.00 | $201.00 | $321.60 | $77.43 | $52.14 | $86.03 | $86.03 | $289.44 | $341.70 | $341.70 | $22.00 | $22.00 | $341.70 |
4100067 | ABO TYPING | 300 | Laboratory | 300 | 86900 | $150.00 | $75.00 | $120.00 | $323.82 | $218.06 | $359.80 | $359.80 | $108.00 | $127.50 | $127.50 | $22.00 | $22.00 | $359.80 |
4100068 | ACETAMINOPHEN LEVEL | 300 | Laboratory | 301 | 80329 | $171.00 | $85.50 | $136.80 | $- | $- | $- | $- | $123.12 | $145.35 | $145.35 | $22.00 | $- | $145.35 |
4101010 | A-ELECTROPHORECTIC FRACTI | 300 | Laboratory | 301 | 84165 | $111.00 | $55.50 | $88.80 | $31.90 | $21.48 | $35.44 | $35.44 | $79.92 | $94.35 | $94.35 | $22.00 | $21.48 | $94.35 |
4101098 | A-ELECTROPHORECTIC FRACTI | 300 | Laboratory | 301 | 84165 | $111.00 | $55.50 | $88.80 | $31.90 | $21.48 | $35.44 | $35.44 | $79.92 | $94.35 | $94.35 | $22.00 | $21.48 | $94.35 |
4100074 | AEROBIC IDENTIFICATION | 300 | Laboratory | 306 | 87077 | $110.00 | $55.00 | $88.00 | $24.00 | $16.16 | $26.66 | $26.66 | $79.20 | $93.50 | $93.50 | $22.00 | $16.16 | $93.50 |
4101193 | AFP, SERUM | 300 | Laboratory | 301 | 82105 | $199.00 | $99.50 | $159.20 | $49.81 | $33.54 | $55.34 | $55.34 | $143.28 | $169.15 | $169.15 | $22.00 | $22.00 | $169.15 |
4101019 | A-INFLUENZA A | 300 | Laboratory | 306 | 87804 | $74.00 | $37.00 | $59.20 | $49.15 | $33.10 | $54.62 | $54.62 | $53.28 | $62.90 | $62.90 | $22.00 | $22.00 | $62.90 |
4100075 | ALBUMIN (SERUM) | 300 | Laboratory | 301 | 82040 | $44.00 | $22.00 | $35.20 | $14.70 | $9.90 | $16.34 | $16.34 | $31.68 | $37.40 | $37.40 | $22.00 | $9.90 | $37.40 |
4100077 | ALCOHOL BLOOD | 300 | Laboratory | 301 | 80320 | $111.00 | $55.50 | $88.80 | $- | $- | $- | $- | $79.92 | $94.35 | $94.35 | $22.00 | $- | $94.35 |
4100399 | ALT (SGPT) | 300 | Laboratory | 301 | 84460 | $62.00 | $31.00 | $49.60 | $15.74 | $10.60 | $17.49 | $17.49 | $44.64 | $52.70 | $52.70 | $22.00 | $10.60 | $52.70 |
4100088 | AMMONIA LEVEL | 300 | Laboratory | 301 | 82140 | $177.00 | $88.50 | $141.60 | $43.27 | $29.14 | $48.08 | $48.08 | $127.44 | $150.45 | $150.45 | $22.00 | $22.00 | $150.45 |
4100089 | AMYLASE SERUM | 300 | Laboratory | 301 | 82150 | $67.00 | $33.50 | $53.60 | $19.25 | $12.96 | $21.38 | $21.38 | $48.24 | $56.95 | $56.95 | $22.00 | $12.96 | $56.95 |
4100100 | ANTIBODY SCREEN CHRG | 300 | Laboratory | 302 | 86850 | $175.00 | $87.50 | $140.00 | $146.93 | $98.94 | $163.25 | $163.25 | $126.00 | $148.75 | $148.75 | $22.00 | $22.00 | $163.25 |
4100102 | ANTI-ENDOMESIAL IGA | 300 | Laboratory | 302 | 86255 | $125.00 | $62.50 | $100.00 | $35.79 | $24.10 | $39.77 | $39.77 | $90.00 | $106.25 | $106.25 | $22.00 | $22.00 | $106.25 |
4100431 | ANTI-MICROSOMAL AB (TPO A | 300 | Laboratory | 302 | 86376 | $156.00 | $78.00 | $124.80 | $43.21 | $29.10 | $48.02 | $48.02 | $112.32 | $132.60 | $132.60 | $22.00 | $22.00 | $132.60 |
4101024 | A-PSA FREE | 300 | Laboratory | 301 | 84154 | $158.00 | $79.00 | $126.40 | $54.62 | $36.78 | $60.69 | $60.69 | $113.76 | $134.30 | $134.30 | $22.00 | $22.00 | $134.30 |
4100398 | AST (SGOT) | 300 | Laboratory | 301 | 84450 | $96.00 | $48.00 | $76.80 | $15.38 | $10.36 | $17.09 | $17.09 | $69.12 | $81.60 | $81.60 | $22.00 | $10.36 | $81.60 |
4100119 | BILIRUBIN DIRECT | 300 | Laboratory | 301 | 82248 | $75.00 | $37.50 | $60.00 | $14.91 | $10.04 | $16.57 | $16.57 | $54.00 | $63.75 | $63.75 | $22.00 | $10.04 | $63.75 |
4100120 | BILIRUBIN TOTAL | 300 | Laboratory | 301 | 82247 | $47.00 | $23.50 | $37.60 | $14.91 | $10.04 | $16.57 | $16.57 | $33.84 | $39.95 | $39.95 | $22.00 | $10.04 | $39.95 |
4101042 | B-INFLUENZA B | 300 | Laboratory | 306 | 87804 | $74.00 | $37.00 | $59.20 | $49.15 | $33.10 | $54.62 | $54.62 | $53.28 | $62.90 | $62.90 | $22.00 | $22.00 | $62.90 |
4100012 | BMP | 300 | Laboratory | 301 | 80048 | $191.00 | $95.50 | $152.80 | $25.13 | $16.92 | $27.92 | $27.92 | $137.52 | $162.35 | $162.35 | $22.00 | $16.92 | $162.35 |
4100124 | BNAP (NATRUIRETIC PEPTIDE | 300 | Laboratory | 301 | 83880 | $338.00 | $169.00 | $270.40 | $116.60 | $78.52 | $129.56 | $129.56 | $243.36 | $287.30 | $287.30 | $22.00 | $22.00 | $287.30 |
4100131 | BODY FLUID CELL COUNT | 300 | Laboratory | 301 | 89050 | $117.00 | $58.50 | $93.60 | $14.02 | $9.44 | $15.58 | $15.58 | $84.24 | $99.45 | $99.45 | $22.00 | $9.44 | $99.45 |
4101045 | B-PSA TOTAL | 300 | Laboratory | 301 | 84153 | $173.00 | $86.50 | $138.40 | $54.62 | $36.78 | $60.69 | $60.69 | $124.56 | $147.05 | $147.05 | $22.00 | $22.00 | $147.05 |
4100133 | BUN(UREA NITROGEN) | 300 | Laboratory | 301 | 84520 | $68.00 | $34.00 | $54.40 | $11.73 | $7.90 | $13.04 | $13.04 | $48.96 | $57.80 | $57.80 | $22.00 | $7.90 | $57.80 |
4101326 | CALPROTECTIN, STOOL | 300 | Laboratory | 301 | 83993 | $192.00 | $96.00 | $153.60 | $58.30 | $39.26 | $64.78 | $64.78 | $138.24 | $163.20 | $163.20 | $22.00 | $22.00 | $163.20 |
4100016 | CBC | 300 | Laboratory | 305 | 85025 | $123.00 | $61.50 | $98.40 | $23.08 | $15.54 | $25.64 | $25.64 | $88.56 | $104.55 | $104.55 | $22.00 | $15.54 | $104.55 |
4101111 | CBC W/O DIFFERENTIAL | 300 | Laboratory | 305 | 85027 | $68.00 | $34.00 | $54.40 | $19.22 | $12.94 | $21.35 | $21.35 | $48.96 | $57.80 | $57.80 | $22.00 | $12.94 | $57.80 |
4100017 | CEA (CARCINO EMBRYONIC AN | 300 | Laboratory | 301 | 82378 | $193.00 | $96.50 | $154.40 | $56.31 | $37.92 | $62.57 | $62.57 | $138.96 | $164.05 | $164.05 | $22.00 | $22.00 | $164.05 |
4100152 | CHLAMYDIA TRACH AMP PROBE | 300 | Laboratory | 306 | 87491 | $372.00 | $186.00 | $297.60 | $104.22 | $70.18 | $115.80 | $115.80 | $267.84 | $316.20 | $316.20 | $22.00 | $22.00 | $316.20 |
4101256 | CMA-COUMADIN | 300 | Laboratory | 300 | 85610 | $80.00 | $40.00 | $64.00 | $12.74 | $8.58 | $14.16 | $14.16 | $57.60 | $68.00 | $68.00 | $22.00 | $8.58 | $68.00 |
4101259 | CMA-UA | 300 | Laboratory | 300 | 81002 | $22.00 | $11.00 | $17.60 | $10.34 | $6.96 | $11.48 | $11.48 | $15.84 | $18.70 | $18.70 | $22.00 | $6.96 | $22.00 |
4101360 | CMV DNA BY PCR QUAN | 300 | Laboratory | 306 | 87497 | $150.00 | $75.00 | $120.00 | $127.23 | $85.68 | $141.37 | $141.37 | $108.00 | $127.50 | $127.50 | $22.00 | $22.00 | $141.37 |
4100021 | COMPLETE METABOLIC PROFI | 300 | Laboratory | 301 | 80053 | $256.00 | $128.00 | $204.80 | $31.36 | $21.12 | $34.85 | $34.85 | $184.32 | $217.60 | $217.60 | $22.00 | $21.12 | $217.60 |
4100164 | COOMBS DIRECT | 300 | Laboratory | 302 | 86880 | $115.00 | $57.50 | $92.00 | $99.29 | $66.86 | $110.32 | $110.32 | $82.80 | $97.75 | $97.75 | $22.00 | $22.00 | $110.32 |
4101466 | COVID-19 REFERENCE LAB | 300 | Laboratory | 300 | 87635 | $250.00 | $125.00 | $200.00 | $152.39 | $102.62 | $169.32 | $169.32 | $180.00 | $212.50 | $212.50 | $22.00 | $22.00 | $212.50 |
4100169 | CPK | 300 | Laboratory | 301 | 82550 | $134.00 | $67.00 | $107.20 | $19.33 | $13.02 | $21.48 | $21.48 | $96.48 | $113.90 | $113.90 | $22.00 | $13.02 | $113.90 |
4100171 | C-REACTIVE PROTEIN | 300 | Laboratory | 302 | 86140 | $95.00 | $47.50 | $76.00 | $15.38 | $10.36 | $17.09 | $17.09 | $68.40 | $80.75 | $80.75 | $22.00 | $10.36 | $80.75 |
4100172 | CREATININE | 300 | Laboratory | 301 | 82565 | $74.00 | $37.00 | $59.20 | $15.21 | $10.24 | $16.90 | $16.90 | $53.28 | $62.90 | $62.90 | $22.00 | $10.24 | $62.90 |
4100175 | CREATININE 24HR URINE | 300 | Laboratory | 301 | 82570 | $67.00 | $33.50 | $53.60 | $15.38 | $10.36 | $17.09 | $17.09 | $48.24 | $56.95 | $56.95 | $22.00 | $10.36 | $56.95 |
4100176 | CREATININE, URINE, RANDOM | 300 | Laboratory | 301 | 82570 | $67.00 | $33.50 | $53.60 | $15.38 | $10.36 | $17.09 | $17.09 | $48.24 | $56.95 | $56.95 | $22.00 | $10.36 | $56.95 |
4101373 | CRYTOCOCCOUS ANTIGEN | 300 | Laboratory | 302 | 86403 | $40.00 | $20.00 | $32.00 | $34.27 | $23.08 | $38.08 | $38.08 | $28.80 | $34.00 | $34.00 | $22.00 | $22.00 | $38.08 |
4101053 | C-THROMBOPLASTIN TIME; PA | 300 | Laboratory | 305 | 85730 | $117.00 | $58.50 | $93.60 | $17.85 | $12.02 | $19.83 | $19.83 | $84.24 | $99.45 | $99.45 | $22.00 | $12.02 | $99.45 |
4101370 | C-TRICHOMONAS VAGINALIS | 300 | Laboratory | 306 | 87661 | $130.00 | $65.00 | $104.00 | $104.22 | $70.18 | $115.80 | $115.80 | $93.60 | $110.50 | $110.50 | $22.00 | $22.00 | $115.80 |
4100184 | CULTURE BLOOD | 300 | Laboratory | 306 | 87040 | $110.00 | $55.00 | $88.00 | $30.65 | $20.64 | $34.06 | $34.06 | $79.20 | $93.50 | $93.50 | $22.00 | $20.64 | $93.50 |
4100191 | CULTURE UA | 300 | Laboratory | 306 | 87086 | $135.00 | $67.50 | $108.00 | $23.97 | $16.14 | $26.63 | $26.63 | $97.20 | $114.75 | $114.75 | $22.00 | $16.14 | $114.75 |
4100192 | CULTURE, FUNGI, DEFINITIV | 300 | Laboratory | 306 | 87106 | $134.00 | $67.00 | $107.20 | $30.65 | $20.64 | $34.06 | $34.06 | $96.48 | $113.90 | $113.90 | $22.00 | $20.64 | $113.90 |
4100196 | CULTURE, WOUND | 300 | Laboratory | 306 | 87070 | $165.00 | $82.50 | $132.00 | $25.60 | $17.24 | $28.45 | $28.45 | $118.80 | $140.25 | $140.25 | $22.00 | $17.24 | $140.25 |
4101112 | CYCLIC CITRILLINATED PEPT | 300 | Laboratory | 302 | 86200 | $135.00 | $67.50 | $108.00 | $38.46 | $25.90 | $42.74 | $42.74 | $97.20 | $114.75 | $114.75 | $22.00 | $22.00 | $114.75 |
4100200 | D-DIMER | 300 | Laboratory | 305 | 85378 | $169.00 | $84.50 | $135.20 | $28.87 | $19.44 | $32.08 | $32.08 | $121.68 | $143.65 | $143.65 | $22.00 | $19.44 | $143.65 |
4100036 | DIGOXIN (LANOXIN) | 300 | Laboratory | 301 | 80162 | $177.00 | $88.50 | $141.60 | $39.44 | $26.56 | $43.82 | $43.82 | $127.44 | $150.45 | $150.45 | $22.00 | $22.00 | $150.45 |
4100204 | DILANTIN | 300 | Laboratory | 301 | 80185 | $182.00 | $91.00 | $145.60 | $39.35 | $26.50 | $43.73 | $43.73 | $131.04 | $154.70 | $154.70 | $22.00 | $22.00 | $154.70 |
4101185 | DNA/RNA DIRECT PROBE X2 | 300 | Laboratory | 306 | 87149 | $307.00 | $153.50 | $245.60 | $59.55 | $40.10 | $66.17 | $66.17 | $221.04 | $260.95 | $260.95 | $22.00 | $22.00 | $260.95 |
4100390 | ESR (SED RATE) | 300 | Laboratory | 305 | 85651 | $73.00 | $36.50 | $58.40 | $12.68 | $8.54 | $14.09 | $14.09 | $52.56 | $62.05 | $62.05 | $22.00 | $8.54 | $62.05 |
4100217 | ESTRADIOL SERUM | 300 | Laboratory | 301 | 82670 | $259.00 | $129.50 | $207.20 | $82.98 | $55.88 | $92.20 | $92.20 | $186.48 | $220.15 | $220.15 | $22.00 | $22.00 | $220.15 |
4100022 | FERRITIN | 300 | Laboratory | 301 | 82728 | $167.00 | $83.50 | $133.60 | $40.48 | $27.26 | $44.98 | $44.98 | $120.24 | $141.95 | $141.95 | $22.00 | $22.00 | $141.95 |
4100228 | FOLIC ACID | 300 | Laboratory | 301 | 82746 | $148.00 | $74.00 | $118.40 | $43.66 | $29.40 | $48.51 | $48.51 | $106.56 | $125.80 | $125.80 | $22.00 | $22.00 | $125.80 |
4100229 | FOLLICLE STIMULATING HORM | 300 | Laboratory | 301 | 83001 | $203.00 | $101.50 | $162.40 | $55.18 | $37.16 | $61.31 | $61.31 | $146.16 | $172.55 | $172.55 | $22.00 | $22.00 | $172.55 |
4100420 | FT3 (FREE T3) | 300 | Laboratory | 301 | 84481 | $238.00 | $119.00 | $190.40 | $50.31 | $33.88 | $55.90 | $55.90 | $171.36 | $202.30 | $202.30 | $22.00 | $22.00 | $202.30 |
4100433 | FT4 (FREE THYROXINE) | 300 | Laboratory | 301 | 84439 | $133.00 | $66.50 | $106.40 | $26.79 | $18.04 | $29.77 | $29.77 | $95.76 | $113.05 | $113.05 | $22.00 | $18.04 | $113.05 |
4101164 | GASTRIC OCCULT BLOOD | 300 | Laboratory | 301 | 82270 | $66.00 | $33.00 | $52.80 | $13.01 | $8.76 | $14.45 | $14.45 | $47.52 | $56.10 | $56.10 | $22.00 | $8.76 | $56.10 |
4101121 | GEN. HEALTH PANEL W/O TSH | 300 | Laboratory | 301 | 80050 | $382.00 | $191.00 | $305.60 | $104.90 | $70.64 | $116.56 | $116.56 | $275.04 | $324.70 | $324.70 | $22.00 | $22.00 | $324.70 |
4100233 | GENERAL HEALTH PANEL W/ T | 300 | Laboratory | 301 | 80050 | $382.00 | $191.00 | $305.60 | $104.90 | $70.64 | $116.56 | $116.56 | $275.04 | $324.70 | $324.70 | $22.00 | $22.00 | $324.70 |
4100235 | GGT | 300 | Laboratory | 301 | 82977 | $150.00 | $75.00 | $120.00 | $21.38 | $14.40 | $23.76 | $23.76 | $108.00 | $127.50 | $127.50 | $22.00 | $14.40 | $127.50 |
4100025 | GLUCOSE 1 HR -50 GRMS | 300 | Laboratory | 301 | 82950 | $70.00 | $35.00 | $56.00 | $14.11 | $9.50 | $15.68 | $15.68 | $50.40 | $59.50 | $59.50 | $22.00 | $9.50 | $59.50 |
4100406 | GRAM STAIN SMEAR | 300 | Laboratory | 306 | 87205 | $75.00 | $37.50 | $60.00 | $12.68 | $8.54 | $14.09 | $14.09 | $54.00 | $63.75 | $63.75 | $22.00 | $8.54 | $63.75 |
4100028 | GTT FIRST THREE SPECIMEN | 300 | Laboratory | 301 | 82951 | $90.00 | $45.00 | $72.00 | $38.22 | $25.74 | $42.47 | $42.47 | $64.80 | $76.50 | $76.50 | $22.00 | $22.00 | $76.50 |
4100240 | HBSAB QUANITATIVE | 300 | Laboratory | 302 | 86706 | $152.00 | $76.00 | $121.60 | $31.90 | $21.48 | $35.44 | $35.44 | $109.44 | $129.20 | $129.20 | $22.00 | $21.48 | $129.20 |
4100241 | HBSAG | 300 | Laboratory | 306 | 87340 | $184.00 | $92.00 | $147.20 | $30.68 | $20.66 | $34.09 | $34.09 | $132.48 | $156.40 | $156.40 | $22.00 | $20.66 | $156.40 |
4100029 | HCG QUALITATIVE SERUM | 300 | Laboratory | 301 | 84703 | $164.00 | $82.00 | $131.20 | $22.33 | $15.04 | $24.82 | $24.82 | $118.08 | $139.40 | $139.40 | $22.00 | $15.04 | $139.40 |
4100351 | HCG QUALITATIVE URINE | 300 | Laboratory | 307 | 81025 | $41.00 | $20.50 | $32.80 | $25.57 | $17.22 | $28.41 | $28.41 | $29.52 | $34.85 | $34.85 | $22.00 | $17.22 | $34.85 |
4100041 | HCG QUANTITATIVE SERUM | 300 | Laboratory | 925 | 84702 | $280.00 | $140.00 | $224.00 | $44.70 | $30.10 | $49.67 | $49.67 | $201.60 | $238.00 | $238.00 | $22.00 | $22.00 | $238.00 |
4100246 | HCV RNA QUANTITATIVE (VIR | 300 | Laboratory | 302 | 87522 | $293.00 | $146.50 | $234.40 | $127.23 | $85.68 | $141.37 | $141.37 | $210.96 | $249.05 | $249.05 | $22.00 | $22.00 | $249.05 |
4100031 | HEMATOCRIT | 300 | Laboratory | 305 | 85014 | $40.00 | $20.00 | $32.00 | $7.04 | $4.74 | $7.82 | $7.82 | $28.80 | $34.00 | $34.00 | $22.00 | $4.74 | $34.00 |
4100032 | HEMOGLOBIN A1C | 300 | Laboratory | 301 | 83036 | $108.00 | $54.00 | $86.40 | $28.84 | $19.42 | $32.04 | $32.04 | $77.76 | $91.80 | $91.80 | $22.00 | $19.42 | $91.80 |
4100251 | HEPATITIS C ANTIBODY | 300 | Laboratory | 302 | 86803 | $254.00 | $127.00 | $203.20 | $42.38 | $28.54 | $47.09 | $47.09 | $182.88 | $215.90 | $215.90 | $22.00 | $22.00 | $215.90 |
4100247 | HEPATITIS PROFILE | 300 | Laboratory | 302 | 80074 | $431.00 | $215.50 | $344.80 | $141.46 | $95.26 | $157.18 | $157.18 | $310.32 | $366.35 | $366.35 | $22.00 | $22.00 | $366.35 |
4100033 | HIV AB SCREEN | 300 | Laboratory | 302 | G0432 | $180.00 | $90.00 | $144.00 | $58.12 | $39.14 | $64.58 | $64.58 | $129.60 | $153.00 | $153.00 | $22.00 | $22.00 | $153.00 |
4100256 | HPYLORI, ANTIGEN, STOOL | 300 | Laboratory | 306 | 87338 | $151.00 | $75.50 | $120.80 | $42.71 | $28.76 | $47.45 | $47.45 | $108.72 | $128.35 | $128.35 | $22.00 | $22.00 | $128.35 |
4100261 | IGA (IMMUNOGLOBULIN A) | 300 | Laboratory | 301 | 82784 | $96.00 | $48.00 | $76.80 | $27.62 | $18.60 | $30.69 | $30.69 | $69.12 | $81.60 | $81.60 | $22.00 | $18.60 | $81.60 |
4100265 | IGF1-SOMATOMEDIN | 300 | Laboratory | 301 | 84305 | $237.00 | $118.50 | $189.60 | $63.14 | $42.52 | $70.16 | $70.16 | $170.64 | $201.45 | $201.45 | $22.00 | $22.00 | $201.45 |
4100415 | ILLUMIGENE C-DIFF | 300 | Laboratory | 306 | 87493 | $156.00 | $78.00 | $124.80 | $110.69 | $74.54 | $122.99 | $122.99 | $112.32 | $132.60 | $132.60 | $22.00 | $22.00 | $132.60 |
4100278 | INFLUENZA , RAPID ANTIGEN | 300 | Laboratory | 306 | 87400 | $132.00 | $66.00 | $105.60 | $41.97 | $28.26 | $46.63 | $46.63 | $95.04 | $112.20 | $112.20 | $22.00 | $22.00 | $112.20 |
4100034 | IRON BINDING CAPACITY | 300 | Laboratory | 301 | 83550 | $110.00 | $55.00 | $88.00 | $25.96 | $17.48 | $28.84 | $28.84 | $79.20 | $93.50 | $93.50 | $22.00 | $17.48 | $93.50 |
4100035 | IRON SERUM | 300 | Laboratory | 301 | 83540 | $78.00 | $39.00 | $62.40 | $19.22 | $12.94 | $21.35 | $21.35 | $56.16 | $66.30 | $66.30 | $22.00 | $12.94 | $66.30 |
4100285 | KEPPRA (LEVETIRACETAM) | 300 | Laboratory | 301 | 80177 | $135.00 | $67.50 | $108.00 | $39.35 | $26.50 | $43.73 | $43.73 | $97.20 | $114.75 | $114.75 | $22.00 | $22.00 | $114.75 |
4100367 | KETONE/ACETONE | 300 | Laboratory | 301 | 82009 | $77.00 | $38.50 | $61.60 | $13.42 | $9.04 | $14.92 | $14.92 | $55.44 | $65.45 | $65.45 | $22.00 | $9.04 | $65.45 |
4100288 | LACTATE/LACTIC ACID | 300 | Laboratory | 301 | 83605 | $145.00 | $72.50 | $116.00 | $34.36 | $23.14 | $38.18 | $38.18 | $104.40 | $123.25 | $123.25 | $22.00 | $22.00 | $123.25 |
4100290 | LDH | 300 | Laboratory | 301 | 83615 | $125.00 | $62.50 | $100.00 | $17.94 | $12.08 | $19.93 | $19.93 | $90.00 | $106.25 | $106.25 | $22.00 | $12.08 | $106.25 |
4100293 | LDL DIRECT | 300 | Laboratory | 301 | 83721 | $110.00 | $55.00 | $88.00 | $31.19 | $21.00 | $34.65 | $34.65 | $79.20 | $93.50 | $93.50 | $22.00 | $21.00 | $93.50 |
4100297 | LIPASE | 300 | Laboratory | 301 | 83690 | $134.00 | $67.00 | $107.20 | $20.46 | $13.78 | $22.74 | $22.74 | $96.48 | $113.90 | $113.90 | $22.00 | $13.78 | $113.90 |
4100037 | LIPID PROFILE | 300 | Laboratory | 301 | 80061 | $169.00 | $84.50 | $135.20 | $39.77 | $26.78 | $44.19 | $44.19 | $121.68 | $143.65 | $143.65 | $22.00 | $22.00 | $143.65 |
4100299 | LITHIUM (LI) | 300 | Laboratory | 301 | 80178 | $97.00 | $48.50 | $77.60 | $19.63 | $13.22 | $21.81 | $21.81 | $69.84 | $82.45 | $82.45 | $22.00 | $13.22 | $82.45 |
4100300 | LIVER PANEL | 300 | Laboratory | 301 | 80076 | $90.00 | $45.00 | $72.00 | $24.26 | $16.34 | $26.96 | $26.96 | $64.80 | $76.50 | $76.50 | $22.00 | $16.34 | $76.50 |
4100303 | LUTEINIZING HORMONE | 300 | Laboratory | 301 | 83002 | $190.00 | $95.00 | $152.00 | $55.00 | $37.04 | $61.12 | $61.12 | $136.80 | $161.50 | $161.50 | $22.00 | $22.00 | $161.50 |
4100038 | MAGNESIUM (MG) SERUM | 300 | Laboratory | 301 | 83735 | $116.00 | $58.00 | $92.80 | $19.90 | $13.40 | $22.11 | $22.11 | $83.52 | $98.60 | $98.60 | $22.00 | $13.40 | $98.60 |
4100076 | MICROALBUMIN, RANDOM URIN | 300 | Laboratory | 301 | 82043 | $94.00 | $47.00 | $75.20 | $17.17 | $11.56 | $19.07 | $19.07 | $67.68 | $79.90 | $79.90 | $22.00 | $11.56 | $79.90 |
4100313 | MONOSPOT | 300 | Laboratory | 302 | 86308 | $51.00 | $25.50 | $40.80 | $15.38 | $10.36 | $17.09 | $17.09 | $36.72 | $43.35 | $43.35 | $22.00 | $10.36 | $43.35 |
4100237 | NEISSERIA AMP PROBE TECH | 300 | Laboratory | 306 | 87591 | $372.00 | $186.00 | $297.60 | $104.22 | $70.18 | $115.80 | $115.80 | $267.84 | $316.20 | $316.20 | $22.00 | $22.00 | $316.20 |
4101263 | NEPHELOMETRY, EA ANALYTE | 300 | Laboratory | 301 | 83883 | $117.00 | $58.50 | $93.60 | $40.39 | $27.20 | $44.88 | $44.88 | $84.24 | $99.45 | $99.45 | $22.00 | $22.00 | $99.45 |
4101224 | OB PANEL | 300 | Laboratory | 301 | 80081 | $275.00 | $137.50 | $220.00 | $222.33 | $149.72 | $247.04 | $247.04 | $198.00 | $233.75 | $233.75 | $22.00 | $22.00 | $247.04 |
4100330 | OCCULT BLOOD STOOL- SINGL | 300 | Laboratory | 301 | 82274 | $66.00 | $33.00 | $52.80 | $47.28 | $31.84 | $52.54 | $52.54 | $47.52 | $56.10 | $56.10 | $22.00 | $22.00 | $56.10 |
4101237 | PERIPHERAL BLD SMEAR | 300 | Laboratory | 971 | 85060 | $174.00 | $87.00 | $139.20 | $74.93 | $50.46 | $83.26 | $83.26 | $125.28 | $147.90 | $147.90 | $22.00 | $22.00 | $147.90 |
4100341 | PHLEBOTOMY THERAPEAUTIC | 300 | Laboratory | 940 | 99195 | $175.00 | $87.50 | $140.00 | $157.00 | $109.03 | $174.45 | $174.45 | $126.00 | $148.75 | $148.75 | $22.00 | $22.00 | $174.45 |
4100342 | PHOSPHORUS INORGANIC | 300 | Laboratory | 301 | 84100 | $78.00 | $39.00 | $62.40 | $14.08 | $9.48 | $15.64 | $15.64 | $56.16 | $66.30 | $66.30 | $22.00 | $9.48 | $66.30 |
4100283 | POTASSIUM (K) | 300 | Laboratory | 301 | 84132 | $54.00 | $27.00 | $43.20 | $14.14 | $9.52 | $15.71 | $15.71 | $38.88 | $45.90 | $45.90 | $22.00 | $9.52 | $45.90 |
4100040 | PRE-ALBUMIN | 300 | Laboratory | 301 | 84134 | $115.00 | $57.50 | $92.00 | $43.33 | $29.18 | $48.15 | $48.15 | $82.80 | $97.75 | $97.75 | $22.00 | $22.00 | $97.75 |
4100353 | PROGESTERONE ASSAY | 300 | Laboratory | 301 | 84144 | $275.00 | $137.50 | $220.00 | $61.95 | $41.72 | $68.84 | $68.84 | $198.00 | $233.75 | $233.75 | $22.00 | $22.00 | $233.75 |
4100354 | PROLACTIN | 300 | Laboratory | 301 | 84146 | $214.00 | $107.00 | $171.20 | $57.56 | $38.76 | $63.95 | $63.95 | $154.08 | $181.90 | $181.90 | $22.00 | $22.00 | $181.90 |
4100042 | PROSTATE SPEC ANTI | 300 | Laboratory | 301 | 84153 | $187.00 | $93.50 | $149.60 | $54.62 | $36.78 | $60.69 | $60.69 | $134.64 | $158.95 | $158.95 | $22.00 | $22.00 | $158.95 |
4101200 | PROTEIN E-PHORESIS URINE | 300 | Laboratory | 301 | 84166 | $158.00 | $79.00 | $126.40 | $52.96 | $35.66 | $58.84 | $58.84 | $113.76 | $134.30 | $134.30 | $22.00 | $22.00 | $134.30 |
4100361 | PROTEIN TOTAL SERUM | 300 | Laboratory | 301 | 84155 | $38.00 | $19.00 | $30.40 | $10.90 | $7.34 | $12.11 | $12.11 | $27.36 | $32.30 | $32.30 | $22.00 | $7.34 | $32.30 |
4100362 | PROTEIN, URINE RANDOM | 300 | Laboratory | 301 | 84155 | $38.00 | $19.00 | $30.40 | $10.90 | $7.34 | $12.11 | $12.11 | $27.36 | $32.30 | $32.30 | $22.00 | $7.34 | $32.30 |
4100045 | PSA SCRN/ULTRASENSATIVE | 300 | Laboratory | 301 | G0103 | $185.00 | $92.50 | $148.00 | $57.35 | $38.62 | $63.72 | $63.72 | $133.20 | $157.25 | $157.25 | $22.00 | $22.00 | $157.25 |
4100043 | PT/INR | 300 | Laboratory | 305 | 85610 | $80.00 | $40.00 | $64.00 | $12.74 | $8.58 | $14.16 | $14.16 | $57.60 | $68.00 | $68.00 | $22.00 | $8.58 | $68.00 |
4100336 | PTH INTACT | 300 | Laboratory | 301 | 83970 | $461.00 | $230.50 | $368.80 | $122.60 | $82.56 | $136.22 | $136.22 | $331.92 | $391.85 | $391.85 | $22.00 | $22.00 | $391.85 |
4100046 | PTT (PART.THROMB.TIME) | 300 | Laboratory | 305 | 85730 | $117.00 | $58.50 | $93.60 | $17.85 | $12.02 | $19.83 | $19.83 | $84.24 | $99.45 | $99.45 | $22.00 | $12.02 | $99.45 |
4100047 | RAST PER ALLERGEN | 300 | Laboratory | 302 | 86003 | $74.00 | $37.00 | $59.20 | $15.50 | $10.44 | $17.23 | $17.23 | $53.28 | $62.90 | $62.90 | $22.00 | $10.44 | $62.90 |
4100048 | RENAL PROFILE | 300 | Laboratory | 301 | 80069 | $174.00 | $87.00 | $139.20 | $25.78 | $17.36 | $28.64 | $28.64 | $125.28 | $147.90 | $147.90 | $22.00 | $17.36 | $147.90 |
4100377 | RETICULOCYTE COUNT | 300 | Laboratory | 305 | 85045 | $67.00 | $33.50 | $53.60 | $11.85 | $7.98 | $13.17 | $13.17 | $48.24 | $56.95 | $56.95 | $22.00 | $7.98 | $56.95 |
4100378 | Rh (D) TYPING | 300 | Laboratory | 302 | 86901 | $115.00 | $57.50 | $92.00 | $99.29 | $66.86 | $110.32 | $110.32 | $82.80 | $97.75 | $97.75 | $22.00 | $22.00 | $110.32 |
4100381 | RHEUMATIOID FACTOR,QUAL | 300 | Laboratory | 302 | 86430 | $84.00 | $42.00 | $67.20 | $18.24 | $12.28 | $20.26 | $20.26 | $60.48 | $71.40 | $71.40 | $22.00 | $12.28 | $71.40 |
4100049 | RPR (STS) | 300 | Laboratory | 302 | 86780 | $156.00 | $78.00 | $124.80 | $39.32 | $26.48 | $43.69 | $43.69 | $112.32 | $132.60 | $132.60 | $22.00 | $22.00 | $132.60 |
4100386 | RSV ANTIGEN | 300 | Laboratory | 302 | 86756 | $357.00 | $178.50 | $285.60 | $47.19 | $31.78 | $52.44 | $52.44 | $257.04 | $303.45 | $303.45 | $22.00 | $22.00 | $303.45 |
4101246 | RUBELLA IGG | 300 | Laboratory | 302 | 86762 | $101.00 | $50.50 | $80.80 | $42.74 | $28.78 | $47.49 | $47.49 | $72.72 | $85.85 | $85.85 | $22.00 | $22.00 | $85.85 |
4100388 | SALICYLATE (ASA, ASPIRIN) | 300 | Laboratory | 301 | 80329 | $171.00 | $85.50 | $136.80 | $- | $- | $- | $- | $123.12 | $145.35 | $145.35 | $22.00 | $- | $145.35 |
41087426 | SARS Rapid Antigen Covid Antigen | 300 | Laboratory | 301 | 87426 | $150.00 | $75.00 | $120.00 | $134.33 | $90.46 | $149.26 | $149.26 | $108.00 | $127.50 | $127.50 | $22.00 | $22.00 | $149.26 |
4100391 | SENSITIVITY TEST DUE TO G | 300 | Laboratory | 306 | 87186 | $131.00 | $65.50 | $104.80 | $25.69 | $17.30 | $28.55 | $28.55 | $94.32 | $111.35 | $111.35 | $22.00 | $17.30 | $111.35 |
4100270 | SIEP | 300 | Laboratory | 302 | 86334 | $242.00 | $121.00 | $193.60 | $66.35 | $44.68 | $73.72 | $73.72 | $174.24 | $205.70 | $205.70 | $22.00 | $22.00 | $205.70 |
4100050 | SMA 7 PANEL | 300 | Laboratory | 301 | 80048 | $167.00 | $83.50 | $133.60 | $25.13 | $16.92 | $27.92 | $27.92 | $120.24 | $141.95 | $141.95 | $22.00 | $16.92 | $141.95 |
4101216 | SPEC STAIN, GROUP 1 | 300 | Laboratory | 310 | 88312 | $208.00 | $104.00 | $166.40 | $146.93 | $98.94 | $163.25 | $163.25 | $149.76 | $176.80 | $176.80 | $30.00 | $30.00 | $176.80 |
4100411 | SPECIMEN COLLECTION | 300 | Laboratory | 300 | 99001 | $25.00 | $12.50 | $20.00 | $18.21 | $12.26 | $20.23 | $20.23 | $18.00 | $21.25 | $21.25 | $15.00 | $12.26 | $21.25 |
4100412 | SSA ANTIBODY | 300 | Laboratory | 302 | 86235 | $180.00 | $90.00 | $144.00 | $53.25 | $35.86 | $59.17 | $59.17 | $129.60 | $153.00 | $153.00 | $22.00 | $22.00 | $153.00 |
4100051 | STREP SCREEN RAPID | 300 | Laboratory | 306 | 86403 | $125.00 | $62.50 | $100.00 | $34.27 | $23.08 | $38.08 | $38.08 | $90.00 | $106.25 | $106.25 | $22.00 | $22.00 | $106.25 |
4101211 | SURG PATH GRS/MICRO LEV 3 | 300 | Laboratory | 310 | 88304 | $170.00 | $85.00 | $136.00 | $146.93 | $98.94 | $163.25 | $163.25 | $122.40 | $144.50 | $144.50 | $30.00 | $30.00 | $163.25 |
4101212 | SURG PATH GRS/MICRO LEV 4 | 300 | Laboratory | 310 | 88305 | $214.00 | $107.00 | $171.20 | $146.93 | $98.94 | $163.25 | $163.25 | $154.08 | $181.90 | $181.90 | $30.00 | $30.00 | $181.90 |
4100421 | T3 TOTAL (TRI-IODOTHYRONN | 300 | Laboratory | 301 | 84480 | $158.00 | $79.00 | $126.40 | $42.11 | $28.36 | $46.79 | $46.79 | $113.76 | $134.30 | $134.30 | $22.00 | $22.00 | $134.30 |
4100053 | T3 UPTAKE | 300 | Laboratory | 301 | 84479 | $67.00 | $33.50 | $53.60 | $19.22 | $12.94 | $21.35 | $21.35 | $48.24 | $56.95 | $56.95 | $22.00 | $12.94 | $56.95 |
4100434 | T4 (THYROXINE) | 300 | Laboratory | 301 | 84436 | $104.00 | $52.00 | $83.20 | $20.40 | $13.74 | $22.67 | $22.67 | $74.88 | $88.40 | $88.40 | $22.00 | $13.74 | $88.40 |
4100054 | TACROLIMUS | 300 | Laboratory | 301 | 80197 | $241.00 | $120.50 | $192.80 | $40.78 | $27.46 | $45.31 | $45.31 | $173.52 | $204.85 | $204.85 | $22.00 | $22.00 | $204.85 |
4100425 | TESTOSTERONE TOTAL | 300 | Laboratory | 301 | 84403 | $272.00 | $136.00 | $217.60 | $76.66 | $51.62 | $85.17 | $85.17 | $195.84 | $231.20 | $231.20 | $22.00 | $22.00 | $231.20 |
4101198 | TISSUE TRANSGLTMINASE IGA | 300 | Laboratory | 301 | 83516 | $78.00 | $39.00 | $62.40 | $34.24 | $23.06 | $38.05 | $38.05 | $56.16 | $66.30 | $66.30 | $22.00 | $22.00 | $66.30 |
4100444 | TROPONIN I | 300 | Laboratory | 301 | 84484 | $218.00 | $109.00 | $174.40 | $37.04 | $24.94 | $41.15 | $41.15 | $156.96 | $185.30 | $185.30 | $22.00 | $22.00 | $185.30 |
4100058 | TSH THYROID STIM HORM | 300 | Laboratory | 301 | 84443 | $178.00 | $89.00 | $142.40 | $49.90 | $33.60 | $55.44 | $55.44 | $128.16 | $151.30 | $151.30 | $22.00 | $22.00 | $151.30 |
4100447 | UA W/MICRO | 300 | Laboratory | 307 | 81001 | $76.00 | $38.00 | $60.80 | $9.41 | $6.34 | $10.46 | $10.46 | $54.72 | $64.60 | $64.60 | $22.00 | $6.34 | $64.60 |
4100448 | URIC ACID BLOOD | 300 | Laboratory | 301 | 84550 | $84.00 | $42.00 | $67.20 | $13.42 | $9.04 | $14.92 | $14.92 | $60.48 | $71.40 | $71.40 | $22.00 | $9.04 | $71.40 |
4100450 | URINALYSIS BY DIP STICK | 300 | Laboratory | 300 | 81002 | $41.00 | $20.50 | $32.80 | $10.34 | $6.96 | $11.48 | $11.48 | $29.52 | $34.85 | $34.85 | $22.00 | $6.96 | $34.85 |
4100453 | VALPROIC ACID (DEPAKOTE) | 300 | Laboratory | 301 | 80164 | $179.00 | $89.50 | $143.20 | $40.21 | $27.08 | $44.68 | $44.68 | $128.88 | $152.15 | $152.15 | $22.00 | $22.00 | $152.15 |
4100454 | VANCOMYCIN CHARGE | 300 | Laboratory | 301 | 80202 | $211.00 | $105.50 | $168.80 | $40.21 | $27.08 | $44.68 | $44.68 | $151.92 | $179.35 | $179.35 | $22.00 | $22.00 | $179.35 |
4100459 | VITAMIN B12 | 300 | Laboratory | 301 | 82607 | $168.00 | $84.00 | $134.40 | $44.79 | $30.16 | $49.76 | $49.76 | $120.96 | $142.80 | $142.80 | $22.00 | $22.00 | $142.80 |
4100463 | VITAMIN D 25-HYDROXY | 300 | Laboratory | 301 | 82306 | $100.00 | $50.00 | $80.00 | $87.91 | $59.20 | $97.68 | $97.68 | $72.00 | $85.00 | $85.00 | $22.00 | $22.00 | $97.68 |
4100467 | WBC | 300 | Laboratory | 305 | 85048 | $22.00 | $11.00 | $17.60 | $7.54 | $5.08 | $8.38 | $8.38 | $15.84 | $18.70 | $18.70 | $22.00 | $5.08 | $22.00 |
3100467 | CATARACT REMOVAL | 360 | Operating Room | 361 | 66984 | $3,450.00 | $1,725.00 | $2,760.00 | $2,139.00 | $2,139.00 | $2,242.50 | $2,242.50 | $2,484.00 | $2,932.50 | $2,932.50 | $2,932.50 | $2,139.00 | $2,932.50 |
3100018 | COLNSCPY FLEX RMVE TMR S | 360 | Operating Room | 360 | 45385 | $1,363.00 | $681.50 | $1,090.40 | $845.06 | $845.06 | $885.95 | $885.95 | $981.36 | $1,158.55 | $1,158.55 | $1,158.55 | $845.06 | $1,158.55 |
3100019 | COLNSCPY TO TRANSVERSE C | 360 | Operating Room | 360 | 45378 | $1,100.00 | $550.00 | $880.00 | $682.00 | $682.00 | $715.00 | $715.00 | $792.00 | $935.00 | $935.00 | $935.00 | $682.00 | $935.00 |
3100139 | COLONOSCOPY W/BX L/MULTI | 360 | Operating Room | 360 | 45380 | $875.00 | $437.50 | $700.00 | $542.50 | $542.50 | $568.75 | $568.75 | $630.00 | $743.75 | $743.75 | $743.75 | $542.50 | $743.75 |
3100046 | ENDOSCOPY W/WO SPECIMENS | 360 | Operating Room | 360 | 43235 | $1,313.00 | $656.50 | $1,050.40 | $814.06 | $814.06 | $853.45 | $853.45 | $945.36 | $1,116.05 | $1,116.05 | $1,116.05 | $814.06 | $1,116.05 |
3100223 | EX TUMOR FARM WRIST SUBCA | 360 | Operating Room | 361 | 25075 | $1,600.00 | $800.00 | $1,280.00 | $992.00 | $992.00 | $1,040.00 | $1,040.00 | $1,152.00 | $1,360.00 | $1,360.00 | $1,360.00 | $992.00 | $1,360.00 |
3100294 | LAP SURG CHOLECYSTECTOMY | 360 | Operating Room | 360 | 47562 | $4,400.00 | $2,200.00 | $3,520.00 | $2,728.00 | $2,728.00 | $2,860.00 | $2,860.00 | $3,168.00 | $3,740.00 | $3,740.00 | $3,740.00 | $2,728.00 | $3,740.00 |
3100364 | RPR HERNIA INGUINAL 5YRS | 360 | Operating Room | 360 | 49505 | $3,050.00 | $1,525.00 | $2,440.00 | $1,891.00 | $1,891.00 | $1,982.50 | $1,982.50 | $2,196.00 | $2,592.50 | $2,592.50 | $2,592.50 | $1,891.00 | $2,592.50 |
3401005 | EKG 12 LEAD (WELCOME TO MEDICARE) | 999 | Other | 730 | 93000 | $165.00 | $82.50 | $132.00 | $51.38 | $102.30 | $107.25 | $107.25 | $118.80 | $140.25 | $140.25 | $140.25 | $51.38 | $140.25 |
3401003 | CARDIAC REHAB | 420 | Physical Therapy | 943 | 93798 | $200.00 | $100.00 | $160.00 | $20.76 | $14.42 | $23.07 | $23.07 | $144.00 | $170.00 | $170.00 | $170.00 | $14.42 | $170.00 |
3401001 | CARDIAC STRESS TEST TRAC | 420 | Physical Therapy | 482 | 93017 | $410.00 | $205.00 | $328.00 | $364.46 | $253.10 | $404.96 | $404.96 | $295.20 | $348.50 | $348.50 | $348.50 | $253.10 | $404.96 |
4450015 | OT EVAL - LOW COMPLEXITY | 420 | Physical Therapy | 434 | 97165 | $150.00 | $75.00 | $120.00 | $133.89 | $92.98 | $148.77 | $148.77 | $108.00 | $127.50 | $127.50 | $127.50 | $92.98 | $148.77 |
4450018 | OT-MANUAL THERAPY | 420 | Physical Therapy | 431 | 97140 | $76.00 | $38.00 | $60.80 | $41.00 | $28.47 | $45.55 | $45.55 | $54.72 | $64.60 | $64.60 | $64.60 | $28.47 | $64.60 |
4450012 | OT-SELF CARE/HOME MGMT TRAIN | 420 | Physical Therapy | 431 | 97535 | $87.00 | $43.50 | $69.60 | $50.34 | $34.96 | $55.94 | $55.94 | $62.64 | $73.95 | $73.95 | $73.95 | $34.96 | $73.95 |
4401030 | PT EVAL HIGH COMPLEXITY | 420 | Physical Therapy | 424 | 97163 | $276.00 | $138.00 | $220.80 | $124.55 | $86.49 | $138.38 | $138.38 | $198.72 | $234.60 | $234.60 | $234.60 | $86.49 | $234.60 |
4401028 | PT EVAL LOW COMPLEXITY | 420 | Physical Therapy | 424 | 97161 | $175.00 | $87.50 | $140.00 | $124.55 | $86.49 | $138.38 | $138.38 | $126.00 | $148.75 | $148.75 | $148.75 | $86.49 | $148.75 |
4401029 | PT EVAL MOD COMPLEXITY | 420 | Physical Therapy | 424 | 97162 | $178.00 | $89.00 | $142.40 | $124.55 | $86.49 | $138.38 | $138.38 | $128.16 | $151.30 | $151.30 | $151.30 | $86.49 | $151.30 |
4400017 | PT -THERAPEUTIC ACTIVITIES | 420 | Physical Therapy | 421 | 97530 | $75.00 | $37.50 | $60.00 | $58.64 | $40.72 | $65.15 | $65.15 | $54.00 | $63.75 | $63.75 | $63.75 | $40.72 | $65.15 |
4400015 | PT -THERAPEUTIC EXERCISE | 420 | Physical Therapy | 421 | 97110 | $82.00 | $41.00 | $65.60 | $45.14 | $31.35 | $50.16 | $50.16 | $59.04 | $69.70 | $69.70 | $69.70 | $31.35 | $69.70 |
4400010 | PT-ELECTICAL STIM UNATTENDED | 420 | Physical Therapy | 421 | G0283 | $33.00 | $16.50 | $26.40 | $20.76 | $14.42 | $23.07 | $23.07 | $23.76 | $28.05 | $28.05 | $28.05 | $14.42 | $28.05 |
4400037 | PT-MANUAL THERAPY | 420 | Physical Therapy | 421 | 97140 | $76.00 | $38.00 | $60.80 | $41.00 | $28.47 | $45.55 | $45.55 | $54.72 | $64.60 | $64.60 | $64.60 | $28.47 | $64.60 |
4500010 | SP EVAL SWALLOWING (DYSPHAGIA) | 420 | Physical Therapy | 444 | 92610 | $490.00 | $245.00 | $392.00 | $106.91 | $74.24 | $118.78 | $118.78 | $352.80 | $416.50 | $416.50 | $416.50 | $74.24 | $416.50 |
4500018 | SP TRT SPEECH/LANGUAGE | 420 | Physical Therapy | 440 | 92507 | $150.00 | $75.00 | $120.00 | $115.73 | $80.37 | $128.59 | $128.59 | $108.00 | $127.50 | $127.50 | $127.50 | $80.37 | $128.59 |
4500017 | SP TRT SWALLOWING/DYSPHAGIA | 420 | Physical Therapy | 440 | 92526 | $160.00 | $80.00 | $128.00 | $126.63 | $87.94 | $140.70 | $140.70 | $115.20 | $136.00 | $136.00 | $136.00 | $87.94 | $140.70 |
4450014 | THERAPEUTIC PRO >1 AREA E | 420 | Physical Therapy | 431 | 97110 | $82.00 | $41.00 | $65.60 | $45.14 | $31.35 | $50.16 | $50.16 | $59.04 | $69.70 | $69.70 | $69.70 | $31.35 | $69.70 |
4400018 | TRACTION MECHANICAL | 420 | Physical Therapy | 421 | 97012 | $63.00 | $31.50 | $50.40 | $21.80 | $15.14 | $24.22 | $24.22 | $45.36 | $53.55 | $53.55 | $53.55 | $15.14 | $53.55 |
4400020 | ULTRASOUND | 420 | Physical Therapy | 421 | 97035 | $29.00 | $14.50 | $23.20 | $20.25 | $14.06 | $22.50 | $22.50 | $20.88 | $24.65 | $24.65 | $24.65 | $14.06 | $24.65 |
4201060 | BONE AGE STUDIES | 320 | Radiology | 320 | 77072 | $175.00 | $87.50 | $140.00 | $110.96 | $105.36 | $123.29 | $123.29 | $126.00 | $148.75 | $148.75 | $148.75 | $105.36 | $148.75 |
4220025 | CT ABD W | 320 | Radiology | 352 | 74160 | $1,545.00 | $772.50 | $1,236.00 | $328.00 | $309.77 | $364.44 | $364.44 | $1,112.40 | $1,313.25 | $1,313.25 | $1,313.25 | $309.77 | $1,313.25 |
4220024 | CT ABD W/WO | 320 | Radiology | 352 | 74170 | $2,773.79 | $1,386.90 | $2,219.03 | $328.00 | $309.77 | $364.44 | $364.44 | $1,997.13 | $2,357.72 | $2,357.72 | $2,357.72 | $309.77 | $2,357.72 |
4220067 | CT ABD/PEL W & W/O | 320 | Radiology | 352 | 74178 | $2,060.00 | $1,030.00 | $1,648.00 | $687.33 | $649.15 | $763.70 | $763.70 | $1,483.20 | $1,751.00 | $1,751.00 | $1,751.00 | $649.15 | $1,751.00 |
4220066 | CT ABD/PEL W/ CONTRAST | 320 | Radiology | 352 | 74177 | $1,545.00 | $772.50 | $1,236.00 | $687.33 | $649.15 | $763.70 | $763.70 | $1,112.40 | $1,313.25 | $1,313.25 | $1,313.25 | $649.15 | $1,313.25 |
4220065 | CT ABD/PEL W/O CONTRAST | 320 | Radiology | 352 | 74176 | $1,030.00 | $515.00 | $824.00 | $419.47 | $396.17 | $466.08 | $466.08 | $741.60 | $875.50 | $875.50 | $875.50 | $396.17 | $875.50 |
4220018 | CT CHEST W | 320 | Radiology | 352 | 71260 | $2,159.91 | $1,079.96 | $1,727.93 | $328.00 | $309.77 | $364.44 | $364.44 | $1,555.14 | $1,835.92 | $1,835.92 | $1,835.92 | $309.77 | $1,835.92 |
4220019 | CT CHEST W/O | 320 | Radiology | 352 | 71250 | $1,848.85 | $924.43 | $1,479.08 | $201.74 | $190.54 | $224.16 | $224.16 | $1,331.17 | $1,571.52 | $1,571.52 | $1,571.52 | $190.54 | $1,571.52 |
4220050 | CT C-SPINE W/O | 320 | Radiology | 352 | 72125 | $2,097.08 | $1,048.54 | $1,677.66 | $201.74 | $190.54 | $224.16 | $224.16 | $1,509.90 | $1,782.52 | $1,782.52 | $1,782.52 | $190.54 | $1,782.52 |
4220020 | CT HEAD/BRAIN W/O | 320 | Radiology | 351 | 70450 | $1,736.00 | $868.00 | $1,388.80 | $201.74 | $190.54 | $224.16 | $224.16 | $1,249.92 | $1,475.60 | $1,475.60 | $1,475.60 | $190.54 | $1,475.60 |
4220021 | CT L-SPINE W/O | 320 | Radiology | 352 | 72131 | $2,029.10 | $1,014.55 | $1,623.28 | $201.74 | $190.54 | $224.16 | $224.16 | $1,460.95 | $1,724.74 | $1,724.74 | $1,724.74 | $190.54 | $1,724.74 |
4220029 | CT LWR EXT LT W/O | 320 | Radiology | 352 | 73700 | $1,675.00 | $837.50 | $1,340.00 | $201.74 | $190.54 | $224.16 | $224.16 | $1,206.00 | $1,423.75 | $1,423.75 | $1,423.75 | $190.54 | $1,423.75 |
4220052 | CT LWR EXT RT W/O | 320 | Radiology | 352 | 73700 | $1,675.00 | $837.50 | $1,340.00 | $201.74 | $190.54 | $224.16 | $224.16 | $1,206.00 | $1,423.75 | $1,423.75 | $1,423.75 | $190.54 | $1,423.75 |
4220031 | CT MAXILLOFACIAL W | 320 | Radiology | 351 | 70487 | $1,632.55 | $816.28 | $1,306.04 | $328.00 | $309.77 | $364.44 | $364.44 | $1,175.44 | $1,387.67 | $1,387.67 | $1,387.67 | $309.77 | $1,387.67 |
4220057 | CT MAXILLOFACIAL W/O | 320 | Radiology | 351 | 70486 | $1,793.23 | $896.62 | $1,434.58 | $201.74 | $190.54 | $224.16 | $224.16 | $1,291.13 | $1,524.25 | $1,524.25 | $1,524.25 | $190.54 | $1,524.25 |
4220049 | CT NCK SFT TISSUE W | 320 | Radiology | 351 | 70491 | $1,533.67 | $766.84 | $1,226.94 | $328.00 | $309.77 | $364.44 | $364.44 | $1,104.24 | $1,303.62 | $1,303.62 | $1,303.62 | $309.77 | $1,303.62 |
4220035 | CT PELVIS W | 320 | Radiology | 352 | 72193 | $1,534.70 | $767.35 | $1,227.76 | $328.00 | $309.77 | $364.44 | $364.44 | $1,104.98 | $1,304.50 | $1,304.50 | $1,304.50 | $309.77 | $1,304.50 |
4220036 | CT PELVIS W/O | 320 | Radiology | 352 | 72192 | $1,852.97 | $926.49 | $1,482.38 | $201.74 | $190.54 | $224.16 | $224.16 | $1,334.14 | $1,575.02 | $1,575.02 | $1,575.02 | $190.54 | $1,575.02 |
4220048 | CT SINUS W/O | 320 | Radiology | 351 | 70486 | $1,793.86 | $896.93 | $1,435.09 | $201.74 | $190.54 | $224.16 | $224.16 | $1,291.58 | $1,524.78 | $1,524.78 | $1,524.78 | $190.54 | $1,524.78 |
4220016 | CT T-SPINE W/O | 320 | Radiology | 352 | 72128 | $1,874.60 | $937.30 | $1,499.68 | $201.74 | $190.54 | $224.16 | $224.16 | $1,349.71 | $1,593.41 | $1,593.41 | $1,593.41 | $190.54 | $1,593.41 |
4220070 | CTA ABD AORTA W/ RUNOFF | 320 | Radiology | 323 | 75635 | $3,861.00 | $1,930.50 | $3,088.80 | $328.00 | $309.77 | $364.44 | $364.44 | $2,779.92 | $3,281.85 | $3,281.85 | $3,281.85 | $309.77 | $3,281.85 |
4220069 | CTA ABD/PEL W/ CONTRAST | 320 | Radiology | 352 | 74174 | $2,446.25 | $1,223.13 | $1,957.00 | $522.86 | $493.82 | $580.96 | $580.96 | $1,761.30 | $2,079.31 | $2,079.31 | $2,079.31 | $493.82 | $2,079.31 |
4220027 | CTA CHEST W/WO | 320 | Radiology | 352 | 71275 | $2,435.95 | $1,217.98 | $1,948.76 | $328.00 | $309.77 | $364.44 | $364.44 | $1,753.88 | $2,070.56 | $2,070.56 | $2,070.56 | $309.77 | $2,070.56 |
4220061 | CTA HEAD W/WO | 320 | Radiology | 350 | 70496 | $1,854.00 | $927.00 | $1,483.20 | $328.00 | $309.77 | $364.44 | $364.44 | $1,334.88 | $1,575.90 | $1,575.90 | $1,575.90 | $309.77 | $1,575.90 |
4220060 | CTA NECK W/WO | 320 | Radiology | 350 | 70498 | $1,862.24 | $931.12 | $1,489.79 | $328.00 | $309.77 | $364.44 | $364.44 | $1,340.81 | $1,582.90 | $1,582.90 | $1,582.90 | $309.77 | $1,582.90 |
4280012 | DUP CAROTID BILAT | 320 | Radiology | 921 | 93880 | $1,094.00 | $547.00 | $875.20 | $236.65 | $164.34 | $262.94 | $262.94 | $787.68 | $929.90 | $929.90 | $929.90 | $164.34 | $929.90 |
4280013 | DUPLEX EXT LOWER BILAT | 320 | Radiology | 921 | 93922 | $399.00 | $199.50 | $319.20 | $157.00 | $109.03 | $174.45 | $174.45 | $287.28 | $339.15 | $339.15 | $339.15 | $109.03 | $339.15 |
4280014 | DUPLEX EXT VEINS BILAT | 320 | Radiology | 921 | 93970 | $1,115.00 | $557.50 | $892.00 | $235.61 | $163.62 | $261.79 | $261.79 | $802.80 | $947.75 | $947.75 | $947.75 | $163.62 | $947.75 |
4201070 | ELBOW LEFT 3 VIEWS | 320 | Radiology | 320 | 73080 | $248.00 | $124.00 | $198.40 | $79.01 | $75.02 | $87.79 | $87.79 | $178.56 | $210.80 | $210.80 | $210.80 | $75.02 | $210.80 |
4201071 | ELBOW RIGHT 3 VIEWS | 320 | Radiology | 320 | 73080 | $248.00 | $124.00 | $198.40 | $79.01 | $75.02 | $87.79 | $87.79 | $178.56 | $210.80 | $210.80 | $210.80 | $75.02 | $210.80 |
4201066 | RIBS LEFT W/ PA CHEST | 320 | Radiology | 324 | 71101 | $458.00 | $229.00 | $366.40 | $110.96 | $105.36 | $123.29 | $123.29 | $329.76 | $389.30 | $389.30 | $389.30 | $105.36 | $389.30 |
4201067 | RIBS RIGHT W/ PA CHEST | 320 | Radiology | 324 | 71101 | $458.00 | $229.00 | $366.40 | $110.96 | $105.36 | $123.29 | $123.29 | $329.76 | $389.30 | $389.30 | $389.30 | $105.36 | $389.30 |
4201065 | T-SPINE 3 VIEWS | 320 | Radiology | 320 | 72072 | $458.00 | $229.00 | $366.40 | $110.96 | $105.36 | $123.29 | $123.29 | $329.76 | $389.30 | $389.30 | $389.30 | $105.36 | $389.30 |
4281018 | US AAA-MCR | 320 | Radiology | 402 | 76706 | $562.00 | $281.00 | $449.60 | $86.34 | $81.98 | $95.93 | $95.93 | $404.64 | $477.70 | $477.70 | $477.70 | $81.98 | $477.70 |
4280016 | US ABD COMPLETE | 320 | Radiology | 402 | 76700 | $766.00 | $383.00 | $612.80 | $110.96 | $105.36 | $123.29 | $123.29 | $551.52 | $651.10 | $651.10 | $651.10 | $105.36 | $651.10 |
4280017 | US ABD LMTD (GALLBLADDER | 320 | Radiology | 402 | 76705 | $661.00 | $330.50 | $528.80 | $110.96 | $105.36 | $123.29 | $123.29 | $475.92 | $561.85 | $561.85 | $561.85 | $105.36 | $561.85 |
4281017 | US ABD LMTD (LIVER) | 320 | Radiology | 402 | 76705 | $661.00 | $330.50 | $528.80 | $110.96 | $105.36 | $123.29 | $123.29 | $475.92 | $561.85 | $561.85 | $561.85 | $105.36 | $561.85 |
4280029 | US BREAST UNI COMPLETE | 320 | Radiology | 402 | 76641 | $304.00 | $152.00 | $243.20 | $110.96 | $105.36 | $123.29 | $123.29 | $218.88 | $258.40 | $258.40 | $258.40 | $105.36 | $258.40 |
4280020 | US DUP LWR EXT ART COMP | 320 | Radiology | 921 | 93925 | $1,043.00 | $521.50 | $834.40 | $318.12 | $220.92 | $353.47 | $353.47 | $750.96 | $886.55 | $886.55 | $886.55 | $220.92 | $886.55 |
4280021 | US DUP LWR EXT ART UNILA | 320 | Radiology | 921 | 93926 | $351.00 | $175.50 | $280.80 | $161.91 | $112.44 | $179.90 | $179.90 | $252.72 | $298.35 | $298.35 | $298.35 | $112.44 | $298.35 |
4280015 | US DUPLEX EXT VEINS UNI | 320 | Radiology | 921 | 93971 | $735.00 | $367.50 | $588.00 | $144.27 | $100.19 | $160.30 | $160.30 | $529.20 | $624.75 | $624.75 | $624.75 | $100.19 | $624.75 |
4280019 | US ECHO CONGENITAL CARDI | 320 | Radiology | 483 | 93303 | $824.00 | $412.00 | $659.20 | $251.18 | $174.43 | $279.09 | $279.09 | $593.28 | $700.40 | $700.40 | $700.40 | $174.43 | $700.40 |
4280031 | US EXT NON-VASC LMTD | 320 | Radiology | 402 | 76882 | $304.00 | $152.00 | $243.20 | $110.96 | $105.36 | $123.29 | $123.29 | $218.88 | $258.40 | $258.40 | $258.40 | $105.36 | $258.40 |
4281019 | US OB < 14 WKS SINGLE | 320 | Radiology | 402 | 76801 | $618.00 | $309.00 | $494.40 | $72.78 | $69.11 | $80.87 | $80.87 | $444.96 | $525.30 | $525.30 | $525.30 | $69.11 | $525.30 |
4280033 | US OB COMPLETE>14 WKS | 320 | Radiology | 402 | 76805 | $335.00 | $167.50 | $268.00 | $90.62 | $86.05 | $100.69 | $100.69 | $241.20 | $284.75 | $284.75 | $284.75 | $86.05 | $284.75 |
4280043 | US OB LIMITED | 320 | Radiology | 402 | 76815 | $201.00 | $100.50 | $160.80 | $110.96 | $105.36 | $123.29 | $123.29 | $144.72 | $170.85 | $170.85 | $170.85 | $105.36 | $170.85 |
4281020 | US OB, TRANSVAGINAL | 320 | Radiology | 402 | 76817 | $567.00 | $283.50 | $453.60 | $110.96 | $105.36 | $123.29 | $123.29 | $408.24 | $481.95 | $481.95 | $481.95 | $105.36 | $481.95 |
4280039 | US PELVIC NON-OB LMT | 320 | Radiology | 402 | 76857 | $288.00 | $144.00 | $230.40 | $110.96 | $105.36 | $123.29 | $123.29 | $207.36 | $244.80 | $244.80 | $244.80 | $105.36 | $244.80 |
4280034 | US PELVIC, NON-OB | 320 | Radiology | 402 | 76856 | $663.00 | $331.50 | $530.40 | $110.96 | $105.36 | $123.29 | $123.29 | $477.36 | $563.55 | $563.55 | $563.55 | $105.36 | $563.55 |
4280040 | US PREGNANCY FOLLOW-UP | 320 | Radiology | 402 | 76816 | $194.00 | $97.00 | $155.20 | $110.96 | $105.36 | $123.29 | $123.29 | $139.68 | $164.90 | $164.90 | $164.90 | $105.36 | $164.90 |
4280023 | US RENAL | 320 | Radiology | 402 | 76770 | $770.00 | $385.00 | $616.00 | $110.96 | $105.36 | $123.29 | $123.29 | $554.40 | $654.50 | $654.50 | $654.50 | $105.36 | $654.50 |
4280032 | US SCROTUM | 320 | Radiology | 402 | 76870 | $804.00 | $402.00 | $643.20 | $110.96 | $105.36 | $123.29 | $123.29 | $578.88 | $683.40 | $683.40 | $683.40 | $105.36 | $683.40 |
4280037 | US SOFT TISSUE HEAD/NCK | 320 | Radiology | 402 | 76536 | $602.00 | $301.00 | $481.60 | $110.96 | $105.36 | $123.29 | $123.29 | $433.44 | $511.70 | $511.70 | $511.70 | $105.36 | $511.70 |
4281015 | US THYROID | 320 | Radiology | 402 | 76536 | $602.00 | $301.00 | $481.60 | $110.96 | $105.36 | $123.29 | $123.29 | $433.44 | $511.70 | $511.70 | $511.70 | $105.36 | $511.70 |
4280036 | US TRANSTHORACIC (ECHO) W/ DOPPLER | 320 | Radiology | 483 | 93306 | $1,854.00 | $927.00 | $1,483.20 | $195.13 | $135.51 | $216.82 | $216.82 | $1,334.88 | $1,575.90 | $1,575.90 | $1,575.90 | $135.51 | $1,575.90 |
4280035 | US TRANSVAGINAL | 320 | Radiology | 402 | 76830 | $689.00 | $344.50 | $551.20 | $87.42 | $83.00 | $97.13 | $97.13 | $496.08 | $585.65 | $585.65 | $585.65 | $83.00 | $585.65 |
4200030 | XR ABD 1V | 320 | Radiology | 320 | 74018 | $234.00 | $117.00 | $187.20 | $79.01 | $75.02 | $87.79 | $87.79 | $168.48 | $198.90 | $198.90 | $198.90 | $75.02 | $198.90 |
4200040 | XR ABD ACUTE COMP | 320 | Radiology | 320 | 74022 | $430.00 | $215.00 | $344.00 | $110.96 | $105.36 | $123.29 | $123.29 | $309.60 | $365.50 | $365.50 | $365.50 | $105.36 | $365.50 |
4200035 | XR ABD COMPL W/DCBTS&ERC | 320 | Radiology | 320 | 74019 | $309.00 | $154.50 | $247.20 | $110.96 | $105.36 | $123.29 | $123.29 | $222.48 | $262.65 | $262.65 | $262.65 | $105.36 | $262.65 |
4200045 | XR ANKLE 2V LT | 320 | Radiology | 320 | 73600 | $242.00 | $121.00 | $193.60 | $79.01 | $75.02 | $87.79 | $87.79 | $174.24 | $205.70 | $205.70 | $205.70 | $75.02 | $205.70 |
4201026 | XR ANKLE 2V RT | 320 | Radiology | 320 | 73600 | $242.00 | $121.00 | $193.60 | $79.01 | $75.02 | $87.79 | $87.79 | $174.24 | $205.70 | $205.70 | $205.70 | $75.02 | $205.70 |
4200050 | XR ANKLE COMP MIN 3V LT | 320 | Radiology | 320 | 73610 | $273.00 | $136.50 | $218.40 | $79.01 | $75.02 | $87.79 | $87.79 | $196.56 | $232.05 | $232.05 | $232.05 | $75.02 | $232.05 |
4201027 | XR ANKLE COMP MIN 3V RT | 320 | Radiology | 320 | 73610 | $273.00 | $136.50 | $218.40 | $79.01 | $75.02 | $87.79 | $87.79 | $196.56 | $232.05 | $232.05 | $232.05 | $75.02 | $232.05 |
4200010 | XR CHEST 1V | 320 | Radiology | 324 | 71045 | $249.00 | $124.50 | $199.20 | $79.01 | $75.02 | $87.79 | $87.79 | $179.28 | $211.65 | $211.65 | $211.65 | $75.02 | $211.65 |
4200020 | XR CHEST AP/LAT | 320 | Radiology | 324 | 71046 | $283.00 | $141.50 | $226.40 | $79.01 | $75.02 | $87.79 | $87.79 | $203.76 | $240.55 | $240.55 | $240.55 | $75.02 | $240.55 |
4200065 | XR CLAVICLE LT | 320 | Radiology | 320 | 73000 | $262.00 | $131.00 | $209.60 | $79.01 | $75.02 | $87.79 | $87.79 | $188.64 | $222.70 | $222.70 | $222.70 | $75.02 | $222.70 |
4201006 | XR CLAVICLE RT | 320 | Radiology | 320 | 73000 | $262.00 | $131.00 | $209.60 | $79.01 | $75.02 | $87.79 | $87.79 | $188.64 | $222.70 | $222.70 | $222.70 | $75.02 | $222.70 |
4200335 | XR C-SPINE 2-3V | 320 | Radiology | 320 | 72040 | $264.00 | $132.00 | $211.20 | $79.01 | $75.02 | $87.79 | $87.79 | $190.08 | $224.40 | $224.40 | $224.40 | $75.02 | $224.40 |
4200085 | XR ELBOW 2V LT | 320 | Radiology | 320 | 73070 | $220.00 | $110.00 | $176.00 | $79.01 | $75.02 | $87.79 | $87.79 | $158.40 | $187.00 | $187.00 | $187.00 | $75.02 | $187.00 |
4201014 | XR ELBOW 2V RT | 320 | Radiology | 320 | 73070 | $220.00 | $110.00 | $176.00 | $79.01 | $75.02 | $87.79 | $87.79 | $158.40 | $187.00 | $187.00 | $187.00 | $75.02 | $187.00 |
4200105 | XR FEMUR 2V LT | 320 | Radiology | 320 | 73552 | $267.00 | $133.50 | $213.60 | $79.01 | $75.02 | $87.79 | $87.79 | $192.24 | $226.95 | $226.95 | $226.95 | $75.02 | $226.95 |
4201022 | XR FEMUR 2V RT | 320 | Radiology | 320 | 73552 | $267.00 | $133.50 | $213.60 | $79.01 | $75.02 | $87.79 | $87.79 | $192.24 | $226.95 | $226.95 | $226.95 | $75.02 | $226.95 |
4200115 | XR FINGER 2V LT | 320 | Radiology | 320 | 73140 | $220.00 | $110.00 | $176.00 | $79.01 | $75.02 | $87.79 | $87.79 | $158.40 | $187.00 | $187.00 | $187.00 | $75.02 | $187.00 |
4201018 | XR FINGER 2V RT | 320 | Radiology | 320 | 73140 | $220.00 | $110.00 | $176.00 | $79.01 | $75.02 | $87.79 | $87.79 | $158.40 | $187.00 | $187.00 | $187.00 | $75.02 | $187.00 |
4201037 | XR FOOT 2V LT | 320 | Radiology | 320 | 73620 | $214.00 | $107.00 | $171.20 | $79.01 | $75.02 | $87.79 | $87.79 | $154.08 | $181.90 | $181.90 | $181.90 | $75.02 | $181.90 |
4201038 | XR FOOT 2V RT | 320 | Radiology | 320 | 73620 | $214.00 | $107.00 | $171.20 | $79.01 | $75.02 | $87.79 | $87.79 | $154.08 | $181.90 | $181.90 | $181.90 | $75.02 | $181.90 |
4200125 | XR FOOT COMP MIN 3V LT | 320 | Radiology | 320 | 73630 | $250.00 | $125.00 | $200.00 | $79.01 | $75.02 | $87.79 | $87.79 | $180.00 | $212.50 | $212.50 | $212.50 | $75.02 | $212.50 |
4201028 | XR FOOT COMP MIN 3V RT | 320 | Radiology | 320 | 73630 | $250.00 | $125.00 | $200.00 | $79.01 | $75.02 | $87.79 | $87.79 | $180.00 | $212.50 | $212.50 | $212.50 | $75.02 | $212.50 |
4200130 | XR FOREARM 2V LT | 320 | Radiology | 320 | 73090 | $266.00 | $133.00 | $212.80 | $79.01 | $75.02 | $87.79 | $87.79 | $191.52 | $226.10 | $226.10 | $226.10 | $75.02 | $226.10 |
4201015 | XR FOREARM 2V RT | 320 | Radiology | 320 | 73090 | $266.00 | $133.00 | $212.80 | $79.01 | $75.02 | $87.79 | $87.79 | $191.52 | $226.10 | $226.10 | $226.10 | $75.02 | $226.10 |
4201074 | XR HAND LT 2 VIEWS | 320 | Radiology | 320 | 73120 | $175.00 | $87.50 | $140.00 | $110.96 | $105.36 | $123.29 | $123.29 | $126.00 | $148.75 | $148.75 | $148.75 | $105.36 | $148.75 |
4200160 | XR HAND MIN 3V LT | 320 | Radiology | 320 | 73130 | $265.00 | $132.50 | $212.00 | $79.01 | $75.02 | $87.79 | $87.79 | $190.80 | $225.25 | $225.25 | $225.25 | $75.02 | $225.25 |
4201017 | XR HAND RT | 320 | Radiology | 320 | 73130 | $265.00 | $132.50 | $212.00 | $79.01 | $75.02 | $87.79 | $87.79 | $190.80 | $225.25 | $225.25 | $225.25 | $75.02 | $225.25 |
4201073 | XR HAND RT 2 VIEWS | 320 | Radiology | 320 | 73120 | $175.00 | $87.50 | $140.00 | $110.96 | $105.36 | $123.29 | $123.29 | $126.00 | $148.75 | $148.75 | $148.75 | $105.36 | $148.75 |
4200170 | XR HIP 1V LT | 320 | Radiology | 320 | 73501 | $205.00 | $102.50 | $164.00 | $79.01 | $75.02 | $87.79 | $87.79 | $147.60 | $174.25 | $174.25 | $174.25 | $75.02 | $174.25 |
4200175 | XR HIP 2-3V LT | 320 | Radiology | 320 | 73502 | $256.00 | $128.00 | $204.80 | $79.01 | $75.02 | $87.79 | $87.79 | $184.32 | $217.60 | $217.60 | $217.60 | $75.02 | $217.60 |
4201020 | XR HIP 2-3V RT | 320 | Radiology | 320 | 73502 | $256.00 | $128.00 | $204.80 | $79.01 | $75.02 | $87.79 | $87.79 | $184.32 | $217.60 | $217.60 | $217.60 | $75.02 | $217.60 |
4200185 | XR HIPS BILAT 2V | 320 | Radiology | 320 | 73521 | $348.00 | $174.00 | $278.40 | $110.96 | $105.36 | $123.29 | $123.29 | $250.56 | $295.80 | $295.80 | $295.80 | $105.36 | $295.80 |
4200190 | XR HUMERUS 2V LT | 320 | Radiology | 320 | 73060 | $264.00 | $132.00 | $211.20 | $79.01 | $75.02 | $87.79 | $87.79 | $190.08 | $224.40 | $224.40 | $224.40 | $75.02 | $224.40 |
4201012 | XR HUMERUS 2V RT | 320 | Radiology | 320 | 73060 | $264.00 | $132.00 | $211.20 | $79.01 | $75.02 | $87.79 | $87.79 | $190.08 | $224.40 | $224.40 | $224.40 | $75.02 | $224.40 |
4201024 | XR KNEE 1/2V RT | 320 | Radiology | 320 | 73560 | $215.00 | $107.50 | $172.00 | $79.01 | $75.02 | $87.79 | $87.79 | $154.80 | $182.75 | $182.75 | $182.75 | $75.02 | $182.75 |
4200210 | XR KNEE 1/2V LT | 320 | Radiology | 320 | 73560 | $215.00 | $107.50 | $172.00 | $79.01 | $75.02 | $87.79 | $87.79 | $154.80 | $182.75 | $182.75 | $182.75 | $75.02 | $182.75 |
4201033 | XR KNEE 3V LT | 320 | Radiology | 320 | 73562 | $275.00 | $137.50 | $220.00 | $79.01 | $75.02 | $87.79 | $87.79 | $198.00 | $233.75 | $233.75 | $233.75 | $75.02 | $233.75 |
4201034 | XR KNEE 3V RT | 320 | Radiology | 320 | 73562 | $275.00 | $137.50 | $220.00 | $79.01 | $75.02 | $87.79 | $87.79 | $198.00 | $233.75 | $233.75 | $233.75 | $75.02 | $233.75 |
4201035 | XR KNEE COMP 4V LT | 320 | Radiology | 320 | 73564 | $406.00 | $203.00 | $324.80 | $110.96 | $105.36 | $123.29 | $123.29 | $292.32 | $345.10 | $345.10 | $345.10 | $105.36 | $345.10 |
4201036 | XR KNEE COMP 4V RT | 320 | Radiology | 320 | 73564 | $406.00 | $203.00 | $324.80 | $110.96 | $105.36 | $123.29 | $123.29 | $292.32 | $345.10 | $345.10 | $345.10 | $105.36 | $345.10 |
4201039 | XR KNEE STANDING BILAT | 320 | Radiology | 320 | 73565 | $205.00 | $102.50 | $164.00 | $79.01 | $75.02 | $87.79 | $87.79 | $147.60 | $174.25 | $174.25 | $174.25 | $75.02 | $174.25 |
4201025 | XR LEG 2V RT | 320 | Radiology | 320 | 73590 | $278.00 | $139.00 | $222.40 | $79.01 | $75.02 | $87.79 | $87.79 | $200.16 | $236.30 | $236.30 | $236.30 | $75.02 | $236.30 |
4200220 | XR LEG 2V LT | 320 | Radiology | 320 | 73590 | $278.00 | $139.00 | $222.40 | $79.01 | $75.02 | $87.79 | $87.79 | $200.16 | $236.30 | $236.30 | $236.30 | $75.02 | $236.30 |
4200345 | XR L-SPINE 2-3V | 320 | Radiology | 320 | 72100 | $281.00 | $140.50 | $224.80 | $110.96 | $105.36 | $123.29 | $123.29 | $202.32 | $238.85 | $238.85 | $238.85 | $105.36 | $238.85 |
4200350 | XR L-SPINE W/OBLIQ 4V | 320 | Radiology | 320 | 72110 | $633.00 | $316.50 | $506.40 | $110.96 | $105.36 | $123.29 | $123.29 | $455.76 | $538.05 | $538.05 | $538.05 | $105.36 | $538.05 |
4200205 | XR MANDIBLE <4V | 320 | Radiology | 320 | 70100 | $205.00 | $102.50 | $164.00 | $79.01 | $75.02 | $87.79 | $87.79 | $147.60 | $174.25 | $174.25 | $174.25 | $75.02 | $174.25 |
4201058 | XR ORBITS, FOR FB | 320 | Radiology | 320 | 70030 | $205.00 | $102.50 | $164.00 | $79.01 | $75.02 | $87.79 | $87.79 | $147.60 | $174.25 | $174.25 | $174.25 | $75.02 | $174.25 |
4200255 | XR PELVIS 1V | 320 | Radiology | 320 | 72170 | $254.00 | $127.00 | $203.20 | $110.96 | $105.36 | $123.29 | $123.29 | $182.88 | $215.90 | $215.90 | $215.90 | $105.36 | $215.90 |
4200260 | XR PELVIS COMP MIN 3V | 320 | Radiology | 320 | 72190 | $518.00 | $259.00 | $414.40 | $110.96 | $105.36 | $123.29 | $123.29 | $372.96 | $440.30 | $440.30 | $440.30 | $105.36 | $440.30 |
4200280 | XR RIBS LT 2V | 320 | Radiology | 320 | 71100 | $271.00 | $135.50 | $216.80 | $79.01 | $75.02 | $87.79 | $87.79 | $195.12 | $230.35 | $230.35 | $230.35 | $75.02 | $230.35 |
4201004 | XR RIBS RT 2V | 320 | Radiology | 320 | 71100 | $271.00 | $135.50 | $216.80 | $79.01 | $75.02 | $87.79 | $87.79 | $195.12 | $230.35 | $230.35 | $230.35 | $75.02 | $230.35 |
4200290 | XR SACRUM/COCCYX 2V | 320 | Radiology | 320 | 72220 | $276.00 | $138.00 | $220.80 | $79.01 | $75.02 | $87.79 | $87.79 | $198.72 | $234.60 | $234.60 | $234.60 | $75.02 | $234.60 |
4200305 | XR SHOULDER 1V LT | 320 | Radiology | 320 | 73020 | $248.00 | $124.00 | $198.40 | $79.01 | $75.02 | $87.79 | $87.79 | $178.56 | $210.80 | $210.80 | $210.80 | $75.02 | $210.80 |
4201010 | XR SHOULDER 1V RT | 320 | Radiology | 320 | 73020 | $248.00 | $124.00 | $198.40 | $79.01 | $75.02 | $87.79 | $87.79 | $178.56 | $210.80 | $210.80 | $210.80 | $75.02 | $210.80 |
4200310 | XR SHOULDER 2V LT | 320 | Radiology | 320 | 73030 | $288.00 | $144.00 | $230.40 | $79.01 | $75.02 | $87.79 | $87.79 | $207.36 | $244.80 | $244.80 | $244.80 | $75.02 | $244.80 |
4201011 | XR SHOULDER 2V RT | 320 | Radiology | 320 | 73030 | $288.00 | $144.00 | $230.40 | $79.01 | $75.02 | $87.79 | $87.79 | $207.36 | $244.80 | $244.80 | $244.80 | $75.02 | $244.80 |
4200385 | XR TOES 2V LT | 320 | Radiology | 320 | 73660 | $235.00 | $117.50 | $188.00 | $79.01 | $75.02 | $87.79 | $87.79 | $169.20 | $199.75 | $199.75 | $199.75 | $75.02 | $199.75 |
4200360 | XR T-SPINE | 320 | Radiology | 320 | 72070 | $260.00 | $130.00 | $208.00 | $110.96 | $105.36 | $123.29 | $123.29 | $187.20 | $221.00 | $221.00 | $221.00 | $105.36 | $221.00 |
4200395 | XR WRIST 3V LT | 320 | Radiology | 320 | 73110 | $261.00 | $130.50 | $208.80 | $79.01 | $75.02 | $87.79 | $87.79 | $187.92 | $221.85 | $221.85 | $221.85 | $75.02 | $221.85 |
4201016 | XR WRIST 3V RT | 320 | Radiology | 320 | 73110 | $261.00 | $130.50 | $208.80 | $79.01 | $75.02 | $87.79 | $87.79 | $187.92 | $221.85 | $221.85 | $221.85 | $75.02 | $221.85 |
4201076 | XR WRIST LT 2 VIEWS | 320 | Radiology | 320 | 73100 | $175.00 | $87.50 | $140.00 | $79.01 | $75.02 | $87.79 | $87.79 | $126.00 | $148.75 | $148.75 | $148.75 | $75.02 | $148.75 |
4201075 | XR WRIST RT 2 VIEWS | 320 | Radiology | 320 | 73100 | $175.00 | $87.50 | $140.00 | $79.01 | $75.02 | $87.79 | $87.79 | $126.00 | $148.75 | $148.75 | $148.75 | $75.02 | $148.75 |
99386 | 1st Preventive Medicine New Patient Age | 521 | Rural Health Clinic | 521 | 99386 | $218.00 | $163.50 | $193.74 | $174.37 | $121.09 | $193.74 | $193.74 | $193.74 | $193.74 | $193.74 | $193.74 | $121.09 | $193.74 |
99385 | 1st Preventive Medicine New Patient Age | 521 | Rural Health Clinic | 521 | 99385 | $186.00 | $139.50 | $159.15 | $143.24 | $99.47 | $159.15 | $159.15 | $159.15 | $159.15 | $159.15 | $159.15 | $99.47 | $159.15 |
99203 | New patient visit 30 min | 521 | Rural Health Clinic | 521 | 99203 | $165.00 | $123.75 | $114.19 | $111.57 | $77.48 | $123.97 | $123.97 | $114.19 | $114.19 | $114.19 | $114.19 | $77.48 | $123.97 |
85610 | Prothrombin Tm | 521 | Rural Health Clinic | 521 | 85610 | $10.00 | $7.50 | $- | $10.00 | $8.58 | $10.00 | $10.00 | $- | $- | $- | $- | $- | $10.00 |
81002 | Urnls Dip Stick/Tablet Rgnt Non-Auto W/O | 521 | Rural Health Clinic | 521 | 81002 | $5.00 | $3.75 | $- | $5.00 | $5.00 | $5.00 | $5.00 | $- | $- | $- | $- | $- | $5.00 |
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call (877)-696-6775
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