Hospital Charges / Price Transparency

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! 

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Average Charges

Searchable Shoppable Services

Coleman County Medical Center Shoppable Services as of 7/20/2022

Charge CodeCharge Code DescriptionDeptDept NameRev CodeCPT CodeGross ChargeCash PriceAetnaBCBS TX - HMOBCBS TX - Blue AdvantageBCBS TX - Traditional PARBCBS TX - PPOCIGNAFirstCareScott & WhiteUnitedMinimum Negotiated PriceMaximum Negotiated Rate
3550010EKG 12 LEAD TRACING ONLY730EKG/ECG73093005 $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)300Laboratory30585025 $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
410006324HR URINE, PROTEIN300Laboratory30184156 $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
4100065A N A ANTINUCLEAR ANTIBOD300Laboratory30286038 $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
4100121ABG300Laboratory30182803 $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
4100067ABO TYPING300Laboratory30086900 $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
4100068ACETAMINOPHEN LEVEL300Laboratory30180329 $171.00 $85.50 $136.80 $- $- $- $- $123.12 $145.35 $145.35 $22.00 $- $145.35
4101010A-ELECTROPHORECTIC FRACTI300Laboratory30184165 $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
4101098A-ELECTROPHORECTIC FRACTI300Laboratory30184165 $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
4100074AEROBIC IDENTIFICATION300Laboratory30687077 $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
4101193AFP, SERUM300Laboratory30182105 $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
4101019A-INFLUENZA A300Laboratory30687804 $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
4100075ALBUMIN (SERUM)300Laboratory30182040 $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
4100077ALCOHOL BLOOD300Laboratory30180320 $111.00 $55.50 $88.80 $- $- $- $- $79.92 $94.35 $94.35 $22.00 $- $94.35
4100399ALT (SGPT)300Laboratory30184460 $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
4100088AMMONIA LEVEL300Laboratory30182140 $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
4100089AMYLASE SERUM300Laboratory30182150 $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
4100100ANTIBODY SCREEN CHRG300Laboratory30286850 $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
4100102ANTI-ENDOMESIAL IGA300Laboratory30286255 $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
4100431ANTI-MICROSOMAL AB (TPO A300Laboratory30286376 $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
4101024A-PSA FREE300Laboratory30184154 $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
4100398AST (SGOT)300Laboratory30184450 $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
4100119BILIRUBIN DIRECT300Laboratory30182248 $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
4100120BILIRUBIN TOTAL300Laboratory30182247 $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
4101042B-INFLUENZA B300Laboratory30687804 $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
4100012BMP300Laboratory30180048 $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
4100124BNAP (NATRUIRETIC PEPTIDE300Laboratory30183880 $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
4100131BODY FLUID CELL COUNT300Laboratory30189050 $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
4101045B-PSA TOTAL300Laboratory30184153 $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
4100133BUN(UREA NITROGEN)300Laboratory30184520 $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
4101326CALPROTECTIN, STOOL300Laboratory30183993 $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
4100016CBC300Laboratory30585025 $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
4101111CBC W/O DIFFERENTIAL300Laboratory30585027 $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
4100017CEA (CARCINO EMBRYONIC AN300Laboratory30182378 $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
4100152CHLAMYDIA TRACH AMP PROBE300Laboratory30687491 $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
4101256CMA-COUMADIN300Laboratory30085610 $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
4101259CMA-UA300Laboratory30081002 $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
4101360CMV DNA BY PCR QUAN300Laboratory30687497 $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
4100021COMPLETE METABOLIC PROFI300Laboratory30180053 $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
4100164COOMBS DIRECT300Laboratory30286880 $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
4101466COVID-19 REFERENCE LAB300Laboratory30087635 $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
4100169CPK300Laboratory30182550 $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
4100171C-REACTIVE PROTEIN300Laboratory30286140 $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
4100172CREATININE300Laboratory30182565 $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
4100175CREATININE 24HR URINE300Laboratory30182570 $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
4100176CREATININE, URINE, RANDOM300Laboratory30182570 $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
4101373CRYTOCOCCOUS ANTIGEN300Laboratory30286403 $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
4101053C-THROMBOPLASTIN TIME; PA300Laboratory30585730 $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
4101370C-TRICHOMONAS VAGINALIS300Laboratory30687661 $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
4100184CULTURE BLOOD300Laboratory30687040 $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
4100191CULTURE UA300Laboratory30687086 $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
4100192CULTURE, FUNGI, DEFINITIV300Laboratory30687106 $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
4100196CULTURE, WOUND300Laboratory30687070 $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
4101112CYCLIC CITRILLINATED PEPT300Laboratory30286200 $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
4100200D-DIMER300Laboratory30585378 $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
4100036DIGOXIN (LANOXIN)300Laboratory30180162 $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
4100204DILANTIN300Laboratory30180185 $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
4101185DNA/RNA DIRECT PROBE X2300Laboratory30687149 $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
4100390ESR (SED RATE)300Laboratory30585651 $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
4100217ESTRADIOL SERUM300Laboratory30182670 $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
4100022FERRITIN300Laboratory30182728 $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
4100228FOLIC ACID300Laboratory30182746 $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
4100229FOLLICLE STIMULATING HORM300Laboratory30183001 $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
4100420FT3 (FREE T3)300Laboratory30184481 $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
4100433FT4 (FREE THYROXINE)300Laboratory30184439 $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
4101164GASTRIC OCCULT BLOOD300Laboratory30182270 $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
4101121GEN. HEALTH PANEL W/O TSH300Laboratory30180050 $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
4100233GENERAL HEALTH PANEL W/ T300Laboratory30180050 $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
4100235GGT300Laboratory30182977 $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
4100025GLUCOSE 1 HR -50 GRMS300Laboratory30182950 $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
4100406GRAM STAIN SMEAR300Laboratory30687205 $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
4100028GTT FIRST THREE SPECIMEN300Laboratory30182951 $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
4100240HBSAB QUANITATIVE300Laboratory30286706 $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
4100241HBSAG300Laboratory30687340 $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
4100029HCG QUALITATIVE SERUM300Laboratory30184703 $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
4100351HCG QUALITATIVE URINE300Laboratory30781025 $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
4100041HCG QUANTITATIVE SERUM300Laboratory92584702 $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
4100246HCV RNA QUANTITATIVE (VIR300Laboratory30287522 $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
4100031HEMATOCRIT300Laboratory30585014 $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
4100032HEMOGLOBIN A1C300Laboratory30183036 $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
4100251HEPATITIS C ANTIBODY300Laboratory30286803 $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
4100247HEPATITIS PROFILE300Laboratory30280074 $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
4100033HIV AB SCREEN300Laboratory302G0432 $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
4100256HPYLORI, ANTIGEN, STOOL300Laboratory30687338 $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
4100261IGA (IMMUNOGLOBULIN A)300Laboratory30182784 $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
4100265IGF1-SOMATOMEDIN300Laboratory30184305 $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
4100415ILLUMIGENE C-DIFF300Laboratory30687493 $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
4100278INFLUENZA , RAPID ANTIGEN300Laboratory30687400 $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
4100034IRON BINDING CAPACITY300Laboratory30183550 $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
4100035IRON SERUM300Laboratory30183540 $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
4100285KEPPRA (LEVETIRACETAM)300Laboratory30180177 $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
4100367KETONE/ACETONE300Laboratory30182009 $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
4100288LACTATE/LACTIC ACID300Laboratory30183605 $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
4100290LDH300Laboratory30183615 $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
4100293LDL DIRECT300Laboratory30183721 $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
4100297LIPASE300Laboratory30183690 $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
4100037LIPID PROFILE300Laboratory30180061 $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
4100299LITHIUM (LI)300Laboratory30180178 $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
4100300LIVER PANEL300Laboratory30180076 $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
4100303LUTEINIZING HORMONE300Laboratory30183002 $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
4100038MAGNESIUM (MG) SERUM300Laboratory30183735 $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
4100076MICROALBUMIN, RANDOM URIN300Laboratory30182043 $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
4100313MONOSPOT300Laboratory30286308 $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
4100237NEISSERIA AMP PROBE TECH300Laboratory30687591 $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
4101263NEPHELOMETRY, EA ANALYTE300Laboratory30183883 $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
4101224OB PANEL300Laboratory30180081 $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
4100330OCCULT BLOOD STOOL- SINGL300Laboratory30182274 $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
4101237PERIPHERAL BLD SMEAR300Laboratory97185060 $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
4100341PHLEBOTOMY THERAPEAUTIC300Laboratory94099195 $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
4100342PHOSPHORUS INORGANIC300Laboratory30184100 $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
4100283POTASSIUM (K)300Laboratory30184132 $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
4100040PRE-ALBUMIN300Laboratory30184134 $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
4100353PROGESTERONE ASSAY300Laboratory30184144 $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
4100354PROLACTIN300Laboratory30184146 $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
4100042PROSTATE SPEC ANTI300Laboratory30184153 $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
4101200PROTEIN E-PHORESIS URINE300Laboratory30184166 $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
4100361PROTEIN TOTAL SERUM300Laboratory30184155 $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
4100362PROTEIN, URINE RANDOM300Laboratory30184155 $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
4100045PSA SCRN/ULTRASENSATIVE300Laboratory301G0103 $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
4100043PT/INR300Laboratory30585610 $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
4100336PTH INTACT300Laboratory30183970 $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
4100046PTT (PART.THROMB.TIME)300Laboratory30585730 $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
4100047RAST PER ALLERGEN300Laboratory30286003 $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
4100048RENAL PROFILE300Laboratory30180069 $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
4100377RETICULOCYTE COUNT300Laboratory30585045 $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
4100378Rh (D) TYPING300Laboratory30286901 $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
4100381RHEUMATIOID FACTOR,QUAL300Laboratory30286430 $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
4100049RPR (STS)300Laboratory30286780 $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
4100386RSV ANTIGEN300Laboratory30286756 $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
4101246RUBELLA IGG300Laboratory30286762 $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
4100388SALICYLATE (ASA, ASPIRIN)300Laboratory30180329 $171.00 $85.50 $136.80 $- $- $- $- $123.12 $145.35 $145.35 $22.00 $- $145.35
41087426SARS Rapid Antigen Covid Antigen300Laboratory30187426 $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
4100391SENSITIVITY TEST DUE TO G300Laboratory30687186 $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
4100270SIEP300Laboratory30286334 $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
4100050SMA 7 PANEL300Laboratory30180048 $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
4101216SPEC STAIN, GROUP 1300Laboratory31088312 $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
4100411SPECIMEN COLLECTION300Laboratory30099001 $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
4100412SSA ANTIBODY300Laboratory30286235 $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
4100051STREP SCREEN RAPID300Laboratory30686403 $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
4101211SURG PATH GRS/MICRO LEV 3300Laboratory31088304 $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
4101212SURG PATH GRS/MICRO LEV 4300Laboratory31088305 $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
4100421T3 TOTAL (TRI-IODOTHYRONN300Laboratory30184480 $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
4100053T3 UPTAKE300Laboratory30184479 $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
4100434T4 (THYROXINE)300Laboratory30184436 $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
4100054TACROLIMUS300Laboratory30180197 $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
4100425TESTOSTERONE TOTAL300Laboratory30184403 $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
4101198TISSUE TRANSGLTMINASE IGA300Laboratory30183516 $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
4100444TROPONIN I300Laboratory30184484 $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
4100058TSH THYROID STIM HORM300Laboratory30184443 $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
4100447UA W/MICRO300Laboratory30781001 $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
4100448URIC ACID BLOOD300Laboratory30184550 $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
4100450URINALYSIS BY DIP STICK300Laboratory30081002 $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
4100453VALPROIC ACID (DEPAKOTE)300Laboratory30180164 $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
4100454VANCOMYCIN CHARGE300Laboratory30180202 $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
4100459VITAMIN B12300Laboratory30182607 $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
4100463VITAMIN D 25-HYDROXY300Laboratory30182306 $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
4100467WBC300Laboratory30585048 $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
3100467CATARACT REMOVAL360Operating Room36166984 $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
3100018COLNSCPY FLEX RMVE TMR S360Operating Room36045385 $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
3100019COLNSCPY TO TRANSVERSE C360Operating Room36045378 $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
3100139COLONOSCOPY W/BX L/MULTI360Operating Room36045380 $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
3100046ENDOSCOPY W/WO SPECIMENS360Operating Room36043235 $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
3100223EX TUMOR FARM WRIST SUBCA360Operating Room36125075 $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
3100294LAP SURG CHOLECYSTECTOMY360Operating Room36047562 $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
3100364RPR HERNIA INGUINAL 5YRS360Operating Room36049505 $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
3401005EKG 12 LEAD (WELCOME TO MEDICARE)999Other73093000 $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
3401003CARDIAC REHAB420Physical Therapy94393798 $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
3401001CARDIAC STRESS TEST TRAC420Physical Therapy48293017 $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
4450015OT EVAL - LOW COMPLEXITY420Physical Therapy43497165 $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
4450018OT-MANUAL THERAPY420Physical Therapy43197140 $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
4450012OT-SELF CARE/HOME MGMT TRAIN420Physical Therapy43197535 $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
4401030PT EVAL HIGH COMPLEXITY420Physical Therapy42497163 $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
4401028PT EVAL LOW COMPLEXITY420Physical Therapy42497161 $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
4401029PT EVAL MOD COMPLEXITY420Physical Therapy42497162 $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
4400017PT -THERAPEUTIC ACTIVITIES420Physical Therapy42197530 $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
4400015PT -THERAPEUTIC EXERCISE420Physical Therapy42197110 $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
4400010PT-ELECTICAL STIM UNATTENDED420Physical Therapy421G0283 $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
4400037PT-MANUAL THERAPY420Physical Therapy42197140 $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
4500010SP EVAL SWALLOWING (DYSPHAGIA)420Physical Therapy44492610 $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
4500018SP TRT SPEECH/LANGUAGE420Physical Therapy44092507 $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
4500017SP TRT SWALLOWING/DYSPHAGIA420Physical Therapy44092526 $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
4450014THERAPEUTIC PRO >1 AREA E420Physical Therapy43197110 $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
4400018TRACTION MECHANICAL420Physical Therapy42197012 $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
4400020ULTRASOUND420Physical Therapy42197035 $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
4201060BONE AGE STUDIES320Radiology32077072 $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
4220025CT ABD W320Radiology35274160 $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
4220024CT ABD W/WO320Radiology35274170 $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
4220067CT ABD/PEL W & W/O320Radiology35274178 $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
4220066CT ABD/PEL W/ CONTRAST320Radiology35274177 $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
4220065CT ABD/PEL W/O CONTRAST320Radiology35274176 $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
4220018CT CHEST W320Radiology35271260 $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
4220019CT CHEST W/O320Radiology35271250 $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
4220050CT C-SPINE W/O320Radiology35272125 $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
4220020CT HEAD/BRAIN W/O320Radiology35170450 $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
4220021CT L-SPINE W/O320Radiology35272131 $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
4220029CT LWR EXT LT W/O320Radiology35273700 $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
4220052CT LWR EXT RT W/O320Radiology35273700 $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
4220031CT MAXILLOFACIAL W320Radiology35170487 $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
4220057CT MAXILLOFACIAL W/O320Radiology35170486 $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
4220049CT NCK SFT TISSUE W320Radiology35170491 $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
4220035CT PELVIS W320Radiology35272193 $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
4220036CT PELVIS W/O320Radiology35272192 $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
4220048CT SINUS W/O320Radiology35170486 $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
4220016CT T-SPINE W/O320Radiology35272128 $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
4220070CTA ABD AORTA W/ RUNOFF320Radiology32375635 $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
4220069CTA ABD/PEL W/ CONTRAST320Radiology35274174 $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
4220027CTA CHEST W/WO320Radiology35271275 $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
4220061CTA HEAD W/WO320Radiology35070496 $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
4220060CTA NECK W/WO320Radiology35070498 $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
4280012DUP CAROTID BILAT320Radiology92193880 $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
4280013DUPLEX EXT LOWER BILAT320Radiology92193922 $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
4280014DUPLEX EXT VEINS BILAT320Radiology92193970 $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
4201070ELBOW LEFT 3 VIEWS320Radiology32073080 $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
4201071ELBOW RIGHT 3 VIEWS320Radiology32073080 $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
4201066RIBS LEFT W/ PA CHEST320Radiology32471101 $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
4201067RIBS RIGHT W/ PA CHEST320Radiology32471101 $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
4201065T-SPINE 3 VIEWS320Radiology32072072 $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
4281018US AAA-MCR320Radiology40276706 $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
4280016US ABD COMPLETE320Radiology40276700 $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
4280017US ABD LMTD (GALLBLADDER320Radiology40276705 $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
4281017US ABD LMTD (LIVER)320Radiology40276705 $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
4280029US BREAST UNI COMPLETE320Radiology40276641 $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
4280020US DUP LWR EXT ART COMP320Radiology92193925 $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
4280021US DUP LWR EXT ART UNILA320Radiology92193926 $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
4280015US DUPLEX EXT VEINS UNI320Radiology92193971 $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
4280019US ECHO CONGENITAL CARDI320Radiology48393303 $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
4280031US EXT NON-VASC LMTD320Radiology40276882 $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
4281019US OB < 14 WKS SINGLE320Radiology40276801 $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
4280033US OB COMPLETE>14 WKS320Radiology40276805 $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
4280043US OB LIMITED320Radiology40276815 $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
4281020US OB, TRANSVAGINAL320Radiology40276817 $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
4280039US PELVIC NON-OB LMT320Radiology40276857 $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
4280034US PELVIC, NON-OB320Radiology40276856 $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
4280040US PREGNANCY FOLLOW-UP320Radiology40276816 $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
4280023US RENAL320Radiology40276770 $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
4280032US SCROTUM320Radiology40276870 $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
4280037US SOFT TISSUE HEAD/NCK320Radiology40276536 $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
4281015US THYROID320Radiology40276536 $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
4280036US TRANSTHORACIC (ECHO) W/ DOPPLER320Radiology48393306 $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
4280035US TRANSVAGINAL320Radiology40276830 $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
4200030XR ABD 1V320Radiology32074018 $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
4200040XR ABD ACUTE COMP320Radiology32074022 $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
4200035XR ABD COMPL W/DCBTS&ERC320Radiology32074019 $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
4200045XR ANKLE 2V LT320Radiology32073600 $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
4201026XR ANKLE 2V RT320Radiology32073600 $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
4200050XR ANKLE COMP MIN 3V LT320Radiology32073610 $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
4201027XR ANKLE COMP MIN 3V RT320Radiology32073610 $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
4200010XR CHEST 1V320Radiology32471045 $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
4200020XR CHEST AP/LAT320Radiology32471046 $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
4200065XR CLAVICLE LT320Radiology32073000 $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
4201006XR CLAVICLE RT320Radiology32073000 $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
4200335XR C-SPINE 2-3V320Radiology32072040 $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
4200085XR ELBOW 2V LT320Radiology32073070 $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
4201014XR ELBOW 2V RT320Radiology32073070 $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
4200105XR FEMUR 2V LT320Radiology32073552 $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
4201022XR FEMUR 2V RT320Radiology32073552 $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
4200115XR FINGER 2V LT320Radiology32073140 $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
4201018XR FINGER 2V RT320Radiology32073140 $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
4201037XR FOOT 2V LT320Radiology32073620 $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
4201038XR FOOT 2V RT320Radiology32073620 $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
4200125XR FOOT COMP MIN 3V LT320Radiology32073630 $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
4201028XR FOOT COMP MIN 3V RT320Radiology32073630 $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
4200130XR FOREARM 2V LT320Radiology32073090 $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
4201015XR FOREARM 2V RT320Radiology32073090 $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
4201074XR HAND LT 2 VIEWS320Radiology32073120 $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
4200160XR HAND MIN 3V LT320Radiology32073130 $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
4201017XR HAND RT320Radiology32073130 $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
4201073XR HAND RT 2 VIEWS320Radiology32073120 $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
4200170XR HIP 1V LT320Radiology32073501 $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
4200175XR HIP 2-3V LT320Radiology32073502 $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
4201020XR HIP 2-3V RT320Radiology32073502 $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
4200185XR HIPS BILAT 2V320Radiology32073521 $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
4200190XR HUMERUS 2V LT320Radiology32073060 $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
4201012XR HUMERUS 2V RT320Radiology32073060 $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
4201024XR KNEE 1/2V RT320Radiology32073560 $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
4200210XR KNEE 1/2V LT320Radiology32073560 $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
4201033XR KNEE 3V LT320Radiology32073562 $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
4201034XR KNEE 3V RT320Radiology32073562 $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
4201035XR KNEE COMP 4V LT320Radiology32073564 $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
4201036XR KNEE COMP 4V RT320Radiology32073564 $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
4201039XR KNEE STANDING BILAT320Radiology32073565 $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
4201025XR LEG 2V RT320Radiology32073590 $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
4200220XR LEG 2V LT320Radiology32073590 $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
4200345XR L-SPINE 2-3V320Radiology32072100 $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
4200350XR L-SPINE W/OBLIQ 4V320Radiology32072110 $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
4200205XR MANDIBLE <4V320Radiology32070100 $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
4201058XR ORBITS, FOR FB320Radiology32070030 $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
4200255XR PELVIS 1V320Radiology32072170 $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
4200260XR PELVIS COMP MIN 3V320Radiology32072190 $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
4200280XR RIBS LT 2V320Radiology32071100 $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
4201004XR RIBS RT 2V320Radiology32071100 $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
4200290XR SACRUM/COCCYX 2V320Radiology32072220 $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
4200305XR SHOULDER 1V LT320Radiology32073020 $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
4201010XR SHOULDER 1V RT320Radiology32073020 $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
4200310XR SHOULDER 2V LT320Radiology32073030 $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
4201011XR SHOULDER 2V RT320Radiology32073030 $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
4200385XR TOES 2V LT320Radiology32073660 $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
4200360XR T-SPINE320Radiology32072070 $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
4200395XR WRIST 3V LT320Radiology32073110 $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
4201016XR WRIST 3V RT320Radiology32073110 $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
4201076XR WRIST LT 2 VIEWS320Radiology32073100 $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
4201075XR WRIST RT 2 VIEWS320Radiology32073100 $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
993861st Preventive Medicine New Patient Age521Rural Health Clinic52199386 $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
993851st Preventive Medicine New Patient Age521Rural Health Clinic52199385 $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
99203New patient visit 30 min521Rural Health Clinic52199203 $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
85610Prothrombin Tm521Rural Health Clinic52185610 $10.00 $7.50 $- $10.00 $8.58 $10.00 $10.00 $- $- $- $- $- $10.00
81002Urnls Dip Stick/Tablet Rgnt Non-Auto W/O521Rural Health Clinic52181002 $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.

  • 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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