OVERVIEW
In compliance with the Centers for Medicare and Medicaid Services (CMS), Sabine County Hospital is making available to the public a copy of its standard charges known as a “Charge Master,” “Charge Description Master” or “CDM”.
Since payment rates for hospital care provided to insured patients are either negotiated with health plans, set by the federal government for Medicare, or set by state governments for Medicaid enrollees, the payments hospitals receive for patient care do not necessarily reflect the prices reflected in the Charge Master. A patient’s responsibility may vary depending on the payment plans negotiated with insurance companies as well as the patient’s individual and/or family deductibles and co-payments with their insurance plan. Additionally, uninsured patients are not generally expected to pay the hospital’s standard charges as reflected in the CDM and may be eligible for financial assistance.
The information provided is based on information we have gathered from contracts with managed care commercial insurance plans. This is not a guarantee of what you will be charged. Your actual charges may differ from the estimated charges for many reasons, including the seriousness of your medical condition, actual time the procedure takes and the services and supplies that you receive.
The charges listed here are for services from the Hospital. They do not reflect the charges for physicians (such as surgeon, anesthesiologist, radiologist, pathologist, etc.) who may be involved in providing particular services to a patient. These charges are billed separately from the individual physician/physicians group.
Sabine County Hospital shall not be liable for any difference between charges listed in the price lists and the final bill for services.
AVAILABLE FILES
There are two files regarding the hospital’s CDM for price transparency.
The CSV file is a comprehensive, machine-readable file that makes public all standard charge information for all hospital items and services. This can easily be imported into Microsoft Excel or similar software. This file contains the following information:
The PDF file is a searchable consumer-friendly format of payer-specific negotiated charge information of 300 “shoppable outpatient services” at the hospital. The file contains the following information:
QUESTIONS?
If you have further questions about the Sabine County Hospital CDM, please contact our hospital business office at (409) 737-3300 or come by and speak to one of our business office representatives. Thank you for choosing Sabine County Hospital for your health care needs!
Sabine County Hospital Shoppable Services as of 7/15/2022
Charge Number | Description | Dept | Dept Description | Rev Code | CPT Code | Price | Shoppable | Discounted Cash Price | Aetna Commercial | Aetna Medicare Advantage | BCBS - Blue Advantage | BCBS - HMO | BCBS - PPO | BCBS - Traditional | CIGNA | Humana Commercial | Humana Medicare Advantage | United Commercial | United Medicare Advantage | Minimum Negotiated Price | Maximum Negotiated Price |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
7300001 | #EKG 12 LEAD TRACING | 730 | EKG | 730 | 93005 | $170.00 | O | $85.00 | $85.00 | $58.96 | $88.02 | $108.92 | $128.17 | $128.17 | $110.50 | $106.59 | $58.38 | $121.21 | $57.80 | $57.80 | $128.17 |
3000120 | (CK) MB FRACTION ONLY | 300 | Lab | 301 | 82553 | $200.00 | O | $100.00 | $100.00 | $69.36 | $28.30 | $33.03 | $38.92 | $38.92 | $130.00 | $125.40 | $68.68 | $142.60 | $68.00 | $28.30 | $142.60 |
3000908 | 24 HR URN CREA | 300 | Lab | 301 | 82570 | $57.00 | O | $28.50 | $28.50 | $19.77 | $12.69 | $14.81 | $17.46 | $17.46 | $37.05 | $35.74 | $19.57 | $40.64 | $19.38 | $12.69 | $40.64 |
3000850 | 24hr Microalbu(R) | 300 | Lab | 301 | 82043 | $93.00 | O | $46.50 | $46.50 | $32.25 | $14.16 | $16.53 | $19.48 | $19.48 | $60.45 | $58.31 | $31.94 | $66.31 | $31.62 | $14.16 | $66.31 |
3000693 | AEROBIC ID #2 (RL) | 300 | Lab | 306 | 87077 | $94.00 | O | $47.00 | $47.00 | $32.60 | $19.80 | $23.11 | $27.23 | $27.23 | $61.10 | $58.94 | $32.28 | $67.02 | $31.96 | $19.80 | $67.02 |
3000499 | AEROBIC ID (RL) | 300 | Lab | 306 | 87077 | $94.00 | O | $47.00 | $47.00 | $32.60 | $19.80 | $23.11 | $27.23 | $27.23 | $61.10 | $58.94 | $32.28 | $67.02 | $31.96 | $19.80 | $67.02 |
3000181 | AEROBIC SUSCEPTIBILITY | 300 | Lab | 306 | 87186 | $125.00 | O | $62.50 | $62.50 | $43.35 | $21.19 | $24.74 | $29.15 | $29.15 | $81.25 | $78.38 | $42.93 | $89.13 | $42.50 | $21.19 | $89.13 |
3000498 | AEROBIC SUSCEPTIBILITY | 300 | Lab | 306 | 87186 | $125.00 | O | $62.50 | $62.50 | $43.35 | $21.19 | $24.74 | $29.15 | $29.15 | $81.25 | $78.38 | $42.93 | $89.13 | $42.50 | $21.19 | $89.13 |
3000017 | ALBUMIN;SERUM, PLASMA | 300 | Lab | 301 | 82040 | $43.00 | O | $21.50 | $21.50 | $14.91 | $12.13 | $14.16 | $16.68 | $16.68 | $27.95 | $26.96 | $14.77 | $30.66 | $14.62 | $12.13 | $30.66 |
3000415 | ALPHA-FETOPROTEIN SER | 300 | Lab | 301 | 82105 | $89.00 | O | $44.50 | $44.50 | $30.87 | $41.09 | $47.96 | $56.51 | $56.51 | $57.85 | $55.80 | $30.56 | $63.46 | $30.26 | $30.26 | $63.46 |
3000166 | AMMONIA (R) | 300 | Lab | 301 | 82140 | $74.00 | O | $37.00 | $37.00 | $25.66 | $35.70 | $41.67 | $49.10 | $49.10 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $25.16 | $52.76 |
3000022 | AMYLASE | 300 | Lab | 301 | 82150 | $91.00 | O | $45.50 | $45.50 | $31.56 | $15.88 | $18.53 | $21.84 | $21.84 | $59.15 | $57.06 | $31.25 | $64.88 | $30.94 | $15.88 | $64.88 |
3000224 | ANA W/RFX (R) | 300 | Lab | 302 | 86038 | $191.00 | O | $95.50 | $95.50 | $66.24 | $29.62 | $34.58 | $40.74 | $40.74 | $124.15 | $119.76 | $65.59 | $136.18 | $64.94 | $29.62 | $136.18 |
3000581 | ANCA W/REFLEX TITER | 300 | Lab | 300 | 86021 | $151.00 | O | $75.50 | $75.50 | $52.37 | $36.87 | $43.04 | $50.72 | $50.72 | $98.15 | $94.68 | $51.85 | $107.66 | $51.34 | $36.87 | $107.66 |
3000094 | ANCA-C TITER (RL) | 300 | Lab | 300 | 86021 | $151.00 | O | $75.50 | $75.50 | $52.37 | $36.87 | $43.04 | $50.72 | $50.72 | $98.15 | $94.68 | $51.85 | $107.66 | $51.34 | $36.87 | $107.66 |
3000486 | ANGIOTENSION CONVERTIN | 300 | Lab | 301 | 82164 | $84.00 | O | $42.00 | $42.00 | $29.13 | $35.77 | $41.76 | $49.20 | $49.20 | $54.60 | $52.67 | $28.85 | $59.89 | $28.56 | $28.56 | $59.89 |
3000152 | Antibody Screen | 300 | Lab | 302 | 86885 | $500.00 | O | $250.00 | $250.00 | $173.40 | $351.58 | $410.41 | $483.60 | $483.60 | $325.00 | $313.50 | $171.70 | $356.50 | $170.00 | $170.00 | $483.60 |
3000549 | ANTI-DSNA AB, EIA (R) | 300 | Lab | 302 | 86225 | $83.00 | O | $41.50 | $41.50 | $28.78 | $33.66 | $39.30 | $46.30 | $46.30 | $53.95 | $52.04 | $28.50 | $59.18 | $28.22 | $28.22 | $59.18 |
3000372 | ANTI-HEPATITIS B SURFA | 300 | Lab | 302 | 86706 | $58.00 | O | $29.00 | $29.00 | $20.11 | $26.31 | $30.72 | $36.19 | $36.19 | $37.70 | $36.37 | $19.92 | $41.35 | $19.72 | $19.72 | $41.35 |
3000242 | APTT-LA | 300 | Lab | 305 | 85730 | $60.00 | R | $30.00 | $30.00 | $20.81 | $14.72 | $17.19 | $20.25 | $20.25 | $39.00 | $37.62 | $20.60 | $42.78 | $20.40 | $14.72 | $42.78 |
3000391 | BASIC METABOLIC PANEL, | 300 | Lab | 301 | 80048 | $228.00 | R | $114.00 | $114.00 | $79.07 | $20.73 | $24.20 | $28.51 | $28.51 | $148.20 | $142.96 | $78.30 | $162.56 | $77.52 | $20.73 | $162.56 |
3000299 | BETA HCG SERUM (RL) | 300 | Lab | 301 | 84702 | $74.00 | O | $37.00 | $37.00 | $25.66 | $36.87 | $43.04 | $50.72 | $50.72 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $25.16 | $52.76 |
3000029 | BILIRUBIN BLOOD DIRECT | 300 | Lab | 301 | 82248 | $57.00 | O | $28.50 | $28.50 | $19.77 | $12.30 | $14.36 | $16.92 | $16.92 | $37.05 | $35.74 | $19.57 | $40.64 | $19.38 | $12.30 | $40.64 |
3000028 | BILIRUBIN;BLOOD,TOTAL | 300 | Lab | 301 | 82247 | $57.00 | O | $28.50 | $28.50 | $19.77 | $12.30 | $14.36 | $16.92 | $16.92 | $37.05 | $35.74 | $19.57 | $40.64 | $19.38 | $12.30 | $40.64 |
3000434 | BNP - Natriuretic Peptide | 300 | Lab | 301 | 83880 | $201.00 | O | $100.50 | $100.50 | $69.71 | $96.19 | $112.28 | $132.31 | $132.31 | $130.65 | $126.03 | $69.02 | $143.31 | $68.34 | $68.34 | $143.31 |
3000766 | BNP (RL) | 300 | Lab | 301 | 83880 | $201.00 | O | $100.50 | $100.50 | $69.71 | $96.19 | $112.28 | $132.31 | $132.31 | $130.65 | $126.03 | $69.02 | $143.31 | $68.34 | $68.34 | $143.31 |
3000131 | BUN-UREA NITROGEN BLOOD | 300 | Lab | 301 | 84520 | $74.00 | O | $37.00 | $37.00 | $25.66 | $9.68 | $11.30 | $13.31 | $13.31 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $9.68 | $52.76 |
3000797 | CA 19-9 | 300 | Lab | 302 | 86301 | $158.00 | O | $79.00 | $79.00 | $54.79 | $50.98 | $59.52 | $70.13 | $70.13 | $102.70 | $99.07 | $54.26 | $112.65 | $53.72 | $50.98 | $112.65 |
3000767 | CALC, Totall (R) | 300 | Lab | 301 | 82310 | $45.00 | O | $22.50 | $22.50 | $15.61 | $12.64 | $14.76 | $17.39 | $17.39 | $29.25 | $28.22 | $15.45 | $32.09 | $15.30 | $12.64 | $32.09 |
3000032 | CALCIUM | 300 | Lab | 301 | 82310 | $45.00 | O | $22.50 | $22.50 | $15.61 | $12.64 | $14.76 | $17.39 | $17.39 | $29.25 | $28.22 | $15.45 | $32.09 | $15.30 | $12.64 | $32.09 |
3000212 | CARBAMAZEPINE(TEGRETOL | 300 | Lab | 301 | 80156 | $127.00 | O | $63.50 | $63.50 | $44.04 | $35.70 | $41.67 | $49.10 | $49.10 | $82.55 | $79.63 | $43.61 | $90.55 | $43.18 | $35.70 | $90.55 |
3000981 | Cardio PROBNP(R) | 300 | Lab | 301 | 83880 | $201.00 | O | $100.50 | $100.50 | $69.71 | $96.19 | $112.28 | $132.31 | $132.31 | $130.65 | $126.03 | $69.02 | $143.31 | $68.34 | $68.34 | $143.31 |
3000891 | CARDIQ VITD25(R) | 300 | Lab | 301 | 82306 | $223.00 | O | $111.50 | $111.50 | $77.34 | $72.52 | $84.66 | $99.75 | $99.75 | $144.95 | $139.82 | $76.58 | $159.00 | $75.82 | $72.52 | $159.00 |
3000504 | CBC AUTO W/O DIFF | 300 | Lab | 305 | 85027 | $100.00 | R | $50.00 | $50.00 | $34.68 | $15.85 | $18.50 | $21.80 | $21.80 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $15.85 | $71.30 |
3000139 | CBC W/ Auto Diff | 300 | Lab | 305 | 85025 | $145.00 | R | $72.50 | $72.50 | $50.29 | $19.04 | $22.22 | $26.18 | $26.18 | $94.25 | $90.92 | $49.79 | $103.39 | $49.30 | $19.04 | $103.39 |
3000567 | CENTROMERE AB | 300 | Lab | 302 | 86038 | $191.00 | O | $95.50 | $95.50 | $66.24 | $29.62 | $34.58 | $40.74 | $40.74 | $124.15 | $119.76 | $65.59 | $136.18 | $64.94 | $29.62 | $136.18 |
3000041 | CHOLESTEROL SERUM TOT | 300 | Lab | 301 | 82465 | $54.00 | O | $27.00 | $27.00 | $18.73 | $10.66 | $12.44 | $14.66 | $14.66 | $35.10 | $33.86 | $18.54 | $38.50 | $18.36 | $10.66 | $38.50 |
3000774 | Chromatin (Nucleosomal) Antibody | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000143 | CLOSTRIDIUM DIFFICILE (R) | 300 | Lab | 306 | 87230 | $256.00 | O | $128.00 | $128.00 | $88.78 | $48.36 | $56.46 | $66.52 | $66.52 | $166.40 | $160.51 | $87.91 | $182.53 | $87.04 | $48.36 | $182.53 |
3000731 | CMP (RL) | 300 | Lab | 301 | 80053 | $267.00 | R | $133.50 | $133.50 | $92.60 | $25.87 | $30.20 | $35.59 | $35.59 | $173.55 | $167.41 | $91.69 | $190.37 | $90.78 | $25.87 | $190.37 |
3000617 | CMV DNA BY PCR QN | 300 | Lab | 306 | 87497 | $825.00 | O | $412.50 | $412.50 | $286.11 | $104.96 | $122.52 | $144.37 | $144.37 | $536.25 | $517.28 | $283.31 | $588.23 | $280.50 | $104.96 | $588.23 |
3000116 | COMPLEMENT C3 | 300 | Lab | 302 | 86160 | $129.00 | O | $64.50 | $64.50 | $44.74 | $29.40 | $34.32 | $40.44 | $40.44 | $83.85 | $80.88 | $44.30 | $91.98 | $43.86 | $29.40 | $91.98 |
3000118 | COMPLEMENT C4 | 300 | Lab | 302 | 86160 | $129.00 | O | $64.50 | $64.50 | $44.74 | $29.40 | $34.32 | $40.44 | $40.44 | $83.85 | $80.88 | $44.30 | $91.98 | $43.86 | $29.40 | $91.98 |
3000184 | COMPREHENSIVE METABOLI | 300 | Lab | 301 | 80053 | $267.00 | R | $133.50 | $133.50 | $92.60 | $25.87 | $30.20 | $35.59 | $35.59 | $173.55 | $167.41 | $91.69 | $190.37 | $90.78 | $25.87 | $190.37 |
3000990 | COVID-19 (RL) | 300 | Lab | 306 | 87635 | $250.00 | O | $125.00 | $125.00 | $86.70 | $125.71 | $146.75 | $172.91 | $172.91 | $162.50 | $156.75 | $85.85 | $178.25 | $85.00 | $85.00 | $178.25 |
3000991 | COVID-19 (STATE_CDC) | 300 | Lab | 306 | U0001 | $150.00 | O | $75.00 | $75.00 | $52.02 | $88.00 | $102.73 | $121.05 | $121.05 | $97.50 | $94.05 | $51.51 | $106.95 | $51.00 | $51.00 | $121.05 |
3000021 | C-PEPTIDE (RL) | 300 | Lab | 301 | 84681 | $108.00 | O | $54.00 | $54.00 | $37.45 | $50.98 | $59.52 | $70.13 | $70.13 | $70.20 | $67.72 | $37.09 | $77.00 | $36.72 | $36.72 | $77.00 |
3000903 | CREA RAND URN | 300 | Lab | 301 | 82570 | $57.00 | O | $28.50 | $28.50 | $19.77 | $12.69 | $14.81 | $17.46 | $17.46 | $37.05 | $35.74 | $19.57 | $40.64 | $19.38 | $12.69 | $40.64 |
3000411 | C-REACTIVE PROTEIN (R) | 300 | Lab | 302 | 86140 | $61.00 | O | $30.50 | $30.50 | $21.15 | $12.69 | $14.81 | $17.46 | $17.46 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $12.69 | $43.49 |
3000043 | CREATINE KINASE (CK) ( | 300 | Lab | 301 | 82550 | $116.00 | O | $58.00 | $58.00 | $40.23 | $15.95 | $18.62 | $21.94 | $21.94 | $75.40 | $72.73 | $39.83 | $82.71 | $39.44 | $15.95 | $82.71 |
3000219 | CREATININE | 300 | Lab | 301 | 82565 | $74.00 | O | $37.00 | $37.00 | $25.66 | $12.54 | $14.64 | $17.25 | $17.25 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $12.54 | $52.76 |
3000367 | CREATININE RAND URINE (R) | 300 | Lab | 301 | 82570 | $57.00 | O | $28.50 | $28.50 | $19.77 | $12.69 | $14.81 | $17.46 | $17.46 | $37.05 | $35.74 | $19.57 | $40.64 | $19.38 | $12.69 | $40.64 |
3000301 | CULTURE AEROBIC BAC (R) | 300 | Lab | 306 | 87070 | $114.00 | O | $57.00 | $57.00 | $39.54 | $21.12 | $24.65 | $29.05 | $29.05 | $74.10 | $71.48 | $39.15 | $81.28 | $38.76 | $21.12 | $81.28 |
3000354 | CULTURE ANAEROBIC | 300 | Lab | 306 | 87075 | $151.00 | O | $75.50 | $75.50 | $52.37 | $23.20 | $27.08 | $31.91 | $31.91 | $98.15 | $94.68 | $51.85 | $107.66 | $51.34 | $23.20 | $107.66 |
3000172 | CULTURE ANY OTHER SOUR | 300 | Lab | 306 | 87070 | $114.00 | O | $57.00 | $57.00 | $39.54 | $21.12 | $24.65 | $29.05 | $29.05 | $74.10 | $71.48 | $39.15 | $81.28 | $38.76 | $21.12 | $81.28 |
3000171 | CULTURE EXCEP UR/BLOOD | 300 | Lab | 306 | 87070 | $114.00 | O | $57.00 | $57.00 | $39.54 | $21.12 | $24.65 | $29.05 | $29.05 | $74.10 | $71.48 | $39.15 | $81.28 | $38.76 | $21.12 | $81.28 |
3000240 | CULTURE SPUTUM | 300 | Lab | 306 | 87070 | $114.00 | O | $57.00 | $57.00 | $39.54 | $21.12 | $24.65 | $29.05 | $29.05 | $74.10 | $71.48 | $39.15 | $81.28 | $38.76 | $21.12 | $81.28 |
3000378 | CULTURE STOOL A S/S (R | 300 | Lab | 306 | 87045 | $66.00 | O | $33.00 | $33.00 | $22.89 | $23.13 | $27.00 | $31.81 | $31.81 | $42.90 | $41.38 | $22.66 | $47.06 | $22.44 | $22.44 | $47.06 |
3000379 | CULTURE STOOL B CMPY ( | 300 | Lab | 306 | 87046 | $54.00 | O | $27.00 | $27.00 | $18.73 | $23.13 | $27.00 | $31.81 | $31.81 | $35.10 | $33.86 | $18.54 | $38.50 | $18.36 | $18.36 | $38.50 |
30087070 | Culture, throat | 300 | Lab | 300 | 87070 | $114.00 | O | $57.00 | $57.00 | $39.54 | $21.12 | $24.65 | $29.05 | $29.05 | $74.10 | $71.48 | $39.15 | $81.28 | $38.76 | $21.12 | $81.28 |
3000173 | CULTURE; BACTERIAL URI | 300 | Lab | 306 | 87086 | $83.00 | O | $41.50 | $41.50 | $28.78 | $19.77 | $23.08 | $27.20 | $27.20 | $53.95 | $52.04 | $28.50 | $59.18 | $28.22 | $19.77 | $59.18 |
3000183 | CULTURE; BLOOD, BACTERIAL (R) | 300 | Lab | 306 | 87040 | $250.00 | O | $125.00 | $125.00 | $86.70 | $25.28 | $29.52 | $34.78 | $34.78 | $162.50 | $156.75 | $85.85 | $178.25 | $85.00 | $25.28 | $178.25 |
3000524 | CYCLIC CITRULLINATED P | 300 | Lab | 302 | 86200 | $254.00 | O | $127.00 | $127.00 | $88.09 | $31.73 | $37.04 | $43.64 | $43.64 | $165.10 | $159.26 | $87.22 | $181.10 | $86.36 | $31.73 | $181.10 |
3000702 | CYTO THIN PREP (Pap Smear) (R) | 300 | Lab | 310 | 88175 | $110.00 | O | $55.00 | $55.00 | $38.15 | $65.19 | $76.10 | $89.68 | $89.68 | $71.50 | $68.97 | $37.77 | $78.43 | $37.40 | $37.40 | $89.68 |
3000762 | D-Dimer | 300 | Lab | 305 | 85379 | $158.00 | O | $79.00 | $79.00 | $54.79 | $24.94 | $29.11 | $34.31 | $34.31 | $102.70 | $99.07 | $54.26 | $112.65 | $53.72 | $24.94 | $112.65 |
3000753 | DIGOXIN (RL) | 300 | Lab | 301 | 80162 | $170.00 | O | $85.00 | $85.00 | $58.96 | $32.54 | $37.98 | $44.75 | $44.75 | $110.50 | $106.59 | $58.38 | $121.21 | $57.80 | $32.54 | $121.21 |
3000207 | DIGOXIN LEVEL | 300 | Lab | 301 | 80162 | $170.00 | O | $85.00 | $85.00 | $58.96 | $32.54 | $37.98 | $44.75 | $44.75 | $110.50 | $106.59 | $58.38 | $121.21 | $57.80 | $32.54 | $121.21 |
3000285 | DRUG SCREEN MULTI | 300 | Lab | 301 | 80305 | $165.00 | O | $82.50 | $82.50 | $57.22 | $30.87 | $36.04 | $42.46 | $42.46 | $107.25 | $103.46 | $56.66 | $117.65 | $56.10 | $30.87 | $117.65 |
3000261 | Drug Test by Chem Analyzer_UDOA (R) | 300 | Lab | 301 | 80307 | $225.00 | O | $112.50 | $112.50 | $78.03 | $152.24 | $177.72 | $209.41 | $209.41 | $146.25 | $141.08 | $77.27 | $160.43 | $76.50 | $76.50 | $209.41 |
3000365 | ELECTROLYTES | 300 | Lab | 301 | 80051 | $78.00 | O | $39.00 | $39.00 | $27.05 | $17.17 | $20.05 | $23.62 | $23.62 | $50.70 | $48.91 | $26.79 | $55.61 | $26.52 | $17.17 | $55.61 |
3000630 | ESBL CONFIRMATION | 300 | Lab | 306 | 87184 | $52.00 | O | $26.00 | $26.00 | $18.03 | $18.33 | $21.39 | $25.21 | $25.21 | $33.80 | $32.60 | $17.86 | $37.08 | $17.68 | $17.68 | $37.08 |
3000685 | ESTRADIOL (RL) | 300 | Lab | 301 | 82670 | $193.00 | O | $96.50 | $96.50 | $66.93 | $68.45 | $79.91 | $94.16 | $94.16 | $125.45 | $121.01 | $66.28 | $137.61 | $65.62 | $65.62 | $137.61 |
3000384 | FERRITIN (R) | 300 | Lab | 301 | 82728 | $83.00 | O | $41.50 | $41.50 | $28.78 | $33.39 | $38.98 | $45.93 | $45.93 | $53.95 | $52.04 | $28.50 | $59.18 | $28.22 | $28.22 | $59.18 |
3000271 | FOLATE, SERUM (R) | 300 | Lab | 301 | 82746 | $84.00 | O | $42.00 | $42.00 | $29.13 | $36.02 | $42.04 | $49.54 | $49.54 | $54.60 | $52.67 | $28.85 | $59.89 | $28.56 | $28.56 | $59.89 |
3000287 | FOLIC ACID RBC (RL) | 300 | Lab | 301 | 82747 | $87.00 | O | $43.50 | $43.50 | $30.17 | $43.24 | $50.48 | $59.48 | $59.48 | $56.55 | $54.55 | $29.88 | $62.03 | $29.58 | $29.58 | $62.03 |
3000141 | FREE PSA-A (RL) | 300 | Lab | 301 | 84154 | $108.00 | R | $54.00 | $54.00 | $37.45 | $45.06 | $52.60 | $61.97 | $61.97 | $70.20 | $67.72 | $37.09 | $77.00 | $36.72 | $36.72 | $77.00 |
3000150 | FREE PSA-B (RL) | 300 | Lab | 301 | 84153 | $176.00 | R | $88.00 | $88.00 | $61.04 | $45.06 | $52.60 | $61.97 | $61.97 | $114.40 | $110.35 | $60.44 | $125.49 | $59.84 | $45.06 | $125.49 |
3000466 | FREE TESTOSTERONE (RL) | 300 | Lab | 301 | 84402 | $220.00 | O | $110.00 | $110.00 | $76.30 | $62.40 | $72.84 | $85.83 | $85.83 | $143.00 | $137.94 | $75.55 | $156.86 | $74.80 | $62.40 | $156.86 |
3000189 | FSH (R) | 300 | Lab | 301 | 83001 | $80.00 | O | $40.00 | $40.00 | $27.74 | $45.52 | $53.14 | $62.61 | $62.61 | $52.00 | $50.16 | $27.47 | $57.04 | $27.20 | $27.20 | $62.61 |
3000070 | GGT | 300 | Lab | 301 | 82977 | $82.00 | O | $41.00 | $41.00 | $28.44 | $17.64 | $20.59 | $24.26 | $24.26 | $53.30 | $51.41 | $28.16 | $58.47 | $27.88 | $17.64 | $58.47 |
3000216 | GLUCOSE BLOOD BY GMD | 300 | Lab | 301 | 82962 | $48.00 | O | $24.00 | $24.00 | $16.65 | $8.04 | $9.38 | $11.05 | $11.05 | $31.20 | $30.10 | $16.48 | $34.22 | $16.32 | $8.04 | $34.22 |
3000060 | GLUCOSE QUANT | 300 | Lab | 301 | 82947 | $50.00 | O | $25.00 | $25.00 | $17.34 | $9.63 | $11.24 | $13.24 | $13.24 | $32.50 | $31.35 | $17.17 | $35.65 | $17.00 | $9.63 | $35.65 |
3000591 | GLUCOSE-6-PHOSPHATE DE | 300 | Lab | 301 | 82955 | $96.00 | O | $48.00 | $48.00 | $33.29 | $23.77 | $27.74 | $32.69 | $32.69 | $62.40 | $60.19 | $32.97 | $68.45 | $32.64 | $23.77 | $68.45 |
3000114 | HELICOBACTER PYLORI | 300 | Lab | 302 | 86677 | $148.00 | O | $74.00 | $74.00 | $51.33 | $41.28 | $48.19 | $56.78 | $56.78 | $96.20 | $92.80 | $50.82 | $105.52 | $50.32 | $41.28 | $105.52 |
3000135 | HEMATOCRIT | 300 | Lab | 305 | 85014 | $32.00 | O | $16.00 | $16.00 | $11.10 | $5.81 | $6.78 | $7.99 | $7.99 | $20.80 | $20.06 | $10.99 | $22.82 | $10.88 | $5.81 | $22.82 |
3000136 | HEMOGLOBIN | 300 | Lab | 305 | 85018 | $32.00 | O | $16.00 | $16.00 | $11.10 | $5.81 | $6.78 | $7.99 | $7.99 | $20.80 | $20.06 | $10.99 | $22.82 | $10.88 | $5.81 | $22.82 |
3000243 | HEMOGLOBIN; GLYOSYLATE | 300 | Lab | 301 | 83036 | $100.00 | O | $50.00 | $50.00 | $34.68 | $23.79 | $27.77 | $32.72 | $32.72 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $23.79 | $71.30 |
3000226 | HEP B SURF AG W/CONF (R) | 300 | Lab | 306 | 87340 | $72.00 | O | $36.00 | $36.00 | $24.97 | $25.31 | $29.54 | $34.81 | $34.81 | $46.80 | $45.14 | $24.72 | $51.34 | $24.48 | $24.48 | $51.34 |
3000190 | HEP B SURFACE AB QN (R) | 300 | Lab | 302 | 86317 | $78.00 | O | $39.00 | $39.00 | $27.05 | $36.73 | $42.87 | $50.52 | $50.52 | $50.70 | $48.91 | $26.79 | $55.61 | $26.52 | $26.52 | $55.61 |
3000339 | HEP C AB (R) | 300 | Lab | 302 | 86803 | $78.00 | O | $39.00 | $39.00 | $27.05 | $34.96 | $40.81 | $48.09 | $48.09 | $50.70 | $48.91 | $26.79 | $55.61 | $26.52 | $26.52 | $55.61 |
3000292 | HEPATIC FUNCTION PAN | 300 | Lab | 301 | 80076 | $176.00 | R | $88.00 | $88.00 | $61.04 | $20.02 | $23.37 | $27.53 | $27.53 | $114.40 | $110.35 | $60.44 | $125.49 | $59.84 | $20.02 | $125.49 |
3000456 | HEPATITIS A AB IGM | 300 | Lab | 302 | 86709 | $110.00 | O | $55.00 | $55.00 | $38.15 | $27.59 | $32.20 | $37.95 | $37.95 | $71.50 | $68.97 | $37.77 | $78.43 | $37.40 | $27.59 | $78.43 |
3000420 | HEPATITIS A AB Tot(R) | 300 | Lab | 302 | 86708 | $110.00 | O | $55.00 | $55.00 | $38.15 | $30.36 | $35.44 | $41.75 | $41.75 | $71.50 | $68.97 | $37.77 | $78.43 | $37.40 | $30.36 | $78.43 |
3000191 | HEPATITIS B CORE AB, TOT | 300 | Lab | 302 | 86704 | $95.00 | O | $47.50 | $47.50 | $32.95 | $29.52 | $34.46 | $40.61 | $40.61 | $61.75 | $59.57 | $32.62 | $67.74 | $32.30 | $29.52 | $67.74 |
3000717 | HGB A1C W/Reflex to Glycomark (R) | 300 | Lab | 301 | 83036 | $100.00 | O | $50.00 | $50.00 | $34.68 | $23.79 | $27.77 | $32.72 | $32.72 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $23.79 | $71.30 |
3000227 | HIV 1/2 (RL) | 300 | Lab | 302 | 86703 | $493.00 | O | $246.50 | $246.50 | $170.97 | $33.59 | $39.21 | $46.20 | $46.20 | $320.45 | $309.11 | $169.30 | $351.51 | $167.62 | $33.59 | $351.51 |
3000199 | IMMUNOFIXATION (RL) | 300 | Lab | 302 | 86334 | $225.00 | O | $112.50 | $112.50 | $78.03 | $54.73 | $63.89 | $75.29 | $75.29 | $146.25 | $141.08 | $77.27 | $160.43 | $76.50 | $54.73 | $160.43 |
3000948 | Influenza A | 300 | Lab | 306 | 87804 | $83.00 | O | $41.50 | $41.50 | $28.78 | $40.55 | $47.33 | $55.77 | $55.77 | $53.95 | $52.04 | $28.50 | $59.18 | $28.22 | $28.22 | $59.18 |
3000949 | Influenza B | 300 | Lab | 306 | 87804 | $83.00 | O | $41.50 | $41.50 | $28.78 | $40.55 | $47.33 | $55.77 | $55.77 | $53.95 | $52.04 | $28.50 | $59.18 | $28.22 | $28.22 | $59.18 |
3000154 | IRON (RL) | 300 | Lab | 301 | 83540 | $48.00 | O | $24.00 | $24.00 | $16.65 | $15.85 | $18.50 | $21.80 | $21.80 | $31.20 | $30.10 | $16.48 | $34.22 | $16.32 | $15.85 | $34.22 |
3000547 | JO-1 AB | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000086 | LACTATE DEHYDROGENASE | 300 | Lab | 301 | 83615 | $74.00 | O | $37.00 | $37.00 | $25.66 | $14.80 | $17.27 | $20.35 | $20.35 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $14.80 | $52.76 |
3000558 | LACTATE PLASMA | 300 | Lab | 301 | 83605 | $50.00 | O | $25.00 | $25.00 | $17.34 | $28.35 | $33.09 | $38.99 | $38.99 | $32.50 | $31.35 | $17.17 | $35.65 | $17.00 | $17.00 | $38.99 |
3000429 | LEVETIRACETAM (R) | 300 | Lab | 301 | 80177 | $158.00 | O | $79.00 | $79.00 | $54.79 | $32.46 | $37.90 | $44.65 | $44.65 | $102.70 | $99.07 | $54.26 | $112.65 | $53.72 | $32.46 | $112.65 |
3000355 | LH (R) | 300 | Lab | 301 | 83002 | $75.00 | O | $37.50 | $37.50 | $26.01 | $45.37 | $52.97 | $62.41 | $62.41 | $48.75 | $47.03 | $25.76 | $53.48 | $25.50 | $25.50 | $62.41 |
3000093 | LIPASE BLOOD | 300 | Lab | 301 | 83690 | $69.00 | O | $34.50 | $34.50 | $23.93 | $16.88 | $19.71 | $23.22 | $23.22 | $44.85 | $43.26 | $23.69 | $49.20 | $23.46 | $16.88 | $49.20 |
3000389 | LIPID PANEL | 300 | Lab | 301 | 80061 | $150.00 | R | $75.00 | $75.00 | $52.02 | $32.81 | $38.30 | $45.12 | $45.12 | $97.50 | $94.05 | $51.51 | $106.95 | $51.00 | $32.81 | $106.95 |
3000732 | LIPID PANEL (RL) | 300 | Lab | 301 | 80061 | $150.00 | R | $75.00 | $75.00 | $52.02 | $32.81 | $38.30 | $45.12 | $45.12 | $97.50 | $94.05 | $51.51 | $106.95 | $51.00 | $32.81 | $106.95 |
3000312 | LITHIUM | 300 | Lab | 301 | 80178 | $91.00 | O | $45.50 | $45.50 | $31.56 | $16.19 | $18.90 | $22.28 | $22.28 | $59.15 | $57.06 | $31.25 | $64.88 | $30.94 | $16.19 | $64.88 |
3000218 | LYME DISEASE | 300 | Lab | 302 | 86618 | $158.00 | O | $79.00 | $79.00 | $54.79 | $41.72 | $48.71 | $57.39 | $57.39 | $102.70 | $99.07 | $54.26 | $112.65 | $53.72 | $41.72 | $112.65 |
3000098 | MAGNESIUM | 300 | Lab | 301 | 83735 | $66.00 | O | $33.00 | $33.00 | $22.89 | $16.42 | $19.16 | $22.58 | $22.58 | $42.90 | $41.38 | $22.66 | $47.06 | $22.44 | $16.42 | $47.06 |
3000127 | MANUAL DIFFERENTIAL | 300 | Lab | 305 | 85007 | $43.00 | O | $21.50 | $21.50 | $14.91 | $9.31 | $10.87 | $12.81 | $12.81 | $27.95 | $26.96 | $14.77 | $30.66 | $14.62 | $9.31 | $30.66 |
3000743 | MEASLES AB IGG, EIA (R) | 300 | Lab | 302 | 86765 | $134.00 | O | $67.00 | $67.00 | $46.47 | $31.56 | $36.84 | $43.41 | $43.41 | $87.10 | $84.02 | $46.02 | $95.54 | $45.56 | $31.56 | $95.54 |
3000874 | Measles IGM(R) | 300 | Lab | 302 | 86765 | $134.00 | O | $67.00 | $67.00 | $46.47 | $31.56 | $36.84 | $43.41 | $43.41 | $87.10 | $84.02 | $46.02 | $95.54 | $45.56 | $31.56 | $95.54 |
3000011 | METHYLMALONIC ACID(RL) | 300 | Lab | 301 | 83921 | $235.00 | O | $117.50 | $117.50 | $81.50 | $51.96 | $60.66 | $71.48 | $71.48 | $152.75 | $147.35 | $80.70 | $167.56 | $79.90 | $51.96 | $167.56 |
3000097 | MICRO ALBUMIN RAND UR w/o CR (R) | 300 | Lab | 301 | 82044 | $93.00 | O | $46.50 | $46.50 | $32.25 | $15.26 | $17.82 | $21.00 | $21.00 | $60.45 | $58.31 | $31.94 | $66.31 | $31.62 | $15.26 | $66.31 |
3000711 | Microalbumin (Urine) Semi-QNT | 300 | Lab | 301 | 82044 | $25.00 | O | $12.50 | $12.50 | $8.67 | $15.26 | $17.82 | $21.00 | $21.00 | $16.25 | $15.68 | $8.59 | $17.83 | $8.50 | $8.50 | $21.00 |
3000155 | MONO TEST | 300 | Lab | 302 | 86308 | $61.00 | O | $30.50 | $30.50 | $21.15 | $12.69 | $14.81 | $17.46 | $17.46 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $12.69 | $43.49 |
3000451 | MUMPS IGM | 300 | Lab | 302 | 86735 | $64.00 | O | $32.00 | $32.00 | $22.20 | $31.97 | $37.32 | $43.98 | $43.98 | $41.60 | $40.13 | $21.98 | $45.63 | $21.76 | $21.76 | $45.63 |
3000450 | MUMPS VIRUS IGG, EIA(R) | 300 | Lab | 302 | 86735 | $64.00 | O | $32.00 | $32.00 | $22.20 | $31.97 | $37.32 | $43.98 | $43.98 | $41.60 | $40.13 | $21.98 | $45.63 | $21.76 | $21.76 | $45.63 |
3000328 | NEONATAL BILIRUBIN | 300 | Lab | 301 | 82248 | $57.00 | O | $28.50 | $28.50 | $19.77 | $12.30 | $14.36 | $16.92 | $16.92 | $37.05 | $35.74 | $19.57 | $40.64 | $19.38 | $12.30 | $40.64 |
3000695 | OCCULT BLOOD FE | 300 | Lab | 301 | 82274 | $59.00 | O | $29.50 | $29.50 | $20.46 | $39.00 | $45.53 | $53.65 | $53.65 | $38.35 | $36.99 | $20.26 | $42.07 | $20.06 | $20.06 | $53.65 |
3000031 | OCCULT BLOOD GASTRIC | 300 | Lab | 301 | 82271 | $30.00 | O | $15.00 | $15.00 | $10.40 | $13.03 | $15.22 | $17.93 | $17.93 | $19.50 | $18.81 | $10.30 | $21.39 | $10.20 | $10.20 | $21.39 |
3000176 | OVA & PARASITES STOOL | 300 | Lab | 306 | 87177 | $87.00 | O | $43.50 | $43.50 | $30.17 | $21.81 | $25.45 | $29.99 | $29.99 | $56.55 | $54.55 | $29.88 | $62.03 | $29.58 | $21.81 | $62.03 |
3000124 | PARTIAL THROMBOPLASTIN | 300 | Lab | 305 | 85730 | $60.00 | R | $30.00 | $30.00 | $20.81 | $14.72 | $17.19 | $20.25 | $20.25 | $39.00 | $37.62 | $20.60 | $42.78 | $20.40 | $14.72 | $42.78 |
3000770 | PATTERN | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000027 | PHENOBARBITAL QUANITAT | 300 | Lab | 301 | 80184 | $116.00 | O | $58.00 | $58.00 | $40.23 | $37.49 | $43.76 | $51.56 | $51.56 | $75.40 | $72.73 | $39.83 | $82.71 | $39.44 | $37.49 | $82.71 |
3000194 | PHLEBOTOMY THEREPEUTIC | 300 | Lab | 940 | 99195 | $300.00 | O | $150.00 | $150.00 | $104.04 | $174.45 | $215.88 | $254.04 | $254.04 | $195.00 | $188.10 | $103.02 | $213.90 | $102.00 | $102.00 | $254.04 |
3000109 | PHOSPHORUS INORGANIC P | 300 | Lab | 301 | 84100 | $50.00 | O | $25.00 | $25.00 | $17.34 | $11.61 | $13.56 | $15.97 | $15.97 | $32.50 | $31.35 | $17.17 | $35.65 | $17.00 | $11.61 | $35.65 |
3000111 | POTASSIUM; SERUM PLASM | 300 | Lab | 301 | 84132 | $48.00 | O | $24.00 | $24.00 | $16.65 | $11.66 | $13.61 | $16.04 | $16.04 | $31.20 | $30.10 | $16.48 | $34.22 | $16.32 | $11.66 | $34.22 |
3000168 | PREGNANCY TEST SERUM | 300 | Lab | 301 | 84703 | $74.00 | O | $37.00 | $37.00 | $25.66 | $18.42 | $21.51 | $25.34 | $25.34 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $18.42 | $52.76 |
3000074 | PREGNANCY TEST URINE | 300 | Lab | 301 | 84703 | $74.00 | O | $37.00 | $37.00 | $25.66 | $18.42 | $21.51 | $25.34 | $25.34 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $18.42 | $52.76 |
3000387 | PRIMIDONE (RL) | 300 | Lab | 301 | 80188 | $70.00 | O | $35.00 | $35.00 | $24.28 | $40.65 | $47.45 | $55.91 | $55.91 | $45.50 | $43.89 | $24.04 | $49.91 | $23.80 | $23.80 | $55.91 |
3000117 | PROGESTERONE (RL) | 300 | Lab | 301 | 84144 | $93.00 | O | $46.50 | $46.50 | $32.25 | $51.11 | $59.66 | $70.30 | $70.30 | $60.45 | $58.31 | $31.94 | $66.31 | $31.62 | $31.62 | $70.30 |
3000356 | PROLACTIN (RL) | 300 | Lab | 301 | 84146 | $93.00 | O | $46.50 | $46.50 | $32.25 | $47.48 | $55.43 | $65.31 | $65.31 | $60.45 | $58.31 | $31.94 | $66.31 | $31.62 | $31.62 | $66.31 |
3000907 | PROTEIN 24HR UR | 300 | Lab | 301 | 84156 | $52.00 | O | $26.00 | $26.00 | $18.03 | $8.99 | $10.50 | $12.37 | $12.37 | $33.80 | $32.60 | $17.86 | $37.08 | $17.68 | $8.99 | $37.08 |
3000310 | PROTEIN TOTAL UA w/o Creat (R) | 300 | Lab | 301 | 84156 | $52.00 | O | $26.00 | $26.00 | $18.03 | $8.99 | $10.50 | $12.37 | $12.37 | $33.80 | $32.60 | $17.86 | $37.08 | $17.68 | $8.99 | $37.08 |
3000904 | PROTEIN URINE | 300 | Lab | 301 | 84156 | $52.00 | O | $26.00 | $26.00 | $18.03 | $8.99 | $10.50 | $12.37 | $12.37 | $33.80 | $32.60 | $17.86 | $37.08 | $17.68 | $8.99 | $37.08 |
3000146 | PROTHROMBIN, TIME | 300 | Lab | 305 | 85610 | $90.00 | R | $45.00 | $45.00 | $31.21 | $10.51 | $12.27 | $14.46 | $14.46 | $58.50 | $56.43 | $30.91 | $64.17 | $30.60 | $10.51 | $64.17 |
3000269 | PSA SCREENING | 300 | Lab | 309 | G0103 | $176.00 | O | $88.00 | $88.00 | $61.04 | $47.31 | $55.23 | $65.07 | $65.07 | $114.40 | $110.35 | $60.44 | $125.49 | $59.84 | $47.31 | $125.49 |
3000295 | PSA; TOTAL | 300 | Lab | 301 | 84153 | $176.00 | R | $88.00 | $88.00 | $61.04 | $45.06 | $52.60 | $61.97 | $61.97 | $114.40 | $110.35 | $60.44 | $125.49 | $59.84 | $45.06 | $125.49 |
3000024 | PTH INTACT (R) | 300 | Lab | 301 | 83970 | $174.00 | O | $87.00 | $87.00 | $60.34 | $101.14 | $118.06 | $139.11 | $139.11 | $113.10 | $109.10 | $59.75 | $124.06 | $59.16 | $59.16 | $139.11 |
3000588 | RAPAMYCIN (SIROLIMUS) | 300 | Lab | 300 | 80195 | $191.00 | O | $95.50 | $95.50 | $66.24 | $33.64 | $39.27 | $46.27 | $46.27 | $124.15 | $119.76 | $65.59 | $136.18 | $64.94 | $33.64 | $136.18 |
3000158 | RENAL FUNCTION PANEL | 300 | Lab | 301 | 80069 | $165.00 | R | $82.50 | $82.50 | $57.22 | $21.27 | $24.82 | $29.25 | $29.25 | $107.25 | $103.46 | $56.66 | $117.65 | $56.10 | $21.27 | $117.65 |
3000223 | RHEUMATOID FACTOR (R) | 300 | Lab | 302 | 86431 | $54.00 | O | $27.00 | $27.00 | $18.73 | $13.89 | $16.22 | $19.11 | $19.11 | $35.10 | $33.86 | $18.54 | $38.50 | $18.36 | $13.89 | $38.50 |
3000349 | RNP ANTIBODIES (RL) | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000215 | RPR | 300 | Lab | 302 | 86592 | $54.00 | O | $27.00 | $27.00 | $18.73 | $10.46 | $12.21 | $14.39 | $14.39 | $35.10 | $33.86 | $18.54 | $38.50 | $18.36 | $10.46 | $38.50 |
3000748 | RSV Screen, IA | 300 | Lab | 306 | 87807 | $96.00 | O | $48.00 | $48.00 | $33.29 | $32.10 | $37.47 | $44.15 | $44.15 | $62.40 | $60.19 | $32.97 | $68.45 | $32.64 | $32.10 | $68.45 |
3000837 | Rubella IGM (R) | 300 | Lab | 302 | 86762 | $93.00 | O | $46.50 | $46.50 | $32.25 | $35.26 | $41.16 | $48.49 | $48.49 | $60.45 | $58.31 | $31.94 | $66.31 | $31.62 | $31.62 | $66.31 |
3000257 | RUBELLA IMMUNE (R) | 300 | Lab | 302 | 86762 | $93.00 | O | $46.50 | $46.50 | $32.25 | $35.26 | $41.16 | $48.49 | $48.49 | $60.45 | $58.31 | $31.94 | $66.31 | $31.62 | $31.62 | $66.31 |
3000345 | SCL-70 (R) | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000147 | SEDIMENTATION RATE; NO | 300 | Lab | 305 | 85651 | $56.00 | O | $28.00 | $28.00 | $19.42 | $10.46 | $12.21 | $14.39 | $14.39 | $36.40 | $35.11 | $19.23 | $39.93 | $19.04 | $10.46 | $39.93 |
3000128 | SGOT | 300 | Lab | 301 | 84450 | $61.00 | O | $30.50 | $30.50 | $21.15 | $12.69 | $14.81 | $17.46 | $17.46 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $12.69 | $43.49 |
3000129 | SGPT | 300 | Lab | 301 | 84460 | $61.00 | O | $30.50 | $30.50 | $21.15 | $12.99 | $15.16 | $17.86 | $17.86 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $12.99 | $43.49 |
3000298 | SJOGREN'S AB SS-A(R) | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000357 | SJOGREN'S AB SS-B(R) | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000294 | SM ANTIBODIES (RL) | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000811 | SM/RNP Antibody (R) | 300 | Lab | 302 | 86235 | $157.00 | O | $78.50 | $78.50 | $54.45 | $43.93 | $51.28 | $60.42 | $60.42 | $102.05 | $98.44 | $53.91 | $111.94 | $53.38 | $43.93 | $111.94 |
3000119 | SODIUM;SERUM PLASMA/WH | 300 | Lab | 301 | 84295 | $48.00 | O | $24.00 | $24.00 | $16.65 | $11.78 | $13.76 | $16.21 | $16.21 | $31.20 | $30.10 | $16.48 | $34.22 | $16.32 | $11.78 | $34.22 |
3000186 | STREPTOCOCCUS GROUP A | 300 | Lab | 306 | 87880 | $75.00 | O | $37.50 | $37.50 | $26.01 | $40.50 | $47.28 | $55.71 | $55.71 | $48.75 | $47.03 | $25.76 | $53.48 | $25.50 | $25.50 | $55.71 |
3000543 | T3 FREE | 300 | Lab | 301 | 84481 | $159.00 | O | $79.50 | $79.50 | $55.14 | $41.50 | $48.45 | $57.09 | $57.09 | $103.35 | $99.69 | $54.60 | $113.37 | $54.06 | $41.50 | $113.37 |
3000063 | T3 TOTAL (RL) | 300 | Lab | 301 | 84480 | $61.00 | O | $30.50 | $30.50 | $21.15 | $34.74 | $40.55 | $47.79 | $47.79 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $20.74 | $47.79 |
3000163 | T-3 UPTAKE (R) | 300 | Lab | 301 | 84479 | $61.00 | O | $30.50 | $30.50 | $21.15 | $15.85 | $18.50 | $21.80 | $21.80 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $15.85 | $43.49 |
3000350 | T-4 (THYROXINE) (R) | 300 | Lab | 301 | 84436 | $61.00 | O | $30.50 | $30.50 | $21.15 | $16.83 | $19.65 | $23.15 | $23.15 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $16.83 | $43.49 |
3000042 | T-4 FREE (R) | 300 | Lab | 301 | 84439 | $95.00 | O | $47.50 | $47.50 | $32.95 | $22.10 | $25.80 | $30.40 | $30.40 | $61.75 | $59.57 | $32.62 | $67.74 | $32.30 | $22.10 | $67.74 |
3000471 | TACROLIMUS (R) | 300 | Lab | 301 | 80197 | $214.00 | O | $107.00 | $107.00 | $74.22 | $33.64 | $39.27 | $46.27 | $46.27 | $139.10 | $134.18 | $73.49 | $152.58 | $72.76 | $33.64 | $152.58 |
3000836 | TB Gold Quant(R) | 300 | Lab | 302 | 86480 | $255.00 | O | $127.50 | $127.50 | $88.43 | $151.85 | $177.26 | $208.87 | $208.87 | $165.75 | $159.89 | $87.57 | $181.82 | $86.70 | $86.70 | $208.87 |
3000214 | TB SKIN TEST | 300 | Lab | 302 | 86580 | $100.00 | O | $50.00 | $50.00 | $34.68 | $56.33 | $65.75 | $77.48 | $77.48 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $34.00 | $77.48 |
3000933 | TESTOST, TOT (R) | 300 | Lab | 301 | 84403 | $141.00 | O | $70.50 | $70.50 | $48.90 | $63.23 | $73.82 | $86.98 | $86.98 | $91.65 | $88.41 | $48.42 | $100.53 | $47.94 | $47.94 | $100.53 |
3000138 | TESTOSTERONE TOTAL (R) | 300 | Lab | 301 | 84403 | $141.00 | O | $70.50 | $70.50 | $48.90 | $63.23 | $73.82 | $86.98 | $86.98 | $91.65 | $88.41 | $48.42 | $100.53 | $47.94 | $47.94 | $100.53 |
3000203 | THYROID PEROXIDASE AN | 300 | Lab | 302 | 86376 | $78.00 | O | $39.00 | $39.00 | $27.05 | $35.65 | $41.61 | $49.03 | $49.03 | $50.70 | $48.91 | $26.79 | $55.61 | $26.52 | $26.52 | $55.61 |
3000390 | TIBC (RL) | 300 | Lab | 301 | 83550 | $93.00 | O | $46.50 | $46.50 | $32.25 | $21.41 | $25.00 | $29.45 | $29.45 | $60.45 | $58.31 | $31.94 | $66.31 | $31.62 | $21.41 | $66.31 |
3000703 | TISSUE PATHOLOGY REPORT | 300 | Lab | 310 | 88302 | $100.00 | O | $50.00 | $50.00 | $34.68 | $56.33 | $65.75 | $77.48 | $77.48 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $34.00 | $77.48 |
3000769 | TITER | 300 | Lab | 302 | 86309 | $52.00 | O | $26.00 | $26.00 | $18.03 | $15.85 | $18.50 | $21.80 | $21.80 | $33.80 | $32.60 | $17.86 | $37.08 | $17.68 | $15.85 | $37.08 |
3000359 | TRANSFERRIN(RL) | 300 | Lab | 301 | 84466 | $74.00 | O | $37.00 | $37.00 | $25.66 | $31.26 | $36.49 | $43.00 | $43.00 | $48.10 | $46.40 | $25.41 | $52.76 | $25.16 | $25.16 | $52.76 |
3000130 | TRIGLYCERIDES BLOOD | 300 | Lab | 301 | 84478 | $48.00 | O | $24.00 | $24.00 | $16.65 | $14.06 | $16.42 | $19.34 | $19.34 | $31.20 | $30.10 | $16.48 | $34.22 | $16.32 | $14.06 | $34.22 |
3000162 | TROPONIN, QUANTITATIVE | 300 | Lab | 301 | 84484 | $345.00 | O | $172.50 | $172.50 | $119.65 | $30.55 | $35.66 | $42.02 | $42.02 | $224.25 | $216.32 | $118.47 | $245.99 | $117.30 | $30.55 | $245.99 |
3000399 | TSH (R) | 300 | Lab | 301 | 84443 | $170.00 | R | $85.00 | $85.00 | $58.96 | $41.16 | $48.05 | $56.62 | $56.62 | $110.50 | $106.59 | $58.38 | $121.21 | $57.80 | $41.16 | $121.21 |
3000744 | TSH W/RFLX FT4 (R) | 300 | Lab | 301 | 84443 | $170.00 | R | $85.00 | $85.00 | $58.96 | $41.16 | $48.05 | $56.62 | $56.62 | $110.50 | $106.59 | $58.38 | $121.21 | $57.80 | $41.16 | $121.21 |
3000132 | URIC ACID | 300 | Lab | 301 | 84550 | $54.00 | O | $27.00 | $27.00 | $18.73 | $11.07 | $12.93 | $15.23 | $15.23 | $35.10 | $33.86 | $18.54 | $38.50 | $18.36 | $11.07 | $38.50 |
3000009 | URINALYSIS | 300 | Lab | 307 | 81001 | $59.00 | R | $29.50 | $29.50 | $20.46 | $7.77 | $9.07 | $10.68 | $10.68 | $38.35 | $36.99 | $20.26 | $42.07 | $20.06 | $7.77 | $42.07 |
3000003 | Urine Dipstick | 300 | Lab | 307 | 81003 | $40.00 | R | $20.00 | $20.00 | $13.87 | $5.51 | $6.44 | $7.58 | $7.58 | $26.00 | $25.08 | $13.74 | $28.52 | $13.60 | $5.51 | $28.52 |
3000977 | Urine Ictotest | 300 | Lab | 307 | 81002 | $121.00 | R | $60.50 | $60.50 | $41.96 | $8.53 | $9.95 | $11.73 | $11.73 | $78.65 | $75.87 | $41.55 | $86.27 | $41.14 | $8.53 | $86.27 |
3000248 | VALPROIC ACID (R) | 300 | Lab | 301 | 80164 | $116.00 | O | $58.00 | $58.00 | $40.23 | $33.17 | $38.72 | $45.63 | $45.63 | $75.40 | $72.73 | $39.83 | $82.71 | $39.44 | $33.17 | $82.71 |
3000105 | VANCOMYCIN | 300 | Lab | 301 | 80202 | $116.00 | O | $58.00 | $58.00 | $40.23 | $33.17 | $38.72 | $45.63 | $45.63 | $75.40 | $72.73 | $39.83 | $82.71 | $39.44 | $33.17 | $82.71 |
3000340 | VARICELLA IGM AB (RL) | 300 | Lab | 302 | 86787 | $125.00 | O | $62.50 | $62.50 | $43.35 | $31.56 | $36.84 | $43.41 | $43.41 | $81.25 | $78.38 | $42.93 | $89.13 | $42.50 | $31.56 | $89.13 |
3000258 | VARICELLA-ZOSTER IGG AB (R) | 300 | Lab | 302 | 86787 | $125.00 | O | $62.50 | $62.50 | $43.35 | $31.56 | $36.84 | $43.41 | $43.41 | $81.25 | $78.38 | $42.93 | $89.13 | $42.50 | $31.56 | $89.13 |
3000534 | VDRL (SERUM) | 300 | Lab | 302 | 86592 | $61.00 | O | $30.50 | $30.50 | $21.15 | $10.46 | $12.21 | $14.39 | $14.39 | $39.65 | $38.25 | $20.95 | $43.49 | $20.74 | $10.46 | $43.49 |
3000768 | VIT B1, PLASMA | 300 | Lab | 301 | 84425 | $176.00 | O | $88.00 | $88.00 | $61.04 | $52.01 | $60.72 | $71.55 | $71.55 | $114.40 | $110.35 | $60.44 | $125.49 | $59.84 | $52.01 | $125.49 |
3000470 | VIT D 25 HYDROXYL-URIN | 300 | Lab | 301 | 82306 | $223.00 | O | $111.50 | $111.50 | $77.34 | $72.52 | $84.66 | $99.75 | $99.75 | $144.95 | $139.82 | $76.58 | $159.00 | $75.82 | $72.52 | $159.00 |
3000523 | VIT D 25 OH LS/MS/MS (SERUM)(R) | 300 | Lab | 301 | 82306 | $223.00 | O | $111.50 | $111.50 | $77.34 | $72.52 | $84.66 | $99.75 | $99.75 | $144.95 | $139.82 | $76.58 | $159.00 | $75.82 | $72.52 | $159.00 |
3000642 | VIT D I 25-DIHYDORXY | 300 | Lab | 301 | 82652 | $315.00 | O | $157.50 | $157.50 | $109.24 | $94.33 | $110.11 | $129.75 | $129.75 | $204.75 | $197.51 | $108.17 | $224.60 | $107.10 | $94.33 | $224.60 |
3000270 | VITAMIN B12 (R) | 300 | Lab | 301 | 82607 | $127.00 | O | $63.50 | $63.50 | $44.04 | $36.95 | $43.13 | $50.82 | $50.82 | $82.55 | $79.63 | $43.61 | $90.55 | $43.18 | $36.95 | $90.55 |
3000308 | VITAMIN B1-THIAMINE (R | 300 | Lab | 301 | 84425 | $176.00 | O | $88.00 | $88.00 | $61.04 | $52.01 | $60.72 | $71.55 | $71.55 | $114.40 | $110.35 | $60.44 | $125.49 | $59.84 | $52.01 | $125.49 |
3000605 | VITAMIN B6 | 300 | Lab | 301 | 84207 | $179.00 | O | $89.50 | $89.50 | $62.08 | $68.85 | $80.37 | $94.70 | $94.70 | $116.35 | $112.23 | $61.47 | $127.63 | $60.86 | $60.86 | $127.63 |
3000405 | WBC STOOL (RL) | 300 | Lab | 300 | 89055 | $43.00 | O | $21.50 | $21.50 | $14.91 | $10.46 | $12.21 | $14.39 | $14.39 | $27.95 | $26.96 | $14.77 | $30.66 | $14.62 | $10.46 | $30.66 |
4200015 | Electric Stem/Manual | 420 | Physical Therapy | 420 | 97032 | $140.00 | O | $70.00 | $70.00 | $48.55 | $24.22 | $29.98 | $35.28 | $35.28 | $91.00 | $87.78 | $48.08 | $99.82 | $47.60 | $24.22 | $99.82 |
4200014 | ELECTRIC STEM/MOD 1 | 420 | Physical Therapy | 420 | G0283 | $46.00 | O | $23.00 | $23.00 | $15.95 | $23.07 | $28.55 | $33.60 | $33.60 | $29.90 | $28.84 | $15.80 | $32.80 | $15.64 | $15.64 | $33.60 |
4200003 | EXERCISE/PRO EACH 15 M | 420 | Physical Therapy | 420 | 97110 | $100.00 | R | $50.00 | $50.00 | $34.68 | $50.16 | $62.07 | $73.05 | $73.05 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $34.00 | $73.05 |
4200006 | GAIT TRAINING EA 15 M | 420 | Physical Therapy | 420 | 97116 | $90.00 | O | $45.00 | $45.00 | $31.21 | $49.58 | $61.36 | $72.21 | $72.21 | $58.50 | $56.43 | $30.91 | $64.17 | $30.60 | $30.60 | $72.21 |
4200025 | IONTOPHORESIS EA 15 MI | 420 | Physical Therapy | 420 | 97033 | $75.00 | O | $37.50 | $37.50 | $26.01 | $34.02 | $42.09 | $49.54 | $49.54 | $48.75 | $47.03 | $25.76 | $53.48 | $25.50 | $25.50 | $53.48 |
4200049 | NEUROMUSCULAR RE-ED | 420 | Physical Therapy | 420 | 97112 | $100.00 | O | $50.00 | $50.00 | $34.68 | $57.09 | $70.65 | $83.13 | $83.13 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $34.00 | $83.13 |
4200033 | PT Eval High Complexity 45 Mins | 420 | Physical Therapy | 424 | 97163 | $225.00 | O | $112.50 | $112.50 | $78.03 | $138.38 | $171.25 | $201.52 | $201.52 | $146.25 | $141.08 | $77.27 | $160.43 | $76.50 | $76.50 | $201.52 |
4200031 | PT Eval Low Complexity 20 Mins | 420 | Physical Therapy | 424 | 97161 | $255.00 | O | $127.50 | $127.50 | $88.43 | $138.38 | $171.25 | $201.52 | $201.52 | $165.75 | $159.89 | $87.57 | $181.82 | $86.70 | $86.70 | $201.52 |
4200032 | PT Eval Moderate Complexity 30 Min | 420 | Physical Therapy | 424 | 97162 | $225.00 | O | $112.50 | $112.50 | $78.03 | $138.38 | $171.25 | $201.52 | $201.52 | $146.25 | $141.08 | $77.27 | $160.43 | $76.50 | $76.50 | $201.52 |
42097597 | REMOVE DEVITAL TISS 20 CM/< | 420 | Physical Therapy | 420 | 97597 | $220.00 | O | $110.00 | $110.00 | $76.30 | $39.22 | $48.53 | $57.11 | $57.11 | $143.00 | $137.94 | $75.55 | $156.86 | $74.80 | $39.22 | $156.86 |
42097598 | REMOVE DEVITAL TISS WN Add'l 20CM | 420 | Physical Therapy | 420 | 97598 | $80.00 | O | $40.00 | $40.00 | $27.74 | $18.45 | $22.83 | $26.86 | $26.86 | $52.00 | $50.16 | $27.47 | $57.04 | $27.20 | $18.45 | $57.04 |
4200050 | THERAPEUTIC ACTIVITY | 420 | Physical Therapy | 420 | 97530 | $100.00 | O | $50.00 | $50.00 | $34.68 | $65.15 | $80.63 | $94.88 | $94.88 | $65.00 | $62.70 | $34.34 | $71.30 | $34.00 | $34.00 | $94.88 |
4200037 | TRACTION MANUAL EA 15 | 420 | Physical Therapy | 420 | 97140 | $80.00 | O | $40.00 | $40.00 | $27.74 | $45.55 | $56.37 | $66.34 | $66.34 | $52.00 | $50.16 | $27.47 | $57.04 | $27.20 | $27.20 | $66.34 |
3200001 | ABDOMEN 1 VIEW | 320 | Radiology | 320 | 74018 | $166.00 | O | $83.00 | $83.00 | $57.57 | $100.56 | $106.15 | $124.50 | $124.50 | $107.90 | $104.08 | $57.00 | $118.36 | $56.44 | $56.44 | $124.50 |
3200002 | ABDOMEN 2 VIEWS | 320 | Radiology | 320 | 74019 | $300.00 | O | $150.00 | $150.00 | $104.04 | $141.22 | $149.07 | $174.84 | $174.84 | $195.00 | $188.10 | $103.02 | $213.90 | $102.00 | $102.00 | $213.90 |
3200003 | ABDOMEN 3 VIEWS | 320 | Radiology | 320 | 74022 | $339.00 | O | $169.50 | $169.50 | $117.57 | $141.22 | $149.07 | $174.84 | $174.84 | $220.35 | $212.55 | $116.41 | $241.71 | $115.26 | $115.26 | $241.71 |
4000184 | ABDOMEN COMPLETE US | 320 | Radiology | 402 | 76700 | $539.00 | R | $269.50 | $269.50 | $186.93 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $337.95 | $185.09 | $384.31 | $183.26 | $141.22 | $384.31 |
4000185 | ABDOMINAL AORTA US | 320 | Radiology | 402 | 76770 | $472.00 | O | $236.00 | $236.00 | $163.69 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $295.94 | $162.08 | $336.54 | $160.48 | $141.22 | $336.54 |
3200206 | ANKLE 2 VIEWS | 320 | Radiology | 320 | 73600 | $350.00 | O | $175.00 | $175.00 | $121.38 | $100.56 | $106.15 | $124.50 | $124.50 | $227.50 | $219.45 | $120.19 | $249.55 | $119.00 | $100.56 | $249.55 |
3200206R | ANKLE 2 VIEWS | 320 | Radiology | 320 | 73600 | $350.00 | O | $175.00 | $175.00 | $121.38 | $100.56 | $106.15 | $124.50 | $124.50 | $227.50 | $219.45 | $120.19 | $249.55 | $119.00 | $100.56 | $249.55 |
3200044 | ANKLE 4 VIEWS | 320 | Radiology | 320 | 73610 | $428.00 | O | $214.00 | $214.00 | $148.43 | $100.56 | $106.15 | $124.50 | $124.50 | $278.20 | $268.36 | $146.98 | $305.16 | $145.52 | $100.56 | $305.16 |
3200044R | ANKLE 4 VIEWS | 320 | Radiology | 320 | 73610 | $428.00 | O | $214.00 | $214.00 | $148.43 | $100.56 | $106.15 | $124.50 | $124.50 | $278.20 | $268.36 | $146.98 | $305.16 | $145.52 | $100.56 | $305.16 |
3200228 | Ankle Bilateral Complete Xray min 3views | 320 | Radiology | 320 | 73610 | $428.00 | O | $214.00 | $214.00 | $148.43 | $100.56 | $106.15 | $124.50 | $124.50 | $278.20 | $268.36 | $146.98 | $305.16 | $145.52 | $100.56 | $305.16 |
3200227 | Ankle Bilateral Xray 2views | 320 | Radiology | 320 | 73600 | $350.00 | O | $175.00 | $175.00 | $121.38 | $100.56 | $106.15 | $124.50 | $124.50 | $227.50 | $219.45 | $120.19 | $249.55 | $119.00 | $100.56 | $249.55 |
3200009 | ANKLE MIN 3 VIEWS | 320 | Radiology | 320 | 73610 | $428.00 | O | $214.00 | $214.00 | $148.43 | $100.56 | $106.15 | $124.50 | $124.50 | $278.20 | $268.36 | $146.98 | $305.16 | $145.52 | $100.56 | $305.16 |
3200009R | ANKLE MIN 3 VIEWS | 320 | Radiology | 320 | 73610 | $428.00 | O | $214.00 | $214.00 | $148.43 | $100.56 | $106.15 | $124.50 | $124.50 | $278.20 | $268.36 | $146.98 | $305.16 | $145.52 | $100.56 | $305.16 |
3200015 | CHEST 1 VIEW | 320 | Radiology | 324 | 71045 | $185.00 | O | $92.50 | $92.50 | $64.16 | $100.56 | $106.15 | $124.50 | $124.50 | $120.25 | $116.00 | $63.53 | $131.91 | $62.90 | $62.90 | $131.91 |
3200016 | CHEST 2 VIEWS | 320 | Radiology | 324 | 71046 | $236.00 | O | $118.00 | $118.00 | $81.84 | $100.56 | $106.15 | $124.50 | $124.50 | $153.40 | $147.97 | $81.04 | $168.27 | $80.24 | $80.24 | $168.27 |
3200021 | CLAVICLE 2 VIEWS | 320 | Radiology | 320 | 73000 | $199.00 | O | $99.50 | $99.50 | $69.01 | $100.56 | $106.15 | $124.50 | $124.50 | $129.35 | $124.77 | $68.34 | $141.89 | $67.66 | $67.66 | $141.89 |
3500179 | CT ABDOMEN W/CONTRAST | 320 | Radiology | 352 | 74160 | $1,805.00 | O | $902.50 | $902.50 | $625.97 | $575.82 | $619.55 | $728.88 | $728.88 | $575.00 | $1,131.74 | $619.84 | $1,286.97 | $613.70 | $575.00 | $1,286.97 |
3500167 | CT ABDOMEN WITHOUT CON | 320 | Radiology | 352 | 74150 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500246 | CT ABDOMEN/PELVIS W/CO | 320 | Radiology | 352 | 74177 | $2,300.00 | R | $1,150.00 | $1,150.00 | $797.64 | $1,206.65 | $1,298.29 | $1,527.40 | $1,527.40 | $575.00 | $1,442.10 | $789.82 | $1,639.90 | $782.00 | $575.00 | $1,639.90 |
3500245 | CT ABDOMEN/PELVIS W/O | 320 | Radiology | 352 | 74176 | $2,100.00 | O | $1,050.00 | $1,050.00 | $728.28 | $736.41 | $792.34 | $932.16 | $932.16 | $575.00 | $1,316.70 | $721.14 | $1,497.30 | $714.00 | $575.00 | $1,497.30 |
3500247 | CT ABDOMEN/PELVIS W/WO | 320 | Radiology | 352 | 74178 | $3,400.00 | O | $1,700.00 | $1,700.00 | $1,179.12 | $1,206.65 | $1,298.29 | $1,527.40 | $1,527.40 | $575.00 | $2,131.80 | $1,167.56 | $2,424.20 | $1,156.00 | $575.00 | $2,424.20 |
3500241 | CT ANGIO CHEST W/WO | 320 | Radiology | 352 | 71275 | $1,700.00 | O | $850.00 | $850.00 | $589.56 | $575.82 | $619.55 | $728.88 | $728.88 | $575.00 | $1,065.90 | $583.78 | $1,212.10 | $578.00 | $575.00 | $1,212.10 |
3500140 | CT CHEST W/O CONTRAST | 320 | Radiology | 352 | 71250 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500143 | CT CHEST W/WO CONTRAS | 320 | Radiology | 352 | 71270 | $1,608.00 | O | $804.00 | $804.00 | $557.65 | $575.82 | $619.55 | $728.88 | $728.88 | $575.00 | $1,008.22 | $552.19 | $1,146.50 | $546.72 | $546.72 | $1,146.50 |
3500163 | CT CHEST WITH CONTRAS | 320 | Radiology | 352 | 71260 | $1,805.00 | O | $902.50 | $902.50 | $625.97 | $575.82 | $619.55 | $728.88 | $728.88 | $575.00 | $1,131.74 | $619.84 | $1,286.97 | $613.70 | $575.00 | $1,286.97 |
3500197 | CT C-SPINE WO CONTRAST | 320 | Radiology | 352 | 72125 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500186 | CT FACIAL W/CONTRAST | 320 | Radiology | 351 | 70487 | $1,152.00 | O | $576.00 | $576.00 | $399.51 | $575.82 | $619.55 | $728.88 | $728.88 | $575.00 | $722.30 | $395.60 | $821.38 | $391.68 | $391.68 | $821.38 |
3500187 | CT FACIAL WO/CONTRAST | 320 | Radiology | 351 | 70486 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500141 | CT HEAD WITHOUT CONT. | 320 | Radiology | 351 | 70450 | $1,500.00 | R | $750.00 | $750.00 | $520.20 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $940.50 | $515.10 | $1,069.50 | $510.00 | $354.17 | $1,069.50 |
3500169R | CT Lower Joint w/o contrast; Right | 320 | Radiology | 352 | 73700 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500169 | CT LOWER JOINT WO CONT | 320 | Radiology | 352 | 73700 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500198 | CT L-SPINE W0/ CONTRAS | 320 | Radiology | 352 | 72131 | $1,500.00 | O | $750.00 | $750.00 | $520.20 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $940.50 | $515.10 | $1,069.50 | $510.00 | $354.17 | $1,069.50 |
3500190 | CT NECK W/WO CONTRAST | 320 | Radiology | 351 | 70492 | $2,708.00 | O | $1,354.00 | $1,354.00 | $939.13 | $575.82 | $619.55 | $728.88 | $728.88 | $575.00 | $1,697.92 | $929.93 | $1,930.80 | $920.72 | $575.00 | $1,930.80 |
3500191 | CT NECK WO/CONTRAST | 320 | Radiology | 351 | 70490 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500180 | CT PELVIS W/CONTRAST | 320 | Radiology | 352 | 72193 | $1,805.00 | R | $902.50 | $902.50 | $625.97 | $575.82 | $619.55 | $728.88 | $728.88 | $575.00 | $1,131.74 | $619.84 | $1,286.97 | $613.70 | $575.00 | $1,286.97 |
3500151 | CT PELVIS WITHOUT CO | 320 | Radiology | 352 | 72192 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500233 | CT SINUSES | 320 | Radiology | 351 | 70486 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500200 | CT T-SPINE WO/CONTRAST | 320 | Radiology | 352 | 72128 | $1,305.00 | O | $652.50 | $652.50 | $452.57 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $818.24 | $448.14 | $930.47 | $443.70 | $354.17 | $930.47 |
3500168R | CT Upper Joint w/o contrast; Right | 320 | Radiology | 352 | 73200 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
3500168 | CT UPPER JOINT WO/CONT | 320 | Radiology | 352 | 73200 | $1,467.00 | O | $733.50 | $733.50 | $508.76 | $354.17 | $381.07 | $448.32 | $448.32 | $575.00 | $919.81 | $503.77 | $1,045.97 | $498.78 | $354.17 | $1,045.97 |
4000213 | ECHO TTHRC R-T 2D W/WOM | 320 | Radiology | 483 | 93306 | $800.00 | O | $400.00 | $400.00 | $277.44 | $216.82 | $268.31 | $315.74 | $315.74 | $520.00 | $501.60 | $274.72 | $570.40 | $272.00 | $216.82 | $570.40 |
3200028 | ELBOW 2V | 320 | Radiology | 320 | 73070 | $331.00 | O | $165.50 | $165.50 | $114.79 | $100.56 | $106.15 | $124.50 | $124.50 | $215.15 | $207.54 | $113.67 | $236.00 | $112.54 | $100.56 | $236.00 |
3200028R | ELBOW 2V | 320 | Radiology | 320 | 73070 | $331.00 | O | $165.50 | $165.50 | $114.79 | $100.56 | $106.15 | $124.50 | $124.50 | $215.15 | $207.54 | $113.67 | $236.00 | $112.54 | $100.56 | $236.00 |
3200215 | Elbow Bilateral Xray 2views | 320 | Radiology | 320 | 73070 | $331.00 | O | $165.50 | $165.50 | $114.79 | $100.56 | $106.15 | $124.50 | $124.50 | $215.15 | $207.54 | $113.67 | $236.00 | $112.54 | $100.56 | $236.00 |
3200232 | Elbow Complete X Min 3V | 320 | Radiology | 320 | 73080 | $165.00 | O | $82.50 | $82.50 | $57.22 | $100.56 | $106.15 | $124.50 | $124.50 | $107.25 | $103.46 | $56.66 | $117.65 | $56.10 | $56.10 | $124.50 |
3200232R | Elbow Complete X Min 3V | 320 | Radiology | 320 | 73080 | $165.00 | O | $82.50 | $82.50 | $57.22 | $100.56 | $106.15 | $124.50 | $124.50 | $107.25 | $103.46 | $56.66 | $117.65 | $56.10 | $56.10 | $124.50 |
3200035 | FEMUR 2 V | 320 | Radiology | 320 | 73552 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200035R | FEMUR 2 V | 320 | Radiology | 320 | 73552 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200222 | Femur Bilateral Xray 2views | 320 | Radiology | 320 | 73552 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200038 | FINGER(S) 3 VIEW | 320 | Radiology | 320 | 73140 | $337.00 | O | $168.50 | $168.50 | $116.87 | $100.56 | $106.15 | $124.50 | $124.50 | $219.05 | $211.30 | $115.73 | $240.28 | $114.58 | $100.56 | $240.28 |
3200038R | FINGER(S) 3 VIEW | 320 | Radiology | 320 | 73140 | $337.00 | O | $168.50 | $168.50 | $116.87 | $100.56 | $106.15 | $124.50 | $124.50 | $219.05 | $211.30 | $115.73 | $240.28 | $114.58 | $100.56 | $240.28 |
3200246 | Fingers xray 2v; left | 320 | Radiology | 320 | 73140 | $139.00 | O | $69.50 | $69.50 | $48.21 | $100.56 | $106.15 | $124.50 | $124.50 | $90.35 | $87.15 | $47.73 | $99.11 | $47.26 | $47.26 | $124.50 |
3200246R | Fingers xray 2v; right | 320 | Radiology | 320 | 73140 | $139.00 | O | $69.50 | $69.50 | $48.21 | $100.56 | $106.15 | $124.50 | $124.50 | $90.35 | $87.15 | $47.73 | $99.11 | $47.26 | $47.26 | $124.50 |
3200207 | FOOT 2 VIEWS | 320 | Radiology | 320 | 73620 | $306.00 | O | $153.00 | $153.00 | $106.12 | $100.56 | $106.15 | $124.50 | $124.50 | $198.90 | $191.86 | $105.08 | $218.18 | $104.04 | $100.56 | $218.18 |
3200207R | FOOT 2 VIEWS | 320 | Radiology | 320 | 73620 | $306.00 | O | $153.00 | $153.00 | $106.12 | $100.56 | $106.15 | $124.50 | $124.50 | $198.90 | $191.86 | $105.08 | $218.18 | $104.04 | $100.56 | $218.18 |
3200041 | FOOT 3+V | 320 | Radiology | 320 | 73630 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200041R | FOOT 3+V | 320 | Radiology | 320 | 73630 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200230 | Foot Bilateral Complete Xray min 3views | 320 | Radiology | 320 | 73630 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200229 | Foot Bilateral Xray 2views | 320 | Radiology | 320 | 73620 | $360.00 | O | $180.00 | $180.00 | $124.85 | $100.56 | $106.15 | $124.50 | $124.50 | $234.00 | $225.72 | $123.62 | $256.68 | $122.40 | $100.56 | $256.68 |
3200042 | FOREARM 2V | 320 | Radiology | 320 | 73090 | $368.00 | O | $184.00 | $184.00 | $127.62 | $100.56 | $106.15 | $124.50 | $124.50 | $239.20 | $230.74 | $126.37 | $262.38 | $125.12 | $100.56 | $262.38 |
3200042R | FOREARM 2V | 320 | Radiology | 320 | 73090 | $368.00 | O | $184.00 | $184.00 | $127.62 | $100.56 | $106.15 | $124.50 | $124.50 | $239.20 | $230.74 | $126.37 | $262.38 | $125.12 | $100.56 | $262.38 |
3200216 | Forearm Bilateral Xray 2views | 320 | Radiology | 320 | 73090 | $368.00 | O | $184.00 | $184.00 | $127.62 | $100.56 | $106.15 | $124.50 | $124.50 | $239.20 | $230.74 | $126.37 | $262.38 | $125.12 | $100.56 | $262.38 |
4000188 | GALLBLADDER US | 320 | Radiology | 402 | 76705 | $472.00 | O | $236.00 | $236.00 | $163.69 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $295.94 | $162.08 | $336.54 | $160.48 | $141.22 | $336.54 |
3200257 | Groin Ultrasound | 320 | Radiology | 402 | 76882 | $410.00 | O | $205.00 | $205.00 | $142.19 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $257.07 | $140.79 | $292.33 | $139.40 | $139.40 | $292.33 |
3200202 | HAND 2 VIEWS | 320 | Radiology | 320 | 73120 | $325.00 | O | $162.50 | $162.50 | $112.71 | $141.22 | $149.07 | $174.84 | $174.84 | $211.25 | $203.78 | $111.61 | $231.73 | $110.50 | $110.50 | $231.73 |
3200202R | HAND 2 VIEWS | 320 | Radiology | 320 | 73120 | $325.00 | O | $162.50 | $162.50 | $112.71 | $141.22 | $149.07 | $174.84 | $174.84 | $211.25 | $203.78 | $111.61 | $231.73 | $110.50 | $110.50 | $231.73 |
3200048 | HAND 3 V | 320 | Radiology | 320 | 73130 | $374.00 | O | $187.00 | $187.00 | $129.70 | $100.56 | $106.15 | $124.50 | $124.50 | $243.10 | $234.50 | $128.43 | $266.66 | $127.16 | $100.56 | $266.66 |
3200048R | HAND 3 V | 320 | Radiology | 320 | 73130 | $374.00 | O | $187.00 | $187.00 | $129.70 | $100.56 | $106.15 | $124.50 | $124.50 | $243.10 | $234.50 | $128.43 | $266.66 | $127.16 | $100.56 | $266.66 |
3200219 | Hand Bilateral Xray 2views | 320 | Radiology | 320 | 73120 | $325.00 | O | $162.50 | $162.50 | $112.71 | $141.22 | $149.07 | $174.84 | $174.84 | $211.25 | $203.78 | $111.61 | $231.73 | $110.50 | $110.50 | $231.73 |
3200220 | Hand Bilateral Xray min 3view | 320 | Radiology | 320 | 73130 | $374.00 | O | $187.00 | $187.00 | $129.70 | $100.56 | $106.15 | $124.50 | $124.50 | $243.10 | $234.50 | $128.43 | $266.66 | $127.16 | $100.56 | $266.66 |
3200051 | HIP JOINT 2 VIEWS UNIL | 320 | Radiology | 320 | 73502 | $211.00 | O | $105.50 | $105.50 | $73.17 | $100.56 | $106.15 | $124.50 | $124.50 | $137.15 | $132.30 | $72.46 | $150.44 | $71.74 | $71.74 | $150.44 |
3200051R | HIP JOINT 2 VIEWS UNIL | 320 | Radiology | 320 | 73502 | $211.00 | O | $105.50 | $105.50 | $73.17 | $100.56 | $106.15 | $124.50 | $124.50 | $137.15 | $132.30 | $72.46 | $150.44 | $71.74 | $71.74 | $150.44 |
3200052 | HIP JOINT BILATERAL CO | 320 | Radiology | 320 | 73521 | $253.00 | O | $126.50 | $126.50 | $87.74 | $141.22 | $149.07 | $174.84 | $174.84 | $164.45 | $158.63 | $86.88 | $180.39 | $86.02 | $86.02 | $180.39 |
3200055 | HUMERUS 2V | 320 | Radiology | 320 | 73060 | $407.00 | O | $203.50 | $203.50 | $141.15 | $100.56 | $106.15 | $124.50 | $124.50 | $264.55 | $255.19 | $139.76 | $290.19 | $138.38 | $100.56 | $290.19 |
3200055R | HUMERUS 2V | 320 | Radiology | 320 | 73060 | $407.00 | O | $203.50 | $203.50 | $141.15 | $100.56 | $106.15 | $124.50 | $124.50 | $264.55 | $255.19 | $139.76 | $290.19 | $138.38 | $100.56 | $290.19 |
3200214 | Humerus Bilateral Xray min 2views | 320 | Radiology | 320 | 73060 | $407.00 | O | $203.50 | $203.50 | $141.15 | $100.56 | $106.15 | $124.50 | $124.50 | $264.55 | $255.19 | $139.76 | $290.19 | $138.38 | $100.56 | $290.19 |
3200004 | KNEE 1-2 V | 320 | Radiology | 320 | 73560 | $370.00 | O | $185.00 | $185.00 | $128.32 | $100.56 | $106.15 | $124.50 | $124.50 | $240.50 | $231.99 | $127.06 | $263.81 | $125.80 | $100.56 | $263.81 |
3200004R | KNEE 1-2 V | 320 | Radiology | 320 | 73560 | $370.00 | O | $185.00 | $185.00 | $128.32 | $100.56 | $106.15 | $124.50 | $124.50 | $240.50 | $231.99 | $127.06 | $263.81 | $125.80 | $100.56 | $263.81 |
3200211 | KNEE 3V | 320 | Radiology | 320 | 73562 | $471.00 | O | $235.50 | $235.50 | $163.34 | $100.56 | $106.15 | $124.50 | $124.50 | $306.15 | $295.32 | $161.74 | $335.82 | $160.14 | $100.56 | $335.82 |
3200211R | KNEE 3V | 320 | Radiology | 320 | 73562 | $471.00 | O | $235.50 | $235.50 | $163.34 | $100.56 | $106.15 | $124.50 | $124.50 | $306.15 | $295.32 | $161.74 | $335.82 | $160.14 | $100.56 | $335.82 |
3200225 | Knee Bilateral Completel Xray min 4views | 320 | Radiology | 320 | 73564 | $282.00 | O | $141.00 | $141.00 | $97.80 | $141.22 | $149.07 | $174.84 | $174.84 | $183.30 | $176.81 | $96.84 | $201.07 | $95.88 | $95.88 | $201.07 |
3200224 | Knee Bilateral Xray 3views | 320 | Radiology | 320 | 73562 | $471.00 | O | $235.50 | $235.50 | $163.34 | $100.56 | $106.15 | $124.50 | $124.50 | $306.15 | $295.32 | $161.74 | $335.82 | $160.14 | $100.56 | $335.82 |
3200058 | KNEE COMPLETE 4+V | 320 | Radiology | 320 | 73564 | $282.00 | O | $141.00 | $141.00 | $97.80 | $141.22 | $149.07 | $174.84 | $174.84 | $183.30 | $176.81 | $96.84 | $201.07 | $95.88 | $95.88 | $201.07 |
3200058R | KNEE COMPLETE 4+V | 320 | Radiology | 320 | 73564 | $282.00 | O | $141.00 | $141.00 | $97.80 | $141.22 | $149.07 | $174.84 | $174.84 | $183.30 | $176.81 | $96.84 | $201.07 | $95.88 | $95.88 | $201.07 |
3200250 | Knee xray 2v; bilateral | 320 | Radiology | 320 | 73560 | $165.00 | O | $82.50 | $82.50 | $57.22 | $100.56 | $106.15 | $124.50 | $124.50 | $107.25 | $103.46 | $56.66 | $117.65 | $56.10 | $56.10 | $124.50 |
3200057 | KUB 1 V | 320 | Radiology | 320 | 74018 | $166.00 | O | $83.00 | $83.00 | $57.57 | $100.56 | $106.15 | $124.50 | $124.50 | $107.90 | $104.08 | $57.00 | $118.36 | $56.44 | $56.44 | $124.50 |
3200057R | KUB 1 V | 320 | Radiology | 320 | 74018 | $166.00 | O | $83.00 | $83.00 | $57.57 | $100.56 | $106.15 | $124.50 | $124.50 | $107.90 | $104.08 | $57.00 | $118.36 | $56.44 | $56.44 | $124.50 |
3200062 | LEG 2 V | 320 | Radiology | 320 | 73590 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200062R | LEG 2 V | 320 | Radiology | 320 | 73590 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200226 | Leg Bilateral Xray 2views | 320 | Radiology | 320 | 73590 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
4000199 | LIVER US | 320 | Radiology | 402 | 76705 | $472.00 | O | $236.00 | $236.00 | $163.69 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $295.94 | $162.08 | $336.54 | $160.48 | $141.22 | $336.54 |
6100015 | MRI BRAIN W&WO CONT | 320 | Radiology | 611 | 70553 | $2,704.00 | R | $1,352.00 | $1,352.00 | $937.75 | $1,206.65 | $1,298.29 | $1,527.40 | $1,527.40 | $650.00 | $1,695.41 | $928.55 | $1,927.95 | $919.36 | $650.00 | $1,927.95 |
3500243 | MRI BRAIN With & W/O CONTRAST | 320 | Radiology | 610 | 70553 | $2,704.00 | R | $1,352.00 | $1,352.00 | $937.75 | $1,206.65 | $1,298.29 | $1,527.40 | $1,527.40 | $650.00 | $1,695.41 | $928.55 | $1,927.95 | $919.36 | $650.00 | $1,927.95 |
6100024 | MRI C-SPINE WO CONT | 320 | Radiology | 612 | 72141 | $2,024.00 | O | $1,012.00 | $1,012.00 | $701.92 | $736.41 | $792.34 | $932.16 | $932.16 | $650.00 | $1,269.05 | $695.04 | $1,443.11 | $688.16 | $650.00 | $1,443.11 |
6100070 | MRI LOW EXTREM JT WO C | 320 | Radiology | 614 | 73721 | $2,699.00 | R | $1,349.50 | $1,349.50 | $936.01 | $736.41 | $792.34 | $932.16 | $932.16 | $650.00 | $1,692.27 | $926.84 | $1,924.39 | $917.66 | $650.00 | $1,924.39 |
6100072 | MRI LOW EXTREM JT WO C | 320 | Radiology | 610 | 73721 | $2,699.00 | R | $1,349.50 | $1,349.50 | $936.01 | $736.41 | $792.34 | $932.16 | $932.16 | $650.00 | $1,692.27 | $926.84 | $1,924.39 | $917.66 | $650.00 | $1,924.39 |
6100072R | MRI LOW EXTREM JT WO C | 320 | Radiology | 610 | 73721 | $2,699.00 | R | $1,349.50 | $1,349.50 | $936.01 | $736.41 | $792.34 | $932.16 | $932.16 | $650.00 | $1,692.27 | $926.84 | $1,924.39 | $917.66 | $650.00 | $1,924.39 |
6100028 | MRI L-SPINE WO CONT | 320 | Radiology | 612 | 72148 | $1,969.00 | R | $984.50 | $984.50 | $682.85 | $736.41 | $792.34 | $932.16 | $932.16 | $650.00 | $1,234.56 | $676.15 | $1,403.90 | $669.46 | $650.00 | $1,403.90 |
3200192 | NECK, SOFT TISSUE 2 VI | 320 | Radiology | 320 | 70360 | $185.00 | O | $92.50 | $92.50 | $64.16 | $100.56 | $106.15 | $124.50 | $124.50 | $120.25 | $116.00 | $63.53 | $131.91 | $62.90 | $62.90 | $131.91 |
4000191 | PANCREAS US | 320 | Radiology | 402 | 76705 | $472.00 | O | $236.00 | $236.00 | $163.69 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $295.94 | $162.08 | $336.54 | $160.48 | $141.22 | $336.54 |
4000193 | PELVIC US NON-OB LIMIT | 320 | Radiology | 402 | 76857 | $221.00 | O | $110.50 | $110.50 | $76.64 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $138.57 | $75.89 | $157.57 | $75.14 | $75.14 | $174.84 |
4000207 | PELVIC US TRANSVAG NON | 320 | Radiology | 402 | 76830 | $523.00 | R | $261.50 | $261.50 | $181.38 | $111.26 | $117.44 | $137.75 | $137.75 | $150.00 | $327.92 | $179.60 | $372.90 | $177.82 | $111.26 | $372.90 |
3200072 | PELVIS 1V | 320 | Radiology | 320 | 72170 | $300.00 | O | $150.00 | $150.00 | $104.04 | $141.22 | $149.07 | $174.84 | $174.84 | $195.00 | $188.10 | $103.02 | $213.90 | $102.00 | $102.00 | $213.90 |
4000209 | PREGNANCY US > 14 WKS | 320 | Radiology | 402 | 76805 | $450.00 | R | $225.00 | $225.00 | $156.06 | $115.34 | $121.75 | $142.80 | $142.80 | $150.00 | $282.15 | $154.53 | $320.85 | $153.00 | $115.34 | $320.85 |
4000196 | RENAL COMPLETE US | 320 | Radiology | 402 | 76770 | $472.00 | O | $236.00 | $236.00 | $163.69 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $295.94 | $162.08 | $336.54 | $160.48 | $141.22 | $336.54 |
3200196R | Ribs 3 views w/AP Chest; Right | 320 | Radiology | 320 | 71101 | $247.00 | O | $123.50 | $123.50 | $85.66 | $141.22 | $149.07 | $174.84 | $174.84 | $160.55 | $154.87 | $84.82 | $176.11 | $83.98 | $83.98 | $176.11 |
3200078 | RIBS BILAT 3V | 320 | Radiology | 320 | 71110 | $289.00 | O | $144.50 | $144.50 | $100.23 | $141.22 | $149.07 | $174.84 | $174.84 | $187.85 | $181.20 | $99.24 | $206.06 | $98.26 | $98.26 | $206.06 |
3200196 | RIBS MIN 3 VIEW/AP CHEST | 320 | Radiology | 320 | 71101 | $247.00 | O | $123.50 | $123.50 | $85.66 | $141.22 | $149.07 | $174.84 | $174.84 | $160.55 | $154.87 | $84.82 | $176.11 | $83.98 | $83.98 | $176.11 |
3200079 | RIBS UNILAT MIN 2 VIEWS | 320 | Radiology | 320 | 71100 | $231.00 | O | $115.50 | $115.50 | $80.11 | $100.56 | $106.15 | $124.50 | $124.50 | $150.15 | $144.84 | $79.33 | $164.70 | $78.54 | $78.54 | $164.70 |
3200079R | RIBS UNILAT MIN 2 VIEWS | 320 | Radiology | 320 | 71100 | $231.00 | O | $115.50 | $115.50 | $80.11 | $100.56 | $106.15 | $124.50 | $124.50 | $150.15 | $144.84 | $79.33 | $164.70 | $78.54 | $78.54 | $164.70 |
3200080 | RIBS UNILATERAL 2V | 320 | Radiology | 320 | 71100 | $231.00 | O | $115.50 | $115.50 | $80.11 | $100.56 | $106.15 | $124.50 | $124.50 | $150.15 | $144.84 | $79.33 | $164.70 | $78.54 | $78.54 | $164.70 |
3200080R | RIBS UNILATERAL 2V | 320 | Radiology | 320 | 71100 | $231.00 | O | $115.50 | $115.50 | $80.11 | $100.56 | $106.15 | $124.50 | $124.50 | $150.15 | $144.84 | $79.33 | $164.70 | $78.54 | $78.54 | $164.70 |
3200188 | RIBS/CHEST MIN 4 VIEW | 320 | Radiology | 320 | 71111 | $365.00 | O | $182.50 | $182.50 | $126.58 | $141.22 | $149.07 | $174.84 | $174.84 | $237.25 | $228.86 | $125.34 | $260.25 | $124.10 | $124.10 | $260.25 |
3200082 | SACRUM & COCCYX MIN 2 | 320 | Radiology | 320 | 72220 | $391.00 | O | $195.50 | $195.50 | $135.60 | $100.56 | $106.15 | $124.50 | $124.50 | $254.15 | $245.16 | $134.27 | $278.78 | $132.94 | $100.56 | $278.78 |
3200085 | SCAPULA CMPLTE 2V | 320 | Radiology | 320 | 73010 | $191.00 | O | $95.50 | $95.50 | $66.24 | $141.22 | $149.07 | $174.84 | $174.84 | $124.15 | $119.76 | $65.59 | $136.18 | $64.94 | $64.94 | $174.84 |
3200085R | Scapula Complete 2 view; Right | 320 | Radiology | 320 | 73010 | $191.00 | O | $95.50 | $95.50 | $66.24 | $141.22 | $149.07 | $174.84 | $174.84 | $124.15 | $119.76 | $65.59 | $136.18 | $64.94 | $64.94 | $174.84 |
3200198 | SCOLIOSIS STANDING SER | 320 | Radiology | 320 | 72082 | $236.00 | O | $118.00 | $118.00 | $81.84 | $141.22 | $149.07 | $174.84 | $174.84 | $153.40 | $147.97 | $81.04 | $168.27 | $80.24 | $80.24 | $174.84 |
4000201 | SCROTUM | 320 | Radiology | 402 | 76870 | $477.00 | O | $238.50 | $238.50 | $165.42 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $299.08 | $163.80 | $340.10 | $162.18 | $141.22 | $340.10 |
3200089 | SHOULDER 2 V | 320 | Radiology | 320 | 73030 | $440.00 | O | $220.00 | $220.00 | $152.59 | $100.56 | $106.15 | $124.50 | $124.50 | $286.00 | $275.88 | $151.10 | $313.72 | $149.60 | $100.56 | $313.72 |
3200089R | SHOULDER 2 V | 320 | Radiology | 320 | 73030 | $440.00 | O | $220.00 | $220.00 | $152.59 | $100.56 | $106.15 | $124.50 | $124.50 | $286.00 | $275.88 | $151.10 | $313.72 | $149.60 | $100.56 | $313.72 |
3200253 | Shoulder xray 2v; bilateral | 320 | Radiology | 320 | 73030 | $165.00 | O | $82.50 | $82.50 | $57.22 | $100.56 | $106.15 | $124.50 | $124.50 | $107.25 | $103.46 | $56.66 | $117.65 | $56.10 | $56.10 | $124.50 |
4000202 | SINGLE ORGAN | 320 | Radiology | 402 | 76705 | $472.00 | O | $236.00 | $236.00 | $163.69 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $295.94 | $162.08 | $336.54 | $160.48 | $141.22 | $336.54 |
3200094 | SKULL COMPLETE 4+V | 320 | Radiology | 320 | 70260 | $328.00 | O | $164.00 | $164.00 | $113.75 | $141.22 | $149.07 | $174.84 | $174.84 | $213.20 | $205.66 | $112.64 | $233.86 | $111.52 | $111.52 | $233.86 |
3200098 | SPINE C 4+V | 320 | Radiology | 320 | 72050 | $367.00 | O | $183.50 | $183.50 | $127.28 | $141.22 | $149.07 | $174.84 | $174.84 | $238.55 | $230.11 | $126.03 | $261.67 | $124.78 | $124.78 | $261.67 |
3200097 | SPINE CERVICAL 2V or 3V | 320 | Radiology | 320 | 72040 | $234.00 | O | $117.00 | $117.00 | $81.15 | $100.56 | $106.15 | $124.50 | $124.50 | $152.10 | $146.72 | $80.36 | $166.84 | $79.56 | $79.56 | $166.84 |
3200103 | SPINE LUMBAR 2V OR 3V | 320 | Radiology | 320 | 72100 | $300.00 | O | $150.00 | $150.00 | $104.04 | $141.22 | $149.07 | $174.84 | $174.84 | $195.00 | $188.10 | $103.02 | $213.90 | $102.00 | $102.00 | $213.90 |
3200104 | SPINE LUMBAR COMP SER MIN 4 VIEWS | 320 | Radiology | 320 | 72110 | $387.00 | R | $193.50 | $193.50 | $134.21 | $141.22 | $149.07 | $174.84 | $174.84 | $251.55 | $242.65 | $132.90 | $275.93 | $131.58 | $131.58 | $275.93 |
3200100 | SPINE THORACIX 2 VIEW | 320 | Radiology | 320 | 72070 | $234.00 | O | $117.00 | $117.00 | $81.15 | $141.22 | $149.07 | $174.84 | $174.84 | $152.10 | $146.72 | $80.36 | $166.84 | $79.56 | $79.56 | $174.84 |
3200180 | SPINE THORACIX W/SWIMM | 320 | Radiology | 320 | 72072 | $296.00 | O | $148.00 | $148.00 | $102.65 | $141.22 | $149.07 | $174.84 | $174.84 | $192.40 | $185.59 | $101.65 | $211.05 | $100.64 | $100.64 | $211.05 |
4000200 | THYROID SOFT TISSUE US | 320 | Radiology | 402 | 76536 | $444.00 | O | $222.00 | $222.00 | $153.98 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $278.39 | $152.47 | $316.57 | $150.96 | $141.22 | $316.57 |
3200111 | TOE(S) 3V | 320 | Radiology | 320 | 73660 | $337.00 | O | $168.50 | $168.50 | $116.87 | $100.56 | $106.15 | $124.50 | $124.50 | $219.05 | $211.30 | $115.73 | $240.28 | $114.58 | $100.56 | $240.28 |
3200111R | TOE(S) 3V | 320 | Radiology | 320 | 73660 | $337.00 | O | $168.50 | $168.50 | $116.87 | $100.56 | $106.15 | $124.50 | $124.50 | $219.05 | $211.30 | $115.73 | $240.28 | $114.58 | $100.56 | $240.28 |
3200254 | Toes xray 2v; left | 320 | Radiology | 320 | 73660 | $175.00 | O | $87.50 | $87.50 | $60.69 | $100.56 | $106.15 | $124.50 | $124.50 | $113.75 | $109.73 | $60.10 | $124.78 | $59.50 | $59.50 | $124.78 |
3200254R | Toes xray 2v; Right | 320 | Radiology | 320 | 73660 | $175.00 | O | $87.50 | $87.50 | $60.69 | $100.56 | $106.15 | $124.50 | $124.50 | $113.75 | $109.73 | $60.10 | $124.78 | $59.50 | $59.50 | $124.78 |
3200256 | US Extremity non vascular; Rt | 320 | Radiology | 402 | 76882 | $410.00 | O | $205.00 | $205.00 | $142.19 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $257.07 | $140.79 | $292.33 | $139.40 | $139.40 | $292.33 |
4000125 | US, Limited, Joint or other nonvascular | 320 | Radiology | 402 | 76882 | $410.00 | O | $205.00 | $205.00 | $142.19 | $141.22 | $149.07 | $174.84 | $174.84 | $150.00 | $257.07 | $140.79 | $292.33 | $139.40 | $139.40 | $292.33 |
3200130 | WRIST 3 VIEWS | 320 | Radiology | 320 | 73110 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200130R | WRIST 3 VIEWS | 320 | Radiology | 320 | 73110 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200218 | Wrist Bilateral Complete Xray min 3views | 320 | Radiology | 320 | 73110 | $416.00 | O | $208.00 | $208.00 | $144.27 | $100.56 | $106.15 | $124.50 | $124.50 | $270.40 | $260.83 | $142.85 | $296.61 | $141.44 | $100.56 | $296.61 |
3200217 | Wrist Bilateral Xray 2views | 320 | Radiology | 320 | 73100 | $292.00 | O | $146.00 | $146.00 | $101.27 | $100.56 | $106.15 | $124.50 | $124.50 | $189.80 | $183.08 | $100.27 | $208.20 | $99.28 | $99.28 | $208.20 |
3200201 | WRIST TWO VIEWS | 320 | Radiology | 320 | 73100 | $292.00 | O | $146.00 | $146.00 | $101.27 | $100.56 | $106.15 | $124.50 | $124.50 | $189.80 | $183.08 | $100.27 | $208.20 | $99.28 | $99.28 | $208.20 |
3200201R | WRIST TWO VIEWS | 320 | Radiology | 320 | 73100 | $292.00 | O | $146.00 | $146.00 | $101.27 | $100.56 | $106.15 | $124.50 | $124.50 | $189.80 | $183.08 | $100.27 | $208.20 | $99.28 | $99.28 | $208.20 |
51093000 | EKG COMPLETE | 521 | Rural Health Clinic | 521 | 93000 | $64.00 | R | $32.00 | $14.59 | $- | $14.59 | $14.59 | $14.59 | $14.59 | $14.59 | $14.59 | $- | $14.59 | $- | $- | $32.00 |
51099386 | PREVENTIVE EXAM NEW 40 | 521 | Rural Health Clinic | 521 | 99386 | $218.00 | R | $109.00 | $- | $212.66 | $- | $- | $- | $- | $- | $- | $212.66 | $- | $212.66 | $- | $212.66 |
51081002 | URINE DIPSTICK | 521 | Rural Health Clinic | 521 | 81002 | $15.00 | R | $7.50 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- | $7.50 |
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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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