Hospital Payment Policy - Sabine County Hospital

Hospital Charges / Price Transparency

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:

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

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

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

QUESTIONS?

If you have further questions about the 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!

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Searchable Shoppable Services

Sabine County Hospital Shoppable Services as of 7/15/2023

Charge Number	Description	Dept	Dept Description	Rev Code	CPT Code	Price	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	$173.00	$86.50	$86.50	$60.00	$88.02	$108.92	$128.17	$128.17	$112.45	$108.47	$59.41	$123.35	$58.82	$58.82	$128.17
3000391	BASIC METABOLIC PANEL,	300	Lab	301	80048	$233.00	$116.50	$116.50	$80.80	$20.73	$24.20	$28.51	$28.51	$151.45	$146.09	$80.01	$166.13	$79.22	$20.73	$166.13
3000365	ELECTROLYTES	300	Lab	301	80051	$80.00	$40.00	$40.00	$27.74	$17.17	$20.05	$23.62	$23.62	$52.00	$50.16	$27.47	$57.04	$27.20	$17.17	$57.04
3000184	COMPREHENSIVE METABOLI	300	Lab	301	80053	$272.00	$136.00	$136.00	$94.33	$25.87	$30.20	$35.59	$35.59	$176.80	$170.54	$93.40	$193.94	$92.48	$25.87	$193.94
3000731	CMP (RL)	300	Lab	301	80053	$272.00	$136.00	$136.00	$94.33	$25.87	$30.20	$35.59	$35.59	$176.80	$170.54	$93.40	$193.94	$92.48	$25.87	$193.94
3000389	LIPID PANEL	300	Lab	301	80061	$153.00	$76.50	$76.50	$53.06	$32.81	$38.30	$45.12	$45.12	$99.45	$95.93	$52.54	$109.09	$52.02	$32.81	$109.09
3000732	LIPID PANEL (RL)	300	Lab	301	80061	$153.00	$76.50	$76.50	$53.06	$32.81	$38.30	$45.12	$45.12	$99.45	$95.93	$52.54	$109.09	$52.02	$32.81	$109.09
3000158	RENAL FUNCTION PANEL	300	Lab	301	80069	$168.00	$84.00	$84.00	$58.26	$21.27	$24.82	$29.25	$29.25	$109.20	$105.34	$57.69	$119.78	$57.12	$21.27	$119.78
3000292	HEPATIC FUNCTION PAN	300	Lab	301	80076	$180.00	$90.00	$90.00	$62.42	$20.02	$23.37	$27.53	$27.53	$117.00	$112.86	$61.81	$128.34	$61.20	$20.02	$128.34
3000212	CARBAMAZEPINE(TEGRETOL	300	Lab	301	80156	$130.00	$65.00	$65.00	$45.08	$35.70	$41.67	$49.10	$49.10	$84.50	$81.51	$44.64	$92.69	$44.20	$35.70	$92.69
3000207	DIGOXIN LEVEL	300	Lab	301	80162	$173.00	$86.50	$86.50	$60.00	$32.54	$37.98	$44.75	$44.75	$112.45	$108.47	$59.41	$123.35	$58.82	$32.54	$123.35
3000753	DIGOXIN (RL)	300	Lab	301	80162	$173.00	$86.50	$86.50	$60.00	$32.54	$37.98	$44.75	$44.75	$112.45	$108.47	$59.41	$123.35	$58.82	$32.54	$123.35
3000248	VALPROIC ACID (R)	300	Lab	301	80164	$118.00	$59.00	$59.00	$40.92	$33.17	$38.72	$45.63	$45.63	$76.70	$73.99	$40.52	$84.13	$40.12	$33.17	$84.13
3000429	LEVETIRACETAM (R)	300	Lab	301	80177	$161.00	$80.50	$80.50	$55.83	$32.46	$37.90	$44.65	$44.65	$104.65	$100.95	$55.29	$114.79	$54.74	$32.46	$114.79
3000312	LITHIUM	300	Lab	301	80178	$93.00	$46.50	$46.50	$32.25	$16.19	$18.90	$22.28	$22.28	$60.45	$58.31	$31.94	$66.31	$31.62	$16.19	$66.31
3000027	PHENOBARBITAL QUANITAT	300	Lab	301	80184	$118.00	$59.00	$59.00	$40.92	$37.49	$43.76	$51.56	$51.56	$76.70	$73.99	$40.52	$84.13	$40.12	$37.49	$84.13
3000387	PRIMIDONE (RL)	300	Lab	301	80188	$71.00	$35.50	$35.50	$24.62	$40.65	$47.45	$55.91	$55.91	$46.15	$44.52	$24.38	$50.62	$24.14	$24.14	$55.91
3000588	RAPAMYCIN (SIROLIMUS)	300	Lab	300	80195	$195.00	$97.50	$97.50	$67.63	$33.64	$39.27	$46.27	$46.27	$126.75	$122.27	$66.96	$139.04	$66.30	$33.64	$139.04
3000471	TACROLIMUS (R)	300	Lab	301	80197	$218.00	$109.00	$109.00	$75.60	$33.64	$39.27	$46.27	$46.27	$141.70	$136.69	$74.86	$155.43	$74.12	$33.64	$155.43
3000105	VANCOMYCIN	300	Lab	301	80202	$118.00	$59.00	$59.00	$40.92	$33.17	$38.72	$45.63	$45.63	$76.70	$73.99	$40.52	$84.13	$40.12	$33.17	$84.13
3000285	DRUG SCREEN MULTI	300	Lab	301	80305	$168.00	$84.00	$84.00	$58.26	$30.87	$36.04	$42.46	$42.46	$109.20	$105.34	$57.69	$119.78	$57.12	$30.87	$119.78
3000261	Drug Test by Chem Analyzer_UDOA (	300	Lab	301	80307	$230.00	$115.00	$115.00	$79.76	$152.24	$177.72	$209.41	$209.41	$149.50	$144.21	$78.98	$163.99	$78.20	$78.20	$209.41
3000009	URINALYSIS	300	Lab	307	81001	$60.00	$30.00	$30.00	$20.81	$7.77	$9.07	$10.68	$10.68	$39.00	$37.62	$20.60	$42.78	$20.40	$7.77	$42.78
3000977	Urine Ictotest	300	Lab	307	81002	$123.00	$61.50	$61.50	$42.66	$8.53	$9.95	$11.73	$11.73	$79.95	$77.12	$42.24	$87.70	$41.82	$8.53	$87.70
3000003	Urine Dipstick	300	Lab	307	81003	$41.00	$20.50	$20.50	$14.22	$5.51	$6.44	$7.58	$7.58	$26.65	$25.71	$14.08	$29.23	$13.94	$5.51	$29.23
3000017	ALBUMIN;SERUM, PLASMA	300	Lab	301	82040	$44.00	$22.00	$22.00	$15.26	$12.13	$14.16	$16.68	$16.68	$28.60	$27.59	$15.11	$31.37	$14.96	$12.13	$31.37
3000850	24hr Microalbu(R)	300	Lab	301	82043	$95.00	$47.50	$47.50	$32.95	$14.16	$16.53	$19.48	$19.48	$61.75	$59.57	$32.62	$67.74	$32.30	$14.16	$67.74
3000711	Microalbumin (Urine) Semi-QNT	300	Lab	301	82044	$26.00	$13.00	$13.00	$9.02	$15.26	$17.82	$21.00	$21.00	$16.90	$16.30	$8.93	$18.54	$8.84	$8.84	$21.00
3000097	MICRO ALBUMIN RAND UR w/o CR (	300	Lab	301	82044	$95.00	$47.50	$47.50	$32.95	$15.26	$17.82	$21.00	$21.00	$61.75	$59.57	$32.62	$67.74	$32.30	$15.26	$67.74
3000415	ALPHA-FETOPROTEIN SER	300	Lab	301	82105	$91.00	$45.50	$45.50	$31.56	$41.09	$47.96	$56.51	$56.51	$59.15	$57.06	$31.25	$64.88	$30.94	$30.94	$64.88
3000166	AMMONIA (R)	300	Lab	301	82140	$75.00	$37.50	$37.50	$26.01	$35.70	$41.67	$49.10	$49.10	$48.75	$47.03	$25.76	$53.48	$25.50	$25.50	$53.48
3000022	AMYLASE	300	Lab	301	82150	$93.00	$46.50	$46.50	$32.25	$15.88	$18.53	$21.84	$21.84	$60.45	$58.31	$31.94	$66.31	$31.62	$15.88	$66.31
3000486	ANGIOTENSION CONVERTIN	300	Lab	301	82164	$86.00	$43.00	$43.00	$29.82	$35.77	$41.76	$49.20	$49.20	$55.90	$53.92	$29.53	$61.32	$29.24	$29.24	$61.32
3000028	BILIRUBIN;BLOOD,TOTAL	300	Lab	301	82247	$58.00	$29.00	$29.00	$20.11	$12.30	$14.36	$16.92	$16.92	$37.70	$36.37	$19.92	$41.35	$19.72	$12.30	$41.35
3000029	BILIRUBIN BLOOD DIRECT	300	Lab	301	82248	$58.00	$29.00	$29.00	$20.11	$12.30	$14.36	$16.92	$16.92	$37.70	$36.37	$19.92	$41.35	$19.72	$12.30	$41.35
3000328	NEONATAL BILIRUBIN	300	Lab	301	82248	$58.00	$29.00	$29.00	$20.11	$12.30	$14.36	$16.92	$16.92	$37.70	$36.37	$19.92	$41.35	$19.72	$12.30	$41.35
3000031	OCCULT BLOOD GASTRIC	300	Lab	301	82271	$31.00	$15.50	$15.50	$10.75	$13.03	$15.22	$17.93	$17.93	$20.15	$19.44	$10.65	$22.10	$10.54	$10.54	$22.10
3000695	OCCULT BLOOD FE	300	Lab	301	82274	$60.00	$30.00	$30.00	$20.81	$39.00	$45.53	$53.65	$53.65	$39.00	$37.62	$20.60	$42.78	$20.40	$20.40	$53.65
3000470	VIT D 25 HYDROXYL-URIN	300	Lab	301	82306	$227.00	$113.50	$113.50	$78.72	$72.52	$84.66	$99.75	$99.75	$147.55	$142.33	$77.95	$161.85	$77.18	$72.52	$161.85
3000523	VIT D 25 OH LS/MS/MS (SERUM)(R)	300	Lab	301	82306	$227.00	$113.50	$113.50	$78.72	$72.52	$84.66	$99.75	$99.75	$147.55	$142.33	$77.95	$161.85	$77.18	$72.52	$161.85
3000891	CARDIQ VITD25(R)	300	Lab	301	82306	$227.00	$113.50	$113.50	$78.72	$72.52	$84.66	$99.75	$99.75	$147.55	$142.33	$77.95	$161.85	$77.18	$72.52	$161.85
3000032	CALCIUM	300	Lab	301	82310	$46.00	$23.00	$23.00	$15.95	$12.64	$14.76	$17.39	$17.39	$29.90	$28.84	$15.80	$32.80	$15.64	$12.64	$32.80
3000767	CALC, Totall (R)	300	Lab	301	82310	$46.00	$23.00	$23.00	$15.95	$12.64	$14.76	$17.39	$17.39	$29.90	$28.84	$15.80	$32.80	$15.64	$12.64	$32.80
3000041	CHOLESTEROL SERUM TOT	300	Lab	301	82465	$55.00	$27.50	$27.50	$19.07	$10.66	$12.44	$14.66	$14.66	$35.75	$34.49	$18.89	$39.22	$18.70	$10.66	$39.22
3000043	CREATINE KINASE (CK) (	300	Lab	301	82550	$118.00	$59.00	$59.00	$40.92	$15.95	$18.62	$21.94	$21.94	$76.70	$73.99	$40.52	$84.13	$40.12	$15.95	$84.13
3000120	(CK) MB FRACTION ONLY	300	Lab	301	82553	$204.00	$102.00	$102.00	$70.75	$28.30	$33.03	$38.92	$38.92	$132.60	$127.91	$70.05	$145.45	$69.36	$28.30	$145.45
3000219	CREATININE	300	Lab	301	82565	$75.00	$37.50	$37.50	$26.01	$12.54	$14.64	$17.25	$17.25	$48.75	$47.03	$25.76	$53.48	$25.50	$12.54	$53.48
3000367	CREATININE RAND URINE (R)	300	Lab	301	82570	$58.00	$29.00	$29.00	$20.11	$12.69	$14.81	$17.46	$17.46	$37.70	$36.37	$19.92	$41.35	$19.72	$12.69	$41.35
3000903	CREA RAND URN	300	Lab	301	82570	$58.00	$29.00	$29.00	$20.11	$12.69	$14.81	$17.46	$17.46	$37.70	$36.37	$19.92	$41.35	$19.72	$12.69	$41.35
3000908	24 HR URN CREA	300	Lab	301	82570	$58.00	$29.00	$29.00	$20.11	$12.69	$14.81	$17.46	$17.46	$37.70	$36.37	$19.92	$41.35	$19.72	$12.69	$41.35
3000270	VITAMIN B12 (R)	300	Lab	301	82607	$130.00	$65.00	$65.00	$45.08	$36.95	$43.13	$50.82	$50.82	$84.50	$81.51	$44.64	$92.69	$44.20	$36.95	$92.69
3000642	VIT D I 25-DIHYDORXY	300	Lab	301	82652	$321.00	$160.50	$160.50	$111.32	$94.33	$110.11	$129.75	$129.75	$208.65	$201.27	$110.23	$228.87	$109.14	$94.33	$228.87
3000685	ESTRADIOL (RL)	300	Lab	301	82670	$197.00	$98.50	$98.50	$68.32	$68.45	$79.91	$94.16	$94.16	$128.05	$123.52	$67.65	$140.46	$66.98	$66.98	$140.46
3000384	FERRITIN (R)	300	Lab	301	82728	$85.00	$42.50	$42.50	$29.48	$33.39	$38.98	$45.93	$45.93	$55.25	$53.30	$29.19	$60.61	$28.90	$28.90	$60.61
3000271	FOLATE, SERUM (R)	300	Lab	301	82746	$86.00	$43.00	$43.00	$29.82	$36.02	$42.04	$49.54	$49.54	$55.90	$53.92	$29.53	$61.32	$29.24	$29.24	$61.32
3000287	FOLIC ACID RBC (RL)	300	Lab	301	82747	$89.00	$44.50	$44.50	$30.87	$43.24	$50.48	$59.48	$59.48	$57.85	$55.80	$30.56	$63.46	$30.26	$30.26	$63.46
3000060	GLUCOSE QUANT	300	Lab	301	82947	$51.00	$25.50	$25.50	$17.69	$9.63	$11.24	$13.24	$13.24	$33.15	$31.98	$17.51	$36.36	$17.34	$9.63	$36.36
Sabine County Hospital Shoppable Services for Charge Description Master As of 7/15/2023
Charge Number	Description	Dept	Dept Description	Rev Code	CPT Code	Price	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
3000591	GLUCOSE-6-PHOSPHATE DE	300	Lab	301	82955	$98.00	$49.00	$49.00	$33.99	$23.77	$27.74	$32.69	$32.69	$63.70	$61.45	$33.65	$69.87	$33.32	$23.77	$69.87
3000216	GLUCOSE BLOOD BY GMD	300	Lab	301	82962	$49.00	$24.50	$24.50	$16.99	$8.04	$9.38	$11.05	$11.05	$31.85	$30.72	$16.83	$34.94	$16.66	$8.04	$34.94
3000070	GGT	300	Lab	301	82977	$84.00	$42.00	$42.00	$29.13	$17.64	$20.59	$24.26	$24.26	$54.60	$52.67	$28.85	$59.89	$28.56	$17.64	$59.89
3000189	FSH (R)	300	Lab	301	83001	$82.00	$41.00	$41.00	$28.44	$45.52	$53.14	$62.61	$62.61	$53.30	$51.41	$28.16	$58.47	$27.88	$27.88	$62.61
3000355	LH (R)	300	Lab	301	83002	$77.00	$38.50	$38.50	$26.70	$45.37	$52.97	$62.41	$62.41	$50.05	$48.28	$26.44	$54.90	$26.18	$26.18	$62.41
3000243	HEMOGLOBIN; GLYOSYLATE	300	Lab	301	83036	$102.00	$51.00	$51.00	$35.37	$23.79	$27.77	$32.72	$32.72	$66.30	$63.95	$35.03	$72.73	$34.68	$23.79	$72.73
3000717	HGB A1C W/Reflex to Glycomark (R)	300	Lab	301	83036	$102.00	$51.00	$51.00	$35.37	$23.79	$27.77	$32.72	$32.72	$66.30	$63.95	$35.03	$72.73	$34.68	$23.79	$72.73
3000154	IRON (RL)	300	Lab	301	83540	$49.00	$24.50	$24.50	$16.99	$15.85	$18.50	$21.80	$21.80	$31.85	$30.72	$16.83	$34.94	$16.66	$15.85	$34.94
3000390	TIBC (RL)	300	Lab	301	83550	$95.00	$47.50	$47.50	$32.95	$21.41	$25.00	$29.45	$29.45	$61.75	$59.57	$32.62	$67.74	$32.30	$21.41	$67.74
3000558	LACTATE PLASMA	300	Lab	301	83605	$51.00	$25.50	$25.50	$17.69	$28.35	$33.09	$38.99	$38.99	$33.15	$31.98	$17.51	$36.36	$17.34	$17.34	$38.99
3000086	LACTATE DEHYDROGENASE	300	Lab	301	83615	$75.00	$37.50	$37.50	$26.01	$14.80	$17.27	$20.35	$20.35	$48.75	$47.03	$25.76	$53.48	$25.50	$14.80	$53.48
3000093	LIPASE BLOOD	300	Lab	301	83690	$70.00	$35.00	$35.00	$24.28	$16.88	$19.71	$23.22	$23.22	$45.50	$43.89	$24.04	$49.91	$23.80	$16.88	$49.91
3000098	MAGNESIUM	300	Lab	301	83735	$67.00	$33.50	$33.50	$23.24	$16.42	$19.16	$22.58	$22.58	$43.55	$42.01	$23.01	$47.77	$22.78	$16.42	$47.77
3000434	BNP - Natriuretic Peptide	300	Lab	301	83880	$205.00	$102.50	$102.50	$71.09	$96.19	$112.28	$132.31	$132.31	$133.25	$128.54	$70.40	$146.17	$69.70	$69.70	$146.17
3000766	BNP (RL)	300	Lab	301	83880	$205.00	$102.50	$102.50	$71.09	$96.19	$112.28	$132.31	$132.31	$133.25	$128.54	$70.40	$146.17	$69.70	$69.70	$146.17
3000981	Cardio PROBNP(R)	300	Lab	301	83880	$205.00	$102.50	$102.50	$71.09	$96.19	$112.28	$132.31	$132.31	$133.25	$128.54	$70.40	$146.17	$69.70	$69.70	$146.17
3000011	METHYLMALONIC ACID(RL)	300	Lab	301	83921	$240.00	$120.00	$120.00	$83.23	$51.96	$60.66	$71.48	$71.48	$156.00	$150.48	$82.42	$171.12	$81.60	$51.96	$171.12
3000024	PTH INTACT (R)	300	Lab	301	83970	$177.00	$88.50	$88.50	$61.38	$101.14	$118.06	$139.11	$139.11	$115.05	$110.98	$60.78	$126.20	$60.18	$60.18	$139.11
3000109	PHOSPHORUS INORGANIC P	300	Lab	301	84100	$51.00	$25.50	$25.50	$17.69	$11.61	$13.56	$15.97	$15.97	$33.15	$31.98	$17.51	$36.36	$17.34	$11.61	$36.36
3000111	POTASSIUM; SERUM PLASM	300	Lab	301	84132	$49.00	$24.50	$24.50	$16.99	$11.66	$13.61	$16.04	$16.04	$31.85	$30.72	$16.83	$34.94	$16.66	$11.66	$34.94
3000117	PROGESTERONE (RL)	300	Lab	301	84144	$125.00	$62.50	$62.50	$43.35	$51.11	$59.66	$70.30	$70.30	$81.25	$78.38	$42.93	$89.13	$42.50	$42.50	$89.13
3000356	PROLACTIN (RL)	300	Lab	301	84146	$95.00	$47.50	$47.50	$32.95	$47.48	$55.43	$65.31	$65.31	$61.75	$59.57	$32.62	$67.74	$32.30	$32.30	$67.74
3000150	FREE PSA-B (RL)	300	Lab	301	84153	$180.00	$90.00	$90.00	$62.42	$45.06	$52.60	$61.97	$61.97	$117.00	$112.86	$61.81	$128.34	$61.20	$45.06	$128.34
3000295	PSA; TOTAL	300	Lab	301	84153	$180.00	$90.00	$90.00	$62.42	$45.06	$52.60	$61.97	$61.97	$117.00	$112.86	$61.81	$128.34	$61.20	$45.06	$128.34
3000141	FREE PSA-A (RL)	300	Lab	301	84154	$110.00	$55.00	$55.00	$38.15	$45.06	$52.60	$61.97	$61.97	$71.50	$68.97	$37.77	$78.43	$37.40	$37.40	$78.43
3000310	PROTEIN TOTAL UA w/o Creat (R)	300	Lab	301	84156	$53.00	$26.50	$26.50	$18.38	$8.99	$10.50	$12.37	$12.37	$34.45	$33.23	$18.20	$37.79	$18.02	$8.99	$37.79
3000904	PROTEIN URINE	300	Lab	301	84156	$53.00	$26.50	$26.50	$18.38	$8.99	$10.50	$12.37	$12.37	$34.45	$33.23	$18.20	$37.79	$18.02	$8.99	$37.79
3000907	PROTEIN 24HR UR	300	Lab	301	84156	$53.00	$26.50	$26.50	$18.38	$8.99	$10.50	$12.37	$12.37	$34.45	$33.23	$18.20	$37.79	$18.02	$8.99	$37.79
3000605	VITAMIN B6	300	Lab	301	84207	$183.00	$91.50	$91.50	$63.46	$68.85	$80.37	$94.70	$94.70	$118.95	$114.74	$62.84	$130.48	$62.22	$62.22	$130.48
3000119	SODIUM;SERUM PLASMA/WH	300	Lab	301	84295	$49.00	$24.50	$24.50	$16.99	$11.78	$13.76	$16.21	$16.21	$31.85	$30.72	$16.83	$34.94	$16.66	$11.78	$34.94
3000466	FREE TESTOSTERONE (RL)	300	Lab	301	84402	$224.00	$112.00	$112.00	$77.68	$62.40	$72.84	$85.83	$85.83	$145.60	$140.45	$76.92	$159.71	$76.16	$62.40	$159.71
3000138	TESTOSTERONE TOTAL (R)	300	Lab	301	84403	$144.00	$72.00	$72.00	$49.94	$63.23	$73.82	$86.98	$86.98	$93.60	$90.29	$49.45	$102.67	$48.96	$48.96	$102.67
3000933	TESTOST, TOT (R)	300	Lab	301	84403	$144.00	$72.00	$72.00	$49.94	$63.23	$73.82	$86.98	$86.98	$93.60	$90.29	$49.45	$102.67	$48.96	$48.96	$102.67
3000308	VITAMIN B1-THIAMINE (R	300	Lab	301	84425	$180.00	$90.00	$90.00	$62.42	$52.01	$60.72	$71.55	$71.55	$117.00	$112.86	$61.81	$128.34	$61.20	$52.01	$128.34
3000768	VIT B1, PLASMA	300	Lab	301	84425	$180.00	$90.00	$90.00	$62.42	$52.01	$60.72	$71.55	$71.55	$117.00	$112.86	$61.81	$128.34	$61.20	$52.01	$128.34
3000350	T-4 (THYROXINE) (R)	300	Lab	301	84436	$62.00	$31.00	$31.00	$21.50	$16.83	$19.65	$23.15	$23.15	$40.30	$38.87	$21.29	$44.21	$21.08	$16.83	$44.21
3000042	T-4 FREE (R)	300	Lab	301	84439	$97.00	$48.50	$48.50	$33.64	$22.10	$25.80	$30.40	$30.40	$63.05	$60.82	$33.31	$69.16	$32.98	$22.10	$69.16
3000399	TSH (R)	300	Lab	301	84443	$173.00	$86.50	$86.50	$60.00	$41.16	$48.05	$56.62	$56.62	$112.45	$108.47	$59.41	$123.35	$58.82	$41.16	$123.35
3000744	TSH W/RFLX FT4 (R)	300	Lab	301	84443	$173.00	$86.50	$86.50	$60.00	$41.16	$48.05	$56.62	$56.62	$112.45	$108.47	$59.41	$123.35	$58.82	$41.16	$123.35
3000128	SGOT	300	Lab	301	84450	$62.00	$31.00	$31.00	$21.50	$12.69	$14.81	$17.46	$17.46	$40.30	$38.87	$21.29	$44.21	$21.08	$12.69	$44.21
3000129	SGPT	300	Lab	301	84460	$62.00	$31.00	$31.00	$21.50	$12.99	$15.16	$17.86	$17.86	$40.30	$38.87	$21.29	$44.21	$21.08	$12.99	$44.21
3000359	TRANSFERRIN(RL)	300	Lab	301	84466	$75.00	$37.50	$37.50	$26.01	$31.26	$36.49	$43.00	$43.00	$48.75	$47.03	$25.76	$53.48	$25.50	$25.50	$53.48
3000130	TRIGLYCERIDES BLOOD	300	Lab	301	84478	$49.00	$24.50	$24.50	$16.99	$14.06	$16.42	$19.34	$19.34	$31.85	$30.72	$16.83	$34.94	$16.66	$14.06	$34.94
3000163	T-3 UPTAKE (R)	300	Lab	301	84479	$62.00	$31.00	$31.00	$21.50	$15.85	$18.50	$21.80	$21.80	$40.30	$38.87	$21.29	$44.21	$21.08	$15.85	$44.21
3000063	T3 TOTAL (RL)	300	Lab	301	84480	$62.00	$31.00	$31.00	$21.50	$34.74	$40.55	$47.79	$47.79	$40.30	$38.87	$21.29	$44.21	$21.08	$21.08	$47.79
3000543	T3 FREE	300	Lab	301	84481	$162.00	$81.00	$81.00	$56.18	$41.50	$48.45	$57.09	$57.09	$105.30	$101.57	$55.63	$115.51	$55.08	$41.50	$115.51
3000162	TROPONIN, QUANTITATIVE	300	Lab	301	84484	$352.00	$176.00	$176.00	$122.07	$30.55	$35.66	$42.02	$42.02	$228.80	$220.70	$120.88	$250.98	$119.68	$30.55	$250.98
3000131	BUN-UREA NITROGEN BLOOD	300	Lab	301	84520	$75.00	$37.50	$37.50	$26.01	$9.68	$11.30	$13.31	$13.31	$48.75	$47.03	$25.76	$53.48	$25.50	$9.68	$53.48
3000132	URIC ACID	300	Lab	301	84550	$55.00	$27.50	$27.50	$19.07	$11.07	$12.93	$15.23	$15.23	$35.75	$34.49	$18.89	$39.22	$18.70	$11.07	$39.22
3000021	C-PEPTIDE (RL)	300	Lab	301	84681	$110.00	$55.00	$55.00	$38.15	$50.98	$59.52	$70.13	$70.13	$71.50	$68.97	$37.77	$78.43	$37.40	$37.40	$78.43
3000299	BETA HCG SERUM (RL)	300	Lab	301	84702	$75.00	$37.50	$37.50	$26.01	$36.87	$43.04	$50.72	$50.72	$48.75	$47.03	$25.76	$53.48	$25.50	$25.50	$53.48
3000074	PREGNANCY TEST URINE	300	Lab	301	84703	$75.00	$37.50	$37.50	$26.01	$18.42	$21.51	$25.34	$25.34	$48.75	$47.03	$25.76	$53.48	$25.50	$18.42	$53.48
3000168	PREGNANCY TEST SERUM	300	Lab	301	84703	$75.00	$37.50	$37.50	$26.01	$18.42	$21.51	$25.34	$25.34	$48.75	$47.03	$25.76	$53.48	$25.50	$18.42	$53.48
3000127	MANUAL DIFFERENTIAL	300	Lab	305	85007	$44.00	$22.00	$22.00	$15.26	$9.31	$10.87	$12.81	$12.81	$28.60	$27.59	$15.11	$31.37	$14.96	$9.31	$31.37
3000135	HEMATOCRIT	300	Lab	305	85014	$33.00	$16.50	$16.50	$11.44	$5.81	$6.78	$7.99	$7.99	$21.45	$20.69	$11.33	$23.53	$11.22	$5.81	$23.53
3000136	HEMOGLOBIN	300	Lab	305	85018	$33.00	$16.50	$16.50	$11.44	$5.81	$6.78	$7.99	$7.99	$21.45	$20.69	$11.33	$23.53	$11.22	$5.81	$23.53
3000139	CBC W/ Auto Diff	300	Lab	305	85025	$148.00	$74.00	$74.00	$51.33	$19.04	$22.22	$26.18	$26.18	$96.20	$92.80	$50.82	$105.52	$50.32	$19.04	$105.52
Sabine County Hospital Shoppable Services for Charge Description Master As of 7/15/2023
Charge Number	Description	Dept	Dept Description	Rev Code	CPT Code	Price	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
3000504	CBC AUTO W/O DIFF	300	Lab	305	85027	$102.00	$51.00	$51.00	$35.37	$15.85	$18.50	$21.80	$21.80	$66.30	$63.95	$35.03	$72.73	$34.68	$15.85	$72.73
3000762	D-Dimer	300	Lab	305	85379	$161.00	$80.50	$80.50	$55.83	$24.94	$29.11	$34.31	$34.31	$104.65	$100.95	$55.29	$114.79	$54.74	$24.94	$114.79
3000146	PROTHROMBIN, TIME	300	Lab	305	85610	$92.00	$46.00	$46.00	$31.91	$10.51	$12.27	$14.46	$14.46	$59.80	$57.68	$31.59	$65.60	$31.28	$10.51	$65.60
3000147	SEDIMENTATION RATE; NO	300	Lab	305	85651	$57.00	$28.50	$28.50	$19.77	$10.46	$12.21	$14.39	$14.39	$37.05	$35.74	$19.57	$40.64	$19.38	$10.46	$40.64
3000124	PARTIAL THROMBOPLASTIN	300	Lab	305	85730	$61.00	$30.50	$30.50	$21.15	$14.72	$17.19	$20.25	$20.25	$39.65	$38.25	$20.95	$43.49	$20.74	$14.72	$43.49
3000242	APTT-LA	300	Lab	305	85730	$61.00	$30.50	$30.50	$21.15	$14.72	$17.19	$20.25	$20.25	$39.65	$38.25	$20.95	$43.49	$20.74	$14.72	$43.49
3000094	ANCA-C TITER (RL)	300	Lab	300	86021	$154.00	$77.00	$77.00	$53.41	$36.87	$43.04	$50.72	$50.72	$100.10	$96.56	$52.88	$109.80	$52.36	$36.87	$109.80
3000581	ANCA W/REFLEX TITER	300	Lab	300	86021	$154.00	$77.00	$77.00	$53.41	$36.87	$43.04	$50.72	$50.72	$100.10	$96.56	$52.88	$109.80	$52.36	$36.87	$109.80
3000224	ANA W/RFX (R)	300	Lab	302	86038	$195.00	$97.50	$97.50	$67.63	$29.62	$34.58	$40.74	$40.74	$126.75	$122.27	$66.96	$139.04	$66.30	$29.62	$139.04
3000567	CENTROMERE AB	300	Lab	302	86038	$195.00	$97.50	$97.50	$67.63	$29.62	$34.58	$40.74	$40.74	$126.75	$122.27	$66.96	$139.04	$66.30	$29.62	$139.04
3000411	C-REACTIVE PROTEIN (R)	300	Lab	302	86140	$62.00	$31.00	$31.00	$21.50	$12.69	$14.81	$17.46	$17.46	$40.30	$38.87	$21.29	$44.21	$21.08	$12.69	$44.21
3000116	COMPLEMENT C3	300	Lab	302	86160	$132.00	$66.00	$66.00	$45.78	$29.40	$34.32	$40.44	$40.44	$85.80	$82.76	$45.33	$94.12	$44.88	$29.40	$94.12
3000118	COMPLEMENT C4	300	Lab	302	86160	$132.00	$66.00	$66.00	$45.78	$29.40	$34.32	$40.44	$40.44	$85.80	$82.76	$45.33	$94.12	$44.88	$29.40	$94.12
3000524	CYCLIC CITRULLINATED P	300	Lab	302	86200	$259.00	$129.50	$129.50	$89.82	$31.73	$37.04	$43.64	$43.64	$168.35	$162.39	$88.94	$184.67	$88.06	$31.73	$184.67
3000549	ANTI-DSNA AB, EIA (R)	300	Lab	302	86225	$85.00	$42.50	$42.50	$29.48	$33.66	$39.30	$46.30	$46.30	$55.25	$53.30	$29.19	$60.61	$28.90	$28.90	$60.61
3000294	SM ANTIBODIES (RL)	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000298	SJOGREN'S AB SS-A(R)	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000345	SCL-70 (R)	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000349	RNP ANTIBODIES (RL)	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000357	SJOGREN'S AB SS-B(R)	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000547	JO-1 AB	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000770	PATTERN	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000774	Chromatin (Nucleosomal) Antibody	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000811	SM/RNP Antibody (R)	300	Lab	302	86235	$160.00	$80.00	$80.00	$55.49	$43.93	$51.28	$60.42	$60.42	$104.00	$100.32	$54.94	$114.08	$54.40	$43.93	$114.08
3000797	CA 19-9	300	Lab	302	86301	$161.00	$80.50	$80.50	$55.83	$50.98	$59.52	$70.13	$70.13	$104.65	$100.95	$55.29	$114.79	$54.74	$50.98	$114.79
3000155	MONO TEST	300	Lab	302	86308	$62.00	$31.00	$31.00	$21.50	$12.69	$14.81	$17.46	$17.46	$40.30	$38.87	$21.29	$44.21	$21.08	$12.69	$44.21
3000769	TITER	300	Lab	302	86309	$53.00	$26.50	$26.50	$18.38	$15.85	$18.50	$21.80	$21.80	$34.45	$33.23	$18.20	$37.79	$18.02	$15.85	$37.79
3000190	HEP B SURFACE AB QN (R)	300	Lab	302	86317	$80.00	$40.00	$40.00	$27.74	$36.73	$42.87	$50.52	$50.52	$52.00	$50.16	$27.47	$57.04	$27.20	$27.20	$57.04
3000199	IMMUNOFIXATION (RL)	300	Lab	302	86334	$230.00	$115.00	$115.00	$79.76	$54.73	$63.89	$75.29	$75.29	$149.50	$144.21	$78.98	$163.99	$78.20	$54.73	$163.99
3000203	THYROID PEROXIDASE AN	300	Lab	302	86376	$80.00	$40.00	$40.00	$27.74	$35.65	$41.61	$49.03	$49.03	$52.00	$50.16	$27.47	$57.04	$27.20	$27.20	$57.04
3000223	RHEUMATOID FACTOR (R)	300	Lab	302	86431	$55.00	$27.50	$27.50	$19.07	$13.89	$16.22	$19.11	$19.11	$35.75	$34.49	$18.89	$39.22	$18.70	$13.89	$39.22
3000836	TB Gold Quant(R)	300	Lab	302	86480	$400.00	$200.00	$200.00	$138.72	$151.85	$177.26	$208.87	$208.87	$260.00	$250.80	$137.36	$285.20	$136.00	$136.00	$285.20
3000214	TB SKIN TEST	300	Lab	302	86580	$102.00	$51.00	$51.00	$35.37	$56.33	$65.75	$77.48	$77.48	$66.30	$63.95	$35.03	$72.73	$34.68	$34.68	$77.48
3000215	RPR	300	Lab	302	86592	$55.00	$27.50	$27.50	$19.07	$10.46	$12.21	$14.39	$14.39	$35.75	$34.49	$18.89	$39.22	$18.70	$10.46	$39.22
3000534	VDRL (SERUM)	300	Lab	302	86592	$62.00	$31.00	$31.00	$21.50	$10.46	$12.21	$14.39	$14.39	$40.30	$38.87	$21.29	$44.21	$21.08	$10.46	$44.21
3000218	LYME DISEASE	300	Lab	302	86618	$161.00	$80.50	$80.50	$55.83	$41.72	$48.71	$57.39	$57.39	$104.65	$100.95	$55.29	$114.79	$54.74	$41.72	$114.79
3000114	HELICOBACTER PYLORI	300	Lab	302	86677	$151.00	$75.50	$75.50	$52.37	$41.28	$48.19	$56.78	$56.78	$98.15	$94.68	$51.85	$107.66	$51.34	$41.28	$107.66
3000227	HIV 1/2 (RL)	300	Lab	302	86703	$503.00	$251.50	$251.50	$174.44	$33.59	$39.21	$46.20	$46.20	$326.95	$315.38	$172.73	$358.64	$171.02	$33.59	$358.64
3000191	HEPATITIS B CORE AB, TOT	300	Lab	302	86704	$97.00	$48.50	$48.50	$33.64	$29.52	$34.46	$40.61	$40.61	$63.05	$60.82	$33.31	$69.16	$32.98	$29.52	$69.16
3000372	ANTI-HEPATITIS B SURFA	300	Lab	302	86706	$59.00	$29.50	$29.50	$20.46	$26.31	$30.72	$36.19	$36.19	$38.35	$36.99	$20.26	$42.07	$20.06	$20.06	$42.07
3000420	HEPATITIS A AB Tot(R)	300	Lab	302	86708	$112.00	$56.00	$56.00	$38.84	$30.36	$35.44	$41.75	$41.75	$72.80	$70.22	$38.46	$79.86	$38.08	$30.36	$79.86
3000456	HEPATITIS A AB IGM	300	Lab	302	86709	$112.00	$56.00	$56.00	$38.84	$27.59	$32.20	$37.95	$37.95	$72.80	$70.22	$38.46	$79.86	$38.08	$27.59	$79.86
3000450	MUMPS VIRUS IGG, EIA(R)	300	Lab	302	86735	$65.00	$32.50	$32.50	$22.54	$31.97	$37.32	$43.98	$43.98	$42.25	$40.76	$22.32	$46.35	$22.10	$22.10	$46.35
3000451	MUMPS IGM	300	Lab	302	86735	$65.00	$32.50	$32.50	$22.54	$31.97	$37.32	$43.98	$43.98	$42.25	$40.76	$22.32	$46.35	$22.10	$22.10	$46.35
3000257	RUBELLA IMMUNE (R)	300	Lab	302	86762	$95.00	$47.50	$47.50	$32.95	$35.26	$41.16	$48.49	$48.49	$61.75	$59.57	$32.62	$67.74	$32.30	$32.30	$67.74
3000837	Rubella IGM (R)	300	Lab	302	86762	$95.00	$47.50	$47.50	$32.95	$35.26	$41.16	$48.49	$48.49	$61.75	$59.57	$32.62	$67.74	$32.30	$32.30	$67.74
3000743	MEASLES AB IGG, EIA (R)	300	Lab	302	86765	$137.00	$68.50	$68.50	$47.51	$31.56	$36.84	$43.41	$43.41	$89.05	$85.90	$47.05	$97.68	$46.58	$31.56	$97.68
3000874	Measles IGM(R)	300	Lab	302	86765	$137.00	$68.50	$68.50	$47.51	$31.56	$36.84	$43.41	$43.41	$89.05	$85.90	$47.05	$97.68	$46.58	$31.56	$97.68
3000258	VARICELLA-ZOSTER IGG AB (R)	300	Lab	302	86787	$128.00	$64.00	$64.00	$44.39	$31.56	$36.84	$43.41	$43.41	$83.20	$80.26	$43.96	$91.26	$43.52	$31.56	$91.26
3000340	VARICELLA IGM AB (RL)	300	Lab	302	86787	$128.00	$64.00	$64.00	$44.39	$31.56	$36.84	$43.41	$43.41	$83.20	$80.26	$43.96	$91.26	$43.52	$31.56	$91.26
3000339	HEP C AB (R)	300	Lab	302	86803	$80.00	$40.00	$40.00	$27.74	$34.96	$40.81	$48.09	$48.09	$52.00	$50.16	$27.47	$57.04	$27.20	$27.20	$57.04
3000152	Antibody Screen	300	Lab	302	86885	$510.00	$255.00	$255.00	$176.87	$351.58	$410.41	$483.60	$483.60	$331.50	$319.77	$175.13	$363.63	$173.40	$173.40	$483.60
3000183	CULTURE; BLOOD, BACTERIAL (R)	300	Lab	306	87040	$255.00	$127.50	$127.50	$88.43	$25.28	$29.52	$34.78	$34.78	$165.75	$159.89	$87.57	$181.82	$86.70	$25.28	$181.82
3000378	CULTURE STOOL A S/S (R	300	Lab	306	87045	$67.00	$33.50	$33.50	$23.24	$23.13	$27.00	$31.81	$31.81	$43.55	$42.01	$23.01	$47.77	$22.78	$22.78	$47.77
3000379	CULTURE STOOL B CMPY (	300	Lab	306	87046	$55.00	$27.50	$27.50	$19.07	$23.13	$27.00	$31.81	$31.81	$35.75	$34.49	$18.89	$39.22	$18.70	$18.70	$39.22
3000171	CULTURE EXCEP UR/BLOOD	300	Lab	306	87070	$116.00	$58.00	$58.00	$40.23	$21.12	$24.65	$29.05	$29.05	$75.40	$72.73	$39.83	$82.71	$39.44	$21.12	$82.71
3000172	CULTURE ANY OTHER SOUR	300	Lab	306	87070	$116.00	$58.00	$58.00	$40.23	$21.12	$24.65	$29.05	$29.05	$75.40	$72.73	$39.83	$82.71	$39.44	$21.12	$82.71
Sabine County Hospital Shoppable Services for Charge Description Master As of 7/15/2023
Charge Number	Description	Dept	Dept Description	Rev Code	CPT Code	Price	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
3000240	CULTURE SPUTUM	300	Lab	306	87070	$116.00	$58.00	$58.00	$40.23	$21.12	$24.65	$29.05	$29.05	$75.40	$72.73	$39.83	$82.71	$39.44	$21.12	$82.71
3000301	CULTURE AEROBIC BAC (R)	300	Lab	306	87070	$116.00	$58.00	$58.00	$40.23	$21.12	$24.65	$29.05	$29.05	$75.40	$72.73	$39.83	$82.71	$39.44	$21.12	$82.71
30087070	Culture, throat	300	Lab	300	87070	$116.00	$58.00	$58.00	$40.23	$21.12	$24.65	$29.05	$29.05	$75.40	$72.73	$39.83	$82.71	$39.44	$21.12	$82.71
3000354	CULTURE ANAEROBIC	300	Lab	306	87075	$154.00	$77.00	$77.00	$53.41	$23.20	$27.08	$31.91	$31.91	$100.10	$96.56	$52.88	$109.80	$52.36	$23.20	$109.80
3000499	AEROBIC ID (RL)	300	Lab	306	87077	$96.00	$48.00	$48.00	$33.29	$19.80	$23.11	$27.23	$27.23	$62.40	$60.19	$32.97	$68.45	$32.64	$19.80	$68.45
3000693	AEROBIC ID #2 (RL)	300	Lab	306	87077	$96.00	$48.00	$48.00	$33.29	$19.80	$23.11	$27.23	$27.23	$62.40	$60.19	$32.97	$68.45	$32.64	$19.80	$68.45
3000173	CULTURE; BACTERIAL URI	300	Lab	306	87086	$85.00	$42.50	$42.50	$29.48	$19.77	$23.08	$27.20	$27.20	$55.25	$53.30	$29.19	$60.61	$28.90	$19.77	$60.61
3000176	OVA & PARASITES STOOL	300	Lab	306	87177	$89.00	$44.50	$44.50	$30.87	$21.81	$25.45	$29.99	$29.99	$57.85	$55.80	$30.56	$63.46	$30.26	$21.81	$63.46
3000630	ESBL CONFIRMATION	300	Lab	306	87184	$53.00	$26.50	$26.50	$18.38	$18.33	$21.39	$25.21	$25.21	$34.45	$33.23	$18.20	$37.79	$18.02	$18.02	$37.79
3000181	AEROBIC SUSCEPTIBILITY	300	Lab	306	87186	$128.00	$64.00	$64.00	$44.39	$21.19	$24.74	$29.15	$29.15	$83.20	$80.26	$43.96	$91.26	$43.52	$21.19	$91.26
3000498	AEROBIC SUSCEPTIBILITY	300	Lab	306	87186	$128.00	$64.00	$64.00	$44.39	$21.19	$24.74	$29.15	$29.15	$83.20	$80.26	$43.96	$91.26	$43.52	$21.19	$91.26
3000143	CLOSTRIDIUM DIFFICILE (R)	300	Lab	306	87230	$261.00	$130.50	$130.50	$90.51	$48.36	$56.46	$66.52	$66.52	$169.65	$163.65	$89.63	$186.09	$88.74	$48.36	$186.09
3000226	HEP B SURF AG W/CONF (R)	300	Lab	306	87340	$73.00	$36.50	$36.50	$25.32	$25.31	$29.54	$34.81	$34.81	$47.45	$45.77	$25.07	$52.05	$24.82	$24.82	$52.05
3000617	CMV DNA BY PCR QN	300	Lab	306	87497	$842.00	$421.00	$421.00	$292.01	$104.96	$122.52	$144.37	$144.37	$547.30	$527.93	$289.14	$600.35	$286.28	$104.96	$600.35
3000990	COVID-19 (RL)	300	Lab	306	87635	$255.00	$127.50	$127.50	$88.43	$125.71	$146.75	$172.91	$172.91	$165.75	$159.89	$87.57	$181.82	$86.70	$86.70	$181.82
3000948	Influenza A	300	Lab	306	87804	$85.00	$42.50	$42.50	$29.48	$40.55	$47.33	$55.77	$55.77	$55.25	$53.30	$29.19	$60.61	$28.90	$28.90	$60.61
3000949	Influenza B	300	Lab	306	87804	$85.00	$42.50	$42.50	$29.48	$40.55	$47.33	$55.77	$55.77	$55.25	$53.30	$29.19	$60.61	$28.90	$28.90	$60.61
3000748	RSV Screen, IA	300	Lab	306	87807	$98.00	$49.00	$49.00	$33.99	$32.10	$37.47	$44.15	$44.15	$63.70	$61.45	$33.65	$69.87	$33.32	$32.10	$69.87
3000186	STREPTOCOCCUS GROUP A	300	Lab	306	87880	$77.00	$38.50	$38.50	$26.70	$40.50	$47.28	$55.71	$55.71	$50.05	$48.28	$26.44	$54.90	$26.18	$26.18	$55.71
3000702	CYTO THIN PREP (Pap Smear) (R)	300	Lab	310	88175	$225.00	$112.50	$112.50	$78.03	$65.19	$76.10	$89.68	$89.68	$146.25	$141.08	$77.27	$160.43	$76.50	$65.19	$160.43
3000703	TISSUE PATHOLOGY REPORT	300	Lab	310	88302	$102.00	$51.00	$51.00	$35.37	$56.33	$65.75	$77.48	$77.48	$66.30	$63.95	$35.03	$72.73	$34.68	$34.68	$77.48
3000405	WBC STOOL (RL)	300	Lab	300	89055	$44.00	$22.00	$22.00	$15.26	$10.46	$12.21	$14.39	$14.39	$28.60	$27.59	$15.11	$31.37	$14.96	$10.46	$31.37
3000194	PHLEBOTOMY THEREPEUTIC	300	Lab	940	99195	$306.00	$153.00	$153.00	$106.12	$174.45	$215.88	$254.04	$254.04	$198.90	$191.86	$105.08	$218.18	$104.04	$104.04	$254.04
3000269	PSA SCREENING	300	Lab	309	G0103	$180.00	$90.00	$90.00	$62.42	$47.31	$55.23	$65.07	$65.07	$117.00	$112.86	$61.81	$128.34	$61.20	$47.31	$128.34
3000991	COVID-19 (STATE_CDC)	300	Lab	306	U0001	$153.00	$76.50	$76.50	$53.06	$88.00	$102.73	$121.05	$121.05	$99.45	$95.93	$52.54	$109.09	$52.02	$52.02	$121.05
4200015	Electric Stem/Manual	420	Physical Therapy	420	97032	$143.00	$71.50	$71.50	$49.59	$24.22	$29.98	$35.28	$35.28	$92.95	$89.66	$49.11	$101.96	$48.62	$24.22	$101.96
4200025	IONTOPHORESIS EA 15 MI	420	Physical Therapy	420	97033	$77.00	$38.50	$38.50	$26.70	$34.02	$42.09	$49.54	$49.54	$50.05	$48.28	$26.44	$54.90	$26.18	$26.18	$54.90
4200003	EXERCISE/PRO EACH 15 M	420	Physical Therapy	420	97110	$102.00	$51.00	$51.00	$35.37	$50.16	$62.07	$73.05	$73.05	$66.30	$63.95	$35.03	$72.73	$34.68	$34.68	$73.05
4200049	NEUROMUSCULAR RE-ED	420	Physical Therapy	420	97112	$102.00	$51.00	$51.00	$35.37	$57.09	$70.65	$83.13	$83.13	$66.30	$63.95	$35.03	$72.73	$34.68	$34.68	$83.13
4200006	GAIT TRAINING EA 15 M	420	Physical Therapy	420	97116	$92.00	$46.00	$46.00	$31.91	$49.58	$61.36	$72.21	$72.21	$59.80	$57.68	$31.59	$65.60	$31.28	$31.28	$72.21
4200037	TRACTION MANUAL EA 15	420	Physical Therapy	420	97140	$82.00	$41.00	$41.00	$28.44	$45.55	$56.37	$66.34	$66.34	$53.30	$51.41	$28.16	$58.47	$27.88	$27.88	$66.34
4200031	PT Eval Low Complexity 20 Mins	420	Physical Therapy	424	97161	$260.00	$130.00	$130.00	$90.17	$138.38	$171.25	$201.52	$201.52	$169.00	$163.02	$89.28	$185.38	$88.40	$88.40	$201.52
4200032	PT Eval Moderate Complexity 30 Min	420	Physical Therapy	424	97162	$230.00	$115.00	$115.00	$79.76	$138.38	$171.25	$201.52	$201.52	$149.50	$144.21	$78.98	$163.99	$78.20	$78.20	$201.52
4200033	PT Eval High Complexity 45 Mins	420	Physical Therapy	424	97163	$230.00	$115.00	$115.00	$79.76	$138.38	$171.25	$201.52	$201.52	$149.50	$144.21	$78.98	$163.99	$78.20	$78.20	$201.52
4200050	THERAPEUTIC ACTIVITY	420	Physical Therapy	420	97530	$102.00	$51.00	$51.00	$35.37	$65.15	$80.63	$94.88	$94.88	$66.30	$63.95	$35.03	$72.73	$34.68	$34.68	$94.88
42097597	REMOVE DEVITAL TISS 20 CM/<	420	Physical Therapy	420	97597	$224.00	$112.00	$112.00	$77.68	$39.22	$48.53	$57.11	$57.11	$145.60	$140.45	$76.92	$159.71	$76.16	$39.22	$159.71
42097598	REMOVE DEVITAL TISS WN Add'l 20	420	Physical Therapy	420	97598	$82.00	$41.00	$41.00	$28.44	$18.45	$22.83	$26.86	$26.86	$53.30	$51.41	$28.16	$58.47	$27.88	$18.45	$58.47
4200014	ELECTRIC STEM/MOD 1	420	Physical Therapy	420	G0283	$47.00	$23.50	$23.50	$16.30	$23.07	$28.55	$33.60	$33.60	$30.55	$29.47	$16.14	$33.51	$15.98	$15.98	$33.60
3200094	SKULL COMPLETE 4+V	320	Radiology	320	70260	$335.00	$167.50	$167.50	$116.18	$141.22	$149.07	$174.84	$174.84	$217.75	$210.05	$115.04	$238.86	$113.90	$113.90	$238.86
3200192	NECK, SOFT TISSUE 2 VI	320	Radiology	320	70360	$189.00	$94.50	$94.50	$65.55	$100.56	$106.15	$124.50	$124.50	$122.85	$118.50	$64.90	$134.76	$64.26	$64.26	$134.76
3500141	CT HEAD WITHOUT CONT.	320	Radiology	351	70450	$1,530.00	$765.00	$765.00	$530.60	$354.17	$381.07	$448.32	$448.32	$575.00	$959.31	$525.40	$1,090.89	$520.20	$354.17	$1,090.89
3500187	CT FACIAL WO/CONTRAST	320	Radiology	351	70486	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500233	CT SINUSES	320	Radiology	351	70486	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500186	CT FACIAL W/CONTRAST	320	Radiology	351	70487	$1,175.00	$587.50	$587.50	$407.49	$575.82	$619.55	$728.88	$728.88	$575.00	$736.73	$403.50	$837.78	$399.50	$399.50	$837.78
3500191	CT NECK WO/CONTRAST	320	Radiology	351	70490	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500190	CT NECK W/WO CONTRAST	320	Radiology	351	70492	$2,762.00	$1,381.00	$1,381.00	$957.86	$575.82	$619.55	$728.88	$728.88	$575.00	$1,731.77	$948.47	$1,969.31	$939.08	$575.00	$1,969.31
3500243	MRI BRAIN With & W/O CONTRAST	320	Radiology	610	70553	$2,758.00	$1,379.00	$1,379.00	$956.47	$1,206.65	$1,298.29	$1,527.40	$1,527.40	$650.00	$1,729.27	$947.10	$1,966.45	$937.72	$650.00	$1,966.45
6100015	MRI BRAIN W&WO CONT	320	Radiology	611	70553	$2,758.00	$1,379.00	$1,379.00	$956.47	$1,206.65	$1,298.29	$1,527.40	$1,527.40	$650.00	$1,729.27	$947.10	$1,966.45	$937.72	$650.00	$1,966.45
3200015	CHEST 1 VIEW	320	Radiology	324	71045	$189.00	$94.50	$94.50	$65.55	$100.56	$106.15	$124.50	$124.50	$122.85	$118.50	$64.90	$134.76	$64.26	$64.26	$134.76
3200016	CHEST 2 VIEWS	320	Radiology	324	71046	$241.00	$120.50	$120.50	$83.58	$100.56	$106.15	$124.50	$124.50	$156.65	$151.11	$82.76	$171.83	$81.94	$81.94	$171.83
3200079	RIBS UNILAT MIN 2 VIEWS	320	Radiology	320	71100	$236.00	$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
3200079R	RIBS UNILAT MIN 2 VIEWS	320	Radiology	320	71100	$236.00	$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
3200080	RIBS UNILATERAL 2V	320	Radiology	320	71100	$236.00	$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
3200080R	RIBS UNILATERAL 2V	320	Radiology	320	71100	$236.00	$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
3200196	RIBS MIN 3 VIEW/AP CHEST	320	Radiology	320	71101	$252.00	$126.00	$126.00	$87.39	$141.22	$149.07	$174.84	$174.84	$163.80	$158.00	$86.54	$179.68	$85.68	$85.68	$179.68
3200196R	Ribs 3 views w/AP Chest; Right	320	Radiology	320	71101	$252.00	$126.00	$126.00	$87.39	$141.22	$149.07	$174.84	$174.84	$163.80	$158.00	$86.54	$179.68	$85.68	$85.68	$179.68
3200078	RIBS BILAT 3V	320	Radiology	320	71110	$295.00	$147.50	$147.50	$102.31	$141.22	$149.07	$174.84	$174.84	$191.75	$184.97	$101.30	$210.34	$100.30	$100.30	$210.34
Sabine County Hospital Shoppable Services for Charge Description Master As of 7/15/2023
Charge Number	Description	Dept	Dept Description	Rev Code	CPT Code	Price	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
3200188	RIBS/CHEST MIN 4 VIEW	320	Radiology	320	71111	$372.00	$186.00	$186.00	$129.01	$141.22	$149.07	$174.84	$174.84	$241.80	$233.24	$127.74	$265.24	$126.48	$126.48	$265.24
3500140	CT CHEST W/O CONTRAST	320	Radiology	352	71250	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500163	CT CHEST WITH CONTRAS	320	Radiology	352	71260	$1,841.00	$920.50	$920.50	$638.46	$575.82	$619.55	$728.88	$728.88	$575.00	$1,154.31	$632.20	$1,312.63	$625.94	$575.00	$1,312.63
3500143	CT CHEST W/WO CONTRAS	320	Radiology	352	71270	$1,640.00	$820.00	$820.00	$568.75	$575.82	$619.55	$728.88	$728.88	$575.00	$1,028.28	$563.18	$1,169.32	$557.60	$557.60	$1,169.32
3500241	CT ANGIO CHEST W/WO	320	Radiology	352	71275	$1,734.00	$867.00	$867.00	$601.35	$575.82	$619.55	$728.88	$728.88	$575.00	$1,087.22	$595.46	$1,236.34	$589.56	$575.00	$1,236.34
3200097	SPINE CERVICAL 2V or 3V	320	Radiology	320	72040	$239.00	$119.50	$119.50	$82.89	$100.56	$106.15	$124.50	$124.50	$155.35	$149.85	$82.07	$170.41	$81.26	$81.26	$170.41
3200098	SPINE C 4+V	320	Radiology	320	72050	$374.00	$187.00	$187.00	$129.70	$141.22	$149.07	$174.84	$174.84	$243.10	$234.50	$128.43	$266.66	$127.16	$127.16	$266.66
3200100	SPINE THORACIX 2 VIEW	320	Radiology	320	72070	$239.00	$119.50	$119.50	$82.89	$141.22	$149.07	$174.84	$174.84	$155.35	$149.85	$82.07	$170.41	$81.26	$81.26	$174.84
3200180	SPINE THORACIX W/SWIMM	320	Radiology	320	72072	$302.00	$151.00	$151.00	$104.73	$141.22	$149.07	$174.84	$174.84	$196.30	$189.35	$103.71	$215.33	$102.68	$102.68	$215.33
3200198	SCOLIOSIS STANDING SER	320	Radiology	320	72082	$241.00	$120.50	$120.50	$83.58	$141.22	$149.07	$174.84	$174.84	$156.65	$151.11	$82.76	$171.83	$81.94	$81.94	$174.84
3200103	SPINE LUMBAR 2V OR 3V	320	Radiology	320	72100	$306.00	$153.00	$153.00	$106.12	$141.22	$149.07	$174.84	$174.84	$198.90	$191.86	$105.08	$218.18	$104.04	$104.04	$218.18
3200104	SPINE LUMBAR COMP SER MIN 4 V	320	Radiology	320	72110	$395.00	$197.50	$197.50	$136.99	$141.22	$149.07	$174.84	$174.84	$256.75	$247.67	$135.64	$281.64	$134.30	$134.30	$281.64
3500197	CT C-SPINE WO CONTRAST	320	Radiology	352	72125	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500200	CT T-SPINE WO/CONTRAST	320	Radiology	352	72128	$1,331.00	$665.50	$665.50	$461.59	$354.17	$381.07	$448.32	$448.32	$575.00	$834.54	$457.07	$949.00	$452.54	$354.17	$949.00
3500198	CT L-SPINE W0/ CONTRAS	320	Radiology	352	72131	$1,530.00	$765.00	$765.00	$530.60	$354.17	$381.07	$448.32	$448.32	$575.00	$959.31	$525.40	$1,090.89	$520.20	$354.17	$1,090.89
6100024	MRI C-SPINE WO CONT	320	Radiology	612	72141	$2,064.00	$1,032.00	$1,032.00	$715.80	$736.41	$792.34	$932.16	$932.16	$650.00	$1,294.13	$708.78	$1,471.63	$701.76	$650.00	$1,471.63
6100028	MRI L-SPINE WO CONT	320	Radiology	612	72148	$2,008.00	$1,004.00	$1,004.00	$696.37	$736.41	$792.34	$932.16	$932.16	$650.00	$1,259.02	$689.55	$1,431.70	$682.72	$650.00	$1,431.70
3200072	PELVIS 1V	320	Radiology	320	72170	$306.00	$153.00	$153.00	$106.12	$141.22	$149.07	$174.84	$174.84	$198.90	$191.86	$105.08	$218.18	$104.04	$104.04	$218.18
3500151	CT PELVIS WITHOUT CO	320	Radiology	352	72192	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500180	CT PELVIS W/CONTRAST	320	Radiology	352	72193	$1,841.00	$920.50	$920.50	$638.46	$575.82	$619.55	$728.88	$728.88	$575.00	$1,154.31	$632.20	$1,312.63	$625.94	$575.00	$1,312.63
3200082 SACRUM & COCCYX MIN 2 320			Radiology	320	72220	$399.00	$199.50	$199.50	$138.37	$100.56	$106.15	$124.50	$124.50	$259.35	$250.17	$137.02	$284.49	$135.66	$100.56	$284.49
3200021 CLAVICLE 2 VIEWS 320			Radiology	320	73000	$203.00	$101.50	$101.50	$70.40	$100.56	$106.15	$124.50	$124.50	$131.95	$127.28	$69.71	$144.74	$69.02	$69.02	$144.74
3200085 SCAPULA CMPLTE 2V 320			Radiology	320	73010	$195.00	$97.50	$97.50	$67.63	$141.22	$149.07	$174.84	$174.84	$126.75	$122.27	$66.96	$139.04	$66.30	$66.30	$174.84
3200085R Scapula Complete 2 view; Right 320			Radiology	320	73010	$195.00	$97.50	$97.50	$67.63	$141.22	$149.07	$174.84	$174.84	$126.75	$122.27	$66.96	$139.04	$66.30	$66.30	$174.84
3200253 Shoulder xray 2v; bilateral 320			Radiology	320	73030	$168.00	$84.00	$84.00	$58.26	$100.56	$106.15	$124.50	$124.50	$109.20	$105.34	$57.69	$119.78	$57.12	$57.12	$124.50
3200089 SHOULDER 2 V 320			Radiology	320	73030	$449.00	$224.50	$224.50	$155.71	$100.56	$106.15	$124.50	$124.50	$291.85	$281.52	$154.19	$320.14	$152.66	$100.56	$320.14
3200089R SHOULDER 2 V 320			Radiology	320	73030	$449.00	$224.50	$224.50	$155.71	$100.56	$106.15	$124.50	$124.50	$291.85	$281.52	$154.19	$320.14	$152.66	$100.56	$320.14
3200055 HUMERUS 2V 320			Radiology	320	73060	$415.00	$207.50	$207.50	$143.92	$100.56	$106.15	$124.50	$124.50	$269.75	$260.21	$142.51	$295.90	$141.10	$100.56	$295.90
3200055R HUMERUS 2V 320			Radiology	320	73060	$415.00	$207.50	$207.50	$143.92	$100.56	$106.15	$124.50	$124.50	$269.75	$260.21	$142.51	$295.90	$141.10	$100.56	$295.90
3200214 Humerus Bilateral Xray min 2views 320			Radiology	320	73060	$415.00	$207.50	$207.50	$143.92	$100.56	$106.15	$124.50	$124.50	$269.75	$260.21	$142.51	$295.90	$141.10	$100.56	$295.90
3200028 ELBOW 2V 320			Radiology	320	73070	$338.00	$169.00	$169.00	$117.22	$100.56	$106.15	$124.50	$124.50	$219.70	$211.93	$116.07	$240.99	$114.92	$100.56	$240.99
3200028R ELBOW 2V 320			Radiology	320	73070	$338.00	$169.00	$169.00	$117.22	$100.56	$106.15	$124.50	$124.50	$219.70	$211.93	$116.07	$240.99	$114.92	$100.56	$240.99
3200215 Elbow Bilateral Xray 2views 320			Radiology	320	73070	$338.00	$169.00	$169.00	$117.22	$100.56	$106.15	$124.50	$124.50	$219.70	$211.93	$116.07	$240.99	$114.92	$100.56	$240.99
3200232 Elbow Complete X Min 3V 320			Radiology	320	73080	$168.00	$84.00	$84.00	$58.26	$100.56	$106.15	$124.50	$124.50	$109.20	$105.34	$57.69	$119.78	$57.12	$57.12	$124.50
3200232R Elbow Complete X Min 3V 320			Radiology	320	73080	$168.00	$84.00	$84.00	$58.26	$100.56	$106.15	$124.50	$124.50	$109.20	$105.34	$57.69	$119.78	$57.12	$57.12	$124.50
3200042 FOREARM 2V 320			Radiology	320	73090	$375.00	$187.50	$187.50	$130.05	$100.56	$106.15	$124.50	$124.50	$243.75	$235.13	$128.78	$267.38	$127.50	$100.56	$267.38
3200042R FOREARM 2V 320			Radiology	320	73090	$375.00	$187.50	$187.50	$130.05	$100.56	$106.15	$124.50	$124.50	$243.75	$235.13	$128.78	$267.38	$127.50	$100.56	$267.38
3200216 Forearm Bilateral Xray 2views 320			Radiology	320	73090	$375.00	$187.50	$187.50	$130.05	$100.56	$106.15	$124.50	$124.50	$243.75	$235.13	$128.78	$267.38	$127.50	$100.56	$267.38
3200201 WRIST TWO VIEWS 320			Radiology	320	73100	$298.00	$149.00	$149.00	$103.35	$100.56	$106.15	$124.50	$124.50	$193.70	$186.85	$102.33	$212.47	$101.32	$100.56	$212.47
3200201R WRIST TWO VIEWS 320			Radiology	320	73100	$298.00	$149.00	$149.00	$103.35	$100.56	$106.15	$124.50	$124.50	$193.70	$186.85	$102.33	$212.47	$101.32	$100.56	$212.47
3200217 Wrist Bilateral Xray 2views 320			Radiology	320	73100	$298.00	$149.00	$149.00	$103.35	$100.56	$106.15	$124.50	$124.50	$193.70	$186.85	$102.33	$212.47	$101.32	$100.56	$212.47
3200130 WRIST 3 VIEWS 320			Radiology	320	73110	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200130R WRIST 3 VIEWS 320			Radiology	320	73110	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200218 Wrist Bilateral Complete Xray min 3vie 320			Radiology	320	73110	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200202 HAND 2 VIEWS 320			Radiology	320	73120	$332.00	$166.00	$166.00	$115.14	$141.22	$149.07	$174.84	$174.84	$215.80	$208.16	$114.01	$236.72	$112.88	$112.88	$236.72
3200202R HAND 2 VIEWS 320			Radiology	320	73120	$332.00	$166.00	$166.00	$115.14	$141.22	$149.07	$174.84	$174.84	$215.80	$208.16	$114.01	$236.72	$112.88	$112.88	$236.72
3200219 Hand Bilateral Xray 2views 320			Radiology	320	73120	$332.00	$166.00	$166.00	$115.14	$141.22	$149.07	$174.84	$174.84	$215.80	$208.16	$114.01	$236.72	$112.88	$112.88	$236.72
3200048 HAND 3 V 320			Radiology	320	73130	$381.00	$190.50	$190.50	$132.13	$100.56	$106.15	$124.50	$124.50	$247.65	$238.89	$130.84	$271.65	$129.54	$100.56	$271.65
3200048R HAND 3 V 320			Radiology	320	73130	$381.00	$190.50	$190.50	$132.13	$100.56	$106.15	$124.50	$124.50	$247.65	$238.89	$130.84	$271.65	$129.54	$100.56	$271.65
3200220 Hand Bilateral Xray min 3view 320			Radiology	320	73130	$381.00	$190.50	$190.50	$132.13	$100.56	$106.15	$124.50	$124.50	$247.65	$238.89	$130.84	$271.65	$129.54	$100.56	$271.65
3200246 Fingers xray 2v; left 320			Radiology	320	73140	$142.00	$71.00	$71.00	$49.25	$100.56	$106.15	$124.50	$124.50	$92.30	$89.03	$48.76	$101.25	$48.28	$48.28	$124.50
3200246R Fingers xray 2v; right 320			Radiology	320	73140	$142.00	$71.00	$71.00	$49.25	$100.56	$106.15	$124.50	$124.50	$92.30	$89.03	$48.76	$101.25	$48.28	$48.28	$124.50
3200038 FINGER(S) 3 VIEW 320			Radiology	320	73140	$344.00	$172.00	$172.00	$119.30	$100.56	$106.15	$124.50	$124.50	$223.60	$215.69	$118.13	$245.27	$116.96	$100.56	$245.27
3200038R FINGER(S) 3 VIEW 320			Radiology	320	73140	$344.00	$172.00	$172.00	$119.30	$100.56	$106.15	$124.50	$124.50	$223.60	$215.69	$118.13	$245.27	$116.96	$100.56	$245.27
3500168 CT UPPER JOINT WO/CONT		320	Radiology	352	73200	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500168R CT Upper Joint w/o contrast; Right		320	Radiology	352	73200	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3200051 HIP JOINT 2 VIEWS UNIL		320	Radiology	320	73502	$215.00	$107.50	$107.50	$74.56	$100.56	$106.15	$124.50	$124.50	$139.75	$134.81	$73.83	$153.30	$73.10	$73.10	$153.30
Sabine County Hospital Shoppable Services for Charge Description Master As of 7/15/2023
Charge Number	Description	Dept	Dept Description	Rev Code	CPT Code	Price	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
3200051R HIP JOINT 2 VIEWS UNIL 320			Radiology	320	73502	$215.00	$107.50	$107.50	$74.56	$100.56	$106.15	$124.50	$124.50	$139.75	$134.81	$73.83	$153.30	$73.10	$73.10	$153.30
3200052 HIP JOINT BILATERAL CO 320			Radiology	320	73521	$258.00	$129.00	$129.00	$89.47	$141.22	$149.07	$174.84	$174.84	$167.70	$161.77	$88.60	$183.95	$87.72	$87.72	$183.95
3200035 FEMUR 2 V 320			Radiology	320	73552	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200035R FEMUR 2 V 320			Radiology	320	73552	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200222 Femur Bilateral Xray 2views 320			Radiology	320	73552	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200250 Knee xray 2v; bilateral 320			Radiology	320	73560	$168.00	$84.00	$84.00	$58.26	$100.56	$106.15	$124.50	$124.50	$109.20	$105.34	$57.69	$119.78	$57.12	$57.12	$124.50
3200004 KNEE 1-2 V 320			Radiology	320	73560	$377.00	$188.50	$188.50	$130.74	$100.56	$106.15	$124.50	$124.50	$245.05	$236.38	$129.46	$268.80	$128.18	$100.56	$268.80
3200004R KNEE 1-2 V 320			Radiology	320	73560	$377.00	$188.50	$188.50	$130.74	$100.56	$106.15	$124.50	$124.50	$245.05	$236.38	$129.46	$268.80	$128.18	$100.56	$268.80
3200211 KNEE 3V 320			Radiology	320	73562	$480.00	$240.00	$240.00	$166.46	$100.56	$106.15	$124.50	$124.50	$312.00	$300.96	$164.83	$342.24	$163.20	$100.56	$342.24
3200211R KNEE 3V 320			Radiology	320	73562	$480.00	$240.00	$240.00	$166.46	$100.56	$106.15	$124.50	$124.50	$312.00	$300.96	$164.83	$342.24	$163.20	$100.56	$342.24
3200224 Knee Bilateral Xray 3views 320			Radiology	320	73562	$480.00	$240.00	$240.00	$166.46	$100.56	$106.15	$124.50	$124.50	$312.00	$300.96	$164.83	$342.24	$163.20	$100.56	$342.24
3200058 KNEE COMPLETE 4+V 320			Radiology	320	73564	$288.00	$144.00	$144.00	$99.88	$141.22	$149.07	$174.84	$174.84	$187.20	$180.58	$98.90	$205.34	$97.92	$97.92	$205.34
3200058R KNEE COMPLETE 4+V 320			Radiology	320	73564	$288.00	$144.00	$144.00	$99.88	$141.22	$149.07	$174.84	$174.84	$187.20	$180.58	$98.90	$205.34	$97.92	$97.92	$205.34
3200225 Knee Bilateral Completel Xray min 4vi 320			Radiology	320	73564	$288.00	$144.00	$144.00	$99.88	$141.22	$149.07	$174.84	$174.84	$187.20	$180.58	$98.90	$205.34	$97.92	$97.92	$205.34
3200062 LEG 2 V 320			Radiology	320	73590	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200062R LEG 2 V 320			Radiology	320	73590	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200226 Leg Bilateral Xray 2views 320			Radiology	320	73590	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200206 ANKLE 2 VIEWS 320			Radiology	320	73600	$357.00	$178.50	$178.50	$123.81	$100.56	$106.15	$124.50	$124.50	$232.05	$223.84	$122.59	$254.54	$121.38	$100.56	$254.54
3200206R ANKLE 2 VIEWS 320			Radiology	320	73600	$357.00	$178.50	$178.50	$123.81	$100.56	$106.15	$124.50	$124.50	$232.05	$223.84	$122.59	$254.54	$121.38	$100.56	$254.54
3200227 Ankle Bilateral Xray 2views 320			Radiology	320	73600	$357.00	$178.50	$178.50	$123.81	$100.56	$106.15	$124.50	$124.50	$232.05	$223.84	$122.59	$254.54	$121.38	$100.56	$254.54
3200009 ANKLE MIN 3 VIEWS 320			Radiology	320	73610	$437.00	$218.50	$218.50	$151.55	$100.56	$106.15	$124.50	$124.50	$284.05	$274.00	$150.07	$311.58	$148.58	$100.56	$311.58
3200009R ANKLE MIN 3 VIEWS 320			Radiology	320	73610	$437.00	$218.50	$218.50	$151.55	$100.56	$106.15	$124.50	$124.50	$284.05	$274.00	$150.07	$311.58	$148.58	$100.56	$311.58
3200044 ANKLE 4 VIEWS 320			Radiology	320	73610	$437.00	$218.50	$218.50	$151.55	$100.56	$106.15	$124.50	$124.50	$284.05	$274.00	$150.07	$311.58	$148.58	$100.56	$311.58
3200044R ANKLE 4 VIEWS 320			Radiology	320	73610	$437.00	$218.50	$218.50	$151.55	$100.56	$106.15	$124.50	$124.50	$284.05	$274.00	$150.07	$311.58	$148.58	$100.56	$311.58
3200228 Ankle Bilateral Complete Xray min 3vie 320			Radiology	320	73610	$437.00	$218.50	$218.50	$151.55	$100.56	$106.15	$124.50	$124.50	$284.05	$274.00	$150.07	$311.58	$148.58	$100.56	$311.58
3200207 FOOT 2 VIEWS 320			Radiology	320	73620	$312.00	$156.00	$156.00	$108.20	$100.56	$106.15	$124.50	$124.50	$202.80	$195.62	$107.14	$222.46	$106.08	$100.56	$222.46
3200207R FOOT 2 VIEWS 320			Radiology	320	73620	$312.00	$156.00	$156.00	$108.20	$100.56	$106.15	$124.50	$124.50	$202.80	$195.62	$107.14	$222.46	$106.08	$100.56	$222.46
3200229 Foot Bilateral Xray 2views 320			Radiology	320	73620	$367.00	$183.50	$183.50	$127.28	$100.56	$106.15	$124.50	$124.50	$238.55	$230.11	$126.03	$261.67	$124.78	$100.56	$261.67
3200041 FOOT 3+V 320			Radiology	320	73630	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200041R FOOT 3+V 320			Radiology	320	73630	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200230 Foot Bilateral Complete Xray min 3vie 320			Radiology	320	73630	$424.00	$212.00	$212.00	$147.04	$100.56	$106.15	$124.50	$124.50	$275.60	$265.85	$145.60	$302.31	$144.16	$100.56	$302.31
3200254 Toes xray 2v; left 320			Radiology	320	73660	$179.00	$89.50	$89.50	$62.08	$100.56	$106.15	$124.50	$124.50	$116.35	$112.23	$61.47	$127.63	$60.86	$60.86	$127.63
3200254R Toes xray 2v; Right 320			Radiology	320	73660	$179.00	$89.50	$89.50	$62.08	$100.56	$106.15	$124.50	$124.50	$116.35	$112.23	$61.47	$127.63	$60.86	$60.86	$127.63
3200111 TOE(S) 3V 320			Radiology	320	73660	$344.00	$172.00	$172.00	$119.30	$100.56	$106.15	$124.50	$124.50	$223.60	$215.69	$118.13	$245.27	$116.96	$100.56	$245.27
3200111R TOE(S) 3V 320			Radiology	320	73660	$344.00	$172.00	$172.00	$119.30	$100.56	$106.15	$124.50	$124.50	$223.60	$215.69	$118.13	$245.27	$116.96	$100.56	$245.27
3500169 CT LOWER JOINT WO CONT 320			Radiology	352	73700	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500169R CT Lower Joint w/o contrast; Right 320			Radiology	352	73700	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
6100070 MRI LOW EXTREM JT WO C 320			Radiology	614	73721	$2,753.00	$1,376.50	$1,376.50	$954.74	$736.41	$792.34	$932.16	$932.16	$650.00	$1,726.13	$945.38	$1,962.89	$936.02	$650.00	$1,962.89
6100072 MRI LOW EXTREM JT WO C 320			Radiology	610	73721	$2,753.00	$1,376.50	$1,376.50	$954.74	$736.41	$792.34	$932.16	$932.16	$650.00	$1,726.13	$945.38	$1,962.89	$936.02	$650.00	$1,962.89
6100072R MRI LOW EXTREM JT WO C 320			Radiology	610	73721	$2,753.00	$1,376.50	$1,376.50	$954.74	$736.41	$792.34	$932.16	$932.16	$650.00	$1,726.13	$945.38	$1,962.89	$936.02	$650.00	$1,962.89
3200001 ABDOMEN 1 VIEW 320			Radiology	320	74018	$169.00	$84.50	$84.50	$58.61	$100.56	$106.15	$124.50	$124.50	$109.85	$105.96	$58.03	$120.50	$57.46	$57.46	$124.50
3200057 KUB 1 V 320			Radiology	320	74018	$169.00	$84.50	$84.50	$58.61	$100.56	$106.15	$124.50	$124.50	$109.85	$105.96	$58.03	$120.50	$57.46	$57.46	$124.50
3200057R KUB 1 V 320			Radiology	320	74018	$169.00	$84.50	$84.50	$58.61	$100.56	$106.15	$124.50	$124.50	$109.85	$105.96	$58.03	$120.50	$57.46	$57.46	$124.50
3200002 ABDOMEN 2 VIEWS 320			Radiology	320	74019	$306.00	$153.00	$153.00	$106.12	$141.22	$149.07	$174.84	$174.84	$198.90	$191.86	$105.08	$218.18	$104.04	$104.04	$218.18
3200003 ABDOMEN 3 VIEWS 320			Radiology	320	74022	$346.00	$173.00	$173.00	$119.99	$141.22	$149.07	$174.84	$174.84	$224.90	$216.94	$118.82	$246.70	$117.64	$117.64	$246.70
3500167 CT ABDOMEN WITHOUT CON		320	Radiology	352	74150	$1,496.00	$748.00	$748.00	$518.81	$354.17	$381.07	$448.32	$448.32	$575.00	$937.99	$513.73	$1,066.65	$508.64	$354.17	$1,066.65
3500179 CT ABDOMEN W/CONTRAST		320	Radiology	352	74160	$1,841.00	$920.50	$920.50	$638.46	$575.82	$619.55	$728.88	$728.88	$575.00	$1,154.31	$632.20	$1,312.63	$625.94	$575.00	$1,312.63
3500245 CT ABDOMEN/PELVIS W/O		320	Radiology	352	74176	$2,142.00	$1,071.00	$1,071.00	$742.85	$736.41	$792.34	$932.16	$932.16	$575.00	$1,343.03	$735.56	$1,527.25	$728.28	$575.00	$1,527.25
3500246 CT ABDOMEN/PELVIS W/CO		320	Radiology	352	74177	$2,346.00	$1,173.00	$1,173.00	$813.59	$1,206.65	$1,298.29	$1,527.40	$1,527.40	$575.00	$1,470.94	$805.62	$1,672.70	$797.64	$575.00	$1,672.70
3500247 CT ABDOMEN/PELVIS W/WO		320	Radiology	352	74178	$3,468.00	$1,734.00	$1,734.00	$1,202.70	$1,206.65	$1,298.29	$1,527.40	$1,527.40	$575.00	$2,174.44	$1,190.91	$2,472.68	$1,179.12	$575.00	$2,472.68
4000200 THYROID SOFT TISSUE US		320	Radiology	402	76536	$453.00	$226.50	$226.50	$157.10	$141.22	$149.07	$174.84	$174.84	$150.00	$284.03	$155.56	$322.99	$154.02	$141.22	$322.99
4000184 ABDOMEN COMPLETE US		320	Radiology	402	76700	$550.00	$275.00	$275.00	$190.74	$141.22	$149.07	$174.84	$174.84	$150.00	$344.85	$188.87	$392.15	$187.00	$141.22	$392.15
4000188 GALLBLADDER US		320	Radiology	402	76705	$481.00	$240.50	$240.50	$166.81	$141.22	$149.07	$174.84	$174.84	$150.00	$301.59	$165.18	$342.95	$163.54	$141.22	$342.95
4000191 PANCREAS US		320	Radiology	402	76705	$481.00	$240.50	$240.50	$166.81	$141.22	$149.07	$174.84	$174.84	$150.00	$301.59	$165.18	$342.95	$163.54	$141.22	$342.95
4000199 LIVER US		320	Radiology	402	76705	$481.00	$240.50	$240.50	$166.81	$141.22	$149.07	$174.84	$174.84	$150.00	$301.59	$165.18	$342.95	$163.54	$141.22	$342.95
4000202 SINGLE ORGAN		320	Radiology	402	76705	$481.00	$240.50	$240.50	$166.81	$141.22	$149.07	$174.84	$174.84	$150.00	$301.59	$165.18	$342.95	$163.54	$141.22	$342.95
4000185 ABDOMINAL AORTA US		320	Radiology	402	76770	$481.00	$240.50	$240.50	$166.81	$141.22	$149.07	$174.84	$174.84	$150.00	$301.59	$165.18	$342.95	$163.54	$141.22	$342.95
Sabine County Hospital Shoppable Services for Charge Description Master As of 7/15/2023
Charge Number	Description	Dept	Dept Description	Rev Code	CPT Code	Price	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
4000196	RENAL COMPLETE US	320	Radiology	402	76770	$481.00	$240.50	$240.50	$166.81	$141.22	$149.07	$174.84	$174.84	$150.00	$301.59	$165.18	$342.95	$163.54	$141.22	$342.95
4000209	PREGNANCY US > 14 WKS	320	Radiology	402	76805	$459.00	$229.50	$229.50	$159.18	$115.34	$121.75	$142.80	$142.80	$150.00	$287.79	$157.62	$327.27	$156.06	$115.34	$327.27
4000207	PELVIC US TRANSVAG NON	320	Radiology	402	76830	$533.00	$266.50	$266.50	$184.84	$111.26	$117.44	$137.75	$137.75	$150.00	$334.19	$183.03	$380.03	$181.22	$111.26	$380.03
4000193	PELVIC US NON-OB LIMIT	320	Radiology	402	76857	$225.00	$112.50	$112.50	$78.03	$141.22	$149.07	$174.84	$174.84	$150.00	$141.08	$77.27	$160.43	$76.50	$76.50	$174.84
4000201	SCROTUM	320	Radiology	402	76870	$487.00	$243.50	$243.50	$168.89	$141.22	$149.07	$174.84	$174.84	$150.00	$305.35	$167.24	$347.23	$165.58	$141.22	$347.23
3200256	US Extremity non vascular; Rt	320	Radiology	402	76882	$418.00	$209.00	$209.00	$144.96	$141.22	$149.07	$174.84	$174.84	$150.00	$262.09	$143.54	$298.03	$142.12	$141.22	$298.03
3200257	Groin Ultrasound	320	Radiology	402	76882	$418.00	$209.00	$209.00	$144.96	$141.22	$149.07	$174.84	$174.84	$150.00	$262.09	$143.54	$298.03	$142.12	$141.22	$298.03
4000125	US, Limited, Joint or other nonvascula	320	Radiology	402	76882	$418.00	$209.00	$209.00	$144.96	$141.22	$149.07	$174.84	$174.84	$150.00	$262.09	$143.54	$298.03	$142.12	$141.22	$298.03
4000213	ECHO TTHRC R-T 2D W/WOM	320	Radiology	483	93306	$816.00	$408.00	$408.00	$282.99	$216.82	$268.31	$315.74	$315.74	$530.40	$511.63	$280.21	$581.81	$277.44	$216.82	$581.81
51081002	URINE DIPSTICK	521	Rural Health Clinic	521	81002	$15.00	$7.50	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$ -	$7.50
51093000	EKG COMPLETE	521	Rural Health Clinic	521	93000	$64.00	$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	$109.00	$ -	$212.66	$ -	$ -	$ -	$ -	$ -	$ -	$212.66	$ -	$212.66	$ -	$212.66

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}

2301 Worth Street Hemphill, TX 75948

409-787-3300

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