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 7/15/2023
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.
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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