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 NumberDescriptionDeptDept DescriptionRev CodeCPT CodePriceDiscounted Cash PriceAetna CommercialAetna Medicare AdvantageBCBS - Blue AdvantageBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAHumana CommercialHumana Medicare AdvantageUnited CommercialUnited Medicare AdvantageMinimum Negotiated PriceMaximum Negotiated Price
7300001#EKG 12 LEAD TRACING730EKG73093005$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
3000391BASIC METABOLIC PANEL,300Lab30180048$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
3000365ELECTROLYTES300Lab30180051$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
3000184COMPREHENSIVE METABOLI300Lab30180053$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
3000731CMP (RL)300Lab30180053$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
3000389LIPID PANEL300Lab30180061$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
3000732LIPID PANEL (RL)300Lab30180061$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
3000158RENAL FUNCTION PANEL300Lab30180069$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
3000292HEPATIC FUNCTION PAN300Lab30180076$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
3000212CARBAMAZEPINE(TEGRETOL300Lab30180156$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
3000207DIGOXIN LEVEL300Lab30180162$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
3000753DIGOXIN (RL)300Lab30180162$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
3000248VALPROIC ACID (R)300Lab30180164$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
3000429LEVETIRACETAM (R)300Lab30180177$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
3000312LITHIUM300Lab30180178$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
3000027PHENOBARBITAL QUANITAT300Lab30180184$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
3000387PRIMIDONE (RL)300Lab30180188$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
3000588RAPAMYCIN (SIROLIMUS)300Lab30080195$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
3000471TACROLIMUS (R)300Lab30180197$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
3000105VANCOMYCIN300Lab30180202$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
3000285DRUG SCREEN MULTI300Lab30180305$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
3000261Drug Test by Chem Analyzer_UDOA (300Lab30180307$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
3000009URINALYSIS300Lab30781001$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
3000977Urine Ictotest300Lab30781002$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
3000003Urine Dipstick300Lab30781003$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
3000017ALBUMIN;SERUM, PLASMA300Lab30182040$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
300085024hr Microalbu(R)300Lab30182043$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
3000711Microalbumin (Urine) Semi-QNT300Lab30182044$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
3000097MICRO ALBUMIN RAND UR w/o CR (300Lab30182044$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
3000415ALPHA-FETOPROTEIN SER300Lab30182105$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
3000166AMMONIA (R)300Lab30182140$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
3000022AMYLASE300Lab30182150$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
3000486ANGIOTENSION CONVERTIN300Lab30182164$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
3000028BILIRUBIN;BLOOD,TOTAL300Lab30182247$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
3000029BILIRUBIN BLOOD DIRECT300Lab30182248$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
3000328NEONATAL BILIRUBIN300Lab30182248$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
3000031OCCULT BLOOD GASTRIC300Lab30182271$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
3000695OCCULT BLOOD FE300Lab30182274$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
3000470VIT D 25 HYDROXYL-URIN300Lab30182306$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
3000523VIT D 25 OH LS/MS/MS (SERUM)(R)300Lab30182306$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
3000891CARDIQ VITD25(R)300Lab30182306$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
3000032CALCIUM300Lab30182310$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
3000767CALC, Totall (R)300Lab30182310$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
3000041CHOLESTEROL SERUM TOT300Lab30182465$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
3000043CREATINE KINASE (CK) (300Lab30182550$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 ONLY300Lab30182553$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
3000219CREATININE300Lab30182565$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
3000367CREATININE RAND URINE (R)300Lab30182570$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
3000903CREA RAND URN300Lab30182570$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
300090824 HR URN CREA300Lab30182570$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
3000270VITAMIN B12 (R)300Lab30182607$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
3000642VIT D I 25-DIHYDORXY300Lab30182652$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
3000685ESTRADIOL (RL)300Lab30182670$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
3000384FERRITIN (R)300Lab30182728$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
3000271FOLATE, SERUM (R)300Lab30182746$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
3000287FOLIC ACID RBC (RL)300Lab30182747$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
3000060GLUCOSE QUANT300Lab30182947$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 NumberDescriptionDeptDept DescriptionRev CodeCPT CodePriceDiscounted Cash PriceAetna CommercialAetna Medicare AdvantageBCBS - Blue AdvantageBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAHumana CommercialHumana Medicare AdvantageUnited CommercialUnited Medicare AdvantageMinimum Negotiated PriceMaximum Negotiated Price
3000591GLUCOSE-6-PHOSPHATE DE300Lab30182955$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
3000216GLUCOSE BLOOD BY GMD300Lab30182962$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
3000070GGT300Lab30182977$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
3000189FSH (R)300Lab30183001$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
3000355LH (R)300Lab30183002$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
3000243HEMOGLOBIN; GLYOSYLATE300Lab30183036$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
3000717HGB A1C W/Reflex to Glycomark (R)300Lab30183036$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
3000154IRON (RL)300Lab30183540$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
3000390TIBC (RL)300Lab30183550$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
3000558LACTATE PLASMA300Lab30183605$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
3000086LACTATE DEHYDROGENASE300Lab30183615$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
3000093LIPASE BLOOD300Lab30183690$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
3000098MAGNESIUM300Lab30183735$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
3000434BNP - Natriuretic Peptide300Lab30183880$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
3000766BNP (RL)300Lab30183880$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
3000981Cardio PROBNP(R)300Lab30183880$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
3000011METHYLMALONIC ACID(RL)300Lab30183921$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
3000024PTH INTACT (R)300Lab30183970$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
3000109PHOSPHORUS INORGANIC P300Lab30184100$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
3000111POTASSIUM; SERUM PLASM300Lab30184132$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
3000117PROGESTERONE (RL)300Lab30184144$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
3000356PROLACTIN (RL)300Lab30184146$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
3000150FREE PSA-B (RL)300Lab30184153$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
3000295PSA; TOTAL300Lab30184153$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
3000141FREE PSA-A (RL)300Lab30184154$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
3000310PROTEIN TOTAL UA w/o Creat (R)300Lab30184156$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
3000904PROTEIN URINE300Lab30184156$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
3000907PROTEIN 24HR UR300Lab30184156$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
3000605VITAMIN B6300Lab30184207$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
3000119SODIUM;SERUM PLASMA/WH300Lab30184295$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
3000466FREE TESTOSTERONE (RL)300Lab30184402$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
3000138TESTOSTERONE TOTAL (R)300Lab30184403$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
3000933TESTOST, TOT (R)300Lab30184403$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
3000308VITAMIN B1-THIAMINE (R300Lab30184425$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
3000768VIT B1, PLASMA300Lab30184425$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
3000350T-4 (THYROXINE) (R)300Lab30184436$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
3000042T-4 FREE (R)300Lab30184439$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
3000399TSH (R)300Lab30184443$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
3000744TSH W/RFLX FT4 (R)300Lab30184443$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
3000128SGOT300Lab30184450$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
3000129SGPT300Lab30184460$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
3000359TRANSFERRIN(RL)300Lab30184466$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
3000130TRIGLYCERIDES BLOOD300Lab30184478$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
3000163T-3 UPTAKE (R)300Lab30184479$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
3000063T3 TOTAL (RL)300Lab30184480$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
3000543T3 FREE300Lab30184481$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
3000162TROPONIN, QUANTITATIVE300Lab30184484$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
3000131BUN-UREA NITROGEN BLOOD300Lab30184520$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
3000132URIC ACID300Lab30184550$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
3000021C-PEPTIDE (RL)300Lab30184681$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
3000299BETA HCG SERUM (RL)300Lab30184702$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
3000074PREGNANCY TEST URINE300Lab30184703$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
3000168PREGNANCY TEST SERUM300Lab30184703$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
3000127MANUAL DIFFERENTIAL300Lab30585007$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
3000135HEMATOCRIT300Lab30585014$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
3000136HEMOGLOBIN300Lab30585018$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
3000139CBC W/ Auto Diff300Lab30585025$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 NumberDescriptionDeptDept DescriptionRev CodeCPT CodePriceDiscounted Cash PriceAetna CommercialAetna Medicare AdvantageBCBS - Blue AdvantageBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAHumana CommercialHumana Medicare AdvantageUnited CommercialUnited Medicare AdvantageMinimum Negotiated PriceMaximum Negotiated Price
3000504CBC AUTO W/O DIFF300Lab30585027$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
3000762D-Dimer300Lab30585379$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
3000146PROTHROMBIN, TIME300Lab30585610$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
3000147SEDIMENTATION RATE; NO300Lab30585651$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
3000124PARTIAL THROMBOPLASTIN300Lab30585730$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
3000242APTT-LA300Lab30585730$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
3000094ANCA-C TITER (RL)300Lab30086021$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
3000581ANCA W/REFLEX TITER300Lab30086021$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
3000224ANA W/RFX (R)300Lab30286038$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
3000567CENTROMERE AB300Lab30286038$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
3000411C-REACTIVE PROTEIN (R)300Lab30286140$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
3000116COMPLEMENT C3300Lab30286160$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
3000118COMPLEMENT C4300Lab30286160$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
3000524CYCLIC CITRULLINATED P300Lab30286200$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
3000549ANTI-DSNA AB, EIA (R)300Lab30286225$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
3000294SM ANTIBODIES (RL)300Lab30286235$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
3000298SJOGREN'S AB SS-A(R)300Lab30286235$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
3000345SCL-70 (R)300Lab30286235$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
3000349RNP ANTIBODIES (RL)300Lab30286235$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
3000357SJOGREN'S AB SS-B(R)300Lab30286235$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
3000547JO-1 AB300Lab30286235$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
3000770PATTERN300Lab30286235$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
3000774Chromatin (Nucleosomal) Antibody300Lab30286235$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
3000811SM/RNP Antibody (R)300Lab30286235$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
3000797CA 19-9300Lab30286301$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
3000155MONO TEST300Lab30286308$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
3000769TITER300Lab30286309$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
3000190HEP B SURFACE AB QN (R)300Lab30286317$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
3000199IMMUNOFIXATION (RL)300Lab30286334$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
3000203THYROID PEROXIDASE AN300Lab30286376$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
3000223RHEUMATOID FACTOR (R)300Lab30286431$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
3000836TB Gold Quant(R)300Lab30286480$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
3000214TB SKIN TEST300Lab30286580$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
3000215RPR300Lab30286592$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
3000534VDRL (SERUM)300Lab30286592$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
3000218LYME DISEASE300Lab30286618$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
3000114HELICOBACTER PYLORI300Lab30286677$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
3000227HIV 1/2 (RL)300Lab30286703$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
3000191HEPATITIS B CORE AB, TOT300Lab30286704$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
3000372ANTI-HEPATITIS B SURFA300Lab30286706$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
3000420HEPATITIS A AB Tot(R)300Lab30286708$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
3000456HEPATITIS A AB IGM300Lab30286709$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
3000450MUMPS VIRUS IGG, EIA(R)300Lab30286735$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
3000451MUMPS IGM300Lab30286735$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
3000257RUBELLA IMMUNE (R)300Lab30286762$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
3000837Rubella IGM (R)300Lab30286762$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
3000743MEASLES AB IGG, EIA (R)300Lab30286765$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
3000874Measles IGM(R)300Lab30286765$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
3000258VARICELLA-ZOSTER IGG AB (R)300Lab30286787$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
3000340VARICELLA IGM AB (RL)300Lab30286787$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
3000339HEP C AB (R)300Lab30286803$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
3000152Antibody Screen300Lab30286885$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
3000183CULTURE; BLOOD, BACTERIAL (R)300Lab30687040$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
3000378CULTURE STOOL A S/S (R300Lab30687045$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
3000379CULTURE STOOL B CMPY (300Lab30687046$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
3000171CULTURE EXCEP UR/BLOOD300Lab30687070$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
3000172CULTURE ANY OTHER SOUR300Lab30687070$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 NumberDescriptionDeptDept DescriptionRev CodeCPT CodePriceDiscounted Cash PriceAetna CommercialAetna Medicare AdvantageBCBS - Blue AdvantageBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAHumana CommercialHumana Medicare AdvantageUnited CommercialUnited Medicare AdvantageMinimum Negotiated PriceMaximum Negotiated Price
3000240CULTURE SPUTUM300Lab30687070$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
3000301CULTURE AEROBIC BAC (R)300Lab30687070$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
30087070Culture, throat300Lab30087070$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
3000354CULTURE ANAEROBIC300Lab30687075$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
3000499AEROBIC ID (RL)300Lab30687077$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
3000693AEROBIC ID #2 (RL)300Lab30687077$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
3000173CULTURE; BACTERIAL URI300Lab30687086$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
3000176OVA & PARASITES STOOL300Lab30687177$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
3000630ESBL CONFIRMATION300Lab30687184$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
3000181AEROBIC SUSCEPTIBILITY300Lab30687186$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
3000498AEROBIC SUSCEPTIBILITY300Lab30687186$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
3000143CLOSTRIDIUM DIFFICILE (R)300Lab30687230$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
3000226HEP B SURF AG W/CONF (R)300Lab30687340$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
3000617CMV DNA BY PCR QN300Lab30687497$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
3000990COVID-19 (RL)300Lab30687635$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
3000948Influenza A300Lab30687804$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
3000949Influenza B300Lab30687804$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
3000748RSV Screen, IA300Lab30687807$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
3000186STREPTOCOCCUS GROUP A300Lab30687880$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
3000702CYTO THIN PREP (Pap Smear) (R)300Lab31088175$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
3000703TISSUE PATHOLOGY REPORT300Lab31088302$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
3000405WBC STOOL (RL)300Lab30089055$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
3000194PHLEBOTOMY THEREPEUTIC300Lab94099195$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
3000269PSA SCREENING300Lab309G0103$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
3000991COVID-19 (STATE_CDC)300Lab306U0001$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
4200015Electric Stem/Manual420Physical Therapy42097032$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
4200025IONTOPHORESIS EA 15 MI420Physical Therapy42097033$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
4200003EXERCISE/PRO EACH 15 M420Physical Therapy42097110$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
4200049NEUROMUSCULAR RE-ED420Physical Therapy42097112$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
4200006GAIT TRAINING EA 15 M420Physical Therapy42097116$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
4200037TRACTION MANUAL EA 15420Physical Therapy42097140$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
4200031PT Eval Low Complexity 20 Mins420Physical Therapy42497161$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
4200032PT Eval Moderate Complexity 30 Min420Physical Therapy42497162$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
4200033PT Eval High Complexity 45 Mins420Physical Therapy42497163$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
4200050THERAPEUTIC ACTIVITY420Physical Therapy42097530$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
42097597REMOVE DEVITAL TISS 20 CM/<420Physical Therapy42097597$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
42097598REMOVE DEVITAL TISS WN Add'l 20420Physical Therapy42097598$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
4200014ELECTRIC STEM/MOD 1420Physical Therapy420G0283$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
3200094SKULL COMPLETE 4+V320Radiology32070260$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
3200192NECK, SOFT TISSUE 2 VI320Radiology32070360$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
3500141CT HEAD WITHOUT CONT.320Radiology35170450$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
3500187CT FACIAL WO/CONTRAST320Radiology35170486$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
3500233CT SINUSES320Radiology35170486$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
3500186CT FACIAL W/CONTRAST320Radiology35170487$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
3500191CT NECK WO/CONTRAST320Radiology35170490$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
3500190CT NECK W/WO CONTRAST320Radiology35170492$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
3500243MRI BRAIN With & W/O CONTRAST320Radiology61070553$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
6100015MRI BRAIN W&WO CONT320Radiology61170553$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
3200015CHEST 1 VIEW320Radiology32471045$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
3200016CHEST 2 VIEWS320Radiology32471046$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
3200079RIBS UNILAT MIN 2 VIEWS320Radiology32071100$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
3200079RRIBS UNILAT MIN 2 VIEWS320Radiology32071100$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
3200080RIBS UNILATERAL 2V320Radiology32071100$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
3200080RRIBS UNILATERAL 2V320Radiology32071100$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
3200196RIBS MIN 3 VIEW/AP CHEST320Radiology32071101$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
3200196RRibs 3 views w/AP Chest; Right320Radiology32071101$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
3200078RIBS BILAT 3V320Radiology32071110$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 NumberDescriptionDeptDept DescriptionRev CodeCPT CodePriceDiscounted Cash PriceAetna CommercialAetna Medicare AdvantageBCBS - Blue AdvantageBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAHumana CommercialHumana Medicare AdvantageUnited CommercialUnited Medicare AdvantageMinimum Negotiated PriceMaximum Negotiated Price
3200188RIBS/CHEST MIN 4 VIEW320Radiology32071111$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
3500140CT CHEST W/O CONTRAST320Radiology35271250$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
3500163CT CHEST WITH CONTRAS320Radiology35271260$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
3500143CT CHEST W/WO CONTRAS320Radiology35271270$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
3500241CT ANGIO CHEST W/WO320Radiology35271275$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
3200097SPINE CERVICAL 2V or 3V320Radiology32072040$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
3200098SPINE C 4+V320Radiology32072050$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
3200100SPINE THORACIX 2 VIEW320Radiology32072070$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
3200180SPINE THORACIX W/SWIMM320Radiology32072072$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
3200198SCOLIOSIS STANDING SER320Radiology32072082$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
3200103SPINE LUMBAR 2V OR 3V320Radiology32072100$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
3200104SPINE LUMBAR COMP SER MIN 4 V320Radiology32072110$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
3500197CT C-SPINE WO CONTRAST320Radiology35272125$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
3500200CT T-SPINE WO/CONTRAST320Radiology35272128$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
3500198CT L-SPINE W0/ CONTRAS320Radiology35272131$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
6100024MRI C-SPINE WO CONT320Radiology61272141$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
6100028MRI L-SPINE WO CONT320Radiology61272148$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
3200072PELVIS 1V320Radiology32072170$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
3500151CT PELVIS WITHOUT CO320Radiology35272192$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
3500180CT PELVIS W/CONTRAST320Radiology35272193$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 320Radiology32072220$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 320Radiology32073000$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 320Radiology32073010$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 320Radiology32073010$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 320Radiology32073030$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 320Radiology32073030$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 320Radiology32073030$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 320Radiology32073060$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 320Radiology32073060$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 320Radiology32073060$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 320Radiology32073070$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 320Radiology32073070$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 320Radiology32073070$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 320Radiology32073080$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 320Radiology32073080$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 320Radiology32073090$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 320Radiology32073090$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 320Radiology32073090$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 320Radiology32073100$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 320Radiology32073100$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 320Radiology32073100$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 320Radiology32073110$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 320Radiology32073110$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 320Radiology32073110$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 320Radiology32073120$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 320Radiology32073120$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 320Radiology32073120$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 320Radiology32073130$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 320Radiology32073130$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 320Radiology32073130$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 320Radiology32073140$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 320Radiology32073140$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 320Radiology32073140$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 320Radiology32073140$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/CONT320Radiology35273200$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; Right320Radiology35273200$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 UNIL320Radiology32073502$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 NumberDescriptionDeptDept DescriptionRev CodeCPT CodePriceDiscounted Cash PriceAetna CommercialAetna Medicare AdvantageBCBS - Blue AdvantageBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAHumana CommercialHumana Medicare AdvantageUnited CommercialUnited Medicare AdvantageMinimum Negotiated PriceMaximum Negotiated Price
3200051R HIP JOINT 2 VIEWS UNIL 320Radiology32073502$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 320Radiology32073521$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 320Radiology32073552$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 320Radiology32073552$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 320Radiology32073552$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 320Radiology32073560$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 320Radiology32073560$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 320Radiology32073560$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 320Radiology32073562$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 320Radiology32073562$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 320Radiology32073562$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 320Radiology32073564$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 320Radiology32073564$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 320Radiology32073564$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 320Radiology32073590$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 320Radiology32073590$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 320Radiology32073590$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 320Radiology32073600$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 320Radiology32073600$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 320Radiology32073600$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 320Radiology32073610$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 320Radiology32073610$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 320Radiology32073610$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 320Radiology32073610$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 320Radiology32073610$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 320Radiology32073620$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 320Radiology32073620$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 320Radiology32073620$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 320Radiology32073630$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 320Radiology32073630$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 320Radiology32073630$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 320Radiology32073660$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 320Radiology32073660$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 320Radiology32073660$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 320Radiology32073660$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 320Radiology35273700$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 320Radiology35273700$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 320Radiology61473721$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 320Radiology61073721$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 320Radiology61073721$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 320Radiology32074018$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 320Radiology32074018$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 320Radiology32074018$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 320Radiology32074019$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 320Radiology32074022$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 CON320Radiology35274150$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/CONTRAST320Radiology35274160$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/O320Radiology35274176$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/CO320Radiology35274177$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/WO320Radiology35274178$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 US320Radiology40276536$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 US320Radiology40276700$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 US320Radiology40276705$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 US320Radiology40276705$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 US320Radiology40276705$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 ORGAN320Radiology40276705$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 US320Radiology40276770$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 NumberDescriptionDeptDept DescriptionRev CodeCPT CodePriceDiscounted Cash PriceAetna CommercialAetna Medicare AdvantageBCBS - Blue AdvantageBCBS - HMOBCBS - PPOBCBS - TraditionalCIGNAHumana CommercialHumana Medicare AdvantageUnited CommercialUnited Medicare AdvantageMinimum Negotiated PriceMaximum Negotiated Price
4000196RENAL COMPLETE US320Radiology40276770$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
4000209PREGNANCY US > 14 WKS320Radiology40276805$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
4000207PELVIC US TRANSVAG NON320Radiology40276830$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
4000193PELVIC US NON-OB LIMIT320Radiology40276857$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
4000201SCROTUM320Radiology40276870$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
3200256US Extremity non vascular; Rt320Radiology40276882$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
3200257Groin Ultrasound320Radiology40276882$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
4000125US, Limited, Joint or other nonvascula320Radiology40276882$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
4000213ECHO TTHRC R-T 2D W/WOM320Radiology48393306$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
51081002URINE DIPSTICK521Rural Health Clinic52181002$15.00$7.50$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$ -$7.50
51093000EKG COMPLETE521Rural Health Clinic52193000$64.00$32.00$14.59$ -$14.59$14.59$14.59$14.59$14.59$14.59$ -$14.59$ -$ -$32.00
51099386PREVENTIVE EXAM NEW 40521Rural Health Clinic52199386$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}

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