Hospital Charges / Price Transparency
OVERVIEW
In compliance with the Centers for Medicare and Medicaid Services (CMS), Shamrock General 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.
Shamrock General 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 Shamrock General Hospital CDM, please contact our hospital business office at (806) 256-2423 or come by and speak to one of our business office representatives. Thank you for choosing Shamrock General Hospital for your health care needs!
Downloadable CDM and Shoppable Services
Charge Description Master
Shoppable Services
Searchable Shoppable Services
Shamrock General Hospital Shoppable Services as of 7/15/2023
| Charge Number | Description | Rev Code | Dept | CPT Code | Price | Cash Price | Aetna | Aetna Medicare Advantage | BCBS Choice PPO | BCBS HMO Blue | BCBS Traditional | BCBS Advantage | CIGNA | Firstcare HMO | Firstcare PPO | Firstcare MA | Medicare Advantage | United | Negotiated Charge | Negotiated Charge |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 300212 | CT SCAN HEAD W/O CONTRAST | 350 | CT Scan | 70450 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300213 | CT SCAN HEAD W/CONTRAST | 350 | CT Scan | 70460 | $ 1,480.00 | $ 1,036.00 | $ 1,258.00 | $ 1,391.20 | $ 876.59 | $ 579.44 | $ 936.02 | $ 297.15 | $ 814.00 | $ 1,258.00 | $ 1,258.00 | $ 1,480.00 | $ 1,480.00 | $ 1,110.00 | $ 297.15 | $ 1,480.00 |
| 300209 | CT SCAN MAXILLA W/O CONTRAST | 350 | CT Scan | 70486 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300210 | CT SCAN MAXILLA W/CONTRAST | 350 | CT Scan | 70487 | $ 1,300.00 | $ 910.00 | $ 1,105.00 | $ 1,222.00 | $ 876.59 | $ 579.44 | $ 936.02 | $ 297.15 | $ 715.00 | $ 1,105.00 | $ 1,105.00 | $ 1,300.00 | $ 1,300.00 | $ 975.00 | $ 297.15 | $ 1,300.00 |
| 300229 | CT SCAN SOFT TISSUE NECK W/O C | 350 | CT Scan | 70490 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300230 | CT SCAN SOFT TISSUE NECK W CON | 350 | CT Scan | 70491 | $ 1,480.00 | $ 1,036.00 | $ 1,258.00 | $ 1,391.20 | $ 876.59 | $ 579.44 | $ 936.02 | $ 297.15 | $ 814.00 | $ 1,258.00 | $ 1,258.00 | $ 1,480.00 | $ 1,480.00 | $ 1,110.00 | $ 297.15 | $ 1,480.00 |
| 300215 | CT SCAN CHEST W/O CONTRAST | 350 | CT Scan | 71250 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300216 | CT SCAN CHEST W/CONTRAST | 350 | CT Scan | 71260 | $ 1,480.00 | $ 1,036.00 | $ 1,258.00 | $ 1,391.20 | $ 876.59 | $ 579.44 | $ 936.02 | $ 297.15 | $ 814.00 | $ 1,258.00 | $ 1,258.00 | $ 1,480.00 | $ 1,480.00 | $ 1,110.00 | $ 297.15 | $ 1,480.00 |
| 300217 | CT SCAN CHEST W & W/O CONTRAST | 350 | CT Scan | 71270 | $ 1,950.00 | $ 1,365.00 | $ 1,657.50 | $ 1,833.00 | $ 971.55 | $ 642.21 | $ 1,037.42 | $ 329.34 | $ 1,072.50 | $ 1,657.50 | $ 1,657.50 | $ 1,950.00 | $ 1,950.00 | $ 1,462.50 | $ 329.34 | $ 1,950.00 |
| 300203 | CT SCAN CERVICAL W/O CONTRAST | 350 | CT Scan | 72125 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300228 | CT SCAN T-SPINE W/O CONTRAST | 350 | CT Scan | 72128 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300218 | CT SCAN LUMBAR W/O CONTRAST | 350 | CT Scan | 72131 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300221 | CT SCAN PELVIS W/O CONTRAST | 350 | CT Scan | 72192 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300222 | CT SCAN PELVIS W/CONTRAST | 350 | CT Scan | 72193 | $ 1,880.00 | $ 1,316.00 | $ 1,598.00 | $ 1,767.20 | $ 876.59 | $ 579.44 | $ 936.02 | $ 297.15 | $ 1,034.00 | $ 1,598.00 | $ 1,598.00 | $ 1,880.00 | $ 1,880.00 | $ 1,410.00 | $ 297.15 | $ 1,880.00 |
| 300226 | CT SCAN UPPER EXTREMITY W/O CO | 350 | CT Scan | 73200 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300224 | CT SCAN LOWER EXTREMITY W/O CO | 350 | CT Scan | 73700 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300225 | CT SCAN LOWER EXTREMITY WITH C | 350 | CT Scan | 73701 | $ 1,300.00 | $ 910.00 | $ 1,105.00 | $ 1,222.00 | $ 876.59 | $ 579.44 | $ 936.02 | $ 297.15 | $ 715.00 | $ 1,105.00 | $ 1,105.00 | $ 1,300.00 | $ 1,300.00 | $ 975.00 | $ 297.15 | $ 1,300.00 |
| 300200 | CT SCAN ABDOMEN W/O CONTRAST | 350 | CT Scan | 74150 | $ 1,250.00 | $ 875.00 | $ 1,062.50 | $ 1,175.00 | $ 512.06 | $ 338.48 | $ 546.78 | $ 173.58 | $ 687.50 | $ 1,062.50 | $ 1,062.50 | $ 1,250.00 | $ 1,250.00 | $ 937.50 | $ 173.58 | $ 1,250.00 |
| 300201 | CT SCAN ABDOMEN W/CONTRAST | 350 | CT Scan | 74160 | $ 1,480.00 | $ 1,036.00 | $ 1,258.00 | $ 1,391.20 | $ 876.59 | $ 579.44 | $ 936.02 | $ 297.15 | $ 814.00 | $ 1,258.00 | $ 1,258.00 | $ 1,480.00 | $ 1,480.00 | $ 1,110.00 | $ 297.15 | $ 1,480.00 |
| 300202 | CT SCAN ABDOMEN W & W/O CONTRA | 350 | CT Scan | 74170 | $ 2,060.00 | $ 1,442.00 | $ 1,751.00 | $ 1,936.40 | $ 971.55 | $ 642.21 | $ 1,037.42 | $ 329.34 | $ 1,133.00 | $ 1,751.00 | $ 1,751.00 | $ 2,060.00 | $ 2,060.00 | $ 1,545.00 | $ 329.34 | $ 2,060.00 |
| 300330 | CT ABDOMEN & PELVIS W/O | 350 | CT Scan | 74176 | $ 2,500.00 | $ 1,750.00 | $ 2,125.00 | $ 2,350.00 | $ 902.85 | $ 596.80 | $ 964.06 | $ 306.05 | $ 1,375.00 | $ 2,125.00 | $ 2,125.00 | $ 2,500.00 | $ 2,500.00 | $ 1,875.00 | $ 306.05 | $ 2,500.00 |
| 300331 | CT ABDOMEN & PELVIS WITH CONTR | 350 | CT Scan | 74177 | $ 2,600.00 | $ 1,820.00 | $ 2,210.00 | $ 2,444.00 | $ 1,423.61 | $ 941.03 | $ 1,520.13 | $ 482.58 | $ 1,430.00 | $ 2,210.00 | $ 2,210.00 | $ 2,600.00 | $ 2,600.00 | $ 1,950.00 | $ 482.58 | $ 2,600.00 |
| 300332 | CT ABDOMEN & PELVIS W & W/O CO | 350 | CT Scan | 74178 | $ 2,550.00 | $ 1,785.00 | $ 2,167.50 | $ 2,397.00 | $ 1,423.61 | $ 941.03 | $ 1,520.13 | $ 482.58 | $ 1,402.50 | $ 2,167.50 | $ 2,167.50 | $ 2,550.00 | $ 2,550.00 | $ 1,912.50 | $ 482.58 | $ 2,550.00 |
| 300227 | BONE DENSITY SCAN | 350 | CT Scan | 77080 | $ 225.00 | $ 157.50 | $ 191.25 | $ 211.50 | $ 131.40 | $ 78.84 | $ 139.48 | $ 40.43 | $ 123.75 | $ 191.25 | $ 191.25 | $ 225.00 | $ 225.00 | $ 168.75 | $ 40.43 | $ 225.00 |
| 260001 | EKG | 730 | EKG/ECG | 93005 | $ 250.00 | $ 175.00 | $ 212.50 | $ 235.00 | $ 25.48 | $ 15.29 | $ 28.02 | $ 10.19 | $ 137.50 | $ 212.50 | $ 212.50 | $ 250.00 | $ 250.00 | $ 50.00 | $ 10.19 | $ 250.00 |
| 170001 | CARDIAC MONITOR | 730 | EKG/ECG | 93225 | $ 250.00 | $ 175.00 | $ 212.50 | $ 235.00 | $ 70.50 | $ 42.30 | $ 77.55 | $ 28.20 | $ 137.50 | $ 212.50 | $ 212.50 | $ 250.00 | $ 250.00 | $ 187.50 | $ 28.20 | $ 250.00 |
| 200089 | NEONATAL SCREEN COLLECTION | 300 | Laboratory | 36416 | $ 35.50 | $ 24.85 | $ 30.18 | $ 33.37 | $ - | $ - | $ - | $ - | $ 19.53 | $ 30.18 | $ 30.18 | $ 35.50 | $ 35.50 | $ 26.63 | $ - | $ 35.50 |
| 200047 | BASIC METABOLIC PANEL | 300 | Laboratory | 80048 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 37.80 | $ 22.68 | $ 40.12 | $ 11.63 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 11.63 | $ 130.00 |
| GHP | BC General Health Panel | 300 | Laboratory | 80050 | $ 410.00 | $ 287.00 | $ 348.50 | $ 385.40 | $ 108.23 | $ 64.94 | $ 114.89 | $ 33.30 | $ 225.50 | $ 348.50 | $ 348.50 | $ 410.00 | $ 212.75 | $ 307.50 | $ 33.30 | $ 410.00 |
| 200020 | COMPREHENSIVE METABOLIC PANEL | 300 | Laboratory | 80053 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 47.22 | $ 28.33 | $ 50.13 | $ 14.53 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 14.53 | $ 200.00 |
| 200117 | LIPID PANEL | 300 | Laboratory | 80061 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 49.04 | $ 29.43 | $ 52.06 | $ 15.09 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 15.09 | $ 120.00 |
| 200038 | RENAL FUNCTION PANEL | 300 | Laboratory | 80069 | $ 150.00 | $ 105.00 | $ 127.50 | $ 141.00 | $ 38.81 | $ 23.28 | $ 41.19 | $ 11.94 | $ 82.50 | $ 127.50 | $ 127.50 | $ 150.00 | $ 150.00 | $ 112.50 | $ 11.94 | $ 150.00 |
| 200911 | ACUTE HEPATITIS PANEL LC144000 | 300 | Laboratory | 80074 | $ 383.00 | $ 268.10 | $ 325.55 | $ 360.02 | $ 208.46 | $ 125.07 | $ 221.28 | $ 64.14 | $ 210.65 | $ 325.55 | $ 325.55 | $ 383.00 | $ 383.00 | $ 287.25 | $ 64.14 | $ 383.00 |
| 200118 | HEPATIC FUNCTION PANEL | 300 | Laboratory | 80076 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 36.50 | $ 21.90 | $ 38.74 | $ 11.23 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 11.23 | $ 140.00 |
| 200152 | CARBAMAZEPINE TEGRETOL | 300 | Laboratory | 80156 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 65.07 | $ 39.04 | $ 69.07 | $ 20.02 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 20.02 | $ 130.00 |
| 200144 | CYCLOSPORIN LC706556 | 300 | Laboratory | 80158 | $ 170.00 | $ 119.00 | $ 144.50 | $ 159.80 | $ 80.63 | $ 48.38 | $ 85.59 | $ 24.81 | $ 93.50 | $ 144.50 | $ 144.50 | $ 170.00 | $ 170.00 | $ 127.50 | $ 24.81 | $ 170.00 |
| 200050 | DIGOXIN | 300 | Laboratory | 80162 | $ 150.00 | $ 105.00 | $ 127.50 | $ 141.00 | $ 59.31 | $ 35.59 | $ 62.96 | $ 18.25 | $ 82.50 | $ 127.50 | $ 127.50 | $ 150.00 | $ 150.00 | $ 112.50 | $ 18.25 | $ 150.00 |
| 200181 | VALPORIC(DEPAKOTE),S LC007260 | 300 | Laboratory | 80164 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 60.55 | $ 36.33 | $ 64.27 | $ 18.63 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 18.63 | $ 120.00 |
| 200986 | PHENOBARBITAL LC007823 | 300 | Laboratory | 80184 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 51.16 | $ 30.69 | $ 54.30 | $ 15.74 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 15.74 | $ 110.00 |
| 200121 | DILANTIN PHENYTOIN | 300 | Laboratory | 80185 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 59.22 | $ 35.53 | $ 62.86 | $ 18.22 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 18.22 | $ 120.00 |
| 200902 | SIROLIMUS LC716712 | 300 | Laboratory | 80195 | $ 172.00 | $ 120.40 | $ 146.20 | $ 161.68 | $ 32.60 | $ 19.56 | $ 34.60 | $ 10.03 | $ 94.60 | $ 146.20 | $ 146.20 | $ 172.00 | $ 172.00 | $ 129.00 | $ 10.03 | $ 172.00 |
| 200904 | TACROLIMUS LC700248 | 300 | Laboratory | 80197 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 32.60 | $ 19.56 | $ 34.60 | $ 10.03 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 10.03 | $ 230.00 |
| 200183 | VANCOMYCIN TROUGH,SER LC70328 | 300 | Laboratory | 80202 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 60.55 | $ 36.33 | $ 64.27 | $ 18.63 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 18.63 | $ 130.00 |
| 200182 | VANCOMYCIN PEAK,SERUM LC070327 | 300 | Laboratory | 80202 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 60.55 | $ 36.33 | $ 64.27 | $ 18.63 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 18.63 | $ 130.00 |
| 200130 | URINE DRUG SCREEN (UDS) | 300 | Laboratory | 80306 | $ 75.00 | $ 52.50 | $ 63.75 | $ 70.50 | $ 49.60 | $ 29.76 | $ 52.65 | $ 15.26 | $ 41.25 | $ 63.75 | $ 63.75 | $ 75.00 | $ 75.00 | $ 56.25 | $ 15.26 | $ 75.00 |
| 200141 | ALCOHOL(ETHANOL),BLOOD | 300 | Laboratory | 80320 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 13.36 | $ 8.01 | $ 14.18 | $ 4.11 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 4.11 | $ 110.00 |
| 200080 | UA W/MICRO | 300 | Laboratory | 81001 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 14.14 | $ 8.48 | $ 15.01 | $ 4.35 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 4.35 | $ 70.00 |
| 200029 | UA DIPSTICK ONLY | 300 | Laboratory | 81003 | $ 11.00 | $ 7.70 | $ 9.35 | $ 10.34 | $ 7.93 | $ 4.76 | $ 8.42 | $ 2.44 | $ 6.05 | $ 9.35 | $ 9.35 | $ 11.00 | $ 11.00 | $ 8.25 | $ 2.44 | $ 11.00 |
| 201089 | UR ALBUMIN QUANTITATIVE | 300 | Laboratory | 82043 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 24.15 | $ 14.49 | $ 25.63 | $ 7.43 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 7.43 | $ 110.00 |
| 200127 | MICROALBUMIN, SEMIQUANTITATIVE | 300 | Laboratory | 82044 | $ 50.00 | $ 35.00 | $ 42.50 | $ 47.00 | $ 20.44 | $ 12.27 | $ 21.70 | $ 6.29 | $ 27.50 | $ 42.50 | $ 42.50 | $ 50.00 | $ 50.00 | $ 37.50 | $ 6.29 | $ 50.00 |
| 200969 | A1-ANTITRYPSIN,SERUM LC001982 | 300 | Laboratory | 82103 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 60.03 | $ 36.02 | $ 63.72 | $ 18.47 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 18.47 | $ 210.00 |
| 200941 | AFP,SERUM,TUMOR MARKER LC002253 | 300 | Laboratory | 82105 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 64.84 | $ 38.90 | $ 68.83 | $ 19.95 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 19.95 | $ 140.00 |
| 201113 | AMMONIA | 300 | Laboratory | 82140 | $ 135.00 | $ 94.50 | $ 114.75 | $ 126.90 | $ 65.10 | $ 39.06 | $ 69.10 | $ 20.03 | $ 74.25 | $ 114.75 | $ 114.75 | $ 135.00 | $ 135.00 | $ 101.25 | $ 20.03 | $ 135.00 |
| 200005 | AMYLASE | 300 | Laboratory | 82150 | $ 100.00 | $ 70.00 | $ 85.00 | $ 94.00 | $ 25.81 | $ 15.48 | $ 27.39 | $ 7.94 | $ 55.00 | $ 85.00 | $ 85.00 | $ 100.00 | $ 100.00 | $ 75.00 | $ 7.94 | $ 100.00 |
| 201135 | ANGIOTENSIN CONVERTING ENZYME ACE | 300 | Laboratory | 82164 | $ 98.00 | $ 68.60 | $ 83.30 | $ 92.12 | $ 65.23 | $ 39.14 | $ 69.24 | $ 20.07 | $ 53.90 | $ 83.30 | $ 83.30 | $ 98.00 | $ 98.00 | $ 73.50 | $ 20.07 | $ 98.00 |
| 200007 | BILIRUBIN TOTAL | 300 | Laboratory | 82247 | $ 150.00 | $ 105.00 | $ 127.50 | $ 141.00 | $ 22.43 | $ 13.46 | $ 23.81 | $ 6.90 | $ 82.50 | $ 127.50 | $ 127.50 | $ 150.00 | $ 150.00 | $ 112.50 | $ 6.90 | $ 150.00 |
| 201020 | BILIRUBIN,TOTAL,NEONATAL | 300 | Laboratory | 82247 | $ 150.00 | $ 105.00 | $ 127.50 | $ 141.00 | $ 22.43 | $ 13.46 | $ 23.81 | $ 6.90 | $ 82.50 | $ 127.50 | $ 127.50 | $ 150.00 | $ 150.00 | $ 112.50 | $ 6.90 | $ 150.00 |
| 200008 | BILIRUBIN DIRECT | 300 | Laboratory | 82248 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 22.43 | $ 13.46 | $ 23.81 | $ 6.90 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 6.90 | $ 80.00 |
| 200131 | OCCULT BLOOD STOOL X 3 | 300 | Laboratory | 82270 | $ 60.00 | $ 42.00 | $ 51.00 | $ 56.40 | $ 14.56 | $ 8.74 | $ 15.46 | $ 4.48 | $ 33.00 | $ 51.00 | $ 51.00 | $ 60.00 | $ 60.00 | $ 45.00 | $ 4.48 | $ 60.00 |
| Charge Number | Description | Rev Code | Dept | CPT Code | Price | Cash Price | Aetna | Aetna Medicare Advantage | BCBS Choice PPO | BCBS HMO Blue | BCBS Traditional | BCBS Advantage | CIGNA | Firstcare HMO | Firstcare PPO | Firstcare MA | Medicare Advantage | United | Negotiated Charge | Negotiated Charge |
| 200025 | OCCULT BLOOD STOOL | 300 | Laboratory | 82272 | $ 24.00 | $ 16.80 | $ 20.40 | $ 22.56 | $ 14.56 | $ 8.74 | $ 15.46 | $ 4.48 | $ 13.20 | $ 20.40 | $ 20.40 | $ 24.00 | $ 24.00 | $ 18.00 | $ 4.48 | $ 24.00 |
| 200908 | VIT D 25-HYDROXY LC081950 | 300 | Laboratory | 82306 | $ 219.00 | $ 153.30 | $ 186.15 | $ 205.86 | $ 132.28 | $ 79.37 | $ 140.42 | $ 40.70 | $ 120.45 | $ 186.15 | $ 186.15 | $ 219.00 | $ 219.00 | $ 164.25 | $ 40.70 | $ 219.00 |
| 200013 | CALCIUM | 300 | Laboratory | 82310 | $ 40.00 | $ 28.00 | $ 34.00 | $ 37.60 | $ 18.04 | $ 10.82 | $ 19.15 | $ 5.55 | $ 22.00 | $ 34.00 | $ 34.00 | $ 40.00 | $ 40.00 | $ 30.00 | $ 5.55 | $ 40.00 |
| 200996 | CALCIUM, IONIZED LC004804 | 300 | Laboratory | 82330 | $ 91.00 | $ 63.70 | $ 77.35 | $ 85.54 | $ 61.07 | $ 36.64 | $ 64.83 | $ 18.79 | $ 50.05 | $ 77.35 | $ 77.35 | $ 91.00 | $ 91.00 | $ 68.25 | $ 18.79 | $ 91.00 |
| 201114 | CALCULI WITH PHOTO LC 910180 | 300 | Laboratory | 82365 | $ 98.00 | $ 68.60 | $ 83.30 | $ 92.12 | $ 57.59 | $ 34.55 | $ 61.13 | $ 17.72 | $ 53.90 | $ 83.30 | $ 83.30 | $ 98.00 | $ 98.00 | $ 73.50 | $ 17.72 | $ 98.00 |
| 200153 | CARBON MONOXIDE,BLOOD LC007187 | 300 | Laboratory | 82375 | $ 107.00 | $ 74.90 | $ 90.95 | $ 100.58 | $ 40.66 | $ 24.39 | $ 43.16 | $ 12.51 | $ 58.85 | $ 90.95 | $ 90.95 | $ 107.00 | $ 107.00 | $ 80.25 | $ 12.51 | $ 107.00 |
| 200157 | CORTISOL LC004051 | 300 | Laboratory | 82533 | $ 150.00 | $ 105.00 | $ 127.50 | $ 141.00 | $ 72.83 | $ 43.70 | $ 77.31 | $ 22.41 | $ 82.50 | $ 127.50 | $ 127.50 | $ 150.00 | $ 150.00 | $ 112.50 | $ 22.41 | $ 150.00 |
| 200171 | LEVETIRACETAM (KEPPRA),S | 300 | Laboratory | 82542 | $ 160.00 | $ 112.00 | $ 136.00 | $ 150.40 | $ 80.67 | $ 48.40 | $ 85.63 | $ 24.82 | $ 88.00 | $ 136.00 | $ 136.00 | $ 160.00 | $ 160.00 | $ 120.00 | $ 24.82 | $ 160.00 |
| 200045 | CK LC001362 | 300 | Laboratory | 82550 | $ 90.00 | $ 63.00 | $ 76.50 | $ 84.60 | $ 29.09 | $ 17.45 | $ 30.88 | $ 8.95 | $ 49.50 | $ 76.50 | $ 76.50 | $ 90.00 | $ 90.00 | $ 67.50 | $ 8.95 | $ 90.00 |
| 200046 | MI PANEL TEST 1 CKMB | 300 | Laboratory | 82553 | $ 150.00 | $ 105.00 | $ 127.50 | $ 141.00 | $ 34.65 | $ 20.79 | $ 36.78 | $ 10.66 | $ 82.50 | $ 127.50 | $ 127.50 | $ 150.00 | $ 150.00 | $ 112.50 | $ 10.66 | $ 150.00 |
| 200093 | CREATININE | 300 | Laboratory | 82565 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 22.88 | $ 13.73 | $ 24.29 | $ 7.04 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 7.04 | $ 70.00 |
| 200128 | CREATININE URINE LC013672 | 300 | Laboratory | 82570 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 23.11 | $ 13.86 | $ 24.53 | $ 7.11 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 7.11 | $ 70.00 |
| 200916 | CREATININE, 24 HR URINE | 300 | Laboratory | 82570 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 23.11 | $ 13.86 | $ 24.53 | $ 7.11 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 7.11 | $ 70.00 |
| 200107 | CREATININE CLEARANCE LC003004 | 300 | Laboratory | 82575 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 22.00 | $ 13.20 | $ 23.36 | $ 6.77 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 6.77 | $ 80.00 |
| 200903 | B-12 VITAMIN LC001503 | 300 | Laboratory | 82607 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 46.57 | $ 27.94 | $ 49.44 | $ 14.33 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 14.33 | $ 130.00 |
| 201136 | CYSTAIN WITH GLOMERULAR FILTRATION RATE | 300 | Laboratory | 82610 | $ 193.00 | $ 135.10 | $ 164.05 | $ 181.42 | $ 50.73 | $ 30.44 | $ 53.85 | $ 15.61 | $ 106.15 | $ 164.05 | $ 164.05 | $ 193.00 | $ 193.00 | $ 144.75 | $ 15.61 | $ 193.00 |
| 201009 | CALCITRIOL LC081091 | 300 | Laboratory | 82652 | $ 295.00 | $ 206.50 | $ 250.75 | $ 277.30 | $ 171.99 | $ 103.19 | $ 182.57 | $ 52.92 | $ 162.25 | $ 250.75 | $ 250.75 | $ 295.00 | $ 295.00 | $ 221.25 | $ 52.92 | $ 295.00 |
| 200912 | ESTRADIOL LC004515 | 300 | Laboratory | 82670 | $ 300.00 | $ 210.00 | $ 255.00 | $ 282.00 | $ 122.62 | $ 73.57 | $ 130.17 | $ 37.73 | $ 165.00 | $ 255.00 | $ 255.00 | $ 300.00 | $ 300.00 | $ 225.00 | $ 37.73 | $ 300.00 |
| 200159 | ESTROGENS,TOTAL LC004549 | 300 | Laboratory | 82672 | $ 270.00 | $ 189.00 | $ 229.50 | $ 253.80 | $ 88.92 | $ 53.35 | $ 94.39 | $ 27.36 | $ 148.50 | $ 229.50 | $ 229.50 | $ 270.00 | $ 270.00 | $ 202.50 | $ 27.36 | $ 270.00 |
| 200161 | FERRITIN,SERUM LC004598 | 300 | Laboratory | 82728 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 60.87 | $ 36.52 | $ 64.62 | $ 18.73 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 18.73 | $ 120.00 |
| 200906 | FOLATE LC002014 | 300 | Laboratory | 82746 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 60.68 | $ 36.41 | $ 64.41 | $ 18.67 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 18.67 | $ 120.00 |
| 201031 | IMMUNOGLOBULIN A, QUANTATIVE | 300 | Laboratory | 82784 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 33.22 | $ 19.93 | $ 35.26 | $ 10.22 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 10.22 | $ 200.00 |
| 201043 | IMMUNOGLOBULIN G, QUANT | 300 | Laboratory | 82784 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 33.22 | $ 19.93 | $ 35.26 | $ 10.22 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 10.22 | $ 200.00 |
| 201071 | IGM,QN,SERUM LC001792 | 300 | Laboratory | 82784 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 33.22 | $ 19.93 | $ 35.26 | $ 10.22 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 10.22 | $ 200.00 |
| 201051 | IMMUNOGLOBULIN E, TOTAL | 300 | Laboratory | 82785 | $ 100.00 | $ 70.00 | $ 85.00 | $ 94.00 | $ 73.58 | $ 44.15 | $ 78.11 | $ 22.64 | $ 55.00 | $ 85.00 | $ 85.00 | $ 100.00 | $ 100.00 | $ 75.00 | $ 22.64 | $ 100.00 |
| 280045 | ARTERIAL BLOOD GAS EACH (ABG) | 300 | Laboratory | 82803 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 86.45 | $ 51.87 | $ 91.77 | $ 26.60 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 26.60 | $ 230.00 |
| 201078 | VENOUS BLOOD GAS | 300 | Laboratory | 82803 | $ 117.00 | $ 81.90 | $ 99.45 | $ 109.98 | $ 86.45 | $ 51.87 | $ 91.77 | $ 26.60 | $ 64.35 | $ 99.45 | $ 99.45 | $ 117.00 | $ 117.00 | $ 87.75 | $ 26.60 | $ 117.00 |
| 200053 | GLUCOSE | 300 | Laboratory | 82947 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 17.52 | $ 10.51 | $ 18.60 | $ 5.39 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 5.39 | $ 70.00 |
| 200052 | GLUCOSE O'SULLIVAN | 300 | Laboratory | 82950 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 21.22 | $ 12.73 | $ 22.53 | $ 6.53 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 6.53 | $ 80.00 |
| 200014 | GLUCOSE GESTATIONAL GTT | 300 | Laboratory | 82951 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 57.49 | $ 34.50 | $ 61.03 | $ 17.69 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 17.69 | $ 140.00 |
| 200054 | GLUCOSE TOLERANCE 3-HOUR | 300 | Laboratory | 82951 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 57.49 | $ 34.50 | $ 61.03 | $ 17.69 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 17.69 | $ 140.00 |
| 200055 | GLUCOSE TOLERANCE 4-HOUR | 300 | Laboratory | 82951 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 57.49 | $ 34.50 | $ 61.03 | $ 17.69 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 17.69 | $ 140.00 |
| 200104 | GLUCOSE TOLERANCE 2-HOUR (WHO | 300 | Laboratory | 82951 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 57.49 | $ 34.50 | $ 61.03 | $ 17.69 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 17.69 | $ 140.00 |
| 201035 | GESTATIONAL GLUCOSE TOLERANCE | 300 | Laboratory | 82952 | $ 105.00 | $ 73.50 | $ 89.25 | $ 98.70 | $ 12.87 | $ 7.72 | $ 13.66 | $ 3.96 | $ 57.75 | $ 89.25 | $ 89.25 | $ 105.00 | $ 105.00 | $ 78.75 | $ 3.96 | $ 105.00 |
| 200910 | GGT LC001958 | 300 | Laboratory | 82977 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 32.18 | $ 19.31 | $ 34.16 | $ 9.90 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 9.90 | $ 80.00 |
| 200913 | FSH LC004309 | 300 | Laboratory | 83001 | $ 160.00 | $ 112.00 | $ 136.00 | $ 150.40 | $ 83.01 | $ 49.80 | $ 88.11 | $ 25.54 | $ 88.00 | $ 136.00 | $ 136.00 | $ 160.00 | $ 160.00 | $ 120.00 | $ 25.54 | $ 160.00 |
| 200914 | LH LC004283 | 300 | Laboratory | 83002 | $ 104.00 | $ 72.80 | $ 88.40 | $ 97.76 | $ 79.43 | $ 47.66 | $ 84.32 | $ 24.44 | $ 57.20 | $ 88.40 | $ 88.40 | $ 104.00 | $ 104.00 | $ 78.00 | $ 24.44 | $ 104.00 |
| 201066 | H.PYLORI UREA BREATH TEST | 300 | Laboratory | 83013 | $ 324.00 | $ 226.80 | $ 275.40 | $ 304.56 | $ 300.92 | $ 180.55 | $ 319.44 | $ 92.59 | $ 178.20 | $ 275.40 | $ 275.40 | $ 324.00 | $ 324.00 | $ 243.00 | $ 92.59 | $ 324.00 |
| 201072 | H-PYLORI UREA BREATH TEST PEDI | 300 | Laboratory | 83013 | $ 324.00 | $ 226.80 | $ 275.40 | $ 304.56 | $ 300.92 | $ 180.55 | $ 319.44 | $ 92.59 | $ 178.20 | $ 275.40 | $ 275.40 | $ 324.00 | $ 324.00 | $ 243.00 | $ 92.59 | $ 324.00 |
| 201108 | HBA1C | 300 | Laboratory | 83036 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 43.36 | $ 26.01 | $ 46.02 | $ 13.34 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 13.34 | $ 80.00 |
| 200168 | HOMOCYST(E)INE,PLASMA LC706994 | 300 | Laboratory | 83090 | $ 186.00 | $ 130.20 | $ 158.10 | $ 174.84 | $ 75.37 | $ 45.22 | $ 80.01 | $ 23.19 | $ 102.30 | $ 158.10 | $ 158.10 | $ 186.00 | $ 186.00 | $ 139.50 | $ 23.19 | $ 186.00 |
| 200022 | IRON BINDING CAPACITY-TIBC | 300 | Laboratory | 83540 | $ 71.00 | $ 49.70 | $ 60.35 | $ 66.74 | $ 28.93 | $ 17.36 | $ 30.71 | $ 8.90 | $ 39.05 | $ 60.35 | $ 60.35 | $ 71.00 | $ 71.00 | $ 53.25 | $ 8.90 | $ 71.00 |
| 200021 | IRON LC001339 | 300 | Laboratory | 83540 | $ 60.00 | $ 42.00 | $ 51.00 | $ 56.40 | $ 28.93 | $ 17.36 | $ 30.71 | $ 8.90 | $ 33.00 | $ 51.00 | $ 51.00 | $ 60.00 | $ 60.00 | $ 45.00 | $ 8.90 | $ 60.00 |
| 201102 | LACTATE | 300 | Laboratory | 83605 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 47.71 | $ 28.63 | $ 50.65 | $ 14.68 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 14.68 | $ 110.00 |
| 200023 | LDH LC001115 | 300 | Laboratory | 83615 | $ 100.00 | $ 70.00 | $ 85.00 | $ 94.00 | $ 26.98 | $ 16.19 | $ 28.64 | $ 8.30 | $ 55.00 | $ 85.00 | $ 85.00 | $ 100.00 | $ 100.00 | $ 75.00 | $ 8.30 | $ 100.00 |
| 201056 | LACTOFERRIN FECAL QUANTITATIVE | 300 | Laboratory | 83631 | $ 132.75 | $ 92.93 | $ 112.84 | $ 124.79 | $ 87.69 | $ 52.61 | $ 93.08 | $ 26.98 | $ 73.01 | $ 112.84 | $ 112.84 | $ 132.75 | $ 132.75 | $ 99.56 | $ 26.98 | $ 132.75 |
| 200975 | LEAD,BLOOD(ADULT) LC007625 | 300 | Laboratory | 83655 | $ 74.00 | $ 51.80 | $ 62.90 | $ 69.56 | $ 54.08 | $ 32.45 | $ 57.41 | $ 16.64 | $ 40.70 | $ 62.90 | $ 62.90 | $ 74.00 | $ 74.00 | $ 55.50 | $ 16.64 | $ 74.00 |
| 200129 | LIPASE | 300 | Laboratory | 83690 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 20.77 | $ 12.46 | $ 22.05 | $ 6.39 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 6.39 | $ 80.00 |
| 201070 | LDL-DIRECT LC120295 | 300 | Laboratory | 83721 | $ 93.00 | $ 65.10 | $ 79.05 | $ 87.42 | $ 40.98 | $ 24.59 | $ 43.50 | $ 12.61 | $ 51.15 | $ 79.05 | $ 79.05 | $ 93.00 | $ 93.00 | $ 69.75 | $ 12.61 | $ 93.00 |
| 200122 | MAGNESIUM | 300 | Laboratory | 83735 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 29.93 | $ 17.96 | $ 31.77 | $ 9.21 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 9.21 | $ 70.00 |
| 200135 | BNP | 300 | Laboratory | 83880 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 151.65 | $ 90.99 | $ 160.98 | $ 46.66 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 46.66 | $ 230.00 |
| 201022 | METHYLMALONIC ACID SERUM (MMA) | 300 | Laboratory | 83921 | $ 242.00 | $ 169.40 | $ 205.70 | $ 227.48 | $ 73.52 | $ 44.11 | $ 78.04 | $ 22.62 | $ 133.10 | $ 205.70 | $ 205.70 | $ 242.00 | $ 242.00 | $ 181.50 | $ 22.62 | $ 242.00 |
| 200961 | OSMOLALITY, URINE LC003442 | 300 | Laboratory | 83935 | $ 66.00 | $ 46.20 | $ 56.10 | $ 62.04 | $ 30.45 | $ 18.27 | $ 32.33 | $ 9.37 | $ 36.30 | $ 56.10 | $ 56.10 | $ 66.00 | $ 66.00 | $ 49.50 | $ 9.37 | $ 66.00 |
| 200139 | PTH INTACT LC015610 | 300 | Laboratory | 83970 | $ 300.00 | $ 210.00 | $ 255.00 | $ 282.00 | $ 184.41 | $ 110.64 | $ 195.75 | $ 56.74 | $ 165.00 | $ 255.00 | $ 255.00 | $ 300.00 | $ 300.00 | $ 225.00 | $ 56.74 | $ 300.00 |
| 201058 | CALPROTECTIN FECAL LC123255 | 300 | Laboratory | 83993 | $ 390.00 | $ 273.00 | $ 331.50 | $ 366.60 | $ 87.69 | $ 52.61 | $ 93.08 | $ 26.98 | $ 214.50 | $ 331.50 | $ 331.50 | $ 390.00 | $ 390.00 | $ 292.50 | $ 26.98 | $ 390.00 |
| 200004 | ALKALINE PHOSPHATE | 300 | Laboratory | 84075 | $ 43.00 | $ 30.10 | $ 36.55 | $ 40.42 | $ 22.91 | $ 13.75 | $ 24.32 | $ 7.05 | $ 23.65 | $ 36.55 | $ 36.55 | $ 43.00 | $ 43.00 | $ 32.25 | $ 7.05 | $ 43.00 |
| 200120 | PHOS | 300 | Laboratory | 84100 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 21.19 | $ 12.71 | $ 22.49 | $ 6.52 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 6.52 | $ 70.00 |
| 200031 | POTASSIUM | 300 | Laboratory | 84132 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 20.54 | $ 12.32 | $ 21.80 | $ 6.32 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 6.32 | $ 70.00 |
| 200174 | PROGESTERONE LC004317 | 300 | Laboratory | 84144 | $ 138.00 | $ 96.60 | $ 117.30 | $ 129.72 | $ 93.21 | $ 55.93 | $ 98.95 | $ 28.68 | $ 75.90 | $ 117.30 | $ 117.30 | $ 138.00 | $ 138.00 | $ 103.50 | $ 28.68 | $ 138.00 |
| Charge Number | Description | Rev Code | Dept | CPT Code | Price | Cash Price | Aetna | Aetna Medicare Advantage | BCBS Choice PPO | BCBS HMO Blue | BCBS Traditional | BCBS Advantage | CIGNA | Firstcare HMO | Firstcare PPO | Firstcare MA | Medicare Advantage | United | Negotiated Charge | Negotiated Charge |
| 201116 | PROCALCITONIN LC164750 | 300 | Laboratory | 84145 | $ 314.00 | $ 219.80 | $ 266.90 | $ 295.16 | $ 119.67 | $ 71.80 | $ 127.03 | $ 36.82 | $ 172.70 | $ 266.90 | $ 266.90 | $ 314.00 | $ 314.00 | $ 235.50 | $ 36.82 | $ 314.00 |
| 200992 | PROLACTIN LC004465 | 300 | Laboratory | 84146 | $ 170.00 | $ 119.00 | $ 144.50 | $ 159.80 | $ 86.58 | $ 51.95 | $ 91.91 | $ 26.64 | $ 93.50 | $ 144.50 | $ 144.50 | $ 170.00 | $ 170.00 | $ 127.50 | $ 26.64 | $ 170.00 |
| 200934 | PSA TOTAL+ % FREE LC480947 | 300 | Laboratory | 84153 | $ 183.00 | $ 128.10 | $ 155.55 | $ 172.02 | $ 82.19 | $ 49.32 | $ 87.25 | $ 25.29 | $ 100.65 | $ 155.55 | $ 155.55 | $ 183.00 | $ 183.00 | $ 137.25 | $ 25.29 | $ 183.00 |
| 201148 | ASSAY OF PSA TOTAL ultrasensitive | 300 | Laboratory | 84153 | $ 334.00 | $ 233.80 | $ 283.90 | $ 313.96 | $ 82.19 | $ 49.32 | $ 87.25 | $ 25.29 | $ 183.70 | $ 283.90 | $ 283.90 | $ 334.00 | $ 334.00 | $ 250.50 | $ 25.29 | $ 334.00 |
| 200175 | PROTEIN ELEC+INTERP,SERUM | 300 | Laboratory | 84155 | $ 89.00 | $ 62.30 | $ 75.65 | $ 83.66 | $ 16.38 | $ 9.83 | $ 17.39 | $ 5.04 | $ 48.95 | $ 75.65 | $ 75.65 | $ 89.00 | $ 89.00 | $ 66.75 | $ 5.04 | $ 89.00 |
| 200185 | PROTEIN TOTAL URINE LC013664 | 300 | Laboratory | 84156 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 16.38 | $ 9.83 | $ 17.39 | $ 5.04 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 5.04 | $ 230.00 |
| 201041 | PROTEIN ELECTROPHORESIS, 24 HR | 300 | Laboratory | 84156 | $ 160.00 | $ 112.00 | $ 136.00 | $ 150.40 | $ 16.38 | $ 9.83 | $ 17.39 | $ 5.04 | $ 88.00 | $ 136.00 | $ 136.00 | $ 160.00 | $ 160.00 | $ 120.00 | $ 5.04 | $ 160.00 |
| 200186 | PROTEIN TOTAL, QN, 24-HR URINE | 300 | Laboratory | 84156 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 16.38 | $ 9.83 | $ 17.39 | $ 5.04 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 5.04 | $ 230.00 |
| 200982 | IFE AND PRO. ELEC LC003467 | 300 | Laboratory | 84156 | $ 362.00 | $ 253.40 | $ 307.70 | $ 340.28 | $ 16.38 | $ 9.83 | $ 17.39 | $ 5.04 | $ 199.10 | $ 307.70 | $ 307.70 | $ 362.00 | $ 362.00 | $ 271.50 | $ 5.04 | $ 362.00 |
| 201012 | IMMUNOFIXATION (IFE), SERUM AN | 300 | Laboratory | 84165 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 47.97 | $ 28.78 | $ 50.92 | $ 14.76 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 14.76 | $ 130.00 |
| 201001 | PROTEIN ELECTROPHORESIS,RANDON | 300 | Laboratory | 84165 | $ 160.00 | $ 112.00 | $ 136.00 | $ 150.40 | $ 47.97 | $ 28.78 | $ 50.92 | $ 14.76 | $ 88.00 | $ 136.00 | $ 136.00 | $ 160.00 | $ 160.00 | $ 120.00 | $ 14.76 | $ 160.00 |
| 200090 | SODIUM | 300 | Laboratory | 84295 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 19.53 | $ 11.72 | $ 20.73 | $ 6.01 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 6.01 | $ 70.00 |
| 200953 | SODIUM,URINE RANDOM LC013326 | 300 | Laboratory | 84300 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 21.74 | $ 13.05 | $ 23.08 | $ 6.69 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 6.69 | $ 70.00 |
| 201014 | TESTOSTERONE,FREETOTAL LC84403 | 300 | Laboratory | 84402 | $ 334.25 | $ 233.98 | $ 284.11 | $ 314.20 | $ 113.75 | $ 68.25 | $ 120.75 | $ 35.00 | $ 183.84 | $ 284.11 | $ 284.11 | $ 334.25 | $ 334.25 | $ 250.69 | $ 35.00 | $ 334.25 |
| 200947 | TESTOSTERONE,FREE LC144980 | 300 | Laboratory | 84402 | $ 199.00 | $ 139.30 | $ 169.15 | $ 187.06 | $ 113.75 | $ 68.25 | $ 120.75 | $ 35.00 | $ 109.45 | $ 169.15 | $ 169.15 | $ 199.00 | $ 199.00 | $ 149.25 | $ 35.00 | $ 199.00 |
| 200137 | TESTOSTERONE LEVEL LC004226 | 300 | Laboratory | 84403 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 108.62 | $ 65.17 | $ 115.30 | $ 33.42 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 33.42 | $ 230.00 |
| 201129 | TESTOSTERONE TOTAL LC070001 | 300 | Laboratory | 84403 | $ 125.00 | $ 87.50 | $ 106.25 | $ 117.50 | $ 108.62 | $ 65.17 | $ 115.30 | $ 33.42 | $ 68.75 | $ 106.25 | $ 106.25 | $ 125.00 | $ 125.00 | $ 93.75 | $ 33.42 | $ 125.00 |
| 200905 | T4 THYROXINE LC001149 | 300 | Laboratory | 84436 | $ 60.00 | $ 42.00 | $ 51.00 | $ 56.40 | $ 30.68 | $ 18.41 | $ 32.57 | $ 9.44 | $ 33.00 | $ 51.00 | $ 51.00 | $ 60.00 | $ 60.00 | $ 45.00 | $ 9.44 | $ 60.00 |
| 200125 | T4 FREE LC001974 | 300 | Laboratory | 84439 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 40.30 | $ 24.18 | $ 42.78 | $ 12.40 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 12.40 | $ 130.00 |
| 200108 | TSH LC004259 | 300 | Laboratory | 84443 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 75.08 | $ 45.05 | $ 79.70 | $ 23.10 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 23.10 | $ 140.00 |
| 200074 | AST | 300 | Laboratory | 84450 | $ 50.25 | $ 35.18 | $ 42.71 | $ 47.24 | $ 23.11 | $ 13.86 | $ 24.53 | $ 7.11 | $ 27.64 | $ 42.71 | $ 42.71 | $ 50.25 | $ 50.25 | $ 37.69 | $ 7.11 | $ 50.25 |
| 200124 | T3 UPTAKE LC001156 | 300 | Laboratory | 84479 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 28.89 | $ 17.34 | $ 30.67 | $ 8.89 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 8.89 | $ 70.00 |
| 200995 | (T3)TRIIODOTHYRONINE LC002188 | 300 | Laboratory | 84480 | $ 150.00 | $ 105.00 | $ 127.50 | $ 141.00 | $ 63.34 | $ 38.01 | $ 67.24 | $ 19.49 | $ 82.50 | $ 127.50 | $ 127.50 | $ 150.00 | $ 150.00 | $ 112.50 | $ 19.49 | $ 150.00 |
| 200178 | T3 FREE (FREE T3) LC010389 | 300 | Laboratory | 84481 | $ 245.00 | $ 171.50 | $ 208.25 | $ 230.30 | $ 75.69 | $ 45.42 | $ 80.35 | $ 23.29 | $ 134.75 | $ 208.25 | $ 208.25 | $ 245.00 | $ 245.00 | $ 183.75 | $ 23.29 | $ 245.00 |
| 200959 | REVERSE T3,SERUM LC070104 | 300 | Laboratory | 84482 | $ 236.00 | $ 165.20 | $ 200.60 | $ 221.84 | $ 68.02 | $ 40.81 | $ 72.21 | $ 20.93 | $ 129.80 | $ 200.60 | $ 200.60 | $ 236.00 | $ 236.00 | $ 177.00 | $ 20.93 | $ 236.00 |
| 200097 | MI PANEL TEST 3 TROPONINI | 300 | Laboratory | 84484 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 43.97 | $ 26.38 | $ 46.68 | $ 13.53 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 13.53 | $ 80.00 |
| 200078 | BUN | 300 | Laboratory | 84520 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 15.60 | $ 9.36 | $ 16.56 | $ 4.80 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 4.80 | $ 70.00 |
| 200079 | URIC ACID | 300 | Laboratory | 84550 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 20.18 | $ 12.11 | $ 21.42 | $ 6.21 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 6.21 | $ 80.00 |
| 200977 | VITAMIN A,SERUM LC017509 | 300 | Laboratory | 84590 | $ 111.00 | $ 77.70 | $ 94.35 | $ 104.34 | $ 51.84 | $ 31.10 | $ 55.03 | $ 15.95 | $ 61.05 | $ 94.35 | $ 94.35 | $ 111.00 | $ 111.00 | $ 83.25 | $ 15.95 | $ 111.00 |
| 200165 | HCG,BETA SUBUNIT QNT SERUM (LA | 300 | Laboratory | 84702 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 67.28 | $ 40.37 | $ 71.42 | $ 20.70 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 20.70 | $ 120.00 |
| 200033 | HCG-BETA (B-HCG) URINE/SERUM | 300 | Laboratory | 84703 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 33.57 | $ 20.14 | $ 35.64 | $ 10.33 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 10.33 | $ 80.00 |
| 200016 | HEMATOCRIT | 300 | Laboratory | 85014 | $ 40.00 | $ 28.00 | $ 34.00 | $ 37.60 | $ 10.60 | $ 6.36 | $ 11.25 | $ 3.26 | $ 22.00 | $ 34.00 | $ 34.00 | $ 40.00 | $ 40.00 | $ 30.00 | $ 3.26 | $ 40.00 |
| 200017 | HEMOGLOBIN | 300 | Laboratory | 85018 | $ 40.00 | $ 28.00 | $ 34.00 | $ 37.60 | $ 10.60 | $ 6.36 | $ 11.25 | $ 3.26 | $ 22.00 | $ 34.00 | $ 34.00 | $ 40.00 | $ 40.00 | $ 30.00 | $ 3.26 | $ 40.00 |
| 200042 | CBC 1 W/PLT | 300 | Laboratory | 85025 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 34.74 | $ 20.85 | $ 36.88 | $ 10.69 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 10.69 | $ 70.00 |
| 201157 | CBC W/O DIFF | 300 | Laboratory | 85027 | $ 45.00 | $ 31.50 | $ 38.25 | $ 42.30 | $ 28.89 | $ 17.34 | $ 30.67 | $ 8.89 | $ 24.75 | $ 38.25 | $ 38.25 | $ 45.00 | $ 45.00 | $ 33.75 | $ 8.89 | $ 45.00 |
| 200063 | RETIC COUNT LC005280 | 300 | Laboratory | 85045 | $ 50.00 | $ 35.00 | $ 42.50 | $ 47.00 | $ 17.88 | $ 10.73 | $ 18.98 | $ 5.50 | $ 27.50 | $ 42.50 | $ 42.50 | $ 50.00 | $ 50.00 | $ 37.50 | $ 5.50 | $ 50.00 |
| 200083 | WBC | 300 | Laboratory | 85048 | $ 19.50 | $ 13.65 | $ 16.58 | $ 18.33 | $ 11.34 | $ 6.81 | $ 12.04 | $ 3.49 | $ 10.73 | $ 16.58 | $ 16.58 | $ 19.50 | $ 19.50 | $ 14.63 | $ 3.49 | $ 19.50 |
| 200140 | D-DIMER | 300 | Laboratory | 85379 | $ 125.00 | $ 87.50 | $ 106.25 | $ 117.50 | $ 45.47 | $ 27.28 | $ 48.27 | $ 13.99 | $ 68.75 | $ 106.25 | $ 106.25 | $ 125.00 | $ 125.00 | $ 93.75 | $ 13.99 | $ 125.00 |
| 200059 | PT INR | 300 | Laboratory | 85610 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 17.55 | $ 10.53 | $ 18.63 | $ 5.40 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 5.40 | $ 80.00 |
| 201163 | PROTHROMBIN TIME LC005199 | 300 | Laboratory | 85610 | $ 36.00 | $ 25.20 | $ 30.60 | $ 33.84 | $ 17.55 | $ 10.53 | $ 18.63 | $ 5.40 | $ 19.80 | $ 30.60 | $ 30.60 | $ 36.00 | $ 36.00 | $ 27.00 | $ 5.40 | $ 36.00 |
| 200067 | ESR (SEDRATE) | 300 | Laboratory | 85651 | $ 60.00 | $ 42.00 | $ 51.00 | $ 56.40 | $ 15.86 | $ 9.52 | $ 16.84 | $ 4.88 | $ 33.00 | $ 51.00 | $ 51.00 | $ 60.00 | $ 60.00 | $ 45.00 | $ 4.88 | $ 60.00 |
| 201100 | APTT (PTT) LC005207 | 300 | Laboratory | 85730 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 26.81 | $ 16.09 | $ 28.46 | $ 8.25 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 8.25 | $ 80.00 |
| 200028 | PTT | 300 | Laboratory | 85730 | $ 45.00 | $ 31.50 | $ 38.25 | $ 42.30 | $ 26.81 | $ 16.09 | $ 28.46 | $ 8.25 | $ 24.75 | $ 38.25 | $ 38.25 | $ 45.00 | $ 45.00 | $ 33.75 | $ 8.25 | $ 45.00 |
| 201021 | ANA TITER LC164947 | 300 | Laboratory | 86038 | $ 100.00 | $ 70.00 | $ 85.00 | $ 94.00 | $ 54.02 | $ 32.41 | $ 57.34 | $ 16.62 | $ 55.00 | $ 85.00 | $ 85.00 | $ 100.00 | $ 100.00 | $ 75.00 | $ 16.62 | $ 100.00 |
| 200150 | C-REACTIVE PROTEIN QUANT | 300 | Laboratory | 86140 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 15.44 | $ 9.26 | $ 16.39 | $ 4.75 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 4.75 | $ 80.00 |
| 200949 | COPLEMENT C4,SERUM LC001834 | 300 | Laboratory | 86160 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 53.63 | $ 32.18 | $ 56.93 | $ 16.50 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 16.50 | $ 110.00 |
| 200950 | COMPLEMENT C3,SERUM LC006452 | 300 | Laboratory | 86160 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 53.63 | $ 32.18 | $ 56.93 | $ 16.50 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 16.50 | $ 110.00 |
| 200956 | CCP ANTIBODIES LC164914 | 300 | Laboratory | 86200 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 57.85 | $ 34.71 | $ 61.41 | $ 17.80 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 17.80 | $ 140.00 |
| 200938 | ANTI-DS DNA ABS LC096339 | 300 | Laboratory | 86225 | $ 170.00 | $ 119.00 | $ 144.50 | $ 159.80 | $ 61.36 | $ 36.82 | $ 65.14 | $ 18.88 | $ 93.50 | $ 144.50 | $ 144.50 | $ 170.00 | $ 170.00 | $ 127.50 | $ 18.88 | $ 170.00 |
| 200943 | SLE PROFILE A LC056499 | 300 | Laboratory | 86225 | $ 619.00 | $ 433.30 | $ 526.15 | $ 581.86 | $ 61.36 | $ 36.82 | $ 65.14 | $ 18.88 | $ 340.45 | $ 526.15 | $ 526.15 | $ 619.00 | $ 619.00 | $ 464.25 | $ 18.88 | $ 619.00 |
| 201027 | RNP SMITH ABS LC 006338 | 300 | Laboratory | 86235 | $ 248.00 | $ 173.60 | $ 210.80 | $ 233.12 | $ 80.11 | $ 48.07 | $ 85.04 | $ 24.65 | $ 136.40 | $ 210.80 | $ 210.80 | $ 248.00 | $ 248.00 | $ 186.00 | $ 24.65 | $ 248.00 |
| 200151 | CA-125 LC002303 | 300 | Laboratory | 86304 | $ 166.00 | $ 116.20 | $ 141.10 | $ 156.04 | $ 92.98 | $ 55.79 | $ 98.70 | $ 28.61 | $ 91.30 | $ 141.10 | $ 141.10 | $ 166.00 | $ 166.00 | $ 124.50 | $ 28.61 | $ 166.00 |
| 200024 | MONO TEST | 300 | Laboratory | 86308 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 23.11 | $ 13.86 | $ 24.53 | $ 7.11 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 7.11 | $ 80.00 |
| 201044 | HEP.B SURFACE,AB,QUANTLC006530 | 300 | Laboratory | 86317 | $ 170.00 | $ 119.00 | $ 144.50 | $ 159.80 | $ 66.98 | $ 40.19 | $ 71.10 | $ 20.61 | $ 93.50 | $ 144.50 | $ 144.50 | $ 170.00 | $ 170.00 | $ 127.50 | $ 20.61 | $ 170.00 |
| 201023 | THYROID ANTIBODIES LC# 006684 | 300 | Laboratory | 86376 | $ 216.00 | $ 151.20 | $ 183.60 | $ 203.04 | $ 64.97 | $ 38.98 | $ 68.97 | $ 19.99 | $ 118.80 | $ 183.60 | $ 183.60 | $ 216.00 | $ 216.00 | $ 162.00 | $ 19.99 | $ 216.00 |
| 200065 | RA FACTOR LC006502 | 300 | Laboratory | 86431 | $ 100.00 | $ 70.00 | $ 85.00 | $ 94.00 | $ 25.35 | $ 15.21 | $ 26.91 | $ 7.80 | $ 55.00 | $ 85.00 | $ 85.00 | $ 100.00 | $ 100.00 | $ 75.00 | $ 7.80 | $ 100.00 |
| 201094 | QUANTIFERON-TB GOLD PLUS | 300 | Laboratory | 86480 | $ 330.00 | $ 231.00 | $ 280.50 | $ 310.20 | $ 272.29 | $ 163.37 | $ 289.04 | $ 83.78 | $ 181.50 | $ 280.50 | $ 280.50 | $ 330.00 | $ 330.00 | $ 247.50 | $ 83.78 | $ 330.00 |
| 201046 | QUANTIFERON-TB GOLD LC18273 | 300 | Laboratory | 86480 | $ 300.00 | $ 210.00 | $ 255.00 | $ 282.00 | $ 272.29 | $ 163.37 | $ 289.04 | $ 83.78 | $ 165.00 | $ 255.00 | $ 255.00 | $ 300.00 | $ 300.00 | $ 225.00 | $ 83.78 | $ 300.00 |
| 200060 | RPR LC006072 | 300 | Laboratory | 86592 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 17.00 | $ 10.20 | $ 18.04 | $ 5.23 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 5.23 | $ 70.00 |
| Charge Number | Description | Rev Code | Dept | CPT Code | Price | Cash Price | Aetna | Aetna Medicare Advantage | BCBS Choice PPO | BCBS HMO Blue | BCBS Traditional | BCBS Advantage | CIGNA | Firstcare HMO | Firstcare PPO | Firstcare MA | Medicare Advantage | United | Negotiated Charge | Negotiated Charge |
| 200983 | LYME DISEASE SCREEN LC160325 | 300 | Laboratory | 86618 | $ 136.00 | $ 95.20 | $ 115.60 | $ 127.84 | $ 63.83 | $ 38.30 | $ 67.76 | $ 19.64 | $ 74.80 | $ 115.60 | $ 115.60 | $ 136.00 | $ 136.00 | $ 102.00 | $ 19.64 | $ 136.00 |
| 201133 | COCCIDIOIDES IMMITIS ANTIBODIES IGG AND IGM EIA | 300 | Laboratory | 86635 | $ 270.00 | $ 189.00 | $ 229.50 | $ 253.80 | $ 51.25 | $ 30.75 | $ 54.41 | $ 15.77 | $ 148.50 | $ 229.50 | $ 229.50 | $ 270.00 | $ 270.00 | $ 202.50 | $ 15.77 | $ 270.00 |
| 201045 | CYTOMEGALOVIRUS(CMV)AB IGG | 300 | Laboratory | 86644 | $ 112.00 | $ 78.40 | $ 95.20 | $ 105.28 | $ 64.32 | $ 38.59 | $ 68.28 | $ 19.79 | $ 61.60 | $ 95.20 | $ 95.20 | $ 112.00 | $ 112.00 | $ 84.00 | $ 19.79 | $ 112.00 |
| 201112 | EBV ANTIBODY PROFILE | 300 | Laboratory | 86664 | $ 315.00 | $ 220.50 | $ 267.75 | $ 296.10 | $ 63.83 | $ 38.30 | $ 67.76 | $ 19.64 | $ 173.25 | $ 267.75 | $ 267.75 | $ 315.00 | $ 315.00 | $ 236.25 | $ 19.64 | $ 315.00 |
| 200002 | H PYLORI LC162289 | 300 | Laboratory | 86677 | $ 140.00 | $ 98.00 | $ 119.00 | $ 131.60 | $ 64.84 | $ 38.90 | $ 68.83 | $ 19.95 | $ 77.00 | $ 119.00 | $ 119.00 | $ 140.00 | $ 140.00 | $ 105.00 | $ 19.95 | $ 140.00 |
| 200173 | HIV PANEL LC083935 | 300 | Laboratory | 86703 | $ 170.00 | $ 119.00 | $ 144.50 | $ 159.80 | $ 47.19 | $ 28.31 | $ 50.09 | $ 14.52 | $ 93.50 | $ 144.50 | $ 144.50 | $ 170.00 | $ 170.00 | $ 127.50 | $ 14.52 | $ 170.00 |
| 200936 | HEP B CORE AB TOTAL LC006718 | 300 | Laboratory | 86704 | $ 96.00 | $ 67.20 | $ 81.60 | $ 90.24 | $ 53.85 | $ 32.31 | $ 57.17 | $ 16.57 | $ 52.80 | $ 81.60 | $ 81.60 | $ 96.00 | $ 96.00 | $ 72.00 | $ 16.57 | $ 96.00 |
| 200921 | HEP B SURF AB LC006395 | 300 | Laboratory | 86706 | $ 87.00 | $ 60.90 | $ 73.95 | $ 81.78 | $ 47.97 | $ 28.78 | $ 50.92 | $ 14.76 | $ 47.85 | $ 73.95 | $ 73.95 | $ 87.00 | $ 87.00 | $ 65.25 | $ 14.76 | $ 87.00 |
| 200958 | HEP A AB,TOTAL LC006726 | 300 | Laboratory | 86708 | $ 91.00 | $ 63.70 | $ 77.35 | $ 85.54 | $ 55.35 | $ 33.21 | $ 58.75 | $ 17.03 | $ 50.05 | $ 77.35 | $ 77.35 | $ 91.00 | $ 91.00 | $ 68.25 | $ 17.03 | $ 91.00 |
| 201055 | MEASLES, MUMPS, RUBELLA IMMUNI | 300 | Laboratory | 86735 | $ 320.00 | $ 224.00 | $ 272.00 | $ 300.80 | $ 58.31 | $ 34.98 | $ 61.89 | $ 17.94 | $ 176.00 | $ 272.00 | $ 272.00 | $ 320.00 | $ 320.00 | $ 240.00 | $ 17.94 | $ 320.00 |
| 201131 | SARS CoV-2 ANTIBODY, IgM, SPIKE | 300 | Laboratory | 86769 | $ 108.00 | $ 75.60 | $ 91.80 | $ 101.52 | $ 81.00 | $ 75.60 | $ 86.40 | $ 81.00 | $ 59.40 | $ 91.80 | $ 91.80 | $ 108.00 | $ 108.00 | $ 81.00 | $ 59.40 | $ 108.00 |
| 201118 | SARS COV 2 ANTIBODY IGG | 300 | Laboratory | 86769 | $ 60.00 | $ 42.00 | $ 51.00 | $ 56.40 | $ 45.00 | $ 42.00 | $ 48.00 | $ 45.00 | $ 33.00 | $ 51.00 | $ 51.00 | $ 60.00 | $ 60.00 | $ 45.00 | $ 33.00 | $ 60.00 |
| 201127 | TREPONEMA PALLIDUM ANTIBODIES | 300 | Laboratory | 86780 | $ 98.00 | $ 68.60 | $ 83.30 | $ 92.12 | $ 59.15 | $ 35.49 | $ 62.79 | $ 18.20 | $ 53.90 | $ 83.30 | $ 83.30 | $ 98.00 | $ 98.00 | $ 73.50 | $ 18.20 | $ 98.00 |
| 201085 | FTA-ABS TREPONEMA LC#006379 | 300 | Laboratory | 86780 | $ 190.00 | $ 133.00 | $ 161.50 | $ 178.60 | $ 59.15 | $ 35.49 | $ 62.79 | $ 18.20 | $ 104.50 | $ 161.50 | $ 161.50 | $ 190.00 | $ 190.00 | $ 142.50 | $ 18.20 | $ 190.00 |
| 201111 | VZV IGM LC096776 | 300 | Laboratory | 86787 | $ 113.00 | $ 79.10 | $ 96.05 | $ 106.22 | $ 57.56 | $ 34.53 | $ 61.10 | $ 17.71 | $ 62.15 | $ 96.05 | $ 96.05 | $ 113.00 | $ 113.00 | $ 84.75 | $ 17.71 | $ 113.00 |
| 200907 | VARICELLA-ZOSTER(VZV,IGG) | 300 | Laboratory | 86787 | $ 102.00 | $ 71.40 | $ 86.70 | $ 95.88 | $ 57.56 | $ 34.53 | $ 61.10 | $ 17.71 | $ 56.10 | $ 86.70 | $ 86.70 | $ 102.00 | $ 102.00 | $ 76.50 | $ 17.71 | $ 102.00 |
| 201096 | THYROGLOBULIN ANTIBODY&IMA OR | 300 | Laboratory | 86800 | $ 102.00 | $ 71.40 | $ 86.70 | $ 95.88 | $ 53.98 | $ 32.39 | $ 57.30 | $ 16.61 | $ 56.10 | $ 86.70 | $ 86.70 | $ 102.00 | $ 102.00 | $ 76.50 | $ 16.61 | $ 102.00 |
| 200166 | HCV ANTIBODY LC140659 | 300 | Laboratory | 86803 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 59.44 | $ 35.67 | $ 63.10 | $ 18.29 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 18.29 | $ 120.00 |
| 200951 | HEP C VIRUS(HCV) (LABCORP #140 | 300 | Laboratory | 86803 | $ 107.00 | $ 74.90 | $ 90.95 | $ 100.58 | $ 59.44 | $ 35.67 | $ 63.10 | $ 18.29 | $ 58.85 | $ 90.95 | $ 90.95 | $ 107.00 | $ 107.00 | $ 80.25 | $ 18.29 | $ 107.00 |
| 200044 | ANTIBODY SCREEN (AB SCREEN) | 300 | Laboratory | 86850 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 58.37 | $ 35.02 | $ 61.96 | $ 17.96 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 17.96 | $ 70.00 |
| 200010 | BLOOD TYPE - ABO | 300 | Laboratory | 86900 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 31.43 | $ 18.86 | $ 33.36 | $ 9.67 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 9.67 | $ 110.00 |
| 200012 | BLOOD TYPE RH | 300 | Laboratory | 86901 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 31.43 | $ 18.86 | $ 33.36 | $ 9.67 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 9.67 | $ 110.00 |
| 200087 | CROSSMATCH | 300 | Laboratory | 86922 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 81.22 | $ 48.73 | $ 86.22 | $ 24.99 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 24.99 | $ 210.00 |
| 200979 | CROSSMATCH # 2 | 300 | Laboratory | 86922 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 81.22 | $ 48.73 | $ 86.22 | $ 24.99 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 24.99 | $ 210.00 |
| 200048 | CULTURE BLOOD LC008300 | 300 | Laboratory | 87040 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 33.67 | $ 20.20 | $ 35.74 | $ 10.36 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 10.36 | $ 120.00 |
| 200177 | CULTURE STOOL LC008144 | 300 | Laboratory | 87045 | $ 196.00 | $ 137.20 | $ 166.60 | $ 184.24 | $ 42.15 | $ 25.29 | $ 44.75 | $ 12.97 | $ 107.80 | $ 166.60 | $ 166.60 | $ 196.00 | $ 196.00 | $ 147.00 | $ 12.97 | $ 196.00 |
| 200145 | CULTURE AEROBIC LC008649 | 300 | Laboratory | 87070 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 38.48 | $ 23.09 | $ 40.85 | $ 11.84 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 11.84 | $ 110.00 |
| 200162 | CULTURE GENITAL LC008334 | 300 | Laboratory | 87070 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 38.48 | $ 23.09 | $ 40.85 | $ 11.84 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 11.84 | $ 110.00 |
| 200172 | CULTURE SPUTUM LC180810 | 300 | Laboratory | 87070 | $ 82.00 | $ 57.40 | $ 69.70 | $ 77.08 | $ 38.48 | $ 23.09 | $ 40.85 | $ 11.84 | $ 45.10 | $ 69.70 | $ 69.70 | $ 82.00 | $ 82.00 | $ 61.50 | $ 11.84 | $ 82.00 |
| 200179 | CULTURE NASAL/THROAT LC008342 | 300 | Laboratory | 87070 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 38.48 | $ 23.09 | $ 40.85 | $ 11.84 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 11.84 | $ 110.00 |
| 200985 | MRSA SCREENING CULTURE | 300 | Laboratory | 87081 | $ 93.00 | $ 65.10 | $ 79.05 | $ 87.42 | $ 18.36 | $ 11.02 | $ 19.49 | $ 5.65 | $ 51.15 | $ 79.05 | $ 79.05 | $ 93.00 | $ 93.00 | $ 69.75 | $ 5.65 | $ 93.00 |
| 200180 | CULTURE URINE ROUTINE LC008847 | 300 | Laboratory | 87086 | $ 100.00 | $ 70.00 | $ 85.00 | $ 94.00 | $ 25.77 | $ 15.46 | $ 27.36 | $ 7.93 | $ 55.00 | $ 85.00 | $ 85.00 | $ 100.00 | $ 100.00 | $ 75.00 | $ 7.93 | $ 100.00 |
| 201004 | YEAST ONLY, CULTURE LC182776 | 300 | Laboratory | 87101 | $ 98.00 | $ 68.60 | $ 83.30 | $ 92.12 | $ 33.67 | $ 20.20 | $ 35.74 | $ 10.36 | $ 53.90 | $ 83.30 | $ 83.30 | $ 98.00 | $ 98.00 | $ 73.50 | $ 10.36 | $ 98.00 |
| 201074 | ORGANISM IDENTIFICATION, YEAST | 300 | Laboratory | 87106 | $ 116.00 | $ 81.20 | $ 98.60 | $ 109.04 | $ 46.12 | $ 27.67 | $ 48.96 | $ 14.19 | $ 63.80 | $ 98.60 | $ 98.60 | $ 116.00 | $ 116.00 | $ 87.00 | $ 14.19 | $ 116.00 |
| 200990 | CHLAMYDIA TRACHOMATIS CULT | 300 | Laboratory | 87110 | $ 142.00 | $ 99.40 | $ 120.70 | $ 133.48 | $ 87.52 | $ 52.51 | $ 92.91 | $ 26.93 | $ 78.10 | $ 120.70 | $ 120.70 | $ 142.00 | $ 142.00 | $ 106.50 | $ 26.93 | $ 142.00 |
| 200027 | OVA & PARASITES CONCENTRATE ST | 300 | Laboratory | 87177 | $ 130.00 | $ 91.00 | $ 110.50 | $ 122.20 | $ 39.75 | $ 23.85 | $ 42.19 | $ 12.23 | $ 71.50 | $ 110.50 | $ 110.50 | $ 130.00 | $ 130.00 | $ 97.50 | $ 12.23 | $ 130.00 |
| 200049 | CULTURE W/SENSITIVITY LC182261 | 300 | Laboratory | 87186 | $ 82.75 | $ 57.93 | $ 70.34 | $ 77.79 | $ 38.61 | $ 23.17 | $ 40.99 | $ 11.88 | $ 45.51 | $ 70.34 | $ 70.34 | $ 82.75 | $ 82.75 | $ 62.06 | $ 11.88 | $ 82.75 |
| 201080 | GRAM STAIN EVAL WITH SPUTUM CU | 300 | Laboratory | 87205 | $ 82.00 | $ 57.40 | $ 69.70 | $ 77.08 | $ 19.08 | $ 11.45 | $ 20.25 | $ 5.87 | $ 45.10 | $ 69.70 | $ 69.70 | $ 82.00 | $ 82.00 | $ 61.50 | $ 5.87 | $ 82.00 |
| 200015 | GRAM STAIN LC008540 | 300 | Laboratory | 87205 | $ 31.00 | $ 21.70 | $ 26.35 | $ 29.14 | $ 19.08 | $ 11.45 | $ 20.25 | $ 5.87 | $ 17.05 | $ 26.35 | $ 26.35 | $ 31.00 | $ 31.00 | $ 23.25 | $ 5.87 | $ 31.00 |
| 200901 | C-DIFF A&B EIA LC086207 | 300 | Laboratory | 87324 | $ 128.00 | $ 89.60 | $ 108.80 | $ 120.32 | $ 51.16 | $ 30.69 | $ 54.30 | $ 15.74 | $ 70.40 | $ 108.80 | $ 108.80 | $ 128.00 | $ 128.00 | $ 96.00 | $ 15.74 | $ 128.00 |
| 201057 | GIARDIA CRYPTOSPOIDIUM EIA | 300 | Laboratory | 87328 | $ 232.75 | $ 162.93 | $ 197.84 | $ 218.79 | $ 51.16 | $ 30.69 | $ 54.30 | $ 15.74 | $ 128.01 | $ 197.84 | $ 197.84 | $ 232.75 | $ 232.75 | $ 174.56 | $ 15.74 | $ 232.75 |
| 201007 | PYLORI STOOL ANTIGEN LC180764 | 300 | Laboratory | 87338 | $ 221.00 | $ 154.70 | $ 187.85 | $ 207.74 | $ 51.25 | $ 30.75 | $ 54.41 | $ 15.77 | $ 121.55 | $ 187.85 | $ 187.85 | $ 221.00 | $ 221.00 | $ 165.75 | $ 15.77 | $ 221.00 |
| 200952 | HEP B SURF AG LC006510 | 300 | Laboratory | 87340 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 46.15 | $ 27.69 | $ 48.99 | $ 14.20 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 14.20 | $ 80.00 |
| 201076 | CHLAMDIA TRACH, NEISSERIA, TRI | 300 | Laboratory | 87491 | $ 384.00 | $ 268.80 | $ 326.40 | $ 360.96 | $ 116.38 | $ 69.83 | $ 123.54 | $ 35.81 | $ 211.20 | $ 326.40 | $ 326.40 | $ 384.00 | $ 384.00 | $ 288.00 | $ 35.81 | $ 384.00 |
| 200155 | CULTURE CHLAMYDIA/GC AMP | 300 | Laboratory | 87491 | $ 246.00 | $ 172.20 | $ 209.10 | $ 231.24 | $ 116.38 | $ 69.83 | $ 123.54 | $ 35.81 | $ 135.30 | $ 209.10 | $ 209.10 | $ 246.00 | $ 246.00 | $ 184.50 | $ 35.81 | $ 246.00 |
| 201103 | CH, NG, TV, HSV BY NAA NU SWAB | 300 | Laboratory | 87491 | $ 756.00 | $ 529.20 | $ 642.60 | $ 710.64 | $ 116.38 | $ 69.83 | $ 123.54 | $ 35.81 | $ 415.80 | $ 642.60 | $ 642.60 | $ 756.00 | $ 756.00 | $ 567.00 | $ 35.81 | $ 756.00 |
| 201104 | VAGINITIS PLUS NU SWAB | 300 | Laboratory | 87491 | $ 909.00 | $ 636.30 | $ 772.65 | $ 854.46 | $ 116.38 | $ 69.83 | $ 123.54 | $ 35.81 | $ 499.95 | $ 772.65 | $ 772.65 | $ 909.00 | $ 909.00 | $ 681.75 | $ 35.81 | $ 909.00 |
| 200955 | TRICH VAGINALIS,NAA LC188052 | 300 | Laboratory | 87798 | $ 138.00 | $ 96.60 | $ 117.30 | $ 129.72 | $ 116.38 | $ 69.83 | $ 123.54 | $ 35.81 | $ 75.90 | $ 117.30 | $ 117.30 | $ 138.00 | $ 138.00 | $ 103.50 | $ 35.81 | $ 138.00 |
| 200126 | FLU TEST | 300 | Laboratory | 87804 | $ 120.00 | $ 84.00 | $ 102.00 | $ 112.80 | $ 51.16 | $ 30.69 | $ 54.30 | $ 15.74 | $ 66.00 | $ 102.00 | $ 102.00 | $ 120.00 | $ 120.00 | $ 90.00 | $ 15.74 | $ 120.00 |
| 200176 | RSV AG, EIA LC014548 | 300 | Laboratory | 87807 | $ 123.00 | $ 86.10 | $ 104.55 | $ 115.62 | $ 51.16 | $ 30.69 | $ 54.30 | $ 15.74 | $ 67.65 | $ 104.55 | $ 104.55 | $ 123.00 | $ 123.00 | $ 92.25 | $ 15.74 | $ 123.00 |
| 200109 | STREP SCREEN | 300 | Laboratory | 87880 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 51.16 | $ 30.69 | $ 54.30 | $ 15.74 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 15.74 | $ 80.00 |
| 200922 | T.PHLEBOTOMY | 300 | Laboratory | 99195 | $ 390.00 | $ 273.00 | $ 331.50 | $ 366.60 | $ 292.50 | $ 273.00 | $ 312.00 | $ 292.50 | $ 214.50 | $ 331.50 | $ 331.50 | $ 390.00 | $ 390.00 | $ 292.50 | $ 214.50 | $ 390.00 |
| 200034 | PSA LC010322 | 300 | Laboratory | G0103 | $ 137.00 | $ 95.90 | $ 116.45 | $ 128.78 | $ 82.19 | $ 49.32 | $ 87.25 | $ 25.29 | $ 75.35 | $ 116.45 | $ 116.45 | $ 137.00 | $ 137.00 | $ 102.75 | $ 25.29 | $ 137.00 |
| 201147 | NEWBORN METABLIC SCREENING PANEL | 300 | Laboratory | S3620 | $ 126.00 | $ 88.20 | $ 107.10 | $ 118.44 | $ 94.50 | $ 88.20 | $ 100.80 | $ 94.50 | $ 69.30 | $ 107.10 | $ 107.10 | $ 126.00 | $ 126.00 | $ 94.50 | $ 69.30 | $ 126.00 |
| 201117 | COVID-19,NAA LC 139900 | 300 | Laboratory | U0003 | $ 350.00 | $ 245.00 | $ 297.50 | $ 329.00 | $ 325.00 | $ 195.00 | $ 345.00 | $ 100.00 | $ 192.50 | $ 297.50 | $ 297.50 | $ 350.00 | $ 350.00 | $ 262.50 | $ 100.00 | $ 350.00 |
| 270003 | ELECTRIC STIMULATION THERAPY | 420 | Physical Therapy | 97014 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 39.93 | $ 23.96 | $ 43.92 | $ 15.97 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 15.97 | $ 80.00 |
| 270004 | MANUAL ELECTRIC STIMULATION | 420 | Physical Therapy | 97032 | $ 70.00 | $ 49.00 | $ 59.50 | $ 65.80 | $ 47.58 | $ 28.55 | $ 52.33 | $ 19.03 | $ 38.50 | $ 59.50 | $ 59.50 | $ 70.00 | $ 70.00 | $ 52.50 | $ 19.03 | $ 70.00 |
| 270001 | ULTRASOUND THERAPY | 420 | Physical Therapy | 97035 | $ 80.00 | $ 56.00 | $ 68.00 | $ 75.20 | $ 31.43 | $ 18.86 | $ 34.57 | $ 12.57 | $ 44.00 | $ 68.00 | $ 68.00 | $ 80.00 | $ 80.00 | $ 60.00 | $ 12.57 | $ 80.00 |
| 270014 | THERAPEUTIC EXERCISE | 420 | Physical Therapy | 97110 | $ 90.00 | $ 63.00 | $ 76.50 | $ 84.60 | $ 79.85 | $ 47.91 | $ 87.84 | $ 31.94 | $ 49.50 | $ 76.50 | $ 76.50 | $ 90.00 | $ 90.00 | $ 67.50 | $ 31.94 | $ 90.00 |
| Charge Number | Description | Rev Code | Dept | CPT Code | Price | Cash Price | Aetna | Aetna Medicare Advantage | BCBS Choice PPO | BCBS HMO Blue | BCBS Traditional | BCBS Advantage | CIGNA | Firstcare HMO | Firstcare PPO | Firstcare MA | Medicare Advantage | United | Negotiated Charge | Negotiated Charge |
| 270010 | GAIT TRAINING THERAPY | 420 | Physical Therapy | 97116 | $ 90.00 | $ 63.00 | $ 76.50 | $ 84.60 | $ 70.50 | $ 42.30 | $ 77.55 | $ 28.20 | $ 49.50 | $ 76.50 | $ 76.50 | $ 90.00 | $ 90.00 | $ 67.50 | $ 28.20 | $ 90.00 |
| 270005 | MASSAGE THERAPY | 420 | Physical Therapy | 97124 | $ 110.00 | $ 77.00 | $ 93.50 | $ 103.40 | $ 65.40 | $ 39.24 | $ 71.94 | $ 26.16 | $ 60.50 | $ 93.50 | $ 93.50 | $ 110.00 | $ 110.00 | $ 82.50 | $ 26.16 | $ 110.00 |
| 270006 | PT EVAL LOW COMPLEX 20 MIN | 420 | Physical Therapy | 97161 | $ 250.00 | $ 175.00 | $ 212.50 | $ 235.00 | $ 203.80 | $ 122.28 | $ 224.18 | $ 81.52 | $ 137.50 | $ 212.50 | $ 212.50 | $ 250.00 | $ 250.00 | $ 187.50 | $ 81.52 | $ 250.00 |
| 270080 | PT EVAL MOD COMPLEX 30 MIN | 420 | Physical Therapy | 97162 | $ 275.00 | $ 192.50 | $ 233.75 | $ 258.50 | $ 203.80 | $ 122.28 | $ 224.18 | $ 81.52 | $ 151.25 | $ 233.75 | $ 233.75 | $ 275.00 | $ 275.00 | $ 206.25 | $ 81.52 | $ 275.00 |
| 270008 | THERAPEUTIC ACTIVITIES | 420 | Physical Therapy | 97530 | $ 100.00 | $ 70.00 | $ 85.00 | $ 94.00 | $ 87.50 | $ 52.50 | $ 96.25 | $ 35.00 | $ 55.00 | $ 85.00 | $ 85.00 | $ 100.00 | $ 100.00 | $ 75.00 | $ 35.00 | $ 100.00 |
| 300046 | MANDIBLE TWO VIEWS | 320 | Radiology | 70100 | $ 175.00 | $ 122.50 | $ 148.75 | $ 164.50 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 96.25 | $ 148.75 | $ 148.75 | $ 175.00 | $ 175.00 | $ 131.25 | $ 45.95 | $ 175.00 |
| 300106 | FACIAL BONES-2 VIEWS | 320 | Radiology | 70140 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300024 | FACIAL BONES COMPLETE SERIES | 320 | Radiology | 70150 | $ 250.00 | $ 175.00 | $ 212.50 | $ 235.00 | $ 230.23 | $ 138.14 | $ 244.40 | $ 70.84 | $ 137.50 | $ 212.50 | $ 212.50 | $ 250.00 | $ 250.00 | $ 187.50 | $ 70.84 | $ 250.00 |
| 300050 | NOSE | 320 | Radiology | 70160 | $ 175.00 | $ 122.50 | $ 148.75 | $ 164.50 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 96.25 | $ 148.75 | $ 148.75 | $ 175.00 | $ 175.00 | $ 131.25 | $ 45.95 | $ 175.00 |
| 300073 | SINUSES, PARANASAL COMPLETE | 320 | Radiology | 70220 | $ 260.00 | $ 182.00 | $ 221.00 | $ 244.40 | $ 230.23 | $ 138.14 | $ 244.40 | $ 70.84 | $ 143.00 | $ 221.00 | $ 221.00 | $ 260.00 | $ 260.00 | $ 195.00 | $ 70.84 | $ 260.00 |
| 300067 | SKULL THREE VIEWS | 320 | Radiology | 70250 | $ 175.00 | $ 122.50 | $ 148.75 | $ 164.50 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 96.25 | $ 148.75 | $ 148.75 | $ 175.00 | $ 175.00 | $ 131.25 | $ 45.95 | $ 175.00 |
| 300066 | SKULL TWO VIEWS | 320 | Radiology | 70250 | $ 175.00 | $ 122.50 | $ 148.75 | $ 164.50 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 96.25 | $ 148.75 | $ 148.75 | $ 175.00 | $ 175.00 | $ 131.25 | $ 45.95 | $ 175.00 |
| 300008 | CHEST ONE VIEW | 320 | Radiology | 71045 | $ 225.00 | $ 157.50 | $ 191.25 | $ 211.50 | $ 201.86 | $ 121.11 | $ 214.28 | $ 62.11 | $ 123.75 | $ 191.25 | $ 191.25 | $ 225.00 | $ 225.00 | $ 168.75 | $ 62.11 | $ 225.00 |
| 300009 | CHEST TWO VIEWS | 320 | Radiology | 71046 | $ 240.00 | $ 168.00 | $ 204.00 | $ 225.60 | $ 201.86 | $ 121.11 | $ 214.28 | $ 62.11 | $ 132.00 | $ 204.00 | $ 204.00 | $ 240.00 | $ 240.00 | $ 180.00 | $ 62.11 | $ 240.00 |
| 300076 | STERNUM TWO VIEWS | 320 | Radiology | 71120 | $ 175.00 | $ 122.50 | $ 148.75 | $ 164.50 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 96.25 | $ 148.75 | $ 148.75 | $ 175.00 | $ 175.00 | $ 131.25 | $ 45.95 | $ 175.00 |
| 300079 | SPINE-CERVICAL THREE VIEWS | 320 | Radiology | 72040 | $ 270.00 | $ 189.00 | $ 229.50 | $ 253.80 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 148.50 | $ 229.50 | $ 229.50 | $ 270.00 | $ 270.00 | $ 202.50 | $ 45.95 | $ 270.00 |
| 300078 | SPINE-CERVICAL TWO VIEWS | 320 | Radiology | 72040 | $ 270.00 | $ 189.00 | $ 229.50 | $ 253.80 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 148.50 | $ 229.50 | $ 229.50 | $ 270.00 | $ 270.00 | $ 202.50 | $ 45.95 | $ 270.00 |
| 300011 | SPINE CERVICAL (5) COMPLETE | 320 | Radiology | 72052 | $ 330.00 | $ 231.00 | $ 280.50 | $ 310.20 | $ 230.23 | $ 138.14 | $ 244.40 | $ 70.84 | $ 181.50 | $ 280.50 | $ 280.50 | $ 330.00 | $ 330.00 | $ 247.50 | $ 70.84 | $ 330.00 |
| 300081 | SPINE-THORACIC TWO VIEWS | 320 | Radiology | 72070 | $ 270.00 | $ 189.00 | $ 229.50 | $ 253.80 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 148.50 | $ 229.50 | $ 229.50 | $ 270.00 | $ 270.00 | $ 202.50 | $ 45.95 | $ 270.00 |
| 300083 | SPINE-LUMBO-SACRAL THREE VIEWS | 320 | Radiology | 72100 | $ 290.00 | $ 203.00 | $ 246.50 | $ 272.60 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 159.50 | $ 246.50 | $ 246.50 | $ 290.00 | $ 290.00 | $ 217.50 | $ 45.95 | $ 290.00 |
| 300116 | SPINE-LUMBO-SACRAL TWO VIEWS | 320 | Radiology | 72110 | $ 340.00 | $ 238.00 | $ 289.00 | $ 319.60 | $ 230.23 | $ 138.14 | $ 244.40 | $ 70.84 | $ 187.00 | $ 289.00 | $ 289.00 | $ 340.00 | $ 340.00 | $ 255.00 | $ 70.84 | $ 340.00 |
| 300084 | SPINE-LUMBO-SACRAL FIVE VIEWS | 320 | Radiology | 72114 | $ 250.00 | $ 175.00 | $ 212.50 | $ 235.00 | $ 230.23 | $ 138.14 | $ 244.40 | $ 70.84 | $ 137.50 | $ 212.50 | $ 212.50 | $ 250.00 | $ 250.00 | $ 187.50 | $ 70.84 | $ 250.00 |
| 300052 | PELVIS ONE VIEW | 320 | Radiology | 72170 | $ 250.00 | $ 175.00 | $ 212.50 | $ 235.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 137.50 | $ 212.50 | $ 212.50 | $ 250.00 | $ 250.00 | $ 187.50 | $ 45.95 | $ 250.00 |
| 300014 | COCCYX TWO VIEWS | 320 | Radiology | 72220 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300070 | SACRUM TWO VIEWS | 320 | Radiology | 72220 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300012 | CLAVICLE ONE VIEW | 320 | Radiology | 73000 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300013 | CLAVICLE TWO VIEWS | 320 | Radiology | 73000 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300062 | SCAPULA TWO VIEWS | 320 | Radiology | 73010 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 45.95 | $ 230.00 |
| 300064 | SHOULDER TWO VIEWS | 320 | Radiology | 73030 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 45.95 | $ 210.00 |
| 300039 | HUMERUS | 320 | Radiology | 73060 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300020 | ELBOW | 320 | Radiology | 73070 | $ 190.00 | $ 133.00 | $ 161.50 | $ 178.60 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 104.50 | $ 161.50 | $ 161.50 | $ 190.00 | $ 190.00 | $ 142.50 | $ 45.95 | $ 190.00 |
| 300030 | FOREARM | 320 | Radiology | 73090 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300094 | WRIST TWO VIEWS | 320 | Radiology | 73100 | $ 180.00 | $ 126.00 | $ 153.00 | $ 169.20 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 99.00 | $ 153.00 | $ 153.00 | $ 180.00 | $ 180.00 | $ 135.00 | $ 45.95 | $ 180.00 |
| 300095 | WRIST THREE VIEWS | 320 | Radiology | 73110 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 45.95 | $ 210.00 |
| 300034 | HAND TWO VIEWS | 320 | Radiology | 73120 | $ 190.00 | $ 133.00 | $ 161.50 | $ 178.60 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 104.50 | $ 161.50 | $ 161.50 | $ 190.00 | $ 190.00 | $ 142.50 | $ 45.95 | $ 190.00 |
| 340042 | HAND 3 VIEW | 320 | Radiology | 73130 | $ 190.00 | $ 133.00 | $ 161.50 | $ 178.60 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 104.50 | $ 161.50 | $ 161.50 | $ 190.00 | $ 190.00 | $ 142.50 | $ 45.95 | $ 190.00 |
| 300027 | FINGER | 320 | Radiology | 73140 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 45.95 | $ 210.00 |
| 300038 | HIP TWO VIEWS | 320 | Radiology | 73502 | $ 230.00 | $ 161.00 | $ 195.50 | $ 216.20 | $ 197.60 | $ 118.56 | $ 209.76 | $ 60.80 | $ 126.50 | $ 195.50 | $ 195.50 | $ 230.00 | $ 230.00 | $ 172.50 | $ 60.80 | $ 230.00 |
| 300022 | FEMUR ONE VIEW | 320 | Radiology | 73551 | $ 225.00 | $ 157.50 | $ 191.25 | $ 211.50 | $ 197.60 | $ 118.56 | $ 209.76 | $ 60.80 | $ 123.75 | $ 191.25 | $ 191.25 | $ 225.00 | $ 225.00 | $ 168.75 | $ 60.80 | $ 225.00 |
| 300023 | FEMUR TWO VIEWS | 320 | Radiology | 73552 | $ 220.00 | $ 154.00 | $ 187.00 | $ 206.80 | $ 197.60 | $ 118.56 | $ 209.76 | $ 60.80 | $ 121.00 | $ 187.00 | $ 187.00 | $ 220.00 | $ 220.00 | $ 165.00 | $ 60.80 | $ 220.00 |
| 300042 | KNEE TWO VIEWS | 320 | Radiology | 73560 | $ 190.00 | $ 133.00 | $ 161.50 | $ 178.60 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 104.50 | $ 161.50 | $ 161.50 | $ 190.00 | $ 190.00 | $ 142.50 | $ 45.95 | $ 190.00 |
| 300043 | KNEE THREE VIEWS | 320 | Radiology | 73562 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 45.95 | $ 210.00 |
| 300087 | TIBIA AND FIBULA TWO VIEWS | 320 | Radiology | 73590 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 45.95 | $ 210.00 |
| 300086 | TIBIA AND FIBULA ONE VIEW | 320 | Radiology | 73590 | $ 210.00 | $ 147.00 | $ 178.50 | $ 197.40 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 115.50 | $ 178.50 | $ 178.50 | $ 210.00 | $ 210.00 | $ 157.50 | $ 45.95 | $ 210.00 |
| 300001 | ANKLE TWO VIEWS | 320 | Radiology | 73600 | $ 190.00 | $ 133.00 | $ 161.50 | $ 178.60 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 104.50 | $ 161.50 | $ 161.50 | $ 190.00 | $ 190.00 | $ 142.50 | $ 45.95 | $ 190.00 |
| 300002 | ANKLE THREE VIEWS | 320 | Radiology | 73610 | $ 220.00 | $ 154.00 | $ 187.00 | $ 206.80 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 121.00 | $ 187.00 | $ 187.00 | $ 220.00 | $ 220.00 | $ 165.00 | $ 45.95 | $ 220.00 |
| 300003 | ANKLE & FOOT FIVE VIEWS COMPLE | 320 | Radiology | 73610 | $ 220.00 | $ 154.00 | $ 187.00 | $ 206.80 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 121.00 | $ 187.00 | $ 187.00 | $ 220.00 | $ 220.00 | $ 165.00 | $ 45.95 | $ 220.00 |
| 300028 | FOOT TWO VIEWS | 320 | Radiology | 73620 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| 300029 | FOOT THREE VIEWS | 320 | Radiology | 73630 | $ 220.00 | $ 154.00 | $ 187.00 | $ 206.80 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 121.00 | $ 187.00 | $ 187.00 | $ 220.00 | $ 220.00 | $ 165.00 | $ 45.95 | $ 220.00 |
| 300088 | TOES | 320 | Radiology | 73660 | $ 190.00 | $ 133.00 | $ 161.50 | $ 178.60 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 104.50 | $ 161.50 | $ 161.50 | $ 190.00 | $ 190.00 | $ 142.50 | $ 45.95 | $ 190.00 |
| 300004 | ABDOMEN ONE VIEW | 320 | Radiology | 74018 | $ 225.00 | $ 157.50 | $ 191.25 | $ 211.50 | $ 201.86 | $ 121.11 | $ 214.28 | $ 62.11 | $ 123.75 | $ 191.25 | $ 191.25 | $ 225.00 | $ 225.00 | $ 168.75 | $ 62.11 | $ 225.00 |
| 300005 | ABDOMEN TWO VIEWS | 320 | Radiology | 74019 | $ 425.00 | $ 297.50 | $ 361.25 | $ 399.50 | $ 385.91 | $ 231.54 | $ 409.65 | $ 118.74 | $ 233.75 | $ 361.25 | $ 361.25 | $ 425.00 | $ 425.00 | $ 318.75 | $ 118.74 | $ 425.00 |
| 300006 | ABDOMEN THREE VIEWS | 320 | Radiology | 74021 | $ 425.00 | $ 297.50 | $ 361.25 | $ 399.50 | $ 385.91 | $ 231.54 | $ 409.65 | $ 118.74 | $ 233.75 | $ 361.25 | $ 361.25 | $ 425.00 | $ 425.00 | $ 318.75 | $ 118.74 | $ 425.00 |
| 41212 | OFFICE/OUTPATIENT VISIT NEW | 521 | Rural Health Clinic | 99203 | $ 180.00 | $ 171.00 | $ 120.83 | $ 168.48 | $ 85.38 | $ 85.38 | $ 85.38 | $ 85.38 | $ 82.00 | $ 100.18 | $ 100.18 | $ 168.83 | $ 168.83 | $ 131.48 | $ 82.00 | $ 168.83 |
| 41213 | OFFICE/OUTPATIENT VISIT NEW | 521 | Rural Health Clinic | 99204 | $ 245.00 | $ 232.75 | $ 171.50 | $ 168.48 | $ 124.84 | $ 124.84 | $ 124.84 | $ 124.84 | $ 129.59 | $ 137.89 | $ 137.89 | $ 168.83 | $ 168.83 | $ 168.34 | $ 124.84 | $ 171.50 |
| 41214 | OFFICE/OUTPATIENT VISIT NEW | 521 | Rural Health Clinic | 99205 | $ 305.00 | $ 289.75 | $ 213.50 | $ 168.48 | $ 167.75 | $ 167.75 | $ 167.75 | $ 167.75 | $ 161.31 | $ 171.65 | $ 171.65 | $ 168.83 | $ 168.83 | $ 209.54 | $ 161.31 | $ 213.50 |
| 41224 | PREV VISIT NEW AGE 18-39 | 521 | Rural Health Clinic | 99385 | $ 186.00 | $ 176.70 | $ 150.01 | $ 168.48 | $ 128.35 | $ 128.35 | $ 128.35 | $ 128.35 | $ 114.20 | $ 80.00 | $ 156.89 | $ 168.83 | $ 168.83 | $ 167.40 | $ 80.00 | $ 168.83 |
| 41225 | PREV VISIT NEW AGE 40-64 | 521 | Rural Health Clinic | 99386 | $ 218.00 | $ 207.10 | $ 170.93 | $ 168.48 | $ 122.58 | $ 122.58 | $ 122.58 | $ 122.58 | $ 133.85 | $ 101.00 | $ 101.00 | $ 168.83 | $ 168.83 | $ 196.20 | $ 101.00 | $ 196.20 |
| 300118 | SOFT TISSUE NECK | 402 | Ultrasound | 70360 | $ 200.00 | $ 140.00 | $ 170.00 | $ 188.00 | $ 149.34 | $ 89.60 | $ 158.53 | $ 45.95 | $ 110.00 | $ 170.00 | $ 170.00 | $ 200.00 | $ 200.00 | $ 150.00 | $ 45.95 | $ 200.00 |
| Charge Number | Description | Rev Code | Dept | CPT Code | Price | Cash Price | Aetna | Aetna Medicare Advantage | BCBS Choice PPO | BCBS HMO Blue | BCBS Traditional | BCBS Advantage | CIGNA | Firstcare HMO | Firstcare PPO | Firstcare MA | Medicare Advantage | United | Negotiated Charge | Negotiated Charge |
| 340027 | US NECK SOFT TISSUE | 402 | Ultrasound | 76536 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 319.12 | $ 191.47 | $ 338.76 | $ 98.19 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 98.19 | $ 450.00 |
| 340016 | US THYROID | 402 | Ultrasound | 76536 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 319.12 | $ 191.47 | $ 338.76 | $ 98.19 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 98.19 | $ 450.00 |
| 340001 | US ABODOMEN COMPLETE | 402 | Ultrasound | 76700 | $ 600.00 | $ 420.00 | $ 510.00 | $ 564.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 330.00 | $ 510.00 | $ 510.00 | $ 600.00 | $ 600.00 | $ 450.00 | $ 99.32 | $ 600.00 |
| 340006 | US GALLBLADDER | 402 | Ultrasound | 76705 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340007 | US HEPATIC | 402 | Ultrasound | 76705 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340041 | US ABDOMEN LIMITED | 402 | Ultrasound | 76705 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340015 | US SPLEEN | 402 | Ultrasound | 76705 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 350.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340036 | US KIDNEY LIMITED | 402 | Ultrasound | 76705 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 350.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340008 | US PANCREATIC | 402 | Ultrasound | 76705 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340013 | US RENAL RETROPERITONEAL LIMITED | 402 | Ultrasound | 76775 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340009 | US PELVIC | 402 | Ultrasound | 76856 | $ 450.00 | $ 315.00 | $ 382.50 | $ 423.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 247.50 | $ 382.50 | $ 382.50 | $ 450.00 | $ 450.00 | $ 337.50 | $ 99.32 | $ 450.00 |
| 340037 | US BLADDER LIMITED | 402 | Ultrasound | 76857 | $ 240.00 | $ 168.00 | $ 204.00 | $ 225.60 | $ 209.85 | $ 125.91 | $ 222.77 | $ 64.57 | $ 132.00 | $ 204.00 | $ 204.00 | $ 240.00 | $ 240.00 | $ 180.00 | $ 64.57 | $ 240.00 |
| 340026 | US SCROTUM | 402 | Ultrasound | 76870 | $ 350.00 | $ 245.00 | $ 297.50 | $ 329.00 | $ 322.79 | $ 193.67 | $ 342.65 | $ 99.32 | $ 192.50 | $ 297.50 | $ 297.50 | $ 350.00 | $ 350.00 | $ 262.50 | $ 99.32 | $ 350.00 |
| 340040 | US EXTREMITY LIMITED | 402 | Ultrasound | 76882 | $ 240.00 | $ 168.00 | $ 204.00 | $ 225.60 | $ 37.54 | $ 22.52 | $ 39.85 | $ 11.55 | $ 132.00 | $ 204.00 | $ 204.00 | $ 240.00 | $ 240.00 | $ 180.00 | $ 11.55 | $ 240.00 |
| 340018 | US ECHOCARDIOGRAM COMPLETE | 402 | Ultrasound | 93306 | $ 1,470.00 | $ 1,029.00 | $ 1,249.50 | $ 1,381.80 | $ 318.53 | $ 191.12 | $ 350.38 | $ 127.41 | $ 808.50 | $ 1,249.50 | $ 1,249.50 | $ 1,470.00 | $ 1,470.00 | $ 1,102.50 | $ 127.41 | $ 1,470.00 |
| 340019 | US CAROTID BILATERAL | 402 | Ultrasound | 93880 | $ 845.00 | $ 591.50 | $ 718.25 | $ 794.30 | $ 525.78 | $ 315.47 | $ 578.35 | $ 210.31 | $ 464.75 | $ 718.25 | $ 718.25 | $ 845.00 | $ 845.00 | $ 633.75 | $ 210.31 | $ 845.00 |
| 340031 | US ART DOPPLER BIL LOWER EXT | 402 | Ultrasound | 93925 | $ 845.00 | $ 591.50 | $ 718.25 | $ 794.30 | $ 525.78 | $ 315.47 | $ 578.35 | $ 210.31 | $ 464.75 | $ 718.25 | $ 718.25 | $ 845.00 | $ 845.00 | $ 633.75 | $ 210.31 | $ 845.00 |
| 340030 | US ARTERIAL DOPPLER UNI LOWER | 402 | Ultrasound | 93926 | $ 480.00 | $ 336.00 | $ 408.00 | $ 451.20 | $ 308.33 | $ 185.00 | $ 339.16 | $ 123.33 | $ 264.00 | $ 408.00 | $ 408.00 | $ 480.00 | $ 480.00 | $ 360.00 | $ 123.33 | $ 480.00 |
| 340029 | US VENOUS DOPPLER BIL LOWER EX | 402 | Ultrasound | 93970 | $ 1,000.00 | $ 700.00 | $ 850.00 | $ 940.00 | $ 394.13 | $ 236.48 | $ 433.54 | $ 157.65 | $ 550.00 | $ 850.00 | $ 850.00 | $ 1,000.00 | $ 1,000.00 | $ 750.00 | $ 157.65 | $ 1,000.00 |
| 340028 | US VENOUS DOPPLER UNI LOWER EX | 402 | Ultrasound | 93971 | $ 740.00 | $ 518.00 | $ 629.00 | $ 695.60 | $ 238.68 | $ 143.21 | $ 262.54 | $ 95.47 | $ 407.00 | $ 629.00 | $ 629.00 | $ 740.00 | $ 740.00 | $ 555.00 | $ 95.47 | $ 740.00 |
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This included related costs like medical test, prescription drugs, equipment, and hospital fees.
- Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
- Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call {877-696-6775}
