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1000 S. Main Street Shamrock, Texas 79079

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 NumberDescriptionRev CodeDeptCPT CodePriceCash PriceAetnaAetna Medicare AdvantageBCBS Choice PPOBCBS HMO BlueBCBS TraditionalBCBS AdvantageCIGNAFirstcare HMOFirstcare PPOFirstcare MAMedicare AdvantageUnitedNegotiated ChargeNegotiated Charge
300212CT SCAN HEAD W/O CONTRAST350CT Scan70450$ 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
300213CT SCAN HEAD W/CONTRAST350CT Scan70460$ 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
300209CT SCAN MAXILLA W/O CONTRAST350CT Scan70486$ 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
300210CT SCAN MAXILLA W/CONTRAST350CT Scan70487$ 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
300229CT SCAN SOFT TISSUE NECK W/O C350CT Scan70490$ 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
300230CT SCAN SOFT TISSUE NECK W CON350CT Scan70491$ 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
300215CT SCAN CHEST W/O CONTRAST350CT Scan71250$ 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
300216CT SCAN CHEST W/CONTRAST350CT Scan71260$ 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
300217CT SCAN CHEST W & W/O CONTRAST350CT Scan71270$ 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
300203CT SCAN CERVICAL W/O CONTRAST350CT Scan72125$ 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
300228CT SCAN T-SPINE W/O CONTRAST350CT Scan72128$ 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
300218CT SCAN LUMBAR W/O CONTRAST350CT Scan72131$ 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
300221CT SCAN PELVIS W/O CONTRAST350CT Scan72192$ 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
300222CT SCAN PELVIS W/CONTRAST350CT Scan72193$ 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
300226CT SCAN UPPER EXTREMITY W/O CO350CT Scan73200$ 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
300224CT SCAN LOWER EXTREMITY W/O CO350CT Scan73700$ 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
300225CT SCAN LOWER EXTREMITY WITH C350CT Scan73701$ 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
300200CT SCAN ABDOMEN W/O CONTRAST350CT Scan74150$ 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
300201CT SCAN ABDOMEN W/CONTRAST350CT Scan74160$ 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
300202CT SCAN ABDOMEN W & W/O CONTRA350CT Scan74170$ 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
300330CT ABDOMEN & PELVIS W/O350CT Scan74176$ 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
300331CT ABDOMEN & PELVIS WITH CONTR350CT Scan74177$ 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
300332CT ABDOMEN & PELVIS W & W/O CO350CT Scan74178$ 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
300227BONE DENSITY SCAN350CT Scan77080$ 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
260001EKG730EKG/ECG93005$ 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
170001CARDIAC MONITOR730EKG/ECG93225$ 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
200089NEONATAL SCREEN COLLECTION300Laboratory36416$ 35.50$ 24.85$ 30.18$ 33.37$ -$ -$ -$ -$ 19.53$ 30.18$ 30.18$ 35.50$ 35.50$ 26.63$ -$ 35.50
200047BASIC METABOLIC PANEL300Laboratory80048$ 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
GHPBC General Health Panel300Laboratory80050$ 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
200020COMPREHENSIVE METABOLIC PANEL300Laboratory80053$ 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
200117LIPID PANEL300Laboratory80061$ 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
200038RENAL FUNCTION PANEL300Laboratory80069$ 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
200911ACUTE HEPATITIS PANEL LC144000300Laboratory80074$ 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
200118HEPATIC FUNCTION PANEL300Laboratory80076$ 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
200152CARBAMAZEPINE TEGRETOL300Laboratory80156$ 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
200144CYCLOSPORIN LC706556300Laboratory80158$ 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
200050DIGOXIN300Laboratory80162$ 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
200181VALPORIC(DEPAKOTE),S LC007260300Laboratory80164$ 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
200986PHENOBARBITAL LC007823300Laboratory80184$ 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
200121DILANTIN PHENYTOIN300Laboratory80185$ 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
200902SIROLIMUS LC716712300Laboratory80195$ 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
200904TACROLIMUS LC700248300Laboratory80197$ 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
200183VANCOMYCIN TROUGH,SER LC70328300Laboratory80202$ 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
200182VANCOMYCIN PEAK,SERUM LC070327300Laboratory80202$ 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
200130URINE DRUG SCREEN (UDS)300Laboratory80306$ 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
200141ALCOHOL(ETHANOL),BLOOD300Laboratory80320$ 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
200080UA W/MICRO300Laboratory81001$ 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
200029UA DIPSTICK ONLY300Laboratory81003$ 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
201089UR ALBUMIN QUANTITATIVE300Laboratory82043$ 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
200127MICROALBUMIN, SEMIQUANTITATIVE300Laboratory82044$ 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
200969A1-ANTITRYPSIN,SERUM LC001982300Laboratory82103$ 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
200941AFP,SERUM,TUMOR MARKER LC002253300Laboratory82105$ 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
201113AMMONIA300Laboratory82140$ 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
200005AMYLASE300Laboratory82150$ 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
201135ANGIOTENSIN CONVERTING ENZYME ACE300Laboratory82164$ 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
200007BILIRUBIN TOTAL300Laboratory82247$ 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
201020BILIRUBIN,TOTAL,NEONATAL300Laboratory82247$ 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
200008BILIRUBIN DIRECT300Laboratory82248$ 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
200131OCCULT BLOOD STOOL X 3300Laboratory82270$ 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 NumberDescriptionRev CodeDeptCPT CodePriceCash PriceAetnaAetna Medicare AdvantageBCBS Choice PPOBCBS HMO BlueBCBS TraditionalBCBS AdvantageCIGNAFirstcare HMOFirstcare PPOFirstcare MAMedicare AdvantageUnitedNegotiated ChargeNegotiated Charge
200025OCCULT BLOOD STOOL300Laboratory82272$ 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
200908VIT D 25-HYDROXY LC081950300Laboratory82306$ 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
200013CALCIUM300Laboratory82310$ 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
200996CALCIUM, IONIZED LC004804300Laboratory82330$ 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
201114CALCULI WITH PHOTO LC 910180300Laboratory82365$ 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
200153CARBON MONOXIDE,BLOOD LC007187300Laboratory82375$ 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
200157CORTISOL LC004051300Laboratory82533$ 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
200171LEVETIRACETAM (KEPPRA),S300Laboratory82542$ 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
200045CK LC001362300Laboratory82550$ 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
200046MI PANEL TEST 1 CKMB300Laboratory82553$ 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
200093CREATININE300Laboratory82565$ 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
200128CREATININE URINE LC013672300Laboratory82570$ 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
200916CREATININE, 24 HR URINE300Laboratory82570$ 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
200107CREATININE CLEARANCE LC003004300Laboratory82575$ 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
200903B-12 VITAMIN LC001503300Laboratory82607$ 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
201136CYSTAIN WITH GLOMERULAR FILTRATION RATE300Laboratory82610$ 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
201009CALCITRIOL LC081091300Laboratory82652$ 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
200912ESTRADIOL LC004515300Laboratory82670$ 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
200159ESTROGENS,TOTAL LC004549300Laboratory82672$ 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
200161FERRITIN,SERUM LC004598300Laboratory82728$ 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
200906FOLATE LC002014300Laboratory82746$ 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
201031IMMUNOGLOBULIN A, QUANTATIVE300Laboratory82784$ 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
201043IMMUNOGLOBULIN G, QUANT300Laboratory82784$ 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
201071IGM,QN,SERUM LC001792300Laboratory82784$ 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
201051IMMUNOGLOBULIN E, TOTAL300Laboratory82785$ 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
280045ARTERIAL BLOOD GAS EACH (ABG)300Laboratory82803$ 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
201078VENOUS BLOOD GAS300Laboratory82803$ 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
200053GLUCOSE300Laboratory82947$ 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
200052GLUCOSE O'SULLIVAN300Laboratory82950$ 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
200014GLUCOSE GESTATIONAL GTT300Laboratory82951$ 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
200054GLUCOSE TOLERANCE 3-HOUR300Laboratory82951$ 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
200055GLUCOSE TOLERANCE 4-HOUR300Laboratory82951$ 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
200104GLUCOSE TOLERANCE 2-HOUR (WHO300Laboratory82951$ 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
201035GESTATIONAL GLUCOSE TOLERANCE300Laboratory82952$ 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
200910GGT LC001958300Laboratory82977$ 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
200913FSH LC004309300Laboratory83001$ 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
200914LH LC004283300Laboratory83002$ 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
201066H.PYLORI UREA BREATH TEST300Laboratory83013$ 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
201072H-PYLORI UREA BREATH TEST PEDI300Laboratory83013$ 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
201108HBA1C300Laboratory83036$ 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
200168HOMOCYST(E)INE,PLASMA LC706994300Laboratory83090$ 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
200022IRON BINDING CAPACITY-TIBC300Laboratory83540$ 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
200021IRON LC001339300Laboratory83540$ 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
201102LACTATE300Laboratory83605$ 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
200023LDH LC001115300Laboratory83615$ 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
201056LACTOFERRIN FECAL QUANTITATIVE300Laboratory83631$ 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
200975LEAD,BLOOD(ADULT) LC007625300Laboratory83655$ 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
200129LIPASE300Laboratory83690$ 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
201070LDL-DIRECT LC120295300Laboratory83721$ 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
200122MAGNESIUM300Laboratory83735$ 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
200135BNP300Laboratory83880$ 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
201022METHYLMALONIC ACID SERUM (MMA)300Laboratory83921$ 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
200961OSMOLALITY, URINE LC003442300Laboratory83935$ 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
200139PTH INTACT LC015610300Laboratory83970$ 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
201058CALPROTECTIN FECAL LC123255300Laboratory83993$ 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
200004ALKALINE PHOSPHATE300Laboratory84075$ 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
200120PHOS300Laboratory84100$ 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
200031POTASSIUM300Laboratory84132$ 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
200174PROGESTERONE LC004317300Laboratory84144$ 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 NumberDescriptionRev CodeDeptCPT CodePriceCash PriceAetnaAetna Medicare AdvantageBCBS Choice PPOBCBS HMO BlueBCBS TraditionalBCBS AdvantageCIGNAFirstcare HMOFirstcare PPOFirstcare MAMedicare AdvantageUnitedNegotiated ChargeNegotiated Charge
201116PROCALCITONIN LC164750300Laboratory84145$ 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
200992PROLACTIN LC004465300Laboratory84146$ 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
200934PSA TOTAL+ % FREE LC480947300Laboratory84153$ 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
201148ASSAY OF PSA TOTAL ultrasensitive300Laboratory84153$ 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
200175PROTEIN ELEC+INTERP,SERUM300Laboratory84155$ 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
200185PROTEIN TOTAL URINE LC013664300Laboratory84156$ 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
201041PROTEIN ELECTROPHORESIS, 24 HR300Laboratory84156$ 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
200186PROTEIN TOTAL, QN, 24-HR URINE300Laboratory84156$ 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
200982IFE AND PRO. ELEC LC003467300Laboratory84156$ 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
201012IMMUNOFIXATION (IFE), SERUM AN300Laboratory84165$ 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
201001PROTEIN ELECTROPHORESIS,RANDON300Laboratory84165$ 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
200090SODIUM300Laboratory84295$ 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
200953SODIUM,URINE RANDOM LC013326300Laboratory84300$ 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
201014TESTOSTERONE,FREETOTAL LC84403300Laboratory84402$ 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
200947TESTOSTERONE,FREE LC144980300Laboratory84402$ 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
200137TESTOSTERONE LEVEL LC004226300Laboratory84403$ 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
201129TESTOSTERONE TOTAL LC070001300Laboratory84403$ 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
200905T4 THYROXINE LC001149300Laboratory84436$ 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
200125T4 FREE LC001974300Laboratory84439$ 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
200108TSH LC004259300Laboratory84443$ 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
200074AST300Laboratory84450$ 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
200124T3 UPTAKE LC001156300Laboratory84479$ 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 LC002188300Laboratory84480$ 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
200178T3 FREE (FREE T3) LC010389300Laboratory84481$ 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
200959REVERSE T3,SERUM LC070104300Laboratory84482$ 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
200097MI PANEL TEST 3 TROPONINI300Laboratory84484$ 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
200078BUN300Laboratory84520$ 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
200079URIC ACID300Laboratory84550$ 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
200977VITAMIN A,SERUM LC017509300Laboratory84590$ 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
200165HCG,BETA SUBUNIT QNT SERUM (LA300Laboratory84702$ 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
200033HCG-BETA (B-HCG) URINE/SERUM300Laboratory84703$ 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
200016HEMATOCRIT300Laboratory85014$ 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
200017HEMOGLOBIN300Laboratory85018$ 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
200042CBC 1 W/PLT300Laboratory85025$ 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
201157CBC W/O DIFF300Laboratory85027$ 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
200063RETIC COUNT LC005280300Laboratory85045$ 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
200083WBC300Laboratory85048$ 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
200140D-DIMER300Laboratory85379$ 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
200059PT INR300Laboratory85610$ 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
201163PROTHROMBIN TIME LC005199300Laboratory85610$ 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
200067ESR (SEDRATE)300Laboratory85651$ 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
201100APTT (PTT) LC005207300Laboratory85730$ 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
200028PTT300Laboratory85730$ 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
201021ANA TITER LC164947300Laboratory86038$ 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
200150C-REACTIVE PROTEIN QUANT300Laboratory86140$ 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
200949COPLEMENT C4,SERUM LC001834300Laboratory86160$ 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
200950COMPLEMENT C3,SERUM LC006452300Laboratory86160$ 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
200956CCP ANTIBODIES LC164914300Laboratory86200$ 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
200938ANTI-DS DNA ABS LC096339300Laboratory86225$ 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
200943SLE PROFILE A LC056499300Laboratory86225$ 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
201027RNP SMITH ABS LC 006338300Laboratory86235$ 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
200151CA-125 LC002303300Laboratory86304$ 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
200024MONO TEST300Laboratory86308$ 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
201044HEP.B SURFACE,AB,QUANTLC006530300Laboratory86317$ 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
201023THYROID ANTIBODIES LC# 006684300Laboratory86376$ 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
200065RA FACTOR LC006502300Laboratory86431$ 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
201094QUANTIFERON-TB GOLD PLUS300Laboratory86480$ 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
201046QUANTIFERON-TB GOLD LC18273300Laboratory86480$ 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
200060RPR LC006072300Laboratory86592$ 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 NumberDescriptionRev CodeDeptCPT CodePriceCash PriceAetnaAetna Medicare AdvantageBCBS Choice PPOBCBS HMO BlueBCBS TraditionalBCBS AdvantageCIGNAFirstcare HMOFirstcare PPOFirstcare MAMedicare AdvantageUnitedNegotiated ChargeNegotiated Charge
200983LYME DISEASE SCREEN LC160325300Laboratory86618$ 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
201133COCCIDIOIDES IMMITIS ANTIBODIES IGG AND IGM EIA300Laboratory86635$ 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
201045CYTOMEGALOVIRUS(CMV)AB IGG300Laboratory86644$ 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
201112EBV ANTIBODY PROFILE300Laboratory86664$ 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
200002H PYLORI LC162289300Laboratory86677$ 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
200173HIV PANEL LC083935300Laboratory86703$ 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
200936HEP B CORE AB TOTAL LC006718300Laboratory86704$ 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
200921HEP B SURF AB LC006395300Laboratory86706$ 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
200958HEP A AB,TOTAL LC006726300Laboratory86708$ 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
201055MEASLES, MUMPS, RUBELLA IMMUNI300Laboratory86735$ 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
201131SARS CoV-2 ANTIBODY, IgM, SPIKE300Laboratory86769$ 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
201118SARS COV 2 ANTIBODY IGG300Laboratory86769$ 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
201127TREPONEMA PALLIDUM ANTIBODIES300Laboratory86780$ 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
201085FTA-ABS TREPONEMA LC#006379300Laboratory86780$ 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
201111VZV IGM LC096776300Laboratory86787$ 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
200907VARICELLA-ZOSTER(VZV,IGG)300Laboratory86787$ 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
201096THYROGLOBULIN ANTIBODY&IMA OR300Laboratory86800$ 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
200166HCV ANTIBODY LC140659300Laboratory86803$ 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
200951HEP C VIRUS(HCV) (LABCORP #140300Laboratory86803$ 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
200044ANTIBODY SCREEN (AB SCREEN)300Laboratory86850$ 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
200010BLOOD TYPE - ABO300Laboratory86900$ 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
200012BLOOD TYPE RH300Laboratory86901$ 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
200087CROSSMATCH300Laboratory86922$ 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
200979CROSSMATCH # 2300Laboratory86922$ 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
200048CULTURE BLOOD LC008300300Laboratory87040$ 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
200177CULTURE STOOL LC008144300Laboratory87045$ 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
200145CULTURE AEROBIC LC008649300Laboratory87070$ 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
200162CULTURE GENITAL LC008334300Laboratory87070$ 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
200172CULTURE SPUTUM LC180810300Laboratory87070$ 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
200179CULTURE NASAL/THROAT LC008342300Laboratory87070$ 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
200985MRSA SCREENING CULTURE300Laboratory87081$ 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
200180CULTURE URINE ROUTINE LC008847300Laboratory87086$ 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
201004YEAST ONLY, CULTURE LC182776300Laboratory87101$ 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
201074ORGANISM IDENTIFICATION, YEAST300Laboratory87106$ 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
200990CHLAMYDIA TRACHOMATIS CULT300Laboratory87110$ 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
200027OVA & PARASITES CONCENTRATE ST300Laboratory87177$ 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
200049CULTURE W/SENSITIVITY LC182261300Laboratory87186$ 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
201080GRAM STAIN EVAL WITH SPUTUM CU300Laboratory87205$ 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
200015GRAM STAIN LC008540300Laboratory87205$ 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
200901C-DIFF A&B EIA LC086207300Laboratory87324$ 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
201057GIARDIA CRYPTOSPOIDIUM EIA300Laboratory87328$ 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
201007PYLORI STOOL ANTIGEN LC180764300Laboratory87338$ 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
200952HEP B SURF AG LC006510300Laboratory87340$ 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
201076CHLAMDIA TRACH, NEISSERIA, TRI300Laboratory87491$ 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
200155CULTURE CHLAMYDIA/GC AMP300Laboratory87491$ 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
201103CH, NG, TV, HSV BY NAA NU SWAB300Laboratory87491$ 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
201104VAGINITIS PLUS NU SWAB300Laboratory87491$ 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
200955TRICH VAGINALIS,NAA LC188052300Laboratory87798$ 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
200126FLU TEST300Laboratory87804$ 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
200176RSV AG, EIA LC014548300Laboratory87807$ 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
200109STREP SCREEN300Laboratory87880$ 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
200922T.PHLEBOTOMY300Laboratory99195$ 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
200034PSA LC010322300LaboratoryG0103$ 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
201147NEWBORN METABLIC SCREENING PANEL300LaboratoryS3620$ 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
201117COVID-19,NAA LC 139900300LaboratoryU0003$ 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
270003ELECTRIC STIMULATION THERAPY420Physical Therapy97014$ 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
270004MANUAL ELECTRIC STIMULATION420Physical Therapy97032$ 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
270001ULTRASOUND THERAPY420Physical Therapy97035$ 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
270014THERAPEUTIC EXERCISE420Physical Therapy97110$ 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 NumberDescriptionRev CodeDeptCPT CodePriceCash PriceAetnaAetna Medicare AdvantageBCBS Choice PPOBCBS HMO BlueBCBS TraditionalBCBS AdvantageCIGNAFirstcare HMOFirstcare PPOFirstcare MAMedicare AdvantageUnitedNegotiated ChargeNegotiated Charge
270010GAIT TRAINING THERAPY420Physical Therapy97116$ 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
270005MASSAGE THERAPY420Physical Therapy97124$ 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
270006PT EVAL LOW COMPLEX 20 MIN420Physical Therapy97161$ 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
270080PT EVAL MOD COMPLEX 30 MIN420Physical Therapy97162$ 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
270008THERAPEUTIC ACTIVITIES420Physical Therapy97530$ 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
300046MANDIBLE TWO VIEWS320Radiology70100$ 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
300106FACIAL BONES-2 VIEWS320Radiology70140$ 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
300024FACIAL BONES COMPLETE SERIES320Radiology70150$ 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
300050NOSE320Radiology70160$ 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
300073SINUSES, PARANASAL COMPLETE320Radiology70220$ 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
300067SKULL THREE VIEWS320Radiology70250$ 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
300066SKULL TWO VIEWS320Radiology70250$ 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
300008CHEST ONE VIEW320Radiology71045$ 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
300009CHEST TWO VIEWS320Radiology71046$ 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
300076STERNUM TWO VIEWS320Radiology71120$ 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
300079SPINE-CERVICAL THREE VIEWS320Radiology72040$ 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
300078SPINE-CERVICAL TWO VIEWS320Radiology72040$ 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
300011SPINE CERVICAL (5) COMPLETE320Radiology72052$ 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
300081SPINE-THORACIC TWO VIEWS320Radiology72070$ 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
300083SPINE-LUMBO-SACRAL THREE VIEWS320Radiology72100$ 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
300116SPINE-LUMBO-SACRAL TWO VIEWS320Radiology72110$ 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
300084SPINE-LUMBO-SACRAL FIVE VIEWS320Radiology72114$ 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
300052PELVIS ONE VIEW320Radiology72170$ 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
300014COCCYX TWO VIEWS320Radiology72220$ 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
300070SACRUM TWO VIEWS320Radiology72220$ 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
300012CLAVICLE ONE VIEW320Radiology73000$ 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
300013CLAVICLE TWO VIEWS320Radiology73000$ 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
300062SCAPULA TWO VIEWS320Radiology73010$ 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
300064SHOULDER TWO VIEWS320Radiology73030$ 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
300039HUMERUS320Radiology73060$ 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
300020ELBOW320Radiology73070$ 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
300030FOREARM320Radiology73090$ 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
300094WRIST TWO VIEWS320Radiology73100$ 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
300095WRIST THREE VIEWS320Radiology73110$ 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
300034HAND TWO VIEWS320Radiology73120$ 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
340042HAND 3 VIEW320Radiology73130$ 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
300027FINGER320Radiology73140$ 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
300038HIP TWO VIEWS320Radiology73502$ 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
300022FEMUR ONE VIEW320Radiology73551$ 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
300023FEMUR TWO VIEWS320Radiology73552$ 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
300042KNEE TWO VIEWS320Radiology73560$ 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
300043KNEE THREE VIEWS320Radiology73562$ 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
300087TIBIA AND FIBULA TWO VIEWS320Radiology73590$ 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
300086TIBIA AND FIBULA ONE VIEW320Radiology73590$ 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
300001ANKLE TWO VIEWS320Radiology73600$ 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
300002ANKLE THREE VIEWS320Radiology73610$ 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
300003ANKLE & FOOT FIVE VIEWS COMPLE320Radiology73610$ 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
300028FOOT TWO VIEWS320Radiology73620$ 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
300029FOOT THREE VIEWS320Radiology73630$ 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
300088TOES320Radiology73660$ 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
300004ABDOMEN ONE VIEW320Radiology74018$ 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
300005ABDOMEN TWO VIEWS320Radiology74019$ 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
300006ABDOMEN THREE VIEWS320Radiology74021$ 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
41212OFFICE/OUTPATIENT VISIT NEW521Rural Health Clinic99203$ 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
41213OFFICE/OUTPATIENT VISIT NEW521Rural Health Clinic99204$ 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
41214OFFICE/OUTPATIENT VISIT NEW521Rural Health Clinic99205$ 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
41224PREV VISIT NEW AGE 18-39521Rural Health Clinic99385$ 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
41225PREV VISIT NEW AGE 40-64521Rural Health Clinic99386$ 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
300118SOFT TISSUE NECK402Ultrasound70360$ 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 NumberDescriptionRev CodeDeptCPT CodePriceCash PriceAetnaAetna Medicare AdvantageBCBS Choice PPOBCBS HMO BlueBCBS TraditionalBCBS AdvantageCIGNAFirstcare HMOFirstcare PPOFirstcare MAMedicare AdvantageUnitedNegotiated ChargeNegotiated Charge
340027US NECK SOFT TISSUE402Ultrasound76536$ 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
340016US THYROID402Ultrasound76536$ 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
340001US ABODOMEN COMPLETE402Ultrasound76700$ 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
340006US GALLBLADDER402Ultrasound76705$ 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
340007US HEPATIC402Ultrasound76705$ 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
340041US ABDOMEN LIMITED402Ultrasound76705$ 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
340015US SPLEEN402Ultrasound76705$ 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
340036US KIDNEY LIMITED402Ultrasound76705$ 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
340008US PANCREATIC402Ultrasound76705$ 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
340013US RENAL RETROPERITONEAL LIMITED402Ultrasound76775$ 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
340009US PELVIC402Ultrasound76856$ 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
340037US BLADDER LIMITED402Ultrasound76857$ 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
340026US SCROTUM402Ultrasound76870$ 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
340040US EXTREMITY LIMITED402Ultrasound76882$ 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
340018US ECHOCARDIOGRAM COMPLETE402Ultrasound93306$ 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
340019US CAROTID BILATERAL402Ultrasound93880$ 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
340031US ART DOPPLER BIL LOWER EXT402Ultrasound93925$ 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
340030US ARTERIAL DOPPLER UNI LOWER402Ultrasound93926$ 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
340029US VENOUS DOPPLER BIL LOWER EX402Ultrasound93970$ 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
340028US VENOUS DOPPLER UNI LOWER EX402Ultrasound93971$ 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}

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