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The table below is an estimate of the charges and payer-specific negotiated payment for a service or the amount that you may owe. In order to ensure accuracy, please contact your health insurance company and reference your policy with them as Insurance companies ultimately determine what is paid for services (aka “Cost of Services”) which would include your out-of-pocket costs and as well a contractual adjustments to hospitals and clinics.
These out-of-pocket costs include deductibles, co-pay, co-insurance, and out of pocket maximums. This information can be obtained directly from your insurance company and recommended that you do in fact contact them to make sure you are aware of what your insurance will and will not cover. Your insurance may also bundle certain types of services together as well and bundle the amount that is paid to the hospital or clinic for services.
|
ChargeCode Description |
Procedure Code |
UB |
Gross Rate Charges |
Payer-specific Negotiated Charges |
|
CT:CHEST WITH AND
WITHOUT CONTRAST |
71270 |
350 |
2,455.00 |
1,816.70 |
|
SCOLIOSIS EVAL |
72081 |
320 |
205.00 |
151.70 |
|
LUMBAR SPINE; 2-3
VIEWS |
72100 |
320 |
266.00 |
196.84 |
|
MRI:THORACIC |
72146 |
612 |
1,155.00 |
854.70 |
|
FOREARM; INCL. 1
JOINT, 2 VIEWS |
73090 |
320 |
206.00 |
152.44 |
|
HAND; MIN. 3 VIEWS
|
73130 |
320 |
212.00 |
156.88 |
|
MRI:ANY JT UPPER E
XT |
73221 |
610 |
1,207.50 |
893.55 |
|
FEMUR, MIN 2 VIEWS
|
73552 |
320 |
229.00 |
169.46 |
|
KNEE; 1 OR 2 VIEWS
|
73560 |
320 |
159.00 |
117.66 |
|
FOOT; COMPLETE, MI
N. 3
VIEWS |
73630 |
320 |
187.00 |
138.38 |
|
ABDOMINAL AORTA
ULTRASOUND (AAA) |
76706 |
402 |
476.00 |
352.24 |
|
US SCROTUM AND
CONTENTS |
76870 |
402 |
508.00 |
375.92 |
|
ELECTROLYTE PANEL
(NA,K,CL,CO2) |
80051 |
300 |
113.00 |
83.62 |
|
TEGRETOL
(CARBAMAZEPINE); TOTAL |
80156 |
300 |
143.00 |
105.82 |
|
VALPROIC ACID
(DEPAKOTE) |
80164 |
300 |
145.00 |
107.30 |
|
VALPROIC ACID
(DIPROPYLACETIC ACID) FREE |
80165 |
300 |
135.00 |
99.90 |
|
CORTISOL; TOTAL |
82533 |
300 |
152.00 |
112.48 |
|
CPK MB FRACTION ON
LY |
82553 |
300 |
150.00 |
111.00 |
|
QUANTITATIVE, NOT
OTHERWISE SPECIFIED |
83520 |
300 |
95.00 |
70.30 |
|
LACTATE, (LACTIC A
CID) |
83605 |
300 |
126.00 |
93.24 |
|
LIPASE |
83690 |
300 |
110.00 |
81.40 |
|
ALKALINE PHOSPHATA
SE |
84075 |
300 |
70.00 |
51.80 |
|
PROLACTIN; SERUM |
84146 |
300 |
182.00 |
134.68 |
|
PSA; TOTAL |
84153 |
300 |
131.00 |
96.94 |
|
URINE MONOCLANAL
PROTEIN 84156,86335 |
84166 |
300 |
168.30 |
124.54 |
|
SODIUM; SERUM (NA)
|
84295 |
300 |
62.00 |
45.88 |
|
T.S.H. RIA |
84443 |
300 |
122.00 |
90.28 |
|
QUANTITATIVE D-DIM
ER |
85379 |
300 |
141.00 |
104.34 |
|
RPR, VDRL, ART;
QUALITATIVE |
86592 |
300 |
70.00 |
51.80 |
|
EBV VCA IgG/IgM |
86663 |
300 |
89.25 |
66.05 |
|
EPSTEIN-BARR ANTIB
ODY
VIRUS |
86665 |
300 |
117.00 |
86.58 |
|
POTASSIUM (K); SER
UM |
84132 |
300 |
58.00 |
42.92 |
|
TB TEST, CELL MEDI
ATED
IMMUNITY |
86480 |
300 |
111.25 |
82.33 |
|
GAMMA INTERFERON-P
RODUCING
T-CELLS |
86481 |
300 |
127.50 |
94.35 |
|
BARTONELLA |
86611 |
300 |
84.00 |
62.16 |
|
CYTOMEGALOVIRUS |
86644 |
300 |
143.00 |
105.82 |
|
ANTIB EHRILICHIA |
86666 |
300 |
31.30 |
23.16 |
|
ELBOW; 2 VIEWS |
73070 |
320 |
170.00 |
125.80 |
|
ELBOW 3 VIEWS |
73080 |
320 |
152.15 |
112.59 |
|
LIPID PANEL
82465,83718,84478 |
80061 |
300 |
144.00 |
106.56 |
|
CALCIUM SERUM; TOT
AL |
82310 |
300 |
81.00 |
59.94 |
|
THYROGLOBULIN |
84432 |
300 |
74.50 |
55.13 |
|
THYROXINE T4; FREE
|
84439 |
300 |
106.00 |
78.44 |
|
ALT (SGPT) ALANINE
AMINO |
84460 |
300 |
86.00 |
63.64 |
|
T3; TOTAL (TT-3) |
84480 |
300 |
114.00 |
84.36 |
|
URIC ACID; BLOOD |
84550 |
300 |
73.00 |
54.02 |
|
RETICULOCYTE,
AUTOMATED |
85045 |
300 |
56.00 |
41.44 |
|
BLOOD COUNT; WBC
(WHITE BLOOD CELL) |
85048 |
300 |
58.00 |
42.92 |
|
CYCLIC CITRULLINAT
ED
PEPTIDE, ANTIBODY |
86200 |
300 |
225.00 |
166.50 |
|
DNA ANTIBODY NATIV
E /2
STRANDED |
86225 |
300 |
26.25 |
19.43 |
|
CT: ABD & PELV
IS
W/O CONTRAST |
74176 |
350 |
1,567.80 |
1,160.17 |
|
CMP(GLUC,BUN,CREAT
,AST,ALP,TBIL,ALT, |
80053 |
300 |
232.00 |
171.68 |
|
DRUG SCR QUAN
LEVETIRACETAM |
80177 |
300 |
85.00 |
62.90 |
|
PHENOBARBITAL |
80184 |
300 |
154.00 |
113.96 |
|
DILANTIN (PHENYTOI
N);
TOTAL |
80185 |
300 |
131.00 |
96.94 |
|
TACROLIMUS |
80197 |
300 |
231.00 |
170.94 |
|
VANCOMYCIN |
80202 |
300 |
140.00 |
103.60 |
|
LACOSAMIDE, ASSAY |
80235 |
300 |
200.00 |
148.00 |
|
QUANT. OF DRUG, NO
OTHER SPECIFICATI |
80299 |
300 |
183.00 |
135.42 |
|
DRUG SCR QUAL MLT
DRUG
CLASSES |
80305 |
300 |
169.00 |
125.06 |
|
DRUG SCREENING, SI
NGLE |
80307 |
300 |
290.00 |
214.60 |
|
ALCOHOL, (ETOH) AN
SPEC BUT BREATH |
80320 |
300 |
188.00 |
139.12 |
|
CPK (CREATINE
PHOSPHOKINASE); TOTAL |
82550 |
300 |
105.00 |
77.70 |
|
VITAMIN B 12 |
82607 |
300 |
127.00 |
93.98 |
|
ERYTHROPOIETIN |
82668 |
300 |
47.13 |
34.88 |
|
FOLATE (FOLIC) ACI
D;
SERUM |
82746 |
300 |
144.00 |
106.56 |
|
FSH (FOLLICLE
STIMULATING HORMONE) |
83001 |
300 |
148.00 |
109.52 |
|
GONADOTROPIN;
LUTEINIZING HORMONE |
83002 |
300 |
84.90 |
62.83 |
|
IRON SERUM |
83540 |
300 |
73.00 |
54.02 |
|
PROCALCITONIN (PCT
) |
84145 |
300 |
125.00 |
92.50 |
|
PROTEIN-TOTAL |
84155 |
300 |
90.00 |
66.60 |
|
ANTITHROMBIN
III,ANTIGEN ASSAY |
85301 |
300 |
84.25 |
62.35 |
|
PROTEIN S, FREE |
85306 |
300 |
368.00 |
272.32 |
|
FIBRINOLYSINS/COAG
ULOPATHY
SCR I&R |
85390 |
300 |
45.00 |
33.30 |
|
PROTIME SUBSTITUTI
ON,
PLASMA FRACTIONS |
85611 |
300 |
175.00 |
129.50 |
|
RUSSEL VIPER VENOM
DILUTED |
85613 |
300 |
39.00 |
28.86 |
|
LOWER LEG, TIB/FIB
; 2
VIEWS |
73590 |
320 |
215.00 |
159.10 |
|
ANKLE; COMPLETE, M
IN.
3 VIEWS |
73610 |
320 |
220.00 |
162.80 |
|
OS CALCIS (CALCANE
US);
MIN. 2 VIEWS |
73650 |
320 |
176.00 |
130.24 |
|
MAMMOGRAM, SCREENI
NG |
77067 |
403 |
255.00 |
188.70 |
|
BILIRUBIN; TOTAL |
82247 |
300 |
69.00 |
51.06 |
|
DIHYDROXVITAMIN D
1.25 |
82652 |
300 |
131.40 |
97.24 |
|
BNP-NATRIURETIC
PEPTIDE |
83880 |
300 |
230.00 |
170.20 |
|
VITAMIN B-6 (PYRID
OXAL
PHOSPHATE) |
84207 |
300 |
137.80 |
101.97 |
|
HCT |
85014 |
300 |
32.00 |
23.68 |
|
MRI:ANY JT LOWR EX
T |
73721 |
610 |
1,210.00 |
895.40 |
|
SARS-COV-2 IGG
ANTIBODY |
86769 |
300 |
150.00 |
111.00 |
|
CHEST PA W/RIBS MI
N 3
VIEWS |
71101 |
320 |
212.80 |
157.47 |
|
CERVICAL SPINE; 2-
VIEWS |
72040 |
320 |
288.50 |
213.49 |
|
THORACIC SPINE; 2
VIEWS |
72070 |
320 |
200.00 |
148.00 |
|
MRI:CERVICAL W/O
CONTRAST |
72141 |
612 |
1,155.00 |
854.70 |
|
TOE(S); MIN. 2 VIE
WS |
73660 |
320 |
172.00 |
127.28 |
|
ULTRASOUND, RENAL |
76775 |
402 |
442.00 |
327.08 |
|
ULTRASOUND,TRANSVA
GINAL |
76830 |
402 |
509.00 |
376.66 |
|
DIGOXIN |
80162 |
300 |
111.00 |
82.14 |
|
URINE AUTOMATED W/
MICROSCOPY |
81003 |
300 |
47.00 |
34.78 |
|
ALBUMIN; SERUM |
82040 |
300 |
59.00 |
43.66 |
|
AMYLASE; SERUM OR
URINE |
82150 |
300 |
99.00 |
73.26 |
|
VITAMIN D; 25 HYDR
OXY
(CALCIFEDIOL) |
82306 |
300 |
260.00 |
192.40 |
|
CALCIUM; IONIZED |
82330 |
300 |
84.90 |
62.83 |
|
CHLORIDE; BLOOD |
82435 |
300 |
59.00 |
43.66 |
|
SERUM ESTROGEN,
ESTRADIOL |
82670 |
300 |
175.00 |
129.50 |
|
ANTI-MITOCHONDRIAL
AB |
83516 |
300 |
117.00 |
86.58 |
|
LACTATE DEHYDROGEN
ASE
(LD), (LDH) |
83615 |
300 |
73.00 |
54.02 |
|
PSA, FREE |
84154 |
300 |
185.00 |
136.90 |
|
URINE SODIUM |
84300 |
300 |
62.00 |
45.88 |
|
AST (SGOT) |
84450 |
300 |
71.00 |
52.54 |
|
T3 FREE |
84481 |
300 |
125.63 |
92.97 |
|
REVERSE T3 TEST |
84482 |
300 |
79.40 |
58.76 |
|
TROPONIN, QUANTITA
TIVE |
84484 |
300 |
168.00 |
124.32 |
|
PLATELET COUNT |
85049 |
300 |
30.85 |
22.83 |
|
BLOOD SMEAR,
PERIPHERAL; INT. BY DR. |
85060 |
300 |
61.75 |
45.70 |
|
RA TITER (RHEUMATO
ID
ARTHRITIS)QUANT |
86431 |
300 |
46.30 |
34.26 |
|
LYME DISEASE SEROL
OGY
EVALUATION |
86618 |
300 |
147.00 |
108.78 |
|
ANTIBO PROTOZOA |
86753 |
300 |
31.31 |
23.17 |
|
RUBELLA ANTIBODY |
86762 |
300 |
108.00 |
79.92 |
|
MRI: LUMBAR W/O CO
NTRAST |
72148 |
612 |
1,155.00 |
854.70 |
|
PELVIS; 1-2 VIEWS |
72170 |
320 |
196.00 |
145.04 |
|
SACRUM & COCCY
X;
MIN. 2 VIEWS |
72220 |
320 |
206.00 |
152.44 |
|
CLAVICLE, COMPLETE
|
73000 |
320 |
231.00 |
170.94 |
|
SHOULDER; COMPLETE
MIN. 2 VIEWS |
73030 |
320 |
240.00 |
177.60 |
|
HUMERUS; INCL. 1 J
OINT,
MIN. 2 VIEWS |
73060 |
320 |
222.00 |
164.28 |
|
FINGER(S), MIN. 2
VIEWS |
73140 |
320 |
164.00 |
121.36 |
|
HIP, COMPLETE 2-3
VIEWS |
73502 |
320 |
215.00 |
159.10 |
|
ABDOMEN, GB, BILIA
RY
TREE SINGLE QUAD |
76705 |
402 |
476.00 |
352.24 |
|
ACUTE HEPATITIS PA
NEL |
80074 |
300 |
557.00 |
412.18 |
|
LIVER (HEPATIC)
FUNCTION PANEL |
80076 |
300 |
149.00 |
110.26 |
|
ALCOHOL, (ETOH) AN
SPEC BUT BREATH |
80320 |
300 |
550.00 |
407.00 |
|
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
131.00 |
96.94 |
|
UA-ROUTINE W/O
MICROSCP, NON AUTOMATED |
81002 |
300 |
47.00 |
34.78 |
|
MICROALBUMIN-URINE
QUANTITATIVE |
82043 |
300 |
98.00 |
72.52 |
|
AMMONIA; BLOOD |
82140 |
300 |
128.00 |
94.72 |
|
BILIRUBIN; DIRECT |
82248 |
300 |
53.00 |
39.22 |
|
CALCULUS (STONE) Q
UANT |
82365 |
300 |
40.00 |
29.60 |
|
CREATININE; BLOOD |
82565 |
300 |
59.00 |
43.66 |
|
ESTRONE |
82679 |
300 |
115.75 |
85.66 |
|
FERRITIN, RIA |
82728 |
300 |
145.00 |
107.30 |
|
GAMMAGLOBULIN,IgA,
IgD,IgG,IgM |
82784 |
300 |
178.00 |
131.72 |
|
GLUCOSE; QUANT. BL
OOD,
FBS 2H |
82947 |
300 |
46.00 |
34.04 |
|
GGT GAMMA GT |
82977 |
300 |
71.00 |
52.54 |
|
HEMOGLOBIN; GLYCAT
ED |
83036 |
300 |
92.00 |
68.08 |
|
PARATHYROID HORMON
(C-TERMINAL) |
83970 |
300 |
264.00 |
195.36 |
|
PRE-ALBUMIN
|
84134 |
300 |
108.00 |
79.92 |
|
PROGESTRONE; SERUM
|
84144 |
300 |
148.00 |
109.52 |
|
TESTOSTERONE; FREE
|
84402 |
300 |
149.00 |
110.26 |
|
TESTOSTERONE; TOTA
L |
84403 |
300 |
176.00 |
130.24 |
|
VITAMIN B-1 (THIAM
INE) |
84425 |
300 |
164.45 |
121.69 |
|
ZINC |
84630 |
300 |
50.70 |
37.52 |
|
BETA hCG; QUANTITATIVE |
84702 |
300 |
142.00 |
105.08 |
|
BETA hCG; QUALITATIVE |
84703 |
300 |
113.00 |
83.62 |
|
BLOOD COUNT;
HEMOGLOBIN |
85018 |
300 |
23.00 |
17.02 |
|
CBC W/ AUTO DIFF.
W/PLATELET COUNT |
85025 |
300 |
112.00 |
82.88 |
|
BLOOD COUNT;
HEMOGRAM/PLATELET COUNT |
85027 |
300 |
88.00 |
65.12 |
|
FACTOR V, LABILE
FACTOR |
85220 |
300 |
262.00 |
193.88 |
|
PROTEIN C, ACTIVIT
Y |
85303 |
300 |
303.00 |
224.22 |
|
ESR (ERYTHROCYTE);
NON-AUTOMATED |
85651 |
300 |
85.00 |
62.90 |
|
THROMBIN TIME, PLA
SMA |
85670 |
300 |
190.00 |
140.60 |
|
APPT, PARTIAL
(PTT);PLASMA OR WHOLE |
85730 |
300 |
70.00 |
51.80 |
|
CARDIOLIPIN
(PHOSPHOLIPID)ANTIBODY |
86147 |
300 |
162.00 |
119.88 |
|
COMPLEMENT;ANTIGEN
,EA
COMPONENT |
86160 |
300 |
60.64 |
44.87 |
|
AUTO ANTIBODIES TO
SSA
& SSB |
86235 |
300 |
50.40 |
37.30 |
|
MONOSPOT |
86308 |
300 |
75.00 |
55.50 |
|
ANTIMICROSOMAL
ANTIBODY |
86376 |
300 |
139.00 |
102.86 |
|
HEPATITIS B SURFAC
ANTIBODY (HBsAb) |
86706 |
300 |
108.00 |
79.92 |
|
MUMPS ANTIBODY/IgG
& IgM x (2) |
86735 |
300 |
120.00 |
88.80 |
|
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
550.00 |
407.00 |
|
URINE, AUTOMATED W
ITH
MICROSCOPY |
81001 |
300 |
59.00 |
43.66 |
|
UA MICROSCOPIC |
81015 |
300 |
50.00 |
37.00 |
|
IRON BINDING CAPAC
ITY
(IBC) |
83550 |
300 |
103.00 |
76.22 |
|
BLOOD LEAD |
83655 |
300 |
101.00 |
74.74 |
|
PROTEIN;
ELECTROPHORESIS-(SERUM) |
84165 |
300 |
156.00 |
115.44 |
|
B.U.N. (UREA NITRO
GEN);
QUANTITATIVE |
84520 |
300 |
56.00 |
41.44 |
|
THROMBOPLASTIN TIM
E,
PTT; SUB PLASMA |
85732 |
300 |
190.00 |
140.60 |
|
C-REACTIVE PROTEIN
|
86140 |
300 |
107.00 |
79.18 |
|
HERPES SIMPLEX, TY
PE 1 |
86695 |
300 |
58.80 |
43.51 |
|
HERPES SIMPLEX, TY
PE 2 |
86696 |
300 |
30.30 |
22.42 |
|
HEPATITIS B CORE
ANTIBODY; TOTAL |
86704 |
300 |
103.00 |
76.22 |
|
RIBS, UNILATERAL;
VIEWS |
71100 |
320 |
218.00 |
161.32 |
|
MRI: UPPER EXT OTH
/THN
JT, W/WO CONTRAST |
73218 |
610 |
1,650.00 |
1,221.00 |
|
RENAL FUNCTION PAN
EL |
80069 |
300 |
190.00 |
140.60 |
|
AFP (ALPHA-FETOPRO
TEIN:
SERUM) |
82105 |
300 |
139.00 |
102.86 |
|
MAGNESIUM |
83735 |
300 |
75.00 |
55.50 |
|
ORGANIC
ACID,SINGLE,QUANTITATIVE |
83921 |
300 |
240.00 |
177.60 |
|
BLOOD COUNT; MANUAL
DIFF. W/PLATELET |
85007 |
300 |
46.00 |
34.04 |
|
OCCULT BLOOD; FECE
S,
1-3 SPECIMENS |
82270 |
300 |
27.00 |
19.98 |
|
VARICELLA TITRE |
86787 |
300 |
44.10 |
32.63 |
|
THYROID
(THYROGLOBULIN) ANTIBODIES |
86800 |
300 |
76.05 |
56.28 |
|
HLA TYPING, A,B, O
R C,
SINGLE ANTIGEN |
86812 |
300 |
246.00 |
182.04 |
|
ANTIBODY SCREEN,RB
C,EA
SERUM TECHNIQ |
86850 |
300 |
62.00 |
45.88 |
|
BLOOD TYPING; ABO
GROUP |
86900 |
300 |
48.00 |
35.52 |
|
BLOOD TYPING; RH(D
) |
86901 |
300 |
47.00 |
34.78 |
|
CROSSMATCH |
86922 |
300 |
234.00 |
173.16 |
|
SPECIMEN CONCENTRA
TION |
87015 |
300 |
101.00 |
74.74 |
|
CULTURE, BACTERIAL
BLOOD |
87040 |
300 |
172.00 |
127.28 |
|
CULTURE, BACTERIAL
FECES (STOOL) |
87045 |
300 |
139.00 |
102.86 |
|
STOOL CULTURE
(CAMPYLOBACTER) |
87046 |
300 |
95.00 |
70.30 |
|
CULTURE,OTHER SOUR
CE
EXCEPT URINE/BLD/S |
87070 |
300 |
132.00 |
97.68 |
|
CULTURE
BACTERIA,EXCEPT BLOOD |
87075 |
300 |
153.00 |
113.22 |
|
CULTURE; ID, AEROB
IC,
ORGANISM ID |
87077 |
300 |
75.00 |
55.50 |
|
CULTURE, BACTERIAL
URINE-COLONY CNT |
87086 |
300 |
113.00 |
83.62 |
|
CULTURE, BACTERIAL
ID, URINE |
87088 |
300 |
73.00 |
54.02 |
|
CULTURE,FUNGI;OTHE
SOURCE BUT BLOOD |
87102 |
300 |
233.00 |
172.42 |
|
CULTURE, IMMUNOLOG
IC
METHOD |
87147 |
300 |
164.00 |
121.36 |
|
SENSITIVITIES (ALL
) |
87186 |
300 |
127.00 |
93.98 |
|
GRAM, PRIM WRIGHTS
& STOOL SMEARS |
87205 |
300 |
64.00 |
47.36 |
|
STRAIN
MALARIA,COCCIDIA,HERP VIRUSES |
87207 |
300 |
70.30 |
52.02 |
|
OVA PARASITS SMR P
RIM
CPLX SPEC STRAIN |
87209 |
300 |
47.78 |
35.36 |
|
SMEAR PRIM SRC WET
MOUNT NFCT |
87210 |
300 |
8.50 |
6.29 |
|
KOH TISSUE EXAM FO
FUNGI |
87220 |
300 |
27.85 |
20.61 |
|
CLOSTRIDIUM DIFFIC
ILE
TOXIN; ENZYME |
87324 |
300 |
171.00 |
126.54 |
|
CRYPTOSPORIDUM |
87328 |
300 |
113.00 |
83.62 |
|
GIARDIA ANTIGEN |
87329 |
300 |
124.00 |
91.76 |
|
HELICOBACTOR PYLOR
I,
STOOL |
87338 |
300 |
75.00 |
55.50 |
|
HEPATITIS B SURFACE
ANTIGEN (HBsAg) |
87340 |
300 |
106.00 |
78.44 |
|
HIV-1/2 AG AND AB |
87389 |
300 |
157.50 |
116.55 |
|
CHLAMYDIA TRACH
AMPLIFIED PROBE |
87491 |
300 |
130.00 |
96.20 |
|
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
79.00 |
58.46 |
|
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
150.00 |
111.00 |
|
INFECTIOUS AGENT
DNA/RNA INFLUENZA 1ST 2 |
87502 |
300 |
121.50 |
89.91 |
|
KUB, I VIEW
|
74018 |
320 |
182.00 |
134.68 |
|
BONE DENSITY ,DXA,
1OR
MORE SITES, |
77080 |
320 |
322.00 |
238.28 |
|
LITHIUM |
80178 |
300 |
115.00 |
85.10 |
|
POLYSOM 6>YRS S
LEEP
W/CPAP 4>ADDL |
95811 |
740 |
3,032.00 |
2,243.68 |
|
KNEE; 3 VIEWS |
73562 |
320 |
257.00 |
190.18 |
|
US SOFT TISS,
HEAD,NECK, THYROID |
76536 |
402 |
433.00 |
320.42 |
|
ULTRASOUND,ABDOMIN
AL,COMPLETE |
76700 |
402 |
654.00 |
483.96 |
|
BASIC METABOLIC
PANEL(BUN,CREAT,GLUC |
80048 |
300 |
168.00 |
124.32 |
|
CREATININE; OTHER
SOURCE
(URINE) |
82570 |
300 |
71.00 |
52.54 |
|
BLOOD GASES; ABG
pH,pCO2,pO2,CO2,HCO |
82803 |
300 |
212.00 |
156.88 |
|
HOMOCYSTEINE LEVEL
|
83090 |
300 |
188.00 |
139.12 |
|
CLOTTING FACTOR II
PROTHROMBIN, SPECIFI |
85210 |
300 |
150.00 |
111.00 |
|
PROTHROMBIN TIME (
PT) |
85610 |
300 |
50.00 |
37.00 |
|
RUSSEL VIPER VENOM
DILUTED |
85613 |
300 |
250.00 |
185.00 |
|
RA FACTOR (RHEUMAT
OID
ARTHRITIS)QUAL |
86430 |
300 |
62.00 |
45.88 |
|
RHC:PREV VISIT, ES
T (1
THRU 4 YEARS) |
99392 |
521 |
135.00 |
99.90 |
|
URINE PROTEIN |
84156 |
300 |
60.00 |
44.40 |
|
ULTRASOUND,EXTREMI
TY
COMPLETE |
76881 |
402 |
285.00 |
210.90 |
|
CARBON
DIOXIDE(BICARBONATE -ECO 2 |
82374 |
300 |
63.00 |
46.62 |
|
ANA (ANTINUCLEAR
ANTIBODIES) |
86038 |
300 |
137.00 |
101.38 |
|
SCAPULA, COMPLETE |
73010 |
320 |
300.00 |
222.00 |
|
ABDOMEN, 2 VIEWS |
74019 |
320 |
281.00 |
207.94 |
|
LAMOTRIGINE
|
80175 |
300 |
90.00 |
66.60 |
|
CT: ABD & PELV
IS
WITH CONTRAST |
74177 |
350 |
1,757.80 |
1,300.77 |
|
DRUG/SUBST DEF
QUAL/QUANT NOS 1-3 |
80375 |
300 |
131.00 |
96.94 |
|
URINE PREGNANCY TE
ST |
81025 |
300 |
12.50 |
9.25 |
|
FACTOR V, LEIDEN |
81241 |
300 |
284.30 |
210.38 |
|
METHYLENETETRAHYDR
OFOLATE
REDUCTASE |
81291 |
300 |
300.00 |
222.00 |
|
ANTIBODY; RUBEOLA |
86765 |
300 |
113.00 |
83.62 |
|
POLYSOM 6>YRS S
LEEP
4>ADDL PARAM ATTENDED |
95810 |
740 |
2,756.00 |
2,039.44 |
|
CANALITH REPOSITIO
NING
PROCEDURE |
95992 |
420 |
93.75 |
69.38 |
|
IV INFUSION (SPECI
FY
DRUG) UP TO 1 HR |
96365 |
260 |
231.00 |
170.94 |
|
IONTOPHORESIS, EAC
H 15
MIN. |
97033 |
420 |
81.00 |
59.94 |
|
WRIST; COMPLETE, M
IN.
3 VIEWS |
73110 |
320 |
180.00 |
133.20 |
|
MANUAL THERAPY
TECHNIQUES,EA.15 MIN. |
97140 |
420 |
122.00 |
90.28 |
|
PT EVAL LOW COMP,
20
MIN |
97161 |
424 |
137.90 |
102.05 |
|
PT EVAL MOD COMP,
30
MIN |
97162 |
424 |
197.00 |
145.78 |
|
DUPLEX CAROTID,
COMPLETE BILATERAL |
93880 |
921 |
888.60 |
657.56 |
|
IV INFUSION - EA
ADDITIONAL HOUR |
96366 |
260 |
99.00 |
73.26 |
|
IV INFURSION -
ADDITIONAL INFUSION, UP TO 1 HOUR |
96367 |
260 |
137.00 |
101.38 |
|
ELECTRICAL STIMULA
TION
(UNATTENDED) |
97014 |
420 |
135.00 |
99.90 |
|
ELECTRICAL STIMULA
TION
(MANUAL) |
97032 |
420 |
165.00 |
122.10 |
|
ULTRASOUND, EACH 1
MIN. |
97035 |
420 |
62.00 |
45.88 |
|
ROM/STRENGTH EXERC
ISE,
EACH 15 MIN. |
97110 |
420 |
99.00 |
73.26 |
|
NEUROMUSCULAR RE-E
D. |
97112 |
420 |
90.00 |
66.60 |
|
GAIT TRAINING (15
MIN) |
97116 |
420 |
90.00 |
66.60 |
|
OCCULT BLOOD,1-3,N
OT
SCREENING |
82272 |
300 |
24.25 |
17.95 |
|
PHOSPHORUS INORGAN
IC;
SERUM |
84100 |
300 |
59.00 |
43.66 |
|
BK-VIRUS(DETECTION
)POLYMERASE
CHAIN |
87798 |
300 |
240.00 |
177.60 |
|
NOS ASSAY W/OPTIC
(SHIGA TOXIN 1) |
87899 |
300 |
91.00 |
67.34 |
|
CELL COUNT, W/DIFF
MISC.BODY FLUIDS |
89051 |
300 |
60.65 |
44.88 |
|
INJ IMM FIRST
VACC/TOXIOD THRU 18YRS, |
90460 |
521 |
36.00 |
26.64 |
|
APP OF MODALITY
VASOPNEUMATIC DEVICES |
90716 |
420 |
25.00 |
18.50 |
|
EKG/ECG, 12 LEADS
OR
>; TRACING ONLY |
93005 |
730 |
141.00 |
104.34 |
|
HOLTER MONITOR, EX
TRNL
ECG SCANNING |
93226 |
731 |
605.00 |
447.70 |
|
RHC:PREV VISIT, ES
(40 THRU 64 YEARS) |
99396 |
521 |
160.00 |
118.40 |
|
REHAB W/CONTINUOUS
ECG, PER SESSION |
93798 |
943 |
105.85 |
78.33 |
|
ECHO TTHRC R-T 2D
-+M-MODE |
93306 |
921 |
1,518.49 |
1,123.68 |
|
PSA SCREEN; TOTAL
(MEDICARE) |
G0103 |
300 |
131.00 |
96.94 |
|
HEPATITIS C ANTIBO
DY |
86803 |
300 |
128.00 |
94.72 |
|
RHC:PREV VISIT, ES
T (5
THRU 11 YEARS) |
99393 |
521 |
135.00 |
99.90 |
|
CRYSTALS POLARIZAT
ION,
ALL BUT URINE |
89060 |
300 |
44.10 |
32.63 |
|
RHC:PREV VISIT, ES
(65 AND OVER) |
99397 |
521 |
165.00 |
122.10 |
|
CHEST, SINGLE VIEW
|
71045 |
324 |
133.00 |
98.42 |
|
CT: HEAD OR BRAIN
WITHOUT CONTRAST |
70450 |
350 |
1,463.00 |
1,082.62 |
|
CHEST 2 VIEWS, FRO
NT
& LAT |
71046 |
324 |
195.00 |
144.30 |
|
RHC:PREV VISIT, NE
W (5
THRU 11 YEARS) |
99383 |
521 |
188.00 |
139.12 |
|
RHC:PREV VISIT, NE
(12 THRU 17 YEARS) |
99384 |
521 |
221.00 |
163.54 |
|
RHC:PREV VISIT, NE
(18 THRU 39 YEARS) |
99385 |
521 |
221.00 |
163.54 |
|
RHC:PREV VISIT, NE
(40 THRU 64 YEARS) |
99386 |
521 |
194.25 |
143.75 |
|
RHC:PREV VISIT, NE
(65 AND OVER) |
99387 |
521 |
212.00 |
156.88 |
|
RHC:PREV VISIT, ES
(AGE YOUNGER THAN 1 YEAR) |
99391 |
521 |
125.00 |
92.50 |
|
HEPATITIS C QUANT |
87522 |
300 |
773.00 |
572.02 |
|
GONORRHOEAE AMPLIF
IED
PROBE |
87591 |
300 |
119.00 |
88.06 |
|
SARS-CoV-2 COVID-1
AMP PROBE TQ |
87635 |
300 |
150.00 |
111.00 |
|
STAPHYLOCOCCUS AUR
EUS |
87641 |
300 |
62.50 |
46.25 |
|
RHC:PREV VISIT, ES
(12 THRU 17 YEARS) |
99394 |
521 |
145.00 |
107.30 |
|
RHC:PREV VISIT, ES
(18 THRU 39 YEARS) |
99395 |
521 |
150.00 |
111.00 |
|
STREPTOCOCCUS GRP
A,
AMP PRB |
87651 |
300 |
99.80 |
73.85 |
|
TRICHOMONAS VAGINA
LIS,
AMP |
87661 |
300 |
150.00 |
111.00 |
|
PT EVAL HIGH COMP,
45
MIN |
97163 |
424 |
256.10 |
189.51 |
|
PT RE-EVAL EST PLA
CARE |
97164 |
424 |
99.00 |
73.26 |
|
OT EVAL LOW COMP,
30
MINUTES |
97165 |
434 |
142.93 |
105.77 |
|
OT EVAL MOD COMP,
45 MINUTES |
97166 |
434 |
204.19 |
151.10 |
|
OT EVAL HIGH COMP,
60
MINUTES |
97167 |
434 |
265.45 |
196.43 |
|
PT THER/ACT/TRANSF
ER
(FUNCTIONAL)15 MN |
97530 |
420 |
90.00 |
66.60 |
|
RHC:NEW OFFICE OUT
PT,
MINOR-MOD, 20 MIN |
99202 |
521 |
88.00 |
65.12 |
|
CARDIOLOGY VISIT,
NEW
20 MINUTES |
99202 |
480 |
131.00 |
96.94 |
|
RHEUMATOLOGY VISIT
NEW, 20 MINUTES |
99202 |
960 |
131.00 |
96.94 |
|
RHC:NEW OFFICE OUT
PT,
MOD-SEV 30 MIN |
99203 |
521 |
134.00 |
99.16 |
|
CARDIOLOGY VISIT,
NEW
30 MINUTES |
99203 |
480 |
190.00 |
140.60 |
|
RHEUMATOLOGY VISIT
NEW, 30 MINUTES |
99203 |
960 |
190.00 |
140.60 |
|
RHC:NEW OFFICE OUT
PT,
MOD-HIGH 45 MIN |
99204 |
521 |
225.00 |
166.50 |
|
CARDIOLOGY VISIT,
NEW
45 MINUTES |
99204 |
480 |
288.00 |
213.12 |
|
RHEUMATOLOGY VISIT
NEW, 45 MINUTES |
99204 |
960 |
288.00 |
213.12 |
|
RHC:NEW OFFICE OUT
PT,
HIGH, 60 MIN |
99205 |
521 |
290.00 |
214.60 |
|
CARDIOLOGY VISIT,
NEW
60 MINUTES |
99205 |
480 |
363.00 |
268.62 |
|
RHEUMATOLOGY VISIT
NEW, 60 MINUTES |
99205 |
960 |
363.00 |
268.62 |
|
RHC:EST PATIENT MI
NOR
LEVEL, 10 MIN |
99212 |
521 |
65.00 |
48.10 |
|
CARDIOLOGY VISIT,
10
MINUTES |
99212 |
480 |
77.00 |
56.98 |
|
RHEUMATIOLOGY VISI
T, EST,
10 MINUTES |
99212 |
960 |
77.00 |
56.98 |
|
RHC:EST PATIENT
LOW-MOD, 15 MIN |
99213 |
521 |
110.00 |
81.40 |
|
CARDIOLOGY VISIT 1
MINUTES |
99213 |
480 |
128.00 |
94.72 |
|
RHEUMATOLOGY VISIT
EST, 15 MINUTES |
99213 |
960 |
128.00 |
94.72 |
|
RHC:EST PATIENT
MODERATE-HIGH, 25 MIN |
99214 |
521 |
160.00 |
118.40 |
|
CARDIOLOGY VISIT 2
MINUTES |
99214 |
480 |
188.00 |
139.12 |
|
RHEUMATOLOGY VISIT
EST, 25 MINUTES |
99214 |
960 |
188.00 |
139.12 |
|
RHC:EST PATIENT HI
GH
LEVEL |
99215 |
521 |
210.00 |
155.40 |
|
CARDIOLOGY VISIT 4
MINUTES |
99215 |
480 |
253.00 |
187.22 |
|
RHEUMATOLOGY VISIT
EST, 40 MINUTES |
99215 |
960 |
253.00 |
187.22 |
|
RHC:PREV VISIT,
INITIAL (AGE YOUNGER THAN 1 YEAR) |
99381 |
521 |
118.00 |
87.32 |
|
RHC:PREV VISIT, NE
W (1
THRU 4 YEARS) |
99382 |
521 |
188.00 |
139.12 |
|
RHC:ANNUAL WELLNES
VISIT, INIT |
G0438 |
521 |
296.25 |
219.23 |
|
DRUG TEST, DEFINIT
IVE,
1-7 DRUG CLASSES |
G0480 |
300 |
146.25 |
108.23 |
|
DRUG TEST, DEFINIT
IVE,
1-7 DRUG CLASSES |
G0480 |
300 |
550.00 |
407.00 |
|
LONG TERM CARE
ROOM-SEMI PRIVATE |
n-a |
120 |
147.84 |
n-a |
|
LONG TERM CARE-SHO
RT
STAY |
n-a |
120 |
225.00 |
n-a |
|
SKILLED CARE ROOM |
n-a |
120 |
800.00 |
n-a |
|
ACUTE CARE-(ISOLAT
ION) |
n-a |
120 |
1,250.00 |
n-a |
|
RED BLOOD CELL |
P9016 |
390 |
389.43 |
288.18 |
|
TRANSFUSION
BLOOD/BLOOD COMPONENTS |
36430 |
391 |
547.00 |
404.78 |
|
ORBITS X-RAY |
70030 |
320 |
110.25 |
81.59 |
|
MANDIBLE; LESS THA
N 4
VIEWS |
70100 |
320 |
290.00 |
214.60 |
|
NECK, SOFT TISSUE |
70360 |
320 |
222.00 |
164.28 |