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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 |
ACUTE CARE-(ISOLAT
ION) |
n-a |
120 |
1,250.00 |
n-a |
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 |
IV INFURSION -
ADDITIONAL INFUSION, UP TO 1 HOUR |
96367 |
260 |
137.00 |
130.15 |
IV INFUSION - EA A
DDITIONAL
HOUR |
96366 |
260 |
99.00 |
94.05 |
IV INFUSION (SPECI
FY
DRUG) UP TO 1 HR |
96365 |
260 |
231.00 |
219.45 |
ACUTE HEPATITIS PA
NEL |
80074 |
300 |
557.00 |
529.15 |
AFP
(ALPHA-FETOPROTEIN: SERUM) |
82105 |
300 |
139.00 |
132.05 |
ALBUMIN; SERUM |
82040 |
300 |
59.00 |
56.05 |
ALCOHOL, (ETOH) AN
SPEC BUT BREATH |
80320 |
300 |
550.00 |
522.50 |
ALCOHOL, (ETOH) ANY
SPEC BUT BREATH |
80320 |
300 |
188.00 |
178.60 |
ALKALINE PHOSPHATA
SE |
84075 |
300 |
70.00 |
66.50 |
ALT (SGPT) ALANINE
AMINO |
84460 |
300 |
86.00 |
81.70 |
AMMONIA; BLOOD |
82140 |
300 |
128.00 |
121.60 |
AMYLASE; SERUM OR
URINE |
82150 |
300 |
99.00 |
94.05 |
ANA (ANTINUCLEAR
ANTIBODIES) |
86038 |
300 |
137.00 |
130.15 |
ANTI-MITOCHONDRIAL
AB |
83516 |
300 |
117.00 |
111.15 |
ANTIB EHRILICHIA
span> |
86666 |
300 |
31.30 |
29.74 |
ANTIBO PROTOZOA |
86753 |
300 |
31.31 |
29.74 |
ANTIBODY SCREEN,RB
C,EA
SERUM TECHNIQ |
86850 |
300 |
62.00 |
58.90 |
ANTIBODY; RUBEOLA |
86765 |
300 |
113.00 |
107.35 |
ANTIMICROSOMAL
ANTIBODY |
86376 |
300 |
139.00 |
132.05 |
ANTITHROMBIN
III,ANTIGEN ASSAY |
85301 |
300 |
84.25 |
80.04 |
APPT, PARTIAL
(PTT);PLASMA OR WHOLE |
85730 |
300 |
70.00 |
66.50 |
AST (SGOT) |
84450 |
300 |
71.00 |
67.45 |
AUTO ANTIBODIES TO
SSA
& SSB |
86235 |
300 |
50.40 |
47.88 |
B.U.N. (UREA
NITROGEN); QUANTITATIVE |
84520 |
300 |
56.00 |
53.20 |
BARTONELLA |
86611 |
300 |
84.00 |
79.80 |
BASIC METABOLIC
PANEL(BUN,CREAT,GLUC |
80048 |
300 |
168.00 |
159.60 |
BETA hCG; QUALITATIVE |
84703 |
300 |
113.00 |
107.35 |
BETA hCG; QUANTITATIVE |
84702 |
300 |
142.00 |
134.90 |
BILIRUBIN; DIRECT |
82248 |
300 |
53.00 |
50.35 |
BILIRUBIN; TOTAL
span> |
82247 |
300 |
69.00 |
65.55 |
BK-VIRUS(DETECTION
)POLYMERASE
CHAIN |
87798 |
300 |
240.00 |
228.00 |
BLOOD COUNT; HEMOG
LOBIN |
85018 |
300 |
23.00 |
21.85 |
BLOOD COUNT;
HEMOGRAM/PLATELET COUNT |
85027 |
300 |
88.00 |
83.60 |
BLOOD COUNT; MANUAL
DIFF. W/PLATELET |
85007 |
300 |
46.00 |
43.70 |
BLOOD COUNT; WBC
(WHITE BLOOD CELL) |
85048 |
300 |
58.00 |
55.10 |
BLOOD GASES; ABG p
H,pCO2,pO2,CO2,HCO |
82803 |
300 |
212.00 |
201.40 |
BLOOD LEAD |
83655 |
300 |
101.00 |
95.95 |
BLOOD SMEAR,
PERIPHERAL; INT. BY DR. |
85060 |
300 |
61.75 |
58.66 |
BLOOD TYPING; ABO
GROUP |
86900 |
300 |
48.00 |
45.60 |
BLOOD TYPING; RH(D
) |
86901 |
300 |
47.00 |
44.65 |
BNP-NATRIURETIC
PEPTIDE |
83880 |
300 |
230.00 |
218.50 |
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
79.00 |
75.05 |
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
150.00 |
142.50 |
C-REACTIVE PROTEIN
|
86140 |
300 |
107.00 |
101.65 |
CALCIUM SERUM; TOT
AL |
82310 |
300 |
81.00 |
76.95 |
CALCIUM; IONIZED
span> |
82330 |
300 |
84.90 |
80.66 |
CALCULUS (STONE) Q
UANT |
82365 |
300 |
40.00 |
38.00 |
CARBON
DIOXIDE(BICARBONATE -ECO 2 |
82374 |
300 |
63.00 |
59.85 |
CARDIOLIPIN
(PHOSPHOLIPID)ANTIBODY |
86147 |
300 |
162.00 |
153.90 |
CBC W/ AUTO DIFF.
W/PLATELET COUNT |
85025 |
300 |
112.00 |
106.40 |
CELL COUNT, W/DIFF
MISC.BODY FLUIDS |
89051 |
300 |
60.65 |
57.62 |
CHLAMYDIA TRACH
AMPLIFIED PROBE |
87491 |
300 |
130.00 |
123.50 |
CHLORIDE; BLOOD |
82435 |
300 |
59.00 |
56.05 |
CLOSTRIDIUM DIFFIC
ILE
TOXIN; ENZYME |
87324 |
300 |
171.00 |
162.45 |
CLOTTING FACTOR II
PROTHROMBIN, SPECIFI |
85210 |
300 |
150.00 |
142.50 |
CMP(GLUC,BUN,CREAT
,AST,ALP,TBIL,ALT, |
80053 |
300 |
232.00 |
220.40 |
COMPLEMENT;ANTIGEN
,EA
COMPONENT |
86160 |
300 |
60.64 |
57.61 |
CORTISOL; TOTAL |
82533 |
300 |
152.00 |
144.40 |
CPK (CREATINE
PHOSPHOKINASE); TOTAL |
82550 |
300 |
105.00 |
99.75 |
CPK MB FRACTION ON
LY |
82553 |
300 |
150.00 |
142.50 |
CREATININE; BLOOD |
82565 |
300 |
59.00 |
56.05 |
CREATININE; OTHER
SOURCE (URINE) |
82570 |
300 |
71.00 |
67.45 |
CROSSMATCH |
86922 |
300 |
234.00 |
222.30 |
CRYPTOSPORIDUM |
87328 |
300 |
113.00 |
107.35 |
CRYSTALS POLARIZAT
ION,
ALL BUT URINE |
89060 |
300 |
44.10 |
41.90 |
CULTURE
BACTERIA,EXCEPT BLOOD |
87075 |
300 |
153.00 |
145.35 |
CULTURE, BACTERIAL
BLOOD |
87040 |
300 |
172.00 |
163.40 |
CULTURE, BACTERIAL
FECES (STOOL) |
87045 |
300 |
139.00 |
132.05 |
CULTURE, BACTERIAL
ID, URINE |
87088 |
300 |
73.00 |
69.35 |
CULTURE, BACTERIAL
URINE-COLONY CNT |
87086 |
300 |
113.00 |
107.35 |
CULTURE, IMMUNOLOG
IC
METHOD |
87147 |
300 |
164.00 |
155.80 |
CULTURE,FUNGI;OTHE
SOURCE BUT BLOOD |
87102 |
300 |
233.00 |
221.35 |
CULTURE,OTHER SOUR
CE
EXCEPT URINE/BLD/S |
87070 |
300 |
132.00 |
125.40 |
CULTURE; ID, AEROB
IC,
ORGANISM ID |
87077 |
300 |
75.00 |
71.25 |
CYCLIC CITRULLINAT
ED
PEPTIDE, ANTIBODY |
86200 |
300 |
225.00 |
213.75 |
CYTOMEGALOVIRUS |
86644 |
300 |
143.00 |
135.85 |
DIGOXIN |
80162 |
300 |
111.00 |
105.45 |
DIHYDROXVITAMIN D
1.25 |
82652 |
300 |
131.40 |
124.83 |
DILANTIN (PHENYTOI
N);
TOTAL |
80185 |
300 |
131.00 |
124.45 |
DNA ANTIBODY NATIV
E /2
STRANDED |
86225 |
300 |
26.25 |
24.94 |
DRUG SCR QUAL MLT
DRUG
CLASSES |
80305 |
300 |
169.00 |
160.55 |
DRUG SCR QUAN
LEVETIRACETAM |
80177 |
300 |
85.00 |
80.75 |
DRUG SCREENING, SI
NGLE |
80307 |
300 |
290.00 |
275.50 |
DRUG TEST, DEFINIT
IVE,
1-7 DRUG CLASSES |
G0480 |
300 |
550.00 |
522.50 |
DRUG TEST, DEFINIT
IVE,
1-7 DRUG CLASSES |
G0480 |
300 |
146.25 |
138.94 |
DRUG/SUBST DEF
QUAL/QUANT NOS 1-3 |
80375 |
300 |
131.00 |
124.45 |
EBV VCA IgG/IgM |
86663 |
300 |
89.25 |
84.79 |
ELECTROLYTE PANEL
(NA,K,CL,CO2) |
80051 |
300 |
113.00 |
107.35 |
EPSTEIN-BARR ANTIB
ODY
VIRUS |
86665 |
300 |
117.00 |
111.15 |
ERYTHROPOIETIN |
82668 |
300 |
47.13 |
44.77 |
ESR (ERYTHROCYTE);
NON-AUTOMATED |
85651 |
300 |
85.00 |
80.75 |
ESTRONE |
82679 |
300 |
115.75 |
109.96 |
FACTOR V, LABILE
FACTOR |
85220 |
300 |
262.00 |
248.90 |
FACTOR V, LEIDEN
span> |
81241 |
300 |
284.30 |
270.09 |
FERRITIN, RIA |
82728 |
300 |
145.00 |
137.75 |
FIBRINOLYSINS/COAG
ULOPATHY
SCR I&R |
85390 |
300 |
45.00 |
42.75 |
FOLATE (FOLIC) ACI
D;
SERUM |
82746 |
300 |
144.00 |
136.80 |
FSH (FOLLICLE STIM
ULATING
HORMONE) |
83001 |
300 |
148.00 |
140.60 |
GAMMA
INTERFERON-PRODUCING T-CELLS |
86481 |
300 |
127.50 |
121.13 |
GAMMAGLOBULIN,IgA,
IgD,IgG,IgM |
82784 |
300 |
178.00 |
169.10 |
GGT GAMMA GT |
82977 |
300 |
71.00 |
67.45 |
GIARDIA ANTIGEN |
87329 |
300 |
124.00 |
117.80 |
GLUCOSE; QUANT. BL
OOD,
FBS 2H |
82947 |
300 |
46.00 |
43.70 |
GONADOTROPIN;
LUTEINIZING HORMONE |
83002 |
300 |
84.90 |
80.66 |
GONORRHOEAE AMPLIF
IED
PROBE |
87591 |
300 |
119.00 |
113.05 |
GRAM, PRIM WRIGHTS
& STOOL SMEARS |
87205 |
300 |
64.00 |
60.80 |
HCT |
85014 |
300 |
32.00 |
30.40 |
HELICOBACTOR PYLOR
I,
STOOL |
87338 |
300 |
75.00 |
71.25 |
HEMOGLOBIN; GLYCAT
ED |
83036 |
300 |
92.00 |
87.40 |
HEPATITIS B CORE
ANTIBODY; TOTAL |
86704 |
300 |
103.00 |
97.85 |
HEPATITIS B SURFAC
ANTIBODY (HBsAb) |
86706 |
300 |
108.00 |
102.60 |
HEPATITIS B SURFAC
ANTIGEN (HBsAg) |
87340 |
300 |
106.00 |
100.70 |
HEPATITIS C ANTIBO
DY |
86803 |
300 |
128.00 |
121.60 |
HEPATITIS C QUANT |
87522 |
300 |
773.00 |
734.35 |
HERPES SIMPLEX, TY
PE 1 |
86695 |
300 |
58.80 |
55.86 |
HERPES SIMPLEX, TY
PE 2 |
86696 |
300 |
30.30 |
28.79 |
HIV-1/2 AG AND AB |
87389 |
300 |
157.50 |
149.63 |
HLA TYPING, A,B, O
R C,
SINGLE ANTIGEN |
86812 |
300 |
246.00 |
233.70 |
HOMOCYSTEINE LEVEL
|
83090 |
300 |
188.00 |
178.60 |
INFECTIOUS AGENT
DNA/RNA INFLUENZA 1ST 2 |
87502 |
300 |
121.50 |
115.43 |
IRON BINDING CAPAC
ITY
(IBC) |
83550 |
300 |
103.00 |
97.85 |
IRON SERUM |
83540 |
300 |
73.00 |
69.35 |
KOH TISSUE EXAM FO
FUNGI |
87220 |
300 |
27.85 |
26.46 |
LACOSAMIDE, ASSAY |
80235 |
300 |
200.00 |
190.00 |
LACTATE DEHYDROGEN
ASE
(LD), (LDH) |
83615 |
300 |
73.00 |
69.35 |
LACTATE, (LACTIC A
CID) |
83605 |
300 |
126.00 |
119.70 |
LAMOTRIGINE
|
80175 |
300 |
90.00 |
85.50 |
LIPASE |
83690 |
300 |
110.00 |
104.50 |
LIPID PANEL
82465,83718,84478 |
80061 |
300 |
144.00 |
136.80 |
LITHIUM |
80178 |
300 |
115.00 |
109.25 |
LIVER (HEPATIC)
FUNCTION PANEL |
80076 |
300 |
149.00 |
141.55 |
LYME DISEASE SEROL
OGY
EVALUATION |
86618 |
300 |
147.00 |
139.65 |
MAGNESIUM |
83735 |
300 |
75.00 |
71.25 |
METHYLENETETRAHYDR
OFOLATE
REDUCTASE |
81291 |
300 |
300.00 |
285.00 |
MICROALBUMIN-URINE
QUANTITATIVE |
82043 |
300 |
98.00 |
93.10 |
MONOSPOT |
86308 |
300 |
75.00 |
71.25 |
MUMPS ANTIBODY/IgG
& IgM x (2) |
86735 |
300 |
120.00 |
114.00 |
NOS ASSAY W/OPTIC
(SHIGA TOXIN 1) |
87899 |
300 |
91.00 |
86.45 |
OCCULT BLOOD,1-3,N
OT
SCREENING |
82272 |
300 |
24.25 |
23.04 |
OCCULT BLOOD; FECE
S,
1-3 SPECIMENS |
82270 |
300 |
27.00 |
25.65 |
ORGANIC
ACID,SINGLE,QUANTITATIVE |
83921 |
300 |
240.00 |
228.00 |
OVA PARASITS SMR P
RIM
CPLX SPEC STRAIN |
87209 |
300 |
47.78 |
45.39 |
PARATHYROID HORMON
(C-TERMINAL) |
83970 |
300 |
264.00 |
250.80 |
PHENOBARBITAL |
80184 |
300 |
154.00 |
146.30 |
PHOSPHORUS INORGAN
IC;
SERUM |
84100 |
300 |
59.00 |
56.05 |
PLATELET COUNT |
85049 |
300 |
30.85 |
29.31 |
POTASSIUM (K); SER
UM |
84132 |
300 |
58.00 |
55.10 |
PRE-ALBUMIN
|
84134 |
300 |
108.00 |
102.60 |
PROCALCITONIN (PCT
) |
84145 |
300 |
125.00 |
118.75 |
PROGESTRONE; SERUM
|
84144 |
300 |
148.00 |
140.60 |
PROLACTIN; SERUM
span> |
84146 |
300 |
182.00 |
172.90 |
PROTEIN C, ACTIVIT
Y |
85303 |
300 |
303.00 |
287.85 |
PROTEIN S, FREE |
85306 |
300 |
368.00 |
349.60 |
PROTEIN-TOTAL |
84155 |
300 |
90.00 |
85.50 |
PROTEIN;
ELECTROPHORESIS-(SERUM) |
84165 |
300 |
156.00 |
148.20 |
PROTHROMBIN TIME (
PT) |
85610 |
300 |
50.00 |
47.50 |
PROTIME SUBSTITUTI
ON,
PLASMA FRACTIONS |
85611 |
300 |
175.00 |
166.25 |
PSA SCREEN; TOTAL
(MEDICARE) |
G0103 |
300 |
131.00 |
124.45 |
PSA, FREE |
84154 |
300 |
185.00 |
175.75 |
PSA; TOTAL |
84153 |
300 |
131.00 |
124.45 |
QUANT. OF DRUG, NO
OTHER SPECIFICATI |
80299 |
300 |
183.00 |
173.85 |
QUANTITATIVE D-DIM
ER |
85379 |
300 |
141.00 |
133.95 |
QUANTITATIVE, NOT
OTHERWISE SPECIFIED |
83520 |
300 |
95.00 |
90.25 |
RA FACTOR (RHEUMAT
OID
ARTHRITIS)QUAL |
86430 |
300 |
62.00 |
58.90 |
RA TITER (RHEUMATO
ID
ARTHRITIS)QUANT |
86431 |
300 |
46.30 |
43.99 |
RENAL FUNCTION PAN
EL |
80069 |
300 |
190.00 |
180.50 |
RETICULOCYTE,
AUTOMATED |
85045 |
300 |
56.00 |
53.20 |
REVERSE T3 TEST |
84482 |
300 |
79.40 |
75.43 |
RPR, VDRL, ART;
QUALITATIVE |
86592 |
300 |
70.00 |
66.50 |
RUBELLA ANTIBODY
span> |
86762 |
300 |
108.00 |
102.60 |
RUSSEL VIPER VENOM
DILUTED |
85613 |
300 |
250.00 |
237.50 |
RUSSEL VIPER VENOM
DILUTED |
85613 |
300 |
39.00 |
37.05 |
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
550.00 |
522.50 |
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
131.00 |
124.45 |
SARS-CoV-2 COVID-1
AMP PROBE TQ |
87635 |
300 |
150.00 |
142.50 |
SARS-COV-2 IGG
ANTIBODY |
86769 |
300 |
150.00 |
142.50 |
SENSITIVITIES (ALL
) |
87186 |
300 |
127.00 |
120.65 |
SERUM ESTROGEN,
ESTRADIOL |
82670 |
300 |
175.00 |
166.25 |
SMEAR PRIM SRC WET
MOUNT NFCT |
87210 |
300 |
8.50 |
8.08 |
SODIUM; SERUM (NA)
|
84295 |
300 |
62.00 |
58.90 |
SPECIMEN CONCENTRA
TION |
87015 |
300 |
101.00 |
95.95 |
STAPHYLOCOCCUS AUR
EUS |
87641 |
300 |
62.50 |
59.38 |
STOOL CULTURE
(CAMPYLOBACTER) |
87046 |
300 |
95.00 |
90.25 |
STRAIN
MALARIA,COCCIDIA,HERP VIRUSES |
87207 |
300 |
70.30 |
66.79 |
STREPTOCOCCUS GRP
A,
AMP PRB |
87651 |
300 |
99.80 |
94.81 |
T.S.H. RIA |
84443 |
300 |
122.00 |
115.90 |
T3 FREE |
84481 |
300 |
125.63 |
119.35 |
T3; TOTAL (TT-3)
span> |
84480 |
300 |
114.00 |
108.30 |
TACROLIMUS |
80197 |
300 |
231.00 |
219.45 |
TB TEST, CELL MEDI
ATED
IMMUNITY |
86480 |
300 |
111.25 |
105.69 |
TEGRETOL
(CARBAMAZEPINE); TOTAL |
80156 |
300 |
143.00 |
135.85 |
TESTOSTERONE; FREE
|
84402 |
300 |
149.00 |
141.55 |
TESTOSTERONE; TOTA
L |
84403 |
300 |
176.00 |
167.20 |
THROMBIN TIME, PLA
SMA |
85670 |
300 |
190.00 |
180.50 |
THROMBOPLASTIN TIM
E,
PTT; SUB PLASMA |
85732 |
300 |
190.00 |
180.50 |
THYROGLOBULIN |
84432 |
300 |
74.50 |
70.78 |
THYROID
(THYROGLOBULIN) ANTIBODIES |
86800 |
300 |
76.05 |
72.25 |
THYROXINE T4; FREE
|
84439 |
300 |
106.00 |
100.70 |
TRICHOMONAS VAGINA
LIS,
AMP |
87661 |
300 |
150.00 |
142.50 |
TROPONIN, QUANTITA
TIVE |
84484 |
300 |
168.00 |
159.60 |
UA MICROSCOPIC |
81015 |
300 |
50.00 |
47.50 |
UA-ROUTINE W/O
MICROSCP, NON AUTOMATED |
81002 |
300 |
47.00 |
44.65 |
URIC ACID; BLOOD
span> |
84550 |
300 |
73.00 |
69.35 |
URINE AUTOMATED W/
O MICROSCOPY |
81003 |
300 |
47.00 |
44.65 |
URINE MONOCLANAL
PROTEIN 84156,86335 |
84166 |
300 |
168.30 |
159.89 |
URINE PREGNANCY TE
ST |
81025 |
300 |
12.50 |
11.88 |
URINE PROTEIN |
84156 |
300 |
60.00 |
57.00 |
URINE SODIUM |
84300 |
300 |
62.00 |
58.90 |
URINE, AUTOMATED W
ITH
MICROSCOPY |
81001 |
300 |
59.00 |
56.05 |
VALPROIC ACID
(DEPAKOTE) |
80164 |
300 |
145.00 |
137.75 |
VALPROIC ACID
(DIPROPYLACETIC ACID) FREE |
80165 |
300 |
135.00 |
128.25 |
VANCOMYCIN |
80202 |
300 |
140.00 |
133.00 |
VARICELLA TITRE |
86787 |
300 |
44.10 |
41.90 |
VITAMIN B 12 |
82607 |
300 |
127.00 |
120.65 |
VITAMIN B-1 (THIAM
INE) |
84425 |
300 |
164.45 |
156.23 |
VITAMIN B-6 (PYRID
OXAL
PHOSPHATE) |
84207 |
300 |
137.80 |
130.91 |
VITAMIN D; 25 HYDR
OXY
(CALCIFEDIOL) |
82306 |
300 |
260.00 |
247.00 |
ZINC |
84630 |
300 |
50.70 |
48.17 |
ABDOMEN, 2 VIEWS
span> |
74019 |
320 |
281.00 |
266.95 |
ANKLE; COMPLETE, M
IN.
3 VIEWS |
73610 |
320 |
220.00 |
209.00 |
BONE DENSITY ,DXA,
1OR
MORE SITES, |
77080 |
320 |
322.00 |
305.90 |
CERVICAL SPINE; 2-
VIEWS |
72040 |
320 |
288.50 |
274.08 |
CHEST PA W/RIBS MI
N 3
VIEWS |
71101 |
320 |
212.80 |
202.16 |
CLAVICLE, COMPLETE
|
73000 |
320 |
231.00 |
219.45 |
ELBOW 3 VIEWS |
73080 |
320 |
152.15 |
144.54 |
ELBOW; 2 VIEWS |
73070 |
320 |
170.00 |
161.50 |
FEMUR, MIN 2 VIEWS
|
73552 |
320 |
229.00 |
217.55 |
FINGER(S), MIN. 2
VIEWS |
73140 |
320 |
164.00 |
155.80 |
FOOT; COMPLETE, MI
N. 3
VIEWS |
73630 |
320 |
187.00 |
177.65 |
FOREARM; INCL. 1 J
OINT,
2 VIEWS |
73090 |
320 |
206.00 |
195.70 |
HAND; MIN. 3 VIEWS
|
73130 |
320 |
212.00 |
201.40 |
HIP, COMPLETE 2-3
VIEWS |
73502 |
320 |
215.00 |
204.25 |
HUMERUS; INCL. 1
JOINT, MIN. 2 VIEWS |
73060 |
320 |
222.00 |
210.90 |
KNEE; 1 OR 2 VIEWS
|
73560 |
320 |
159.00 |
151.05 |
KNEE; 3 VIEWS |
73562 |
320 |
257.00 |
244.15 |
KUB, I VIEW
|
74018 |
320 |
182.00 |
172.90 |
LOWER LEG, TIB/FIB
; 2
VIEWS |
73590 |
320 |
215.00 |
204.25 |
LUMBAR SPINE; 2-3
VIEWS |
72100 |
320 |
266.00 |
252.70 |
MANDIBLE; LESS THA
N 4
VIEWS |
70100 |
320 |
290.00 |
275.50 |
NECK, SOFT TISSUE |
70360 |
320 |
222.00 |
210.90 |
ORBITS X-RAY |
70030 |
320 |
110.25 |
104.74 |
OS CALCIS (CALCANE
US);
MIN. 2 VIEWS |
73650 |
320 |
176.00 |
167.20 |
PELVIS; 1-2 VIEWS |
72170 |
320 |
196.00 |
186.20 |
RIBS, UNILATERAL;
VIEWS |
71100 |
320 |
218.00 |
207.10 |
SACRUM & COCCY
X;
MIN. 2 VIEWS |
72220 |
320 |
206.00 |
195.70 |
SCAPULA, COMPLETE |
73010 |
320 |
300.00 |
285.00 |
SCOLIOSIS EVAL |
72081 |
320 |
205.00 |
194.75 |
SHOULDER; COMPLETE
MIN. 2 VIEWS |
73030 |
320 |
240.00 |
228.00 |
THORACIC SPINE; 2
VIEWS |
72070 |
320 |
200.00 |
190.00 |
TOE(S); MIN. 2 VIE
WS |
73660 |
320 |
172.00 |
163.40 |
WRIST; COMPLETE, M
IN.
3 VIEWS |
73110 |
320 |
180.00 |
171.00 |
CHEST 2 VIEWS, FRO
NT
& LAT |
71046 |
324 |
195.00 |
185.25 |
CHEST, SINGLE VIEW
|
71045 |
324 |
133.00 |
126.35 |
CT: ABD & PELV
IS
W/O CONTRAST |
74176 |
350 |
1,567.80 |
1,489.41 |
CT: ABD & PELV
IS
WITH CONTRAST |
74177 |
350 |
1,757.80 |
1,669.91 |
CT: HEAD OR BRAIN
WITHOUT CONTRAST |
70450 |
350 |
1,463.00 |
1,389.85 |
CT:CHEST WITH AND
WITHOUT CONTRAST |
71270 |
350 |
2,455.00 |
2,332.25 |
RED BLOOD CELL |
P9016 |
390 |
389.43 |
369.96 |
TRANSFUSION
BLOOD/BLOOD COMPONENTS |
36430 |
391 |
547.00 |
519.65 |
ABDOMEN, GB, BILIA
RY
TREE SINGLE QUAD |
76705 |
402 |
476.00 |
452.20 |
ABDOMINAL AORTA
ULTRASOUND (AAA) |
76706 |
402 |
476.00 |
452.20 |
ULTRASOUND, RENAL |
76775 |
402 |
442.00 |
419.90 |
ULTRASOUND,ABDOMIN
AL,COMPLETE |
76700 |
402 |
654.00 |
621.30 |
ULTRASOUND,EXTREMI
TY
COMPLETE |
76881 |
402 |
285.00 |
270.75 |
ULTRASOUND,TRANSVA
GINAL |
76830 |
402 |
509.00 |
483.55 |
US SCROTUM AND
CONTENTS |
76870 |
402 |
508.00 |
482.60 |
US SOFT TISS,
HEAD,NECK, THYROID |
76536 |
402 |
433.00 |
411.35 |
MAMMOGRAM, SCREENI
NG |
77067 |
403 |
255.00 |
242.25 |
APP OF MODALITY
VASOPNEUMATIC DEVICES |
90716 |
420 |
25.00 |
23.75 |
CANALITH REPOSITIO
NING
PROCEDURE |
95992 |
420 |
93.75 |
89.06 |
ELECTRICAL STIMULA
TION
(MANUAL) |
97032 |
420 |
165.00 |
156.75 |
ELECTRICAL STIMULA
TION
(UNATTENDED) |
97014 |
420 |
135.00 |
128.25 |
GAIT TRAINING (15
MIN) |
97116 |
420 |
90.00 |
85.50 |
IONTOPHORESIS, EAC
H 15
MIN. |
97033 |
420 |
81.00 |
76.95 |
MANUAL THERAPY
TECHNIQUES,EA.15 MIN. |
97140 |
420 |
122.00 |
115.90 |
NEUROMUSCULAR RE-E
D. |
97112 |
420 |
90.00 |
85.50 |
PT THER/ACT/TRANSF
ER
(FUNCTIONAL)15 MN |
97530 |
420 |
90.00 |
85.50 |
ROM/STRENGTH EXERC
ISE,
EACH 15 MIN. |
97110 |
420 |
99.00 |
94.05 |
ULTRASOUND, EACH 1
MIN. |
97035 |
420 |
62.00 |
58.90 |
PT EVAL HIGH COMP,
45
MIN |
97163 |
424 |
256.10 |
243.30 |
PT EVAL LOW COMP,
20
MIN |
97161 |
424 |
137.90 |
131.01 |
PT EVAL MOD COMP,
30
MIN |
97162 |
424 |
197.00 |
187.15 |
PT RE-EVAL EST PLA
CARE |
97164 |
424 |
99.00 |
94.05 |
OT EVAL HIGH COMP,
60
MINUTES |
97167 |
434 |
265.45 |
252.18 |
OT EVAL LOW COMP,
30
MINUTES |
97165 |
434 |
142.93 |
135.78 |
OT EVAL MOD COMP,
45
MINUTES |
97166 |
434 |
204.19 |
193.98 |
CARDIOLOGY VISIT 2
5 MINUTES |
99214 |
480 |
188.00 |
178.60 |
CARDIOLOGY VISIT 1
MINUTES |
99213 |
480 |
128.00 |
121.60 |
CARDIOLOGY VISIT 4
MINUTES |
99215 |
480 |
253.00 |
240.35 |
CARDIOLOGY VISIT,
10
MINUTES |
99212 |
480 |
77.00 |
73.15 |
CARDIOLOGY VISIT,
NEW
20 MINUTES |
99202 |
480 |
131.00 |
124.45 |
CARDIOLOGY VISIT,
NEW
30 MINUTES |
99203 |
480 |
190.00 |
180.50 |
CARDIOLOGY VISIT,
NEW
45 MINUTES |
99204 |
480 |
288.00 |
273.60 |
CARDIOLOGY VISIT,
NEW
60 MINUTES |
99205 |
480 |
363.00 |
344.85 |
INJ IMM FIRST
VACC/TOXIOD THRU 18YRS, |
90460 |
521 |
36.00 |
34.20 |
RHC:ANNUAL WELLNESS
VISIT, INIT |
G0438 |
521 |
296.25 |
281.44 |
RHC:EST PATIENT HI
GH
LEVEL |
99215 |
521 |
210.00 |
199.50 |
RHC:EST PATIENT
LOW-MOD, 15 MIN |
99213 |
521 |
110.00 |
104.50 |
RHC:EST PATIENT MI
NOR
LEVEL, 10 MIN |
99212 |
521 |
65.00 |
61.75 |
RHC:EST PATIENT MO
DERATE-HIGH,
25 MIN |
99214 |
521 |
160.00 |
152.00 |
RHC:NEW OFFICE OUT
PT,
HIGH, 60 MIN |
99205 |
521 |
290.00 |
275.50 |
RHC:NEW OFFICE OUT
PT,
MINOR-MOD, 20 MIN |
99202 |
521 |
88.00 |
83.60 |
RHC:NEW OFFICE OUT
PT,
MOD-HIGH 45 MIN |
99204 |
521 |
225.00 |
213.75 |
RHC:NEW OFFICE OUT
PT,
MOD-SEV 30 MIN |
99203 |
521 |
134.00 |
127.30 |
RHC:PREV VISIT, EST
T (1
THRU 4 YEARS) |
99392 |
521 |
135.00 |
128.25 |
RHC:PREV VISIT, EST
(12 THRU 17 YEARS) |
99394 |
521 |
145.00 |
137.75 |
RHC:PREV VISIT, EST
(18 THRU 39 YEARS) |
99395 |
521 |
150.00 |
142.50 |
RHC:PREV VISIT, EST
(40 THRU 64 YEARS) |
99396 |
521 |
160.00 |
152.00 |
RHC:PREV VISIT, EST
T (5
THRU 11 YEARS) |
99393 |
521 |
135.00 |
128.25 |
RHC:PREV VISIT, EST
(65 AND OVER) |
99397 |
521 |
165.00 |
156.75 |
RHC:PREV VISIT, EST
(AGE YOUNGER THAN 1 YEAR) |
99391 |
521 |
125.00 |
118.75 |
RHC:PREV VISIT,
INITIAL (AGE YOUNGER THAN 1 YEAR) |
99381 |
521 |
118.00 |
112.10 |
RHC:PREV VISIT, NEW (1
THRU 4 YEARS) |
99382 |
521 |
188.00 |
178.60 |
RHC:PREV VISIT, NE
(12 THRU 17 YEARS) |
99384 |
521 |
221.00 |
209.95 |
RHC:PREV VISIT, NE
(18 THRU 39 YEARS) |
99385 |
521 |
221.00 |
209.95 |
RHC:PREV VISIT, NE
(40 THRU 64 YEARS) |
99386 |
521 |
194.25 |
184.54 |
RHC:PREV VISIT, NE
W (5
THRU 11 YEARS) |
99383 |
521 |
188.00 |
178.60 |
RHC:PREV VISIT, NE
(65 AND OVER) |
99387 |
521 |
212.00 |
201.40 |
MRI: UPPER EXT OTH
/THN
JT, W/WO CONTRAST |
73218 |
610 |
1,650.00 |
1,567.50 |
MRI:ANY JT LOWR EX
T |
73721 |
610 |
1,210.00 |
1,149.50 |
MRI:ANY JT UPPER E
XT |
73221 |
610 |
1,207.50 |
1,147.13 |
MRI: LUMBAR W/O
CONTRAST |
72148 |
612 |
1,155.00 |
1,097.25 |
MRI:CERVICAL W/O
CONTRAST |
72141 |
612 |
1,155.00 |
1,097.25 |
MRI:THORACIC |
72146 |
612 |
1,155.00 |
1,097.25 |
EKG/ECG, 12 LEADS
OR
>; TRACING ONLY |
93005 |
730 |
141.00 |
133.95 |
HOLTER MONITOR, EX
TRNL
ECG SCANNING |
93226 |
731 |
605.00 |
574.75 |
POLYSOM 6>YRS S
LEEP
4>ADDL PARAM ATTENDED |
95810 |
740 |
2,756.00 |
2,618.20 |
POLYSOM 6>YRS S
LEEP
W/CPAP 4>ADDL |
95811 |
740 |
3,032.00 |
2,880.40 |
DUPLEX CAROTID,
COMPLETE BILATERAL |
93880 |
921 |
888.60 |
844.17 |
ECHO TTHRC R-T 2D
-+M-MODE |
93306 |
921 |
1,518.49 |
1,442.57 |
REHAB W/CONTINUOUS
ECG, PER SESSION |
93798 |
943 |
105.85 |
100.56 |
RHEUMATIOLOGY VISI
T,
EST, 10 MINUTES |
99212 |
960 |
77.00 |
73.15 |
RHEUMATOLOGY VISIT
EST, 15 MINUTES |
99213 |
960 |
128.00 |
121.60 |
RHEUMATOLOGY VISIT
EST, 25 MINUTES |
99214 |
960 |
188.00 |
178.60 |
RHEUMATOLOGY VISIT
EST, 40 MINUTES |
99215 |
960 |
253.00 |
240.35 |
RHEUMATOLOGY VISIT
NEW, 20 MINUTES |
99202 |
960 |
131.00 |
124.45 |
RHEUMATOLOGY VISIT
NEW, 30 MINUTES |
99203 |
960 |
190.00 |
180.50 |
RHEUMATOLOGY VISIT
NEW, 45 MINUTES |
99204 |
960 |
288.00 |
273.60 |
RHEUMATOLOGY VISIT
NEW, 60 MINUTES |
99205 |
960 |
363.00 |
344.85 |