Humana (Member Portal - https://www.humana.com/logon/ or 1-800-448-6262)
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 |
TRANSFUSION
BLOOD/BLOOD COMPONENTS |
36430 |
391 |
547.00 |
410.25 |
ORBITS X-RAY |
70030 |
320 |
110.25 |
82.69 |
MANDIBLE; LESS THA
N 4
VIEWS |
70100 |
320 |
290.00 |
217.50 |
NECK, SOFT TISSUE |
70360 |
320 |
222.00 |
166.50 |
CT: HEAD OR BRAIN
WITHOUT CONTRAST |
70450 |
350 |
1,463.00 |
1,097.25 |
CHEST, SINGLE VIEW
|
71045 |
324 |
133.00 |
99.75 |
CHEST 2 VIEWS, FRO
NT
& LAT |
71046 |
324 |
195.00 |
146.25 |
RIBS, UNILATERAL;
VIEWS |
71100 |
320 |
218.00 |
163.50 |
CHEST PA W/RIBS MI
N 3
VIEWS |
71101 |
320 |
212.80 |
159.60 |
CT:CHEST WITH AND
WITHOUT CONTRAST |
71270 |
350 |
2,455.00 |
1,841.25 |
CERVICAL SPINE; 2-3
VIEWS |
72040 |
320 |
288.50 |
216.38 |
THORACIC SPINE; 2
VIEWS |
72070 |
320 |
200.00 |
150.00 |
SCOLIOSIS EVAL |
72081 |
320 |
205.00 |
153.75 |
LUMBAR SPINE; 2-3
VIEWS |
72100 |
320 |
266.00 |
199.50 |
MRI:CERVICAL W/O
CONTRAST |
72141 |
612 |
1,155.00 |
866.25 |
MRI:THORACIC |
72146 |
612 |
1,155.00 |
866.25 |
MRI: LUMBAR W/O
CONTRAST |
72148 |
612 |
1,155.00 |
866.25 |
PELVIS; 1-2 VIEWS |
72170 |
320 |
196.00 |
147.00 |
SACRUM & COCCY
X;
MIN. 2 VIEWS |
72220 |
320 |
206.00 |
154.50 |
CLAVICLE, COMPLETE
|
73000 |
320 |
231.00 |
173.25 |
SCAPULA, COMPLETE |
73010 |
320 |
300.00 |
225.00 |
SHOULDER; COMPLETE
MIN. 2 VIEWS |
73030 |
320 |
240.00 |
180.00 |
HUMERUS; INCL. 1
JOINT, MIN. 2 VIEWS |
73060 |
320 |
222.00 |
166.50 |
ELBOW; 2 VIEWS |
73070 |
320 |
170.00 |
127.50 |
ELBOW 3 VIEWS |
73080 |
320 |
152.15 |
114.11 |
FOREARM; INCL. 1
JOINT, 2 VIEWS |
73090 |
320 |
206.00 |
154.50 |
WRIST; COMPLETE, M
IN.
3 VIEWS |
73110 |
320 |
180.00 |
135.00 |
HAND; MIN. 3 VIEWS
|
73130 |
320 |
212.00 |
159.00 |
FINGER(S), MIN. 2
VIEWS |
73140 |
320 |
164.00 |
123.00 |
MRI: UPPER EXT OTH
/THN
JT, W/WO CONTRAST |
73218 |
610 |
1,650.00 |
1,237.50 |
MRI:ANY JT UPPER E
XT |
73221 |
610 |
1,207.50 |
905.63 |
HIP, COMPLETE 2-3
VIEWS |
73502 |
320 |
215.00 |
161.25 |
FEMUR, MIN 2 VIEWS
|
73552 |
320 |
229.00 |
171.75 |
KNEE; 1 OR 2 VIEWS
|
73560 |
320 |
159.00 |
119.25 |
KNEE; 3 VIEWS |
73562 |
320 |
257.00 |
192.75 |
LOWER LEG, TIB/FIB
; 2
VIEWS |
73590 |
320 |
215.00 |
161.25 |
ANKLE; COMPLETE, M
IN.
3 VIEWS |
73610 |
320 |
220.00 |
165.00 |
FOOT; COMPLETE, MI
N. 3
VIEWS |
73630 |
320 |
187.00 |
140.25 |
OS CALCIS (CALCANE
US);
MIN. 2 VIEWS |
73650 |
320 |
176.00 |
132.00 |
TOE(S); MIN. 2 VIE
WS |
73660 |
320 |
172.00 |
129.00 |
MRI:ANY JT LOWR EX
T |
73721 |
610 |
1,210.00 |
907.50 |
KUB, I VIEW
|
74018 |
320 |
182.00 |
136.50 |
ABDOMEN, 2 VIEWS
span> |
74019 |
320 |
281.00 |
210.75 |
CT: ABD & PELV
IS
W/O CONTRAST |
74176 |
350 |
1,567.80 |
1,175.85 |
CT: ABD & PELV
IS
WITH CONTRAST |
74177 |
350 |
1,757.80 |
1,318.35 |
US SOFT TISS,
HEAD,NECK, THYROID |
76536 |
402 |
433.00 |
324.75 |
ULTRASOUND,ABDOMIN
AL,COMPLETE |
76700 |
402 |
654.00 |
490.50 |
ABDOMEN, GB, BILIA
RY
TREE SINGLE QUAD |
76705 |
402 |
476.00 |
357.00 |
ABDOMINAL AORTA
ULTRASOUND (AAA) |
76706 |
402 |
476.00 |
357.00 |
ULTRASOUND, RENAL |
76775 |
402 |
442.00 |
331.50 |
ULTRASOUND,TRANSVA
GINAL |
76830 |
402 |
509.00 |
381.75 |
US SCROTUM AND
CONTENTS |
76870 |
402 |
508.00 |
381.00 |
ULTRASOUND,EXTREMI
TY
COMPLETE |
76881 |
402 |
285.00 |
213.75 |
MAMMOGRAM, SCREENI
NG |
77067 |
403 |
255.00 |
191.25 |
BONE DENSITY ,DXA,
1OR
MORE SITES, |
77080 |
320 |
322.00 |
241.50 |
BASIC METABOLIC
PANEL(BUN,CREAT,GLUC |
80048 |
300 |
168.00 |
126.00 |
ELECTROLYTE PANEL
(NA,K,CL,CO2) |
80051 |
300 |
113.00 |
84.75 |
CMP(GLUC,BUN,CREAT
,AST,ALP,TBIL,ALT, |
80053 |
300 |
232.00 |
174.00 |
LIPID PANEL
82465,83718,84478 |
80061 |
300 |
144.00 |
108.00 |
RENAL FUNCTION PAN
EL |
80069 |
300 |
190.00 |
142.50 |
ACUTE HEPATITIS PA
NEL |
80074 |
300 |
557.00 |
417.75 |
LIVER (HEPATIC)
FUNCTION PANEL |
80076 |
300 |
149.00 |
111.75 |
TEGRETOL
(CARBAMAZEPINE); TOTAL |
80156 |
300 |
143.00 |
107.25 |
DIGOXIN |
80162 |
300 |
111.00 |
83.25 |
VALPROIC ACID (DEP
AKOTE) |
80164 |
300 |
145.00 |
108.75 |
VALPROIC ACID
(DIPROPYLACETIC ACID) FREE |
80165 |
300 |
135.00 |
101.25 |
LAMOTRIGINE
|
80175 |
300 |
90.00 |
67.50 |
DRUG SCR QUAN
LEVETIRACETAM |
80177 |
300 |
85.00 |
63.75 |
LITHIUM |
80178 |
300 |
115.00 |
86.25 |
PHENOBARBITAL |
80184 |
300 |
154.00 |
115.50 |
DILANTIN (PHENYTOI
N);
TOTAL |
80185 |
300 |
131.00 |
98.25 |
TACROLIMUS |
80197 |
300 |
231.00 |
173.25 |
VANCOMYCIN |
80202 |
300 |
140.00 |
105.00 |
LACOSAMIDE, ASSAY |
80235 |
300 |
200.00 |
150.00 |
QUANT. OF DRUG, NO
OTHER SPECIFICATI |
80299 |
300 |
183.00 |
137.25 |
DRUG SCR QUAL MLT
DRUG
CLASSES |
80305 |
300 |
169.00 |
126.75 |
DRUG SCREENING, SI
NGLE |
80307 |
300 |
290.00 |
217.50 |
ALCOHOL, (ETOH) AN
SPEC BUT BREATH |
80320 |
300 |
188.00 |
141.00 |
ALCOHOL, (ETOH) AN
SPEC BUT BREATH |
80320 |
300 |
550.00 |
412.50 |
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
131.00 |
98.25 |
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
550.00 |
412.50 |
DRUG/SUBST DEF
QUAL/QUANT NOS 1-3 |
80375 |
300 |
131.00 |
98.25 |
URINE, AUTOMATED W
ITH
MICROSCOPY |
81001 |
300 |
59.00 |
44.25 |
UA-ROUTINE W/O
MICROSCP, NON AUTOMATED |
81002 |
300 |
47.00 |
35.25 |
URINE AUTOMATED W/
MICROSCOPY |
81003 |
300 |
47.00 |
35.25 |
UA MICROSCOPIC |
81015 |
300 |
50.00 |
37.50 |
URINE PREGNANCY TE
ST |
81025 |
300 |
12.50 |
9.38 |
FACTOR V, LEIDEN
span> |
81241 |
300 |
284.30 |
213.23 |
METHYLENETETRAHYDR
OFOLATE
REDUCTASE |
81291 |
300 |
300.00 |
225.00 |
ALBUMIN; SERUM |
82040 |
300 |
59.00 |
44.25 |
MICROALBUMIN-URINE
QUANTITATIVE |
82043 |
300 |
98.00 |
73.50 |
AFP
(ALPHA-FETOPROTEIN: SERUM) |
82105 |
300 |
139.00 |
104.25 |
AMMONIA; BLOOD |
82140 |
300 |
128.00 |
96.00 |
AMYLASE; SERUM OR
URINE |
82150 |
300 |
99.00 |
74.25 |
BILIRUBIN; TOTAL |
82247 |
300 |
69.00 |
51.75 |
BILIRUBIN; DIRECT |
82248 |
300 |
53.00 |
39.75 |
OCCULT BLOOD; FECE
S,
1-3 SPECIMENS |
82270 |
300 |
27.00 |
20.25 |
OCCULT BLOOD,1-3,N
OT
SCREENING |
82272 |
300 |
24.25 |
18.19 |
VITAMIN D; 25 HYDR
OXY
(CALCIFEDIOL) |
82306 |
300 |
260.00 |
195.00 |
CALCIUM SERUM; TOT
AL |
82310 |
300 |
81.00 |
60.75 |
CALCIUM; IONIZED
span> |
82330 |
300 |
84.90 |
63.68 |
CALCULUS (STONE) Q
UANT |
82365 |
300 |
40.00 |
30.00 |
CARBON
DIOXIDE(BICARBONATE -ECO 2 |
82374 |
300 |
63.00 |
47.25 |
CHLORIDE; BLOOD |
82435 |
300 |
59.00 |
44.25 |
CORTISOL; TOTAL |
82533 |
300 |
152.00 |
114.00 |
CPK (CREATINE
PHOSPHOKINASE); TOTAL |
82550 |
300 |
105.00 |
78.75 |
CPK MB FRACTION ON
LY |
82553 |
300 |
150.00 |
112.50 |
CREATININE; BLOOD |
82565 |
300 |
59.00 |
44.25 |
CREATININE; OTHER
SOURCE (URINE) |
82570 |
300 |
71.00 |
53.25 |
VITAMIN B 12 |
82607 |
300 |
127.00 |
95.25 |
DIHYDROXVITAMIN D
1.25 |
82652 |
300 |
131.40 |
98.55 |
ERYTHROPOIETIN |
82668 |
300 |
47.13 |
35.35 |
SERUM ESTROGEN,
ESTRADIOL |
82670 |
300 |
175.00 |
131.25 |
ESTRONE |
82679 |
300 |
115.75 |
86.81 |
FERRITIN, RIA |
82728 |
300 |
145.00 |
108.75 |
FOLATE (FOLIC) ACI
D;
SERUM |
82746 |
300 |
144.00 |
108.00 |
GAMMAGLOBULIN,IgA,
IgD,IgG,IgM |
82784 |
300 |
178.00 |
133.50 |
BLOOD GASES; ABG
pH,pCO2,pO2,CO2,HCO |
82803 |
300 |
212.00 |
159.00 |
GLUCOSE; QUANT. BL
OOD,
FBS 2H |
82947 |
300 |
46.00 |
34.50 |
GGT GAMMA GT |
82977 |
300 |
71.00 |
53.25 |
FSH (FOLLICLE STIM
ULATING
HORMONE) |
83001 |
300 |
148.00 |
111.00 |
GONADOTROPIN;
LUTEINIZING HORMONE |
83002 |
300 |
84.90 |
63.68 |
HEMOGLOBIN; GLYCAT
ED |
83036 |
300 |
92.00 |
69.00 |
HOMOCYSTEINE LEVEL
|
83090 |
300 |
188.00 |
141.00 |
ANTI-MITOCHONDRIAL
AB |
83516 |
300 |
117.00 |
87.75 |
QUANTITATIVE, NOT
OTHERWISE SPECIFIED |
83520 |
300 |
95.00 |
71.25 |
IRON SERUM |
83540 |
300 |
73.00 |
54.75 |
IRON BINDING CAPAC
ITY
(IBC) |
83550 |
300 |
103.00 |
77.25 |
LACTATE, (LACTIC A
CID) |
83605 |
300 |
126.00 |
94.50 |
LACTATE DEHYDROGEN
ASE
(LD), (LDH) |
83615 |
300 |
73.00 |
54.75 |
BLOOD LEAD |
83655 |
300 |
101.00 |
75.75 |
LIPASE |
83690 |
300 |
110.00 |
82.50 |
MAGNESIUM |
83735 |
300 |
75.00 |
56.25 |
BNP-NATRIURETIC
PEPTIDE |
83880 |
300 |
230.00 |
172.50 |
ORGANIC
ACID,SINGLE,QUANTITATIVE |
83921 |
300 |
240.00 |
180.00 |
PARATHYROID HORMON
(C-TERMINAL) |
83970 |
300 |
264.00 |
198.00 |
ALKALINE PHOSPHATA
SE |
84075 |
300 |
70.00 |
52.50 |
PHOSPHORUS INORGAN
IC;
SERUM |
84100 |
300 |
59.00 |
44.25 |
POTASSIUM (K); SER
UM |
84132 |
300 |
58.00 |
43.50 |
PRE-ALBUMIN
|
84134 |
300 |
108.00 |
81.00 |
PROGESTRONE; SERUM
|
84144 |
300 |
148.00 |
111.00 |
PROCALCITONIN (PCT
) |
84145 |
300 |
125.00 |
93.75 |
PROLACTIN; SERUM
span> |
84146 |
300 |
182.00 |
136.50 |
PSA; TOTAL |
84153 |
300 |
131.00 |
98.25 |
PSA, FREE |
84154 |
300 |
185.00 |
138.75 |
PROTEIN-TOTAL |
84155 |
300 |
90.00 |
67.50 |
URINE PROTEIN |
84156 |
300 |
60.00 |
45.00 |
PROTEIN; ELECTROPH
ORESIS-(SERUM) |
84165 |
300 |
156.00 |
117.00 |
URINE MONOCLANAL
PROTEIN 84156,86335 |
84166 |
300 |
168.30 |
126.23 |
VITAMIN B-6 (PYRID
OXAL
PHOSPHATE) |
84207 |
300 |
137.80 |
103.35 |
SODIUM; SERUM (NA)
|
84295 |
300 |
62.00 |
46.50 |
URINE SODIUM |
84300 |
300 |
62.00 |
46.50 |
TESTOSTERONE; FREE
|
84402 |
300 |
149.00 |
111.75 |
TESTOSTERONE; TOTA
L |
84403 |
300 |
176.00 |
132.00 |
VITAMIN B-1 (THIAM
INE) |
84425 |
300 |
164.45 |
123.34 |
THYROGLOBULIN |
84432 |
300 |
74.50 |
55.88 |
THYROXINE T4; FREE
|
84439 |
300 |
106.00 |
79.50 |
T.S.H. RIA |
84443 |
300 |
122.00 |
91.50 |
AST (SGOT) |
84450 |
300 |
71.00 |
53.25 |
ALT (SGPT) ALANINE
AMINO |
84460 |
300 |
86.00 |
64.50 |
T3; TOTAL (TT-3)
span> |
84480 |
300 |
114.00 |
85.50 |
T3 FREE |
84481 |
300 |
125.63 |
94.22 |
REVERSE T3 TEST |
84482 |
300 |
79.40 |
59.55 |
TROPONIN, QUANTITA
TIVE |
84484 |
300 |
168.00 |
126.00 |
B.U.N. (UREA
NITROGEN); QUANTITATIVE |
84520 |
300 |
56.00 |
42.00 |
URIC ACID; BLOOD
span> |
84550 |
300 |
73.00 |
54.75 |
ZINC |
84630 |
300 |
50.70 |
38.03 |
BETA hCG; QUANTITATIVE |
84702 |
300 |
142.00 |
106.50 |
BETA hCG; QUALITATIVE |
84703 |
300 |
113.00 |
84.75 |
BLOOD COUNT; MANUA
DIFF. W/PLATELET |
85007 |
300 |
46.00 |
34.50 |
HCT |
85014 |
300 |
32.00 |
24.00 |
BLOOD COUNT;
HEMOGLOBIN |
85018 |
300 |
23.00 |
17.25 |
CBC W/ AUTO DIFF.
W/PLATELET COUNT |
85025 |
300 |
112.00 |
84.00 |
BLOOD COUNT;
HEMOGRAM/PLATELET COUNT |
85027 |
300 |
88.00 |
66.00 |
RETICULOCYTE, AUTO
MATED |
85045 |
300 |
56.00 |
42.00 |
BLOOD COUNT; WBC
(WHITE BLOOD CELL) |
85048 |
300 |
58.00 |
43.50 |
PLATELET COUNT |
85049 |
300 |
30.85 |
23.14 |
BLOOD SMEAR,
PERIPHERAL; INT. BY DR. |
85060 |
300 |
61.75 |
46.31 |
CLOTTING FACTOR II
PROTHROMBIN, SPECIFI |
85210 |
300 |
150.00 |
112.50 |
FACTOR V, LABILE
FACTOR |
85220 |
300 |
262.00 |
196.50 |
ANTITHROMBIN
III,ANTIGEN ASSAY |
85301 |
300 |
84.25 |
63.19 |
PROTEIN C, ACTIVIT
Y |
85303 |
300 |
303.00 |
227.25 |
PROTEIN S, FREE |
85306 |
300 |
368.00 |
276.00 |
QUANTITATIVE D-DIM
ER |
85379 |
300 |
141.00 |
105.75 |
FIBRINOLYSINS/COAG
ULOPATHY
SCR I&R |
85390 |
300 |
45.00 |
33.75 |
PROTHROMBIN TIME (
PT) |
85610 |
300 |
50.00 |
37.50 |
PROTIME SUBSTITUTI
ON,
PLASMA FRACTIONS |
85611 |
300 |
175.00 |
131.25 |
RUSSEL VIPER VENOM
DILUTED |
85613 |
300 |
39.00 |
29.25 |
RUSSEL VIPER VENOM
DILUTED |
85613 |
300 |
250.00 |
187.50 |
ESR (ERYTHROCYTE);
NON-AUTOMATED |
85651 |
300 |
85.00 |
63.75 |
THROMBIN TIME, PLA
SMA |
85670 |
300 |
190.00 |
142.50 |
APPT, PARTIAL
(PTT);PLASMA OR WHOLE |
85730 |
300 |
70.00 |
52.50 |
THROMBOPLASTIN TIM
E,
PTT; SUB PLASMA |
85732 |
300 |
190.00 |
142.50 |
ANA (ANTINUCLEAR
ANTIBODIES) |
86038 |
300 |
137.00 |
102.75 |
C-REACTIVE PROTEIN
|
86140 |
300 |
107.00 |
80.25 |
CARDIOLIPIN
(PHOSPHOLIPID)ANTIBODY |
86147 |
300 |
162.00 |
121.50 |
COMPLEMENT;ANTIGEN
,EA
COMPONENT |
86160 |
300 |
60.64 |
45.48 |
CYCLIC CITRULLINAT
ED
PEPTIDE, ANTIBODY |
86200 |
300 |
225.00 |
168.75 |
DNA ANTIBODY NATIV
E /2
STRANDED |
86225 |
300 |
26.25 |
19.69 |
AUTO ANTIBODIES TO
SSA
& SSB |
86235 |
300 |
50.40 |
37.80 |
MONOSPOT |
86308 |
300 |
75.00 |
56.25 |
ANTIMICROSOMAL
ANTIBODY |
86376 |
300 |
139.00 |
104.25 |
RA FACTOR (RHEUMAT
OID ARTHRITIS)QUAL |
86430 |
300 |
62.00 |
46.50 |
RA TITER (RHEUMATO
ID
ARTHRITIS)QUANT |
86431 |
300 |
46.30 |
34.73 |
TB TEST, CELL MEDI
ATED
IMMUNITY |
86480 |
300 |
111.25 |
83.44 |
GAMMA
INTERFERON-PRODUCING T-CELLS |
86481 |
300 |
127.50 |
95.63 |
RPR, VDRL, ART;
QUALITATIVE |
86592 |
300 |
70.00 |
52.50 |
BARTONELLA |
86611 |
300 |
84.00 |
63.00 |
LYME DISEASE SEROL
OGY
EVALUATION |
86618 |
300 |
147.00 |
110.25 |
CYTOMEGALOVIRUS |
86644 |
300 |
143.00 |
107.25 |
EBV VCA IgG/IgM |
86663 |
300 |
89.25 |
66.94 |
EPSTEIN-BARR ANTIB
ODY
VIRUS |
86665 |
300 |
117.00 |
87.75 |
ANTIB EHRILICHIA
span> |
86666 |
300 |
31.30 |
23.48 |
HERPES SIMPLEX, TY
PE 1 |
86695 |
300 |
58.80 |
44.10 |
HERPES SIMPLEX, TY
PE 2 |
86696 |
300 |
30.30 |
22.73 |
HEPATITIS B CORE
ANTIBODY; TOTAL |
86704 |
300 |
103.00 |
77.25 |
HEPATITIS B SURFAC
ANTIBODY (HBsAb) |
86706 |
300 |
108.00 |
81.00 |
MUMPS ANTIBODY/IgG
& IgM x (2) |
86735 |
300 |
120.00 |
90.00 |
ANTIBO PROTOZOA |
86753 |
300 |
31.31 |
23.48 |
RUBELLA ANTIBODY |
86762 |
300 |
108.00 |
81.00 |
ANTIBODY; RUBEOLA |
86765 |
300 |
113.00 |
84.75 |
SARS-COV-2 IGG
ANTIBODY |
86769 |
300 |
150.00 |
112.50 |
VARICELLA TITRE |
86787 |
300 |
44.10 |
33.08 |
THYROID
(THYROGLOBULIN) ANTIBODIES |
86800 |
300 |
76.05 |
57.04 |
HEPATITIS C ANTIBO
DY |
86803 |
300 |
128.00 |
96.00 |
HLA TYPING, A,B, O
R C,
SINGLE ANTIGEN |
86812 |
300 |
246.00 |
184.50 |
ANTIBODY SCREEN,RB
C,EA
SERUM TECHNIQ |
86850 |
300 |
62.00 |
46.50 |
BLOOD TYPING; ABO
GROUP |
86900 |
300 |
48.00 |
36.00 |
BLOOD TYPING; RH(D
) |
86901 |
300 |
47.00 |
35.25 |
CROSSMATCH |
86922 |
300 |
234.00 |
175.50 |
SPECIMEN CONCENTRA
TION |
87015 |
300 |
101.00 |
75.75 |
CULTURE, BACTERIAL
BLOOD |
87040 |
300 |
172.00 |
129.00 |
CULTURE, BACTERIAL
FECES (STOOL) |
87045 |
300 |
139.00 |
104.25 |
STOOL CULTURE
(CAMPYLOBACTER) |
87046 |
300 |
95.00 |
71.25 |
CULTURE,OTHER SOUR
CE
EXCEPT URINE/BLD/S |
87070 |
300 |
132.00 |
99.00 |
CULTURE
BACTERIA,EXCEPT BLOOD |
87075 |
300 |
153.00 |
114.75 |
CULTURE; ID, AEROB
IC,
ORGANISM ID |
87077 |
300 |
75.00 |
56.25 |
CULTURE, BACTERIAL
URINE-COLONY CNT |
87086 |
300 |
113.00 |
84.75 |
CULTURE, BACTERIAL
ID, URINE |
87088 |
300 |
73.00 |
54.75 |
CULTURE,FUNGI;OTHE
SOURCE BUT BLOOD |
87102 |
300 |
233.00 |
174.75 |
CULTURE, IMMUNOLOG
IC
METHOD |
87147 |
300 |
164.00 |
123.00 |
SENSITIVITIES (ALL
) |
87186 |
300 |
127.00 |
95.25 |
GRAM, PRIM WRIGHTS
& STOOL SMEARS |
87205 |
300 |
64.00 |
48.00 |
STRAIN
MALARIA,COCCIDIA,HERP VIRUSES |
87207 |
300 |
70.30 |
52.73 |
OVA PARASITS SMR P
RIM
CPLX SPEC STRAIN |
87209 |
300 |
47.78 |
35.84 |
SMEAR PRIM SRC WET
MOUNT NFCT |
87210 |
300 |
8.50 |
6.38 |
KOH TISSUE EXAM FO
FUNGI |
87220 |
300 |
27.85 |
20.89 |
CLOSTRIDIUM DIFFIC
ILE
TOXIN; ENZYME |
87324 |
300 |
171.00 |
128.25 |
CRYPTOSPORIDUM |
87328 |
300 |
113.00 |
84.75 |
GIARDIA ANTIGEN |
87329 |
300 |
124.00 |
93.00 |
HELICOBACTOR PYLOR
I,
STOOL |
87338 |
300 |
75.00 |
56.25 |
HEPATITIS B SURFAC
ANTIGEN (HBsAg) |
87340 |
300 |
106.00 |
79.50 |
HIV-1/2 AG AND AB |
87389 |
300 |
157.50 |
118.13 |
CHLAMYDIA TRACH
AMPLIFIED PROBE |
87491 |
300 |
130.00 |
97.50 |
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
79.00 |
59.25 |
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
150.00 |
112.50 |
INFECTIOUS AGENT
DNA/RNA INFLUENZA 1ST 2 |
87502 |
300 |
121.50 |
91.13 |
HEPATITIS C QUANT |
87522 |
300 |
773.00 |
579.75 |
GONORRHOEAE AMPLIF
IED
PROBE |
87591 |
300 |
119.00 |
89.25 |
SARS-CoV-2 COVID-1
AMP PROBE TQ |
87635 |
300 |
150.00 |
112.50 |
STAPHYLOCOCCUS AUR
EUS |
87641 |
300 |
62.50 |
46.88 |
STREPTOCOCCUS GRP
A,
AMP PRB |
87651 |
300 |
99.80 |
74.85 |
TRICHOMONAS VAGINA
LIS,
AMP |
87661 |
300 |
150.00 |
112.50 |
BK-VIRUS(DETECTION
)POLYMERASE
CHAIN |
87798 |
300 |
240.00 |
180.00 |
NOS ASSAY W/OPTIC
(SHIGA TOXIN 1) |
87899 |
300 |
91.00 |
68.25 |
CELL COUNT, W/DIFF
MISC.BODY FLUIDS |
89051 |
300 |
60.65 |
45.49 |
CRYSTALS POLARIZAT
ION,
ALL BUT URINE |
89060 |
300 |
44.10 |
33.08 |
INJ IMM FIRST
VACC/TOXIOD THRU 18YRS, |
90460 |
521 |
36.00 |
27.00 |
APP OF MODALITY
VASOPNEUMATIC DEVICES |
90716 |
420 |
25.00 |
18.75 |
EKG/ECG, 12 LEADS
OR
>; TRACING ONLY |
93005 |
730 |
141.00 |
105.75 |
HOLTER MONITOR, EX
TRNL
ECG SCANNING |
93226 |
731 |
605.00 |
453.75 |
ECHO TTHRC R-T 2D
-+M-MODE |
93306 |
921 |
1,518.49 |
1,138.87 |
REHAB W/CONTINUOUS
ECG, PER SESSION |
93798 |
943 |
105.85 |
79.39 |
DUPLEX CAROTID, CO
MPLETE
BILATERAL |
93880 |
921 |
888.60 |
666.45 |
POLYSOM 6>YRS S
LEEP
4>ADDL PARAM ATTENDED |
95810 |
740 |
2,756.00 |
2,067.00 |
POLYSOM 6>YRS S
LEEP
W/CPAP 4>ADDL |
95811 |
740 |
3,032.00 |
2,274.00 |
CANALITH REPOSITIO
NING
PROCEDURE |
95992 |
420 |
93.75 |
70.31 |
IV INFUSION (SPECI
FY
DRUG) UP TO 1 HR |
96365 |
260 |
231.00 |
173.25 |
IV INFUSION - EA
ADDITIONAL HOUR |
96366 |
260 |
99.00 |
74.25 |
IV INFURSION -
ADDITIONAL INFUSION, UP TO 1 HOUR |
96367 |
260 |
137.00 |
102.75 |
ELECTRICAL STIMULA
TION
(UNATTENDED) |
97014 |
420 |
135.00 |
101.25 |
ELECTRICAL STIMULA
TION
(MANUAL) |
97032 |
420 |
165.00 |
123.75 |
IONTOPHORESIS, EAC
H 15
MIN. |
97033 |
420 |
81.00 |
60.75 |
ULTRASOUND, EACH 1
MIN. |
97035 |
420 |
62.00 |
46.50 |
ROM/STRENGTH EXERC
ISE,
EACH 15 MIN. |
97110 |
420 |
99.00 |
74.25 |
NEUROMUSCULAR RE-E
D. |
97112 |
420 |
90.00 |
67.50 |
GAIT TRAINING (15
MIN) |
97116 |
420 |
90.00 |
67.50 |
MANUAL THERAPY
TECHNIQUES,EA.15 MIN. |
97140 |
420 |
122.00 |
91.50 |
PT EVAL LOW COMP,
20
MIN |
97161 |
424 |
137.90 |
103.43 |
PT EVAL MOD COMP,
30
MIN |
97162 |
424 |
197.00 |
147.75 |
PT EVAL HIGH COMP,
45
MIN |
97163 |
424 |
256.10 |
192.08 |
PT RE-EVAL EST PLA
CARE |
97164 |
424 |
99.00 |
74.25 |
OT EVAL LOW COMP,
30
MINUTES |
97165 |
434 |
142.93 |
107.20 |
OT EVAL MOD COMP,
45
MINUTES |
97166 |
434 |
204.19 |
153.14 |
OT EVAL HIGH COMP,
60
MINUTES |
97167 |
434 |
265.45 |
199.09 |
PT THER/ACT/TRANSF
ER
(FUNCTIONAL)15 MN |
97530 |
420 |
90.00 |
67.50 |
RHC:NEW OFFICE OUT
PT,
MINOR-MOD, 20 MIN |
99202 |
521 |
88.00 |
66.00 |
CARDIOLOGY VISIT,
NEW
20 MINUTES |
99202 |
480 |
131.00 |
98.25 |
RHEUMATOLOGY VISIT
NEW, 20 MINUTES |
99202 |
960 |
131.00 |
98.25 |
RHC:NEW OFFICE OUT
PT,
MOD-SEV 30 MIN |
99203 |
521 |
134.00 |
100.50 |
CARDIOLOGY VISIT,
NEW
30 MINUTES |
99203 |
480 |
190.00 |
142.50 |
RHEUMATOLOGY VISIT
NEW, 30 MINUTES |
99203 |
960 |
190.00 |
142.50 |
RHC:NEW OFFICE OUT
PT,
MOD-HIGH 45 MIN |
99204 |
521 |
225.00 |
168.75 |
CARDIOLOGY VISIT,
NEW
45 MINUTES |
99204 |
480 |
288.00 |
216.00 |
RHEUMATOLOGY VISIT
NEW, 45 MINUTES |
99204 |
960 |
288.00 |
216.00 |
RHC:NEW OFFICE OUT
PT,
HIGH, 60 MIN |
99205 |
521 |
290.00 |
217.50 |
CARDIOLOGY VISIT,
NEW
60 MINUTES |
99205 |
480 |
363.00 |
272.25 |
RHEUMATOLOGY VISIT
NEW, 60 MINUTES |
99205 |
960 |
363.00 |
272.25 |
RHC:EST PATIENT MI
NOR
LEVEL, 10 MIN |
99212 |
521 |
65.00 |
48.75 |
CARDIOLOGY VISIT,
10
MINUTES |
99212 |
480 |
77.00 |
57.75 |
RHEUMATIOLOGY VISI
T,
EST, 10 MINUTES |
99212 |
960 |
77.00 |
57.75 |
RHC:EST PATIENT
LOW-MOD, 15 MIN |
99213 |
521 |
110.00 |
82.50 |
CARDIOLOGY VISIT 1
MINUTES |
99213 |
480 |
128.00 |
96.00 |
RHEUMATOLOGY VISIT
EST, 15 MINUTES |
99213 |
960 |
128.00 |
96.00 |
RHC:EST PATIENT
MODERATE-HIGH, 25 MIN |
99214 |
521 |
160.00 |
120.00 |
CARDIOLOGY VISIT 2
MINUTES |
99214 |
480 |
188.00 |
141.00 |
RHEUMATOLOGY VISIT
EST, 25 MINUTES |
99214 |
960 |
188.00 |
141.00 |
RHC:EST PATIENT HI
GH
LEVEL |
99215 |
521 |
210.00 |
157.50 |
CARDIOLOGY VISIT 4
MINUTES |
99215 |
480 |
253.00 |
189.75 |
RHEUMATOLOGY VISIT
EST, 40 MINUTES |
99215 |
960 |
253.00 |
189.75 |
RHC:PREV VISIT, IN
ITIAL
(AGE YOUNGER THAN 1 YEAR) |
99381 |
521 |
118.00 |
88.50 |
RHC:PREV VISIT, NE
W (1
THRU 4 YEARS) |
99382 |
521 |
188.00 |
141.00 |
RHC:PREV VISIT, NE
W (5
THRU 11 YEARS) |
99383 |
521 |
188.00 |
141.00 |
RHC:PREV VISIT, NE
(12 THRU 17 YEARS) |
99384 |
521 |
221.00 |
165.75 |
RHC:PREV VISIT, NE
(18 THRU 39 YEARS) |
99385 |
521 |
221.00 |
165.75 |
RHC:PREV VISIT, NE
(40 THRU 64 YEARS) |
99386 |
521 |
194.25 |
145.69 |
RHC:PREV VISIT, NE
(65 AND OVER) |
99387 |
521 |
212.00 |
159.00 |
RHC:PREV VISIT, ES
(AGE YOUNGER THAN 1 YEAR) |
99391 |
521 |
125.00 |
93.75 |
RHC:PREV VISIT, ES
T (1
THRU 4 YEARS) |
99392 |
521 |
135.00 |
101.25 |
RHC:PREV VISIT, ES
T (5
THRU 11 YEARS) |
99393 |
521 |
135.00 |
101.25 |
RHC:PREV VISIT, ES
(12 THRU 17 YEARS) |
99394 |
521 |
145.00 |
108.75 |
RHC:PREV VISIT, ES
(18 THRU 39 YEARS) |
99395 |
521 |
150.00 |
112.50 |
RHC:PREV VISIT, ES
(40 THRU 64 YEARS) |
99396 |
521 |
160.00 |
120.00 |
RHC:PREV VISIT, ES
(65 AND OVER) |
99397 |
521 |
165.00 |
123.75 |
PSA SCREEN; TOTAL
(MEDICARE) |
G0103 |
300 |
131.00 |
98.25 |
RHC:ANNUAL WELLNES
VISIT, INIT |
G0438 |
521 |
296.25 |
222.19 |
DRUG TEST, DEFINIT
IVE,
1-7 DRUG CLASSES |
G0480 |
300 |
146.25 |
109.69 |
DRUG TEST, DEFINIT
IVE,
1-7 DRUG CLASSES |
G0480 |
300 |
550.00 |
412.50 |
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 |
292.07 |