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Website https://www.medica.com/members or 1-866-745-9919 Member Portal Access - https://www.mymedica.com/member/prewelcome.do?currentLanguageFromPreCheck=en

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
Revenue Code

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

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

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

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

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

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

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)

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

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

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