Midlands Choice (Member Portal - https://www.midlandschoice.com/ (select “Login” or call 1-800-605-8259)
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 |
ABDOMEN, 2 VIEWS
span> |
74019 |
320 |
281.00 |
269.76 |
ABDOMEN, GB, BILIA
RY
TREE SINGLE QUAD |
76705 |
402 |
476.00 |
456.96 |
ABDOMINAL AORTA
ULTRASOUND (AAA) |
76706 |
402 |
476.00 |
456.96 |
ACUTE CARE-(ISOLAT
ION) |
n-a |
120 |
1,250.00 |
1,200.00 |
ACUTE HEPATITIS PANEL |
80074 |
300 |
557.00 |
534.72 |
AFP
(ALPHA-FETOPROTEIN: SERUM) |
82105 |
300 |
139.00 |
133.44 |
ALBUMIN; SERUM |
82040 |
300 |
59.00 |
56.64 |
ALCOHOL, (ETOH) ANY
SPEC BUT BREATH |
80320 |
300 |
550.00 |
528.00 |
ALCOHOL, (ETOH) ANY
SPEC BUT BREATH |
80320 |
300 |
188.00 |
180.48 |
ALKALINE PHOSPHATA
SE |
84075 |
300 |
70.00 |
67.20 |
ALT (SGPT) ALANINE
AMINO |
84460 |
300 |
86.00 |
82.56 |
AMMONIA; BLOOD |
82140 |
300 |
128.00 |
122.88 |
AMYLASE; SERUM OR
URINE |
82150 |
300 |
99.00 |
95.04 |
ANA (ANTINUCLEAR
ANTIBODIES) |
86038 |
300 |
137.00 |
131.52 |
ANKLE; COMPLETE, MIN.
3 VIEWS |
73610 |
320 |
220.00 |
211.20 |
ANTI-MITOCHONDRIAL
AB |
83516 |
300 |
117.00 |
112.32 |
ANTIB EHRILICHIA
span> |
86666 |
300 |
31.30 |
30.05 |
ANTIBO PROTOZOA |
86753 |
300 |
31.31 |
30.06 |
ANTIBODY SCREEN,RB
C,EA
SERUM TECHNIQ |
86850 |
300 |
62.00 |
59.52 |
ANTIBODY; RUBEOLA |
86765 |
300 |
113.00 |
108.48 |
ANTIMICROSOMAL
ANTIBODY |
86376 |
300 |
139.00 |
133.44 |
ANTITHROMBIN
III,ANTIGEN ASSAY |
85301 |
300 |
84.25 |
80.88 |
APP OF MODALITY
VASOPNEUMATIC DEVICES |
90716 |
420 |
25.00 |
24.00 |
APPT, PARTIAL
(PTT);PLASMA OR WHOLE |
85730 |
300 |
70.00 |
67.20 |
AST (SGOT) |
84450 |
300 |
71.00 |
68.16 |
AUTO ANTIBODIES TO
SSA
& SSB |
86235 |
300 |
50.40 |
48.38 |
B.U.N. (UREA
NITROGEN); QUANTITATIVE |
84520 |
300 |
56.00 |
53.76 |
BARTONELLA |
86611 |
300 |
84.00 |
80.64 |
BASIC METABOLIC
PANEL(BUN,CREAT,GLUC |
80048 |
300 |
168.00 |
161.28 |
BETA hCG; QUALITATIVE |
84703 |
300 |
113.00 |
108.48 |
BETA hCG; QUANTITATIVE |
84702 |
300 |
142.00 |
136.32 |
BILIRUBIN; DIRECT |
82248 |
300 |
53.00 |
50.88 |
BILIRUBIN; TOTAL
span> |
82247 |
300 |
69.00 |
66.24 |
BK-VIRUS(DETECTION
)POLYMERASE
CHAIN |
87798 |
300 |
240.00 |
230.40 |
BLOOD COUNT;
HEMOGLOBIN |
85018 |
300 |
23.00 |
22.08 |
BLOOD COUNT;
HEMOGRAM/PLATELET COUNT |
85027 |
300 |
88.00 |
84.48 |
BLOOD COUNT; MANUAL
DIFF. W/PLATELET |
85007 |
300 |
46.00 |
44.16 |
BLOOD COUNT; WBC (
WHITE
BLOOD CELL) |
85048 |
300 |
58.00 |
55.68 |
BLOOD GASES; ABG
pH,pCO2,pO2,CO2,HCO |
82803 |
300 |
212.00 |
203.52 |
BLOOD LEAD |
83655 |
300 |
101.00 |
96.96 |
BLOOD SMEAR,
PERIPHERAL; INT. BY DR. |
85060 |
300 |
61.75 |
59.28 |
BLOOD TYPING; ABO
GROUP |
86900 |
300 |
48.00 |
46.08 |
BLOOD TYPING; RH(D
) |
86901 |
300 |
47.00 |
45.12 |
BNP-NATRIURETIC
PEPTIDE |
83880 |
300 |
230.00 |
220.80 |
BONE DENSITY ,DXA,
1OR
MORE SITES, |
77080 |
320 |
322.00 |
309.12 |
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
79.00 |
75.84 |
C DIFF AMPLIFIED P
ROBE |
87493 |
300 |
150.00 |
144.00 |
C-REACTIVE PROTEIN
|
86140 |
300 |
107.00 |
102.72 |
CALCIUM SERUM; TOT
AL |
82310 |
300 |
81.00 |
77.76 |
CALCIUM; IONIZED
span> |
82330 |
300 |
84.90 |
81.50 |
CALCULUS (STONE) Q
UANT |
82365 |
300 |
40.00 |
38.40 |
CANALITH REPOSITIO
NING
PROCEDURE |
95992 |
420 |
93.75 |
90.00 |
CARBON DIOXIDE(BIC
ARBONATE
-ECO 2 |
82374 |
300 |
63.00 |
60.48 |
CARDIOLIPIN
(PHOSPHOLIPID)ANTIBODY |
86147 |
300 |
162.00 |
155.52 |
CARDIOLOGY VISIT 25
MINUTES |
99214 |
480 |
188.00 |
180.48 |
CARDIOLOGY VISIT 15
MINUTES |
99213 |
480 |
128.00 |
122.88 |
CARDIOLOGY VISIT 40
MINUTES |
99215 |
480 |
253.00 |
242.88 |
CARDIOLOGY VISIT,
10
MINUTES |
99212 |
480 |
77.00 |
73.92 |
CARDIOLOGY VISIT,
NEW
20 MINUTES |
99202 |
480 |
131.00 |
125.76 |
CARDIOLOGY VISIT,
NEW
30 MINUTES |
99203 |
480 |
190.00 |
182.40 |
CARDIOLOGY VISIT,
NEW
45 MINUTES |
99204 |
480 |
288.00 |
276.48 |
CARDIOLOGY VISIT,
NEW
60 MINUTES |
99205 |
480 |
363.00 |
348.48 |
CBC W/ AUTO DIFF.
W/PLATELET COUNT |
85025 |
300 |
112.00 |
107.52 |
CELL COUNT, W/DIFF;
MISC.BODY FLUIDS |
89051 |
300 |
60.65 |
58.22 |
CERVICAL SPINE; 2-3
VIEWS |
72040 |
320 |
288.50 |
276.96 |
CHEST 2 VIEWS, FRONT
& LAT |
71046 |
324 |
195.00 |
187.20 |
CHEST PA W/RIBS MIN 3 VIEWS |
71101 |
320 |
212.80 |
204.29 |
CHEST, SINGLE VIEW
|
71045 |
324 |
133.00 |
127.68 |
CHLAMYDIA TRACH
AMPLIFIED PROBE |
87491 |
300 |
130.00 |
124.80 |
CHLORIDE; BLOOD |
82435 |
300 |
59.00 |
56.64 |
CLAVICLE, COMPLETE
|
73000 |
320 |
231.00 |
221.76 |
CLOSTRIDIUM DIFFICILE
TOXIN; ENZYME |
87324 |
300 |
171.00 |
164.16 |
CLOTTING FACTOR II,
PROTHROMBIN, SPECIFI |
85210 |
300 |
150.00 |
144.00 |
CMP(GLUC,BUN,CREAT,AST,ALP,TBIL,ALT, |
80053 |
300 |
232.00 |
222.72 |
COMPLEMENT;ANTIGEN
,EA
COMPONENT |
86160 |
300 |
60.64 |
58.21 |
CORTISOL; TOTAL
|
82533 |
300 |
152.00 |
145.92 |
CPK (CREATINEPHOSPHOKINASE); TOTAL |
82550 |
300 |
105.00 |
100.80 |
CPK MB FRACTION ONLY |
82553 |
300 |
150.00 |
144.00 |
CREATININE; BLOOD
|
82565 |
300 |
59.00 |
56.64 |
CREATININE; OTHER
SOURCE (URINE) |
82570 |
300 |
71.00 |
68.16 |
CROSSMATCH |
86922 |
300 |
234.00 |
224.64 |
CRYPTOSPORIDUM |
87328 |
300 |
113.00 |
108.48 |
CRYSTALS POLARIZATION,
ALL BUT URINE |
89060 |
300 |
44.10 |
42.34 |
CT: ABD & PELVIS W/O CONTRAST |
74176 |
350 |
1,567.80 |
1,505.09 |
CT: ABD & PELV WITH CONTRAST |
74177 |
350 |
1,757.80 |
1,687.49 |
CT: HEAD OR BRAIN
WITHOUT CONTRAST |
70450 |
350 |
1,463.00 |
1,404.48 |
CT:CHEST WITH AND WITHOUT CONTRAST |
71270 |
350 |
2,455.00 |
2,356.80 |
CULTURE
BACTERIA,EXCEPT BLOOD |
87075 |
300 |
153.00 |
146.88 |
CULTURE, BACTERIAL;
BLOOD |
87040 |
300 |
172.00 |
165.12 |
CULTURE, BACTERIAL;
FECES (STOOL) |
87045 |
300 |
139.00 |
133.44 |
CULTURE, BACTERIAL;
ID, URINE |
87088 |
300 |
73.00 |
70.08 |
CULTURE, BACTERIAL;
URINE-COLONY CNT |
87086 |
300 |
113.00 |
108.48 |
CULTURE, IMMUNOLOGIC METHOD |
87147 |
300 |
164.00 |
157.44 |
CULTURE,FUNGI;OTHER
SOURCE BUT BLOOD |
87102 |
300 |
233.00 |
223.68 |
CULTURE,OTHER SOURCE EXCEPT URINE/BLD/S |
87070 |
300 |
132.00 |
126.72 |
CULTURE; ID, AEROBIC, ORGANISM ID |
87077 |
300 |
75.00 |
72.00 |
CYCLIC CITRULLINATED PEPTIDE, ANTIBODY |
86200 |
300 |
225.00 |
216.00 |
CYTOMEGALOVIRUS
|
86644 |
300 |
143.00 |
137.28 |
DIGOXIN |
80162 |
300 |
111.00 |
106.56 |
DIHYDROXVITAMIN D 1.25 |
82652 |
300 |
131.40 |
126.14 |
DILANTIN (PHENYTOIN);
TOTAL |
80185 |
300 |
131.00 |
125.76 |
DNA ANTIBODY NATIVE /2 STRANDED |
86225 |
300 |
26.25 |
25.20 |
DRUG SCR QUAL MLT DRUG
CLASSES |
80305 |
300 |
169.00 |
162.24 |
DRUG SCR QUAN LEVETIRACETAM |
80177 |
300 |
85.00 |
81.60 |
DRUG SCREENING, SINGLE |
80307 |
300 |
290.00 |
278.40 |
DRUG TEST, DEFINITIVE,
1-7 DRUG CLASSES |
G0480 |
300 |
550.00 |
528.00 |
DRUG TEST, DEFINITIVE,
1-7 DRUG CLASSES |
G0480 |
300 |
146.25 |
140.40 |
DRUG/SUBST DEF
QUAL/QUANT NOS 1-3 |
80375 |
300 |
131.00 |
125.76 |
DUPLEX CAROTID,
COMPLETE BILATERAL |
93880 |
921 |
888.60 |
853.06 |
EBV VCA IgG/IgM |
86663 |
300 |
89.25 |
85.68 |
ECHO TTHRC R-T 2D
-+M-MODE |
93306 |
921 |
1,518.49 |
1,457.75 |
EKG/ECG, 12 LEADS
OR
>; TRACING ONLY |
93005 |
730 |
141.00 |
135.36 |
ELBOW 3 VIEWS |
73080 |
320 |
152.15 |
146.06 |
ELBOW; 2 VIEWS |
73070 |
320 |
170.00 |
163.20 |
ELECTRICAL STIMULATION
(MANUAL) |
97032 |
420 |
165.00 |
158.40 |
ELECTRICAL STIMULA
TION
(UNATTENDED) |
97014 |
420 |
135.00 |
129.60 |
ELECTROLYTE PANEL
(NA,K,CL,CO2) |
80051 |
300 |
113.00 |
108.48 |
EPSTEIN-BARR ANTIB
ODY
VIRUS |
86665 |
300 |
117.00 |
112.32 |
ERYTHROPOIETIN |
82668 |
300 |
47.13 |
45.24 |
ESR (ERYTHROCYTE);
NON-AUTOMATED |
85651 |
300 |
85.00 |
81.60 |
ESTRONE |
82679 |
300 |
115.75 |
111.12 |
FACTOR V, LABILE
FACTOR |
85220 |
300 |
262.00 |
251.52 |
FACTOR V, LEIDEN |
81241 |
300 |
284.30 |
272.93 |
FEMUR, MIN 2 VIEWS
|
73552 |
320 |
229.00 |
219.84 |
FERRITIN, RIA |
82728 |
300 |
145.00 |
139.20 |
FIBRINOLYSINS/COAG
ULOPATHY
SCR I&R |
85390 |
300 |
45.00 |
43.20 |
FINGER(S), MIN. 2
VIEWS |
73140 |
320 |
164.00 |
157.44 |
FOLATE (FOLIC) ACI
D;
SERUM |
82746 |
300 |
144.00 |
138.24 |
FOOT; COMPLETE, MI
N. 3
VIEWS |
73630 |
320 |
187.00 |
179.52 |
FOREARM; INCL. 1
JOINT, 2 VIEWS |
73090 |
320 |
206.00 |
197.76 |
FSH (FOLLICLE
STIMULATING HORMONE) |
83001 |
300 |
148.00 |
142.08 |
GAIT TRAINING (15
MIN) |
97116 |
420 |
90.00 |
86.40 |
GAMMA
INTERFERON-PRODUCING T-CELLS |
86481 |
300 |
127.50 |
122.40 |
GAMMAGLOBULIN,IgA,
IgD,IgG,IgM |
82784 |
300 |
178.00 |
170.88 |
GGT GAMMA GT |
82977 |
300 |
71.00 |
68.16 |
GIARDIA ANTIGEN |
87329 |
300 |
124.00 |
119.04 |
GLUCOSE; QUANT. BL
OOD,
FBS 2H |
82947 |
300 |
46.00 |
44.16 |
GONADOTROPIN;
LUTEINIZING HORMONE |
83002 |
300 |
84.90 |
81.50 |
GONORRHOEAE AMPLIF
IED
PROBE |
87591 |
300 |
119.00 |
114.24 |
GRAM, PRIM WRIGHTS
& STOOL SMEARS |
87205 |
300 |
64.00 |
61.44 |
HAND; MIN. 3 VIEWS
|
73130 |
320 |
212.00 |
203.52 |
HCT |
85014 |
300 |
32.00 |
30.72 |
HELICOBACTOR PYLOR
I,
STOOL |
87338 |
300 |
75.00 |
72.00 |
HEMOGLOBIN; GLYCAT
ED |
83036 |
300 |
92.00 |
88.32 |
HEPATITIS B CORE
ANTIBODY; TOTAL |
86704 |
300 |
103.00 |
98.88 |
HEPATITIS B SURFAC
ANTIBODY (HBsAb) |
86706 |
300 |
108.00 |
103.68 |
HEPATITIS B SURFACE
ANTIGEN (HBsAg) |
87340 |
300 |
106.00 |
101.76 |
HEPATITIS C ANTIBO
DY |
86803 |
300 |
128.00 |
122.88 |
HEPATITIS C QUANT |
87522 |
300 |
773.00 |
742.08 |
HERPES SIMPLEX, TY
PE 1 |
86695 |
300 |
58.80 |
56.45 |
HERPES SIMPLEX, TY
PE 2 |
86696 |
300 |
30.30 |
29.09 |
HIP, COMPLETE 2-3
VIEWS |
73502 |
320 |
215.00 |
206.40 |
HIV-1/2 AG AND AB |
87389 |
300 |
157.50 |
151.20 |
HLA TYPING, A,B, O
R C,
SINGLE ANTIGEN |
86812 |
300 |
246.00 |
236.16 |
HOLTER MONITOR, EX
TRNL
ECG SCANNING |
93226 |
731 |
605.00 |
580.80 |
HOMOCYSTEINE LEVEL
|
83090 |
300 |
188.00 |
180.48 |
HUMERUS; INCL. 1
JOINT, MIN. 2 VIEWS |
73060 |
320 |
222.00 |
213.12 |
INFECTIOUS AGENT
DNA/RNA INFLUENZA 1ST 2 |
87502 |
300 |
121.50 |
116.64 |
INJ IMM FIRST
VACC/TOXIOD THRU 18YRS, |
90460 |
521 |
36.00 |
34.56 |
IONTOPHORESIS, EAC
H 15
MIN. |
97033 |
420 |
81.00 |
77.76 |
IRON BINDING CAPAC
ITY
(IBC) |
83550 |
300 |
103.00 |
98.88 |
IRON SERUM |
83540 |
300 |
73.00 |
70.08 |
IV INFURSION -
ADDITIONAL INFUSION, UP TO 1 HOUR |
96367 |
260 |
137.00 |
131.52 |
IV INFUSION - EA
ADDITIONAL HOUR |
96366 |
260 |
99.00 |
95.04 |
IV INFUSION (SPECI
FY
DRUG) UP TO 1 HR |
96365 |
260 |
231.00 |
221.76 |
KNEE; 1 OR 2 VIEWS
|
73560 |
320 |
159.00 |
152.64 |
KNEE; 3 VIEWS |
73562 |
320 |
257.00 |
246.72 |
KOH TISSUE EXAM FOR
FUNGI |
87220 |
300 |
27.85 |
26.74 |
KUB, I VIEW
|
74018 |
320 |
182.00 |
174.72 |
LACOSAMIDE, ASSAY |
80235 |
300 |
200.00 |
192.00 |
LACTATE DEHYDROGENASE
(LD), (LDH) |
83615 |
300 |
73.00 |
70.08 |
LACTATE, (LACTIC ACID) |
83605 |
300 |
126.00 |
120.96 |
LAMOTRIGINE
|
80175 |
300 |
90.00 |
86.40 |
LIPASE |
83690 |
300 |
110.00 |
105.60 |
LIPID PANEL
82465,83718,84478 |
80061 |
300 |
144.00 |
138.24 |
LITHIUM |
80178 |
300 |
115.00 |
110.40 |
LIVER (HEPATIC)
FUNCTION PANEL |
80076 |
300 |
149.00 |
143.04 |
LONG TERM CARE
ROOM-SEMI PRIVATE |
n-a |
120 |
147.84 |
141.93 |
LONG TERM CARE-SHO
RT
STAY |
n-a |
120 |
225.00 |
216.00 |
LOWER LEG, TIB/FIB
; 2
VIEWS |
73590 |
320 |
215.00 |
206.40 |
LUMBAR SPINE; 2-3
VIEWS |
72100 |
320 |
266.00 |
255.36 |
LYME DISEASE SEROL
OGY
EVALUATION |
86618 |
300 |
147.00 |
141.12 |
MAGNESIUM |
83735 |
300 |
75.00 |
72.00 |
MAMMOGRAM, SCREENI
NG |
77067 |
403 |
255.00 |
244.80 |
MANDIBLE; LESS THA
N 4
VIEWS |
70100 |
320 |
290.00 |
278.40 |
MANUAL THERAPY
TECHNIQUES,EA.15 MIN. |
97140 |
420 |
122.00 |
117.12 |
METHYLENETETRAHYDR
OFOLATE
REDUCTASE |
81291 |
300 |
300.00 |
288.00 |
MICROALBUMIN-URINE
QUANTITATIVE |
82043 |
300 |
98.00 |
94.08 |
MONOSPOT |
86308 |
300 |
75.00 |
72.00 |
MRI: LUMBAR W/O
CONTRAST |
72148 |
612 |
1,155.00 |
1,108.80 |
MRI: UPPER EXT OTH
/THN
JT, W/WO CONTRAST |
73218 |
610 |
1,650.00 |
1,584.00 |
MRI:ANY JT LOWR EX
T |
73721 |
610 |
1,210.00 |
1,161.60 |
MRI:ANY JT UPPER E
XT |
73221 |
610 |
1,207.50 |
1,159.20 |
MRI:CERVICAL W/O
CONTRAST |
72141 |
612 |
1,155.00 |
1,108.80 |
MRI:THORACIC |
72146 |
612 |
1,155.00 |
1,108.80 |
MUMPS ANTIBODY/IgG
& IgM x (2) |
86735 |
300 |
120.00 |
115.20 |
NECK, SOFT TISSUE |
70360 |
320 |
222.00 |
213.12 |
NEUROMUSCULAR RE-ED. |
97112 |
420 |
90.00 |
86.40 |
NOS ASSAY W/OPTIC
(SHIGA TOXIN 1) |
87899 |
300 |
91.00 |
87.36 |
OCCULT BLOOD,1-3,NOT SCREENING |
82272 |
300 |
24.25 |
23.28 |
OCCULT BLOOD; FECES,
1-3 SPECIMENS |
82270 |
300 |
27.00 |
25.92 |
ORBITS X-RAY |
70030 |
320 |
110.25 |
105.84 |
ORGANIC ACID,SINGLE,QUANTITATIVE |
83921 |
300 |
240.00 |
230.40 |
OS CALCIS (CALCANE
US);
MIN. 2 VIEWS |
73650 |
320 |
176.00 |
168.96 |
OT EVAL HIGH COMP,
60
MINUTES |
97167 |
434 |
265.45 |
254.83 |
OT EVAL LOW COMP,
30
MINUTES |
97165 |
434 |
142.93 |
137.21 |
OT EVAL MOD COMP,
45
MINUTES |
97166 |
434 |
204.19 |
196.02 |
OVA PARASITS SMR P
RIM
CPLX SPEC STRAIN |
87209 |
300 |
47.78 |
45.87 |
PARATHYROID HORMON
(C-TERMINAL) |
83970 |
300 |
264.00 |
253.44 |
PELVIS; 1-2 VIEWS |
72170 |
320 |
196.00 |
188.16 |
PHENOBARBITAL |
80184 |
300 |
154.00 |
147.84 |
PHOSPHORUS INORGAN
IC;
SERUM |
84100 |
300 |
59.00 |
56.64 |
PLATELET COUNT |
85049 |
300 |
30.85 |
29.62 |
POLYSOM 6>YRS S
LEEP
4>ADDL PARAM ATTENDED |
95810 |
740 |
2,756.00 |
2,645.76 |
POLYSOM 6>YRS S
LEEP
W/CPAP 4>ADDL |
95811 |
740 |
3,032.00 |
2,910.72 |
POTASSIUM (K); SER
UM |
84132 |
300 |
58.00 |
55.68 |
PRE-ALBUMIN
|
84134 |
300 |
108.00 |
103.68 |
PROCALCITONIN (PCT
) |
84145 |
300 |
125.00 |
120.00 |
PROGESTRONE; SERUM
|
84144 |
300 |
148.00 |
142.08 |
PROLACTIN; SERUM=
span> |
84146 |
300 |
182.00 |
174.72 |
PROTEIN C, ACTIVIT
Y |
85303 |
300 |
303.00 |
290.88 |
PROTEIN S, FREE |
85306 |
300 |
368.00 |
353.28 |
PROTEIN-TOTAL |
84155 |
300 |
90.00 |
86.40 |
PROTEIN;
ELECTROPHORESIS-(SERUM) |
84165 |
300 |
156.00 |
149.76 |
PROTHROMBIN TIME (
PT) |
85610 |
300 |
50.00 |
48.00 |
PROTIME SUBSTITUTI
ON,
PLASMA FRACTIONS |
85611 |
300 |
175.00 |
168.00 |
PSA SCREEN; TOTAL
(MEDICARE) |
G0103 |
300 |
131.00 |
125.76 |
PSA, FREE |
84154 |
300 |
185.00 |
177.60 |
PSA; TOTAL |
84153 |
300 |
131.00 |
125.76 |
PT EVAL HIGH COMP,
45
MIN |
97163 |
424 |
256.10 |
245.86 |
PT EVAL LOW COMP,
20 MIN |
97161 |
424 |
137.90 |
132.38 |
PT EVAL MOD COMP,
30
MIN |
97162 |
424 |
197.00 |
189.12 |
PT RE-EVAL EST PLAN
CARE |
97164 |
424 |
99.00 |
95.04 |
PT THER/ACT/TRANSF
ER
(FUNCTIONAL)15 MN |
97530 |
420 |
90.00 |
86.40 |
QUANT. OF DRUG, NO
OTHER SPECIFICATI |
80299 |
300 |
183.00 |
175.68 |
QUANTITATIVE D-DIMER |
85379 |
300 |
141.00 |
135.36 |
QUANTITATIVE, NOT
OTHERWISE SPECIFIED |
83520 |
300 |
95.00 |
91.20 |
RA FACTOR (RHEUMATOID
ARTHRITIS)QUAL |
86430 |
300 |
62.00 |
59.52 |
RA TITER (RHEUMATOID
ARTHRITIS)QUANT |
86431 |
300 |
46.30 |
44.45 |
RED BLOOD CELL |
P9016 |
390 |
389.43 |
373.85 |
REHAB W/CONTINUOUS
ECG, PER SESSION |
93798 |
943 |
105.85 |
101.62 |
RENAL FUNCTION PAN
EL |
80069 |
300 |
190.00 |
182.40 |
RETICULOCYTE,
AUTOMATED |
85045 |
300 |
56.00 |
53.76 |
REVERSE T3 TEST |
84482 |
300 |
79.40 |
76.22 |
RHC:ANNUAL WELLNESS
VISIT, INIT |
G0438 |
521 |
296.25 |
284.40 |
RHC:EST PATIENT HI
GH
LEVEL |
99215 |
521 |
210.00 |
201.60 |
RHC:EST PATIENT
LOW-MOD, 15 MIN |
99213 |
521 |
110.00 |
105.60 |
RHC:EST PATIENT MI
NOR
LEVEL, 10 MIN |
99212 |
521 |
65.00 |
62.40 |
RHC:EST PATIENT
MODERATE-HIGH, 25 MIN |
99214 |
521 |
160.00 |
153.60 |
RHC:NEW OFFICE OUT
PT,
HIGH, 60 MIN |
99205 |
521 |
290.00 |
278.40 |
RHC:NEW OFFICE OUT
PT,
MINOR-MOD, 20 MIN |
99202 |
521 |
88.00 |
84.48 |
RHC:NEW OFFICE OUT
PT,
MOD-HIGH 45 MIN |
99204 |
521 |
225.00 |
216.00 |
RHC:NEW OFFICE OUT
PT,
MOD-SEV 30 MIN |
99203 |
521 |
134.00 |
128.64 |
RHC:PREV VISIT, ES
T (1
THRU 4 YEARS) |
99392 |
521 |
135.00 |
129.60 |
RHC:PREV VISIT, EST
(12 THRU 17 YEARS) |
99394 |
521 |
145.00 |
139.20 |
RHC:PREV VISIT, EST
(18 THRU 39 YEARS) |
99395 |
521 |
150.00 |
144.00 |
RHC:PREV VISIT, EST
(40 THRU 64 YEARS) |
99396 |
521 |
160.00 |
153.60 |
RHC:PREV VISIT, EST (5
THRU 11 YEARS) |
99393 |
521 |
135.00 |
129.60 |
RHC:PREV VISIT, EST
(65 AND OVER) |
99397 |
521 |
165.00 |
158.40 |
RHC:PREV VISIT, EST
(AGE YOUNGER THAN 1 YEAR) |
99391 |
521 |
125.00 |
120.00 |
RHC:PREV VISIT,
INITIAL (AGE YOUNGER THAN 1 YEAR) |
99381 |
521 |
118.00 |
113.28 |
RHC:PREV VISIT, NEW (1
THRU 4 YEARS) |
99382 |
521 |
188.00 |
180.48 |
RHC:PREV VISIT, NEW
(12 THRU 17 YEARS) |
99384 |
521 |
221.00 |
212.16 |
RHC:PREV VISIT, NEW
(18 THRU 39 YEARS) |
99385 |
521 |
221.00 |
212.16 |
RHC:PREV VISIT, NEW
(40 THRU 64 YEARS) |
99386 |
521 |
194.25 |
186.48 |
RHC:PREV VISIT, NEW (5
THRU 11 YEARS) |
99383 |
521 |
188.00 |
180.48 |
RHC:PREV VISIT, NEW
(65 AND OVER) |
99387 |
521 |
212.00 |
203.52 |
RHEUMATIOLOGY VISIT,
EST, 10 MINUTES |
99212 |
960 |
77.00 |
73.92 |
RHEUMATOLOGY VISIT,
EST, 15 MINUTES |
99213 |
960 |
128.00 |
122.88 |
RHEUMATOLOGY VISIT,
EST, 25 MINUTES |
99214 |
960 |
188.00 |
180.48 |
RHEUMATOLOGY VISIT,
EST, 40 MINUTES |
99215 |
960 |
253.00 |
242.88 |
RHEUMATOLOGY VISIT,
NEW, 20 MINUTES |
99202 |
960 |
131.00 |
125.76 |
RHEUMATOLOGY VISIT,
NEW, 30 MINUTES |
99203 |
960 |
190.00 |
182.40 |
RHEUMATOLOGY VISIT,
NEW, 45 MINUTES |
99204 |
960 |
288.00 |
276.48 |
RHEUMATOLOGY VISIT,
NEW, 60 MINUTES |
99205 |
960 |
363.00 |
348.48 |
RIBS, UNILATERAL; 2
VIEWS |
71100 |
320 |
218.00 |
209.28 |
ROM/STRENGTH EXERCISE,
EACH 15 MIN. |
97110 |
420 |
99.00 |
95.04 |
RPR, VDRL, ART;
QUALITATIVE |
86592 |
300 |
70.00 |
67.20 |
RUBELLA ANTIBODY |
86762 |
300 |
108.00 |
103.68 |
RUSSEL VIPER VENOM,
DILUTED |
85613 |
300 |
250.00 |
240.00 |
RUSSEL VIPER VENOM,
DILUTED |
85613 |
300 |
39.00 |
37.44 |
SACRUM & COCCY
X;
MIN. 2 VIEWS |
72220 |
320 |
206.00 |
197.76 |
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
550.00 |
528.00 |
SALICYLATE /
ANALEGESICS, OTC, 1OR 2 |
80329 |
300 |
131.00 |
125.76 |
SARS-CoV-2 COVID-19
AMP PROBE TQ |
87635 |
300 |
150.00 |
144.00 |
SARS-COV-2 IGG
ANTIBODY |
86769 |
300 |
150.00 |
144.00 |
SCAPULA, COMPLETE |
73010 |
320 |
300.00 |
288.00 |
SCOLIOSIS EVAL |
72081 |
320 |
205.00 |
196.80 |
SENSITIVITIES (ALL
) |
87186 |
300 |
127.00 |
121.92 |
SERUM ESTROGEN,
ESTRADIOL |
82670 |
300 |
175.00 |
168.00 |
SHOULDER; COMPLETE,
MIN. 2 VIEWS |
73030 |
320 |
240.00 |
230.40 |
SKILLED CARE ROOM |
n-a |
120 |
800.00 |
768.00 |
SMEAR PRIM SRC WET
MOUNT NFCT |
87210 |
300 |
8.50 |
8.16 |
SODIUM; SERUM (NA)
|
84295 |
300 |
62.00 |
59.52 |
SPECIMEN CONCENTRATION |
87015 |
300 |
101.00 |
96.96 |
STAPHYLOCOCCUS AUR
EUS |
87641 |
300 |
62.50 |
60.00 |
STOOL CULTURE
(CAMPYLOBACTER) |
87046 |
300 |
95.00 |
91.20 |
STRAIN
MALARIA,COCCIDIA,HERP VIRUSES |
87207 |
300 |
70.30 |
67.49 |
STREPTOCOCCUS GRP
A,
AMP PRB |
87651 |
300 |
99.80 |
95.81 |
T.S.H. RIA |
84443 |
300 |
122.00 |
117.12 |
T3 FREE |
84481 |
300 |
125.63 |
120.60 |
T3; TOTAL (TT-3)
span> |
84480 |
300 |
114.00 |
109.44 |
TACROLIMUS |
80197 |
300 |
231.00 |
221.76 |
TB TEST, CELL MEDI
ATED
IMMUNITY |
86480 |
300 |
111.25 |
106.80 |
TEGRETOL
(CARBAMAZEPINE); TOTAL |
80156 |
300 |
143.00 |
137.28 |
TESTOSTERONE; FREE
|
84402 |
300 |
149.00 |
143.04 |
TESTOSTERONE; TOTA
L |
84403 |
300 |
176.00 |
168.96 |
THORACIC SPINE; 2
VIEWS |
72070 |
320 |
200.00 |
192.00 |
THROMBIN TIME, PLA
SMA |
85670 |
300 |
190.00 |
182.40 |
THROMBOPLASTIN TIM
E,
PTT; SUB PLASMA |
85732 |
300 |
190.00 |
182.40 |
THYROGLOBULIN |
84432 |
300 |
74.50 |
71.52 |
THYROID
(THYROGLOBULIN) ANTIBODIES |
86800 |
300 |
76.05 |
73.01 |
THYROXINE T4; FREE
|
84439 |
300 |
106.00 |
101.76 |
TOE(S); MIN. 2 VIE
WS |
73660 |
320 |
172.00 |
165.12 |
TRANSFUSION
BLOOD/BLOOD COMPONENTS |
36430 |
391 |
547.00 |
525.12 |
TRICHOMONAS VAGINA
LIS,
AMP |
87661 |
300 |
150.00 |
144.00 |
TROPONIN, QUANTITATIVE |
84484 |
300 |
168.00 |
161.28 |
UA MICROSCOPIC |
81015 |
300 |
50.00 |
48.00 |
UA-ROUTINE W/O
MICROSCP, NON AUTOMATED |
81002 |
300 |
47.00 |
45.12 |
ULTRASOUND, EACH 15
MIN. |
97035 |
420 |
62.00 |
59.52 |
ULTRASOUND, RENAL |
76775 |
402 |
442.00 |
424.32 |
ULTRASOUND,ABDOMIN
AL,COMPLETE |
76700 |
402 |
654.00 |
627.84 |
ULTRASOUND,EXTREMI
TY
COMPLETE |
76881 |
402 |
285.00 |
273.60 |
ULTRASOUND,TRANSVA
GINAL |
76830 |
402 |
509.00 |
488.64 |
URIC ACID; BLOOD |
84550 |
300 |
73.00 |
70.08 |
URINE AUTOMATED W/O
MICROSCOPY |
81003 |
300 |
47.00 |
45.12 |
URINE MONOCLANAL
PROTEIN 84156,86335 |
84166 |
300 |
168.30 |
161.57 |
URINE PREGNANCY TEST |
81025 |
300 |
12.50 |
12.00 |
URINE PROTEIN |
84156 |
300 |
60.00 |
57.60 |
URINE SODIUM |
84300 |
300 |
62.00 |
59.52 |
URINE, AUTOMATED WITH MICROSCOPY |
81001 |
300 |
59.00 |
56.64 |
US SCROTUM AND
CONTENTS |
76870 |
402 |
508.00 |
487.68 |
US SOFT TISS,
HEAD,NECK, THYROID |
76536 |
402 |
433.00 |
415.68 |
VALPROIC ACID
(DEPAKOTE) |
80164 |
300 |
145.00 |
139.20 |
VALPROIC ACID
(DIPROPYLACETIC ACID) FREE |
80165 |
300 |
135.00 |
129.60 |
VANCOMYCIN |
80202 |
300 |
140.00 |
134.40 |
VARICELLA TITRE |
86787 |
300 |
44.10 |
42.34 |
VITAMIN B 12 |
82607 |
300 |
127.00 |
121.92 |
VITAMIN B-1 (THIAMINE) |
84425 |
300 |
164.45 |
157.87 |
VITAMIN B-6 (PYRIDOXAL
PHOSPHATE) |
84207 |
300 |
137.80 |
132.29 |
VITAMIN D; 25 HYDROXY
(CALCIFEDIOL) |
82306 |
300 |
260.00 |
249.60 |
WRIST; COMPLETE, MIN.
3 VIEWS |
73110 |
320 |
180.00 |
172.80 |
ZINC |
84630 |
300 |
50.70 |
48.67 |