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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 ROO
M-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
ADDITIONAL 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) ANY
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,RBC,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 |
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;
HEMOGLOBIN |
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 pH,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;OTHER SOURCE BUT BLOOD |
87102 |
300 |
233.00 |
221.35 |
CULTURE,OTHER SOURCE 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
STIMULATING 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 A
NTIBODY;
TOTAL |
86704 |
300 |
103.00 |
97.85 |
HEPATITIS B SURFAC
ANTIBODY (HBsAb) |
86706 |
300 |
108.00 |
102.60 |
HEPATITIS B SURFACE
ANTIGEN (HBsAg) |
87340 |
300 |
106.00 |
100.70 |
HEPATITIS C ANTIBODY |
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, OR 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 FOR
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- |
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 HORMONE
(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; ELECTROPH
ORESIS-(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-19
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; TOTAL |
84403 |
300 |
176.00 |
167.20 |
THROMBIN TIME, PLA
SMA |
85670 |
300 |
190.00 |
180.50 |
THROMBOPLASTIN TIME,
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, QUANTITATIVE |
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 (DEP
AKOTE) |
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; 2-3
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
JOINT, 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; 2
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, EACH 15
MIN. |
97033 |
420 |
81.00 |
76.95 |
MANUAL THERAPY |
97140 |
420 |
122.00 |
115.90 |
NEUROMUSCULAR RE-E
D. |
97112 |
420 |
90.00 |
85.50 |
PT THER/ACT/TRANSFER
(FUNCTIONAL)15 MN |
97530 |
420 |
90.00 |
85.50 |
ROM/STRENGTH EXERCISE,
EACH 15 MIN. |
97110 |
420 |
99.00 |
94.05 |
ULTRASOUND, EACH 15
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 PLAN
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 25
MINUTES |
99214 |
480 |
188.00 |
178.60 |
CARDIOLOGY VISIT 15
MINUTES |
99213 |
480 |
128.00 |
121.60 |
CARDIOLOGY VISIT 40
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 HIGH LEVEL |
99215 |
521 |
210.00 |
199.50 |
RHC:EST PATIENT LOW-MOD, 15 MIN |
99213 |
521 |
110.00 |
104.50 |
RHC:EST PATIENT MINOR LEVEL, 10 MIN |
99212 |
521 |
65.00 |
61.75 |
RHC:EST PATIENT MODERATE-HIGH, 25 MIN |
99214 |
521 |
160.00 |
152.00 |
RHC:NEW OFFICE OUTPT, HIGH, 60 MIN |
99205 |
521 |
290.00 |
275.50 |
RHC:NEW OFFICE OUTPT, MINOR-MOD, 20 MIN |
99202 |
521 |
88.00 |
83.60 |
RHC:NEW OFFICE OUTPT, MOD-HIGH 45 MIN |
99204 |
521 |
225.00 |
213.75 |
RHC:NEW OFFICE OUTPT, MOD-SEV 30 MIN |
99203 |
521 |
134.00 |
127.30 |
RHC:PREV VISIT, EST (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 (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)<
/span> |
99381 |
521 |
118.00 |
112.10 |
RHC:PREV VISIT, NEW (1 THRU 4 YEARS) |
99382 |
521 |
188.00 |
178.60 |
RHC:PREV VISIT, NEW (12 THRU 17 YEARS) |
99384 |
521 |
221.00 |
209.95 |
RHC:PREV VISIT, NEW (18 THRU 39 YEARS) |
99385 |
521 |
221.00 |
209.95 |
RHC:PREV VISIT, NEW (40 THRU 64 YEARS) |
99386 |
521 |
194.25 |
184.54 |
RHC:PREV VISIT, NEW (5 THRU 11 YEARS) |
99383 |
521 |
188.00 |
178.60 |
RHC:PREV VISIT, NEW (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 EXT |
73721 |
610 |
1,210.00 |
1,149.50 |
MRI:ANY JT UPPER EXT |
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 |