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Wellmark (Member Portal - https://www.wellmark.com/mywellmark-info/ 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

Gross Rate Charges

Discounted Cash Pr ice Charges

EAPG Negotiated HM Payment

EAPG Negotiated PP Payment

De-Identified Maxi mum Negotiated Charges

RED BLOOD CELL

P9016

389.43

n-a

 $61.38

 $67.52

n-a

ACUTE CARE-(ISOLATION)/span>

n-a

1,250.00

n-a

96%

96%

n-a

SKILLED CARE ROOM

n-a

800.00

n-a

96%

96%

n-a

LONG TERM CARE ROOM-SEMI PRIVATE

n-a

147.84

n-a

n-a

n-a

n-a

LONG TERM CARE-SHORT STAY

n-a

225.00

n-a

n-a

n-a

n-a

DRUG TEST, DEFINITIVE, 1-7 DRUG CLASSES

G0480

550.00

n-a

 $ 102.92

 $ 113.22

n-a

DRUG TEST, DEFINITIVE, 1-7 DRUG CLASSES

G0480

146.25

n-a

 $ 102.92

 $ 113.22

n-a

RHC:ANNUAL WELLNESS VISIT, INIT

G0438

296.25

n-a

n-a

n-a

n-a

PSA SCREEN; TOTAL (MEDICARE)

G0103

131.00

n-a

 $45.88

 $50.47

n-a

CARDIOLOGY VISIT 40 MINUTES

99215

253.00

n-a

n-a

n-a

n-a

RHC:EST PATIENT MODERATE-HIGH, 25 MIN

99214

160.00

n-a

n-a

n-a

n-a

CARDIOLOGY VISIT  25 MINUTES

99214

188.00

n-a

n-a

n-a

n-a

RHEUMATOLOGY VISIT, EST, 25 MINUTES

99214

188.00

n-a

n-a

n-a

n-a

RHC:EST PATIENT LOW-MOD, 15 MIN

99213

110.00

n-a

n-a

n-a

n-a

CARDIOLOGY VISIT 15 MINUTES

99213

128.00

n-a

n-a

n-a

n-a

RHEUMATOLOGY VISIT, EST, 15 MINUTES

99213

128.00

n-a

n-a

n-a

n-a

CARDIOLOGY VISIT, NEW 45 MINUTES

99204

288.00

n-a

n-a

n-a

n-a

CARDIOLOGY VISIT, NEW 30 MINUTES

99203

190.00

n-a

n-a

n-a

n-a

PT THER/ACT/TRANSFER (FUNCTIONAL)15 MN

97530

90.00

n-a

 $ 136.40

 $ 150.04

n-a

PT RE-EVAL EST PLAN CARE

97164

99.00

n-a

 $ 136.40

 $ 150.04

n-a

PT EVAL HIGH COMP, 45 MIN

97163

256.10

n-a

 $ 136.40

 $ 150.04

n-a

PT EVAL MOD COMP, 30 MIN

97162

197.00

n-a

 $ 136.40

 $ 150.04

n-a

PT EVAL LOW COMP, 20 MIN

97161

137.90

n-a

 $ 136.40

 $ 150.04

n-a

MANUAL THERAPY TECHNIQUES,EA.15 MIN.<

97140

122.00

n-a

 $ 136.40

 $ 150.04

n-a

GAIT TRAINING (15 MIN)

97116

90.00

n-a

 $ 110.98

 $ 122.08

n-a

NEUROMUSCULAR RE-ED.

97112

90.00

n-a

 $ 136.40

 $ 150.04

n-a

ROM/STRENGTH EXERCISE, EACH 15 MIN.

97110

99.00

n-a

 $ 136.40

 $ 150.04

n-a

ULTRASOUND, EACH 15 MIN.an>

97035

62.00

n-a

 $ 110.98

 $ 122.08

n-a

IONTOPHORESIS, EACH 15 MIN.

97033

81.00

n-a

 $ 110.98

 $ 122.08

n-a

ELECTRICAL STIMULATION (MANUAL)

97032

165.00

n-a

 $ 110.98

 $ 122.08

n-a

ELECTRICAL STIMULATION (UNATTENDED)

97014

135.00

n-a

 $62.00

 $68.20

n-a

CANALITH REPOSITIONING PROCEDURE

95992

93.75

n-a

 $ 136.40

 $ 150.04

n-a

DUPLEX CAROTID, COMPLETE BILATERAL

93880

888.60

n-a

 $ 191.58

 $ 210.74

n-a

REHAB W/CONTINUOUS ECG, PER SESSION

93798

105.85

n-a

 $ 231.88

 $ 255.07

n-a

ECHO TTHRC R-T 2D -+M-MODE

93306

1,518.49

n-a

 $ 415.40

 $ 456.94

n-a

HOLTER MONITOR, EXTRNL ECG SCANNING

93226

605.00

n-a

 $ 281.48

 $ 309.63

n-a

EKG/ECG, 12 LEADS OR >; TRACING ONLY

93005

141.00

n-a

 $83.08

 $91.39

n-a

APP  OF MODALITY VASOPNEUMATIC DEVICES

90716

25.00

n-a

 $ 207.70

 $ 228.47

n-a

INJ IMM FIRST VACC/TOXIOD THRU 18YRS,

90460

36.00

n-a

n-a

n-a

n-a

CRYSTALS POLARIZATION, ALL BUT URINE /o:p

89060

44.10

n-a

 $61.38

 $67.52

n-a

CELL COUNT, W/DIFF; MISC.BODY FLUIDS

89051

60.65

n-a

 $61.38

 $67.52

n-a

NOS ASSAY W/OPTIC (SHIGA TOXIN 1)

87899

91.00

n-a

 $31.00

 $34.10

n-a

BK-VIRUS(DETECTION)POLYMERASE CHAIN

87798

240.00

n-a

 $68.82

 $75.71

n-a

TRICHOMONAS VAGINALIS, AMP

87661

150.00

n-a

 $68.82

 $75.71

n-a

STREPTOCOCCUS GRP A, AMP PRB

87651

99.80

n-a

 $68.82

 $75.71

n-a

STAPHYLOCOCCUS AUREUS

87641

62.50

n-a

 $68.82

 $75.71

n-a

SARS-CoV-2 COVID-19 AMP PROBE TQ

87635

150.00

n-a

 $68.82

 $75.71

n-a

GONORRHOEAE AMPLIFIED PROBE

87591

119.00

n-a

 $68.82

 $75.71

n-a

HEPATITIS C QUANT

87522

773.00

n-a

 $68.82

 $75.71

n-a

INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2

87502

121.50

n-a

 $68.82

 $75.71

n-a

C DIFF AMPLIFIED PROBE

87493

79.00

n-a

 $68.82

 $75.71

n-a

C DIFF AMPLIFIED PROBE

87493

150.00

n-a

 $68.82

 $75.71

n-a

CHLAMYDIA TRACH AMPLIFIED PROBE

87491

130.00

n-a

 $68.82

 $75.71

n-a

HIV-12 AG AND AB

87389

157.50

n-a

 $31.00

 $34.10

n-a

HEPATITIS B SURFACE ANTIGEN (HBsAg)

87340

106.00

n-a

 $31.00

 $34.10

n-a

HELICOBACTOR PYLORI, STOOL

87338

75.00

n-a

 $31.00

 $34.10

n-a

GIARDIA ANTIGEN

87329

124.00

n-a

 $31.00

 $34.10

n-a

CRYPTOSPORIDUM

87328

113.00

n-a

 $31.00

 $34.10

n-a

CLOSTRIDIUM DIFFICILE TOXIN; ENZYME

87324

171.00

n-a

 $31.00

 $34.10

n-a

KOH TISSUE EXAM FOR FUNGI

87220

27.85

n-a

 $31.00

 $34.10

n-a

SMEAR PRIM SRC WET MOUNT NFCT/

87210

8.50s p

n-a

 $31.00

 $34.10

n-a

OVA PARASITS SMR PRIM CPLX SPEC STRAIN

87209

47.78

n-a

 $31.00

 $34.10

n-a

STRAIN MALARIA,COCCIDIA,HERP VIRUSES

87207

70.30

n-a

 $31.00

 $34.10

n-a

GRAM, PRIM WRIGHTS & STOOL SMEARS

87205

64.00

n-a

 $31.00

 $34.10

n-a

SENSITIVITIES (ALL)

87186

127.00

n-a

 $31.00

 $34.10

n-a

CULTURE, IMMUNOLOGIC METHOD

87147

164.00

n-a

 $31.00

 $34.10

n-a

CULTURE,FUNGI;OTHER SOURCE BUT BLOOD

87102

233.00

n-a

 $31.00

 $34.10

n-a

CULTURE, BACTERIAL; ID, URINE/

87088

73.00

n-a

 $31.00

 $34.10

n-a

CULTURE, BACTERIAL; URINE-COLONY CNT

87086

113.00

n-a

 $31.00

 $34.10

n-a

CULTURE; ID, AEROBIC, ORGANISM ID

87077

75.00

n-a

 $31.00

 $34.10

n-a

CULTURE BACTERIA,EXCEPT BLOOD/

87075

153.00

n-a

 $31.00

 $34.10

n-a

CULTURE,OTHER SOURCE EXCEPT URINE/BLD

87070

132.00

n-a

 $31.00

 $34.10

n-a

STOOL CULTURE (CAMPYLOBACTER)

87046

95.00

n-a

 $31.00

 $34.10

n-a

CULTURE, BACTERIAL; FECES (STOOL)

87045

139.00

n-a

 $31.00

 $34.10

n-a

CULTURE, BACTERIAL; BLOOD/span >

87040

172.00

n-a

 $31.00

 $34.10

n-a

SPECIMEN CONCENTRATIOn

87015

101.00

n-a

 $31.00

 $34.10

n-a

CROSSMATCH

86922

234.00

n-a

 $97.34

 $ 107.08

n-a

BLOOD TYPING; RH(D)

86901

47.00

n-a

 $31.00

 $34.10

n-a

BLOOD TYPING; ABO GROUP<

86900

48.00

n-a

 $97.34

 $ 107.08

n-a

ANTIBODY SCREEN,RBC,EA SERUM TECHNIQ

86850

62.00

n-a

 $97.34

 $ 107.08

n-a

HLA TYPING, A,B, OR C, SINGLE ANTIGEN

86812

246.00

n-a

 $31.00

 $34.10

n-a

HEPATITIS C ANTIBODY

86803

128.00

n-a

 $47.12

 $51.84

n-a

THYROID (THYROGLOBULIN) ANTIBODIES

86800

76.05

n-a

 $47.12

 $51.84

n-a

VARICELLA TITRE

86787

44.10

n-a

 $47.12

 $51.84

n-a

SARS-COV-2 IGG ANTIBODY<

86769

150.00

n-a

 $47.12

 $51.84

n-a

ANTIBODY; RUBEOLA

86765

113.00

n-a

 $47.12

 $51.84

n-a

RUBELLA ANTIBODY

86762

108.00

n-a

 $47.12

 $51.84

n-a

ANTIBO PROTOZOA

86753

31.31

n-a

 $47.12

 $51.84

n-a

MUMPS ANTIBODY/IgG & IgM x (2)

86735

120.00

n-a

 $47.12

 $51.84

n-a

HEPATITIS B SURFACE ANTIBODY (HBsAb)

86706

108.00

n-a

 $47.12

 $51.84

n-a

HEPATITIS B CORE ANTIBODY; TOTAL

86704

103.00

n-a

 $47.12

 $51.84

n-a

HERPES SIMPLEX, TYPE 2span>

86696

30.30

n-a

 $47.12

 $51.84

n-a

HERPES SIMPLEX, TYPE 1span>

86695

58.80

n-a

 $47.12

 $51.84

n-a

ANTIB EHRILICHIA

86666

31.30

n-a

 $47.12

 $51.84

n-a

EPSTEIN-BARR ANTIBODY VIRUS

86665

117.00

n-a

 $47.12

 $51.84

n-a

EBV VCA IgG/IgM

86663

89.25

n-a

 $47.12

 $51.84

n-a

CYTOMEGALOVIRUS

86644

143.00

n-a

 $47.12

 $51.84

n-a

LYME DISEASE SEROLOGY EVALUATION

86618

147.00

n-a

 $47.12

 $51.84

n-a

BARTONELLA

86611

84.00

n-a

 $47.12

 $51.84

n-a

RPR, VDRL, ART; QUALITATIVE

86592

70.00

n-a

 $47.12

 $51.84

n-a

GAMMA INTERFERON-PRODUCING T-CELLS

86481

127.50

n-a

 $96.72

 $ 106.40

n-a

TB TEST, CELL MEDIATED IMMUNITY

86480

111.25

n-a

 $96.72

 $ 106.40

n-a

RA TITER (RHEUMATOID ARTHRITIS)QUANT

86431

46.30

n-a

 $47.12

 $51.84

n-a

RA FACTOR (RHEUMATOID ARTHRITIS)QUAL

86430

62.00

n-a

 $47.12

 $51.84

n-a

ANTIMICROSOMAL ANTIBODY<

86376

139.00

n-a

 $47.12

 $51.84

n-a

MONOSPOT

86308

75.00

n-a

 $47.12

 $51.84

n-a

AUTO ANTIBODIES TO SSA & SSB

86235

50.40

n-a

 $ 112.84

 $ 124.13

n-a

DNA ANTIBODY NATIVE /2 STRANDED

86225

26.25

n-a

 $47.12

 $51.84

n-a

CYCLIC CITRULLINATED PEPTIDE, ANTIBODY

86200

225.00

n-a

 $47.12

 $51.84

n-a

COMPLEMENT;ANTIGEN,EA COMPONENT

86160

60.64

n-a

 $47.12

 $51.84

n-a

CARDIOLIPIN (PHOSPHOLIPID)ANTIBODY

86147

162.00

n-a

 $96.72

 $ 106.40

n-a

C-REACTIVE PROTEIN

86140

107.00

n-a

 $47.12

 $51.84

n-a

ANA (ANTINUCLEAR ANTIBODIES)

86038

137.00

n-a

 $47.12

 $51.84

n-a

THROMBOPLASTIN TIME, PTT; SUB PLASMA

85732

190.00

n-a

 $24.18

 $26.60

n-a

APPT, PARTIAL (PTT);PLASMA OR WHOLE

85730

70.00

n-a

 $24.18

 $26.60

n-a

THROMBIN TIME, PLASMA

85670

190.00

n-a

 $24.18

 $26.60

n-a

ESR (ERYTHROCYTE); NON-AUTOMATED

85651

85.00

n-a

 $32.86

 $36.15

n-a

RUSSEL VIPER VENOM, DILUTED

85613

250.00

n-a

 $24.18

 $26.60

n-a

RUSSEL VIPER VENOM, DILUTED

85613

39.00

n-a

 $24.18

 $26.60

n-a

PROTIME SUBSTITUTION, PLASMA FRACTIONS

85611

175.00

n-a

 $24.18

 $26.60

n-a

PROTHROMBIN TIME (PT)/span>

85610

50.00

n-a

 $24.18

 $26.60

n-a

FIBRINOLYSINS/COAGULOPATHY SCR I&R

85390

45.00

n-a

 $24.18

 $26.60

n-a

QUANTITATIVE D-DIMER

85379

141.00

n-a

 $24.18

 $26.60

n-a

PROTEIN S, FREE

85306

368.00

n-a

 $24.18

 $26.60

n-a

PROTEIN C, ACTIVITY

85303

303.00

n-a

 $24.18

 $26.60

n-a

ANTITHROMBIN III,ANTIGEN ASSAY

85301

84.25

n-a

 $24.18

 $26.60

n-a

FACTOR V, LABILE FACTOR/span><

85220

262.00

n-a

 $56.42

 $62.07

n-a

CLOTTING FACTOR II, PROTHROMBIN, SPECIFI

85210

150.00

n-a

 $24.18

 $26.60

n-a

BLOOD SMEAR, PERIPHERAL; INT. BY DR.<

85060

61.75

n-a

 $61.38

 $67.52

n-a

PLATELET COUNT

85049

30.85

n-a

 $32.86

 $36.15

n-a

BLOOD COUNT; WBC (WHITE BLOOD CELL)

85048

58.00

n-a

 $32.86

 $36.15

n-a

RETICULOCYTE, AUTOMATED<

85045

56.00

n-a

 $32.86

 $36.15

n-a

BLOOD COUNT; HEMOGRAM/PLATELET COUNT

85027

88.00

n-a

 $32.86

 $36.15

n-a

CBC W/ AUTO DIFF. W/PLATELET COUNT

85025

112.00

n-a

 $32.86

 $36.15

n-a

BLOOD COUNT; HEMOGLOBIn<

85018

23.00

n-a

 $32.86

 $36.15

n-a

HCT

85014

32.00

n-a

 $32.86

 $36.15

n-a

BLOOD COUNT; MANUAL DIFF. W/PLATELET

85007

46.00

n-a

 $32.86

 $36.15

n-a

BETA hCG; QUALITATIVE

84703

113.00

n-a

 $20.46

 $22.51

n-a

BETA hCG; QUANTITATIVE

84702

142.00

n-a

 $47.12

 $51.84

n-a

ZINC

84630

50.70

n-a

 $37.20

 $40.92

n-a

URIC ACID; BLOOD

84550

73.00

n-a

 $20.46

 $22.51

n-a

B.U.N. (UREA NITROGEN); QUANTITATIVE

84520

56.00

n-a

 $20.46

 $22.51

n-a

TROPONIN, QUANTITATIVE

84484

168.00

n-a

 $45.88

 $50.47

n-a

REVERSE T3 TEST

84482

79.40

n-a

 $47.12

 $51.84

n-a

T3 FREE

84481

125.63

n-a

 $47.12

 $51.84

n-a

T3; TOTAL (TT-3)

84480

114.00

n-a

 $47.12

 $51.84

n-a

ALT (SGPT) ALANINE AMINO

84460

86.00

n-a

 $20.46

 $22.51

n-a

AST (SGOT)

84450

71.00

n-a

 $20.46

 $22.51

n-a

T.S.H. RIA

84443

122.00

n-a

 $47.12

 $51.84

n-a

THYROXINE T4; FREE

84439

106.00

n-a

 $47.12

 $51.84

n-a

THYROGLOBULIN

84432

74.50

n-a

 $47.12

 $51.84

n-a

VITAMIN B-1 (THIAMINE)/span>

84425

164.45

n-a

 $45.88

 $50.47

n-a

TESTOSTERONE; TOTAL

84403

176.00

n-a

 $47.12

 $51.84

n-a

TESTOSTERONE; FREE

84402

149.00

n-a

 $47.12

 $51.84

n-a

URINE SODIUM

84300

62.00

n-a

 $20.46

 $22.51

n-a

SODIUM; SERUM (NA)

84295

62.00

n-a

 $20.46

 $22.51

n-a

VITAMIN B-6 (PYRIDOXAL PHOSPHATE)

84207

137.80

n-a

 $45.88

 $50.47

n-a

URINE MONOCLANAL PROTEIN 84156,86335

84166

168.30

n-a

 $45.88

 $50.47

n-a

PROTEIN; ELECTROPHORESIS-(SERUM)

84165

156.00

n-a

 $45.88

 $50.47

n-a

URINE PROTEIN

84156

60.00

n-a

 $20.46

 $22.51

n-a

PROTEIN-TOTAL

84155

90.00

n-a

 $ 102.92

 $ 113.22

n-a

PSA, FREE

84154

185.00

n-a

 $45.88

 $50.47

n-a

PSA; TOTAL

84153

131.00

n-a

 $45.88

 $50.47

n-a

PROLACTIN; SERUM

84146

182.00

n-a

 $47.12

 $51.84

n-a

PROCALCITONIN (PCT)

84145

125.00

n-a

 $47.12

 $51.84

n-a

PROGESTRONE; SERUM

84144

148.00

n-a

 $47.12

 $51.84

n-a

PRE-ALBUMIN

84134

108.00

n-a

 $45.88

 $50.47

n-a

POTASSIUM (K); SERUM

84132

58.00

n-a

 $20.46

 $22.51

n-a

PHOSPHORUS INORGANIC; SERUM

84100

59.00

n-a

 $20.46

 $22.51

n-a

ALKALINE PHOSPHATASE

84075

70.00

n-a

 $20.46

 $22.51

n-a

PARATHYROID HORMONE (C-TERMINAL)

83970

264.00

n-a

 $85.56

 $94.12

n-a

ORGANIC ACID,SINGLE,QUANTITATIVE

83921

240.00

n-a

 $45.88

 $50.47

n-a

BNP-NATRIURETIC PEPTIDE<

83880

230.00

n-a

 $ 102.92

 $ 113.22

n-a

MAGNESIUM

83735

75.00

n-a

 $20.46

 $22.51

n-a

LIPASE

83690

110.00

n-a

 $20.46

 $22.51

n-a

BLOOD LEAD

83655

101.00

n-a

 $37.20

 $40.92

n-a

LACTATE DEHYDROGENASE (LD), (LDH)

83615

73.00

n-a

 $20.46

 $22.51

n-a

LACTATE, (LACTIC ACID)/span>

83605

126.00

n-a

 $45.88

 $50.47

n-a

IRON BINDING CAPACITY (IBC)/sp

83550

103.00

n-a

 $45.88

 $50.47

n-a

IRON SERUM

83540

73.00

n-a

 $20.46

 $22.51

n-a

QUANTITATIVE, NOT OTHERWISE  SPECIFIED

83520

95.00

n-a

 $47.12

 $51.84

n-a

ANTI-MITOCHONDRIAL AB

83516

117.00

n-a

 $47.12

 $51.84

n-a

HOMOCYSTEINE LEVEL

83090

188.00

n-a

 $47.12

 $51.84

n-a

HEMOGLOBIN; GLYCATED

83036

92.00

n-a

 $45.88

 $50.47

n-a

GONADOTROPIN; LUTEINIZING HORMONE

83002

84.90

n-a

 $47.12

 $51.84

n-a

FSH (FOLLICLE STIMULATING HORMONE)

83001

148.00

n-a

 $47.12

 $51.84

n-a

GGT  GAMMA GT

82977

71.00

n-a

 $20.46

 $22.51

n-a

GLUCOSE; QUANT. BLOOD, FBS 2H/

82947

46.00

n-a

 $20.46

 $22.51

n-a

BLOOD GASES; ABG pH,pCO2,pO2,CO2,HCO

82803

212.00

n-a

 $45.88

 $50.47

n-a

GAMMAGLOBULIN,IgA, IgD,IgG,IgM

82784

178.00

n-a

 $45.88

 $50.47

n-a

FOLATE (FOLIC) ACID; SERUM

82746

144.00

n-a

 $45.88

 $50.47

n-a

FERRITIN, RIA

82728

145.00

n-a

 $45.88

 $50.47

n-a

ESTRONE

82679

115.75

n-a

 $47.12

 $51.84

n-a

SERUM ESTROGEN, ESTRADIOL/span >

82670

175.00

n-a

 $47.12

 $51.84

n-a

ERYTHROPOIETIN

82668

47.13

n-a

 $45.88

 $50.47

n-a

DIHYDROXVITAMIN D 1.25

82652

131.40

n-a

 $ 102.92

 $ 113.22

n-a

VITAMIN B 12

82607

127.00

n-a

 $47.12

 $51.84

n-a

CREATININE; OTHER SOURCE (URINE)

82570

71.00

n-a

 $20.46

 $22.51

n-a

CREATININE; BLOOD

82565

59.00

n-a

 $20.46

 $22.51

n-a

CPK MB FRACTION ONLY

82553

150.00

n-a

 $45.88

 $50.47

n-a

CPK (CREATINE PHOSPHOKINASE); TOTAL

82550

105.00

n-a

 $20.46

 $22.51

n-a

CORTISOL; TOTAL

82533

152.00

n-a

 $47.12

 $51.84

n-a

CHLORIDE; BLOOD

82435

59.00

n-a

 $20.46

 $22.51

n-a

CARBON DIOXIDE(BICARBONATE -ECO 2

82374

63.00

n-a

 $20.46

 $22.51

n-a

CALCULUS (STONE) QUANT

82365

40.00

n-a

 $45.88

 $50.47

n-a

CALCIUM; IONIZED

82330

84.90

n-a

 $45.88

 $50.47

n-a

CALCIUM SERUM; TOTAL

82310

81.00

n-a

 $20.46

 $22.51

n-a

VITAMIN D; 25 HYDROXY (CALCIFEDIOL)

82306

260.00

n-a

 $ 102.92

 $ 113.22

n-a

OCCULT BLOOD,1-3,NOT SCREENING

82272

24.25

n-a

 $20.46

 $22.51

n-a

OCCULT BLOOD; FECES, 1-3 SPECIMENS

82270

27.00

n-a

 $20.46

 $22.51

n-a

BILIRUBIN; DIRECT

82248

53.00

n-a

 $20.46

 $22.51

n-a

BILIRUBIN; TOTAL

82247

69.00

n-a

 $20.46

 $22.51

n-a

AMYLASE; SERUM OR URINE<

82150

99.00

n-a

 $20.46

 $22.51

n-a

AMMONIA; BLOOD

82140

128.00

n-a

 $45.88

 $50.47

n-a

AFP (ALPHA-FETOPROTEIN: SERUM)

82105

139.00

n-a

 $45.88

 $50.47

n-a

MICROALBUMIN-URINE, QUANTITATIVE

82043

98.00

n-a

 $22.32

 $24.56

n-a

ALBUMIN; SERUM

82040

59.00

n-a

 $20.46

 $22.51

n-a

METHYLENETETRAHYDROFOLATE REDUCTASE

81291

300.00

n-a

 $ 143.22

 $ 157.55

n-a

FACTOR V, LEIDEN

81241

284.30

n-a

 $ 143.22

 $ 157.55

n-a

URINE PREGNANCY TEST

81025

12.50

n-a

 $22.32

 $24.56

n-a

UA MICROSCOPIC

81015

50.00

n-a

 $22.32

 $24.56

n-a

URINE  AUTOMATED W/O MICROSCOPY

81003

47.00

n-a

 $22.32

 $24.56

n-a

UA-ROUTINE W/O MICROSCP, NON AUTOMATED

81002

47.00

n-a

 $22.32

 $24.56

n-a

URINE, AUTOMATED WITH MICROSCOPY

81001

59.00

n-a

 $22.32

 $24.56

n-a

DRUG/SUBST DEF QUAL/QUANT NOS 1-3

80375

131.00

n-a

 $45.88

 $50.47

n-a

SALICYLATE /  ANALEGESICS, OTC, 1OR 2

80329

550.00

n-a

 $45.88

 $50.47

n-a

SALICYLATE /  ANALEGESICS, OTC, 1OR 2

80329

131.00

n-a

 $45.88

 $50.47

n-a

ALCOHOL, (ETOH) ANY SPEC BUT BREATH

80320

550.00

n-a

 $45.88

 $50.47

n-a

ALCOHOL, (ETOH) ANY SPEC BUT BREATH

80320

188.00

n-a

 $45.88

 $50.47

n-a

DRUG SCREENING, SINGLE

80307

290.00

n-a

 $ 102.92

 $ 113.22

n-a

DRUG SCR QUAL MLT DRUG CLASSES

80305

169.00

n-a

 $45.88

 $50.47

n-a

QUANT. OF DRUG, NO OTHER SPECIFICATI

80299

183.00

n-a

 $49.60

 $54.56

n-a

LACOSAMIDE, ASSAY

80235

200.00

n-a

 $49.60

 $54.56

n-a

VANCOMYCIN

80202

140.00

n-a

 $49.60

 $54.56

n-a

TACROLIMUS

80197

231.00

n-a

 $49.60

 $54.56

n-a

DILANTIN (PHENYTOIN); TOTAL

80185

131.00

n-a

 $49.60

 $54.56

n-a

PHENOBARBITAL

80184

154.00

n-a

 $49.60

 $54.56

n-a

LITHIUM

80178

115.00

n-a

 $32.86

 $36.15

n-a

DRUG SCR QUAN LEVETIRACETAM

80177

85.00

n-a

 $49.60

 $54.56

n-a

LAMOTRIGINE

80175

90.00

n-a

 $49.60

 $54.56

n-a

VALPROIC ACID (DIPROPYLACETIC ACID) FREE

80165

135.00

n-a

 $49.60

 $54.56

n-a

VALPROIC ACID (DEPAKOTE)

80164

145.00

n-a

 $49.60

 $54.56

n-a

DIGOXIN

80162

111.00

n-a

 $49.60

 $54.56

n-a

TEGRETOL (CARBAMAZEPINE); TOTAL

80156

143.00

n-a

 $49.60

 $54.56

n-a

LIVER (HEPATIC) FUNCTION PANEL

80076

149.00

n-a

 $52.08

 $57.29

n-a

ACUTE HEPATITIS PANEL

80074

557.00

n-a

 $52.08

 $57.29

n-a

RENAL FUNCTION PANEL

80069

190.00

n-a

 $52.08

 $57.29

n-a

LIPID PANEL 82465,83718,84478

80061

144.00

n-a

 $52.08

 $57.28

n-a

CMP(GLUC,BUN,CREAT,AST,ALP,TBIL,ALT,<

80053

232.00

n-a

 $52.08

 $57.28

n-a

ELECTROLYTE PANEL (NA,K,CL,CO2)

80051

113.00

n-a

 $52.08

 $57.29

n-a

BASIC METABOLIC PANEL(BUN,CREAT,GLUC

80048

168.00

n-a

 $52.08

 $57.28

n-a

BONE DENSITY ,DXA,1OR MORE SITES,

77080

322.00

n-a

 $ 245.52

 $ 270.08

n-a

MAMMOGRAM, SCREENING

77067

255.00

n-a

 $ 221.34

 $ 243.48

n-a

ULTRASOUND,EXTREMITY COMPLETE/

76881

285.00

n-a

 $ 191.58

 $ 210.74

n-a

US  SCROTUM AND CONTENTS

76870

508.00

n-a

 $ 191.58

 $ 210.74

n-a

ULTRASOUND,TRANSVAGINAL/span><

76830

509.00

n-a

 $ 191.58

 $ 210.74

n-a

ULTRASOUND, RENAL

76775

442.00

n-a

 $ 191.58

 $ 210.74

n-a

ABDOMINAL AORTA ULTRASOUND (AAA)

76706

476.00

n-a

 $ 191.58

 $ 210.74

n-a

ABDOMEN, GB, BILIARY TREE SINGLE QUAD

76705

476.00

n-a

 $ 191.58

 $ 210.74

n-a

ULTRASOUND,ABDOMINAL,COMPLETE/

76700

654.00

n-a

 $ 302.56

 $ 332.82

n-a

US  SOFT TISS, HEAD,NECK, THYROID

76536

433.00

n-a

 $ 191.58

 $ 210.74

n-a

CT: ABD & PELVIS WITH CONTRAST

74177

1,757.80

n-a

 $1,042.22

 $1,146.45

n-a

CT: ABD & PELVIS W/O CONTRAST

74176

1,567.80

n-a

 $1,042.22

 $1,146.45

n-a

ABDOMEN, 2 VIEWS

74019

281.00

n-a

 $59.52

 $65.48

n-a

KUB, I VIEW

74018

182.00

n-a

 $59.52

 $65.48

n-a

MRI:ANY JT LOWR EXT

73721

1,210.00

n-a

 $ 983.32

 $1,081.66

n-a

TOE(S); MIN. 2 VIEWS

73660

172.00

n-a

 $59.52

 $65.48

n-a

OS CALCIS (CALCANEUS); MIN. 2 VIEWS

73650

176.00

n-a

 $59.52

 $65.48

n-a

FOOT; COMPLETE, MIN. 3 VIEWS p

73630

187.00

n-a

 $59.52

 $65.48

n-a

ANKLE; COMPLETE, MIN. 3 VIEWS/

73610

220.00

n-a

 $59.52

 $65.48

n-a

LOWER LEG, TIB/FIB; 2 VIEWS

73590

215.00

n-a

 $59.52

 $65.48

n-a

KNEE; 3 VIEWS

73562

257.00

n-a

 $59.52

 $65.48

n-a

KNEE; 1 OR  2 VIEWS

73560

159.00

n-a

 $59.52

 $65.48

n-a

FEMUR,  MIN  2 VIEWS p

73552

229.00

n-a

 $59.52

 $65.48

n-a

HIP, COMPLETE 2-3 VIEWS/span><

73502

215.00

n-a

 $59.52

 $65.48

n-a

MRI:ANY JT UPPER EXT

73221

1,207.50

n-a

 $ 983.32

 $1,081.66

n-a

MRI: UPPER EXT OTH/THN JT, W/WO CONTRAST

73218

1,650.00

n-a

 $ 983.32

 $1,081.66

n-a

FINGER(S), MIN. 2 VIEWS/span><

73140

164.00

n-a

 $59.52

 $65.48

n-a

HAND; MIN. 3 VIEWS

73130

212.00

n-a

 $59.52

 $65.48

n-a

WRIST; COMPLETE, MIN. 3 VIEWS/

73110

180.00

n-a

 $59.52

 $65.48

n-a

FOREARM; INCL. 1 JOINT, 2 VIEWS

73090

206.00

n-a

 $59.52

 $65.48

n-a

ELBOW 3 VIEWS

73080

152.15

n-a

 $59.52

 $65.48

n-a

ELBOW; 2 VIEWS

73070

170.00

n-a

 $59.52

 $65.48

n-a

HUMERUS; INCL. 1 JOINT, MIN. 2 VIEWS

73060

222.00

n-a

 $59.52

 $65.48

n-a

SHOULDER; COMPLETE, MIN. 2 VIEWS

73030

240.00

n-a

 $59.52

 $65.48

n-a

SCAPULA, COMPLETE

73010

300.00

n-a

 $59.52

 $65.48

n-a

CLAVICLE, COMPLETE

73000

231.00

n-a

 $59.52

 $65.48

n-a

SACRUM & COCCYX; MIN. 2 VIEWS

72220

206.00

n-a

 $59.52

 $65.48

n-a

PELVIS; 1-2 VIEWS

72170

196.00

n-a

 $59.52

 $65.48

n-a

MRI: LUMBAR W/O CONTRAST

72148

1,155.00

n-a

 $ 983.32

 $1,081.66

n-a

MRI:THORACIC

72146

1,155.00

n-a

 $ 983.32

 $1,081.66

n-a

MRI:CERVICAL W/O CONTRAST/span >

72141

1,155.00

n-a

 $ 983.32

 $1,081.66

n-a

LUMBAR SPINE; 2-3 VIEWS/span><

72100

266.00

n-a

 $59.52

 $65.48

n-a

SCOLIOSIS EVAL

72081

205.00

n-a

 $59.52

 $65.48

n-a

THORACIC  SPINE; 2 VIEWS

72070

200.00

n-a

 $59.52

 $65.48

n-a

CERVICAL SPINE; 2-3 VIEWS/span >

72040

288.50

n-a

 $59.52

 $65.48

n-a

CT:CHEST WITH AND WITHOUT CONTRAST

71270

2,455.00

n-a

 $1,042.22

 $1,146.45

n-a

CHEST PA W/RIBS MIN 3 VIEWS

71101

212.80

n-a

 $59.52

 $65.48

n-a

RIBS, UNILATERAL; 2 VIEWS/span >

71100

218.00

n-a

 $59.52

 $65.48

n-a

CHEST 2 VIEWS, FRONT & LAT

71046

195.00

n-a

 $59.52

 $65.48

n-a

CHEST, SINGLE VIEW

71045

133.00

n-a

 $59.52

 $65.48

n-a

CT: HEAD OR BRAIN WITHOUT CONTRAST

70450

1,463.00

n-a

 $1,042.22

 $1,146.45

n-a

NECK, SOFT TISSUE

70360

222.00

n-a

 $59.52

 $65.48

n-a

MANDIBLE; LESS THAN 4 VIEWS

70100

290.00

n-a

 $59.52

 $65.48

n-a

ORBITS X-RAY

70030

110.25

n-a

 $59.52

 $65.48

n-a

TRANSFUSION BLOOD/BLOOD COMPONENTS

36430

547.00

n-a

 $ 112.84

 $ 124.13

n-a

RHC:PREV VISIT, EST (65 AND OVER)

99397

165.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, EST (40 THRU 64 YEARS)

99396

160.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, EST (18 THRU 39 YEARS)

99395

150.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, EST (12 THRU 17 YEARS)

99394

145.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, EST (5 THRU 11 YEARS)

99393

135.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, EST (1 THRU 4 YEARS)<

99392

135.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, EST (AGE YOUNGER THAN 1 YE AR)

99391

125.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, NEW (65 AND OVER)

99387

212.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, NEW (40 THRU 64 YEARS)

99386

194.25

n-a

n-a

n-a

n-a

RHC:PREV VISIT, NEW (18 THRU 39 YEARS)

99385

221.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, NEW (12 THRU 17 YEARS)

99384

221.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, NEW (5 THRU 11 YEARS)

99383

188.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, NEW (1 THRU 4 YEARS)<

99382

188.00

n-a

n-a

n-a

n-a

RHC:PREV VISIT, INITIAL (AGE YOUNGER THAN YEAR)

99381

118.00

n-a

n-a

n-a

n-a

RHC:EST PATIENT HIGH LEVEL

99215

210.00

n-a

n-a

n-a

n-a

RHEUMATOLOGY VISIT, EST, 40 MINUTES

99215

253.00

n-a

n-a

n-a

n-a

RHC:EST PATIENT MINOR LEVEL, 10 MIN

99212

65.00

n-a

n-a

n-a

n-a

CARDIOLOGY VISIT, 10 MINUTES p

99212

77.00

n-a

n-a

n-a

n-a

RHEUMATIOLOGY VISIT, EST, 10 MINUTES

99212

77.00

n-a

n-a

n-a

n-a

RHC:NEW OFFICE OUTPT, HIGH, 60 MIN

99205

290.00

n-a

n-a

n-a

n-a

CARDIOLOGY VISIT, NEW 60 MINUTES

99205

363.00

n-a

n-a

n-a

n-a

RHEUMATOLOGY VISIT, NEW, 60 MINUTES

99205

363.00

n-a

n-a

n-a

n-a

RHC:NEW OFFICE OUTPT, MOD-HIGH 45 MIN

99204

225.00

n-a

n-a

n-a

n-a

RHEUMATOLOGY VISIT, NEW, 45 MINUTES

99204

288.00

n-a

n-a

n-a

n-a

RHC:NEW OFFICE OUTPT, MOD-SEV 30 MIN

99203

134.00

n-a

n-a

n-a

n-a

RHEUMATOLOGY VISIT, NEW, 30 MINUTES

99203

190.00

n-a

n-a

n-a

n-a

RHC:NEW OFFICE OUTPT, MINOR-MOD, 20 MIN

99202

88.00

n-a

n-a

n-a

n-a

CARDIOLOGY VISIT, NEW 20 MINUTES

99202

131.00

n-a

n-a

n-a

n-a

RHEUMATOLOGY VISIT, NEW, 20 MINUTES

99202

131.00

n-a

n-a

n-a

n-a

OT EVAL HIGH COMP, 60 MINUTES/

97167

265.45

n-a

 $ 120.90

 $ 132.99

n-a

OT EVAL MOD COMP, 45 MINUTES p

97166

204.19

n-a

 $ 120.90

 $ 132.99

n-a

OT EVAL LOW COMP, 30 MINUTES p

97165

142.93

n-a

 $ 120.90

 $ 132.99

n-a

IV INFURSION - ADDITIONAL INFUSION, UP TO HOUR

96367

137.00

n-a

 $ 554.90

 $ 610.39

n-a

IV INFUSION - EA ADDITIONAL HOUR

96366

99.00

n-a

 $ 553.66

 $ 609.03

n-a

IV INFUSION (SPECIFY DRUG) UP TO 1 HR

96365

231.00

n-a

 $ 554.90

 $ 610.39

n-a

POLYSOM 6>YRS SLEEP W/CPAP 4>ADDL

95811

3,032.00

n-a

 $1,115.38

 $1,226.92

n-a

POLYSOM 6>YRS SLEEP 4>ADDL PARAM ATTENDED

95810

2,756.00

n-a

 $1,115.38

 $1,226.92

n-a