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 |
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> p> |
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 p> |
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> p> |
86696 |
30.30 |
n-a |
$47.12 |
$51.84 |
n-a |
HERPES SIMPLEX, TYPE 1span> p> |
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 p> |
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> p> |
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> p> |
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 p> |
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 p> |
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 |