OVERVIEW
In compliance with the Centers for Medicare and Medicaid Services (CMS), Culberson Hospital is making available to the public a copy of its standard charges known as a “Charge Master,” “Charge Description Master” or “CDM”.
Since payment rates for hospital care provided to insured patients are either negotiated with health plans, set by the federal government for Medicare, or set by state governments for Medicaid enrollees, the payments hospitals receive for patient care do not necessarily reflect the prices reflected in the Charge Master. A patient’s responsibility may vary depending on the payment plans negotiated with insurance companies as well as the patient’s individual and/or family deductibles and co-payments with their insurance plan. Additionally, uninsured patients are not generally expected to pay the hospital’s standard charges as reflected in the CDM and may be eligible for financial assistance.
The information provided is based on information we have gathered from contracts with managed care commercial insurance plans. This is not a guarantee of what you will be charged. Your actual charges may differ from the estimated charges for many reasons, including the seriousness of your medical condition, actual time the procedure takes and the services and supplies that you receive.
The charges listed here are for services from the Hospital. They do not reflect the charges for physicians (such as surgeon, anesthesiologist, radiologist, pathologist, etc.) who may be involved in providing particular services to a patient. These charges are billed separately from the individual physician/physicians group.
Culberson Hospital shall not be liable for any difference between charges listed in the price lists and the final bill for services.
AVAILABLE FILES
There are two files regarding the hospital’s CDM for price transparency.
The CSV file is a comprehensive, machine-readable file that makes public all standard charge information for all hospital items and services. This can easily be imported into Microsoft Excel or similar software. This file contains the following information:
The PDF file is a searchable consumer-friendly format of payer-specific negotiated charge information of 300 “shoppable outpatient services” at the hospital. The file contains the following information:
QUESTIONS?
If you have further questions about the Culberson Hospital CDM, please contact our hospital business office at (432) 283-2760 or come by and speak to one of our business office representatives. Thank you for choosing Culberson Hospital for your health care needs!
Culberson Hospital Shoppable Services as of 7/15/2023
| CHARGE CODE | DESCRIPTION | Department | REV CODE | CPT CODE | RATE | Cash Pay | Aetna | BCBS TX - Blue Advantage | BCBS TX Blue Essentials | BCBS TX PPO | BCBS TX Trad | CIGNA | Humana | Unicare | United | Minimum Negotiated Charge | Maximum Negotiated Charge |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3904013 | ANTIBODY SCREEN-REDC | Blood/Blood Products | 390 | 86850 | $ 42.00 | $ 31.50 | $ 36.96 | $ 32.34 | $ 34.02 | $ 37.80 | $ 37.80 | $ 30.91 | $ 33.60 | $ 33.60 | $ 33.60 | $ 30.91 | $ 37.80 |
| 3900300 | COOMBS-CROSSMATCH | Blood/Blood Products | 300 | 86921 | $ 110.00 | $ 82.50 | $ 96.80 | $ 84.70 | $ 89.10 | $ 99.00 | $ 99.00 | $ 80.96 | $ 88.00 | $ 88.00 | $ 88.00 | $ 80.96 | $ 99.00 |
| 3000048 | PRBC PACKED RED BLOOD CELLS | Blood/Blood Products | 390 | P9016 | $ 300.00 | $ 225.00 | $ 264.00 | $ 231.00 | $ 243.00 | $ 270.00 | $ 270.00 | $ 220.80 | $ 240.00 | $ 240.00 | $ 240.00 | $ 220.80 | $ 270.00 |
| 45036430 | TRANSFUSION | Blood/Blood Products | 391 | 36430 | $ 900.00 | $ 675.00 | $ 792.00 | $ 693.00 | $ 729.00 | $ 810.00 | $ 810.00 | $ 662.40 | $ 720.00 | $ 720.00 | $ 720.00 | $ 662.40 | $ 810.00 |
| 7300250 | EKG (12 LEAD)UNINTERPRETED | EKG/ECG | 730 | 93005 | $ 50.00 | $ 37.50 | $ 44.00 | $ 38.50 | $ 40.50 | $ 45.00 | $ 45.00 | $ 36.80 | $ 40.00 | $ 40.00 | $ 40.00 | $ 36.80 | $ 45.00 |
| 7300150 | ELECTROCARDIOGRAM | EKG/ECG | 730 | 93005 | $ 164.00 | $ 123.00 | $ 144.32 | $ 126.28 | $ 132.84 | $ 147.60 | $ 147.60 | $ 120.70 | $ 131.20 | $ 131.20 | $ 131.20 | $ 120.70 | $ 147.60 |
| 3000116 | 17OHP 17 HYDROXYPREGNENOLONE | Laboratory | 300 | 84143 | $ 148.00 | $ 111.00 | $ 130.24 | $ 113.96 | $ 119.88 | $ 133.20 | $ 133.20 | $ 108.93 | $ 118.40 | $ 118.40 | $ 118.40 | $ 108.93 | $ 133.20 |
| 3003832 | 24 HR URINE SODIUM | Laboratory | 301 | 84300 | $ 47.00 | $ 35.25 | $ 41.36 | $ 36.19 | $ 38.07 | $ 42.30 | $ 42.30 | $ 34.59 | $ 37.60 | $ 37.60 | $ 37.60 | $ 34.59 | $ 42.30 |
| 30082306 | 3 EPI -Vitamin D, 25-Hydroxy | Laboratory | 301 | 82306 | $ 312.00 | $ 234.00 | $ 274.56 | $ 240.24 | $ 252.72 | $ 280.80 | $ 280.80 | $ 229.63 | $ 249.60 | $ 249.60 | $ 249.60 | $ 229.63 | $ 280.80 |
| 3000300 | ACETAMINOPHEN LEVEL | Laboratory | 301 | 80299 | $ 93.00 | $ 69.75 | $ 81.84 | $ 71.61 | $ 75.33 | $ 83.70 | $ 83.70 | $ 68.45 | $ 74.40 | $ 74.40 | $ 74.40 | $ 68.45 | $ 83.70 |
| 3000704 | AEROBIC ISOLATE, ADD METH REQ | Laboratory | 306 | 87077 | $ 32.00 | $ 24.00 | $ 28.16 | $ 24.64 | $ 25.92 | $ 28.80 | $ 28.80 | $ 23.55 | $ 25.60 | $ 25.60 | $ 25.60 | $ 23.55 | $ 28.80 |
| 3000482 | ALPHA-FETOPRTEIN SERUM | Laboratory | 301 | 82105 | $ 98.00 | $ 73.50 | $ 86.24 | $ 75.46 | $ 79.38 | $ 88.20 | $ 88.20 | $ 72.13 | $ 78.40 | $ 78.40 | $ 78.40 | $ 72.13 | $ 88.20 |
| 3000333 | ALT (ALANINE AMINOTRANSFERASE | Laboratory | 301 | 84460 | $ 45.00 | $ 33.75 | $ 39.60 | $ 34.65 | $ 36.45 | $ 40.50 | $ 40.50 | $ 33.12 | $ 36.00 | $ 36.00 | $ 36.00 | $ 33.12 | $ 40.50 |
| 3001570 | AMMONIA LEVEL | Laboratory | 301 | 82140 | $ 72.00 | $ 54.00 | $ 63.36 | $ 55.44 | $ 58.32 | $ 64.80 | $ 64.80 | $ 52.99 | $ 57.60 | $ 57.60 | $ 57.60 | $ 52.99 | $ 64.80 |
| 3000351 | AMYLASE | Laboratory | 301 | 82150 | $ 87.00 | $ 65.25 | $ 76.56 | $ 66.99 | $ 70.47 | $ 78.30 | $ 78.30 | $ 64.03 | $ 69.60 | $ 69.60 | $ 69.60 | $ 64.03 | $ 78.30 |
| 3000122 | ANCA INFLAMMATORY BOWELDISEASE | Laboratory | 300 | 86255 | $ 168.00 | $ 126.00 | $ 147.84 | $ 129.36 | $ 136.08 | $ 151.20 | $ 151.20 | $ 123.65 | $ 134.40 | $ 134.40 | $ 134.40 | $ 123.65 | $ 151.20 |
| 3001710 | ANDROSTENEDIONE | Laboratory | 300 | 82157 | $ 218.00 | $ 163.50 | $ 191.84 | $ 167.86 | $ 176.58 | $ 196.20 | $ 196.20 | $ 160.45 | $ 174.40 | $ 174.40 | $ 174.40 | $ 160.45 | $ 196.20 |
| 3000339 | ANTIBODY SCREEN KH-MOTHERS | Laboratory | 300 | 86885 | $ 110.00 | $ 82.50 | $ 96.80 | $ 84.70 | $ 89.10 | $ 99.00 | $ 99.00 | $ 80.96 | $ 88.00 | $ 88.00 | $ 88.00 | $ 80.96 | $ 99.00 |
| 30083520 | ANTI-CCP/CITRULLINE ANTIBODY | Laboratory | 302 | 86200 | $ 122.00 | $ 91.50 | $ 107.36 | $ 93.94 | $ 98.82 | $ 109.80 | $ 109.80 | $ 89.79 | $ 97.60 | $ 97.60 | $ 97.60 | $ 89.79 | $ 109.80 |
| 3000353 | ANTIHUMAN GLOBULIN TEST COOMBS | Laboratory | 302 | 86885 | $ 110.00 | $ 82.50 | $ 96.80 | $ 84.70 | $ 89.10 | $ 99.00 | $ 99.00 | $ 80.96 | $ 88.00 | $ 88.00 | $ 88.00 | $ 80.96 | $ 99.00 |
| 3000507 | ANTI-NUCLEAR ANTIBODIES (ANA) | Laboratory | 302 | 86038 | $ 50.00 | $ 37.50 | $ 44.00 | $ 38.50 | $ 40.50 | $ 45.00 | $ 45.00 | $ 36.80 | $ 40.00 | $ 40.00 | $ 40.00 | $ 36.80 | $ 45.00 |
| 3000355 | ANTISTREPTOLYSIN O (ASO TITER) | Laboratory | 300 | 86060 | $ 29.00 | $ 21.75 | $ 25.52 | $ 22.33 | $ 23.49 | $ 26.10 | $ 26.10 | $ 21.34 | $ 23.20 | $ 23.20 | $ 23.20 | $ 21.34 | $ 26.10 |
| 3000516 | ARTERIAL PUNCTURE | Laboratory | 361 | 36600 | $ 139.00 | $ 104.25 | $ 122.32 | $ 107.03 | $ 112.59 | $ 125.10 | $ 125.10 | $ 102.30 | $ 111.20 | $ 111.20 | $ 111.20 | $ 102.30 | $ 125.10 |
| 30084244 | ASSAY OF RENIN | Laboratory | 301 | 84244 | $ 112.00 | $ 84.00 | $ 98.56 | $ 86.24 | $ 90.72 | $ 100.80 | $ 100.80 | $ 82.43 | $ 89.60 | $ 89.60 | $ 89.60 | $ 82.43 | $ 100.80 |
| 3000332 | AST (ASPARTATE AMINOTRANSFERAS | Laboratory | 301 | 84450 | $ 41.00 | $ 30.75 | $ 36.08 | $ 31.57 | $ 33.21 | $ 36.90 | $ 36.90 | $ 30.18 | $ 32.80 | $ 32.80 | $ 32.80 | $ 30.18 | $ 36.90 |
| 3000359 | BILIRUBIN DIRECT | Laboratory | 301 | 82248 | $ 35.00 | $ 26.25 | $ 30.80 | $ 26.95 | $ 28.35 | $ 31.50 | $ 31.50 | $ 25.76 | $ 28.00 | $ 28.00 | $ 28.00 | $ 25.76 | $ 31.50 |
| 3000362 | BLOOD SMEAR STUDY | Laboratory | 300 | 85060 | $ 27.00 | $ 20.25 | $ 23.76 | $ 20.79 | $ 21.87 | $ 24.30 | $ 24.30 | $ 19.87 | $ 21.60 | $ 21.60 | $ 21.60 | $ 19.87 | $ 24.30 |
| 3000363 | BLOOD TYPING, ABO | Laboratory | 390 | 86900 | $ 90.00 | $ 67.50 | $ 79.20 | $ 69.30 | $ 72.90 | $ 81.00 | $ 81.00 | $ 66.24 | $ 72.00 | $ 72.00 | $ 72.00 | $ 66.24 | $ 81.00 |
| 3000214 | BLOOD TYPING, RH PHENOTYPING | Laboratory | 390 | 86901 | $ 75.00 | $ 56.25 | $ 66.00 | $ 57.75 | $ 60.75 | $ 67.50 | $ 67.50 | $ 55.20 | $ 60.00 | $ 60.00 | $ 60.00 | $ 55.20 | $ 67.50 |
| 3000364 | BLOOD UREA NITROGEN (BUN) | Laboratory | 301 | 84520 | $ 35.00 | $ 26.25 | $ 30.80 | $ 26.95 | $ 28.35 | $ 31.50 | $ 31.50 | $ 25.76 | $ 28.00 | $ 28.00 | $ 28.00 | $ 25.76 | $ 31.50 |
| 3000308 | BLOOD, OCCULT, OTHER SOURCE | Laboratory | 301 | 82274 | $ 48.00 | $ 36.00 | $ 42.24 | $ 36.96 | $ 38.88 | $ 43.20 | $ 43.20 | $ 35.33 | $ 38.40 | $ 38.40 | $ 38.40 | $ 35.33 | $ 43.20 |
| 3001794 | C4 & C3 COMPLEMENT GROUP | Laboratory | 300 | 86160 | $ 83.00 | $ 62.25 | $ 73.04 | $ 63.91 | $ 67.23 | $ 74.70 | $ 74.70 | $ 61.09 | $ 66.40 | $ 66.40 | $ 66.40 | $ 61.09 | $ 74.70 |
| 3000163 | CA 19-9 | Laboratory | 300 | 86301 | $ 109.00 | $ 81.75 | $ 95.92 | $ 83.93 | $ 88.29 | $ 98.10 | $ 98.10 | $ 80.22 | $ 87.20 | $ 87.20 | $ 87.20 | $ 80.22 | $ 98.10 |
| 3000062 | CARBAMAZEDINE | Laboratory | 300 | 80201 | $ 82.00 | $ 61.50 | $ 72.16 | $ 63.14 | $ 66.42 | $ 73.80 | $ 73.80 | $ 60.35 | $ 65.60 | $ 65.60 | $ 65.60 | $ 60.35 | $ 73.80 |
| 3001579 | CARCINOEMBRYONIC ANTIGEN (CEA) | Laboratory | 300 | 82378 | $ 112.00 | $ 84.00 | $ 98.56 | $ 86.24 | $ 90.72 | $ 100.80 | $ 100.80 | $ 82.43 | $ 89.60 | $ 89.60 | $ 89.60 | $ 82.43 | $ 100.80 |
| 30087798C | CDC COVID-19 STATE TEST | Laboratory | 300 | U0001 | $ 150.00 | $ 112.50 | $ 132.00 | $ 115.50 | $ 121.50 | $ 135.00 | $ 135.00 | $ 110.40 | $ 120.00 | $ 120.00 | $ 120.00 | $ 110.40 | $ 135.00 |
| 3000481 | CHLAMYDIA DNA PROBE | Laboratory | 306 | 87490 | $ 65.00 | $ 48.75 | $ 57.20 | $ 50.05 | $ 52.65 | $ 58.50 | $ 58.50 | $ 47.84 | $ 52.00 | $ 52.00 | $ 52.00 | $ 47.84 | $ 58.50 |
| 3001792 | CLOSTRIDIUM DIFFICILE TOXIN | Laboratory | 306 | 87324 | $ 78.00 | $ 58.50 | $ 68.64 | $ 60.06 | $ 63.18 | $ 70.20 | $ 70.20 | $ 57.41 | $ 62.40 | $ 62.40 | $ 62.40 | $ 57.41 | $ 70.20 |
| 3000157 | COCCIDIOIDES ANTIBODY | Laboratory | 300 | 86635 | $ 105.00 | $ 78.75 | $ 92.40 | $ 80.85 | $ 85.05 | $ 94.50 | $ 94.50 | $ 77.28 | $ 84.00 | $ 84.00 | $ 84.00 | $ 77.28 | $ 94.50 |
| 3000335 | COMPATIBILITY TEST ANTIGLOBULI | Laboratory | 390 | 86922 | $ 160.00 | $ 120.00 | $ 140.80 | $ 123.20 | $ 129.60 | $ 144.00 | $ 144.00 | $ 117.76 | $ 128.00 | $ 128.00 | $ 128.00 | $ 117.76 | $ 144.00 |
| 3000056 | COMPLEMENT C-4 | Laboratory | 300 | 86160 | $ 83.00 | $ 62.25 | $ 73.04 | $ 63.91 | $ 67.23 | $ 74.70 | $ 74.70 | $ 61.09 | $ 66.40 | $ 66.40 | $ 66.40 | $ 61.09 | $ 74.70 |
| 3000054 | COMPLEMENT COMPONENT C3C | Laboratory | 300 | 86160 | $ 83.00 | $ 62.25 | $ 73.04 | $ 63.91 | $ 67.23 | $ 74.70 | $ 74.70 | $ 61.09 | $ 66.40 | $ 66.40 | $ 66.40 | $ 61.09 | $ 74.70 |
| 3000152 | CORTISOL | Laboratory | 301 | 82533 | $ 129.00 | $ 96.75 | $ 113.52 | $ 99.33 | $ 104.49 | $ 116.10 | $ 116.10 | $ 94.94 | $ 103.20 | $ 103.20 | $ 103.20 | $ 94.94 | $ 116.10 |
| 30087798B | COVID-19 REFERENCE LAB | Laboratory | 300 | 87635 | $ 250.00 | $ 187.50 | $ 220.00 | $ 192.50 | $ 202.50 | $ 225.00 | $ 225.00 | $ 184.00 | $ 200.00 | $ 200.00 | $ 200.00 | $ 184.00 | $ 225.00 |
| 3000433 | C-REACTIVE PROTEIN | Laboratory | 302 | 86140 | $ 32.00 | $ 24.00 | $ 28.16 | $ 24.64 | $ 25.92 | $ 28.80 | $ 28.80 | $ 23.55 | $ 25.60 | $ 25.60 | $ 25.60 | $ 23.55 | $ 28.80 |
| 3000382 | CREATINE PHOSPHOKINASE (CPK) | Laboratory | 301 | 82550 | $ 49.00 | $ 36.75 | $ 43.12 | $ 37.73 | $ 39.69 | $ 44.10 | $ 44.10 | $ 36.06 | $ 39.20 | $ 39.20 | $ 39.20 | $ 36.06 | $ 44.10 |
| 3000381 | CREATININE, SERUM | Laboratory | 301 | 82565 | $ 40.00 | $ 30.00 | $ 35.20 | $ 30.80 | $ 32.40 | $ 36.00 | $ 36.00 | $ 29.44 | $ 32.00 | $ 32.00 | $ 32.00 | $ 29.44 | $ 36.00 |
| 3001549 | CREATININE, URINE | Laboratory | 301 | 82570 | $ 82.00 | $ 61.50 | $ 72.16 | $ 63.14 | $ 66.42 | $ 73.80 | $ 73.80 | $ 60.35 | $ 65.60 | $ 65.60 | $ 65.60 | $ 60.35 | $ 73.80 |
| 3000047 | CREATININE; OTHER SOURCE | Laboratory | 301 | 82570 | $ 82.00 | $ 61.50 | $ 72.16 | $ 63.14 | $ 66.42 | $ 73.80 | $ 73.80 | $ 60.35 | $ 65.60 | $ 65.60 | $ 65.60 | $ 60.35 | $ 73.80 |
| 30087899 | Cryptococcus Antigen | Laboratory | 300 | 87899 | $ 125.00 | $ 93.75 | $ 110.00 | $ 96.25 | $ 101.25 | $ 112.50 | $ 112.50 | $ 92.00 | $ 100.00 | $ 100.00 | $ 100.00 | $ 92.00 | $ 112.50 |
| 3000151 | CRYSTAL IDENTIFICATION | Laboratory | 300 | 89060 | $ 63.00 | $ 47.25 | $ 55.44 | $ 48.51 | $ 51.03 | $ 56.70 | $ 56.70 | $ 46.37 | $ 50.40 | $ 50.40 | $ 50.40 | $ 46.37 | $ 56.70 |
| 3000392 | CULTURE, BACTERIAL; BLOOD | Laboratory | 306 | 87040 | $ 163.00 | $ 122.25 | $ 143.44 | $ 125.51 | $ 132.03 | $ 146.70 | $ 146.70 | $ 119.97 | $ 130.40 | $ 130.40 | $ 130.40 | $ 119.97 | $ 146.70 |
| 3000352 | CULTURE: AEROBIC/ROUTINE/MISC | Laboratory | 306 | 87070 | $ 100.00 | $ 75.00 | $ 88.00 | $ 77.00 | $ 81.00 | $ 90.00 | $ 90.00 | $ 73.60 | $ 80.00 | $ 80.00 | $ 80.00 | $ 73.60 | $ 90.00 |
| 3001770 | CULTURE: ANAEROBIC MISC. | Laboratory | 306 | 87075 | $ 105.00 | $ 78.75 | $ 92.40 | $ 80.85 | $ 85.05 | $ 94.50 | $ 94.50 | $ 77.28 | $ 84.00 | $ 84.00 | $ 84.00 | $ 77.28 | $ 94.50 |
| 3000393 | CULTURE: THROAT | Laboratory | 306 | 87070 | $ 100.00 | $ 75.00 | $ 88.00 | $ 77.00 | $ 81.00 | $ 90.00 | $ 90.00 | $ 73.60 | $ 80.00 | $ 80.00 | $ 80.00 | $ 73.60 | $ 90.00 |
| 3000041 | CULTURE: URINE, CATH | Laboratory | 300 | 87088 | $ 32.00 | $ 24.00 | $ 28.16 | $ 24.64 | $ 25.92 | $ 28.80 | $ 28.80 | $ 23.55 | $ 25.60 | $ 25.60 | $ 25.60 | $ 23.55 | $ 28.80 |
| 3000394 | CULTURE; BACTERIAL WITH ISO | Laboratory | 306 | 87088 | $ 32.00 | $ 24.00 | $ 28.16 | $ 24.64 | $ 25.92 | $ 28.80 | $ 28.80 | $ 23.55 | $ 25.60 | $ 25.60 | $ 25.60 | $ 23.55 | $ 28.80 |
| 3000442 | CYANOCOBALAMIN (VITAMIN B-12) | Laboratory | 301 | 82607 | $ 50.00 | $ 37.50 | $ 44.00 | $ 38.50 | $ 40.50 | $ 45.00 | $ 45.00 | $ 36.80 | $ 40.00 | $ 40.00 | $ 40.00 | $ 36.80 | $ 45.00 |
| 30082610 | Cystatin C | Laboratory | 301 | 82610 | $ 175.00 | $ 131.25 | $ 154.00 | $ 134.75 | $ 141.75 | $ 157.50 | $ 157.50 | $ 128.80 | $ 140.00 | $ 140.00 | $ 140.00 | $ 128.80 | $ 157.50 |
| 3000133 | DHEA SULFATE | Laboratory | 301 | 82627 | $ 122.00 | $ 91.50 | $ 107.36 | $ 93.94 | $ 98.82 | $ 109.80 | $ 109.80 | $ 89.79 | $ 97.60 | $ 97.60 | $ 97.60 | $ 89.79 | $ 109.80 |
| 3000194 | DIRECT LDL | Laboratory | 301 | 83721 | $ 41.00 | $ 30.75 | $ 36.08 | $ 31.57 | $ 33.21 | $ 36.90 | $ 36.90 | $ 30.18 | $ 32.80 | $ 32.80 | $ 32.80 | $ 30.18 | $ 36.90 |
| CHARGE CODE | DESCRIPTION | Department | REV CODE | CPT CODE | RATE | Cash Pay | Aetna | BCBS TX - Blue Advantage | BCBS TX Blue Essentials | BCBS TX PPO | BCBS TX Trad | CIGNA | Humana | Unicare | United | Minimum Negotiated Charge | Maximum Negotiated Charge |
| 3000484 | DNA ANTIBODY DOUBLE STANDED | Laboratory | 300 | 86225 | $ 71.00 | $ 53.25 | $ 62.48 | $ 54.67 | $ 57.51 | $ 63.90 | $ 63.90 | $ 52.26 | $ 56.80 | $ 56.80 | $ 56.80 | $ 52.26 | $ 63.90 |
| 3001763 | DRUG SCREEN | Laboratory | 301 | 80305 | $ 56.00 | $ 42.00 | $ 49.28 | $ 43.12 | $ 45.36 | $ 50.40 | $ 50.40 | $ 41.22 | $ 44.80 | $ 44.80 | $ 44.80 | $ 41.22 | $ 50.40 |
| 3000405 | DRUG SCREEN | Laboratory | 301 | 80306 | $ 56.00 | $ 42.00 | $ 49.28 | $ 43.12 | $ 45.36 | $ 50.40 | $ 50.40 | $ 41.22 | $ 44.80 | $ 44.80 | $ 44.80 | $ 41.22 | $ 50.40 |
| 3001764 | DRUG SCREEN: COLLECTION ONLY | Laboratory | 301 | 80305 | $ 26.00 | $ 19.50 | $ 22.88 | $ 20.02 | $ 21.06 | $ 23.40 | $ 23.40 | $ 19.14 | $ 20.80 | $ 20.80 | $ 20.80 | $ 19.14 | $ 23.40 |
| 3000491 | ESTRADIOL | Laboratory | 300 | 82670 | $ 116.00 | $ 87.00 | $ 102.08 | $ 89.32 | $ 93.96 | $ 104.40 | $ 104.40 | $ 85.38 | $ 92.80 | $ 92.80 | $ 92.80 | $ 85.38 | $ 104.40 |
| 3000446 | ETHANOL (BLOOD ALCOHOL) | Laboratory | 301 | G0480 | $ 87.00 | $ 65.25 | $ 76.56 | $ 66.99 | $ 70.47 | $ 78.30 | $ 78.30 | $ 64.03 | $ 69.60 | $ 69.60 | $ 69.60 | $ 64.03 | $ 78.30 |
| 3000371 | FERRINTIN, SERUM | Laboratory | 301 | 82728 | $ 79.00 | $ 59.25 | $ 69.52 | $ 60.83 | $ 63.99 | $ 71.10 | $ 71.10 | $ 58.14 | $ 63.20 | $ 63.20 | $ 63.20 | $ 58.14 | $ 71.10 |
| 3000703 | FIBRIN DEGRADATION D-DIMER | Laboratory | 305 | 85379 | $ 151.00 | $ 113.25 | $ 132.88 | $ 116.27 | $ 122.31 | $ 135.90 | $ 135.90 | $ 111.14 | $ 120.80 | $ 120.80 | $ 120.80 | $ 111.14 | $ 135.90 |
| 3000487 | FOLATE STIMULATING HORMONE,FSH | Laboratory | 301 | 83001 | $ 70.00 | $ 52.50 | $ 61.60 | $ 53.90 | $ 56.70 | $ 63.00 | $ 63.00 | $ 51.52 | $ 56.00 | $ 56.00 | $ 56.00 | $ 51.52 | $ 63.00 |
| 3000441 | FOLATE, SERUM | Laboratory | 301 | 82746 | $ 87.00 | $ 65.25 | $ 76.56 | $ 66.99 | $ 70.47 | $ 78.30 | $ 78.30 | $ 64.03 | $ 69.60 | $ 69.60 | $ 69.60 | $ 64.03 | $ 78.30 |
| 3000104 | FREE TESTOSTERONE | Laboratory | 301 | 84402 | $ 236.00 | $ 177.00 | $ 207.68 | $ 181.72 | $ 191.16 | $ 212.40 | $ 212.40 | $ 173.70 | $ 188.80 | $ 188.80 | $ 188.80 | $ 173.70 | $ 212.40 |
| 3000356 | GASES, BLOOD ANY COMBINATION | Laboratory | 301 | 82803 | $ 259.00 | $ 194.25 | $ 227.92 | $ 199.43 | $ 209.79 | $ 233.10 | $ 233.10 | $ 190.62 | $ 207.20 | $ 207.20 | $ 207.20 | $ 190.62 | $ 233.10 |
| 3000479 | GC DNA PROBE | Laboratory | 306 | 87590 | $ 61.00 | $ 45.75 | $ 53.68 | $ 46.97 | $ 49.41 | $ 54.90 | $ 54.90 | $ 44.90 | $ 48.80 | $ 48.80 | $ 48.80 | $ 44.90 | $ 54.90 |
| 3000498 | GENTAMICIN | Laboratory | 300 | 80170 | $ 84.00 | $ 63.00 | $ 73.92 | $ 64.68 | $ 68.04 | $ 75.60 | $ 75.60 | $ 61.82 | $ 67.20 | $ 67.20 | $ 67.20 | $ 61.82 | $ 75.60 |
| 30087507 | GI profile, Stool PCR | Laboratory | 306 | 87507 | $ 1,060.00 | $ 795.00 | $ 932.80 | $ 816.20 | $ 858.60 | $ 954.00 | $ 954.00 | $ 780.16 | $ 848.00 | $ 800.00 | $ 848.00 | $ 780.16 | $ 954.00 |
| 2700361 | GLUCOSE BLOOD, REAGENT STRIP | Laboratory | 301 | 82948 | $ 23.00 | $ 17.25 | $ 20.24 | $ 17.71 | $ 18.63 | $ 20.70 | $ 20.70 | $ 16.93 | $ 18.40 | $ 18.40 | $ 18.40 | $ 16.93 | $ 20.70 |
| 3000387 | GLUCOSE TLERANCE 1 HR | Laboratory | 301 | 82947 | $ 78.00 | $ 58.50 | $ 68.64 | $ 60.06 | $ 63.18 | $ 70.20 | $ 70.20 | $ 57.41 | $ 62.40 | $ 62.40 | $ 62.40 | $ 57.41 | $ 70.20 |
| 3000388 | GLUCOSE TOLERANCE MAXINMUM | Laboratory | 301 | 82951 | $ 147.00 | $ 110.25 | $ 129.36 | $ 113.19 | $ 119.07 | $ 132.30 | $ 132.30 | $ 108.19 | $ 117.60 | $ 117.60 | $ 117.60 | $ 108.19 | $ 132.30 |
| 3000389 | GRAM STAIN | Laboratory | 306 | 87205 | $ 25.00 | $ 18.75 | $ 22.00 | $ 19.25 | $ 20.25 | $ 22.50 | $ 22.50 | $ 18.40 | $ 20.00 | $ 20.00 | $ 20.00 | $ 18.40 | $ 22.50 |
| 30083014 | H PYLORI ADMINISTRATION | Laboratory | 301 | 83014 | $ 35.00 | $ 26.25 | $ 30.80 | $ 26.95 | $ 28.35 | $ 31.50 | $ 31.50 | $ 25.76 | $ 28.00 | $ 28.00 | $ 28.00 | $ 25.76 | $ 31.50 |
| 30083013 | H PYLORI BREATH TEST | Laboratory | 301 | 83013 | $ 302.00 | $ 226.50 | $ 265.76 | $ 232.54 | $ 244.62 | $ 271.80 | $ 271.80 | $ 222.27 | $ 241.60 | $ 241.60 | $ 241.60 | $ 222.27 | $ 271.80 |
| 3000473 | HCG BETA QUANTITATIVE | Laboratory | 301 | 84702 | $ 77.00 | $ 57.75 | $ 67.76 | $ 59.29 | $ 62.37 | $ 69.30 | $ 69.30 | $ 56.67 | $ 61.60 | $ 61.60 | $ 61.60 | $ 56.67 | $ 69.30 |
| 3000295 | HEMATOCRIT (HCT) | Laboratory | 305 | 85014 | $ 15.00 | $ 11.25 | $ 13.20 | $ 11.55 | $ 12.15 | $ 13.50 | $ 13.50 | $ 11.04 | $ 12.00 | $ 12.00 | $ 12.00 | $ 11.04 | $ 13.50 |
| 3000297 | HEMOGLOBIN (HGB) | Laboratory | 305 | 85018 | $ 15.00 | $ 11.25 | $ 13.20 | $ 11.55 | $ 12.15 | $ 13.50 | $ 13.50 | $ 11.04 | $ 12.00 | $ 12.00 | $ 12.00 | $ 11.04 | $ 13.50 |
| 3000413 | HEMOGLOBIN GLYCOSYLATED (A1C) | Laboratory | 301 | 83036 | $ 72.00 | $ 54.00 | $ 63.36 | $ 55.44 | $ 58.32 | $ 64.80 | $ 64.80 | $ 52.99 | $ 57.60 | $ 57.60 | $ 57.60 | $ 52.99 | $ 64.80 |
| 3000454 | HEPATITIS A AB IGG/IGM | Laboratory | 302 | 86708 | $ 63.00 | $ 47.25 | $ 55.44 | $ 48.51 | $ 51.03 | $ 56.70 | $ 56.70 | $ 46.37 | $ 50.40 | $ 50.40 | $ 50.40 | $ 46.37 | $ 56.70 |
| 3000510 | HEPATITIS B CORE AB, IGG, IGM | Laboratory | 302 | 86704 | $ 68.00 | $ 51.00 | $ 59.84 | $ 52.36 | $ 55.08 | $ 61.20 | $ 61.20 | $ 50.05 | $ 54.40 | $ 54.40 | $ 54.40 | $ 50.05 | $ 61.20 |
| 3000512 | HEPATITIS B SURFACE AB HBSAB | Laboratory | 302 | 86706 | $ 68.00 | $ 51.00 | $ 59.84 | $ 52.36 | $ 55.08 | $ 61.20 | $ 61.20 | $ 50.05 | $ 54.40 | $ 54.40 | $ 54.40 | $ 50.05 | $ 61.20 |
| 3000514 | HEPATITIS B SURFACE AG HBSAG | Laboratory | 300 | 87340 | $ 68.00 | $ 51.00 | $ 59.84 | $ 52.36 | $ 55.08 | $ 61.20 | $ 61.20 | $ 50.05 | $ 54.40 | $ 54.40 | $ 54.40 | $ 50.05 | $ 61.20 |
| 3000344 | HEPATITIS B SURFACE ANTIBODY | Laboratory | 300 | 86706 | $ 68.00 | $ 51.00 | $ 59.84 | $ 52.36 | $ 55.08 | $ 61.20 | $ 61.20 | $ 50.05 | $ 54.40 | $ 54.40 | $ 54.40 | $ 50.05 | $ 61.20 |
| 3000508 | HEPATITIS C AB | Laboratory | 300 | 86803 | $ 68.00 | $ 51.00 | $ 59.84 | $ 52.36 | $ 55.08 | $ 61.20 | $ 61.20 | $ 50.05 | $ 54.40 | $ 54.40 | $ 54.40 | $ 50.05 | $ 61.20 |
| 3000900 | HEPATITIS C ANTIBODY | Laboratory | 302 | 86803 | $ 68.00 | $ 51.00 | $ 59.84 | $ 52.36 | $ 55.08 | $ 61.20 | $ 61.20 | $ 50.05 | $ 54.40 | $ 54.40 | $ 54.40 | $ 50.05 | $ 61.20 |
| 30087385 | Histoplasma Antigen, Urine | Laboratory | 300 | 87385 | $ 200.00 | $ 150.00 | $ 176.00 | $ 154.00 | $ 162.00 | $ 180.00 | $ 180.00 | $ 147.20 | $ 160.00 | $ 160.00 | $ 160.00 | $ 147.20 | $ 180.00 |
| 3000434 | HIV | Laboratory | 302 | 86701 | $ 61.00 | $ 45.75 | $ 53.68 | $ 46.97 | $ 49.41 | $ 54.90 | $ 54.90 | $ 44.90 | $ 48.80 | $ 48.80 | $ 48.80 | $ 44.90 | $ 54.90 |
| 3000427 | HLAB 27 ANTIGEN | Laboratory | 300 | 86812 | $ 137.00 | $ 102.75 | $ 120.56 | $ 105.49 | $ 110.97 | $ 123.30 | $ 123.30 | $ 100.83 | $ 109.60 | $ 109.60 | $ 109.60 | $ 100.83 | $ 123.30 |
| 3000057 | IGA | Laboratory | 301 | 82784 | $ 72.00 | $ 54.00 | $ 63.36 | $ 55.44 | $ 58.32 | $ 64.80 | $ 64.80 | $ 52.99 | $ 57.60 | $ 57.60 | $ 57.60 | $ 52.99 | $ 64.80 |
| 3001798 | IGE | Laboratory | 301 | 82785 | $ 150.00 | $ 112.50 | $ 132.00 | $ 115.50 | $ 121.50 | $ 135.00 | $ 135.00 | $ 110.40 | $ 120.00 | $ 120.00 | $ 120.00 | $ 110.40 | $ 135.00 |
| 3000494 | IGG | Laboratory | 301 | 82784 | $ 72.00 | $ 54.00 | $ 63.36 | $ 55.44 | $ 58.32 | $ 64.80 | $ 64.80 | $ 52.99 | $ 57.60 | $ 57.60 | $ 57.60 | $ 52.99 | $ 64.80 |
| 30016743 | IGM | Laboratory | 300 | 82784 | $ 72.00 | $ 54.00 | $ 63.36 | $ 55.44 | $ 58.32 | $ 64.80 | $ 64.80 | $ 52.99 | $ 57.60 | $ 57.60 | $ 57.60 | $ 52.99 | $ 64.80 |
| 3000562 | INFLUENZA A & B | Laboratory | 306 | 87804 | $ 63.00 | $ 47.25 | $ 55.44 | $ 48.51 | $ 51.03 | $ 56.70 | $ 56.70 | $ 46.37 | $ 50.40 | $ 50.40 | $ 50.40 | $ 46.37 | $ 56.70 |
| 5200186 | INFLUENZA SWAB | Laboratory | 306 | 87804 | $ 63.00 | $ 47.25 | $ 55.44 | $ 48.51 | $ 51.03 | $ 56.70 | $ 56.70 | $ 46.37 | $ 50.40 | $ 50.40 | $ 50.40 | $ 46.37 | $ 56.70 |
| 3000042 | INSULIN | Laboratory | 301 | 83525 | $ 72.00 | $ 54.00 | $ 63.36 | $ 55.44 | $ 58.32 | $ 64.80 | $ 64.80 | $ 52.99 | $ 57.60 | $ 57.60 | $ 57.60 | $ 52.99 | $ 64.80 |
| 3000438 | IRON AND TIBC | Laboratory | 301 | 83550 | $ 45.00 | $ 33.75 | $ 39.60 | $ 34.65 | $ 36.45 | $ 40.50 | $ 40.50 | $ 33.12 | $ 36.00 | $ 36.00 | $ 36.00 | $ 33.12 | $ 40.50 |
| 3000189 | KEPPRA LEVEL | Laboratory | 301 | 80177 | $ 93.00 | $ 69.75 | $ 81.84 | $ 71.61 | $ 75.33 | $ 83.70 | $ 83.70 | $ 68.45 | $ 74.40 | $ 74.40 | $ 74.40 | $ 68.45 | $ 83.70 |
| 3000301 | LACTATE DEHYDROGENASE (LDH) | Laboratory | 301 | 83615 | $ 44.00 | $ 33.00 | $ 38.72 | $ 33.88 | $ 35.64 | $ 39.60 | $ 39.60 | $ 32.38 | $ 35.20 | $ 35.20 | $ 35.20 | $ 32.38 | $ 39.60 |
| 30083605 | Lactic Acid | Laboratory | 301 | 83605 | $ 32.00 | $ 24.00 | $ 28.16 | $ 24.64 | $ 25.92 | $ 28.80 | $ 28.80 | $ 23.55 | $ 25.60 | $ 25.60 | $ 25.60 | $ 23.55 | $ 28.80 |
| 30016333 | LEAD LEVEL BLOOD | Laboratory | 301 | 83655 | $ 78.00 | $ 58.50 | $ 68.64 | $ 60.06 | $ 63.18 | $ 70.20 | $ 70.20 | $ 57.41 | $ 62.40 | $ 62.40 | $ 62.40 | $ 57.41 | $ 70.20 |
| 3000486 | LIPASE | Laboratory | 301 | 83690 | $ 67.00 | $ 50.25 | $ 58.96 | $ 51.59 | $ 54.27 | $ 60.30 | $ 60.30 | $ 49.31 | $ 53.60 | $ 53.60 | $ 53.60 | $ 49.31 | $ 60.30 |
| 3000307 | LITHIUM LEVEL | Laboratory | 301 | 80178 | $ 48.00 | $ 36.00 | $ 42.24 | $ 36.96 | $ 38.88 | $ 43.20 | $ 43.20 | $ 35.33 | $ 38.40 | $ 38.40 | $ 38.40 | $ 35.33 | $ 43.20 |
| 3000488 | LUTEINIZING HORMONE (LH) | Laboratory | 300 | 83002 | $ 85.00 | $ 63.75 | $ 74.80 | $ 65.45 | $ 68.85 | $ 76.50 | $ 76.50 | $ 62.56 | $ 68.00 | $ 68.00 | $ 68.00 | $ 62.56 | $ 76.50 |
| 3000304 | MAGNESIUM-R | Laboratory | 301 | 83735 | $ 49.00 | $ 36.75 | $ 43.12 | $ 37.73 | $ 39.69 | $ 44.10 | $ 44.10 | $ 36.06 | $ 39.20 | $ 39.20 | $ 39.20 | $ 36.06 | $ 44.10 |
| 3000380 | MB FRACTION ONLY | Laboratory | 301 | 82553 | $ 181.00 | $ 135.75 | $ 159.28 | $ 139.37 | $ 146.61 | $ 162.90 | $ 162.90 | $ 133.22 | $ 144.80 | $ 144.80 | $ 144.80 | $ 133.22 | $ 162.90 |
| 3000306 | MONO TEST | Laboratory | 302 | 86308 | $ 30.00 | $ 22.50 | $ 26.40 | $ 23.10 | $ 24.30 | $ 27.00 | $ 27.00 | $ 22.08 | $ 24.00 | $ 24.00 | $ 24.00 | $ 22.08 | $ 27.00 |
| 30086735 | MUMPS AB (ANTIBODY) | Laboratory | 302 | 86735 | $ 65.00 | $ 48.75 | $ 57.20 | $ 50.05 | $ 52.65 | $ 58.50 | $ 58.50 | $ 47.84 | $ 52.00 | $ 52.00 | $ 52.00 | $ 47.84 | $ 58.50 |
| 3000046 | NATRIURETIC PEPTIDE | Laboratory | 301 | 83880 | $ 194.00 | $ 145.50 | $ 170.72 | $ 149.38 | $ 157.14 | $ 174.60 | $ 174.60 | $ 142.78 | $ 155.20 | $ 155.20 | $ 155.20 | $ 142.78 | $ 174.60 |
| 3000459 | PANEL: GENERAL HEALTH | Laboratory | 300 | 80050 | $ 495.00 | $ 371.25 | $ 435.60 | $ 381.15 | $ 400.95 | $ 445.50 | $ 445.50 | $ 364.32 | $ 396.00 | $ 396.00 | $ 396.00 | $ 364.32 | $ 445.50 |
| 3000424 | PANEL: HEPATITIS ABC ACUTE | Laboratory | 301 | 80074 | $ 259.00 | $ 194.25 | $ 227.92 | $ 199.43 | $ 209.79 | $ 233.10 | $ 233.10 | $ 190.62 | $ 207.20 | $ 207.20 | $ 207.20 | $ 190.62 | $ 233.10 |
| 3000443 | PAP SMEAR | Laboratory | 311 | 88142 | $ 44.00 | $ 33.00 | $ 38.72 | $ 33.88 | $ 35.64 | $ 39.60 | $ 39.60 | $ 32.38 | $ 35.20 | $ 35.20 | $ 35.20 | $ 32.38 | $ 39.60 |
| 3000398 | PHENYTOIN (DILANTIN) | Laboratory | 301 | 80185 | $ 81.00 | $ 60.75 | $ 71.28 | $ 62.37 | $ 65.61 | $ 72.90 | $ 72.90 | $ 59.62 | $ 64.80 | $ 64.80 | $ 64.80 | $ 59.62 | $ 72.90 |
| 3000314 | PHOSPHORUS (PO4) | Laboratory | 301 | 84100 | $ 33.00 | $ 24.75 | $ 29.04 | $ 25.41 | $ 26.73 | $ 29.70 | $ 29.70 | $ 24.29 | $ 26.40 | $ 26.40 | $ 26.40 | $ 24.29 | $ 29.70 |
| 3000464 | PREGNANCY TEST SERUM | Laboratory | 301 | 84703 | $ 37.00 | $ 27.75 | $ 32.56 | $ 28.49 | $ 29.97 | $ 33.30 | $ 33.30 | $ 27.23 | $ 29.60 | $ 29.60 | $ 29.60 | $ 27.23 | $ 33.30 |
| CHARGE CODE | DESCRIPTION | Department | REV CODE | CPT CODE | RATE | Cash Pay | Aetna | BCBS TX - Blue Advantage | BCBS TX Blue Essentials | BCBS TX PPO | BCBS TX Trad | CIGNA | Humana | Unicare | United | Minimum Negotiated Charge | Maximum Negotiated Charge |
| 3000425 | PREGNANCY TEST URINE | Laboratory | 307 | 81025 | $ 37.00 | $ 27.75 | $ 32.56 | $ 28.49 | $ 29.97 | $ 33.30 | $ 33.30 | $ 27.23 | $ 29.60 | $ 29.60 | $ 29.60 | $ 27.23 | $ 33.30 |
| 30084145 | Procalcitonin | Laboratory | 301 | 84145 | $ 530.00 | $ 397.50 | $ 466.40 | $ 408.10 | $ 429.30 | $ 477.00 | $ 477.00 | $ 390.08 | $ 424.00 | $ 424.00 | $ 424.00 | $ 390.08 | $ 477.00 |
| 3000501 | PROGESTERONE | Laboratory | 301 | 84144 | $ 72.00 | $ 54.00 | $ 63.36 | $ 55.44 | $ 58.32 | $ 64.80 | $ 64.80 | $ 52.99 | $ 57.60 | $ 57.60 | $ 57.60 | $ 52.99 | $ 64.80 |
| 3000411 | PROLACTIN | Laboratory | 301 | 84146 | $ 88.00 | $ 66.00 | $ 77.44 | $ 67.76 | $ 71.28 | $ 79.20 | $ 79.20 | $ 64.77 | $ 70.40 | $ 70.40 | $ 70.40 | $ 64.77 | $ 79.20 |
| 3000340 | PROTEIN URINE 24 HR | Laboratory | 301 | 84156 | $ 41.00 | $ 30.75 | $ 36.08 | $ 31.57 | $ 33.21 | $ 36.90 | $ 36.90 | $ 30.18 | $ 32.80 | $ 32.80 | $ 32.80 | $ 30.18 | $ 36.90 |
| 3000321 | PSA ANNUAL SCN | Laboratory | 309 | G0103 | $ 171.00 | $ 128.25 | $ 150.48 | $ 131.67 | $ 138.51 | $ 153.90 | $ 153.90 | $ 125.86 | $ 136.80 | $ 136.80 | $ 136.80 | $ 125.86 | $ 153.90 |
| 3000208 | PTH,INTACT & CALCIUM | Laboratory | 301 | 83970 | $ 137.00 | $ 102.75 | $ 120.56 | $ 105.49 | $ 110.97 | $ 123.30 | $ 123.30 | $ 100.83 | $ 109.60 | $ 109.60 | $ 109.60 | $ 100.83 | $ 123.30 |
| 30086480 | QUANTIFERON | Laboratory | 302 | 86480 | $ 274.00 | $ 205.50 | $ 241.12 | $ 210.98 | $ 221.94 | $ 246.60 | $ 246.60 | $ 201.66 | $ 219.20 | $ 219.20 | $ 219.20 | $ 201.66 | $ 246.60 |
| 3000327 | RHEUMATOID ARTHRITIS QUALITATI | Laboratory | 302 | 86430 | $ 28.00 | $ 21.00 | $ 24.64 | $ 21.56 | $ 22.68 | $ 25.20 | $ 25.20 | $ 20.61 | $ 22.40 | $ 22.40 | $ 22.40 | $ 20.61 | $ 25.20 |
| 3000483 | RHEUMATOID ARTHRITIS QUANTITAT | Laboratory | 300 | 86431 | $ 27.00 | $ 20.25 | $ 23.76 | $ 20.79 | $ 21.87 | $ 24.30 | $ 24.30 | $ 19.87 | $ 21.60 | $ 21.60 | $ 21.60 | $ 19.87 | $ 24.30 |
| 3000326 | RPR (RAPID PLASMA REAGIN) | Laboratory | 302 | 86592 | $ 29.00 | $ 21.75 | $ 25.52 | $ 22.33 | $ 23.49 | $ 26.10 | $ 26.10 | $ 21.34 | $ 23.20 | $ 23.20 | $ 23.20 | $ 21.34 | $ 26.10 |
| 3000124 | RSV NASAL SWAB | Laboratory | 302 | 86756 | $ 94.00 | $ 70.50 | $ 82.72 | $ 72.38 | $ 76.14 | $ 84.60 | $ 84.60 | $ 69.18 | $ 75.20 | $ 75.20 | $ 75.20 | $ 69.18 | $ 84.60 |
| 3000406 | RUBELLA AB | Laboratory | 302 | 86762 | $ 100.00 | $ 75.00 | $ 88.00 | $ 77.00 | $ 81.00 | $ 90.00 | $ 90.00 | $ 73.60 | $ 80.00 | $ 80.00 | $ 80.00 | $ 73.60 | $ 90.00 |
| 3001724 | RUBELLA AB (IMMUNITY) | Laboratory | 302 | 86762 | $ 100.00 | $ 75.00 | $ 88.00 | $ 77.00 | $ 81.00 | $ 90.00 | $ 90.00 | $ 73.60 | $ 80.00 | $ 80.00 | $ 80.00 | $ 73.60 | $ 90.00 |
| 3000403 | RUBEOLA AB | Laboratory | 302 | 86765 | $ 63.00 | $ 47.25 | $ 55.44 | $ 48.51 | $ 51.03 | $ 56.70 | $ 56.70 | $ 46.37 | $ 50.40 | $ 50.40 | $ 50.40 | $ 46.37 | $ 56.70 |
| 3000196 | SALICYLATE LEVEL | Laboratory | 301 | 80299 | $ 93.00 | $ 69.75 | $ 81.84 | $ 71.61 | $ 75.33 | $ 83.70 | $ 83.70 | $ 68.45 | $ 74.40 | $ 74.40 | $ 74.40 | $ 68.45 | $ 83.70 |
| 3000328 | SEDIMENTATION RATE | Laboratory | 305 | 85651 | $ 52.00 | $ 39.00 | $ 45.76 | $ 40.04 | $ 42.12 | $ 46.80 | $ 46.80 | $ 38.27 | $ 41.60 | $ 41.60 | $ 41.60 | $ 38.27 | $ 46.80 |
| 3000538 | SJORGREN'S ANTIBODIES(SSA,SSB) | Laboratory | 302 | 86235 | $ 151.00 | $ 113.25 | $ 132.88 | $ 116.27 | $ 122.31 | $ 135.90 | $ 135.90 | $ 111.14 | $ 120.80 | $ 120.80 | $ 120.80 | $ 111.14 | $ 135.90 |
| 3001396 | STREPTOCOCCUS, GROUP A | Laboratory | 306 | 87430 | $ 74.00 | $ 55.50 | $ 65.12 | $ 56.98 | $ 59.94 | $ 66.60 | $ 66.60 | $ 54.46 | $ 59.20 | $ 59.20 | $ 59.20 | $ 54.46 | $ 66.60 |
| 3000705 | SUSCEPTIBILITY STUDIES | Laboratory | 306 | 87186 | $ 88.00 | $ 66.00 | $ 77.44 | $ 67.76 | $ 71.28 | $ 79.20 | $ 79.20 | $ 64.77 | $ 70.40 | $ 70.40 | $ 70.40 | $ 64.77 | $ 79.20 |
| 3000742 | T UPTAKE | Laboratory | 301 | 84479 | $ 31.00 | $ 23.25 | $ 27.28 | $ 23.87 | $ 25.11 | $ 27.90 | $ 27.90 | $ 22.82 | $ 24.80 | $ 24.80 | $ 24.80 | $ 22.82 | $ 27.90 |
| 3000419 | T-3 (TOTAL) | Laboratory | 301 | 84480 | $ 46.00 | $ 34.50 | $ 40.48 | $ 35.42 | $ 37.26 | $ 41.40 | $ 41.40 | $ 33.86 | $ 36.80 | $ 36.80 | $ 36.80 | $ 33.86 | $ 41.40 |
| 3000471 | T-3 FREE | Laboratory | 301 | 84481 | $ 125.00 | $ 93.75 | $ 110.00 | $ 96.25 | $ 101.25 | $ 112.50 | $ 112.50 | $ 92.00 | $ 100.00 | $ 100.00 | $ 100.00 | $ 92.00 | $ 112.50 |
| 3000348 | T-4 (TOTAL) | Laboratory | 301 | 84436 | $ 31.00 | $ 23.25 | $ 27.28 | $ 23.87 | $ 25.11 | $ 27.90 | $ 27.90 | $ 22.82 | $ 24.80 | $ 24.80 | $ 24.80 | $ 22.82 | $ 27.90 |
| 30080197 | Tacrolimus (Prograft) Level | Laboratory | 301 | 80197 | $ 129.00 | $ 96.75 | $ 113.52 | $ 99.33 | $ 104.49 | $ 116.10 | $ 116.10 | $ 94.94 | $ 103.20 | $ 103.20 | $ 103.20 | $ 94.94 | $ 116.10 |
| 3000313 | TESTOSTERONE | Laboratory | 301 | 84403 | $ 119.00 | $ 89.25 | $ 104.72 | $ 91.63 | $ 96.39 | $ 107.10 | $ 107.10 | $ 87.58 | $ 95.20 | $ 95.20 | $ 95.20 | $ 87.58 | $ 107.10 |
| 3000346 | THYROID PEROXIDASE | Laboratory | 302 | 86376 | $ 111.00 | $ 83.25 | $ 97.68 | $ 85.47 | $ 89.91 | $ 99.90 | $ 99.90 | $ 81.70 | $ 88.80 | $ 88.80 | $ 88.80 | $ 81.70 | $ 99.90 |
| 3000476 | THYROXINE; FREE | Laboratory | 301 | 84439 | $ 93.00 | $ 69.75 | $ 81.84 | $ 71.61 | $ 75.33 | $ 83.70 | $ 83.70 | $ 68.45 | $ 74.40 | $ 74.40 | $ 74.40 | $ 68.45 | $ 83.70 |
| 3000395 | TISSUE COLLECTION PROCESS | Laboratory | 310 | 88300 | $ 84.00 | $ 63.00 | $ 73.92 | $ 64.68 | $ 68.04 | $ 75.60 | $ 75.60 | $ 61.82 | $ 67.20 | $ 67.20 | $ 67.20 | $ 61.82 | $ 75.60 |
| 3000532 | TISSUE PROCESSED | Laboratory | 310 | 88305 | $ 102.00 | $ 76.50 | $ 89.76 | $ 78.54 | $ 82.62 | $ 91.80 | $ 91.80 | $ 75.07 | $ 81.60 | $ 81.60 | $ 81.60 | $ 75.07 | $ 91.80 |
| 30083516 | TRANSGLUTAMINASE | Laboratory | 301 | 83516 | $ 151.00 | $ 113.25 | $ 132.88 | $ 116.27 | $ 122.31 | $ 135.90 | $ 135.90 | $ 111.14 | $ 120.80 | $ 120.80 | $ 120.80 | $ 111.14 | $ 135.90 |
| 3000334 | TRIGLYCERIDES | Laboratory | 300 | 84478 | $ 41.00 | $ 30.75 | $ 36.08 | $ 31.57 | $ 33.21 | $ 36.90 | $ 36.90 | $ 30.18 | $ 32.80 | $ 32.80 | $ 32.80 | $ 30.18 | $ 36.90 |
| 3001840 | TROPONIN, QUALITATIVE | Laboratory | 301 | 84512 | $ 193.00 | $ 144.75 | $ 169.84 | $ 148.61 | $ 156.33 | $ 173.70 | $ 173.70 | $ 142.05 | $ 154.40 | $ 154.40 | $ 154.40 | $ 142.05 | $ 173.70 |
| 3000336 | URIC ACID | Laboratory | 301 | 84550 | $ 37.00 | $ 27.75 | $ 32.56 | $ 28.49 | $ 29.97 | $ 33.30 | $ 33.30 | $ 27.23 | $ 29.60 | $ 29.60 | $ 29.60 | $ 27.23 | $ 33.30 |
| 3000560 | URIC ACID | Laboratory | 300 | 84560 | $ 44.00 | $ 33.00 | $ 38.72 | $ 33.88 | $ 35.64 | $ 39.60 | $ 39.60 | $ 32.38 | $ 35.20 | $ 35.20 | $ 35.20 | $ 32.38 | $ 39.60 |
| 3000188 | URINE OSMOLALITY | Laboratory | 300 | 83935 | $ 88.00 | $ 66.00 | $ 77.44 | $ 67.76 | $ 71.28 | $ 79.20 | $ 79.20 | $ 64.77 | $ 70.40 | $ 70.40 | $ 70.40 | $ 64.77 | $ 79.20 |
| 3000311 | VALPORIC ACID DEPAKNE, VALPRO | Laboratory | 301 | 80164 | $ 84.00 | $ 63.00 | $ 73.92 | $ 64.68 | $ 68.04 | $ 75.60 | $ 75.60 | $ 61.82 | $ 67.20 | $ 67.20 | $ 67.20 | $ 61.82 | $ 75.60 |
| 3000565 | VARECILLA ZOSTER IGG | Laboratory | 302 | 86787 | $ 93.00 | $ 69.75 | $ 81.84 | $ 71.61 | $ 75.33 | $ 83.70 | $ 83.70 | $ 68.45 | $ 74.40 | $ 74.40 | $ 74.40 | $ 68.45 | $ 83.70 |
| 3000200 | VARICELLA TITER IGM | Laboratory | 300 | 86787 | $ 93.00 | $ 69.75 | $ 81.84 | $ 71.61 | $ 75.33 | $ 83.70 | $ 83.70 | $ 68.45 | $ 74.40 | $ 74.40 | $ 74.40 | $ 68.45 | $ 83.70 |
| 3000148 | VIRUS CULTURE | Laboratory | 306 | 87252 | $ 288.00 | $ 216.00 | $ 253.44 | $ 221.76 | $ 233.28 | $ 259.20 | $ 259.20 | $ 211.97 | $ 230.40 | $ 230.40 | $ 230.40 | $ 211.97 | $ 259.20 |
| 3000155 | VITAMIN D 1.25 DIHYDROXY | Laboratory | 301 | 82652 | $ 156.00 | $ 117.00 | $ 137.28 | $ 120.12 | $ 126.36 | $ 140.40 | $ 140.40 | $ 114.82 | $ 124.80 | $ 124.80 | $ 124.80 | $ 114.82 | $ 140.40 |
| 3001550 | WET MOUNT SMEAR | Laboratory | 306 | 87210 | $ 24.00 | $ 18.00 | $ 21.12 | $ 18.48 | $ 19.44 | $ 21.60 | $ 21.60 | $ 17.66 | $ 19.20 | $ 19.20 | $ 19.20 | $ 17.66 | $ 21.60 |
| 42097535 | ADLS / 15MIN | Physical Therapy | 420 | 97535 | $ 44.00 | $ 33.00 | $ 38.72 | $ 33.88 | $ 35.64 | $ 39.60 | $ 39.60 | $ 32.38 | $ 35.20 | $ 35.20 | $ 35.20 | $ 32.38 | $ 39.60 |
| 42097032 | ELECT. STIM / 15MIN. | Physical Therapy | 420 | 97032 | $ 38.00 | $ 28.50 | $ 33.44 | $ 29.26 | $ 30.78 | $ 34.20 | $ 34.20 | $ 27.97 | $ 30.40 | $ 30.40 | $ 30.40 | $ 27.97 | $ 34.20 |
| 4201802 | EVAL REASSEMMENT ( EA 0-15 | Physical Therapy | 421 | 97164 | $ 51.00 | $ 38.25 | $ 44.88 | $ 39.27 | $ 41.31 | $ 45.90 | $ 45.90 | $ 37.54 | $ 40.80 | $ 40.80 | $ 40.80 | $ 37.54 | $ 45.90 |
| 42097116 | GAIT TRAINING / 15MIN | Physical Therapy | 420 | 97116 | $ 49.00 | $ 36.75 | $ 43.12 | $ 37.73 | $ 39.69 | $ 44.10 | $ 44.10 | $ 36.06 | $ 39.20 | $ 39.20 | $ 39.20 | $ 36.06 | $ 44.10 |
| 4201760 | IONTOPHORESIS | Physical Therapy | 420 | 97033 | $ 42.00 | $ 31.50 | $ 36.96 | $ 32.34 | $ 34.02 | $ 37.80 | $ 37.80 | $ 30.91 | $ 33.60 | $ 33.60 | $ 33.60 | $ 30.91 | $ 37.80 |
| 42097140 | MANUAL THERAPY | Physical Therapy | 420 | 97140 | $ 44.00 | $ 33.00 | $ 38.72 | $ 33.88 | $ 35.64 | $ 39.60 | $ 39.60 | $ 32.38 | $ 35.20 | $ 35.20 | $ 35.20 | $ 32.38 | $ 39.60 |
| 42097124 | MASSAGE / 15MIN | Physical Therapy | 420 | 97124 | $ 55.00 | $ 41.25 | $ 48.40 | $ 42.35 | $ 44.55 | $ 49.50 | $ 49.50 | $ 40.48 | $ 44.00 | $ 44.00 | $ 44.00 | $ 40.48 | $ 49.50 |
| 42097112 | NEUROMUSCULAR REEDUCATION / 15MIN | Physical Therapy | 420 | 97112 | $ 44.00 | $ 33.00 | $ 38.72 | $ 33.88 | $ 35.64 | $ 39.60 | $ 39.60 | $ 32.38 | $ 35.20 | $ 35.20 | $ 35.20 | $ 32.38 | $ 39.60 |
| 42097018 | PARAFFIN BATH | Physical Therapy | 420 | 97018 | $ 38.00 | $ 28.50 | $ 33.44 | $ 29.26 | $ 30.78 | $ 34.20 | $ 34.20 | $ 27.97 | $ 30.40 | $ 30.40 | $ 30.40 | $ 27.97 | $ 34.20 |
| 42097163 | PT EVAL; HIGH COMPLEXITY | Physical Therapy | 420 | 97163 | $ 150.00 | $ 112.50 | $ 132.00 | $ 115.50 | $ 121.50 | $ 135.00 | $ 135.00 | $ 110.40 | $ 120.00 | $ 120.00 | $ 120.00 | $ 110.40 | $ 135.00 |
| 42097161 | PT EVAL; LOW COMPLEXITY | Physical Therapy | 420 | 97161 | $ 100.00 | $ 75.00 | $ 88.00 | $ 77.00 | $ 81.00 | $ 90.00 | $ 90.00 | $ 73.60 | $ 80.00 | $ 80.00 | $ 80.00 | $ 73.60 | $ 90.00 |
| 42097162 | PT EVAL; MODERATE COMPLEXITY | Physical Therapy | 420 | 97162 | $ 125.00 | $ 93.75 | $ 110.00 | $ 96.25 | $ 101.25 | $ 112.50 | $ 112.50 | $ 92.00 | $ 100.00 | $ 100.00 | $ 100.00 | $ 92.00 | $ 112.50 |
| 42097002 | REEVAL/DISCHARGE | Physical Therapy | 424 | 97164 | $ 49.00 | $ 36.75 | $ 43.12 | $ 37.73 | $ 39.69 | $ 44.10 | $ 44.10 | $ 36.06 | $ 39.20 | $ 39.20 | $ 39.20 | $ 36.06 | $ 44.10 |
| 42097530 | THERAPEUTIC ACTIVITIES FUNCTIONAL 15MIN | Physical Therapy | 420 | 97530 | $ 44.00 | $ 33.00 | $ 38.72 | $ 33.88 | $ 35.64 | $ 39.60 | $ 39.60 | $ 32.38 | $ 35.20 | $ 35.20 | $ 35.20 | $ 32.38 | $ 39.60 |
| 42097035 | ULTRASOUND / 15MIN | Physical Therapy | 420 | 97035 | $ 71.00 | $ 53.25 | $ 62.48 | $ 54.67 | $ 57.51 | $ 63.90 | $ 63.90 | $ 52.26 | $ 56.80 | $ 56.80 | $ 56.80 | $ 52.26 | $ 63.90 |
| 3201415 | ABDOMEN 1 VIEW | Radiology Diagnostic | 320 | 74018 | $ 167.00 | $ 125.25 | $ 146.96 | $ 128.59 | $ 135.27 | $ 150.30 | $ 150.30 | $ 122.91 | $ 133.60 | $ 133.60 | $ 133.60 | $ 122.91 | $ 150.30 |
| 3201416 | ABDOMEN-2 VIEWS | Radiology Diagnostic | 320 | 74019 | $ 247.00 | $ 185.25 | $ 217.36 | $ 190.19 | $ 200.07 | $ 222.30 | $ 222.30 | $ 181.79 | $ 197.60 | $ 197.60 | $ 197.60 | $ 181.79 | $ 222.30 |
| 3201417 | ABDOMEN-3 VIEWS | Radiology Diagnostic | 320 | 74021 | $ 340.00 | $ 255.00 | $ 299.20 | $ 261.80 | $ 275.40 | $ 306.00 | $ 306.00 | $ 250.24 | $ 272.00 | $ 272.00 | $ 272.00 | $ 250.24 | $ 306.00 |
| 4005101 | ABDOMINAL LIMIT, Ultra Sound | Radiology Diagnostic | 400 | 76705 | $ 359.00 | $ 269.25 | $ 315.92 | $ 276.43 | $ 290.79 | $ 323.10 | $ 323.10 | $ 264.22 | $ 287.20 | $ 287.20 | $ 287.20 | $ 264.22 | $ 323.10 |
| CHARGE CODE | DESCRIPTION | Department | REV CODE | CPT CODE | RATE | Cash Pay | Aetna | BCBS TX - Blue Advantage | BCBS TX Blue Essentials | BCBS TX PPO | BCBS TX Trad | CIGNA | Humana | Unicare | United | Minimum Negotiated Charge | Maximum Negotiated Charge |
| 3200125 | ANKLE 2 VIEWS | Radiology Diagnostic | 320 | 73600 | $ 175.00 | $ 131.25 | $ 154.00 | $ 134.75 | $ 141.75 | $ 157.50 | $ 157.50 | $ 128.80 | $ 140.00 | $ 140.00 | $ 140.00 | $ 128.80 | $ 157.50 |
| 3201419 | ANKLE SERIES | Radiology Diagnostic | 320 | 73610 | $ 214.00 | $ 160.50 | $ 188.32 | $ 164.78 | $ 173.34 | $ 192.60 | $ 192.60 | $ 157.50 | $ 171.20 | $ 171.20 | $ 171.20 | $ 157.50 | $ 192.60 |
| 40093925 | ARTERIES LOW EXT CMPLE BI | Radiology Diagnostic | 921 | 93925 | $ 551.00 | $ 413.25 | $ 484.88 | $ 424.27 | $ 446.31 | $ 495.90 | $ 495.90 | $ 405.54 | $ 440.80 | $ 440.80 | $ 440.80 | $ 405.54 | $ 495.90 |
| 4005162 | BLADDER, Ultra Sound | Radiology Diagnostic | 402 | 76857 | $ 450.00 | $ 337.50 | $ 396.00 | $ 346.50 | $ 364.50 | $ 405.00 | $ 405.00 | $ 331.20 | $ 360.00 | $ 360.00 | $ 360.00 | $ 331.20 | $ 405.00 |
| 4007200 | CAROTID DOPPLER | Radiology Diagnostic | 921 | 93880 | $ 515.00 | $ 386.25 | $ 453.20 | $ 396.55 | $ 417.15 | $ 463.50 | $ 463.50 | $ 379.04 | $ 412.00 | $ 412.00 | $ 412.00 | $ 379.04 | $ 463.50 |
| 3201420 | CHEST VIEW | Radiology Diagnostic | 320 | 71045 | $ 185.00 | $ 138.75 | $ 162.80 | $ 142.45 | $ 149.85 | $ 166.50 | $ 166.50 | $ 136.16 | $ 148.00 | $ 148.00 | $ 148.00 | $ 136.16 | $ 166.50 |
| 3201421 | CHEST 2 VIEWS | Radiology Diagnostic | 320 | 71046 | $ 237.00 | $ 177.75 | $ 208.56 | $ 182.49 | $ 191.97 | $ 213.30 | $ 213.30 | $ 174.43 | $ 189.60 | $ 189.60 | $ 189.60 | $ 174.43 | $ 213.30 |
| 4005116 | CHEST, Ultra Sound | Radiology Diagnostic | 402 | 76604 | $ 414.00 | $ 310.50 | $ 364.32 | $ 318.78 | $ 335.34 | $ 372.60 | $ 372.60 | $ 304.70 | $ 331.20 | $ 331.20 | $ 331.20 | $ 304.70 | $ 372.60 |
| 3201423 | CLAVICLE Complete | Radiology Diagnostic | 320 | 73000 | $ 200.00 | $ 150.00 | $ 176.00 | $ 154.00 | $ 162.00 | $ 180.00 | $ 180.00 | $ 147.20 | $ 160.00 | $ 160.00 | $ 160.00 | $ 147.20 | $ 180.00 |
| 3207524 | CT ABDOMEN W/O CONTRAST | Radiology Diagnostic | 350 | 74150 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 32074176 | CT Abdomen/Pelvis w/o contrast | Radiology Diagnostic | 320 | 74176 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 35074176 | CT Abdomen/Pelvis W/O contrast | Radiology Diagnostic | 350 | 74176 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207541 | CT ANGIOGRAPHY NECK-CAROTIDS | Radiology Diagnostic | 350 | 70498 | $ 1,237.00 | $ 927.75 | $ 1,088.56 | $ 952.49 | $ 1,001.97 | $ 1,113.30 | $ 1,113.30 | $ 910.43 | $ 989.60 | $ 800.00 | $ 989.60 | $ 800.00 | $ 1,113.30 |
| 35071275 | CT CHEST ANGIOGRAPHY/PE PROTOC | Radiology Diagnostic | 350 | 71275 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207503 | CT CHEST W/O CONTRAST | Radiology Diagnostic | 350 | 71250 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207506 | CT C-SPINE W/O CONTRAST | Radiology Diagnostic | 350 | 72125 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207502 | CT HEAD/BRAIN W/W/O CONTRAST | Radiology Diagnostic | 320 | 70470 | $ 1,858.00 | $ 1,393.50 | $ 1,635.04 | $ 1,430.66 | $ 1,504.98 | $ 1,672.20 | $ 1,672.20 | $ 1,367.49 | $ 1,486.40 | $ 800.00 | $ 1,486.40 | $ 800.00 | $ 1,672.20 |
| 3207522 | CT LOWER EXTREM W/CONTRAST | Radiology Diagnostic | 350 | 73701 | $ 1,410.00 | $ 1,057.50 | $ 1,240.80 | $ 1,085.70 | $ 1,142.10 | $ 1,269.00 | $ 1,269.00 | $ 1,037.76 | $ 1,128.00 | $ 800.00 | $ 1,128.00 | $ 800.00 | $ 1,269.00 |
| 3207521 | CT LOWER EXTREM W/O CONTRAST | Radiology Diagnostic | 350 | 73700 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207512 | CT L-SPINE W/O CONTRAST | Radiology Diagnostic | 350 | 72131 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207530 | CT MAXILLOFACIAL W/O | Radiology Diagnostic | 350 | 70486 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207515 | CT PELVIS W/O CONTRAST | Radiology Diagnostic | 350 | 72192 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207540 | CT QCT BMD SURVEY | Radiology Diagnostic | 350 | 77078 | $ 282.00 | $ 211.50 | $ 248.16 | $ 217.14 | $ 228.42 | $ 253.80 | $ 253.80 | $ 207.55 | $ 225.60 | $ 225.60 | $ 225.60 | $ 207.55 | $ 253.80 |
| 3207538 | CT SINUS W/O | Radiology Diagnostic | 320 | 70486 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207533 | CT SOFT TISSUE NECK W/O CONTRA | Radiology Diagnostic | 320 | 72125 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207534 | CT SOFTIS NECK W/CONTRAST | Radiology Diagnostic | 350 | 70491 | $ 1,174.00 | $ 880.50 | $ 1,033.12 | $ 903.98 | $ 950.94 | $ 1,056.60 | $ 1,056.60 | $ 864.06 | $ 939.20 | $ 939.20 | $ 939.20 | $ 864.06 | $ 1,056.60 |
| 3207535 | CT SOFTIS NECK W/W/O CONTRAST | Radiology Diagnostic | 350 | 70492 | $ 2,709.00 | $ 2,031.75 | $ 2,383.92 | $ 2,085.93 | $ 2,194.29 | $ 2,438.10 | $ 2,438.10 | $ 1,993.82 | $ 2,167.20 | $ 800.00 | $ 2,167.20 | $ 800.00 | $ 2,438.10 |
| 3207504 | CT THORAX W/CONTRAST | Radiology Diagnostic | 350 | 71260 | $ 1,806.00 | $ 1,354.50 | $ 1,589.28 | $ 1,390.62 | $ 1,462.86 | $ 1,625.40 | $ 1,625.40 | $ 1,329.22 | $ 1,444.80 | $ 800.00 | $ 1,444.80 | $ 800.00 | $ 1,625.40 |
| 3207509 | CT T-SPINE W/O CONTRAST | Radiology Diagnostic | 350 | 72128 | $ 1,305.00 | $ 978.75 | $ 1,148.40 | $ 1,004.85 | $ 1,057.05 | $ 1,174.50 | $ 1,174.50 | $ 960.48 | $ 1,044.00 | $ 800.00 | $ 1,044.00 | $ 800.00 | $ 1,174.50 |
| 3207518 | CT UPPER EXTREM W/O CONTRAST | Radiology Diagnostic | 350 | 73200 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3201428 | ELBOW COMPLETE | Radiology Diagnostic | 320 | 73080 | $ 166.00 | $ 124.50 | $ 146.08 | $ 127.82 | $ 134.46 | $ 149.40 | $ 149.40 | $ 122.18 | $ 132.80 | $ 132.80 | $ 132.80 | $ 122.18 | $ 149.40 |
| 3201220 | ELBOW LIMITED | Radiology Diagnostic | 320 | 73070 | $ 166.00 | $ 124.50 | $ 146.08 | $ 127.82 | $ 134.46 | $ 149.40 | $ 149.40 | $ 122.18 | $ 132.80 | $ 132.80 | $ 132.80 | $ 122.18 | $ 149.40 |
| 3201429 | FACIAL BONES COMPLETE | Radiology Diagnostic | 320 | 70150 | $ 283.00 | $ 212.25 | $ 249.04 | $ 217.91 | $ 229.23 | $ 254.70 | $ 254.70 | $ 208.29 | $ 226.40 | $ 226.40 | $ 226.40 | $ 208.29 | $ 254.70 |
| 3201431 | FEMUR 2 VIEWS | Radiology Diagnostic | 320 | 73552 | $ 208.00 | $ 156.00 | $ 183.04 | $ 160.16 | $ 168.48 | $ 187.20 | $ 187.20 | $ 153.09 | $ 166.40 | $ 166.40 | $ 166.40 | $ 153.09 | $ 187.20 |
| 3201432 | FINGER MIN 2 VIEWS | Radiology Diagnostic | 320 | 73140 | $ 169.00 | $ 126.75 | $ 148.72 | $ 130.13 | $ 136.89 | $ 152.10 | $ 152.10 | $ 124.38 | $ 135.20 | $ 135.20 | $ 135.20 | $ 124.38 | $ 152.10 |
| 3201975 | FOOT 2 VIEWS | Radiology Diagnostic | 320 | 73620 | $ 170.00 | $ 127.50 | $ 149.60 | $ 130.90 | $ 137.70 | $ 153.00 | $ 153.00 | $ 125.12 | $ 136.00 | $ 136.00 | $ 136.00 | $ 125.12 | $ 153.00 |
| 3201434 | FOOT COMPLETE | Radiology Diagnostic | 320 | 73630 | $ 180.00 | $ 135.00 | $ 158.40 | $ 138.60 | $ 145.80 | $ 162.00 | $ 162.00 | $ 132.48 | $ 144.00 | $ 144.00 | $ 144.00 | $ 132.48 | $ 162.00 |
| 3201435 | FOREARM 2 VIEWS | Radiology Diagnostic | 320 | 73090 | $ 184.00 | $ 138.00 | $ 161.92 | $ 141.68 | $ 149.04 | $ 165.60 | $ 165.60 | $ 135.42 | $ 147.20 | $ 147.20 | $ 147.20 | $ 135.42 | $ 165.60 |
| 4005104 | GALLBLADDER, Ultra Sound | Radiology Diagnostic | 402 | 76705 | $ 359.00 | $ 269.25 | $ 315.92 | $ 276.43 | $ 290.79 | $ 323.10 | $ 323.10 | $ 264.22 | $ 287.20 | $ 287.20 | $ 287.20 | $ 264.22 | $ 323.10 |
| 3201436 | HAND 2 VIEWS | Radiology Diagnostic | 320 | 73120 | $ 163.00 | $ 122.25 | $ 143.44 | $ 125.51 | $ 132.03 | $ 146.70 | $ 146.70 | $ 119.97 | $ 130.40 | $ 130.40 | $ 130.40 | $ 119.97 | $ 146.70 |
| 3201437 | HAND 3 VIEWS | Radiology Diagnostic | 320 | 73130 | $ 187.00 | $ 140.25 | $ 164.56 | $ 143.99 | $ 151.47 | $ 168.30 | $ 168.30 | $ 137.63 | $ 149.60 | $ 149.60 | $ 149.60 | $ 137.63 | $ 168.30 |
| 3201438 | HEEL (CALCANEUS) | Radiology Diagnostic | 320 | 73650 | $ 151.00 | $ 113.25 | $ 132.88 | $ 116.27 | $ 122.31 | $ 135.90 | $ 135.90 | $ 111.14 | $ 120.80 | $ 120.80 | $ 120.80 | $ 111.14 | $ 135.90 |
| 3201440 | HIP 2 VEIWS | Radiology Diagnostic | 320 | 73502 | $ 211.00 | $ 158.25 | $ 185.68 | $ 162.47 | $ 170.91 | $ 189.90 | $ 189.90 | $ 155.30 | $ 168.80 | $ 168.80 | $ 168.80 | $ 155.30 | $ 189.90 |
| 3202875 | HUMERUS 2 VIEWS | Radiology Diagnostic | 320 | 73060 | $ 204.00 | $ 153.00 | $ 179.52 | $ 157.08 | $ 165.24 | $ 183.60 | $ 183.60 | $ 150.14 | $ 163.20 | $ 163.20 | $ 163.20 | $ 150.14 | $ 183.60 |
| 4005105 | KIDNEY, Ultra Sound | Radiology Diagnostic | 402 | 76770 | $ 359.00 | $ 269.25 | $ 315.92 | $ 276.43 | $ 290.79 | $ 323.10 | $ 323.10 | $ 264.22 | $ 287.20 | $ 287.20 | $ 287.20 | $ 264.22 | $ 323.10 |
| 3201442 | KNEE 2 VIEWS | Radiology Diagnostic | 320 | 73560 | $ 185.00 | $ 138.75 | $ 162.80 | $ 142.45 | $ 149.85 | $ 166.50 | $ 166.50 | $ 136.16 | $ 148.00 | $ 148.00 | $ 148.00 | $ 136.16 | $ 166.50 |
| 3201510 | KNEE 3 VEIWS | Radiology Diagnostic | 320 | 73562 | $ 185.00 | $ 138.75 | $ 162.80 | $ 142.45 | $ 149.85 | $ 166.50 | $ 166.50 | $ 136.16 | $ 148.00 | $ 148.00 | $ 148.00 | $ 136.16 | $ 166.50 |
| 3203125 | KNEE COMP INCL PATELLAR | Radiology Diagnostic | 320 | 73564 | $ 282.00 | $ 211.50 | $ 248.16 | $ 217.14 | $ 228.42 | $ 253.80 | $ 253.80 | $ 207.55 | $ 225.60 | $ 225.60 | $ 225.60 | $ 207.55 | $ 253.80 |
| 3201445 | LEG 2 VIEWS | Radiology Diagnostic | 320 | 73590 | $ 208.00 | $ 156.00 | $ 183.04 | $ 160.16 | $ 168.48 | $ 187.20 | $ 187.20 | $ 153.09 | $ 166.40 | $ 166.40 | $ 166.40 | $ 153.09 | $ 187.20 |
| 4005106 | LIVER, Ultra Sound | Radiology Diagnostic | 400 | 76705 | $ 359.00 | $ 269.25 | $ 315.92 | $ 276.43 | $ 290.79 | $ 323.10 | $ 323.10 | $ 264.22 | $ 287.20 | $ 287.20 | $ 287.20 | $ 264.22 | $ 323.10 |
| 3201448 | MANDIBLE / MAXILLA | Radiology Diagnostic | 320 | 70100 | $ 233.00 | $ 174.75 | $ 205.04 | $ 179.41 | $ 188.73 | $ 209.70 | $ 209.70 | $ 171.49 | $ 186.40 | $ 186.40 | $ 186.40 | $ 171.49 | $ 209.70 |
| 3201449 | NOSE COMP MIN 2 VIEWS | Radiology Diagnostic | 320 | 70160 | $ 196.00 | $ 147.00 | $ 172.48 | $ 150.92 | $ 158.76 | $ 176.40 | $ 176.40 | $ 144.26 | $ 156.80 | $ 156.80 | $ 156.80 | $ 144.26 | $ 176.40 |
| 3201450 | ORBITS | Radiology Diagnostic | 320 | 70030 | $ 92.00 | $ 69.00 | $ 80.96 | $ 70.84 | $ 74.52 | $ 82.80 | $ 82.80 | $ 67.71 | $ 73.60 | $ 73.60 | $ 73.60 | $ 67.71 | $ 82.80 |
| 4005108 | PELVIC, Ultra Sound | Radiology Diagnostic | 402 | 76856 | $ 416.00 | $ 312.00 | $ 366.08 | $ 320.32 | $ 336.96 | $ 374.40 | $ 374.40 | $ 306.18 | $ 332.80 | $ 332.80 | $ 332.80 | $ 306.18 | $ 374.40 |
| 3201452 | PELVIS 1 VIEW | Radiology Diagnostic | 320 | 72170 | $ 183.00 | $ 137.25 | $ 161.04 | $ 140.91 | $ 148.23 | $ 164.70 | $ 164.70 | $ 134.69 | $ 146.40 | $ 146.40 | $ 146.40 | $ 134.69 | $ 164.70 |
| 32074178 | PELVIS/ABDOMEN W/W/O CONTRAST | Radiology Diagnostic | 350 | 74178 | $ 2,418.00 | $ 1,813.50 | $ 2,127.84 | $ 1,861.86 | $ 1,958.58 | $ 2,176.20 | $ 2,176.20 | $ 1,779.65 | $ 1,934.40 | $ 800.00 | $ 1,934.40 | $ 800.00 | $ 2,176.20 |
| 40093971 | PERI. VEN. (LTD) | Radiology Diagnostic | 921 | 93971 | $ 394.00 | $ 295.50 | $ 346.72 | $ 303.38 | $ 319.14 | $ 354.60 | $ 354.60 | $ 289.98 | $ 315.20 | $ 315.20 | $ 315.20 | $ 289.98 | $ 354.60 |
| 3201456 | RIBS 1 SIDE 3 VIEWS | Radiology Diagnostic | 320 | 71110 | $ 289.00 | $ 216.75 | $ 254.32 | $ 222.53 | $ 234.09 | $ 260.10 | $ 260.10 | $ 212.70 | $ 231.20 | $ 231.20 | $ 231.20 | $ 212.70 | $ 260.10 |
| 3201458 | SACRO-ILIAC JTS 3 VIEWS | Radiology Diagnostic | 320 | 72202 | $ 106.00 | $ 79.50 | $ 93.28 | $ 81.62 | $ 85.86 | $ 95.40 | $ 95.40 | $ 78.02 | $ 84.80 | $ 84.80 | $ 84.80 | $ 78.02 | $ 95.40 |
| 3201459 | SACRUM & COCCYX | Radiology Diagnostic | 320 | 72220 | $ 196.00 | $ 147.00 | $ 172.48 | $ 150.92 | $ 158.76 | $ 176.40 | $ 176.40 | $ 144.26 | $ 156.80 | $ 156.80 | $ 156.80 | $ 144.26 | $ 176.40 |
| 3201461 | SCAPULA 2 VIEWS | Radiology Diagnostic | 320 | 73010 | $ 192.00 | $ 144.00 | $ 168.96 | $ 147.84 | $ 155.52 | $ 172.80 | $ 172.80 | $ 141.31 | $ 153.60 | $ 153.60 | $ 153.60 | $ 141.31 | $ 172.80 |
| CHARGE CODE | DESCRIPTION | Department | REV CODE | CPT CODE | RATE | Cash Pay | Aetna | BCBS TX - Blue Advantage | BCBS TX Blue Essentials | BCBS TX PPO | BCBS TX Trad | CIGNA | Humana | Unicare | United | Minimum Negotiated Charge | Maximum Negotiated Charge |
| 32072090 | Scoliosis Study | Radiology Diagnostic | 320 | 72081 | $ 137.00 | $ 102.75 | $ 120.56 | $ 105.49 | $ 110.97 | $ 123.30 | $ 123.30 | $ 100.83 | $ 109.60 | $ 109.60 | $ 109.60 | $ 100.83 | $ 123.30 |
| 4005113 | SCROTUM, Ultra Sound | Radiology Diagnostic | 402 | 76856 | $ 416.00 | $ 312.00 | $ 366.08 | $ 320.32 | $ 336.96 | $ 374.40 | $ 374.40 | $ 306.18 | $ 332.80 | $ 332.80 | $ 332.80 | $ 306.18 | $ 374.40 |
| 3201463 | SHOULDER 2 VEIWS | Radiology Diagnostic | 320 | 73030 | $ 220.00 | $ 165.00 | $ 193.60 | $ 169.40 | $ 178.20 | $ 198.00 | $ 198.00 | $ 161.92 | $ 176.00 | $ 176.00 | $ 176.00 | $ 161.92 | $ 198.00 |
| 3201464 | SHOULDER 3 VEIWS | Radiology Diagnostic | 320 | 73040 | $ 360.00 | $ 270.00 | $ 316.80 | $ 277.20 | $ 291.60 | $ 324.00 | $ 324.00 | $ 264.96 | $ 288.00 | $ 288.00 | $ 288.00 | $ 264.96 | $ 324.00 |
| 3201498 | SINUSES COMP MIN 3 VIEWS | Radiology Diagnostic | 320 | 70220 | $ 270.00 | $ 202.50 | $ 237.60 | $ 207.90 | $ 218.70 | $ 243.00 | $ 243.00 | $ 198.72 | $ 216.00 | $ 216.00 | $ 216.00 | $ 198.72 | $ 243.00 |
| 3201465 | SKULL 2 VIEWS | Radiology Diagnostic | 320 | 70250 | $ 208.00 | $ 156.00 | $ 183.04 | $ 160.16 | $ 168.48 | $ 187.20 | $ 187.20 | $ 153.09 | $ 166.40 | $ 166.40 | $ 166.40 | $ 153.09 | $ 187.20 |
| 3201466 | SKULL SERIES MIN 3 VIEWS | Radiology Diagnostic | 320 | 70260 | $ 233.00 | $ 174.75 | $ 205.04 | $ 179.41 | $ 188.73 | $ 209.70 | $ 209.70 | $ 171.49 | $ 186.40 | $ 186.40 | $ 186.40 | $ 171.49 | $ 209.70 |
| 3201499 | SPINE CERVICAL 3 VIEWS | Radiology Diagnostic | 320 | 72040 | $ 235.00 | $ 176.25 | $ 206.80 | $ 180.95 | $ 190.35 | $ 211.50 | $ 211.50 | $ 172.96 | $ 188.00 | $ 188.00 | $ 188.00 | $ 172.96 | $ 211.50 |
| 3206575 | SPINE DORSAL 2 VIEW | Radiology Diagnostic | 320 | 72070 | $ 235.00 | $ 176.25 | $ 206.80 | $ 180.95 | $ 190.35 | $ 211.50 | $ 211.50 | $ 172.96 | $ 188.00 | $ 188.00 | $ 188.00 | $ 172.96 | $ 211.50 |
| 3201502 | SPINE LUMBAR 2 VIEWS | Radiology Diagnostic | 320 | 72100 | $ 229.00 | $ 171.75 | $ 201.52 | $ 176.33 | $ 185.49 | $ 206.10 | $ 206.10 | $ 168.54 | $ 183.20 | $ 183.20 | $ 183.20 | $ 168.54 | $ 206.10 |
| 4005112 | THYROID, Ultra Sound | Radiology Diagnostic | 402 | 76536 | $ 501.00 | $ 375.75 | $ 440.88 | $ 385.77 | $ 405.81 | $ 450.90 | $ 450.90 | $ 368.74 | $ 400.80 | $ 400.80 | $ 400.80 | $ 368.74 | $ 450.90 |
| 3207225 | TOES MIN 2 VIEWS | Radiology Diagnostic | 320 | 73660 | $ 115.00 | $ 86.25 | $ 101.20 | $ 88.55 | $ 93.15 | $ 103.50 | $ 103.50 | $ 84.64 | $ 92.00 | $ 92.00 | $ 92.00 | $ 84.64 | $ 103.50 |
| 40076882 | US Extremity Non Vascular Limited | Radiology Diagnostic | 402 | 76882 | $ 150.00 | $ 112.50 | $ 132.00 | $ 115.50 | $ 121.50 | $ 135.00 | $ 135.00 | $ 110.40 | $ 120.00 | $ 120.00 | $ 120.00 | $ 110.40 | $ 135.00 |
| 40093970 | VEINS EXTREMITY CMPLE BIL | Radiology Diagnostic | 921 | 93970 | $ 675.00 | $ 506.25 | $ 594.00 | $ 519.75 | $ 546.75 | $ 607.50 | $ 607.50 | $ 496.80 | $ 540.00 | $ 540.00 | $ 540.00 | $ 496.80 | $ 607.50 |
| 3207475 | WRIST 2 VIEWS AP/LAT | Radiology Diagnostic | 320 | 73100 | $ 146.00 | $ 109.50 | $ 128.48 | $ 112.42 | $ 118.26 | $ 131.40 | $ 131.40 | $ 107.46 | $ 116.80 | $ 116.80 | $ 116.80 | $ 107.46 | $ 131.40 |
| 3201476 | WRIST COMP MIN 3 VIEWS | Radiology Diagnostic | 320 | 73110 | $ 208.00 | $ 156.00 | $ 183.04 | $ 160.16 | $ 168.48 | $ 187.20 | $ 187.20 | $ 153.09 | $ 166.40 | $ 166.40 | $ 166.40 | $ 153.09 | $ 187.20 |
| 99394 | EST PT PHYSICAL 12-17 YEARS | Rural Health Clinic | 521 | 99394 | $ 158.00 | $ 118.50 | $ 96.18 | $ 119.76 | $ 122.12 | $ 122.65 | $ 122.65 | $ 96.18 | $ 96.18 | $ 96.18 | $ 96.18 | $ 96.18 | $ 122.65 |
| 99397 | EST PT PHYSICAL- 65 AND OVER | Rural Health Clinic | 521 | 99397 | $ 186.00 | $ 139.50 | $ 112.56 | $ 140.14 | $ 142.91 | $ 143.53 | $ 143.53 | $ 112.56 | $ 112.56 | $ 112.56 | $ 112.56 | $ 112.56 | $ 143.53 |
| 99391 | EST PT PHYSICAL UNDER 1 YEAR | Rural Health Clinic | 521 | 99391 | $ 123.00 | $ 92.25 | $ 82.30 | $ 102.65 | $ 104.68 | $ 105.13 | $ 105.13 | $ 82.30 | $ 82.30 | $ 82.30 | $ 82.30 | $ 82.30 | $ 105.13 |
| 99396 | EST PT PHYSICAL-40-64 YEARS | Rural Health Clinic | 521 | 99396 | $ 168.00 | $ 126.00 | $ 104.75 | $ 130.31 | $ 132.89 | $ 133.46 | $ 133.46 | $ 104.75 | $ 104.75 | $ 104.75 | $ 104.75 | $ 104.75 | $ 133.46 |
| 99395 | EST PT-PHYSICAL 18-39 YEARS | Rural Health Clinic | 521 | 99395 | $ 152.00 | $ 114.00 | $ 98.27 | $ 122.30 | $ 124.72 | $ 125.26 | $ 125.26 | $ 98.27 | $ 98.27 | $ 98.27 | $ 98.27 | $ 98.27 | $ 125.26 |
| 99214 | ESTAB PAT-DETAILED IV | Rural Health Clinic | 521 | 99214 | $ 115.00 | $ 86.25 | $ 89.28 | $ 93.74 | $ 113.59 | $ 114.08 | $ 114.08 | $ 106.43 | $ 106.43 | $ 106.43 | $ 115.00 | $ 89.28 | $ 115.00 |
| 99212 | ESTAB PAT-FOCUSED II | Rural Health Clinic | 521 | 99212 | $ 75.00 | $ 56.25 | $ 36.79 | $ 46.23 | $ 47.14 | $ 47.35 | $ 47.35 | $ 48.62 | $ 48.62 | $ 48.62 | $ 55.87 | $ 36.79 | $ 55.87 |
| 99213 | ESTAB PAT-LOW COMPLEX III | Rural Health Clinic | 521 | 99213 | $ 90.00 | $ 67.50 | $ 60.87 | $ 64.03 | $ 77.58 | $ 77.92 | $ 77.92 | $ 73.23 | $ 73.23 | $ 73.23 | $ 89.50 | $ 60.87 | $ 89.50 |
| 99393 | ESTAB PT PHYSICAL 5-11 YEARS | Rural Health Clinic | 521 | 99393 | $ 137.50 | $ 103.13 | $ 87.62 | $ 109.20 | $ 111.36 | $ 111.84 | $ 111.84 | $ 87.62 | $ 87.62 | $ 87.62 | $ 87.62 | $ 87.62 | $ 111.84 |
| 99392 | ESTAB PT PHYSICAL-1-4YEARS | Rural Health Clinic | 521 | 99392 | $ 137.50 | $ 103.13 | $ 87.90 | $ 109.56 | $ 111.73 | $ 112.21 | $ 112.21 | $ 87.90 | $ 87.90 | $ 87.90 | $ 87.90 | $ 87.90 | $ 112.21 |
| 99384 | NEW E/M PHYS AGE 12-17 YEARS | Rural Health Clinic | 521 | 99384 | $ 186.00 | $ 139.50 | $ 112.56 | $ 140.14 | $ 142.91 | $ 143.53 | $ 143.53 | $ 112.56 | $ 112.56 | $ 112.56 | $ 112.56 | $ 112.56 | $ 143.53 |
| 99382 | NEW E/M PHYSICAL 1-4 YEARS | Rural Health Clinic | 521 | 99382 | $ 175.00 | $ 131.25 | $ 95.71 | $ 119.39 | $ 121.75 | $ 122.28 | $ 122.28 | $ 95.71 | $ 95.71 | $ 95.71 | $ 95.71 | $ 95.71 | $ 122.28 |
| 99383 | NEW E/M PHYSICAL 5-11 YEARS | Rural Health Clinic | 521 | 99383 | $ 171.00 | $ 128.25 | $ 99.59 | $ 124.12 | $ 126.58 | $ 127.12 | $ 127.12 | $ 99.59 | $ 99.59 | $ 99.59 | $ 99.59 | $ 99.59 | $ 127.12 |
| 99381 | NEW E/M PHYSICAL UNDER 1 YEAR | Rural Health Clinic | 521 | 99381 | $ 162.00 | $ 121.50 | $ 91.31 | $ 113.93 | $ 116.19 | $ 116.69 | $ 116.69 | $ 91.31 | $ 91.31 | $ 91.31 | $ 91.31 | $ 91.31 | $ 116.69 |
| 99202 | NEW PATIENT INTERMED II | Rural Health Clinic | 521 | 99202 | $ 130.00 | $ 97.50 | $ 62.45 | $ 78.26 | $ 79.81 | $ 80.15 | $ 80.15 | $ 74.08 | $ 74.08 | $ 74.08 | $ 74.08 | $ 62.45 | $ 80.15 |
| 99201 | OV/NEW PT.SIMPLE I | Rural Health Clinic | 521 | 99201 | $ 100.00 | $ 75.00 | $ 37.32 | $ 46.96 | $ 47.88 | $ 48.09 | $ 48.09 | $ 44.54 | $ 44.54 | $ 44.54 | $ 54.15 | $ 37.32 | $ 54.15 |
| 3000429 | BASIC METABOLIC PANEL | Laboratory | 301 | 80048 | $ 220.00 | $ 165.00 | $ 193.60 | $ 169.40 | $ 178.20 | $ 198.00 | $ 198.00 | $ 161.92 | $ 176.00 | $ 176.00 | $ 176.00 | $ 161.92 | $ 198.00 |
| 3000655 | COMPLETE (CBC) AUTO HGB,HCT, | Laboratory | 305 | 85025 | $ 71.00 | $ 53.25 | $ 62.48 | $ 54.67 | $ 57.51 | $ 63.90 | $ 63.90 | $ 52.26 | $ 56.80 | $ 56.80 | $ 56.80 | $ 52.26 | $ 63.90 |
| 3000447 | COMPREHESIVE METABOLIC PANEL | Laboratory | 301 | 80053 | $ 259.00 | $ 194.25 | $ 227.92 | $ 199.43 | $ 209.79 | $ 233.10 | $ 233.10 | $ 190.62 | $ 207.20 | $ 207.20 | $ 207.20 | $ 190.62 | $ 233.10 |
| 3000402 | HEPATIC FUNCTION PANEL | Laboratory | 301 | 80076 | $ 280.00 | $ 210.00 | $ 246.40 | $ 215.60 | $ 226.80 | $ 252.00 | $ 252.00 | $ 206.08 | $ 224.00 | $ 224.00 | $ 224.00 | $ 206.08 | $ 252.00 |
| 3000318 | LIPID PANEL | Laboratory | 301 | 80061 | $ 129.00 | $ 96.75 | $ 113.52 | $ 99.33 | $ 104.49 | $ 116.10 | $ 116.10 | $ 94.94 | $ 103.20 | $ 103.20 | $ 103.20 | $ 94.94 | $ 116.10 |
| 3000533 | PANEL: RENAL FUNCTION RFT | Laboratory | 301 | 80069 | $ 147.00 | $ 110.25 | $ 129.36 | $ 113.19 | $ 119.07 | $ 132.30 | $ 132.30 | $ 108.19 | $ 117.60 | $ 117.60 | $ 117.60 | $ 108.19 | $ 132.30 |
| 3000324 | PROTHROMBIN TIME; | Laboratory | 305 | 85610 | $ 75.00 | $ 56.25 | $ 66.00 | $ 57.75 | $ 60.75 | $ 67.50 | $ 67.50 | $ 55.20 | $ 60.00 | $ 60.00 | $ 60.00 | $ 55.20 | $ 67.50 |
| 30084153 | PSA | Laboratory | 300 | 84153 | $ 156.00 | $ 117.00 | $ 137.28 | $ 120.12 | $ 126.36 | $ 140.40 | $ 140.40 | $ 114.82 | $ 124.80 | $ 124.80 | $ 124.80 | $ 114.82 | $ 140.40 |
| 3000254 | PSA FREE | Laboratory | 301 | 84154 | $ 198.00 | $ 148.50 | $ 174.24 | $ 152.46 | $ 160.38 | $ 178.20 | $ 178.20 | $ 145.73 | $ 158.40 | $ 158.40 | $ 158.40 | $ 145.73 | $ 178.20 |
| 3000312 | THROMBOPLASTINE TIME PART PTT | Laboratory | 305 | 85730 | $ 90.00 | $ 67.50 | $ 79.20 | $ 69.30 | $ 72.90 | $ 81.00 | $ 81.00 | $ 66.24 | $ 72.00 | $ 72.00 | $ 72.00 | $ 66.24 | $ 81.00 |
| 3000420 | THYROID STIMIULATING HORMONE | Laboratory | 301 | 84443 | $ 165.00 | $ 123.75 | $ 145.20 | $ 127.05 | $ 133.65 | $ 148.50 | $ 148.50 | $ 121.44 | $ 132.00 | $ 132.00 | $ 132.00 | $ 121.44 | $ 148.50 |
| 3000337 | URINALYSIS AUTOMATED W/MICRO | Laboratory | 307 | 81001 | $ 67.00 | $ 50.25 | $ 58.96 | $ 51.59 | $ 54.27 | $ 60.30 | $ 60.30 | $ 49.31 | $ 53.60 | $ 53.60 | $ 53.60 | $ 49.31 | $ 60.30 |
| 3001527 | URINALYSIS, AUTOMATED W/O MICR | Laboratory | 300 | 81003 | $ 38.00 | $ 28.50 | $ 33.44 | $ 29.26 | $ 30.78 | $ 34.20 | $ 34.20 | $ 27.97 | $ 30.40 | $ 30.40 | $ 30.40 | $ 27.97 | $ 34.20 |
| 81002 | URINE DIPSTICK | Laboratory | 300 | 81002 | $ 15.45 | $ 11.59 | $ 13.60 | $ 11.90 | $ 12.51 | $ 13.91 | $ 13.91 | $ 11.37 | $ 12.36 | $ 12.36 | $ 12.36 | $ 11.37 | $ 13.91 |
| 42097110 | THEREX 15 / 15MIN | Physical Therapy | 420 | 97110 | $ 77.00 | $ 57.75 | $ 67.76 | $ 59.29 | $ 62.37 | $ 69.30 | $ 69.30 | $ 56.67 | $ 61.60 | $ 61.60 | $ 61.60 | $ 56.67 | $ 69.30 |
| 4005100 | ABDOMINAL COMPLETE, Ultra Sound | Radiology Diagnostic | 402 | 76700 | $ 481.00 | $ 360.75 | $ 423.28 | $ 370.37 | $ 389.61 | $ 432.90 | $ 432.90 | $ 354.02 | $ 384.80 | $ 384.80 | $ 384.80 | $ 354.02 | $ 432.90 |
| 35074177 | CT Abdomen/Pelvis w/ contrast | Radiology Diagnostic | 350 | 74177 | $ 1,468.00 | $ 1,101.00 | $ 1,291.84 | $ 1,130.36 | $ 1,189.08 | $ 1,321.20 | $ 1,321.20 | $ 1,080.45 | $ 1,174.40 | $ 800.00 | $ 1,174.40 | $ 800.00 | $ 1,321.20 |
| 3207500 | CT HEAD/BRAIN W/O CONTRAST | Radiology Diagnostic | 350 | 70450 | $ 1,501.00 | $ 1,125.75 | $ 1,320.88 | $ 1,155.77 | $ 1,215.81 | $ 1,350.90 | $ 1,350.90 | $ 1,104.74 | $ 1,200.80 | $ 800.00 | $ 1,200.80 | $ 800.00 | $ 1,350.90 |
| 3201469 | SPINE LUMBAR COMP | Radiology Diagnostic | 320 | 72110 | $ 386.00 | $ 289.50 | $ 339.68 | $ 297.22 | $ 312.66 | $ 347.40 | $ 347.40 | $ 284.10 | $ 308.80 | $ 308.80 | $ 308.80 | $ 284.10 | $ 347.40 |
| 99385 | NEW E/M PHYSICAL 18-39YEARS | Rural Health Clinic | 521 | 99385 | $ 204.00 | $ 153.00 | $ 108.76 | $ 135.41 | $ 138.09 | $ 138.68 | $ 138.68 | $ 108.76 | $ 108.76 | $ 108.76 | $ 108.76 | $ 108.76 | $ 138.68 |
| 99386 | NEW E/M PHYSICAL 40-64 YEARS | Rural Health Clinic | 521 | 99386 | $ 218.00 | $ 163.50 | $ 126.44 | $ 157.25 | $ 160.36 | $ 161.05 | $ 161.05 | $ 126.44 | $ 126.44 | $ 126.44 | $ 126.44 | $ 126.44 | $ 161.05 |
| 99205 | NEW PAT-COMPLEX V | Rural Health Clinic | 521 | 99205 | $ 305.00 | $ 228.75 | $ 170.05 | $ 211.85 | $ 216.04 | $ 216.97 | $ 216.97 | $ 203.40 | $ 203.40 | $ 203.40 | $ 203.40 | $ 170.05 | $ 216.97 |
| 99204 | NEW PAT-COMPREHENSIVE IV | Rural Health Clinic | 521 | 99204 | $ 245.00 | $ 183.75 | $ 135.13 | $ 168.53 | $ 171.87 | $ 172.61 | $ 172.61 | $ 160.85 | $ 160.85 | $ 160.85 | $ 160.85 | $ 135.13 | $ 172.61 |
| 99203 | NEW PAT-DETAILED III | Rural Health Clinic | 521 | 99203 | $ 180.00 | $ 135.00 | $ 88.67 | $ 111.02 | $ 113.22 | $ 113.70 | $ 113.70 | $ 105.07 | $ 105.07 | $ 105.07 | $ 105.07 | $ 88.67 | $ 113.70 |
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call {877-696-6775}
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