Price Transparency

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: 

  • Charge Code – specific charge code for each item or service
  • Description – description of each item or service
  • Department – department where item or service performed
  • Rev Code – corresponding department’s revenue code for item or service
  • CPT Code – corresponding CPT billing code for item or service (if applicable)
  • Gross Charge – corresponding gross charge for each individual item or service
  • Cash Price – corresponding discounted cash price that applies to each item or service
  • Payer-Specific Negotiated Charge – each column lists the negotiated charge with the name of each specific third-party payer as the column header
  • De-identified minimum negotiated charge that applies to each item or service
  • De-identified maximum negotiated charge that applies to each item or service

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: 

  • Charge Code – specific charge code for each item or service
  • Description – description of each item or service
  • Department – department where item or service performed
  • Rev Code – corresponding department’s revenue code for item or service
  • CPT Code – corresponding CPT billing code for item or service (if applicable)
  • Gross Charge – corresponding gross charge for each individual item or service
  • Cash Price – corresponding discounted cash price that applies to each item or service
  • Payer-Specific Negotiated Charge – each column lists the negotiated charge with the name of each specific third-party payer as the column header
  • De-identified minimum negotiated charge that applies to each item or service
  • De-identified maximum negotiated charge that applies to each item or service

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! 

Downloadable CDM and Shoppable Services

Charge Description Master

Shoppable Services

Searchable Shoppable Services

Culberson Hospital Shoppable Services as of 7/15/2023

CHARGE CODEDESCRIPTIONDepartmentREV CODECPT CODERATECash PayAetnaBCBS TX - Blue AdvantageBCBS TX Blue EssentialsBCBS TX PPOBCBS TX TradCIGNAHumanaUnicareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
3904013ANTIBODY SCREEN-REDCBlood/Blood Products39086850$ 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
3900300COOMBS-CROSSMATCHBlood/Blood Products30086921$ 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
3000048PRBC PACKED RED BLOOD CELLSBlood/Blood Products390P9016$ 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
45036430TRANSFUSIONBlood/Blood Products39136430$ 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
7300250EKG (12 LEAD)UNINTERPRETEDEKG/ECG73093005$ 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
7300150ELECTROCARDIOGRAMEKG/ECG73093005$ 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
300011617OHP 17 HYDROXYPREGNENOLONELaboratory30084143$ 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
300383224 HR URINE SODIUMLaboratory30184300$ 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
300823063 EPI -Vitamin D, 25-HydroxyLaboratory30182306$ 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
3000300ACETAMINOPHEN LEVELLaboratory30180299$ 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
3000704AEROBIC ISOLATE, ADD METH REQLaboratory30687077$ 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
3000482ALPHA-FETOPRTEIN SERUMLaboratory30182105$ 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
3000333ALT (ALANINE AMINOTRANSFERASELaboratory30184460$ 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
3001570AMMONIA LEVELLaboratory30182140$ 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
3000351AMYLASELaboratory30182150$ 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
3000122ANCA INFLAMMATORY BOWELDISEASELaboratory30086255$ 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
3001710ANDROSTENEDIONELaboratory30082157$ 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
3000339ANTIBODY SCREEN KH-MOTHERSLaboratory30086885$ 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
30083520ANTI-CCP/CITRULLINE ANTIBODYLaboratory30286200$ 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
3000353ANTIHUMAN GLOBULIN TEST COOMBSLaboratory30286885$ 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
3000507ANTI-NUCLEAR ANTIBODIES (ANA)Laboratory30286038$ 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
3000355ANTISTREPTOLYSIN O (ASO TITER)Laboratory30086060$ 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
3000516ARTERIAL PUNCTURELaboratory36136600$ 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
30084244ASSAY OF RENINLaboratory30184244$ 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
3000332AST (ASPARTATE AMINOTRANSFERASLaboratory30184450$ 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
3000359BILIRUBIN DIRECTLaboratory30182248$ 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
3000362BLOOD SMEAR STUDYLaboratory30085060$ 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
3000363BLOOD TYPING, ABOLaboratory39086900$ 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
3000214BLOOD TYPING, RH PHENOTYPINGLaboratory39086901$ 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
3000364BLOOD UREA NITROGEN (BUN)Laboratory30184520$ 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
3000308BLOOD, OCCULT, OTHER SOURCELaboratory30182274$ 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
3001794C4 & C3 COMPLEMENT GROUPLaboratory30086160$ 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
3000163CA 19-9Laboratory30086301$ 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
3000062CARBAMAZEDINELaboratory30080201$ 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
3001579CARCINOEMBRYONIC ANTIGEN (CEA)Laboratory30082378$ 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
30087798CCDC COVID-19 STATE TESTLaboratory300U0001$ 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
3000481CHLAMYDIA DNA PROBELaboratory30687490$ 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
3001792CLOSTRIDIUM DIFFICILE TOXINLaboratory30687324$ 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
3000157COCCIDIOIDES ANTIBODYLaboratory30086635$ 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
3000335COMPATIBILITY TEST ANTIGLOBULILaboratory39086922$ 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
3000056COMPLEMENT C-4Laboratory30086160$ 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
3000054COMPLEMENT COMPONENT C3CLaboratory30086160$ 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
3000152CORTISOLLaboratory30182533$ 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
30087798BCOVID-19 REFERENCE LABLaboratory30087635$ 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
3000433C-REACTIVE PROTEINLaboratory30286140$ 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
3000382CREATINE PHOSPHOKINASE (CPK)Laboratory30182550$ 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
3000381CREATININE, SERUMLaboratory30182565$ 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
3001549CREATININE, URINELaboratory30182570$ 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
3000047CREATININE; OTHER SOURCELaboratory30182570$ 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
30087899Cryptococcus AntigenLaboratory30087899$ 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
3000151CRYSTAL IDENTIFICATIONLaboratory30089060$ 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
3000392CULTURE, BACTERIAL; BLOODLaboratory30687040$ 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
3000352CULTURE: AEROBIC/ROUTINE/MISCLaboratory30687070$ 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
3001770CULTURE: ANAEROBIC MISC.Laboratory30687075$ 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
3000393CULTURE: THROATLaboratory30687070$ 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
3000041CULTURE: URINE, CATHLaboratory30087088$ 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
3000394CULTURE; BACTERIAL WITH ISOLaboratory30687088$ 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
3000442CYANOCOBALAMIN (VITAMIN B-12)Laboratory30182607$ 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
30082610Cystatin CLaboratory30182610$ 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
3000133DHEA SULFATELaboratory30182627$ 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
3000194DIRECT LDLLaboratory30183721$ 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 CODEDESCRIPTIONDepartmentREV CODECPT CODERATECash PayAetnaBCBS TX - Blue AdvantageBCBS TX Blue EssentialsBCBS TX PPOBCBS TX TradCIGNAHumanaUnicareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
3000484DNA ANTIBODY DOUBLE STANDEDLaboratory30086225$ 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
3001763DRUG SCREENLaboratory30180305$ 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
3000405DRUG SCREENLaboratory30180306$ 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
3001764DRUG SCREEN: COLLECTION ONLYLaboratory30180305$ 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
3000491ESTRADIOLLaboratory30082670$ 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
3000446ETHANOL (BLOOD ALCOHOL)Laboratory301G0480$ 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
3000371FERRINTIN, SERUMLaboratory30182728$ 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
3000703FIBRIN DEGRADATION D-DIMERLaboratory30585379$ 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
3000487FOLATE STIMULATING HORMONE,FSHLaboratory30183001$ 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
3000441FOLATE, SERUMLaboratory30182746$ 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
3000104FREE TESTOSTERONELaboratory30184402$ 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
3000356GASES, BLOOD ANY COMBINATIONLaboratory30182803$ 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
3000479GC DNA PROBELaboratory30687590$ 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
3000498GENTAMICINLaboratory30080170$ 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
30087507GI profile, Stool PCRLaboratory30687507$ 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
2700361GLUCOSE BLOOD, REAGENT STRIPLaboratory30182948$ 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
3000387GLUCOSE TLERANCE 1 HRLaboratory30182947$ 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
3000388GLUCOSE TOLERANCE MAXINMUMLaboratory30182951$ 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
3000389GRAM STAINLaboratory30687205$ 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
30083014H PYLORI ADMINISTRATIONLaboratory30183014$ 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
30083013H PYLORI BREATH TESTLaboratory30183013$ 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
3000473HCG BETA QUANTITATIVELaboratory30184702$ 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
3000295HEMATOCRIT (HCT)Laboratory30585014$ 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
3000297HEMOGLOBIN (HGB)Laboratory30585018$ 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
3000413HEMOGLOBIN GLYCOSYLATED (A1C)Laboratory30183036$ 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
3000454HEPATITIS A AB IGG/IGMLaboratory30286708$ 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
3000510HEPATITIS B CORE AB, IGG, IGMLaboratory30286704$ 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
3000512HEPATITIS B SURFACE AB HBSABLaboratory30286706$ 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
3000514HEPATITIS B SURFACE AG HBSAGLaboratory30087340$ 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
3000344HEPATITIS B SURFACE ANTIBODYLaboratory30086706$ 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
3000508HEPATITIS C ABLaboratory30086803$ 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
3000900HEPATITIS C ANTIBODYLaboratory30286803$ 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
30087385Histoplasma Antigen, UrineLaboratory30087385$ 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
3000434HIVLaboratory30286701$ 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
3000427HLAB 27 ANTIGENLaboratory30086812$ 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
3000057IGALaboratory30182784$ 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
3001798IGELaboratory30182785$ 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
3000494IGGLaboratory30182784$ 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
30016743IGMLaboratory30082784$ 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
3000562INFLUENZA A & BLaboratory30687804$ 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
5200186INFLUENZA SWABLaboratory30687804$ 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
3000042INSULINLaboratory30183525$ 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
3000438IRON AND TIBCLaboratory30183550$ 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
3000189KEPPRA LEVELLaboratory30180177$ 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
3000301LACTATE DEHYDROGENASE (LDH)Laboratory30183615$ 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
30083605Lactic AcidLaboratory30183605$ 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
30016333LEAD LEVEL BLOODLaboratory30183655$ 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
3000486LIPASELaboratory30183690$ 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
3000307LITHIUM LEVELLaboratory30180178$ 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
3000488LUTEINIZING HORMONE (LH)Laboratory30083002$ 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
3000304MAGNESIUM-RLaboratory30183735$ 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
3000380MB FRACTION ONLYLaboratory30182553$ 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
3000306MONO TESTLaboratory30286308$ 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
30086735MUMPS AB (ANTIBODY)Laboratory30286735$ 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
3000046NATRIURETIC PEPTIDELaboratory30183880$ 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
3000459PANEL: GENERAL HEALTHLaboratory30080050$ 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
3000424PANEL: HEPATITIS ABC ACUTELaboratory30180074$ 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
3000443PAP SMEARLaboratory31188142$ 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
3000398PHENYTOIN (DILANTIN)Laboratory30180185$ 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
3000314PHOSPHORUS (PO4)Laboratory30184100$ 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
3000464PREGNANCY TEST SERUMLaboratory30184703$ 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 CODEDESCRIPTIONDepartmentREV CODECPT CODERATECash PayAetnaBCBS TX - Blue AdvantageBCBS TX Blue EssentialsBCBS TX PPOBCBS TX TradCIGNAHumanaUnicareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
3000425PREGNANCY TEST URINELaboratory30781025$ 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
30084145ProcalcitoninLaboratory30184145$ 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
3000501PROGESTERONELaboratory30184144$ 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
3000411PROLACTINLaboratory30184146$ 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
3000340PROTEIN URINE 24 HRLaboratory30184156$ 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
3000321PSA ANNUAL SCNLaboratory309G0103$ 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
3000208PTH,INTACT & CALCIUMLaboratory30183970$ 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
30086480QUANTIFERONLaboratory30286480$ 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
3000327RHEUMATOID ARTHRITIS QUALITATILaboratory30286430$ 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
3000483RHEUMATOID ARTHRITIS QUANTITATLaboratory30086431$ 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
3000326RPR (RAPID PLASMA REAGIN)Laboratory30286592$ 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
3000124RSV NASAL SWABLaboratory30286756$ 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
3000406RUBELLA ABLaboratory30286762$ 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
3001724RUBELLA AB (IMMUNITY)Laboratory30286762$ 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
3000403RUBEOLA ABLaboratory30286765$ 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
3000196SALICYLATE LEVELLaboratory30180299$ 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
3000328SEDIMENTATION RATELaboratory30585651$ 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
3000538SJORGREN'S ANTIBODIES(SSA,SSB)Laboratory30286235$ 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
3001396STREPTOCOCCUS, GROUP ALaboratory30687430$ 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
3000705SUSCEPTIBILITY STUDIESLaboratory30687186$ 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
3000742T UPTAKELaboratory30184479$ 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
3000419T-3 (TOTAL)Laboratory30184480$ 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
3000471T-3 FREELaboratory30184481$ 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
3000348T-4 (TOTAL)Laboratory30184436$ 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
30080197Tacrolimus (Prograft) LevelLaboratory30180197$ 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
3000313TESTOSTERONELaboratory30184403$ 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
3000346THYROID PEROXIDASELaboratory30286376$ 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
3000476THYROXINE; FREELaboratory30184439$ 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
3000395TISSUE COLLECTION PROCESSLaboratory31088300$ 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
3000532TISSUE PROCESSEDLaboratory31088305$ 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
30083516TRANSGLUTAMINASELaboratory30183516$ 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
3000334TRIGLYCERIDESLaboratory30084478$ 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
3001840TROPONIN, QUALITATIVELaboratory30184512$ 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
3000336URIC ACIDLaboratory30184550$ 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
3000560URIC ACIDLaboratory30084560$ 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
3000188URINE OSMOLALITYLaboratory30083935$ 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
3000311VALPORIC ACID DEPAKNE, VALPROLaboratory30180164$ 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
3000565VARECILLA ZOSTER IGGLaboratory30286787$ 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
3000200VARICELLA TITER IGMLaboratory30086787$ 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
3000148VIRUS CULTURELaboratory30687252$ 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
3000155VITAMIN D 1.25 DIHYDROXYLaboratory30182652$ 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
3001550WET MOUNT SMEARLaboratory30687210$ 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
42097535ADLS / 15MINPhysical Therapy42097535$ 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
42097032ELECT. STIM / 15MIN.Physical Therapy42097032$ 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
4201802EVAL REASSEMMENT ( EA 0-15Physical Therapy42197164$ 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
42097116GAIT TRAINING / 15MINPhysical Therapy42097116$ 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
4201760IONTOPHORESISPhysical Therapy42097033$ 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
42097140MANUAL THERAPYPhysical Therapy42097140$ 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
42097124MASSAGE / 15MINPhysical Therapy42097124$ 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
42097112NEUROMUSCULAR REEDUCATION / 15MINPhysical Therapy42097112$ 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
42097018PARAFFIN BATHPhysical Therapy42097018$ 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
42097163PT EVAL; HIGH COMPLEXITYPhysical Therapy42097163$ 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
42097161PT EVAL; LOW COMPLEXITYPhysical Therapy42097161$ 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
42097162PT EVAL; MODERATE COMPLEXITYPhysical Therapy42097162$ 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
42097002REEVAL/DISCHARGEPhysical Therapy42497164$ 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
42097530THERAPEUTIC ACTIVITIES FUNCTIONAL 15MINPhysical Therapy42097530$ 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
42097035ULTRASOUND / 15MINPhysical Therapy42097035$ 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
3201415ABDOMEN 1 VIEWRadiology Diagnostic32074018$ 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
3201416ABDOMEN-2 VIEWSRadiology Diagnostic32074019$ 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
3201417ABDOMEN-3 VIEWSRadiology Diagnostic32074021$ 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
4005101ABDOMINAL LIMIT, Ultra SoundRadiology Diagnostic40076705$ 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 CODEDESCRIPTIONDepartmentREV CODECPT CODERATECash PayAetnaBCBS TX - Blue AdvantageBCBS TX Blue EssentialsBCBS TX PPOBCBS TX TradCIGNAHumanaUnicareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
3200125ANKLE 2 VIEWSRadiology Diagnostic32073600$ 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
3201419ANKLE SERIESRadiology Diagnostic32073610$ 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
40093925ARTERIES LOW EXT CMPLE BIRadiology Diagnostic92193925$ 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
4005162BLADDER, Ultra SoundRadiology Diagnostic40276857$ 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
4007200CAROTID DOPPLERRadiology Diagnostic92193880$ 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
3201420CHEST VIEWRadiology Diagnostic32071045$ 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
3201421CHEST 2 VIEWSRadiology Diagnostic32071046$ 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
4005116CHEST, Ultra SoundRadiology Diagnostic40276604$ 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
3201423CLAVICLE CompleteRadiology Diagnostic32073000$ 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
3207524CT ABDOMEN W/O CONTRASTRadiology Diagnostic35074150$ 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
32074176CT Abdomen/Pelvis w/o contrastRadiology Diagnostic32074176$ 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
35074176CT Abdomen/Pelvis W/O contrastRadiology Diagnostic35074176$ 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
3207541CT ANGIOGRAPHY NECK-CAROTIDSRadiology Diagnostic35070498$ 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
35071275CT CHEST ANGIOGRAPHY/PE PROTOCRadiology Diagnostic35071275$ 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
3207503CT CHEST W/O CONTRASTRadiology Diagnostic35071250$ 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
3207506CT C-SPINE W/O CONTRASTRadiology Diagnostic35072125$ 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
3207502CT HEAD/BRAIN W/W/O CONTRASTRadiology Diagnostic32070470$ 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
3207522CT LOWER EXTREM W/CONTRASTRadiology Diagnostic35073701$ 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
3207521CT LOWER EXTREM W/O CONTRASTRadiology Diagnostic35073700$ 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
3207512CT L-SPINE W/O CONTRASTRadiology Diagnostic35072131$ 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
3207530CT MAXILLOFACIAL W/ORadiology Diagnostic35070486$ 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
3207515CT PELVIS W/O CONTRASTRadiology Diagnostic35072192$ 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
3207540CT QCT BMD SURVEYRadiology Diagnostic35077078$ 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
3207538CT SINUS W/ORadiology Diagnostic32070486$ 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
3207533CT SOFT TISSUE NECK W/O CONTRARadiology Diagnostic32072125$ 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
3207534CT SOFTIS NECK W/CONTRASTRadiology Diagnostic35070491$ 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
3207535CT SOFTIS NECK W/W/O CONTRASTRadiology Diagnostic35070492$ 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
3207504CT THORAX W/CONTRASTRadiology Diagnostic35071260$ 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
3207509CT T-SPINE W/O CONTRASTRadiology Diagnostic35072128$ 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
3207518CT UPPER EXTREM W/O CONTRASTRadiology Diagnostic35073200$ 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
3201428ELBOW COMPLETERadiology Diagnostic32073080$ 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
3201220ELBOW LIMITEDRadiology Diagnostic32073070$ 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
3201429FACIAL BONES COMPLETERadiology Diagnostic32070150$ 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
3201431FEMUR 2 VIEWSRadiology Diagnostic32073552$ 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
3201432FINGER MIN 2 VIEWSRadiology Diagnostic32073140$ 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
3201975FOOT 2 VIEWSRadiology Diagnostic32073620$ 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
3201434FOOT COMPLETERadiology Diagnostic32073630$ 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
3201435FOREARM 2 VIEWSRadiology Diagnostic32073090$ 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
4005104GALLBLADDER, Ultra SoundRadiology Diagnostic40276705$ 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
3201436HAND 2 VIEWSRadiology Diagnostic32073120$ 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
3201437HAND 3 VIEWSRadiology Diagnostic32073130$ 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
3201438HEEL (CALCANEUS)Radiology Diagnostic32073650$ 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
3201440HIP 2 VEIWSRadiology Diagnostic32073502$ 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
3202875HUMERUS 2 VIEWSRadiology Diagnostic32073060$ 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
4005105KIDNEY, Ultra SoundRadiology Diagnostic40276770$ 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
3201442KNEE 2 VIEWSRadiology Diagnostic32073560$ 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
3201510KNEE 3 VEIWSRadiology Diagnostic32073562$ 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
3203125KNEE COMP INCL PATELLARRadiology Diagnostic32073564$ 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
3201445LEG 2 VIEWSRadiology Diagnostic32073590$ 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
4005106LIVER, Ultra SoundRadiology Diagnostic40076705$ 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
3201448MANDIBLE / MAXILLARadiology Diagnostic32070100$ 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
3201449NOSE COMP MIN 2 VIEWSRadiology Diagnostic32070160$ 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
3201450ORBITSRadiology Diagnostic32070030$ 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
4005108PELVIC, Ultra SoundRadiology Diagnostic40276856$ 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
3201452PELVIS 1 VIEWRadiology Diagnostic32072170$ 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
32074178PELVIS/ABDOMEN W/W/O CONTRASTRadiology Diagnostic35074178$ 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
40093971PERI. VEN. (LTD)Radiology Diagnostic92193971$ 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
3201456RIBS 1 SIDE 3 VIEWSRadiology Diagnostic32071110$ 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
3201458SACRO-ILIAC JTS 3 VIEWSRadiology Diagnostic32072202$ 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
3201459SACRUM & COCCYXRadiology Diagnostic32072220$ 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
3201461SCAPULA 2 VIEWSRadiology Diagnostic32073010$ 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 CODEDESCRIPTIONDepartmentREV CODECPT CODERATECash PayAetnaBCBS TX - Blue AdvantageBCBS TX Blue EssentialsBCBS TX PPOBCBS TX TradCIGNAHumanaUnicareUnitedMinimum Negotiated ChargeMaximum Negotiated Charge
32072090Scoliosis StudyRadiology Diagnostic32072081$ 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
4005113SCROTUM, Ultra SoundRadiology Diagnostic40276856$ 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
3201463SHOULDER 2 VEIWSRadiology Diagnostic32073030$ 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
3201464SHOULDER 3 VEIWSRadiology Diagnostic32073040$ 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
3201498SINUSES COMP MIN 3 VIEWSRadiology Diagnostic32070220$ 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
3201465SKULL 2 VIEWSRadiology Diagnostic32070250$ 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
3201466SKULL SERIES MIN 3 VIEWSRadiology Diagnostic32070260$ 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
3201499SPINE CERVICAL 3 VIEWSRadiology Diagnostic32072040$ 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
3206575SPINE DORSAL 2 VIEWRadiology Diagnostic32072070$ 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
3201502SPINE LUMBAR 2 VIEWSRadiology Diagnostic32072100$ 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
4005112THYROID, Ultra SoundRadiology Diagnostic40276536$ 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
3207225TOES MIN 2 VIEWSRadiology Diagnostic32073660$ 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
40076882US Extremity Non Vascular LimitedRadiology Diagnostic40276882$ 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
40093970VEINS EXTREMITY CMPLE BILRadiology Diagnostic92193970$ 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
3207475WRIST 2 VIEWS AP/LATRadiology Diagnostic32073100$ 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
3201476WRIST COMP MIN 3 VIEWSRadiology Diagnostic32073110$ 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
99394EST PT PHYSICAL 12-17 YEARSRural Health Clinic52199394$ 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
99397EST PT PHYSICAL- 65 AND OVERRural Health Clinic52199397$ 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
99391EST PT PHYSICAL UNDER 1 YEARRural Health Clinic52199391$ 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
99396EST PT PHYSICAL-40-64 YEARSRural Health Clinic52199396$ 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
99395EST PT-PHYSICAL 18-39 YEARSRural Health Clinic52199395$ 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
99214ESTAB PAT-DETAILED IVRural Health Clinic52199214$ 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
99212ESTAB PAT-FOCUSED IIRural Health Clinic52199212$ 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
99213ESTAB PAT-LOW COMPLEX IIIRural Health Clinic52199213$ 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
99393ESTAB PT PHYSICAL 5-11 YEARSRural Health Clinic52199393$ 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
99392ESTAB PT PHYSICAL-1-4YEARSRural Health Clinic52199392$ 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
99384NEW E/M PHYS AGE 12-17 YEARSRural Health Clinic52199384$ 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
99382NEW E/M PHYSICAL 1-4 YEARSRural Health Clinic52199382$ 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
99383NEW E/M PHYSICAL 5-11 YEARSRural Health Clinic52199383$ 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
99381NEW E/M PHYSICAL UNDER 1 YEARRural Health Clinic52199381$ 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
99202NEW PATIENT INTERMED IIRural Health Clinic52199202$ 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
99201OV/NEW PT.SIMPLE IRural Health Clinic52199201$ 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
3000429BASIC METABOLIC PANELLaboratory30180048$ 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
3000655COMPLETE (CBC) AUTO HGB,HCT,Laboratory30585025$ 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
3000447COMPREHESIVE METABOLIC PANELLaboratory30180053$ 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
3000402HEPATIC FUNCTION PANELLaboratory30180076$ 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
3000318LIPID PANELLaboratory30180061$ 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
3000533PANEL: RENAL FUNCTION RFTLaboratory30180069$ 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
3000324PROTHROMBIN TIME;Laboratory30585610$ 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
30084153PSALaboratory30084153$ 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
3000254PSA FREELaboratory30184154$ 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
3000312THROMBOPLASTINE TIME PART PTTLaboratory30585730$ 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
3000420THYROID STIMIULATING HORMONELaboratory30184443$ 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
3000337URINALYSIS AUTOMATED W/MICROLaboratory30781001$ 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
3001527URINALYSIS, AUTOMATED W/O MICRLaboratory30081003$ 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
81002URINE DIPSTICKLaboratory30081002$ 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
42097110THEREX 15 / 15MINPhysical Therapy42097110$ 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
4005100ABDOMINAL COMPLETE, Ultra SoundRadiology Diagnostic40276700$ 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
35074177CT Abdomen/Pelvis w/ contrastRadiology Diagnostic35074177$ 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
3207500CT HEAD/BRAIN W/O CONTRASTRadiology Diagnostic35070450$ 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
3201469SPINE LUMBAR COMPRadiology Diagnostic32072110$ 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
99385NEW E/M PHYSICAL 18-39YEARSRural Health Clinic52199385$ 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
99386NEW E/M PHYSICAL 40-64 YEARSRural Health Clinic52199386$ 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
99205NEW PAT-COMPLEX VRural Health Clinic52199205$ 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
99204NEW PAT-COMPREHENSIVE IVRural Health Clinic52199204$ 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
99203NEW PAT-DETAILED IIIRural Health Clinic52199203$ 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.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.  This included related costs like medical test, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item.  You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
  • Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call {877-696-6775}

Skip to content