Prices on the shoppable services list represent the standard amount for each service and do not represent the actual amount the patient will pay. The actual amount will depend on application of insurance contract/benefit plan discounts or self-pay discounts, which are dependent on each patientís benefit plan terms. Shoppable services are defined as a health care services that consumers can schedule in advance, at a time that is convenient for them.

This list defines each shoppable service by a service category and displays the estimated total charge, categorized by plan terms. Additionally, each shoppable service is identified by a common service billing code.


                          View Standard Charges
Shoppable Service Primary Service and Ancillary Services CPT/HCPCS Code Self Pay Rate Aetna HMO Aetna POS Aetna PPO AARP Medicare Advantage†† BCBS Choice BCBS Preferred BCBS Traditional Blue Lincs Cigna PPO Choice Cigna Open Access Plus†† Generations Medicare Advantage Healthchoice Humana Medicare Advanatge Medicare Medicaid Preferred Community Choice†† United Health Care PPO†† United Health Care HMO†† United Health Care Medicare Advantage Minimum Rate Maximum Rate
MANDIBLE COMPLETE MINIMUM 4V Radiology Hospital Services 70110 163.8 174.04 174.04 174.04 206.7975 99.989 99.9894 99.9894 100 174.04 139.23 206.7975 252.18 206.7975 165.438 24.84 163.8 143.325 143.33 206.7975 24.84 252.18
Radiology Physician Services Not provided by hospital (may be billed separately)    
FACIAL BONES COMPLETE MIN 3V Radiology Hospital Services 70150 163.8 174.04 174.04 174.04 206.7975 99.989 99.9894 99.9894 100 174.04 139.23 206.7975 252.18 206.7975 165.438 27.24 163.8 143.325 143.33 206.7975 27.24 252.18
Radiology Physician Services Not provided by hospital (may be billed separately)    
NASAL BONES COMPLETE MINIMUM 3V Radiology Hospital Services 70160 163.8 174.04 174.04 174.04 206.7975 99.989 99.9894 99.9894 100 174.04 139.23 206.7975 179.57 206.7975 165.438 23.05 163.8 143.325 143.33 206.7975 23.05 206.7975
Radiology Physician Services Not provided by hospital (may be billed separately)    
ORBITS OPTIC FORAMINA Radiology Hospital Services 70190 163.8 174.04 174.04 174.04 206.7975 99.989 99.9894 99.9894 100 174.04 139.23 206.7975 179.57 206.7975 165.438 22.75 163.8 143.325 143.33 206.7975 22.75 206.7975
Radiology Physician Services Not provided by hospital (may be billed separately)    
SINUS COMPLETE MINIMUM 3V Radiology Hospital Services 70220 326 346.38 346.38 346.38 411.575 99.989 99.9894 99.9894 100 346.38 277.1 411.575 179.57 411.575 329.26 21.25 326 285.25 285.25 411.575 21.25 411.575
Radiology Physician Services Not provided by hospital (may be billed separately)    
SKULL LESS THAN 4V Radiology Hospital Services 70250 381.536 405.38 405.38 405.38 481.6892 99.989 99.9894 99.9894 100 405.38 324.31 481.6892 252.18 481.6892 385.3514 21.25 381.536 333.844 333.84 481.6892 21.25 481.6892
Radiology Physician Services Not provided by hospital (may be billed separately)    
NECK SOFT TISSUE 2 VIEWS Radiology Hospital Services 70360 307.456 326.67 326.67 326.67 388.1632 99.989 99.9894 99.9894 100 326.67 261.34 388.1632 179.57 388.1632 310.5306 17.96 307.456 269.024 269.02 388.1632 17.96 388.1632
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT HEAD/BRAIN W/O CONTRAST Radiology Hospital Services 70450 1353.15 1437.7 1437.7 1437.7 1708.3544 372.11 372.1052 372.1052 372 1437.7 1150.2 1708.3544 336.24 1708.3544 1366.6835 61.07 1353.152 1184.008 1184 1708.3544 61.07 1708.3544
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT HEAD/BRAIN W/ CONTRAST Radiology Hospital Services 70460 1464.96 1556.5 1556.5 1556.5 1849.512 372.11 372.1052 372.1052 372 1556.5 1245.2 1849.512 546.66 1849.512 1479.6096 89.51 1464.96 1281.84 1281.8 1849.512 89.51 1849.512
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT HEAD/BRAIN W/ & W/O CONTRAST Radiology Hospital Services 70470 1703.62 1810.1 1810.1 1810.1 2150.8253 372.11 372.1052 372.1052 372 1810.1 1448.1 2150.8253 546.66 2150.8253 1720.6602 107.17 1703.624 1490.671 1490.7 2150.8253 107.17 2150.8253
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT MAXILLOFACIAL W/O CONTRAST Radiology Hospital Services 70486 1329.6 1412.7 1412.7 1412.7 1678.62 784.59 784.5928 784.5928 785 1412.7 1130.2 1678.62 336.24 1678.62 1342.896 80.83 1329.6 1163.4 1163.4 1678.62 80.83 1678.62
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT MAXILLOFACIAL W/ & W/O CONTRAST Radiology Hospital Services 70488 1628.74 1730.5 1730.5 1730.5 2056.2792 784.59 784.5928 784.5928 785 1730.5 1384.4 2056.2792 546.66 2056.2792 1645.0234 117.65 1628.736 1425.144 1425.1 2056.2792 117.65 2056.2792
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT SOFT TISSUE NECK W/O CONTRAST Radiology Hospital Services 70490 1356.5 1441.3 1441.3 1441.3 1712.5863 784.59 784.5928 784.5928 785 1441.3 1153 1712.5863 252.18 1712.5863 1370.069 84.12 1356.504 1186.941 1186.9 1712.5863 84.12 1712.5863
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT SOFT TISSUE NECK W/CONTRAST Radiology Hospital Services 70491 1668.64 1772.9 1772.9 1772.9 2106.658 784.59 784.5928 784.5928 785 1772.9 1418.3 2106.658 410 2106.658 1685.3264 111.96 1668.64 1460.06 1460.1 2106.658 111.96 2106.658
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT SOFT TISSUE NECK W/ & W/O CONTRAST Radiology Hospital Services 70492 1980.77 2104.6 2104.6 2104.6 2500.7196 784.59 784.5928 784.5928 785 2104.6 1683.7 2500.7196 410 2500.7196 2000.5757 137.11 1980.768 1733.172 1733.2 2500.7196 137.11 2500.7196
Radiology Physician Services Not provided by hospital (may be billed separately)    
CHEST XRAY 1 VIEW Radiology Hospital Services 71045 198.784 211.21 211.21 211.21 250.9648 99.989 99.9894 99.9894 100 211.21 168.97 250.9648 179.57 250.9648 200.7718 13.77 198.784 173.936 173.94 250.9648 13.77 250.9648
Radiology Physician Services Not provided by hospital (may be billed separately)    
CHEST XRAY 2 VIEW Radiology Hospital Services 71046 198.784 211.21 211.21 211.21 250.9648 99.989 99.9894 99.9894 100 211.21 168.97 250.9648 179.57 250.9648 200.7718 18.26 198.784 173.936 173.94 250.9648 18.26 250.9648
Radiology Physician Services Not provided by hospital (may be billed separately)    
RIBS UNILATERAL 2V Radiology Hospital Services 71100 263.264 279.72 279.72 279.72 332.3708 99.989 99.9894 99.9894 100 279.72 223.77 332.3708 179.57 332.3708 265.8966 20.35 263.264 230.356 230.36 332.3708 20.35 332.3708
Radiology Physician Services Not provided by hospital (may be billed separately)    
RIBS BILATERAL 3V Radiology Hospital Services 71110 92.664 98.456 98.456 98.456 116.9883 99.989 99.9894 99.9894 100 98.456 78.764 116.9883 252.18 116.9883 93.5906 23.65 92.664 81.081 81.081 116.9883 23.65 252.18
Radiology Physician Services Not provided by hospital (may be billed separately)    
STERNUM MINIMUM 2V Radiology Hospital Services 71120 182 193.38 193.38 193.38 229.775 99.989 99.9894 99.9894 100 193.38 154.7 229.775 179.57 229.775 183.82 18.86 182 159.25 159.25 229.775 18.86 229.775
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT CHEST W/O CONTRAST Radiology Hospital Services 71250 1356.5 1441.3 1441.3 1441.3 1712.5863 784.59 784.5928 784.5928 785 1441.3 1153 1712.5863 336.24 1712.5863 1370.069 84.12 1356.504 1186.941 1186.9 1712.5863 84.12 1712.5863
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT CHEST W/ CONTRAST Radiology Hospital Services 71260 1464.96 1556.5 1556.5 1556.5 1849.512 784.59 784.5928 784.5928 785 1556.5 1245.2 1849.512 546.66 1849.512 1479.6096 112.26 1464.96 1281.84 1281.8 1849.512 112.26 1849.512
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT CHEST W/ & W/O CONTRAST Radiology Hospital Services 71270 1710.18 1817.1 1817.1 1817.1 2159.0972 784.59 784.5928 784.5928 785 1817.1 1453.6 2159.0972 546.66 2159.0972 1727.2778 137.11 1710.176 1496.404 1496.4 2159.0972 137.11 2159.0972
Radiology Physician Services Not provided by hospital (may be billed separately)    
CTA CHEST (PE PROTOCOL) Radiology Hospital Services 71275 728.88 774.44 774.44 774.44 920.211 1059 1058.9998 1058.9998 1059 774.44 619.55 920.211 410 920.211 736.1688 151.18 728.88 637.77 637.77 920.211 151.18 1058.9998
Radiology Physician Services Not provided by hospital (may be billed separately)    
C-SPINE 1V SPECIFY LEVEL Radiology Hospital Services 72020 107.52 114.24 114.24 114.24 135.744 99.989 99.9894 99.9894 100 114.24 91.392 135.744 179.57 135.744 108.5952 13.47 107.52 94.08 94.08 135.744 13.47 179.57
Radiology Physician Services Not provided by hospital (may be billed separately)    
L-SPINE 1V SPECIFY LEVEL Radiology Hospital Services 72020 107.52 114.24 114.24 114.24 135.744 99.989 99.9894 99.9894 100 114.24 91.392 135.744 179.57 135.744 108.5952 13.47 107.52 94.08 94.08 135.744 13.47 179.57
Radiology Physician Services Not provided by hospital (may be billed separately)    
C-SPINE 2V OR 3V Radiology Hospital Services 72040 279.368 296.83 296.83 296.83 352.7021 99.989 99.9894 99.9894 100 296.83 237.46 352.7021 179.57 352.7021 282.1617 22.45 279.368 244.447 244.45 352.7021 22.45 352.7021
Radiology Physician Services Not provided by hospital (may be billed separately)    
C-SPINE 4V OR 5V Radiology Hospital Services 72050 396.76 421.56 421.56 421.56 500.9095 99.989 99.9894 99.9894 100 421.56 337.25 500.9095 252.18 500.9095 400.7276 30.83 396.76 347.165 347.17 500.9095 30.83 500.9095
Radiology Physician Services Not provided by hospital (may be billed separately)    
T-SPINE 2V Radiology Hospital Services 72070 250.912 266.59 266.59 266.59 316.7764 99.989 99.9894 99.9894 100 266.59 213.28 316.7764 252.18 316.7764 253.4211 17.96 250.912 219.548 219.55 316.7764 17.96 316.7764
Radiology Physician Services Not provided by hospital (may be billed separately)    
T-SPINE 2 VIEWS W/SWIMMERS Radiology Hospital Services 72072 358.656 381.07 381.07 381.07 452.8032 99.989 99.9894 99.9894 100 381.07 304.86 452.8032 252.18 452.8032 362.2426 22.45 358.656 313.824 313.82 452.8032 22.45 452.8032
Radiology Physician Services Not provided by hospital (may be billed separately)    
SPINE ENTIRE INCLUDING SKULL 1V Radiology Hospital Services 72081 271.312 288.27 288.27 288.27 342.5314 99.989 99.9894 99.9894 100 288.27 230.62 342.5314 179.57 342.5314 274.0251 23.65 271.312 237.398 237.4 342.5314 23.65 342.5314
Radiology Physician Services Not provided by hospital (may be billed separately)    
L-SPINE 2V OR 3V Radiology Hospital Services 72100 260.36 276.63 276.63 276.63 328.7045 99.989 99.9894 99.9894 100 276.63 221.31 328.7045 252.18 328.7045 262.9636 22.45 260.36 227.815 227.82 328.7045 22.45 328.7045
Radiology Physician Services Not provided by hospital (may be billed separately)    
L-SPINE MINIMUM 4V Radiology Hospital Services 72110 283.4 301.11 301.11 301.11 357.7925 99.989 99.9894 99.9894 100 301.11 240.89 357.7925 252.18 357.7925 286.234 29.63 283.4 247.975 247.98 357.7925 29.63 357.7925
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT C-SPINE W/O CONTRAST Radiology Hospital Services 72125 1356.5 1441.3 1441.3 1441.3 1712.5863 652.24 652.2402 652.2402 652 1441.3 1153 1712.5863 252.18 1712.5863 1370.069 88.61 1356.504 1186.941 1186.9 1712.5863 88.61 1712.5863
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT T-SPINE W/O CONTRAST Radiology Hospital Services 72128 1356.5 1441.3 1441.3 1441.3 1712.5863 652.24 652.2402 652.2402 652 1441.3 1153 1712.5863 252.18 1712.5863 1370.069 88.61 1356.504 1186.941 1186.9 1712.5863 88.61 1712.5863
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT L-SPINE W/O CONTRAST Radiology Hospital Services 72131 1512.62 1607.2 1607.2 1607.2 1909.6878 652.24 652.2402 652.2402 652 1607.2 1285.7 1909.6878 252.18 1909.6878 1527.7502 88.01 1512.624 1323.546 1323.5 1909.6878 88.01 1909.6878
Radiology Physician Services Not provided by hospital (may be billed separately)    
PELVIS 1V OR 2V Radiology Hospital Services 72170 215.424 228.89 228.89 228.89 271.9728 99.989 99.9894 99.9894 100 228.89 183.11 271.9728 252.18 271.9728 217.5782 16.46 215.424 188.496 188.5 271.9728 16.46 271.9728
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT PELVIS W/O CONTRAST Radiology Hospital Services 72192 1280.08 1360.1 1360.1 1360.1 1616.101 963.59 963.5928 963.5928 964 1360.1 1088.1 1616.101 336.24 1616.101 1292.8808 76.34 1280.08 1120.07 1120.1 1616.101 76.34 1616.101
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT PELVIS W/ & W/O CONTRAST Radiology Hospital Services 72194 1724.3 1832.1 1832.1 1832.1 2176.9237 963.59 963.5928 963.5928 964 1832.1 1465.7 2176.9237 410 2176.9237 1741.539 151.18 1724.296 1508.759 1508.8 2176.9237 151.18 2176.9237
Radiology Physician Services Not provided by hospital (may be billed separately)    
SACRUM/COCCYX MINIMUM 2V Radiology Hospital Services 72220 235.624 250.35 250.35 250.35 297.4753 99.989 99.9894 99.9894 100 250.35 200.28 297.4753 179.57 297.4753 237.9802 18.86 235.624 206.171 206.17 297.4753 18.86 297.4753
Radiology Physician Services Not provided by hospital (may be billed separately)    
XRAY CLAVICLE COMPLETE Radiology Hospital Services 73000 279.576 297.05 297.05 297.05 352.9647 99.989 99.9894 99.9894 100 297.05 237.64 352.9647 179.57 352.9647 282.3718 19.15 279.576 244.629 244.63 352.9647 19.15 352.9647
Radiology Physician Services Not provided by hospital (may be billed separately)    
SHOULDER COMPLETE MINIMUM 2V Radiology Hospital Services 73030 247.416 262.88 262.88 262.88 312.3627 99.989 99.9894 99.9894 100 262.88 210.3 312.3627 179.57 312.3627 249.8902 19.75 247.416 216.489 216.49 312.3627 19.75 312.3627
Radiology Physician Services Not provided by hospital (may be billed separately)    
HUMERUS MINIMUM 2V Radiology Hospital Services 73060 229.368 243.7 243.7 243.7 289.5771 99.989 99.9894 99.9894 100 243.7 194.96 289.5771 179.57 289.5771 231.6617 19.15 229.368 200.697 200.7 289.5771 19.15 289.5771
Radiology Physician Services Not provided by hospital (may be billed separately)    
ELBOW 2V Radiology Hospital Services 73070 233.584 248.18 248.18 248.18 294.8998 99.989 99.9894 99.9894 100 248.18 198.55 294.8998 179.57 294.8998 235.9198 16.76 233.584 204.386 204.39 294.8998 16.76 294.8998
Radiology Physician Services Not provided by hospital (may be billed separately)    
ELBOW COMPLETE 3V Radiology Hospital Services 73080 120 127.5 127.5 127.5 151.5 99.989 99.9894 99.9894 100 127.5 102 151.5 179.57 151.5 121.2 18.56 120 105 105 151.5 18.56 179.57
Radiology Physician Services Not provided by hospital (may be billed separately)    
FOREARM 2V Radiology Hospital Services 73090 212.712 226.01 226.01 226.01 268.5489 99.989 99.9894 99.9894 100 226.01 180.81 268.5489 179.57 268.5489 214.8391 17.06 212.712 186.123 186.12 268.5489 17.06 268.5489
Radiology Physician Services Not provided by hospital (may be billed separately)    
WRIST (2V) Radiology Hospital Services 73100 255.392 271.35 271.35 271.35 322.4324 99.989 99.9894 99.9894 100 271.35 217.08 322.4324 179.57 322.4324 257.9459 20.35 255.392 223.468 223.47 322.4324 20.35 322.4324
Radiology Physician Services Not provided by hospital (may be billed separately)    
WRIST COMPLETE MINIMUM 3V Radiology Hospital Services 73110 227.824 242.06 242.06 242.06 287.6278 99.989 99.9894 99.9894 100 242.06 193.65 287.6278 179.57 287.6278 230.1022 25.14 227.824 199.346 199.35 287.6278 25.14 287.6278
Radiology Physician Services Not provided by hospital (may be billed separately)    
HAND (2V) Radiology Hospital Services 73120 358.656 381.07 381.07 381.07 452.8032 99.989 99.9894 99.9894 100 381.07 304.86 452.8032 252.18 452.8032 362.2426 18.26 358.656 313.824 313.82 452.8032 18.26 452.8032
Radiology Physician Services Not provided by hospital (may be billed separately)    
HAND MINIMUM 3V Radiology Hospital Services 73130 223.032 236.97 236.97 236.97 281.5779 99.989 99.9894 99.9894 100 236.97 189.58 281.5779 179.57 281.5779 225.2623 21.85 223.032 195.153 195.15 281.5779 21.85 281.5779
Radiology Physician Services Not provided by hospital (may be billed separately)    
FINGER(S) MINIMUM 2V Radiology Hospital Services 73140 194.224 206.36 206.36 206.36 245.2078 99.989 99.9894 99.9894 100 206.36 165.09 245.2078 179.57 245.2078 196.1662 23.94 194.224 169.946 169.95 245.2078 23.94 245.2078
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT UPPER EXTREMITY W/O CONTRAST Radiology Hospital Services 73200 1240.82 1318.4 1318.4 1318.4 1566.5403 784.59 784.5928 784.5928 785 1318.4 1054.7 1566.5403 252.18 1566.5403 1253.2322 93.11 1240.824 1085.721 1085.7 1566.5403 93.11 1566.5403
Radiology Physician Services Not provided by hospital (may be billed separately)    
UPPER EXT W/O CONTRAST Radiology Hospital Services 73202 1417.66 1506.3 1506.3 1506.3 1789.8008 784.59 784.5928 784.5928 785 1506.3 1205 1789.8008 410 1789.8008 1431.8406 151.18 1417.664 1240.456 1240.5 1789.8008 151.18 1789.8008
Radiology Physician Services Not provided by hospital (may be billed separately)    
HIP COMPLETE MINIMUM 2V Radiology Hospital Services 73502 222.96 236.9 236.9 236.9 281.487 99.989 99.9894 99.9894 100 236.9 189.52 281.487 179.57 281.487 225.1896 28.44 222.96 195.09 195.09 281.487 28.44 281.487
Radiology Physician Services Not provided by hospital (may be billed separately)    
HIPS BILATERAL MINIMUM 2V Radiology Hospital Services 73521 143.36 152.32 152.32 152.32 180.992 99.989 99.9894 99.9894 100 152.32 121.86 180.992 252.18 180.992 144.7936 23.94 143.36 125.44 125.44 180.992 23.94 252.18
Radiology Physician Services Not provided by hospital (may be billed separately)    
FEMUR 2V Radiology Hospital Services 73552 265.344 281.93 281.93 281.93 334.9968 99.989 99.9894 99.9894 100 281.93 225.54 334.9968 179.57 334.9968 267.9974 21.25 265.344 232.176 232.18 334.9968 21.25 334.9968
Radiology Physician Services Not provided by hospital (may be billed separately)    
KNEE 1V OR 2V Radiology Hospital Services 73560 221.872 235.74 235.74 235.74 280.1134 99.989 99.9894 99.9894 100 235.74 188.59 280.1134 179.57 280.1134 224.0907 20.95 221.872 194.138 194.14 280.1134 20.95 280.1134
Radiology Physician Services Not provided by hospital (may be billed separately)    
KNEE COMPLETE 4 OR MORE VIEWS Radiology Hospital Services 73564 198 210.38 210.38 210.38 249.975 99.989 99.9894 99.9894 100 210.38 168.3 249.975 252.18 249.975 199.98 27.24 198 173.25 173.25 249.975 27.24 252.18
Radiology Physician Services Not provided by hospital (may be billed separately)    
BOTH KNEES STANDING ANTEROPOSTERIOR Radiology Hospital Services 73565 143.36 152.32 152.32 152.32 180.992 99.989 99.9894 99.9894 100 152.32 121.86 180.992 179.57 180.992 144.7936 25.14 143.36 125.44 125.44 180.992 25.14 180.992
Radiology Physician Services Not provided by hospital (may be billed separately)    
TIBIA/FIBULA 2V Radiology Hospital Services 73590 226.256 240.4 240.4 240.4 285.6482 99.989 99.9894 99.9894 100 240.4 192.32 285.6482 179.57 285.6482 228.5186 18.86 226.256 197.974 197.97 285.6482 18.86 285.6482
Radiology Physician Services Not provided by hospital (may be billed separately)    
ANKLE COMPLETE MINIMUM 3V Radiology Hospital Services 73610 227.84 242.08 242.08 242.08 287.648 99.989 99.9894 99.9894 100 242.08 193.66 287.648 179.57 287.648 230.1184 21.85 227.84 199.36 199.36 287.648 21.85 287.648
Radiology Physician Services Not provided by hospital (may be billed separately)    
FOOT COMPLETE MINIMUM 3V Radiology Hospital Services 73630 233.328 247.91 247.91 247.91 294.5766 99.989 99.9894 99.9894 100 247.91 198.33 294.5766 179.57 294.5766 235.6613 20.35 233.328 204.162 204.16 294.5766 20.35 294.5766
Radiology Physician Services Not provided by hospital (may be billed separately)    
CALCANEOUS 2V Radiology Hospital Services 73650 230.392 244.79 244.79 244.79 290.8699 99.989 99.9894 99.9894 100 244.79 195.83 290.8699 179.57 290.8699 232.6959 16.76 230.392 201.593 201.59 290.8699 16.76 290.8699
Radiology Physician Services Not provided by hospital (may be billed separately)    
TOE(S) MINIMUM 2V Radiology Hospital Services 73660 198.48 210.89 210.89 210.89 250.581 99.989 99.9894 99.9894 100 210.89 168.71 250.581 179.57 250.581 200.4648 17.96 198.48 173.67 173.67 250.581 17.96 250.581
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT LOWER EXTREMITIES W/O CONTRAST Radiology Hospital Services 73700 1353.23 1437.8 1437.8 1437.8 1708.4554 784.59 784.5928 784.5928 785 1437.8 1150.2 1708.4554 252.18 1708.4554 1366.7643 88.01 1353.232 1184.078 1184.1 1708.4554 88.01 1708.4554
Radiology Physician Services Not provided by hospital (may be billed separately)    
ABDOMEN XRAY 1 VIEW Radiology Hospital Services 74018 198.784 211.21 211.21 211.21 250.9648 99.989 99.9894 99.9894 100 211.21 168.97 250.9648 179.57 250.9648 200.7718 16.76 198.784 173.936 173.94 250.9648 16.76 250.9648
Radiology Physician Services Not provided by hospital (may be billed separately)    
ABDOMEN XRAY 2 VIEW Radiology Hospital Services 74019 366.272 389.16 389.16 389.16 462.4184 99.989 99.9894 99.9894 100 389.16 311.33 462.4184 252.18 462.4184 369.9347 20.35 366.272 320.488 320.49 462.4184 20.35 462.4184
Radiology Physician Services Not provided by hospital (may be billed separately)    
ABDOMEN XRAY 3 OR MORE VIEWS Radiology Hospital Services 74021 366.272 389.16 389.16 389.16 462.4184 99.989 99.9894 99.9894 100 389.16 311.33 462.4184 252.18 462.4184 369.9347 23.65 366.272 320.488 320.49 462.4184 23.65 462.4184
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT ABD W/O CONTRAST Radiology Hospital Services 74150 1358.26 1443.2 1443.2 1443.2 1714.8083 963.59 963.5928 963.5928 964 1443.2 1154.5 1714.8083 336.24 1714.8083 1371.8466 75.14 1358.264 1188.481 1188.5 1714.8083 75.14 1714.8083
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT ABD/PELVIS W/O CONTRAST Radiology Hospital Services 74176 1646.04 1748.9 1748.9 1748.9 2078.1255 963.59 963.5928 963.5928 964 1748.9 1399.1 2078.1255 524.34 2078.1255 1662.5004 94.6 1646.04 1440.285 1440.3 2078.1255 94.6 2078.1255
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT ABD/PELVIS W/ CONTRAST Radiology Hospital Services 74177 1886.82 2004.7 2004.7 2004.7 2382.1052 963.59 963.5928 963.5928 964 2004.7 1603.8 2382.1052 859.16 2382.1052 1905.6842 198.18 1886.816 1650.964 1651 2382.1052 198.18 2382.1052
Radiology Physician Services Not provided by hospital (may be billed separately)    
CT ABD/PELVIS W/ & W/O CONTRAST Radiology Hospital Services 74178 1886.82 2004.7 2004.7 2004.7 2382.1052 963.59 963.5928 963.5928 964 2004.7 1603.8 2382.1052 859.16 2382.1052 1905.6842 224.83 1886.816 1650.964 1651 2382.1052 224.83 2382.1052
Radiology Physician Services Not provided by hospital (may be billed separately)    
US SOFT TISSUE HEAD/NECK/THYROID Radiology Hospital Services 76536 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 73.94 360.736 315.644 315.64 455.4292 73.94 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US CHEST W/MEDIASTINUM Radiology Hospital Services 76604 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 42.21 360.736 315.644 315.64 455.4292 42.21 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US BREAST UNILATERAL COMPLETE Radiology Hospital Services 76641 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 59.57 360.736 315.644 315.64 455.4292 59.57 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US ABDOMINAL COMPLETE Radiology Hospital Services 76700 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 69.15 360.736 315.644 315.64 455.4292 69.15 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US SINGLE ORGAN Radiology Hospital Services 76705 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 52.09 360.736 315.644 315.64 455.4292 52.09 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US ABDOMINAL AORTA SCREEN FOR AAA Radiology Hospital Services 76706 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 0 360.736 315.644 315.64 455.4292 0 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US RETROPERITONEAL COMPLETE Radiology Hospital Services 76770 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 64.36 360.736 315.644 315.64 455.4292 64.36 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US RETROPERITONEAL LIMITED Radiology Hospital Services 76775 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 25.14 360.736 315.644 315.64 455.4292 25.14 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US OB >/=14 WEEKS SINGLE/FIRST GESTATION Radiology Hospital Services 76805 360.736 383.28 383.28 383.28 455.4292 372.96 372.9644 372.9644 373 383.28 306.63 455.4292 252.18 455.4292 364.3434 76.04 360.736 315.644 315.64 455.4292 76.04 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US OB >/=14 WEEKS ADDITIONAL FETUS Radiology Hospital Services 76810 180.384 191.66 191.66 191.66 227.7348 372.96 372.9644 372.9644 373 191.66 153.33 227.7348 173.62 227.7348 182.1878 35.62 180.384 157.836 157.84 227.7348 35.62 372.9644
Radiology Physician Services Not provided by hospital (may be billed separately)    
US OB DETAILED SINGLE FETUS OR 1ST GEST Radiology Hospital Services 76811 360.736 383.28 383.28 383.28 455.4292 372.96 372.9644 372.9644 373 383.28 306.63 455.4292 524.34 455.4292 364.3434 69.74 360.736 315.644 315.64 455.4292 69.74 524.34
Radiology Physician Services Not provided by hospital (may be billed separately)    
US PELVIC/NON-OBSTETRIC COMPLETE Radiology Hospital Services 76856 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 63.46 360.736 315.644 315.64 455.4292 63.46 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US PELVIC/NON-OBSTETRIC LIMITED Radiology Hospital Services 76857 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 20.05 360.736 315.644 315.64 455.4292 20.05 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US SCROTUM AND CONTENTS Radiology Hospital Services 76870 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 61.67 360.736 315.644 315.64 455.4292 61.67 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US EXTREMITY NONVASCULAR COMPLETE Radiology Hospital Services 76881 360.736 383.28 383.28 383.28 455.4292 352.02 352.0214 352.0214 352 383.28 306.63 455.4292 252.18 455.4292 364.3434 38.91 360.736 315.644 315.64 455.4292 38.91 455.4292
Radiology Physician Services Not provided by hospital (may be billed separately)    
US EXTREMITY NONVASCULAR LIMITED Radiology Hospital Services 76882 191.552 203.52 203.52 203.52 241.8344 352.02 352.0214 352.0214 352 203.52 162.82 241.8344 252.18 241.8344 193.4675 27.54 191.552 167.608 167.61 241.8344 27.54 352.0214
Radiology Physician Services Not provided by hospital (may be billed separately)    
BASIC METABOLIC PANEL Laboratory Services 80048 115.2 122.4 122.4 122.4 145.44 49.368 49.3682 49.3682 49.4 122.4 97.92 145.44 13.96 145.44 116.352 7.53 115.2 100.8 100.8 145.44 7.53 145.44
GENERAL HEALTH PANEL NOT FOR MCR Laboratory Services 80050 344 365.5 365.5 365.5 434.3 49.368 49.3682 49.3682 49.4 365.5 292.4 434.3 78.98 434.3 347.44 31.24 344 301 301 434.3 31.24 434.3
CMP COMP METOBOLIC PANEL Laboratory Services 80053 140.8 149.6 149.6 149.6 177.76 49.368 49.3682 49.3682 49.4 149.6 119.68 177.76 52.58 177.76 142.208 9.39 140.8 123.2 123.2 177.76 9.39 177.76
LIPID PANEL Laboratory Services 80061 90.4 96.05 96.05 96.05 114.13 49.368 49.3682 49.3682 49.4 96.05 76.84 114.13 22.09 114.13 91.304 11.91 90.4 79.1 79.1 114.13 11.91 114.13
RENAL PANEL Laboratory Services 80069 122.4 130.05 130.05 130.05 154.53 49.368 49.3682 49.3682 49.4 130.05 104.04 154.53 14.32 154.53 123.624 7.72 122.4 107.1 107.1 154.53 7.72 154.53
ACUTE HEPATITS PANEL Laboratory Services 80074 157.6 167.45 167.45 167.45 198.97 49.368 49.3682 49.3682 49.4 167.45 133.96 198.97 78.59 198.97 159.176 42.37 157.6 137.9 137.9 198.97 42.37 198.97
HEPATIC FUNCTION Laboratory Services 80076 93.6 99.45 99.45 99.45 118.17 49.368 49.3682 49.3682 49.4 99.45 79.56 118.17 13.48 118.17 94.536 7.27 93.6 81.9 81.9 118.17 7.27 118.17
AMIKACIN PEAK Laboratory Services 80150 64.704 68.748 68.748 68.748 81.6888 59.464 59.4638 59.4638 59.5 68.748 54.998 81.6888 24.88 81.6888 65.351 13.41 64.704 56.616 56.616 81.6888 13.41 81.6888
AMIKACIN TROUGH Laboratory Services 80150 64.704 68.748 68.748 68.748 81.6888 59.464 59.4638 59.4638 59.5 68.748 54.998 81.6888 24.88 81.6888 65.351 13.41 64.704 56.616 56.616 81.6888 13.41 81.6888
TEGRETOL (CARBAMAZEPINE) Laboratory Services 80156 113.8 120.91 120.91 120.91 143.6725 59.464 59.4638 59.4638 59.5 120.91 96.73 143.6725 24.04 143.6725 114.938 12.96 113.8 99.575 99.575 143.6725 12.96 143.6725
CYCLOSPORINE LEVEL Laboratory Services 80158 60.552 64.337 64.337 64.337 76.4469 59.464 59.4638 59.4638 59.5 64.337 51.469 76.4469 29.78 76.4469 61.1575 16.06 60.552 52.983 52.983 76.4469 16.06 76.4469
DIGOXIN LEVEL Laboratory Services 80162 84.984 90.296 90.296 90.296 107.2923 59.464 59.4638 59.4638 59.5 90.296 72.236 107.2923 21.91 107.2923 85.8338 11.81 84.984 74.361 74.361 107.2923 11.81 107.2923
DEPAKOTE (VALPROIC ACID) Laboratory Services 80164 114.72 121.89 121.89 121.89 144.834 59.464 59.4638 59.4638 59.5 121.89 97.512 144.834 22.34 144.834 115.8672 12.04 114.72 100.38 100.38 144.834 12.04 144.834
LITHIUM Laboratory Services 80178 69.144 73.466 73.466 73.466 87.2943 59.464 59.4638 59.4638 59.5 73.466 58.772 87.2943 10.91 87.2943 69.8354 5.88 69.144 60.501 60.501 87.2943 5.88 87.2943
PHENOBARBITAL Laboratory Services 80184 84.544 89.828 89.828 89.828 106.7368 59.464 59.4638 59.4638 59.5 89.828 71.862 106.7368 25.25 106.7368 85.3894 13.61 84.544 73.976 73.976 106.7368 13.61 106.7368
DILANTIN-LEVEL Laboratory Services 80185 95.992 101.99 101.99 101.99 121.1899 59.464 59.4638 59.4638 59.5 101.99 81.593 121.1899 21.86 121.1899 96.9519 11.79 95.992 83.993 83.993 121.1899 11.79 121.1899
PHENYTOIN, FREE Laboratory Services 80186 58.8 62.475 62.475 62.475 74.235 59.464 59.4638 59.4638 59.5 62.475 49.98 74.235 22.7 74.235 59.388 12.24 58.8 51.45 51.45 74.235 12.24 74.235
TACROLIMUS Laboratory Services 80197 180 191.25 191.25 191.25 227.25 59.464 59.4638 59.4638 59.5 191.25 153 227.25 22.65 227.25 181.8 12.21 180 157.5 157.5 227.25 12.21 227.25
THEOPHYLLINE - LEVEL Laboratory Services 80198 66 70.125 70.125 70.125 83.325 59.464 59.4638 59.4638 59.5 70.125 56.1 83.325 23.33 83.325 66.66 12.58 66 57.75 57.75 83.325 12.58 83.325
VANCOMYCIN LEVEL Laboratory Services 80202 129.64 137.74 137.74 137.74 163.6705 59.464 59.4638 59.4638 59.5 137.74 110.19 163.6705 22.34 163.6705 130.9364 12.04 129.64 113.435 113.44 163.6705 12.04 163.6705
URINE DRUG SCREEN/CHAIN OF CUSTODY Laboratory Services 80305 89.992 95.617 95.617 95.617 113.6149 45.573 45.5734 45.5734 45.6 95.617 76.493 113.6149 20.79 113.6149 90.8919 11.21 89.992 78.743 78.743 113.6149 11.21 113.6149
URINE DRUG SCREEN/COLLECT ONLY Laboratory Services 80305 17.6 18.7 18.7 18.7 22.22 45.573 45.5734 45.5734 45.6 18.7 14.96 22.22 20.79 22.22 17.776 11.21 17.6 15.4 15.4 22.22 11.21 45.5734
DRUG SCREEN - PANEL 10 Laboratory Services 80305 52.8 56.1 56.1 56.1 66.66 45.573 45.5734 45.5734 45.6 56.1 44.88 66.66 20.79 66.66 53.328 11.21 52.8 46.2 46.2 66.66 11.21 66.66
ETHANOL BLOOD Laboratory Services 80320 136.656 145.2 145.2 145.2 172.5282 0 0 0 0 145.2 116.16 172.5282 0 172.5282 138.0226 0 136.656 119.574 119.57 172.5282 0 172.5282
ACETAMINOPHEN LEVEL Laboratory Services 80329 167.024 177.46 177.46 177.46 210.8678 0 0 0 0 177.46 141.97 210.8678 0 210.8678 168.6942 0 167.024 146.146 146.15 210.8678 0 210.8678
NORTRIPTILINE LEVEL Laboratory Services 80335 80.712 85.757 85.757 85.757 101.8989 0 0 0 0 85.757 68.605 101.8989 0 101.8989 81.5191 0 80.712 70.623 70.623 101.8989 0 101.8989
OXYCODONE 5 MG TAB Laboratory Services 80365 4.4 4.675 4.675 4.675 5.555 0 0 0 0 4.675 3.74 5.555 0 5.555 4.444 0 4.4 3.85 3.85 5.555 0 5.555
UA COMPLETE Laboratory Services 81001 55.112 58.557 58.557 58.557 69.5789 14.427 14.4274 14.4274 14.4 58.557 46.845 69.5789 5.23 69.5789 55.6631 2.82 55.112 48.223 48.223 69.5789 2.82 69.5789
UA DIP/SG Laboratory Services 81003 27.552 29.274 29.274 29.274 34.7844 10.167 10.1672 10.1672 10.2 29.274 23.419 34.7844 3.71 34.7844 27.8275 2 27.552 24.108 24.108 34.7844 2 34.7844
URINALYSIS - MICROSCOPIC Laboratory Services 81015 24.976 26.537 26.537 26.537 31.5322 14.427 14.4274 14.4274 14.4 26.537 21.23 31.5322 5.03 31.5322 25.2258 2.71 24.976 21.854 21.854 31.5322 2.71 31.5322
HCG - URINE Laboratory Services 81025 78.976 83.912 83.912 83.912 99.7072 14.427 14.4274 14.4274 14.4 83.912 67.13 99.7072 14.21 99.7072 79.7658 7.66 78.976 69.104 69.104 99.7072 7.66 99.7072
ALBUMIN Laboratory Services 82040 184.32 195.84 195.84 195.84 232.704 23.807 23.807 23.807 23.8 195.84 156.67 232.704 8.17 232.704 186.1632 4.4 184.32 161.28 161.28 232.704 4.4 232.704
ALBUMIN URINE MICROALBUMIN QUANTITATIVE Laboratory Services 82043 68.552 72.837 72.837 72.837 86.5469 14.427 14.4274 14.4274 14.4 72.837 58.269 86.5469 9.54 86.5469 69.2375 5.14 68.552 59.983 59.983 86.5469 5.14 86.5469
AMMONIA Laboratory Services 82140 83.256 88.46 88.46 88.46 105.1107 45.573 45.5734 45.5734 45.6 88.46 70.768 105.1107 24.04 105.1107 84.0886 12.96 83.256 72.849 72.849 105.1107 12.96 105.1107
AMYLASE-SERUM Laboratory Services 82150 76.264 81.031 81.031 81.031 96.2833 45.573 45.5734 45.5734 45.6 81.031 64.824 96.2833 10.69 96.2833 77.0266 5.76 76.264 66.731 66.731 96.2833 5.76 96.2833
BILIRUBIN - TOTAL Laboratory Services 82247 35.2 37.4 37.4 37.4 44.44 23.807 23.807 23.807 23.8 37.4 29.92 44.44 8.28 44.44 35.552 4.47 35.2 30.8 30.8 44.44 4.47 44.44
BILIRUBEN - DIRECT Laboratory Services 82248 44.92 47.728 47.728 47.728 56.7115 23.807 23.807 23.807 23.8 47.728 38.182 56.7115 8.28 56.7115 45.3692 4.47 44.92 39.305 39.305 56.7115 4.47 56.7115
OCCULT BLOOD, 1-3 SPECIMENS Laboratory Services 82272 32.384 34.408 34.408 34.408 40.8848 23.807 23.807 23.807 23.8 34.408 27.526 40.8848 6.98 40.8848 32.7078 3.76 32.384 28.336 28.336 40.8848 3.76 40.8848
VITAMIN D, 25 Laboratory Services 82306 132.664 140.96 140.96 140.96 167.4883 138.33 138.3312 138.3312 138 140.96 112.76 167.4883 48.84 167.4883 133.9906 26.33 132.664 116.081 116.08 167.4883 26.33 167.4883
CALCIUM Laboratory Services 82310 41.744 44.353 44.353 44.353 52.7018 23.807 23.807 23.807 23.8 44.353 35.482 52.7018 8.51 52.7018 42.1614 4.59 41.744 36.526 36.526 52.7018 4.59 52.7018
IONIZED CALCIUM Laboratory Services 82330 48.96 52.02 52.02 52.02 61.812 45.573 45.5734 45.5734 45.6 52.02 41.616 61.812 22.57 61.812 49.4496 12.17 48.96 42.84 42.84 61.812 12.17 61.812
STONE ANALYSIS Laboratory Services 82365 113.616 120.72 120.72 120.72 143.4402 45.573 45.5734 45.5734 45.6 120.72 96.574 143.4402 21.29 143.4402 114.7522 11.47 113.616 99.414 99.414 143.4402 11.47 143.4402
CHLORIDE-URINE Laboratory Services 82436 38.8 41.225 41.225 41.225 48.985 23.807 23.807 23.807 23.8 41.225 32.98 48.985 9.49 48.985 39.188 5.11 38.8 33.95 33.95 48.985 5.11 48.985
CORTISOL-SERUM, RANDOM Laboratory Services 82533 103.992 110.49 110.49 110.49 131.2899 98.665 98.6648 98.6648 98.7 110.49 88.393 131.2899 26.9 131.2899 105.0319 14.5 103.992 90.993 90.993 131.2899 14.5 131.2899
CORTISOL-SERUM AM OR PM Laboratory Services 82533 86.4 91.8 91.8 91.8 109.08 98.665 98.6648 98.6648 98.7 91.8 73.44 109.08 26.9 109.08 87.264 14.5 86.4 75.6 75.6 109.08 14.5 109.08
CK Laboratory Services 82550 64.32 68.34 68.34 68.34 81.204 23.807 23.807 23.807 23.8 68.34 54.672 81.204 10.74 81.204 64.9632 5.79 64.32 56.28 56.28 81.204 5.79 81.204
CK-MB Laboratory Services 82553 104.92 111.48 111.48 111.48 132.4615 45.573 45.5734 45.5734 45.6 111.48 89.182 132.4615 19.06 132.4615 105.9692 10.27 104.92 91.805 91.805 132.4615 10.27 132.4615
CREATININE SERUM Laboratory Services 82565 46.952 49.887 49.887 49.887 59.2769 23.807 23.807 23.807 23.8 49.887 39.909 59.2769 8.45 59.2769 47.4215 4.55 46.952 41.083 41.083 59.2769 4.55 59.2769
CREATININE-URINE Laboratory Services 82570 69.6 73.95 73.95 73.95 87.87 23.807 23.807 23.807 23.8 73.95 59.16 87.87 8.55 87.87 70.296 4.61 69.6 60.9 60.9 87.87 4.61 87.87
CREATININE CLEARANCE Laboratory Services 82575 113.216 120.29 120.29 120.29 142.9352 45.573 45.5734 45.5734 45.6 120.29 96.234 142.9352 15.61 142.9352 114.3482 8.41 113.216 99.064 99.064 142.9352 8.41 142.9352
B12 Laboratory Services 82607 81.68 86.785 86.785 86.785 103.121 74.321 74.3208 74.3208 74.3 86.785 69.428 103.121 24.88 103.121 82.4968 13.41 81.68 71.47 71.47 103.121 13.41 103.121
ESTRADIOL Laboratory Services 82670 159.216 169.17 169.17 169.17 201.0102 98.665 98.6648 98.6648 98.7 169.17 135.33 201.0102 46.1 201.0102 160.8082 24.85 159.216 139.314 139.31 201.0102 24.85 201.0102
ESTROGEN - SERUM Laboratory Services 82672 145.2 154.28 154.28 154.28 183.315 98.665 98.6648 98.6648 98.7 154.28 123.42 183.315 35.81 183.315 146.652 19.3 145.2 127.05 127.05 183.315 19.3 183.315
FERRITIN Laboratory Services 82728 79.408 84.371 84.371 84.371 100.2526 45.573 45.5734 45.5734 45.6 84.371 67.497 100.2526 22.49 100.2526 80.2021 12.12 79.408 69.482 69.482 100.2526 12.12 100.2526
FOLATE (FOLIC ACID) SERUM Laboratory Services 82746 82.456 87.61 87.61 87.61 104.1007 45.573 45.5734 45.5734 45.6 87.61 70.088 104.1007 24.26 104.1007 83.2806 13.08 82.456 72.149 72.149 104.1007 13.08 104.1007
TTG Laboratory Services 82784 204 216.75 216.75 216.75 257.55 45.573 45.5734 45.5734 45.6 216.75 173.4 257.55 15.35 257.55 206.04 8.27 204 178.5 178.5 257.55 8.27 257.55
PH-VENOUS Laboratory Services 82800 88 93.5 93.5 93.5 111.1 45.573 45.5734 45.5734 45.6 93.5 74.8 111.1 18.15 111.1 88.88 9.78 88 77 77 111.1 9.78 111.1
ARTERIAL BLOOD GASES Laboratory Services 82803 152.088 161.59 161.59 161.59 192.0111 45.573 45.5734 45.5734 45.6 161.59 129.27 192.0111 43.02 192.0111 153.6089 23.19 152.088 133.077 133.08 192.0111 23.19 192.0111
GLUCOSE - SERUM Laboratory Services 82947 36.184 38.446 38.446 38.446 45.6823 23.807 23.807 23.807 23.8 38.446 30.756 45.6823 6.48 45.6823 36.5458 3.5 36.184 31.661 31.661 45.6823 3.5 45.6823
GTT EACH ADDTL HOUR Laboratory Services 82952 37.472 39.814 39.814 39.814 47.3084 45.573 45.5734 45.5734 45.6 39.814 31.851 47.3084 6.47 47.3084 37.8467 3.49 37.472 32.788 32.788 47.3084 3.49 47.3084
FSBS/GLUCOMETER Laboratory Services 82962 63 66.938 66.938 66.938 79.5375 23.807 23.807 23.807 23.8 66.938 53.55 79.5375 5.41 79.5375 63.63 2.92 63 55.125 55.125 79.5375 2.92 79.5375
GLUCOMETER Laboratory Services 82962 56.04 59.543 59.543 59.543 70.7505 23.807 23.807 23.807 23.8 59.543 47.634 70.7505 5.41 70.7505 56.6004 2.92 56.04 49.035 49.035 70.7505 2.92 70.7505
GGTP Laboratory Services 82977 39.6 42.075 42.075 42.075 49.995 23.807 23.807 23.807 23.8 42.075 33.66 49.995 11.88 49.995 39.996 6.4 39.6 34.65 34.65 49.995 6.4 49.995
FSH - SERUM Laboratory Services 83001 100.856 107.16 107.16 107.16 127.3307 98.665 98.6648 98.6648 98.7 107.16 85.728 127.3307 30.66 127.3307 101.8646 16.53 100.856 88.249 88.249 127.3307 16.53 127.3307
LUTEINIZING HORMONE SERUM Laboratory Services 83002 101.376 107.71 107.71 107.71 127.9872 98.665 98.6648 98.6648 98.7 107.71 86.17 127.9872 30.56 127.9872 102.3898 16.47 101.376 88.704 88.704 127.9872 16.47 127.9872
HAPTOGLOBIN Laboratory Services 83010 129.184 137.26 137.26 137.26 163.0948 45.573 45.5734 45.5734 45.6 137.26 109.81 163.0948 20.76 163.0948 130.4758 11.19 129.184 113.036 113.04 163.0948 11.19 163.0948
HGB A1C Laboratory Services 83036 65.744 69.853 69.853 69.853 83.0018 45.573 45.5734 45.5734 45.6 69.853 55.882 83.0018 16.02 83.0018 66.4014 8.64 65.744 57.526 57.526 83.0018 8.64 83.0018
HYDROXYPROGESTERONE 17-D Laboratory Services 83498 163.56 173.78 173.78 173.78 206.4945 98.665 98.6648 98.6648 98.7 173.78 139.03 206.4945 44.83 206.4945 165.1956 24.17 163.56 143.115 143.12 206.4945 24.17 206.4945
THYROTROPIN RECEPTOR ANTIBODY Laboratory Services 83519 413.832 439.7 439.7 439.7 522.4629 39.774 39.7738 39.7738 39.8 439.7 351.76 522.4629 30.36 522.4629 417.9703 16.37 413.832 362.103 362.1 522.4629 16.37 522.4629
INSULIN, RANDOM Laboratory Services 83525 68.92 73.228 73.228 73.228 87.0115 74.321 74.3208 74.3208 74.3 73.228 58.582 87.0115 18.86 87.0115 69.6092 10.17 68.92 60.305 60.305 87.0115 10.17 87.0115
IRON - SERUM Laboratory Services 83540 50.128 53.261 53.261 53.261 63.2866 23.807 23.807 23.807 23.8 53.261 42.609 63.2866 10.68 63.2866 50.6293 5.75 50.128 43.862 43.862 63.2866 5.75 63.2866
TIBC Laboratory Services 83550 57.912 61.532 61.532 61.532 73.1139 45.573 45.5734 45.5734 45.6 61.532 49.225 73.1139 14.42 73.1139 58.4911 7.77 57.912 50.673 50.673 73.1139 7.77 73.1139
LACTIC ACID IN HOUSE Laboratory Services 83605 50.64 53.805 53.805 53.805 63.933 45.573 45.5734 45.5734 45.6 53.805 43.044 63.933 19.09 63.933 51.1464 10.29 50.64 44.31 44.31 63.933 10.29 63.933
LDH Laboratory Services 83615 46.768 49.691 49.691 49.691 59.0446 23.807 23.807 23.807 23.8 49.691 39.753 59.0446 9.97 59.0446 47.2357 5.37 46.768 40.922 40.922 59.0446 5.37 59.0446
LEAD - BLOOD Laboratory Services 83655 58 61.625 61.625 61.625 73.225 67.59 67.5904 67.5904 67.6 61.625 49.3 73.225 19.98 73.225 58.58 10.77 58 50.75 50.75 73.225 10.77 73.225
LIPASE Laboratory Services 83690 82.72 87.89 87.89 87.89 104.434 23.807 23.807 23.807 23.8 87.89 70.312 104.434 11.37 104.434 83.5472 6.13 82.72 72.38 72.38 104.434 6.13 104.434
MAGNESIUM LEVEL - SERUM Laboratory Services 83735 59.904 63.648 63.648 63.648 75.6288 23.807 23.807 23.807 23.8 63.648 50.918 75.6288 11.06 75.6288 60.503 5.96 59.904 52.416 52.416 75.6288 5.96 75.6288
MYOGLOBIN Laboratory Services 83874 676.992 719.3 719.3 719.3 854.7024 45.573 45.5734 45.5734 45.6 719.3 575.44 854.7024 21.32 854.7024 683.7619 11.49 676.992 592.368 592.37 854.7024 11.49 854.7024
NT ProBNP Laboratory Services 83880 309.6 328.95 328.95 328.95 390.87 138.33 138.3312 138.3312 138 328.95 263.16 390.87 64.78 390.87 312.696 34.92 309.6 270.9 270.9 390.87 34.92 390.87
BNP Laboratory Services 83880 160.88 170.94 170.94 170.94 203.111 138.33 138.3312 138.3312 138 170.94 136.75 203.111 64.78 203.111 162.4888 34.92 160.88 140.77 140.77 203.111 34.92 203.111
URINE OSMOLALITY Laboratory Services 83935 57.2 60.775 60.775 60.775 72.215 23.807 23.807 23.807 23.8 60.775 48.62 72.215 11.25 72.215 57.772 6.07 57.2 50.05 50.05 72.215 6.07 72.215
PTH C-TERMINAL Laboratory Services 83970 176 187 187 187 222.2 98.665 98.6648 98.6648 98.7 187 149.6 222.2 68.11 222.2 177.76 36.72 176 154 154 222.2 36.72 222.2
CALPROTECTIN Laboratory Services 83993 336 357 357 357 424.2 45.573 45.5734 45.5734 45.6 357 285.6 424.2 32.39 424.2 339.36 17.46 336 294 294 424.2 17.46 424.2
ALK PHOS Laboratory Services 84075 39.6 42.075 42.075 42.075 49.995 23.807 23.807 23.807 23.8 42.075 33.66 49.995 8.55 49.995 39.996 4.61 39.6 34.65 34.65 49.995 4.61 49.995
PHOSPHORUS-SERUM Laboratory Services 84100 37.344 39.678 39.678 39.678 47.1468 23.807 23.807 23.807 23.8 39.678 31.742 47.1468 7.82 47.1468 37.7174 4.22 37.344 32.676 32.676 47.1468 4.22 47.1468
POTASSIUM - SERUM Laboratory Services 84132 39.552 42.024 42.024 42.024 49.9344 23.807 23.807 23.807 23.8 42.024 33.619 49.9344 7.85 49.9344 39.9475 4.23 39.552 34.608 34.608 49.9344 4.23 49.9344
PRE-ALBUMIN Laboratory Services 84134 73.368 77.954 77.954 77.954 92.6271 45.573 45.5734 45.5734 45.6 77.954 62.363 92.6271 24.07 92.6271 74.1017 12.98 73.368 64.197 64.197 92.6271 12.98 92.6271
PROGESTERONE Laboratory Services 84144 72.08 76.585 76.585 76.585 91.001 74.321 74.3208 74.3208 74.3 76.585 61.268 91.001 34.42 91.001 72.8008 18.55 72.08 63.07 63.07 91.001 18.55 91.001
PROCALCITONIN (PCT) Laboratory Services 84145 60 63.75 63.75 63.75 75.75 98.665 98.6648 98.6648 98.7 63.75 51 75.75 44.91 75.75 60.6 24.21 60 52.5 52.5 75.75 24.21 98.6648
PROLACTIN Laboratory Services 84146 73.896 78.515 78.515 78.515 93.2937 98.665 98.6648 98.6648 98.7 78.515 62.812 93.2937 31.98 93.2937 74.635 17.24 73.896 64.659 64.659 93.2937 17.24 98.6648
PSA TOTAL Laboratory Services 84153 98.472 104.63 104.63 104.63 124.3209 45.573 45.5734 45.5734 45.6 104.63 83.701 124.3209 30.34 124.3209 99.4567 16.36 98.472 86.163 86.163 124.3209 16.36 124.3209
PROTEIN TOTAL - SERUM Laboratory Services 84155 31.6 33.575 33.575 33.575 39.895 23.807 23.807 23.807 23.8 33.575 26.86 39.895 6.06 39.895 31.916 3.26 31.6 27.65 27.65 39.895 3.26 39.895
PROTEIN-URINE RANDOM Laboratory Services 84156 42.2 44.838 44.838 44.838 53.2775 23.807 23.807 23.807 23.8 44.838 35.87 53.2775 6.06 53.2775 42.622 3.26 42.2 36.925 36.925 53.2775 3.26 53.2775
SODIUM - SERUM Laboratory Services 84295 45.256 48.085 48.085 48.085 57.1357 23.807 23.807 23.807 23.8 48.085 38.468 57.1357 7.94 57.1357 45.7086 4.28 45.256 39.599 39.599 57.1357 4.28 57.1357
SODIUM - URINE Laboratory Services 84300 39.6 42.075 42.075 42.075 49.995 23.807 23.807 23.807 23.8 42.075 33.66 49.995 8.35 49.995 39.996 4.5 39.6 34.65 34.65 49.995 4.5 49.995
GLYCOMARK Laboratory Services 84378 66 70.125 70.125 70.125 83.325 45.573 45.5734 45.5734 45.6 70.125 56.1 83.325 19.02 83.325 66.66 10.26 66 57.75 57.75 83.325 10.26 83.325
TESTOSTERONE - FREE Laboratory Services 84402 93.888 99.756 99.756 99.756 118.5336 98.665 98.6648 98.6648 98.7 99.756 79.805 118.5336 42.03 118.5336 94.8269 22.66 93.888 82.152 82.152 118.5336 22.66 118.5336
TESTOSTERONE - TOTAL Laboratory Services 84403 552.96 587.52 587.52 587.52 698.112 98.665 98.6648 98.6648 98.7 587.52 470.02 698.112 42.59 698.112 558.4896 22.96 552.96 483.84 483.84 698.112 22.96 698.112
T4 FREE Laboratory Services 84439 72.688 77.231 77.231 77.231 91.7686 74.321 74.3208 74.3208 74.3 77.231 61.785 91.7686 14.88 91.7686 73.4149 8.02 72.688 63.602 63.602 91.7686 8.02 91.7686
TSH Laboratory Services 84443 100.584 106.87 106.87 106.87 126.9873 74.321 74.3208 74.3208 74.3 106.87 85.496 126.9873 27.72 126.9873 101.5898 14.94 100.584 88.011 88.011 126.9873 14.94 126.9873
AST Laboratory Services 84450 42.648 45.314 45.314 45.314 53.8431 23.807 23.807 23.807 23.8 45.314 36.251 53.8431 8.55 53.8431 43.0745 4.61 42.648 37.317 37.317 53.8431 4.61 53.8431
ALT Laboratory Services 84460 39.6 42.075 42.075 42.075 49.995 23.807 23.807 23.807 23.8 42.075 33.66 49.995 8.75 49.995 39.996 4.71 39.6 34.65 34.65 49.995 4.71 49.995
TRANSFERRIN Laboratory Services 84466 110.16 117.05 117.05 117.05 139.077 45.573 45.5734 45.5734 45.6 117.05 93.636 139.077 21.05 139.077 111.2616 11.35 110.16 96.39 96.39 139.077 11.35 139.077
TRIGLYCERIDES Laboratory Services 84478 66 70.125 70.125 70.125 83.325 23.807 23.807 23.807 23.8 70.125 56.1 83.325 9.47 83.325 66.66 5.11 66 57.75 57.75 83.325 5.11 83.325
7444 Laboratory Services 84479 17.696 18.802 18.802 18.802 22.3412 74.321 74.3208 74.3208 74.3 18.802 15.042 22.3412 10.68 22.3412 17.873 5.75 17.696 15.484 15.484 22.3412 5.75 74.3208
T3 TOTAL Laboratory Services 84480 81.032 86.097 86.097 86.097 102.3029 74.321 74.3208 74.3208 74.3 86.097 68.877 102.3029 23.4 102.3029 81.8423 12.61 81.032 70.903 70.903 102.3029 12.61 102.3029
T3 FREE-34429 Laboratory Services 84481 143.112 152.06 152.06 152.06 180.6789 74.321 74.3208 74.3208 74.3 152.06 121.65 180.6789 27.95 180.6789 144.5431 15.07 143.112 125.223 125.22 180.6789 15.07 180.6789
TROPONIN Laboratory Services 84484 122.592 130.25 130.25 130.25 154.7724 45.573 45.5734 45.5734 45.6 130.25 104.2 154.7724 20.58 154.7724 123.8179 11.09 122.592 107.268 107.27 154.7724 11.09 154.7724
BUN-SERUM Laboratory Services 84520 44.136 46.895 46.895 46.895 55.7217 23.807 23.807 23.807 23.8 46.895 37.516 55.7217 6.52 55.7217 44.5774 3.51 44.136 38.619 38.619 55.7217 3.51 55.7217
URIC ACID Laboratory Services 84550 41.72 44.328 44.328 44.328 52.6715 23.807 23.807 23.807 23.8 44.328 35.462 52.6715 7.46 52.6715 42.1372 4.02 41.72 36.505 36.505 52.6715 4.02 52.6715
VITAMIN K Laboratory Services 84597 119.6 127.08 127.08 127.08 150.995 45.573 45.5734 45.5734 45.6 127.08 101.66 150.995 22.64 150.995 120.796 12.2 119.6 104.65 104.65 150.995 12.2 150.995
C PEPTIDE Laboratory Services 84681 108.312 115.08 115.08 115.08 136.7439 45.573 45.5734 45.5734 45.6 115.08 92.065 136.7439 34.34 136.7439 109.3951 18.51 108.312 94.773 94.773 136.7439 18.51 136.7439
HCG-QUANTITATIVE Laboratory Services 84702 308.688 327.98 327.98 327.98 389.7186 74.321 74.3208 74.3208 74.3 327.98 262.38 389.7186 24.83 389.7186 311.7749 13.39 308.688 270.102 270.1 389.7186 13.39 389.7186
CBC MANUAL DIFFRENTIAL Laboratory Services 85007 16.704 17.748 17.748 17.748 21.0888 33.509 33.5088 33.5088 33.5 17.748 14.198 21.0888 6.27 21.0888 16.871 3.38 16.704 14.616 14.616 21.0888 3.38 33.5088
HGB Laboratory Services 85018 28.448 30.226 30.226 30.226 35.9156 33.509 33.5088 33.5088 33.5 30.226 24.181 35.9156 3.91 35.9156 28.7325 2.11 28.448 24.892 24.892 35.9156 2.11 35.9156
CBC Laboratory Services 85025 75.672 80.402 80.402 80.402 95.5359 33.509 33.5088 33.5088 33.5 80.402 64.321 95.5359 12.82 95.5359 76.4287 6.91 75.672 66.213 66.213 95.5359 6.91 95.5359
RETICULOYCTE COUNT Laboratory Services 85045 50.52 53.678 53.678 53.678 63.7815 33.509 33.5088 33.5088 33.5 53.678 42.942 63.7815 6.58 63.7815 51.0252 3.55 50.52 44.205 44.205 63.7815 3.55 63.7815
D-DIMER Laboratory Services 85378 132 140.25 140.25 140.25 166.65 57.423 57.4232 57.4232 57.4 140.25 112.2 166.65 16.04 166.65 133.32 8.65 132 115.5 115.5 166.65 8.65 166.65
PT-PROTHROMBIN TIME Laboratory Services 85610 44.672 47.464 47.464 47.464 56.3984 17.828 17.8284 17.8284 17.8 47.464 37.971 56.3984 7.08 56.3984 45.1187 3.82 44.672 39.088 39.088 56.3984 3.82 56.3984
SED RATE (ESR) Laboratory Services 85651 55.464 58.931 58.931 58.931 70.0233 33.509 33.5088 33.5088 33.5 58.931 47.144 70.0233 7.05 70.0233 56.0186 3.8 55.464 48.531 48.531 70.0233 3.8 70.0233
PTT Laboratory Services 85730 31.68 33.66 33.66 33.66 39.996 17.828 17.8284 17.8284 17.8 33.66 26.928 39.996 9.92 39.996 31.9968 5.35 31.68 27.72 27.72 39.996 5.35 39.996
FOOD ALLERGY PROFILE Laboratory Services 86003 230.4 244.8 244.8 244.8 290.88 39.774 39.7738 39.7738 39.8 244.8 195.84 290.88 8.61 290.88 232.704 4.64 230.4 201.6 201.6 290.88 4.64 290.88
ANA W/RFX Laboratory Services 86038 80.496 85.527 85.527 85.527 101.6262 39.774 39.7738 39.7738 39.8 85.527 68.422 101.6262 19.95 101.6262 81.301 10.75 80.496 70.434 70.434 101.6262 10.75 101.6262
C-REACTIVE PROTEIN Laboratory Services 86140 55.76 59.245 59.245 59.245 70.397 39.774 39.7738 39.7738 39.8 59.245 47.396 70.397 8.55 70.397 56.3176 4.61 55.76 48.79 48.79 70.397 4.61 70.397
ANTI SCL-70 Laboratory Services 86235 67.688 71.919 71.919 71.919 85.4561 66.015 66.0152 66.0152 66 71.919 57.535 85.4561 29.58 85.4561 68.3649 15.95 67.688 59.227 59.227 85.4561 15.95 85.4561
MONO SCREEN Laboratory Services 86308 84.312 89.582 89.582 89.582 106.4439 39.774 39.7738 39.7738 39.8 89.582 71.665 106.4439 8.55 106.4439 85.1551 4.61 84.312 73.773 73.773 106.4439 4.61 106.4439
RHEUM FACTOR Laboratory Services 86431 52.624 55.913 55.913 55.913 66.4378 39.774 39.7738 39.7738 39.8 55.913 44.73 66.4378 9.36 66.4378 53.1502 5.04 52.624 46.046 46.046 66.4378 5.04 66.4378
QUANTIFERON TB Laboratory Services 86480 316.8 336.6 336.6 336.6 399.96 66.015 66.0152 66.0152 66 336.6 269.28 399.96 102.27 399.96 319.968 55.13 316.8 277.2 277.2 399.96 55.13 399.96
RPR W/REFLEX TO TITER Laboratory Services 86592 53.328 56.661 56.661 56.661 67.3266 39.774 39.7738 39.7738 39.8 56.661 45.329 67.3266 7.05 67.3266 53.8613 3.8 53.328 46.662 46.662 67.3266 3.8 67.3266
LYMES TITER SCREEN Laboratory Services 86618 88.944 94.503 94.503 94.503 112.2918 66.015 66.0152 66.0152 66 94.503 75.602 112.2918 28.1 112.2918 89.8334 15.15 88.944 77.826 77.826 112.2918 15.15 112.2918
HELICOBACTER PYLOR QUALAT (02) Laboratory Services 86677 90.92 96.603 96.603 96.603 114.7865 66.015 66.0152 66.0152 66 96.603 77.282 114.7865 27.8 114.7865 91.8292 14.99 90.92 79.555 79.555 114.7865 14.99 114.7865
H I V ANTIBODY Laboratory Services 86703 80.32 85.34 85.34 85.34 101.404 39.774 39.7738 39.7738 39.8 85.34 68.272 101.404 22.62 101.404 81.1232 7.91 80.32 70.28 70.28 101.404 7.91 101.404
HEP B CORE ANTIBODY Laboratory Services 86705 16.8 17.85 17.85 17.85 21.21 39.774 39.7738 39.7738 39.8 17.85 14.28 21.21 19.42 21.21 16.968 10.47 16.8 14.7 14.7 21.21 10.47 39.7738
HEPATITIS B SURFACE ANTIBODY QUALITATIVE Laboratory Services 86706 115.184 122.38 122.38 122.38 145.4198 39.774 39.7738 39.7738 39.8 122.38 97.906 145.4198 17.72 145.4198 116.3358 9.55 115.184 100.786 100.79 145.4198 9.55 145.4198
HEPATITIS A AB, TOTAL Laboratory Services 86708 149.896 159.26 159.26 159.26 189.2437 39.774 39.7738 39.7738 39.8 159.26 127.41 189.2437 20.44 189.2437 151.395 11.02 149.896 131.159 131.16 189.2437 11.02 189.2437
MUMPS TITER Laboratory Services 86735 89.248 94.826 94.826 94.826 112.6756 39.774 39.7738 39.7738 39.8 94.826 75.861 112.6756 21.53 112.6756 90.1405 11.61 89.248 78.092 78.092 112.6756 11.61 112.6756
RUBELLA ANTIBODY (IGG) Laboratory Services 86762 78.56 83.47 83.47 83.47 99.182 39.774 39.7738 39.7738 39.8 83.47 66.776 99.182 23.74 99.182 79.3456 12.8 78.56 68.74 68.74 99.182 12.8 99.182
RUBEOLA IGG Laboratory Services 86765 22 23.375 23.375 23.375 27.775 39.774 39.7738 39.7738 39.8 23.375 18.7 27.775 21.25 27.775 22.22 11.46 22 19.25 19.25 27.775 11.46 39.7738
SARS COV 2 COVID 19 ANTIBODY Laboratory Services 86769 156 165.75 165.75 165.75 196.95 39.774 39.7738 39.7738 39.8 165.75 132.6 196.95 34.05 196.95 157.56 42.13 156 136.5 136.5 196.95 34.05 196.95
VARICELLA IGG Laboratory Services 86787 22 23.375 23.375 23.375 27.775 39.774 39.7738 39.7738 39.8 23.375 18.7 27.775 21.25 27.775 22.22 11.46 22 19.25 19.25 27.775 11.46 39.7738
HEP C AB W/REFLEX TO RIBA Laboratory Services 86803 90.848 96.526 96.526 96.526 114.6956 66.015 66.0152 66.0152 66 96.526 77.221 114.6956 23.55 114.6956 91.7565 12.69 90.848 79.492 79.492 114.6956 12.69 114.6956
HLA-B-27 Laboratory Services 86812 125 132.81 132.81 132.81 157.8125 210.68 210.683 210.683 211 132.81 106.25 157.8125 42.59 157.8125 126.25 22.96 125 109.375 109.38 157.8125 22.96 210.683
ANTIBODY SCREEN Laboratory Services 86850 293.52 311.87 311.87 311.87 370.569 39.774 39.7738 39.7738 39.8 311.87 249.49 370.569 86.57 370.569 296.4552 8.69 293.52 256.83 256.83 370.569 8.69 370.569
ABO TYPING Laboratory Services 86900 143.04 151.98 151.98 151.98 180.588 13.532 13.5324 13.5324 13.5 151.98 121.58 180.588 190.8 180.588 144.4704 2.66 143.04 125.16 125.16 180.588 2.66 190.8
RH TYPING Laboratory Services 86901 143.04 151.98 151.98 151.98 180.588 13.532 13.5324 13.5324 13.5 151.98 121.58 180.588 58.5 180.588 144.4704 2.66 143.04 125.16 125.16 180.588 2.66 180.588
COMPATIBILITY TEST IS Laboratory Services 86920 228.24 242.51 242.51 242.51 288.153 13.532 13.5324 13.5324 13.5 242.51 194 288.153 251.13 288.153 230.5224 14.05 228.24 199.71 199.71 288.153 13.5324 288.153
COMPATIBILITY TEST INCUBATING Laboratory Services 86921 91.296 97.002 97.002 97.002 115.2612 13.532 13.5324 13.5324 13.5 97.002 77.602 115.2612 251.13 115.2612 92.209 18.72 91.296 79.884 79.884 115.2612 13.5324 251.13
COMPATIBILITY TEST AHG Laboratory Services 86922 303.6 322.58 322.58 322.58 383.295 210.68 210.683 210.683 211 322.58 258.06 383.295 251.13 383.295 306.636 42.14 303.6 265.65 265.65 383.295 42.14 383.295
GIARDIA Laboratory Services 87015 241.392 256.48 256.48 256.48 304.7574 35.549 35.5494 35.5494 35.5 256.48 205.18 304.7574 11.02 304.7574 243.8059 5.94 241.392 211.218 211.22 304.7574 5.94 304.7574
CULTURE - BLOOD Laboratory Services 87040 135.192 143.64 143.64 143.64 170.6799 129.09 129.0948 129.0948 129 143.64 114.91 170.6799 17.03 170.6799 136.5439 9.18 135.192 118.293 118.29 170.6799 9.18 170.6799
CULTURE - STOOL (01) Laboratory Services 87045 103.888 110.38 110.38 110.38 131.1586 35.549 35.5494 35.5494 35.5 110.38 88.305 131.1586 15.58 131.1586 104.9269 8.4 103.888 90.902 90.902 131.1586 8.4 131.1586
CULTURE - STOOL (02) Laboratory Services 87046 48.616 51.655 51.655 51.655 61.3777 35.549 35.5494 35.5494 35.5 51.655 41.324 61.3777 15.58 61.3777 49.1022 8.4 48.616 42.539 42.539 61.3777 8.4 61.3777
CULTURE - SPUTUM/RESPIRATORY (01) Laboratory Services 87070 33.8 35.913 35.913 35.913 42.6725 35.549 35.5494 35.5494 35.5 35.913 28.73 42.6725 14.22 42.6725 34.138 7.67 33.8 29.575 29.575 42.6725 7.67 42.6725
CULTURE - THROAT Laboratory Services 87070 19.2 20.4 20.4 20.4 24.24 35.549 35.5494 35.5494 35.5 20.4 16.32 24.24 14.22 24.24 19.392 7.67 19.2 16.8 16.8 24.24 7.67 35.5494
CULTURE - AEROBIC Laboratory Services 87070 33.8 35.913 35.913 35.913 42.6725 35.549 35.5494 35.5494 35.5 35.913 28.73 42.6725 14.22 42.6725 34.138 7.67 33.8 29.575 29.575 42.6725 7.67 42.6725
CULTURE - ANAEROBIC Laboratory Services 87075 152.192 161.7 161.7 161.7 192.1424 35.549 35.5494 35.5494 35.5 161.7 129.36 192.1424 15.63 192.1424 153.7139 8.42 152.192 133.168 133.17 192.1424 8.42 192.1424
AEROB/ANAER CULTURE OR ID Laboratory Services 87076 40.8 43.35 43.35 43.35 51.51 35.549 35.5494 35.5494 35.5 43.35 34.68 51.51 13.33 51.51 41.208 7.19 40.8 35.7 35.7 51.51 7.19 51.51
CULTURE - URINE Laboratory Services 87086 87.92 93.415 93.415 93.415 110.999 35.549 35.5494 35.5494 35.5 93.415 74.732 110.999 13.32 110.999 88.7992 7.18 87.92 76.93 76.93 110.999 7.18 110.999
OVA & PARASITES STOOL Laboratory Services 87177 100.448 106.73 106.73 106.73 126.8156 35.549 35.5494 35.5494 35.5 106.73 85.381 126.8156 14.69 126.8156 101.4525 7.92 100.448 87.892 87.892 126.8156 7.92 126.8156
GRAM STAIN Laboratory Services 87205 55.104 58.548 58.548 58.548 69.5688 35.549 35.5494 35.5494 35.5 58.548 46.838 69.5688 7.05 69.5688 55.655 3.8 55.104 48.216 48.216 69.5688 3.8 69.5688
WET MOUNT Laboratory Services 87210 62.176 66.062 66.062 66.062 78.4972 35.549 35.5494 35.5494 35.5 66.062 52.85 78.4972 9.6 78.4972 62.7978 5.18 62.176 54.404 54.404 78.4972 5.18 78.4972
RESP VIRUS SCREEN DFA W/REFLEX TO ID Laboratory Services 87300 156 165.75 165.75 165.75 196.95 39.774 39.7738 39.7738 39.8 165.75 132.6 196.95 19.77 196.95 157.56 10.66 156 136.5 136.5 196.95 10.66 196.95
CLOSTRIDIUM DIFF. TOXIN A Laboratory Services 87324 74.8 79.475 79.475 79.475 94.435 39.774 39.7738 39.7738 39.8 79.475 63.58 94.435 19.77 94.435 75.548 10.66 74.8 65.45 65.45 94.435 10.66 94.435
H PYLORI AG-STOOL Laboratory Services 87338 348 369.75 369.75 369.75 439.35 39.774 39.7738 39.7738 39.8 369.75 295.8 439.35 23.73 439.35 351.48 12.79 348 304.5 304.5 439.35 12.79 439.35
HEP B SURFACE ANTIGEN Laboratory Services 87340 63 66.938 66.938 66.938 79.5375 39.774 39.7738 39.7738 39.8 66.938 53.55 79.5375 17.04 79.5375 63.63 9.19 63 55.125 55.125 79.5375 9.19 79.5375
INFLUENZA A Laboratory Services 87400 81.496 86.59 86.59 86.59 102.8887 66.015 66.0152 66.0152 66 86.59 69.272 102.8887 23.31 102.8887 82.311 12.57 81.496 71.309 71.309 102.8887 12.57 102.8887
INFLUENZA B Laboratory Services 87400 81.496 86.59 86.59 86.59 102.8887 66.015 66.0152 66.0152 66 86.59 69.272 102.8887 23.31 102.8887 82.311 12.57 81.496 71.309 71.309 102.8887 12.57 102.8887
ECOLI SHIGA TOXIN Laboratory Services 87427 123.6 131.33 131.33 131.33 156.045 39.774 39.7738 39.7738 39.8 131.33 105.06 156.045 19.77 156.045 124.836 10.66 123.6 108.15 108.15 156.045 10.66 156.045
STREP SCREEN Laboratory Services 87430 64.256 68.272 68.272 68.272 81.1232 39.774 39.7738 39.7738 39.8 68.272 54.618 81.1232 27.74 81.1232 64.8986 14.95 64.256 56.224 56.224 81.1232 14.95 81.1232
HBV DNA QUANTITATIVE PER PLASMA Laboratory Services 87517 271.2 288.15 288.15 288.15 342.39 129.09 129.0948 129.0948 129 288.15 230.52 342.39 70.69 342.39 273.912 38.11 271.2 237.3 237.3 342.39 38.11 342.39
GC LCX Laboratory Services 87591 124.664 132.46 132.46 132.46 157.3883 129.09 129.0948 129.0948 129 132.46 105.96 157.3883 57.9 157.3883 125.9106 31.21 124.664 109.081 109.08 157.3883 31.21 157.3883
COVID-19 Laboratory Services 87635 477.6 507.45 507.45 507.45 602.97 129.09 129.0948 129.0948 129 507.45 405.96 602.97 73.4 602.97 482.376 51.31 477.6 417.9 417.9 602.97 51.31 602.97
RSV - RAPID Laboratory Services 87807 54.368 57.766 57.766 57.766 68.6396 35.549 35.5494 35.5494 35.5 57.766 46.213 68.6396 21.62 68.6396 54.9117 11.65 54.368 47.572 47.572 68.6396 11.65 68.6396
PATH CONSULT W/SLIDE PREP Laboratory Services 88323 114.576 121.74 121.74 121.74 144.6522 106.72 106.7198 106.7198 107 121.74 97.39 144.6522 86.57 144.6522 115.7218 104.63 114.576 100.254 100.25 144.6522 86.57 144.6522
FECAL LEUKOCYTES Laboratory Services 89055 52.288 55.556 55.556 55.556 66.0136 33.509 33.5088 33.5088 33.5 55.556 44.445 66.0136 7.05 66.0136 52.8109 3.8 52.288 45.752 45.752 66.0136 3.8 66.0136
Psychotherapy, 30 min N/A 90832 Service not offered at this hospital
Psychotherapy, 45 min N/A 90834 Service not offered at this hospital
Psychotherapy, 60 min N/A 90837 Service not offered at this hospital
Family psychotherapy, not including patient, 50 min N/A 90846 Service not offered at this hospital
Family psychotherapy, including patient, 50 min N/A 90847 Service not offered at this hospital
Group psychotherapy N/A 90853 Service not offered at this hospital
New patient office or other outpatient visit, typically 30 min N/A 99203 Service not offered at this hospital
New patient office of other outpatient visit, typically 45 min N/A 99204 Service not offered at this hospital
New patient office of other outpatient visit, typically 60 min N/A 99205 Service not offered at this hospital
Patient office consultation, typically 40 min N/A 99243 Service not offered at this hospital
Patient office consultation, typically 60 min N/A 99244 Service not offered at this hospital
Initial new patient preventive medicine evaluation (18-39 years) N/A 99385 Service not offered at this hospital
Initial new patient preventive medicine evaluation (40-64 years) N/A 99386 Service not offered at this hospital
Obstetric blood test panel N/A 80055 Service not offered at this hospital
Automated urinalysis test N/A 81002 or 81003 Service not offered at this hospital
Complete blood count, automated N/A 85027 Service not offered at this hospital
Coagulation assessment blood test N/A 85730 Service not offered at this hospital
MRI scan of brain before and after contrast N/A 70553 Service not offered at this hospital
MRI scan of lower spinal canal N/A 72148 Service not offered at this hospital
MRI scan of leg joint N/A 73721 Service not offered at this hospital
US TRANSVAGINAL N/A 76830 Service not offered at this hospital
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus N/A 76805 Service not offered at this hospital
Mammography of one breast N/A 77065 Service not offered at this hospital
Mammography of both breasts N/A 77066 Service not offered at this hospital
Mammography, screening, bilateral N/A 77067 Service not offered at this hospital
Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities N/A 216 Service not offered at this hospital
Spinal fusion except cervical without major comorbid conditions or complications (MCC) N/A 460 Service not offered at this hospital
Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC) N/A 470 Service not offered at this hospital
Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC) N/A 473 Service not offered at this hospital
Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC) N/A 743 Service not offered at this hospital
REMOVAL OF TONSILS/ADENOIDS N/A 42820 Service not offered at this hospital
EGD UPPER W/WO SPECIMEN N/A 43235 Service not offered at this hospital
Ultrasound examination of lower large bowel using an endoscope N/A 45391 Service not offered at this hospital
Removal of gallbladder using an endoscope N/A 47562 Service not offered at this hospital
Biopsy of prostate gland N/A 55700 Service not offered at this hospital
Surgical removal of prostate and surrounding lymph nodes using an endoscope N/A 55866 Service not offered at this hospital
Routine obstetric care for vaginal delivery, including pre-and post-delivery care N/A 59400 Service not offered at this hospital
Routine obstetric care for cesarean delivery, including pre-and post-delivery care N/A 59510 Service not offered at this hospital
Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care N/A 59610 Service not offered at this hospital
INJECTION OF SUBSTANCE INTO SPINAL CANAL-LUMBAR N/A 62322 Service not offered at this hospital
Removal of recurring cataract in lens capsule using laser N/A 66821 Service not offered at this hospital
Electrocardiogram, routine, with interpretation and report N/A 93000 Service not offered at this hospital
Insertion of catheter into left heart for diagnosis N/A 93452 Service not offered at this hospital
Sleep study N/A 95810 Service not offered at this hospital
Removal of 1 or more breast growth, open N/A 19120 Service not offered at this hospital
Shaving of shoulder bone using endoscope N/A 29826 Service not offered at this hospital
Removal of one knee cartilage using endoscope N/A 29881 Service not offered at this hospital
Biopsy of esophagus, stomach and/or upper small bowel using endoscope N/A 43239 Service not offered at this hospital
Diagnostic examination of large bowel using endoscope N/A 45378 Service not offered at this hospital
Biopsy of large bowel using endoscope N/A 43580 Service not offered at this hospital
Removal of polyps or growths of large bowel using endoscope N/A 45385 Service not offered at this hospital
Repair of groin hernia patient age 5 years or older N/A 49505 Service not offered at this hospital
Injections of anesthetic and/or steriod drug into lower or sacral spine nerve root using imaging guidance N/A 64483 Service not offered at this hospital
Removal of cataract with insertion of lens N/A 66984 Service not offered at this hospital