| Procedure Name | CPT_CODE | Charge | Charge 2022 | BCBS ALLOWED AMOUNT | HEALTHCHOICE ALLOWED AMOUNT | Medicaid Allowed Amount | Medicare Allowed Amount | AETNA ALLOWED AMOUNT | Self / Private-Pay | Highest Allowed | Lowest Allowed |
|---|---|---|---|---|---|---|---|---|---|---|---|
| HC THER EXERCISE EA 15 MIN PT | 97110 | $94.50 | $96.00 | $77.05 | $35.59 | $15.92 | $44.42 | $20.68 | $57.60 | $77.05 | $15.92 |
| LCHG CBC W AUTO DIFFERENTIAL | 85025 | $48.19 | $49.00 | $33.51 | $9.32 | $6.91 | $22.65 | $7.48 | $29.40 | $33.51 | $6.91 |
| LCHG COMPREHENSIVE METABOLIC PANEL | 80053 | $131.61 | $134.00 | $49.37 | $12.67 | $9.39 | $61.86 | $10.17 | $80.40 | $80.40 | $9.39 |
| LCHG URINALYSIS ROUTINE AUTO W MICROSCOPIC | 81001 | $36.75 | $37.00 | $14.43 | $3.80 | $2.82 | $17.27 | $3.05 | $22.20 | $22.20 | $2.82 |
| LCHG LIPID PROFILE | 80061 | $80.62 | $82.00 | $49.37 | $16.07 | $11.91 | $37.89 | $12.89 | $49.20 | $49.37 | $11.91 |
| LCHG TSH | 84443 | $111.72 | $114.00 | $74.32 | $20.16 | $14.94 | $52.51 | $16.17 | $68.40 | $74.32 | $14.94 |
| LCHG PT-INR | 85610 | $32.34 | $33.00 | $17.83 | $5.15 | $3.82 | $15.20 | $3.78 | $19.80 | $19.80 | $3.78 |
| LCHG URINALYSIS DIPSTICK AUTO | 81003 | $29.40 | $30.00 | $10.17 | $2.70 | $2.00 | $13.82 | $2.16 | $18.00 | $18.00 | $2.00 |
| LCHG BASIC METABOLIC PANEL (CA TOTAL) | 80048 | $89.28 | $91.00 | $49.37 | $10.15 | $7.53 | $41.96 | $8.14 | $54.60 | $54.60 | $7.53 |
| PR OFFICE/OUTPT VISIT,NEW,LEVL III | 99203 | $174.30 | $178.00 | $135.89 | $92.74 | $96.11 | $81.92 | $98.99 | $106.80 | $135.89 | $81.92 |
| HC CT HEAD NON CONTRAST | 70450 | $1,711.50 | $1,746.00 | $335.21 | $161.07 | $100.54 | $804.41 | $184.06 | $1,047.60 | $1,047.60 | $100.54 |
| LCHG PROSTATE SPECIFIC ANTIGEN DIAG | 84153 | $112.13 | $114.00 | $45.57 | $22.07 | $16.36 | $52.70 | $17.70 | $68.40 | $68.40 | $16.36 |
| PR PSYTX PT AND OR FAMILY 60 MINUTES | 90837 | $264.60 | $270.00 | $126.96 | $133.90 | $128.85 | $124.36 | $92.00 | $162.00 | $162.00 | $92.00 |
| PR PSYTX PT AND OR FAMILY 30 MINUTES | 90832 | $198.45 | $202.00 | $63.65 | $67.12 | $64.72 | $93.27 | $45.00 | $121.20 | $121.20 | $45.00 |
| LCHG CBC W/O AUTO DIFFERENTIAL | 85027 | $44.10 | $45.00 | $33.51 | $7.76 | $5.75 | $20.73 | $6.22 | $27.00 | $33.51 | $5.75 |
| PR PSYTX PT AND OR FAMILY 45 MINUTES | 90834 | $254.10 | $259.00 | $84.38 | $89.49 | $86.09 | $119.43 | $80.00 | $155.40 | $155.40 | $80.00 |
| HC CT ABDOMEN PELVIS W CONTRAST | 74177 | $3,003.00 | $3,063.00 | $868.04 | $452.87 | $282.68 | $1,411.41 | $384.81 | $1,837.80 | $1,837.80 | $282.68 |
| LCHG HEPATIC FUNCTION PANEL | 80076 | $104.37 | $106.00 | $49.37 | $9.80 | $7.27 | $49.05 | $7.86 | $63.60 | $63.60 | $7.27 |
| PR OFFICE/OUTPT VISIT,NEW,LEVL IV | 99204 | $245.70 | $251.00 | $208.15 | $158.60 | $147.84 | $115.48 | $151.91 | $150.60 | $208.15 | $115.48 |
| REMOVAL OF CATARACT W/INSERTION OF LENS | 66984 | $- | $- | $5,341.70 | $723.00 | $490.54 | $- | $589.64 | $- | $5,341.70 | $- |
| LCHG PTT | 85730 | $44.10 | $45.00 | $17.83 | $7.21 | $5.35 | $20.73 | $5.78 | $27.00 | $27.00 | $5.35 |
| BIOPSY OF LARGE BOWEL, ENDOSCOPE | 45380 | $4,596.07 | $4,688.00 | $2,007.01 | $275.34 | $376.62 | $2,160.15 | $446.46 | $2,812.80 | $2,812.80 | $275.34 |
| BIOPSY OF ESOPHAGUS, STOMACH, AND/OR UPPER SMALL BOWEL, ENDOSCOPE | 43239 | $5,007.03 | $5,107.00 | $1,927.03 | $189.38 | $327.28 | $2,353.31 | $326.26 | $3,064.20 | $3,064.20 | $189.38 |
| HC MRI SPINE LUMBAR NON CONTRAST | 72148 | $2,163.00 | $2,206.00 | $671.54 | $302.58 | $188.87 | $1,016.61 | $417.32 | $1,323.60 | $1,323.60 | $188.87 |
| HC MRI LOWER EXT ANY JOINT NON CONTRAST | 73721 | $2,163.00 | $2,206.00 | $758.13 | $317.13 | $135.31 | $1,016.61 | $309.49 | $1,323.60 | $1,323.60 | $135.31 |
| LCHG PSA FREE | 84154 | $219.03 | $223.00 | $45.57 | $65.00 | $16.36 | $102.94 | $17.70 | $133.80 | $133.80 | $16.36 |
| HC LUMBAR SPINE 4+ VW | 72110 | $567.00 | $578.00 | $99.99 | $66.81 | $41.71 | $266.49 | $37.79 | $346.80 | $346.80 | $37.79 |
| REMOVAL OF POLYPS OR GROWTHS LARGE BOWEL, ENDOSCOPE | 45385 | $4,663.93 | $4,757.00 | $3,263.41 | $349.80 | $396.61 | $2,192.05 | $503.74 | $2,854.20 | $3,263.41 | $349.80 |
| HC US ABDOMEN COMPLETE | 76700 | $758.10 | $773.00 | $317.11 | $171.38 | $69.15 | $356.31 | $103.95 | $463.80 | $463.80 | $69.15 |
| HC MRI BRAIN WITH & WITHOUT CONTRAST | 70553 | $3,360.00 | $3,427.00 | $1,190.12 | $506.58 | $210.16 | $1,579.20 | $625.64 | $2,056.20 | $2,056.20 | $210.16 |
| HC US TRANSVAGINAL NON OB | 76830 | $758.10 | $773.00 | $371.11 | $170.66 | $75.54 | $356.31 | $58.18 | $463.80 | $463.80 | $58.18 |
| HC US OB 14+ WKS SINGLE GEST | 76805 | $758.10 | $773.00 | $372.96 | $195.51 | $122.03 | $356.31 | $111.42 | $463.80 | $463.80 | $111.42 |
| FAMILY PSYCHOTHERAPY 50 MINUTES | 90846 | $- | $- | $134.46 | $- | $95.11 | $- | $82.00 | $- | $134.46 | $- |
| FAMILY PSYCHOTHERAPY W/PATIENT 50 MINUTES | 90847 | $- | $- | $139.72 | $112.21 | $98.49 | $- | $82.00 | $- | $139.72 | $- |
| GROUP PSYCHOTHERAPY | 90853 | $- | $- | $33.50 | $26.54 | $25.61 | $- | $40.00 | $- | $40.00 | $- |
| PR OFFICE/OUTPT VISIT, NEW LEVL V | 99205 | $- | $- | $262.22 | $207.13 | $187.18 | $- | $188.86 | $- | $262.22 | $- |
| OFFICE CONSULTATION 40 MINUTES | 99243 | $- | $- | $- | $114.88 | $- | $- | $108.76 | $- | $114.88 | $- |
| OFFICE CONSULTATION 60 MINUTES | 99244 | $- | $- | $- | $182.45 | $- | $- | $162.02 | $- | $182.45 | $- |
| INITIAL PREVENTIVE MED EVAL 18-39 AGE | 99385 | $- | $- | $167.00 | $124.93 | $- | $- | $106.22 | $- | $167.00 | $- |
| INITIAL PREVENTIVE MED EVAL 40-64 AGE | 99386 | $- | $- | $193.79 | $147.24 | $- | $- | $123.29 | $- | $193.79 | $- |
| OBSTETRIC BLOOD TEST PANEL | 80055 | $- | $- | $49.37 | $57.37 | $- | $- | $35.68 | $- | $57.37 | $- |
| KIDNEY FUNCTION PANEL | 80069 | $- | $- | $49.37 | $10.42 | $- | $- | $8.36 | $- | $49.37 | $- |
| CT SCAN, PELVIS W/CONTRAST | 72193 | $- | $- | $868.04 | $327.98 | $- | $- | $304.11 | $- | $868.04 | $- |
| MAMMOGRAM ONE BREAST | 77065 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| MAMMOGRAM BOTH BREAST | 77066 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| MAMMOGRAM, SCREENING BILATERAL | 77067 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| DRG 216 | 0 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| DRG 460 | 0 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| DRG 470 | 0 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| DRG 473 | 0 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| DRG 743 | 0 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| REMOVAL OF BREAST GROWTH, OPEN | 19120 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| SHAVING OF SHOULDER BONE, ENDOSCOPE | 29826 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| REMOVAL OF KNEE CARTILAGE, ENDOSCOPE | 29881 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| REMOVAL OF TONSILS AND ADENOIDS YOUNGER THAN 12 | 42820 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| DIAGNOSTIC EXAM OF ESOPHAGUS, STOMACH, AND/OR UPPER SMALL BOWEL ENDOSCOPE | 43235 | $- | $- | $1,927.03 | $167.84 | $- | $- | $282.49 | $- | $1,927.03 | $- |
| DIAGNOSIC EXAM OF LARGE BOWEL, ENDOSCOPE | 45378 | $- | $- | $2,007.01 | $254.21 | $- | $- | $374.50 | $- | $2,007.01 | $- |
| ULTRASOUND EXAMINATION OF LOWER LARGE BOWEL, ENDOSCOPE | 45391 | $- | $- | $1,654.68 | $- | $- | $- | $- | $- | $1,654.68 | $- |
| REMOVAL OF GALLBLADDER, ENDOSCOPE | 47562 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| REPAIR OF GROIN HERNIA PATIENT 5 OR OLDER | 49505 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| BIOPSY OF PROSTATE GLAND | 55700 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| REMOVAL OF PROSTATE AND LYMPH NODES, ENDOSCOPE | 55866 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| ROUTINE OBSTETRIC CARE FOR VAG DELIVERY, INCLUDING PRE-AND POST-DELIVERY CARE | 59400 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| ROUTINE OBSTETRIC CARE FOR CESAREAN DELIVERY, INCLUDING PRE-AND POST-DELIVERY CARE | 59510 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| ROUTINE OBSTETRIC CARE FOR VAG DELIVERY AFTER PRIOR CESAREAN DELIERY INCLUDING PRE-AND POST-DELIVERY CARE | 59610 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| INJ OF SUB INTO SPINAL CANAL USING GUIDANCE | 62322 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| INJ OF ANESTHETIC INTO SPINE USING IMAGING GUIDANCE | 64483 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| REMOVAL OF RECURRING CATARACT IN LENS CAPSULE | 66821 | $- | $- | $1,193.54 | $407.93 | $- | $- | $300.57 | $- | $1,193.54 | $- |
| ELECTROCARDIOGRAM, ROUTINE, WITH REPORT AND INTERPRETATION | 93000 | $- | $- | $43.53 | $17.47 | $- | $- | $14.33 | $- | $43.53 | $- |
| INSERTION OF CATH INTO LEFT HEART FOR DX | 93452 | $- | $- | $- | $- | $- | $- | $- | $- | $- | $- |
| SLEEP STUDY | 95810 | $- | $- | $55.35 | $610.89 | $- | $- | $490.81 | $- | $610.89 | $- |
| LCHG BLOOD DRAW | 36415 | $13.23 | $13.00 | $- | $4.14 | $2.67 | $6.22 | $3.12 | $7.80 | $7.80 | $- |
| PR OFFICE/OUTPT VISIT,EST,LEVL III | 99213 | $97.64 | $100.00 | $90.92 | $62.88 | $66.86 | $45.89 | $66.79 | $60.00 | $90.92 | $45.89 |
| PR OFFICE/OUTPT VISIT,EST,LEVL IV | 99214 | $153.30 | $156.00 | $135.42 | $96.75 | $97.32 | $72.05 | $98.38 | $93.60 | $135.42 | $72.05 |
| HC INHALATION TREATMENT W/MED SUBSEQUENT | 94640 | $82.12 | $84.00 | $815.38 | $17.42 | $14.96 | $38.60 | $14.41 | $50.40 | $815.38 | $14.41 |
| LCHG INFLUENZA A+B ANTIGEN RAPID | 87804 | $74.97 | $76.00 | $35.55 | $19.86 | $14.72 | $35.24 | $11.54 | $45.60 | $45.60 | $11.54 |
| HC RB OBSERVATION PER HR | G0378 | $35.00 | $36.00 | $73.57 | $- | $- | $16.45 | $45.30 | $21.60 | $73.57 | $- |
| HC MANUAL THER TECH 1+REGIONS EA 15 MIN PT | 97140 | $82.90 | $85.00 | $77.05 | $32.81 | $25.60 | $38.96 | $19.39 | $51.00 | $77.05 | $19.39 |
| HC LAB GLUCOSE BLD POCT (IP) | 82962 | $18.18 | $19.00 | $23.81 | $3.94 | $2.92 | $8.55 | $2.25 | $11.40 | $23.81 | $2.25 |
| HP EMERGENCY DEPT VISIT LEVEL 3 PROFESSIONAL FEE | 99283 | $321.30 | $328.00 | $80.87 | $119.49 | $60.48 | $151.01 | $57.41 | $196.80 | $196.80 | $57.41 |
| HC IV INF HYDRATION EA ADDL HR | 96361 | $71.31 | $73.00 | $121.20 | $22.52 | $11.72 | $33.52 | $11.75 | $43.80 | $121.20 | $11.72 |
| LCHG STREP A SCREEN DIRECT IMMUNO | 87880 | $74.97 | $76.00 | $35.55 | $19.84 | $14.70 | $35.24 | $11.54 | $45.60 | $45.60 | $11.54 |
| LCHG CULTURE URINE | 87086 | $64.68 | $66.00 | $35.55 | $9.68 | $7.18 | $30.40 | $7.77 | $39.60 | $39.60 | $7.18 |
| LCHG HEMOGLOBIN A1C | 83036 | $57.33 | $58.00 | $45.57 | $11.65 | $7.18 | $26.95 | $8.32 | $34.80 | $45.57 | $7.18 |
| HC CARD REHAB W/ EKG | 93798 | $216.30 | $221.00 | $152.35 | $15.18 | $22.62 | $101.66 | $19.65 | $132.60 | $152.35 | $15.18 |
| HC ED EMERGENT LEVEL IV FACILITY | 99284 | $850.00 | $867.00 | $154.08 | $207.55 | $111.04 | $399.50 | $109.78 | $520.20 | $520.20 | $109.78 |
| HC ED INJ THER/PROPH/DIAG SUBQ/IM | 96372 | $111.68 | $114.00 | $30.62 | $24.26 | $12.62 | $52.49 | $19.95 | $68.40 | $68.40 | $12.62 |
| HC ED EMERGENT LEVEL III FACILITY | 99283 | $525.00 | $536.00 | $80.87 | $119.49 | $60.48 | $246.75 | $57.41 | $321.60 | $321.60 | $57.41 |
| HC EKG 12 LEAD | 93005 | $204.78 | $209.00 | $43.53 | $8.36 | $7.18 | $96.25 | $7.57 | $125.40 | $125.40 | $7.18 |
| LCHG ORGANISM ID URINE | 87088 | $49.98 | $51.00 | $35.55 | $9.71 | $7.20 | $23.49 | $5.92 | $30.60 | $35.55 | $5.92 |
| HC XRAY CHEST 2 VIEWS | 71046 | $290.44 | $296.00 | $99.99 | $45.47 | $28.38 | $136.51 | $23.96 | $177.60 | $177.60 | $23.96 |
| LCHG TROPONIN I | 84484 | $64.68 | $66.00 | $45.57 | $14.96 | $11.09 | $30.40 | $9.47 | $39.60 | $45.57 | $9.47 |
| LCHG SUSCEPTIBILITY URINE | 87186 | $55.86 | $57.00 | $35.55 | $10.38 | $7.69 | $26.25 | $8.32 | $34.20 | $35.55 | $7.69 |
| LCHG B-TYPE NATRIURETIC PEPTIDE | 83880 | $393.96 | $402.00 | $138.33 | $47.11 | $34.92 | $185.16 | $32.66 | $241.20 | $241.20 | $32.66 |
| PR OFFICE/OUTPT VISIT,EST,LEVL I | 99211 | $42.03 | $43.00 | $24.40 | $11.31 | $20.15 | $19.75 | $93.70 | $25.80 | $93.70 | $11.31 |
| HC DRUG COLLECTION NON DOT | 99001 | $16.53 | $17.00 | $- | $8.00 | $- | $7.77 | $13.00 | $10.20 | $13.00 | $- |
| HP EMERGENCY DEPT VISIT LEVEL 4 PROFESSIONAL FEE | 99284 | $685.65 | $699.00 | $154.08 | $207.55 | $111.04 | $322.26 | $109.78 | $419.40 | $419.40 | $109.78 |
| HC XRAY CHEST 1 VIEW | 71045 | $156.91 | $160.00 | $99.99 | $35.63 | $22.24 | $73.75 | $15.69 | $96.00 | $99.99 | $15.69 |
| HC PT EVAL LOW COMPLEXITY | 97161 | $171.15 | $175.00 | $77.05 | $99.12 | $77.34 | $80.44 | $54.12 | $105.00 | $105.00 | $54.12 |
| LCHG VITAMIN D 25-HYDROXY | 82306 | $185.22 | $189.00 | $138.33 | $35.52 | $26.33 | $87.05 | $28.49 | $113.40 | $138.33 | $26.33 |
| LCHG PROSTATE SPECIFIC ANTIGEN SCREEN | G0103 | $100.30 | $102.00 | $45.57 | $- | $17.18 | $47.14 | $17.70 | $61.20 | $61.20 | $- |
| HC ED INJ THER/DIAG IVP EA ADDL NEW DRUG | 96375 | $138.01 | $141.00 | $- | $27.20 | $14.15 | $64.86 | $17.11 | $84.60 | $84.60 | $- |
| LCHG MAGNESIUM BLOOD | 83735 | $44.10 | $45.00 | $23.81 | $8.04 | $5.96 | $20.73 | $6.45 | $27.00 | $27.00 | $5.96 |
| PR OFFICE/OUTPT VISIT,EST,LEVL II | 99212 | $76.47 | $78.00 | $54.07 | $31.60 | $40.14 | $35.94 | $39.76 | $46.80 | $54.07 | $31.60 |
| LCHG T3 FREE | 84481 | $114.66 | $117.00 | $74.32 | $20.33 | $15.07 | $53.89 | $16.30 | $70.20 | $74.32 | $15.07 |
| HC IV INF THER/PROPH/DIAG EA ADDL HR | 96366 | $58.93 | $60.00 | $121.20 | $36.43 | $18.95 | $27.69 | $16.95 | $36.00 | $121.20 | $16.95 |
| LCHG CULTURE BLOOD | 87040 | $82.32 | $84.00 | $129.09 | $12.38 | $9.18 | $38.69 | $9.93 | $50.40 | $129.09 | $9.18 |
| LCHG VITAMIN B12 | 82607 | $92.18 | $94.00 | $74.32 | $18.10 | $13.41 | $43.32 | $14.50 | $56.40 | $74.32 | $13.41 |
| LCHG TESTOSTERONE TOTAL | 84403 | $173.46 | $177.00 | $98.66 | $30.97 | $22.96 | $81.53 | $24.84 | $106.20 | $106.20 | $22.96 |
| LCHG ISTAT LACTIC ACID | 83605 | $78.75 | $80.00 | $45.57 | $13.88 | $10.29 | $37.01 | $10.28 | $48.00 | $48.00 | $10.28 |
| HC INHALATION TREATMENT W/MED | 94640 | $90.30 | $92.00 | $815.38 | $17.42 | $14.96 | $42.44 | $14.41 | $55.20 | $815.38 | $14.41 |
| LCHG SARS-COV-2 (COVID-19) | 87635 | $109.08 | $111.00 | $129.09 | $- | $51.31 | $51.27 | $51.31 | $66.60 | $129.09 | $- |
| LCHG T4 FREE | 84439 | $69.09 | $70.00 | $74.32 | $10.82 | $8.02 | $32.47 | $8.68 | $42.00 | $74.32 | $8.02 |
| HC ED INJ THER/PROPH/DIAG IVP SNGL OR INIT | 96374 | $152.57 | $156.00 | $- | $65.20 | $33.91 | $71.71 | $43.48 | $93.60 | $93.60 | $- |
| HC ED IVP TPD EA ADD PUSH SAME DRUG | 96376 | $69.18 | $71.00 | $- | $13.60 | $- | $32.51 | $11.33 | $42.60 | $42.60 | $- |
| LCHG T4 TOTAL | 84436 | $57.33 | $58.00 | $74.32 | $8.24 | $6.11 | $26.95 | $6.61 | $34.80 | $74.32 | $6.11 |
| LCHG SP G+M LEVEL IV TC NL | 88305 | $108.78 | $111.00 | $106.72 | $79.66 | $62.16 | $51.13 | $44.51 | $66.60 | $106.72 | $44.51 |
| HC ED IV INF THER/PROPH/DIAG 1ST HR | 96365 | $382.78 | $390.00 | $- | $116.60 | $60.66 | $179.91 | $57.04 | $234.00 | $234.00 | $- |
| LCHG CK BLOOD | 82550 | $52.92 | $54.00 | $23.81 | $7.81 | $5.79 | $24.87 | $6.27 | $32.40 | $32.40 | $5.79 |
| LCHG DRUG SCREEN SGLCLS A V | 80307 | $80.85 | $82.00 | $138.33 | $74.57 | $55.27 | $38.00 | $55.87 | $49.20 | $138.33 | $38.00 |
| HC ELEC STIM UNATTENDED NON WOUND PT | G0283 | $63.00 | $64.00 | $77.05 | $- | $- | $29.61 | $8.74 | $38.40 | $77.05 | $- |
| HC ED EMERGENT LEVEL V | 99285 | $1,200.00 | $1,224.00 | $228.72 | $284.41 | $161.39 | $564.00 | $160.95 | $734.40 | $734.40 | $160.95 |
| HC CT ABDOMEN PELVIS WO CONTRAST | 74176 | $1,904.70 | $1,943.00 | $868.04 | $280.68 | $175.20 | $895.21 | $258.73 | $1,165.80 | $1,165.80 | $175.20 |
| HC ED IV INF HYDRATION INIT 31 MIN TO 1HR | 96360 | $201.98 | $206.00 | $245.13 | $56.48 | $29.38 | $94.93 | $44.20 | $123.60 | $245.13 | $29.38 |
| HC DEBRID SELECTIVE 1ST 20SQ CM OR < PT | 97597 | $210.00 | $214.00 | $214.05 | $44.04 | $84.96 | $98.70 | $60.27 | $128.40 | $214.05 | $44.04 |
| PR DOM/R-HOME E/M EST PT LW MOD SEVERITY | 99335 | $113.40 | $116.00 | $122.02 | $111.64 | $87.11 | $53.30 | $87.23 | $69.60 | $122.02 | $53.30 |
| LCHG DIFFERENTIAL MANUAL | 85007 | $57.33 | $58.00 | $33.51 | $4.56 | $3.38 | $26.95 | $3.31 | $34.80 | $34.80 | $3.31 |
| HC ULTRASOUND THERAPY EA 15 MIN PT | 97035 | $52.50 | $54.00 | $77.05 | $16.76 | $- | $24.68 | $8.23 | $32.40 | $77.05 | $- |
| LCHG RSV RAPID AG BY IMMUNOASSAY | 87807 | $92.61 | $94.00 | $35.55 | $15.72 | $11.65 | $43.53 | $11.54 | $56.40 | $56.40 | $11.54 |
| HC KNEE 3 VW | 73562 | $424.20 | $433.00 | $99.99 | $53.85 | $33.61 | $199.37 | $29.08 | $259.80 | $259.80 | $29.08 |
| HC HAND 3+ VW | 73130 | $424.20 | $433.00 | $99.99 | $48.03 | $29.98 | $199.37 | $25.14 | $259.80 | $259.80 | $25.14 |
| LCHG FOLATE | 82746 | $96.16 | $98.00 | $45.57 | $17.64 | $13.08 | $45.19 | $14.15 | $58.80 | $58.80 | $13.08 |
| HC ED EMERGENT LEVEL II | 99282 | $350.00 | $357.00 | $53.59 | $86.20 | $40.35 | $164.50 | $38.39 | $214.20 | $214.20 | $38.39 |
| LCHG LIPASE BLOOD | 83690 | $57.75 | $59.00 | $23.81 | $8.27 | $6.13 | $27.14 | $6.63 | $35.40 | $35.40 | $6.13 |
| HC FOOT 3+ VW | 73630 | $424.20 | $433.00 | $99.99 | $45.15 | $28.19 | $199.37 | $24.40 | $259.80 | $259.80 | $24.40 |
| HC SHOULDER 2+ VW | 73030 | $424.20 | $433.00 | $99.99 | $45.69 | $28.52 | $199.37 | $23.88 | $259.80 | $259.80 | $23.88 |
| HC GAIT TRAINING EA 15 MIN PT | 97116 | $78.75 | $80.00 | $77.05 | $35.21 | $27.47 | $37.01 | $18.26 | $48.00 | $77.05 | $18.26 |
| LCHG OCCULT BLOOD FECES | 82270 | $20.58 | $21.00 | $23.81 | $5.26 | $3.90 | $9.67 | $3.14 | $12.60 | $23.81 | $3.14 |
| LCHG PLATELET PHERESIS LR | P9035 | $2,257.92 | $2,303.00 | $2,683.30 | $- | $389.81 | $1,061.22 | $424.17 | $1,381.80 | $2,683.30 | $- |
| LCHG TESTOSTERONE FREE | 84402 | $155.82 | $159.00 | $98.66 | $30.56 | $22.66 | $73.24 | $24.50 | $95.40 | $98.66 | $22.66 |
| LCHG AMYLASE BLOOD | 82150 | $64.68 | $66.00 | $45.57 | $7.78 | $5.76 | $30.40 | $6.24 | $39.60 | $45.57 | $5.76 |
| LCHG HCG URINE QUALITATIVE | 81025 | $41.16 | $42.00 | $14.43 | $10.33 | $7.66 | $19.35 | $6.09 | $25.20 | $25.20 | $6.09 |
| LCHG MICROSOMAL ANTIBODY | 86376 | $47.04 | $48.00 | $98.66 | $17.46 | $12.94 | $22.11 | $13.99 | $28.80 | $98.66 | $12.94 |
| HC LUMBAR SPINE 2 OR 3 VW | 72100 | $424.20 | $433.00 | $99.99 | $52.66 | $32.87 | $199.37 | $27.76 | $259.80 | $259.80 | $27.76 |
| PR PREVENTIVE VISIT,EST,INFANT | 99391 | $168.00 | $171.00 | $94.93 | $103.43 | $89.94 | $78.96 | $79.90 | $102.60 | $103.43 | $78.96 |
| LCHG FSH | 83001 | $124.95 | $127.00 | $88.88 | $22.30 | $16.53 | $58.73 | $17.88 | $76.20 | $88.88 | $16.53 |
| PR PREVENTIVE VISIT,EST,AGE 1-4 | 99392 | $192.15 | $196.00 | $133.98 | $92.48 | $95.83 | $90.31 | $85.55 | $117.60 | $133.98 | $85.55 |
| PR PSYTX PT AND OR FAMILY 45 MINUTES | 90834 | $254.10 | $259.00 | $84.38 | $89.49 | $86.09 | $119.43 | $80.00 | $155.40 | $155.40 | $80.00 |
| LCHG ESTRADIOL | 82670 | $148.47 | $151.00 | $98.66 | $33.53 | $54.85 | $69.78 | $26.89 | $90.60 | $98.66 | $26.89 |
| LCHG D-DIMER QUANTITATIVE | 85379 | $147.00 | $150.00 | $57.42 | $12.22 | $9.05 | $69.09 | $9.79 | $90.00 | $90.00 | $9.05 |
| LCHG IRON BLOOD | 83540 | $36.29 | $37.00 | $23.81 | $7.76 | $5.75 | $17.06 | $5.36 | $22.20 | $23.81 | $5.36 |
| LCHG BLOOD TYPE RH I | 86901 | $32.34 | $33.00 | $13.53 | $3.59 | $2.66 | $15.20 | $2.87 | $19.80 | $19.80 | $2.66 |
| LCHG BLOOD TYPE ABO | 86900 | $32.34 | $33.00 | $13.53 | $3.59 | $2.66 | $15.20 | $2.87 | $19.80 | $19.80 | $2.66 |
| LCHG URIC ACID BLOOD | 84550 | $44.10 | $45.00 | $23.81 | $5.42 | $4.02 | $20.73 | $4.35 | $27.00 | $27.00 | $4.02 |
| LCHG SED RATE WINTROBE | 85651 | $32.34 | $33.00 | $33.51 | $5.12 | $3.80 | $15.20 | $3.42 | $19.80 | $33.51 | $3.42 |
| HC THER ACTIVITIES EA 15 MIN PT | 97530 | $80.85 | $82.00 | $77.05 | $45.13 | $35.21 | $38.00 | $22.48 | $49.20 | $77.05 | $22.48 |
| HC IMMUNIZ ADMIN 1 SNGL/COMB VAC/TOXOID | 90471 | $78.75 | $80.00 | $30.62 | $17.52 | $12.62 | $37.01 | $10.00 | $48.00 | $48.00 | $10.00 |
| LCHG COMPATIBILITY TEST ANTIGLOBULIN | 86922 | $220.50 | $225.00 | $210.68 | $- | $42.14 | $103.64 | $15.49 | $135.00 | $210.68 | $- |
| HC WRIST 3+ VW | 73110 | $424.20 | $433.00 | $99.99 | $53.31 | $33.28 | $199.37 | $29.11 | $259.80 | $259.80 | $29.11 |
| LCHG RBC LR | P9016 | $573.30 | $585.00 | $2,683.30 | $- | $136.54 | $269.45 | $197.09 | $351.00 | $2,683.30 | $- |
| HC XRAY ABDOMEN 2 VIEWS | 74019 | $424.20 | $433.00 | $99.99 | $49.84 | $31.11 | $199.37 | $26.16 | $259.80 | $259.80 | $26.16 |
| LCHG SP STAIN GROUP II TC NL | 88313 | $207.27 | $211.00 | $106.72 | $83.28 | $64.98 | $97.42 | $41.33 | $126.60 | $126.60 | $41.33 |
| LCHG CULTURE ROUTINE | 87070 | $64.68 | $66.00 | $35.55 | $10.34 | $7.67 | $30.40 | $8.29 | $39.60 | $39.60 | $7.67 |
| LCHG GRAM STAIN SMEAR | 87205 | $32.34 | $33.00 | $35.55 | $5.12 | $3.80 | $15.20 | $4.11 | $19.80 | $35.55 | $3.80 |
| LCHG CULTURE ANAEROBE | 87075 | $64.68 | $66.00 | $35.55 | $11.36 | $8.42 | $30.40 | $9.11 | $39.60 | $39.60 | $8.42 |
| HC ANKLE 3+ VW | 73610 | $424.20 | $433.00 | $99.99 | $48.03 | $29.98 | $199.37 | $25.89 | $259.80 | $259.80 | $25.89 |
| PR OFFICE/OUTPT VISIT,EST,LEVL V | 99215 | $207.90 | $212.00 | $183.27 | $136.64 | $131.08 | $97.71 | $132.08 | $127.20 | $183.27 | $97.71 |
| LCHG ANA BLOOD SCREEN | 86038 | $29.40 | $30.00 | $39.77 | $14.51 | $10.75 | $13.82 | $11.63 | $18.00 | $39.77 | $10.75 |
| LCHG TIBC | 83550 | $57.92 | $59.00 | $45.57 | $10.49 | $7.77 | $27.22 | $8.41 | $35.40 | $45.57 | $7.77 |
| LCHG PTH INTACT | 83970 | $254.31 | $259.00 | $98.66 | $49.54 | $36.72 | $119.53 | $39.72 | $155.40 | $155.40 | $36.72 |
| LCHG TRANSFUSION SERVICE FEE | 36430 | $936.39 | $955.00 | $2,683.30 | $43.66 | $29.63 | $440.10 | $30.85 | $573.00 | $2,683.30 | $29.63 |
| LCHG BLOOD GASES ARTERIAL I | 82803 | $182.28 | $186.00 | $45.57 | $31.28 | $23.19 | $85.67 | $18.62 | $111.60 | $111.60 | $18.62 |
| HC XRAY HIP UNILAT 2-3 VIEWS | 73502 | $424.20 | $433.00 | $99.99 | $62.25 | $38.86 | $199.37 | $31.62 | $259.80 | $259.80 | $31.62 |
| PR IMPLANT,HORMONE,SUBCUTANEOUS | 11980 | $367.50 | $375.00 | 789..29 | $- | $84.69 | $172.73 | $93.22 | $225.00 | $225.00 | $- |
| PR PREVENTIVE VISIT,EST,AGE5-11 | 99393 | $190.05 | $194.00 | $133.50 | $91.26 | $95.53 | $89.32 | $85.29 | $116.40 | $133.50 | $85.29 |
| LCHG T3 UPTAKE | 84479 | $39.69 | $40.00 | $74.32 | $7.76 | $5.75 | $18.65 | $6.22 | $24.00 | $74.32 | $5.75 |
| LCHG LDH BLOOD | 83615 | $44.10 | $45.00 | $23.81 | $7.25 | $5.37 | $20.73 | $5.81 | $27.00 | $27.00 | $5.37 |
| HC BAT NON DOT DOT | 82075 | $26.25 | $27.00 | $45.57 | $36.00 | $- | $12.34 | $0.01 | $16.20 | $45.57 | $- |
| LCHG SUSCEPTIBILITY EACH REFER | 87186 | $55.86 | $57.00 | $35.55 | $10.38 | $7.69 | $26.25 | $8.32 | $34.20 | $35.55 | $7.69 |
| LCHG LDL CHOLESTEROL | 83721 | $58.80 | $60.00 | $45.57 | $12.60 | $9.34 | $27.64 | $9.18 | $36.00 | $45.57 | $9.18 |
| HC CT CHEST NON CONTRAST | 71250 | $1,711.50 | $1,746.00 | $706.79 | $220.53 | $137.66 | $804.41 | $233.83 | $1,047.60 | $1,047.60 | $137.66 |
| PR DRAIN/INJECT LARGE JOINT/BURSA | 20610 | $161.44 | $165.00 | $1,073.44 | $62.62 | $55.96 | $75.88 | $60.73 | $99.00 | $1,073.44 | $55.96 |
| PR SUBSEQUENT HOSPITAL CARE,LEVL I | 99231 | $100.80 | $103.00 | $50.72 | $48.23 | $36.12 | $47.38 | $36.13 | $61.80 | $61.80 | $36.12 |
| LCHG IMMUNOGLOBULIN | 82784 | $44.10 | $45.00 | $45.57 | $11.16 | $8.27 | $20.73 | $8.95 | $27.00 | $45.57 | $8.27 |
| LCHG ORGANISM ID AEROBE EACH REFER | 87077 | $49.98 | $51.00 | $35.55 | $9.70 | $7.19 | $23.49 | $7.78 | $30.60 | $35.55 | $7.19 |
| LCHG T4 TOTAL I | 84436 | $57.33 | $58.00 | $74.32 | $8.24 | $6.11 | $26.95 | $6.61 | $34.80 | $74.32 | $6.11 |
| HC CERVICAL SPINE 2 OR 3 VW | 72040 | $424.20 | $433.00 | $99.99 | $52.66 | $32.87 | $199.37 | $27.51 | $259.80 | $259.80 | $27.51 |
| LCHG ANTIBODY SCREEN | 86850 | $54.39 | $55.00 | $39.77 | $11.72 | $8.69 | $25.56 | $10.19 | $33.00 | $39.77 | $8.69 |
| HC CT CERVICAL SPINE NON CONTRAST | 72125 | $1,711.50 | $1,746.00 | $487.56 | $216.19 | $134.95 | $804.41 | $239.23 | $1,047.60 | $1,047.60 | $134.95 |
| HC EPIFIX PER SQ CM | Q4186 | $581.96 | $594.00 | $- | $- | $150.27 | $273.52 | $93.67 | $356.40 | $356.40 | $- |
| LCHG FERRITIN | 82728 | $91.14 | $93.00 | $45.57 | $16.36 | $12.12 | $42.84 | $13.11 | $55.80 | $55.80 | $12.12 |
| LCHG CHLAMYDIA DNA PROBE | 87491 | $123.48 | $126.00 | $39.77 | $42.11 | $31.21 | $58.04 | $33.77 | $75.60 | $75.60 | $31.21 |
| HC US ABDOMEN LIMITED | 76705 | $758.10 | $773.00 | $317.11 | $126.87 | $79.19 | $356.31 | $82.52 | $463.80 | $463.80 | $79.19 |
| PR HC PRO PHONE CALL 21-30 MIN | 98968 | $119.70 | $122.00 | $98.66 | $- | $36.98 | $56.26 | $32.15 | $73.20 | $98.66 | $- |
| LCHG THYROGLOBULIN ANTIBODY | 86800 | $47.04 | $48.00 | $23.81 | $19.09 | $14.15 | $22.11 | $15.30 | $28.80 | $28.80 | $14.15 |
| LCHG PHOSPHORUS BLOOD | 84100 | $44.10 | $45.00 | $23.81 | $5.69 | $4.22 | $20.73 | $4.56 | $27.00 | $27.00 | $4.22 |
| HC ED RPR SCLP/TRNK/EXTRM SMPL <= 2.5CM | 12001 | $277.20 | $283.00 | $789.29 | $62.00 | $80.39 | $130.28 | $41.14 | $169.80 | $789.29 | $41.14 |
| LCHG C-REACTIVE PROTEIN | 86140 | $32.34 | $33.00 | $39.77 | $6.22 | $4.61 | $15.20 | $4.98 | $19.80 | $39.77 | $4.61 |
| LCHG GC AMPLIFIED PROBE | 87591 | $114.66 | $117.00 | $129.09 | $42.11 | $31.21 | $53.89 | $33.77 | $70.20 | $129.09 | $31.21 |
| LCHG CREATININE URINE RANDOM | 82570 | $32.34 | $33.00 | $23.81 | $6.22 | $4.61 | $15.20 | $4.98 | $19.80 | $23.81 | $4.61 |
| HC DEXA BONE DENSITY AXIAL SKELETON | 77080 | $295.88 | $302.00 | $141.93 | $54.45 | $33.99 | $139.07 | $37.40 | $181.20 | $181.20 | $33.99 |
| PR OFFICE/OUTPT VISIT,NEW,LEVL II | 99202 | $123.90 | $126.00 | $93.31 | $61.86 | $67.60 | $58.23 | $68.05 | $75.60 | $93.31 | $58.23 |
| PR PREVENTIVE VISIT,EST,40-64 | 99396 | $233.10 | $238.00 | $160.78 | $112.76 | $115.01 | $109.56 | $101.81 | $142.80 | $160.78 | $101.81 |
| LCHG HEMOGLOBIN | 85018 | $17.64 | $18.00 | $33.51 | $2.84 | $2.11 | $8.29 | $2.28 | $10.80 | $33.51 | $2.11 |
| LCHG HEMATOCRIT | 85014 | $17.64 | $18.00 | $33.51 | $2.84 | $2.11 | $8.29 | $2.28 | $10.80 | $33.51 | $2.11 |
| HC MOD SED SAME PHYS 5>=YRS INIT 15 MIN | 99152 | $57.75 | $59.00 | $- | $14.65 | $43.76 | $27.14 | $40.86 | $35.40 | $43.76 | $- |
| PR DESTRUCT BENIGN LESION, 1-14 | 17110 | $99.75 | $102.00 | $759.33 | $88.18 | $97.55 | $46.88 | $98.93 | $61.20 | $759.33 | $46.88 |
| HC MOD SED SAME PHYS EA ADDL 15 MIN | 99153 | $57.75 | $59.00 | $- | $11.51 | $8.98 | $27.14 | $8.54 | $35.40 | $35.40 | $- |
| HC PT EVAL MOD COMPLEXITY | 97162 | $223.65 | $228.00 | $77.05 | $99.12 | $77.34 | $105.12 | $54.12 | $136.80 | $136.80 | $54.12 |
| LCHG SHIGA-LIKE TOXIN | 87427 | $264.60 | $270.00 | $39.77 | $14.38 | $10.66 | $124.36 | $11.54 | $162.00 | $162.00 | $10.66 |
| LCHG WET PREP SMEAR | 87210 | $44.10 | $45.00 | $35.55 | $6.98 | $5.18 | $20.73 | $4.11 | $27.00 | $35.55 | $4.11 |
| LCHG CULTURE SALMONELLA+SHIGELLA | 87045 | $64.68 | $66.00 | $35.55 | $11.33 | $8.40 | $30.40 | $9.08 | $39.60 | $39.60 | $8.40 |
| LCHG T3 TOTAL | 84480 | $44.10 | $45.00 | $74.32 | $17.02 | $12.61 | $20.73 | $13.64 | $27.00 | $74.32 | $12.61 |
| IMPLT LENS TECNIS SILICON | V2632 | $425.25 | $434.00 | $- | $- | $303.02 | $199.87 | $106.85 | $260.40 | $303.02 | $- |
| HC CLIN DECISION SUPPORT NDSC AUC2 | G1004 | $0.00 | $0.00 | $- | $- | $- | $0.00 | $- | $0.00 | $0.00 | $- |
| LCHG CULTURE STOOL EACH ORGANISM | 87046 | $69.09 | $70.00 | $35.55 | $11.33 | $8.40 | $32.47 | $9.08 | $42.00 | $42.00 | $8.40 |
| HC CT ABDOMEN PELVIS WWO CONTRAST | 74178 | $3,822.00 | $3,898.00 | $868.04 | $508.71 | $317.54 | $1,796.34 | $449.95 | $2,338.80 | $2,338.80 | $317.54 |
| LCHG CLOSTRIDIUM DIFFICILE TOXIN BY EIA | 87324 | $88.20 | $90.00 | $39.77 | $14.38 | $10.66 | $41.45 | $11.54 | $54.00 | $54.00 | $10.66 |
| PR ANNUAL WELLNESS VST; PPS SUBSQT VST | G0439 | $252.00 | $257.00 | $- | $- | $33.01 | $118.44 | $123.65 | $154.20 | $154.20 | $- |
| LCHG LYME DISEASE AB IGM | 86618 | $114.66 | $117.00 | $66.02 | $20.44 | $15.15 | $53.89 | $16.39 | $70.20 | $70.20 | $15.15 |
| LCHG HEPATITIS C ANTIBODY | 86803 | $97.02 | $99.00 | $66.02 | $17.12 | $12.69 | $45.60 | $13.73 | $59.40 | $66.02 | $12.69 |
| LCHG PROTEIN URINE RANDOM QUANTITATIVE | 84156 | $29.40 | $30.00 | $23.81 | $4.40 | $3.26 | $13.82 | $3.53 | $18.00 | $23.81 | $3.26 |
| HC ELBOW 2 VW | 73070 | $424.20 | $433.00 | $99.99 | $39.34 | $24.56 | $199.37 | $22.09 | $259.80 | $259.80 | $22.09 |
| PR NURSING FAC CARE SUBSEQ, LVL I | 99307 | $88.63 | $90.00 | $56.94 | $51.29 | $40.02 | $41.66 | $40.84 | $54.00 | $56.94 | $40.02 |
| HC TTE 2D WO CON W DOPPLER AND COLOR CMPL | 93306 | $2,656.50 | $2,710.00 | $- | $210.91 | $181.18 | $1,248.56 | $- | $1,626.00 | $1,626.00 | $- |
| LCHG CULTURE RESPIRATORY | 87070 | $64.68 | $66.00 | $35.55 | $10.34 | $7.67 | $30.40 | $8.29 | $39.60 | $39.60 | $7.67 |
| LCHG PROGESTERONE | 84144 | $58.80 | $60.00 | $74.32 | $25.03 | $18.55 | $27.64 | $20.08 | $36.00 | $74.32 | $18.55 |
| LCHG SS-A ANTIBODY | 86235 | $114.66 | $117.00 | $66.02 | $21.52 | $15.95 | $53.89 | $17.26 | $70.20 | $70.20 | $15.95 |
| LCHG SS-B ANTIBODY | 86235 | $110.25 | $112.00 | $66.02 | $21.52 | $15.95 | $51.82 | $17.26 | $67.20 | $67.20 | $15.95 |
| LCHG GGT | 82977 | $61.74 | $63.00 | $23.81 | $8.64 | $6.40 | $29.02 | $6.93 | $37.80 | $37.80 | $6.40 |
| LCHG VALPROIC ACID LEVEL | 80164 | $91.14 | $93.00 | $59.46 | $13.25 | $12.04 | $42.84 | $13.04 | $55.80 | $59.46 | $12.04 |
| HC KNEE 1 OR 2 VW | 73560 | $424.20 | $133.00 | $99.99 | $46.05 | $28.75 | $199.37 | $24.08 | $79.80 | $199.37 | $24.08 |
| HC TX SPEECH DISORDER INDIVID 30 MIN ST | 92507 | $310.80 | $317.00 | $161.93 | $84.21 | $72.34 | $146.08 | $45.52 | $190.20 | $190.20 | $45.52 |
| PR HOSPITAL DISCHARGE DAY,<30 MIN | 99238 | $187.95 | $192.00 | $93.79 | $88.85 | $71.08 | $88.34 | $66.56 | $115.20 | $115.20 | $66.56 |
| LCHG PROTEIN ELECTROPHORESIS BLOOD | 84165 | $72.03 | $73.00 | $45.57 | $12.89 | $9.55 | $33.85 | $10.33 | $43.80 | $45.57 | $9.55 |
| HC CT CHEST WITH CONTRAST | 71260 | $2,641.80 | $2,695.00 | $706.79 | $272.34 | $170.00 | $1,241.65 | $292.23 | $1,617.00 | $1,617.00 | $170.00 |
| HC PULM REHAB W/ EXER ONE HR FOR COPD | G0424 | $277.83 | $283.00 | $409.54 | $- | $- | $130.58 | $33.30 | $169.80 | $409.54 | $- |
| HC SLEEP STUDY UNATTENDED | 95806 | $380.10 | $388.00 | $98.66 | $119.16 | $- | $178.65 | $141.61 | $232.80 | $232.80 | $- |
| LCHG PSA TOTAL | 84153 | $113.19 | $115.00 | $45.57 | $22.07 | $16.36 | $53.20 | $17.70 | $69.00 | $69.00 | $16.36 |
| LCHG PROLACTIN | 84146 | $129.36 | $132.00 | $98.66 | $23.26 | $17.24 | $60.80 | $18.65 | $79.20 | $98.66 | $17.24 |
| LCHG DIGOXIN LEVEL | 80162 | $110.25 | $112.00 | $59.46 | $15.94 | $11.81 | $51.82 | $12.78 | $67.20 | $67.20 | $11.81 |
| HC TIBIA AND FIBULA 2 VW | 73590 | $424.20 | $433.00 | $99.99 | $42.21 | $26.35 | $199.37 | $21.43 | $259.80 | $259.80 | $21.43 |
| HC FINGERS (MULTIPLE) | 73140 | $424.20 | $433.00 | $99.99 | $48.75 | $30.43 | $199.37 | $25.97 | $259.80 | $259.80 | $25.97 |
| HC PELVIS 1 OR 2 VW | 72170 | $424.20 | $433.00 | $99.99 | $39.41 | $24.59 | $199.37 | $22.35 | $259.80 | $259.80 | $22.35 |
| PR INITIAL HOSPITAL CARE,LEVL I | 99221 | $243.60 | $248.00 | $131.11 | $124.83 | $93.50 | $114.49 | $93.70 | $148.80 | $148.80 | $93.50 |
| LCHG SARS-COV-2 (COVID-19) ANTIBODY IGG | 86769 | $52.50 | $54.00 | $39.77 | $30.95 | $42.13 | $24.68 | $42.13 | $32.40 | $42.13 | $24.68 |
| LCHG RNP ANTIBODY | 86235 | $132.30 | $135.00 | $66.02 | $21.52 | $15.95 | $62.18 | $17.26 | $81.00 | $81.00 | $15.95 |
| LCHG SM ANTIBODY ENA | 86235 | $110.25 | $112.00 | $66.02 | $21.52 | $15.95 | $51.82 | $17.26 | $67.20 | $67.20 | $15.95 |
| HC FOREARM 2 VW | 73090 | $424.20 | $433.00 | $99.99 | $39.83 | $24.85 | $199.37 | $21.64 | $259.80 | $259.80 | $21.64 |
| HC INSERT BLADDER CATH FOR SPECIMEN | P9612 | $63.00 | $64.00 | $- | $- | $2.67 | $29.61 | $2.10 | $38.40 | $38.40 | $- |
| LCHG DNA ANTIBODY DOUBLE STRANDED | 86225 | $83.79 | $85.00 | $39.77 | $16.49 | $12.22 | $39.38 | $13.22 | $51.00 | $51.00 | $12.22 |
| LCHG PROTEIN TOTAL BLOOD I | 84155 | $44.10 | $45.00 | $23.81 | $4.40 | $3.26 | $20.73 | $3.53 | $27.00 | $27.00 | $3.26 |
| LCHG CREATININE BLOOD | 82565 | $44.10 | $45.00 | $23.81 | $6.14 | $4.55 | $20.73 | $4.93 | $27.00 | $27.00 | $4.55 |
| LCHG ALCOHOL BREATH TEST | 82075 | $73.50 | $75.00 | $45.57 | $36.00 | $- | $34.55 | $0.01 | $45.00 | $45.57 | $- |
| LCHG MICROALBUMIN URINE RANDOM QUANT | 82043 | $36.75 | $37.00 | $14.43 | $6.94 | $5.14 | $17.27 | $5.57 | $22.20 | $22.20 | $5.14 |
| PR PURE TONE HEARING TEST, AIR | 92551 | $12.60 | $13.00 | $125.71 | $28.00 | $9.87 | $5.92 | $9.34 | $7.80 | $125.71 | $5.92 |
| PR PREVENTIVE VISIT,EST,18-39 | 99395 | $213.15 | $217.00 | $150.25 | $102.22 | $107.85 | $100.18 | $95.34 | $130.20 | $150.25 | $95.34 |
| LCHG RHEUMATOID FACTOR BLOOD QUANT | 86431 | $44.10 | $45.00 | $39.77 | $6.80 | $5.04 | $20.73 | $5.46 | $27.00 | $39.77 | $5.04 |
| LCHG HCG BETA BLOOD QUANTITATIVE | 84702 | $99.96 | $102.00 | $74.32 | $18.06 | $13.39 | $46.98 | $14.49 | $61.20 | $74.32 | $13.39 |
| LCHG BUN | 84520 | $44.10 | $45.00 | $23.81 | $4.74 | $3.51 | $20.73 | $3.80 | $27.00 | $27.00 | $3.51 |
| LCHG BASIC METABOLIC PANEL (CA IONIZED) | 80047 | $64.05 | $65.00 | $49.37 | $16.48 | $12.21 | $30.10 | $8.14 | $39.00 | $49.37 | $8.14 |
| HC ED INSERT CATH TEMP INDWELL BLADDER SMPL | 51702 | $215.04 | $219.00 | $214.05 | $35.44 | $53.98 | $101.07 | $77.35 | $131.40 | $214.05 | $35.44 |
| HC ED RPR FACE EAR SMPL <=2.5CM | 12011 | $332.64 | $339.00 | $789.29 | $77.82 | $98.30 | $156.34 | $99.12 | $203.40 | $789.29 | $77.82 |
| PR PREVENTIVE VISIT,EST,12-17 | 99394 | $213.15 | $217.00 | $146.90 | $101.00 | $105.27 | $100.18 | $93.33 | $130.20 | $146.90 | $93.33 |
| LCHG VANCOMYCIN LEVEL TROUGH | 80202 | $101.43 | $103.00 | $59.46 | $16.25 | $12.04 | $47.67 | $13.04 | $61.80 | $61.80 | $12.04 |
| LCHG HEPATITIS SCREEN ACUTE | 80074 | $124.95 | $127.00 | $49.37 | $57.16 | $42.37 | $58.73 | $45.83 | $76.20 | $76.20 | $42.37 |
| LCHG STAIN TRICHROME | 87209 | $44.10 | $45.00 | $129.09 | $21.58 | $15.99 | $20.73 | $17.30 | $27.00 | $129.09 | $15.99 |
| LCHG O+P | 87177 | $44.10 | $45.00 | $35.55 | $10.68 | $7.92 | $20.73 | $841.00 | $27.00 | $841.00 | $7.92 |
| LCHG HELICOBACTER PYLORI IGM | 86677 | $97.02 | $99.00 | $66.02 | $20.22 | $14.99 | $45.60 | $13.97 | $59.40 | $66.02 | $13.97 |
| LCHG RHEUMATOID FACTOR BLOOD QUANT I | 86431 | $44.10 | $45.00 | $39.77 | $6.80 | $5.04 | $20.73 | $5.46 | $27.00 | $39.77 | $5.04 |
| PR NURSING FAC DISCHRGE DAY,1-30 MIN | 99315 | $145.62 | $149.00 | $93.31 | $85.68 | $66.85 | $68.44 | $67.10 | $89.40 | $93.31 | $66.85 |
| PR PREVENTIVE VISIT,NEW,INFANT | 99381 | $202.65 | $207.00 | $139.24 | $136.39 | $99.42 | $95.25 | $88.88 | $124.20 | $139.24 | $88.88 |
| PR DIAB MANAGE TRN PER INDIV | G0108 | $79.00 | $81.00 | $67.47 | $- | $50.74 | $37.13 | $58.51 | $48.60 | $67.47 | $- |
| PR TELEHEALTH FACILITY FEE | Q3014 | $26.25 | $27.00 | $20.00 | $- | $- | $12.34 | $26.65 | $16.20 | $26.65 | $- |
| HC RIBS UNILATERAL 2 VW | 71100 | $424.20 | $433.00 | $99.99 | $49.30 | $30.77 | $199.37 | $25.11 | $259.80 | $259.80 | $25.11 |
| LCHG HAPTOGLOBIN | 83010 | $76.44 | $78.00 | $45.57 | $15.10 | $11.19 | $35.93 | $12.10 | $46.80 | $46.80 | $11.19 |
| LCHG LIGHT CHAINS FREE EA | 83883 | $379.05 | $387.00 | $66.02 | $16.32 | $12.10 | $178.15 | $13.08 | $232.20 | $232.20 | $12.10 |
| LCHG HELICOBACTER PYLORI ANTIBODY IGG | 86677 | $97.02 | $99.00 | $66.02 | $20.22 | $14.99 | $45.60 | $13.97 | $59.40 | $66.02 | $13.97 |
| LCHG CULTURE GENITAL | 87070 | $64.68 | $66.00 | $35.55 | $10.34 | $7.67 | $30.40 | $8.29 | $39.60 | $39.60 | $7.67 |
| PR NURSING FACILITY CARE INIT, STGHTFWD COMPLEXITY | 99304 | $196.00 | $200.00 | $117.71 | $105.85 | $82.59 | $92.12 | $85.80 | $120.00 | $120.00 | $82.59 |
| HC CT SINUS FACIAL BONES NON CONTRAST | 70486 | $1,711.50 | $1,746.00 | $602.69 | $193.20 | $120.60 | $804.41 | $251.31 | $1,047.60 | $1,047.60 | $120.60 |
| HC CT ANGIO CHEST W/WO CONTRAST | 71275 | $2,948.40 | $3,007.00 | $813.48 | $377.08 | $235.38 | $1,385.75 | $449.45 | $1,804.20 | $1,804.20 | $235.38 |
| HC HUMERUS 2+ VW | 73060 | $424.20 | $433.00 | $99.99 | $43.17 | $26.95 | $199.37 | $22.42 | $259.80 | $259.80 | $22.42 |
| HC US HEAD NECK TISSUES B - SCAN REAL TIME | 76536 | $758.10 | $773.00 | $270.41 | $160.26 | $100.03 | $356.31 | $93.04 | $463.80 | $463.80 | $93.04 |
| LCHG MONONUCLEOSIS SCREEN | 86308 | $79.38 | $81.00 | $39.77 | $6.22 | $4.61 | $37.31 | $4.98 | $48.60 | $48.60 | $4.61 |
| HC SPIROMETRY | 94010 | $173.25 | $17.00 | $216.55 | $35.60 | $30.58 | $81.43 | $28.52 | $10.20 | $216.55 | $10.20 |
| PR PREVENTIVE VISIT, NEW, AGE 5-11 | 99383 | $217.41 | $222.00 | $151.68 | $115.20 | $108.86 | $102.18 | $96.67 | $133.20 | $151.68 | $96.67 |
| PR DESTROY PREMALIG LESION, 1ST LESION | 17000 | $91.88 | $94.00 | $647.49 | $70.92 | $57.70 | $43.18 | $72.72 | $56.40 | $647.49 | $43.18 |
| HC CT LOWER EXTREMITY NON CONTRAST | 73700 | $1,711.50 | $1,746.00 | $602.69 | $215.24 | $134.35 | $804.41 | $233.24 | $1,047.60 | $1,047.60 | $134.35 |
| HC US PELVIS COMPLETE | 76856 | $758.10 | $773.00 | $270.41 | $152.43 | $95.14 | $356.31 | $95.07 | $463.80 | $463.80 | $95.07 |
| LCHG LH | 83002 | $124.95 | $127.00 | $98.66 | $22.22 | $16.47 | $58.73 | $17.82 | $76.20 | $98.66 | $16.47 |
| LCHG HELICOBACTER PYLORI ANTIBODY IGG QUAL | 86677 | $42.00 | $43.00 | $66.02 | $20.22 | $14.99 | $19.74 | $13.97 | $25.80 | $66.02 | $13.97 |
| LCHG HELICOBACTER PYLORI IGA | 86677 | $97.02 | $99.00 | $66.02 | $20.22 | $14.99 | $45.60 | $13.97 | $59.40 | $66.02 | $13.97 |
| HC CLIN DECISION SUPPORT NDSC AUC2 | G1004 | $0.00 | $0.00 | $- | $- | $- | $0.00 | $- | $0.00 | $0.00 | $- |
| PR DESTROY PREMALIG LESION, 2-14 | 17003 | $23.63 | $24.00 | $647.49 | $2.87 | $5.24 | $11.10 | $6.00 | $14.40 | $647.49 | $2.87 |
| HC ED STRAPPING ANKLE/FOOT | 29540 | $117.60 | $120.00 | $617.93 | $24.69 | $25.73 | $55.27 | $37.52 | $72.00 | $617.93 | $24.69 |
| HC THORACIC SPINE 3 VW | 72072 | $424.20 | $433.00 | $99.99 | $53.20 | $33.21 | $199.37 | $28.57 | $259.80 | $259.80 | $28.57 |
| HC MRI SPINE CERVICAL NON CONTRAST | 72141 | $2,163.00 | $2,206.00 | $572.63 | $302.10 | $188.57 | $1,016.61 | $423.51 | $1,323.60 | $1,323.60 | $188.57 |
| LCHG VOLUME MEASURE URINE | 81050 | $36.75 | $37.00 | $14.43 | $4.37 | $3.24 | $17.27 | $2.88 | $22.20 | $22.20 | $2.88 |
| HC THER ACTIVITIES EA 15 MIN OT | 97530 | $80.85 | $82.00 | $65.70 | $45.13 | $35.21 | $38.00 | $22.48 | $49.20 | $65.70 | $22.48 |
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