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hospital_name Fairview Regional Medical Center Authority
last_updated_on 7/1/2024
version 2.0.0
hospital_location Fairview Regional Medical Center
hospital_address 523 E State Road Fairview, OK 73737
license_number| OK 2248
**To the best of its knowledge and belief, Fairview Regional Medical Center has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.
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| PROC_NAME | CPT_CODE | Charge | Charge 2024 | BCBS ALLOWED AMOUNT | HEALTHCHOICE ALLOWED AMOUNT | Medicaid Allowed Amount | Medicare Allowed Amount | AETNA ALLOWED AMOUNT | Private-Pay | Highest Allowed | Lowest Allowed |
|---|---|---|---|---|---|---|---|---|---|---|---|
| HC THER EXERCISE EA 15 MIN PT | 97110 | $94.50 | $96.00 | $77.05 | $35.59 | $26.34 | $54.81 | $20.68 | $57.60 | $77.05 | $20.68 |
| LCHG CBC W AUTO DIFFERENTIAL | 85025 | $48.19 | $49.00 | $33.51 | $9.32 | $26.34 | $27.95 | $7.48 | $29.40 | $33.51 | $7.48 |
| LCHG COMPREHENSIVE METABOLIC PANEL | 80053 | $131.61 | $134.00 | $49.37 | $12.67 | $9.39 | $76.33 | $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 | $21.32 | $3.05 | $22.20 | $22.20 | $2.82 |
| LCHG LIPID PROFILE | 80061 | $80.62 | $82.00 | $49.37 | $16.07 | $11.91 | $46.76 | $12.89 | $49.20 | $49.37 | $11.91 |
| LCHG TSH | 84443 | $111.72 | $114.00 | $74.32 | $20.16 | $14.94 | $64.80 | $16.17 | $68.40 | $74.32 | $14.94 |
| LCHG PT-INR | 85610 | $32.34 | $33.00 | $17.83 | $5.15 | $3.82 | $18.76 | $3.78 | $19.80 | $19.80 | $3.78 |
| LCHG URINALYSIS DIPSTICK AUTO | 81003 | $29.40 | $30.00 | $10.17 | $2.70 | $2.00 | $17.05 | $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 | $51.78 | $8.14 | $54.60 | $54.60 | $7.53 |
| PR OFFICE/OUTPT VISIT,NEW,LEVL III | 99203 | $174.30 | $178.00 | $135.89 | $92.74 | $98.92 | $101.09 | $98.99 | $106.80 | $135.89 | $92.74 |
| HC CT HEAD NON CONTRAST | 70450 | $1,711.50 | $1,746.00 | $335.21 | $161.07 | $95.42 | $992.67 | $184.06 | $1,047.60 | $1,047.60 | $95.42 |
| LCHG PROSTATE SPECIFIC ANTIGEN DIAG | 84153 | $112.13 | $114.00 | $45.57 | $22.07 | $16.36 | $65.04 | $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 | $133.75 | $153.47 | $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 | $68.73 | $115.10 | $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 | $25.58 | $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 | $90.86 | $147.38 | $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 | $273.87 | $1,741.74 | $384.81 | $1,837.80 | $1,837.80 | $273.87 |
| LCHG HEPATIC FUNCTION PANEL | 80076 | $104.37 | $106.00 | $49.37 | $9.80 | $7.27 | $60.53 | $7.86 | $63.60 | $63.60 | $7.27 |
| PR OFFICE/OUTPT VISIT,NEW,LEVL IV | 99204 | $245.70 | $251.00 | $208.15 | $158.60 | $147.63 | $142.51 | $151.91 | $150.60 | $208.15 | $142.51 |
| REMOVAL OF CATARACT W/INSERTION OF LENS | 66984 | $0.00 | $0.00 | $5,341.70 | $723.00 | $474.55 | $0.00 | $589.64 | $0.00 | $5,341.70 | $0.00 |
| LCHG PTT | 85730 | $44.10 | $45.00 | $17.83 | $7.21 | $5.35 | $25.58 | $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 | $378.22 | $2,665.72 | $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 | $326.62 | $2,904.08 | $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 | $172.62 | $1,254.54 | $417.32 | $1,323.60 | $1,323.60 | $172.62 |
| HC MRI LOWER EXT ANY JOINT NON CONTRAST | 73721 | $2,163.00 | $2,206.00 | $758.13 | $317.13 | $182.02 | $1,254.54 | $309.49 | $1,323.60 | $1,323.60 | $182.02 |
| LCHG PSA FREE | 84154 | $219.03 | $223.00 | $45.57 | $65.00 | $16.36 | $127.04 | $17.70 | $133.80 | $133.80 | $16.36 |
| HC LUMBAR SPINE 4+ VW | 72110 | $567.00 | $434.00 | $99.99 | $66.81 | $44.18 | $328.86 | $37.79 | $260.40 | $328.86 | $37.79 |
| REMOVAL OF POLYPS OR GROWTHS LARGE BOWEL, ENDOSCOPE | 45385 | $4,663.93 | $4,757.00 | $3,263.41 | $349.80 | $397.59 | $2,705.08 | $503.74 | $2,854.20 | $3,263.41 | $349.80 |
| HC US ABDOMEN COMPLETE | 76700 | $758.10 | $773.00 | $317.11 | $171.38 | $101.46 | $439.70 | $103.95 | $463.80 | $463.80 | $101.46 |
| HC MRI BRAIN WITH & WITHOUT CONTRAST | 70553 | $3,360.00 | $3,427.00 | $1,190.12 | $506.58 | $287.83 | $1,948.80 | $625.64 | $2,056.20 | $2,056.20 | $287.83 |
| HC US TRANSVAGINAL NON OB | 76830 | $758.10 | $773.00 | $371.11 | $170.66 | $103.84 | $439.70 | $58.18 | $463.80 | $463.80 | $58.18 |
| HC US OB 14+ WKS SINGLE GEST | 76805 | $758.10 | $773.00 | $372.96 | $195.51 | $118.11 | $439.70 | $111.42 | $463.80 | $463.80 | $111.42 |
| FAMILY PSYCHOTHERAPY 50 MINUTES | 90846 | $0.00 | $0.00 | $134.46 | $0.00 | $87.76 | $0.00 | $82.00 | $0.00 | $134.46 | $0.00 |
| FAMILY PSYCHOTHERAPY W/PATIENT 50 MINUTES | 90847 | $0.00 | $0.00 | $139.72 | $112.21 | $91.50 | $0.00 | $82.00 | $0.00 | $139.72 | $0.00 |
| GROUP PSYCHOTHERAPY | 90853 | $0.00 | $0.00 | $33.50 | $26.54 | $24.29 | $0.00 | $40.00 | $0.00 | $40.00 | $0.00 |
| PR OFFICE/OUTPT VISIT, NEW LEVL V | 99205 | $0.00 | $0.00 | $262.22 | $207.13 | $195.08 | $0.00 | $188.86 | $0.00 | $262.22 | $0.00 |
| OFFICE CONSULTATION 40 MINUTES | 99243 | $0.00 | $0.00 | $0.00 | $114.88 | $0.00 | $0.00 | $108.76 | $0.00 | $114.88 | $0.00 |
| OFFICE CONSULTATION 60 MINUTES | 99244 | $0.00 | $0.00 | $0.00 | $182.45 | $0.00 | $0.00 | $162.02 | $0.00 | $182.45 | $0.00 |
| INITIAL PREVENTIVE MED EVAL 18-39 AGE | 99385 | $0.00 | $0.00 | $167.00 | $124.93 | $114.28 | $0.00 | $106.22 | $0.00 | $167.00 | $0.00 |
| INITIAL PREVENTIVE MED EVAL 40-64 AGE | 99386 | $0.00 | $0.00 | $193.79 | $147.24 | $132.01 | $0.00 | $123.29 | $0.00 | $193.79 | $0.00 |
| OBSTETRIC BLOOD TEST PANEL | 80055 | $0.00 | $0.00 | $49.37 | $57.37 | $42.53 | $0.00 | $35.68 | $0.00 | $57.37 | $0.00 |
| KIDNEY FUNCTION PANEL | 80069 | $0.00 | $0.00 | $49.37 | $10.42 | $7.72 | $0.00 | $8.36 | $0.00 | $49.37 | $0.00 |
| CT SCAN, PELVIS W/CONTRAST | 72193 | $0.00 | $0.00 | $868.04 | $327.98 | $192.78 | $0.00 | $304.11 | $0.00 | $868.04 | $0.00 |
| MAMMOGRAM ONE BREAST | 77065 | $0.00 | $0.00 | $0.00 | $0.00 | $108.49 | $0.00 | $0.00 | $0.00 | $108.49 | $0.00 |
| MAMMOGRAM BOTH BREAST | 77066 | $0.00 | $0.00 | $0.00 | $0.00 | $136.73 | $0.00 | $0.00 | $0.00 | $136.73 | $0.00 |
| MAMMOGRAM, SCREENING BILATERAL | 77067 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| DRG 216 | 0 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| DRG 460 | 0 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| DRG 470 | 0 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| DRG 473 | 0 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| DRG 743 | 0 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| REMOVAL OF BREAST GROWTH, OPEN | 19120 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| SHAVING OF SHOULDER BONE, ENDOSCOPE | 29826 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| REMOVAL OF KNEE CARTILAGE, ENDOSCOPE | 29881 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| REMOVAL OF TONSILS AND ADENOIDS YOUNGER THAN 12 | 42820 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| DIAGNOSTIC EXAM OF ESOPHAGUS, STOMACH, AND/OR UPPER SMALL BOWEL ENDOSCOPE | 43235 | $0.00 | $0.00 | $1,927.03 | $167.84 | $0.00 | $0.00 | $282.49 | $0.00 | $1,927.03 | $0.00 |
| DIAGNOSIC EXAM OF LARGE BOWEL, ENDOSCOPE | 45378 | $0.00 | $0.00 | $2,007.01 | $254.21 | $0.00 | $0.00 | $374.50 | $0.00 | $2,007.01 | $0.00 |
| ULTRASOUND EXAMINATION OF LOWER LARGE BOWEL, ENDOSCOPE | 45391 | $0.00 | $0.00 | $1,654.68 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $1,654.68 | $0.00 |
| REMOVAL OF GALLBLADDER, ENDOSCOPE | 47562 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| REPAIR OF GROIN HERNIA PATIENT 5 OR OLDER | 49505 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| BIOPSY OF PROSTATE GLAND | 55700 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| REMOVAL OF PROSTATE AND LYMPH NODES, ENDOSCOPE | 55866 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| ROUTINE OBSTETRIC CARE FOR VAG DELIVERY, INCLUDING PRE-AND POST-DELIVERY CARE | 59400 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| ROUTINE OBSTETRIC CARE FOR CESAREAN DELIVERY, INCLUDING PRE-AND POST-DELIVERY CARE | 59510 | $0.00 | $0.00 | $0.00 | $0.00 | $2,348.39 | $0.00 | $0.00 | $0.00 | $2,348.39 | $0.00 |
| ROUTINE OBSTETRIC CARE FOR VAG DELIVERY AFTER PRIOR CESAREAN DELIERY INCLUDING PRE-AND POST-DELIVERY CARE | 59610 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| INJ OF SUB INTO SPINAL CANAL USING GUIDANCE | 62322 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| INJ OF ANESTHETIC INTO SPINE USING IMAGING GUIDANCE | 64483 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| REMOVAL OF RECURRING CATARACT IN LENS CAPSULE | 66821 | $0.00 | $0.00 | $1,193.54 | $407.93 | $0.00 | $0.00 | $300.57 | $0.00 | $1,193.54 | $0.00 |
| ELECTROCARDIOGRAM, ROUTINE, WITH REPORT AND INTERPRETATION | 93000 | $0.00 | $0.00 | $43.53 | $17.47 | $0.00 | $0.00 | $14.33 | $0.00 | $43.53 | $0.00 |
| INSERTION OF CATH INTO LEFT HEART FOR DX | 93452 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| SLEEP STUDY | 95810 | $0.00 | $0.00 | $55.35 | $610.89 | $0.00 | $0.00 | $490.81 | $0.00 | $610.89 | $0.00 |
| LCHG BLOOD DRAW | 36415 | $13.23 | $13.00 | $0.00 | $4.14 | $7.85 | $7.67 | $3.12 | $7.80 | $7.85 | $0.00 |
| PR OFFICE/OUTPT VISIT,EST,LEVL III | 99213 | $97.64 | $100.00 | $90.92 | $62.88 | $79.76 | $56.63 | $66.79 | $60.00 | $90.92 | $56.63 |
| PR OFFICE/OUTPT VISIT,EST,LEVL IV | 99214 | $153.30 | $156.00 | $135.42 | $96.75 | $113.10 | $88.91 | $98.38 | $93.60 | $135.42 | $88.91 |
| HC INHALATION TREATMENT W/MED SUBSEQUENT | 94640 | $82.12 | $84.00 | $815.38 | $17.42 | $7.56 | $47.63 | $14.41 | $50.40 | $815.38 | $7.56 |
| LCHG INFLUENZA A+B ANTIGEN RAPID | 87804 | $74.97 | $76.00 | $35.55 | $19.86 | $14.72 | $43.48 | $11.54 | $45.60 | $45.60 | $11.54 |
| HC RB OBSERVATION PER HR | G0378 | $35.00 | $36.00 | $73.57 | $0.00 | $0.00 | $20.30 | $45.30 | $21.60 | $73.57 | $0.00 |
| HC MANUAL THER TECH 1+REGIONS EA 15 MIN PT | 97140 | $82.90 | $85.00 | $77.05 | $32.81 | $24.30 | $48.08 | $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 | $10.55 | $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 | $65.16 | $186.35 | $57.41 | $196.80 | $196.80 | $57.41 |
| HC IV INF HYDRATION EA ADDL HR | 96361 | $71.31 | $73.00 | $121.20 | $22.52 | $10.98 | $41.36 | $11.75 | $43.80 | $121.20 | $10.98 |
| LCHG STREP A SCREEN DIRECT IMMUNO | 87880 | $74.97 | $76.00 | $35.55 | $19.84 | $14.70 | $43.48 | $11.54 | $45.60 | $45.60 | $11.54 |
| LCHG CULTURE URINE | 87086 | $64.68 | $66.00 | $35.55 | $9.68 | $7.18 | $37.51 | $7.77 | $39.60 | $39.60 | $7.18 |
| LCHG HEMOGLOBIN A1C | 83036 | $57.33 | $58.00 | $45.57 | $11.65 | $8.64 | $33.25 | $8.32 | $34.80 | $45.57 | $8.32 |
| HC CARD REHAB W/ EKG | 93798 | $216.30 | $221.00 | $152.35 | $15.18 | $22.32 | $125.45 | $19.65 | $132.60 | $152.35 | $15.18 |
| HC ED EMERGENT LEVEL IV FACILITY | 99284 | $850.00 | $867.00 | $154.08 | $207.55 | $109.80 | $493.00 | $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 | $12.39 | $64.78 | $19.95 | $68.40 | $68.40 | $12.39 |
| HC ED EMERGENT LEVEL III FACILITY | 99283 | $525.00 | $536.00 | $80.87 | $119.49 | $65.16 | $304.50 | $57.41 | $321.60 | $321.60 | $57.41 |
| HC EKG 12 LEAD | 93005 | $204.78 | $211.00 | $43.53 | $8.36 | $5.31 | $118.78 | $7.57 | $126.60 | $126.60 | $5.31 |
| LCHG ORGANISM ID URINE | 87088 | $49.98 | $51.00 | $35.55 | $9.71 | $7.20 | $28.99 | $5.92 | $30.60 | $35.55 | $5.92 |
| HC XRAY CHEST 2 VIEWS | 71046 | $290.44 | $223.00 | $99.99 | $45.47 | $29.13 | $168.46 | $23.96 | $133.80 | $168.46 | $23.96 |
| LCHG TROPONIN I | 84484 | $64.68 | $66.00 | $45.57 | $14.96 | $11.09 | $37.51 | $9.47 | $39.60 | $45.57 | $9.47 |
| LCHG SUSCEPTIBILITY URINE | 87186 | $55.86 | $57.00 | $35.55 | $10.38 | $7.69 | $32.40 | $8.32 | $34.20 | $35.55 | $7.69 |
| LCHG B-TYPE NATRIURETIC PEPTIDE | 83880 | $393.96 | $402.00 | $138.33 | $47.11 | $34.92 | $228.50 | $32.66 | $241.20 | $241.20 | $32.66 |
| PR OFFICE/OUTPT VISIT,EST,LEVL I | 99211 | $42.03 | $43.00 | $24.40 | $11.31 | $20.02 | $24.38 | $93.70 | $25.80 | $93.70 | $11.31 |
| HC DRUG COLLECTION NON DOT | 99001 | $16.53 | $17.00 | $0.00 | $8.00 | $0.00 | $9.59 | $13.00 | $10.20 | $13.00 | $0.00 |
| HP EMERGENCY DEPT VISIT LEVEL 4 PROFESSIONAL FEE | 99284 | $685.65 | $699.00 | $154.08 | $207.55 | $109.80 | $397.68 | $109.78 | $419.40 | $419.40 | $109.78 |
| HC XRAY CHEST 1 VIEW | 71045 | $156.91 | $121.00 | $99.99 | $35.63 | $22.52 | $91.01 | $15.69 | $72.60 | $99.99 | $15.69 |
| HC PT EVAL LOW COMPLEXITY | 97161 | $171.15 | $175.00 | $77.05 | $99.12 | $89.79 | $99.27 | $54.12 | $105.00 | $105.00 | $54.12 |
| LCHG VITAMIN D 25-HYDROXY | 82306 | $185.22 | $189.00 | $138.33 | $35.52 | $26.33 | $107.43 | $28.49 | $113.40 | $138.33 | $26.33 |
| LCHG PROSTATE SPECIFIC ANTIGEN SCREEN | G0103 | $100.30 | $102.00 | $45.57 | $0.00 | $17.18 | $58.17 | $17.70 | $61.20 | $61.20 | $0.00 |
| HC ED INJ THER/DIAG IVP EA ADDL NEW DRUG | 96375 | $138.01 | $141.00 | $0.00 | $27.20 | $13.27 | $80.04 | $17.11 | $84.60 | $84.60 | $0.00 |
| LCHG MAGNESIUM BLOOD | 83735 | $44.10 | $45.00 | $23.81 | $8.04 | $5.96 | $25.58 | $6.45 | $27.00 | $27.00 | $5.96 |
| PR OFFICE/OUTPT VISIT,EST,LEVL II | 99212 | $76.47 | $78.00 | $54.07 | $31.60 | $49.59 | $44.35 | $39.76 | $46.80 | $54.07 | $31.60 |
| LCHG T3 FREE | 84481 | $114.66 | $117.00 | $74.32 | $20.33 | $15.07 | $66.50 | $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 | $17.77 | $34.18 | $16.95 | $36.00 | $121.20 | $16.95 |
| LCHG CULTURE BLOOD | 87040 | $82.32 | $84.00 | $129.09 | $12.38 | $9.18 | $47.75 | $9.93 | $50.40 | $129.09 | $9.18 |
| LCHG VITAMIN B12 | 82607 | $92.18 | $94.00 | $74.32 | $18.10 | $13.41 | $53.46 | $14.50 | $56.40 | $74.32 | $13.41 |
| LCHG TESTOSTERONE TOTAL | 84403 | $173.46 | $177.00 | $98.66 | $30.97 | $22.96 | $100.61 | $24.84 | $106.20 | $106.20 | $22.96 |
| LCHG ISTAT LACTIC ACID | 83605 | $78.75 | $80.00 | $45.57 | $13.88 | $10.29 | $45.68 | $10.28 | $48.00 | $48.00 | $10.28 |
| HC INHALATION TREATMENT W/MED | 94640 | $90.30 | $92.00 | $815.38 | $17.42 | $7.56 | $52.37 | $14.41 | $55.20 | $815.38 | $7.56 |
| LCHG SARS-COV-2 (COVID-19) | 87635 | $109.08 | $111.00 | $129.09 | $0.00 | $48.74 | $63.27 | $51.31 | $66.60 | $129.09 | $0.00 |
| LCHG T4 FREE | 84439 | $69.09 | $70.00 | $74.32 | $10.82 | $8.02 | $40.07 | $8.68 | $42.00 | $74.32 | $8.02 |
| HC ED INJ THER/PROPH/DIAG IVP SNGL OR INIT | 96374 | $152.57 | $156.00 | $0.00 | $65.20 | $31.80 | $88.49 | $43.48 | $93.60 | $93.60 | $0.00 |
| HC ED IVP TPD EA ADD PUSH SAME DRUG | 96376 | $69.18 | $71.00 | $0.00 | $13.60 | $0.00 | $40.12 | $11.33 | $42.60 | $42.60 | $0.00 |
| LCHG T4 TOTAL | 84436 | $57.33 | $58.00 | $74.32 | $8.24 | $6.11 | $33.25 | $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 | $62.25 | $63.09 | $44.51 | $66.60 | $106.72 | $44.51 |
| HC ED IV INF THER/PROPH/DIAG 1ST HR | 96365 | $382.78 | $390.00 | $0.00 | $116.60 | $54.35 | $222.01 | $57.04 | $234.00 | $234.00 | $0.00 |
| LCHG CK BLOOD | 82550 | $52.92 | $54.00 | $23.81 | $7.81 | $5.79 | $30.69 | $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 | $46.89 | $55.87 | $49.20 | $138.33 | $46.89 |
| HC ELEC STIM UNATTENDED NON WOUND PT | G0283 | $63.00 | $64.00 | $77.05 | $0.00 | $0.00 | $36.54 | $8.74 | $38.40 | $77.05 | $0.00 |
| HC ED EMERGENT LEVEL V | 99285 | $1,200.00 | $1,224.00 | $228.72 | $284.41 | $159.76 | $696.00 | $160.95 | $734.40 | $734.40 | $159.76 |
| HC CT ABDOMEN PELVIS WO CONTRAST | 74176 | $1,904.70 | $1,943.00 | $868.04 | $280.68 | $165.63 | $1,104.73 | $258.73 | $1,165.80 | $1,165.80 | $165.63 |
| HC ED IV INF HYDRATION INIT 31 MIN TO 1HR | 96360 | $201.98 | $206.00 | $245.13 | $56.48 | $27.86 | $117.15 | $44.20 | $123.60 | $245.13 | $27.86 |
| HC DEBRID SELECTIVE 1ST 20SQ CM OR < PT | 97597 | $210.00 | $214.00 | $214.05 | $44.04 | $87.23 | $121.80 | $60.27 | $128.40 | $214.05 | $44.04 |
| PR DOM/R-HOME E/M EST PT LW MOD SEVERITY | 99347 | $113.40 | $116.00 | $122.02 | $111.64 | $0.00 | $65.77 | $87.23 | $69.60 | $122.02 | $0.00 |
| LCHG DIFFERENTIAL MANUAL | 85007 | $57.33 | $58.00 | $33.51 | $4.56 | $3.38 | $33.25 | $3.31 | $34.80 | $34.80 | $3.31 |
| HC ULTRASOUND THERAPY EA 15 MIN PT | 97035 | $52.50 | $54.00 | $77.05 | $16.76 | $0.00 | $30.45 | $8.23 | $32.40 | $77.05 | $0.00 |
| LCHG RSV RAPID AG BY IMMUNOASSAY | 87807 | $92.61 | $94.00 | $35.55 | $15.72 | $11.65 | $53.71 | $11.54 | $56.40 | $56.40 | $11.54 |
| HC KNEE 3 VW | 73562 | $424.20 | $325.00 | $99.99 | $53.85 | $34.89 | $246.04 | $29.08 | $195.00 | $246.04 | $29.08 |
| HC HAND 3+ VW | 73130 | $424.20 | $325.00 | $99.99 | $48.03 | $31.76 | $246.04 | $25.14 | $195.00 | $246.04 | $25.14 |
| LCHG FOLATE | 82746 | $96.16 | $98.00 | $45.57 | $17.64 | $13.08 | $55.77 | $14.15 | $58.80 | $58.80 | $13.08 |
| HC ED EMERGENT LEVEL II | 99282 | $350.00 | $357.00 | $53.59 | $86.20 | $37.94 | $203.00 | $38.39 | $214.20 | $214.20 | $37.94 |
| LCHG LIPASE BLOOD | 83690 | $57.75 | $59.00 | $23.81 | $8.27 | $6.13 | $33.50 | $6.63 | $35.40 | $35.40 | $6.13 |
| HC FOOT 3+ VW | 73630 | $424.20 | $325.00 | $99.99 | $45.15 | $29.51 | $246.04 | $24.40 | $195.00 | $246.04 | $24.40 |
| HC SHOULDER 2+ VW | 73030 | $424.20 | $325.00 | $99.99 | $45.69 | $29.83 | $246.04 | $23.88 | $195.00 | $246.04 | $23.88 |
| HC GAIT TRAINING EA 15 MIN PT | 97116 | $78.75 | $80.00 | $77.05 | $35.21 | $26.34 | $45.68 | $18.26 | $48.00 | $77.05 | $18.26 |
| LCHG OCCULT BLOOD FECES | 82270 | $20.58 | $21.00 | $23.81 | $5.26 | $3.90 | $11.94 | $3.14 | $12.60 | $23.81 | $3.14 |
| LCHG PLATELET PHERESIS LR | P9035 | $2,257.92 | $2,303.00 | $2,683.30 | $0.00 | $389.81 | $1,309.59 | $424.17 | $1,381.80 | $2,683.30 | $0.00 |
| LCHG TESTOSTERONE FREE | 84402 | $155.82 | $159.00 | $98.66 | $30.56 | $22.66 | $90.38 | $24.50 | $95.40 | $98.66 | $22.66 |
| LCHG AMYLASE BLOOD | 82150 | $64.68 | $66.00 | $45.57 | $7.78 | $5.76 | $37.51 | $6.24 | $39.60 | $45.57 | $5.76 |
| LCHG HCG URINE QUALITATIVE | 81025 | $41.16 | $42.00 | $14.43 | $10.33 | $7.66 | $23.87 | $6.09 | $25.20 | $25.20 | $6.09 |
| LCHG MICROSOMAL ANTIBODY | 86376 | $47.04 | $48.00 | $98.66 | $17.46 | $12.94 | $27.28 | $13.99 | $28.80 | $98.66 | $12.94 |
| HC LUMBAR SPINE 2 OR 3 VW | 72100 | $424.20 | $325.00 | $99.99 | $52.66 | $34.47 | $246.04 | $27.76 | $195.00 | $246.04 | $27.76 |
| PR PREVENTIVE VISIT,EST,INFANT | 99391 | $168.00 | $171.00 | $94.93 | $103.43 | $86.26 | $97.44 | $79.90 | $102.60 | $103.43 | $79.90 |
| LCHG FSH | 83001 | $124.95 | $127.00 | $88.88 | $22.30 | $16.53 | $72.47 | $17.88 | $76.20 | $88.88 | $16.53 |
| PR PREVENTIVE VISIT,EST,AGE 1-4 | 99392 | $192.15 | $196.00 | $133.98 | $92.48 | $92.29 | $111.45 | $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 | $90.86 | $147.38 | $80.00 | $155.40 | $155.40 | $80.00 |
| LCHG ESTRADIOL | 82670 | $148.47 | $151.00 | $98.66 | $33.53 | $24.85 | $86.11 | $26.89 | $90.60 | $98.66 | $24.85 |
| LCHG D-DIMER QUANTITATIVE | 85379 | $147.00 | $150.00 | $57.42 | $12.22 | $9.05 | $85.26 | $9.79 | $90.00 | $90.00 | $9.05 |
| LCHG IRON BLOOD | 83540 | $36.29 | $37.00 | $23.81 | $7.76 | $5.75 | $21.05 | $5.36 | $22.20 | $23.81 | $5.36 |
| LCHG BLOOD TYPE RH I | 86901 | $32.34 | $33.00 | $13.53 | $3.59 | $2.66 | $18.76 | $2.87 | $19.80 | $19.80 | $2.66 |
| LCHG BLOOD TYPE ABO | 86900 | $32.34 | $33.00 | $13.53 | $3.59 | $2.66 | $18.76 | $2.87 | $19.80 | $19.80 | $2.66 |
| LCHG URIC ACID BLOOD | 84550 | $44.10 | $45.00 | $23.81 | $5.42 | $4.02 | $25.58 | $4.35 | $27.00 | $27.00 | $4.02 |
| LCHG SED RATE WINTROBE | 85651 | $32.34 | $33.00 | $33.51 | $5.12 | $3.80 | $18.76 | $3.42 | $19.80 | $33.51 | $3.42 |
| HC THER ACTIVITIES EA 15 MIN PT | 97530 | $80.85 | $82.00 | $77.05 | $45.13 | $32.77 | $46.89 | $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 | $17.45 | $45.68 | $10.00 | $48.00 | $48.00 | $10.00 |
| LCHG COMPATIBILITY TEST ANTIGLOBULIN | 86922 | $220.50 | $225.00 | $210.68 | $0.00 | $42.14 | $127.89 | $15.49 | $135.00 | $210.68 | $0.00 |
| HC WRIST 3+ VW | 73110 | $424.20 | $325.00 | $99.99 | $53.31 | $35.14 | $246.04 | $29.11 | $195.00 | $246.04 | $29.11 |
| LCHG RBC LR | P9016 | $573.30 | $585.00 | $2,683.30 | $0.00 | $136.54 | $332.51 | $197.09 | $351.00 | $2,683.30 | $0.00 |
| HC XRAY ABDOMEN 2 VIEWS | 74019 | $424.20 | $325.00 | $99.99 | $49.84 | $31.98 | $246.04 | $26.16 | $195.00 | $246.04 | $26.16 |
| LCHG SP STAIN GROUP II TC NL | 88313 | $207.27 | $211.00 | $106.72 | $83.28 | $69.40 | $120.22 | $41.33 | $126.60 | $126.60 | $41.33 |
| LCHG CULTURE ROUTINE | 87070 | $64.68 | $66.00 | $35.55 | $10.34 | $7.67 | $37.51 | $8.29 | $39.60 | $39.60 | $7.67 |
| LCHG GRAM STAIN SMEAR | 87205 | $32.34 | $33.00 | $35.55 | $5.12 | $3.80 | $18.76 | $4.11 | $19.80 | $35.55 | $3.80 |
| LCHG CULTURE ANAEROBE | 87075 | $64.68 | $66.00 | $35.55 | $11.36 | $8.42 | $37.51 | $9.11 | $39.60 | $39.60 | $8.42 |
| HC ANKLE 3+ VW | 73610 | $424.20 | $325.00 | $99.99 | $48.03 | $31.76 | $246.04 | $25.89 | $195.00 | $246.04 | $25.89 |
| PR OFFICE/OUTPT VISIT,EST,LEVL V | 99215 | $207.90 | $212.00 | $183.27 | $136.64 | $158.84 | $120.58 | $132.08 | $127.20 | $183.27 | $120.58 |
| LCHG ANA BLOOD SCREEN | 86038 | $29.40 | $30.00 | $39.77 | $14.51 | $10.75 | $17.05 | $11.63 | $18.00 | $39.77 | $10.75 |
| LCHG TIBC | 83550 | $57.92 | $59.00 | $45.57 | $10.49 | $7.77 | $33.59 | $8.41 | $35.40 | $45.57 | $7.77 |
| LCHG PTH INTACT | 83970 | $254.31 | $259.00 | $98.66 | $49.54 | $36.72 | $147.50 | $39.72 | $155.40 | $155.40 | $36.72 |
| LCHG TRANSFUSION SERVICE FEE | 36430 | $936.39 | $955.00 | $2,683.30 | $43.66 | $32.83 | $543.11 | $30.85 | $573.00 | $2,683.30 | $30.85 |
| LCHG BLOOD GASES ARTERIAL I | 82803 | $182.28 | $186.00 | $45.57 | $31.28 | $23.19 | $105.72 | $18.62 | $111.60 | $111.60 | $18.62 |
| HC XRAY HIP UNILAT 2-3 VIEWS | 73502 | $424.20 | $325.00 | $99.99 | $62.25 | $40.38 | $246.04 | $31.62 | $195.00 | $246.04 | $31.62 |
| PR IMPLANT,HORMONE,SUBCUTANEOUS | 11980 | $367.50 | $375.00 | 789..29 | $0.00 | $82.78 | $213.15 | $93.22 | $225.00 | $225.00 | $0.00 |
| PR PREVENTIVE VISIT,EST,AGE5-11 | 99393 | $190.05 | $194.00 | $133.50 | $91.26 | $92.01 | $110.23 | $85.29 | $116.40 | $133.50 | $85.29 |
| LCHG T3 UPTAKE | 84479 | $39.69 | $40.00 | $74.32 | $7.76 | $5.75 | $23.02 | $6.22 | $24.00 | $74.32 | $5.75 |
| LCHG LDH BLOOD | 83615 | $44.10 | $45.00 | $23.81 | $7.25 | $5.37 | $25.58 | $5.81 | $27.00 | $27.00 | $5.37 |
| HC BAT NON DOT DOT | 82075 | $26.25 | $27.00 | $45.57 | $36.00 | $0.00 | $15.23 | $0.01 | $16.20 | $45.57 | $0.00 |
| LCHG SUSCEPTIBILITY EACH REFER | 87186 | $55.86 | $57.00 | $35.55 | $10.38 | $7.69 | $32.40 | $8.32 | $34.20 | $35.55 | $7.69 |
| LCHG LDL CHOLESTEROL | 83721 | $58.80 | $60.00 | $45.57 | $12.60 | $9.34 | $34.10 | $9.18 | $36.00 | $45.57 | $9.18 |
| HC CT CHEST NON CONTRAST | 71250 | $1,711.50 | $1,746.00 | $706.79 | $220.53 | $119.81 | $992.67 | $233.83 | $1,047.60 | $1,047.60 | $119.81 |
| PR DRAIN/INJECT LARGE JOINT/BURSA | 20610 | $161.44 | $165.00 | $1,073.44 | $62.62 | $56.78 | $93.63 | $60.73 | $99.00 | $1,073.44 | $56.78 |
| PR SUBSEQUENT HOSPITAL CARE,LEVL I | 99231 | $100.80 | $103.00 | $50.72 | $48.23 | $44.66 | $58.46 | $36.13 | $61.80 | $61.80 | $36.13 |
| LCHG IMMUNOGLOBULIN | 82784 | $44.10 | $45.00 | $45.57 | $11.16 | $8.27 | $25.58 | $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 | $28.99 | $7.78 | $30.60 | $35.55 | $7.19 |
| LCHG T4 TOTAL I | 84436 | $57.33 | $58.00 | $74.32 | $8.24 | $6.11 | $33.25 | $6.61 | $34.80 | $74.32 | $6.11 |
| HC CERVICAL SPINE 2 OR 3 VW | 72040 | $424.20 | $325.00 | $99.99 | $52.66 | $34.19 | $246.04 | $27.51 | $195.00 | $246.04 | $27.51 |
| LCHG ANTIBODY SCREEN | 86850 | $54.39 | $55.00 | $39.77 | $11.72 | $8.69 | $31.55 | $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 | $116.49 | $992.67 | $239.23 | $1,047.60 | $1,047.60 | $116.49 |
| HC EPIFIX PER SQ CM | Q4186 | $581.96 | $594.00 | $0.00 | $0.00 | $143.68 | $337.54 | $93.67 | $356.40 | $356.40 | $0.00 |
| LCHG FERRITIN | 82728 | $91.14 | $93.00 | $45.57 | $16.36 | $12.12 | $52.86 | $13.11 | $55.80 | $55.80 | $12.12 |
| LCHG CHLAMYDIA DNA PROBE | 87491 | $123.48 | $126.00 | $39.77 | $42.11 | $31.21 | $71.62 | $33.77 | $75.60 | $75.60 | $31.21 |
| HC US ABDOMEN LIMITED | 76705 | $758.10 | $773.00 | $317.11 | $126.87 | $76.49 | $439.70 | $82.52 | $463.80 | $463.80 | $76.49 |
| PR HC PRO PHONE CALL 21-30 MIN | 98968 | $119.70 | $122.00 | $98.66 | $0.00 | $30.49 | $69.43 | $32.15 | $73.20 | $98.66 | $0.00 |
| LCHG THYROGLOBULIN ANTIBODY | 86800 | $47.04 | $48.00 | $23.81 | $19.09 | $14.15 | $27.28 | $15.30 | $28.80 | $28.80 | $14.15 |
| LCHG PHOSPHORUS BLOOD | 84100 | $44.10 | $45.00 | $23.81 | $5.69 | $4.22 | $25.58 | $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 | $82.12 | $160.78 | $41.14 | $169.80 | $789.29 | $41.14 |
| LCHG C-REACTIVE PROTEIN | 86140 | $32.34 | $33.00 | $39.77 | $6.22 | $4.61 | $18.76 | $4.98 | $19.80 | $39.77 | $4.61 |
| LCHG GC AMPLIFIED PROBE | 87591 | $114.66 | $117.00 | $129.09 | $42.11 | $31.21 | $66.50 | $33.77 | $70.20 | $129.09 | $31.21 |
| LCHG CREATININE URINE RANDOM | 82570 | $32.34 | $33.00 | $23.81 | $6.22 | $4.61 | $18.76 | $4.98 | $19.80 | $23.81 | $4.61 |
| HC DEXA BONE DENSITY AXIAL SKELETON | 77080 | $295.88 | $302.00 | $141.93 | $54.45 | $32.71 | $171.61 | $37.40 | $181.20 | $181.20 | $32.71 |
| PR OFFICE/OUTPT VISIT,NEW,LEVL II | 99202 | $123.90 | $126.00 | $93.31 | $61.86 | $63.58 | $71.86 | $68.05 | $75.60 | $93.31 | $61.86 |
| PR PREVENTIVE VISIT,EST,40-64 | 99396 | $233.10 | $238.00 | $160.78 | $112.76 | $109.45 | $135.20 | $101.81 | $142.80 | $160.78 | $101.81 |
| LCHG HEMOGLOBIN | 85018 | $17.64 | $18.00 | $33.51 | $2.84 | $2.11 | $10.23 | $2.28 | $10.80 | $33.51 | $2.11 |
| LCHG HEMATOCRIT | 85014 | $17.64 | $18.00 | $33.51 | $2.84 | $2.11 | $10.23 | $2.28 | $10.80 | $33.51 | $2.11 |
| HC MOD SED SAME PHYS 5>=YRS INIT 15 MIN | 99152 | $57.75 | $59.00 | $0.00 | $14.65 | $42.96 | $33.50 | $40.86 | $35.40 | $42.96 | $0.00 |
| PR DESTRUCT BENIGN LESION, 1-14 | 17110 | $99.75 | $102.00 | $759.33 | $88.18 | $98.20 | $57.86 | $98.93 | $61.20 | $759.33 | $57.86 |
| HC MOD SED SAME PHYS EA ADDL 15 MIN | 99153 | $57.75 | $59.00 | $0.00 | $11.51 | $9.22 | $33.50 | $8.54 | $35.40 | $35.40 | $0.00 |
| HC PT EVAL MOD COMPLEXITY | 97162 | $223.65 | $228.00 | $77.05 | $99.12 | $89.79 | $129.72 | $54.12 | $136.80 | $136.80 | $54.12 |
| LCHG SHIGA-LIKE TOXIN | 87427 | $264.60 | $270.00 | $39.77 | $14.38 | $10.66 | $153.47 | $11.54 | $162.00 | $162.00 | $10.66 |
| LCHG WET PREP SMEAR | 87210 | $44.10 | $45.00 | $35.55 | $6.98 | $5.18 | $25.58 | $4.11 | $27.00 | $35.55 | $4.11 |
| LCHG CULTURE SALMONELLA+SHIGELLA | 87045 | $64.68 | $66.00 | $35.55 | $11.33 | $8.40 | $37.51 | $9.08 | $39.60 | $39.60 | $8.40 |
| LCHG T3 TOTAL | 84480 | $44.10 | $45.00 | $74.32 | $17.02 | $12.61 | $25.58 | $13.64 | $27.00 | $74.32 | $12.61 |
| IMPLT LENS TECNIS SILICON | V2632 | $425.25 | $434.00 | $0.00 | $0.00 | $0.00 | $246.65 | $106.85 | $260.40 | $260.40 | $0.00 |
| HC CLIN DECISION SUPPORT NDSC AUC2 | G1004 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $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 | $40.07 | $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 | $306.61 | $2,216.76 | $449.95 | $2,338.80 | $2,338.80 | $306.61 |
| LCHG CLOSTRIDIUM DIFFICILE TOXIN BY EIA | 87324 | $88.20 | $90.00 | $39.77 | $14.38 | $10.66 | $51.16 | $11.54 | $54.00 | $54.00 | $10.66 |
| PR ANNUAL WELLNESS VST; PPS SUBSQT VST | G0439 | $252.00 | $257.00 | $0.00 | $0.00 | $0.00 | $146.16 | $123.65 | $154.20 | $154.20 | $0.00 |
| LCHG LYME DISEASE AB IGM | 86618 | $114.66 | $117.00 | $66.02 | $20.44 | $15.15 | $66.50 | $16.39 | $70.20 | $70.20 | $15.15 |
| LCHG HEPATITIS C ANTIBODY | 86803 | $97.02 | $99.00 | $66.02 | $17.12 | $12.69 | $56.27 | $13.73 | $59.40 | $66.02 | $12.69 |
| LCHG PROTEIN URINE RANDOM QUANTITATIVE | 84156 | $29.40 | $30.00 | $23.81 | $4.40 | $3.26 | $17.05 | $3.53 | $18.00 | $23.81 | $3.26 |
| HC ELBOW 2 VW | 73070 | $424.20 | $325.00 | $99.99 | $39.34 | $25.26 | $246.04 | $22.09 | $195.00 | $246.04 | $22.09 |
| PR NURSING FAC CARE SUBSEQ, LVL I | 99307 | $88.63 | $90.00 | $56.94 | $51.29 | $35.31 | $51.41 | $40.84 | $54.00 | $56.94 | $35.31 |
| HC TTE 2D WO CON W DOPPLER AND COLOR CMPL | 93306 | $2,656.50 | $2,710.00 | $0.00 | $210.91 | $169.79 | $1,540.77 | $0.00 | $1,626.00 | $1,626.00 | $0.00 |
| LCHG CULTURE RESPIRATORY | 87070 | $64.68 | $66.00 | $35.55 | $10.34 | $7.67 | $37.51 | $8.29 | $39.60 | $39.60 | $7.67 |
| LCHG PROGESTERONE | 84144 | $58.80 | $60.00 | $74.32 | $25.03 | $18.55 | $34.10 | $20.08 | $36.00 | $74.32 | $18.55 |
| LCHG SS-A ANTIBODY | 86235 | $114.66 | $117.00 | $66.02 | $21.52 | $15.95 | $66.50 | $17.26 | $70.20 | $70.20 | $15.95 |
| LCHG SS-B ANTIBODY | 86235 | $110.25 | $112.00 | $66.02 | $21.52 | $15.95 | $63.95 | $17.26 | $67.20 | $67.20 | $15.95 |
| LCHG GGT | 82977 | $61.74 | $63.00 | $23.81 | $8.64 | $6.40 | $35.81 | $6.93 | $37.80 | $37.80 | $6.40 |
| LCHG VALPROIC ACID LEVEL | 80164 | $91.14 | $93.00 | $59.46 | $13.25 | $12.04 | $52.86 | $13.04 | $55.80 | $59.46 | $12.04 |
| HC KNEE 1 OR 2 VW | 73560 | $424.20 | $325.00 | $99.99 | $46.05 | $29.48 | $246.04 | $24.08 | $195.00 | $246.04 | $24.08 |
| HC TX SPEECH DISORDER INDIVID 30 MIN ST | 92507 | $310.80 | $317.00 | $161.93 | $84.21 | $68.69 | $180.26 | $45.52 | $190.20 | $190.20 | $45.52 |
| PR HOSPITAL DISCHARGE DAY,<30 MIN | 99238 | $187.95 | $192.00 | $93.79 | $88.85 | $77.22 | $109.01 | $66.56 | $115.20 | $115.20 | $66.56 |
| LCHG PROTEIN ELECTROPHORESIS BLOOD | 84165 | $72.03 | $73.00 | $45.57 | $12.89 | $9.55 | $41.78 | $10.33 | $43.80 | $45.57 | $9.55 |
| HC CT CHEST WITH CONTRAST | 71260 | $2,641.80 | $2,695.00 | $706.79 | $272.34 | $149.59 | $1,532.24 | $292.23 | $1,617.00 | $1,617.00 | $149.59 |
| HC PULM REHAB W/ EXER ONE HR FOR COPD | G0424 | $277.83 | $283.00 | $409.54 | $0.00 | $0.00 | $161.14 | $33.30 | $169.80 | $409.54 | $0.00 |
| HC SLEEP STUDY UNATTENDED | 95806 | $380.10 | $388.00 | $98.66 | $119.16 | $0.00 | $220.46 | $141.61 | $232.80 | $232.80 | $0.00 |
| LCHG PSA TOTAL | 84153 | $113.19 | $115.00 | $45.57 | $22.07 | $16.36 | $65.65 | $17.70 | $69.00 | $69.00 | $16.36 |
| LCHG PROLACTIN | 84146 | $129.36 | $132.00 | $98.66 | $23.26 | $17.24 | $75.03 | $18.65 | $79.20 | $98.66 | $17.24 |
| LCHG DIGOXIN LEVEL | 80162 | $110.25 | $112.00 | $59.46 | $15.94 | $11.81 | $63.95 | $12.78 | $67.20 | $67.20 | $11.81 |
| HC TIBIA AND FIBULA 2 VW | 73590 | $424.20 | $325.00 | $99.99 | $42.21 | $27.33 | $246.04 | $21.43 | $195.00 | $246.04 | $21.43 |
| HC FINGERS (MULTIPLE) | 73140 | $424.20 | $325.00 | $99.99 | $48.75 | $32.46 | $246.04 | $25.97 | $195.00 | $246.04 | $25.97 |
| HC PELVIS 1 OR 2 VW | 72170 | $424.20 | $325.00 | $99.99 | $39.41 | $24.17 | $246.04 | $22.35 | $195.00 | $246.04 | $22.35 |
| PR INITIAL HOSPITAL CARE,LEVL I | 99221 | $243.60 | $248.00 | $131.11 | $124.83 | $74.55 | $141.29 | $93.70 | $148.80 | $148.80 | $74.55 |
| LCHG SARS-COV-2 (COVID-19) ANTIBODY IGG | 86769 | $52.50 | $54.00 | $39.77 | $30.95 | $40.02 | $30.45 | $42.13 | $32.40 | $42.13 | $30.45 |
| LCHG RNP ANTIBODY | 86235 | $132.30 | $135.00 | $66.02 | $21.52 | $15.95 | $76.73 | $17.26 | $81.00 | $81.00 | $15.95 |
| LCHG SM ANTIBODY ENA | 86235 | $110.25 | $112.00 | $66.02 | $21.52 | $15.95 | $63.95 | $17.26 | $67.20 | $67.20 | $15.95 |
| HC FOREARM 2 VW | 73090 | $424.20 | $325.00 | $99.99 | $39.83 | $25.26 | $246.04 | $21.64 | $195.00 | $246.04 | $21.64 |
| HC INSERT BLADDER CATH FOR SPECIMEN | P9612 | $63.00 | $64.00 | $0.00 | $0.00 | $7.85 | $36.54 | $2.10 | $38.40 | $38.40 | $0.00 |
| LCHG DNA ANTIBODY DOUBLE STRANDED | 86225 | $83.79 | $85.00 | $39.77 | $16.49 | $12.22 | $48.60 | $13.22 | $51.00 | $51.00 | $12.22 |
| LCHG PROTEIN TOTAL BLOOD I | 84155 | $44.10 | $45.00 | $23.81 | $4.40 | $3.26 | $25.58 | $3.53 | $27.00 | $27.00 | $3.26 |
| LCHG CREATININE BLOOD | 82565 | $44.10 | $45.00 | $23.81 | $6.14 | $4.55 | $25.58 | $4.93 | $27.00 | $27.00 | $4.55 |
| LCHG ALCOHOL BREATH TEST | 82075 | $73.50 | $75.00 | $45.57 | $36.00 | $0.00 | $42.63 | $0.01 | $45.00 | $45.57 | $0.00 |
| LCHG MICROALBUMIN URINE RANDOM QUANT | 82043 | $36.75 | $37.00 | $14.43 | $6.94 | $5.14 | $21.32 | $5.57 | $22.20 | $22.20 | $5.14 |
| PR PURE TONE HEARING TEST, AIR | 92551 | $12.60 | $13.00 | $125.71 | $28.00 | $10.09 | $7.31 | $9.34 | $7.80 | $125.71 | $7.31 |
| PR PREVENTIVE VISIT,EST,18-39 | 99395 | $213.15 | $217.00 | $150.25 | $102.22 | $103.61 | $123.63 | $95.34 | $130.20 | $150.25 | $95.34 |
| LCHG RHEUMATOID FACTOR BLOOD QUANT | 86431 | $44.10 | $45.00 | $39.77 | $6.80 | $5.04 | $25.58 | $5.46 | $27.00 | $39.77 | $5.04 |
| LCHG HCG BETA BLOOD QUANTITATIVE | 84702 | $99.96 | $102.00 | $74.32 | $18.06 | $13.39 | $57.98 | $14.49 | $61.20 | $74.32 | $13.39 |
| LCHG BUN | 84520 | $44.10 | $45.00 | $23.81 | $4.74 | $3.51 | $25.58 | $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 | $37.15 | $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 | $53.37 | $124.72 | $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 | $98.33 | $192.93 | $99.12 | $203.40 | $789.29 | $77.82 |
| PR PREVENTIVE VISIT,EST,12-17 | 99394 | $213.15 | $217.00 | $146.90 | $101.00 | $100.61 | $123.63 | $93.33 | $130.20 | $146.90 | $93.33 |
| LCHG VANCOMYCIN LEVEL TROUGH | 80202 | $101.43 | $103.00 | $59.46 | $16.25 | $12.04 | $58.83 | $13.04 | $61.80 | $61.80 | $12.04 |
| LCHG HEPATITIS SCREEN ACUTE | 80074 | $124.95 | $127.00 | $49.37 | $57.16 | $42.37 | $72.47 | $45.83 | $76.20 | $76.20 | $42.37 |
| LCHG STAIN TRICHROME | 87209 | $44.10 | $45.00 | $129.09 | $21.58 | $15.99 | $25.58 | $17.30 | $27.00 | $129.09 | $15.99 |
| LCHG O+P | 87177 | $44.10 | $45.00 | $35.55 | $10.68 | $7.92 | $25.58 | $841.00 | $27.00 | $841.00 | $7.92 |
| LCHG HELICOBACTER PYLORI IGM | 86677 | $97.02 | $99.00 | $66.02 | $20.22 | $14.99 | $56.27 | $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 | $25.58 | $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 | $72.90 | $84.46 | $67.10 | $89.40 | $93.31 | $67.10 |
| PR PREVENTIVE VISIT,NEW,INFANT | 99381 | $202.65 | $207.00 | $139.24 | $136.39 | $95.95 | $117.54 | $88.88 | $124.20 | $139.24 | $88.88 |
| PR DIAB MANAGE TRN PER INDIV | G0108 | $79.00 | $81.00 | $67.47 | $0.00 | $48.68 | $45.82 | $58.51 | $48.60 | $67.47 | $0.00 |
| PR TELEHEALTH FACILITY FEE | Q3014 | $26.25 | $27.00 | $20.00 | $0.00 | $0.00 | $15.23 | $26.65 | $16.20 | $26.65 | $0.00 |
| HC RIBS UNILATERAL 2 VW | 71100 | $424.20 | $325.00 | $99.99 | $49.30 | $31.94 | $246.04 | $25.11 | $195.00 | $246.04 | $25.11 |
| LCHG HAPTOGLOBIN | 83010 | $76.44 | $78.00 | $45.57 | $15.10 | $11.19 | $44.34 | $12.10 | $46.80 | $46.80 | $11.19 |
| LCHG LIGHT CHAINS FREE EA | 83883 | $379.05 | $387.00 | $66.02 | $16.32 | $12.10 | $219.85 | $13.08 | $232.20 | $232.20 | $12.10 |
| LCHG HELICOBACTER PYLORI ANTIBODY IGG | 86677 | $97.02 | $99.00 | $66.02 | $20.22 | $14.99 | $56.27 | $13.97 | $59.40 | $66.02 | $13.97 |
| LCHG CULTURE GENITAL | 87070 | $64.68 | $66.00 | $35.55 | $10.34 | $7.67 | $37.51 | $8.29 | $39.60 | $39.60 | $7.67 |
| PR NURSING FACILITY CARE INIT, STGHTFWD COMPLEXITY | 99304 | $196.00 | $200.00 | $117.71 | $105.85 | $72.02 | $113.68 | $85.80 | $120.00 | $120.00 | $72.02 |
| HC CT SINUS FACIAL BONES NON CONTRAST | 70486 | $1,711.50 | $1,746.00 | $602.69 | $193.20 | $114.82 | $992.67 | $251.31 | $1,047.60 | $1,047.60 | $114.82 |
| HC CT ANGIO CHEST W/WO CONTRAST | 71275 | $2,948.40 | $3,007.00 | $813.48 | $377.08 | $220.35 | $1,710.07 | $449.45 | $1,804.20 | $1,804.20 | $220.35 |
| HC HUMERUS 2+ VW | 73060 | $424.20 | $325.00 | $99.99 | $43.17 | $27.79 | $246.04 | $22.42 | $195.00 | $246.04 | $22.42 |
| HC US HEAD NECK TISSUES B - SCAN REAL TIME | 76536 | $758.10 | $773.00 | $270.41 | $160.26 | $96.06 | $439.70 | $93.04 | $463.80 | $463.80 | $93.04 |
| LCHG MONONUCLEOSIS SCREEN | 86308 | $79.38 | $81.00 | $39.77 | $6.22 | $4.61 | $46.04 | $4.98 | $48.60 | $48.60 | $4.61 |
| HC SPIROMETRY | 94010 | $173.25 | $17.00 | $216.55 | $35.60 | $23.05 | $100.49 | $28.52 | $10.20 | $216.55 | $10.20 |
| PR PREVENTIVE VISIT, NEW, AGE 5-11 | 99383 | $217.41 | $222.00 | $151.68 | $115.20 | $104.26 | $126.10 | $96.67 | $133.20 | $151.68 | $96.67 |
| PR DESTROY PREMALIG LESION, 1ST LESION | 17000 | $91.88 | $94.00 | $647.49 | $70.92 | $58.54 | $53.29 | $72.72 | $56.40 | $647.49 | $53.29 |
| HC CT LOWER EXTREMITY NON CONTRAST | 73700 | $1,711.50 | $1,746.00 | $602.69 | $215.24 | $116.21 | $992.67 | $233.24 | $1,047.60 | $1,047.60 | $116.21 |
| HC US PELVIS COMPLETE | 76856 | $758.10 | $773.00 | $270.41 | $152.43 | $91.75 | $439.70 | $95.07 | $463.80 | $463.80 | $91.75 |
| LCHG LH | 83002 | $124.95 | $127.00 | $98.66 | $22.22 | $16.47 | $72.47 | $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 | $24.36 | $13.97 | $25.80 | $66.02 | $13.97 |
| LCHG HELICOBACTER PYLORI IGA | 86677 | $97.02 | $99.00 | $66.02 | $20.22 | $14.99 | $56.27 | $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 | $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 | $5.77 | $13.70 | $6.00 | $14.40 | $647.49 | $2.87 |
| HC ED STRAPPING ANKLE/FOOT | 29540 | $117.60 | $120.00 | $617.93 | $24.69 | $24.91 | $68.21 | $37.52 | $72.00 | $617.93 | $24.69 |
| HC THORACIC SPINE 3 VW | 72072 | $424.20 | $325.00 | $99.99 | $53.20 | $33.95 | $246.04 | $28.57 | $195.00 | $246.04 | $28.57 |
| HC MRI SPINE CERVICAL NON CONTRAST | 72141 | $2,163.00 | $2,206.00 | $572.63 | $302.10 | $172.06 | $1,254.54 | $423.51 | $1,323.60 | $1,323.60 | $172.06 |
| LCHG VOLUME MEASURE URINE | 81050 | $36.75 | $37.00 | $14.43 | $4.37 | $3.24 | $21.32 | $2.88 | $22.20 | $22.20 | $2.88 |
| HC THER ACTIVITIES EA 15 MIN OT | 97530 | $80.85 | $82.00 | $65.70 | $45.13 | $32.77 | $46.89 | $22.48 | $49.20 | $65.70 | $22.48 |
