300 SHOPPABLE SERVICES 2024 2024 2024 Service description CPT minimum maximum self pay price HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION 10005 "$7,359.00 " "$7,359.00 " "$3,679.50 " HC RESUP NPTERF WND BODY 2.6-7.5 CM 12002 $744.00 $744.00 $372.00 HC RESUPERF WND FACE <2.5 CM 12011 $744.00 $744.00 $372.00 HC BX BREAST W DEVICE 1ST LESION ULTRASOUND GUIDE 19083 "$6,345.00 " "$6,345.00 " "$3,172.50 " HC PT NEEDLE INSERTION W/OUT INJECTIONS 1 OR 2 MUSCLE   20560 $92.00 $92.00 $46.00 HC PT NEEDLE INSERTION W/O INJECTIONS 3 OR MORE MUSCLES 20561 $117.00 $117.00 $58.50 HC BLOOD TRANSFUSION SERVICE 36430 "$4,484.00 " "$4,484.00 " "$2,242.00 " HC ABDOM PARACENTESIS DX/THER W IMAGING GUIDANCE 49083 "$6,079.00 " "$6,079.00 " "$3,039.50 " HC NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN 62323 "$2,154.00 " "$2,154.00 " "$1,077.00 " "HC INJECT ANES/STEROID FORAMEN LUMBAR/SACRAL W IMG GUIDE ,1 LEVEL" 64483 $837.00 $837.00 $418.50 "HC CT SCAN,HEAD/BRAIN,W/O CONTRAST MATL - CT HEAD WO CONTRAST" 70450 "$9,003.00 " "$9,003.00 " "$4,501.50 " "HC CT SCAN,MAXILLOFACIAL W/O CONTRAST" 70486 "$9,732.00 " "$9,732.00 " "$4,866.00 " HC CT NECK TISSUE CONTRAST - CT SOFT TISSUE NECK W CONTRAST 70491 "$9,732.00 " "$9,732.00 " "$4,866.00 " "HC CT ANGIO,HEAD COMBO" 70496 "$9,732.00 " "$9,732.00 " "$4,866.00 " "HC CT ANGIO,NECK COMBO - CT NECK ANGIO W AND WO IV CONTRAST" 70498 "$9,732.00 " "$9,732.00 " "$4,866.00 " HC MRI BRAIN W/O CONTRAST 70551 "$11,770.00 " "$11,770.00 " "$5,885.00 " HC MRI BRAIN COMBO - MRI BRAIN W WO CONTRAST 70553 "$11,770.00 " "$11,770.00 " "$5,885.00 " HC RADIOLOGIC EXAM CHEST LATERAL SINGLE VIEW 71045 "$1,125.00 " "$1,125.00 " $562.50 HC RADIOLOGIC EXAM CHEST 2 VIEWS - XR CHEST 2 VIEWS 71046 "$1,277.00 " "$1,277.00 " $638.50 "HC X-RAY RIBS UNI, INC CHEST 3+ VIEWS" 71101 "$1,648.00 " "$1,648.00 " $824.00 "HC CT SCAN,THORAX,W/O CONTRAST - CT CHEST WO CONTRAST" 71250 "$9,002.00 " "$9,002.00 " "$4,501.00 " HC CAT SCAN OF CHEST CONTRAST - CT CHEST W CONTRAST 71260 "$9,732.00 " "$9,732.00 " "$4,866.00 " "HC CT ANGIO, CHEST, COMBO, INCL IMAGE - CT CHEST ANGIO W AND WO IV CONT" 71275 "$9,732.00 " "$9,732.00 " "$4,866.00 " "HC RAD EX SPINE, CERVICAL 2 OR 3 VIEWS" 72040 "$1,497.00 " "$1,497.00 " $748.50 HC RADEX SPINE CERVICAL 4 OR 5 VIEWS - XR CERVICAL SPINE COMP 4-5 VIEWS 72050 "$2,427.00 " "$2,427.00 " "$1,213.50 " HC X-RAY THORACIC SPINE 2 VW - XR THORACIC SPINE 2 VIEWS 72070 "$1,497.00 " "$1,497.00 " $748.50 HC X-RAY LUMBAR SPINE 2/3 VW - XR LUMBAR SPINE 2-3 VIEWS 72100 "$1,648.00 " "$1,648.00 " $824.00 HC X-RAY LUMBAR SPINE 4 VW - XR LUMBAR SPINE COMPLETE 4+ VIEWS 72110 "$2,674.00 " "$2,674.00 " "$1,337.00 " HC X-RAY LUMBAR SPINE FLEX/EXTEN - XR LUMBAR SPINE 2-3 VIEWS W/ FLEX EXT 72120 $566.00 $566.00 $283.00 "HC CT SCAN,CERVICAL SPINE,W/O CONTRAST - CT CERVICAL SPINE WO CONTRAST" 72125 "$9,732.00 " "$9,732.00 " "$4,866.00 " "HC MRI, CERV SPINE - MRI CERVICAL SPINE WO CONTRAST" 72141 "$11,770.00 " "$11,770.00 " "$5,885.00 " "HC MRI, LUMBAR SPINE - MRI LUMBAR SPINE WO CONTRAST" 72148 "$11,770.00 " "$11,770.00 " "$5,885.00 " HC X-RAY PELVIS 1/2 VW - XR PELVIS 1-2 VIEWS 72170 "$1,205.00 " "$1,205.00 " $602.50 HC CT SCAN OF PELVIS CONTRAST - CT PELVIS W CONTRAST 72193 "$9,732.00 " "$9,732.00 " "$4,866.00 " "HC MRI, PELVIS, COMBO - MRI PELVIS W WO CONTRAST" 72197 "$11,770.00 " "$11,770.00 " "$5,885.00 " "HC X-RAY SHOULDER COMPLETE, 2+ VW" 73030 "$1,390.00 " "$1,390.00 " $695.00 HC X-RAY ELBOW 3+ VW 73080 "$1,350.00 " "$1,350.00 " $675.00 HC X-RAY FOREARM 2 VIEWS 73090 "$1,205.00 " "$1,205.00 " $602.50 HC X-RAY WRIST 3+ VIEWS 73110 "$1,313.00 " "$1,313.00 " $656.50 HC X-RAY HAND 3+ VIEWS 73130 "$1,350.00 " "$1,350.00 " $675.00 "HC X-RAY EXAM OF FINGER(S), 2+VIEWS" 73140 "$1,125.00 " "$1,125.00 " $562.50 "HC MRI, JOINT UPPER EXTREM W/O CONTRAST" 73221 "$11,770.00 " "$11,770.00 " "$5,885.00 " HC X-RAY EXAM HIP UNI W/PELVIS 2-3 VIEWS 73502 "$1,350.00 " "$1,350.00 " $675.00 HC X-RAY KNEE 1 OR 2 VIEWS 73560 "$1,166.00 " "$1,166.00 " $583.00 HC X-RAY KNEE 3 VIEW 73562 "$1,426.00 " "$1,426.00 " $713.00 HC X-RAY KNEE 4+ VIEW 73564 "$1,648.00 " "$1,648.00 " $824.00 "HC X-RAY TIBIA + FIBULA, 2VIEWS" 73590 "$1,277.00 " "$1,277.00 " $638.50 "HC X-RAY ANKLE COMPLETE, 3+ VIEWS" 73610 "$1,277.00 " "$1,277.00 " $638.50 "HC X-RAY EXAM FOOT COMPLETE, 3+ VIEWS" 73630 "$1,277.00 " "$1,277.00 " $638.50 HC X-RAY TOE(S) MINIMUM 2 VIEWS 73660 "$1,125.00 " "$1,125.00 " $562.50 "HC CT SCAN, LOWER EXTREMITY, W/O CONTRAST" 73700 "$9,732.00 " "$9,732.00 " "$4,866.00 " HC MRI ANY JOINT OF LWR EXTRE W/O CONTRAST 73721 "$11,770.00 " "$11,770.00 " "$5,885.00 " HC RADIOLOGIC EXAM ABDOMEN 1 VIEW - XR ABDOMEN 1 VIEW 74018 "$1,166.00 " "$1,166.00 " $583.00 HC RADIOLOGIC EXAM ABDOMEN 2 VIEWS 74019 "$1,537.00 " "$1,537.00 " $768.50 HC CT ABD & PELVIS W/O CONTRAST - CT ABDOMEN PELVIS WO CONTRAST 74176 "$9,732.00 " "$9,732.00 " "$4,866.00 " HC CT ABDOMEN & PELVIS W/CONTRAST 74177 "$9,732.00 " "$9,732.00 " "$4,866.00 " HC CT ABD & PELV 1/> REGNS - CT ABDOMEN PELVIS W WO CONTRAST 74178 "$9,732.00 " "$9,732.00 " "$4,866.00 " HC MRI ABDOMEN COMBO 74183 "$11,770.00 " "$11,770.00 " "$5,885.00 " HC ESOPHAGRAM - FL ESOPHAGUS BARIUM SWALLOW 74220 "$2,385.00 " "$2,385.00 " "$1,192.50 " HC VIDEO FLUORO SPEECH STUDY 74230 "$3,046.00 " "$3,046.00 " "$1,523.00 " HC CT HEART WITH IV CONTRAST 75572 "$2,413.00 " "$2,413.00 " "$1,206.50 " HC FLUOROSCOPY <1 HR 76000 "$3,332.00 " "$3,332.00 " "$1,666.00 " HC 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION - CT 3D RECONSTRUCT 76376 "$11,770.00 " "$11,770.00 " "$5,885.00 " HC MRI PROSTATE CAD 76377 "$2,320.00 " "$2,320.00 " "$1,160.00 " "HC US, SOFT TISSUES, HEAD/NECK, REAL TIME" 76536 "$2,797.00 " "$2,797.00 " "$1,398.50 " "HC ULTRASOUND BREAST LIMITED UNILATERAL, REAL TIME" 76642 $477.00 $477.00 $238.50 "HC US, ABDOMEN COMPLETE" 76700 "$3,689.00 " "$3,689.00 " "$1,844.50 " "HC US, ABDOMINAL, REAL TIME, SINGLE ORGAN/QUADRANT" 76705 "$3,119.00 " "$3,119.00 " "$1,559.50 " HC US - US RENAL COMPLETE 76770 "$3,295.00 " "$3,295.00 " "$1,647.50 " HC OB US < 14 WKS SINGLE FETUS - US OB < 14 WEEKS SINGLE OR FIRST GEST 76801 "$1,486.00 " "$1,486.00 " $743.00 HC OB US >/= 14 WKS SNGL FETUS - US OB 14+ WEEKS SINGLE OR FIRST GEST 76805 "$1,486.00 " "$1,486.00 " $743.00 HC OB US DETAILED SNGL FETUS - US OB DETAIL FETAL ANAT SING OR 1ST GEST 76811 "$1,486.00 " "$1,486.00 " $743.00 "HC US,PREG UTER,NUCHAL MEAS, 1ST TRIMEST, SINGLETON" 76813 "$1,486.00 " "$1,486.00 " $743.00 HC OB US LIMITED FETUS(S) - US OB LIMITED 1+ FETUSES 76815 $869.00 $869.00 $434.50 HC OB US FOLLOW-UP PER FETUS - US OB FOLLOW UP TRANSABDOMINAL APPROACH 76816 $824.00 $824.00 $412.00 HC US PELVIS TRANSVAGINAL 76830 "$2,797.00 " "$2,797.00 " "$1,398.50 " HC PELVIC (NONOBSTETRIC) - US PELVIS COMPLETE 76856 "$3,478.00 " "$3,478.00 " "$1,739.00 " "HC ECHO,SCROTUM & CONTENTS - US SCROTUM" 76870 "$3,009.00 " "$3,009.00 " "$1,504.50 " HC US LMTD NONVASC XTR STRUX 76882 "$2,118.00 " "$2,118.00 " "$1,059.00 " "HC US GUIDE, VASCULAR ACCESS - XR PICC LINE VASCULAR INSERTION" 76937 "$1,832.00 " "$1,832.00 " $916.00 HC ECHO GUIDE FOR BIOPSY 76942 "$2,847.00 " "$2,847.00 " "$1,423.50 " HC MRI BREAST BILATERAL W & WO CONTRAST 77049 "$7,624.00 " "$7,624.00 " "$3,812.00 " HC DX BREAST MAMMO TOMO UNI - MAMMO BREAST DIAGNOSTIC TOMO UNI 77061 $50.00 $50.00 $25.00 HC DX BREAST TOMO BI - MAMMO BREAST DIAGNOSTIC TOMOSYNTHESIS BI 77062 $50.00 $50.00 $25.00 HC DX MAMMO DIG UNI - MAMMO BREAST DIAGNOSTIC 77065 $446.00 $446.00 $223.00 HC DX MAMMO DIG BI - MAMMO BREAST DIAGNOSTIC BILATERAL 77066 $569.00 $569.00 $284.50 HC SCR MAMMO BI - MAMMO BREAST SCREENING BILATERAL 77067 $471.00 $471.00 $235.50 HC DXA BONE DENSITY AXIAL - DEXA BONE DENSITY 77080 $944.00 $944.00 $472.00 "HC BONE IMAGING, WHOLE BODY - NM BONE WHOLE BODY" 78306 "$5,884.00 " "$5,884.00 " "$2,942.00 " HC HT MUSCLE IMAGE SPECT MULT 78452 "$15,372.00 " "$15,372.00 " "$7,686.00 " HC BASIC METABOLIC PANEL CALCIUM TOTAL 80048 $98.00 $189.00 $94.50 "HC METABOLIC PANEL,COMPREHENSIVE" 80053 $315.00 $315.00 $157.50 HC LIPID PANEL 80061 $221.00 $221.00 $110.50 HC RENAL FUNCTION PANEL 80069 $229.00 $229.00 $114.50 "HC HEPATITIS PANEL, ACUTE" 80074 $578.00 $578.00 $289.00 HC HEPATIC FUNCTION PANEL 80076 $86.00 $172.00 $86.00 HC ASSAY OF LITHIUM - LITHIUM 80178 $142.00 $142.00 $71.00 HC DRUG TEST PRSMV DIR OPT OBS - TOXICOLOGY SCREEN URINE 80305 $173.00 $173.00 $86.50 "HC DRUG SCREEN, PRESC/OTC, U" 80307 $77.00 $154.00 $77.00 HC DRUG SCREEN QUANTITATIVE ALCOHOLS 80320 $136.00 $136.00 $68.00 HC AMPHETAMINES SCRN SENDOUT 80326 $44.00 $230.00 $115.00 HC DRUG SCREEN ANALGESICS NON-OPIOID 1 OR 2 80329 $178.00 $227.00 $113.50 HC TARGETED BENZODIAZEPINE SCREEN 80347 $75.00 $234.00 $117.00 "HC TARGETED OPIOID SCREEN, U " 80364 $58.00 $550.00 $275.00 "HC URINALYSIS, AUTO, W/SCOPE - URINALYSIS MICROSCOPIC" 81001 $176.00 $176.00 $88.00 "HC URINALYSIS, AUTO, W/O SCOPE - URINALYSIS" 81003 $32.50 $119.00 $59.50 HC URINE MICROSCOPIC 81015 $5.00 $74.00 $37.00 HC URINE PREGNANCY TEST - PREGNANCY URINE 81025 $24.00 $194.00 $97.00 HC BACT VAGINOSIS RNA APTIMA 81513 $74.00 $286.00 $143.00 HC ASSAY OF SERUM ALBUMIN - ALBUMIN 82040 $24.00 $110.00 $55.00 "HC MICROALBUMIN, QUANTITATIVE - MICROALBUMIN RANDOM URINE" 82043 $9.00 $203.00 $101.50 HC ASSAY OF AMYLASE - AMYLASE 82150 $10.00 $488.00 $244.00 HC BILIRUBIN TOTAL - BILIRUBIN TOTAL AND DIRECT 82247 $55.00 $55.00 $27.50 HC BILIRUBIN DIRECT - BILIRUBIN DIRECT 82248 $55.00 $55.00 $27.50 HC BLOOD OCCULT FECES IMMUNOASSAY 82274 $80.00 $80.00 $40.00 "HC ASSAY OF VIT D,CALCIFEDIOL WO FRACTIONS - VITAMIN D" 82306 $42.00 $274.00 $137.00 "HC ASSAY OF CALCIUM, TOTAL - CALCIUM" 82310 $55.00 $55.00 $27.50 "HC CALCULUS ASSAY,INFRARED SPECTR - KIDNEY STONE ANALYSIS" 82365 $112.00 $112.00 $56.00 HC TOTAL CORTISOL - CORTISOL 82533 $210.00 $210.00 $105.00 HC ASSAY OF CK (CPK) - CK 82550 $121.00 $121.00 $60.50 "HC CREATINE, MB FRACTION - CKMB" 82553 $174.00 $174.00 $87.00 HC ASSAY OF CREATININE - CREATININE SERUM 82565 $55.00 $55.00 $27.50 HC ASSAY OF URINE - NTX RANDOM URINE CREATININE 82570 $26.00 $26.00 $13.00 HC VITAMIN B-12 - VITAMIN B12 82607 $301.00 $301.00 $150.50 "HC ASSAY, DIHYDROXYVITAMIN D W/FRACTIONS, IF PERFORMED - VITAMIN D 1" 82652 $90.00 $90.00 $45.00 HC ASSAY OF ESTRADIOL - ESTRADIOL 82670 $479.00 $479.00 $239.50 HC ASSAY OF FERRITIN - FERRITIN 82728 $20.00 $265.00 $132.50 HC BLOOD FOLIC ACID SERUM - FOLATE 82746 $297.00 $297.00 $148.50 "HC ASSAY OF GAMMAGLOBULIN IGA, IGD, IGG, IGM, EACH " 82784 $12.00 $168.00 $84.00 "HC GLUCOSE FINGRSTCK, REAGNT STRP" 82948 $53.00 $53.00 $26.50 HC ASSAY OF GGT - GAMMA GT 82977 $55.00 $129.00 $64.50 HC GONADOTROPIN (FSH) - FSH 83001 $266.00 $266.00 $133.00 HC GONADOTROPIN (LH) - LUTEINIZING HORMONE 83002 $266.00 $266.00 $133.00 HC IMMUNOASSAY NONANTIBODY 83516 $377.00 $377.00 $188.50 HC ASSAY OF IRON - IRON 83540 $112.00 $234.00 $117.00 HC IRON BINDING TEST 83550 $134.00 $134.00 $67.00 HC ASSAY OF LACTIC ACID - LACTATE 83605 $89.00 $294.00 $147.00 HC LACTATE (LD) (LDH) ENZYME - LACTATE DEHYDROGENASE 83615 $9.00 $121.00 $60.50 HC ASSAY OF LIPASE - LIPASE 83690 $153.00 $153.00 $76.50 "HC ASSAY OF BLOOD LIPOPROTEIN,HDL CHOLEST " 83718 $12.00 $129.00 $64.50 "HC ASSAY OF BLOOD LIPOPROTEIN,LDL CHOLEST " 83721 $14.00 $151.00 $75.50 HC ASSAY OF MAGNESIUM - MAGNESIUM 83735 $10.00 $321.00 $160.50 HC NATRIURETIC PEPTIDE - B-TYPE NATRIURETIC PEPTIDE (BNP) 83880 $47.00 $398.00 $199.00 HC ASSAY OF PARATHORMONE - PTH INTACT 83970 $173.00 $173.00 $86.50 HC ASSAY ALKAL PHOSPHATASE - ALKALINE PHOSPHATASE 84075 $8.00 $55.00 $27.50 HC ASSAY OF INORGANIC PHOSPHORUS - PHOSPHORUS 84100 $7.00 $55.00 $27.50 HC ASSAY OF SERUM POTASSIUM - POTASSIUM 84132 $7.00 $55.00 $27.50 HC ASSAY OF PROGESTERONE - PROGESTERONE 84144 $221.00 $221.00 $110.50 HC ASSAY OF PROLACTIN - PROLACTIN 84146 $333.00 $333.00 $166.50 "HC PROSTATE SPECIFIC ANTIGEN,TOTAL - PSA SCREENING" 84153 $22.00 $100.00 $50.00 HC PROTEIN TOT XCPT REFRACTOMETRY SERUM - PROTEIN TOTAL 84155 $55.00 $55.00 $27.50 HC PROTEIN TOT XCPT REFRACTOMETRY URINE 84156 $32.00 $141.00 $70.50 "HC PROTEIN E-PHORESIS, SERUM - PROTEIN ELECTROPHORESIS SERUM" 84165 $196.00 $196.00 $98.00 HC TESTOSTERONE FREE S/O 84402 $52.00 $52.00 $26.00 HC TESTOSTERONE TOTAL 84403 $52.00 $52.00 $26.00 HC ASSAY OF FREE THYROXINE - T4 FREE 84439 $265.00 $265.00 $132.50 HC ASSAY THYROID STIM HORMONE - THYROID STIMULATING HORMONE 84443 $24.00 $97.00 $48.50 HC TRANSFERASE ASPARTATE AMINO (AST) (SGOT) - AST (SGOT) 84450 $55.00 $55.00 $27.50 HC TRANSFERASE ALANINE AMINO (ALT) (SGPT) - ALT (SGPT) 84460 $55.00 $55.00 $27.50 HC ASSAY OF TRIGLYCERIDES - TRIGLYCERIDES 84478 $38.00 $84.00 $42.00 "HC TRIIODOTHYRONINE TOTAL ASSAY, TT-3 - T3 (THYROID HORMONE)" 84480 $173.00 $173.00 $86.50 HC TRIIODOTHYRONINE FREE ASSAY (FT-3) - T3 FREE 84481 $266.00 $266.00 $133.00 "HC ASSAY OF URIC ACID, BLOOD - URIC ACID" 84550 $7.00 $284.00 $142.00 "HC CHORIONIC GONADOTROPIN, QUANT " 84702 $22.00 $257.00 $128.50 "HC CHORIONIC GONADOTROPIN, QUAL - HCG QUALITATIVE" 84703 $194.00 $194.00 $97.00 "HC BLOOD SMEAR,MICRO EXAM,MANUAL DIFF WBC - MANUAL DIFFERENTIAL" 85007 $60.00 $60.00 $30.00 HC HEMATOCRIT - HEMATOCRIT 85014 $72.00 $87.00 $43.50 HC HEMOGLOBIN - HEMOGLOBIN 85018 $80.00 $80.00 $40.00 HC COMPLETE CBC & AUTO DIFF WBC 85025 $173.00 $173.00 $86.50 HC COMPLETE CBC - CBC 85027 $151.00 $151.00 $75.50 "HC COAGULATION TIME, ACTIVATED - ACTIVATED CLOTTING TIME " 85347 $472.00 $472.00 $236.00 "HC FIBRIN DEGRADPRODUCTS, D-DIMER, QUANT - D-DIMER, QUANTITATIVE" 85379 $12.00 $863.00 $431.50 HC PROTHROMBIN TIME 85610 $6.00 $136.00 $68.00 "HC RBC SED RATE, AUTO - SEDIMENTATION RATE" 85652 $111.00 $111.00 $55.50 HC THROMBOPLAS TIME PARTIAL - APTT 85730 $9.00 $172.00 $86.00 HC ALLERGEN SPEC IGE 86003 $7.00 $242.00 $121.00 HC ANTINUCLEAR ANTIBODIES - ANA (ANTINUCLEAR ANTIBODIES) 86038 $33.00 $173.00 $86.50 HC C-REACTIVE PROTEIN - C-REACTIVE PROTEIN 86140 $112.00 $112.00 $56.00 "HC C-REACTIVE PROTEIN,HIGH SENSITIVITY - HIGH SENSITIVITY CRP " 86141 $19.00 $121.00 $60.50 "HC COMPLEMENT, ANTIGEN " 86160 $24.00 $342.00 $171.00 HC CYCLIC CIRULLINATED PEPTIDE ANTIBODY 86200 $35.00 $72.00 $36.00 HC FLUORESCENT ANTIBODY; SCREEN 86255 $48.00 $520.00 $260.00 "HC HETEROPHILE ANTIBODIES,SCREEN - MONONUCLEOSIS SCREEN" 86308 $129.00 $129.00 $64.50 "HC T CELLS, TOTAL COUNT - T CELLS, TOTAL COUNT" 86359 $62.00 $100.00 $50.00 HC T CELL ABSOLUTE COUNT/RATIO 86360 $74.00 $112.00 $56.00 HC MICROSOMAL ANTIBODY 86376 $26.00 $98.00 $49.00 "HC RHEUMATOID FACTOR, QUANT - RHEUMATOID FACTOR" 86431 $141.00 $141.00 $70.50 HC SYPHILIS TEST NON TREPONEMAL ANTIBODY QUAL 86592 $76.00 $184.00 $92.00 HC EPSTEIN-BARR CAPSID VCA - EPSTEIN-BARR VIRUS VCA 86665 $188.00 $188.00 $94.00 "HC HERPES SIMPLEX TEST, TYPE 1 - HSV 1 IGG ANTIBODY" 86695 $28.00 $28.00 $14.00 "HC HERPES SIMPLEX TEST, TYPE 2 - HSV 2 IGG ANTIBODY" 86696 $40.00 $40.00 $20.00 "HC HIV-1/HIV-2, SINGLE ASSAY - HIV 1 AND 2 SCREEN" 86703 $265.00 $265.00 $132.50 HC HEPATITIS B SURFACE AB TEST - HEPATITIS B SURFACE ANTIBODY 86706 $151.00 $151.00 $75.50 HC RUBELLA - RUBELLA ANTIBODY 86762 $256.00 $256.00 $128.00 HC SARS-COV-2 ANTIBODY FTH 86769 $80.00 $80.00 $40.00 HC ANTIBODY TREPONEMA PALLIDUM 86780 $19.00 $150.00 $75.00 HC THYROGLOBULIN ANTIBODY - THYROID AUTO AB PNL 86800 $66.00 $66.00 $33.00 HC HEPATITIS C AB TEST - HEPATITIS C ANTIBODY 86803 $366.00 $366.00 $183.00 HC RBC ANTIBODY SCREEN - ANTIBODY SCREEN 86850 $16.00 $400.00 $200.00 HC BLOOD TYPING SEROLOGIC ABO 86900 $8.00 $224.00 $112.00 HC BLOOD TYPING SEROLOGIC RH (D) 86901 $8.00 $69.00 $34.50 "HC CULTURE, BLOOD (ONE SET)" 87040 $461.00 $461.00 $230.50 HC CULTURE 87070 $265.00 $265.00 $132.50 "HC CULTURE, ANAEROBIC ISOLATION" 87075 $265.00 $265.00 $132.50 "HC BACTERIA IDENTIFICATION, AEROBIC ISOLATE " 87077 $11.00 $87.00 $43.50 HC BACTERIA CULTURE SCREEN 87081 $10.00 $129.00 $64.50 "HC CULTURE, BACTERIAL, URINE ID" 87088 $173.00 $173.00 $86.50 "HC CULTURE, FUNGUS (OTHER SOURCE)" 87102 $66.00 $66.00 $33.00 "HC ANTIBIOTIC SENS,MIC,EACH - SUSCEPTIBILITY CHARGE" 87186 $13.00 $482.00 $241.00 HC GRAM STAIN 87205 $60.00 $60.00 $30.00 HC IAAD IA HEPATITIS B SURFACE ANTIGEN - HEPATITIS B SURFACE ANTIGEN 87340 $15.00 $192.00 $96.00 HC CANDIDA DNA AMP PROBE 87481 $72.00 $72.00 $36.00 "HC CHYLMD TRACH, DNA, AMP PROBE" 87491 $155.00 $155.00 $77.50 "HC, IADNA-DNA/RNA PROBE TQ 12-25 - GASTROINTESTINAL PANEL" 87507 $265.00 $265.00 $132.50 "HC HSV, DNA, AMP PROBE - HSV PCR" 87529 $100.00 $333.00 $166.50 HC HIV-1 QUANT&REVRSE TRNSCRPJ 87536 $121.00 $837.00 $418.50 "HC N.GONORRHOEAE, DNA, AMP PROB - GC DNA PCR" 87591 $155.00 $155.00 $77.50 HC IADNA HUMAN PAPILLOMAVIRUS HIGH-RISK TYPES 87624 $50.00 $240.00 $120.00 "HC INFECTIOUS AGENT DETECTION BY NUCLEIC ACID; SARS-COV-2 AND INFLUENZA VIRUS TYPES A AND B, POCT" 87636 $100.00 $100.00 $50.00 "HC NUCLEIC ACID DETECTION OF SARS-COV-2, INFLUENZA A/B, RSV, MULTIPLEX PROBE TECHNIQUE" 87637 $250.00 $250.00 $125.00 "HC STREP A, DNA, AMP PROBE - STREP A DNA PROBE, AMPLIFICATION" 87651 $110.00 $110.00 $55.00 "HC STREP B, DNA, AMP PROBE - STREP B DNA PROBE, AMPLIFICATION" 87653 $173.00 $173.00 $86.50 "HB TRICHOMONAS VAGINALIS, AMPLIFIED " 87661 $60.00 $222.00 $111.00 "HC DETECT AGENT NOS, DNA, AMP " 87798 $553.00 $553.00 $276.50 HC STREP A ASSAY - RAPID STREP A SCREEN 87880 $17.00 $114.00 $57.00 "HC CYTOPATH CELL ENHANCE TECH - LAB CYTOPATH, CELL ENHANCE TECH" 88112 $53.00 $53.00 $26.50 "HC CYTP DX EVAL FNA 1ST EA SITE - LAB EVALUATION OF FNA SMEAR, FIRST" 88172 $168.00 $168.00 $84.00 HC CYTOPATH EVAL FNA REPORT - LAB INTERPRETATION OF FNA SMEAR 88173 $168.00 $168.00 $84.00 "HC SURG PATH,LEVEL III - LAB SURG PATH,LEVEL III" 88304 $168.00 $168.00 $84.00 "HC SURG PATH,LEVEL IV - LAB SURG PATH,LEVEL IV - BX" 88305 "$1,118.00 " "$1,118.00 " $559.00 "HC SURG PATH,LEVEL V - LAB SURG PATH,LEVEL V" 88307 $265.00 $265.00 $132.50 HC DECALCIFY TISSUE - LAB SURG PATH 88311 $81.00 $87.00 $43.50 HC IMMUNOHISTO ANTB ADDL SLIDE 88341 $237.00 $306.00 $153.00 HC IMMUNOPEROXIDASE 88342 $125.00 $304.00 $152.00 HC SURG-PATH HER 2 NEU 88360 $404.00 $600.00 $300.00 "HC HER2, BREAST IHC, AUTOMATED" 88361 $348.00 $348.00 $174.00 "HC CELL COUNT,MISC BODY FLUIDS - BODY FLUID CELL COUNT" 89050 $174.00 $174.00 $87.00 HC BODY FLUID CELL COUNT W DIFF 89051 $391.00 $391.00 $195.50 "HC IMMUNIZ ADMIN,1 SINGLE/COMB VAC/TOXOID" 90471 $195.00 $213.00 $106.50 HC TLC ED CRISIS INTERVENTION 90791 $150.00 "$1,617.00 " $808.50 HC PSYCHOTHERAPY PATIENT &/ FAMILY 30 MINUTES 90832 $368.00 $407.00 $203.50 HC PSYCHOTHERAPY PATIENT &/ FAMILY 45 MINUTES 90834 $490.00 $534.00 $267.00 HC PSYCHOTHERAPY PATIENT &/ FAMILY 60 MINUTES 90837 "$1,092.00 " "$1,189.00 " $594.50 HC GROUP PSYCHOTHERAPY 90853 $270.00 "$1,363.00 " $681.50 "HC ELECTROCONVULSIVE THERAPY,1 SEIZ" 90870 "$3,107.00 " "$3,382.00 " "$1,691.00 " HC SARS COV2 VACCINE ADD26 0.5 ML IM 91303 $0.01 $0.01 $0.01 HC SLP TREATMENT OF SPEECH/LANGUAGE/VOICE/COMM/AUD 92507 $795.00 $951.00 $475.50 HC SLP EVAL SPEECH SOUND/LANGUAGE/COMP & EXPRESSION 92523 $138.00 "$1,191.00 " $595.50 HC SLP TREATMENT OF SWALLOWING DYSFUNCTION/FEEDING 92526 $477.00 "$1,038.00 " $519.00 "HC SLP EVAL,ORAL & PHARYNGEAL SWALLOW FUNCTION" 92610 "$1,094.00 " "$1,191.00 " $595.50 HC SLP EVAL VIDEO/SWALLOW 92611 "$1,094.00 " "$1,191.00 " $595.50 HC CARDIOVERSION ELECTRIC EXT - CARDIOVERSION EXTERNAL 92960 "$7,840.00 " "$12,955.00 " "$6,477.50 " "HC CARDIAC STRESS TST,TRACING " 93017 "$3,716.00 " "$4,044.00 " "$2,022.00 " "HC EXT ECG RECORD CONTIN 48 HR, RECORD - HOLTER MONITOR " 93225 "$1,420.00 " "$1,673.00 " $836.50 HC ECG MONIT/REPRT UP TO 48 HRS - HOLTER MONITOR - 48 HOUR 93226 "$2,360.00 " "$2,780.00 " "$1,390.00 " HC TTE W/DOPPLER COMPLETE - TTE COMPLETE 93306 "$8,307.00 " "$9,041.00 " "$4,520.50 " HC ECHO TRANSESOPHAGEAL - TEE COMPLETE 93312 "$8,290.00 " "$9,023.00 " "$4,511.50 " "HC CATH PLACE/CORON ANGIO, IMG SUPER/INTERP,W LEFT HEART VENTRICULOGRAPHY" 93458 "$45,400.00 " "$49,413.00 " "$24,706.50 " HC OUTPATIENT CARDIAC REHAB W/CONT ECG MONITORING 93798 "$1,118.00 " "$1,217.00 " $608.50 "HC DUPLEX SCAN EXTRACRANIAL,BILAT " 93880 $215.00 "$1,456.00 " $728.00 "HC DUPLEX EXTREM VENOUS,BILAT " 93970 "$4,563.00 " "$5,367.00 " "$2,683.50 " "HC DUPLEX EXTREM VENOUS,UNI OR LTD" 93971 $215.00 "$5,367.00 " "$2,683.50 " HC VASCULAR STUDY - US ABDOMEN DOPPLER LIMITED 93976 $15.00 "$3,261.00 " "$1,630.50 " HC POLYSOMNOGRAPHY STAGE 4> ATTEN 95810 $954.00 "$7,289.00 " "$3,644.50 " HC POLYSOMN STAGE W/AIRWAY TH ATT 95811 "$1,060.00 " "$7,575.00 " "$3,787.50 " "HC IV INFUSION, HYDRATION, 31-60 MIN" 96360 "$1,350.00 " "$1,470.00 " $735.00 "HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR" 96365 "$1,431.00 " "$1,558.00 " $779.00 "HC IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,EA ADD HOUR" 96366 $383.00 $417.00 $208.50 "HC IV INFUSION, THERAP/PROPH/DIAGNOST,ADD INFUSION,1ST HOUR" 96367 $293.00 $319.00 $159.50 "HC INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT" 96372 $110.00 $240.00 $120.00 "HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG" 96375 $415.00 $451.00 $225.50 "HC INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, SAME DRUG" 96376 $415.00 $451.00 $225.50 HC PT OR OT HOT OR COLD PACKS THERAPY 97010 $52.00 $56.00 $28.00 HC PT OR OT INFRARED THERAPY 97026 $121.00 $132.00 $66.00 HC PT OR OT IONTOPHORESIS 97033 $239.00 $260.00 $130.00 HC PT OR OT ULTRASOUND THERAPY 97035 $239.00 $260.00 $130.00 HC THERAPEUTIC EXERCISES 97110 $239.00 $260.00 $130.00 HC PT OR OT NEUROMUSCULAR RE-EDUCATION 97112 $239.00 $260.00 $130.00 HC OT OR PT GAIT TRAINING THERAPY 97116 $239.00 $260.00 $130.00 HC MASSAGE THERAPY 97124 $81.00 $287.00 $143.50 HC PT EVAL LOW COMPLEX 97161 $138.00 $920.00 $460.00 HC PT EVAL MOD COMPLEX 97162 $845.00 $920.00 $460.00 HC OT EVAL LOW COMPLEX 97165 $423.00 $920.00 $460.00 HC OT EVAL MOD COMPLEX 97166 $423.00 $920.00 $460.00 HC PT OR OT THERAPEUTIC ACTVITY 97530 $81.00 $260.00 $130.00 HC OT OR PT SENSORY INTEGRATIVE TECHNIQUES 97533 $238.00 $260.00 $130.00 HC OT OR PT SELF-CARE/HOME MGMT TRAINING 97535 $238.00 $260.00 $130.00 HC PT OR OT DEBRIDEMENT OPEN WOUND 20 SQ CM< 97597 $578.00 $629.00 $314.50 "HC PT OR OT WOUND DEBRIDEMNT, NON-SELECTIVE, EA" 97602 $453.00 $494.00 $247.00 HC ACUPUNCT W/O STIM INIT 15 MIN 97810 $247.00 $268.00 $134.00 HC ACUPUNCT W/O STIMUL ADDL 15 97811 $247.00 $268.00 $134.00 HC MOD SED SAME PHYS/QHP 5/> YRS 99152 "$1,089.00 " "$1,185.00 " $592.50 HC MOD SED SAME PHYS/QHP EACH ADDL 15 MINS 99153 $460.00 $501.00 $250.50 HC NEW OV MODERATE 45-59 MINUTES 99204 $971.00 "$2,259.00 " "$1,129.50 " HC NEW OV HIGH 99205 "$1,426.00 " "$3,407.00 " "$1,703.50 " HC EST OV MINOR 99211 $82.00 $895.00 $447.50 HC EST OV MODERATE 99213 $554.00 "$1,368.00 " $684.00 HC EST OV MODERATE/HIGH 99214 $160.00 "$2,089.00 " "$1,044.50 " HC EST OV HIGH 99215 $240.00 "$3,151.00 " "$1,575.50 " HC ER VISIT STRAIGHTFORWARD 99282 "$1,493.00 " "$1,625.00 " $812.50 "HC CRITICAL CARE, E/M 30-74 MINUTES" 99291 "$14,615.00 " "$15,907.00 " "$7,953.50 " 2024 2024 2024 Service description DRG minimum maximum self pay price CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC 216 "$44,892.33 " "$319,674.05 " "$276,014.45 " SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC 460 "$18,542.91 " "$121,123.99 " "$60,561.99 " MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC 470 "$12,986.08 " "$107,588.58 " "$53,794.29 " CERVICAL SPINAL FUSION WITHOUT CC/MCC 473 "$17,663.04 " "$55,409.68 " "$27,704.84 " UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC 743 "$10,061.68 " "$22,994.10 " "$11,497.05 " location-name: Boulder Community Health source-page-url: www.bch.org mrf-url: www.bch.org/patient-visitors/patient-services/compliance/medicare-compliance/ contact-name: Jay Pekarek contact-email: jpekarek@bch.org