Hospital Indianapolis-Carmel-Greenwood, IN

Riverview Health

Riverview Health in Noblesville, IN publishes cash prices for 361 common procedures listed here, from its own machine-readable price file updated Apr 1, 2026. Compared with other hospitals in the state, its outpatient cash prices are above the Indiana median for 220 of 355 procedures and below it for 128. By typical cash price it ranks #50 of 84 Indiana hospitals and #11 of 16 hospitals in the Indianapolis, IN area, cheapest first. Select a procedure to compare it with other hospitals nearby.

395 Westfield Rd, Noblesville, IN 46060 Collected Sep 22, 2026 Source price file Check a bill from this hospital (317) 773-0760

Acute care hospital Government-owned hospital Emergency department CMS star rating 4 of 5 CCN 150059 · CMS hospital register NPI 1700883717

Financial assistance

Public hospital: ask for its charity care or sliding-scale discount

Riverview Health is government-owned (CMS register). The federal financial assistance rules for nonprofit hospitals do not always apply to public ones, but many public hospitals run charity care or sliding-scale discounts for uninsured and low-income patients. Ask the billing office for its financial assistance or charity care policy and application before you pay. Letters you can copy.

Scans and imaging

Procedure	Cash price	List price	Insurers pay	vs Indiana	Off list
Abdominal CT scan without and with contrast CPT 74170 CT ABDOMEN W/WO CONT	$1,356.60	$2,261.00	—	at median	40%
Abdominal CT scan without and with contrast inpatient CPT 74170 CT ABDOMEN W/WO CONT	$1,356.60	$2,261.00	—	—	40%
Abdominal X-ray, 2 views CPT 74019 XR ABDOMEN 2 VIEWS	$261.60	$436.00	—	3% below	40%
Abdominal X-ray, 2 views inpatient CPT 74019 XR ABDOMEN 2 VIEWS	$261.60	$436.00	—	—	40%
Ankle X-ray, complete, 3 or more views one side CPT 73610 XR ANKLE COMPLETE MIN 3V RT	$310.80	$518.00	—	58% above	40%
Ankle X-ray, complete, 3 or more views one side CPT 73610 XR ANKLE COMPLETE MIN 3V LT	$310.80	$518.00	—	58% above	40%
Ankle X-ray, complete, 3 or more views inpatient one side CPT 73610 XR ANKLE COMPLETE MIN 3V LT	$310.80	$518.00	—	—	40%
Ankle X-ray, complete, 3 or more views inpatient one side CPT 73610 XR ANKLE COMPLETE MIN 3V RT	$310.80	$518.00	—	—	40%
Ankle-brachial index (ABI), blood pressure test for leg arteries both sides CPT 93922 ART NON INVAS EXTR BI SNGL LEVEL	$841.20	$1,402.00	—	—	40%
Ankle-brachial index (ABI), blood pressure test for leg arteries inpatient both sides CPT 93922 ART NON INVAS EXTR BI SNGL LEVEL	$841.20	$1,402.00	—	—	40%
Arm CT scan without contrast (shoulder to hand, any part) one side CPT 73200 CT EXTREMITY UPPER WO CONT LT	$789.00	$1,315.00	—	2% below	40%
Arm CT scan without contrast (shoulder to hand, any part) one side CPT 73200 CT EXTREMITY UPPER WO CONT RT	$789.00	$1,315.00	—	2% below	40%
Arm CT scan without contrast (shoulder to hand, any part) inpatient one side CPT 73200 CT EXTREMITY UPPER WO CONT RT	$789.00	$1,315.00	—	—	40%
Arm CT scan without contrast (shoulder to hand, any part) inpatient one side CPT 73200 CT EXTREMITY UPPER WO CONT LT	$789.00	$1,315.00	—	—	40%
Barium swallow (esophagus X-ray with contrast) CPT 74220 XR ESOPHAGUS/BARIUM SWALLOW	$715.20	$1,192.00	—	54% above	40%
Barium swallow (esophagus X-ray with contrast) inpatient CPT 74220 XR ESOPHAGUS/BARIUM SWALLOW	$715.20	$1,192.00	—	—	40%
Bone scan, whole body (nuclear medicine) CPT 78306 NM BONE AND OR JNT IMAG WHOL BODY	$2,634.00	$4,390.00	—	67% above	40%
Bone scan, whole body (nuclear medicine) inpatient CPT 78306 NM BONE AND OR JNT IMAG WHOL BODY	$2,634.00	$4,390.00	—	—	40%
Breast ultrasound, complete, one breast one side CPT 76641 BREAST ULTRASOUND COMPLETE RT	$411.60	$686.00	—	5% below	40%
Breast ultrasound, complete, one breast one side CPT 76641 BREAST ULTRASOUND COMPLETE LT	$411.60	$686.00	—	5% below	40%
Breast ultrasound, complete, one breast inpatient one side CPT 76641 BREAST ULTRASOUND COMPLETE LT	$411.60	$686.00	—	—	40%
Breast ultrasound, complete, one breast inpatient one side CPT 76641 BREAST ULTRASOUND COMPLETE RT	$411.60	$686.00	—	—	40%
Breast ultrasound, limited (one breast or one area) one side CPT 76642 BREAST ULTRASOUND LIMITED LT	$315.60	$526.00	—	3% below	40%
Breast ultrasound, limited (one breast or one area) one side CPT 76642 BREAST ULTRASOUND LIMITED RT	$315.60	$526.00	—	3% below	40%
Breast ultrasound, limited (one breast or one area) inpatient one side CPT 76642 BREAST ULTRASOUND LIMITED RT	$315.60	$526.00	—	—	40%
Breast ultrasound, limited (one breast or one area) inpatient one side CPT 76642 BREAST ULTRASOUND LIMITED LT	$315.60	$526.00	—	—	40%
CT angiography (CTA) of the abdomen and pelvis CPT 74174 CTA ABD PELVIS WWO CONTRAST	$1,906.20	$3,177.00	—	1% above	40%
CT angiography (CTA) of the abdomen and pelvis inpatient CPT 74174 CTA ABD PELVIS WWO CONTRAST	$1,906.20	$3,177.00	—	—	40%
CT angiography (CTA) of the head CPT 70496 CTA HEAD W/WO CONT	$1,327.80	$2,213.00	—	4% above	40%
CT angiography (CTA) of the head inpatient CPT 70496 CTA HEAD W/WO CONT	$1,327.80	$2,213.00	—	—	40%
CT angiography (CTA) of the neck CPT 70498 CTA NECK W AND/OR WO CONTRAST	$1,326.00	$2,210.00	—	9% above	40%
CT angiography (CTA) of the neck inpatient CPT 70498 CTA NECK W AND/OR WO CONTRAST	$1,326.00	$2,210.00	—	—	40%
CT angiography of the chest (CTA), for blood clots in the lungs CPT 71275 CTA CHEST W AND/OR WO CONT	$1,343.40	$2,239.00	—	6% above	40%
CT angiography of the chest (CTA), for blood clots in the lungs inpatient CPT 71275 CTA CHEST W AND/OR WO CONT	$1,343.40	$2,239.00	—	—	40%
CT angiography of the heart arteries with contrast dye (coronary CTA), including calcium score CPT 75574 CTA HEART W CONTR W 3D	$1,428.00	$2,380.00	—	70% above	40%
CT angiography of the heart arteries with contrast dye (coronary CTA), including calcium score inpatient CPT 75574 CTA HEART W CONTR W 3D	$1,428.00	$2,380.00	—	—	40%
CT of the heart without contrast dye to measure coronary calcium CPT 75571 CT HEART WO CONT EVAL CORON CALC	$491.40	$819.00	—	163% above	40%
CT of the heart without contrast dye to measure coronary calcium inpatient CPT 75571 CT HEART WO CONT EVAL CORON CALC	$491.40	$819.00	—	—	40%
CT scan of abdomen and pelvis, no contrast dye CPT 74176 CT ABD PELVIS WITHOUT CONTRAST	$697.20	$1,162.00	—	42% below	40%
CT scan of abdomen and pelvis, no contrast dye inpatient CPT 74176 CT ABD PELVIS WITHOUT CONTRAST	$697.20	$1,162.00	—	—	40%
CT scan of abdomen and pelvis, with contrast dye CPT 74177 CT ABD PELVIS WITH CONTRAST	$1,508.40	$2,514.00	—	12% below	40%
CT scan of abdomen and pelvis, with contrast dye inpatient CPT 74177 CT ABD PELVIS WITH CONTRAST	$1,508.40	$2,514.00	—	—	40%
CT scan of abdomen and pelvis, without and then with contrast dye CPT 74178 CT ABD PELVIS WO CONT THEN W CONT	$1,701.60	$2,836.00	—	1% below	40%
CT scan of abdomen and pelvis, without and then with contrast dye inpatient CPT 74178 CT ABD PELVIS WO CONT THEN W CONT	$1,701.60	$2,836.00	—	—	40%
CT scan of the abdomen with contrast CPT 74160 CT ABDOMEN W CONT	$1,199.40	$1,999.00	—	13% above	40%
CT scan of the abdomen with contrast inpatient CPT 74160 CT ABDOMEN W CONT	$1,199.40	$1,999.00	—	—	40%
CT scan of the abdomen without contrast CPT 74150 CT ABDOMEN WO CONT	$556.20	$927.00	—	34% below	40%
CT scan of the abdomen without contrast inpatient CPT 74150 CT ABDOMEN WO CONT	$556.20	$927.00	—	—	40%
CT scan of the face and sinuses, no contrast dye CPT 70486 CT MAXILLOFACIAL AREA WO CONT	$602.40	$1,004.00	—	28% below	40%
CT scan of the face and sinuses, no contrast dye inpatient CPT 70486 CT MAXILLOFACIAL AREA WO CONT	$602.40	$1,004.00	—	—	40%
CT scan of the head or brain, no contrast dye CPT 70450 CT HEAD/BRAIN WO CONT	$454.20	$757.00	—	41% below	40%
CT scan of the head or brain, no contrast dye inpatient CPT 70450 CT HEAD/BRAIN WO CONT	$454.20	$757.00	—	—	40%
CT scan of the head with contrast CPT 70460 CT HEAD/BRAIN W CONT	$649.80	$1,083.00	—	24% below	40%
CT scan of the head with contrast inpatient CPT 70460 CT HEAD/BRAIN W CONT	$649.80	$1,083.00	—	—	40%
CT scan of the head without and with contrast CPT 70470 CT HEAD/BRAIN W/WO CONT	$782.40	$1,304.00	—	25% below	40%
CT scan of the head without and with contrast inpatient CPT 70470 CT HEAD/BRAIN W/WO CONT	$782.40	$1,304.00	—	—	40%
CT scan of the lower back (lumbar spine) without contrast CPT 72131 CT LUMBAR SPINE WO CONT	$565.20	$942.00	—	36% below	40%
CT scan of the lower back (lumbar spine) without contrast inpatient CPT 72131 CT LUMBAR SPINE WO CONT	$565.20	$942.00	—	—	40%
CT scan of the neck (cervical spine), no contrast dye CPT 72125 CT CERVICAL SPINE WO CONT	$569.40	$949.00	—	32% below	40%
CT scan of the neck (cervical spine), no contrast dye inpatient CPT 72125 CT CERVICAL SPINE WO CONT	$569.40	$949.00	—	—	40%
CT scan of the pelvis, with contrast dye CPT 72193 CT PELVIS W CONT	$1,206.60	$2,011.00	—	31% above	40%
CT scan of the pelvis, with contrast dye inpatient CPT 72193 CT PELVIS W CONT	$1,206.60	$2,011.00	—	—	40%
Carotid artery ultrasound (duplex), both sides of the neck both sides CPT 93880 CAROTID DUPLEX SCAN BILAT	$1,691.40	$2,819.00	—	—	40%
Carotid artery ultrasound (duplex), both sides of the neck inpatient both sides CPT 93880 CAROTID DUPLEX SCAN BILAT	$1,691.40	$2,819.00	—	—	40%
Chest CT scan without and with contrast CPT 71270 CT CHEST DIAG W/WO CONT	$945.60	$1,576.00	—	13% below	40%
Chest CT scan without and with contrast inpatient CPT 71270 CT CHEST DIAG W/WO CONT	$945.60	$1,576.00	—	—	40%
Chest X-ray, 2 views CPT 71046 XR CHEST 2 VIEWS	$240.60	$401.00	—	17% above	40%
Chest X-ray, 2 views inpatient CPT 71046 XR CHEST 2 VIEWS	$240.60	$401.00	—	—	40%
Chest X-ray, single view CPT 71045 XR CHEST 1 VIEW	$178.20	$297.00	—	10% above	40%
Chest X-ray, single view inpatient CPT 71045 XR CHEST 1 VIEW	$178.20	$297.00	—	—	40%
Collarbone (clavicle) X-ray, complete one side CPT 73000 XR CLAVICLE COMPLETE LT	$264.00	$440.00	—	38% above	40%
Collarbone (clavicle) X-ray, complete one side CPT 73000 XR CLAVICLE COMPLETE RT	$264.00	$440.00	—	38% above	40%
Collarbone (clavicle) X-ray, complete inpatient one side CPT 73000 XR CLAVICLE COMPLETE RT	$264.00	$440.00	—	—	40%
Collarbone (clavicle) X-ray, complete inpatient one side CPT 73000 XR CLAVICLE COMPLETE LT	$264.00	$440.00	—	—	40%
Complete ultrasound of the back of the abdomen, such as both kidneys CPT 76770 US RETROPERITONEUM COMPLETE	$442.80	$738.00	—	12% below	40%
Complete ultrasound of the back of the abdomen, such as both kidneys inpatient CPT 76770 US RETROPERITONEUM COMPLETE	$442.80	$738.00	—	—	40%
DEXA bone density scan of the hip, pelvis or spine CPT 77080 XR DXA BONE DENSITY AXIAL	$310.80	$518.00	—	8% above	40%
DEXA bone density scan of the hip, pelvis or spine inpatient CPT 77080 XR DXA BONE DENSITY AXIAL	$310.80	$518.00	—	—	40%
DEXA bone density scan of the wrist, heel or finger (peripheral) CPT 77081 XR DXA BONE DENSITY APPENDICULAR	$235.20	$392.00	—	62% above	40%
DEXA bone density scan of the wrist, heel or finger (peripheral) inpatient CPT 77081 XR DXA BONE DENSITY APPENDICULAR	$235.20	$392.00	—	—	40%
Detailed fetal anatomy ultrasound, through the belly, one baby CPT 76811 US PREG UTER W DETL FETL	$514.80	$858.00	—	9% below	40%
Detailed fetal anatomy ultrasound, through the belly, one baby inpatient CPT 76811 US PREG UTER W DETL FETL	$514.80	$858.00	—	—	40%
Diagnostic CT scan of the chest, no contrast dye CPT 71250 CT CHEST DIAG WO CONT	$565.20	$942.00	—	32% below	40%
Diagnostic CT scan of the chest, no contrast dye inpatient CPT 71250 CT CHEST DIAG WO CONT	$565.20	$942.00	—	—	40%
Diagnostic CT scan of the chest, with contrast dye CPT 71260 CT CHEST DIAG W CONT	$767.40	$1,279.00	—	18% below	40%
Diagnostic CT scan of the chest, with contrast dye inpatient CPT 71260 CT CHEST DIAG W CONT	$767.40	$1,279.00	—	—	40%
Diagnostic mammogram, both breasts both sides CPT 77066 MAMM DIAGNOSTIC BILAT W CAD	$378.60	$631.00	—	—	40%
Diagnostic mammogram, both breasts inpatient both sides CPT 77066 MAMM DIAGNOSTIC BILAT W CAD	$378.60	$631.00	—	—	40%
Diagnostic mammogram, one breast one side CPT 77065 MAMM DIAGNOSTIC UNILAT LT W CAD	$297.00	$495.00	—	33% above	40%
Diagnostic mammogram, one breast one side CPT 77065 MAMM DIAGNOSTIC UNILAT RT W CAD	$297.00	$495.00	—	33% above	40%
Diagnostic mammogram, one breast inpatient one side CPT 77065 MAMM DIAGNOSTIC UNILAT RT W CAD	$297.00	$495.00	—	—	40%
Diagnostic mammogram, one breast inpatient one side CPT 77065 MAMM DIAGNOSTIC UNILAT LT W CAD	$297.00	$495.00	—	—	40%
Duplex ultrasound of the leg arteries, both legs both sides CPT 93925 ART LWR EXTR DUPLEX GRAFT COMP BI	$1,691.40	$2,819.00	—	—	40%
Duplex ultrasound of the leg arteries, both legs inpatient both sides CPT 93925 ART LWR EXTR DUPLEX GRAFT COMP BI	$1,691.40	$2,819.00	—	—	40%
Duplex ultrasound of the leg veins, both legs both sides CPT 93970 VENOUS DUPLEX LOWER EXT COMP BI	$1,691.40	$2,819.00	—	—	40%
Duplex ultrasound of the leg veins, both legs both sides CPT 93970 VENOUS DUPLEX UPPER EXT COMP BI	$1,691.40	$2,819.00	—	—	40%
Duplex ultrasound of the leg veins, both legs inpatient both sides CPT 93970 VENOUS DUPLEX UPPER EXT COMP BI	$1,691.40	$2,819.00	—	—	40%
Duplex ultrasound of the leg veins, both legs inpatient both sides CPT 93970 VENOUS DUPLEX LOWER EXT COMP BI	$1,691.40	$2,819.00	—	—	40%
Echocardiogram through the chest wall, complete, with Doppler CPT 93306 ECHO 2D W/M-MODE & DOPP COMP	$1,167.00	$1,945.00	—	29% below	40%
Echocardiogram through the chest wall, complete, with Doppler inpatient CPT 93306 ECHO 2D W/M-MODE & DOPP COMP	$1,167.00	$1,945.00	—	—	40%
Elbow X-ray, 2 views one side CPT 73070 XR ELBOW 2 VIEWS LT	$231.60	$386.00	—	40% above	40%
Elbow X-ray, 2 views one side CPT 73070 XR ELBOW 2 VIEWS RT	$231.60	$386.00	—	40% above	40%
Elbow X-ray, 2 views inpatient one side CPT 73070 XR ELBOW 2 VIEWS RT	$231.60	$386.00	—	—	40%
Elbow X-ray, 2 views inpatient one side CPT 73070 XR ELBOW 2 VIEWS LT	$231.60	$386.00	—	—	40%
Elbow X-ray, complete, 3 or more views one side CPT 73080 XR ELBOW COMPLETE MIN 3 VIEWS RT	$264.00	$440.00	—	3% above	40%
Elbow X-ray, complete, 3 or more views one side CPT 73080 XR ELBOW COMPLETE MIN 3 VIEWS LT	$264.00	$440.00	—	3% above	40%
Elbow X-ray, complete, 3 or more views inpatient one side CPT 73080 XR ELBOW COMPLETE MIN 3 VIEWS LT	$264.00	$440.00	—	—	40%
Elbow X-ray, complete, 3 or more views inpatient one side CPT 73080 XR ELBOW COMPLETE MIN 3 VIEWS RT	$264.00	$440.00	—	—	40%
Eye socket (orbit) CT scan without contrast CPT 70480 CT ORBIT/SELLA/IAC/FOSSA WO CONT	$674.40	$1,124.00	—	21% below	40%
Eye socket (orbit) CT scan without contrast inpatient CPT 70480 CT ORBIT/SELLA/IAC/FOSSA WO CONT	$674.40	$1,124.00	—	—	40%
Facial bones X-ray, complete, 3 or more views CPT 70150 XR FACIAL BONES COMP MIN 3 VIEWS	$376.80	$628.00	—	38% above	40%
Facial bones X-ray, complete, 3 or more views inpatient CPT 70150 XR FACIAL BONES COMP MIN 3 VIEWS	$376.80	$628.00	—	—	40%
Forearm X-ray (radius and ulna), 2 views one side CPT 73090 XR FOREARM 2 VIEWS RT	$235.20	$392.00	—	28% above	40%
Forearm X-ray (radius and ulna), 2 views one side CPT 73090 XR FOREARM 2 VIEWS LT	$235.20	$392.00	—	28% above	40%
Forearm X-ray (radius and ulna), 2 views inpatient one side CPT 73090 XR FOREARM 2 VIEWS RT	$235.20	$392.00	—	—	40%
Forearm X-ray (radius and ulna), 2 views inpatient one side CPT 73090 XR FOREARM 2 VIEWS LT	$235.20	$392.00	—	—	40%
HIDA scan: nuclear imaging of the liver, bile ducts and gallbladder CPT 78226 NM HEPATOBILIARY SYSTEM	$3,000.00	$5,000.00	—	128% above	40%
HIDA scan: nuclear imaging of the liver, bile ducts and gallbladder inpatient CPT 78226 NM HEPATOBILIARY SYSTEM	$3,000.00	$5,000.00	—	—	40%
Hand X-ray, 2 views one side CPT 73120 XR HAND 2 VIEWS RIGHT	$253.80	$423.00	—	48% above	40%
Hand X-ray, 2 views one side CPT 73120 XR HAND 2 VIEWS LEFT	$253.80	$423.00	—	48% above	40%
Hand X-ray, 2 views inpatient one side CPT 73120 XR HAND 2 VIEWS LEFT	$253.80	$423.00	—	—	40%
Hand X-ray, 2 views inpatient one side CPT 73120 XR HAND 2 VIEWS RIGHT	$253.80	$423.00	—	—	40%
Heel bone (calcaneus) X-ray, 2 or more views one side CPT 73650 XR CALCANEUS MIN 2V RT	$228.00	$380.00	—	7% above	40%
Heel bone (calcaneus) X-ray, 2 or more views one side CPT 73650 XR CALCANEUS MIN 2V LT	$228.00	$380.00	—	7% above	40%
Heel bone (calcaneus) X-ray, 2 or more views inpatient one side CPT 73650 XR CALCANEUS MIN 2V RT	$228.00	$380.00	—	—	40%
Heel bone (calcaneus) X-ray, 2 or more views inpatient one side CPT 73650 XR CALCANEUS MIN 2V LT	$228.00	$380.00	—	—	40%
Home sleep apnea test, unattended, recording breathing and oxygen CPT 95806 SLEEP STUDY UNATTENDED	$337.20	$562.00	—	18% below	40%
Home sleep apnea test, unattended, recording breathing and oxygen inpatient CPT 95806 SLEEP STUDY UNATTENDED	$337.20	$562.00	—	—	40%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 POLYSOM ATTENDED W CPAP/BIP 6/> YRS	$2,166.60	$3,611.00	—	33% below	40%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 POLYSOM ATTENDED W CPAP/BIP 6/> YRS	$2,166.60	$3,611.00	—	—	40%
Knee X-ray, 3 views one side CPT 73562 XR KNEE 3 VIEWS RIGHT	$343.80	$573.00	—	50% above	40%
Knee X-ray, 3 views one side CPT 73562 XR KNEE 3 VIEWS LEFT	$343.80	$573.00	—	50% above	40%
Knee X-ray, 3 views inpatient one side CPT 73562 XR KNEE 3 VIEWS RIGHT	$343.80	$573.00	—	—	40%
Knee X-ray, 3 views inpatient one side CPT 73562 XR KNEE 3 VIEWS LEFT	$343.80	$573.00	—	—	40%
Knee X-ray, complete, 4 or more views one side CPT 73564 XR KNEE COMPLETE MIN 4V LT	$387.60	$646.00	—	48% above	40%
Knee X-ray, complete, 4 or more views one side CPT 73564 XR KNEE COMPLETE MIN 4V RT	$387.60	$646.00	—	48% above	40%
Knee X-ray, complete, 4 or more views inpatient one side CPT 73564 XR KNEE COMPLETE MIN 4V RT	$387.60	$646.00	—	—	40%
Knee X-ray, complete, 4 or more views inpatient one side CPT 73564 XR KNEE COMPLETE MIN 4V LT	$387.60	$646.00	—	—	40%
Leg CT scan without contrast (hip to foot, any part) one side CPT 73700 CT EXTREMITY LOWER WO CONT RT	$567.00	$945.00	—	28% below	40%
Leg CT scan without contrast (hip to foot, any part) one side CPT 73700 CT EXTREMITY LOWER WO CONT LT	$567.00	$945.00	—	28% below	40%
Leg CT scan without contrast (hip to foot, any part) inpatient one side CPT 73700 CT EXTREMITY LOWER WO CONT RT	$567.00	$945.00	—	—	40%
Leg CT scan without contrast (hip to foot, any part) inpatient one side CPT 73700 CT EXTREMITY LOWER WO CONT LT	$567.00	$945.00	—	—	40%
Limited abdominal ultrasound of one organ or area, such as the gallbladder CPT 76705 US ABDOMEN LIMITED	$360.00	$600.00	—	21% below	40%
Limited abdominal ultrasound of one organ or area, such as the gallbladder inpatient CPT 76705 US ABDOMEN LIMITED	$360.00	$600.00	—	—	40%
Limited ultrasound of an arm or leg (non-vascular) one side CPT 76882 US EXTREM NONVASCULAR LIMITED RT	$55.20	$92.00	—	82% below	40%
Limited ultrasound of an arm or leg (non-vascular) one side CPT 76882 US EXTREM NONVASCULAR LIMITED LT	$55.20	$92.00	—	82% below	40%
Limited ultrasound of an arm or leg (non-vascular) inpatient one side CPT 76882 US EXTREM NONVASCULAR LIMITED LT	$55.20	$92.00	—	—	40%
Limited ultrasound of an arm or leg (non-vascular) inpatient one side CPT 76882 US EXTREM NONVASCULAR LIMITED RT	$55.20	$92.00	—	—	40%
Low-dose CT of the chest for lung cancer screening, no contrast dye CPT 71271 CT THORAX LUNG CANCER SCREEN	$595.20	$992.00	—	213% above	40%
Low-dose CT of the chest for lung cancer screening, no contrast dye inpatient CPT 71271 CT THORAX LUNG CANCER SCREEN	$595.20	$992.00	—	—	40%
Lower leg X-ray (tibia and fibula), 2 views one side CPT 73590 XR TIBIA AND FIBULA 2V RT	$260.40	$434.00	—	31% above	40%
Lower leg X-ray (tibia and fibula), 2 views one side CPT 73590 XR TIBIA AND FIBULA 2V LT	$260.40	$434.00	—	31% above	40%
Lower leg X-ray (tibia and fibula), 2 views inpatient one side CPT 73590 XR TIBIA AND FIBULA 2V LT	$260.40	$434.00	—	—	40%
Lower leg X-ray (tibia and fibula), 2 views inpatient one side CPT 73590 XR TIBIA AND FIBULA 2V RT	$260.40	$434.00	—	—	40%
MR angiography (MRA) of the head without contrast CPT 70544 MRA HEAD WO CONT	$1,686.00	$2,810.00	—	51% above	40%
MR angiography (MRA) of the head without contrast inpatient CPT 70544 MRA HEAD WO CONT	$1,686.00	$2,810.00	—	—	40%
MRI of knee or other lower-limb joint, no contrast dye one side CPT 73721 MRI EXTR LWR JT WO CONT LT	$1,474.20	$2,457.00	—	43% above	40%
MRI of knee or other lower-limb joint, no contrast dye one side CPT 73721 MRI EXTR LWR JT WO CONT RT	$1,474.20	$2,457.00	—	43% above	40%
MRI of knee or other lower-limb joint, no contrast dye inpatient one side CPT 73721 MRI EXTR LWR JT WO CONT LT	$1,474.20	$2,457.00	—	—	40%
MRI of knee or other lower-limb joint, no contrast dye inpatient one side CPT 73721 MRI EXTR LWR JT WO CONT RT	$1,474.20	$2,457.00	—	—	40%
MRI of knee or other lower-limb joint, without and then with contrast dye one side CPT 73723 MRI EXTR LWR JT W/WO CONT RT	$3,052.80	$5,088.00	—	111% above	40%
MRI of knee or other lower-limb joint, without and then with contrast dye one side CPT 73723 MRI EXTR LWR JT W/WO CONT LT	$3,052.80	$5,088.00	—	111% above	40%
MRI of knee or other lower-limb joint, without and then with contrast dye inpatient one side CPT 73723 MRI EXTR LWR JT W/WO CONT RT	$3,052.80	$5,088.00	—	—	40%
MRI of knee or other lower-limb joint, without and then with contrast dye inpatient one side CPT 73723 MRI EXTR LWR JT W/WO CONT LT	$3,052.80	$5,088.00	—	—	40%
MRI of the abdomen without contrast CPT 74181 MRI ABDOMEN WO CONT	$1,363.20	$2,272.00	—	28% above	40%
MRI of the abdomen without contrast inpatient CPT 74181 MRI ABDOMEN WO CONT	$1,363.20	$2,272.00	—	—	40%
MRI of the abdomen, without and then with contrast dye CPT 74183 MRI ABDOMEN W/WO CONT	$2,521.80	$4,203.00	—	60% above	40%
MRI of the abdomen, without and then with contrast dye inpatient CPT 74183 MRI ABDOMEN W/WO CONT	$2,521.80	$4,203.00	—	—	40%
MRI of the brain, no contrast dye CPT 70551 MRI BRAIN WO CONT	$1,347.00	$2,245.00	—	32% above	40%
MRI of the brain, no contrast dye inpatient CPT 70551 MRI BRAIN WO CONT	$1,347.00	$2,245.00	—	—	40%
MRI of the brain, with and without contrast dye CPT 70553 MRI BRAIN W/WO CONT	$2,256.60	$3,761.00	—	73% above	40%
MRI of the brain, with and without contrast dye inpatient CPT 70553 MRI BRAIN W/WO CONT	$2,256.60	$3,761.00	—	—	40%
MRI of the lower back, no contrast dye CPT 72148 MRI LUMBAR SPINE WO CONT	$1,296.00	$2,160.00	—	27% above	40%
MRI of the lower back, no contrast dye inpatient CPT 72148 MRI LUMBAR SPINE WO CONT	$1,296.00	$2,160.00	—	—	40%
MRI of the lower back, without and then with contrast dye CPT 72158 MRI LUMBAR SPINE W/WO CONT	$2,266.80	$3,778.00	—	55% above	40%
MRI of the lower back, without and then with contrast dye inpatient CPT 72158 MRI LUMBAR SPINE W/WO CONT	$2,266.80	$3,778.00	—	—	40%
MRI of the mid back (thoracic spine), no contrast dye CPT 72146 MRI THORACIC SPINE WO CONT	$1,289.40	$2,149.00	—	28% above	40%
MRI of the mid back (thoracic spine), no contrast dye inpatient CPT 72146 MRI THORACIC SPINE WO CONT	$1,289.40	$2,149.00	—	—	40%
MRI of the neck (cervical spine) without and with contrast CPT 72156 MRI CERVICAL SPINE W/WO CONT	$2,274.00	$3,790.00	—	55% above	40%
MRI of the neck (cervical spine) without and with contrast inpatient CPT 72156 MRI CERVICAL SPINE W/WO CONT	$2,274.00	$3,790.00	—	—	40%
MRI of the neck (cervical spine), no contrast dye CPT 72141 MRI CERVICAL SPINE WO CONT	$1,289.40	$2,149.00	—	24% above	40%
MRI of the neck (cervical spine), no contrast dye inpatient CPT 72141 MRI CERVICAL SPINE WO CONT	$1,289.40	$2,149.00	—	—	40%
MRI of the pelvis without and with contrast CPT 72197 MRI PELVIS W/WO CONT	$2,508.00	$4,180.00	—	72% above	40%
MRI of the pelvis without and with contrast inpatient CPT 72197 MRI PELVIS W/WO CONT	$2,508.00	$4,180.00	—	—	40%
MRI of the pelvis, no contrast dye CPT 72195 MRI PELVIS WO CONT	$1,712.40	$2,854.00	—	63% above	40%
MRI of the pelvis, no contrast dye inpatient CPT 72195 MRI PELVIS WO CONT	$1,712.40	$2,854.00	—	—	40%
MRI of the shoulder, elbow or wrist joint, no contrast dye one side CPT 73221 MRI EXTR UPPR JT WO CONT RT	$1,474.20	$2,457.00	—	38% above	40%
MRI of the shoulder, elbow or wrist joint, no contrast dye one side CPT 73221 MRI EXTR UPPR JT WO CONT LT	$1,474.20	$2,457.00	—	38% above	40%
MRI of the shoulder, elbow or wrist joint, no contrast dye inpatient one side CPT 73221 MRI EXTR UPPR JT WO CONT LT	$1,474.20	$2,457.00	—	—	40%
MRI of the shoulder, elbow or wrist joint, no contrast dye inpatient one side CPT 73221 MRI EXTR UPPR JT WO CONT RT	$1,474.20	$2,457.00	—	—	40%
Neck (cervical spine) X-ray, 4 or 5 views CPT 72050 XR SPINE CERVICAL 4 OR 5 VIEWS	$438.00	$730.00	—	26% above	40%
Neck (cervical spine) X-ray, 4 or 5 views inpatient CPT 72050 XR SPINE CERVICAL 4 OR 5 VIEWS	$438.00	$730.00	—	—	40%
Neck soft tissue CT scan with contrast CPT 70491 CT SOFT TISSUE NECK W CONT	$821.40	$1,369.00	—	16% below	40%
Neck soft tissue CT scan with contrast inpatient CPT 70491 CT SOFT TISSUE NECK W CONT	$821.40	$1,369.00	—	—	40%
Neck soft tissue CT scan without contrast CPT 70490 CT SOFT TISSUE NECK WO CONT	$617.40	$1,029.00	—	26% below	40%
Neck soft tissue CT scan without contrast inpatient CPT 70490 CT SOFT TISSUE NECK WO CONT	$617.40	$1,029.00	—	—	40%
Neck soft tissue X-ray CPT 70360 XR SOFT TISSUE NECK	$231.60	$386.00	—	34% above	40%
Neck soft tissue X-ray inpatient CPT 70360 XR SOFT TISSUE NECK	$231.60	$386.00	—	—	40%
Nuclear stress test imaging (SPECT), rest and stress studies CPT 78452 MYCRD PERF W WALL MOT&EJEC FRT MULT	$4,056.00	$6,760.00	—	5% above	40%
Nuclear stress test imaging (SPECT), rest and stress studies inpatient CPT 78452 MYCRD PERF W WALL MOT&EJEC FRT MULT	$4,056.00	$6,760.00	—	—	40%
PET/CT scan from the base of the skull to mid-thigh CPT 78815 NM PET IMAG W CT SKL BASE MID THG	$3,453.00	$5,755.00	—	15% below	40%
PET/CT scan from the base of the skull to mid-thigh inpatient CPT 78815 NM PET IMAG W CT SKL BASE MID THG	$3,453.00	$5,755.00	—	—	40%
Pelvic CT scan without contrast CPT 72192 CT PELVIS WO CONT	$563.40	$939.00	—	32% below	40%
Pelvic CT scan without contrast inpatient CPT 72192 CT PELVIS WO CONT	$563.40	$939.00	—	—	40%
Pelvic ultrasound (not pregnancy), limited or follow-up CPT 76857 US PELVIC NON OB LIMITED F/U	$151.20	$252.00	—	58% below	40%
Pelvic ultrasound (not pregnancy), limited or follow-up inpatient CPT 76857 US PELVIC NON OB LIMITED F/U	$151.20	$252.00	—	—	40%
Pelvic ultrasound through the belly, complete (not pregnancy) CPT 76856 US PELVIC NON OB COMPLETE	$437.40	$729.00	—	6% below	40%
Pelvic ultrasound through the belly, complete (not pregnancy) inpatient CPT 76856 US PELVIC NON OB COMPLETE	$437.40	$729.00	—	—	40%
Pregnancy ultrasound after 14 weeks, one baby CPT 76805 US PREG UTER 14 WKS OR>	$530.40	$884.00	—	4% below	40%
Pregnancy ultrasound after 14 weeks, one baby inpatient CPT 76805 US PREG UTER 14 WKS OR>	$530.40	$884.00	—	—	40%
Pregnancy ultrasound before 14 weeks, through the belly, one baby CPT 76801 US PREG UTER <14 WEEKS GEST	$425.40	$709.00	—	17% below	40%
Pregnancy ultrasound before 14 weeks, through the belly, one baby inpatient CPT 76801 US PREG UTER <14 WEEKS GEST	$425.40	$709.00	—	—	40%
Pregnancy ultrasound, limited (heartbeat, position, fluid) CPT 76815 US PREG UTER LTD 1 OR MORE FETUS	$301.80	$503.00	—	21% below	40%
Pregnancy ultrasound, limited (heartbeat, position, fluid) inpatient CPT 76815 US PREG UTER LTD 1 OR MORE FETUS	$301.80	$503.00	—	—	40%
Rib X-ray, one side, 2 views one side CPT 71100 XR RIBS 2 VIEWS LT	$285.60	$476.00	—	40% above	40%
Rib X-ray, one side, 2 views one side CPT 71100 XR RIBS 2 VIEWS RT	$285.60	$476.00	—	40% above	40%
Rib X-ray, one side, 2 views inpatient one side CPT 71100 XR RIBS 2 VIEWS LT	$285.60	$476.00	—	—	40%
Rib X-ray, one side, 2 views inpatient one side CPT 71100 XR RIBS 2 VIEWS RT	$285.60	$476.00	—	—	40%
Rib X-ray, one side, with a chest view, 3 or more views one side CPT 71101 XR RIBS RT W CHEST PA MIN 3 VWS	$321.60	$536.00	—	32% above	40%
Rib X-ray, one side, with a chest view, 3 or more views one side CPT 71101 XR RIBS LT W CHEST PA MIN 3 VWS	$321.60	$536.00	—	32% above	40%
Rib X-ray, one side, with a chest view, 3 or more views inpatient one side CPT 71101 XR RIBS LT W CHEST PA MIN 3 VWS	$321.60	$536.00	—	—	40%
Rib X-ray, one side, with a chest view, 3 or more views inpatient one side CPT 71101 XR RIBS RT W CHEST PA MIN 3 VWS	$321.60	$536.00	—	—	40%
Screening mammogram, both breasts both sides CPT 77067 MAMM SCRN BILATERAL W CAD	$313.80	$523.00	—	—	40%
Screening mammogram, both breasts both sides CPT 77067 MAMM SCRN BILAT IMPLANT W CAD	$313.80	$523.00	—	—	40%
Screening mammogram, both breasts inpatient both sides CPT 77067 MAMM SCRN BILAT IMPLANT W CAD	$313.80	$523.00	—	—	40%
Screening mammogram, both breasts inpatient both sides CPT 77067 MAMM SCRN BILATERAL W CAD	$313.80	$523.00	—	—	40%
Shoulder X-ray, complete, 2 or more views one side CPT 73030 XR SHOULDER COMPLETE MIN 2V RT	$279.00	$465.00	—	33% above	40%
Shoulder X-ray, complete, 2 or more views one side CPT 73030 XR SHOULDER COMPLETE MIN 2V LT	$279.00	$465.00	—	33% above	40%
Shoulder X-ray, complete, 2 or more views inpatient one side CPT 73030 XR SHOULDER COMPLETE MIN 2V LT	$279.00	$465.00	—	—	40%
Shoulder X-ray, complete, 2 or more views inpatient one side CPT 73030 XR SHOULDER COMPLETE MIN 2V RT	$279.00	$465.00	—	—	40%
Sinus X-ray, complete, 3 or more views CPT 70220 XR SINUSES PARANASAL COMP MIN 3V	$297.00	$495.00	—	5% above	40%
Sinus X-ray, complete, 3 or more views inpatient CPT 70220 XR SINUSES PARANASAL COMP MIN 3V	$297.00	$495.00	—	—	40%
Skull X-ray, fewer than 4 views CPT 70250 XR SKULL <4 VIEWS	$297.00	$495.00	—	28% above	40%
Skull X-ray, fewer than 4 views inpatient CPT 70250 XR SKULL <4 VIEWS	$297.00	$495.00	—	—	40%
Sleep study in a lab (polysomnography) CPT 95810 POLYSOM ATTENDED >3 CHN 6/> YRS	$2,166.60	$3,611.00	—	18% below	40%
Sleep study in a lab (polysomnography) inpatient CPT 95810 POLYSOM ATTENDED >3 CHN 6/> YRS	$2,166.60	$3,611.00	—	—	40%
Stress echocardiogram, complete, including the stress test and supervision CPT 93351 ECHO STRESS W CONT ECG MONITOR	$1,167.00	$1,945.00	—	35% below	40%
Stress echocardiogram, complete, including the stress test and supervision inpatient CPT 93351 ECHO STRESS W CONT ECG MONITOR	$1,167.00	$1,945.00	—	—	40%
Swallow study (modified barium swallow, video X-ray) CPT 74230 XR SWALLOWING FUNCTION W VIDEO	$1,027.80	$1,713.00	—	184% above	40%
Swallow study (modified barium swallow, video X-ray) inpatient CPT 74230 XR SWALLOWING FUNCTION W VIDEO	$1,027.80	$1,713.00	—	—	40%
Thigh bone (femur) X-ray, 2 or more views one side CPT 73552 XR FEMUR 2 VW LEFT	$293.40	$489.00	—	46% above	40%
Thigh bone (femur) X-ray, 2 or more views one side CPT 73552 XR FEMUR 2 VW RIGHT	$293.40	$489.00	—	46% above	40%
Thigh bone (femur) X-ray, 2 or more views inpatient one side CPT 73552 XR FEMUR 2 VW RIGHT	$293.40	$489.00	—	—	40%
Thigh bone (femur) X-ray, 2 or more views inpatient one side CPT 73552 XR FEMUR 2 VW LEFT	$293.40	$489.00	—	—	40%
Thoracic spine (mid back) CT scan without contrast CPT 72128 CT THORACIC SPINE WO CONT	$569.40	$949.00	—	33% below	40%
Thoracic spine (mid back) CT scan without contrast inpatient CPT 72128 CT THORACIC SPINE WO CONT	$569.40	$949.00	—	—	40%
Toe X-ray, 2 or more views one side CPT 73660 XR TOE/S MIN 2V LT	$249.60	$416.00	—	63% above	40%
Toe X-ray, 2 or more views one side CPT 73660 XR TOE/S MIN 2V RT	$249.60	$416.00	—	63% above	40%
Toe X-ray, 2 or more views inpatient one side CPT 73660 XR TOE/S MIN 2V LT	$249.60	$416.00	—	—	40%
Toe X-ray, 2 or more views inpatient one side CPT 73660 XR TOE/S MIN 2V RT	$249.60	$416.00	—	—	40%
Transvaginal pelvic ultrasound CPT 76830 US TRANSVAGINAL NON OB	$520.20	$867.00	—	28% above	40%
Transvaginal pelvic ultrasound inpatient CPT 76830 US TRANSVAGINAL NON OB	$520.20	$867.00	—	—	40%
Transvaginal ultrasound during pregnancy CPT 76817 US PREG UTER TRANSVAGINAL	$341.40	$569.00	—	8% below	40%
Transvaginal ultrasound during pregnancy inpatient CPT 76817 US PREG UTER TRANSVAGINAL	$341.40	$569.00	—	—	40%
Ultrasound of the abdomen, complete CPT 76700 US ABDOMEN COMPLETE	$470.40	$784.00	—	10% below	40%
Ultrasound of the abdomen, complete inpatient CPT 76700 US ABDOMEN COMPLETE	$470.40	$784.00	—	—	40%
Ultrasound of the scrotum and testicles CPT 76870 US SCROTUM AND CONTENTS	$423.60	$706.00	—	at median	40%
Ultrasound of the scrotum and testicles inpatient CPT 76870 US SCROTUM AND CONTENTS	$423.60	$706.00	—	—	40%
Ultrasound of the soft tissues of the head and neck, such as the thyroid CPT 76536 US HEAD/NECK SOFT TISSUE	$504.60	$841.00	—	18% above	40%
Ultrasound of the soft tissues of the head and neck, such as the thyroid inpatient CPT 76536 US HEAD/NECK SOFT TISSUE	$504.60	$841.00	—	—	40%
Upper GI series (X-ray of esophagus, stomach and duodenum with contrast) CPT 74240 XR UPPER GI SINGLE CONTRAST	$873.00	$1,455.00	—	67% above	40%
Upper GI series (X-ray of esophagus, stomach and duodenum with contrast) inpatient CPT 74240 XR UPPER GI SINGLE CONTRAST	$873.00	$1,455.00	—	—	40%
Upper arm X-ray (humerus), 2 views one side CPT 73060 XR HUMERUS MIN 2 VIEWS LT	$264.00	$440.00	—	38% above	40%
Upper arm X-ray (humerus), 2 views one side CPT 73060 XR HUMERUS MIN 2 VIEWS RT	$264.00	$440.00	—	38% above	40%
Upper arm X-ray (humerus), 2 views inpatient one side CPT 73060 XR HUMERUS MIN 2 VIEWS RT	$264.00	$440.00	—	—	40%
Upper arm X-ray (humerus), 2 views inpatient one side CPT 73060 XR HUMERUS MIN 2 VIEWS LT	$264.00	$440.00	—	—	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study one side CPT 93971 VENOUS DUPLEX UPPER EXT LTD RT	$774.00	$1,290.00	—	22% above	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study one side CPT 93971 VENOUS DUPLEX UPPER EXT LTD LT	$774.00	$1,290.00	—	22% above	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study one side CPT 93971 VENOUS DUPLEX LOWER EXT LTD RT	$774.00	$1,290.00	—	22% above	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study one side CPT 93971 VENOUS DUPLEX LOWER EXT LTD LT	$774.00	$1,290.00	—	22% above	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study inpatient one side CPT 93971 VENOUS DUPLEX LOWER EXT LTD RT	$774.00	$1,290.00	—	—	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study inpatient one side CPT 93971 VENOUS DUPLEX UPPER EXT LTD LT	$774.00	$1,290.00	—	—	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study inpatient one side CPT 93971 VENOUS DUPLEX UPPER EXT LTD RT	$774.00	$1,290.00	—	—	40%
Vein ultrasound (duplex) of one arm or leg, or a limited study inpatient one side CPT 93971 VENOUS DUPLEX LOWER EXT LTD LT	$774.00	$1,290.00	—	—	40%
Wrist X-ray, 2 views one side CPT 73100 XR WRIST 2 VIEWS LEFT	$282.00	$470.00	—	80% above	40%
Wrist X-ray, 2 views one side CPT 73100 XR WRIST 2 VIEWS RIGHT	$282.00	$470.00	—	80% above	40%
Wrist X-ray, 2 views inpatient one side CPT 73100 XR WRIST 2 VIEWS LEFT	$282.00	$470.00	—	—	40%
Wrist X-ray, 2 views inpatient one side CPT 73100 XR WRIST 2 VIEWS RIGHT	$282.00	$470.00	—	—	40%
Wrist X-ray, complete, 3 or more views one side CPT 73110 XR WRIST COMPLETE MIN 3V RT	$354.60	$591.00	—	39% above	40%
Wrist X-ray, complete, 3 or more views one side CPT 73110 XR WRIST COMPLETE MIN 3V LT	$354.60	$591.00	—	39% above	40%
Wrist X-ray, complete, 3 or more views inpatient one side CPT 73110 XR WRIST COMPLETE MIN 3V RT	$354.60	$591.00	—	—	40%
Wrist X-ray, complete, 3 or more views inpatient one side CPT 73110 XR WRIST COMPLETE MIN 3V LT	$354.60	$591.00	—	—	40%
X-ray of one hip, 2 or 3 views, with the pelvis when included one side CPT 73502 XR HIP W PELVIS 2-3 VIEWS LT	$394.80	$658.00	—	49% above	40%
X-ray of one hip, 2 or 3 views, with the pelvis when included one side CPT 73502 XR HIP W PELVIS 2-3 VIEWS RT	$394.80	$658.00	—	49% above	40%
X-ray of one hip, 2 or 3 views, with the pelvis when included inpatient one side CPT 73502 XR HIP W PELVIS 2-3 VIEWS RT	$394.80	$658.00	—	—	40%
X-ray of one hip, 2 or 3 views, with the pelvis when included inpatient one side CPT 73502 XR HIP W PELVIS 2-3 VIEWS LT	$394.80	$658.00	—	—	40%
X-ray of the abdomen, 1 view CPT 74018 XR ABDOMEN 1 VIEW	$214.80	$358.00	—	1% below	40%
X-ray of the abdomen, 1 view inpatient CPT 74018 XR ABDOMEN 1 VIEW	$214.80	$358.00	—	—	40%
X-ray of the ankle, 2 views one side CPT 73600 XR ANKLE 2 VIEWS LEFT	$267.60	$446.00	—	67% above	40%
X-ray of the ankle, 2 views one side CPT 73600 XR ANKLE 2 VIEWS RIGHT	$267.60	$446.00	—	67% above	40%
X-ray of the ankle, 2 views inpatient one side CPT 73600 XR ANKLE 2 VIEWS LEFT	$267.60	$446.00	—	—	40%
X-ray of the ankle, 2 views inpatient one side CPT 73600 XR ANKLE 2 VIEWS RIGHT	$267.60	$446.00	—	—	40%
X-ray of the finger(s), 2 or more views one side CPT 73140 XR FINGER/S MIN 2 VIEWS LT	$340.20	$567.00	—	113% above	40%
X-ray of the finger(s), 2 or more views one side CPT 73140 XR FINGER/S MIN 2 VIEWS RT	$340.20	$567.00	—	113% above	40%
X-ray of the finger(s), 2 or more views inpatient one side CPT 73140 XR FINGER/S MIN 2 VIEWS LT	$340.20	$567.00	—	—	40%
X-ray of the finger(s), 2 or more views inpatient one side CPT 73140 XR FINGER/S MIN 2 VIEWS RT	$340.20	$567.00	—	—	40%
X-ray of the foot, 2 views one side CPT 73620 XR FOOT 2 VIEWS RIGHT	$228.00	$380.00	—	39% above	40%
X-ray of the foot, 2 views one side CPT 73620 XR FOOT 2 VIEWS LEFT	$228.00	$380.00	—	39% above	40%
X-ray of the foot, 2 views inpatient one side CPT 73620 XR FOOT 2 VIEWS LEFT	$228.00	$380.00	—	—	40%
X-ray of the foot, 2 views inpatient one side CPT 73620 XR FOOT 2 VIEWS RIGHT	$228.00	$380.00	—	—	40%
X-ray of the foot, complete, 3 or more views one side CPT 73630 XR FOOT COMPLETE MIN 3V RT	$285.60	$476.00	—	42% above	40%
X-ray of the foot, complete, 3 or more views one side CPT 73630 XR FOOT COMPLETE MIN 3V LT	$285.60	$476.00	—	42% above	40%
X-ray of the foot, complete, 3 or more views inpatient one side CPT 73630 XR FOOT COMPLETE MIN 3V LT	$285.60	$476.00	—	—	40%
X-ray of the foot, complete, 3 or more views inpatient one side CPT 73630 XR FOOT COMPLETE MIN 3V RT	$285.60	$476.00	—	—	40%
X-ray of the hand, 3 or more views one side CPT 73130 XR HAND COMPLETE MIN 3V LT	$310.80	$518.00	—	54% above	40%
X-ray of the hand, 3 or more views one side CPT 73130 XR HAND COMPLETE MIN 3V RT	$310.80	$518.00	—	54% above	40%
X-ray of the hand, 3 or more views inpatient one side CPT 73130 XR HAND COMPLETE MIN 3V RT	$310.80	$518.00	—	—	40%
X-ray of the hand, 3 or more views inpatient one side CPT 73130 XR HAND COMPLETE MIN 3V LT	$310.80	$518.00	—	—	40%
X-ray of the knee, 1 or 2 views one side CPT 73560 XR KNEE 1 OR 2 VIEWS RIGHT	$285.60	$476.00	—	37% above	40%
X-ray of the knee, 1 or 2 views one side CPT 73560 XR KNEE 1 OR 2 VIEWS LEFT	$285.60	$476.00	—	37% above	40%
X-ray of the knee, 1 or 2 views inpatient one side CPT 73560 XR KNEE 1 OR 2 VIEWS LEFT	$285.60	$476.00	—	—	40%
X-ray of the knee, 1 or 2 views inpatient one side CPT 73560 XR KNEE 1 OR 2 VIEWS RIGHT	$285.60	$476.00	—	—	40%
X-ray of the lower back (lumbar spine), 2 or 3 views CPT 72100 XR SPINE LUMBAR 2 OR 3 VIEWS	$318.60	$531.00	—	27% above	40%
X-ray of the lower back (lumbar spine), 2 or 3 views inpatient CPT 72100 XR SPINE LUMBAR 2 OR 3 VIEWS	$318.60	$531.00	—	—	40%
X-ray of the lower back, 4 or more views CPT 72110 XR SPINE LUMBAR MIN 4 VIEWS	$423.60	$706.00	—	22% above	40%
X-ray of the lower back, 4 or more views inpatient CPT 72110 XR SPINE LUMBAR MIN 4 VIEWS	$423.60	$706.00	—	—	40%
X-ray of the mid back (thoracic spine), 2 views CPT 72070 XR SPINE THORACIC 2 VIEWS	$253.80	$423.00	—	9% above	40%
X-ray of the mid back (thoracic spine), 2 views inpatient CPT 72070 XR SPINE THORACIC 2 VIEWS	$253.80	$423.00	—	—	40%
X-ray of the nasal bones, 3 or more views CPT 70160 XR NASAL BONES COMP MIN 3 VIEWS	$325.80	$543.00	—	61% above	40%
X-ray of the nasal bones, 3 or more views inpatient CPT 70160 XR NASAL BONES COMP MIN 3 VIEWS	$325.80	$543.00	—	—	40%
X-ray of the neck (cervical spine), 2 or 3 views CPT 72040 XR SPINE CERVICAL 3 VIEWS OR LESS	$315.00	$525.00	—	26% above	40%
X-ray of the neck (cervical spine), 2 or 3 views inpatient CPT 72040 XR SPINE CERVICAL 3 VIEWS OR LESS	$315.00	$525.00	—	—	40%
X-ray of the pelvis, 1 or 2 views CPT 72170 XR PELVIS 1 OR 2 VIEWS	$213.00	$355.00	—	8% above	40%
X-ray of the pelvis, 1 or 2 views inpatient CPT 72170 XR PELVIS 1 OR 2 VIEWS	$213.00	$355.00	—	—	40%
X-ray of the tailbone (sacrum and coccyx), 2 or more views CPT 72220 XR SACRUM AND COCCYX MIN 2 VIEWS	$264.00	$440.00	—	21% above	40%
X-ray of the tailbone (sacrum and coccyx), 2 or more views inpatient CPT 72220 XR SACRUM AND COCCYX MIN 2 VIEWS	$264.00	$440.00	—	—	40%

Lab tests

Procedure	Cash price	List price	Insurers pay	vs Indiana	Off list
ACTH blood test CPT 82024 ACTH ADRENOCORTICOTROPIC HORMONE	$236.40	$394.00	—	5% below	40%
ACTH blood test inpatient CPT 82024 ACTH ADRENOCORTICOTROPIC HORMONE	$236.40	$394.00	—	—	40%
ALT (alanine aminotransferase) liver enzyme test CPT 84460 POC ALT SGPT	$18.00	$30.00	—	35% below	40%
ALT (alanine aminotransferase) liver enzyme test CPT 84460 ALT SGPT	$33.00	$55.00	—	20% above	40%
ALT (alanine aminotransferase) liver enzyme test inpatient CPT 84460 POC ALT SGPT	$18.00	$30.00	—	—	40%
ALT (alanine aminotransferase) liver enzyme test inpatient CPT 84460 ALT SGPT	$33.00	$55.00	—	—	40%
AST (aspartate aminotransferase) enzyme test CPT 84450 POC AST SGOT	$18.00	$30.00	—	38% below	40%
AST (aspartate aminotransferase) enzyme test CPT 84450 AST SGOT	$31.80	$53.00	—	10% above	40%
AST (aspartate aminotransferase) enzyme test inpatient CPT 84450 POC AST SGOT	$18.00	$30.00	—	—	40%
AST (aspartate aminotransferase) enzyme test inpatient CPT 84450 AST SGOT	$31.80	$53.00	—	—	40%
Acute hepatitis panel (hepatitis A, B and C) CPT 80074 HEPATITIS PANEL ACUTE	$291.60	$486.00	—	8% below	40%
Acute hepatitis panel (hepatitis A, B and C) inpatient CPT 80074 HEPATITIS PANEL ACUTE	$291.60	$486.00	—	—	40%
Albumin blood test CPT 82040 POC ALBUMIN SERUM	$18.00	$30.00	—	21% below	40%
Albumin blood test CPT 82040 ALBUMIN SERUM	$30.00	$50.00	—	32% above	40%
Albumin blood test inpatient CPT 82040 POC ALBUMIN SERUM	$18.00	$30.00	—	—	40%
Albumin blood test inpatient CPT 82040 ALBUMIN SERUM	$30.00	$50.00	—	—	40%
Aldosterone blood test CPT 82088 ALDOSTERONE SERUM	$249.60	$416.00	—	21% above	40%
Aldosterone blood test CPT 82088 ALDOSTERONE 24 HR URINE	$249.60	$416.00	—	21% above	40%
Aldosterone blood test inpatient CPT 82088 ALDOSTERONE 24 HR URINE	$249.60	$416.00	—	—	40%
Aldosterone blood test inpatient CPT 82088 ALDOSTERONE SERUM	$249.60	$416.00	—	—	40%
Alkaline phosphatase (ALP) blood test CPT 84075 POC ALKALINE PHOSPHATASE	$18.00	$30.00	—	44% below	40%
Alkaline phosphatase (ALP) blood test CPT 84075 ALKALINE PHOSPHATASE	$31.80	$53.00	—	1% below	40%
Alkaline phosphatase (ALP) blood test inpatient CPT 84075 POC ALKALINE PHOSPHATASE	$18.00	$30.00	—	—	40%
Alkaline phosphatase (ALP) blood test inpatient CPT 84075 ALKALINE PHOSPHATASE	$31.80	$53.00	—	—	40%
Allergy blood test, specific IgE, per allergen CPT 86003 ALLERGEN SPECIFIC IGE CRUDE EXTRACT EA	$32.40	$54.00	—	69% above	40%
Allergy blood test, specific IgE, per allergen inpatient CPT 86003 ALLERGEN SPECIFIC IGE CRUDE EXTRACT EA	$32.40	$54.00	—	—	40%
Alpha-fetoprotein (AFP) blood test CPT 82105 ALPHA FETOPROTEIN MATERNAL	$102.60	$171.00	—	1% above	40%
Alpha-fetoprotein (AFP) blood test CPT 82105 ALPHA FETOPROTEIN SERUM	$102.60	$171.00	—	1% above	40%
Alpha-fetoprotein (AFP) blood test inpatient CPT 82105 ALPHA FETOPROTEIN MATERNAL	$102.60	$171.00	—	—	40%
Alpha-fetoprotein (AFP) blood test inpatient CPT 82105 ALPHA FETOPROTEIN SERUM	$102.60	$171.00	—	—	40%
Ammonia blood test CPT 82140 AMMONIA	$89.40	$149.00	—	26% below	40%
Ammonia blood test inpatient CPT 82140 AMMONIA	$89.40	$149.00	—	—	40%
Amylase blood test CPT 82150 POC AMYLASE	$18.00	$30.00	—	65% below	40%
Amylase blood test CPT 82150 AMYLASE URINE	$39.60	$66.00	—	24% below	40%
Amylase blood test CPT 82150 AMYLASE FLUID	$39.60	$66.00	—	24% below	40%
Amylase blood test CPT 82150 AMYLASE SERUM	$39.60	$66.00	—	24% below	40%
Amylase blood test CPT 82150 AMYLASE PANCREATIC	$39.60	$66.00	—	24% below	40%
Amylase blood test inpatient CPT 82150 POC AMYLASE	$18.00	$30.00	—	—	40%
Amylase blood test inpatient CPT 82150 AMYLASE URINE	$39.60	$66.00	—	—	40%
Amylase blood test inpatient CPT 82150 AMYLASE SERUM	$39.60	$66.00	—	—	40%
Amylase blood test inpatient CPT 82150 AMYLASE PANCREATIC	$39.60	$66.00	—	—	40%
Amylase blood test inpatient CPT 82150 AMYLASE FLUID	$39.60	$66.00	—	—	40%
Anti-CCP antibody test (rheumatoid arthritis) CPT 86200 CYCLIC CITRULLINATED PEPTIDE, ANTIBODY	$79.20	$132.00	—	50% above	40%
Anti-CCP antibody test (rheumatoid arthritis) inpatient CPT 86200 CYCLIC CITRULLINATED PEPTIDE, ANTIBODY	$79.20	$132.00	—	—	40%
Antinuclear antibody (ANA) blood test, screen CPT 86038 ANA SCREEN	$74.40	$124.00	—	24% above	40%
Antinuclear antibody (ANA) blood test, screen inpatient CPT 86038 ANA SCREEN	$74.40	$124.00	—	—	40%
BNP or NT-proBNP blood test (heart failure marker) CPT 83880 POC BRAIN NATRIURETIC PEPTIDE	$240.60	$401.00	—	41% above	40%
BNP or NT-proBNP blood test (heart failure marker) CPT 83880 BRAIN NATRIURETIC PEPTIDE	$240.60	$401.00	—	41% above	40%
BNP or NT-proBNP blood test (heart failure marker) inpatient CPT 83880 BRAIN NATRIURETIC PEPTIDE	$240.60	$401.00	—	—	40%
BNP or NT-proBNP blood test (heart failure marker) inpatient CPT 83880 POC BRAIN NATRIURETIC PEPTIDE	$240.60	$401.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE IV CATHETER TIP	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE AEROBIC ONLY	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE NASOPHARYNGEAL	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE WOUND AEROBIC	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE THROAT	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE SPUTUM	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE SPINAL FLUID	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE RESPIRATORY	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE PLACENTA	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE GENITAL	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE EYE	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE EAR	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE BLOOD PRODUCT	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) CPT 87070 CULTURE ANY OTHER SOURCE	$52.80	$88.00	—	43% below	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE SPINAL FLUID	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE EYE	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE NASOPHARYNGEAL	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE WOUND AEROBIC	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE AEROBIC ONLY	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE EAR	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE THROAT	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE ANY OTHER SOURCE	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE GENITAL	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE SPUTUM	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE PLACENTA	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE RESPIRATORY	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE IV CATHETER TIP	$52.80	$88.00	—	—	40%
Bacterial culture of a sample other than urine, blood or stool (wound, throat, fluid) inpatient CPT 87070 CULTURE BLOOD PRODUCT	$52.80	$88.00	—	—	40%
Basic metabolic panel (blood test) CPT 80048 BASIC METABOLIC PNL CALCIUM TOTAL	$51.60	$86.00	—	34% below	40%
Basic metabolic panel (blood test) inpatient CPT 80048 BASIC METABOLIC PNL CALCIUM TOTAL	$51.60	$86.00	—	—	40%
Bilirubin blood test, total CPT 82247 POC BILIRUBIN TOTAL	$18.00	$30.00	—	48% below	40%
Bilirubin blood test, total CPT 82247 BILIRUBIN TOTAL	$30.60	$51.00	—	12% below	40%
Bilirubin blood test, total inpatient CPT 82247 POC BILIRUBIN TOTAL	$18.00	$30.00	—	—	40%
Bilirubin blood test, total inpatient CPT 82247 BILIRUBIN TOTAL	$30.60	$51.00	—	—	40%
Biopsy tissue exam by a pathologist (level IV) CPT 88305 PATH EXAM-CELL BLOCK	$143.40	$239.00	—	45% below	40%
Biopsy tissue exam by a pathologist (level IV) CPT 88305 PROSTATE NEEDLE BX GROSS AND MICRO	$143.40	$239.00	—	45% below	40%
Biopsy tissue exam by a pathologist (level IV) CPT 88305 SURG PATH LEV IV GROSS AND MICRO	$143.40	$239.00	—	45% below	40%
Biopsy tissue exam by a pathologist (level IV) inpatient CPT 88305 PROSTATE NEEDLE BX GROSS AND MICRO	$143.40	$239.00	—	—	40%
Biopsy tissue exam by a pathologist (level IV) inpatient CPT 88305 SURG PATH LEV IV GROSS AND MICRO	$143.40	$239.00	—	—	40%
Biopsy tissue exam by a pathologist (level IV) inpatient CPT 88305 PATH EXAM-CELL BLOCK	$143.40	$239.00	—	—	40%
Blood culture for bacteria CPT 87040 CULTURE BLOOD BACTERIAL	$63.00	$105.00	—	52% below	40%
Blood culture for bacteria inpatient CPT 87040 CULTURE BLOOD BACTERIAL	$63.00	$105.00	—	—	40%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 VENIPUNCTURE	$46.80	$78.00	—	182% above	40%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 REF LAB VENIPUNCTURE BLOOD COLLECT	$46.80	$78.00	—	182% above	40%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 REF LAB VENIPUNCTURE BLOOD COLLECT	$46.80	$78.00	—	—	40%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 VENIPUNCTURE	$46.80	$78.00	—	—	40%
Blood glucose (sugar) test CPT 82947 POC GLUCOSE QUANT BLOOD	$24.00	$40.00	—	10% below	40%
Blood glucose (sugar) test CPT 82947 GLUCOSE QUANT BLOOD	$24.00	$40.00	—	10% below	40%
Blood glucose (sugar) test inpatient CPT 82947 GLUCOSE QUANT BLOOD	$24.00	$40.00	—	—	40%
Blood glucose (sugar) test inpatient CPT 82947 POC GLUCOSE QUANT BLOOD	$24.00	$40.00	—	—	40%
Blood lead test CPT 83655 LEAD BLOOD	$74.40	$124.00	—	4% above	40%
Blood lead test CPT 83655 LEAD URINE	$74.40	$124.00	—	4% above	40%
Blood lead test inpatient CPT 83655 LEAD BLOOD	$74.40	$124.00	—	—	40%
Blood lead test inpatient CPT 83655 LEAD URINE	$74.40	$124.00	—	—	40%
Blood pregnancy test (hCG, qualitative: yes or no) CPT 84703 POC HCG QUAL PREGNANCY SCREEN	$46.20	$77.00	—	37% below	40%
Blood pregnancy test (hCG, qualitative: yes or no) CPT 84703 HCG QUAL PREGNANCY SCREEN	$46.20	$77.00	—	37% below	40%
Blood pregnancy test (hCG, qualitative: yes or no) inpatient CPT 84703 HCG QUAL PREGNANCY SCREEN	$46.20	$77.00	—	—	40%
Blood pregnancy test (hCG, qualitative: yes or no) inpatient CPT 84703 POC HCG QUAL PREGNANCY SCREEN	$46.20	$77.00	—	—	40%
Blood type test, ABO group only (Rh factor is a separate test) CPT 86900 ABO BLOOD TYPING	$30.00	$50.00	—	39% below	40%
Blood type test, ABO group only (Rh factor is a separate test) inpatient CPT 86900 ABO BLOOD TYPING	$30.00	$50.00	—	—	40%
Blood urea nitrogen (BUN) test CPT 84520 BUN BLOOD UREA NITROGEN	$24.00	$40.00	—	2% above	40%
Blood urea nitrogen (BUN) test CPT 84520 POC BUN BLOOD UREA NITROGEN	$24.00	$40.00	—	2% above	40%
Blood urea nitrogen (BUN) test inpatient CPT 84520 POC BUN BLOOD UREA NITROGEN	$24.00	$40.00	—	—	40%
Blood urea nitrogen (BUN) test inpatient CPT 84520 BUN BLOOD UREA NITROGEN	$24.00	$40.00	—	—	40%
C-peptide blood test CPT 84681 C PEPTIDE	$127.20	$212.00	—	7% below	40%
C-peptide blood test inpatient CPT 84681 C PEPTIDE	$127.20	$212.00	—	—	40%
C-reactive protein (CRP) blood test, standard (not high-sensitivity) CPT 86140 C REACTIVE PROTEIN	$31.80	$53.00	—	54% below	40%
C-reactive protein (CRP) blood test, standard (not high-sensitivity) inpatient CPT 86140 C REACTIVE PROTEIN	$31.80	$53.00	—	—	40%
C. difficile toxin gene test (stool PCR) CPT 87493 CLOSTRIDIUM DIFFICILE AMP PROBE	$228.00	$380.00	—	71% above	40%
C. difficile toxin gene test (stool PCR) inpatient CPT 87493 CLOSTRIDIUM DIFFICILE AMP PROBE	$228.00	$380.00	—	—	40%
CA 19-9 blood test (tumor marker) CPT 86301 CA 19 9	$127.20	$212.00	—	12% below	40%
CA 19-9 blood test (tumor marker) inpatient CPT 86301 CA 19 9	$127.20	$212.00	—	—	40%
CA-125 blood test (ovarian cancer marker) CPT 86304 CA 125	$127.20	$212.00	—	22% below	40%
CA-125 blood test (ovarian cancer marker) inpatient CPT 86304 CA 125	$127.20	$212.00	—	—	40%
COVID-19 PCR test (SARS-CoV-2 lab test) one side CPT 87635 COVID-19, RT-PCR	$314.40	$524.00	—	197% above	40%
COVID-19 PCR test (SARS-CoV-2 lab test) inpatient one side CPT 87635 COVID-19, RT-PCR	$314.40	$524.00	—	—	40%
Calcium blood test, total CPT 82310 CALCIUM TOTAL URINE	$31.80	$53.00	—	20% above	40%
Calcium blood test, total CPT 82310 CALCIUM TOTAL SERUM	$31.80	$53.00	—	20% above	40%
Calcium blood test, total inpatient CPT 82310 CALCIUM TOTAL URINE	$31.80	$53.00	—	—	40%
Calcium blood test, total inpatient CPT 82310 CALCIUM TOTAL SERUM	$31.80	$53.00	—	—	40%
Carcinoembryonic antigen (CEA) test CPT 82378 CARCINOEMBRYONIC ANTIGEN CEA	$115.80	$193.00	—	4% below	40%
Carcinoembryonic antigen (CEA) test inpatient CPT 82378 CARCINOEMBRYONIC ANTIGEN CEA	$115.80	$193.00	—	—	40%
Chickenpox (varicella) immunity blood test CPT 86787 VARICELLA ZOSTER AB IGM	$78.60	$131.00	—	19% below	40%
Chickenpox (varicella) immunity blood test CPT 86787 VARICELLA ZOSTER AB IGG	$78.60	$131.00	—	19% below	40%
Chickenpox (varicella) immunity blood test inpatient CPT 86787 VARICELLA ZOSTER AB IGG	$78.60	$131.00	—	—	40%
Chickenpox (varicella) immunity blood test inpatient CPT 86787 VARICELLA ZOSTER AB IGM	$78.60	$131.00	—	—	40%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) CPT 87491 CHLAMYDIA TRACHOMATIS AMPL PROBE	$214.80	$358.00	—	121% above	40%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) CPT 87491 CHLAMYDIA TRACHOMATIS URINE AMPL PROBE	$214.80	$358.00	—	121% above	40%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87491 CHLAMYDIA TRACHOMATIS URINE AMPL PROBE	$214.80	$358.00	—	—	40%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87491 CHLAMYDIA TRACHOMATIS AMPL PROBE	$214.80	$358.00	—	—	40%
Cholesterol and triglycerides (lipid panel) blood test CPT 80061 POC LIPID PANEL	$82.20	$137.00	—	22% below	40%
Cholesterol and triglycerides (lipid panel) blood test CPT 80061 LIPID PANEL	$82.20	$137.00	—	22% below	40%
Cholesterol and triglycerides (lipid panel) blood test inpatient CPT 80061 POC LIPID PANEL	$82.20	$137.00	—	—	40%
Cholesterol and triglycerides (lipid panel) blood test inpatient CPT 80061 LIPID PANEL	$82.20	$137.00	—	—	40%
Complete blood count (CBC) with differential CPT 85025 POC CBC W AUTO DIFF	$48.00	$80.00	—	16% above	40%
Complete blood count (CBC) with differential CPT 85025 CBC W AUTO DIFF	$48.00	$80.00	—	16% above	40%
Complete blood count (CBC) with differential inpatient CPT 85025 POC CBC W AUTO DIFF	$48.00	$80.00	—	—	40%
Complete blood count (CBC) with differential inpatient CPT 85025 CBC W AUTO DIFF	$48.00	$80.00	—	—	40%
Complete blood count (CBC), no differential CPT 85027 CBC AUTOMATED WO DIFF	$39.60	$66.00	—	34% above	40%
Complete blood count (CBC), no differential inpatient CPT 85027 CBC AUTOMATED WO DIFF	$39.60	$66.00	—	—	40%
Comprehensive metabolic panel (blood test) CPT 80053 COMPREHENSIVE METABOLIC PANEL	$64.80	$108.00	—	27% below	40%
Comprehensive metabolic panel (blood test) inpatient CPT 80053 COMPREHENSIVE METABOLIC PANEL	$64.80	$108.00	—	—	40%
Cortisol blood test, total CPT 82533 CORTISOL SALIVA	$99.60	$166.00	—	6% above	40%
Cortisol blood test, total CPT 82533 CORTISOL	$99.60	$166.00	—	6% above	40%
Cortisol blood test, total inpatient CPT 82533 CORTISOL SALIVA	$99.60	$166.00	—	—	40%
Cortisol blood test, total inpatient CPT 82533 CORTISOL	$99.60	$166.00	—	—	40%
Creatine kinase (CK) blood test, total CPT 82550 CPK CREATINE KINASE TOTAL	$39.60	$66.00	—	2% above	40%
Creatine kinase (CK) blood test, total inpatient CPT 82550 CPK CREATINE KINASE TOTAL	$39.60	$66.00	—	—	40%
Creatinine blood test CPT 82565 CREATININE BLOOD	$31.80	$53.00	—	10% above	40%
Creatinine blood test CPT 82565 POC CREATININE	$31.80	$53.00	—	10% above	40%
Creatinine blood test inpatient CPT 82565 POC CREATININE	$31.80	$53.00	—	—	40%
Creatinine blood test inpatient CPT 82565 CREATININE BLOOD	$31.80	$53.00	—	—	40%
Cytomegalovirus (CMV) antibody test CPT 86644 CYTOMEGALOVIRUS IGG ANTIBODY	$88.20	$147.00	—	11% above	40%
Cytomegalovirus (CMV) antibody test inpatient CPT 86644 CYTOMEGALOVIRUS IGG ANTIBODY	$88.20	$147.00	—	—	40%
D-dimer blood test (blood clot marker) CPT 85379 D DIMER QUANTITATIVE	$62.40	$104.00	—	49% below	40%
D-dimer blood test (blood clot marker) CPT 85379 POC D DIMER QUANTITATIVE	$62.40	$104.00	—	49% below	40%
D-dimer blood test (blood clot marker) inpatient CPT 85379 POC D DIMER QUANTITATIVE	$62.40	$104.00	—	—	40%
D-dimer blood test (blood clot marker) inpatient CPT 85379 D DIMER QUANTITATIVE	$62.40	$104.00	—	—	40%
DHEA sulfate (DHEA-S) blood test CPT 82627 DHEA SULFATE	$136.20	$227.00	—	7% below	40%
DHEA sulfate (DHEA-S) blood test inpatient CPT 82627 DHEA SULFATE	$136.20	$227.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 DRUG SCREEN 14 UMBILICAL CORD	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 DRUG SCREEN 33 UMBILICAL CORD	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 RVHH CORD DRUG PANEL, QUAL	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 ETHYL GLUCURONIDE SCREEN URINE	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 COTININE SCREEN	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 MULT DRUG CLASS METHOD EA	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 DRUG SCREEN PRESUMPTIVE PER DOS	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) CPT 80307 DRUG SCN MECONIUM MULT DRUG NON CHROM	$342.60	$571.00	—	200% above	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 DRUG SCREEN 33 UMBILICAL CORD	$342.60	$571.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 DRUG SCREEN PRESUMPTIVE PER DOS	$342.60	$571.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 COTININE SCREEN	$342.60	$571.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 ETHYL GLUCURONIDE SCREEN URINE	$342.60	$571.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 DRUG SCREEN 14 UMBILICAL CORD	$342.60	$571.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 RVHH CORD DRUG PANEL, QUAL	$342.60	$571.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 MULT DRUG CLASS METHOD EA	$342.60	$571.00	—	—	40%
Drug screen by lab instrument (any number of drug classes) inpatient CPT 80307 DRUG SCN MECONIUM MULT DRUG NON CHROM	$342.60	$571.00	—	—	40%
Electrolyte panel (sodium, potassium, chloride, CO2) CPT 80051 ELECTROLYTE PANEL	$42.60	$71.00	—	34% below	40%
Electrolyte panel (sodium, potassium, chloride, CO2) inpatient CPT 80051 ELECTROLYTE PANEL	$42.60	$71.00	—	—	40%
Epstein-Barr virus (EBV) antibody test CPT 86665 EBV VCA IGM	$111.00	$185.00	—	36% above	40%
Epstein-Barr virus (EBV) antibody test CPT 86665 EBV VCA IGG	$111.00	$185.00	—	36% above	40%
Epstein-Barr virus (EBV) antibody test inpatient CPT 86665 EBV VCA IGM	$111.00	$185.00	—	—	40%
Epstein-Barr virus (EBV) antibody test inpatient CPT 86665 EBV VCA IGG	$111.00	$185.00	—	—	40%
Estradiol blood test CPT 82670 ESTRADIOL, TOTAL	$171.60	$286.00	—	34% above	40%
Estradiol blood test inpatient CPT 82670 ESTRADIOL, TOTAL	$171.60	$286.00	—	—	40%
FSH (follicle-stimulating hormone) test CPT 83001 FSH FOLLICLE STIMULATING HORMONE	$114.00	$190.00	—	11% below	40%
FSH (follicle-stimulating hormone) test inpatient CPT 83001 FSH FOLLICLE STIMULATING HORMONE	$114.00	$190.00	—	—	40%
Fecal calprotectin (stool inflammation test) CPT 83993 CALPROTECTIN FECAL	$241.20	$402.00	—	33% above	40%
Fecal calprotectin (stool inflammation test) inpatient CPT 83993 CALPROTECTIN FECAL	$241.20	$402.00	—	—	40%
Ferritin blood test (iron stores) CPT 82728 FERRITIN	$84.00	$140.00	—	5% above	40%
Ferritin blood test (iron stores) inpatient CPT 82728 FERRITIN	$84.00	$140.00	—	—	40%
Fibrinogen blood test CPT 85384 FIBRINOGEN ACTIVITY	$60.00	$100.00	—	at median	40%
Fibrinogen blood test inpatient CPT 85384 FIBRINOGEN ACTIVITY	$60.00	$100.00	—	—	40%
Folate (folic acid) blood test CPT 82746 FOLIC ACID SERUM	$90.00	$150.00	—	17% above	40%
Folate (folic acid) blood test inpatient CPT 82746 FOLIC ACID SERUM	$90.00	$150.00	—	—	40%
Free T3 thyroid hormone test CPT 84481 T3 FREE	$103.80	$173.00	—	22% below	40%
Free T3 thyroid hormone test inpatient CPT 84481 T3 FREE	$103.80	$173.00	—	—	40%
Free T4 (free thyroxine) thyroid blood test CPT 84439 T4 THYROXINE FREE	$55.20	$92.00	—	32% below	40%
Free T4 (free thyroxine) thyroid blood test inpatient CPT 84439 T4 THYROXINE FREE	$55.20	$92.00	—	—	40%
Free testosterone test CPT 84402 TESTOSTERONE FREE	$156.00	$260.00	—	87% above	40%
Free testosterone test inpatient CPT 84402 TESTOSTERONE FREE	$156.00	$260.00	—	—	40%
Gamma-glutamyl transferase (GGT) blood test CPT 82977 POC GGT GLUTAMYLTRANSFERASE GAMMA	$18.00	$30.00	—	45% below	40%
Gamma-glutamyl transferase (GGT) blood test CPT 82977 GGT GLUTAMYLTRANSFERASE GAMMA	$44.40	$74.00	—	36% above	40%
Gamma-glutamyl transferase (GGT) blood test inpatient CPT 82977 POC GGT GLUTAMYLTRANSFERASE GAMMA	$18.00	$30.00	—	—	40%
Gamma-glutamyl transferase (GGT) blood test inpatient CPT 82977 GGT GLUTAMYLTRANSFERASE GAMMA	$44.40	$74.00	—	—	40%
General health panel: metabolic panel, blood count and TSH in one order CPT 80050 GENERAL HEALTH PANEL	$396.00	$660.00	—	29% above	40%
General health panel: metabolic panel, blood count and TSH in one order inpatient CPT 80050 GENERAL HEALTH PANEL	$396.00	$660.00	—	—	40%
Glucose challenge test (1-hour glucose after a sugar drink) CPT 82950 GLUCOSE POST GLUCOSE DOSE	$28.80	$48.00	—	30% below	40%
Glucose challenge test (1-hour glucose after a sugar drink) CPT 82950 GLUCOSE TOLERANCE 1 HR OB	$28.80	$48.00	—	30% below	40%
Glucose challenge test (1-hour glucose after a sugar drink) CPT 82950 POC GLUCOSE POST GLUCOSE DOSE	$28.80	$48.00	—	30% below	40%
Glucose challenge test (1-hour glucose after a sugar drink) CPT 82950 GLUCOSE POSTPRANDIAL	$28.80	$48.00	—	30% below	40%
Glucose challenge test (1-hour glucose after a sugar drink) inpatient CPT 82950 GLUCOSE POSTPRANDIAL	$28.80	$48.00	—	—	40%
Glucose challenge test (1-hour glucose after a sugar drink) inpatient CPT 82950 GLUCOSE POST GLUCOSE DOSE	$28.80	$48.00	—	—	40%
Glucose challenge test (1-hour glucose after a sugar drink) inpatient CPT 82950 POC GLUCOSE POST GLUCOSE DOSE	$28.80	$48.00	—	—	40%
Glucose challenge test (1-hour glucose after a sugar drink) inpatient CPT 82950 GLUCOSE TOLERANCE 1 HR OB	$28.80	$48.00	—	—	40%
Glucose tolerance test, 3 samples CPT 82951 GLUCOSE TOL TEST 3 SPECIMEN	$78.60	$131.00	—	6% above	40%
Glucose tolerance test, 3 samples inpatient CPT 82951 GLUCOSE TOL TEST 3 SPECIMEN	$78.60	$131.00	—	—	40%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) CPT 87591 NEISSERIA GONORRHOEAE URINE AMPL PROBE	$214.80	$358.00	—	121% above	40%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) CPT 87591 NEISSERIA GONORRHOEAE AMPL PROBE	$214.80	$358.00	—	121% above	40%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87591 NEISSERIA GONORRHOEAE AMPL PROBE	$214.80	$358.00	—	—	40%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87591 NEISSERIA GONORRHOEAE URINE AMPL PROBE	$214.80	$358.00	—	—	40%
H. pylori stool antigen test CPT 87338 HELICOBACTER PYLORI STOOL EIA	$88.20	$147.00	—	33% below	40%
H. pylori stool antigen test inpatient CPT 87338 HELICOBACTER PYLORI STOOL EIA	$88.20	$147.00	—	—	40%
HIV viral load test (HIV-1 RNA, quantitative) CPT 87536 HIV 1 QUANTIFICATION	$520.80	$868.00	—	47% above	40%
HIV viral load test (HIV-1 RNA, quantitative) inpatient CPT 87536 HIV 1 QUANTIFICATION	$520.80	$868.00	—	—	40%
HIV-1/2 antigen and antibody combination blood test (4th generation) CPT 87389 HIV-1 AG W HIV-1 & 2 AB IA	$147.60	$246.00	—	147% above	40%
HIV-1/2 antigen and antibody combination blood test (4th generation) inpatient CPT 87389 HIV-1 AG W HIV-1 & 2 AB IA	$147.60	$246.00	—	—	40%
HPV test for high-risk types, one combined (pooled) result CPT 87624 HUMAN PAPILLOMAVIRUS AMPL PROBE HIGH RISK	$214.80	$358.00	—	106% above	40%
HPV test for high-risk types, one combined (pooled) result inpatient CPT 87624 HUMAN PAPILLOMAVIRUS AMPL PROBE HIGH RISK	$214.80	$358.00	—	—	40%
Hemoglobin A1C blood test (average blood sugar over about 3 months) CPT 83036 HEMOGLOBIN A1C GLYCATED	$59.40	$99.00	—	9% below	40%
Hemoglobin A1C blood test (average blood sugar over about 3 months) inpatient CPT 83036 HEMOGLOBIN A1C GLYCATED	$59.40	$99.00	—	—	40%
Hemoglobin blood test CPT 85018 HEMOGLOBIN	$14.40	$24.00	—	22% below	40%
Hemoglobin blood test CPT 85018 POC HEMOGLOBIN	$14.40	$24.00	—	22% below	40%
Hemoglobin blood test inpatient CPT 85018 HEMOGLOBIN	$14.40	$24.00	—	—	40%
Hemoglobin blood test inpatient CPT 85018 POC HEMOGLOBIN	$14.40	$24.00	—	—	40%
Hepatitis B core antibody test (total) CPT 86704 HEPATITIS B CORE ANTIBODY TOTAL	$73.80	$123.00	—	10% above	40%
Hepatitis B core antibody test (total) inpatient CPT 86704 HEPATITIS B CORE ANTIBODY TOTAL	$73.80	$123.00	—	—	40%
Hepatitis B surface antibody (anti-HBs) test, immunity check CPT 86706 HEPATITIS B SURFACE AB	$65.40	$109.00	—	at median	40%
Hepatitis B surface antibody (anti-HBs) test, immunity check inpatient CPT 86706 HEPATITIS B SURFACE AB	$65.40	$109.00	—	—	40%
Hepatitis B surface antigen (HBsAg) test CPT 87340 HEPATITIS B SURFACE ANTIGEN EIA	$63.00	$105.00	—	3% above	40%
Hepatitis B surface antigen (HBsAg) test inpatient CPT 87340 HEPATITIS B SURFACE ANTIGEN EIA	$63.00	$105.00	—	—	40%
Hepatitis C antibody blood test (screening) CPT 86803 HEPATITIS C ANTIBODY	$87.60	$146.00	—	12% below	40%
Hepatitis C antibody blood test (screening) inpatient CPT 86803 HEPATITIS C ANTIBODY	$87.60	$146.00	—	—	40%
Hepatitis C viral load (HCV RNA) test CPT 87522 HEPATITIS C VIRUS QUANTIFICATION	$262.80	$438.00	—	17% above	40%
Hepatitis C viral load (HCV RNA) test inpatient CPT 87522 HEPATITIS C VIRUS QUANTIFICATION	$262.80	$438.00	—	—	40%
Herpes blood test, HSV-1 antibody CPT 86695 HERPES SIMPLEX AB TYPE 1	$80.40	$134.00	—	59% above	40%
Herpes blood test, HSV-1 antibody inpatient CPT 86695 HERPES SIMPLEX AB TYPE 1	$80.40	$134.00	—	—	40%
Herpes blood test, HSV-2 antibody CPT 86696 HERPES SIMPLEX AB TYPE 2	$118.20	$197.00	—	63% above	40%
Herpes blood test, HSV-2 antibody inpatient CPT 86696 HERPES SIMPLEX AB TYPE 2	$118.20	$197.00	—	—	40%
High-sensitivity CRP (hs-CRP) test CPT 86141 C REACTIVE PROTEIN HIGH SENSITIVE	$79.20	$132.00	—	7% above	40%
High-sensitivity CRP (hs-CRP) test inpatient CPT 86141 C REACTIVE PROTEIN HIGH SENSITIVE	$79.20	$132.00	—	—	40%
Homocysteine blood test CPT 83090 HOMOCYSTEINE	$109.80	$183.00	—	15% below	40%
Homocysteine blood test inpatient CPT 83090 HOMOCYSTEINE	$109.80	$183.00	—	—	40%
Insulin blood test CPT 83525 INSULIN TOTAL	$70.20	$117.00	—	2% below	40%
Insulin blood test inpatient CPT 83525 INSULIN TOTAL	$70.20	$117.00	—	—	40%
Iron blood test (serum iron) CPT 83540 IRON SERUM	$39.60	$66.00	—	18% below	40%
Iron blood test (serum iron) inpatient CPT 83540 IRON SERUM	$39.60	$66.00	—	—	40%
Iron-binding capacity (TIBC) test CPT 83550 IRON BINDING CAPACITY	$53.40	$89.00	—	21% above	40%
Iron-binding capacity (TIBC) test inpatient CPT 83550 IRON BINDING CAPACITY	$53.40	$89.00	—	—	40%
Kidney function blood test panel CPT 80069 RENAL FUNCTION PANEL	$52.80	$88.00	—	48% below	40%
Kidney function blood test panel inpatient CPT 80069 RENAL FUNCTION PANEL	$52.80	$88.00	—	—	40%
LH (luteinizing hormone) test CPT 83002 LH LUTEINIZING HORMONE	$113.40	$189.00	—	20% below	40%
LH (luteinizing hormone) test inpatient CPT 83002 LH LUTEINIZING HORMONE	$113.40	$189.00	—	—	40%
Lactate (lactic acid) blood test CPT 83605 POC LACTIC ACID	$70.80	$118.00	—	21% below	40%
Lactate (lactic acid) blood test CPT 83605 LACTIC ACID	$70.80	$118.00	—	21% below	40%
Lactate (lactic acid) blood test inpatient CPT 83605 LACTIC ACID	$70.80	$118.00	—	—	40%
Lactate (lactic acid) blood test inpatient CPT 83605 POC LACTIC ACID	$70.80	$118.00	—	—	40%
Lactate dehydrogenase (LDH) blood test CPT 83615 LDH LACTATE DEHYDROGENASE FLUID	$37.20	$62.00	—	13% below	40%
Lactate dehydrogenase (LDH) blood test CPT 83615 LDH LACTATE DEHYDROGENASE	$37.20	$62.00	—	13% below	40%
Lactate dehydrogenase (LDH) blood test inpatient CPT 83615 LDH LACTATE DEHYDROGENASE	$37.20	$62.00	—	—	40%
Lactate dehydrogenase (LDH) blood test inpatient CPT 83615 LDH LACTATE DEHYDROGENASE FLUID	$37.20	$62.00	—	—	40%
Lipase blood test (pancreas enzyme) CPT 83690 LIPASE	$42.00	$70.00	—	53% below	40%
Lipase blood test (pancreas enzyme) CPT 83690 LIPASE FLUID	$42.00	$70.00	—	53% below	40%
Lipase blood test (pancreas enzyme) inpatient CPT 83690 LIPASE FLUID	$42.00	$70.00	—	—	40%
Lipase blood test (pancreas enzyme) inpatient CPT 83690 LIPASE	$42.00	$70.00	—	—	40%
Liver function blood test panel CPT 80076 HEPATIC FUNCTION PANEL	$49.80	$83.00	—	47% below	40%
Liver function blood test panel inpatient CPT 80076 HEPATIC FUNCTION PANEL	$49.80	$83.00	—	—	40%
Lyme disease antibody test CPT 86618 LYME DISEASE ANTIBODY IGG	$54.60	$91.00	—	56% below	40%
Lyme disease antibody test CPT 86618 LYME DISEASE ANTIBODY IGM	$54.60	$91.00	—	56% below	40%
Lyme disease antibody test CPT 86618 LYME DISEASE ANTIBODY	$104.40	$174.00	—	15% below	40%
Lyme disease antibody test inpatient CPT 86618 LYME DISEASE ANTIBODY IGG	$54.60	$91.00	—	—	40%
Lyme disease antibody test inpatient CPT 86618 LYME DISEASE ANTIBODY IGM	$54.60	$91.00	—	—	40%
Lyme disease antibody test inpatient CPT 86618 LYME DISEASE ANTIBODY	$104.40	$174.00	—	—	40%
Magnesium blood test CPT 83735 MAGNESIUM	$40.80	$68.00	—	14% below	40%
Magnesium blood test CPT 83735 MAGNESIUM 24 HR URINE	$40.80	$68.00	—	14% below	40%
Magnesium blood test CPT 83735 MAGNESIUM URINE	$40.80	$68.00	—	14% below	40%
Magnesium blood test CPT 83735 MAGNESIUM RBC	$66.60	$111.00	—	40% above	40%
Magnesium blood test inpatient CPT 83735 MAGNESIUM	$40.80	$68.00	—	—	40%
Magnesium blood test inpatient CPT 83735 MAGNESIUM URINE	$40.80	$68.00	—	—	40%
Magnesium blood test inpatient CPT 83735 MAGNESIUM 24 HR URINE	$40.80	$68.00	—	—	40%
Magnesium blood test inpatient CPT 83735 MAGNESIUM RBC	$66.60	$111.00	—	—	40%
Measles (rubeola) antibody test CPT 86765 RUBEOLA ANTIBODY IGG	$78.60	$131.00	—	at median	40%
Measles (rubeola) antibody test inpatient CPT 86765 RUBEOLA ANTIBODY IGG	$78.60	$131.00	—	—	40%
Mono test (heterophile antibody, Monospot) CPT 86308 POC MONOTEST HETEROPHILE AB SCREEN	$31.80	$53.00	—	59% below	40%
Mono test (heterophile antibody, Monospot) CPT 86308 MONOTEST HETEROPHILE AB SCREEN	$31.80	$53.00	—	59% below	40%
Mono test (heterophile antibody, Monospot) inpatient CPT 86308 POC MONOTEST HETEROPHILE AB SCREEN	$31.80	$53.00	—	—	40%
Mono test (heterophile antibody, Monospot) inpatient CPT 86308 MONOTEST HETEROPHILE AB SCREEN	$31.80	$53.00	—	—	40%
Mumps immunity blood test CPT 86735 MUMPS IGM ANTIBODY	$79.80	$133.00	—	5% above	40%
Mumps immunity blood test CPT 86735 MUMPS IGG ANTIBODY	$79.80	$133.00	—	5% above	40%
Mumps immunity blood test inpatient CPT 86735 MUMPS IGG ANTIBODY	$79.80	$133.00	—	—	40%
Mumps immunity blood test inpatient CPT 86735 MUMPS IGM ANTIBODY	$79.80	$133.00	—	—	40%
Obstetric blood test panel CPT 80055 OBSTETRIC PANEL	$292.80	$488.00	—	9% below	40%
Obstetric blood test panel inpatient CPT 80055 OBSTETRIC PANEL	$292.80	$488.00	—	—	40%
PSA (prostate-specific antigen) blood test, free CPT 84154 PSA FREE	$112.80	$188.00	—	62% above	40%
PSA (prostate-specific antigen) blood test, free inpatient CPT 84154 PSA FREE	$112.80	$188.00	—	—	40%
PSA (prostate-specific antigen) blood test, total CPT 84153 PSA TOTAL DIAGNOSTIC	$112.80	$188.00	—	42% above	40%
PSA (prostate-specific antigen) blood test, total inpatient CPT 84153 PSA TOTAL DIAGNOSTIC	$112.80	$188.00	—	—	40%
Pap test (liquid-based, automated screening with review) CPT 88175 PAP SMEAR AUTO SCRN MAN RESCRN	$202.20	$337.00	—	144% above	40%
Pap test (liquid-based, automated screening with review) inpatient CPT 88175 PAP SMEAR AUTO SCRN MAN RESCRN	$202.20	$337.00	—	—	40%
Parathyroid hormone (PTH) blood test CPT 83970 PTH INTACT SURG POST RESE	$252.60	$421.00	—	31% above	40%
Parathyroid hormone (PTH) blood test CPT 83970 PTH INTACT	$252.60	$421.00	—	31% above	40%
Parathyroid hormone (PTH) blood test CPT 83970 PTH INTACT SURG BASELINE	$252.60	$421.00	—	31% above	40%
Parathyroid hormone (PTH) blood test inpatient CPT 83970 PTH INTACT SURG POST RESE	$252.60	$421.00	—	—	40%
Parathyroid hormone (PTH) blood test inpatient CPT 83970 PTH INTACT	$252.60	$421.00	—	—	40%
Parathyroid hormone (PTH) blood test inpatient CPT 83970 PTH INTACT SURG BASELINE	$252.60	$421.00	—	—	40%
Partial thromboplastin time (PTT) clotting test CPT 85730 PTT MIXING	$36.60	$61.00	—	27% below	40%
Partial thromboplastin time (PTT) clotting test CPT 85730 PTT PARTIAL THROMBOPLASTIN TIME	$36.60	$61.00	—	27% below	40%
Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 PTT PARTIAL THROMBOPLASTIN TIME	$36.60	$61.00	—	—	40%
Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 PTT MIXING	$36.60	$61.00	—	—	40%
Phosphorus (phosphate) blood test CPT 84100 PHOSPHORUS	$28.80	$48.00	—	1% above	40%
Phosphorus (phosphate) blood test inpatient CPT 84100 PHOSPHORUS	$28.80	$48.00	—	—	40%
Potassium blood test CPT 84132 POTASSIUM PLASMA/WB	$28.80	$48.00	—	1% above	40%
Potassium blood test CPT 84132 POC POTASSIUM SER PLASMA WB	$28.80	$48.00	—	1% above	40%
Potassium blood test inpatient CPT 84132 POC POTASSIUM SER PLASMA WB	$28.80	$48.00	—	—	40%
Potassium blood test inpatient CPT 84132 POTASSIUM PLASMA/WB	$28.80	$48.00	—	—	40%
Progesterone blood test CPT 84144 PROGESTERONE	$127.80	$213.00	—	7% below	40%
Progesterone blood test inpatient CPT 84144 PROGESTERONE	$127.80	$213.00	—	—	40%
Prolactin blood test CPT 84146 PROLACTIN	$118.20	$197.00	—	17% above	40%
Prolactin blood test inpatient CPT 84146 PROLACTIN	$118.20	$197.00	—	—	40%
Prothrombin time (PT/INR) clotting test CPT 85610 PROTHROMBIN TIME MIXING TEST	$26.40	$44.00	—	at median	40%
Prothrombin time (PT/INR) clotting test CPT 85610 POC PROTHROMBIN TIME	$26.40	$44.00	—	at median	40%
Prothrombin time (PT/INR) clotting test CPT 85610 PROTHROMBIN TIME	$26.40	$44.00	—	at median	40%
Prothrombin time (PT/INR) clotting test inpatient CPT 85610 PROTHROMBIN TIME	$26.40	$44.00	—	—	40%
Prothrombin time (PT/INR) clotting test inpatient CPT 85610 POC PROTHROMBIN TIME	$26.40	$44.00	—	—	40%
Prothrombin time (PT/INR) clotting test inpatient CPT 85610 PROTHROMBIN TIME MIXING TEST	$26.40	$44.00	—	—	40%
Rapid drug screen read by eye (cup, dipstick or card), per day CPT 80305 POC DRUG SCRN MULTICLASS CHROMATOGRAPHI	$69.60	$116.00	—	30% below	40%
Rapid drug screen read by eye (cup, dipstick or card), per day CPT 80305 POC DRUG SCREEN MULTICLASS	$69.60	$116.00	—	30% below	40%
Rapid drug screen read by eye (cup, dipstick or card), per day inpatient CPT 80305 POC DRUG SCRN MULTICLASS CHROMATOGRAPHI	$69.60	$116.00	—	—	40%
Rapid drug screen read by eye (cup, dipstick or card), per day inpatient CPT 80305 POC DRUG SCREEN MULTICLASS	$69.60	$116.00	—	—	40%
Rapid strep A antigen test from a throat swab, read visually CPT 87880 RAPID STREP DIR OPTICAL OBSERV	$101.40	$169.00	—	31% above	40%
Rapid strep A antigen test from a throat swab, read visually inpatient CPT 87880 RAPID STREP DIR OPTICAL OBSERV	$101.40	$169.00	—	—	40%
Renin blood test CPT 84244 RENIN	$135.00	$225.00	—	22% above	40%
Renin blood test inpatient CPT 84244 RENIN	$135.00	$225.00	—	—	40%
Rh blood typing CPT 86901 RH (D) BLOOD TYPING	$30.00	$50.00	—	22% below	40%
Rh blood typing inpatient CPT 86901 RH (D) BLOOD TYPING	$30.00	$50.00	—	—	40%
Rheumatoid factor (RF) test CPT 86431 RHEUMATOID FACTOR QUANTITATIVE	$34.80	$58.00	—	29% below	40%
Rheumatoid factor (RF) test inpatient CPT 86431 RHEUMATOID FACTOR QUANTITATIVE	$34.80	$58.00	—	—	40%
Rubella antibody test (immunity check) CPT 86762 RUBELLA ANTIBODY IGG	$88.20	$147.00	—	32% above	40%
Rubella antibody test (immunity check) CPT 86762 RUBELLA ANTIBODY IGM	$88.20	$147.00	—	32% above	40%
Rubella antibody test (immunity check) inpatient CPT 86762 RUBELLA ANTIBODY IGG	$88.20	$147.00	—	—	40%
Rubella antibody test (immunity check) inpatient CPT 86762 RUBELLA ANTIBODY IGM	$88.20	$147.00	—	—	40%
Sed rate (ESR, erythrocyte sedimentation rate) CPT 85652 SEDIMENTATION RATE AUTOMATED	$16.20	$27.00	—	58% below	40%
Sed rate (ESR, erythrocyte sedimentation rate) inpatient CPT 85652 SEDIMENTATION RATE AUTOMATED	$16.20	$27.00	—	—	40%
Sodium blood test CPT 84295 POC SODIUM PLASMA/WB	$29.40	$49.00	—	20% below	40%
Sodium blood test CPT 84295 SODIUM PLASMA/WB	$29.40	$49.00	—	20% below	40%
Sodium blood test inpatient CPT 84295 SODIUM PLASMA/WB	$29.40	$49.00	—	—	40%
Sodium blood test inpatient CPT 84295 POC SODIUM PLASMA/WB	$29.40	$49.00	—	—	40%
Stool ova and parasites exam CPT 87177 OVA AND PARASITES	$54.60	$91.00	—	13% above	40%
Stool ova and parasites exam inpatient CPT 87177 OVA AND PARASITES	$54.60	$91.00	—	—	40%
Stool test for hidden blood by immunoassay (FIT) CPT 82274 POC OCCULT BLOOD,IMMUNO,QUAL,STOOL	$97.80	$163.00	—	88% above	40%
Stool test for hidden blood by immunoassay (FIT) CPT 82274 OCCULT BLOOD FECES IMMUNO QUAL 1-3 DET	$97.80	$163.00	—	88% above	40%
Stool test for hidden blood by immunoassay (FIT) inpatient CPT 82274 POC OCCULT BLOOD,IMMUNO,QUAL,STOOL	$97.80	$163.00	—	—	40%
Stool test for hidden blood by immunoassay (FIT) inpatient CPT 82274 OCCULT BLOOD FECES IMMUNO QUAL 1-3 DET	$97.80	$163.00	—	—	40%
Syphilis antibody test (Treponema pallidum) CPT 86780 SYPHILIS TOTAL	$81.00	$135.00	—	20% above	40%
Syphilis antibody test (Treponema pallidum) CPT 86780 MHA TREPONEMA PALLIDUM AB BY TP-PA	$81.00	$135.00	—	20% above	40%
Syphilis antibody test (Treponema pallidum) CPT 86780 FTA TREPONEMA PALLIDUM	$81.00	$135.00	—	20% above	40%
Syphilis antibody test (Treponema pallidum) CPT 86780 SYPHILIS IGG	$81.00	$135.00	—	20% above	40%
Syphilis antibody test (Treponema pallidum) inpatient CPT 86780 SYPHILIS IGG	$81.00	$135.00	—	—	40%
Syphilis antibody test (Treponema pallidum) inpatient CPT 86780 MHA TREPONEMA PALLIDUM AB BY TP-PA	$81.00	$135.00	—	—	40%
Syphilis antibody test (Treponema pallidum) inpatient CPT 86780 FTA TREPONEMA PALLIDUM	$81.00	$135.00	—	—	40%
Syphilis antibody test (Treponema pallidum) inpatient CPT 86780 SYPHILIS TOTAL	$81.00	$135.00	—	—	40%
Syphilis screening blood test, non-treponemal (RPR or VDRL), yes/no result CPT 86592 VDRL QUALITATIVE CSF	$26.40	$44.00	—	35% below	40%
Syphilis screening blood test, non-treponemal (RPR or VDRL), yes/no result inpatient CPT 86592 VDRL QUALITATIVE CSF	$26.40	$44.00	—	—	40%
TB blood test measuring immune response (IGRA, gamma interferon) CPT 86480 QUANTIFERON R TB GOLD	$379.80	$633.00	—	157% above	40%
TB blood test measuring immune response (IGRA, gamma interferon) inpatient CPT 86480 QUANTIFERON R TB GOLD	$379.80	$633.00	—	—	40%
Testosterone blood test, total (not free testosterone) CPT 84403 TESTOSTERONE TOTAL	$158.40	$264.00	—	33% above	40%
Testosterone blood test, total (not free testosterone) inpatient CPT 84403 TESTOSTERONE TOTAL	$158.40	$264.00	—	—	40%
Thyroid peroxidase (TPO) antibody test CPT 86376 THYROID PEROXIDASE AB EACH	$88.80	$148.00	—	4% below	40%
Thyroid peroxidase (TPO) antibody test CPT 86376 LIVER KIDNEY MICROSOMAL AB EACH	$88.80	$148.00	—	4% below	40%
Thyroid peroxidase (TPO) antibody test inpatient CPT 86376 LIVER KIDNEY MICROSOMAL AB EACH	$88.80	$148.00	—	—	40%
Thyroid peroxidase (TPO) antibody test inpatient CPT 86376 THYROID PEROXIDASE AB EACH	$88.80	$148.00	—	—	40%
Thyroid-stimulating hormone (TSH) blood test CPT 84443 TSH NEWBORN	$22.20	$37.00	—	73% below	40%
Thyroid-stimulating hormone (TSH) blood test CPT 84443 TSH THYROID STIMULATING HORMONE	$102.60	$171.00	—	26% above	40%
Thyroid-stimulating hormone (TSH) blood test CPT 84443 ULTRASENSITIVE TSH	$102.60	$171.00	—	26% above	40%
Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 TSH NEWBORN	$22.20	$37.00	—	—	40%
Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 ULTRASENSITIVE TSH	$102.60	$171.00	—	—	40%
Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 TSH THYROID STIMULATING HORMONE	$102.60	$171.00	—	—	40%
Total IgE blood test CPT 82785 IMMUNOGLOBULIN E	$100.80	$168.00	—	34% above	40%
Total IgE blood test inpatient CPT 82785 IMMUNOGLOBULIN E	$100.80	$168.00	—	—	40%
Total cholesterol blood test CPT 82465 CHOLESTEROL SERUM/WHOLE BLD TOTAL	$26.40	$44.00	—	14% below	40%
Total cholesterol blood test inpatient CPT 82465 CHOLESTEROL SERUM/WHOLE BLD TOTAL	$26.40	$44.00	—	—	40%
Total thyroxine (T4) blood test CPT 84436 T4 THYROXINE TOTAL	$42.00	$70.00	—	11% below	40%
Total thyroxine (T4) blood test inpatient CPT 84436 T4 THYROXINE TOTAL	$42.00	$70.00	—	—	40%
Total triiodothyronine (T3) blood test CPT 84480 T3 TOTAL	$87.00	$145.00	—	28% below	40%
Total triiodothyronine (T3) blood test inpatient CPT 84480 T3 TOTAL	$87.00	$145.00	—	—	40%
Transferrin blood test CPT 84466 TRANSFERRIN	$78.00	$130.00	—	8% below	40%
Transferrin blood test inpatient CPT 84466 TRANSFERRIN	$78.00	$130.00	—	—	40%
Trichomonas test (NAAT) CPT 87661 TRICHOMONAL VAGINALIS AMP PROBE	$214.80	$358.00	—	126% above	40%
Trichomonas test (NAAT) inpatient CPT 87661 TRICHOMONAL VAGINALIS AMP PROBE	$214.80	$358.00	—	—	40%
Triglycerides blood test CPT 84478 TRIGLYCERIDES FLUID	$35.40	$59.00	—	1% below	40%
Triglycerides blood test CPT 84478 TRIGLYCERIDES	$35.40	$59.00	—	1% below	40%
Triglycerides blood test inpatient CPT 84478 TRIGLYCERIDES FLUID	$35.40	$59.00	—	—	40%
Triglycerides blood test inpatient CPT 84478 TRIGLYCERIDES	$35.40	$59.00	—	—	40%
Troponin test, quantitative CPT 84484 POC TROPONIN QUANTITATIVE	$76.20	$127.00	—	37% below	40%
Troponin test, quantitative CPT 84484 TROPONIN QUANTITATIVE	$76.20	$127.00	—	37% below	40%
Troponin test, quantitative inpatient CPT 84484 TROPONIN QUANTITATIVE	$76.20	$127.00	—	—	40%
Troponin test, quantitative inpatient CPT 84484 POC TROPONIN QUANTITATIVE	$76.20	$127.00	—	—	40%
Uric acid blood test CPT 84550 URIC ACID BLOOD	$27.60	$46.00	—	42% below	40%
Uric acid blood test inpatient CPT 84550 URIC ACID BLOOD	$27.60	$46.00	—	—	40%
Urinalysis with microscope exam, automated CPT 81001 URINALYSIS AUTOMATED W MICRO	$24.60	$41.00	—	41% below	40%
Urinalysis with microscope exam, automated inpatient CPT 81001 URINALYSIS AUTOMATED W MICRO	$24.60	$41.00	—	—	40%
Urinalysis with microscope exam, manual CPT 81000 URINALYSIS NON AUTOMATED W MICRO	$30.60	$51.00	—	15% above	40%
Urinalysis with microscope exam, manual inpatient CPT 81000 URINALYSIS NON AUTOMATED W MICRO	$30.60	$51.00	—	—	40%
Urinalysis without microscope exam, automated CPT 81003 URINALYSIS AUTOMATED W/O MICRO	$17.40	$29.00	—	29% below	40%
Urinalysis without microscope exam, automated CPT 81003 URINE KETONES AUTOMATED	$17.40	$29.00	—	29% below	40%
Urinalysis without microscope exam, automated CPT 81003 POC URINALYSIS AUTOMATED W/O MICRO	$17.40	$29.00	—	29% below	40%
Urinalysis without microscope exam, automated CPT 81003 SPECIFIC GRAVITY URINE AUTOMATED	$17.40	$29.00	—	29% below	40%
Urinalysis without microscope exam, automated CPT 81003 URINE PH AUTOMATED	$17.40	$29.00	—	29% below	40%
Urinalysis without microscope exam, automated inpatient CPT 81003 URINE KETONES AUTOMATED	$17.40	$29.00	—	—	40%
Urinalysis without microscope exam, automated inpatient CPT 81003 SPECIFIC GRAVITY URINE AUTOMATED	$17.40	$29.00	—	—	40%
Urinalysis without microscope exam, automated inpatient CPT 81003 POC URINALYSIS AUTOMATED W/O MICRO	$17.40	$29.00	—	—	40%
Urinalysis without microscope exam, automated inpatient CPT 81003 URINE PH AUTOMATED	$17.40	$29.00	—	—	40%
Urinalysis without microscope exam, automated inpatient CPT 81003 URINALYSIS AUTOMATED W/O MICRO	$17.40	$29.00	—	—	40%
Urinalysis without microscope exam, manual CPT 81002 POC URINALYSIS NON-AUTO	$27.00	$45.00	—	73% above	40%
Urinalysis without microscope exam, manual CPT 81002 URINALYSIS NON AUTOMATED WO MICRO	$27.00	$45.00	—	73% above	40%
Urinalysis without microscope exam, manual inpatient CPT 81002 POC URINALYSIS NON-AUTO	$27.00	$45.00	—	—	40%
Urinalysis without microscope exam, manual inpatient CPT 81002 URINALYSIS NON AUTOMATED WO MICRO	$27.00	$45.00	—	—	40%
Urine culture for bacteria, with colony count CPT 87086 CULTURE URINE BACTERIAL QUANT CNT	$49.20	$82.00	—	13% above	40%
Urine culture for bacteria, with colony count inpatient CPT 87086 CULTURE URINE BACTERIAL QUANT CNT	$49.20	$82.00	—	—	40%
Urine microalbumin (albumin) test CPT 82043 MICROALBUMIN URINE QUANT	$35.40	$59.00	—	2% above	40%
Urine microalbumin (albumin) test CPT 82043 MICROALBUMIN 24 HR URINE QUANT	$35.40	$59.00	—	2% above	40%
Urine microalbumin (albumin) test inpatient CPT 82043 MICROALBUMIN 24 HR URINE QUANT	$35.40	$59.00	—	—	40%
Urine microalbumin (albumin) test inpatient CPT 82043 MICROALBUMIN URINE QUANT	$35.40	$59.00	—	—	40%
Urine pregnancy test, read by color change CPT 81025 URINE PREGNANCY TEST	$65.40	$109.00	—	21% above	40%
Urine pregnancy test, read by color change inpatient CPT 81025 URINE PREGNANCY TEST	$65.40	$109.00	—	—	40%
Vitamin B12 (cobalamin) blood test CPT 82607 VITAMIN B12	$92.40	$154.00	—	25% above	40%
Vitamin B12 (cobalamin) blood test inpatient CPT 82607 VITAMIN B12	$92.40	$154.00	—	—	40%
Vitamin D blood test, 25-hydroxy (the standard vitamin D level test) CPT 82306 VITAMIN D 25 HYDROXY	$181.20	$302.00	—	34% above	40%
Vitamin D blood test, 25-hydroxy (the standard vitamin D level test) inpatient CPT 82306 VITAMIN D 25 HYDROXY	$181.20	$302.00	—	—	40%
Vitamin D, 1,25-dihydroxy blood test CPT 82652 VITAMIN D 1 25 DIHYDROXY	$235.80	$393.00	—	32% above	40%
Vitamin D, 1,25-dihydroxy blood test inpatient CPT 82652 VITAMIN D 1 25 DIHYDROXY	$235.80	$393.00	—	—	40%
Zinc blood test CPT 84630 ZINC URINE	$70.20	$117.00	—	15% below	40%
Zinc blood test CPT 84630 ZINC 24 HR URINE	$70.20	$117.00	—	15% below	40%
Zinc blood test CPT 84630 ZINC SERUM	$70.20	$117.00	—	15% below	40%
Zinc blood test CPT 84630 ZINC BLOOD	$113.40	$189.00	—	37% above	40%
Zinc blood test inpatient CPT 84630 ZINC URINE	$70.20	$117.00	—	—	40%
Zinc blood test inpatient CPT 84630 ZINC 24 HR URINE	$70.20	$117.00	—	—	40%
Zinc blood test inpatient CPT 84630 ZINC SERUM	$70.20	$117.00	—	—	40%
Zinc blood test inpatient CPT 84630 ZINC BLOOD	$113.40	$189.00	—	—	40%
hCG pregnancy hormone blood test, quantitative (measures the level) CPT 84702 HCG-MATERNAL SCREEN	$91.80	$153.00	—	15% above	40%
hCG pregnancy hormone blood test, quantitative (measures the level) CPT 84702 HCG QUANT TUMOR MARKER	$91.80	$153.00	—	15% above	40%
hCG pregnancy hormone blood test, quantitative (measures the level) CPT 84702 HCG QUANT	$91.80	$153.00	—	15% above	40%
hCG pregnancy hormone blood test, quantitative (measures the level) CPT 84702 POC HCG QUANT	$91.80	$153.00	—	15% above	40%
hCG pregnancy hormone blood test, quantitative (measures the level) inpatient CPT 84702 HCG QUANT TUMOR MARKER	$91.80	$153.00	—	—	40%
hCG pregnancy hormone blood test, quantitative (measures the level) inpatient CPT 84702 POC HCG QUANT	$91.80	$153.00	—	—	40%
hCG pregnancy hormone blood test, quantitative (measures the level) inpatient CPT 84702 HCG-MATERNAL SCREEN	$91.80	$153.00	—	—	40%
hCG pregnancy hormone blood test, quantitative (measures the level) inpatient CPT 84702 HCG QUANT	$91.80	$153.00	—	—	40%

Surgery and procedures

Procedure	Cash price	List price	Insurers pay	vs Indiana	Off list
Botox injections for chronic migraine CPT 64615 CHEMODENERV OF MUSC(S) INNRV FAC NRV BIL	$790.80	$1,318.00	—	23% above	40%
Botox injections for chronic migraine inpatient CPT 64615 CHEMODENERV OF MUSC(S) INNRV FAC NRV BIL	$790.80	$1,318.00	—	—	40%
Breast needle biopsy guided by mammogram (stereotactic), with marker clip, first lesion CPT 19081 BX BREAST STEREOTACTIC PERCUTANEOUS	$3,476.40	$5,794.00	—	39% above	40%
Breast needle biopsy guided by mammogram (stereotactic), with marker clip, first lesion inpatient CPT 19081 BX BREAST STEREOTACTIC PERCUTANEOUS	$3,476.40	$5,794.00	—	—	40%
Cardiac catheterization with coronary angiogram CPT 93458 LT HEART ARTERY/VENTRICLE ANGIO	$6,858.60	$11,431.00	—	31% below	40%
Cardiac catheterization with coronary angiogram inpatient CPT 93458 LT HEART ARTERY/VENTRICLE ANGIO	$6,858.60	$11,431.00	—	—	40%
Cardioversion, elective (restoring heart rhythm) CPT 92960 CARDIOVERSION ELECTIVE EXT	$1,648.80	$2,748.00	—	17% above	40%
Cardioversion, elective (restoring heart rhythm) inpatient CPT 92960 CARDIOVERSION ELECTIVE EXT	$1,648.80	$2,748.00	—	—	40%
Circumcision with a clamp or device and a numbing nerve block, usually newborns CPT 54150 CIRCUMCISION CLAMP OTH DEV W BLOCK	$5,201.40	$8,669.00	—	630% above	40%
Circumcision with a clamp or device and a numbing nerve block, usually newborns inpatient CPT 54150 CIRCUMCISION CLAMP OTH DEV W BLOCK	$5,201.40	$8,669.00	—	—	40%
Colonoscopy, diagnostic CPT 45378 GI COLONOSCOPY	$2,166.00	$3,610.00	—	7% above	40%
Colonoscopy, diagnostic inpatient CPT 45378 GI COLONOSCOPY	$2,166.00	$3,610.00	—	—	40%
Destruction of a precancerous skin lesion (actinic keratosis), first lesion CPT 17000 DESTRUCTION PREMALIGNANT LESION 1ST	$506.40	$844.00	—	171% above	40%
Destruction of a precancerous skin lesion (actinic keratosis), first lesion inpatient CPT 17000 DESTRUCTION PREMALIGNANT LESION 1ST	$506.40	$844.00	—	—	40%
Earwax removal by irrigation (rinsing), one ear one side CPT 69209 RVHH IMPACT CERUMEN IRR/LAVAGE UNILAT	$162.00	$270.00	—	8% below	40%
Earwax removal by irrigation (rinsing), one ear inpatient one side CPT 69209 RVHH IMPACT CERUMEN IRR/LAVAGE UNILAT	$162.00	$270.00	—	—	40%
Earwax removal with instruments, one ear one side CPT 69210 RVHH REM IMPACT CERUMEN INSTRUMENT UNILAT	$162.00	$270.00	—	1% above	40%
Earwax removal with instruments, one ear inpatient one side CPT 69210 RVHH REM IMPACT CERUMEN INSTRUMENT UNILAT	$162.00	$270.00	—	—	40%
Endometrial biopsy (uterine lining sample) without dilating the cervix CPT 58100 ENDOMETRIAL BIOPSY	$356.40	$594.00	—	24% above	40%
Endometrial biopsy (uterine lining sample) without dilating the cervix inpatient CPT 58100 ENDOMETRIAL BIOPSY	$356.40	$594.00	—	—	40%
Epidural steroid injection, neck or mid back, with imaging guidance CPT 62321 INJECT INTERLAMINAR CERV OR THORACIC W IMAG	$1,807.20	$3,012.00	—	70% above	40%
Epidural steroid injection, neck or mid back, with imaging guidance inpatient CPT 62321 INJECT INTERLAMINAR CERV OR THORACIC W IMAG	$1,807.20	$3,012.00	—	—	40%
Facet joint injection, lower back, one level, with imaging guidance CPT 64493 INJ PARAVERT F JNT L/S 1ST LEV	$2,183.40	$3,639.00	—	89% above	40%
Facet joint injection, lower back, one level, with imaging guidance inpatient CPT 64493 INJ PARAVERT F JNT L/S 1ST LEV	$2,183.40	$3,639.00	—	—	40%
Flexible sigmoidoscopy, diagnostic (lower colon only) CPT 45330 GI SIGMOIDISCOPE FLEXIBLE	$2,389.20	$3,982.00	—	15% above	40%
Flexible sigmoidoscopy, diagnostic (lower colon only) inpatient CPT 45330 GI SIGMOIDISCOPE FLEXIBLE	$2,389.20	$3,982.00	—	—	40%
Hysterosalpingogram (HSG): contrast injection to check the fallopian tubes CPT 58340 INJ HYSTEROSALPINGOGRAM	$739.20	$1,232.00	—	157% above	40%
Hysterosalpingogram (HSG): contrast injection to check the fallopian tubes inpatient CPT 58340 INJ HYSTEROSALPINGOGRAM	$739.20	$1,232.00	—	—	40%
Incision and drainage of a simple or single skin abscess CPT 10060 RVHH I/D ABSCESS SIMPLE	$506.40	$844.00	—	10% above	40%
Incision and drainage of a simple or single skin abscess CPT 10060 I/D ABSESS SIMPLE	$506.40	$844.00	—	10% above	40%
Incision and drainage of a simple or single skin abscess inpatient CPT 10060 RVHH I/D ABSCESS SIMPLE	$506.40	$844.00	—	—	40%
Incision and drainage of a simple or single skin abscess inpatient CPT 10060 I/D ABSESS SIMPLE	$506.40	$844.00	—	—	40%
Injection into a tendon sheath or ligament (for example trigger finger) CPT 20550 INJ SGL TEN SHEATH/LIG/APO	$762.60	$1,271.00	—	43% above	40%
Injection into a tendon sheath or ligament (for example trigger finger) inpatient CPT 20550 INJ SGL TEN SHEATH/LIG/APO	$762.60	$1,271.00	—	—	40%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 ASP/INJ MAJOR JT WO US GUID	$762.60	$1,271.00	—	85% above	40%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 RVHH ASP/INJ MAJOR JT W/O US GUID	$994.20	$1,657.00	—	141% above	40%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 ASP/INJ MAJOR JT WO US GUID	$762.60	$1,271.00	—	—	40%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 RVHH ASP/INJ MAJOR JT W/O US GUID	$994.20	$1,657.00	—	—	40%
Insertion of a drug-delivery implant, such as the arm birth control implant CPT 11981 INSERT, NON-BIODEGRADABLE DRUG DELIVERY IMPLA	$340.80	$568.00	—	82% below	40%
Insertion of a drug-delivery implant, such as the arm birth control implant inpatient CPT 11981 INSERT, NON-BIODEGRADABLE DRUG DELIVERY IMPLA	$340.80	$568.00	—	—	40%
Joint injection or drainage, medium joint (wrist, elbow, ankle) CPT 20605 ASP/INJ INTERMED JT WO US GUID	$762.60	$1,271.00	—	78% above	40%
Joint injection or drainage, medium joint (wrist, elbow, ankle) CPT 20605 RVHH ASP/INJ INTERM JT W/O US GUID	$994.20	$1,657.00	—	133% above	40%
Joint injection or drainage, medium joint (wrist, elbow, ankle) inpatient CPT 20605 ASP/INJ INTERMED JT WO US GUID	$762.60	$1,271.00	—	—	40%
Joint injection or drainage, medium joint (wrist, elbow, ankle) inpatient CPT 20605 RVHH ASP/INJ INTERM JT W/O US GUID	$994.20	$1,657.00	—	—	40%
Joint injection or drainage, small joint (fingers, toes) CPT 20600 RVHH ASP/INJ SM JT W/O US	$762.60	$1,271.00	—	160% above	40%
Joint injection or drainage, small joint (fingers, toes) CPT 20600 ASP/INJ SMALL JT WO US GUID	$762.60	$1,271.00	—	160% above	40%
Joint injection or drainage, small joint (fingers, toes) inpatient CPT 20600 ASP/INJ SMALL JT WO US GUID	$762.60	$1,271.00	—	—	40%
Joint injection or drainage, small joint (fingers, toes) inpatient CPT 20600 RVHH ASP/INJ SM JT W/O US	$762.60	$1,271.00	—	—	40%
Laser treatment of clouding after cataract surgery (YAG) CPT 66821 LASER YAG TREATMENT	$1,230.60	$2,051.00	—	41% below	40%
Laser treatment of clouding after cataract surgery (YAG) inpatient CPT 66821 LASER YAG TREATMENT	$1,230.60	$2,051.00	—	—	40%
Layered stitches for a cut up to 2.5 cm, intermediate repair, scalp, body, arms or legs CPT 12031 RVHH INT REP SC/AX/TR/EXT 2.5/<	$285.00	$475.00	—	60% below	40%
Layered stitches for a cut up to 2.5 cm, intermediate repair, scalp, body, arms or legs inpatient CPT 12031 RVHH INT REP SC/AX/TR/EXT 2.5/<	$285.00	$475.00	—	—	40%
Left heart catheterization, diagnostic one side CPT 93452 LT HEART CATH INCLUDING INJ LT VENTRICULOGRAPHY, S/I	$6,858.60	$11,431.00	—	12% below	40%
Left heart catheterization, diagnostic inpatient one side CPT 93452 LT HEART CATH INCLUDING INJ LT VENTRICULOGRAPHY, S/I	$6,858.60	$11,431.00	—	—	40%
Lower-back epidural injection, with imaging guidance CPT 62323 INJECT INTERLAMINAR LUMBAR OR SACRAL W IMAG	$1,807.20	$3,012.00	—	41% above	40%
Lower-back epidural injection, with imaging guidance inpatient CPT 62323 INJECT INTERLAMINAR LUMBAR OR SACRAL W IMAG	$1,807.20	$3,012.00	—	—	40%
Lower-back epidural injection, without imaging guidance CPT 62322 INJ DX/TX EPID/SUBARACR LMBR/SAC WO IMAG	$2,389.80	$3,983.00	—	69% above	40%
Lower-back epidural injection, without imaging guidance inpatient CPT 62322 INJ DX/TX EPID/SUBARACR LMBR/SAC WO IMAG	$2,389.80	$3,983.00	—	—	40%
Lower-back nerve root steroid injection, with imaging guidance CPT 64483 INJ TRANSFORMINAL EPI/LUMB/SACRAL SNGL LEVEL	$2,389.80	$3,983.00	—	46% above	40%
Lower-back nerve root steroid injection, with imaging guidance inpatient CPT 64483 INJ TRANSFORMINAL EPI/LUMB/SACRAL SNGL LEVEL	$2,389.80	$3,983.00	—	—	40%
Nail removal (partial or complete), one nail CPT 11730 RVHH AVULSION NAIL PLATE SINGLE	$506.40	$844.00	—	28% above	40%
Nail removal (partial or complete), one nail inpatient CPT 11730 RVHH AVULSION NAIL PLATE SINGLE	$506.40	$844.00	—	—	40%
Occipital nerve block (injection for headaches) CPT 64405 RVHH INJ ANESTH/STEROID GREATER OCCIP NRV	$762.60	$1,271.00	—	26% above	40%
Occipital nerve block (injection for headaches) CPT 64405 INJ ANES GTR OCCIPTAL NERVE	$762.60	$1,271.00	—	26% above	40%
Occipital nerve block (injection for headaches) inpatient CPT 64405 RVHH INJ ANESTH/STEROID GREATER OCCIP NRV	$762.60	$1,271.00	—	—	40%
Occipital nerve block (injection for headaches) inpatient CPT 64405 INJ ANES GTR OCCIPTAL NERVE	$762.60	$1,271.00	—	—	40%
Pacemaker implant (dual chamber) CPT 33208 INS NEW OR REPL PERM PACEMAKER A AND V	$23,946.60	$39,911.00	—	98% above	40%
Pacemaker implant (dual chamber) inpatient CPT 33208 INS NEW OR REPL PERM PACEMAKER A AND V	$23,946.60	$39,911.00	—	—	40%
Paracentesis with imaging guidance CPT 49083 ABD PARACENTESIS WITH IMAG GUIDANCE	$1,914.00	$3,190.00	—	38% above	40%
Paracentesis with imaging guidance inpatient CPT 49083 ABD PARACENTESIS WITH IMAG GUIDANCE	$1,914.00	$3,190.00	—	—	40%
Permanent removal of a nail and nail root (partial or complete) CPT 11750 RVHH EXC NAIL/MATRIX PERM REM	$1,046.40	$1,744.00	—	50% above	40%
Permanent removal of a nail and nail root (partial or complete) inpatient CPT 11750 RVHH EXC NAIL/MATRIX PERM REM	$1,046.40	$1,744.00	—	—	40%
Radiofrequency ablation of facet joint nerves, lower back, one level CPT 64635 DESTRUCT NEU FACET W IMAG GUID L/S SNGL	$4,167.60	$6,946.00	—	26% above	40%
Radiofrequency ablation of facet joint nerves, lower back, one level inpatient CPT 64635 DESTRUCT NEU FACET W IMAG GUID L/S SNGL	$4,167.60	$6,946.00	—	—	40%
Removal of a foreign object under the skin, simple CPT 10120 RVHH RFB SUBQ TISSUE SIMPLE	$1,046.40	$1,744.00	—	70% above	40%
Removal of a foreign object under the skin, simple inpatient CPT 10120 RVHH RFB SUBQ TISSUE SIMPLE	$1,046.40	$1,744.00	—	—	40%
Short arm splint (forearm and hand) CPT 29125 RVHH APPL SPLINT SHORT ARM	$325.20	$542.00	—	79% above	40%
Short arm splint (forearm and hand) inpatient CPT 29125 RVHH APPL SPLINT SHORT ARM	$325.20	$542.00	—	—	40%
Short leg splint (calf to foot) CPT 29515 RVHH APPL SPLINT SHORT LEG	$408.60	$681.00	—	69% above	40%
Short leg splint (calf to foot) inpatient CPT 29515 RVHH APPL SPLINT SHORT LEG	$408.60	$681.00	—	—	40%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs CPT 12001 RVHH SIMP REP S/NK/TR/EXT 2.5/<	$506.40	$844.00	—	16% above	40%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs CPT 12001 SIMP REP S/NK/TR/EXT 2.5/<	$506.40	$844.00	—	16% above	40%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs inpatient CPT 12001 SIMP REP S/NK/TR/EXT 2.5/<	$506.40	$844.00	—	—	40%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs inpatient CPT 12001 RVHH SIMP REP S/NK/TR/EXT 2.5/<	$506.40	$844.00	—	—	40%
Skin biopsy, punch, one lesion CPT 11104 PUNCH BX SKIN SINGLE LESION	$1,046.40	$1,744.00	—	132% above	40%
Skin biopsy, punch, one lesion inpatient CPT 11104 PUNCH BX SKIN SINGLE LESION	$1,046.40	$1,744.00	—	—	40%
Skin tag removal, up to 15 tags CPT 11200 REM SKIN TAGS UP TO 15 LESIONS	$506.40	$844.00	—	79% above	40%
Skin tag removal, up to 15 tags inpatient CPT 11200 REM SKIN TAGS UP TO 15 LESIONS	$506.40	$844.00	—	—	40%
Spinal tap (lumbar puncture), diagnostic CPT 62270 RVHH PUNCTURE SPINAL/LUMBAR DX	$1,807.20	$3,012.00	—	76% above	40%
Spinal tap (lumbar puncture), diagnostic CPT 62270 PUNCTURE SPINAL/LUMBAR DX	$1,807.20	$3,012.00	—	76% above	40%
Spinal tap (lumbar puncture), diagnostic inpatient CPT 62270 PUNCTURE SPINAL/LUMBAR DX	$1,807.20	$3,012.00	—	—	40%
Spinal tap (lumbar puncture), diagnostic inpatient CPT 62270 RVHH PUNCTURE SPINAL/LUMBAR DX	$1,807.20	$3,012.00	—	—	40%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs CPT 12002 SIMP REP S/NK/TR/EXT 2.6 TO 7.5CM	$506.40	$844.00	—	27% above	40%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs CPT 12002 RVHH SIMP REP S/NK/TR/EXT 2.6 TO 7.5CM	$506.40	$844.00	—	27% above	40%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs inpatient CPT 12002 SIMP REP S/NK/TR/EXT 2.6 TO 7.5CM	$506.40	$844.00	—	—	40%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs inpatient CPT 12002 RVHH SIMP REP S/NK/TR/EXT 2.6 TO 7.5CM	$506.40	$844.00	—	—	40%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair CPT 12011 RVHH SIMP REP F/EEN/LP/MM 2.5CM/<	$506.40	$844.00	—	18% above	40%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair inpatient CPT 12011 RVHH SIMP REP F/EEN/LP/MM 2.5CM/<	$506.40	$844.00	—	—	40%
Tangential (shave-style) skin biopsy, one lesion CPT 11102 TANGNTL BX SKIN LES	$506.40	$844.00	—	24% above	40%
Tangential (shave-style) skin biopsy, one lesion inpatient CPT 11102 TANGNTL BX SKIN LES	$506.40	$844.00	—	—	40%
Thoracentesis with imaging guidance CPT 32555 THORACENTESIS PLEURAL SPACE W GUIDANCE	$1,621.80	$2,703.00	—	48% above	40%
Thoracentesis with imaging guidance inpatient CPT 32555 THORACENTESIS PLEURAL SPACE W GUIDANCE	$1,621.80	$2,703.00	—	—	40%
Trigger point injections, 1 or 2 muscles CPT 20552 INJ TRIGGER PT 1 OR 2 MUSC	$762.60	$1,271.00	—	34% above	40%
Trigger point injections, 1 or 2 muscles CPT 20552 RVHH INJ TRIGGER PT 1 OR 2 MUSC	$762.60	$1,271.00	—	34% above	40%
Trigger point injections, 1 or 2 muscles inpatient CPT 20552 RVHH INJ TRIGGER PT 1 OR 2 MUSC	$762.60	$1,271.00	—	—	40%
Trigger point injections, 1 or 2 muscles inpatient CPT 20552 INJ TRIGGER PT 1 OR 2 MUSC	$762.60	$1,271.00	—	—	40%
Ultrasound-guided breast needle biopsy with marker clip, first lesion CPT 19083 BX BREAST ULTRASOUND PERCUTANEOUS	$3,476.40	$5,794.00	—	50% above	40%
Ultrasound-guided breast needle biopsy with marker clip, first lesion inpatient CPT 19083 BX BREAST ULTRASOUND PERCUTANEOUS	$3,476.40	$5,794.00	—	—	40%
Upper endoscopy (EGD), diagnostic CPT 43235 GI UPPER ENDOSCOPY COMPLEX	$2,373.60	$3,956.00	—	at median	40%
Upper endoscopy (EGD), diagnostic inpatient CPT 43235 GI UPPER ENDOSCOPY COMPLEX	$2,373.60	$3,956.00	—	—	40%
Vein ablation, radiofrequency, first vein CPT 36475 ENDOVENOUS RF 1ST VEIN	$6,906.60	$11,511.00	—	11% above	40%
Vein ablation, radiofrequency, first vein inpatient CPT 36475 ENDOVENOUS RF 1ST VEIN	$6,906.60	$11,511.00	—	—	40%
Wart removal, up to 14 warts CPT 17110 DESTRUCT BENIGN/ CUTANEOUS VASC LESIONS 1-14	$438.60	$731.00	—	48% above	40%
Wart removal, up to 14 warts inpatient CPT 17110 DESTRUCT BENIGN/ CUTANEOUS VASC LESIONS 1-14	$438.60	$731.00	—	—	40%
Wound debridement, skin and tissue under it, first 20 sq cm CPT 11042 DEBRID SKIN AND SUBQ TISSUE	$978.00	$1,630.00	—	26% above	40%
Wound debridement, skin and tissue under it, first 20 sq cm inpatient CPT 11042 DEBRID SKIN AND SUBQ TISSUE	$978.00	$1,630.00	—	—	40%

Doctor visits and therapy

Procedure	Cash price	List price	Insurers pay	vs Indiana	Off list
Blood transfusion (giving blood or blood components) CPT 36430 BLOOD / PRODUCTS TRANSFUSION PER HOUR	$1,143.60	$1,906.00	—	27% above	40%
Blood transfusion (giving blood or blood components) CPT 36430 RAPID BLOOD / PRODUCTS TRANSFUSION	$1,143.60	$1,906.00	—	27% above	40%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 RAPID BLOOD / PRODUCTS TRANSFUSION	$1,143.60	$1,906.00	—	—	40%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 BLOOD / PRODUCTS TRANSFUSION PER HOUR	$1,143.60	$1,906.00	—	—	40%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 AIRWAY OBSTRUCTION SPUTUM INDUCT	$262.80	$438.00	—	133% above	40%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 METER DOSE INHALER	$262.80	$438.00	—	133% above	40%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 INHALATION/NEBULIZER TREATMENT	$262.80	$438.00	—	133% above	40%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 INHALATION/NEBULIZER TREATMENT	$262.80	$438.00	—	—	40%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 AIRWAY OBSTRUCTION SPUTUM INDUCT	$262.80	$438.00	—	—	40%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 METER DOSE INHALER	$262.80	$438.00	—	—	40%
Chemotherapy IV infusion, first hour CPT 96413 CHEMO IV INFUSION SGL/INIT<1HR	$771.00	$1,285.00	—	14% above	40%
Chemotherapy IV infusion, first hour inpatient CPT 96413 CHEMO IV INFUSION SGL/INIT<1HR	$771.00	$1,285.00	—	—	40%
Critical care, first 30 to 74 minutes CPT 99291 CRITICAL CARE FIRST 30 - 74 MIN	$2,491.20	$4,152.00	—	17% above	40%
Critical care, first 30 to 74 minutes inpatient CPT 99291 CRITICAL CARE FIRST 30 - 74 MIN	$2,491.20	$4,152.00	—	—	40%
EEG (brain wave test), awake and drowsy, routine CPT 95816 EEG W AWAKE AND DROWSY RECORD	$649.80	$1,083.00	—	5% below	40%
EEG (brain wave test), awake and drowsy, routine inpatient CPT 95816 EEG W AWAKE AND DROWSY RECORD	$649.80	$1,083.00	—	—	40%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge CPT 93005 EKG 12 LEAD TRACING ONLY	$166.20	$277.00	—	18% below	40%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient CPT 93005 EKG 12 LEAD TRACING ONLY	$166.20	$277.00	—	—	40%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor CPT 99281 ED VISIT CARE LEVEL 1	$243.60	$406.00	—	12% above	40%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor inpatient CPT 99281 ED VISIT CARE LEVEL 1	$243.60	$406.00	—	—	40%
Emergency room visit, level 2 of 5, straightforward problem CPT 99282 ED VISIT CARE LEVEL 2	$453.60	$756.00	—	8% above	40%
Emergency room visit, level 2 of 5, straightforward problem inpatient CPT 99282 ED VISIT CARE LEVEL 2	$453.60	$756.00	—	—	40%
Emergency room visit, level 3 of 5, low-complexity problem CPT 99283 ED VISIT CARE LEVEL 3	$795.60	$1,326.00	—	2% above	40%
Emergency room visit, level 3 of 5, low-complexity problem inpatient CPT 99283 ED VISIT CARE LEVEL 3	$795.60	$1,326.00	—	—	40%
Emergency room visit, level 4 of 5, moderate-complexity problem CPT 99284 ED VISIT CARE LEVEL 4	$1,238.40	$2,064.00	—	5% above	40%
Emergency room visit, level 4 of 5, moderate-complexity problem inpatient CPT 99284 ED VISIT CARE LEVEL 4	$1,238.40	$2,064.00	—	—	40%
Emergency room visit, level 5 of 5, high-complexity problem CPT 99285 ED VISIT CARE LEVEL 5	$1,779.00	$2,965.00	—	2% above	40%
Emergency room visit, level 5 of 5, high-complexity problem inpatient CPT 99285 ED VISIT CARE LEVEL 5	$1,779.00	$2,965.00	—	—	40%
Exercise stress test, tracing only, the hospital charge CPT 93017 CARDIAC STRESS TEST TRACING ONLY	$649.20	$1,082.00	—	15% below	40%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 CARDIAC STRESS TEST TRACING ONLY	$649.20	$1,082.00	—	—	40%
Family therapy with the patient, 50 minutes CPT 90847 PSYCH FAM THER W PT 50MIN (MAX QTY 2)	$304.20	$507.00	—	61% above	40%
Family therapy with the patient, 50 minutes inpatient CPT 90847 PSYCH FAM THER W PT 50MIN (MAX QTY 2)	$304.20	$507.00	—	—	40%
Family therapy without the patient, 50 minutes CPT 90846 PSYCH FAM THER WO PT 50MIN (MAX QTY 2)	$304.20	$507.00	—	49% above	40%
Family therapy without the patient, 50 minutes inpatient CPT 90846 PSYCH FAM THER WO PT 50MIN (MAX QTY 2)	$304.20	$507.00	—	—	40%
Group psychotherapy session CPT 90853 GROUP PSYCHOTHERAPY	$158.40	$264.00	—	21% below	40%
Group psychotherapy session inpatient CPT 90853 GROUP PSYCHOTHERAPY	$158.40	$264.00	—	—	40%
IV hydration (fluids through a vein), first 31 to 60 minutes CPT 96360 IV INFUSION, HYDRATION INIT UP TO 1HR	$478.80	$798.00	—	30% above	40%
IV hydration (fluids through a vein), first 31 to 60 minutes inpatient CPT 96360 IV INFUSION, HYDRATION INIT UP TO 1HR	$478.80	$798.00	—	—	40%
IV infusion of a medicine, first hour CPT 96365 IV INFUSION,TX,PROPH,DX INIT UP TO 1 HR	$478.80	$798.00	—	18% above	40%
IV infusion of a medicine, first hour inpatient CPT 96365 IV INFUSION,TX,PROPH,DX INIT UP TO 1 HR	$478.80	$798.00	—	—	40%
IV push of a medicine, first drug CPT 96374 INJ IVP,INITIAL DRUGS/SUB	$478.80	$798.00	—	126% above	40%
IV push of a medicine, first drug inpatient CPT 96374 INJ IVP,INITIAL DRUGS/SUB	$478.80	$798.00	—	—	40%
Injection under the skin or into a muscle, for treatment or testing CPT 96372 INJECTION SQ/IM	$156.00	$260.00	—	48% above	40%
Injection under the skin or into a muscle, for treatment or testing inpatient CPT 96372 INJECTION SQ/IM	$156.00	$260.00	—	—	40%
Mental health diagnostic evaluation (intake), without medical services CPT 90791 PYSCH EVAL W/O MED SERVICES	$304.20	$507.00	—	21% above	40%
Mental health diagnostic evaluation (intake), without medical services inpatient CPT 90791 PYSCH EVAL W/O MED SERVICES	$304.20	$507.00	—	—	40%
Nerve conduction study, 7 or 8 nerve studies CPT 95910 NERVE CONDUCT STUDIES 7-8 STUDIES	$649.80	$1,083.00	—	25% below	40%
Nerve conduction study, 7 or 8 nerve studies inpatient CPT 95910 NERVE CONDUCT STUDIES 7-8 STUDIES	$649.80	$1,083.00	—	—	40%
New patient office visit, about 30 minutes CPT 99203 RVHH OP UC VISIT LEVEL III NEW PT	$195.60	$326.00	—	18% above	40%
New patient office visit, about 30 minutes CPT 99203 RVHH LD OP NEW LEVEL 3	$207.00	$345.00	—	25% above	40%
New patient office visit, about 30 minutes CPT 99203 OP VISIT LEVEL III NEW PT	$235.20	$392.00	—	42% above	40%
New patient office visit, about 30 minutes inpatient CPT 99203 RVHH OP UC VISIT LEVEL III NEW PT	$195.60	$326.00	—	—	40%
New patient office visit, about 30 minutes inpatient CPT 99203 RVHH LD OP NEW LEVEL 3	$207.00	$345.00	—	—	40%
New patient office visit, about 30 minutes inpatient CPT 99203 OP VISIT LEVEL III NEW PT	$235.20	$392.00	—	—	40%
New patient office visit, about 45 minutes CPT 99204 RVHH OP UC VISIT LEVEL IV NEW PT	$224.40	$374.00	—	19% above	40%
New patient office visit, about 45 minutes CPT 99204 RVHH LD OP NEW LEVEL 4	$273.00	$455.00	—	44% above	40%
New patient office visit, about 45 minutes CPT 99204 OP VISIT LEVEL IV NEW PT	$310.80	$518.00	—	64% above	40%
New patient office visit, about 45 minutes inpatient CPT 99204 RVHH OP UC VISIT LEVEL IV NEW PT	$224.40	$374.00	—	—	40%
New patient office visit, about 45 minutes inpatient CPT 99204 RVHH LD OP NEW LEVEL 4	$273.00	$455.00	—	—	40%
New patient office visit, about 45 minutes inpatient CPT 99204 OP VISIT LEVEL IV NEW PT	$310.80	$518.00	—	—	40%
New patient office visit, about 60 minutes CPT 99205 RVHH OP UC VISIT LEVEL V NEW PT	$253.80	$423.00	—	at median	40%
New patient office visit, about 60 minutes CPT 99205 RVHH LD OP NEW LEVEL 5	$375.00	$625.00	—	48% above	40%
New patient office visit, about 60 minutes CPT 99205 OP VISIT LEVEL V NEW PT	$426.60	$711.00	—	68% above	40%
New patient office visit, about 60 minutes inpatient CPT 99205 RVHH OP UC VISIT LEVEL V NEW PT	$253.80	$423.00	—	—	40%
New patient office visit, about 60 minutes inpatient CPT 99205 RVHH LD OP NEW LEVEL 5	$375.00	$625.00	—	—	40%
New patient office visit, about 60 minutes inpatient CPT 99205 OP VISIT LEVEL V NEW PT	$426.60	$711.00	—	—	40%
New patient office visit, straightforward problem or 15+ minutes CPT 99202 RVHH OP UC VISIT LEVEL II NEW PT	$166.80	$278.00	—	19% above	40%
New patient office visit, straightforward problem or 15+ minutes CPT 99202 RVHH LD OP NEW LEVEL 2	$170.40	$284.00	—	21% above	40%
New patient office visit, straightforward problem or 15+ minutes CPT 99202 OP VISIT LEVEL II NEW PT	$193.80	$323.00	—	38% above	40%
New patient office visit, straightforward problem or 15+ minutes inpatient CPT 99202 RVHH OP UC VISIT LEVEL II NEW PT	$166.80	$278.00	—	—	40%
New patient office visit, straightforward problem or 15+ minutes inpatient CPT 99202 RVHH LD OP NEW LEVEL 2	$170.40	$284.00	—	—	40%
New patient office visit, straightforward problem or 15+ minutes inpatient CPT 99202 OP VISIT LEVEL II NEW PT	$193.80	$323.00	—	—	40%
Nutrition counseling (medical nutrition therapy), first visit, 15 minutes CPT 97802 MED NUTRITION THERAPY EA 15M	$42.60	$71.00	—	25% above	40%
Nutrition counseling (medical nutrition therapy), first visit, 15 minutes inpatient CPT 97802 MED NUTRITION THERAPY EA 15M	$42.60	$71.00	—	—	40%
Psychological testing evaluation by a psychologist or physician, first hour CPT 96130 PSYCHOLOGICAL TEST EVAL PHYS/QHP, FIRST HR	$649.80	$1,083.00	—	370% above	40%
Psychological testing evaluation by a psychologist or physician, first hour inpatient CPT 96130 PSYCHOLOGICAL TEST EVAL PHYS/QHP, FIRST HR	$649.80	$1,083.00	—	—	40%
Psychotherapy session, 30 minutes CPT 90832 PSYCH THER 30 MIN WITH PATIENT	$304.20	$507.00	—	209% above	40%
Psychotherapy session, 30 minutes inpatient CPT 90832 PSYCH THER 30 MIN WITH PATIENT	$304.20	$507.00	—	—	40%
Psychotherapy session, 45 minutes CPT 90834 PSYCH THER 45 MIN WITH PATIENT	$304.20	$507.00	—	116% above	40%
Psychotherapy session, 45 minutes inpatient CPT 90834 PSYCH THER 45 MIN WITH PATIENT	$304.20	$507.00	—	—	40%
Psychotherapy session, 60 minutes CPT 90837 PSYCH THER 60 MIN WITH PATIENT	$304.20	$507.00	—	43% above	40%
Psychotherapy session, 60 minutes inpatient CPT 90837 PSYCH THER 60 MIN WITH PATIENT	$304.20	$507.00	—	—	40%
Quit-smoking counseling, 3 to 10 minutes CPT 99406 SMOKING CESS > 3MIN UP TO 10 MIN	$61.80	$103.00	—	106% above	40%
Quit-smoking counseling, 3 to 10 minutes inpatient CPT 99406 SMOKING CESS > 3MIN UP TO 10 MIN	$61.80	$103.00	—	—	40%
Returning patient office visit, high complexity or 40+ minutes CPT 99215 RVHH OP UC VISIT LEVEL V EST PT	$238.80	$398.00	—	59% above	40%
Returning patient office visit, high complexity or 40+ minutes CPT 99215 OP VISIT LEVEL V EST PT	$356.40	$594.00	—	137% above	40%
Returning patient office visit, high complexity or 40+ minutes CPT 99215 EST PT-LEVEL 5 TWOC	$356.40	$594.00	—	137% above	40%
Returning patient office visit, high complexity or 40+ minutes CPT 99215 RVH TELEHLTH LACT CONS >60MIN	$366.60	$611.00	—	143% above	40%
Returning patient office visit, high complexity or 40+ minutes CPT 99215 LACTATION CONSULT >60 MINUTES	$366.60	$611.00	—	143% above	40%
Returning patient office visit, high complexity or 40+ minutes CPT 99215 RVHH LD OP EST LEVEL 5	$375.00	$625.00	—	149% above	40%
Returning patient office visit, high complexity or 40+ minutes inpatient CPT 99215 RVHH OP UC VISIT LEVEL V EST PT	$238.80	$398.00	—	—	40%
Returning patient office visit, high complexity or 40+ minutes inpatient CPT 99215 EST PT-LEVEL 5 TWOC	$356.40	$594.00	—	—	40%
Returning patient office visit, high complexity or 40+ minutes inpatient CPT 99215 OP VISIT LEVEL V EST PT	$356.40	$594.00	—	—	40%
Returning patient office visit, high complexity or 40+ minutes inpatient CPT 99215 LACTATION CONSULT >60 MINUTES	$366.60	$611.00	—	—	40%
Returning patient office visit, high complexity or 40+ minutes inpatient CPT 99215 RVH TELEHLTH LACT CONS >60MIN	$366.60	$611.00	—	—	40%
Returning patient office visit, high complexity or 40+ minutes inpatient CPT 99215 RVHH LD OP EST LEVEL 5	$375.00	$625.00	—	—	40%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 RVHH OP UC VISIT LEVEL III EST PT	$181.20	$302.00	—	106% above	40%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 OP VISIT LEVEL III EST PT	$196.80	$328.00	—	124% above	40%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 EST PT-LEVEL 3 TWOC	$196.80	$328.00	—	124% above	40%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 RVHH LD OP EST LEVEL 3	$207.00	$345.00	—	135% above	40%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 RVH TELEHLTH LACT CONS 31-45MIN	$207.00	$345.00	—	135% above	40%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 LACTATION CONSULT 31-45 MINUTES	$207.00	$345.00	—	135% above	40%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 LEVEL III VISIT ANTICOAGULATION	$237.60	$396.00	—	170% above	40%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 RVHH OP UC VISIT LEVEL III EST PT	$181.20	$302.00	—	—	40%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 EST PT-LEVEL 3 TWOC	$196.80	$328.00	—	—	40%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 OP VISIT LEVEL III EST PT	$196.80	$328.00	—	—	40%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 RVHH LD OP EST LEVEL 3	$207.00	$345.00	—	—	40%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 LACTATION CONSULT 31-45 MINUTES	$207.00	$345.00	—	—	40%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 RVH TELEHLTH LACT CONS 31-45MIN	$207.00	$345.00	—	—	40%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 LEVEL III VISIT ANTICOAGULATION	$237.60	$396.00	—	—	40%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 RVHH OP UC VISIT LEVEL IV EST PT	$210.00	$350.00	—	89% above	40%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 OP VISIT LEVEL IV EST PT	$260.40	$434.00	—	135% above	40%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 EST PT-LEVEL 4 TWOC	$260.40	$434.00	—	135% above	40%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 RVHH LD OP EST LEVEL 4	$273.00	$455.00	—	146% above	40%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 RVH TELEHLTH LACT CONS 46-60MIN	$294.00	$490.00	—	165% above	40%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 LACTATION CONSULT 46-60 MINUTES	$294.00	$490.00	—	165% above	40%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 RVHH OP UC VISIT LEVEL IV EST PT	$210.00	$350.00	—	—	40%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 OP VISIT LEVEL IV EST PT	$260.40	$434.00	—	—	40%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 EST PT-LEVEL 4 TWOC	$260.40	$434.00	—	—	40%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 RVHH LD OP EST LEVEL 4	$273.00	$455.00	—	—	40%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 LACTATION CONSULT 46-60 MINUTES	$294.00	$490.00	—	—	40%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 RVH TELEHLTH LACT CONS 46-60MIN	$294.00	$490.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 RVHH OP VISIT LEVEL II RAD ONC	$16.20	$27.00	—	69% below	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 RVHH OP UC VISIT LEVEL II EST PT	$152.40	$254.00	—	196% above	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 OP VISIT LEVEL II EST PT	$162.00	$270.00	—	214% above	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 EST PT-LEVEL 2 TWOC	$162.00	$270.00	—	214% above	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 RVHH LD OP EST LEVEL 2	$170.40	$284.00	—	230% above	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 RVH TELEHLTH LACT CONS 16-30MIN	$170.40	$284.00	—	230% above	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 LACTATION CONSULT 16-30 MINUTES	$170.40	$284.00	—	230% above	40%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 LEVEL II VISIT ANTICOAGULATION	$190.20	$317.00	—	269% above	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 RVHH OP VISIT LEVEL II RAD ONC	$16.20	$27.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 RVHH OP UC VISIT LEVEL II EST PT	$152.40	$254.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 EST PT-LEVEL 2 TWOC	$162.00	$270.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 OP VISIT LEVEL II EST PT	$162.00	$270.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 RVHH LD OP EST LEVEL 2	$170.40	$284.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 RVH TELEHLTH LACT CONS 16-30MIN	$170.40	$284.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 LACTATION CONSULT 16-30 MINUTES	$170.40	$284.00	—	—	40%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 LEVEL II VISIT ANTICOAGULATION	$190.20	$317.00	—	—	40%
Spirometry (breathing test) CPT 94010 RVHH SPIROMETRY FIRST RESPONDERS	$165.00	$275.00	—	33% below	40%
Spirometry (breathing test) CPT 94010 SPIROMETRY W/WO MAX VOLUNTARY VNT	$165.00	$275.00	—	33% below	40%
Spirometry (breathing test) CPT 94010 RVHH SPIROMETRY WORKMED	$165.00	$275.00	—	33% below	40%
Spirometry (breathing test) inpatient CPT 94010 RVHH SPIROMETRY WORKMED	$165.00	$275.00	—	—	40%
Spirometry (breathing test) inpatient CPT 94010 SPIROMETRY W/WO MAX VOLUNTARY VNT	$165.00	$275.00	—	—	40%
Spirometry (breathing test) inpatient CPT 94010 RVHH SPIROMETRY FIRST RESPONDERS	$165.00	$275.00	—	—	40%
Spirometry before and after a bronchodilator CPT 94060 BRONCHODIAL PRE AND POST W MVV	$317.40	$529.00	—	42% below	40%
Spirometry before and after a bronchodilator inpatient CPT 94060 BRONCHODIAL PRE AND POST W MVV	$317.40	$529.00	—	—	40%

Vaccines

Procedure	Cash price	List price	Insurers pay	vs Indiana	Off list
Hepatitis B vaccine, adult dose (3-dose schedule) CPT 90746 HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [167799]	$196.80	$328.00	—	12% above	40%
Hepatitis B vaccine, adult dose (3-dose schedule) inpatient CPT 90746 HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE [167799]	$196.80	$328.00	—	—	40%
Hepatitis B vaccine, child and teen dose (3-dose schedule) CPT 90744 HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [168401]	$82.80	$138.00	—	13% above	40%
Hepatitis B vaccine, child and teen dose (3-dose schedule) inpatient CPT 90744 HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE [168401]	$82.80	$138.00	—	—	40%
Hib vaccine (Haemophilus influenzae type b), 4-dose schedule (ActHIB, Hiberix) CPT 90648 HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [177957]	$28.80	$48.00	—	41% below	40%
Hib vaccine (Haemophilus influenzae type b), 4-dose schedule (ActHIB, Hiberix) inpatient CPT 90648 HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [177957]	$28.80	$48.00	—	—	40%
High-dose flu shot, preservative-free, mainly for age 65 and older CPT 90662 FLU VACCINE QUAD 2022-23 (65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE [241650]	$188.40	$314.00	—	5% above	40%
High-dose flu shot, preservative-free, mainly for age 65 and older inpatient CPT 90662 FLU VACCINE QUAD 2022-23 (65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE [241650]	$188.40	$314.00	—	—	40%
MMR vaccine (measles, mumps and rubella), live CPT 90707 MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [178633]	$261.60	$436.00	—	2% above	40%
MMR vaccine (measles, mumps and rubella), live CPT 90707 MEASLES,MUMPS,RUBELLA VACC LIVE(PF)10EXP3.4-4.2-3.3CCID50/0.5ML SUBCUT [241515]	$261.60	$436.00	—	2% above	40%
MMR vaccine (measles, mumps and rubella), live inpatient CPT 90707 MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT [178633]	$261.60	$436.00	—	—	40%
MMR vaccine (measles, mumps and rubella), live inpatient CPT 90707 MEASLES,MUMPS,RUBELLA VACC LIVE(PF)10EXP3.4-4.2-3.3CCID50/0.5ML SUBCUT [241515]	$261.60	$436.00	—	—	40%
Meningococcal ACWY (MenACWY) vaccine CPT 90734 MENINGOCOCCAL A VACCINE LYOPHYLIZED COMPONENT (1 OF 2) [213475]	$325.80	$543.00	—	7% below	40%
Meningococcal ACWY (MenACWY) vaccine inpatient CPT 90734 MENINGOCOCCAL A VACCINE LYOPHYLIZED COMPONENT (1 OF 2) [213475]	$325.80	$543.00	—	—	40%
Meningococcal B vaccine (Bexsero), 2-dose schedule CPT 90620 MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [212663]	$405.00	$675.00	—	4% above	40%
Meningococcal B vaccine (Bexsero), 2-dose schedule inpatient CPT 90620 MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE [212663]	$405.00	$675.00	—	—	40%
Pneumonia vaccine, 20-valent conjugate (Prevnar 20) CPT 90677 PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [238449]	$579.60	$966.00	—	7% below	40%
Pneumonia vaccine, 20-valent conjugate (Prevnar 20) inpatient CPT 90677 PNEUMOCOCCAL 20-VALENT CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE [238449]	$579.60	$966.00	—	—	40%
Rabies vaccine, one dose CPT 90675 RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP [85758]	$940.20	$1,567.00	—	17% above	40%
Rabies vaccine, one dose inpatient CPT 90675 RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP [85758]	$940.20	$1,567.00	—	—	40%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older CPT 90715 DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP [94541]	$133.80	$223.00	—	9% above	40%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older inpatient CPT 90715 DIPHTH,PERTUSSIS(ACELL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5 ML IM SUSP [94541]	$133.80	$223.00	—	—	40%
Vaccine administration fee (giving the shot), first vaccine of the visit CPT 90471 IMM ADMIN VAC/TOXOID X1	$156.00	$260.00	—	153% above	40%
Vaccine administration fee (giving the shot), first vaccine of the visit inpatient CPT 90471 IMM ADMIN VAC/TOXOID X1	$156.00	$260.00	—	—	40%
Vaccine administration fee, each additional vaccine at the same visit CPT 90472 IMM ADMIN VAC/TOXOID EA ADDL	$43.20	$72.00	—	9% above	40%
Vaccine administration fee, each additional vaccine at the same visit inpatient CPT 90472 IMM ADMIN VAC/TOXOID EA ADDL	$43.20	$72.00	—	—	40%

Procedure The service, with its billing code (CPT or HCPCS) and, in small type, the line exactly as the hospital wrote it in its price file. More

Cash price The hospital's own price for a patient paying without insurance (“discounted cash” in its price file). Hospitals must publish it under federal law, 45 CFR 180.50. Call to confirm it before booking. More

List price The hospital's full chargemaster price (“gross charge”) before any discount. Almost nobody pays it; the gap to the cash price shows what the self-pay discount is worth. More

Insurers pay The lowest and highest rates this hospital has agreed with insurance plans for the same item, from its price file. If the cash price is below what your plan pays and you have not met your deductible, paying cash can cost you less. More

Against the state median This hospital's cash price compared with the median cash price of hospitals in the state for the same code. Shown when at least three hospitals in the state price it.

Off list How much lower the cash price is than the list price.

No cash discount This line's cash price equals the hospital's full list price. Many hospitals still reduce bills for uninsured patients: ask the billing office for its self-pay discount in writing. More

At or below Medicare This cash price is at or below what Medicare pays a hospital for the same service, which is unusually low. It is what the hospital's file says; confirm it and what it includes before booking. More

Check the item The description in the hospital file looks like a supply or device (a catheter, a brace, an implant), not this procedure. The hospital may have filed it under the wrong code: ask before relying on this price.

Source file: https://riverview.org/sites/default/files/pdf/25-005054-1_riverview-health_standardcharges.csv