Hospital Whitewater-Elkhorn, WI

Mercyhealth Hospital & Medical Center - Walworth

Mercyhealth Hospital & Medical Center - Walworth in Lake Geneva, WI publishes cash prices for 260 common procedures listed here, from its own machine-readable price file updated Mar 1, 2026. Compared with other hospitals in the state, its outpatient cash prices are above the Wisconsin median for 232 of 255 procedures and below it for 22. By typical cash price it ranks #96 of 101 Wisconsin hospitals, cheapest first. Click a procedure to compare it with other hospitals nearby.

N2950 State Road 67, Lake Geneva, WI 53147 Collected Sep 29, 2026 Source price file (262) 245-0535

Critical access hospital (rural, 25 beds or fewer) Emergency department CMS star rating 3 of 5 CCN 521357 · CMS hospital register NPI 1699728550

Scans and imaging

Procedure	Cash price	List price	Insurers pay	vs Wisconsin	Off list
Ankle X-ray, complete, 3 or more views both sides CPT 73610 HC XR ANKLE COM MIN 3V BILATERAL	$355.77	$474.36	—	—	25%
Ankle X-ray, complete, 3 or more views both sides CPT 73610 HC XR ANKLE COM MIN 3V BILATERAL	$355.77	$474.36	—	—	25%
Ankle X-ray, complete, 3 or more views CPT 73610 HC XR ANKLE COM MIN 3V	$355.77	$474.36	—	106% above	25%
Ankle X-ray, complete, 3 or more views CPT 73610 HC XR ANKLE COM MIN 3V	$355.77	$474.36	—	106% above	25%
Ankle X-ray, complete, 3 or more views inpatient both sides CPT 73610 HC XR ANKLE COM MIN 3V BILATERAL	$355.77	$474.36	—	—	25%
Ankle X-ray, complete, 3 or more views inpatient both sides CPT 73610 HC XR ANKLE COM MIN 3V BILATERAL	$355.77	$474.36	—	—	25%
Ankle X-ray, complete, 3 or more views inpatient CPT 73610 HC XR ANKLE COM MIN 3V	$355.77	$474.36	—	—	25%
Ankle X-ray, complete, 3 or more views inpatient CPT 73610 HC XR ANKLE COM MIN 3V	$355.77	$474.36	—	—	25%
Ankle-brachial index (ABI), blood pressure test for leg arteries both sides CPT 93922 HC US ARTERIAL DOPPLER ABI-BILATERAL	$575.67	$767.56	—	—	25%
Ankle-brachial index (ABI), blood pressure test for leg arteries both sides CPT 93922 HC US ARTERIAL DOPPLER ABI-BILATERAL	$575.67	$767.56	—	—	25%
Ankle-brachial index (ABI), blood pressure test for leg arteries inpatient both sides CPT 93922 HC US ARTERIAL DOPPLER ABI-BILATERAL	$575.67	$767.56	—	—	25%
Ankle-brachial index (ABI), blood pressure test for leg arteries inpatient both sides CPT 93922 HC US ARTERIAL DOPPLER ABI-BILATERAL	$575.67	$767.56	—	—	25%
Barium swallow (esophagus X-ray with contrast) CPT 74220 HC ESOPHAGRAM	$964.63	$1,286.17	—	91% above	25%
Barium swallow (esophagus X-ray with contrast) CPT 74220 HC ESOPHAGRAM	$964.63	$1,286.17	—	91% above	25%
Barium swallow (esophagus X-ray with contrast) inpatient CPT 74220 HC ESOPHAGRAM	$964.63	$1,286.17	—	—	25%
Barium swallow (esophagus X-ray with contrast) inpatient CPT 74220 HC ESOPHAGRAM	$964.63	$1,286.17	—	—	25%
Bone scan, whole body (nuclear medicine) CPT 78306 HC BONE SCAN WHOLE BODY	$1,798.28	$2,397.71	—	28% above	25%
Bone scan, whole body (nuclear medicine) CPT 78306 HC BONE SCAN WHOLE BODY	$1,798.28	$2,397.71	—	28% above	25%
Bone scan, whole body (nuclear medicine) inpatient CPT 78306 HC BONE SCAN WHOLE BODY	$1,798.28	$2,397.71	—	—	25%
Bone scan, whole body (nuclear medicine) inpatient CPT 78306 HC BONE SCAN WHOLE BODY	$1,798.28	$2,397.71	—	—	25%
Breast ultrasound, complete, one breast one side CPT 76641 HC US BREAST UNILAT COMPLETE	$865.74	$1,154.32	—	63% above	25%
Breast ultrasound, complete, one breast one side CPT 76641 HC US BREAST UNILAT COMPLETE	$865.74	$1,154.32	—	63% above	25%
Breast ultrasound, complete, one breast inpatient one side CPT 76641 HC US BREAST UNILAT COMPLETE	$865.74	$1,154.32	—	—	25%
Breast ultrasound, complete, one breast inpatient one side CPT 76641 HC US BREAST UNILAT COMPLETE	$865.74	$1,154.32	—	—	25%
Breast ultrasound, limited (one breast or one area) both sides CPT 76642 HC US BREAST BILAT LIMITED	$492.40	$656.54	—	—	25%
Breast ultrasound, limited (one breast or one area) both sides CPT 76642 HC US BREAST BILAT LIMITED	$492.40	$656.54	—	—	25%
Breast ultrasound, limited (one breast or one area) one side CPT 76642 HC US BREAST UNILAT LIMITED	$656.54	$875.39	—	75% above	25%
Breast ultrasound, limited (one breast or one area) one side CPT 76642 HC US BREAST UNILAT LIMITED	$656.54	$875.39	—	75% above	25%
Breast ultrasound, limited (one breast or one area) inpatient both sides CPT 76642 HC US BREAST BILAT LIMITED	$492.40	$656.54	—	—	25%
Breast ultrasound, limited (one breast or one area) inpatient both sides CPT 76642 HC US BREAST BILAT LIMITED	$492.40	$656.54	—	—	25%
Breast ultrasound, limited (one breast or one area) inpatient one side CPT 76642 HC US BREAST UNILAT LIMITED	$656.54	$875.39	—	—	25%
Breast ultrasound, limited (one breast or one area) inpatient one side CPT 76642 HC US BREAST UNILAT LIMITED	$656.54	$875.39	—	—	25%
CT angiography of the chest (CTA), for blood clots in the lungs CPT 71275 HC CT CTA CHEST	$3,946.08	$5,261.44	—	103% above	25%
CT angiography of the chest (CTA), for blood clots in the lungs CPT 71275 HC CT CTA CHEST	$3,946.08	$5,261.44	—	103% above	25%
CT angiography of the chest (CTA), for blood clots in the lungs inpatient CPT 71275 HC CT CTA CHEST	$3,946.08	$5,261.44	—	—	25%
CT angiography of the chest (CTA), for blood clots in the lungs inpatient CPT 71275 HC CT CTA CHEST	$3,946.08	$5,261.44	—	—	25%
CT of the heart without contrast dye to measure coronary calcium CPT 75571 HC CT AORTIC VALVE CALCIUM SCORING	$368.18	$490.91	—	757% above	25%
CT of the heart without contrast dye to measure coronary calcium CPT 75571 HC HEART CAL SCOR W/O CONTRAST	$368.18	$490.91	—	757% above	25%
CT of the heart without contrast dye to measure coronary calcium CPT 75571 HC CT AORTIC VALVE CALCIUM SCORING	$368.18	$490.91	—	757% above	25%
CT of the heart without contrast dye to measure coronary calcium CPT 75571 HC HEART CAL SCOR W/O CONTRAST	$368.18	$490.91	—	757% above	25%
CT of the heart without contrast dye to measure coronary calcium inpatient CPT 75571 HC CT AORTIC VALVE CALCIUM SCORING	$368.18	$490.91	—	—	25%
CT of the heart without contrast dye to measure coronary calcium inpatient CPT 75571 HC CT AORTIC VALVE CALCIUM SCORING	$368.18	$490.91	—	—	25%
CT of the heart without contrast dye to measure coronary calcium inpatient CPT 75571 HC HEART CAL SCOR W/O CONTRAST	$368.18	$490.91	—	—	25%
CT of the heart without contrast dye to measure coronary calcium inpatient CPT 75571 HC HEART CAL SCOR W/O CONTRAST	$368.18	$490.91	—	—	25%
CT scan of abdomen and pelvis, no contrast dye CPT 74176 HC CT ABDOMEN/PELVIS W/O CONTRAST	$4,647.44	$6,196.58	—	85% above	25%
CT scan of abdomen and pelvis, no contrast dye CPT 74176 HC CT ABDOMEN/PELVIS W/O CONTRAST	$4,647.44	$6,196.58	—	85% above	25%
CT scan of abdomen and pelvis, no contrast dye inpatient CPT 74176 HC CT ABDOMEN/PELVIS W/O CONTRAST	$4,647.44	$6,196.58	—	—	25%
CT scan of abdomen and pelvis, no contrast dye inpatient CPT 74176 HC CT ABDOMEN/PELVIS W/O CONTRAST	$4,647.44	$6,196.58	—	—	25%
CT scan of abdomen and pelvis, with contrast dye CPT 74177 HC CT ABDOMEN/PELVIS W/CONTRAST	$5,534.21	$7,378.95	—	80% above	25%
CT scan of abdomen and pelvis, with contrast dye CPT 74177 HC CT ABDOMEN/PELVIS W/CONTRAST	$5,534.21	$7,378.95	—	80% above	25%
CT scan of abdomen and pelvis, with contrast dye inpatient CPT 74177 HC CT ABDOMEN/PELVIS W/CONTRAST	$5,534.21	$7,378.95	—	—	25%
CT scan of abdomen and pelvis, with contrast dye inpatient CPT 74177 HC CT ABDOMEN/PELVIS W/CONTRAST	$5,534.21	$7,378.95	—	—	25%
CT scan of abdomen and pelvis, without and then with contrast dye CPT 74178 RC CT ABDOMEN/PELVIS UROGRAPHY	$5,719.32	$7,625.76	—	61% above	25%
CT scan of abdomen and pelvis, without and then with contrast dye CPT 74178 RC CT ABDOMEN/PELVIS UROGRAPHY	$5,719.32	$7,625.76	—	61% above	25%
CT scan of abdomen and pelvis, without and then with contrast dye CPT 74178 HC CT ABDOMEN/PELVIS W/WO CONTRAST	$8,367.62	$11,156.82	—	136% above	25%
CT scan of abdomen and pelvis, without and then with contrast dye CPT 74178 HC CT ABDOMEN/PELVIS W/WO CONTRAST	$8,367.62	$11,156.82	—	136% above	25%
CT scan of abdomen and pelvis, without and then with contrast dye inpatient CPT 74178 RC CT ABDOMEN/PELVIS UROGRAPHY	$5,719.32	$7,625.76	—	—	25%
CT scan of abdomen and pelvis, without and then with contrast dye inpatient CPT 74178 RC CT ABDOMEN/PELVIS UROGRAPHY	$5,719.32	$7,625.76	—	—	25%
CT scan of abdomen and pelvis, without and then with contrast dye inpatient CPT 74178 HC CT ABDOMEN/PELVIS W/WO CONTRAST	$8,367.62	$11,156.82	—	—	25%
CT scan of abdomen and pelvis, without and then with contrast dye inpatient CPT 74178 HC CT ABDOMEN/PELVIS W/WO CONTRAST	$8,367.62	$11,156.82	—	—	25%
CT scan of the abdomen with contrast CPT 74160 HC CT ABDOMEN W/ CONTRAST	$2,367.63	$3,156.84	—	51% above	25%
CT scan of the abdomen with contrast CPT 74160 HC CT ABDOMEN W/ CONTRAST	$2,367.63	$3,156.84	—	51% above	25%
CT scan of the abdomen with contrast inpatient CPT 74160 HC CT ABDOMEN W/ CONTRAST	$2,367.63	$3,156.84	—	—	25%
CT scan of the abdomen with contrast inpatient CPT 74160 HC CT ABDOMEN W/ CONTRAST	$2,367.63	$3,156.84	—	—	25%
CT scan of the abdomen without contrast CPT 74150 HC CT ABDOMEN W/O CONTRAST	$1,987.94	$2,650.59	—	57% above	25%
CT scan of the abdomen without contrast CPT 74150 HC CT ABDOMEN W/O CONTRAST	$1,987.94	$2,650.59	—	57% above	25%
CT scan of the abdomen without contrast inpatient CPT 74150 HC CT ABDOMEN W/O CONTRAST	$1,987.94	$2,650.59	—	—	25%
CT scan of the abdomen without contrast inpatient CPT 74150 HC CT ABDOMEN W/O CONTRAST	$1,987.94	$2,650.59	—	—	25%
CT scan of the face and sinuses, no contrast dye CPT 70486 HC CT MAXILLOFAC AREA W/O CONT.	$1,878.48	$2,504.64	—	36% above	25%
CT scan of the face and sinuses, no contrast dye CPT 70486 HC CT MAXILLOFAC AREA W/O CONT.	$1,878.48	$2,504.64	—	36% above	25%
CT scan of the face and sinuses, no contrast dye inpatient CPT 70486 HC CT MAXILLOFAC AREA W/O CONT.	$1,878.48	$2,504.64	—	—	25%
CT scan of the face and sinuses, no contrast dye inpatient CPT 70486 HC CT MAXILLOFAC AREA W/O CONT.	$1,878.48	$2,504.64	—	—	25%
CT scan of the head or brain, no contrast dye CPT 70450 HC CT HEAD W/O CONTRAST	$2,000.62	$2,667.49	—	55% above	25%
CT scan of the head or brain, no contrast dye CPT 70450 HC CT HEAD W/O CONTRAST	$2,000.62	$2,667.49	—	55% above	25%
CT scan of the head or brain, no contrast dye inpatient CPT 70450 HC CT HEAD W/O CONTRAST	$2,000.62	$2,667.49	—	—	25%
CT scan of the head or brain, no contrast dye inpatient CPT 70450 HC CT HEAD W/O CONTRAST	$2,000.62	$2,667.49	—	—	25%
CT scan of the head with contrast CPT 70460 HC CT HEAD WITH CONTRAST	$2,499.62	$3,332.82	—	62% above	25%
CT scan of the head with contrast CPT 70460 HC CT HEAD WITH CONTRAST	$2,499.62	$3,332.82	—	62% above	25%
CT scan of the head with contrast inpatient CPT 70460 HC CT HEAD WITH CONTRAST	$2,499.62	$3,332.82	—	—	25%
CT scan of the head with contrast inpatient CPT 70460 HC CT HEAD WITH CONTRAST	$2,499.62	$3,332.82	—	—	25%
CT scan of the head without and with contrast CPT 70470 HC CT HEAD W & W/O CONTRAST	$2,801.60	$3,735.47	—	53% above	25%
CT scan of the head without and with contrast CPT 70470 HC CT HEAD W & W/O CONTRAST	$2,801.60	$3,735.47	—	53% above	25%
CT scan of the head without and with contrast inpatient CPT 70470 HC CT HEAD W & W/O CONTRAST	$2,801.60	$3,735.47	—	—	25%
CT scan of the head without and with contrast inpatient CPT 70470 HC CT HEAD W & W/O CONTRAST	$2,801.60	$3,735.47	—	—	25%
CT scan of the lower back (lumbar spine) without contrast CPT 72131 HC CT LUMBAR SPINE W/O CONTRAST	$2,390.62	$3,187.49	—	68% above	25%
CT scan of the lower back (lumbar spine) without contrast CPT 72131 HC CT LUMBAR SPINE W/O CONTRAST	$2,390.62	$3,187.49	—	68% above	25%
CT scan of the lower back (lumbar spine) without contrast inpatient CPT 72131 HC CT LUMBAR SPINE W/O CONTRAST	$2,390.62	$3,187.49	—	—	25%
CT scan of the lower back (lumbar spine) without contrast inpatient CPT 72131 HC CT LUMBAR SPINE W/O CONTRAST	$2,390.62	$3,187.49	—	—	25%
CT scan of the neck (cervical spine), no contrast dye CPT 72125 HC CT CERVICAL SPINE W/O CONTRAST	$2,286.06	$3,048.08	—	56% above	25%
CT scan of the neck (cervical spine), no contrast dye CPT 72125 HC CT CERVICAL SPINE W/O CONTRAST	$2,286.06	$3,048.08	—	56% above	25%
CT scan of the neck (cervical spine), no contrast dye inpatient CPT 72125 HC CT CERVICAL SPINE W/O CONTRAST	$2,286.06	$3,048.08	—	—	25%
CT scan of the neck (cervical spine), no contrast dye inpatient CPT 72125 HC CT CERVICAL SPINE W/O CONTRAST	$2,286.06	$3,048.08	—	—	25%
CT scan of the pelvis, with contrast dye CPT 72193 HC CT PELVIS WITH CONTRAST	$2,322.86	$3,097.15	—	48% above	25%
CT scan of the pelvis, with contrast dye CPT 72193 HC CT PELVIS WITH CONTRAST	$2,322.86	$3,097.15	—	48% above	25%
CT scan of the pelvis, with contrast dye inpatient CPT 72193 HC CT PELVIS WITH CONTRAST	$2,322.86	$3,097.15	—	—	25%
CT scan of the pelvis, with contrast dye inpatient CPT 72193 HC CT PELVIS WITH CONTRAST	$2,322.86	$3,097.15	—	—	25%
Carotid artery ultrasound (duplex), both sides of the neck both sides CPT 93880 HC VL BILAT CAROTID DUPLEX	$894.10	$1,192.13	—	—	25%
Carotid artery ultrasound (duplex), both sides of the neck both sides CPT 93880 HC VL BILAT CAROTID DUPLEX	$894.10	$1,192.13	—	—	25%
Carotid artery ultrasound (duplex), both sides of the neck inpatient both sides CPT 93880 HC VL BILAT CAROTID DUPLEX	$894.10	$1,192.13	—	—	25%
Carotid artery ultrasound (duplex), both sides of the neck inpatient both sides CPT 93880 HC VL BILAT CAROTID DUPLEX	$894.10	$1,192.13	—	—	25%
Chest X-ray, 2 views CPT 71046 HC XRAY CHEST 2 VIEWS	$369.68	$492.91	—	78% above	25%
Chest X-ray, 2 views CPT 71046 HC XRAY CHEST 2 VIEWS	$369.68	$492.91	—	78% above	25%
Chest X-ray, 2 views inpatient CPT 71046 HC XRAY CHEST 2 VIEWS	$369.68	$492.91	—	—	25%
Chest X-ray, 2 views inpatient CPT 71046 HC XRAY CHEST 2 VIEWS	$369.68	$492.91	—	—	25%
Chest X-ray, single view CPT 71045 HC XRAY CHEST 1 VIEW	$184.03	$245.37	—	14% above	25%
Chest X-ray, single view CPT 71045 HC XRAY CHEST 1 VIEW	$184.03	$245.37	—	14% above	25%
Chest X-ray, single view CPT 71045 HC XRAY CHEST 1 VIEW PORTABLE	$237.11	$316.15	—	46% above	25%
Chest X-ray, single view CPT 71045 HC XRAY CHEST 1 VIEW PORTABLE	$237.11	$316.15	—	46% above	25%
Chest X-ray, single view inpatient CPT 71045 HC XRAY CHEST 1 VIEW	$184.03	$245.37	—	—	25%
Chest X-ray, single view inpatient CPT 71045 HC XRAY CHEST 1 VIEW	$184.03	$245.37	—	—	25%
Chest X-ray, single view inpatient CPT 71045 HC XRAY CHEST 1 VIEW PORTABLE	$237.11	$316.15	—	—	25%
Chest X-ray, single view inpatient CPT 71045 HC XRAY CHEST 1 VIEW PORTABLE	$237.11	$316.15	—	—	25%
Complete ultrasound of the back of the abdomen, such as both kidneys CPT 76770 HC US RETROPERITONEAL COMPLETE	$520.94	$694.58	—	3% below	25%
Complete ultrasound of the back of the abdomen, such as both kidneys CPT 76770 HC US RETROPERITONEAL COMPLETE	$520.94	$694.58	—	3% below	25%
Complete ultrasound of the back of the abdomen, such as both kidneys inpatient CPT 76770 HC US RETROPERITONEAL COMPLETE	$520.94	$694.58	—	—	25%
Complete ultrasound of the back of the abdomen, such as both kidneys inpatient CPT 76770 HC US RETROPERITONEAL COMPLETE	$520.94	$694.58	—	—	25%
DEXA bone density scan of the hip, pelvis or spine CPT 77080 HC DXA BONE DENSITY AXIAL	$599.53	$799.37	—	50% above	25%
DEXA bone density scan of the hip, pelvis or spine CPT 77080 HC DXA BONE DENSITY AXIAL	$599.53	$799.37	—	50% above	25%
DEXA bone density scan of the hip, pelvis or spine inpatient CPT 77080 HC DXA BONE DENSITY AXIAL	$599.53	$799.37	—	—	25%
DEXA bone density scan of the hip, pelvis or spine inpatient CPT 77080 HC DXA BONE DENSITY AXIAL	$599.53	$799.37	—	—	25%
DEXA bone density scan of the wrist, heel or finger (peripheral) CPT 77081 HC DXA BONE DENSITY PERIPH	$160.93	$214.57	—	40% below	25%
DEXA bone density scan of the wrist, heel or finger (peripheral) CPT 77081 HC DXA BONE DENSITY PERIPH	$160.93	$214.57	—	40% below	25%
DEXA bone density scan of the wrist, heel or finger (peripheral) inpatient CPT 77081 HC DXA BONE DENSITY PERIPH	$160.93	$214.57	—	—	25%
DEXA bone density scan of the wrist, heel or finger (peripheral) inpatient CPT 77081 HC DXA BONE DENSITY PERIPH	$160.93	$214.57	—	—	25%
Diagnostic CT scan of the chest, no contrast dye CPT 71250 HC CT CHEST WITHOUT CONTRAST	$2,139.95	$2,853.27	—	49% above	25%
Diagnostic CT scan of the chest, no contrast dye CPT 71250 HC CT CHEST WITHOUT CONTRAST	$2,139.95	$2,853.27	—	49% above	25%
Diagnostic CT scan of the chest, no contrast dye inpatient CPT 71250 HC CT CHEST WITHOUT CONTRAST	$2,139.95	$2,853.27	—	—	25%
Diagnostic CT scan of the chest, no contrast dye inpatient CPT 71250 HC CT CHEST WITHOUT CONTRAST	$2,139.95	$2,853.27	—	—	25%
Diagnostic CT scan of the chest, with contrast dye CPT 71260 HC CT CHEST WITH CONTRAST	$2,493.32	$3,324.43	—	59% above	25%
Diagnostic CT scan of the chest, with contrast dye CPT 71260 HC CT CHEST WITH CONTRAST	$2,493.32	$3,324.43	—	59% above	25%
Diagnostic CT scan of the chest, with contrast dye inpatient CPT 71260 HC CT CHEST WITH CONTRAST	$2,493.32	$3,324.43	—	—	25%
Diagnostic CT scan of the chest, with contrast dye inpatient CPT 71260 HC CT CHEST WITH CONTRAST	$2,493.32	$3,324.43	—	—	25%
Diagnostic mammogram, both breasts both sides CPT 77066 HC MM MAMMO BILATERAL DIAGNOSTIC	$874.84	$1,166.45	—	—	25%
Diagnostic mammogram, both breasts both sides CPT 77066 HC MM MAMMO BILATERAL DIAGNOSTIC	$874.84	$1,166.45	—	—	25%
Diagnostic mammogram, both breasts inpatient both sides CPT 77066 HC MM MAMMO BILATERAL DIAGNOSTIC	$874.84	$1,166.45	—	—	25%
Diagnostic mammogram, both breasts inpatient both sides CPT 77066 HC MM MAMMO BILATERAL DIAGNOSTIC	$874.84	$1,166.45	—	—	25%
Diagnostic mammogram, one breast one side CPT 77065 HC MM MAMMO UNILAT DIAGNOSTIC	$640.83	$854.44	—	108% above	25%
Diagnostic mammogram, one breast one side CPT 77065 HC MM MAMMO UNILAT DIAGNOSTIC	$640.83	$854.44	—	108% above	25%
Diagnostic mammogram, one breast one side CPT 77065 RC MM MAMMO DIAG UNILAT W/IMPLANTS	$691.27	$921.69	—	124% above	25%
Diagnostic mammogram, one breast one side CPT 77065 RC MM MAMMO DIAG UNILAT W/IMPLANTS	$691.27	$921.69	—	124% above	25%
Diagnostic mammogram, one breast inpatient one side CPT 77065 HC MM MAMMO UNILAT DIAGNOSTIC	$640.83	$854.44	—	—	25%
Diagnostic mammogram, one breast inpatient one side CPT 77065 HC MM MAMMO UNILAT DIAGNOSTIC	$640.83	$854.44	—	—	25%
Diagnostic mammogram, one breast inpatient one side CPT 77065 RC MM MAMMO DIAG UNILAT W/IMPLANTS	$691.27	$921.69	—	—	25%
Diagnostic mammogram, one breast inpatient one side CPT 77065 RC MM MAMMO DIAG UNILAT W/IMPLANTS	$691.27	$921.69	—	—	25%
Duplex ultrasound of the leg veins, both legs both sides CPT 93970 HC VL BILAT VENOUS DUPLEX COMPLEX	$1,147.42	$1,529.90	—	—	25%
Duplex ultrasound of the leg veins, both legs both sides CPT 93970 HC VL BILAT VENOUS DUPLEX COMPLEX	$1,147.42	$1,529.90	—	—	25%
Duplex ultrasound of the leg veins, both legs inpatient both sides CPT 93970 HC VL BILAT VENOUS DUPLEX COMPLEX	$1,147.42	$1,529.90	—	—	25%
Duplex ultrasound of the leg veins, both legs inpatient both sides CPT 93970 HC VL BILAT VENOUS DUPLEX COMPLEX	$1,147.42	$1,529.90	—	—	25%
Echocardiogram through the chest wall, complete, with Doppler CPT 93306 HC 2-D M-MODE ECHO W/DOPPLER	$1,808.93	$2,411.91	—	3% above	25%
Echocardiogram through the chest wall, complete, with Doppler CPT 93306 HC 2-D M-MODE ECHO W/DOPPLER	$1,808.93	$2,411.91	—	3% above	25%
Echocardiogram through the chest wall, complete, with Doppler CPT 93306 HC EC ECHO WITH BUBBLE STUDY	$1,966.59	$2,622.12	—	12% above	25%
Echocardiogram through the chest wall, complete, with Doppler CPT 93306 HC EC ECHO WITH BUBBLE STUDY	$1,966.59	$2,622.12	—	12% above	25%
Echocardiogram through the chest wall, complete, with Doppler inpatient CPT 93306 HC 2-D M-MODE ECHO W/DOPPLER	$1,808.93	$2,411.91	—	—	25%
Echocardiogram through the chest wall, complete, with Doppler inpatient CPT 93306 HC 2-D M-MODE ECHO W/DOPPLER	$1,808.93	$2,411.91	—	—	25%
Echocardiogram through the chest wall, complete, with Doppler inpatient CPT 93306 HC EC ECHO WITH BUBBLE STUDY	$1,966.59	$2,622.12	—	—	25%
Echocardiogram through the chest wall, complete, with Doppler inpatient CPT 93306 HC EC ECHO WITH BUBBLE STUDY	$1,966.59	$2,622.12	—	—	25%
HIDA scan: nuclear imaging of the liver, bile ducts and gallbladder CPT 78226 HC HEPATOBIL SCAN	$2,151.40	$2,868.53	—	56% above	25%
HIDA scan: nuclear imaging of the liver, bile ducts and gallbladder CPT 78226 HC HEPATOBIL SCAN	$2,151.40	$2,868.53	—	56% above	25%
HIDA scan: nuclear imaging of the liver, bile ducts and gallbladder inpatient CPT 78226 HC HEPATOBIL SCAN	$2,151.40	$2,868.53	—	—	25%
HIDA scan: nuclear imaging of the liver, bile ducts and gallbladder inpatient CPT 78226 HC HEPATOBIL SCAN	$2,151.40	$2,868.53	—	—	25%
Home sleep apnea test, unattended, recording breathing and oxygen CPT 95806 HC SLEEP STUDY, UNATTENDED	$511.97	$682.63	—	17% below	25%
Home sleep apnea test, unattended, recording breathing and oxygen CPT 95806 HC SLEEP STUDY, UNATTENDED	$511.97	$682.63	—	17% below	25%
Home sleep apnea test, unattended, recording breathing and oxygen inpatient CPT 95806 HC SLEEP STUDY, UNATTENDED	$511.97	$682.63	—	—	25%
Home sleep apnea test, unattended, recording breathing and oxygen inpatient CPT 95806 HC SLEEP STUDY, UNATTENDED	$511.97	$682.63	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC VPAP SLEEP STUDY	$5,161.36	$6,881.81	—	52% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC VPAP SLEEP STUDY	$5,161.36	$6,881.81	—	52% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC ORAL APPLIANCE SLEEP STUDY	$5,161.36	$6,881.81	—	52% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC ORAL APPLIANCE SLEEP STUDY	$5,161.36	$6,881.81	—	52% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC CPAP SLEEP STUDY	$5,407.32	$7,209.76	—	60% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC SPLIT SLEEP STUDY	$5,407.32	$7,209.76	—	60% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC CPAP SLEEP STUDY	$5,407.32	$7,209.76	—	60% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC SPLIT SLEEP STUDY	$5,407.32	$7,209.76	—	60% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC PEDS 6-17 YRS SPLIT SLEEP STUDY	$7,022.22	$9,362.96	—	107% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older CPT 95811 HC PEDS 6-17 YRS SPLIT SLEEP STUDY	$7,022.22	$9,362.96	—	107% above	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC ORAL APPLIANCE SLEEP STUDY	$5,161.36	$6,881.81	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC VPAP SLEEP STUDY	$5,161.36	$6,881.81	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC ORAL APPLIANCE SLEEP STUDY	$5,161.36	$6,881.81	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC VPAP SLEEP STUDY	$5,161.36	$6,881.81	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC SPLIT SLEEP STUDY	$5,407.32	$7,209.76	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC CPAP SLEEP STUDY	$5,407.32	$7,209.76	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC SPLIT SLEEP STUDY	$5,407.32	$7,209.76	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC CPAP SLEEP STUDY	$5,407.32	$7,209.76	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC PEDS 6-17 YRS SPLIT SLEEP STUDY	$7,022.22	$9,362.96	—	—	25%
In-lab sleep study with CPAP or bilevel titration, age 6 and older inpatient CPT 95811 HC PEDS 6-17 YRS SPLIT SLEEP STUDY	$7,022.22	$9,362.96	—	—	25%
Knee X-ray, 3 views both sides CPT 73562 HC XR KNEE COMPLETE 3V BILATERAL	$423.20	$564.26	—	—	25%
Knee X-ray, 3 views both sides CPT 73562 HC XR KNEE COMPLETE 3V BILATERAL	$423.20	$564.26	—	—	25%
Knee X-ray, 3 views CPT 73562 HC XR KNEE COMPLETE 3V	$423.20	$564.26	—	67% above	25%
Knee X-ray, 3 views CPT 73562 HC XR KNEE COMPLETE 3V	$423.20	$564.26	—	67% above	25%
Knee X-ray, 3 views inpatient both sides CPT 73562 HC XR KNEE COMPLETE 3V BILATERAL	$423.20	$564.26	—	—	25%
Knee X-ray, 3 views inpatient both sides CPT 73562 HC XR KNEE COMPLETE 3V BILATERAL	$423.20	$564.26	—	—	25%
Knee X-ray, 3 views inpatient CPT 73562 HC XR KNEE COMPLETE 3V	$423.20	$564.26	—	—	25%
Knee X-ray, 3 views inpatient CPT 73562 HC XR KNEE COMPLETE 3V	$423.20	$564.26	—	—	25%
Limited abdominal ultrasound of one organ or area, such as the gallbladder CPT 76705 HC US ABDOMINAL LIMITED	$1,351.12	$1,801.49	—	218% above	25%
Limited abdominal ultrasound of one organ or area, such as the gallbladder CPT 76705 HC US ABDOMINAL LIMITED	$1,351.12	$1,801.49	—	218% above	25%
Limited abdominal ultrasound of one organ or area, such as the gallbladder inpatient CPT 76705 HC US ABDOMINAL LIMITED	$1,351.12	$1,801.49	—	—	25%
Limited abdominal ultrasound of one organ or area, such as the gallbladder inpatient CPT 76705 HC US ABDOMINAL LIMITED	$1,351.12	$1,801.49	—	—	25%
Low-dose CT of the chest for lung cancer screening, no contrast dye CPT 71271 HC CT LOW DOSE LUNG SCREENING	$1,120.60	$1,494.14	—	152% above	25%
Low-dose CT of the chest for lung cancer screening, no contrast dye CPT 71271 HC CT LOW DOSE LUNG SCREENING	$1,120.60	$1,494.14	—	152% above	25%
Low-dose CT of the chest for lung cancer screening, no contrast dye inpatient CPT 71271 HC CT LOW DOSE LUNG SCREENING	$1,120.60	$1,494.14	—	—	25%
Low-dose CT of the chest for lung cancer screening, no contrast dye inpatient CPT 71271 HC CT LOW DOSE LUNG SCREENING	$1,120.60	$1,494.14	—	—	25%
MRI of both breasts, without and then with contrast dye both sides CPT 77049 HC MRI BREAST W&WO CONTRAST W/CAD BI	$9,958.10	$13,277.46	—	—	25%
MRI of both breasts, without and then with contrast dye both sides CPT 77049 HC MRI BREAST W&WO CONTRAST W/CAD BI	$9,958.10	$13,277.46	—	—	25%
MRI of both breasts, without and then with contrast dye inpatient both sides CPT 77049 HC MRI BREAST W&WO CONTRAST W/CAD BI	$9,958.10	$13,277.46	—	—	25%
MRI of both breasts, without and then with contrast dye inpatient both sides CPT 77049 HC MRI BREAST W&WO CONTRAST W/CAD BI	$9,958.10	$13,277.46	—	—	25%
MRI of knee or other lower-limb joint, no contrast dye CPT 73721 HC MRI EXT LOWER, JOINT WO CON	$4,328.99	$5,771.99	—	105% above	25%
MRI of knee or other lower-limb joint, no contrast dye CPT 73721 HC MRI EXT LOWER, JOINT WO CON	$4,328.99	$5,771.99	—	105% above	25%
MRI of knee or other lower-limb joint, no contrast dye inpatient CPT 73721 HC MRI EXT LOWER, JOINT WO CON	$4,328.99	$5,771.99	—	—	25%
MRI of knee or other lower-limb joint, no contrast dye inpatient CPT 73721 HC MRI EXT LOWER, JOINT WO CON	$4,328.99	$5,771.99	—	—	25%
MRI of knee or other lower-limb joint, without and then with contrast dye CPT 73723 HC MRI EXT LOWER, JOINT W/WO CON	$4,772.72	$6,363.62	—	49% above	25%
MRI of knee or other lower-limb joint, without and then with contrast dye CPT 73723 HC MRI EXT LOWER, JOINT W/WO CON	$4,772.72	$6,363.62	—	49% above	25%
MRI of knee or other lower-limb joint, without and then with contrast dye inpatient CPT 73723 HC MRI EXT LOWER, JOINT W/WO CON	$4,772.72	$6,363.62	—	—	25%
MRI of knee or other lower-limb joint, without and then with contrast dye inpatient CPT 73723 HC MRI EXT LOWER, JOINT W/WO CON	$4,772.72	$6,363.62	—	—	25%
MRI of the abdomen without contrast CPT 74181 HC MRI ABDOMEN W/O CONTRAST	$5,971.90	$7,962.54	—	183% above	25%
MRI of the abdomen without contrast CPT 74181 HC MRI ABDOMEN W/O CONTRAST	$5,971.90	$7,962.54	—	183% above	25%
MRI of the abdomen without contrast inpatient CPT 74181 HC MRI ABDOMEN W/O CONTRAST	$5,971.90	$7,962.54	—	—	25%
MRI of the abdomen without contrast inpatient CPT 74181 HC MRI ABDOMEN W/O CONTRAST	$5,971.90	$7,962.54	—	—	25%
MRI of the abdomen, without and then with contrast dye CPT 74183 HC MRI ABDOMEN W/WO CONTRAST	$8,496.81	$11,329.08	—	160% above	25%
MRI of the abdomen, without and then with contrast dye CPT 74183 HC MRI ABDOMEN W/WO CONTRAST	$8,496.81	$11,329.08	—	160% above	25%
MRI of the abdomen, without and then with contrast dye inpatient CPT 74183 HC MRI ABDOMEN W/WO CONTRAST	$8,496.81	$11,329.08	—	—	25%
MRI of the abdomen, without and then with contrast dye inpatient CPT 74183 HC MRI ABDOMEN W/WO CONTRAST	$8,496.81	$11,329.08	—	—	25%
MRI of the brain, no contrast dye CPT 70551 HC MRI BRAIN W/O CONTRAST	$4,713.19	$6,284.25	—	123% above	25%
MRI of the brain, no contrast dye CPT 70551 HC MRI BRAIN W/O CONTRAST	$4,713.19	$6,284.25	—	123% above	25%
MRI of the brain, no contrast dye inpatient CPT 70551 HC MRI BRAIN W/O CONTRAST	$4,713.19	$6,284.25	—	—	25%
MRI of the brain, no contrast dye inpatient CPT 70551 HC MRI BRAIN W/O CONTRAST	$4,713.19	$6,284.25	—	—	25%
MRI of the brain, with and without contrast dye CPT 70553 HC MRI BRAIN W/WO CONTRAST	$4,878.56	$6,504.75	—	49% above	25%
MRI of the brain, with and without contrast dye CPT 70553 HC MRI BRAIN W/WO CONTRAST	$4,878.56	$6,504.75	—	49% above	25%
MRI of the brain, with and without contrast dye inpatient CPT 70553 HC MRI BRAIN W/WO CONTRAST	$4,878.56	$6,504.75	—	—	25%
MRI of the brain, with and without contrast dye inpatient CPT 70553 HC MRI BRAIN W/WO CONTRAST	$4,878.56	$6,504.75	—	—	25%
MRI of the lower back, no contrast dye CPT 72148 HC MRI LUMBAR SPINE W/O CONTRAST	$5,462.52	$7,283.36	—	159% above	25%
MRI of the lower back, no contrast dye CPT 72148 HC MRI LUMBAR SPINE W/O CONTRAST	$5,462.52	$7,283.36	—	159% above	25%
MRI of the lower back, no contrast dye inpatient CPT 72148 HC MRI LUMBAR SPINE W/O CONTRAST	$5,462.52	$7,283.36	—	—	25%
MRI of the lower back, no contrast dye inpatient CPT 72148 HC MRI LUMBAR SPINE W/O CONTRAST	$5,462.52	$7,283.36	—	—	25%
MRI of the lower back, without and then with contrast dye CPT 72158 HC MRI LUMBAR SPINE W/WO CONTRAST	$7,649.90	$10,199.86	—	134% above	25%
MRI of the lower back, without and then with contrast dye CPT 72158 HC MRI LUMBAR SPINE W/WO CONTRAST	$7,649.90	$10,199.86	—	134% above	25%
MRI of the lower back, without and then with contrast dye inpatient CPT 72158 HC MRI LUMBAR SPINE W/WO CONTRAST	$7,649.90	$10,199.86	—	—	25%
MRI of the lower back, without and then with contrast dye inpatient CPT 72158 HC MRI LUMBAR SPINE W/WO CONTRAST	$7,649.90	$10,199.86	—	—	25%
MRI of the mid back (thoracic spine), no contrast dye CPT 72146 HC MRI THORACIC SPINE W/O CONTRAST	$4,918.25	$6,557.67	—	133% above	25%
MRI of the mid back (thoracic spine), no contrast dye CPT 72146 HC MRI THORACIC SPINE W/O CONTRAST	$4,918.25	$6,557.67	—	133% above	25%
MRI of the mid back (thoracic spine), no contrast dye inpatient CPT 72146 HC MRI THORACIC SPINE W/O CONTRAST	$4,918.25	$6,557.67	—	—	25%
MRI of the mid back (thoracic spine), no contrast dye inpatient CPT 72146 HC MRI THORACIC SPINE W/O CONTRAST	$4,918.25	$6,557.67	—	—	25%
MRI of the neck (cervical spine) without and with contrast CPT 72156 HC MRI CERVICAL SPINE W/WO CONTRAST	$6,673.60	$8,898.13	—	104% above	25%
MRI of the neck (cervical spine) without and with contrast CPT 72156 HC MRI CERVICAL SPINE W/WO CONTRAST	$6,673.60	$8,898.13	—	104% above	25%
MRI of the neck (cervical spine) without and with contrast inpatient CPT 72156 HC MRI CERVICAL SPINE W/WO CONTRAST	$6,673.60	$8,898.13	—	—	25%
MRI of the neck (cervical spine) without and with contrast inpatient CPT 72156 HC MRI CERVICAL SPINE W/WO CONTRAST	$6,673.60	$8,898.13	—	—	25%
MRI of the neck (cervical spine), no contrast dye CPT 72141 HC MRI CERVICAL SPINE W/O CONTRAST	$4,798.25	$6,397.67	—	127% above	25%
MRI of the neck (cervical spine), no contrast dye CPT 72141 HC MRI CERVICAL SPINE W/O CONTRAST	$4,798.25	$6,397.67	—	127% above	25%
MRI of the neck (cervical spine), no contrast dye inpatient CPT 72141 HC MRI CERVICAL SPINE W/O CONTRAST	$4,798.25	$6,397.67	—	—	25%
MRI of the neck (cervical spine), no contrast dye inpatient CPT 72141 HC MRI CERVICAL SPINE W/O CONTRAST	$4,798.25	$6,397.67	—	—	25%
MRI of the pelvis without and with contrast CPT 72197 HC MRI PELVIS W & W/O CONTRAST	$6,144.02	$8,192.02	—	88% above	25%
MRI of the pelvis without and with contrast CPT 72197 HC MRI PELVIS W & W/O CONTRAST	$6,144.02	$8,192.02	—	88% above	25%
MRI of the pelvis without and with contrast inpatient CPT 72197 HC MRI PELVIS W & W/O CONTRAST	$6,144.02	$8,192.02	—	—	25%
MRI of the pelvis without and with contrast inpatient CPT 72197 HC MRI PELVIS W & W/O CONTRAST	$6,144.02	$8,192.02	—	—	25%
MRI of the pelvis, no contrast dye CPT 72195 HC MRI PELVIS W/O CONTRAST	$4,783.45	$6,377.93	—	127% above	25%
MRI of the pelvis, no contrast dye CPT 72195 HC MRI PELVIS W/O CONTRAST	$4,783.45	$6,377.93	—	127% above	25%
MRI of the pelvis, no contrast dye inpatient CPT 72195 HC MRI PELVIS W/O CONTRAST	$4,783.45	$6,377.93	—	—	25%
MRI of the pelvis, no contrast dye inpatient CPT 72195 HC MRI PELVIS W/O CONTRAST	$4,783.45	$6,377.93	—	—	25%
MRI of the shoulder, elbow or wrist joint, no contrast dye CPT 73221 HC MRI EXT UPPER, JOINT WO CON	$4,841.08	$6,454.78	—	129% above	25%
MRI of the shoulder, elbow or wrist joint, no contrast dye CPT 73221 HC MRI EXT UPPER, JOINT WO CON	$4,841.08	$6,454.78	—	129% above	25%
MRI of the shoulder, elbow or wrist joint, no contrast dye inpatient CPT 73221 HC MRI EXT UPPER, JOINT WO CON	$4,841.08	$6,454.78	—	—	25%
MRI of the shoulder, elbow or wrist joint, no contrast dye inpatient CPT 73221 HC MRI EXT UPPER, JOINT WO CON	$4,841.08	$6,454.78	—	—	25%
Nuclear stress test imaging (SPECT), rest and stress studies CPT 78452 HC MYOC PERF SPECT MULT W/M & EF	$4,512.98	$6,017.31	—	46% above	25%
Nuclear stress test imaging (SPECT), rest and stress studies CPT 78452 HC MYOC PERF SPECT MULT W/M & EF	$4,512.98	$6,017.31	—	46% above	25%
Nuclear stress test imaging (SPECT), rest and stress studies inpatient CPT 78452 HC MYOC PERF SPECT MULT W/M & EF	$4,512.98	$6,017.31	—	—	25%
Nuclear stress test imaging (SPECT), rest and stress studies inpatient CPT 78452 HC MYOC PERF SPECT MULT W/M & EF	$4,512.98	$6,017.31	—	—	25%
PET/CT scan from the base of the skull to mid-thigh CPT 78815 HC PET CT TUMOR IMAGING MIDTHIGH	$5,875.00	$7,833.34	—	45% above	25%
PET/CT scan from the base of the skull to mid-thigh CPT 78815 HC PET CT TUMOR IMAGING MIDTHIGH	$5,875.00	$7,833.34	—	45% above	25%
PET/CT scan from the base of the skull to mid-thigh inpatient CPT 78815 HC PET CT TUMOR IMAGING MIDTHIGH	$5,875.00	$7,833.34	—	—	25%
PET/CT scan from the base of the skull to mid-thigh inpatient CPT 78815 HC PET CT TUMOR IMAGING MIDTHIGH	$5,875.00	$7,833.34	—	—	25%
Pelvic ultrasound (not pregnancy), limited or follow-up CPT 76857 HC US SUPERFICIAL PELVIS LTD	$451.48	$601.97	—	14% above	25%
Pelvic ultrasound (not pregnancy), limited or follow-up CPT 76857 HC US SUPERFICIAL PELVIS LTD	$451.48	$601.97	—	14% above	25%
Pelvic ultrasound (not pregnancy), limited or follow-up inpatient CPT 76857 HC US SUPERFICIAL PELVIS LTD	$451.48	$601.97	—	—	25%
Pelvic ultrasound (not pregnancy), limited or follow-up inpatient CPT 76857 HC US SUPERFICIAL PELVIS LTD	$451.48	$601.97	—	—	25%
Pelvic ultrasound through the belly, complete (not pregnancy) CPT 76856 HC US PELVIS	$1,324.66	$1,766.21	—	208% above	25%
Pelvic ultrasound through the belly, complete (not pregnancy) CPT 76856 HC US PELVIS	$1,324.66	$1,766.21	—	208% above	25%
Pelvic ultrasound through the belly, complete (not pregnancy) inpatient CPT 76856 HC US PELVIS	$1,324.66	$1,766.21	—	—	25%
Pelvic ultrasound through the belly, complete (not pregnancy) inpatient CPT 76856 HC US PELVIS	$1,324.66	$1,766.21	—	—	25%
Pregnancy ultrasound after 14 weeks, one baby CPT 76805 HC US FETAL>14 WEEKS	$1,055.92	$1,407.89	—	116% above	25%
Pregnancy ultrasound after 14 weeks, one baby CPT 76805 HC US FETAL>14 WEEKS	$1,055.92	$1,407.89	—	116% above	25%
Pregnancy ultrasound after 14 weeks, one baby inpatient CPT 76805 HC US FETAL>14 WEEKS	$1,055.92	$1,407.89	—	—	25%
Pregnancy ultrasound after 14 weeks, one baby inpatient CPT 76805 HC US FETAL>14 WEEKS	$1,055.92	$1,407.89	—	—	25%
Pregnancy ultrasound before 14 weeks, through the belly, one baby CPT 76801 HC US FETAL < 14 WKS	$1,055.09	$1,406.79	—	146% above	25%
Pregnancy ultrasound before 14 weeks, through the belly, one baby CPT 76801 HC US FETAL < 14 WKS	$1,055.09	$1,406.79	—	146% above	25%
Pregnancy ultrasound before 14 weeks, through the belly, one baby inpatient CPT 76801 HC US FETAL < 14 WKS	$1,055.09	$1,406.79	—	—	25%
Pregnancy ultrasound before 14 weeks, through the belly, one baby inpatient CPT 76801 HC US FETAL < 14 WKS	$1,055.09	$1,406.79	—	—	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) CPT 76815 HC L/D ULTRASOUND-FETAL POS	$203.20	$270.94	—	45% below	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) CPT 76815 HC L/D ULTRASOUND-FETAL POS	$203.20	$270.94	—	45% below	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) CPT 76815 HC US FETAL LIMITD/FHB/PLAC/AFI/POS	$555.66	$740.88	—	51% above	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) CPT 76815 HC US FETAL LIMITD/FHB/PLAC/AFI/POS	$555.66	$740.88	—	51% above	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) inpatient CPT 76815 HC L/D ULTRASOUND-FETAL POS	$203.20	$270.94	—	—	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) inpatient CPT 76815 HC L/D ULTRASOUND-FETAL POS	$203.20	$270.94	—	—	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) inpatient CPT 76815 HC US FETAL LIMITD/FHB/PLAC/AFI/POS	$555.66	$740.88	—	—	25%
Pregnancy ultrasound, limited (heartbeat, position, fluid) inpatient CPT 76815 HC US FETAL LIMITD/FHB/PLAC/AFI/POS	$555.66	$740.88	—	—	25%
Screening mammogram, both breasts both sides CPT 77067 RC MAMMO BILAT SCREEN W/IMPLANTS	$883.93	$1,178.57	—	—	25%
Screening mammogram, both breasts both sides CPT 77067 RC MAMMO BILAT SCREEN W/IMPLANTS	$883.93	$1,178.57	—	—	25%
Screening mammogram, both breasts CPT 77067 RC MAMMO UNI SCREEN W/IMPLANTS	$419.87	$559.83	—	130% above	25%
Screening mammogram, both breasts CPT 77067 RC MAMMO UNI SCREEN W/IMPLANTS	$419.87	$559.83	—	130% above	25%
Screening mammogram, both breasts CPT 77067 RC MM MAMMO BIL SCREEN-PHYS REFER	$812.82	$1,083.76	—	345% above	25%
Screening mammogram, both breasts CPT 77067 RC MM MAMMO BIL SCREEN-PHYS REFER	$812.82	$1,083.76	—	345% above	25%
Screening mammogram, both breasts inpatient both sides CPT 77067 RC MAMMO BILAT SCREEN W/IMPLANTS	$883.93	$1,178.57	—	—	25%
Screening mammogram, both breasts inpatient both sides CPT 77067 RC MAMMO BILAT SCREEN W/IMPLANTS	$883.93	$1,178.57	—	—	25%
Screening mammogram, both breasts inpatient CPT 77067 RC MAMMO UNI SCREEN W/IMPLANTS	$419.87	$559.83	—	—	25%
Screening mammogram, both breasts inpatient CPT 77067 RC MAMMO UNI SCREEN W/IMPLANTS	$419.87	$559.83	—	—	25%
Screening mammogram, both breasts inpatient CPT 77067 RC MM MAMMO BIL SCREEN-PHYS REFER	$812.82	$1,083.76	—	—	25%
Screening mammogram, both breasts inpatient CPT 77067 RC MM MAMMO BIL SCREEN-PHYS REFER	$812.82	$1,083.76	—	—	25%
Shoulder X-ray, complete, 2 or more views both sides CPT 73030 HC XR SHOULDER COM MIN 2V BILATERAL	$383.78	$511.71	—	—	25%
Shoulder X-ray, complete, 2 or more views both sides CPT 73030 HC XR SHOULDER COM MIN 2V BILATERAL	$383.78	$511.71	—	—	25%
Shoulder X-ray, complete, 2 or more views CPT 73030 HC XR SHOULDER COM MIN 2V	$383.78	$511.71	—	117% above	25%
Shoulder X-ray, complete, 2 or more views CPT 73030 HC XR SHOULDER COM MIN 2V	$383.78	$511.71	—	117% above	25%
Shoulder X-ray, complete, 2 or more views inpatient both sides CPT 73030 HC XR SHOULDER COM MIN 2V BILATERAL	$383.78	$511.71	—	—	25%
Shoulder X-ray, complete, 2 or more views inpatient both sides CPT 73030 HC XR SHOULDER COM MIN 2V BILATERAL	$383.78	$511.71	—	—	25%
Shoulder X-ray, complete, 2 or more views inpatient CPT 73030 HC XR SHOULDER COM MIN 2V	$383.78	$511.71	—	—	25%
Shoulder X-ray, complete, 2 or more views inpatient CPT 73030 HC XR SHOULDER COM MIN 2V	$383.78	$511.71	—	—	25%
Sleep study in a lab (polysomnography) CPT 95810 HC PARTIAL SLEEP STUDY	$2,806.48	$3,741.98	—	17% below	25%
Sleep study in a lab (polysomnography) CPT 95810 HC PARTIAL SLEEP STUDY	$2,806.48	$3,741.98	—	17% below	25%
Sleep study in a lab (polysomnography) CPT 95810 HC PEDS 6-17 YRS PSG SLEEP STUDY	$4,948.84	$6,598.46	—	46% above	25%
Sleep study in a lab (polysomnography) CPT 95810 HC PEDS 6-17 YRS PSG SLEEP STUDY	$4,948.84	$6,598.46	—	46% above	25%
Sleep study in a lab (polysomnography) CPT 95810 HC COMPLETE PSG SLEEP STUDY	$5,184.68	$6,912.90	—	53% above	25%
Sleep study in a lab (polysomnography) CPT 95810 HC COMPLETE PSG SLEEP STUDY	$5,184.68	$6,912.90	—	53% above	25%
Sleep study in a lab (polysomnography) inpatient CPT 95810 HC PARTIAL SLEEP STUDY	$2,806.48	$3,741.98	—	—	25%
Sleep study in a lab (polysomnography) inpatient CPT 95810 HC PARTIAL SLEEP STUDY	$2,806.48	$3,741.98	—	—	25%
Sleep study in a lab (polysomnography) inpatient CPT 95810 HC PEDS 6-17 YRS PSG SLEEP STUDY	$4,948.84	$6,598.46	—	—	25%
Sleep study in a lab (polysomnography) inpatient CPT 95810 HC PEDS 6-17 YRS PSG SLEEP STUDY	$4,948.84	$6,598.46	—	—	25%
Sleep study in a lab (polysomnography) inpatient CPT 95810 HC COMPLETE PSG SLEEP STUDY	$5,184.68	$6,912.90	—	—	25%
Sleep study in a lab (polysomnography) inpatient CPT 95810 HC COMPLETE PSG SLEEP STUDY	$5,184.68	$6,912.90	—	—	25%
Swallow study (modified barium swallow, video X-ray) CPT 74230 HC VIDEO SWALLOWING STUDY	$869.20	$1,158.94	—	99% above	25%
Swallow study (modified barium swallow, video X-ray) CPT 74230 HC VIDEO SWALLOWING STUDY	$869.20	$1,158.94	—	99% above	25%
Swallow study (modified barium swallow, video X-ray) inpatient CPT 74230 HC VIDEO SWALLOWING STUDY	$869.20	$1,158.94	—	—	25%
Swallow study (modified barium swallow, video X-ray) inpatient CPT 74230 HC VIDEO SWALLOWING STUDY	$869.20	$1,158.94	—	—	25%
Transvaginal pelvic ultrasound CPT 76830 HC US TRANSVAGINAL NON OB	$925.28	$1,233.70	—	108% above	25%
Transvaginal pelvic ultrasound CPT 76830 HC US TRANSVAGINAL NON OB	$925.28	$1,233.70	—	108% above	25%
Transvaginal pelvic ultrasound inpatient CPT 76830 HC US TRANSVAGINAL NON OB	$925.28	$1,233.70	—	—	25%
Transvaginal pelvic ultrasound inpatient CPT 76830 HC US TRANSVAGINAL NON OB	$925.28	$1,233.70	—	—	25%
Transvaginal ultrasound during pregnancy CPT 76817 HC US TRANSVAGINAL OB	$436.59	$582.12	—	18% above	25%
Transvaginal ultrasound during pregnancy CPT 76817 HC US TRANSVAGINAL OB	$436.59	$582.12	—	18% above	25%
Transvaginal ultrasound during pregnancy inpatient CPT 76817 HC US TRANSVAGINAL OB	$436.59	$582.12	—	—	25%
Transvaginal ultrasound during pregnancy inpatient CPT 76817 HC US TRANSVAGINAL OB	$436.59	$582.12	—	—	25%
Ultrasound of the abdomen, complete CPT 76700 HC US ABDOMEN COMPLETE	$1,389.98	$1,853.30	—	136% above	25%
Ultrasound of the abdomen, complete CPT 76700 HC US ABDOMEN COMPLETE	$1,389.98	$1,853.30	—	136% above	25%
Ultrasound of the abdomen, complete inpatient CPT 76700 HC US ABDOMEN COMPLETE	$1,389.98	$1,853.30	—	—	25%
Ultrasound of the abdomen, complete inpatient CPT 76700 HC US ABDOMEN COMPLETE	$1,389.98	$1,853.30	—	—	25%
Ultrasound of the scrotum and testicles CPT 76870 HC US SCROTUM	$716.90	$955.87	—	58% above	25%
Ultrasound of the scrotum and testicles CPT 76870 HC US SCROTUM	$716.90	$955.87	—	58% above	25%
Ultrasound of the scrotum and testicles inpatient CPT 76870 HC US SCROTUM	$716.90	$955.87	—	—	25%
Ultrasound of the scrotum and testicles inpatient CPT 76870 HC US SCROTUM	$716.90	$955.87	—	—	25%
Ultrasound of the soft tissues of the head and neck, such as the thyroid CPT 76536 HC US HEAD / NECK	$1,170.86	$1,561.14	—	161% above	25%
Ultrasound of the soft tissues of the head and neck, such as the thyroid CPT 76536 HC US HEAD / NECK	$1,170.86	$1,561.14	—	161% above	25%
Ultrasound of the soft tissues of the head and neck, such as the thyroid inpatient CPT 76536 HC US HEAD / NECK	$1,170.86	$1,561.14	—	—	25%
Ultrasound of the soft tissues of the head and neck, such as the thyroid inpatient CPT 76536 HC US HEAD / NECK	$1,170.86	$1,561.14	—	—	25%
Upper GI series (X-ray of esophagus, stomach and duodenum with contrast) CPT 74240 HC UPPER GI SERIES	$1,178.30	$1,571.06	—	80% above	25%
Upper GI series (X-ray of esophagus, stomach and duodenum with contrast) CPT 74240 HC UPPER GI SERIES	$1,178.30	$1,571.06	—	80% above	25%
Upper GI series (X-ray of esophagus, stomach and duodenum with contrast) inpatient CPT 74240 HC UPPER GI SERIES	$1,178.30	$1,571.06	—	—	25%
Upper GI series (X-ray of esophagus, stomach and duodenum with contrast) inpatient CPT 74240 HC UPPER GI SERIES	$1,178.30	$1,571.06	—	—	25%
Vein ultrasound (duplex) of one arm or leg, or a limited study one side CPT 93971 HC VL UNILATERAL VENOUS DUPLEX COMP	$918.58	$1,224.78	—	53% above	25%
Vein ultrasound (duplex) of one arm or leg, or a limited study one side CPT 93971 HC VL UNILATERAL VENOUS DUPLEX COMP	$918.58	$1,224.78	—	53% above	25%
Vein ultrasound (duplex) of one arm or leg, or a limited study inpatient one side CPT 93971 HC VL UNILATERAL VENOUS DUPLEX COMP	$918.58	$1,224.78	—	—	25%
Vein ultrasound (duplex) of one arm or leg, or a limited study inpatient one side CPT 93971 HC VL UNILATERAL VENOUS DUPLEX COMP	$918.58	$1,224.78	—	—	25%
Wrist X-ray, complete, 3 or more views both sides CPT 73110 HC XR WRIST COM MIN 3V BILATERAL	$344.13	$458.84	—	—	25%
Wrist X-ray, complete, 3 or more views both sides CPT 73110 HC XR WRIST COM MIN 3V BILATERAL	$344.13	$458.84	—	—	25%
Wrist X-ray, complete, 3 or more views CPT 73110 HC XR WRIST COM MIN 3V	$344.36	$459.14	—	68% above	25%
Wrist X-ray, complete, 3 or more views CPT 73110 HC XR WRIST COM MIN 3V	$344.36	$459.14	—	68% above	25%
Wrist X-ray, complete, 3 or more views inpatient both sides CPT 73110 HC XR WRIST COM MIN 3V BILATERAL	$344.13	$458.84	—	—	25%
Wrist X-ray, complete, 3 or more views inpatient both sides CPT 73110 HC XR WRIST COM MIN 3V BILATERAL	$344.13	$458.84	—	—	25%
Wrist X-ray, complete, 3 or more views inpatient CPT 73110 HC XR WRIST COM MIN 3V	$344.36	$459.14	—	—	25%
Wrist X-ray, complete, 3 or more views inpatient CPT 73110 HC XR WRIST COM MIN 3V	$344.36	$459.14	—	—	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included both sides CPT 73502 HC XR HIP 2-3V W/PELVIS, BILAT	$662.10	$882.80	—	—	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included both sides CPT 73502 HC XR HIP 2-3V W/PELVIS, BILAT	$662.10	$882.80	—	—	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included one side CPT 73502 HC XR HIP UNILAT 2-3V W/PELVIS	$761.33	$1,015.11	—	161% above	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included one side CPT 73502 HC XR HIP UNILAT 2-3V W/PELVIS	$761.33	$1,015.11	—	161% above	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included inpatient both sides CPT 73502 HC XR HIP 2-3V W/PELVIS, BILAT	$662.10	$882.80	—	—	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included inpatient both sides CPT 73502 HC XR HIP 2-3V W/PELVIS, BILAT	$662.10	$882.80	—	—	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included inpatient one side CPT 73502 HC XR HIP UNILAT 2-3V W/PELVIS	$761.33	$1,015.11	—	—	25%
X-ray of one hip, 2 or 3 views, with the pelvis when included inpatient one side CPT 73502 HC XR HIP UNILAT 2-3V W/PELVIS	$761.33	$1,015.11	—	—	25%
X-ray of the abdomen, 1 view CPT 74018 HC XRAY ABDOMEN ONE VIEW	$299.75	$399.67	—	42% above	25%
X-ray of the abdomen, 1 view CPT 74018 HC XRAY ABDOMEN ONE VIEW	$299.75	$399.67	—	42% above	25%
X-ray of the abdomen, 1 view inpatient CPT 74018 HC XRAY ABDOMEN ONE VIEW	$299.75	$399.67	—	—	25%
X-ray of the abdomen, 1 view inpatient CPT 74018 HC XRAY ABDOMEN ONE VIEW	$299.75	$399.67	—	—	25%
X-ray of the ankle, 2 views CPT 73600 HC XR ANKLE 2 VIEWS	$328.80	$438.40	—	65% above	25%
X-ray of the ankle, 2 views CPT 73600 HC XR ANKLE 2 VIEWS	$328.80	$438.40	—	65% above	25%
X-ray of the ankle, 2 views inpatient CPT 73600 HC XR ANKLE 2 VIEWS	$328.80	$438.40	—	—	25%
X-ray of the ankle, 2 views inpatient CPT 73600 HC XR ANKLE 2 VIEWS	$328.80	$438.40	—	—	25%
X-ray of the finger(s), 2 or more views CPT 73140 HC XR FINGER(S) MIN 2V	$314.29	$419.05	—	80% above	25%
X-ray of the finger(s), 2 or more views CPT 73140 HC XR FINGER(S) MIN 2V	$314.29	$419.05	—	80% above	25%
X-ray of the finger(s), 2 or more views inpatient CPT 73140 HC XR FINGER(S) MIN 2V	$314.29	$419.05	—	—	25%
X-ray of the finger(s), 2 or more views inpatient CPT 73140 HC XR FINGER(S) MIN 2V	$314.29	$419.05	—	—	25%
X-ray of the foot, 2 views both sides CPT 73620 HC XR FOOT 2V BILATERAL	$280.06	$373.41	—	—	25%
X-ray of the foot, 2 views both sides CPT 73620 HC XR FOOT 2V BILATERAL	$280.06	$373.41	—	—	25%
X-ray of the foot, 2 views CPT 73620 HC XR FOOT 2V	$280.06	$373.41	—	55% above	25%
X-ray of the foot, 2 views CPT 73620 HC XR FOOT 2V	$280.06	$373.41	—	55% above	25%
X-ray of the foot, 2 views inpatient both sides CPT 73620 HC XR FOOT 2V BILATERAL	$280.06	$373.41	—	—	25%
X-ray of the foot, 2 views inpatient both sides CPT 73620 HC XR FOOT 2V BILATERAL	$280.06	$373.41	—	—	25%
X-ray of the foot, 2 views inpatient CPT 73620 HC XR FOOT 2V	$280.06	$373.41	—	—	25%
X-ray of the foot, 2 views inpatient CPT 73620 HC XR FOOT 2V	$280.06	$373.41	—	—	25%
X-ray of the foot, complete, 3 or more views both sides CPT 73630 HC XR FOOT COM MIN 3V BILATERAL	$328.94	$438.59	—	—	25%
X-ray of the foot, complete, 3 or more views both sides CPT 73630 HC XR FOOT COM MIN 3V BILATERAL	$328.94	$438.59	—	—	25%
X-ray of the foot, complete, 3 or more views CPT 73630 HC XR FOOT COM MIN 3V	$378.58	$504.78	—	80% above	25%
X-ray of the foot, complete, 3 or more views CPT 73630 HC XR FOOT COM MIN 3V	$378.58	$504.78	—	80% above	25%
X-ray of the foot, complete, 3 or more views inpatient both sides CPT 73630 HC XR FOOT COM MIN 3V BILATERAL	$328.94	$438.59	—	—	25%
X-ray of the foot, complete, 3 or more views inpatient both sides CPT 73630 HC XR FOOT COM MIN 3V BILATERAL	$328.94	$438.59	—	—	25%
X-ray of the foot, complete, 3 or more views inpatient CPT 73630 HC XR FOOT COM MIN 3V	$378.58	$504.78	—	—	25%
X-ray of the foot, complete, 3 or more views inpatient CPT 73630 HC XR FOOT COM MIN 3V	$378.58	$504.78	—	—	25%
X-ray of the hand, 3 or more views both sides CPT 73130 HC XR HAND COM MIN 3V BILATERAL	$382.74	$510.32	—	—	25%
X-ray of the hand, 3 or more views both sides CPT 73130 HC XR HAND COM MIN 3V BILATERAL	$382.74	$510.32	—	—	25%
X-ray of the hand, 3 or more views CPT 73130 HC XR HAND COM MIN 3V	$382.74	$510.32	—	97% above	25%
X-ray of the hand, 3 or more views CPT 73130 HC XR HAND COM MIN 3V	$382.74	$510.32	—	97% above	25%
X-ray of the hand, 3 or more views inpatient both sides CPT 73130 HC XR HAND COM MIN 3V BILATERAL	$382.74	$510.32	—	—	25%
X-ray of the hand, 3 or more views inpatient both sides CPT 73130 HC XR HAND COM MIN 3V BILATERAL	$382.74	$510.32	—	—	25%
X-ray of the hand, 3 or more views inpatient CPT 73130 HC XR HAND COM MIN 3V	$382.74	$510.32	—	—	25%
X-ray of the hand, 3 or more views inpatient CPT 73130 HC XR HAND COM MIN 3V	$382.74	$510.32	—	—	25%
X-ray of the knee, 1 or 2 views both sides CPT 73560 HC XR KNEE 1 OR 2 VIEWS BILATERAL	$376.13	$501.51	—	—	25%
X-ray of the knee, 1 or 2 views both sides CPT 73560 HC XR KNEE 1 OR 2 VIEWS BILATERAL	$376.13	$501.51	—	—	25%
X-ray of the knee, 1 or 2 views CPT 73560 HC XR KNEE 1 OR 2 VIEWS	$376.52	$502.03	—	78% above	25%
X-ray of the knee, 1 or 2 views CPT 73560 HC XR KNEE 1 OR 2 VIEWS	$376.52	$502.03	—	78% above	25%
X-ray of the knee, 1 or 2 views inpatient both sides CPT 73560 HC XR KNEE 1 OR 2 VIEWS BILATERAL	$376.13	$501.51	—	—	25%
X-ray of the knee, 1 or 2 views inpatient both sides CPT 73560 HC XR KNEE 1 OR 2 VIEWS BILATERAL	$376.13	$501.51	—	—	25%
X-ray of the knee, 1 or 2 views inpatient CPT 73560 HC XR KNEE 1 OR 2 VIEWS	$376.52	$502.03	—	—	25%
X-ray of the knee, 1 or 2 views inpatient CPT 73560 HC XR KNEE 1 OR 2 VIEWS	$376.52	$502.03	—	—	25%
X-ray of the lower back (lumbar spine), 2 or 3 views CPT 72100 HC XR LUMBAR SPINE 2V OR 3V	$311.17	$414.89	—	32% above	25%
X-ray of the lower back (lumbar spine), 2 or 3 views CPT 72100 HC XR LUMBAR SPINE 2V OR 3V	$311.17	$414.89	—	32% above	25%
X-ray of the lower back (lumbar spine), 2 or 3 views inpatient CPT 72100 HC XR LUMBAR SPINE 2V OR 3V	$311.17	$414.89	—	—	25%
X-ray of the lower back (lumbar spine), 2 or 3 views inpatient CPT 72100 HC XR LUMBAR SPINE 2V OR 3V	$311.17	$414.89	—	—	25%
X-ray of the lower back, 4 or more views CPT 72110 HC XR LUMBAR SPINE MIN 4V	$342.28	$456.38	—	6% above	25%
X-ray of the lower back, 4 or more views CPT 72110 HC XR LUMBAR SPINE MIN 4V	$342.28	$456.38	—	6% above	25%
X-ray of the lower back, 4 or more views inpatient CPT 72110 HC XR LUMBAR SPINE MIN 4V	$342.28	$456.38	—	—	25%
X-ray of the lower back, 4 or more views inpatient CPT 72110 HC XR LUMBAR SPINE MIN 4V	$342.28	$456.38	—	—	25%
X-ray of the mid back (thoracic spine), 2 views CPT 72070 HC XR THORACIC SPINE 2V	$353.69	$471.59	—	62% above	25%
X-ray of the mid back (thoracic spine), 2 views CPT 72070 HC XR THORACIC SPINE 2V	$353.69	$471.59	—	62% above	25%
X-ray of the mid back (thoracic spine), 2 views inpatient CPT 72070 HC XR THORACIC SPINE 2V	$353.69	$471.59	—	—	25%
X-ray of the mid back (thoracic spine), 2 views inpatient CPT 72070 HC XR THORACIC SPINE 2V	$353.69	$471.59	—	—	25%
X-ray of the nasal bones, 3 or more views CPT 70160 HC XR NASAL BONES COM MIN 3V	$318.44	$424.58	—	59% above	25%
X-ray of the nasal bones, 3 or more views CPT 70160 HC XR NASAL BONES COM MIN 3V	$318.44	$424.58	—	59% above	25%
X-ray of the nasal bones, 3 or more views inpatient CPT 70160 HC XR NASAL BONES COM MIN 3V	$318.44	$424.58	—	—	25%
X-ray of the nasal bones, 3 or more views inpatient CPT 70160 HC XR NASAL BONES COM MIN 3V	$318.44	$424.58	—	—	25%
X-ray of the neck (cervical spine), 2 or 3 views CPT 72040 HC XR CERVICAL SPINE 2V OR 3V	$332.95	$443.93	—	51% above	25%
X-ray of the neck (cervical spine), 2 or 3 views CPT 72040 HC XR CERVICAL SPINE 2V OR 3V	$332.95	$443.93	—	51% above	25%
X-ray of the neck (cervical spine), 2 or 3 views inpatient CPT 72040 HC XR CERVICAL SPINE 2V OR 3V	$332.95	$443.93	—	—	25%
X-ray of the neck (cervical spine), 2 or 3 views inpatient CPT 72040 HC XR CERVICAL SPINE 2V OR 3V	$332.95	$443.93	—	—	25%
X-ray of the pelvis, 1 or 2 views CPT 72170 HC XR PELVIS 1 OR 2 VIEWS	$442.90	$590.53	—	130% above	25%
X-ray of the pelvis, 1 or 2 views CPT 72170 HC XR PELVIS 1 OR 2 VIEWS	$442.90	$590.53	—	130% above	25%
X-ray of the pelvis, 1 or 2 views inpatient CPT 72170 HC XR PELVIS 1 OR 2 VIEWS	$442.90	$590.53	—	—	25%
X-ray of the pelvis, 1 or 2 views inpatient CPT 72170 HC XR PELVIS 1 OR 2 VIEWS	$442.90	$590.53	—	—	25%
X-ray of the tailbone (sacrum and coccyx), 2 or more views CPT 72220 HC XR SACRUM/COCCYX MIN 2V	$418.01	$557.35	—	122% above	25%
X-ray of the tailbone (sacrum and coccyx), 2 or more views CPT 72220 HC XR SACRUM/COCCYX MIN 2V	$418.01	$557.35	—	122% above	25%
X-ray of the tailbone (sacrum and coccyx), 2 or more views inpatient CPT 72220 HC XR SACRUM/COCCYX MIN 2V	$418.01	$557.35	—	—	25%
X-ray of the tailbone (sacrum and coccyx), 2 or more views inpatient CPT 72220 HC XR SACRUM/COCCYX MIN 2V	$418.01	$557.35	—	—	25%

Lab tests

Procedure	Cash price	List price	Insurers pay	vs Wisconsin	Off list
ALT (alanine aminotransferase) liver enzyme test CPT 84460 CHG TRANSFERASE ALANINE AMINO ALT SGPT	$79.65	$106.20	—	77% above	25%
ALT (alanine aminotransferase) liver enzyme test CPT 84460 CHG TRANSFERASE ALANINE AMINO ALT SGPT	$79.65	$106.20	—	77% above	25%
ALT (alanine aminotransferase) liver enzyme test inpatient CPT 84460 CHG TRANSFERASE ALANINE AMINO ALT SGPT	$79.65	$106.20	—	—	25%
ALT (alanine aminotransferase) liver enzyme test inpatient CPT 84460 CHG TRANSFERASE ALANINE AMINO ALT SGPT	$79.65	$106.20	—	—	25%
AST (aspartate aminotransferase) enzyme test CPT 84450 CHG TRANSFERASE ASPARTATE AMINO AST SGOT	$73.16	$97.55	—	54% above	25%
AST (aspartate aminotransferase) enzyme test CPT 84450 CHG TRANSFERASE ASPARTATE AMINO AST SGOT	$73.16	$97.55	—	54% above	25%
AST (aspartate aminotransferase) enzyme test inpatient CPT 84450 CHG TRANSFERASE ASPARTATE AMINO AST SGOT	$73.16	$97.55	—	—	25%
AST (aspartate aminotransferase) enzyme test inpatient CPT 84450 CHG TRANSFERASE ASPARTATE AMINO AST SGOT	$73.16	$97.55	—	—	25%
Acute hepatitis panel (hepatitis A, B and C) CPT 80074 CHG ACUTE HEPATITIS PANEL	$635.82	$847.76	—	101% above	25%
Acute hepatitis panel (hepatitis A, B and C) CPT 80074 CHG ACUTE HEPATITIS PANEL	$635.82	$847.76	—	101% above	25%
Acute hepatitis panel (hepatitis A, B and C) inpatient CPT 80074 CHG ACUTE HEPATITIS PANEL	$635.82	$847.76	—	—	25%
Acute hepatitis panel (hepatitis A, B and C) inpatient CPT 80074 CHG ACUTE HEPATITIS PANEL	$635.82	$847.76	—	—	25%
Allergy blood test, specific IgE, per allergen CPT 86003 CHG ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH	$49.61	$66.15	—	98% above	25%
Allergy blood test, specific IgE, per allergen CPT 86003 CHG ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH	$49.61	$66.15	—	98% above	25%
Allergy blood test, specific IgE, per allergen inpatient CPT 86003 CHG ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH	$49.61	$66.15	—	—	25%
Allergy blood test, specific IgE, per allergen inpatient CPT 86003 CHG ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH	$49.61	$66.15	—	—	25%
Anti-CCP antibody test (rheumatoid arthritis) CPT 86200 CHG CYCLIC CITRULLINATED PEPTIDE ANTIBODY	$220.18	$293.57	—	175% above	25%
Anti-CCP antibody test (rheumatoid arthritis) CPT 86200 CHG CYCLIC CITRULLINATED PEPTIDE ANTIBODY	$220.18	$293.57	—	175% above	25%
Anti-CCP antibody test (rheumatoid arthritis) inpatient CPT 86200 CHG CYCLIC CITRULLINATED PEPTIDE ANTIBODY	$220.18	$293.57	—	—	25%
Anti-CCP antibody test (rheumatoid arthritis) inpatient CPT 86200 CHG CYCLIC CITRULLINATED PEPTIDE ANTIBODY	$220.18	$293.57	—	—	25%
Antinuclear antibody (ANA) blood test, screen CPT 86038 CHG ANTINUCLEAR ANTIBODIES ANA	$119.43	$159.24	—	74% above	25%
Antinuclear antibody (ANA) blood test, screen CPT 86038 CHG ANTINUCLEAR ANTIBODIES ANA	$119.43	$159.24	—	74% above	25%
Antinuclear antibody (ANA) blood test, screen inpatient CPT 86038 CHG ANTINUCLEAR ANTIBODIES ANA	$119.43	$159.24	—	—	25%
Antinuclear antibody (ANA) blood test, screen inpatient CPT 86038 CHG ANTINUCLEAR ANTIBODIES ANA	$119.43	$159.24	—	—	25%
BNP or NT-proBNP blood test (heart failure marker) CPT 83880 CHG NATRIURETIC PEPTIDE	$220.42	$293.89	—	58% above	25%
BNP or NT-proBNP blood test (heart failure marker) CPT 83880 CHG NATRIURETIC PEPTIDE	$220.42	$293.89	—	58% above	25%
BNP or NT-proBNP blood test (heart failure marker) inpatient CPT 83880 CHG NATRIURETIC PEPTIDE	$220.42	$293.89	—	—	25%
BNP or NT-proBNP blood test (heart failure marker) inpatient CPT 83880 CHG NATRIURETIC PEPTIDE	$220.42	$293.89	—	—	25%
Basic metabolic panel (blood test) CPT 80048 CHG BASIC METABOLIC PANEL CALCIUM TOTAL	$135.88	$181.17	—	58% above	25%
Basic metabolic panel (blood test) CPT 80048 CHG BASIC METABOLIC PANEL CALCIUM TOTAL	$135.88	$181.17	—	58% above	25%
Basic metabolic panel (blood test) inpatient CPT 80048 CHG BASIC METABOLIC PANEL CALCIUM TOTAL	$135.88	$181.17	—	—	25%
Basic metabolic panel (blood test) inpatient CPT 80048 CHG BASIC METABOLIC PANEL CALCIUM TOTAL	$135.88	$181.17	—	—	25%
Biopsy tissue exam by a pathologist (level IV) CPT 88305 CHG LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM	$316.70	$422.26	—	47% above	25%
Biopsy tissue exam by a pathologist (level IV) CPT 88305 CHG LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM	$316.70	$422.26	—	47% above	25%
Biopsy tissue exam by a pathologist (level IV) inpatient CPT 88305 CHG LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM	$316.70	$422.26	—	—	25%
Biopsy tissue exam by a pathologist (level IV) inpatient CPT 88305 CHG LEVEL IV SURG PATHOLOGY GROSS&MICROSCOPIC EXAM	$316.70	$422.26	—	—	25%
Blood culture for bacteria CPT 87040 CHG CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES	$133.12	$177.50	—	56% above	25%
Blood culture for bacteria CPT 87040 CHG CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES	$133.12	$177.50	—	56% above	25%
Blood culture for bacteria inpatient CPT 87040 CHG CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES	$133.12	$177.50	—	—	25%
Blood culture for bacteria inpatient CPT 87040 CHG CULTURE BACTERIAL BLOOD AEROBIC W/ID ISOLATES	$133.12	$177.50	—	—	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 HC PBB COLLECTION VENOUS BLOOD,VENIPUNCTURE	$20.87	$27.83	—	48% above	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 HC PBB COLLECTION VENOUS BLOOD,VENIPUNCTURE	$20.87	$27.83	—	48% above	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 HC LAB DRAW OTHER	$37.21	$49.61	—	164% above	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 HC LAB DRAW OTHER	$37.21	$49.61	—	164% above	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 PR COLLECTION VENOUS BLOOD VENIPUNCTURE	$37.21	$49.61	—	164% above	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 HC VENIPUNCTURE	$37.21	$49.61	—	164% above	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 PR COLLECTION VENOUS BLOOD VENIPUNCTURE	$37.21	$49.61	—	164% above	25%
Blood draw from a vein (venipuncture), collection fee only CPT 36415 HC VENIPUNCTURE	$37.21	$49.61	—	164% above	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 HC PBB COLLECTION VENOUS BLOOD,VENIPUNCTURE	$20.87	$27.83	—	—	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 HC PBB COLLECTION VENOUS BLOOD,VENIPUNCTURE	$20.87	$27.83	—	—	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 HC VENIPUNCTURE	$37.21	$49.61	—	—	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 PR COLLECTION VENOUS BLOOD VENIPUNCTURE	$37.21	$49.61	—	—	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 PR COLLECTION VENOUS BLOOD VENIPUNCTURE	$37.21	$49.61	—	—	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 HC VENIPUNCTURE	$37.21	$49.61	—	—	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 HC LAB DRAW OTHER	$37.21	$49.61	—	—	25%
Blood draw from a vein (venipuncture), collection fee only inpatient CPT 36415 HC LAB DRAW OTHER	$37.21	$49.61	—	—	25%
Blood glucose (sugar) test CPT 82947 CHG GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP	$75.02	$100.02	—	232% above	25%
Blood glucose (sugar) test CPT 82947 CHG GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP	$75.02	$100.02	—	232% above	25%
Blood glucose (sugar) test inpatient CPT 82947 CHG GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP	$75.02	$100.02	—	—	25%
Blood glucose (sugar) test inpatient CPT 82947 CHG GLUCOSE QUANTITATIVE BLOOD XCPT REAGENT STRIP	$75.02	$100.02	—	—	25%
Blood lead test CPT 83655 CHG ASSAY OF LEAD	$95.42	$127.23	—	93% above	25%
Blood lead test CPT 83655 CHG ASSAY OF LEAD	$95.42	$127.23	—	93% above	25%
Blood lead test inpatient CPT 83655 CHG ASSAY OF LEAD	$95.42	$127.23	—	—	25%
Blood lead test inpatient CPT 83655 CHG ASSAY OF LEAD	$95.42	$127.23	—	—	25%
Blood pregnancy test (hCG, qualitative: yes or no) CPT 84703 CHG GONADOTROPIN CHORIONIC QUALITATIVE	$148.18	$197.57	—	139% above	25%
Blood pregnancy test (hCG, qualitative: yes or no) CPT 84703 CHG GONADOTROPIN CHORIONIC QUALITATIVE	$148.18	$197.57	—	139% above	25%
Blood pregnancy test (hCG, qualitative: yes or no) inpatient CPT 84703 CHG GONADOTROPIN CHORIONIC QUALITATIVE	$148.18	$197.57	—	—	25%
Blood pregnancy test (hCG, qualitative: yes or no) inpatient CPT 84703 CHG GONADOTROPIN CHORIONIC QUALITATIVE	$148.18	$197.57	—	—	25%
Blood type test, ABO group only (Rh factor is a separate test) CPT 86900 CHG BLOOD TYPING SEROLOGIC ABO	$72.50	$96.67	—	81% above	25%
Blood type test, ABO group only (Rh factor is a separate test) CPT 86900 CHG BLOOD TYPING SEROLOGIC ABO	$72.50	$96.67	—	81% above	25%
Blood type test, ABO group only (Rh factor is a separate test) inpatient CPT 86900 CHG BLOOD TYPING SEROLOGIC ABO	$72.50	$96.67	—	—	25%
Blood type test, ABO group only (Rh factor is a separate test) inpatient CPT 86900 CHG BLOOD TYPING SEROLOGIC ABO	$72.50	$96.67	—	—	25%
C-reactive protein (CRP) blood test, standard (not high-sensitivity) CPT 86140 CHG C-REACTIVE PROTEIN	$40.30	$53.73	—	26% below	25%
C-reactive protein (CRP) blood test, standard (not high-sensitivity) CPT 86140 CHG C-REACTIVE PROTEIN	$40.30	$53.73	—	26% below	25%
C-reactive protein (CRP) blood test, standard (not high-sensitivity) inpatient CPT 86140 CHG C-REACTIVE PROTEIN	$40.30	$53.73	—	—	25%
C-reactive protein (CRP) blood test, standard (not high-sensitivity) inpatient CPT 86140 CHG C-REACTIVE PROTEIN	$40.30	$53.73	—	—	25%
C. difficile toxin gene test (stool PCR) CPT 87493 CHG INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE	$170.40	$227.20	—	13% above	25%
C. difficile toxin gene test (stool PCR) CPT 87493 CHG INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE	$170.40	$227.20	—	13% above	25%
C. difficile toxin gene test (stool PCR) inpatient CPT 87493 CHG INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE	$170.40	$227.20	—	—	25%
C. difficile toxin gene test (stool PCR) inpatient CPT 87493 CHG INF AGENT DET NUCLEIC ACID CLOSTRIDIUM AMP PROBE	$170.40	$227.20	—	—	25%
CA 19-9 blood test (tumor marker) CPT 86301 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 19-9	$232.53	$310.04	—	111% above	25%
CA 19-9 blood test (tumor marker) CPT 86301 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 19-9	$232.53	$310.04	—	111% above	25%
CA 19-9 blood test (tumor marker) inpatient CPT 86301 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 19-9	$232.53	$310.04	—	—	25%
CA 19-9 blood test (tumor marker) inpatient CPT 86301 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 19-9	$232.53	$310.04	—	—	25%
CA-125 blood test (ovarian cancer marker) CPT 86304 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125	$227.38	$303.17	—	94% above	25%
CA-125 blood test (ovarian cancer marker) CPT 86304 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125	$227.38	$303.17	—	94% above	25%
CA-125 blood test (ovarian cancer marker) inpatient CPT 86304 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125	$227.38	$303.17	—	—	25%
CA-125 blood test (ovarian cancer marker) inpatient CPT 86304 CHG IMMUNOASSAY TUMOR ANTIGEN QUANTITATIVE CA 125	$227.38	$303.17	—	—	25%
COVID-19 PCR test (SARS-CoV-2 lab test) CPT 87635 CHG IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ	$135.00	$180.00	—	at median	25%
COVID-19 PCR test (SARS-CoV-2 lab test) CPT 87635 CHG IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ	$135.00	$180.00	—	at median	25%
COVID-19 PCR test (SARS-CoV-2 lab test) inpatient CPT 87635 CHG IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ	$135.00	$180.00	—	—	25%
COVID-19 PCR test (SARS-CoV-2 lab test) inpatient CPT 87635 CHG IADNA SARS-COV-2 COVID-19 AMPLIFIED PROBE TQ	$135.00	$180.00	—	—	25%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) CPT 87491 CHG IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ	$224.91	$299.88	—	57% above	25%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) CPT 87491 CHG IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ	$224.91	$299.88	—	57% above	25%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87491 CHG IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ	$224.91	$299.88	—	—	25%
Chlamydia test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87491 CHG IADNA CHLAMYDIA TRACHOMATIS AMPLIFIED PROBE TQ	$224.91	$299.88	—	—	25%
Cholesterol and triglycerides (lipid panel) blood test CPT 80061 CHG LIPID PANEL	$155.60	$207.46	—	68% above	25%
Cholesterol and triglycerides (lipid panel) blood test CPT 80061 CHG LIPID PANEL	$155.60	$207.46	—	68% above	25%
Cholesterol and triglycerides (lipid panel) blood test inpatient CPT 80061 CHG LIPID PANEL	$155.60	$207.46	—	—	25%
Cholesterol and triglycerides (lipid panel) blood test inpatient CPT 80061 CHG LIPID PANEL	$155.60	$207.46	—	—	25%
Complete blood count (CBC) with differential CPT 85025 CHG BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC	$116.69	$155.59	—	67% above	25%
Complete blood count (CBC) with differential CPT 85025 CHG BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC	$116.69	$155.59	—	67% above	25%
Complete blood count (CBC) with differential inpatient CPT 85025 CHG BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC	$116.69	$155.59	—	—	25%
Complete blood count (CBC) with differential inpatient CPT 85025 CHG BLOOD COUNT COMPLETE AUTO&AUTO DIFRNTL WBC	$116.69	$155.59	—	—	25%
Complete blood count (CBC), no differential CPT 85027 CHG BLOOD COUNT COMPLETE AUTOMATED	$88.19	$117.59	—	76% above	25%
Complete blood count (CBC), no differential CPT 85027 CHG BLOOD COUNT COMPLETE AUTOMATED	$88.19	$117.59	—	76% above	25%
Complete blood count (CBC), no differential inpatient CPT 85027 CHG BLOOD COUNT COMPLETE AUTOMATED	$88.19	$117.59	—	—	25%
Complete blood count (CBC), no differential inpatient CPT 85027 CHG BLOOD COUNT COMPLETE AUTOMATED	$88.19	$117.59	—	—	25%
Comprehensive metabolic panel (blood test) CPT 80053 CHG COMPREHENSIVE METABOLIC PANEL	$163.88	$218.51	—	44% above	25%
Comprehensive metabolic panel (blood test) CPT 80053 CHG COMPREHENSIVE METABOLIC PANEL	$163.88	$218.51	—	44% above	25%
Comprehensive metabolic panel (blood test) inpatient CPT 80053 CHG COMPREHENSIVE METABOLIC PANEL	$163.88	$218.51	—	—	25%
Comprehensive metabolic panel (blood test) inpatient CPT 80053 CHG COMPREHENSIVE METABOLIC PANEL	$163.88	$218.51	—	—	25%
D-dimer blood test (blood clot marker) CPT 85379 CHG FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE	$142.62	$190.16	—	108% above	25%
D-dimer blood test (blood clot marker) CPT 85379 CHG FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE	$142.62	$190.16	—	108% above	25%
D-dimer blood test (blood clot marker) inpatient CPT 85379 CHG FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE	$142.62	$190.16	—	—	25%
D-dimer blood test (blood clot marker) inpatient CPT 85379 CHG FIBRIN DGRADJ PRODUCTS D-DIMER QUANTITATIVE	$142.62	$190.16	—	—	25%
DHEA sulfate (DHEA-S) blood test CPT 82627 CHG DEHYDROEPIANDROSTERONE-SULFATE	$322.58	$430.11	—	135% above	25%
DHEA sulfate (DHEA-S) blood test CPT 82627 CHG DEHYDROEPIANDROSTERONE-SULFATE	$322.58	$430.11	—	135% above	25%
DHEA sulfate (DHEA-S) blood test inpatient CPT 82627 CHG DEHYDROEPIANDROSTERONE-SULFATE	$322.58	$430.11	—	—	25%
DHEA sulfate (DHEA-S) blood test inpatient CPT 82627 CHG DEHYDROEPIANDROSTERONE-SULFATE	$322.58	$430.11	—	—	25%
Estradiol blood test CPT 82670 CHG ASSAY OF TOTAL ESTRADIOL	$230.27	$307.03	—	79% above	25%
Estradiol blood test CPT 82670 CHG ASSAY OF TOTAL ESTRADIOL	$230.27	$307.03	—	79% above	25%
Estradiol blood test inpatient CPT 82670 CHG ASSAY OF TOTAL ESTRADIOL	$230.27	$307.03	—	—	25%
Estradiol blood test inpatient CPT 82670 CHG ASSAY OF TOTAL ESTRADIOL	$230.27	$307.03	—	—	25%
FSH (follicle-stimulating hormone) test CPT 83001 CHG GONADOTROPIN FOLLICLE STIMULATING HORMONE	$324.65	$432.87	—	181% above	25%
FSH (follicle-stimulating hormone) test CPT 83001 CHG GONADOTROPIN FOLLICLE STIMULATING HORMONE	$324.65	$432.87	—	181% above	25%
FSH (follicle-stimulating hormone) test inpatient CPT 83001 CHG GONADOTROPIN FOLLICLE STIMULATING HORMONE	$324.65	$432.87	—	—	25%
FSH (follicle-stimulating hormone) test inpatient CPT 83001 CHG GONADOTROPIN FOLLICLE STIMULATING HORMONE	$324.65	$432.87	—	—	25%
Fecal calprotectin (stool inflammation test) CPT 83993 CHG ASSAY OF CALPROTECTIN FECAL	$307.02	$409.36	—	51% above	25%
Fecal calprotectin (stool inflammation test) CPT 83993 CHG ASSAY OF CALPROTECTIN FECAL	$307.02	$409.36	—	51% above	25%
Fecal calprotectin (stool inflammation test) inpatient CPT 83993 CHG ASSAY OF CALPROTECTIN FECAL	$307.02	$409.36	—	—	25%
Fecal calprotectin (stool inflammation test) inpatient CPT 83993 CHG ASSAY OF CALPROTECTIN FECAL	$307.02	$409.36	—	—	25%
Ferritin blood test (iron stores) CPT 82728 CHG ASSAY OF FERRITIN	$152.80	$203.74	—	70% above	25%
Ferritin blood test (iron stores) CPT 82728 CHG ASSAY OF FERRITIN	$152.80	$203.74	—	70% above	25%
Ferritin blood test (iron stores) inpatient CPT 82728 CHG ASSAY OF FERRITIN	$152.80	$203.74	—	—	25%
Ferritin blood test (iron stores) inpatient CPT 82728 CHG ASSAY OF FERRITIN	$152.80	$203.74	—	—	25%
Folate (folic acid) blood test CPT 82746 CHG ASSAY OF FOLIC ACID SERUM	$156.51	$208.68	—	58% above	25%
Folate (folic acid) blood test CPT 82746 CHG ASSAY OF FOLIC ACID SERUM	$156.51	$208.68	—	58% above	25%
Folate (folic acid) blood test inpatient CPT 82746 CHG ASSAY OF FOLIC ACID SERUM	$156.51	$208.68	—	—	25%
Folate (folic acid) blood test inpatient CPT 82746 CHG ASSAY OF FOLIC ACID SERUM	$156.51	$208.68	—	—	25%
Free T3 thyroid hormone test CPT 84481 CHG ASSAY OF TRIIODOTHYRONINE T3 FREE	$297.28	$396.37	—	213% above	25%
Free T3 thyroid hormone test CPT 84481 CHG ASSAY OF TRIIODOTHYRONINE T3 FREE	$297.28	$396.37	—	213% above	25%
Free T3 thyroid hormone test inpatient CPT 84481 CHG ASSAY OF TRIIODOTHYRONINE T3 FREE	$297.28	$396.37	—	—	25%
Free T3 thyroid hormone test inpatient CPT 84481 CHG ASSAY OF TRIIODOTHYRONINE T3 FREE	$297.28	$396.37	—	—	25%
Free T4 (free thyroxine) thyroid blood test CPT 84439 CHG ASSAY OF FREE THYROXINE	$137.74	$183.66	—	71% above	25%
Free T4 (free thyroxine) thyroid blood test CPT 84439 CHG ASSAY OF FREE THYROXINE	$137.74	$183.66	—	71% above	25%
Free T4 (free thyroxine) thyroid blood test inpatient CPT 84439 CHG ASSAY OF FREE THYROXINE	$137.74	$183.66	—	—	25%
Free T4 (free thyroxine) thyroid blood test inpatient CPT 84439 CHG ASSAY OF FREE THYROXINE	$137.74	$183.66	—	—	25%
General health panel: metabolic panel, blood count and TSH in one order CPT 80050 CHG GENERAL HEALTH PANEL	$348.81	$465.08	—	27% above	25%
General health panel: metabolic panel, blood count and TSH in one order CPT 80050 CHG GENERAL HEALTH PANEL	$348.81	$465.08	—	27% above	25%
General health panel: metabolic panel, blood count and TSH in one order inpatient CPT 80050 CHG GENERAL HEALTH PANEL	$348.81	$465.08	—	—	25%
General health panel: metabolic panel, blood count and TSH in one order inpatient CPT 80050 CHG GENERAL HEALTH PANEL	$348.81	$465.08	—	—	25%
Glucose challenge test (1-hour glucose after a sugar drink) CPT 82950 CHG GLUCOSE POST GLUCOSE DOSE	$122.40	$163.20	—	151% above	25%
Glucose challenge test (1-hour glucose after a sugar drink) CPT 82950 CHG GLUCOSE POST GLUCOSE DOSE	$122.40	$163.20	—	151% above	25%
Glucose challenge test (1-hour glucose after a sugar drink) inpatient CPT 82950 CHG GLUCOSE POST GLUCOSE DOSE	$122.40	$163.20	—	—	25%
Glucose challenge test (1-hour glucose after a sugar drink) inpatient CPT 82950 CHG GLUCOSE POST GLUCOSE DOSE	$122.40	$163.20	—	—	25%
Glucose tolerance test, 3 samples CPT 82951 CHG GLUCOSE TOLERANCE TEST GTT 3 SPECIMENS	$198.11	$264.15	—	121% above	25%
Glucose tolerance test, 3 samples CPT 82951 CHG GLUCOSE TOLERANCE TEST GTT 3 SPECIMENS	$198.11	$264.15	—	121% above	25%
Glucose tolerance test, 3 samples inpatient CPT 82951 CHG GLUCOSE TOLERANCE TEST GTT 3 SPECIMENS	$198.11	$264.15	—	—	25%
Glucose tolerance test, 3 samples inpatient CPT 82951 CHG GLUCOSE TOLERANCE TEST GTT 3 SPECIMENS	$198.11	$264.15	—	—	25%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) CPT 87591 CHG IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ	$179.61	$239.48	—	26% above	25%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) CPT 87591 CHG IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ	$179.61	$239.48	—	26% above	25%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87591 CHG IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ	$179.61	$239.48	—	—	25%
Gonorrhea test by nucleic acid amplification (NAAT, PCR-type) inpatient CPT 87591 CHG IADNA NEISSERIA GONORRHOEAE AMPLIFIED PROBE TQ	$179.61	$239.48	—	—	25%
H. pylori antibody blood test CPT 86677 CHG ANTIBODY HELICOBACTER PYLORI	$266.75	$355.67	—	181% above	25%
H. pylori antibody blood test CPT 86677 CHG ANTIBODY HELICOBACTER PYLORI	$266.75	$355.67	—	181% above	25%
H. pylori antibody blood test inpatient CPT 86677 CHG ANTIBODY HELICOBACTER PYLORI	$266.75	$355.67	—	—	25%
H. pylori antibody blood test inpatient CPT 86677 CHG ANTIBODY HELICOBACTER PYLORI	$266.75	$355.67	—	—	25%
H. pylori stool antigen test CPT 87338 CHG IAAD IA HPYLORI STOOL	$254.68	$339.57	—	104% above	25%
H. pylori stool antigen test CPT 87338 CHG IAAD IA HPYLORI STOOL	$254.68	$339.57	—	104% above	25%
H. pylori stool antigen test inpatient CPT 87338 CHG IAAD IA HPYLORI STOOL	$254.68	$339.57	—	—	25%
H. pylori stool antigen test inpatient CPT 87338 CHG IAAD IA HPYLORI STOOL	$254.68	$339.57	—	—	25%
HIV viral load test (HIV-1 RNA, quantitative) CPT 87536 CHG IADNA HIV-1 QUANT & REVERSE TRANSCRIPTION	$773.30	$1,031.06	—	106% above	25%
HIV viral load test (HIV-1 RNA, quantitative) CPT 87536 CHG IADNA HIV-1 QUANT & REVERSE TRANSCRIPTION	$773.30	$1,031.06	—	106% above	25%
HIV viral load test (HIV-1 RNA, quantitative) inpatient CPT 87536 CHG IADNA HIV-1 QUANT & REVERSE TRANSCRIPTION	$773.30	$1,031.06	—	—	25%
HIV viral load test (HIV-1 RNA, quantitative) inpatient CPT 87536 CHG IADNA HIV-1 QUANT & REVERSE TRANSCRIPTION	$773.30	$1,031.06	—	—	25%
HIV-1 and HIV-2 antibody test CPT 86703 CHG ANTIBODY HIV-1&HIV-2 SINGLE RESULT	$134.78	$179.71	—	80% above	25%
HIV-1 and HIV-2 antibody test CPT 86703 CHG ANTIBODY HIV-1&HIV-2 SINGLE RESULT	$134.78	$179.71	—	80% above	25%
HIV-1 and HIV-2 antibody test inpatient CPT 86703 CHG ANTIBODY HIV-1&HIV-2 SINGLE RESULT	$134.78	$179.71	—	—	25%
HIV-1 and HIV-2 antibody test inpatient CPT 86703 CHG ANTIBODY HIV-1&HIV-2 SINGLE RESULT	$134.78	$179.71	—	—	25%
HIV-1/2 antigen and antibody combination blood test (4th generation) CPT 87389 CHG IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE	$168.10	$224.14	—	68% above	25%
HIV-1/2 antigen and antibody combination blood test (4th generation) CPT 87389 CHG IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE	$168.10	$224.14	—	68% above	25%
HIV-1/2 antigen and antibody combination blood test (4th generation) inpatient CPT 87389 CHG IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE	$168.10	$224.14	—	—	25%
HIV-1/2 antigen and antibody combination blood test (4th generation) inpatient CPT 87389 CHG IAAD IA HIV-1 AG W/HIV-1 & HIV-2 ANTBDY SINGLE	$168.10	$224.14	—	—	25%
HPV test for high-risk types, one combined (pooled) result CPT 87624 CHG IADNA HUMAN PAPILLOMAVIRUS HI-RSK TYP POOLD RSLT	$219.95	$293.27	—	54% above	25%
HPV test for high-risk types, one combined (pooled) result CPT 87624 CHG IADNA HUMAN PAPILLOMAVIRUS HI-RSK TYP POOLD RSLT	$219.95	$293.27	—	54% above	25%
HPV test for high-risk types, one combined (pooled) result inpatient CPT 87624 CHG IADNA HUMAN PAPILLOMAVIRUS HI-RSK TYP POOLD RSLT	$219.95	$293.27	—	—	25%
HPV test for high-risk types, one combined (pooled) result inpatient CPT 87624 CHG IADNA HUMAN PAPILLOMAVIRUS HI-RSK TYP POOLD RSLT	$219.95	$293.27	—	—	25%
Hemoglobin A1C blood test (average blood sugar over about 3 months) CPT 83036 CHG HEMOGLOBIN GLYCOSYLATED A1C	$113.96	$151.95	—	109% above	25%
Hemoglobin A1C blood test (average blood sugar over about 3 months) CPT 83036 CHG HEMOGLOBIN GLYCOSYLATED A1C	$113.96	$151.95	—	109% above	25%
Hemoglobin A1C blood test (average blood sugar over about 3 months) inpatient CPT 83036 CHG HEMOGLOBIN GLYCOSYLATED A1C	$113.96	$151.95	—	—	25%
Hemoglobin A1C blood test (average blood sugar over about 3 months) inpatient CPT 83036 CHG HEMOGLOBIN GLYCOSYLATED A1C	$113.96	$151.95	—	—	25%
Hepatitis B surface antibody (anti-HBs) test, immunity check CPT 86706 CHG HEPATITIS B SURF ANTIBODY HBSAB	$140.95	$187.93	—	90% above	25%
Hepatitis B surface antibody (anti-HBs) test, immunity check CPT 86706 CHG HEPATITIS B SURF ANTIBODY HBSAB	$140.95	$187.93	—	90% above	25%
Hepatitis B surface antibody (anti-HBs) test, immunity check inpatient CPT 86706 CHG HEPATITIS B SURF ANTIBODY HBSAB	$140.95	$187.93	—	—	25%
Hepatitis B surface antibody (anti-HBs) test, immunity check inpatient CPT 86706 CHG HEPATITIS B SURF ANTIBODY HBSAB	$140.95	$187.93	—	—	25%
Hepatitis B surface antigen (HBsAg) test CPT 87340 CHG IAAD IA HEPATITIS B SURFACE ANTIGEN	$108.82	$145.10	—	62% above	25%
Hepatitis B surface antigen (HBsAg) test CPT 87340 CHG IAAD IA HEPATITIS B SURFACE ANTIGEN	$108.82	$145.10	—	62% above	25%
Hepatitis B surface antigen (HBsAg) test inpatient CPT 87340 CHG IAAD IA HEPATITIS B SURFACE ANTIGEN	$108.82	$145.10	—	—	25%
Hepatitis B surface antigen (HBsAg) test inpatient CPT 87340 CHG IAAD IA HEPATITIS B SURFACE ANTIGEN	$108.82	$145.10	—	—	25%
Hepatitis C antibody blood test (screening) CPT 86803 CHG HEPATITIS C ANTIBODY	$192.66	$256.88	—	134% above	25%
Hepatitis C antibody blood test (screening) CPT 86803 CHG HEPATITIS C ANTIBODY	$192.66	$256.88	—	134% above	25%
Hepatitis C antibody blood test (screening) inpatient CPT 86803 CHG HEPATITIS C ANTIBODY	$192.66	$256.88	—	—	25%
Hepatitis C antibody blood test (screening) inpatient CPT 86803 CHG HEPATITIS C ANTIBODY	$192.66	$256.88	—	—	25%
Hepatitis C viral load (HCV RNA) test CPT 87522 CHG IADNA HEPATITIS C QUANT & REVERSE TRANSCRIPTION	$704.76	$939.68	—	198% above	25%
Hepatitis C viral load (HCV RNA) test CPT 87522 CHG IADNA HEPATITIS C QUANT & REVERSE TRANSCRIPTION	$704.76	$939.68	—	198% above	25%
Hepatitis C viral load (HCV RNA) test inpatient CPT 87522 CHG IADNA HEPATITIS C QUANT & REVERSE TRANSCRIPTION	$704.76	$939.68	—	—	25%
Hepatitis C viral load (HCV RNA) test inpatient CPT 87522 CHG IADNA HEPATITIS C QUANT & REVERSE TRANSCRIPTION	$704.76	$939.68	—	—	25%
Herpes blood test, HSV-1 antibody CPT 86695 CHG ANTIBODY HERPES SMPLX TYPE 1	$141.99	$189.32	—	114% above	25%
Herpes blood test, HSV-1 antibody CPT 86695 CHG ANTIBODY HERPES SMPLX TYPE 1	$141.99	$189.32	—	114% above	25%
Herpes blood test, HSV-1 antibody inpatient CPT 86695 CHG ANTIBODY HERPES SMPLX TYPE 1	$141.99	$189.32	—	—	25%
Herpes blood test, HSV-1 antibody inpatient CPT 86695 CHG ANTIBODY HERPES SMPLX TYPE 1	$141.99	$189.32	—	—	25%
Herpes blood test, HSV-2 antibody CPT 86696 CHG ANTIBODY HERPES SMPLX TYPE 2	$198.56	$264.75	—	129% above	25%
Herpes blood test, HSV-2 antibody CPT 86696 CHG ANTIBODY HERPES SMPLX TYPE 2	$198.56	$264.75	—	129% above	25%
Herpes blood test, HSV-2 antibody inpatient CPT 86696 CHG ANTIBODY HERPES SMPLX TYPE 2	$198.56	$264.75	—	—	25%
Herpes blood test, HSV-2 antibody inpatient CPT 86696 CHG ANTIBODY HERPES SMPLX TYPE 2	$198.56	$264.75	—	—	25%
High-sensitivity CRP (hs-CRP) test CPT 86141 CHG C-REACTIVE PROTEIN HIGH SENSITIVITY	$168.74	$224.98	—	118% above	25%
High-sensitivity CRP (hs-CRP) test CPT 86141 CHG C-REACTIVE PROTEIN HIGH SENSITIVITY	$168.74	$224.98	—	118% above	25%
High-sensitivity CRP (hs-CRP) test inpatient CPT 86141 CHG C-REACTIVE PROTEIN HIGH SENSITIVITY	$168.74	$224.98	—	—	25%
High-sensitivity CRP (hs-CRP) test inpatient CPT 86141 CHG C-REACTIVE PROTEIN HIGH SENSITIVITY	$168.74	$224.98	—	—	25%
Homocysteine blood test CPT 83090 CHG ASSAY OF HOMOCYSTEINE	$228.20	$304.26	—	93% above	25%
Homocysteine blood test CPT 83090 CHG ASSAY OF HOMOCYSTEINE	$228.20	$304.26	—	93% above	25%
Homocysteine blood test inpatient CPT 83090 CHG ASSAY OF HOMOCYSTEINE	$228.20	$304.26	—	—	25%
Homocysteine blood test inpatient CPT 83090 CHG ASSAY OF HOMOCYSTEINE	$228.20	$304.26	—	—	25%
Insulin blood test CPT 83525 CHG ASSAY OF INSULIN TOTAL	$182.55	$243.40	—	181% above	25%
Insulin blood test CPT 83525 CHG ASSAY OF INSULIN TOTAL	$182.55	$243.40	—	181% above	25%
Insulin blood test inpatient CPT 83525 CHG ASSAY OF INSULIN TOTAL	$182.55	$243.40	—	—	25%
Insulin blood test inpatient CPT 83525 CHG ASSAY OF INSULIN TOTAL	$182.55	$243.40	—	—	25%
Iron blood test (serum iron) CPT 83540 CHG ASSAY OF IRON	$120.40	$160.53	—	126% above	25%
Iron blood test (serum iron) CPT 83540 CHG ASSAY OF IRON	$120.40	$160.53	—	126% above	25%
Iron blood test (serum iron) inpatient CPT 83540 CHG ASSAY OF IRON	$120.40	$160.53	—	—	25%
Iron blood test (serum iron) inpatient CPT 83540 CHG ASSAY OF IRON	$120.40	$160.53	—	—	25%
Iron-binding capacity (TIBC) test CPT 83550 CHG IRON BINDING CAPACITY	$117.62	$156.82	—	90% above	25%
Iron-binding capacity (TIBC) test CPT 83550 CHG IRON BINDING CAPACITY	$117.62	$156.82	—	90% above	25%
Iron-binding capacity (TIBC) test inpatient CPT 83550 CHG IRON BINDING CAPACITY	$117.62	$156.82	—	—	25%
Iron-binding capacity (TIBC) test inpatient CPT 83550 CHG IRON BINDING CAPACITY	$117.62	$156.82	—	—	25%
Kidney function blood test panel CPT 80069 CHG RENAL FUNCTION PANEL	$158.69	$211.59	—	55% above	25%
Kidney function blood test panel CPT 80069 CHG RENAL FUNCTION PANEL	$158.69	$211.59	—	55% above	25%
Kidney function blood test panel inpatient CPT 80069 CHG RENAL FUNCTION PANEL	$158.69	$211.59	—	—	25%
Kidney function blood test panel inpatient CPT 80069 CHG RENAL FUNCTION PANEL	$158.69	$211.59	—	—	25%
LH (luteinizing hormone) test CPT 83002 CHG GONADOTROPIN LUTEINIZING HORMONE	$218.86	$291.82	—	129% above	25%
LH (luteinizing hormone) test CPT 83002 CHG GONADOTROPIN LUTEINIZING HORMONE	$218.86	$291.82	—	129% above	25%
LH (luteinizing hormone) test inpatient CPT 83002 CHG GONADOTROPIN LUTEINIZING HORMONE	$218.86	$291.82	—	—	25%
LH (luteinizing hormone) test inpatient CPT 83002 CHG GONADOTROPIN LUTEINIZING HORMONE	$218.86	$291.82	—	—	25%
Lipase blood test (pancreas enzyme) CPT 83690 CHG ASSAY OF LIPASE	$141.69	$188.92	—	109% above	25%
Lipase blood test (pancreas enzyme) CPT 83690 CHG ASSAY OF LIPASE	$141.69	$188.92	—	109% above	25%
Lipase blood test (pancreas enzyme) inpatient CPT 83690 CHG ASSAY OF LIPASE	$141.69	$188.92	—	—	25%
Lipase blood test (pancreas enzyme) inpatient CPT 83690 CHG ASSAY OF LIPASE	$141.69	$188.92	—	—	25%
Liver function blood test panel CPT 80076 CHG HEPATIC FUNCTION PANEL	$161.81	$215.75	—	59% above	25%
Liver function blood test panel CPT 80076 CHG HEPATIC FUNCTION PANEL	$161.81	$215.75	—	59% above	25%
Liver function blood test panel inpatient CPT 80076 CHG HEPATIC FUNCTION PANEL	$161.81	$215.75	—	—	25%
Liver function blood test panel inpatient CPT 80076 CHG HEPATIC FUNCTION PANEL	$161.81	$215.75	—	—	25%
Lyme disease antibody test CPT 86618 CHG ANTIBODY BORRELIA BURGDORFERI LYME DISEASE	$163.60	$218.13	—	97% above	25%
Lyme disease antibody test CPT 86618 CHG ANTIBODY BORRELIA BURGDORFERI LYME DISEASE	$163.60	$218.13	—	97% above	25%
Lyme disease antibody test inpatient CPT 86618 CHG ANTIBODY BORRELIA BURGDORFERI LYME DISEASE	$163.60	$218.13	—	—	25%
Lyme disease antibody test inpatient CPT 86618 CHG ANTIBODY BORRELIA BURGDORFERI LYME DISEASE	$163.60	$218.13	—	—	25%
Magnesium blood test CPT 83735 CHG ASSAY OF MAGNESIUM	$31.49	$41.99	—	37% below	25%
Magnesium blood test CPT 83735 CHG ASSAY OF MAGNESIUM	$31.49	$41.99	—	37% below	25%
Magnesium blood test inpatient CPT 83735 CHG ASSAY OF MAGNESIUM	$31.49	$41.99	—	—	25%
Magnesium blood test inpatient CPT 83735 CHG ASSAY OF MAGNESIUM	$31.49	$41.99	—	—	25%
Measles (rubeola) antibody test CPT 86765 CHG ANTIBODY RUBEOLA	$243.83	$325.11	—	205% above	25%
Measles (rubeola) antibody test CPT 86765 CHG ANTIBODY RUBEOLA	$243.83	$325.11	—	205% above	25%
Measles (rubeola) antibody test inpatient CPT 86765 CHG ANTIBODY RUBEOLA	$243.83	$325.11	—	—	25%
Measles (rubeola) antibody test inpatient CPT 86765 CHG ANTIBODY RUBEOLA	$243.83	$325.11	—	—	25%
Mono test (heterophile antibody, Monospot) CPT 86308 CHG HETEROPHILE ANTIBODIES SCREEN	$117.29	$156.39	—	113% above	25%
Mono test (heterophile antibody, Monospot) CPT 86308 CHG HETEROPHILE ANTIBODIES SCREEN	$117.29	$156.39	—	113% above	25%
Mono test (heterophile antibody, Monospot) inpatient CPT 86308 CHG HETEROPHILE ANTIBODIES SCREEN	$117.29	$156.39	—	—	25%
Mono test (heterophile antibody, Monospot) inpatient CPT 86308 CHG HETEROPHILE ANTIBODIES SCREEN	$117.29	$156.39	—	—	25%
Obstetric blood test panel CPT 80055 CHG OBSTETRIC PANEL	$434.60	$579.47	—	127% above	25%
Obstetric blood test panel CPT 80055 CHG OBSTETRIC PANEL	$434.60	$579.47	—	127% above	25%
Obstetric blood test panel inpatient CPT 80055 CHG OBSTETRIC PANEL	$434.60	$579.47	—	—	25%
Obstetric blood test panel inpatient CPT 80055 CHG OBSTETRIC PANEL	$434.60	$579.47	—	—	25%
PSA (prostate-specific antigen) blood test, free CPT 84154 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE	$211.15	$281.53	—	135% above	25%
PSA (prostate-specific antigen) blood test, free CPT 84154 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE	$211.15	$281.53	—	135% above	25%
PSA (prostate-specific antigen) blood test, free inpatient CPT 84154 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE	$211.15	$281.53	—	—	25%
PSA (prostate-specific antigen) blood test, free inpatient CPT 84154 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN FREE	$211.15	$281.53	—	—	25%
PSA (prostate-specific antigen) blood test, total CPT 84153 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL	$134.77	$179.69	—	45% above	25%
PSA (prostate-specific antigen) blood test, total CPT 84153 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL	$134.77	$179.69	—	45% above	25%
PSA (prostate-specific antigen) blood test, total inpatient CPT 84153 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL	$134.77	$179.69	—	—	25%
PSA (prostate-specific antigen) blood test, total inpatient CPT 84153 CHG ASSAY OF PROSTATE SPECIFIC ANTIGEN TOTAL	$134.77	$179.69	—	—	25%
Pap test (liquid-based, automated screening with review) CPT 88175 CHG CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS	$154.63	$206.17	—	47% above	25%
Pap test (liquid-based, automated screening with review) CPT 88175 CHG CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS	$154.63	$206.17	—	47% above	25%
Pap test (liquid-based, automated screening with review) inpatient CPT 88175 CHG CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS	$154.63	$206.17	—	—	25%
Pap test (liquid-based, automated screening with review) inpatient CPT 88175 CHG CYTP C/V AUTO THIN LYR PREPJ SCR MNL RESCR PHYS	$154.63	$206.17	—	—	25%
Parathyroid hormone (PTH) blood test CPT 83970 CHG ASSAY OF PARATHORMONE	$311.15	$414.87	—	46% above	25%
Parathyroid hormone (PTH) blood test CPT 83970 CHG ASSAY OF PARATHORMONE	$311.15	$414.87	—	46% above	25%
Parathyroid hormone (PTH) blood test inpatient CPT 83970 CHG ASSAY OF PARATHORMONE	$311.15	$414.87	—	—	25%
Parathyroid hormone (PTH) blood test inpatient CPT 83970 CHG ASSAY OF PARATHORMONE	$311.15	$414.87	—	—	25%
Partial thromboplastin time (PTT) clotting test CPT 85730 CHG THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD	$95.13	$126.84	—	90% above	25%
Partial thromboplastin time (PTT) clotting test CPT 85730 CHG THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD	$95.13	$126.84	—	90% above	25%
Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 CHG THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD	$95.13	$126.84	—	—	25%
Partial thromboplastin time (PTT) clotting test inpatient CPT 85730 CHG THROMBOPLASTIN TIME PARTIAL PLASMA/WHOLE BLOOD	$95.13	$126.84	—	—	25%
Prenatal cell-free DNA screen for trisomy 21, 18 and 13 (NIPT) CPT 81420 CHG FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS	$2,507.08	$3,342.78	—	108% above	25%
Prenatal cell-free DNA screen for trisomy 21, 18 and 13 (NIPT) CPT 81420 CHG FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS	$2,507.08	$3,342.78	—	108% above	25%
Prenatal cell-free DNA screen for trisomy 21, 18 and 13 (NIPT) inpatient CPT 81420 CHG FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS	$2,507.08	$3,342.78	—	—	25%
Prenatal cell-free DNA screen for trisomy 21, 18 and 13 (NIPT) inpatient CPT 81420 CHG FETAL CHROMOSOMAL ANEUPLOIDY GENOMIC SEQ ANALYS	$2,507.08	$3,342.78	—	—	25%
Progesterone blood test CPT 84144 CHG ASSAY OF PROGESTERONE	$296.66	$395.54	—	147% above	25%
Progesterone blood test CPT 84144 CHG ASSAY OF PROGESTERONE	$296.66	$395.54	—	147% above	25%
Progesterone blood test inpatient CPT 84144 CHG ASSAY OF PROGESTERONE	$296.66	$395.54	—	—	25%
Progesterone blood test inpatient CPT 84144 CHG ASSAY OF PROGESTERONE	$296.66	$395.54	—	—	25%
Prolactin blood test CPT 84146 CHG ASSAY OF PROLACTIN	$233.38	$311.17	—	93% above	25%
Prolactin blood test CPT 84146 CHG ASSAY OF PROLACTIN	$233.38	$311.17	—	93% above	25%
Prolactin blood test inpatient CPT 84146 CHG ASSAY OF PROLACTIN	$233.38	$311.17	—	—	25%
Prolactin blood test inpatient CPT 84146 CHG ASSAY OF PROLACTIN	$233.38	$311.17	—	—	25%
Prothrombin time (PT/INR) clotting test CPT 85610 CHG PROTHROMBIN TIME	$54.64	$72.86	—	69% above	25%
Prothrombin time (PT/INR) clotting test CPT 85610 CHG PROTHROMBIN TIME	$54.64	$72.86	—	69% above	25%
Prothrombin time (PT/INR) clotting test inpatient CPT 85610 CHG PROTHROMBIN TIME	$54.64	$72.86	—	—	25%
Prothrombin time (PT/INR) clotting test inpatient CPT 85610 CHG PROTHROMBIN TIME	$54.64	$72.86	—	—	25%
Rapid strep A antigen test from a throat swab, read visually CPT 87880 CHG IAADIADOO STREPTOCOCCUS GROUP A	$119.04	$158.72	—	161% above	25%
Rapid strep A antigen test from a throat swab, read visually CPT 87880 CHG IAADIADOO STREPTOCOCCUS GROUP A	$119.04	$158.72	—	161% above	25%
Rapid strep A antigen test from a throat swab, read visually inpatient CPT 87880 CHG IAADIADOO STREPTOCOCCUS GROUP A	$119.04	$158.72	—	—	25%
Rapid strep A antigen test from a throat swab, read visually inpatient CPT 87880 CHG IAADIADOO STREPTOCOCCUS GROUP A	$119.04	$158.72	—	—	25%
Rheumatoid factor (RF) test CPT 86431 CHG RHEUMATOID FACTOR QUANTITATIVE	$118.50	$158.00	—	106% above	25%
Rheumatoid factor (RF) test CPT 86431 CHG RHEUMATOID FACTOR QUANTITATIVE	$118.50	$158.00	—	106% above	25%
Rheumatoid factor (RF) test inpatient CPT 86431 CHG RHEUMATOID FACTOR QUANTITATIVE	$118.50	$158.00	—	—	25%
Rheumatoid factor (RF) test inpatient CPT 86431 CHG RHEUMATOID FACTOR QUANTITATIVE	$118.50	$158.00	—	—	25%
Rubella antibody test (immunity check) CPT 86762 CHG ANTIBODY RUBELLA	$105.98	$141.30	—	32% above	25%
Rubella antibody test (immunity check) CPT 86762 CHG ANTIBODY RUBELLA	$105.98	$141.30	—	32% above	25%
Rubella antibody test (immunity check) inpatient CPT 86762 CHG ANTIBODY RUBELLA	$105.98	$141.30	—	—	25%
Rubella antibody test (immunity check) inpatient CPT 86762 CHG ANTIBODY RUBELLA	$105.98	$141.30	—	—	25%
Sed rate (ESR, erythrocyte sedimentation rate) CPT 85652 CHG SEDIMENTATION RATE RBC AUTOMATED	$66.39	$88.52	—	60% above	25%
Sed rate (ESR, erythrocyte sedimentation rate) CPT 85652 CHG SEDIMENTATION RATE RBC AUTOMATED	$66.39	$88.52	—	60% above	25%
Sed rate (ESR, erythrocyte sedimentation rate) inpatient CPT 85652 CHG SEDIMENTATION RATE RBC AUTOMATED	$66.39	$88.52	—	—	25%
Sed rate (ESR, erythrocyte sedimentation rate) inpatient CPT 85652 CHG SEDIMENTATION RATE RBC AUTOMATED	$66.39	$88.52	—	—	25%
Semen analysis: volume, sperm count, motility and morphology CPT 89320 CHG SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT	$287.31	$383.08	—	141% above	25%
Semen analysis: volume, sperm count, motility and morphology CPT 89320 CHG SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT	$287.31	$383.08	—	141% above	25%
Semen analysis: volume, sperm count, motility and morphology inpatient CPT 89320 CHG SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT	$287.31	$383.08	—	—	25%
Semen analysis: volume, sperm count, motility and morphology inpatient CPT 89320 CHG SEMEN ANALYSIS VOLUME COUNT MOTILITY DIFFERENT	$287.31	$383.08	—	—	25%
Stool ova and parasites exam CPT 87177 CHG OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID	$126.87	$169.16	—	103% above	25%
Stool ova and parasites exam CPT 87177 CHG OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID	$126.87	$169.16	—	103% above	25%
Stool ova and parasites exam inpatient CPT 87177 CHG OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID	$126.87	$169.16	—	—	25%
Stool ova and parasites exam inpatient CPT 87177 CHG OVA&PARASITES DIRECT SMEARS CONCENTRATION & ID	$126.87	$169.16	—	—	25%
Stool test for hidden blood (guaiac FOBT) CPT 82270 CHG BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER	$19.72	$26.30	—	4% below	25%
Stool test for hidden blood (guaiac FOBT) CPT 82270 CHG BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER	$19.72	$26.30	—	4% below	25%
Stool test for hidden blood (guaiac FOBT) inpatient CPT 82270 CHG BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER	$19.72	$26.30	—	—	25%
Stool test for hidden blood (guaiac FOBT) inpatient CPT 82270 CHG BLOOD OCCULT PEROXIDASE ACTV QUAL FECES 1 DETER	$19.72	$26.30	—	—	25%
Stool test for hidden blood by immunoassay (FIT) CPT 82274 CHG BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3	$89.20	$118.94	—	52% above	25%
Stool test for hidden blood by immunoassay (FIT) CPT 82274 CHG BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3	$89.20	$118.94	—	52% above	25%
Stool test for hidden blood by immunoassay (FIT) inpatient CPT 82274 CHG BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3	$89.20	$118.94	—	—	25%
Stool test for hidden blood by immunoassay (FIT) inpatient CPT 82274 CHG BLOOD OCCULT FECAL HGB DETER IA QUAL FECES 1-3	$89.20	$118.94	—	—	25%
Syphilis screening blood test, non-treponemal (RPR or VDRL), yes/no result CPT 86592 CHG SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL	$79.92	$106.56	—	113% above	25%
Syphilis screening blood test, non-treponemal (RPR or VDRL), yes/no result CPT 86592 CHG SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL	$79.92	$106.56	—	113% above	25%
Syphilis screening blood test, non-treponemal (RPR or VDRL), yes/no result inpatient CPT 86592 CHG SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL	$79.92	$106.56	—	—	25%
Syphilis screening blood test, non-treponemal (RPR or VDRL), yes/no result inpatient CPT 86592 CHG SYPHILIS TEST NON-TREPONEMAL ANTIBODY QUAL	$79.92	$106.56	—	—	25%
TB blood test measuring immune response (IGRA, gamma interferon) CPT 86480 CHG TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON	$403.31	$537.75	—	60% above	25%
TB blood test measuring immune response (IGRA, gamma interferon) CPT 86480 CHG TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON	$403.31	$537.75	—	60% above	25%
TB blood test measuring immune response (IGRA, gamma interferon) inpatient CPT 86480 CHG TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON	$403.31	$537.75	—	—	25%
TB blood test measuring immune response (IGRA, gamma interferon) inpatient CPT 86480 CHG TB CELL MEDIATED ANTIGN RESPNSE GAMMA INTERFERON	$403.31	$537.75	—	—	25%
Testosterone blood test, total (not free testosterone) CPT 84403 CHG ASSAY OF TESTOSTERONE TOTAL	$307.02	$409.36	—	171% above	25%
Testosterone blood test, total (not free testosterone) CPT 84403 CHG ASSAY OF TESTOSTERONE TOTAL	$307.02	$409.36	—	171% above	25%
Testosterone blood test, total (not free testosterone) inpatient CPT 84403 CHG ASSAY OF TESTOSTERONE TOTAL	$307.02	$409.36	—	—	25%
Testosterone blood test, total (not free testosterone) inpatient CPT 84403 CHG ASSAY OF TESTOSTERONE TOTAL	$307.02	$409.36	—	—	25%
Thyroid peroxidase (TPO) antibody test CPT 86376 CHG MICROSOMAL ANTIBODIES EACH	$312.78	$417.04	—	363% above	25%
Thyroid peroxidase (TPO) antibody test CPT 86376 CHG MICROSOMAL ANTIBODIES EACH	$312.78	$417.04	—	363% above	25%
Thyroid peroxidase (TPO) antibody test inpatient CPT 86376 CHG MICROSOMAL ANTIBODIES EACH	$312.78	$417.04	—	—	25%
Thyroid peroxidase (TPO) antibody test inpatient CPT 86376 CHG MICROSOMAL ANTIBODIES EACH	$312.78	$417.04	—	—	25%
Thyroid-stimulating hormone (TSH) blood test CPT 84443 CHG ASSAY OF THYROID STIMULATING HORMONE TSH	$188.00	$250.67	—	116% above	25%
Thyroid-stimulating hormone (TSH) blood test CPT 84443 CHG ASSAY OF THYROID STIMULATING HORMONE TSH	$188.00	$250.67	—	116% above	25%
Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 CHG ASSAY OF THYROID STIMULATING HORMONE TSH	$188.00	$250.67	—	—	25%
Thyroid-stimulating hormone (TSH) blood test inpatient CPT 84443 CHG ASSAY OF THYROID STIMULATING HORMONE TSH	$188.00	$250.67	—	—	25%
Trichomonas test (NAAT) CPT 87661 CHG IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH	$234.83	$313.11	—	65% above	25%
Trichomonas test (NAAT) CPT 87661 CHG IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH	$234.83	$313.11	—	65% above	25%
Trichomonas test (NAAT) inpatient CPT 87661 CHG IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH	$234.83	$313.11	—	—	25%
Trichomonas test (NAAT) inpatient CPT 87661 CHG IADNA TRICHOMONAS VAGINALIS AMPLIFIED PROBE TECH	$234.83	$313.11	—	—	25%
Uric acid blood test CPT 84550 CHG ASSAY OF BLOOD/URIC ACID	$43.60	$58.14	—	7% below	25%
Uric acid blood test CPT 84550 CHG ASSAY OF BLOOD/URIC ACID	$43.60	$58.14	—	7% below	25%
Uric acid blood test inpatient CPT 84550 CHG ASSAY OF BLOOD/URIC ACID	$43.60	$58.14	—	—	25%
Uric acid blood test inpatient CPT 84550 CHG ASSAY OF BLOOD/URIC ACID	$43.60	$58.14	—	—	25%
Urinalysis with microscope exam, automated CPT 81001 CHG URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY	$94.27	$125.69	—	134% above	25%
Urinalysis with microscope exam, automated CPT 81001 CHG URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY	$94.27	$125.69	—	134% above	25%
Urinalysis with microscope exam, automated inpatient CPT 81001 CHG URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY	$94.27	$125.69	—	—	25%
Urinalysis with microscope exam, automated inpatient CPT 81001 CHG URNLS DIP STICK/TABLET REAGENT AUTO MICROSCOPY	$94.27	$125.69	—	—	25%
Urinalysis without microscope exam, automated CPT 81003 CHG URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY	$53.74	$71.66	—	120% above	25%
Urinalysis without microscope exam, automated CPT 81003 CHG URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY	$53.74	$71.66	—	120% above	25%
Urinalysis without microscope exam, automated inpatient CPT 81003 CHG URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY	$53.74	$71.66	—	—	25%
Urinalysis without microscope exam, automated inpatient CPT 81003 CHG URNLS DIP STICK/TABLET RGNT AUTO W/O MICROSCOPY	$53.74	$71.66	—	—	25%
Urine culture for bacteria, with colony count CPT 87086 CHG CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE	$111.48	$148.64	—	48% above	25%
Urine culture for bacteria, with colony count CPT 87086 CHG CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE	$111.48	$148.64	—	48% above	25%
Urine culture for bacteria, with colony count inpatient CPT 87086 CHG CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE	$111.48	$148.64	—	—	25%
Urine culture for bacteria, with colony count inpatient CPT 87086 CHG CULTURE BACTERIAL QUANTTATIVE COLONY COUNT URINE	$111.48	$148.64	—	—	25%
Urine pregnancy test, read by color change CPT 81025 CHG URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS	$104.19	$138.92	—	74% above	25%
Urine pregnancy test, read by color change CPT 81025 CHG URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS	$104.19	$138.92	—	74% above	25%
Urine pregnancy test, read by color change inpatient CPT 81025 CHG URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS	$104.19	$138.92	—	—	25%
Urine pregnancy test, read by color change inpatient CPT 81025 CHG URINE PREGNANCY TEST VISUAL COLOR CMPRSN METHS	$104.19	$138.92	—	—	25%
Vitamin B12 (cobalamin) blood test CPT 82607 CHG CYANOCOBALAMIN VITAMIN B-12	$156.51	$208.68	—	57% above	25%
Vitamin B12 (cobalamin) blood test CPT 82607 CHG CYANOCOBALAMIN VITAMIN B-12	$156.51	$208.68	—	57% above	25%
Vitamin B12 (cobalamin) blood test inpatient CPT 82607 CHG CYANOCOBALAMIN VITAMIN B-12	$156.51	$208.68	—	—	25%
Vitamin B12 (cobalamin) blood test inpatient CPT 82607 CHG CYANOCOBALAMIN VITAMIN B-12	$156.51	$208.68	—	—	25%
Vitamin D blood test, 25-hydroxy (the standard vitamin D level test) CPT 82306 CHG 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED	$294.50	$392.67	—	96% above	25%
Vitamin D blood test, 25-hydroxy (the standard vitamin D level test) CPT 82306 CHG 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED	$294.50	$392.67	—	96% above	25%
Vitamin D blood test, 25-hydroxy (the standard vitamin D level test) inpatient CPT 82306 CHG 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED	$294.50	$392.67	—	—	25%
Vitamin D blood test, 25-hydroxy (the standard vitamin D level test) inpatient CPT 82306 CHG 25 HYDROXY INCLUDES FRACTIONS IF PERFORMED	$294.50	$392.67	—	—	25%
Zinc blood test CPT 84630 CHG ASSAY OF ZINC	$182.55	$243.40	—	136% above	25%
Zinc blood test CPT 84630 CHG ASSAY OF ZINC	$182.55	$243.40	—	136% above	25%
Zinc blood test inpatient CPT 84630 CHG ASSAY OF ZINC	$182.55	$243.40	—	—	25%
Zinc blood test inpatient CPT 84630 CHG ASSAY OF ZINC	$182.55	$243.40	—	—	25%
hCG pregnancy hormone blood test, quantitative (measures the level) CPT 84702 CHG GONADOTROPIN CHORIONIC QUANTITATIVE	$194.23	$258.97	—	73% above	25%
hCG pregnancy hormone blood test, quantitative (measures the level) CPT 84702 CHG GONADOTROPIN CHORIONIC QUANTITATIVE	$194.23	$258.97	—	73% above	25%
hCG pregnancy hormone blood test, quantitative (measures the level) inpatient CPT 84702 CHG GONADOTROPIN CHORIONIC QUANTITATIVE	$194.23	$258.97	—	—	25%
hCG pregnancy hormone blood test, quantitative (measures the level) inpatient CPT 84702 CHG GONADOTROPIN CHORIONIC QUANTITATIVE	$194.23	$258.97	—	—	25%

Surgery and procedures

Procedure	Cash price	List price	Insurers pay	vs Wisconsin	Off list
Botox injections for chronic migraine CPT 64615 HC CHEMODENERVATION FACIAL/TRIGEMINAL/CERVICAL, BIL	$641.74	$855.65	—	12% below	25%
Botox injections for chronic migraine CPT 64615 HC CHEMODENERVATION FACIAL/TRIGEMINAL/CERVICAL, BIL	$641.74	$855.65	—	12% below	25%
Botox injections for chronic migraine inpatient CPT 64615 HC CHEMODENERVATION FACIAL/TRIGEMINAL/CERVICAL, BIL	$641.74	$855.65	—	—	25%
Botox injections for chronic migraine inpatient CPT 64615 HC CHEMODENERVATION FACIAL/TRIGEMINAL/CERVICAL, BIL	$641.74	$855.65	—	—	25%
Cardioversion, elective (restoring heart rhythm) CPT 92960 HC CARDIOVERSION	$1,251.94	$1,669.26	—	27% above	25%
Cardioversion, elective (restoring heart rhythm) CPT 92960 HC CARDIOVERSION	$1,251.94	$1,669.26	—	27% above	25%
Cardioversion, elective (restoring heart rhythm) CPT 92960 HC CC CARDIOVERSION ELECTIVE	$1,422.04	$1,896.06	—	44% above	25%
Cardioversion, elective (restoring heart rhythm) CPT 92960 HC ELECTIVE CARDIOVERSION	$1,422.04	$1,896.06	—	44% above	25%
Cardioversion, elective (restoring heart rhythm) CPT 92960 HC ELECTIVE CARDIOVERSION	$1,422.04	$1,896.06	—	44% above	25%
Cardioversion, elective (restoring heart rhythm) CPT 92960 HC CC CARDIOVERSION ELECTIVE	$1,422.04	$1,896.06	—	44% above	25%
Cardioversion, elective (restoring heart rhythm) inpatient CPT 92960 HC CARDIOVERSION	$1,251.94	$1,669.26	—	—	25%
Cardioversion, elective (restoring heart rhythm) inpatient CPT 92960 HC CARDIOVERSION	$1,251.94	$1,669.26	—	—	25%
Cardioversion, elective (restoring heart rhythm) inpatient CPT 92960 HC CC CARDIOVERSION ELECTIVE	$1,422.04	$1,896.06	—	—	25%
Cardioversion, elective (restoring heart rhythm) inpatient CPT 92960 HC CC CARDIOVERSION ELECTIVE	$1,422.04	$1,896.06	—	—	25%
Cardioversion, elective (restoring heart rhythm) inpatient CPT 92960 HC ELECTIVE CARDIOVERSION	$1,422.04	$1,896.06	—	—	25%
Cardioversion, elective (restoring heart rhythm) inpatient CPT 92960 HC ELECTIVE CARDIOVERSION	$1,422.04	$1,896.06	—	—	25%
Earwax removal by irrigation (rinsing), one ear CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE	$119.28	$159.04	—	87% above	25%
Earwax removal by irrigation (rinsing), one ear CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE	$119.28	$159.04	—	87% above	25%
Earwax removal by irrigation (rinsing), one ear CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE 69209	$119.28	$159.04	—	87% above	25%
Earwax removal by irrigation (rinsing), one ear CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE 69209	$119.28	$159.04	—	87% above	25%
Earwax removal by irrigation (rinsing), one ear inpatient CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE 69209	$119.28	$159.04	—	—	25%
Earwax removal by irrigation (rinsing), one ear inpatient CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE	$119.28	$159.04	—	—	25%
Earwax removal by irrigation (rinsing), one ear inpatient CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE 69209	$119.28	$159.04	—	—	25%
Earwax removal by irrigation (rinsing), one ear inpatient CPT 69209 HC EAR IMPACTED CERUMEN IRR/LAVAGE	$119.28	$159.04	—	—	25%
Earwax removal with instruments, one ear one side CPT 69210 HC REMOVAL IMPACT CERUMEN UNILATERAL	$206.71	$275.61	—	147% above	25%
Earwax removal with instruments, one ear one side CPT 69210 HC REMOVAL IMPACT CERUMEN UNILATERAL	$206.71	$275.61	—	147% above	25%
Earwax removal with instruments, one ear inpatient one side CPT 69210 HC REMOVAL IMPACT CERUMEN UNILATERAL	$206.71	$275.61	—	—	25%
Earwax removal with instruments, one ear inpatient one side CPT 69210 HC REMOVAL IMPACT CERUMEN UNILATERAL	$206.71	$275.61	—	—	25%
Hysterosalpingogram (HSG): contrast injection to check the fallopian tubes CPT 58340 HC HYSTEROSONOGRAPHY CATH & INJ	$383.59	$511.45	—	45% above	25%
Hysterosalpingogram (HSG): contrast injection to check the fallopian tubes CPT 58340 HC HYSTEROSONOGRAPHY CATH & INJ	$383.59	$511.45	—	45% above	25%
Hysterosalpingogram (HSG): contrast injection to check the fallopian tubes inpatient CPT 58340 HC HYSTEROSONOGRAPHY CATH & INJ	$383.59	$511.45	—	—	25%
Hysterosalpingogram (HSG): contrast injection to check the fallopian tubes inpatient CPT 58340 HC HYSTEROSONOGRAPHY CATH & INJ	$383.59	$511.45	—	—	25%
Incision and drainage of a simple or single skin abscess CPT 10060 HC SIMPLE SKIN ABSCESS I & D 10060	$267.61	$356.81	—	13% below	25%
Incision and drainage of a simple or single skin abscess CPT 10060 HC SIMPLE SKIN ABSCESS I & D 10060	$267.61	$356.81	—	13% below	25%
Incision and drainage of a simple or single skin abscess inpatient CPT 10060 HC SIMPLE SKIN ABSCESS I & D 10060	$267.61	$356.81	—	—	25%
Incision and drainage of a simple or single skin abscess inpatient CPT 10060 HC SIMPLE SKIN ABSCESS I & D 10060	$267.61	$356.81	—	—	25%
Injection into a tendon sheath or ligament (for example trigger finger) CPT 20550 HC INJ TENDON SHEATH/LIGAMENT	$535.22	$713.62	—	57% above	25%
Injection into a tendon sheath or ligament (for example trigger finger) CPT 20550 HC INJ TENDON SHEATH/LIGAMENT	$535.22	$713.62	—	57% above	25%
Injection into a tendon sheath or ligament (for example trigger finger) inpatient CPT 20550 HC INJ TENDON SHEATH/LIGAMENT	$535.22	$713.62	—	—	25%
Injection into a tendon sheath or ligament (for example trigger finger) inpatient CPT 20550 HC INJ TENDON SHEATH/LIGAMENT	$535.22	$713.62	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound both sides CPT 20610 HC SP LARGE JOINT INJ/ASP BILAT	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound both sides CPT 20610 HC INTRA ARTICULAR, MAJOR JOINT BILATERAL	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound both sides CPT 20610 HC SP LARGE JOINT INJ/ASP BILAT	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound both sides CPT 20610 HC INTRA ARTICULAR, MAJOR JOINT BILATERAL	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 HC IR ARTHROCENTESIS ASPIR/INJECT LG JOINT	$642.60	$856.80	—	48% above	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 HC INJ LARGE JOINT ASPIRATION	$642.60	$856.80	—	48% above	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 HC LARGE JOINT INJ ASP UNI	$642.60	$856.80	—	48% above	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 HC INJ LARGE JOINT ASPIRATION	$642.60	$856.80	—	48% above	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 HC LARGE JOINT INJ ASP UNI	$642.60	$856.80	—	48% above	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound CPT 20610 HC IR ARTHROCENTESIS ASPIR/INJECT LG JOINT	$642.60	$856.80	—	48% above	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient both sides CPT 20610 HC SP LARGE JOINT INJ/ASP BILAT	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient both sides CPT 20610 HC INTRA ARTICULAR, MAJOR JOINT BILATERAL	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient both sides CPT 20610 HC SP LARGE JOINT INJ/ASP BILAT	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient both sides CPT 20610 HC INTRA ARTICULAR, MAJOR JOINT BILATERAL	$481.95	$642.60	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 HC IR ARTHROCENTESIS ASPIR/INJECT LG JOINT	$642.60	$856.80	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 HC IR ARTHROCENTESIS ASPIR/INJECT LG JOINT	$642.60	$856.80	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 HC LARGE JOINT INJ ASP UNI	$642.60	$856.80	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 HC INJ LARGE JOINT ASPIRATION	$642.60	$856.80	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 HC LARGE JOINT INJ ASP UNI	$642.60	$856.80	—	—	25%
Injection or fluid drainage of a major joint (knee, shoulder, hip), no ultrasound inpatient CPT 20610 HC INJ LARGE JOINT ASPIRATION	$642.60	$856.80	—	—	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) both sides CPT 20605 HC SP INTERMEDIATE JT INJ/ASP BILAT	$463.05	$617.40	—	—	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) both sides CPT 20605 HC SP INTERMEDIATE JT INJ/ASP BILAT	$463.05	$617.40	—	—	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) CPT 20605 HC ARTHRCNTSIS-INTM JT/BRSA 20605	$617.40	$823.20	—	90% above	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) CPT 20605 HC ARTHRCNTSIS-INTM JT/BRSA 20605	$617.40	$823.20	—	90% above	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) inpatient both sides CPT 20605 HC SP INTERMEDIATE JT INJ/ASP BILAT	$463.05	$617.40	—	—	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) inpatient both sides CPT 20605 HC SP INTERMEDIATE JT INJ/ASP BILAT	$463.05	$617.40	—	—	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) inpatient CPT 20605 HC ARTHRCNTSIS-INTM JT/BRSA 20605	$617.40	$823.20	—	—	25%
Joint injection or drainage, medium joint (wrist, elbow, ankle) inpatient CPT 20605 HC ARTHRCNTSIS-INTM JT/BRSA 20605	$617.40	$823.20	—	—	25%
Joint injection or drainage, small joint (fingers, toes) CPT 20600 HC ARTHRCNTESIS.SM JT/BURSA	$619.90	$826.53	—	56% above	25%
Joint injection or drainage, small joint (fingers, toes) CPT 20600 HC ARTHROCENTESIS OR INJ SM JOINT	$619.90	$826.53	—	56% above	25%
Joint injection or drainage, small joint (fingers, toes) CPT 20600 HC ARTHRCNTESIS.SM JT/BURSA	$619.90	$826.53	—	56% above	25%
Joint injection or drainage, small joint (fingers, toes) CPT 20600 HC ARTHROCENTESIS OR INJ SM JOINT	$619.90	$826.53	—	56% above	25%
Joint injection or drainage, small joint (fingers, toes) inpatient CPT 20600 HC ARTHROCENTESIS OR INJ SM JOINT	$619.90	$826.53	—	—	25%
Joint injection or drainage, small joint (fingers, toes) inpatient CPT 20600 HC ARTHROCENTESIS OR INJ SM JOINT	$619.90	$826.53	—	—	25%
Joint injection or drainage, small joint (fingers, toes) inpatient CPT 20600 HC ARTHRCNTESIS.SM JT/BURSA	$619.90	$826.53	—	—	25%
Joint injection or drainage, small joint (fingers, toes) inpatient CPT 20600 HC ARTHRCNTESIS.SM JT/BURSA	$619.90	$826.53	—	—	25%
Layered stitches for a cut up to 2.5 cm, intermediate repair, scalp, body, arms or legs CPT 12031 HC LAYER CLOSURE 2.5 OR <	$341.49	$455.32	—	31% below	25%
Layered stitches for a cut up to 2.5 cm, intermediate repair, scalp, body, arms or legs CPT 12031 HC LAYER CLOSURE 2.5 OR <	$341.49	$455.32	—	31% below	25%
Layered stitches for a cut up to 2.5 cm, intermediate repair, scalp, body, arms or legs inpatient CPT 12031 HC LAYER CLOSURE 2.5 OR <	$341.49	$455.32	—	—	25%
Layered stitches for a cut up to 2.5 cm, intermediate repair, scalp, body, arms or legs inpatient CPT 12031 HC LAYER CLOSURE 2.5 OR <	$341.49	$455.32	—	—	25%
Lower-back epidural injection, with imaging guidance CPT 62323 HC EPIDURAL INJ LUMBAR/SAC W/IMAGE GUIDANCE	$2,267.09	$3,022.79	—	98% above	25%
Lower-back epidural injection, with imaging guidance CPT 62323 HC EPIDURAL INJ LUMBAR/SAC W/IMAGE GUIDANCE	$2,267.09	$3,022.79	—	98% above	25%
Lower-back epidural injection, with imaging guidance inpatient CPT 62323 HC EPIDURAL INJ LUMBAR/SAC W/IMAGE GUIDANCE	$2,267.09	$3,022.79	—	—	25%
Lower-back epidural injection, with imaging guidance inpatient CPT 62323 HC EPIDURAL INJ LUMBAR/SAC W/IMAGE GUIDANCE	$2,267.09	$3,022.79	—	—	25%
Lower-back nerve root steroid injection, with imaging guidance CPT 64483 HC INJ TRANSFORAMINAL EPI LUMBAR/SAC UNI	$1,268.54	$1,691.38	—	19% above	25%
Lower-back nerve root steroid injection, with imaging guidance CPT 64483 HC INJ TRANSFORAMINAL EPI LUMBAR/SAC UNI	$1,268.54	$1,691.38	—	19% above	25%
Lower-back nerve root steroid injection, with imaging guidance inpatient CPT 64483 HC INJ TRANSFORAMINAL EPI LUMBAR/SAC UNI	$1,268.54	$1,691.38	—	—	25%
Lower-back nerve root steroid injection, with imaging guidance inpatient CPT 64483 HC INJ TRANSFORAMINAL EPI LUMBAR/SAC UNI	$1,268.54	$1,691.38	—	—	25%
Nail removal (partial or complete), one nail CPT 11730 HC REMOVAL OF NAIL PLATE	$180.02	$240.02	—	20% below	25%
Nail removal (partial or complete), one nail CPT 11730 HC REMOVAL OF NAIL PLATE	$180.02	$240.02	—	20% below	25%
Nail removal (partial or complete), one nail inpatient CPT 11730 HC REMOVAL OF NAIL PLATE	$180.02	$240.02	—	—	25%
Nail removal (partial or complete), one nail inpatient CPT 11730 HC REMOVAL OF NAIL PLATE	$180.02	$240.02	—	—	25%
Occipital nerve block (injection for headaches) CPT 64405 HC OCCIPITAL NERVE BLOCK W/O PHENOL	$504.07	$672.09	—	9% above	25%
Occipital nerve block (injection for headaches) CPT 64405 HC OCCIPITAL NERVE BLOCK W/O PHENOL	$504.07	$672.09	—	9% above	25%
Occipital nerve block (injection for headaches) inpatient CPT 64405 HC OCCIPITAL NERVE BLOCK W/O PHENOL	$504.07	$672.09	—	—	25%
Occipital nerve block (injection for headaches) inpatient CPT 64405 HC OCCIPITAL NERVE BLOCK W/O PHENOL	$504.07	$672.09	—	—	25%
Pacemaker implant (dual chamber) CPT 33208 HC PACER - PERM DUAL	$16,262.32	$21,683.09	—	156% above	25%
Pacemaker implant (dual chamber) CPT 33208 HC PACER - PERM DUAL	$16,262.32	$21,683.09	—	156% above	25%
Pacemaker implant (dual chamber) inpatient CPT 33208 HC PACER - PERM DUAL	$16,262.32	$21,683.09	—	—	25%
Pacemaker implant (dual chamber) inpatient CPT 33208 HC PACER - PERM DUAL	$16,262.32	$21,683.09	—	—	25%
Paracentesis with imaging guidance CPT 49083 HC PARACENTESIS W/IMAGING	$1,672.02	$2,229.36	—	30% above	25%
Paracentesis with imaging guidance CPT 49083 HC PARACENTESIS W/IMAGING	$1,672.02	$2,229.36	—	30% above	25%
Paracentesis with imaging guidance inpatient CPT 49083 HC PARACENTESIS W/IMAGING	$1,672.02	$2,229.36	—	—	25%
Paracentesis with imaging guidance inpatient CPT 49083 HC PARACENTESIS W/IMAGING	$1,672.02	$2,229.36	—	—	25%
Radiofrequency ablation of facet joint nerves, lower back, one level CPT 64635 HC DESTROY LUMB/SAC FACET JNT	$2,697.29	$3,596.39	—	14% above	25%
Radiofrequency ablation of facet joint nerves, lower back, one level CPT 64635 HC DESTROY LUMB/SAC FACET JNT	$2,697.29	$3,596.39	—	14% above	25%
Radiofrequency ablation of facet joint nerves, lower back, one level inpatient CPT 64635 HC DESTROY LUMB/SAC FACET JNT	$2,697.29	$3,596.39	—	—	25%
Radiofrequency ablation of facet joint nerves, lower back, one level inpatient CPT 64635 HC DESTROY LUMB/SAC FACET JNT	$2,697.29	$3,596.39	—	—	25%
Removal of a foreign object under the skin, simple CPT 10120 HC REMOVE FOREIGN BODY 10120	$459.50	$612.66	—	30% above	25%
Removal of a foreign object under the skin, simple CPT 10120 HC REMOVE FOREIGN BODY	$459.50	$612.66	—	30% above	25%
Removal of a foreign object under the skin, simple CPT 10120 HC REMOVE FOREIGN BODY	$459.50	$612.66	—	30% above	25%
Removal of a foreign object under the skin, simple CPT 10120 HC REMOVE FOREIGN BODY 10120	$459.50	$612.66	—	30% above	25%
Removal of a foreign object under the skin, simple inpatient CPT 10120 HC REMOVE FOREIGN BODY	$459.50	$612.66	—	—	25%
Removal of a foreign object under the skin, simple inpatient CPT 10120 HC REMOVE FOREIGN BODY 10120	$459.50	$612.66	—	—	25%
Removal of a foreign object under the skin, simple inpatient CPT 10120 HC REMOVE FOREIGN BODY	$459.50	$612.66	—	—	25%
Removal of a foreign object under the skin, simple inpatient CPT 10120 HC REMOVE FOREIGN BODY 10120	$459.50	$612.66	—	—	25%
Short arm splint (forearm and hand) CPT 29125 HC FOREARM SPLINT APPLY	$286.28	$381.70	—	63% above	25%
Short arm splint (forearm and hand) CPT 29125 HC FOREARM SPLINT APPLY	$286.28	$381.70	—	63% above	25%
Short arm splint (forearm and hand) inpatient CPT 29125 HC FOREARM SPLINT APPLY	$286.28	$381.70	—	—	25%
Short arm splint (forearm and hand) inpatient CPT 29125 HC FOREARM SPLINT APPLY	$286.28	$381.70	—	—	25%
Short leg cast (below the knee) CPT 29405 HC APPLY SHORT LEG CAST	$57.47	$76.63	—	74% below	25%
Short leg cast (below the knee) CPT 29405 HC APPLY SHORT LEG CAST	$57.47	$76.63	—	74% below	25%
Short leg cast (below the knee) inpatient CPT 29405 HC APPLY SHORT LEG CAST	$57.47	$76.63	—	—	25%
Short leg cast (below the knee) inpatient CPT 29405 HC APPLY SHORT LEG CAST	$57.47	$76.63	—	—	25%
Short leg splint (calf to foot) CPT 29515 HC APPLY SHORT LEG SPLINT	$168.03	$224.04	—	19% below	25%
Short leg splint (calf to foot) CPT 29515 HC APPLY SHORT LEG SPLINT	$168.03	$224.04	—	19% below	25%
Short leg splint (calf to foot) inpatient CPT 29515 HC APPLY SHORT LEG SPLINT	$168.03	$224.04	—	—	25%
Short leg splint (calf to foot) inpatient CPT 29515 HC APPLY SHORT LEG SPLINT	$168.03	$224.04	—	—	25%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs CPT 12001 HC REPR WOUND 2.5 OR < 12001	$484.88	$646.50	—	49% above	25%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs CPT 12001 HC REPR WOUND 2.5 OR < 12001	$484.88	$646.50	—	49% above	25%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs inpatient CPT 12001 HC REPR WOUND 2.5 OR < 12001	$484.88	$646.50	—	—	25%
Simple repair of a superficial wound 2.5 cm or less, scalp, neck, body or limbs inpatient CPT 12001 HC REPR WOUND 2.5 OR < 12001	$484.88	$646.50	—	—	25%
Skin tag removal, up to 15 tags CPT 11200 HC EXCISION OF SKIN TAGS <16	$80.45	$107.27	—	43% below	25%
Skin tag removal, up to 15 tags CPT 11200 HC EXCISION OF SKIN TAGS <16	$80.45	$107.27	—	43% below	25%
Skin tag removal, up to 15 tags inpatient CPT 11200 HC EXCISION OF SKIN TAGS <16	$80.45	$107.27	—	—	25%
Skin tag removal, up to 15 tags inpatient CPT 11200 HC EXCISION OF SKIN TAGS <16	$80.45	$107.27	—	—	25%
Spinal tap (lumbar puncture), diagnostic CPT 62270 HC SPINAL PUNCTURE LUMBAR DIAGNOSTIC	$1,316.43	$1,755.24	—	123% above	25%
Spinal tap (lumbar puncture), diagnostic CPT 62270 HC SPINAL PUNCTURE LUMBAR DIAGNOSTIC	$1,316.43	$1,755.24	—	123% above	25%
Spinal tap (lumbar puncture), diagnostic CPT 62270 HC SPINAL FLUID TAP DIAG	$1,316.43	$1,755.24	—	123% above	25%
Spinal tap (lumbar puncture), diagnostic CPT 62270 HC SPINAL FLUID TAP DIAG	$1,316.43	$1,755.24	—	123% above	25%
Spinal tap (lumbar puncture), diagnostic inpatient CPT 62270 HC SPINAL PUNCTURE LUMBAR DIAGNOSTIC	$1,316.43	$1,755.24	—	—	25%
Spinal tap (lumbar puncture), diagnostic inpatient CPT 62270 HC SPINAL FLUID TAP DIAG	$1,316.43	$1,755.24	—	—	25%
Spinal tap (lumbar puncture), diagnostic inpatient CPT 62270 HC SPINAL PUNCTURE LUMBAR DIAGNOSTIC	$1,316.43	$1,755.24	—	—	25%
Spinal tap (lumbar puncture), diagnostic inpatient CPT 62270 HC SPINAL FLUID TAP DIAG	$1,316.43	$1,755.24	—	—	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs CPT 12002 HC REPR WOUND 2.6 - 7.5 12002	$582.47	$776.63	—	188% above	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs CPT 12002 HC REPAIR SUPERFICIAL WOUND(S) 12002	$582.47	$776.63	—	188% above	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs CPT 12002 HC REPAIR SUPERFICIAL WOUND(S) 12002	$582.47	$776.63	—	188% above	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs CPT 12002 HC REPR WOUND 2.6 - 7.5 12002	$582.47	$776.63	—	188% above	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs inpatient CPT 12002 HC REPR WOUND 2.6 - 7.5 12002	$582.47	$776.63	—	—	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs inpatient CPT 12002 HC REPAIR SUPERFICIAL WOUND(S) 12002	$582.47	$776.63	—	—	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs inpatient CPT 12002 HC REPR WOUND 2.6 - 7.5 12002	$582.47	$776.63	—	—	25%
Stitches for a cut 2.6 to 7.5 cm (1 to 3 inches), simple repair, scalp, body, arms or legs inpatient CPT 12002 HC REPAIR SUPERFICIAL WOUND(S) 12002	$582.47	$776.63	—	—	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair CPT 12011 HC REPR WOUND 2.5 OR < 12011	$541.16	$721.54	—	75% above	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair CPT 12011 HC REPR WOUND 2.5 OR < 12011	$541.16	$721.54	—	75% above	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair CPT 12011 HC REPR WOUND 2.5 OR <	$541.16	$721.54	—	75% above	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair CPT 12011 HC REPR WOUND 2.5 OR <	$541.16	$721.54	—	75% above	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair inpatient CPT 12011 HC REPR WOUND 2.5 OR < 12011	$541.16	$721.54	—	—	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair inpatient CPT 12011 HC REPR WOUND 2.5 OR < 12011	$541.16	$721.54	—	—	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair inpatient CPT 12011 HC REPR WOUND 2.5 OR <	$541.16	$721.54	—	—	25%
Stitches for a cut on the face up to 2.5 cm (1 inch), simple repair inpatient CPT 12011 HC REPR WOUND 2.5 OR <	$541.16	$721.54	—	—	25%
Thoracentesis with imaging guidance CPT 32555 HC THORACENTESIS W/IMAGING	$1,890.87	$2,521.16	—	64% above	25%
Thoracentesis with imaging guidance CPT 32555 HC THORACENTESIS W/IMAGING	$1,890.87	$2,521.16	—	64% above	25%
Thoracentesis with imaging guidance inpatient CPT 32555 HC THORACENTESIS W/IMAGING	$1,890.87	$2,521.16	—	—	25%
Thoracentesis with imaging guidance inpatient CPT 32555 HC THORACENTESIS W/IMAGING	$1,890.87	$2,521.16	—	—	25%
Trigger point injections, 1 or 2 muscles CPT 20552 HC TC INJ, TRIGGER PT, 1 OR 2 MUSCL	$821.40	$1,095.20	—	131% above	25%
Trigger point injections, 1 or 2 muscles CPT 20552 HC TC INJ, TRIGGER PT, 1 OR 2 MUSCL	$821.40	$1,095.20	—	131% above	25%
Trigger point injections, 1 or 2 muscles CPT 20552 HC INJ TRIGGER PTS SGL/MULT 1-2	$821.40	$1,095.20	—	131% above	25%
Trigger point injections, 1 or 2 muscles CPT 20552 HC INJ TRIGGER PTS SGL/MULT 1-2	$821.40	$1,095.20	—	131% above	25%
Trigger point injections, 1 or 2 muscles inpatient CPT 20552 HC TC INJ, TRIGGER PT, 1 OR 2 MUSCL	$821.40	$1,095.20	—	—	25%
Trigger point injections, 1 or 2 muscles inpatient CPT 20552 HC INJ TRIGGER PTS SGL/MULT 1-2	$821.40	$1,095.20	—	—	25%
Trigger point injections, 1 or 2 muscles inpatient CPT 20552 HC TC INJ, TRIGGER PT, 1 OR 2 MUSCL	$821.40	$1,095.20	—	—	25%
Trigger point injections, 1 or 2 muscles inpatient CPT 20552 HC INJ TRIGGER PTS SGL/MULT 1-2	$821.40	$1,095.20	—	—	25%
Ultrasound-guided breast needle biopsy with marker clip, first lesion CPT 19083 HC BREAST BIOPSY, UNI	$3,293.21	$4,390.95	—	70% above	25%
Ultrasound-guided breast needle biopsy with marker clip, first lesion CPT 19083 HC BREAST BIOPSY, UNI	$3,293.21	$4,390.95	—	70% above	25%
Ultrasound-guided breast needle biopsy with marker clip, first lesion inpatient CPT 19083 HC BREAST BIOPSY, UNI	$3,293.21	$4,390.95	—	—	25%
Ultrasound-guided breast needle biopsy with marker clip, first lesion inpatient CPT 19083 HC BREAST BIOPSY, UNI	$3,293.21	$4,390.95	—	—	25%
Vein ablation, radiofrequency, first vein CPT 36475 HC ENDOVENOUS RF, 1ST VEIN	$7,143.05	$9,524.07	—	108% above	25%
Vein ablation, radiofrequency, first vein CPT 36475 HC ENDOVENOUS RF, 1ST VEIN	$7,143.05	$9,524.07	—	108% above	25%
Vein ablation, radiofrequency, first vein inpatient CPT 36475 HC ENDOVENOUS RF, 1ST VEIN	$7,143.05	$9,524.07	—	—	25%
Vein ablation, radiofrequency, first vein inpatient CPT 36475 HC ENDOVENOUS RF, 1ST VEIN	$7,143.05	$9,524.07	—	—	25%

Doctor visits and therapy

Procedure	Cash price	List price	Insurers pay	vs Wisconsin	Off list
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 0-2 HRS	$724.00	$965.33	—	24% above	25%
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 0-2 HRS	$724.00	$965.33	—	24% above	25%
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 2-4 HRS	$756.14	$1,008.19	—	30% above	25%
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 2-4 HRS	$756.14	$1,008.19	—	30% above	25%
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 4-6 HRS	$888.91	$1,185.21	—	52% above	25%
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 4-6 HRS	$888.91	$1,185.21	—	52% above	25%
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 6-8 HRS	$1,534.06	$2,045.42	—	163% above	25%
Blood transfusion (giving blood or blood components) CPT 36430 HC BLD TRANSFUSION 6-8 HRS	$1,534.06	$2,045.42	—	163% above	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 0-2 HRS	$724.00	$965.33	—	—	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 0-2 HRS	$724.00	$965.33	—	—	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 2-4 HRS	$756.14	$1,008.19	—	—	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 2-4 HRS	$756.14	$1,008.19	—	—	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 4-6 HRS	$888.91	$1,185.21	—	—	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 4-6 HRS	$888.91	$1,185.21	—	—	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 6-8 HRS	$1,534.06	$2,045.42	—	—	25%
Blood transfusion (giving blood or blood components) inpatient CPT 36430 HC BLD TRANSFUSION 6-8 HRS	$1,534.06	$2,045.42	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC AIRWAY INHALATION TREATMENT	$68.46	$91.28	—	21% below	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC AIRWAY INHALATION TREATMENT	$68.46	$91.28	—	21% below	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC AEROSOL DAILY	$78.82	$105.10	—	9% below	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC AEROSOL DAILY	$78.82	$105.10	—	9% below	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC INHALER	$105.81	$141.08	—	22% above	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC INHALER	$105.81	$141.08	—	22% above	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC NEBULIZER	$107.87	$143.83	—	25% above	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction CPT 94640 HC NEBULIZER	$107.87	$143.83	—	25% above	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC AIRWAY INHALATION TREATMENT	$68.46	$91.28	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC AIRWAY INHALATION TREATMENT	$68.46	$91.28	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC AEROSOL DAILY	$78.82	$105.10	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC AEROSOL DAILY	$78.82	$105.10	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC INHALER	$105.81	$141.08	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC INHALER	$105.81	$141.08	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC NEBULIZER	$107.87	$143.83	—	—	25%
Breathing treatment (nebulizer or inhaler) for airway obstruction inpatient CPT 94640 HC NEBULIZER	$107.87	$143.83	—	—	25%
Chemotherapy IV infusion, first hour CPT 96413 HC CHEMO INIT INFU 16-90MIN	$568.89	$758.52	—	2% above	25%
Chemotherapy IV infusion, first hour CPT 96413 HC CHEMO INIT INFU 16-90MIN	$568.89	$758.52	—	2% above	25%
Chemotherapy IV infusion, first hour inpatient CPT 96413 HC CHEMO INIT INFU 16-90MIN	$568.89	$758.52	—	—	25%
Chemotherapy IV infusion, first hour inpatient CPT 96413 HC CHEMO INIT INFU 16-90MIN	$568.89	$758.52	—	—	25%
Critical care, first 30 to 74 minutes CPT 99291 HC CRITICAL CARE 1ST 30-74 MIN	$1,383.92	$1,845.22	—	12% below	25%
Critical care, first 30 to 74 minutes CPT 99291 HC CRITICAL CARE 1ST 30-74 MIN	$1,383.92	$1,845.22	—	12% below	25%
Critical care, first 30 to 74 minutes inpatient CPT 99291 HC CRITICAL CARE 1ST 30-74 MIN	$1,383.92	$1,845.22	—	—	25%
Critical care, first 30 to 74 minutes inpatient CPT 99291 HC CRITICAL CARE 1ST 30-74 MIN	$1,383.92	$1,845.22	—	—	25%
EEG (brain wave test), awake and drowsy, routine CPT 95816 HC EEG AWAKE & DROWSY	$556.43	$741.91	—	18% below	25%
EEG (brain wave test), awake and drowsy, routine CPT 95816 HC EEG AWAKE & DROWSY	$556.43	$741.91	—	18% below	25%
EEG (brain wave test), awake and drowsy, routine inpatient CPT 95816 HC EEG AWAKE & DROWSY	$556.43	$741.91	—	—	25%
EEG (brain wave test), awake and drowsy, routine inpatient CPT 95816 HC EEG AWAKE & DROWSY	$556.43	$741.91	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge CPT 93005 HC TC ELECTROCARDIOGRAM	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge CPT 93005 HC ECG 12 LEAD TRACE ONLY	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge CPT 93005 HC EKG RESTING	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge CPT 93005 HC TC ELECTROCARDIOGRAM	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge CPT 93005 HC ECG 12 LEAD TRACE ONLY	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge CPT 93005 HC EKG RESTING	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge one side CPT 93005 HC RT EKG	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge one side CPT 93005 HC RT EKG	$212.31	$283.08	—	52% above	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient CPT 93005 HC EKG RESTING	$212.31	$283.08	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient CPT 93005 HC TC ELECTROCARDIOGRAM	$212.31	$283.08	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient CPT 93005 HC ECG 12 LEAD TRACE ONLY	$212.31	$283.08	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient CPT 93005 HC ECG 12 LEAD TRACE ONLY	$212.31	$283.08	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient CPT 93005 HC EKG RESTING	$212.31	$283.08	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient CPT 93005 HC TC ELECTROCARDIOGRAM	$212.31	$283.08	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient one side CPT 93005 HC RT EKG	$212.31	$283.08	—	—	25%
Electrocardiogram (ECG/EKG), tracing only, the hospital charge inpatient one side CPT 93005 HC RT EKG	$212.31	$283.08	—	—	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor CPT 99281 HC EMTALA EMERGENCY MEDICAL SCREENING SERVICE	$123.02	$164.02	—	12% below	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor CPT 99281 HC EMTALA EMERGENCY MEDICAL SCREENING SERVICE	$123.02	$164.02	—	12% below	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor CPT 99281 HC EMERGENCY ROOM LEVEL 1	$293.70	$391.60	—	110% above	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor CPT 99281 HC EMERGENCY ROOM LEVEL 1	$293.70	$391.60	—	110% above	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor inpatient CPT 99281 HC EMTALA EMERGENCY MEDICAL SCREENING SERVICE	$123.02	$164.02	—	—	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor inpatient CPT 99281 HC EMTALA EMERGENCY MEDICAL SCREENING SERVICE	$123.02	$164.02	—	—	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor inpatient CPT 99281 HC EMERGENCY ROOM LEVEL 1	$293.70	$391.60	—	—	25%
Emergency room visit, level 1 of 5, minor problem that may not need a doctor inpatient CPT 99281 HC EMERGENCY ROOM LEVEL 1	$293.70	$391.60	—	—	25%
Emergency room visit, level 2 of 5, straightforward problem CPT 99282 HC EMERGENCY ROOM LEVEL 2	$657.36	$876.48	—	129% above	25%
Emergency room visit, level 2 of 5, straightforward problem CPT 99282 HC EMERGENCY ROOM LEVEL 2	$657.36	$876.48	—	129% above	25%
Emergency room visit, level 2 of 5, straightforward problem inpatient CPT 99282 HC EMERGENCY ROOM LEVEL 2	$657.36	$876.48	—	—	25%
Emergency room visit, level 2 of 5, straightforward problem inpatient CPT 99282 HC EMERGENCY ROOM LEVEL 2	$657.36	$876.48	—	—	25%
Emergency room visit, level 3 of 5, low-complexity problem CPT 99283 HC EMERGENCY ROOM LEVEL 3	$838.04	$1,117.38	—	82% above	25%
Emergency room visit, level 3 of 5, low-complexity problem CPT 99283 HC EMERGENCY ROOM LEVEL 3	$838.04	$1,117.38	—	82% above	25%
Emergency room visit, level 3 of 5, low-complexity problem inpatient CPT 99283 HC EMERGENCY ROOM LEVEL 3	$838.04	$1,117.38	—	—	25%
Emergency room visit, level 3 of 5, low-complexity problem inpatient CPT 99283 HC EMERGENCY ROOM LEVEL 3	$838.04	$1,117.38	—	—	25%
Emergency room visit, level 4 of 5, moderate-complexity problem CPT 99284 HC EMERGENCY ROOM LEVEL 4	$1,345.47	$1,793.96	—	82% above	25%
Emergency room visit, level 4 of 5, moderate-complexity problem CPT 99284 HC EMERGENCY ROOM LEVEL 4	$1,345.47	$1,793.96	—	82% above	25%
Emergency room visit, level 4 of 5, moderate-complexity problem inpatient CPT 99284 HC EMERGENCY ROOM LEVEL 4	$1,345.47	$1,793.96	—	—	25%
Emergency room visit, level 4 of 5, moderate-complexity problem inpatient CPT 99284 HC EMERGENCY ROOM LEVEL 4	$1,345.47	$1,793.96	—	—	25%
Emergency room visit, level 5 of 5, high-complexity problem CPT 99285 HC EMERGENCY ROOM LEVEL 5	$2,018.20	$2,690.94	—	40% above	25%
Emergency room visit, level 5 of 5, high-complexity problem CPT 99285 HC EMERGENCY ROOM LEVEL 5	$2,018.20	$2,690.94	—	40% above	25%
Emergency room visit, level 5 of 5, high-complexity problem inpatient CPT 99285 HC EMERGENCY ROOM LEVEL 5	$2,018.20	$2,690.94	—	—	25%
Emergency room visit, level 5 of 5, high-complexity problem inpatient CPT 99285 HC EMERGENCY ROOM LEVEL 5	$2,018.20	$2,690.94	—	—	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC STRESS TEST COMPLETE	$979.64	$1,306.19	—	24% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC STRESS TEST COMPLETE	$979.64	$1,306.19	—	24% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC STRESS TEST-LIMITED	$979.90	$1,306.54	—	24% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC STRESS TEST-LIMITED	$979.90	$1,306.54	—	24% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC NUCLEAR CHEMICAL TEST	$1,240.18	$1,653.57	—	57% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC NUCLEAR CHEMICAL TEST	$1,240.18	$1,653.57	—	57% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC STRESS ECHO TREADMILL	$1,254.40	$1,672.53	—	58% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC STRESS ECHO TREADMILL	$1,254.40	$1,672.53	—	58% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC NUCLEAR STRESS TEST TREADMILL	$2,094.76	$2,793.02	—	164% above	25%
Exercise stress test, tracing only, the hospital charge CPT 93017 HC NUCLEAR STRESS TEST TREADMILL	$2,094.76	$2,793.02	—	164% above	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC STRESS TEST COMPLETE	$979.64	$1,306.19	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC STRESS TEST COMPLETE	$979.64	$1,306.19	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC STRESS TEST-LIMITED	$979.90	$1,306.54	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC STRESS TEST-LIMITED	$979.90	$1,306.54	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC NUCLEAR CHEMICAL TEST	$1,240.18	$1,653.57	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC NUCLEAR CHEMICAL TEST	$1,240.18	$1,653.57	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC STRESS ECHO TREADMILL	$1,254.40	$1,672.53	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC STRESS ECHO TREADMILL	$1,254.40	$1,672.53	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC NUCLEAR STRESS TEST TREADMILL	$2,094.76	$2,793.02	—	—	25%
Exercise stress test, tracing only, the hospital charge inpatient CPT 93017 HC NUCLEAR STRESS TEST TREADMILL	$2,094.76	$2,793.02	—	—	25%
IV hydration (fluids through a vein), first 31 to 60 minutes CPT 96360 HC IV INFUSION HYDRATION,INITIAL HR	$426.45	$568.60	—	49% above	25%
IV hydration (fluids through a vein), first 31 to 60 minutes CPT 96360 HC IV INFUSION HYDRATION,INITIAL HR	$426.45	$568.60	—	49% above	25%
IV hydration (fluids through a vein), first 31 to 60 minutes CPT 96360 HC IV INFUSION HYDRATION, INITIAL HR	$426.45	$568.60	—	49% above	25%
IV hydration (fluids through a vein), first 31 to 60 minutes CPT 96360 HC IV INFUSION HYDRATION, INITIAL HR	$426.45	$568.60	—	49% above	25%
IV hydration (fluids through a vein), first 31 to 60 minutes inpatient CPT 96360 HC IV INFUSION HYDRATION, INITIAL HR	$426.45	$568.60	—	—	25%
IV hydration (fluids through a vein), first 31 to 60 minutes inpatient CPT 96360 HC IV INFUSION HYDRATION,INITIAL HR	$426.45	$568.60	—	—	25%
IV hydration (fluids through a vein), first 31 to 60 minutes inpatient CPT 96360 HC IV INFUSION HYDRATION,INITIAL HR	$426.45	$568.60	—	—	25%
IV hydration (fluids through a vein), first 31 to 60 minutes inpatient CPT 96360 HC IV INFUSION HYDRATION, INITIAL HR	$426.45	$568.60	—	—	25%
IV infusion of a medicine, first hour CPT 96365 HC IV INFUSION 1ST HOUR	$479.34	$639.12	—	53% above	25%
IV infusion of a medicine, first hour CPT 96365 HC IV INFUSION 1ST HOUR	$479.34	$639.12	—	53% above	25%
IV infusion of a medicine, first hour inpatient CPT 96365 HC IV INFUSION 1ST HOUR	$479.34	$639.12	—	—	25%
IV infusion of a medicine, first hour inpatient CPT 96365 HC IV INFUSION 1ST HOUR	$479.34	$639.12	—	—	25%
Injection under the skin or into a muscle, for treatment or testing CPT 96372 HC INJECTION SQ/IM ADMIN	$138.92	$185.22	—	68% above	25%
Injection under the skin or into a muscle, for treatment or testing CPT 96372 HC INJECTION SQ/IM ADMIN	$138.92	$185.22	—	68% above	25%
Injection under the skin or into a muscle, for treatment or testing inpatient CPT 96372 HC INJECTION SQ/IM ADMIN	$138.92	$185.22	—	—	25%
Injection under the skin or into a muscle, for treatment or testing inpatient CPT 96372 HC INJECTION SQ/IM ADMIN	$138.92	$185.22	—	—	25%
Neuromuscular re-education, 15 minutes CPT 97112 HC NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	58% above	25%
Neuromuscular re-education, 15 minutes CPT 97112 HC OT NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	58% above	25%
Neuromuscular re-education, 15 minutes CPT 97112 HC PT NEURO RE-ED BALANCE	$147.64	$196.86	—	58% above	25%
Neuromuscular re-education, 15 minutes CPT 97112 HC NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	58% above	25%
Neuromuscular re-education, 15 minutes CPT 97112 HC OT NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	58% above	25%
Neuromuscular re-education, 15 minutes CPT 97112 HC PT NEURO RE-ED BALANCE	$147.64	$196.86	—	58% above	25%
Neuromuscular re-education, 15 minutes inpatient CPT 97112 HC NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	—	25%
Neuromuscular re-education, 15 minutes inpatient CPT 97112 HC PT NEURO RE-ED BALANCE	$147.64	$196.86	—	—	25%
Neuromuscular re-education, 15 minutes inpatient CPT 97112 HC OT NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	—	25%
Neuromuscular re-education, 15 minutes inpatient CPT 97112 HC NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	—	25%
Neuromuscular re-education, 15 minutes inpatient CPT 97112 HC PT NEURO RE-ED BALANCE	$147.64	$196.86	—	—	25%
Neuromuscular re-education, 15 minutes inpatient CPT 97112 HC OT NEURO RE-ED BALANCE 15 MIN	$147.64	$196.86	—	—	25%
New patient office visit, about 45 minutes CPT 99204 HC OFFICE/OP VISIT, NEW LEVEL IV	$403.92	$538.56	—	91% above	25%
New patient office visit, about 45 minutes CPT 99204 HC OFFICE/OP VISIT, NEW LEVEL IV	$403.92	$538.56	—	91% above	25%
New patient office visit, about 45 minutes CPT 99204 HC NEW PATIENT LEVEL IV	$423.97	$565.29	—	100% above	25%
New patient office visit, about 45 minutes CPT 99204 HC NEW PATIENT LEVEL IV	$423.97	$565.29	—	100% above	25%
New patient office visit, about 45 minutes inpatient CPT 99204 HC OFFICE/OP VISIT, NEW LEVEL IV	$403.92	$538.56	—	—	25%
New patient office visit, about 45 minutes inpatient CPT 99204 HC OFFICE/OP VISIT, NEW LEVEL IV	$403.92	$538.56	—	—	25%
New patient office visit, about 45 minutes inpatient CPT 99204 HC NEW PATIENT LEVEL IV	$423.97	$565.29	—	—	25%
New patient office visit, about 45 minutes inpatient CPT 99204 HC NEW PATIENT LEVEL IV	$423.97	$565.29	—	—	25%
New patient office visit, straightforward problem or 15+ minutes CPT 99202 HC NEW PATIENT LEVEL II	$111.14	$148.18	—	15% below	25%
New patient office visit, straightforward problem or 15+ minutes CPT 99202 HC NEW PATIENT LEVEL II	$111.14	$148.18	—	15% below	25%
New patient office visit, straightforward problem or 15+ minutes inpatient CPT 99202 HC NEW PATIENT LEVEL II	$111.14	$148.18	—	—	25%
New patient office visit, straightforward problem or 15+ minutes inpatient CPT 99202 HC NEW PATIENT LEVEL II	$111.14	$148.18	—	—	25%
Nutrition counseling (medical nutrition therapy), first visit, 15 minutes CPT 97802 HC MNT-OP INI, IND ASSESS/INT QTR HR	$57.20	$76.27	—	1% below	25%
Nutrition counseling (medical nutrition therapy), first visit, 15 minutes CPT 97802 HC MNT-OP INI, IND ASSESS/INT QTR HR	$57.20	$76.27	—	1% below	25%
Nutrition counseling (medical nutrition therapy), first visit, 15 minutes inpatient CPT 97802 HC MNT-OP INI, IND ASSESS/INT QTR HR	$57.20	$76.27	—	—	25%
Nutrition counseling (medical nutrition therapy), first visit, 15 minutes inpatient CPT 97802 HC MNT-OP INI, IND ASSESS/INT QTR HR	$57.20	$76.27	—	—	25%
Occupational therapy evaluation, low complexity CPT 97165 HC OT EVAL LOW COMPLEX	$283.41	$377.88	—	60% above	25%
Occupational therapy evaluation, low complexity CPT 97165 HC OT EVAL LOW COMPLEX	$283.41	$377.88	—	60% above	25%
Occupational therapy evaluation, low complexity inpatient CPT 97165 HC OT EVAL LOW COMPLEX	$283.41	$377.88	—	—	25%
Occupational therapy evaluation, low complexity inpatient CPT 97165 HC OT EVAL LOW COMPLEX	$283.41	$377.88	—	—	25%
Physical therapy evaluation, high complexity (typically about 45 minutes) CPT 97163 HC PT EVAL HIGH COMPLEX	$400.07	$533.43	—	29% above	25%
Physical therapy evaluation, high complexity (typically about 45 minutes) CPT 97163 HC PT EVAL HIGH COMPLEX	$400.07	$533.43	—	29% above	25%
Physical therapy evaluation, high complexity (typically about 45 minutes) inpatient CPT 97163 HC PT EVAL HIGH COMPLEX	$400.07	$533.43	—	—	25%
Physical therapy evaluation, high complexity (typically about 45 minutes) inpatient CPT 97163 HC PT EVAL HIGH COMPLEX	$400.07	$533.43	—	—	25%
Physical therapy evaluation, low complexity (typically about 20 minutes) CPT 97161 HC PT EVAL LOW COMPLEX	$324.14	$432.19	—	83% above	25%
Physical therapy evaluation, low complexity (typically about 20 minutes) CPT 97161 HC PT EVAL LOW COMPLEX	$324.14	$432.19	—	83% above	25%
Physical therapy evaluation, low complexity (typically about 20 minutes) inpatient CPT 97161 HC PT EVAL LOW COMPLEX	$324.14	$432.19	—	—	25%
Physical therapy evaluation, low complexity (typically about 20 minutes) inpatient CPT 97161 HC PT EVAL LOW COMPLEX	$324.14	$432.19	—	—	25%
Physical therapy evaluation, moderate complexity (typically about 30 minutes) CPT 97162 HC PT EVAL MOD COMPLEX	$385.47	$513.96	—	61% above	25%
Physical therapy evaluation, moderate complexity (typically about 30 minutes) CPT 97162 HC PT EVAL MOD COMPLEX	$385.47	$513.96	—	61% above	25%
Physical therapy evaluation, moderate complexity (typically about 30 minutes) inpatient CPT 97162 HC PT EVAL MOD COMPLEX	$385.47	$513.96	—	—	25%
Physical therapy evaluation, moderate complexity (typically about 30 minutes) inpatient CPT 97162 HC PT EVAL MOD COMPLEX	$385.47	$513.96	—	—	25%
Physical therapy, hands-on manual therapy (15-minute unit) CPT 97140 HC MANUAL THERAPY	$151.61	$202.15	—	64% above	25%
Physical therapy, hands-on manual therapy (15-minute unit) CPT 97140 HC OT MANUAL THERAPY	$151.61	$202.15	—	64% above	25%
Physical therapy, hands-on manual therapy (15-minute unit) CPT 97140 HC OT MANUAL THERAPY	$151.61	$202.15	—	64% above	25%
Physical therapy, hands-on manual therapy (15-minute unit) CPT 97140 HC MANUAL THERAPY	$151.61	$202.15	—	64% above	25%
Physical therapy, hands-on manual therapy (15-minute unit) inpatient CPT 97140 HC MANUAL THERAPY	$151.61	$202.15	—	—	25%
Physical therapy, hands-on manual therapy (15-minute unit) inpatient CPT 97140 HC MANUAL THERAPY	$151.61	$202.15	—	—	25%
Physical therapy, hands-on manual therapy (15-minute unit) inpatient CPT 97140 HC OT MANUAL THERAPY	$151.61	$202.15	—	—	25%
Physical therapy, hands-on manual therapy (15-minute unit) inpatient CPT 97140 HC OT MANUAL THERAPY	$151.61	$202.15	—	—	25%
Physical therapy, therapeutic exercise (15-minute unit) CPT 97110 HC THERAPEUTIC EXERCISES	$147.64	$196.86	—	55% above	25%
Physical therapy, therapeutic exercise (15-minute unit) CPT 97110 HC THERAPEUTIC EXERCISES	$147.64	$196.86	—	55% above	25%
Physical therapy, therapeutic exercise (15-minute unit) CPT 97110 HC OT THERAPEUTIC EXERCISE	$147.64	$196.86	—	55% above	25%
Physical therapy, therapeutic exercise (15-minute unit) CPT 97110 HC OT THERAPEUTIC EXERCISE	$147.64	$196.86	—	55% above	25%
Physical therapy, therapeutic exercise (15-minute unit) inpatient CPT 97110 HC OT THERAPEUTIC EXERCISE	$147.64	$196.86	—	—	25%
Physical therapy, therapeutic exercise (15-minute unit) inpatient CPT 97110 HC THERAPEUTIC EXERCISES	$147.64	$196.86	—	—	25%
Physical therapy, therapeutic exercise (15-minute unit) inpatient CPT 97110 HC OT THERAPEUTIC EXERCISE	$147.64	$196.86	—	—	25%
Physical therapy, therapeutic exercise (15-minute unit) inpatient CPT 97110 HC THERAPEUTIC EXERCISES	$147.64	$196.86	—	—	25%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 HC EST PATIENT LEVEL III	$193.57	$258.09	—	18% above	25%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 HC OT/PT CARE ASSESSM LEVEL III	$193.57	$258.09	—	18% above	25%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 HC EST PATIENT LEVEL III	$193.57	$258.09	—	18% above	25%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 HC OT/PT CARE ASSESSM LEVEL III	$193.57	$258.09	—	18% above	25%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 HC OSTOMY CARE - 45	$295.61	$394.15	—	80% above	25%
Returning patient office visit, low complexity or 20+ minutes CPT 99213 HC OSTOMY CARE - 45	$295.61	$394.15	—	80% above	25%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 HC EST PATIENT LEVEL III	$193.57	$258.09	—	—	25%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 HC OT/PT CARE ASSESSM LEVEL III	$193.57	$258.09	—	—	25%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 HC EST PATIENT LEVEL III	$193.57	$258.09	—	—	25%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 HC OT/PT CARE ASSESSM LEVEL III	$193.57	$258.09	—	—	25%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 HC OSTOMY CARE - 45	$295.61	$394.15	—	—	25%
Returning patient office visit, low complexity or 20+ minutes inpatient CPT 99213 HC OSTOMY CARE - 45	$295.61	$394.15	—	—	25%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 HC OTPT CARE ASSESSM LEVEL IV	$280.82	$374.43	—	53% above	25%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 HC OTPT CARE ASSESSM LEVEL IV	$280.82	$374.43	—	53% above	25%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 HC EST PATIENT LEVEL IV	$281.02	$374.70	—	53% above	25%
Returning patient office visit, moderate complexity or 30+ minutes CPT 99214 HC EST PATIENT LEVEL IV	$281.02	$374.70	—	53% above	25%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 HC OTPT CARE ASSESSM LEVEL IV	$280.82	$374.43	—	—	25%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 HC OTPT CARE ASSESSM LEVEL IV	$280.82	$374.43	—	—	25%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 HC EST PATIENT LEVEL IV	$281.02	$374.70	—	—	25%
Returning patient office visit, moderate complexity or 30+ minutes inpatient CPT 99214 HC EST PATIENT LEVEL IV	$281.02	$374.70	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC EST PATIENT LEVEL II	$144.47	$192.63	—	33% above	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC EST PATIENT LEVEL II	$144.47	$192.63	—	33% above	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC OTPT CARE ASSESSM LEVEL II	$151.48	$201.97	—	39% above	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC OT/PT CARE ASSESSM LEVEL II	$151.48	$201.97	—	39% above	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC OTPT CARE ASSESSM LEVEL II	$151.48	$201.97	—	39% above	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC OT/PT CARE ASSESSM LEVEL II	$151.48	$201.97	—	39% above	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC OSTOMY CARE - 30	$231.44	$308.58	—	113% above	25%
Returning patient office visit, straightforward problem or 10+ minutes CPT 99212 HC OSTOMY CARE - 30	$231.44	$308.58	—	113% above	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC EST PATIENT LEVEL II	$144.47	$192.63	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC EST PATIENT LEVEL II	$144.47	$192.63	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC OT/PT CARE ASSESSM LEVEL II	$151.48	$201.97	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC OT/PT CARE ASSESSM LEVEL II	$151.48	$201.97	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC OTPT CARE ASSESSM LEVEL II	$151.48	$201.97	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC OTPT CARE ASSESSM LEVEL II	$151.48	$201.97	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC OSTOMY CARE - 30	$231.44	$308.58	—	—	25%
Returning patient office visit, straightforward problem or 10+ minutes inpatient CPT 99212 HC OSTOMY CARE - 30	$231.44	$308.58	—	—	25%
Speech and language evaluation CPT 92523 HC ST SPEECH SOUND LANG COMP EVAL	$666.46	$888.62	—	96% above	25%
Speech and language evaluation CPT 92523 HC ST SPEECH SOUND LANG COMP EVAL	$666.46	$888.62	—	96% above	25%
Speech and language evaluation inpatient CPT 92523 HC ST SPEECH SOUND LANG COMP EVAL	$666.46	$888.62	—	—	25%
Speech and language evaluation inpatient CPT 92523 HC ST SPEECH SOUND LANG COMP EVAL	$666.46	$888.62	—	—	25%
Speech therapy session, individual CPT 92507 HC ST SPEECH LANGUAGE THERAPY VISIT	$314.09	$418.79	—	24% above	25%
Speech therapy session, individual CPT 92507 HC ST SPEECH LANGUAGE THERAPY VISIT	$314.09	$418.79	—	24% above	25%
Speech therapy session, individual inpatient CPT 92507 HC ST SPEECH LANGUAGE THERAPY VISIT	$314.09	$418.79	—	—	25%
Speech therapy session, individual inpatient CPT 92507 HC ST SPEECH LANGUAGE THERAPY VISIT	$314.09	$418.79	—	—	25%
Spirometry (breathing test) CPT 94010 HC SPIROMETRY NO BRONCHO	$309.10	$412.14	—	17% above	25%
Spirometry (breathing test) CPT 94010 HC SPIROMETRY NO BRONCHO	$309.10	$412.14	—	17% above	25%
Spirometry (breathing test) inpatient CPT 94010 HC SPIROMETRY NO BRONCHO	$309.10	$412.14	—	—	25%
Spirometry (breathing test) inpatient CPT 94010 HC SPIROMETRY NO BRONCHO	$309.10	$412.14	—	—	25%
Spirometry before and after a bronchodilator CPT 94060 HC SPIROMETRY PRE POST	$795.56	$1,060.74	—	70% above	25%
Spirometry before and after a bronchodilator CPT 94060 HC SPIROMETRY PRE POST	$795.56	$1,060.74	—	70% above	25%
Spirometry before and after a bronchodilator inpatient CPT 94060 HC SPIROMETRY PRE POST	$795.56	$1,060.74	—	—	25%
Spirometry before and after a bronchodilator inpatient CPT 94060 HC SPIROMETRY PRE POST	$795.56	$1,060.74	—	—	25%
Therapeutic activities (functional training), 15 minutes CPT 97530 HC THERAPEUTIC ACTIVITY - 15 MIN.	$113.06	$150.74	—	29% above	25%
Therapeutic activities (functional training), 15 minutes CPT 97530 HC THERAPEUTIC ACTIVITY - 15 MIN.	$113.06	$150.74	—	29% above	25%
Therapeutic activities (functional training), 15 minutes CPT 97530 HC OT THERAPEUTIC ACTIV/TRANSFERS	$153.51	$204.68	—	75% above	25%
Therapeutic activities (functional training), 15 minutes CPT 97530 HC OT THERAPEUTIC ACTIV/TRANSFERS	$153.51	$204.68	—	75% above	25%
Therapeutic activities (functional training), 15 minutes inpatient CPT 97530 HC THERAPEUTIC ACTIVITY - 15 MIN.	$113.06	$150.74	—	—	25%
Therapeutic activities (functional training), 15 minutes inpatient CPT 97530 HC THERAPEUTIC ACTIVITY - 15 MIN.	$113.06	$150.74	—	—	25%
Therapeutic activities (functional training), 15 minutes inpatient CPT 97530 HC OT THERAPEUTIC ACTIV/TRANSFERS	$153.51	$204.68	—	—	25%
Therapeutic activities (functional training), 15 minutes inpatient CPT 97530 HC OT THERAPEUTIC ACTIV/TRANSFERS	$153.51	$204.68	—	—	25%

Vaccines

Procedure	Cash price	List price	Insurers pay	vs Wisconsin	Off list
Chickenpox (varicella) vaccine, live (Varivax) CPT 90716 varicella virus vaccine (live) 1,350 unit/0.5 mL Susr 1 each Vial	$701.17	$934.89	—	325% above	25%
Chickenpox (varicella) vaccine, live (Varivax) CPT 90716 varicella virus vaccine (live) 1,350 unit/0.5 mL Susr 1 each Vial	$701.17	$934.89	—	325% above	25%
Chickenpox (varicella) vaccine, live (Varivax) inpatient CPT 90716 varicella virus vaccine (live) 1,350 unit/0.5 mL Susr 1 each Vial	$701.17	$934.89	—	—	25%
Chickenpox (varicella) vaccine, live (Varivax) inpatient CPT 90716 varicella virus vaccine (live) 1,350 unit/0.5 mL Susr 1 each Vial	$701.17	$934.89	—	—	25%
Flu shot, standard dose, preservative-free, for age 6 months and older CPT 90656 flu vac ts 2025-26(6mos up)-PF 45 mcg (15 mcg x 3)/0.5 mL Syrg 0.5 mL Syringe	$127.54	$170.05	—	306% above	25%
Flu shot, standard dose, preservative-free, for age 6 months and older CPT 90656 flu vac ts 2025-26(6mos up)-PF 45 mcg (15 mcg x 3)/0.5 mL Syrg 0.5 mL Syringe	$127.54	$170.05	—	306% above	25%
Flu shot, standard dose, preservative-free, for age 6 months and older inpatient CPT 90656 flu vac ts 2025-26(6mos up)-PF 45 mcg (15 mcg x 3)/0.5 mL Syrg 0.5 mL Syringe	$127.54	$170.05	—	—	25%
Flu shot, standard dose, preservative-free, for age 6 months and older inpatient CPT 90656 flu vac ts 2025-26(6mos up)-PF 45 mcg (15 mcg x 3)/0.5 mL Syrg 0.5 mL Syringe	$127.54	$170.05	—	—	25%
High-dose flu shot, preservative-free, mainly for age 65 and older CPT 90662 flu vacc ts2025-26(65yr up)-PF 180 mcg/0.5 mL Syrg 0.5 mL Syringe	$432.56	$576.75	—	445% above	25%
High-dose flu shot, preservative-free, mainly for age 65 and older CPT 90662 flu vacc ts2025-26(65yr up)-PF 180 mcg/0.5 mL Syrg 0.5 mL Syringe	$432.56	$576.75	—	445% above	25%
High-dose flu shot, preservative-free, mainly for age 65 and older inpatient CPT 90662 flu vacc ts2025-26(65yr up)-PF 180 mcg/0.5 mL Syrg 0.5 mL Syringe	$432.56	$576.75	—	—	25%
High-dose flu shot, preservative-free, mainly for age 65 and older inpatient CPT 90662 flu vacc ts2025-26(65yr up)-PF 180 mcg/0.5 mL Syrg 0.5 mL Syringe	$432.56	$576.75	—	—	25%
MMR vaccine (measles, mumps and rubella), live CPT 90707 measles, mumps and rubella vaccine 1,000-12,500 TCID50/0.5 mL Solr 1 each Vial	$454.18	$605.57	—	196% above	25%
MMR vaccine (measles, mumps and rubella), live CPT 90707 measles, mumps and rubella vaccine 1,000-12,500 TCID50/0.5 mL Solr 1 each Vial	$454.18	$605.57	—	196% above	25%
MMR vaccine (measles, mumps and rubella), live inpatient CPT 90707 measles, mumps and rubella vaccine 1,000-12,500 TCID50/0.5 mL Solr 1 each Vial	$454.18	$605.57	—	—	25%
MMR vaccine (measles, mumps and rubella), live inpatient CPT 90707 measles, mumps and rubella vaccine 1,000-12,500 TCID50/0.5 mL Solr 1 each Vial	$454.18	$605.57	—	—	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) CPT 90732 pneumococcal 23-val ps vaccine 25 mcg/0.5 mL Soln 0.5 mL Vial	$565.34	$753.79	—	301% above	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) CPT 90732 pneumococcal 23-val ps vaccine 25 mcg/0.5 mL Soln 0.5 mL Vial	$565.34	$753.79	—	301% above	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) CPT 90732 pneumococcal 20-val conj vaccine 0.5 mL Syrg 0.5 mL Syringe	$875.14	$1,166.85	—	520% above	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) CPT 90732 pneumococcal 20-val conj vaccine 0.5 mL Syrg 0.5 mL Syringe	$875.14	$1,166.85	—	520% above	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) inpatient CPT 90732 pneumococcal 23-val ps vaccine 25 mcg/0.5 mL Soln 0.5 mL Vial	$565.34	$753.79	—	—	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) inpatient CPT 90732 pneumococcal 23-val ps vaccine 25 mcg/0.5 mL Soln 0.5 mL Vial	$565.34	$753.79	—	—	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) inpatient CPT 90732 pneumococcal 20-val conj vaccine 0.5 mL Syrg 0.5 mL Syringe	$875.14	$1,166.85	—	—	25%
Pneumonia vaccine, 23-valent polysaccharide (Pneumovax 23) inpatient CPT 90732 pneumococcal 20-val conj vaccine 0.5 mL Syrg 0.5 mL Syringe	$875.14	$1,166.85	—	—	25%
RSV antibody shot for infants, seasonal dose (0.5 mL) CPT 90380 nirsevimab-alip 50 mg/0.5 mL Syrg 0.5 mL Syringe	$2,013.47	$2,684.63	—	97% above	25%
RSV antibody shot for infants, seasonal dose (0.5 mL) CPT 90380 nirsevimab-alip 50 mg/0.5 mL Syrg 0.5 mL Syringe	$2,013.47	$2,684.63	—	97% above	25%
RSV antibody shot for infants, seasonal dose (0.5 mL) inpatient CPT 90380 nirsevimab-alip 50 mg/0.5 mL Syrg 0.5 mL Syringe	$2,013.47	$2,684.63	—	—	25%
RSV antibody shot for infants, seasonal dose (0.5 mL) inpatient CPT 90380 nirsevimab-alip 50 mg/0.5 mL Syrg 0.5 mL Syringe	$2,013.47	$2,684.63	—	—	25%
Rabies vaccine, one dose CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each Vial	$1,115.59	$1,487.45	—	99% above	25%
Rabies vaccine, one dose CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each Vial	$1,115.59	$1,487.45	—	99% above	25%
Rabies vaccine, one dose CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each KIT	$1,528.38	$2,037.84	—	173% above	25%
Rabies vaccine, one dose CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each KIT	$1,528.38	$2,037.84	—	173% above	25%
Rabies vaccine, one dose inpatient CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each Vial	$1,115.59	$1,487.45	—	—	25%
Rabies vaccine, one dose inpatient CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each Vial	$1,115.59	$1,487.45	—	—	25%
Rabies vaccine, one dose inpatient CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each KIT	$1,528.38	$2,037.84	—	—	25%
Rabies vaccine, one dose inpatient CPT 90675 rabies vaccine, PCEC 2.5 unit Susr 1 each KIT	$1,528.38	$2,037.84	—	—	25%
Shingles vaccine (Shingrix), recombinant, one dose CPT 90750 varicella-zoster PF 50 mcg/0.5 mL Susr 1 each KIT	$716.74	$955.65	—	262% above	25%
Shingles vaccine (Shingrix), recombinant, one dose CPT 90750 varicella-zoster PF 50 mcg/0.5 mL Susr 1 each KIT	$716.74	$955.65	—	262% above	25%
Shingles vaccine (Shingrix), recombinant, one dose inpatient CPT 90750 varicella-zoster PF 50 mcg/0.5 mL Susr 1 each KIT	$716.74	$955.65	—	—	25%
Shingles vaccine (Shingrix), recombinant, one dose inpatient CPT 90750 varicella-zoster PF 50 mcg/0.5 mL Susr 1 each KIT	$716.74	$955.65	—	—	25%
Td vaccine (tetanus and diphtheria booster), age 7 and older CPT 90714 tetanus & diphtheria toxoids (adult) 5-2 Lf unit/0.5 mL Syrg 0.5 mL Syringe	$289.39	$385.85	—	598% above	25%
Td vaccine (tetanus and diphtheria booster), age 7 and older CPT 90714 tetanus & diphtheria toxoids (adult) 5-2 Lf unit/0.5 mL Syrg 0.5 mL Syringe	$289.39	$385.85	—	598% above	25%
Td vaccine (tetanus and diphtheria booster), age 7 and older inpatient CPT 90714 tetanus & diphtheria toxoids (adult) 5-2 Lf unit/0.5 mL Syrg 0.5 mL Syringe	$289.39	$385.85	—	—	25%
Td vaccine (tetanus and diphtheria booster), age 7 and older inpatient CPT 90714 tetanus & diphtheria toxoids (adult) 5-2 Lf unit/0.5 mL Syrg 0.5 mL Syringe	$289.39	$385.85	—	—	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Syrg 0.5 mL Syringe	$265.24	$353.65	—	225% above	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Susp 0.5 mL Vial	$265.24	$353.65	—	225% above	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Syrg 0.5 mL Syringe	$265.24	$353.65	—	225% above	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Susp 0.5 mL Vial	$265.24	$353.65	—	225% above	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older inpatient CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Syrg 0.5 mL Syringe	$265.24	$353.65	—	—	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older inpatient CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Syrg 0.5 mL Syringe	$265.24	$353.65	—	—	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older inpatient CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Susp 0.5 mL Vial	$265.24	$353.65	—	—	25%
Tdap vaccine (tetanus, diphtheria and whooping cough), age 7 and older inpatient CPT 90715 Tdap 2.5-8-5 Lf-mcg-Lf/0.5mL Susp 0.5 mL Vial	$265.24	$353.65	—	—	25%
Vaccine administration fee (giving the shot), first vaccine of the visit CPT 90471 HC UC IMMUNIZATION ADMIN	$80.20	$106.94	—	107% above	25%
Vaccine administration fee (giving the shot), first vaccine of the visit CPT 90471 HC UC IMMUNIZATION ADMIN	$80.20	$106.94	—	107% above	25%
Vaccine administration fee (giving the shot), first vaccine of the visit CPT 90471 HC IMMUNIZATION ADMIN	$80.20	$106.94	—	107% above	25%
Vaccine administration fee (giving the shot), first vaccine of the visit CPT 90471 HC IMMUNIZATION ADMIN	$80.20	$106.94	—	107% above	25%
Vaccine administration fee (giving the shot), first vaccine of the visit inpatient CPT 90471 HC UC IMMUNIZATION ADMIN	$80.20	$106.94	—	—	25%
Vaccine administration fee (giving the shot), first vaccine of the visit inpatient CPT 90471 HC UC IMMUNIZATION ADMIN	$80.20	$106.94	—	—	25%
Vaccine administration fee (giving the shot), first vaccine of the visit inpatient CPT 90471 HC IMMUNIZATION ADMIN	$80.20	$106.94	—	—	25%
Vaccine administration fee (giving the shot), first vaccine of the visit inpatient CPT 90471 HC IMMUNIZATION ADMIN	$80.20	$106.94	—	—	25%
Vaccine administration fee, each additional vaccine at the same visit CPT 90472 HC IMMUNIZATION ADMIN, EACH ADD	$52.92	$70.56	—	63% above	25%
Vaccine administration fee, each additional vaccine at the same visit CPT 90472 HC IMMUNIZATION ADMIN, EACH ADD	$52.92	$70.56	—	63% above	25%
Vaccine administration fee, each additional vaccine at the same visit inpatient CPT 90472 HC IMMUNIZATION ADMIN, EACH ADD	$52.92	$70.56	—	—	25%
Vaccine administration fee, each additional vaccine at the same visit inpatient CPT 90472 HC IMMUNIZATION ADMIN, EACH ADD	$52.92	$70.56	—	—	25%

Source file: https://www.mercyhealthsystem.org/media/5014c1033bbf4dfd915202e2e2cd1dcf/390816848-mercywalworthhospital-standardcharges.json