2026_Sevier_County_Medical_Center_Shoppable_ServicesFINAL.xlsx

	A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	P	Q	R	S	T	U	V	W
1	09/03/2026 Sevier County Medical Center Shoppable Services
2	Chargecode	CPT/HCPCs/DRG/Revenue_Code	Description	Price	Cash_Discount	Aetna	BCBS	BreastCare	CareSource	Centene	Empower	Healthchoice	Humana	AR_Medicaid	Medicare	OK_Medicaid	Municipal	Summit	UHC	Tribute	VA	Minimum_Charge	Maximum_Charge
3	60110250	110	ROOM RATE - SWINGBED	500.00	300.00																	300.00	500.00
4	60110251	110	ROOM RATE - PRIVATE	900.00	540.00																	540.00	900.00
5		216	Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with major complications or comorbidities	N/A
6	61710005	270	O2SAT,DIRCT MEAS,EXC PULSO	273.00	163.80	78.77			78.77	67.71	78.77	78.77	78.77	78.77	78.77	78.77	42.31	78.77	78.77	78.77	78.77	42.31	78.77
7	61710085	270	OXYGEN 2-24 HR EA HR	25.00	15.00																	15.00	25.00
8		460	Spinal fusion except cervical without major comorbid conditions or complications (MCC)	N/A
9		470	Major joint replacement or reattachment of lower extremity without major comorbid conditions or complications (MCC)	N/A
10		473	Cervical spinal fusion without comorbid conditions (CC) or major comorbid conditions or complications (MCC)	N/A
11		743	Uterine and adnexa procedures for non-malignancy without comorbid conditions (CC) or major comorbid conditions or complications (MCC)	N/A
12		19120	Removal of 1 or more breast growth, open procedure	N/A
13		29826	Shaving of shoulder bone using an endoscope	N/A
14		29881	Removal of one knee cartilage using an endoscope	N/A
15		42820	Removal of tonsils and adenoid glands patient younger than age 12	N/A
16		43235	Diagnostic examination of esophagus, stomach, and/or upper small bowel using an endoscope	N/A
17		43239	Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope	N/A
18		45378	Diagnostic examination of large bowel using an endoscope	N/A
19		45380	Biopsy of large bowel using an endoscope	N/A
20		45385	Removal of polyps or growths of large bowel using an endoscope	N/A
21		45391	Ultrasound examination of lower large bowel using an endoscope	N/A
22		47562	Removal of gallbladder using an endoscope	N/A
23		49505	Repair of groin hernia patient age 5 years or older	N/A
24		55700	Biopsy of prostate gland	N/A
25		55866	Surgical removal of prostate and surrounding lymph nodes using an endoscope	N/A
26		59400	Routine obstetric care for vaginal delivery, including pre-and post-delivery care	N/A
27		59510	Routine obstetric care for cesarean delivery, including pre-and post-delivery care	N/A
28		59610	Routine obstetric care for vaginal delivery after prior cesarean delivery including pre-and post-delivery care	N/A
29		64483	Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance	N/A
30		66821	Removal of recurring cataract in lens capsule using laser	N/A
31		66984	Removal of cataract with insertion of lens	N/A
32	20000585	72110	X-Ray, lower back, minimum four views	368.00	220.80	106.81	108.00		106.81	60.32	106.81	54.53	106.81	106.81	106.81	106.81	46.04	106.81	106.81	106.81	106.81	46.04	108.00
33	20002801	72110	PF X-Ray, lower back, minimum four views	36.00	21.60	11.91	25.34	0.00	20.51	20.50	20.51	18.23	11.91	20.51	11.91	11.39	21.09	20.51	11.91	11.91	11.91	11.39	25.34
34	20000693	72193	CT scan, pelvis, with contrast	616.00	396.60	179.20	175.00	0.00	179.20	255.72	179.20	230.75	179.20	179.20	179.20	179.20	291.82	179.20	179.20	179.20	179.20	175.00	291.82
35	20002831	72193	PF CT scan, pelvis, with contrast	146.00	87.54	50.68	87.99	0.00	106.00	87.23	106.00	77.24	50.68	106.00	50.68	48.26	78.73	106.00	50.68	50.68	50.68	48.26	106.00
36	20000622	77065	Mammography of one breast	285.00	171.00	0.00	88.00	73.91	0.00	127.86	0.00	115.37	0.00	0.00	0.00	0.00	65.64	0.00	0.00	0.00	0.00	65.64	127.86
37	20003324	77065	PF Mammography of one breast	76.00	45.60	35.74	59.49	0.00	42.92	61.53	42.92	54.50	35.74	42.92	35.74	34.06	37.72	42.92	35.74	35.74	35.74	34.06	61.53
38	20001719	77066	Mammography Diagnostic of both breasts	360.00	216.00	0.00	112.00	40.63	0.00	163.90	0.00	147.98	0.00	0.00	0.00	0.00	112.71	0.00	0.00	0.00	0.00	40.63	163.90
39	20003333	77066	PF Mammography Diagnostic of both breasts	94.00	56.40	44.03	73.37	35.37	56.31	75.79	56.31	67.10	44.03	56.31	44.03	41.93	68.94	56.31	44.03	44.03	44.03	35.37	75.79
40		80055	Obstetric blood test panel	N/A
41	70110005	80069-36415	Kidney function panel test / VENIPUNCTURE	116.42	33.86																	33.86	116.42
42	70110007	80076-36415	Liver function blood test panel / VENIPUNCTURE	113.11	31.87																	31.87	113.11
43	70111042	85027-36415	Complete blood count, automated / VENIPUNCTURE	102.00	25.50																	25.50	102.00
44		90832	Psychotherapy, 30 min	N/A
45		90834	Psychotherapy, 45 min	N/A
46		90837	Psychotherapy, 60 min	N/A
47		90846	Family psychotherapy, not including patient, 50 min	N/A
48		90847	Family psychotherapy, including patient, 50 min	N/A
49		90853	Group psychotherapy	N/A
50		93000	Electrocardiogram, routine, with interpretation and report	N/A
51		93452	Insertion of catheter into left heart for diagnosis	N/A
52		95810	Sleep study	N/A
53	60610021	99203	New patient office or other outpatient visit, typically 30 min	409.00	245.40		74.00			78.17		86.16					111.40					74.00	111.40
54	61910049	99203	PF New patient office or other outpatient visit, typically 30 min	137.00	82.20	67.43	136.54		70.19	78.17	70.19	86.16	67.43	70.19	67.43	64.69	111.40	70.19	67.43	67.43	67.43	64.69	136.54
55	60610023	99204	New patient office of other outpatient visit, typically 45 min	409.00	245.40		126.00			128.04		140.95					172.18					126.00	172.18
56	61910050	99204	PF New patient office of other outpatient visit, typically 45 min	137.00	82.20	110.46	205.49		95.17	128.04	95.17	140.95	110.46	95.17	110.46	105.80	172.18	95.17	110.46			95.17	205.49
57	60610025	99205	New patient office of other outpatient visit, typically 60 min	409.00	245.40		164.00			174.83		192.85					216.70					164.00	216.70
58	61910051	99205	PF New patient office of other outpatient visit, typically 60 min	164.00	98.40	150.81	271.08		148.71	174.83	148.71	192.85	150.81	148.71	150.81	144.80	216.70	148.71	150.81	150.81	150.81	144.80	271.08
59		99243	Patient office consultation, typically 40 min	N/A
60		99244	Patient office consultation, typically 60 min	N/A
61		99385	Initial new patient preventive medicine evaluation (18-39 years)	N/A
62		99386	Initial new patient preventive medicine evaluation (40-64 years)	N/A
63	62310000	10060	I/D ABC/CYST,SMPL	615.00	357.66	204.98	184.00		55.60	146.56	55.60	129.07	204.98	55.60	204.98	204.98	132.62	55.60	204.98	204.98	204.98	55.60	204.98
64	60110114	11042	DEBRID SK SUBQ 1ST 20 SQ CM	1246.00	678.00	415.32	379.00		76.21	82.68	76.21	72.88	415.32	76.21	415.32	415.32	87.51	76.21	415.32	415.32	415.32	72.88	415.32
65	61910033	11042	PF Debride, subq tiss lst 20sq cm	416.00	78.60	51.29	190.00		76.21	82.68	76.21	72.88	51.29	76.21	51.29	49.56	87.51	76.21	51.29	51.29	51.29	49.56	189.59
66	62310036	12001	SMPL RPR 2.5CM OR LESS	615.00	357.66	204.98	184.00		86.54	64.26	86.54	57.41	204.98	86.54	204.98	204.98	179.94	86.54	204.98	204.98	204.98	57.41	204.98
67	62310320	12001	PF SMPL RPR 2.5CM OR LESS	503.00	64.20	39.86	137.00		86.54	64.26	86.54	57.41	39.86	86.54	39.86	39.14	179.94	86.54	39.86	39.86	39.86	39.14	179.94
68	62310037	12002	RPR S/N/AX/GEN/TMK 2.6-7.5CM	615.00	357.66	204.98	184.00		95.20	83.95	95.20	74.99	204.98	95.20	204.98	204.98	191.18	95.20	204.98	204.98	204.98	74.99	204.98
69	62310321	12002	PF RPR S/N/AX/GEN/TMK 2.6-7.5	170.00	84.60	52.08	167.00		95.20	83.95	95.20	74.99	52.08	95.20	52.08	51.13	191.18	95.20	52.08	52.08	52.08	51.13	191.18
70	62310042	12011	RPR F/E/E/N/L/M 2.5 CM/<	615.00	357.66	204.98	184.00		92.05	79.42	92.05	70.99	204.98	92.05	204.98	204.98	190.80	92.05	204.98	204.98	204.98	70.99	204.98
71	62310043	12013	RPR F/E/E/N/L/M 2.6-5.0 CM	615.00	357.66	204.98	184.00		104.38	81.67	104.38	73.17	204.98	104.38	204.98	204.98	210.18	104.38	204.98	204.98	204.98	73.17	210.18
72	62310255	29125	AP SH ARM SPLT:STATIC	408.00	232.02	135.93	118.00		53.50	59.23	53.50	52.56	135.93	53.50	135.93	135.93	78.83	53.50	135.93	135.93	135.93	52.56	135.93
73	62310191	31500	INTUBATION ENDOTRACHEAL EMER	726.00	418.00	241.98	211.00		89.17	198.41	89.17	175.70	241.98	89.17	241.98	241.98	144.20	89.17	241.98	241.98	241.98	89.17	241.98
74	62310326	31500	PF INTUB ENDOTRACHEAL EMER	402.00	206.40	123.09	207.00		89.17	198.41	89.17	175.70	123.09	89.17	123.09	119.72	144.20	89.17	123.09	123.09	123.09	89.17	207.33
75	70110000	36415	VENIPUNCTURE	60.00	36.00	9.34			3.00	9.34	3.00	9.34	9.34	3.00	9.34	9.34	2.55	3.00	9.34	9.34	9.34	2.55	9.34
76	70111343	36430	BLOOD ADMINISTRATION	1353.00	656.40	450.73	415.00		55.00	65.44	55.00	58.29	450.73	55.00	450.73	450.73	42.35	55.00	450.73	450.73	450.73	42.35	450.73
77	60110032	36600	ART PUNCT W/DRAW BL DIAG	408.00	267.60	135.93	118.00		39.00	20.12	39.00	17.47	135.93	39.00	135.93	135.93	38.71	39.00	135.93	135.93	135.93	17.47	135.93
78	60110147	51701	IN/OUT CATH(INSERTION OF)	408.00	267.60	135.93	118.00		65.59	33.11	65.59	29.21	135.93	65.59	135.93	135.93	77.34	65.59	135.93	135.93	135.93	29.21	135.93
79	60110136	51702	FOLEY CATH(INSERTION OF)	408.00	267.60	135.93	118.00		103.13	34.04	103.13	30.03	135.93	103.13	135.93	135.93	98.63	103.13	135.93	135.93	135.93	30.03	135.93
80	62310302	51798	Bedside Bladder Scan	181.00	106.92	60.27	58.00		22.68	17.29	22.68	15.54	60.27	22.68	60.27	60.27	23.83	22.68	60.27	60.27	60.27	15.54	60.27
81	61910012 - 20002644	62322-62323	Injection of substance into spinal canal of lower back or sacrum using imaging guidance	4527.00	2716.20																	2716.20	4527.00
82	20000713	70450	CT HEAD W/O CONTRAST	321.00	220.80	106.81	108.00		106.81	99.57	106.81	89.87	106.81	106.81	106.81	106.81	191.39	106.81	106.81	106.81	106.81	89.87	191.39
83	20002693	70450	PF CT HEAD/BRAIN W/O CONTRAST	212.00	85.80	37.38	64.00		86.00	64.34	86.00	56.96	37.38	86.00	37.38	35.59	57.65	86.00	37.38	37.38	37.38	35.59	86.00
84	20000715	70470	CT HEAD W/WO	538.00	369.60	179.20	175.00		179.20	169.85	179.20	153.35	179.20	179.20	179.20	179.20	304.78	179.20	179.20	179.20	179.20	153.35	304.78
85	20002702	70470	PF CT HEAD/BRAIN W/WO CONTRAST	252.00	109.20	55.52	96.00		125.00	95.57	125.00	84.54	55.52	125.00	55.52	52.82	86.10	125.00	55.52	55.52	55.52	52.82	125.00
86	20000719	70486	CT SINUSES W/OUT	321.00	220.80	106.81	108.00		106.81	131.34	106.81	118.50	106.81	106.81	106.81	106.81	244.61	106.81	106.81	106.81	106.81	106.81	244.61
87	20002716	70486	PF CT SINUSES WITHOUT CONTRAST	186.00	79.20	37.66	65.00		92.00	64.84	92.00	57.41	37.66	92.00	37.66	35.87	77.04	92.00	37.66	37.66	37.66	35.87	92.00
88	20002717	70486	PF CT FACIAL BONES WO CONTRAST	186.00	79.20	37.66	65.00		92.00	64.84	92.00	57.41	37.66	92.00	37.66	35.87	77.04	92.00	37.66	37.66	37.66	35.87	92.00
89	20000675	70491	CT NECK W/CONTRAST	538.00	369.60	179.20	175.00		179.20	177.80	179.20	160.95	179.20	179.20	179.20	179.20	294.14	179.20	179.20	179.20	179.20	160.95	294.14
90	20003442	70491	PF CT Neck W/ Contrast	267.00	81.60	60.37	104.00		96.00	103.92	96.00	91.83	60.37	96.00	60.37	57.37	93.47	96.00	60.37	60.37	60.37	57.37	104.50
91	20000725	70496	CT ANGIO HEAD W/WO	538.00	369.60	179.20	175.00		179.20	287.29	179.20	240.08	179.20	179.20	179.20	179.20	426.98	179.20	179.20	179.20	179.20	175.00	426.98
92	20002725	70496	PF CT ANGIO HEAD	397.00	90.60	76.26	132.00		94.13	131.27	94.13	116.03	76.26	94.13	76.26	72.48	118.95	94.13	76.26	76.26	76.26	72.48	132.15
93	20000726	70498	CT ANGIO NECK	538.00	369.60	179.20	175.00		179.20	287.29	179.20	240.08	179.20	179.20	179.20	179.20	426.98	179.20	179.20	179.20	179.20	175.00	426.98
94	20002726	70498	PF CT ANGIO NECK	397.00	90.60	76.26	132.00		94.13	131.27	94.13	116.03	76.26	94.13	76.26	72.48	118.95	94.13	76.26	76.26	76.26	72.48	132.15
95	20001789	70551	MR HEAD/BRAIN WO CON	732.00	501.60	243.77	224.00		243.77	189.21	243.77	170.79	243.77	243.77	243.77	243.77	438.55	243.77	243.77	243.77	243.77	170.79	438.55
96	20002760	70551	PF MR HEAD/BRAIN W/O CONTRAST	285.00	131.40	64.43	112.00		162.00	110.90	162.00	98.09	64.43	162.00	64.43	61.28	100.09	162.00	64.43	64.43	64.43	61.28	162.00
97	20001790	70553	MR HEAD/BRAIN WO/W CON	1236.00	741.60	356.43	367.00		356.43	314.10	356.43	283.49	356.43	356.43	356.43	356.43	671.36	356.43	356.43	356.43	356.43	283.49	671.36
98	20002761	70553	PF MR HEAD/BRAIN W/WO CONTRAST	461.00	143.40	99.88	173.00		182.00	171.94	182.00	152.13	99.88	182.00	99.88	95.06	159.46	182.00	99.88	99.88	99.88	95.06	182.00
99	20000560	71045	XR CHEST 1 VIEW	267.00	183.00	88.91	77.00		88.91	25.12	88.91	22.76	88.91	88.91	88.91	88.91	19.52	88.91	88.91	88.91	88.91	19.52	88.91
100	20002762	71045	PF XR CHEST 1 VIEW	27.00	16.20	7.95	14.00		11.09	13.68	11.09	12.09	7.95	11.09	7.95	7.56	11.09	11.09	7.95	7.95	7.95	7.56	13.78