Test Name CPT Price Note ABO TYPE $ ACETAMINOPHEN $ 61.25
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1 This list is provided to comply with Maine law, 22 MRSA 1718-B, requiring health care entities to maintain a list of prices and billing codes for services provided at least 50 times in the year previous Price estimating tools are available from the Maine Health Data Organization This tool shows the average cost of common healthcare procedures at different facilities in Maine. Test Name CPT Price Note ABO TYPE $ ACETAMINOPHEN $ AEROBIC CULTURE and GRAM STAIN* 87070, $ *pathogen ID, add $16.25; susceptibility, add $61.25 ALANINE AMINOTRANSFERASE $ ALBUMIN $ ALKALINE PHOSPHATASE $ AMMONIA $ AMYLASE $ ANAEROBIC CULTURE and GRAM STAIN* 87075, $ *pathogen ID, add $16.25; susceptibility, add $61.25 ANTIBODY SCREEN $ ANTINUCLEAR ABY (ANA) $ ANTITHROMBIN III $ ASPARATE AMINOTRANSFERASE $ BACTERIAL IDENTIFICATION $ BASIC METABOLIC PANEL $ BENZODIAZEPINES $ BETA HCG QUAL (SERUM PREG) $ BETA HCG QUANTITATIVE $ BETA-2 GLYCOPROTEIN 1 AB IgG/IgM 86146X2 $ BILIRUBIN DIRECT $ BILIRUBIN TOTAL $ BLOOD CULTURE* $ *pathogen ID, add $16.25; susceptibility, add $61.25 BODY FLUID CELL COUNT $ BODY FLUID CRYSTALS $ BORDETELLA PERTUSSIS PCR $ B-TYPE NATRIURETC PEPTIDE $ BUN (UREA NITROGEN) $ BUPRENORPHINE SEMIQUANT $ C REACTIVE PROTEIN $ C REACTIVE PROTEIN HIGH SENSITIVITY $ CALCIUM $ CANCER ANTIGEN $ CANNABINOID SEMIQUANT $ CARBAMAZEPINE $ CARCINOEMBRYONIC AG (CEA) $ CARDIOLIPIN AB IGG OR IGM 86147X2 $ CBC WITH DIFF $ CBC WITHOUT DIFFERENTIAL $ CELIAC REFLEX PANEL $ CHLAMYDIA DIRECT TEST $ CHOLESTEROL $ CLOSTRIDIUM DIFFICILE BY PCR $ 77.50
2 CLOZAPINE (CLOZARIL) $ COMPLEMENT C $ COMPLEMENT C $ COMPREHENSIVE METABOLIC PANEL $ CORTISOL $ CREATINE KINASE (CPK) $ CREATININE $ CREATININE CLEARANCE $ D DIMER QUANT $ DHEA SULFATE $ DIGOXIN $ DILUTE RUSSELL VIPER VENOM $ DOUBLE STRANDED DNA $ DRUG SCREEN URINE COMPREHENSIVE G0431, $ DRUG SUBSTANCE ABUSE SCREEN 1 G0431 $ DRUG SUBSTANCE ABUSE SCREEN 5 G0431 $ EBV ANTIBODY NUCLEAR AG IGG $ EBV ANTIBODY VIRAL CAPSID $ ELECTROLYTES PANEL $ ELECTROPHORESIS PROTEIN $ ELECTROPHORESIS URINE $ ESTRADIOL $ FACTOR 2 BY PCR $ FACTOR 5 LEIDEN BY PCR $ FERRITIN $ FETAL FIBRONECTIN $ FIBRINOGEN $ FOLATE $ FOLLICLE STIMULATING HORMONE -FSH $ GC AMPLIFIED PROBE $ GENITAL BETA STREP SCREEN $ GLUCOSE $ GLUCOSE POST GLUCOSE DRINK $ GLUTAMYLTRANSFERASE GGT $ GRAM STAIN $ HAPTOGLOBIN $ HELICOBACTER PYLORI ANTIBODY $ HEMATOCRIT $ 8.50 HEMOGLOBIN $ HEMOGLOBIN A1C $ HEPATIC FUNCTION PANEL $ HEPATITIS 1 (ACUTE) $ HEPATITIS 2 (EXPOSED) 86706, 87340, 86704, $ HEPATITIS A ANTIBODY TOTAL $ HEPATITIS B CORE TOTAL $ HEPATITIS B SURFACE ANTIBODY $ HEPATITIS B SURFACE ANTIGEN $ 45.00
3 HEPATITIS C RNA QUANT $ HEPATITIS C VIRUS AB $ HERPES SIMPLEX 1 & 2 VIRUS BY PCR 87529X2 $ HERPES SIMPLEX TYPE $ HERPES SIMPLEX TYPE $ HIV $ HOMOCYSTEINE $ IMMUNOFIXATION SERUM $ IMMUNOGLOBULIN A (IGA) $ IMMUNOGLOBULIN G (IGG) $ IMMUNOGLOBULIN M (IGM) $ INSULIN $ IRON $ IRON BINDING CAPACITY $ LACTATE DEHYDROGENASE - LDH $ LAMOTRIGINE (LAMICTAL) $ LDL DIRECT $ LIPASE $ LITHIUM $ LIPID PANEL (HDL2) $ LUTEINIZING HORMONE - LH $ LYME DISEASE $ MAGNESIUM $ METHYLPHENIDATE (RITALIN) URINE $ MONONUCLEOSIS, INFECTIOUS $ MUMPS IgG $ OPIATES CONFIRMATION $ OSMOLALITY URINE $ OVA & PARASITE 87328, $ OVA & PARASITE COMPREHENSIVE 87177, $ PHENOBARBITAL $ PHENYTOIN $ PHOSPHORUS $ PLATELET COUNT $ POTASSIUM $ PREALBUMIN $ PREGNANCY TEST URINE $ PRENATAL PROFILE $ PROGESTERONE $ PROLACTIN $ PROTEIN C ACTIVITY $ PROTEIN S ACTIVITY $ PROTHROMBIN TIME (INR) $ PSA $ PSA FREE $ PTH INTACT/N-TERMINAL $ PTT $ 34.75
4 RAPID PLASMA REAGIN - RPR $ RENAL FUNCTION PANEL $ RESPIRATORY VIRUS PCR $ RETICULOCYTE COUNT AUTO $ RH TYPE $ RHEUMATOID FACTOR $ ROTAVIRUS $ RUBELLA IGG $ RUBEOLA IGG $ SEDIMENTATION RATE AUTO $ SEDIMENTATION RATE MANUAL $ SICKLE CELL SCREEN $ SODIUM $ STOOL CULTURE 87427, 87046, $ STOOL OCCULT BLOOD IOB $ STREP SCREEN $ SUSCEPTIBILITY STUDIES $ T3 FREE $ T3 TOTAL $ T3 UPTAKE $ T4 FREE $ T4 TOTAL (THYROXINE) $ TACROLIMUS (FK506) $ TESTOSTERONE $ THYROGLOBULIN ANTIBODY $ THYROID PEROXIDASE (TPO) $ THYROID STIMULATIN HORMONE - TSH $ TISSUE TRANSGLUTAMIN IGA $ TISSUE TRANSGLUTAMIN IGG $ TOTAL PROTEIN $ TRANSFERRIN $ TRICHOMONAS VAGINALIS SCREEN $ TRIGLYCERIDES $ TROPONIN T $ URIC ACID $ URINALYSIS (REFLEX/SCRN) $ URINALYSIS COMPLETE $ URINALYSIS DIP ONLY $ URINE CALCIUM $ URINE CREATININE $ URINE CULTURE* $ *pathogen ID, add $16.25; susceptibility, add $61.25 URINE MICROALBUMIN $ URINE PROTEIN $ URINE SODIUM $ VAGINITIS REPRODUCTIVE AGE 87081, $ VAGINITIS SCREEN PP 87070, $ VALPROIC ACID (DEPAKOTE) $ 59.25
5 VANCOMYCIN $ VARICELLA IgG $ VENIPUNCTURE $ 6.00 VITAMIN B $ VITAMIN D 25 HYDROXY $ VOLATILE PANEL $ WBC SMEAR $ WORM ID $ 35.75
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