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 2017. Price estimating tools are available from the Maine Health Data Organization www.comparemaine.org. This tool shows the average cost of common healthcare procedures at different facilities in Maine. Test Name CPT Price Note ABO TYPE 86900 $ 23.50 ACETAMINOPHEN 80329 $ 61.25 AEROBIC CULTURE and GRAM STAIN* 87070, 87205 $ 65.25 *pathogen ID, add $16.25; susceptibility, add $61.25 ALANINE AMINOTRANSFERASE 84460 $ 24.25 ALBUMIN 82040 $ 24.25 ALKALINE PHOSPHATASE 84075 $ 24.25 AMMONIA 82140 $ 63.25 AMYLASE 82150 $ 29.50 ANAEROBIC CULTURE and GRAM STAIN* 87075, 87205 $ 82.75 *pathogen ID, add $16.25; susceptibility, add $61.25 ANTIBODY SCREEN 86850 $ 51.00 ANTINUCLEAR ABY (ANA) 86038 $ 36.75 ANTITHROMBIN III 85300 $ 43.75 ASPARATE AMINOTRANSFERASE 84450 $ 24.25 BACTERIAL IDENTIFICATION 87077 $ 16.25 BASIC METABOLIC PANEL 80048 $ 26.00 BENZODIAZEPINES 80346 $ 72.50 BETA HCG QUAL (SERUM PREG) 84703 $ 33.75 BETA HCG QUANTITATIVE 84702 $ 64.25 BETA-2 GLYCOPROTEIN 1 AB IgG/IgM 86146X2 $ 75.50 BILIRUBIN DIRECT 82248 $ 24.25 BILIRUBIN TOTAL 82247 $ 24.25 BLOOD CULTURE* 87040 $ 91.75 *pathogen ID, add $16.25; susceptibility, add $61.25 BODY FLUID CELL COUNT 89050 $ 54.00 BODY FLUID CRYSTALS 89060 $ 23.50 BORDETELLA PERTUSSIS PCR 87798 $ 90.00 B-TYPE NATRIURETC PEPTIDE 83880 $ 130.50 BUN (UREA NITROGEN) 84520 $ 24.25 BUPRENORPHINE SEMIQUANT 80348 $ 41.75 C REACTIVE PROTEIN 86140 $ 25.50 C REACTIVE PROTEIN HIGH SENSITIVITY 86141 $ 40.75 CALCIUM 82310 $ 24.25 CANCER ANTIGEN 125 86304 $ 48.00 CANNABINOID SEMIQUANT 80349 $ 41.75 CARBAMAZEPINE 80156 $ 59.25 CARCINOEMBRYONIC AG (CEA) 82378 $ 61.25 CARDIOLIPIN AB IGG OR IGM 86147X2 $ 81.50 CBC WITH DIFF 85025 $ 23.00 CBC WITHOUT DIFFERENTIAL 85027 $ 22.00 CELIAC REFLEX PANEL 82784 $ 34.75 CHLAMYDIA DIRECT TEST 87491 $ 59.25 CHOLESTEROL 82465 $ 24.25 CLOSTRIDIUM DIFFICILE BY PCR 87493 $ 77.50
CLOZAPINE (CLOZARIL) 80159 $ 55.00 COMPLEMENT C3 86160 $ 39.75 COMPLEMENT C4 86160 $ 39.75 COMPREHENSIVE METABOLIC PANEL 80053 $ 28.75 CORTISOL 82533 $ 56.00 CREATINE KINASE (CPK) 82550 $ 27.50 CREATININE 82565 $ 24.25 CREATININE CLEARANCE 82575 $ 38.75 D DIMER QUANT 85379 $ 62.25 DHEA SULFATE 82627 $ 66.25 DIGOXIN 80162 $ 45.00 DILUTE RUSSELL VIPER VENOM 85613 $ 45.00 DOUBLE STRANDED DNA 86225 $ 40.75 DRUG SCREEN URINE COMPREHENSIVE G0431, 84600 $ 241.75 DRUG SUBSTANCE ABUSE SCREEN 1 G0431 $ 178.50 DRUG SUBSTANCE ABUSE SCREEN 5 G0431 $ 127.50 EBV ANTIBODY NUCLEAR AG IGG 86664 $ 42.75 EBV ANTIBODY VIRAL CAPSID 86665 $ 42.75 ELECTROLYTES PANEL 80051 $ 25.00 ELECTROPHORESIS PROTEIN 84165 $ 45.00 ELECTROPHORESIS URINE 84166 $ 71.50 ESTRADIOL 82670 $ 101.00 FACTOR 2 BY PCR 81240 $ 194.00 FACTOR 5 LEIDEN BY PCR 81241 $ 194.00 FERRITIN 82728 $ 71.50 FETAL FIBRONECTIN 82731 $ 294.75 FIBRINOGEN 85384 $ 32.75 FOLATE 82746 $ 46.00 FOLLICLE STIMULATING HORMONE -FSH 83001 $ 61.25 GC AMPLIFIED PROBE 87591 $ 59.25 GENITAL BETA STREP SCREEN 87081 $ 25.50 GLUCOSE 82947 $ 24.25 GLUCOSE POST GLUCOSE DRINK 82950 $ 28.50 GLUTAMYLTRANSFERASE GGT 82977 $ 24.25 GRAM STAIN 87205 $ 23.50 HAPTOGLOBIN 83010 $ 37.75 HELICOBACTER PYLORI ANTIBODY 86677 $ 52.00 HEMATOCRIT 85014 $ 8.50 HEMOGLOBIN 85018 $ 14.25 HEMOGLOBIN A1C 83036 $ 29.20 HEPATIC FUNCTION PANEL 80076 $ 25.75 HEPATITIS 1 (ACUTE) 80074 $ 105.00 HEPATITIS 2 (EXPOSED) 86706, 87340, 86704, 86803 $ 203.25 HEPATITIS A ANTIBODY TOTAL 86708 $ 37.75 HEPATITIS B CORE TOTAL 86704 $ 50.00 HEPATITIS B SURFACE ANTIBODY 86706 $ 45.00 HEPATITIS B SURFACE ANTIGEN 87340 $ 45.00
HEPATITIS C RNA QUANT 87522 $ 182.50 HEPATITIS C VIRUS AB 86803 $ 63.25 HERPES SIMPLEX 1 & 2 VIRUS BY PCR 87529X2 $ 181.50 HERPES SIMPLEX TYPE 1 86695 $ 30.29 HERPES SIMPLEX TYPE 2 86696 $ 30.29 HIV 86703 $ 34.75 HOMOCYSTEINE 83090 $ 62.25 IMMUNOFIXATION SERUM 86334 $ 83.75 IMMUNOGLOBULIN A (IGA) 82784 $ 39.75 IMMUNOGLOBULIN G (IGG) 82784 $ 39.75 IMMUNOGLOBULIN M (IGM) 82784 $ 39.75 INSULIN 83525 $ 34.75 IRON 83540 $ 29.50 IRON BINDING CAPACITY 83550 $ 26.50 LACTATE DEHYDROGENASE - LDH 83615 $ 24.25 LAMOTRIGINE (LAMICTAL) 80175 $ 42.75 LDL DIRECT 83721 $ 37.75 LIPASE 83690 $ 51.00 LITHIUM 80178 $ 37.75 LIPID PANEL (HDL2) 80061 $ 39.00 LUTEINIZING HORMONE - LH 83002 $ 61.25 LYME DISEASE 86618 $ 43.75 MAGNESIUM 83735 $ 25.50 METHYLPHENIDATE (RITALIN) URINE 80360 $ 80.00 MONONUCLEOSIS, INFECTIOUS 86308 $ 28.50 MUMPS IgG 86735 $ 39.75 OPIATES CONFIRMATION 83925 $ 85.75 OSMOLALITY URINE 83935 $ 47.00 OVA & PARASITE 87328, 87329 $ 69.50 OVA & PARASITE COMPREHENSIVE 87177, 88313 $ 82.50 PHENOBARBITAL 80184 $ 48.00 PHENYTOIN 80185 $ 48.00 PHOSPHORUS 84100 $ 24.25 PLATELET COUNT 85049 $ 21.50 POTASSIUM 84132 $ 24.25 PREALBUMIN 84134 $ 43.75 PREGNANCY TEST URINE 81025 $ 26.50 PRENATAL PROFILE 80055 $ 85.75 PROGESTERONE 84144 $ 72.50 PROLACTIN 84146 $ 67.25 PROTEIN C ACTIVITY 85303 $ 71.50 PROTEIN S ACTIVITY 85306 $ 43.75 PROTHROMBIN TIME (INR) 85610 $ 30.50 PSA 84153 $ 55.00 PSA FREE 84154 $ 41.75 PTH INTACT/N-TERMINAL 83970 $ 118.25 PTT 85730 $ 34.75
RAPID PLASMA REAGIN - RPR 86592 $ 25.50 RENAL FUNCTION PANEL 80069 $ 27.25 RESPIRATORY VIRUS PCR 87631 $ 219.00 RETICULOCYTE COUNT AUTO 85045 $ 30.50 RH TYPE 86901 $ 21.50 RHEUMATOID FACTOR 86431 $ 21.50 ROTAVIRUS 87425 $ 43.75 RUBELLA IGG 86762 $ 42.75 RUBEOLA IGG 86765 $ 38.75 SEDIMENTATION RATE AUTO 85652 $ 30.50 SEDIMENTATION RATE MANUAL 85651 $ 30.50 SICKLE CELL SCREEN 85660 $ 37.75 SODIUM 84295 $ 24.25 STOOL CULTURE 87427, 87046, 87045 $ 77.50 STOOL OCCULT BLOOD IOB 82274 $ 38.75 STREP SCREEN 87081 $ 42.75 SUSCEPTIBILITY STUDIES 87186 $ 61.25 T3 FREE 84481 $ 51.00 T3 TOTAL 84480 $ 63.25 T3 UPTAKE 84479 $ 30.50 T4 FREE 84439 $ 30.50 T4 TOTAL (THYROXINE) 84436 $ 30.50 TACROLIMUS (FK506) 80197 $ 80.50 TESTOSTERONE 84403 $ 82.50 THYROGLOBULIN ANTIBODY 86800 $ 41.75 THYROID PEROXIDASE (TPO) 86376 $ 43.75 THYROID STIMULATIN HORMONE - TSH 84443 $ 52.50 TISSUE TRANSGLUTAMIN IGA 83516 $ 34.00 TISSUE TRANSGLUTAMIN IGG 83516 $ 40.00 TOTAL PROTEIN 84155 $ 24.25 TRANSFERRIN 84466 $ 40.00 TRICHOMONAS VAGINALIS SCREEN 87661 $ 52.00 TRIGLYCERIDES 84478 $ 24.25 TROPONIN T 84484 $ 66.25 URIC ACID 84550 $ 24.25 URINALYSIS (REFLEX/SCRN) 81003 $ 20.50 URINALYSIS COMPLETE 81001 $ 29.50 URINALYSIS DIP ONLY 81003 $ 14.25 URINE CALCIUM 82340 $ 23.50 URINE CREATININE 82570 $ 23.50 URINE CULTURE* 87086 $ 46.00 *pathogen ID, add $16.25; susceptibility, add $61.25 URINE MICROALBUMIN 82043 $ 43.75 URINE PROTEIN 84156 $ 23.50 URINE SODIUM 84300 $ 23.50 VAGINITIS REPRODUCTIVE AGE 87081, 87205 $ 51.00 VAGINITIS SCREEN PP 87070, 87205 $ 51.00 VALPROIC ACID (DEPAKOTE) 80164 $ 59.25
VANCOMYCIN 80202 $ 82.50 VARICELLA IgG 86787 $ 38.75 VENIPUNCTURE 36415 $ 6.00 VITAMIN B12 82607 $ 46.00 VITAMIN D 25 HYDROXY 82306 $ 88.75 VOLATILE PANEL 84600 $ 37.75 WBC SMEAR 89055 $ 24.50 WORM ID 87169 $ 35.75