| Abdomen 2 views (74019) |
— |
$137 |
— |
| Acute gi blood loss imaging (78278) |
— |
$827 |
— |
| Ankle 2 views (73600) |
— |
$105 |
— |
| Aortography abdl bi iliofem low extrem cath rs&i (75630) |
— |
$2,100 |
— |
| Bone &/Joint Imaging Multiple Areas (78305) |
— |
$413 |
— |
| Bone age studies (77072) |
— |
$105 |
— |
| Bone Imaging 3 Phase (78315) |
— |
$975 |
— |
| Bone survey infant (77076) |
— |
$144 |
— |
| Bowel imaging (78290) |
— |
$827 |
— |
| Brain imaging < 4 static views (78600) |
— |
$295 |
— |
| Brain Imaging Min 4 Static Views W Vascular Flow (78606) |
— |
$721 |
— |
| Card Bpi Gtd =Brm Plnr 1 Std Rest/Strs (78472) |
— |
$573 |
— |
| Cardiac MRI w/w/o contrast & further seq (75561) |
— |
$4,725 |
— |
| Cervical spine 2 or 3 views (72040) |
— |
$123 |
— |
| Chest 1 view (71045) |
— |
$113 |
— |
| Chest xray 3 views (71047) |
— |
$184 |
— |
| Cholecystography, oral contrast Non-Facility (74290) |
— |
$163 |
— |
| Cine/Vid X-Ray Throat/Esoph - Fl Esoph Barium Swlw W/ Video & Speech (74230) |
— |
$253 |
— |
| Clavicle complete (73000) |
— |
$112 |
— |
| Computed Tomography Thorax Lw Dose Lng Ca Scr C- (71271) |
— |
$472.50 |
— |
| Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, pelvis, spine) Non-Facility (77078) |
— |
$2,100 |
— |
| Corpora cavernosography (74445) |
— |
$326 |
— |
| CT abdomen and pelvis without and with contrast (74178) |
— |
$2,205 |
— |
| CT abdomen and pelvis without contrast (74176) |
— |
$1,470 |
— |
| CT abdomen w contrast (74160) |
— |
$849.50 |
— |
| CT abdomen w wo contrast (74170) |
— |
$918 |
— |
| CT abdomen w/o contrast (74150) |
— |
$883 |
— |
| CT angio hrt w/3d image (75574) |
— |
$1,155 |
— |
| CT angio lwr extr w/o&w/dye (73706) |
— |
$1,449 |
— |
| CT angiography upper extremity lt (73206) |
— |
$1,449 |
— |
| CT c-spine w/contrast (72126) |
— |
$1,108 |
— |
| CT c-spine w/o contrast (72125) |
— |
$1,108 |
— |
| CT cervical spine w&w/o contrast (72127) |
— |
$1,077 |
— |
| CT chest w contrast (71260) |
— |
$978 |
— |
| CT chest w/wo contrast (71270) |
— |
$1,047 |
— |
| CT head/brain with contrast (70460) |
— |
$978 |
— |
| CT head/brain without and with contrast (70470) |
— |
$1,068 |
— |
| CT heart contrast eval cardiac structure&morph (75572) |
— |
$2,625 |
— |
| CT heart w/o contrast quant eval coronary calcium (75571) |
— |
$168 |
— |
| CT hrt w/3d image congen (75573) |
— |
$2,625 |
— |
| CT iac w contrast (70481) |
— |
$929.50 |
— |
| CT limited/localized follow up study (76380) |
— |
$883 |
— |
| CT lower ext w/o (73700) |
— |
$883 |
— |
| CT lower extremity w wo contrast (73702) |
— |
$1,062 |
— |
| CT lower extremity w/contrast material (73701) |
— |
$928 |
— |
| CT lumbar spine w & w/o contrast (72133) |
— |
$1,103 |
— |
| CT lumbar spine w/contrast (72132) |
— |
$1,108 |
— |
| CT lumbar spine w/o contrast (72131) |
— |
$860 |
— |
| CT maxillofacial w contrast (70487) |
— |
$909 |
— |
| CT maxillofacial w/wo contrast (70488) |
— |
$906 |
— |
| CT maxillofacial wo contrast (70486) |
— |
$871.50 |
— |
| CT orbit sella/post fossa/ear w/o & w/contr matr (70482) |
— |
$858 |
— |
| CT orbits w/o contrast (70480) |
— |
$872 |
— |
| CT pelvis w/o contrast (72192) |
— |
$883 |
— |
| CT pelvis w/wo contrast (72194) |
— |
$1,047 |
— |
| CT scan of arm combo (73202) |
— |
$837 |
— |
| CT soft tissue neck w contrast (70491) |
— |
$931 |
— |
| CT soft tissue neck w/o & w/contrast material (70492) |
— |
$922.50 |
— |
| CT soft tissue neck w/o contrast (70490) |
— |
$673 |
— |
| CT thoracic spine w/contrast (72129) |
— |
$898 |
— |
| CT thoracic spine w/o contrast (72128) |
— |
$1,260 |
— |
| CT thoracic spine w/wo contrast (72130) |
— |
$1,077 |
— |
| CT thorax w/o contrast (71250) |
— |
$883 |
— |
| CT upper ext wo (73200) |
— |
$883 |
— |
| CT upper extremity with contrast (73201) |
— |
$900 |
— |
| Cta Aa&Bi Iliofem Lxtr Rs&I C-/C+ Post-Pxessing (75635) |
— |
$1,554 |
— |
| Cta Abdomen (74175) |
— |
$1,441 |
— |
| CTA abdomen pelvis (74174) |
— |
$1,622 |
— |
| CTA chest (71275) |
— |
$1,391 |
— |
| Cta Head (70496) |
— |
$1,932 |
— |
| CTA head&neck c+ w/noncontrast img&post-pxessing (70471) |
— |
$1,068 |
— |
| Cta Neck (70498) |
— |
$1,928 |
— |
| Cystography minimum 3 views rs&i (74430) |
— |
$541 |
— |
| Diskography lumbar (72295) |
— |
$2,100 |
— |
| Dxa bone density study 1/> sites axial skel (77080) |
— |
$2,100 |
— |
| Dxa bone density study 1/>sites appendiclr skel (77081) |
— |
$2,100 |
— |
| Esophagus (74220) |
— |
$219 |
— |
| Facial bones min 3 views (70150) |
— |
$176 |
— |
| Fetal biophysical profile non-stress testing (76818) |
— |
$227 |
— |
| Fluoroscopy up to 1 hr (76000) |
— |
$349 |
— |
| Foot 2 views (73620) |
— |
$105 |
— |
| Forearm 2 views (73090) |
— |
$105 |
— |
| Hand 2 views (73120) |
— |
$105 |
— |
| Heart first pass single,planar (78481) |
— |
$650 |
— |
| Heart Infarct Image (78466) |
— |
$768 |
— |
| Hepatobil Syst Imag Inc Gb W/Pharma Intervenj (78227) |
— |
$2,495 |
— |
| Hepatobiliary syst imaging including gallbladder (78226) |
— |
$768 |
— |
| Hysterosalpingogram (74740) |
— |
$585 |
— |
| Kidney Img Morphology Vascular Flow 1 W/O Rx (78707) |
— |
$1,050 |
— |
| Liver imaging static only (78201) |
— |
$450 |
— |
| Liver imaging w/vascular flow (78202) |
— |
$354 |
— |
| Lung perf&ventilat diferentl (78598) |
— |
$1,365 |
— |
| Lung perfusion differential (78597) |
— |
$931.50 |
— |
| Lung ventilation imaging (78579) |
— |
$1,024 |
— |
| Lymphoscintigraphy (78195) |
— |
$577 |
— |
| Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Non-Facility (73222) |
— |
$3,150 |
— |
| Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by… (73220) |
— |
$3,150 |
— |
| Mammary ductogram or galactogram multiple (77054) |
— |
$315 |
— |
| Mammary ductogram or galactogram single (77053) |
— |
$263 |
— |
| MRA head w & w/o contrast (70546) |
— |
$3,150 |
— |
| MRA head w/o contrast (70544) |
— |
$3,150 |
— |
| MRA head with contrast (70545) |
— |
$3,150 |
— |
| MRA neck w contrast (70548) |
— |
$3,150 |
— |
| Mra Neck W/O &W/Contrast Material (70549) |
— |
$3,150 |
— |
| MRA neck w/o contrast (70547) |
— |
$3,150 |
— |
| MRI abdomen w contrast (74182) |
— |
$3,150 |
— |
| MRI abdomen w/o & w/contrast material (74183) |
— |
$3,150 |
— |
| MRI abdomen w/o contrast (74181) |
— |
$3,150 |
— |
| MRI any jt lower extrem w/contrast material (73722) |
— |
$3,150 |
— |
| MRI any jt lower extrem w/o & w/contrast matrl (73723) |
— |
$3,150 |
— |
| MRI c-spine with contrast (72142) |
— |
$3,150 |
— |
| MRI cardiac w/o contrast (75557) |
— |
$3,150 |
— |
| MRI cervical spine w/o contrast (72141) |
— |
$3,150 |
— |
| MRI chest w/o & w/contrast material (71552) |
— |
$3,150 |
— |
| MRI chest w/o contrast (71550) |
— |
$3,150 |
— |
| MRI chest with contrast (71551) |
— |
$3,150 |
— |
| MRI lower extrem oth/thn jt w/o & w/contr matr (73720) |
— |
$3,150 |
— |
| MRI lower extrem oth/thn jt w/o contr matrl (73718) |
— |
$3,150 |
— |
| MRI orbit face &/neck w/o contrast (70540) |
— |
$3,150 |
— |
| MRI orbit/face/neck w&w/o cont (70543) |
— |
$3,150 |
— |
| MRI pelvis w/contrast (72196) |
— |
$3,150 |
— |
| MRI pelvis w/o & w/contrast material (72197) |
— |
$3,150 |
— |
| MRI pelvis w/o contrast (72195) |
— |
$3,150 |
— |
| MRI spinal canal cervical w/o & w/contr matrl (72156) |
— |
$3,150 |
— |
| MRI spinal canal lumbar w/contrast material (72149) |
— |
$3,150 |
— |
| MRI spinal canal lumbar w/o & w/contr matrl (72158) |
— |
$3,150 |
— |
| MRI spinal canal thoracic w/contrast matrl (72147) |
— |
$3,150 |
— |
| MRI spinal canal thoracic w/o & w/contr matrl (72157) |
— |
$3,150 |
— |
| MRI temporomandibular joint (70336) |
— |
$3,150 |
— |
| MRI thoracic spine w/o contrast (72146) |
— |
$3,150 |
— |
| MRI up ext w/o contrast (73218) |
— |
$3,150 |
— |
| MRI upper ext joint w/o contrast (73221) |
— |
$3,150 |
— |
| MRI, joint upper extrem combo (73223) |
— |
$3,150 |
— |
| Musculoskeletal Nuclear Exam (78399) |
— |
$774.50 |
— |
| Myelography 2 or more regions (72270) |
— |
$182 |
— |
| Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motionºs» and/or… (78492) |
— |
$2,100 |
— |
| Myocardial Perfusion Planar 1 Study Rest/Stress (78453) |
— |
$768 |
— |
| Myocardial Spect Multiple Studies (78452) |
— |
$1,536 |
— |
| Neck soft tissue (70360) |
— |
$92 |
— |
| Nm bone marrow wb (78104) |
— |
$803.50 |
— |
| Nm gastric emptying study (78264) |
— |
$532 |
— |
| Noncardiac Vascular Flow Imaging (78445) |
— |
$726.50 |
— |
| Nuclear medicine study of endocrine organs (78099) |
— |
$1,575 |
— |
| Nuclear Rx Oral Admin (79005) |
— |
$1,063 |
— |
| Ophthalmic biometry by ultrasound echography, A-scan; Non-Facility (76516) |
— |
$413 |
— |
| Osseous survey limited (77074) |
— |
$325 |
— |
| Parathyroid Planar Imaging (78070) |
— |
$525 |
— |
| Pelvis 1 or 2 views (72170) |
— |
$124.50 |
— |
| Pulmonary Perfusion Imaging Particulate (78580) |
— |
$1,024 |
— |
| Pulmonary Ventilation & Perfusion Imaging (78582) |
— |
$997.50 |
— |
| Radex abscess/fistula/sinus tract rs&i (76080) |
— |
$312 |
— |
| Radex Ankle Compl Minimum 3 Views (73610) |
— |
$116 |
— |
| Radex Elbw Compl Minimum 3 Views (73080) |
— |
$116 |
— |
| Radex entir thrc lmbr crv sac spi w/skull 2/3 vw (72082) |
— |
$315 |
— |
| Radex fingr minimum 2 views (73140) |
— |
$105 |
— |
| Radex Foot Compl Minimum 3 Views (73630) |
— |
$116 |
— |
| Radex Hand Minimum 3 Views (73130) |
— |
$116 |
— |
| Radex Hip Unilateral With Pelvis 1 View (73501) |
— |
$208 |
— |
| Radex Hips Bilateral With Pelvis 2 Views (73521) |
— |
$173.50 |
— |
| Radex Humerus Minimum 2 Views (73060) |
— |
$116 |
— |
| Radex Kne 1/2 Views (73560) |
— |
$118 |
— |
| Radex Kne Compl 4/More Views (73564) |
— |
$127 |
— |
| Radex Mndbl Compl Minimum 4 Views (70110) |
— |
$176 |
— |
| Radex Nasal Bones Complete Minimum 3 Views (70160) |
— |
$112 |
— |
| Radex Pelvis Compl Minimum 3 Views (72190) |
— |
$210 |
— |
| Radex Sho Compl Minimum 2 Views (73030) |
— |
$126 |
— |
| Radex Temporomandble Jt Opn & Clsd Mouth Bilat (70330) |
— |
$673 |
— |
| Radex Toe Minimum 2 Views (73660) |
— |
$105 |
— |
| Radex Wrst Compl Minimum 3 Views (73110) |
— |
$116 |
— |
| Radiologic Exam Abdomen 1 View - Xr Abdomen 1 View (74018) |
— |
$171.50 |
— |
| Radiologic exam chest 2 views (71046) |
— |
$137 |
— |
| Radiologic exam colon single contrast study (74270) |
— |
$233 |
— |
| Radiologic exam upr gi trc double contrast study (74246) |
— |
$325 |
— |
| Radiologic examination tibia & fibula 2 views (73590) |
— |
$111 |
— |
| Radiologic examination, internal auditory meati, complete Non-Facility (70134) |
— |
$177 |
— |
| Radiologic examination, mastoids; complete, minimum of 3 views per side Non-Facility (70130) |
— |
$216 |
— |
| Radiologic examination, mastoids; less than 3 views per side Non-Facility (70120) |
— |
$198 |
— |
| Radiological examination surgical specimen (76098) |
— |
$467 |
— |
| Red cell volume determination (separate procedure); single sampling Non-Facility (78120) |
— |
$851 |
— |
| Ribs bilateral 3 views (71110) |
— |
$219 |
— |
| Rp Loclzj Tum Plnr 1 Area Single Day Imaging (78800) |
— |
$1,260 |
— |
| Rp loclzj tum plnr 2+area 1+d img/1 area img>2+d (78801) |
— |
$2,100 |
— |
| Rp loclzj tum spect 1 area single day imaging (78803) |
— |
$541 |
— |
| Rp loclzj tum spect CT 2area 1d img/1 ar img>2+d (78832) |
— |
$2,212 |
— |
| Sacroiliac Joints < 3 Views (72200) |
— |
$149 |
— |
| Scapula (73010) |
— |
$111.50 |
— |
| Screening Digital Breast Tomosynthesis Bi (77063) |
— |
$210 |
— |
| Sella turcica (70240) |
— |
$112 |
— |
| Shoulder 1 view (73020) |
— |
$105 |
— |
| Small bowel series (74250) |
— |
$233 |
— |
| Spine thoracic 3 views (72072) |
— |
$123 |
— |
| Spleen imaging only (78185) |
— |
$532 |
— |
| Testicular Imaging With Vascular Flow (78761) |
— |
$1,181 |
— |
| Thyroid uptake measurement (78012) |
— |
$551 |
— |
| Tmj unilateral (70328) |
— |
$83 |
— |
| Ultrasound breast complete (76641) |
— |
$339 |
— |
| Ultrasound, abdomen limited (76705) |
— |
$343 |
— |
| Unlisted genitourinary px dx nuclear medicine (78799) |
— |
$827 |
— |
| Urethrocystogram voiding (74455) |
— |
$325 |
— |
| Urethrocystography retrograde rs&i (74450) |
— |
$325 |
— |
| Urography, infusion, drip technique and/or bolus technique; Non-Facility (74410) |
— |
$273 |
— |
| Urography, infusion, drip technique and/or bolus technique; with nephrotomography Non-Facility (74415) |
— |
$325 |
— |
| Us breast unilateral limited (76642) |
— |
$210 |
— |
| Us chest (76604) |
— |
$223.50 |
— |
| Us compl joint r-t w/image documentation (76881) |
— |
$282 |
— |
| Us lmtd joint/oth nonvasc xtr strux r-t w/img (76882) |
— |
$241.50 |
— |
| Us ob limited (76815) |
— |
$298 |
— |
| Us ob transvaginal (76817) |
— |
$525 |
— |
| Us pelvic non ob complete (76856) |
— |
$525 |
— |
| Us pelvic nonobstetric image dcmtn limited/f/u (76857) |
— |
$272.50 |
— |
| Us retroperitoneal complete (76770) |
— |
$1,234 |
— |
| Us retroperitoneal limited (76775) |
— |
$273 |
— |
| Us scrotum and contents (76870) |
— |
$272.50 |
— |
| Us soft tissue head/neck (76536) |
— |
$339 |
— |
| Us spinal canal and contents (76800) |
— |
$256 |
— |
| Us transrectal (76872) |
— |
$385 |
— |
| Wrist 2 views (73100) |
— |
$105 |
— |
| X-Ray Abdomen,Comp Acute Series - Xr Abdomen 2 Vws With Chest 1 View (74022) |
— |
$176 |
— |
| X-Ray Ac Jts - Xr Acromioclavicular Joints Bilateral (73050) |
— |
$128 |
— |
| X-Ray Colon Air Contrast - Fl Barium Enema Air Contrast (74280) |
— |
$325 |
— |
| X-Ray Elbow 2 Vw - Xr Elbow 1-2 Views Right (73070) |
— |
$105 |
— |
| X-Ray Exam Hip Uni 2-3 Views (73502) |
— |
$116 |
— |
| X-ray exam of femur 2/> (73552) |
— |
$111 |
— |
| X-ray eye for foreign body (70030) |
— |
$219 |
— |
| X-ray IV pyelogram (ivp) (74400) |
— |
$246 |
— |
| X-Ray Lumbar Spine 2/3 Vw - Xr Lumbar Spine 2-3 Views (72100) |
— |
$116.50 |
— |
| X-ray optic foramen (70190) |
— |
$112 |
— |
| X-Ray Orbits - Xr Orbits Complete 4+ Views (70200) |
— |
$149 |
— |
| X-ray retrograde pyelogram (74420) |
— |
$233.50 |
— |
| X-Ray Ribs 2 Vw Unilat - Xr Ribs 2 Views Right (71100) |
— |
$111 |
— |
| X-Ray Sacrum/Coccyx 2+ Vw - Xr Sacrum Coccyx 2+ Views (72220) |
— |
$1,631 |
— |
| X-Ray Sinuses 3+ Vw - Xr Paranasal Sinuses 3+ Views (70220) |
— |
$176 |
— |
| X-Ray Skull 4+ Vw - Xr Skull Complete 4+ Views (70260) |
— |
$142 |
— |
| X-Ray Skull <4 Vw - Xr Skull 1-3 Views (70250) |
— |
$299 |
— |
| X-Ray Spine One View - Xr Spine (72020) |
— |
$109 |
— |
| X-Ray Sterno-Clavicluar Jt - Xr Sternoclavicular Joints 3+ Views (71130) |
— |
$135 |
— |
| X-Ray Sternum 2+ Vw - Xr Sternum 2+ Views (71120) |
— |
$112 |
— |
| X-Ray Thoracic Spine 2 Vw - Xr Thoracic Spine 2 Views (72070) |
— |
$110 |
— |
| Xr c-spine 4 or 5 views (72050) |
— |
$135 |
— |
| Xr c-spine 6 or more views (72052) |
— |
$213 |
— |
| Xr chest 4+ views (71048) |
— |
$210 |
— |
| Xr urogram antegrade (74425) |
— |
$315 |
— |