| Acute Gastrointestinal Blood Loss Imaging (78278) |
— |
$1,200 |
— |
| Angio pulmonary bilat (75743) |
— |
$5,627.15 |
— |
| Angiography extremity bilateral rs&i (75716) |
— |
$5,627.15 |
— |
Angiography extremity unilateral rs&i (75710)
range across 4 matching MRF lines |
— |
$5,627.15–$9,000 |
— |
| Ankle 2 views (73600) |
— |
$300 |
— |
| Aortography thoracic serialography rs&i (75605) |
— |
$9,781.91 |
— |
| Arthrogram hip (73525) |
— |
$2,050 |
— |
| Bone age studies (77072) |
— |
$500 |
— |
| Bone Imaging 3 Phase (78315) |
— |
$2,500 |
— |
| Bone Imaging Limited Area (78300) |
— |
$1,600 |
— |
| Bone Imaging Whole Body (78306) |
— |
$2,500 |
— |
| Bone survey infant (77076) |
— |
$1,050 |
— |
| Brain Imaging Min 4 Static Views W Vascular Flow (78606) |
— |
$2,700 |
— |
| Brain Imaging Minimum 4 Static Views (78605) |
— |
$2,700 |
— |
Cat Scan Follow-Up Study (76380)
range across 4 matching MRF lines |
— |
$517.20–$967.20 |
— |
| Chest 1 view (71045) |
— |
$250 |
— |
| Chest 2 views (71046) |
— |
$375 |
— |
| Chest 3 views (71047) |
— |
$190 |
— |
| Chest 4 or more views (71048) |
— |
$345 |
— |
| Clavicle complete (73000) |
— |
$300 |
— |
| Computed Tomography Thorax Lw Dose Lng Ca Scr C- (71271) |
— |
$2,350 |
— |
| Contrast Exam Abdominl Aorta (75625) |
— |
$5,627.15 |
— |
| Contrast X-Ray Bladder (74430) |
— |
$800 |
— |
| Contrast X-Ray Of Knee Joint (73580) |
— |
$1,400 |
— |
| CT abdomen and pelvis without and with contrast (74178) |
— |
$5,047.20 |
— |
| CT abdomen and pelvis without contrast (74176) |
— |
$4,327.20 |
— |
| CT abdomen w contrast (74160) |
— |
$2,800.80 |
— |
| CT abdomen w wo contrast (74170) |
— |
$3,064.80 |
— |
| CT abdomen w/o contrast (74150) |
— |
$2,348.40 |
— |
| CT Angio Abdomen and Pelvis (74174) |
— |
$1,723.20 |
— |
| CT Angio Chest (71275) |
— |
$3,030 |
— |
| CT Angio Head (70496) |
— |
$2,067.60 |
— |
CT Angio Neck (70498)
range across 4 matching MRF lines |
— |
$531.60–$2,049.60 |
— |
Ct Angio Upr Extrm W/O&W/Dye (73206)
range across 4 matching MRF lines |
— |
$750–$800 |
— |
| CT cervical spine w/ contrast (72126) |
— |
$2,640 |
— |
| CT cervical spine w/o contrast (72125) |
— |
$2,348.40 |
— |
| CT cervical spine w/wo cont (72127) |
— |
$2,800.80 |
— |
| CT chest w contrast (71260) |
— |
$2,800.80 |
— |
| CT chest w/wo contrast (71270) |
— |
$3,201.60 |
— |
| CT head/brain with contrast (70460) |
— |
$2,840.40 |
— |
| CT head/brain without and with contrast (70470) |
— |
$2,937.60 |
— |
| CT heart no contrast quant eval coronry calcium (75571) |
— |
$150 |
— |
| CT iac w contrast (70481) |
— |
$2,793.60 |
— |
| CT l-spine w&w/o contrast (72133) |
— |
$628.36 |
— |
| CT lower ext w/o (73700) |
— |
$2,214 |
— |
| CT lower extremity w/contrast material (73701) |
— |
$2,565.60 |
— |
| CT lumbar spine w contrast (72132) |
— |
$2,728.80 |
— |
| CT lumbar spine w/o contrast (72131) |
— |
$2,348.40 |
— |
| CT maxillofacial w contrast (70487) |
— |
$2,952 |
— |
| CT maxillofacial wo contrast (70486) |
— |
$2,502 |
— |
| CT neck tissue combo (70492) |
— |
$3,061.20 |
— |
| Ct Orbit/Ear/Fossa W/O&W/Dye (70482) |
— |
$2,942.40 |
— |
| CT orbits w/o contrast (70480) |
— |
$2,523.60 |
— |
| CT pelvis w&w/o contrast (72194) |
— |
$3,061.20 |
— |
| CT pelvis w/o contrast (72192) |
— |
$2,348.40 |
— |
| CT scan of leg combo (73702) |
— |
$2,925.60 |
— |
| CT scans face/jaw combo (70488) |
— |
$3,247.20 |
— |
| CT soft tissue neck w contrast (70491) |
— |
$2,925.60 |
— |
| CT soft tissue neck w/o contrast (70490) |
— |
$2,056.80 |
— |
| CT thoracic spine w contrast (72129) |
— |
$2,726.40 |
— |
| CT thoracic spine w/o contrast (72128) |
— |
$2,348.40 |
— |
| CT thoracic spine w/wo cont (72130) |
— |
$2,925.60 |
— |
| CT thorax w/o contrast (71250) |
— |
$2,348.40 |
— |
| CT upper ext wo (73200) |
— |
$2,211.60 |
— |
| CT upper extremity w/o & w/contrast material (73202) |
— |
$2,754 |
— |
| CT upper extremity with contrast (73201) |
— |
$2,437.20 |
— |
| Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp (75635) |
— |
$4,041.60 |
— |
| Cta Abdomen (74175) |
— |
$4,062 |
— |
| CTA pelvis (72191) |
— |
$1,500 |
— |
| Dxa Bone Density Axial (77080) |
— |
$550 |
— |
| Esophagram (74220) |
— |
$800 |
— |
| Fluoroscopy up to 1 hr (76000) |
— |
$700 |
— |
| Foot 2 views (73620) |
— |
$300 |
— |
| Forearm 2 views (73090) |
— |
$300 |
— |
| Gastric emptying imaging study (78264) |
— |
$1,200 |
— |
| Gastroesophageal Reflux Exam (78262) |
— |
$1,200 |
— |
| Gated Heart Planar Single (78472) |
— |
$1,600 |
— |
| Hand 2 views (73120) |
— |
$300 |
— |
| Hepatobil Syst Image W/Drug (78227) |
— |
$2,000 |
— |
| Hepatobiliary System Imaging (78226) |
— |
$1,710 |
— |
| Hysterosalpingogram (74740) |
— |
$750 |
— |
| Infant hip ultrasound with hip movement (dynamic) (76885) |
— |
$1,400 |
— |
| K Flow/Funct Image W/Drug (78708) |
— |
$2,700 |
— |
| Knee 3 Views (73562) |
— |
$500 |
— |
| Liver & Spleen Imaging Static Only (78215) |
— |
$1,700 |
— |
| Liver imaging static only (78201) |
— |
$3,600 |
— |
| Liver imaging w/vascular flow (78202) |
— |
$3,600 |
— |
| Lung Ventilat&Perfus Imaging (78582) |
— |
$1,500 |
— |
| Lung Ventilation Imaging (78579) |
— |
$1,600 |
— |
| Meckels Divert Exam (78290) |
— |
$1,200 |
— |
| Mra Head W/O & W/Contrast Material (70546) |
— |
$5,769.60 |
— |
MRA head w/o contrast (70544)
range across 6 matching MRF lines |
— |
$3,434.40–$3,998.40 |
— |
| MRA head with contrast (70545) |
— |
$3,998.40 |
— |
MRA neck w contrast (70548)
range across 4 matching MRF lines |
— |
$3,651.60–$3,736.80 |
— |
| Mra Neck W/O &W/Contrast Material (70549) |
— |
$4,160.40 |
— |
MRA neck w/o contrast (70547)
range across 4 matching MRF lines |
— |
$3,434.40–$3,476.40 |
— |
| MRI abdomen w contrast (74182) |
— |
$3,441.60 |
— |
MRI abdomen w/o contrast (74181)
range across 4 matching MRF lines |
— |
$3,236.40–$3,714 |
— |
MRI any jt lower extrem w/contrast material (73722)
range across 10 matching MRF lines |
— |
$3,043.20–$3,566.40 |
— |
| MRI any jt lower extrem w/o & w/contrast matrl (73723) |
— |
$3,564 |
— |
MRI any jt upper extremity w/contrast matrl (73222)
range across 6 matching MRF lines |
— |
$2,500–$2,941.20 |
— |
| MRI cervical spine w contrast (72142) |
— |
$2,886 |
— |
| MRI cervical spine w/o cont (72141) |
— |
$2,776.80 |
— |
| MRI chest wo w contrast (71552) |
— |
$5,300 |
— |
MRI lower extrem oth/thn jt w/o & w/contr matr (73720)
range across 4 matching MRF lines |
— |
$3,824.40–$3,852 |
— |
| MRI lower extrem oth/thn jt w/o contr matrl (73718) |
— |
$3,824.40 |
— |
MRI lumbar spine w contrast (72149)
range across 4 matching MRF lines |
— |
$2,886–$3,098.40 |
— |
| Mri Neck Spine W/O & W/Dye (72156) |
— |
$4,444.80 |
— |
| MRI orbit face &/neck w/o contrast (70540) |
— |
$2,805.60 |
— |
| Mri Orbt/Fac/Nck W/O &W/Dye (70543) |
— |
$5,203.20 |
— |
| MRI pelvis w contrast (72196) |
— |
$3,182.40 |
— |
| MRI pelvis w/o & w contrast (72197) |
— |
$4,728 |
— |
| MRI pelvis w/o contrast (72195) |
— |
$2,348.40 |
— |
MRI thoracic spine w/o contrast (72146)
range across 4 matching MRF lines |
— |
$1,567.20–$2,904 |
— |
| MRI upper extremity oth than jt w/contr matrl (73219) |
— |
$3,824.40 |
— |
MRI upper extremity oth than jt w/o contr matrl (73218)
range across 4 matching MRF lines |
— |
$2,590.80–$3,434.40 |
— |
Mri Uppr Extremity W/O&W/Dye (73220)
range across 4 matching MRF lines |
— |
$3,434.40–$4,551.60 |
— |
| MRI, abdomen, combo (74183) |
— |
$5,242.80 |
— |
| MRI, dorsal spine combo (72157) |
— |
$4,570.80 |
— |
| MRI, dorsal spine contrast (72147) |
— |
$2,886 |
— |
| MRI, joint upper extrem (73221) |
— |
$2,526 |
— |
| MRI, joint upper extrem combo (73223) |
— |
$3,500.40 |
— |
MRI, lumbar spine combo (72158)
range across 5 matching MRF lines |
— |
$4,039.20–$4,444.80 |
— |
| Myocardial Spect Multiple Studies (78452) |
— |
$3,600 |
— |
| Neck soft tissue (70360) |
— |
$250 |
— |
| Optic foramina (70190) |
— |
$300 |
— |
| Parathyroid Planar Imaging (78070) |
— |
$1,200 |
— |
| Pelvis 1 or 2 views (72170) |
— |
$350 |
— |
| Pulmonary Perfusion Imaging Particulate (78580) |
— |
$1,600 |
— |
| Radex Abd Compl Aqt Abd W/S/E/D Views 1 View Ch (74022) |
— |
$450 |
— |
| Radex abscess/fistula/sinus tract rs&i (76080) |
— |
$700 |
— |
| Radex Ankle Complete Minimum 3 Views (73610) |
— |
$300 |
— |
| Radex Calcaneus Minimum 2 Views (73650) |
— |
$400 |
— |
| Radex elbow complete minimum 3 views (73080) |
— |
$300 |
— |
Radex Facial Bones Complete Minimum 3 Views (70150)
range across 4 matching MRF lines |
— |
$450–$500 |
— |
| Radex fingr minimum 2 views (73140) |
— |
$300 |
— |
| Radex foot complete minimum 3 views (73630) |
— |
$300 |
— |
| Radex Hand Minimum 3 Views (73130) |
— |
$300 |
— |
| Radex lower extremity infant minimum 2 views (73592) |
— |
$300 |
— |
| Radex Mastoids Compl Minimum 3 Views PR Side (70130) |
— |
$750 |
— |
| Radex Nasal Bones Complete Minimum 3 Views (70160) |
— |
$300 |
— |
| Radex Ribs Unilateral 2 Views (71100) |
— |
$450 |
— |
| Radex shoulder complete minimum 2 views (73030) |
— |
$400 |
— |
| Radex Sinuses Paransl < 3 Views (70210) |
— |
$225 |
— |
| Radex sm int w/mlt srl imges via enteroclss tube (74251) |
— |
$750 |
— |
Radex Spine 1 View Specify Level (72020)
range across 4 matching MRF lines |
— |
$225–$275 |
— |
| Radex Sternum Minimum 2 Views (71120) |
— |
$475 |
— |
| Radex Temporomandble Jt Opn & Clsd Mouth Bilat (70330) |
— |
$350 |
— |
| Radex Toe Minimum 2 Views (73660) |
— |
$350 |
— |
| Radex upper extremity infant minimum 2 views (73092) |
— |
$350 |
— |
| Radex Wrist Complete Minimum 3 Views (73110) |
— |
$300 |
— |
| Radiolog exam mandible compl minimum 4 views (70110) |
— |
$450 |
— |
| Radiologic Exam Abdomen 3+ Views - Xr Abdomen 3+ Views (74021) |
— |
$343.38 |
— |
| Radiologic exam colon double contrast study (74280) |
— |
$1,100 |
— |
| Radiologic exam knee complete 4/more views (73564) |
— |
$550 |
— |
| Radiologic Exam Small Int Single Contrast Study (74250) |
— |
$750 |
— |
| Radiologic exam swallow function contrast study (74230) |
— |
$1,050 |
— |
Radiologic exam upr gi trc double contrast study (74246)
range across 4 matching MRF lines |
— |
$850–$1,500 |
— |
| Radiologic examination femur 1 view (73551) |
— |
$300 |
— |
| Radiologic examination femur minimum 2 views (73552) |
— |
$350 |
— |
| Radiologic examination knee 1/2 views (73560) |
— |
$300 |
— |
| Radiologic examination tibia & fibula 2 views (73590) |
— |
$350 |
— |
| Ribs bilateral 3 views (71110) |
— |
$580 |
— |
Rp Loclzj Tum Spect 1 Area Single Day Imaging (78803)
range across 6 matching MRF lines |
— |
$2,500–$4,700 |
— |
| Scapula (73010) |
— |
$375 |
— |
| Screening Digital Breast Tomosynthesis Bi (77063) |
— |
$300 |
— |
| Shoulder 1 view (73020) |
— |
$250 |
— |
| Shoulder Arthrography (73040) |
— |
$1,400 |
— |
| Skull less than 4 views (70250) |
— |
$360 |
— |
| Speech evaluation, complex (70371) |
— |
$700 |
— |
| Sternoclavicular joints (71130) |
— |
$250 |
— |
| Thoracic spine 2 views (72070) |
— |
$400 |
— |
| Thoracic spine 3 views (72072) |
— |
$425 |
— |
| Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas (78014) |
— |
$2,500 |
— |
Ultrasound Breast Limited (76642)
range across 5 matching MRF lines |
— |
$400–$700 |
— |
| Ultrasound Exam Aaa Screen (76706) |
— |
$500 |
— |
| Ultrasound, abdomen limited (76705) |
— |
$700 |
— |
| Umbilical-artery Doppler (OB) (76820) |
— |
$350 |
— |
| Unlisted respiratory px dx nuclear medicine (78599) |
— |
$1,100 |
— |
| Us breast unilateral complete (76641) |
— |
$700 |
— |
| Us chest (76604) |
— |
$700 |
— |
Us complete joint (76881)
range across 6 matching MRF lines |
— |
$1,400–$1,600 |
— |
| Us exam, pelvic, limited (76857) |
— |
$1,400 |
— |
| Us lmtd joint/oth nonvasc xtr strux r-t w/img (76882) |
— |
$1,400 |
— |
| Us ob limited 1 or more fetuses (76815) |
— |
$1,400 |
— |
| Us ob transvaginal (76817) |
— |
$1,400 |
— |
| Us pelvic non ob complete (76856) |
— |
$1,400 |
— |
| Us pg uter img f&mat 14 wk tabdl 1/1st gestation (76801) |
— |
$1,400 |
— |
Us preg uterus real time f/u trnsabdl per fetus (76816)
range across 6 matching MRF lines |
— |
$700–$1,500 |
— |
| Us retroperitoneal complete (76770) |
— |
$500 |
— |
| Us retroperitoneal limited (76775) |
— |
$700 |
— |
| Us scrotum and contents (76870) |
— |
$1,400 |
— |
| Us spinal canal and contents (76800) |
— |
$500 |
— |
| Us thyroid (76536) |
— |
$650 |
— |
| Us transrectal (76872) |
— |
$750 |
— |
| Venography extremity bilateral rs&i (75822) |
— |
$3,000 |
— |
| Venography extremity unilateral rs&i (75820) |
— |
$6,298 |
— |
| Vertebral fracture assessment via dxa (77086) |
— |
$700 |
— |
| Wrist 2 views (73100) |
— |
$300 |
— |
| X-ray antegrade pyelogram tube (74425) |
— |
$1,000 |
— |
| X-Ray Aorta Leg Arteries (75630) |
— |
$5,627.15 |
— |
| X-Ray Elbow 2 Vw - Xr Elbow 1-2 Views Right (73070) |
— |
$300 |
— |
| X-Ray Exam Breast Specimen (76098) |
— |
$1,500 |
— |
| X-Ray Exam Entire Spi 1 Vw (72081) |
— |
$350 |
— |
| X-Ray Exam Hip Uni 1 View (73501) |
— |
$300 |
— |
X-Ray Exam Hip Uni 2-3 Views (73502)
range across 8 matching MRF lines |
— |
$300–$1,200 |
— |
| X-Ray Exam Hips Bi 2 Views (73521) |
— |
$400 |
— |
| X-Ray Exam Neck Spine 2-3 Vw (72040) |
— |
$450 |
— |
| X-Ray Exam Neck Spine 6/>Vws (72052) |
— |
$800 |
— |
| X-Ray Exam Unilat Ribs/Chest (71101) |
— |
$565 |
— |
| X-ray eye for foreign body (70030) |
— |
$300 |
— |
| X-ray humerus (73060) |
— |
$400 |
— |
| X-ray IV pyelogram (ivp) (74400) |
— |
$900 |
— |
| X-Ray Knee Bilat Standing - Xr Knees Anteroposterior Standing Bilat (73565) |
— |
$300 |
— |
| X-Ray Lumbar Spine 2/3 Vw - Xr Lumbar Spine 2-3 Views (72100) |
— |
$350 |
— |
| X-ray nose-rectum child f.b. (76010) |
— |
$250 |
— |
| X-Ray Ribs, Chest 4+ Vw - Xr Ribs 3 Vws Bil W/ Chest Posteroanterior (71111) |
— |
$875 |
— |
| X-Ray Sacroiliac Jts 3+ Vw - Xr Sacroiliac Joints 3+ Views (72202) |
— |
$350 |
— |
| X-Ray Sacrum/Coccyx 2+ Vw - Xr Sacrum Coccyx 2+ Views (72220) |
— |
$500 |
— |
| X-Ray Sinuses 3+ Vw - Xr Paranasal Sinuses 3+ Views (70220) |
— |
$450 |
— |
| X-Ray Skull 4+ Vw - Xr Skull Complete 4+ Views (70260) |
— |
$600 |
— |
| X-Ray Urinary Tract Exam With Contrast Material (74420) |
— |
$1,400 |
— |
| X-Rays Bone Survey Complete (77075) |
— |
$1,050 |
— |
| Xr orbits complete 4 views (70200) |
— |
$450 |
— |