| Acute gastrointestinal blood loss imaging (78278) |
— |
$1,200 |
— |
| Angiography extremity bilateral rs&i (75716) |
— |
$5,627.15 |
— |
| Angiography extremity unilateral rs&i (75710) |
— |
$7,313.58 |
— |
| Angiography pulmonary bilateral slctv rs&i (75743) |
— |
$5,627.15 |
— |
| Ankle 2 views (73600) |
— |
$300 |
— |
| Antegrade urography radiological supvj & interpj (74425) |
— |
$1,000 |
— |
| Aortogram thoracic (75605) |
— |
$9,781.91 |
— |
| Aortography abdl bi iliofem low extrem cath rs&i (75630) |
— |
$5,627.15 |
— |
| Aortography abdominal serialography rs&i (75625) |
— |
$5,627.15 |
— |
| Arthrogram hip (73525) |
— |
$2,050 |
— |
| Arthrogram shoulder (73040) |
— |
$1,400 |
— |
| Arthrography knee lt (73580) |
— |
$1,400 |
— |
| Bone &/Joint Imaging Limited Area (78300) |
— |
$1,600 |
— |
| Bone &/joint imaging whole body (78306) |
— |
$2,500 |
— |
| Bone age studies (77072) |
— |
$500 |
— |
| Bone Imaging 3 Phase (78315) |
— |
$2,500 |
— |
| Bone survey complete (77075) |
— |
$1,050 |
— |
| Brain image w/flow 4 + views (78606) |
— |
$2,700 |
— |
| Brain Imaging Minimum 4 Static Views (78605) |
— |
$2,700 |
— |
| Cervical spine 2 or 3 views (72040) |
— |
$450 |
— |
| Chest 1 view (71045) |
— |
$250 |
— |
| Chest 3 views (71047) |
— |
$190 |
— |
| Cine/Vid X-Ray Throat/Esoph - Fl Esoph Barium Swlw W/ Video & Speech (74230) |
— |
$1,050 |
— |
| Clavicle complete (73000) |
— |
$300 |
— |
| Computed Tomography Thorax Lw Dose Lng Ca Scr C- (71271) |
— |
$2,350 |
— |
| 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 angiography upper extremity lt (73206) |
— |
$775 |
— |
| CT c-spine w/o contrast (72125) |
— |
$2,348.40 |
— |
| CT cervical spine w&w/o contrast (72127) |
— |
$2,800.80 |
— |
| CT cervical spine with contrast (72126) |
— |
$2,640 |
— |
| CT chest w/wo contrast (71270) |
— |
$3,201.60 |
— |
| CT chest with contrast (71260) |
— |
$2,800.80 |
— |
| 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 limited/localized follow up study (76380) |
— |
$742.20 |
— |
| CT lower ext w/o (73700) |
— |
$2,214 |
— |
| CT lower extremity w wo contrast (73702) |
— |
$2,925.60 |
— |
| CT lower extremity with contrast (73701) |
— |
$2,565.60 |
— |
| CT lumbar spine w & w/o contrast (72133) |
— |
$628.36 |
— |
| CT lumbar spine w/o contrast (72131) |
— |
$2,348.40 |
— |
| CT lumbar spine with contrast (72132) |
— |
$2,728.80 |
— |
| CT maxillofacial w contrast (70487) |
— |
$2,952 |
— |
| CT maxillofacial w/o contrast (70486) |
— |
$2,502 |
— |
| CT maxillofacial w/wo contrast (70488) |
— |
$3,247.20 |
— |
| CT neck soft tissue w contrast (70491) |
— |
$2,925.60 |
— |
| CT orbit sella/post fossa/ear w/o & w/contr matr (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 soft tissue neck w/o & w/contrast material (70492) |
— |
$3,061.20 |
— |
| 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 contrast (72130) |
— |
$2,925.60 |
— |
| CT thorax w/o contrast (71250) |
— |
$2,348.40 |
— |
| CT upper extremity w/o & w/contrast material (73202) |
— |
$2,754 |
— |
| CT upper extremity w/o contrast rt (73200) |
— |
$2,211.60 |
— |
| 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 abdomen pelvis (74174) |
— |
$1,723.20 |
— |
| CTA chest (71275) |
— |
$3,030 |
— |
| Cta Head (70496) |
— |
$2,067.60 |
— |
| Cta Neck (70498) |
— |
$1,290.60 |
— |
| Cta Pelvis (72191) |
— |
$1,500 |
— |
| Cystography minimum 3 views rs&i (74430) |
— |
$800 |
— |
| Dxa bone density study 1/> sites axial skel (77080) |
— |
$550 |
— |
| Esophagus (74220) |
— |
$800 |
— |
| Fluoroscopy up to 1 hr (76000) |
— |
$700 |
— |
| Foot 2 views (73620) |
— |
$300 |
— |
| Forearm 2 views (73090) |
— |
$300 |
— |
| Gated Heart Planar Single (78472) |
— |
$1,600 |
— |
| Hand 2 views (73120) |
— |
$300 |
— |
| Hand 3 views (73130) |
— |
$300 |
— |
| Hepatobil Syst Imag Inc Gb W/Pharma Intervenj (78227) |
— |
$2,000 |
— |
| Hepatobiliary syst imaging including gallbladder (78226) |
— |
$1,710 |
— |
| Humerus Min 2 Views Left (73060) |
— |
$400 |
— |
| Hysterosalpingogram (74740) |
— |
$750 |
— |
| Kidney img morphology vascular flow 1 w/rx (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 Ventilation Imaging (78579) |
— |
$1,600 |
— |
| Meckels Diverticulum (78290) |
— |
$1,200 |
— |
| MRA head w & w/o contrast (70546) |
— |
$5,769.60 |
— |
| MRA head w/o contrast (70544) |
— |
$3,441.60 |
— |
| MRA head with contrast (70545) |
— |
$3,998.40 |
— |
| MRA neck w contrast (70548) |
— |
$3,694.20 |
— |
| Mra Neck W/O &W/Contrast Material (70549) |
— |
$4,160.40 |
— |
| MRA neck w/o contrast (70547) |
— |
$3,455.40 |
— |
| MRI abdomen w contrast (74182) |
— |
$3,441.60 |
— |
| MRI abdomen w/o & w/contrast material (74183) |
— |
$5,242.80 |
— |
| MRI abdomen w/o contrast (74181) |
— |
$3,475.20 |
— |
| MRI any jnt lwr ext with con lt (73722) |
— |
$3,460.80 |
— |
| MRI any jt upper extremity w/contrast matrl (73222) |
— |
$2,610 |
— |
| MRI c-spine with contrast (72142) |
— |
$2,886 |
— |
| MRI cervical spine w/o contrast (72141) |
— |
$2,776.80 |
— |
| MRI chest w/o & w/contrast material (71552) |
— |
$5,300 |
— |
| MRI Forearm w/ Contrast Bilateral 73219 (73219) |
— |
$3,824.40 |
— |
| MRI lower extrem oth/thn jt w/o contr matrl (73718) |
— |
$3,824.40 |
— |
| MRI orbit face &/neck w/o contrast (70540) |
— |
$2,805.60 |
— |
| MRI orbit/face/neck w&w/o cont (70543) |
— |
$5,203.20 |
— |
| MRI pelvis w contrast (72196) |
— |
$3,182.40 |
— |
| MRI pelvis w/o & w/contrast material (72197) |
— |
$4,728 |
— |
| MRI pelvis w/o contrast (72195) |
— |
$2,348.40 |
— |
| MRI scan of arm joint before and after contrast (73223) |
— |
$3,500.40 |
— |
| MRI scan of leg joint before and after contrast (73723) |
— |
$3,564 |
— |
| MRI spinal canal cervical w/o & w/contr matrl (72156) |
— |
$4,444.80 |
— |
| MRI spinal canal lumbar w/contrast material (72149) |
— |
$2,992.20 |
— |
| MRI spinal canal lumbar w/o & w/contr matrl (72158) |
— |
$4,039.20 |
— |
| MRI spinal canal thoracic w/contrast matrl (72147) |
— |
$2,886 |
— |
| MRI spinal canal thoracic w/o & w/contr matrl (72157) |
— |
$4,570.80 |
— |
| MRI thoracic spine w/o contrast (72146) |
— |
$2,235.60 |
— |
| MRI upper ext joint w/o contrast (73221) |
— |
$2,526 |
— |
| MRI upper extrem other than jt w/o & w/contras (73220) |
— |
$3,993 |
— |
| MRI upper extremity oth than jt w/o contr matrl (73218) |
— |
$3,012.60 |
— |
| Myocardial Spect Multiple Studies (78452) |
— |
$3,600 |
— |
| Neck soft tissue (70360) |
— |
$250 |
— |
| Nm gastric emptying study (78264) |
— |
$1,200 |
— |
| Nm gastroesophageal reflux study (78262) |
— |
$1,200 |
— |
| Ob Us Follow-Up Per Fetus - Us Ob Follow Up Transabdominal Approach (76816) |
— |
$1,400 |
— |
| Osseous survey infant (77076) |
— |
$1,050 |
— |
| Parathyroid imaging (78070) |
— |
$1,200 |
— |
| Pelvis 1 or 2 views (72170) |
— |
$350 |
— |
| Pr MRI, lower extr, w/o contrast f/u by contrast (73720) |
— |
$3,838.20 |
— |
| Pulmonary Perfusion Imaging Particulate (78580) |
— |
$1,600 |
— |
| Pulmonary Ventilation & Perfusion Imaging (78582) |
— |
$1,500 |
— |
| Radex abscess/fistula/sinus tract rs&i (76080) |
— |
$700 |
— |
| Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw - Xr Scoliosis 1 Vw (72081) |
— |
$350 |
— |
| Radex hips bilateral with pelvis 2 views (73521) |
— |
$400 |
— |
| Radex mastoids compl minimum 3 views pr side (70130) |
— |
$750 |
— |
| Radiolog exam mandible compl minimum 4 views (70110) |
— |
$450 |
— |
| Radiologic Exam Abdomen 3+ Views - Xr Abdomen 3+ Views (74021) |
— |
$343.38 |
— |
| Radiologic Exam Chest 2 Views - Xr Chest 2 Views (71046) |
— |
$375 |
— |
| Radiologic exam upr gi trc double contrast study (74246) |
— |
$1,175 |
— |
| Radiologic Examination Femur Minimum 2 Views - Xr Femur 2+ Vw Lt (73552) |
— |
$350 |
— |
| Radiological examination surgical specimen (76098) |
— |
$1,500 |
— |
| Ribs bilateral 3 views (71110) |
— |
$580 |
— |
| Rp loclzj tum spect 1 area single day imaging (78803) |
— |
$3,600 |
— |
| Scapula complete (73010) |
— |
$375 |
— |
| Screening digital breast tomosynthesis (77063) |
— |
$300 |
— |
| Small bowel series (74250) |
— |
$750 |
— |
| Speech evaluation complex (70371) |
— |
$700 |
— |
| Spine thoracic 3 views (72072) |
— |
$425 |
— |
| Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas (78014) |
— |
$2,500 |
— |
| Ultrasound, abdomen limited (76705) |
— |
$700 |
— |
| Umbilical-artery Doppler (OB) (76820) |
— |
$350 |
— |
| Unlisted respiratory procedure, diagnostic nuclear medicine UNSCHEDULED (78599) |
— |
$1,100 |
— |
| Upper Extremity Infant (73092) |
— |
$350 |
— |
| Urography (pyelography), intravenous, with or without KUB, with or without tomography (74400) |
— |
$900 |
— |
| Us abdl aorta screen aaa (76706) |
— |
$500 |
— |
| Us breast unilateral complete (76641) |
— |
$700 |
— |
| Us breast unilateral limited (76642) |
— |
$400 |
— |
| Us chest (76604) |
— |
$700 |
— |
| Us compl joint r-t w/image documentation (76881) |
— |
$1,500 |
— |
| Us infant hips dynamic (76885) |
— |
$1,400 |
— |
| Us ob transvaginal (76817) |
— |
$1,400 |
— |
| Us pelvic non ob complete (76856) |
— |
$1,400 |
— |
| Us pelvic nonobstetric image dcmtn limited/f/u (76857) |
— |
$1,400 |
— |
| Us pregnancy ltd (76815) |
— |
$1,400 |
— |
| Us pregnant uterus 14 wk transabdl 1/1st gestat (76801) |
— |
$1,400 |
— |
| Us retroperitoneal complete (76770) |
— |
$500 |
— |
| Us retroperitoneal limited (76775) |
— |
$700 |
— |
| Us scrotum and contents (76870) |
— |
$1,400 |
— |
| Us soft tissue head/neck (76536) |
— |
$650 |
— |
| Us spinal canal and contents (76800) |
— |
$500 |
— |
| Us transrectal (76872) |
— |
$750 |
— |
| Us xtr non-vasc lmtd (76882) |
— |
$1,400 |
— |
| Venogram extremity bilateral (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 Abdomen,Comp Acute Series - Xr Abdomen 2 Vws With Chest 1 View (74022) |
— |
$450 |
— |
| X-Ray Ankle 3+ Vw - Xr Ankle 3+ Views Right (73610) |
— |
$300 |
— |
| X-Ray Colon Air Contrast - Fl Barium Enema Air Contrast (74280) |
— |
$1,100 |
— |
| X-Ray Elbow 2 Vw - Xr Elbow 1-2 Views Right (73070) |
— |
$300 |
— |
| X-Ray Elbow 3+ Vw - Xr Elbow 3+ Views Right (73080) |
— |
$300 |
— |
| X-ray exam hip uni 1 view (73501) |
— |
$300 |
— |
| X-Ray Exam Hip Uni 2-3 Views (73502) |
— |
$350 |
— |
| X-ray exam of femur 1 (73551) |
— |
$300 |
— |
| X-ray exam of small bowel - fl small bowel series enteroclysis tube (74251) |
— |
$750 |
— |
| X-ray eye for foreign body (70030) |
— |
$300 |
— |
| X-Ray Facial Bones 3+ Vw - Xr Facial Bones 3+ Views (70150) |
— |
$475 |
— |
| X-Ray Foot 3+ Vw - Xr Foot 3+ Views Right (73630) |
— |
$300 |
— |
| X-Ray Heel - Xr Calcaneus 2 Views Right (73650) |
— |
$400 |
— |
| X-Ray Knee 4+ View - Xr Knee 4+ Views Right (73564) |
— |
$550 |
— |
| X-Ray Knee Bilat Standing - Xr Knees Anteroposterior Standing Bilat (73565) |
— |
$300 |
— |
| X-Ray Leg, Infant - Xr Lower Extremity 2+ Views Infant Left (73592) |
— |
$300 |
— |
| X-Ray Lumbar Spine 2/3 Vw - Xr Lumbar Spine 2-3 Views (72100) |
— |
$350 |
— |
| X-Ray Nasal Bones - Xr Nasal Bones (70160) |
— |
$300 |
— |
| X-Ray Nose-Rectum Child F.B. - Xr Nose to Rectum Foreign Body Peds (76010) |
— |
$250 |
— |
| X-Ray Orbits - Xr Orbits Complete 4+ Views (70200) |
— |
$450 |
— |
| X-Ray Retrograde Pyelogram - Fl Pyelogram Retrograde (74420) |
— |
$1,400 |
— |
| X-Ray Ribs 2 Vw Unilat - Xr Ribs 2 Views Right (71100) |
— |
$450 |
— |
| X-Ray Ribs, Chest 3+ Vw - Xr Ribs 2 Vws Lt W/ Chest Anteroposterior (71101) |
— |
$565 |
— |
| 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 Shoulder 2+ Vw - Xr Shoulder 2+ Views Right (73030) |
— |
$400 |
— |
| X-Ray Sinuses 3+ Vw - Xr Paranasal Sinuses 3+ Views (70220) |
— |
$450 |
— |
| X-Ray Sinuses <3 Vw - Xr Paranasal Sinuses 1-2 Views (70210) |
— |
$225 |
— |
| X-Ray Skull 4+ Vw - Xr Skull Complete 4+ Views (70260) |
— |
$600 |
— |
| X-Ray Skull <4 Vw - Xr Skull 1-3 Views (70250) |
— |
$360 |
— |
| X-Ray Spine One View - Xr Spine (72020) |
— |
$250 |
— |
| X-Ray Sterno-Clavicluar Jt - Xr Sternoclavicular Joints 3+ Views (71130) |
— |
$250 |
— |
| X-Ray Sternum 2+ Vw - Xr Sternum 2+ Views (71120) |
— |
$475 |
— |
| X-Ray Thoracic Spine 2 Vw - Xr Thoracic Spine 2 Views (72070) |
— |
$400 |
— |
| X-Ray Toe(S) - Xr Toes 2+ Views Right (73660) |
— |
$350 |
— |
| X-Ray Wrist 3+ Vw - Xr Wrist 3+ Views Right (73110) |
— |
$300 |
— |
| Xr c-spine 6 or more views (72052) |
— |
$800 |
— |
| Xr chest 4+ views (71048) |
— |
$345 |
— |
| Xr finger(s) 2+ views (73140) |
— |
$300 |
— |
| Xr optic foramina (70190) |
— |
$300 |
— |
| Xr shoulder 1 view (73020) |
— |
$250 |
— |
| Xr tibia/fibula 2 views (73590) |
— |
$350 |
— |
| Xr tmj bilateral (70330) |
— |
$350 |
— |
| Xray knee 1 or 2 views rt (73560) |
— |
$300 |
— |