| CT scan of abdomen and pelvis, with contrast dye
CPT 74177
CT ABD & PELV W/CONTRAST |
$1,620.00 |
$2,700.00 |
40% |
| CT scan of abdomen and pelvis, with contrast dye inpatient
CPT 74177
CT ABD & PELV W/CONTRAST |
$1,620.00 |
$2,700.00 |
40% |
| CT scan of the head or brain, no contrast dye
CPT 70450
CT HEAD W/O C.M. |
$447.60 |
$746.00 |
40% |
| CT scan of the head or brain, no contrast dye
CPT 70450
GAMMA KNIFE CT HEAD W/O C.M. |
$447.60 |
$746.00 |
40% |
| CT scan of the head or brain, no contrast dye inpatient
CPT 70450
CT HEAD W/O C.M. |
$447.60 |
$746.00 |
40% |
| CT scan of the head or brain, no contrast dye inpatient
CPT 70450
GAMMA KNIFE CT HEAD W/O C.M. |
$447.60 |
$746.00 |
40% |
| CT scan of the pelvis, with contrast dye
CPT 72193
CT PELVIS WITH C.M. |
$837.60 |
$1,396.00 |
40% |
| CT scan of the pelvis, with contrast dye inpatient
CPT 72193
CT PELVIS WITH C.M. |
$837.60 |
$1,396.00 |
40% |
| Diagnostic mammogram, both breasts both sides
CPT 77066
MAMMOGRAPHY BILAT DX |
$516.00 |
$860.00 |
40% |
| Diagnostic mammogram, both breasts both sides
CPT 77066
POST PROCEDURE MAMMO BILAT DX |
$516.00 |
$860.00 |
40% |
| Diagnostic mammogram, both breasts both sides
CPT 77066
MAMMO - BILAT-SCR TO DIAG BIL |
$516.00 |
$860.00 |
40% |
| Diagnostic mammogram, both breasts inpatient both sides
CPT 77066
MAMMO - BILAT-SCR TO DIAG BIL |
$516.00 |
$860.00 |
40% |
| Diagnostic mammogram, both breasts inpatient both sides
CPT 77066
POST PROCEDURE MAMMO BILAT DX |
$516.00 |
$860.00 |
40% |
| Diagnostic mammogram, both breasts inpatient both sides
CPT 77066
MAMMOGRAPHY BILAT DX |
$516.00 |
$860.00 |
40% |
| Diagnostic mammogram, one breast
CPT 77065
MAMMO-UNI-SCR TO DIAG BIL |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast
CPT 77065
MAMMOGRAPHY BIL |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast one side
CPT 77065
PNEUMOMAMMOGRAM S & I - RIGHT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast one side
CPT 77065
MAMMOGRAPHY UNI - RT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast one side
CPT 77065
MAMMOGRAPHY UNIL - LT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast one side
CPT 77065
MAMMO - UNI - SCR TO DIAG LEFT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast one side
CPT 77065
MAMMO-UNI-SCR TO DIAG RIGHT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast one side
CPT 77065
POST PROCEDURE MAMMO UNIL - RT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast one side
CPT 77065
POST PROCEDURE MAMMO UNIL - LT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient
CPT 77065
MAMMOGRAPHY BIL |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient
CPT 77065
MAMMO-UNI-SCR TO DIAG BIL |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
POST PROCEDURE MAMMO UNIL - LT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
POST PROCEDURE MAMMO UNIL - RT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
MAMMO-UNI-SCR TO DIAG RIGHT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
MAMMO - UNI - SCR TO DIAG LEFT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
MAMMOGRAPHY UNIL - LT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
MAMMOGRAPHY UNI - RT |
$405.60 |
$676.00 |
40% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
PNEUMOMAMMOGRAM S & I - RIGHT |
$405.60 |
$676.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ARTHROGRAM KNEE - LEFT |
$982.80 |
$1,638.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ARTHROGRAM KNEE - RIGHT |
$982.80 |
$1,638.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI HIP RT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI LOW EXT JOINT W/O C RT |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI LOWER EXTREM JNT W/O C LT |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ANKLE RT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI TOE JOINT RT W/O CONTRAST |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI HIP LT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ANKLE LT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI TOE JOINT LT W/O CONTRAST |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI HIP W PROSTHESIS - LT |
$1,593.60 |
$2,656.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI HIP W PROSTHESIS RT |
$1,593.60 |
$2,656.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI ARTHROGRAM KNEE - RIGHT |
$982.80 |
$1,638.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI ARTHROGRAM KNEE - LEFT |
$982.80 |
$1,638.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI HIP LT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI HIP RT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI ANKLE RT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI ANKLE LT W/MAVRIC W/O CON |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI LOW EXT JOINT W/O C RT |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI LOWER EXTREM JNT W/O C LT |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI TOE JOINT LT W/O CONTRAST |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI TOE JOINT RT W/O CONTRAST |
$1,330.20 |
$2,217.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI HIP W PROSTHESIS - LT |
$1,593.60 |
$2,656.00 |
40% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI HIP W PROSTHESIS RT |
$1,593.60 |
$2,656.00 |
40% |
| MRI of knee or other lower-limb joint, without and then with contrast dye one side
CPT 73723
MRI LOW EXT JOINT W/O & W C RT |
$2,655.00 |
$4,425.00 |
40% |
| MRI of knee or other lower-limb joint, without and then with contrast dye one side
CPT 73723
MRI LOW EXTR JNT W/O & W C LT |
$2,655.00 |
$4,425.00 |
40% |
| MRI of knee or other lower-limb joint, without and then with contrast dye inpatient one side
CPT 73723
MRI LOW EXTR JNT W/O & W C LT |
$2,655.00 |
$4,425.00 |
40% |
| MRI of knee or other lower-limb joint, without and then with contrast dye inpatient one side
CPT 73723
MRI LOW EXT JOINT W/O & W C RT |
$2,655.00 |
$4,425.00 |
40% |
| MRI of the brain, no contrast dye
CPT 70551
MRI BRAIN WITHOUT CON |
$1,080.00 |
$1,800.00 |
40% |
| MRI of the brain, no contrast dye
CPT 70551
GAMMA KNIFE BRAIN W/O CONT |
$1,335.00 |
$2,225.00 |
40% |
| MRI of the brain, no contrast dye inpatient
CPT 70551
MRI BRAIN WITHOUT CON |
$1,080.00 |
$1,800.00 |
40% |
| MRI of the brain, no contrast dye inpatient
CPT 70551
GAMMA KNIFE BRAIN W/O CONT |
$1,335.00 |
$2,225.00 |
40% |
| MRI of the brain, with and without contrast dye
CPT 70553
GAMMA KNIFE BRAIN W/O & W CON |
$1,698.60 |
$2,831.00 |
40% |
| MRI of the brain, with and without contrast dye
CPT 70553
MR BRAIN AND PITUITARY |
$2,100.00 |
$3,500.00 |
40% |
| MRI of the brain, with and without contrast dye
CPT 70553
MRI BRAIN W/O & WITH CON |
$2,100.00 |
$3,500.00 |
40% |
| MRI of the brain, with and without contrast dye inpatient
CPT 70553
GAMMA KNIFE BRAIN W/O & W CON |
$1,698.60 |
$2,831.00 |
40% |
| MRI of the brain, with and without contrast dye inpatient
CPT 70553
MRI BRAIN W/O & WITH CON |
$2,100.00 |
$3,500.00 |
40% |
| MRI of the brain, with and without contrast dye inpatient
CPT 70553
MR BRAIN AND PITUITARY |
$2,100.00 |
$3,500.00 |
40% |
| MRI of the lower back, no contrast dye
CPT 72148
MRI LUM SPINE W/O CONTR |
$877.80 |
$1,463.00 |
40% |
| MRI of the lower back, no contrast dye inpatient
CPT 72148
MRI LUM SPINE W/O CONTR |
$877.80 |
$1,463.00 |
40% |
| Pregnancy ultrasound after 14 weeks, one baby
CPT 76805
US EXAM PG UTERUS >= 14 WKS |
$385.20 |
$642.00 |
40% |
| Pregnancy ultrasound after 14 weeks, one baby
CPT 76805
US EXAM PG UTERUS >= 14WKS |
$509.40 |
$849.00 |
40% |
| Pregnancy ultrasound after 14 weeks, one baby inpatient
CPT 76805
US EXAM PG UTERUS >= 14 WKS |
$385.20 |
$642.00 |
40% |
| Pregnancy ultrasound after 14 weeks, one baby inpatient
CPT 76805
US EXAM PG UTERUS >= 14WKS |
$509.40 |
$849.00 |
40% |
| Screening mammogram, both breasts
CPT 77067
MAMMOGRAPHY-SCREEN BIL |
$479.40 |
$799.00 |
40% |
| Screening mammogram, both breasts one side
CPT 77067
MAMMOGRAPHY-SCREEN UNILAT LEFT |
$479.40 |
$799.00 |
40% |
| Screening mammogram, both breasts one side
CPT 77067
MAMMOGRAPHY-SCREEN UNILAT RT |
$479.40 |
$799.00 |
40% |
| Screening mammogram, both breasts inpatient
CPT 77067
MAMMOGRAPHY-SCREEN BIL |
$479.40 |
$799.00 |
40% |
| Screening mammogram, both breasts inpatient one side
CPT 77067
MAMMOGRAPHY-SCREEN UNILAT RT |
$479.40 |
$799.00 |
40% |
| Screening mammogram, both breasts inpatient one side
CPT 77067
MAMMOGRAPHY-SCREEN UNILAT LEFT |
$479.40 |
$799.00 |
40% |
| Sleep study in a lab (polysomnography)
CPT 95810
POLYSOMNOGRAPHY > 4 PAR |
$4,566.60 |
$7,611.00 |
40% |
| Sleep study in a lab (polysomnography) inpatient
CPT 95810
POLYSOMNOGRAPHY > 4 PAR |
$4,566.60 |
$7,611.00 |
40% |
| Transvaginal pelvic ultrasound
CPT 76830
TRANSVAGINAL ULTRASOUND (GYN) |
$300.00 |
$500.00 |
40% |
| Transvaginal pelvic ultrasound
CPT 76830
US ENDOVAGINAL ONLY |
$471.60 |
$786.00 |
40% |
| Transvaginal pelvic ultrasound
CPT 76830
US TRANSVAGINAL |
$540.60 |
$901.00 |
40% |
| Transvaginal pelvic ultrasound
CPT 76830
ENDOVAGINAL ULTRASOUND |
$593.40 |
$989.00 |
40% |
| Transvaginal pelvic ultrasound inpatient
CPT 76830
TRANSVAGINAL ULTRASOUND (GYN) |
$300.00 |
$500.00 |
40% |
| Transvaginal pelvic ultrasound inpatient
CPT 76830
US ENDOVAGINAL ONLY |
$471.60 |
$786.00 |
40% |
| Transvaginal pelvic ultrasound inpatient
CPT 76830
US TRANSVAGINAL |
$540.60 |
$901.00 |
40% |
| Transvaginal pelvic ultrasound inpatient
CPT 76830
ENDOVAGINAL ULTRASOUND |
$593.40 |
$989.00 |
40% |
| Ultrasound of the abdomen, complete
CPT 76700
ABDOMINAL-G.B.LIV REN PAN |
$498.60 |
$831.00 |
40% |
| Ultrasound of the abdomen, complete inpatient
CPT 76700
ABDOMINAL-G.B.LIV REN PAN |
$498.60 |
$831.00 |
40% |
| X-ray of the lower back, 4 or more views
CPT 72110
LUMBAR SPINE AP LAT FLEX/EXT |
$355.80 |
$593.00 |
40% |
| X-ray of the lower back, 4 or more views
CPT 72110
LUMBAR SPINE MIN 4 VIEWS |
$355.80 |
$593.00 |
40% |
| X-ray of the lower back, 4 or more views inpatient
CPT 72110
LUMBAR SPINE MIN 4 VIEWS |
$355.80 |
$593.00 |
40% |
| X-ray of the lower back, 4 or more views inpatient
CPT 72110
LUMBAR SPINE AP LAT FLEX/EXT |
$355.80 |
$593.00 |
40% |