| CT scan of abdomen and pelvis, with contrast dye
CPT 74177
CT ABD & PELVIS WITH CONTRAST |
$2,104.00 |
$5,260.00 |
60% |
| CT scan of the head or brain, no contrast dye
CPT 70450
CT HEAD OR BRAIN W/O CONTRAST |
$1,952.80 |
$4,882.00 |
60% |
| CT scan of the pelvis, with contrast dye
CPT 72193
CT PELVIS, WITH CONTRAST |
$2,104.00 |
$5,260.00 |
60% |
| Diagnostic mammogram, both breasts both sides
CPT 77066
DX MAMMO INCL CAD BILATERAL |
$768.00 |
$1,920.00 |
60% |
| Diagnostic mammogram, one breast one side
CPT 77065
DX MAMMO INCL CAD UNILATERAL LEFT |
$653.20 |
$1,633.00 |
60% |
| Diagnostic mammogram, one breast one side
CPT 77065
DX MAMMO INCL CAD UNILATERAL LEFT |
$653.20 |
$1,633.00 |
60% |
| Diagnostic mammogram, one breast one side
CPT 77065
DX MAMMO INCL CAD UNILATERAL RIGHT |
$653.20 |
$1,633.00 |
60% |
| Diagnostic mammogram, one breast one side
CPT 77065
DX MAMMO INCL CAD UNILATERAL RIGHT |
$653.20 |
$1,633.00 |
60% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
DX MAMMO INCL CAD UNILATERAL RIGHT |
$653.20 |
$1,633.00 |
60% |
| Diagnostic mammogram, one breast inpatient one side
CPT 77065
DX MAMMO INCL CAD UNILATERAL LEFT |
$653.20 |
$1,633.00 |
60% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ANY JNT LWR EXTREM W/O CON RT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ANY JNT LWR EXTREM W/O CON LT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ANY JNT LWR EXTREM W/O CON RT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, no contrast dye one side
CPT 73721
MRI ANY JNT LWR EXTREM W/O CON LT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI ANY JNT LWR EXTREM W/O CON LT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, no contrast dye inpatient one side
CPT 73721
MRI ANY JNT LWR EXTREM W/O CON RT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye
CPT 73723
MRI LWR EXT JNT W&W/O CON BIL |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye
CPT 73723
MRI LWR EXT JNT W&W/O CON BIL |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye one side
CPT 73723
MRI ANY JNT LWR EXT W/O & W/ CON RT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye one side
CPT 73723
MRI ANY JNT LWR EXT W/O & W/ CON RT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye one side
CPT 73723
MRI ANY JNT LWR EXT W/O & W/ CON LT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye one side
CPT 73723
MRI ANY JNT LWR EXT W/O & W/ CON LT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye inpatient
CPT 73723
MRI LWR EXT JNT W&W/O CON BIL |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye inpatient one side
CPT 73723
MRI ANY JNT LWR EXT W/O & W/ CON RT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of knee or other lower-limb joint, without and then with contrast dye inpatient one side
CPT 73723
MRI ANY JNT LWR EXT W/O & W/ CON LT |
$1,325.60 |
$3,314.00 |
60% |
| MRI of the brain, no contrast dye
CPT 70551
MRI BRAIN, W/O CONTRAST |
$799.60 |
$1,999.00 |
60% |
| MRI of the brain, with and without contrast dye
CPT 70553
MRI BRAIN, W/O THEN W/ CONTRAST |
$1,325.60 |
$3,314.00 |
60% |
| MRI of the lower back, no contrast dye
CPT 72148
MRI LUMBAR SPINE, W/O CON |
$1,286.40 |
$3,216.00 |
60% |
| Pregnancy ultrasound after 14 weeks, one baby
CPT 76805
ED OB US>/=14WEEKS SNGL FETUS |
$282.40 |
$706.00 |
60% |
| Pregnancy ultrasound after 14 weeks, one baby
CPT 76805
US OB >OR=14 WKS 1ST GESTATION |
$1,263.60 |
$3,159.00 |
60% |
| Screening mammogram, both breasts both sides
CPT 77067
SCREENING MAMMO BILATERAL INCL CAD |
$527.20 |
$1,318.00 |
60% |
| Screening mammogram, both breasts
CPT 77067
MG MAMMO SCRN BIL-RED SVC |
$530.40 |
$1,326.00 |
60% |
| Screening mammogram, both breasts
CPT 77067
MG MAMMO SCRN BIL-RED SVC |
$530.40 |
$1,326.00 |
60% |
| Screening mammogram, both breasts one side
CPT 77067
SCREENING MAMMO BIL INCL CAD LEFT |
$527.20 |
$1,318.00 |
60% |
| Screening mammogram, both breasts one side
CPT 77067
SCREENING MAMMO BIL INCL CAD RIGHT |
$527.20 |
$1,318.00 |
60% |
| Screening mammogram, both breasts one side
CPT 77067
SCREENING MAMMO BIL INCL CAD LEFT |
$527.20 |
$1,318.00 |
60% |
| Screening mammogram, both breasts one side
CPT 77067
SCREENING MAMMO BIL INCL CAD RIGHT |
$527.20 |
$1,318.00 |
60% |
| Screening mammogram, both breasts inpatient
CPT 77067
MG MAMMO SCRN BIL-RED SVC |
$530.40 |
$1,326.00 |
60% |
| Screening mammogram, both breasts inpatient one side
CPT 77067
SCREENING MAMMO BIL INCL CAD RIGHT |
$527.20 |
$1,318.00 |
60% |
| Screening mammogram, both breasts inpatient one side
CPT 77067
SCREENING MAMMO BIL INCL CAD LEFT |
$527.20 |
$1,318.00 |
60% |
| Transvaginal pelvic ultrasound
CPT 76830
US TRANSVAGINAL, NON-OB |
$878.40 |
$2,196.00 |
60% |
| Ultrasound of the abdomen, complete
CPT 76700
US ABDOMINAL, COMPLETE |
$2,552.40 |
$6,381.00 |
60% |
| X-ray of the lower back, 4 or more views
CPT 72110
XRAY LUMBOSACRAL SPINE 4+ VIEWS |
$1,516.40 |
$3,791.00 |
60% |
| X-ray of the lower back, 4 or more views
CPT 72110
XRAY LUMBOSACRAL SPINE, MIN 4 VIEWS |
$1,516.40 |
$3,791.00 |
60% |