Exam Costs - Cypress Imaging

Wichita Radiological Group strives to make your medical imaging as affordable as possible. While we participate in most major health insurance plans, we understand that not everyone has insurance. Even if you don’t have insurance, you don’t have to pay more than a big insurance company. We offer a 20% discount for payment in full at the time of service.

If you have a high deductible health plan, we will work with you to set up a convenient, affordable payment plan.

How much will it cost? Use the menus below to find our fees for common procedures.

Fee Look Up Table 1

Lookup1	Lookup2	Lookup3	Code	Description	Regular Fee	Pay at Time of Service	Misc Info
Bone Density - DEXA			77081	DEXA SCAN - WRIST OR HEEL	$70.00	$56.00
Bone Density - DEXA			77080	AXIAL BONE DENSITY STUDY - HIP, PELVIS OR SPINE	$255.00	$204.00	Most common
Bone Density - DEXA			77085	AXIAL BONE DENSITY, WITH VERTEBRAL FRACTURE ASSESSMENT	$270.00	$216.00
CT (CAT Scan)	Abdomen and Pelvis		74176	CT ABD & PELVIS WITHOUT CONTRAST	$800.00	$640.00
CT (CAT Scan)	Abdomen and Pelvis		74177	CT ABD & PELVIS WITH CONTRAST	$900.00	$720.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Abdomen and Pelvis		74178	CT ABD & PELVIS WITHOUT AND WITH CONTRAST	$1,200.00	$960.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Chest/Thorax		71250	CT THORAX WITHOUT CONTRAST	$635.00	$508.00
CT (CAT Scan)	Chest/Thorax		71260	CT THORAX WITH CONTRAST	$760.00	$608.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Chest/Thorax		71270	CT THORAX WITH AND WITHOUT CONTRAST	$940.00	$752.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Face/Jaws		70486	CT MAXILLOFACIAL AREA WITHOUT CONTRAST	$625.00	$500.00
CT (CAT Scan)	Face/Jaws		70487	CT MAXILLOFACIAL AREA WITH CONTRAST	$755.00	$604.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Face/Jaws		70488	CT MAXILLOFACIAL AREA WITH AND WITHOUT CONTRAST	$920.00	$736.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Head/Brain		70450	CT HEAD/BRAIN WITHOUT CONTRAST	$520.00	$416.00
CT (CAT Scan)	Head/Brain		70460	CT HEAD/BRAIN WITH CONTRAST	$630.00	$504.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Head/Brain		70470	CT HEAD/BRAIN WITHOUT AND WITH CONTRAST	$760.00	$608.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Spine	Cervical (Upper)	72125	CT CERVICAL SPINE WITHOUT CONTRAST	$635.00	$508.00
CT (CAT Scan)	Spine	Cervical (Upper)	72126	CT CERVICAL SPINE WITH CONTRAST	$760.00	$608.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Spine	Cervical (Upper)	72127	CT CERVICAL SPINE WITHOUT AND WITH CONTRAST	$925.00	$740.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Spine	Lumbar (lower)	72131	CT LUMBAR SPINE WITHOUT CONTRAST	$635.00	$508.00
CT (CAT Scan)	Spine	Lumbar (lower)	72132	CT LUMBAR SPINE WITH CONTRAST	$760.00	$608.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Spine	Lumbar (lower)	72133	CT LUMBAR SPINE WITHOUT AND WITH CONTRAST	$930.00	$744.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Spine	Thoracic (Mid)	72128	CT THORACIC SPINE WITHOUT CONTRAST	$635.00	$508.00
CT (CAT Scan)	Spine	Thoracic (Mid)	72129	CT THORACIC SPINE WITH CONTRAST	$760.00	$608.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
CT (CAT Scan)	Spine	Thoracic (Mid)	72130	CT THORACIC SPINE WITHOUT AND WITH CONTRAST	$930.00	$744.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
Mammogram	Diagnostic		77051	COMPUTER AIDED DETECTION	$35.00	$28.00	Normally done with diagnostic mammogram
Mammogram	Diagnostic			BREAST TOMOSYNTHESIS	$75.00	$60.00	Patient selected option
Mammogram	Diagnostic		G0206	DIGITAL UNILATERAL DIAGNOSTIC MAMMOGRAM	$215.00	$172.00	One breast
Mammogram	Diagnostic		G0204	DIGITAL BILATERAL DIAGNOSTIC MAMMOGRAM	$275.00	$220.00	Both breasts
Mammogram	Screening		77052	COMPUTER AIDED DETECTION	$35.00	$28.00	Normally done with screening mammogram. Usually paid 100% by insurance
Mammogram	Screening		77063	BREAST TOMOSYNTHESIS	$75.00	$60.00	Patient selected option. Usually paid 100% by Medicare. Other insurance coverage varies
Mammogram	Screening		G0202	DIGITAL SCREENING MAMMOGRAM	$235.00	$188.00	Usually paid 100% by insurance
MRI	Brain		70551	MRI BRAIN WITHOUT CONTRAST	$1,300.00	$1,040.00
MRI	Brain		70552	MRI BRAIN WITH CONTRAST	$1,400.00	$1,120.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Brain		70553	MRI BRAIN WITHOUT AND WITH CONTRAST	$1,750.00	$1,400.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Breast		0159T	COMPUTER AIDED DETECTION - MRI BREAST	$75.00	$60.00	Normally done with MRI of Breast
MRI	Breast		77058	MRI ONE BREAST	$1,700.00	$1,360.00	Plus contrast material, if used
MRI	Breast		77059	MRI BOTH BREASTS	$1,750.00	$1,400.00	Plus contrast material, if used
MRI	Lower Extremity (leg)		73722	MRI ANY JOINT LOWER EXTR WITH CONTRAST	$1,300.00	$1,040.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Lower Extremity (leg)		73721	MRI ANY LOWER EXTREMITY JOINT, WITHOUT CONTRAST	$1,700.00	$1,360.00
MRI	Lower Extremity (leg)		73723	MRI ANY JOINT LOWER EXTR WITHOUT AND WITH CONTRAST	$1,800.00	$1,440.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Spine	Cervical (Upper)	72142	MRI CERVICAL SPINE WITH CONTRAST	$1,750.00	$1,400.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Spine	Cervical (Upper)	72141	MRI CERVICAL SPINE WITHOUT CONTRAST	$1,750.00	$1,400.00
MRI	Spine	Cervical (Upper)	72156	MRI CERVICAL SPINE WITHOUT AND WITH CONTRAST	$1,900.00	$1,520.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Spine	Lumbar (lower)	72148	MRI LUMBAR SPINE WITHOUT CONTRAST	$1,750.00	$1,400.00
MRI	Spine	Lumbar (lower)	72149	MRI LUMBAR SPINE WITH CONTRAST	$1,750.00	$1,400.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Spine	Lumbar (lower)	72158	MRI LUMBAR SPINE WITHOUT AND WITH CONTRAST	$1,900.00	$1,520.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Spine	Thoracic (Mid)	72147	MRI THORACIC SPINE WITH CONTRAST	$1,750.00	$1,400.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Spine	Thoracic (Mid)	72146	MRI THORACIC SPINE WITHOUT CONTRAST	$1,750.00	$1,400.00
MRI	Spine	Thoracic (Mid)	72157	MRI THORACIC SPINE WITHOUT AND WITH CONTRAST	$1,800.00	$1,440.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Upper Extremity (Arm)		73222	MRI ANY JOINT UPPER EXT WITH CONTRAST	$1,300.00	$1,040.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
MRI	Upper Extremity (Arm)		73221	MRI ANY JOINT UPPER EXTREMITY WITHOUT CONTRAST	$1,700.00	$1,360.00
MRI	Upper Extremity (Arm)		73223	MRI ANY JOINT UPPER EXT WITHOUT AND WITH CONTRAST	$1,800.00	$1,440.00	Plus contrast material used. Commonly $42.00 ($33.60 if paid at time of service)
Ultrasound/Sonogram	Abdomen		76705	ULTRASOUND ABDOMINAL, LIMITED	$215.00	$172.00	Single organ/quadrant, or follow-up
Ultrasound/Sonogram	Abdomen		76700	ULTRASOUND ABDOMINAL, COMPLETE	$300.00	$240.00
Ultrasound/Sonogram	Breast		76642	US BREAST LIMITED	$180.00	$144.00	Per breast
Ultrasound/Sonogram	Breast		76641	US BREAST COMPLETE	$220.00	$176.00	Per breast
Ultrasound/Sonogram	Extracranial (neck) Arteries		93882	DUPLEX SCAN EXTRACRANIAL ARTERIES COMPLETE UNILATERAL OR LIMITED	$365.00	$292.00	One side only
Ultrasound/Sonogram	Extracranial (neck) Arteries		93880	DUPLEX SCAN EXTRACRANIAL ARTERIES COMPLETE BILATERAL	$500.00	$400.00	Left and right
Ultrasound/Sonogram	Extremity Veins		93971	DUPLEX SCAN EXTREMITY VEINS UNILATERAL OR LIMITED	$375.00	$300.00	One arm or leg
Ultrasound/Sonogram	Extremity Veins		93970	DUPLEX SCAN EXTREMITY VEINS - BILATERAL	$500.00	$400.00
Ultrasound/Sonogram	Head/Neck		76536	ULTRASOUND SOFT TISSUES HEAD & NECK	$220.00	$176.00
Ultrasound/Sonogram	Pelvis - Not Pregnant		76857	ULTRASOUND PELVIC, LIMITED/FOLLOW UP EXAM	$200.00	$160.00	Transabdominal approach. Some females may need transvaginal
Ultrasound/Sonogram	Pelvis - Not Pregnant		76856	ULTRASOUND PELVIC COMPLETE	$270.00	$216.00	Transabdominal approach. Some females may need transvaginal
Ultrasound/Sonogram	Pelvis - Not Pregnant		76830	ULTRASOUND TRANSVAGINAL NON OBSTETRIC	$275.00	$220.00	Transabdominal approach may be required in some cases
Ultrasound/Sonogram	Pregnancy		76801	FIRST TRIMESTER, FIRST GESTATION, TRANSABDOMINAL	$295.00	$236.00
Ultrasound/Sonogram	Pregnancy		76802	FIRST TRIMESTER, ADD GESTATION, TRANSABDOMINAL	$170.00	$136.00	Per gestation beyond one
Ultrasound/Sonogram	Pregnancy		76805	AFTER 1ST TRIMESTER, FIRST GESTATION, TRANSABDOMINAL	$325.00	$260.00
Ultrasound/Sonogram	Pregnancy		76810	AFTER 1ST TRIMESTER, ADD GESTATION, TRANSABDOMINAL	$230.00	$184.00	Per gestation beyond one
Ultrasound/Sonogram	Pregnancy		76819	FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING	$200.00	$160.00	Per fetus
Ultrasound/Sonogram	Pregnancy		76818	FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING	$225.00	$180.00	Per fetus
Ultrasound/Sonogram	Pregnancy		76816	US PREGNANT FOLLOW UP	$240.00	$192.00	Follow up to previous exam. Per fetus
Ultrasound/Sonogram	Pregnancy		76817	ULTRASOUND PREGNANT UTERUS, TRANSVAGINAL	$260.00	$208.00
Ultrasound/Sonogram	Retroperitoneal		76775	ULTRASOUND RETROPERITONEAL, LIMITED	$220.00	$176.00
Ultrasound/Sonogram	Retroperitoneal		76770	ULTRASOUND RETROPERITONEAL, COMPLETE	$250.00	$200.00

Fee Look Up Table 2

Service Type	Body Part	Contrast? Only applicable to CT and MRI	Procedure Code	Procedure Description	Regular Fee	Pay at Time of Service	Misc Info
RENDERING			76376	3D RENDERING NOT ON INDEPNDT WK STA	$250.00	$200.00
RENDERING			76377	3D RENDERING ON INDEPENDENT WK STATI	$375.00	$300.00
SLEEP MEDICINE			95803	ACTIGRAPHY TESTING	$275.00	$220.00
BIOPSY	LYMPH NODE		38505	BIOPSY OR EXCISION LYMPH NODE BY NEEDLE	$270.00	$216.00
BIOPSY	BREAST		19085	BIOPSY BREAST MR GUIDANCE, FIRST LESION	$2,300.00	$1,840.00	Includes imaging guidance
BIOPSY	BREAST		19086	BIOPSY BREAST MR GUIDANCE, EACH ADDTL LESION	$1,800.00	$1,440.00	Includes imaging guidance
BIOPSY	BREAST		19082	BIOPSY BREAST STEREOTACTIC GUIDANCE, EACH ADDITIONAL LESION	$1,200.00	$960.00	Includes imaging guidance
BIOPSY	BREAST		19081	BIOPSY BREAST STEREOTACTIC GUIDANCE, FIRST LESION	$1,500.00	$1,200.00	Includes imaging guidance
BIOPSY	BREAST		19083	BIOPSY BREAST ULTRASOUND GUIDANCE, FIRST LESION	$1,500.00	$1,200.00	Includes imaging guidance
BIOPSY	BREAST		19084	BIOPSY BREAST ULTRASOUND GUIDANCE, EACH ADDITIONAL LESION	$1,200.00	$960.00	Includes imaging guidance
BIOPSY	MUSCLE		20206	BIOPSY MUSCLE NEEDLE	$525.00	$420.00
BIOPSY	BREAST		19100	BIOPSY OF BREAST WITHOUT IMAGING GUIDANCE NEEDLE CORE	$285.00	$228.00
BIOPSY	BREAST		19101	BIOPSY OF BREAST OPEN INCISIONAL	$650.00	$520.00
BIOPSY	SKIN		11100	BIOPSY OF SKIN SUBCUTANEOUS TISSUE, FIRST LESION	$200.00	$160.00
BIOPSY	THYROID		60100	BIOPSY THYROID PERCUTANEOUS NEEDLE	$250.00	$200.00
MRI	BREAST	WITHOUT CONTRAST	0159T	CAD FOR MRI BREAST	$75.00	$60.00	Normally done with MRI of Breast
SLEEP MEDICINE			36415	COLLECTION OF VENOUS BLOOD BY VENIPU	$11.00	$8.80
SLEEP MEDICINE			A7027	COMBINATION ORAL/NASAL MASK	$215.00	$172.00
MAMMOGRAM			77051	COMPUTER AID DETECTION DIAGNOSITC	$35.00	$28.00	Normally done with diagnostic mammogram
MAMMOGRAM			77052	COMPUTER AID DETECTION SCREENING	$35.00	$28.00	Normally done with screening mammogram
SLEEP MEDICINE			99241	CONSULTATION OP LEVEL 1	$110.00	$88.00	Level will vary with scope of exam and complexity of case
SLEEP MEDICINE			99242	CONSULTATION OP LEVEL 2	$200.00	$160.00	Level will vary with scope of exam and complexity of case
SLEEP MEDICINE			99243	CONSULTATION OP LEVEL 3	$285.00	$228.00	Level will vary with scope of exam and complexity of case
SLEEP MEDICINE			99244	CONSULTATION OP LEVEL 4	$420.00	$336.00	Level will vary with scope of exam and complexity of case
SLEEP MEDICINE			99245	CONSULTATION OP LEVEL 5	$515.00	$412.00	Level will vary with scope of exam and complexity of case
SLEEP MEDICINE			E0601	CPAP - CONT AIRWAY PRESSURE DEVICE - PURCHASE	$1,225.00	$980.00
SLEEP MEDICINE			E0601RR	CPAP - CONT AIRWAY PRESSURE DEVICE - MONTHLY RENTAL	$110.00	$88.00
SLEEP MEDICINE			A7030	CPAP FULL FACE MASK	$215.00	$172.00
CT (AKA CAT SCAN)	ABDOMEN & PELVIS	WITH AND WITHOUT CONTRAST	74178	CT ABD & PELVIS W/WO CONTRAST FURTHE	$1,200.00	$960.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	ABDOMEN & PELVIS	WITH CONTRAST	74177	CT ABD & PELVIS WITH CONTRAST	$900.00	$720.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	ABDOMEN & PELVIS	WITHOUT CONTRAST	74176	CT ABD & PELVIS WO CONTRAST	$800.00	$640.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	ABDOMEN	WITH AND WITHOUT CONTRAST	74170	CT ABDOMEN W/WO CONTRAST FURTH SECT	$995.00	$796.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	ABDOMEN	WITH CONTRAST	74160	CT ABDOMEN WITH CONTRAST	$800.00	$640.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	ABDOMEN	WITHOUT CONTRAST	74150	CT ABDOMEN WO CONTRAST	$600.00	$480.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	BONE DENSITY	WITHOUT CONTRAST	77078	CT BONE DENSITY STUDY	$375.00	$300.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	SPINE - CERVICAL (UPPER)	WITH AND WITHOUT CONTRAST	72127	CT CERVICAL SPINE W/WO CONTRAST	$925.00	$740.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	SPINE - CERVICAL (UPPER)	WITH CONTRAST	72126	CT CERVICAL SPINE WITH CONTRAST	$760.00	$608.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	SPINE - CERVICAL (UPPER)	WITHOUT CONTRAST	72125	CT CERVICAL SPINE WO CONTRAST	$635.00	$508.00	Some studies may require rendering at additional charge
BIOPSY			77012	CT GUIDANCE NEEDLE BIOPSY	$495.00	$396.00
CT (AKA CAT SCAN)	RADIATION THERAPY FIELDS	WITHOUT CONTRAST	77014	CT GUIDANCE PLACEMENT OF RADIATION THERAPY FIELDS	$375.00	$300.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	HEAD/BRAIN	WITH AND WITHOUT CONTRAST	70470	CT HEAD/BRAIN W/WO CONTRAST	$760.00	$608.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	HEAD/BRAIN	WITH CONTRAST	70460	CT HEAD/BRAIN WITH CONTRAST	$630.00	$504.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	HEAD/BRAIN	WITHOUT CONTRAST	70450	CT HEAD/BRAIN WO CONTRAST	$520.00	$416.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	LIMITED FOLLOW UP STUDY	WITHOUT CONTRAST	76380	CT LMTD OR LOCALIZED FOLLOW UP STUDY	$430.00	$344.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	EXTREMITY - LOWER (LEG)	WITH AND WITHOUT CONTRAST	73702	CT LOWER EXTREM W/WO CON FURTH SECT	$925.00	$740.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	EXTREMITY - LOWER (LEG)	WITH CONTRAST	73701	CT LOWER EXTREMITY WITH CONTRAST	$725.00	$580.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	EXTREMITY - LOWER (LEG)	WITHOUT CONTRAST	73700	CT LOWER EXTREMITY WO CONTRAST	$600.00	$480.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	SPINE - LUMBAR (LOWER)	WITH AND WITHOUT CONTRAST	72133	CT LUMBAR SPINE W/WO CONTRAST	$930.00	$744.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	SPINE - LUMBAR (LOWER)	WITH CONTRAST	72132	CT LUMBAR SPINE WITH CONTRAST	$760.00	$608.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	SPINE - LUMBAR (LOWER)	WITHOUT CONTRAST	72131	CT LUMBAR SPINE WO CONTRAST	$635.00	$508.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	FACE/JAWS	WITH AND WITHOUT CONTRAST	70488	CT MAXILLOFACIAL AREA W/WO CONTRAST	$920.00	$736.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	FACE/JAWS	WITH CONTRAST	70487	CT MAXILLOFACIAL AREA WITH CONTRAST	$755.00	$604.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	FACE/JAWS	WITHOUT CONTRAST	70486	CT MAXILLOFACIAL AREA WO CONTRAST	$625.00	$500.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	EYES/ORBITS	WITH AND WITHOUT CONTRAST	70482	CT ORBIT ETC WITH AND WO CONTRAST	$980.00	$784.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	EYES/ORBITS	WITH CONTRAST	70481	CT ORBIT ETC WITH CONTRAST	$855.00	$684.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	EYES/ORBITS	WITHOUT CONTRAST	70480	CT ORBIT ETC WO CONTRAST	$735.00	$588.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	PELVIS	WITH AND WITHOUT CONTRAST	72194	CT PELVIS W/WO CONTRAST & FURTH SECT	$920.00	$736.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	PELVIS	WITH CONTRAST	72193	CT PELVIS WITH CONTRAST	$725.00	$580.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	PELVIS	WITHOUT CONTRAST	72192	CT PELVIS WO CONTRAST	$600.00	$480.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	NECK - SOFT TISSUE	WITH AND WITHOUT CONTRAST	70492	CT SOFT TISSUE NECK W/WO CONTRAST	$900.00	$720.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	NECK - SOFT TISSUE	WITH CONTRAST	70491	CT SOFT TISSUE NECK WITH CONTRAST	$745.00	$596.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	NECK - SOFT TISSUE	WITHOUT CONTRAST	70490	CT SOFT TISSUE NECK WO CONTRAST	$620.00	$496.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	SPINE - THORACIC (MID)	WITH AND WITHOUT CONTRAST	72130	CT THORACIC SPINE W/WO CONTRAST	$930.00	$744.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	SPINE - THORACIC (MID)	WITH CONTRAST	72129	CT THORACIC SPINE WITH CONTRAST	$760.00	$608.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	SPINE - THORACIC (MID)	WITHOUT CONTRAST	72128	CT THORACIC SPINE WO CONTRAST	$635.00	$508.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	CHEST/THORAX	WITH AND WITHOUT CONTRAST	71270	CT THORAX WITH AND WITHOUT CONTRAST	$940.00	$752.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	CHEST/THORAX	WITH CONTRAST	71260	CT THORAX WITH CONTRAST	$760.00	$608.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	CHEST/THORAX	WITHOUT CONTRAST	71250	CT THORAX WITHOUT CONTRAST	$635.00	$508.00	Some studies may require rendering at additional charge
CT (AKA CAT SCAN)	EXTREMITY - UPPER (ARM)	WITH AND WITHOUT CONTRAST	73202	CT UPPER EXTREMITY W/WO CONTRAST	$920.00	$736.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	EXTREMITY - UPPER (ARM)	WITH CONTRAST	73201	CT UPPER EXTREMITY WITH CONTRAST	$720.00	$576.00	Contrast material billed separately. Some studies may require rendering
CT (AKA CAT SCAN)	EXTREMITY - UPPER (ARM)	WITHOUT CONTRAST	73200	CT UPPER EXTREMITY WO CONTRAST	$600.00	$480.00	Some studies may require rendering at additional charge
CT ANGIOGRAPHY	AORTA		75635	CT ANGIOGRAPHY ABDOMINAL AORTA AND LOWER EXTREMITY RUNOFF	$1,300.00	$1,040.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	ABDOMEN & PELVIS		74174	CT ANGIOGRAPHY ABDOMEN AND PELVIS	$1,300.00	$1,040.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	ABDOMEN		74175	CT ANGIOGRAPHY ABDOMEN	$1,175.00	$940.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	CHEST/THORAX		71275	CT ANGIOGRAPHY CHEST	$1,150.00	$920.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	HEAD/BRAIN		70496	CT ANGIOGRAPHY HEAD	$1,400.00	$1,120.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	NECK - SOFT TISSUE		70498	CT ANGIOGRAPHY NECK	$1,400.00	$1,120.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	PELVIS		72191	CTA PELVIS W/WO CONTRAST	$1,100.00	$880.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	EXTREMITY - UPPER (ARM)		73206	CTA UPPER EXTREMIT W/WO CONTRAST	$1,100.00	$880.00	CTA = CT Angiography, contrast material may be billed separately
CT ANGIOGRAPHY	EXTREMITY - LOWER (LEG)		73706	CTA, LOWER EXTREM W/WO CONTRAST	$1,100.00	$880.00	CTA = CT Angiography, contrast material may be billed separately
BONE DENSITY - DEXA			77080	AXIAL BONE DENSITY STUDY - HIP, PELVIS OR SPINE	$255.00	$204.00
BONE DENSITY - DEXA			77085	AXIAL BONE DENSITY STUDY, W VERTEBRAL FRACTURE ASSESSMENT	$270.00	$216.00
BONE DENSITY - DEXA			77081	DEXA SCAN - WRIST OR HEEL	$70.00	$56.00
MAMMOGRAM			G0204	DIGITAL BILATERAL DIAGNOSTIC MAMMOGRAM	$275.00	$220.00	Plus additional charge for CAD (Computer Aided Detection)
MAMMOGRAM			G0202	DIGITAL SCREENING MAMMOGRAM	$235.00	$188.00	Plus additional charge for CAD (Computer Aided Detection)
MAMMOGRAM			G0206	DIGITAL UNILATERAL DIAGNOSTIC MAMMOGRAM - ONE BREAST ONLY	$215.00	$172.00	Plus additional charge for CAD (Computer Aided Detection)
ULTRASOUND/SONO/ECHO	FETUS		76827	DOPPLER ECHOCARDIOGRAPHY FETAL COMPLETE	$165.00	$132.00
ULTRASOUND/SONO/ECHO	FETUS		76821	DOPPLER VELOCIMETRY FETAL MID CEREBRAL ARTERY	$220.00	$176.00
ULTRASOUND/SONO/ECHO	FETUS		76820	DOPPLER VELOCIMETRY, FETAL UMBILICAL ARTERY	$140.00	$112.00
ULTRASOUND/SONO/ECHO	PENIS		93981	DUPLEX SCAN OF PENILE VESSELS, LIMITED/FOLLOW UP	$295.00	$236.00
ULTRASOUND/SONO/ECHO	AORTA		93978	DUPLEX SCAN OF AORTA, COMPLETE	$535.00	$428.00
ULTRASOUND/SONO/ECHO	HEMODIALYSIS ACCESS		93990	DUPLEX SCAN OF HEMODIALYSIS ACCESS	$430.00	$344.00
ULTRASOUND/SONO/ECHO	PENIS		93980	DUPLEX SCAN PENILE VESSELS, COMPLETE	$420.00	$336.00
ULTRASOUND/SONO/ECHO	ABDOMEN AND/OR PELVIS		93975	DUPLEX SCAN ABDOMINAL, PELVIC, SCROTAL AND/OR RETROPERITONEAL COMPLETE	$845.00	$676.00
ULTRASOUND/SONO/ECHO	ABDOMEN AND/OR PELVIS		93976	DUPLEX SCAN ABDOMINAL, PELVIC, SCROTAL AND/OR RETROPERITONEAL LTD	$490.00	$392.00
ULTRASOUND/SONO/ECHO	HEAD/BRAIN		93880	DUPLEX SCAN EXTRACRANIAL ARTERIES COMPLETE BILATERAL	$500.00	$400.00
ULTRASOUND/SONO/ECHO	HEAD/BRAIN		93882	DUPLEX SCAN EXTRACRANIAL ARTERIES COMPLETE UNILATERAL OR LIMITED	$365.00	$292.00
ULTRASOUND/SONO/ECHO	EXTREMITY - LOWER OR UPPER		93971	DUPLEX SCAN EXTREMITY VEINS UNILATERAL OR LIMITED	$375.00	$300.00
ULTRASOUND/SONO/ECHO	EXTREMITY - LOWER OR UPPER		93970	DUPLEX SCAN EXTREMITY VEINS - BILATERAL	$500.00	$400.00
ULTRASOUND/SONO/ECHO	EXTREMITY - LOWER (LEG)		93925	DUPLEX SCAN LOWER EXTREMITY ARTERIES OR BYPASS GRAFTS, COMPLETE BILATERAL	$680.00	$544.00
ULTRASOUND/SONO/ECHO	EXTREMITY - LOWER (LEG)		93926	DUPLEX SCAN LOWER EXTREMITY ARTERIES OR BYPASS GRAFTS, LIMITED	$435.00	$348.00
ULTRASOUND/SONO/ECHO	EXTREMITY - UPPER (ARM)		93930	DUPLEX SCAN UPPER EXTREMITY ARTERIES OR BYPASS GRAFTS, COMPLETE BILATERAL	$545.00	$436.00
ULTRASOUND/SONO/ECHO	EXTREMITY - UPPER (ARM)		93931	DUPLEX SCAN UPPER EXTREMITY ARTERIES OR BYPASS GRAFTS, LIMITED	$365.00	$292.00
ULTRASOUND/SONO/ECHO	SPINE		76800	SPINAL CANAL AND CONTENTS	$275.00	$220.00
MRI/MRA	CONTRAST MATERIAL		A9581	EOVIST GADOXETATE DISODIUM 1ML	$17.00	$13.60	MRI contrast material, priced per ML
PET			A9552	FDG	$550.00	$440.00	Radiopharmaceutical for PET Scans
ULTRASOUND/SONO/ECHO	FETUS		76818	FETAL BIOPHYSICAL PROFILE WITH NON-STRESS TESTING	$225.00	$180.00
ULTRASOUND/SONO/ECHO	FETUS		76819	FETAL BIOPHYSICAL PROFILE WITHOUT NON-STRESS TESTING	$200.00	$160.00
SLEEP MEDICINE			A7039	FILTER, NON DISPOSABLE W PAP	$25.00	$20.00
ASPIRATION			10022	FINE NEEDLE ASPIRATION WITH IMAGING GUIDANCE	$250.00	$200.00	Radiologist supervision and interpretation charged separately
BONE DENSITY - DEXA			77086	VERTEBRAL FRACTURE ASSESSMENT VIA DEXA	$85.00	$68.00
MRI/MRA	CONTRAST MATERIAL		A9579	GADOLINIUM MRI CONTRAST ML	$2.10	$1.68	MRI contrast material, priced per ML
SLEEP MEDICINE			G0398	HOME SLEEP TEST/TYPE 2 PORTA	$420.00	$336.00
SLEEP MEDICINE			G0399	HOME SLEEP TEST/TYPE 3 PORTA	$420.00	$336.00
SLEEP MEDICINE			G0400	HOME SLEEP TEST/TYPE 4 PORTA	$420.00	$336.00
SLEEP MEDICINE			E0562	HUMIDIFIER HEATED USED W PAP	$435.00	$348.00
SLEEP MEDICINE			E0562RR	HUMIDIFIER HEATED USED W PAP RENT	$30.00	$24.00
SLEEP MEDICINE			E0561	HUMIDIFIER NONHEATED W PAP	$155.00	$124.00
SLEEP MEDICINE			E0561RR	HUMIDIFIER NONHEATED W PAP RENT	$10.00	$8.00
ULTRASOUND/SONO/ECHO	UTERUS		76831	SALINE INFUSION SONOHYSTEROGRAPHY (SIS)	$265.00	$212.00
ARTHROGRAM	ANKLE		27648	INJECTION FOR ANKLE ARTHROGRAPHY	$325.00	$260.00
ARTHROGRAM	ELBOW		24220	INJECTION FOR ELBOW ARTHROGRAPHY	$350.00	$280.00
ARTHROGRAM	WRIST		25246	INJECTION FOR WRIST ARTHROGRAPHY	$400.00	$320.00
ARTHROGRAM	HIP		27093	INJECTION FOR HIP ARTHROGRAM WITHOUT ANESTHESIA	$440.00	$352.00
ARTHROGRAM	KNEE		27370	INJECTION FOR KNEE ARTHROGRAM	$525.00	$420.00
ARTHROGRAM	BREAST		19030	INJECTION FOR MAMMARY DUCTOGRAM OR GALACTOGRAM	$300.00	$240.00
ARTHROGRAM	LYMPH NODE		38792	INJECTION TO IDENTIFY SENTINEL NODE	$235.00	$188.00
ARTHROGRAM	SHOULDER		23350	INJECTION FOR SHOULDER ARTHRO	$360.00	$288.00
MAMMOGRAM	BREAST		77054	MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS	$255.00	$204.00
MAMMOGRAM	BREAST		77053	MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT	$230.00	$184.00
MRA	ABDOMEN		74185	MRA ABDOMEN	$1,300.00	$1,040.00	Contrast material billed separately, if used
MRA	CHEST/THORAX		71555	MRA CHEST	$1,300.00	$1,040.00	Contrast material billed separately, if used
MRA	HEAD/BRAIN		70546	MRA HEAD WITH AND WITHOUT CONTRAST	$1,900.00	$1,520.00	Contrast material billed separately
MRA	HEAD/BRAIN		70545	MRA HEAD WITH CONTRAST	$1,300.00	$1,040.00	Contrast material billed separately
MRA	HEAD/BRAIN		70544	MRA HEAD WITHOUT CONTRAST	$1,300.00	$1,040.00
MRA	EXTREMITY - LOWER (LEG)		73725	MRA LOWER EXTREMITY	$1,200.00	$960.00	Contrast material billed separately, if used
MRA	NECK - SOFT TISSUE		70548	MRA NECK WITH CONTRAST	$1,300.00	$1,040.00	Contrast material billed separately
MRA	NECK - SOFT TISSUE		70549	MRA NECK WITH AND WITHOUT CONTRAST	$1,900.00	$1,520.00	Contrast material billed separately
MRA	NECK - SOFT TISSUE		70547	MRA NECK WITHOUT CONTRAST	$1,300.00	$1,040.00
MRA			72198	MRA PELVIS W/WO CONTRAST	$1,165.00	$932.00
MRA			72159	MRA SPINAL CANAL W/WO CONTRAST	$1,400.00	$1,120.00
MRA			73225	MRA UPPER EXTREMITY W/WO CONTRAST	$1,300.00	$1,040.00
MRI			74183	MRI ABDOMEN W/WO CONTRAST	$1,900.00	$1,520.00
MRI			74182	MRI ABDOMEN WITH CONTRAST	$1,500.00	$1,200.00
MRI			74181	MRI ABDOMEN WO CONTRAST	$1,100.00	$880.00
MRI			73723	MRI ANY JOINT LOWER EXTR W/WO CONTRA	$1,800.00	$1,440.00
MRI			73722	MRI ANY JOINT LOWER EXTR WTH CONTRAS	$1,300.00	$1,040.00
MRI			73721	MRI ANY JOINT LOWER EXTREMITY	$1,700.00	$1,360.00
MRI			73222	MRI ANY JOINT UPPER EXT W/CONTRAST	$1,300.00	$1,040.00
MRI			73223	MRI ANY JOINT UPPER EXT W/WO CONTRAS	$1,800.00	$1,440.00
MRI			73221	MRI ANY JOINT UPPER EXTREMITY	$1,700.00	$1,360.00
MRI			70551	MRI BRAIN INC BRAIN STEM WO CONTRAST	$1,300.00	$1,040.00
MRI			70553	MRI BRAIN W/WO CONTR & FURTHER SEQUE	$1,750.00	$1,400.00
MRI			70552	MRI BRAIN WITH CONTRAST	$1,400.00	$1,120.00
MRI			77059	MRI BREAST BILATERAL W/WO CONTRAST	$1,750.00	$1,400.00
MRI			77058	MRI BREAST UNILAT W/WO CONTRAST	$1,700.00	$1,360.00
MRI			75561	MRI CARDIAC W/WO CONTRAST	$1,600.00	$1,280.00
MRI			72156	MRI CERVICAL SPINE W/WO CONTRAST	$1,900.00	$1,520.00
MRI			72142	MRI CERVICAL SPINE WITH CONTRAST	$1,750.00	$1,400.00
MRI			72141	MRI CERVICAL SPINE WO CONTRAST	$1,750.00	$1,400.00
MRI			71552	MRI CHEST W/WO CONTRAST	$1,900.00	$1,520.00
MRI			71551	MRI CHEST WITH CONTRAST	$1,500.00	$1,200.00
MRI			71550	MRI CHEST WO CONTRAST	$1,400.00	$1,120.00
MRI			77021	MRI GUIDE NEEDLE PLACEMENT	$995.00	$796.00
MRI			73720	MRI LOWER EXTREMITY W/WO CONTRAST	$1,800.00	$1,440.00
MRI			73719	MRI LOWER EXTREMITY WITH CONTRAST	$1,400.00	$1,120.00
MRI			73718	MRI LOWER EXTREMITY WO CONTRAST	$1,200.00	$960.00
MRI			72158	MRI LUMBAR/CONTENTS W/WO CONTRAST	$1,900.00	$1,520.00
MRI			72149	MRI LUMBAR/CONTENTS WITH CONTRAST	$1,750.00	$1,400.00
MRI			72148	MRI LUMBAR/CONTENTS WO CONTRAST	$1,750.00	$1,400.00
MRI			70540	MRI ORBIT FACE AND NECK WO CONTRAST	$1,100.00	$880.00
MRI			70543	MRI ORBIT W/WO	$1,700.00	$1,360.00
MRI			72197	MRI PELVIS W/WO CONTRAST	$1,900.00	$1,520.00
MRI			72196	MRI PELVIS WITH CONTRAST	$1,400.00	$1,120.00
MRI			72195	MRI PELVIS WO CONTRAST	$1,200.00	$960.00
MRI			70336	MRI TEMPOROMANDIBULAR JOINT	$1,100.00	$880.00
MRI			72147	MRI THORACIC SPINE WITH CONTRAST	$1,750.00	$1,400.00
MRI			72146	MRI THORACIC SPINE WO CONTRAST	$1,750.00	$1,400.00
MRI			72157	MRI THORACIC/CONTENTS W/WO CONTRAST	$1,800.00	$1,440.00
MRI			73220	MRI UPPER EXTREMITY OTHER THAN JOINT	$1,900.00	$1,520.00
MRI			73219	MRI UPPER EXTREMITY WITH CONTRAST	$1,400.00	$1,120.00
MRI			73218	MRI UPPER EXTREMITY WO CONTRAST	$1,200.00	$960.00
MRI			70542	MRI WITH CONTRAST	$1,400.00	$1,120.00
SLEEP MEDICINE			95805	MULTIPLE SLEEP LATENCY TEST	$925.00	$740.00
SLEEP MEDICINE			A7034	NASAL APPLICATION DEVICE	$145.00	$116.00
SLEEP MEDICINE			99212	OFC VISIT EST PT 10 MINUTES	$85.00	$68.00
SLEEP MEDICINE			99213	OFC VISIT EST PT 15 MINUTES	$140.00	$112.00
SLEEP MEDICINE			99214	OFC VISIT EST PT 25 MINUTES	$210.00	$168.00
SLEEP MEDICINE			99215	OFC VISIT EST PT 40 MINUTES	$285.00	$228.00
SLEEP MEDICINE			99211	OFC VISIT EST PT 5 MINUTES	$40.00	$32.00
SLEEP MEDICINE			99201	OFC VISIT NEW PT 10 MINUTES	$85.00	$68.00
SLEEP MEDICINE			99202	OFC VISIT NEW PT 20 MINUTES	$145.00	$116.00
SLEEP MEDICINE			99203	OFC VISIT NEW PT 30 MINUTES	$210.00	$168.00
SLEEP MEDICINE			99204	OFC VISIT NEW PT 45 MINUTES	$325.00	$260.00
SLEEP MEDICINE			99205	OFC VISIT NEW PT 60 MINUTES	$410.00	$328.00
CT			Q9967	OMNIPAQUE 350MG	$0.22	$0.18
SLEEP MEDICINE			94762	OXIMETRY CONTINUOUS OVERNIGHT MONITORING	$100.00	$80.00
PET			78609	P.E.T. SCAN, BRAIN	$3,400.00	$2,720.00
SLEEP MEDICINE			A7044	PAP ORAL INTERFACE	$120.00	$96.00
PET			78812	PET IMAGING SKULL BASE TO MID THIGH	$3,200.00	$2,560.00
PET			78814	PET IMAGING WITH CT LIMITED AREA	$5,200.00	$4,160.00
PET			78815	PET IMAGING WITH CT SKULL BASE TO MI	$5,500.00	$4,400.00
PET			78816	PET IMAGING WITH CT WHOLE BODY	$5,600.00	$4,480.00
PET			78608	PET SCAN; METABOLIC EVALUATION	$3,100.00	$2,480.00
PET			78459	PET, METABOLIC EVALUATION	$3,400.00	$2,720.00
ULTRASOUND/SONO/ECHO			93965	PHYSIOLOGIC STUDIEEXTEM. BILAT	$275.00	$220.00
			38999	PLACEMENT WIRE LOCALIZATION	$300.00	$240.00
LOCALIZATION			19281	PLC BREAST LOC DEV MAMMO GUIDE 1ST L	$550.00	$440.00
LOCALIZATION			19282	PLC BREAST LOC DEV MAMMO GUIDE ADDL	$380.00	$304.00
LOCALIZATION			19287	PLC BREAST LOC DEV MR GUIDE 1ST LESI	$1,900.00	$1,520.00
LOCALIZATION			19288	PLC BREAST LOC DEV MR GUIDE ADDL LES	$1,500.00	$1,200.00
LOCALIZATION			19283	PLC BREAST LOC DEV STEREO GUIDE 1ST	$625.00	$500.00
LOCALIZATION			19284	PLC BREAST LOC DEV STEREO GUIDE ADDL	$450.00	$360.00
LOCALIZATION			19285	PLC BREAST LOC DEV US GUIDE 1ST LESI	$1,100.00	$880.00
LOCALIZATION			19286	PLC BREAST LOC DEV US GUIDE ADDL LES	$875.00	$700.00
SLEEP MEDICINE			95810	POLYSOM 6/> YRS 4/> PARAM	$1,700.00	$1,360.00
SLEEP MEDICINE			95811	POLYSOM 6/>YRS CPAP 4/> PARM	$1,850.00	$1,480.00
SLEEP MEDICINE			95808	POLYSOM ANY AGE 1-3> PARAM	$1,925.00	$1,540.00
SLEEP MEDICINE			A7036	POS AIRWAY PRESS CHINSTRAP	$25.00	$20.00
SLEEP MEDICINE			A7035	POS AIRWAY PRESS HEADGEAR	$55.00	$44.00
SLEEP MEDICINE			94660	POS AIRWAY PRESSURE CPAP	$125.00	$100.00
SLEEP MEDICINE			A7038	POS AIRWAY PRESSURE FILTER	$8.00	$6.40
SLEEP MEDICINE			A7037	POS AIRWAY PRESSURE TUBING	$60.00	$48.00
MRI			A9576	PROHANCE GADOTERIDOL INJ	$2.50	$2.00
			10160	PUNCTURE ASPIRATION OF ABSCESS, ETC	$230.00	$184.00
			19000	PUNCTURE ASPIRATION OF BREAST CYST	$200.00	$160.00
			19001	PUNCTURE ASPIRATION OF CYST EA ADDL	$60.00	$48.00
			E0471	RAD W/BACKUP NON INV INTRFC	$4,700.00	$3,760.00
			E0471RR	RAD W/BACKUP NON INV INTRFC RENT	$620.00	$496.00
			E0470	RAD W/O BACKUP NON-INV INTFC	$2,800.00	$2,240.00
			E0470RR	RAD W/O BACKUP NON-INV INTFC RENT	$250.00	$200.00
			76098	RADIOLOGICAL EXAM SURGICAL SPECIMEN	$45.00	$36.00
			76098	RADIOLOGICAL EXAM SURGICAL SPECIMEN	$45.00	$36.00
			A7045	REPL EXHALATION PORT FOR PAP	$25.00	$20.00
			A7045RR	REPL EXHALATION PORT FOR PAP RENT	$2.00	$1.60
			A7029	REPL NASAL PILLOW COMB MASK	$35.00	$28.00
			A7028	REPL ORAL CUSHION COMBO MASK	$55.00	$44.00
			A7031	REPLACEMENT FACEMASK INTERFA	$100.00	$80.00
			A7032	REPLACEMENT NASAL CUSHION	$45.00	$36.00
			A7033	REPLACEMENT NASAL PILLOWS	$40.00	$32.00
			95807	SLEEP STUDY ATTENDED	$1,300.00	$1,040.00
			95806	SLEEP STUDY UNATT&RESP EFFT	$475.00	$380.00
			95801	SLP STDY UNATND W/ANAL	$420.00	$336.00
			95800	SLP STDY UNATTENDED	$420.00	$336.00
			76970	SONO FOLLOW UP SPECIFY	$185.00	$148.00
			76886	SONO INFANT HIPS LIMITED	$225.00	$180.00
			76885	SONO INFANT HIPS REAL TIME	$300.00	$240.00
			76936	SONO SOFT TISSUE COMPRESSION REPAIR	$700.00	$560.00
			94060	SPIROMETRY	$92.00	$73.60
			A9500	TC99CM SESTAMIBI	$150.00	$120.00
			A9520	TC99M SULFUR COLLOID	$325.00	$260.00
			A9541	TC99M SULFUR COLLOID	$120.00	$96.00
			G0389	ULTRASOUND - AAA SCREENING	$250.00	$200.00
			76700	ULTRASOUND ABDOMINAL	$300.00	$240.00
			76705	ULTRASOUND ABDOMINAL LTD	$215.00	$172.00
			76506	ULTRASOUND CEREBRAL	$250.00	$200.00
			76604	ULTRASOUND CHEST	$155.00	$124.00
			76881	ULTRASOUND EXTREM NONVASCULAR COMPLE	$245.00	$196.00
			76882	ULTRASOUND EXTREM NONVASCULAR LIMITE	$75.00	$60.00
			76825	ULTRASOUND FETAL CARDIOVASCULAR REAL	$465.00	$372.00
			76856	ULTRASOUND PELVIC	$270.00	$216.00
			76857	ULTRASOUND PELVIC LTD OR FOLLOW UP	$200.00	$160.00
			76770	ULTRASOUND RENAL/ RETROPERITONEAL	$250.00	$200.00
			76775	ULTRASOUND RETROPERITONEAL LIMITED	$220.00	$176.00
			76870	ULTRASOUND SCROTUM AND CONTENTS	$265.00	$212.00
			76536	ULTRASOUND SOFT TISSUES HEAD & NECK	$220.00	$176.00
			76872	ULTRASOUND TRANSRECTAL PROSTATE	$315.00	$252.00
			76830	ULTRASOUND TRANSVAGINAL NOT OB	$275.00	$220.00
			20999	UNLISTED PROC MUSCULOSKELETAL	$600.00	$480.00
			76641	US BREAST COMPLETE	$220.00	$176.00
			76642	US BREAST LIMITED	$180.00	$144.00
			76946	US GUIDANCE FOR AMNIOCENTESIS	$100.00	$80.00
			76965	US GUIDE FOR INTERSTITIAL APPLICATIO	$340.00	$272.00
			76942	US GUIDE FOR NEEDLE PLACEMENT	$400.00	$320.00
			76950	US GUIDE PLACEMENTRAD THERAPY FIELD	$160.00	$128.00
			76937	US GUIDE VASCULAR PROCEDURE	$85.00	$68.00
			76802	US PREGNANT 1ST TRI ADDTL GESTATION	$170.00	$136.00
			76801	US PREGNANT 1ST TRIMESTER	$295.00	$236.00
			76810	US PREGNANT AFTER 1ST TRI ADD GESTAT	$230.00	$184.00
			76805	US PREGNANT AFTER 1ST TRIMESTER	$325.00	$260.00
			76816	US PREGNANT FOLLOW UP	$240.00	$192.00
			76815	US PREGNANT LIMITED	$185.00	$148.00
			76814	US PREGNANT NUCHAL TRANS ADD GESTATI	$190.00	$152.00
			76813	US PREGNANT NUCHAL TRANSLUCENCY	$290.00	$232.00
			76811	US PREGNANT PLUS FETAL EXAM	$435.00	$348.00
			76812	US PREGNANT PLUS FETAL EXAM ADD GEST	$460.00	$368.00
			76817	US PREGNANT TRANSVAGINAL	$260.00	$208.00
			76873	US PROSTATE VOLUME STUDY	$400.00	$320.00
			A7046	WATER CHAMBER	$38.00	$30.40

Fee Look Up Table 3

Procedure Code	Procedure Description	Regular Fee	Pay at Time of Service
0159T	CAD FOR MRI BREAST	$75.00	$60.00
10022	FINE NEEDLE ASPIRATION W GUIDE	$250.00	$200.00
10160	PUNCTURE ASPIRATION OF ABSCESS, ETC	$230.00	$184.00
11100	BIOPSY OF SKIN SUBCUTANEOUS TISSUE	$200.00	$160.00
19000	PUNCTURE ASPIRATION OF BREAST CYST	$200.00	$160.00
19001	PUNCTURE ASPIRATION OF CYST EA ADDL	$60.00	$48.00
19030	INJ PROC ONLY FOR MAMMARY DUCTOGRAM	$300.00	$240.00
19081	BIOPSY BREAST STEREOTACTIC 1ST LESIO	$1,500.00	$1,200.00
19082	BIOPSY BREAST STEREO ADDTL LESIONS	$1,200.00	$960.00
19083	BIOPSY BREAST US GUIDE 1ST LESION	$1,500.00	$1,200.00
19084	BIOPSY BREAST US GUIDE ADDTL LESIONS	$1,200.00	$960.00
19085	BIOPSY BREAST MR GUIDE 1ST LESION	$2,300.00	$1,840.00
19086	BIOPSY BREAST MR GUIDE ADDTL LESION	$1,800.00	$1,440.00
19100	BIOPSY OF BREAST NEEDLE CORE	$285.00	$228.00
19101	BIOPSY OF BREAST OPEN INCISIONAL	$650.00	$520.00
19281	PLC BREAST LOC DEV MAMMO GUIDE 1ST L	$550.00	$440.00
19282	PLC BREAST LOC DEV MAMMO GUIDE ADDL	$380.00	$304.00
19283	PLC BREAST LOC DEV STEREO GUIDE 1ST	$625.00	$500.00
19284	PLC BREAST LOC DEV STEREO GUIDE ADDL	$450.00	$360.00
19285	PLC BREAST LOC DEV US GUIDE 1ST LESI	$1,100.00	$880.00
19286	PLC BREAST LOC DEV US GUIDE ADDL LES	$875.00	$700.00
19287	PLC BREAST LOC DEV MR GUIDE 1ST LESI	$1,900.00	$1,520.00
19288	PLC BREAST LOC DEV MR GUIDE ADDL LES	$1,500.00	$1,200.00
20206	BIOPSY MUSCLE PERCUT NEEDLE	$525.00	$420.00
20999	UNLISTED PROC MUSCULOSKELETAL	$600.00	$480.00
23350	INJECTION FOR SHOULDER ARTHRO	$360.00	$288.00
24220	INJ FOR ELBOW ARTHROGRAPHY	$350.00	$280.00
25246	INJ FOR WRIST ARTHROGRAPHY	$400.00	$320.00
27093	INJ PROC FOR HIP ARTHRO WO ANESTHESI	$440.00	$352.00
27370	INJ PROC FOR KNEE ARTHROGRAPHY	$525.00	$420.00
27648	INJ ANKLE ARTHROGRAPHY	$325.00	$260.00
36415	COLLECTION OF VENOUS BLOOD BY VENIPU	$11.00	$8.80
38505	BIOP OR EXCISION LYMPH NODE BY NEEDL	$270.00	$216.00
38792	INJ PROCEDURE FOR ID SENTINEL NODE	$235.00	$188.00
38999	PLACEMENT WIRE LOCALIZATION	$300.00	$240.00
60100	BIOPSY THYROID PERCUTANEOUS NEEDLE	$250.00	$200.00
70336	MRI TEMPOROMANDIBULAR JOINT	$1,100.00	$880.00
70450	CT HEAD/BRAIN WO CONTRAST	$520.00	$416.00
70460	CT HEAD/BRAIN WITH CONTRAST	$630.00	$504.00
70470	CT HEAD/BRAIN W/WO CONTRAST	$760.00	$608.00
70480	CT ORBIT ETC WO CONTRAST	$735.00	$588.00
70481	CT ORBIT ETC WITH CONTRAST	$855.00	$684.00
70482	CT ORBIT ETC WITH AND WO CONTRAST	$980.00	$784.00
70486	CT MAXILLOFACIAL AREA WO CONTRAST	$625.00	$500.00
70487	CT MAXILLOFACIAL AREA WITH CONTRAST	$755.00	$604.00
70488	CT MAXILLOFACIAL AREA W/WO CONTRAST	$920.00	$736.00
70490	CT SOFT TISSUE NECK WO CONTRAST	$620.00	$496.00
70491	CT SOFT TISSUE NECK WITH CONTRAST	$745.00	$596.00
70492	CT SOFT TISSUE NECK W/WO CONTRAST	$900.00	$720.00
70496	CTA HEAD W & WO CONTRAST	$1,400.00	$1,120.00
70498	CTA NECK W & WO CONTRAST	$1,400.00	$1,120.00
70540	MRI ORBIT FACE AND NECK WO CONTRAST	$1,100.00	$880.00
70542	MRI WITH CONTRAST	$1,400.00	$1,120.00
70543	MRI ORBIT W/WO	$1,700.00	$1,360.00
70544	MRA HEAD WO	$1,300.00	$1,040.00
70545	MRA HEAD WITH CONTRAST	$1,300.00	$1,040.00
70546	MRA HEAD W/WO CONTRAST	$1,900.00	$1,520.00
70547	MRA NECK WO	$1,300.00	$1,040.00
70548	MRA NECK W CONTRAST	$1,300.00	$1,040.00
70549	MRA NECK W&WO CONTRAST	$1,900.00	$1,520.00
70551	MRI BRAIN INC BRAIN STEM WO CONTRAST	$1,300.00	$1,040.00
70552	MRI BRAIN WITH CONTRAST	$1,400.00	$1,120.00
70553	MRI BRAIN W/WO CONTR & FURTHER SEQUE	$1,750.00	$1,400.00
71250	CT THORAX WO CONTRAST	$635.00	$508.00
71260	CT THORAX WITH CONTRAST	$760.00	$608.00
71270	CT THORAX W/WO CONTRAST FURTHER SECT	$940.00	$752.00
71275	CTA CHEST WITH AND WO CONTRAST	$1,150.00	$920.00
71550	MRI CHEST WO CONTRAST	$1,400.00	$1,120.00
71551	MRI CHEST WITH CONTRAST	$1,500.00	$1,200.00
71552	MRI CHEST W/WO CONTRAST	$1,900.00	$1,520.00
71555	MRA CHEST W & WO CONTRAST	$1,300.00	$1,040.00
72125	CT CERVICAL SPINE WO CONTRAST	$635.00	$508.00
72126	CT CERVICAL SPINE WITH CONTRAST	$760.00	$608.00
72127	CT CERVICAL SPINE W/WO CONTRAST	$925.00	$740.00
72128	CT THORACIC SPINE WO CONTRAST	$635.00	$508.00
72129	CT THORACIC SPINE WITH CONTRAST	$760.00	$608.00
72130	CT THORACIC SPINE W/WO CONTRAST	$930.00	$744.00
72131	CT LUMBAR SPINE WO CONTRAST	$635.00	$508.00
72132	CT LUMBAR SPINE WITH CONTRAST	$760.00	$608.00
72133	CT LUMBAR SPINE W/WO CONTRAST	$930.00	$744.00
72141	MRI CERVICAL SPINE WO CONTRAST	$1,750.00	$1,400.00
72142	MRI CERVICAL SPINE WITH CONTRAST	$1,750.00	$1,400.00
72146	MRI THORACIC SPINE WO CONTRAST	$1,750.00	$1,400.00
72147	MRI THORACIC SPINE WITH CONTRAST	$1,750.00	$1,400.00
72148	MRI LUMBAR/CONTENTS WO CONTRAST	$1,750.00	$1,400.00
72149	MRI LUMBAR/CONTENTS WITH CONTRAST	$1,750.00	$1,400.00
72156	MRI CERVICAL SPINE W/WO CONTRAST	$1,900.00	$1,520.00
72157	MRI THORACIC/CONTENTS W/WO CONTRAST	$1,800.00	$1,440.00
72158	MRI LUMBAR/CONTENTS W/WO CONTRAST	$1,900.00	$1,520.00
72159	MRA SPINAL CANAL W/WO CONTRAST	$1,400.00	$1,120.00
72191	CTA PELVIS W/WO CONTRAST	$1,100.00	$880.00
72192	CT PELVIS WO CONTRAST	$600.00	$480.00
72193	CT PELVIS WITH CONTRAST	$725.00	$580.00
72194	CT PELVIS W/WO CONTRAST & FURTH SECT	$920.00	$736.00
72195	MRI PELVIS WO CONTRAST	$1,200.00	$960.00
72196	MRI PELVIS WITH CONTRAST	$1,400.00	$1,120.00
72197	MRI PELVIS W/WO CONTRAST	$1,900.00	$1,520.00
72198	MRA PELVIS W/WO CONTRAST	$1,165.00	$932.00
73200	CT UPPER EXTREMITY WO CONTRAST	$600.00	$480.00
73201	CT UPPER EXTREMITY WITH CONTRAST	$720.00	$576.00
73202	CT UPPER EXTREMITY W/WO CONTRAST	$920.00	$736.00
73206	CTA UPPER EXTREMIT W/WO CONTRAST	$1,100.00	$880.00
73218	MRI UPPER EXTREMITY WO CONTRAST	$1,200.00	$960.00
73219	MRI UPPER EXTREMITY WITH CONTRAST	$1,400.00	$1,120.00
73220	MRI UPPER EXTREMITY OTHER THAN JOINT	$1,900.00	$1,520.00
73221	MRI ANY JOINT UPPER EXTREMITY	$1,700.00	$1,360.00
73222	MRI ANY JOINT UPPER EXT W/CONTRAST	$1,300.00	$1,040.00
73223	MRI ANY JOINT UPPER EXT W/WO CONTRAS	$1,800.00	$1,440.00
73225	MRA UPPER EXTREMITY W/WO CONTRAST	$1,300.00	$1,040.00
73700	CT LOWER EXTREMITY WO CONTRAST	$600.00	$480.00
73701	CT LOWER EXTREMITY WITH CONTRAST	$725.00	$580.00
73702	CT LOWER EXTREM W/WO CON FURTH SECT	$925.00	$740.00
73706	CTA, LOWER EXTREM W/WO CONTRAST	$1,100.00	$880.00
73718	MRI LOWER EXTREMITY WO CONTRAST	$1,200.00	$960.00
73719	MRI LOWER EXTREMITY WITH CONTRAST	$1,400.00	$1,120.00
73720	MRI LOWER EXTREMITY W/WO CONTRAST	$1,800.00	$1,440.00
73721	MRI ANY JOINT LOWER EXTREMITY	$1,700.00	$1,360.00
73722	MRI ANY JOINT LOWER EXTR WTH CONTRAS	$1,300.00	$1,040.00
73723	MRI ANY JOINT LOWER EXTR W/WO CONTRA	$1,800.00	$1,440.00
73725	MRA LOWER EXTREMITY W/WO CONTRAST	$1,200.00	$960.00
74150	CT ABDOMEN WO CONTRAST	$600.00	$480.00
74160	CT ABDOMEN WITH CONTRAST	$800.00	$640.00
74170	CT ABDOMEN W/WO CONTRAST FURTH SECT	$995.00	$796.00
74174	CTA ABD PELVIC W AND WO CONTRAST	$1,300.00	$1,040.00
74175	CTA ABDOMEN W AND WO	$1,175.00	$940.00
74176	CT ABD & PELVIS WO CONTRAST	$800.00	$640.00
74177	CT ABD & PELVIS WITH CONTRAST	$900.00	$720.00
74178	CT ABD & PELVIS W/WO CONTRAST FURTHE	$1,200.00	$960.00
74181	MRI ABDOMEN WO CONTRAST	$1,100.00	$880.00
74182	MRI ABDOMEN WITH CONTRAST	$1,500.00	$1,200.00
74183	MRI ABDOMEN W/WO CONTRAST	$1,900.00	$1,520.00
74185	MRA ABDOMEN WITH OR WO CONTRAST	$1,300.00	$1,040.00
75561	MRI CARDIAC W/WO CONTRAST	$1,600.00	$1,280.00
75571	CT HEART WO CONTRAST CALCIUM SCORING	$200.00	$160.00
75572	CT HEART W CONTRAST STRUCTURE MORPHO	$675.00	$540.00
75573	CT HEART W CONTRAST CONG HRT DISEASE	$975.00	$780.00
75574	CTA W CONTRAST 3D	$1,500.00	$1,200.00
75635	CTA ABD AORTA LOWER EXTREMITY	$1,300.00	$1,040.00
76098	RADIOLOGICAL EXAM SURGICAL SPECIMEN	$45.00	$36.00
76098	RADIOLOGICAL EXAM SURGICAL SPECIMEN	$45.00	$36.00
76376	3D RENDERING NOT ON INDEPNDT WK STA	$250.00	$200.00
76377	3D RENDERING ON INDEPENDENT WK STATI	$375.00	$300.00
76380	CT LMTD OR LOCALIZED FOLLOW UP STUDY	$430.00	$344.00
76506	ULTRASOUND CEREBRAL	$250.00	$200.00
76536	ULTRASOUND SOFT TISSUES HEAD & NECK	$220.00	$176.00
76604	ULTRASOUND CHEST	$155.00	$124.00
76641	US BREAST COMPLETE	$220.00	$176.00
76642	US BREAST LIMITED	$180.00	$144.00
76700	ULTRASOUND ABDOMINAL	$300.00	$240.00
76705	ULTRASOUND ABDOMINAL LTD	$215.00	$172.00
76770	ULTRASOUND RENAL/ RETROPERITONEAL	$250.00	$200.00
76775	ULTRASOUND RETROPERITONEAL LIMITED	$220.00	$176.00
76800	ECHOGRAPHY, SPINAL CANAL AND CONTENT	$275.00	$220.00
76801	US PREGNANT 1ST TRIMESTER	$295.00	$236.00
76802	US PREGNANT 1ST TRI ADDTL GESTATION	$170.00	$136.00
76805	US PREGNANT AFTER 1ST TRIMESTER	$325.00	$260.00
76810	US PREGNANT AFTER 1ST TRI ADD GESTAT	$230.00	$184.00
76811	US PREGNANT PLUS FETAL EXAM	$435.00	$348.00
76812	US PREGNANT PLUS FETAL EXAM ADD GEST	$460.00	$368.00
76813	US PREGNANT NUCHAL TRANSLUCENCY	$290.00	$232.00
76814	US PREGNANT NUCHAL TRANS ADD GESTATI	$190.00	$152.00
76815	US PREGNANT LIMITED	$185.00	$148.00
76816	US PREGNANT FOLLOW UP	$240.00	$192.00
76817	US PREGNANT TRANSVAGINAL	$260.00	$208.00
76818	FETAL BIOPHYSICAL PROFILE	$225.00	$180.00
76819	FETAL BIOPHYSICAL PROFILE WO	$200.00	$160.00
76820	DOPPLER VELOCIMETRY, FETAL	$140.00	$112.00
76821	DOPPLER VELOC FETAL MID CEREBRAL ART	$220.00	$176.00
76825	ULTRASOUND FETAL CARDIOVASCULAR REAL	$465.00	$372.00
76827	DOPPLER ECHOCARDIO FETAL COMPLETE	$165.00	$132.00
76830	ULTRASOUND TRANSVAGINAL NOT OB	$275.00	$220.00
76831	HYSTEROSONOGRAPHY W/WO CONTRAST	$265.00	$212.00
76856	ULTRASOUND PELVIC	$270.00	$216.00
76857	ULTRASOUND PELVIC LTD OR FOLLOW UP	$200.00	$160.00
76870	ULTRASOUND SCROTUM AND CONTENTS	$265.00	$212.00
76872	ULTRASOUND TRANSRECTAL PROSTATE	$315.00	$252.00
76873	US PROSTATE VOLUME STUDY	$400.00	$320.00
76881	ULTRASOUND EXTREM NONVASCULAR COMPLE	$245.00	$196.00
76882	ULTRASOUND EXTREM NONVASCULAR LIMITE	$75.00	$60.00
76885	SONO INFANT HIPS REAL TIME	$300.00	$240.00
76886	SONO INFANT HIPS LIMITED	$225.00	$180.00
76936	SONO SOFT TISSUE COMPRESSION REPAIR	$700.00	$560.00
76937	US GUIDE VASCULAR PROCEDURE	$85.00	$68.00
76942	US GUIDE FOR NEEDLE PLACEMENT	$400.00	$320.00
76946	US GUIDANCE FOR AMNIOCENTESIS	$100.00	$80.00
76950	US GUIDE PLACEMENTRAD THERAPY FIELD	$160.00	$128.00
76965	US GUIDE FOR INTERSTITIAL APPLICATIO	$340.00	$272.00
76970	SONO FOLLOW UP SPECIFY	$185.00	$148.00
77012	CT GUIDANCE NEEDLE BIOPSY	$495.00	$396.00
77013	CT GUIDE PARENCHYMAL TISSUE ABLATION	$1,300.00	$1,040.00
77014	CT GUIDE PLCMNT OF RAD THERAP FLD	$375.00	$300.00
77021	MRI GUIDE NEEDLE PLACEMENT	$995.00	$796.00
77051	COMPUTER AID DETECTION DIAGNOSITC	$35.00	$28.00
77052	COMPUTER AID DETECTION SCREENING	$35.00	$28.00
77053	MAMM DUCTOGRM OR GALACTOGRM SGL DUCT	$230.00	$184.00
77054	MAMM DUCTOGRAM OR GALACTOGRAM	$255.00	$204.00
77058	MRI BREAST UNILAT W/WO CONTRAST	$1,700.00	$1,360.00
77059	MRI BREAST BILATERAL W/WO CONTRAST	$1,750.00	$1,400.00
77078	CT BONE DENSITY STUDY	$375.00	$300.00
77080	DEXA BONE DENSITY STUDY	$255.00	$204.00
77081	DEXA SCAN PERIPHERAL	$70.00	$56.00
77082	DEXA VERTEBRAL FX ASSESSMENT	$65.00	$52.00
77085	DEXA BONE DENSITY STUDY	$270.00	$216.00
77086	FRACTURE ASSESSMENT VIA DXA	$85.00	$68.00
78459	PET, METABOLIC EVALUATION	$3,400.00	$2,720.00
78608	PET SCAN; METABOLIC EVALUATION	$3,100.00	$2,480.00
78609	P.E.T. SCAN, BRAIN	$3,400.00	$2,720.00
78812	PET IMAGING SKULL BASE TO MID THIGH	$3,200.00	$2,560.00
78814	PET IMAGING WITH CT LIMITED AREA	$5,200.00	$4,160.00
78815	PET IMAGING WITH CT SKULL BASE TO MI	$5,500.00	$4,400.00
78816	PET IMAGING WITH CT WHOLE BODY	$5,600.00	$4,480.00
93880	DUPLX SCAN EXTRACRAN ARTER COMP BILA	$500.00	$400.00
93882	DUPLX SCAN EXTRACRAN ARTER FOLLOW UP	$365.00	$292.00
93925	DUPLX SCAN LOWER EXT ART OR ART BY	$680.00	$544.00
93926	DUPLX SCAN LOWER EXTR ART FOLLOW UP	$435.00	$348.00
93930	DUPLX SCAN UP EXTREM ART OR ART BY	$545.00	$436.00
93931	DUPLX SCAN UP EXTREM ART OR ART BY	$365.00	$292.00
93965	PHYSIOLOGIC STUDIEEXTEM. BILAT	$275.00	$220.00
93970	DUPLX SCAN EXTREM VEINS INC RESPONS	$500.00	$400.00
93971	DUPLX SCAN EXTREM VEINS FOLLOW UP	$375.00	$300.00
93975	DUPLX SCAN ART INFLOW VENOUS OUTFLOW	$845.00	$676.00
93976	DUPLX SCAN ART INFLOW VENOUS OUTFLOW	$490.00	$392.00
93978	DUPLEX SCAN OF AORTA	$535.00	$428.00
93980	DUPLEX SCAN PENILEVESSELS	$420.00	$336.00
93981	DPLX SCN OF ART INF VENOUS OTFL OF P	$295.00	$236.00
93990	DUPLEX SCAN OF HEMODIALYSIS ACCESS	$430.00	$344.00
94060	SPIROMETRY	$92.00	$73.60
94660	POS AIRWAY PRESSURE CPAP	$125.00	$100.00
94762	OXIMETRY CONTINUOUS OVERNIGHT MONITORING	$100.00	$80.00
95800	SLP STDY UNATTENDED	$420.00	$336.00
95801	SLP STDY UNATND W/ANAL	$420.00	$336.00
95803	ACTIGRAPHY TESTING	$275.00	$220.00
95805	MULTIPLE SLEEP LATENCY TEST	$925.00	$740.00
95806	SLEEP STUDY UNATT&RESP EFFT	$475.00	$380.00
95807	SLEEP STUDY ATTENDED	$1,300.00	$1,040.00
95808	POLYSOM ANY AGE 1-3> PARAM	$1,925.00	$1,540.00
95810	POLYSOM 6/> YRS 4/> PARAM	$1,700.00	$1,360.00
95811	POLYSOM 6/>YRS CPAP 4/> PARM	$1,850.00	$1,480.00
99201	OFC VISIT NEW PT 10 MINUTES	$85.00	$68.00
99202	OFC VISIT NEW PT 20 MINUTES	$145.00	$116.00
99203	OFC VISIT NEW PT 30 MINUTES	$210.00	$168.00
99204	OFC VISIT NEW PT 45 MINUTES	$325.00	$260.00
99205	OFC VISIT NEW PT 60 MINUTES	$410.00	$328.00
99211	OFC VISIT EST PT 5 MINUTES	$40.00	$32.00
99212	OFC VISIT EST PT 10 MINUTES	$85.00	$68.00
99213	OFC VISIT EST PT 15 MINUTES	$140.00	$112.00
99214	OFC VISIT EST PT 25 MINUTES	$210.00	$168.00
99215	OFC VISIT EST PT 40 MINUTES	$285.00	$228.00
99241	CONSULTATION OP LEVEL 1	$110.00	$88.00
99242	CONSULTATION OP LEVEL 2	$200.00	$160.00
99243	CONSULTATION OP LEVEL 3	$285.00	$228.00
99244	CONSULTATION OP LEVEL 4	$420.00	$336.00
99245	CONSULTATION OP LEVEL 5	$515.00	$412.00
A7027	COMBINATION ORAL/NASAL MASK	$215.00	$172.00
A7028	REPL ORAL CUSHION COMBO MASK	$55.00	$44.00
A7029	REPL NASAL PILLOW COMB MASK	$35.00	$28.00
A7030	CPAP FULL FACE MASK	$215.00	$172.00
A7031	REPLACEMENT FACEMASK INTERFA	$100.00	$80.00
A7032	REPLACEMENT NASAL CUSHION	$45.00	$36.00
A7033	REPLACEMENT NASAL PILLOWS	$40.00	$32.00
A7034	NASAL APPLICATION DEVICE	$145.00	$116.00
A7035	POS AIRWAY PRESS HEADGEAR	$55.00	$44.00
A7036	POS AIRWAY PRESS CHINSTRAP	$25.00	$20.00
A7037	POS AIRWAY PRESSURE TUBING	$60.00	$48.00
A7038	POS AIRWAY PRESSURE FILTER	$8.00	$6.40
A7039	FILTER, NON DISPOSABLE W PAP	$25.00	$20.00
A7044	PAP ORAL INTERFACE	$120.00	$96.00
A7045	REPL EXHALATION PORT FOR PAP	$25.00	$20.00
A7045RR	REPL EXHALATION PORT FOR PAP RENT	$2.00	$1.60
A7046	WATER CHAMBER	$38.00	$30.40
A9500	TC99CM SESTAMIBI	$150.00	$120.00
A9520	TC99M SULFUR COLLOID	$325.00	$260.00
A9541	TC99M SULFUR COLLOID	$120.00	$96.00
A9552	FDG	$550.00	$440.00
A9576	PROHANCE GADOTERIDOL INJ	$2.50	$2.00
A9579	GADOLINIUM MRI CONTRAST ML	$2.10	$1.68
A9581	EOVIST GADOXETATE DISODIUM 1ML	$17.00	$13.60
E0470	RAD W/O BACKUP NON-INV INTFC	$2,800.00	$2,240.00
E0470RR	RAD W/O BACKUP NON-INV INTFC RENT	$250.00	$200.00
E0471	RAD W/BACKUP NON INV INTRFC	$4,700.00	$3,760.00
E0471RR	RAD W/BACKUP NON INV INTRFC RENT	$620.00	$496.00
E0561	HUMIDIFIER NONHEATED W PAP	$155.00	$124.00
E0561RR	HUMIDIFIER NONHEATED W PAP RENT	$10.00	$8.00
E0562	HUMIDIFIER HEATED USED W PAP	$435.00	$348.00
E0562RR	HUMIDIFIER HEATED USED W PAP RENT	$30.00	$24.00
E0601	CONT AIRWAY PRESSURE DEVICE	$1,225.00	$980.00
E0601RR	CONT AIRWAY PRESSURE DEVICE RENT	$110.00	$88.00
G0202	DIGITAL SCREENING MAMMOGRAM	$235.00	$188.00
G0204	DIGITAL BILATERAL DX MAMMOGRAM	$275.00	$220.00
G0206	DIGITAL UNILAT DX MAMMOGRAM	$215.00	$172.00
G0389	ULTRASOUND - AAA SCREENING	$250.00	$200.00
G0398	HOME SLEEP TEST/TYPE 2 PORTA	$420.00	$336.00
G0399	HOME SLEEP TEST/TYPE 3 PORTA	$420.00	$336.00
G0400	HOME SLEEP TEST/TYPE 4 PORTA	$420.00	$336.00
Q9967	OMNIPAQUE 350MG	$0.22	$0.18

Fee Look Up Table 1

Fee Look Up Table 2

Fee Look Up Table 3

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