RADIOLOGY - X-RAY - COMPUTERIZED AXIAL TOMMOGRAPHY - MAGNETIC RESONENCE IMAGIN For the Time Period : 10/01/16 and 09/30/2017 IF YOU ARE COVERED BY HEALTH INSURANCE, YOU ARE STRONGLY ENCOURAGED TO CONSULT WITH YOUR HEALTH INSURER TO DETERMINE ACCURATE INFORMATION ABOUT YOUR FINACIAL RESPONSIBILITY FOR A PARTICULAR HEALTH CARE SERVICE PROVIDED AT THIS HEALTHCARE FACILITY. IF YOU ARE NOT COVERED BY HEALTH INSURANCE YOU ARE STRONGLY ENCOURAGED TO CONTACT THE BUSINESS OFFICE AT (719)584-4508 OR TOLL FREE AT 800-543-4046 TO DISCUSS PAYMENT OPTIONS PRIOR TO RECEIVING A HEALTH CARE SERVICE FROM THIS HEALTH CARE FACILITY SINCE POSTED HEALTHCARE SERVICES MAY NOT REFLECT THE ACTUAL AMOUNT OF YOUR FINANCIAL RESPONSIBILITY. Note: 1. The pricing on this page is for Radiology studies only. It is not combined pricing with other testing 2. Charging is based on the Length of Stay, amount of supplies used, therapies provided, testing given as well as other care provided 3. This pricing is based on an average charge and not intended to be the exact charge for any particular patient 4. Theself pay charge shown is an estimate and that actual charges for the service depend on the patient's circumstances at the time the service is provided. 5. Any insurance discount is negotiated by the insurance carrier. Most insurance carriers should be able to tell their members what financial responsibility they will have. 6. The charge shown is only for patients without insurance. CPT Description Self Pay Charge 70030 X-RAY EYE FOR FOREIGN BODY $ 365.67 70110 X-RAY EXAM OF JAW 4 VIEWS OR MORE $ 486.96 70130 X-RAY EXAM OF MASTOIDS $ 352.79 70140 X-RAY EXAM OF FACIAL BONES $ 718.20 70150 X-RAY EXAM OF FACIAL BONES $ 458.51 70160 X-RAY EXAM OF NASAL BONES $ 516.34 70200 X-RAY EXAM OF EYE SOCKETS $ 371.77 70210 X-RAY EXAM OF SINUSES $ 280.59
70220 X-RAY EXAM OF SINUSES $ 541.05 70250 X-RAY EXAM OF SKULL $ 363.45 70260 X-RAY EXAM OF SKULL $ 644.67 70330 X-RAY EXAM OF JAW JOINTS $ 412.14 70360 X-RAY EXAM OF NECK $ 303.77 70450 CT HEAD/BRAIN W/OUT DYE $ 1,641.42 70460 CT HEAD/BRAIN W/DYE $ 1,745.38 70470 CT HEAD/BRAIN W/OUT W/DYE $ 3,152.89 70480 CT ORBIT/EAR/FOSSA W/OUT DYE $ 1,599.27 70481 CT ORBIT/EAR/FOSSA W/DYE $ 2,474.56 70482 CT ORBIT/EAR/FOSSA W/OUT AND W/DYE $ 3,703.14 70486 CT MAXILLOFACIAL W/OUT DYE $ 1,486.85 70487 CT MAXILLOFACIAL W/DYE $ 2,187.74 70488 CT MAXILLOFACIAL W/OUT AND W/DYE $ 3,447.04 70490 CT SOFT TISSUE NECK W/OUT DYE $ 1,262.59 70491 CT SOFT TISSUE NECK W/DYE $ 2,115.25 70492 CT SFT TSUE NCK W/O W/DYE $ 3,368.97 70496 CT ANGIOGRAPHY HEAD $ 3,159.56 70498 CT ANGIOGRAPHY NECK $ 3,130.72 70540 MRI ORBIT, FACE, NECK W/OUT DYE $ 1,019.16 70542 MRI ORBIT, FACE,NECK W/DYE $ 1,381.30 70543 MRI ORBT, FACE, NECK W/OUT AND W/DYE $ 1,547.28 70544 MR ANGIOGRAPHY HEAD W/OUT DYE $ 965.84 70546 MR ANGIOGRAPH HEAD W/OUT AND W/DYE $ 832.20 70547 MR ANGIOGRAPHY NECK W/OUT DYE $ 1,009.47 70548 MR ANGIOGRAPHY NECK W/DYE $ 572.28 70549 MR ANGIOGRAPH NECK W/OUT AND W/DYE $ 1,719.75 70551 MRI BRAIN STEM W/OUT DYE $ 916.26 70552 MRI BRAIN STEM W/DYE $ 1,057.70 70553 MRI BRAIN STEM W/OUT AND W/DYE $ 1,413.81 71010 CHEST X-RAY 1 VIEW FRONTAL $ 307.33 71020 CHEST X-RAY 2 VIEWS FRONTAL $ 374.67 71035 CHEST X-RAY SPECIAL VIEWS $ 256.44 71110 X-RAY EXAM RIBS BILATERAL 3 VIEWS $ 579.50
71111 X-RAY EXAM RIBS, CHEST 4 VIEWS OR MORE $ 516.31 71120 X-RAY EXAM BREASTBONE 2 VIEWS OR MORE $ 330.72 71130 X-RAY STRENOCLAVIC JT 3 VIEWS OR MORE $ 277.78 71250 CT THORAX W/OUT DYE $ 1,093.53 71260 CT THORAX W/DYE $ 2,164.83 71270 CT THORAX W/OUT AND W/DYE $ 2,224.62 71275 CT ANGIOGRAPHY CHEST $ 3,141.79 71550 MRI CHEST W/OUT DYE $ 750.09 71552 MRI CHEST W/OUT AND W/DYE $ 1,299.03 72020 X-RAY EXAM OF SPINE 1 VIEW $ 262.58 72040 X-RAY EXAM NECK SPINE 2-3 VIEWS $ 456.20 72050 X-RAY EXAM NECK SPINE 4-5 VIEWS $ 625.77 72052 X-RAY EXAM NECK SPINE 6 VIEWS OR MORE $ 607.08 72070 X-RAY EXAM THORAC SPINE 2 VIEWS $ 448.97 72072 X-RAY EXAM THORAC SPINE 3VIEWS $ 488.29 72074 X-RAY EXAM THORAC SPINE 4 VIEWS OR MORE $ 55.10 72080 X-RAY EXAM THORACOLUMBAR 2 VIEWS OR MORE $ 305.90 72081 X-RAY EXAM ENTIRE SPINE 1 VIEW $ 132.62 72082 X-RAY EXAM ENTIRE SPINE 2-3 VIEWS $ 266.67 72100 X-RAY EXAM LUMBAR SACRAL SPINE 2-3 VIEWS $ 447.68 72110 X-RAY EXAM LUMBAR SACRAL SPINE 4 VIEWS OR MORE $ 544.16 72114 X-RAY EXAM LUMBAR SACRAL SPINE - BENDING $ 746.03 72120 X-RAY BENDING ONLY LUMBAR-SACRAL SPINE $ 229.05 72125 CT NECK SPINE W/OUT DYE $ 2,642.80 72126 CT NECK SPINE W/DYE $ 2,692.28 72128 CT CHEST SPINE W/OUT DYE $ 2,101.20 72129 CT CHEST SPINE W/DYE $ 2,697.49 72131 CT LUMBAR SPINE W/OUT DYE $ 1,782.07 72132 CT LUMBAR SPINE W/DYE $ 2,687.06 72133 CT LUMBAR SPINE W/OUT AND W/DYE $ 528.20 72141 MRI NECK SPINE W/OUT DYE $ 844.76 72142 MRI NECK SPINE W/DYE $ 954.99 72146 MRI CHEST SPINE W/OUT DYE $ 857.61 72147 MRI CHEST SPINE W/DYE $ 1,315.18
72148 MRI LUMBAR SPINE W/OUT DYE $ 845.90 72149 MRI LUMBAR SPINE W/DYE $ 823.84 72156 MRI NECK SPINE W/OUT AND W/DYE $ 1,519.06 72157 MRI CHEST SPINE W/OUT AND W/DYE $ 1,564.02 72158 MRI LUMBAR SPINE W/OUT AND W/DYE $ 1,675.23 72170 X-RAY EXAM OF PELVIS $ 336.30 72191 CT ANGIOGRAPH PELV W/OUT AND W/DYE $ 3,161.22 72192 CT PELVIS W/OUT DYE $ 2,053.11 72193 CT PELVIS W/DYE $ 1,995.65 72194 CT PELVIS W/OUT AND W/DYE $ 2,390.20 72195 MRI PELVIS W/OUT DYE $ 799.98 72197 MRI PELVIS W/OUT AND W/DYE $ 1,344.07 72202 X-RAY EXAM SI JOINTS 3 VIEWS OR MORE $ 268.22 72220 X-RAY EXAM SACRUM TAILBONE $ 321.50 72295 X-RAY OF LOWER SPINE DISK $ 2,941.96 73050 X-RAY EXAM OF SHOULDERS $ 395.96 73085 CONTRAST X-RAY OF ELBOW $ 203.19 73200 CT UPPER EXTREMITY W/OUT DYE $ 1,419.05 73201 CT UPPER EXTREMITY W/DYE $ 2,416.69 73202 CT UPPR EXTREMITY W/OUT AND W/DYE $ 2,588.05 73206 CT ANGIO UPR EXTRM W/OUT AND W/DYE $ 3,131.55 73218 MRI UPPER EXTREMITY W/OUT DYE $ 875.37 73219 MRI UPPER EXTREMITY W/DYE $ 693.12 73220 MRI UPPR EXTREMITY W/OUT AND W/DYE $ 1,325.39 73221 MRI JOINT UPR EXTREM W/OUT DYE $ 779.64 73222 MRI JOINT UPR EXTREM W/DYE $ 1,487.72 73223 MRI JOINT UPR EXTR W/OUT AND W/DYE $ 1,512.44 73501 X-RAY EXAM HIP UNILATERAL 1 VIEW $ 202.82 73523 X-RAY EXAM HIPS BILATERAL 5 VIEWS OR MORE $ 279.93 73525 CONTRAST X-RAY OF HIP $ 273.19 73562 X-RAY EXAM OF KNEE 3 VIEWS $ 283.48 73564 X-RAY EXAM KNEE 4 VIEWS OR MORE $ 288.04 73565 X-RAY EXAM OF KNEES $ 296.97 73700 CT LOWER EXTREMITY W/OUT DYE $ 1,804.05
73701 CT LOWER EXTREMITY W/DYE $ 2,442.36 73706 CT ANGIO LWR EXTR W/OUT AND W/DYE $ 3,143.42 73718 MRI LOWER EXTREMITY W/OUT DYE $ 830.34 73719 MRI LOWER EXTREMITY W/DYE $ 660.06 73720 MRI LWR EXTREMITY W/OUT AND W/DYE $ 1,598.59 73721 MRI JNT OF LWR EXTRE W/OUT DYE $ 794.01 73722 MRI JOINT OF LOWER EXTREMITY(S) W/DYE $ 1,195.86 73723 MRI JOINT LOWER EXTREMITY W/OUT AND W/DYE $ 1,312.07 74000 X-RAY EXAM OF ABDOMEN $ 307.64 74020 X-RAY EXAM OF ABDOMEN $ 638.25 74022 X-RAY EXAM SERIES ABDOMEN $ 583.63 74150 CT ABDOMEN W/OUT DYE $ 1,202.80 74160 CT ABDOMEN W/DYE $ 2,425.17 74170 CT ABDOMEN W/OUT AND W/DYE $ 2,273.01 74174 CT ANGIOGRAPHY ABDOMEN/PELVIS W/OUT AND W/DYE $ 4,726.06 74175 CT ANGIOGRAPHY ABDOMEN W/OUT AND W/DYE $ 3,119.14 74176 CT ABDOMEN/PELVIS W/OUT CONTRAST $ 3,030.94 74177 CT ABDOMEN/PELVIS W/CONTRAST $ 3,708.61 74178 CT ABDOMEN/PELVIS 1 OR MORE REGIONS $ 3,810.59 74181 MRI ABDOMEN W/OUT DYE $ 1,017.37 74183 MRI ABDOMEN W/OUT AND W/DYE $ 1,402.33 74220 CONTRAST X-RAY ESOPHAGUS $ 352.36 74230 CINE/VIDEO X-RAY THROAT/ESOPHAGUS $ 324.10 74240 X-RAY UPPER GI DELAY W/OUT KUB $ 348.08 74246 CONTRAST X-RAY UPPER GASTROINTESTINAL TRACT $ 605.84 74249 CONTRAST X-RAY UPPER GASTROINTESTIAL TRACT $ 845.88 74250 X-RAY EXAM OF SMALL BOWEL $ 344.03 74270 CONTRAST X-RAY EXAM OF COLON $ 640.40 74280 CONTRAST X-RAY EXAM OF COLON $ 863.93 74300 X-RAY BILE DUCTS/PANCREAS $ 282.64 74328 X-RAY BILE DUCT ENDOSCOPY $ 262.11 74340 X-RAY GUIDANCE FOR GASTROINTESTINAL TUBE $ 507.68 74360 X-RAY GUIDANCE FOR GASTOINTESTINAL DILATION $ 266.00 74400 CONTRST X-RAY URINARY TRACT $ 662.77
74420 CONTRST X-RAY URINARY TRACT $ 428.52 74430 CONTRAST X-RAY BLADDER $ 268.10 74450 X-RAY URETHRA/BLADDER $ 227.76 74455 X-RAY URETHRA/BLADDER $ 268.52 74740 X-RAY FEMALE GENITAL TRACT $ 724.28 75561 CARDIAC MRI FOR MORPH W/DYE $ 1,801.20 75563 CARDIAC MRI W/STRESS IMAGING W/DYE $ 2,102.66 75572 CT HEART W/3D IMAGE $ 411.54 75574 CT ANGIOGRAM HEART W/3D IMAGE $ 3,639.96 75625 CONTRAST EXAM ABDOMINAL AORTA $ 2,220.72 75630 X-RAY AORTA LEG ARTERIES $ 2,220.72 75635 CT ANGIO ABDOMINAL ARTERIES $ 3,128.87 75710 ARTERY X-RAYS ARM/LEG $ 1,598.28 75716 ARTERY X-RAYS ARMS/LEGS $ 2,257.83 75978 REPAIR VENOUS BLOCKAGE $ 2,034.52 75984 XRAY CONTROL CATHETER CHANGE $ 1,539.00 76000 FLUOROSCOPE EXAMINATION $ 243.08 76010 X-RAY NOSE TO RECTUM $ 434.33 76376 3D RENDER W/INTERPRETATION POSTPROCESS $ 66.50 76506 ECHO EXAM OF HEAD $ 302.73 76536 US (ULTRASOUND)EXAM OF HEAD AND NECK $ 612.96 76604 US (ULTRASOUND)EXAM CHEST $ 98.70 76641 ULTRASOUND BREAST COMPLETE $ 546.50 76642 ULTRASOUND BREAST LIMITED $ 536.18 76700 US (ULTRASOUND)EXAM ABDOM COMPLETE $ 698.04 76705 ECHO EXAM OF ABDOMEN $ 456.61 76706 US (ULTRASOUND) ABDOMINALL AORTA SCREEN AAA $ 457.91 76775 US (ULTRASOUND) EXAM ABDOMINAL BACK WALL LIMITED STUDY $ 448.32 76800 US (ULTRASOUND) EXAM SPINAL CANAL $ 329.69 76801 OB US (ULTRASOUND) LESS THAN 14 WKS SINGLE FETUS $ 501.53 76802 OB US (ULTRASOUND) LESS THAN 14 WKS ADDL FETUS $ 268.28 76805 OB US (ULTRASOUND)GREATER THAN OR EQUAL TO 14 WKS SNGL FETUS $ 642.85 76810 OB US (ULTRASOUND) GREATER THAN OR EQUAL TO 14 WKS ADDL FETUS $ 462.08 76815 OB US (ULTRASOUND) LIMITED FETUS(S) $ 395.89
76816 OB US (ULTRASOUND) FOLLOW-UP PER FETUS $ 389.88 76817 TRANSVAGINAL US (ULTRASOUND) OBSTETRIC $ 470.88 76819 FETAL BIOPHYS PROFILE W/O NST(NON-STRESS TESTING) $ 829.49 76820 UMBILICAL ARTERY ECHOCARDIOGRAM $ 87.78 76830 TRANSVAGINAL US (ULTRASOUND) NON-OB $ 690.35 76856 US (ULTRASOUND) EXAM PELVIC COMPLETE $ 687.46 76857 US (ULTRASOUND) EXAM PELVIC LIMITED $ 213.51 76870 US (ULTRASOUND) EXAM SCROTUM $ 768.26 76882 US (ULTRASOUND)XTREMITY NON-VASCULAR LIMITED $ 571.43 76885 US (ULTRASOUND) EXAM INFANT HIPS DYNAMIC $ 40.66 76942 ECHO(ULTRASONIC) GUIDANCE FOR BIOPSY $ 491.40 76998 US (ULTRASOUND) GUIDE INTRAOP $ 463.60 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL VEIN ACCESS DEVICE $ 331.36 77002 FLUORSCOPIC GUIDANCE FOR NEEDLE LOCALIZATION $ 261.00 77003 FLUOROSCOPIC GUIDANCE FOR SPINE INJECTION $ 270.34 77012 CT GUIDANCE FOR BIOPSY $ 2,028.79 77066 DIAGNOSTIC MAMMOGRAPHY; COMPUTER AIDED DETECTION, BILATERAL $ 428.64 77067 SCREENING MAMMOGRAPHY; COMPUTER AIDED DETECTION, BILATERAL $ 281.20 77063 SCREENING BREAST TOMOSYNTHESIS ADDED TO SCREENING OR DIAGNOSTIC $ 424.24 MAMMOGRAM 77072 X-RAYS FOR BONE AGE $ 257.78 77073 X-RAYS BONE LENGTH STUDIES $ 389.92 77074 X-RAYS BONE SURVEY LIMITED $ 573.74 77080 DXA BONE DENSITY AXIAL (DUAL ENERGY XRAY ABSORBTIOMETRY BONE DENISITY) $ 125.65 77081 DXA BONE DENSITY/PERIPHERAL (DUAL ENERGY XRAY ABSORBTIOMETRY BONE DENISITY) $ 159.43 78014 THYROID IMAGING W/BLOOD FLOW $ 998.47 78018 THYROID MET IMAGING BODY $ 942.65 78070 PARATHYROID PLANAR IMAGING $ 695.89 78215 LIVER AND SPLEEN IMAGING $ 865.64 78226 HEPATOBILIARY SYSTEM IMAGING $ 950.76 78227 HEPATOBILIARY SYSTEM IMAGING W/DRUG $ 1,031.62 78264 GASTRIC EMPTYING IMAGING STUDY $ 835.36
78278 ACUTE GI BLOOD LOSS IMAGING $ 1,348.24 78306 BONE IMAGING WHOLE BODY $ 1,261.62 78315 BONE IMAGING 3 PHASE $ 1,233.87 78452 HEART MUSCLE IMAGE SPECT(MYOCARDIO PERFUSION IMAGING TOMOGRAPHIC) $ 889.54 MULTIPLE STUDIES 78472 GATED(CARDIAC BLOOD POOL) HEART PLANAR SINGLE STUDY $ 907.82 78580 LUNG PERFUSION IMAGING $ 720.69 78582 LUNG VENTILATED PERFUSION IMAGING $ 1,377.88 78630 CEREBROSPINAL FLUID SCAN $ 2,554.99 78645 CSF(CEREBROSPINAL FLUID) SHUNT EVALUATION $ 537.11 78707 KIDNEY IMAGING FLOW/FUNCT IMAGE W/O DRUG $ 897.56 78708 KIDNEY IMAGING FLOW/FUNCT IMAGE W/DRUG $ 605.70 78804 TUMOR IMAGING WHOLE BODY $ 1,280.98 79005 NUCLEAR RX(RADIOPHARMACEUTICAL) ORAL ADMIN $ 715.87