Description CPT Charge Amount
CT Abdomen and Pelvis 1 or more Regions GLR 74178 $2570.00
CT Abdomen and Pelvis 1 or more Regions PFR 74178 $329.00
CT, Angiography Head GLR 70496 $1367.00
CT, Angiography Head PFR 70496 $284.50
CT, Angiography Neck GLR 70498 $1367.00
CT, Angiography Neck PFR 70498 $284.50
CT, Head/Brain without contrast GLR 70450 $654.00
CT, Head/Brain without contrast PFR 70450 $138.00
CT, Lumbar Spine without contrast GLR 72131 $816.00
CT, Lumbar Spine without contrast PFR 72131 $163.00
CT, Maxillofacial without contrast GLR 70486 $618.00
CT, Maxillofacial without contrast PFR 70486 $187.50
CT, Neck Spine without contrast GLR 72125 $816.00
CT, Neck Spine without contrast PFR 72125 $175.50
CT, Pelvis with contrast GLR 72193 $946.00
CT, Pelvis with contrast PFR 72193 $190.00
CT, Soft Tissue Neck, with contrast GLR 70491 $782.00
CT, Soft Tissue Neck, with contrast PFR 70491 $226.00
CT, Thorax with contrast GLR 71260 $977.00
CT, Thorax with contrast PFR 71260 $204.50
CT, Thorax without contrast GLR 71250 $816.00
CT, Thorax without contrast PFR 71250 $166.00
CTA, Abdomen and Pelvis with and without contrast GLR 74174 $2848.00
CTA, Abdomen and Pelvis with and without contrast PFR 74174 $527.50
CTA, Abdomen and Pelvis with contrast GLR 74177 $1654.00
CTA, Abdomen and Pelvis with contrast PFR 74177 $297.00
CTA, Abdomen and Pelvis without contrast GLR 74176 $1396.00
CTA, Abdomen and Pelvis without contrast PFR 74176 $283.50
CTA, Abdomen with and without contrast GLR 74175 $1424.00
CTA, Abdomen with and without contrast PFR 74175 $310.50
CTA, Chest GLR 71275 $1471.00
CTA, Chest PFR 71275 $312.50
DXA Scan, Bone Density, 1 or more Sites, Axial GLR 77080 $212.00
DXA Scan, Bone Density, 1 or more Sites, Axial PFR 77080 $72.00
Mammgoram, Screening, Bilateral GLR 77067 $465.00
Mammgoram, Screening, Bilateral PFR 77067 $128.50
Mammogram, Diagnostic, Bilteral GLR 77066 $283.00
Mammogram, Diagnostic, Bilteral PFR 77066 $158.00
Mammogram, Diagnostic, Unilteral GLR 77065 $243.00
Mammogram, Diagnostic, Unilteral PFR 77065 $128.50
MRA, Head without contrast GLR 70544 $1501.00
MRA, Head without contrast PFR 70544 $194.50
MRA, Neck without contrast GLR 70547 $1501.00
MRA, Neck without contrast GLR 70551 $1521.00
MRA, Neck without contrast PFR 70547 $196.50
MRA, Neck without contrast PFR 70551 $242.00
MRI, Abdomen with and without contrast GLR 74183 $3302.00
MRI, Abdomen with and without contrast PFR 74183 $367.00
MRI, Brain Stem with and without contrast GLR 70553 $3369.00
MRI, Brain Stem with and without contrast PFR 70553 $385.50
MRI, Joint, Lower Extremity, without contrast GLR 73721 $1501.00
MRI, Joint, Lower Extremity, without contrast PFR 73721 $224.50
MRI, Lumbar Spine without contrast GLR 72148 $1675.00
MRI, Lumbar Spine without contrast GLR 72158 $3369.00
MRI, Lumbar Spine without contrast PFR 72148 $243.00
MRI, Lumbar Spine without contrast PFR 72158 $388.00
MRI, Neck Spine without contrast GLR 72141 $1521.00
MRI, Neck Spine without contrast PFR 72141 $262.50
MRI, Pelvis with and without contrast GLR 72197 $3302.00
MRI, Pelvis with and without contrast PFR 72197 $367.00
Perfusion,Spect, Multiple, Rest/Stress GLR 78452 $4485.00
Perfusion,Spect, Multiple, Rest/Stress PFR 78452 $422.00
Pet/CT,Skull to Mid-Thigh GLR 78815 $6874.00
Pet/CT,Skull to Mid-Thigh PFR 78815 $1245.00
Pulmonary Ventilation/Perfusion Img GLR 78582 $784.50
Pulmonary Ventilation/Perfusion Img PFR 78582 $256.00
Simulation, Radiation Treatment, Simple 77280 $1307.00
Tomosynthesis, Bilateral GLR 77062 $25.00
Tomosynthesis, Bilateral PFR 77062 $38.00
Tomosynthesis, Bilateral Screening GLR 77063 $40.00
Tomosynthesis, Bilateral Screening PFR 77063 $36.00
Tomosynthesis, Unilateral GLR 77061 $25.00
Tomosynthesis, Unilateral PFR 77601 $38.00
US Guidance, Vascular Access 76937 $79.00
US, Abdomen Complete GLR 76700 $379.00
US, Abdomen Complete PFR 76700 $133.00
US, Abdomen Limited GLR 76705 $273.00
US, Abdomen Limited PFR 76705 $94.50
US, Breast, Limited, Bilateral GLR 76642 $152.00
US, Breast, Limited, Bilateral PFR 76642 $134.00
US, Extremity, Non-Vascular, Limited GLR 76882 $90.00
US, Extremity, Non-Vascular, Limited PFR 76882 $79.00
US, Head and Neck GLR 76536 $273.00
US, Head and Neck PFR 76536 $92.50
US, Pelvic Complete GLR 76856 $294.00
US, Pelvic Complete PFR 76856 $111.50
US, Pregnant, 1st Trimest, 1st Gestation GLR 76801 $579.00
US, Pregnant, 1st Trimest, 1st Gestation PFR 76801 $164.00
US, Pregnant, greater than 14 weeks, 1st Gestation GLR 76805 $404.00
US, Pregnant, greater than 14 weeks, 1st Gestation PFR 76805 $164.00
US, Pregnant, Limited GLR 76815 $273.00
US, Pregnant, Limited PFR 76815 $164.00
US, Pregnant, Transvaginal GLR 76817 $423.00
US, Pregnant, Transvaginal PFR 76817 $189.50
US, Retroperitoneal Complete GLR 76770 $379.00
US, Retroperitoneal Complete PFR 76770 $120.50
US, Scrotum and Contents, Limited GLR 76870 $294.00
US, Scrotum and Contents, Limited PFR 76870 $105.00
US, Transvaginal Non-OB GLR 76830 $293.00
US, Transvaginal Non-OB PFR 76830 $114.50
XRAY, Abdomen 1 View GLR 74018 $103.00
XRAY, Abdomen 1 View PFR 74018 $29.00
XRAY, Abdomen 3 or more Views GLR 74021 $124.00
XRAY, Abdomen 3 or more Views PFR 74021 $43.50
XRAY, Ankle 2 Views GLR 73600 $81.00
XRAY, Ankle 2 Views PFR 73600 $28.00
XRAY, Ankle, Complete, => 3 Views GLR 73610 $105.00
XRAY, Ankle, Complete, => 3 Views PFR 73610 $28.00
XRAY, Chest 2 Views GLR 71046 $124.00
XRAY, Chest 2 Views PFR 71046 $36.50
XRAY, Chest, Single View, Frontal GLR 71045 $94.00
XRAY, Chest, Single View, Frontal PFR 71045 $29.00
XRAY, Elbow 2 Views GLR 73070 $103.00
XRAY, Elbow 2 Views PFR 73070 $27.00
XRAY, Femur 2 Views GLR 73552 $114.00
XRAY, Femur 2 Views PFR 73552 $30.00
XRAY, Fingers GLR 73140 $83.00
XRAY, Fingers PFR 73140 $24.00
XRAY, Foot, Complete, => 3 Views GLR 73630 $105.00
XRAY, Foot, Complete, => 3 Views PFR 73630 $28.00
XRAY, Forearm 2 Views GLR 73090 $103.00
XRAY, Forearm 2 Views PFR 73090 $28.00
XRAY, Hand 3 Views GLR 73130 $105.00
XRAY, Hand 3 Views PFR 73130 $28.00
XRAY, Humerus GLR 73060 $114.00
XRAY, Humerus PFR 73060 $28.00
XRAY, Knee 1 or 2 Views GLR 73560 $103.00
XRAY, Knee 1 or 2 Views PFR 73560 $30.00
XRAY, Knee 3 Views GLR 73562 $114.00
XRAY, Knee 3 Views PFR 73562 $31.50
XRAY, Lumbar Spine 2-3 Views GLR 72100 $132.00
XRAY, Lumbar Spine 2-3 Views PFR 72100 $39.50
XRAY, Lumbar Spine 4 or more Views GLR 72110 $178.00
XRAY, Lumbar Spine 4 or more Views PFR 72110 $53.00
XRAY, Neck Spine 2-3 Views GLR 72040 $119.00
XRAY, Neck Spine 2-3 Views PFR 72040 $39.50
XRAY, Pelvis GLR 72170 $103.00
XRAY, Pelvis PFR 72170 $30.00
XRAY, Shoulder GLR 73030 $114.00
XRAY, Shoulder PFR 73030 $31.50
XRAY, Thoracic Spine 2 Views GLR 72070 $126.00
XRAY, Thoracic Spine 2 Views PFR 72070 $38.50
XRAY, Tibia Fibula 2 Views GLR 73590 $103.00
XRAY, Tibia Fibula 2 Views PFR 73590 $28.00
XRAY, Wrist 3 Views GLR 73110 $105.00
XRAY, Wrist 3 Views PFR 73110 $28.00