FULL PAYMENT IN PAYMENTS. Computed Tomography (CT)

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1 Private Pay Fees For the convenience our patients, Diagnostic Outpatient Imaging particpates in most group healthcare plans (Medicare, Blue Cross/Blue Shield, Aetna, etc.) Under these programs we accept the fee schedule of the insurance program. For private pay patients we charge near Medicare rates. Payment is expected at time of exam. If not paid in full, down payment is required & the remainder divided into post dated checks. Considerably lower exam fees if payment is Paid in Full. Computed Tomography (CT) IN PAYMENTS FULL PAYMENT Abdomen w/contrast $431 $ Abdomen w/o contract $302 $ Abdomen w/wo contrast $480 $ Abdomen & Pelvis w/o contrast $563 $ Abdomen & Pelvis w/ contrast $767 $ Abdomen & Pelvis w/wo $779 $ Pelvis w/contrast $425 $ Pelvis w/o contrast $295 $ Pelvis w/wo contrast $469 $ Lower extremity w/contrast $425 $ Lower extremity w/o contrast $291 $ Lower extremity w/wo contrast $469 $ Upper extremity w/contrast $425 $ Upper extremity w/o contrast $291 $ Upper extremtiy w/wo contrast $469 $ Brain/Head w/contrast $422 $ Brain/Head w/o contrast $280 $ Brain/Head w/wo contrast $472 $ CT Chest w/out contrast $291 $ CT Chest W/contrast $416 $ CT Chest w/wo contrast $478 $ Cervical spine w/o contrast $291 $256

2 72131 Lumar spine w/o contrast $291 $ Thoracic spine w/o contrast $291 $ Lumbar sspine w/ contrast $340 $ Orbit/Ear/Fossa/Mastoids w/o contrast $307 $ Orbit/Ear/FossaMastoids w/ contrast $438 $ Orbit/Ear/FossaMastoids w/wo contrast $482 $ Sinus/Facial Bone (maxillofacial area) w/o contr $298 $263 Dental Planning (same code) $ Orbits w/o contrast $307 $ Orbits w/wo contrast $482 $ Soft tissue neck w/contrast $437 $ Soft tissue neck w/o contrast $307 $ Soft tissue neck w/wo contrast $482 $ CT guidance for biopsy $196 $172

3 Private Pay Fees CTA IN PAYMENTS FULL PAYMENT Abdomen w/wo contrast $516 $ Pelvis w/wo contrast $511 $ Chest w/wo contrast $517 $ Lower extremity w/wo contrast $516 $ Neck w/wo contrast $507 $ Runoff CT Angio Abdominal arteries $547 $ Brain w/wo contrast $507 $ Carotid Arteries $4,058 $3,571 CT MYELOGRAMS Lumbar $639 $ Thoracic/Dorsal $643 $ Cervical $644 $ Two or more regions $670 $ Injection (bill also) $196 $172 CT & MRI ARTHROGRAM- (Authorize all codes) MRI shoulder arthrogram $615 $ CT shoulder arthrogram $469 $ Needle guidance for CT $196 $ Injection procedure for shoulder $177 $156 Total $1,456 $1,281 CT UROGRAMS (Authorize all codes) CT Angiography Abdomen w/wo contrast $507 $ CT Angiography Pelvis w/wo contrast $502 $ Abdomen & Pelvis w/wo $779 $686 Total $1,789 $1,574 \ MAMMOGRAPHY- Full Field Digital G0202 Digital screening bilateral $109 $90 G0204 Digital diagnostic bilateral $155 $135 G0206 Digital diagnostic unilateral $158 $ Computer screening add on $16 $ Computer diagnostic add on $16 $ Spot Mag Unilateral $104 $80

4 BONE DENSITY- DEXA Bone Density (Lumbar and Hips) $115 $100

5 Private Pay Fees ULTRASOUNDS IN PAYMENTS FULL PAYMENT Abdomen complete $163 $143 Gallbladder/ Bladder/ Renal Abdomen limited (single organ) $149 $ Pelvis (nonobstetric) transabdomin $155 $ Pelvis (nonobsteric) limited $97 $ Pelvis- Transvaginal $155 $ Scrotum/Testicles $153 $ Axilla (underarm) US exam chest $107 $ Neck/Thyroid $148 $ Breast US exam breast (s) $107 $ Extremity (upper or lower) $100 $ Prostate $151 $133 3 codes Breast Biopsy (Ultrasound)- Authorize all Bx-Vaccum assisted $653 $ US guidance $235 $ Breast clip $107 $94 Total $995 $ Biopsy of Thyroid 3 codes-authorize all $144 $ US Guidance $235 $ Xylocaine Injection $31 $27 Total $410 $ Arterial Doppler Bilateral $216 $ Arterial Doppler Unilateral $138 $ Venous Doppler Bilateral $223 $ Venous Doppler Unilateral $142 $ Carotid Doppler $217 $192 OB ULTRASOUND OB-1st Trimester $173 $ OB>=14 Weeks (2nd-3rd trimester single) $173 $ Multiple Gestastion add on code $124 $109 3D/4D Ultrasound Non- diagnostic $100 (weeks 25-32, best at weeks)

6 X-Ray- (Computed Radiography) Most Exams $68 $60 Spine Complete $117 $103 Spine Lumbar 4 views $109 $96

7 Private Pay Fees MRI IN PAYMENTS FULL PAYMENT Abdomen w/o contrast $493 $ Abdomen w/wo contrast $767 $ MRI Brain + IAC MRI brain w/o & w/dye $774 $ Pelvis w/o contrast (Sacrum & Coccyx) $495 $ Pelvis w/wo contrast $767 $ Lower extremity joint w/o contrast $488 $ Lower extremity joint w/wo contrast $761 $ Lower extremity not joint w/o contrast $487 $ Lower extremity not joint w/wo contrast $761 $ Upper extremity joint w/o contrast $489 $ Upper extremity joint w/wo contrast $761 $ Upper extremity not joint w/o contrast $487 $ Upper extremity not joint w/wo contrast $761 $ Brain/Head w/contrast $625 $ Brain/Head w/o contrast $495 $ Brain/Head w/wo contrast $774 $ Orbit, Face, Neck w/o contrast $487 $ Orbit, Face, Neck w/wo contrast $760 $ Cervical spine w/o contrast $502 $ Cervical joint w/wo contrast $787 $ Lumbar spine w/o contrast $495 $ Lumbar spine w/wo contrast $775 $ Thoracic spine w/o contrast $502 $ Thoracic spine w/wo contrast $787 $ Prostate with/without $767 $675 ADD Prostate Biopsy $256 $225 ALL MRI Guidance $516 $454 THREE Needle (Patient must pay even with insurance!) $500 Prostate biopsy Total: $1,355 $1,179

8 77059 Breast w/wo bilateral $750 $ Breast w/wo unilateral $729 $642 ADD Biopsy $653 $575 BOTH Guidance $516 $454 Breast Biopsy (MRI) vacuum assisted unilateral $1,670 Totals bilateral $1,728 MRA Abdomen w/wo contrast $739 $ Chest w/wo contrast $740 $ Brain/Head w/o contrast $478 $ Brain/Head w/wo contrast $740 $ Neck w/wo contrast $739 $651

9 For the convenience our patients, Diagnostic Outpatient Imaging particpates in most group healthcare plans (Medicare, Blue Cross/Blue Shield, Aetna, etc.) Under these programs we accept the fee schedule of the insurance program. Private Pay Fees For private pay patients we charge near Medicare rates. A down payment is required and the rest in mohtly payments when the patient pays according to the schedule. Considerably lower exam fees if payment is Paid in Full. Examples are: IN Computed Tomography (CT) MEDICARE PAYMENTS FULL PAYMENT For In Office Copy Only 20% of Medicare Collectable Amount Abdomen w/contrast $ $ 420 $ 370 $ Abdomen w/o contract $ $ 289 $ 255 $ Abdomen w/wo contrast $ $ 464 $ 408 $ Pelvis w/contrast $ $ 414 $ 364 $ Pelvis w/o contrast $ $ 284 $ 250 $ Pelvis w/wo contrast $ $ 454 $ 399 $ Lower extremity w/contrast $ $ 418 $ 368 $ Lower extremity w/o contrast $ $ 288 $ 253 $ Lower extremity w/wo contrast $ $ 464 $ 408 $ Upper extremity w/contrast $ $ 414 $ 364 $ Upper extremity w/o contrast $ $ 283 $ 249 $ Upper extremtiy w/wo contrast $ $ 453 $ 399 $ Brain/Head w/contrast $ $ 411 $ 362 $ Brain/Head w/o contrast $ $ 269 $ 237 $ Brain/Head w/wo contrast $ $ 458 $ 403 $ Cervical spine w/o contrast $ $ 288 $ 253 $ Lumar spine w/o contrast $ $ 288 $ 253 $ Thoracic spine w/o contrast $ $ 288 $ 253 $ Temporal Bones (Mastoids) $ $ 294 $ 259 $ Sinus/Facial Bone (maxillofacial a$ $ 286 $ 252 $ CT Maxillofacial (Dental Planning) $ 294 $ Orbits w/o contrast $ $ 294 $ 259 $ Orbits w/wo contrast $ $ 467 $ 411 $ Soft tissue neck w/contrast $ $ 426 $ 375 $ Soft tissue neck w/o contrast $ $ 295 $ 260 $ 47.22

10 70492 Soft tissue neck w/wo contrast $ $ 467 $ 411 $ CT guidance for biopsy $ $ 230 $ 203 $ (add to CT code)

11 Private Pay Fees CTA MEDICARE IN PAYMENTS FULL PAYMENT 20% of Medicare Abdomen w/wo contrast $ $ 507 $ 447 $ Pelvis w/wo contrast $ $ 502 $ 442 $ Chest w/wo contrast $ $ 509 $ 448 $ Lower extremity w/wo contrast $ $ 508 $ 447 $ Neck w/wo contrast $ $ 499 $ 439 $ Runoff $ $ 540 $ 475 $ Brain $ $ 499 $ 439 $ CT MYELOGRAMS Lumbar $ $ 582 $ 512 $ Thoraci $ $ 586 $ 516 $ Cervical $ $ 613 $ 539 $ Two or more regions $ $ 613 $ 539 $ CT ARTHROGRAM- (Authorize all codes) MRI shoulder arthrogram $ $ 573 $ 504 $ CT shoulder arthrogram $ $ 453 $ 399 $ Needle guidance for CT $ $ 230 $ 203 $ Total $ 1, $ 1,257 $ 1,106 $ CT UROGRAMS (Authorize all codes) CT Angiography Abdomen w/wo c$ $ 507 $ 447 $ CT Angiography Pelvis w/wo cont$ $ 502 $ 442 $ CT Abdomen w/wo contrast $ $ 464 $ 408 $ CT Pelvis w/wo $ $ 454 $ 399 $ Total $ 1, $ 1,927 $ 1,696 $ MAMMOGRAPHY- Full Field Digital G0202 Digital screening bilateral $ $ 150 $ $ G0204 Digital diagnostic bilateral $ $ 200 $ $ G0206 Digital diagnostic unilateral $ $ 130 $ $ Computer screening add on $ $ 16 $ $ Computer diagnostic add on $ $ 16 $ $ Mammogram unilateral $ $ 125 $ $ BONE DENSITY- DEXA Bone Density (Lumbar and Hips) $ $ 91 $ 83 $ 15.16

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13 Private Pay Fees ULTRASOUNDS MEDICARE IN PAYMENTS FULL PAYMENT 20% of Medicare Abdomen complete $ $ 152 $ 139 $ Gallbladder/ Bladder/ Renal Abdomen limited (single organ) $ $ 139 $ 128 $ Pelvis (nonobstetric) $ $ 145 $ 133 $ Pelvis (nonobsteric) limited $ $ 90 $ 82 $ Pelvis- Transvaginal $ $ 145 $ 133 $ Scrotum/Testicles $ $ 142 $ 130 $ Axilla (underarm) $ $ 99 $ 91 $ Neck/Thyroid $ $ 137 $ 125 $ Breast $ $ 98 $ 90 $ codes Breast Biopsy (Ultrasound)- Authorize all Bx $ $ 570 $ US guidance $ $ 199 $ Breast clip $ $ 90 $ 82 Total $ $ 894 $ 787 $ Arterial Doppler Bilateral $ $ 197 $ 181 $ Arterial Doppler Unilateral $ $ 128 $ 117 $ Venous Doppler Bilateral $ $ 205 $ 188 $ Venous Doppler Unilateral $ $ 131 $ 121 $ Carotid Doppler $ $ 200 $ 183 $ OB ULTRASOUND OB-1st Trimester $ $ 163 $ 149 $ OB>=14 Weeks (after 1st trimeste $ $ 156 $ 143 $ Multiple Gestastion add on code $ $ 116 $ 106 $ D/4D Ultrasound $ 150 $ 100 (weeks 25-32, best at weeks) Non- diagnostic X-Ray- (Computed Radiography) $ $ 63 $ 55 Most Exams $ $ 101 $ 89 Spine Complete $ $ 105 $ 92 Spine Lumbar 4 views

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15 Private Pay Fees MRI MEDICARE IN PAYMENTS FULL PAYMENT 20% of Medicare Abdomen w/o contrast $ $ 476 $ 418 $ Abdomen w/wo contrast $ $ 737 $ 649 $ Pelvis w/o contrast $ $ 475 $ 418 $ Pelvis w/wo contrast $ $ 737 $ 649 $ Lower extremity joint w/o contras $ $ 475 $ 418 $ Lower extremity joint w/wo contra$ $ 737 $ 649 $ Lower extremity not joint w/o con $ $ 468 $ 412 $ Lower extremity not joint w/wo co$ $ 730 $ 643 $ Upper extremity joint w/o contras $ $ 468 $ 412 $ Upper extremity joint w/wo contra$ $ 730 $ 642 $ Upper extremity not joint w/o con $ $ 467 $ 411 $ Upper extremity not joint w/wo co$ $ 730 $ 643 $ Brain/Head w/contrast $ $ 584 $ 514 $ Brain/Head w/o contrast $ $ 478 $ 420 $ Brain/Head w/wo contrast $ $ 745 $ 656 $ Orbit, Face, Neck w/o contrast $ $ 468 $ 412 $ Orbit, Face, Neck w/wo contrast $ $ 730 $ 642 $ Cervical spine w/o contrast $ $ 485 $ 427 $ Cervical joint w/wo contrast $ $ 759 $ 668 $ Lumbar spine w/o contrast $ $ 478 $ 421 $ Lumbar spine w/wo contrast $ $ 746 $ 656 $ Thoracic spine w/o contrast $ $ 485 $ 427 $ Thoracic spine w/wo contrast $ $ 760 $ 668 $ Breast w/wo bilateral $ $ 1,014 $ 892 $ Breat w/wo unilateral $ $ 940 $ 827 $ mult. Breast Biopsy (MRI) vacuum assisted unilateral $1,250 bilateral $1,375 MRA Abdomen w/wo contrast $ $ 585 $ 515 $ Chest w/wo contrast $ $ 586 $ 516 $ Brain/Head w/o contrast $ $ 460 $ 404 $ Brain/Head w/wo contrast $ $ 706 $ 621 $ Neck w/wo contrast $ $ 706 $ 621 $

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