6. D.6. CPT Code Table.xlsx
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- 36C26321R0009
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Year 1 of Ordering Period
| D.6 - Attachment 6 - 36C26321R0009 |
| Year 1 of the Ordering Period: April 1, 2021 to March 31, 2022 |
| 100% | Input the proposed percentage price increase to the current Medicare CPT Code with modifier 26 (Professional Component) Facility calendar rate for South Dakota. |
| * Note: If lower than 100% then result will be a reduced price to the Medicare rate. |
| $ 323,241.69 | This is the Total Extended Price to be entered in the corresponding Schedule under the Estimated Total Price column for line item three (1003, 2003, 3003, 4003, and 5003). | ||||
| * Note: These are estimates only and do not obligate the government to the estimated amounts. | |||||
| * Note: The 2020 Medicare CPT Code with modifier 26 (Professional Component) Facility current calendar year rate for South Dakota is used for estimating cost. However, throughout the life of the contract VA shall pay the current Medicare calendar Facility rate with modifier 26 (Professional Component) for South Dakota, plus the proposed percentage price increase. | |||||
| CPT Code | Procedure Description | Estimated Quantity | 2020 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 1 | $9.16 | 100% | $9.16 |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 70150 | FACIAL BONES | 1 | $13.49 | 100% | $13.49 |
| 70160 | NASAL BONES 3 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70220 | SINUSES 3 OR MORE VIEWS | 2 | $11.32 | 100% | $22.64 |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $10.24 | 100% | $593.92 |
| 70328 | TMJ UNILATERAL OPEN/CLOSED | 1 | $9.16 | 100% | $9.16 |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $12.40 | 100% | $12.40 |
| 70360 | NECK SOFT TISSUE | 1 | $9.16 | 100% | $9.16 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $42.53 | 100% | $3,147.22 |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $63.59 | 100% | $127.18 |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $63.23 | 100% | $63.23 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $42.89 | 100% | $557.57 |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $64.31 | 100% | $64.31 |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $69.37 | 100% | $693.70 |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $81.31 | 100% | $81.31 |
| 70496 | CTA HEAD | 2 | $87.45 | 100% | $174.90 |
| 70498 | CTA NECK | 5 | $87.45 | 100% | $437.25 |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $107.30 | 100% | $643.80 |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $59.98 | 100% | $4,018.66 |
| 70547 | MRA NECK W/O CONTRAST | 2 | $60.34 | 100% | $120.68 |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $90.34 | 100% | $3,703.94 |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $74.32 | 100% | $15,012.64 |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 240 | $114.78 | 100% | $27,547.20 |
| 71045 | CHEST ONE VIEW | 137 | $9.16 | 100% | $1,254.92 |
| 71046 | CHEST 2 VIEWS PA&LAT | 343 | $10.96 | 100% | $3,759.28 |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $16.37 | 100% | $16.37 |
| 71100 | RIBS 2 VIEWS LEFT | 1 | $11.32 | 100% | $11.32 |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 18 | $13.49 | 100% | $242.82 |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $14.93 | 100% | $14.93 |
| 71120 | STERNUM | 1 | $10.24 | 100% | $10.24 |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 71250 | CT CHEST W/O CONTRAST | 82 | $58.05 | 100% | $4,760.10 |
| 71260 | CT CHEST W CONTRAST | 53 | $62.51 | 100% | $3,313.03 |
| 71270 | CT CHEST W/WO | 1 | $69.01 | 100% | $69.01 |
| 71275 | CTA CHEST | 20 | $91.06 | 100% | $1,821.20 |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 24 | $13.85 | 100% | $332.40 |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 1 | $15.29 | 100% | $15.29 |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $10.24 | 100% | $20.48 |
| 72072 | THORACIC SPINE 3 VIEWS | 11 | $11.68 | 100% | $128.48 |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 1 | $12.40 | 100% | $12.40 |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 63 | $11.32 | 100% | $713.16 |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $13.13 | 100% | $13.13 |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 1 | $15.29 | 100% | $15.29 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $50.11 | 100% | $651.43 |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $50.11 | 100% | $250.55 |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 254 | $74.32 | 100% | $18,877.28 |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 55 | $74.32 | 100% | $4,087.60 |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 487 | $74.32 | 100% | $36,193.84 |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 21 | $114.78 | 100% | $2,410.38 |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 18 | $114.78 | 100% | $2,066.04 |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $114.78 | 100% | $17,676.12 |
| 72170 | PELVIS 1 OR 2 VIEWS | 2 | $8.79 | 100% | $17.58 |
| 72190 | PELVIS 3 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $54.44 | 100% | $54.44 |
| 72193 | CT PELVIS W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $73.24 | 100% | $439.44 |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $109.82 | 100% | $1,317.84 |
| 72200 | SI JOINTS 2 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 72202 | SI JOINTS 3 VIEWS | 1 | $11.68 | 100% | $11.68 |
| 72220 | SACRUM COCCYX 2 VIEWS | 3 | $8.79 | 100% | $26.37 |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73010 | SCAPULA LEFT 2 VIEWS | 1 | $9.16 | 100% | $9.16 |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.71 | 100% | $7.71 |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 89 | $9.52 | 100% | $847.28 |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.52 | 100% | $9.52 |
| 73060 | HUMERUS RIGHT 2 VIEWS | 3 | $8.43 | 100% | $25.29 |
| 73070 | ELBOW LEFT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 20 | $8.79 | 100% | $175.80 |
| 73090 | FOREARM RIGHT 2 VIEWS | 4 | $8.43 | 100% | $33.72 |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73110 | WRIST RIGHT 3 VIEWS | 30 | $8.79 | 100% | $263.70 |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73130 | HAND LEFT 3 VIEWS | 54 | $8.79 | 100% | $474.66 |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 5 | $6.99 | 100% | $34.95 |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $61.07 | 100% | $61.07 |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $67.92 | 100% | $135.84 |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $107.66 | 100% | $430.64 |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $68.55 | 100% | $19,262.55 |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 53 | $81.68 | 100% | $4,329.04 |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $107.66 | 100% | $861.28 |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $9.52 | 100% | $19.04 |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 57 | $11.32 | 100% | $645.24 |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $13.85 | 100% | $13.85 |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 16 | $11.32 | 100% | $181.12 |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $16.01 | 100% | $16.01 |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $9.16 | 100% | $45.80 |
| 73560 | KNEE LEFT 2 VIEWS | 11 | $8.43 | 100% | $92.73 |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.52 | 100% | $9.52 |
| 73564 | KNEE LEFT 4 VIEWS | 151 | $11.32 | 100% | $1,709.32 |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.79 | 100% | $8.79 |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 7 | $8.07 | 100% | $56.49 |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73610 | ANKLE LEFT 3 VIEWS | 38 | $8.79 | 100% | $334.02 |
| 73620 | FOOT (B) LEFT 3 VIEWS | 28 | $7.71 | 100% | $215.88 |
| 73630 | FOOT RIGHT 3 VIEWS | 57 | $8.43 | 100% | $480.51 |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 2 | $8.07 | 100% | $16.14 |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 2 | $6.63 | 100% | $13.26 |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $50.11 | 100% | $200.44 |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $93.95 | 100% | $93.95 |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $67.56 | 100% | $405.36 |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $107.30 | 100% | $1,287.60 |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $67.92 | 100% | $17,591.28 |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $81.68 | 100% | $1,633.60 |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $107.66 | 100% | $2,260.86 |
| 74018 | ABDOMEN 1 VIEW | 48 | $9.16 | 100% | $439.68 |
| 74019 | ABDOMEN 2 VIEWS | 24 | $11.68 | 100% | $280.32 |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $59.62 | 100% | $59.62 |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $69.99 | 100% | $279.96 |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $109.37 | 100% | $656.22 |
| 74175 | CTA ABDOMEN | 1 | $90.70 | 100% | $90.70 |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $87.09 | 100% | $3,135.24 |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $91.42 | 100% | $7,770.70 |
| 74178 | CT ABDOMEN/PELVIS W/O & W CONTRAST | 33 | $100.44 | 100% | $3,314.52 |
| 75635 | CTA ABDOMINAL ARTERIES AND BILATERAL ILIOFEM RUNOFF | 3 | $118.39 | 100% | $355.17 |
| 76536 | US THYROID AND/OR SOFT TISSUE HEAD AND NECK | 10 | $28.19 | 100% | $281.90 |
| 76604 | US CHEST | 1 | $28.91 | 100% | $28.91 |
| 76700 | US ABDOMEN COMPLETE | 16 | $40.72 | 100% | $651.52 |
| 76705 | US ABDOMEN LIMITED | 29 | $29.27 | 100% | $848.83 |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $36.85 | 100% | $1,326.60 |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $28.91 | 100% | $1,011.85 |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $24.81 | 100% | $49.62 |
| 76870 | US SCROTUM | 12 | $31.80 | 100% | $381.60 |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $31.66 | 100% | $31.66 |
| 76882 | US EXTREMITY NONVASCULAR LIMITED | 2 | $24.45 | 100% | $48.90 |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $22.28 | 100% | $22.28 |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $27.83 | 100% | $55.66 |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $24.45 | 100% | $244.50 |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $41.54 | 100% | $124.62 |
| 78020 | TTHYROID CA METASTASES, UPTAKE, ADD-ON 78020 | 2 | $28.05 | 100% | $56.10 |
| 78070 | PARATHYROID PLANAR W/SUBTRATRACTION | 7 | $39.01 | 100% | $273.07 |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $58.41 | 100% | $292.05 |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 41 | $36.49 | 100% | $1,496.09 |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 25 | $39.01 | 100% | $975.25 |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 1 | $31.07 | 100% | $31.07 |
| 78306 | BONE IMAGING, WHOLE BODY | 183 | $42.53 | 100% | $7,782.99 |
| 78315 | BONE IMAGING, THREE PHASE | 9 | $50.47 | 100% | $454.23 |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $67.43 | 100% | $269.72 |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 911 | $79.47 | 100% | $72,397.17 |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $48.30 | 100% | $289.80 |
| 78496 | CARDIAC BLOOD POOL, RIGHT EF, ADD-ON | 6 | $24.45 | 100% | $146.70 |
| 78582 | LUNG VENT IMAGING (AEROSOL OR GAS) & PERF | 10 | $52.63 | 100% | $526.30 |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 2 | $59.13 | 100% | $118.26 |
| 93880 | US CAROTID BILATERAL | 55 | $39.41 | 100% | $2,167.55 |
| 93882 | US CAROTID UNILATERAL | 1 | $24.16 | 100% | $24.16 |
| 93923 | ABI | 22 | $21.60 | 100% | $475.20 |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $23.76 | 100% | $23.76 |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $34.00 | 100% | $544.00 |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $22.05 | 100% | $661.50 |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $56.77 | 100% | $56.77 |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $39.64 | 100% | $39.64 |
TOTAL: $323,241.69
Year 2 of Ordering Period
| D.6 - Attachment 6 - 36C26321R0009 |
| Year 2 of the Ordering Period: April 1, 2022 to March 31, 2023 |
| 100% | Input the proposed percentage price increase to the current Medicare CPT Code with modifier 26 (Professional Component) Facility calendar rate for South Dakota. |
| * Note: If lower than 100% then result will be a reduced price to the Medicare rate. |
| $ 323,241.69 | This is the Total Extended Price to be entered in the corresponding Schedule under the Estimated Total Price column for line item three (1003, 2003, 3003, 4003, and 5003). | ||||
| * Note: These are estimates only and do not obligate the government to the estimated amounts. | |||||
| * Note: The 2020 Medicare CPT Code with modifier 26 (Professional Component) Facility current calendar year rate for South Dakota is used for estimating cost. However, throughout the life of the contract VA shall pay the current Medicare calendar Facility rate with modifier 26 (Professional Component) for South Dakota, plus the proposed percentage price increase. | |||||
| CPT Code | Procedure Description | Estimated Quantity | 2020 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 1 | $9.16 | 100% | $9.16 |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 70150 | FACIAL BONES | 1 | $13.49 | 100% | $13.49 |
| 70160 | NASAL BONES 3 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70220 | SINUSES 3 OR MORE VIEWS | 2 | $11.32 | 100% | $22.64 |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $10.24 | 100% | $593.92 |
| 70328 | TMJ UNILATERAL OPEN/CLOSED | 1 | $9.16 | 100% | $9.16 |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $12.40 | 100% | $12.40 |
| 70360 | NECK SOFT TISSUE | 1 | $9.16 | 100% | $9.16 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $42.53 | 100% | $3,147.22 |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $63.59 | 100% | $127.18 |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $63.23 | 100% | $63.23 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $42.89 | 100% | $557.57 |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $64.31 | 100% | $64.31 |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $69.37 | 100% | $693.70 |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $81.31 | 100% | $81.31 |
| 70496 | CTA HEAD | 2 | $87.45 | 100% | $174.90 |
| 70498 | CTA NECK | 5 | $87.45 | 100% | $437.25 |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $107.30 | 100% | $643.80 |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $59.98 | 100% | $4,018.66 |
| 70547 | MRA NECK W/O CONTRAST | 2 | $60.34 | 100% | $120.68 |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $90.34 | 100% | $3,703.94 |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $74.32 | 100% | $15,012.64 |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 240 | $114.78 | 100% | $27,547.20 |
| 71045 | CHEST ONE VIEW | 137 | $9.16 | 100% | $1,254.92 |
| 71046 | CHEST 2 VIEWS PA&LAT | 343 | $10.96 | 100% | $3,759.28 |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $16.37 | 100% | $16.37 |
| 71100 | RIBS 2 VIEWS LEFT | 1 | $11.32 | 100% | $11.32 |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 18 | $13.49 | 100% | $242.82 |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $14.93 | 100% | $14.93 |
| 71120 | STERNUM | 1 | $10.24 | 100% | $10.24 |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 71250 | CT CHEST W/O CONTRAST | 82 | $58.05 | 100% | $4,760.10 |
| 71260 | CT CHEST W CONTRAST | 53 | $62.51 | 100% | $3,313.03 |
| 71270 | CT CHEST W/WO | 1 | $69.01 | 100% | $69.01 |
| 71275 | CTA CHEST | 20 | $91.06 | 100% | $1,821.20 |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 24 | $13.85 | 100% | $332.40 |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 1 | $15.29 | 100% | $15.29 |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $10.24 | 100% | $20.48 |
| 72072 | THORACIC SPINE 3 VIEWS | 11 | $11.68 | 100% | $128.48 |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 1 | $12.40 | 100% | $12.40 |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 63 | $11.32 | 100% | $713.16 |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $13.13 | 100% | $13.13 |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 1 | $15.29 | 100% | $15.29 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $50.11 | 100% | $651.43 |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $50.11 | 100% | $250.55 |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 254 | $74.32 | 100% | $18,877.28 |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 55 | $74.32 | 100% | $4,087.60 |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 487 | $74.32 | 100% | $36,193.84 |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 21 | $114.78 | 100% | $2,410.38 |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 18 | $114.78 | 100% | $2,066.04 |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $114.78 | 100% | $17,676.12 |
| 72170 | PELVIS 1 OR 2 VIEWS | 2 | $8.79 | 100% | $17.58 |
| 72190 | PELVIS 3 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $54.44 | 100% | $54.44 |
| 72193 | CT PELVIS W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $73.24 | 100% | $439.44 |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $109.82 | 100% | $1,317.84 |
| 72200 | SI JOINTS 2 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 72202 | SI JOINTS 3 VIEWS | 1 | $11.68 | 100% | $11.68 |
| 72220 | SACRUM COCCYX 2 VIEWS | 3 | $8.79 | 100% | $26.37 |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73010 | SCAPULA LEFT 2 VIEWS | 1 | $9.16 | 100% | $9.16 |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.71 | 100% | $7.71 |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 89 | $9.52 | 100% | $847.28 |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.52 | 100% | $9.52 |
| 73060 | HUMERUS RIGHT 2 VIEWS | 3 | $8.43 | 100% | $25.29 |
| 73070 | ELBOW LEFT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 20 | $8.79 | 100% | $175.80 |
| 73090 | FOREARM RIGHT 2 VIEWS | 4 | $8.43 | 100% | $33.72 |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73110 | WRIST RIGHT 3 VIEWS | 30 | $8.79 | 100% | $263.70 |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73130 | HAND LEFT 3 VIEWS | 54 | $8.79 | 100% | $474.66 |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 5 | $6.99 | 100% | $34.95 |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $61.07 | 100% | $61.07 |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $67.92 | 100% | $135.84 |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $107.66 | 100% | $430.64 |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $68.55 | 100% | $19,262.55 |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 53 | $81.68 | 100% | $4,329.04 |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $107.66 | 100% | $861.28 |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $9.52 | 100% | $19.04 |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 57 | $11.32 | 100% | $645.24 |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $13.85 | 100% | $13.85 |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 16 | $11.32 | 100% | $181.12 |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $16.01 | 100% | $16.01 |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $9.16 | 100% | $45.80 |
| 73560 | KNEE LEFT 2 VIEWS | 11 | $8.43 | 100% | $92.73 |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.52 | 100% | $9.52 |
| 73564 | KNEE LEFT 4 VIEWS | 151 | $11.32 | 100% | $1,709.32 |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.79 | 100% | $8.79 |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 7 | $8.07 | 100% | $56.49 |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73610 | ANKLE LEFT 3 VIEWS | 38 | $8.79 | 100% | $334.02 |
| 73620 | FOOT (B) LEFT 3 VIEWS | 28 | $7.71 | 100% | $215.88 |
| 73630 | FOOT RIGHT 3 VIEWS | 57 | $8.43 | 100% | $480.51 |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 2 | $8.07 | 100% | $16.14 |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 2 | $6.63 | 100% | $13.26 |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $50.11 | 100% | $200.44 |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $93.95 | 100% | $93.95 |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $67.56 | 100% | $405.36 |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $107.30 | 100% | $1,287.60 |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $67.92 | 100% | $17,591.28 |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $81.68 | 100% | $1,633.60 |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $107.66 | 100% | $2,260.86 |
| 74018 | ABDOMEN 1 VIEW | 48 | $9.16 | 100% | $439.68 |
| 74019 | ABDOMEN 2 VIEWS | 24 | $11.68 | 100% | $280.32 |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $59.62 | 100% | $59.62 |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $69.99 | 100% | $279.96 |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $109.37 | 100% | $656.22 |
| 74175 | CTA ABDOMEN | 1 | $90.70 | 100% | $90.70 |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $87.09 | 100% | $3,135.24 |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $91.42 | 100% | $7,770.70 |
| 74178 | CT ABDOMEN/PELVIS W/O & W CONTRAST | 33 | $100.44 | 100% | $3,314.52 |
| 75635 | CTA ABDOMINAL ARTERIES AND BILATERAL ILIOFEM RUNOFF | 3 | $118.39 | 100% | $355.17 |
| 76536 | US THYROID AND/OR SOFT TISSUE HEAD AND NECK | 10 | $28.19 | 100% | $281.90 |
| 76604 | US CHEST | 1 | $28.91 | 100% | $28.91 |
| 76700 | US ABDOMEN COMPLETE | 16 | $40.72 | 100% | $651.52 |
| 76705 | US ABDOMEN LIMITED | 29 | $29.27 | 100% | $848.83 |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $36.85 | 100% | $1,326.60 |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $28.91 | 100% | $1,011.85 |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $24.81 | 100% | $49.62 |
| 76870 | US SCROTUM | 12 | $31.80 | 100% | $381.60 |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $31.66 | 100% | $31.66 |
| 76882 | US EXTREMITY NONVASCULAR LIMITED | 2 | $24.45 | 100% | $48.90 |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $22.28 | 100% | $22.28 |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $27.83 | 100% | $55.66 |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $24.45 | 100% | $244.50 |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $41.54 | 100% | $124.62 |
| 78020 | TTHYROID CA METASTASES, UPTAKE, ADD-ON 78020 | 2 | $28.05 | 100% | $56.10 |
| 78070 | PARATHYROID PLANAR W/SUBTRATRACTION | 7 | $39.01 | 100% | $273.07 |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $58.41 | 100% | $292.05 |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 41 | $36.49 | 100% | $1,496.09 |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 25 | $39.01 | 100% | $975.25 |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 1 | $31.07 | 100% | $31.07 |
| 78306 | BONE IMAGING, WHOLE BODY | 183 | $42.53 | 100% | $7,782.99 |
| 78315 | BONE IMAGING, THREE PHASE | 9 | $50.47 | 100% | $454.23 |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $67.43 | 100% | $269.72 |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 911 | $79.47 | 100% | $72,397.17 |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $48.30 | 100% | $289.80 |
| 78496 | CARDIAC BLOOD POOL, RIGHT EF, ADD-ON | 6 | $24.45 | 100% | $146.70 |
| 78582 | LUNG VENT IMAGING (AEROSOL OR GAS) & PERF | 10 | $52.63 | 100% | $526.30 |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 2 | $59.13 | 100% | $118.26 |
| 93880 | US CAROTID BILATERAL | 55 | $39.41 | 100% | $2,167.55 |
| 93882 | US CAROTID UNILATERAL | 1 | $24.16 | 100% | $24.16 |
| 93923 | ABI | 22 | $21.60 | 100% | $475.20 |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $23.76 | 100% | $23.76 |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $34.00 | 100% | $544.00 |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $22.05 | 100% | $661.50 |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $56.77 | 100% | $56.77 |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $39.64 | 100% | $39.64 |
TOTAL: $323,241.69
Year 3 of Ordering Period
| D.6 - Attachment 6 - 36C26321R0009 |
| Year 3 of the Ordering Period: April 1, 2023 to March 31, 2024 |
| 100% | Input the proposed percentage price increase to the current Medicare CPT Code with modifier 26 (Professional Component) Facility calendar rate for South Dakota. |
| * Note: If lower than 100% then result will be a reduced price to the Medicare rate. |
| $ 323,241.69 | This is the Total Extended Price to be entered in the corresponding Schedule under the Estimated Total Price column for line item three (1003, 2003, 3003, 4003, and 5003). | ||||
| * Note: These are estimates only and do not obligate the government to the estimated amounts. | |||||
| * Note: The 2020 Medicare CPT Code with modifier 26 (Professional Component) Facility current calendar year rate for South Dakota is used for estimating cost. However, throughout the life of the contract VA shall pay the current Medicare calendar Facility rate with modifier 26 (Professional Component) for South Dakota, plus the proposed percentage price increase. | |||||
| CPT Code | Procedure Description | Estimated Quantity | 2020 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 1 | $9.16 | 100% | $9.16 |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 70150 | FACIAL BONES | 1 | $13.49 | 100% | $13.49 |
| 70160 | NASAL BONES 3 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70220 | SINUSES 3 OR MORE VIEWS | 2 | $11.32 | 100% | $22.64 |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $10.24 | 100% | $593.92 |
| 70328 | TMJ UNILATERAL OPEN/CLOSED | 1 | $9.16 | 100% | $9.16 |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $12.40 | 100% | $12.40 |
| 70360 | NECK SOFT TISSUE | 1 | $9.16 | 100% | $9.16 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $42.53 | 100% | $3,147.22 |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $63.59 | 100% | $127.18 |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $63.23 | 100% | $63.23 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $42.89 | 100% | $557.57 |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $64.31 | 100% | $64.31 |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $69.37 | 100% | $693.70 |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $81.31 | 100% | $81.31 |
| 70496 | CTA HEAD | 2 | $87.45 | 100% | $174.90 |
| 70498 | CTA NECK | 5 | $87.45 | 100% | $437.25 |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $107.30 | 100% | $643.80 |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $59.98 | 100% | $4,018.66 |
| 70547 | MRA NECK W/O CONTRAST | 2 | $60.34 | 100% | $120.68 |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $90.34 | 100% | $3,703.94 |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $74.32 | 100% | $15,012.64 |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 240 | $114.78 | 100% | $27,547.20 |
| 71045 | CHEST ONE VIEW | 137 | $9.16 | 100% | $1,254.92 |
| 71046 | CHEST 2 VIEWS PA&LAT | 343 | $10.96 | 100% | $3,759.28 |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $16.37 | 100% | $16.37 |
| 71100 | RIBS 2 VIEWS LEFT | 1 | $11.32 | 100% | $11.32 |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 18 | $13.49 | 100% | $242.82 |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $14.93 | 100% | $14.93 |
| 71120 | STERNUM | 1 | $10.24 | 100% | $10.24 |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 71250 | CT CHEST W/O CONTRAST | 82 | $58.05 | 100% | $4,760.10 |
| 71260 | CT CHEST W CONTRAST | 53 | $62.51 | 100% | $3,313.03 |
| 71270 | CT CHEST W/WO | 1 | $69.01 | 100% | $69.01 |
| 71275 | CTA CHEST | 20 | $91.06 | 100% | $1,821.20 |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 24 | $13.85 | 100% | $332.40 |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 1 | $15.29 | 100% | $15.29 |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $10.24 | 100% | $20.48 |
| 72072 | THORACIC SPINE 3 VIEWS | 11 | $11.68 | 100% | $128.48 |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 1 | $12.40 | 100% | $12.40 |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 63 | $11.32 | 100% | $713.16 |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $13.13 | 100% | $13.13 |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 1 | $15.29 | 100% | $15.29 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $50.11 | 100% | $651.43 |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $50.11 | 100% | $250.55 |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 254 | $74.32 | 100% | $18,877.28 |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 55 | $74.32 | 100% | $4,087.60 |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 487 | $74.32 | 100% | $36,193.84 |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 21 | $114.78 | 100% | $2,410.38 |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 18 | $114.78 | 100% | $2,066.04 |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $114.78 | 100% | $17,676.12 |
| 72170 | PELVIS 1 OR 2 VIEWS | 2 | $8.79 | 100% | $17.58 |
| 72190 | PELVIS 3 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $54.44 | 100% | $54.44 |
| 72193 | CT PELVIS W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $73.24 | 100% | $439.44 |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $109.82 | 100% | $1,317.84 |
| 72200 | SI JOINTS 2 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 72202 | SI JOINTS 3 VIEWS | 1 | $11.68 | 100% | $11.68 |
| 72220 | SACRUM COCCYX 2 VIEWS | 3 | $8.79 | 100% | $26.37 |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73010 | SCAPULA LEFT 2 VIEWS | 1 | $9.16 | 100% | $9.16 |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.71 | 100% | $7.71 |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 89 | $9.52 | 100% | $847.28 |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.52 | 100% | $9.52 |
| 73060 | HUMERUS RIGHT 2 VIEWS | 3 | $8.43 | 100% | $25.29 |
| 73070 | ELBOW LEFT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 20 | $8.79 | 100% | $175.80 |
| 73090 | FOREARM RIGHT 2 VIEWS | 4 | $8.43 | 100% | $33.72 |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73110 | WRIST RIGHT 3 VIEWS | 30 | $8.79 | 100% | $263.70 |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73130 | HAND LEFT 3 VIEWS | 54 | $8.79 | 100% | $474.66 |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 5 | $6.99 | 100% | $34.95 |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $61.07 | 100% | $61.07 |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $67.92 | 100% | $135.84 |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $107.66 | 100% | $430.64 |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $68.55 | 100% | $19,262.55 |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 53 | $81.68 | 100% | $4,329.04 |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $107.66 | 100% | $861.28 |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $9.52 | 100% | $19.04 |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 57 | $11.32 | 100% | $645.24 |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $13.85 | 100% | $13.85 |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 16 | $11.32 | 100% | $181.12 |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $16.01 | 100% | $16.01 |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $9.16 | 100% | $45.80 |
| 73560 | KNEE LEFT 2 VIEWS | 11 | $8.43 | 100% | $92.73 |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.52 | 100% | $9.52 |
| 73564 | KNEE LEFT 4 VIEWS | 151 | $11.32 | 100% | $1,709.32 |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.79 | 100% | $8.79 |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 7 | $8.07 | 100% | $56.49 |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73610 | ANKLE LEFT 3 VIEWS | 38 | $8.79 | 100% | $334.02 |
| 73620 | FOOT (B) LEFT 3 VIEWS | 28 | $7.71 | 100% | $215.88 |
| 73630 | FOOT RIGHT 3 VIEWS | 57 | $8.43 | 100% | $480.51 |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 2 | $8.07 | 100% | $16.14 |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 2 | $6.63 | 100% | $13.26 |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $50.11 | 100% | $200.44 |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $93.95 | 100% | $93.95 |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $67.56 | 100% | $405.36 |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $107.30 | 100% | $1,287.60 |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $67.92 | 100% | $17,591.28 |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $81.68 | 100% | $1,633.60 |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $107.66 | 100% | $2,260.86 |
| 74018 | ABDOMEN 1 VIEW | 48 | $9.16 | 100% | $439.68 |
| 74019 | ABDOMEN 2 VIEWS | 24 | $11.68 | 100% | $280.32 |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $59.62 | 100% | $59.62 |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $69.99 | 100% | $279.96 |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $109.37 | 100% | $656.22 |
| 74175 | CTA ABDOMEN | 1 | $90.70 | 100% | $90.70 |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $87.09 | 100% | $3,135.24 |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $91.42 | 100% | $7,770.70 |
| 74178 | CT ABDOMEN/PELVIS W/O & W CONTRAST | 33 | $100.44 | 100% | $3,314.52 |
| 75635 | CTA ABDOMINAL ARTERIES AND BILATERAL ILIOFEM RUNOFF | 3 | $118.39 | 100% | $355.17 |
| 76536 | US THYROID AND/OR SOFT TISSUE HEAD AND NECK | 10 | $28.19 | 100% | $281.90 |
| 76604 | US CHEST | 1 | $28.91 | 100% | $28.91 |
| 76700 | US ABDOMEN COMPLETE | 16 | $40.72 | 100% | $651.52 |
| 76705 | US ABDOMEN LIMITED | 29 | $29.27 | 100% | $848.83 |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $36.85 | 100% | $1,326.60 |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $28.91 | 100% | $1,011.85 |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $24.81 | 100% | $49.62 |
| 76870 | US SCROTUM | 12 | $31.80 | 100% | $381.60 |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $31.66 | 100% | $31.66 |
| 76882 | US EXTREMITY NONVASCULAR LIMITED | 2 | $24.45 | 100% | $48.90 |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $22.28 | 100% | $22.28 |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $27.83 | 100% | $55.66 |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $24.45 | 100% | $244.50 |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $41.54 | 100% | $124.62 |
| 78020 | TTHYROID CA METASTASES, UPTAKE, ADD-ON 78020 | 2 | $28.05 | 100% | $56.10 |
| 78070 | PARATHYROID PLANAR W/SUBTRATRACTION | 7 | $39.01 | 100% | $273.07 |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $58.41 | 100% | $292.05 |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 41 | $36.49 | 100% | $1,496.09 |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 25 | $39.01 | 100% | $975.25 |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 1 | $31.07 | 100% | $31.07 |
| 78306 | BONE IMAGING, WHOLE BODY | 183 | $42.53 | 100% | $7,782.99 |
| 78315 | BONE IMAGING, THREE PHASE | 9 | $50.47 | 100% | $454.23 |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $67.43 | 100% | $269.72 |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 911 | $79.47 | 100% | $72,397.17 |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $48.30 | 100% | $289.80 |
| 78496 | CARDIAC BLOOD POOL, RIGHT EF, ADD-ON | 6 | $24.45 | 100% | $146.70 |
| 78582 | LUNG VENT IMAGING (AEROSOL OR GAS) & PERF | 10 | $52.63 | 100% | $526.30 |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 2 | $59.13 | 100% | $118.26 |
| 93880 | US CAROTID BILATERAL | 55 | $39.41 | 100% | $2,167.55 |
| 93882 | US CAROTID UNILATERAL | 1 | $24.16 | 100% | $24.16 |
| 93923 | ABI | 22 | $21.60 | 100% | $475.20 |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $23.76 | 100% | $23.76 |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $34.00 | 100% | $544.00 |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $22.05 | 100% | $661.50 |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $56.77 | 100% | $56.77 |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $39.64 | 100% | $39.64 |
TOTAL: $323,241.69
Year 4 of Ordering Period
| D.6 - Attachment 6 - 36C26321R0009 |
| Year 4 of the Ordering Period: April 1, 2024 to March 31, 2025 |
| 100% | Input the proposed percentage price increase to the current Medicare CPT Code with modifier 26 (Professional Component) Facility calendar rate for South Dakota. |
| * Note: If lower than 100% then result will be a reduced price to the Medicare rate. |
| $ 323,241.69 | This is the Total Extended Price to be entered in the corresponding Schedule under the Estimated Total Price column for line item three (1003, 2003, 3003, 4003, and 5003). | ||||
| * Note: These are estimates only and do not obligate the government to the estimated amounts. | |||||
| * Note: The 2020 Medicare CPT Code with modifier 26 (Professional Component) Facility current calendar year rate for South Dakota is used for estimating cost. However, throughout the life of the contract VA shall pay the current Medicare calendar Facility rate with modifier 26 (Professional Component) for South Dakota, plus the proposed percentage price increase. | |||||
| CPT Code | Procedure Description | Estimated Quantity | 2020 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 1 | $9.16 | 100% | $9.16 |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 70150 | FACIAL BONES | 1 | $13.49 | 100% | $13.49 |
| 70160 | NASAL BONES 3 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70220 | SINUSES 3 OR MORE VIEWS | 2 | $11.32 | 100% | $22.64 |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $10.24 | 100% | $593.92 |
| 70328 | TMJ UNILATERAL OPEN/CLOSED | 1 | $9.16 | 100% | $9.16 |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $12.40 | 100% | $12.40 |
| 70360 | NECK SOFT TISSUE | 1 | $9.16 | 100% | $9.16 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $42.53 | 100% | $3,147.22 |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $63.59 | 100% | $127.18 |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $63.23 | 100% | $63.23 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $42.89 | 100% | $557.57 |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $64.31 | 100% | $64.31 |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $69.37 | 100% | $693.70 |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $81.31 | 100% | $81.31 |
| 70496 | CTA HEAD | 2 | $87.45 | 100% | $174.90 |
| 70498 | CTA NECK | 5 | $87.45 | 100% | $437.25 |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $107.30 | 100% | $643.80 |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $59.98 | 100% | $4,018.66 |
| 70547 | MRA NECK W/O CONTRAST | 2 | $60.34 | 100% | $120.68 |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $90.34 | 100% | $3,703.94 |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $74.32 | 100% | $15,012.64 |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 240 | $114.78 | 100% | $27,547.20 |
| 71045 | CHEST ONE VIEW | 137 | $9.16 | 100% | $1,254.92 |
| 71046 | CHEST 2 VIEWS PA&LAT | 343 | $10.96 | 100% | $3,759.28 |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $16.37 | 100% | $16.37 |
| 71100 | RIBS 2 VIEWS LEFT | 1 | $11.32 | 100% | $11.32 |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 18 | $13.49 | 100% | $242.82 |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $14.93 | 100% | $14.93 |
| 71120 | STERNUM | 1 | $10.24 | 100% | $10.24 |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 71250 | CT CHEST W/O CONTRAST | 82 | $58.05 | 100% | $4,760.10 |
| 71260 | CT CHEST W CONTRAST | 53 | $62.51 | 100% | $3,313.03 |
| 71270 | CT CHEST W/WO | 1 | $69.01 | 100% | $69.01 |
| 71275 | CTA CHEST | 20 | $91.06 | 100% | $1,821.20 |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 24 | $13.85 | 100% | $332.40 |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 1 | $15.29 | 100% | $15.29 |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $10.24 | 100% | $20.48 |
| 72072 | THORACIC SPINE 3 VIEWS | 11 | $11.68 | 100% | $128.48 |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 1 | $12.40 | 100% | $12.40 |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 63 | $11.32 | 100% | $713.16 |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $13.13 | 100% | $13.13 |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 1 | $15.29 | 100% | $15.29 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $50.11 | 100% | $651.43 |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $50.11 | 100% | $250.55 |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 254 | $74.32 | 100% | $18,877.28 |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 55 | $74.32 | 100% | $4,087.60 |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 487 | $74.32 | 100% | $36,193.84 |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 21 | $114.78 | 100% | $2,410.38 |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 18 | $114.78 | 100% | $2,066.04 |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $114.78 | 100% | $17,676.12 |
| 72170 | PELVIS 1 OR 2 VIEWS | 2 | $8.79 | 100% | $17.58 |
| 72190 | PELVIS 3 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $54.44 | 100% | $54.44 |
| 72193 | CT PELVIS W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $73.24 | 100% | $439.44 |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $109.82 | 100% | $1,317.84 |
| 72200 | SI JOINTS 2 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 72202 | SI JOINTS 3 VIEWS | 1 | $11.68 | 100% | $11.68 |
| 72220 | SACRUM COCCYX 2 VIEWS | 3 | $8.79 | 100% | $26.37 |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73010 | SCAPULA LEFT 2 VIEWS | 1 | $9.16 | 100% | $9.16 |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.71 | 100% | $7.71 |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 89 | $9.52 | 100% | $847.28 |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.52 | 100% | $9.52 |
| 73060 | HUMERUS RIGHT 2 VIEWS | 3 | $8.43 | 100% | $25.29 |
| 73070 | ELBOW LEFT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 20 | $8.79 | 100% | $175.80 |
| 73090 | FOREARM RIGHT 2 VIEWS | 4 | $8.43 | 100% | $33.72 |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73110 | WRIST RIGHT 3 VIEWS | 30 | $8.79 | 100% | $263.70 |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73130 | HAND LEFT 3 VIEWS | 54 | $8.79 | 100% | $474.66 |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 5 | $6.99 | 100% | $34.95 |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $61.07 | 100% | $61.07 |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $67.92 | 100% | $135.84 |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $107.66 | 100% | $430.64 |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $68.55 | 100% | $19,262.55 |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 53 | $81.68 | 100% | $4,329.04 |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $107.66 | 100% | $861.28 |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $9.52 | 100% | $19.04 |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 57 | $11.32 | 100% | $645.24 |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $13.85 | 100% | $13.85 |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 16 | $11.32 | 100% | $181.12 |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $16.01 | 100% | $16.01 |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $9.16 | 100% | $45.80 |
| 73560 | KNEE LEFT 2 VIEWS | 11 | $8.43 | 100% | $92.73 |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.52 | 100% | $9.52 |
| 73564 | KNEE LEFT 4 VIEWS | 151 | $11.32 | 100% | $1,709.32 |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.79 | 100% | $8.79 |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 7 | $8.07 | 100% | $56.49 |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73610 | ANKLE LEFT 3 VIEWS | 38 | $8.79 | 100% | $334.02 |
| 73620 | FOOT (B) LEFT 3 VIEWS | 28 | $7.71 | 100% | $215.88 |
| 73630 | FOOT RIGHT 3 VIEWS | 57 | $8.43 | 100% | $480.51 |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 2 | $8.07 | 100% | $16.14 |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 2 | $6.63 | 100% | $13.26 |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $50.11 | 100% | $200.44 |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $93.95 | 100% | $93.95 |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $67.56 | 100% | $405.36 |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $107.30 | 100% | $1,287.60 |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $67.92 | 100% | $17,591.28 |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $81.68 | 100% | $1,633.60 |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $107.66 | 100% | $2,260.86 |
| 74018 | ABDOMEN 1 VIEW | 48 | $9.16 | 100% | $439.68 |
| 74019 | ABDOMEN 2 VIEWS | 24 | $11.68 | 100% | $280.32 |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $59.62 | 100% | $59.62 |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $69.99 | 100% | $279.96 |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $109.37 | 100% | $656.22 |
| 74175 | CTA ABDOMEN | 1 | $90.70 | 100% | $90.70 |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $87.09 | 100% | $3,135.24 |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $91.42 | 100% | $7,770.70 |
| 74178 | CT ABDOMEN/PELVIS W/O & W CONTRAST | 33 | $100.44 | 100% | $3,314.52 |
| 75635 | CTA ABDOMINAL ARTERIES AND BILATERAL ILIOFEM RUNOFF | 3 | $118.39 | 100% | $355.17 |
| 76536 | US THYROID AND/OR SOFT TISSUE HEAD AND NECK | 10 | $28.19 | 100% | $281.90 |
| 76604 | US CHEST | 1 | $28.91 | 100% | $28.91 |
| 76700 | US ABDOMEN COMPLETE | 16 | $40.72 | 100% | $651.52 |
| 76705 | US ABDOMEN LIMITED | 29 | $29.27 | 100% | $848.83 |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $36.85 | 100% | $1,326.60 |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $28.91 | 100% | $1,011.85 |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $24.81 | 100% | $49.62 |
| 76870 | US SCROTUM | 12 | $31.80 | 100% | $381.60 |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $31.66 | 100% | $31.66 |
| 76882 | US EXTREMITY NONVASCULAR LIMITED | 2 | $24.45 | 100% | $48.90 |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $22.28 | 100% | $22.28 |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $27.83 | 100% | $55.66 |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $24.45 | 100% | $244.50 |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $41.54 | 100% | $124.62 |
| 78020 | TTHYROID CA METASTASES, UPTAKE, ADD-ON 78020 | 2 | $28.05 | 100% | $56.10 |
| 78070 | PARATHYROID PLANAR W/SUBTRATRACTION | 7 | $39.01 | 100% | $273.07 |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $58.41 | 100% | $292.05 |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 41 | $36.49 | 100% | $1,496.09 |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 25 | $39.01 | 100% | $975.25 |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 1 | $31.07 | 100% | $31.07 |
| 78306 | BONE IMAGING, WHOLE BODY | 183 | $42.53 | 100% | $7,782.99 |
| 78315 | BONE IMAGING, THREE PHASE | 9 | $50.47 | 100% | $454.23 |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $67.43 | 100% | $269.72 |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 911 | $79.47 | 100% | $72,397.17 |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $48.30 | 100% | $289.80 |
| 78496 | CARDIAC BLOOD POOL, RIGHT EF, ADD-ON | 6 | $24.45 | 100% | $146.70 |
| 78582 | LUNG VENT IMAGING (AEROSOL OR GAS) & PERF | 10 | $52.63 | 100% | $526.30 |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 2 | $59.13 | 100% | $118.26 |
| 93880 | US CAROTID BILATERAL | 55 | $39.41 | 100% | $2,167.55 |
| 93882 | US CAROTID UNILATERAL | 1 | $24.16 | 100% | $24.16 |
| 93923 | ABI | 22 | $21.60 | 100% | $475.20 |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $23.76 | 100% | $23.76 |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $34.00 | 100% | $544.00 |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $22.05 | 100% | $661.50 |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $56.77 | 100% | $56.77 |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $39.64 | 100% | $39.64 |
TOTAL: $323,241.69
Year 5 of Ordering Period
| D.6 - Attachment 6 - 36C26321R0009 |
| Year 5 of the Ordering Period: April 1, 2025 to March 31, 2026 |
| 100% | Input the proposed percentage price increase to the current Medicare CPT Code with modifier 26 (Professional Component) Facility calendar rate for South Dakota. |
| * Note: If lower than 100% then result will be a reduced price to the Medicare rate. |
| $ 323,241.69 | This is the Total Extended Price to be entered in the corresponding Schedule under the Estimated Total Price column for line item three (1003, 2003, 3003, 4003, and 5003). | ||||
| * Note: These are estimates only and do not obligate the government to the estimated amounts. | |||||
| * Note: The 2020 Medicare CPT Code with modifier 26 (Professional Component) Facility current calendar year rate for South Dakota is used for estimating cost. However, throughout the life of the contract VA shall pay the current Medicare calendar Facility rate with modifier 26 (Professional Component) for South Dakota, plus the proposed percentage price increase. | |||||
| CPT Code | Procedure Description | Estimated Quantity | 2020 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 1 | $9.16 | 100% | $9.16 |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 70150 | FACIAL BONES | 1 | $13.49 | 100% | $13.49 |
| 70160 | NASAL BONES 3 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.79 | 100% | $8.79 |
| 70220 | SINUSES 3 OR MORE VIEWS | 2 | $11.32 | 100% | $22.64 |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $10.24 | 100% | $593.92 |
| 70328 | TMJ UNILATERAL OPEN/CLOSED | 1 | $9.16 | 100% | $9.16 |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $12.40 | 100% | $12.40 |
| 70360 | NECK SOFT TISSUE | 1 | $9.16 | 100% | $9.16 |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $42.53 | 100% | $3,147.22 |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $63.59 | 100% | $127.18 |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $63.23 | 100% | $63.23 |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $42.89 | 100% | $557.57 |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $56.60 | 100% | $56.60 |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $64.31 | 100% | $64.31 |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $69.37 | 100% | $693.70 |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $81.31 | 100% | $81.31 |
| 70496 | CTA HEAD | 2 | $87.45 | 100% | $174.90 |
| 70498 | CTA NECK | 5 | $87.45 | 100% | $437.25 |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $107.30 | 100% | $643.80 |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $59.98 | 100% | $4,018.66 |
| 70547 | MRA NECK W/O CONTRAST | 2 | $60.34 | 100% | $120.68 |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $90.34 | 100% | $3,703.94 |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $74.32 | 100% | $15,012.64 |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 240 | $114.78 | 100% | $27,547.20 |
| 71045 | CHEST ONE VIEW | 137 | $9.16 | 100% | $1,254.92 |
| 71046 | CHEST 2 VIEWS PA&LAT | 343 | $10.96 | 100% | $3,759.28 |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $16.37 | 100% | $16.37 |
| 71100 | RIBS 2 VIEWS LEFT | 1 | $11.32 | 100% | $11.32 |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 18 | $13.49 | 100% | $242.82 |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $14.93 | 100% | $14.93 |
| 71120 | STERNUM | 1 | $10.24 | 100% | $10.24 |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 71250 | CT CHEST W/O CONTRAST | 82 | $58.05 | 100% | $4,760.10 |
| 71260 | CT CHEST W CONTRAST | 53 | $62.51 | 100% | $3,313.03 |
| 71270 | CT CHEST W/WO | 1 | $69.01 | 100% | $69.01 |
| 71275 | CTA CHEST | 20 | $91.06 | 100% | $1,821.20 |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 1 | $11.32 | 100% | $11.32 |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 24 | $13.85 | 100% | $332.40 |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 1 | $15.29 | 100% | $15.29 |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $10.24 | 100% | $20.48 |
| 72072 | THORACIC SPINE 3 VIEWS | 11 | $11.68 | 100% | $128.48 |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 1 | $12.40 | 100% | $12.40 |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 63 | $11.32 | 100% | $713.16 |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $13.13 | 100% | $13.13 |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 1 | $15.29 | 100% | $15.29 |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $50.11 | 100% | $651.43 |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $50.11 | 100% | $250.55 |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 254 | $74.32 | 100% | $18,877.28 |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 55 | $74.32 | 100% | $4,087.60 |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 487 | $74.32 | 100% | $36,193.84 |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 21 | $114.78 | 100% | $2,410.38 |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 18 | $114.78 | 100% | $2,066.04 |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $114.78 | 100% | $17,676.12 |
| 72170 | PELVIS 1 OR 2 VIEWS | 2 | $8.79 | 100% | $17.58 |
| 72190 | PELVIS 3 OR MORE VIEWS | 1 | $12.76 | 100% | $12.76 |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $54.44 | 100% | $54.44 |
| 72193 | CT PELVIS W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $73.24 | 100% | $439.44 |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $109.82 | 100% | $1,317.84 |
| 72200 | SI JOINTS 2 VIEWS | 1 | $8.79 | 100% | $8.79 |
| 72202 | SI JOINTS 3 VIEWS | 1 | $11.68 | 100% | $11.68 |
| 72220 | SACRUM COCCYX 2 VIEWS | 3 | $8.79 | 100% | $26.37 |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73010 | SCAPULA LEFT 2 VIEWS | 1 | $9.16 | 100% | $9.16 |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.71 | 100% | $7.71 |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 89 | $9.52 | 100% | $847.28 |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.52 | 100% | $9.52 |
| 73060 | HUMERUS RIGHT 2 VIEWS | 3 | $8.43 | 100% | $25.29 |
| 73070 | ELBOW LEFT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 20 | $8.79 | 100% | $175.80 |
| 73090 | FOREARM RIGHT 2 VIEWS | 4 | $8.43 | 100% | $33.72 |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73110 | WRIST RIGHT 3 VIEWS | 30 | $8.79 | 100% | $263.70 |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73130 | HAND LEFT 3 VIEWS | 54 | $8.79 | 100% | $474.66 |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 5 | $6.99 | 100% | $34.95 |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $50.11 | 100% | $50.11 |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $61.07 | 100% | $61.07 |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $67.92 | 100% | $135.84 |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $107.66 | 100% | $430.64 |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $68.55 | 100% | $19,262.55 |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 53 | $81.68 | 100% | $4,329.04 |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $107.66 | 100% | $861.28 |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $9.52 | 100% | $19.04 |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 57 | $11.32 | 100% | $645.24 |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $13.85 | 100% | $13.85 |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 16 | $11.32 | 100% | $181.12 |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $16.01 | 100% | $16.01 |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $9.16 | 100% | $45.80 |
| 73560 | KNEE LEFT 2 VIEWS | 11 | $8.43 | 100% | $92.73 |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.52 | 100% | $9.52 |
| 73564 | KNEE LEFT 4 VIEWS | 151 | $11.32 | 100% | $1,709.32 |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.79 | 100% | $8.79 |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 7 | $8.07 | 100% | $56.49 |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $8.43 | 100% | $8.43 |
| 73610 | ANKLE LEFT 3 VIEWS | 38 | $8.79 | 100% | $334.02 |
| 73620 | FOOT (B) LEFT 3 VIEWS | 28 | $7.71 | 100% | $215.88 |
| 73630 | FOOT RIGHT 3 VIEWS | 57 | $8.43 | 100% | $480.51 |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 2 | $8.07 | 100% | $16.14 |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 2 | $6.63 | 100% | $13.26 |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $50.11 | 100% | $200.44 |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $58.05 | 100% | $58.05 |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $93.95 | 100% | $93.95 |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $67.56 | 100% | $405.36 |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $107.30 | 100% | $1,287.60 |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $67.92 | 100% | $17,591.28 |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $81.68 | 100% | $1,633.60 |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $107.66 | 100% | $2,260.86 |
| 74018 | ABDOMEN 1 VIEW | 48 | $9.16 | 100% | $439.68 |
| 74019 | ABDOMEN 2 VIEWS | 24 | $11.68 | 100% | $280.32 |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $59.62 | 100% | $59.62 |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $63.95 | 100% | $63.95 |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $69.99 | 100% | $279.96 |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $109.37 | 100% | $656.22 |
| 74175 | CTA ABDOMEN | 1 | $90.70 | 100% | $90.70 |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $87.09 | 100% | $3,135.24 |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $91.42 | 100% | $7,770.70 |
| 74178 | CT ABDOMEN/PELVIS W/O & W CONTRAST | 33 | $100.44 | 100% | $3,314.52 |
| 75635 | CTA ABDOMINAL ARTERIES AND BILATERAL ILIOFEM RUNOFF | 3 | $118.39 | 100% | $355.17 |
| 76536 | US THYROID AND/OR SOFT TISSUE HEAD AND NECK | 10 | $28.19 | 100% | $281.90 |
| 76604 | US CHEST | 1 | $28.91 | 100% | $28.91 |
| 76700 | US ABDOMEN COMPLETE | 16 | $40.72 | 100% | $651.52 |
| 76705 | US ABDOMEN LIMITED | 29 | $29.27 | 100% | $848.83 |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $36.85 | 100% | $1,326.60 |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $28.91 | 100% | $1,011.85 |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $24.81 | 100% | $49.62 |
| 76870 | US SCROTUM | 12 | $31.80 | 100% | $381.60 |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $31.66 | 100% | $31.66 |
| 76882 | US EXTREMITY NONVASCULAR LIMITED | 2 | $24.45 | 100% | $48.90 |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $22.28 | 100% | $22.28 |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $27.83 | 100% | $55.66 |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $24.45 | 100% | $244.50 |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $41.54 | 100% | $124.62 |
| 78020 | TTHYROID CA METASTASES, UPTAKE, ADD-ON 78020 | 2 | $28.05 | 100% | $56.10 |
| 78070 | PARATHYROID PLANAR W/SUBTRATRACTION | 7 | $39.01 | 100% | $273.07 |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $58.41 | 100% | $292.05 |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 41 | $36.49 | 100% | $1,496.09 |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 25 | $39.01 | 100% | $975.25 |
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