D.6 Attachment 6 - CPT Code Table.xlsx
XLSX spreadsheet 54 KB Posted
- Solicitation number
- 36C26326R0001
About this file
This file is a CPT Code Table attachment for a radiology physician services solicitation issued by the Department of Veterans Affairs Veterans Health Administration, Veterans Integrated Service Network 23 (VISN 23). The table serves as a reference document that lists Current Procedural Terminology (CPT) codes relevant to the radiology services that will be provided at the Sioux Falls, South Dakota location under the contract period of August 1, 2026, through July 31, 2031 (five-year performance period).
This attachment is a technical appendix designed to standardize billing and service descriptions for radiology procedures covered under the solicitation. It functions as a coding reference tool for contractors to ensure accurate reporting, billing, and documentation of radiology services delivered to Veterans Affairs patients. The specific CPT codes listed in the table establish the scope of radiology services that may be rendered and provide clarity on procedure classification for contract performance and compensation purposes.
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Ordering Period 1
| D.6 - Attachment 6 - |
| Ordering Period 1: 08/01/2026 - 07/31/2027 |
| % | 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. |
| $ - 0 | 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 2026 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 | 2026 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 4 | $8.80 | $0.00 | |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $11.47 | $0.00 | |
| 70150 | FACIAL BONES | 1 | $12.14 | $0.00 | |
| 70160 | NASAL BONES 3 VIEWS | 3 | $8.13 | $0.00 | |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.13 | $0.00 | |
| 70220 | SINUSES 3 OR MORE VIEWS | 5 | $10.13 | $0.00 | |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $8.46 | $0.00 | |
| 70260 | SKULL 4 VIEWS OR LESS | 10 | $12.80 | $0.00 | |
| 70328 | TMJ UNILATERAL | 5 | $8.46 | $0.00 | |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $11.13 | $0.00 | |
| 70336 | MRI TMJ WO | 5 | $65.25 | $0.00 | |
| 70360 | NECK SOFT TISSUE | 5 | $8.46 | $0.00 | |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $38.30 | $0.00 | |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $50.55 | $0.00 | |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $56.90 | $0.00 | |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $50.55 | $0.00 | |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $56.57 | $0.00 | |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $38.64 | $0.00 | |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $50.55 | $0.00 | |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $61.91 | $0.00 | |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $72.04 | $0.00 | |
| 70496 | CTA HEAD | 2 | $78.17 | $0.00 | |
| 70498 | CTA NECK | 5 | $78.17 | $0.00 | |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $96.21 | $0.00 | |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $53.56 | $0.00 | |
| 70547 | MRA NECK W/O CONTRAST | 2 | $56.56 | $0.00 | |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $80.50 | $0.00 | |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $66.03 | $0.00 | |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 336 | $102.33 | $0.00 | |
| 71045 | CHEST ONE VIEW | 150 | $8.13 | $0.00 | |
| 71046 | CHEST 2 VIEWS PA&LAT | 350 | $9.80 | $0.00 | |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $14.25 | $0.00 | |
| 71100 | RIBS 2 VIEWS LEFT | 10 | $10.13 | $0.00 | |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 50 | $12.25 | $0.00 | |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $13.14 | $0.00 | |
| 71120 | STERNUM | 5 | $9.13 | $0.00 | |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $10.13 | $0.00 | |
| 71250 | CT CHEST W/O CONTRAST | 82 | $48.10 | $0.00 | |
| 71260 | CT CHEST W CONTRAST | 53 | $52.22 | $0.00 | |
| 71270 | CT CHEST W/WO | 1 | $55.90 | $0.00 | |
| 71275 | CTA CHEST | 20 | $81.06 | $0.00 | |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 5 | $10.13 | $0.00 | |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 30 | $12.58 | $0.00 | |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 7 | $13.92 | $0.00 | |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $9.46 | $0.00 | |
| 72072 | THORACIC SPINE 3 VIEWS | 175 | $10.13 | $0.00 | |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 5 | $11.13 | $0.00 | |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 100 | $10.47 | $0.00 | |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $12.25 | $0.00 | |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 15 | $13.92 | $0.00 | |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $45.10 | $0.00 | |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $45.10 | $0.00 | |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 300 | $66.36 | $0.00 | |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 65 | $66.36 | $0.00 | |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 505 | $66.70 | $0.00 | |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 60 | $102.66 | $0.00 | |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 35 | $102.66 | $0.00 | |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $102.66 | $0.00 | |
| 72170 | PELVIS 1 OR 2 VIEWS | 15 | $8.13 | $0.00 | |
| 72190 | PELVIS 3 OR MORE VIEWS | 5 | $11.91 | $0.00 | |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $48.44 | $0.00 | |
| 72193 | CT PELVIS W CONTRAST | 1 | $51.89 | $0.00 | |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $65.25 | $0.00 | |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $98.66 | $0.00 | |
| 72200 | SI JOINTS 2 VIEWS | 11 | $8.13 | $0.00 | |
| 72202 | SI JOINTS 3 VIEWS | 18 | $10.13 | $0.00 | |
| 72220 | SACRUM COCCYX 2 VIEWS | 40 | $8.13 | $0.00 | |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73010 | SCAPULA LEFT 2 VIEWS | 5 | $8.80 | $0.00 | |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.13 | $0.00 | |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 15 | $8.80 | $0.00 | |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.13 | $0.00 | |
| 73060 | HUMERUS RIGHT 2 VIEWS | 10 | $7.79 | $0.00 | |
| 73070 | ELBOW LEFT 2 VIEWS | 15 | $7.79 | $0.00 | |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 15 | $8.13 | $0.00 | |
| 73090 | FOREARM RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.13 | $0.00 | |
| 73110 | WRIST RIGHT 3 VIEWS | 10 | $8.46 | $0.00 | |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73130 | HAND LEFT 3 VIEWS | 100 | $8.46 | $0.00 | |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 10 | $6.46 | $0.00 | |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $54.23 | $0.00 | |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $61.24 | $0.00 | |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $96.87 | $0.00 | |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $61.58 | $0.00 | |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 80 | $73.38 | $0.00 | |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $96.87 | $0.00 | |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $8.80 | $0.00 | |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 25 | $10.47 | $0.00 | |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $12.92 | $0.00 | |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 25 | $10.47 | $0.00 | |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $14.25 | $0.00 | |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $8.46 | $0.00 | |
| 73560 | KNEE LEFT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.13 | $0.00 | |
| 73564 | KNEE LEFT 4 VIEWS | 150 | $10.80 | $0.00 | |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.13 | $0.00 | |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73610 | ANKLE LEFT 3 VIEWS | 100 | $8.13 | $0.00 | |
| 73620 | FOOT (B) LEFT 3 VIEWS | 100 | $7.46 | $0.00 | |
| 73630 | FOOT RIGHT 3 VIEWS | 100 | $7.79 | $0.00 | |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 4 | $7.46 | $0.00 | |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 10 | $6.12 | $0.00 | |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $45.10 | $0.00 | |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $84.18 | $0.00 | |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $60.57 | $0.00 | |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $96.54 | $0.00 | |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $61.24 | $0.00 | |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $73.38 | $0.00 | |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $96.54 | $0.00 | |
| 74018 | ABDOMEN 1 VIEW | 50 | $8.46 | $0.00 | |
| 74019 | ABDOMEN 2 VIEWS | 50 | $10.47 | $0.00 | |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $53.23 | $0.00 | |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $56.90 | $0.00 | |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $62.58 | $0.00 | |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $97.99 | $0.00 | |
| 74175 | CTA ABDOMEN | 1 | $80.73 | $0.00 | |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $77.83 | $0.00 | |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $81.40 | $0.00 | |
| 74220 | ESOPHAGRAM | 0 | $27.06 | $0.00 | |
| 74230 | VIDEO SWALLOW | 0 | $24.05 | $0.00 | |
| 76000 | FLUORO UP TO 1 HR | 0 | $14.70 | $0.00 | |
| 76604 | US CHEST | 1 | $26.84 | $0.00 | |
| 76700 | US ABDOMEN COMPLETE | 16 | $36.52 | $0.00 | |
| 76705 | US ABDOMEN LIMITED | 29 | $26.72 | $0.00 | |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $33.18 | $0.00 | |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $26.39 | $0.00 | |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $23.05 | $0.00 | |
| 76870 | US SCROTUM | 12 | $28.84 | $0.00 | |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $41.87 | $0.00 | |
| 77002 | IR GUIDED FLUORO | 0 | $26.39 | $0.00 | |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $20.04 | $0.00 | |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $25.05 | $0.00 | |
| 77080 | DEXA | 0 | $9.13 | $0.00 | |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $22.05 | $0.00 | |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $37.19 | $0.00 | |
| 78072 | PARATHYROID | 7 | $69.26 | $0.00 | |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $52.11 | $0.00 | |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 10 | $32.85 | $0.00 | |
| 78227 | HEPATOBILIARY DUCT IMAGING,W PHARM INTERVENTION | 50 | $39.97 | $0.00 | |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 50 | $34.85 | $0.00 | |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 15 | $27.39 | $0.00 | |
| 78306 | BONE IMAGING, WHOLE BODY | 150 | $37.86 | $0.00 | |
| 78315 | BONE IMAGING, THREE PHASE | 10 | $44.98 | $0.00 | |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $62.02 | $0.00 | |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 900 | $73.15 | $0.00 | |
| 78290 | MECKELS | 6 | $43.52 | $0.00 | |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $43.87 | $0.00 | |
| 78278 | GI BLEED | 6 | $43.98 | $0.00 | |
| 78580 | LUNG PERFUSION | 10 | $32.85 | $0.00 | |
| 78582 | LUNG VENTILATION/PERFUSION | 10 | $47.10 | $0.00 | |
| 78597 | LUNG QUANTITATIVE | 10 | $32.40 | $0.00 | |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 10 | $52.78 | $0.00 | |
| 78707 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING | 5 | $42.31 | $0.00 | |
| 78102 | BONE MARROW IMAGING LTD | 15 | $24.05 | $0.00 | |
| 78104 | BONE MARROW IMAGING WB | 0 | $34.85 | $0.00 | |
| 78802 | TUMOR LOCALIZATION WHOLE BODY 1 DAY | 15 | $34.85 | $0.00 | |
| 78803 | TUMOR LOCALIZATION SPECT ONLY | 100 | $47.99 | $0.00 | |
| 78830 | TUMOR LOCALIZATION SPECT W/CT | 100 | $63.80 | $0.00 | |
| 93880 | US CAROTID BILATERAL | 55 | $35.86 | $0.00 | |
| 93882 | US CAROTID UNILATERAL | 1 | $22.05 | $0.00 | |
| 93923 | ABI | 22 | $20.05 | $0.00 | |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $21.27 | $0.00 | |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $30.73 | $0.00 | |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $19.71 | $0.00 | |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $51.11 | $0.00 | |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $35.97 | $0.00 | |
| Total for Ordering Period One (CLIN 1003) | $0.00 |
Ordering Period 2
| D.6 - Attachment 6 - |
| Ordering Period 2: 08/01/2027 - 07/31/2028 |
| % | 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. |
| $ - 0 | 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 2026 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 | 2026 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 4 | $8.80 | $0.00 | |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $11.47 | $0.00 | |
| 70150 | FACIAL BONES | 1 | $12.14 | $0.00 | |
| 70160 | NASAL BONES 3 VIEWS | 3 | $8.13 | $0.00 | |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.13 | $0.00 | |
| 70220 | SINUSES 3 OR MORE VIEWS | 5 | $10.13 | $0.00 | |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $8.46 | $0.00 | |
| 70260 | SKULL 4 VIEWS OR LESS | 10 | $12.80 | $0.00 | |
| 70328 | TMJ UNILATERAL | 5 | $8.46 | $0.00 | |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $11.13 | $0.00 | |
| 70336 | MRI TMJ WO | 5 | $65.25 | $0.00 | |
| 70360 | NECK SOFT TISSUE | 5 | $8.46 | $0.00 | |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $38.30 | $0.00 | |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $50.55 | $0.00 | |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $56.90 | $0.00 | |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $50.55 | $0.00 | |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $56.57 | $0.00 | |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $38.64 | $0.00 | |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $50.55 | $0.00 | |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $61.91 | $0.00 | |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $72.04 | $0.00 | |
| 70496 | CTA HEAD | 2 | $78.17 | $0.00 | |
| 70498 | CTA NECK | 5 | $78.17 | $0.00 | |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $96.21 | $0.00 | |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $53.56 | $0.00 | |
| 70547 | MRA NECK W/O CONTRAST | 2 | $56.56 | $0.00 | |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $80.50 | $0.00 | |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $66.03 | $0.00 | |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 336 | $102.33 | $0.00 | |
| 71045 | CHEST ONE VIEW | 150 | $8.13 | $0.00 | |
| 71046 | CHEST 2 VIEWS PA&LAT | 350 | $9.80 | $0.00 | |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $14.25 | $0.00 | |
| 71100 | RIBS 2 VIEWS LEFT | 10 | $10.13 | $0.00 | |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 50 | $12.25 | $0.00 | |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $13.14 | $0.00 | |
| 71120 | STERNUM | 5 | $9.13 | $0.00 | |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $10.13 | $0.00 | |
| 71250 | CT CHEST W/O CONTRAST | 82 | $48.10 | $0.00 | |
| 71260 | CT CHEST W CONTRAST | 53 | $52.22 | $0.00 | |
| 71270 | CT CHEST W/WO | 1 | $55.90 | $0.00 | |
| 71275 | CTA CHEST | 20 | $81.06 | $0.00 | |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 5 | $10.13 | $0.00 | |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 30 | $12.58 | $0.00 | |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 7 | $13.92 | $0.00 | |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $9.46 | $0.00 | |
| 72072 | THORACIC SPINE 3 VIEWS | 175 | $10.13 | $0.00 | |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 5 | $11.13 | $0.00 | |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 100 | $10.47 | $0.00 | |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $12.25 | $0.00 | |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 15 | $13.92 | $0.00 | |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $45.10 | $0.00 | |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $45.10 | $0.00 | |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 300 | $66.36 | $0.00 | |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 65 | $66.36 | $0.00 | |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 505 | $66.70 | $0.00 | |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 60 | $102.66 | $0.00 | |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 35 | $102.66 | $0.00 | |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $102.66 | $0.00 | |
| 72170 | PELVIS 1 OR 2 VIEWS | 15 | $8.13 | $0.00 | |
| 72190 | PELVIS 3 OR MORE VIEWS | 5 | $11.91 | $0.00 | |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $48.44 | $0.00 | |
| 72193 | CT PELVIS W CONTRAST | 1 | $51.89 | $0.00 | |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $65.25 | $0.00 | |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $98.66 | $0.00 | |
| 72200 | SI JOINTS 2 VIEWS | 11 | $8.13 | $0.00 | |
| 72202 | SI JOINTS 3 VIEWS | 18 | $10.13 | $0.00 | |
| 72220 | SACRUM COCCYX 2 VIEWS | 40 | $8.13 | $0.00 | |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73010 | SCAPULA LEFT 2 VIEWS | 5 | $8.80 | $0.00 | |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.13 | $0.00 | |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 15 | $8.80 | $0.00 | |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.13 | $0.00 | |
| 73060 | HUMERUS RIGHT 2 VIEWS | 10 | $7.79 | $0.00 | |
| 73070 | ELBOW LEFT 2 VIEWS | 15 | $7.79 | $0.00 | |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 15 | $8.13 | $0.00 | |
| 73090 | FOREARM RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.13 | $0.00 | |
| 73110 | WRIST RIGHT 3 VIEWS | 10 | $8.46 | $0.00 | |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73130 | HAND LEFT 3 VIEWS | 100 | $8.46 | $0.00 | |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 10 | $6.46 | $0.00 | |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $54.23 | $0.00 | |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $61.24 | $0.00 | |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $96.87 | $0.00 | |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $61.58 | $0.00 | |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 80 | $73.38 | $0.00 | |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $96.87 | $0.00 | |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $8.80 | $0.00 | |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 25 | $10.47 | $0.00 | |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $12.92 | $0.00 | |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 25 | $10.47 | $0.00 | |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $14.25 | $0.00 | |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $8.46 | $0.00 | |
| 73560 | KNEE LEFT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.13 | $0.00 | |
| 73564 | KNEE LEFT 4 VIEWS | 150 | $10.80 | $0.00 | |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.13 | $0.00 | |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73610 | ANKLE LEFT 3 VIEWS | 100 | $8.13 | $0.00 | |
| 73620 | FOOT (B) LEFT 3 VIEWS | 100 | $7.46 | $0.00 | |
| 73630 | FOOT RIGHT 3 VIEWS | 100 | $7.79 | $0.00 | |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 4 | $7.46 | $0.00 | |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 10 | $6.12 | $0.00 | |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $45.10 | $0.00 | |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $84.18 | $0.00 | |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $60.57 | $0.00 | |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $96.54 | $0.00 | |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $61.24 | $0.00 | |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $73.38 | $0.00 | |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $96.54 | $0.00 | |
| 74018 | ABDOMEN 1 VIEW | 50 | $8.46 | $0.00 | |
| 74019 | ABDOMEN 2 VIEWS | 50 | $10.47 | $0.00 | |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $53.23 | $0.00 | |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $56.90 | $0.00 | |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $62.58 | $0.00 | |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $97.99 | $0.00 | |
| 74175 | CTA ABDOMEN | 1 | $80.73 | $0.00 | |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $77.83 | $0.00 | |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $81.40 | $0.00 | |
| 74220 | ESOPHAGRAM | 0 | $27.06 | $0.00 | |
| 74230 | VIDEO SWALLOW | 0 | $24.05 | $0.00 | |
| 76000 | FLUORO UP TO 1 HR | 0 | $14.70 | $0.00 | |
| 76604 | US CHEST | 1 | $26.84 | $0.00 | |
| 76700 | US ABDOMEN COMPLETE | 16 | $36.52 | $0.00 | |
| 76705 | US ABDOMEN LIMITED | 29 | $26.72 | $0.00 | |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $33.18 | $0.00 | |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $26.39 | $0.00 | |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $23.05 | $0.00 | |
| 76870 | US SCROTUM | 12 | $28.84 | $0.00 | |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $41.87 | $0.00 | |
| 77002 | IR GUIDED FLUORO | 0 | $26.39 | $0.00 | |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $20.04 | $0.00 | |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $25.05 | $0.00 | |
| 77080 | DEXA | 0 | $9.13 | $0.00 | |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $22.05 | $0.00 | |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $37.19 | $0.00 | |
| 78072 | PARATHYROID | 7 | $69.26 | $0.00 | |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $52.11 | $0.00 | |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 10 | $32.85 | $0.00 | |
| 78227 | HEPATOBILIARY DUCT IMAGING,W PHARM INTERVENTION | 50 | $39.97 | $0.00 | |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 50 | $34.85 | $0.00 | |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 15 | $27.39 | $0.00 | |
| 78306 | BONE IMAGING, WHOLE BODY | 150 | $37.86 | $0.00 | |
| 78315 | BONE IMAGING, THREE PHASE | 10 | $44.98 | $0.00 | |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $62.02 | $0.00 | |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 900 | $73.15 | $0.00 | |
| 78290 | MECKELS | 6 | $43.52 | $0.00 | |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $43.87 | $0.00 | |
| 78278 | GI BLEED | 6 | $43.98 | $0.00 | |
| 78580 | LUNG PERFUSION | 10 | $32.85 | $0.00 | |
| 78582 | LUNG VENTILATION/PERFUSION | 10 | $47.10 | $0.00 | |
| 78597 | LUNG QUANTITATIVE | 10 | $32.40 | $0.00 | |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 10 | $52.78 | $0.00 | |
| 78707 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING | 5 | $42.31 | $0.00 | |
| 78102 | BONE MARROW IMAGING LTD | 15 | $24.05 | $0.00 | |
| 78104 | BONE MARROW IMAGING WB | 0 | $34.85 | $0.00 | |
| 78802 | TUMOR LOCALIZATION WHOLE BODY 1 DAY | 15 | $34.85 | $0.00 | |
| 78803 | TUMOR LOCALIZATION SPECT ONLY | 100 | $47.99 | $0.00 | |
| 78830 | TUMOR LOCALIZATION SPECT W/CT | 100 | $63.80 | $0.00 | |
| 93880 | US CAROTID BILATERAL | 55 | $35.86 | $0.00 | |
| 93882 | US CAROTID UNILATERAL | 1 | $22.05 | $0.00 | |
| 93923 | ABI | 22 | $20.05 | $0.00 | |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $21.27 | $0.00 | |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $30.73 | $0.00 | |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $19.71 | $0.00 | |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $51.11 | $0.00 | |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $35.97 | $0.00 | |
| Total for Ordering Period Two (CLIN 2003) | $0.00 |
Ordering Period 3
| D.6 - Attachment 6 - |
| Ordering Period 3: 08/01/2028 - 07/31/2029 |
| % | 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. |
| $ - 0 | 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 2026 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 | 2026 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 4 | $8.80 | $0.00 | |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $11.47 | $0.00 | |
| 70150 | FACIAL BONES | 1 | $12.14 | $0.00 | |
| 70160 | NASAL BONES 3 VIEWS | 3 | $8.13 | $0.00 | |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.13 | $0.00 | |
| 70220 | SINUSES 3 OR MORE VIEWS | 5 | $10.13 | $0.00 | |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $8.46 | $0.00 | |
| 70260 | SKULL 4 VIEWS OR LESS | 10 | $12.80 | $0.00 | |
| 70328 | TMJ UNILATERAL | 5 | $8.46 | $0.00 | |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $11.13 | $0.00 | |
| 70336 | MRI TMJ WO | 5 | $65.25 | $0.00 | |
| 70360 | NECK SOFT TISSUE | 5 | $8.46 | $0.00 | |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $38.30 | $0.00 | |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $50.55 | $0.00 | |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $56.90 | $0.00 | |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $50.55 | $0.00 | |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $56.57 | $0.00 | |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $38.64 | $0.00 | |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $50.55 | $0.00 | |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $61.91 | $0.00 | |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $72.04 | $0.00 | |
| 70496 | CTA HEAD | 2 | $78.17 | $0.00 | |
| 70498 | CTA NECK | 5 | $78.17 | $0.00 | |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $96.21 | $0.00 | |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $53.56 | $0.00 | |
| 70547 | MRA NECK W/O CONTRAST | 2 | $56.56 | $0.00 | |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $80.50 | $0.00 | |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $66.03 | $0.00 | |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 336 | $102.33 | $0.00 | |
| 71045 | CHEST ONE VIEW | 150 | $8.13 | $0.00 | |
| 71046 | CHEST 2 VIEWS PA&LAT | 350 | $9.80 | $0.00 | |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $14.25 | $0.00 | |
| 71100 | RIBS 2 VIEWS LEFT | 10 | $10.13 | $0.00 | |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 50 | $12.25 | $0.00 | |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $13.14 | $0.00 | |
| 71120 | STERNUM | 5 | $9.13 | $0.00 | |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $10.13 | $0.00 | |
| 71250 | CT CHEST W/O CONTRAST | 82 | $48.10 | $0.00 | |
| 71260 | CT CHEST W CONTRAST | 53 | $52.22 | $0.00 | |
| 71270 | CT CHEST W/WO | 1 | $55.90 | $0.00 | |
| 71275 | CTA CHEST | 20 | $81.06 | $0.00 | |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 5 | $10.13 | $0.00 | |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 30 | $12.58 | $0.00 | |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 7 | $13.92 | $0.00 | |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $9.46 | $0.00 | |
| 72072 | THORACIC SPINE 3 VIEWS | 175 | $10.13 | $0.00 | |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 5 | $11.13 | $0.00 | |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 100 | $10.47 | $0.00 | |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $12.25 | $0.00 | |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 15 | $13.92 | $0.00 | |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $45.10 | $0.00 | |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $45.10 | $0.00 | |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 300 | $66.36 | $0.00 | |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 65 | $66.36 | $0.00 | |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 505 | $66.70 | $0.00 | |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 60 | $102.66 | $0.00 | |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 35 | $102.66 | $0.00 | |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $102.66 | $0.00 | |
| 72170 | PELVIS 1 OR 2 VIEWS | 15 | $8.13 | $0.00 | |
| 72190 | PELVIS 3 OR MORE VIEWS | 5 | $11.91 | $0.00 | |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $48.44 | $0.00 | |
| 72193 | CT PELVIS W CONTRAST | 1 | $51.89 | $0.00 | |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $65.25 | $0.00 | |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $98.66 | $0.00 | |
| 72200 | SI JOINTS 2 VIEWS | 11 | $8.13 | $0.00 | |
| 72202 | SI JOINTS 3 VIEWS | 18 | $10.13 | $0.00 | |
| 72220 | SACRUM COCCYX 2 VIEWS | 40 | $8.13 | $0.00 | |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73010 | SCAPULA LEFT 2 VIEWS | 5 | $8.80 | $0.00 | |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.13 | $0.00 | |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 15 | $8.80 | $0.00 | |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.13 | $0.00 | |
| 73060 | HUMERUS RIGHT 2 VIEWS | 10 | $7.79 | $0.00 | |
| 73070 | ELBOW LEFT 2 VIEWS | 15 | $7.79 | $0.00 | |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 15 | $8.13 | $0.00 | |
| 73090 | FOREARM RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.13 | $0.00 | |
| 73110 | WRIST RIGHT 3 VIEWS | 10 | $8.46 | $0.00 | |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73130 | HAND LEFT 3 VIEWS | 100 | $8.46 | $0.00 | |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 10 | $6.46 | $0.00 | |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $54.23 | $0.00 | |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $61.24 | $0.00 | |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $96.87 | $0.00 | |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $61.58 | $0.00 | |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 80 | $73.38 | $0.00 | |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $96.87 | $0.00 | |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $8.80 | $0.00 | |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 25 | $10.47 | $0.00 | |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $12.92 | $0.00 | |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 25 | $10.47 | $0.00 | |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $14.25 | $0.00 | |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $8.46 | $0.00 | |
| 73560 | KNEE LEFT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.13 | $0.00 | |
| 73564 | KNEE LEFT 4 VIEWS | 150 | $10.80 | $0.00 | |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.13 | $0.00 | |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73610 | ANKLE LEFT 3 VIEWS | 100 | $8.13 | $0.00 | |
| 73620 | FOOT (B) LEFT 3 VIEWS | 100 | $7.46 | $0.00 | |
| 73630 | FOOT RIGHT 3 VIEWS | 100 | $7.79 | $0.00 | |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 4 | $7.46 | $0.00 | |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 10 | $6.12 | $0.00 | |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $45.10 | $0.00 | |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $84.18 | $0.00 | |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $60.57 | $0.00 | |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $96.54 | $0.00 | |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $61.24 | $0.00 | |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $73.38 | $0.00 | |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $96.54 | $0.00 | |
| 74018 | ABDOMEN 1 VIEW | 50 | $8.46 | $0.00 | |
| 74019 | ABDOMEN 2 VIEWS | 50 | $10.47 | $0.00 | |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $53.23 | $0.00 | |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $56.90 | $0.00 | |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $62.58 | $0.00 | |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $97.99 | $0.00 | |
| 74175 | CTA ABDOMEN | 1 | $80.73 | $0.00 | |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $77.83 | $0.00 | |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $81.40 | $0.00 | |
| 74220 | ESOPHAGRAM | 0 | $27.06 | $0.00 | |
| 74230 | VIDEO SWALLOW | 0 | $24.05 | $0.00 | |
| 76000 | FLUORO UP TO 1 HR | 0 | $14.70 | $0.00 | |
| 76604 | US CHEST | 1 | $26.84 | $0.00 | |
| 76700 | US ABDOMEN COMPLETE | 16 | $36.52 | $0.00 | |
| 76705 | US ABDOMEN LIMITED | 29 | $26.72 | $0.00 | |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $33.18 | $0.00 | |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $26.39 | $0.00 | |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $23.05 | $0.00 | |
| 76870 | US SCROTUM | 12 | $28.84 | $0.00 | |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $41.87 | $0.00 | |
| 77002 | IR GUIDED FLUORO | 0 | $26.39 | $0.00 | |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $20.04 | $0.00 | |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $25.05 | $0.00 | |
| 77080 | DEXA | 0 | $9.13 | $0.00 | |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $22.05 | $0.00 | |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $37.19 | $0.00 | |
| 78072 | PARATHYROID | 7 | $69.26 | $0.00 | |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $52.11 | $0.00 | |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 10 | $32.85 | $0.00 | |
| 78227 | HEPATOBILIARY DUCT IMAGING,W PHARM INTERVENTION | 50 | $39.97 | $0.00 | |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 50 | $34.85 | $0.00 | |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 15 | $27.39 | $0.00 | |
| 78306 | BONE IMAGING, WHOLE BODY | 150 | $37.86 | $0.00 | |
| 78315 | BONE IMAGING, THREE PHASE | 10 | $44.98 | $0.00 | |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $62.02 | $0.00 | |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 900 | $73.15 | $0.00 | |
| 78290 | MECKELS | 6 | $43.52 | $0.00 | |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $43.87 | $0.00 | |
| 78278 | GI BLEED | 6 | $43.98 | $0.00 | |
| 78580 | LUNG PERFUSION | 10 | $32.85 | $0.00 | |
| 78582 | LUNG VENTILATION/PERFUSION | 10 | $47.10 | $0.00 | |
| 78597 | LUNG QUANTITATIVE | 10 | $32.40 | $0.00 | |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 10 | $52.78 | $0.00 | |
| 78707 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING | 5 | $42.31 | $0.00 | |
| 78102 | BONE MARROW IMAGING LTD | 15 | $24.05 | $0.00 | |
| 78104 | BONE MARROW IMAGING WB | 0 | $34.85 | $0.00 | |
| 78802 | TUMOR LOCALIZATION WHOLE BODY 1 DAY | 15 | $34.85 | $0.00 | |
| 78803 | TUMOR LOCALIZATION SPECT ONLY | 100 | $47.99 | $0.00 | |
| 78830 | TUMOR LOCALIZATION SPECT W/CT | 100 | $63.80 | $0.00 | |
| 93880 | US CAROTID BILATERAL | 55 | $35.86 | $0.00 | |
| 93882 | US CAROTID UNILATERAL | 1 | $22.05 | $0.00 | |
| 93923 | ABI | 22 | $20.05 | $0.00 | |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $21.27 | $0.00 | |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $30.73 | $0.00 | |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $19.71 | $0.00 | |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $51.11 | $0.00 | |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $35.97 | $0.00 | |
| Total for Ordering Period Three (CLIN 3003) | $0.00 |
Ordering Period 4
| D.6 - Attachment 6 - |
| Ordering Period 4: 08/01/2029 - 07/31/2030 |
| % | 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. |
| $ - 0 | 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 2026 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 | 2026 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 4 | $8.80 | $0.00 | |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $11.47 | $0.00 | |
| 70150 | FACIAL BONES | 1 | $12.14 | $0.00 | |
| 70160 | NASAL BONES 3 VIEWS | 3 | $8.13 | $0.00 | |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.13 | $0.00 | |
| 70220 | SINUSES 3 OR MORE VIEWS | 5 | $10.13 | $0.00 | |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $8.46 | $0.00 | |
| 70260 | SKULL 4 VIEWS OR LESS | 10 | $12.80 | $0.00 | |
| 70328 | TMJ UNILATERAL | 5 | $8.46 | $0.00 | |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $11.13 | $0.00 | |
| 70336 | MRI TMJ WO | 5 | $65.25 | $0.00 | |
| 70360 | NECK SOFT TISSUE | 5 | $8.46 | $0.00 | |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $38.30 | $0.00 | |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $50.55 | $0.00 | |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $56.90 | $0.00 | |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $50.55 | $0.00 | |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $56.57 | $0.00 | |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $38.64 | $0.00 | |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $50.55 | $0.00 | |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $61.91 | $0.00 | |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $72.04 | $0.00 | |
| 70496 | CTA HEAD | 2 | $78.17 | $0.00 | |
| 70498 | CTA NECK | 5 | $78.17 | $0.00 | |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $96.21 | $0.00 | |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $53.56 | $0.00 | |
| 70547 | MRA NECK W/O CONTRAST | 2 | $56.56 | $0.00 | |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $80.50 | $0.00 | |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $66.03 | $0.00 | |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 336 | $102.33 | $0.00 | |
| 71045 | CHEST ONE VIEW | 150 | $8.13 | $0.00 | |
| 71046 | CHEST 2 VIEWS PA&LAT | 350 | $9.80 | $0.00 | |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $14.25 | $0.00 | |
| 71100 | RIBS 2 VIEWS LEFT | 10 | $10.13 | $0.00 | |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 50 | $12.25 | $0.00 | |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $13.14 | $0.00 | |
| 71120 | STERNUM | 5 | $9.13 | $0.00 | |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $10.13 | $0.00 | |
| 71250 | CT CHEST W/O CONTRAST | 82 | $48.10 | $0.00 | |
| 71260 | CT CHEST W CONTRAST | 53 | $52.22 | $0.00 | |
| 71270 | CT CHEST W/WO | 1 | $55.90 | $0.00 | |
| 71275 | CTA CHEST | 20 | $81.06 | $0.00 | |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 5 | $10.13 | $0.00 | |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 30 | $12.58 | $0.00 | |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 7 | $13.92 | $0.00 | |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $9.46 | $0.00 | |
| 72072 | THORACIC SPINE 3 VIEWS | 175 | $10.13 | $0.00 | |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 5 | $11.13 | $0.00 | |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 100 | $10.47 | $0.00 | |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $12.25 | $0.00 | |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 15 | $13.92 | $0.00 | |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $45.10 | $0.00 | |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $45.10 | $0.00 | |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 300 | $66.36 | $0.00 | |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 65 | $66.36 | $0.00 | |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 505 | $66.70 | $0.00 | |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 60 | $102.66 | $0.00 | |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 35 | $102.66 | $0.00 | |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $102.66 | $0.00 | |
| 72170 | PELVIS 1 OR 2 VIEWS | 15 | $8.13 | $0.00 | |
| 72190 | PELVIS 3 OR MORE VIEWS | 5 | $11.91 | $0.00 | |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $48.44 | $0.00 | |
| 72193 | CT PELVIS W CONTRAST | 1 | $51.89 | $0.00 | |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $65.25 | $0.00 | |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $98.66 | $0.00 | |
| 72200 | SI JOINTS 2 VIEWS | 11 | $8.13 | $0.00 | |
| 72202 | SI JOINTS 3 VIEWS | 18 | $10.13 | $0.00 | |
| 72220 | SACRUM COCCYX 2 VIEWS | 40 | $8.13 | $0.00 | |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73010 | SCAPULA LEFT 2 VIEWS | 5 | $8.80 | $0.00 | |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.13 | $0.00 | |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 15 | $8.80 | $0.00 | |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.13 | $0.00 | |
| 73060 | HUMERUS RIGHT 2 VIEWS | 10 | $7.79 | $0.00 | |
| 73070 | ELBOW LEFT 2 VIEWS | 15 | $7.79 | $0.00 | |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 15 | $8.13 | $0.00 | |
| 73090 | FOREARM RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.13 | $0.00 | |
| 73110 | WRIST RIGHT 3 VIEWS | 10 | $8.46 | $0.00 | |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73130 | HAND LEFT 3 VIEWS | 100 | $8.46 | $0.00 | |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 10 | $6.46 | $0.00 | |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $54.23 | $0.00 | |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $61.24 | $0.00 | |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $96.87 | $0.00 | |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $61.58 | $0.00 | |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 80 | $73.38 | $0.00 | |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $96.87 | $0.00 | |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $8.80 | $0.00 | |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 25 | $10.47 | $0.00 | |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $12.92 | $0.00 | |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 25 | $10.47 | $0.00 | |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $14.25 | $0.00 | |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $8.46 | $0.00 | |
| 73560 | KNEE LEFT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.13 | $0.00 | |
| 73564 | KNEE LEFT 4 VIEWS | 150 | $10.80 | $0.00 | |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.13 | $0.00 | |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73610 | ANKLE LEFT 3 VIEWS | 100 | $8.13 | $0.00 | |
| 73620 | FOOT (B) LEFT 3 VIEWS | 100 | $7.46 | $0.00 | |
| 73630 | FOOT RIGHT 3 VIEWS | 100 | $7.79 | $0.00 | |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 4 | $7.46 | $0.00 | |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 10 | $6.12 | $0.00 | |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $45.10 | $0.00 | |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $84.18 | $0.00 | |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $60.57 | $0.00 | |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $96.54 | $0.00 | |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $61.24 | $0.00 | |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $73.38 | $0.00 | |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $96.54 | $0.00 | |
| 74018 | ABDOMEN 1 VIEW | 50 | $8.46 | $0.00 | |
| 74019 | ABDOMEN 2 VIEWS | 50 | $10.47 | $0.00 | |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $53.23 | $0.00 | |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $56.90 | $0.00 | |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $62.58 | $0.00 | |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $97.99 | $0.00 | |
| 74175 | CTA ABDOMEN | 1 | $80.73 | $0.00 | |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $77.83 | $0.00 | |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $81.40 | $0.00 | |
| 74220 | ESOPHAGRAM | 0 | $27.06 | $0.00 | |
| 74230 | VIDEO SWALLOW | 0 | $24.05 | $0.00 | |
| 76000 | FLUORO UP TO 1 HR | 0 | $14.70 | $0.00 | |
| 76604 | US CHEST | 1 | $26.84 | $0.00 | |
| 76700 | US ABDOMEN COMPLETE | 16 | $36.52 | $0.00 | |
| 76705 | US ABDOMEN LIMITED | 29 | $26.72 | $0.00 | |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $33.18 | $0.00 | |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $26.39 | $0.00 | |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $23.05 | $0.00 | |
| 76870 | US SCROTUM | 12 | $28.84 | $0.00 | |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $41.87 | $0.00 | |
| 77002 | IR GUIDED FLUORO | 0 | $26.39 | $0.00 | |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $20.04 | $0.00 | |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $25.05 | $0.00 | |
| 77080 | DEXA | 0 | $9.13 | $0.00 | |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $22.05 | $0.00 | |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $37.19 | $0.00 | |
| 78072 | PARATHYROID | 7 | $69.26 | $0.00 | |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $52.11 | $0.00 | |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 10 | $32.85 | $0.00 | |
| 78227 | HEPATOBILIARY DUCT IMAGING,W PHARM INTERVENTION | 50 | $39.97 | $0.00 | |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 50 | $34.85 | $0.00 | |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 15 | $27.39 | $0.00 | |
| 78306 | BONE IMAGING, WHOLE BODY | 150 | $37.86 | $0.00 | |
| 78315 | BONE IMAGING, THREE PHASE | 10 | $44.98 | $0.00 | |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $62.02 | $0.00 | |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 900 | $73.15 | $0.00 | |
| 78290 | MECKELS | 6 | $43.52 | $0.00 | |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $43.87 | $0.00 | |
| 78278 | GI BLEED | 6 | $43.98 | $0.00 | |
| 78580 | LUNG PERFUSION | 10 | $32.85 | $0.00 | |
| 78582 | LUNG VENTILATION/PERFUSION | 10 | $47.10 | $0.00 | |
| 78597 | LUNG QUANTITATIVE | 10 | $32.40 | $0.00 | |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 10 | $52.78 | $0.00 | |
| 78707 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING | 5 | $42.31 | $0.00 | |
| 78102 | BONE MARROW IMAGING LTD | 15 | $24.05 | $0.00 | |
| 78104 | BONE MARROW IMAGING WB | 0 | $34.85 | $0.00 | |
| 78802 | TUMOR LOCALIZATION WHOLE BODY 1 DAY | 15 | $34.85 | $0.00 | |
| 78803 | TUMOR LOCALIZATION SPECT ONLY | 100 | $47.99 | $0.00 | |
| 78830 | TUMOR LOCALIZATION SPECT W/CT | 100 | $63.80 | $0.00 | |
| 93880 | US CAROTID BILATERAL | 55 | $35.86 | $0.00 | |
| 93882 | US CAROTID UNILATERAL | 1 | $22.05 | $0.00 | |
| 93923 | ABI | 22 | $20.05 | $0.00 | |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $21.27 | $0.00 | |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $30.73 | $0.00 | |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $19.71 | $0.00 | |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $51.11 | $0.00 | |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $35.97 | $0.00 | |
| Total for Ordering Period Four (CLIN 4003) | $0.00 |
Ordering Period 5
| D.6 - Attachment 6 - |
| Ordering Period 5: 08/01/2030 - 07/31/2031 |
| % | 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. |
| $ - 0 | 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 2026 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 | 2026 Medicare Facility Professional Component South Dakota Rate | Offeror Proposed Percentage of Medicare Rate | Estimated Cost |
| 70100 | MANDIBLE 3 VIEWS OR LESS | 4 | $8.80 | $0.00 | |
| 70110 | MANDIBLE 4 OR MORE VIEWS | 1 | $11.47 | $0.00 | |
| 70150 | FACIAL BONES | 1 | $12.14 | $0.00 | |
| 70160 | NASAL BONES 3 VIEWS | 3 | $8.13 | $0.00 | |
| 70210 | SINUSES 1+ VIEWS | 1 | $8.13 | $0.00 | |
| 70220 | SINUSES 3 OR MORE VIEWS | 5 | $10.13 | $0.00 | |
| 70250 | SKULL 3 VIEWS OR LESS | 58 | $8.46 | $0.00 | |
| 70260 | SKULL 4 VIEWS OR LESS | 10 | $12.80 | $0.00 | |
| 70328 | TMJ UNILATERAL | 5 | $8.46 | $0.00 | |
| 70330 | TMJ BILATERAL OPEN/CLOSED | 1 | $11.13 | $0.00 | |
| 70336 | MRI TMJ WO | 5 | $65.25 | $0.00 | |
| 70360 | NECK SOFT TISSUE | 5 | $8.46 | $0.00 | |
| 70450 | CT HEAD/BRAIN W/O CONTRAST | 74 | $38.30 | $0.00 | |
| 70460 | CT HEAD/BRAIN W CONTRAST | 1 | $50.55 | $0.00 | |
| 70470 | CT HEAD/BRAIN W/O & W CONTRAST | 2 | $56.90 | $0.00 | |
| 70480 | CT ORBIT/EAR/FOSSA W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70481 | CT ORBIT/EAR/FOSSA W CONTRAST | 1 | $50.55 | $0.00 | |
| 70482 | CT ORBIT/EAR/FOSSA W/O & W CONTRAST | 1 | $56.57 | $0.00 | |
| 70486 | CT MAXILLOFACIAL W/O CONTRAST | 13 | $38.64 | $0.00 | |
| 70487 | CT MAXILLOFACIAL W CONTRAST | 1 | $50.55 | $0.00 | |
| 70490 | CT NECK SOFT TISSUE W/O CONTRAST | 1 | $57.57 | $0.00 | |
| 70491 | CT NECK SOFT TISSUE W CONTRAST | 10 | $61.91 | $0.00 | |
| 70492 | CT NECK SOFT TISSUE W/O & W CONTRAST | 1 | $72.04 | $0.00 | |
| 70496 | CTA HEAD | 2 | $78.17 | $0.00 | |
| 70498 | CTA NECK | 5 | $78.17 | $0.00 | |
| 70543 | MRI NECK/FACE/ORBIT W & W/O CONTRAST | 6 | $96.21 | $0.00 | |
| 70544 | MRA HEAD W/O CONTRAST | 67 | $53.56 | $0.00 | |
| 70547 | MRA NECK W/O CONTRAST | 2 | $56.56 | $0.00 | |
| 70549 | MRA NECK W & W/O CONTRAST | 41 | $80.50 | $0.00 | |
| 70551 | MRI BRAIN/BRAINSTEM W/O CONTRAST | 202 | $66.03 | $0.00 | |
| 70553 | MRI BRAIN/BRAIN STEM W & W/O CONTRAST | 336 | $102.33 | $0.00 | |
| 71045 | CHEST ONE VIEW | 150 | $8.13 | $0.00 | |
| 71046 | CHEST 2 VIEWS PA&LAT | 350 | $9.80 | $0.00 | |
| 71048 | CHEST DECUBITUS RIGHT SIDE DOWN | 1 | $14.25 | $0.00 | |
| 71100 | RIBS 2 VIEWS LEFT | 10 | $10.13 | $0.00 | |
| 71101 | RIBS UNILAT+CHEST 3 OR MORE VIEWS | 50 | $12.25 | $0.00 | |
| 71110 | RIBS BILATERAL 3 + VIEWS | 1 | $13.14 | $0.00 | |
| 71120 | STERNUM | 5 | $9.13 | $0.00 | |
| 71130 | STERNOCLAV JOINT MIN 3 VIEWS | 1 | $10.13 | $0.00 | |
| 71250 | CT CHEST W/O CONTRAST | 82 | $48.10 | $0.00 | |
| 71260 | CT CHEST W CONTRAST | 53 | $52.22 | $0.00 | |
| 71270 | CT CHEST W/WO | 1 | $55.90 | $0.00 | |
| 71275 | CTA CHEST | 20 | $81.06 | $0.00 | |
| 72040 | CERVICAL SPINE 2 OR 3 VIEWS | 5 | $10.13 | $0.00 | |
| 72050 | CERVICAL SPINE MINIMUM 4 VIEWS | 30 | $12.58 | $0.00 | |
| 72052 | CERVICAL SPINE COMPLETE WITH FLEX/EXT | 7 | $13.92 | $0.00 | |
| 72070 | THORACIC SPINE 2 VIEWS | 2 | $9.46 | $0.00 | |
| 72072 | THORACIC SPINE 3 VIEWS | 175 | $10.13 | $0.00 | |
| 72074 | THORACIC SPINE MINIMUM 4 VIEWS | 5 | $11.13 | $0.00 | |
| 72100 | LUMBAR SPINE 2 OR 3 VIEWS | 100 | $10.47 | $0.00 | |
| 72110 | LUMBAR SPINE W OBLIQUES MIN 4 VIEWS | 1 | $12.25 | $0.00 | |
| 72114 | LUMBAR SPINE COMPLETE W/FLEXION/EXTENSION | 15 | $13.92 | $0.00 | |
| 72125 | CT CERVICAL SPINE W/O CONTRAST | 13 | $45.10 | $0.00 | |
| 72128 | CT THORACIC SPINE W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 72131 | CT LUMBAR SPINE W/O CONTRAST | 5 | $45.10 | $0.00 | |
| 72141 | MRI SPINE CERVICAL W/O CONTRAST | 300 | $66.36 | $0.00 | |
| 72146 | MRI SPINE THORACIC W/O CONTRAST | 65 | $66.36 | $0.00 | |
| 72148 | MRI SPINE LUMBAR W/O CONTRAST | 505 | $66.70 | $0.00 | |
| 72156 | MRI SPINE CERVICAL W & W/O CONTRAST | 60 | $102.66 | $0.00 | |
| 72157 | MRI SPINE THORACIC W & W/O CONTRAST | 35 | $102.66 | $0.00 | |
| 72158 | MRI SPINE LUMBAR W & W/O CONTRAST | 154 | $102.66 | $0.00 | |
| 72170 | PELVIS 1 OR 2 VIEWS | 15 | $8.13 | $0.00 | |
| 72190 | PELVIS 3 OR MORE VIEWS | 5 | $11.91 | $0.00 | |
| 72192 | CT PELVIS W/O CONTRAST | 1 | $48.44 | $0.00 | |
| 72193 | CT PELVIS W CONTRAST | 1 | $51.89 | $0.00 | |
| 72195 | MRI PELVIS W/O CONTRAST | 6 | $65.25 | $0.00 | |
| 72197 | MRI PELVIS W/O & W CONTRAST | 12 | $98.66 | $0.00 | |
| 72200 | SI JOINTS 2 VIEWS | 11 | $8.13 | $0.00 | |
| 72202 | SI JOINTS 3 VIEWS | 18 | $10.13 | $0.00 | |
| 72220 | SACRUM COCCYX 2 VIEWS | 40 | $8.13 | $0.00 | |
| 73000 | CLAVICLE RIGHT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73010 | SCAPULA LEFT 2 VIEWS | 5 | $8.80 | $0.00 | |
| 73020 | SHOULDER LEFT 1 VIEW | 1 | $7.13 | $0.00 | |
| 73030 | SHOULDER RIGHT MIN 2 VIEWS | 15 | $8.80 | $0.00 | |
| 73050 | ACROMIOCLAVICULAR JOINTS BILATERAL | 1 | $9.13 | $0.00 | |
| 73060 | HUMERUS RIGHT 2 VIEWS | 10 | $7.79 | $0.00 | |
| 73070 | ELBOW LEFT 2 VIEWS | 15 | $7.79 | $0.00 | |
| 73080 | ELBOW LEFT 3 OR MORE VIEWS | 15 | $8.13 | $0.00 | |
| 73090 | FOREARM RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73100 | WRIST RIGHT 2 VIEWS | 1 | $8.13 | $0.00 | |
| 73110 | WRIST RIGHT 3 VIEWS | 10 | $8.46 | $0.00 | |
| 73120 | HAND RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73130 | HAND LEFT 3 VIEWS | 100 | $8.46 | $0.00 | |
| 73140 | FINGER(S) LEFT 2 VIEWS OR MORE | 10 | $6.46 | $0.00 | |
| 73200 | CT UPPER EXTREMITY LEFT W/O CONTRAST | 1 | $45.10 | $0.00 | |
| 73201 | CT UPPER EXTREMITY RIGHT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73202 | CT UPPER EXTREMITY LEFT W/O & W CONTRAST | 1 | $54.23 | $0.00 | |
| 73218 | MRI UPPER EXT SOFT TISSUE RIGHT W/O CONTRAST | 2 | $61.24 | $0.00 | |
| 73220 | MRI UPPER EXT SOFTTISSUE RT W&WO CONTRAST | 4 | $96.87 | $0.00 | |
| 73221 | MRI SHOULDER LEFT W/O CONTRAST | 281 | $61.58 | $0.00 | |
| 73222 | MRI ARTHROGRAM SHOULDER RIGHT | 80 | $73.38 | $0.00 | |
| 73223 | MRI WRIST/HAND RIGHT W/O & W CONTRAST | 8 | $96.87 | $0.00 | |
| 73501 | HIP LEFT 1 VIEW (W/PELVIS WHEN PERFORMED) | 2 | $8.80 | $0.00 | |
| 73502 | HIP LEFT 2-3 VIEWS (W/PELVIS WHEN PERFORMED) | 25 | $10.47 | $0.00 | |
| 73503 | CR HIP - LEFT (>=4V) INCLD 1V PELVIS | 1 | $12.92 | $0.00 | |
| 73521 | HIPS BILATERAL 2 VIEWS W/AP PELVIS | 25 | $10.47 | $0.00 | |
| 73523 | CR HIP BILAT INCL PELVIS >=5V | 1 | $14.25 | $0.00 | |
| 73552 | FEMUR LEFT 2 VIEWS | 5 | $8.46 | $0.00 | |
| 73560 | KNEE LEFT 2 VIEWS | 20 | $7.79 | $0.00 | |
| 73562 | CR KNEE 3 VIEWS LEFT | 1 | $9.13 | $0.00 | |
| 73564 | KNEE LEFT 4 VIEWS | 150 | $10.80 | $0.00 | |
| 73565 | CR AP BILATERAL KNEES STANDING | 1 | $8.13 | $0.00 | |
| 73590 | TIBIA/FIBULA RIGHT 2 VIEWS | 10 | $7.46 | $0.00 | |
| 73600 | ANKLE RIGHT 2 VIEWS | 1 | $7.79 | $0.00 | |
| 73610 | ANKLE LEFT 3 VIEWS | 100 | $8.13 | $0.00 | |
| 73620 | FOOT (B) LEFT 3 VIEWS | 100 | $7.46 | $0.00 | |
| 73630 | FOOT RIGHT 3 VIEWS | 100 | $7.79 | $0.00 | |
| 73650 | CALCANEOUS LEFT MIN 2 VIEWS | 4 | $7.46 | $0.00 | |
| 73660 | TOE(S) LEFT 2 VIEWS OR MORE | 10 | $6.12 | $0.00 | |
| 73700 | CT LOWER EXTREMITY LEFT W/O CONTRAST | 4 | $45.10 | $0.00 | |
| 73701 | CT LOWER EXTREMITY LEFT W CONTRAST | 1 | $51.89 | $0.00 | |
| 73706 | CTA LOWER EXTREMITY RIGHT | 1 | $84.18 | $0.00 | |
| 73718 | MRI LOWER EXT SOFT TISSUE RIGHT W/O CONTRAST | 6 | $60.57 | $0.00 | |
| 73720 | MRI LOWER EXTR SOFT TISSUE LEFT W/O & W/ | 12 | $96.54 | $0.00 | |
| 73721 | MRI KNEE RIGHT W/O CONTRAST | 259 | $61.24 | $0.00 | |
| 73722 | MRI ARTHROGRAM HIP RIGHT W/ | 20 | $73.38 | $0.00 | |
| 73723 | MRI ANKLE/FOOT RIGHT W/O & W CONTRAST | 21 | $96.54 | $0.00 | |
| 74018 | ABDOMEN 1 VIEW | 50 | $8.46 | $0.00 | |
| 74019 | ABDOMEN 2 VIEWS | 50 | $10.47 | $0.00 | |
| 74150 | CT ABDOMEN W/O CONTRAST | 1 | $53.23 | $0.00 | |
| 74160 | CT ABDOMEN W CONTRAST | 1 | $56.90 | $0.00 | |
| 74170 | CT ABDOMEN W/O & W CONTRAST | 4 | $62.58 | $0.00 | |
| 74174 | CTA ABDOMEN & PELVIS | 6 | $97.99 | $0.00 | |
| 74175 | CTA ABDOMEN | 1 | $80.73 | $0.00 | |
| 74176 | CT ABDOMEN/PELVIS W/O CONTRAST | 36 | $77.83 | $0.00 | |
| 74177 | CT ABDOMEN/PELVIS W CONTRAST | 85 | $81.40 | $0.00 | |
| 74220 | ESOPHAGRAM | 0 | $27.06 | $0.00 | |
| 74230 | VIDEO SWALLOW | 0 | $24.05 | $0.00 | |
| 76000 | FLUORO UP TO 1 HR | 0 | $14.70 | $0.00 | |
| 76604 | US CHEST | 1 | $26.84 | $0.00 | |
| 76700 | US ABDOMEN COMPLETE | 16 | $36.52 | $0.00 | |
| 76705 | US ABDOMEN LIMITED | 29 | $26.72 | $0.00 | |
| 76770 | US RETROPERITONEAL COMPLETE | 36 | $33.18 | $0.00 | |
| 76775 | US RETROPERITONEAL LIMITED | 35 | $26.39 | $0.00 | |
| 76857 | US PELVIC (NON OB) LIMITED | 2 | $23.05 | $0.00 | |
| 76870 | US SCROTUM | 12 | $28.84 | $0.00 | |
| 76881 | US EXTREMITY NON VASCULAR - RIGHT | 1 | $41.87 | $0.00 | |
| 77002 | IR GUIDED FLUORO | 0 | $26.39 | $0.00 | |
| 77074 | BONE SURVEY LTMD (EG. FOR METASTASES) | 1 | $20.04 | $0.00 | |
| 77075 | BONE SURVEY COMPLETE (INCL APPENDIC SKEL) | 2 | $25.05 | $0.00 | |
| 77080 | DEXA | 0 | $9.13 | $0.00 | |
| 78014 | THYROID UPTAKE AND SCAN | 10 | $22.05 | $0.00 | |
| 78018 | THYROID CA METASTASES, WHOLE BODY 78018 | 3 | $37.19 | $0.00 | |
| 78072 | PARATHYROID | 7 | $69.26 | $0.00 | |
| 78195 | LYMPHATIC/LYMPH NODE IMAGING 78195 | 5 | $52.11 | $0.00 | |
| 78226 | HEPATOBILIARY DUCT IMAGING,W/O PHARM INTERVENTION | 10 | $32.85 | $0.00 | |
| 78227 | HEPATOBILIARY DUCT IMAGING,W PHARM INTERVENTION | 50 | $39.97 | $0.00 | |
| 78264 | GASTRIC EMPTY IMAGING (SOLID) 78264 | 50 | $34.85 | $0.00 | |
| 78300 | BONE IMAGING, LIMITED AREA ONLY, PLANAR | 15 | $27.39 | $0.00 | |
| 78306 | BONE IMAGING, WHOLE BODY | 150 | $37.86 | $0.00 | |
| 78315 | BONE IMAGING, THREE PHASE | 10 | $44.98 | $0.00 | |
| 78451 | MYOCARDIAL PERFUSION IMAGING, SPECT STUDY, SINGLE | 4 | $62.02 | $0.00 | |
| 78452 | MYOCARDIA PERFUSION IMAGING, SPECT STUDY, MULTIPLE | 900 | $73.15 | $0.00 | |
| 78290 | MECKELS | 6 | $43.52 | $0.00 | |
| 78472 | GATED CARDIAC BLOOD POOL, SINGLE 78472 | 6 | $43.87 | $0.00 | |
| 78278 | GI BLEED | 6 | $43.98 | $0.00 | |
| 78580 | LUNG PERFUSION | 10 | $32.85 | $0.00 | |
| 78582 | LUNG VENTILATION/PERFUSION | 10 | $47.10 | $0.00 | |
| 78597 | LUNG QUANTITATIVE | 10 | $32.40 | $0.00 | |
| 78708 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING, W/PHARM | 10 | $52.78 | $0.00 | |
| 78707 | KIDNE IMAGING MORPH, W/ VASC FLOW&FUNC, SING | 5 | $42.31 | $0.00 | |
| 78102 | BONE MARROW IMAGING LTD | 15 | $24.05 | $0.00 | |
| 78104 | BONE MARROW IMAGING WB | 0 | $34.85 | $0.00 | |
| 78802 | TUMOR LOCALIZATION WHOLE BODY 1 DAY | 15 | $34.85 | $0.00 | |
| 78803 | TUMOR LOCALIZATION SPECT ONLY | 100 | $47.99 | $0.00 | |
| 78830 | TUMOR LOCALIZATION SPECT W/CT | 100 | $63.80 | $0.00 | |
| 93880 | US CAROTID BILATERAL | 55 | $35.86 | $0.00 | |
| 93882 | US CAROTID UNILATERAL | 1 | $22.05 | $0.00 | |
| 93923 | ABI | 22 | $20.05 | $0.00 | |
| 93926 | US LOWER EXTREMITY ARTERIES UNILAT | 1 | $21.27 | $0.00 | |
| 93970 | US EXTREMITY VEINS BILAT | 16 | $30.73 | $0.00 | |
| 93971 | US EXTREMITY VEINS UNILAT | 30 | $19.71 | $0.00 | |
| 93975 | US VISCERAL VASCULAR ABDOMEN COMPLETE | 1 | $51.11 | $0.00 | |
| 93976 | US VISCERAL VASCULAR ABDOMEN LIMITED | 1 | $35.97 | $0.00 | |
| Total for Ordering Period Five (CLIN 5003) | $0.00 |
File details come from the government source that posted it. Updated .