Breast Imaging Billing Policy

Please note, in order to provide a complete examination, it may become necessary to convert a screening mammogram to a diagnostic mammogram.  Reasons for diagnostic mammography include, but are not limited to, the following conditions and/or findings:

• Breast lump or area of thickening
• Indeterminate finding on a screening mammogram, such as a nodule or calcifications
• Nipple discharge or bleeding
• Breast pain or tenderness
• Personal history of breast cancer

Your insurance carrier will be billed accordingly and may include, but are not limited to, any of the charges listed below. You will be responsible for any copay, coinsurance and/or deductible applied to these services:

Digital Screening Mammography with CAD (77067/G0202)	$250.00
Digital Diagnostic Mammography with CAD (77066/G0204)	$325.00
Digital Unilateral Mammography with CAD (77065/G0206)	$230.00
Digital Breast Tomosynthesis (77063/G0279)	$75.00
Breast Ultrasound, Unilateral (76641/complete)	$215.00
Breast Ultrasound, Unilateral (76642/limited)	$185.00
Breast Elastography, Targeted	$120.00
Breast Elastography, Additional Lesion	$90.00

Please sign below indicating you have read and understood the above information. If our prices change or this is modified in the future, you will be asked to sign a new sheet. Otherwise, your electronic signature below means you have read and understood our policies as stated regarding the breast imaging studies you are having today and in the future. This signed notification will become a part of your permanent record at Weinstein Imaging Associates.

By submitting the information below, you are indicating that you have read and understand our billing policy.