| Item Number | Description | Schedule Fee |
|---|---|---|
| 63502 | MRI—scan of one or both breasts for the evaluation of implant integrity, if: (a) a dedicated breast coil is used; and (b) the request for the scan identifies that the patient: (i) has or is suspected of having a silicone breast implant manufactured by Poly Implant Prosthese (PIP); and (ii) the result of the scan does not demonstrate a loss of integrity of the implant (R) |
$560.60 |
| Total: | $560.60 | |