| Ankle 2 views (73600) |
— |
$334.55 |
— |
| Cholecystography, oral contrast Age Under 21 (74290) |
— |
$542.90 |
— |
| Clavicle complete (73000) |
— |
$334.55 |
— |
| Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if… (74174) |
— |
$7,074.20 |
— |
| Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and… (74175) |
— |
$6,041.65 |
— |
| Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast… (75635) |
— |
$4,564.65 |
— |
| Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if… (71275) |
— |
$3,365.20 |
— |
| Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if… (73706) |
— |
$2,206.40 |
— |
| Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and… (70498) |
— |
$3,156.80 |
— |
| Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if… (73206) |
— |
$2,243.50 |
— |
| Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections… (72127) |
— |
$3,028.35 |
— |
| Computed tomography, lower extremity; without contrast material Age Under 21 (73700) |
— |
$1,252.55 |
— |
| Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections… (73702) |
— |
$2,480.78 |
— |
| Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections Age… (72133) |
— |
$2,899.85 |
— |
| Computed tomography, maxillofacial area; with contrast material(s) Age Under 21 (70487) |
— |
$1,922.80 |
— |
| Computed tomography, maxillofacial area; without contrast material Age Under 21 (70486) |
— |
$1,701.70 |
— |
| Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) Age… (70481) |
— |
$1,940.20 |
— |
| Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Age… (70480) |
— |
$1,741.05 |
— |
| Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material,… (70482) |
— |
$2,359.25 |
— |
| Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections… (70492) |
— |
$2,346.50 |
— |
| Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections… (72130) |
— |
$2,985.50 |
— |
| Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further… (71270) |
— |
$2,697.25 |
— |
| CT abdomen and pelvis without and with contrast (74178) |
— |
$5,279.90 |
— |
| CT abdomen and pelvis without contrast (74176) |
— |
$2,230.70 |
— |
| CT abdomen w & w/o contrast (74170) |
— |
$5,116.70 |
— |
| CT abdomen w/contrast (74160) |
— |
$4,300.60 |
— |
| CT abdomen w/o contrast (74150) |
— |
$3,366.35 |
— |
| CT cervical spine w/contrast (72126) |
— |
$2,499.30 |
— |
| CT cervical spine w/o contrast (72125) |
— |
$2,108.05 |
— |
| CT chest w/contrast (71260) |
— |
$2,175.20 |
— |
| CT extremity upper w & w/o contrast (73202) |
— |
$1,646.15 |
— |
| CT extremity upper w/o contrast (73200) |
— |
$1,256 |
— |
| CT head/brain with contrast (70460) |
— |
$1,908.90 |
— |
| CT head/brain without and with contrast (70470) |
— |
$2,370.80 |
— |
| CT heart no contrast quant eval coronry calcium (75571) |
— |
$482.90 |
— |
| CT l-spine w/contrast (72132) |
— |
$2,436.80 |
— |
| CT limited/localized follow up study (76380) |
— |
$1,422.70 |
— |
| CT lower extremity w/dye (73701) |
— |
$1,398.40 |
— |
| CT lumbar spine w/o contrast (72131) |
— |
$2,096.45 |
— |
| CT maxillofacial w/wo contrast (70488) |
— |
$2,326.80 |
— |
| CT neck w/contrast (70491) |
— |
$1,920.50 |
— |
| CT neck w/o contrast (70490) |
— |
$1,721.35 |
— |
| CT pelvis w & w/o contrast (72194) |
— |
$2,597.70 |
— |
| CT pelvis w/o contrast (72192) |
— |
$1,891.55 |
— |
| CT thoracic spine w/contrast (72129) |
— |
$2,478.45 |
— |
| CT thoracic spine w/o contrast (72128) |
— |
$2,104.55 |
— |
| CT thorax lung cancer scr c- (71271) |
— |
$1,359.05 |
— |
| CT thorax w/o contrast (71250) |
— |
$1,967.95 |
— |
| CT upper extremity w/dye (73201) |
— |
$1,414.60 |
— |
| CTA head w contrast (70496) |
— |
$3,161.45 |
— |
| Cystography, minimum of 3 views, radiological supervision and interpretation Age Under 21 (74430) |
— |
$1,273.40 |
— |
| Discography, cervical or thoracic, radiological supervision and interpretation Age Under 21 (72285) |
— |
$13,004.75 |
— |
| Diskography lumbar s&i (72295) |
— |
$13,004.75 |
— |
| Fetal biophys profile w/o nst (76819) |
— |
$762.85 |
— |
| Fetal biophysical profile non-stress testing (76818) |
— |
$762.85 |
— |
| Fluoroscopy up to 1 hour physician/qhp time (76000) |
— |
$799.90 |
— |
| Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by… (73723) |
— |
$3,743.75 |
— |
| Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) Age Under 21 (73719) |
— |
$3,072.35 |
— |
| Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Age Under 21 (73718) |
— |
$2,740.10 |
— |
| Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by… (73720) |
— |
$3,803.95 |
— |
| Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) Age Under 21 (70542) |
— |
$4,558.75 |
— |
| Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) Age Under 21 (70540) |
— |
$3,974.15 |
— |
| Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) Age Under 21 (73219) |
— |
$2,704.20 |
— |
| Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by… (73220) |
— |
$3,329.35 |
— |
| Magnetic resonance angiography, head; with contrast material(s) Age Under 21 (70545) |
— |
$3,967.15 |
— |
| Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further… (70546) |
— |
$5,051.85 |
— |
| Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further… (70549) |
— |
$5,051.85 |
— |
| Mandible min 4v (70110) |
— |
$491.95 |
— |
| MRA head w/o contrast (70544) |
— |
$3,603.70 |
— |
| MRA neck w/ contrast (70548) |
— |
$4,012.30 |
— |
| MRA neck w/o contrast (70547) |
— |
$3,552.70 |
— |
| MRI abdomen w/contrast (74182) |
— |
$5,143.30 |
— |
| MRI abdomen w/o contrast (74181) |
— |
$4,493.90 |
— |
| MRI abdomen w/wo contrast (74183) |
— |
$6,069.40 |
— |
| MRI any jt lower extrem w/contrast material (73722) |
— |
$3,043.35 |
— |
| MRI c-spine w&w/o cont (72156) |
— |
$5,465.15 |
— |
| MRI cervical spine w/contrast (72142) |
— |
$4,289 |
— |
| MRI chest w/contrast (71551) |
— |
$4,409.35 |
— |
| MRI chest w/o contrast (71550) |
— |
$4,021.60 |
— |
| MRI chest w/wo contrast (71552) |
— |
$6,025.40 |
— |
| MRI joint upr extr w/o&w/dye (73223) |
— |
$3,695.15 |
— |
| MRI joint upr extrem w/dye (73222) |
— |
$2,943.85 |
— |
| MRI joint upr extrem w/o dye (73221) |
— |
$2,590.75 |
— |
| MRI lumbar spine w/contrast (72149) |
— |
$4,467.25 |
— |
| MRI lumbar spine w/wo contrast (72158) |
— |
$5,710.60 |
— |
| MRI orbit/face/neck w&w/o cont (70543) |
— |
$5,626.05 |
— |
| MRI pelvis w & w/o contrast (72197) |
— |
$5,573.95 |
— |
| MRI pelvis w/contrast (72196) |
— |
$4,445.30 |
— |
| MRI pelvis w/o contrast (72195) |
— |
$3,891.95 |
— |
| MRI spine cervical w/o contrast (72141) |
— |
$3,859.55 |
— |
| MRI t-spine w&w/o cont (72157) |
— |
$5,740.65 |
— |
| MRI thoracic spine w/contrast (72147) |
— |
$4,526.30 |
— |
| MRI thoracic spine w/o contrst (72146) |
— |
$4,164 |
— |
| MRI upper extremity oth than jt w/o contr matrl (73218) |
— |
$2,322.20 |
— |
| Ob us limited fetus(s) (76815) |
— |
$762.85 |
— |
| Optic foramina (70190) |
— |
$347.30 |
— |
| Radex abscess/fistula/sinus tract rs&i (76080) |
— |
$1,555.85 |
— |
| Radex entir thrc lmbr crv sac spi w/skull 1 vw (72081) |
— |
$350.75 |
— |
| Radex entir thrc lmbr crv sac spi w/skull 2/3 vw (72082) |
— |
$532.50 |
— |
| Radex entir thrc lmbr crv sac spi w/skull 4/5 vw (72083) |
— |
$709.60 |
— |
| Radex entir thrc lmbr crv sac spi w/skull 6/> vw (72084) |
— |
$955 |
— |
| Radex hip unilateral with pelvis 1 view (73501) |
— |
$334.55 |
— |
| Radex hip unilateral with pelvis 2-3 views (73502) |
— |
$353.08 |
— |
| Radex hip unilateral with pelvis minimum 4 views (73503) |
— |
$532.50 |
— |
| Radex hips bilateral with pelvis 2 views (73521) |
— |
$532.50 |
— |
| Radex spine cervical 2 or 3 views (72040) |
— |
$384.35 |
— |
| Radex spine cervical 4 or 5 views (72050) |
— |
$520.90 |
— |
| Radex spine cervical 6 or more views (72052) |
— |
$608.90 |
— |
| Radiologic exam chest 3 views (71047) |
— |
$334.55 |
— |
| Radiologic exam chest 4+ views (71048) |
— |
$512.80 |
— |
| Radiologic exam colon double contrast study (74280) |
— |
$1,151.85 |
— |
| Radiologic exam colon single contrast study (74270) |
— |
$849.70 |
— |
| Radiologic exam esophagus single contrast study (74220) |
— |
$559.10 |
— |
| Radiologic exam small int single contrast study (74250) |
— |
$641.35 |
— |
| Radiologic exam swallow function contrast study (74230) |
— |
$617.05 |
— |
| Radiologic exam upr gi trc double contrast study (74246) |
— |
$1,112.45 |
— |
| Radiologic exam upr gi trc single contrast study (74240) |
— |
$774.40 |
— |
| Radiologic examination femur 1 view (73551) |
— |
$347.30 |
— |
| Radiologic examination femur minimum 2 views (73552) |
— |
$355.35 |
— |
| Radiologic examination from nose to rectum for foreign body, single view, child Age Under 21 (76010) |
— |
$334.55 |
— |
| Radiologic examination, ankle; complete, minimum of 3 views Age Under 21 (73610) |
— |
$334.55 |
— |
| Radiologic examination, complete acute abdomen series, including 2 or more views of the abdomen (eg, supine, erect,… (74022) |
— |
$915.65 |
— |
| Radiologic examination, elbow; 2 views Age Under 21 (73070) |
— |
$334.55 |
— |
| Radiologic examination, elbow; complete, minimum of 3 views Age Under 21 (73080) |
— |
$341.50 |
— |
| Radiologic examination, facial bones; less than 3 views Age Under 21 (70140) |
— |
$364.65 |
— |
| Radiologic examination, foot; complete, minimum of 3 views Age Under 21 (73630) |
— |
$334.55 |
— |
| Radiologic examination, hand; minimum of 3 views Age Under 21 (73130) |
— |
$334.55 |
— |
| Radiologic examination, knee; both knees, standing, anteroposterior Age Under 21 (73565) |
— |
$334.55 |
— |
| Radiologic examination, knee; complete, 4 or more views Age Under 21 (73564) |
— |
$401.65 |
— |
| Radiologic examination, mandible; partial, less than 4 views Age Under 21 (70100) |
— |
$334.55 |
— |
| Radiologic examination, mastoids; complete, minimum of 3 views per side Age Under 21 (70130) |
— |
$429.45 |
— |
| Radiologic examination, nasal bones, complete, minimum of 3 views Age Under 21 (70160) |
— |
$334.55 |
— |
| Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views Age Under 21 (71111) |
— |
$497.75 |
— |
| Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views Age Under 21 (71101) |
— |
$417.88 |
— |
| Radiologic examination, sacroiliac joints; less than 3 views Age Under 21 (72200) |
— |
$334.55 |
— |
| Radiologic examination, shoulder, arthrography, radiological supervision and interpretation Age Under 21 (73040) |
— |
$1,656.55 |
— |
| Radiologic examination, shoulder; complete, minimum of 2 views Age Under 21 (73030) |
— |
$373.90 |
— |
| Radiologic examination, sinuses, paranasal, less than 3 views Age Under 21 (70210) |
— |
$334.55 |
— |
| Radiologic examination, skull; less than 4 views Age Under 21 (70250) |
— |
$343.80 |
— |
| Radiologic examination, spine, lumbosacral; 2 or 3 views Age Under 21 (72100) |
— |
$402.85 |
— |
| Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views Age Under 21 (72120) |
— |
$537.10 |
— |
| Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views Age Under 21 (72114) |
— |
$1,078.90 |
— |
| Radiologic examination, spine; thoracic, minimum of 4 views Age Under 21 (72074) |
— |
$537.10 |
— |
| Radiologic examination, wrist; complete, minimum of 3 views Age Under 21 (73110) |
— |
$334.55 |
— |
| Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction Age Under 21 (73050) |
— |
$387.80 |
— |
| Radiologic examination; humerus, minimum of 2 views Age Under 21 (73060) |
— |
$351.90 |
— |
| Radiologic examination; sternoclavicular joint or joints, minimum of 3 views Age Under 21 (71130) |
— |
$401.65 |
— |
| Radiologic examination; toe(s), minimum of 2 views Age Under 21 (73660) |
— |
$334.55 |
— |
| Review by radiologist of urinary bladder and urethra images with contrast and after passing urine (74455) |
— |
$1,273.40 |
— |
| Saline infusion sonohysterography (SIS), including color flow Doppler, when performed Age Under 21 (76831) |
— |
$815 |
— |
| Scapula complete (73010) |
— |
$344.95 |
— |
| Screening digital breast tomosynthesis bi (77063) |
— |
$84.20 |
— |
| Ultrasound breast limited (76642) |
— |
$455.45 |
— |
| Ultrasound, abdomen limited (76705) |
— |
$762.85 |
— |
| Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space,… (76882) |
— |
$537.35 |
— |
| Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Age Under 21 (76856) |
— |
$762.85 |
— |
| Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal… (76811) |
— |
$1,026.80 |
— |
| Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14… (76801) |
— |
$762.85 |
— |
| Urethrocystography retrograde rs&i (74450) |
— |
$1,273.40 |
— |
| Urography (pyelography), intravenous, with or without KUB, with or without tomography Age Under 21 (74400) |
— |
$1,273.40 |
— |
| Us breast uni real time with image complete (76641) |
— |
$580.72 |
— |
| Us chest (76604) |
— |
$861.25 |
— |
| Us compl joint r-t w/image documentation (76881) |
— |
$762.85 |
— |
| Us exam, pelvic, limited (76857) |
— |
$554.50 |
— |
| Us inft hips r-t img dynamic req phys/qhp manj (76885) |
— |
$737.10 |
— |
| US OB Follow-Up/Repeat (76816) |
— |
$554.50 |
— |
| Us ob transvaginal (76817) |
— |
$762.85 |
— |
| Us retroperitoneal complete (76770) |
— |
$762.85 |
— |
| Us retroperitoneal ltd (76775) |
— |
$762.85 |
— |
| Us scrotum (76870) |
— |
$762.85 |
— |
| Us soft tissue head/neck (76536) |
— |
$762.85 |
— |
| Us transrectal (76872) |
— |
$762.85 |
— |
| Us unlstd proc (76999) |
— |
$657.50 |
— |
| Venography, extremity, bilateral, radiological supervision and interpretation Age Under 21 (75822) |
— |
$3,527.25 |
— |
| Venography, extremity, unilateral, radiological supervision and interpretation Age Under 21 (75820) |
— |
$3,941.70 |
— |
| X-ray exam hips bi 3-4 views (73522) |
— |
$491.95 |
— |
| X-ray exam of finger(s) (73140) |
— |
$334.55 |
— |
| X-ray exam of knee 1 or 2 (73560) |
— |
$334.55 |
— |
| X-ray exam ribs bil 3 views (71110) |
— |
$491.95 |
— |
| X-ray exam ribs uni 2 views (71100) |
— |
$343.80 |
— |
| X-ray heel (73650) |
— |
$334.55 |
— |
| X-ray of joint between lower spine and hip bone 3 or more views|PROFESSIONAL COMPONENT (72202) |
— |
$334.55 |
— |
| X-ray retrograde pyelogram (74420) |
— |
$1,273.40 |
— |
| Xr abdomen 1 view (74018) |
— |
$375.05 |
— |
| Xr abdomen 2 views (74019) |
— |
$456.10 |
— |
| Xr arthrogram hip (73525) |
— |
$1,656.55 |
— |
| Xr arthrogram knee (73580) |
— |
$1,656.55 |
— |
| Xr arthrogram wrist (73115) |
— |
$1,656.55 |
— |
| Xr bone age studies (77072) |
— |
$334.55 |
— |
| Xr bone length study (77073) |
— |
$675.48 |
— |
| Xr bone survey ltd (77074) |
— |
$491.95 |
— |
| Xr chest 1 view (71045) |
— |
$334.55 |
— |
| Xr chest 2 views (71046) |
— |
$578.80 |
— |
| Xr eye foreign body (70030) |
— |
$358.85 |
— |
| Xr facial bones 3+ views (70150) |
— |
$491.95 |
— |
| Xr foot arthritis pa only bilateral - report(ortho pro) (73620) |
— |
$334.55 |
— |
| Xr forearm 2 views (73090) |
— |
$334.55 |
— |
| Xr hand 2v (73120) |
— |
$334.55 |
— |
| Xr hysterosalpingogram (74740) |
— |
$1,555.85 |
— |
| Xr myelogram t-spine (72255) |
— |
$2,865.15 |
— |
| Xr neck soft tissue (70360) |
— |
$334.55 |
— |
| Xr o knee w/ merchant view bilat - report(ortho pro) (73562) |
— |
$356.50 |
— |
| Xr osseous survey complete (77075) |
— |
$491.95 |
— |
| Xr pelvis 1-2 views (72170) |
— |
$334.55 |
— |
| Xr pelvis min 3 view (72190) |
— |
$334.55 |
— |
| Xr sacrum/coccyx 2+ views (72220) |
— |
$334.55 |
— |
| Xr sella turcica (70240) |
— |
$334.55 |
— |
| Xr shoulder 1 view (73020) |
— |
$334.55 |
— |
| Xr sinuses 3+ views (70220) |
— |
$483.90 |
— |
| Xr skull min 4 view (70260) |
— |
$491.95 |
— |
| Xr spine 1 view (72020) |
— |
$334.55 |
— |
| Xr spine thoracic 3v (72072) |
— |
$491.95 |
— |
| Xr sternum 2+ views (71120) |
— |
$368.15 |
— |
| Xr stress view joint (77071) |
— |
$334.55 |
— |
| Xr surgical specimen (76098) |
— |
$606 |
— |
| Xr t-spine 2 views (72070) |
— |
$397.05 |
— |
| Xr tibia/fibula 2 views (73590) |
— |
$334.55 |
— |
| Xr tmj bilateral (70330) |
— |
$640.20 |
— |
| Xr tmj unilateral (70328) |
— |
$353.05 |
— |
| Xr wrist 2 views (73100) |
— |
$334.55 |
— |