| Ankle 2 views (73600) |
$151.80 |
$253 |
1.7× |
| Arthrogram elbow (73085) |
$2,074.80 |
$3,458 |
5.9× |
| Arthrogram hip (73525) |
$2,074.80 |
$3,458 |
5.9× |
| Arthrogram shoulder (73040) |
$2,074.80 |
$3,458 |
5.9× |
| Arthrogram wrist (73115) |
$2,074.80 |
$3,458 |
5.9× |
| Arthrography knee lt (73580) |
$2,074.80 |
$3,458 |
5.9× |
| Bone age studies (77072) |
$105 |
$175 |
1.0× |
| Bone survey complete (77075) |
$105 |
$175 |
1.0× |
| Cervical spine 2 or 3 views (72040) |
$236.40 |
$394 |
2.7× |
| Chest 1 view (71045) |
$105 |
$175 |
1.2× |
| Chest 3 views (71047) |
$302.10 |
$503.50 |
3.5× |
| Cine/Vid X-Ray Throat/Esoph - Fl Esoph Barium Swlw W/ Video & Speech (74230) |
$90 |
$150 |
0.5× |
| Cisternography Positive Contrast Rs&I (70015) |
$2,276.40 |
$3,794 |
2.9× |
| Clavicle complete (73000) |
$105 |
$175 |
1.2× |
| CT abdomen and pelvis without and with contrast (74178) |
$7,291.80 |
$12,153 |
20.8× |
| CT abdomen and pelvis without contrast (74176) |
$6,326.40 |
$10,544 |
26.4× |
| CT abdomen w contrast (74160) |
$3,164.40 |
$5,274 |
18.0× |
| CT abdomen w wo contrast (74170) |
$3,648.60 |
$6,081 |
20.7× |
| CT abdomen w/o contrast (74150) |
$2,365.20 |
$3,942 |
22.5× |
| CT angiography upper extremity lt (73206) |
$5,715.60 |
$9,526 |
32.4× |
| CT c-spine w/o contrast (72125) |
$3,308.40 |
$5,514 |
31.5× |
| CT cervical spine w&w/o contrast (72127) |
$4,591.20 |
$7,652 |
26.1× |
| CT cervical spine with contrast (72126) |
$4,107.60 |
$6,846 |
11.7× |
| CT chest w/wo contrast (71270) |
$3,648.60 |
$6,081 |
20.7× |
| CT chest with contrast (71260) |
$3,164.40 |
$5,274 |
18.0× |
| CT head/brain with contrast (70460) |
$3,164.40 |
$5,274 |
18.0× |
| CT head/brain without and with contrast (70470) |
$3,648.60 |
$6,081 |
20.7× |
| CT iac w contrast (70481) |
$3,164.40 |
$5,274 |
18.0× |
| CT limited/localized follow up study (76380) |
$1,069.80 |
$1,783 |
12.2× |
| CT lower ext w/o (73700) |
$3,308.40 |
$5,514 |
31.5× |
| CT lower extremity w wo contrast (73702) |
$4,591.20 |
$7,652 |
26.1× |
| CT lower extremity with contrast (73701) |
$4,107.60 |
$6,846 |
23.3× |
| CT lumbar spine w & w/o contrast (72133) |
$4,591.20 |
$7,652 |
26.1× |
| CT lumbar spine w/o contrast (72131) |
$3,308.40 |
$5,514 |
31.5× |
| CT lumbar spine with contrast (72132) |
$4,107.60 |
$6,846 |
11.7× |
| CT maxillofacial w contrast (70487) |
$3,164.40 |
$5,274 |
18.0× |
| CT maxillofacial w/o contrast (70486) |
$2,365.20 |
$3,942 |
22.5× |
| CT maxillofacial w/wo contrast (70488) |
$3,648.60 |
$6,081 |
20.7× |
| CT neck soft tissue w contrast (70491) |
$3,648.60 |
$6,081 |
20.7× |
| CT orbit sella/post fossa/ear w/o & w/contr matr (70482) |
$3,648.60 |
$6,081 |
20.7× |
| CT orbits w/o contrast (70480) |
$2,365.20 |
$3,942 |
22.5× |
| CT pelvis w & w/o contrast (72194) |
$3,648.60 |
$6,081 |
20.7× |
| CT pelvis w/o contrast (72192) |
$2,365.20 |
$3,942 |
22.5× |
| CT soft tissue neck w/o & w/contrast material (70492) |
$3,648.60 |
$6,081 |
20.7× |
| CT soft tissue neck w/o contrast (70490) |
$2,365.20 |
$3,942 |
22.5× |
| CT thoracic spine w/contrast (72129) |
$4,107.60 |
$6,846 |
23.3× |
| CT thoracic spine w/o contrast (72128) |
$3,308.40 |
$5,514 |
31.5× |
| CT thoracic spine w/wo contrast (72130) |
$4,591.20 |
$7,652 |
26.1× |
| CT thorax w/o contrast (71250) |
$2,365.20 |
$3,942 |
22.5× |
| CT unlisted procedure (76497) |
$2,947.80 |
$4,913 |
33.7× |
| CT upper extremity w/o & w/contrast material (73202) |
$4,591.20 |
$7,652 |
26.1× |
| CT upper extremity w/o contrast rt (73200) |
$3,308.40 |
$5,514 |
31.5× |
| CT upper extremity with contrast (73201) |
$4,107.60 |
$6,846 |
11.7× |
| Cta Abdomen (74175) |
$2,475 |
$4,125 |
14.0× |
| CTA abdomen pelvis (74174) |
$2,076 |
$3,460 |
5.9× |
| CTA chest (71275) |
$1,801.20 |
$3,002 |
10.2× |
| Cta Head (70496) |
$1,925.40 |
$3,209 |
10.9× |
| CTA lwr ext w&w/o contrast (73706) |
$5,715.60 |
$9,526 |
32.4× |
| Cta Neck (70498) |
$1,915.80 |
$3,193 |
10.9× |
| Cta Pelvis (72191) |
$1,925.40 |
$3,209 |
10.9× |
| Diskogram cervical (72285) |
$1,283.40 |
$2,139 |
0.7× |
| Diskography lumbar (72295) |
$937.80 |
$1,563 |
0.5× |
| Dxa bone density study 1/> sites axial skel (77080) |
$134.40 |
$224 |
1.3× |
| Esophagus (74220) |
$1,811.40 |
$3,019 |
10.3× |
| Fluoroscopy up to 1 hr (76000) |
$990.60 |
$1,651 |
4.1× |
| Foot 2 views (73620) |
$302.10 |
$503.50 |
3.5× |
| Forearm 2 views (73090) |
$302.10 |
$503.50 |
3.5× |
| Functional MRI brain by tech (70554) |
$6,763.80 |
$11,273 |
28.2× |
| Hand 2 views (73120) |
$302.10 |
$503.50 |
2.9× |
| Hand 3 views (73130) |
$105 |
$175 |
1.2× |
| Humerus Min 2 Views Left (73060) |
$302.10 |
$503.50 |
3.5× |
| Knee 3 views (73562) |
$105 |
$175 |
1.2× |
| Manual appl stress pfrmd phys/qhp joint films (77071) |
$105 |
$175 |
1.2× |
| MRA head w & w/o contrast (70546) |
$5,823 |
$9,705 |
16.6× |
| MRA head w/o contrast (70544) |
$4,039.80 |
$6,733 |
16.9× |
| MRA head with contrast (70545) |
$5,798.40 |
$9,664 |
16.5× |
| MRA neck w contrast (70548) |
$4,502.40 |
$7,504 |
12.8× |
| Mra Neck W/O &W/Contrast Material (70549) |
$5,823 |
$9,705 |
16.6× |
| MRA neck w/o contrast (70547) |
$4,039.80 |
$6,733 |
16.9× |
| MRI abdomen w contrast (74182) |
$5,798.40 |
$9,664 |
16.5× |
| MRI abdomen w/o & w/contrast material (74183) |
$6,763.80 |
$11,273 |
19.3× |
| MRI abdomen w/o contrast (74181) |
$4,834.20 |
$8,057 |
20.2× |
| MRI any jnt lwr ext with con lt (73722) |
$5,798.40 |
$9,664 |
7.4× |
| MRI any jt upper extremity w/contrast matrl (73222) |
$5,798.40 |
$9,664 |
7.4× |
| MRI c-spine with contrast (72142) |
$5,798.40 |
$9,664 |
16.5× |
| MRI cervical spine w/o contrast (72141) |
$4,834.20 |
$8,057 |
20.2× |
| MRI chest w/o & w/contrast material (71552) |
$6,763.80 |
$11,273 |
19.3× |
| MRI chest w/o contrast (71550) |
$4,834.20 |
$8,057 |
20.2× |
| MRI chest with contrast (71551) |
$5,798.40 |
$9,664 |
7.4× |
| MRI Forearm w/ Contrast Bilateral 73219 (73219) |
$5,798.40 |
$9,664 |
16.5× |
| MRI lower extrem oth/thn jt w/contrast matrl (73719) |
$5,798.40 |
$9,664 |
16.5× |
| MRI lower extrem oth/thn jt w/o contr matrl (73718) |
$4,834.20 |
$8,057 |
20.2× |
| MRI orbit face &/neck w/o contrast (70540) |
$4,834.20 |
$8,057 |
20.2× |
| MRI orbit/face/neck w&w/o cont (70543) |
$6,763.80 |
$11,273 |
19.3× |
| MRI orbit/face/neck w/contrast (70542) |
$5,798.40 |
$9,664 |
16.5× |
| MRI pelvis w contrast (72196) |
$5,798.40 |
$9,664 |
16.5× |
| MRI pelvis w/o & w/contrast material (72197) |
$6,763.80 |
$11,273 |
19.3× |
| MRI pelvis w/o contrast (72195) |
$4,834.20 |
$8,057 |
20.2× |
| MRI scan of arm joint before and after contrast (73223) |
$6,763.80 |
$11,273 |
19.3× |
| MRI scan of leg joint before and after contrast (73723) |
$6,763.80 |
$11,273 |
19.3× |
| MRI spectroscopy (76390) |
$1,091.40 |
$1,819 |
12.5× |
| MRI spinal canal cervical w/o & w/contr matrl (72156) |
$6,763.80 |
$11,273 |
19.3× |
| MRI spinal canal lumbar w/contrast material (72149) |
$5,798.40 |
$9,664 |
16.5× |
| MRI spinal canal lumbar w/o & w/contr matrl (72158) |
$6,763.80 |
$11,273 |
19.3× |
| MRI spinal canal thoracic w/contrast matrl (72147) |
$5,798.40 |
$9,664 |
16.5× |
| MRI spinal canal thoracic w/o & w/contr matrl (72157) |
$6,763.80 |
$11,273 |
19.3× |
| MRI thoracic spine w/o contrast (72146) |
$4,834.20 |
$8,057 |
20.2× |
| MRI tmj (70336) |
$6,763.80 |
$11,273 |
28.2× |
| MRI upper ext joint w/o contrast (73221) |
$4,834.20 |
$8,057 |
20.2× |
| MRI upper extrem other than jt w/o & w/contras (73220) |
$6,763.80 |
$11,273 |
19.3× |
| MRI upper extremity oth than jt w/o contr matrl (73218) |
$4,834.20 |
$8,057 |
20.2× |
| Myelogram Cervical (72240) |
$2,276.40 |
$3,794 |
2.9× |
| Myelogram Lumbar (72265) |
$2,276.40 |
$3,794 |
2.9× |
| Myelogram thoracic (72255) |
$2,276.40 |
$3,794 |
2.9× |
| Myelography 2 or more regions (72270) |
$3,505.80 |
$5,843 |
4.5× |
| Neck soft tissue (70360) |
$105 |
$175 |
1.2× |
| Osseous survey limited (77074) |
$105 |
$175 |
1.0× |
| Pelvis 1 or 2 views (72170) |
$302.10 |
$503.50 |
2.9× |
| Pr MRI, lower extr, w/o contrast f/u by contrast (73720) |
$6,763.80 |
$11,273 |
19.3× |
| Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw - Xr Scoliosis 1 Vw (72081) |
$105 |
$175 |
1.2× |
| Radex entir thrc lmbr crv sac spi w/skull 2/3 vw (72082) |
$105 |
$175 |
1.0× |
| Radex hips bilateral with pelvis 2 views (73521) |
$105 |
$175 |
1.0× |
| Radex mastoids compl minimum 3 views pr side (70130) |
$105 |
$175 |
1.0× |
| Radex X-Ray Exam Entire Spi 6/> Vw - Xr Entire Spine 6+ Vw (72084) |
$247.80 |
$413 |
2.4× |
| Radiolog exam mandible compl minimum 4 views (70110) |
$105 |
$175 |
1.0× |
| Radiologic Exam Abdomen 1 View - Xr Abdomen 1 View (74018) |
$105 |
$175 |
1.2× |
| Radiologic Exam Abdomen 3+ Views - Xr Abdomen 3+ Views (74021) |
$105 |
$175 |
1.0× |
| Radiologic Exam Chest 2 Views - Xr Chest 2 Views (71046) |
$105 |
$175 |
1.2× |
| Radiologic exam upr gi trc double contrast study (74246) |
$829.20 |
$1,382 |
4.7× |
| Radiologic exam upr gi trc single contrast study (74240) |
$90 |
$150 |
0.5× |
| Radiologic Examination Femur Minimum 2 Views - Xr Femur 2+ Vw Lt (73552) |
$305.10 |
$508.50 |
3.5× |
| Ribs bilateral 3 views (71110) |
$105 |
$175 |
1.0× |
| Sacroiliac Joints < 3 Views (72200) |
$105 |
$175 |
1.0× |
| Scanogram (77073) |
$105 |
$175 |
1.0× |
| Scapula complete (73010) |
$105 |
$175 |
1.0× |
| Small bowel series (74250) |
$959.40 |
$1,599 |
5.4× |
| Spine thoracic 3 views (72072) |
$105 |
$175 |
1.0× |
| Temporomandble Jt Arthrography Rs&I (70332) |
$105 |
$175 |
0.4× |
| Thoracolumbar 2 views (72080) |
$302.10 |
$503.50 |
3.5× |
| Ultrasound, abdomen limited (76705) |
$504 |
$840 |
4.8× |
| Unlisted fluoroscopic procedure (76496) |
$199.80 |
$333 |
2.3× |
| Urography (pyelography), intravenous, with or without KUB, with or without tomography (74400) |
$105 |
$175 |
0.6× |
| Us breast unilateral complete (76641) |
$337.80 |
$563 |
3.2× |
| Us breast unilateral limited (76642) |
$337.80 |
$563 |
3.9× |
| Us compl joint r-t w/image documentation (76881) |
$411.60 |
$686 |
3.9× |
| Us kidney transplant (76776) |
$789 |
$1,315 |
7.5× |
| Us ob transvaginal (76817) |
$646.20 |
$1,077 |
6.2× |
| Us pelvic non ob complete (76856) |
$829.20 |
$1,382 |
7.9× |
| Us pelvic nonobstetric image dcmtn limited/f/u (76857) |
$442.80 |
$738 |
4.2× |
| Us pregnancy ltd (76815) |
$267.60 |
$446 |
2.5× |
| Us pregnant uterus 14 wk transabdl 1/1st gestat (76801) |
$578.40 |
$964 |
5.5× |
| Us retroperitoneal complete (76770) |
$622.20 |
$1,037 |
5.9× |
| Us retroperitoneal limited (76775) |
$606.90 |
$1,011.50 |
5.8× |
| Us scrotum and contents (76870) |
$475.80 |
$793 |
4.5× |
| Us soft tissue head/neck (76536) |
$165.60 |
$276 |
1.6× |
| Wrist 2 views (73100) |
$165.30 |
$275.50 |
1.9× |
| X-Ray Abdomen,Comp Acute Series - Xr Abdomen 2 Vws With Chest 1 View (74022) |
$105 |
$175 |
1.0× |
| X-Ray Ac Jts - Xr Acromioclavicular Joints Bilateral (73050) |
$105 |
$175 |
1.2× |
| X-Ray Ankle 3+ Vw - Xr Ankle 3+ Views Right (73610) |
$161.10 |
$268.50 |
1.8× |
| X-Ray Elbow 2 Vw - Xr Elbow 1-2 Views Right (73070) |
$302.10 |
$503.50 |
3.5× |
| X-Ray Elbow 3+ Vw - Xr Elbow 3+ Views Right (73080) |
$105 |
$175 |
1.2× |
| X-ray exam entire spi 4/5 vw (72083) |
$247.80 |
$413 |
2.4× |
| X-ray exam hip uni 1 view (73501) |
$302.10 |
$503.50 |
3.5× |
| X-Ray Exam Hip Uni 2-3 Views (73502) |
$499.20 |
$832 |
5.7× |
| X-ray exam hip uni 4/> views (73503) |
$383.70 |
$639.50 |
3.7× |
| X-Ray Exam Hips Bi 3-4 Views (73522) |
$351.30 |
$585.50 |
3.3× |
| X-Ray Exam Hips Bi 5/> Views (73523) |
$541.50 |
$902.50 |
5.2× |
| X-ray exam of femur 1 (73551) |
$111 |
$185 |
1.3× |
| X-ray eye for foreign body (70030) |
$105 |
$175 |
1.2× |
| X-Ray Facial Bones 3+ Vw - Xr Facial Bones 3+ Views (70150) |
$105 |
$175 |
1.0× |
| X-Ray Facial Bones <3 Vw - Xr Facial Bones 1-2 Views (70140) |
$105 |
$175 |
1.2× |
| X-Ray Foot 3+ Vw - Xr Foot 3+ Views Right (73630) |
$302.10 |
$503.50 |
3.5× |
| X-Ray Heel - Xr Calcaneus 2 Views Right (73650) |
$302.10 |
$503.50 |
3.5× |
| X-ray IV pyelogram+drip infusn (74410) |
$105 |
$175 |
0.6× |
| X-Ray Jaw <4 Vw - Xr Mandible < 4 Views (70100) |
$105 |
$175 |
1.2× |
| X-Ray Knee 4+ View - Xr Knee 4+ Views Right (73564) |
$105 |
$175 |
1.0× |
| X-Ray Knee Bilat Standing - Xr Knees Anteroposterior Standing Bilat (73565) |
$302.10 |
$503.50 |
3.5× |
| X-Ray Lumbar Spine 2/3 Vw - Xr Lumbar Spine 2-3 Views (72100) |
$302.10 |
$503.50 |
2.9× |
| X-Ray Lumbar Spine 6+ Vw - Xr Lumbar Spine 6+ Vws Including Bending (72114) |
$105 |
$175 |
1.0× |
| X-Ray Lumbar Spine Flex/Exten - Xr Lumbar Spine 4+ Views W/ Flex Ext (72120) |
$105 |
$175 |
1.0× |
| X-Ray Nasal Bones - Xr Nasal Bones (70160) |
$105 |
$175 |
1.2× |
| X-Ray Orbits - Xr Orbits Complete 4+ Views (70200) |
$105 |
$175 |
1.0× |
| X-Ray Pelvis 3+ Vw - Xr Pelvis 3+ Views (72190) |
$105 |
$175 |
1.0× |
| X-Ray Ribs 2 Vw Unilat - Xr Ribs 2 Views Right (71100) |
$105 |
$175 |
1.2× |
| X-Ray Ribs, Chest 3+ Vw - Xr Ribs 2 Vws Lt W/ Chest Anteroposterior (71101) |
$105 |
$175 |
1.0× |
| X-Ray Ribs, Chest 4+ Vw - Xr Ribs 3 Vws Bil W/ Chest Posteroanterior (71111) |
$105 |
$175 |
1.0× |
| X-Ray Sacroiliac Jts 3+ Vw - Xr Sacroiliac Joints 3+ Views (72202) |
$105 |
$175 |
1.0× |
| X-Ray Sacrum/Coccyx 2+ Vw - Xr Sacrum Coccyx 2+ Views (72220) |
$105 |
$175 |
1.2× |
| X-Ray Shoulder 2+ Vw - Xr Shoulder 2+ Views Right (73030) |
$302.10 |
$503.50 |
3.5× |
| X-Ray Sinuses 3+ Vw - Xr Paranasal Sinuses 3+ Views (70220) |
$105 |
$175 |
1.2× |
| X-Ray Sinuses <3 Vw - Xr Paranasal Sinuses 1-2 Views (70210) |
$105 |
$175 |
1.2× |
| X-Ray Skull 4+ Vw - Xr Skull Complete 4+ Views (70260) |
$105 |
$175 |
1.0× |
| X-Ray Skull <4 Vw - Xr Skull 1-3 Views (70250) |
$105 |
$175 |
1.0× |
| X-Ray Spine One View - Xr Spine (72020) |
$499.20 |
$832 |
5.7× |
| X-Ray Sternum 2+ Vw - Xr Sternum 2+ Views (71120) |
$105 |
$175 |
1.2× |
| X-Ray Thoracic Spine 2 Vw - Xr Thoracic Spine 2 Views (72070) |
$302.10 |
$503.50 |
2.9× |
| X-Ray Thoracic Spine 4 Vw - Xr Thoracic Spine Complete 4+ Views (72074) |
$105 |
$175 |
1.0× |
| X-Ray Toe(S) - Xr Toes 2+ Views Right (73660) |
$105 |
$175 |
1.2× |
| X-Ray Wrist 3+ Vw - Xr Wrist 3+ Views Right (73110) |
$151.80 |
$253 |
1.7× |
| Xr arthrogram ankle (73615) |
$2,076 |
$3,460 |
5.9× |
| Xr c-spine 6 or more views (72052) |
$105 |
$175 |
1.0× |
| Xr chest 4+ views (71048) |
$105 |
$175 |
1.0× |
| Xr finger(s) 2+ views (73140) |
$105 |
$175 |
1.2× |
| XR Mastoids < 3 Views Bilateral (70120) |
$105 |
$175 |
1.0× |
| Xr myelogram posterior fossa (70010) |
$2,276.40 |
$3,794 |
6.5× |
| Xr optic foramina (70190) |
$105 |
$175 |
1.2× |
| Xr shoulder 1 view (73020) |
$302.10 |
$503.50 |
3.5× |
| Xr spine cervical 4 or 5 views (72050) |
$105 |
$175 |
1.0× |
| Xr tibia/fibula 2 views (73590) |
$302.10 |
$503.50 |
3.5× |
| Xray knee 1 or 2 views rt (73560) |
$302.10 |
$503.50 |
3.5× |