| Abdomen 2 views (74019) |
$150 |
$300 |
1.4× |
| Acute gi blood loss imaging (78278) |
$729 |
$1,458 |
1.7× |
| Ankle 2 views (73600) |
$150 |
$300 |
1.7× |
| Arthrogram shoulder (73040) |
$341.75 |
$1,067 |
0.9× |
| Bone &/Joint Imaging Limited Area (78300) |
$729 |
$1,458 |
1.7× |
| Bone &/joint imaging whole body (78306) |
$729 |
$1,615 |
1.7× |
| Bone age studies (77072) |
$156 |
$300 |
1.4× |
| Bone Imaging 3 Phase (78315) |
$807.50 |
$1,563 |
1.9× |
| Bone survey complete (77075) |
$150 |
$503 |
1.4× |
| Bone survey infant (77076) |
$251.50 |
$300 |
2.3× |
| Bowel imaging (78290) |
$729 |
$1,458 |
1.7× |
| Card Bpi Gtd =Brm Plnr 1 Std Rest/Strs (78472) |
$1,798 |
$1,458 |
4.3× |
| Cervical spine 2 or 3 views (72040) |
$150 |
$300 |
1.7× |
| Chest 1 view (71045) |
$128 |
$256 |
1.4× |
| Chest xray 3 views (71047) |
$150 |
$256 |
1.7× |
| Cine/Vid X-Ray Throat/Esoph - Fl Esoph Barium Swlw W/ Video & Speech (74230) |
$238 |
$530 |
1.3× |
| Clavicle complete (73000) |
$142 |
$284 |
1.6× |
| Computed Tomography Thorax Lw Dose Lng Ca Scr C- (71271) |
$755.25 |
$1,458 |
6.9× |
| CT abdomen and pelvis without and with contrast (74178) |
$768.25 |
$1,510.50 |
2.1× |
| CT abdomen and pelvis without contrast (74176) |
$729 |
$1,458 |
2.9× |
| CT abdomen w contrast (74160) |
$729 |
$1,510 |
4.0× |
| CT abdomen w wo contrast (74170) |
$755 |
$1,563 |
4.1× |
| CT abdomen w/o contrast (74150) |
$150 |
$1,458 |
1.4× |
| CT angio lwr extr w/o&w/dye (73706) |
$781.50 |
$1,458 |
4.3× |
| CT angiography upper extremity lt (73206) |
$729 |
$1,458 |
4.0× |
| CT c-spine w/contrast (72126) |
$729 |
$1,510 |
2.0× |
| CT c-spine w/o contrast (72125) |
$150 |
$1,458 |
1.4× |
| CT cervical spine w&w/o contrast (72127) |
$755 |
$1,563 |
4.1× |
| CT chest w contrast (71260) |
$729 |
$1,510 |
4.0× |
| CT chest w/wo contrast (71270) |
$755 |
$1,563 |
4.1× |
| CT head/brain with contrast (70460) |
$729 |
$1,510 |
4.0× |
| CT head/brain without and with contrast (70470) |
$755 |
$1,563 |
4.1× |
| CT heart w/o contrast quant eval coronary calcium (75571) |
$532 |
$104 |
5.9× |
| CT iac w contrast (70481) |
$729 |
$1,510 |
4.0× |
| CT lower ext w/o (73700) |
$729 |
$1,458 |
6.7× |
| CT lower extremity w wo contrast (73702) |
$1,119.50 |
$2,239 |
6.1× |
| CT lower extremity w/contrast material (73701) |
$755 |
$1,510 |
4.1× |
| CT lumbar spine w & w/o contrast (72133) |
$755 |
$1,563 |
4.1× |
| CT lumbar spine w/contrast (72132) |
$729 |
$1,510 |
2.0× |
| CT lumbar spine w/o contrast (72131) |
$781.50 |
$1,458 |
7.2× |
| CT maxillofacial w contrast (70487) |
$742 |
$1,510 |
4.1× |
| CT maxillofacial w/wo contrast (70488) |
$755 |
$1,563 |
4.1× |
| CT maxillofacial wo contrast (70486) |
$755.25 |
$1,458 |
6.9× |
| CT orbit sella/post fossa/ear w/o & w/contr matr (70482) |
$768.25 |
$1,563 |
4.2× |
| CT orbits w/o contrast (70480) |
$729 |
$1,458 |
6.7× |
| CT pelvis w/o contrast (72192) |
$781.50 |
$1,458 |
7.2× |
| CT pelvis w/wo contrast (72194) |
$755 |
$1,563 |
4.1× |
| CT scan of arm combo (73202) |
$781.50 |
$1,563 |
4.3× |
| CT soft tissue neck w contrast (70491) |
$729 |
$1,510 |
4.0× |
| CT soft tissue neck w/o & w/contrast material (70492) |
$755 |
$1,563 |
4.1× |
| CT soft tissue neck w/o contrast (70490) |
$781.50 |
$1,458 |
7.2× |
| CT thoracic spine w/contrast (72129) |
$729 |
$1,510 |
4.0× |
| CT thoracic spine w/o contrast (72128) |
$781.50 |
$1,458 |
7.2× |
| CT thoracic spine w/wo contrast (72130) |
$755 |
$1,563 |
4.1× |
| CT thorax w/o contrast (71250) |
$142 |
$1,458 |
1.3× |
| CT upper ext wo (73200) |
$729 |
$1,458 |
6.7× |
| CT upper extremity with contrast (73201) |
$1,106.25 |
$1,510 |
3.0× |
| Cta Aa&Bi Iliofem Lxtr Rs&I C-/C+ Post-Pxessing (75635) |
$52 |
$1,458 |
0.3× |
| Cta Abdomen (74175) |
$530 |
$1,458 |
2.9× |
| CTA abdomen pelvis (74174) |
$781.50 |
$1,060 |
2.1× |
| CTA chest (71275) |
$729 |
$1,458 |
4.0× |
| Cta Head (70496) |
$781.50 |
$1,458 |
4.3× |
| Cta Neck (70498) |
$729 |
$1,458 |
4.0× |
| Cta Pelvis (72191) |
$150 |
$1,563 |
0.8× |
| Cystography minimum 3 views rs&i (74430) |
$419 |
$836 |
1.2× |
| Dxa bone density study 1/> sites axial skel (77080) |
$150 |
$300 |
1.4× |
| Dxa bone density study 1/>sites appendiclr skel (77081) |
$150 |
$284 |
1.7× |
| Esophagus (74220) |
$590.75 |
$503 |
3.2× |
| Facial bones min 3 views (70150) |
$142 |
$300 |
1.3× |
| Fetal Biophysical Profile W/O Non-Stress Testing (76819) |
$253.50 |
$426 |
2.3× |
| Fluoroscopy up to 1 hr (76000) |
$729 |
$503 |
2.9× |
| Foot 2 views (73620) |
$142 |
$284 |
1.6× |
| Forearm 2 views (73090) |
$142 |
$284 |
1.6× |
| Hand 2 views (73120) |
$142 |
$284 |
1.3× |
| Hepatobil Syst Imag Inc Gb W/Pharma Intervenj (78227) |
$729 |
$1,458 |
1.3× |
| Hepatobiliary syst imaging including gallbladder (78226) |
$1,093.25 |
$1,458 |
2.6× |
| Hysterosalpingogram (74740) |
$419 |
$1,064 |
1.7× |
| Kidney Img Morphology Vascular Flow 1 W/O Rx (78707) |
$729 |
$1,458 |
1.3× |
| Kidney img morphology vascular flow 1 w/rx (78708) |
$729 |
$2,426 |
1.3× |
| Knee 3 views (73562) |
$283.50 |
$284 |
3.1× |
| Lung ventilation imaging (78579) |
$729 |
$1,458 |
1.7× |
| Lymphoscintigraphy (78195) |
$667.75 |
$2,186.50 |
1.2× |
| Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Non-Facility (73222) |
$877 |
$1,780 |
1.1× |
| Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) Non-Facility (73219) |
$877 |
$1,780 |
2.4× |
| Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by… (73220) |
$916.50 |
$1,833 |
2.5× |
| MRA head w/o contrast (70544) |
$916.50 |
$1,728 |
3.7× |
| MRA neck w/o contrast (70547) |
$864 |
$1,728 |
3.5× |
| MRI abdomen w contrast (74182) |
$864 |
$1,780 |
2.4× |
| MRI abdomen w/o & w/contrast material (74183) |
$890 |
$1,833 |
2.4× |
| MRI abdomen w/o contrast (74181) |
$796.50 |
$1,728 |
3.2× |
| MRI any jt lower extrem w/contrast material (73722) |
$890 |
$1,780 |
1.1× |
| MRI any jt lower extrem w/o & w/contrast matrl (73723) |
$1,832.50 |
$1,833 |
5.0× |
| MRI c-spine with contrast (72142) |
$864 |
$1,780 |
2.4× |
| MRI cervical spine w/o contrast (72141) |
$781.50 |
$1,728 |
3.1× |
| MRI chest w/o & w/contrast material (71552) |
$864 |
$1,833 |
2.4× |
| MRI chest w/o contrast (71550) |
$729 |
$1,728 |
2.9× |
| MRI lower extrem oth/thn jt w/contrast matrl (73719) |
$1,296.25 |
$1,756 |
3.6× |
| MRI lower extrem oth/thn jt w/o & w/contr matr (73720) |
$916.50 |
$1,833 |
2.5× |
| MRI lower extrem oth/thn jt w/o contr matrl (73718) |
$890 |
$1,780 |
3.6× |
| MRI orbit face &/neck w/o contrast (70540) |
$864 |
$1,728 |
3.5× |
| MRI orbit/face/neck w&w/o cont (70543) |
$890.25 |
$1,833 |
2.4× |
| MRI pelvis w/o & w/contrast material (72197) |
$864 |
$1,833 |
2.4× |
| MRI pelvis w/o contrast (72195) |
$822.75 |
$1,728 |
3.3× |
| MRI spinal canal cervical w/o & w/contr matrl (72156) |
$890 |
$1,833 |
2.4× |
| MRI spinal canal lumbar w/contrast material (72149) |
$864 |
$1,780 |
2.4× |
| MRI spinal canal lumbar w/o & w/contr matrl (72158) |
$916.50 |
$1,833 |
2.5× |
| MRI spinal canal thoracic w/contrast matrl (72147) |
$864 |
$1,780 |
2.4× |
| MRI spinal canal thoracic w/o & w/contr matrl (72157) |
$916.50 |
$1,833 |
2.5× |
| MRI thoracic spine w/o contrast (72146) |
$890 |
$1,728 |
3.6× |
| MRI up ext w/o contrast (73218) |
$864 |
$1,728 |
3.5× |
| MRI upper ext joint w/o contrast (73221) |
$916.50 |
$1,728 |
3.7× |
| MRI, joint upper extrem combo (73223) |
$903.25 |
$1,833 |
2.5× |
| Myocardial Spect Multiple Studies (78452) |
$1,797 |
$3,595 |
1.3× |
| Myocardial spect single study at rest or stress (78451) |
$781.50 |
$3,594 |
0.6× |
| Neck soft tissue (70360) |
$283.50 |
$284 |
3.1× |
| Nm cardiac blood pool multiple (78473) |
$729 |
$1,458 |
1.7× |
| Nm gastric emptying study (78264) |
$729 |
$1,458 |
1.7× |
| Osseous survey limited (77074) |
$150 |
$300 |
1.4× |
| Pelvis 1 or 2 views (72170) |
$916.50 |
$300 |
8.4× |
| Pulmonary Perfusion Imaging Particulate (78580) |
$729 |
$1,458 |
1.7× |
| Pulmonary Ventilation & Perfusion Imaging (78582) |
$729 |
$1,458 |
1.3× |
| Radex abscess/fistula/sinus tract rs&i (76080) |
$130.50 |
$1,062 |
0.2× |
| Radex Ankle Compl Minimum 3 Views (73610) |
$299.50 |
$300 |
3.3× |
| Radex Calcaneus Minimum 2 Views (73650) |
$212.75 |
$284 |
2.3× |
| Radex Elbw Compl Minimum 3 Views (73080) |
$142 |
$284 |
1.6× |
| Radex Entir Thrc Lmbr Crv Sac Spi W/Skull 1 Vw - Xr Scoliosis 1 Vw (72081) |
$150 |
$284 |
1.7× |
| Radex fingr minimum 2 views (73140) |
$142 |
$284 |
1.6× |
| Radex Foot Compl Minimum 3 Views (73630) |
$142 |
$284 |
1.6× |
| Radex Hand Minimum 3 Views (73130) |
$142 |
$284 |
1.6× |
| Radex Hip Unilateral With Pelvis 1 View (73501) |
$529.25 |
$284 |
5.8× |
| Radex Hips Bilateral With Pelvis 2 Views (73521) |
$146 |
$300 |
1.3× |
| Radex Humerus Minimum 2 Views (73060) |
$150 |
$284 |
1.7× |
| Radex Kne 1/2 Views (73560) |
$142 |
$284 |
1.6× |
| Radex Kne Compl 4/More Views (73564) |
$150 |
$300 |
1.4× |
| Radex Mndbl Compl Minimum 4 Views (70110) |
$142 |
$300 |
1.3× |
| Radex Nasal Bones Complete Minimum 3 Views (70160) |
$150 |
$284 |
1.7× |
| Radex Pelvis Compl Minimum 3 Views (72190) |
$150 |
$300 |
1.4× |
| Radex Sho Compl Minimum 2 Views (73030) |
$150 |
$300 |
1.7× |
| Radex Sinuses Paransl < 3 Views (70210) |
$150 |
$284 |
1.7× |
| Radex Spine Lumbosacral Only Bending 2/3 Views (72120) |
$150 |
$300 |
1.4× |
| Radex Temporomandble Jt Opn & Clsd Mouth Bilat (70330) |
$142 |
$567 |
1.6× |
| Radex Toe Minimum 2 Views (73660) |
$212.75 |
$425.50 |
2.3× |
| Radex upper extremity infant minimum 2 views (73092) |
$150 |
$300 |
1.4× |
| Radex Wrst Compl Minimum 3 Views (73110) |
$142 |
$284 |
1.6× |
| Radiologic Exam Abdomen 1 View - Xr Abdomen 1 View (74018) |
$142.50 |
$285 |
1.6× |
| Radiologic exam chest 2 views (71046) |
$128 |
$300 |
1.4× |
| Radiologic exam colon single contrast study (74270) |
$265 |
$476 |
1.4× |
| Radiologic exam upr gi trc double contrast study (74246) |
$238.50 |
$477 |
1.3× |
| Radiologic exam upr gi trc single contrast study (74240) |
$265 |
$476 |
1.4× |
| Radiologic examination tibia & fibula 2 views (73590) |
$142 |
$284 |
1.6× |
| Radiologic examination, mastoids; complete, minimum of 3 views per side Non-Facility (70130) |
$150 |
$300 |
1.4× |
| Radiological examination surgical specimen (76098) |
$531 |
$1,062 |
0.9× |
| Ribs bilateral 3 views (71110) |
$150 |
$300 |
1.4× |
| Rp loclzj tum plnr 2+area 1+d img/1 area img>2+d (78801) |
$1,213 |
$2,226 |
2.9× |
| Rp loclzj tum plnr whole body single day imaging (78802) |
$1,113 |
$2,226 |
2.0× |
| Rp Therapy Intravenous Administration (79101) |
$1,113 |
$728 |
4.6× |
| Scapula (73010) |
$142 |
$284 |
1.3× |
| Screening Digital Breast Tomosynthesis Bi (77063) |
$729 |
$312 |
31.2× |
| Shoulder 1 view (73020) |
$142 |
$284 |
1.6× |
| Small bowel series (74250) |
$212.75 |
$425.50 |
1.2× |
| Spine thoracic 3 views (72072) |
$150 |
$300 |
1.4× |
| Thoracolumbar 2 views (72080) |
$150 |
$300 |
1.7× |
| Thyroid imaging w/blood flow (78013) |
$142 |
$1,458 |
0.3× |
| Thyroid Uptake W/Blood Flow Sngle/Mult Quan Meas (78014) |
$729 |
$1,213 |
1.7× |
| Tmj unilateral (70328) |
$150 |
$284 |
1.7× |
| Tomogram (76100) |
$531 |
$300 |
4.9× |
| Ultrasound breast complete (76641) |
$213 |
$369 |
2.0× |
| Ultrasound Exam Aaa Screen (76706) |
$213 |
$557 |
2.0× |
| Ultrasound, abdomen limited (76705) |
$239 |
$426 |
2.2× |
| Urethrocystogram voiding (74455) |
$418 |
$838 |
1.7× |
| Us breast unilateral limited (76642) |
$184.50 |
$369 |
2.0× |
| Us chest (76604) |
$213 |
$426 |
2.0× |
| Us compl joint r-t w/image documentation (76881) |
$283.50 |
$565 |
2.6× |
| Us elastography parenchyma (76981) |
$184.50 |
$353 |
1.7× |
| Us lmtd joint/oth nonvasc xtr strux r-t w/img (76882) |
$276.50 |
$455 |
2.5× |
| Us ob detailed single fetus (76811) |
$184.50 |
$683 |
0.7× |
| Us ob limited (76815) |
$341.50 |
$426 |
3.1× |
| Us ob transvaginal (76817) |
$184.50 |
$588 |
1.7× |
| Us pelvic non ob complete (76856) |
$288.50 |
$426 |
2.6× |
| Us pelvic nonobstetric image dcmtn limited/f/u (76857) |
$184.50 |
$369 |
1.7× |
| Us pg uter img f&mat 14 wk tabdl 1/1st gestation (76801) |
$213 |
$426 |
2.0× |
| Us pg uter r-t img f-up tabdl appr pr fetus (76816) |
$213 |
$369 |
2.0× |
| Us retroperitoneal complete (76770) |
$285 |
$583 |
2.6× |
| Us retroperitoneal limited (76775) |
$291.50 |
$426 |
2.7× |
| Us scrotum and contents (76870) |
$184.50 |
$567 |
1.7× |
| Us soft tissue head/neck (76536) |
$223.25 |
$490.50 |
2.0× |
| Us spinal canal and contents (76800) |
$213 |
$426 |
2.0× |
| Wrist 2 views (73100) |
$283.50 |
$284 |
3.1× |
| X-Ray Abdomen,Comp Acute Series - Xr Abdomen 2 Vws With Chest 1 View (74022) |
$142 |
$300 |
1.3× |
| X-Ray Ac Jts - Xr Acromioclavicular Joints Bilateral (73050) |
$533.50 |
$599 |
5.9× |
| X-ray b.e. reductn intuss (74283) |
$238 |
$476 |
1.3× |
| X-Ray Colon Air Contrast - Fl Barium Enema Air Contrast (74280) |
$238 |
$476 |
1.3× |
| X-Ray Elbow 2 Vw - Xr Elbow 1-2 Views Right (73070) |
$142 |
$284 |
1.6× |
| X-Ray Exam Hip Uni 2-3 Views (73502) |
$142 |
$284 |
1.6× |
| X-ray exam of femur 2/> (73552) |
$142 |
$284 |
1.6× |
| X-Ray Facial Bones <3 Vw - Xr Facial Bones 1-2 Views (70140) |
$150 |
$284 |
1.7× |
| X-ray IV pyelogram (ivp) (74400) |
$142 |
$836 |
0.8× |
| X-Ray Jaw <4 Vw - Xr Mandible < 4 Views (70100) |
$114.50 |
$284 |
1.3× |
| X-Ray Knee Bilat Standing - Xr Knees Anteroposterior Standing Bilat (73565) |
$299.50 |
$284 |
3.3× |
| X-ray leg, infant (73592) |
$283.50 |
$300 |
3.1× |
| X-Ray Lumbar Spine 2/3 Vw - Xr Lumbar Spine 2-3 Views (72100) |
$142 |
$300 |
1.3× |
| X-Ray Lumbar Spine 6+ Vw - Xr Lumbar Spine 6+ Vws Including Bending (72114) |
$150 |
$300 |
1.4× |
| X-ray nose-rectum child f.b. (76010) |
$201 |
$281 |
2.2× |
| X-Ray Orbits - Xr Orbits Complete 4+ Views (70200) |
$142 |
$300 |
1.3× |
| X-Ray Ribs 2 Vw Unilat - Xr Ribs 2 Views Right (71100) |
$167 |
$284 |
1.8× |
| X-Ray Ribs, Chest 3+ Vw - Xr Ribs 2 Vws Lt W/ Chest Anteroposterior (71101) |
$146 |
$300 |
1.3× |
| X-Ray Ribs, Chest 4+ Vw - Xr Ribs 3 Vws Bil W/ Chest Posteroanterior (71111) |
$150 |
$384 |
1.4× |
| X-Ray Sacroiliac Jts 3+ Vw - Xr Sacroiliac Joints 3+ Views (72202) |
$916.50 |
$300 |
8.4× |
| X-Ray Sacrum/Coccyx 2+ Vw - Xr Sacrum Coccyx 2+ Views (72220) |
$150 |
$284 |
1.7× |
| X-Ray Sinuses 3+ Vw - Xr Paranasal Sinuses 3+ Views (70220) |
$142 |
$300 |
1.6× |
| X-Ray Skull 4+ Vw - Xr Skull Complete 4+ Views (70260) |
$150 |
$300 |
1.4× |
| X-Ray Spine One View - Xr Spine (72020) |
$529.25 |
$284 |
5.8× |
| X-Ray Sterno-Clavicluar Jt - Xr Sternoclavicular Joints 3+ Views (71130) |
$142 |
$284 |
1.6× |
| X-Ray Sternum 2+ Vw - Xr Sternum 2+ Views (71120) |
$192 |
$284 |
2.1× |
| X-Ray Thoracic Spine 2 Vw - Xr Thoracic Spine 2 Views (72070) |
$251.50 |
$300 |
2.3× |
| Xr bone length studies (77073) |
$150 |
$300 |
1.4× |
| Xr c-spine 4 or 5 views (72050) |
$251.50 |
$300 |
2.3× |
| Xr c-spine 6 or more views (72052) |
$150 |
$503 |
1.4× |
| Xr chest 4+ views (71048) |
$128 |
$384 |
1.2× |
| Xr urogram antegrade (74425) |
$418 |
$837 |
1.1× |