| Abdomen 2 views (74019) |
$60 |
$300 |
0.6× |
| Ankle 2 views (73600) |
$50 |
$250 |
0.6× |
| Bone survey complete (77075) |
$312.50 |
$1,250 |
3.3× |
| Cervical spine 2 or 3 views (72040) |
$90 |
$450 |
1.1× |
| Chest 1 view (71045) |
$50 |
$250 |
0.6× |
| Chest 3 views (71047) |
$80 |
$400 |
1.0× |
| Clavicle complete (73000) |
$60 |
$300 |
0.7× |
| Computed Tomography Thorax Lw Dose Lng Ca Scr C- (71271) |
$155 |
$775 |
1.6× |
| CT abdomen and pelvis without and with contrast (74178) |
$750 |
$3,000 |
2.3× |
| CT abdomen and pelvis without contrast (74176) |
$500 |
$2,000 |
2.3× |
| CT abdomen w contrast (74160) |
$500 |
$2,000 |
3.1× |
| CT abdomen w wo contrast (74170) |
$625 |
$2,500 |
3.9× |
| CT abdomen w/o contrast (74150) |
$375 |
$1,500 |
3.9× |
| CT angiography upper extremity lt (73206) |
$687.50 |
$2,750 |
4.3× |
| CT c-spine w/o contrast (72125) |
$375 |
$1,500 |
3.9× |
| CT chest w/wo contrast (71270) |
$625 |
$2,500 |
3.9× |
| CT chest with contrast (71260) |
$500 |
$2,000 |
3.1× |
| CT head/brain without and with contrast (70470) |
$625 |
$2,500 |
3.9× |
| CT iac w contrast (70481) |
$400 |
$1,600 |
2.5× |
| CT lower ext w/o (73700) |
$375 |
$1,500 |
3.9× |
| CT lower extremity w wo contrast (73702) |
$625 |
$2,500 |
3.9× |
| CT lower extremity with contrast (73701) |
$500 |
$2,000 |
3.1× |
| CT lumbar spine w/o contrast (72131) |
$375 |
$1,500 |
3.9× |
| CT lumbar spine with contrast (72132) |
$500 |
$2,000 |
1.6× |
| CT maxillofacial w contrast (70487) |
$500 |
$2,000 |
3.1× |
| CT maxillofacial w/o contrast (70486) |
$375 |
$1,500 |
3.9× |
| CT maxillofacial w/wo contrast (70488) |
$625 |
$2,500 |
3.9× |
| CT neck soft tissue w contrast (70491) |
$500 |
$2,000 |
3.1× |
| CT orbit sella/post fossa/ear w/o & w/contr matr (70482) |
$625 |
$2,500 |
3.9× |
| CT orbits w/o contrast (70480) |
$375 |
$1,500 |
3.9× |
| CT pelvis w & w/o contrast (72194) |
$625 |
$2,500 |
3.9× |
| CT pelvis w/o contrast (72192) |
$375 |
$1,500 |
3.9× |
| CT soft tissue neck w/o & w/contrast material (70492) |
$625 |
$2,500 |
3.9× |
| CT soft tissue neck w/o contrast (70490) |
$375 |
$1,500 |
3.9× |
| CT thoracic spine w/o contrast (72128) |
$375 |
$1,500 |
3.9× |
| CT thorax w/o contrast (71250) |
$375 |
$1,500 |
3.9× |
| CT upper extremity w/o & w/contrast material (73202) |
$625 |
$2,500 |
3.9× |
| CT upper extremity w/o contrast rt (73200) |
$375 |
$1,500 |
3.9× |
| CT upper extremity with contrast (73201) |
$500 |
$2,000 |
1.6× |
| Cta Abdl Aorta&Bi Iliofem W/Contrast&Postp (75635) |
$687.50 |
$2,750 |
4.3× |
| Cta Abdomen (74175) |
$687.50 |
$2,750 |
4.3× |
| CTA chest (71275) |
$625 |
$2,500 |
3.9× |
| Cta Head (70496) |
$687.50 |
$2,750 |
4.3× |
| CTA lwr ext w&w/o contrast (73706) |
$687.50 |
$2,750 |
4.3× |
| Cta Neck (70498) |
$687.50 |
$2,750 |
4.3× |
| Dxa bone density study 1/> sites axial skel (77080) |
$92 |
$460 |
1.0× |
| Fetal Biophysical Profile W/O Non-Stress Testing (76819) |
$100 |
$500 |
1.0× |
| Foot 2 views (73620) |
$50 |
$250 |
0.6× |
| Forearm 2 views (73090) |
$65 |
$325 |
0.8× |
| Hand 2 views (73120) |
$65 |
$325 |
0.7× |
| Hand 3 views (73130) |
$80 |
$400 |
1.0× |
| Ht muscle image spect sing (78451) |
$296.25 |
$1,185 |
0.2× |
| Humerus Min 2 Views Left (73060) |
$70 |
$350 |
0.9× |
| Knee 3 views (73562) |
$65 |
$325 |
0.8× |
| MRA head w/o contrast (70544) |
$750 |
$3,000 |
3.4× |
| Mra Neck W/O &W/Contrast Material (70549) |
$1,000 |
$4,000 |
3.1× |
| MRA neck w/o contrast (70547) |
$750 |
$3,000 |
3.4× |
| MRI abdomen w contrast (74182) |
$625 |
$2,500 |
1.9× |
| MRI abdomen w/o & w/contrast material (74183) |
$750 |
$3,000 |
2.3× |
| MRI abdomen w/o contrast (74181) |
$500 |
$2,000 |
2.3× |
| MRI any jnt lwr ext with con lt (73722) |
$625 |
$2,500 |
0.9× |
| MRI any jt upper extremity w/contrast matrl (73222) |
$625 |
$2,500 |
0.9× |
| MRI c-spine with contrast (72142) |
$625 |
$2,500 |
1.9× |
| MRI cervical spine w/o contrast (72141) |
$500 |
$2,000 |
2.3× |
| MRI chest w/o & w/contrast material (71552) |
$750 |
$3,000 |
2.3× |
| MRI chest w/o contrast (71550) |
$500 |
$2,000 |
2.3× |
| MRI chest with contrast (71551) |
$625 |
$2,500 |
0.9× |
| MRI Forearm w/ Contrast Bilateral 73219 (73219) |
$625 |
$2,500 |
1.9× |
| MRI lower extrem oth/thn jt w/contrast matrl (73719) |
$625 |
$2,500 |
1.9× |
| MRI lower extrem oth/thn jt w/o contr matrl (73718) |
$500 |
$2,000 |
2.3× |
| MRI orbit face &/neck w/o contrast (70540) |
$500 |
$2,000 |
2.3× |
| MRI orbit/face/neck w&w/o cont (70543) |
$750 |
$3,000 |
2.3× |
| MRI orbit/face/neck w/contrast (70542) |
$625 |
$2,500 |
1.9× |
| MRI pelvis w contrast (72196) |
$625 |
$2,500 |
1.9× |
| MRI pelvis w/o & w/contrast material (72197) |
$750 |
$3,000 |
2.3× |
| MRI pelvis w/o contrast (72195) |
$500 |
$2,000 |
2.3× |
| MRI scan of arm joint before and after contrast (73223) |
$750 |
$3,000 |
2.3× |
| MRI scan of leg joint before and after contrast (73723) |
$750 |
$3,000 |
2.3× |
| MRI spinal canal cervical w/o & w/contr matrl (72156) |
$750 |
$3,000 |
2.3× |
| MRI spinal canal lumbar w/contrast material (72149) |
$625 |
$2,500 |
1.9× |
| MRI spinal canal lumbar w/o & w/contr matrl (72158) |
$750 |
$3,000 |
2.3× |
| MRI spinal canal thoracic w/contrast matrl (72147) |
$625 |
$2,500 |
1.9× |
| MRI spinal canal thoracic w/o & w/contr matrl (72157) |
$750 |
$3,000 |
2.3× |
| MRI thoracic spine w/o contrast (72146) |
$500 |
$2,000 |
2.3× |
| MRI tmj (70336) |
$500 |
$2,000 |
2.3× |
| MRI upper ext joint w/o contrast (73221) |
$500 |
$2,000 |
2.3× |
| MRI upper extrem other than jt w/o & w/contras (73220) |
$750 |
$3,000 |
2.3× |
| MRI upper extremity oth than jt w/o contr matrl (73218) |
$500 |
$2,000 |
2.3× |
| Neck soft tissue (70360) |
$60 |
$300 |
0.7× |
| Osseous survey infant (77076) |
$140 |
$700 |
1.5× |
| Pelvis 1 or 2 views (72170) |
$60 |
$300 |
0.6× |
| Pr MRI, lower extr, w/o contrast f/u by contrast (73720) |
$750 |
$3,000 |
2.3× |
| Radex entir thrc lmbr crv sac spi w/skull 2/3 vw (72082) |
$100 |
$500 |
1.0× |
| Radex hips bilateral with pelvis 2 views (73521) |
$70 |
$350 |
0.7× |
| Radex mastoids compl minimum 3 views pr side (70130) |
$70 |
$350 |
0.7× |
| Radiolog exam mandible compl minimum 4 views (70110) |
$100 |
$500 |
1.0× |
| Radiologic Exam Abdomen 1 View - Xr Abdomen 1 View (74018) |
$55 |
$275 |
0.7× |
| Radiologic Exam Chest 2 Views - Xr Chest 2 Views (71046) |
$60 |
$300 |
0.7× |
| Radiologic Examination Femur Minimum 2 Views - Xr Femur 2+ Vw Lt (73552) |
$70 |
$350 |
0.9× |
| Ribs bilateral 3 views (71110) |
$90 |
$450 |
0.9× |
| Scapula complete (73010) |
$60 |
$300 |
0.6× |
| Screening digital breast tomosynthesis (77063) |
$32 |
$160 |
1.4× |
| Thoracolumbar 2 views (72080) |
$85 |
$425 |
1.1× |
| Tmj unilateral (70328) |
$60 |
$300 |
0.7× |
| Ultrasound, abdomen limited (76705) |
$120 |
$600 |
1.2× |
| Us breast unilateral complete (76641) |
$80 |
$400 |
0.8× |
| Us breast unilateral limited (76642) |
$70 |
$350 |
0.9× |
| Us chest (76604) |
$120 |
$600 |
1.2× |
| Us compl joint r-t w/image documentation (76881) |
$130 |
$650 |
1.4× |
| Us ob transvaginal (76817) |
$140 |
$700 |
1.5× |
| Us pelvic non ob complete (76856) |
$140 |
$700 |
1.5× |
| Us pelvic nonobstetric image dcmtn limited/f/u (76857) |
$95 |
$475 |
1.0× |
| Us pregnancy ltd (76815) |
$120 |
$600 |
1.2× |
| Us pregnant uterus 14 wk transabdl 1/1st gestat (76801) |
$120 |
$600 |
1.2× |
| Us retroperitoneal complete (76770) |
$140 |
$700 |
1.5× |
| Us retroperitoneal limited (76775) |
$107.50 |
$537.50 |
1.1× |
| Us scrotum and contents (76870) |
$145 |
$725 |
1.5× |
| Us soft tissue head/neck (76536) |
$200 |
$1,000 |
2.1× |
| Us spinal canal and contents (76800) |
$100 |
$500 |
1.0× |
| Us xtr non-vasc lmtd (76882) |
$120 |
$600 |
1.2× |
| Wrist 2 views (73100) |
$65 |
$325 |
0.8× |
| X-Ray Abdomen,Comp Acute Series - Xr Abdomen 2 Vws With Chest 1 View (74022) |
$110 |
$550 |
1.1× |
| X-Ray Ac Jts - Xr Acromioclavicular Joints Bilateral (73050) |
$70 |
$350 |
0.9× |
| X-Ray Ankle 3+ Vw - Xr Ankle 3+ Views Right (73610) |
$70 |
$350 |
0.9× |
| X-Ray Elbow 2 Vw - Xr Elbow 1-2 Views Right (73070) |
$65 |
$325 |
0.8× |
| X-Ray Elbow 3+ Vw - Xr Elbow 3+ Views Right (73080) |
$80 |
$400 |
1.0× |
| X-ray exam hip uni 1 view (73501) |
$55 |
$275 |
0.7× |
| X-Ray Exam Hip Uni 2-3 Views (73502) |
$70 |
$350 |
0.9× |
| X-ray exam hip uni 4/> views (73503) |
$85 |
$425 |
0.9× |
| X-Ray Exam Hips Bi 3-4 Views (73522) |
$120 |
$600 |
1.2× |
| X-ray exam of femur 1 (73551) |
$50 |
$250 |
0.6× |
| X-ray eye for foreign body (70030) |
$40 |
$200 |
0.5× |
| X-Ray Facial Bones 3+ Vw - Xr Facial Bones 3+ Views (70150) |
$95 |
$475 |
1.0× |
| X-Ray Facial Bones <3 Vw - Xr Facial Bones 1-2 Views (70140) |
$80 |
$400 |
1.0× |
| X-Ray Foot 3+ Vw - Xr Foot 3+ Views Right (73630) |
$70 |
$350 |
0.9× |
| X-Ray Heel - Xr Calcaneus 2 Views Right (73650) |
$60 |
$300 |
0.7× |
| X-Ray Jaw <4 Vw - Xr Mandible < 4 Views (70100) |
$80 |
$400 |
1.0× |
| X-Ray Knee 4+ View - Xr Knee 4+ Views Right (73564) |
$105 |
$525 |
1.1× |
| X-Ray Knee Bilat Standing - Xr Knees Anteroposterior Standing Bilat (73565) |
$50 |
$250 |
0.6× |
| X-Ray Lumbar Spine 2/3 Vw - Xr Lumbar Spine 2-3 Views (72100) |
$80 |
$400 |
0.8× |
| X-Ray Lumbar Spine 6+ Vw - Xr Lumbar Spine 6+ Vws Including Bending (72114) |
$140 |
$700 |
1.5× |
| X-Ray Lumbar Spine Flex/Exten - Xr Lumbar Spine 4+ Views W/ Flex Ext (72120) |
$100 |
$500 |
1.0× |
| X-Ray Nasal Bones - Xr Nasal Bones (70160) |
$75 |
$375 |
0.9× |
| X-Ray Orbits - Xr Orbits Complete 4+ Views (70200) |
$90 |
$450 |
0.9× |
| X-Ray Pelvis 3+ Vw - Xr Pelvis 3+ Views (72190) |
$80 |
$400 |
0.8× |
| X-Ray Ribs 2 Vw Unilat - Xr Ribs 2 Views Right (71100) |
$70 |
$350 |
0.9× |
| X-Ray Ribs, Chest 3+ Vw - Xr Ribs 2 Vws Lt W/ Chest Anteroposterior (71101) |
$120 |
$600 |
1.2× |
| X-Ray Ribs, Chest 4+ Vw - Xr Ribs 3 Vws Bil W/ Chest Posteroanterior (71111) |
$140 |
$700 |
1.5× |
| X-Ray Sacroiliac Jts 3+ Vw - Xr Sacroiliac Joints 3+ Views (72202) |
$70 |
$350 |
0.7× |
| X-Ray Sacrum/Coccyx 2+ Vw - Xr Sacrum Coccyx 2+ Views (72220) |
$90 |
$450 |
1.1× |
| X-Ray Shoulder 2+ Vw - Xr Shoulder 2+ Views Right (73030) |
$70 |
$350 |
0.9× |
| X-Ray Sinuses 3+ Vw - Xr Paranasal Sinuses 3+ Views (70220) |
$85 |
$425 |
1.1× |
| X-Ray Sinuses <3 Vw - Xr Paranasal Sinuses 1-2 Views (70210) |
$75 |
$375 |
0.9× |
| X-Ray Skull 4+ Vw - Xr Skull Complete 4+ Views (70260) |
$100 |
$500 |
1.0× |
| X-Ray Skull <4 Vw - Xr Skull 1-3 Views (70250) |
$90 |
$450 |
0.9× |
| X-Ray Sterno-Clavicluar Jt - Xr Sternoclavicular Joints 3+ Views (71130) |
$60 |
$300 |
0.7× |
| X-Ray Sternum 2+ Vw - Xr Sternum 2+ Views (71120) |
$65 |
$325 |
0.8× |
| X-Ray Thoracic Spine 2 Vw - Xr Thoracic Spine 2 Views (72070) |
$65 |
$325 |
0.7× |
| X-Ray Thoracic Spine 4 Vw - Xr Thoracic Spine Complete 4+ Views (72074) |
$75 |
$375 |
0.8× |
| X-Ray Toe(S) - Xr Toes 2+ Views Right (73660) |
$60 |
$300 |
0.7× |
| X-Ray Wrist 3+ Vw - Xr Wrist 3+ Views Right (73110) |
$80 |
$400 |
1.0× |
| Xr c-spine 6 or more views (72052) |
$130 |
$650 |
1.4× |
| Xr chest 4+ views (71048) |
$90 |
$450 |
0.9× |
| Xr finger(s) 2+ views (73140) |
$60 |
$300 |
0.7× |
| XR Mastoids < 3 Views Bilateral (70120) |
$60 |
$300 |
0.6× |
| Xr shoulder 1 view (73020) |
$60 |
$300 |
0.7× |
| Xr spine cervical 4 or 5 views (72050) |
$110 |
$550 |
1.1× |
| Xr tibia/fibula 2 views (73590) |
$70 |
$350 |
0.9× |
| Xr tmj bilateral (70330) |
$70 |
$350 |
0.9× |
| Xray knee 1 or 2 views rt (73560) |
$55 |
$275 |
0.7× |