| Ankle 2 views (73600) |
$272.25 |
$302.50 |
3.0× |
| Clavicle complete (73000) |
$272.25 |
$302.50 |
3.0× |
| Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if… (74174) |
$1,905.30 |
$2,117 |
5.2× |
| Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast images, if performed, and… (74175) |
$1,905.30 |
$2,117 |
10.3× |
| Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast… (75635) |
$1,632.60 |
$1,814 |
8.8× |
| Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if… (71275) |
$1,632.60 |
$1,814 |
8.8× |
| Computed tomographic angiography, lower extremity, with contrast material(s), including noncontrast images, if… (73706) |
$2,381.85 |
$2,646.50 |
12.9× |
| Computed tomographic angiography, neck, with contrast material(s), including noncontrast images, if performed, and… (70498) |
$1,632.60 |
$1,814 |
8.8× |
| Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast images, if performed, and… (72191) |
$1,650.60 |
$1,834 |
8.9× |
| Computed tomographic angiography, upper extremity, with contrast material(s), including noncontrast images, if… (73206) |
$2,507.40 |
$2,786 |
13.6× |
| Computed tomography, cervical spine; without contrast material, followed by contrast material(s) and further sections… (72127) |
$1,845 |
$2,050 |
10.0× |
| Computed tomography, lower extremity; without contrast material Age Under 21 (73700) |
$1,890 |
$2,100 |
17.1× |
| Computed tomography, lower extremity; without contrast material, followed by contrast material(s) and further sections… (73702) |
$2,298.60 |
$2,554 |
12.4× |
| Computed tomography, lumbar spine; without contrast material, followed by contrast material(s) and further sections Age… (72133) |
$1,845 |
$2,050 |
10.0× |
| Computed tomography, maxillofacial area; with contrast material(s) Age Under 21 (70487) |
$1,663.20 |
$1,848 |
9.0× |
| Computed tomography, maxillofacial area; without contrast material Age Under 21 (70486) |
$1,528.20 |
$1,698 |
13.9× |
| Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with contrast material(s) Age… (70481) |
$1,663.20 |
$1,848 |
9.0× |
| Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material Age… (70480) |
$1,562.40 |
$1,736 |
14.2× |
| Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material,… (70482) |
$1,839.60 |
$2,044 |
9.9× |
| Computed tomography, soft tissue neck; without contrast material followed by contrast material(s) and further sections… (70492) |
$2,035.80 |
$2,262 |
11.0× |
| Computed tomography, thoracic spine; without contrast material, followed by contrast material(s) and further sections… (72130) |
$1,845 |
$2,050 |
10.0× |
| Computed tomography, thorax, diagnostic; without contrast material, followed by contrast material(s) and further… (71270) |
$1,996.20 |
$2,218 |
10.8× |
| CT abdomen and pelvis without and with contrast (74178) |
$1,905.30 |
$2,117 |
5.2× |
| CT abdomen and pelvis without contrast (74176) |
$1,512 |
$1,680 |
6.0× |
| CT abdomen w & w/o contrast (74170) |
$1,905.30 |
$2,117 |
10.3× |
| CT abdomen w/contrast (74160) |
$1,632.60 |
$1,814 |
8.8× |
| CT abdomen w/o contrast (74150) |
$1,512 |
$1,680 |
13.7× |
| CT cervical spine w/contrast (72126) |
$1,764 |
$1,960 |
4.8× |
| CT cervical spine w/o contrast (72125) |
$1,632.60 |
$1,814 |
14.8× |
| CT chest w/contrast (71260) |
$1,799.10 |
$1,999 |
9.7× |
| CT extremity upper w & w/o contrast (73202) |
$2,206.35 |
$2,451.50 |
11.9× |
| CT extremity upper w/o contrast (73200) |
$1,918.35 |
$2,131.50 |
17.4× |
| CT head/brain with contrast (70460) |
$1,899.90 |
$2,111 |
10.3× |
| CT head/brain without and with contrast (70470) |
$2,035.80 |
$2,262 |
11.0× |
| CT l-spine w/contrast (72132) |
$1,764 |
$1,960 |
4.8× |
| CT limited/localized follow up study (76380) |
$1,350 |
$1,500 |
14.7× |
| CT lower extremity w/dye (73701) |
$2,040.75 |
$2,267.50 |
11.0× |
| CT lumbar spine w/o contrast (72131) |
$1,632.60 |
$1,814 |
14.8× |
| CT maxillofacial w/wo contrast (70488) |
$1,839.60 |
$2,044 |
9.9× |
| CT neck w/contrast (70491) |
$1,899.90 |
$2,111 |
10.3× |
| CT neck w/o contrast (70490) |
$1,676.70 |
$1,863 |
15.2× |
| CT pelvis w & w/o contrast (72194) |
$1,764 |
$1,960 |
9.5× |
| CT pelvis w/o contrast (72192) |
$1,512 |
$1,680 |
13.7× |
| CT thoracic spine w/contrast (72129) |
$1,764 |
$1,960 |
9.5× |
| CT thoracic spine w/o contrast (72128) |
$1,632.60 |
$1,814 |
14.8× |
| CT thorax w/o contrast (71250) |
$1,602.90 |
$1,781 |
14.5× |
| CT upper extremity w/dye (73201) |
$2,074.50 |
$2,305 |
5.6× |
| CTA head w contrast (70496) |
$1,632.60 |
$1,814 |
8.8× |
| Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)… (77080) |
$305.10 |
$339 |
2.8× |
| Dxa bone density/peripheral (77081) |
$201.60 |
$224 |
2.2× |
| Fetal biophys profile w/o nst (76819) |
$252.90 |
$281 |
2.3× |
| Fluoroscopy up to 1 hour physician/qhp time (76000) |
$593.10 |
$659 |
2.4× |
| Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material(s), followed by… (73723) |
$1,518.75 |
$1,687.50 |
4.1× |
| Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast material(s) Age Under 21 (73719) |
$1,265.85 |
$1,406.50 |
3.4× |
| Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s) Age Under 21 (73718) |
$1,125 |
$1,250 |
4.5× |
| Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s), followed by… (73720) |
$1,518.75 |
$1,687.50 |
4.1× |
| Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) Age Under 21 (70542) |
$1,057.50 |
$1,175 |
2.9× |
| Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) Age Under 21 (70540) |
$900 |
$1,000 |
3.6× |
| Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast material(s) Age Under 21 (73219) |
$1,367.10 |
$1,519 |
3.7× |
| Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast material(s), followed by… (73220) |
$1,518.75 |
$1,687.50 |
4.1× |
| Magnetic resonance angiography, head; with contrast material(s) Age Under 21 (70545) |
$1,057.50 |
$1,175 |
2.9× |
| Magnetic resonance angiography, head; without contrast material(s), followed by contrast material(s) and further… (70546) |
$1,215 |
$1,350 |
3.3× |
| Magnetic resonance angiography, neck; without contrast material(s), followed by contrast material(s) and further… (70549) |
$1,215 |
$1,350 |
3.3× |
| Mandible min 4v (70110) |
$283.50 |
$315 |
2.6× |
| MRA head w/o contrast (70544) |
$1,012.50 |
$1,125 |
4.0× |
| MRA neck w/ contrast (70548) |
$1,057.50 |
$1,175 |
2.9× |
| MRA neck w/o contrast (70547) |
$900 |
$1,000 |
3.6× |
| MRI abdomen w/contrast (74182) |
$1,012.50 |
$1,125 |
2.8× |
| MRI abdomen w/o contrast (74181) |
$900 |
$1,000 |
3.6× |
| MRI abdomen w/wo contrast (74183) |
$1,012.50 |
$1,125 |
2.8× |
| MRI any jt lower extrem w/contrast material (73722) |
$1,215 |
$1,350 |
1.5× |
| MRI c-spine w&w/o cont (72156) |
$1,215 |
$1,350 |
3.3× |
| MRI cervical spine w/contrast (72142) |
$1,093.50 |
$1,215 |
3.0× |
| MRI chest w/contrast (71551) |
$1,125 |
$1,250 |
1.4× |
| MRI chest w/o contrast (71550) |
$900 |
$1,000 |
3.6× |
| MRI chest w/wo contrast (71552) |
$1,350 |
$1,500 |
3.7× |
| MRI joint upr extr w/o&w/dye (73223) |
$1,518.75 |
$1,687.50 |
4.1× |
| MRI joint upr extrem w/dye (73222) |
$1,367.10 |
$1,519 |
1.7× |
| MRI joint upr extrem w/o dye (73221) |
$1,215 |
$1,350 |
4.8× |
| MRI lumbar spine w/contrast (72149) |
$1,093.50 |
$1,215 |
3.0× |
| MRI lumbar spine w/wo contrast (72158) |
$1,215 |
$1,350 |
3.3× |
| MRI orbit/face/neck w&w/o cont (70543) |
$1,215 |
$1,350 |
3.3× |
| MRI pelvis w & w/o contrast (72197) |
$1,350 |
$1,500 |
3.7× |
| MRI pelvis w/contrast (72196) |
$1,215 |
$1,350 |
3.3× |
| MRI pelvis w/o contrast (72195) |
$1,125 |
$1,250 |
4.5× |
| MRI spine cervical w/o contrast (72141) |
$972 |
$1,080 |
3.9× |
| MRI t-spine w&w/o cont (72157) |
$1,215 |
$1,350 |
3.3× |
| MRI thoracic spine w/contrast (72147) |
$1,093.50 |
$1,215 |
3.0× |
| MRI thoracic spine w/o contrst (72146) |
$972 |
$1,080 |
3.9× |
| MRI tmj (70336) |
$1,125 |
$1,250 |
4.5× |
| MRI upper extremity oth than jt w/o contr matrl (73218) |
$1,215 |
$1,350 |
4.8× |
| Ob us limited fetus(s) (76815) |
$252.90 |
$281 |
2.3× |
| Radex entir thrc lmbr crv sac spi w/skull 1 vw (72081) |
$217.80 |
$242 |
2.4× |
| Radex entir thrc lmbr crv sac spi w/skull 2/3 vw (72082) |
$283.50 |
$315 |
2.6× |
| Radex entir thrc lmbr crv sac spi w/skull 4/5 vw (72083) |
$306 |
$340 |
2.8× |
| Radex hip unilateral with pelvis 1 view (73501) |
$217.80 |
$242 |
2.4× |
| Radex hip unilateral with pelvis 2-3 views (73502) |
$252 |
$280 |
2.7× |
| Radex hips bilateral with pelvis 2 views (73521) |
$435.60 |
$484 |
3.9× |
| Radex spine cervical 2 or 3 views (72040) |
$217.80 |
$242 |
2.4× |
| Radex spine cervical 4 or 5 views (72050) |
$305.10 |
$339 |
2.8× |
| Radex spine cervical 6 or more views (72052) |
$337.50 |
$375 |
3.1× |
| Radex spine thoracolumbar junction min 2 views (72080) |
$217.80 |
$242 |
2.4× |
| Radiologic exam abdomen 3+ views (74021) |
$305.10 |
$339 |
2.8× |
| Radiologic exam chest 3 views (71047) |
$246.60 |
$274 |
2.7× |
| Radiologic exam chest 4+ views (71048) |
$283.50 |
$315 |
2.6× |
| Radiologic examination femur 1 view (73551) |
$217.80 |
$242 |
2.4× |
| Radiologic examination femur minimum 2 views (73552) |
$315 |
$350 |
3.4× |
| Radiologic examination from nose to rectum for foreign body, single view, child Age Under 21 (76010) |
$180 |
$200 |
2.0× |
| Radiologic examination, ankle; complete, minimum of 3 views Age Under 21 (73610) |
$315 |
$350 |
3.4× |
| Radiologic examination, complete acute abdomen series, including 2 or more views of the abdomen (eg, supine, erect,… (74022) |
$305.10 |
$339 |
2.8× |
| Radiologic examination, elbow; 2 views Age Under 21 (73070) |
$272.25 |
$302.50 |
3.0× |
| Radiologic examination, elbow; complete, minimum of 3 views Age Under 21 (73080) |
$315 |
$350 |
3.4× |
| Radiologic examination, facial bones; less than 3 views Age Under 21 (70140) |
$201.60 |
$224 |
2.2× |
| Radiologic examination, foot; complete, minimum of 3 views Age Under 21 (73630) |
$315 |
$350 |
3.4× |
| Radiologic examination, hand; minimum of 3 views Age Under 21 (73130) |
$315 |
$350 |
3.4× |
| Radiologic examination, knee; both knees, standing, anteroposterior Age Under 21 (73565) |
$360 |
$400 |
3.9× |
| Radiologic examination, knee; complete, 4 or more views Age Under 21 (73564) |
$381.60 |
$424 |
3.5× |
| Radiologic examination, mandible; partial, less than 4 views Age Under 21 (70100) |
$201.60 |
$224 |
2.2× |
| Radiologic examination, mastoids; complete, minimum of 3 views per side Age Under 21 (70130) |
$337.50 |
$375 |
3.1× |
| Radiologic examination, mastoids; less than 3 views per side Age Under 21 (70120) |
$316.35 |
$351.50 |
2.9× |
| Radiologic examination, nasal bones, complete, minimum of 3 views Age Under 21 (70160) |
$217.80 |
$242 |
2.4× |
| Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views Age Under 21 (71111) |
$569.70 |
$633 |
5.2× |
| Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views Age Under 21 (71101) |
$305.10 |
$339 |
2.8× |
| Radiologic examination, sacroiliac joints; less than 3 views Age Under 21 (72200) |
$272.70 |
$303 |
2.5× |
| Radiologic examination, shoulder; complete, minimum of 2 views Age Under 21 (73030) |
$315 |
$350 |
3.4× |
| Radiologic examination, sinuses, paranasal, less than 3 views Age Under 21 (70210) |
$201.60 |
$224 |
2.2× |
| Radiologic examination, skull; less than 4 views Age Under 21 (70250) |
$272.70 |
$303 |
2.5× |
| Radiologic examination, spine, lumbosacral; 2 or 3 views Age Under 21 (72100) |
$305.10 |
$339 |
2.8× |
| Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views Age Under 21 (72120) |
$305.10 |
$339 |
2.8× |
| Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 views Age Under 21 (72114) |
$368.10 |
$409 |
3.3× |
| Radiologic examination, spine; thoracic, minimum of 4 views Age Under 21 (72074) |
$369 |
$410 |
3.3× |
| Radiologic examination, wrist; complete, minimum of 3 views Age Under 21 (73110) |
$315 |
$350 |
3.4× |
| Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction Age Under 21 (73050) |
$201.60 |
$224 |
2.2× |
| Radiologic examination; humerus, minimum of 2 views Age Under 21 (73060) |
$217.80 |
$242 |
2.4× |
| Radiologic examination; lower extremity, infant, minimum of 2 views Age Under 21 (73592) |
$225 |
$250 |
2.5× |
| Radiologic examination; orbits, complete, minimum of 4 views Age Under 21 (70200) |
$283.50 |
$315 |
2.6× |
| Radiologic examination; sternoclavicular joint or joints, minimum of 3 views Age Under 21 (71130) |
$216 |
$240 |
2.4× |
| Radiologic examination; toe(s), minimum of 2 views Age Under 21 (73660) |
$252 |
$280 |
2.7× |
| Radiologic examination; upper extremity, infant, minimum of 2 views Age Under 21 (73092) |
$316.35 |
$351.50 |
2.9× |
| Scapula complete (73010) |
$381.60 |
$424 |
3.5× |
| Ultrasound breast limited (76642) |
$217.80 |
$242 |
2.4× |
| Ultrasound, abdomen limited (76705) |
$305.10 |
$339 |
2.8× |
| Ultrasound, limited, joint or focal evaluation of other nonvascular extremity structure(s) (eg, joint space,… (76882) |
$305.10 |
$339 |
2.8× |
| Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Age Under 21 (76856) |
$305.10 |
$339 |
2.8× |
| Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal… (76811) |
$524.70 |
$583 |
2.1× |
| Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14… (76801) |
$283.50 |
$315 |
2.6× |
| Urography (pyelography), intravenous, with or without KUB, with or without tomography Age Under 21 (74400) |
$410.40 |
$456 |
2.2× |
| Us abdominal aorta real time screen study aaa (76706) |
$305.10 |
$339 |
2.8× |
| Us breast uni real time with image complete (76641) |
$305.10 |
$339 |
2.8× |
| Us compl joint r-t w/image documentation (76881) |
$305.10 |
$339 |
2.8× |
| Us exam, pelvic, limited (76857) |
$305.10 |
$339 |
2.8× |
| US OB Follow-Up/Repeat (76816) |
$252.90 |
$281 |
2.3× |
| Us ob transvaginal (76817) |
$252.90 |
$281 |
2.3× |
| Us retroperitoneal complete (76770) |
$305.10 |
$339 |
2.8× |
| Us retroperitoneal ltd (76775) |
$305.10 |
$339 |
2.8× |
| Us scrotum (76870) |
$305.10 |
$339 |
2.8× |
| Us soft tissue head/neck (76536) |
$305.10 |
$339 |
2.8× |
| Us unlstd proc (76999) |
$305.10 |
$339 |
3.3× |
| X-ray exam of finger(s) (73140) |
$315 |
$350 |
3.4× |
| X-ray exam of knee 1 or 2 (73560) |
$272.25 |
$302.50 |
3.0× |
| X-ray exam ribs bil 3 views (71110) |
$526.50 |
$585 |
4.8× |
| X-ray exam ribs uni 2 views (71100) |
$217.80 |
$242 |
2.4× |
| X-ray heel (73650) |
$252 |
$280 |
2.7× |
| X-ray of joint between lower spine and hip bone 3 or more views|PROFESSIONAL COMPONENT (72202) |
$305.10 |
$339 |
2.8× |
| Xr abdomen 1 view (74018) |
$217.80 |
$242 |
2.4× |
| Xr abdomen 2 views (74019) |
$283.50 |
$315 |
2.6× |
| Xr bone age studies (77072) |
$252.90 |
$281 |
2.3× |
| Xr bone length study (77073) |
$252.90 |
$281 |
2.3× |
| Xr bone survey infant (77076) |
$252.90 |
$281 |
2.3× |
| Xr bone survey ltd (77074) |
$252.90 |
$281 |
2.3× |
| Xr chest 1 view (71045) |
$205.20 |
$228 |
2.2× |
| Xr chest 2 views (71046) |
$225 |
$250 |
2.5× |
| Xr eye foreign body (70030) |
$272.25 |
$302.50 |
3.0× |
| Xr facial bones 3+ views (70150) |
$283.50 |
$315 |
2.6× |
| Xr foot arthritis pa only bilateral - report(ortho pro) (73620) |
$272.25 |
$302.50 |
3.0× |
| Xr forearm 2 views (73090) |
$272.25 |
$302.50 |
3.0× |
| Xr hand 2v (73120) |
$272.25 |
$302.50 |
2.5× |
| Xr neck soft tissue (70360) |
$217.80 |
$242 |
2.4× |
| Xr o knee w/ merchant view bilat - report(ortho pro) (73562) |
$315 |
$350 |
3.4× |
| Xr osseous survey complete (77075) |
$283.50 |
$315 |
2.6× |
| Xr pelvis 1-2 views (72170) |
$279 |
$310 |
2.5× |
| Xr pelvis min 3 view (72190) |
$305.10 |
$339 |
2.8× |
| Xr sacrum/coccyx 2+ views (72220) |
$217.80 |
$242 |
2.4× |
| Xr sella turcica (70240) |
$180 |
$200 |
2.0× |
| Xr shoulder 1 view (73020) |
$272.25 |
$302.50 |
3.0× |
| Xr sinuses 3+ views (70220) |
$217.80 |
$242 |
2.4× |
| Xr skull min 4 view (70260) |
$305.10 |
$339 |
2.8× |
| Xr spine 1 view (72020) |
$217.80 |
$242 |
2.4× |
| Xr spine thoracic 3v (72072) |
$337.50 |
$375 |
3.1× |
| Xr sternum 2+ views (71120) |
$217.80 |
$242 |
2.4× |
| Xr t-spine 2 views (72070) |
$305.10 |
$339 |
2.8× |
| Xr tibia/fibula 2 views (73590) |
$272.25 |
$302.50 |
3.0× |
| Xr tmj bilateral (70330) |
$360 |
$400 |
3.9× |
| Xr tmj unilateral (70328) |
$180 |
$200 |
2.0× |
| Xr wrist 2 views (73100) |
$272.25 |
$302.50 |
3.0× |