Medical Imaging Services Fee Schedule

Procedure Code Modifier Code Description Rate

70010 myelograpy post fossa rs&i $58.77

70015 cisternography positive contrast rs&i $90.43

70015 TC cisternography positive contrast rs&i $49.24

70015 26 cisternography positive contrast rs&i $41.18

70030 radiologic examination eye detect foreign body $17.51

70030 TC radiologic examination eye detect foreign body $11.75

70030 26 radiologic examination eye detect foreign body $5.77

70100 radiologic examination mandiple prtl < 4 views $18.89

70100 TC radiologic examination mandiple prtl < 4 views $12.87

70100 26 radiologic examination mandiple prtl < 4 views $6.02

70110 radiolog exam mandible compl minimum 4 views $24.52

70110 TC radiolog exam mandible compl minimum 4 views $16.05

70110 26 radiolog exam mandible compl minimum 4 views $8.46

70120 radiologic exam mastoids < 3 views per side $20.50

70120 TC radiologic exam mastoids < 3 views per side $14.48

70120 26 radiologic exam mastoids < 3 views per side $6.02

70130 radex mastoids compl minimum 3 views pr side $34.03

70130 TC radex mastoids compl minimum 3 views pr side $22.49

70130 26 radex mastoids compl minimum 3 views pr side $11.54

70134 radex internal auditory meati complete $29.30

70134 TC radex internal auditory meati complete $17.75

70134 26 radex internal auditory meati complete $11.54

70140 radex facial bones < 3 views $18.49

70140 TC radex facial bones < 3 views $12.22

70140 26 radex facial bones < 3 views $6.27

70150 radex facial bones complete minimum 3 views $26.47

70150 TC radex facial bones complete minimum 3 views $17.75

70150 26 radex facial bones complete minimum 3 views $8.72

70160 radex nasal bones complete minimum 3 views $19.77

70160 TC radex nasal bones complete minimum 3 views $14.00

70160 26 radex nasal bones complete minimum 3 views $5.77

70170 dacryocstograpy nasolacrimal duct rs&i $34.36

70170 TC dacryocstograpy nasolacrimal duct rs&i $23.72

70170 26 dacryocstograpy nasolacrimal duct rs&i $10.18

70190 radex optic foramina $21.93

70190 TC radex optic foramina $14.92

70190 26 radex optic foramina $7.01

70200 radex orbits complete minimum 4 views $27.43

70200 TC radex orbits complete minimum 4 views $17.98

70200 26 radex orbits complete minimum 4 views $9.45

70210 radex sinuses paranasal < 3 views $18.44

70210 TC radex sinuses paranasal < 3 views $12.67

70210 26 radex sinuses paranasal < 3 views $5.77

70220 radex sinuses paranasal compl minimum 3 views $24.19

70220 TC radex sinuses paranasal compl minimum 3 views $15.95

70220 26 radex sinuses paranasal compl minimum 3 views $8.24

70240 radiologic examination sella turcica $18.25

70240 TC radiologic examination sella turcica $11.75

Medical Imaging Services Fee Schedule

Effective September 1, 2010 (Updated 04/01/13)




70240 26 radiologic examination sella turcica $6.50

70250 radiologic examination skull 4/> views $22.46

70250 TC radiologic examination skull 4/> views $14.48

70250 26 radiologic examination skull 4/> views $7.99

70260 radiologic exam skull complete minimum 4 views $29.87

70260 TC radiologic exam skull complete minimum 4 views $18.56

70260 26 radiologic exam skull complete minimum 4 views $11.31

70300 radiologic examination teeth 1 view $8.76

70300 TC radiologic examination teeth 1 view $5.21

70300 26 radiologic examination teeth 1 view $3.55

70310 radiologic exam teeth prtl exam < full mouth $20.87

70310 TC radiologic exam teeth prtl exam < full mouth $15.35

70310 26 radiologic exam teeth prtl exam < full mouth $5.52

70320 radiologic exam teeth complete full mouth $26.92

70320 TC radiologic exam teeth complete full mouth $19.43

70320 26 radiologic exam teeth complete full mouth $7.48

70328 radex temporomandble jt opn & clsd mouth unilat $18.45

70328 TC radex temporomandble jt opn & clsd mouth unilat $12.43

70328 26 radex temporomandble jt opn & clsd mouth unilat $6.02

70330 radex temporomandble jt opn & clsd mouth bilat $29.13

70330 TC radex temporomandble jt opn & clsd mouth bilat $20.91

70330 26 radex temporomandble jt opn & clsd mouth bilat $8.21

70332 temporomandble jt arthrography rs&i $52.57

70332 TC temporomandble jt arthrography rs&i $34.63

70332 26 temporomandble jt arthrography rs&i $17.94

70336 mri temporomandibular joint $263.21

70336 TC mri temporomandibular joint $212.80

70336 26 mri temporomandibular joint $50.41

70350 cephalogram orthodontic $12.78

70350 TC cephalogram orthodontic $7.01

70350 26 cephalogram orthodontic $5.77

70355 orthopantogram $14.24

70355 TC orthopantogram $7.48

70355 26 orthopantogram $6.76

70360 radiologic examination neck soft tissue $16.84

70360 TC radiologic examination neck soft tissue $11.07

70360 26 radiologic examination neck soft tissue $5.77

70370 radex pharynx/larx w/fluor&/magnification tq $45.82

70370 TC radex pharynx/larx w/fluor&/magnification tq $35.14

70370 26 radex pharynx/larx w/fluor&/magnification tq $10.68

70371 cplx dynamic pharyngeal&sp eval c/v rec $61.30

70371 TC cplx dynamic pharyngeal&sp eval c/v rec $33.50

70371 26 cplx dynamic pharyngeal&sp eval c/v rec $27.79

70373 laryngograpy contrast rs&i $49.70

70373 TC laryngograpy contrast rs&i $35.64

70373 26 laryngograpy contrast rs&i $14.06

70380 radiologic examination salivary gland calculus $22.72

70380 TC radiologic examination salivary gland calculus $16.95




70380 26 radiologic examination salivary gland calculus $5.77

70390 sialograpy rs&i $61.26

70390 TC sialograpy rs&i $48.26

70390 26 sialograpy rs&i $13.00

70450 ct head/brain w/o contrast material $135.98

70450 TC ct head/brain w/o contrast material $106.81

70450 26 ct head/brain w/o contrast material $29.17

70460 ct head/brain w/contrast material $176.04

70460 TC ct head/brain w/contrast material $137.42

70460 26 ct head/brain w/contrast material $38.62

70470 ct head/brain w/o&w/contrast material $204.06

70470 TC ct head/brain w/o&w/contrast material $145.09

70470 26 ct head/brain w/o&w/contrast material $43.41

70480 ct orbit sella/post fossa/ear w/o contrast matrl $163.35

70480 TC ct orbit sella/post fossa/ear w/o contrast matrl $119.69

70480 26 ct orbit sella/post fossa/ear w/o contrast matrl $43.66

70481 ct orbit sella/post fossa/ear w/contrast matrl $236.46

70481 TC ct orbit sella/post fossa/ear w/contrast matrl $189.38

70481 26 ct orbit sella/post fossa/ear w/contrast matrl $47.08

70482 ct orbit sella/post fossa/ear w/o & w/contr matr $258.91

70482 TC ct orbit sella/post fossa/ear w/o & w/contr matr $209.61

70482 26 ct orbit sella/post fossa/ear w/o & w/contr matr $49.30

70486 ct maxillofacial w/o contrast material $158.17

70486 TC ct maxillofacial w/o contrast material $119.29

70486 26 ct maxillofacial w/o contrast material $38.87

70487 ct maxillofacial w/contrast material $212.02

70487 TC ct maxillofacial w/contrast material $167.41

70487 26 ct maxillofacial w/contrast material $44.61

70488 ct maxillofacial w/o &w/contrast material $257.63

70488 TC ct maxillofacial w/o &w/contrast material $209.31

70488 26 ct maxillofacial w/o &w/contrast material $48.32

70490 ct soft tissue neck w/o contrast material $163.07

70490 TC ct soft tissue neck w/o contrast material $119.19

70490 26 ct soft tissue neck w/o contrast material $43.88

70491 ct soft tissue neck w/contrast material $208.63

70491 TC ct soft tissue neck w/contrast material $161.55

70491 26 ct soft tissue neck w/contrast material $47.08

70492 ct soft tissue neck w/o &w/contrast material $252.75

70492 TC ct soft tissue neck w/o &w/contrast material $203.45

70492 26 ct soft tissue neck w/o &w/contrast material $49.30

70496 ct angiography head w/contrast/noncontrast $276.35

70496 TC ct angiography head w/contrast/noncontrast $216.29

70496 26 ct angiography head w/contrast/noncontrast $60.05

70498 ct angiography neck w/contrast/noncontrast $276.58

70498 TC ct angiography neck w/contrast/noncontrast $216.29

70498 26 ct angiography neck w/contrast/noncontrast $60.28

70540 mri orbit face &/neck w/o contrast $260.60

70540 TC mri orbit face &/neck w/o contrast $214.73




70540 26 mri orbit face &/neck w/o contrast $45.88

70542 mri orbit face & neck w/contrast material $318.39

70542 TC mri orbit face & neck w/contrast material $263.31

70542 26 mri orbit face & neck w/contrast material $55.07

70543 mri orbit face & nck w/o &w/contrast matrl $403.66

70543 TC mri orbit face & nck w/o &w/contrast matrl $330.55

70543 26 mri orbit face & nck w/o &w/contrast matrl $73.11

70544 mra head w/o contrst material $254.55

70544 TC mra head w/o contrst material $213.72

70544 26 mra head w/o contrst material $40.84

70545 mra head w/contrast material $303.24

70545 TC mra head w/contrast material $262.40

70545 26 mra head w/contrast material $40.84

70546 mra head w/o &w/contrast material $394.17

70546 TC mra head w/o &w/contrast material $332.86

70546 26 mra head w/o &w/contrast material $61.32

70547 mra neck w/o contrst material $254.45

70547 TC mra neck w/o contrst material $213.61

70547 26 mra neck w/o contrst material $40.84

70548 mra neck w/contrast material $303.44

70548 TC mra neck w/contrast material $262.61

70548 26 mra neck w/contrast material $40.84

70549 mra neck w/o &w/contrast material $394.17

70549 TC mra neck w/o &w/contrast material $332.86

70549 26 mra neck w/o &w/contrast material $61.32

70551 mri brain brain stem w/o contrast material $263.94

70551 TC mri brain brain stem w/o contrast material $213.54

70551 26 mri brain brain stem w/o contrast material $50.41

70552 mri brain brain stem w/contrast material $322.41

70552 TC mri brain brain stem w/contrast material $261.59

70552 26 mri brain brain stem w/contrast material $60.82

70553 mri brain brain stem w/o w/contrast material $407.32

70553 TC mri brain brain stem w/o w/contrast material $326.88

70553 26 mri brain brain stem w/o w/contrast material $80.44

70554 mri brain functional w/o physician admnistration $383.49

70554 TC mri brain functional w/o physician admnistration $310.94

70554 26 mri brain functional w/o physician admnistration $72.55

70555 TC mri brain functional w/physician admnistration $322.01

70555 26 mri brain functional w/physician admnistration $87.58

70557 26 mri brain open intracranial px w/o contrast matl $99.69

70558 26 mri brain open intracranial px w/contrast matl $108.86

70559 26 mri brain open intracranial px w/o &w/contrast $110.46

71010 radiologic examination chest single view frontal $15.06

71010 TC radiologic examination chest single view frontal $9.04

71010 26 radiologic examination chest single view frontal $6.02

71015 radiologic examination chest stero frontal $18.52

71015 TC radiologic examination chest stero frontal $11.52

71015 26 radiologic examination chest stero frontal $7.01




71020 radiologic exam chest 2 views frontal&lateral $19.93

71020 TC radiologic exam chest 2 views frontal&lateral $12.45

71020 26 radiologic exam chest 2 views frontal&lateral $7.48

71021 radex ch 2 views frnt&lat apical lordotic px $24.02

71021 TC radex ch 2 views frnt&lat apical lordotic px $15.05

71021 26 radex ch 2 views frnt&lat apical lordotic px $8.97

71022 radex ch 2 views frontal&lateral oblique prjcj $28.86

71022 TC radex ch 2 views frontal&lateral oblique prjcj $18.43

71022 26 radex ch 2 views frontal&lateral oblique prjcj $10.43

71023 radex ch 2 views frontal&lateral w/fluoro $41.68

71023 TC radex ch 2 views frontal&lateral w/fluoro $28.57

71023 26 radex ch 2 views frontal&lateral w/fluoro $13.10

71030 radex chest complete minimum 4 views $29.09

71030 TC radex chest complete minimum 4 views $18.66

71030 26 radex chest complete minimum 4 views $10.43

71034 radex chest complete minimum 4 views w/fluoro $57.04

71034 TC radex chest complete minimum 4 views w/fluoro $40.45

71034 26 radex chest complete minimum 4 views w/fluoro $16.60

71035 radex chest special views $21.38

71035 TC radex chest special views $15.13

71035 26 radex chest special views $6.24

71100 radex ribs unilateral 2 views $20.38

71100 TC radex ribs unilateral 2 views $12.89

71100 26 radex ribs unilateral 2 views $7.48

71101 radex ribs uni w/posteroant ch minimum 3 views $24.57

71101 TC radex ribs uni w/posteroant ch minimum 3 views $15.60

71101 26 radex ribs uni w/posteroant ch minimum 3 views $8.97

71110 radex ribs bilateral 3 views $25.38

71110 TC radex ribs bilateral 3 views $16.40

71110 26 radex ribs bilateral 3 views $8.97

71111 radex ribs bi w/posteroant ch minimum 4 views $32.40

71111 TC radex ribs bi w/posteroant ch minimum 4 views $21.71

71111 26 radex ribs bi w/posteroant ch minimum 4 views $10.68

71120 radex sternum minimum 2 views $20.33

71120 TC radex sternum minimum 2 views $13.57

71120 26 radex sternum minimum 2 views $6.76

71130 radex sternoclavicular jt/jts minimum 3 views $23.31

71130 TC radex sternoclavicular jt/jts minimum 3 views $15.83

71130 26 radex sternoclavicular jt/jts minimum 3 views $7.48

71250 ct thorax w/o contrast material $158.39

71250 TC ct thorax w/o contrast material $118.78

71250 26 ct thorax w/o contrast material $39.60

71260 ct thorax w/contrast material $212.83

71260 TC ct thorax w/contrast material $170.53

71260 26 ct thorax w/contrast material $42.30

71270 ct thorax w/o &w/contrast material $255.81

71270 TC ct thorax w/o &w/contrast material $208.72

71270 26 ct thorax w/o &w/contrast material $47.08




71275 ct angiography chest w/contrast/noncontrast $282.53

71275 TC ct angiography chest w/contrast/noncontrast $216.70

71275 26 ct angiography chest w/contrast/noncontrast $65.82

71550 mri chest w/o contrast material $264.18

71550 TC mri chest w/o contrast material $214.63

71550 26 mri chest w/o contrast material $49.55

71551 mri chest w/contrast material $322.06

71551 TC mri chest w/contrast material $263.42

71551 26 mri chest w/contrast material $58.65

71552 mri chest w/o &w/contrast material $409.61

71552 TC mri chest w/o &w/contrast material $332.14

71552 26 mri chest w/o &w/contrast material $77.46

71555 mra chest w/o &w/contrast material $324.45

71555 TC mra chest w/o &w/contrast material $262.20

71555 26 mra chest w/o &w/contrast material $62.24

72010 radex spine entire survey std anteropost&lat $43.02

72010 TC radex spine entire survey std anteropost&lat $28.25

72010 26 radex spine entire survey std anteropost&lat $14.76

72020 radex spine 1 view specify level $14.76

72020 TC radex spine 1 view specify level $9.49

72020 26 radex spine 1 view specify level $5.26

72040 radex spine cervical 3 views or less $22.86

72040 TC radex spine cervical 3 views or less $15.38

72040 26 radex spine cervical 3 views or less $7.48

72050 radex spine cervical 4 or 5 views $32.37

72050 TC radex spine cervical 4 or 5 views $21.94

72050 26 radex spine cervical 4 or 5 views $10.43

72052 radex spine cervical 6 or more views $40.52

72052 TC radex spine cervical 6 or more views $28.25

72052 26 radex spine cervical 6 or more views $12.27

72069 radex spine thoracolmbr standing scoliosis $21.71

72069 TC radex spine thoracolmbr standing scoliosis $14.22

72069 26 radex spine thoracolmbr standing scoliosis $7.48

72070 radex spine thoracic 2 views $21.06

72070 TC radex spine thoracic 2 views $13.57

72070 26 radex spine thoracic 2 views $7.48

72072 radex spine thoracic 3 views $23.88

72072 TC radex spine thoracic 3 views $16.40

72072 26 radex spine thoracic 3 views $7.48

72074 radex spine thoracic minimum 4 views $27.84

72074 TC radex spine thoracic minimum 4 views $20.36

72074 26 radex spine thoracic minimum 4 views $7.48

72080 radex spine thoracolumbar 2 views $21.96

72080 TC radex spine thoracolumbar 2 views $14.48

72080 26 radex spine thoracolumbar 2 views $7.48

72090 radex spine scolios study w/supine & erect study $28.88

72090 TC radex spine scolios study w/supine & erect study $19.21

72090 26 radex spine scolios study w/supine & erect study $9.67




72100 radex spine lumbosacral 2/3 views $23.99

72100 TC radex spine lumbosacral 2/3 views $16.51

72100 26 radex spine lumbosacral 2/3 views $7.48

72110 radex spine lumbosacral minimum 4 views $33.50

72110 TC radex spine lumbosacral minimum 4 views $23.07

72110 26 radex spine lumbosacral minimum 4 views $10.43

72114 radex spine lumbscrl compl w/bending views min 6 $43.67

72114 TC radex spine lumbscrl compl w/bending views min 6 $31.41

72114 26 radex spine lumbscrl compl w/bending views min 6 $12.27

72120 radex spine lumbosacral only bending 2/3 views $29.87

72120 TC radex spine lumbosacral only bending 2/3 views $22.39

72120 26 radex spine lumbosacral only bending 2/3 views $7.48

72125 ct cervical spine w/o contrast material $158.39

72125 TC ct cervical spine w/o contrast material $118.78

72125 26 ct cervical spine w/o contrast material $39.60

72126 ct cervical spine w/contrast material $212.32

72126 TC ct cervical spine w/contrast material $170.75

72126 26 ct cervical spine w/contrast material $41.57

72127 ct cervical spine w/o &w/contrast material $251.90

72127 TC ct cervical spine w/o &w/contrast material $208.72

72127 26 ct cervical spine w/o &w/contrast material $43.18

72128 ct thoracic spine w/o contrast material $158.39

72128 TC ct thoracic spine w/o contrast material $118.78

72128 26 ct thoracic spine w/o contrast material $39.60

72129 ct thoracic spine w/contrast material $212.55

72129 TC ct thoracic spine w/contrast material $170.75

72129 26 ct thoracic spine w/contrast material $41.79

72130 ct thoracic spine w/o & w/contrast material $252.13

72130 TC ct thoracic spine w/o & w/contrast material $208.72

72130 26 ct thoracic spine w/o & w/contrast material $43.41

72131 ct lumbar spine w/o contrast material $158.39

72131 TC ct lumbar spine w/o contrast material $118.78

72131 26 ct lumbar spine w/o contrast material $39.60

72132 ct lumbar spine w/contrast material $212.32

72132 TC ct lumbar spine w/contrast material $170.53

72132 26 ct lumbar spine w/contrast material $41.79

72133 ct lumbar spine w/o & w/contrast material $252.13

72133 TC ct lumbar spine w/o & w/contrast material $208.72

72133 26 ct lumbar spine w/o & w/contrast material $43.41

72141 mri spinal canal cervical w/o contrast matrl $267.14

72141 TC mri spinal canal cervical w/o contrast matrl $212.80

72141 26 mri spinal canal cervical w/o contrast matrl $54.34

72142 mri spinal canal cervical w/contrast matrl $326.96

72142 TC mri spinal canal cervical w/contrast matrl $261.59

72142 26 mri spinal canal cervical w/contrast matrl $65.37

72146 mri spinal canal thoracic w/o contrast matrl $267.17

72146 TC mri spinal canal thoracic w/o contrast matrl $212.60

72146 26 mri spinal canal thoracic w/o contrast matrl $54.57




72147 mri spinal canal thoracic w/contrast matrl $326.59

72147 TC mri spinal canal thoracic w/contrast matrl $260.99

72147 26 mri spinal canal thoracic w/contrast matrl $65.60

72148 mri spinal canal lumbar w/o contrast material $263.01

72148 TC mri spinal canal lumbar w/o contrast material $212.60

72148 26 mri spinal canal lumbar w/o contrast material $50.41

72149 mri spinal canal lumbar w/contrast material $322.41

72149 TC mri spinal canal lumbar w/contrast material $261.59

72149 26 mri spinal canal lumbar w/contrast material $60.82

72156 mri spinal canal cervical w/o & w/contr matrl $414.34

72156 TC mri spinal canal cervical w/o & w/contr matrl $326.91

72156 26 mri spinal canal cervical w/o & w/contr matrl $87.44

72157 mri spinal canal thoracic w/o & w/contr matrl $413.97

72157 TC mri spinal canal thoracic w/o & w/contr matrl $326.30

72157 26 mri spinal canal thoracic w/o & w/contr matrl $87.67

72158 mri spinal canal lumbar w/o &w/contr matrl $407.12

72158 TC mri spinal canal lumbar w/o &w/contr matrl $326.91

72158 26 mri spinal canal lumbar w/o &w/contr matrl $80.21

72159 mra spinal canal w/wo contrast material $343.22

72159 TC mra spinal canal w/wo contrast material $280.25

72159 26 mra spinal canal w/wo contrast material $62.99

72170 radiologic examination pelvis 1/2 views $16.16

72170 TC radiologic examination pelvis 1/2 views $10.40

72170 26 radiologic examination pelvis 1/2 views $5.77

72190 radiologic exam pelvis compl minimum 3 views $24.41

72190 TC radiologic exam pelvis compl minimum 3 views $17.18

72190 26 radiologic exam pelvis compl minimum 3 views $7.23

72191 ct angiography pelvis w/contrast/noncontrast $278.62

72191 TC ct angiography pelvis w/contrast/noncontrast $216.60

72191 26 ct angiography pelvis w/contrast/noncontrast $62.02

72192 ct pelvis w/o contrast material $156.07

72192 TC ct pelvis w/o contrast material $112.18

72192 26 ct pelvis w/o contrast material $37.38

72193 ct pelvis w/contrast material $201.89

72193 TC ct pelvis w/contrast material $162.29

72193 26 ct pelvis w/contrast material $39.60

72194 ct pelvis w/o & w/contrast material $250.59

72194 TC ct pelvis w/o & w/contrast material $209.03

72194 26 ct pelvis w/o & w/contrast material $41.57

72195 mri pelvis w/o contrast material $263.88

72195 TC mri pelvis w/o contrast material $214.32

72195 26 mri pelvis w/o contrast material $49.55

72196 mri pelvis w/contrast material $322.11

72196 TC mri pelvis w/contrast material $263.01

72196 26 mri pelvis w/contrast material $59.10

72197 mri pelvis w/o & w/contrast material $407.06

72197 TC mri pelvis w/o & w/contrast material $330.04

72197 26 mri pelvis w/o & w/contrast material $77.01




72198 mra pelvis w/wo contrast material $323.74

72198 TC mra pelvis w/wo contrast material $262.20

72198 26 mra pelvis w/wo contrast material $61.54

72200 radiologic examination sacroiliac jnts < 3 views $17.97

72200 TC radiologic examination sacroiliac jnts < 3 views $12.19

72200 26 radiologic examination sacroiliac jnts < 3 views $5.77

72202 radiologic exam sacroiliac joints 3/more views $21.65

72202 TC radiologic exam sacroiliac joints 3/more views $15.15

72202 26 radiologic exam sacroiliac joints 3/more views $6.50

72220 radex sacrum & coccyx minimum 2 views $18.21

72220 TC radex sacrum & coccyx minimum 2 views $12.45

72220 26 radex sacrum & coccyx minimum 2 views $5.77

72240 myelograpy cervical rs&i $98.50

72240 TC myelograpy cervical rs&i $67.59

72240 26 myelograpy cervical rs&i $30.91

72255 myelograpy thoracic rs&i $90.23

72255 TC myelograpy thoracic rs&i $60.00

72255 26 myelograpy thoracic rs&i $30.23

72265 myelograpy lumbosacral rs&i $91.60

72265 TC myelograpy lumbosacral rs&i $63.38

72265 26 myelograpy lumbosacral rs&i $28.22

72270 myelograpy 2/more regions rs&i $143.03

72270 TC myelograpy 2/more regions rs&i $97.66

72270 26 myelograpy 2/more regions rs&i $45.37

72275 epidurograpy rs&i $64.80

72275 TC epidurograpy rs&i $40.38

72275 26 epidurograpy rs&i $24.42

72285 diskograpy cervical/thoracic rs&i $109.89

72285 TC diskograpy cervical/thoracic rs&i $53.75

72285 26 diskograpy cervical/thoracic rs&i $37.82

72291 rad s&i perq vrtpls/sacrplsty pr vrt body fluo $48.40

72291 26 rad s&i perq vrtpls/sacrplsty pr vrt body fluo $45.82

72292 rad s&i perq vrtpls/sacrplsty per vrt body ct $50.19

72292 26 rad s&i perq vrtpls/sacrplsty per vrt body ct $47.89

72295 diskograpy lumbar rs&i $96.75

72295 TC diskograpy lumbar rs&i $55.59

72295 26 diskograpy lumbar rs&i $27.56

73000 radex clavicle complete $17.04

73000 TC radex clavicle complete $11.52

73000 26 radex clavicle complete $5.52

73010 radex scapula complete $17.51

73010 TC radex scapula complete $11.75

73010 26 radex scapula complete $5.77

73020 radex shoulder 1 view $14.53

73020 TC radex shoulder 1 view $9.49

73020 26 radex shoulder 1 view $5.04

73030 radex shoulder complete minimum 2 views $18.47

73030 TC radex shoulder complete minimum 2 views $12.22




73030 26 radex shoulder complete minimum 2 views $6.24

73040 radex shoulder arthrography rs&i $66.10

73040 TC radex shoulder arthrography rs&i $47.71

73040 26 radex shoulder arthrography rs&i $18.39

73050 radex a-c joints bi w/wo weighted distrcj $22.13

73050 TC radex a-c joints bi w/wo weighted distrcj $15.15

73050 26 radex a-c joints bi w/wo weighted distrcj $6.98

73060 radex humerus minimum 2 views $17.99

73060 TC radex humerus minimum 2 views $12.22

73060 26 radex humerus minimum 2 views $5.77

73070 radex elbow 2 views $16.56

73070 TC radex elbow 2 views $11.52

73070 26 radex elbow 2 views $5.04

73080 radex elbow complete minimum 3 views $21.15

73080 TC radex elbow complete minimum 3 views $15.38

73080 26 radex elbow complete minimum 3 views $5.77

73085 radex elbow arthrography rs&i $59.79

73085 TC radex elbow arthrography rs&i $41.62

73085 26 radex elbow arthrography rs&i $18.17

73090 radex forearm 2 views $16.81

73090 TC radex forearm 2 views $11.52

73090 26 radex forearm 2 views $5.29

73092 radex upper extremity infant minimum 2 views $17.26

73092 TC radex upper extremity infant minimum 2 views $11.97

73092 26 radex upper extremity infant minimum 2 views $5.29

73100 radex wrist 2 views $17.49

73100 TC radex wrist 2 views $11.97

73100 26 radex wrist 2 views $5.52

73110 radex wrist complete minimum 3 views $20.90

73110 TC radex wrist complete minimum 3 views $15.13

73110 26 radex wrist complete minimum 3 views $5.77

73115 radex wrist arthrography rs&i $63.37

73115 TC radex wrist arthrography rs&i $44.98

73115 26 radex wrist arthrography rs&i $18.39

73120 radex hand 2 views $16.59

73120 TC radex hand 2 views $11.30

73120 26 radex hand 2 views $5.29

73130 radex hand minimum 3 views $19.10

73130 TC radex hand minimum 3 views $13.33

73130 26 radex hand minimum 3 views $5.77

73140 radex fingr minimum 2 views $17.63

73140 TC radex fingr minimum 2 views $13.10

73140 26 radex fingr minimum 2 views $4.54

73200 ct upper extremity w/o contrast material $156.35

73200 TC ct upper extremity w/o contrast material $119.19

73200 26 ct upper extremity w/o contrast material $37.16

73201 ct upper extremity w/o & w/contrast material $201.94

73201 TC ct upper extremity w/o & w/contrast material $162.34




73201 26 ct upper extremity w/o & w/contrast material $39.60

73202 ct upper extremity w/o & w/contrast material $251.00

73202 TC ct upper extremity w/o & w/contrast material $209.43

73202 26 ct upper extremity w/o & w/contrast material $41.57

73206 ct angiography upper extremity $278.87

73206 TC ct angiography upper extremity $216.40

73206 26 ct angiography upper extremity $62.48

73218 mri upper extremity oth than jt w/o contr matrl $260.48

73218 TC mri upper extremity oth than jt w/o contr matrl $214.83

73218 26 mri upper extremity oth than jt w/o contr matrl $45.65

73219 mri upper extremity oth than jt w/contr matrl $318.61

73219 TC mri upper extremity oth than jt w/contr matrl $263.54

73219 26 mri upper extremity oth than jt w/contr matrl $55.07

73220 mri upper extrem other than jt w/o & w/contras $403.98

73220 TC mri upper extrem other than jt w/o & w/contras $330.65

73220 26 mri upper extrem other than jt w/o & w/contras $73.33

73221 mri any jt upper extremity w/o contrast matrl $258.53

73221 TC mri any jt upper extremity w/o contrast matrl $194.61

73221 26 mri any jt upper extremity w/o contrast matrl $45.88

73222 mri any jt upper extremity w/contrast matrl $318.19

73222 TC mri any jt upper extremity w/contrast matrl $263.11

73222 26 mri any jt upper extremity w/contrast matrl $55.07

73223 mri any jt upper extremity w/o & w/contr matrl $403.45

73223 TC mri any jt upper extremity w/o & w/contr matrl $330.34

73223 26 mri any jt upper extremity w/o & w/contr matrl $73.11

73225 mra upper extremity w/wo contrast material $340.69

73225 TC mra upper extremity w/wo contrast material $280.25

73225 26 mra upper extremity w/wo contrast material $60.45

73500 radex hip unilateral 1 view $15.72

73500 TC radex hip unilateral 1 view $9.94

73500 26 radex hip unilateral 1 view $5.77

73510 radex hip unilateral complete minimum 2 views $22.60

73510 TC radex hip unilateral complete minimum 2 views $15.38

73510 26 radex hip unilateral complete minimum 2 views $7.23

73520 radex hips bilateral 2 views anteropost pelvis $24.54

73520 TC radex hips bilateral 2 views anteropost pelvis $15.83

73520 26 radex hips bilateral 2 views anteropost pelvis $8.72

73525 radex hip arthrography rs&i $59.68

73525 TC radex hip arthrography rs&i $41.17

73525 26 radex hip arthrography rs&i $18.52

73530 radex hip operative procedure $23.14

73530 TC radex hip operative procedure $12.76

73530 26 radex hip operative procedure $9.93

73540 radex pelvis&hips inft/chld minimum 2 views $22.58

73540 TC radex pelvis&hips inft/chld minimum 2 views $15.83

73540 26 radex pelvis&hips inft/chld minimum 2 views $6.76

73550 radiologic examination femur 2 views $17.54

73550 TC radiologic examination femur 2 views $11.77




73550 26 radiologic examination femur 2 views $5.77

73560 radiologic examination knee 1/2 views $17.51

73560 TC radiologic examination knee 1/2 views $11.75

73560 26 radiologic examination knee 1/2 views $5.77

73562 radiologic examination knee 3 views $20.94

73562 TC radiologic examination knee 3 views $14.70

73562 26 radiologic examination knee 3 views $6.24

73564 radiologic exam knee complete 4/more views $24.44

73564 TC radiologic exam knee complete 4/more views $16.95

73564 26 radiologic exam knee complete 4/more views $7.48

73565 radiologic exam both knees standing anteropost $18.64

73565 TC radiologic exam both knees standing anteropost $12.65

73565 26 radiologic exam both knees standing anteropost $5.99

73580 radiologic exam knee arthrography rs&i $74.14

73580 TC radiologic exam knee arthrography rs&i $55.62

73580 26 radiologic exam knee arthrography rs&i $18.52

73590 radiologic examination tibia & fibula 2 views $16.84

73590 TC radiologic examination tibia & fibula 2 views $11.07

73590 26 radiologic examination tibia & fibula 2 views $5.77

73592 radex lower extremity infant minimum 2 views $17.26

73592 TC radex lower extremity infant minimum 2 views $11.97

73592 26 radex lower extremity infant minimum 2 views $5.29

73600 radiologic examination ankle 2 views $16.59

73600 TC radiologic examination ankle 2 views $11.30

73600 26 radiologic examination ankle 2 views $5.29

73610 radex ankle complete minimum 3 views $19.10

73610 TC radex ankle complete minimum 3 views $13.33

73610 26 radex ankle complete minimum 3 views $5.77

73615 radex ankle arthroggraphy rs&i $61.26

73615 TC radex ankle arthroggraphy rs&i $42.97

73615 26 radex ankle arthroggraphy rs&i $18.29

73620 radiologic examination foot 2 views $16.14

73620 TC radiologic examination foot 2 views $10.84

73620 26 radiologic examination foot 2 views $5.29

73630 radex foot complete minimum 3 views $18.87

73630 TC radex foot complete minimum 3 views $13.10

73630 26 radex foot complete minimum 3 views $5.77

73650 radex calcaneus minimum 2 views $16.36

73650 TC radex calcaneus minimum 2 views $11.07

73650 26 radex calcaneus minimum 2 views $5.29

73660 radex toe minimum 2 views $16.73

73660 TC radex toe minimum 2 views $12.43

73660 26 radex toe minimum 2 views $4.31

73700 ct lower extremity w/o contrast material $156.35

73700 TC ct lower extremity w/o contrast material $119.19

73700 26 ct lower extremity w/o contrast material $37.16

73701 ct lower extremity w/contrast material $203.30

73701 TC ct lower extremity w/contrast material $163.47




73701 26 ct lower extremity w/contrast material $39.83

73702 ct lower extremity w/o & w/contrast matrl $251.22

73702 TC ct lower extremity w/o & w/contrast matrl $209.43

73702 26 ct lower extremity w/o & w/contrast matrl $41.79

73706 ct angiography lower extremity $282.22

73706 TC ct angiography lower extremity $216.57

73706 26 ct angiography lower extremity $65.65

73718 mri lower extrem oth/thn jt w/o contr matrl $260.60

73718 TC mri lower extrem oth/thn jt w/o contr matrl $214.73

73718 26 mri lower extrem oth/thn jt w/o contr matrl $45.88

73719 mri lower extrem oth/thn jt w/contrast matrl $318.39

73719 TC mri lower extrem oth/thn jt w/contrast matrl $263.31

73719 26 mri lower extrem oth/thn jt w/contrast matrl $55.07

73720 mri lower extrem oth/thn jt w/o & w/contr matr $403.98

73720 TC mri lower extrem oth/thn jt w/o & w/contr matr $330.65

73720 26 mri lower extrem oth/thn jt w/o & w/contr matr $73.33

73721 mri any jt lower extrem w/o contrast matrl $258.53

73721 TC mri any jt lower extrem w/o contrast matrl $194.61

73721 26 mri any jt lower extrem w/o contrast matrl $45.88

73722 mri any jt lower extrem w/contrast material $318.51

73722 TC mri any jt lower extrem w/contrast material $263.21

73722 26 mri any jt lower extrem w/contrast material $55.29

73723 mri any jt lower extrem w/o & w/contrast matrl $403.45

73723 TC mri any jt lower extrem w/o & w/contrast matrl $330.12

73723 26 mri any jt lower extrem w/o & w/contrast matrl $73.33

73725 mra lower extremity w/wo contrast material $324.60

73725 TC mra lower extremity w/wo contrast material $262.33

73725 26 mra lower extremity w/wo contrast material $62.27

74000 radex abdomen 1 anteroposterior view $15.97

74000 TC radex abdomen 1 anteroposterior view $9.94

74000 26 radex abdomen 1 anteroposterior view $6.02

74010 radex abd anteropost&addl oblq&cone views $23.34

74010 TC radex abd anteropost&addl oblq&cone views $15.60

74010 26 radex abd anteropost&addl oblq&cone views $7.74

74020 radex abdomen compl w/dcbts&/erc views $25.03

74020 TC radex abdomen compl w/dcbts&/erc views $15.83

74020 26 radex abdomen compl w/dcbts&/erc views $9.20

74022 radex abd compl aqt abd w/s/e/d views 1 view ch $30.24

74022 TC radex abd compl aqt abd w/s/e/d views 1 view ch $19.33

74022 26 radex abd compl aqt abd w/s/e/d views 1 view ch $10.91

74150 ct abdomen w/o contrast material $159.37

74150 TC ct abdomen w/o contrast material $110.65

74150 26 ct abdomen w/o contrast material $40.59

74160 ct abdomen w/contrast material $226.44

74160 TC ct abdomen w/contrast material $182.81

74160 26 ct abdomen w/contrast material $43.63

74170 ct abdomen w/o &w/contrast material $257.22

74170 TC ct abdomen w/o &w/contrast material $209.41




74170 26 ct abdomen w/o &w/contrast material $47.82

74174 ct angio abd&plvis cntrst mtrl w/wo cntrst img $360.04

74174 TC ct angio abd&plvis cntrst mtrl w/wo cntrst img $289.00

74174 26 ct angio abd&plvis cntrst mtrl w/wo cntrst img $71.04

74175 ct angiography abdomen w/contrast/noncontrast $282.00

74175 TC ct angiography abdomen w/contrast/noncontrast $216.80

74175 26 ct angiography abdomen w/contrast/noncontrast $65.20

74176 ct abdomen & pelvis w/o contrast material $144.72

74176 TC ct abdomen & pelvis w/o contrast material $87.30

74176 26 ct abdomen & pelvis w/o contrast material $57.41

74177 ct abdoen & pelvis w/contrast material $226.80

74177 TC ct abdoen & pelvis w/contrast material $166.59

74177 26 ct abdoen & pelvis w/contrast material $60.21

74178 ct abdomen & pelvis w/o contrst 1/> body re $286.78

74178 TC ct abdomen & pelvis w/o contrst 1/> body re $220.19

74178 26 ct abdomen & pelvis w/o contrst 1/> body re $66.59

74181 mri abdomen w/o contrast material $263.70

74181 TC mri abdomen w/o contrast material $213.92

74181 26 mri abdomen w/o contrast material $49.78

74182 mri abdomen w/contrast material $322.41

74182 TC mri abdomen w/contrast material $263.31

74182 26 mri abdomen w/contrast material $59.10

74183 mri abdomen w/o &w/contrast material $407.06

74183 TC mri abdomen w/o &w/contrast material $330.04

74183 26 mri abdomen w/o &w/contrast material $77.01

74185 mra abdomen w/wo contrast material $323.65

74185 TC mra abdomen w/wo contrast material $262.10

74185 26 mra abdomen w/wo contrast material $61.54

74190 peritoneogram rs&i $49.59

74190 TC peritoneogram rs&i $32.49

74190 26 peritoneogram rs&i $16.42

74210 radex pharynx&/cervical esophagus $47.51

74210 TC radex pharynx&/cervical esophagus $35.01

74210 26 radex pharynx&/cervical esophagus $12.50

74220 radex esophagus $54.09

74220 TC radex esophagus $38.40

74220 26 radex esophagus $15.69

74230 swallowing funcj w/cineradiograpy/vidradiog $55.76

74230 TC swallowing funcj w/cineradiograpy/vidradiog $37.62

74230 26 swallowing funcj w/cineradiograpy/vidradiog $18.14

74235 rmvl fb esophageal w/use balloon cath rs&i $108.36

74235 TC rmvl fb esophageal w/use balloon cath rs&i $65.81

74235 26 rmvl fb esophageal w/use balloon cath rs&i $41.49

74240 radex gi tract upper w/wo delayed films w/o kub $67.26

74240 TC radex gi tract upper w/wo delayed films w/o kub $43.60

74240 26 radex gi tract upper w/wo delayed films w/o kub $23.65

74241 radex gi tract upper w/wo delayed films w/kub $71.54

74241 TC radex gi tract upper w/wo delayed films w/kub $48.11




74241 26 radex gi tract upper w/wo delayed films w/kub $23.43

74245 radex gi tract upr w/sm int w/mult serial flms $106.93

74245 TC radex gi tract upr w/sm int w/mult serial flms $75.79

74245 26 radex gi tract upr w/sm int w/mult serial flms $31.14

74246 radex upper gi w/wo glucagon/delay films w/o kub $76.75

74246 TC radex upper gi w/wo glucagon/delay films w/o kub $53.10

74246 26 radex upper gi w/wo glucagon/delay films w/o kub $23.65

74247 radex upper gi w/wo glucagon/delay flms w/kub $77.65

74247 TC radex upper gi w/wo glucagon/delay flms w/kub $54.00

74247 26 radex upper gi w/wo glucagon/delay flms w/kub $23.65

74249 radex gi upr w/wo glucose w/sm intest follw-thru $114.49

74249 TC radex gi upr w/wo glucose w/sm intest follw-thru $83.36

74249 26 radex gi upr w/wo glucose w/sm intest follw-thru $31.14

74250 radex small intestine w/multiple serial films $62.81

74250 TC radex small intestine w/multiple serial films $46.87

74250 26 radex small intestine w/multiple serial films $15.95

74251 radex sm int w/mlt srl flms via enteroclss tube $112.53

74251 TC radex sm int w/mlt srl flms via enteroclss tube $88.87

74251 26 radex sm int w/mlt srl flms via enteroclss tube $23.65

74260 duodenograpy hypotonic $71.64

74260 TC duodenograpy hypotonic $54.71

74260 26 duodenograpy hypotonic $16.93

74261 ct colonogrphy dx image postprocess w/o contrast $206.05

74261 TC ct colonogrphy dx image postprocess w/o contrast $129.19

74261 26 ct colonogrphy dx image postprocess w/o contrast $76.86

74262 ct colonogrphy dx image postprocess w/contrast $281.02

74262 TC ct colonogrphy dx image postprocess w/contrast $196.65

74262 26 ct colonogrphy dx image postprocess w/contrast $84.37

74270 radex colon barium enema w/wokub $77.76

74270 TC radex colon barium enema w/wokub $54.10

74270 26 radex colon barium enema w/wokub $23.65

74280 radex colon w/spec hi dns barium w/wo glucagon $121.79

74280 TC radex colon w/spec hi dns barium w/wo glucagon $87.96

74280 26 radex colon w/spec hi dns barium w/wo glucagon $33.83

74283 therapeutic enema rdctj intussusception/obstrcj $122.60

74283 TC therapeutic enema rdctj intussusception/obstrcj $53.80

74283 26 therapeutic enema rdctj intussusception/obstrcj $68.80

74290 cholecystography oral contrst $40.16

74290 TC cholecystography oral contrst $29.25

74290 26 cholecystography oral contrst $10.91

74291 cholecyst oral cntrst addl/repeat xm/mult day xm $34.50

74291 TC cholecyst oral cntrst addl/repeat xm/mult day xm $27.76

74291 26 cholecyst oral cntrst addl/repeat xm/mult day xm $6.76

74300 26 cholangiography&/pancreatography ntraop rs&i $12.27

74301 26 cholangio&/pancreatography addl set intraop rs $7.23

74305 cholangio&/pancreatography thru cath rs&i $34.50

74305 TC cholangio&/pancreatography thru cath rs&i $19.49

74305 26 cholangio&/pancreatography thru cath rs&i $14.46




74320 cholangio&/pancreatography transhepatc rs&i $71.00

74320 TC cholangio&/pancreatography transhepatc rs&i $52.39

74320 26 cholangio&/pancreatography transhepatc rs&i $18.61

74327 postop biliary stone rmvl prq t-tube rs&i $81.19

74327 TC postop biliary stone rmvl prq t-tube rs&i $57.05

74327 26 postop biliary stone rmvl prq t-tube rs&i $24.13

74328 endoscopic cathj biliary ductal system rs&i $103.26

74328 TC endoscopic cathj biliary ductal system rs&i $78.39

74328 26 endoscopic cathj biliary ductal system rs&i $24.13

74329 endoscopic cathj pancreatic ductal sys rs&i $104.11

74329 TC endoscopic cathj pancreatic ductal sys rs&i $79.16

74329 26 endoscopic cathj pancreatic ductal sys rs&i $24.13

74330 cmbn ndsc cathj biliary&pncrtc ductal sys rs&i $110.26

74330 TC cmbn ndsc cathj biliary&pncrtc ductal sys rs&i $78.39

74330 26 cmbn ndsc cathj biliary&pncrtc ductal sys rs&i $30.88

74340 intro long gi tube w/mult fluoro&films rs& $84.41

74340 TC intro long gi tube w/mult fluoro&films rs& $65.21

74340 26 intro long gi tube w/mult fluoro&films rs& $18.39

74355 percutaneous placement enteroclysis tube rs&i $92.18

74355 TC percutaneous placement enteroclysis tube rs&i $65.21

74355 26 percutaneous placement enteroclysis tube rs&i $26.10

74360 intraluminal dilation strictures&/obstrcjs rs&i $97.82

74360 TC intraluminal dilation strictures&/obstrcjs rs&i $78.39

74360 26 intraluminal dilation strictures&/obstrcjs rs&i $19.07

74363 prq transhepatc dilat biliary duct strictre rs&i $184.74

74363 TC prq transhepatc dilat biliary duct strictre rs&i $153.31

74363 26 prq transhepatc dilat biliary duct strictre rs&i $30.38

74400 urography iv w/wo kub w/wo tomography $67.87

74400 TC urography iv w/wo kub w/wo tomography $51.19

74400 26 urography iv w/wo kub w/wo tomography $16.67

74410 urography infusion drip &/bolus technique $71.48

74410 TC urography infusion drip &/bolus technique $54.57

74410 26 urography infusion drip &/bolus technique $16.91

74415 urograpy infusion drip &/bolus techq w/wo tomo $81.75

74415 TC urograpy infusion drip &/bolus techq w/wo tomo $65.07

74415 26 urograpy infusion drip &/bolus techq w/wo tomo $16.67

74420 x-ray urinary tract exam with contrast material $78.12

74420 TC x-ray urinary tract exam with contrast material $65.21

74420 26 x-ray urinary tract exam with contrast material $12.50

74425 urography antegrade rs&i $45.40

74425 TC urography antegrade rs&i $32.49

74425 26 urography antegrade rs&i $12.50

74430 cystography minimum 3 views rs&i $38.41

74430 TC cystography minimum 3 views rs&i $23.91

74430 26 cystography minimum 3 views rs&i $11.03

74440 vasograpy vesiculograpy/epididymograpy rs&i $52.30

74440 TC vasograpy vesiculograpy/epididymograpy rs&i $39.30

74440 26 vasograpy vesiculograpy/epididymograpy rs&i $13.00




74445 corpora cavernosograpy rs&i $68.78

74445 TC corpora cavernosograpy rs&i $28.02

74445 26 corpora cavernosograpy rs&i $39.80

74450 urethrocystography retrograde rs&i $48.11

74450 TC urethrocystography retrograde rs&i $36.23

74450 26 urethrocystography retrograde rs&i $11.51

74455 urethrocystography voiding rs&i $56.04

74455 TC urethrocystography voiding rs&i $44.53

74455 26 urethrocystography voiding rs&i $11.51

74470 radex renal cyst study translumbar rs&i $50.25

74470 TC radex renal cyst study translumbar rs&i $31.05

74470 26 radex renal cyst study translumbar rs&i $18.61

74475 intro cath in renal pelvis drg&/njx prq rs&i $76.59

74475 TC intro cath in renal pelvis drg&/njx prq rs&i $57.97

74475 26 intro cath in renal pelvis drg&/njx prq rs&i $18.61

74480 intro ureteral cath/stent prq rs&i $76.81

74480 TC intro ureteral cath/stent prq rs&i $58.19

74480 26 intro ureteral cath/stent prq rs&i $18.61

74485 dilation nephrostomy/ureter/urethra rs&i $73.38

74485 TC dilation nephrostomy/ureter/urethra rs&i $54.64

74485 26 dilation nephrostomy/ureter/urethra rs&i $18.74

74710 pelvimetry w/woplacental localization $27.39

74710 TC pelvimetry w/woplacental localization $15.62

74710 26 pelvimetry w/woplacental localization $11.76

74740 hysterosalpingography rs&i $48.36

74740 TC hysterosalpingography rs&i $35.36

74740 26 hysterosalpingography rs&i $13.00

74742 transcervical cathj fallopian tube rs&i $100.96

74742 TC transcervical cathj fallopian tube rs&i $79.16

74742 26 transcervical cathj fallopian tube rs&i $20.73

74775 perineogram $58.49

74775 TC perineogram $36.23

74775 26 perineogram $21.21

75557 cardiac mri morphology & function w/o contrast $292.88

75557 TC cardiac mri morphology & function w/o contrast $209.77

75557 26 cardiac mri morphology & function w/o contrast $83.12

75559 cardiac mri w/o contrast w stress imaging $318.56

75559 TC cardiac mri w/o contrast w stress imaging $212.40

75559 26 cardiac mri w/o contrast w stress imaging $106.16

75561 cardiac mri w/wo contrast & further seq $419.22

75561 TC cardiac mri w/wo contrast & further seq $327.41

75561 26 cardiac mri w/wo contrast & further seq $91.81

75563 cardiac mri w/w/o contrast w stress $438.70

75563 TC cardiac mri w/w/o contrast w stress $329.13

75563 26 cardiac mri w/w/o contrast w stress $109.57

75565 cardiac mri for velocity flow mapping $58.48

75565 TC cardiac mri for velocity flow mapping $46.98

75565 26 cardiac mri for velocity flow mapping $8.78




75571 ct heart no contrast quant eval coronry calcium $49.45

75571 TC ct heart no contrast quant eval coronry calcium $29.95

75571 26 ct heart no contrast quant eval coronry calcium $19.50

75572 ct heart contrast eval cardiac structure&morph $207.87

75572 TC ct heart contrast eval cardiac structure&morph $148.50

75572 26 ct heart contrast eval cardiac structure&morph $59.37

75573 ct hrt contrst cardiac struct&morph cong hrt d $263.72

75573 TC ct hrt contrst cardiac struct&morph cong hrt d $178.32

75573 26 ct hrt contrst cardiac struct&morph cong hrt d $85.40

75574 cta hrt cornry art/bypass grfts contrst 3d post $259.48

75574 TC cta hrt cornry art/bypass grfts contrst 3d post $178.19

75574 26 cta hrt cornry art/bypass grfts contrst 3d post $81.28

75600 aortography thoracic w/o serialography rs&i $196.32

75600 TC aortography thoracic w/o serialography rs&i $174.93

75600 26 aortography thoracic w/o serialography rs&i $17.81

75605 aortography thoracic serialography rs&i $144.89

75605 TC aortography thoracic serialography rs&i $92.50

75605 26 aortography thoracic serialography rs&i $40.22

75625 aortography abdominal serialography rs&i $144.97

75625 TC aortography abdominal serialography rs&i $92.81

75625 26 aortography abdominal serialography rs&i $39.22

75630 aortography abdl bi iliofem low extrem cath rs&i $173.54

75630 TC aortography abdl bi iliofem low extrem cath rs&i $91.89

75630 26 aortography abdl bi iliofem low extrem cath rs&i $62.57

75635 cta abdl aorta&bi iliofem w/contrast&postp $300.48

75635 TC cta abdl aorta&bi iliofem w/contrast&postp $217.11

75635 26 cta abdl aorta&bi iliofem w/contrast&postp $83.38

75658 aniography brachial retrograde rs&i $171.51

75658 TC aniography brachial retrograde rs&i $112.49

75658 26 aniography brachial retrograde rs&i $44.31

75705 angiography spinal selective rs&i $210.37

75705 TC angiography spinal selective rs&i $130.95

75705 26 angiography spinal selective rs&i $75.59

75710 angiography extremity unilateral rs&i $168.11

75710 TC angiography extremity unilateral rs&i $116.49

75710 26 angiography extremity unilateral rs&i $39.35

75716 angiography extremity bilateral rs&i $197.13

75716 TC angiography extremity bilateral rs&i $140.63

75716 26 angiography extremity bilateral rs&i $45.21

75726 angiography visceral slctv/supraslctv rs&i $168.50

75726 TC angiography visceral slctv/supraslctv rs&i $115.88

75726 26 angiography visceral slctv/supraslctv rs&i $39.32

75731 angiography adrenal unilateral slctv rs&i $156.50

75731 TC angiography adrenal unilateral slctv rs&i $103.88

75731 26 angiography adrenal unilateral slctv rs&i $41.25

75733 angiography adrenal bilateral slctv rs&i $194.12

75733 TC angiography adrenal bilateral slctv rs&i $133.87

75733 26 angiography adrenal bilateral slctv rs&i $48.02




75736 angiography pelvic slctv/supraslctv rs&i $163.19

75736 TC angiography pelvic slctv/supraslctv rs&i $111.88

75736 26 angiography pelvic slctv/supraslctv rs&i $39.67

75741 angiography pulmonary unilateral slctv rs&i $152.44

75741 TC angiography pulmonary unilateral slctv rs&i $92.19

75741 26 angiography pulmonary unilateral slctv rs&i $45.32

75743 angiography pulmonary bilateral slctv rs&i $177.73

75743 TC angiography pulmonary bilateral slctv rs&i $101.73

75743 26 angiography pulmonary bilateral slctv rs&i $57.66

75746 angrph pulmonary nonslctv cath/ven njx rs&i $158.73

75746 TC angrph pulmonary nonslctv cath/ven njx rs&i $105.73

75746 26 angrph pulmonary nonslctv cath/ven njx rs&i $39.10

75756 angiography internal mammary rs&i $176.95

75756 TC angiography internal mammary rs&i $121.72

75756 26 angiography internal mammary rs&i $41.68

75774 angrph slctv ea vsl studied after basic xm rs&i $93.75

75774 TC angrph slctv ea vsl studied after basic xm rs&i $77.12

75774 26 angrph slctv ea vsl studied after basic xm rs&i $12.50

75791 angiogrphy av shunt complete eval fluor s&i $164.93

75791 TC angiogrphy av shunt complete eval fluor s&i $106.95

75791 26 angiogrphy av shunt complete eval fluor s&i $57.98

75801 lymphangiography extremity only unilateral rs&i $164.31

75801 TC lymphangiography extremity only unilateral rs&i $134.65

75801 26 lymphangiography extremity only unilateral rs&i $27.08

75803 lymphangiography extremity only bilateral rs&i $176.13

75803 TC lymphangiography extremity only bilateral rs&i $134.65

75803 26 lymphangiography extremity only bilateral rs&i $40.31

75805 angrph cath f/u study ther/embolization/infusion $180.96

75805 TC angrph cath f/u study ther/embolization/infusion $151.82

75805 26 angrph cath f/u study ther/embolization/infusion $28.06

75807 lymphangiography pelvic/abdominal bilateral rs&i $194.91

75807 TC lymphangiography pelvic/abdominal bilateral rs&i $153.31

75807 26 lymphangiography pelvic/abdominal bilateral rs&i $40.31

75809 shuntogram indwelling nonvascular shunt rs&i $54.45

75809 TC shuntogram indwelling nonvascular shunt rs&i $38.50

75809 26 shuntogram indwelling nonvascular shunt rs&i $15.95

75810 splenoportograpy rs&i $353.44

75810 TC splenoportograpy rs&i $313.03

75810 26 splenoportograpy rs&i $39.55

75820 venography extremity unilateral rs&i $74.93

75820 TC venography extremity unilateral rs&i $50.57

75820 26 venography extremity unilateral rs&i $24.36

75822 venography extremity bilateral rs&i $92.18

75822 TC venography extremity bilateral rs&i $56.01

75822 26 venography extremity bilateral rs&i $36.18

75825 venography caval inferior serialography rs&i $139.89

75825 TC venography caval inferior serialography rs&i $87.89

75825 26 venography caval inferior serialography rs&i $38.89




75827 venography caval superior serialography rs&i $143.05

75827 TC venography caval superior serialography rs&i $91.27

75827 26 venography caval superior serialography rs&i $38.19

75831 venography renal unilateral selective rs&i $149.11

75831 TC venography renal unilateral selective rs&i $93.12

75831 26 venography renal unilateral selective rs&i $39.00

75833 venography renal bilateral selective rs&i $175.18

75833 TC venography renal bilateral selective rs&i $108.49

75833 26 venography renal bilateral selective rs&i $50.46

75840 venography adrenal unilateral selective rs&i $149.42

75840 TC venography adrenal unilateral selective rs&i $92.19

75840 26 venography adrenal unilateral selective rs&i $38.44

75842 venography adrenal bilateral selective rs&i $180.10

75842 TC venography adrenal bilateral selective rs&i $110.65

75842 26 venography adrenal bilateral selective rs&i $51.11

75860 venography venous sinus/jugular cath rs&i $145.12

75860 TC venography venous sinus/jugular cath rs&i $92.50

75860 26 venography venous sinus/jugular cath rs&i $39.87

75870 venography superior sagittal sinus rs&i $144.89

75870 TC venography superior sagittal sinus rs&i $91.89

75870 26 venography superior sagittal sinus rs&i $38.87

75872 venography epidural rs&i $144.89

75872 TC venography epidural rs&i $91.89

75872 26 venography epidural rs&i $40.66

75880 venography orbital rs&i $75.61

75880 TC venography orbital rs&i $52.15

75880 26 venography orbital rs&i $23.46

75885 prq transhepatc portograpy hemodyn eval rs&i $159.33

75885 TC prq transhepatc portograpy hemodyn eval rs&i $93.12

75885 26 prq transhepatc portograpy hemodyn eval rs&i $49.73

75887 prq transhepatc portograpy w/o hemodyn evl intrp $158.02

75887 TC prq transhepatc portograpy w/o hemodyn evl intrp $92.50

75887 26 prq transhepatc portograpy w/o hemodyn evl intrp $49.73

75889 hepatc vngrph wdg/fr hemodyn eval rs&i $146.12

75889 TC hepatc vngrph wdg/fr hemodyn eval rs&i $93.73

75889 26 hepatc vngrph wdg/fr hemodyn eval rs&i $39.32

75891 hepatc vngrph wdg/fr w/o hemodyn eval rs&i $146.12

75891 TC hepatc vngrph wdg/fr w/o hemodyn eval rs&i $93.42

75891 26 hepatc vngrph wdg/fr w/o hemodyn eval rs&i $39.32

75893 venous sampling thru cath w/wo angiography rs& $117.87

75893 TC venous sampling thru cath w/wo angiography rs& $93.42

75893 26 venous sampling thru cath w/wo angiography rs& $18.39

75894 transcatheter embolization any meth rs&i $646.69

75894 TC transcatheter embolization any meth rs&i $599.74

75894 26 transcatheter embolization any meth rs&i $45.12

75896 transcatheter infusion other than thrombolysis $568.51

75896 TC transcatheter infusion other than thrombolysis $521.59

75896 26 transcatheter infusion other than thrombolysis $45.42




75898 angrph cath f-up std tcat other than thrombylsis $84.92

75898 TC angrph cath f-up std tcat other than thrombylsis $26.10

75898 26 angrph cath f-up std tcat other than thrombylsis $57.18

75901 mechanical rmvl pericatheter obstr matrl rs&i $101.39

75901 TC mechanical rmvl pericatheter obstr matrl rs&i $84.71

75901 26 mechanical rmvl pericatheter obstr matrl rs&i $16.67

75902 mechanical rmvl intraluminal obstr matrl rs&i $56.03

75902 TC mechanical rmvl intraluminal obstr matrl rs&i $42.78

75902 26 mechanical rmvl intraluminal obstr matrl rs&i $13.25

75945 iv ultrasound rs&i initial vessel $106.35

75945 TC iv ultrasound rs&i initial vessel $92.37

75945 26 iv ultrasound rs&i initial vessel $13.98

75946 iv ultrasound rs&i each non-coronary vessel $72.69

75946 TC iv ultrasound rs&i each non-coronary vessel $57.67

75946 26 iv ultrasound rs&i each non-coronary vessel $13.65

75952 26 evasc rpr infrarenal aaa/dissection rs&i $150.71

75953 26 plmt xtn prosth evasc rpr infrarenal rs&i $45.65

75954 26 evasc rpr iliac art w/ilio-iliac prosth rs&i $74.68

75956 26 evasc rpr descnd thorcic aorta subclav orig rs&i $236.03

75957 26 evasc rpr descnd thorcic aorta celiac orig rs&i $202.10

75958 26 plmt prox xtn prsth evasc desc thorac aorta rs&i $133.56

75959 26 plmt dstl xtn prsth evasc desc thorac aorta rs&i $117.38

75960 tcat stent iliac/low ext art prq/opn rsi ea vsl $116.94

75960 TC tcat stent iliac/low ext art prq/opn rsi ea vsl $79.58

75960 26 tcat stent iliac/low ext art prq/opn rsi ea vsl $28.54

75962 transluminal balloon angiop peripheral art rsi $139.86

75962 TC transluminal balloon angiop peripheral art rsi $115.26

75962 26 transluminal balloon angiop peripheral art rsi $18.52

75964 trluml baloon angiop peripher ea addl artery rsi $90.29

75964 TC trluml baloon angiop peripher ea addl artery rsi $73.43

75964 26 trluml baloon angiop peripher ea addl artery rsi $12.39

75966 trluml balo angioplasty renal/oth visc art rs& $166.05

75966 TC trluml balo angioplasty renal/oth visc art rs& $106.65

75966 26 trluml balo angioplasty renal/oth visc art rs& $46.22

75968 trluml balo angioplasty ea visceral art rs&i $82.22

75968 TC trluml balo angioplasty ea visceral art rs&i $66.05

75968 26 trluml balo angioplasty ea visceral art rs&i $12.72

75970 transcatheter biopsy rs&i $316.35

75970 TC transcatheter biopsy rs&i $286.60

75970 26 transcatheter biopsy rs&i $28.67

75978 transluminal balloon angioplasty venous rs&i $138.63

75978 TC transluminal balloon angioplasty venous rs&i $114.03

75978 26 transluminal balloon angioplasty venous rs&i $18.17

75980 prq transhepatc biliary drg w/contrast mntr rs&i $185.73

75980 TC prq transhepatc biliary drg w/contrast mntr rs&i $134.65

75980 26 prq transhepatc biliary drg w/contrast mntr rs&i $49.50

75982 prq plmt int/ext biliary drng cath/stent rs&i $204.54

75982 TC prq plmt int/ext biliary drng cath/stent rs&i $153.31




75982 26 prq plmt int/ext biliary drng cath/stent rs&i $49.50

75984 change prq tube/drainage cath w contrast rs&i $71.77

75984 TC change prq tube/drainage cath w contrast rs&i $46.91

75984 26 change prq tube/drainage cath w contrast rs&i $24.86

75989 radiological guidance prq drg w/plmt cath rs&i $91.17

75989 TC radiological guidance prq drg w/plmt cath rs&i $50.36

75989 26 radiological guidance prq drg w/plmt cath rs&i $40.81

76000 fluoroscopy spx up to 1 hour phys/qhp time $48.38

76000 TC fluoroscopy spx up to 1 hour phys/qhp time $40.21

76000 26 fluoroscopy spx up to 1 hour phys/qhp time $5.77

76001 fluoroscopy spx >1 hour phys/qhp time $89.38

76001 TC fluoroscopy spx >1 hour phys/qhp time $65.21

76001 26 fluoroscopy spx >1 hour phys/qhp time $23.17

76010 radex from nose rectum foreign body 1 view chld $17.54

76010 TC radex from nose rectum foreign body 1 view chld $11.30

76010 26 radex from nose rectum foreign body 1 view chld $6.24

76080 radex abscess/fistula/sinus tract rs&i $40.33

76080 TC radex abscess/fistula/sinus tract rs&i $21.71

76080 26 radex abscess/fistula/sinus tract rs&i $18.61

76098 radiological examination surgical specimen $12.53

76098 TC radiological examination surgical specimen $7.01

76098 26 radiological examination surgical specimen $5.52

76100 radex 1 plne body section oth/thn w/urograpy $65.69

76100 TC radex 1 plne body section oth/thn w/urograpy $45.93

76100 26 radex 1 plne body section oth/thn w/urograpy $19.75

76101 radex cplx motion bdy sctj oth/thn urograpy uni $115.44

76101 TC radex cplx motion bdy sctj oth/thn urograpy uni $95.91

76101 26 radex cplx motion bdy sctj oth/thn urograpy uni $19.52

76102 radex cplx motion bdy sctj oth/thn urograpy bi $142.96

76102 TC radex cplx motion bdy sctj oth/thn urograpy bi $123.66

76102 26 radex cplx motion bdy sctj oth/thn urograpy bi $19.30

76120 cineradiograpy/vidradiograpy xcpt where spec $47.11

76120 TC cineradiograpy/vidradiograpy xcpt where spec $34.34

76120 26 cineradiograpy/vidradiograpy xcpt where spec $12.78

76125 cineradiograpy/vidradiograpy routine examination $29.08

76125 TC cineradiograpy/vidradiograpy routine examination $19.49

76125 26 cineradiograpy/vidradiograpy routine examination $9.65

76140 consltj x-ray xm made elsewhere wrttn reprt $18.00

76376 3d rendering w/interp & postprocess supervision $49.58

76376 TC 3d rendering w/interp & postprocess supervision $42.48

76376 26 3d rendering w/interp & postprocess supervision $7.10

76377 3d rendering w/interp&postproc diff work station $69.43

76377 TC 3d rendering w/interp&postproc diff work station $40.21

76377 26 3d rendering w/interp&postproc diff work station $27.48

76380 ct limited/localized follow up study $97.75

76380 TC ct limited/localized follow up study $64.39

76380 26 ct limited/localized follow up study $33.36

76390 mri spectroscopy $300.25




76390 TC mri spectroscopy $150.13

76390 26 mri spectroscopy $150.13

76499 unlisted diagnostic radiographic procedure $709.50

76499 TC unlisted diagnostic radiographic procedure $617.27

76499 26 unlisted diagnostic radiographic procedure $92.23

76506 echoencephalograpy real time imaging $60.24

76506 TC echoencephalograpy real time imaging $38.40

76506 26 echoencephalograpy real time imaging $21.83

76510 oph us dx b-scan&quan a-scan sm pt enctr $95.16

76510 TC oph us dx b-scan&quan a-scan sm pt enctr $41.45

76510 26 oph us dx b-scan&quan a-scan sm pt enctr $53.71

76511 ophthalmic ultrasound dx quan a-scan only $61.73

76511 TC ophthalmic ultrasound dx quan a-scan only $29.27

76511 26 ophthalmic ultrasound dx quan a-scan only $32.45

76512 ophthalmic ultrasound dx b-scan w/wo a-scan $57.91

76512 TC ophthalmic ultrasound dx b-scan w/wo a-scan $25.37

76512 26 ophthalmic ultrasound dx b-scan w/wo a-scan $32.55

76513 oph us dx ant sgm us immersion b-scan/hr biom $52.87

76513 TC oph us dx ant sgm us immersion b-scan/hr biom $30.55

76513 26 oph us dx ant sgm us immersion b-scan/hr biom $22.32

76514 ophthalmic us dx corneal pachymetry uni/bi $8.15

76514 TC ophthalmic us dx corneal pachymetry uni/bi $2.16

76514 26 ophthalmic us dx corneal pachymetry uni/bi $5.99

76516 ophthalmic biometry us echograpy a-scan $42.36

76516 TC ophthalmic biometry us echograpy a-scan $23.86

76516 26 ophthalmic biometry us echograpy a-scan $18.49

76519 oph bmtry us echograpy a-scan io lens pwr cal $45.29

76519 TC oph bmtry us echograpy a-scan io lens pwr cal $26.57

76519 26 oph bmtry us echograpy a-scan io lens pwr cal $18.72

76529 ophthalmic ultrasonic foreign body localization $42.91

76529 TC ophthalmic ultrasonic foreign body localization $23.31

76529 26 ophthalmic ultrasonic foreign body localization $19.60

76536 us soft tissue head & neck real time imge docm $69.04

76536 TC us soft tissue head & neck real time imge docm $50.37

76536 26 us soft tissue head & neck real time imge docm $18.67

76604 us chest real time w/image documentation $54.23

76604 TC us chest real time w/image documentation $35.59

76604 26 us chest real time w/image documentation $18.64

76645 us breast real time w/image documentation $56.78

76645 TC us breast real time w/image documentation $38.40

76645 26 us breast real time w/image documentation $18.39

76700 us abdominal real time w/image documentation $85.67

76700 TC us abdominal real time w/image documentation $58.18

76700 26 us abdominal real time w/image documentation $27.48

76705 ultrasound abdominal real time w/image limited $64.96

76705 TC ultrasound abdominal real time w/image limited $44.73

76705 26 ultrasound abdominal real time w/image limited $20.23

76770 us retroperitoneal real time w/image complete $81.97




76770 TC us retroperitoneal real time w/image complete $56.83

76770 26 us retroperitoneal real time w/image complete $25.14

76775 us retroperitoneal real time w/image limited $69.90

76775 TC us retroperitoneal real time w/image limited $49.69

76775 26 us retroperitoneal real time w/image limited $20.20

76776 us trnsplnt kidney real time w/image docmtn $91.04

76776 TC us trnsplnt kidney real time w/image docmtn $65.17

76776 26 us trnsplnt kidney real time w/image docmtn $25.87

76800 ultrasound spinal canal & contents $78.16

76800 TC ultrasound spinal canal & contents $41.80

76800 26 ultrasound spinal canal & contents $36.37

76801 us pregnant uterus 14 wk transabdl 1/1st gestat $82.67

76801 TC us pregnant uterus 14 wk transabdl 1/1st gestat $49.29

76801 26 us pregnant uterus 14 wk transabdl 1/1st gestat $33.38

76802 us preg uterus 14 wk transabdl each gestation $47.07

76802 TC us preg uterus 14 wk transabdl each gestation $19.30

76802 26 us preg uterus 14 wk transabdl each gestation $27.76

76805 us preg uterus after 1st trimest 1/1st gestation $91.91

76805 TC us preg uterus after 1st trimest 1/1st gestation $58.76

76805 26 us preg uterus after 1st trimest 1/1st gestation $33.16

76810 us preg uterus > 1st trimester abdl ea gestatio $63.60

76810 TC us preg uterus > 1st trimester abdl ea gestatio $30.91

76810 26 us preg uterus > 1st trimester abdl ea gestatio $32.68

76811 us preg uterus w/detail fetal anat 1st gestation $129.50

76811 TC us preg uterus w/detail fetal anat 1st gestation $66.66

76811 26 us preg uterus w/detail fetal anat 1st gestation $62.84

76812 us preg uterus detail fetal anat exam ea gestat $95.56

76812 TC us preg uterus detail fetal anat exam ea gestat $36.78

76812 26 us preg uterus detail fetal anat exam ea gestat $58.79

76813 us fetal nuchal translucency 1st gestation $81.07

76813 TC us fetal nuchal translucency 1st gestation $42.55

76813 26 us fetal nuchal translucency 1st gestation $38.53

76814 us fetal nuchal translucency ea addl gestation $53.05

76814 TC us fetal nuchal translucency ea addl gestation $20.68

76814 26 us fetal nuchal translucency ea addl gestation $32.38

76815 us pregnant uterus limited 1/> fetuses $57.23

76815 TC us pregnant uterus limited 1/> fetuses $35.49

76815 26 us pregnant uterus limited 1/> fetuses $21.74

76816 us preg uterus real time f/u trnsabdl per fetus $66.77

76816 TC us preg uterus real time f/u trnsabdl per fetus $38.50

76816 26 us preg uterus real time f/u trnsabdl per fetus $28.27

76817 us preg uterus real time w/image dcmtn transvag $63.34

76817 TC us preg uterus real time w/image dcmtn transvag $38.40

76817 26 us preg uterus real time w/image dcmtn transvag $24.94

76818 fetal biophysical profile non-stress testing $76.62

76818 TC fetal biophysical profile non-stress testing $41.83

76818 26 fetal biophysical profile non-stress testing $34.80

76819 fetal biophysical profile w/o non-stress testing $59.16




76819 TC fetal biophysical profile w/o non-stress testing $33.48

76819 26 fetal biophysical profile w/o non-stress testing $25.68

76820 doppler velocimetry fetal umbilical artery $34.10

76820 TC doppler velocimetry fetal umbilical artery $14.69

76820 26 doppler velocimetry fetal umbilical artery $16.60

76821 doppler velocimetry fetal middle cerebral art $61.24

76821 TC doppler velocimetry fetal middle cerebral art $38.02

76821 26 doppler velocimetry fetal middle cerebral art $23.23

76825 echo fetal cardiovasc w/wo m-mode recording $132.10

76825 TC echo fetal cardiovasc w/wo m-mode recording $76.66

76825 26 echo fetal cardiovasc w/wo m-mode recording $55.43

76826 echo fetal cardiovasc w/wo m-mode repeat std $72.67

76826 TC echo fetal cardiovasc w/wo m-mode repeat std $45.49

76826 26 echo fetal cardiovasc w/wo m-mode repeat std $27.19

76827 doppler echo fetal spectral display complete $45.24

76827 TC doppler echo fetal spectral display complete $26.07

76827 26 doppler echo fetal spectral display complete $19.17

76828 doppler echo fetal puls spectral f/u/repeat $33.77

76828 TC doppler echo fetal puls spectral f/u/repeat $15.20

76828 26 doppler echo fetal puls spectral f/u/repeat $18.57

76830 ultrasound transvaginal $70.84

76830 TC ultrasound transvaginal $38.37

76830 26 ultrasound transvaginal $23.21

76831 saline infus sonohysterography w/color doppler $75.26

76831 TC saline infus sonohysterography w/color doppler $51.52

76831 26 saline infus sonohysterography w/color doppler $23.74

76856 us pelvic nonobstetric real-time image complete $75.62

76856 TC us pelvic nonobstetric real-time image complete $52.19

76856 26 us pelvic nonobstetric real-time image complete $23.43

76857 us pelvic nonobstetric image dcmtn limited/f/u $51.95

76857 TC us pelvic nonobstetric image dcmtn limited/f/u $38.72

76857 26 us pelvic nonobstetric image dcmtn limited/f/u $13.22

76870 ultrasound scrotum & contents $74.81

76870 TC ultrasound scrotum & contents $52.87

76870 26 ultrasound scrotum & contents $21.94

76872 ultrasound transrectal $68.30

76872 TC ultrasound transrectal $36.52

76872 26 ultrasound transrectal $24.23

76873 us transrct prstate vol brachytx plnning spx $112.35

76873 TC us transrct prstate vol brachytx plnning spx $59.48

76873 26 us transrct prstate vol brachytx plnning spx $52.88

76881 us extremity non-vasc real-time img compl $76.66

76881 TC us extremity non-vasc real-time img compl $57.12

76881 26 us extremity non-vasc real-time img compl $19.54

76882 us extremity non-vasc real-time img lmtd $20.22

76882 TC us extremity non-vasc real-time img lmtd $6.67

76882 26 us extremity non-vasc real-time img lmtd $13.55

76885 us inft hips r-t img dynamic req phys/qhp manj $63.54




76885 TC us inft hips r-t img dynamic req phys/qhp manj $38.40

76885 26 us inft hips r-t img dynamic req phys/qhp manj $25.14

76886 us inft hips r-t img lmtd static phys/qhp manj $59.05

76886 TC us inft hips r-t img lmtd static phys/qhp manj $38.30

76886 26 us inft hips r-t img lmtd static phys/qhp manj $20.76

76930 us guidance pericardiocentesis rs&i $61.92

76930 TC us guidance pericardiocentesis rs&i $37.54

76930 26 us guidance pericardiocentesis rs&i $24.38

76932 us endomyocardial biopsy rs&i $62.39

76932 TC us endomyocardial biopsy rs&i $38.02

76932 26 us endomyocardial biopsy rs&i $24.38

76936 us cmprn rpr artl pseudoarysm/arven fstl $125.86

76936 TC us cmprn rpr artl pseudoarysm/arven fstl $57.55

76936 26 us cmprn rpr artl pseudoarysm/arven fstl $68.31

76937 us vasc access sits vsl patency ndl entry $22.49

76937 TC us vasc access sits vsl patency ndl entry $12.06

76937 26 us vasc access sits vsl patency ndl entry $10.43

76940 us &mntr parenchymal tissue ablation $116.03

76940 TC us &mntr parenchymal tissue ablation $41.28

76940 26 us &mntr parenchymal tissue ablation $69.90

76941 us intrauterine ftl tfuj/cordocnts img s&i $86.46

76941 TC us intrauterine ftl tfuj/cordocnts img s&i $37.91

76941 26 us intrauterine ftl tfuj/cordocnts img s&i $44.62

76942 us guidance needle placement rs&i $115.47

76942 TC us guidance needle placement rs&i $92.55

76942 26 us guidance needle placement rs&i $22.93

76945 us guidance chorionic villus sampling rs&i $61.74

76945 TC us guidance chorionic villus sampling rs&i $37.91

76945 26 us guidance chorionic villus sampling rs&i $22.25

76946 us guidance amniocentesis rs&i $27.99

76946 TC us guidance amniocentesis rs&i $12.53

76946 26 us guidance amniocentesis rs&i $12.55

76948 us guidance aspiration ova rs&i $27.99

76948 TC us guidance aspiration ova rs&i $12.84

76948 26 us guidance aspiration ova rs&i $12.55

76950 us guidance placement radiation therapy fields $44.74

76950 TC us guidance placement radiation therapy fields $19.91

76950 26 us guidance placement radiation therapy fields $19.52

76965 us guidance interstitial radioelment application $84.88

76965 TC us guidance interstitial radioelment application $22.07

76965 26 us guidance interstitial radioelment application $46.32

76975 gi endoscopic ultrasound rs&i $67.22

76975 TC gi endoscopic ultrasound rs&i $38.02

76975 26 gi endoscopic ultrasound rs&i $27.94

76977 us bone density meas & interp periph any metho $6.47

76977 TC us bone density meas & interp periph any metho $3.92

76977 26 us bone density meas & interp periph any metho $1.83

76998 ultrasonic guidance intraoperative $109.34




76998 TC ultrasonic guidance intraoperative $65.21

76998 26 ultrasonic guidance intraoperative $40.71

76999 unlisted ultrasound procedure $205.24

76999 TC unlisted ultrasound procedure $170.79

76999 26 unlisted ultrasound procedure $34.45

77001 fluoro central venous access dev placement $64.84

77001 TC fluoro central venous access dev placement $51.97

77001 26 fluoro central venous access dev placement $12.87

77002 fluoroscopic guidance needle placement $44.74

77002 TC fluoroscopic guidance needle placement $26.80

77002 26 fluoroscopic guidance needle placement $17.94

77003 fluoro needle/cath spine/paraspinal dx/ther $37.58

77003 TC fluoro needle/cath spine/paraspinal dx/ther $18.68

77003 26 fluoro needle/cath spine/paraspinal dx/ther $18.90

77011 ct guidance stereotactic localization $208.40

77011 TC ct guidance stereotactic localization $150.63

77011 26 ct guidance stereotactic localization $40.87

77012 ct guidance needle placement $119.66

77012 TC ct guidance needle placement $66.66

77012 26 ct guidance needle placement $39.83

77013 ct guidance &monitoring visc tiss ablation $364.49

77013 TC ct guidance &monitoring visc tiss ablation $222.80

77013 26 ct guidance &monitoring visc tiss ablation $137.24

77014 ct guidance radiation therapy flds placement $114.96

77014 TC ct guidance radiation therapy flds placement $74.66

77014 26 ct guidance radiation therapy flds placement $28.50

77021 mr guidance needle placement $277.59

77021 TC mr guidance needle placement $225.97

77021 26 mr guidance needle placement $51.61

77022 mr guidance &monitoring tissue ablation $446.51

77022 TC mr guidance &monitoring tissue ablation $295.14

77022 26 mr guidance &monitoring tissue ablation $143.62

77031 strtctc loclzj gid breast bx/needle placement $121.38

77031 TC strtctc loclzj gid breast bx/needle placement $46.98

77031 26 strtctc loclzj gid breast bx/needle placement $54.11

77032 mammographic gid needle placementt breast $38.02

77032 TC mammographic gid needle placementt breast $18.91

77032 26 mammographic gid needle placementt breast $19.12

77051 computer-aided detection dx mammography $7.62

77051 TC computer-aided detection dx mammography $5.54

77051 26 computer-aided detection dx mammography $2.09

77052 computer-aided detection screening mammography $7.62

77052 TC computer-aided detection screening mammography $5.54

77052 26 computer-aided detection screening mammography $2.09

77053 mammary ductogram or galactogram single $47.38

77053 TC mammary ductogram or galactogram single $35.11

77053 26 mammary ductogram or galactogram single $12.27

77054 mammary ductogram or galactogram multiple $63.79




77054 TC mammary ductogram or galactogram multiple $48.35

77054 26 mammary ductogram or galactogram multiple $15.44

77055 mammography unilateral $53.96

77055 TC mammography unilateral $30.05

77055 26 mammography unilateral $23.91

77056 mammography bilateral $68.42

77056 TC mammography bilateral $38.75

77056 26 mammography bilateral $29.67

77057 screening mammography bilateral $51.83

77057 TC screening mammography bilateral $27.92

77057 26 screening mammography bilateral $23.91

77058 mri breast unilateral $519.46

77058 TC mri breast unilateral $463.91

77058 26 mri breast unilateral $55.55

77059 mri breast bilateral $556.80

77059 TC mri breast bilateral $494.80

77059 26 mri breast bilateral $55.55

77071 manual appl stress pfrmd phys/qhp joint films $25.07

77072 bone age studies $14.86

77072 TC bone age studies $8.37

77072 26 bone age studies $6.50

77073 bone length studies $23.57

77073 TC bone length studies $14.37

77073 26 bone length studies $9.20

77074 radiologic examination osseous survey limited $43.24

77074 TC radiologic examination osseous survey limited $27.80

77074 26 radiologic examination osseous survey limited $15.44

77075 radiologic examination osseous survey compl $62.45

77075 TC radiologic examination osseous survey compl $44.06

77075 26 radiologic examination osseous survey compl $18.39

77076 radiologic examination osseous survey infant $58.80

77076 TC radiologic examination osseous survey infant $35.79

77076 26 radiologic examination osseous survey infant $23.00

77077 joint survey single view 2 or more joints $26.63

77077 TC joint survey single view 2 or more joints $16.08

77077 26 joint survey single view 2 or more joints $10.56

77078 ct bone minerl density study 1/> sits axial ske $52.62

77078 TC ct bone minerl density study 1/> sits axial ske $44.16

77078 26 ct bone minerl density study 1/> sits axial ske $8.46

77080 dxa bone density study 1/> sites axial skel $43.58

77080 TC dxa bone density study 1/> sites axial skel $36.52

77080 26 dxa bone density study 1/> sites axial skel $6.76

77081 dxa bone density study 1/>sites appendiclr skel $18.93

77081 TC dxa bone density study 1/>sites appendiclr skel $11.67

77081 26 dxa bone density study 1/>sites appendiclr skel $7.26

77082 dxa bone density study vertebral fracture $18.12

77082 TC dxa bone density study vertebral fracture $12.57

77082 26 dxa bone density study vertebral fracture $5.54




77084 bone marrow blood supply $268.21

77084 TC bone marrow blood supply $213.41

77084 26 bone marrow blood supply $54.79

77261 therapeutic radiology tx planning simple $47.46

77262 therapeutic radiology tx planning intermediate $71.32

77263 therapeutic radiology tx planning complex $105.83

77280 ther rad simulaj-aided field setting simple $114.87

77280 TC ther rad simulaj-aided field setting simple $91.29

77280 26 ther rad simulaj-aided field setting simple $23.58

77285 ther rad simulaj-aided field setting intermed $197.69

77285 TC ther rad simulaj-aided field setting intermed $162.44

77285 26 ther rad simulaj-aided field setting intermed $35.25

77290 ther rad simulaj-aided field setting complex $307.15

77290 TC ther rad simulaj-aided field setting complex $254.83

77290 26 ther rad simulaj-aided field setting complex $52.33

77295 ther rad simulaj-aided fld setting 3-dimensional $415.33

77295 TC ther rad simulaj-aided fld setting 3-dimensional $197.76

77295 26 ther rad simulaj-aided fld setting 3-dimensional $152.93

77299 29 unlis px ther radiol clinical tx planning $56.77

77300 basic radiation dosimetry calculation $45.30

77300 TC basic radiation dosimetry calculation $24.54

77300 26 basic radiation dosimetry calculation $20.76

77301 ntsty modul radthx pln dose-vol histos $1,350.76

77301 TC ntsty modul radthx pln dose-vol histos $1,082.75

77301 26 ntsty modul radthx pln dose-vol histos $268.01

77305 teletherapy isodose plan simple $46.59

77305 TC teletherapy isodose plan simple $21.76

77305 26 teletherapy isodose plan simple $23.58

77310 teletherapy isodose plan intermediate $65.04

77310 TC teletherapy isodose plan intermediate $29.45

77310 26 teletherapy isodose plan intermediate $35.25

77315 teletherapy isodose plan complete $95.10

77315 TC teletherapy isodose plan complete $42.77

77315 26 teletherapy isodose plan complete $52.33

77321 spec telethx port pln parts hemibdy tot bdy $77.04

77321 TC spec telethx port pln parts hemibdy tot bdy $39.60

77321 26 spec telethx port pln parts hemibdy tot bdy $31.82

77326 brachytherapy isodose plan simple $89.97

77326 TC brachytherapy isodose plan simple $58.88

77326 26 brachytherapy isodose plan simple $31.09

77327 brachytherapy isodose plan intermediate $128.38

77327 TC brachytherapy isodose plan intermediate $81.82

77327 26 brachytherapy isodose plan intermediate $46.56

77328 brachytherapy isodose plan complex $176.27

77328 TC brachytherapy isodose plan complex $106.13

77328 26 brachytherapy isodose plan complex $70.14

77331 spec dosim only prescribed treating phys $40.75

77331 TC spec dosim only prescribed treating phys $11.52




77331 26 spec dosim only prescribed treating phys $29.23

77332 tx devices design & construction simple $49.15

77332 TC tx devices design & construction simple $31.08

77332 26 tx devices design & construction simple $18.07

77333 tx devices design & construction intermediate $44.26

77333 TC tx devices design & construction intermediate $8.53

77333 26 tx devices design & construction intermediate $28.25

77334 tx devices design & construction complex $100.22

77334 TC tx devices design & construction complex $58.70

77334 26 tx devices design & construction complex $41.52

77336 continuing medical physics consltj pr wk $37.61

77338 mlc imrt design & construction per imrt plan $320.58

77338 TC mlc imrt design & construction per imrt plan $166.36

77338 26 mlc imrt design & construction per imrt plan $154.22

77370 spec medical radj physics consltj $71.90

77371 radiation delivery stereotactic cranial cobalt $731.33

77372 radiation delivery stereotactic cranial linear $504.37

77373 stereotactic body radiation delivery $934.54

77399 26 unlis medical radj dosim tx dev spec svcs $56.77

77401 radiation tx delivery superficial&/ortho volta $18.68

77402 radj dlvr 1 area 1/prll opsd ports smpl <5mev $83.66

77403 radj dlvr 1 area 1/prll opsd ports smpl 6-10mev $73.51

77404 radj dlvr 1 area 1/prll opsd ports smpl 11-19mev $80.95

77406 radj dlvr 1 area 1/prll opsd ports smpl 20mev/< $81.63

77407 radj dlvr 2 areas 3/>ports 1 mlt blks <5mev $131.35

77408 radj dlvr 2 areas 3/>ports 1 mlt blks 6-1mev $98.66

77409 radj dlvr 2 areas 3/>ports 1 mlt blks 11-19mev $108.81

77411 radj dlvr 2 areas 3/> ports 1 tx area 20 mev/< $108.13

77412 radj dlvr 3/> areas custom blking <5mev $127.19

77413 radj dlvr 3/> areas custom blking 6-10mev $128.09

77414 radj dlvr 3/> areas custom blking 11-19mev $142.30

77416 radj dlvr 3/> areas custom blking 20mev/< $142.98

77417 therapeutic radiology port films $9.74

77418 ntsty modul dlvr 1/mlt flds/arcs pr tx session $321.76

77421 strsc x-ray gdn loclzj target vol dlvr radj ther $68.48

77421 TC strsc x-ray gdn loclzj target vol dlvr radj ther $50.06

77421 26 strsc x-ray gdn loclzj target vol dlvr radj ther $13.03

77422 high energy neutron radj tx dlvr 1 tx area $119.75

77423 high energy neutron radj tx dlvr 1/> isocenter $137.56

77427 radiation treatment management 5 treatments $125.96

77431 radiation therapy mgmt 1/2 fractions only $64.18

77432 steretctc radiation tx management cranial lesion $267.72

77435 stereotactic body radiation management $443.84

77469 intraoperative radiation treatment management $198.85

77470 special treatment procedure $142.84

77470 TC special treatment procedure $43.29

77470 26 special treatment procedure $70.14

77600 hyperthermia external generated superficial $232.20




77600 TC hyperthermia external generated superficial $179.87

77600 26 hyperthermia external generated superficial $52.33

77605 hyperthermia external generated deep $413.70

77605 TC hyperthermia external generated deep $345.42

77605 26 hyperthermia external generated deep $68.28

77610 hyperthermia interstitial probe 5/< applicators $385.95

77610 TC hyperthermia interstitial probe 5/< applicators $334.98

77610 26 hyperthermia interstitial probe 5/< applicators $50.97

77615 hyperthermia interstial probe 5/> applicators $545.64

77615 TC hyperthermia interstial probe 5/> applicators $475.73

77615 26 hyperthermia interstial probe 5/> applicators $69.92

77620 hyperthermia intracavitary probes $242.70

77620 TC hyperthermia intracavitary probes $190.46

77620 26 hyperthermia intracavitary probes $52.24

77750 nfs/instlj radioelmnt sln 3 mo follow-up care $222.03

77750 TC nfs/instlj radioelmnt sln 3 mo follow-up care $56.33

77750 26 nfs/instlj radioelmnt sln 3 mo follow-up care $165.70

77761 intracavitary radiation source applic simple $226.57

77761 TC intracavitary radiation source applic simple $99.36

77761 26 intracavitary radiation source applic simple $127.21

77762 intracavitary radiation source applic intermed $310.25

77762 TC intracavitary radiation source applic intermed $118.02

77762 26 intracavitary radiation source applic intermed $192.23

77763 intracavitary radiation source applic complex $440.40

77763 TC intracavitary radiation source applic complex $151.88

77763 26 intracavitary radiation source applic complex $288.52

77776 interstitial radiation source applic simple $265.89

77776 TC interstitial radiation source applic simple $107.35

77776 26 interstitial radiation source applic simple $158.54

77777 interstitial radiation source applic intermed $372.98

77777 TC interstitial radiation source applic intermed $118.84

77777 26 interstitial radiation source applic intermed $254.14

77778 interstitial radiation source applic complex $535.19

77778 TC interstitial radiation source applic complex $158.01

77778 26 interstitial radiation source applic complex $377.17

77785 remote aftld radionuclide brachytx 1 channel $118.15

77785 TC remote aftld radionuclide brachytx 1 channel $70.38

77785 26 remote aftld radionuclide brachytx 1 channel $47.77

77786 remote aftld radionuclide brachytx 2-12 channel $352.90

77786 TC remote aftld radionuclide brachytx 2-12 channel $245.29

77786 26 remote aftld radionuclide brachytx 2-12 channel $107.61

77787 remote aftld radionuclide brachytx > 12 channel $524.54

77787 TC remote aftld radionuclide brachytx > 12 channel $359.43

77787 26 remote aftld radionuclide brachytx > 12 channel $165.12

77789 surface application radiation source $67.42

77789 TC surface application radiation source $29.11

77789 26 surface application radiation source $38.32

77799 unlisted procedure clinical brachytherapy $694.51




77799 26 unlisted procedure clinical brachytherapy $166.70

78012 thyroid uptake single/multiple quant measurement $52.86

78012 TC thyroid uptake single/multiple quant measurement $46.66

78012 26 thyroid uptake single/multiple quant measurement $6.20

78013 thyroid imaging with vascular flow $106.83

78013 TC thyroid imaging with vascular flow $94.84

78013 26 thyroid imaging with vascular flow $11.98

78014 thyroid uptake w/blood flow sngle/mult quan meas $154.32

78014 TC thyroid uptake w/blood flow sngle/mult quan meas $138.27

78014 26 thyroid uptake w/blood flow sngle/mult quan meas $16.05

78015 thyroid carcinoma metastases img lmtd area $125.89

78015 TC thyroid carcinoma metastases img lmtd area $102.97

78015 26 thyroid carcinoma metastases img lmtd area $22.93

78016 thyroid carcinoma metastases img addl study $190.82

78016 TC thyroid carcinoma metastases img addl study $162.76

78016 26 thyroid carcinoma metastases img addl study $28.06

78018 thyroid carcinoma metastases img whole body $192.19

78018 TC thyroid carcinoma metastases img whole body $162.77

78018 26 thyroid carcinoma metastases img whole body $29.42

78020 thyroid carcinoma metastases uptake $56.81

78020 TC thyroid carcinoma metastases uptake $36.23

78020 26 thyroid carcinoma metastases uptake $20.58

78070 parathyroid planar imaging $107.34

78070 TC parathyroid planar imaging $79.15

78070 26 parathyroid planar imaging $28.19

78071 parathyroid planar imaging w/wo subtraction $231.12

78071 TC parathyroid planar imaging w/wo subtraction $192.96

78071 26 parathyroid planar imaging w/wo subtraction $38.16

78072 26 parathyroid imaging w/tomographic spect & ct $52.91

78075 adrenal imaging cortex &/medulla $249.24

78075 TC adrenal imaging cortex &/medulla $223.87

78075 26 adrenal imaging cortex &/medulla $25.37

78099 26 unlisted endocrine px dx nuclear medicine $80.27

78102 bone marrow imaging limited area $99.04

78102 TC bone marrow imaging limited area $80.17

78102 26 bone marrow imaging limited area $18.87

78103 bone marrow imaging multiple areas $133.02

78103 TC bone marrow imaging multiple areas $107.40

78103 26 bone marrow imaging multiple areas $25.62

78104 bone marrow imaging whole body $152.26

78104 TC bone marrow imaging whole body $124.71

78104 26 bone marrow imaging whole body $27.56

78110 plasma vol radiopharm vol dilution spx 1 sample $47.15

78110 TC plasma vol radiopharm vol dilution spx 1 sample $40.65

78110 26 plasma vol radiopharm vol dilution spx 1 sample $6.50

78111 plasma vol radiopharm vol dilute spx mult smples $59.95

78111 TC plasma vol radiopharm vol dilute spx mult smples $52.24

78111 26 plasma vol radiopharm vol dilute spx mult smples $7.71




78120 red cell volume determination spx 1 sampling $53.52

78120 TC red cell volume determination spx 1 sampling $45.56

78120 26 red cell volume determination spx 1 sampling $7.96

78121 red cell volume determination spx mult samplings $64.95

78121 TC red cell volume determination spx mult samplings $54.05

78121 26 red cell volume determination spx mult samplings $10.91

78122 whole blood volume determ plasma&red cell volu $80.42

78122 TC whole blood volume determ plasma&red cell volu $64.98

78122 26 whole blood volume determ plasma&red cell volu $15.44

78130 red cell survival study $94.62

78130 TC red cell survival study $73.66

78130 26 red cell survival study $20.96

78135 rbc survival study differntl organ/tiss kinetics $195.94

78135 TC rbc survival study differntl organ/tiss kinetics $174.00

78135 26 rbc survival study differntl organ/tiss kinetics $21.94

78140 labeled rbc sequestration differntl organ/tissue $91.43

78140 TC labeled rbc sequestration differntl organ/tissue $70.47

78140 26 labeled rbc sequestration differntl organ/tissue $20.96

78185 spleen imaging only w/wo vascular flow $114.32

78185 TC spleen imaging only w/wo vascular flow $100.59

78185 26 spleen imaging only w/wo vascular flow $13.73

78190 kinetics platelet w/wo diffrntl organ/tis loclzj $138.26

78190 TC kinetics platelet w/wo diffrntl organ/tis loclzj $101.41

78190 26 kinetics platelet w/wo diffrntl organ/tis loclzj $36.86

78191 platelet survival study $121.82

78191 TC platelet survival study $101.09

78191 26 platelet survival study $20.73

78195 lymphatics & lymph nodes imaging $203.09

78195 TC lymphatics & lymph nodes imaging $161.90

78195 26 lymphatics & lymph nodes imaging $41.19

78199 26 unlis hematop ret/endo&lymphatic dx nuc med $142.52

78201 liver imaging static only $105.63

78201 TC liver imaging static only $90.90

78201 26 liver imaging static only $14.74

78202 liver imaging w/vascular flow $121.95

78202 TC liver imaging w/vascular flow $104.77

78202 26 liver imaging w/vascular flow $17.19

78205 liver imaging spect $145.70

78205 TC liver imaging spect $121.31

78205 26 liver imaging spect $24.39

78206 liver imaging spect w/vascular flow $203.76

78206 TC liver imaging spect w/vascular flow $170.91

78206 26 liver imaging spect w/vascular flow $32.85

78215 liver & spleen imaging static only $112.88

78215 TC liver & spleen imaging static only $96.20

78215 26 liver & spleen imaging static only $16.67

78216 liver & spleen imaging w/vascular flow $85.64

78216 TC liver & spleen imaging w/vascular flow $66.26




78216 26 liver & spleen imaging w/vascular flow $19.38

78226 hepatobiliary syst imaging including gallbladder $209.17

78226 TC hepatobiliary syst imaging including gallbladder $185.50

78226 26 hepatobiliary syst imaging including gallbladder $23.66

78227 hepatobil syst imag inc gb w/pharma intervenj $214.05

78227 TC hepatobil syst imag inc gb w/pharma intervenj $185.50

78227 26 hepatobil syst imag inc gb w/pharma intervenj $28.55

78230 salivary gland imaging $96.19

78230 TC salivary gland imaging $80.98

78230 26 salivary gland imaging $15.22

78231 salivary gland imaging serial images $82.22

78231 TC salivary gland imaging serial images $64.56

78231 26 salivary gland imaging serial images $17.66

78232 salivary gland function study $83.57

78232 TC salivary gland function study $67.39

78232 26 salivary gland function study $16.17

78258 esophageal motility $134.42

78258 TC esophageal motility $108.83

78258 26 esophageal motility $25.59

78261 gastric mucosa imaging $147.90

78261 TC gastric mucosa imaging $124.25

78261 26 gastric mucosa imaging $23.65

78262 gastroesophageal reflux study $145.85

78262 TC gastroesophageal reflux study $122.90

78262 26 gastroesophageal reflux study $22.95

78264 gastric emptying study $167.99

78264 TC gastric emptying study $141.39

78264 26 gastric emptying study $26.60

78267 urea breath test c-14 isotopic acquisj analysis $7.69

78268 urea breath test c-14 isotopic analysis $65.88

78268 TC urea breath test c-14 isotopic analysis $53.36

78268 26 urea breath test c-14 isotopic analysis $12.52

78270 vitamin b-12 absrpj study w/o intrinsic factor $48.57

78270 TC vitamin b-12 absrpj study w/o intrinsic factor $41.83

78270 26 vitamin b-12 absrpj study w/o intrinsic factor $6.76

78271 vitamin b-12 absrpj study w/intrinsic factor $49.03

78271 TC vitamin b-12 absrpj study w/intrinsic factor $42.50

78271 26 vitamin b-12 absrpj study w/intrinsic factor $6.52

78272 vitamin b-12 absrpj stdy w/wo intrinsic fact $55.68

78272 TC vitamin b-12 absrpj stdy w/wo intrinsic fact $46.93

78272 26 vitamin b-12 absrpj stdy w/wo intrinsic fact $8.74

78278 acute gastrointestinal blood loss imaging $183.56

78278 TC acute gastrointestinal blood loss imaging $149.73

78278 26 acute gastrointestinal blood loss imaging $33.83

78290 intestine imaging $173.84

78290 TC intestine imaging $150.44

78290 26 intestine imaging $23.40

78291 peritoneal-venous shunt patency test $148.02




78291 TC peritoneal-venous shunt patency test $117.87

78291 26 peritoneal-venous shunt patency test $30.16

78299 26 unlisted gastrointestinal px dx nuclear medicine $136.43

78300 bone &/joint imaging limited area $103.89

78300 TC bone &/joint imaging limited area $82.68

78300 26 bone &/joint imaging limited area $21.21

78305 bone &/joint imaging multiple areas $138.12

78305 TC bone &/joint imaging multiple areas $109.90

78305 26 bone &/joint imaging multiple areas $28.22

78306 bone &/joint imaging whole body $152.78

78306 TC bone &/joint imaging whole body $123.35

78306 26 bone &/joint imaging whole body $29.42

78315 bone &/joint imaging 3 phase study $186.25

78315 TC bone &/joint imaging 3 phase study $151.43

78315 26 bone &/joint imaging 3 phase study $34.82

78320 bone &/joint imaging tomographic spect $156.86

78320 TC bone &/joint imaging tomographic spect $121.31

78320 26 bone &/joint imaging tomographic spect $35.55

78350 bone density 1/> sites 1 photon absorptiometry $26.12

78351 bone densty 1/> sites dual photon absorptiometr $10.47

78399 26 unlisted musculoskeletal px dx nuclear medicine $136.44

78414 26 card-vasc hemodynam w/wo pharm/exer 1/mlt determ $14.54

78428 cardiac shunt detection $120.88

78428 TC cardiac shunt detection $93.15

78428 26 cardiac shunt detection $27.73

78445 noncardiac vascular flow imaging $101.01

78445 TC noncardiac vascular flow imaging $84.34

78445 26 noncardiac vascular flow imaging $16.67

78451 myocardial spect single study at rest or stress $213.35

78451 TC myocardial spect single study at rest or stress $166.96

78451 26 myocardial spect single study at rest or stress $46.40

78452 myocardial spect multiple studies $299.36

78452 TC myocardial spect multiple studies $244.32

78452 26 myocardial spect multiple studies $55.03

78453 myocardial perfusion planar 1 study rest/stress $183.50

78453 TC myocardial perfusion planar 1 study rest/stress $149.60

78453 26 myocardial perfusion planar 1 study rest/stress $33.89

78454 myocardial perfusion planar multiple studies $260.35

78454 TC myocardial perfusion planar multiple studies $215.48

78454 26 myocardial perfusion planar multiple studies $44.87

78456 acute venous thrombosis imaging peptide $150.98

78456 TC acute venous thrombosis imaging peptide $114.86

78456 26 acute venous thrombosis imaging peptide $36.11

78457 venous thrombosis imaging venogram unilateral $116.47

78457 TC venous thrombosis imaging venogram unilateral $90.34

78457 26 venous thrombosis imaging venogram unilateral $26.12

78458 venous thrombosis imaging venogram bilateral $128.41

78458 TC venous thrombosis imaging venogram bilateral $97.52




78458 26 venous thrombosis imaging venogram bilateral $30.88

78459 myocardial imaging pet metabolic evaluation $750.38

78459 TC myocardial imaging pet metabolic evaluation $697.24

78459 26 myocardial imaging pet metabolic evaluation $53.14

78466 myocardial imaging infarct avid planar qual/quan $111.06

78466 TC myocardial imaging infarct avid planar qual/quan $86.74

78466 26 myocardial imaging infarct avid planar qual/quan $24.33

78468 myocrd img infarct avid plnr ejec fxj 1st ps tq $139.94

78468 TC myocrd img infarct avid plnr ejec fxj 1st ps tq $111.03

78468 26 myocrd img infarct avid plnr ejec fxj 1st ps tq $28.91

78469 myocrd infarct avid plnr tomog spect w/wo quantj $158.97

78469 TC myocrd infarct avid plnr tomog spect w/wo quantj $126.35

78469 26 myocrd infarct avid plnr tomog spect w/wo quantj $32.62

78472 card blood pool gated planar 1 study rest/stress $161.76

78472 TC card blood pool gated planar 1 study rest/stress $127.27

78472 26 card blood pool gated planar 1 study rest/stress $34.48

78473 card bl pool gated mlt stdy wal motn eject fract $221.41

78473 TC card bl pool gated mlt stdy wal motn eject fract $168.90

78473 26 card bl pool gated mlt stdy wal motn eject fract $52.51

78481 card bl pool planar 1 stdy wal motn eject fract $142.22

78481 TC card bl pool planar 1 stdy wal motn eject fract $106.51

78481 26 card bl pool planar 1 stdy wal motn eject fract $35.71

78483 card bl pool plnr mlt stdy wal motn eject fract $201.10

78483 TC card bl pool plnr mlt stdy wal motn eject fract $146.90

78483 26 card bl pool plnr mlt stdy wal motn eject fract $54.19

78491 myocrd image pet perfus single study rest/stress $750.95

78491 TC myocrd image pet perfus single study rest/stress $697.24

78491 26 myocrd image pet perfus single study rest/stress $53.72

78492 myocrd image pet perfus multpl study rest/stress $764.93

78492 TC myocrd image pet perfus multpl study rest/stress $697.24

78492 26 myocrd image pet perfus multpl study rest/stress $67.70

78496 card bl pool gated 1 stdy rest rt vent ejct frct $42.38

78496 TC card bl pool gated 1 stdy rest rt vent ejct frct $19.61

78496 26 card bl pool gated 1 stdy rest rt vent ejct frct $18.06

78499 26 unlisted cardiovascular px dx nuclear medicine $168.63

78579 pulmonary ventilation imaging $111.34

78579 TC pulmonary ventilation imaging $95.74

78579 26 pulmonary ventilation imaging $15.60

78580 pulmonary perfusion imaging particulate $128.16

78580 TC pulmonary perfusion imaging particulate $102.79

78580 26 pulmonary perfusion imaging particulate $25.37

78582 pulmonary ventilation & perfusion imaging $205.77

78582 TC pulmonary ventilation & perfusion imaging $171.93

78582 26 pulmonary ventilation & perfusion imaging $33.84

78597 quant differential pulm perfusion w/wo imaging $125.99

78597 TC quant differential pulm perfusion w/wo imaging $102.63

78597 26 quant differential pulm perfusion w/wo imaging $23.36

78598 quant diff pulm prfusion & ventlaj w/wo imagin $192.89




78598 TC quant diff pulm prfusion & ventlaj w/wo imagin $166.33

78598 26 quant diff pulm prfusion & ventlaj w/wo imagin $26.55

78599 26 unlisted respiratory px dx nuclear medicine $113.83

78600 brain imaging <4 static views $105.98

78600 TC brain imaging <4 static views $90.79

78600 26 brain imaging <4 static views $15.19

78601 brain imaging <4 static views w/vascular flow $126.06

78601 TC brain imaging <4 static views w/vascular flow $108.65

78601 26 brain imaging <4 static views w/vascular flow $17.41

78605 brain imaging minimum 4 static views $117.99

78605 TC brain imaging minimum 4 static views $99.63

78605 26 brain imaging minimum 4 static views $18.36

78606 brain imaging min 4 static views w vascular flow $184.62

78606 TC brain imaging min 4 static views w vascular flow $162.68

78606 26 brain imaging min 4 static views w vascular flow $21.94

78607 brain imaging tomographic spect $222.24

78607 TC brain imaging tomographic spect $180.20

78607 26 brain imaging tomographic spect $42.04

78608 brain imaging pet metabolic evaluation $676.13

78608 TC brain imaging pet metabolic evaluation $624.89

78608 26 brain imaging pet metabolic evaluation $51.24

78609 brain imaging pet perfusion evaluation $676.13

78609 TC brain imaging pet perfusion evaluation $624.89

78609 26 brain imaging pet perfusion evaluation $51.24

78610 brain imaging vascular flow only $106.79

78610 TC brain imaging vascular flow only $96.16

78610 26 brain imaging vascular flow only $10.63

78630 cerebrospinal fluid flow w/o matl cisternography $195.85

78630 TC cerebrospinal fluid flow w/o matl cisternography $172.45

78630 26 cerebrospinal fluid flow w/o matl cisternography $23.40

78635 cerebrospinal fluid flow w/o matl ventriclgraphy $178.58

78635 TC cerebrospinal fluid flow w/o matl ventriclgraphy $157.53

78635 26 cerebrospinal fluid flow w/o matl ventriclgraphy $21.06

78645 cerebrospinal fluid flow w/o matl shunt evaltj $134.84

78645 TC cerebrospinal fluid flow w/o matl shunt evaltj $115.24

78645 26 cerebrospinal fluid flow w/o matl shunt evaltj $19.60

78647 cerebrospinal fluid flow w/o matl tomog spect $206.98

78647 TC cerebrospinal fluid flow w/o matl tomog spect $176.32

78647 26 cerebrospinal fluid flow w/o matl tomog spect $30.66

78650 cerebrospinal fluid leak detection&localizatio $191.00

78650 TC cerebrospinal fluid leak detection&localizatio $170.04

78650 26 cerebrospinal fluid leak detection&localizatio $20.96

78660 radiopharmaceutical dacryocystography $100.11

78660 TC radiopharmaceutical dacryocystography $81.98

78660 26 radiopharmaceutical dacryocystography $18.14

78699 26 unlisted nervous system px dx nuclear medicine $108.46

78700 kidney imaging morphology $105.13

78700 TC kidney imaging morphology $89.69




78700 26 kidney imaging morphology $15.44

78701 kidney imaging morphoogy w/vascular flow $125.78

78701 TC kidney imaging morphoogy w/vascular flow $109.10

78701 26 kidney imaging morphoogy w/vascular flow $16.67

78707 kidney img morphology vascular flow 1 w/o rx $147.31

78707 TC kidney img morphology vascular flow 1 w/o rx $114.46

78707 26 kidney img morphology vascular flow 1 w/o rx $32.85

78708 kidney img morphology vascular flow 1 w/rx $120.83

78708 TC kidney img morphology vascular flow 1 w/rx $79.28

78708 26 kidney img morphology vascular flow 1 w/rx $41.54

78709 kidney img morphology vascular flow multiple $217.31

78709 TC kidney img morphology vascular flow multiple $169.02

78709 26 kidney img morphology vascular flow multiple $48.29

78710 kidney imaging morphology tomographic $144.43

78710 TC kidney imaging morphology tomographic $121.77

78710 26 kidney imaging morphology tomographic $22.67

78725 kidney funcj study non-img radioisotopic study $61.26

78725 TC kidney funcj study non-img radioisotopic study $48.49

78725 26 kidney funcj study non-img radioisotopic study $12.78

78730 urinary bladder residual study $46.74

78730 TC urinary bladder residual study $40.90

78730 26 urinary bladder residual study $5.84

78740 ureteral reflux study rp voiding cystogram $125.37

78740 TC ureteral reflux study rp voiding cystogram $105.65

78740 26 ureteral reflux study rp voiding cystogram $19.73

78761 testicular imaging with vascular flow $125.92

78761 TC testicular imaging with vascular flow $101.54

78761 26 testicular imaging with vascular flow $24.39

78799 26 unlisted genitourinary px dx nuclear medicine $179.24

78800 rp loclzj tumor/dstrbj agent limited area $112.50

78800 TC rp loclzj tumor/dstrbj agent limited area $90.16

78800 26 rp loclzj tumor/dstrbj agent limited area $22.34

78801 rp loclzj tumor/dstrbj agent multiple areas $150.45

78801 TC rp loclzj tumor/dstrbj agent multiple areas $123.35

78801 26 rp loclzj tumor/dstrbj agent multiple areas $27.10

78802 rp loclzj tumor/dstrbj agent whole bdy 1 day $196.60

78802 TC rp loclzj tumor/dstrbj agent whole bdy 1 day $167.18

78802 26 rp loclzj tumor/dstrbj agent whole bdy 1 day $29.42

78803 rp loclzj tumor/dstrbj agent tomog spect $216.91

78803 TC rp loclzj tumor/dstrbj agent tomog spect $179.52

78803 26 rp loclzj tumor/dstrbj agent tomog spect $37.38

78804 rp loclzj tumor/dstrbj agt whol bdy req 2/> day $346.19

78804 TC rp loclzj tumor/dstrbj agt whol bdy req 2/> day $309.44

78804 26 rp loclzj tumor/dstrbj agt whol bdy req 2/> day $36.76

78805 rp loclzj inflammatory process limited area $113.02

78805 TC rp loclzj inflammatory process limited area $88.13

78805 26 rp loclzj inflammatory process limited area $24.89

78806 rp loclzj inflammatory process whole body $205.57




78806 TC rp loclzj inflammatory process whole body $176.14

78806 26 rp loclzj inflammatory process whole body $29.42

78807 rp loclzj inflammatory process tomog spect $217.23

78807 TC rp loclzj inflammatory process tomog spect $179.75

78807 26 rp loclzj inflammatory process tomog spect $37.49

78808 njx rp loclzj non-img probe study intravenous $27.81

78811 pet imaging limited area chest head/neck $678.22

78811 TC pet imaging limited area chest head/neck $624.89

78811 26 pet imaging limited area chest head/neck $53.32

78812 pet imaging skull base to mid-thigh $691.44

78812 TC pet imaging skull base to mid-thigh $624.89

78812 26 pet imaging skull base to mid-thigh $66.55

78813 pet imaging whole body $693.88

78813 TC pet imaging whole body $624.89

78813 26 pet imaging whole body $68.99

78814 pet imaging ct for attenuation limited area $700.51

78814 TC pet imaging ct for attenuation limited area $624.89

78814 26 pet imaging ct for attenuation limited area $75.62

78815 pet imaging ct attenuation skull base mid-thigh $708.60

78815 TC pet imaging ct attenuation skull base mid-thigh $624.89

78815 26 pet imaging ct attenuation skull base mid-thigh $83.71

78816 pet imaging for ct attenuation whole body $710.79

78816 TC pet imaging for ct attenuation whole body $624.89

78816 26 pet imaging for ct attenuation whole body $85.90

78999 26 unlisted miscellaneous px dx nuclear medicine $62.05

79005 rp therapy oral administration $98.68

79005 TC rp therapy oral administration $37.81

79005 26 rp therapy oral administration $60.87

79101 rp therapy intravenous administration $111.06

79101 TC rp therapy intravenous administration $41.20

79101 26 rp therapy intravenous administration $69.87

79200 rp therapy inracavitary administration $112.62

79200 TC rp therapy inracavitary administration $44.35

79200 26 rp therapy inracavitary administration $68.27

79300 26 rp therapy interstitial radioactive colloid admn $55.08

79403 rp ther radiolbld monoclonal antibody iv infus $140.50

79403 TC rp ther radiolbld monoclonal antibody iv infus $62.84

79403 26 rp ther radiolbld monoclonal antibody iv infus $77.66

79440 rp therapy intra-articular administration $104.38

79440 TC rp therapy intra-articular administration $36.23

79440 26 rp therapy intra-articular administration $68.15

79445 rp therapy intra-arterial particulate admn $152.75

79445 TC rp therapy intra-arterial particulate admn $66.17

79445 26 rp therapy intra-arterial particulate admn $82.60

79999 26 rp therapy unlisted procedure $120.27

93005 ecg routine ecg w/least 12 lds trcg only w/o i&r $7.24

93880 duplex scan extracranial art compl bi study $113.89

93880 TC duplex scan extracranial art compl bi study $93.29




93880 26 duplex scan extracranial art compl bi study $20.61

93925 dup-scan lxtr art/artl bpgs compl bi study $113.32

93925 TC dup-scan lxtr art/artl bpgs compl bi study $93.67

93925 26 dup-scan lxtr art/artl bpgs compl bi study $19.65

93970 dup-scan xtr veins complete bilateral study $116.08

93970 TC dup-scan xtr veins complete bilateral study $92.98

93970 26 dup-scan xtr veins complete bilateral study $23.10

93971 dup-scan xtr veins unilateral/limited study $74.61

93971 TC dup-scan xtr veins unilateral/limited study $59.28

93971 26 dup-scan xtr veins unilateral/limited study $15.34

93978 dup-scan aorta ivc iliac vascl/bpgs complete $115.10

93978 TC dup-scan aorta ivc iliac vascl/bpgs complete $92.98

93978 26 dup-scan aorta ivc iliac vascl/bpgs complete $22.11

A9552 Flurodeoxyglucose F-18 fdg, diag 45 mCi $315.00

A9577 Injection multihance per ml $1.95

A9579 Gadolinium-base MR contrast NOS,1ml $1.64

G0202 Screening Mammogram, digital bilateral $82.04

G0202 TC Screening Mammogram, digital bilateral $58.58

G0202 26 Screening Mammogram, digital bilateral $23.46

G0204 Diagnostic Mammogram, digital bilateral $96.60

G0204 TC Diagnostic Mammogram, digital bilateral $67.61

G0204 26 Diagnostic Mammogram, digital bilateral $29.00

G0206 Diagnostic Mammogram, digital unilateral $76.73

G0206 TC Diagnostic Mammogram, digital unilateral $53.28

G0206 26 Diagnostic Mammogram, digital unilateral $23.46

Documents

Medical Imaging Services Fee Schedule