70450 | CT scan, head or brain, without contrast | $1,757.20 | $162.75 |
70553 | MRI scan of brain before and after contrast | $3,353.70 | $561.80 |
72110 | X-Ray, lower back, minimum four views | $570.60 | $163.41 |
72148 | MRI scan of lower spinal canal | $2,681.60 | $356.34 |
72193 | CT scan, pelvis, with contrast | $2,058.95 | $274.89 |
73721 | MRI scan of leg joint | $2,493.65 | $356.04 |
74177 | CT scan of abdomen and pelvis with contrast | $2,009.55 | $561.59 |
76700 | Ultrasound of abdomen | $826.05 | $325.50 |
76805 | Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus | $738.50 | $325.65 |
76830 | Ultrasound pelvis through vagina | $561.35 | $325.50 |
70030 | X-ray eye for foreign body | $175.10 | $132.42 |
70100 | X-ray exam of jaw <4views | $321.35 | $129.81 |
70110 | X-ray exam of jaw 4/> views | $399.65 | $157.17 |
70130 | X-ray exam of mastoids 4> views | $337.85 | $157.17 |
70140 | X-ray exam of facial bones < 3views | $332.70 | $133.01 |
70150 | X-ray exam of facial bones > 3 views | $443.95 | $157.17 |
70160 | X-ray exam of nasal bones minimum 3 views | $338.85 | $130.15 |
70190 | X-ray exam of eye sockets bilateral | $152.45 | $129.67 |
70200 | X-ray exam of eye sockets bilateral minimum 4 views | $390.35 | $162.89 |
70210 | X-ray exam of sinuses < 3 views | $218.55 | $132.42 |
70220 | X-ray exam of sinuses > 3 views | $291.50 | $132.42 |
70240 | X-ray exam pituitary saddle | $125.65 | $132.42 |
70250 | X-ray exam of skull < 4 views | $353.30 | $163.47 |
70260 | X-ray exam of skull > 4 views | $524.25 | $162.89 |
70328 | X-ray exam of jaw joint Unilateral | $433.10 | $132.42 |
70330 | X-ray exam of jaw joints Bilateral | $639.10 | $132.35 |
70336 | MRI TMJ | $1,821.05 | $355.97 |
70360 | X-ray exam of neck | $281.20 | $133.01 |
70450 | Ct head/brain w/o dye | $1,757.20 | $162.75 |
70460 | Ct head/brain w/dye | $1,651.10 | $274.89 |
70470 | Ct head/brain w/o & w/dye | $1,911.70 | $274.97 |
70480 | Ct orbit/ear/fossa w/o dye | $1,443.05 | $162.75 |
70481 | Ct orbit/ear/fossa w/dye | $2,010.55 | $275.48 |
70482 | Ct orbit/ear/fossa w/o&w/dye | $2,799.55 | $274.89 |
70486 | Ct maxillofacial w/o dye | $1,925.05 | $162.75 |
70487 | Ct maxillofacial w/dye | $2,068.25 | $275.40 |
70488 | Ct maxillofacial w/o & w/dye | $2,468.90 | $275.48 |
70490 | Ct soft tissue neck w/o dye | $1,348.25 | $162.75 |
70491 | Ct soft tissue neck w/dye | $1,878.70 | $274.97 |
70492 | Ct sft tsue nck w/o & w/dye | $2,143.45 | $274.89 |
70496 | Ct angiography head | $1,472.90 | $274.97 |
70498 | Ct angiography neck | $1,359.60 | $274.97 |
70540 | Mri orbit/face/neck w/o dye | $1,873.55 | $356.55 |
70542 | Mri orbit/face/neck w/dye | $2,810.85 | $561.59 |
70543 | Mri orbt/fac/nck w/o &w/dye | $2,343.25 | $562.31 |
70544 | Mr angiography head w/o dye | $1,888.00 | $356.04 |
70545 | Mr angiography head w/dye | $2,094.00 | $561.93 |
70546 | Mr angiograph head w/o&w/dye | $3,145.60 | $561.72 |
70547 | Mr angiography neck w/o dye | $1,806.60 | $356.04 |
70548 | Mr angiography neck w/dye | $2,630.60 | $562.46 |
70549 | Mr angiograph neck w/o&w/dye | $2,636.80 | $561.72 |
70551 | Mri brain stem w/o dye | $1,823.10 | $356.04 |
70552 | Mri brain stem w/dye | $2,126.95 | $561.87 |
70553 | Mri brain stem w/o & w/dye | $3,353.70 | $552.25 |
71045 | X-ray exam chest 1 view | $487.50 | $133.08 |
71046 | X-ray exam chest 2 views | $322.40 | $133.01 |
71047 | X-ray exam chest 3 views | $355.35 | $132.93 |
71048 | X-ray exam chest 4+ views | $482.05 | $162.89 |
71100 | X-ray exam ribs uni 2 views | $305.90 | $132.42 |
71101 | X-ray exam unilat ribs/chest | $401.70 | $162.89 |
71110 | X-ray exam ribs bil 3 views | $679.80 | $162.89 |
71111 | X-ray exam ribs/chest4/> vws | $764.75 | $163.41 |
71120 | X-ray exam breastbone 2/>vws | $253.40 | $132.42 |
71130 | X-ray strenoclavic jt 3/>vws | $303.85 | $132.93 |
71250 | Ct thorax w/o dye | $1,591.35 | $162.75 |
71260 | Ct thorax w/dye | $2,276.30 | $274.97 |
71270 | Ct thorax w/o & w/dye | $2,585.30 | $274.89 |
71275 | Ct angiography chest | $1,773.65 | $274.97 |
72020 | X-ray exam of spine 1 view | $266.75 | $132.56 |
72040 | X-ray exam neck spine 2-3 vw | $316.20 | $132.42 |
72050 | X-ray exam neck spine 4/5vws | $442.90 | $163.41 |
72052 | X-ray exam neck spine 6/>vws | $542.80 | $162.83 |
72070 | X-ray exam thorac spine 2vws | $395.50 | $162.96 |
72072 | X-ray exam thorac spine 3vws | $393.45 | $163.47 |
72074 | X-ray exam thorac spine4/>vw | $288.40 | $162.89 |
72080 | X-ray exam thoracolmb 2/> vw | $319.30 | $132.42 |
72081 | X-ray exam entire spi 1 vw | $200.00 | $132.93 |
72082 | X-ray exam entire spi 2/3 vw | $501.60 | $163.34 |
72083 | X-ray exam entire spi 4/5 vw | $604.60 | $163.34 |
72084 | X-ray exam entire spi 6/> vw | $656.10 | $163.41 |
72100 | X-ray exam l-s spine 2/3 vws | $428.50 | $163.47 |
72110 | X-ray exam l-2 spine 4/>vws | $570.60 | $163.41 |
72114 | X-ray exam l-s spine bending | $620.05 | $162.83 |
72120 | X-ray bend only l-s spine | $529.40 | $162.89 |
72125 | Ct neck spine w/o dye | $1,572.80 | $162.75 |
72126 | Ct neck spine w/dye | $2,190.80 | $561.80 |
72127 | Ct neck spine w/o & w/dye | $2,849.00 | $274.89 |
72128 | Ct chest spine w/o dye | $1,597.55 | $162.75 |
72129 | Ct chest spine w/dye | $2,225.85 | $274.97 |
72130 | Ct chest spine w/o & w/dye | $3,093.10 | $274.89 |
72131 | Ct lumbar spine w/o dye | $1,752.05 | $162.75 |
72132 | Ct lumbar spine w/dye | $2,440.05 | $561.80 |
72133 | Ct lumbar spine w/o & w/dye | $3,400.05 | $274.89 |
72141 | Mri neck spine w/o dye | $2,232.00 | $356.63 |
72142 | Mri neck spine w/dye | $2,564.70 | $562.17 |
72146 | Mri chest spine w/o dye | $2,012.60 | $356.63 |
72147 | Mri chest spine w/dye | $2,048.65 | $562.17 |
72148 | Mri lumbar spine w/o dye | $2,681.60 | $356.04 |
72149 | Mri lumbar spine w/dye | $2,626.50 | $412.17 |
72156 | Mri neck spine w/o & w/dye | $3,101.35 | $561.80 |
72157 | Mri chest spine w/o & w/dye | $2,679.05 | $561.80 |
72158 | Mri lumbar spine w/o & w/dye | $2,962.30 | $561.80 |
72159 | Mr angio spine w/o&w/dye | $2,409.15 | $561.72 |
72170 | X-ray exam of pelvis 1 or 2 views | $217.35 | $163.04 |
72190 | X-ray exam of pelvis minimum 3 views | $306.95 | $162.89 |
72191 | Ct angiograph pelv w/o&w/dye | $1,650.05 | $274.97 |
72192 | Ct pelvis w/o dye | $1,831.35 | $162.75 |
72193 | Ct pelvis w/dye | $2,058.95 | $274.89 |
72194 | Ct pelvis w/o & w/dye | $2,080.60 | $275.40 |
72195 | Mri pelvis w/o dye | $2,017.75 | $356.04 |
72196 | Mri pelvis w/dye | $2,431.85 | $562.17 |
72197 | Mri pelvis w/o & w/dye | $2,479.20 | $562.31 |
72198 | Mr angio pelvis w/o & w/dye | $1,609.90 | $561.72 |
72200 | X-ray exam si joints < 3 views | $297.65 | $162.96 |
72202 | X-ray exam si joints 3/> vws | $327.55 | $163.47 |
72220 | X-ray exam sacrum tailbone | $310.05 | $132.42 |
73000 | X-ray exam of collar bone | $323.40 | $132.42 |
73010 | X-ray exam of shoulder blade | $303.85 | $163.68 |
73020 | X-ray exam of shoulder 1 view | $290.45 | $133.14 |
73030 | X-ray exam of shoulder Minimum 2 views | $329.60 | $132.42 |
73060 | X-ray exam of humerus | $301.80 | $132.42 |
73070 | X-ray exam of elbow 2 views | $233.80 | $132.50 |
73080 | X-ray exam of elbow minimum 3 views | $282.20 | $132.42 |
73090 | X-ray exam of forearm 2 views | $276.05 | $133.01 |
73092 | X-ray exam of arm infant | $251.30 | $162.96 |
73100 | X-ray exam of wrist 2 views | $258.55 | $132.42 |
73110 | X-ray exam of wrist minimum 3 views | $300.75 | $132.93 |
73120 | X-ray exam of hand 2 views | $252.35 | $162.96 |
73130 | X-ray exam of hand minimum 3 views | $279.15 | $132.42 |
73140 | X-ray exam of finger(s) Minimum 2 views | $241.00 | $132.93 |
73200 | Ct upper extremity w/o dye | $1,417.30 | $163.26 |
73201 | Ct upper extremity w/dye | $1,980.70 | $562.25 |
73202 | Ct uppr extremity w/o&w/dye | $2,285.55 | $274.89 |
73206 | Ct angio upr extrm w/o&w/dye | $1,255.55 | $274.97 |
73218 | Mri upper extremity w/o dye | $2,426.70 | $356.63 |
73219 | Mri upper extremity w/dye | $3,380.45 | $561.72 |
73220 | Mri uppr extremity w/o&w/dye | $2,395.80 | $561.66 |
73221 | Mri joint upr extrem w/o dye | $2,251.60 | $356.04 |
73222 | Mri joint upr extrem w/dye | $2,387.55 | $1,149.84 |
73223 | Mri joint upr extr w/o&w/dye | $2,592.50 | $562.25 |
73225 | Mr angio upr extr w/o&w/dye | $2,359.75 | $561.72 |
73501 | X-ray exam hip uni 1 view | $234.85 | $132.42 |
73502 | X-ray exam hip uni 2-3 views | $327.55 | $132.35 |
73503 | X-ray exam hip uni 4/> views | $379.05 | $162.83 |
73521 | X-ray exam hips bi 2 views | $693.45 | $162.89 |
73522 | X-ray exam hips bi 3-4 views | $796.45 | $163.41 |
73523 | X-ray exam hips bi 5/> views | $899.45 | $162.83 |
73551 | X-ray exam of femur 1 view | $192.60 | $132.50 |
73552 | X-ray exam of femur 2/> | $213.20 | $132.42 |
73560 | X-ray exam of knee 1 or 2 views | $252.35 | $132.42 |
73562 | X-ray exam of knee 3 | $309.00 | $132.93 |
73564 | X-ray exam knee 4 or more | $345.05 | $163.41 |
73565 | X-ray exam of knees bilateral standing | $321.35 | $132.93 |
73590 | X-ray exam of lower leg Tibia and Fibula 2 views | $294.60 | $132.42 |
73592 | X-ray exam of leg infant | $276.05 | $132.42 |
73600 | X-ray exam of ankle 2 views | $271.90 | $132.42 |
73610 | X-ray exam of ankle minimum 3 views | $291.50 | $132.42 |
73620 | X-ray exam of foot 2 views | $264.70 | $132.50 |
73630 | X-ray exam of foot minimum 3 views | $299.75 | $132.42 |
73650 | X-ray exam of heel 2 views | $256.45 | $132.50 |
73660 | X-ray exam of toe(s) 2 views | $245.15 | $133.01 |
73700 | Ct lower extremity w/o dye | $1,602.70 | $162.75 |
73701 | Ct lower extremity w/dye | $1,483.20 | $274.96 |
73702 | Ct lwr extremity w/o&w/dye | $1,717.00 | $274.89 |
73706 | Ct angio lwr extr w/o&w/dye | $1,510.00 | $274.97 |
73718 | Mri lower extremity w/o dye | $2,084.70 | $356.04 |
73719 | Mri lower extremity w/dye | $2,201.10 | $562.17 |
73720 | Mri lwr extremity w/o&w/dye | $2,613.10 | $562.31 |
73721 | Mri jnt of lwr extre w/o dye | $2,493.65 | $356.04 |
73722 | Mri joint of lwr extr w/dye | $2,714.05 | $1,143.91 |
73723 | Mri joint lwr extr w/o&w/dye | $294.75 | $562.25 |
74018 | X-ray exam abdomen 1 view | $260.60 | $132.50 |
74019 | X-ray exam abdomen 2 views | $309.00 | $162.96 |
74021 | X-ray exam abdomen 3+ views | $482.10 | $162.89 |
74022 | X-ray exam series abdomen | $480.00 | $162.89 |
74150 | Ct abdomen w/o dye | $1,899.55 | $162.75 |
74160 | Ct abdomen w/dye | $2,573.95 | $274.89 |
74170 | Ct abdomen w/o & w/dye | $2,790.25 | $275.40 |
74174 | Ct angio abd&pelv w/o&w/dye | $3,027.15 | $561.72 |
74175 | Ct angio abdom w/o & w/dye | $1,997.15 | $274.97 |
74176 | Ct abd & pelvis w/o contrast | $2,111.50 | $356.12 |
74177 | Ct abd & pelv w/contrast | $2,009.55 | $561.59 |
74178 | Ct abd & pelv 1/> regns | $2,729.50 | $562.10 |
74181 | Mri abdomen w/o dye | $2,479.20 | $356.04 |
74182 | Mri abdomen w/dye | $2,816.00 | $561.80 |
74183 | Mri abdomen w/o & w/dye | $3,239.60 | $562.31 |
74185 | Mri angio abdom w orw/o dye | $2,278.35 | $561.72 |
75635 | Ct angio abdominal arteries | $1,801.45 | $274.89 |
76010 | X-ray nose to rectum | $175.10 | $132.50 |
76380 | Cat scan follow-up study | $245.15 | $132.29 |
76536 | Us exam of head and neck | $593.30 | $162.75 |
76604 | Us exam chest | $254.40 | $163.47 |
76700 | Us exam abdom complete | $826.05 | $162.75 |
76705 | Echo exam of abdomen | $647.85 | $163.34 |
76770 | Us exam abdo back wall comp | $406.85 | $162.75 |
76775 | Us exam abdo back wall lim | $406.85 | $162.89 |
76776 | Us exam k transpl w/doppler | $358.45 | $188.25 |
76801 | Ob us < 14 wks single fetus | $345.05 | $162.75 |
76802 | Ob us < 14 wks addl fetus | $186.45 | $162.75 |
76805 | Ob us >/= 14 wks sngl fetus | $738.50 | $162.83 |
76810 | Ob us >/= 14 wks addl fetus | $443.95 | $162.83 |
76815 | Ob us limited fetus(s) | $416.10 | $162.83 |
76816 | Ob us follow-up per fetus | $453.20 | $162.75 |
76817 | Transvaginal us obstetric | $520.90 | $163.34 |
76830 | Transvaginal us non-ob | $561.35 | $162.75 |
76856 | Us exam pelvic complete | $707.60 | $162.75 |
76857 | Us exam pelvic limited | $431.55 | $162.96 |
76870 | Us exam scrotum | $573.70 | $162.75 |
76881 | Us xtr non-vasc complete | $573.70 | $163.31 |
76881 | Us compl joint r-t w/img | $367.70 | $163.31 |
76882 | Us xtr non-vasc lmtd | $417.40 | $163.46 |
76882 | Us lmtd jt/nonvasc xtr strux | $417.40 | $163.46 |
77072 | X-rays for bone age | $226.60 | $163.10 |
77073 | X-rays bone length studies | $328.55 | $162.89 |
77074 | X-rays bone survey limited | $395.50 | $162.83 |
77075 | X-rays bone survey complete | $515.00 | $163.41 |
77076 | X-rays bone survey infant | $304.90 | $163.41 |
93880 | Extracranial bilat study | $914.40 | $356.25 |
93882 | Extracranial uni/ltd study | $447.00 | $162.83 |
93923 | Upr/lxtr art stdy 3+ lvls | $708.65 | $362.28 |
93924 | Lwr xtr vasc stdy bilat | $543.85 | $362.42 |
93925 | Lower extremity study | $698.65 | $356.12 |
93926 | Lower extremity study | $684.65 | $163.34 |
93930 | Upper extremity study | $539.70 | $356.25 |
93931 | Upper extremity study | $533.55 | $162.83 |
93970 | Extremity study | $991.70 | $356.25 |
93971 | Extremity study | $764.25 | $162.83 |
93975 | Vascular study | $636.00 | $356.12 |
93978 | Vascular study | $410.95 | $356.26 |
93979 | Vascular study | $349.40 | $162.83 |