Procedure
CodeModifier Code Description Rate End Date
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)
Procedure
CodeModifier Code Description Rate End Date
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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 12/31/2013
75960 TC tcat stent iliac/low ext art prq/opn rsi ea vsl $79.58 12/31/2013
75960 26 tcat stent iliac/low ext art prq/opn rsi ea vsl $28.54 12/31/2013
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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 12/31/2013
77031 TC strtctc loclzj gid breast bx/needle placement $46.98 12/31/2013
77031 26 strtctc loclzj gid breast bx/needle placement $54.11 12/31/2013
77032 mammographic gid needle placementt breast $38.02 12/31/2013
77032 TC mammographic gid needle placementt breast $18.91 12/31/2013
77032 26 mammographic gid needle placementt breast $19.12 12/31/2013
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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 26 unlisted 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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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 unlisted 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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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 unlisted 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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
Procedure
CodeModifier Code Description Rate End Date
Medical Imaging Services Fee Schedule
Effective September 1, 2010 (Updated 04/01/13)
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
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