|
Wound therapy negative pressure per session <= 50 sq cm
|
$770.10 |
$770.10 |
$770.10 |
$558.97
|
|
Wound therapy negative pressure per session > 50 sq cm
|
$760.92 |
$760.92 |
$760.92 |
$611.25
|
|
Wound therapy negative pressure per session <= 50 sq cm dme
|
$1,166.37 |
$1,166.37 |
$1,166.37 |
$288.91
|
|
Wound therapy negative pressure per session > 50 sq cm dme
|
$1,265.31 |
$1,265.31 |
$1,265.31 |
$436.15
|
|
Wrist X-ray
|
$993.99 |
$993.99 |
$993.99 |
$343.70
|
|
Xfer tis f/c/c/m/n/a/g/h/f 10sq cm/<
|
$3,760.74 |
$3,760.74 |
$3,760.74 |
$2,830.00
|
|
Xfer tis s/a/l 10 sq cm/<
|
$3,738.30 |
$3,738.30 |
$3,738.30 |
$2,623.24
|
|
X-ray abdomen 1 view
|
$343.74 |
$343.74 |
$343.74 |
$255.00
|
|
X-ray abdomen 2 views
|
$1,083.75 |
$1,083.75 |
$1,083.75 |
$312.36
|
|
X-ray abdomen >=3 views
|
$1,448.40 |
$1,448.40 |
$1,448.40 |
$332.15
|
|
X-ray abdomen complete acute series including spine erect and/or decubitus single view chest
|
$1,448.40 |
$1,448.40 |
$1,448.40 |
$418.63
|
|
X-ray acromioclavicular joints without or w/weighted distraction bilateral
|
$1,051.11 |
$1,051.11 |
$1,051.11 |
$271.44
|
|
X-ray ankle 2 views (both sides)
|
$750.72 |
$750.72 |
$750.72 |
$283.00
|
|
X-ray arthrogram shoulder supervision & interpretation (both sides)
|
$610.98 |
$610.98 |
$610.98 |
$768.30
|
|
X-ray bone age studies
|
$750.21 |
$750.21 |
$750.21 |
$246.75
|
|
X-ray bone length studies
|
$694.62 |
$694.62 |
$694.62 |
$287.25
|
|
X-ray bone survey complete
|
$2,262.87 |
$2,262.87 |
$2,262.87 |
$666.60
|
|
X-ray bone survey infant
|
$1,112.82 |
$1,112.82 |
$1,112.82 |
$410.73
|
|
X-ray cervical spine 2-3 views
|
$1,143.42 |
$1,143.42 |
$1,143.42 |
$326.04
|
|
X-ray cervical spine 4-5 views
|
$2,043.57 |
$2,043.57 |
$2,043.57 |
$455.65
|
|
X-ray cervical spine >= 6 views
|
$2,210.34 |
$2,210.34 |
$2,210.34 |
$515.35
|
|
X-ray clavicle complete (both sides)
|
$1,125.06 |
$1,125.06 |
$1,125.06 |
$299.65
|
|
X-ray colon abdominal radiograph(s) & delayed images single contrast study
|
$1,015.41 |
$1,015.41 |
$1,015.41 |
$647.40
|
|
X-ray colon abdominal radiograph(s) & delayed images with glucagon double contrast study
|
$1,197.48 |
$1,197.48 |
$1,197.48 |
$820.15
|
|
X-ray elbow 2 views (both sides)
|
$811.41 |
$811.41 |
$811.41 |
$291.94
|
|
X-ray elbow >= 3 views (both sides)
|
$945.54 |
$945.54 |
$945.54 |
$342.00
|
|
X-ray esophogram chest radiograph(s) & delayed images single contrast study
|
$800.70 |
$800.70 |
$800.70 |
$486.24
|
|
X-ray exam entire spi 4/5 vw
|
$1,569.27 |
$1,569.27 |
$1,569.27 |
$486.01
|
|
X-ray exam entire spi 6/> vw
|
$1,569.27 |
$1,569.27 |
$1,569.27 |
$575.76
|
|
X-ray exam of arm infant
|
$148.92 |
$148.92 |
$148.92 |
$248.82
|
|
X-ray exam of eye sockets
|
$1,557.54 |
$1,557.54 |
$1,557.54 |
$349.05
|
|
X-ray exam of femur 1
|
$557.94 |
$557.94 |
$557.94 |
$232.36
|
|
X-ray exam of jaw joint
|
$1,538.67 |
$1,538.67 |
$1,538.67 |
$192.39
|
|
X-ray exam of sinuses
|
$247.86 |
$247.86 |
$247.86 |
$211.00
|
|
X-ray exam si joints
|
$773.16 |
$773.16 |
$773.16 |
$246.16
|
|
X-ray exam thorac spine4/>vw
|
$1,786.53 |
$1,786.53 |
$1,786.53 |
$395.59
|
|
X-ray eye detection foreign body (both sides)
|
$444.21 |
$444.21 |
$444.21 |
$235.00
|
|
X-ray facial bones complete > 3 views
|
$1,415.76 |
$1,415.76 |
$1,415.76 |
$366.60
|
|
X-ray femur >=2 views (both sides)
|
$976.14 |
$976.14 |
$976.14 |
$304.15
|
|
X-ray finger(s) >= 2 views (both sides)
|
$678.30 |
$678.30 |
$678.30 |
$262.40
|
|
X-ray foot 2 views (both sides)
|
$756.33 |
$756.33 |
$756.33 |
$288.40
|
|
X-ray forearm 2 views (both sides)
|
$926.16 |
$926.16 |
$926.16 |
$319.00
|
|
X-ray hand 2 views (both sides)
|
$484.50 |
$484.50 |
$484.50 |
$316.50
|
|
X-ray heel/calcaneus > 2 views (both sides)
|
$1,209.72 |
$1,209.72 |
$1,209.72 |
$270.00
|
|
X-ray hip uni w/wo pelvis min 4 views
|
$823.65 |
$823.65 |
$823.65 |
$370.80
|
|
X-ray hip with pelvis when performed bilateral 2 views
|
$823.65 |
$823.65 |
$823.65 |
$350.35
|
|
X-ray hip with pelvis when performed bilateral 3-4 views
|
$869.04 |
$869.04 |
$869.04 |
$409.24
|
|
X-ray hip with pelvis when performed bilateral >= 5 views
|
$1,569.27 |
$1,569.27 |
$1,569.27 |
$508.00
|
|
X-ray hip with pelvis when performed unilateral 1 view left
|
$496.74 |
$496.74 |
$496.74 |
$207.35
|
|
X-ray humerus >= 2 views left
|
$963.90 |
$963.90 |
$963.90 |
$304.15
|
|
X-ray joint survey 1 view
|
$159.63 |
$159.63 |
$159.63 |
$211.00
|
|
X-ray knee 1-2 views (both sides)
|
$806.82 |
$806.82 |
$806.82 |
$283.50
|
|
X-ray knee 3 views (both sides)
|
$1,033.26 |
$1,033.26 |
$1,033.26 |
$353.25
|
|
X-ray knee ap standing bilateral
|
$201.96 |
$201.96 |
$201.96 |
$276.25
|
|
X-ray lower extremities infant > 2 views (both sides)
|
$706.86 |
$706.86 |
$706.86 |
$249.13
|
|
X-ray l/s-spine bend vw only 2-3 vw
|
$1,323.45 |
$1,323.45 |
$1,323.45 |
$364.75
|
|
X-ray lumbosacral spine >= 4 views
|
$2,267.46 |
$2,267.46 |
$2,267.46 |
$505.83
|
|
X-ray lumbosacral spine complete including bending views >= 6 views
|
$2,337.33 |
$2,337.33 |
$2,337.33 |
$559.65
|
|
X-ray mandible complete > 4 views
|
$1,611.09 |
$1,611.09 |
$1,611.09 |
$352.83
|
|
X-ray mandible ltd <4 views
|
$1,080.18 |
$1,080.18 |
$1,080.18 |
$238.00
|
|
X-ray nasal bones complete > 3 views
|
$1,098.03 |
$1,098.03 |
$1,098.03 |
$277.70
|
|
X-ray neck soft tissue
|
$364.65 |
$364.65 |
$364.65 |
$237.43
|
|
X-ray nose to rectum for foreign body child
|
$463.08 |
$463.08 |
$463.08 |
$225.96
|
|
X-ray pelvis 1-2 views
|
$819.06 |
$819.06 |
$819.06 |
$270.84
|
|
X-ray pelvis complete > 3 views
|
$1,098.03 |
$1,098.03 |
$1,098.03 |
$342.30
|
|
Xray place prox ext thor ao
|
$21,218.55 |
$21,218.55 |
$21,218.55 |
$1,005.84
|
|
X-ray retrograde pyelogram with or without kidney ureter bladder w/supervision & interpretation
|
$1,005.21 |
$1,005.21 |
$1,005.21 |
$742.00
|
|
X-ray ribs 2 views left
|
$1,210.23 |
$1,210.23 |
$1,210.23 |
$296.32
|
|
X-ray ribs 3 views bilateral
|
$1,765.62 |
$1,765.62 |
$1,765.62 |
$394.34
|
|
X-ray ribs w/posterior anterior chest 3 views left
|
$1,575.39 |
$1,575.39 |
$1,575.39 |
$359.47
|
|
X-ray ribs w/posterior anterior chest > 4 views bilateral
|
$1,765.62 |
$1,765.62 |
$1,765.62 |
$497.00
|
|
X-ray sacroiliac joints >= 3 views
|
$811.41 |
$811.41 |
$811.41 |
$313.95
|
|
X-ray sacrum/coccyx >= 2 views
|
$1,050.60 |
$1,050.60 |
$1,050.60 |
$285.60
|
|
X-ray scapula complete (both sides)
|
$1,100.58 |
$1,100.58 |
$1,100.58 |
$292.50
|
|
X-ray shoulder 1 view (both sides)
|
$811.41 |
$811.41 |
$811.41 |
$264.48
|
|
X-ray sinuses paranasal complete > 3 views
|
$931.26 |
$931.26 |
$931.26 |
$339.00
|
|
X-ray sinus tract/fistula/abscess
|
$800.70 |
$800.70 |
$800.70 |
$601.30
|
|
X-ray skull < 4 views
|
$1,039.38 |
$1,039.38 |
$1,039.38 |
$291.78
|
|
X-ray skull > 4 views complete
|
$1,746.24 |
$1,746.24 |
$1,746.24 |
$414.60
|
|
X-ray small bowel multi serial images abdominal radiographs(s)&delayed images single contrast study
|
$896.58 |
$896.58 |
$896.58 |
$557.70
|
|
X-ray small intestine follow-through study
|
$392.70 |
$392.70 |
$392.70 |
$504.14
|
|
X-ray spine single view
|
$767.55 |
$767.55 |
$767.55 |
$252.60
|
|
X-ray sternoclavicular joint(s) > 3 views
|
$810.90 |
$810.90 |
$810.90 |
$263.49
|
|
X-ray sternum > 2 views
|
$975.12 |
$975.12 |
$975.12 |
$269.75
|
|
X-ray surgical specimen
|
$689.52 |
$689.52 |
$689.52 |
$482.24
|
|
X-ray swallowing function w/ciner/videoradiography neck radiographs(s)&delayed images contrast study
|
$655.86 |
$655.86 |
$655.86 |
$514.00
|
|
X-ray temporomandibular joint open/closed mouth bilateral
|
$1,647.81 |
$1,647.81 |
$1,647.81 |
$317.70
|
|
X-ray thoracic spine 2 views
|
$1,186.77 |
$1,186.77 |
$1,186.77 |
$318.50
|
|
X-ray thoracic spine 3 views
|
$1,716.15 |
$1,716.15 |
$1,716.15 |
$387.60
|
|
X-ray thoracolumbar spine >=2 views
|
$1,072.53 |
$1,072.53 |
$1,072.53 |
$294.00
|
|
X-ray thoracolumbar spine including skull cervical & sacral spine 1 view
|
$496.74 |
$496.74 |
$496.74 |
$256.85
|
|
X-ray thoracolumbar spine including skull cervical & sacral spine 2-3 views
|
$823.65 |
$823.65 |
$823.65 |
$385.80
|
|
X-ray tibia/fibula 2 views (both sides)
|
$912.90 |
$912.90 |
$912.90 |
$328.00
|
|
X-ray toe(s) > 2 views (both sides)
|
$765.00 |
$765.00 |
$765.00 |
$264.00
|
|
X-ray upper gastrointestinal tract scout abdominal radiographs delayed images double contrast
|
$788.97 |
$788.97 |
$788.97 |
$657.77
|
|
X-ray upper gastrointestinal tract scout abdominal radiographs delayed images single contrast study
|
$646.68 |
$646.68 |
$646.68 |
$555.04
|
|
X-ray wrist 2 views (both sides)
|
$761.94 |
$761.94 |
$761.94 |
$290.40
|
|
X-ray xm phrnx&/crv esoph c+
|
$328.44 |
$328.44 |
$328.44 |
$324.20
|
|
Zidovudine in d5w IV syringe 4 mg/ml (neo/peds) - cnr
|
$148.77 |
$148.77 |
$148.77 |
$106.94
|
|
Zika virus dna/rna amp probe
|
$255.00 |
$255.00 |
$255.00 |
$175.00
|