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Home , Coronary CT calcium scan, Echoencephalography, Endoscopic ultrasound, Myelography, Sialography

Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 70010 - - $46.52 - - , posterior fossa, radiological supervision and interpretation 70015 - - $130.09 $45.79 $84.30 Cisternography, positive contrast, radiological supervision and interpretation 70030 - - $24.71 $6.49 $18.21 Radiologic examination, eye, for detection of foreign body 70100 - - $29.32 $7.05 $22.27 Radiologic examination, mandible; partial, less than 4 views 70110 - - $33.79 $9.78 $24.01 Radiologic examination, mandible; complete, minimum of 4 views 70120 - - $29.32 $7.05 $22.27 Radiologic examination, mastoids; less than 3 views per side 70130 - - $47.72 $13.28 $34.45 Radiologic examination, mastoids; complete, minimum of 3 views per side 70134 - - $45.16 $13.61 $31.55 Radiologic examination, internal auditory meati, complete 70140 - - $24.95 $7.89 $17.06 Radiologic examination, facial bones; less than 3 views 70150 - - $36.66 $10.33 $26.33 Radiologic examination, facial bones; complete, minimum of 3 views 70160 - - $29.06 $6.78 $22.27 Radiologic examination, nasal bones, complete, minimum of 3 views 70170 - - - $11.39 $187.19 Dacryocystography, nasolacrimal duct, radiological supervision and interpretation 70190 - - $30.70 $8.71 $21.98 Radiologic examination; optic foramina 70200 - - $37.19 $10.86 $26.33 Radiologic examination; orbits, complete, minimum of 4 views 70210 - - $24.71 $6.78 $17.92 Radiologic examination, sinuses, paranasal, less than 3 views 70220 - - $29.22 $8.69 $20.53 Radiologic examination, sinuses, paranasal, complete, minimum of 3 views 70240 - - $26.69 $7.60 $19.08 Radiologic examination, sella turcica 70250 - - $28.45 $7.92 $20.53 Radiologic examination, ; less than 4 views 70260 - - $35.16 $11.15 $24.01 Radiologic examination, skull; complete, minimum of 4 views 70300 - - $10.97 $4.35 $6.62 Radiologic examination, teeth; single view 70310 - - $31.40 $5.94 $25.46 Radiologic examination, teeth; partial examination, less than full mouth 70320 - - $44.58 $8.98 $35.60 Radiologic examination, teeth; complete, full mouth 70328 - - $26.71 $7.05 $19.66 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral 70330 - - $41.35 $9.51 $31.84 Radiologic examination, temporomandibular joint, open and closed mouth; bilateral 70332 - - $64.87 $20.86 $44.01 Temporomandibular joint arthrography, radiological supervision and interpretation 70336 - - $298.41 $56.87 $241.54 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) 70350 - - $13.69 $7.07 $6.62 Cephalogram, orthodontic 70355 - - $15.07 $8.16 $6.91 Orthopantogram (eg, panoramic x-ray) 70360 - - $24.39 $7.05 $17.35 Radiologic examination; neck, soft tissue Radiologic examination; pharynx or larynx, including and/or magnification 70370 - - $71.29 $11.34 $59.95 technique 70371 - - $85.44 $32.74 $52.70 Complex dynamic pharyngeal and speech evaluation by cine or video recording 70380 - - $28.77 $6.49 $22.27 Radiologic examination, for calculus 70390 - - $90.52 $14.63 $75.89 , radiological supervision and interpretation 70450 - - $91.84 $32.76 $59.08 Computed , head or ; without contrast material 70460 - - $129.99 $43.37 $86.62 Computed tomography, head or brain; with contrast material(s) Computed tomography, head or brain; without contrast material, followed by contrast 70470 - - $152.50 $48.78 $103.72 material(s) and further sections Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without 70480 - - $139.14 $49.05 $90.09 contrast material Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; with 70481 - - $179.26 $43.37 $135.89 contrast material(s) Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without 70482 - - $194.77 $48.49 $146.28 contrast material, followed by contrast material(s) and further sections 70486 - - $111.26 $33.05 $78.21 Computed tomography, maxillofacial area; without contrast material 70487 - - $133.18 $43.37 $89.80 Computed tomography, maxillofacial area; with contrast material(s) Computed tomography, maxillofacial area; without contrast material, followed by contrast 70488 - - $162.64 $48.78 $113.86 material(s) and further sections 70490 - - $130.74 $49.34 $81.40 Computed tomography, soft tissue neck; without contrast material 70491 - - $161.50 $53.15 $108.35 Computed tomography, soft tissue neck; with contrast material(s) Computed tomography, soft tissue neck; without contrast material followed by contrast 70492 - - $195.27 $62.57 $132.70 material(s) and further sections Computed tomographic , head, with contrast material(s), including noncontrast 70496 - - $213.45 $67.18 $146.28 images, if performed, and image postprocessing Computed tomographic angiography, neck, with contrast material(s), including noncontrast 70498 - - $213.45 $67.18 $146.28 images, if performed, and image postprocessing

70540 - - $277.15 $51.48 $225.67 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s) 70542 - - $431.34 $62.57 $368.77 Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; with contrast material(s) Magnetic resonance (eg, proton) imaging, orbit, face, and/or neck; without contrast material(s), 70543 - - $471.81 $82.14 $389.67 followed by contrast material(s) and further sequences 70544 - - $295.37 $46.06 $249.31 Magnetic resonance angiography, head; without contrast material(s) 70545 - - $317.29 $46.06 $271.23 Magnetic resonance angiography, head; with contrast material(s) Magnetic resonance angiography, head; without contrast material(s), followed by contrast 70546 - - $488.62 $57.16 $431.46 material(s) and further sequences 70547 - - $296.18 $46.35 $249.83 Magnetic resonance angiography, neck; without contrast material(s)

Page 1 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 70548 - - $350.24 $57.69 $292.55 Magnetic resonance angiography, neck; with contrast material(s) Magnetic resonance angiography, neck; without contrast material(s), followed by contrast 70549 - - $501.87 $69.37 $432.50 material(s) and further sequences Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast 70551 - - $265.46 $57.16 $208.30 material

70552 - - $331.04 $68.55 $262.49 Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s) Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast 70553 - - $465.47 $88.08 $377.39 material, followed by contrast material(s) and further sequences Magnetic resonance imaging, brain, functional MRI; including test selection and administration 70554 - - $370.32 $81.07 $289.25 of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist 70555 - - - $96.74 - administration of entire neurofunctional testing Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during 70557 - - - $123.41 $386.60 open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during 70558 - - - $132.71 $146.32 open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); with contrast material(s)

Magnetic resonance (eg, proton) imaging, brain (including brain stem and skull base), during 70559 - - - $126.37 $146.32 open intracranial procedure (eg, to assess for residual tumor or residual vascular malformation); without contrast material(s), followed by contrast material(s) and further sequences 71045 - - $20.34 $7.05 $13.29 Radiologic examination, chest; single view 71046 - - $26.03 $8.40 $17.63 Radiologic examination, chest; 2 views 71047 - - $32.87 $10.60 $22.27 Radiologic examination, chest; 3 views 71048 - - $35.67 $12.53 $23.14 Radiologic examination, chest; 4 or more views 71100 - - $28.35 $8.69 $19.66 Radiologic examination, ribs, unilateral; 2 views 71101 - - $32.58 $10.31 $22.27 Radiologic examination, ribs, unilateral; including posteroanterior chest, minimum of 3 views 71110 - - $34.27 $11.42 $22.85 Radiologic examination, ribs, bilateral; 3 views 71111 - - $40.86 $12.50 $28.36 Radiologic examination, ribs, bilateral; including posteroanterior chest, minimum of 4 views 71120 - - $26.08 $7.87 $18.21 Radiologic examination; sternum, minimum of 2 views 71130 - - $31.83 $8.69 $23.14 Radiologic examination; sternoclavicular joint or joints, minimum of 3 views 71250 - - $125.86 $44.46 $81.40 Computed tomography, ; without contrast material 71260 - - $156.63 $47.99 $108.64 Computed tomography, thorax; with contrast material(s) Computed tomography, thorax; without contrast material, followed by contrast material(s) and 71270 - - $185.56 $52.86 $132.70 further sections

71271 - - $209.27 $41.23 $168.04 Computed tomography, thorax, low dose for screening, without contrast material(s) Computed tomographic angiography, chest (noncoronary), with contrast material(s), including 71275 - - $216.18 $69.90 $146.28 noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal 71550 - - $333.21 $56.34 $276.87 lymphadenopathy); without contrast material(s) Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal 71551 - - $621.66 $66.36 $555.30 lymphadenopathy); with contrast material(s) Magnetic resonance (eg, proton) imaging, chest (eg, for evaluation of hilar and mediastinal 71552 - - $538.57 $86.21 $452.36 lymphadenopathy); without contrast material(s), followed by contrast material(s) and further sequences Magnetic resonance angiography, chest (excluding myocardium), with or without contrast 71555 - - $370.10 $68.77 $301.33 material(s) 72020 - - $19.23 $6.23 $13.00 Radiologic examination, spine, single view, specify level 72040 - - $30.38 $8.69 $21.69 Radiologic examination, spine, cervical; 2 or 3 views 72050 - - $40.40 $10.60 $29.81 Radiologic examination, spine, cervical; 4 or 5 views 72052 - - $47.58 $11.68 $35.89 Radiologic examination, spine, cervical; 6 or more views 72070 - - $25.21 $7.87 $17.35 Radiologic examination, spine; thoracic, 2 views 72072 - - $30.65 $8.95 $21.69 Radiologic examination, spine; thoracic, 3 views 72074 - - $34.37 $9.49 $24.88 Radiologic examination, spine; thoracic, minimum of 4 views 72080 - - $27.22 $8.42 $18.79 Radiologic examination, spine; thoracolumbar junction, minimum of 2 views Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral 72081 - - $33.18 $10.33 $22.85 spine if performed (eg, scoliosis evaluation); one view Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral 72082 - - $54.17 $12.48 $41.69 spine if performed (eg, scoliosis evaluation); 2 or 3 views Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral 72083 - - $63.06 $14.12 $48.94 spine if performed (eg, scoliosis evaluation); 4 or 5 views

Page 2 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral 72084 - - $74.80 $16.00 $58.79 spine if performed (eg, scoliosis evaluation); minimum of 6 views 72100 - - $30.38 $8.69 $21.69 Radiologic examination, spine, lumbosacral; 2 or 3 views 72110 - - $38.69 $10.04 $28.65 Radiologic examination, spine, lumbosacral; minimum of 4 views Radiologic examination, spine, lumbosacral; complete, including bending views, minimum of 6 72114 - - $47.58 $11.68 $35.89 views 72120 - - $31.54 $8.69 $22.85 Radiologic examination, spine, lumbosacral; bending views only, 2 or 3 views 72125 - - $124.22 $38.48 $85.75 Computed tomography, cervical spine; without contrast material 72126 - - $156.10 $46.88 $109.22 Computed tomography, cervical spine; with contrast material Computed tomography, cervical spine; without contrast material, followed by contrast 72127 - - $184.38 $48.78 $135.60 material(s) and further sections 72128 - - $124.22 $38.48 $85.75 Computed tomography, thoracic spine; without contrast material 72129 - - $157.26 $46.88 $110.38 Computed tomography, thoracic spine; with contrast material Computed tomography, thoracic spine; without contrast material, followed by contrast 72130 - - $184.67 $48.78 $135.89 material(s) and further sections 72131 - - $123.64 $38.48 $85.17 Computed tomography, lumbar spine; without contrast material 72132 - - $156.39 $46.88 $109.51 Computed tomography, lumbar spine; with contrast material Computed tomography, lumbar spine; without contrast material, followed by contrast 72133 - - $183.51 $48.49 $135.02 material(s) and further sections Magnetic resonance (eg, proton) imaging, and contents, cervical; without contrast 72141 - - $263.11 $57.16 $205.95 material Magnetic resonance (eg, proton) imaging, spinal canal and contents, cervical; with contrast 72142 - - $436.30 $68.84 $367.46 material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; without contrast 72146 - - $263.24 $57.16 $206.08 material Magnetic resonance (eg, proton) imaging, spinal canal and contents, thoracic; with contrast 72147 - - $435.23 $68.55 $366.68 material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; without contrast 72148 - - $263.11 $57.16 $205.95 material Magnetic resonance (eg, proton) imaging, spinal canal and contents, lumbar; with contrast 72149 - - $434.44 $68.55 $365.89 material(s) Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, 72156 - - $466.25 $88.08 $378.17 followed by contrast material(s) and further sequences; cervical Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, 72157 - - $466.51 $88.08 $378.43 followed by contrast material(s) and further sequences; thoracic Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, 72158 - - $465.86 $88.08 $377.78 followed by contrast material(s) and further sequences; lumbar

72159 - - $379.29 $69.37 $309.92 Magnetic resonance angiography, spinal canal and contents, with or without contrast material(s) 72170 - - $22.68 $6.78 $15.90 Radiologic examination, pelvis; 1 or 2 views 72190 - - $32.34 $9.78 $22.56 Radiologic examination, pelvis; complete, minimum of 3 views Computed tomographic angiography, pelvis, with contrast material(s), including noncontrast 72191 - - $215.05 $68.77 $146.28 images, if performed, and image postprocessing 72192 - - $115.60 $41.73 $73.86 Computed tomography, pelvis; without contrast material 72193 - - $190.78 $44.46 $146.32 Computed tomography, pelvis; with contrast material(s) Computed tomography, pelvis; without contrast material, followed by contrast material(s) and 72194 - - $193.15 $46.88 $146.28 further sections 72195 - - $296.77 $56.34 $240.43 Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s) 72196 - - $442.99 $66.65 $376.34 Magnetic resonance (eg, proton) imaging, pelvis; with contrast material(s) Magnetic resonance (eg, proton) imaging, pelvis; without contrast material(s), followed by 72197 - - $480.76 $84.04 $396.72 contrast material(s) and further sequences 72198 - - $371.26 $68.21 $303.05 Magnetic resonance angiography, pelvis, with or without contrast material(s) 72200 - - $25.58 $6.78 $18.79 Radiologic examination, sacroiliac joints; less than 3 views 72202 - - $30.36 $8.95 $21.40 Radiologic examination, sacroiliac joints; 3 or more views 72220 - - $25.00 $6.78 $18.21 Radiologic examination, sacrum and coccyx, minimum of 2 views 72240 - - $88.50 $35.22 $53.28 Myelography, cervical, radiological supervision and interpretation 72255 - - $89.82 $36.53 $53.28 Myelography, thoracic, radiological supervision and interpretation 72265 - - $81.74 $31.36 $50.39 Myelography, lumbosacral, radiological supervision and interpretation Myelography, 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, 72270 - - $112.35 $51.82 $60.53 lumbar/thoracic/cervical), radiological supervision and interpretation 72275 - - $104.81 $30.37 $74.44 Epidurography, radiological supervision and interpretation 72285 - - $96.83 $45.57 $51.26 Discography, cervical or thoracic, radiological supervision and interpretation 72295 - - $85.22 $32.81 $52.42 Discography, lumbar, radiological supervision and interpretation 73000 - - $25.02 $6.52 $18.50 Radiologic examination; clavicle, complete 73010 - - $22.10 $7.07 $15.03 Radiologic examination; scapula, complete 73020 - - $16.93 $5.96 $10.97 Radiologic examination, shoulder; 1 view 73030 - - $26.42 $7.34 $19.08 Radiologic examination, shoulder; complete, minimum of 2 views

Page 3 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 73040 - - $96.75 $21.15 $75.60 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation 73050 - - $24.97 $7.34 $17.63 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction 73060 - - $25.02 $6.52 $18.50 Radiologic examination; humerus, minimum of 2 views 73070 - - $22.70 $6.52 $16.19 Radiologic examination, elbow; 2 views 73080 - - $24.71 $6.78 $17.92 Radiologic examination, elbow; complete, minimum of 3 views 73085 - - $90.57 $22.51 $68.07 Radiologic examination, elbow, arthrography, radiological supervision and interpretation 73090 - - $22.99 $6.52 $16.48 Radiologic examination; forearm, 2 views 73092 - - $24.15 $6.23 $17.92 Radiologic examination; upper extremity, infant, minimum of 2 views 73100 - - $26.18 $6.52 $19.66 Radiologic examination, wrist; 2 views 73110 - - $31.08 $6.78 $24.30 Radiologic examination, wrist; complete, minimum of 3 views 73115 - - $101.68 $21.73 $79.95 Radiologic examination, wrist, arthrography, radiological supervision and interpretation 73120 - - $24.15 $6.52 $17.63 Radiologic examination, hand; 2 views 73130 - - $27.90 $6.78 $21.11 Radiologic examination, hand; minimum of 3 views 73140 - - $28.57 $5.43 $23.14 Radiologic examination, finger(s), minimum of 2 views 73200 - - $128.57 $38.48 $90.09 Computed tomography, upper extremity; without contrast material 73201 - - $178.32 $44.46 $133.86 Computed tomography, upper extremity; with contrast material(s) Computed tomography, upper extremity; without contrast material, followed by contrast 73202 - - $193.15 $46.88 $146.28 material(s) and further sections Computed tomographic angiography, upper extremity, with contrast material(s), including 73206 - - $215.05 $68.77 $146.28 noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast 73218 - - $312.99 $52.06 $260.93 material(s) Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; with contrast 73219 - - $461.80 $62.86 $398.94 material(s) Magnetic resonance (eg, proton) imaging, upper extremity, other than joint; without contrast 73220 - - $507.37 $82.43 $424.94 material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast 73221 - - $265.83 $52.84 $212.99 material(s)

73222 - - $591.26 $62.86 $528.40 Magnetic resonance (eg, proton) imaging, any joint of upper extremity; with contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of upper extremity; without contrast 73223 - - $496.52 $82.43 $414.09 material(s), followed by contrast material(s) and further sequences 73225 - - $380.30 $66.94 $313.36 Magnetic resonance angiography, upper extremity, with or without contrast material(s) 73501 - - $25.26 $7.34 $17.92 Radiologic examination, hip, unilateral, with pelvis when performed; 1 view 73502 - - $36.18 $8.69 $27.49 Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views 73503 - - $44.75 $10.60 $34.16 Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4 views 73521 - - $31.83 $8.69 $23.14 Radiologic examination, hips, bilateral, with pelvis when performed; 2 views 73522 - - $41.51 $11.42 $30.10 Radiologic examination, hips, bilateral, with pelvis when performed; 3-4 views 73523 - - $47.26 $12.24 $35.02 Radiologic examination, hips, bilateral, with pelvis when performed; minimum of 5 views 73525 - - $98.98 $22.79 $76.18 Radiologic examination, hip, arthrography, radiological supervision and interpretation 73551 - - $23.28 $6.52 $16.77 Radiologic examination, femur; 1 view 73552 - - $27.58 $7.05 $20.53 Radiologic examination, femur; minimum 2 views 73560 - - $26.76 $6.52 $20.24 Radiologic examination, knee; 1 or 2 views 73562 - - $31.35 $7.34 $24.01 Radiologic examination, knee; 3 views 73564 - - $35.02 $8.69 $26.33 Radiologic examination, knee; complete, 4 or more views 73565 - - $31.11 $6.81 $24.30 Radiologic examination, knee; both knees, standing, anteroposterior 73580 - - $109.70 $22.22 $87.49 Radiologic examination, knee, arthrography, radiological supervision and interpretation 73590 - - $24.44 $6.23 $18.21 Radiologic examination; tibia and fibula, 2 views 73592 - - $24.15 $6.23 $17.92 Radiologic examination; lower extremity, infant, minimum of 2 views 73600 - - $25.31 $6.52 $18.79 Radiologic examination, ankle; 2 views 73610 - - $27.90 $6.78 $21.11 Radiologic examination, ankle; complete, minimum of 3 views 73615 - - $103.03 $22.51 $80.53 Radiologic examination, ankle, arthrography, radiological supervision and interpretation 73620 - - $22.12 $5.94 $16.19 Radiologic examination, foot; 2 views 73630 - - $26.16 $6.49 $19.66 Radiologic examination, foot; complete, minimum of 3 views 73650 - - $22.41 $6.23 $16.19 Radiologic examination; calcaneus, minimum of 2 views 73660 - - $22.49 $5.14 $17.35 Radiologic examination; toe(s), minimum of 2 views 73700 - - $123.64 $38.48 $85.17 Computed tomography, lower extremity; without contrast material 73701 - - $154.84 $44.46 $110.38 Computed tomography, lower extremity; with contrast material(s) Computed tomography, lower extremity; without contrast material, followed by contrast 73702 - - $186.82 $46.59 $140.24 material(s) and further sections Computed tomographic angiography, lower extremity, with contrast material(s), including 73706 - - $218.30 $72.03 $146.28 noncontrast images, if performed, and image postprocessing Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast 73718 - - $290.63 $51.77 $238.86 material(s) Magnetic resonance (eg, proton) imaging, lower extremity other than joint; with contrast 73719 - - $330.25 $62.57 $267.68 material(s)

Page 4 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast 73720 - - $479.65 $82.14 $397.51 material(s), followed by contrast material(s) and further sequences Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast 73721 - - $265.05 $52.06 $212.99 material

73722 - - $592.17 $62.86 $529.31 Magnetic resonance (eg, proton) imaging, any joint of lower extremity; with contrast material(s) Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast 73723 - - $496.39 $82.43 $413.96 material(s), followed by contrast material(s) and further sequences 73725 - - $371.39 $69.03 $302.36 Magnetic resonance angiography, lower extremity, with or without contrast material(s) 74018 - - $23.23 $7.05 $16.19 Radiologic examination, ; 1 view 74019 - - $28.62 $8.95 $19.66 Radiologic examination, abdomen; 2 views 74021 - - $33.16 $10.31 $22.85 Radiologic examination, abdomen; 3 or more views Radiologic examination, complete acute abdomen series, including 2 or more views of the 74022 - - $38.54 $12.21 $26.33 abdomen (eg, supine, erect, decubitus), and a single view chest 74150 - - $118.49 $45.79 $72.70 Computed tomography, abdomen; without contrast material 74160 - - $195.39 $49.07 $146.32 Computed tomography, abdomen; with contrast material(s) Computed tomography, abdomen; without contrast material, followed by contrast material(s) 74170 - - $200.16 $53.88 $146.28 and further sections Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including 74174 - - $324.38 $83.95 $240.43 noncontrast images, if performed, and image postprocessing Computed tomographic angiography, abdomen, with contrast material(s), including noncontrast 74175 - - $215.89 $69.61 $146.28 images, if performed, and image postprocessing 74176 - - $158.45 $66.91 $91.54 Computed tomography, abdomen and pelvis; without contrast material 74177 - - $261.97 $70.19 $191.78 Computed tomography, abdomen and pelvis; with contrast material(s) Computed tomography, abdomen and pelvis; without contrast material in one or both body 74178 - - $294.55 $76.97 $217.58 regions, followed by contrast material(s) and further sections in one or both body regions 74181 - - $284.10 $56.34 $227.76 Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s) 74182 - - $371.04 $66.65 $304.39 Magnetic resonance (eg, proton) imaging, abdomen; with contrast material(s) Magnetic resonance (eg, proton) imaging, abdomen; without contrast material(s), followed by 74183 - - $409.75 $84.04 $325.71 with contrast material(s) and further sequences 74185 - - $373.61 $68.50 $305.11 Magnetic resonance angiography, abdomen, with or without contrast material(s) 74190 - - - $17.82 $386.60 Peritoneogram (eg, after injection of air or contrast), radiological supervision and interpretation Radiologic examination, pharynx and/or cervical , including scout neck radiograph(s) 74210 - - $75.47 $22.76 $52.70 and delayed image(s), when performed, contrast (eg, barium) study Radiologic examination, esophagus, including scout (s) and delayed image(s), 74220 - - $76.89 $23.03 $53.86 when performed; single-contrast (eg, barium) study

74221 - - $86.79 $26.84 $59.95 Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) study

74230 - - $104.06 $20.35 $83.72 Radiologic examination, swallowing function, with cineradiography/videoradiography, including scout neck radiograph(s) and delayed image(s), when performed, contrast (eg, barium) study Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision 74235 - - - $45.79 - and interpretation Radiologic examination, upper , including scout abdominal radiograph(s) 74240 - - $96.02 $31.14 $64.88 and delayed image(s), when performed; single-contrast (eg, barium) study Radiologic examination, upper gastrointestinal tract, including scout abdominal radiograph(s) 74246 - - $110.56 $34.66 $75.89 and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) study, including glucagon, when administered Radiologic follow-through study, including multiple serial images (List separately 74248 - - $65.39 $26.84 $38.55 in addition to code for primary procedure for upper GI radiologic examination) Radiologic examination, small intestine, including multiple serial images and scout abdominal 74250 - - $96.57 $31.41 $65.17 radiograph(s), when performed; single-contrast (eg, barium) study Radiologic examination, small intestine, including multiple serial images and scout abdominal 74251 - - $191.29 $44.97 $146.32 radiograph(s), when performed; double-contrast (eg, high-density barium and air via enteroclysis tube) study, including glucagon, when administered Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without 74261 - - $182.25 $92.16 $90.09 contrast material Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with 74262 - - $242.29 $95.97 $146.32 contrast material(s) including non-contrast images, if performed 74263 - - $606.91 $88.19 $518.72 Computed tomographic (CT) colonography, screening, including image postprocessing Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), 74270 - - $122.96 $39.83 $83.14 when performed; single-contrast (eg, barium) study Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), 74280 - - $177.45 $48.23 $129.22 when performed; double-contrast (eg, high density barium and air) study, including glucagon, when administered

Page 5 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal 74283 - - $197.47 $79.85 $117.63 obstruction (eg, meconium ileus) 74290 - - $66.08 $12.21 $53.86 , oral contrast and/or pancreatography; intraoperative, radiological supervision and 74300 - - - $13.81 - interpretation Cholangiography and/or pancreatography; additional set intraoperative, radiological supervision 74301 - - - $8.13 - and interpretation (List separately in addition to code for primary procedure) Endoscopic catheterization of the biliary ductal system, radiological supervision and 74328 - - - $27.42 - interpretation Endoscopic catheterization of the pancreatic ductal system, radiological supervision and 74329 - - - $27.42 - interpretation Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological 74330 - - - $35.24 - supervision and interpretation Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopies 74340 - - - $20.86 - and images, radiological supervision and interpretation 74355 - - - $29.50 - Percutaneous placement of enteroclysis tube, radiological supervision and interpretation Intraluminal dilation of strictures and/or obstructions (eg, esophagus), radiological supervision 74360 - - - $21.64 - and interpretation Percutaneous transhepatic dilation of biliary duct stricture with or without placement of stent, 74363 - - - $33.55 - radiological supervision and interpretation 74400 - - $103.00 $18.71 $84.30 Urography (pyelography), intravenous, with or without KUB, with or without tomography 74410 - - $104.74 $18.42 $86.33 Urography, infusion, drip technique and/or bolus technique; 74415 - - $122.71 $18.71 $104.01 Urography, infusion, drip technique and/or bolus technique; with nephrotomography 74420 - - $58.87 $19.50 $39.37 Urography, retrograde, with or without KUB Urography, antegrade (pyelostogram, nephrostogram, loopogram), radiological supervision and 74425 - - $104.69 $19.24 $85.46 interpretation 74430 - - $31.88 $12.21 $19.66 , minimum of 3 views, radiological supervision and interpretation

74440 - - $74.04 $14.09 $59.95 Vasography, vesiculography, or epididymography, radiological supervision and interpretation 74445 - - - $42.28 $90.09 Corpora cavernosography, radiological supervision and interpretation 74450 - - - $12.48 $187.19 Urethrocystography, retrograde, radiological supervision and interpretation 74455 - - $78.51 $12.48 $66.04 Urethrocystography, voiding, radiological supervision and interpretation Radiologic examination, renal study, translumbar, contrast visualization, radiological 74470 - - - $20.28 $386.60 supervision and interpretation 74485 - - $90.24 $30.87 $59.37 Dilation of ureter(s) or urethra, radiological supervision and interpretation 74710 - - $31.49 $13.28 $18.21 Pelvimetry, with or without placental localization Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging 74712 - - $340.28 $114.94 $225.34 when performed; single or first gestation Magnetic resonance (eg, proton) imaging, fetal, including placental and maternal pelvic imaging 74713 - - $212.15 $71.28 $140.87 when performed; each additional gestation (List separately in addition to code for primary procedure) 74740 - - $72.55 $14.63 $57.92 , radiological supervision and interpretation 74742 - - - $23.58 - Transcervical catheterization of fallopian tube, radiological supervision and interpretation 74775 - - - $23.85 $187.19 Perineogram (eg, vaginogram, for sex determination or extent of anomalies)

75557 - - $296.43 $88.89 $207.54 Cardiac magnetic resonance imaging for morphology and function without contrast material; Cardiac magnetic resonance imaging for morphology and function without contrast material; 75559 - - $457.20 $109.16 $348.04 with stress imaging Cardiac magnetic resonance imaging for morphology and function without contrast material(s), 75561 - - $409.25 $97.84 $311.41 followed by contrast material(s) and further sequences; Cardiac magnetic resonance imaging for morphology and function without contrast material(s), 75563 - - $553.55 $113.00 $440.55 followed by contrast material(s) and further sequences; with stress imaging Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to 75565 - - $50.73 $9.49 $41.24 code for primary procedure) Computed tomography, heart, without contrast material, with quantitative evaluation of 75571 - - $83.90 $22.21 $61.69 coronary calcium Computed tomography, heart, with contrast material, for evaluation of cardiac structure and 75572 - - $198.43 $66.64 $131.78 morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, 75573 - - $243.53 $97.29 $146.23 assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed) Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac 75574 - - $237.07 $90.80 $146.28 structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

Page 6 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 75600 - - $162.15 $19.01 $143.13 , thoracic, without serialography, radiological supervision and interpretation 75605 - - $103.12 $42.01 $61.11 Aortography, thoracic, by serialography, radiological supervision and interpretation 75625 - - $109.22 $53.33 $55.89 Aortography, abdominal, by serialography, radiological supervision and interpretation Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, 75630 - - $133.60 $74.52 $59.08 radiological supervision and interpretation Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity 75635 - - $236.98 $90.71 $146.28 runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing 75705 - - $198.52 $89.05 $109.47 Angiography, spinal, selective, radiological supervision and interpretation 75710 - - $128.86 $65.72 $63.14 Angiography, extremity, unilateral, radiological supervision and interpretation 75716 - - $137.40 $72.85 $64.54 Angiography, extremity, bilateral, radiological supervision and interpretation Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological 75726 - - $145.10 $75.00 $70.10 supervision and interpretation 75731 - - $130.21 $43.93 $86.28 Angiography, adrenal, unilateral, selective, radiological supervision and interpretation 75733 - - $140.47 $49.02 $91.45 Angiography, adrenal, bilateral, selective, radiological supervision and interpretation 75736 - - $119.89 $41.43 $78.46 Angiography, pelvic, selective or supraselective, radiological supervision and interpretation 75741 - - $113.14 $48.26 $64.88 Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation 75743 - - $127.26 $61.51 $65.75 Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision 75746 - - $114.80 $42.43 $72.37 and interpretation 75756 - - $130.47 $42.74 $87.73 Angiography, internal mammary, radiological supervision and interpretation Angiography, selective, each additional vessel studied after basic examination, radiological 75774 - - $85.18 $37.11 $48.07 supervision and interpretation (List separately in addition to code for primary procedure) 75801 - - - $33.17 $506.30 Lymphangiography, extremity only, unilateral, radiological supervision and interpretation 75803 - - - $45.01 $1,309.72 Lymphangiography, extremity only, bilateral, radiological supervision and interpretation 75805 - - - $31.41 $1,309.72 Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation 75807 - - - $42.65 $2,225.31 Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation Shuntogram for investigation of previously placed indwelling nonvascular shunt (eg, LeVeen 75809 - - $73.15 $18.13 $55.02 shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and interpretation 75810 - - - $37.71 $1,309.72 Splenoportography, radiological supervision and interpretation 75820 - - $86.08 $26.41 $59.66 , extremity, unilateral, radiological supervision and interpretation 75822 - - $100.13 $39.60 $60.53 Venography, extremity, bilateral, radiological supervision and interpretation 75825 - - $99.51 $42.16 $57.34 Venography, caval, inferior, with serialography, radiological supervision and interpretation 75827 - - $103.52 $42.41 $61.11 Venography, caval, superior, with serialography, radiological supervision and interpretation 75831 - - $103.99 $41.43 $62.56 Venography, renal, unilateral, selective, radiological supervision and interpretation 75833 - - $124.42 $55.24 $69.18 Venography, renal, bilateral, selective, radiological supervision and interpretation 75840 - - $112.00 $43.93 $68.07 Venography, adrenal, unilateral, selective, radiological supervision and interpretation 75842 - - $136.17 $57.72 $78.46 Venography, adrenal, bilateral, selective, radiological supervision and interpretation Venography, venous sinus (eg, petrosal and inferior sagittal) or jugular, catheter, radiological 75860 - - $109.50 $42.88 $66.62 supervision and interpretation 75870 - - $146.01 $48.67 $97.34 Venography, superior sagittal sinus, radiological supervision and interpretation 75872 - - $112.00 $43.93 $68.07 Venography, epidural, radiological supervision and interpretation 75880 - - $94.91 $26.84 $68.07 Venography, orbital, radiological supervision and interpretation Percutaneous transhepatic with hemodynamic evaluation, radiological supervision 75885 - - $118.03 $52.00 $66.04 and interpretation Percutaneous transhepatic portography without hemodynamic evaluation, radiological 75887 - - $118.90 $52.58 $66.33 supervision and interpretation Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision 75889 - - $107.31 $41.28 $66.04 and interpretation Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision 75891 - - $109.05 $42.15 $66.91 and interpretation Venous sampling through catheter, with or without angiography (eg, for parathyroid hormone, 75893 - - $92.60 $20.77 $71.83 renin), radiological supervision and interpretation

75894 - - - $54.92 - Transcatheter therapy, embolization, any method, radiological supervision and interpretation Angiography through existing catheter for follow-up study for transcatheter therapy, 75898 - - - $68.93 $1,309.72 embolization or infusion, other than for thrombolysis Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous 75901 - - $176.82 $18.08 $158.74 device via separate venous access, radiologic supervision and interpretation Mechanical removal of intraluminal (intracatheter) obstructive material from central venous 75902 - - $68.42 $14.56 $53.86 device through device lumen, radiologic supervision and interpretation

Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, 75956 - - - $261.22 - penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation

Page 7 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, 75957 - - - $223.53 - penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin, radiological supervision and interpretation Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta 75958 - - - $148.26 - (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption), radiological supervision and interpretation

75959 - - - $130.34 - Placement of distal extension prosthesis(s) (delayed) after endovascular repair of descending thoracic aorta, as needed, to level of celiac origin, radiological supervision and interpretation 75970 - - - $30.49 - Transcatheter biopsy, radiological supervision and interpretation Change of percutaneous tube or drainage catheter with contrast monitoring (eg, genitourinary 75984 - - $78.83 $26.70 $52.13 system, abscess), radiological supervision and interpretation Radiological guidance (ie, fluoroscopy, , or computed tomography), for percutaneous 75989 - - $96.09 $44.83 $51.26 drainage (eg, abscess, specimen collection), with placement of catheter, radiological supervision and interpretation Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care 76000 - - $33.28 $11.88 $21.40 professional time 76010 - - $22.94 $7.05 $15.90 Radiologic examination from nose to for foreign body, single view, child Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and 76080 - - $46.90 $19.99 $26.91 interpretation 76098 - - $34.17 $12.19 $21.98 Radiological examination, surgical specimen

76100 - - $78.01 $23.86 $54.15 Radiologic examination, single plane body section (eg, tomography), other than with urography Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid 76101 - - $78.27 $20.69 $57.59 polytomography), other than with urography; unilateral Radiologic examination, complex motion (ie, hypercycloidal) body section (eg, mastoid 76102 - - $114.28 $24.24 $90.05 polytomography), other than with urography; bilateral 76120 - - $87.58 $14.58 $72.99 Cineradiography/videoradiography, except where specifically included Cineradiography/videoradiography to complement routine examination (List separately in 76125 - - - $10.31 - addition to code for primary procedure) 76140 - - I.C. - - Consultation on X-ray examination made elsewhere, written report Medical physics dose evaluation for radiation exposure that exceeds institutional review 76145 - - $703.38 - - threshold, including report

3D rendering with interpretation and reporting of computed tomography, magnetic resonance 76376 - - $18.26 $7.58 $10.68 imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation

3D rendering with interpretation and reporting of computed tomography, magnetic resonance 76377 - - $56.63 $30.59 $26.04 imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation 76380 - - $113.94 $37.08 $76.86 Computed tomography, limited or localized follow-up study 76390 - - $422.96 $54.26 $368.70 Magnetic resonance spectroscopy 76391 - - $256.61 $42.87 $213.74 Magnetic resonance (eg, vibration) 76496 - - - - $64.01 Unlisted fluoroscopic procedure (eg, diagnostic, interventional) 76497 - - - - $64.01 Unlisted computed tomography procedure (eg, diagnostic, interventional) 76498 - - - - $76.86 Unlisted magnetic resonance procedure (eg, diagnostic, interventional) 76499 - - I.C. - - Unlisted diagnostic radiographic procedure , real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other 76506 - - $92.38 $24.60 $67.78 intracranial abnormalities), including A-mode encephalography as secondary component where indicated Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same 76510 - - $72.39 $37.07 $35.31 patient encounter 76511 - - $49.06 $27.95 $21.11 Ophthalmic ultrasound, diagnostic; quantitative A-scan only Ophthalmic ultrasound, diagnostic; B-scan (with or without superimposed non-quantitative A- 76512 - - $41.72 $24.38 $17.35 scan) Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion (water bath) B-scan 76513 - - $79.73 $27.90 $51.84 or high resolution biomicroscopy Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral (determination of 76514 - - $9.42 $6.28 $3.14 corneal thickness) 76516 - - $38.35 $17.81 $20.53 Ophthalmic biometry by ultrasound echography, A-scan; 76519 - - $53.07 $24.13 $28.94 Ophthalmic biometry by ultrasound echography, A-scan; with intraocular lens power calculation 76529 - - $66.62 $25.51 $41.11 Ophthalmic ultrasonic foreign body localization

Page 8 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), real time with 76536 - - $93.22 $21.68 $71.54 image documentation 76604 - - $63.00 $22.18 $40.82 Ultrasound, chest (includes mediastinum), real time with image documentation Ultrasound, breast, unilateral, real time with image documentation, including axilla when 76641 - - $85.56 $27.93 $57.63 performed; complete Ultrasound, breast, unilateral, real time with image documentation, including axilla when 76642 - - $69.74 $26.02 $43.72 performed; limited 76700 - - $98.31 $31.41 $66.91 Ultrasound, abdominal, real time with image documentation; complete Ultrasound, abdominal, real time with image documentation; limited (eg, single , 76705 - - $72.86 $22.47 $50.39 quadrant, follow-up) Ultrasound, abdominal aorta, real time with image documentation, screening study for 76706 - - $91.51 $21.12 $70.38 abdominal aortic aneurysm (AAA) Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; 76770 - - $90.46 $28.19 $62.27 complete Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation; 76775 - - $46.51 $22.21 $24.30 limited 76776 - - $125.64 $29.50 $96.14 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation 76800 - - $113.69 $44.75 $68.94 Ultrasound, spinal canal and contents

76801 - - $97.29 $38.21 $59.08 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76802 - - $49.42 $31.74 $17.68 evaluation, first trimester (< 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76805 - - $111.78 $38.21 $73.57 evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76810 - - $72.39 $37.95 $34.45 evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76811 - - $140.18 $72.74 $67.44 evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76812 - - $157.87 $68.11 $89.76 evaluation plus detailed fetal anatomic examination, transabdominal approach; each additional gestation (List separately in addition to code for primary procedure)

76813 - - $95.96 $45.28 $50.68 Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal 76814 - - $61.73 $38.01 $23.72 translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure)

76815 - - $66.91 $24.93 $41.98 Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), 1 or more fetuses Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation 76816 - - $90.19 $32.56 $57.63 of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus 76817 - - $76.23 $28.75 $47.49 Ultrasound, pregnant uterus, real time with image documentation, transvaginal 76818 - - $93.71 $40.18 $53.53 Fetal biophysical profile; with non-stress testing 76819 - - $68.94 $29.57 $39.37 Fetal biophysical profile; without non-stress testing 76820 - - $36.90 $19.26 $17.63 Doppler velocimetry, fetal; umbilical artery 76821 - - $72.05 $26.60 $45.46 Doppler velocimetry, fetal; middle cerebral artery , fetal, cardiovascular system, real time with image documentation (2D), with 76825 - - $219.05 $63.21 $155.84 or without M-mode recording; Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with 76826 - - $130.48 $31.45 $99.03 or without M-mode recording; follow-up or repeat study , fetal, pulsed wave and/or continuous wave with spectral display; 76827 - - $58.44 $21.96 $36.47 complete Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; 76828 - - $41.10 $21.43 $19.66 follow-up or repeat study 76830 - - $98.70 $26.57 $72.12 Ultrasound, transvaginal 76831 - - $95.44 $27.66 $67.78 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed 76856 - - $87.68 $26.28 $61.40 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete Ultrasound, pelvic (nonobstetric), real time with image documentation; limited or follow-up (eg, 76857 - - $38.34 $18.97 $19.37 for follicles)

Page 9 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 76870 - - $84.04 $24.38 $59.66 Ultrasound, scrotum and contents 76872 - - $115.84 $25.75 $90.09 Ultrasound, transrectal; Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate 76873 - - $139.68 $60.31 $79.37 procedure) Ultrasound, complete joint (ie, joint space and peri-articular soft tissue structures) real-time 76881 - - $61.79 $24.16 $37.63 with image documentation Ultrasound, limited, joint or other nonvascular extremity structure(s) (eg, joint space, peri- 76882 - - $45.33 $18.71 $26.62 articular tendon[s], muscle[s], nerve[s], other soft tissue structure[s], or soft tissue mass[es]), real-time with image documentation Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician or 76885 - - $92.49 $28.48 $64.01 other qualified health care professional manipulation) Ultrasound, infant hips, real time with imaging documentation; limited, static (not requiring 76886 - - $84.38 $23.85 $60.53 physician or other qualified health care professional manipulation) 76932 - - - $26.53 - Ultrasonic guidance for endomyocardial biopsy, imaging supervision and interpretation Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae 76936 - - $214.93 $74.45 $140.48 (includes diagnostic ultrasound evaluation, compression of lesion and imaging) Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of 76937 - - $29.03 $11.06 $17.97 vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 76940 - - - $78.97 - Ultrasound guidance for, and monitoring of, parenchymal tissue ablation Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis, imaging supervision and 76941 - - - $51.55 - interpretation Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), 76942 - - $45.13 $24.31 $20.82 imaging supervision and interpretation 76945 - - - $25.51 - Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation 76946 - - $25.35 $14.38 $10.97 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation 76948 - - $60.53 $25.51 $35.02 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation 76965 - - $72.96 $52.42 $20.53 Ultrasonic guidance for interstitial radioelement application 76975 - - - $32.12 $187.19 Gastrointestinal , supervision and interpretation 76977 - - $5.58 $2.15 $3.43 Ultrasound bone density measurement and interpretation, peripheral site(s), any method Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); 76978 - - $262.51 $61.99 $200.52 initial lesion Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); 76979 - - $179.03 $33.00 $146.03 each additional lesion with separate injection (List separately in addition to code for primary procedure) 76981 - - $86.48 $22.76 $63.72 Ultrasound, elastography; parenchyma (eg, organ) 76982 - - $76.92 $22.76 $54.15 Ultrasound, elastography; first target lesion Ultrasound, elastography; each additional target lesion (List separately in addition to code for 76983 - - $47.08 $19.26 $27.82 primary procedure) 76998 - - - $48.28 - Ultrasonic guidance, intraoperative 76999 - - I.C. - - Unlisted ultrasound procedure (eg, diagnostic, interventional)

Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter 77001 - - $77.43 $14.29 $63.14 manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure) Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization 77002 - - $86.89 $21.44 $65.46 device) (List separately in addition to code for primary procedure) Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous 77003 - - $80.95 $23.03 $57.92 diagnostic or therapeutic injection procedures (epidural or subarachnoid) (List separately in addition to code for primary procedure) 77011 - - $187.00 $49.08 $137.92 Computed tomography guidance for stereotactic localization Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, 77012 - - $119.34 $56.78 $62.56 localization device), radiological supervision and interpretation 77013 - - - $146.35 - Computed tomography guidance for, and monitoring of, parenchymal tissue ablation 77014 - - $97.73 $34.88 $62.85 Computed tomography guidance for placement of radiation therapy fields

77021 - - $375.64 $56.04 $319.60 Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation 77022 - - - $166.16 - Magnetic resonance imaging guidance for, and monitoring of, parenchymal tissue ablation 77046 - - $267.96 $55.79 $212.17 Magnetic resonance imaging, breast, without contrast material; unilateral 77047 - - $273.28 $61.50 $211.78 Magnetic resonance imaging, breast, without contrast material; bilateral Magnetic resonance imaging, breast, without and with contrast material(s), including computer- 77048 - - $361.54 $80.52 $281.02 aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; unilateral

Page 10 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Magnetic resonance imaging, breast, without and with contrast material(s), including computer- 77049 - - $367.98 $88.34 $279.64 aided detection (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; bilateral

77053 - - $45.35 $13.81 $31.55 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation

77054 - - $58.76 $17.35 $41.40 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77061 - - I.C. - - Diagnostic digital breast tomosynthesis; unilateral 77062 - - I.C. - - Diagnostic digital breast tomosynthesis; bilateral Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary 77063 - - $43.32 $23.03 $20.29 procedure) Diagnostic , including computer-aided detection (CAD) when performed; 77065 - - $107.30 $31.41 $75.89 unilateral

77066 - - $135.24 $38.48 $96.76 Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral Screening mammography, bilateral (2-view study of each breast), including computer-aided 77067 - - $148.95 $42.79 $106.16 detection (CAD) when performed Manual application of stress performed by physician or other qualified health care professional 77071 - - $42.11 - - for joint , including contralateral joint if indicated 77072 - - $20.02 $7.31 $12.71 Bone age studies 77073 - - $35.17 $10.58 $24.59 Bone length studies (orthoroentgenogram, scanogram) 77074 - - $50.38 $17.09 $33.29 Radiologic examination, osseous survey; limited (eg, for metastases) 77075 - - $76.15 $21.41 $54.73 Radiologic examination, osseous survey; complete (axial and appendicular skeleton) 77076 - - $82.15 $26.84 $55.31 Radiologic examination, osseous survey, infant 77077 - - $36.44 $13.30 $23.14 Joint survey, single view, 2 or more joints (specify) Computed tomography, bone mineral density study, 1 or more sites, axial skeleton (eg, hips, 77078 - - $73.49 $9.49 $64.01 pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, 77080 - - $31.59 $7.58 $24.01 hips, pelvis, spine) Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; appendicular 77081 - - $25.79 $7.87 $17.92 skeleton (peripheral) (eg, radius, wrist, heel) 77084 - - $362.09 $61.79 $300.30 Magnetic resonance (eg, proton) imaging, bone marrow blood supply Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, 77085 - - $42.65 $11.39 $31.26 hips, pelvis, spine), including vertebral fracture assessment 77086 - - $27.61 $6.49 $21.11 Vertebral fracture assessment via dual-energy X-ray absorptiometry (DXA) 77261 - - $55.53 - - Therapeutic radiology treatment planning; simple 77262 - - $84.06 - - Therapeutic radiology treatment planning; intermediate 77263 - - $131.24 - - Therapeutic radiology treatment planning; complex 77280 - - $225.62 $29.16 $196.46 Therapeutic radiology simulation-aided field setting; simple 77285 - - $378.24 $45.02 $333.22 Therapeutic radiology simulation-aided field setting; intermediate 77290 - - $403.90 $64.30 $339.60 Therapeutic radiology simulation-aided field setting; complex Respiratory motion management simulation (List separately in addition to code for primary 77293 - - $364.67 $82.50 $282.16 procedure) 77295 - - $388.49 $175.45 $213.05 3-dimensional radiotherapy plan, including dose-volume histograms 77299 - - I.C. - - Unlisted procedure, therapeutic radiology clinical treatment planning Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non- 77300 - - $52.83 $25.34 $27.49 surface and depth dose, as required during course of treatment, only when prescribed by the treating physician Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical 77301 - - $1,543.26 $326.63 $1,216.63 structure partial tolerance specifications Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), 77306 - - $118.85 $57.49 $61.35 includes basic dosimetry calculation(s) Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of 77307 - - $229.82 $118.75 $111.07 wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote 77316 - - $174.94 $57.49 $117.45 afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote 77317 - - $229.40 $75.43 $153.97 afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)

77318 - - $327.36 $118.46 $208.90 Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) 77321 - - $75.07 $39.47 $35.60 Special teletherapy port plan, particles, hemibody, total body Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating 77331 - - $51.01 $35.70 $15.32 physician 77332 - - $37.60 $18.51 $19.08 Treatment devices, design and construction; simple (simple block, simple bolus)

Page 11 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, 77333 - - $96.81 $30.77 $66.04 special bolus) Treatment devices, design and construction; complex (irregular blocks, special shields, 77334 - - $101.54 $47.38 $54.15 compensators, wedges, molds or casts) Continuing medical physics consultation, including assessment of treatment parameters, quality 77336 - - $64.94 - - assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design 77338 - - $387.82 $175.45 $212.38 and construction per IMRT plan 77370 - - $101.24 - - Special medical radiation physics consultation Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of 77371 - - I.C. - - cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of 77372 - - $858.11 - - cranial lesion(s) consisting of 1 session; linear accelerator based Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, 77373 - - $987.48 - - including image guidance, entire course not to exceed 5 fractions Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when 77385 - - I.C. - - performed; simple Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when 77386 - - I.C. - - performed; complex Guidance for localization of target volume for delivery of radiation treatment, includes 77387 - - I.C. - - intrafraction tracking, when performed Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special 77399 - - I.C. - - services 77401 - - $19.95 - - Radiation treatment delivery, superficial and/or ortho voltage, per day 77402 - - I.C. - - Radiation treatment delivery, => 1 MeV; simple 77407 - - I.C. - - Radiation treatment delivery, => 1 MeV; intermediate 77412 - - I.C. - - Radiation treatment delivery, => 1 MeV; complex 77417 - - $9.23 - - Therapeutic radiology port image(s) High energy neutron radiation treatment delivery, 1 or more isocenter(s) with coplanar or non- 77423 - - I.C. - - coplanar geometry with blocking and/or wedge, and/or compensator(s) 77424 - - I.C. - - Intraoperative radiation treatment delivery, x-ray, single treatment session 77425 - - I.C. - - Intraoperative radiation treatment delivery, electrons, single treatment session 77427 - - $148.27 - - Radiation treatment management, 5 treatments Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions 77431 - - $82.50 - - only Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment 77432 - - $330.47 - - consisting of 1 session) Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or 77435 - - $499.16 - - more lesions, including image guidance, entire course not to exceed 5 fractions 77469 - - $247.74 - - Intraoperative radiation treatment management Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or 77470 - - $104.41 $83.59 $20.82 endocavitary irradiation) 77499 - - I.C. - - Unlisted procedure, therapeutic radiology treatment management 77520 - - I.C. - - Proton treatment delivery; simple, without compensation 77522 - - I.C. - - Proton treatment delivery; simple, with compensation 77523 - - I.C. - - Proton treatment delivery; intermediate 77525 - - I.C. - - Proton treatment delivery; complex 77600 - - $378.00 $55.35 $322.65 Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) 77605 - - $689.46 $79.30 $610.17 Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) 77610 - - $555.43 $53.66 $501.77 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators 77615 - - $869.35 $75.70 $793.65 Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators 77620 - - $496.21 $65.45 $430.76 Hyperthermia generated by intracavitary probe(s) 77750 - - $302.61 $204.29 $98.32 Infusion or instillation of radioelement solution (includes 3-month follow-up care) 77761 - - $321.26 $157.49 $163.78 Intracavitary radiation source application; simple 77762 - - $423.90 $236.15 $187.74 Intracavitary radiation source application; intermediate 77763 - - $597.05 $354.66 $242.39 Intracavitary radiation source application; complex Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic 77767 - - $193.48 $43.28 $150.20 dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel Remote afterloading high dose rate radionuclide skin surface brachytherapy, includes basic 77768 - - $290.54 $57.49 $233.05 dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, 77770 - - $270.26 $80.06 $190.20 includes basic dosimetry, when performed; 1 channel Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, 77771 - - $481.53 $155.29 $326.24 includes basic dosimetry, when performed; 2-12 channels

Page 12 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, 77772 - - $726.12 $219.49 $506.63 includes basic dosimetry, when performed; over 12 channels Interstitial radiation source application, complex, includes supervision, handling, loading of 77778 - - $688.25 $358.14 $330.12 radiation source, when performed 77789 - - $102.10 $47.41 $54.69 Surface application of low dose rate radionuclide source 77790 - - $12.42 - - Supervision, handling, loading of radiation source 77799 - - I.C. - - Unlisted procedure, clinical brachytherapy Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, 78012 - - $66.88 $7.31 $59.57 suppression, or discharge, when performed) 78013 - - $158.03 $13.83 $144.20 Thyroid imaging (including vascular flow, when performed); Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) 78014 - - $197.28 $18.68 $178.60 quantitative measurement(s) (including stimulation, suppression, or discharge, when performed) 78015 - - $184.36 $25.46 $158.89 Thyroid carcinoma metastases imaging; limited area (eg, neck and chest only) 78016 - - $231.90 $26.06 $205.85 Thyroid carcinoma metastases imaging; with additional studies (eg, urinary recovery) 78018 - - $257.22 $31.66 $225.56 Thyroid carcinoma metastases imaging; whole body 78020 - - $67.04 $21.33 $45.70 Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure) 78070 - - $243.46 $29.78 $213.67 Parathyroid planar imaging (including subtraction, when performed); 78071 - - $289.92 $44.94 $244.98 Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT) Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), 78072 - - $365.41 $58.99 $306.42 and concurrently acquired computed tomography (CT) for anatomical localization 78075 - - $369.35 $28.48 $340.87 Adrenal imaging, cortex and/or medulla 78099 - - I.C. - - Unlisted endocrine procedure, diagnostic nuclear 78102 - - $139.57 $20.30 $119.28 Bone marrow imaging; limited area 78103 - - $177.54 $26.76 $150.78 Bone marrow imaging; multiple areas 78104 - - $204.62 $29.78 $174.84 Bone marrow imaging; whole body Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single 78110 - - $57.03 $6.15 $50.88 sampling Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); multiple 78111 - - $60.43 $7.24 $53.19 samplings 78120 - - $58.38 $7.51 $50.88 Red cell volume determination (separate procedure); single sampling 78121 - - $63.67 $10.47 $53.19 Red cell volume determination (separate procedure); multiple samplings Whole blood volume determination, including separate measurement of plasma volume and red 78122 - - $78.42 $16.24 $62.18 cell volume (radiopharmaceutical volume-dilution technique) 78130 - - $102.28 $19.62 $82.67 Red cell survival study; 78140 - - $90.69 $19.62 $71.07 Labeled red cell sequestration, differential organ/tissue (eg, splenic and/or hepatic) 78185 - - $140.19 $12.89 $127.30 Spleen imaging only, with or without vascular flow 78191 - - $102.28 $19.62 $82.67 Platelet survival study 78195 - - $290.79 $44.65 $246.13 Lymphatics and lymph nodes imaging Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear 78199 - - I.C. - - medicine 78201 - - $156.85 $16.22 $140.63 imaging; static only 78202 - - $168.86 $18.37 $150.49 Liver imaging; with vascular flow 78215 - - $160.50 $18.42 $142.08 Liver and spleen imaging; static only 78216 - - $105.23 $20.83 $84.41 Liver and spleen imaging; with vascular flow 78226 - - $269.69 $27.90 $241.79 Hepatobiliary system imaging, including when present; Hepatobiliary system imaging, including gallbladder when present; with pharmacologic 78227 - - $364.52 $34.37 $330.14 intervention, including quantitative measurement(s) when performed 78230 - - $143.30 $17.35 $125.94 Salivary gland imaging; 78231 - - $85.98 $16.65 $69.33 Salivary gland imaging; with serial images 78232 - - $84.37 $15.03 $69.33 Salivary gland function study 78258 - - $177.28 $26.79 $150.49 Esophageal motility 78261 - - $167.30 $22.03 $145.27 Gastric mucosa imaging 78262 - - $196.80 $25.73 $171.07 Gastroesophageal reflux study 78264 - - $273.62 $29.81 $243.82 Gastric emptying imaging study (eg, solid, liquid, or both); 78265 - - $323.45 $37.08 $286.38 Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel transit Gastric emptying imaging study (eg, solid, liquid, or both); with small bowel and colon transit, 78266 - - $353.73 $37.79 $315.94 multiple days 78267 - - I.C. - - , C-14 (isotopic); acquisition for analysis 78268 - - I.C. - - Urea breath test, C-14 (isotopic); analysis 78278 - - $286.08 $37.63 $248.45 Acute gastrointestinal blood loss imaging 78282 - - - $12.35 $295.59 Gastrointestinal protein loss 78290 - - $271.57 $25.44 $246.13 Intestine imaging (eg, ectopic gastric mucosa, Meckel's localization, volvulus) 78291 - - $208.97 $32.97 $175.99 Peritoneal-venous shunt patency test (eg, for LeVeen, Denver shunt) 78299 - - I.C. - - Unlisted gastrointestinal procedure, diagnostic

Page 13 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 78300 - - $188.34 $23.85 $164.49 Bone and/or joint imaging; limited area 78305 - - $228.02 $31.65 $196.37 Bone and/or joint imaging; multiple areas 78306 - - $247.28 $32.73 $214.54 Bone and/or joint imaging; whole body 78315 - - $284.27 $38.72 $245.55 Bone and/or joint imaging; 3 phase study 78350 - - $25.74 $8.40 $17.35 Bone density (bone mineral content) study, 1 or more sites; single photon absorptiometry Bone density (bone mineral content) study, 1 or more sites; dual photon absorptiometry, 1 or 78351 - - $11.93 - - more sites 78399 - - I.C. - - Unlisted musculoskeletal procedure, diagnostic nuclear medicine Determination of central c-v hemodynamics (non-imaging) (eg, ejection fraction with probe 78414 - - - $16.82 - technique) with or without pharmacologic intervention or exercise, single or multiple determinations 78428 - - $151.43 $28.96 $122.47 Cardiac shunt detection Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including 78429 - - - $64.10 $11.55 ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; with concurrently acquired computed tomography transmission scan Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress 78430 - - - $60.84 $11.55 (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress 78431 - - - $70.91 $1,807.37 (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic 78432 - - - $75.42 $2,208.79 evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when 78433 - - - $82.45 $2,208.79 performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan

78434 - - - $23.87 - Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) 78445 - - $160.74 $19.44 $141.30 Non-cardiac vascular flow imaging (ie, angiography, venography) Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 78451 - - $275.27 $51.46 $223.82 additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 78452 - - $384.64 $60.68 $323.97 additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection 78453 - - $248.09 $38.19 $209.91 fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple 78454 - - $356.14 $51.22 $304.93 studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 78456 - - $252.82 $37.12 $215.70 Acute venous thrombosis imaging, peptide 78457 - - $143.34 $28.70 $114.64 Venous thrombosis imaging, venogram; unilateral 78458 - - $167.85 $34.95 $132.90 Venous thrombosis imaging, venogram; bilateral

78459 - - - $58.14 $1,021.63 Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single study; 78466 - - $163.82 $27.15 $136.67 Myocardial imaging, infarct avid, planar; qualitative or quantitative 78468 - - $157.37 $29.78 $127.59 Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique 78469 - - $182.59 $34.71 $147.88 Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise 78472 - - $185.92 $37.08 $148.84 and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection 78473 - - $235.34 $54.42 $180.92 fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress 78481 - - $143.02 $37.08 $105.94 (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification

Page 14 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with 78483 - - $195.73 $55.00 $140.72 stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular 78491 - - - $56.52 $1,158.72 wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic) Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular 78492 - - - $66.61 $1,158.72 wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic) Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection 78494 - - $184.15 $44.68 $139.48 fraction, with or without quantitative processing Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular 78496 - - $34.29 $18.68 $15.61 ejection fraction by first pass technique (List separately in addition to code for primary procedure) 78499 - - I.C. - - Unlisted cardiovascular procedure, diagnostic nuclear medicine 78579 - - $153.92 $18.42 $135.51 Pulmonary ventilation imaging (eg, aerosol or gas) 78580 - - $194.13 $27.90 $166.23 Pulmonary perfusion imaging (eg, particulate) 78582 - - $273.43 $40.33 $233.09 Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging 78597 - - $164.30 $27.05 $137.25 Quantitative differential pulmonary perfusion, including imaging when performed Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including 78598 - - $249.71 $31.40 $218.31 imaging when performed 78599 - - I.C. - - Unlisted respiratory procedure, diagnostic nuclear medicine 78600 - - $151.06 $16.80 $134.26 Brain imaging, less than 4 static views; 78601 - - $178.13 $19.24 $158.89 Brain imaging, less than 4 static views; with vascular flow 78605 - - $163.88 $20.35 $143.53 Brain imaging, minimum 4 static views; 78606 - - $271.96 $24.09 $247.87 Brain imaging, minimum 4 static views; with vascular flow 78608 - - - $54.93 $1,158.72 Brain imaging, positron emission tomography (PET); metabolic evaluation 78609 - - $58.56 $58.56 - Brain imaging, positron emission tomography (PET); perfusion evaluation 78610 - - $143.13 $11.39 $131.74 Brain imaging, vascular flow only 78630 - - $277.95 $25.73 $252.22 flow, imaging (not including introduction of material); cisternography 78635 - - $278.12 $23.58 $254.54 Cerebrospinal fluid flow, imaging (not including introduction of material); ventriculography 78645 - - $267.25 $21.12 $246.13 Cerebrospinal fluid flow, imaging (not including introduction of material); shunt evaluation 78650 - - $226.91 $19.62 $207.30 Cerebrospinal fluid leakage detection and localization 78660 - - $151.22 $20.35 $130.87 Radiopharmaceutical dacryocystography 78699 - - I.C. - - Unlisted nervous system procedure, diagnostic nuclear medicine 78700 - - $140.40 $16.77 $123.62 Kidney imaging morphology; 78701 - - $179.63 $18.42 $161.21 Kidney imaging morphology; with vascular flow Kidney imaging morphology; with vascular flow and function, single study without 78707 - - $190.22 $35.97 $154.26 pharmacological intervention Kidney imaging morphology; with vascular flow and function, single study, with pharmacological 78708 - - $143.24 $45.21 $98.03 intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic)

78709 - - $300.41 $52.25 $248.16 Kidney imaging morphology; with vascular flow and function, multiple studies, with and without pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) 78725 - - $88.74 $13.80 $74.93 Kidney function study, non-imaging radioisotopic study 78730 - - $62.48 $6.01 $56.47 Urinary bladder residual study (List separately in addition to code for primary procedure) 78740 - - $178.27 $20.83 $157.44 Ureteral reflux study (radiopharmaceutical voiding cystogram) 78761 - - $173.54 $27.40 $146.14 Testicular imaging with vascular flow 78799 - - I.C. - - Unlisted genitourinary procedure, diagnostic nuclear medicine Radiopharmaceutical localization of tumor, inflammatory process or distribution of 78800 - - $212.55 $24.58 $187.97 radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, single area (eg, head, neck, chest, pelvis), single day imaging Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); 78801 - - $233.39 $27.84 $205.56 planar, 2 or more areas (eg, abdomen and pelvis, head and chest), 1 or more days imaging or single area imaging over 2 or more days Radiopharmaceutical localization of tumor, inflammatory process or distribution of 78802 - - $256.50 $29.49 $227.01 radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, single day imaging

Radiopharmaceutical localization of tumor, inflammatory process or distribution of 78803 - - $319.17 $40.28 $278.89 radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT), single area (eg, head, neck, chest, pelvis), single day imaging Radiopharmaceutical localization of tumor, inflammatory process or distribution of 78804 - - $543.81 $37.87 $505.94 radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); planar, whole body, requiring 2 or more days imaging

Page 15 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Injection procedure for radiopharmaceutical localization by non-imaging probe study, 78808 - - $32.51 - - intravenous (eg, parathyroid adenoma) 78811 - - - $57.88 $1,021.63 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) 78812 - - - $71.13 $1,158.72 Positron emission tomography (PET) imaging; skull base to mid-thigh 78813 - - - $71.34 $1,158.72 Positron emission tomography (PET) imaging; whole body

78814 - - - $81.43 $1,158.72 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for 78815 - - - $91.28 $1,158.72 attenuation correction and anatomical localization imaging; skull base to mid-thigh Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for 78816 - - - $92.00 $1,158.72 attenuation correction and anatomical localization imaging; whole body Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); 78830 - - $403.64 $55.20 $348.45 tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of , single area (eg, head, neck, chest, pelvis), single day imaging Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); 78831 - - $584.58 $67.34 $517.24 tomographic (SPECT), minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s) (includes vascular flow and blood pool imaging, when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan 78832 - - $761.47 $78.44 $683.03 for anatomical review, localization and determination/detection of pathology, minimum 2 areas (eg, pelvis and knees, abdomen and pelvis), single day imaging, or single area imaging over 2 or more days Radiopharmaceutical quantification measurement(s) single area (List separately in addition to 78835 - - $84.21 $17.31 $66.91 code for primary procedure) 78999 - - I.C. - - Unlisted miscellaneous procedure, diagnostic nuclear medicine 79005 - - $108.75 $67.68 $41.07 Radiopharmaceutical therapy, by oral administration 79101 - - $117.34 $75.69 $41.65 Radiopharmaceutical therapy, by intravenous administration 79200 - - $106.81 $63.43 $43.39 Radiopharmaceutical therapy, by intracavitary administration 79300 - - - $50.81 - Radiopharmaceutical therapy, by interstitial radioactive colloid administration 79403 - - $150.20 $83.67 $66.53 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion 79440 - - $95.80 $63.43 $32.37 Radiopharmaceutical therapy, by intra-articular administration 79445 - - - $87.52 - Radiopharmaceutical therapy, by intra-arterial particulate administration 79999 - - I.C. - - Radiopharmaceutical therapy, unlisted procedure High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic 0394T - - I.C. - - dosimetry, when performed High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, 0395T - - I.C. - - includes basic dosimetry, when performed A4641 - - I.C. - - Radiopharmaceutical, diagnostic, not otherwise classified A9500 - - I.C. - - Technetium Tc-99m sestamibi, diagnostic, per study dose A9502 - - I.C. - - Technetium Tc-99m tetrofosmin, diagnostic, per study dose A9503 - - I.C. - - Technetium Tc-99m medronate, diagnostic, per study dose, up to 30 mCi A9505 - - I.C. - - Thallium Tl-201 thallous chloride, diagnostic, per mCi A9512 - - I.C. - - Technetium Tc-99m pertechnetate, diagnostic, per mCi A9537 - - I.C. - - Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 mCi A9552 - - I.C. - - Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries A9586 - - I.C. - - Florbetapir f18, diagnostic, per study dose, up to 10 millicuries A9587 - - I.C. - - Gallium ga-68, dotatate, diagnostic, 0.1 millicurie A9588 - - I.C. - - Fluciclovine f-18, diagnostic, 1 millicurie A9591 - - I.C. - - Fluoroestradiol f 18, diagnostic, 1 mCi Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0279 - - $43.32 $23.03 $20.29 77065 or 77066) G0297 - - $191.42 $39.30 $152.12 Low dose CT scan (LDCT) for lung G6001 - - $94.38 $24.86 $69.52 Ultrasonic guidance for placement of radiation therapy fields Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation G6002 - - $60.40 $15.81 $44.59 therapy Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple G6003 - - $152.41 - - blocks or no blocks: up to 5 mev Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple G6004 - - $115.31 - - blocks or no blocks: 6-10 mev Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple G6005 - - $115.31 - - blocks or no blocks: 11-19 mev

Page 16 of 17 Radiology Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple G6006 - - $115.31 - - blocks or no blocks: 20 mev or greater Radiation treatment delivery, two separate treatment areas, three or more ports on a single G6007 - - $216.46 - - treatment area, use of multiple blocks: up to 5 mev Radiation treatment delivery, two separate treatment areas, three or more ports on a single G6008 - - $159.07 - - treatment area, use of multiple blocks: 6-10 mev Radiation treatment delivery, two separate treatment areas, three or more ports on a single G6009 - - $157.92 - - treatment area, use of multiple blocks: 11-19 mev Radiation treatment delivery, two separate treatment areas, three or more ports on a single G6010 - - $157.92 - - treatment area, use of multiple blocks: 20 mev or greater Radiation treatment delivery, three or more separate treatment areas, custom blocking, G6011 - - $213.85 - - tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 mev Radiation treatment delivery, three or more separate treatment areas, custom blocking, G6012 - - $210.96 - - tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 mev Radiation treatment delivery, three or more separate treatment areas, custom blocking, G6013 - - $211.24 - - tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 mev

G6014 - - $211.24 - - Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 mev or greater Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and G6015 - - $296.86 - - temporally modulated beams, binary, dynamic MLC, per treatment session Compensator-based beam modulation treatment delivery of inverse planned treatment using G6016 - - $295.88 - - three or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session

G6017 - - $60.40 $15.81 $44.59 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to R0075 - - I.C. - - facility or location, more than one patient seen

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