Radiological/Imaging Fee Schedule

Radiological / Imaging Services Fee Schedule Provider Specialty 093

The inclusion of a rate on this table does not guarantee that a service is covered. Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical Coverage Policies on the DMA Web site

Medicaid Maximum Allowable NON- EFFECTIVE CODE MOD Description FACILITY FACILITY DATE 70250 TC RADIOLOGIC EXAM SKULL $18.17 $18.17 11/1/2011 71010 TC RADIOLOGIC EXAM, CHEST $11.33 $11.33 11/1/2011 71020 TC RADILOGICAL EXAM CHEST TWO VIEWS FRONTAL/LATERAL $15.65 $15.65 11/1/2011 71100 TC RADIOLOGIC EXAM, RIBS $16.21 $16.21 11/1/2011 71101 TC RADIOLOGIC EXAM RIBS /POSTEROANTERIOR CHEST $19.57 $19.57 11/1/2011 71110 TC RADIOLOGIC EXAM, RIBS BILATERAL $20.61 $20.61 11/1/2011 71111 TC RADIOLOGIC EXAM INCLUDING POSTEROANTERIOR $27.26 $27.26 11/1/2011 71120 26 STERNUM $8.22 $8.22 11/1/2011 71120 TC RADIOLOGIC EXAM STERNUM $17.05 $17.05 11/1/2011 71120 X-RAY EXAM OF BREASTBONE $25.28 $25.28 11/1/2011 71130 26 STERNOCLAVICULAR JOINTS $9.11 $9.11 11/1/2011 71130 TC RADIOLOGIC EXAM STERNOCLAVICULAR JOINT(S) $19.86 $19.86 11/1/2011 71130 X-RAY EXAM OF BREASTBONE $28.98 $28.98 11/1/2011 72010 26 RADIOLOGIC EXAM STERNUM $17.97 $17.97 11/1/2011 72010 TC RADIOLOGIC EXAM STERNUM $35.40 $35.40 11/1/2011 72010 RADIOLOGIC EXAM STERNUM $53.38 $53.38 11/1/2011 72020 26 RADIOLOGIC EXAM STERNOCLAVICULAR JOINT(S) $6.43 $6.43 11/1/2011 72020 TC RADIOLOGIC EXAM SPINE /SPECIFY LEVEL $11.89 $11.89 11/1/2011 72020 RADIOLOGIC EXAM STERNOCLAVICULAR JOINT(S) $18.33 $18.33 11/1/2011 72040 26 RADILOGIC EXAM SPINE $9.11 $9.11 11/1/2011 72040 TC RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VI $19.30 $19.30 11/1/2011 72040 RADIOLOGIC EXAM STERNOCLAVICULAR JOINT(S) $28.41 $28.41 11/1/2011 72050 26 RADILOGIC EXAM SPINE $12.69 $12.69 11/1/2011 72050 TC RADIOLOGIC EXAM SPINE /SPECIFY LEVEL $27.54 $27.54 11/1/2011 72050 RADILOGIC EXAM SPINE $40.23 $40.23 11/1/2011 72052 26 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VI $14.96 $14.96 11/1/2011 72052 TC RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VI $35.40 $35.40 11/1/2011 72052 RADIOLOGIC EXAM SPINE /SPECIFY LEVEL $50.36 $50.36 11/1/2011 72069 26 RADIOLOGIC EXAM SPINE. 4 VIEWS $9.11 $9.11 11/1/2011 72069 TC RADIOLOGIC EXAM SPINE. 4 VIEWS $17.78 $17.78 11/1/2011 72069 RADIOLOGIC EXAM SPINE. 4 VIEWS $26.91 $26.91 11/1/2011 72070 26 RADIOLOGIC EXAM SPINE, COMPLETE $9.11 $9.11 11/1/2011 72070 TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS $17.05 $17.05 11/1/2011 72070 RADIOLOGIC EXAM SPINE, COMPLETE $26.16 $26.16 11/1/2011 72072 26 RADIOLOGIC EXAM SPINE THORACOLUMBAR $9.11 $9.11 11/1/2011 72072 TC RADIOLOGIC EXAM SPINE THORACOLUMBAR $20.61 $20.61 11/1/2011 72072 RADIOLOGIC EXAM SPINE, COMPLETE $29.72 $29.72 11/1/2011 72074 26 RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS $9.11 $9.11 11/1/2011 72074 TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS $25.58 $25.58 11/1/2011 72074 RADIOLOGIC EXAM SPINE THORACOLUMBAR $34.69 $34.69 11/1/2011 72080 26 RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS $9.11 $9.11 11/1/2011 72080 TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS $18.17 $18.17 11/1/2011 72080 RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS $27.29 $27.29 11/1/2011 72090 26 RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR $11.78 $11.78 11/1/2011 72090 TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR $24.06 $24.06 11/1/2011 72090 RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR $35.85 $35.85 11/1/2011 72100 26 RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEW $9.11 $9.11 11/1/2011 72100 TC RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THR $20.70 $20.70 11/1/2011 72100 RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEW $29.81 $29.81 11/1/2011 72110 26 RADIOLOGIC EXAM SPINE. SCOLIIOSIS $12.69 $12.69 11/1/2011 72110 TC RADIOLOGIC EXAM SPINE. SCOLIIOSIS $28.95 $28.95 11/1/2011 72110 RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEW $41.64 $41.64 11/1/2011 72114 26 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THR $14.96 $14.96 11/1/2011

Page 1 of 6 Radiological / Imaging Services Fee Schedule Provider Specialty 093

Medicaid Maximum Allowable NON- EFFECTIVE CODE MOD Description FACILITY FACILITY DATE 72114 TC RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THR $39.33 $39.33 11/1/2011 72114 RADIOLOGIC EXAM SPINE. SCOLIIOSIS $54.29 $54.29 11/1/2011 72120 26 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF $9.11 $9.11 11/1/2011 72120 TC RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF $28.10 $28.10 11/1/2011 72120 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF $37.22 $37.22 11/1/2011 72170 26 RADIOLOGIC EXAM SPINE COMPLETE /BENDING VIEW $7.04 $7.04 11/1/2011 72170 TC RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS $13.02 $13.02 11/1/2011 72170 RADIOLOGIC EXAM SPINE COMPLETE /BENDING VIEW $20.05 $20.05 11/1/2011 72190 26 RADIOLOGIC EXAM SPINE BENDING VIEW $8.81 $8.81 11/1/2011 72190 TC RADIOLOGIC EXAM SPINE BENDING VIEW $21.54 $21.54 11/1/2011 72190 RADIOLOGIC EXAM SPINE COMPLETE /BENDING VIEW $30.36 $30.36 11/1/2011 72196 26 RADIOLOGIC EXAM SPINE BENDING VIEW $72.00 $72.00 11/1/2011 72200 26 RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS $7.04 $7.04 11/1/2011 72200 TC RADIOLOGIC EXAM PELVIC COMPLETE $15.26 $15.26 11/1/2011 72200 RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS $22.30 $22.30 11/1/2011 72202 26 RADIOLOGIC EXAM PELVIC COMPLETE $7.92 $7.92 11/1/2011 72202 TC MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CO $19.02 $19.02 11/1/2011 72202 RADIOLOGIC EXAM PELVIC COMPLETE $26.94 $26.94 11/1/2011 72220 26 RADIOLOGIC EXAM SACRUM, COCCYX $7.04 $7.04 11/1/2011 72220 TC SACRUM AND COCCYX $15.65 $15.65 11/1/2011 72220 RADIOLOGIC EXAM SACRUM, COCCYX $22.69 $22.69 11/1/2011 73000 26 X-RAY EXAM OF SACROILIAC JOINTS, 3 OR MORE VIEWS $6.74 $6.74 11/1/2011 73000 TC RADIOLOGIC EXAM CLAVICLE, COMPLETE $14.41 $14.41 11/1/2011 73000 RADIOLOGIC EXAM SACRUM, COCCYX $21.15 $21.15 11/1/2011 73010 26 X-RAY EXAM OF SACROILIAC JOINTS, 3 OR MORE VIEWS $7.04 $7.04 11/1/2011 73010 TC SACRUM AND COCCYX $14.71 $14.71 11/1/2011 73010 X-RAY EXAM OF SACROILIAC JOINTS, 3 OR MORE VIEWS $21.73 $21.73 11/1/2011 73020 26 RADIOLOGIC EXAM CLAVICLE, COMPLETE $6.15 $6.15 11/1/2011 73020 TC RADIOLOGIC EXAM CLAVICLE, COMPLETE $11.89 $11.89 11/1/2011 73020 SACRUM AND COCCYX $18.04 $18.04 11/1/2011 73030 26 RADIOLOGIC EXAM, SCAPULA/ COMPLETE $7.62 $7.62 11/1/2011 73030 TC RADIOLOGIC EXAM SHOULDER COMPLETE $15.37 $15.37 11/1/2011 73030 RADIOLOGIC EXAM, SCAPULA/ COMPLETE $22.98 $22.98 11/1/2011 73060 TC RADIOLOGIC EXAM HUMERUS $15.37 $15.37 11/1/2011 73070 26 RADIOLOGIC EXAM SHOULDER $6.15 $6.15 11/1/2011 73070 TC RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS $14.41 $14.41 11/1/2011 73070 RADIOLOGIC EXAM, SCAPULA/ COMPLETE $20.57 $20.57 11/1/2011 73080 26 RADIOLOGIC EXAM SHOULDER $7.04 $7.04 11/1/2011 73080 TC RADILOGIC EXAM ELBOW, COMPLETE $19.30 $19.30 11/1/2011 73080 RADIOLOGIC EXAM SHOULDER $26.33 $26.33 11/1/2011 73090 26 RADIOLOGIC EXAM SHOULDER COMPLETE $6.44 $6.44 11/1/2011 73090 TC RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS $14.41 $14.41 11/1/2011 73090 RADIOLOGIC EXAM SHOULDER COMPLETE $20.88 $20.88 11/1/2011 73092 26 RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS $6.44 $6.44 11/1/2011 73092 TC RADILOGIC EXAM ELBOW, COMPLETE $14.99 $14.99 11/1/2011 73092 RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS $21.43 $21.43 11/1/2011 73100 26 RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS $6.74 $6.74 11/1/2011 73100 TC RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS $14.99 $14.99 11/1/2011 73100 RADILOGIC EXAM ELBOW, COMPLETE $21.71 $21.71 11/1/2011 73110 26 RADIOLOGIC EXAM FOREARM INFANT $7.04 $7.04 11/1/2011 73110 TC RADIOLOGIC EXAM WRIST, COMPLETE $18.91 $18.91 11/1/2011 73110 RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS $25.95 $25.95 11/1/2011 73120 26 RADIOLOGIC EXAM FOREARM INFANT $6.44 $6.44 11/1/2011 73120 TC RADIOLOGIC EXAM, HAND $14.13 $14.13 11/1/2011

Page 2 of 6 Radiological / Imaging Services Fee Schedule Provider Specialty 093

Medicaid Maximum Allowable NON- EFFECTIVE CODE MOD Description FACILITY FACILITY DATE 73120 RADIOLOGIC EXAM FOREARM INFANT $20.60 $20.60 11/1/2011 73130 26 RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS $7.04 $7.04 11/1/2011 73130 TC RADIOLOGIC EXAM HAND MIN/3 VIEWS $16.67 $16.67 11/1/2011 73130 RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS $23.70 $23.70 11/1/2011 73140 26 RADIOLOGIC EXAM WRIST, COMPLETE $5.55 $5.55 11/1/2011 73140 TC RADIOLOGIC EXAM FINGER(S) $16.39 $16.39 11/1/2011 73140 RADIOLOGIC EXAM WRIST, COMPLETE $21.93 $21.93 11/1/2011 73500 26 RADIOLOGIC EXAM, HAND $7.04 $7.04 11/1/2011 73500 TC RADIOLOGIC EXAM HIP $12.45 $12.45 11/1/2011 73500 RADIOLOGIC EXAM, HAND $19.50 $19.50 11/1/2011 73510 26 RADIOLOGIC EXAM HAND MIN/3 VIEWS $8.81 $8.81 11/1/2011 73510 TC RADIOLOGIC EXAM, HIP $19.30 $19.30 11/1/2011 73510 RADIOLOGIC EXAM HAND MIN/3 VIEWS $28.10 $28.10 11/1/2011 73520 26 RADIOLOGIC EXAM FINGER(S) $10.61 $10.61 11/1/2011 73520 TC RADILOGIC EXAM HIP BILATERAL $19.86 $19.86 11/1/2011 73520 RADIOLOGIC EXAM FINGER(S) $30.46 $30.46 11/1/2011 73540 26 RADIOLOGIC EXAM HIP $8.22 $8.22 11/1/2011 73540 TC RADIOLOGIC EXAM, HIP $19.86 $19.86 11/1/2011 73540 RADIOLOGIC EXAM HIP $28.09 $28.09 11/1/2011 73550 26 RADILOGIC EXAM HIP BILATERAL $7.04 $7.04 11/1/2011 73550 TC RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS $14.81 $14.81 11/1/2011 73550 RADIOLOGIC EXAM, HIP $21.84 $21.84 11/1/2011 73560 26 RADIOLOGIC EXAM HIP/ PELVIS; CHILD $7.04 $7.04 11/1/2011 73560 TC RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS $14.71 $14.71 11/1/2011 73560 RADILOGIC EXAM HIP BILATERAL $21.73 $21.73 11/1/2011 73562 26 RADIOLOGIC EXAM HIP/ PELVIS; CHILD $7.62 $7.62 11/1/2011 73562 TC RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS $18.45 $18.45 11/1/2011 73562 RADIOLOGIC EXAM HIP/ PELVIS; CHILD $26.07 $26.07 11/1/2011 73564 26 RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS $9.11 $9.11 11/1/2011 73564 TC RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE V $21.27 $21.27 11/1/2011 73564 RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS $30.38 $30.38 11/1/2011 73565 26 RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS $7.32 $7.32 11/1/2011 73565 TC RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS $15.83 $15.83 11/1/2011 73565 RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS $23.15 $23.15 11/1/2011 73590 26 RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE V $7.04 $7.04 11/1/2011 73590 TC RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS $13.86 $13.86 11/1/2011 73590 RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS $20.90 $20.90 11/1/2011 73592 26 RADIOLOGIC EXAM KNEE (BOTH) $6.44 $6.44 11/1/2011 73592 TC RADIOLOGIC EXAM KNEE (BOTH) $14.99 $14.99 11/1/2011 73592 RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE V $21.43 $21.43 11/1/2011 73600 26 RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS $6.44 $6.44 11/1/2011 73600 TC RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS $14.13 $14.13 11/1/2011 73600 RADIOLOGIC EXAM KNEE (BOTH) $20.60 $20.60 11/1/2011 73610 26 RAD EXAM LOWER EXTREMITY INFANT $7.04 $7.04 11/1/2011 73610 TC RADIOLOGIC EXAM COMPLETE $16.67 $16.67 11/1/2011 73610 RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS $23.70 $23.70 11/1/2011 73620 26 RAD EXAM LOWER EXTREMITY INFANT $6.44 $6.44 11/1/2011 73620 TC RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS $13.58 $13.58 11/1/2011 73620 RAD EXAM LOWER EXTREMITY INFANT $20.03 $20.03 11/1/2011 73630 26 RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS $7.04 $7.04 11/1/2011 73630 TC RADIOLOGIC EXAM FOOT COMPLETE $16.39 $16.39 11/1/2011 73630 RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS $23.42 $23.42 11/1/2011 73650 26 RADIOLOGIC EXAM COMPLETE $6.44 $6.44 11/1/2011 73650 TC RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS $13.86 $13.86 11/1/2011

Page 3 of 6 Radiological / Imaging Services Fee Schedule Provider Specialty 093

Medicaid Maximum Allowable NON- EFFECTIVE CODE MOD Description FACILITY FACILITY DATE 73650 RADIOLOGIC EXAM COMPLETE $20.31 $20.31 11/1/2011 73660 26 RADIOLOGIC EXAM FOOT COMPLETE $5.27 $5.27 11/1/2011 73660 TC RADIOLOGIC EXAM FOOT COMPLETE $15.54 $15.54 11/1/2011 73660 RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS $20.81 $20.81 11/1/2011 74000 26 RADIOLOGIC EXAM CALCANEUS $7.34 $7.34 11/1/2011 74000 TC RADIOLOGIC EXAM ABDOMEN $12.45 $12.45 11/1/2011 74000 RADIOLOGIC EXAM CALCANEUS $19.80 $19.80 11/1/2011 74010 26 RADIOLOGIC EXAM CALCANEUS TOE OR TOES $9.42 $9.42 11/1/2011 74010 TC RADIOLOGIC EXAM ABDOMEN ANTEROPOSTERIOR/ OBLIQUE $19.57 $19.57 11/1/2011 74010 RADIOLOGIC EXAM CALCANEUS $28.99 $28.99 11/1/2011 74020 26 RADIOLOGIC EXAM CALCANEUS TOE OR TOES $11.19 $11.19 11/1/2011 74020 TC RADIOLOGIC EXAM ABDOMEN, COMPLETE $19.86 $19.86 11/1/2011 74020 RADIOLOGIC EXAM CALCANEUS TOE OR TOES $31.05 $31.05 11/1/2011 74022 26 RADIOLOGIC EXAM ABDOMEN $13.27 $13.27 11/1/2011 74022 TC RAD EXAM ABDOMEN. COMPLETE ABDOMEN SERIES $24.25 $24.25 11/1/2011 74022 RADIOLOGIC EXAM ABDOMEN $37.54 $37.54 11/1/2011 76510 RADIOLOGIC EXAM ABDOMEN ANTEROPOSTERIOR/ OBLIQUE $117.18 $117.18 11/1/2011 76536 TC ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID $63.02 $63.02 11/1/2011 76536 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID $85.73 $85.73 3/15/2012 76604 ULTRASOUND, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR $67.26 $67.26 3/15/2012 76645 TC ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN A $48.60 $48.60 11/1/2011 76645 ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN A $70.98 $70.98 3/15/2012 76700 TC ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMA $72.86 $72.86 11/1/2011 76700 ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMA $106.34 $106.34 3/15/2012 76705 TC ECHOG, ABD, B-SCAN &/OR REAL TIME W/ IMG DOCUMNTN $55.99 $55.99 11/1/2011 76705 ECHOG, ABD, B-SCAN &/OR REAL TIME W/ IMG DOCUMNTN $80.65 $80.65 3/15/2012 76770 TC ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), $71.18 $71.18 11/1/2011 76770 ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), $101.79 $101.79 3/15/2012 76775 TC ECHOG,RETROPRTNL,B-SCAN&/OR REL TM W/IMG DOC; LMTD $62.17 $62.17 11/1/2011 76775 ECHOG,RETROPRTNL,B-SCAN&/OR REL TM W/IMG DOC; LMTD $86.53 $86.53 3/15/2012 76776 ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX $113.06 $113.06 3/15/2012 76800 TC RADIOLOGIC EXAM ABDOMEN ANTEROPOSTERIOR/ OBLIQUE $52.34 $52.34 11/1/2011 76800 ULTRASOUND, SPINAL CANAL AND CONTENTS $96.59 $96.59 3/15/2012 76801 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $102.46 $102.46 3/15/2012 76802 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $58.31 $58.31 3/15/2012 76805 TC ULTRASOUND, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $73.61 $73.61 11/1/2011 76805 ULTRASOUND, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $113.96 $113.96 3/15/2012 76810 TC RADIOLOGIC EXAM ABDOMEN, COMPLETE $39.32 $39.32 11/1/2011 76810 ECHOGRAPHY; COMPLETE WITH MULTIPLE GESTATION $79.09 $79.09 3/15/2012 76811 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $161.15 $161.15 3/15/2012 76812 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $157.76 $157.76 3/15/2012 76813 TC RADIOLOGIC EXAM ABDOMEN, COMPLETE $53.50 $53.50 11/1/2011 76813 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $100.38 $100.38 3/15/2012 76814 TC RAD EXAM ABDOMEN. COMPLETE ABDOMEN SERIES $26.27 $26.27 11/1/2011 76814 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $65.70 $65.70 3/15/2012 76815 TC RAD EXAM ABDOMEN. COMPLETE ABDOMEN SERIES $44.49 $44.49 11/1/2011 76815 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $70.96 $70.96 3/15/2012 76816 ECHOGRAPH PREGNANT UTERUS FOLLOW UP $87.23 $87.23 3/15/2012 76817 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $79.24 $79.24 3/15/2012 76818 TC OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITA $52.45 $52.45 11/1/2011 76818 FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING $94.82 $94.82 3/15/2012 76819 26 ECHOGRAPHY; COMPLETE WITH MULTIPLE GESTATION $31.24 $31.24 11/1/2011 76819 TC ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $42.07 $42.07 11/1/2011 76819 ULTRASOUND, SPINAL CANAL AND CONTENTS $73.31 $73.31 11/1/2011

Page 4 of 6 Radiological / Imaging Services Fee Schedule Provider Specialty 093

Medicaid Maximum Allowable NON- EFFECTIVE CODE MOD Description FACILITY FACILITY DATE 76819 FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING $73.31 $73.31 3/15/2012 76820 DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY $42.47 $42.47 3/15/2012 76821 DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY $76.06 $76.06 3/15/2012 76825 TC ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $95.88 $95.88 11/1/2011 76825 ECHOCARDIOGRAPHY FETAL $163.34 $163.34 3/15/2012 76826 ECHOCARDIOGRAPHY, FETAL HEART IN UTERO $89.89 $89.89 3/15/2012 76827 TC ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $32.91 $32.91 11/1/2011 76827 DOPPLER ECG, FETAL HEART PULSED &/OR CONT. WAVE COMP. $56.23 $56.23 3/15/2012 76828 DOPPLER ECG, FETAL HEART PULS.&/OR CONT WAVE FOLUP $41.85 $41.85 3/15/2012 76830 TC ULTRASOUND, TRANSVAGINAL $65.08 $65.08 11/1/2011 76830 ULTRASOUND, TRANSVAGINAL $93.34 $93.34 3/15/2012 76831 TC FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING $64.52 $64.52 11/1/2011 76831 HYSTEROSONOGRAPHY, WITH OR WITHOUT COLOR FLOW DOPPL $93.41 $93.41 3/15/2012 76856 TC ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL T $65.37 $65.37 11/1/2011 76856 ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL T $93.90 $93.90 3/15/2012 76857 TC ECHO, PELV (NON-OB) B-SCAN&/OR REL TM W/IMG D;LTD/ $61.79 $61.79 11/1/2011 76857 ECHO, PELV (NON-OB) B-SCAN&/OR REL TM W/IMG D;LTD/ $77.91 $77.91 3/15/2012 76870 TC ULTRASOUND, SCROTUM AND CONTENTS $66.20 $66.20 11/1/2011 76870 ULTRASOUND, SCROTUM AND CONTENTS $92.95 $92.95 3/15/2012 76872 TC FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING $81.09 $81.09 11/1/2011 76872 ECHOGRAPHY, TRANSRECTAL $110.65 $110.65 3/15/2012 76881 TC ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $69.27 $69.27 11/1/2011 76881 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $92.80 $92.80 3/15/2012 76882 TC ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $8.10 $8.10 11/1/2011 76882 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $24.42 $24.42 3/15/2012 76977 TC FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING $8.54 $8.54 11/1/2011 76977 ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETAT $10.81 $10.81 3/15/2012 77051 TC COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYS $6.93 $6.93 11/1/2011 77052 TC COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYS $6.93 $6.93 11/1/2011 77055 TC FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING $37.65 $37.65 11/1/2011 77055 MAMMOGRAPHY; UNILATERAL $66.77 $66.77 3/15/2012 77056 TC ECHOCARDIOGRAPHY FETAL $48.51 $48.51 11/1/2011 77056 MAMMOGRAPHY; BILATERAL $84.67 $84.67 3/15/2012 77057 TC DOPPLER ECG, FETAL HEART PULSED &/OR CONT. WAVE COMP. $35.03 $35.03 11/1/2011 77057 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF $64.15 $64.15 3/15/2012 78811 HYSTEROSONOGRAPHY, WITH OR WITHOUT COLOR FLOW DOPPL $851.86 $851.86 11/1/2011 78812 ECHOGRAPHY, TRANSRECTAL $867.91 $867.91 11/1/2011 78813 ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETAT $870.88 $870.88 11/1/2011 78814 MAMMOGRAPHY; UNILATERAL $878.91 $878.91 11/1/2011 78815 MAMMOGRAPHY; BILATERAL $888.72 $888.72 11/1/2011 78816 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF $891.38 $891.38 11/1/2011 79005 TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); LIMI $121.74 $121.74 11/1/2011 79101 TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); SKU $136.98 $136.98 11/1/2011 79445 TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); WHO $179.53 $179.53 11/1/2011 93303 TC TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH $114.19 $114.19 11/1/2011 93303 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARD $170.40 $170.40 3/15/2012 93304 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARD $105.37 $105.37 3/15/2012 93306 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE $207.98 $207.98 3/15/2012 93307 TC ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE $97.07 $97.07 11/1/2011 93307 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE $137.62 $137.62 3/15/2012 93308 ECHOCARDIOGRAPHY, RL-TIME IMAG.DOC.W/WOM-MOD,LMT S $86.91 $86.91 3/15/2012 93320 TC DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTIN $43.85 $43.85 11/1/2011 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTIN $60.64 $60.64 3/15/2012 93321 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTIN $26.78 $26.78 3/15/2012

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Medicaid Maximum Allowable NON- EFFECTIVE CODE MOD Description FACILITY FACILITY DATE 93325 TC DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPIN $37.16 $37.16 11/1/2011 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPIN $40.32 $40.32 3/15/2012 93350 TC TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH $101.03 $101.03 11/1/2011 93875 TC TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH $69.21 $69.21 11/1/2011 93875 BILAT. EXTRACRANIAL ARTERY STUDIES, NON-INVASIVE $78.32 $78.32 3/15/2012 93880 TC DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMP BIL STY $166.17 $166.17 11/1/2011 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMP BIL STY $191.33 $191.33 3/15/2012 93882 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; $126.05 $126.05 3/15/2012 93922 TC NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTR $82.79 $82.79 11/1/2011 93922 NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTR $93.00 $93.00 3/15/2012 93923 TC RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION $124.93 $124.93 11/1/2011 93923 NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTR $143.57 $143.57 3/15/2012 93924 NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY ART $176.74 $176.74 3/15/2012 93925 TC DUPLEX SCAN LOWER EXTREM. ARTERIES; BILAT, COMPLET $213.90 $213.90 11/1/2011 93925 DUPLEX SCAN LOWER EXTREM. ARTERIES; BILAT, COMPLET $237.88 $237.88 3/15/2012 93926 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BY $151.78 $151.78 3/15/2012 93930 TC RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS ADMINISTR $168.24 $168.24 11/1/2011 93930 DUPLEX SCAN UPPER EXTREM. ARTERIES; COMP.BILAT STY $187.47 $187.47 3/15/2012 93931 DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BY $125.49 $125.49 3/15/2012 93965 TC NON-INVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COM $80.91 $80.91 11/1/2011 93965 NON-INVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COM $95.29 $95.29 3/15/2012 93970 TC DUPLEX SCAN OF EXTREMITY VEINS, COMP. BILAT. STUDY $166.85 $166.85 11/1/2011 93970 DUPLEX SCAN OF EXTREMITY VEINS, COMP. BILAT. STUDY $195.10 $195.10 3/15/2012 93971 TC DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO $110.47 $110.47 11/1/2011 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO $129.19 $129.19 3/15/2012 93975 TC RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICU $218.24 $218.24 11/1/2011 93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF $293.62 $293.62 3/15/2012 93976 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF $169.50 $169.50 3/15/2012 93978 TC DUPLEX SCAN COMPLETE; AORTA,VENA CAVA,ILIAC VASC. $156.46 $156.46 11/1/2011 93978 DUPLEX SCAN COMPLETE; AORTA,VENA CAVA,ILIAC VASC. $183.51 $183.51 3/15/2012 93979 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULAT $126.90 $126.90 3/15/2012 93990 TC TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARD $138.32 $138.32 11/1/2011 93990 DUPLEX SCAN OF HEMODIALYSIS $148.46 $148.46 3/15/2012 95851 26 RANGE OF MOTION EVALUATION $4.85 $10.39 11/1/2011 R0070 PORTABLE X-RAY ONE PATIENT SEEN PER TRIP. $91.43 $91.43 11/1/2011

Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions, changes, and deletion to this schedule.

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