X-Ray Procedures RH 3/15

XR ABD (KUB) 1 VIEW 74000 XR ABD (KUB) W/DECUB &OR ERECT 74020 XR ABD (KUB) ERECT W/CHEST 74022 XR ABD (KUB) W/OBL OR CONE DOW 74010 XR AC JOINTS W OR WO WEIGHTS 73050 XR ANKLE AP/LAT 73600 XR ANKLE COMPLETE 3VW 73610 XR BONE AGE 77072 XR BONE LENGTH 77073 XR BONE SURVEY LIMITED 77074 XR BONE SURVEY COMPLETE 77075 XR CALCANEUS 73650 XR CHEST 1 VIEW 71010 XR CHEST 2 VIEWS 71020 XR CHEST 2VW W/APICAL LORDOTIC 71021 XR CHEST 2VW W/OBLIQUES 71022 XR CHEST 4+VW MIN 71030 XR CHEST SPEC VIEW OBL/LOR/DEC 71035 XR CLAVICLE 73000 XR C-SPINE 1 VW 72020 XR C-SPINE AP&LAT 2-3 VIEW STD 72040 XR C-SPINE COMP OBL/FLEX/EXT 72052 XR C-SPINE W/FLEX & EST 72050 XR C-SPINE W/OBLIQUES 72050 XR ELBOW AP/LAT 73070 XR ELBOW 3VW 73080 XR EYE FOR FOREIGN BODY 70030 XR FACIAL BONES 1-2 VIEWS 70140 XR FACIAL BONES 3+ VIEWS 70150 XR FOREARM 73090 XR FEMUR 73550 XR FINGER 73140 XR FLUORO ABS/FIST/SINUS TRACT Imaging charge 76080 INJ SINUS TRACT Procedure Charge 20501 XR FLUORO ABS/FIST/SINUS TUBE 49465 XR FLUORO ARTHROCENTESI JNT Imaging Charge 77002 XR JOINT DRAINAGE/INJECTION 20610 XR FLUORO ARTHRO HIP Imaging charge 73525 INJ ARTHROGRAM,HIP Procedure charge 27093 XR FLUORO ARTHRO KNEE Imaging Charge 73580 INJ ARTHROGRAM,KNEE Procedure charge 27370 XR FLUORO ARTHRO SHOULDER Imaging Charge 73040 INJ ARTHROGRAM,SHOULDER Procedure charge 23350 XR FLUORO THERAPEUTIC ENEMA 74283 XR FLUORO BE WITH AIR 74280 XR FLUORO BE WITHOUT AIR 74270 XR FLUORO BA SWALLOW/ESOPHAGUS 74220 X-Ray Procedures RH 3/15

XR FLUORO MODIFIED BASW 74230 XR FLUORO CHEST WITH 2VW 71023 XR FLUORO CHEST WITH 4VW 71034 XR FLUORO OPERATIVE CHOLANGIO 74300 XR FLUORO T-TUBE CHOLANGIOGRAM Imaging Charge 74305 INJ THRU T-TUBE Procedure Charge 47505 XR FLUORO CYSTOGRAM 3VW 74430 XR FLUORO VOIDING CYSTOGRAM 74455 INJ VOIDING CYSTOGRAM Procedure charge 51600 XR FLUORO FNA Imaging Charge 77002 FINE NEEDLE ASPIRATION Procedure Charge 10022 XR FLUORO 1 HOUR OR MORE 76001 XR FLUORO UP TO 1 HOUR 76000 XR FLUORO HYSTEROSALPINGOGRAM Imaging charge 74740 HYSTEROSALPING CATH PLACE Procedure Charge 58340 XR FLUORO LOC SPINAL/LESI INJ 77003 XR FLUORO MYELOGRAM C-SPINE Imaging Charge 72240 XR INJ FOR MYELO C3-L5 Procedure charge 62284 XR FLUORO MYELOGRAM COMP SPINE Imaging Charge 72270 XR INJ FOR MYELO C3-L5 Procedure Charge 62284 XR FLUORO MYELOGRAM L-SPINE Imaging Charge 72265 XR INJ FOR MYELO C3-L5 Procedure Charge 62284 XR FLUORO MYELOGRAM T-SPINE Imaging Charge 72255 XR INJ FOR MYELO C3-L5 Procedure Charge 62284 XR FLUORO NECK SOFT TISSUE 70370 XR FLUORO PAIN MANAG LG JNT Imaging Charge 77002 MAJOR JOINT INJECTION Procedure charg 20610 XR FLUORO PAIN MANAG SM JNT Imaging Charge 77002 SMALL JOINT INJECTION Procedure charge 20605 XR FLUORO SMALL BOWEL 74250 XR FLUORO SMALL BOWEL VIA NG 74251 XR FLUORO SPINAL THERAP DRAIN 62272 XR FLUORO UGI W/AIR W/KUB 74247 XR FLUORO UGI W/AIR WO/KUB 74246 XR FLUORO UGI WO/AIR WO/KUB 74240 XR FLUORO UGI W/AIR W/SBFT 74249 XR FLUORO UGI W/AIR W/KUB BASW 74247 XR FLUORO UGI W/AIR W/BASW SBF 74249 XR FLUORO URETH/CYSTO RETROGRA Imaging charge 74450 RETROGRADE URETHROGRAM INJ Procedure charge 51610 XR FLUORO VASCULAR ACCESS DEV 77001 XR FLUORO NEEDLE PLACEMENT 77002 XR FOOT 2 VW 73620 XR FOOT 3 VW 73630 XR HAND 2 VIEW 73120 XR HAND 3VW 73130 XR HAND/WRIST AP 1VW 77077 X-Ray Procedures RH 3/15

XR HIP 1 VW 73500 XR HIP AP/LAT OR 2VW 73510 XR HIP BILAT INCUD AP PELVIS 73520 XR HIP IN OPARATING ROOM 73530 XR HUMERUS 73060 XR INFANT BONE SURVEY 77076 XR INFANT LOWER EXT 2VW 73592 XR INFANT UPPER EXT MIN 2VW 73092 XR INFANT FOREIGN BOD NOSE/REC 76010 XR INF/CHILD PELVIS BILAT HIPS 73540 XR IVP WITH TOMOS 74415 XR IVP WO TOMO 74400 XR KNEE AP/LAT 73560 XR KNEE 3VW 73562 XR KNEE 4+VW 73564 XR KNEE BILAT STANDING AP 73565 XR LOWER LEG (TIB-FIB 73590 XR L-SPINE 1 VW 72020 XR L-SPINE 2-3 VIEWS STD 72100 XR L-SPINE BENDING ONLY 4VW 72120 XR L-SPINE COMP BENDING 7VW 72114 XR L-SPINE FLEX & EXT 72110 XR L-SPINE W/OBLIQUES 72110 XR L-SPINE PUNC DIAGNOSTIC 62270 XR MANDIBLE BILATERAL 70110 XR MANDIBLE 70100 XR MASTOIDS 1-2 VW 70120 XR MASTOIDS BILATERAL 70130 XR NASAL BONES 70160 XR NECK SOFT TISSUE 70360 XR OPTIC FORAMINA 70190 XR ORBITS 4 VIEWS 70200 XR PELVIS 1-2 VIEW 72170 XR PELVIS 3 VIEWS 72190 XR RIBS 2VW 71100 XR RIBS BILATERAL 3 VW 71110 XR RIBS W/PA CXR BILAT MIN 4VW 71111 XR RIBS W/PA CXR MIN 3VW 71101 XR RETROGRADE PYELOGRAPY 74420 XR SACRUM/COCCYX 2+VIEWS 72220 XR SCAPULA 73010 XR SCOLIOSIS SURVEY SUP & EREC 72090 XR SCOLIOSIS SURVEY ERECT 72069 XR SHOULDER 1VW 73020 XR SHOULDER AP/Y/AXIL 73030 XR SACROILIAC JOINT BILAT STD 72202 XR SACROILIAC JOINT 72200 X-Ray Procedures RH 3/15

XR SINUS 1-2 VIEWS 70210 XR SINUS 3+ VIEWS 70220 XR SKULL 1-3 VIEWS 70250 XR SKULL 4 VIEWS STD 70260 XR SPINE ENTIRE AP/LAT 72010 XR SPINE THORCOLUMBAR AP & LAT 72080 XR STERNOCLAVICULAR JOINT 3 VW 71130 XR STERNUM 2 VW 71120 XR TMJ OPEN/CLOSED BILAT 70330 XRTMJ OPEN/CLOSED UNILATERAL 70328 XR TOE 2+VW 73660 XR TOMO SINGLE PLANES 76100 XR T-SPINE 1 VIEW 72020 XR T-SPINE 2 VIEW 72070 XR T-SPINE 3 VIEW STD 72072 XR T-SPINE 4+ VIEW 72074 XR WRIST PA/LAT 73100 XR WRIST MIN 3 VW 73110 XR ZYGOMATIC ARCH 3+VIEWS 70150

Contrast Material XR ISOVUE 300 50ML VIAL Q9967 XR CYSTOFRAFIN 300ML Q9965 XR GASTROGRAFIN 120ML Q9967 OMNIPAQUE 240 10ML Q9966