Radiological / Imaging Services Fee Schedule Provider Specialty 093

Transcription

1 CODE MOD Description TC RADIOLOGIC EXAM SKULL $18.30 $ /1/ TC RADIOLOGIC EXAM, CHEST $11.41 $ /1/ TC RADILOGICAL EXAM CHEST TWO VIEWS FRONTAL/LATERAL $15.76 $ /1/ TC RADIOLOGIC EXAM, RIBS $16.32 $ /1/ TC RADIOLOGIC EXAM RIBS /POSTEROANTERIOR CHEST $19.71 $ /1/ TC RADIOLOGIC EXAM, RIBS BILATERAL $20.76 $ /1/ TC RADIOLOGIC EXAM INCLUDING POSTEROANTERIOR $27.45 $ /1/ RADIOLOGIC EXAM STERNUM $8.28 $8.28 7/1/ TC RADIOLOGIC EXAM STERNUM $17.17 $ /1/ RADIOLOGIC EXAM STERNUM $25.45 $ /1/ RADIOLOGIC EXAM STERNOCLAVICULAR JOINT(S) $9.17 $9.17 7/1/ TC RADIOLOGIC EXAM STERNOCLAVICULAR JOINT(S) $19.99 $ /1/ RADIOLOGIC EXAM STERNOCLAVICULAR JOINT(S) $29.17 $ /1/ RADILOGIC EXAM SPINE $18.09 $ /1/ TC RADILOGIC EXAM SPINE $35.64 $ /1/ RADILOGIC EXAM SPINE $53.74 $ /1/ RADIOLOGIC EXAM SPINE /SPECIFY LEVEL $6.48 $6.48 7/1/ TC RADIOLOGIC EXAM SPINE /SPECIFY LEVEL $11.98 $ /1/ RADIOLOGIC EXAM SPINE /SPECIFY LEVEL $18.45 $ /1/ RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VI $9.17 $9.17 7/1/ TC RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VI $19.43 $ /1/ RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VI $28.61 $ /1/ RADIOLOGIC EXAM SPINE. 4 VIEWS $12.78 $ /1/ TC RADIOLOGIC EXAM SPINE. 4 VIEWS $27.73 $ /1/ RADIOLOGIC EXAM SPINE. 4 VIEWS $40.50 $ /1/ RADIOLOGIC EXAM SPINE, COMPLETE $15.06 $ /1/ TC RADIOLOGIC EXAM SPINE, COMPLETE $35.64 $ /1/ RADIOLOGIC EXAM SPINE, COMPLETE $50.71 $ /1/ RADIOLOGIC EXAM SPINE THORACOLUMBAR $9.17 $9.17 7/1/ TC RADIOLOGIC EXAM SPINE THORACOLUMBAR $17.90 $ /1/ RADIOLOGIC EXAM SPINE THORACOLUMBAR $27.10 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS $9.17 $9.17 7/1/ TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS $17.17 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS $26.34 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS $9.17 $9.17 7/1/ TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS $20.76 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS $29.93 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR $9.17 $9.17 7/1/ TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR $25.75 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR $34.93 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEW $9.17 $9.17 7/1/ TC RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEW $18.30 $ /1/ RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEW $27.48 $ /1/ RADIOLOGIC EXAM SPINE. SCOLIIOSIS $11.86 $ /1/ TC RADIOLOGIC EXAM SPINE. SCOLIIOSIS $24.23 $ /1/ RADIOLOGIC EXAM SPINE. SCOLIIOSIS $36.09 $ /1/ RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THR $9.17 $9.17 7/1/ TC RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THR $20.84 $ /1/ RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THR $30.02 $ /1/ RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF $12.78 $ /1/ TC RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF $29.15 $ /1/ RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF $41.92 $ /1/ RADIOLOGIC EXAM SPINE COMPLETE /BENDING VIEW $15.06 $ /1/2012 Page 1 of 6

2 CODE MOD Description TC RADIOLOGIC EXAM SPINE COMPLETE /BENDING VIEW $39.60 $ /1/ RADIOLOGIC EXAM SPINE COMPLETE /BENDING VIEW $54.66 $ /1/ RADIOLOGIC EXAM SPINE BENDING VIEW $9.17 $9.17 7/1/ TC RADIOLOGIC EXAM SPINE BENDING VIEW $28.29 $ /1/ RADIOLOGIC EXAM SPINE BENDING VIEW $37.48 $ /1/ RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS $7.09 $7.09 7/1/ TC RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS $13.11 $ /1/ RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS $20.19 $ /1/ RADIOLOGIC EXAM PELVIC COMPLETE $8.87 $8.87 7/1/ TC RADIOLOGIC EXAM PELVIC COMPLETE $21.69 $ /1/ RADIOLOGIC EXAM PELVIC COMPLETE $30.57 $ /1/ MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH CO $72.50 $ /1/ RADIOLOGIC EXAM SACRUM, COCCYX $7.09 $7.09 7/1/ TC RADIOLOGIC EXAM SACRUM, COCCYX $15.37 $ /1/ RADIOLOGIC EXAM SACRUM, COCCYX $22.45 $ /1/ X-RAY EXAM OF SACROILIAC JOINTS, 3 OR MORE VIEWS $7.98 $7.98 7/1/ TC X-RAY EXAM OF SACROILIAC JOINTS, 3 OR MORE VIEWS $19.15 $ /1/ X-RAY EXAM OF SACROILIAC JOINTS, 3 OR MORE VIEWS $27.13 $ /1/ SACRUM AND COCCYX $7.09 $7.09 7/1/ TC SACRUM AND COCCYX $15.76 $ /1/ SACRUM AND COCCYX $22.84 $ /1/ RADIOLOGIC EXAM CLAVICLE, COMPLETE $6.78 $6.78 7/1/ TC RADIOLOGIC EXAM CLAVICLE, COMPLETE $14.51 $ /1/ RADIOLOGIC EXAM CLAVICLE, COMPLETE $21.30 $ /1/ RADIOLOGIC EXAM, SCAPULA/ COMPLETE $7.09 $7.09 7/1/ TC RADIOLOGIC EXAM, SCAPULA/ COMPLETE $14.81 $ /1/ RADIOLOGIC EXAM, SCAPULA/ COMPLETE $21.88 $ /1/ RADIOLOGIC EXAM SHOULDER $6.19 $6.19 7/1/ TC RADIOLOGIC EXAM SHOULDER $11.98 $ /1/ RADIOLOGIC EXAM SHOULDER $18.17 $ /1/ RADIOLOGIC EXAM SHOULDER COMPLETE $7.67 $7.67 7/1/ TC RADIOLOGIC EXAM SHOULDER COMPLETE $15.47 $ /1/ RADIOLOGIC EXAM SHOULDER COMPLETE $23.14 $ /1/ TC RADIOLOGIC EXAM HUMERUS $15.47 $ /1/ RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS $6.19 $6.19 7/1/ TC RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS $14.51 $ /1/ RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS $20.71 $ /1/ RADILOGIC EXAM ELBOW, COMPLETE $7.09 $7.09 7/1/ TC RADILOGIC EXAM ELBOW, COMPLETE $19.43 $ /1/ RADILOGIC EXAM ELBOW, COMPLETE $26.51 $ /1/ RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS $6.49 $6.49 7/1/ TC RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS $14.51 $ /1/ RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS $21.02 $ /1/ RADIOLOGIC EXAM FOREARM INFANT $6.49 $6.49 7/1/ TC RADIOLOGIC EXAM FOREARM INFANT $15.09 $ /1/ RADIOLOGIC EXAM FOREARM INFANT $21.58 $ /1/ RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS $6.78 $6.78 7/1/ TC RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS $15.09 $ /1/ RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS $21.86 $ /1/ RADIOLOGIC EXAM WRIST, COMPLETE $7.09 $7.09 7/1/ TC RADIOLOGIC EXAM WRIST, COMPLETE $19.04 $ /1/ RADIOLOGIC EXAM WRIST, COMPLETE $26.13 $ /1/ RADIOLOGIC EXAM, HAND $6.49 $6.49 7/1/ TC RADIOLOGIC EXAM, HAND $14.23 $ /1/2012 Page 2 of 6

3 CODE MOD Description RADIOLOGIC EXAM, HAND $20.74 $ /1/ RADIOLOGIC EXAM HAND MIN/3 VIEWS $7.09 $7.09 7/1/ TC RADIOLOGIC EXAM HAND MIN/3 VIEWS $16.79 $ /1/ RADIOLOGIC EXAM HAND MIN/3 VIEWS $23.86 $ /1/ RADIOLOGIC EXAM FINGER(S) $5.59 $5.59 7/1/ TC RADIOLOGIC EXAM FINGER(S) $16.50 $ /1/ RADIOLOGIC EXAM FINGER(S) $22.08 $ /1/ RADIOLOGIC EXAM HIP $7.09 $7.09 7/1/ TC RADIOLOGIC EXAM HIP $12.53 $ /1/ RADIOLOGIC EXAM HIP $19.63 $ /1/ RADIOLOGIC EXAM, HIP $8.87 $8.87 7/1/ TC RADIOLOGIC EXAM, HIP $19.43 $ /1/ RADIOLOGIC EXAM, HIP $28.29 $ /1/ RADILOGIC EXAM HIP BILATERAL $10.68 $ /1/ TC RADILOGIC EXAM HIP BILATERAL $19.99 $ /1/ RADILOGIC EXAM HIP BILATERAL $30.67 $ /1/ RADIOLOGIC EXAM HIP/ PELVIS; CHILD $8.28 $8.28 7/1/ TC RADIOLOGIC EXAM HIP/ PELVIS; CHILD $19.99 $ /1/ RADIOLOGIC EXAM HIP/ PELVIS; CHILD $28.28 $ /1/ RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS $7.09 $7.09 7/1/ TC RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS $14.92 $ /1/ RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS $21.99 $ /1/ RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS $7.09 $7.09 7/1/ TC RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS $14.81 $ /1/ RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS $21.88 $ /1/ RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS $7.67 $7.67 7/1/ TC RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS $18.58 $ /1/ RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS $26.25 $ /1/ RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE V $9.17 $9.17 7/1/ TC RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE V $21.41 $ /1/ RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE V $30.59 $ /1/ RADIOLOGIC EXAM KNEE (BOTH) $7.37 $7.37 7/1/ TC RADIOLOGIC EXAM KNEE (BOTH) $15.93 $ /1/ RADIOLOGIC EXAM KNEE (BOTH) $23.30 $ /1/ RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS $7.09 $7.09 7/1/ TC RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS $13.96 $ /1/ RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS $21.04 $ /1/ RAD EXAM LOWER EXTREMITY INFANT $6.49 $6.49 7/1/ TC RAD EXAM LOWER EXTREMITY INFANT $15.09 $ /1/ RAD EXAM LOWER EXTREMITY INFANT $21.58 $ /1/ RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS $6.49 $6.49 7/1/ TC RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS $14.23 $ /1/ RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS $20.74 $ /1/ RADIOLOGIC EXAM COMPLETE $7.09 $7.09 7/1/ TC RADIOLOGIC EXAM COMPLETE $16.79 $ /1/ RADIOLOGIC EXAM COMPLETE $23.86 $ /1/ RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS $6.49 $6.49 7/1/ TC RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS $13.67 $ /1/ RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS $20.17 $ /1/ RADIOLOGIC EXAM FOOT COMPLETE $7.09 $7.09 7/1/ TC RADIOLOGIC EXAM FOOT COMPLETE $16.50 $ /1/ RADIOLOGIC EXAM FOOT COMPLETE $23.58 $ /1/ RADIOLOGIC EXAM CALCANEUS $6.49 $6.49 7/1/ TC RADIOLOGIC EXAM CALCANEUS $13.96 $ /1/2012 Page 3 of 6

4 CODE MOD Description RADIOLOGIC EXAM CALCANEUS $20.45 $ /1/ RADIOLOGIC EXAM CALCANEUS TOE OR TOES $5.30 $5.30 7/1/ TC RADIOLOGIC EXAM CALCANEUS TOE OR TOES $15.65 $ /1/ RADIOLOGIC EXAM CALCANEUS TOE OR TOES $20.95 $ /1/ RADIOLOGIC EXAM ABDOMEN $7.39 $7.39 7/1/ TC RADIOLOGIC EXAM ABDOMEN $12.53 $ /1/ RADIOLOGIC EXAM ABDOMEN $19.93 $ /1/ RADIOLOGIC EXAM ABDOMEN ANTEROPOSTERIOR/ OBLIQUE $9.49 $9.49 7/1/ TC RADIOLOGIC EXAM ABDOMEN ANTEROPOSTERIOR/ OBLIQUE $19.71 $ /1/ RADIOLOGIC EXAM ABDOMEN ANTEROPOSTERIOR/ OBLIQUE $29.19 $ /1/ RADIOLOGIC EXAM ABDOMEN, COMPLETE $11.27 $ /1/ TC RADIOLOGIC EXAM ABDOMEN, COMPLETE $19.99 $ /1/ RADIOLOGIC EXAM ABDOMEN, COMPLETE $31.26 $ /1/ RAD EXAM ABDOMEN. COMPLETE ABDOMEN SERIES $13.36 $ /1/ TC RAD EXAM ABDOMEN. COMPLETE ABDOMEN SERIES $24.42 $ /1/ RAD EXAM ABDOMEN. COMPLETE ABDOMEN SERIES $37.80 $ /1/ OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITA $ $ /1/ TC ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID $63.46 $ /1/ ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID $86.32 $ /1/ ULTRASOUND, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR $67.73 $ /1/ TC ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN A $48.93 $ /1/ ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN A $71.47 $ /1/ TC ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMA $73.36 $ /1/ ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMA $ $ /1/ TC ECHOG, ABD, B-SCAN &/OR REAL TIME W/ IMG DOCUMNTN $56.38 $ /1/ ECHOG, ABD, B-SCAN &/OR REAL TIME W/ IMG DOCUMNTN $81.20 $ /1/ TC ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), $71.67 $ /1/ ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), $ $ /1/ TC ECHOG,RETROPRTNL,B-SCAN&/OR REL TM W/IMG DOC; LMTD $62.60 $ /1/ ECHOG,RETROPRTNL,B-SCAN&/OR REL TM W/IMG DOC; LMTD $87.12 $ /1/ ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX $ $ /1/ TC ULTRASOUND, SPINAL CANAL AND CONTENTS $52.70 $ /1/ ULTRASOUND, SPINAL CANAL AND CONTENTS $97.26 $ /1/ ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $ $ /1/ ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $58.71 $ /1/ TC ULTRASOUND, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $74.12 $ /1/ ULTRASOUND, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $ $ /1/ TC ECHOGRAPHY; COMPLETE WITH MULTIPLE GESTATION $39.59 $ /1/ ECHOGRAPHY; COMPLETE WITH MULTIPLE GESTATION $79.63 $ /1/ ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $ $ /1/ ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $ $ /1/ TC ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $53.87 $ /1/ ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $ $ /1/ TC ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $26.45 $ /1/ ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $66.15 $ /1/ TC ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $44.80 $ /1/ ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME W $71.45 $ /1/ ECHOGRAPH PREGNANT UTERUS FOLLOW UP $87.83 $ /1/ ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOC $79.78 $ /1/ TC FETAL BIOPHYSICAL PROFILE; WITH STRESS TESTING $52.81 $ /1/ FETAL BIOPHYSICAL PROFILE; WITH STRESS TESTING $95.47 $ /1/ FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS TESTING $31.46 $ /1/ TC FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS TESTING $42.36 $ /1/ FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS TESTING $73.81 $ /1/2012 Page 4 of 6

5 CODE MOD Description DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY $42.77 $ /1/ DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY $76.59 $ /1/ TC ECHOCARDIOGRAPHY FETAL $96.54 $ /1/ ECHOCARDIOGRAPHY FETAL $ $ /1/ ECHOCARDIOGRAPHY, FETAL HEART IN UTERO $90.51 $ /1/ TC DOPPLER ECG, FETAL HEART PULSED &/OR CONT. WAVE COMP. $33.13 $ /1/ DOPPLER ECG, FETAL HEART PULSED &/OR CONT. WAVE COMP. $56.61 $ /1/ DOPPLER ECG, FETAL HEART PULS.&/OR CONT WAVE FOLUP $42.14 $ /1/ TC ULTRASOUND, TRANSVAGINAL $65.53 $ /1/ ULTRASOUND, TRANSVAGINAL $93.98 $ /1/ TC HYSTEROSONOGRAPHY, WITH OR WITHOUT COLOR FLOW DOPPL $64.96 $ /1/ HYSTEROSONOGRAPHY, WITH OR WITHOUT COLOR FLOW DOPPL $94.05 $ /1/ TC ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL T $65.82 $ /1/ ULTRASOUND, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL T $94.55 $ /1/ TC ECHO, PELV (OB) B-SCAN&/OR REL TM W/IMG D;LTD/ $62.21 $ /1/ ECHO, PELV (OB) B-SCAN&/OR REL TM W/IMG D;LTD/ $78.45 $ /1/ TC ULTRASOUND, SCROTUM AND CONTENTS $66.66 $ /1/ ULTRASOUND, SCROTUM AND CONTENTS $93.59 $ /1/ TC ECHOGRAPHY, TRANSRECTAL $81.64 $ /1/ ECHOGRAPHY, TRANSRECTAL $ $ /1/ TC ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $69.75 $ /1/ ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $93.44 $ /1/ TC ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $8.15 $8.15 7/1/ ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMA $24.59 $ /1/ TC ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETAT $8.59 $8.59 7/1/ ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETAT $10.89 $ /1/ TC COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYS $6.98 $6.98 7/1/ TC COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYS $6.98 $6.98 7/1/ TC MAMMOGRAPHY; UNILATERAL $37.91 $ /1/ MAMMOGRAPHY; UNILATERAL $67.23 $ /1/ TC MAMMOGRAPHY; BILATERAL $48.84 $ /1/ MAMMOGRAPHY; BILATERAL $85.25 $ /1/ TC SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF $35.27 $ /1/ SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF $64.59 $ /1/ TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); LIMI $ $ /1/ TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); SKU $ $ /1/ TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); WHO $ $ /1/ TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH $ $ /1/ TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH $ $ /1/ TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) WITH $ $ /1/ RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION $ $ /1/ RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS ADMINISTR $ $ /1/ RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICU $ $ /1/ TC TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARD $ $ /1/ TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARD $ $ /1/ TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARD $ $ /1/ ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE $ $ /1/ TC ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE $97.74 $ /1/ ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE $ $ /1/ ECHOCARDIOGRAPHY, RL-TIME IMAG.DOC.W/WOM-MOD,LMT S $87.50 $ /1/ TC DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTIN $44.15 $ /1/ DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTIN $61.05 $ /1/ DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTIN $26.96 $ /1/ TC DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPIN $37.42 $ /1/2012 Page 5 of 6

6 CODE MOD Description DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPIN $40.60 $ /1/ TC ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE $ $ /1/ TC DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMP BIL STY $ $ /1/ DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMP BIL STY $ $ /1/ DUPLEX SCAN OF EXTRACRANIAL ARTERIES; $ $ /1/ TC NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTR $83.36 $ /1/ NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTR $93.64 $ /1/ TC NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTR $ $ /1/ NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTR $ $ /1/ NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY ART $ $ /1/ TC DUPLEX SCAN LOWER EXTREM. ARTERIES; BILAT, COMPLET $ $ /1/ DUPLEX SCAN LOWER EXTREM. ARTERIES; BILAT, COMPLET $ $ /1/ DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BY $ $ /1/ TC DUPLEX SCAN UPPER EXTREM. ARTERIES; COMP.BILAT STY $ $ /1/ DUPLEX SCAN UPPER EXTREM. ARTERIES; COMP.BILAT STY $ $ /1/ DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BY $ $ /1/ TC INVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COM $81.47 $ /1/ INVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COM $95.94 $ /1/ TC DUPLEX SCAN OF EXTREMITY VEINS, COMP. BILAT. STUDY $ $ /1/ DUPLEX SCAN OF EXTREMITY VEINS, COMP. BILAT. STUDY $ $ /1/ TC DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO $ $ /1/ DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO $ $ /1/ TC DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF $ $ /1/ DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF $ $ /1/ DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF $ $ /1/ TC DUPLEX SCAN COMPLETE; AORTA,VENA CAVA,ILIAC VASC. $ $ /1/ DUPLEX SCAN COMPLETE; AORTA,VENA CAVA,ILIAC VASC. $ $ /1/ DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULAT $ $ /1/ TC DUPLEX SCAN OF HEMODIALYSIS $ $ /1/ DUPLEX SCAN OF HEMODIALYSIS $ $ /1/ RANGE OF MOTION EVALUATION $4.88 $ /1/2012 R0070 PORTABLE X-RAY ONE PATIENT SEEN PER TRIP. $92.06 $ /1/2012 Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions, changes, and deletion to this schedule. Page 6 of 6