radiology fee schedule effective january 1,...

The fees below are reimbursed for services provided to adults age 21 and over. For

services provided to children under the age of 21, there is a 4% increase over the

adult fee. To calculate reimbursement for services to children, multiply the fee by

1.04. Example: $83.39 X 1.04 = $86.73.

In addition to the 4% increase noted above, the following physician specialty types

receive a 24% increase for services provided to children under 21: 02, 03, 04, 05, 08,

10, 14, 15, 17, 21, 23, 29, 30, 31, 36, 37, 38, 39, 43, 46, 51, 53, 55, 57, 58, 60, 62.

To calculate the specialty fee, multiply the fee by 1.04, as noted above for children,

and then multiply that result by 1.24. Example: $83.39 X 1.04 = $86.73 X 1.24 =

$107.54. The same method applies to the PC Fee and TC Fee. Fees are rounded to

the nearest hundredth.

Note: Reimbursement increases noted above do not apply to the following services:

Regional Perinatal Intensive Care Center services, injectable medications,

immunizations, supplies, devices, portable x-ray, and laboratory/pathology services.

RADIOLOGY FEE SCHEDULE

Effective January 1, 2017

Procedure Mod FSI PCI TCI PA

70010 67.54

70015 82.90 33.68 49.22

70030 15.71 4.22 11.48

70100 18.73 5.24 13.49

70110 21.55 7.25 14.30

70120 19.13 4.53 14.60

70130 31.01 9.87 21.15

70134 25.38 8.56 16.82

70140 16.92 5.54 11.37

70150 23.56 7.65 15.91

70160 18.53 5.03 13.49

70170 39.40 7.88 31.52

70190 20.14 5.00 15.14

70200 23.97 7.38 16.59

70210 16.92 5.03 11.88

70220 21.35 7.25 14.10

70240 16.24 5.41 10.83

70250 20.54 7.25 13.29

70260 25.98 9.38 16.60

70300 8.06 3.29 4.77

70310 20.95 4.12 16.83

70320 29.36 6.57 22.79

70328 17.32 4.56 12.76

70330 27.39 6.97 20.42

70332 38.32 13.79 24.53

70336 202.64 40.41 162.23 Y

70350 10.83 5.19 5.64

70355 11.88 6.44 5.44

70360 15.91 4.83 11.08

70370 44.04 8.87 35.17

70380 21.31 4.83 16.48

70390 51.04 9.85 41.19

70450 77.20 21.06 56.14 Y

70460 101.71 28.02 73.69 Y

70470 122.65 31.49 91.16 Y

70480 132.51 36.04 96.47 Y

70481 156.68 39.67 117.01 Y

70482 170.98 35.85 135.13 Y

70486 104.93 23.50 81.43 Y

70487 127.53 28.02 99.51 Y

70488 155.53 31.49 124.04 Y

70490 109.76 36.85 72.90 Y

70491 133.92 39.87 94.05 Y

70492 157.89 41.69 116.20 Y



2017_01_01_Radiology_Fee_Schedule




70496 247.88 43.34 204.54 Y

70498 249.17 43.33 205.84 Y

70540 202.79 33.41 169.38 Y

70542 244.88 44.66 200.21 Y

70543 277.41 53.07 224.33 Y

70544 224.50 29.75 194.74 Y

70545 248.02 33.06 214.96 Y

70546 335.97 44.54 291.43 Y

70547 223.94 30.27 193.67 Y

70548 234.64 29.75 204.89 Y

70549 342.16 50.34 291.82 Y

70551 210.89 36.72 174.17 Y

70552 231.06 44.20 186.86 Y

70553 277.93 56.90 221.03 Y

70555 348.00 69.60 278.40 Y

70557 402.85 80.57 322.28 Y

70558 442.75 88.55 354.20 Y

70559 445.65 89.13 356.52 Y

71010 12.89 5.24 7.65

71015 16.47 5.37 11.10

71020 15.91 6.24 9.67

71021 19.33 7.42 11.91

71022 23.20 8.87 14.34

71023 39.00 11.47 27.52

71030 23.76 8.19 15.58

71034 45.05 11.46 33.59

71035 18.53 5.24 13.29

71100 18.73 6.44 12.28

71101 20.74 7.85 12.89

71110 21.35 7.31 14.04

71111 27.39 8.81 18.58

71120 16.72 5.84 10.87

71130 19.53 6.19 13.34

71250 102.71 26.41 76.30 Y

71260 130.50 35.85 94.65 Y

71270 156.28 38.36 117.92 Y

71275 179.94 45.07 134.87 Y

71550 236.03 39.63 196.40 Y

71551 316.79 47.56 269.23 Y

71552 360.76 62.26 298.51 Y

71555 250.87 49.30 201.56 Y

72020 12.49 4.43 8.06

72040 18.73 6.44 12.28

72050 25.78 9.06 16.72

72052 31.82 10.47 21.35





72070 19.33 6.44 12.89

72072 19.53 6.24 13.29

72074 22.15 5.39 16.76

72080 17.32 5.39 11.93

72081 22.15 7.05 15.10

72082 35.44 8.01 27.43

72083 38.47 8.70 29.76

72084 45.71 10.09 35.63

72100 19.94 6.44 13.49

72110 27.79 9.06 18.73

72114 35.24 8.18 27.06

72120 22.96 5.73 17.23

72125 105.12 29.90 75.22 Y

72126 136.43 33.64 102.79 Y

72127 166.53 35.00 131.54 Y

72128 102.71 25.88 76.82 Y

72129 136.28 33.64 102.64 Y

72130 154.06 31.50 122.56 Y

72131 102.30 25.86 76.45 Y

72132 136.14 33.64 102.50 Y

72133 153.26 34.74 118.52 Y

72141 187.24 36.89 150.35 Y

72142 233.11 44.55 188.56 Y

72146 188.03 36.89 151.14 Y

72147 207.17 44.20 162.97 Y

72148 185.72 36.89 148.82 Y

72149 230.27 44.37 185.90 Y

72156 276.90 56.90 220.01 Y

72157 257.13 56.91 200.22 Y

72158 272.92 56.91 216.01 Y

72159 297.77 49.63 248.14 Y

72170 18.12 5.03 13.09

72190 21.55 6.24 15.31

72191 192.72 49.69 143.03 Y

72192 95.43 26.97 68.45 Y

72193 128.49 33.43 95.05 Y

72194 167.53 33.45 134.08 Y

72195 213.27 41.27 172.00 Y

72196 250.87 47.76 203.11 Y

72197 287.38 57.48 229.90 Y

72198 248.87 49.11 199.76 Y

72200 16.11 5.03 11.08

72202 18.73 5.44 13.29

72220 15.91 5.03 10.87

72240 62.20 25.13 37.06





72255 59.30 25.52 33.77

72265 61.07 23.01 38.07

72270 95.07 36.93 58.14

72275 65.65 20.13 45.52

72285 62.45 31.34 31.11

72295 53.94 23.97 29.97

73000 15.71 4.83 10.87

73010 17.12 4.79 12.33

73020 13.09 4.63 8.46

73030 16.51 5.44 11.08

73040 56.79 13.62 43.18

73050 20.14 5.22 14.92

73060 16.51 4.83 11.68

73070 15.51 4.63 10.87

73080 17.72 5.03 12.69

73085 52.98 15.85 37.12

73090 14.70 4.83 9.87

73092 15.71 4.39 11.32

73100 16.51 4.83 11.68

73110 20.14 5.03 15.10

73115 60.42 14.09 46.32

73120 14.90 4.83 10.07

73130 17.52 5.03 12.49

73140 17.92 4.03 13.90

73200 102.10 27.84 74.27 Y

73201 126.47 33.43 93.04 Y

73202 173.24 33.64 139.60 Y

73206 186.65 49.50 137.15 Y

73218 208.96 33.58 175.38 Y

73219 248.44 44.66 203.78 Y

73220 284.16 56.70 227.46 Y

73221 194.83 33.76 161.07 Y

73222 214.88 42.98 171.90 Y

73223 267.24 53.45 213.79 Y

73225 266.00 47.18 218.83 Y

73501 16.92 4.79 12.12

73502 23.56 5.70 17.86

73503 29.40 7.28 22.12

73521 22.56 5.76 16.80

73522 27.79 7.80 19.99

73523 32.22 8.19 24.04

73525 57.80 14.41 43.38

73551 15.91 4.43 11.48

73552 18.53 4.92 13.61

73560 17.52 4.83 12.69





73562 20.34 5.44 14.90

73564 22.56 6.44 16.11

73565 20.34 4.35 15.99

73580 64.65 14.09 50.55

73590 16.31 4.83 11.48

73592 15.08 4.45 10.63

73600 16.92 4.83 12.08

73610 17.92 5.03 12.89

73615 57.23 15.85 41.38

73620 14.70 4.43 10.27

73630 16.51 4.83 11.68

73650 15.31 4.63 10.67

73660 15.91 3.83 12.08

73700 102.30 27.78 74.52 Y

73701 128.49 33.43 95.05 Y

73702 156.18 30.10 126.07 Y

73706 207.63 52.01 155.62 Y

73718 207.23 36.61 170.62 Y

73719 230.19 46.04 184.15 Y

73720 285.57 58.06 227.51 Y

73721 198.94 33.76 165.19 Y

73722 216.69 43.34 173.35 Y

73723 267.44 58.17 209.27 Y

73725 258.78 51.76 207.03 Y

74000 13.49 5.24 8.26

74010 19.94 6.65 13.29

74020 21.35 7.85 13.49

74022 25.37 9.26 16.11

74150 97.09 29.58 67.51 Y

74160 133.83 31.49 102.34 Y

74170 179.16 34.80 144.36 Y

74174 221.12 59.32 161.80 Y

74175 186.48 44.89 141.59 Y

74176 114.39 50.15 64.24 Y

74177 177.02 52.36 124.66 Y

74178 200.98 57.80 143.19 Y

74181 189.10 41.89 147.21 Y

74182 258.38 50.66 207.72 Y

74183 287.98 61.21 226.77 Y

74185 229.18 50.33 178.85 Y

74190 64.75 12.95 51.80

74210 42.26 9.85 32.41

74220 50.15 13.29 36.85

74230 59.36 16.16 43.20

74240 64.04 19.94 44.10





74241 66.86 19.94 46.92

74245 97.27 26.18 71.09

74246 72.10 19.94 52.16

74247 80.35 17.40 62.95

74249 104.32 26.18 78.14

74250 59.01 13.69 45.31

74251 226.84 19.14 207.70

74260 186.92 12.71 174.21

74270 85.19 19.94 65.25

74280 121.24 24.71 96.52

74283 111.56 55.35 56.21

74290 37.78 8.87 28.91

74300 52.36 10.47 41.89

74301 29.00 5.80 23.20

74328 102.71 20.54 82.17

74329 98.60 19.72 78.88

74330 130.90 26.18 104.72

74340 74.45 14.89 59.56

74355 99.35 19.87 79.48

74360 80.56 16.11 64.44

74363 117.95 23.59 94.36

74400 62.63 12.53 50.11

74410 60.34 13.34 47.00

74415 77.53 13.78 63.75

74420 50.35 10.07 40.28

74425 50.35 10.07 40.28

74430 30.07 7.79 22.28

74440 45.30 9.85 35.45

74445 146.80 29.36 117.44

74450 45.45 9.09 36.36

74455 46.52 9.47 37.06

74470 72.50 14.50 58.00

74485 57.71 15.74 41.97

74710 19.49 9.53 9.97

74712 261.59 82.94 178.65 Y

74713 125.67 49.11 76.56 Y

74740 42.49 9.39 33.11

74742 79.65 15.93 63.72

75557 204.92 63.61 141.31 Y

75559 328.85 74.12 254.73 Y

75561 302.96 77.21 225.75 Y

75563 375.30 80.43 294.87 Y

75565 36.25 6.77 29.48 Y

75571 64.62 17.32 47.30 Y

75572 153.90 47.56 106.34 Y





75573 211.91 69.22 142.69 Y

75574 239.45 68.07 171.38 Y

75600 107.50 13.34 94.16

75605 78.54 28.99 49.55

75625 78.14 29.01 49.13

75630 96.87 47.74 49.13

75635 217.10 68.47 148.62 Y

75658 97.76 35.00 62.76

75705 133.02 60.65 72.37

75710 92.24 32.22 60.01

75716 106.13 31.84 74.29

75726 84.99 31.82 53.17

75731 93.97 28.65 65.32

75733 103.90 32.76 71.14

75736 91.03 28.50 62.52

75741 86.65 35.00 51.65

75743 100.80 44.28 56.52

75746 90.59 30.94 59.65

75756 100.86 34.02 66.84

75774 50.35 10.07 40.28

75801 127.88 25.58 102.30

75803 161.45 32.29 129.16

75805 105.65 21.13 84.52

75807 162.40 32.48 129.92

75809 56.19 11.84 44.35

75810 157.60 31.52 126.08

75820 65.65 17.37 48.28

75822 77.94 30.01 47.93

75825 77.13 29.28 47.85

75827 78.74 29.62 49.13

75831 85.76 30.36 55.40

75833 89.71 39.83 49.88

75840 85.95 31.52 54.43

75842 102.41 37.96 64.45

75860 78.11 30.74 47.37

75870 82.53 31.52 51.01

75872 114.34 29.01 85.33

75880 78.31 19.34 58.97

75885 86.23 38.09 48.14

75887 98.47 42.11 56.36

75889 81.76 27.32 54.44

75891 91.58 33.81 57.76

75893 67.68 14.57 53.11

75894 195.35 39.07 156.28

75898 231.05 46.21 184.84





75901 100.69 14.47 86.23

75902 40.96 10.44 30.52

75952 619.65 123.93 495.72

75953 194.34 38.87 155.47

75954 313.20 62.64 250.56

75956 967.70 193.54 774.16

75957 830.40 166.08 664.32

75958 551.05 110.21 440.84

75959 463.70 92.74 370.96

75970 110.20 22.04 88.16

75984 60.21 17.68 42.54

75989 65.74 32.10 33.64

76000 38.14 4.35 33.80

76010 14.90 5.24 9.67

76080 31.42 14.40 17.02

76098 9.47 4.63 4.83

76100 60.08 16.30 43.78

76101 95.30 18.44 76.86

76102 117.31 18.80 98.51

76120 49.18 11.70 37.48

76125 36.70 7.34 29.36

76376 25.67 4.87 20.80

76377 40.68 22.96 17.72

76380 83.90 27.07 56.83 Y

76390 241.88 38.28 203.59 Y

76496 Y

76497 Y

76498 Y

76499 Y

76506 67.67 18.53 49.14

76510 96.67 47.75 48.92

76511 55.30 29.00 26.29

76512 52.76 28.95 23.82

76513 54.17 18.65 35.52

76514 8.66 5.47 3.19

76516 44.71 16.00 28.71

76519 48.13 16.23 31.90

76529 43.33 17.79 25.54

76536 66.66 16.11 50.55

76604 50.55 15.51 35.04

76641 60.35 20.71 39.63

76642 49.70 19.33 30.37

76700 70.08 23.16 46.92

76705 52.36 16.92 35.44

76706 53.57 10.71 42.86





76770 64.85 21.15 43.70

76775 47.28 14.27 33.00

76776 89.82 18.79 71.03

76800 81.76 31.50 50.26

76801 70.89 28.80 42.09

76802 37.06 24.37 12.69

76805 81.76 29.00 52.76

76810 53.57 27.32 26.25

76811 105.53 56.59 48.94

76812 118.21 49.31 68.90

76813 70.28 35.24 35.04

76814 46.72 29.60 17.12

76815 48.74 18.93 29.81

76816 66.66 25.37 41.28

76817 55.99 21.95 34.03

76818 71.09 31.42 39.67

76819 51.96 22.76 29.20

76820 26.00 15.61 10.39

76821 53.57 19.33 34.24

76825 141.25 50.83 90.42

76826 85.14 25.09 60.05

76827 38.55 17.43 21.12

76828 28.59 17.23 11.36

76830 70.08 19.94 50.15

76831 68.67 19.33 49.35

76856 63.24 19.94 43.30

76857 41.48 9.76 31.73

76870 54.09 15.83 38.26

76872 54.37 16.53 37.84

76873 97.87 44.06 53.81

76881 67.67 18.12 49.54

76882 20.54 14.10 6.44

76885 83.98 21.35 62.63

76886 62.43 17.13 45.30

76930 45.12 17.98 27.14

76932 93.65 18.73 74.92

76936 150.94 54.14 96.80

76937 17.92 8.26 9.67

76940 284.20 56.84 227.36

76941 188.50 37.70 150.80

76942 88.90 16.53 72.37

76945 100.69 20.14 80.56

76946 18.73 11.28 7.45

76965 49.30 36.35 12.95

76975 116.95 23.39 93.56





76977 3.87 1.44 2.43

76998 182.26 36.45 145.80

76999 Y

77001 51.63 9.40 42.24

77002 50.92 17.02 33.90

77003 41.84 18.29 23.55

77011 306.24 34.42 271.83 Y

77012 70.69 32.83 37.86 Y

77013 537.50 107.50 430.00 Y

77014 69.35 21.57 47.78 Y

77021 218.87 41.18 177.68 Y

77022 583.90 116.78 467.12 Y

77053 31.71 9.85 21.86

77054 41.76 11.46 30.30

77058 309.14 40.37 268.78 Y

77059 311.45 40.37 271.08 Y

77065 69.99 19.14 50.85

77066 88.94 23.97 64.96

77067 72.89 19.14 53.75

77071 27.59

77072 13.09 5.44 7.65

77073 20.34 8.26 12.08

77074 36.65 13.09 23.56

77075 49.54 15.51 34.03

77076 57.42 21.26 36.16

77077 21.15 9.26 11.88

77078 73.06 6.77 66.30 Y

77080 23.36 5.84 17.52

77081 15.91 5.70 10.21

77084 264.79 44.28 220.51 Y

77085 31.16 8.48 22.68

77086 17.93 4.48 13.45

77261 43.50

77262 64.65

77263 94.85

77280 115.26 21.69 93.57

77285 203.86 32.76 171.11

77290 294.83 46.32 248.51

77293 261.48 62.11 199.38

77295 280.33 129.88 150.45

77300 38.06 18.53 19.53

77301 1,116.49 223.30 893.19

77306 80.27 39.84 40.43

77307 157.19 83.03 74.16

77316 102.95 39.84 63.11





77317 134.71 52.46 82.25

77318 194.67 83.04 111.63

77321 53.17 27.01 26.16

77331 36.65 25.38 11.28

77332 40.90 13.92 26.97

77333 31.90 26.16 5.74

77334 74.83 31.50 43.33

77336 27.95

77338 290.00 126.67 163.33

77370 69.68

77371 593.72

77372 499.80

77373 778.36

77385 130.42

77386 151.65

77387 45.03

77399 Y

77401 13.13

77402 84.88

77407 118.89

77412 126.41

77417 6.24

77422 130.42

77423 151.65

77427 106.13

77431 58.40

77432 239.05

77435 360.28

77470 82.37 58.71 23.66

77499 Y

77520 712.03 Y

77522 731.18 Y

77523 699.39 Y

77525 669.40 Y

77600 236.63 44.52 192.11

77605 424.80 63.61 361.19

77610 405.02 40.28 364.74

77615 536.24 54.43 481.81

77620 295.36 43.72 251.64

77750 202.43 130.34 72.09

77761 221.96 118.04 103.92

77762 293.66 178.22 115.43

77763 414.18 248.16 166.02

77767 122.58 29.77 92.80

77768 191.99 39.44 152.55





77770 183.26 51.19 132.08

77771 341.35 100.82 240.54

77772 497.27 152.16 345.11

77778 468.11 291.93 176.18

77789 67.87 35.25 32.62

77790 40.32

77799 Y

78012 47.33 5.74 41.58

78013 107.11 10.05 97.06

78014 142.38 14.30 128.08

78015 123.74 17.98 105.76

78016 153.18 18.55 134.63

78018 175.36 22.62 152.74

78020 46.79 15.27 31.52

78070 106.94 23.61 83.34

78071 201.08 32.10 168.98

78075 232.22 19.33 212.89

78099 Y

78102 95.13 14.50 80.63

78103 117.27 18.08 99.19

78104 134.46 21.07 113.39

78110 49.95 4.83 45.12

78111 45.66 5.07 40.59

78120 49.24 5.73 43.51

78121 44.70 7.13 37.57

78122 53.18 10.74 42.44

78130 86.84 15.76 71.08

78135 193.55 16.47 177.08

78140 72.87 15.58 57.29

78185 114.95 10.03 104.92

78190 222.01 28.11 193.90

78191 87.02 15.76 71.26

78195 209.85 33.83 176.01

78199 Y

78201 100.98 11.60 89.38

78202 99.75 11.83 87.91

78205 103.62 16.70 86.91

78206 201.59 26.78 174.80

78215 114.39 14.67 99.71

78216 73.26 16.59 56.67

78226 194.94 20.94 174.00

78227 264.42 25.58 238.85

78230 93.82 11.46 82.36

78231 69.65 14.19 55.46

78232 55.81 10.63 45.18





78258 109.42 18.08 91.34

78261 136.97 17.55 119.42

78262 122.31 16.35 105.96

78264 189.12 22.12 167.00

78265 235.02 29.14 205.88

78266 266.04 29.39 236.65

78267 9.80

78268 84.50

78270 46.19 5.01 41.18

78271 50.49 5.19 45.30

78272 50.85 6.80 44.05

78278 170.16 24.19 145.97

78282 49.25 9.85 39.40

78290 187.55 18.56 168.98

78299 Y

78300 106.74 17.92 88.81

78305 129.93 22.62 107.31

78306 148.02 24.17 123.85

78315 203.80 28.80 175.01

78320 127.80 27.65 100.15

78350 17.98 5.73 12.25

78399 Y

78414 59.10 11.82 47.28

78428 99.73 19.16 80.57

78445 93.46 11.64 81.82

78451 176.56 40.40 136.16

78452 277.51 45.11 232.40

78453 153.63 29.78 123.85

78454 134.43 40.19 94.24

78456 192.29 24.89 167.40

78457 110.47 19.34 91.13

78458 101.34 20.69 80.65

78459 193.35 38.67 154.68 Y

78466 102.71 19.14 83.57

78468 108.32 20.05 88.27

78469 123.00 23.28 99.72

78472 134.53 27.59 106.94

78473 169.57 35.15 134.41

78481 97.64 24.35 73.29

78483 134.30 36.70 97.60

78491 195.30 39.06 156.24 Y

78492 245.55 49.11 196.44 Y

78494 125.87 31.71 94.16

78496 25.58 12.17 13.41

78499 Y





78579 104.79 12.95 91.84

78580 121.11 18.08 103.03

78582 197.16 30.41 166.75

78597 102.14 17.57 84.57

78598 172.46 22.81 149.65

78599 Y

78600 99.37 12.01 87.36

78601 126.47 15.10 111.37

78605 118.01 16.16 101.85

78606 180.29 17.14 163.15

78607 197.21 32.48 164.73

78608 1,150.50 39.44 1,111.06 Y

78609 1,146.79 40.66 1,106.13 Y

78610 95.78 8.27 87.51

78630 190.45 18.56 171.88

78635 183.52 15.04 168.48

78645 156.95 13.74 143.21

78647 198.56 22.38 176.18

78650 195.14 18.07 177.07

78660 102.41 13.97 88.44

78699 Y

78700 96.67 12.18 84.49

78701 118.52 12.95 105.57

78707 136.94 27.39 109.55

78708 103.31 34.03 69.28

78709 214.68 41.26 173.42

78710 110.65 16.74 93.91

78725 59.98 10.05 49.93

78730 39.77 3.76 36.01

78740 110.15 13.57 96.58

78761 117.17 19.53 97.64

78799 Y

78800 102.77 18.51 84.26

78801 145.15 21.67 123.48

78802 182.71 23.01 159.70

78803 201.19 31.26 169.92

78804 333.50 31.26 302.24

78805 107.74 20.54 87.20

78806 186.96 23.01 163.96

78807 182.80 28.42 154.38

78808 23.84

78811 1,150.50 42.34 1,108.16 Y

78812 1,150.50 51.62 1,098.88 Y

78813 1,151.78 50.85 1,100.85 Y

78814 1,151.78 59.55 1,092.23 Y





78815 1,036.60 58.99 977.62 Y

78816 1,151.78 66.12 1,085.66 Y

78999 Y

79005 78.54 48.97 29.57

79101 82.37 53.66 28.71

79200 82.00 52.10 29.90

79300 208.60 41.72 166.88

79403 99.90 60.90 39.00

79440 75.20 49.77 25.43

79445 316.10 63.22 252.88

79999 Y

A4641 Y

A9500 150.00

A9502 143.66

A9505 71.37

A9552 150.00

A9600 879.75 Y

A9699 Y

R0070 21.83


radiology fee schedule effective january 1,...

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