radiology procedure codes

Radiology Procedure Codes Procedure Code Procedure Description Allowed Amount Effective Date End Date 70010 MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION AND INTERPRETATION $196.68 7/1/2019 12/31/2382 70010 MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION AND INTERPRETATION 26 $64.13 7/1/2019 12/31/2382 70010 MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION AND INTERPRETATION TC $147.81 7/1/2019 12/31/2382 70015 CISTERNOGRAPHY, POSITIVE CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION $196.68 7/1/2019 12/31/2382 70015 CISTERNOGRAPHY, POSITIVE CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION 26 $64.13 7/1/2019 12/31/2382 70015 CISTERNOGRAPHY, POSITIVE CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION TC $46.34 7/1/2019 12/31/2382 70030 RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY $49.20 7/1/2019 12/31/2382 70030 RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY 26 $9.30 7/1/2019 12/31/2382 70030 RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY 50 $49.20 7/1/2019 12/31/2382 70030 RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY TC $14.44 7/1/2019 12/31/2382 70100 RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN FOUR VIEWS $49.20 7/1/2019 12/31/2382 70100 RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN FOUR VIEWS 26 $9.83 7/1/2019 12/31/2382 70100 RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN FOUR VIEWS TC $18.13 7/1/2019 12/31/2382 70110 RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF FOUR VIEWS $49.20 7/1/2019 12/31/2382 70110 RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF FOUR VIEWS 26 $13.37 7/1/2019 12/31/2382 70110 RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF FOUR VIEWS TC $21.38 7/1/2019 12/31/2382 70120 RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN THREE VIEWS PER SIDE $49.20 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 70120 70120 70130 70130 70130 70134 70134 70134 70140 70140 70140 70150 70150 70150 70150 70150 70160 70160 70160 70160 70160 70170 70170 70170 Procedure Description Modifier Allowed Amount Effective Date End Date RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN THREE VIEWS PER SIDE RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN THREE VIEWS PER SIDE RADIOLOGIC EXAMINATION, MASTOIDS; COMPLETE, MINIMUM OF THREE VIEWS PER SIDE RADIOLOGIC EXAMINATION, MASTOIDS; COMPLETE, MINIMUM OF THREE VIEWS PER SIDE RADIOLOGIC EXAMINATION, MASTOIDS; COMPLETE, MINIMUM OF THREE VIEWS PER SIDE RADIOLOGIC EXAMINATION, INTERNAL AUDITORY MEATI, COMPLETE RADIOLOGIC EXAMINATION, INTERNAL AUDITORY MEATI, COMPLETE RADIOLOGIC EXAMINATION, INTERNAL AUDITORY MEATI, COMPLETE RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF THREE VIEWS DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION 26 TC $9.83 $21.38 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $17.92 7/1/2019 12/31/2382 TC $26.97 $83.74 $17.92 $25.30 $49.20 $10.14 $21.38 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $14.00 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $26.97 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $9.15 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $18.13 7/1/2019 12/31/2382 $232.98 7/1/2019 12/31/2382 26 $15.31 7/1/2019 12/31/2382 TC $32.24 7/1/2019 12/31/2382 26 TC 26 TC Radiology Procedure Codes Procedure Code 70190 70190 70190 70200 70200 70200 Procedure Description RADIOLOGIC EXAMINATION; OPTIC FORAMINA RADIOLOGIC EXAMINATION; OPTIC FORAMINA RADIOLOGIC EXAMINATION; OPTIC FORAMINA RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF FOUR VIEWS Allowed Amount $49.20 $11.44 $21.38 $49.20 $14.98 $26.97 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 70210 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN THREE VIEWS $49.20 7/1/2019 12/31/2382 70210 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN THREE VIEWS 26 $9.15 7/1/2019 12/31/2382 70210 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, SELLA TURCICA RADIOLOGIC EXAMINATION, SELLA TURCICA RADIOLOGIC EXAMINATION, SELLA TURCICA RADIOLOGIC EXAMINATION, SKULL; LESS THAN FOUR VIEWS, WITH OR WITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; LESS THAN FOUR VIEWS, WITH OR WITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; LESS THAN FOUR VIEWS, WITH OR WITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR VIEWS, WITH OR WITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR VIEWS, WITH OR WITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR VIEWS, WITH OR WITHOUT STEREO RADIOLOGIC EXAMINATION, TEETH; SINGLE VIEW RADIOLOGIC EXAMINATION, TEETH; SINGLE VIEW RADIOLOGIC EXAMINATION, TEETH; SINGLE VIEW RADIOLOGIC EXAMINATION, TEETH; PARTIAL EXAMINATION, LESS THAN FULL MOUTH RADIOLOGIC EXAMINATION, TEETH; PARTIAL EXAMINATION, LESS THAN FULL MOUTH $21.38 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $13.38 7/1/2019 12/31/2382 TC $26.97 $49.20 $10.39 $14.44 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $13.01 7/1/2019 12/31/2382 TC $21.38 7/1/2019 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $17.92 7/1/2019 12/31/2382 TC $30.56 $54.08 $5.37 $8.85 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $54.08 7/1/2019 12/31/2382 $8.33 7/1/2019 12/31/2382 70220 70220 70220 70240 70240 70240 70250 70250 70250 70260 70260 70260 70300 70300 70300 70310 70310 Modifier 26 TC 26 TC TC 26 TC 26 TC 26 Radiology Procedure Codes Procedure Code 70310 70320 70320 70320 70328 70328 70328 70330 70330 70330 70332 70332 70332 70336 70336 70336 70350 70350 70350 70355 70355 70355 70360 70360 70360 70370 Procedure Description RADIOLOGIC EXAMINATION, TEETH; PARTIAL EXAMINATION, LESS THAN FULL MOUTH RADIOLOGIC EXAMINATION, TEETH; COMPLETE, FULL MOUTH RADIOLOGIC EXAMINATION, TEETH; COMPLETE, FULL MOUTH RADIOLOGIC EXAMINATION, TEETH; COMPLETE, FULL MOUTH RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; UNILATERAL RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; UNILATERAL RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; UNILATERAL RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND CLOSED MOUTH; BILATERAL TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR JOINT CEPHALOGRAM, ORTHODONTIC CEPHALOGRAM, ORTHODONTIC CEPHALOGRAM, ORTHODONTIC ORTHOPANTOGRAM ORTHOPANTOGRAM ORTHOPANTOGRAM RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE RADIOLOGIC EXAMINATION; PHARYNX OR LARYNX, INCLUDING FLUOROSCOPY AND/OR MAGNIFICATION TECHNIQUE Allowed Amount Effective Date End Date $14.44 $54.08 $11.94 $26.97 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $9.83 7/1/2019 12/31/2382 TC $17.12 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $13.01 7/1/2019 12/31/2382 TC $28.64 7/1/2019 12/31/2382 $235.57 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $71.73 7/1/2019 12/31/2382 $343.96 7/1/2019 12/31/2382 26 $48.97 7/1/2019 12/31/2382 TC $382.71 $49.20 $8.87 $12.53 $49.20 $10.69 $19.70 $49.20 $9.07 $14.44 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $89.64 7/1/2019 12/31/2382 Modifier TC 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 70370 70370 70371 70371 70371 70373 70373 70373 70380 70380 70380 70390 70390 70390 70450 70450 70450 70450 70450 70450 70450 70460 70460 Procedure Description RADIOLOGIC EXAMINATION; PHARYNX OR LARYNX, INCLUDING FLUOROSCOPY AND/OR MAGNIFICATION TECHNIQUE RADIOLOGIC EXAMINATION; PHARYNX OR LARYNX, INCLUDING FLUOROSCOPY AND/OR MAGNIFICATION TECHNIQUE COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE OR VIDEO RECORDING COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE OR VIDEO RECORDING COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE OR VIDEO RECORDING LARYNGOGRAPHY, CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION LARYNGOGRAPHY, CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION LARYNGOGRAPHY, CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, SALIVARY GLAND FOR CALCULUS RADIOLOGIC EXAMINATION, SALIVARY GLAND FOR CALCULUS RADIOLOGIC EXAMINATION, SALIVARY GLAND FOR CALCULUS SIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION SIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION SIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S) Modifier Allowed Amount Effective Date End Date 26 $17.11 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 $89.64 7/1/2019 12/31/2382 26 $45.45 7/1/2019 12/31/2382 TC $71.73 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $22.63 7/1/2019 12/31/2382 TC $60.88 $49.20 $9.15 $23.05 $114.52 $19.26 $60.88 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $46.13 7/1/2019 12/31/2382 59 $213.19 7/1/2019 12/31/2382 76 $213.19 7/1/2019 12/31/2382 ET $213.19 7/1/2019 12/31/2382 GA $213.19 7/1/2019 12/31/2382 TC $161.25 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 $60.94 7/1/2019 12/31/2382 26 TC 26 TC 26 Radiology Procedure Codes Procedure Code 70460 70470 70470 70470 70480 70480 70480 70480 70481 70481 70481 70482 70482 70482 70486 70486 70486 70487 70487 70487 Procedure Description COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRA COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRA COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRA COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRA COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRA COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRA COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRA COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) Modifier Allowed Amount Effective Date End Date TC $193.15 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $68.81 7/1/2019 12/31/2382 TC $241.50 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $69.41 7/1/2019 12/31/2382 59 $212.87 7/1/2019 12/31/2382 TC $161.25 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $74.73 7/1/2019 12/31/2382 TC $193.15 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $78.51 7/1/2019 12/31/2382 TC $241.50 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $61.48 7/1/2019 12/31/2382 TC $161.25 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $70.18 7/1/2019 12/31/2382 TC $193.15 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 70488 70488 70488 70490 70490 70490 70491 70491 70491 70492 70492 70492 70496 70498 70540 70540 70540 70542 70543 70544 70545 70546 Procedure Description COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTERIZED AXIAL TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FUR MAGNETIC RESONANCE (EG, PROTON) IMAGING; ORBIT, FACE, AND NECK MAGNETIC RESONANCE (EG, PROTON) IMAGING; ORBIT, FACE, AND NECK MAGNETIC RESONANCE (EG, PROTON) IMAGING; ORBIT, FACE, AND NECK MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND NECK WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE INAMGING, ORBIT, FACE AND NECK WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTH Allowed Amount Effective Date End Date $344.34 7/1/2019 12/31/2382 26 $77.14 7/1/2019 12/31/2382 TC $241.50 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $69.41 7/1/2019 12/31/2382 TC $161.25 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $74.73 7/1/2019 12/31/2382 TC $193.15 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $78.51 7/1/2019 12/31/2382 TC $241.50 7/1/2019 12/31/2382 $336.85 7/1/2019 12/31/2382 $336.85 $395.76 $80.09 $382.71 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 Modifier 26 TC Radiology Procedure Codes Procedure Code 70546 70547 70548 70549 70551 70551 70551 70552 70552 70552 70553 70553 70553 70553 70554 70555 70557 70558 70559 71010 71010 71010 Procedure Description MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTH MAGNETIC RESONANCE ANGIOGRAPHY, NECK, WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, NECK, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTH MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY MAGNETIC RESONANCE IMAGING, BRAIN FUNCATIONAL MRI; INCLUDING TEST SELECTION AND ADMINISTRATION OF REPETITIVE MAGNETIC RESONANCE IMAGING, BRAIN FUNCATIONAL MRI; REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIR MAGNETIC RESONANCE IMAGIN, BRAIN, DURING INTRACRANIAL PROCEDURE; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE IMAGIN, BRAIN, DURING INTRACRANIAL PROCEDURE; WITH CONTRAST MATERIAL MAGNETIC RESONANCE IMAGIN, BRAIN, DURING INTRACRANIAL PROCEDURE; WITHOUT CONTRAST MATERIAL FOLLOWED RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL Modifier Allowed Amount Effective Date End Date XS $573.77 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 26 $80.09 7/1/2019 12/31/2382 TC $382.71 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 26 $91.88 7/1/2019 12/31/2382 TC $459.03 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 26 $122.18 7/1/2019 12/31/2382 52 $573.77 7/1/2019 12/31/2382 TC $850.02 7/1/2019 12/31/2382 $382.73 7/1/2019 12/31/2382 $382.73 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 $49.20 $9.61 $49.20 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 26 59 Radiology Procedure Codes Procedure Code 71010 71010 71010 71010 71015 71015 71015 71020 71020 71020 71020 71020 71021 71021 71021 71022 71022 71022 71023 71023 71023 71030 71030 71030 71034 71034 71034 71035 Procedure Description RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL RADIOLOGIC EXAMINATION, CHEST; STEREO, FRONTAL RADIOLOGIC EXAMINATION, CHEST; STEREO, FRONTAL RADIOLOGIC EXAMINATION, CHEST; STEREO, FRONTAL RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH APICAL LORDOTIC PROCEDURE RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH APICAL LORDOTIC PROCEDURE RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH APICAL LORDOTIC PROCEDURE RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL DECUBITUS, BUCKY STUDIES) Allowed Amount $49.20 $49.20 $16.46 $49.20 $49.20 $11.19 $18.13 $49.20 $11.74 $49.20 $49.20 $21.38 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $14.21 7/1/2019 12/31/2382 TC $25.30 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $16.50 7/1/2019 12/31/2382 TC $25.30 7/1/2019 12/31/2382 $89.64 7/1/2019 12/31/2382 26 $20.31 7/1/2019 12/31/2382 TC $26.97 $49.20 $16.50 $26.97 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $89.64 7/1/2019 12/31/2382 26 $25.12 7/1/2019 12/31/2382 TC $49.35 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 Modifier 76 RT TC XU 26 TC 26 59 GA TC 26 TC Radiology Procedure Codes Procedure Code Modifier Allowed Amount Effective Date End Date 26 $9.61 7/1/2019 12/31/2382 TC $18.13 7/1/2019 12/31/2382 $82.21 7/1/2019 12/31/2382 26 $29.87 7/1/2019 12/31/2382 TC $53.94 7/1/2019 12/31/2382 71036 Procedure Description RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL DECUBITUS, BUCKY STUDIES) RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL DECUBITUS, BUCKY STUDIES) NEEDLE BIOPSY OF INTRATHORACIC LESION, INCLUDING FOLLOW-UP FILMS; FLUOROSCOPIC LOCALIZATION ONLY, RADIOLOGICAL NEEDLE BIOPSY OF INTRATHORACIC LESION, INCLUDING FOLLOW-UP FILMS; FLUOROSCOPIC LOCALIZATION ONLY, RADIOLOGICAL NEEDLE BIOPSY OF INTRATHORACIC LESION, INCLUDING FOLLOW-UP FILMS; FLUOROSCOPIC LOCALIZATION ONLY, RADIOLOGICAL 71038 FLUOROSCOPIC LOCALIZATION FOR TRANSBRONCHIAL BIOPSY OR BRUSHING $85.80 7/1/2019 12/31/2382 71038 FLUOROSCOPIC LOCALIZATION FOR TRANSBRONCHIAL BIOPSY OR BRUSHING 26 $29.87 7/1/2019 12/31/2382 71038 FLUOROSCOPIC LOCALIZATION FOR TRANSBRONCHIAL BIOPSY OR BRUSHING BRONCHOGRAPHY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION BRONCHOGRAPHY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION BRONCHOGRAPHY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS RADIOLOGIC EXAMINATION, CHEST; 2 VIEWS RADIOLOGIC EXAMINATION, CHEST; 3 VIEWS RADIOLOGIC EXAMINATION, CHEST; 3 VIEWS RADIOLOGIC EXAMINATION, CHEST; 3 VIEWS RADIOLOGIC EXAMINATION, CHEST; 4 OR MORE VIEWS RADIOLOGIC EXAMINATION, CHEST; 4 OR MORE VIEWS RADIOLOGIC EXAMINATION, CHEST; 4 OR MORE VIEWS BRONCHOGRAPHY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION $57.53 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $30.29 7/1/2019 12/31/2382 TC $50.02 $53.28 $5.76 $53.28 $6.64 $53.28 $53.28 $6.86 $53.28 $53.28 $12.17 $53.28 $8.85 $15.49 $98.17 $10.17 $15.93 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $114.52 7/1/2019 12/31/2382 71035 71035 71036 71036 71040 71040 71040 71045 71045 71045 71045 71045 71046 71046 71046 71046 71046 71047 71047 71047 71048 71048 71048 71060 TC 26 FY TC UD 26 FY PO TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 71060 71060 71090 71090 71090 71100 71100 71100 71100 71100 71100 71101 71101 71101 71101 71101 71101 71110 71110 71110 71111 71111 71111 71111 71120 71120 Procedure Description BRONCHOGRAPHY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION BRONCHOGRAPHY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING POSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF TWO VIEWS Modifier Allowed Amount Effective Date End Date 26 $38.28 7/1/2019 12/31/2382 TC $75.32 7/1/2019 12/31/2382 $89.64 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $57.53 $49.20 $11.94 $49.20 $49.20 $49.20 $19.70 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $14.45 7/1/2019 12/31/2382 59 $49.20 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $23.05 $49.20 $14.45 $26.97 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $16.87 7/1/2019 12/31/2382 59 $83.74 7/1/2019 12/31/2382 TC $30.56 $49.20 $10.69 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 26 59 LT RT TC 26 TC 26 Radiology Procedure Codes Procedure Code 71120 Allowed Amount $22.38 Effective Date 7/1/2019 End Date 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $11.74 7/1/2019 12/31/2382 TC $24.06 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $62.77 7/1/2019 12/31/2382 59 $213.19 7/1/2019 12/31/2382 TC $201.42 7/1/2019 12/31/2382 71250 Procedure Description RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; STERNOCLAVICULAR JOINT OR JOINTS, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION; STERNOCLAVICULAR JOINT OR JOINTS, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION; STERNOCLAVICULAR JOINT OR JOINTS, MINIMUM OF THREE VIEWS COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL 71260 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S) $289.49 7/1/2019 12/31/2382 71260 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S) 26 $67.24 7/1/2019 12/31/2382 71260 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S) 59 $289.49 7/1/2019 12/31/2382 71260 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S), FOLLO MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY) MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY) MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY) MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPH WITH CONTRAS MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG,FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPH WITHOUT $241.50 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $74.73 7/1/2019 12/31/2382 TC $301.80 7/1/2019 12/31/2382 $336.85 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 26 $86.81 7/1/2019 12/31/2382 TC $382.71 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 71130 71130 71130 71250 71250 71250 71270 71270 71270 71275 71550 71550 71550 71551 71552 Modifier TC TC Radiology Procedure Codes Procedure Code 71555 Allowed Amount $501.76 Effective Date 7/1/2019 End Date 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $23.97 7/1/2019 12/31/2382 TC $34.90 $49.20 $7.95 $49.20 $49.20 $14.44 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $11.74 7/1/2019 12/31/2382 TC $20.71 $83.74 $16.50 $83.74 $30.56 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $18.99 7/1/2019 12/31/2382 TC $38.50 7/1/2019 12/31/2382 72052 Procedure Description MAGNETIC RESONANCE IMAGING, CHEST RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL RADIOLOGIC EXAMINATION, SPINE, CERVICAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, CERVICAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, CERVICAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, CERVICAL; MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, CERVICAL; MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, CERVICAL; MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, CERVICAL; MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, CERVICAL; COMPLETE, INCLUDING OBLIQUE AND FLEXION AND/OR EXTENSION STUDIES RADIOLOGIC EXAMINATION, SPINE, CERVICAL; COMPLETE, INCLUDING OBLIQUE AND FLEXION AND/OR EXTENSION STUDIES RADIOLOGIC EXAMINATION, SPINE, CERVICAL; COMPLETE, INCLUDING OBLIQUE AND FLEXION AND/OR EXTENSION STUDIES 72069 RADIOLOGIC EXAMINATION, SPINE, THORACOLUMBAR, STANDING (SCOLIOSIS) $49.20 7/1/2019 12/31/2382 72069 RADIOLOGIC EXAMINATION, SPINE, THORACOLUMBAR, STANDING (SCOLIOSIS) 26 $11.02 7/1/2019 12/31/2382 72069 RADIOLOGIC EXAMINATION, SPINE, THORACOLUMBAR, STANDING (SCOLIOSIS) TC RADIOLOGIC EXAMINATION, SPINE; THORACIC, ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE; THORACIC, ANTEROPOSTERIOR AND LATERAL 26 RADIOLOGIC EXAMINATION, SPINE; THORACIC, ANTEROPOSTERIOR AND LATERAL TC $17.12 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 $11.75 7/1/2019 12/31/2382 $22.38 7/1/2019 12/31/2382 72010 72010 72010 72020 72020 72020 72020 72020 72040 72040 72040 72050 72050 72050 72050 72052 72052 72070 72070 72070 Modifier 26 59 76 TC 26 PO TC Radiology Procedure Codes Procedure Code 72072 72072 72072 72074 72074 72074 72080 72080 72080 72081 72082 72083 72084 72084 72090 72090 72090 72100 72100 72100 72100 72100 72110 Procedure Description RADIOLOGIC EXAMINATION, SPINE; THORACIC, ANTEROPOSTERIOR AND LATERAL, INCLUDING SWIMMER'S VIEW OF THE CERVICOT RADIOLOGIC EXAMINATION, SPINE; THORACIC, ANTEROPOSTERIOR AND LATERAL, INCLUDING SWIMMER'S VIEW OF THE CERVICOT RADIOLOGIC EXAMINATION, SPINE; THORACIC, ANTEROPOSTERIOR AND LATERAL, INCLUDING SWIMMER'S VIEW OF THE CERVICOT RADIOLOGIC EXAMINATION, SPINE; THORACIC, COMPLETE, INCLUDING OBLIQUES, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE; THORACIC, COMPLETE, INCLUDING OBLIQUES, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE; THORACIC, COMPLETE, INCLUDING OBLIQUES, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, ANTEROPOSTERIOR AND LATERAL X-RAY OF SPINE, 1 VIEW X-RAY OF SPINE, 2 OR 3 VIEWS X-RAY OF SPINE, 4 OR 5 VIEWS X-RAY OF SPINE, MINIMUM OF 6 VIEWS X-RAY OF SPINE, MINIMUM OF 6 VIEWS RADIOLOGIC EXAMINATION, SPINE; SCOLIOSIS STUDY, INCLUDING SUPINE AND ERECT STUDIES RADIOLOGIC EXAMINATION, SPINE; SCOLIOSIS STUDY, INCLUDING SUPINE AND ERECT STUDIES RADIOLOGIC EXAMINATION, SPINE; SCOLIOSIS STUDY, INCLUDING SUPINE AND ERECT STUDIES RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; ANTEROPOSTERIOR AND LATERAL RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, WITH OBLIQUE VIEWS Allowed Amount Effective Date End Date $49.20 7/1/2019 12/31/2382 26 $11.74 7/1/2019 12/31/2382 TC $25.30 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $11.74 7/1/2019 12/31/2382 TC $31.23 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $11.74 7/1/2019 12/31/2382 TC $23.05 $55.63 $92.12 $175.63 $175.63 $163.83 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 1/1/2060 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $14.74 7/1/2019 12/31/2382 TC $23.05 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $11.75 7/1/2019 12/31/2382 59 $49.20 7/1/2019 12/31/2382 FY $49.20 7/1/2019 12/31/2382 TC $23.05 7/1/2019 12/31/2382 $83.74 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 72110 72110 72114 72114 72114 72120 72120 72120 72125 72125 72125 72125 72126 72126 72126 72127 72127 72127 72128 72128 Procedure Description RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, WITH OBLIQUE VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, WITH OBLIQUE VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, INCLUDING BENDING VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, INCLUDING BENDING VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, INCLUDING BENDING VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS ONLY, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS ONLY, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS ONLY, MINIMUM OF FOUR VIEWS COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL Modifier Allowed Amount Effective Date End Date 26 $16.50 7/1/2019 12/31/2382 TC $31.23 7/1/2019 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $18.99 7/1/2019 12/31/2382 TC $40.17 7/1/2019 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $11.74 7/1/2019 12/31/2382 TC $30.56 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $62.77 7/1/2019 12/31/2382 59 $213.19 7/1/2019 12/31/2382 TC $201.42 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $65.87 7/1/2019 12/31/2382 TC $241.50 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $68.81 7/1/2019 12/31/2382 TC $301.80 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 $62.77 7/1/2019 12/31/2382 26 Radiology Procedure Codes Procedure Code 72128 72129 72129 72129 72130 72130 72130 72131 72131 72131 72132 72132 72132 72133 72133 72133 72141 72141 72141 72142 Procedure Description COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITH CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND F COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND F COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND F MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S) Modifier Allowed Amount Effective Date End Date TC $201.42 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $65.87 7/1/2019 12/31/2382 TC $241.50 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $68.81 7/1/2019 12/31/2382 TC $301.80 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $62.77 7/1/2019 12/31/2382 TC $201.42 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $65.87 7/1/2019 12/31/2382 TC $241.50 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $68.81 7/1/2019 12/31/2382 TC $301.80 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 26 $86.81 7/1/2019 12/31/2382 TC $382.71 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 72142 72142 72146 72146 72146 72147 72147 72147 72148 72148 72148 72149 72149 72149 72156 72156 72156 72157 72157 72157 Procedure Description MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON Modifier Allowed Amount Effective Date End Date 26 $99.20 7/1/2019 12/31/2382 TC $459.03 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 26 $86.81 7/1/2019 12/31/2382 TC $424.89 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 26 $99.20 7/1/2019 12/31/2382 TC $459.03 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 26 $76.57 7/1/2019 12/31/2382 TC $424.89 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 26 $91.88 7/1/2019 12/31/2382 TC $459.03 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 26 $132.52 7/1/2019 12/31/2382 TC $850.02 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 26 $132.52 7/1/2019 12/31/2382 TC $850.02 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code Allowed Amount Effective Date End Date $573.77 7/1/2019 12/31/2382 26 $122.18 7/1/2019 12/31/2382 TC $850.02 7/1/2019 12/31/2382 $573.77 $49.20 $12.04 $49.20 $49.20 $49.20 $49.20 $18.13 $49.20 $10.69 $23.05 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $336.85 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $55.96 7/1/2019 12/31/2382 TC $201.42 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 72192 Procedure Description MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CON MAGNETIC RESONANCE IMAGING, SPINAL CANAL AND CONTENTS, WITH OR WITHOUT CONTRAST MATERIAL(S) RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR ONLY RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR ONLY RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR ONLY RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR ONLY RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR ONLY RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR ONLY RADIOLOGIC EXAMINATION, PELVIS; ANTEROPOSTERIOR ONLY RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF THREE VIEWS COMPUTED TOMOGRAPHIC ANGIOGRAPHY, PELVIS, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL 72193 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) 72193 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) 26 $59.90 7/1/2019 12/31/2382 72193 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) 59 $289.49 7/1/2019 12/31/2382 72193 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) GZ $289.49 7/1/2019 12/31/2382 72193 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER TC $233.65 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 $62.60 7/1/2019 12/31/2382 72158 72158 72158 72159 72170 72170 72170 72170 72170 72170 72170 72190 72190 72190 72191 72192 72192 72194 72194 Modifier 26 59 FY LT RT TC 26 TC 26 Radiology Procedure Codes Procedure Code Modifier Allowed Amount Effective Date End Date TC $289.93 7/1/2019 12/31/2382 26 TC $395.76 $420.48 $82.88 $382.71 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $573.77 7/1/2019 12/31/2382 $498.14 $49.20 $8.66 $18.13 $49.20 $9.68 $21.38 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 72198 72200 72200 72200 72202 72202 72202 Procedure Description COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER MAGNETIC RESONANCE (EG, PROTON)IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS MAGNETIC RESONANCE (EG, PROTON)IMAGING, PELVIS; WITHOUTCONTRAST MATERIAL(S) AND FURTHER SEQUENCES MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT CONTRAST MATERIAL(S) RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; THREE OR MORE VIEWS RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; THREE OR MORE VIEWS RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; THREE OR MORE VIEWS 72220 RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF TWO VIEWS 72220 RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF TWO VIEWS 26 $9.30 7/1/2019 12/31/2382 72220 RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF TWO VIEWS MYELOGRAPHY, CERVICAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, CERVICAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, CERVICAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TC $19.70 7/1/2019 12/31/2382 $196.68 7/1/2019 12/31/2382 26 $49.16 7/1/2019 12/31/2382 TC $161.93 7/1/2019 12/31/2382 $196.68 7/1/2019 12/31/2382 26 $49.16 7/1/2019 12/31/2382 TC $147.81 7/1/2019 12/31/2382 $196.68 7/1/2019 12/31/2382 26 $44.69 7/1/2019 12/31/2382 TC $138.87 7/1/2019 12/31/2382 72194 72195 72196 72196 72196 72197 72240 72240 72240 72255 72255 72255 72265 72265 72265 26 TC 26 TC Radiology Procedure Codes Procedure Code Allowed Amount Effective Date End Date $196.68 7/1/2019 12/31/2382 26 $71.83 7/1/2019 12/31/2382 TC $208.02 $196.68 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $820.92 7/1/2019 12/31/2382 26 $42.91 7/1/2019 12/31/2382 TC $286.59 7/1/2019 12/31/2382 $172.27 7/1/2019 12/31/2382 $172.27 7/1/2019 12/31/2382 $172.27 7/1/2019 12/31/2382 72292 Procedure Description MYELOGRAPHY, ENTIRE SPINAL CANAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, ENTIRE SPINAL CANAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION MYELOGRAPHY, ENTIRE SPINAL CANAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION EPIDUROGRAPHY, RADIOLOGICAL SUPERVISON AND INTERPRETATION DISKOGRAPHY, CERVICAL OR THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION DISKOGRAPHY, CERVICAL OR THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION DISKOGRAPHY, CERVICAL OR THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGICAL SUPERVISON AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING RADIOLOGICAL SUPERVISON AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING RADIOLOGICAL SUPERVISON AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING 72295 DISKOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND INTERPRETATION $820.92 7/1/2019 12/31/2382 72295 DISKOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND INTERPRETATION 26 $42.91 7/1/2019 12/31/2382 72295 DISKOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND INTERPRETATION 59 $820.92 7/1/2019 12/31/2382 72295 73000 73000 73000 73000 73000 73000 73010 73010 73010 73010 73010 73020 73020 73020 DISKOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW $268.23 $49.20 $8.25 $49.20 $49.20 $49.20 $18.13 $49.20 $9.07 $49.20 $49.20 $18.13 $49.20 $7.85 $49.20 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 72270 72270 72270 72275 72285 72285 72285 72291 72291 Modifier 76 TC 26 50 LT RT TC 26 LT RT TC 26 51 Radiology Procedure Codes Procedure Code 73020 73020 73020 73020 73020 Procedure Description RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW Allowed Amount $49.20 $49.20 $49.20 $49.20 $16.46 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS $49.20 7/1/2019 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS 26 $9.54 7/1/2019 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS 50 $49.20 7/1/2019 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS 59 $49.20 7/1/2019 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS 76 $49.20 7/1/2019 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS LT $49.20 7/1/2019 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS RT $49.20 7/1/2019 12/31/2382 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION $19.70 7/1/2019 12/31/2382 $235.57 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 LT $235.57 7/1/2019 12/31/2382 RT $235.57 7/1/2019 12/31/2382 TC $71.73 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $10.53 7/1/2019 12/31/2382 50 $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $23.05 7/1/2019 12/31/2382 73040 73040 73040 73040 73040 73050 73050 73050 73050 73050 Modifier 59 76 LT RT TC TC Radiology Procedure Codes Procedure Code 73060 73060 73060 73060 73060 73060 73060 73070 73070 73070 73070 73070 73070 73070 73080 73080 73080 73080 73080 73085 73085 73085 73090 73090 73090 73090 Procedure Description RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ELBOW; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL VIEWS Allowed Amount $49.20 $8.79 $49.20 $49.20 $49.20 $49.20 $19.70 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $7.95 7/1/2019 12/31/2382 50 $49.20 7/1/2019 12/31/2382 59 $49.20 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $18.13 $49.20 $9.30 $49.20 $49.20 $19.70 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $235.57 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $71.73 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $8.43 7/1/2019 12/31/2382 50 $49.20 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 Modifier 26 59 76 LT RT TC 26 LT RT TC Radiology Procedure Codes Procedure Code Modifier Allowed Amount Effective Date End Date RT $49.20 7/1/2019 12/31/2382 TC $18.13 7/1/2019 12/31/2382 XU $49.20 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $8.10 7/1/2019 12/31/2382 TC $17.12 7/1/2019 12/31/2382 73092 Procedure Description RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF TWO VIEWS 73100 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS $49.20 7/1/2019 12/31/2382 73100 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS 26 $8.10 7/1/2019 12/31/2382 73100 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS 50 $49.20 7/1/2019 12/31/2382 73100 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS 59 $49.20 7/1/2019 12/31/2382 73100 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS LT $49.20 7/1/2019 12/31/2382 73100 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS PO $49.20 7/1/2019 12/31/2382 73100 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS RT $49.20 7/1/2019 12/31/2382 73100 73110 73110 73110 73110 73110 73110 73110 RADIOLOGIC EXAMINATION, WRIST; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION $17.12 $49.20 $9.30 $49.20 $49.20 $49.20 $49.20 $18.46 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $235.57 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 RT $235.57 7/1/2019 12/31/2382 73090 73090 73090 73092 73092 73115 73115 73115 TC 26 50 76 LT RT TC Radiology Procedure Codes Procedure Code 73115 73120 73120 73120 73120 73120 73130 73130 73130 73130 73130 73130 73130 73130 73140 73140 73140 73140 73140 73140 73140 73140 73140 73140 73140 73140 73140 73140 73200 73200 73200 73200 73200 73201 Procedure Description RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, HAND; TWO VIEWS RADIOLOGIC EXAMINATION, HAND; TWO VIEWS RADIOLOGIC EXAMINATION, HAND; TWO VIEWS RADIOLOGIC EXAMINATION, HAND; TWO VIEWS RADIOLOGIC EXAMINATION, HAND; TWO VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FINGER OR FINGERS, MINIMUM OF TWO VIEWS COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S) Allowed Amount Effective Date End Date $53.94 $49.20 $8.10 $49.20 $49.20 $17.12 $49.20 $9.30 $49.20 $49.20 $49.20 $49.20 $49.20 $18.46 $49.20 $6.73 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $14.44 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $58.48 7/1/2019 12/31/2382 LT $213.19 7/1/2019 12/31/2382 RT $213.19 7/1/2019 12/31/2382 TC $169.18 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 Modifier TC 26 LT RT TC 26 50 59 76 LT RT TC 26 59 76 F1 F3 F4 F5 F6 F7 F8 LT RT TC Radiology Procedure Codes Procedure Code 73201 73201 73202 73202 73202 73206 73218 73218 73218 73219 73220 73220 73220 73220 73220 73221 73221 73221 73221 73221 Procedure Description COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTERIZED AXIAL TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTED TOMOGRAPHIC ANGIOGRAPHY, UPPER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON)IMAGING, UPPER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON)IMAGING, UPPER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON)IMAGING, UPPER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON)IMAGING, UPPER EXTREMITY0THER THAN JOINT; WITH CONTRAST MATERIEL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY Modifier Allowed Amount Effective Date End Date 26 $62.77 7/1/2019 12/31/2382 TC $201.42 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $65.87 7/1/2019 12/31/2382 TC $253.69 7/1/2019 12/31/2382 $336.85 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 LT $395.76 7/1/2019 12/31/2382 RT $395.76 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 26 $80.09 7/1/2019 12/31/2382 LT $573.77 7/1/2019 12/31/2382 RT $573.77 7/1/2019 12/31/2382 TC $382.71 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 26 $48.97 7/1/2019 12/31/2382 50 $395.76 7/1/2019 12/31/2382 LT $395.76 7/1/2019 12/31/2382 RT $395.76 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 73221 73222 73223 73223 73223 73225 73500 73500 73500 73500 73500 73501 73501 73501 73502 73502 73502 73503 73510 73510 73510 73510 73510 73510 73510 73510 73520 73520 73520 73521 73522 73523 Procedure Description MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY 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 MATERIAL(S), FOLLOWED MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED MAGNETIC RSONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S) RADIOLOGIC EXAMINATION, HIP; UNILATERAL, ONE VIEW RADIOLOGIC EXAMINATION, HIP; UNILATERAL, ONE VIEW RADIOLOGIC EXAMINATION, HIP; UNILATERAL, ONE VIEW RADIOLOGIC EXAMINATION, HIP; UNILATERAL, ONE VIEW RADIOLOGIC EXAMINATION, HIP; UNILATERAL, ONE VIEW X-RAY OF HIP WITH PELVIS, 1 VIEW X-RAY OF HIP WITH PELVIS, 1 VIEW X-RAY OF HIP WITH PELVIS, 1 VIEW X-RAY OF HIP WITH PELVIS, 2-3 VIEWS X-RAY OF HIP WITH PELVIS, 2-3 VIEWS X-RAY OF HIP WITH PELVIS, 2-3 VIEWS X-RAY OF HIP WITH PELVIS, MINIMUM OF 4 VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP; COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO VIEWS OF EACH HIP, INCLUDING ANTEROPOSTERIOR VIEW OF P RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO VIEWS OF EACH HIP, INCLUDING ANTEROPOSTERIOR VIEW OF P RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO VIEWS OF EACH HIP, INCLUDING ANTEROPOSTERIOR VIEW OF P X-RAY OF BOTH HIPS WITH PELVIS, 2 VIEWS X-RAY OF BOTH HIPS WITH PELVIS, 3-4 VIEWS X-RAY OF BOTH HIPS WITH PELVIS, MINIMUM OF 5 VIEWS Modifier Allowed Amount Effective Date End Date TC $382.71 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 LT $573.77 7/1/2019 12/31/2382 RT $573.77 7/1/2019 12/31/2382 $408.12 $49.20 $8.87 $49.20 $49.20 $16.46 $55.63 $55.63 $55.63 $55.63 $55.63 $55.63 $92.12 $49.20 $11.19 $49.20 $49.20 $49.20 $49.20 $49.20 $19.70 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $13.95 7/1/2019 12/31/2382 TC $23.05 $92.12 $92.12 $175.63 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 26 LT RT TC LT RT LT RT 26 50 59 76 LT RT TC Radiology Procedure Codes Procedure Code Allowed Amount Effective Date End Date $235.57 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 59 $235.57 7/1/2019 12/31/2382 LT $235.57 7/1/2019 12/31/2382 RT $235.57 7/1/2019 12/31/2382 TC $71.73 $83.74 $15.44 $83.74 $18.13 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $10.89 7/1/2019 12/31/2382 TC $19.70 7/1/2019 12/31/2382 $235.57 7/1/2019 12/31/2382 73542 Procedure Description RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE RADIOLOGIC EXAMINATION, PELVIS AND HIPS, INFANT OR CHILD, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, PELVIS AND HIPS, INFANT OR CHILD, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, PELVIS AND HIPS, INFANT OR CHILD, MINIMUM OF TWO VIEWS RADIOLOGICAL JOINT ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 73550 RADIOLOGIC EXAMINATION, FEMUR, ANTEROPOSTERIOR AND LATERAL VIEWS $49.20 7/1/2019 12/31/2382 73550 RADIOLOGIC EXAMINATION, FEMUR, ANTEROPOSTERIOR AND LATERAL VIEWS 26 $9.15 7/1/2019 12/31/2382 73550 RADIOLOGIC EXAMINATION, FEMUR, ANTEROPOSTERIOR AND LATERAL VIEWS 50 $49.20 7/1/2019 12/31/2382 73550 RADIOLOGIC EXAMINATION, FEMUR, ANTEROPOSTERIOR AND LATERAL VIEWS LT $49.20 7/1/2019 12/31/2382 73550 RADIOLOGIC EXAMINATION, FEMUR, ANTEROPOSTERIOR AND LATERAL VIEWS RT $49.20 7/1/2019 12/31/2382 73550 73551 73551 73551 73552 73552 RADIOLOGIC EXAMINATION, FEMUR, ANTEROPOSTERIOR AND LATERAL VIEWS X-RAY OF FEMUR, 1 VIEW X-RAY OF FEMUR, 1 VIEW X-RAY OF FEMUR, 1 VIEW X-RAY OF FEMUR, MINIMUM 2 VIEWS X-RAY OF FEMUR, MINIMUM 2 VIEWS $19.70 $55.63 $55.63 $55.63 $55.63 $55.63 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 73525 73525 73525 73525 73525 73525 73530 73530 73530 73530 73540 73540 73540 Modifier 26 RT TC TC LT RT LT Radiology Procedure Codes Procedure Code 73552 Procedure Description X-RAY OF FEMUR, MINIMUM 2 VIEWS Allowed Amount $55.63 Effective Date 7/1/2019 End Date 12/31/2382 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL VIEWS $49.20 7/1/2019 12/31/2382 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL VIEWS 26 $8.55 7/1/2019 12/31/2382 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL VIEWS 50 $49.20 7/1/2019 12/31/2382 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL VIEWS 59 $83.74 7/1/2019 12/31/2382 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL VIEWS LT $49.20 7/1/2019 12/31/2382 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL VIEWS RT $49.20 7/1/2019 12/31/2382 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; ANTEROPOSTERIOR AND LATERAL, WITH OBLIQUE(S), MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, KNEE; COMPLETE, INCLUDING OBLIQUE(S), AND TUNNEL, AND/OR PATELLAR AND/OR STANDING VIEW RADIOLOGIC EXAMINATION, KNEE; COMPLETE, INCLUDING OBLIQUE(S), AND TUNNEL, AND/OR PATELLAR AND/OR STANDING VIEW RADIOLOGIC EXAMINATION, KNEE; COMPLETE, INCLUDING OBLIQUE(S), AND TUNNEL, AND/OR PATELLAR AND/OR STANDING VIEW RADIOLOGIC EXAMINATION, KNEE; COMPLETE, INCLUDING OBLIQUE(S), AND TUNNEL, AND/OR PATELLAR AND/OR STANDING VIEW RADIOLOGIC EXAMINATION, KNEE; COMPLETE, INCLUDING OBLIQUE(S), AND TUNNEL, AND/OR PATELLAR AND/OR STANDING VIEW TC $18.13 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $9.83 7/1/2019 12/31/2382 50 $49.20 7/1/2019 12/31/2382 59 $49.20 7/1/2019 12/31/2382 76 $49.20 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $19.70 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $11.94 7/1/2019 12/31/2382 50 $49.20 7/1/2019 12/31/2382 76 $49.20 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 73562 73562 73562 73562 73562 73562 73562 73562 73564 73564 73564 73564 73564 Modifier RT Radiology Procedure Codes Procedure Code Modifier Allowed Amount Effective Date End Date RT $49.20 7/1/2019 12/31/2382 TC $21.38 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $11.43 7/1/2019 12/31/2382 59 $49.20 7/1/2019 12/31/2382 TC $17.12 7/1/2019 12/31/2382 $235.57 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $8.55 7/1/2019 12/31/2382 50 $49.20 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $18.13 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $8.10 7/1/2019 12/31/2382 TC $17.12 7/1/2019 12/31/2382 73592 Procedure Description RADIOLOGIC EXAMINATION, KNEE; COMPLETE, INCLUDING OBLIQUE(S), AND TUNNEL, AND/OR PATELLAR AND/OR STANDING VIEW RADIOLOGIC EXAMINATION, KNEE; COMPLETE, INCLUDING OBLIQUE(S), AND TUNNEL, AND/OR PATELLAR AND/OR STANDING VIEW RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, ANTEROPOSTERIOR RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF TWO VIEWS 73600 RADIOLOGIC EXAMINATION, ANKLE; ANTEROPOSTERIOR AND LATERAL VIEWS $49.20 7/1/2019 12/31/2382 73600 RADIOLOGIC EXAMINATION, ANKLE; ANTEROPOSTERIOR AND LATERAL VIEWS 26 $8.12 7/1/2019 12/31/2382 73564 73564 73565 73565 73565 73565 73580 73580 73580 73590 73590 73590 73590 73590 73590 73592 73592 Radiology Procedure Codes Procedure Code Procedure Description Allowed Amount Effective Date End Date 73600 RADIOLOGIC EXAMINATION, ANKLE; ANTEROPOSTERIOR AND LATERAL VIEWS LT $49.20 7/1/2019 12/31/2382 73600 RADIOLOGIC EXAMINATION, ANKLE; ANTEROPOSTERIOR AND LATERAL VIEWS RT $49.20 7/1/2019 12/31/2382 73600 73610 73610 73610 73610 73610 73610 73610 73610 $17.12 $49.20 $9.30 $49.20 $49.20 $49.20 $49.20 $49.20 $18.46 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $235.57 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 73615 RADIOLOGIC EXAMINATION, ANKLE; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TC $71.73 7/1/2019 12/31/2382 73620 RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR AND LATERAL VIEWS $49.20 7/1/2019 12/31/2382 73620 RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR AND LATERAL VIEWS 26 $8.10 7/1/2019 12/31/2382 73620 RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR AND LATERAL VIEWS 76 $49.20 7/1/2019 12/31/2382 73620 RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR AND LATERAL VIEWS LT $49.20 7/1/2019 12/31/2382 73620 RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR AND LATERAL VIEWS RT $49.20 7/1/2019 12/31/2382 73620 73630 73630 73630 73630 73630 73630 73630 73650 73650 RADIOLOGIC EXAMINATION, FOOT; ANTEROPOSTERIOR AND LATERAL VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS TC $17.12 $49.20 $9.30 $49.20 $49.20 $49.20 $49.20 $18.46 $49.20 $8.10 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 73615 73615 Modifier TC 26 50 59 76 LT RT TC 26 50 59 LT RT TC 26 Radiology Procedure Codes Procedure Code 73650 73650 73650 73650 73660 73660 73660 73660 73660 73660 73660 73660 73660 73660 73700 73700 73700 73700 73700 73700 73700 73701 73701 73701 73701 73701 73701 Procedure Description RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TOE OR TOES, MINIMUM OF TWO VIEWS COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) Allowed Amount $49.20 $49.20 $49.20 $16.46 $49.20 $6.73 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $49.20 $14.44 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $58.48 7/1/2019 12/31/2382 50 $213.19 7/1/2019 12/31/2382 59 $213.19 7/1/2019 12/31/2382 LT $49.20 7/1/2019 12/31/2382 RT $49.20 7/1/2019 12/31/2382 TC $169.18 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $62.77 7/1/2019 12/31/2382 59 $289.49 7/1/2019 12/31/2382 LT $289.49 7/1/2019 12/31/2382 RT $289.49 7/1/2019 12/31/2382 TC $201.42 7/1/2019 12/31/2382 Modifier 50 LT RT TC 26 50 59 76 LT RT T5 T6 TC Radiology Procedure Codes Procedure Code 73702 73702 73702 73706 73706 73706 73718 73718 73718 73719 73720 73720 73720 73720 73720 73721 73721 73721 73721 73721 Procedure Description COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTERIZED AXIAL TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AN COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY, OTHER THAN JOINT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY Allowed Amount Effective Date End Date $344.34 7/1/2019 12/31/2382 26 $65.87 7/1/2019 12/31/2382 TC $253.69 7/1/2019 12/31/2382 $336.85 7/1/2019 12/31/2382 59 $336.85 7/1/2019 12/31/2382 LT $336.85 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 LT $395.76 7/1/2019 12/31/2382 RT $395.76 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 26 $80.09 7/1/2019 12/31/2382 LT $573.77 7/1/2019 12/31/2382 RT $573.77 7/1/2019 12/31/2382 TC $382.71 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 26 $146.63 7/1/2019 12/31/2382 50 $395.76 7/1/2019 12/31/2382 LT $395.76 7/1/2019 12/31/2382 RT $395.76 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 73721 73722 73723 73723 73725 74000 74000 74000 74000 74000 74010 74010 74010 74018 74018 74018 74019 74019 74019 74020 74020 74020 74020 74021 74021 74021 74022 Procedure Description MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY 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 MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S) RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND ADDITIONAL OBLIQUE AND CONE VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND ADDITIONAL OBLIQUE AND CONE VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND ADDITIONAL OBLIQUE AND CONE VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW RADIOLOGIC EXAMINATION, ABDOMEN; 1 VIEW RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; 2 VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING DECUBITUS AND/OR ERECT VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING DECUBITUS AND/OR ERECT VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING DECUBITUS AND/OR ERECT VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING DECUBITUS AND/OR ERECT VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; 3 OR MORE VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/ OR DECUBITUS VIE Modifier Allowed Amount Effective Date End Date TC $382.71 7/1/2019 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 LT $573.77 7/1/2019 12/31/2382 26 59 76 TC $498.94 $49.20 $12.50 $49.20 $49.20 $18.13 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $12.23 7/1/2019 12/31/2382 TC $19.70 $53.28 $5.76 $11.29 $98.17 $7.30 $13.50 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $14.45 7/1/2019 12/31/2382 59 $49.20 7/1/2019 12/31/2382 TC $21.38 $98.17 $8.63 $15.70 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $83.74 7/1/2019 12/31/2382 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 74022 74022 74150 74150 74150 74160 74160 74160 74160 74160 74170 74170 74170 74174 74175 74176 74177 74177 74177 74177 Procedure Description RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/ OR DECUBITUS VIE RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN SERIES, INCLUDING SUPINE, ERECT, AND/ OR DECUBITUS VIE COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHE COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHE COMPUTERIZED AXIAL TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHE COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITHOUT CONTRAST MATERIAL(S),FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITH CONTRAST MATERIAL Modifier Allowed Amount Effective Date End Date 26 $16.87 7/1/2019 12/31/2382 TC $25.30 7/1/2019 12/31/2382 $213.19 7/1/2019 12/31/2382 26 $64.13 7/1/2019 12/31/2382 TC $193.15 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $68.81 7/1/2019 12/31/2382 59 $289.49 7/1/2019 12/31/2382 GZ $289.49 7/1/2019 12/31/2382 TC $233.65 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 26 $75.84 7/1/2019 12/31/2382 TC $289.93 7/1/2019 12/31/2382 $365.52 7/1/2019 12/31/2382 $336.85 7/1/2019 12/31/2382 $189.83 7/1/2019 12/31/2382 $293.59 7/1/2019 12/31/2382 PO $293.59 7/1/2019 12/31/2382 TC $136.74 7/1/2019 12/31/2382 XP $293.59 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 74178 74181 74181 74181 74181 74182 74183 74183 74185 74190 74210 74210 74210 74220 74220 74220 74230 74230 74230 74235 74235 74235 74240 74240 74240 74241 Procedure Description COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATE MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATE MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST MATERIAL(S) PERITONEOGRAM, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION; PHARYNX AND/OR CERVICAL ESOPHAGUS RADIOLOGIC EXAMINATION; PHARYNX AND/OR CERVICAL ESOPHAGUS RADIOLOGIC EXAMINATION; PHARYNX AND/OR CERVICAL ESOPHAGUS RADIOLOGIC EXAMINATION; ESOPHAGUS RADIOLOGIC EXAMINATION; ESOPHAGUS RADIOLOGIC EXAMINATION; ESOPHAGUS SWALLOWING FUNCTION, PHARYNX AND/OR ESOPHAGUS, WITH CINERADIOGRAPHY AND/OR VIDEO SWALLOWING FUNCTION, PHARYNX AND/OR ESOPHAGUS, WITH CINERADIOGRAPHY AND/OR VIDEO SWALLOWING FUNCTION, PHARYNX AND/OR ESOPHAGUS, WITH CINERADIOGRAPHY AND/OR VIDEO REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF BALLOON CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETAT REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF BALLOON CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETAT REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF BALLOON CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETAT RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITHOUT KUB RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITHOUT KUB RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITHOUT KUB RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITH KUB Modifier Allowed Amount Effective Date End Date 26 59 TC $327.30 $395.76 $86.81 $395.76 $382.71 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $420.48 7/1/2019 12/31/2382 $573.77 7/1/2019 12/31/2382 59 $573.77 7/1/2019 12/31/2382 26 TC $498.54 $232.98 $99.10 $18.77 $40.17 $96.42 $25.34 $40.17 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $96.42 7/1/2019 12/31/2382 26 $29.33 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 $153.00 7/1/2019 12/31/2382 26 $64.13 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 $99.10 7/1/2019 12/31/2382 26 $37.41 7/1/2019 12/31/2382 TC $50.02 7/1/2019 12/31/2382 $99.10 7/1/2019 12/31/2382 26 TC Radiology Procedure Codes Procedure Code 74241 74241 74245 74245 74245 74246 74246 74246 74247 74247 74247 74249 74249 74249 74250 74250 74250 74251 74260 74260 74260 74261 Procedure Description RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITH KUB RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITH KUB RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFE RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS RADIOLOGIC EXAMINATION, SMALL BOWEL, INCLUDES MULTIPLE SERIAL FILMS; VIA ENTEROCLYSIS TUBE DUODENOGRAPHY, HYPOTONIC DUODENOGRAPHY, HYPOTONIC DUODENOGRAPHY, HYPOTONIC COMPUTED TOMOGRAPHIC (CT) COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRAST MATERIAL Modifier Allowed Amount Effective Date End Date 26 $37.41 7/1/2019 12/31/2382 TC $51.03 7/1/2019 12/31/2382 $154.80 7/1/2019 12/31/2382 26 $49.32 7/1/2019 12/31/2382 TC $81.59 7/1/2019 12/31/2382 $99.10 7/1/2019 12/31/2382 26 $37.41 7/1/2019 12/31/2382 TC $56.28 7/1/2019 12/31/2382 $99.10 7/1/2019 12/31/2382 26 $37.41 7/1/2019 12/31/2382 TC $57.53 7/1/2019 12/31/2382 $154.80 7/1/2019 12/31/2382 26 $49.32 7/1/2019 12/31/2382 TC $87.85 7/1/2019 12/31/2382 $99.10 7/1/2019 12/31/2382 26 $25.49 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 26 TC $154.80 $154.80 $27.46 $51.03 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $189.83 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 74270 74270 74270 74280 74280 74280 74283 74283 74283 74290 74290 74290 74291 74291 74291 74300 74300 74301 74301 74305 74305 74305 74320 74320 74320 74327 Procedure Description RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST WITH SPECIFIC HIGH DENSITY BARIUM, WITH OR WITHOUT GLUCAGON RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST WITH SPECIFIC HIGH DENSITY BARIUM, WITH OR WITHOUT GLUCAGON RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST WITH SPECIFIC HIGH DENSITY BARIUM, WITH OR WITHOUT GLUCAGON THERAPEUTIC ENEMA, CONTRAST OR AIR, FOR REDUCTION OF INTUSSUSCEPTION OR OTHER INTRALUNIMAL OBSTRUCTION THERAPEUTIC ENEMA, CONTRAST OR AIR, FOR REDUCTION OF INTUSSUSCEPTION OR OTHER INTRALUNIMAL OBSTRUCTION THERAPEUTIC ENEMA, CONTRAST OR AIR, FOR REDUCTION OF INTUSSUSCEPTION OR OTHER INTRALUNIMAL OBSTRUCTION CHOLECYSTOGRAPHY, ORAL CONTRAST; CHOLECYSTOGRAPHY, ORAL CONTRAST; CHOLECYSTOGRAPHY, ORAL CONTRAST; CHOLECYSTOGRAPHY, ORAL CONTRAST; ADDITIONAL OR REPEAT EXAMINATION OR MULTIPLE DAY EXAMINATION CHOLECYSTOGRAPHY, ORAL CONTRAST; ADDITIONAL OR REPEAT EXAMINATION OR MULTIPLE DAY EXAMINATION CHOLECYSTOGRAPHY, ORAL CONTRAST; ADDITIONAL OR REPEAT EXAMINATION OR MULTIPLE DAY EXAMINATION CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; DURING SURGERY CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; DURING SURGERY CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; ADDITIONAL SET DURING SURGERY CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; ADDITIONAL SET DURING SURGERY CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; POSTOPERATIVE CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; POSTOPERATIVE CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; POSTOPERATIVE CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION POSTOPERATIVE BILIARY DUCT STONE REMOVAL, PERCUTANEOUS VIA TTUBE TRACT, BASKET OR SNARE (EG, BURHENNE TECHNIQ Allowed Amount $99.10 $37.41 $58.20 Effective Date 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 $154.80 7/1/2019 12/31/2382 26 $53.46 7/1/2019 12/31/2382 TC $76.33 7/1/2019 12/31/2382 $99.10 7/1/2019 12/31/2382 26 $104.17 7/1/2019 12/31/2382 TC $87.52 $99.10 $16.87 $25.30 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $99.10 7/1/2019 12/31/2382 26 $10.69 7/1/2019 12/31/2382 TC $14.44 $114.52 $19.24 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 $114.52 7/1/2019 12/31/2382 $11.19 $114.52 $22.67 $26.97 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $232.98 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $153.00 7/1/2019 12/31/2382 Modifier 26 TC 26 TC 26 26 26 TC Radiology Procedure Codes Procedure Code 74327 74327 74328 74328 74328 74329 74329 74329 74330 74330 74330 74340 74340 74340 74350 74350 74350 74355 74355 74355 Procedure Description POSTOPERATIVE BILIARY DUCT STONE REMOVAL, PERCUTANEOUS VIA TTUBE TRACT, BASKET OR SNARE (EG, BURHENNE TECHNIQ POSTOPERATIVE BILIARY DUCT STONE REMOVAL, PERCUTANEOUS VIA TTUBE TRACT, BASKET OR SNARE (EG, BURHENNE TECHNIQ ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND PANCREATIC DUCTAL SYSTEMS, RADIOLOGICAL SUPERVISION AND COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND PANCREATIC DUCTAL SYSTEMS, RADIOLOGICAL SUPERVISION AND COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND PANCREATIC DUCTAL SYSTEMS, RADIOLOGICAL SUPERVISION AND INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT), WITH MULTIPLE FLUOROSCOPIES AND FILMS INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT), WITH MULTIPLE FLUOROSCOPIES AND FILMS INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT), WITH MULTIPLE FLUOROSCOPIES AND FILMS PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date 26 $37.97 7/1/2019 12/31/2382 TC $60.20 7/1/2019 12/31/2382 $143.57 7/1/2019 12/31/2382 26 $37.97 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $143.57 7/1/2019 12/31/2382 26 $37.97 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $143.57 7/1/2019 12/31/2382 26 $37.97 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $89.64 7/1/2019 12/31/2382 26 $29.87 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $41.15 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $41.15 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 74360 74360 74360 74363 74363 74400 74400 74400 74405 74405 74405 74410 74410 74410 74415 74415 74415 74420 74420 74420 74420 74425 74425 74425 Procedure Description INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS (EG, ESOPHAGUS), RADIOLOGICAL SUPERVISION AND INTERPRE INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS (EG, ESOPHAGUS), RADIOLOGICAL SUPERVISION AND INTERPRE INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS (EG, ESOPHAGUS), RADIOLOGICAL SUPERVISION AND INTERPRE PERCUTANEOUS TRANSHEPATIC DILATATION OF BILIARY DUCT STRICTURE WITH OR WITHOUT PLACEMENT OF STENT, RADIOLOGICA PERCUTANEOUS TRANSHEPATIC DILATATION OF BILIARY DUCT STRICTURE WITH OR WITHOUT PLACEMENT OF STENT, RADIOLOGICA UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT TOMOGRAPHY; UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT TOMOGRAPHY; UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT TOMOGRAPHY; UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT TOMOGRAPHY; WITH SPECIAL HYPERTENSI UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT TOMOGRAPHY; WITH SPECIAL HYPERTENSI UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT TOMOGRAPHY; WITH SPECIAL HYPERTENSI UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; WITH NEPHROTOMOGRAPHY UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; WITH NEPHROTOMOGRAPHY UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; WITH NEPHROTOMOGRAPHY UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION Allowed Amount Effective Date End Date $153.00 7/1/2019 12/31/2382 26 $29.87 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $343.82 7/1/2019 12/31/2382 $45.60 7/1/2019 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $26.64 7/1/2019 12/31/2382 TC $57.53 7/1/2019 12/31/2382 $93.38 7/1/2019 12/31/2382 26 $26.64 7/1/2019 12/31/2382 TC $68.05 $172.39 $26.64 $66.47 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $26.64 7/1/2019 12/31/2382 TC $72.40 $172.39 $18.77 $172.39 $89.77 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $18.01 7/1/2019 12/31/2382 59 $172.39 7/1/2019 12/31/2382 Modifier 26 26 TC 26 76 TC Radiology Procedure Codes Procedure Code 74425 74425 74425 74430 74430 74430 74440 74440 74440 74445 74445 74445 74450 74450 74450 74455 74455 74455 74470 74470 Procedure Description UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CYSTOGRAPHY, MINIMUM OF THREE VIEWS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CYSTOGRAPHY, MINIMUM OF THREE VIEWS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CYSTOGRAPHY, MINIMUM OF THREE VIEWS, RADIOLOGICAL SUPERVISION AND INTERPRETATION VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CORPORA CAVERNOSOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CORPORA CAVERNOSOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CORPORA CAVERNOSOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL SUPERVISION AND INTERPRETATION URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL SUPERVISION AND INTERPRETATION URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, CONTRAST VISUALIZATION, RADIOLOGICAL SUPERVISION AND IN RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, CONTRAST VISUALIZATION, RADIOLOGICAL SUPERVISION AND IN Modifier Allowed Amount Effective Date End Date LT $172.39 7/1/2019 12/31/2382 RT $172.39 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $16.33 7/1/2019 12/31/2382 TC $35.83 7/1/2019 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $19.26 7/1/2019 12/31/2382 TC $38.50 7/1/2019 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $58.90 7/1/2019 12/31/2382 TC $38.50 7/1/2019 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $16.66 7/1/2019 12/31/2382 TC $50.02 7/1/2019 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $16.66 7/1/2019 12/31/2382 TC $53.94 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 $28.27 7/1/2019 12/31/2382 26 Radiology Procedure Codes Procedure Code 74470 74475 74475 74475 74475 74475 74480 74480 74480 74485 74485 74485 74485 74485 74710 74710 74710 74712 74740 74740 74740 74742 Procedure Description RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, CONTRAST VISUALIZATION, RADIOLOGICAL SUPERVISION AND IN INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIO INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIO INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIO INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIO INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIO INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PER INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PER INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PER DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL SUPERVISION AND INTERPRETATION DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL SUPERVISION AND INTERPRETATION DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL SUPERVISION AND INTERPRETATION DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL SUPERVISION AND INTERPRETATION DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL SUPERVISION AND INTERPRETATION PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION MAGNETIC RESONANCE IMAGING OF FETUS, SINGLE OR FIRST PREGNANCY HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date TC $42.75 7/1/2019 12/31/2382 $343.82 7/1/2019 12/31/2382 26 $29.87 7/1/2019 12/31/2382 LT $343.82 7/1/2019 12/31/2382 RT $343.82 7/1/2019 12/31/2382 TC $138.87 7/1/2019 12/31/2382 $153.00 7/1/2019 12/31/2382 26 $29.87 7/1/2019 12/31/2382 TC $138.87 7/1/2019 12/31/2382 $153.00 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 LT $153.00 7/1/2019 12/31/2382 RT $153.00 7/1/2019 12/31/2382 TC $107.31 $83.74 $18.17 $35.83 $250.25 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $232.98 7/1/2019 12/31/2382 26 $20.05 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 $232.98 7/1/2019 12/31/2382 26 TC Radiology Procedure Codes Procedure Code 74742 74742 74775 74775 74775 75500 75500 75500 75505 75505 75505 75507 75507 75507 75519 75519 75519 75523 75523 75523 Procedure Description TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERINEOGRAM (EG, VAGINOGRAM, FOR SEX DETERMINATION OR EXTENT OF ANOMALIES) PERINEOGRAM (EG, VAGINOGRAM, FOR SEX DETERMINATION OR EXTENT OF ANOMALIES) PERINEOGRAM (EG, VAGINOGRAM, FOR SEX DETERMINATION OR EXTENT OF ANOMALIES) ANGIOCARDIOGRAPHY BY CINERADIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY CINERADIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY CINERADIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, SINGLE PLANE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, SINGLE PLANE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, SINGLE PLANE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, MULTI-PLANE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, MULTI-PLANE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOCARDIOGRAPHY BY SERIALOGRAPHY, MULTI-PLANE, RADIOLOGICAL SUPERVISION AND INTERPRETATION CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, RIGHT SIDE, RADIOLOGICAL SUPERVISION AND INTERPRETATIO CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, RIGHT SIDE, RADIOLOGICAL SUPERVISION AND INTERPRETATIO CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, RIGHT SIDE, RADIOLOGICAL SUPERVISION AND INTERPRETATIO CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, LEFT SIDE, RADIOLOGICAL SUPERVISION AND INTERPRETATION CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, LEFT SIDE, RADIOLOGICAL SUPERVISION AND INTERPRETATION CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, LEFT SIDE, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date 26 $30.64 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $172.39 7/1/2019 12/31/2382 26 $33.89 7/1/2019 12/31/2382 TC $50.02 7/1/2019 12/31/2382 $453.13 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $394.24 7/1/2019 12/31/2382 $453.13 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $394.24 7/1/2019 12/31/2382 $461.80 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $394.24 7/1/2019 12/31/2382 $437.82 7/1/2019 12/31/2382 26 $45.45 7/1/2019 12/31/2382 TC $394.24 7/1/2019 12/31/2382 $437.82 7/1/2019 12/31/2382 26 $45.45 7/1/2019 12/31/2382 TC $394.24 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 75527 75527 75527 75552 75552 75552 75553 75554 75555 75556 75557 75561 75600 75600 75600 75605 75605 75605 75625 75625 75625 75625 Procedure Description CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, RIGHT AND LEFT SIDE, RADIOLOGICAL SUPERVISION AND INTE CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, RIGHT AND LEFT SIDE, RADIOLOGICAL SUPERVISION AND INTE CARDIAC RADIOGRAPHY, SELECTIVE CARDIAC CATHETERIZATION, RIGHT AND LEFT SIDE, RADIOLOGICAL SUPERVISION AND INTE MAGNETIC RESONANCE (EG, PROTON) IMAGING, MYOCARDIUM MAGNETIC RESONANCE (EG, PROTON) IMAGING, MYOCARDIUM MAGNETIC RESONANCE (EG, PROTON) IMAGING, MYOCARDIUM CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY; WITHOUT CONTRAST MATERIAL CARDIAC MAGNETIC RESONANCE IMAGING FOR FUNCTION, WITH OR WITHOUT MORPHOLOGY; COMPLETE STUDY CARDIAC MAGNETIC RESONANCE IMAGING FOR FUNCTION, WITH OR WITHOUT MORPHOLOGY; LIMITED STUDY CARDIAC MAGNETIC RESONANCE IMAGING FOR VELOCITY FLOW MAPPING CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTR AORTOGRAPHY, THORACIC, WITHOUT SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, THORACIC, WITHOUT SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, THORACIC, WITHOUT SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, THORACIC, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, THORACIC, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, THORACIC, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION Allowed Amount Effective Date End Date $471.82 7/1/2019 12/31/2382 26 $81.00 7/1/2019 12/31/2382 TC $394.24 $395.76 $86.81 $382.71 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $420.48 7/1/2019 12/31/2382 $395.76 7/1/2019 12/31/2382 $395.76 $395.76 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $320.14 7/1/2019 12/31/2382 $582.37 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $26.64 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 59 $1,377.18 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 Modifier 26 TC Radiology Procedure Codes Procedure Code 75630 75630 75630 75630 75635 75650 75650 75650 75658 75658 75658 75660 75660 75660 75662 75662 75662 75665 75665 75665 Procedure Description AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SU AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SU AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SU AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SU COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMINAL AORTA AND BILATERAL ILIOFEMORAL LOWER EXTREMITY RUNOFF, RADIOLOGIC ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING VESSEL ORIGIN, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING VESSEL ORIGIN, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING VESSEL ORIGIN, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION Allowed Amount Effective Date End Date $1,377.18 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 59 $1,377.18 7/1/2019 12/31/2382 TC $448.51 7/1/2019 12/31/2382 $336.85 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $80.40 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $89.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 RT $1,377.18 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 75665 75671 75671 75671 75676 75676 75676 75680 75680 75680 75685 75685 75685 75705 75705 75705 75710 75710 75710 75710 Procedure Description ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, VERTEBRAL, CERVICAL, AND/OR INTRACRANIAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, VERTEBRAL, CERVICAL, AND/OR INTRACRANIAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, VERTEBRAL, CERVICAL, AND/OR INTRACRANIAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, SPINAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, SPINAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, SPINAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $89.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $89.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $117.76 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 59 $1,377.18 7/1/2019 12/31/2382 LT $1,377.18 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 75710 75716 75716 75716 75716 75722 75722 75722 75724 75724 75724 75726 75726 75726 75726 75731 75731 75731 75733 75733 Procedure Description ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, RENAL, UNILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETA ANGIOGRAPHY, RENAL, UNILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETA ANGIOGRAPHY, RENAL, UNILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETA ANGIOGRAPHY, RENAL, BILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), ANGIOGRAPHY, RENAL, BILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), ANGIOGRAPHY, RENAL, BILATERAL, SELECTIVE (INCLUDING FLUSH AORTOGRAM), ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE, (WITH OR WITHOUT FLUSH AORTOGRAM) RADIOLOGICAL SUPERVISION ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE, (WITH OR WITHOUT FLUSH AORTOGRAM) RADIOLOGICAL SUPERVISION ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE, (WITH OR WITHOUT FLUSH AORTOGRAM) RADIOLOGICAL SUPERVISION ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE, (WITH OR WITHOUT FLUSH AORTOGRAM) RADIOLOGICAL SUPERVISION ANGIOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 59 $1,377.18 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $80.40 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 59 $1,377.18 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 $70.93 7/1/2019 12/31/2382 26 Radiology Procedure Codes Procedure Code 75733 75736 75736 75736 75741 75741 75741 75743 75743 75743 75746 75746 75746 75750 75750 75750 75752 75752 75752 75754 Procedure Description ANGIOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, PULMONARY, BY NONSELECTIVE CATHETER OR VENOUS INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETAT ANGIOGRAPHY, PULMONARY, BY NONSELECTIVE CATHETER OR VENOUS INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETAT ANGIOGRAPHY, PULMONARY, BY NONSELECTIVE CATHETER OR VENOUS INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETAT ANGIOGRAPHY, CORONARY, ROOT INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY, ROOT INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY, ROOT INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY, UNILATERAL SELECTIVE INJECTION, INCLUDING LEFT VENTRICULAR AND SUPRAVALVULAR ANGIOGRAM ANGIOGRAPHY, CORONARY, UNILATERAL SELECTIVE INJECTION, INCLUDING LEFT VENTRICULAR AND SUPRAVALVULAR ANGIOGRAM ANGIOGRAPHY, CORONARY, UNILATERAL SELECTIVE INJECTION, INCLUDING LEFT VENTRICULAR AND SUPRAVALVULAR ANGIOGRAM ANGIOGRAPHY, CORONARY, BILATERAL SELECTIVE INJECTION, INCLUDING LEFT VENTRICULAR AND SUPRAVALVULAR ANGIOGRAM A Modifier Allowed Amount Effective Date End Date TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $89.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $489.05 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $489.05 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $498.05 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 75754 75754 75756 75756 75756 75762 75762 75762 75766 75766 75766 75774 75774 75774 75790 75790 75790 75790 75790 75801 Procedure Description ANGIOGRAPHY, CORONARY, BILATERAL SELECTIVE INJECTION, INCLUDING LEFT VENTRICULAR AND SUPRAVALVULAR ANGIOGRAM A ANGIOGRAPHY, CORONARY, BILATERAL SELECTIVE INJECTION, INCLUDING LEFT VENTRICULAR AND SUPRAVALVULAR ANGIOGRAM A ANGIOGRAPHY, INTERNAL MAMMARY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, INTERNAL MAMMARY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, INTERNAL MAMMARY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY BYPASS, UNILATERAL SELECTIVE INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY BYPASS, UNILATERAL SELECTIVE INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY BYPASS, UNILATERAL SELECTIVE INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY BYPASS, MULTIPLE SELECTIVE INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY BYPASS, MULTIPLE SELECTIVE INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, CORONARY BYPASS, MULTIPLE SELECTIVE INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER BASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND I ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER BASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND I ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER BASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND I ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, EXTREMITY ONLY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date 26 $71.25 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $489.05 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $497.71 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $18.01 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $99.33 7/1/2019 12/31/2382 LT $586.71 7/1/2019 12/31/2382 RT $586.71 7/1/2019 12/31/2382 TC $46.34 7/1/2019 12/31/2382 $232.98 7/1/2019 11/30/2382 Radiology Procedure Codes Procedure Code Modifier Allowed Amount Effective Date End Date 26 $43.75 7/1/2019 12/31/2382 TC $184.97 7/1/2019 12/31/2382 $232.98 7/1/2019 12/31/2382 26 $62.99 7/1/2019 12/31/2382 TC $184.97 7/1/2019 12/31/2382 $232.98 7/1/2019 12/31/2382 26 $43.75 7/1/2019 12/31/2382 TC $208.02 7/1/2019 12/31/2382 $232.98 7/1/2019 12/31/2382 26 $62.99 7/1/2019 12/31/2382 TC $208.02 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $23.65 7/1/2019 12/31/2382 TC $26.97 7/1/2019 12/31/2382 75809 Procedure Description LYMPHANGIOGRAPHY, EXTREMITY ONLY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, EXTREMITY ONLY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPE SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPE SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPE 75810 SPLENOPORTOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION $586.71 7/1/2019 12/31/2382 75810 SPLENOPORTOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 26 $61.70 7/1/2019 12/31/2382 75810 SPLENOPORTOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TC VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 26 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 59 $430.15 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 $37.97 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 75801 75801 75803 75803 75803 75805 75805 75805 75807 75807 75807 75809 75809 75820 75820 75820 Radiology Procedure Codes Procedure Code 75820 75820 75820 75822 75822 75822 75825 75825 75825 75825 75827 75827 75827 75827 75831 75831 75831 75833 75833 75833 Procedure Description VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date LT $425.62 7/1/2019 12/31/2382 RT $425.62 7/1/2019 12/31/2382 TC $32.24 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $56.96 7/1/2019 12/31/2382 TC $50.68 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 59 $586.71 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 59 $586.71 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $80.40 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code Allowed Amount Effective Date End Date $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $80.40 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 59 $425.62 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 75872 Procedure Description VENOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, SINUS OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, SINUS OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, SINUS OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, SINUS OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, SUPERIOR SAGITTAL SINUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, SUPERIOR SAGITTAL SINUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, SUPERIOR SAGITTAL SINUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EPIDURAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EPIDURAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION VENOGRAPHY, EPIDURAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 75880 VENOGRAPHY, ORBITAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION $425.62 7/1/2019 12/31/2382 75880 VENOGRAPHY, ORBITAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 26 $37.97 7/1/2019 12/31/2382 75880 VENOGRAPHY, ORBITAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TC PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITH HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION $32.24 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 75840 75840 75840 75842 75842 75842 75860 75860 75860 75860 75870 75870 75870 75872 75872 75885 Modifier Radiology Procedure Codes Procedure Code 75885 75885 75887 75887 75887 75889 75889 75889 75891 75891 75891 75893 75893 75893 75893 75894 75894 75894 75896 75896 Procedure Description PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITH HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITH HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETAT PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETAT PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETAT HEPATIC VENOGRAPHY, WEDGED OR FREE, WITH HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION HEPATIC VENOGRAPHY, WEDGED OR FREE, WITH HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION HEPATIC VENOGRAPHY, WEDGED OR FREE, WITH HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION HEPATIC VENOGRAPHY, WEDGED OR FREE, WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATIO HEPATIC VENOGRAPHY, WEDGED OR FREE, WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATIO HEPATIC VENOGRAPHY, WEDGED OR FREE, WITHOUT HEMODYNAMIC EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATIO VENOUS SAMPLING THROUGH CATHETER, WITH OR WITHOUT ANGIOGRAPHY (EG, FOR PARATHYROID HORMONE, RENIN), RADIOLOGIC VENOUS SAMPLING THROUGH CATHETER, WITH OR WITHOUT ANGIOGRAPHY (EG, FOR PARATHYROID HORMONE, RENIN), RADIOLOGIC VENOUS SAMPLING THROUGH CATHETER, WITH OR WITHOUT ANGIOGRAPHY (EG, FOR PARATHYROID HORMONE, RENIN), RADIOLOGIC VENOUS SAMPLING THROUGH CATHETER, WITH OR WITHOUT ANGIOGRAPHY (EG, FOR PARATHYROID HORMONE, RENIN), RADIOLOGIC TRANSCATHETER THERAPY, EMBOLIZATION, ANY METHOD, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCATHETER THERAPY, EMBOLIZATION, ANY METHOD, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCATHETER THERAPY, EMBOLIZATION, ANY METHOD, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCATHETER THERAPY, INFUSION, ANY METHOD (EG, THROMBOLYSIS OTHER THAN CORONARY), RADIOLOGICAL SUPERVISION A TRANSCATHETER THERAPY, INFUSION, ANY METHOD (EG, THROMBOLYSIS OTHER THAN CORONARY), RADIOLOGICAL SUPERVISION A Modifier Allowed Amount Effective Date End Date 26 $77.97 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $77.97 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $1,377.18 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $61.70 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $458.42 7/1/2019 12/31/2382 26 $29.87 7/1/2019 12/31/2382 59 $458.42 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $343.82 7/1/2019 12/31/2382 26 $70.93 7/1/2019 12/31/2382 TC $824.38 7/1/2019 12/31/2382 $343.82 7/1/2019 12/31/2382 $70.93 7/1/2019 12/31/2382 26 Radiology Procedure Codes Procedure Code 75896 75898 75898 75898 75901 75902 75940 75940 75940 75945 75946 75960 75960 75960 75961 75961 75961 75962 75962 75962 Procedure Description TRANSCATHETER THERAPY, INFUSION, ANY METHOD (EG, THROMBOLYSIS OTHER THAN CORONARY), RADIOLOGICAL SUPERVISION A ANGIOGRAM THROUGH EXISTING CATHETER FOR FOLLOW-UP STUDY FOR TRANSCATHETER THERAPY, EMBOLIZATION OR INFUSION ANGIOGRAM THROUGH EXISTING CATHETER FOR FOLLOW-UP STUDY FOR TRANSCATHETER THERAPY, EMBOLIZATION OR INFUSION ANGIOGRAM THROUGH EXISTING CATHETER FOR FOLLOW-UP STUDY FOR TRANSCATHETER THERAPY, EMBOLIZATION OR INFUSION MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE VIA SEPERATE VENOUS ACCESS MECHANICAL REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE THROUGH DEVICE LUMEN, RADIO PERCUTANEOUS PLACEMENT OF IVC FILTER, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS PLACEMENT OF IVC FILTER, RADIOLOGICAL SUPERVISION AND INTERPRETATION PERCUTANEOUS PLACEMENT OF IVC FILTER, RADIOLOGICAL SUPERVISION AND INTERPRETATION INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; INTIAL VESSEL INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL TRANSCATHETER INTRODUCTION OF INTRAVASCULAR STENT(S), (NONCORONARY VESSEL), PERCUTANEOUS AND/OR OPEN, RADIOLO TRANSCATHETER INTRODUCTION OF INTRAVASCULAR STENT(S), (NONCORONARY VESSEL), PERCUTANEOUS AND/OR OPEN, RADIOLO TRANSCATHETER INTRODUCTION OF INTRAVASCULAR STENT(S), (NONCORONARY VESSEL), PERCUTANEOUS AND/OR OPEN, RADIOLO TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETE TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETE TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETE TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date TC $716.49 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $89.40 7/1/2019 12/31/2382 TC $35.83 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 $343.82 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $430.15 7/1/2019 12/31/2382 $172.28 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $42.24 7/1/2019 12/31/2382 TC $508.57 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $230.07 7/1/2019 12/31/2382 TC $358.41 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $537.46 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 75964 75964 75964 75966 75966 75966 75968 75968 75968 75970 75970 75970 75978 75978 75978 75978 75978 75980 75980 75980 Procedure Description TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATI TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATI TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATI TRANSLUMINAL BALLOON ANGIOPLASTY, RENAL OR OTHER VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, RENAL OR OTHER VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, RENAL OR OTHER VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCATHETER BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCATHETER BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSCATHETER BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATIO TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATIO TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATIO TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATIO TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATIO PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE WITH CONTRAST MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATI PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE WITH CONTRAST MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATI PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE WITH CONTRAST MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATI Allowed Amount Effective Date End Date $425.62 7/1/2019 12/31/2382 26 $18.01 7/1/2019 12/31/2382 TC $286.93 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $67.57 7/1/2019 12/31/2382 TC $537.46 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $18.01 7/1/2019 12/31/2382 TC $286.93 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $44.69 7/1/2019 12/31/2382 TC $394.24 7/1/2019 12/31/2382 $425.62 7/1/2019 12/31/2382 26 $36.63 7/1/2019 12/31/2382 59 $425.62 7/1/2019 12/31/2382 LT $425.62 7/1/2019 12/31/2382 RT $425.62 7/1/2019 12/31/2382 $343.82 7/1/2019 12/31/2382 26 $77.97 7/1/2019 12/31/2382 TC $184.97 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 75982 75982 75982 75982 75984 75984 75984 75984 75984 75984 75984 75989 75989 75989 75992 75992 75992 75993 75993 75993 Procedure Description PERCUTANEOUS PLACEMENT OF DRAINAGE CATHETER FOR COMBINED INTERNAL AND EXTERNAL BILIARY DRAINAGE OR OF A DRAINA PERCUTANEOUS PLACEMENT OF DRAINAGE CATHETER FOR COMBINED INTERNAL AND EXTERNAL BILIARY DRAINAGE OR OF A DRAINA PERCUTANEOUS PLACEMENT OF DRAINAGE CATHETER FOR COMBINED INTERNAL AND EXTERNAL BILIARY DRAINAGE OR OF A DRAINA PERCUTANEOUS PLACEMENT OF DRAINAGE CATHETER FOR COMBINED INTERNAL AND EXTERNAL BILIARY DRAINAGE OR OF A DRAINA CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST MONITORING (IE, BILIARY TRACT, URINARY TRACT), RADIOLOG CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST MONITORING (IE, BILIARY TRACT, URINARY TRACT), RADIOLOG CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST MONITORING (IE, BILIARY TRACT, URINARY TRACT), RADIOLOG CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST MONITORING (IE, BILIARY TRACT, URINARY TRACT), RADIOLOG CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST MONITORING (IE, BILIARY TRACT, URINARY TRACT), RADIOLOG CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST MONITORING (IE, BILIARY TRACT, URINARY TRACT), RADIOLOG CHANGE OF PERCUTANEOUS DRAINAGE CATHETER WITH CONTRAST MONITORING (IE, BILIARY TRACT, URINARY TRACT), RADIOLOG RADIOLOGICAL GUIDANCE FOR PERCUTANEOUS DRAINAGE OF ABSCESS, OR SPECIMEN COLLECTION (IE, FLUOROSCOPY, ULTRASOUN RADIOLOGICAL GUIDANCE FOR PERCUTANEOUS DRAINAGE OF ABSCESS, OR SPECIMEN COLLECTION (IE, FLUOROSCOPY, ULTRASOUN RADIOLOGICAL GUIDANCE FOR PERCUTANEOUS DRAINAGE OF ABSCESS, OR SPECIMEN COLLECTION (IE, FLUOROSCOPY, ULTRASOUN TRANSLUMINAL ATHERECTOMY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION Allowed Amount Effective Date End Date $343.82 7/1/2019 12/31/2382 26 $77.97 7/1/2019 12/31/2382 52 $343.82 7/1/2019 12/31/2382 TC $208.02 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $37.27 7/1/2019 12/31/2382 50 $114.52 7/1/2019 12/31/2382 59 $114.52 7/1/2019 12/31/2382 LT $114.52 7/1/2019 12/31/2382 RT $114.52 7/1/2019 12/31/2382 TC $66.47 7/1/2019 12/31/2382 $126.26 7/1/2019 12/31/2382 26 $52.49 7/1/2019 12/31/2382 TC $107.31 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 TC $537.46 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $18.01 7/1/2019 12/31/2382 TC $286.93 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 75994 75994 75994 75995 75995 75995 75996 75996 75996 76000 76000 76000 76000 76000 76001 76001 76001 76001 76001 76003 Procedure Description TRANSLUMINAL ATHERECTOMY, RENAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, RENAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, RENAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, VISCERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, VISCERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, VISCERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL RENAL OR VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATIO TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL RENAL OR VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATIO TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL RENAL OR VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATIO FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, FLUOROSCOPIC LOCALIZATION FOR NEEDLE BIOPSY OR FINE NEEDLE ASPIRATION Allowed Amount Effective Date End Date $586.71 7/1/2019 12/31/2382 26 $67.57 7/1/2019 12/31/2382 TC $537.46 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $67.57 7/1/2019 12/31/2382 TC $537.46 7/1/2019 12/31/2382 $586.71 7/1/2019 12/31/2382 26 $18.01 7/1/2019 12/31/2382 TC $286.93 7/1/2019 12/31/2382 $89.64 7/1/2019 12/31/2382 26 $8.55 7/1/2019 12/31/2382 59 $89.64 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 XU $89.64 7/1/2019 12/31/2382 $124.68 7/1/2019 12/31/2382 26 $36.60 7/1/2019 12/31/2382 59 $124.68 7/1/2019 12/31/2382 76 $124.68 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 $72.69 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 76003 76003 76006 76010 76010 76010 76012 76013 76020 76020 76020 76040 76040 76040 76061 76061 76061 76062 76062 76062 76065 76065 76065 76066 76066 76066 Procedure Description FLUOROSCOPIC LOCALIZATION FOR NEEDLE BIOPSY OR FINE NEEDLE ASPIRATION FLUOROSCOPIC LOCALIZATION FOR NEEDLE BIOPSY OR FINE NEEDLE ASPIRATION MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT RADIOLOGY, INCLUDING CONTRALATERAL JOINT IF IND RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN BODY, SINGLE FILM, CHILD RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN BODY, SINGLE FILM, CHILD RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN BODY, SINGLE FILM, CHILD RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY, PER VERTEBRAL BODY; UNDER FLUOROSCOP RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY; UNDER CT GUIDANCE BONE AGE STUDIES BONE AGE STUDIES BONE AGE STUDIES BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR METASTASES) RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR METASTASES) RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR METASTASES) RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON) RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON) RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON) RADIOLOGIC EXAMINATION OSSEOUS SURVEY; INFANT RADIOLOGIC EXAMINATION OSSEOUS SURVEY; INFANT RADIOLOGIC EXAMINATION OSSEOUS SURVEY; INFANT JOINT SURVEY, SINGLE VIEW, ONE OR MORE JOINTS (SPECIFY) JOINT SURVEY, SINGLE VIEW, ONE OR MORE JOINTS (SPECIFY) JOINT SURVEY, SINGLE VIEW, ONE OR MORE JOINTS (SPECIFY) Modifier Allowed Amount Effective Date End Date 26 $29.87 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $9.61 7/1/2019 12/31/2382 TC $18.13 7/1/2019 12/31/2382 $196.68 7/1/2019 12/31/2382 $196.68 $49.20 $10.39 $18.13 $83.74 $14.45 $26.97 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $24.29 7/1/2019 12/31/2382 TC $33.91 7/1/2019 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $29.87 7/1/2019 12/31/2382 TC $49.35 $83.74 $14.74 $25.30 $49.20 $16.50 $37.83 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 76070 76070 76070 76071 76075 76076 76077 76078 76080 76080 76080 76080 76082 76082 76082 76083 76086 76086 76086 76088 Procedure Description COMPUTERIZED TOMOGRAPHY BONE MINERAL DENSITY STUDY, ONE OR MORE SITES COMPUTERIZED TOMOGRAPHY BONE MINERAL DENSITY STUDY, ONE OR MORE SITES COMPUTERIZED TOMOGRAPHY BONE MINERAL DENSITY STUDY, ONE OR MORE SITES COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, ONE OR MORE SITES;APPENDICULAR SKELETON DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA), BONE DENSITY STUDY, ONE OR MORE SITES; AXIAL SKELETON (EG, HIPS, PEL DUAL ENERGY X-RAY ABSORPTIOMETRY (DEXA), BONE DENSITY STUDY, ONE OR MORE SITES; APPENDICULAR SKELETON DUAL ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, ONE OR MORE SITES; VERTEBRAL FRACTURE ASSESSMENT RADIOGRAPHIC ABSORPTIOMETRY (PHOTODENSITOMETRY), ONE OR MORE SITES RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISION AND INTERPRETATION Allowed Amount Effective Date End Date $82.39 7/1/2019 12/31/2382 26 $13.37 7/1/2019 12/31/2382 TC $100.71 7/1/2019 12/31/2382 $107.47 7/1/2019 12/31/2382 $82.39 7/1/2019 12/31/2382 $43.04 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 $49.20 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $28.27 7/1/2019 12/31/2382 59 $114.52 7/1/2019 12/31/2382 TC $35.83 7/1/2019 12/31/2382 $17.25 7/1/2019 12/31/2382 LT $17.25 7/1/2019 12/31/2382 RT $17.25 7/1/2019 12/31/2382 $17.25 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $18.34 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 76088 76088 76090 76090 76090 76090 76090 76091 76091 76091 76092 76095 76095 76095 76096 76096 76096 76096 76096 76098 76098 76098 76098 76098 76100 76100 76100 Procedure Description MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMOGRAPHY; UNILATERAL MAMMOGRAPHY; UNILATERAL MAMMOGRAPHY; UNILATERAL MAMMOGRAPHY; UNILATERAL MAMMOGRAPHY; UNILATERAL MAMMOGRAPHY; BILATERAL MAMMOGRAPHY; BILATERAL MAMMOGRAPHY; BILATERAL SCREENING MAMMOGRAPHY, BILATERAL (TWO VIEW FILM STUDY OF EACH BREAST) STEREOTACTIC LOCALIZATION FOR BREAST BIOPSY, EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION STEREOTACTIC LOCALIZATION FOR BREAST BIOPSY, EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION STEREOTACTIC LOCALIZATION FOR BREAST BIOPSY, EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGICAL EXAMINATION, BREAST SURGICAL SPECIMEN RADIOLOGICAL EXAMINATION, BREAST SURGICAL SPECIMEN RADIOLOGICAL EXAMINATION, BREAST SURGICAL SPECIMEN RADIOLOGICAL EXAMINATION, BREAST SURGICAL SPECIMEN RADIOLOGICAL EXAMINATION, BREAST SURGICAL SPECIMEN RADIOLOGIC EXAMINATION, SINGLE PLANE BODY SECTION (EG, TOMOGRAPHY), OTHER THAN WITH UROGRAPHY RADIOLOGIC EXAMINATION, SINGLE PLANE BODY SECTION (EG, TOMOGRAPHY), OTHER THAN WITH UROGRAPHY RADIOLOGIC EXAMINATION, SINGLE PLANE BODY SECTION (EG, TOMOGRAPHY), OTHER THAN WITH UROGRAPHY Modifier Allowed Amount Effective Date End Date 26 $22.97 7/1/2019 12/31/2382 TC $125.09 $44.40 $13.37 $44.40 $44.40 $35.83 $55.22 $21.93 $44.42 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $52.00 7/1/2019 12/31/2382 $232.98 7/1/2019 12/31/2382 LT $232.98 7/1/2019 12/31/2382 RT $232.98 7/1/2019 12/31/2382 $114.52 7/1/2019 12/31/2382 26 $29.28 7/1/2019 12/31/2382 LT $114.52 7/1/2019 12/31/2382 RT $114.52 7/1/2019 12/31/2382 TC $44.42 $49.20 $8.10 $49.20 $49.20 $14.44 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $83.74 7/1/2019 12/31/2382 26 $32.00 7/1/2019 12/31/2382 TC $42.75 7/1/2019 12/31/2382 26 LT RT TC 26 TC 26 LT RT TC Radiology Procedure Codes Procedure Code 76101 76101 76101 76102 76102 76102 76120 76120 76120 76125 76125 76125 76150 76355 76355 76355 76360 76360 76360 76362 76365 76365 76365 76370 Procedure Description RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER T RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER T RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER T RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER T RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER T RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER T CINERADIOGRAPHY, EXCEPT WHERE SPECIFICALLY INCLUDED CINERADIOGRAPHY, EXCEPT WHERE SPECIFICALLY INCLUDED CINERADIOGRAPHY, EXCEPT WHERE SPECIFICALLY INCLUDED CINERADIOGRAPHY TO COMPLEMENT ROUTINE EXAMINATION CINERADIOGRAPHY TO COMPLEMENT ROUTINE EXAMINATION CINERADIOGRAPHY TO COMPLEMENT ROUTINE EXAMINATION XERORADIOGRAPHY COMPUTERIZED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED AXIAL TOMOGRAPHIC GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR CYST ASPIRATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR CYST ASPIRATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR CYST ASPIRATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS Allowed Amount Effective Date End Date $114.52 7/1/2019 12/31/2382 26 $32.00 7/1/2019 12/31/2382 TC $48.35 7/1/2019 12/31/2382 $232.98 7/1/2019 12/31/2382 26 $32.00 7/1/2019 12/31/2382 TC $59.21 $89.64 $20.31 $35.83 $49.20 $14.21 $26.97 $49.20 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $65.56 7/1/2019 12/31/2382 TC $282.00 7/1/2019 12/31/2382 $289.49 7/1/2019 12/31/2382 26 $59.57 7/1/2019 12/31/2382 TC $282.00 7/1/2019 12/31/2382 $344.34 7/1/2019 12/31/2382 $341.57 7/1/2019 12/31/2382 26 $59.57 7/1/2019 12/31/2382 TC $282.00 7/1/2019 12/31/2382 $107.47 7/1/2019 12/31/2382 Modifier 26 TC 26 TC Radiology Procedure Codes Procedure Code Modifier Allowed Amount Effective Date End Date 26 $46.13 7/1/2019 12/31/2382 TC $100.71 7/1/2019 12/31/2382 $128.50 7/1/2019 12/31/2382 26 $8.10 7/1/2019 12/31/2382 TC $120.50 7/1/2019 12/31/2382 $41.39 7/1/2019 12/31/2382 59 $41.39 7/1/2019 12/31/2382 LT $41.39 7/1/2019 12/31/2382 RT $41.39 7/1/2019 12/31/2382 $107.47 7/1/2019 12/31/2382 59 $107.47 7/1/2019 12/31/2382 ET $107.47 7/1/2019 12/31/2382 $107.47 7/1/2019 12/31/2382 76377 Procedure Description COMPUTERIZED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS COMPUTERIZED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS CORONAL, SAGITTAL, MULTIPLANAR, OBLIQUE, 3-DIMENSIONAL AND/OR HOLOGRAPHIC RECONSTRUCTION OF COMPUTERIZED TOMO CORONAL, SAGITTAL, MULTIPLANAR, OBLIQUE, 3-DIMENSIONAL AND/OR HOLOGRAPHIC RECONSTRUCTION OF COMPUTERIZED TOMO CORONAL, SAGITTAL, MULTIPLANAR, OBLIQUE, 3-DIMENSIONAL AND/OR HOLOGRAPHIC RECONSTRUCTION OF COMPUTERIZED TOMO 3D REDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, 3D REDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, 3D REDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, 3D REDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, 3D REDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, 3D REDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, 3D REDERING WITH INTERPRETATION AND REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, 76380 COMPUTERIZED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY 76380 COMPUTERIZED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY 26 $50.57 7/1/2019 12/31/2382 76380 COMPUTERIZED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY 59 $107.47 7/1/2019 12/31/2382 76380 COMPUTERIZED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (EG, FOR BIOPSY)RADIOLOGICAL SUPERVISION AND INTERPRETATION MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF, TISSUE ABLATION MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW BLOOD SUPPLY MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW BLOOD SUPPLY TC $119.50 7/1/2019 12/31/2382 $343.96 7/1/2019 12/31/2382 $343.96 7/1/2019 12/31/2382 $343.96 7/1/2019 12/31/2382 $82.88 7/1/2019 12/31/2382 76370 76370 76375 76375 76375 76376 76376 76376 76376 76377 76377 76393 76394 76400 76400 26 Radiology Procedure Codes Procedure Code 76400 76496 76497 76498 76499 76506 76506 76506 76510 76511 76511 76511 76511 76511 76511 76512 76512 76512 76512 76512 76513 Procedure Description MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW BLOOD SUPPLY UNLISTED FLUOROSCOPIC PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL) UNLISTED COMPUTED TOMOGRAPHY PROCEDURE (EG, DIAGNOSTIC INTERVENTIONAL) UNLISTED MAGNETIC RESONANCE PROCEDURE (EG, DIAGNOSTIC, INTERVENTIONAL) UNLISTED DIAGNOSTIC RADIOLOGIC PROCEDURE ECHOENCEPHALOGRAPHY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION (GRAY SCALE) (FOR DETERMINATION OF VENTR ECHOENCEPHALOGRAPHY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION (GRAY SCALE) (FOR DETERMINATION OF VENTR ECHOENCEPHALOGRAPHY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION (GRAY SCALE) (FOR DETERMINATION OF VENTR OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITATIVE A-SCAN PERFORMED DURING THE SAME PATIENT ENCOUNTER OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; A-SCAN ONLY, WITH AMPLITUDE QUANTIFICATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; A-SCAN ONLY, WITH AMPLITUDE QUANTIFICATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; A-SCAN ONLY, WITH AMPLITUDE QUANTIFICATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; A-SCAN ONLY, WITH AMPLITUDE QUANTIFICATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; A-SCAN ONLY, WITH AMPLITUDE QUANTIFICATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; A-SCAN ONLY, WITH AMPLITUDE QUANTIFICATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CONTACT B-SCAN (WITH OR WITHOUT SIMULTANEOUS A-SCAN) OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CONTACT B-SCAN (WITH OR WITHOUT SIMULTANEOUS A-SCAN) OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CONTACT B-SCAN (WITH OR WITHOUT SIMULTANEOUS A-SCAN) OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CONTACT B-SCAN (WITH OR WITHOUT SIMULTANEOUS A-SCAN) OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CONTACT B-SCAN (WITH OR WITHOUT SIMULTANEOUS A-SCAN) OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; ANTERIOR SEGMENT ULTRASOUND, Modifier Allowed Amount Effective Date End Date TC $382.71 7/1/2019 12/31/2382 $89.64 7/1/2019 12/31/2382 $107.47 7/1/2019 12/31/2382 $343.96 $49.20 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $66.98 7/1/2019 12/31/2382 26 $34.43 7/1/2019 12/31/2382 TC $48.35 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $33.25 7/1/2019 12/31/2382 50 $107.12 7/1/2019 12/31/2382 LT $107.12 7/1/2019 12/31/2382 RT $107.12 7/1/2019 12/31/2382 TC $42.75 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $36.00 7/1/2019 12/31/2382 LT $107.12 7/1/2019 12/31/2382 RT $107.12 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 76513 76513 76514 76514 76514 76516 76516 76516 76519 76519 76519 76529 76529 76529 76536 76536 76536 76536 76604 76604 76604 76641 76641 Procedure Description OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; ANTERIOR SEGMENT ULTRASOUND, OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; ANTERIOR SEGMENT ULTRASOUND, OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CORNEAL PACHYMETRY, UNILATERAL OR BILATERAL OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH INTRAOCULAR LENS POWER CALCULATION OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH INTRAOCULAR LENS POWER CALCULATION OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH INTRAOCULAR LENS POWER CALCULATION OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION ECHOGRAPHY, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), B-SCAN AND/OR REAL TIME WITH IM ECHOGRAPHY, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), B-SCAN AND/OR REAL TIME WITH IM ECHOGRAPHY, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), B-SCAN AND/OR REAL TIME WITH IM ECHOGRAPHY, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), B-SCAN AND/OR REAL TIME WITH IM ECHOGRAPHY, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR REAL TIME WITH IMAGE DOCUMENTATION ULTRASOUND, BREAST, UNILATERAL, REALTIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; COMPLETE ULTRASOUND, BREAST, UNILATERAL, REALTIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; COMPLETE Modifier Allowed Amount Effective Date End Date 26 $36.00 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 $41.39 7/1/2019 12/31/2382 50 $41.39 7/1/2019 12/31/2382 PO $0.01 $66.98 $29.63 $42.75 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $29.63 7/1/2019 12/31/2382 TC $42.75 $66.98 $31.40 $46.67 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $30.69 7/1/2019 12/31/2382 59 $107.12 7/1/2019 12/31/2382 TC $48.35 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $30.40 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 $95.46 7/1/2019 12/31/2382 $22.57 7/1/2019 12/31/2382 26 TC 26 TC 26 Radiology Procedure Codes Procedure Code 76641 76641 76642 76642 76645 76645 76645 76645 76645 76645 76700 76700 76700 76700 76705 76705 76705 76705 76705 76705 Procedure Description ULTRASOUND, BREAST, UNILATERAL, REALTIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; COMPLETE ULTRASOUND, BREAST, UNILATERAL, REALTIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; COMPLETE ULTRASOUND, BREAST, UNILATERAL, REALTIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; LIMITED ULTRASOUND, BREAST, UNILATERAL, REALTIME WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED; LIMITED ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN AND/ OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN AND/ OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN AND/ OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN AND/ OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN AND/ OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN AND/ OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, Modifier Allowed Amount Effective Date End Date 50 $95.46 7/1/2019 12/31/2382 TC $44.25 7/1/2019 12/31/2382 $83.38 7/1/2019 12/31/2382 $83.38 7/1/2019 12/31/2382 $66.98 7/1/2019 12/31/2382 26 $29.63 7/1/2019 12/31/2382 50 $66.98 7/1/2019 12/31/2382 LT $66.98 7/1/2019 12/31/2382 RT $66.98 7/1/2019 12/31/2382 TC $35.83 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $43.59 7/1/2019 12/31/2382 59 $107.12 7/1/2019 12/31/2382 TC $67.14 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $32.29 7/1/2019 12/31/2382 59 $107.12 7/1/2019 12/31/2382 GA $107.12 7/1/2019 12/31/2382 TC $48.35 7/1/2019 12/31/2382 XS $107.12 7/1/2019 12/31/2382 XS Radiology Procedure Codes Procedure Code 76705 76770 76770 76770 76770 76770 76770 76775 76775 76775 76775 76776 76778 76778 76778 76800 76800 76800 76801 76802 76805 76805 Procedure Description ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPL ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPL ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPL ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPL ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPL ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPL ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMIT ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMIT ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMIT ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMIT ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION ECHOGRAPHY OF TRANSPLANTED KIDNEY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION, WITH OR WITHOUT DUPLEX DO ECHOGRAPHY OF TRANSPLANTED KIDNEY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION, WITH OR WITHOUT DUPLEX DO ECHOGRAPHY OF TRANSPLANTED KIDNEY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION, WITH OR WITHOUT DUPLEX DO ECHOGRAPHY, SPINAL CANAL AND CONTENTS ECHOGRAPHY, SPINAL CANAL AND CONTENTS ECHOGRAPHY, SPINAL CANAL AND CONTENTS ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIR ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, EACH ADDITIONA ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL AND MA ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL AND MA Modifier Allowed Amount Effective Date End Date XU $107.12 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $40.09 7/1/2019 12/31/2382 59 $107.12 7/1/2019 12/31/2382 GA $107.12 7/1/2019 12/31/2382 TC $67.14 7/1/2019 12/31/2382 XU $107.12 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $32.00 7/1/2019 12/31/2382 59 $107.12 7/1/2019 12/31/2382 TC $48.35 7/1/2019 12/31/2382 $105.26 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $38.28 7/1/2019 12/31/2382 TC $67.14 $107.12 $58.56 $48.35 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $107.12 7/1/2019 12/31/2382 $66.98 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 $53.46 7/1/2019 12/31/2382 26 TC 26 Radiology Procedure Codes Procedure Code 76805 76810 76810 76810 76811 76811 76812 76813 76813 76813 76814 76815 76815 76815 76815 76815 76815 76815 76816 76816 Procedure Description ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL AND MA ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL AND MA ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL AND MA ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL AND MA ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, SINGLE OR FIRS ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, SINGLE OR FIRS ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, EACH ADDITIONA ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; FOLLOW-UP OR REPEAT ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; FOLLOW-UP OR REPEAT Modifier Allowed Amount Effective Date End Date TC $71.73 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $101.56 7/1/2019 12/31/2382 TC $142.89 7/1/2019 12/31/2382 $172.28 7/1/2019 12/31/2382 $172.28 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 $105.26 7/1/2019 12/31/2382 55 $105.26 7/1/2019 12/31/2382 PO $105.26 7/1/2019 12/31/2382 $105.26 7/1/2019 12/31/2382 $66.98 7/1/2019 12/31/2382 22 $66.98 7/1/2019 12/31/2382 25 $66.98 7/1/2019 12/31/2382 26 $35.26 7/1/2019 12/31/2382 52 $66.98 7/1/2019 12/31/2382 59 $66.98 7/1/2019 12/31/2382 TC $48.35 7/1/2019 12/31/2382 $66.98 7/1/2019 12/31/2382 $31.40 7/1/2019 12/31/2382 TC 26 Radiology Procedure Codes Procedure Code 76816 76816 76817 76817 76818 76818 76818 76818 76819 76820 76820 76820 76821 76825 76825 76825 76826 76826 76826 76827 76827 76827 76828 76828 Procedure Description ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; FOLLOW-UP OR REPEAT ECHOGRAPHY, PREGNANT UTERUS, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; FOLLOW-UP OR REPEAT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, TRANSVAGINAL FETAL BIOPHYSICAL PROFILE FETAL BIOPHYSICAL PROFILE FETAL BIOPHYSICAL PROFILE FETAL BIOPHYSICAL PROFILE FETAL BIOPHYSICAL PROFILE; WITHOUT STRESS OR NON-STRESS TESTING DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME WITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M-MODE DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL Modifier Allowed Amount Effective Date End Date PO $66.98 7/1/2019 12/31/2382 TC $37.83 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 $107.12 $107.12 $41.45 $107.12 $55.28 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $107.12 $108.05 $108.05 $108.05 $108.05 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $113.06 7/1/2019 12/31/2382 26 $41.15 7/1/2019 12/31/2382 TC $67.14 7/1/2019 12/31/2382 $101.99 7/1/2019 12/31/2382 26 $53.10 7/1/2019 12/31/2382 TC $24.30 7/1/2019 12/31/2382 $113.06 7/1/2019 12/31/2382 26 $38.51 7/1/2019 12/31/2382 TC $59.37 7/1/2019 12/31/2382 $101.99 7/1/2019 12/31/2382 $26.41 7/1/2019 12/31/2382 25 26 59 TC 51 59 26 Radiology Procedure Codes Procedure Code 76828 76830 76830 76830 76830 76830 76831 76856 76856 76856 76856 76856 76857 76857 76857 76857 76857 76870 76870 76870 76870 76872 76872 76872 76873 76880 76880 Procedure Description DOPPLER ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPL ECHOGRAPHY, TRANSVAGINAL ECHOGRAPHY, TRANSVAGINAL ECHOGRAPHY, TRANSVAGINAL ECHOGRAPHY, TRANSVAGINAL ECHOGRAPHY, TRANSVAGINAL HYSTEROSONOGRAPHY, WITH OR WITHOUT COLOR FLOW DOPPLER ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; COMPLETE ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, ECHOGRAPHY, SCROTUM AND CONTENTS ECHOGRAPHY, SCROTUM AND CONTENTS ECHOGRAPHY, SCROTUM AND CONTENTS ECHOGRAPHY, SCROTUM AND CONTENTS ECHOGRAPHY, TRANSRECTAL ECHOGRAPHY, TRANSRECTAL ECHOGRAPHY, TRANSRECTAL ECHOGRAPHY, TRANSRECTAL; PROSTATE VOLUME STUDY FOR BRACHYTHERAPY TREATMENT PLANNING ECHOGRAPHY, EXTREMITY, NON-VASCULAR, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, EXTREMITY, NON-VASCULAR, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION Allowed Amount Effective Date End Date $5.60 $107.12 $107.12 $37.66 $107.12 $52.27 $172.28 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $107.12 7/1/2019 12/31/2382 26 $37.66 7/1/2019 12/31/2382 59 $107.12 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 XU $107.12 7/1/2019 12/31/2382 $66.98 7/1/2019 12/31/2382 26 $20.05 7/1/2019 12/31/2382 LT $66.98 7/1/2019 12/31/2382 RT $66.98 7/1/2019 12/31/2382 TC $35.83 $107.12 $34.64 $107.12 $52.27 $107.12 $37.66 $52.27 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $107.12 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 $32.29 7/1/2019 12/31/2382 Modifier TC 25 26 59 TC 26 59 TC 26 TC 26 Radiology Procedure Codes Procedure Code 76880 76880 76880 76881 76881 76881 76882 76882 76882 76885 76886 76930 76930 76930 76932 76932 76932 76934 76934 76934 Procedure Description ECHOGRAPHY, EXTREMITY, NON-VASCULAR, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, EXTREMITY, NON-VASCULAR, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION ECHOGRAPHY, EXTREMITY, NON-VASCULAR, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; COMPLETE ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; COMPLETE ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; COMPLETE ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; LIMITED, ANATOMIC SPECIFIC ECHOGRAPHY OF INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; DYNAMIC (EG, REQUIRING MANIPULATION) ECHOGRAPHY OF INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; LIMITED, STATIC (EG, NOT REQUIRING MANIPULATO ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR THORACENTESIS OR ABDOMINAL PARACENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR THORACENTESIS OR ABDOMINAL PARACENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR THORACENTESIS OR ABDOMINAL PARACENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date LT $107.12 7/1/2019 12/31/2382 RT $107.12 7/1/2019 12/31/2382 TC $48.35 7/1/2019 12/31/2382 $94.28 7/1/2019 12/31/2382 LT $94.28 7/1/2019 12/31/2382 RT $94.28 7/1/2019 12/31/2382 $60.95 7/1/2019 12/31/2382 LT $60.95 7/1/2019 12/31/2382 RT $60.95 7/1/2019 12/31/2382 $66.98 7/1/2019 12/31/2382 $107.12 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 26 $34.92 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 26 $34.92 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 $87.19 7/1/2019 12/31/2382 26 $34.92 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 76936 76937 76938 76938 76938 76940 76941 76942 76942 76942 76942 76942 76942 76945 76946 76946 76946 76948 76948 76948 76950 Procedure Description ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDOANEURYSM OR ARTERIOVENOUS FISTULAE (INCLUDES DIAGNOSTI ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, ULTRASONIC GUIDANCE FOR CYST (ANY LOCATION), OR RENAL PELVIS ASPIRATION, RADIOLOGICAL SUPERVISION AND INTERPRE ULTRASONIC GUIDANCE FOR CYST (ANY LOCATION), OR RENAL PELVIS ASPIRATION, RADIOLOGICAL SUPERVISION AND INTERPRE ULTRASONIC GUIDANCE FOR CYST (ANY LOCATION), OR RENAL PELVIS ASPIRATION, RADIOLOGICAL SUPERVISION AND INTERPRE ULTRASOUND GUIDANCE FOR, AND MONITORING OF VISCERAL TISSUE ABLATION ULTRSONIC GUIDANCE FOR INTRAUTERINE FETAL TRANSFUSION OR CORDOCENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRET ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR NEEDLE BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR CHORIONIC VILLUS SAMPLING, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, RADIOLOGICAL SUPERVISION AND INTERPRETATION ECHOGRAPHY FOR PLACEMENT OF RADIATION THERAPY FIELDS, B-SCAN Allowed Amount Effective Date End Date $70.55 7/1/2019 12/31/2382 $20.14 7/1/2019 12/31/2382 $87.19 7/1/2019 12/31/2382 26 $34.92 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 26 $34.92 7/1/2019 12/31/2382 59 $70.55 7/1/2019 12/31/2382 LT $70.55 7/1/2019 12/31/2382 RT $70.55 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 26 $19.26 7/1/2019 12/31/2382 TC $52.27 7/1/2019 12/31/2382 $70.55 7/1/2019 12/31/2382 26 $20.05 7/1/2019 12/31/2382 TC $52.27 $70.55 7/1/2019 7/1/2019 12/31/2382 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 76950 76950 76977 Procedure Description ECHOGRAPHY FOR PLACEMENT OF RADIATION THERAPY FIELDS, B-SCAN ECHOGRAPHY FOR PLACEMENT OF RADIATION THERAPY FIELDS, B-SCAN ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS, EXCEPT FOR B-SCAN ECHOGRAPHY ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS, EXCEPT FOR B-SCAN ECHOGRAPHY ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS, EXCEPT FOR B-SCAN ECHOGRAPHY ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION ULTRASOUND STUDY FOLLOW-UP (SPECIFY) ULTRASOUND STUDY FOLLOW-UP (SPECIFY) ULTRASOUND STUDY FOLLOW-UP (SPECIFY) GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, RADIOLOGICAL SUPERVISION AND INTERPRETATION ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION,PERIPHERAL SITE(S), ANY METHOD 76978 ULTRASOUND USING TARGETED MICROBUBBLE CONTRAST OF FIRST LESION 76978 76986 76986 76986 76998 76999 ULTRASOUND USING TARGETED MICROBUBBLE CONTRAST OF FIRST LESION ECHOGRAPHY, INTRAOPERATIVE ECHOGRAPHY, INTRAOPERATIVE ECHOGRAPHY, INTRAOPERATIVE ULTRASONIC GUIDANCE, INTRAOPERATIVE UNLISTED ULTRASOUND PROCEDURE FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT, OR REMOVAL FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT, OR REMOVAL FLUOROSCOPIC GUIDANCE FOE NEEDLE PLACEMENT FLUOROSCOPIC GUIDANCE FOE NEEDLE PLACEMENT FLUOROSCOPIC GUIDANCE FOE NEEDLE PLACEMENT FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE PARASPINOUS DIAGNOSTIC OR THERAPEUT FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE PARASPINOUS DIAGNOSTIC OR THERAPEUT FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE PARASPINOUS DIAGNOSTIC OR THERAPEUT COMPUTED TOMOGRAPHY GUIDANCE FOR STEROTACTIC COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT, RADIOLOGICAL SUPERVISION AND INTERPRETATION 76960 76960 76960 76965 76970 76970 76970 76975 77001 77001 77002 77002 77002 77003 77003 77003 77011 77012 Allowed Amount $32.00 $44.42 Effective Date 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 $74.72 7/1/2019 12/31/2382 26 $32.00 7/1/2019 12/31/2382 TC $44.42 $70.55 $66.98 $20.61 $35.83 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $107.12 7/1/2019 12/31/2382 $41.39 7/1/2019 12/31/2382 $171.18 7/1/2019 12/31/2382 $171.18 $107.12 $65.27 $89.77 $105.26 $66.98 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $68.05 7/1/2019 12/31/2382 $68.05 $52.46 $52.46 $52.46 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $48.04 7/1/2019 12/31/2382 50 $48.04 7/1/2019 12/31/2382 59 $48.04 $275.35 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $275.36 7/1/2019 12/31/2382 Modifier 26 TC 26 TC XS 26 TC 59 59 LT Radiology Procedure Codes Procedure Code 77012 77013 77014 77014 77021 77022 77031 77031 77031 77031 77031 77032 77032 77032 77032 77051 77051 77051 77052 77053 Procedure Description COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTERIZED TOMOGRAPHY GUIDANCE FOR, AND MONITORING OF PARENCHYMAL TISSUE ABLATION COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT RADIOLOGICAL SUPERVISION AND INTERPRETATION MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF PARENCHYMAL TISSUE ABLATION STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT, EACH LESION, RADIOLOGICAL SUPERVISON STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT, EACH LESION, RADIOLOGICAL SUPERVISON STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT, EACH LESION, RADIOLOGICAL SUPERVISON STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT, EACH LESION, RADIOLOGICAL SUPERVISON STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT, EACH LESION, RADIOLOGICAL SUPERVISON MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST, EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST, EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST, EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST, EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEWFOR INTERPRETATION; DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEWFOR INTERPRETATION; DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEWFOR INTERPRETATION; DIAGNOSTIC MAMMOGRAPHY COMPUTER AIDED DETECTION WITH FURTHER PHYSICIAN REVIEWFOR INTERPRETATION; SCREENING MAMMOGRAPHY MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION AND INTERPRETATION Modifier Allowed Amount Effective Date End Date 59 $275.36 7/1/2019 12/31/2382 $326.48 7/1/2019 12/31/2382 $103.73 7/1/2019 12/31/2382 $103.73 7/1/2019 12/31/2382 $307.04 7/1/2019 12/31/2382 $307.04 7/1/2019 12/31/2382 $199.55 7/1/2019 12/31/2382 50 $199.55 7/1/2019 12/31/2382 59 $199.55 7/1/2019 12/31/2382 LT $199.55 7/1/2019 12/31/2338 RT $199.55 7/1/2019 12/31/2382 $114.36 7/1/2019 12/31/2382 59 $114.36 7/1/2019 12/31/2382 LT $114.36 7/1/2019 12/31/2382 RT $114.36 7/1/2019 12/31/2382 $14.86 7/1/2019 12/31/2382 LT $14.86 7/1/2019 12/31/2382 RT $14.86 7/1/2019 12/31/2382 $14.86 7/1/2019 12/31/2382 $114.36 7/1/2019 12/31/2382 59 Radiology Procedure Codes Procedure Code 77054 77055 77055 77055 77055 77056 77057 77058 77059 77065 77065 77065 77065 77065 77066 77066 77066 77066 77066 77067 77067 77067 77067 Procedure Description MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISON AND INTERPRETATION MAMMOGRAPHY, UNILATERAL MAMMOGRAPHY, UNILATERAL MAMMOGRAPHY, UNILATERAL MAMMOGRAPHY, UNILATERAL MAMMOGRAPHY; BILATERAL SCREENING MAMMOGRAPHY, BILATERAL, 2 VIEW FILM STUDY OF EACH BREAST MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIALS, UNILATERAL MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONTRAST MATERIALS, BILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; UNILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; UNILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; UNILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; UNILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; UNILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; BILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; BILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; BILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; BILATERAL DIAGNOSTIC MAMMORGRAPHY, INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PREFORMED; BILATERAL SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED Allowed Amount Effective Date End Date $114.36 $36.69 $36.69 $36.69 $36.69 $59.31 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $51.26 7/1/2019 12/31/2382 $768.21 7/1/2019 12/31/2382 $969.07 7/1/2019 12/31/2382 $108.18 7/1/2019 12/31/2382 26 $1.20 7/1/2019 12/31/2382 LT $108.18 7/1/2019 12/31/2382 RT $108.18 7/1/2019 12/31/2382 TC $2.86 7/1/2019 12/31/2382 $138.16 7/1/2019 12/31/2382 26 $1.49 7/1/2019 12/31/2382 LT $138.16 7/1/2019 12/31/2382 RT $138.16 7/1/2019 12/31/2382 TC $3.66 7/1/2019 12/31/2382 $114.25 7/1/2019 12/31/2382 26 $1.14 7/1/2019 12/31/2382 LT $114.25 7/1/2019 12/31/2382 RT $114.25 7/1/2019 12/31/2382 Modifier 59 LT RT Radiology Procedure Codes Procedure Code Modifier Allowed Amount Effective Date End Date TC $3.02 7/1/2019 12/31/2382 $47.84 $47.84 $47.84 $82.45 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $82.45 $47.84 $47.84 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 $79.29 7/1/2019 12/31/2382 $103.73 7/1/2019 12/31/2382 $79.29 7/1/2019 12/31/2382 59 $79.29 7/1/2019 12/31/2382 GA $79.29 7/1/2019 12/31/2382 $37.08 7/1/2019 12/31/2382 59 $37.08 7/1/2019 12/31/2382 26 TC $47.84 $82.45 $307.04 $75.50 $113.77 $169.52 $275.53 $37.81 $118.50 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 77082 77083 77084 77261 77262 77263 77280 77280 77280 Procedure Description SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW STUDY OF EACH BREAST), INCLUDING COMPUTER-AIDED DETECTION (CAD) WHEN PERFORMED MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT RADIOLOGY, INCLUDING CONTRALATERAL JOINT IF BONE AGE STUDIES BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND APPENDICULAR SKELETON) RADIOLOGIC EXAMINATION , OSSEOUS SURVEY, INFANT JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS (SPECIFY) COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON DUAL ENERGY X-RAY ABSORPTIOMETRY, DXA, BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON DUAL ENERGY X-RAY ABSORPTIOMETRY, DXA, BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON DUAL ENERGY X-RAY ABSORPTIOMETRY, DXA, BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON DUAL- ENERGY X-RAY ABSORPTIOMETRY, BONE DENSITY STUDY, 1 OR MORE SITE; APPENDICULAR SKELETON DUAL- ENERGY X-RAY ABSORPTIOMETRY, BONE DENSITY STUDY, 1 OR MORE SITE; APPENDICULAR SKELETON DUAL- ENERGY X-RAY ABSORPTIOMETRY, BONE DENSITY STUDY, 1 OR MORE SITE; VERTEBRAL FRACTURE ASSESSMENT RADIOGRAPHIC ABSORPTIOMETRY, 1 OR MORE SITES MAGNETIC RESONANCE IMAGING, BONE MARROW BLOOD SUPPLY THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE THERAPEUTIC RADIOLOGY TREATMENT PLANNING; COMPLEX THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE 77285 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; INTERMEDIATE $265.30 7/1/2019 12/31/2382 77285 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; INTERMEDIATE 26 $56.34 7/1/2019 12/31/2382 77285 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; INTERMEDIATE TC $190.23 7/1/2019 12/31/2382 77067 77071 77072 77073 77074 77075 77076 77077 77078 77079 77080 77080 77080 77081 77081 Radiology Procedure Codes Procedure Code 77290 77290 77290 77295 77299 77300 77300 77300 77301 77301 77305 77305 77305 77310 77310 77310 77310 77315 77315 77315 77315 77321 77321 Procedure Description THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; BY THREE DIMENSIONAL RECONSTRUCTION OF TUMOR VOLUME UNLISTED PROCEDURE, THERAPEUTIC RADIOLOGY CLINICAL TREATMENT PLANNING BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH DOSE, TDF, NSD, GAP CALCULATION, OFF AXIS FACTOR, TI BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH DOSE, TDF, NSD, GAP CALCULATION, OFF AXIS FACTOR, TI BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH DOSE, TDF, NSD, GAP CALCULATION, OFF AXIS FACTOR, TI INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE- VOLUME HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PAR INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE- VOLUME HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PAR TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); SIMPLE (ONE OR TWO PARALLEL OPPOSED UNMODIFIE TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); SIMPLE (ONE OR TWO PARALLEL OPPOSED UNMODIFIE TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); SIMPLE (ONE OR TWO PARALLEL OPPOSED UNMODIFIE TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); INTERMEDIATE (THREE OR MORE TREATMENT PORTS D TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); INTERMEDIATE (THREE OR MORE TREATMENT PORTS D TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); INTERMEDIATE (THREE OR MORE TREATMENT PORTS D TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); INTERMEDIATE (THREE OR MORE TREATMENT PORTS D TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); COMPLEX (MANTLE OR INVERTED Y, TANGENTIAL POR TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); COMPLEX (MANTLE OR INVERTED Y, TANGENTIAL POR TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); COMPLEX (MANTLE OR INVERTED Y, TANGENTIAL POR TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER CALCULATED); COMPLEX (MANTLE OR INVERTED Y, TANGENTIAL POR SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMI-BODY, TOTAL BODY SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMI-BODY, TOTAL BODY Allowed Amount $275.53 $84.54 $222.13 Effective Date 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 $936.28 7/1/2019 12/31/2382 $116.84 7/1/2019 12/31/2382 $116.84 7/1/2019 12/31/2382 26 $33.74 7/1/2019 12/31/2382 TC $45.76 7/1/2019 12/31/2382 $936.28 7/1/2019 12/31/2382 $936.28 7/1/2019 12/31/2382 $116.84 7/1/2019 12/31/2382 26 $37.81 7/1/2019 12/31/2382 TC $63.46 7/1/2019 12/31/2382 $265.30 7/1/2019 12/31/2382 26 $56.34 7/1/2019 12/31/2382 59 $265.30 7/1/2019 12/31/2382 TC $79.57 7/1/2019 12/31/2382 $265.30 7/1/2019 12/31/2382 26 $84.54 7/1/2019 12/31/2382 59 $265.30 7/1/2019 12/31/2382 TC $90.77 $265.30 $51.28 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 Modifier 26 TC 59 26 Radiology Procedure Codes Procedure Code 77321 77326 77326 77326 77327 77327 77327 77328 77328 77328 77331 77331 77331 77332 77332 77332 77332 77333 77333 77333 77333 Procedure Description SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMI-BODY, TOTAL BODY BRACHYTHERAPY ISODOSE CALCULATION; SIMPLE (CALCULATION MADE FROM SINGLE PLANE, ONE TO FOUR SOURCES/ RIBBON APP BRACHYTHERAPY ISODOSE CALCULATION; SIMPLE (CALCULATION MADE FROM SINGLE PLANE, ONE TO FOUR SOURCES/ RIBBON APP BRACHYTHERAPY ISODOSE CALCULATION; SIMPLE (CALCULATION MADE FROM SINGLE PLANE, ONE TO FOUR SOURCES/ RIBBON APP BRACHYTHERAPY ISODOSE CALCULATION; INTERMEDIATE (MULTIPLANE DOSAGE CALCULATIONS, APPLICATION INVOLVING FIVE TO BRACHYTHERAPY ISODOSE CALCULATION; INTERMEDIATE (MULTIPLANE DOSAGE CALCULATIONS, APPLICATION INVOLVING FIVE TO BRACHYTHERAPY ISODOSE CALCULATION; INTERMEDIATE (MULTIPLANE DOSAGE CALCULATIONS, APPLICATION INVOLVING FIVE TO BRACHYTHERAPY ISODOSE CALCULATION; COMPLEX (MULTIPLANE ISODOSE PLAN, VOLUME IMPLANT CALCULATIONS, OVER TEN SOU BRACHYTHERAPY ISODOSE CALCULATION; COMPLEX (MULTIPLANE ISODOSE PLAN, VOLUME IMPLANT CALCULATIONS, OVER TEN SOU BRACHYTHERAPY ISODOSE CALCULATION; COMPLEX (MULTIPLANE ISODOSE PLAN, VOLUME IMPLANT CALCULATIONS, OVER TEN SOU SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE (SIMPLE BLOCK, SIMPLE BOLUS) TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE (SIMPLE BLOCK, SIMPLE BOLUS) TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE (SIMPLE BLOCK, SIMPLE BOLUS) TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE (SIMPLE BLOCK, SIMPLE BOLUS) TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE (MULTIPLE BLOCKS, STENTS, BITE BLOCKS, SPECIAL BOLUS) TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE (MULTIPLE BLOCKS, STENTS, BITE BLOCKS, SPECIAL BOLUS) TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE (MULTIPLE BLOCKS, STENTS, BITE BLOCKS, SPECIAL BOLUS) TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE (MULTIPLE BLOCKS, STENTS, BITE BLOCKS, SPECIAL BOLUS) Allowed Amount $137.62 Effective Date 7/1/2019 End Date 12/31/2382 $116.84 7/1/2019 11/30/2382 26 $50.15 7/1/2019 12/31/2382 TC $80.91 7/1/2019 12/31/2382 $265.30 7/1/2019 12/31/2382 26 $75.50 7/1/2019 12/31/2382 TC $118.50 7/1/2019 12/31/2382 $265.30 7/1/2019 12/31/2382 26 $112.69 7/1/2019 12/31/2382 TC $169.18 7/1/2019 12/31/2382 $116.84 7/1/2019 12/31/2382 26 $47.28 7/1/2019 12/31/2382 TC $17.45 7/1/2019 12/31/2382 $190.47 7/1/2019 12/31/2382 26 $29.78 7/1/2019 12/31/2382 59 $190.47 7/1/2019 12/31/2382 TC $45.76 7/1/2019 12/31/2382 $190.47 7/1/2019 12/31/2382 26 $45.15 7/1/2019 12/31/2382 59 $190.47 7/1/2019 12/31/2382 TC $64.80 7/1/2019 12/31/2382 Modifier TC Radiology Procedure Codes Procedure Code 77334 77334 77334 77334 77334 77334 77336 77336 77336 77336 77338 77370 77371 77385 77386 77399 77401 77402 77403 77404 77406 Procedure Description TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, CONTINUING MEDICAL RADIATION PHYSICS CONSULTATION IN SUPPORT OF THERAPEUTIC RADIOLOGIST INCLUDING CONTINUING Q CONTINUING MEDICAL RADIATION PHYSICS CONSULTATION IN SUPPORT OF THERAPEUTIC RADIOLOGIST INCLUDING CONTINUING Q CONTINUING MEDICAL RADIATION PHYSICS CONSULTATION IN SUPPORT OF THERAPEUTIC RADIOLOGIST INCLUDING CONTINUING Q CONTINUING MEDICAL RADIATION PHYSICS CONSULTATION IN SUPPORT OF THERAPEUTIC RADIOLOGIST INCLUDING CONTINUING Q MULTI-LEAF COLLIMATOR (MLC) DEVICE(S) FOR INTENSITY MODULATED RADIATION THERAPY (IMRT), DESIGN AND SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF TREATMENT OF CEREBRAL LESION INTENSITY MODULATED RADIATION TREATMENT DELIVERY, INCLUDES GUIDANCE AND TRACKING, WHEN PERFORMED; SIMPLE INTENSITY MODULATED RADIATION TREATMENT DELIVERY, INCLUDES GUIDANCE AND TRACKING, WHEN PERFORMED; COMPLEX UNLISTED PROCEDURE, MEDICAL RADIATION PHYSICS, DOSIMETRY AND TREATMENT DEVICES RADIATION TREATMENT DELIVERY, SUPERFICIAL AND/OR ORTHO VOLTAGE RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR N RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR N RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR N RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR N Allowed Amount Effective Date End Date $190.47 7/1/2019 12/31/2382 26 $66.94 7/1/2019 12/31/2382 59 $190.47 7/1/2019 12/31/2382 LT $190.47 7/1/2019 12/31/2382 RT $190.47 7/1/2019 12/31/2382 TC $110.65 7/1/2019 12/31/2382 $116.84 7/1/2019 12/31/2382 59 $116.84 7/1/2019 12/31/2382 LT $116.84 7/1/2019 12/31/2382 RT $116.84 7/1/2019 12/31/2382 $286.03 $116.84 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $9,337.95 7/1/2019 12/31/2382 $524.48 7/1/2019 12/31/2382 $461.71 7/1/2019 12/31/2382 $116.84 $98.88 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $98.88 7/1/2019 12/31/2382 $98.88 7/1/2019 12/31/2382 $98.88 7/1/2019 12/31/2382 $98.88 7/1/2019 12/31/2382 Modifier Radiology Procedure Codes Procedure Code 77407 77408 77409 77411 77412 77413 77413 77414 77416 77417 77418 77420 77421 77422 77423 77425 77430 77431 77470 77470 77470 77520 Procedure Description RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, US RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, US RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, US RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, US RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGE RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGE RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGE RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGE RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGE THERAPEUTIC RADIOLOGY PORT FILM(S) INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE FIELDS/ARCS, VIA NARROW SPATIALLY AND TEPORALLY MOD WEEKLY RADIOLOGY THERAPY MANAGEMENT; SIMPLE STEREOSCOPIC X-RAY GUIDANCE FOR LOCALIZATION OF TARGET VOLUME FOR THE DELIVERY OF RADIATION THERAPY HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; SINGLE TREATMENT AREA USING A SINGLE PORT OR PARALLEL HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; 1 OR MORE ISOCENTER(S) WITH COPLANAR OR NON-COPLANAR GEOMETR INTRAOPERATIVE RADIATION TREATMENT DELIVERY, ELECTRONS, SINGLE TREATMENT SESSION WEEKLY RADIOLOGY THERAPY MANAGEMENT; COMPLEX RADIATION THERAPY MANAGEMENT WITH COMPLETE COURSE OF THERAPY CONSISTING OF ONE OR TWO FRACTIONS ONLY SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, HEMIBODY IRRADIATION, PER ORAL, VAGINAL CONE IRRADIAT SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, HEMIBODY IRRADIATION, PER ORAL, VAGINAL CONE IRRADIAT SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, HEMIBODY IRRADIATION, PER ORAL, VAGINAL CONE IRRADIAT PROTON BEAM DELIVERY TO A SINGLE TREATMENT AREA, SINGLEPORT, CUSTOM BLOCK, W/ OR W/OUT COMPENSATIN, W/TREATMEN Allowed Amount Effective Date End Date $98.88 7/1/2019 12/31/2382 $98.88 7/1/2019 12/31/2382 $98.88 7/1/2019 12/31/2382 $148.76 7/1/2019 12/31/2382 $148.76 7/1/2019 12/31/2382 $148.76 7/1/2019 12/31/2382 $148.76 7/1/2019 12/31/2382 $148.76 7/1/2019 12/31/2382 $148.76 $49.20 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $361.34 $87.04 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $85.00 7/1/2019 11/30/2382 $148.76 7/1/2019 12/31/2382 $148.76 7/1/2019 12/31/2382 $131.95 $194.76 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $93.23 7/1/2019 12/31/2382 $389.02 7/1/2019 12/31/2382 26 $107.53 7/1/2019 12/31/2382 TC $380.46 7/1/2019 12/31/2382 $1,074.34 7/1/2019 12/31/2382 Modifier 76 Radiology Procedure Codes Procedure Code 77522 77523 77525 77600 77600 77600 77605 77605 77605 77610 77610 77610 77615 77615 77615 77620 77620 77620 77750 77750 77750 77761 77761 77761 77762 77762 77762 77763 Procedure Description PROTON TREATMENT DELIVERY; SIMPLE, WITH COMPENSATION PROTON BEAM DELIVERY TO ONE OR TWO TREATMENT AREAS, TWO OR MORE PORTS, TWO OR MORE CUSTOM BLOCKS AND TWO OR MO PROTON TREATMENT DELIVERY; COMPLEX HYPERTHERMIA, EXTERNALLY GENERATED; SUPERFICIAL (IE, HEATING TO A DEPTH OF 4 CM OR LESS) HYPERTHERMIA, EXTERNALLY GENERATED; SUPERFICIAL (IE, HEATING TO A DEPTH OF 4 CM OR LESS) HYPERTHERMIA, EXTERNALLY GENERATED; SUPERFICIAL (IE, HEATING TO A DEPTH OF 4 CM OR LESS) HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (IE, HEATING TO DEPTHS GREATER THAN 4 CM) HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (IE, HEATING TO DEPTHS GREATER THAN 4 CM) HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (IE, HEATING TO DEPTHS GREATER THAN 4 CM) HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); 5 OR FEWER INTERSTITIAL APPLICATORS HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); 5 OR FEWER INTERSTITIAL APPLICATORS HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); 5 OR FEWER INTERSTITIAL APPLICATORS HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); MORE THAN 5 INTERSTITIAL APPLICATORS HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); MORE THAN 5 INTERSTITIAL APPLICATORS HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); MORE THAN 5 INTERSTITIAL APPLICATORS HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S) HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S) HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S) INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION INTRACAVITARY RADIOELEMENT APPLICATION; SIMPLE INTRACAVITARY RADIOELEMENT APPLICATION; SIMPLE INTRACAVITARY RADIOELEMENT APPLICATION; SIMPLE INTRACAVITARY RADIOELEMENT APPLICATION; INTERMEDIATE INTRACAVITARY RADIOELEMENT APPLICATION; INTERMEDIATE INTRACAVITARY RADIOELEMENT APPLICATION; INTERMEDIATE INTRACAVITARY RADIOELEMENT APPLICATION; COMPLEX Allowed Amount $1,074.34 Effective Date 7/1/2019 End Date 12/31/2382 $1,285.31 $1,285.31 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $376.63 7/1/2019 12/31/2382 26 $84.54 7/1/2019 12/31/2382 TC $103.72 7/1/2019 12/31/2382 $376.63 7/1/2019 12/31/2382 26 $112.69 7/1/2019 12/31/2382 TC $138.53 7/1/2019 12/31/2382 $376.63 7/1/2019 12/31/2382 26 $84.54 7/1/2019 12/31/2382 TC $103.72 7/1/2019 12/31/2382 $376.63 7/1/2019 12/31/2382 26 $112.69 7/1/2019 12/31/2382 TC $138.53 $376.63 $84.54 $103.72 $148.76 $236.44 $45.43 $375.50 $183.52 $85.85 $375.50 $289.39 $123.42 $375.50 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 Modifier 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 77763 77763 77767 77768 77770 77771 77772 77776 77776 77776 77777 77777 77777 77778 77778 77778 77781 77781 77781 77782 77782 77782 77782 77783 77783 77783 77784 Procedure Description INTRACAVITARY RADIOELEMENT APPLICATION; COMPLEX INTRACAVITARY RADIOELEMENT APPLICATION; COMPLEX HIGH DOSE BRACHYTHERAPY THROUGH SKIN SURFACE, 1 CHANNEL OR UP TO 2.0 CM HIGH DOSE BRACHYTHERAPY THROUGH SKIN SURFACE, 2 CHANNELS OR MORE THAN 2.0 CM HIGH DOSE BRACHYTHERAPY, 1 CHANNEL HIGH DOSE BRACHYTHERAPY, 2-12 CHANNELS HIGH DOSE BRACHYTHERAPY, MORE THAN 12 CHANNELS INTERSTITIAL RADIOELEMENT APPLICATION; SIMPLE INTERSTITIAL RADIOELEMENT APPLICATION; SIMPLE INTERSTITIAL RADIOELEMENT APPLICATION; SIMPLE INTERSTITIAL RADIOELEMENT APPLICATION; INTERMEDIATE INTERSTITIAL RADIOELEMENT APPLICATION; INTERMEDIATE INTERSTITIAL RADIOELEMENT APPLICATION; INTERMEDIATE INTERSTITIAL RADIOELEMENT APPLICATION; COMPLEX INTERSTITIAL RADIOELEMENT APPLICATION; COMPLEX INTERSTITIAL RADIOELEMENT APPLICATION; COMPLEX REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 1-4 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 1-4 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 1-4 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 5-8 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 5-8 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 5-8 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 5-8 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 9-12 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 9-12 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 9-12 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; OVER 12 SOURCE POSITIONS OR CATHETERS Allowed Amount $412.98 $153.40 Effective Date 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 $177.80 7/1/2019 12/31/2382 $177.80 $636.92 $636.92 $636.92 $375.50 $240.40 $74.32 $375.50 $360.30 $144.46 $755.05 $539.78 $174.78 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $878.17 7/1/2019 12/31/2382 26 $80.19 7/1/2019 12/31/2382 TC $693.44 7/1/2019 12/31/2382 $878.17 7/1/2019 12/31/2382 26 $120.49 7/1/2019 12/31/2382 76 $878.17 7/1/2019 12/31/2382 TC $693.44 7/1/2019 12/31/2382 $878.17 7/1/2019 12/31/2382 26 $179.82 7/1/2019 12/31/2382 TC $693.44 7/1/2019 12/31/2382 $878.17 7/1/2019 12/31/2382 Modifier 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 77784 77784 77785 77786 77787 77789 77789 77789 77790 77790 77790 77799 78000 78000 78000 78001 78001 78001 78003 78003 78003 78006 78006 78006 78007 78007 78007 78010 78010 78010 78011 78011 78011 Procedure Description REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; OVER 12 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; OVER 12 SOURCE POSITIONS OR CATHETERS REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 1 CHANNEL REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 2-12 CHANNELS REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; OVER 12 CHANNELS SURFACE APPLICATION OF RADIOELEMENT SURFACE APPLICATION OF RADIOELEMENT SURFACE APPLICATION OF RADIOELEMENT SUPERVISION, HANDLING, LOADING OF RADIOELEMENT SUPERVISION, HANDLING, LOADING OF RADIOELEMENT SUPERVISION, HANDLING, LOADING OF RADIOELEMENT UNLISTED PROCEDURE, CLINICAL BRACHYTHERAPY THYROID UPTAKE; SINGLE DETERMINATION THYROID UPTAKE; SINGLE DETERMINATION THYROID UPTAKE; SINGLE DETERMINATION THYROID UPTAKE; MULTIPLE DETERMINATIONS THYROID UPTAKE; MULTIPLE DETERMINATIONS THYROID UPTAKE; MULTIPLE DETERMINATIONS THYROID UPTAKE; STIMULATION, SUPPRESSION OR DISCHARGE (NOT INCLUDING INITIAL UPTAKE STUDIES) THYROID UPTAKE; STIMULATION, SUPPRESSION OR DISCHARGE (NOT INCLUDING INITIAL UPTAKE STUDIES) THYROID UPTAKE; STIMULATION, SUPPRESSION OR DISCHARGE (NOT INCLUDING INITIAL UPTAKE STUDIES) THYROID IMAGING, WITH UPTAKE; SINGLE DETERMINATION THYROID IMAGING, WITH UPTAKE; SINGLE DETERMINATION THYROID IMAGING, WITH UPTAKE; SINGLE DETERMINATION THYROID IMAGING, WITH UPTAKE; MULTIPLE DETERMINATIONS THYROID IMAGING, WITH UPTAKE; MULTIPLE DETERMINATIONS THYROID IMAGING, WITH UPTAKE; MULTIPLE DETERMINATIONS THYROID IMAGING; ONLY THYROID IMAGING; ONLY THYROID IMAGING; ONLY THYROID IMAGING; WITH VASCULAR FLOW THYROID IMAGING; WITH VASCULAR FLOW THYROID IMAGING; WITH VASCULAR FLOW Modifier Allowed Amount Effective Date End Date 26 $270.35 7/1/2019 12/31/2382 TC $693.44 7/1/2019 12/31/2382 $748.66 7/1/2019 12/31/2382 $748.66 7/1/2019 12/31/2382 $748.66 $98.88 $53.93 $15.45 $71.38 $53.93 $17.45 $878.17 $96.29 $12.21 $32.90 $96.29 $13.61 $44.42 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $237.62 7/1/2019 12/31/2382 26 $16.66 7/1/2019 12/31/2382 TC $32.90 $166.34 $30.39 $81.59 $187.52 $26.01 $87.85 $166.34 $25.26 $61.88 $166.34 $30.19 $82.25 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 78012 78014 78015 78015 78015 78016 78016 78016 78017 78017 78017 78018 78018 78018 78070 78070 78070 78071 78072 78075 78075 78075 78099 78102 78102 78102 78103 78103 78103 78104 78104 78104 Procedure Description THYROID UPTAKE, SINGLE OR MULTIPLE, QUANTITATIVE MEASUREMENT(S) (INCLUDING STIMULATION, SUPRESSION, OR THYROID IMAGING (INCLUDING VASCULAR FLOW, WHEN PERFORMED); WITH SINGLE OR MULTIPLE UPTAKE(S) THYROID CARCINOMA METASTASES IMAGING; LIMITED AREA (EG, NECK AND CHEST ONLY) THYROID CARCINOMA METASTASES IMAGING; LIMITED AREA (EG, NECK AND CHEST ONLY) THYROID CARCINOMA METASTASES IMAGING; LIMITED AREA (EG, NECK AND CHEST ONLY) THYROID CARCINOMA METASTASES IMAGING; WITH ADDITIONAL STUDIES (EG, URINARY RECOVERY) THYROID CARCINOMA METASTASES IMAGING; WITH ADDITIONAL STUDIES (EG, URINARY RECOVERY) THYROID CARCINOMA METASTASES IMAGING; WITH ADDITIONAL STUDIES (EG, URINARY RECOVERY) THYROID CARCINOMA METASTASES IMAGING; MULTIPLE AREAS THYROID CARCINOMA METASTASES IMAGING; MULTIPLE AREAS THYROID CARCINOMA METASTASES IMAGING; MULTIPLE AREAS THYROID CARCINOMA METASTASES IMAGING; WHOLE BODY THYROID CARCINOMA METASTASES IMAGING; WHOLE BODY THYROID CARCINOMA METASTASES IMAGING; WHOLE BODY PARATHYROID IMAGING PARATHYROID IMAGING PARATHYROID IMAGING PARATHYROID PLANAR IMAGING; WITH TOMOGRAPHIC (SPECT) PARATHYROID PLANAR IMAGING; WITH TOMOGRAPHIC (SPECT), AND CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY ADRENAL IMAGING, CORTEX AND/OR MEDULLA ADRENAL IMAGING, CORTEX AND/OR MEDULLA ADRENAL IMAGING, CORTEX AND/OR MEDULLA UNLISTED ENDOCRINE PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE BONE MARROW IMAGING; LIMITED AREA BONE MARROW IMAGING; LIMITED AREA BONE MARROW IMAGING; LIMITED AREA BONE MARROW IMAGING; MULTIPLE AREAS BONE MARROW IMAGING; MULTIPLE AREAS BONE MARROW IMAGING; MULTIPLE AREAS BONE MARROW IMAGING; WHOLE BODY BONE MARROW IMAGING; WHOLE BODY BONE MARROW IMAGING; WHOLE BODY Allowed Amount Effective Date End Date $130.29 7/1/2019 12/31/2382 $220.31 7/1/2019 12/31/2382 $279.21 7/1/2019 11/30/2382 26 $34.92 7/1/2019 12/31/2382 TC $87.85 7/1/2019 12/31/2382 $279.21 7/1/2019 12/31/2382 26 $42.57 7/1/2019 12/31/2382 TC $118.83 $194.04 $44.93 $127.10 $279.21 $49.40 $185.31 $187.52 $26.59 $61.88 $304.59 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $304.59 $187.52 $40.07 $185.31 $166.34 $264.12 $31.02 $69.72 $264.12 $50.03 $107.97 $264.12 $51.26 $138.87 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 Modifier 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 78110 78110 78110 78111 78111 78111 78120 78120 78120 78121 78121 78121 78122 78122 78122 78130 78130 78130 78135 78135 78135 78140 Procedure Description PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE (SEPARATE PROCEDURE); SINGLE SAMPLING PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE (SEPARATE PROCEDURE); SINGLE SAMPLING PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE (SEPARATE PROCEDURE); SINGLE SAMPLING PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS PLASMA VOLUME, RADIONUCLIDE VOLUME-DILUTION TECHNIQUE (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); SINGLE SAMPLING RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); SINGLE SAMPLING RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); SINGLE SAMPLING RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS WHOLE BLOOD VOLUME DETERMINATION, INCLUDING SEPARATE MEASUREMENT OF PLASMA VOLUME AND RED CELL VOLUME (RADIONU WHOLE BLOOD VOLUME DETERMINATION, INCLUDING SEPARATE MEASUREMENT OF PLASMA VOLUME AND RED CELL VOLUME (RADIONU WHOLE BLOOD VOLUME DETERMINATION, INCLUDING SEPARATE MEASUREMENT OF PLASMA VOLUME AND RED CELL VOLUME (RADIONU RED CELL SURVIVAL STUDY; RED CELL SURVIVAL STUDY; RED CELL SURVIVAL STUDY; RED CELL SURVIVAL STUDY; DIFFERENTIAL ORGAN/TISSUE KINETICS, (EG, SPLENIC AND/OR HEPATIC SEQUESTRATION) RED CELL SURVIVAL STUDY; DIFFERENTIAL ORGAN/TISSUE KINETICS, (EG, SPLENIC AND/OR HEPATIC SEQUESTRATION) RED CELL SURVIVAL STUDY; DIFFERENTIAL ORGAN/TISSUE KINETICS, (EG, SPLENIC AND/OR HEPATIC SEQUESTRATION) LABELED RED CELL SEQUESTRATION, DIFFERENTIAL ORGAN/TISSUE, (EG, SPLENIC AND/OR HEPATIC) Allowed Amount Effective Date End Date $232.47 7/1/2019 12/31/2382 26 $10.71 7/1/2019 12/31/2382 TC $32.24 7/1/2019 12/31/2382 $232.47 7/1/2019 12/31/2382 26 $14.48 7/1/2019 12/31/2382 TC $87.85 7/1/2019 12/31/2382 $232.47 7/1/2019 12/31/2382 26 $17.42 7/1/2019 12/31/2382 TC $59.21 7/1/2019 12/31/2382 $232.47 7/1/2019 12/31/2382 26 $19.53 7/1/2019 12/31/2382 TC $99.13 7/1/2019 12/31/2382 $232.47 7/1/2019 12/31/2382 26 $30.18 7/1/2019 12/31/2382 TC $157.33 $232.47 $33.20 $97.46 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $232.47 7/1/2019 12/31/2382 26 $33.79 7/1/2019 12/31/2382 TC $166.18 7/1/2019 12/31/2382 $232.47 7/1/2019 12/31/2382 Modifier 26 TC Radiology Procedure Codes Procedure Code 78140 78140 78160 78160 78160 78162 78162 78162 78170 78170 78170 78172 78185 78185 78185 78190 78190 78190 78191 78191 78191 78192 78192 78192 78193 78193 78193 78195 78195 78195 78195 78195 78199 78201 78201 Procedure Description LABELED RED CELL SEQUESTRATION, DIFFERENTIAL ORGAN/TISSUE, (EG, SPLENIC AND/OR HEPATIC) LABELED RED CELL SEQUESTRATION, DIFFERENTIAL ORGAN/TISSUE, (EG, SPLENIC AND/OR HEPATIC) PLASMA RADIOIRON DISAPPEARANCE (TURNOVER) RATE PLASMA RADIOIRON DISAPPEARANCE (TURNOVER) RATE PLASMA RADIOIRON DISAPPEARANCE (TURNOVER) RATE RADIOIRON ORAL ABSORPTION RADIOIRON ORAL ABSORPTION RADIOIRON ORAL ABSORPTION RADIOIRON RED CELL UTILIZATION RADIOIRON RED CELL UTILIZATION RADIOIRON RED CELL UTILIZATION CHELATABLE IRON FOR ESTIMATION OF TOTAL BODY IRON SPLEEN IMAGING ONLY, WITH OR WITHOUT VASCULAR FLOW SPLEEN IMAGING ONLY, WITH OR WITHOUT VASCULAR FLOW SPLEEN IMAGING ONLY, WITH OR WITHOUT VASCULAR FLOW KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT DIFFERENTIAL ORGAN/TISSUE LOCALIZATION KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT DIFFERENTIAL ORGAN/TISSUE LOCALIZATION KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT DIFFERENTIAL ORGAN/TISSUE LOCALIZATION PLATELET SURVIVAL STUDY PLATELET SURVIVAL STUDY PLATELET SURVIVAL STUDY WHITE BLOOD CELL LOCALIZATION; LIMITED AREA SCANNING WHITE BLOOD CELL LOCALIZATION; LIMITED AREA SCANNING WHITE BLOOD CELL LOCALIZATION; LIMITED AREA SCANNING WHITE BLOOD CELL LOCALIZATION; WHOLE BODY WHITE BLOOD CELL LOCALIZATION; WHOLE BODY WHITE BLOOD CELL LOCALIZATION; WHOLE BODY LYMPHATICS AND LYMPH GLANDS IMAGING LYMPHATICS AND LYMPH GLANDS IMAGING LYMPHATICS AND LYMPH GLANDS IMAGING LYMPHATICS AND LYMPH GLANDS IMAGING LYMPHATICS AND LYMPH GLANDS IMAGING UNLISTED HEMATOPOIETIC, RETICULOENDOTHELIAL AND LYMPHATIC PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE LIVER IMAGING; STATIC ONLY LIVER IMAGING; STATIC ONLY Modifier Allowed Amount Effective Date End Date 26 $33.20 7/1/2019 12/31/2382 TC $134.28 $154.90 $21.84 $125.09 $146.18 $30.18 $108.98 $154.60 $23.58 $181.38 $36.81 $264.12 $27.88 $80.58 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $237.62 7/1/2019 12/31/2382 26 $55.96 7/1/2019 12/31/2382 TC 26 LT RT TC $195.16 $237.62 $41.88 $250.44 $177.50 $53.93 $115.92 $413.40 $59.60 $332.78 $264.12 $63.16 $264.12 $264.12 $138.87 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 26 $264.12 $290.75 $28.78 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 26 TC 26 TC 26 TC 26 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 78201 78202 78202 78202 78205 78205 78205 78206 78215 78215 78215 78216 78216 78216 Procedure Description LIVER IMAGING; STATIC ONLY LIVER IMAGING; WITH VASCULAR FLOW LIVER IMAGING; WITH VASCULAR FLOW LIVER IMAGING; WITH VASCULAR FLOW LIVER IMAGING (SPECT) LIVER IMAGING (SPECT) LIVER IMAGING (SPECT) LIVER IMAGING (SPECT); WITH VASCULAR FLOW LIVER AND SPLEEN IMAGING; STATIC ONLY LIVER AND SPLEEN IMAGING; STATIC ONLY LIVER AND SPLEEN IMAGING; STATIC ONLY LIVER AND SPLEEN IMAGING; WITH VASCULAR FLOW LIVER AND SPLEEN IMAGING; WITH VASCULAR FLOW LIVER AND SPLEEN IMAGING; WITH VASCULAR FLOW Allowed Amount $80.58 $290.75 $53.30 $98.46 $290.75 $48.59 $201.42 $295.24 $290.75 $32.21 $100.12 $290.75 $33.80 $118.83 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 78220 LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, WITH SERIAL IMAGES $290.75 7/1/2019 12/31/2382 78220 LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, WITH SERIAL IMAGES 26 $36.56 7/1/2019 12/31/2382 78220 LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, WITH SERIAL IMAGES HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING GALLBLADDER, WITH OR WITHOUT PHARMACOLOGIC INTERVENTION, WITH O HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING GALLBLADDER, WITH OR WITHOUT PHARMACOLOGIC INTERVENTION, WITH O HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING GALLBLADDER, WITH OR WITHOUT PHARMACOLOGIC INTERVENTION, WITH O HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN PRESENT HEPATOBILIARY SYSTEM IMAGING, INCLUDING GALLBLADDER WHEN PRESENT; WITH PHARMACOLOGIC INTERVENTION, INCLUDING SALIVARY GLAND IMAGING; SALIVARY GLAND IMAGING; SALIVARY GLAND IMAGING; SALIVARY GLAND IMAGING; WITH SERIAL IMAGES SALIVARY GLAND IMAGING; WITH SERIAL IMAGES SALIVARY GLAND IMAGING; WITH SERIAL IMAGES SALIVARY GLAND FUNCTION STUDY SALIVARY GLAND FUNCTION STUDY SALIVARY GLAND FUNCTION STUDY ESOPHAGEAL MOTILITY ESOPHAGEAL MOTILITY $127.10 7/1/2019 12/31/2382 $290.75 7/1/2019 12/31/2382 26 $39.33 7/1/2019 12/31/2382 TC $125.09 7/1/2019 12/31/2382 $339.22 7/1/2019 12/31/2382 $297.35 $254.25 $46.40 $74.32 $254.25 $59.10 $107.97 $254.25 $32.88 $120.50 $254.25 $50.30 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 78223 78223 78223 78226 78227 78230 78230 78230 78231 78231 78231 78232 78232 78232 78258 78258 Modifier TC 26 TC 26 TC 26 TC 26 TC TC 26 TC 26 TC 26 TC 26 Radiology Procedure Codes Procedure Code 78258 78261 78261 78261 78262 78262 78262 78264 78264 78264 78265 78266 78267 78268 78270 78270 78270 78271 78271 78271 78272 78272 78272 78276 78276 78276 78278 78278 78278 78280 78280 78280 Procedure Description ESOPHAGEAL MOTILITY GASTRIC MUCOSA IMAGING GASTRIC MUCOSA IMAGING GASTRIC MUCOSA IMAGING GASTROESOPHAGEAL REFLUX STUDY GASTROESOPHAGEAL REFLUX STUDY GASTROESOPHAGEAL REFLUX STUDY GASTRIC EMPTYING STUDY GASTRIC EMPTYING STUDY GASTRIC EMPTYING STUDY STOMACH EMPTYING AND SMALL BOWEL TRANSIT STUDY STOMACH EMPTYING AND SMALL BOWEL WITH COLON TRANSIT STUDY UREA BREATH TEST, C-14; ACQUISITION FOR ANALYSIS UREA BREATH TEST, C-14; ANALYSIS VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITHOUT INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITHOUT INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITHOUT INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITH INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITH INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITH INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH AND WITHOUT INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH AND WITHOUT INTRINSIC FACTOR VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH AND WITHOUT INTRINSIC FACTOR GASTROINTESTINAL ASPIRATE BLOOD LOSS LOCALIZATION GASTROINTESTINAL ASPIRATE BLOOD LOSS LOCALIZATION GASTROINTESTINAL ASPIRATE BLOOD LOSS LOCALIZATION ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING GASTROINTESTINAL BLOOD LOSS STUDY (EG, STOOL COUNTING) GASTROINTESTINAL BLOOD LOSS STUDY (EG, STOOL COUNTING) GASTROINTESTINAL BLOOD LOSS STUDY (EG, STOOL COUNTING) Allowed Amount $98.46 $254.25 $46.94 $139.87 $254.25 $46.30 $144.81 $254.25 $40.65 $140.54 $304.32 $403.78 $11.77 $100.89 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $237.62 7/1/2019 12/31/2382 26 $14.86 7/1/2019 12/31/2382 TC $52.95 7/1/2019 12/31/2382 $237.62 7/1/2019 12/31/2382 26 $14.86 7/1/2019 12/31/2382 TC $56.28 7/1/2019 12/31/2382 $237.62 7/1/2019 12/31/2382 26 $16.49 7/1/2019 12/31/2382 TC $79.24 $111.98 $33.67 $108.98 $254.25 $42.68 $166.18 $101.57 $19.61 $110.65 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 11/30/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 Modifier TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code 78282 78282 78290 78290 78290 78291 78291 78291 78299 78300 78300 78300 78305 78305 78305 78306 78306 78306 78310 78310 78310 78315 78315 78315 78315 78320 78320 78320 78350 78350 78350 Procedure Description GASTROINTESTINAL PROTEIN LOSS GASTROINTESTINAL PROTEIN LOSS BOWEL IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S LOCALIZATION, VOLVULUS) BOWEL IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S LOCALIZATION, VOLVULUS) BOWEL IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S LOCALIZATION, VOLVULUS) PERITONEAL-VENOUS SHUNT PATENCY TEST (EG, FOR LEVEEN, DENVER SHUNT) PERITONEAL-VENOUS SHUNT PATENCY TEST (EG, FOR LEVEEN, DENVER SHUNT) PERITONEAL-VENOUS SHUNT PATENCY TEST (EG, FOR LEVEEN, DENVER SHUNT) UNLISTED GASTROINTESTINAL PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE BONE AND/OR JOINT IMAGING; LIMITED AREA BONE AND/OR JOINT IMAGING; LIMITED AREA BONE AND/OR JOINT IMAGING; LIMITED AREA BONE AND/OR JOINT IMAGING; MULTIPLE AREAS BONE AND/OR JOINT IMAGING; MULTIPLE AREAS BONE AND/OR JOINT IMAGING; MULTIPLE AREAS BONE AND/OR JOINT IMAGING; WHOLE BODY BONE AND/OR JOINT IMAGING; WHOLE BODY BONE AND/OR JOINT IMAGING; WHOLE BODY BONE AND/OR JOINT IMAGING; VASCULAR FLOW ONLY BONE AND/OR JOINT IMAGING; VASCULAR FLOW ONLY BONE AND/OR JOINT IMAGING; VASCULAR FLOW ONLY BONE AND/OR JOINT IMAGING; THREE PHASE STUDY BONE AND/OR JOINT IMAGING; THREE PHASE STUDY BONE AND/OR JOINT IMAGING; THREE PHASE STUDY BONE AND/OR JOINT IMAGING; THREE PHASE STUDY BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT) BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT) BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT) BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; SINGLE PHOTON ABSORPTIOMETRY BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; SINGLE PHOTON ABSORPTIOMETRY BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; SINGLE PHOTON ABSORPTIOMETRY Allowed Amount $254.25 $25.47 Effective Date 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 $254.25 7/1/2019 12/31/2382 26 $52.28 7/1/2019 12/31/2382 TC $103.72 7/1/2019 12/31/2382 $254.25 7/1/2019 12/31/2382 26 $59.60 7/1/2019 12/31/2382 TC $104.39 7/1/2019 12/31/2382 $254.25 $269.25 $36.41 $85.17 $269.25 $55.87 $125.09 $269.25 $56.14 $145.80 $118.50 $48.41 $40.17 $269.25 $61.56 $269.25 $162.92 $269.25 $70.41 $201.42 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $49.20 7/1/2019 12/31/2382 26 $15.00 7/1/2019 12/31/2382 TC $25.96 7/1/2019 12/31/2382 Modifier 26 26 TC 26 TC 26 TC 26 TC 26 59 TC 26 TC Radiology Procedure Codes Procedure Code 78399 78414 78414 78428 78428 78428 78445 78445 78445 78451 78452 78454 78455 78455 78455 78456 78457 78457 78457 78458 78458 78458 78459 78460 78460 78460 78461 78461 Procedure Description UNLISTED MUSCULOSKELETAL PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE DETERMINATION OF CENTRAL C-V HEMODYNAMICS (NON-IMAGING) (EG, EJECTION FRACTION WITH PROBE TECHNIQUE) WITH OR W DETERMINATION OF CENTRAL C-V HEMODYNAMICS (NON-IMAGING) (EG, EJECTION FRACTION WITH PROBE TECHNIQUE) WITH OR W CARDIAC SHUNT DETECTION CARDIAC SHUNT DETECTION CARDIAC SHUNT DETECTION NON-CARDIAC VASCULAR FLOW IMAGING (IE, ANGIOGRAPHY, VENOGRAPHY) NON-CARDIAC VASCULAR FLOW IMAGING (IE, ANGIOGRAPHY, VENOGRAPHY) NON-CARDIAC VASCULAR FLOW IMAGING (IE, ANGIOGRAPHY, VENOGRAPHY) MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT); SINGLE STUDY, AT REST OR STRESS MYOCARDIAL PERFUSION IMAGING, TOMOGRAPHIC (SPECT); MULTIPLE STUDIES, AT REST OR STRESS AND/OR REDISTRUBUTION MYOCARDIAL PERFUSION IMAGING, PLANAR; MULITPLE STUDIES, AT REST AND/OR STRESS AND/OR REDISTRIBUTION AND/OR VENOUS THROMBOSIS STUDY (EG, RADIOACTIVE FIBRINOGEN) VENOUS THROMBOSIS STUDY (EG, RADIOACTIVE FIBRINOGEN) VENOUS THROMBOSIS STUDY (EG, RADIOACTIVE FIBRINOGEN) ACUTE VENOUS THROMBOSIS IMAGING, PEPTIDE VENOUS THROMBOSIS IMAGING, VENOGRAM; UNILATERAL VENOUS THROMBOSIS IMAGING, VENOGRAM; UNILATERAL VENOUS THROMBOSIS IMAGING, VENOGRAM; UNILATERAL VENOUS THROMBOSIS IMAGING (EG, VENOGRAM); BILATERAL VENOUS THROMBOSIS IMAGING (EG, VENOGRAM); BILATERAL VENOUS THROMBOSIS IMAGING (EG, VENOGRAM); BILATERAL MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION MYOCARDIAL PERFUSION IMAGING; (PLANAR) SINGLE STUDY, AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH MYOCARDIAL PERFUSION IMAGING; (PLANAR) SINGLE STUDY, AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH MYOCARDIAL PERFUSION IMAGING; (PLANAR) SINGLE STUDY, AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH MYOCARDIAL PERFUSION IMAGING; MULTIPLE STUDIES,(PLANAR)AT REST AND/OR STRESS (EXERCISE AND/OR PHARMACOLOGIC) MYOCARDIAL PERFUSION IMAGING; MULTIPLE STUDIES,(PLANAR)AT REST AND/OR STRESS (EXERCISE AND/OR PHARMACOLOGIC) Allowed Amount Effective Date End Date $269.25 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 $42.64 $283.53 $30.71 $76.99 $140.49 $41.75 $64.47 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $744.13 7/1/2019 12/31/2382 $744.13 7/1/2019 12/31/2382 $775.57 $194.13 $43.69 $135.95 $140.49 $140.49 $44.60 $90.77 $140.49 $47.76 $136.96 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $907.31 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 26 $58.64 7/1/2019 12/31/2382 TC $80.58 7/1/2019 12/31/2382 $450.07 7/1/2019 12/31/2382 $69.45 7/1/2019 12/31/2382 Modifier 26 26 TC 26 TC 26 TC 26 TC 26 TC 26 Radiology Procedure Codes Procedure Code 78461 78464 78464 78464 78465 78465 78465 78466 78466 78466 78468 78468 78468 78469 78469 78469 78472 78472 78472 78473 Procedure Description MYOCARDIAL PERFUSION IMAGING; MULTIPLE STUDIES,(PLANAR)AT REST AND/OR STRESS (EXERCISE AND/OR PHARMACOLOGIC) MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), SINGLE STUDY AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOG MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), SINGLE STUDY AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOG MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), SINGLE STUDY AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOG MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE AND MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE AND MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), MULTIPLE STUDIES, AT REST AND/OR STRESS (EXERCISE AND MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR QUANTITATIVE MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR QUANTITATIVE MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR QUANTITATIVE MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION FRACTION BY FIRST PASS TECHNIQUE MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION FRACTION BY FIRST PASS TECHNIQUE MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION FRACTION BY FIRST PASS TECHNIQUE MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTIFICATION MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTIFICATION MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTIFICATION CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; SINGLE STUDY AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; SINGLE STUDY AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; SINGLE STUDY AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE STUDIES, WALL MOTION STUDY PLUS EJECTION FRACTION, RES Modifier Allowed Amount Effective Date End Date TC $161.25 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 26 $73.69 7/1/2019 12/31/2382 TC $241.83 7/1/2019 12/31/2382 $450.07 7/1/2019 12/31/2382 26 $98.96 7/1/2019 12/31/2382 TC $402.50 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 26 $47.26 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 26 $53.93 7/1/2019 12/31/2382 TC $125.09 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 26 $79.38 7/1/2019 12/31/2382 TC $178.70 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 26 $74.49 7/1/2019 12/31/2382 TC $188.22 7/1/2019 12/31/2382 $339.36 7/1/2019 12/31/2382 Radiology Procedure Codes Procedure Code 78496 Procedure Description CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE STUDIES, WALL MOTION STUDY PLUS EJECTION FRACTION, RES CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE STUDIES, WALL MOTION STUDY PLUS EJECTION FRACTION, RES MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE OR QUANTITATIVE STUDY (LIST SEPARATELY IN ADDITION TO MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE OR QUANTITATIVE STUDY (LIST SEPARATELY IN ADDITION TO MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE OR QUANTITATIVE STUDY (LIST SEPARATELY IN ADDITION TO MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CARDIAC BLOOD POOL IMAGING,(PLANAR), FIRST PASS TECHNIQUE; SINGLE STUDY, AT REST OR WITH STRESS CARDIAC BLOOD POOL IMAGING,(PLANAR), FIRST PASS TECHNIQUE; SINGLE STUDY, AT REST OR WITH STRESS CARDIAC BLOOD POOL IMAGING,(PLANAR), FIRST PASS TECHNIQUE; SINGLE STUDY, AT REST OR WITH STRESS CARDIAC BLOOD POOL IMAGING, (PLANAR) FIRST PASS TECHNIQUE; MULTIPLE STUDIES, AT REST AND WITH STRESS (EXERCISE CARDIAC BLOOD POOL IMAGING, (PLANAR) FIRST PASS TECHNIQUE; MULTIPLE STUDIES, AT REST AND WITH STRESS (EXERCISE CARDIAC BLOOD POOL IMAGING, (PLANAR) FIRST PASS TECHNIQUE; MULTIPLE STUDIES, AT REST AND WITH STRESS (EXERCISE MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; SINGLE STUDY AT REST OR STRESS MYCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), PERFUSION; MULTIPLE STUDIES AT REST AND/OR STRESS CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, WALL MOTION STUDY PLUS EJECTION FRACTION, WITH CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SINGLE STUDY, AT REST, WITH RIGHT VENTRICULAR EJECTION FRACTION 78499 78580 78580 78580 UNLISTED CARDIOVASCULAR PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE PULMONARY PERFUSION IMAGING; PARTICULATE PULMONARY PERFUSION IMAGING; PARTICULATE PULMONARY PERFUSION IMAGING; PARTICULATE 78473 78473 78478 78478 78478 78480 78480 78480 78481 78481 78481 78483 78483 78483 78491 78492 78494 Modifier Allowed Amount Effective Date End Date 26 $75.90 7/1/2019 12/31/2382 TC $282.00 7/1/2019 12/31/2382 $101.43 7/1/2019 12/31/2382 26 $31.98 7/1/2019 12/31/2382 TC $53.28 7/1/2019 12/31/2382 $101.43 7/1/2019 12/31/2382 26 $31.98 7/1/2019 12/31/2382 TC $53.28 7/1/2019 12/31/2382 $283.53 7/1/2019 12/31/2382 26 $66.62 7/1/2019 12/31/2382 TC $178.70 7/1/2019 12/31/2382 $339.36 7/1/2019 12/31/2382 26 $75.90 7/1/2019 12/31/2382 TC $268.80 7/1/2019 12/31/2382 $907.31 7/1/2019 12/31/2382 $2,816.24 7/1/2019 12/31/2382 $278.32 7/1/2019 12/31/2382 $101.43 7/1/2019 12/31/2382 $283.53 $223.69 $48.34 $117.16 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 26 TC Radiology Procedure Codes Procedure Code 78581 78581 78581 Procedure Description PULMONARY PERFUSION IMAGING; GASEOUS PULMONARY PERFUSION IMAGING; GASEOUS PULMONARY PERFUSION IMAGING; GASEOUS Allowed Amount $95.78 $33.22 $81.59 Effective Date 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 78582 PULMONARY VENTILATION ( EG, AEROSOL OR GAS) AND PERFUSION IMAGING $175.64 7/1/2019 12/31/2382 78582 PULMONARY VENTILATION ( EG, AEROSOL OR GAS) AND PERFUSION IMAGING 26 $49.76 7/1/2019 12/31/2382 78582 PULMONARY VENTILATION ( EG, AEROSOL OR GAS) AND PERFUSION IMAGING PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; SINGLE BREATH PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; SINGLE BREATH PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; SINGLE BREATH PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; REBREATHING AND WASHOUT, WITH OR WITHOUT SINGLE BR PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; REBREATHING AND WASHOUT, WITH OR WITHOUT SINGLE BR PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; REBREATHING AND WASHOUT, WITH OR WITHOUT SINGLE BR PULMONARY VENTILATION IMAGING, AEROSOL; SINGLE PROJECTION PULMONARY VENTILATION IMAGING, AEROSOL; SINGLE PROJECTION PULMONARY VENTILATION IMAGING, AEROSOL; SINGLE PROJECTION PULMONARY VENTILATION IMAGING, AEROSOL; MULTIPLE PROJECTIONS (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) PULMONARY VENTILATION IMAGING, AEROSOL; MULTIPLE PROJECTIONS (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) PULMONARY VENTILATION IMAGING, AEROSOL; MULTIPLE PROJECTIONS (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) PULMONY PERFUSION IMAGING PARTICULATE WITH VENTILATION IMAGING PULMONARY VENTILATION IMAGING, GASEOUS, SINGLE BREATH, SINGLE PROJECTION PULMONARY VENTILATION IMAGING, GASEOUS, SINGLE BREATH, SINGLE PROJECTION PULMONARY VENTILATION IMAGING, GASEOUS, SINGLE BREATH, SINGLE PROJECTION PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; SINGLE PRO PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; SINGLE PRO $128.68 7/1/2019 12/31/2382 $364.64 7/1/2019 12/31/2382 26 $51.24 7/1/2019 12/31/2382 TC $108.98 7/1/2019 12/31/2382 $364.64 7/1/2019 12/31/2382 26 $55.96 7/1/2019 12/31/2382 TC $192.23 $223.69 $31.00 $88.52 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $223.69 7/1/2019 12/31/2382 26 $33.44 7/1/2019 12/31/2382 TC $95.78 $364.64 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $223.69 7/1/2019 12/31/2382 26 $31.00 7/1/2019 12/31/2382 TC $97.46 7/1/2019 12/31/2382 $223.69 7/1/2019 12/31/2382 $33.34 7/1/2019 12/31/2382 78584 78584 78584 78585 78585 78585 78586 78586 78586 78587 78587 78587 78588 78591 78591 78591 78593 78593 Modifier 26 TC TC 26 TC 26 Radiology Procedure Codes Procedure Code 78593 78594 78594 78594 78596 78596 78596 78597 78599 78600 78600 78600 78601 78601 78601 78605 78605 78605 78606 78606 78606 78607 78607 78607 78608 78610 78610 78610 78615 78615 78615 78615 Procedure Description PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; SINGLE PRO PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; MULTIPLE P PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; MULTIPLE P PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND WASHOUT WITH OR WITHOUT SINGLE BREATH; MULTIPLE P PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION (VENTILATION/PERFUSION) STUDY PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION (VENTILATION/PERFUSION) STUDY PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION (VENTILATION/PERFUSION) STUDY QUANTITATIVE DIFFERENTIAL PULMONARY PERFUSION, INCLUDING IMAGING WHEN PERFORMED UNLISTED RESPIRATORY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE BRAIN IMAGING, LIMITED PROCEDURE; STATIC BRAIN IMAGING, LIMITED PROCEDURE; STATIC BRAIN IMAGING, LIMITED PROCEDURE; STATIC BRAIN IMAGING, LIMITED PROCEDURE; WITH VASCULAR FLOW BRAIN IMAGING, LIMITED PROCEDURE; WITH VASCULAR FLOW BRAIN IMAGING, LIMITED PROCEDURE; WITH VASCULAR FLOW BRAIN IMAGING, COMPLETE STUDY; STATIC BRAIN IMAGING, COMPLETE STUDY; STATIC BRAIN IMAGING, COMPLETE STUDY; STATIC BRAIN IMAGING, COMPLETE STUDY; WITH VASCULAR FLOW BRAIN IMAGING, COMPLETE STUDY; WITH VASCULAR FLOW BRAIN IMAGING, COMPLETE STUDY; WITH VASCULAR FLOW BRAIN IMAGING, COMPLETE STUDY; TOMOGRAPHIC (SPECT) BRAIN IMAGING, COMPLETE STUDY; TOMOGRAPHIC (SPECT) BRAIN IMAGING, COMPLETE STUDY; TOMOGRAPHIC (SPECT) BRAIN IMAGING POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC EVALUATION BRAIN IMAGING, VASCULAR FLOW ONLY BRAIN IMAGING, VASCULAR FLOW ONLY BRAIN IMAGING, VASCULAR FLOW ONLY CEREBRAL BLOOD FLOW CEREBRAL BLOOD FLOW CEREBRAL BLOOD FLOW CEREBRAL BLOOD FLOW Modifier Allowed Amount Effective Date End Date TC $117.83 7/1/2019 12/31/2382 $223.69 7/1/2019 12/31/2382 26 $57.21 7/1/2019 12/31/2382 TC $169.86 7/1/2019 12/31/2382 $364.64 7/1/2019 12/31/2382 26 $65.54 7/1/2019 12/31/2382 TC $241.83 7/1/2019 12/31/2382 $287.24 $223.69 $348.76 $41.08 $98.46 $348.76 $43.09 $115.92 $348.76 $43.57 $115.92 $348.76 $45.95 $132.03 $348.76 $83.65 $223.80 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $1,303.36 $348.76 $45.47 $53.94 $348.76 $37.41 $66.98 $131.36 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 52 TC Radiology Procedure Codes Procedure Code 78645 78647 78650 78650 78650 78652 78652 78652 78655 78655 78655 78660 78660 78660 Procedure Description CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); CISTERNOGRAPHY CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); CISTERNOGRAPHY CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); CISTERNOGRAPHY CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); VENTRICULOGRAPHY CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); VENTRICULOGRAPHY CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); VENTRICULOGRAPHY CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); SHUNT EVALUATION CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); SHUNT EVALUATION CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION OF MATERIAL); SHUNT EVALUATION CEREBROSPINAL FLUID FLOW, IMAGING; TOMOGRAPHIC (SPECT) CSF LEAKAGE DETECTION AND LOCALIZATION CSF LEAKAGE DETECTION AND LOCALIZATION CSF LEAKAGE DETECTION AND LOCALIZATION CSF LEAKAGE DETECTION AND LOCALIZATION TOMOGRAPHIC (ECT) CSF LEAKAGE DETECTION AND LOCALIZATION TOMOGRAPHIC (ECT) CSF LEAKAGE DETECTION AND LOCALIZATION TOMOGRAPHIC (ECT) RADIONUCLIDE IDENTIFICATION OF EYE TUMOR RADIONUCLIDE IDENTIFICATION OF EYE TUMOR RADIONUCLIDE IDENTIFICATION OF EYE TUMOR RADIONUCLIDE DACRYOCYSTOGRAPHY RADIONUCLIDE DACRYOCYSTOGRAPHY RADIONUCLIDE DACRYOCYSTOGRAPHY 78699 78700 78700 78700 78701 78701 78701 78704 78704 UNLISTED NERVOUS SYSTEM PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE KIDNEY IMAGING; STATIC ONLY KIDNEY IMAGING; STATIC ONLY KIDNEY IMAGING; STATIC ONLY KIDNEY IMAGING; WITH VASCULAR FLOW KIDNEY IMAGING; WITH VASCULAR FLOW KIDNEY IMAGING; WITH VASCULAR FLOW KIDNEY IMAGING; WITH FUNCTION STUDY (IE, IMAGING RENOGRAM) KIDNEY IMAGING; WITH FUNCTION STUDY (IE, IMAGING RENOGRAM) 78630 78630 78630 78635 78635 78635 78645 78645 Allowed Amount Effective Date End Date $236.16 7/1/2019 12/31/2382 26 $70.82 7/1/2019 12/31/2382 TC $171.78 7/1/2019 12/31/2382 $236.16 7/1/2019 12/31/2382 26 $41.88 7/1/2019 12/31/2382 TC $86.84 7/1/2019 12/31/2382 $236.16 7/1/2019 12/31/2382 26 $39.43 7/1/2019 12/31/2382 TC $117.16 $236.16 $236.16 $43.15 $158.33 $275.28 $61.31 $201.42 $219.19 $28.43 $169.86 $236.16 $42.77 $72.40 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $348.76 $246.57 $37.92 $103.72 $246.57 $39.61 $121.51 $246.57 $39.15 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 Modifier 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 Radiology Procedure Codes Procedure Code 78704 78707 78707 78707 78708 78709 78710 78710 78710 78715 78715 78715 78725 78725 78725 78726 78726 78726 78727 78727 78727 78730 78730 78730 78740 78740 78740 78760 78760 78760 78761 78761 78761 78799 78800 78800 Procedure Description KIDNEY IMAGING; WITH FUNCTION STUDY (IE, IMAGING RENOGRAM) KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; SINGLE STUDY, WITH PHARMACOLOGICAL INTERVENTION (EG, ANGIOTEN KIDNEY IMAGING WITH VASCULAR FLOW AND FUNCTION; MULTIPLE STUDIES, WITH AND WITHOUT PHARMACOLOGICAL KIDNEY IMAGING, TOMOGRAPHIC (SPECT) KIDNEY IMAGING, TOMOGRAPHIC (SPECT) KIDNEY IMAGING, TOMOGRAPHIC (SPECT) KIDNEY VASCULAR FLOW ONLY KIDNEY VASCULAR FLOW ONLY KIDNEY VASCULAR FLOW ONLY KIDNEY FUNCTION STUDY WITHOUT PHARMACOLOGIC INTERVENTION KIDNEY FUNCTION STUDY WITHOUT PHARMACOLOGIC INTERVENTION KIDNEY FUNCTION STUDY WITHOUT PHARMACOLOGIC INTERVENTION KIDNEY FUNCTION STUDY INCLUDING PHARMACOLOGIC INTERVENTION KIDNEY FUNCTION STUDY INCLUDING PHARMACOLOGIC INTERVENTION KIDNEY FUNCTION STUDY INCLUDING PHARMACOLOGIC INTERVENTION KIDNEY TRANSPLANT EVALUATION KIDNEY TRANSPLANT EVALUATION KIDNEY TRANSPLANT EVALUATION URINARY BLADDER RESIDUAL STUDY URINARY BLADDER RESIDUAL STUDY URINARY BLADDER RESIDUAL STUDY URETERAL REFLUX STUDY (RADIONUCLIDE VOIDING CYSTOGRAM) URETERAL REFLUX STUDY (RADIONUCLIDE VOIDING CYSTOGRAM) URETERAL REFLUX STUDY (RADIONUCLIDE VOIDING CYSTOGRAM) TESTICULAR IMAGING; TESTICULAR IMAGING; TESTICULAR IMAGING; TESTICULAR IMAGING; WITH VASCULAR FLOW TESTICULAR IMAGING; WITH VASCULAR FLOW TESTICULAR IMAGING; WITH VASCULAR FLOW UNLISTED GENITOURINARY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE RADIONUCLIDE LOCALIZATION OF TUMOR; LIMITED AREA RADIONUCLIDE LOCALIZATION OF TUMOR; LIMITED AREA Allowed Amount $134.94 Effective Date 7/1/2019 End Date 12/31/2382 $246.57 7/1/2019 12/31/2382 26 $48.30 7/1/2019 12/31/2382 TC $152.74 7/1/2019 12/31/2382 $279.86 7/1/2019 12/31/2382 $279.86 $246.57 $45.17 $201.42 $246.57 $17.11 $53.94 $96.29 $26.81 $60.88 $166.72 $59.23 $101.05 $211.58 $67.08 $135.95 $41.39 $23.55 $50.02 $246.57 $39.37 $72.40 $246.57 $33.99 $91.44 $246.57 $36.27 $108.98 $246.57 $279.21 $35.30 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 Modifier TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 TC 26 Radiology Procedure Codes Procedure Code 78800 78801 78801 78801 78802 78802 78802 78803 78803 78803 78804 78805 78805 78805 78806 78806 78806 78807 78811 78812 78813 78814 78814 78814 78815 78815 78815 78815 78815 Procedure Description RADIONUCLIDE LOCALIZATION OF TUMOR; LIMITED AREA RADIONUCLIDE LOCALIZATION OF TUMOR; MULTIPLE AREAS RADIONUCLIDE LOCALIZATION OF TUMOR; MULTIPLE AREAS RADIONUCLIDE LOCALIZATION OF TUMOR; MULTIPLE AREAS RADIONUCLIDE LOCALIZATION OF TUMOR; WHOLE BODY RADIONUCLIDE LOCALIZATION OF TUMOR; WHOLE BODY RADIONUCLIDE LOCALIZATION OF TUMOR; WHOLE BODY TUMOR LOCALIZATION (SPECT) TUMOR LOCALIZATION (SPECT) TUMOR LOCALIZATION (SPECT) RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRUBUTION OF RADIOPHARMACEUTICAL AGENT, WHOLE BODY RADIONUCLIDE LOCALIZATION OF ABSCESS; LIMITED AREA RADIONUCLIDE LOCALIZATION OF ABSCESS; LIMITED AREA RADIONUCLIDE LOCALIZATION OF ABSCESS; LIMITED AREA RADIONUCLIDE LOCALIZATION OF ABSCESS; WHOLE BODY RADIONUCLIDE LOCALIZATION OF ABSCESS; WHOLE BODY RADIONUCLIDE LOCALIZATION OF ABSCESS; WHOLE BODY RADIONUCLIDE LOCALIZATION OF ABSCESS, SPECT TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); LIMITED AREA, ( EG, CHEST, HEAD/NECK ) TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); SKULL BASE TO MID THIGH TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET) ; WHOLE BODY TUMOR IMAGING, (PET); WITH CONCURRENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; LI TUMOR IMAGING, (PET); WITH CONCURRENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; LI TUMOR IMAGING, (PET); WITH CONCURRENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; LI TUMOR IMAGING, (PET) WITHCONCURENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL TUMOR IMAGING, (PET) WITHCONCURENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL TUMOR IMAGING, (PET) WITHCONCURENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL TUMOR IMAGING, (PET) WITHCONCURENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL TUMOR IMAGING, (PET) WITHCONCURENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; SKULL Allowed Amount $115.92 $279.21 $58.88 $144.13 $279.21 $60.75 $188.90 $279.21 $73.69 $223.80 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $736.68 $279.21 $38.23 $115.92 $279.21 $43.92 $188.90 $279.21 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $1,303.36 7/1/2019 12/31/2382 $1,303.36 $1,303.36 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $1,416.69 7/1/2019 12/31/2382 PI $1,416.69 7/1/2019 12/31/2382 PS $1,416.69 7/1/2019 12/31/2382 $1,416.69 7/1/2019 12/31/2382 PI $1,416.69 7/1/2019 12/31/2382 PS $1,416.69 7/1/2019 12/31/2382 QR $1,416.69 7/1/2019 12/31/2382 TC $1,416.69 7/1/2019 12/31/2382 Modifier TC 26 TC 26 TC 26 TC 26 TC 26 TC Radiology Procedure Codes Procedure Code Allowed Amount Effective Date End Date $1,416.69 7/1/2019 12/31/2382 PI $1,416.69 7/1/2019 12/31/2382 PS $1,416.69 7/1/2019 12/31/2382 QR $1,416.69 7/1/2019 12/31/2382 $50.81 7/1/2019 12/31/2382 26 $3.36 7/1/2019 12/31/2382 TC $44.42 7/1/2019 12/31/2382 $101.90 7/1/2019 12/31/2382 26 $6.72 7/1/2019 12/31/2382 TC $89.77 $96.29 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $210.04 7/1/2019 12/31/2382 26 $95.70 7/1/2019 12/31/2382 TC $89.77 7/1/2019 12/31/2382 79000 Procedure Description TUMOR IMAGING, (PET) WITH CONCURRENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; WHO TUMOR IMAGING, (PET) WITH CONCURRENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; WHO TUMOR IMAGING, (PET) WITH CONCURRENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; WHO TUMOR IMAGING, (PET) WITH CONCURRENTLY ACQUIRED CT FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION; WHO GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONA GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONA GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONA GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONA GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONA GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONA UNLISTED MISCELLANEOUS PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE RADIONUCLIDE THERAPY, HYPERTHYROIDISM; INITIAL, INCLUDING EVALUATION OF PATIENT RADIONUCLIDE THERAPY, HYPERTHYROIDISM; INITIAL, INCLUDING EVALUATION OF PATIENT RADIONUCLIDE THERAPY, HYPERTHYROIDISM; INITIAL, INCLUDING EVALUATION OF PATIENT 79001 RADIONUCLIDE THERAPY, HYPERTHYROIDISM; SUBSEQUENT, EACH THERAPY $173.65 7/1/2019 12/31/2382 79001 RADIONUCLIDE THERAPY, HYPERTHYROIDISM; SUBSEQUENT, EACH THERAPY 26 $76.64 7/1/2019 12/31/2382 79001 79005 RADIONUCLIDE THERAPY, HYPERTHYROIDISM; SUBSEQUENT, EACH THERAPY TC RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION RADIONUCLIDE THERAPY, THYROID SUPPRESSION (EUTHYROID CARDIAC DISEASE), INCLUDING EVALUATION OF PATIENT RADIONUCLIDE THERAPY, THYROID SUPPRESSION (EUTHYROID CARDIAC DISEASE), INCLUDING EVALUATION OF PATIENT 26 RADIONUCLIDE THERAPY, THYROID SUPPRESSION (EUTHYROID CARDIAC DISEASE), INCLUDING EVALUATION OF PATIENT TC RADIONUCLIDE ABLATION OF GLAND FOR THYROID CARCINOMA $44.42 $261.41 7/1/2019 7/1/2019 12/31/2382 12/31/2382 $217.53 7/1/2019 12/31/2382 $93.23 7/1/2019 12/31/2382 $89.77 $292.87 7/1/2019 7/1/2019 12/31/2382 12/31/2382 78816 78816 78816 78816 78890 78890 78890 78891 78891 78891 78999 79000 79000 79020 79020 79020 79030 Modifier Radiology Procedure Codes Procedure Code 79030 79030 79035 79035 79035 79100 79100 79100 79101 79200 79200 79200 79300 79300 79400 79400 79400 79403 79420 79440 79440 79440 79445 79999 Procedure Description RADIONUCLIDE ABLATION OF GLAND FOR THYROID CARCINOMA RADIONUCLIDE ABLATION OF GLAND FOR THYROID CARCINOMA RADIONUCLIDE THERAPY FOR METASTASES OF THYROID CARCINOMA RADIONUCLIDE THERAPY FOR METASTASES OF THYROID CARCINOMA RADIONUCLIDE THERAPY FOR METASTASES OF THYROID CARCINOMA RADIONUCLIDE THERAPY, POLYCYTHEMIA VERA, CHRONIC LEUKEMIA, EACH TREATMENT RADIONUCLIDE THERAPY, POLYCYTHEMIA VERA, CHRONIC LEUKEMIA, EACH TREATMENT RADIONUCLIDE THERAPY, POLYCYTHEMIA VERA, CHRONIC LEUKEMIA, EACH TREATMENT RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS ADMINISTRATION INTRACAVITARY RADIOACTIVE COLLOID THERAPY INTRACAVITARY RADIOACTIVE COLLOID THERAPY INTRACAVITARY RADIOACTIVE COLLOID THERAPY INTERSTITIAL RADIOACTIVE COLLOID THERAPY INTERSTITIAL RADIOACTIVE COLLOID THERAPY RADIONUCLIDE THERAPY, NONTHYROID, NONHEMATOLOGIC RADIONUCLIDE THERAPY, NONTHYROID, NONHEMATOLOGIC RADIONUCLIDE THERAPY, NONTHYROID, NONHEMATOLOGIC RADIOPHARMACEUTICAL THERAPY, RADIOLABELED MONOCLONAL ANTIBODY BY INTRAVENOUS INFUSION INTRAVASCULAR RADIONUCLIDE THERAPY, PARTICULATE INTRA-ARTICULAR RADIONUCLIDE THERAPY INTRA-ARTICULAR RADIONUCLIDE THERAPY INTRA-ARTICULAR RADIONUCLIDE THERAPY RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICULATE ADMINISTRATION UNLISTED RADIONUCLIDE THERAPEUTIC PROCEDURE Allowed Amount $133.23 $89.77 $323.10 $106.45 $89.77 Effective Date 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 End Date 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $184.60 7/1/2019 12/31/2382 26 $78.03 7/1/2019 12/31/2382 TC $89.77 $261.41 $261.41 $135.01 $89.77 $261.41 $108.57 $193.13 $96.35 $89.77 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $623.35 $102.20 $261.41 $130.76 $89.77 7/1/2019 7/1/2019 7/1/2019 7/1/2019 7/1/2019 12/31/2382 12/31/2382 12/31/2382 12/31/2382 12/31/2382 $261.41 $261.41 7/1/2019 7/1/2019 12/31/2382 12/31/2382 Modifier 26 TC 26 TC 26 TC 26 26 TC 26 26 TC

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