RADIOLOGY GROUND RULES

(Including Nuclear Medicine and Diagnostic Ultrasound)

1.

DUPLICATION OF X-RAYS: Every attempt should be made to minimize the number of x-rays taken. The
attending health care provider or any other person or institution having possession of x-rays, which pertain to
the patient and are deemed to be needed for diagnostic or treatment purposes, should make those x-rays
available upon request. No payments shall be made for additional x-rays when recent x-rays are available,
except when the charge is supported by adequate information regarding the need to perform another x-ray.

2.

PHOTOGRAPHIC MEDIA: The use of photographic media or imaging is not reported separately but is
considered to be a component of the basic procedure and shall not merit any additional payment.

3.

XERORADIOGRAPHY: Imaging performed by this process shall have the same Maximum Allowable Fees
as those listed for conventional x-ray procedures of the same anatomical area and views.

4.

UNIT VALUES: The Unit Values contained within this fee schedule include both the "professional
component” and the "technical component”. Identification of a service or procedure by its five digit code,
without pertinent modifiers, indicates that the services provided includes both the professional and technical
components.
The professional component includes the examination of the patient when indicated, performance or
supervision of the procedure, interpretation and written report of the examination including procedure results
(e.g., x-ray images), and consultation with the referring health care provider. To identify a charge for the
professional component only, see Appendix A - Modifiers for modifier -26. The percentage is shown in the
“PC/TC” column of this fee schedule.
The technical component includes the charges for personnel, materials and other supplies, and space,
equipment, and other facilities, but excludes the cost of radioisotopes. To identify a charge for the technical
component only, see Appendix A - Modifiers for modifier -TC. The percentage is shown in the “PC/TC”
column of this fee schedule.
Hospital outpatient facilities and ambulatory surgical centers must specify, by use of modifiers, when only the
technical component or the professional component is provided.

5.

SERVICES PROVIDED BY A HOSPITAL OUTPATIENT FACILITY AND/OR AMBULATORY SURGICAL
CENTER: For any radiology service(s) provided by a hospital outpatient facility and/or ambulatory surgical
center, reimbursement for said service is to be limited to the maximum allowable payment contained within
this section of the Fee Schedule.

6.

NECESSITY OF SERVICES OR PROCEDURES: When a patient is referred to radiologists or other health
care providers for services covered in the Radiology Section, the provider(s) shall evaluate the patient's
problem and determine the services or procedures medically necessary. Such evaluations or necessary
consultations with the referring health care providers are an integral part of the professional component and
do not merit any additional charges. No payment shall be made for excessive or inappropriate x-rays
taken on initial or subsequent visits.

7.

MULTIPLE PROCEDURES: It is appropriate to designate multiple procedures that are rendered on the
same day by separate entries. Use modifier -51 to reflect multiple procedures except for the Add-On Codes.

8.

SEPARATE PROCEDURE: Some of the procedures or services listed are commonly carried out as an
integral component of a total service or procedure and are identified by the inclusion of the term “separate
procedure.” The codes designated as “separate procedure” should not be reported in addition to the code
for the total procedure or service of which it is considered an integral component.

CPT only copyright 2004 American Medical Association. All Rights Reserved.

50

RADIOLOGY GROUND RULES
(Including Nuclear Medicine and Diagnostic Ultrasound)
However, when a procedure or service that is designated as a “separate procedure” is carried out
independently or considered to be unrelated or distinct from other procedures/services provided at that time,
it may be reported by itself, or in addition to other procedures/services by appending modifier -59 to the
specific “separate procedure” code to indicate that the procedure is not considered to be a component of
another procedure, but is a distinct, independent procedure. This may represent a different session or
patient encounter, different procedure or surgery, different site or organ system, separate incision/excision,
separate lesion, or separate injury (or area of injury in extensive injuries).
9.

ADD-ON CODES: Certain codes, by the nature of their description and the unit values assigned, have
already been reduced, as they are not to be billed as primary procedures. For a complete list of the codes
which are considered to be add-on codes, refer to the appropriate appendix found within the most recent
publication of the AMA Current Procedural Terminology (CPT).

10. MATERIALS SUPPLIED BY HEALTH CARE PROVIDER: Supplies and materials provided by the health
care provider (e.g., sterile trays, drugs) over and above those usually included with the office visit or other
services rendered may be listed separately. The statement of charges will need to reflect any drugs, trays,
supplies, and materials that were provided. Payment shall not exceed the cost of the item(s) to the health
care provider plus 25% of the cost or the cost of the item(s) plus $15.00 per item, whichever is less. Use
procedure code 99070.
The Unit Values in this section do not include radiopharmaceutical or other radionuclide material costs. List
the name and dosage of radiopharmaceutical material and cost.
11. INJECTION PROCEDURES: Charges for injection procedures are to include all usual pre- and postinjection care specifically related to the injection procedure, necessary local anesthesia, placement of needle
or catheter, and injection of contrast media. Vascular injection procedures are listed under the
Cardiovascular Subsection of the Surgery Section, procedure codes 36000-36299. Other injection
procedures are listed in pertinent sections.
12. PROCEDURES LISTED WITHOUT SPECIFIED MAXIMUM ALLOWANCE: "BR" in the unit value column
indicates that the amount charged for this service is to be determined "by report" because the service is too
unusual, or variable to be assigned a Unit Value. Pertinent information should be furnished concerning the
nature, extent, and need for the procedure or service, the time, skill, and equipment necessary, etc.
Additional items which may be helpful might include: complexity of symptoms, final diagnosis, pertinent
physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.
13. UNLISTED SERVICE OR PROCEDURE: When an unlisted service or procedure is performed, the
procedure should be identified and the amount charged substantiated "by report" (BR). Unlisted service or
procedure codes usually end in "99."
14. MODIFIERS: Procedure codes for radiology services may be modified under certain circumstances. The
circumstances are to be identified by the addition of a hyphen and the appropriate two digit modifier code.
Refer to Appendix A - Modifiers for a list of modifiers that may be used.
15. COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from
entering into payment agreements to promote the continuity of care and the reduction of health care costs.
Such payment agreements, if less, will supersede the limitation amounts specified herein. Please refer to
K.S.A. 44-510i(e) for further clarification, if necessary.

CONVERSION FACTOR = $63.15
CPT only copyright 2004 American Medical Association. All Rights Reserved.

51

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
70010
70015
70030
70100
70110
70120
70130
70134
70140
70150
70160
70170
70190
70200
70210
70220
70240
70250
70260
70300
70310
70320
70328
70330
70332
70336
70350
70355
70360
70370
70371
70373
70380
70390
70450
70460
70470
70480
70481
70482
70486
70487
70488
70490
70491
70492
70496
70498
70540
70542
70543
70544

PC/TC UNIT VALUE
40/60
6.19
40/60
3.09
40/60
0.68
40/60
0.79
40/60
1.00
40/60
0.91
40/60
1.30
40/60
1.25
40/60
0.92
40/60
1.18
40/60
0.78
40/60
1.42
40/60
0.95
40/60
1.21
40/60
0.90
40/60
1.17
40/60
0.70
40/60
0.99
40/60
1.42
40/60
0.44
40/60
0.69
40/60
1.14
40/60
0.76
40/60
1.22
40/60
2.99
20/80
13.83
40/60
0.65
40/60
0.89
40/60
0.68
40/60
1.81
40/60
3.38
40/60
2.49
40/60
0.95
40/60
2.41
20/80
6.14
20/80
7.51
20/80
9.19
20/80
6.73
20/80
7.85
20/80
9.43
20/80
6.53
20/80
7.75
20/80
9.38
20/80
6.73
20/80
7.85
20/80
9.42
20/80
13.58
20/80
13.58
20/80
13.44
20/80
16.13
20/80
28.68
20/80
13.44

CODE
70545
70546
70547
70548
70549
70551
70552
70553
70557
70558
70559
71010
71015
71020
71021
71022
71023
71030
71034
71035
71040
71060
71090
71100
71101
71110
71111
71120
71130
71250
71260
71270
71275
71550
71551
71552
71555
72010
72020
72040
72050
72052
72069
72070
72072
72074
72080
72090
72100
72110
72114
72120

PC/TC UNIT VALUE
20/80
13.43
20/80
25.47
20/80
13.43
20/80
13.43
20/80
25.47
20/80
13.83
20/80
16.59
20/80
29.44
20/80
20.55
20/80
22.70
20/80
22.80
40/60
0.74
40/60
0.83
40/60
0.96
40/60
1.15
40/60
1.20
40/60
1.36
40/60
1.25
40/60
2.16
40/60
0.79
40/60
2.34
40/60
3.35
40/60
2.56
40/60
0.91
40/60
1.08
40/60
1.20
40/60
1.38
40/60
0.97
40/60
1.05
20/80
7.81
20/80
9.15
20/80
11.20
20/80
15.41
20/80
13.65
20/80
16.34
20/80
28.66
20/80
14.28
40/60
1.70
40/60
0.65
40/60
0.94
40/60
1.37
40/60
1.69
40/60
0.82
40/60
0.99
40/60
1.08
40/60
1.27
40/60
1.01
40/60
1.09
40/60
1.01
40/60
1.39
40/60
1.75
40/60
1.25

CPT only copyright 2004 American Medical Association. All Rights Reserved.

52

CODE
72125
72126
72127
72128
72129
72130
72131
72132
72133
72141
72142
72146
72147
72148
72149
72156
72157
72158
72159
72170
72190
72191
72192
72193
72194
72195
72196
72197
72198
72200
72202
72220
72240
72255
72265
72270
72275
72285
72295
73000
73010
73020
73030
73040
73050
73060
73070
73080
73085
73090
73092
73100

PC/TC UNIT VALUE
20/80
7.81
20/80
9.11
20/80
11.06
20/80
7.81
20/80
9.12
20/80
11.06
20/80
7.81
20/80
9.11
20/80
11.06
20/80
13.99
20/80
16.79
20/80
15.28
20/80
16.78
20/80
15.12
20/80
16.60
20/80
29.73
20/80
29.71
20/80
29.44
20/80
15.46
40/60
0.78
40/60
1.00
20/80
14.91
20/80
7.72
20/80
8.79
20/80
10.59
20/80
13.66
20/80
16.34
20/80
28.90
20/80
14.26
40/60
0.78
40/60
0.92
40/60
0.85
40/60
6.24
40/60
5.77
40/60
5.41
40/60
8.24
40/60
3.32
40/60
10.40
40/60
9.42
40/60
0.76
40/60
0.78
40/60
0.70
40/60
0.86
40/60
2.96
40/60
0.99
40/60
0.85
40/60
0.75
40/60
0.85
40/60
2.98
40/60
0.76
40/60
0.73
40/60
0.73

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
73110
73115
73120
73130
73140
73200
73201
73202
73206
73218
73219
73220
73221
73222
73223
73225
73500
73510
73520
73525
73530
73540
73542
73550
73560
73562
73564
73565
73580
73590
73592
73600
73610
73615
73620
73630
73650
73660
73700
73701
73702
73706
73718
73719
73720
73721
73722
73723
73725
74000
74010
74020

PC/TC UNIT VALUE
40/60
0.79
40/60
2.43
40/60
0.73
40/60
0.79
40/60
0.62
20/80
6.71
20/80
7.81
20/80
9.49
20/80
13.83
20/80
13.44
20/80
16.14
20/80
28.68
20/80
13.44
20/80
16.13
20/80
28.68
20/80
14.10
40/60
0.73
40/60
0.90
40/60
1.07
40/60
2.97
40/60
0.94
40/60
0.89
40/60
3.01
40/60
0.85
40/60
0.78
40/60
0.86
40/60
0.96
40/60
0.75
40/60
3.50
40/60
0.78
40/60
0.73
40/60
0.73
40/60
0.79
40/60
2.97
40/60
0.73
40/60
0.79
40/60
0.71
40/60
0.62
20/80
6.71
20/80
7.81
20/80
9.48
20/80
13.96
20/80
13.44
20/80
16.13
20/80
28.67
20/80
13.44
20/80
16.13
20/80
28.68
20/80
14.29
40/60
0.79
40/60
0.93
40/60
1.03

CODE
74022
74150
74160
74170
74175
74181
74182
74183
74185
74190
74210
74220
74230
74235
74240
74241
74245
74246
74247
74249
74250
74251
74260
74270
74280
74283
74290
74291
74300
74301
74305
74320
74327
74328
74329
74330
74340
74350
74355
74360
74363
74400
74410
74415
74420
74425
74430
74440
74445
74450
74455
74470

PC/TC UNIT VALUE
40/60
1.21
20/80
7.59
20/80
8.95
20/80
10.84
20/80
15.02
20/80
13.65
20/80
16.34
20/80
28.90
20/80
14.26
40/60
2.04
40/60
1.75
40/60
1.88
40/60
2.10
40/60
4.40
40/60
2.49
40/60
2.52
40/60
3.76
40/60
2.69
40/60
2.74
40/60
3.96
40/60
2.02
40/60
2.33
40/60
2.25
40/60
2.76
40/60
3.71
40/60
5.47
40/60
1.21
40/60
0.72
40/60
1.43
40/60
0.83
40/60
1.41
40/60
4.06
40/60
2.83
40/60
4.28
40/60
4.28
40/60
4.55
40/60
3.50
40/60
4.36
40/60
3.80
40/60
4.08
40/60
7.64
40/60
2.46
40/60
2.73
40/60
2.91
40/60
3.26
40/60
1.88
40/60
1.55
40/60
1.71
40/60
2.77
40/60
2.00
40/60
2.14
40/60
2.06

CPT only copyright 2004 American Medical Association. All Rights Reserved.

53

CODE
74475
74480
74485
74710
74740
74742
74775
75552
75553
75554
75555
75556
75600
75605
75625
75630
75635
75650
75658
75660
75662
75665
75671
75676
75680
75685
75705
75710
75716
75722
75724
75726
75731
75733
75736
75741
75743
75746
75756
75774
75790
75801
75803
75805
75807
75809
75810
75820
75822
75825
75827
75831

PC/TC UNIT VALUE
40/60
5.03
40/60
5.03
40/60
4.06
40/60
1.58
40/60
1.91
40/60
4.16
40/60
2.40
20/80
13.99
20/80
14.51
20/80
14.33
20/80
14.24
20/80
BR
40/60
13.95
40/60
14.84
40/60
14.83
40/60
16.33
20/80
19.60
40/60
15.31
40/60
15.10
40/60
15.08
40/60
15.58
40/60
15.09
40/60
15.55
40/60
15.09
40/60
15.55
40/60
15.06
40/60
16.29
40/60
14.85
40/60
15.06
40/60
14.85
40/60
15.36
40/60
14.81
40/60
14.82
40/60
15.06
40/60
14.83
40/60
15.05
40/60
15.52
40/60
14.82
40/60
14.88
40/60
13.75
40/60
3.97
40/60
6.85
40/60
7.30
40/60
7.56
40/60
8.03
40/60
1.47
40/60
14.81
40/60
1.98
40/60
3.02
40/60
14.83
40/60
14.82
40/60
14.83

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
75833
75840
75842
75860
75870
75872
75880
75885
75887
75889
75891
75893
75894
75896
75898
75900
75901
75902
75940
75945
75946
75952
75953
75954
75960
75961
75962
75964
75966
75968
75970
75978
75980
75982
75984
75989
75992
75993
75994
75995
75996
75998
76000
76001
76003
76005
76006
76010
76012
76013
76020
76040

PC/TC UNIT VALUE
40/60
15.32
40/60
14.84
40/60
15.29
40/60
14.83
40/60
14.83
40/60
14.89
40/60
1.97
40/60
15.23
40/60
15.22
40/60
14.81
40/60
14.81
40/60
14.00
40/60
27.22
40/60
23.92
40/60
3.39
40/60
22.76
40/60
2.81
40/60
2.68
40/60
14.01
40/60
5.38
40/60
3.01
40/60
64.20
40/60
19.40
40/60
31.80
40/60
16.82
40/60
16.90
40/60
17.33
40/60
9.33
40/60
18.41
40/60
9.33
40/60
13.29
40/60
17.32
40/60
7.67
40/60
8.40
40/60
3.04
40/60
4.95
40/60
17.33
40/60
9.33
40/60
18.41
40/60
18.40
40/60
9.32
40/60
1.93
40/60
1.61
40/60
3.70
40/60
2.12
40/60
2.17
40/60
0.65
40/60
0.79
40/60
5.37
40/60
9.70
40/60
0.80
40/60
1.20

CODE
76061
76062
76065
76066
76070
76071
76075
76076
76077
76078
76080
76082
76083
76086
76088
76090
76091
76092
76093
76094
76095
76096
76098
76100
76101
76102
76120
76125
76140
76150
76350
76355
76360
76362
76370
76375
76380
76390
76393
76394
76400
76496
76497
76498
76499
76506
76510
76511
76512
76513
76514
76516

PC/TC UNIT VALUE
40/60
1.68
40/60
2.26
40/60
1.74
40/60
1.60
20/80
3.45
20/80
3.30
40/60
3.67
40/60
1.11
40/60
1.04
40/60
1.08
40/60
1.85
40/60
0.52
40/60
0.52
40/60
3.26
40/60
4.47
40/60
2.07
40/60
2.57
40/60
2.26
20/80
20.77
20/80
27.38
40/60
9.73
40/60
2.15
40/60
0.66
40/60
2.12
40/60
2.30
40/60
2.64
40/60
1.64
40/60
1.20
40/60
BR
40/60
0.44
40/60
1.04
20/80
10.35
20/80
10.27
20/80
15.20
20/80
4.28
40/60
3.94
20/80
5.02
20/80
13.54
20/80
13.84
20/80
18.62
20/80
13.98
40/60
BR
20/80
BR
20/80
BR
40/60
BR
40/60
2.42
40/60
4.51
40/60
3.47
40/60
3.29
40/60
2.59
40/60
0.32
40/60
2.08

CPT only copyright 2004 American Medical Association. All Rights Reserved.

54

CODE
76519
76529
76536
76604
76645
76700
76705
76770
76775
76778
76800
76801
76802
76805
76810
76811
76812
76815
76816
76817
76818
76819
76820
76821
76825
76826
76827
76828
76830
76831
76856
76857
76870
76872
76873
76880
76885
76886
76930
76932
76936
76937
76940
76941
76942
76945
76946
76948
76950
76965
76970
76975

PC/TC UNIT VALUE
40/60
2.17
40/60
2.04
40/60
2.27
40/60
2.13
40/60
1.85
40/60
3.20
40/60
2.31
40/60
3.09
40/60
2.30
40/60
3.09
40/60
3.02
40/60
3.59
40/60
2.33
40/60
3.59
40/60
2.63
40/60
6.66
40/60
3.98
40/60
2.41
40/60
2.38
40/60
2.62
40/60
3.20
40/60
2.79
40/60
2.45
40/60
2.73
40/60
4.42
40/60
1.91
40/60
2.66
40/60
2.00
40/60
2.57
40/60
2.62
40/60
2.57
40/60
2.29
40/60
2.50
40/60
3.07
40/60
4.40
40/60
2.31
40/60
2.63
40/60
2.35
40/60
2.56
40/60
2.56
40/60
9.41
40/60
0.91
40/60
4.75
40/60
3.49
40/60
3.83
40/60
2.54
40/60
2.16
40/60
2.15
40/60
2.18
40/60
7.71
40/60
1.66
40/60
2.75

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
76977
76986
76999
77261
77262
77263
77280
77285
77290
77295
77299
77300
77301
77305
77310
77315
77321
77326
77327
77328
77331
77332
77333
77334
77336
77370
77399
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
77416
77417
77418
77427
77431
77432
77470
77499
77520
77522
77523
77525
77600

PC/TC UNIT VALUE
40/60
0.95
40/60
4.48
40/60
BR
40/60
1.97
40/60
2.97
40/60
4.41
40/60
4.61
40/60
7.31
40/60
9.00
40/60
35.67
40/60
BR
40/60
2.26
40/60
40.36
40/60
2.94
40/60
3.90
40/60
4.94
40/60
5.55
40/60
3.77
40/60
5.55
40/60
8.08
40/60
1.71
40/60
2.15
40/60
3.15
40/60
5.12
40/60
3.14
40/60
3.67
40/60
BR
40/60
1.88
40/60
1.88
40/60
1.88
40/60
1.88
40/60
1.88
40/60
2.21
40/60
2.21
40/60
2.21
40/60
2.21
40/60
2.46
40/60
2.46
40/60
2.46
40/60
2.46
40/60
0.63
40/60
18.11
40/60
4.54
40/60
2.58
40/60
11.23
40/60
14.61
40/60
BR
40/60
BR
40/60
BR
40/60
BR
40/60
BR
40/60
5.35

CODE
77605
77610
77615
77620
77750
77761
77762
77763
77776
77777
77778
77781
77782
77783
77784
77789
77790
77799
78000
78001
78003
78006
78007
78010
78011
78015
78016
78018
78020
78070
78075
78099
78102
78103
78104
78110
78111
78120
78121
78122
78130
78135
78140
78160
78162
78170
78172
78185
78190
78191
78195
78199

PC/TC UNIT VALUE
40/60
7.19
40/60
5.36
40/60
7.14
40/60
5.49
40/60
8.13
40/60
7.72
40/60
11.64
40/60
16.47
40/60
8.34
40/60
14.70
40/60
20.71
40/60
23.63
40/60
24.78
40/60
26.46
40/60
29.04
40/60
2.01
40/60
1.96
40/60
BR
40/60
1.29
40/60
1.74
40/60
1.48
40/60
3.18
40/60
3.40
40/60
2.47
40/60
3.16
40/60
3.64
40/60
4.80
40/60
6.91
40/60
2.28
40/60
5.52
40/60
6.74
40/60
BR
40/60
2.92
40/60
4.38
40/60
5.39
40/60
1.28
40/60
3.02
40/60
2.16
40/60
3.49
40/60
5.47
40/60
3.84
40/60
6.01
40/60
4.98
40/60
4.34
40/60
4.03
40/60
6.16
40/60
2.88
40/60
3.05
40/60
7.57
40/60
8.55
40/60
5.96
40/60
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

55

CODE
78201
78202
78205
78206
78215
78216
78220
78223
78230
78231
78232
78258
78261
78262
78264
78267
78268
78270
78271
78272
78278
78282
78290
78291
78299
78300
78305
78306
78315
78320
78350
78351
78399
78414
78428
78445
78455
78456
78457
78458
78459
78460
78461
78464
78465
78466
78468
78469
78472
78473
78478
78480

PC/TC UNIT VALUE
40/60
3.10
40/60
3.72
40/60
7.20
40/60
7.35
40/60
3.75
40/60
4.44
40/60
4.58
40/60
5.01
40/60
2.93
40/60
4.06
40/60
4.37
40/60
4.04
40/60
5.28
40/60
5.41
40/60
5.42
40/60
0.29
40/60
2.48
40/60
1.93
40/60
2.02
40/60
2.82
40/60
6.48
40/60
2.12
40/60
4.15
40/60
4.44
40/60
BR
40/60
3.48
40/60
5.00
40/60
5.68
40/60
6.43
40/60
7.66
40/60
1.10
40/60
2.03
40/60
BR
40/60
2.10
40/60
3.48
40/60
2.65
40/60
5.20
40/60
5.65
40/60
3.87
40/60
5.49
40/60
7.07
40/60
3.68
40/60
6.68
40/60
8.95
40/60
14.45
40/60
3.72
40/60
4.95
40/60
6.76
40/60
7.17
40/60
10.72
40/60
2.53
40/60
2.52

RADIOLOGY
(CONVERSION FACTOR = $63.15)
CODE
78481
78483
78491
78492
78494
78496
78499
78580
78584
78585
78586
78587
78588
78591
78593
78594
78596
78599
78600
78601
78605
78606
78607
78608
78609
78610
78615
78630
78635
78645
78647
78650
78660
78699
78700
78701
78704
78707
78708
78709
78710
78715
78725
78730
78740
78760
78761
78799
78800
78801
78802
78803

PC/TC UNIT VALUE
40/60
6.88
40/60
10.34
40/60
7.17
40/60
8.93
40/60
9.03
40/60
8.07
40/60
BR
40/60
4.63
40/60
4.73
40/60
7.44
40/60
3.28
40/60
3.62
40/60
4.88
40/60
3.54
40/60
4.30
40/60
5.96
40/60
9.18
40/60
BR
40/60
3.63
40/60
4.28
40/60
4.31
40/60
4.96
40/60
8.61
40/60
BR
40/60
BR
40/60
2.10
40/60
4.65
40/60
6.25
40/60
3.54
40/60
4.39
40/60
7.47
40/60
5.73
40/60
2.97
40/60
BR
40/60
3.83
40/60
4.41
40/60
5.18
40/60
6.02
40/60
6.37
40/60
6.64
40/60
7.13
40/60
2.10
40/60
2.42
40/60
2.04
40/60
3.03
40/60
3.73
40/60
4.35
40/60
BR
40/60
4.50
40/60
5.55
40/60
7.02
40/60
8.42

CODE
78804
78805
78806
78807
78811
78812
78813
78814
78815
78816
78890
78891
78999
79005
79101
79200
79300
79403
79440
79445
79999

PC/TC UNIT VALUE
40/60
12.84
40/60
4.59
40/60
7.97
40/60
8.42
40/60
6.60
40/60
8.16
40/60
8.44
40/60
9.24
40/60
10.20
40/60
10.44
40/60
1.45
40/60
2.90
40/60
BR
40/60
5.24
40/60
5.47
40/60
5.53
40/60
3.82
40/60
7.65
40/60
5.55
40/60
6.12
40/60
BR

CPT only copyright 2004 American Medical Association. All Rights Reserved.

56

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