| A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | Eminent Medical Center (1351 W. President George Bush Hwy, Richardson, Texas 75080) | ||||||||||||||||
2 | Last Updated: 4/3/24 | ||||||||||||||||
3 | Please find below a list of all shoppable services Eminent Medical Center provides at this time, recognizing that Eminent Medical Center does not provide 300 shoppable services but has provided a list of all shoppable services provided below. | ||||||||||||||||
4 | BILL_ITEM_ID | SHORT_DESCRIPTION | ACTIVITY_TYPE | EMTC_CDM | EMTC_CDM - Description | EMTC_CPT | EMTC_Revenue_Code_Tech | EMTC_Hosp_Tech_Price | Gross Charge | Discounted Cash Price (Self-Pay) | De-Identified Minimum Negotiated Charge | De-Identified Maximum Negotiated Charge | BCBS Plan: | BCBS HMO Plan: | UHC All Plans | Aetna All Plans | Cigna All Plans |
273 | 14219670 | 22551 ARTHRODESIS ACDF 1 LEVEL | Surgery Charges | 36022551 | Arthrodesis anterior interbody | 22551 | 360 | $143,418.45 | $143,418.45 | $13,048.08 | $10,358.00 | $63,137.00 | $23,800.00 | $21,420.00 | $10,358.00 | $63,137.00 | $16,483.00 |
274 | 14219672 | 22554 FUSION BELOW C2 SPINE | Surgery Charges | 36022554 | 22554 | 360 | $143,418.45 | $143,418.45 | $13,048.08 | $10,358.00 | $23,800.00 | $23,800.00 | $21,420.00 | $10,358.00 | $18,508.00 | $16,483.00 | |
1075 | 14223345 | 26727 PERQ PHALANGEAL FX W/MANIPUL | Surgery Charges | 36026727 | 26727 | 360 | $20,246.00 | $20,246.00 | $2,976.66 | $4,005.00 | $16,103.00 | $7,883.00 | $7,094.70 | $4,005.00 | $16,103.00 | $4,065.00 | |
1081 | 14223357 | 26765 TREAT FINGER FX EACH | Surgery Charges | 36026765 | 26765 | 360 | $39,678.45 | $39,678.45 | $2,976.66 | $4,005.00 | $16,103.00 | $7,883.00 | $7,094.70 | $4,005.00 | $16,103.00 | $5,665.00 | |
1099 | 14148679 | 27130 Arthroplasty Hip | Surgery Charges | 36027130 | ARTHRP ACETBLR/PROX FEM PROSTC AGRFT/ALGRFT | 27130 | 360 | $446,405.20 | $446,405.20 | $13,048.08 | $16,280.00 | $41,600.00 | $23,800.00 | $21,420.00 | $16,280.00 | $41,600.00 | $16,483.00 |
1140 | 14148681 | 27446 Knee Arthroplasty Unicompartmental | Surgery Charges | 36027446 | 27446 | 360 | $178,510.65 | $178,510.65 | $13,048.08 | $7,900.00 | $63,137.00 | $23,800.00 | $21,420.00 | $16,280.00 | $63,137.00 | $7,900.00 | |
1142 | 14148682 | 27447 Arthroplasty Knee | Surgery Charges | 36027447 | ARTHRP KNE | 27447 | 360 | $446,405.20 | $446,405.20 | $13,048.08 | $16,280.00 | $63,137.00 | $23,800.00 | $21,420.00 | $16,280.00 | $63,137.00 | $16,483.00 |
1265 | 14225592 | 28289 REPAIR HALLUX RIGIDUS | Surgery Charges | 36028289 | 28289 | 360 | $19,982.00 | $19,982.00 | $2,976.66 | $4,005.00 | $7,883.00 | $7,883.00 | $7,094.70 | $4,005.00 | $4,772.00 | $4,944.00 | |
1269 | 14225596 | 28296 CORR BUNION W/METATAR OS | Surgery Charges | 36028296 | CORRJ HALLUX VALGUS W/WO SESMDC W/METAR OSTEOT | 28296 | 360 | $19,982.00 | $19,982.00 | $2,976.66 | $4,944.00 | $16,103.00 | $7,883.00 | $7,094.70 | $6,150.00 | $16,103.00 | $4,944.00 |
1293 | 14225816 | 29805 SHOULDER ARTHROSCOPY DIAGNOSTIC | Surgery Charges | 36029805 | 29805 | 360 | $19,982.00 | $19,982.00 | $2,976.66 | $4,944.00 | $16,103.00 | $7,883.00 | $7,094.70 | $6,150.00 | $16,103.00 | $4,944.00 | |
1294 | 14225817 | 29806 SHOULDER ARTHROSCOPY CAPSULORRHAPHY | Surgery Charges | 36029806 | 29806 | 360 | $44,349.00 | $44,349.00 | $6,614.63 | $4,944.00 | $17,228.00 | $17,228.00 | $15,505.20 | $10,358.00 | $16,103.00 | $4,944.00 | |
1295 | 14225824 | 29807 Arthroscopy Shoulder SLAP Repair | Surgery Charges | 36029807 | 29807 | 360 | $44,349.00 | $44,349.00 | $6,614.63 | $10,358.00 | $17,228.00 | $17,228.00 | $15,505.20 | $10,358.00 | $16,103.00 | $13,792.00 | |
1296 | 14225831 | 29823 SHOULDER ARTHROSCOPY DEBRIDEMENT EXTENSIVE | Surgery Charges | 36029823 | 29823 | 360 | $19,982.00 | $19,982.00 | $2,976.66 | $4,944.00 | $16,103.00 | $7,883.00 | $7,094.70 | $6,150.00 | $16,103.00 | $4,944.00 | |
1297 | 14225834 | 29825 SHOULDER ARTHROSCOPY W/LYSIS OF ADHESIONS | Surgery Charges | 36029825 | 29825 | 360 | $19,982.00 | $19,982.00 | $2,976.66 | $4,944.00 | $16,103.00 | $7,883.00 | $7,094.70 | $6,150.00 | $16,103.00 | $4,944.00 | |
1298 | 10705013 | Arthroscopy, shoulder, surg decomp subacromi | Surgery Charges | 36029826 | 29826 | 360 | $63,127.00 | $63,127.00 | add on code | $825.00 | $63,137.00 | $0.00 | $0.00 | $825.00 | $63,137.00 | $4,944.00 | |
1299 | 14148684 | Arthroscopy Shoulder Rotator Cuff Repair | Surgery Charges | 36029827 | 29827 | 360 | $44,349.00 | $44,349.00 | $6,614.63 | $10,358.00 | $34,479.00 | $17,228.00 | $15,505.20 | $10,358.00 | $34,479.00 | $12,200.00 | |
1300 | 14225869 | 29870 KNEE ARTHROSCOPY DX W OR W/O SYNOVIAL BIOPSY | Surgery Charges | 36029870 | 29870 | 360 | $39,678.00 | $39,678.00 | $2,976.66 | $4,944.00 | $16,103.00 | $7,883.00 | $7,094.70 | $6,150.00 | $16,103.00 | $4,944.00 | |
1301 | 14225871 | 29873 Knee Arthroscopy w/Lateral Release | Surgery Charges | 36029873 | 29873 | 360 | $39,678.00 | $39,678.00 | $2,976.66 | $4,944.00 | $16,103.00 | $7,883.00 | $7,094.70 | $6,150.00 | $16,103.00 | $4,944.00 | |
1302 | 14225881 | Knee Arthroscopy w/Meniscectomy Medial AND L | Surgery Charges | 36029880 | 29880 | 360 | $63,127.00 | $63,127.00 | $2,976.66 | $5,665.00 | $63,137.00 | $7,883.00 | $7,094.70 | $6,150.00 | $63,137.00 | $5,665.00 | |
1303 | 14148685 | Knee Arthroscopy W/Menisectomy | Surgery Charges | 36029881 | ARTHRS KNE SURG W/MENISCECTOMY MED/LAT W/SHVG | 29881 | 360 | $63,127.00 | $63,127.00 | $2,976.66 | $5,665.00 | $63,137.00 | $7,883.00 | $7,094.70 | $6,150.00 | $63,137.00 | $5,665.00 |
1304 | 14148686 | Arthroscopy Knee Meniscal Repair | Surgery Charges | 36029882 | 29882 | 360 | $63,127.00 | $63,127.00 | $2,976.66 | $5,665.00 | $63,137.00 | $7,883.00 | $7,094.70 | $6,150.00 | $63,137.00 | $5,665.00 | |
1305 | 14225885 | KNEE ARTHROSCOPY W/LYSIS OF ADHESIONS | Surgery Charges | 36029884 | 29884 | 360 | $63,127.00 | $63,127.00 | $2,976.66 | $5,665.00 | $63,137.00 | $7,883.00 | $7,094.70 | $6,150.00 | $63,137.00 | $5,665.00 | |
1306 | 14225888 | 29886 Knee Arthroscopy w/drilling osteo lesion | Surgery Charges | 36029886 | 29886 | 360 | $39,678.00 | $39,678.00 | $2,976.66 | $5,665.00 | $63,137.00 | $7,883.00 | $7,094.70 | $6,150.00 | $63,137.00 | $5,665.00 | |
1307 | 14148687 | 29888 Arthroscopy Knee Anterior Cruciate Ligament | Surgery Charges | 36029888 | 29888 | 360 | $44,349.00 | $44,349.00 | $6,614.63 | $4,944.00 | $34,479.00 | $17,228.00 | $15,505.20 | $10,358.00 | $34,479.00 | $4,944.00 | |
9496 | 14148700 | 63650 Neurostim Perc Imp Electrodes | Surgery Charges | 36063650 | PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL | 63650 | 360 | $46,319.00 | $46,319.00 | $6,603.85 | $10,359.00 | $17,819.00 | $17,819.00 | $16,037.10 | $10,359.00 | $13,273.00 | $12,200.00 |
9497 | 14148701 | 63685 Neurostim Ins/Rep Gen/Receiver | Surgery Charges | 36063685 | INSJ/RPLCMT SPI NPGR DIR/INDUXIVE COUPLING | 63685 | 360 | $186,228.00 | $186,228.00 | $29,358.48 | $20,252.00 | $83,862.00 | $83,862.00 | $75,475.80 | $20,252.00 | $22,269.00 | $46,998.00 |
9498 | 11549242 | 64480 Cervical or Thoracic Epidural Steroid Inject | Surgery Charges | 36064480 | 64480 | 360 | $10,082.70 | $10,082.70 | add on code | $1,750.00 | $10,326.00 | $2,338.00 | $2,104.20 | $1,750.00 | $10,326.00 | $2,281.00 | |
9499 | 11549240 | 64484 Lumbar or Sacral Epidural Steroid Injection | Surgery Charges | 36064484 | 64484 | 360 | $10,082.70 | $10,082.70 | add on code | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 | |
9500 | 14228297 | 64486 TAP BLOCK UNILATERAL BY INJ | Surgery Charges | 36064486 | 64486 | 360 | $10,082.70 | $10,082.70 | $0.00 | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 | |
9501 | 15233648 | 64487 Tap block uni by infusion | Surgery Charges | 36064487 | TAP | 64487 | 360 | $10,082.70 | $10,082.70 | $0.00 | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 |
9502 | 14228298 | 64488 TAP BLOCK BILATERAL BY INJ | Surgery Charges | 36064488 | 64488 | 360 | $10,082.70 | $10,082.70 | $0.00 | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 | |
9503 | 11549235 | Cervical Facet Injection Medial Branch Block | Surgery Charges | 36064490 | 64490 | 360 | $10,082.70 | $10,082.70 | $852.18 | $1,750.00 | $10,326.00 | $2,338.00 | $2,104.20 | $1,750.00 | $10,326.00 | $2,281.00 | |
9504 | 11549236 | Cervical Facet Injection Medial Branch Block | Surgery Charges | 36064491 | 64491 | 360 | $10,082.70 | $10,082.70 | add on code | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 | |
9505 | 14228299 | 64492 INJ W/FLUORO CER/THOR 3+ LEVEL | Surgery Charges | 36064492 | Cervical/Thoracic Facet level 3 | 64492 | 360 | $10,082.70 | $10,082.70 | add on code | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 |
9506 | 11549237 | 64493 Lumbar Facet Injection Medial Branch Block ( | Surgery Charges | 36064493 | Lumbar Facet Injection level 1 | 64493 | 360 | $10,082.70 | $10,082.70 | $852.18 | $1,586.00 | $2,338.00 | $2,338.00 | $2,104.20 | $1,750.00 | $1,586.00 | $2,281.00 |
9507 | 11549238 | Lumbar Facet Injection Medial Branch Block ( | Surgery Charges | 36064494 | 64494 | 360 | $10,082.70 | $10,082.70 | add on code | $825.00 | $15,486.00 | $0.00 | $0.00 | $825.00 | $15,486.00 | $0.00 | |
9508 | 14228300 | 64495 INJ W/FLUOR LUM/SAC 3+ LEVEL | Surgery Charges | 36064495 | Lumbar Facet Injection level 3 | 64495 | 360 | $10,082.70 | $10,082.70 | add on code | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 |
9509 | 11549231 | 64633 Cervical or Thoracic Facet Rafiofrequency T | Surgery Charges | 36064633 | DEST VERT NERVE C/T W/GD | 64633 | 360 | $11,713.00 | $11,713.00 | $1,797.52 | $3,165.00 | $10,326.00 | $4,951.00 | $4,455.90 | $4,005.00 | $10,326.00 | $3,165.00 |
9510 | 11549232 | 64634 Cervical or Thoracic Facet Rafiofrequency Th | Surgery Charges | 36064634 | 64634 | 360 | $5,856.00 | $5,856.00 | add on code | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 | |
9511 | 11549233 | 64635 Lumbar or Sacral Facet Rafiofrequency Thermo | Surgery Charges | 36064635 | DEST VERT NERVE LUM W/GD | 64635 | 360 | $11,713.00 | $11,713.00 | $1,797.52 | $3,372.00 | $10,326.00 | $4,951.00 | $4,455.90 | $4,005.00 | $10,326.00 | $3,372.00 |
9512 | 11549234 | Lumbar or Sacral Facet Rafiofrequency Thermo | Surgery Charges | 36064636 | 64636 | 360 | $11,713.00 | $11,713.00 | add on code | $825.00 | $1,586.00 | $0.00 | $0.00 | $825.00 | $1,586.00 | $0.00 | |
9513 | 1170301 | XR Mandible Complete Minimum 4 Views | Radiology | 32070110 | 70110 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9514 | 1170139 | XR Facial Bones < 3 Views | Radiology | 32070140 | 70140 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9515 | 1170141 | XR Facial Bones Minimum 3 Views | Radiology | 32070150 | 70150 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9516 | 1170329 | XR Nasal Bones Minimum 3 Views | Radiology | 32070160 | 70160 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9517 | 1170438 | XR Skull Complete | Radiology | 32070260 | 70260 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9518 | 1170504 | XR TMJ Open and Closed Left | Radiology | 32070328 | 70328 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9519 | 1170502 | XR TMJ Open and Closed Bilateral | Radiology | 32070330 | 70330 | 320 | $1,737.60 | $1,737.60 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9520 | 1170331 | XR Neck Soft Tissue | Radiology | 32070360 | 70360 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9521 | 1168856 | MRI Face Neck Orbit w/o Contrast | Radiology | 61470540 | MRI Face Neck Orbit w/o Contrast | 70540 | 614 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9522 | 1168854 | MRI Face Neck Orbit w/ Contrast | Radiology | 61470542 | MRI Face Neck Orbit w/ Contrast | 70542 | 614 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9523 | 1168852 | MRI Face Neck Orbit w/ + w/o Contrast | Radiology | 61470543 | MRI Face Neck Orbit w/ + w/o Contrast | 70543 | 614 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9524 | 1168800 | MRI Brain w/o Contrast | Radiology | 61170551 | MRI Brain w/o Contrast | 70551 | 611 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9525 | 1168798 | MRI Brain w/ Contrast | Radiology | 61170552 | MRI Brain w/ Contrast | 70552 | 611 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9526 | 1168796 | MRI Brain w/ + w/o Contrast | Radiology | 61170553 | MRI Brain w/ + w/o Contrast | 70553 | 611 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9527 | 1170371 | XR Ribs 2 Views Left | Radiology | 32071100 | 71100 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9528 | 1170373 | XR Ribs 2 Views Right | Radiology | 32071100 | 71100 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9529 | 1170379 | XR Ribs w/ PA Chest Left | Radiology | 32071101 | 71101 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9530 | 1170381 | XR Ribs w/ PA Chest Right | Radiology | 32071101 | 71101 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9531 | 1170375 | XR Ribs 3 Views Bilateral | Radiology | 32071110 | 71110 | 320 | $2,137.60 | $2,137.60 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9532 | 1170377 | XR Ribs w/ PA Chest Bilateral | Radiology | 32071111 | 71111 | 320 | $2,137.60 | $2,137.60 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9533 | 1170496 | XR Sternum Minimum 2 Views | Radiology | 32071120 | 71120 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9534 | 1170494 | XR Sternoclavicular Joint(s) | Radiology | 32071130 | 71130 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9535 | 1168824 | MRI Chest w/o Contrast | Radiology | 61471550 | MRI Chest w/o Contrast | 71550 | 614 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9536 | 7133122 | MRI Clavicle w/o Contrast Left | Radiology | 77309545 | MRI Clavicle w/o Contrast Left | 71550 | 614 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9537 | 7133125 | MRI Clavicle w/o Contrast Right | Radiology | 77309599 | MRI Clavicle w/o Contrast Right | 71550 | 614 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9538 | 7133134 | MRI SC Joint w/o Contrast Left | Radiology | 77310373 | MRI SC Joint w/o Contrast Left | 71550 | 614 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9539 | 7133137 | MRI SC Joint w/o Contrast Right | Radiology | 77310437 | MRI SC Joint w/o Contrast Right | 71550 | 614 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9540 | 1168822 | MRI Chest w/ Contrast | Radiology | 61471551 | MRI Chest w/ Contrast | 71551 | 614 | $7,407.50 | $7,407.50 | $740.75 | $1,000.00 | $2,500.00 | $1,021.23 | $919.11 | $1,000.00 | $2,500.00 | $1,600.00 |
9541 | 16309727 | MRI Clavicle w/ Contrast Left | Radiology | 3753914931 | MRI Clavicle w/ Contrast Left | 71551 | 614 | $7,407.50 | $7,407.50 | $740.75 | $1,000.00 | $2,500.00 | $1,021.23 | $919.11 | $1,000.00 | $2,500.00 | $1,600.00 |
9542 | 16309730 | MRI Clavicle w/ Contrast Right | Radiology | 3753974789 | MRI Clavicle w/ Contrast Right | 71551 | 614 | $7,407.50 | $7,407.50 | $740.75 | $1,000.00 | $2,500.00 | $1,021.23 | $919.11 | $1,000.00 | $2,500.00 | $1,600.00 |
9543 | 1168820 | MRI Chest w/ + w/o Contrast | Radiology | 61471552 | MRI Chest w/ + w/o Contrast | 71552 | 614 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9544 | 7133116 | MRI Clavicle w/ + w/o Contrast Left | Radiology | 77310075 | MRI Clavicle w/ + w/o Contrast Left | 71552 | 614 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9545 | 7133119 | MRI Clavicle w/ + w/o Contrast Right | Radiology | 77310187 | MRI Clavicle w/ + w/o Contrast Right | 71552 | 614 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9546 | 7133128 | MRI SC Joint w/ + w/o Contrast Left | Radiology | 77310513 | MRI SC Joint w/ + w/o Contrast Left | 71552 | 614 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9547 | 7133131 | MRI SC Joint w/ + w/o Contrast Right | Radiology | 77310603 | MRI SC Joint w/ + w/o Contrast Right | 71552 | 614 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9548 | 1170482 | XR Spine Single View Specify Level | Radiology | 32072020 | 72020 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9549 | 1170452 | XR Spine Cervical 2 or 3 Views | Radiology | 32072040 | 72040 | 320 | $897.90 | $897.90 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9550 | 13587273 | XR Spine Cervical 4-5 Views | Radiology | 32072050 | 72050 | 320 | $1,690.95 | $1,690.95 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9551 | 4365234 | XR Spine Cervical Complete | Radiology | 32072052 | 72052 | 320 | $1,690.95 | $1,690.95 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9552 | 1170484 | XR Spine Thoracic 2 Views | Radiology | 32072070 | 72070 | 320 | $1,716.90 | $1,716.90 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9553 | 1170486 | XR Spine Thoracic 3 Views | Radiology | 32072072 | 72072 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9554 | 1170488 | XR Spine Thoracic Minimum 4 Views | Radiology | 32072074 | 72074 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9555 | 1170490 | XR Spine Thoracolumbar 2 Views | Radiology | 32072080 | 72080 | 320 | $868.80 | $868.80 | $86.88 | $93.18 | $93.18 | $93.18 | $83.86 | $0.00 | $0.00 | $0.00 | |
9556 | 1170470 | XR Spine Lumbosacral 2 or 3 Views | Radiology | 32072100 | 72100 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9557 | 1170476 | XR Spine Lumbosacral Minimum 4 Views | Radiology | 32072110 | 72110 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 | |
9558 | 1170467 | XR Spine Lumbar Flexion + Extension | Radiology | 32072114 | LUMBAR SPINE W/FLEX EXT 6 VWS | 72114 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 |
9559 | 1170472 | XR Spine Lumbosacral Bending Only | Radiology | 32072120 | LUMBAR SPINE BEND VIEWS ONLY | 72120 | 320 | $1,068.80 | $1,068.80 | $106.88 | $171.69 | $171.69 | $171.69 | $154.52 | $0.00 | $0.00 | $0.00 |
9560 | 1169054 | MRI Spine Cervical w/o Contrast | Radiology | 61272141 | MRI Spine Cervical w/o Contrast | 72141 | 612 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9561 | 1169052 | MRI Spine Cervical w/ Contrast | Radiology | 61272142 | MRI Spine Cervical w/ Contrast | 72142 | 612 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9562 | 1169066 | MRI Spine Thoracic w/o Contrast | Radiology | 61272146 | MRI Spine Thoracic w/o Contrast | 72146 | 612 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9563 | 1169064 | MRI Spine Thoracic w/ Contrast | Radiology | 61272147 | MRI Spine Thoracic w/ Contrast | 72147 | 612 | $3,684.30 | $3,684.30 | $368.43 | $381.85 | $2,500.00 | $381.85 | $343.67 | $1,000.00 | $2,500.00 | $1,600.00 |
9564 | 1169060 | MRI Spine Lumbar w/o Contrast | Radiology | 61272148 | MRI Spine Lumbar w/o Contrast | 72148 | 612 | $2,335.20 | $2,335.20 | $233.52 | $350.00 | $2,500.00 | $350.00 | $315.00 | $1,000.00 | $2,500.00 | $1,600.00 |
9565 | 1169058 | MRI Spine Lumbar w/ Contrast | Radiology | 61272149 | MRI Spine Lumbar w/ Contrast | 72149 | 612 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9566 | 1169050 | MRI Spine Cervical w/ + w/o Contrast | Radiology | 61272156 | MRI Spine Cervical w/ + w/o Contrast | 72156 | 612 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |
9567 | 1169062 | MRI Spine Thoracic w/ + w/o Contrast | Radiology | 61272157 | MRI Spine Thoracic w/ + w/o Contrast | 72157 | 612 | $3,684.30 | $3,684.30 | $368.43 | $572.78 | $2,500.00 | $572.78 | $515.50 | $1,000.00 | $2,500.00 | $1,600.00 |