Caitlyn Tolhurst

X323

Base Rate – $264.69
Name – Ultrasound, heart (Echocardiogram), fetal, complete study

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 4 
 1 
 2 – 4
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
130%
100%
100%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Obstetrics Gynecology and Female Pelvis

/// –

//// X323


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X324

Base Rate – $66.17
Name – Ultrasound, pelvis, female, translabial or endo-vaginal (EV), additional benefit

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE L13 Increase Base To 1.3

Diagnostic Radiology

/ Diagnostic Ultrasound

// Obstetrics Gynecology and Female Pelvis

/// –

//// X324


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X331

Base Rate – $84.15
Name – Ultrasound, arterial screening, peripheral

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 4 
 1 
 2 – 4
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
117%
100%
90%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Peripheral Vascular System

/// –

//// X331


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X332

Base Rate – $160.27
Name – Ultrasound, arterial complete mapping, peripheral

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 4 
 1 
 2 – 4
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
117%
100%
90%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Peripheral Vascular System

/// –

//// X332


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X333

Base Rate – $126.22
Name – Ultrasound, venous, peripheral

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 4 
 1 
 2 – 4
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
117%
100%
90%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Peripheral Vascular System

/// –

//// X333


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X334

Base Rate – $114.37
Name – Ultrasound, other than shoulder including joints, tendons, ligaments, muscles, single anatomic site

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 2 
 1 
 2 – 2
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
117%
100%
90%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Musculo-Skeletal

/// –

//// X334


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X335

Base Rate – $159.12
Name – Ultrasound shoulder, dedicated rotator cuff and bicep

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 2 
 1 
 2 – 2
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
117%
100%
90%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Musculo-Skeletal

/// –

//// X335


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X337

Base Rate – $42.07
Name – Doppler, quantitative spectral analysis with directional flow and/or Doppler measurements (e.g. renal artery, portal venous system, resistivity index, etc.), additional benefit

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 2 
 1 
 2 – 2
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
130%
100%
100%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Miscellaneous

/// –

//// X337


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X338

Base Rate – $66.17
Name – Ultrasound, limited soft-tissue study, site unspecified, any single site, not organ related

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
AGE
CALL
CALL
CALL
CALL
L13
CALL13
CALL13
NBRSER
NBRSER
 
 1 
 2 – 2 
 1 
 2 – 2
 
  
  
  
 
Increase Base To
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
For Each Call Pay Base At
130%
130%
117%
100%
90%

Diagnostic Radiology

/ Diagnostic Ultrasound

// Miscellaneous

/// –

//// X338


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Y1

Base Rate – $16.45
Name – Superficial x-ray therapy excluding cancer, per sitting – one area

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
BMI
ROLE
ANU
ANU
BMIANT
ANEST
ANU
ANU
 
  
 1 
 2 – 150
Yes 
 Yes 
  
 
Increase By
Replace Base
For Each Call Pay Base At
For Each Call Increase By
25%
$18.29
100%
$18.29

Therapeutic Radiology

/ X-Ray Therapy

// –

/// –

//// Y1


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Y2

Base Rate – $32.89
Name – Multiple areas treated at one sitting – not to exceed

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
BMI
ROLE
ANU
ANU
BMIANT
ANEST
ANU
ANU
 
  
 1 
 2 – 150
Yes 
 Yes 
  
 
Increase By
Replace Base
For Each Call Pay Base At
For Each Call Increase By
25%
$18.29
100%
$18.29

Therapeutic Radiology

/ X-Ray Therapy

// –

/// –

//// Y2


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Y3

Base Rate – $0.00
Name – Superficial x-ray therapy, cancer

Category – T Test

Fee Modifiers

Type Code # of calls Explicit Action Amount
BMI
BMI
ROLE
ROLE
ANU
ANU
BMIANE
BMIANT
ANE
ANEST
ANU
ANU
 
  
  
  
 1 
 2 – 150
Yes 
 Yes 
 Yes 
 Yes 
  
 
Increase By
Increase By
Replace Base
Replace Base
For Each Call Pay Base At
For Each Call Increase By
25%
25%
$109.92
$18.29
100%
$18.29

Therapeutic Radiology

/ X-Ray Therapy

// –

/// –

//// Y3


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