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Period of Performance: Ordering Period 1: December 1, 2024 to November 30, 2025
| N No. |
| CPT Code |
| Mod |
| Description |
| Est. |
Qty.
| Unit |
| Proposed Unit Cost |
| CMS Unit Cost |
| % of CMS rate unit cost represents |
| Estimated Total |
Annual Cost (for evaluation purposes)
| 0001 |
| 70450 |
| 26 |
| Ct head/brain w/o dye |
| 90 |
| 0002 |
| 70460 |
| 26 |
| Ct head/brain w/dye |
| 90 |
| 0003 |
| 70470 |
| 26 |
| Ct head/brain w/o & w/dye |
| 90 |
| 0004 |
| 70480 |
| 26 |
| Ct orbit/ear/fossa w/o dye |
| 75 |
| 0005 |
| 70481 |
| 26 |
| Ct orbit/ear/fossa w/dye |
| 75 |
| 0006 |
| 70482 |
| 26 |
| Ct orbit/ear/fossa w/o&w/dye |
| 75 |
| 0007 |
| 70486 |
| 26 |
| Ct maxillofacial w/o dye |
| 75 |
| 0008 |
| 70487 |
| 26 |
| Ct maxillofacial w/dye |
| 75 |
| 0009 |
| 70488 |
| 26 |
| Ct maxillofacial w/o & w/dye |
| 75 |
| 0010 |
| 70490 |
| 26 |
| Ct soft tissue neck w/o dye |
| 75 |
| 0011 |
| 70491 |
| 26 |
| Ct soft tissue neck w/dye |
| 75 |
| 0012 |
| 70492 |
| 26 |
| Ct sft tsue nck w/o & w/dye |
| 75 |
| 0013 |
| 70496 |
| 26 |
| Ct angiography head |
| 75 |
| 0014 |
| 70498 |
| 26 |
| Ct angiography neck |
| 75 |
| 0015 |
| 70540 |
| 26 |
| Mri orbit/face/neck w/o dye |
| 75 |
| 0016 |
| 70542 |
| 26 |
| Mri orbit/face/neck w/dye |
| 75 |
| 0017 |
| 70543 |
| 26 |
| Mri orbt/fac/nck w/o &w/dye |
| 75 |
| 0018 |
| 70544 |
| 26 |
| Mr angiography head w/o dye |
| 75 |
| 0019 |
| 70545 |
| 26 |
| Mr angiography head w/dye |
| 75 |
| 0020 |
| 70546 |
| 26 |
| Mr angiograph head w/o&w/dye |
| 75 |
| 0021 |
| 70547 |
| 26 |
| Mr angiography neck w/o dye |
| 75 |
| 0022 |
| 70548 |
| 26 |
| Mr angiography neck w/dye |
| 75 |
| 0023 |
| 70549 |
| 26 |
| Mr angiograph neck w/o&w/dye |
| 90 |
| 0024 |
| 70551 |
| 26 |
| Mri brain stem w/o dye |
| 90 |
| 0025 |
| 70552 |
| 26 |
| Mri brain stem w/dye |
| 90 |
| 0026 |
| 70553 |
| 26 |
| Mri brain stem w/o & w/dye |
| 75 |
| 0027 |
| 70557 |
| 26 |
| Mri brain w/o dye |
| 75 |
| 0028 |
| 70558 |
| 26 |
| Mri brain w/dye |
| 75 |
| 0029 |
| 70559 |
| 26 |
| Mri brain w/o & w/dye |
| 75 |
| 0030 |
| 71250 |
| 26 |
| Ct thorax dx c- |
| 75 |
| 0031 |
| 71260 |
| 26 |
| Ct thorax dx c+ |
| 75 |
| 0032 |
| 71270 |
| 26 |
| Ct thorax dx c-/c+ |
| 75 |
| 0033 |
| 71271 |
| 26 |
| Ct thorax lung cancer scr c- |
| 75 |
| 0034 |
| 71275 |
| 26 |
| Ct angiography chest |
| 75 |
| 0035 |
| 71550 |
| 26 |
| Mri chest w/o dye |
| 75 |
| 0036 |
| 71551 |
| 26 |
| Mri chest w/dye |
| 75 |
| 0037 |
| 71552 |
| 26 |
| Mri chest w/o & w/dye |
| 75 |
| 0038 |
| 71555 |
| 26 |
| Mri angio chest w or w/o dye |
| 75 |
| 0039 |
| 72125 |
| 26 |
| Ct neck spine w/o dye |
| 75 |
| 0040 |
| 72126 |
| 26 |
| Ct neck spine w/dye |
| 75 |
| 0041 |
| 72127 |
| 26 |
| Ct neck spine w/o & w/dye |
| 90 |
| 0042 |
| 72128 |
| 26 |
| Ct chest spine w/o dye |
| 90 |
| 0043 |
| 72129 |
| 26 |
| Ct chest spine w/dye |
| 90 |
| 0044 |
| 72130 |
| 26 |
| Ct chest spine w/o & w/dye |
| 75 |
| 0045 |
| 72131 |
| 26 |
| Ct lumbar spine w/o dye |
| 75 |
| 0046 |
| 72132 |
| 26 |
| Ct lumbar spine w/dye |
| 75 |
| 0047 |
| 72133 |
| 26 |
| Ct lumbar spine w/o & w/dye |
| 90 |
| 0048 |
| 72141 |
| 26 |
| Mri neck spine w/o dye |
| 75 |
| 0049 |
| 72142 |
| 26 |
| Mri neck spine w/dye |
| 75 |
| 0050 |
| 72146 |
| 26 |
| Mri chest spine w/o dye |
| 75 |
| 0051 |
| 72147 |
| 26 |
| Mri chest spine w/dye |
| 90 |
| 0052 |
| 72148 |
| 26 |
| Mri lumbar spine w/o dye |
| 75 |
| 0053 |
| 72149 |
| 26 |
| Mri lumbar spine w/dye |
| 90 |
| 0054 |
| 72156 |
| 26 |
| Mri neck spine w/o & w/dye |
| 90 |
| 0055 |
| 72157 |
| 26 |
| Mri chest spine w/o & w/dye |
| 90 |
| 0056 |
| 72158 |
| 26 |
| Mri lumbar spine w/o & w/dye |
| 75 |
| 0057 |
| 72159 |
| 26 |
| Mr angio spine w/o&w/dye |
| 75 |
| 0058 |
| 72191 |
| 26 |
| Ct angiograph pelv w/o&w/dye |
| 75 |
| 0059 |
| 72192 |
| 26 |
| Ct pelvis w/o dye |
| 75 |
| 0060 |
| 72193 |
| 26 |
| Ct pelvis w/dye |
| 90 |
| 0061 |
| 72194 |
| 26 |
| Ct pelvis w/o & w/dye |
| 75 |
| 0062 |
| 72195 |
| 26 |
| Mri pelvis w/o dye |
| 75 |
| 0063 |
| 72196 |
| 26 |
| Mri pelvis w/dye |
| 90 |
| 0064 |
| 72197 |
| 26 |
| Mri pelvis w/o & w/dye |
| 75 |
| 0065 |
| 72198 |
| 26 |
| Mr angio pelvis w/o & w/dye |
| 75 |
| 0066 |
| 73200 |
| 26 |
| Ct upper extremity w/o dye |
| 75 |
| 0067 |
| 73201 |
| 26 |
| Ct upper extremity w/dye |
| 75 |
| 0068 |
| 73202 |
| 26 |
| Ct uppr extremity w/o&w/dye |
| 75 |
| 0069 |
| 73206 |
| 26 |
| Ct angio upr extrm w/o&w/dye |
| 75 |
| 0070 |
| 73218 |
| 26 |
| Mri upper extremity w/o dye |
| 75 |
| 0071 |
| 73219 |
| 26 |
| Mri upper extremity w/dye |
| 75 |
| 0072 |
| 73220 |
| 26 |
| Mri uppr extremity w/o&w/dye |
| 75 |
| 0073 |
| 73221 |
| 26 |
| Mri joint upr extrem w/o dye |
| 75 |
| 0074 |
| 73222 |
| 26 |
| Mri joint upr extrem w/dye |
| 70 |
| 0075 |
| 73223 |
| 26 |
| Mri joint upr extr w/o&w/dye |
| 70 |
| 0076 |
| 73225 |
| 26 |
| Mr angio upr extr w/o&w/dye |
| 75 |
| 0077 |
| 73700 |
| 26 |
| Ct lower extremity w/o dye |
| 75 |
| 0078 |
| 73701 |
| 26 |
| Ct lower extremity w/dye |
| 70 |
| 0079 |
| 73702 |
| 26 |
| Ct lwr extremity w/o&w/dye |
| 70 |
| 0080 |
| 73706 |
| 26 |
| Ct angio lwr extr w/o&w/dye |
| 70 |
| 0081 |
| 73718 |
| 26 |
| Mri lower extremity w/o dye |
| 70 |
| 0082 |
| 73719 |
| 26 |
| Mri lower extremity w/dye |
| 70 |
| 0083 |
| 73720 |
| 26 |
| Mri lwr extremity w/o&w/dye |
| 70 |
| 0084 |
| 73721 |
| 26 |
| Mri jnt of lwr extre w/o dye |
| 75 |
| 0085 |
| 73722 |
| 26 |
| Mri joint of lwr extr w/dye |
| 75 |
| 0086 |
| 73723 |
| 26 |
| Mri joint lwr extr w/o&w/dye |
| 75 |
| 0087 |
| 73725 |
| 26 |
| Mr ang lwr ext w or w/o dye |
| 90 |
| 0088 |
| 74150 |
| 26 |
| Ct abdomen w/o dye |
| 90 |
| 0089 |
| 74160 |
| 26 |
| Ct abdomen w/dye |
| 90 |
| 0090 |
| 74170 |
| 26 |
| Ct abdomen w/o & w/dye |
| 90 |
| 0091 |
| 74174 |
| 26 |
| Ct angio abd&pelv w/o&w/dye |
| 90 |
| 0092 |
| 74175 |
| 26 |
| Ct angio abdom w/o & w/dye |
| 90 |
| 0093 |
| 74176 |
| 26 |
| Ct abd & pelvis w/o contrast |
| 90 |
| 0094 |
| 74177 |
| 26 |
| Ct abd & pelv w/contrast |
| 85 |
| 0095 |
| 74178 |
| 26 |
| Ct abd & pelv 1/> regns |
| 85 |
| 0096 |
| 74181 |
| 26 |
| Mri abdomen w/o dye |
| 85 |
| 0097 |
| 74182 |
| 26 |
| Mri abdomen w/dye |
| 80 |
| 0098 |
| 74183 |
| 26 |
| Mri abdomen w/o & w/dye |
| 80 |
| 0099 |
| 74185 |
| 26 |
| Mri angio abdom w orw/o dye |
| 80 |
| 0100 |
| 75635 |
| 26 |
| Ct angio abdominal arteries |
| 75 |
| 0101 |
| 76536 |
| 26 |
| Us exam of head and neck |
| 75 |
| 0102 |
| 76604 |
| 26 |
| Us exam chest |
| 75 |
| 0103 |
| 76642 |
| 26 |
| Ultrasound breast limited |
| 75 |
| 0104 |
| 76700 |
| 26 |
| Us exam abdom complete |
| 75 |
| 0105 |
| 76706 |
| 26 |
| Us abdl aorta screen aaa |
| 75 |
| 0106 |
| 76770 |
| 26 |
| Us exam abdo back wall comp |
| 75 |
| 0107 |
| 76775 |
| 26 |
| Us exam abdo back wall lim |
| 65 |
| 0108 |
| 76801 |
| 26 |
| Ob us < 14 wks single fetus |
| 65 |
| 0109 |
| 76802 |
| 26 |
| Ob us < 14 wks addl fetus |
| 85 |
| 0110 |
| 76817 |
| 26 |
| Transvaginal us obstetric |
| 85 |
| 0111 |
| 76830 |
| 26 |
| Transvaginal us non-ob |
| 75 |
| 0112 |
| 76856 |
| 26 |
| Us exam pelvic complete |
| 75 |
| 0113 |
| 76857 |
| 26 |
| Us exam pelvic limited |
| 75 |
| 0114 |
| 76870 |
| 26 |
| Us exam scrotum |
| 75 |
| 0115 |
| 78457 |
| 26 |
| Venous thrombosis imaging |
| 75 |
| 0116 |
| 78458 |
| 26 |
| Ven thrombosis images bilat |
| 75 |
| 0117 |
| 78580 |
| 26 |
| Lung perfusion imaging |
| 75 |
| 0118 |
| 78761 |
| 26 |
| Testicular imaging w/flow |
| 75 |
| 0119 |
| 93922 |
| 26 |
| Upr/l xtremity art 2 levels |
| 75 |
| 0120 |
| 93923 |
| 26 |
| Upr/lxtr art stdy 3+ lvls |
| 75 |
| 0121 |
| 93925 |
| 26 |
| Lower extremity study |
| 75 |
| 0122 |
| 93926 |
| 26 |
| Lower extremity study |
| 75 |
| 0123 |
| 93930 |
| 26 |
| Upper extremity study |
| 75 |
| 0124 |
| 93931 |
| 26 |
| Upper extremity study |
| 75 |
| 0125 |
| 93970 |
| 26 |
| Extremity study |
| 75 |
| 0126 |
| 93971 |
| 26 |
| Extremity study |
| 75 |
| 0127 |
| 93975 |
| 26 |
| Vascular study |
| 75 |
| 0128 |
| 93976 |
| 26 |
| Vascular study |
| 75 |
| 0129 |
| 93978 |
| 26 |
| Vascular study |
| 75 |
| 0130 |
| 93979 |
| 26 |
| Vascular study |
| 75 |
Total
Period of Performance: Ordering Period 2: December 1, 2025 to November 30, 2026
| N No. |
| CPT Code |
| Mod |
| Description |
| Est. |
Qty.
| Unit |
| Proposed Unit Cost |
| CMS Unit Cost |
| % of CMS rate unit cost represents |
| Estimated Total |
Annual Cost (for evaluation purposes)
| 1001 |
| 70450 |
| 26 |
| Ct head/brain w/o dye |
| 90 |
| 1002 |
| 70460 |
| 26 |
| Ct head/brain w/dye |
| 90 |
| 1003 |
| 70470 |
| 26 |
| Ct head/brain w/o & w/dye |
| 90 |
| 1004 |
| 70480 |
| 26 |
| Ct orbit/ear/fossa w/o dye |
| 75 |
| 1005 |
| 70481 |
| 26 |
| Ct orbit/ear/fossa w/dye |
| 75 |
| 1006 |
| 70482 |
| 26 |
| Ct orbit/ear/fossa w/o&w/dye |
| 75 |
| 1007 |
| 70486 |
| 26 |
| Ct maxillofacial w/o dye |
| 75 |
| 1008 |
| 70487 |
| 26 |
| Ct maxillofacial w/dye |
| 75 |
| 1009 |
| 70488 |
| 26 |
| Ct maxillofacial w/o & w/dye |
| 75 |
| 1010 |
| 70490 |
| 26 |
| Ct soft tissue neck w/o dye |
| 75 |
| 1011 |
| 70491 |
| 26 |
| Ct soft tissue neck w/dye |
| 75 |
| 1012 |
| 70492 |
| 26 |
| Ct sft tsue nck w/o & w/dye |
| 75 |
| 1013 |
| 70496 |
| 26 |
| Ct angiography head |
| 75 |
| 1014 |
| 70498 |
| 26 |
| Ct angiography neck |
| 75 |
| 1015 |
| 70540 |
| 26 |
| Mri orbit/face/neck w/o dye |
| 75 |
| 1016 |
| 70542 |
| 26 |
| Mri orbit/face/neck w/dye |
| 75 |
| 1017 |
| 70543 |
| 26 |
| Mri orbt/fac/nck w/o &w/dye |
| 75 |
| 1018 |
| 70544 |
| 26 |
| Mr angiography head w/o dye |
| 75 |
| 1019 |
| 70545 |
| 26 |
| Mr angiography head w/dye |
| 75 |
| 1020 |
| 70546 |
| 26 |
| Mr angiograph head w/o&w/dye |
| 75 |
| 1021 |
| 70547 |
| 26 |
| Mr angiography neck w/o dye |
| 75 |
| 1022 |
| 70548 |
| 26 |
| Mr angiography neck w/dye |
| 75 |
| 1023 |
| 70549 |
| 26 |
| Mr angiograph neck w/o&w/dye |
| 90 |
| 1024 |
| 70551 |
| 26 |
| Mri brain stem w/o dye |
| 90 |
| 1025 |
| 70552 |
| 26 |
| Mri brain stem w/dye |
| 90 |
| 1026 |
| 70553 |
| 26 |
| Mri brain stem w/o & w/dye |
| 75 |
| 1027 |
| 70557 |
| 26 |
| Mri brain w/o dye |
| 75 |
| 1028 |
| 70558 |
| 26 |
| Mri brain w/dye |
| 75 |
| 1029 |
| 70559 |
| 26 |
| Mri brain w/o & w/dye |
| 75 |
| 1030 |
| 71250 |
| 26 |
| Ct thorax dx c- |
| 75 |
| 1031 |
| 71260 |
| 26 |
| Ct thorax dx c+ |
| 75 |
| 1032 |
| 71270 |
| 26 |
| Ct thorax dx c-/c+ |
| 75 |
| 1033 |
| 71271 |
| 26 |
| Ct thorax lung cancer scr c- |
| 75 |
| 1034 |
| 71275 |
| 26 |
| Ct angiography chest |
| 75 |
| 1035 |
| 71550 |
| 26 |
| Mri chest w/o dye |
| 75 |
| 1036 |
| 71551 |
| 26 |
| Mri chest w/dye |
| 75 |
| 1037 |
| 71552 |
| 26 |
| Mri chest w/o & w/dye |
| 75 |
| 1038 |
| 71555 |
| 26 |
| Mri angio chest w or w/o dye |
| 75 |
| 1039 |
| 72125 |
| 26 |
| Ct neck spine w/o dye |
| 75 |
| 1040 |
| 72126 |
| 26 |
| Ct neck spine w/dye |
| 75 |
| 1041 |
| 72127 |
| 26 |
| Ct neck spine w/o & w/dye |
| 90 |
| 1042 |
| 72128 |
| 26 |
| Ct chest spine w/o dye |
| 90 |
| 1043 |
| 72129 |
| 26 |
| Ct chest spine w/dye |
| 90 |
| 1044 |
| 72130 |
| 26 |
| Ct chest spine w/o & w/dye |
| 75 |
| 1045 |
| 72131 |
| 26 |
| Ct lumbar spine w/o dye |
| 75 |
| 1046 |
| 72132 |
| 26 |
| Ct lumbar spine w/dye |
| 75 |
| 1047 |
| 72133 |
| 26 |
| Ct lumbar spine w/o & w/dye |
| 90 |
| 1048 |
| 72141 |
| 26 |
| Mri neck spine w/o dye |
| 75 |
| 1049 |
| 72142 |
| 26 |
| Mri neck spine w/dye |
| 75 |
| 1050 |
| 72146 |
| 26 |
| Mri chest spine w/o dye |
| 75 |
| 1051 |
| 72147 |
| 26 |
| Mri chest spine w/dye |
| 90 |
| 1052 |
| 72148 |
| 26 |
| Mri lumbar spine w/o dye |
| 75 |
| 1053 |
| 72149 |
| 26 |
| Mri lumbar spine w/dye |
| 90 |
| 1054 |
| 72156 |
| 26 |
| Mri neck spine w/o & w/dye |
| 90 |
| 1055 |
| 72157 |
| 26 |
| Mri chest spine w/o & w/dye |
| 90 |
| 1056 |
| 72158 |
| 26 |
| Mri lumbar spine w/o & w/dye |
| 75 |
| 1057 |
| 72159 |
| 26 |
| Mr angio spine w/o&w/dye |
| 75 |
| 1058 |
| 72191 |
| 26 |
| Ct angiograph pelv w/o&w/dye |
| 75 |
| 1059 |
| 72192 |
| 26 |
| Ct pelvis w/o dye |
| 75 |
| 1060 |
| 72193 |
| 26 |
| Ct pelvis w/dye |
| 90 |
| 1061 |
| 72194 |
| 26 |
| Ct pelvis w/o & w/dye |
| 75 |
| 1062 |
| 72195 |
| 26 |
| Mri pelvis w/o dye |
| 75 |
| 1063 |
| 72196 |
| 26 |
| Mri pelvis w/dye |
| 90 |
| 1064 |
| 72197 |
| 26 |
| Mri pelvis w/o & w/dye |
| 75 |
| 1065 |
| 72198 |
| 26 |
| Mr angio pelvis w/o & w/dye |
| 75 |
| 1066 |
| 73200 |
| 26 |
| Ct upper extremity w/o dye |
| 75 |
| 1067 |
| 73201 |
| 26 |
| Ct upper extremity w/dye |
| 75 |
| 1068 |
| 73202 |
| 26 |
| Ct uppr extremity w/o&w/dye |
| 75 |
| 1069 |
| 73206 |
| 26 |
| Ct angio upr extrm w/o&w/dye |
| 75 |
| 1070 |
| 73218 |
| 26 |
| Mri upper extremity w/o dye |
| 75 |
| 1071 |
| 73219 |
| 26 |
| Mri upper extremity w/dye |
| 75 |
| 1072 |
| 73220 |
| 26 |
| Mri uppr extremity w/o&w/dye |
| 75 |
| 1073 |
| 73221 |
| 26 |
| Mri joint upr extrem w/o dye |
| 75 |
| 1074 |
| 73222 |
| 26 |
| Mri joint upr extrem w/dye |
| 70 |
| 1075 |
| 73223 |
| 26 |
| Mri joint upr extr w/o&w/dye |
| 70 |
| 1076 |
| 73225 |
| 26 |
| Mr angio upr extr w/o&w/dye |
| 75 |
| 1077 |
| 73700 |
| 26 |
| Ct lower extremity w/o dye |
| 75 |
| 1078 |
| 73701 |
| 26 |
| Ct lower extremity w/dye |
| 70 |
| 1079 |
| 73702 |
| 26 |
| Ct lwr extremity w/o&w/dye |
| 70 |
| 1080 |
| 73706 |
| 26 |
| Ct angio lwr extr w/o&w/dye |
| 70 |
| 1081 |
| 73718 |
| 26 |
| Mri lower extremity w/o dye |
| 70 |
| 1082 |
| 73719 |
| 26 |
| Mri lower extremity w/dye |
| 70 |
| 1083 |
| 73720 |
| 26 |
| Mri lwr extremity w/o&w/dye |
| 70 |
| 1084 |
| 73721 |
| 26 |
| Mri jnt of lwr extre w/o dye |
| 75 |
| 1085 |
| 73722 |
| 26 |
| Mri joint of lwr extr w/dye |
| 75 |
| 1086 |
| 73723 |
| 26 |
| Mri joint lwr extr w/o&w/dye |
| 75 |
| 1087 |
| 73725 |
| 26 |
| Mr ang lwr ext w or w/o dye |
| 90 |
| 1088 |
| 74150 |
| 26 |
| Ct abdomen w/o dye |
| 90 |
| 1089 |
| 74160 |
| 26 |
| Ct abdomen w/dye |
| 90 |
| 1090 |
| 74170 |
| 26 |
| Ct abdomen w/o & w/dye |
| 90 |
| 1091 |
| 74174 |
| 26 |
| Ct angio abd&pelv w/o&w/dye |
| 90 |
| 1092 |
| 74175 |
| 26 |
| Ct angio abdom w/o & w/dye |
| 90 |
| 1093 |
| 74176 |
| 26 |
| Ct abd & pelvis w/o contrast |
| 90 |
| 1094 |
| 74177 |
| 26 |
| Ct abd & pelv w/contrast |
| 85 |
| 1095 |
| 74178 |
| 26 |
| Ct abd & pelv 1/> regns |
| 85 |
| 1096 |
| 74181 |
| 26 |
| Mri abdomen w/o dye |
| 85 |
| 1097 |
| 74182 |
| 26 |
| Mri abdomen w/dye |
| 80 |
| 1098 |
| 74183 |
| 26 |
| Mri abdomen w/o & w/dye |
| 80 |
| 1099 |
| 74185 |
| 26 |
| Mri angio abdom w orw/o dye |
| 80 |
| 1100 |
| 75635 |
| 26 |
| Ct angio abdominal arteries |
| 75 |
| 1111 |
| 76536 |
| 26 |
| Us exam of head and neck |
| 75 |
| 1102 |
| 76604 |
| 26 |
| Us exam chest |
| 75 |
| 1103 |
| 76642 |
| 26 |
| Ultrasound breast limited |
| 75 |
| 1104 |
| 76700 |
| 26 |
| Us exam abdom complete |
| 75 |
| 1105 |
| 76706 |
| 26 |
| Us abdl aorta screen aaa |
| 75 |
| 1106 |
| 76770 |
| 26 |
| Us exam abdo back wall comp |
| 75 |
| 1107 |
| 76775 |
| 26 |
| Us exam abdo back wall lim |
| 65 |
| 1108 |
| 76811 |
| 26 |
| Ob us < 14 wks single fetus |
| 65 |
| 1109 |
| 76802 |
| 26 |
| Ob us < 14 wks addl fetus |
| 85 |
| 1110 |
| 76817 |
| 26 |
| Transvaginal us obstetric |
| 85 |
| 1111 |
| 76830 |
| 26 |
| Transvaginal us non-ob |
| 75 |
| 1112 |
| 76856 |
| 26 |
| Us exam pelvic complete |
| 75 |
| 1113 |
| 76857 |
| 26 |
| Us exam pelvic limited |
| 75 |
| 1114 |
| 76870 |
| 26 |
| Us exam scrotum |
| 75 |
| 1115 |
| 78457 |
| 26 |
| Venous thrombosis imaging |
| 75 |
| 1116 |
| 78458 |
| 26 |
| Ven thrombosis images bilat |
| 75 |
| 1117 |
| 78580 |
| 26 |
| Lung perfusion imaging |
| 75 |
| 1118 |
| 78761 |
| 26 |
| Testicular imaging w/flow |
| 75 |
| 1119 |
| 93922 |
| 26 |
| Upr/l xtremity art 2 levels |
| 75 |
| 1120 |
| 93923 |
| 26 |
| Upr/lxtr art stdy 3+ lvls |
| 75 |
| 1121 |
| 93925 |
| 26 |
| Lower extremity study |
| 75 |
| 1122 |
| 93926 |
| 26 |
| Lower extremity study |
| 75 |
| 1123 |
| 93930 |
| 26 |
| Upper extremity study |
| 75 |
| 1124 |
| 93931 |
| 26 |
| Upper extremity study |
| 75 |
| 1125 |
| 93970 |
| 26 |
| Extremity study |
| 75 |
| 1126 |
| 93971 |
| 26 |
| Extremity study |
| 75 |
| 1127 |
| 93975 |
| 26 |
| Vascular study |
| 75 |
| 1128 |
| 93976 |
| 26 |
| Vascular study |
| 75 |
| 1129 |
| 93978 |
| 26 |
| Vascular study |
| 75 |
| 1130 |
| 93979 |
| 26 |
| Vascular study |
| 75 |
Total
Period of Performance: Ordering Period 3: December 1, 2026 to November 30, 2027
| N No. |
| CPT Code |
| Mod |
| Description |
| Est. |
Qty.
| Unit |
| Proposed Unit Cost |
| CMS Unit Cost |
| % of CMS rate unit cost represents |
| Estimated Total |
Annual Cost (for evaluation purposes)
| 2001 |
| 70450 |
| 26 |
| Ct head/brain w/o dye |
| 90 |
| 2002 |
| 70460 |
| 26 |
| Ct head/brain w/dye |
| 90 |
| 2003 |
| 70470 |
| 26 |
| Ct head/brain w/o & w/dye |
| 90 |
| 2004 |
| 70480 |
| 26 |
| Ct orbit/ear/fossa w/o dye |
| 75 |
| 2005 |
| 70481 |
| 26 |
| Ct orbit/ear/fossa w/dye |
| 75 |
| 2006 |
| 70482 |
| 26 |
| Ct orbit/ear/fossa w/o&w/dye |
| 75 |
| 2007 |
| 70486 |
| 26 |
| Ct maxillofacial w/o dye |
| 75 |
| 2008 |
| 70487 |
| 26 |
| Ct maxillofacial w/dye |
| 75 |
| 2009 |
| 70488 |
| 26 |
| Ct maxillofacial w/o & w/dye |
| 75 |
| 2010 |
| 70490 |
| 26 |
| Ct soft tissue neck w/o dye |
| 75 |
| 2011 |
| 70491 |
| 26 |
| Ct soft tissue neck w/dye |
| 75 |
| 2012 |
| 70492 |
| 26 |
| Ct sft tsue nck w/o & w/dye |
| 75 |
| 2013 |
| 70496 |
| 26 |
| Ct angiography head |
| 75 |
| 2014 |
| 70498 |
| 26 |
| Ct angiography neck |
| 75 |
| 2015 |
| 70540 |
| 26 |
| Mri orbit/face/neck w/o dye |
| 75 |
| 2016 |
| 70542 |
| 26 |
| Mri orbit/face/neck w/dye |
| 75 |
| 2017 |
| 70543 |
| 26 |
| Mri orbt/fac/nck w/o &w/dye |
| 75 |
| 2018 |
| 70544 |
| 26 |
| Mr angiography head w/o dye |
| 75 |
| 2019 |
| 70545 |
| 26 |
| Mr angiography head w/dye |
| 75 |
| 2020 |
| 70546 |
| 26 |
| Mr angiograph head w/o&w/dye |
| 75 |
| 2021 |
| 70547 |
| 26 |
| Mr angiography neck w/o dye |
| 75 |
| 2022 |
| 70548 |
| 26 |
| Mr angiography neck w/dye |
| 75 |
| 2023 |
| 70549 |
| 26 |
| Mr angiograph neck w/o&w/dye |
| 90 |
| 2024 |
| 70551 |
| 26 |
| Mri brain stem w/o dye |
| 90 |
| 2025 |
| 70552 |
| 26 |
| Mri brain stem w/dye |
| 90 |
| 2026 |
| 70553 |
| 26 |
| Mri brain stem w/o & w/dye |
| 75 |
| 2027 |
| 70557 |
| 26 |
| Mri brain w/o dye |
| 75 |
| 2028 |
| 70558 |
| 26 |
| Mri brain w/dye |
| 75 |
| 2029 |
| 70559 |
| 26 |
| Mri brain w/o & w/dye |
| 75 |
| 2030 |
| 71250 |
| 26 |
| Ct thorax dx c- |
| 75 |
| 2031 |
| 71260 |
| 26 |
| Ct thorax dx c+ |
| 75 |
| 2032 |
| 71270 |
| 26 |
| Ct thorax dx c-/c+ |
| 75 |
| 2033 |
| 71271 |
| 26 |
| Ct thorax lung cancer scr c- |
| 75 |
| 2034 |
| 71275 |
| 26 |
| Ct angiography chest |
| 75 |
| 2035 |
| 71550 |
| 26 |
| Mri chest w/o dye |
| 75 |
| 2036 |
| 71551 |
| 26 |
| Mri chest w/dye |
| 75 |
| 2037 |
| 71552 |
| 26 |
| Mri chest w/o & w/dye |
| 75 |
| 2038 |
| 71555 |
| 26 |
| Mri angio chest w or w/o dye |
| 75 |
| 2039 |
| 72125 |
| 26 |
| Ct neck spine w/o dye |
| 75 |
| 2040 |
| 72126 |
| 26 |
| Ct neck spine w/dye |
| 75 |
| 2041 |
| 72127 |
| 26 |
| Ct neck spine w/o & w/dye |
| 90 |
| 2042 |
| 72128 |
| 26 |
| Ct chest spine w/o dye |
| 90 |
| 2043 |
| 72129 |
| 26 |
| Ct chest spine w/dye |
| 90 |
| 2044 |
| 72130 |
| 26 |
| Ct chest spine w/o & w/dye |
| 75 |
| 2045 |
| 72131 |
| 26 |
| Ct lumbar spine w/o dye |
| 75 |
| 2046 |
| 72132 |
| 26 |
| Ct lumbar spine w/dye |
| 75 |
| 2047 |
| 72133 |
| 26 |
| Ct lumbar spine w/o & w/dye |
| 90 |
| 2048 |
| 72141 |
| 26 |
| Mri neck spine w/o dye |
| 75 |
| 2049 |
| 72142 |
| 26 |
| Mri neck spine w/dye |
| 75 |
| 2050 |
| 72146 |
| 26 |
| Mri chest spine w/o dye |
| 75 |
| 2051 |
| 72147 |
| 26 |
| Mri chest spine w/dye |
| 90 |
| 2052 |
| 72148 |
| 26 |
| Mri lumbar spine w/o dye |
| 75 |
| 2053 |
| 72149 |
| 26 |
| Mri lumbar spine w/dye |
| 90 |
| 2054 |
| 72156 |
| 26 |
| Mri neck spine w/o & w/dye |
| 90 |
| 2055 |
| 72157 |
| 26 |
| Mri chest spine w/o & w/dye |
| 90 |
| 2056 |
| 72158 |
| 26 |
| Mri lumbar spine w/o & w/dye |
| 75 |
| 2057 |
| 72159 |
| 26 |
| Mr angio spine w/o&w/dye |
| 75 |
| 2058 |
| 72191 |
| 26 |
| Ct angiograph pelv w/o&w/dye |
| 75 |
| 2059 |
| 72192 |
| 26 |
| Ct pelvis w/o dye |
| 75 |
| 2060 |
| 72193 |
| 26 |
| Ct pelvis w/dye |
| 90 |
| 2061 |
| 72194 |
| 26 |
| Ct pelvis w/o & w/dye |
| 75 |
| 2062 |
| 72195 |
| 26 |
| Mri pelvis w/o dye |
| 75 |
| 2063 |
| 72196 |
| 26 |
| Mri pelvis w/dye |
| 90 |
| 2064 |
| 72197 |
| 26 |
| Mri pelvis w/o & w/dye |
| 75 |
| 2065 |
| 72198 |
| 26 |
| Mr angio pelvis w/o & w/dye |
| 75 |
| 2066 |
| 73200 |
| 26 |
| Ct upper extremity w/o dye |
| 75 |
| 2067 |
| 73201 |
| 26 |
| Ct upper extremity w/dye |
| 75 |
| 2068 |
| 73202 |
| 26 |
| Ct uppr extremity w/o&w/dye |
| 75 |
| 2069 |
| 73206 |
| 26 |
| Ct angio upr extrm w/o&w/dye |
| 75 |
| 2070 |
| 73218 |
| 26 |
| Mri upper extremity w/o dye |
| 75 |
| 2071 |
| 73219 |
| 26 |
| Mri upper extremity w/dye |
| 75 |
| 2072 |
| 73220 |
| 26 |
| Mri uppr extremity w/o&w/dye |
| 75 |
| 2073 |
| 73221 |
| 26 |
| Mri joint upr extrem w/o dye |
| 75 |
| 2074 |
| 73222 |
| 26 |
| Mri joint upr extrem w/dye |
| 70 |
| 2075 |
| 73223 |
| 26 |
| Mri joint upr extr w/o&w/dye |
| 70 |
| 2076 |
| 73225 |
| 26 |
| Mr angio upr extr w/o&w/dye |
| 75 |
| 2077 |
| 73700 |
| 26 |
| Ct lower extremity w/o dye |
| 75 |
| 2078 |
| 73701 |
| 26 |
| Ct lower extremity w/dye |
| 70 |
| 2079 |
| 73702 |
| 26 |
| Ct lwr extremity w/o&w/dye |
| 70 |
| 2080 |
| 73706 |
| 26 |
| Ct angio lwr extr w/o&w/dye |
| 70 |
| 2081 |
| 73718 |
| 26 |
| Mri lower extremity w/o dye |
| 70 |
| 2082 |
| 73719 |
| 26 |
| Mri lower extremity w/dye |
| 70 |
| 2083 |
| 73720 |
| 26 |
| Mri lwr extremity w/o&w/dye |
| 70 |
| 2084 |
| 73721 |
| 26 |
| Mri jnt of lwr extre w/o dye |
| 75 |
| 2085 |
| 73722 |
| 26 |
| Mri joint of lwr extr w/dye |
| 75 |
| 2086 |
| 73723 |
| 26 |
| Mri joint lwr extr w/o&w/dye |
| 75 |
| 2087 |
| 73725 |
| 26 |
| Mr ang lwr ext w or w/o dye |
| 90 |
| 2088 |
| 74150 |
| 26 |
| Ct abdomen w/o dye |
| 90 |
| 2089 |
| 74160 |
| 26 |
| Ct abdomen w/dye |
| 90 |
| 2090 |
| 74170 |
| 26 |
| Ct abdomen w/o & w/dye |
| 90 |
| 2091 |
| 74174 |
| 26 |
| Ct angio abd&pelv w/o&w/dye |
| 90 |
| 2092 |
| 74175 |
| 26 |
| Ct angio abdom w/o & w/dye |
| 90 |
| 2093 |
| 74176 |
| 26 |
| Ct abd & pelvis w/o contrast |
| 90 |
| 2094 |
| 74177 |
| 26 |
| Ct abd & pelv w/contrast |
| 85 |
| 2095 |
| 74178 |
| 26 |
| Ct abd & pelv 1/> regns |
| 85 |
| 2096 |
| 74181 |
| 26 |
| Mri abdomen w/o dye |
| 85 |
| 2097 |
| 74182 |
| 26 |
| Mri abdomen w/dye |
| 80 |
| 2098 |
| 74183 |
| 26 |
| Mri abdomen w/o & w/dye |
| 80 |
| 2099 |
| 74185 |
| 26 |
| Mri angio abdom w orw/o dye |
| 80 |
| 2100 |
| 75635 |
| 26 |
| Ct angio abdominal arteries |
| 75 |
| 2101 |
| 76536 |
| 26 |
| Us exam of head and neck |
| 75 |
| 2102 |
| 76604 |
| 26 |
| Us exam chest |
| 75 |
| 2103 |
| 76642 |
| 26 |
| Ultrasound breast limited |
| 75 |
| 2104 |
| 76700 |
| 26 |
| Us exam abdom complete |
| 75 |
| 2105 |
| 76706 |
| 26 |
| Us abdl aorta screen aaa |
| 75 |
| 2106 |
| 76770 |
| 26 |
| Us exam abdo back wall comp |
| 75 |
| 2107 |
| 76775 |
| 26 |
| Us exam abdo back wall lim |
| 65 |
| 2108 |
| 76811 |
| 26 |
| Ob us < 14 wks single fetus |
| 65 |
| 2109 |
| 76802 |
| 26 |
| Ob us < 14 wks addl fetus |
| 85 |
| 2110 |
| 76817 |
| 26 |
| Transvaginal us obstetric |
| 85 |
| 2111 |
| 76830 |
| 26 |
| Transvaginal us non-ob |
| 75 |
| 2112 |
| 76856 |
| 26 |
| Us exam pelvic complete |
| 75 |
| 2113 |
| 76857 |
| 26 |
| Us exam pelvic limited |
| 75 |
| 2114 |
| 76870 |
| 26 |
| Us exam scrotum |
| 75 |
| 2115 |
| 78457 |
| 26 |
| Venous thrombosis imaging |
| 75 |
| 2116 |
| 78458 |
| 26 |
| Ven thrombosis images bilat |
| 75 |
| 2117 |
| 78580 |
| 26 |
| Lung perfusion imaging |
| 75 |
| 2118 |
| 78761 |
| 26 |
| Testicular imaging w/flow |
| 75 |
| 2119 |
| 93922 |
| 26 |
| Upr/l xtremity art 2 levels |
| 75 |
| 2120 |
| 93923 |
| 26 |
| Upr/lxtr art stdy 3+ lvls |
| 75 |
| 2121 |
| 93925 |
| 26 |
| Lower extremity study |
| 75 |
| 2122 |
| 93926 |
| 26 |
| Lower extremity study |
| 75 |
| 2123 |
| 93930 |
| 26 |
| Upper extremity study |
| 75 |
| 2124 |
| 93931 |
| 26 |
| Upper extremity study |
| 75 |
| 2125 |
| 93970 |
| 26 |
| Extremity study |
| 75 |
| 2126 |
| 93971 |
| 26 |
| Extremity study |
| 75 |
| 2127 |
| 93975 |
| 26 |
| Vascular study |
| 75 |
| 2128 |
| 93976 |
| 26 |
| Vascular study |
| 75 |
| 2129 |
| 93978 |
| 26 |
| Vascular study |
| 75 |
| 2130 |
| 93979 |
| 26 |
| Vascular study |
| 75 |
Total
Period of Performance: Ordering Period 4: December 1, 2027 to November 30, 2028
| N No. |
| CPT Code |
| Mod |
| Description |
| Est. |
Qty.
| Unit |
| Proposed Unit Cost |
| CMS Unit Cost |
| % of CMS rate unit cost represents |
| Estimated Total |
Annual Cost (for evaluation purposes)
| 3001 |
| 70450 |
| 26 |
| Ct head/brain w/o dye |
| 90 |
| 3002 |
| 70460 |
| 26 |
| Ct head/brain w/dye |
| 90 |
| 3003 |
| 70470 |
| 26 |
| Ct head/brain w/o & w/dye |
| 90 |
| 3004 |
| 70480 |
| 26 |
| Ct orbit/ear/fossa w/o dye |
| 75 |
| 3005 |
| 70481 |
| 26 |
| Ct orbit/ear/fossa w/dye |
| 75 |
| 3006 |
| 70482 |
| 26 |
| Ct orbit/ear/fossa w/o&w/dye |
| 75 |
| 3007 |
| 70486 |
| 26 |
| Ct maxillofacial w/o dye |
| 75 |
| 3008 |
| 70487 |
| 26 |
| Ct maxillofacial w/dye |
| 75 |
| 3009 |
| 70488 |
| 26 |
| Ct maxillofacial w/o & w/dye |
| 75 |
| 3010 |
| 70490 |
| 26 |
| Ct soft tissue neck w/o dye |
| 75 |
| 3011 |
| 70491 |
| 26 |
| Ct soft tissue neck w/dye |
| 75 |
| 3012 |
| 70492 |
| 26 |
| Ct sft tsue nck w/o & w/dye |
| 75 |
| 3013 |
| 70496 |
| 26 |
| Ct angiography head |
| 75 |
| 3014 |
| 70498 |
| 26 |
| Ct angiography neck |
| 75 |
| 3015 |
| 70540 |
| 26 |
| Mri orbit/face/neck w/o dye |
| 75 |
| 3016 |
| 70542 |
| 26 |
| Mri orbit/face/neck w/dye |
| 75 |
| 3017 |
| 70543 |
| 26 |
| Mri orbt/fac/nck w/o &w/dye |
| 75 |
| 3018 |
| 70544 |
| 26 |
| Mr angiography head w/o dye |
| 75 |
| 3019 |
| 70545 |
| 26 |
| Mr angiography head w/dye |
| 75 |
| 3020 |
| 70546 |
| 26 |
| Mr angiograph head w/o&w/dye |
| 75 |
| 3021 |
| 70547 |
| 26 |
| Mr angiography neck w/o dye |
| 75 |
| 3022 |
| 70548 |
| 26 |
| Mr angiography neck w/dye |
| 75 |
| 3023 |
| 70549 |
| 26 |
| Mr angiograph neck w/o&w/dye |
| 90 |
| 3024 |
| 70551 |
| 26 |
| Mri brain stem w/o dye |
| 90 |
| 3025 |
| 70552 |
| 26 |
| Mri brain stem w/dye |
| 90 |
| 3026 |
| 70553 |
| 26 |
| Mri brain stem w/o & w/dye |
| 75 |
| 3027 |
| 70557 |
| 26 |
| Mri brain w/o dye |
| 75 |
| 3028 |
| 70558 |
| 26 |
| Mri brain w/dye |
| 75 |
| 3029 |
| 70559 |
| 26 |
| Mri brain w/o & w/dye |
| 75 |
| 3030 |
| 71250 |
| 26 |
| Ct thorax dx c- |
| 75 |
| 3031 |
| 71260 |
| 26 |
| Ct thorax dx c+ |
| 75 |
| 3032 |
| 71270 |
| 26 |
| Ct thorax dx c-/c+ |
| 75 |
| 3033 |
| 71271 |
| 26 |
| Ct thorax lung cancer scr c- |
| 75 |
| 3034 |
| 71275 |
| 26 |
| Ct angiography chest |
| 75 |
| 3035 |
| 71550 |
| 26 |
| Mri chest w/o dye |
| 75 |
| 3036 |
| 71551 |
| 26 |
| Mri chest w/dye |
| 75 |
| 3037 |
| 71552 |
| 26 |
| Mri chest w/o & w/dye |
| 75 |
| 3038 |
| 71555 |
| 26 |
| Mri angio chest w or w/o dye |
| 75 |
| 3039 |
| 72125 |
| 26 |
| Ct neck spine w/o dye |
| 75 |
| 3040 |
| 72126 |
| 26 |
| Ct neck spine w/dye |
| 75 |
| 3041 |
| 72127 |
| 26 |
| Ct neck spine w/o & w/dye |
| 90 |
| 3042 |
| 72128 |
| 26 |
| Ct chest spine w/o dye |
| 90 |
| 3043 |
| 72129 |
| 26 |
| Ct chest spine w/dye |
| 90 |
| 3044 |
| 72130 |
| 26 |
| Ct chest spine w/o & w/dye |
| 75 |
| 3045 |
| 72131 |
| 26 |
| Ct lumbar spine w/o dye |
| 75 |
| 3046 |
| 72132 |
| 26 |
| Ct lumbar spine w/dye |
| 75 |
| 3047 |
| 72133 |
| 26 |
| Ct lumbar spine w/o & w/dye |
| 90 |
| 3048 |
| 72141 |
| 26 |
| Mri neck spine w/o dye |
| 75 |
| 3049 |
| 72142 |
| 26 |
| Mri neck spine w/dye |
| 75 |
| 3050 |
| 72146 |
| 26 |
| Mri chest spine w/o dye |
| 75 |
| 3051 |
| 72147 |
| 26 |
| Mri chest spine w/dye |
| 90 |
| 3052 |
| 72148 |
| 26 |
| Mri lumbar spine w/o dye |
| 75 |
| 3053 |
| 72149 |
| 26 |
| Mri lumbar spine w/dye |
| 90 |
| 3054 |
| 72156 |
| 26 |
| Mri neck spine w/o & w/dye |
| 90 |
| 3055 |
| 72157 |
| 26 |
| Mri chest spine w/o & w/dye |
| 90 |
| 3056 |
| 72158 |
| 26 |
| Mri lumbar spine w/o & w/dye |
| 75 |
| 3057 |
| 72159 |
| 26 |
| Mr angio spine w/o&w/dye |
| 75 |
| 3058 |
| 72191 |
| 26 |
| Ct angiograph pelv w/o&w/dye |
| 75 |
| 3059 |
| 72192 |
| 26 |
| Ct pelvis w/o dye |
| 75 |
| 3060 |
| 72193 |
| 26 |
| Ct pelvis w/dye |
| 90 |
| 3061 |
| 72194 |
| 26 |
| Ct pelvis w/o & w/dye |
| 75 |
| 3062 |
| 72195 |
| 26 |
| Mri pelvis w/o dye |
| 75 |
| 3063 |
| 72196 |
| 26 |
| Mri pelvis w/dye |
| 90 |
| 3064 |
| 72197 |
| 26 |
| Mri pelvis w/o & w/dye |
| 75 |
| 3065 |
| 72198 |
| 26 |
| Mr angio pelvis w/o & w/dye |
| 75 |
| 3066 |
| 73200 |
| 26 |
| Ct upper extremity w/o dye |
| 75 |
| 3067 |
| 73201 |
| 26 |
| Ct upper extremity w/dye |
| 75 |
| 3068 |
| 73202 |
| 26 |
| Ct uppr extremity w/o&w/dye |
| 75 |
| 3069 |
| 73206 |
| 26 |
| Ct angio upr extrm w/o&w/dye |
| 75 |
| 3070 |
| 73218 |
| 26 |
| Mri upper extremity w/o dye |
| 75 |
| 3071 |
| 73219 |
| 26 |
| Mri upper extremity w/dye |
| 75 |
| 3072 |
| 73220 |
| 26 |
| Mri uppr extremity w/o&w/dye |
| 75 |
| 3073 |
| 73221 |
| 26 |
| Mri joint upr extrem w/o dye |
| 75 |
| 3074 |
| 73222 |
| 26 |
| Mri joint upr extrem w/dye |
| 70 |
| 3075 |
| 73223 |
| 26 |
| Mri joint upr extr w/o&w/dye |
| 70 |
| 3076 |
| 73225 |
| 26 |
| Mr angio upr extr w/o&w/dye |
| 75 |
| 3077 |
| 73700 |
| 26 |
| Ct lower extremity w/o dye |
| 75 |
| 3078 |
| 73701 |
| 26 |
| Ct lower extremity w/dye |
| 70 |
| 3079 |
| 73702 |
| 26 |
| Ct lwr extremity w/o&w/dye |
| 70 |
| 3080 |
| 73706 |
| 26 |
| Ct angio lwr extr w/o&w/dye |
| 70 |
| 3081 |
| 73718 |
| 26 |
| Mri lower extremity w/o dye |
| 70 |
| 3082 |
| 73719 |
| 26 |
| Mri lower extremity w/dye |
| 70 |
| 3083 |
| 73720 |
| 26 |
| Mri lwr extremity w/o&w/dye |
| 70 |
| 3084 |
| 73721 |
| 26 |
| Mri jnt of lwr extre w/o dye |
| 75 |
| 3085 |
| 73722 |
| 26 |
| Mri joint of lwr extr w/dye |
| 75 |
| 3086 |
| 73723 |
| 26 |
| Mri joint lwr extr w/o&w/dye |
| 75 |
| 3087 |
| 73725 |
| 26 |
| Mr ang lwr ext w or w/o dye |
| 90 |
| 3088 |
| 74150 |
| 26 |
| Ct abdomen w/o dye |
| 90 |
| 3089 |
| 74160 |
| 26 |
| Ct abdomen w/dye |
| 90 |
| 3090 |
| 74170 |
| 26 |
| Ct abdomen w/o & w/dye |
| 90 |
| 3091 |
| 74174 |
| 26 |
| Ct angio abd&pelv w/o&w/dye |
| 90 |
| 3092 |
| 74175 |
| 26 |
| Ct angio abdom w/o & w/dye |
| 90 |
| 3093 |
| 74176 |
| 26 |
| Ct abd & pelvis w/o contrast |
| 90 |
| 3094 |
| 74177 |
| 26 |
| Ct abd & pelv w/contrast |
| 85 |
| 3095 |
| 74178 |
| 26 |
| Ct abd & pelv 1/> regns |
| 85 |
| 3096 |
| 74181 |
| 26 |
| Mri abdomen w/o dye |
| 85 |
| 3097 |
| 74182 |
| 26 |
| Mri abdomen w/dye |
| 80 |
| 3098 |
| 74183 |
| 26 |
| Mri abdomen w/o & w/dye |
| 80 |
| 3099 |
| 74185 |
| 26 |
| Mri angio abdom w orw/o dye |
| 80 |
| 3100 |
| 75635 |
| 26 |
| Ct angio abdominal arteries |
| 75 |
| 3101 |
| 76536 |
| 26 |
| Us exam of head and neck |
| 75 |
| 3102 |
| 76604 |
| 26 |
| Us exam chest |
| 75 |
| 3103 |
| 76642 |
| 26 |
| Ultrasound breast limited |
| 75 |
| 3104 |
| 76700 |
| 26 |
| Us exam abdom complete |
| 75 |
| 3105 |
| 76706 |
| 26 |
| Us abdl aorta screen aaa |
| 75 |
| 3106 |
| 76770 |
| 26 |
| Us exam abdo back wall comp |
| 75 |
| 3107 |
| 76775 |
| 26 |
| Us exam abdo back wall lim |
| 65 |
| 3108 |
| 76811 |
| 26 |
| Ob us < 14 wks single fetus |
| 65 |
| 3109 |
| 76802 |
| 26 |
| Ob us < 14 wks addl fetus |
| 85 |
| 3110 |
| 76817 |
| 26 |
| Transvaginal us obstetric |
| 85 |
| 3111 |
| 76830 |
| 26 |
| Transvaginal us non-ob |
| 75 |
| 3112 |
| 76856 |
| 26 |
| Us exam pelvic complete |
| 75 |
| 3113 |
| 76857 |
| 26 |
| Us exam pelvic limited |
| 75 |
| 3114 |
| 76870 |
| 26 |
| Us exam scrotum |
| 75 |
| 3115 |
| 78457 |
| 26 |
| Venous thrombosis imaging |
| 75 |
| 3116 |
| 78458 |
| 26 |
| Ven thrombosis images bilat |
| 75 |
| 3117 |
| 78580 |
| 26 |
| Lung perfusion imaging |
| 75 |
| 3118 |
| 78761 |
| 26 |
| Testicular imaging w/flow |
| 75 |
| 3119 |
| 93922 |
| 26 |
| Upr/l xtremity art 2 levels |
| 75 |
| 3120 |
| 93923 |
| 26 |
| Upr/lxtr art stdy 3+ lvls |
| 75 |
| 3121 |
| 93925 |
| 26 |
| Lower extremity study |
| 75 |
| 3122 |
| 93926 |
| 26 |
| Lower extremity study |
| 75 |
| 3123 |
| 93930 |
| 26 |
| Upper extremity study |
| 75 |
| 3124 |
| 93931 |
| 26 |
| Upper extremity study |
| 75 |
| 3125 |
| 93970 |
| 26 |
| Extremity study |
| 75 |
| 3126 |
| 93971 |
| 26 |
| Extremity study |
| 75 |
| 3127 |
| 93975 |
| 26 |
| Vascular study |
| 75 |
| 3128 |
| 93976 |
| 26 |
| Vascular study |
| 75 |
| 3129 |
| 93978 |
| 26 |
| Vascular study |
| 75 |
| 3130 |
| 93979 |
| 26 |
| Vascular study |
| 75 |
Total
Period of Performance: Ordering Period 5: December 1, 2028 to November 30, 2029
| N No. |
| CPT Code |
| Mod |
| Description |
| Est. |
Qty.
| Unit |
| Proposed Unit Cost |
| CMS Unit Cost |
| % of CMS rate unit cost represents |
| Estimated Total |
Annual Cost (for evaluation purposes)
| 4001 |
| 70450 |
| 26 |
| Ct head/brain w/o dye |
| 90 |
| 4002 |
| 70460 |
| 26 |
| Ct head/brain w/dye |
| 90 |
| 4003 |
| 70470 |
| 26 |
| Ct head/brain w/o & w/dye |
| 90 |
| 4004 |
| 70480 |
| 26 |
| Ct orbit/ear/fossa w/o dye |
| 75 |
| 4005 |
| 70481 |
| 26 |
| Ct orbit/ear/fossa w/dye |
| 75 |
| 4006 |
| 70482 |
| 26 |
| Ct orbit/ear/fossa w/o&w/dye |
| 75 |
| 4007 |
| 70486 |
| 26 |
| Ct maxillofacial w/o dye |
| 75 |
| 4008 |
| 70487 |
| 26 |
| Ct maxillofacial w/dye |
| 75 |
| 4009 |
| 70488 |
| 26 |
| Ct maxillofacial w/o & w/dye |
| 75 |
| 4010 |
| 70490 |
| 26 |
| Ct soft tissue neck w/o dye |
| 75 |
| 4011 |
| 70491 |
| 26 |
| Ct soft tissue neck w/dye |
| 75 |
| 4012 |
| 70492 |
| 26 |
| Ct sft tsue nck w/o & w/dye |
| 75 |
| 4013 |
| 70496 |
| 26 |
| Ct angiography head |
| 75 |
| 4014 |
| 70498 |
| 26 |
| Ct angiography neck |
| 75 |
| 4015 |
| 70540 |
| 26 |
| Mri orbit/face/neck w/o dye |
| 75 |
| 4016 |
| 70542 |
| 26 |
| Mri orbit/face/neck w/dye |
| 75 |
| 4017 |
| 70543 |
| 26 |
| Mri orbt/fac/nck w/o &w/dye |
| 75 |
| 4018 |
| 70544 |
| 26 |
| Mr angiography head w/o dye |
| 75 |
| 4019 |
| 70545 |
| 26 |
| Mr angiography head w/dye |
| 75 |
| 4020 |
| 70546 |
| 26 |
| Mr angiograph head w/o&w/dye |
| 75 |
| 4021 |
| 70547 |
| 26 |
| Mr angiography neck w/o dye |
| 75 |
| 4022 |
| 70548 |
| 26 |
| Mr angiography neck w/dye |
| 75 |
| 4023 |
| 70549 |
| 26 |
| Mr angiograph neck w/o&w/dye |
| 90 |
| 4024 |
| 70551 |
| 26 |
| Mri brain stem w/o dye |
| 90 |
| 4025 |
| 70552 |
| 26 |
| Mri brain stem w/dye |
| 90 |
| 4026 |
| 70553 |
| 26 |
| Mri brain stem w/o & w/dye |
| 75 |
| 4027 |
| 70557 |
| 26 |
| Mri brain w/o dye |
| 75 |
| 4028 |
| 70558 |
| 26 |
| Mri brain w/dye |
| 75 |
| 4029 |
| 70559 |
| 26 |
| Mri brain w/o & w/dye |
| 75 |
| 4030 |
| 71250 |
| 26 |
| Ct thorax dx c- |
| 75 |
| 4031 |
| 71260 |
| 26 |
| Ct thorax dx c+ |
| 75 |
| 4032 |
| 71270 |
| 26 |
| Ct thorax dx c-/c+ |
| 75 |
| 4033 |
| 71271 |
| 26 |
| Ct thorax lung cancer scr c- |
| 75 |
| 4034 |
| 71275 |
| 26 |
| Ct angiography chest |
| 75 |
| 4035 |
| 71550 |
| 26 |
| Mri chest w/o dye |
| 75 |
| 4036 |
| 71551 |
| 26 |
| Mri chest w/dye |
| 75 |
| 4037 |
| 71552 |
| 26 |
| Mri chest w/o & w/dye |
| 75 |
| 4038 |
| 71555 |
| 26 |
| Mri angio chest w or w/o dye |
| 75 |
| 4039 |
| 72125 |
| 26 |
| Ct neck spine w/o dye |
| 75 |
| 4040 |
| 72126 |
| 26 |
| Ct neck spine w/dye |
| 75 |
| 4041 |
| 72127 |
| 26 |
| Ct neck spine w/o & w/dye |
| 90 |
| 4042 |
| 72128 |
| 26 |
| Ct chest spine w/o dye |
| 90 |
| 4043 |
| 72129 |
| 26 |
| Ct chest spine w/dye |
| 90 |
| 4044 |
| 72130 |
| 26 |
| Ct chest spine w/o & w/dye |
| 75 |
| 4045 |
| 72131 |
| 26 |
| Ct lumbar spine w/o dye |
| 75 |
| 4046 |
| 72132 |
| 26 |
| Ct lumbar spine w/dye |
| 75 |
| 4047 |
| 72133 |
| 26 |
| Ct lumbar spine w/o & w/dye |
| 90 |
| 4048 |
| 72141 |
| 26 |
| Mri neck spine w/o dye |
| 75 |
| 4049 |
| 72142 |
| 26 |
| Mri neck spine w/dye |
| 75 |
| 4050 |
| 72146 |
| 26 |
| Mri chest spine w/o dye |
| 75 |
| 4051 |
| 72147 |
| 26 |
| Mri chest spine w/dye |
| 90 |
| 4052 |
| 72148 |
| 26 |
| Mri lumbar spine w/o dye |
| 75 |
| 4053 |
| 72149 |
| 26 |
| Mri lumbar spine w/dye |
| 90 |
| 4054 |
| 72156 |
| 26 |
| Mri neck spine w/o & w/dye |
| 90 |
| 4055 |
| 72157 |
| 26 |
| Mri chest spine w/o & w/dye |
| 90 |
| 4056 |
| 72158 |
| 26 |
| Mri lumbar spine w/o & w/dye |
| 75 |
| 4057 |
| 72159 |
| 26 |
| Mr angio spine w/o&w/dye |
| 75 |
| 4058 |
| 72191 |
| 26 |
| Ct angiograph pelv w/o&w/dye |
| 75 |
| 4059 |
| 72192 |
| 26 |
| Ct pelvis w/o dye |
| 75 |
| 4060 |
| 72193 |
| 26 |
| Ct pelvis w/dye |
| 90 |
| 4061 |
| 72194 |
| 26 |
| Ct pelvis w/o & w/dye |
| 75 |
| 4062 |
| 72195 |
| 26 |
| Mri pelvis w/o dye |
| 75 |
| 4063 |
| 72196 |
| 26 |
| Mri pelvis w/dye |
| 90 |
| 4064 |
| 72197 |
| 26 |
| Mri pelvis w/o & w/dye |
| 75 |
| 4065 |
| 72198 |
| 26 |
| Mr angio pelvis w/o & w/dye |
| 75 |
| 4066 |
| 73200 |
| 26 |
| Ct upper extremity w/o dye |
| 75 |
| 4067 |
| 73201 |
| 26 |
| Ct upper extremity w/dye |
| 75 |
| 4068 |
| 73202 |
| 26 |
| Ct uppr extremity w/o&w/dye |
| 75 |
| 4069 |
| 73206 |
| 26 |
| Ct angio upr extrm w/o&w/dye |
| 75 |
| 4070 |
| 73218 |
| 26 |
| Mri upper extremity w/o dye |
| 75 |
| 4071 |
| 73219 |
| 26 |
| Mri upper extremity w/dye |
| 75 |
| 4072 |
| 73220 |
| 26 |
| Mri uppr extremity w/o&w/dye |
| 75 |
| 4073 |
| 73221 |
| 26 |
| Mri joint upr extrem w/o dye |
| 75 |
| 4074 |
| 73222 |
| 26 |
| Mri joint upr extrem w/dye |
| 70 |
| 4075 |
| 73223 |
| 26 |
| Mri joint upr extr w/o&w/dye |
| 70 |
| 4076 |
| 73225 |
| 26 |
| Mr angio upr extr w/o&w/dye |
| 75 |
| 4077 |
| 73700 |
| 26 |
| Ct lower extremity w/o dye |
| 75 |
| 4078 |
| 73701 |
| 26 |
| Ct lower extremity w/dye |
| 70 |
| 4079 |
| 73702 |
| 26 |
| Ct lwr extremity w/o&w/dye |
| 70 |
| 4080 |
| 73706 |
| 26 |
| Ct angio lwr extr w/o&w/dye |
| 70 |
| 4081 |
| 73718 |
| 26 |
| Mri lower extremity w/o dye |
| 70 |
| 4082 |
| 73719 |
| 26 |
| Mri lower extremity w/dye |
| 70 |
| 4083 |
| 73720 |
| 26 |
| Mri lwr extremity w/o&w/dye |
| 70 |
| 4084 |
| 73721 |
| 26 |
| Mri jnt of lwr extre w/o dye |
| 75 |
| 4085 |
| 73722 |
| 26 |
| Mri joint of lwr extr w/dye |
| 75 |
| 4086 |
| 73723 |
| 26 |
| Mri joint lwr extr w/o&w/dye |
| 75 |
| 4087 |
| 73725 |
| 26 |
| Mr ang lwr ext w or w/o dye |
| 90 |
| 4088 |
| 74150 |
| 26 |
| Ct abdomen w/o dye |
| 90 |
| 4089 |
| 74160 |
| 26 |
| Ct abdomen w/dye |
| 90 |
| 4090 |
| 74170 |
| 26 |
| Ct abdomen w/o & w/dye |
| 90 |
| 4091 |
| 74174 |
| 26 |
| Ct angio abd&pelv w/o&w/dye |
| 90 |
| 4092 |
| 74175 |
| 26 |
| Ct angio abdom w/o & w/dye |
| 90 |
| 4093 |
| 74176 |
| 26 |
| Ct abd & pelvis w/o contrast |
| 90 |
| 4094 |
| 74177 |
| 26 |
| Ct abd & pelv w/contrast |
| 85 |
| 4095 |
| 74178 |
| 26 |
| Ct abd & pelv 1/> regns |
| 85 |
| 4096 |
| 74181 |
| 26 |
| Mri abdomen w/o dye |
| 85 |
| 4097 |
| 74182 |
| 26 |
| Mri abdomen w/dye |
| 80 |
| 4098 |
| 74183 |
| 26 |
| Mri abdomen w/o & w/dye |
| 80 |
| 4099 |
| 74185 |
| 26 |
| Mri angio abdom w orw/o dye |
| 80 |
| 4100 |
| 75635 |
| 26 |
| Ct angio abdominal arteries |
| 75 |
| 4101 |
| 76536 |
| 26 |
| Us exam of head and neck |
| 75 |
| 4102 |
| 76604 |
| 26 |
| Us exam chest |
| 75 |
| 4103 |
| 76642 |
| 26 |
| Ultrasound breast limited |
| 75 |
| 4104 |
| 76700 |
| 26 |
| Us exam abdom complete |
| 75 |
| 4105 |
| 76706 |
| 26 |
| Us abdl aorta screen aaa |
| 75 |
| 4106 |
| 76770 |
| 26 |
| Us exam abdo back wall comp |
| 75 |
| 4107 |
| 76775 |
| 26 |
| Us exam abdo back wall lim |
| 65 |
| 4108 |
| 76811 |
| 26 |
| Ob us < 14 wks single fetus |
| 65 |
| 4109 |
| 76802 |
| 26 |
| Ob us < 14 wks addl fetus |
| 85 |
| 4110 |
| 76817 |
| 26 |
| Transvaginal us obstetric |
| 85 |
| 4111 |
| 76830 |
| 26 |
| Transvaginal us non-ob |
| 75 |
| 4112 |
| 76856 |
| 26 |
| Us exam pelvic complete |
| 75 |
| 4113 |
| 76857 |
| 26 |
| Us exam pelvic limited |
| 75 |
| 4114 |
| 76870 |
| 26 |
| Us exam scrotum |
| 75 |
| 4115 |
| 78457 |
| 26 |
| Venous thrombosis imaging |
| 75 |
| 4116 |
| 78458 |
| 26 |
| Ven thrombosis images bilat |
| 75 |
| 4117 |
| 78580 |
| 26 |
| Lung perfusion imaging |
| 75 |
| 4118 |
| 78761 |
| 26 |
| Testicular imaging w/flow |
| 75 |
| 4119 |
| 93922 |
| 26 |
| Upr/l xtremity art 2 levels |
| 75 |
| 4120 |
| 93923 |
| 26 |
| Upr/lxtr art stdy 3+ lvls |
| 75 |
| 4121 |
| 93925 |
| 26 |
| Lower extremity study |
| 75 |
| 4122 |
| 93926 |
| 26 |
| Lower extremity study |
| 75 |
| 4123 |
| 93930 |
| 26 |
| Upper extremity study |
| 75 |
| 4124 |
| 93931 |
| 26 |
| Upper extremity study |
| 75 |
| 4125 |
| 93970 |
| 26 |
| Extremity study |
| 75 |
| 4126 |
| 93971 |
| 26 |
| Extremity study |
| 75 |
| 4127 |
| 93975 |
| 26 |
| Vascular study |
| 75 |
| 4128 |
| 93976 |
| 26 |
| Vascular study |
| 75 |
| 4129 |
| 93978 |
| 26 |
| Vascular study |
| 75 |
| 4130 |
| 93979 |
| 26 |
| Vascular study |
| 75 |
Total
Total for base performance period and all option years: $_________________________