E448

PDF page 382 / D24

DIAGNOSTIC RADIOLOGY
MISCELLANEOUS EXAMINATIONS
                                                                                                       H             P
X151 Cordotomy, percutaneous.......................................................                   48.40         34.85
X163 Dacrocystogram......................................................................             29.60         11.60
  Discogram(s)
X164   - one or more levels ...........................................................               28.95         25.10
X167 Fistula or sinus........................................................................         21.50         17.55
X169 Laminogram, planigram, tomogram........................................                          39.90         12.40
X170 Laryngogram...........................................................................           28.95         23.00
X171 Lymphangiogram ....................................................................              49.00         25.15
X192 Mammary ductography ...........................................................                  25.05         11.60
  Mammogram
    No signs or symptoms
X172 - unilateral.............................................................................        28.05         21.15
X178 - bilateral...............................................................................       37.15         33.85
    Signs or symptoms
X184 - unilateral.............................................................................        28.05         21.15
X185 - bilateral...............................................................................       37.15         33.85
E448    - with 3D tomosynthesis, to X172C, X178C, X184C, or
          X185C ................................................................ add 50%
      [Commentary:
      “Signs or symptoms” pertains to individuals with identified signs or symptoms or follow-up of
      established disease.
      “No Signs or Symptoms” refers to individuals where the sole reason for the request for a
      mammogram is for an identified risk factor in accordance with clinical practice guidelines]
      Payment rules:
      X169 and X417 are not eligible for payment with X172, X178, X184, or X185.
      Claims submission instructions:
      Where a patient requires an additional mammogram on the same day using a different
      mammogram modality, consistent with practice guidelines, submit claims for payment for the
      additional mammogram using the manual review indicator.

Master, record 1169. Record Layout PDF, page 1.

E44820260401999999990000000000000000000000000000000000000000010000000000100

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