Advanced Family - PSOT



Medicos para la Familia

(Rev. 09-1-21)-WMR

ULTRASOUND/X-RAYS

|PATIENT NAME |

|DATE: |

|IMAGING |

| Ultrasound |

|Abdominal Complete (2 organs*)______76700 $200 |

|Abdominal Limited (1 organ*) ______76705 $150 |

|Breast Ultrasound 76645 $200 |

|Gyn transabdominal ______76856 $200 |

| |

|OB Quick Look ______76805 $150 |

|OB Complete with photos ______76811 $200 |

|OB 1st Trimester ______76801 $150 |

|Scrotum ultrasound 76870 $200 |

|Transvaginal Pregnant ______76817 $150 |

|Transvaginal not pregnant includes ovaries, culde sac ______76830 $200 |

|RADIOGRAPHS[X-RAYS] |

|ABDOMENPelvis |

|Abdomen ______74000 $ 60 |

|Flat and Upright ______74020 $ 100 |

|Pelvis & Bilateral Hips ______73520 $100 |

|Pelvic, standing, AP ______72170 $60 |

|ARM/HAND |

|Elbow, AP & Lateral ______73070 $ 60 |

|Finger (min 2 views) ______73140 $ 60 |

|Forearm AP/Lateral ______73090 $ 60 |

|Hand (2 views) ______73120 $ 60 |

|Wrist, AP & Lat ______73100 $ 60 |

|CHEST/ Clavicle |

| |

|Chest PA & Lateral ______71020 $ 60 |

|Clavicle ______73000 $ 60 |

|FACE/SKULL |

|Mandible-jaw |

|Nasal (min 3 views) ______70160 $100 |

|Sinus - < 3 views ______70210 $ 60 |

|Skull, less than 4 views ______70250 $100 |

|LEG/FOOT |

|Ankle, AP & LAT, oblique ______73610 $ 60 |

|Femur (complete) ______73550 $ 60 |

|Foot (complete) ______73630 $ 60 |

|Foot, AP & Oblique ______73620 $ 60 |

|Hips, Bilateral & Pelvis ______73520 $100 |

|Knee, AP & Lat ______73560 $ 60 |

|Tibia/Fib AP & Lat ______73590 $ 60 |

|Toe(s) (min 2 views) ______73660 $ 60 |

| |

| JOINT PAIN ICD-9-DIAGNOSTIC CODES | |

|Ankle 719.47 Multiple joints 719.49 | |

|Arm,distal 719.43 Shoulder719.41 | |

|Hand 719.44 Hip strain 843.9 | |

|Back Strain 847.2 Leg, lower 719.46 | |

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|Also, see FAMILY MEDICINE-er billing page | |

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|SHOULDER |

|Shoulder, Ext & Int Rotation ______73030 $50 |

|SPINE |

|Cervical Series (4 views) ______72050 $200 |

|Cervical Spine (5 views) ______72052 $250 |

|Thoracic spine AP & Lateral ______72070 $100 |

|L-Spine, AP & Lat ______72100 $100 |

|OTHER |

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|99370 DVT femoral compression US $300 |

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|Care of Miscarriage |

|Dilation and Curettage 59812 $400 |

|Plus injections for preprocedure analgesia, antibiotics |

|Plus postop antibiotics, analgesia, path when indicated |

|Consider followup visit costs |

|Consider limited Gyn ultraound for assist of procedure |

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|DIAGNOSIS FOR SERVICES ON THIS SHEET |

|1. |

|2. |

| |

|Patient Name: _______________________________ |

|Date: ___________________________________________ |

|MD/DO Signature: ___________________________ |

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