Loren Data's SAM Daily™

FBO DAILY ISSUE OF NOVEMBER 24, 2011 FBO #3652
DOCUMENT

Q -- Combined Solicitation for Radiological Services, Mammography and MRI for eligible veterans referred from the Birmingham VA Medical Center (BVAMC) and Community Based Outpatient Clinics. - Attachment

Notice Date

11/22/2011
 

Notice Type

Attachment
 

NAICS

621512 — Diagnostic Imaging Centers
 

Contracting Office

Department of Veterans Affairs;Birmingham VA Medical Center;700 South 19th Street;Birmingham AL 35233
 

ZIP Code

35233
 

Solicitation Number

VA24711RP0066
 

Response Due

12/7/2011
 

Archive Date

3/6/2012
 

Point of Contact

Jayme Skinner
 

E-Mail Address

3-8101,
 

Small Business Set-Aside

N/A
 

Description

This is a pre-solicitation notice for Radiological Services in accordance with FAR Part 5 The Department of Veterans Affairs, Birmingham VA Medical Center (BVAMC), 700 South 19th Street, Birmingham, AL 35233 is seeking sources for a potential contract to provide Radiological Services, and/or Mammography and/or MRI for eligible veterans referred from the Birmingham VA Medical Center (BVAMC) and Community Based Outpatient Clinics (CBOC). For Radiology Services: The contractor ™s facility must be within 15 miles of the CBOC VA facility that the contractor proposes to provide radiologic services. The addresses are the following: Anniston/Oxford Community Based Outpatient Clinic, 96 Ali Way Creekside South, Oxford, AL 36203; Childersburg Community Based Outpatient Clinic, 151 9th Avenue N. W., Childersburg, AL 35044; Decatur/Madison Community Based Outpatient Clinic, 8075 Madison Blvd., Suite 101 Madison, AL 35758; Gadsden Community Based Outpatient Clinic, 206 Rescia Drive, Gadsden, AL 35906; Huntsville Community Based Outpatient Clinic, 301 Governor's Drive, S.W., Huntsville, AL 35801; Jasper Community Based Outpatient Clinic, 3400 Hwy 78 East, Suite 215, Jasper, AL 35501; Muscle Shoals Community Based Outpatient Clinic, 422 DD Cox Blvd., Sheffield, AL 35660; Guntersville Community Based Outpatient Clinic. 101 Judysmith Drive, Guntersville, AL 35976. For Mammography Services: Services are to be provided within 15 miles of the Birmingham VA Medical Center. For MRI Radiological Services: Services are to be provided within 15 miles of the Birmingham VA Medical Center. The intended contract is anticipated as a one base year, with 4 option years. This is a notice that a solicitation will be posted for Radiological Services as follows: The Base and Option Year(s) of the Contract are based on Period of Performance (POP) of 1 year based on a 12 month calendar year. The guaranteed minimum contract amount, including the base year and any option years exercised, is $10,000.00 and the maximum contract amount, including the base year and any option years exercised, shall not exceed $1,250,000.00. Orders will be placed at time of award (or at time of option(s) exercised if applicable) for the estimated quantity for that period of performance. The solicitation (Request for Proposal) will be posted on 7 Dec 2011 via www.fbo.gov under VA-247-11-RP-066 The Contractor shall provide and perform requested radiological services and/or mammography and/or MRI for eligible veterans referred from the Birmingham VA Medical Center (BVAMC) and Community Based Outpatient Clinics as prescribed by the VA attending physician to the beneficiaries of the Birmingham Department of Veterans Affairs Medical Center (BVAMC). Mammography includes screening mammograms, unilateral mammography, bilateral diagnostic mammography, breast ultrasounds, ultrasound guided breast biopsy, ultrasound guided cyst aspiration, fine needle breast biopsy, Stereotactic breast biopsy, unilateral Magnetic Resonance Imaging (MRI), bilateral Magnetic Resonance Imaging (MRI), Computer Aided Detection Technology and all related pathology reporting. Updated procedures will be added to this contract by written modification in accordance with the contract specifications. The BVAMC computerized order form shall serve as an official physician order for service and the ordering physician listed on this form shall serve as the ordering physician of record. This computerized form shall contain at a minimum the following information: 1)Patient ™s full name 2)Social Security number 3)Type of service requested 4)Reason for procedure 5)Attending physician name 6)Date test ordered Contractor shall provide and perform services in the following areas: 1.Plain radiography 2.Urgent CT procedures 3.Urgent MRI procedures 4.Urgent Ultra sound procedures 5.Mammogram Procedures 6.Other/additional Mammography/Radiology procedures, as requested 7.MRI Closed 8.MRI Open 9.MRI Stand Up 10.Other X-Ray procedures as requested 11.Other Radiology procedures, as requested (Technical and Professional Component) and approved by BVAMC Chief of Radiology The anticipated award date: 1 Feb 2012 The schedule is shown below: BASE YEAR: 1 Feb 2011 “ 31 Jan 2012 CLIN 0001:Anniston/Oxford Community Based Outpatient Clinic 96 Ali Way Creekside South, Oxford, AL 36203 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0001AA ABDOMEN 1 VIEW/KUB 74000 1 EA 0001AB ABDOMEN 2 VIEWS 74010 3 EA 0001AC ANKLE 3 OR MORE VIEWS 73610 8 EA 0001AD BARIUM SWALLOW 74220 3 EA 0001AE CHEST 2 VIEWS PA&LAT 71020 45 EA 0001AF CHEST SINGLE VIEW 71010 1 EA 0001AG CLAVICLE 73000 1 EA 0001AH CT ABDOMEN W&W/O CONT 74170 2 EA 0001AI CT ABDOMEN W/O CONT 74150 2 EA 0001AJ CT HEAD W/O CONT 70450 2 EA 0001AK CT PELVIS W&W/O CONT 72194 2 EA 0001AL CT PELVIS W/O CONT 72192 2 EA 0001AM CT THORAX W/O CONT 71250 3 EA 0001AN ELBOW 2 VIEWS 73070 2 EA 0001AO FOOT 3 OR MORE VIEWS 73630 5 EA 0001AP HAND 3 OR MORE VIEWS 73130 5 EA 0001AQ HIP 2 OR MORE VIEWS 73510 17 EA 0001AR INJECTION, REGADENOSON J2785 8 EA 0001AS KNEE 2 VIEWS 73560 20 EA 0001AT KNEE A/P WT.BEAR W LAT FLEX 73562 5 EA 0001AU KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 1 EA 0001AV MAMMO SCREENING, 2 FILMS 77057 128 EA 0001AW MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 10 EA 0001AX MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 0001AY MODIFIED BARIUM SWALLOW 74230 1 EA 0001AZ MRI BRAIN WO AND W CONTRAST 70553 1 EA 0001BA MRI CERVICAL SPINE WO CONTRAST 72141 7 EA 0001BB MRI LO EXT W/WO CONT, NOT JOINT 73720 3 EA 0001BC MRI LOWER JOINT WO CONTRAST 73721 11 EA 0001BD MRI LUMBAR SPINE WO & W CONTRAST 72158 3 EA 0001BE MRI LUMBAR SPINE WO CONTRAST 72148 6 EA 0001BF MRI THORACIC SPINE WO CONTRAST 72146 1 EA 0001BG MRI UPPER JOINT WO/CONTRAST 73221 14 EA 0001BH NASAL BONES MIN 3 VIEWS 70160 1 EA 0001BI NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 3 EA 0001BJ NM CARDIAC STRESS INJECTION A9500 9 EA 0001BK NM CARDIOVASCULAR STRESS TEST 93015 9 EA 0001BL NM SPECT CARDIAC SINGLE 78451 9 EA 0001BM PELVIS 1 VIEW 72170 1 EA 0001BN RIBS UNILAT 2 VIEWS 71100 1 EA 0001BO SHOULDER 2 OR MORE VIEWS 73030 11 EA 0001BP SINUSES MIN 2 VIEWS 70210 1 EA 0001BQ SKULL 4 OR MORE VIEWS 70260 2 EA 0001BR SPINE CERVICAL MIN 3 VIEWS 72040 2 EA 0001BS SPINE CERVICAL MIN 6 VIEWS 72052 8 EA 0001BT SPINE LS BENDING MIN 4 VIEWS 72120 1 EA 0001BU SPINE LUMBOSACRAL MIN 2 VIEWS 72100 16 EA 0001BV SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 0001BW SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 0001BX SPINE THORACIC AP+LAT+SWIM VIEWS 72072 2 EA 0001BY TIBIA & FIBULA 2 VIEWS 73590 1 EA 0001BZ TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 0001CA TOE(S) 2 OR MORE VIEWS 73660 1 EA 0001CB US ABDOMEN 76700 6 EA 0001CC US ABDOMEN LIMITED 76705 1 EA 0001CD US BREAST 76645 9 EA 0001CE US CAROTID BILAT STUDY COMPLE 93880 1 EA 0001CF US EXTREMITY NONVASCULAR 76880 1 EA 0001CG US EXTREMITY VEINS UNILATERAL 93971 2 EA 0001CH US RETROPERITONEAL 76770 1 EA 0001CI US RETROPERITONEAL LIMITED 76775 1 EA 0001CJ US SCROTUM 76870 1 EA 0001CK WRIST 2 VIEWS 73100 3 EA CBOC ANNISTON Total 443 CLIN 0002:Childersburg Community Based Outpatient Clinic 151 9th Avenue N. W., Childersburg, AL 35044 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0002AA ABDOMEN 1 VIEW/KUB 74000 10 EA 0002AB ABDOMEN 2 VIEWS 74010 6 EA 0002AC ANKLE 3 OR MORE VIEWS 73610 7 EA 0002AD BILATERAL KNEE 73565 2 EA 0002AE CALCANEOUS 2 VIEWS 73650 1 EA 0002AF CERVICAL SPINE, FLEXION & EXTENSION ON 72052 9 EA 0002AG CHEST 2 VIEWS PA&LAT 71020 154 EA 0002AH CHEST INCLUDE FLUORO 71034 1 EA 0002AI CHEST SPECIAL (LDECUB ETC) 71035 1 EA 0002AJ CLAVICLE 73000 1 EA 0002AK ELBOW 2 VIEWS 73070 7 EA 0002AL FEMUR 2 VIEWS 73550 3 EA 0002AM FOOT 3 OR MORE VIEWS 73630 22 EA 0002AN FOREARM 2 VIEWS 73090 4 EA 0002AO HAND 3 OR MORE VIEWS 73130 17 EA 0002AP HIP 2 OR MORE VIEWS 73510 19 EA 0002AQ HUMERUS 2 OR MORE VIEWS 73060 2 EA 0002AR KNEE 2 VIEWS 73560 17 EA 0002AS KNEE A/P WT.BEAR W LAT FLEX 73562 8 EA 0002AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 8 EA 0002AU MANDIBLE < 4 VIEWS 70100 1 EA 0002AV ORBIT MIN 4 VIEWS 70200 1 EA 0002AW PELVIS 1 VIEW 72170 1 EA 0002AX RIBS BILAT 3 OR MORE VIEWS 71110 1 EA 0002AY RIBS UNILAT 2 VIEWS 71100 11 EA 0002AZ SHOULDER 2 OR MORE VIEWS 73030 34 EA 0002BA SINUSES 3 OR MORE VIEWS 70220 1 EA 0002BB SINUSES MIN 2 VIEWS 70210 22 EA 0002BC SKULL 4 OR MORE VIEWS 70260 1 EA 0002BD SPINE CERVICAL MIN 3 VIEWS 72040 6 EA 0002BE SPINE CERVICAL MIN 4 VIEWS 72050 3 EA 0002BF SPINE LS BENDING MIN 4 VIEWS 72120 3 EA 0002BG SPINE LUMBOSACRAL MIN 2 VIEWS 72100 44 EA 0002BH SPINE LUMBOSACRAL MIN 4 VIEWS 72110 5 EA 0002BI SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 0002BJ SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 0002BK TIBIA & FIBULA 2 VIEWS 73590 6 EA 0002BL TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 0002BM WRIST 2 VIEWS 73100 7 EA CBOC CHILDERSBURG Total   465 CLIN 0003: Huntsville Community Based Outpatient Clinic 301 Governor's Drive, S.W., Huntsville, AL 35801 & (Combined) Decatur/Madison Community Based Outpatient Clinic 8075 Madison Blvd., Suite 101 Madison, AL 35758 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0003AA ABDOMEN 1 VIEW/KUB 74000 12 EA 0003AB ABDOMEN 2 VIEWS 74010 7 EA 0003AC ANKLE 3 OR MORE VIEWS 73610 42 EA 0003AD BARIUM SWALLOW 74220 5 EA 0003AE BILATERAL KNEE 73565 4 EA 0003AF CALCANEOUS 2 VIEWS 73650 2 EA 0003AG CHEST 2 VIEWS PA&LAT 71020 254 EA 0003AH CHEST SINGLE VIEW 71010 1 EA 0003AI CLAVICLE 73000 1 EA 0003AJ COLON BARIUM ENEMA 74270 1 EA 0003AK CT ABDOMEN W&W/O CONT 74170 33 EA 0003AL CT ABDOMEN W/CONT 74160 2 EA 0003AM CT ABDOMEN W/O CONT 74150 15 EA 0003AN CT CERVICAL SPINE W/O CONT 72125 1 EA 0003AO CT HEAD W&WO CONT 70470 2 EA 0003AP CT HEAD W/O CONT 70450 13 EA 0003AQ CT LUMBAR SPINE W/O CONT 72131 1 EA 0003AR CT NECK SOFT TISSU W&W/O CONT 70492 4 EA 0003AS CT NECK SOFT TISSU W/CONT 70491 1 EA 0003AT CT NECK SOFT TISSU W/O CONT 70490 1 EA 0003AU CT PELVIS W&W/O CONT 72194 13 EA 0003AV CT PELVIS W/CONT 72193 12 EA 0003AW CT PELVIS W/O CONT 72192 14 EA 0003AX CT SINUSES ONLY WO CONTRAST 70486 3 EA 0003AY CT TEMPORAL BONE W/O CONTRAST 70480 2 EA 0003AZ CT THORACIC SPINE W/O CONT 72128 1 EA 0003BA CT THORAX W&W/O CONT 71270 4 EA 0003BB CT THORAX W/CONT 71260 7 EA 0003BC CT THORAX W/O CONT 71250 21 EA 0003BD CT UPPER EXTREMITY W/O CONT 73200 1 EA 0003BE CTA HEAD W/CONT & POST PROCESS 70496 1 EA 0003BF ELBOW 2 VIEWS 73070 16 EA 0003BG ELBOW 3 OR MORE VIEWS 73080 1 EA 0003BH FACIAL BONES MIN 2 VIEWS 70140 1 EA 0003BI FEMUR 2 VIEWS 73550 4 EA 0003BJ FINGER(S) 2 OR MORE VIEWS 73140 7 EA 0003BK FOOT 3 OR MORE VIEWS 73630 41 EA 0003BL FOREARM 2 VIEWS 73090 4 EA 0003BM HAND 3 OR MORE VIEWS 73130 45 EA 0003BN HIP 1 VIEW 73500 1 EA 0003BO HIP 2 OR MORE VIEWS 73510 64 EA 0003BP HUMERUS 2 OR MORE VIEWS 73060 2 EA 0003BQ INJECTION, REGADENOSON J2785 24 EA 0003BR KNEE 2 VIEWS 73560 115 EA 0003BS KNEE A/P WT.BEAR W LAT FLEX 73562 10 EA 0003BT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 12 EA 0003BU MAMMO SCREENING, 2 FILMS 77057 235 EA 0003BV MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 51 EA 0003BW MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 21 EA 0003BX MODIFIED BARIUM SWALLOW 74230 10 EA 0003BY MRA HEAD WO CONTRAST 70544 7 EA 0003BZ MRA NECK W & WO CONTRAST 70549 4 EA 0003CA MRA NECK WO CONTRAST 70547 1 EA 0003CB MRI ABDOMEN W & W/O CONT 74183 1 EA 0003CC MRI BRAIN W CONTRAST 70552 4 EA 0003CD MRI BRAIN WO AND W CONTRAST 70553 24 EA 0003CE MRI BRAIN WO CONTRAST 70551 8 EA 0003CF MRI CERVICAL SPINE W CONTRAST 72142 1 EA 0003CG MRI CERVICAL SPINE WO CONTRAST 72141 21 EA 0003CH MRI CERVICAL SPINE WO/W CONT 72156 5 EA 0003CI MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 0003CJ MRI LOWER JOINT WO CONTRAST 73721 17 EA 0003CK MRI LUMBAR SPINE W CONTRAST 72149 1 EA 0003CL MRI LUMBAR SPINE WO & W CONTRAST 72158 15 EA 0003CM MRI LUMBAR SPINE WO CONTRAST 72148 24 EA 0003CN MRI ORBIT FACE/NECK W/WO CONT 70543 1 EA 0003CO MRI PELVIS W/CONTRAST 72196 4 EA 0003CP MRI THORACIC SPINE WO CONTRAST 72146 5 EA 0003CQ MRI THORACIC SPINE WO/W CONT 72157 5 EA 0003CR MRI UPPER JOINT WO/CONTRAST 73221 10 EA 0003CS NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 4 EA 0003CT NM BONE IMAGING, THREE PHASE 78315 2 EA 0003CU NM BONE IMAGING, WHOLE BODY 78306 6 EA 0003CV NM CARDIAC STRESS INJECTION A9500 30 EA 0003CW NM CARDIOVASCULAR STRESS TEST 93015 30 EA 0003CX NM HEPATOBILIARY SCAN (HIDA SCAN) 78223 1 EA 0003CY NM SPECT CARDIAC SINGLE 78451 30 EA 0003CZ PELVIS 1 VIEW 72170 8 EA 0003DA RIBS UNILAT 2 VIEWS 71100 20 EA 0003DB SCAPULA 73010 1 EA 0003DC SHOULDER 2 OR MORE VIEWS 73030 84 EA 0003DD SIALOGRAM S&I 70390 1 EA 0003DE SPINE CERVICAL MIN 3 VIEWS 72040 3 EA 0003DF SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 0003DG SPINE CERVICAL MIN 6 VIEWS 72052 57 EA 0003DH SPINE LS BENDING MIN 4 VIEWS 72120 2 EA 0003DI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 102 EA 0003DJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 6 EA 0003DK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 3 EA 0003DL SPINE SI JOINT 3 OR MORE VIEWS 72202 2 EA 0003DM SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 0003DN TIBIA & FIBULA 2 VIEWS 73590 12 EA 0003DO TM BONE JOINT UNILAT O&C MOUTH 70328 2 EA 0003DP TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 0003DQ UPPER GI 74240 6 EA 0003DR UPPER GI + SMALL BOWEL 74245 2 EA 0003DS US AAA SCREENING ONLY G0389 1 EA 0003DT US ABDOMEN 76700 39 EA 0003DU US ABDOMEN LIMITED 76705 16 EA 0003DV US ABDOMINAL VASCULAR 93975 6 EA 0003DW US BREAST 76645 52 EA 0003DX US CAROTID BILAT STUDY COMPLE 93880 19 EA 0003DY US EXTREMITY NONVASCULAR 76880 6 EA 0003DZ US EXTREMITY VEINS BILATERAL 93970 7 EA 0003EA US EXTREMITY VEINS UNILATERAL 93971 9 EA 0003EB US LO EXT ARTERIES BILAT 93925 1 EA 0003EC US PELVIC 76856 3 EA 0003ED US RETROPERITONEAL 76770 10 EA 0003EE US RETROPERITONEAL LIMITED 76775 1 EA 0003EF US SCROTUM 76870 8 EA 0003EG US THYROID/NECK SOFT TISSUE 76536 6 EA 0003EH US TRANSVAGINAL 76830 1 EA 0003EI US VASCULAR DOPPLER LIMITED 93976 2 EA 0003EJ WRIST 2 VIEWS 73100 22 EA CBOC HSV/DEC/MAD Total   1947 CIN 0004: Gadsden Community Based Outpatient Clinic 206 Rescia Drive, Gadsden, AL 35906 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0004AA ABDOMEN 1 VIEW/KUB 74000 18 EA 0004AB ABDOMEN 2 VIEWS 74010 13 EA 0004AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 0004AD ANKLE 3 OR MORE VIEWS 73610 27 EA 0004AE BILATERAL KNEE 73565 17 EA 0004AF CALCANEOUS 2 VIEWS 73650 9 EA 0004AG CHEST 2 VIEWS PA&LAT 71020 221 EA 0004AH CHEST SINGLE VIEW 71010 1 EA 0004AI CLAVICLE 73000 2 EA 0004AJ CT ABDOMEN W&W/O CONT 74170 3 EA 0004AK CT ABDOMEN W/O CONT 74150 4 EA 0004AL CT HEAD W/O CONT 70450 3 EA 0004AM CT PELVIS W&W/O CONT 72194 3 EA 0004AN CT PELVIS W/O CONT 72192 4 EA 0004AO CT THORAX W/O CONT 71250 1 EA 0004AP ELBOW 2 VIEWS 73070 13 EA 0004AQ ELBOW 3 OR MORE VIEWS 73080 1 EA 0004AR FEMUR 2 VIEWS 73550 3 EA 0004AS FINGER(S) 2 OR MORE VIEWS 73140 6 EA 0004AT FOOT 3 OR MORE VIEWS 73630 51 EA 0004AU FOREARM 2 VIEWS 73090 3 EA 0004AV HAND 3 OR MORE VIEWS 73130 40 EA 0004AW HIP 2 OR MORE VIEWS 73510 60 EA 0004AX HIP BILATERAL 4 OR MORE VIEWS 73520 2 EA 0004AY HUMERUS 2 OR MORE VIEWS 73060 1 EA 0004AZ KNEE 2 VIEWS 73560 93 EA 0004BA KNEE A/P WT.BEAR W LAT FLEX 73562 18 EA 0004BB KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 0004BC MAMMO SCREENING, 2 FILMS 77057 51 EA 0004BD MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 8 EA 0004BE MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 0004BF MANDIBLE 4 OR MORE VIEWS 70110 1 EA 0004BG MRA HEAD WO CONTRAST 70544 1 EA 0004BH MRA LOW EXT W OR WO CONTRAST 73725 1 EA 0004BI MRA NECK W & WO CONTRAST 70549 1 EA 0004BJ MRI BRAIN W CONTRAST 70552 1 EA 0004BK MRI BRAIN WO AND W CONTRAST 70553 4 EA 0004BL MRI BRAIN WO CONTRAST 70551 4 EA 0004BM MRI CERVICAL SPINE WO CONTRAST 72141 2 EA 0004BN MRI CERVICAL SPINE WO/W CONT 72156 4 EA 0004BO MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 0004BP MRI LOWER JOINT WO CONTRAST 73721 2 EA 0004BQ MRI LUMBAR SPINE WO & W CONTRAST 72158 5 EA 0004BR MRI LUMBAR SPINE WO CONTRAST 72148 3 EA 0004BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 0004BT MRI UPPER JOINT WO/CONTRAST 73221 8 EA 0004BU NASAL BONES MIN 3 VIEWS 70160 1 EA 0004BV NECK SOFT TISSUE 70360 1 EA 0004BW ORBIT MIN 4 VIEWS 70200 1 EA 0004BX PELVIS 1 VIEW 72170 33 EA 0004BY RIBS BILAT 3 OR MORE VIEWS 71110 2 EA 0004BZ RIBS UNILAT 2 VIEWS 71100 23 EA 0004CA SCAPULA 73010 1 EA 0004CB SHOULDER INT/EXT Y-VIEW AXILLARY 73030 82 EA 0004CC SINUSES MIN 2 VIEWS 70210 8 EA 0004CD SKULL 4 OR MORE VIEWS 70260 3 EA 0004CE SPINE CERVICAL MIN 3 VIEWS 72040 42 EA 0004CF SPINE CERVICAL MIN 4 VIEWS 72050 11 EA 0004CG SPINE CERVICAL MIN 6 VIEWS 72052 20 EA 0004CH SPINE LS BENDING MIN 4 VIEWS 72120 8 EA 0004CI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 106 EA 0004CJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 16 EA 0004CK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 2 EA 0004CL SPINE SI JOINT 3 OR MORE VIEWS 72202 1 EA 0004CM SPINE SI JOINTS 1 OR 2 VIEWS 72200 1 EA 0004CN SPINE THORACIC AP+LAT+SWIM VIEWS 72072 26 EA 0004CO TIBIA & FIBULA 2 VIEWS 73590 4 EA 0004CP TOE(S) 2 OR MORE VIEWS 73660 1 EA 0004CQ US ABDOMEN 76700 7 EA 0004CR US BREAST 76645 17 EA 0004CS US CAROTID BILAT STUDY COMPLE 93880 2 EA 0004CT US EXTREMITY VEINS BILATERAL 93970 6 EA 0004CU US EXTREMITY VEINS UNILATERAL 93971 11 EA 0004CV US LO EXT ARTERIES BILAT 93925 1 EA  0004CW US RETROPERITONEAL 76770 2 EA  0004CX US SCROTUM 76870 5 EA  0004CY US VASCULAR DOPPLER LIMITED 93976 2 EA 0004CZ WRIST 2 VIEWS 73100 21 EA CBOC GADSDEN Total   1223 CLIN 0005:Jasper Community Based Outpatient Clinic 3400 Hwy 78 East, Suite 215, Jasper, AL 35501 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0005AA ABDOMEN 1 VIEW/KUB 74000 1 EA 0005AB ANKLE 3 OR MORE VIEWS 73610 2 EA 0005AC BILATERAL KNEE 73565 1 EA 0005AD CHEST 2 VIEWS PA&LAT 71020 21 EA 0005AE CHEST SINGLE VIEW 71010 1 EA 0005AF CT ABDOMEN W&W/O CONT 74170 3 EA 0005AG CT HEAD W/O CONT 70450 3 EA 0005AH CT PELVIS W&W/O CONT 72194 2 EA 0005AI CT PELVIS W/CONT 72193 1 EA 0005AJ CT THORAX W/CONT 71260 1 EA 0005AK ELBOW 2 VIEWS 73070 1 EA 0005AL FOOT 3 OR MORE VIEWS 73630 6 EA 0005AM HAND 3 OR MORE VIEWS 73130 1 EA 0005AN HIP 2 OR MORE VIEWS 73510 7 EA 0005AO INJECTION, REGADENOSON J2785 2 EA 0005AP KNEE 2 VIEWS 73560 12 EA 0005AQ KNEE 4 OR MORE VIEWS 73564 2 EA 0005AR KNEE A/P WT.BEAR W LAT FLEX 73562 1 EA 0005AS MAMMO SCREENING, 2 FILMS 77057 32 EA 0005AT MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 4 EA 0005AU MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 2 EA 0005AV MRI BRAIN WO AND W CONTRAST 70553 1 EA 0005AW MRI CERVICAL SPINE WO CONTRAST 72141 4 EA 0005AX MRI LOWER JOINT WO CONTRAST 73721 3 EA 0005AY MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 0005AZ MRI LUMBAR SPINE WO CONTRAST 72148 5 EA 0005BA MRI UPPER JOINT WO/CONTRAST 73221 3 EA 0005BB NM CARDIAC STRESS INJECTION A9500 2 EA 0005BC NM CARDIOVASCULAR STRESS TEST 93015 2 EA 0005BD NM SPECT CARDIAC SINGLE 78451 2 EA 0005BE PELVIS 1 VIEW 72170 1 EA 0005BF RIBS UNILAT 2 VIEWS 71100 1 EA 0005BG SHOULDER 2 OR MORE VIEWS 73030 13 EA 0005BH SPINE CERVICAL MIN 6 VIEWS 72052 17 EA 0005BI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 35 EA 0005BJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 0005BK SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 0005BL TIBIA & FIBULA 2 VIEWS 73590 1 EA 0005BM UROGRAM INTRAVENOUS 74400 1 EA 0005BN US ABDOMEN 76700 2 EA 0005BO US ABDOMEN LIMITED 76705 1 EA  0005BP US BREAST 76645 5 EA  0005BQ US CAROTID BILAT STUDY COMPLE 93880 6 EA  0005BR US EXTREMITY VEINS UNILATERAL 93971 1 EA  0005BS US PELVIC LIMITED 76857 1 EA  0005BT US RETROPERITONEAL 76770 3 EA  0005BU US SCROTUM 76870 2 EA  0005BV WRIST 2 VIEWS 73100 2 EA CBOC JASPER Total   226 CLIN 0006:Muscle Shoals Community Based Outpatient Clinic 422 DD Cox Blvd., Sheffield, AL 35660 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0006AA ABDOMEN 2 VIEWS 74010 2 EA 0006AB ABDOMEN 3 OR MORE VIEWS 74020 1 EA 0006AC ANKLE 3 OR MORE VIEWS 73610 14 EA 0006AD BILATERAL KNEE 73565 2 EA 0006AE BONE SURVEY, METASTATIC COMPLETE 77075 1 EA 0006AF CHEST 2 VIEWS PA&LAT 71020 140 EA 0006AG CLAVICLE 73000 1 EA 0006AH CT ABDOMEN W&W/O CONT 74170 3 EA 0006AI CT ABDOMEN W/O CONT 74150 1 EA 0006AJ CT CERVICAL SPINE W/O CONT 72125 1 EA 0006AK CT HEAD W/O CONT 70450 2 EA 0006AL CT MAXILLOFACIAL W&W/O CONT 70488 1 EA 0006AM CT NECK SOFT TISSU W&W/O CONT 70492 1 EA 0006AN CT PELVIS W&W/O CONT 72194 1 EA 0006AO CT PELVIS W/CONT 72193 2 EA 0006AP CT PELVIS W/O CONT 72192 1 EA 0006AQ CT SINUSES ONLY WO CONTRAST 70486 1 EA 0006AR CT THORAX W&W/O CONT 71270 5 EA 0006AS CT THORAX W/O CONT 71250 1 EA 0006AT ELBOW 2 VIEWS 73070 7 EA 0006AU FEMUR 2 VIEWS 73550 1 EA 0006AV FINGER(S) 2 OR MORE VIEWS 73140 3 EA 0006AW FOOT 3 OR MORE VIEWS 73630 30 EA 0006AX FOREARM 2 VIEWS 73090 2 EA 0006AY HAND 3 OR MORE VIEWS 73130 11 EA 0006AZ HIP 2 OR MORE VIEWS 73510 24 EA 0006BA HUMERUS 2 OR MORE VIEWS 73060 1 EA 0006BB INJECTION, REGADENOSON J2785 2 EA 0006BC KNEE 2 VIEWS 73560 29 EA 0006BD KNEE A/P WT.BEAR W LAT FLEX 73562 4 EA 0006BE KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 0006BF MAMMO SCREENING, 2 FILMS 77057 71 EA 0006BG MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 3 EA 0006BH MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 9 EA 0006BI MANDIBLE 4 OR MORE VIEWS 70110 2 EA 0006BJ MRA HEAD WO CONTRAST 70544 1 EA 0006BK MRI ABDOMEN W & W/O CONT 74183 1 EA 0006BL MRI BRAIN WO AND W CONTRAST 70553 7 EA 0006BM MRI BRAIN WO CONTRAST 70551 9 EA 0006BN MRI CERVICAL SPINE WO CONTRAST 72141 3 EA 0006BO MRI LOWER JOINT WO CONTRAST 73721 4 EA 0006BP MRI LUMBAR SPINE WO & W CONTRAST 72158 2 EA 0006BQ MRI LUMBAR SPINE WO CONTRAST 72148 12 EA 0006BR MRI PELVIS W/CONTRAST 72196 1 EA 0006BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 0006BT MRI UPPER JOINT WO/CONTRAST 73221 5 EA 0006BU NM CARDIAC STRESS INJECTION A9500 3 EA 0006BV NM CARDIOVASCULAR STRESS TEST 93015 3 EA 0006BW NM SPECT CARDIAC SINGLE 78451 3 EA 0006BX PELVIS 1 VIEW 72170 2 EA 0006BY RIBS UNILAT 2 VIEWS 71100 12 EA 0006BZ SHOULDER 2 OR MORE VIEWS 73030 43 EA 0006CA SKULL 4 OR MORE VIEWS 70260 1 EA 0006CB SPINE CERVICAL MIN 3 VIEWS 72040 8 EA 0006CC SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 0006CD SPINE CERVICAL MIN 6 VIEWS 72052 15 EA 0006CE SPINE LS BENDING MIN 4 VIEWS 72120 14 EA 0006CF SPINE LUMBOSACRAL MIN 2 VIEWS 72100 26 EA 0006CG SPINE LUMBOSACRAL MIN 4 VIEWS 72110 42 EA 0006CH SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 0006CI TOE(S) 2 OR MORE VIEWS 73660 2 EA 0006CJ UROGRAM INTRAVENOUS 74400 1 EA 0006CK US ABDOMEN 76700 3 EA 0006CL US ABDOMEN LIMITED 76705 1 EA 0006CM US BREAST 76645 8 EA 0006CN US EXTREMITY VEINS BILATERAL 93970 1 EA 0006CO WRIST 2 VIEWS 73100 7 EA CBOC SHOALS Total     652 CLIN 0007:Guntersville Community Based Outpatient Clinic 101 Judysmith Drive Guntersville, AL 35976 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0007AA ABDOMEN 1 VIEW/KUB 74000 1 EA 0007AB ABDOMEN 2 VIEWS 74010 2 EA 0007AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 0007AD ANKLE 3 OR MORE VIEWS 73610 3 EA 0007AE CHEST 2 VIEWS PA&LAT 71020 22 EA 0007AF CLAVICLE 73000 1 EA 0007AG CT ABDOMEN W&W/O CONT 74170 2 EA 0007AH CT HEAD W/O CONT 70450 2 EA 0007AI ELBOW 2 VIEWS 73070 1 EA 0007AJ ELBOW 3 OR MORE VIEWS 73080 1 EA 0007AK FINGER(S) 2 OR MORE VIEWS 73140 2 EA 0007AL FOOT 3 OR MORE VIEWS 73630 3 EA 0007AM FOREARM 2 VIEWS 73090 1 EA 0007AN HAND 3 OR MORE VIEWS 73130 5 EA 0007AO HIP 2 OR MORE VIEWS 73510 3 EA 0007AP HIP BILATERAL 4 OR MORE VIEWS 73520 1 EA 0007AQ INJECTION, REGADENOSON J2785 1 EA 0007AR KNEE 2 VIEWS 73560 1 EA 0007AS KNEE A/P WT.BEAR W LAT FLEX 73562 2 EA 0007AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 3 EA 0007AU MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 1 EA 0007AV MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 0007AW NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 1 EA 0007AX NM CARDIAC STRESS INJECTION A9500 1 EA 0007AY NM CARDIOVASCULAR STRESS TEST 93015 1 EA 0007AZ NM SPECT CARDIAC SINGLE 78451 1 EA 0007BA RIBS UNILAT 2 VIEWS 71100 1 EA 0007BB SHOULDER 2 OR MORE VIEWS 73030 6 EA 0007BC SPINE CERVICAL MIN 6 VIEWS 72052 1 EA 0007BD SPINE LUMBOSACRAL MIN 2 VIEWS 72100 2 EA 0007BE SPINE LUMBOSACRAL MIN 4 VIEWS 72110 8 EA 0007BF SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 0007BG SPINE THORACIC AP+LAT+SWIM VIEWS 72072 1 EA 0007BH TOE(S) 2 OR MORE VIEWS 73660 1 EA 0007BI US ABDOMEN LIMITED 76705 1 EA 0007BJ US BREAST 76645 1 EA 0007BK US EXTREMITY NONVASCULAR 76880 1 EA 0007BL US EXTREMITY VEINS UNILATERAL 93971 1 EA CBOC GUNTERSVILLE Total   89 CLIN 0008: MRI Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0008AA CT HEAD W/O CONT 70540 1 EA 0008AB MRI BRAIN W CONTRAST 70552 10 EA 0008AC MRI BRAIN WO AND W CONTRAST 70553 10 EA 0008AD MRI BRAIN WO CONTRAST 70551 10 EA 0008AE MRI BOTH BREASTS   77059 2 EA 0008AF MRI CERVICAL SPINE WO/W CONT 72156 15 EA 0008AG MRI CERVICAL SPINE WO CONTRAST 72141 15 EA 0008AH MRI LOWER JOINT WO CONTRAST 73721 3 EA 0008AI MRI LUMBAR SPINE W CONTRAST 72149 5 EA 0008AJ MRI LUMBAR SPINE WO & W CONTRAST 72158 50 EA 0008AK MRI LUMBAR SPINE WO CONTRAST 72148 40 EA 0008AL MRI THORACIC SPINE WO CONTRAST 72146 5 EA 0008AM MRI UPPER JOINT WO/CONTRAST 73221 7 EA Birmingham MRI Total   173 CLIN 0009: Mammography Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 0009AA BX BREAST PERCUT W/O IMAGE BREAST BIOPSY 19100 5 EA 0009AB BX BREAST OPEN INCISIONAL 19101 5 EA 0009AC BX BREAST PERCUT W/IMAGE BX BREAST PERCUT W/IMAGE 19102 5 EA 0009AD US BREAST 76645 625 EA 0009AE STEROTACTIC GUIDE FOR BX             77031 10 EA 0009AF GUIDANCE FOR NEEDLE PLACEMENT 77032 10 EA 0009AG BREAST MAMMOGRAPHY 77051 10 EA 0009AH X-RAY OF MAMMARY DUCT 77053 132 EA 0009AI X-RAY OF MAMMARY DUCTS 77054 45 EA 0009AJ MAMMOGRAPHY,DIAGNOSTIC, UNILATERAL 77055 44 EA 0009AK MAMMOGRAPHY,DIAGNOSTIC, BILATERAL 77056 10 EA 0009AL MAMMO SCREENING, 2 FILMS 77057 903 EA 0009AM MRI ONE BREAST 77058 5 EA 0009AN MRI BOTH BREASTS   77059 5 EA Birmingham Mammography Total   1814 OPTION YEAR I: 1 Feb 2012 “ 31 Jan 2013 CLIN 1001:Anniston/Oxford Community Based Outpatient Clinic 96 Ali Way Creekside South, Oxford, AL 36203 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1001AA ABDOMEN 1 VIEW/KUB 74000 1 EA 1001AB ABDOMEN 2 VIEWS 74010 3 EA 1001AC ANKLE 3 OR MORE VIEWS 73610 8 EA 1001AD BARIUM SWALLOW 74220 3 EA 1001AE CHEST 2 VIEWS PA&LAT 71020 45 EA 1001AF CHEST SINGLE VIEW 71010 1 EA 1001AG CLAVICLE 73000 1 EA 1001AH CT ABDOMEN W&W/O CONT 74170 2 EA 1001AI CT ABDOMEN W/O CONT 74150 2 EA 1001AJ CT HEAD W/O CONT 70450 2 EA 1001AK CT PELVIS W&W/O CONT 72194 2 EA 1001AL CT PELVIS W/O CONT 72192 2 EA 1001AM CT THORAX W/O CONT 71250 3 EA 1001AN ELBOW 2 VIEWS 73070 2 EA 1001AO FOOT 3 OR MORE VIEWS 73630 5 EA 1001AP HAND 3 OR MORE VIEWS 73130 5 EA 1001AQ HIP 2 OR MORE VIEWS 73510 17 EA 1001AR INJECTION, REGADENOSON J2785 8 EA 1001AS KNEE 2 VIEWS 73560 20 EA 1001AT KNEE A/P WT.BEAR W LAT FLEX 73562 5 EA 1001AU KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 1 EA 1001AV MAMMO SCREENING, 2 FILMS 77057 128 EA 1001AW MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 10 EA 1001AX MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 1001AY MODIFIED BARIUM SWALLOW 74230 1 EA 1001AZ MRI BRAIN WO AND W CONTRAST 70553 1 EA 1001BA MRI CERVICAL SPINE WO CONTRAST 72141 7 EA 1001BB MRI LO EXT W/WO CONT, NOT JOINT 73720 3 EA 1001BC MRI LOWER JOINT WO CONTRAST 73721 11 EA 1001BD MRI LUMBAR SPINE WO & W CONTRAST 72158 3 EA 1001BE MRI LUMBAR SPINE WO CONTRAST 72148 6 EA 1001BF MRI THORACIC SPINE WO CONTRAST 72146 1 EA 1001BG MRI UPPER JOINT WO/CONTRAST 73221 14 EA 1001BH NASAL BONES MIN 3 VIEWS 70160 1 EA 1001BI NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 3 EA 1001BJ NM CARDIAC STRESS INJECTION A9500 9 EA 1001BK NM CARDIOVASCULAR STRESS TEST 93015 9 EA 1001BL NM SPECT CARDIAC SINGLE 78451 9 EA 1001BM PELVIS 1 VIEW 72170 1 EA 1001BN RIBS UNILAT 2 VIEWS 71100 1 EA 1001BO SHOULDER 2 OR MORE VIEWS 73030 11 EA 1001BP SINUSES MIN 2 VIEWS 70210 1 EA 1001BQ SKULL 4 OR MORE VIEWS 70260 2 EA 1001BR SPINE CERVICAL MIN 3 VIEWS 72040 2 EA 1001BS SPINE CERVICAL MIN 6 VIEWS 72052 8 EA 1001BT SPINE LS BENDING MIN 4 VIEWS 72120 1 EA 1001BU SPINE LUMBOSACRAL MIN 2 VIEWS 72100 16 EA 1001BV SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 1001BW SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 1001BX SPINE THORACIC AP+LAT+SWIM VIEWS 72072 2 EA 1001BY TIBIA & FIBULA 2 VIEWS 73590 1 EA 1001BZ TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 1001CA TOE(S) 2 OR MORE VIEWS 73660 1 EA 1001CB US ABDOMEN 76700 6 EA 1001CC US ABDOMEN LIMITED 76705 1 EA 1001CD US BREAST 76645 9 EA 1001CE US CAROTID BILAT STUDY COMPLE 93880 1 EA 1001CF US EXTREMITY NONVASCULAR 76880 1 EA 1001CG US EXTREMITY VEINS UNILATERAL 93971 2 EA 1001CH US RETROPERITONEAL 76770 1 EA 1001CI US RETROPERITONEAL LIMITED 76775 1 EA 1001CJ US SCROTUM 76870 1 EA 1001CK WRIST 2 VIEWS 73100 3 EA CBOC ANNISTON Total 443 CLIN 1002:Childersburg Community Based Outpatient Clinic 151 9th Avenue N. W., Childersburg, AL 35044 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1002AA ABDOMEN 1 VIEW/KUB 74000 10 EA 1002AB ABDOMEN 2 VIEWS 74010 6 EA 1002AC ANKLE 3 OR MORE VIEWS 73610 7 EA 1002AD BILATERAL KNEE 73565 2 EA 1002AE CALCANEOUS 2 VIEWS 73650 1 EA 1002AF CERVICAL SPINE, FLEXION & EXTENSION ON 72052 9 EA 1002AG CHEST 2 VIEWS PA&LAT 71020 154 EA 1002AH CHEST INCLUDE FLUORO 71034 1 EA 1002AI CHEST SPECIAL (LDECUB ETC) 71035 1 EA 1002AJ CLAVICLE 73000 1 EA 1002AK ELBOW 2 VIEWS 73070 7 EA 1002AL FEMUR 2 VIEWS 73550 3 EA 1002AM FOOT 3 OR MORE VIEWS 73630 22 EA 1002AN FOREARM 2 VIEWS 73090 4 EA 1002AO HAND 3 OR MORE VIEWS 73130 17 EA 1002AP HIP 2 OR MORE VIEWS 73510 19 EA 1002AQ HUMERUS 2 OR MORE VIEWS 73060 2 EA 1002AR KNEE 2 VIEWS 73560 17 EA 1002AS KNEE A/P WT.BEAR W LAT FLEX 73562 8 EA 1002AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 8 EA 1002AU MANDIBLE < 4 VIEWS 70100 1 EA 1002AV ORBIT MIN 4 VIEWS 70200 1 EA 1002AW PELVIS 1 VIEW 72170 1 EA 1002AX RIBS BILAT 3 OR MORE VIEWS 71110 1 EA 1002AY RIBS UNILAT 2 VIEWS 71100 11 EA 1002AZ SHOULDER 2 OR MORE VIEWS 73030 34 EA 1002BA SINUSES 3 OR MORE VIEWS 70220 1 EA 1002BB SINUSES MIN 2 VIEWS 70210 22 EA 1002BC SKULL 4 OR MORE VIEWS 70260 1 EA 1002BD SPINE CERVICAL MIN 3 VIEWS 72040 6 EA 1002BE SPINE CERVICAL MIN 4 VIEWS 72050 3 EA 1002BF SPINE LS BENDING MIN 4 VIEWS 72120 3 EA 1002BG SPINE LUMBOSACRAL MIN 2 VIEWS 72100 44 EA 1002BH SPINE LUMBOSACRAL MIN 4 VIEWS 72110 5 EA 1002BI SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 1002BJ SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 1002BK TIBIA & FIBULA 2 VIEWS 73590 6 EA 1002BL TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 1002BM WRIST 2 VIEWS 73100 7 EA CBOC CHILDERSBURG Total   465 CLIN 1003: Huntsville Community Based Outpatient Clinic 301 Governor's Drive, S.W., Huntsville, AL 35801 & (Combined) Decatur/Madison Community Based Outpatient Clinic 8075 Madison Blvd., Suite 101 Madison, AL 35758 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1003AA ABDOMEN 1 VIEW/KUB 74000 12 EA 1003AB ABDOMEN 2 VIEWS 74010 7 EA 1003AC ANKLE 3 OR MORE VIEWS 73610 42 EA 1003AD BARIUM SWALLOW 74220 5 EA 1003AE BILATERAL KNEE 73565 4 EA 1003AF CALCANEOUS 2 VIEWS 73650 2 EA 1003AG CHEST 2 VIEWS PA&LAT 71020 254 EA 1003AH CHEST SINGLE VIEW 71010 1 EA 1003AI CLAVICLE 73000 1 EA 1003AJ COLON BARIUM ENEMA 74270 1 EA 1003AK CT ABDOMEN W&W/O CONT 74170 33 EA 1003AL CT ABDOMEN W/CONT 74160 2 EA 1003AM CT ABDOMEN W/O CONT 74150 15 EA 1003AN CT CERVICAL SPINE W/O CONT 72125 1 EA 1003AO CT HEAD W&WO CONT 70470 2 EA 1003AP CT HEAD W/O CONT 70450 13 EA 1003AQ CT LUMBAR SPINE W/O CONT 72131 1 EA 1003AR CT NECK SOFT TISSU W&W/O CONT 70492 4 EA 1003AS CT NECK SOFT TISSU W/CONT 70491 1 EA 1003AT CT NECK SOFT TISSU W/O CONT 70490 1 EA 1003AU CT PELVIS W&W/O CONT 72194 13 EA 1003AV CT PELVIS W/CONT 72193 12 EA 1003AW CT PELVIS W/O CONT 72192 14 EA 1003AX CT SINUSES ONLY WO CONTRAST 70486 3 EA 1003AY CT TEMPORAL BONE W/O CONTRAST 70480 2 EA 1003AZ CT THORACIC SPINE W/O CONT 72128 1 EA 1003BA CT THORAX W&W/O CONT 71270 4 EA 1003BB CT THORAX W/CONT 71260 7 EA 1003BC CT THORAX W/O CONT 71250 21 EA 1003BD CT UPPER EXTREMITY W/O CONT 73200 1 EA 1003BE CTA HEAD W/CONT & POST PROCESS 70496 1 EA 1003BF ELBOW 2 VIEWS 73070 16 EA 1003BG ELBOW 3 OR MORE VIEWS 73080 1 EA 1003BH FACIAL BONES MIN 2 VIEWS 70140 1 EA 1003BI FEMUR 2 VIEWS 73550 4 EA 1003BJ FINGER(S) 2 OR MORE VIEWS 73140 7 EA 1003BK FOOT 3 OR MORE VIEWS 73630 41 EA 1003BL FOREARM 2 VIEWS 73090 4 EA 1003BM HAND 3 OR MORE VIEWS 73130 45 EA 1003BN HIP 1 VIEW 73500 1 EA 1003BO HIP 2 OR MORE VIEWS 73510 64 EA 1003BP HUMERUS 2 OR MORE VIEWS 73060 2 EA 1003BQ INJECTION, REGADENOSON J2785 24 EA 1003BR KNEE 2 VIEWS 73560 115 EA 1003BS KNEE A/P WT.BEAR W LAT FLEX 73562 10 EA 1003BT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 12 EA 1003BU MAMMO SCREENING, 2 FILMS 77057 235 EA 1003BV MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 51 EA 1003BW MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 21 EA 1003BX MODIFIED BARIUM SWALLOW 74230 10 EA 1003BY MRA HEAD WO CONTRAST 70544 7 EA 1003BZ MRA NECK W & WO CONTRAST 70549 4 EA 1003CA MRA NECK WO CONTRAST 70547 1 EA 1003CB MRI ABDOMEN W & W/O CONT 74183 1 EA 1003CC MRI BRAIN W CONTRAST 70552 4 EA 1003CD MRI BRAIN WO AND W CONTRAST 70553 24 EA 1003CE MRI BRAIN WO CONTRAST 70551 8 EA 1003CF MRI CERVICAL SPINE W CONTRAST 72142 1 EA 1003CG MRI CERVICAL SPINE WO CONTRAST 72141 21 EA 1003CH MRI CERVICAL SPINE WO/W CONT 72156 5 EA 1003CI MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 1003CJ MRI LOWER JOINT WO CONTRAST 73721 17 EA 1003CK MRI LUMBAR SPINE W CONTRAST 72149 1 EA 1003CL MRI LUMBAR SPINE WO & W CONTRAST 72158 15 EA 1003CM MRI LUMBAR SPINE WO CONTRAST 72148 24 EA 1003CN MRI ORBIT FACE/NECK W/WO CONT 70543 1 EA 1003CO MRI PELVIS W/CONTRAST 72196 4 EA 1003CP MRI THORACIC SPINE WO CONTRAST 72146 5 EA 1003CQ MRI THORACIC SPINE WO/W CONT 72157 5 EA 1003CR MRI UPPER JOINT WO/CONTRAST 73221 10 EA 1003CS NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 4 EA 1003CT NM BONE IMAGING, THREE PHASE 78315 2 EA 1003CU NM BONE IMAGING, WHOLE BODY 78306 6 EA 1003CV NM CARDIAC STRESS INJECTION A9500 30 EA 1003CW NM CARDIOVASCULAR STRESS TEST 93015 30 EA 1003CX NM HEPATOBILIARY SCAN (HIDA SCAN) 78223 1 EA 1003CY NM SPECT CARDIAC SINGLE 78451 30 EA 1003CZ PELVIS 1 VIEW 72170 8 EA 1003DA RIBS UNILAT 2 VIEWS 71100 20 EA 1003DB SCAPULA 73010 1 EA 1003DC SHOULDER 2 OR MORE VIEWS 73030 84 EA 1003DD SIALOGRAM S&I 70390 1 EA 1003DE SPINE CERVICAL MIN 3 VIEWS 72040 3 EA 1003DF SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 1003DG SPINE CERVICAL MIN 6 VIEWS 72052 57 EA 1003DH SPINE LS BENDING MIN 4 VIEWS 72120 2 EA 1003DI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 102 EA 1003DJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 6 EA 1003DK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 3 EA 1003DL SPINE SI JOINT 3 OR MORE VIEWS 72202 2 EA 1003DM SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 1003DN TIBIA & FIBULA 2 VIEWS 73590 12 EA 1003DO TM BONE JOINT UNILAT O&C MOUTH 70328 2 EA 1003DP TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 1003DQ UPPER GI 74240 6 EA 1003DR UPPER GI + SMALL BOWEL 74245 2 EA 1003DS US AAA SCREENING ONLY G0389 1 EA 1003DT US ABDOMEN 76700 39 EA 1003DU US ABDOMEN LIMITED 76705 16 EA 1003DV US ABDOMINAL VASCULAR 93975 6 EA 1003DW US BREAST 76645 52 EA 1003DX US CAROTID BILAT STUDY COMPLE 93880 19 EA 1003DY US EXTREMITY NONVASCULAR 76880 6 EA 1003DZ US EXTREMITY VEINS BILATERAL 93970 7 EA 1003EA US EXTREMITY VEINS UNILATERAL 93971 9 EA 1003EB US LO EXT ARTERIES BILAT 93925 1 EA 1003EC US PELVIC 76856 3 EA 1003ED US RETROPERITONEAL 76770 10 EA 1003EE US RETROPERITONEAL LIMITED 76775 1 EA 1003EF US SCROTUM 76870 8 EA 1003EG US THYROID/NECK SOFT TISSUE 76536 6 EA 1003EH US TRANSVAGINAL 76830 1 EA 1003EI US VASCULAR DOPPLER LIMITED 93976 2 EA 1003EJ WRIST 2 VIEWS 73100 22 EA CBOC HSV/DEC/MAD Total   1947 CIN 1004: Gadsden Community Based Outpatient Clinic 206 Rescia Drive, Gadsden, AL 35906 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1004AA ABDOMEN 1 VIEW/KUB 74000 18 EA 1004AB ABDOMEN 2 VIEWS 74010 13 EA 1004AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 1004AD ANKLE 3 OR MORE VIEWS 73610 27 EA 1004AE BILATERAL KNEE 73565 17 EA 1004AF CALCANEOUS 2 VIEWS 73650 9 EA 1004AG CHEST 2 VIEWS PA&LAT 71020 221 EA 1004AH CHEST SINGLE VIEW 71010 1 EA 1004AI CLAVICLE 73000 2 EA 1004AJ CT ABDOMEN W&W/O CONT 74170 3 EA 1004AK CT ABDOMEN W/O CONT 74150 4 EA 1004AL CT HEAD W/O CONT 70450 3 EA 1004AM CT PELVIS W&W/O CONT 72194 3 EA 1004AN CT PELVIS W/O CONT 72192 4 EA 1004AO CT THORAX W/O CONT 71250 1 EA 1004AP ELBOW 2 VIEWS 73070 13 EA 1004AQ ELBOW 3 OR MORE VIEWS 73080 1 EA 1004AR FEMUR 2 VIEWS 73550 3 EA 1004AS FINGER(S) 2 OR MORE VIEWS 73140 6 EA 1004AT FOOT 3 OR MORE VIEWS 73630 51 EA 1004AU FOREARM 2 VIEWS 73090 3 EA 1004AV HAND 3 OR MORE VIEWS 73130 40 EA 1004AW HIP 2 OR MORE VIEWS 73510 60 EA 1004AX HIP BILATERAL 4 OR MORE VIEWS 73520 2 EA 1004AY HUMERUS 2 OR MORE VIEWS 73060 1 EA 1004AZ KNEE 2 VIEWS 73560 93 EA 1004BA KNEE A/P WT.BEAR W LAT FLEX 73562 18 EA 1004BB KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 1004BC MAMMO SCREENING, 2 FILMS 77057 51 EA 1004BD MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 8 EA 1004BE MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 1004BF MANDIBLE 4 OR MORE VIEWS 70110 1 EA 1004BG MRA HEAD WO CONTRAST 70544 1 EA 1004BH MRA LOW EXT W OR WO CONTRAST 73725 1 EA 1004BI MRA NECK W & WO CONTRAST 70549 1 EA 1004BJ MRI BRAIN W CONTRAST 70552 1 EA 1004BK MRI BRAIN WO AND W CONTRAST 70553 4 EA 1004BL MRI BRAIN WO CONTRAST 70551 4 EA 1004BM MRI CERVICAL SPINE WO CONTRAST 72141 2 EA 1004BN MRI CERVICAL SPINE WO/W CONT 72156 4 EA 1004BO MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 1004BP MRI LOWER JOINT WO CONTRAST 73721 2 EA 1004BQ MRI LUMBAR SPINE WO & W CONTRAST 72158 5 EA 1004BR MRI LUMBAR SPINE WO CONTRAST 72148 3 EA 1004BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 1004BT MRI UPPER JOINT WO/CONTRAST 73221 8 EA 1004BU NASAL BONES MIN 3 VIEWS 70160 1 EA 1004BV NECK SOFT TISSUE 70360 1 EA 1004BW ORBIT MIN 4 VIEWS 70200 1 EA 1004BX PELVIS 1 VIEW 72170 33 EA 1004BY RIBS BILAT 3 OR MORE VIEWS 71110 2 EA 1004BZ RIBS UNILAT 2 VIEWS 71100 23 EA 1004CA SCAPULA 73010 1 EA 1004CB SHOULDER INT/EXT Y-VIEW AXILLARY 73030 82 EA 1004CC SINUSES MIN 2 VIEWS 70210 8 EA 1004CD SKULL 4 OR MORE VIEWS 70260 3 EA 1004CE SPINE CERVICAL MIN 3 VIEWS 72040 42 EA 1004CF SPINE CERVICAL MIN 4 VIEWS 72050 11 EA 1004CG SPINE CERVICAL MIN 6 VIEWS 72052 20 EA 1004CH SPINE LS BENDING MIN 4 VIEWS 72120 8 EA 1004CI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 106 EA 1004CJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 16 EA 1004CK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 2 EA 1004CL SPINE SI JOINT 3 OR MORE VIEWS 72202 1 EA 1004CM SPINE SI JOINTS 1 OR 2 VIEWS 72200 1 EA 1004CN SPINE THORACIC AP+LAT+SWIM VIEWS 72072 26 EA 1004CO TIBIA & FIBULA 2 VIEWS 73590 4 EA 1004CP TOE(S) 2 OR MORE VIEWS 73660 1 EA 1004CQ US ABDOMEN 76700 7 EA 1004CR US BREAST 76645 17 EA 1004CS US CAROTID BILAT STUDY COMPLE 93880 2 EA 1004CT US EXTREMITY VEINS BILATERAL 93970 6 EA 1004CU US EXTREMITY VEINS UNILATERAL 93971 11 EA 1004CV US LO EXT ARTERIES BILAT 93925 1 EA 1004CW US RETROPERITONEAL 76770 2 EA 1004CX US SCROTUM 76870 5 EA 1004CY US VASCULAR DOPPLER LIMITED 93976 2 EA 1004CZ WRIST 2 VIEWS 73100 21 EA CBOC GADSDEN Total   1223 CLIN 1005:Jasper Community Based Outpatient Clinic 3400 Hwy 78 East, Suite 215, Jasper, AL 35501 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1005AA ABDOMEN 1 VIEW/KUB 74000 1 EA 1005AB ANKLE 3 OR MORE VIEWS 73610 2 EA 1005AC BILATERAL KNEE 73565 1 EA 1005AD CHEST 2 VIEWS PA&LAT 71020 21 EA 1005AE CHEST SINGLE VIEW 71010 1 EA 1005AF CT ABDOMEN W&W/O CONT 74170 3 EA 1005AG CT HEAD W/O CONT 70450 3 EA 1005AH CT PELVIS W&W/O CONT 72194 2 EA 1005AI CT PELVIS W/CONT 72193 1 EA 1005AJ CT THORAX W/CONT 71260 1 EA 1005AK ELBOW 2 VIEWS 73070 1 EA 1005AL FOOT 3 OR MORE VIEWS 73630 6 EA 1005AM HAND 3 OR MORE VIEWS 73130 1 EA 1005AN HIP 2 OR MORE VIEWS 73510 7 EA 1005AO INJECTION, REGADENOSON J2785 2 EA 1005AP KNEE 2 VIEWS 73560 12 EA 1005AQ KNEE 4 OR MORE VIEWS 73564 2 EA 1005AR KNEE A/P WT.BEAR W LAT FLEX 73562 1 EA 1005AS MAMMO SCREENING, 2 FILMS 77057 32 EA 1005AT MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 4 EA 1005AU MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 2 EA 1005AV MRI BRAIN WO AND W CONTRAST 70553 1 EA 1005AW MRI CERVICAL SPINE WO CONTRAST 72141 4 EA 1005AX MRI LOWER JOINT WO CONTRAST 73721 3 EA 1005AY MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 1005AZ MRI LUMBAR SPINE WO CONTRAST 72148 5 EA 1005BA MRI UPPER JOINT WO/CONTRAST 73221 3 EA 1005BB NM CARDIAC STRESS INJECTION A9500 2 EA 1005BC NM CARDIOVASCULAR STRESS TEST 93015 2 EA 1005BD NM SPECT CARDIAC SINGLE 78451 2 EA 1005BE PELVIS 1 VIEW 72170 1 EA 1005BF RIBS UNILAT 2 VIEWS 71100 1 EA 1005BG SHOULDER 2 OR MORE VIEWS 73030 13 EA 1005BH SPINE CERVICAL MIN 6 VIEWS 72052 17 EA 1005BI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 35 EA 1005BJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 1005BK SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 1005BL TIBIA & FIBULA 2 VIEWS 73590 1 EA 1005BM UROGRAM INTRAVENOUS 74400 1 EA 1005BN US ABDOMEN 76700 2 EA 1005BO US ABDOMEN LIMITED 76705 1 EA  1005BP US BREAST 76645 5 EA  1005BQ US CAROTID BILAT STUDY COMPLE 93880 6 EA  1005BR US EXTREMITY VEINS UNILATERAL 93971 1 EA  1005BS US PELVIC LIMITED 76857 1 EA  1005BT US RETROPERITONEAL 76770 3 EA  1005BU US SCROTUM 76870 2 EA  1005BV WRIST 2 VIEWS 73100 2 EA CBOC JASPER Total   226 CLIN 1006:Muscle Shoals Community Based Outpatient Clinic 422 DD Cox Blvd., Sheffield, AL 35660 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1006AA ABDOMEN 2 VIEWS 74010 2 EA 1006AB ABDOMEN 3 OR MORE VIEWS 74020 1 EA 1006AC ANKLE 3 OR MORE VIEWS 73610 14 EA 1006AD BILATERAL KNEE 73565 2 EA 1006AE BONE SURVEY, METASTATIC COMPLETE 77075 1 EA 1006AF CHEST 2 VIEWS PA&LAT 71020 140 EA 1006AG CLAVICLE 73000 1 EA 1006AH CT ABDOMEN W&W/O CONT 74170 3 EA 1006AI CT ABDOMEN W/O CONT 74150 1 EA 1006AJ CT CERVICAL SPINE W/O CONT 72125 1 EA 1006AK CT HEAD W/O CONT 70450 2 EA 1006AL CT MAXILLOFACIAL W&W/O CONT 70488 1 EA 1006AM CT NECK SOFT TISSU W&W/O CONT 70492 1 EA 1006AN CT PELVIS W&W/O CONT 72194 1 EA 1006AO CT PELVIS W/CONT 72193 2 EA 1006AP CT PELVIS W/O CONT 72192 1 EA 1006AQ CT SINUSES ONLY WO CONTRAST 70486 1 EA 1006AR CT THORAX W&W/O CONT 71270 5 EA 1006AS CT THORAX W/O CONT 71250 1 EA 1006AT ELBOW 2 VIEWS 73070 7 EA 1006AU FEMUR 2 VIEWS 73550 1 EA 1006AV FINGER(S) 2 OR MORE VIEWS 73140 3 EA 1006AW FOOT 3 OR MORE VIEWS 73630 30 EA 1006AX FOREARM 2 VIEWS 73090 2 EA 1006AY HAND 3 OR MORE VIEWS 73130 11 EA 1006AZ HIP 2 OR MORE VIEWS 73510 24 EA 1006BA HUMERUS 2 OR MORE VIEWS 73060 1 EA 1006BB INJECTION, REGADENOSON J2785 2 EA 1006BC KNEE 2 VIEWS 73560 29 EA 1006BD KNEE A/P WT.BEAR W LAT FLEX 73562 4 EA 1006BE KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 1006BF MAMMO SCREENING, 2 FILMS 77057 71 EA 1006BG MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 3 EA 1006BH MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 9 EA 1006BI MANDIBLE 4 OR MORE VIEWS 70110 2 EA 1006BJ MRA HEAD WO CONTRAST 70544 1 EA 1006BK MRI ABDOMEN W & W/O CONT 74183 1 EA 1006BL MRI BRAIN WO AND W CONTRAST 70553 7 EA 1006BM MRI BRAIN WO CONTRAST 70551 9 EA 1006BN MRI CERVICAL SPINE WO CONTRAST 72141 3 EA 1006BO MRI LOWER JOINT WO CONTRAST 73721 4 EA 1006BP MRI LUMBAR SPINE WO & W CONTRAST 72158 2 EA 1006BQ MRI LUMBAR SPINE WO CONTRAST 72148 12 EA 1006BR MRI PELVIS W/CONTRAST 72196 1 EA 1006BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 1006BT MRI UPPER JOINT WO/CONTRAST 73221 5 EA 1006BU NM CARDIAC STRESS INJECTION A9500 3 EA 1006BV NM CARDIOVASCULAR STRESS TEST 93015 3 EA 1006BW NM SPECT CARDIAC SINGLE 78451 3 EA 1006BX PELVIS 1 VIEW 72170 2 EA 1006BY RIBS UNILAT 2 VIEWS 71100 12 EA 1006BZ SHOULDER 2 OR MORE VIEWS 73030 43 EA 1006CA SKULL 4 OR MORE VIEWS 70260 1 EA 1006CB SPINE CERVICAL MIN 3 VIEWS 72040 8 EA 1006CC SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 1006CD SPINE CERVICAL MIN 6 VIEWS 72052 15 EA 1006CE SPINE LS BENDING MIN 4 VIEWS 72120 14 EA 1006CF SPINE LUMBOSACRAL MIN 2 VIEWS 72100 26 EA 1006CG SPINE LUMBOSACRAL MIN 4 VIEWS 72110 42 EA 1006CH SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 1006CI TOE(S) 2 OR MORE VIEWS 73660 2 EA 1006CJ UROGRAM INTRAVENOUS 74400 1 EA 1006CK US ABDOMEN 76700 3 EA 1006CL US ABDOMEN LIMITED 76705 1 EA 1006CM US BREAST 76645 8 EA 1006CN US EXTREMITY VEINS BILATERAL 93970 1 EA 1006CO WRIST 2 VIEWS 73100 7 EA CBOC SHOALS Total     652 CLIN 1007:Guntersville Community Based Outpatient Clinic 101 Judysmith Drive Guntersville, AL 35976 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1007AA ABDOMEN 1 VIEW/KUB 74000 1 EA 1007AB ABDOMEN 2 VIEWS 74010 2 EA 1007AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 1007AD ANKLE 3 OR MORE VIEWS 73610 3 EA 1007AE CHEST 2 VIEWS PA&LAT 71020 22 EA 1007AF CLAVICLE 73000 1 EA 1007AG CT ABDOMEN W&W/O CONT 74170 2 EA 1007AH CT HEAD W/O CONT 70450 2 EA 1007AI ELBOW 2 VIEWS 73070 1 EA 1007AJ ELBOW 3 OR MORE VIEWS 73080 1 EA 1007AK FINGER(S) 2 OR MORE VIEWS 73140 2 EA 1007AL FOOT 3 OR MORE VIEWS 73630 3 EA 1007AM FOREARM 2 VIEWS 73090 1 EA 1007AN HAND 3 OR MORE VIEWS 73130 5 EA 1007AO HIP 2 OR MORE VIEWS 73510 3 EA 1007AP HIP BILATERAL 4 OR MORE VIEWS 73520 1 EA 1007AQ INJECTION, REGADENOSON J2785 1 EA 1007AR KNEE 2 VIEWS 73560 1 EA 1007AS KNEE A/P WT.BEAR W LAT FLEX 73562 2 EA 1007AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 3 EA 1007AU MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 1 EA 1007AV MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 1007AW NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 1 EA 1007AX NM CARDIAC STRESS INJECTION A9500 1 EA 1007AY NM CARDIOVASCULAR STRESS TEST 93015 1 EA 1007AZ NM SPECT CARDIAC SINGLE 78451 1 EA 1007BA RIBS UNILAT 2 VIEWS 71100 1 EA 1007BB SHOULDER 2 OR MORE VIEWS 73030 6 EA 1007BC SPINE CERVICAL MIN 6 VIEWS 72052 1 EA 1007BD SPINE LUMBOSACRAL MIN 2 VIEWS 72100 2 EA 1007BE SPINE LUMBOSACRAL MIN 4 VIEWS 72110 8 EA 1007BF SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 1007BG SPINE THORACIC AP+LAT+SWIM VIEWS 72072 1 EA 1007BH TOE(S) 2 OR MORE VIEWS 73660 1 EA 1007BI US ABDOMEN LIMITED 76705 1 EA 1007BJ US BREAST 76645 1 EA 1007BK US EXTREMITY NONVASCULAR 76880 1 EA 1007BL US EXTREMITY VEINS UNILATERAL 93971 1 EA CBOC GUNTERSVILLE Total   89 CLIN 1008: MRI Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1008AA CT HEAD W/O CONT 70540 1 EA 1008AB MRI BRAIN W CONTRAST 70552 10 EA 1008AC MRI BRAIN WO AND W CONTRAST 70553 10 EA 1008AD MRI BRAIN WO CONTRAST 70551 10 EA 1008AE MRI BOTH BREASTS   77059 2 EA 1008AF MRI CERVICAL SPINE WO/W CONT 72156 15 EA 1008AG MRI CERVICAL SPINE WO CONTRAST 72141 15 EA 1008AH MRI LOWER JOINT WO CONTRAST 73721 3 EA 1008AI MRI LUMBAR SPINE W CONTRAST 72149 5 EA 1008AJ MRI LUMBAR SPINE WO & W CONTRAST 72158 50 EA 1008AK MRI LUMBAR SPINE WO CONTRAST 72148 40 EA 1008AL MRI THORACIC SPINE WO CONTRAST 72146 5 EA 1008AM MRI UPPER JOINT WO/CONTRAST 73221 7 EA Birmingham MRI Total   173 CLIN 1009: Mammography Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 1009AA BX BREAST PERCUT W/O IMAGE BREAST BIOPSY 19100 5 EA 1009AB BX BREAST OPEN INCISIONAL 19101 5 EA 1009AC BX BREAST PERCUT W/IMAGE BX BREAST PERCUT W/IMAGE 19102 5 EA 1009AD US BREAST 76645 625 EA 1009AE STEROTACTIC GUIDE FOR BX             77031 10 EA 1009AF GUIDANCE FOR NEEDLE PLACEMENT 77032 10 EA 1009AG BREAST MAMMOGRAPHY 77051 10 EA 1009AH X-RAY OF MAMMARY DUCT 77053 132 EA 1009AI X-RAY OF MAMMARY DUCTS 77054 45 EA 1009AJ MAMMOGRAPHY,DIAGNOSTIC, UNILATERAL 77055 44 EA 1009AK MAMMOGRAPHY,DIAGNOSTIC, BILATERAL 77056 10 EA 1009AL MAMMO SCREENING, 2 FILMS 77057 903 EA 1009AM MRI ONE BREAST 77058 5 EA 1009AN MRI BOTH BREASTS   77059 5 EA Birmingham Mammography Total   1814 OPTION YEAR II: 1 Feb 2013 “ 31 Jan 2014 CLIN 2001:Anniston/Oxford Community Based Outpatient Clinic 96 Ali Way Creekside South, Oxford, AL 36203 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2001AA ABDOMEN 1 VIEW/KUB 74000 1 EA 2001AB ABDOMEN 2 VIEWS 74010 3 EA 2001AC ANKLE 3 OR MORE VIEWS 73610 8 EA 2001AD BARIUM SWALLOW 74220 3 EA 2001AE CHEST 2 VIEWS PA&LAT 71020 45 EA 2001AF CHEST SINGLE VIEW 71010 1 EA 2001AG CLAVICLE 73000 1 EA 2001AH CT ABDOMEN W&W/O CONT 74170 2 EA 2001AI CT ABDOMEN W/O CONT 74150 2 EA 2001AJ CT HEAD W/O CONT 70450 2 EA 2001AK CT PELVIS W&W/O CONT 72194 2 EA 2001AL CT PELVIS W/O CONT 72192 2 EA 2001AM CT THORAX W/O CONT 71250 3 EA 2001AN ELBOW 2 VIEWS 73070 2 EA 2001AO FOOT 3 OR MORE VIEWS 73630 5 EA 2001AP HAND 3 OR MORE VIEWS 73130 5 EA 2001AQ HIP 2 OR MORE VIEWS 73510 17 EA 2001AR INJECTION, REGADENOSON J2785 8 EA 2001AS KNEE 2 VIEWS 73560 20 EA 2001AT KNEE A/P WT.BEAR W LAT FLEX 73562 5 EA 2001AU KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 1 EA 2001AV MAMMO SCREENING, 2 FILMS 77057 128 EA 2001AW MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 10 EA 2001AX MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 2001AY MODIFIED BARIUM SWALLOW 74230 1 EA 2001AZ MRI BRAIN WO AND W CONTRAST 70553 1 EA 2001BA MRI CERVICAL SPINE WO CONTRAST 72141 7 EA 2001BB MRI LO EXT W/WO CONT, NOT JOINT 73720 3 EA 2001BC MRI LOWER JOINT WO CONTRAST 73721 11 EA 2001BD MRI LUMBAR SPINE WO & W CONTRAST 72158 3 EA 2001BE MRI LUMBAR SPINE WO CONTRAST 72148 6 EA 2001BF MRI THORACIC SPINE WO CONTRAST 72146 1 EA 2001BG MRI UPPER JOINT WO/CONTRAST 73221 14 EA 2001BH NASAL BONES MIN 3 VIEWS 70160 1 EA 2001BI NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 3 EA 2001BJ NM CARDIAC STRESS INJECTION A9500 9 EA 2001BK NM CARDIOVASCULAR STRESS TEST 93015 9 EA 2001BL NM SPECT CARDIAC SINGLE 78451 9 EA 2001BM PELVIS 1 VIEW 72170 1 EA 2001BN RIBS UNILAT 2 VIEWS 71100 1 EA 2001BO SHOULDER 2 OR MORE VIEWS 73030 11 EA 2001BP SINUSES MIN 2 VIEWS 70210 1 EA 2001BQ SKULL 4 OR MORE VIEWS 70260 2 EA 2001BR SPINE CERVICAL MIN 3 VIEWS 72040 2 EA 2001BS SPINE CERVICAL MIN 6 VIEWS 72052 8 EA 2001BT SPINE LS BENDING MIN 4 VIEWS 72120 1 EA 2001BU SPINE LUMBOSACRAL MIN 2 VIEWS 72100 16 EA 2001BV SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 2001BW SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 2001BX SPINE THORACIC AP+LAT+SWIM VIEWS 72072 2 EA 2001BY TIBIA & FIBULA 2 VIEWS 73590 1 EA 2001BZ TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 2001CA TOE(S) 2 OR MORE VIEWS 73660 1 EA 2001CB US ABDOMEN 76700 6 EA 2001CC US ABDOMEN LIMITED 76705 1 EA 2001CD US BREAST 76645 9 EA 2001CE US CAROTID BILAT STUDY COMPLE 93880 1 EA 2001CF US EXTREMITY NONVASCULAR 76880 1 EA 2001CG US EXTREMITY VEINS UNILATERAL 93971 2 EA 2001CH US RETROPERITONEAL 76770 1 EA 2001CI US RETROPERITONEAL LIMITED 76775 1 EA 2001CJ US SCROTUM 76870 1 EA 2001CK WRIST 2 VIEWS 73100 3 EA CBOC ANNISTON Total 443 CLIN 2002:Childersburg Community Based Outpatient Clinic 151 9th Avenue N. W., Childersburg, AL 35044 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2002AA ABDOMEN 1 VIEW/KUB 74000 10 EA 2002AB ABDOMEN 2 VIEWS 74010 6 EA 2002AC ANKLE 3 OR MORE VIEWS 73610 7 EA 2002AD BILATERAL KNEE 73565 2 EA 2002AE CALCANEOUS 2 VIEWS 73650 1 EA 2002AF CERVICAL SPINE, FLEXION & EXTENSION ON 72052 9 EA 2002AG CHEST 2 VIEWS PA&LAT 71020 154 EA 2002AH CHEST INCLUDE FLUORO 71034 1 EA 2002AI CHEST SPECIAL (LDECUB ETC) 71035 1 EA 2002AJ CLAVICLE 73000 1 EA 2002AK ELBOW 2 VIEWS 73070 7 EA 2002AL FEMUR 2 VIEWS 73550 3 EA 2002AM FOOT 3 OR MORE VIEWS 73630 22 EA 2002AN FOREARM 2 VIEWS 73090 4 EA 2002AO HAND 3 OR MORE VIEWS 73130 17 EA 2002AP HIP 2 OR MORE VIEWS 73510 19 EA 2002AQ HUMERUS 2 OR MORE VIEWS 73060 2 EA 2002AR KNEE 2 VIEWS 73560 17 EA 2002AS KNEE A/P WT.BEAR W LAT FLEX 73562 8 EA 2002AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 8 EA 2002AU MANDIBLE < 4 VIEWS 70100 1 EA 2002AV ORBIT MIN 4 VIEWS 70200 1 EA 2002AW PELVIS 1 VIEW 72170 1 EA 2002AX RIBS BILAT 3 OR MORE VIEWS 71110 1 EA 2002AY RIBS UNILAT 2 VIEWS 71100 11 EA 2002AZ SHOULDER 2 OR MORE VIEWS 73030 34 EA 2002BA SINUSES 3 OR MORE VIEWS 70220 1 EA 2002BB SINUSES MIN 2 VIEWS 70210 22 EA 2002BC SKULL 4 OR MORE VIEWS 70260 1 EA 2002BD SPINE CERVICAL MIN 3 VIEWS 72040 6 EA 2002BE SPINE CERVICAL MIN 4 VIEWS 72050 3 EA 2002BF SPINE LS BENDING MIN 4 VIEWS 72120 3 EA 2002BG SPINE LUMBOSACRAL MIN 2 VIEWS 72100 44 EA 2002BH SPINE LUMBOSACRAL MIN 4 VIEWS 72110 5 EA 2002BI SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 2002BJ SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 2002BK TIBIA & FIBULA 2 VIEWS 73590 6 EA 2002BL TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 2002BM WRIST 2 VIEWS 73100 7 EA CBOC CHILDERSBURG Total   465 CLIN 2003: Huntsville Community Based Outpatient Clinic 301 Governor's Drive, S.W., Huntsville, AL 35801 & (Combined) Decatur/Madison Community Based Outpatient Clinic 8075 Madison Blvd., Suite 101 Madison, AL 35758 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2003AA ABDOMEN 1 VIEW/KUB 74000 12 EA 2003AB ABDOMEN 2 VIEWS 74010 7 EA 2003AC ANKLE 3 OR MORE VIEWS 73610 42 EA 2003AD BARIUM SWALLOW 74220 5 EA 2003AE BILATERAL KNEE 73565 4 EA 2003AF CALCANEOUS 2 VIEWS 73650 2 EA 2003AG CHEST 2 VIEWS PA&LAT 71020 254 EA 2003AH CHEST SINGLE VIEW 71010 1 EA 2003AI CLAVICLE 73000 1 EA 2003AJ COLON BARIUM ENEMA 74270 1 EA 2003AK CT ABDOMEN W&W/O CONT 74170 33 EA 2003AL CT ABDOMEN W/CONT 74160 2 EA 2003AM CT ABDOMEN W/O CONT 74150 15 EA 2003AN CT CERVICAL SPINE W/O CONT 72125 1 EA 2003AO CT HEAD W&WO CONT 70470 2 EA 2003AP CT HEAD W/O CONT 70450 13 EA 2003AQ CT LUMBAR SPINE W/O CONT 72131 1 EA 2003AR CT NECK SOFT TISSU W&W/O CONT 70492 4 EA 2003AS CT NECK SOFT TISSU W/CONT 70491 1 EA 2003AT CT NECK SOFT TISSU W/O CONT 70490 1 EA 2003AU CT PELVIS W&W/O CONT 72194 13 EA 2003AV CT PELVIS W/CONT 72193 12 EA 2003AW CT PELVIS W/O CONT 72192 14 EA 2003AX CT SINUSES ONLY WO CONTRAST 70486 3 EA 2003AY CT TEMPORAL BONE W/O CONTRAST 70480 2 EA 2003AZ CT THORACIC SPINE W/O CONT 72128 1 EA 2003BA CT THORAX W&W/O CONT 71270 4 EA 2003BB CT THORAX W/CONT 71260 7 EA 2003BC CT THORAX W/O CONT 71250 21 EA 2003BD CT UPPER EXTREMITY W/O CONT 73200 1 EA 2003BE CTA HEAD W/CONT & POST PROCESS 70496 1 EA 2003BF ELBOW 2 VIEWS 73070 16 EA 2003BG ELBOW 3 OR MORE VIEWS 73080 1 EA 2003BH FACIAL BONES MIN 2 VIEWS 70140 1 EA 2003BI FEMUR 2 VIEWS 73550 4 EA 2003BJ FINGER(S) 2 OR MORE VIEWS 73140 7 EA 2003BK FOOT 3 OR MORE VIEWS 73630 41 EA 2003BL FOREARM 2 VIEWS 73090 4 EA 2003BM HAND 3 OR MORE VIEWS 73130 45 EA 2003BN HIP 1 VIEW 73500 1 EA 2003BO HIP 2 OR MORE VIEWS 73510 64 EA 2003BP HUMERUS 2 OR MORE VIEWS 73060 2 EA 2003BQ INJECTION, REGADENOSON J2785 24 EA 2003BR KNEE 2 VIEWS 73560 115 EA 2003BS KNEE A/P WT.BEAR W LAT FLEX 73562 10 EA 2003BT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 12 EA 2003BU MAMMO SCREENING, 2 FILMS 77057 235 EA 2003BV MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 51 EA 2003BW MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 21 EA 2003BX MODIFIED BARIUM SWALLOW 74230 10 EA 2003BY MRA HEAD WO CONTRAST 70544 7 EA 2003BZ MRA NECK W & WO CONTRAST 70549 4 EA 2003CA MRA NECK WO CONTRAST 70547 1 EA 2003CB MRI ABDOMEN W & W/O CONT 74183 1 EA 2003CC MRI BRAIN W CONTRAST 70552 4 EA 2003CD MRI BRAIN WO AND W CONTRAST 70553 24 EA 2003CE MRI BRAIN WO CONTRAST 70551 8 EA 2003CF MRI CERVICAL SPINE W CONTRAST 72142 1 EA 2003CG MRI CERVICAL SPINE WO CONTRAST 72141 21 EA 2003CH MRI CERVICAL SPINE WO/W CONT 72156 5 EA 2003CI MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 2003CJ MRI LOWER JOINT WO CONTRAST 73721 17 EA 2003CK MRI LUMBAR SPINE W CONTRAST 72149 1 EA 2003CL MRI LUMBAR SPINE WO & W CONTRAST 72158 15 EA 2003CM MRI LUMBAR SPINE WO CONTRAST 72148 24 EA 2003CN MRI ORBIT FACE/NECK W/WO CONT 70543 1 EA 2003CO MRI PELVIS W/CONTRAST 72196 4 EA 2003CP MRI THORACIC SPINE WO CONTRAST 72146 5 EA 2003CQ MRI THORACIC SPINE WO/W CONT 72157 5 EA 2003CR MRI UPPER JOINT WO/CONTRAST 73221 10 EA 2003CS NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 4 EA 2003CT NM BONE IMAGING, THREE PHASE 78315 2 EA 2003CU NM BONE IMAGING, WHOLE BODY 78306 6 EA 2003CV NM CARDIAC STRESS INJECTION A9500 30 EA 2003CW NM CARDIOVASCULAR STRESS TEST 93015 30 EA 2003CX NM HEPATOBILIARY SCAN (HIDA SCAN) 78223 1 EA 2003CY NM SPECT CARDIAC SINGLE 78451 30 EA 2003CZ PELVIS 1 VIEW 72170 8 EA 2003DA RIBS UNILAT 2 VIEWS 71100 20 EA 2003DB SCAPULA 73010 1 EA 2003DC SHOULDER 2 OR MORE VIEWS 73030 84 EA 2003DD SIALOGRAM S&I 70390 1 EA 2003DE SPINE CERVICAL MIN 3 VIEWS 72040 3 EA 2003DF SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 2003DG SPINE CERVICAL MIN 6 VIEWS 72052 57 EA 2003DH SPINE LS BENDING MIN 4 VIEWS 72120 2 EA 2003DI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 102 EA 2003DJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 6 EA 2003DK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 3 EA 2003DL SPINE SI JOINT 3 OR MORE VIEWS 72202 2 EA 2003DM SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 2003DN TIBIA & FIBULA 2 VIEWS 73590 12 EA 2003DO TM BONE JOINT UNILAT O&C MOUTH 70328 2 EA 2003DP TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 2003DQ UPPER GI 74240 6 EA 2003DR UPPER GI + SMALL BOWEL 74245 2 EA 2003DS US AAA SCREENING ONLY G0389 1 EA 2003DT US ABDOMEN 76700 39 EA 2003DU US ABDOMEN LIMITED 76705 16 EA 2003DV US ABDOMINAL VASCULAR 93975 6 EA 2003DW US BREAST 76645 52 EA 2003DX US CAROTID BILAT STUDY COMPLE 93880 19 EA 2003DY US EXTREMITY NONVASCULAR 76880 6 EA 2003DZ US EXTREMITY VEINS BILATERAL 93970 7 EA 2003EA US EXTREMITY VEINS UNILATERAL 93971 9 EA 2003EB US LO EXT ARTERIES BILAT 93925 1 EA 2003EC US PELVIC 76856 3 EA 2003ED US RETROPERITONEAL 76770 10 EA 2003EE US RETROPERITONEAL LIMITED 76775 1 EA 2003EF US SCROTUM 76870 8 EA 2003EG US THYROID/NECK SOFT TISSUE 76536 6 EA 2003EH US TRANSVAGINAL 76830 1 EA 2003EI US VASCULAR DOPPLER LIMITED 93976 2 EA 2003EJ WRIST 2 VIEWS 73100 22 EA CBOC HSV/DEC/MAD Total  1947 CIN 2004: Gadsden Community Based Outpatient Clinic 206 Rescia Drive, Gadsden, AL 35906 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2004AA ABDOMEN 1 VIEW/KUB 74000 18 EA 2004AB ABDOMEN 2 VIEWS 74010 13 EA 2004AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 2004AD ANKLE 3 OR MORE VIEWS 73610 27 EA 2004AE BILATERAL KNEE 73565 17 EA 2004AF CALCANEOUS 2 VIEWS 73650 9 EA 2004AG CHEST 2 VIEWS PA&LAT 71020 221 EA 2004AH CHEST SINGLE VIEW 71010 1 EA 2004AI CLAVICLE 73000 2 EA 2004AJ CT ABDOMEN W&W/O CONT 74170 3 EA 2004AK CT ABDOMEN W/O CONT 74150 4 EA 2004AL CT HEAD W/O CONT 70450 3 EA 2004AM CT PELVIS W&W/O CONT 72194 3 EA 2004AN CT PELVIS W/O CONT 72192 4 EA 2004AO CT THORAX W/O CONT 71250 1 EA 2004AP ELBOW 2 VIEWS 73070 13 EA 2004AQ ELBOW 3 OR MORE VIEWS 73080 1 EA 2004AR FEMUR 2 VIEWS 73550 3 EA 2004AS FINGER(S) 2 OR MORE VIEWS 73140 6 EA 2004AT FOOT 3 OR MORE VIEWS 73630 51 EA 2004AU FOREARM 2 VIEWS 73090 3 EA 2004AV HAND 3 OR MORE VIEWS 73130 40 EA 2004AW HIP 2 OR MORE VIEWS 73510 60 EA 2004AX HIP BILATERAL 4 OR MORE VIEWS 73520 2 EA 2004AY HUMERUS 2 OR MORE VIEWS 73060 1 EA 2004AZ KNEE 2 VIEWS 73560 93 EA 2004BA KNEE A/P WT.BEAR W LAT FLEX 73562 18 EA 2004BB KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 2004BC MAMMO SCREENING, 2 FILMS 77057 51 EA 2004BD MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 8 EA 2004BE MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 2004BF MANDIBLE 4 OR MORE VIEWS 70110 1 EA 2004BG MRA HEAD WO CONTRAST 70544 1 EA 2004BH MRA LOW EXT W OR WO CONTRAST 73725 1 EA 2004BI MRA NECK W & WO CONTRAST 70549 1 EA 2004BJ MRI BRAIN W CONTRAST 70552 1 EA 2004BK MRI BRAIN WO AND W CONTRAST 70553 4 EA 2004BL MRI BRAIN WO CONTRAST 70551 4 EA 2004BM MRI CERVICAL SPINE WO CONTRAST 72141 2 EA 2004BN MRI CERVICAL SPINE WO/W CONT 72156 4 EA 2004BO MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 2004BP MRI LOWER JOINT WO CONTRAST 73721 2 EA 2004BQ MRI LUMBAR SPINE WO & W CONTRAST 72158 5 EA 2004BR MRI LUMBAR SPINE WO CONTRAST 72148 3 EA 2004BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 2004BT MRI UPPER JOINT WO/CONTRAST 73221 8 EA 2004BU NASAL BONES MIN 3 VIEWS 70160 1 EA 2004BV NECK SOFT TISSUE 70360 1 EA 2004BW ORBIT MIN 4 VIEWS 70200 1 EA 2004BX PELVIS 1 VIEW 72170 33 EA 2004BY RIBS BILAT 3 OR MORE VIEWS 71110 2 EA 2004BZ RIBS UNILAT 2 VIEWS 71100 23 EA 2004CA SCAPULA 73010 1 EA 2004CB SHOULDER INT/EXT Y-VIEW AXILLARY 73030 82 EA 2004CC SINUSES MIN 2 VIEWS 70210 8 EA 2004CD SKULL 4 OR MORE VIEWS 70260 3 EA 2004CE SPINE CERVICAL MIN 3 VIEWS 72040 42 EA 2004CF SPINE CERVICAL MIN 4 VIEWS 72050 11 EA 2004CG SPINE CERVICAL MIN 6 VIEWS 72052 20 EA 2004CH SPINE LS BENDING MIN 4 VIEWS 72120 8 EA 2004CI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 106 EA 2004CJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 16 EA 2004CK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 2 EA 2004CL SPINE SI JOINT 3 OR MORE VIEWS 72202 1 EA 2004CM SPINE SI JOINTS 1 OR 2 VIEWS 72200 1 EA 2004CN SPINE THORACIC AP+LAT+SWIM VIEWS 72072 26 EA 2004CO TIBIA & FIBULA 2 VIEWS 73590 4 EA 2004CP TOE(S) 2 OR MORE VIEWS 73660 1 EA 2004CQ US ABDOMEN 76700 7 EA 2004CR US BREAST 76645 17 EA 2004CS US CAROTID BILAT STUDY COMPLE 93880 2 EA 0004CT US EXTREMITY VEINS BILATERAL 93970 6 EA 2004CU US EXTREMITY VEINS UNILATERAL 93971 11 EA 2004CV US LO EXT ARTERIES BILAT 93925 1 EA 2004CW US RETROPERITONEAL 76770 2 EA 2004CX US SCROTUM 76870 5 EA 2004CY US VASCULAR DOPPLER LIMITED 93976 2 EA 2004CZ WRIST 2 VIEWS 73100 21 EA CBOC GADSDEN Total   1223 CLIN 2005:Jasper Community Based Outpatient Clinic 3400 Hwy 78 East, Suite 215, Jasper, AL 35501 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2005AA ABDOMEN 1 VIEW/KUB 74000 1 EA 2005AB ANKLE 3 OR MORE VIEWS 73610 2 EA 2005AC BILATERAL KNEE 73565 1 EA 2005AD CHEST 2 VIEWS PA&LAT 71020 21 EA 2005AE CHEST SINGLE VIEW 71010 1 EA 2005AF CT ABDOMEN W&W/O CONT 74170 3 EA 2005AG CT HEAD W/O CONT 70450 3 EA 2005AH CT PELVIS W&W/O CONT 72194 2 EA 2005AI CT PELVIS W/CONT 72193 1 EA 2005AJ CT THORAX W/CONT 71260 1 EA 2005AK ELBOW 2 VIEWS 73070 1 EA 2005AL FOOT 3 OR MORE VIEWS 73630 6 EA 2005AM HAND 3 OR MORE VIEWS 73130 1 EA 2005AN HIP 2 OR MORE VIEWS 73510 7 EA 2005AO INJECTION, REGADENOSON J2785 2 EA 2005AP KNEE 2 VIEWS 73560 12 EA 2005AQ KNEE 4 OR MORE VIEWS 73564 2 EA 2005AR KNEE A/P WT.BEAR W LAT FLEX 73562 1 EA 2005AS MAMMO SCREENING, 2 FILMS 77057 32 EA 2005AT MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 4 EA 2005AU MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 2 EA 2005AV MRI BRAIN WO AND W CONTRAST 70553 1 EA 2005AW MRI CERVICAL SPINE WO CONTRAST 72141 4 EA 2005AX MRI LOWER JOINT WO CONTRAST 73721 3 EA 2005AY MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 2005AZ MRI LUMBAR SPINE WO CONTRAST 72148 5 EA 2005BA MRI UPPER JOINT WO/CONTRAST 73221 3 EA 2005BB NM CARDIAC STRESS INJECTION A9500 2 EA 2005BC NM CARDIOVASCULAR STRESS TEST 93015 2 EA 2005BD NM SPECT CARDIAC SINGLE 78451 2 EA 2005BE PELVIS 1 VIEW 72170 1 EA 2005BF RIBS UNILAT 2 VIEWS 71100 1 EA 2005BG SHOULDER 2 OR MORE VIEWS 73030 13 EA 2005BH SPINE CERVICAL MIN 6 VIEWS 72052 17 EA 2005BI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 35 EA 2005BJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 2005BK SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 2005BL TIBIA & FIBULA 2 VIEWS 73590 1 EA 2005BM UROGRAM INTRAVENOUS 74400 1 EA 2005BN US ABDOMEN 76700 2 EA 2005BO US ABDOMEN LIMITED 76705 1 EA  2005BP US BREAST 76645 5 EA  2005BQ US CAROTID BILAT STUDY COMPLE 93880 6 EA  2005BR US EXTREMITY VEINS UNILATERAL 93971 1 EA  2005BS US PELVIC LIMITED 76857 1 EA  2005BT US RETROPERITONEAL 76770 3 EA  2005BU US SCROTUM 76870 2 EA  2005BV WRIST 2 VIEWS 73100 2 EA CBOC JASPER Total   226 CLIN 2006:Muscle Shoals Community Based Outpatient Clinic 422 DD Cox Blvd., Sheffield, AL 35660 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2006AA ABDOMEN 2 VIEWS 74010 2 EA 2006AB ABDOMEN 3 OR MORE VIEWS 74020 1 EA 2006AC ANKLE 3 OR MORE VIEWS 73610 14 EA 2006AD BILATERAL KNEE 73565 2 EA 2006AE BONE SURVEY, METASTATIC COMPLETE 77075 1 EA 2006AF CHEST 2 VIEWS PA&LAT 71020 140 EA 2006AG CLAVICLE 73000 1 EA 2006AH CT ABDOMEN W&W/O CONT 74170 3 EA 2006AI CT ABDOMEN W/O CONT 74150 1 EA 2006AJ CT CERVICAL SPINE W/O CONT 72125 1 EA 2006AK CT HEAD W/O CONT 70450 2 EA 2006AL CT MAXILLOFACIAL W&W/O CONT 70488 1 EA 2006AM CT NECK SOFT TISSU W&W/O CONT 70492 1 EA 2006AN CT PELVIS W&W/O CONT 72194 1 EA 2006AO CT PELVIS W/CONT 72193 2 EA 2006AP CT PELVIS W/O CONT 72192 1 EA 2006AQ CT SINUSES ONLY WO CONTRAST 70486 1 EA 2006AR CT THORAX W&W/O CONT 71270 5 EA 2006AS CT THORAX W/O CONT 71250 1 EA 2006AT ELBOW 2 VIEWS 73070 7 EA 2006AU FEMUR 2 VIEWS 73550 1 EA 2006AV FINGER(S) 2 OR MORE VIEWS 73140 3 EA 2006AW FOOT 3 OR MORE VIEWS 73630 30 EA 2006AX FOREARM 2 VIEWS 73090 2 EA 2006AY HAND 3 OR MORE VIEWS 73130 11 EA 2006AZ HIP 2 OR MORE VIEWS 73510 24 EA 2006BA HUMERUS 2 OR MORE VIEWS 73060 1 EA 2006BB INJECTION, REGADENOSON J2785 2 EA 2006BC KNEE 2 VIEWS 73560 29 EA 2006BD KNEE A/P WT.BEAR W LAT FLEX 73562 4 EA 2006BE KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 2006BF MAMMO SCREENING, 2 FILMS 77057 71 EA 2006BG MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 3 EA 2006BH MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 9 EA 2006BI MANDIBLE 4 OR MORE VIEWS 70110 2 EA 2006BJ MRA HEAD WO CONTRAST 70544 1 EA 2006BK MRI ABDOMEN W & W/O CONT 74183 1 EA 2006BL MRI BRAIN WO AND W CONTRAST 70553 7 EA 2006BM MRI BRAIN WO CONTRAST 70551 9 EA 2006BN MRI CERVICAL SPINE WO CONTRAST 72141 3 EA 2006BO MRI LOWER JOINT WO CONTRAST 73721 4 EA 2006BP MRI LUMBAR SPINE WO & W CONTRAST 72158 2 EA 2006BQ MRI LUMBAR SPINE WO CONTRAST 72148 12 EA 2006BR MRI PELVIS W/CONTRAST 72196 1 EA 2006BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 2006BT MRI UPPER JOINT WO/CONTRAST 73221 5 EA 2006BU NM CARDIAC STRESS INJECTION A9500 3 EA 2006BV NM CARDIOVASCULAR STRESS TEST 93015 3 EA 2006BW NM SPECT CARDIAC SINGLE 78451 3 EA 2006BX PELVIS 1 VIEW 72170 2 EA 2006BY RIBS UNILAT 2 VIEWS 71100 12 EA 2006BZ SHOULDER 2 OR MORE VIEWS 73030 43 EA 2006CA SKULL 4 OR MORE VIEWS 70260 1 EA 2006CB SPINE CERVICAL MIN 3 VIEWS 72040 8 EA 2006CC SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 2006CD SPINE CERVICAL MIN 6 VIEWS 72052 15 EA 2006CE SPINE LS BENDING MIN 4 VIEWS 72120 14 EA 2006CF SPINE LUMBOSACRAL MIN 2 VIEWS 72100 26 EA 2006CG SPINE LUMBOSACRAL MIN 4 VIEWS 72110 42 EA 2006CH SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 2006CI TOE(S) 2 OR MORE VIEWS 73660 2 EA 2006CJ UROGRAM INTRAVENOUS 74400 1 EA 2006CK US ABDOMEN 76700 3 EA 2006CL US ABDOMEN LIMITED 76705 1 EA 2006CM US BREAST 76645 8 EA 2006CN US EXTREMITY VEINS BILATERAL 93970 1 EA 2006CO WRIST 2 VIEWS 73100 7 EA CBOC SHOALS Total     652 CLIN 2007:Guntersville Community Based Outpatient Clinic 101 Judysmith Drive Guntersville, AL 35976 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2007AA ABDOMEN 1 VIEW/KUB 74000 1 EA 2007AB ABDOMEN 2 VIEWS 74010 2 EA 2007AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 2007AD ANKLE 3 OR MORE VIEWS 73610 3 EA 2007AE CHEST 2 VIEWS PA&LAT 71020 22 EA 2007AF CLAVICLE 73000 1 EA 2007AG CT ABDOMEN W&W/O CONT 74170 2 EA 2007AH CT HEAD W/O CONT 70450 2 EA 2007AI ELBOW 2 VIEWS 73070 1 EA 2007AJ ELBOW 3 OR MORE VIEWS 73080 1 EA 2007AK FINGER(S) 2 OR MORE VIEWS 73140 2 EA 2007AL FOOT 3 OR MORE VIEWS 73630 3 EA 2007AM FOREARM 2 VIEWS 73090 1 EA 2007AN HAND 3 OR MORE VIEWS 73130 5 EA 2007AO HIP 2 OR MORE VIEWS 73510 3 EA 2007AP HIP BILATERAL 4 OR MORE VIEWS 73520 1 EA 2007AQ INJECTION, REGADENOSON J2785 1 EA 2007AR KNEE 2 VIEWS 73560 1 EA 2007AS KNEE A/P WT.BEAR W LAT FLEX 73562 2 EA 2007AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 3 EA 2007AU MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 1 EA 2007AV MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 2007AW NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 1 EA 2007AX NM CARDIAC STRESS INJECTION A9500 1 EA 2007AY NM CARDIOVASCULAR STRESS TEST 93015 1 EA 2007AZ NM SPECT CARDIAC SINGLE 78451 1 EA 2007BA RIBS UNILAT 2 VIEWS 71100 1 EA 2007BB SHOULDER 2 OR MORE VIEWS 73030 6 EA 2007BC SPINE CERVICAL MIN 6 VIEWS 72052 1 EA 2007BD SPINE LUMBOSACRAL MIN 2 VIEWS 72100 2 EA 2007BE SPINE LUMBOSACRAL MIN 4 VIEWS 72110 8 EA 2007BF SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 2007BG SPINE THORACIC AP+LAT+SWIM VIEWS 72072 1 EA 2007BH TOE(S) 2 OR MORE VIEWS 73660 1 EA 2007BI US ABDOMEN LIMITED 76705 1 EA 2007BJ US BREAST 76645 1 EA 2007BK US EXTREMITY NONVASCULAR 76880 1 EA 2007BL US EXTREMITY VEINS UNILATERAL 93971 1 EA CBOC GUNTERSVILLE Total   89 CLIN 2008: MRI Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2008AA CT HEAD W/O CONT 70540 1 EA 2008AB MRI BRAIN W CONTRAST 70552 10 EA 2008AC MRI BRAIN WO AND W CONTRAST 70553 10 EA 2008AD MRI BRAIN WO CONTRAST 70551 10 EA 2008AE MRI BOTH BREASTS   77059 2 EA 2008AF MRI CERVICAL SPINE WO/W CONT 72156 15 EA 2008AG MRI CERVICAL SPINE WO CONTRAST 72141 15 EA 2008AH MRI LOWER JOINT WO CONTRAST 73721 3 EA 2008AI MRI LUMBAR SPINE W CONTRAST 72149 5 EA 2008AJ MRI LUMBAR SPINE WO & W CONTRAST 72158 50 EA 2008AK MRI LUMBAR SPINE WO CONTRAST 72148 40 EA 2008AL MRI THORACIC SPINE WO CONTRAST 72146 5 EA 2008AM MRI UPPER JOINT WO/CONTRAST 73221 7 EA Birmingham MRI Total   173 CLIN 2009: Mammography Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 2009AA BX BREAST PERCUT W/O IMAGE BREAST BIOPSY 19100 5 EA 2009AB BX BREAST OPEN INCISIONAL 19101 5 EA 2009AC BX BREAST PERCUT W/IMAGE BX BREAST PERCUT W/IMAGE 19102 5 EA 2009AD US BREAST 76645 625 EA 2009AE STEROTACTIC GUIDE FOR BX             77031 10 EA 2009AF GUIDANCE FOR NEEDLE PLACEMENT 77032 10 EA 2009AG BREAST MAMMOGRAPHY 77051 10 EA 2009AH X-RAY OF MAMMARY DUCT 77053 132 EA 2009AI X-RAY OF MAMMARY DUCTS 77054 45 EA 2009AJ MAMMOGRAPHY,DIAGNOSTIC, UNILATERAL 77055 44 EA 2009AK MAMMOGRAPHY,DIAGNOSTIC, BILATERAL 77056 10 EA 2009AL MAMMO SCREENING, 2 FILMS 77057 903 EA 2009AM MRI ONE BREAST 77058 5 EA 2009AN MRI BOTH BREASTS   77059 5 EA Birmingham Mammography Total   1814 OPTION YEAR III: 1 Feb 2014 “ 31 Jan 2015 CLIN 3001:Anniston/Oxford Community Based Outpatient Clinic 96 Ali Way Creekside South, Oxford, AL 36203 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3001AA ABDOMEN 1 VIEW/KUB 74000 1 EA 3001AB ABDOMEN 2 VIEWS 74010 3 EA 3001AC ANKLE 3 OR MORE VIEWS 73610 8 EA 3001AD BARIUM SWALLOW 74220 3 EA 3001AE CHEST 2 VIEWS PA&LAT 71020 45 EA 3001AF CHEST SINGLE VIEW 71010 1 EA 3001AG CLAVICLE 73000 1 EA 3001AH CT ABDOMEN W&W/O CONT 74170 2 EA 3001AI CT ABDOMEN W/O CONT 74150 2 EA 3001AJ CT HEAD W/O CONT 70450 2 EA 3001AK CT PELVIS W&W/O CONT 72194 2 EA 3001AL CT PELVIS W/O CONT 72192 2 EA 3001AM CT THORAX W/O CONT 71250 3 EA 3001AN ELBOW 2 VIEWS 73070 2 EA 3001AO FOOT 3 OR MORE VIEWS 73630 5 EA 3001AP HAND 3 OR MORE VIEWS 73130 5 EA 3001AQ HIP 2 OR MORE VIEWS 73510 17 EA 3001AR INJECTION, REGADENOSON J2785 8 EA 3001AS KNEE 2 VIEWS 73560 20 EA 3001AT KNEE A/P WT.BEAR W LAT FLEX 73562 5 EA 3001AU KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 1 EA 3001AV MAMMO SCREENING, 2 FILMS 77057 128 EA 3001AW MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 10 EA 3001AX MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 3001AY MODIFIED BARIUM SWALLOW 74230 1 EA 3001AZ MRI BRAIN WO AND W CONTRAST 70553 1 EA 3001BA MRI CERVICAL SPINE WO CONTRAST 72141 7 EA 3001BB MRI LO EXT W/WO CONT, NOT JOINT 73720 3 EA 3001BC MRI LOWER JOINT WO CONTRAST 73721 11 EA 3001BD MRI LUMBAR SPINE WO & W CONTRAST 72158 3 EA 3001BE MRI LUMBAR SPINE WO CONTRAST 72148 6 EA 3001BF MRI THORACIC SPINE WO CONTRAST 72146 1 EA 3001BG MRI UPPER JOINT WO/CONTRAST 73221 14 EA 3001BH NASAL BONES MIN 3 VIEWS 70160 1 EA 3001BI NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 3 EA 3001BJ NM CARDIAC STRESS INJECTION A9500 9 EA 3001BK NM CARDIOVASCULAR STRESS TEST 93015 9 EA 3001BL NM SPECT CARDIAC SINGLE 78451 9 EA 3001BM PELVIS 1 VIEW 72170 1 EA 3001BN RIBS UNILAT 2 VIEWS 71100 1 EA 3001BO SHOULDER 2 OR MORE VIEWS 73030 11 EA 3001BP SINUSES MIN 2 VIEWS 70210 1 EA 3001BQ SKULL 4 OR MORE VIEWS 70260 2 EA 3001BR SPINE CERVICAL MIN 3 VIEWS 72040 2 EA 3001BS SPINE CERVICAL MIN 6 VIEWS 72052 8 EA 3001BT SPINE LS BENDING MIN 4 VIEWS 72120 1 EA 3001BU SPINE LUMBOSACRAL MIN 2 VIEWS 72100 16 EA 3001BV SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 3001BW SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 3001BX SPINE THORACIC AP+LAT+SWIM VIEWS 72072 2 EA 3001BY TIBIA & FIBULA 2 VIEWS 73590 1 EA 3001BZ TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 3001CA TOE(S) 2 OR MORE VIEWS 73660 1 EA 3001CB US ABDOMEN 76700 6 EA 3001CC US ABDOMEN LIMITED 76705 1 EA 3001CD US BREAST 76645 9 EA 3001CE US CAROTID BILAT STUDY COMPLE 93880 1 EA 3001CF US EXTREMITY NONVASCULAR 76880 1 EA 3001CG US EXTREMITY VEINS UNILATERAL 93971 2 EA 3001CH US RETROPERITONEAL 76770 1 EA 3001CI US RETROPERITONEAL LIMITED 76775 1 EA 3001CJ US SCROTUM 76870 1 EA 3001CK WRIST 2 VIEWS 73100 3 EA CBOC ANNISTON Total 443 CLIN 3002:Childersburg Community Based Outpatient Clinic 151 9th Avenue N. W., Childersburg, AL 35044 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3002AA ABDOMEN 1 VIEW/KUB 74000 10 EA 3002AB ABDOMEN 2 VIEWS 74010 6 EA 3002AC ANKLE 3 OR MORE VIEWS 73610 7 EA 3002AD BILATERAL KNEE 73565 2 EA 3002AE CALCANEOUS 2 VIEWS 73650 1 EA 3002AF CERVICAL SPINE, FLEXION & EXTENSION ON 72052 9 EA 3002AG CHEST 2 VIEWS PA&LAT 71020 154 EA 3002AH CHEST INCLUDE FLUORO 71034 1 EA 3002AI CHEST SPECIAL (LDECUB ETC) 71035 1 EA 3002AJ CLAVICLE 73000 1 EA 3002AK ELBOW 2 VIEWS 73070 7 EA 3002AL FEMUR 2 VIEWS 73550 3 EA 3002AM FOOT 3 OR MORE VIEWS 73630 22 EA 3002AN FOREARM 2 VIEWS 73090 4 EA 3002AO HAND 3 OR MORE VIEWS 73130 17 EA 3002AP HIP 2 OR MORE VIEWS 73510 19 EA 3002AQ HUMERUS 2 OR MORE VIEWS 73060 2 EA 3002AR KNEE 2 VIEWS 73560 17 EA 3002AS KNEE A/P WT.BEAR W LAT FLEX 73562 8 EA 3002AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 8 EA 3002AU MANDIBLE < 4 VIEWS 70100 1 EA 3002AV ORBIT MIN 4 VIEWS 70200 1 EA 3002AW PELVIS 1 VIEW 72170 1 EA 3002AX RIBS BILAT 3 OR MORE VIEWS 71110 1 EA 3002AY RIBS UNILAT 2 VIEWS 71100 11 EA 3002AZ SHOULDER 2 OR MORE VIEWS 73030 34 EA 3002BA SINUSES 3 OR MORE VIEWS 70220 1 EA 3002BB SINUSES MIN 2 VIEWS 70210 22 EA 3002BC SKULL 4 OR MORE VIEWS 70260 1 EA 3002BD SPINE CERVICAL MIN 3 VIEWS 72040 6 EA 3002BE SPINE CERVICAL MIN 4 VIEWS 72050 3 EA 3002BF SPINE LS BENDING MIN 4 VIEWS 72120 3 EA 3002BG SPINE LUMBOSACRAL MIN 2 VIEWS 72100 44 EA 3002BH SPINE LUMBOSACRAL MIN 4 VIEWS 72110 5 EA 3002BI SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 3002BJ SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 3002BK TIBIA & FIBULA 2 VIEWS 73590 6 EA 3002BL TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 3002BM WRIST 2 VIEWS 73100 7 EA CBOC CHILDERSBURG Total   465 CLIN 3003: Huntsville Community Based Outpatient Clinic 301 Governor's Drive, S.W., Huntsville, AL 35801 & (Combined) Decatur/Madison Community Based Outpatient Clinic 8075 Madison Blvd., Suite 101 Madison, AL 35758 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3003AA ABDOMEN 1 VIEW/KUB 74000 12 EA 3003AB ABDOMEN 2 VIEWS 74010 7 EA 3003AC ANKLE 3 OR MORE VIEWS 73610 42 EA 3003AD BARIUM SWALLOW 74220 5 EA 3003AE BILATERAL KNEE 73565 4 EA 3003AF CALCANEOUS 2 VIEWS 73650 2 EA 3003AG CHEST 2 VIEWS PA&LAT 71020 254 EA 3003AH CHEST SINGLE VIEW 71010 1 EA 3003AI CLAVICLE 73000 1 EA 3003AJ COLON BARIUM ENEMA 74270 1 EA 3003AK CT ABDOMEN W&W/O CONT 74170 33 EA 3003AL CT ABDOMEN W/CONT 74160 2 EA 3003AM CT ABDOMEN W/O CONT 74150 15 EA 3003AN CT CERVICAL SPINE W/O CONT 72125 1 EA 3003AO CT HEAD W&WO CONT 70470 2 EA 3003AP CT HEAD W/O CONT 70450 13 EA 3003AQ CT LUMBAR SPINE W/O CONT 72131 1 EA 3003AR CT NECK SOFT TISSU W&W/O CONT 70492 4 EA 3003AS CT NECK SOFT TISSU W/CONT 70491 1 EA 3003AT CT NECK SOFT TISSU W/O CONT 70490 1 EA 3003AU CT PELVIS W&W/O CONT 72194 13 EA 3003AV CT PELVIS W/CONT 72193 12 EA 3003AW CT PELVIS W/O CONT 72192 14 EA 3003AX CT SINUSES ONLY WO CONTRAST 70486 3 EA 3003AY CT TEMPORAL BONE W/O CONTRAST 70480 2 EA 3003AZ CT THORACIC SPINE W/O CONT 72128 1 EA 3003BA CT THORAX W&W/O CONT 71270 4 EA 3003BB CT THORAX W/CONT 71260 7 EA 3003BC CT THORAX W/O CONT 71250 21 EA 3003BD CT UPPER EXTREMITY W/O CONT 73200 1 EA 3003BE CTA HEAD W/CONT & POST PROCESS 70496 1 EA 3003BF ELBOW 2 VIEWS 73070 16 EA 3003BG ELBOW 3 OR MORE VIEWS 73080 1 EA 3003BH FACIAL BONES MIN 2 VIEWS 70140 1 EA 3003BI FEMUR 2 VIEWS 73550 4 EA 3003BJ FINGER(S) 2 OR MORE VIEWS 73140 7 EA 3003BK FOOT 3 OR MORE VIEWS 73630 41 EA 3003BL FOREARM 2 VIEWS 73090 4 EA 3003BM HAND 3 OR MORE VIEWS 73130 45 EA 3003BN HIP 1 VIEW 73500 1 EA 3003BO HIP 2 OR MORE VIEWS 73510 64 EA 3003BP HUMERUS 2 OR MORE VIEWS 73060 2 EA 3003BQ INJECTION, REGADENOSON J2785 24 EA 3003BR KNEE 2 VIEWS 73560 115 EA 3003BS KNEE A/P WT.BEAR W LAT FLEX 73562 10 EA 3003BT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 12 EA 3003BU MAMMO SCREENING, 2 FILMS 77057 235 EA 3003BV MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 51 EA 3003BW MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 21 EA 0003BX MODIFIED BARIUM SWALLOW 74230 10 EA 3003BY MRA HEAD WO CONTRAST 70544 7 EA 3003BZ MRA NECK W & WO CONTRAST 70549 4 EA 3003CA MRA NECK WO CONTRAST 70547 1 EA 3003CB MRI ABDOMEN W & W/O CONT 74183 1 EA 3003CC MRI BRAIN W CONTRAST 70552 4 EA 3003CD MRI BRAIN WO AND W CONTRAST 70553 24 EA 3003CE MRI BRAIN WO CONTRAST 70551 8 EA 3003CF MRI CERVICAL SPINE W CONTRAST 72142 1 EA 3003CG MRI CERVICAL SPINE WO CONTRAST 72141 21 EA 3003CH MRI CERVICAL SPINE WO/W CONT 72156 5 EA 3003CI MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 3003CJ MRI LOWER JOINT WO CONTRAST 73721 17 EA 3003CK MRI LUMBAR SPINE W CONTRAST 72149 1 EA 3003CL MRI LUMBAR SPINE WO & W CONTRAST 72158 15 EA 3003CM MRI LUMBAR SPINE WO CONTRAST 72148 24 EA 3003CN MRI ORBIT FACE/NECK W/WO CONT 70543 1 EA 3003CO MRI PELVIS W/CONTRAST 72196 4 EA 3003CP MRI THORACIC SPINE WO CONTRAST 72146 5 EA 3003CQ MRI THORACIC SPINE WO/W CONT 72157 5 EA 3003CR MRI UPPER JOINT WO/CONTRAST 73221 10 EA 3003CS NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 4 EA 3003CT NM BONE IMAGING, THREE PHASE 78315 2 EA 3003CU NM BONE IMAGING, WHOLE BODY 78306 6 EA 3003CV NM CARDIAC STRESS INJECTION A9500 30 EA 3003CW NM CARDIOVASCULAR STRESS TEST 93015 30 EA 3003CX NM HEPATOBILIARY SCAN (HIDA SCAN) 78223 1 EA 3003CY NM SPECT CARDIAC SINGLE 78451 30 EA 3003CZ PELVIS 1 VIEW 72170 8 EA 3003DA RIBS UNILAT 2 VIEWS 71100 20 EA 3003DB SCAPULA 73010 1 EA 3003DC SHOULDER 2 OR MORE VIEWS 73030 84 EA 3003DD SIALOGRAM S&I 70390 1 EA 3003DE SPINE CERVICAL MIN 3 VIEWS 72040 3 EA 3003DF SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 3003DG SPINE CERVICAL MIN 6 VIEWS 72052 57 EA 3003DH SPINE LS BENDING MIN 4 VIEWS 72120 2 EA 3003DI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 102 EA 3003DJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 6 EA 3003DK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 3 EA 3003DL SPINE SI JOINT 3 OR MORE VIEWS 72202 2 EA 3003DM SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 3003DN TIBIA & FIBULA 2 VIEWS 73590 12 EA 3003DO TM BONE JOINT UNILAT O&C MOUTH 70328 2 EA 3003DP TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 3003DQ UPPER GI 74240 6 EA 3003DR UPPER GI + SMALL BOWEL 74245 2 EA 3003DS US AAA SCREENING ONLY G0389 1 EA 3003DT US ABDOMEN 76700 39 EA 3003DU US ABDOMEN LIMITED 76705 16 EA 3003DV US ABDOMINAL VASCULAR 93975 6 EA 3003DW US BREAST 76645 52 EA 3003DX US CAROTID BILAT STUDY COMPLE 93880 19 EA 3003DY US EXTREMITY NONVASCULAR 76880 6 EA 3003DZ US EXTREMITY VEINS BILATERAL 93970 7 EA 3003EA US EXTREMITY VEINS UNILATERAL 93971 9 EA 3003EB US LO EXT ARTERIES BILAT 93925 1 EA 3003EC US PELVIC 76856 3 EA 3003ED US RETROPERITONEAL 76770 10 EA 3003EE US RETROPERITONEAL LIMITED 76775 1 EA 3003EF US SCROTUM 76870 8 EA 3003EG US THYROID/NECK SOFT TISSUE 76536 6 EA 3003EH US TRANSVAGINAL 76830 1 EA 3003EI US VASCULAR DOPPLER LIMITED 93976 2 EA 3003EJ WRIST 2 VIEWS 73100 22 EA CBOC HSV/DEC/MAD Total   1947 CIN 3004: Gadsden Community Based Outpatient Clinic 206 Rescia Drive, Gadsden, AL 35906 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3004AA ABDOMEN 1 VIEW/KUB 74000 18 EA 3004AB ABDOMEN 2 VIEWS 74010 13 EA 3004AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 3004AD ANKLE 3 OR MORE VIEWS 73610 27 EA 3004AE BILATERAL KNEE 73565 17 EA 3004AF CALCANEOUS 2 VIEWS 73650 9 EA 3004AG CHEST 2 VIEWS PA&LAT 71020 221 EA 3004AH CHEST SINGLE VIEW 71010 1 EA 3004AI CLAVICLE 73000 2 EA 3004AJ CT ABDOMEN W&W/O CONT 74170 3 EA 3004AK CT ABDOMEN W/O CONT 74150 4 EA 3004AL CT HEAD W/O CONT 70450 3 EA 3004AM CT PELVIS W&W/O CONT 72194 3 EA 3004AN CT PELVIS W/O CONT 72192 4 EA 3004AO CT THORAX W/O CONT 71250 1 EA 3004AP ELBOW 2 VIEWS 73070 13 EA 3004AQ ELBOW 3 OR MORE VIEWS 73080 1 EA 3004AR FEMUR 2 VIEWS 73550 3 EA 3004AS FINGER(S) 2 OR MORE VIEWS 73140 6 EA 3004AT FOOT 3 OR MORE VIEWS 73630 51 EA 3004AU FOREARM 2 VIEWS 73090 3 EA 3004AV HAND 3 OR MORE VIEWS 73130 40 EA 3004AW HIP 2 OR MORE VIEWS 73510 60 EA 3004AX HIP BILATERAL 4 OR MORE VIEWS 73520 2 EA 3004AY HUMERUS 2 OR MORE VIEWS 73060 1 EA 3004AZ KNEE 2 VIEWS 73560 93 EA 3004BA KNEE A/P WT.BEAR W LAT FLEX 73562 18 EA 3004BB KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 3004BC MAMMO SCREENING, 2 FILMS 77057 51 EA 3004BD MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 8 EA 3004BE MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 3004BF MANDIBLE 4 OR MORE VIEWS 70110 1 EA 3004BG MRA HEAD WO CONTRAST 70544 1 EA 3004BH MRA LOW EXT W OR WO CONTRAST 73725 1 EA 3004BI MRA NECK W & WO CONTRAST 70549 1 EA 3004BJ MRI BRAIN W CONTRAST 70552 1 EA 3004BK MRI BRAIN WO AND W CONTRAST 70553 4 EA 3004BL MRI BRAIN WO CONTRAST 70551 4 EA 3004BM MRI CERVICAL SPINE WO CONTRAST 72141 2 EA 3004BN MRI CERVICAL SPINE WO/W CONT 72156 4 EA 3004BO MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 3004BP MRI LOWER JOINT WO CONTRAST 73721 2 EA 3004BQ MRI LUMBAR SPINE WO & W CONTRAST 72158 5 EA 3004BR MRI LUMBAR SPINE WO CONTRAST 72148 3 EA 3004BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 3004BT MRI UPPER JOINT WO/CONTRAST 73221 8 EA 3004BU NASAL BONES MIN 3 VIEWS 70160 1 EA 3004BV NECK SOFT TISSUE 70360 1 EA 3004BW ORBIT MIN 4 VIEWS 70200 1 EA 3004BX PELVIS 1 VIEW 72170 33 EA 3004BY RIBS BILAT 3 OR MORE VIEWS 71110 2 EA 3004BZ RIBS UNILAT 2 VIEWS 71100 23 EA 3004CA SCAPULA 73010 1 EA 3004CB SHOULDER INT/EXT Y-VIEW AXILLARY 73030 82 EA 3004CC SINUSES MIN 2 VIEWS 70210 8 EA 3004CD SKULL 4 OR MORE VIEWS 70260 3 EA 3004CE SPINE CERVICAL MIN 3 VIEWS 72040 42 EA 3004CF SPINE CERVICAL MIN 4 VIEWS 72050 11 EA 3004CG SPINE CERVICAL MIN 6 VIEWS 72052 20 EA 3004CH SPINE LS BENDING MIN 4 VIEWS 72120 8 EA 3004CI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 106 EA 3004CJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 16 EA 3004CK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 2 EA 3004CL SPINE SI JOINT 3 OR MORE VIEWS 72202 1 EA 3004CM SPINE SI JOINTS 1 OR 2 VIEWS 72200 1 EA 3004CN SPINE THORACIC AP+LAT+SWIM VIEWS 72072 26 EA 3004CO TIBIA & FIBULA 2 VIEWS 73590 4 EA 3004CP TOE(S) 2 OR MORE VIEWS 73660 1 EA 3004CQ US ABDOMEN 76700 7 EA 3004CR US BREAST 76645 17 EA 3004CS US CAROTID BILAT STUDY COMPLE 93880 2 EA 3004CT US EXTREMITY VEINS BILATERAL 93970 6 EA 3004CU US EXTREMITY VEINS UNILATERAL 93971 11 EA 3004CV US LO EXT ARTERIES BILAT 93925 1 EA 3004CW US RETROPERITONEAL 76770 2 EA 3004CX US SCROTUM 76870 5 EA 3004CY US VASCULAR DOPPLER LIMITED 93976 2 EA 3004CZ WRIST 2 VIEWS 73100 21 EA CBOC GADSDEN Total   1223 CLIN 3005:Jasper Community Based Outpatient Clinic 3400 Hwy 78 East, Suite 215, Jasper, AL 35501 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3005AA ABDOMEN 1 VIEW/KUB 74000 1 EA 3005AB ANKLE 3 OR MORE VIEWS 73610 2 EA 3005AC BILATERAL KNEE 73565 1 EA 3005AD CHEST 2 VIEWS PA&LAT 71020 21 EA 3005AE CHEST SINGLE VIEW 71010 1 EA 3005AF CT ABDOMEN W&W/O CONT 74170 3 EA 3005AG CT HEAD W/O CONT 70450 3 EA 3005AH CT PELVIS W&W/O CONT 72194 2 EA 3005AI CT PELVIS W/CONT 72193 1 EA 3005AJ CT THORAX W/CONT 71260 1 EA 3005AK ELBOW 2 VIEWS 73070 1 EA 3005AL FOOT 3 OR MORE VIEWS 73630 6 EA 3005AM HAND 3 OR MORE VIEWS 73130 1 EA 3005AN HIP 2 OR MORE VIEWS 73510 7 EA 3005AO INJECTION, REGADENOSON J2785 2 EA 3005AP KNEE 2 VIEWS 73560 12 EA 3005AQ KNEE 4 OR MORE VIEWS 73564 2 EA 3005AR KNEE A/P WT.BEAR W LAT FLEX 73562 1 EA 3005AS MAMMO SCREENING, 2 FILMS 77057 32 EA 3005AT MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 4 EA 3005AU MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 2 EA 3005AV MRI BRAIN WO AND W CONTRAST 70553 1 EA 3005AW MRI CERVICAL SPINE WO CONTRAST 72141 4 EA 3005AX MRI LOWER JOINT WO CONTRAST 73721 3 EA 3005AY MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 3005AZ MRI LUMBAR SPINE WO CONTRAST 72148 5 EA 3005BA MRI UPPER JOINT WO/CONTRAST 73221 3 EA 3005BB NM CARDIAC STRESS INJECTION A9500 2 EA 3005BC NM CARDIOVASCULAR STRESS TEST 93015 2 EA 3005BD NM SPECT CARDIAC SINGLE 78451 2 EA 3005BE PELVIS 1 VIEW 72170 1 EA 3005BF RIBS UNILAT 2 VIEWS 71100 1 EA 3005BG SHOULDER 2 OR MORE VIEWS 73030 13 EA 3005BH SPINE CERVICAL MIN 6 VIEWS 72052 17 EA 3005BI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 35 EA 3005BJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 3005BK SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 3005BL TIBIA & FIBULA 2 VIEWS 73590 1 EA 3005BM UROGRAM INTRAVENOUS 74400 1 EA 3005BN US ABDOMEN 76700 2 EA 3005BO US ABDOMEN LIMITED 76705 1 EA  3005BP US BREAST 76645 5 EA  3005BQ US CAROTID BILAT STUDY COMPLE 93880 6 EA  3005BR US EXTREMITY VEINS UNILATERAL 93971 1 EA  3005BS US PELVIC LIMITED 76857 1 EA  3005BT US RETROPERITONEAL 76770 3 EA  3005BU US SCROTUM 76870 2 EA  3005BV WRIST 2 VIEWS 73100 2 EA CBOC JASPER Total   226 CLIN 3006:Muscle Shoals Community Based Outpatient Clinic 422 DD Cox Blvd., Sheffield, AL 35660 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3006AA ABDOMEN 2 VIEWS 74010 2 EA 3006AB ABDOMEN 3 OR MORE VIEWS 74020 1 EA 3006AC ANKLE 3 OR MORE VIEWS 73610 14 EA 3006AD BILATERAL KNEE 73565 2 EA 3006AE BONE SURVEY, METASTATIC COMPLETE 77075 1 EA 3006AF CHEST 2 VIEWS PA&LAT 71020 140 EA 3006AG CLAVICLE 73000 1 EA 3006AH CT ABDOMEN W&W/O CONT 74170 3 EA 3006AI CT ABDOMEN W/O CONT 74150 1 EA 3006AJ CT CERVICAL SPINE W/O CONT 72125 1 EA 3006AK CT HEAD W/O CONT 70450 2 EA 3006AL CT MAXILLOFACIAL W&W/O CONT 70488 1 EA 3006AM CT NECK SOFT TISSU W&W/O CONT 70492 1 EA 3006AN CT PELVIS W&W/O CONT 72194 1 EA 3006AO CT PELVIS W/CONT 72193 2 EA 3006AP CT PELVIS W/O CONT 72192 1 EA 3006AQ CT SINUSES ONLY WO CONTRAST 70486 1 EA 3006AR CT THORAX W&W/O CONT 71270 5 EA 3006AS CT THORAX W/O CONT 71250 1 EA 3006AT ELBOW 2 VIEWS 73070 7 EA 3006AU FEMUR 2 VIEWS 73550 1 EA 3006AV FINGER(S) 2 OR MORE VIEWS 73140 3 EA 3006AW FOOT 3 OR MORE VIEWS 73630 30 EA 3006AX FOREARM 2 VIEWS 73090 2 EA 3006AY HAND 3 OR MORE VIEWS 73130 11 EA 3006AZ HIP 2 OR MORE VIEWS 73510 24 EA 3006BA HUMERUS 2 OR MORE VIEWS 73060 1 EA 3006BB INJECTION, REGADENOSON J2785 2 EA 3006BC KNEE 2 VIEWS 73560 29 EA 3006BD KNEE A/P WT.BEAR W LAT FLEX 73562 4 EA 3006BE KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 3006BF MAMMO SCREENING, 2 FILMS 77057 71 EA 3006BG MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 3 EA 3006BH MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 9 EA 3006BI MANDIBLE 4 OR MORE VIEWS 70110 2 EA 3006BJ MRA HEAD WO CONTRAST 70544 1 EA 3006BK MRI ABDOMEN W & W/O CONT 74183 1 EA 3006BL MRI BRAIN WO AND W CONTRAST 70553 7 EA 3006BM MRI BRAIN WO CONTRAST 70551 9 EA 3006BN MRI CERVICAL SPINE WO CONTRAST 72141 3 EA 3006BO MRI LOWER JOINT WO CONTRAST 73721 4 EA 3006BP MRI LUMBAR SPINE WO & W CONTRAST 72158 2 EA 3006BQ MRI LUMBAR SPINE WO CONTRAST 72148 12 EA 3006BR MRI PELVIS W/CONTRAST 72196 1 EA 3006BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 3006BT MRI UPPER JOINT WO/CONTRAST 73221 5 EA 3006BU NM CARDIAC STRESS INJECTION A9500 3 EA 3006BV NM CARDIOVASCULAR STRESS TEST 93015 3 EA 3006BW NM SPECT CARDIAC SINGLE 78451 3 EA 3006BX PELVIS 1 VIEW 72170 2 EA 3006BY RIBS UNILAT 2 VIEWS 71100 12 EA 3006BZ SHOULDER 2 OR MORE VIEWS 73030 43 EA 3006CA SKULL 4 OR MORE VIEWS 70260 1 EA 3006CB SPINE CERVICAL MIN 3 VIEWS 72040 8 EA 3006CC SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 3006CD SPINE CERVICAL MIN 6 VIEWS 72052 15 EA 3006CE SPINE LS BENDING MIN 4 VIEWS 72120 14 EA 3006CF SPINE LUMBOSACRAL MIN 2 VIEWS 72100 26 EA 3006CG SPINE LUMBOSACRAL MIN 4 VIEWS 72110 42 EA 3006CH SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 3006CI TOE(S) 2 OR MORE VIEWS 73660 2 EA 3006CJ UROGRAM INTRAVENOUS 74400 1 EA 3006CK US ABDOMEN 76700 3 EA 3006CL US ABDOMEN LIMITED 76705 1 EA 3006CM US BREAST 76645 8 EA 3006CN US EXTREMITY VEINS BILATERAL 93970 1 EA 3006CO WRIST 2 VIEWS 73100 7 EA CBOC SHOALS Total     652 CLIN 3007:Guntersville Community Based Outpatient Clinic 101 Judysmith Drive Guntersville, AL 35976 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3007AA ABDOMEN 1 VIEW/KUB 74000 1 EA 3007AB ABDOMEN 2 VIEWS 74010 2 EA 3007AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 3007AD ANKLE 3 OR MORE VIEWS 73610 3 EA 3007AE CHEST 2 VIEWS PA&LAT 71020 22 EA 3007AF CLAVICLE 73000 1 EA 3007AG CT ABDOMEN W&W/O CONT 74170 2 EA 3007AH CT HEAD W/O CONT 70450 2 EA 3007AI ELBOW 2 VIEWS 73070 1 EA 3007AJ ELBOW 3 OR MORE VIEWS 73080 1 EA 3007AK FINGER(S) 2 OR MORE VIEWS 73140 2 EA 0007AL FOOT 3 OR MORE VIEWS 73630 3 EA 0007AM FOREARM 2 VIEWS 73090 1 EA 0007AN HAND 3 OR MORE VIEWS 73130 5 EA 0007AO HIP 2 OR MORE VIEWS 73510 3 EA 0007AP HIP BILATERAL 4 OR MORE VIEWS 73520 1 EA 0007AQ INJECTION, REGADENOSON J2785 1 EA 0007AR KNEE 2 VIEWS 73560 1 EA 0007AS KNEE A/P WT.BEAR W LAT FLEX 73562 2 EA 0007AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 3 EA 0007AU MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 1 EA 0007AV MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 0007AW NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 1 EA 0007AX NM CARDIAC STRESS INJECTION A9500 1 EA 0007AY NM CARDIOVASCULAR STRESS TEST 93015 1 EA 0007AZ NM SPECT CARDIAC SINGLE 78451 1 EA 0007BA RIBS UNILAT 2 VIEWS 71100 1 EA 0007BB SHOULDER 2 OR MORE VIEWS 73030 6 EA 0007BC SPINE CERVICAL MIN 6 VIEWS 72052 1 EA 0007BD SPINE LUMBOSACRAL MIN 2 VIEWS 72100 2 EA 0007BE SPINE LUMBOSACRAL MIN 4 VIEWS 72110 8 EA 0007BF SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 0007BG SPINE THORACIC AP+LAT+SWIM VIEWS 72072 1 EA 0007BH TOE(S) 2 OR MORE VIEWS 73660 1 EA 0007BI US ABDOMEN LIMITED 76705 1 EA 3007BJ US BREAST 76645 1 EA 3007BK US EXTREMITY NONVASCULAR 76880 1 EA 3007BL US EXTREMITY VEINS UNILATERAL 93971 1 EA CBOC GUNTERSVILLE Total   89 CLIN 3008: MRI Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3008AA CT HEAD W/O CONT 70540 1 EA 3008AB MRI BRAIN W CONTRAST 70552 10 EA 3008AC MRI BRAIN WO AND W CONTRAST 70553 10 EA 3008AD MRI BRAIN WO CONTRAST 70551 10 EA 3008AE MRI BOTH BREASTS   77059 2 EA 3008AF MRI CERVICAL SPINE WO/W CONT 72156 15 EA 3008AG MRI CERVICAL SPINE WO CONTRAST 72141 15 EA 3008AH MRI LOWER JOINT WO CONTRAST 73721 3 EA 3008AI MRI LUMBAR SPINE W CONTRAST 72149 5 EA 3008AJ MRI LUMBAR SPINE WO & W CONTRAST 72158 50 EA 3008AK MRI LUMBAR SPINE WO CONTRAST 72148 40 EA 3008AL MRI THORACIC SPINE WO CONTRAST 72146 5 EA 3008AM MRI UPPER JOINT WO/CONTRAST 73221 7 EA Birmingham MRI Total   173 CLIN 3009: Mammography Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 3009AA BX BREAST PERCUT W/O IMAGE BREAST BIOPSY 19100 5 EA 3009AB BX BREAST OPEN INCISIONAL 19101 5 EA 3009AC BX BREAST PERCUT W/IMAGE BX BREAST PERCUT W/IMAGE 19102 5 EA 3009AD US BREAST 76645 625 EA 3009AE STEROTACTIC GUIDE FOR BX             77031 10 EA 3009AF GUIDANCE FOR NEEDLE PLACEMENT 77032 10 EA 3009AG BREAST MAMMOGRAPHY 77051 10 EA 3009AH X-RAY OF MAMMARY DUCT 77053 132 EA 3009AI X-RAY OF MAMMARY DUCTS 77054 45 EA 3009AJ MAMMOGRAPHY,DIAGNOSTIC, UNILATERAL 77055 44 EA 3009AK MAMMOGRAPHY,DIAGNOSTIC, BILATERAL 77056 10 EA 3009AL MAMMO SCREENING, 2 FILMS 77057 903 EA 3009AM MRI ONE BREAST 77058 5 EA 3009AN MRI BOTH BREASTS   77059 5 EA Birmingham Mammography Total   1814 OPTION IV: 1 Feb 2015 “ 31 Jan 2016 CLIN 4001:Anniston/Oxford Community Based Outpatient Clinic 96 Ali Way Creekside South, Oxford, AL 36203 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4001AA ABDOMEN 1 VIEW/KUB 74000 1 EA 4001AB ABDOMEN 2 VIEWS 74010 3 EA 4001AC ANKLE 3 OR MORE VIEWS 73610 8 EA 4001AD BARIUM SWALLOW 74220 3 EA 4001AE CHEST 2 VIEWS PA&LAT 71020 45 EA 4001AF CHEST SINGLE VIEW 71010 1 EA 4001AG CLAVICLE 73000 1 EA 4001AH CT ABDOMEN W&W/O CONT 74170 2 EA 4001AI CT ABDOMEN W/O CONT 74150 2 EA 4001AJ CT HEAD W/O CONT 70450 2 EA 4001AK CT PELVIS W&W/O CONT 72194 2 EA 4001AL CT PELVIS W/O CONT 72192 2 EA 4001AM CT THORAX W/O CONT 71250 3 EA 4001AN ELBOW 2 VIEWS 73070 2 EA 4001AO FOOT 3 OR MORE VIEWS 73630 5 EA 4001AP HAND 3 OR MORE VIEWS 73130 5 EA 4001AQ HIP 2 OR MORE VIEWS 73510 17 EA 4001AR INJECTION, REGADENOSON J2785 8 EA 4001AS KNEE 2 VIEWS 73560 20 EA 4001AT KNEE A/P WT.BEAR W LAT FLEX 73562 5 EA 4001AU KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 1 EA 4001AV MAMMO SCREENING, 2 FILMS 77057 128 EA 4001AW MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 10 EA 4001AX MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 4001AY MODIFIED BARIUM SWALLOW 74230 1 EA 4001AZ MRI BRAIN WO AND W CONTRAST 70553 1 EA 4001BA MRI CERVICAL SPINE WO CONTRAST 72141 7 EA 4001BB MRI LO EXT W/WO CONT, NOT JOINT 73720 3 EA 4001BC MRI LOWER JOINT WO CONTRAST 73721 11 EA 4001BD MRI LUMBAR SPINE WO & W CONTRAST 72158 3 EA 4001BE MRI LUMBAR SPINE WO CONTRAST 72148 6 EA 4001BF MRI THORACIC SPINE WO CONTRAST 72146 1 EA 4001BG MRI UPPER JOINT WO/CONTRAST 73221 14 EA 4001BH NASAL BONES MIN 3 VIEWS 70160 1 EA 4001BI NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 3 EA 4001BJ NM CARDIAC STRESS INJECTION A9500 9 EA 4001BK NM CARDIOVASCULAR STRESS TEST 93015 9 EA 4001BL NM SPECT CARDIAC SINGLE 78451 9 EA 4001BM PELVIS 1 VIEW 72170 1 EA 4001BN RIBS UNILAT 2 VIEWS 71100 1 EA 4001BO SHOULDER 2 OR MORE VIEWS 73030 11 EA 4001BP SINUSES MIN 2 VIEWS 70210 1 EA 4001BQ SKULL 4 OR MORE VIEWS 70260 2 EA 4001BR SPINE CERVICAL MIN 3 VIEWS 72040 2 EA 4001BS SPINE CERVICAL MIN 6 VIEWS 72052 8 EA 4001BT SPINE LS BENDING MIN 4 VIEWS 72120 1 EA 4001BU SPINE LUMBOSACRAL MIN 2 VIEWS 72100 16 EA 4001BV SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 4001BW SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 4001BX SPINE THORACIC AP+LAT+SWIM VIEWS 72072 2 EA 4001BY TIBIA & FIBULA 2 VIEWS 73590 1 EA 4001BZ TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 4001CA TOE(S) 2 OR MORE VIEWS 73660 1 EA 4001CB US ABDOMEN 76700 6 EA 4001CC US ABDOMEN LIMITED 76705 1 EA 4001CD US BREAST 76645 9 EA 4001CE US CAROTID BILAT STUDY COMPLE 93880 1 EA 4001CF US EXTREMITY NONVASCULAR 76880 1 EA 4001CG US EXTREMITY VEINS UNILATERAL 93971 2 EA 4001CH US RETROPERITONEAL 76770 1 EA 4001CI US RETROPERITONEAL LIMITED 76775 1 EA 4001CJ US SCROTUM 76870 1 EA 4001CK WRIST 2 VIEWS 73100 3 EA CBOC ANNISTON Total 443 CLIN 4002:Childersburg Community Based Outpatient Clinic 151 9th Avenue N. W., Childersburg, AL 35044 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4002AA ABDOMEN 1 VIEW/KUB 74000 10 EA 4002AB ABDOMEN 2 VIEWS 74010 6 EA 4002AC ANKLE 3 OR MORE VIEWS 73610 7 EA 4002AD BILATERAL KNEE 73565 2 EA 4002AE CALCANEOUS 2 VIEWS 73650 1 EA 4002AF CERVICAL SPINE, FLEXION & EXTENSION ON 72052 9 EA 4002AG CHEST 2 VIEWS PA&LAT 71020 154 EA 4002AH CHEST INCLUDE FLUORO 71034 1 EA 4002AI CHEST SPECIAL (LDECUB ETC) 71035 1 EA 4002AJ CLAVICLE 73000 1 EA 4002AK ELBOW 2 VIEWS 73070 7 EA 4002AL FEMUR 2 VIEWS 73550 3 EA 4002AM FOOT 3 OR MORE VIEWS 73630 22 EA 4002AN FOREARM 2 VIEWS 73090 4 EA 4002AO HAND 3 OR MORE VIEWS 73130 17 EA 4002AP HIP 2 OR MORE VIEWS 73510 19 EA 4002AQ HUMERUS 2 OR MORE VIEWS 73060 2 EA 4002AR KNEE 2 VIEWS 73560 17 EA 4002AS KNEE A/P WT.BEAR W LAT FLEX 73562 8 EA 4002AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 8 EA 4002AU MANDIBLE < 4 VIEWS 70100 1 EA 4002AV ORBIT MIN 4 VIEWS 70200 1 EA 4002AW PELVIS 1 VIEW 72170 1 EA 4002AX RIBS BILAT 3 OR MORE VIEWS 71110 1 EA 4002AY RIBS UNILAT 2 VIEWS 71100 11 EA 4002AZ SHOULDER 2 OR MORE VIEWS 73030 34 EA 4002BA SINUSES 3 OR MORE VIEWS 70220 1 EA 4002BB SINUSES MIN 2 VIEWS 70210 22 EA 4002BC SKULL 4 OR MORE VIEWS 70260 1 EA 4002BD SPINE CERVICAL MIN 3 VIEWS 72040 6 EA 4002BE SPINE CERVICAL MIN 4 VIEWS 72050 3 EA 4002BF SPINE LS BENDING MIN 4 VIEWS 72120 3 EA 4002BG SPINE LUMBOSACRAL MIN 2 VIEWS 72100 44 EA 4002BH SPINE LUMBOSACRAL MIN 4 VIEWS 72110 5 EA 4002BI SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 4002BJ SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 4002BK TIBIA & FIBULA 2 VIEWS 73590 6 EA 4002BL TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 4002BM WRIST 2 VIEWS 73100 7 EA CBOC CHILDERSBURG Total   465 CLIN 4003: Huntsville Community Based Outpatient Clinic 301 Governor's Drive, S.W., Huntsville, AL 35801 & (Combined) Decatur/Madison Community Based Outpatient Clinic 8075 Madison Blvd., Suite 101 Madison, AL 35758 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4003AA ABDOMEN 1 VIEW/KUB 74000 12 EA 4003AB ABDOMEN 2 VIEWS 74010 7 EA 4003AC ANKLE 3 OR MORE VIEWS 73610 42 EA 4003AD BARIUM SWALLOW 74220 5 EA 4003AE BILATERAL KNEE 73565 4 EA 4003AF CALCANEOUS 2 VIEWS 73650 2 EA 4003AG CHEST 2 VIEWS PA&LAT 71020 254 EA 4003AH CHEST SINGLE VIEW 71010 1 EA 4003AI CLAVICLE 73000 1 EA 4003AJ COLON BARIUM ENEMA 74270 1 EA 4003AK CT ABDOMEN W&W/O CONT 74170 33 EA 4003AL CT ABDOMEN W/CONT 74160 2 EA 4003AM CT ABDOMEN W/O CONT 74150 15 EA 4003AN CT CERVICAL SPINE W/O CONT 72125 1 EA 4003AO CT HEAD W&WO CONT 70470 2 EA 4003AP CT HEAD W/O CONT 70450 13 EA 4003AQ CT LUMBAR SPINE W/O CONT 72131 1 EA 4003AR CT NECK SOFT TISSU W&W/O CONT 70492 4 EA 4003AS CT NECK SOFT TISSU W/CONT 70491 1 EA 4003AT CT NECK SOFT TISSU W/O CONT 70490 1 EA 4003AU CT PELVIS W&W/O CONT 72194 13 EA 4003AV CT PELVIS W/CONT 72193 12 EA 4003AW CT PELVIS W/O CONT 72192 14 EA 4003AX CT SINUSES ONLY WO CONTRAST 70486 3 EA 4003AY CT TEMPORAL BONE W/O CONTRAST 70480 2 EA 4003AZ CT THORACIC SPINE W/O CONT 72128 1 EA 4003BA CT THORAX W&W/O CONT 71270 4 EA 4003BB CT THORAX W/CONT 71260 7 EA 4003BC CT THORAX W/O CONT 71250 21 EA 4003BD CT UPPER EXTREMITY W/O CONT 73200 1 EA 4003BE CTA HEAD W/CONT & POST PROCESS 70496 1 EA 4003BF ELBOW 2 VIEWS 73070 16 EA 4003BG ELBOW 3 OR MORE VIEWS 73080 1 EA 4003BH FACIAL BONES MIN 2 VIEWS 70140 1 EA 4003BI FEMUR 2 VIEWS 73550 4 EA 4003BJ FINGER(S) 2 OR MORE VIEWS 73140 7 EA 4003BK FOOT 3 OR MORE VIEWS 73630 41 EA 4003BL FOREARM 2 VIEWS 73090 4 EA 4003BM HAND 3 OR MORE VIEWS 73130 45 EA 4003BN HIP 1 VIEW 73500 1 EA 4003BO HIP 2 OR MORE VIEWS 73510 64 EA 4003BP HUMERUS 2 OR MORE VIEWS 73060 2 EA 4003BQ INJECTION, REGADENOSON J2785 24 EA 4003BR KNEE 2 VIEWS 73560 115 EA 4003BS KNEE A/P WT.BEAR W LAT FLEX 73562 10 EA 4003BT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 12 EA 4003BU MAMMO SCREENING, 2 FILMS 77057 235 EA 4003BV MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 51 EA 4003BW MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 21 EA 4003BX MODIFIED BARIUM SWALLOW 74230 10 EA 4003BY MRA HEAD WO CONTRAST 70544 7 EA 4003BZ MRA NECK W & WO CONTRAST 70549 4 EA 4003CA MRA NECK WO CONTRAST 70547 1 EA 4003CB MRI ABDOMEN W & W/O CONT 74183 1 EA 4003CC MRI BRAIN W CONTRAST 70552 4 EA 4003CD MRI BRAIN WO AND W CONTRAST 70553 24 EA 4003CE MRI BRAIN WO CONTRAST 70551 8 EA 4003CF MRI CERVICAL SPINE W CONTRAST 72142 1 EA 4003CG MRI CERVICAL SPINE WO CONTRAST 72141 21 EA 4003CH MRI CERVICAL SPINE WO/W CONT 72156 5 EA 4003CI MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 4003CJ MRI LOWER JOINT WO CONTRAST 73721 17 EA 4003CK MRI LUMBAR SPINE W CONTRAST 72149 1 EA 4003CL MRI LUMBAR SPINE WO & W CONTRAST 72158 15 EA 4003CM MRI LUMBAR SPINE WO CONTRAST 72148 24 EA 4003CN MRI ORBIT FACE/NECK W/WO CONT 70543 1 EA 4003CO MRI PELVIS W/CONTRAST 72196 4 EA 4003CP MRI THORACIC SPINE WO CONTRAST 72146 5 EA 4003CQ MRI THORACIC SPINE WO/W CONT 72157 5 EA 4003CR MRI UPPER JOINT WO/CONTRAST 73221 10 EA 4003CS NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 4 EA 4003CT NM BONE IMAGING, THREE PHASE 78315 2 EA 4003CU NM BONE IMAGING, WHOLE BODY 78306 6 EA 4003CV NM CARDIAC STRESS INJECTION A9500 30 EA 4003CW NM CARDIOVASCULAR STRESS TEST 93015 30 EA 4003CX NM HEPATOBILIARY SCAN (HIDA SCAN) 78223 1 EA 4003CY NM SPECT CARDIAC SINGLE 78451 30 EA 4003CZ PELVIS 1 VIEW 72170 8 EA 4003DA RIBS UNILAT 2 VIEWS 71100 20 EA 4003DB SCAPULA 73010 1 EA 4003DC SHOULDER 2 OR MORE VIEWS 73030 84 EA 4003DD SIALOGRAM S&I 70390 1 EA 4003DE SPINE CERVICAL MIN 3 VIEWS 72040 3 EA 4003DF SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 4003DG SPINE CERVICAL MIN 6 VIEWS 72052 57 EA 4003DH SPINE LS BENDING MIN 4 VIEWS 72120 2 EA 4003DI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 102 EA 4003DJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 6 EA 4003DK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 3 EA 4003DL SPINE SI JOINT 3 OR MORE VIEWS 72202 2 EA 4003DM SPINE THORACIC AP+LAT+SWIM VIEWS 72072 17 EA 4003DN TIBIA & FIBULA 2 VIEWS 73590 12 EA 4003DO TM BONE JOINT UNILAT O&C MOUTH 70328 2 EA 4003DP TM BONE JOINTS BILAT O&C MOUTH 70330 1 EA 4003DQ UPPER GI 74240 6 EA 4003DR UPPER GI + SMALL BOWEL 74245 2 EA 4003DS US AAA SCREENING ONLY G0389 1 EA 4003DT US ABDOMEN 76700 39 EA 4003DU US ABDOMEN LIMITED 76705 16 EA 4003DV US ABDOMINAL VASCULAR 93975 6 EA 4003DW US BREAST 76645 52 EA 4003DX US CAROTID BILAT STUDY COMPLE 93880 19 EA 4003DY US EXTREMITY NONVASCULAR 76880 6 EA 4003DZ US EXTREMITY VEINS BILATERAL 93970 7 EA 4003EA US EXTREMITY VEINS UNILATERAL 93971 9 EA 4003EB US LO EXT ARTERIES BILAT 93925 1 EA 4003EC US PELVIC 76856 3 EA 4003ED US RETROPERITONEAL 76770 10 EA 4003EE US RETROPERITONEAL LIMITED 76775 1 EA 4003EF US SCROTUM 76870 8 EA 4003EG US THYROID/NECK SOFT TISSUE 76536 6 EA 4003EH US TRANSVAGINAL 76830 1 EA 4003EI US VASCULAR DOPPLER LIMITED 93976 2 EA 4003EJ WRIST 2 VIEWS 73100 22 EA CBOC HSV/DEC/MAD Total   1947 CIN 4004: Gadsden Community Based Outpatient Clinic 206 Rescia Drive, Gadsden, AL 35906 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4004AA ABDOMEN 1 VIEW/KUB 74000 18 EA 4004AB ABDOMEN 2 VIEWS 74010 13 EA 4004AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 4004AD ANKLE 3 OR MORE VIEWS 73610 27 EA 4004AE BILATERAL KNEE 73565 17 EA 4004AF CALCANEOUS 2 VIEWS 73650 9 EA 4004AG CHEST 2 VIEWS PA&LAT 71020 221 EA 4004AH CHEST SINGLE VIEW 71010 1 EA 4004AI CLAVICLE 73000 2 EA 4004AJ CT ABDOMEN W&W/O CONT 74170 3 EA 4004AK CT ABDOMEN W/O CONT 74150 4 EA 4004AL CT HEAD W/O CONT 70450 3 EA 4004AM CT PELVIS W&W/O CONT 72194 3 EA 4004AN CT PELVIS W/O CONT 72192 4 EA 4004AO CT THORAX W/O CONT 71250 1 EA 4004AP ELBOW 2 VIEWS 73070 13 EA 4004AQ ELBOW 3 OR MORE VIEWS 73080 1 EA 4004AR FEMUR 2 VIEWS 73550 3 EA 4004AS FINGER(S) 2 OR MORE VIEWS 73140 6 EA 4004AT FOOT 3 OR MORE VIEWS 73630 51 EA 4004AU FOREARM 2 VIEWS 73090 3 EA 4004AV HAND 3 OR MORE VIEWS 73130 40 EA 4004AW HIP 2 OR MORE VIEWS 73510 60 EA 4004AX HIP BILATERAL 4 OR MORE VIEWS 73520 2 EA 4004AY HUMERUS 2 OR MORE VIEWS 73060 1 EA 4004AZ KNEE 2 VIEWS 73560 93 EA 4004BA KNEE A/P WT.BEAR W LAT FLEX 73562 18 EA 4004BB KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 4004BC MAMMO SCREENING, 2 FILMS 77057 51 EA 4004BD MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 8 EA 4004BE MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 12 EA 4004BF MANDIBLE 4 OR MORE VIEWS 70110 1 EA 4004BG MRA HEAD WO CONTRAST 70544 1 EA 4004BH MRA LOW EXT W OR WO CONTRAST 73725 1 EA 4004BI MRA NECK W & WO CONTRAST 70549 1 EA 4004BJ MRI BRAIN W CONTRAST 70552 1 EA 4004BK MRI BRAIN WO AND W CONTRAST 70553 4 EA 4004BL MRI BRAIN WO CONTRAST 70551 4 EA 4004BM MRI CERVICAL SPINE WO CONTRAST 72141 2 EA 4004BN MRI CERVICAL SPINE WO/W CONT 72156 4 EA 4004BO MRI LO EXT W/WO CONT, NOT JOINT 73720 2 EA 4004BP MRI LOWER JOINT WO CONTRAST 73721 2 EA 4004BQ MRI LUMBAR SPINE WO & W CONTRAST 72158 5 EA 4004BR MRI LUMBAR SPINE WO CONTRAST 72148 3 EA 4004BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 4004BT MRI UPPER JOINT WO/CONTRAST 73221 8 EA 4004BU NASAL BONES MIN 3 VIEWS 70160 1 EA 4004BV NECK SOFT TISSUE 70360 1 EA 4004BW ORBIT MIN 4 VIEWS 70200 1 EA 4004BX PELVIS 1 VIEW 72170 33 EA 4004BY RIBS BILAT 3 OR MORE VIEWS 71110 2 EA 4004BZ RIBS UNILAT 2 VIEWS 71100 23 EA 4004CA SCAPULA 73010 1 EA 4004CB SHOULDER INT/EXT Y-VIEW AXILLARY 73030 82 EA 4004CC SINUSES MIN 2 VIEWS 70210 8 EA 4004CD SKULL 4 OR MORE VIEWS 70260 3 EA 4004CE SPINE CERVICAL MIN 3 VIEWS 72040 42 EA 4004CF SPINE CERVICAL MIN 4 VIEWS 72050 11 EA 4004CG SPINE CERVICAL MIN 6 VIEWS 72052 20 EA 4004CH SPINE LS BENDING MIN 4 VIEWS 72120 8 EA 4004CI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 106 EA 4004CJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 16 EA 4004CK SPINE SACRUM & COCCYX 2 VIEW MIN 72220 2 EA 4004CL SPINE SI JOINT 3 OR MORE VIEWS 72202 1 EA 4004CM SPINE SI JOINTS 1 OR 2 VIEWS 72200 1 EA 4004CN SPINE THORACIC AP+LAT+SWIM VIEWS 72072 26 EA 4004CO TIBIA & FIBULA 2 VIEWS 73590 4 EA 4004CP TOE(S) 2 OR MORE VIEWS 73660 1 EA 4004CQ US ABDOMEN 76700 7 EA 4004CR US BREAST 76645 17 EA 4004CS US CAROTID BILAT STUDY COMPLE 93880 2 EA 4004CT US EXTREMITY VEINS BILATERAL 93970 6 EA 4004CU US EXTREMITY VEINS UNILATERAL 93971 11 EA 4004CV US LO EXT ARTERIES BILAT 93925 1 EA 4004CW US RETROPERITONEAL 76770 2 EA 4004CX US SCROTUM 76870 5 EA 4004CY US VASCULAR DOPPLER LIMITED 93976 2 EA 4004CZ WRIST 2 VIEWS 73100 21 EA CBOC GADSDEN Total   1223 CLIN 4005:Jasper Community Based Outpatient Clinic 3400 Hwy 78 East, Suite 215, Jasper, AL 35501 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4005AA ABDOMEN 1 VIEW/KUB 74000 1 EA 4005AB ANKLE 3 OR MORE VIEWS 73610 2 EA 4005AC BILATERAL KNEE 73565 1 EA 4005AD CHEST 2 VIEWS PA&LAT 71020 21 EA 4005AE CHEST SINGLE VIEW 71010 1 EA 4005AF CT ABDOMEN W&W/O CONT 74170 3 EA 4005AG CT HEAD W/O CONT 70450 3 EA 4005AH CT PELVIS W&W/O CONT 72194 2 EA 4005AI CT PELVIS W/CONT 72193 1 EA 4005AJ CT THORAX W/CONT 71260 1 EA 4005AK ELBOW 2 VIEWS 73070 1 EA 4005AL FOOT 3 OR MORE VIEWS 73630 6 EA 4005AM HAND 3 OR MORE VIEWS 73130 1 EA 4005AN HIP 2 OR MORE VIEWS 73510 7 EA 4005AO INJECTION, REGADENOSON J2785 2 EA 4005AP KNEE 2 VIEWS 73560 12 EA 4005AQ KNEE 4 OR MORE VIEWS 73564 2 EA 4005AR KNEE A/P WT.BEAR W LAT FLEX 73562 1 EA 4005AS MAMMO SCREENING, 2 FILMS 77057 32 EA 4005AT MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 4 EA 4005AU MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 2 EA 4005AV MRI BRAIN WO AND W CONTRAST 70553 1 EA 4005AW MRI CERVICAL SPINE WO CONTRAST 72141 4 EA 4005AX MRI LOWER JOINT WO CONTRAST 73721 3 EA 4005AY MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 4005AZ MRI LUMBAR SPINE WO CONTRAST 72148 5 EA 4005BA MRI UPPER JOINT WO/CONTRAST 73221 3 EA 4005BB NM CARDIAC STRESS INJECTION A9500 2 EA 4005BC NM CARDIOVASCULAR STRESS TEST 93015 2 EA 4005BD NM SPECT CARDIAC SINGLE 78451 2 EA 4005BE PELVIS 1 VIEW 72170 1 EA 4005BF RIBS UNILAT 2 VIEWS 71100 1 EA 4005BG SHOULDER 2 OR MORE VIEWS 73030 13 EA 4005BH SPINE CERVICAL MIN 6 VIEWS 72052 17 EA 4005BI SPINE LUMBOSACRAL MIN 2 VIEWS 72100 35 EA 4005BJ SPINE LUMBOSACRAL MIN 4 VIEWS 72110 2 EA 4005BK SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 4005BL TIBIA & FIBULA 2 VIEWS 73590 1 EA 4005BM UROGRAM INTRAVENOUS 74400 1 EA 4005BN US ABDOMEN 76700 2 EA 4005BO US ABDOMEN LIMITED 76705 1 EA  4005BP US BREAST 76645 5 EA  4005BQ US CAROTID BILAT STUDY COMPLE 93880 6 EA  4005BR US EXTREMITY VEINS UNILATERAL 93971 1 EA  4005BS US PELVIC LIMITED 76857 1 EA  4005BT US RETROPERITONEAL 76770 3 EA  4005BU US SCROTUM 76870 2 EA  4005BV WRIST 2 VIEWS 73100 2 EA CBOC JASPER Total   226 CLIN 4006:Muscle Shoals Community Based Outpatient Clinic 422 DD Cox Blvd., Sheffield, AL 35660 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4006AA ABDOMEN 2 VIEWS 74010 2 EA 4006AB ABDOMEN 3 OR MORE VIEWS 74020 1 EA 4006AC ANKLE 3 OR MORE VIEWS 73610 14 EA 4006AD BILATERAL KNEE 73565 2 EA 4006AE BONE SURVEY, METASTATIC COMPLETE 77075 1 EA 4006AF CHEST 2 VIEWS PA&LAT 71020 140 EA 4006AG CLAVICLE 73000 1 EA 4006AH CT ABDOMEN W&W/O CONT 74170 3 EA 4006AI CT ABDOMEN W/O CONT 74150 1 EA 4006AJ CT CERVICAL SPINE W/O CONT 72125 1 EA 4006AK CT HEAD W/O CONT 70450 2 EA 4006AL CT MAXILLOFACIAL W&W/O CONT 70488 1 EA 4006AM CT NECK SOFT TISSU W&W/O CONT 70492 1 EA 4006AN CT PELVIS W&W/O CONT 72194 1 EA 4006AO CT PELVIS W/CONT 72193 2 EA 4006AP CT PELVIS W/O CONT 72192 1 EA 4006AQ CT SINUSES ONLY WO CONTRAST 70486 1 EA 4006AR CT THORAX W&W/O CONT 71270 5 EA 4006AS CT THORAX W/O CONT 71250 1 EA 4006AT ELBOW 2 VIEWS 73070 7 EA 4006AU FEMUR 2 VIEWS 73550 1 EA 4006AV FINGER(S) 2 OR MORE VIEWS 73140 3 EA 4006AW FOOT 3 OR MORE VIEWS 73630 30 EA 4006AX FOREARM 2 VIEWS 73090 2 EA 4006AY HAND 3 OR MORE VIEWS 73130 11 EA 4006AZ HIP 2 OR MORE VIEWS 73510 24 EA 4006BA HUMERUS 2 OR MORE VIEWS 73060 1 EA 4006BB INJECTION, REGADENOSON J2785 2 EA 4006BC KNEE 2 VIEWS 73560 29 EA 4006BD KNEE A/P WT.BEAR W LAT FLEX 73562 4 EA 4006BE KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 27 EA 4006BF MAMMO SCREENING, 2 FILMS 77057 71 EA 4006BG MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 3 EA 4006BH MAMMOGRAPHY, DIAGNOSTIC, UNILATERAL 77055 9 EA 4006BI MANDIBLE 4 OR MORE VIEWS 70110 2 EA 4006BJ MRA HEAD WO CONTRAST 70544 1 EA 4006BK MRI ABDOMEN W & W/O CONT 74183 1 EA 4006BL MRI BRAIN WO AND W CONTRAST 70553 7 EA 4006BM MRI BRAIN WO CONTRAST 70551 9 EA 4006BN MRI CERVICAL SPINE WO CONTRAST 72141 3 EA 4006BO MRI LOWER JOINT WO CONTRAST 73721 4 EA 4006BP MRI LUMBAR SPINE WO & W CONTRAST 72158 2 EA 4006BQ MRI LUMBAR SPINE WO CONTRAST 72148 12 EA 4006BR MRI PELVIS W/CONTRAST 72196 1 EA 4006BS MRI UP EXT NOT JOINT, W/WO CONT 73220 1 EA 4006BT MRI UPPER JOINT WO/CONTRAST 73221 5 EA 4006BU NM CARDIAC STRESS INJECTION A9500 3 EA 4006BV NM CARDIOVASCULAR STRESS TEST 93015 3 EA 4006BW NM SPECT CARDIAC SINGLE 78451 3 EA 4006BX PELVIS 1 VIEW 72170 2 EA 4006BY RIBS UNILAT 2 VIEWS 71100 12 EA 4006BZ SHOULDER 2 OR MORE VIEWS 73030 43 EA 4006CA SKULL 4 OR MORE VIEWS 70260 1 EA 4006CB SPINE CERVICAL MIN 3 VIEWS 72040 8 EA 4006CC SPINE CERVICAL MIN 4 VIEWS 72050 1 EA 4006CD SPINE CERVICAL MIN 6 VIEWS 72052 15 EA 4006CE SPINE LS BENDING MIN 4 VIEWS 72120 14 EA 4006CF SPINE LUMBOSACRAL MIN 2 VIEWS 72100 26 EA 4006CG SPINE LUMBOSACRAL MIN 4 VIEWS 72110 42 EA 4006CH SPINE THORACIC AP+LAT+SWIM VIEWS 72072 3 EA 4006CI TOE(S) 2 OR MORE VIEWS 73660 2 EA 4006CJ UROGRAM INTRAVENOUS 74400 1 EA 4006CK US ABDOMEN 76700 3 EA 4006CL US ABDOMEN LIMITED 76705 1 EA 4006CM US BREAST 76645 8 EA 4006CN US EXTREMITY VEINS BILATERAL 93970 1 EA 4006CO WRIST 2 VIEWS 73100 7 EA CBOC SHOALS Total     652 CLIN 4007:Guntersville Community Based Outpatient Clinic 101 Judysmith Drive Guntersville, AL 35976 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4007AA ABDOMEN 1 VIEW/KUB 74000 1 EA 4007AB ABDOMEN 2 VIEWS 74010 2 EA 4007AC ABDOMEN 3 OR MORE VIEWS 74020 1 EA 4007AD ANKLE 3 OR MORE VIEWS 73610 3 EA 4007AE CHEST 2 VIEWS PA&LAT 71020 22 EA 4007AF CLAVICLE 73000 1 EA 4007AG CT ABDOMEN W&W/O CONT 74170 2 EA 4007AH CT HEAD W/O CONT 70450 2 EA 4007AI ELBOW 2 VIEWS 73070 1 EA 4007AJ ELBOW 3 OR MORE VIEWS 73080 1 EA 4007AK FINGER(S) 2 OR MORE VIEWS 73140 2 EA 4007AL FOOT 3 OR MORE VIEWS 73630 3 EA 4007AM FOREARM 2 VIEWS 73090 1 EA 4007AN HAND 3 OR MORE VIEWS 73130 5 EA 4007AO HIP 2 OR MORE VIEWS 73510 3 EA 4007AP HIP BILATERAL 4 OR MORE VIEWS 73520 1 EA 4007AQ INJECTION, REGADENOSON J2785 1 EA 4007AR KNEE 2 VIEWS 73560 1 EA 4007AS KNEE A/P WT.BEAR W LAT FLEX 73562 2 EA 4007AT KNEE A/P WT.BEAR,FLEX,NOTCH,MERCH 73564 3 EA 4007AU MAMMOGRAPHY, DIAGNOSTIC, BILATERAL 77056 1 EA 4007AV MRI LUMBAR SPINE WO & W CONTRAST 72158 1 EA 4007AW NM BONE DENSITY STUDY, SINGLE PHOTON A 78350 1 EA 4007AX NM CARDIAC STRESS INJECTION A9500 1 EA 4007AY NM CARDIOVASCULAR STRESS TEST 93015 1 EA 4007AZ NM SPECT CARDIAC SINGLE 78451 1 EA 4007BA RIBS UNILAT 2 VIEWS 71100 1 EA 4007BB SHOULDER 2 OR MORE VIEWS 73030 6 EA 4007BC SPINE CERVICAL MIN 6 VIEWS 72052 1 EA 4007BD SPINE LUMBOSACRAL MIN 2 VIEWS 72100 2 EA 4007BE SPINE LUMBOSACRAL MIN 4 VIEWS 72110 8 EA 4007BF SPINE SACRUM & COCCYX 2 VIEW MIN 72220 1 EA 4007BG SPINE THORACIC AP+LAT+SWIM VIEWS 72072 1 EA 4007BH TOE(S) 2 OR MORE VIEWS 73660 1 EA 4007BI US ABDOMEN LIMITED 76705 1 EA 4007BJ US BREAST 76645 1 EA 4007BK US EXTREMITY NONVASCULAR 76880 1 EA 4007BL US EXTREMITY VEINS UNILATERAL 93971 1 EA CBOC GUNTERSVILLE Total   89 CLIN 4008: MRI Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4008AA CT HEAD W/O CONT 70540 1 EA 4008AB MRI BRAIN W CONTRAST 70552 10 EA 4008AC MRI BRAIN WO AND W CONTRAST 70553 10 EA 4008AD MRI BRAIN WO CONTRAST 70551 10 EA 4008AE MRI BOTH BREASTS   77059 2 EA 4008AF MRI CERVICAL SPINE WO/W CONT 72156 15 EA 4008AG MRI CERVICAL SPINE WO CONTRAST 72141 15 EA 4008AH MRI LOWER JOINT WO CONTRAST 73721 3 EA 4008AI MRI LUMBAR SPINE W CONTRAST 72149 5 EA 4008AJ MRI LUMBAR SPINE WO & W CONTRAST 72158 50 EA 4008AK MRI LUMBAR SPINE WO CONTRAST 72148 40 EA 4008AL MRI THORACIC SPINE WO CONTRAST 72146 5 EA 4008AM MRI UPPER JOINT WO/CONTRAST 73221 7 EA Birmingham MRI Total   173 CLIN 4009: Mammography Radiological Services Services provided are within 15 miles of the Birmingham VA Medical Center Located at 700 S. 19th Street Birmingham, AL 35233 Item No. Supplies/Service Exam Description CPT Code Est. Quantity Unit Facility Medicare Price Per Code Percent % +/- Medicare Rates Total Amount 4009AA BX BREAST PERCUT W/O IMAGE BREAST BIOPSY 19100 5 EA 4009AB BX BREAST OPEN INCISIONAL 19101 5 EA 4009AC BX BREAST PERCUT W/IMAGE BX BREAST PERCUT W/IMAGE 19102 5 EA 4009AD US BREAST 76645 625 EA 4009AE STEROTACTIC GUIDE FOR BX             77031 10 EA 4009AF GUIDANCE FOR NEEDLE PLACEMENT 77032 10 EA 4009AG BREAST MAMMOGRAPHY 77051 10 EA 4009AH X-RAY OF MAMMARY DUCT 77053 132 EA 4009AI X-RAY OF MAMMARY DUCTS 77054 45 EA 4009AJ MAMMOGRAPHY,DIAGNOSTIC, UNILATERAL 77055 44 EA 4009AK MAMMOGRAPHY,DIAGNOSTIC, BILATERAL 77056 10 EA 4009AL MAMMO SCREENING, 2 FILMS 77057 903 EA 4009AM MRI ONE BREAST 77058 5 EA 4009AN MRI BOTH BREASTS   77059 5 EA Birmingham Mammography Total   1814
 

Web Link

FBO.gov Permalink
(https://www.fbo.gov/spg/VA/BiVAMC521/BiVAMC521/VA24711RP0066/listing.html)
 

Document(s)

Attachment
 

File Name: VA-247-11-RP-0066 VA-247-11-RP-0066_3.doc (https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=275827&FileName=VA-247-11-RP-0066-001.doc)

Link: https://www.vendorportal.ecms.va.gov/FBODocumentServer/DocumentServer.aspx?DocumentId=275827&FileName=VA-247-11-RP-0066-001.doc

 

Note: If links are broken, refer to Point of Contact above or contact the FBO Help Desk at 877-472-3779.
 

Place of Performance

Address: Contractor's Facility must be within 15 miles;of the VA Facility (Community Based Outpatient;Clinic (CBOC) or Birmingham VAMC) when proposing;to provide radioligcal servies for specified;facility (Line Item).

Zip Code: 35233
 

Record

SN02627494-W 20111124/111122234542-ad4df50c2fe21a761ab58ad6fedd569a (fbodaily.com)
 

Source

FedBizOpps Link to This Notice
(may not be valid after Archive Date)

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