Contrast Agents and Radiopharmaceuticals 2023
Diagnostic radiopharmaceuticals will be reimbursed according to the information within the table below.
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The radiopharmaceuticals administered up to 96 hours before the primary procedure will be subject to these rules.
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The contrast agents listed in columns 1 and 2 will be considered for reimbursement when provided in support of the diagnostic services listed in columns 3 and 4 (up to the MUE unit maximum listed in column 5).
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The procedure codes listed in column 6 will be considered inclusive of the corresponding diagnostic services listed in columns 3 and 4 and not considered for separate reimbursement.
This information was last revised on January 23, 2023 and may be subject to change.
Recent /Upcoming Changes:
- Beginning January 1, 2023 the diagnostic radiopharmaceuticals represented by codes A9596, A9601, A9602 and A9800 are no longer covered under Horizon Medicaid plans.
| Contrast Agent Code | Contrast Agent Code Description |
Allow With Code(s) | Allow with Code Description | MUE Units | Deny as Included |
| A9500 | Technetium Tc-99m, Sestamibi, diagnostic, per study dose | 78012 | Thyroid uptake measurement | 3 | |
| 78013, 78014 | Thyroid imaging w/blood flow | ||||
| 78015, 78016, 78018 | Thyroid carcinoma metastases imaging | ||||
| 78020 | Thyroid met uptake | ||||
| 78070-78072 | Parathyroid study | ||||
| 78075 | Adrenal Imaging, Cortex and/or Medulla | ||||
| 78099 | Unlisted Endocrine Procedure | ||||
| 78428 | Cardiac shunt detection | ||||
| 78445 | Non-cardiac vascular flow imaging | ||||
| 78451-78452 | MPI, SPECT | ||||
| 78453-78454 | MPI, PLANAR | ||||
| 78456 | Acute Venous thrombosis imaging | ||||
| 78457-78458 | Venous thrombosis imaging/Unilateral/Bilateral | ||||
| 78483 | Cardiac blood pool imaging, (planar) | ||||
| 78499 | Unlisted cardiovascular procedure, diagnostic nuclear medicine | ||||
| 78605, 78606 | Brain image 4+ views; Brain image w/flow 4 + views | ||||
| 78800, 78801, 78802, 78803 | Radiopharmaceutical localization of tumor | ||||
| 78804 | Radiopharmaceutical localization of tumor | ||||
| 78808 | Injection procedure for radiopharmaceutical localization | ||||
| 78830-78832 | Radiopharmaceutical localization of tumor | ||||
| 78999 | Unlisted miscellaneous, procedure, diagnostic nuclear medicine | ||||
| A9502 | Technetium Tc-99m tetrofosmin, diagnostic, per study dose | 78012 | Thyroid uptake measurement | 3 | |
| 78013, 78014 | Thyroid imaging w/blood flow | ||||
| 78015, 78016, 78018 | Thyroid carcinoma metastases imaging | ||||
| 78020 | Thyroid met uptake | ||||
| 78070-78072 | Parathyroid study | ||||
| 78075 | Adrenal Imaging, Cortex and/or Medulla | ||||
| 78099 | Unlisted Endocrine Procedure | ||||
| 78428 | Cardiac shunt detection | ||||
| 78445 | Non-cardiac vascular flow imaging | ||||
| 78451-78452 | MPI, SPECT | ||||
| 78453-78454 | MPI, PLANAR | ||||
| 78456 | Acute Venous thrombosis imaging | ||||
| 78457-78458 | Venous thrombosis imaging/Unilateral/Bilateral | ||||
| 78483 | Cardiac blood pool imaging, (planar) | ||||
| 78499 | Unlisted cardiovascular procedure, diagnostic nuclear medicine | ||||
| 78804 | Radiopharmaceutical localization of tumor | ||||
| 78808 | Injection procedure for radiopharmaceutical localization | ||||
| 78830-78832 | Radiopharmaceutical localization of tumor | ||||
| 78999 | Unlisted miscellaneous, procedure, diagnostic nuclear medicine | ||||
| A9503 | Technetium Tc-99m, Medronate, (MDP), diagnostic, per study dose, up to 30 mCi's | 78300, 78305, 78306, 78315 | Bone and/or joint imaging | 1 | |
| 78399 | Unlisted musculoskeletal procedure | ||||
| 78803 | Tumor imaging | ||||
| A9505 | Thallous Chloride TL-201, diagnostic, per mCi | 78012-78016 | Thyroid study | 4 | |
| 78020 | Thyroid study | ||||
| 78070-78072 | Parathyroid study | ||||
| 78075 | Adrenal Imaging, Cortex and/or Medulla | ||||
| 78099 | Unlisted Endocrine Procedure | ||||
| 78428 | Cardiac shunt detection | ||||
| 78445 | Non-cardiac vascular flow imaging | ||||
| 78451-78452 | MPI, SPECT | ||||
| 78453-78454 | MPI, PLANAR | ||||
| 78456 | AcuteVenous thrombosis imaging | ||||
| 78457-78458 | Venous thrombosis imaging/Unilateral/Bilateral | ||||
| 78481 | Cardiac blood pool imaging, (planar) | ||||
| 78494 | Heart image spect | ||||
| 78496 | Heart image spect | ||||
| 78499 | Unlisted cardiovascular procedure, diagnostic nuclear medicine | ||||
| 78800-78803 | Radiopharmaceutical localization of tumor | ||||
| 78804 | Radiopharmaceutical localization of tumor | ||||
| 78808 | Injection procedure for radiopharmaceutical localization | ||||
| 78999 | Unlisted miscellaneous, procedure, diagnostic nuclear medicine | ||||
| A9512 | Technetium Tc-99m-Pertechnetate, Diagnostic, per mCi | 78012-78015 | Thyroid uptake measurement; Thyroid imaging w/blood flow; Thyroid met imaging | 30 | |
| 78020 | Thyroid study | ||||
| 78070-78072 | Parathyroid study | ||||
| 78075 | Adrenal Imaging, Cortex and/or Medulla | ||||
| 78099 | Unlisted Endocrine Procedure | ||||
| 78102-78104 | Bone marrow imaging; | ||||
| 78110, 78111 | Plasma volume, radiopharmaceutical volume dilution technique | ||||
| 78120, 78121 | Red cell volume determination | ||||
| 78122 | Whole blood volume determination | ||||
| 78130 | Red cell survival study | ||||
| 78191 | Platelet survival study | ||||
| 78195 | Lymphatics and lymph nodes imaging | ||||
| 78199 | Blood/lymph nuclear exam | ||||
| 78201, 78202 | Liver imaging | ||||
| 78215, 78216 | Liver & Spleen Imaging | ||||
| 78226, 78227 | Hepatobiliary system imaging | ||||
| 78230-78232 | Parotid or salivary scan | ||||
| 78258 | Esophageal motility study | ||||
| 78261 | Gastric mucosa imaging | ||||
| 78262 | Gastroesophageal reflux study | ||||
| 78264-78266 | Gastric emptying imaging study | ||||
| 78267, 78268 | Breath test attain/anal c-14; Breath test analysis c-14 | ||||
| 78278 | Acute gastrointestinal blood loss imaging | ||||
| 78282 | Gastrointestinal protein loss | ||||
| 78290 | Intestine imaging | ||||
| 78299 | Unlisted gastrointestinal procedure | ||||
| 78600-78606 | Brain image < 4 views; Brain image w/flow < 4 views; Brain image 4+ views | ||||
| 78610 | Brain flow imaging only | ||||
| 78630, 78635, 78650 | Cerebrospinal fluid flow imaging/study | ||||
| 78660 | Dacryocystography | ||||
| 78699 | Nervous system nuclear exam | ||||
| 78725 | Kidney function study | ||||
| 78730 | Urinary bladder residual study | ||||
| 78740 | Ureteral reflux study | ||||
| 78761 | Testicular imaging | ||||
| 78799 | Unlisted genitourinary procedure | ||||
| 78803 | Rp loclzj tum spect 1 area | ||||
| 78481 | Cardiac blood pool imaging, (planar) | 62323, 62327 | |||
| A9515 | Choline c-11, diagnostic, per study dose up to 20 millicuries | 78429 | Myocrd img PET 1 std w/ct | 1 | |
| 78430-78432 | Myocardial imaging (PET) | ||||
| 78459 | Myocardial imaging (PET) | ||||
| 78491, 78492 | Myocardial imaging (PET) | ||||
| 78608, 78609 | Brain imaging (PET) | ||||
| 78811 | PET image ltd area | ||||
| 78812 | PET image skull-thigh | ||||
| 78813 | PET image full body | ||||
| 78814 | PET image W CT lmtd | ||||
| 78815 | PET image W CT skull-thigh | ||||
| 78816 | PET image W CT full body | ||||
| 78466-78469 | Myocardial imaging, infarct avid | ||||
| 78481, 78483 | Heart first pass single; Heart first pass multiple | ||||
| A9520 | Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 millicurie | 78102-78104 | Bone marrow imaging; | 1 | |
| 78110, 78111 | Plasma volume, radiopharmaceutical volume dilution technique | ||||
| 78120, 78121 | Red cell volume determination | ||||
| 78122 | Whole blood volume determination | ||||
| 78130 | Red cell survival study | ||||
| 78185 | Spleen imaging only | ||||
| 78191 | Platelet survival study | ||||
| 78195 | Lymphatics and lymph nodes imaging | ||||
| 78199 | Blood/lymph nuclear exam | ||||
| A9521 | Technetium Tc-99m Exametazine (Ceretec ®), Diagnostic, per study dose, up to 25 mCi’s | 78600-78606 | Brain study | 2 | |
| 78610 | Brain imaging | ||||
| 78630 | Cerebrospinal fluid flow imaging/study | ||||
| 78635 | Csf ventriculography | ||||
| 78645 | Csf shunt evaluation | ||||
| 78650 | Csf leakage imaging | ||||
| 78660 | Dacryocystography | ||||
| 78699 | Nervous system nuclear exam | ||||
| 78803 | Radiopharmaceutical localization of tumor | ||||
| A9528 | Iodine I-131 Sodium Iodide capsule(s), Diagnostic, per mCi | 78012-78015 | Thyroid study | 10 | |
| 78016, 78018, 78020 | Thyroid study | ||||
| 78070-78072 | Parathyroid study | ||||
| 78075 | Adrenal Imaging, Cortex and/or Medulla | ||||
| 78099 | Unlisted Endocrine Procedure | ||||
| 78803 | Radiopharmaceutical localization of tumor | ||||
| A9537 | Technetium Tc-99m Mebrofenin (Choletec ®) Diagnostic, per study dose, up to 15 mCi's | 78201 | Liver imaging; static only | 1 | |
| 78202 | Liver imaging | ||||
| 78215, 78216 | Liver and spleen imaging | ||||
| 78226, 78227 | Hepatobiliary system imaging | ||||
| 78230-78232 | Parotid or salivary scan | ||||
| 78258 | Esophageal motility | ||||
| 78261 | Gastric mucosa imaging | ||||
| 78262 | Gastroesophageal reflux study | ||||
| 78264-78266 | Gastric emptying imaging study | ||||
| 78267, 78268 | Breath test attain/anal c-14; Breath test analysis c-14 | ||||
| 78278 | Acute gastrointestinal blood loss imaging | ||||
| 78282 | Gastrointestinal protein loss | ||||
| 78290 | Intestine imaging | ||||
| 78291 | Peritoneal-venous shunt patency test | ||||
| 78299 | Unlisted gastrointestinal procedure | ||||
| A9540 | Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mCi's | 78291 | Leveen/shunt patency exam | 2 | |
| 78201, 78215, 78216 | Liver imaging | ||||
| 78202 | Liver imaging | ||||
| 78428 | Cardiac shunt detection | ||||
| 78580 | Pulmonary perfusion imaging | ||||
| 78582 | Pulmonary ventilation | ||||
| 78597, 78598 | Lung perfusion differential; Lung perf&ventilat diferentl | ||||
| 78599 | Unlisted respiratory procedure, diagnostic nuclear medicine | ||||
| 78800, 78801, 78802, 78803 | Radiopharmaceutical localization of tumor | ||||
| A9541 | Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to20 mCi's | 78102-78104 | Bone marrow studies | 1 | |
| 78110-78111 | Plasma volume, radiopharmaceutical volume dilution technique | ||||
| 78120, 78121 | Red cell volume determination | ||||
| 78122 | Whole blood volume determination | ||||
| 78130 | Red cell survival study | ||||
| 78185 | Spleen imaging | ||||
| 78191 | Platelet survival study | ||||
| 78195 | Lymphatics & Lymph glands | ||||
| 78199 | Blood/lymph nuclear exam | ||||
| 78201, 78202 | Liver imaging | ||||
| 78215, 78216 | Liver and spleen imaging | ||||
| 78226, 78227 | Hepatobiliary system imaging | ||||
| 78230 | Salivary gland imaging; | ||||
| 78231-78232 | Serial salivary imaging ; Salivary gland function exam | ||||
| 78258 | Esophageal motility study | ||||
| 78261 | Gastric mucosa imaging | ||||
| 78262 | Gastroesophageal reflux study | ||||
| 78264-78266 | Gastric emptying imaging study | ||||
| 78267, 78268 | Breath test attain/anal c-14; Breath test analysis c-14 | ||||
| 78278 | Acute gastrointestinal blood loss imaging | ||||
| 78282 | Gastrointestinal protein loss | ||||
| 78290 | Intestine imaging | ||||
| 78291 | Peritoneal-venous shunt patency test | ||||
| 78299 | Unlisted gastrointestinal procedure | ||||
| 78730 | Urinary bladder residual study | ||||
| 78740 | Ureteral reflux study | ||||
| A9552 | Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries | 78600-78606 | Brain Imaging (PET) | 1 | |
| 78608, 78609, 78610 | Brain imaging (PET); Brain flow imaging only | ||||
| 78630, 78635, 78645 | Cerebrospinal fluid flow imaging/study | ||||
| 78650 | Cerebrospinal fluid leakage detection and localization | ||||
| 78660 | Dacryocystography | ||||
| 78699 | Unlisted nervous system procedure, diagnostic nuclear medicine | ||||
| 78429, 78431, 78432 | Myocardial imaging, PET | ||||
| 78430 | Myocrd img PET rst/strs w/ct | ||||
| 78459 | Myocardial imaging, positron emission tomography (PET) | ||||
| 78491, 78492 | Myocardial imaging, PET | ||||
| 78800, 78801, 78802, 78803 | Radiopharmaceutical localization of tumor | ||||
| 78808 | Injection procedure for radiopharmaceutical localization | ||||
| 78811 | PET image ltd area | ||||
| 78812 | PET image skull-thigh | ||||
| 78813 | PET image full body | ||||
| 78814 | PET image W CT lmtd | ||||
| 78815 | PET image W CT skull-thigh | ||||
| 78816 | PET image W CT full body | ||||
| 78660 | Radiopharmaceutical Dacryocystography | ||||
| 78699 | Unlisted Nervous System Procedure | 62323, 62327 | |||
| A9556 | Gallium Ga-67 Citrate, Diagnostic, per mCi | 78700, 78701 | Kidney imaging morphol; Kidney imaging with flow | 10 | |
| 78707-78709 | K flow/funct image w/o drug; K flow/funct image multiple | ||||
| 78725 | Kidney function study | ||||
| 78730 | Urinary bladder retention | ||||
| 78740 | Ureteral reflux study | ||||
| 78761 | Testicular imaging | ||||
| 78799 | Unlisted genitourinary procedure | ||||
| 78800 | Rp loclzj tum 1 area 1 d img | ||||
| 78801 | Rp loclzj tum 2+area 1+d img | ||||
| 78802 | Rp loclzj tum whbdy 1 d img | ||||
| 78803 | Radiopharmaceutical localization of tumor | ||||
| 78804 | Radiopharmaceutical localization of tumor | ||||
| 78808 | Iv inj ra drug dx study | ||||
| 78830-78832 | Radiopharmaceutical localization of tumor | ||||
| 78999 | Nuclear diagnostic exam_unlisted | ||||
| A9558 | Xenon Xe-133 Gas, Diagnostic, per 10 mCi's | 78579 | Pulmonary perfusion imaging | 7 | |
| 78580 | Pulmonary perfusion imaging | ||||
| 78582 | Pulmonary ventilation | ||||
| 78597 | Quantitative differential pulmonary perfusion | ||||
| 78598 | Quantitative differential pulmonary perfusion | ||||
| 78599 | Unlisted respiratory procedure, diagnostic nuclear medicine | ||||
| A9560 | Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mCi's (Ultra Tag ® or cold pyrophosphate (pyp) +99m technetium) | 78201, 78202 | Liver scan (for Hemangioma) | 2 | |
| 78215, 78216 | Liver and spleen imaging | ||||
| 78226, 78227 | Hepatobiliary system imaging | ||||
| 78230-78232 | Parotid or salivary scan | ||||
| 78258 | Esophageal motility | ||||
| 78261 | Gastric mucosa imaging | ||||
| 78262 | Gastroesophageal reflux study | ||||
| 78264, 78265, 78266 | Gastric emptying imaging study | ||||
| 78267, 78268 | Breath tst attain/anal c-14; Breath test analysis c-14 | ||||
| 78278 | Acute gastrointestinal blood loss imaging | ||||
| 78282 | Gastrointestinal protein loss | ||||
| 78290 | Intestine imaging | ||||
| 78291 | Peritoneal-venous shunt patency test | ||||
| 78299 | Unlisted gastrointestinal procedure | ||||
| 78300, 78305, 78306, 78315 | Bone and/or joint imaging | ||||
| 78399 | Unlisted musculoskeletal procedure | ||||
| 78414 | Non-imaging heart function | ||||
| 78428 | Cardiac shunt detection | ||||
| 78445 | Non-cardiac vascular flow imaging | ||||
| 78451 | MPI, SPECT | ||||
| 78452 | MPI, SPECT | ||||
| 78453 | Myocardial perfusion imaging, planar | ||||
| 78454 | MPI, PLANAR | ||||
| 78456 | AcuteVenous thrombosis imaging | ||||
| 78457, 78458 | Venous thrombosis imaging/Unilateral/Bilateral | ||||
| 78466, 78468, 78468, 78469 | Myocardial imaging, infarct avid | ||||
| 78472-78473 | Cardiac blood pool imaging, gated equilibrium | ||||
| 78481, 78483 | Cardiac blood pool imaging, (planar) | ||||
| 78494 | Myocrd img PET 1std rst/strs | ||||
| 78496 | Heart first pass add-on | ||||
| 78499 | Unlisted cardiovascular procedure, diagnostic nuclear medicine | ||||
| A9561 | Technetium Tc-99m Oxidronate, Diagnostic, per study dose, up to 30 mCi's | 78300, 78305, 78306, 78315 | Bone and/or joint imaging | 1 | |
| 78399 | Unlisted musculoskeletal procedure | ||||
| 78803 | Radiopharmaceutical localization of tumo | ||||
| A9562 | Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 15 mCi's | 78700-78709 | Kidney imaging morphology/study | 2 | |
| 78725 | Kidney function study | ||||
| 78730 | Urinary bladder residual study | ||||
| 78740 | Ureteral reflux study | ||||
| 78761 | Testicular imaging | ||||
| 78799 | Unlisted genitourinary procedure | ||||
| 78803 | Rp loclzj tum spect 1 area | ||||
| A9567 | Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 75 mCi's | 78579 | Pulmonary ventilation imaging | 2 | |
| 78580 | Pulmonary perfusion imaging | ||||
| 78582 | Pulmonary ventilation | ||||
| 78597 | Quantitative differential pulmonary perfusion | ||||
| 78598 | Quantitative differential pulmonary perfusion | ||||
| 78599 | Unlisted respiratory procedure, diagnostic nuclear medicine | ||||
| A9575 | Injection, gadoterate meglumine, 0.1 ml | 70336 | Magnetic image jaw joint | 300 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70545, 70546 | MRA head | ||||
| 70548, 70549 | MRA neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 71551, 71552 | MRI chest | ||||
| 71555 | MRI ang chest | ||||
| 72142 | MRI cervical spine | ||||
| 72147 | MRI thoracic spine | ||||
| 72149 | MRI lumbar spine | ||||
| 72156 | MRI cervical spine | ||||
| 72157 | MRI thoracic spine | ||||
| 72158 | MRI lumbar spine | ||||
| 72196, 72197 | MRI pelvis | ||||
| 72198 | MRI ang pelvis | ||||
| 73219, 73220 | MRI upper extremity | ||||
| 73222, 73223 | MRI upper extremity any joint | ||||
| 73225 | MRI upper extremity w/w/o Contrast | C8900-C8902 | |||
| 73719, 73720 | MRI joint lower extremity | C8903-C8905 | |||
| 73722, 73723 | MRI lower extremity any joint | C8906-C8908 | |||
| 73725 | MRI ang lower extremity | C8909-C8911 | |||
| 74182, 74183 | MRI abd | C8912-C8914 | |||
| 74185 | MRI angio abdom | C8918-C8920 | |||
| 74712, 74713 | MRI fetal | C8931-C8933 | |||
| 75559-75565 | MRI Cardiac | C8934-C8936 | |||
| A9576 | Injection, gadoteridol, (prohance multipack), per ml | 70542, 70543 | MRI orbit/face/neck | 40 | |
| 70545, 70546 | MRA head | ||||
| 70548, 70549 | MRA neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 72142 | MRI neck spine | ||||
| 72147 | MRI chest spine | ||||
| 72149 | MRI lumbar spine | ||||
| 72156 | MRI neck spine | ||||
| 72157 | MRI chest spine | ||||
| 72158 | MRI lumbar spine | ||||
| 72159 | Magnetic Resonance Angiography | C8931-C8933 | |||
| A9577 | Injection, gadobenate dimeglumine (multihance), per ml | 70542, 70543 | MRI orbit/face/neck | 50 | |
| 70545, 70546 | MRA head | ||||
| 70548, 70549 | MRA neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 72142 | MRI neck spine | ||||
| 72147 | MRI chest spine | ||||
| 72149 | MRI lumbar spine | ||||
| 72156 | MRI neck spine | ||||
| 72157 | MRI chest spine | ||||
| 72158 | MRI lumbar spine | ||||
| 72159 | Magnetic Resonance Angiography | ||||
| 72196, 72197 | MRI pelvis | ||||
| 72198 | MRI ang pelvis | ||||
| 73725 | MRI ang lower extremity | C8931-C8933 | |||
| A9579 | Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml | 70336 | Magnetic image jaw joint | 100 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70545, 70546 | MRA head | ||||
| 70548, 70549 | MRA neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 71551, 71552 | MRI chest | ||||
| 71555 | MRI angio chest | ||||
| 72142 | MRI neck spine | ||||
| 72147 | MRI chest spine | ||||
| 72149 | MRI lumbar spine | ||||
| 72156 | MRI neck spine | ||||
| 72157 | MRI chest spine | ||||
| 72158 | MRI lumbar spine | ||||
| 72159 | Magnetic Resonance Angiography | ||||
| 72196, 72197 | MRI pelvis | ||||
| 72198 | MRA pelvis | ||||
| 73219, 73220 | MRI upr extremity | ||||
| 73222, 73223 | MRI joint upr extremity | ||||
| 73225 | MRI upper extremity w/w/o Contrast | ||||
| 73719, 73720 | MRI lwr extremity | ||||
| 73722, 73723 | MRI joint lwr extremity | ||||
| 73725 | MRA lower extremity | ||||
| 74182, 74183 | MRI abd | C8903-C8905 | |||
| 74185 | MRI angio abdomen | C8906-C8908 | |||
| 75557-75559 | Cardiac magnetic resonance imaging for morphology and function | C8909-C8911 | |||
| 75561-75563 | Cardiac magnetic resonance imaging for morphology and function; Further sequences; with stress imaging | C8912-C8914 | |||
| 75565 | Cardiac MRI for Velocity Flow Mapping | C8918-C8920 | |||
| 77084 | Magnetic image bone marrow | C8931-C8933 | |||
| A9581 | Injection, gadoxetate disodium, 1 ml | 74182, 74183 | MRI abd | 20 | C8934-C8936 |
| 74185 | MRI angio abdom | C8900-C8902 | |||
| A9582 | Iodine i-123 Iobenguane, diagnostic, per study dose, up to 15 millicuries AdreView ®) | 78012-78015, 78016 | Thyroid uptake measurement; Thyroid imaging w/blood flow; Thyroid met imaging | 1 | |
| 78018 | Thyroid carcinoma metastases imaging | ||||
| 78020 | Thyroid met uptake | ||||
| 78070-78072 | Parathyroid study | ||||
| 78075 | Adrenal Imaging, Cortex and/or Medulla | ||||
| 78099 | Unlisted endocrine procedure | 1 | |||
| 78414 | Non-imaging heart function | ||||
| 78428 | Cardiac shunt detection | ||||
| 78445 | Non-Cardiac Vascular Flow Imaging | ||||
| 78451, 78452, 78453, 78454 | Myocardial perfusion imaging | ||||
| 78456, 78457, 78458 | Venous Thrombosis Imaging Venogram | ||||
| 78466, 78468, 78469 | Myocardial Imaging | ||||
| 78472, 78473, 78481, 78483, 78494, 78496 | Cardiac Blood Pool Imaging | ||||
| 78499 | Unlisted cardiovascular procedure, diagnostic nuclear medicine | ||||
| 78800-78804 | Radiopharmaceutical localization of tumor | ||||
| 78808 | Iv inj ra drug dx study | ||||
| 78830-78832 | Radiopharmaceutical localization of tumor | ||||
| 78999 | Unlisted miscellaneous, procedure, diagnostic nuclear medicine | ||||
| A9585 | Injection, gadobutrol, 0.1 ml | 70545, 70546 | MRA head | 300 | |
| 70548, 70549 | MRA neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 71551, 71552 | MRI chest | ||||
| 71555 | MRI angio chest | ||||
| 72142 | MRI neck spine | ||||
| 72147 | MRI chest spine | ||||
| 72149 | MRI lumbar spine | ||||
| 72156 | MRI neck spine | ||||
| 72157 | MRI chest spine | ||||
| 72158 | MRI lumbar spine | C8900-C8902 | |||
| 74182, 74183 | MRI abd | C8903-C8905 | |||
| 74185 | MRI angio abdomen | C8906-C8908 | |||
| 75557, 75559, 75561, 75563 | Cardiac magnetic resonance imaging for morphology | C8909-C8911 | |||
| 75565 | Cardiac MRI for velocity flow mapping | C8931-C8933 | |||
| C9067 | Gallium ga-68, dotatoc, diagnostic, 0.01 mci | 78811 | PET image ltd area | 500 | |
| 78812 | PET image skull-thigh | ||||
| 78813 | PET image full body | ||||
| 78814 | PET image W CT lmtd | ||||
| 78815 | PET image W CT skull-thigh | ||||
| 78816 | PET image W CT full body | ||||
| Q9958 | High osmolar contrast material, up to 149 mg/ml iodine concentration, per Ml | 70336 | MRI jaw joint (TMJ) | 300 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 74251 | X-ray exam sm int 2cntrst std | ||||
| 74263 | CT colonography screening | ||||
| 76380 | CT f/up study | ||||
| 77053 | X-ray of mammary duct | ||||
| 77054 | X-ray of mammary ducts | ||||
| 75572, 75573 | Cardiac CT for Morphology; Cardiac CT for Congenital HD | 70450-70498 | |||
| 75574 | Coronary CTA | 71250-71275 | |||
| 93452-93461 | Medicine-Cardiovascular | 72125-72133 | |||
| 70010, 70015, 70332 | Diagnostic Radiology-Head and Neck | 72191-72194 | |||
| 72240, 72255, 72265, 72270, 72285, 72295 | Diagnostic Radiology-Spine and Pelvis | 73200-73206 | |||
| 73040, 73085, 73115 | Diagnostic Radiology-Upper Extremities | 73700-73706 | |||
| 73525, 73580, 73615 | Diagnostic Radiology-Lower Extremities | 74150-74178 | |||
| 74190 | Diagnostic Radiology-Abdomen | 74261-74262 | |||
| 74220, 74246, 74270, 74280, 74283, 74290,74340, 74363 | Diagnostic Radiology-Gastrointestinal Tract | 75635, 76000, 75710 | |||
| 74420, 74425, 74430, 74450, 74455, | Diagnostic Radiology-Urinary Tract | 77021, 77022 | |||
| Q9960 | High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml | 70336 | MRI jaw joint (TMJ) | 250 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 74251 | X-ray exam sm int 2cntrst std | ||||
| 74263 | CT colonography screening | ||||
| 76380 | CT f/up study | ||||
| 77053 | X-ray of mammary duct | ||||
| 77054 | X-ray of mammary ducts | ||||
| 75572, 75573 | Cardiac CT for Morphology; Cardiac CT for Congenital HD | 70450-70498 | |||
| 75574 | Coronary CTA | 71250-71275 | |||
| 93452-93461 | Medicine-Cardiovascular | 72125-72133 | |||
| 70010, 70015, 70332 | Diagnostic Radiology-Head and Neck | 72191-72194 | |||
| 72240, 72255, 72265, 72270, 72285, 72295 | Diagnostic Radiology-Spine and Pelvis | 73200-73206 | |||
| 73040, 73085, 73115 | Diagnostic Radiology-Upper Extremities | 73700-73706 | |||
| 73525, 73580, 73615 | Diagnostic Radiology-Lower Extremities | 74150-74178 | |||
| 74190 | Diagnostic Radiology-Abdomen | 74261-74262 | |||
| 74220, 74246, 74270, 74280, 74283, 74290,74340, 74363 | Diagnostic Radiology-Gastrointestinal Tract | 75635, 76000, 75710 | |||
| 74420, 74425, 74430, 74450, 74455, | Diagnostic Radiology-Urinary Tract | 77021, 77022 | |||
| Q9961 | High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml | 70336 | MRI jaw joint (TMJ) | 200 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 74251 | X-ray exam sm int 2cntrst std | ||||
| 74263 | CT colonography screening | ||||
| 76380 | CT f/up study | ||||
| 77053 | X-ray of mammary duct | ||||
| 77054 | X-ray of mammary ducts | ||||
| 75572, 75573 | Cardiac CT for Morphology; Cardiac CT for Congenital HD | 70450-70498 | |||
| 75574 | Coronary CTA | 71250-71275 | |||
| 93452-93461 | Medicine-Cardiovascular | 72125-72133 | |||
| 70010, 70015, 70332 | Diagnostic Radiology-Head and Neck | 72191-72194 | |||
| 72240, 72255, 72265, 72270, 72285, 72295 | Diagnostic Radiology-Spine and Pelvis | 73200-73206 | |||
| 73040, 73085, 73115 | Diagnostic Radiology-Upper Extremities | 73700-73706 | |||
| 73525, 73580, 73615 | Diagnostic Radiology-Lower Extremities | 74150-74178 | |||
| 74190 | Diagnostic Radiology-Abdomen | 74261-74262 | |||
| 74220, 74246, 74270, 74280, 74283, 74290,74340, 74363 | Diagnostic Radiology-Gastrointestinal Tract | 75635, 76000, 75710 | |||
| 74420, 74425, 74430, 74450, 74455s | Diagnostic Radiology-Urinary Tract | 77021, 77022 | |||
| Q9963 | High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml | 70336 | MRI jaw joint (TMJ) | 240 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 74251 | X-ray exam sm int 2cntrst std | ||||
| 74263 | CT colonography screening | ||||
| 76380 | CT f/up study | ||||
| 77053 | X-ray of mammary duct | ||||
| 77054 | X-ray of mammary ducts | ||||
| 75572, 75573 | Cardiac CT for Morphology; Cardiac CT for Congenital HD | 70450-70498 | |||
| 75574 | Coronary CTA | 71250-71275 | |||
| 93452-93461 | Medicine-Cardiovascular | 72125-72133 | |||
| 70010, 70015, 70332 | Diagnostic Radiology-Head and Neck | 72191-72194 | |||
| 72240, 72255, 72265, 72270, 72285, 72295 | Diagnostic Radiology-Spine and Pelvis | 73200-73206 | |||
| 73040, 73085, 73115 | Diagnostic Radiology-Upper Extremities | 73700-73706 | |||
| 73525, 73580, 73615 | Diagnostic Radiology-Lower Extremities | 74150-74178 | |||
| 74190 | Diagnostic Radiology-Abdomen | 74261-74262 | |||
| 74220, 74246, 74270, 74280, 74283, 74290,74340, 74363 | Diagnostic Radiology-Gastrointestinal Tract | 75635, 76000, 75710 | |||
| 74420, 74425, 74430, 74450, 74455, | Diagnostic Radiology-Urinary Tract | 77021, 77022 | |||
| Q9965 | Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml | 70336 | MRI jaw joint (TMJ) | 250 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 70460, 70470 | CT head & brain | ||||
| 70481, 70482 | CT orbit/ear/fossa | ||||
| 70487, 70488 | CT maxillofacial | ||||
| 70491, 70492 | CT soft tissue neck | ||||
| 70496 | CTA head | ||||
| 70498 | CTA neck | ||||
| 71260, 71270 | CT thorax | ||||
| 71275 | CTA chest | ||||
| 72126, 72127 | CT cervical spine | ||||
| 72129, 72130 | CT thoracic spine | ||||
| 72132, 72133 | CT lumbar spine | ||||
| 72191 | CTA pelvis | ||||
| 72193, 72194 | CT pelvis | ||||
| 73201, 73202 | CT upper extremity | ||||
| 73206 | CTA upper extremity | ||||
| 73701, 73702 | CT lower extremity | ||||
| 73706 | CTA lower extremity | ||||
| 74160, 74170 | CT abdomen | ||||
| 74174 | CTA abdomen & pelvis | ||||
| 74175 | CTA abdomen | ||||
| 74177, 74178 | CT abdomen & pelvis | ||||
| 74251 | X-ray exam sm int 2cntrst std | ||||
| 74262, 74263 | CT colonography screening | ||||
| 75635 | CTA abdominal arteries | ||||
| 75860 | Vein x-ray neck | ||||
| 75870 | Vein x-ray skull | ||||
| 75984 | Xray control catheter change | ||||
| 76380 | CT f/up study | ||||
| 77053 | X-ray of mammary duct | ||||
| 77054 | X-ray of mammary ducts | ||||
| 75572, 75573 | Cardiac CT for Morphology; Cardiac CT for Congenital HD | ||||
| 75574 | Coronary CTA | ||||
| 93452-93461 | Medicine-Cardiovascular | ||||
| 70010, 70015, 70332 | Diagnostic Radiology-Head and Neck | ||||
| 72240, 72255, 72265, 72270, 72285, 72295 | Diagnostic Radiology-Spine and Pelvis | ||||
| 73040, 73085, 73115 | Diagnostic Radiology-Upper Extremities | ||||
| 73525, 73580, 73615 | Diagnostic Radiology-Lower Extremities | ||||
| 74190 | Diagnostic Radiology-Abdomen | ||||
| 74220, 74246, 74270, 74280, 74283, 74290,74340, 74363 | Diagnostic Radiology-Gastrointestinal Tract | ||||
| 74420, 74425, 74430, 74450, 74455, | Diagnostic Radiology-Urinary Tract | 76000, 75710 | |||
| 93452-93461 | Medicine-Cardiovascular | 77021, 77022 | |||
| Q9967 | Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml | 70336 | MRI jaw joint (TMJ) | 300 | |
| 70542, 70543 | MRI orbit/face/neck | ||||
| 70552, 70553 | MRI brain stem | ||||
| 70554 | FMRI brain by tech | ||||
| 70555 | FMRI brain by phys/psych | ||||
| 70460, 70470 | CT head & brain | ||||
| 70481, 70482 | CT orbit/ear/fossa | ||||
| 70487, 70488 | CT maxillofacial | ||||
| 70491, 70492 | CT soft tissue neck | ||||
| 70496 | CTA head | ||||
| 70498 | CTA neck | ||||
| 71260, 71270 | CT thorax | ||||
| 71275 | CTA chest | ||||
| 72126, 72127 | CT cervical spine | ||||
| 72129, 72130 | CT thoracic spine | ||||
| 72132, 72133 | CT lumbar spine | ||||
| 72191 | CTA pelvis | ||||
| 72193, 72194 | CT pelvis | ||||
| 73201, 73202 | CT upper extremity | ||||
| 73206 | CTA upper extremity | ||||
| 73701, 73702 | CT lower extremity | ||||
| 73706 | CTA lower extremity | ||||
| 74160, 74170 | CT abdomen | ||||
| 74174 | CTA abdomen & pelvis | ||||
| 74175 | CTA abdomen | ||||
| 74177, 74178 | CT abdomen & pelvis | ||||
| 74251 | X-ray exam sm int 2cntrst std | ||||
| 74262, 74263 | CT colonography screening | ||||
| 75635 | CTA abdominal arteries | ||||
| 75860 | Vein x-ray neck | ||||
| 75870 | Vein x-ray skull | ||||
| 75984 | Xray control catheter change | ||||
| 76380 | CT f/up study | ||||
| 77053 | X-ray of mammary duct | ||||
| 77054 | X-ray of mammary ducts | ||||
| 75572, 75573 | Cardiac CT for Morphology; Cardiac CT for Congenital HD | ||||
| 75574 | Coronary CTA | ||||
| 93452-93461 | Medicine-Cardiovascular | ||||
| 70010, 70015, 70332 | Diagnostic Radiology-Head and Neck | ||||
| 72240, 72255, 72265, 72270, 72285, 72295 | Diagnostic Radiology-Spine and Pelvis | ||||
| 73040, 73085, 73115 | Diagnostic Radiology-Upper Extremities | ||||
| 73525, 73580, 73615 | Diagnostic Radiology-Lower Extremities | ||||
| 74190 | Diagnostic Radiology-Abdomen | ||||
| 74220, 74246, 74270, 74280, 74283, 74290,74340, 74363 | Diagnostic Radiology-Gastrointestinal Tract | 76000, 75710 | |||
| 74420, 74425, 74430, 74450, 74455, | Diagnostic Radiology-Urinary Tract | 77021, 77022 |