Contrast Agents and Radiopharmaceuticals 2023

Diagnostic radiopharmaceuticals will be reimbursed according to the information within the table below.

  • The radiopharmaceuticals administered up to 96 hours before the primary procedure will be subject to these rules.

  • 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).

  • 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