Contrast Agents and Radiopharmaceuticals Medicaid 2021

Covered:

 

(AG) - H91

 

Code

Code Description


Allow Contrast agent when following
Inscope codes pays

Code Description

MUE
Units

 


Code(s)
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

AcuteVenous thrombosis imaging

 

 

 

78457-78458

Venous thrombosis imaging/Unitlateral/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

AcuteVenous thrombosis imaging

 

 

 

78457-78458

Venous thrombosis imaging/Unitlateral/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/Unitlateral/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 tst 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 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

 

 

 

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 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

 

 

 

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/Unitlateral/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

 

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, 72275, 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, 72275, 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, 72275, 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

 

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, 72275, 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, 72275, 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, 72275, 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