Page 1 HORIZON NJ HEALTH PRE-AUTHORIZATION CODES MANAGED BY NIA HORIZON NJ HEALTH 7/22/14 CODE CODE PROCEDURE PROCEDURE

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1 Page 1 PRE-ORIZATION S MANAGED BY DA Bone Density, Axial DA Bone Density, Vert F Throat -Ray and Fluoroscopy Contrast -Ray of Larynx Perq Verte/Sacroplsty, Fluor Perq Verte/Sacroplsty, CT Contrast -Ray Exam of Throat Contrast -Ray, Esophagus Cine/Vid -Ray, Throat/ Esophagus Remove Esophagus Obstruction Ray Exam, Upper GI Tract Ray Exam, Upper GI Tract Ray Exam, Upper GI Tract Contrast -Ray Upper GI Tract Contrast -Ray Upper GI Tract Contrast -Ray Upper GI Tract Ray Exam of Small Bowel Ray Exam of Small Bowel Contrast -Ray Exam of Colon Contrast -Ray Exam of Colon Contrast -Ray Exam of Colon Contrast -Ray, Bladder Ray Control, Catheter Insert Ray Guide, GU Dilation Rays, Transcatheter Therapy Remove CVA Device Obstruct Remove CVA Lumen Obstruct Transcatheter IV Stent RS&I Repair Arterial Blockage Repair Artery Blockage, each Vascular Biopsy Repair Venous Blockage Fluoroscope Examination Fluoroscope Exam, extensive Cine/Video -Rays Fluoroscopic Procedure Fluoroscopic Procedure Fluoroguide for Vein Device Needle Localization by -Ray Fluoroguide for Spine Inject Computer D Mammogram Add-On Comp Screen Mammogram Add-On PRE-ORIZATION S MANAGED BY Mammogram, one breast Mammogram, both breasts Mammogram, screening G0202 Diagnostic Mammography, producing direct digital image, bilateral, all views G0204 Diagnostic Mammography, producing direct digital image, bilateral, all views G0206 Diagnostic Mammography, producing direct digital image, unilateral, all views Ray Eye for Foreign Body Ray Exam of Jaw Ray Exam of Jaw Ray Exam of Mastoids Ray Exam of Mastoids Ray Exam of Middle Ear Ray Exam of Facial Bones Ray Exam of Facial Bones Ray Exam of Nasal Bones Ray Exam of Eye Sockets Ray Exam of Eye Sockets Ray Exam of Sinuses Ray Exam of Sinuses Ray Exam, Pituitary Saddle Ray Exam of Skull Ray Exam of Skull Ray Exam of Teeth Ray Exam of Teeth Full Mouth -Ray of Teeth Ray Exam of Jaw Joint Ray Exam of Jaw Joints Ray Head for Orthodontia Panoramic -Ray of Jaws Ray Exam of Neck Speech Evaluation, complex Ray Exam of Salivary Gland Chest -Ray Chest -Ray Chest -Ray Chest -Ray Chest -Ray Chest -Ray and Fluoroscopy Chest -Ray Chest -Ray and Fluoroscopy Chest -Ray

2 Page 2 PRE-ORIZATION S MANAGED BY Ray Exam of Ribs Ray Exam of Ribs/Chest Ray Exam of Ribs Ray Exam of Ribs/Chest Ray Exam of Breastbone Ray Exam of Breastbone Ray Exam of Spine Ray Exam of Spine Ray Exam of Neck Spine Ray Exam of Neck Spine Ray Exam of Neck Spine Ray Exam of Trunk Spine Ray Exam of Thoracic Spine Ray Exam of Thoracic Spine Ray Exam of Thoracic Spine Ray Exam of Trunk Spine Ray Exam of Trunk Spine Ray Exam of Lower Spine Ray Exam of Lower Spine Ray Exam of Lower Spine Ray Exam of Lower Spine Ray Exam of Pelvis Ray Exam of Pelvis Ray Exam Sacroiliac Joints Ray Exam Sacroiliac Joints Ray Exam of Tailbone Ray Exam of Collar Bone Ray Exam of Shoulder Blade Ray Exam of Shoulder Ray Exam of Shoulder Ray Exam of Shoulders Ray Exam of Humerus Ray Exam of Elbow Ray Exam of Elbow Ray Exam of Forearm Ray Exam of Arm, Infant Ray Exam of Wrist Ray Exam of Wrist Ray Exam of Hand Ray Exam of Hand Ray Exam of Finger(s) Ray Exam of Hip PRE-ORIZATION S MANAGED BY Ray Exam of Hip Ray Exam of Hips Ray Exam of Hip Ray Exam of Pelvis and Hips Ray Exam of Thigh Ray Exam of Knee, 1 or Ray Exam of Knee, Ray Exam, Knee, 4 or more Ray Exam of Knees Ray Exam of Lower Leg Ray Exam of Leg, Infant Ray Exam of Ankle Ray Exam of Ankle Ray Exam of Foot Ray Exam of Foot Ray Exam of Heel Ray Exam of Toe(s) Ray Exam of Abdomen Ray Exam of Abdomen Ray Exam of Abdomen Ray Exam Series, Abdomen Contrast -Ray, Gallbladder Contrast -Rays, Gallbladder Rays at Surgery Add-On Contrast -Ray, Urinary Tract Contrast -Ray, Urinary Tract Contrast -Ray, Urinary Tract Ray Measurement of Pelvis Ray, Nose to Rectum Ray Exam, Breast Specimen Ray Exam of Body Section Complex Body Section -Ray Complex Body Section -Rays Cine/Video -Rays Add-On Ray Consultation Radiographic Procedure Stereotactic Guide for Breast B Guidance For Needle, Breast Ray of Mammary Duct Ray of Mammary Ducts Ray Stress View Rays for Bone Age

3 Page 3 PRE-ORIZATION S MANAGED BY Rays, Bone Length Studies Rays, Bone Survey, limited Rays, Bone Survey, complete Rays, Bone Survey, infant Joint Survey, single view Echo Exam of Head US Exam, Chest US Exam K Transpl with Doppler US Exam, Spinal Canal Echo Exam, Uterus US, Transrectal Echograp Trans R, Pros Study Ultrasound, Extremity, Nonvascular, real-time with image documentation, complete Ultrasound, Extremity, Nonvascular, real-time with image documentation, limited US Exam Infant Hips, Dynamic US Exam Infant Hips, Static Ultrasound Exam Follow-Up GI Endoscopic Ultrasound Echo Examination Procedure Carotid Duplex Sonogram Bilateral Unilateral or Limited Study Transcranial Doppler Study of the intracranial arteries, complete study Limited study Duplex Scan of lower extremity arteries or arterial bypass grafts, complete bilateral study Limited study Duplex Scan of upper extremity arteries or arterial bypass grafts, complete bilateral study Limited study Duplex Scan of extremity veins, complete bilateral study Unilateral or limited study Duplex Scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal or retroperitoneal organs, complete Limited study Duplex Scan of aorta, IVC, iliac vasculature or bypass grafts, complete study Unilateral or limited PRE-ORIZATION S MANAGED BY Duplex Scan of arterial inflow and venous outflow or penile vessels, complete study Follow-up or limited study US Exam of Head and Neck US Exam, Abdomen, complete Echo Exam of Abdomen US Exam Abdomen Back Wall, complete US Exam Abdomen Back Wall, limited Ultrasound Pelvic Non-Obstetric, complete Ultrasound Pelvic, Non-Obstetric, limited or follow-up US Exam, Scrotum Computed Tomographic angiography, heart, coronary arteries and bypass grafts (when present) Echo Transthoracic Echo Transthoracic Echo Transthoracic Echo Exam of Heart Echo Exam of Heart Echo Transesophageal Echo Transesophageal Echo Transesophageal Echo Transesophageal Echo Transesophageal Echo Transesophageal Echo Transesophageal Intra-op Doppler Echo Exam, Heart Doppler Echo Exam, Heart Doppler Color Flow C8921 TTE with/without fol with cont, com C8922 TTE with/without fol with cont, f/u C8923 2D TTE with/without fol with con, com C8924 2D TTE with/without fol with con, f/u C8925 2D TEE with/without fol with con, in C8926 TEE with/without fol with cont, cong C8927 TEE with/without fol with cont, mon C8929 TTE with/without fol with con, Doppler Echo Transthoracic Stress Echocardiography including stress ECG Echo Transthoracic C8928 TTE with/without fol with con stres

4 Page 4 PRE-ORIZATION S MANAGED BY C8930 TTE with/without contr, cont ECG Nuclear Exam of Heart Flow Nuclear Exam, Heart Shunt Myocardial or Heart Muscle Imaging Infarct Myocardial or Heart Muscle Ejection Fraction Tomographic SPECT with/without quantitation Cardiac or Heart Blood Pool Imaging MUGA Heart Scan Heart First Pass, single Heart First Pass, multiple Cardiac Blood Pool Imaging, gated equilibrium, SPECT, at rest, wall motion Cardiac Blood Pool Imaging, gated equilibrium, single study, at rest, with Cardiovascular Nuclear Exam Provide Radioisotope(s) Myocardial or Heart Muscle SPECT, Single Thallium SPECT, Myocardial/Heart Myocardial or Heart Thallium Perfusion, single study Myocardial or Heart Muscle Perfusion, multiple studies A9500 Tc99m Sestamibi A9502 Tc99m Tetrofosmin A9505 TL201 Thallium CABG Vein, Single CABG Vein, Two CABG Vein, Three CABG Vein, Four CABG Vein, Five CABG Vein, Six or more CABG Artery-Vein, Single CABG Artery-Vein, Two CABG Artery-Vein, Three CABG Artery-Vein, Four CABG Artery-Vein, Five CABG Artery-Vein, Six or more CABG Arterial, Single CABG Arterial, Two CABG Arterial, Three CABG Arterial, Four or more Left Heart Cath with Ventrclgrphy PRE-ORIZATION S MANAGED BY R&L Heart Cath with Ventriclgrphy Coronary Artery Angio S&I Coronary Art/Grft Angio S&I Coronary Art/Grft Angio S&I Coronary Art/Grft Angio S&I L Heart Artery/Ventricle Angio L Heart Art/Grft Angio R&L Heart Art/Ventricle Angio R&L Heart Art/Ventricle Angio Insertion of pacemaker pulse generator only, with existing multiple leads Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including ) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including ) Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, multiple lead system Insertion of pacing cardioverterdefibrillator pulse generator only, with existing multiple leads Removal of pacing cardioverterdefibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator, multiple lead system Insertion of pacing cardioverterdefibrillator pulse generator only, with existing dual leads Insertion of pacing cardioverterdefibrillator pulse generator only, with existing single lead Insertion or replacement of permanent pacing cardioverter-defibrillator system with transvenous lead(s), single or dual chamber Removal of pacing cardioverterdefibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator, single lead system Removal of pacing cardioverterdefibrillator pulse generator with replacement of pacing cardioverterdefibrillator pulse generator, dual lead system Insertion of new or replacement of permanent pacemaker with transvenous electrode(s), atrial

5 Page 5 PRE-ORIZATION S MANAGED BY Insertion of new or replacement of permanent pacemaker with transvenous electrode(s), ventricular Insertion of new or replacement of permanent pacemaker with transvenous electrode(s), atrial and ventricular Insertion of pacemaker pulse generator only, with existing single lead Insertion of pacemaker pulse generator only, with existing dual leads Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generation) Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, single lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator, dual lead system Inject L Ventr/Atrial Angio Inject R Ventr/Atrial Angio Inject Suprvlv Aortography Inject Pulm Art Heart Cath Prq Cardiac Angioplasty, 1 Art Prq Cardiac Angio, Add Art Prq Card Angio/Athrect, 1 Art Prq Card/Angio/Athrect, Add Prq Card Stent with Angio, 1 Vsl Prq Card Stent with Angio, Add Prq Card Stent/Ath/Angio Prq Card Stent/Ath/Angio Prq Revasc Byp Graft, 1 Vsl Prq Revasc Byp Graft, Add Prq Card Revasc Mi, 1 Vsl Prq Card Revasc Chronic, 1 Vsl Prq Card Revasc Chronic, Add Percut Coronary Thrombectomy C9600 Percutaneous Transcatheter Placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery or branch PRE-ORIZATION S MANAGED BY C9601 C9602 C9603 C9604 C9605 C9606 C9607 Percutaneous Transcatheter Placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed, each additional branch of a major coronary artery (list separately, in addition to code for primary procedure) Percutaneous Transluminal Coronary Atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed, single major coronary artery or branch Percutaneous Transluminal Coronary Atherectomy, with drug-eluting intracoronary stent, with coronary angioplasty when performed, each additional branch of a major coronary artery (list separately in addition to code for primary procedure) Percutaneous Transluminal Revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed, single vessel Percutaneous Transluminal Revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including distal protection when performed, each additional branch subtended by the bypass graft (list separately in addition to code for primary procedure) Percutaneous Transluminal Revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel Percutaneous Transluminal Revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drugeluting intracoronary stent, atherectomy and angioplasty; single vessel

6 Page 6 PRE-ORIZATION S MANAGED BY C9608 Percutaneous Transluminal Revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of drugeluting intracoronary stent, atherectomy and angioplasty; each additional coronary artery, coronary artery branch, or bypass graft (list separately in addition to code for primary procedure) G0290 Drug-eluting Stents, single Applicator Insertion Breast (breast surgeon) Applicator Insertion Breast (breast surgeon) Applicator Insertion Breast (breast surgeon) Ultrasonic Guidance Computed Tomography Guidance Clinical Treatment Planning - simple Clinical Treatment Planning - intermediate Clinical Treatment Planning - complex Simulation simple Simulation - intermediate Simulation - complex D - Isodose Plan Dosimetry - Basic Radiation Calculation LMRT - Isodose Plan Teletherapy Isodose Plan - simple Teletherapy Isodose Plan - intermediate Teletherapy Isodose Plan - complex Isodose Plan - special Brachytherapy Isodose Calculation - simple Brachytherapy Isodose Calculation - intermediate Brachytherapy Isodose Calculation - complex Dosimetry - special Treatment Devices - simple Treatment Devices - intermediate Treatment Devices - complex Weekly Physics Consultation MLC Devices for LMRT Special Medical Radiation Physics Consultation Radiation Treatment SRS Radiation Treatment SRS PRE-ORIZATION S MANAGED BY Stereotactic Body Radiation Therapy Unlisted Procedure for Physics Dosimetry and Devices Port Films Intensity Modulated Treatment Stereoscopic -ray Guidance High Energy Neutron Radiation Treatment High Energy Neutron Radiation Treatment Intra-Operative Radiation Treatment, -ray or electron single treatment session Intra-Operative Radiation Treatment, -ray or electron single treatment session Radiation Therapy Management, 5 treatments Radiation Therapy Management, 1 or 2 sessions for complete treatment Stereotactic Radiation Treatment Management Stereotactic Body Radiation Therapy Management Intra-Operative Radiation Treatment Management Special Treatment Procedure Management Radiation Therapy Management, unlisted Proton Treatment Proton Treatment

7 Page 7 PRE-ORIZATION S MANAGED BY Proton Treatment Proton Treatment Hyperthermia, externally generated Hyperthermia, externally generated Hyperthermia, generated by interstitial probe Hyperthermia, generated by interstitial probe Hyperthermia, generated by intracavitary probe Intracavitary Radiation - simple Intracavitary Radiation - intermediate Intracavitary Radiation - complex Interstitial Radiation - simple Interstitial Radiation - intermediate Interstitial Radiation- complex High Dose Rate Brachytherapy High Dose Rate Brachytherapy High Dose Rate Brachytherapy Brachytherapy Surface Application Supervision Handling Loading Rad Source Unlisted Procedure Clinical Brachytherapy 0073T Compensator-based Modulation Treatment 0182T High Dose Rate Electronic Brachytherapy 0197T Intrafraction Tracking G0173 G0251 G0339 G0340 Linear Accelerator Stereotactic Radiosurgery LINAC Stereotactic Radiosurgery Stereotactic Body Radiation Therapy Stereotactic Body Radiation Therapy CT Brain, Head CT Head or Brain with Contrast CT Head or Brain without/with Contrast CT Orbit, eye socket, sella turcica, posterior fossa, ear, etc. CT Orbit, eye socket, sella turcica, posterior fossa, ear with contrast CT Orbit, eye socket, sella turcica, posterior fossa, ear, with/without contrast CT Sinus, face, jaw, mandible, maxillofacial, no contrast CT Face, jaw or mandible, maxillofacial, with contrast PRE-ORIZATION S MANAGED BY CT Face, jaw or mandible, maxillofacial, without/with contrast CT Neck soft tissues, larynx, thyroid, etc., no contrast CT Neck soft tissues, larynx, thyroid, etc., with contrast CT Neck soft tissues, larynx, thyroid, etc., without/with contrast CT Angiography, head CT Angiography, Neck MRI Face, neck, orbit MRI Orbit, face, neck with dye MRI Orbit, face, neck without/with dye MR Angiography, head without dye MR Angiography, head with dye MR Angiography, head without/with dye MR Angiography, neck without dye MR Angiography, neck with dye MR Angiography, neck without/with dye MRI Brain, head, brainstem without contrast MRI Head, brain, brainstem with contrast MRI Head, brain, brainstem without/with contrast FMRI Brain by tech FMRI Brain by phys/psych L Heart Cath trnsptl puncture Drug Admin and Hemodynmic Meas Exercise with Hemodynamic Meas Thyroid Uptake, single or multiple quantitative measurement(s) Thyroid Imaging, including vascular flow, when performed Thyroid Imaging, with single or multi uptake measurement Thyroid Carcinoma/Neoplasm Imaging, neck and chest Thyroid Neoplasm Imaging, with additional studies Thyroid Neoplasm Imaging, multiple areas Thyroid Neoplasm Imaging, whole body Thyroid Carcinoma Metastases Uptake (list separately in addition to code for initial procedure) Parathyroid Scan Parathyroid Planar Imaging, with tomographic (SPECT)

8 Page 8 PRE-ORIZATION S MANAGED BY Parathyroid Planar Imaging, with tomographic (SPECT) and concurrently acquired CT Adrenal Scan or Isotope Imaging Endocrine Nuclear Procedure Bone Marrow, limited area Bone Marrow, multiple areas Bone Marrow, whole body Plasma Volume Nuclear Exam, Plasma Volume RBC or Red Blood Cell Mass or Volume or Survival Study Red Cell Volume Determination, multiple samplings Whole Blood Volume or Plasma, RBC or red blood cell volume Red Cell Survival Exam Differential Organ/Tissue Kinetics (EG, splenic and/or hepatic sequestration) RBC or Red Blood Cell Sequestration Study Plasma Radioiron Disappearance (Turnover) Rate Spleen Imaging Only, with or without vascular flow Kinetics, study of platelet survival, with or without differential organ/tissue Platelet Survival Study White Blood Cell or WBC localization, limited area White Blood Cell or WBC localization, whole body Lymphatics and lymph glands or lymph or lymphatic system Blood/Lymph Nuclear Exam Hepatic or Liver Scan, static only Hepatic or Liver Scan, with vascular flow Hepatic or Liver Scan, SPECT Liver Imaging (SPECT), with vascular flow Hepatic or Liver and Spleen Imaging or Scan, static only Hepatic or Liver and Spleen Imaging or Scan, with vascular flow Liver Function with hepatobiliary agents Hepatobiliary, TC HIDA scan - biliary tract, gall bladder Hepatobiliary System Imaging Hepatobiliary System Imaging with drug Salivary Gland Imaging Salivary Gland Imaging, with multiple images PRE-ORIZATION S MANAGED BY Salivary Gland Function Study Esophageal Motility or Esophageal Scan Stomach or Gastric Mucosa or Lining Study Gastro-esophageal Reflux Study Stomach or Gastric Emptying Study Vitamin B-12 Absorption Study or Schilling Test, no intrinsic factor Vitamin B-12 Absorption Study or Schilling Test, with intrinsic factor Vitamin B-12 Absorption Study or Schilling Test, combined without and with Nuclear Exam, GI Blood Loss Nuclear Scan, GI Blood Loss GI Blood Loss Exam GI Protein Loss Exam Nuclear Scan of Bowel Test Venous Drain, abdomen GI Nuclear Procedure Bone Scan and/or Joint Limited Area Bone Scan and/or Joint Multiple Areas Bone or Skeleton Scan, whole body Nuclear Scan of Bone Bone and/or Joint Multiple Areas, tomographic or SPECT Bone Mineral, single photon Bone Density Dual Photon, osteoporosis study Musculoskeletal Nuclear Exam Vascular Flow Imaging or Isotope Angiography or Isotope Venography Acute Venous Thrombus Image Venous Thrombosis or Blood Clot Imaging, unilateral Venous Thrombosis or Blood Clot Imaging, bilateral Myocardial Imaging, PET Heart Image (PET), single Heart Image (PET), multiple Lung Ventilation Imaging Lung Lung Ventilation and Perfusion Imaging Lung Perfusion Lung Perfusion Imaging, rebreathing and washout, with/without single breath Lung

9 Page 9 PRE-ORIZATION S MANAGED BY Lung Pulmonary Perfusion Imaging, particulate, with ventilation imaging, aerosol Lung Lung Ventilation Imaging, gaseous, with rebreathing and washout, single pro Lung Ventilation Imaging, gaseous, with rebreathing and washout, multiple pro Lung Scan Differential Function (Ventilation/Perfusion) Study Lung Perfusion Differential Lung Perfusion and Ventilation Differential Unlisted Respiratory Procedure Nervous System, Brain Nervous System, Brain Nervous System, Brain Brain Scan or Imaging, with vascular flow Brain Scan or Imaging SPECT or tomographic Brain PET [Positron Emission Tomography] Brain PET [Positron Emission Tomography] Perfusion Brain Cerebrospinal Fluid Cerebrospinal Fluid Cerebrospinal Fluid Cerebrospinal Fluid Cerebrospinal Fluid Leakage Detection And Localization Nuclear Exam of eye lesion Tear Flow, 1 Not Nervous System Nuclear Exam Renal or Kidney Imaging, static Renal or Kidney Imaging, with vascular flow Renal or Kidney Imaging, with vascular flow and function study Kidney Flow and Function Image Kidney Flow and Function Image Renal or Kidney Imaging, SPECT Kidney, no pharmaceuticals Kidney, with pharmaceuticals Renal or Kidney Transplant Evaluation Urinary Bladder Residual Study PRE-ORIZATION S MANAGED BY Ureteral Reflux Study Scan of Testes/Blood Flow Genitourinary Nuclear Exam Nuclear Tumor Localization, limited Nuclear Tumor Localization, multiple Nuclear Tumor Localization, whole body Tomographic (SPECT) Tumor Imaging, whole body Abscess Localization or Gallium Scan, limited area Abscess Localization or Gallium Scan, whole body Tomographic (SPECT) Tumor Imaging (PET), limited Tumor Image (PET), skull-thigh Tumor Image (PET), full body Tumor Image PET/CT, limited Tumor Image PET/CT, skull-thigh Tumor Image PET/CT, full body Nuclear, Unlisted Exam Initial Hyperthyroid Therapy Nuclear Rx, Oral Admin Nuclear Rx, IV Admin Intracavitary Nuclear Treatment Nuclear Joint Therapy Nuclear Rx, Intra-Arterial Nuclear Medicine Therapy 0042T 0042T CT with Contrast, Cerebral Perfusion Analysis CT with Contrast, Cerebral Perfusion Analysis 0159T CAD Breast MRI 3111F CT/MRI Brain done within 24 hrs 3112F CT/MRI Brain done greater than 24 hrs 3269F Bone Scan B/4 Treatment/After D CT Multiplanar Reconstructions A9503 Tc99m Medronate A9510 Technetium Tc99m Disofenin A9516 Iodine I-123 Sodium Iodide, diagnostic, per 100 microcuries, up to 999 microcuries A9521 Technetiumtc-99m Exametazine A9537 Tc99m Mebrofenin A9540 Tc99m MAA

10 Page 10 PRE-ORIZATION S MANAGED BY A9547 Indium In-111 Oxyquinoline, diagnostic, per 0.5 millicurie A9548 In111 Pentetate A9551 Tc99m Succimer A9552 F18 FDG A9555 RB82 Rubidium A9558 enon e-133 Gas, diagnostic, per 10 millicuries A9561 Tc99m Oxidronate A9562 Tc99m Mertiatide A9567 Technetium TC-99m Aerosol A9584 Iodine I-123 Ioflupane C8900 MRA with contrast, abdomen C8901 MRA without contrast, abdomen C8902 MRA without/with contrast, abdomen C8903 MRI with contrast, breast, unilateral C8904 MRI without contrast, breast, unilateral C8905 MRI without/with contrast, breast, unilateral C8906 MRI with contrast, breast, bilateral C8907 MRI without contrast, breast, bilateral C8908 MRI without/with contrast, breast, bilateral C8909 MRA with contrast, chest C8910 MRA without contrast, chest C8911 MRA without/with contrast, chest excl myocardium C8912 MRA with contrast, lower extremity C8913 MRA without contrast, lower extremity C8914 MRA without/with contrast, lower extremity C8918 MRA with contrast, pelvis C8919 MRA with contrast, pelvis C8920 MRA without/with contrast, pelvis C8931 MRA with contrast, spinal canal and contents C8932 MRA without contrast, spinal canal and contents C8933 MRA, without contrast followed by with contrast, spinal canal and contents C8934 MRA, with contrast, upper extremity C8935 MRA, without contrast, upper extremity C8936 MRA, without contrast followed by with contrast, upper extremity G0062 Peripheral Bone Densitometry G0063 Central Bone Densitometry G0288 Reconstruction, CTA of aorta for surgical planning for vascular surgery S8035 Magnetic Source Imaging PRE-ORIZATION S MANAGED BY S8040 Topographic Brain Mapping S8085 Fluorine-18 Fluorodeoxyglucose G0219 PET Imaging Whole Body, melanoma for non-covered indications G0235 PET, not otherwise specified G0252 PET Imaging, initial D S8037 MRCP S8042 MRI Low Field S8092 Electron Beam Computed Tomography