CT HEAD OR BRAIN WITHOUT AND WITH CONTRAST Computerized Tomography Advanced

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1 Procedure Code Description Exam Category Copay 321 ANGIOCARDIOGRAPHY Angiography/Interventional Advanced 323 ARTERIOGRAPHY Angiography/Interventional Advanced 0144T CT heart wo dye; qual calc Computerized Tomography Advanced 0145T CT heart w/wo dye funct Computerized Tomography Advanced 0146T CCTA w/wo dye Computerized Tomography Advanced 0147T CCTA w/wo, quan calcium Computerized Tomography Advanced 0148T CCTA w/wo, strxr Computerized Tomography Advanced 0149T CCTA w/wo, strxr quan calc Computerized Tomography Advanced 0150T CCTA w/wo, disease strxr Computerized Tomography Advanced 350 CT SCAN, GENERAL Computerized Tomography Advanced 351 CT SCAN, HEAD Computerized Tomography Advanced 352 CT SCAN, BODY Computerized Tomography Advanced 359 CT SCAN, OTHER Computerized Tomography Advanced CT BRAIN, HEAD Computerized Tomography Advanced CT HEAD OR BRAIN WITH CT HEAD OR BRAIN WITHOUT AND WITH CT ORBIT,EYE SOCKET, SELLA TURCICA, POSTERIOR FOSSA,EAR ETC. Computerized Tomography Advanced CT ORBIT,EYE SOCKET, SELLA TURCICA, POSTERIOR FOSSA, EAR WIT Computerized Tomography Advanced CTORBIT,EYE SOCKET, SELLA TURCICA, POSTERIOR FOSSA,EAR,W/WO Computerized Tomography Advanced CT SINUS, FACE,JAW,MANDIBLE,MAXILLOFACIAL NO CT FACE, JAW OR MANDIBLE, MAXILLOFACIAL, WITH CT FACE, JAW OR MANDIBLE, MAXILLOFACIAL,WITHOUT/WITH CONTRAS Computerized Tomography Advanced CT NECK SOFT TISSUES,LARNYX,THYROID ETC. NO CT NECK SOFT TISSUES,LARYNX,THYROID,ETC.WITH CT NECK SOFT TISSUES, LARYNX,THYROID,ETC.WITHOUT/WITH CONTRA Computerized Tomography Advanced Ct angiography, head Computerized Tomography Advanced Ct angiography, neck Computerized Tomography Advanced CT CHEST, THORAX Computerized Tomography Advanced CT CHEST, THORAX WITH CT CHEST, THORAX WITHOUT AND WITH Ct angiography, chest Computerized Tomography Advanced CT CERVICAL SPINE, NECK SPINE NO CT CERVICAL SPINE, NECK SPINE WITH CT CERVICAL SPINE, NECK SPINE WITHOUT AND WITH CT THORACIC SPINE, UPPER BACK NO 1 of 14

2 Procedure Code Description Exam Category Copay CT THORACIC SPINE, UPPER BACK WITH CT THORACIC SPINE, UPPER BACK WITHOUT AND WITH CT LUMBAR SPINE, LOW BACK Computerized Tomography Advanced CT LUMBAR SPINE, LOW BACK WITH CT LUMBAR SPINE, LOW BACK WITHOUT AND WITH Ct angiograph pelv w/o&w dye Computerized Tomography Advanced CT PELVIS NO CT PELVIS WITH CT PELVIS WITHOUT/WITH CT ARM OR UPPER EXTREMITY Computerized Tomography Advanced CT ARM OR UPPER EXTREMITY WITH CT ARM OR UPPER EXTREMITY WITHOUT AND WITH Ct angio upr extrm w/o&w dye Computerized Tomography Advanced CT LEG OR LOWER EXTREMITY Computerized Tomography Advanced CT LEG OR LOWER EXTREMITY WITH CT LEG OR LOWER EXTREMITY WITHOUT/WITH Ct angio lwr extr w/o&w dye Computerized Tomography Advanced CT ABDOMEN WITHOUT CT ABDOMEN WITH CT ABDOMEN WITHOUT AND WITH Ct angio abdom w/o&w dye Computerized Tomography Advanced Ct angio abdominal arteries Computerized Tomography Advanced CT SCAN FOR STEREOTACTIC LOCALIZATION Computerized Tomography Advanced CT MULTIPLANAR RECONSTRUCTIONS Computerized Tomography Advanced CT SCAN FOR LOCALIZATION Computerized Tomography Advanced CT SCAN FOR NEEDLE BIOPSY Computerized Tomography Advanced CT GUIDE FOR TISSUE ABLATION Computerized Tomography Advanced CT SCAN FOR THERAPY GUIDE Computerized Tomography Advanced G0131 CT scan, bone density study Computerized Tomography Advanced G0132 CT scan, bone density study Computerized Tomography Advanced S8092 Electron beam computed tomog Computerized Tomography Advanced S8093 CT angiography coronary Computerized Tomography Advanced 340 NUCLEAR MEDICINE, GENERAL DX Nuclear Medicine Advanced 341 NUCLEAR MEDICINE, DIAGNOSTIC DX Nuclear Medicine Advanced 349 NUCLEAR MEDICINE, OTHER DX Nuclear Medicine Advanced 615 MRA, HEAD AND NECK Magnetic Resonance Angiography Advanced 616 MRA, LOWER EXTREMITIES Magnetic Resonance Angiography Advanced 618 MRA, OTHER Magnetic Resonance Angiography Advanced MRA, MRI ANGIOGRAPHY HEAD AND/OR NECK WITH OR WITHOUT CONTRA Magnetic Resonance Angiography Advanced MR angiography head w/o dye Magnetic Resonance Angiography Advanced MR angiography head w/dye Magnetic Resonance Angiography Advanced MR angiograph head w/o&w dye Magnetic Resonance Angiography Advanced MR angiography neck w/o dye Magnetic Resonance Angiography Advanced 2 of 14

3 Procedure Code Description Exam Category Copay MR angiography neck w/dye Magnetic Resonance Angiography Advanced MR angiograph neck w/o&w dye Magnetic Resonance Angiography Advanced MRA, MRI ANGIOGRAPHY CHEST[NOT MYOCARDIUM] WITH/WITHOUT CONT Magnetic Resonance Angiography Advanced MRA, MRI ANGIOGRAPHY SPINAL CANAL & CONTENTS WITH / WITHOUT Magnetic Resonance Angiography Advanced MRA, MRI PELVIS ANGIOGRAPHY WITH/WITHOUT CONTRAST Magnetic Resonance Angiography Advanced MRA, MRI ANGIOGRAPHY UPPER EXTREMITY WITH/WITHOUT CONTRAST Magnetic Resonance Angiography Advanced MRA, MRI ANGIOGRAPHY LOWER EXTREMITY WITH/WITHOUT CONTRAST Magnetic Resonance Angiography Advanced MRA, MRI ANGIOGRAPHY ABDOMEN WITH/WITHOUT CONTRAST Magnetic Resonance Angiography Advanced S8037 MRcp Magnetic Resonance Angiography Advanced 610 MRI, GENERAL Magnetic Resonance Imaging Advanced 611 MRI, BRAIN & BRAINSTEM Magnetic Resonance Imaging Advanced 612 MRI, SPINE & SPINAL CORD Magnetic Resonance Imaging Advanced 614 MRI, OTHER Magnetic Resonance Imaging Advanced 619 OTHER MR TECHNOLOGY Magnetic Resonance Imaging Advanced MRI TEMPROMANDIBULAR JOINT,TMJ,JAW JOINT Magnetic Resonance Imaging Advanced MRI FACE, NECK, ORBIT Magnetic Resonance Imaging Advanced MRI orbit/face/neck w/dye Magnetic Resonance Imaging Advanced MRI orbt/fac/nck w/o&w dye Magnetic Resonance Imaging Advanced MRI BRAIN HEAD BRAINSTEM WITHOUT CONTRAST Magnetic Resonance Imaging Advanced MRI HEAD, BRAIN, BRAINSTEM WITH CONTRAST Magnetic Resonance Imaging Advanced MRI HEAD,BRAIN,BRAINSTEM WITHOUT /WITH CONTRAST Magnetic Resonance Imaging Advanced FMRI BRAIN BY TECH Magnetic Resonance Imaging Advanced FMRI BRAIN BY PHYS/PSYCH Magnetic Resonance Imaging Advanced MRI brain w/o dye Magnetic Resonance Imaging Advanced MRI brain w/ dye Magnetic Resonance Imaging Advanced MRI brain w/o & w/ dye Magnetic Resonance Imaging Advanced MRI CHEST Magnetic Resonance Imaging Advanced MRI chest w/dye Magnetic Resonance Imaging Advanced MRI chest w/o&w dye Magnetic Resonance Imaging Advanced MRI CERVICAL SPINE OR NECK SPINE WITHOUT CONTRAST Magnetic Resonance Imaging Advanced MRI CERVICAL SPINE OR NECK SPINE WITH CONTRAST Magnetic Resonance Imaging Advanced MRI THORACIC SPINE CHEST SPINE UPPER BACK WITHOUT CONTRAST Magnetic Resonance Imaging Advanced MRI THORACIC SPINE OR CHEST SPINE OR UPPER BACK WITH CONTRAS Magnetic Resonance Imaging Advanced MRI LUMBAR SPINE OR LOW BACK WITHOUT CONTRAST Magnetic Resonance Imaging Advanced MRI LUMBAR SPINE OR LOW BACK WITH CONTRAST Magnetic Resonance Imaging Advanced MRI CERVICAL SPINE NECK SPINE WITHOUT/WITH CONTRAST Magnetic Resonance Imaging Advanced 3 of 14

4 Procedure Code Description Exam Category Copay MRI THORACIC SPINE OR CHEST SPINE WITHOUT/WITH CONTRAST Magnetic Resonance Imaging Advanced MRI LUMBAR SPINE OR LOW BACK WITHOUT/ WITH CONTRAST Magnetic Resonance Imaging Advanced MRI pelvis w/o dye Magnetic Resonance Imaging Advanced MRI PELVIS Magnetic Resonance Imaging Advanced MRI pelvis w/o & w dye Magnetic Resonance Imaging Advanced MRI upper extremity w/o dye Magnetic Resonance Imaging Advanced MRI upper extremity w/dye Magnetic Resonance Imaging Advanced MRI UPPER EXTREMITY, ENTIRE EXTREMITY, NOT A JOINT Magnetic Resonance Imaging Advanced MRI JOINT OF UPPER EXTREMITY Magnetic Resonance Imaging Advanced MRI joint upr extrem w/ dye Magnetic Resonance Imaging Advanced MRI joint upr extr w/o&w dye Magnetic Resonance Imaging Advanced MRI lower extremity w/o dye Magnetic Resonance Imaging Advanced MRI lower extremity w/dye Magnetic Resonance Imaging Advanced MRI LEG OR LOWER EXTREMITY, OTHER THAN JOINT Magnetic Resonance Imaging Advanced MRI JOINT OF LOWER EXTREMITY, HIP OR KNEE OR ANKLE OR FOOT J Magnetic Resonance Imaging Advanced MRI joint of lwr extr w/dye Magnetic Resonance Imaging Advanced MRI joint lwr extr w/o&w dye Magnetic Resonance Imaging Advanced MRI ABDOMEN Magnetic Resonance Imaging Advanced MRI abdomen w/dye Magnetic Resonance Imaging Advanced MRI abdomen w/o&w dye Magnetic Resonance Imaging Advanced MRI CARDIAC HEART Magnetic Resonance Imaging Advanced Magnetic image, myocardium Magnetic Resonance Imaging Advanced CARDIAC MRI FOR FUNCTION COMPLETE STUDY Magnetic Resonance Imaging Advanced Cardiac MRI/limited study Magnetic Resonance Imaging Advanced Cardiac MRI/flow mapping Magnetic Resonance Imaging Advanced MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH CONT Magnetic Resonance Imaging Advanced MRI BREAST BILATERAL Magnetic Resonance Imaging Advanced MR spectroscopy Magnetic Resonance Imaging Advanced MRI BONE MARROW BLOOD SUPPLY Magnetic Resonance Imaging Advanced MR GUIDANCE FOR NEEDLE PLACE Magnetic Resonance Imaging Advanced MRI FOR TISSUE ABLATION Magnetic Resonance Imaging Advanced MRI, ONE BREAST Magnetic Resonance Imaging Advanced MRI, BOTH BREASTS Magnetic Resonance Imaging Advanced MAGNETIC IMAGE, BONE MARROW Magnetic Resonance Imaging Advanced S8035 Magnetic source imaging Magnetic Resonance Imaging Advanced S8040 Topographic brain mapping Magnetic Resonance Imaging Advanced MYOCARDIAL OR HEART MUSCLE PERFUSION; MULTIPLE STUDIES Nuclear Cardiology Advanced MYOCARDIAL OR HEART MUSCLE SPECT; SINGLE Nuclear Cardiology Advanced THALLIUM* SPECT;MYOCARDIAL/HEART Nuclear Cardiology Advanced TOMOGRAPHIC SPECT WITH OR WITHOUT QUANTITATION. Nuclear Cardiology Advanced CARDIAC OR HEART BLOOD POOL IMAGING Nuclear Cardiology Advanced MUGA HEART SCAN Nuclear Cardiology Advanced HEART WALL MOTION (ADD-ON) Nuclear Cardiology Advanced 4 of 14

5 Procedure Code Description Exam Category Copay HEART FUNCTION (ADD-ON) Nuclear Cardiology Advanced HEART FIRST PASS SINGLE Nuclear Cardiology Advanced HEART FIRST PASS MULTIPLE Nuclear Cardiology Advanced Heart image, spect Nuclear Cardiology Advanced Heart first pass add-on Nuclear Cardiology Advanced CARDIOVASCULAR NUCLEAR EXAM Nuclear Cardiology Advanced 409 OTHER IMAGING SERVICES, OTHER Other Advanced Ct procedure Other Advanced MRI procedure Other Advanced UNLISTED PROCEDURE Other Advanced 921 Other Diagnostic Peripheral Vascular Lab Other Advanced 972 Professional Fees Diagnostic Radiology Other Advanced 974 Professional Fees Nuclear Medicine Other Advanced 404 POSITRON EMISSION TOMOGRAPHY (PET) Positron Emission Tomography Advanced Myocardial imaging, PET Positron Emission Tomography Advanced Heart image (pet) single Positron Emission Tomography Advanced Heart image (pet) multiple Positron Emission Tomography Advanced BRAIN PET [POSITRON EMISSION TOMOGRAPHY] Positron Emission Tomography Advanced BRAIN PET [POSITRON EMISSION TOMOGRAPHY] PERFUSION Positron Emission Tomography Advanced Tumor imaging, whole body Positron Emission Tomography Advanced TUMOR IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC Positron Emission Tomography Advanced Tumor imaging (pet), limited Positron Emission Tomography Advanced Tumor image (pet)/skul-thigh Positron Emission Tomography Advanced Tumor image (pet) full body Positron Emission Tomography Advanced Tumor image pet/ct, limited Positron Emission Tomography Advanced Tumorimage pet/ct skul-thigh Positron Emission Tomography Advanced Tumor image pet/ct full body Positron Emission Tomography Advanced G0030 PET imaging prev PET single Positron Emission Tomography Advanced G0031 PET imaging prev PET multple Positron Emission Tomography Advanced G0032 PET follow SPECT singl Positron Emission Tomography Advanced G0033 PET follow SPECT mult Positron Emission Tomography Advanced G0034 PET follow SPECT singl Positron Emission Tomography Advanced G0035 PET follow SPECT mult Positron Emission Tomography Advanced G0036 PET follow cornry angio sing Positron Emission Tomography Advanced G0037 PET follow cornry angio mult Positron Emission Tomography Advanced G0038 PET follow myocard perf sing Positron Emission Tomography Advanced G0039 PET follow myocard perf mult Positron Emission Tomography Advanced G0040 PET follow stress echo singl Positron Emission Tomography Advanced G0041 PET follow stress echo mult Positron Emission Tomography Advanced G0042 PET follow ventriculogm sing Positron Emission Tomography Advanced G0043 PET follow ventriculogm mult Positron Emission Tomography Advanced G0044 PET following rest ECG singl Positron Emission Tomography Advanced G0045 PET following rest ECG mult Positron Emission Tomography Advanced G0046 PET follow stress ECG singl Positron Emission Tomography Advanced G0047 PET follow stress ECG mult Positron Emission Tomography Advanced G0125 PET image pulmonary nodule Positron Emission Tomography Advanced G0163 Pet for rec of colorectal ca Positron Emission Tomography Advanced G0164 Pet for lymphoma staging Positron Emission Tomography Advanced G0165 Pet,rec of melanoma/met ca Positron Emission Tomography Advanced G0210 PET img wholebody dxlung Positron Emission Tomography Advanced G0211 PET img wholbody init lung Positron Emission Tomography Advanced 5 of 14

6 Procedure Code Description Exam Category Copay G0212 PET img wholebod restag lung Positron Emission Tomography Advanced G0213 PET img wholbody dx Positron Emission Tomography Advanced G0214 PET img wholebod init Positron Emission Tomography Advanced G0215 PETimg wholebod restag Positron Emission Tomography Advanced G0216 PET img wholebod dx melanoma Positron Emission Tomography Advanced G0217 PET img wholebod init melan Positron Emission Tomography Advanced G0218 PET img wholebod restag mela Positron Emission Tomography Advanced G0219 PET img wholbod melano nonco Positron Emission Tomography Advanced G0220 PET img wholebod dx lymphoma Positron Emission Tomography Advanced G0221 PET imag wholbod init lympho Positron Emission Tomography Advanced G0222 PET imag wholbod resta lymph Positron Emission Tomography Advanced G0223 PET imag wholbod reg dx head Positron Emission Tomography Advanced G0224 PET imag wholbod reg ini hea Positron Emission Tomography Advanced G0225 PET whol restag headneckonly Positron Emission Tomography Advanced G0226 PET img wholbody dx esophagl Positron Emission Tomography Advanced G0227 PET img wholbod ini esophage Positron Emission Tomography Advanced G0228 PET img WhBD ring restg esop Positron Emission Tomography Advanced G0229 PET img metaboloc brain pres Positron Emission Tomography Advanced G0230 PET myocard viability post Positron Emission Tomography Advanced G0231 PET WhBD colorec; gamma cam Positron Emission Tomography Advanced G0232 PET WhBD lymphoma; gamma cam Positron Emission Tomography Advanced G0233 PET WhBD melanoma; gamma cam Positron Emission Tomography Advanced G0234 PET WhBD pulm nod; gamma cam Positron Emission Tomography Advanced G0235 PET not otherwise specified Positron Emission Tomography Advanced G0252 PET imaging initial dx Positron Emission Tomography Advanced G0253 PET image brst dection recur Positron Emission Tomography Advanced G0254 PET image brst eval to tx Positron Emission Tomography Advanced G0296 PET imge restag thyrod cance Positron Emission Tomography Advanced G0336 PET imaging brain alzheimers Positron Emission Tomography Advanced ULTRASOUND UNLISTED Ultrasound General Advanced CARDIAC MRI FOR MORPH MRI Advanced CARDIAC MRI FLOW/VELOCITY MRI Advanced CARDIAC MRI W/STRESS IMG MRI Advanced CARDIAC MRI FLOW/VEL/STRESS MRI Advanced CARDIAC MRI FOR MORPH W/DYE MRI Advanced CARD MRI FLOW/VEL W/DYE MRI Advanced CARD MRI W/STRESS IMG & DYE MRI Advanced HT MRI W/FLO/VEL/STRS & DYE MRI Advanced Ct colonography, w/o dye Computerized Tomography Advanced Ct colonography, w/dye Computerized Tomography Advanced Ct hrt w/3d image Computerized Tomography Advanced Ct hrt w/3d image, congen Computerized Tomography Advanced Ct angio hrt w/3d image Computerized Tomography Advanced Ht muscle image spect, sing Nuclear Cardiology Advanced Ht muscle image spect, mult Nuclear Cardiology Advanced Ht muscle image,planar,sing Nuclear Cardiology Advanced Ht musc image, planar, mult Nuclear Cardiology Advanced Card mri vel flw map add-on Magnetic Resonance Imaging Advanced Ct abd & pelvis w/o contrast Computerized tomography Advanced Ct abdomen&pelvis w/contrast Computerized tomography Advanced Ct abd&pelv 1+ section/regns Computerized tomography Advanced C8931 MRA, w/dye, spinal canal Magnetic Resonance Angiography Advanced C8932 MRA, w/o dye, spinal canal Magnetic Resonance Angiography Advanced C8933 MRA, w/o&w/dye, spinal canal Magnetic Resonance Angiography Advanced 6 of 14

7 Procedure Code Description Exam Category Copay C8934 MRA, w/dye, upper extremity Magnetic Resonance Angiography Advanced C8935 MRA, w/o dye, upper extr Magnetic Resonance Angiography Advanced C8936 MRA, w/o&w/dye, upper extr Magnetic Resonance Angiography Advanced Ct angio abd&pelv w/o&w/dye Computerized tomography Advanced 7 of 14

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05/02/ CPT Preauthorization Groupings Effective May 2, Computerized Tomography (CT) Abdomen 6. CPT Description SEGR CT01

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