73725x2 MRA Pelvis Runoff (to ankle) CTA Abdomen with & without CTA Cardiac Brain without 70551

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1 CT CT Myelogram MRI Abdomen without Cervical Abdomen / MRCP Abdomen with Thoracic Abdomen / MRCP with & without Abdomen with & without Lumbar Abdomen / Pelvis without or more MRA Abdomen Abdomen / Pelvis with Regions MRA Brain Abdomen / Pelvis with & without MRA Carotid / Neck Abdomen with & without Pelvis with MRI Arthrogram MRA Chest (joint contrast) 73725x2 MRA Pelvis Runoff (to ankle) CTA Abdomen with & without CTA Abdomen Runoff (to toes) Ankle MRA Pelvis Without CTA Abdomen / Pelvis CTA Cardiac Brain without CTA Chest with & without Hip Brain with & without CTA Coronary Brain & Orbits with & without CTA Head with & without CTA Neck with & without Knee Breast Bilateral CTA Pelvis with & without without or with & without DX=cander add 0159T Cervical without Shoulder Thoracic without Cardiac Lumbar without Thumb Cervical without Chest without Cervical with & without Chest with Thoracic without Wrist (1 Chest with & without Thoracic with & without compartment) Chest PE Protocol Lumbar without Facial Bones without Lumbar with & without Wrist ( compartment) 25246x Hip Head without Head with Dexascan Lower Extremity - Joint Head with & without Axial Skeleton Specify: Hip, Knee, Ankle Plus Vertebral Lower Extremity without Fracture ONLY Vertebral Orbits without Fracture Orbits without Orbits with Orbits with & without Pelvis without Pelvis with & without Pelvis without Pelvis with S.T. Neck without Pelvis with & without S.T. Neck with & without Lower Extremity - Not a Joint Specify: Femur, TibFib, Foot 2018 CPT CODES MR/CT S.T. Neck without TMJ S.T. Neck with S.T. Neck with & without Sinus without Upper Extremity - Joint Upper Extremity - Not a Joint Specify: Shoulder, Elbow, Wrist Specify: Humerus, Forearm, Hand Temp Bones / IAC's without Breast Biopsy Upper Extremity without Additional Lesion Urogram Page 1 of 5 Updated 01/08/2018

2 NM/Fluoro/Mammo/US Nuclear Medicine Bone Scan Whole Body A Bone Scan Limited A9503 Specify: Body Part Bone Scan 3 Phase A9503 Specify: Body Part Bone Spect A Gastric Emptying A Heart Treadmill J1245 Heart Pharmacologic J1245 Hida with CCK Hida without CCK A I-131 Whole Body Scan A9528 I-131 Whole Body Scan with Therapy I-131 Therapy All I-131 Addt'l Info on Pg 4 Liver Spect Scan A Liver Spleen A9567 Lung VQ A Muga Scan A Parathyroid Scan A Renal Mag 3 Renal Lasix Renal Captopril Renal Scan-DMSA A Thyroid Uptake and Scan WBC Whole Body A WBC Limited A Fluoroscopy Ultrasound Barium Swallow Abdominal Complete Modified Barium Swallow Abdominal Limited (must have speech pathologist) Aorta Iliac IVC for Aneurysm Barium Enema Breast (Bilateral x2) Barium Enema with Air Carotid Hysterosalpingogram (HSG) Lumbar Puncture Chest Doppler, Arterial Unilateral Lower Doppler, Arterial Bilateral Lower Doppler, Arterial Bilateral Upper Doppler, Arterial Unilateral Upper Pain Mgmt - Hip Injection Doppler Aorta Iliac Pain Mgmt - Sm Joint IVC for Transplant Specify: Toes, Fingers Doppler, Mesenteric Pain Mgmt - Int Joint Doppler Renal Artery Specify: Ankle, Wrist, Elbow Doppler, Portal Vein Pain Mgmt - Lg Joint Doppler, Venous Bilateral Specify: Hip Right or Left Doppler, Venous Unilateral Small Bowel Follow Through Extremity Specify: Body Part Upper G.I. Barium Swallow Fetal Hips Upper G.I. with KUB Head / Soft Tissue Neck Upper G.I. with Small Bowel Series HSG VCUG Digital Mammography OB Single >14wks OB Multiple OB 1st Trimester < 14 wks OB T-Vag Screening Bilateral Screening Unilateral Pain Mgmt - Sm Joint Specify: Toes, Fingers Diagnostic Bilateral Pain Mgmt - Int Joint Specify: Ankle, Wrist, Elbow Diagnostic Unilateral U/S Pain Mgmt - Lg Joint Specify: Hip Right or Left Mag / Spot Bilateral Paracentesis Pelvis Mag / Spot Unilateral Pelvis with T-Vag Stereotactic Breast Biopsy Additional Lesion Renal Ultrasound Guided Procedures Renal Post Transplant Scrotal (Testicular) Breast Biopsy G0206 Thoracentesis Thyroid A4550 Transrectal (Prostate) Additional Lesion Transvaginal Breast Cyst Aspiration Specify: Side, Nodule Thyroid Biopsy Specify: Side, Nodule Soft Tissue Neck Biopsy Specify: Side, Nodule Page 2 of 5 Updated 01/08/2018

3 Additional Guide for Nuclear Medicine THYROID UPTAKE SINGLE DETERMINATION * Probe only with one return (2, 4, 6, OR 24HOURS) THYROID IMAGING, WITH UPTAKE-SINGLE DETERMINATION * Return with probe plus one image of the thyroid gland acquired at 6 hours after dose THYROID IMAGING WITH UPTAKE-MULTIPLE DETERMINATIONS * Return with probe and Includes the above with two returns for determination I131 WHOLE BODY SCAN-NO THYROGEN NO HIGH DOSE *TSH >30 *SDMI Dose *SDMI Whole Body Scan THYROGEN I131 WHOLE BODY SCAN NO HIGH DOSE *Thyrogen given by doctor s office Monday and Tuesday *SDMI Dose Wednesday *SDMI Whole Body Scan Friday- I131 WHOLE BODY SCAN WITH HIGH DOSE (29.9 MCI-200MCI) *TSH>30 Pregnancy test Required within 7 days unless Hysterectomy/Tubal Ligation *SDMI High Dose *SDMI Whole Body Scan 1 week after High Dose THYROGEN I131 WHOLE BODY SCAN WITH HIGH DOSE (29.9 MCI-200MCI) *Pregnancy test Required within 7 days unless Hysterectomy/Tubal Ligation *Thyroid labs within 3 months *Thyrogen given by doctor s office Monday and Tuesday *SDMI High Dose Wednesday *SDMI Whole Body Scan 1 week after High Dose Page 3 of 5 Updated 01/08/2018

4 Interventional Radiology Angiography and Venography Abdomen Angio (Aortagram) w/ Bilateral Lower Ext Arteriogram (Bilateral Runoff) A45550, x2 Carotid w/cerebral w/vertebral Arterties 4 Vessel 36223x2 Cerebral Vertebral Angio Carotid Angio Bilateral w/unilateral Vertebral 36222x2 (selective cath placement) x2 Bilateral Common Carotid Angio (w/head & neck) Bilateral Common Carotid Angio (w/neck only) 36222x2 Renal Angio Bilateral (aortagram) Renal Angio Unilateral (aortagram) Upper Extremity Angio Bilateral Upper Extremity Angio Unilateral Extremity (Arm or Leg) Venogram Bilateral Extremity (Arm or Leg) Venogram Unilateral Varicocele Embolization (VA Ins Only) x Venous Access Procedures Chest Port - Insertion Chest Port - Exchange/Replace Arm Port - Insertion Arm Port - Exchange/Replace Port Removal (Arm or Chest) Port Repair (Arm or Chest) Not Replaced Tunneled Catheter Placement Tunneled Catheter Exchange Tunneled Catheter Removal IVC Filter Insertion IVC Filter Removal A4450, Other Special Procedures Vertobroplasty 1 Level Thoracic Vertebroplasty 1 Level Lumbar Additional Level Thoracic or Lumbar Kyphoplasty Consultation (New Patient) Kyphoplasty Consultation (Established Patient) Kyphoplasty 1 Level Thoracic Kyphoplasty 1 Level Lumbar Kyphoplasty Additional Level Thoracic or Lumbar Post Op Care 99212,2 Page 4 of 5 Updated 01/08/2018

5 Interventional Radiology Nephrostogram (*Unilateral) Tube Insertion Tube Check Tube Change Tube Removal Urological Special Procedures *If Bilateral is needed, x2 Nephrostogram w/ Ureteral Stent Insertion (Ureteral Blockage) Retroperitoneal or Peritoneal Percutaneous Drain Cavity Space Soft Tissue / Muscle A4450,1 Organ A4649 Peritoneal Cath Insertion Renal Cyst Aspiration or Pelvis Inj Cholangiogram thru Cath (T-Tube Check) Lung Biopsy Mediastinum Liver Biopsy (hep c or random) Pleural Biopsy Abdomen / Retroperitoneal Biopsy Lymph Node Biopsy Bone Biopsy Trocar or Neddle;Superficial Bone Biopsy Needle; Deep Bone Marrow Biopsy Pancreas Biopsy CT Guided Special Procedures Renal or Adrenal Biopsy (patient must have a urologist or urology consult) Soft Tissue / Muscle Biopsy 32405(core) 71035x (core) 32400(core) 71035x (core) 1002(FNA) 38505(core) (core) 50200(core) 20206(core) PET Scan and PET/CT Fusion codes call For additional Special Procedure contact Specials at Page 5 of 5 Updated 01/08/2018

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