Ct thoracic spine, upper back no - ConnectiCare

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
70450 CT BRAIN, HEAD Computerized Tomography Advanced
70460 CT HEAD OR BRAIN WITH CONTRAST Computerized Tomography Advanced
70470
CT HEAD OR BRAIN WITHOUT AND WITH
CONTRAST Computerized Tomography Advanced
70480
CT ORBIT,EYE SOCKET, SELLA TURCICA,
POSTERIOR FOSSA,EAR ETC. Computerized Tomography Advanced
70481
CT ORBIT,EYE SOCKET, SELLA TURCICA,
POSTERIOR FOSSA, EAR WIT Computerized Tomography Advanced
70482
CTORBIT,EYE SOCKET, SELLA TURCICA,
POSTERIOR FOSSA,EAR,W/WO Computerized Tomography Advanced
70486
CT SINUS,
FACE,JAW,MANDIBLE,MAXILLOFACIAL NO
CONTRAST Computerized Tomography Advanced
70487
CT FACE, JAW OR MANDIBLE,
MAXILLOFACIAL , WITH CONTRAST Computerized Tomography Advanced
70488
CT FACE, JAW OR MANDIBLE,
MAXILLOFACIAL,WITHOUT/WITH CONTRAS Computerized Tomography Advanced
70490
CT NECK SOFT TISSUES,LARNYX,THYROID
ETC. NO CONTRAST Computerized Tomography Advanced
70491
CT NECK SOFT
TISSUES,LARYNX,THYROID,ETC.WITH
CONTRAST Computerized Tomography Advanced
CT NECK SOFT TISSUES,
LARYNX,THYROID,ETC.WITHOUT/WITH
CONTRA Computerized Tomography Advanced
70492
70496 Ct angiography, head Computerized Tomography Advanced
70498 Ct angiography, neck Computerized Tomography Advanced
71250 CT CHEST, THORAX Computerized Tomography Advanced
71260 CT CHEST, THORAX WITH CONTRAST Computerized Tomography Advanced
71270
CT CHEST, THORAX WITHOUT AND WITH
CONTRAST Computerized Tomography Advanced
71275 Ct angiography, chest Computerized Tomography Advanced
72125
CT CERVICAL SPINE, NECK SPINE NO
CONTRAST Computerized Tomography Advanced
72126
CT CERVICAL SPINE, NECK SPINE WITH
CONTRAST Computerized Tomography Advanced
72127
CT CERVICAL SPINE, NECK SPINE
WITHOUT AND WITH CONTRAST Computerized Tomography Advanced

Procedure Code Description Exam Category Copay
CT THORACIC SPINE, UPPER BACK NO
72128
CONTRAST Computerized Tomography Advanced
72129
CT THORACIC SPINE, UPPER BACK WITH
CONTRAST Computerized Tomography Advanced
72130
CT THORACIC SPINE, UPPER BACK
WITHOUT AND WITH CONTRAST Computerized Tomography Advanced
72131 CT LUMBAR SPINE, LOW BACK Computerized Tomography Advanced
72132
CT LUMBAR SPINE, LOW BACK WITH
CONTRAST Computerized Tomography Advanced
72133
CT LUMBAR SPINE, LOW BACK WITHOUT
AND WITH CONTRAST Computerized Tomography Advanced
72191 Ct angiograph pelv w/o&w dye Computerized Tomography Advanced
72192 CT PELVIS NO CONTRAST Computerized Tomography Advanced
72193 CT PELVIS WITH CONTRAST Computerized Tomography Advanced
72194 CT PELVIS WITHOUT/WITH CONTRAST Computerized Tomography Advanced
73200 CT ARM OR UPPER EXTREMITY Computerized Tomography Advanced
73201
CT ARM OR UPPER EXTREMITY WITH
CONTRAST Computerized Tomography Advanced
73202
CT ARM OR UPPER EXTREMITY WITHOUT
AND WITH CONTRAST Computerized Tomography Advanced
73206 Ct angio upr extrm w/o&w dye Computerized Tomography Advanced
73700 CT LEG OR LOWER EXTREMITY Computerized Tomography Advanced
73701
CT LEG OR LOWER EXTREMITY WITH
CONTRAST Computerized Tomography Advanced
73702
CT LEG OR LOWER EXTREMITY
WITHOUT/WITH CONTRAST Computerized Tomography Advanced
73706 Ct angio lwr extr w/o&w dye Computerized Tomography Advanced
74150 CT ABDOMEN WITHOUT CONTRAST Computerized Tomography Advanced
74160 CT ABDOMEN WITH CONTRAST Computerized Tomography Advanced
74170
CT ABDOMEN WITHOUT AND WITH
CONTRAST Computerized Tomography Advanced
74175 Ct angio abdom w/o&w dye Computerized Tomography Advanced
75635 Ct angio abdominal arteries Computerized Tomography Advanced
76355
CT SCAN FOR STEREOTACTIC
LOCALIZATION Computerized Tomography Advanced
76375 CT MULTIPLANAR RECONSTRUCTIONS Computerized Tomography Advanced
77011 CT SCAN FOR LOCALIZATION Computerized Tomography Advanced
77012 CT SCAN FOR NEEDLE BIOPSY Computerized Tomography Advanced
77013 CT GUIDE FOR TISSUE ABLATION Computerized Tomography Advanced
77014 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 Advanced
616 MRA, LOWER EXTREMITIES Magnetic Resonance Advanced
618 MRA, OTHER Magnetic Resonance Advanced

Procedure Code Description Exam Category Copay
MRA, MRI ANGIOGRAPHY HEAD AND/OR Magnetic Resonance
70541
NECK WITH OR WITHOUT CONTRA Angiography
Advanced
70544 MR angiography head w/o dye Magnetic Resonance Advanced
70545 MR angiography head w/dye Magnetic Resonance Advanced
70546 MR angiograph head w/o&w dye Magnetic Resonance Advanced
70547 MR angiography neck w/o dye Magnetic Resonance Advanced
70548 MR angiography neck w/dye Magnetic Resonance Advanced
70549 MR angiograph neck w/o&w dye Magnetic Resonance Advanced
71555
MRA, MRI ANGIOGRAPHY CHEST[NOT
MYOCARDIUM] WITH/WITHOUT CONT
Magnetic Resonance
Angiography
Advanced
MRA, MRI ANGIOGRAPHY SPINAL CANAL & Magnetic Resonance
72159
CONTENTS WITH / WITHOUT
Angiography
Advanced
72198
MRA , MRI PELVIS ANGIOGRAPHY
WITH/WITHOUT CONTRAST
Magnetic Resonance
Angiography
Advanced
73225
MRA, MRI ANGIOGRAPHY UPPER
EXTREMITY WITH/WITHOUT CONTRAST
Magnetic Resonance
Angiography
Advanced
73725
MRA, MRI ANGIOGRAPHY LOWER
EXTREMITY WITH/WITHOUT CONTRAST
Magnetic Resonance
Angiography
Advanced
74185
MRA, MRI ANGIOGRAPHY ABDOMEN
WITH/WITHOUT CONTRAST
Magnetic Resonance
Angiography
Advanced
S8037 MRcp Magnetic Resonance 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
70336
MRI TEMPROMANDIBULAR JOINT,TMJ,JAW
JOINT
Magnetic Resonance Imaging Advanced
70540 MRI FACE , NECK, ORBIT Magnetic Resonance Imaging Advanced
70542 MRI orbit/face/neck w/dye Magnetic Resonance Imaging Advanced
70543 MRI orbt/fac/nck w/o&w dye Magnetic Resonance Imaging Advanced
70551
MRI BRAIN HEAD BRAINSTEM WITHOUT
CONTRAST
Magnetic Resonance Imaging Advanced
70552
MRI HEAD, BRAIN, BRAINSTEM WITH
CONTRAST
Magnetic Resonance Imaging Advanced
70553
MRI HEAD,BRAIN,BRAINSTEM WITHOUT
/WITH CONTRAST
Magnetic Resonance Imaging Advanced
70554 FMRI BRAIN BY TECH Magnetic Resonance Imaging Advanced
70555 FMRI BRAIN BY PHYS/PSYCH Magnetic Resonance Imaging Advanced
70557 MRI brain w/o dye Magnetic Resonance Imaging Advanced
70558 MRI brain w/ dye Magnetic Resonance Imaging Advanced
70559 MRI brain w/o & w/ dye Magnetic Resonance Imaging Advanced
71550 MRI CHEST Magnetic Resonance Imaging Advanced
71551 MRI chest w/dye Magnetic Resonance Imaging Advanced
71552 MRI chest w/o&w dye Magnetic Resonance Imaging Advanced
72141
MRI CERVICAL SPINE OR NECK SPINE
WITHOUT CONTRAST
Magnetic Resonance Imaging Advanced
72142
MRI CERVICAL SPINE OR NECK SPINE
WITH CONTRAST
Magnetic Resonance Imaging Advanced
72146
MRI THORACIC SPINE CHEST SPINE
UPPER BACK WITHOUT CONTRAST Magnetic Resonance Imaging Advanced

Procedure Code Description Exam Category Copay
MRI THORACIC SPINE OR CHEST SPINE OR
72147
UPPER BACK WITH CONTRAS
Magnetic Resonance Imaging Advanced
72148
MRI LUMBAR SPINE OR LOW BACK
WITHOUT CONTRAST
Magnetic Resonance Imaging Advanced
72149
MRI LUMBAR SPINE OR LOW BACK WITH
CONTRAST
Magnetic Resonance Imaging Advanced
72156
MRI CERVICAL SPINE NECK SPINE
WITHOUT/WITH CONTRAST
Magnetic Resonance Imaging Advanced
72157
MRI THORACIC SPINE OR CHEST SPINE
WITHOUT/WITH CONTRAST
Magnetic Resonance Imaging Advanced
72158
MRI LUMBAR SPINE OR LOW BACK
WITHOUT/ WITH CONTRAST
Magnetic Resonance Imaging Advanced
72195 MRI pelvis w/o dye Magnetic Resonance Imaging Advanced
72196 MRI PELVIS Magnetic Resonance Imaging Advanced
72197 MRI pelvis w/o & w dye Magnetic Resonance Imaging Advanced
73218 MRI upper extremity w/o dye Magnetic Resonance Imaging Advanced
73219 MRI upper extremity w/dye Magnetic Resonance Imaging Advanced
73220
MRI UPPER EXTREMITY , ENTIRE
EXTREMITY, NOT A JOINT
Magnetic Resonance Imaging Advanced
73221 MRI JOINT OF UPPER EXTREMITY Magnetic Resonance Imaging Advanced
73222 MRI joint upr extrem w/ dye Magnetic Resonance Imaging Advanced
73223 MRI joint upr extr w/o&w dye Magnetic Resonance Imaging Advanced
73718 MRI lower extremity w/o dye Magnetic Resonance Imaging Advanced
73719 MRI lower extremity w/dye Magnetic Resonance Imaging Advanced
73720
MRI LEG OR LOWER EXTREMITY , OTHER
THAN JOINT
Magnetic Resonance Imaging Advanced
73721
MRI JOINT OF LOWER EXTREMITY, HIP OR
KNEE OR ANKLE OR FOOT J
Magnetic Resonance Imaging Advanced
73722 MRI joint of lwr extr w/dye Magnetic Resonance Imaging Advanced
73723 MRI joint lwr extr w/o&w dye Magnetic Resonance Imaging Advanced
74181 MRI ABDOMEN Magnetic Resonance Imaging Advanced
74182 MRI abdomen w/dye Magnetic Resonance Imaging Advanced
74183 MRI abdomen w/o&w dye Magnetic Resonance Imaging Advanced
75552 MRI CARDIAC HEART Magnetic Resonance Imaging Advanced
75553 Magnetic image, myocardium Magnetic Resonance Imaging Advanced
75554
CARDIAC MRI FOR FUNCTION COMPLETE
STUDY
Magnetic Resonance Imaging Advanced
75555 Cardiac MRI/limited study Magnetic Resonance Imaging Advanced
75556 Cardiac MRI/flow mapping Magnetic Resonance Imaging Advanced
76093
MAGNETIC RESONANCE IMAGING,
BREAST, WITHOUT AND/OR WITH CONT Magnetic Resonance Imaging Advanced
76094 MRI BREAST BILATERAL Magnetic Resonance Imaging Advanced
76390 MR spectroscopy Magnetic Resonance Imaging Advanced
76400 MRI BONE MARROW BLOOD SUPPLY Magnetic Resonance Imaging Advanced
77021 MR GUIDANCE FOR NEEDLE PLACE Magnetic Resonance Imaging Advanced
77022 MRI FOR TISSUE ABLATION Magnetic Resonance Imaging Advanced
77058 MRI, ONE BREAST Magnetic Resonance Imaging Advanced
77059 MRI, BOTH BREASTS Magnetic Resonance Imaging Advanced
77084 MAGNETIC IMAGE, BONE MARROW Magnetic Resonance Imaging Advanced
S8035 Magnetic source imaging Magnetic Resonance Imaging Advanced
S8040 Topographic brain mapping Magnetic Resonance Imaging Advanced

Procedure Code Description Exam Category Copay
MYOCARDIAL OR HEART MUSCLE
78461
PERFUSION; MULTIPLE STUDIES Nuclear Cardiology Advanced
78464
MYOCARDIAL OR HEART MUSCLE SPECT;
SINGLE Nuclear Cardiology Advanced
78465 THALLIUM* SPECT;MYOCARDIAL/HEART Nuclear Cardiology Advanced
78469
TOMOGRAPHIC SPECT WITH OR WITHOUT
QUANTITATION. Nuclear Cardiology Advanced
78472
CARDIAC OR HEART BLOOD POOL
IMAGING Nuclear Cardiology Advanced
78473 MUGA HEART SCAN Nuclear Cardiology Advanced
78478 HEART WALL MOTION (ADD-ON) Nuclear Cardiology Advanced
78480 HEART FUNCTION (ADD-ON) Nuclear Cardiology Advanced
78481 HEART FIRST PASS SINGLE Nuclear Cardiology Advanced
78483 HEART FIRST PASS MULTIPLE Nuclear Cardiology Advanced
78494 Heart image, spect Nuclear Cardiology Advanced
78496 Heart first pass add-on Nuclear Cardiology Advanced
78499 CARDIOVASCULAR NUCLEAR EXAM Nuclear Cardiology Advanced
409 OTHER IMAGING SERVICES, OTHER Other Advanced
76497 Ct procedure Other Advanced
76498 MRI procedure Other Advanced
76499 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 Advanced
78459 Myocardial imaging, PET Positron Emission Advanced
78491 Heart image (pet) single Positron Emission Advanced
78492 Heart image (pet) multiple Positron Emission Advanced
78608
BRAIN PET [POSITRON EMISSION
TOMOGRAPHY]
Positron Emission
Tomography
Advanced
78609
BRAIN PET [POSITRON EMISSION
TOMOGRAPHY] PERFUSION
Positron Emission
Tomography
Advanced
78804 Tumor imaging, whole body Positron Emission Advanced
78810
TUMOR IMAGING, POSITRON EMISSION
TOMOGRAPHY (PET), METABOLIC
Positron Emission
Tomography
Advanced
78811 Tumor imaging (pet), limited Positron Emission Advanced
78812 Tumor image (pet)/skul-thigh Positron Emission Advanced
78813 Tumor image (pet) full body Positron Emission Advanced
78814 Tumor image pet/ct, limited Positron Emission Advanced
78815 Tumorimage pet/ct skul-thigh Positron Emission Advanced
78816 Tumor image pet/ct full body Positron Emission Advanced
G0030 PET imaging prev PET single Positron Emission Advanced
G0031 PET imaging prev PET multple Positron Emission Advanced
G0032 PET follow SPECT 78464 singl Positron Emission Advanced
G0033 PET follow SPECT 78464 mult Positron Emission Advanced
G0034 PET follow SPECT 76865 singl Positron Emission Advanced
G0035 PET follow SPECT 78465 mult Positron Emission Advanced
G0036 PET follow cornry angio sing Positron Emission Advanced
G0037 PET follow cornry angio mult Positron Emission Advanced
G0038 PET follow myocard perf sing Positron Emission Advanced
G0039 PET follow myocard perf mult Positron Emission Advanced

Procedure Code Description Exam Category Copay
G0040 PET follow stress echo singl Positron Emission Advanced
G0041 PET follow stress echo mult Positron Emission Advanced
G0042 PET follow ventriculogm sing Positron Emission Advanced
G0043 PET follow ventriculogm mult Positron Emission Advanced
G0044 PET following rest ECG singl Positron Emission Advanced
G0045 PET following rest ECG mult Positron Emission Advanced
G0046 PET follow stress ECG singl Positron Emission Advanced
G0047 PET follow stress ECG mult Positron Emission Advanced
G0125 PET image pulmonary nodule Positron Emission Advanced
G0163 Pet for rec of colorectal ca Positron Emission Advanced
G0164 Pet for lymphoma staging Positron Emission Advanced
G0165 Pet,rec of melanoma/met ca Positron Emission Advanced
G0210 PET img wholebody dxlung Positron Emission Advanced
G0211 PET img wholbody init lung Positron Emission Advanced
G0212 PET img wholebod restag lung Positron Emission Advanced
G0213 PET img wholbody dx Positron Emission Advanced
G0214 PET img wholebod init Positron Emission Advanced
G0215 PETimg wholebod restag Positron Emission Advanced
G0216 PET img wholebod dx melanoma Positron Emission Advanced
G0217 PET img wholebod init melan Positron Emission Advanced
G0218 PET img wholebod restag mela Positron Emission Advanced
G0219 PET img wholbod melano nonco Positron Emission Advanced
G0220 PET img wholebod dx lymphoma Positron Emission Advanced
G0221 PET imag wholbod init lympho Positron Emission Advanced
G0222 PET imag wholbod resta lymph Positron Emission Advanced
G0223 PET imag wholbod reg dx head Positron Emission Advanced
G0224 PET imag wholbod reg ini hea Positron Emission Advanced
G0225 PET whol restag headneckonly Positron Emission Advanced
G0226 PET img wholbody dx esophagl Positron Emission Advanced
G0227 PET img wholbod ini esophage Positron Emission Advanced
G0228 PET img WhBD ring restg esop Positron Emission Advanced
G0229 PET img metaboloc brain pres Positron Emission Advanced
G0230 PET myocard viability post Positron Emission Advanced
G0231 PET WhBD colorec; gamma cam Positron Emission Advanced
G0232 PET WhBD lymphoma; gamma cam Positron Emission Advanced
G0233 PET WhBD melanoma; gamma cam Positron Emission Advanced
G0234 PET WhBD pulm nod; gamma cam Positron Emission Advanced
G0235 PET not otherwise specified Positron Emission Advanced
G0252 PET imaging initial dx Positron Emission Advanced
G0253 PET image brst dection recur Positron Emission Advanced
G0254 PET image brst eval to tx Positron Emission Advanced
G0296 PET imge restag thyrod cance Positron Emission Advanced
G0336 PET imaging brain alzheimers Positron Emission Advanced
76999 ULTRASOUND UNLISTED Ultrasound General Advanced
70010 MYELOGRAM Angiography/ Interventional
Non-
Advanced
70015 CISTERNOGRAPHY Angiography/ Interventional
Non-
Advanced
Non-
70170 DACROCYSTOGRAPHY ,TEAR DUCT Angiography/ Interventional Advanced

Procedure Code Description Exam Category Copay
TMJ,TEMPROMANDIBULAR JOINT,JAW
Non-
70332
JOINT, ARTHROGRAPHY
Angiography/ Interventional Advanced
70390
SIALOGRAPHY, CONTRAST EXAM
SALIVARY DUCT
Angiography/ Interventional
Non-
Advanced
71040 BRONCHOGRAPHY UNILATERAL Angiography/ Interventional
Non-
Advanced
71060 BRONCHOGRAPHY BILATERAL Angiography/ Interventional
Non-
Advanced
72240 CERVICAL MYELOGRAM Angiography/ Interventional
Non-
Advanced
72255 THORACIC MYELOGRAM Angiography/ Interventional
Non-
Advanced
72265 LUMBAR MYELOGRAM Angiography/ Interventional
Non-
Advanced
72270 MYELOGRAM FULL SPINE Angiography/ Interventional
Non-
Advanced
72275 Epidurography Angiography/ Interventional
Non-
Advanced
72285 CERVICAL DISCOGRAPHY Angiography/ Interventional
Non-
Advanced
72295 LUMBAR DISCOGRAPHY Angiography/ Interventional
Non-
Advanced
73040
SHOULDER ARTHROGRAM, CONTRAST
EXAM OF SHOULDER
Angiography/ Interventional
Non-
Advanced
73085
ELBOW,ARTHROGRAM, X-RAY WITH
CONTRAST
Angiography/ Interventional
Non-
Advanced
73115
WRIST ARTHROGRAM, CONTRAST EXAM
OF WRIST
Angiography/ Interventional
Non-
Advanced
73525
HIP ARTHROGRAM, CONTRAST X-RAY OF
HIP
Angiography/ Interventional
Non-
Advanced
73580
KNEE ARTHROGRAM, CONTRAST
EXAMINATION OF KNEE
Angiography/ Interventional
Non-
Advanced
73615
ANKLE ARTHROGRAM, ARTHROGRAPHY,
CONTRAST STUDY
Angiography/ Interventional
Non-
Advanced
74190 PERITONEOGRAM Angiography/ Interventional
Non-
Advanced
74251
SMALL BOWEL SERIES, SMALL BOWEL VIA
TUBE
Angiography/ Interventional
Non-
Advanced
74320 CHOLANGIOGRAM PERCUTANEOUS Angiography/ Interventional
Non-
Advanced
74328 X-RAY FOR BILE DUCT ENDOSCOPY Angiography/ Interventional
Non-
Advanced
74329 X-RAY FOR PANCREAS ENDOSCOPY Angiography/ Interventional
Non-
Advanced
74330 X-RAY, BILE/PANCREAS ENDOSCOPY Angiography/ Interventional
Non-
Advanced
74420
UROGRAM , RETROGRADE [RETROGRADE
PYELOGRAM]
Angiography/ Interventional
Non-
Advanced
Non-
74425 UROGRAM ANTEGRADE Angiography/ Interventional Advanced

Procedure Code Description Exam Category Copay
VASOGRAPHY,
Non-
74440
VESICULOGRAPHY,EPIDIDYMOGRAPHY Angiography/ Interventional Advanced
74445 PENIS,CORPORA CAVERNOSOGRAPHY Angiography/ Interventional
Non-
Advanced
74450
URETHROCYSTOGRAM RETROGRADE,
CONTRAST EXAM URETHRA & BLADDER Angiography/ Interventional
Non-
Advanced
74455
URETHROCYSTOGRAM
VOIDING,CONTRAST EXAM URETHRA &
BLADDER
Angiography/ Interventional
Non-
Advanced
74470 RENAL CYST X-RAY Angiography/ Interventional
Non-
Advanced
74740
HYSTEROSALPINGOGRAM, CONTRAST
STUDY UTERUS AND TUBES, FERTIL Angiography/ Interventional
Non-
Advanced
74742 X-ray fallopian tube Angiography/ Interventional
Non-
Advanced
74775 VAGINOGRAM Angiography/ Interventional
Non-
Advanced
75600 CONTRAST X-RAY EXAM OF AORTA Angiography/ Interventional
Non-
Advanced
75605 CONTRAST X-RAY EXAM OF AORTA Angiography/ Interventional
Non-
Advanced
75625 CONTRAST X-RAY EXAM OF AORTA Angiography/ Interventional
Non-
Advanced
75630 X-RAY AORTA, LEG ARTERIES Angiography/ Interventional
Non-
Advanced
75650 ARTERY X-RAYS, HEAD & NECK Angiography/ Interventional
Non-
Advanced
75658 X-RAY EXAM OF ARM ARTERIES Angiography/ Interventional
Non-
Advanced
75660 ARTERY X-RAYS, HEAD & NECK Angiography/ Interventional
Non-
Advanced
75662 ARTERY X-RAYS, HEAD & NECK Angiography/ Interventional
Non-
Advanced
75665 ARTERY X-RAYS, HEAD & NECK Angiography/ Interventional
Non-
Advanced
75671 ARTERY X-RAYS, HEAD & NECK Angiography/ Interventional
Non-
Advanced
75676 ARTERY X-RAYS, NECK Angiography/ Interventional
Non-
Advanced
75680 ARTERY X-RAYS, NECK Angiography/ Interventional
Non-
Advanced
75685 ARTERY X-RAYS, SPINE Angiography/ Interventional
Non-
Advanced
75705 ARTERY X-RAYS, SPINE Angiography/ Interventional
Non-
Advanced
75710 ARTERY X-RAYS, ARM/LEG Angiography/ Interventional
Non-
Advanced
75716 ARTERY X-RAYS, ARM/LEG Angiography/ Interventional
Non-
Advanced
Non-
75722 ARTERY X-RAYS, KIDNEY Angiography/ Interventional Advanced

Procedure Code Description Exam Category Copay
Non-
75724 ARTERY X-RAYS, KIDNEYS Angiography/ Interventional Advanced
75726 ARTERY X-RAYS, ABDOMEN Angiography/ Interventional
Non-
Advanced
75731 ARTERY X-RAYS, ADRENAL GLAND Angiography/ Interventional
Non-
Advanced
75733 ARTERY X-RAYS, ADRENAL GLANDS Angiography/ Interventional
Non-
Advanced
75736 ARTERY X-RAYS, PELVIS Angiography/ Interventional
Non-
Advanced
75741 ARTERY X-RAYS, LUNG Angiography/ Interventional
Non-
Advanced
75743 ARTERY X-RAYS, LUNGS Angiography/ Interventional
Non-
Advanced
75746 ARTERY X-RAYS, LUNG Angiography/ Interventional
Non-
Advanced
75756 ARTERY X-RAYS, CHEST Angiography/ Interventional
Non-
Advanced
75774 ARTERY X-RAY, EACH VESSEL Angiography/ Interventional
Non-
Advanced
75790 VISUALIZE A-V SHUNT Angiography/ Interventional
Non-
Advanced
75801 LYMPH VESSEL, ARM/LEG UNILATERAL Angiography/ Interventional
Non-
Advanced
75803 LYMPH VESSEL, ARMS/LEGS BILATERAL Angiography/ Interventional
Non-
Advanced
75805 LYMPH VESSEL, TRUNK UNILATERAL Angiography/ Interventional
Non-
Advanced
75807 LYMPH VESSEL, TRUNK BILATERAL Angiography/ Interventional
Non-
Advanced
75809
SHUNTOGRAM FOR INVESTIGATION OF
PREVIOUSLY PLACED INDWELLING Angiography/ Interventional
Non-
Advanced
75810 SPLENOPORTAGRAM Angiography/ Interventional
Non-
Advanced
75820
VENOGRAM, CONTRAST EXAM OF VEIN,
ANY EXTREMITY UNILAT.
Angiography/ Interventional
Non-
Advanced
75822
VENOGRAM, CONTRAST EXAM OF VEIN,
ANY EXTREMITY BILAT.
Angiography/ Interventional
Non-
Advanced
75825 INFERIOR VENA CAVOGRAM Angiography/ Interventional
Non-
Advanced
75827 SUPERIOR VENA CAVOGRAM Angiography/ Interventional
Non-
Advanced
75831 VEIN X-RAY, KIDNEY Angiography/ Interventional
Non-
Advanced
75833 VEIN X-RAY, KIDNEYS Angiography/ Interventional
Non-
Advanced
75840 VEIN X-RAY, ADRENAL GLAND Angiography/ Interventional
Non-
Advanced
Non-
75842 VEIN X-RAY, ADRENAL GLANDS Angiography/ Interventional Advanced

Procedure Code Description Exam Category Copay
Non-
75860 VEIN X-RAY, NECK Angiography/ Interventional Advanced
75870 VEIN X-RAY, SKULL Angiography/ Interventional
Non-
Advanced
75872 VEIN X-RAY, SKULL Angiography/ Interventional
Non-
Advanced
75880 VEIN X-RAY, EYE SOCKET Angiography/ Interventional
Non-
Advanced
75885 VEIN X-RAY, LIVER Angiography/ Interventional
Non-
Advanced
75887 VEIN X-RAY, LIVER Angiography/ Interventional
Non-
Advanced
75889 VEIN X-RAY, LIVER Angiography/ Interventional
Non-
Advanced
75891 VEIN X-RAY, LIVER Angiography/ Interventional
Non-
Advanced
75992 Atherectomy, x-ray exam Angiography/ Interventional
Non-
Advanced
75993 Atherectomy, x-ray exam Angiography/ Interventional
Non-
Advanced
75994 Atherectomy, x-ray exam Angiography/ Interventional
Non-
Advanced
75995 Atherectomy, x-ray exam Angiography/ Interventional
Non-
Advanced
75996 Atherectomy, x-ray exam Angiography/ Interventional
Non-
Advanced
76080
FISTULA X-RAY,SINUS TRACT X-RAY,
SINOGRAM
Angiography/ Interventional
Non-
Advanced
76086
MAMMARY DUCTOGRAM OR
GALACTOGRAM, SINGLE DUCT
Angiography/ Interventional
Non-
Advanced
76088
MAMMARY DUCTOGRAM OR
GALACTOGRAM, MULTIPLE DUCTS Angiography/ Interventional
Non-
Advanced
76076 Dual energy x-ray study Bone Density
Non-
Advanced
76077 Dxa bone density/v-fracture Bone Density
Non-
Advanced
78350 BONE MINERAL, SINGLE PHOTON Bone Density
Non-
Advanced
78351
BONE DENSITY DUAL PHOTON
,OSTEOPOROSIS STUDY
Bone Density
Non-
Advanced
0151T CT heart funct add-on Computerized Tomography
Non-
Advanced
0152T Computer chest add-on Computerized Tomography
Non-
Advanced
76380
CT FOLLOW-UP OR LIMITED STUDY ANY
AREA
Computerized Tomography
Non-
Advanced
77053 X-RAY OF MAMMARY DUCT Diagnostic mammography
Nonadvanced
Nonadvanced
77054 X-RAY OF MAMMARY DUCTS Diagnostic mammography

Procedure Code Description Exam Category Copay
Nonadvanced
77055 MAMMOGRAM, ONE BREAST Diagnostic mammography
77056 MAMMOGRAM, BOTH BREASTS Diagnostic mammography
Nonadvanced
76977 Us bone density measure DX Nuclear Medicine
Non-
Advanced
78000
THYROID UPTAKE; SINGLE
DETERMINATION
DX Nuclear Medicine
Non-
Advanced
78001
THYROID UPTAKE; MULTIPLE
DETERMINATIONS
DX Nuclear Medicine
Non-
Advanced
78003
STIMULATION, SUPPRESSION OR
DISCHARGE (NOT INCLUDING INTAKE DX Nuclear Medicine
Non-
Advanced
78006
THYROID IMAGING WITH UPTAKE; SINGLE
DETERMINATION
DX Nuclear Medicine
Non-
Advanced
78007
THYROID IMAGING* WITH UPTAKE:
MULTIPLE DETERMINATIONS
DX Nuclear Medicine
Non-
Advanced
78010 THYROID IMAGING OR SCAN ONLY DX Nuclear Medicine
Non-
Advanced
78011
THYROID IMAGING OR SCAN WITH
VASCULAR FLOW
DX Nuclear Medicine
Non-
Advanced
78015
THYROID CARCINOMA /NEOPLASM
IMAGING; NECK AND CHEST
DX Nuclear Medicine
Non-
Advanced
78016
THYROID NEOPLASM IMAGING; WITH
ADDITIONAL STUDIES
DX Nuclear Medicine
Non-
Advanced
78017
THYROID NEOPLASM IMAGING; MULTIPLE
AREAS
DX Nuclear Medicine
Non-
Advanced
78018
THYROID NEOPLASM IMAGING; WHOLE
BODY
DX Nuclear Medicine
Non-
Advanced
78020 Thyroid met uptake DX Nuclear Medicine
Non-
Advanced
78070 PARATHYROID SCAN DX Nuclear Medicine
Non-
Advanced
78075 ADRENAL SCAN OR ISOTOPE IMAGING DX Nuclear Medicine
Non-
Advanced
78099 ENDOCRINE NUCLEAR PROCEDURE DX Nuclear Medicine
Non-
Advanced
78102 BONE MARROW; LIMITED AREA DX Nuclear Medicine
Non-
Advanced
78103 BONE MARROW : MULTIPLE AREAS DX Nuclear Medicine
Non-
Advanced
78104 BONE MARROW WHOLE BODY DX Nuclear Medicine
Non-
Advanced
78110 PLASMA VOLUME DX Nuclear Medicine
Non-
Advanced
78111 NUCLEAR EXAM, PLASMA VOLUME DX Nuclear Medicine
Non-
Advanced
78120
RBC OR RED BLOOD CELL MASS OR
VOLUME OR SURVIVAL STUDY
DX Nuclear Medicine
Non-
Advanced
78121
RED CELL VOLUME DETERMINATION,
MULTIPLE SAMPLINGS
DX Nuclear Medicine
Non-
Advanced

Procedure Code Description Exam Category Copay
WHOLE BLOOD VOLUME OR PLASMA/ RBC
Non-
78122
OR RED BLOOD CELL VOLUME
DX Nuclear Medicine Advanced
78130 RED CELL SURVIVAL EXAM DX Nuclear Medicine
Non-
Advanced
78135
DIFFERENTIAL ORGAN/TISSUE KINETICS
(EG, SPLENIC AND/OR HEPAT
DX Nuclear Medicine
Non-
Advanced
78140
RBC OR RED BLOOD CELL
SEQUESTRATION STUDY
DX Nuclear Medicine
Non-
Advanced
78160
PLASMA RADIOIRON DISSAPEARANCE
(TURNOVER) RATE
DX Nuclear Medicine
Non-
Advanced
78162 IRON OR RADIOIRON ORAL ABSORPTION DX Nuclear Medicine
Non-
Advanced
78170
IRON OR RADIORION ORAL ABSORPTION
RED CELL UTILIZATION
DX Nuclear Medicine
Non-
Advanced
Non-
78172 TOTAL BODY IRON OR CHEALATABLE IRON DX Nuclear Medicine Advanced
SPLEEN IMAGING ONLY WITH OR
Non-
78185
WITHOUT VASCULAR FLOW
DX Nuclear Medicine Advanced
78190
KINETICS, STUDY OF PLATELET SURVIVAL,
WITH OR WITHOUT DIFFER
DX Nuclear Medicine
Non-
Advanced
78191 PLATELET SURVIVAL STUDY DX Nuclear Medicine
Non-
Advanced
78195
LYMPHATICS AND LYMPH GLANDS OR
LYMPH OR LYMPHATIC SYSTEM
DX Nuclear Medicine
Non-
Advanced
78199 Blood/lymph nuclear exam DX Nuclear Medicine
Non-
Advanced
78201 HEPATIC OR LIVER SCAN; STATIC ONLY DX Nuclear Medicine
Non-
Advanced
78202
HEPATIC OR LIVER SCAN; WITH VASCULAR
FLOW
DX Nuclear Medicine
Non-
Advanced
78205 HEPATIC OR LIVER SCAN; SPECT DX Nuclear Medicine
Non-
Advanced
78206 Liver image (3-d) w/flow DX Nuclear Medicine
Non-
Advanced
78215
HEPATIC OR LIVER AND SPLEEN IMAGING
OR SCAN; STATIC ONLY
DX Nuclear Medicine
Non-
Advanced
78216
HEPATIC OR LIVER AND SPLEEN IMAGING*
OR SCAN; WITH VASCULAR
DX Nuclear Medicine
Non-
Advanced
78220
LIVER FUNCTION WITH HEPATOBILIARY
AGENTS
DX Nuclear Medicine
Non-
Advanced
78223
HEPATOBILIARY,TC HIDA SCAN /BILIARY
TRACT,GALL BLADDER
DX Nuclear Medicine
Non-
Advanced
78230 SALIVARY GLAND IMAGING DX Nuclear Medicine
Non-
Advanced
78231
SALIVARY GLAND IMAGING WITH
MULTIPLE IMAGES
DX Nuclear Medicine
Non-
Advanced
78232 SALIVARY GLAND FUNCTION STUDY DX Nuclear Medicine
Non-
Advanced
78258
ESOPHAGEAL MOTILITY OR ESOPHAGEAL
SCAN
DX Nuclear Medicine
Non-
Advanced

Procedure Code Description Exam Category Copay
STOMACH OR GASTRIC MUCOSA OR
Non-
78261
LINING STUDY
DX Nuclear Medicine Advanced
78262 GASTROESOPHAGEAL REFLUX STUDY DX Nuclear Medicine
Non-
Advanced
78264 STOMACH OR GASTRIC EMPTYING STUDY DX Nuclear Medicine
Non-
Advanced
78270
VITAMIN B-12 ABSORPTION STUDY OR
SCHILLING TEST; NO INTRINSI
DX Nuclear Medicine
Non-
Advanced
78271
VITAMIN B-12 ABSORPTION
STUDY/SCHILLING TEST; WITH INTRINSIC DX Nuclear Medicine
Non-
Advanced
78272
VITAMIN B-12 ABSORPTION STUDY OR
SCHILLING TEST; COMBINED WI
DX Nuclear Medicine
Non-
Advanced
78278 NUCLEAR SCAN, GI BLOOD LOSS DX Nuclear Medicine
Non-
Advanced
78282 G.I. PROTEIN LOSS EXAM DX Nuclear Medicine
Non-
Advanced
78290 NUCLEAR SCAN OF BOWEL DX Nuclear Medicine
Non-
Advanced
78291 TEST VENOUS DRAIN, ABDOMEN DX Nuclear Medicine
Non-
Advanced
78299 GI nuclear procedure DX Nuclear Medicine
Non-
Advanced
78300 BONE SCAN AND/ OR JOINT LIMITED AREA DX Nuclear Medicine
Non-
Advanced
78305
BONE SCAN AND/ OR JOINT MULTIPLE
AREAS
DX Nuclear Medicine
Non-
Advanced
78306 BONE OR SKELETON SCAN, WHOLE BODY DX Nuclear Medicine
Non-
Advanced
78315 NUCLEAR SCAN OF BONE DX Nuclear Medicine
Non-
Advanced
78320
BONE AND/OR JOINT MULTIPLE AREAS,
TOMOGRAHIC OR SPECT
DX Nuclear Medicine
Non-
Advanced
78399 Musculoskeletal nuclear exam DX Nuclear Medicine
Non-
Advanced
78445
VASCULAR FLOW IMAGING OR ISOTOPE
ANGIOGRAPHY OR ISOTOPE VENO DX Nuclear Medicine
Non-
Advanced
78455 NUCLEAR SCAN OF VEIN CLOT DX Nuclear Medicine
Non-
Advanced
78457
VENOUS THROMBOSIS OR BLOOD CLOT
IMAGING; UNILATERAL
DX Nuclear Medicine
Non-
Advanced
78458
VENOUS THROMBOSIS OR BLOOD CLOT
IMAGING; BILATERAL
DX Nuclear Medicine
Non-
Advanced
78580 LUNG DX Nuclear Medicine
Non-
Advanced
Non-
Advanced
78584 LUNG PEFUSION DX Nuclear Medicine
LUNG PERFUSION IMAGING,
REBREATHING AND WASHOUT, W/WO
78585
SINGLE
DX Nuclear Medicine
78586 LUNG DX Nuclear Medicine
Non-
Advanced
Non-
Advanced

Procedure Code Description Exam Category Copay
Non-
78587 LUNG DX Nuclear Medicine Advanced
78588 Perfusion lung image DX Nuclear Medicine
Non-
Advanced
78591 LUNG DX Nuclear Medicine
Non-
Advanced
78593
LUNG VENTILATION IMAGING, GASEOUS,
WITH REBREATHING AND WASH
DX Nuclear Medicine
Non-
Advanced
78594
LUNG VENTILATION IMAGING, GASEOUS,
WITH REBREATHING AND WASH
DX Nuclear Medicine
Non-
Advanced
78596
LUNG SCAN* DIFFERENTIAL FUNCTION
(VENTILATION/PERFUSION) STU
DX Nuclear Medicine
Non-
Advanced
78599 UNLISTED RESPIRATORY PROCEDURE DX Nuclear Medicine
Non-
Advanced
78600 NERVOUS SYSTEM, BRAIN DX Nuclear Medicine
Non-
Advanced
78601 NERVOUS SYSTEM, BRAIN DX Nuclear Medicine
Non-
Advanced
78605 NERVOUS SYSTEM, BRAIN DX Nuclear Medicine
Non-
Advanced
78606
BRAIN SCAN OR IMAGING, WITH
VASCULAR FLOW
DX Nuclear Medicine
Non-
Advanced
78607
BRAIN SCAN OR IMAGING SPECT OR
TOMOGRAPHIC
DX Nuclear Medicine
Non-
Advanced
78610 BRAIN DX Nuclear Medicine
Non-
Advanced
78615 BRAIN CEREBRAL BLOOD FLOW DX Nuclear Medicine
Non-
Advanced
78630 CEREBROSPINAL FLUID DX Nuclear Medicine
Non-
Advanced
78635 CEREBROSPINAL FLUID DX Nuclear Medicine
Non-
Advanced
78645 CEREBROSPINAL FLUID DX Nuclear Medicine
Non-
Advanced
78647 CEREBROSPINAL FLUID DX Nuclear Medicine
Non-
Advanced
78650
CSF LEAKAGE DETECTION AND
LOCALIZATION
DX Nuclear Medicine
Non-
Advanced
78660 TEAR FLOW, 1 NOT 8 DX Nuclear Medicine
Non-
Advanced
78699 Nervous system nuclear exam DX Nuclear Medicine
Non-
Advanced
78700 RENAL OR KIDNEY IMAGING; STATIC DX Nuclear Medicine
Non-
Advanced
78701
RENAL OR KIDNEY IMAGING; WITH
VASCULAR FLOW
DX Nuclear Medicine
Non-
Advanced
78704
RENAL* OR KIDNEY IMAGING; WITH
FUNCTION STUDY/ IMAGING RENOG DX Nuclear Medicine
Non-
Advanced
78707
RENAL OR KIDNEY IMAGING; WITH
VASCULAR FLOW AND FUNCTION STU DX Nuclear Medicine
Non-
Advanced

Procedure Code Description Exam Category Copay
Non-
78708 Kidney flow & function image DX Nuclear Medicine Advanced
78709 Kidney flow & function image DX Nuclear Medicine
Non-
Advanced
78710 RENAL OR KIDNEY IMAGING; SPECT DX Nuclear Medicine
Non-
Advanced
78715 NUCLEAR EXAM OF KIDNEY DX Nuclear Medicine
Non-
Advanced
78725 KIDNEY NO PHARMACEUTICALS DX Nuclear Medicine
Non-
Advanced
78726 KIDNEY WITH PHARMACEUTICALS DX Nuclear Medicine
Non-
Advanced
78727
RENAL OR KIDNEY TRANSPLANT
EVALUATION
DX Nuclear Medicine
Non-
Advanced
78730 URINARY BLADDER RESIDUAL STUDY DX Nuclear Medicine
Non-
Advanced
78740 URETERAL REFLUX STUDY DX Nuclear Medicine
Non-
Advanced
78760 TESTICULAR IMAGING OR ISOTOPE SCAN DX Nuclear Medicine
Non-
Advanced
78761 SCAN OF TESTES/BLOOD FLOW DX Nuclear Medicine
Non-
Advanced
78799 GENITOURINARY NUCLEAR EXAM DX Nuclear Medicine
Non-
Advanced
78800 NUCLEAR TUMOR LOCALIZATION, LTD DX Nuclear Medicine
Non-
Advanced
78801
NUCLEAR TUMOR LOCALIZATION,
MULTIPLE
DX Nuclear Medicine
Non-
Advanced
78802
NUCLEAR TUMOR LOCALIZATION,WHOLE
BODY
DX Nuclear Medicine
Non-
Advanced
78803 TOMOGRAPHIC (SPECT) DX Nuclear Medicine
Non-
Advanced
78805
ABSCESS LOCALIZATION OR GALLIUM
SCAN; LIMITED AREA
DX Nuclear Medicine
Non-
Advanced
78806
ABSCESS LOCALIZATION OR GALLIUM
SCAN ; WHOLE BODY
DX Nuclear Medicine
Non-
Advanced
78807 TOMOGRAPHIC (SPECT) DX Nuclear Medicine
Non-
Advanced
78999 NUCLEAR UNLISTED EXAM DX Nuclear Medicine
Non-
Advanced
G0062 peripheral bone densitometry DX Nuclear Medicine
Non-
Advanced
G0063 central bone densitometry DX Nuclear Medicine
Non-
Advanced
483 ECHOCARDIOLOGY Echocardiography
Non-
Advanced
93303 Echo transthoracic Echocardiography
Non-
Advanced
Non-
93304 Echo transthoracic Echocardiography
Advanced

Procedure Code Description Exam Category Copay
Non-
93307 Echo exam of heart Echocardiography
Advanced
93308 Echo exam of heart Echocardiography
Non-
Advanced
93312 Echo transesophageal Echocardiography
Non-
Advanced
93313 Echo transesophageal Echocardiography
Non-
Advanced
93314 Echo transesophageal Echocardiography
Non-
Advanced
93315 Echo transesophageal Echocardiography
Non-
Advanced
93316 Echo transesophageal Echocardiography
Non-
Advanced
93317 Echo transesophageal Echocardiography
Non-
Advanced
93318 Echo transesophageal intraop Echocardiography
Non-
Advanced
93320 Doppler echo exam, heart Echocardiography
Non-
Advanced
93321 Doppler echo exam, heart Echocardiography
Non-
Advanced
93325 Doppler color flow add-on Echocardiography
Non-
Advanced
93350 Echo transthoracic Echocardiography
Non-
Advanced
70370
THROAT OR , PHARYNX OR , LARYNX X-
RAY INCL. FLUOROSCOPY
Fluoroscopy
Non-
Advanced
70373 LARYNGOGRAM ,LARNYNGOGRAPHY Fluoroscopy
Non-
Advanced
74210
74220
74230
74240
74241
74245
74246
74247
74249
74250
CERVICAL ESOPHAGRAM,
PHARYNGOGRAM, CERVICAL ESOPHAGUS Fluoroscopy
BARIUM SWALLOW,ESOPHAGRAM,
ESOPHAGUS X-RAY WITH CONTRAST, Fluoroscopy
CINE OR VIDEO ESOPHAGRAM,
SWALLOWING FUNCTION, PHARYNX Fluoroscopy
UGI,* UPPER GI SERIES, UPPER
GASTROINTESTINAL TRACT,WITHOUT Fluoroscopy
UGI, UPPER GI SERIES, UPPER
GASTROINTESTINAL TRACT, WITH KU Fluoroscopy
UGI, UPPER GI SERIES,WITH SMALL
BOWEL SERIES OR FOLLOW-THRU Fluoroscopy
UGI, UPPER GI SERIES,AIR OR DOUBLE
CONTRAST WITHOUT KUB
Fluoroscopy
UGI, UPPER GI SERIES,AIR OR DOUBLE
CONTRAST WITH KUB
Fluoroscopy
UGI UPPER GI SERIES AIR OR DOUBLE
CONTRAST&SMALL BOWEL SERIE Fluoroscopy
SMALL BOWEL SERIES, SMALL BOWEL
FOLLOW-THROUGH
Fluoroscopy
Non-
Advanced
Non-
Advanced
Non-
Advanced
Non-
Advanced
Non-
Advanced
Non-
Advanced
Non-
Advanced
Non-
Advanced
Non-
Advanced
Non-
Advanced

Procedure Code Description Exam Category Copay
Non-
74260 DUODENOGRAPHY HYPOTONIC Fluoroscopy
Advanced
74270
BARIUM ENEMA*, COLON, SINGLE
CONTRAST COLON OR BARIUM ENEMA, Fluoroscopy
Non-
Advanced
74280
BARIUM ENEMA COLON DOUBLE
CONTRAST,
Fluoroscopy
Non-
Advanced
74430
CYSTOGRAM, CYSTOGRAPHY, CONTRAST
EXAM URINARY BLADDER
Fluoroscopy
Non-
Advanced
76000 FLUOROSCOPY ANY BODY PART Fluoroscopy
Non-
Advanced
76120 Cinematic x-rays Fluoroscopy
Non-
Advanced
G0120 Colon ca scrn; barium enema Fluoroscopy
Non-
Advanced
G0121 Colon ca scrn; barium enema Fluoroscopy
Non-
Advanced
G0122 Colon ca scrn; barium enema Fluoroscopy
Non-
Advanced
76645
ULTRASOUND BREAST ECHO SONOGRAM
UNILAT/BILAT
Gynecological Ultrasound
Non-
Advanced
76856
ULTRASOUND PELVIC NON OBSTETRIC
COMPLETE
Gynecological Ultrasound
Non-
Advanced
76857
ULTRASOUND PELVIC, LIMITED OR
FOLLOW-UP,NON OBSTETRIC
Gynecological Ultrasound
Non-
Advanced
78414 NUCLEAR EXAM OF HEART FLOW Nuclear Cardiology
Non-
Advanced
78428 NUCLEAR EXAM, HEART SHUNT Nuclear Cardiology
Non-
Advanced
78460
MYOCARDIAL OR HEART THALLIUM
PERFUSION; SINGLE STUDY
Nuclear Cardiology
Non-
Advanced
78466
MYOCARDIAL OR HEART MUSCLE IMAGING
INFARCT
Nuclear Cardiology
Non-
Advanced
78468
MYOCARDIAL OR HEART MUSCLE
EJECTION FRACTION
Nuclear Cardiology
Non-
Advanced
76830
ULTRASOUND ENDOVAGINAL
TRANSVAGINAL,TV
OB Ultrasound
Non-
Advanced
0126T Chd risk imt study Other
Non-
Advanced
329 DIAGNOSTIC OTHER RADIOLOGY Other
Non-
Advanced
76071 Ct bone density, peripheral Other
Non-
Advanced
76078 Photodensitometry Other
Non-
Advanced
76150 X-ray exam, dry process Other
Non-
Advanced
76496 Fluoroscopic procedure Other
Non-
Advanced
Nonadvanced
77072 X-RAYS FOR BONE AGE Other

Procedure Code Description Exam Category Copay
Nonadvanced
77079 CT BONE DENSITY, PERIPHERAL other
77081 DXA BONE DENSITY/PERIPHERAL other
Nonadvanced
77082 DXA BONE DENSITY, VERT FX other
Nonadvanced
77083 RADIOGRAPHIC ABSORPTIOMETRY other
Nonadvanced
78456 Acute venous thrombus image Other
Non-
Advanced
93875 Extracranial study Other
Non-
Advanced
93888 Intracranial study Other
Non-
Advanced
93922 Extremity study Other
Non-
Advanced
93923 Extremity study Other
Non-
Advanced
93924 Extremity study Other
Non-
Advanced
93965 Extremity study Other
Non-
Advanced
93980 Penile vascular study Other
Non-
Advanced
93981 Penile vascular study Other
Non-
Advanced
93990 Doppler flow testing Other
Non-
Advanced
G0106 Colon CA screen;barium enema Other
Non-
Advanced
G0389 ULTRASOUND EXAM AAA SCREEN other
Nonadvanced
320 RADIOLOGY, DIAGNOSTIC GENERAL Plain Films
Non-
Advanced
322 ARTHROGRAPHY Plain Films
Non-
Advanced
324 CHEST X-RAY Plain Films
Non-
Advanced
400 OTHER IMAGING SERVICES, GENERAL Plain Films
Non-
Advanced
70030 EYE FOREIGN BODY Plain Films
Non-
Advanced
70100
MANDIBLE OR JAW, LIMITED, LESS THAN 4
VIEWS
Plain Films
Non-
Advanced
70110
MANDIBLE* OR JAW,COMPLETE, MINIMUM
4 VIEWS Plain Films
Non-
Advanced
70120
MASTOIDS LIMITED, LESS THAN 3 VIEWS
PER SIDE
Plain Films
Non-
Advanced
70130
MASTOIDS* COMPLETE, COMPLETE
MINIMUM 3 VIEWS PER SIDE
Plain Films
Non-
Advanced

Procedure Code Description Exam Category Copay
INTERNAL AUDITORY CANALS OR
Non-
70134
MEATI,MIDDLE EAR
Plain Films
Advanced
70140
FACIAL BONES LIMITED, LESS THAN 3
VIEWS
Plain Films
Non-
Advanced
70150
FACIAL BONES* COMPLETE , 3 OR MORE
VIEWS
Plain Films
Non-
Advanced
70160
NASAL BONES OR NOSE, COMPLETE
MINIMUM 3 VIEWS
Plain Films
Non-
Advanced
70190 OPTIC FORAMINA Plain Films
Non-
Advanced
70200
ORBITS, EYE SOCKETS, COMPLETE
MINIMUM 4 VIEWS
Plain Films
Non-
Advanced
70210
SINUSES, PARANASAL SINUSES , WATER'S
VIEW, LIMITED, 2 VIEW
Plain Films
Non-
Advanced
70220
SINUSES*, PARANASAL SINUSES, SINUS
CAVITIES, COMPLETE
Plain Films
Non-
Advanced
70240 SELLA TURCICA, PITUITARY GLAND Plain Films
Non-
Advanced
70250
SKULL OR CRANIUM OR HEAD, LIMITED
LESS THAN 4 VIEWS
Plain Films
Non-
Advanced
70260
SKULL OR CRANIUM OR HEAD, COMPLETE
MINIMUM 4 VIEWS
Plain Films
Non-
Advanced
70300 TEETH , PARTIAL Plain Films
Non-
Advanced
70310 TEETH , MULTIPLE Plain Films
Non-
Advanced
70320 TEETH, FULL MOUTH Plain Films
Non-
Advanced
70328
TMJ, TEMPROMANDIBULAR JOINT, JAW
JOINT, OPEN/CLOSED MOUTH UN
Plain Films
Non-
Advanced
70330
TMJ, TEMPROMANDIBULAR JOINT, JAW
JOINT, OPEN/CLOSED MOUTH BI
Plain Films
Non-
Advanced
70350 CEPHALOGRAM, ORTHODONTIC Plain Films
Non-
Advanced
70355 PANORAMIC X-RAY OF JAWS Plain Films
Non-
Advanced
70360
NECK,SOFT TISSUES, AIRWAY, NECK SOFT
TISSUES
Plain Films
Non-
Advanced
70371
THROAT, PHARYNX, LARYNX, DYNAMIC
SPEECH EVALUATION
Plain Films
Non-
Advanced
70380 SALIVARY GLAND FOR CALCULUS Plain Films
Non-
Advanced
71010
CHEST, ANY SINGLE VIEW CHEST, PA
CHEST,
Plain Films
Non-
Advanced
71015 CHEST STEREO Plain Films
Non-
Advanced
71020
CHEST* PA AND LAT 2 VIEW, AP AND
LATERAL
Plain Films
Non-
Advanced
Non-
71021 CHEST 2 VIEWS WITH APICAL LORDOTIC, Plain Films
Advanced

Procedure Code Description Exam Category Copay
CHEST TWO VIEWS OR PA AND LAT WITH
Non-
71022
OBLIQUES
Plain Films
Advanced
71023
CHEST PA AND LAT OR TWO VIEWS WITH
FLUOROSCOPY
Plain Films
Non-
Advanced
71030 CHEST WITH OBLIQUES 4 VIEWS Plain Films
Non-
Advanced
71034
CHEST COMPLETE 4 VIEWS WITH
FLUOROSCOPY
Plain Films
Non-
Advanced
71035
CHEST WITH SPECIAL VIEWS , BUCKY, LAT
DECUBITUS VIEWS,
Plain Films
Non-
Advanced
71100 RIBS UNILATERAL, 2 VIEWS Plain Films
Non-
Advanced
71101 RIBS UNILAT AND PA CHEST, 3 VIEWS Plain Films
Non-
Advanced
71110 RIBS* BILATERAL 3 VIEWS Plain Films
Non-
Advanced
71111 RIBS BILATERAL AND PA CHEST Plain Films
Non-
Advanced
71120
STERNUM, BREASTBONE, MINIMUM 2
VIEWS
Plain Films
Non-
Advanced
71130
STERNOCLAVICULAR JOINT OR JOINTS
MINIMUM 3 VIEWS
Plain Films
Non-
Advanced
72010
SPINE ENTIRE FULL AP AND LAT, SPINE
SURVEY
Plain Films
Non-
Advanced
72020 SPINE SINGLE VIEW ANY LEVEL Plain Films
Non-
Advanced
72040
CERVICAL SPINE LIMITED OR AP AND
LATERAL, 2 VIEW CERVICAL SP
Plain Films
Non-
Advanced
72050 C-SPINE Plain Films
Non-
Advanced
72052
COMPLETE WITH FLEXION AND
EXTENSION VIEWS,
Plain Films
Non-
Advanced
72069
THORACO-LUMBAR SPINE, ERECT
SCOLIOSIS
Plain Films
Non-
Advanced
72070 T-SPINE Plain Films
Non-
Advanced
72072
THORACIC SPINE, 3 VIEW, AP AND LAT
AND SWIMMERS VIEW .
Plain Films
Non-
Advanced
72074
THORACIC SPINE , UPPER BACK,4 VIEW
WITH OBLIQUES
Plain Films
Non-
Advanced
72080 THORACOLUMBAR JUNCTION, T-L SPINE Plain Films
Non-
Advanced
72090
SPINE SCOLOSIS STUDY, SUPINE AND
ERECT AP VIEWS
Plain Films
Non-
Advanced
72100
LUMBAR SPINE LUMBOSACRAL SPINE
LIMITED AP AND LAT
Plain Films
Non-
Advanced
72110 L-SPINE Plain Films
Non-
Advanced
72114
LUMBAR SPINE LUMBOSACRAL SPINE
COMPLETE WITH BENDING VIEWS Plain Films
Non-
Advanced

Procedure Code Description Exam Category Copay
LUMBAR SPINE LUMBOSACRAL SPINE
Non-
72120
,BENDING VIEWS ONLY
Plain Films
Advanced
72170 PELVIS* AP, PELVIS PA, PELVIS 1 VIEW Plain Films
Non-
Advanced
72190 PELVIS COMPLETE MINIMUM 3 VIEWS Plain Films
Non-
Advanced
72200
SI JOINTS, SACROILIAC JOINTS, LESS
THAN 3 VIEWS , LIMITED
Plain Films
Non-
Advanced
72202
SI JONTS*, SACROILIAC JOINTS,
COMPLETE 3 OR MORE VIEWS
Plain Films
Non-
Advanced
72220
SACRUM AND COCCYX, TAILBONE [
MINIMUM 2 VIEWS]
Plain Films
Non-
Advanced
73000 CLAVICLE OR , COLLARBONE COMPLETE Plain Films
Non-
Advanced
73010 SCAPULA, SHOULDER BLADE COMPLETE Plain Films
Non-
Advanced
73020 SHOULDER, 1 VIEW OR LIMITED Plain Films
Non-
Advanced
Non-
73030 SHOULDER*, COMPLETE MINIMUM 2 VIEWS Plain Films
Advanced
ACROMIOCLAVICULAR JTS, A-C JOINTS,
Non-
73050
BILATERAL WITH OR WITHOUT
Plain Films
Advanced
73060 HUMERUS, ARM, UPPER ARM Plain Films
Non-
Advanced
73070
ELBOW LIMITED, AP AND LAT ELBOW, 2
VIEW ELBOW
Plain Films
Non-
Advanced
73080 ELBOW*,COMPLETE MINIMUM 3 VIEWS. Plain Films
Non-
Advanced
73090 FOREARM, RADIUS AND ULNA, RADIUS, Plain Films
Non-
Advanced
73092 UPPER EXTREMITY OF CHILD Plain Films
Non-
Advanced
73100 WRIST, LIMITED OR AP AND LAT Plain Films
Non-
Advanced
73110 WRIST*, COMPLETE MINIMUM 3 VIEWS Plain Films
Non-
Advanced
73120 HAND, LIMITED HAND AP & LAT, 2 VIEW Plain Films
Non-
Advanced
73130
HAND *AP &LAT & OBLIQUE VIEWS,
MINIMUM 3 VIEWS,
Plain Films
Non-
Advanced
73140 FINGER OR FINGERS Plain Films
Non-
Advanced
73500
HIP UNILATERAL 1 VIEW, LIMITED HIP
UNILATERAL
Plain Films
Non-
Advanced
73510
HIP* UNILATERAL MINIMUM 2 VIEWS OR
COMPLETE.
Plain Films
Non-
Advanced
73520
HIPS, BILATERAL HIPS, HIPS AND AP OR 1
VIEW PELVIS
Plain Films
Non-
Advanced
Non-
73530 DURING OPERATION HIP X-RAY Plain Films
Advanced

Procedure Code Description Exam Category Copay
PELVIS AND HIPS INFANT OR CHILD, 2
Non-
73540
VIEWS AP AND FROG LEG
Plain Films
Advanced
73542 X-ray exam, sacroiliac joint Plain Films
Non-
Advanced
73550 FEMUR, THIGH, UPPER LEG, Plain Films
Non-
Advanced
73560
KNEE AP&LAT LIMITED KNEE, 2 VIEW
KNEE
Plain Films
Non-
Advanced
73562 KNEE AP LAT OBLIQUE MINIMUM 3 VIEW, Plain Films
Non-
Advanced
73564
KNEE* COMPLETE OBLIQUES TUNNEL
VIEWS PATELLAR /STANDING VIEW Plain Films
Non-
Advanced
73565 KNEES STANDING AP VIEW Plain Films
Non-
Advanced
73590 LOWER LEG, TIBIA AND FIBULA, SHIN Plain Films
Non-
Advanced
73592
INFANT LEG INCLUDES UPPER AND
LOWER
Plain Films
Non-
Advanced
73600
ANKLE 2 VIEW , AP AND LATERAL ANKLE,
LIMITED ANKLE
Plain Films
Non-
Advanced
73610
ANKLE,* 3 VIEW, AP AND OBLIQUE AND
LATERAL
Plain Films
Non-
Advanced
73620
FOOT AP AND LATERAL OR 2 VIEW FOOT
OR LIMITED FOOT
Plain Films
Non-
Advanced
73630
FOOT*,COMPLETE, 3 VIEW FOOT , AP LAT
AND OBLIQUE VIEWS,
Plain Films
Non-
Advanced
73650
HEEL, OS CALCIS, CALCANEUS MINIMUM 2
VIEWS
Plain Films
Non-
Advanced
73660 TOE OR TOES Plain Films
Non-
Advanced
74000 KUB ABDOMEN 1 VIEW Plain Films
Non-
Advanced
74010
ABDOMEN AP & ADDITIONAL VIEW*, 2
VIEW, SUPINE&ERECT,UPRIGHT
Plain Films
Non-
Advanced
74020
ABDOMINAL 4 VIEW SERIES COMPLETE,
ERECT SUPINE& DECUBITUS
Plain Films
Non-
Advanced
74022
ABDOMINAL SERIES COMPLETE AND
UPRIGHT PA CHEST
Plain Films
Non-
Advanced
74290
GALL BLADDER X-RAY,ORAL
CHOLECYSTOGRAM, SINGLE DOSE Plain Films
Non-
Advanced
74291
GALL BLADDER X-RAY,ORAL
CHOLECYSTOGRAM,, DOUBLE DOSE OR
REPE
Plain Films
Non-
Advanced
74400
IVP*, INTRAVENOUS PYLOGRAM,
EXCRETORY UROGRAM, KIDNEY X-RAY, Plain Films
Non-
Advanced
74405
IVP OR , INTRAVENOUS PYLOGRAM OR
,WITH HYPERTENSIVE SEQUENCE Plain Films
Non-
Advanced
74410
IVP OR , INTRAVENOUS PYLOGRAM OR
WITH INFUSION TECHNIQUE
Plain Films
Non-
Advanced
74415
IVP OR, INTRAVENOUS PYLOGRAM WITH
TOMOGRAMS/NEPHROTOMOGRAMS. Plain Films
Non-
Advanced

Procedure Code Description Exam Category Copay
Non-
74710 PELVIMETRY, OBSTETRICAL Plain Films
Advanced
76006 X-ray stress view Plain Films
Non-
Advanced
76010
CHILD CHEST AND ABDOMEN AP NOSE TO
RECTUM, SINGLE VIEW
Plain Films
Non-
Advanced
76020
BONE AGE STUDY, HAND AND WRIST FOR
BONE AGE.
Plain Films
Non-
Advanced
76040
BONE LENGTH STUDY, SCANOGRAM, LEG
LENGTH STUDY
Plain Films
Non-
Advanced
76061 LIMITED METASTATIC BONE SURVEY, Plain Films
Non-
Advanced
76062 METASTATIC BONE SURVEY Plain Films
Non-
Advanced
76065 BONE SURVEY INFANT, Plain Films
Non-
Advanced
76066
JOINT SURVEY, SINGLE VIEW ONE OR
MORE JOINTS
Plain Films
Non-
Advanced
76100
TOMOGRAPHY OR PLANOGRAPHY ANY
BODY PART.
Plain Films
Non-
Advanced
76101
RADIOLOGICAL EXAMINATION, SURGICAL
SPECIMEN
Plain Films
Non-
Advanced
76102
POLY-TOMOGRAPHY, COMPLEX MOTION
TOMOGRAPHY ANY BODY PART
Plain Films
Non-
Advanced
76125
CINDERADIOGRAPHY, EXCEPT WHERE
SPECIFICALLY INCLUDED
Plain Films
Non-
Advanced
77071 X-RAY STRESS VIEW plain films
Nonadvanced
77073 X-RAYS BONE LENGTH STUDIES plain films
Nonadvanced
77074 X-RAYS BONE SURVEY, LIMITED plain films
Nonadvanced
77075 X-RAYS BONE SURVEY COMPLETE plain films
Nonadvanced
77076 X-RAYS BONE SURVEY, INFANT plain films
Nonadvanced
77077 JOINT SURVEY, SINGLE VIEW plain films
Nonadvanced
D0350 Oral/facial images Plain Films
Non-
Advanced
G0188 Xray lwr extrmty-full lngth Plain Films
Non-
Advanced
76776 US EXAM K TRANSPLANT W/DOPPLER Ultrasound
Nonadvanced
76813 OB US NUCHAL MEAS, 1 GEST Ultrasound
Nonadvanced
76814 OB US NUCHAL MEAS, ADD-ON Ultrasound
Nonadvanced
Non-
402 ULTRASOUND Ultrasound General
Advanced

Procedure Code Description Exam Category Copay
HEAD BRAIN UTLRASOUND, ECHO,
Non-
76506
SONOGRAM
Ultrasound General
Advanced
76510 Ophth us, b & quant a Ultrasound General
Non-
Advanced
76511
OPTHALMIC, EYE
ULTRASOUND,ECHO,SONOGRAM A-SCAN Ultrasound General
Non-
Advanced
76512
OPTHALMIC,EYE, ULTRASOUND,ECHO,
SONOGRAM B-SCAN
Ultrasound General
Non-
Advanced
76513 Echo exam of eye, water bath Ultrasound General
Non-
Advanced
76514 Echo exam of eye, thickness Ultrasound General
Non-
Advanced
76516 Echo exam of eye Ultrasound General
Non-
Advanced
76519 Echo exam of eye Ultrasound General
Non-
Advanced
76529 Echo exam of eye Ultrasound General
Non-
Advanced
76536
ULTRASOUND THYROID NECK ECHO
SONOGRAM
Ultrasound General
Non-
Advanced
76604 CHEST ULTRASOUND,ECHO,SONOGRAM Ultrasound General
Non-
Advanced
76700
ULTRASOUND ABDOMINAL* ECHO
SONOGRAM COMPLETE
Ultrasound General
Non-
Advanced
76705
ULTRASOUND ABDOMINAL LIMITED LIVER,
GALL BLADDER , PANCREAS
Ultrasound General
Non-
Advanced
76770
ULTRASOUND AORTIC RENAL
RETROPERITONEAL NODES COMPLETE Ultrasound General
Non-
Advanced
76775
RETROPERITONEAL OR BACK WALL
LIMITED ULTRASOUND
Ultrasound General
Non-
Advanced
76778
ULTRASOUND RENAL OR KIDNEY
TRANSPLANT
Ultrasound General
Non-
Advanced
76800 SPINAL CANAL ULTRASOUND Ultrasound General
Non-
Advanced
76831 Echo exam, uterus Ultrasound General
Non-
Advanced
76870
ULTRASOUND SCROTAL TESTICULAR
ECHO SONOGRAM
Ultrasound General
Non-
Advanced
76872 ULTRASOUND PROSTATE TRANSRECTAL Ultrasound General
Non-
Advanced
76873 Echograp trans r, pros study Ultrasound General
Non-
Advanced
76880
EXTREMITY ULTRASOUND, NON
VASCULAR
Ultrasound General
Non-
Advanced
76885 Echo exam, infant hips Ultrasound General
Non-
Advanced
76886 Echo exam, infant hips Ultrasound General
Non-
Advanced
76970
ULTRASOUND OR ECHO FOLLOW-UP
STUDY ANY AREA
Ultrasound General
Non-
Advanced

Procedure Code Description Exam Category Copay
Non-
93880 ULTRASOUND CAROTID ARTERY Ultrasound General
Advanced
93882 Extracranial study Ultrasound General
Non-
Advanced
93886 Intracranial study Ultrasound General
Non-
Advanced
93925 Lower extremity study Ultrasound General
Non-
Advanced
93926 Lower extremity study Ultrasound General
Non-
Advanced
93930 Upper extremity study Ultrasound General
Non-
Advanced
93931 Upper extremity study Ultrasound General
Non-
Advanced
93970
ULTRASOUND VENOUS DOPPLER
EXTREMETRIES
Ultrasound General
Non-
Advanced
93971 Extremity study Ultrasound General
Non-
Advanced
93975 Vascular study Ultrasound General
Non-
Advanced
93976 Vascular study Ultrasound General
Non-
Advanced
93978 Vascular study Ultrasound General
Non-
Advanced
93979 Vascular study Ultrasound General
Non-
Advanced
G0050 Residual urine by ultrasound Ultrasound General
Non-
Advanced
0005T Perc Cath stent/brain cv art Angiography/ Interventional Exempt
0006T Perc Cath stent/brain cv art Angiography/ Interventional Exempt
0007T Perc Cath stent/brain cv art Angiography/ Interventional Exempt
20501 INJECTION SONOGRAM Angiography/ Interventional Exempt
23350 INJECTION SHOULDER Angiography/ Interventional Exempt
24220 INJECTION ELBOW Angiography/ Interventional Exempt
25246 INJECTION WRIST Angiography/ Interventional Exempt
27093 INJECTION HIP Angiography/ Interventional Exempt
27370 INJECTION KNEE Angiography/ Interventional Exempt
34800 Endovasc abdo repair w/tube Angiography/ Interventional Exempt
34802 Endovasc abdo repr w/device Angiography/ Interventional Exempt
34804 Endovasc abdo repr w/device Angiography/ Interventional Exempt
34808 Endovasc abdo occlud device Angiography/ Interventional Exempt
34825 Endovasc extend prosth, init Angiography/ Interventional Exempt
34826 Endovasc exten prosth, addl Angiography/ Interventional Exempt
36597 Reposition veExemptus Catheter Angiography/ Interventional Exempt
37203 TransCatheter retrieval Angiography/ Interventional Exempt
37204 TransCatheter occlusion Angiography/ Interventional Exempt
37205 TransCatheter stent Angiography/ Interventional Exempt
37206 TransCatheter stent add-on Angiography/ Interventional Exempt
37207 TransCatheter stent Angiography/ Interventional Exempt
37208 TransCatheter stent add-on Angiography/ Interventional Exempt
42550 INJECTION SIALOGRAM Angiography/ Interventional Exempt

Procedure Code Description Exam Category Copay
50394 INJECTION KIDNEY Angiography/ Interventional Exempt
50684 INJECTION URETER Angiography/ Interventional Exempt
50690 INJECTION LEAL CONDUIT Angiography/ Interventional Exempt
51600 INJECTION BLADDER Angiography/ Interventional Exempt
58340 INJECTION HYSTERO Angiography/ Interventional Exempt
61623 Endovasc tempory vessel occl Angiography/ Interventional Exempt
CHEST FILMS AND FLUROSCOPY
GUIDANCE NEEDLE BIOPSY Angiography/ Interventional Exempt
71036
71090 PACEMAKER INSERTION Angiography/ Interventional Exempt
74235 REMOVE ESOPHAGEAL FOREIGN BODY Angiography/ Interventional Exempt
74300 CHOLANGIOGRAM IN SURGERY Angiography/ Interventional Exempt
74305 CHOLANGIOGRAM, POST-OPERATIVE Angiography/ Interventional Exempt
74327 X-RAY FOR BILE STONE REMOVAL Angiography/ Interventional Exempt
74340 X-RAY GUIDE FOR GI TUBE Angiography/ Interventional Exempt
74350 X-RAY GUIDE, STOMACH TUBE Angiography/ Interventional Exempt
74355 X-RAY GUIDE, INTESTINAL TUBE Angiography/ Interventional Exempt
74360 X-RAY GUIDE, GI DILATION Angiography/ Interventional Exempt
74363 X-RAY, BILE DUCT DILATATION Angiography/ Interventional Exempt
74475 X-RAY CONTROL Catheter INSERT Angiography/ Interventional Exempt
75893 VENOUS SAMPLING BY Catheter Angiography/ Interventional Exempt
STEREOTACTIC BREAST BIOPSY/ FINE OR
CORE NEEDLE Angiography/ Interventional Exempt
76095
76096 BREAST NEEDLE LOCALIZATION Angiography/ Interventional Exempt
76013 Percut vertebroplasty, CT Computerized Tomography Exempt
76360 CT GUIDANCE FOR NEEDLE BIOPSY Computerized Tomography Exempt
76362 CT scan for tissue ablation Computerized Tomography Exempt
76365 CT GUIDANCE FOR CYST ASPIRATION Computerized Tomography Exempt
76370 CT GUIDANCE FOR RADIATION FIELDS Computerized Tomography Exempt
77078 CT BONE DENSITY, AXIAL DEXA Exempt
77080 DXA BONE DENSITY, AXIAL DEXA Exempt
78890
GENERATION OF AUTOMATED DATA;
INTERACTIVE PROCESS INVOLVING DX Nuclear Medicine Exempt
78891
COMPLEX MANIPULATIONS AND
INTERPRETATION, EXCEEDING 30 MINUT DX Nuclear Medicine Exempt
76826
ECHO EXAM, FETAL HEART; FOLLOW UP
OR REPEAT Echocardiography Exempt
76827
ECHO EXAM, FETAL HEART; DOPPLER,
PULSED WAVE A/O CONTIN. WAV Echocardiography Exempt
76828
ECHO EXAM, FETAL HEART; FOLLOW UP
OR REPEAT Echocardiography Exempt
19102 Bx breast percut w/image Fluoroscopy Exempt
19103 Bx breast percut w/device Fluoroscopy Exempt
71038
CHEST FLUROSCOPY FOR
TRANSBRONCHIAL BRUSH/BIOPSY Fluoroscopy Exempt
BARIUM ENEMA THERAPEUTIC FOR
INTUSSECPTION Fluoroscopy Exempt
74283
74480 Xray control Catheter insert Fluoroscopy Exempt
74485 X-ray guide, GU dilation Fluoroscopy Exempt
75998 Fluoroguide for vein device Fluoroscopy Exempt
76001
FLUOROSCOPY, PHYSICIAN TIME MORE
THAN ONE HOUR, ASSISTING A Fluoroscopy Exempt

Procedure Code Description Exam Category Copay
FLUOROSCOPIC LOCALIZATION FOR
76003
NEEDLE BIOPSY OR FINE NEEDLE A Fluoroscopy Exempt
76005 Fluoroguide for spine inject Fluoroscopy Exempt
76012 Percut vertebroplasty fluor Fluoroscopy Exempt
76393 MR guidance for needle place Magnetic Resonance Imaging Exempt
76394 MRI for tissue ablation Magnetic Resonance Imaging Exempt
77051 COMPUTER DX MAMMOGRAM ADD-ON Mammography Exempt
77052 COMP SCREEN MAMMOGRAM ADD-ON Mammography Exempt
77057 MAMMOGRAM, SCREENING Mammography Exempt
78990 PROVIDE RADIOISOTOPE(S) Nuclear Cardiology Exempt
93015 Cardiovascular stress test Nuclear Cardiology Exempt
93016 Cardiovascular stress test Nuclear Cardiology Exempt
93017 Cardiovascular stress test Nuclear Cardiology Exempt
93018 Cardiovascular stress test Nuclear Cardiology Exempt
76801 Ob us < 14 wks, single fetus OB Ultrasound Exempt
76802 Ob us < 14 wks, addl fetus OB Ultrasound Exempt
76805
ULTRASOUND OBSTETRICAL * PREGNANT
UTERUS COMPLETE OB Ultrasound Exempt
76810
ULTRASOUND OBSTETRIC PREGNANT
UTERUS,TWINS OB Ultrasound Exempt
76811 Ob us, detailed, sngl fetus OB Ultrasound Exempt
76812 Ob us, detailed, addl fetus OB Ultrasound Exempt
76815
ULTRASOUND OBSTETRICAL LIMITED ,
AGE, HEART BEAT,PLACENTA, P OB Ultrasound Exempt
76816
ULTRASOUND OBSTETRICAL OB
ULTRASOUND OR ECHO, FOLLOW-UP /REP OB Ultrasound
Exempt
76817 Transvaginal us, obstetric OB Ultrasound Exempt
76818
ULTRASOUND OBSTETRICAL ECHO
PREGNANT UTERUS BIOPHYSICAL PRO OB Ultrasound Exempt
76819 Fetl biophys profil w/o strs OB Ultrasound Exempt
76825 FETAL ECHOCARDIOGRAM OB Ultrasound Exempt
76945 CHORIONIC VILLUS SAMPLING OB Ultrasound Exempt
ULTRASOUND GUIDANCE FOR
76946
AMNIOCENTESIS OB Ultrasound Exempt
0082T Stereotactic rad delivery Other Exempt
0083T Stereotactic rad tx mngmt Other Exempt
0174T CAD CXR WITH INTERP Other Exempt
0175T CAD CXR REMOTE other Exempt
10022 Fna w/image Other Exempt
PHARMACY, DRUGS INCIDENT TO
RADIOLOGY Other Exempt
255
330 Therapeutic Radiology General Other Exempt
331 Therapeutic Radiology Chemotherapy Inject Other Exempt
332 Therapeutic Radiology Oral Chemo Other Exempt
333 Therapeutic Radiology Radiation Therapy Other Exempt
335 Therapeutic Radiology IV Chemo Other Exempt
339 Therapeutic Radiology Other Other Exempt
342 Nuclear Medicine Therapeutic Other Exempt
36000 Place needle in vein Other Exempt
36005 Injection, venography Other Exempt

Procedure Code Description Exam Category Copay
36010 Place Catheter in vein Other Exempt
36011 Place Catheter in vein Other Exempt
36012 Place Catheter in vein Other Exempt
36013 Place Catheter in artery Other Exempt
36014 Place Catheter in artery Other Exempt
36015 Place Catheter in artery Other Exempt
36100 Establish access to artery Other Exempt
36120 Establish access to artery Other Exempt
36140 Establish access to artery Other Exempt
36145 Artery to vein shunt Other Exempt
36160 Establish access to aorta Other Exempt
36200 Place Catheter in aorta Other Exempt
36215 Place Catheter in artery Other Exempt
36216 Place Catheter in artery Other Exempt
36217 Place Catheter in artery Other Exempt
36218 Place Catheter in artery Other Exempt
36245 Place Catheter in artery Other Exempt
36246 Place Catheter in artery Other Exempt
36247 Place Catheter in artery Other Exempt
36248 Place Catheter in artery Other Exempt
371 ANESTHESIA, INCIDENT TO RADIOLOGY Other Exempt
37250 Intravascular us Other Exempt
37251 Intravascular us Other Exempt
47560 Laparoscopy w/cholangio Other Exempt
47561 Laparo w/cholangio/biopsy Other Exempt
621 Med/Surg Supplies Incident. to Radiology Other Exempt
62284 Injection for myelogram Other Exempt
62290 Inject for spine disk x-ray Other Exempt
62291 Inject for spine disk x-ray Other Exempt
68850 Injection for tear sac x-ray Other Exempt
72291 PERQ VERTEBROPLASTY, FLUOR Other Exempt
72292 PERQ VERTEBROPLASTY, CT Other Exempt
75956 Xray, endovasc thor ao repr Other Exempt
75957 Xray, endovasc thor ao repr Other Exempt
75958 Xray, place prox ext thor ao Other Exempt
75959 Xray, place dist ext thor ao Other Exempt
76376 3d render w/o postprocess Other Exempt
76377 3d rendering w/postprocess Other Exempt
76998 US GUIDE, INTRAOP Other Exempt
77001 FLUOROGUIDE FOR VEIN DEVICE Other Exempt
77002 NEEDLE LOCALIZATION BY X-RAY Other Exempt
77003 FLUOROGUIDE FOR SPINE INJECT Other Exempt
77031 STEREOTACT GUIDE FOR BRST BX Other Exempt
77032 GUIDANCE FOR NEEDLE, BREAST Other Exempt
77261 Radiation therapy planning Other Exempt
77262 Radiation therapy planning Other Exempt
77263 Radiation therapy planning Other Exempt
77280 Set radiation therapy field Other Exempt
77285 Set radiation therapy field Other Exempt
77290 Set radiation therapy field Other Exempt
77295 Set radiation therapy field Other Exempt

Procedure Code Description Exam Category Copay
77299 Radiation therapy planning Other Exempt
77300 Radiation therapy dose plan Other Exempt
77301 Radioltherapy dos plan, imrt Other Exempt
77305 Radiation therapy dose plan Other Exempt
77310 Radiation therapy dose plan Other Exempt
77315 Radiation therapy dose plan Other Exempt
77321 Radiation therapy port plan Other Exempt
77326 Radiation therapy dose plan Other Exempt
77327 Radiation therapy dose plan Other Exempt
77328 Radiation therapy dose plan Other Exempt
77331 Special radiation dosimetry Other Exempt
77332 Radiation treatment aid(s) Other Exempt
77333 Radiation treatment aid(s) Other Exempt
77334 Radiation treatment aid(s) Other Exempt
77336 Radiation physics consu Other Exempt
77370 Radiation physics consult Other Exempt
77380 Proton beam delivery Other Exempt
77381 Proton beam treatment Other Exempt
77399 External radiation dosimetry Other Exempt
77401 Radiation treatment delivery Other Exempt
77402 Radiation treatment delivery Other Exempt
77403 Radiation treatment delivery Other Exempt
77404 Radiation treatment delivery Other Exempt
77406 Radiation treatment delivery Other Exempt
77407 Radiation treatment delivery Other Exempt
77408 Radiation treatment delivery Other Exempt
77409 Radiation treatment delivery Other Exempt
77411 Radiation treatment delivery Other Exempt
77412 Radiation treatment delivery Other Exempt
77413 Radiation treatment delivery Other Exempt
77414 Radiation treatment delivery Other Exempt
77416 Radiation treatment delivery Other Exempt
77417 Radiology port film(s) Other Exempt
77418 Radiation tx delivery, imrt Other Exempt
77419 Weekly radiation therapy Other Exempt
77420 Weekly radiation therapy Other Exempt
77421 Stereoscopic x-ray guidance Other Exempt
77422 Neutron beam tx, simple Other Exempt
77423 Neutron beam tx, complex Other Exempt
77425 Weekly radiation therapy Other Exempt
77427 Radiation tx management, x5 Other Exempt
77430 Weekly radiation therapy Other Exempt
77431 Radiation therapy management Other Exempt
77432 Stereotactic radiation trmt Other Exempt
77470 Special radiation treatment Other Exempt
77499 Radiation therapy management Other Exempt
77520 Proton trmt, simple w/o comp Other Exempt
77522 Proton trmt, simple w/comp Other Exempt
77523 Proton trmt, intermediate Other Exempt
77525 Proton treatment, complex Other Exempt
77600 Hyperthermia treatment Other Exempt

Procedure Code Description Exam Category Copay
77605 Hyperthermia treatment Other Exempt
77610 Hyperthermia treatment Other Exempt
77615 Hyperthermia treatment Other Exempt
77620 Hyperthermia treatment Other Exempt
77750 Infuse radioactive materials Other Exempt
77761 Radioelement application Other Exempt
77762 Radioelement application Other Exempt
77763 Radioelement application Other Exempt
77776 Radioelement application Other Exempt
77777 Radioelement application Other Exempt
77778 Radioelement application Other Exempt
77781 High intensity brachytherapy Other Exempt
77782 High intensity brachytherapy Other Exempt
77783 High intensity brachytherapy Other Exempt
77784 High intensity brachytherapy Other Exempt
77789 Radioelement application Other Exempt
77790 Radioelement handling Other Exempt
77799 Radium/radioisotope therapy Other Exempt
78267 Breath tst attain/anal c-14 Other Exempt
78268 Breath test analysis, c-14 Other Exempt
Radiofrequency energy to anus to create
thermal lesions Other Exempt
C9716
C9725 Place endorectal app Other Exempt
G0338 Linear accelerator stero pln Other Exempt
G0339 Robot lin-radsurg com, first Other Exempt
G0340 Robt lin-radsurg fractx 2-5 Other Exempt
R0070 Transport portable x-ray Other Exempt
R0075 Transport port x-ray multipl Other Exempt
S8060 Supply of contrast material Other Exempt
19030 Injection for breast x-ray Plain Films Exempt
74301 ADDITIONAL X-RAYS AT SURGERY Plain Films Exempt
76490 Us for tissue ablation Ultrasound General Exempt
76820 Umbilical artery echo Ultrasound General Exempt
76821 Middle cerebral artery echo Ultrasound General Exempt
76932
ULTRASOUND GUIDANCE FOR
MYOCARDIAL BIOPSY Ultrasound General Exempt
76934
ULTRASOUND GUIDANCE
THORACENTESIS Ultrasound General Exempt
76937 Us guide, vascular access Ultrasound General Exempt
76942
ULTRASOUND GUIDANCE FOR NEEDLE
BIOPSY Ultrasound General Exempt
76948
ULTRASOUND GUIDANCE FOR ASPIRATION
OF OVA Ultrasound General Exempt
GASTROINTESTINAL ENDOSCOPIC
ULTRASOUND Ultrasound General Exempt
76975
76986 ULTRASOUND AT SURGERY Ultrasound General Exempt
G0161 Echo guide for cryo probes Ultrasound General Exempt