Magnetic Resonance (Eg, Proton) Imaging, Temporomandibular Joint(S) MRI

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1 High Tech Radiology and s (Sorted by s) # Full Description Magnetic Resonance (Eg, Proton) Imaging, Temporomandibular Joint(S) Computed Tomography, Head Or Brain; Without Contrast Material Computed Tomography, Head Or Brain; With Computed Tomography, Head Or Brain; Without Contrast Material, Followed By And Further Sections Computed Tomography, Orbit, Sella, Or Posterior Fossa Or Outer, Middle, Or Inner Ear; Without Contrast Material Computed Tomography, Orbit, Sella, Or Posterior Fossa Or Outer, Middle, Or Inner Ear; With Computed Tomography, Orbit, Sella, Or Posterior Fossa Or Outer, Middle, Or Inner Ear; Without Contrast Material, Followed By And Further Sections Computed Tomography, Maxillofacial Area; Without Contrast Material Computed Tomography, Maxillofacial Area; With Computed Tomography, Maxillofacial Area; Without Contrast Material, Followed By And Further Sections Computed Tomography, Soft Tissue Neck; Without Contrast Material Computed Tomography, Soft Tissue Neck; With Computed Tomography, Soft Tissue Neck; Without Contrast Material Followed By And Further Sections Computed Tomographic Angiography, Head, With, Including Computed Tomographic Angiography, Neck, With, Including Magnetic Resonance (Eg, Proton) Imaging, Orbit, Face, And/Or Neck; Without Contrast Magnetic Resonance (Eg, Proton) Imaging, Orbit, Face, And/Or Neck; With Contrast Magnetic Resonance (Eg, Proton) Imaging, Orbit, Face, And/Or Neck; Without Contrast, Followed By And Further Sequences Magnetic Resonance Angiography, Head; Without Magnetic Resonance Angiography, Head; With Magnetic Resonance Angiography, Head; Without, Followed By And Further Sequences Magnetic Resonance Angiography, Neck; Without Magnetic Resonance Angiography, Neck; With Magnetic Resonance Angiography, Neck; Without, Followed By And Further Sequences Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem); Without Contrast Material 1 of 7

2 High Tech Radiology and s (Sorted by s) Full Description Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem); With Contrast Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem); Without Contrast Material, Followed By And Further Sequences Magnetic Resonance Imaging, Brain, Functional Mri; Including Test Selection And Administration Of Repetitive Body Part Movement And/Or Visual Stimulation, Not Requiring Physician Or Psychologist Administration Magnetic Resonance Imaging, Brain, Functional Mri; Requiring Physician Or Psychologist Administration Of Entire Neurofunctional Testing Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem And Skull Base), During Open Intracranial Procedure (Eg, To Assess For Residual Tumor Or Residual Vascular Malformation); Without Contrast Material Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem And Skull Base), During Open Intracranial Procedure (Eg, To Assess For Residual Tumor Or Residual Vascular Malformation); With Magnetic Resonance (Eg, Proton) Imaging, Brain (Including Brain Stem And Skull Base), During Open Intracranial Procedure (Eg, To Assess For Residual Tumor Or Residual Vascular Malformation); Without, Followed By Contrast And Further Sequences Computed Tomography, Thorax; Without Contrast Material Computed Tomography, Thorax; With Computed Tomography, Thorax; Without Contrast Material, Followed By Contrast And Further Sections Computed Tomographic Angiography, Chest (Noncoronary), With, Including Magnetic Resonance (Eg, Proton) Imaging, Chest (Eg, For Evaluation Of Hilar And Mediastinal Lymphadenopathy); Without Magnetic Resonance (Eg, Proton) Imaging, Chest (Eg, For Evaluation Of Hilar And Mediastinal Lymphadenopathy); With Magnetic Resonance (Eg, Proton) Imaging, Chest (Eg, For Evaluation Of Hilar And Mediastinal Lymphadenopathy); Without, Followed By Contrast And Further Sequences Magnetic Resonance Angiography, Chest (Excluding Myocardium), With Or Without Computed Tomography, Cervical Spine; Without Contrast Material Computed Tomography, Cervical Spine; With Contrast Material Computed Tomography, Cervical Spine; Without Contrast Material, Followed By And Further Sections Computed Tomography, Thoracic Spine; Without Contrast Material Computed Tomography, Thoracic Spine; With Contrast Material Computed Tomography, Thoracic Spine; Without Contrast Material, Followed By And Further Sections Computed Tomography, Lumbar Spine; Without Contrast Material 2 of 7

3 High Tech Radiology and s (Sorted by s) # Full Description Computed Tomography, Lumbar Spine; With Contrast Material Computed Tomography, Lumbar Spine; Without Contrast Material, Followed By And Further Sections Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Cervical; Without Contrast Material Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Cervical; With Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Thoracic; Without Contrast Material Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Thoracic; With Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Lumbar; Without Contrast Material Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Lumbar; With Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Without Contrast Material, Followed By And Further Sequences; Cervical Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Without Contrast Material, Followed By And Further Sequences; Thoracic Magnetic Resonance (Eg, Proton) Imaging, Spinal Canal And Contents, Without Contrast Material, Followed By And Further Sequences; Lumbar Magnetic Resonance Angiography, Spinal Canal And Contents, With Or Without Computed Tomographic Angiography, Pelvis, With, Including Computed Tomography, Pelvis; Without Contrast Material Computed Tomography, Pelvis; With Computed Tomography, Pelvis; Without Contrast Material, Followed By Contrast And Further Sections Magnetic Resonance (Eg, Proton) Imaging, Pelvis; Without Magnetic Resonance (Eg, Proton) Imaging, Pelvis; With Magnetic Resonance (Eg, Proton) Imaging, Pelvis; Without, Followed By And Further Sequences Magnetic Resonance Angiography, Pelvis, With Or Without Computed Tomography, Upper Extremity; Without Contrast Material 3 of 7

4 High Tech Radiology and s (Sorted by s) # Full Description Computed Tomography, Upper Extremity; With Computed Tomography, Upper Extremity; Without Contrast Material, Followed By And Further Sections Computed Tomographic Angiography, Upper Extremity, With, Including Magnetic Resonance (Eg, Proton) Imaging, Upper Extremity, Other Than Joint; Without Magnetic Resonance (Eg, Proton) Imaging, Upper Extremity, Other Than Joint; With Magnetic Resonance (Eg, Proton) Imaging, Upper Extremity, Other Than Joint; Without, Followed By And Further Sequences Magnetic Resonance (Eg, Proton) Imaging, Any Joint Of Upper Extremity; Without Magnetic Resonance (Eg, Proton) Imaging, Any Joint Of Upper Extremity; With Magnetic Resonance (Eg, Proton) Imaging, Any Joint Of Upper Extremity; Without, Followed By And Further Sequences Magnetic Resonance Angiography, Upper Extremity, With Or Without Contrast Computed Tomography, Lower Extremity; Without Contrast Material Computed Tomography, Lower Extremity; With Computed Tomography, Lower Extremity; Without Contrast Material, Followed By And Further Sections Computed Tomographic Angiography, Lower Extremity, With, Including Magnetic Resonance (Eg, Proton) Imaging, Lower Extremity Other Than Joint; Without Magnetic Resonance (Eg, Proton) Imaging, Lower Extremity Other Than Joint; With Magnetic Resonance (Eg, Proton) Imaging, Lower Extremity Other Than Joint; Without, Followed By And Further Sequences Magnetic Resonance (Eg, Proton) Imaging, Any Joint Of Lower Extremity; Without Contrast Material Magnetic Resonance (Eg, Proton) Imaging, Any Joint Of Lower Extremity; With Magnetic Resonance (Eg, Proton) Imaging, Any Joint Of Lower Extremity; Without, Followed By And Further Sequences Magnetic Resonance Angiography, Lower Extremity, With Or Without Contrast Computed Tomography, Abdomen; Without Contrast Material Computed Tomography, Abdomen; With 4 of 7

5 High Tech Radiology and s (Sorted by s) Full Description Computed Tomography, Abdomen; Without Contrast Material, Followed By Contrast And Further Sections Computed Tomographic Angiography Abdomen And Pelvis, With Contract ; Including Non-Contrast Images, If Performed, And Image Postprocessing Computed Tomographic Angiography, Abdomen, With, Including Computed Tomography, Abdomen And Pelvis; Without Contrast Material Computed Tomography, Abdomen And Pelvis; With Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By And Further Sections In One Or Both Body Regions Magnetic Resonance (Eg, Proton) Imaging, Abdomen; Without Magnetic Resonance (Eg, Proton) Imaging, Abdomen; With Magnetic Resonance (Eg, Proton) Imaging, Abdomen; Without, Followed By With And Further Sequences Magnetic Resonance Angiography, Abdomen, With Or Without Computed Tomographic (Ct) Colonography, Diagnostic, Including Image Postprocessing; Without Contrast Material Computed Tomographic (Ct) Colonography, Diagnostic, Including Image Postprocessing; With Including Non-Contrast Images, If Performed Computed Tomographic (Ct) Colonography, Screening, Including Image Postprocessing Material; Material; With Stress Imaging , Followed By And Further Sequences; , Followed By And Further Sequences; With Stress Imaging Cardiac Magnetic Resonance Imaging For Velocity Flow Mapping (List Separately In Addition To For Primary Procedure) Computed Tomography, Heart, Without Contrast Material, With Quantitative Evaluation Of Coronary Calcium Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology (Including 3d Image Postprocessing, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed) Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology In The Setting Of Congenital Heart Disease (Including 3d Image Postprocessing, Assessment Of Lv Cardiac Function, Rv Structure And Function And Evaluation Of Venous Structures, If Performed) Computed Tomographic Angiography, Heart, Coronary Arteries And Bypass Grafts (When Present), With Contrast Material, Including 3d Image Postprocessing (Including Evaluation Of Cardiac Structure And Morphology, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed) 5 of 7

6 High Tech Radiology and s (Sorted by s) Full Description Computed Tomographic Angiography, Abdominal Aorta And Bilateral Iliofemoral Lower Extremity Runoff, With, Including Noncontrast Images, If Performed, And Image Postprocessing Computed Tomography, Limited Or Localized Follow-Up Study Magnetic Resonance Spectroscopy Computed Tomography Guidance For Needle Placement (Eg, Biopsy, Aspiration, Injection, Localization Device), Radiological Supervision And Interpretation Computed Tomography Guidance For, And Monitoring Of, Parenchymal Tissue Ablation Magnetic Resonance Guidance For Needle Placement (Eg, For Biopsy, Needle Aspiration, Injection, Or Placement Of Localization Device) Radiological Supervision And Interpretation Magnetic Resonance Guidance For, And Monitoring Of, Parenchymal Tissue Ablation Magnetic Resonance Imaging, Breast, Without And/Or With ; Unilateral Magnetic Resonance Imaging, Breast, Without And/Or With ; Bilateral Myocardial Perfusion Imaging, Tomographic (Spect) (Including Attenuation Correction, Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Single Study, At Rest Or Stress (Exercise Or Pharmacologic) Myocardial Perfusion Imaging, Tomographic (Spect) (Including Attenuation Correction, Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Multiple Studies, At Rest And/Or Stress (Exercise Or Pharmacologic) And/Or Redistribution And/Or Rest Reinjection Myocardial Perfusion Imaging, Planar (Including Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Single Study, At Rest Or Stress (Exercise Or Pharmacologic) Myocardial Perfusion Imaging, Planar (Including Qualitative Or Quantitative Wall Motion, Ejection Fraction By First Pass Or Gated Technique, Additional Quantification, When Performed); Multiple Studies, At Rest And/Or Stress (Exercise Or Pharmacologic) And/Or Redistribution And/Or Rest Reinjection Myocardial Imaging, Positron Emission Tomography (Pet), Metabolic Evaluation Myocardial Imaging, Infarct Avid, Planar; Qualitative Or Quantitative Myocardial Imaging, Infarct Avid, Planar; With Ejection Fraction By First Pass Technique Myocardial Imaging, Infarct Avid, Planar; Tomoggraphic Spect With Or Without Quantification Myocardial Imaging, Infarct Avid, Planar; Tomographic Spect With Or Without Quantification Cardiac Blood Pool Imaging, Gated Equilibrium; Planar, Single Study At Rest Or Stress (Exercise And/Or Pharmacologic), Wall Motion Study Plus Ejection Fraction, With Or Without Additional Quantitative Processing 6 of 7

7 High Tech Radiology and s (Sorted by s) Full Description Cardiac Blood Pool Imaging, Gated Equilibrium; Multiple Studies, Wall Motion Study Plus Ejection Fraction, At Rest And Stress (Exercise And/Or Pharmacologic), With Or Without Additional Quantification Cardiac Blood Pool Imaging (Planar), First Pass Technique; Single Study, At Rest Or With Stress (Exercise And/Or Pharmacologic), Wall Motion Study Plus Ejection Fraction, With Or Without Quantification Cardiac Blood Pool Imaging (Planar), First Pass Technique; Multiple Studies, At Rest And With Stress (Exercise And/Or Pharmacologic), Wall Motion Study Plus Ejection Fraction, With Or Without Quantification Myocardial Imaging, Positron Emission Tomography (Pet), Perfusion; Single Study At Rest Or Stress Myocardial Imaging, Positron Emission Tomography (Pet), Perfusion; Multiple Studies At Rest And/Or Stress Cardiac Blood Pool Imaging, Gated Equilibrium, Spect, At Rest, Wall Motion Study Plus Ejection Fraction, With Or Without Quantitative Processing Cardiac Blood Pool Imaging, Gated Equilibrium, Single Study, At Rest, With Right Ventricular Ejection Fraction By First Pass Technique (List Separately In Addition To For Primary Procedure) Brain Imaging, Positron Emission Tomography (Pet); Metabolic Evaluation Brain Imaging, Positron Emission Tomography (Pet); Perfusion Evaluation Positron Emission Tomography (Pet) Imaging; Limited Area (Eg, Chest, Head/Neck) Positron Emission Tomography (Pet) Imaging; Skull Base To Mid-Thigh Positron Emission Tomography (Pet) Imaging; Whole Body Positron Emission Tomography (Pet) With Concurrently Acquired Computed Tomography (Ct) For Attenuation Correction And Anatomical Localization Imaging; Limited Area (Eg, Chest, Head/Neck) Positron Emission Tomography (Pet) With Concurrently Acquired Computed Tomography (Ct) For Attenuation Correction And Anatomical Localization Imaging; Skull Base To Mid-Thigh Positron Emission Tomography (Pet) With Concurrently Acquired Computed Tomography (Ct) For Attenuation Correction And Anatomical Localization Imaging; Whole Body 148 G0235 Pet Imaging, Any Site, Not Otherwise Specified Pet Imaging, Full And Partial-Ring Pet Scanners Only, For Initial Diagnosis Of Breast 149 G0252 Cancer And/Or Surgical Planning For Breast Cancer (E.G. Initial Staging Of Axillary Lymph Nodes) 7 of 7

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