YourCare Health Plan 2015 CPT Code/Prior Authorization List

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1 Programs:, Cardiology, Radiation Therapy, and Sleep Management MRI MRI TMJ Tempomandibular joint/jaw CT SCANS CT Head/Brain w/o Contrast CT SCANS CT Head/Brain w/o & w/ Contrast CT SCANS CT Orbit w/o Contrast Temporal Bone/Mastoid/Ears CT SCANS CT Orbit w/ Contrast Temporal Bone/Mastoid/Ears CT SCANS CT Orbit w/o & w/ Contrast Temporal Bone/Mastoid/Ears CT SCANS CT Maxllfcl w/o Contrast Sinus/Denta Scan/TMJ CT SCANS CT Maxllfcl w/ Contrast Sinus/Denta Scan/TMJ CT SCANS CT Maxllfcl w/o & w/ Contrast Sinus/Denta Scan/TMJ CT SCANS CT Soft Tissue Neck w/o Contrast Parotid; Not used for Cervical Bone CT SCANS CT Soft Tissue Neck w/ Contrast Parotid; Not used for Cervical Bone CT SCANS CT Soft Tissue Neck w/o & w/ Contrast Parotid; Not used for Cervical Bone CT SCANS Ct Angiography Head CT SCANS Ct Angiography Neck MRI MRI Face, Orbit, Neck w/o Contrast Sinus/3 areas (soft tissue neck) eyes/temporal MRI MRI Face, Orbit, Neck w/ Contrast Gadolinium MRI MRI Face, Orbit, Neck w & w/o Contrast Gadolinium MRA MRA Head w/o Contrast Also known as MRV MRA MRA Head w/ Contrast Gadolinium/ Also known as MRV MRA MRA Head w & w/o Contrast Gadolinium/ Also known as MRV MRA MRA Neck w/o Contrast Also known as MRV MRA MRA Neck w/ Contrast Gadolinium/ Also known as MRV MRA MRA Neck w & w/o Contrast Gadolinium/ Also known as MRV MRI MRI Head w/o Contrast IACs (Internal Auditory Canal) MRI MRI Head w/ Contrast IACs (Internal Auditory Canal) MRI MRI Head w/ & w/o Contrast IACs (Internal Auditory Canal) Page 1 of 42

2 Programs:, Cardiology, Radiation Therapy, and Sleep Management MRI MRI MRI, Brain, Functional MRI; Including Test Selection and Administration of Repetitive Body Part Movement and/or Visual Stimulation, Not Requiring Physician or Psychologist Administration MRI, Brain, Functional MRI; Requiring Physician or Psychologist Administration of Entire Neurofunctional Testing CT SCANS CT Thorax w/o Contrast Can be CT Chest or a Ultrafast CT/EBT/EBCT CT SCANS CT Thorax w/ Contrast Chest/Ultrafast CT/EBT/EBCT CT SCANS CT Thorax w/o & w/ Contrast Chest/Ultrafast CT/EBT/EBCT CT SCANS Ct Angiography Chest MRI MRI Chest w/o Contrast Brachial Plexus MRI MRI Chest w/ Contrast MRI MRI Chest w/ & w/o Contrast Gadolinium MRA MRA Chest (Emc Myocardium) w/ or w/o Gadolinium/ Also known as MRV Contrast CT SCANS CT C Spine w/ Contrast CT SCANS CT C Spine w/o & w/ Contrast CT SCANS CT T Spine w/o Contrast CT SCANS CT T Spine w/ Contrast CT SCANS CT T Spine w/o & w/ Contrast CT SCANS CT L Spine w/ Contrast Includes Sacrum CT SCANS CT L Spine w/o & w/ Contrast Includes Sacrum MRI MRI Cervical Spine w/o Contrast Vertebrae of the Neck MRI MRI Cervical Spine w/ Contrast Gadolinium MRI MRI Thoracic Spine w/o Contrast MRI MRI Thoracic Spine w/ Contrast Gadolinium MRI MRI Lumbar Spine w/o Contrast Includes Sacrum Page 2 of 42

3 Programs:, Cardiology, Radiation Therapy, and Sleep Management MRI MRI Lumbar Spine w/ Contrast Gadolinium Includes Sacrum MRI MRI C Spine w/ & w/o Contrast Gadolinium MRI MRI T Spine w/ & w/o Contrast Gadolinium MRI MRI L Spine w/ & w/o Contrast Gadolinium Includes Sacrum MRA MRA Spinal Canal w/ or w/o Contrast Gadolinium/ Also known as MRV CT SCANS CT Angiography Pelvis Aortic Aneurysm CT SCANS CT Pelvis w/o Contrast Below Belly Button/Coccyx CT SCANS CT Pelvis w/ Contrast Below Belly Button/Coccyx CT SCANS CT Pelvis w/o & w/ Contrast Below Belly Button/Coccyx MRI MRI Pelvis w/o Contrast Coccyx MRI MRI Pelvis w/ Contrast Gadolinium/coccyx MRI MRI Pelvis w & w/o Contrast Gadolinium/coccyx MRA MRA Pelvis w/ or w/o Contrast Gadolinium/ Also known as MRV CT SCANS CT Upper Extremity w/o Contrast Hand/Arm/Shoulder/ Elbow/Wrist CT SCANS CT Upper Extremity w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist CT SCANS CT Upper Extremity w/o & w/ Contrast Hand/Arm/Shoulder/ Elbow/Wrist CT SCANS CT Angiography Upper Extremity Hand/Arm/Shoulder/ Elbow/Wrist MRI MRI Upper Extremity w/o Contrast Hand/Arm/Axilla MRI MRI Upper Extremity w/ Contrast Hand/Arm/Axilla Gadolinium MRI MRI Upper Extremity w & w/o Contrast Hand/Arm/Axilla Gadolinium MRI MRI Upper Extremity w/o Contrast Shoulder/Elbow/Wrist MRI MRI Upper Extremity w/ Contrast Arthrogram Shoulder/Elbow/Wrist Gadolinium MRI MRI Upper Extremity Joint w & w/o Contrast Shoulder/Elbow/Wrist Gadolinium MRA MRA Upper Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV CT SCANS CT Lower Extremity w/o Contrast Hip/Leg/Knee/Ankle/ Foot CT SCANS CT Lower Extremity w/ Contrast Hip/Leg/Knee/Ankle/ Foot Page 3 of 42

4 Programs:, Cardiology, Radiation Therapy, and Sleep Management CT SCANS CT Lower Extremity w/o & w/ Contrast Hip/Leg/Knee/Ankle/ Foot CT SCANS CT Angiography Lower Extremity Hip/Leg/Knee/Ankle/ Foot MRI MRI Lower Extremity w/o Contrast Foot/Leg MRI MRI Lower Extremity w/ Contrast Foot/Leg Gadolinium MRI MRI Lower Extremity w/ & w/o Contrast Foot/Leg Gadolinium MRI MRI Lower Extremity w/o Contrast Hip/Knee/Ankle MRI MRI Lower Extremity w/ Contrast Arthrogram Hip/Knee/Ankle Gadolinium MRI MRI Lower Extremity Joint w/ & w/o Contrast Hip/Knee/Ankle Gadolinium MRA MRA Lower Extremity w/ or w/o Contrast Gadolinium/ Also known as MRV CT SCANS CT Abdomen w/o Contrast Diaphragm to Belly Button CT SCANS CT Abdomen w/ Contrast Aneurysm/Diaphragm to Belly Button CT SCANS CT Abdomen w/o & w/ Contrast Diaphragm to Belly Button CT SCANS Computed tomographic angiography, abdomen and pelvis, with contrast material(s), including noncontrast images, if performed, and image postprocessing CT SCANS Ct Angiography Abdomen Diaphragm to Belly Button MRI MRI Abdomen w/o Contrast MRCP MR Cholangiogram MRI MRI Abdomen w/ Contrast MRCP MR Cholangiogram Gadolinium MRI MRI Abdomen w/ & w/o Contrast MRCP MR Cholangiogram Gadolinium MRA MRA Abdomen w/ or w/o Contrast Also known as MRV MRI MRI Cardiac MRI For Morphology And Function Without Contrast Material Cardiac MRI For Morphology And Function Without Contrast Material; With Stress Imaging MRI Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences Page 4 of 42

5 Programs:, Cardiology, Radiation Therapy, and Sleep Management MRI Cardiac MRI For Morphology And Function Without Contrast Material(s), Followed By Contrast Material(s) And Further Sequences; With Stress Imaging CT SCANS CT Limited or Localized Follow Up Study MRI MRI Spectroscopy MRS CT SCANS Unlisted Computed Tomography Procedure MRI Unlisted MRI Procedure Redirect to valid code MRI Unlisted Radiologic Procedure ULTRASOUND U/S OB Pelvis, Pregnant Uterus, First Trimester <14 Weeks Single Or First Gestation ULTRASOUND U/S OB Pelvis, Pregnant Uterus, First Trimester <14 Weeks Each Additional Gestation Multiple Gestation only ULTRASOUND ULTRASOUND U/S OB Pelvis, Pregnant Uterus, B Scan (Allowed Once Per Gestation) U/S OB Pelvis Complete, Multiple Gestation after 1st Trimester (Allowed Once For Each Additional Fetus per Gestation; Must Be Billed With 76805) Level 1 Multiple Gestation only ULTRASOUND Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Single or First Gestation (Allowed Once Per Gestation; Second Study Allowed If Performed By A Different Physician) Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Ventricular Insertion Of New Or Replacement Of Permanent Pacemaker With Transvenous Electrode(s); Atrial And Ventricular Level 2 Page 5 of 42

6 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology CARDIAC IMPLANTABLES ULTRASOUND Insertion or Replacement of Permanent Pacemaker Pulse Generator Only; Single Chamber, Atrial or Ventricular US Pregnant Uterus Fetal & Maternal Eval Plus Fetal Anatomic Eval Transabdominal Each Additional Gestation (Allowed Once For Each Additional Fetus Per Gestation; Must Be Billed With 76811; Second Study Allowed If Performed By A Different Physician) ULTRASOUND Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation. (Allowed once per gestation) Multiple Gestation only ULTRASOUND Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation (List separately in addition to code for primary procedure) (Allowed once for each additional fetus per gestation) ULTRASOUND U/S Pregnant Uterus, Real Time w/ Image Documentation, Limited (E.G. Fetal Heart Beat, Placental Location, Fetal Position and/or Qualitative Amniotic Fluid Volume), 1 or More Fetuses One CPT code per DOS regardless the # of fetuses ULTRASOUND U/S OB Pelvis Follow Up or Repeat One exam per fetus ULTRASOUND US Pregnant Uterus Transvaginal One CPT code per DOS regardless the # of fetuses ULTRASOUND Fetal Biophysical Profile One exam per fetus Page 6 of 42

7 Programs:, Cardiology, Radiation Therapy, and Sleep Management ULTRASOUND Fetal Biophysical Profile w/o Stress Non Stress One exam per fetus ULTRASOUND Doppler Velocimetry, Fetal; Umbilical Artery One exam per fetus ULTRASOUND Doppler Velocimetry, Fetal; Middle Cerebral One exam per fetus Artery ULTRASOUND U/S OB Echocardiography, Fetal, Cardiovascular Fetal Echo System One exam per fetus ULTRASOUND Follow Up or Repeat Study One exam per fetus ULTRASOUND Doppler Echocardiography Fetal Complete One exam per fetus ULTRASOUND Follow Up or Repeat Study One exam per fetus Rdil ULTRASOUND U/S Gastrointestinal, i CT SCANS CT Guidance Sterotactic Localization CT SCANS CT Guidance Needle BX RAD S & I CT Guidance for and Monitoring of Tissue CT SCANS Ablation CT SCANS CT Guidance for Placement of Radiation Therapy Fields MRI MRI Guidance for Needle Placement MRI MRI Guidance for and Monitoring of Tissue Ablation MRI MRI Breast w/ and/or w/o Contrast; Unilateral Unilateral One Gadolinium MRI MRI Breast Bilateral Both CT SCANS CT Bone Density Study, Axial Skeleton CT SCANS CT Bone Density Study, Appendicular Skeleton MRI MRI Bone Marrow Blood Supply Thyroid uptake; single determination Redirect to valid code Thyroid uptake; multiple determinations Redirect to valid code Thyroid uptake stimulation, suppression or discharge (not including initial uptake studies) Redirect to valid code Page 7 of 42

8 Programs:, Cardiology, Radiation Therapy, and Sleep Management Thyroid imaging, with uptake; single Redirect to valid code determination Thyroid imaging, multiple determinations Redirect to valid code Thyroid imaging; only Redirect to valid code Thyroid imaging; with vascular flow Redirect to valid code Thyroid Uptake, Single or Multiple Quantitative Measurements(s) (Including Stimulation, Suppression, or Discharge, When Performed) Thyroid Imaging (Including Vascular Flow, When Performed) Thyroid Imaging (Including Vascular Flow, When Performed); With Single or Multiple Uptake(s) Quantitative Measurement(s) (Including Stimulation, Suppression, or Discharge, When Performed) Thyroid Met Imaging Thyroid Met Imaging with Additional Studies Thyroid Scan Whole Body For CA thyroid (I 31 scan) Thyroid Carcinoma Metastases Uptake Parathyroid Planar Imaging (Including Subtraction, When Performed) Adrenal Nuclear Imaging MIBG Unlisted Endocrine Procedure Bone Marrow Imaging, Limited Bone Marrow Imaging, Multiple Bone Marrow Imaging, Whole Body Differential Organ/Tissues Kinetic Labeled Red Cell Sequestration Page 8 of 42

9 Programs:, Cardiology, Radiation Therapy, and Sleep Management Spleen Imaging w & w/o Vascular Flow Platelet Survival, Kinetics Platelet Survival Lymph System Imaging MIBG Unlisted Hematopoetic Procedure Liver Imaging Liver Imaging w/ Flow Liver Imaging Spect Liver Imaging Spect w/ Vascular Flow Liver and Spleen Imaging Red Cell Tagging Liver and Spleen Imaging w/ Flow Hepatobiliary system imaging, including gallbladder when present; Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed Salivary Gland Imaging Serial Salivary Gland Salivary Gland Function Test Esophagus Motility Study Gastric Mucosa Imaging Gastroesophagael Reflum Emam Gastric Emptying Study GI Bleeder Scan GI Protein Loss Exam Meckel's Diverticulum Imaging Leveen Shunt Patency Exam Page 9 of 42

10 Programs:, Cardiology, Radiation Therapy, and Sleep Management Unlisted Gastroinestinal Procedure Bone or Joint Imaging Ltd One Bone Bone or Joint Imaging Multiple More than one Bone Bone Scan Whole Body Used Often with CA studies/all bones Bone and/or Joint Imaging; 3 Phase Study Osteomyelitis Technesium Bone Joint Imaging Tomo Test Spect Unlisted Musculoskeletal Procedure Non Imaging Heart Function Cardiac Shunt Imaging Radionuclide Venogram Non Cardiac Acute Venous Thrombosis Imaging Venous Thrombosis Imaging Unilateral Venous Thrombosis Imaging Bilateral PET SCANS Myocardial Imaging, Positron Emission Tomography (PET) Metabolic Eval Myocardial Infarction Scan Heart Infarct Image Ef Heart Infarct Image Spect Gated Heart, Rest or Stress Cardiac Blood Pool Muga Scan Heart First Pass Single Cardiac Blood Pool Imaging, Multi PET SCANS PET SCANS Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Single Study At Rest Or Stress Myocardial Imaging, Positron Emission Tomography (PET), Perfusion; Multiple Studies At Rest Or Stress Page 10 of 42

11 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiac Blood Pool Imaging, Spect Cardiac Blood Pool Imaging, Single at Rest Insertion Of Pacemaker Pulse Generator Only; Cardiology CARDIAC IMPLANTABLES With Existing Dual Leads Unlisted Cardiovascular Procedure Cardiology CARDIAC IMPLANTABLES Upgrade Of Implanted Pacemaker System, Conversion Of Single Chamber System To Dual Chamber System (Includes Removal Of Previously Placed Pulse Generator, Testing Of Existing Lead, Insertion Of New Lead, Insertion Of New Generator) Pulmonary ventilation imaging (eg, aerosol or gas) Pulmonary perfusion imaging (eg, particulate); Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging Quantitative differential pulmonary perfusion, including imaging when performed Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed Unlisted Respiratory Procedure Brain Imaging Ltd Static Brain Ltd Imaging and Flow Brain Imaging Complete Brain Imaging Complete w/ Flow Brain Imaging Spect SPECT PET SCANS Brain Imaging, Positron Emission Tomography (PET) Metabolic Evaluation Page 11 of 42

12 Programs:, Cardiology, Radiation Therapy, and Sleep Management PET SCANS Brain Imaging, Positron Emission Tomography (PET) Perfusion Evaluation Brain Flow Imaging Only Cisternogram (Cerebrospinal Fluid Flow) Cerebrospinal Ventriculography CSF Shunt Evaluation Cerebrospinal Fluid Scan Spect CSF Leakage Detection and Localization Radiopharmaceutical Dacryocystorgraphy Unlisted Nuclear Medicine Procedure Kidney Imaging Morphology Kidney Imaging Morphology w/ Vascular Flow Kidney Imaging Morphology w/ Vascular Flow and Function Study Kidney Imaging Morphology w/ Vascular Flow and Function, Single w/ Pharm Intervention Renal Scan Kidney Imaging Morphology w/ Vascular Flow, Captorpril/Renal Scan/MAG Multi, w/o and w/ Pharm Intervention Kidney Imaging, Spect Kidney Function Study, Non Image Radioisotropic Urinary Bladder Residual Study Ureteral Reflum Study VCUG/Cystogram Testicular Imaging w/ Vascular Flow Unlisted Genitourinary Procedure Radiopharm Localization of Tumor, Limited Area Radiopharm Localization of Tumor, Multi Areas Gallium Scan/Mammo Scintogram/OctreoScan Page 12 of 42

13 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiopharm Localization of Tumor, Whole Body Gallium Scan/Octreo Scan Radiopharm Localization of Tumor, Spect Gallium Scan/FUO Radiopharmaceutical Localization of Tumor or Distribution of Radiopharmaceutical Agent(s); Whole Body, Requiring 2 or More Days Imaging Radiopharm Localization of Abscess, Limited Area Gallium Scan/Indium Scan/WBC Scan/MBIG Radiopharm Localization of Abscess, Whole Body Gallium Scan/Indium Scan/WBC Scan/MBIG Radiopharm Localization of Abscess, Spect Galliium Scan/Indium Scan/WBC Scan/MBIG PET SCANS Positron Emission Tomography (PET) Imaging; Limited Area (Eg, Chest, Head/Neck) PET SCANS PET SCANS PET SCANS PET SCANS Positron Emission Tomography (PET) Imaging; Skull Base To Mid Thigh Positron Emission Tomography (PET) Imaging; Whole Body Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Limited Area (Eg Chest, Head/Neck) Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Skull Base to Mid Thigh PET with CT PET with CT PET SCANS Positron Emission Tomography (PET) with Concurrently Acquired Computer Tomography (CT) for Attenuation Correction and Anatomical Localization Imaging; Whole Body PET with CT Unlisted Misc. Procedeure Diagnostic Nuclear Med Page 13 of 42

14 Programs:, Cardiology, Radiation Therapy, and Sleep Management T CODES T CODES 0042T 0159T CT Perfusion Brain Investigational Computer Aided Detection, Including Computer Algorithm Analysis of MRI Image Data For Lesion Detection/Characterization, Pharmacokinetic Analysis, with Further Physician Review for Interpretation, Breast MRI (List Separately In Addition To Code For Primary Procedure) Not Covered CT SCANS CT Head/Brain w/ Contrast CT SCANS CT C Spine w/o Contrast CT SCANS CT L Spine w/o Contrast Computed Tomography, Abdomen and Pelvis; CT SCANS without Contrast Material Computed Tomography, Abdomen and Pelvis; CT SCANS with Contrast Material(s) CT SCANS Computed Tomography, Abdomen And Pelvis; Without Contrast Material In One Or Both Body Regions, Followed By Contrast Material(s) And Further Sections In One Or Both Body Regions CT SCANS CT SCANS CT SCANS MRI CT SCANS Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; Without Contrast Material Computed Tomographic (CT) Colonography, Diagnostic, Including Image Postprocessing; With Contrast Material(s) Including Non Contrast Images, If Performed Computed Tomographic (CT) Colonography, Screening, Including Image Postprocessing Cardiac MRI For Velocity Flow Mapping (List Separately In Addition To Code For Primary Procedure) CT Heart Without Contrast Material, With Quantitive Evaluation Of Coronary Calcium Page 14 of 42

15 Programs:, Cardiology, Radiation Therapy, and Sleep Management CT SCANS Cardiac CT For Morphology CT SCANS Cardiac CT For Congenital HD CT SCANS CT Angio Coronary Artery CT SCANS CT Angiography Abdominal Aorta Aortic Aneurysm 3DI D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Not Requiring Image Postprocessing On An Independent Workstation 3DI D Rendering With Interpretation And Reporting Of Computed Tomography, Magnetic Resonance Imaging, Ultrasound, Or Other Tomographic Modality With Image Postprocessing Under Concurrent Supervision; Requiring Image Postprocessing On An Independent Workstation Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect) Parathyroid Planar Imaging (Including Subtraction, When Performed); With Tomographic (Spect), And Concurrently Acquired Computed Tomography (CT) For Anatomical Localization MPI, Spect, Single Rest or Stress MPI, Spect, Multiple Rest or Stress MPI, Planar, Single Rest or Stress MPI, Planar, Multiple Rest or Stress C CODES C8900 MRA with Contrast, Abdomen Page 15 of 42

16 Programs:, Cardiology, Radiation Therapy, and Sleep Management C CODES C8901 MRA without Contrast, Abdomen C CODES C8902 MRA with and without Contrast, Abdomen C CODES C8903 MRI with Contrast, Breast; Unilateral C CODES C8904 MRI without Contrast, Breast; Unilateral C CODES MRI with and without Contrast, Breast; Unilateral C8905 C CODES C8906 MRI with Contrast, Breast; Bilateral C CODES C8907 MRI without Contrast, Breast; Bilateral C CODES MRI with and without Contrast, Breast; Bilateral C8908 C CODES MRA with Contrast, Chest (Excluding C8909 Myocardium) C CODES MRA without Contrast, Chest (Excluding C8910 Myocardium) C CODES MRA with and Without Contrast, Chest C8911 (Excluding Myocardium) C CODES C8912 MRA with Contrast, Lower Extremity C CODES C8913 MRA without Contrast, Lower Extremity C CODES MRA with and Without Contrast, Lower C8914 Extremity C CODES C8918 MRA with Contrast, Pelvis C CODES C8919 MRA without Contrast, Pelvis C CODES C8920 MRA with and without Contrast, Pelvis Page 16 of 42

17 Programs:, Cardiology, Radiation Therapy, and Sleep Management C CODES Transthoracic Echocardiography w/contrast For Congenital Cardiac Anomalies; Complete C8921 C CODES C CODES C CODES C8922 C8923 C8924 Transthoracic Echocardiography w/contrast for Congenital Cardiac Anomalies; F/U or Limited Study Transthoracic Echocardiography w/contrast, Real Time w/image Documentation (2D), w or w/o M Mode Recording; Complete Transthoracic Echocardiography w/contrast, Real Time w/image Documentation (2D), w or w/o M Mode Recording; F/U Or Limited Study C CODES C8928 Transthoracic Echocardiography with Contrast, Real Time w/image Documentation (2D), w/ or w/o M Mode Recording, During Rest And Cardiovascular Stress Test, w/interpretation and Report (Crosswalked To Either Or 93351) RADIOLOGY C CODES C8929 Transthoracic Echocardiography with Contrast, or without Contrast Followed By with Contrast, Real Time with Image Documentation (2D), Includes M Mode Recording, When Performed, Complete, with Spectral Doppler Echocardiography, and with Color Flow Doppler Echocardiography Page 17 of 42

18 Programs:, Cardiology, Radiation Therapy, and Sleep Management RADIOLOGY C CODES C8930 Transthoracic Echocardiography, with Contrast, or without Contrast Followed By with Contrast, Real Time With Image Documentation (2D), Includes M Mode Recording, When Performed, During Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, with Interpretation and Report; Including Performance of Continuous Electrocardiographic Monitoring, with Physician Supervision RADIOLOGY RADIOLOGY RADIOLOGY RADIOLOGY RADIOLOGY RADIOLOGY C CODES C CODES C CODES C CODES C CODES C CODES G CODES C8931 C8932 C8933 C8934 C8935 C8936 G0219 Magnetic Resonance Angiography with Contrast, Spinal Canal and Contents Magnetic Resonance Angiography without Contrast, Spinal Canal and Contents Magnetic Resonance Angiography without Contrast Followed by with Contrast, Spinal Canal and Contents Magnetic Resonance Angiography with Contrast, Upper Extremity Magnetic Resonance Angiography without Contrast, Upper Extremity Magnetic Resonance Angiography without Contrast Followed by with Contrast, Upper Extremity Pet Imaging Whole Body; Melanoma for Non Covered Indications Investigational G CODES G0235 Pet Imaging, Any Site, Not Otherwise Specified Redirect to valid code G CODES G0252 Pet Imaging, Full and Partial Ring Pet Scanners Only for Initial Diagnosis of Breast Cancer and/or Surgical Planning for Breast Cancer Redirect to valid code Cardiology CARDIAC IMPLANTABLES Insertion Of Pacemaker Pulse Generator Only; With Existing Multiple Leads Page 18 of 42

19 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology CARDIAC IMPLANTABLES Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, With Attachment To Previously Placed Pacemaker Or Implantable Defibrillator Pulse Generator (Including Revision Of Pocket, Removal, Insertion, And/Or Replacement Of Existing Generator) Cardiology CARDIAC IMPLANTABLES Insertion Of Pacing Electrode, Cardiac Venous System, For Left Ventricular Pacing, At Time Of Insertion Of Implantable Defibrillator Or Pacemaker Pulse Generator (Eg, For Upgrade To DualChamber System) (List Separately In Addition To Code For Primary Procedure) Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Single Lead System Removal of Permanent Pacemaker Pulse Generator with Replacement of Pacemaker Pulse Generator; Dual Lead System Removal Of Permanent Pacemaker Pulse Generator With Replacement Of Pacemaker Pulse Generator; Multiple Lead System Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Dual Leads Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Multiple Leads Insertion Of Implantable Defibrillator Pulse Generator Only; With Existing Single Lead Insertion Or Replacement Of Permanent Implantable Defibrillator System With Transvenous Lead(s), Single Or Dual Chamber Cardiology CARDIAC IMPLANTABLES Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Single Lead System Page 19 of 42

20 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology CARDIAC IMPLANTABLES Removal Of Implantable Defibrillator Pulse Generator With Replacement Of Implantable Defibrillator Pulse Generator; Dual Lead System Cardiology CARDIAC IMPLANTABLES Cardiology CARDIAC IMPLANTABLES Removal of Implantable Defibrillator Pulse Generator with Replacement of Pacing Cardioverter Defibrillator Pulse Generator; Multiple Lead System Insertion Or Replacement Of Permanent Subcutaneous Implantable Defibrillator System, with Subcutaneous Electrode, Including Defibrillation Threshold Evaluation, Indication of Arrythmia,Evaluation Of Sensing For Arrythmia Termination, and Programming Or Reprogramming Of Sensing Or Therapeutic Parameters When Performed Cardiology MRI Cardiology MRI Cardiology MRI Cardiology MRI Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material; With Stress Imaging Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences Cardiac Magnetic Resonance Imaging For Morphology And Function Without Contrast Material(S), Followed By Contrast Material(S) And Further Sequences; With Stress Imaging Cardiology MRI Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) Page 20 of 42

21 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology CT SCANS Cardiology CT SCANS 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 Post processing, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed) (Managed Under ) (Managed Under ) Cardiology CT SCANS Computed Tomography, Heart, With Contrast Material, For Evaluation Of Cardiac Structure And Morphology In The Setting Of Congenital Heart Disease (Including 3D Image Post processing, Assessment Of LV Cardiac Function, RV Structure And Function And Evaluation Of Venous Structures, If Performed) (Managed Under ) CT SCANS S8032 Low Dose Computed Tomography for Lung Cancer Screening Cardiology CT SCANS Computed Tomographic Angiography, Heart, Coronary Arteries And Bypass Grafts (When Present), With Contrast Material, Including 3D Image Post processing (Including Evaluation Of Cardiac Structure And Morphology, Assessment Of Cardiac Function, And Evaluation Of Venous Structures, If Performed) (Managed Under ) S CODES S CODES S8037 S8042 Magnetic Resonance Cholangiopancreatography (MRCP) Magnetic Resonance Imaging (MRI), Low Field Redirect Redirect to valid code to valid code Page 21 of 42

22 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology NUCLEAR STRESS 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) (Managed Under ) S CODES Scintimammography (Radioimmunoscintigraphy of the Breast), Unilateral, Including Supply of Radiopharmaceutical S8080 p g Cardiology NUCLEAR STRESS S CODES S8085 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 Fluorine 18 Fluorodeomyglucose (F 18 Fdg) Imaging Using Dual Head Coincidence Detection System. (Non Dedicated PET Scan) (Managed Under ) Investigational Page 22 of 42

23 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology NUCLEAR STRESS S CODES 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) Electron Beam Computed Tomography (Also Known as Ultrafast CT, Cinet) (Managed Under ) S8092 Cardiology NUCLEAR STRESS 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 (Managed Under ) Cardiology PET PET Myocardial Imaging; Positron Emission Tomography (PET) Metabolic Evaluation (Managed Under ) Cardiology Gated Cardiac Radionuclide Angiography Cardiology Gated Multiple Cardiac Radionuclide Angiography Cardiology Cardiology Cardiology PET Cardiology PET Planar First Pass Cardiac Radionuclide Angiography Planar First Pass Multiple Cardiac Radionuclide Angiography Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Single Study, Rest or Stress Myocardial Perfusion Imaging, Positron Emission Tomography (PET) Multiple Studies, Rest and/or Stress (Managed Under ) (Managed Under ) (Managed Under ) (Managed Under ) Page 23 of 42

24 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology Cardiology Cardiology ECHOCARDIOGRAPHY Cardiology ECHOCARDIOGRAPHY SPECT Equilbrium Cardiac Radionuclide Angiography SPECT EquilbriumMultiple Radionuclide Angiography Transthoracic Echocardiography For Congenital Cardiac Anomalies; Complete Transthoracic Echocardiography For Congenital Cardiac Anomalies; Follow Up Or Limited Study (Managed Under ) (Managed Under ) Cardiology ECHOCARDIOGRAPHY Echocardiography, Transthoracic, Real Time With Image Documentation (2D), Includes M Mode Recording, When Performed, Complete, With Spectral Doppler Echocardiography, And With Color Flow Doppler Echocardiography Excluded dfrom program Cardiology ECHOCARDIOGRAPHY Cardiology ECHOCARDIOGRAPHY Echocardiography, Transthoracic, Real Time With Image Documentation (2D) With Or Without M Mode Recording; Complete Echocardiography, Transthoracic, Real Time With Image Documentation (2D) With Or Without M Mode Recording; Follow Up Or Limited Study Cardiology ECHOCARDIOGRAPHY Cardiology ECHOCARDIOGRAPHY Cardiology ECHOCARDIOGRAPHY Cardiology ECHO STRESS Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Complete Doppler Echocardiography, Pulsed Wave and/or Continuous Wave With Spectral Display; Follow Up Or Limited Study Doppler Echocardiography Color Flow Velocity Mapping Echocardiography, Transthoracic, Real Time With Image Documentation (2D), With Or Without M Mode Recording, During Rest And Cardiovascular Stress Test, With Interpretation And Report Page 24 of 42

25 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology ECHO STRESS Echocardiography, Transthoracic, Real Time With Image Documentation (2D), Includes M Mode Recording, When Performed, During Rest And Cardiovascular Stress Test Using Treadmill, Bicycle Exercise and/or Pharmacologically Induced Stress, With Interpretation And Report; Including Performance Of Continuous Electrocardiographic Monitoring, With Supervision By A Physician Or Other Qualified Health Care Professional. Cardiology ECHO STRESS Useof echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure) Cardiology CARDIAC CATH Cardiology CARDIAC CATH Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed Combined Right And Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, Imaging Supervision And Interpretation, When Performed Cardiology CARDIAC CATH Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation Cardiology CARDIAC CATH Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary FreeArterialVenous Grafts) Including Page 25 of 42

26 Programs:, Cardiology, Radiation Therapy, and Sleep Management Cardiology CARDIAC CATH Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right Heart Catheterization Cardiology CARDIAC CATH Cardiology CARDIAC CATH Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Catheter Placement(s) In Bypass Graft(s) (Internal Mammary, Free Arterial, Venous Grafts) Including Intraprocedural Injection(s) For Bypass Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed Cardiology CARDIAC CATH Cardiology CARDIAC CATH Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Left Heart Catheterization Including Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass G Catheter ft( )(I Placement t l M In Coronary F Artery(s) At il For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Supervision And Interpretation; With Right And Left Heart Catheterization Including Page 26 of 42

27 Programs:, Cardiology, Radiation Therapy, and Sleep Management Catheter Placement In Coronary Artery(s) For Coronary Angiography, Including Intraprocedural Injection(s) For Coronary Angiography, Imaging Cardiology CARDIAC CATH Supervision And Interpretation; With Right And Left Heart Catheterization Including Radiation Therapy CPT Intraprocedural Injection(s) For Left Ventriculography, When Performed, Catheter Placement(s) In Bypass Graft(s) (Internal High Dose Rate Electronic Brachytherapy, Per 0182T Fraction Radiation Therapy CPT Placement Of Intraocular Radiation Source 0190T Applicator Radiation Therapy REV Code 0330 /Therapeutic General Classification Radiation Therapy REV Code 0333 /Therapeutic Radiation Therapy Radiation Therapy REV Code 0339 /Therapeutic Other Radiation Therapy REV Code 0344 Therapeutic Radiopharmaceuticals Radiation Therapy REV Code 0973 Professional Fees /Therapeutic Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy On Date Separate From Partial Mastectomy Placement Of Radiation Therapy After loading Expandable Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy, Concurrent With Partial Mastectomy) Placement Of Radiation Therapy After loading Brachytherapy Catheter Into The Breast For Interstitial Radioelement Application Following Partial Mastectomy Bronchoscopy (Rigid Or Flexible), With Placement Of Catheter For Intracavitary Radioelement Application Page 27 of 42

28 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Placement Of Interstitial Device For Radiation Therapy Guidance, Percutaneous, Intra Thoracic, Single Or Multiple Placement Of Needles, Catheters, And Other Devices Into The Head and/or Neck Region Upper Gastrointestinal Endoscopy Including Esophagus, Stomach And Either The Duodenum and/or Jejunum As Appropriate; W/ Transendoscopic Intraluminal Tube Or Catheter Placement Placement Of Interstitial Device(s) For Radiation Therapy Guidance, Open, Intra Abdominal, Intra Pelvic and/or Retroperitoneum, Including Image Guidance, Single Or Multiple Radiation Therapy CPT Placement Of Interstitial Device(s) For Radiation Therapy Guidance (Eg, Fiducial Markers, Dosimeter), Open, Intra Abdominal, Intrapelvic, and/or Retroperitoneum, Including Image Guidance, If Performed, Single Or Multiple (List Separately In Addition To Code For Primary Procedure) Radiation Therapy CPT Transperineal Placement Of Needles Or Catheters Into Prostate For Interstitial Radioelement Application, With Or Out Cytosocopy Radiation Therapy CPT Fiducial Marker Placement In The Prostate Radiation Therapy CPT Placement Of Needles, Catheters, Or Other Device(s) Into The Head and/or Neck Region (Percutaneous, Transoral, Or Transnasal) For Subsequent Interstitial Radioelement Application Radiation Therapy CPT Insertion Of Uterine Tandem and/or Vaginal Ovoids For Clinical Brachytherapy Page 28 of 42

29 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiation Therapy CPT Insertion Of A Vaginal Radiation After Loading Apparatus For Clinical Brachytherapy Radiation Therapy CPT Insertion Of Heyman Capsulesfor Clinical Brachytherapy Radiation Therapy CPT US Transrectal Prostate Volume Study For Brachytherapy Radiation Therapy CPT Ultrasound Guidance For Interstitial Radioelement Application Radiation Therapy CPT Computed Tomography Guidance For Stereotactic Localization Rditi CT Guidance For Placement Of Radiation Therapy Radiation Therapy CPT Fields PA Mdi Medical lnecessity Review Therapeutic Treatment Planning; Radiation Therapy CPT Simple Therapeutic Treatment Planning; Radiation Therapy CPT Intermediate Therapeutic Treatment Planning; Radiation Therapy CPT Complex Radiation Therapy CPT Therapeutic Simulation; Simple Radiation Therapy CPT Therapeutic Simulation; Intermediate Radiation Therapy CPT Therapeutic Simulation; Complex Radiation Therapy CPT Respiratory Motion Management Simulation (List Separately In Addition To Code For Primary Procedure) Radiation Therapy CPT 3 Dimensional Radiotherapy Plan, Including Dose Volume Histograms Radiation Therapy CPT Unlisted Procedure; Therapeutic Treatment Planning Radiation Therapy CPT Basic Radiation Dosimetry Radiation Therapy CPT IMRT Planning Radiation Therapy CPT Teletherapy Isodose Plan; Simple (1 Or 2 Unmodified Ports Directed To A Single Area Of Interest), Includes Basic Dosimetry Calculation(s) Page 29 of 42

30 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Teletherapy Isodose Plan; Complex (Multiple Treatment Areas, Tangential Ports, The Use Of Wedges, Blocking, Rotational Beam, Or Special Beam Considerations), Includes Basic Dosimetry Calculation(s) Brachytherapy Isodose Plan; Simple (Calculation(s) Made From 1 To 4 Sources, Or Remote Afterloading Brachytherapy, 1 Channel), Includes Basic Dosimetry Calculation(S) Brachytherapy Isodose Plan; Intermediate (Calculation(s) ( Made From 5 To 10 Sources, Or Remote Afterloading Brachytherapy, 2 12 Channels), Includes Basic Dosimetry Calculation(S) Brachytherapy Isodose Plan; Complex (Calculation(s) Made From Over 10 Sources, Or Remote Afterloading Brachytherapy, 12 Channels), Includes Basic Dosimetry Calculation(s) Radiation Therapy CPT Special Teletherapy Port Plan, Particles, Hemibody, Total Body Radiation Therapy CPT Special Radiation Dosimetry Radiation Therapy CPT Treatment Devices; Simple Radiation Therapy CPT Treatment Devices; Intermediate Radiation Therapy CPT Treatment Devices; Complex Radiation Therapy CPT Continuing Medical Physics Consultation Radiation Therapy CPT Multi Leaf Collimator (MLC) Device(s) For IMRT, Design And Construction Per IMRT Plan Radiation Therapy CPT Special Medical Physics Consultation Radiation Therapy CPT Stereotactic Radiosurgery Treatment Delivery, Complete Course Of Treatment Of Cerebral Lesion(s) 1 Session, Multi Source Cobalt 60 Based Page 30 of 42

31 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Stereotactic Radiosurgery Treatment Delivery, Complete Course Of Treatment Of Cerebral Lesion(s) 1 Session, Linac Based Stereotactic Body Radiation Therapy Delivery Per Fraction 1 Or More Lesions; Including Image Guidance Not To Exceed 5 Fractions Intensity Modulated Radiation Treatment Delivery (IMRT), Includes Guidance And Tracking, When Performed; Simple Intensity Modulated Radiation Treatment Delivery (IMRT), Includes Guidance And Tracking, When Performed; Complex Guidance For Localization Of Target Volume For Delivery Of Radiation Treatment Delivery, Includes Intrafraction Tracking, When Performed Radiation Therapy CPT Unlisted Procedure, Medical Radiation Physics Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Treatment Delivery, Superficial and/or Ortho Voltage, Per Day Radiation Treatment Delivery; Single Treatment Area, One Or Two Ports; And Two Or Fewer Simple Blocks; >1 MEV; Simple Radiation Treatment Delivery; Two Separate Treatment Areas; Three Or More Ports On A Single Treatment Area; Or Three Or More Simple Blocks; >1 MEV; Intermediate Radiation Treatment Delivery; Three Or More Separate Treatment Areas; Custom Blocking; Tangential Ports; Wedges; Rotational Beam; Field In Field Or Other Tissue Compensation That Does Not Meet IMRT Guidelines; Or Electron Beam; >1 MEV; Complex Radiation Therapy CPT Therapeutic Port Films Radiation Therapy CPT Neutron Beam TX, Simple Page 31 of 42

32 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiation Therapy CPT Neutron Beam TX, Complex Intraoperative Radiation Treatment Delivery, X Radiation Therapy CPT Ray, Single Treatment Session Intraoperative Radiation Treatment Delivery, Radiation Therapy CPT Electrons, Single Treatment Session Radiation Treatment Management, Five Radiation Therapy CPT Treatments Radiation Therapy CPT Radiation Treatment Management, With Complete Course Of Therapy Consisting Of 1 2 Fractions Stereotactic Radiation Treatment Management Radiation Therapy CPT Cerebral Lesion(s) Complete Course Of Treatment Consisting Of 1 Session Stereotactic Body Radiation Treatment Management Per Treatment Course; 1 Or More Radiation Therapy CPT Lesions, Including Image Guidance Entire Course Not To Exceed 5 Fractions Radiation Therapy CPT Intraoperative Radiation Treatment Management Radiation Therapy CPT Special Treatment Procedure (Eg. Total Body Radiation, Hemibody Radiation Or Per Oral Endocavity) Radiation Therapy CPT Unlisted Procedure, Therapeutic Treatment Management Radiation Therapy CPT Proton Treatment Delivery, Simple w/o Compensation Radiation Therapy CPT Proton Treatment Delivery, Simple w/ Compensation Radiation Therapy CPT Proton Treatment Delivery, Intermediate Radiation Therapy CPT Proton Treatment Delivery, Complex Hyperthermia Treatment; Externally Generated, Radiation Therapy CPT Deep Hyperthermia Treatment; Externally Generated, Radiation Therapy CPT Superficial Radiation Therapy CPT Hyperthermia Generated By Interstitial Probe(s); Or Fewer Applicators Page 32 of 42

33 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Radiation Therapy CPT Hyperthermia Generated By Interstitial Probe(s); 5 Or More Applicators Hyperthermia Generated By Intracavitary Probe(s) Infusion Or Instillation Of Radioelement Solution (Includes 3 Month Follow Up Care) Intracavitary Radiation Source Application; Simple Intracavitary Radiation Source Application; Intermediate Intracavitary Radiation Source Application; Complex Radiation Therapy CPT Interstitial Radiation Source; Simple Radiation Therapy CPT Interstitial Radiation Source; Intermediate Radiation Therapy CPT Interstitial Radiation Source; Complex Remote After loading High Dose Rate Radiation Therapy CPT Radionuclide Brachytherapy; 1 Channel Remote After loading High Dose Rate Radiation Therapy CPT Radionuclide Brachytherapy; 2 12 Channels Radiation Therapy CPT Remote After loading High Dose Rate Radionuclide Brachytherapy; Over 12 Channels Radiation Therapy CPT Apply Surface Radiation Radiation Therapy CPT Radio Isotope Supervision, Handling, Loading Radiation Therapy CPT Radium/Radioisotope Therapy Radiation Therapy HCPS A4648 Tissue Marker, Implantable, Any Type Each Radiation Therapy HCPS A4650 Implant Radiation Dosimeter, Each Radiation Therapy HCPS C1715 Brachytherapy Needle Brachytherapy Source, Non Stranded, Gold 198, Radiation Therapy HCPS C1716 Per... Brachytherapy Source, Non Stranded, Gold 198 Radiation Therapy HCPS C1717 Per Page 33 of 42

34 Programs:, Cardiology, Radiation Therapy, and Sleep Management Radiation Therapy HCPS Brachytherapy Source, Non Stranded, Non High C1719 Dose... Radiation Therapy HCPS C1728 Catheter, Brachytherapy Seed Administration Radiation Therapy HCPS C2616 Radiation Therapy HCPS C2634 Radiation Therapy HCPS C2635 Radiation Therapy HCPS C2636 Radiation Therapy HCPS C2637 Radiation Therapy HCPS C2638 Radiation Therapy HCPS C2639 Radiation Therapy HCPS C2640 Radiation Therapy HCPS C2641 Radiation Therapy HCPS C2642 Radiation Therapy HCPS C2643 Radiation Therapy HCPS C2644 Radiation Therapy HCPS C2698 Radiation Therapy HCPS C2699 Radiation Therapy HCPS C9725 Brachytherapy Source, Non Stranded, Yttrium 90, Per Source Brachytherapy Source, Non Stranded, High Activity,... Brachytherapy Source, Non Stranded, High Activity,... Brachytherapy Linear Source, Non Stranded, Paladiu... Brachytherapy Source, Non Stranded, Ytterbium 169,... Brachytherapy Source, Stranded, Iodine 125, Per So... Brachytherapy Source, Non Stranded, Iodine 125, Per... Brachytherapy Source, Stranded, Palladium 103, Per... Brachytherapy Source, Non Stranded, Palladium 103,... Brachytherapy Source, Stranded, Cesium 131, Per So... Brachytherapy Source, Non Stranded, Cesium 131, Per... Brachytherapy Source, Cesium 131 Chloride Solution, Per Millicurie Brachytherapy Source, Stranded, Not Otherwise Spec... Brachytherapy Source, Non Stranded, Not Otherwise Placement Ofÿendorectal Intracavitary Applicator For High Intensity Brachytherapy Page 34 of 42

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