CLICK on the LISTS Below CT - Computed Tomography CTA Computed Tomographic Angiography CT - Computed Tomography Radiation Treatment Planning Studies

PROCEDURE LISTS CT/CTA, MRI/MRA, PET, Nuclear Cardiac Imaging (MPI), 3D Rendering, US & Cardiology CLICK on the LISTS Below CT - Computed Tomography CTA Computed Tomographic Angiography CT - Computed Tomography Radiation Treatment Planning Studies MRI - Magnetic Resonance Imaging MRA Magnetic Resonance Angiography MPI - Myocardial Perfusion Imaging and Nuclear Cardiac Imaging Positron Emission Tomography (PET) and PET/CT 3D RENDERING ULTRASOUND (US) CARDIOLOGY Outcomes Focused Cardiac Imaging (OFCI) Program NOTE: These procedure codes listed herein are provided for informational purposes only. Each health plan has a specific list of procedure codes that require pre-authorization. An individual plan s pre-authorization list may differ slightly from the ones posted here. CPT (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA).

0042T 0066T 0067T 0144T 0145T 0146T 0147T 0148T 0149T 0150T 0151T PROCEDURE LISTS - By Modality and In Numerical Order CT - Computed Tomography Cerebral perfusion analysis using CT with contrast CT COLONOGRAPHY (ie. virtual colonoscopy); Screening CT COLONOGRAPHY (ie. virtual colonoscopy); Diagnostic CT HEART, WO contrast, including post processing and evaluation of coronary calcium CT HEART, WO contrast followed by contrast and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology CTA CORONARY ARTERIES (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CTA CORONARY ARTERIES (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CTA CORONARY ARTERIES and cardiac structure and morphology (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CTA CORONARY ARTERIES and cardiac structure and morphology (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CT HEART, without contrast material followed by contrast material(s) and further sections, including cardiac gating and 3D image post processing; cardiac structure and morphology in congenital heart disease CT HEART, W/O, followed by contrast, including cardiac gating and 3D image post processing; function evaluation (left and right ventricular function, ejection fraction and segmental wall motion) 70450 CT Head without contrast 70460 CT Head with contrast 70470 CT Head with & without contrast W & W/O 70480 CT Orbit, sella, or posterior fossa or outer, middle, or inner ear without contrast 70481 CT Orbit, sella, or posterior fossa or outer, middle, or inner ear with contrast 70482 CT Orbit, sella, or posterior fossa or outer, middle, or inner ear W & W/O 70486 CT Maxillofacial area, (sinus) without contrast 70487 CT Maxillofacial area, (sinus) with contrast 70488 CT Maxillofacial area, (sinus) with & without contrast W & W/O 70490 CT Soft-tissue Neck without contrast 70491 CT Soft-tissue Neck with contrast 70492 CT Soft-tissue Neck with & without contrast W & W/O 71250 CT Chest without contrast 71260 CT Chest with contrast 71270 CT Chest with and without contrast W & W/O 72125 CT Cervical Spine without contrast 72126 CT Cervical Spine with contrast 72127 CT Cervical Spine with and without contrast W & W/O 72128 CT Thoracic Spine without contrast 72129 CT Thoracic Spine with contrast 72130 CT Thoracic Spine with and without contrast W & W/O RETURN Page 2 of 24

CT - Computed Tomography 72131 CT Lumbar Spine without contrast 72132 CT Lumbar Spine with contrast 72133 CT Lumbar Spine with and without out contrast W & W/O 72192 CT Pelvis without contrast 72193 CT Pelvis with contrast 72194 CT Pelvis with and without contrast W & W/O 73200 CT Upper Extremity without contrast 73201 CT Upper Extremity with contrast 73202 CT Upper Extremity with and without contrast W & W/O 73700 CT Lower Extremity without contrast 73701 CT Lower Extremity with contrast 73702 CT Lower Extremity with and without contrast W & W/O 74150 CT Abdomen without contrast 74160 CT Abdomen with contrast 74170 CT Abdomen with and without contrast W & W/O 76380 CT Limited or Localized follow-up 76497 Unlisted CT procedure (eg, diagnostic, interventional) 77011 CT Guidance for stereotactic localization 77012 CT Guidance for needle placement (eg, biopsy, aspiration, injection); radiological S & I 77013 CT Guidance for, and monitoring of, parenchymal tissue ablation 77078 CT BONE MINERAL DENSITY study, 1 or more sites, axial skeleton 77079 CT BONE MINERAL DENSITY study, 1 or more sites, appendicular S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring RETURN Page 3 of 24

CTA - Computed Tomographic Angiography 70496 CT Angiography (CTA), Head- includes post-processing 70498 CT Angiography (CTA), Neck-includes post-processing 71275 CT Angiography (CTA), Chest (NON-CORONARY) includes post-processing 72191 CT Angiography (CTA) Pelvis-includes post-processing 73206 CT Angiography (CTA) Upper Extremity-includes post-processing 73706 CT Angiography (CTA) Lower Extremity- includes post-processing 74175 CT Angiography (CTA) Abdomen- W & W/O includes post-processing 75635 CT Angiography (CTA) Abdominal Aorta and bilateral iliofemoral lower extremity runoff RETURN Page 4 of 24

CT Computed Tomography Radiation Treatment Planning Studies 77014 CT Guidance for placement of radiation therapy fields 77261 Therapeutic radiology treatment planning; simple 77262 Therapeutic radiology treatment planning; intermediate 77263 Therapeutic radiology treatment planning; complex 77280 Therapeutic radiology simulation-aided field setting; simple 77285 Therapeutic radiology simulation-aided field setting; intermediate 77290 Therapeutic radiology simulation-aided field setting; complex 77295 Therapeutic radiology simulation-aided field setting; three-dimensional RETURN Page 5 of 24

MRI Magnetic Resonance Imaging 0159T CAD, including computer algorithm analysis, BREAST MRI 70336 MRI Temporomandibular Joint (s) {TMJ} 70540 MRI Orbit, Face and/or Neck without contrast 70542 MRI Orbit, Face and/or Neck with contrast 70543 MRI Orbit, Face and/or Neck with and without contrast W & W/O 70551 MRI Brain (Head) without contrast 70552 MRI Brain (Head) with contrast 70553 MRI Brain (Head) with and without contrast W & W/O 70554 MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 70555 MRI, Brain, functional MRI; requiring physician or psychologist administration of testing 71550 MRI Chest without contrast 71551 MRI Chest with contrast 71552 MRI Chest with and without contrast W & W/O 72141 MRI Cervical Spine without contrast 72142 MRI Cervical Spine with contrast 72146 MRI Thoracic Spine without contrast 72147 MRI Thoracic Spine with contrast 72148 MRI Lumbar Spine without contrast 72149 MRI Lumbar Spine with contrast 72156 MRI Cervical Spine with and without contrast W & W/O 72157 MRI Thoracic Spine with and without contrast W & W/O 72158 MRI Lumbar Spine with and without contrast W & W/O 72195 MRI Pelvis without contrast 72196 MRI Pelvis with contrast 72197 MRI Pelvis with and without contrast W & W/O 73218 MRI Upper Extremity-other than joint-without contrast 73219 MRI Upper Extremity-other than joint-with contrast 73220 MRI Upper Extremity-other than joint-with and without contrast W & W/O 73221 MRI Any Joint of Upper Extremity--without contrast 73222 MRI Any Joint of Upper Extremity--with contrast 73223 MRI Any Joint of Upper Extremity with and without contrast W & W/O 73718 MRI Lower Extremity-other than joint-without contrast 73719 MRI Lower Extremity-other than joint-with contrast 73720 MRI Lower Extremity-other than joint-with and without contrast W & W/O 73721 MRI Any Joint of Lower Extremity--without contrast 73722 MRI Any Joint of Lower Extremity--with contrast 73723 MRI Any Joint of Lower Extremity with and without contrast W & W/O 74181 MRI Abdomen without contrast 74182 MRI Abdomen with contrast 74183 MRI Abdomen with and without contrast W & W/O RETURN Page 6 of 24

MRI Magnetic Resonance Imaging 75557 Cardiac MRI for morphology and function without contrast materials 75558 Cardiac MRI for morphology and function without contrast materials; with flow/velocity 75559 Cardiac MRI for morphology and function without contrast materials; with stress imaging 75560 Cardiac MRI for morphology and function without contrast materials; with flow/velocity and stress 75561 Cardiac MRI for morphology and function WO, followed by contrast 75562 Cardiac MRI for morphology and function WO, followed by contrast with flow/velocity 75563 Cardiac MRI for morphology and function WO, followed by contrast; with stress imaging 75564 Cardiac MRI for morphology and function WO, followed by contrast; with flow/velocity and stress 76390 MR Spectroscopy (MRS) 76498 Unlisted MR procedure (eg, diagnostic, interventional) 77021 MR Guidance for needle placement (eg, biopsy, aspiration, injection); radiological S & I 77022 MR Guidance for, and monitoring of, parenchymal tissue ablation 77058 MRI BREAST, without and/or with contrast UNILATERAL 77059 MRI BREAST, without and/or with contrast BILATERAL 77084 MRI Bone Marrow blood supply S8035 Magnetic Source Imaging S8037 MRCP (Magnetic Resonance Cholangiopancreatography) S8042 MRI Low Field RETURN Page 7 of 24

MRA Magnetic Resonance Angiography 70544 MR Angiography (MRA) Head without contrast 70545 MR Angiography (MRA) Head with contrast 70546 MR Angiography (MRA) Head with and without contrast W & W/O 70547 MR Angiography (MRA) Neck without contrast 70548 MR Angiography (MRA) Neck with contrast 70549 MR Angiography (MRA) Neck with and without contrast W & W/O 71555 MR Angiography (MRA) Chest (excluding myocardium)- W or W/O 72159 MR Angiography (MRA) Spinal Canal and contents 72198 MR Angiography (MRA) Pelvis -with or without contrast 73225 MR Angiography (MRA) Upper Extremity -with or without contrast 73725 MR Angiography (MRA) Lower Extremity-with or without contrast 74185 MR Angiography (MRA) Abdomen-with or without contrast RETURN Page 8 of 24

MPI Myocardial Perfusion Imaging NCM Nuclear Cardiac Imaging 78460 MPI; (planar) single study, at rest or stress 78461 MPI; (planar) multiple studies, at rest and/or stress 78464 MPI; (SPECT) single study at rest or stress 78465 MPI; (SPECT) multiple studies at rest and/or stress 78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitative 78468 Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique 78469 Myocardial Imaging, infarct avid, planar; tomographic SPECT 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress, 78478 Myocardial perfusion study with wall motion 78480 Myocardial perfusion study with ejection fraction (EF) 78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction 78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction 78494 Cardiac Blood Pool imaging, gated equilibrium, SPECT 78496 Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass UNLISTED NCM Nuclear Cardiac Imaging 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine RETURN Page 9 of 24

PET and PET/CT - Positron Emission Tomography 78459 PET Cardiac (myocardial imaging) metabolic evaluation 78491 PET Cardiac (myocardial imaging), perfusion single study at rest or stress 78492 PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress 78608 PET Brain metabolic evaluation 78609 PET Brain perfusion evaluation 78811 PET Imaging; limited area (ex: chest, head/neck) 78812 PET Imaging; skull base to mid-thigh 78813 PET Imaging; whole body 78814 PET/CT; limited area (ex: chest, head/neck) 78815 PET/CT; skull base to mid-thigh 78816 PET/CT; whole body G0219 PET imaging whole body; melanoma for non-covered indications G0235 PET imaging, any site, not otherwise specified PET imaging, for initial diagnosis of breast cancer and/or surgical planning for breast G0252 cancer (e.g. initial staging of axillary lymph nodes) S8085 F-18 FDG Imaging Using Dual Head Coincidence Detection System RETURN Page 10 of 24

76376 76377 3D RENDERING 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation RETURN Page 11 of 24

ULTRASOUND (US) 76506 Echoencephalography, real time with image documentation (gray scale) 76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan 76511 Ophthalmic ultrasound, diagnostic; quantitative A-scan only 76512 Ophthalmic ultrasound, diagnostic; B-scan (W or W/O superimposed A-scan 76513 Ophthalmic ultrasound, diagnostic; anterior segment ultrasound, immersion 76514 Ophthalmic ultrasound, diagnostic; corneal pachymetry, unilateral or bilateral 76516 Ophthalmic biometry by ultrasound echography, A-scan 76519 Ophthalmic biometry by ultrasound echography, A-scan; W lens power calculation 76529 Ophthalmic ultrasonic foreign body localization 76536 Ultrasound, soft tissues of head and neck (eg, thyroid, parathyroid, parotid), B-scan and/or real time with image documentation 76604 Ultrasound, chest, (includes mediastinum) real time with image documentation 76645 Ultrasound breast(s) (unilateral or bilateral), real time with image documentation 76700 Ultrasound, abdominal, B-scan and/or real time with image documentation; complete 76705 Ultrasound, abdominal, B-scan and/or real time with image documentation; limited 76770 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; complete 76775 Ultrasound, retroperitoneal (eg, renal, aorta, nodes), B-scan and/or real time with image documentation; limited 76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation 76800 Ultrasound, spinal canal and contents Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76801 evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation 76802... each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76805 evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation 76810... each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal 76811 evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation 76812... each additional gestation (List separately in addition to code for primary procedure) Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal 76813 nuchal translucency measurement, transabdominal or transvaginal approach; single or first gestation Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal 76814 nuchal translucency measurement, transabdominal or transvaginal approach; each additional gestation RETURN Page 12 of 24

ULTRASOUND (US) Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heart 76815 beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, reevaluation 76816 of fetal size by measuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal 76818 Fetal biophysical profile; with non-stress testing 76819 Fetal biophysical profile; without non-stress testing 76820 Doppler velocimetry, fetal; umbilical artery 76821 Doppler velocimetry, fetal; middle cerebral artery 76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; 76826 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; follow-up or repeat study 76827 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete 76828 Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study 76830 Ultrasound, transvaginal 76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed 76856 Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation, complete 76857 Ultrasound, pelvic (nonobstetric), B-scan and/or real time with image documentation, limited or follow-up 76870 Ultrasound, scrotum and contents 76872 Ultrasound, transrectal 76873 Ultrasound, transrectal: prostate volume study for brachytherapy treatment planning (separate procedure) 76880 Ultrasound, extremity, non-vascular, real time with image documentation 76885 Ultrasound, infant hips, real time with image documentation; dynamic (requiring physician manipulation) 76886 Ultrasound, infant hips, real time with image documentation; limited, static (not requiring physician manipulation) 75989 Radiological guidance (ie, fluoroscopy, ultrasound, or CT), for percutaneous drainage with placement of catheter, radiological S & I 76930 Ultrasonic guidance for pericardiocentesis, imaging S & I 76932 Ultrasonic guidance for endomyocardial biopsy, imaging S & I 76936 Ultrasound guided compression repair of arterial pseudoaneurysm or arteriovenous fistulae (includes diagnostic ultrasound evaluation) RETURN Page 13 of 24

ULTRASOUND (US) 76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites (List separately in addition to code for primary procedure) 76940 Ultrasound guidance for, and monitoring of, parenchymal tissue ablation 76941 Ultrasonic guidance for intrauterine fetal transfusion or cordocentesis imaging SI 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection) S&I 76945 Ultrasonic guidance for chorionic villus sampling, imaging S & I 76946 Ultrasonic guidance for amniocentesis, imaging S & I 76948 Ultrasonic guidance for aspiration of ova, imaging S & I 76970 Ultrasound study follow-up (specify) 93875 Non-invasive physiologic studies of extracranial arteries, complete bilateral study 93880 Duplex scan of extracranial arteries; complete bilateral study 93882 Duplex scan of extracranial arteries; unilateral or limited study 93886 Transcranial Doppler study of the intracranial arteries; complete study 93888 Transcranial Doppler study of the intracranial arteries; limited study 93890 Transcranial Doppler study of the intracranial arteries; vasoreactive study 93892 Transcranial Doppler study of the intracranial arteries; emboli detection W/O intravenous microbubble injection 93893 Transcranial Doppler study of the intracranial arteries; emboli detection with intravenous microbubble injection Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral 93922 (eg, ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (eg, segmental blood pressure 93923 measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, 93924 measurements with postural provocative tests, measurements with reactive hyperemia) Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 Duplex scan of lower extremity arteries or arterial bypass grafts; unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 Duplex scan of upper extremity arteries or arterial bypass grafts; unilateral or limited study Non-invasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler 93965 waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study RETURN Page 14 of 24

ULTRASOUND (US) Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents 93976 and/or retroperitoneal organs; limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; limited study 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 93981 Duplex scan of arterial inflow and venous outflow of penile vessels; limited study Duplex scan of hemodialysis access (including arterial inflow, body of access and venous 93990 outflow) Vessel mapping of vessels for hemodialysis access (services for preoperative vessel G0365 mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow Ultrasound, B-scan and/or real time with image documentation; for abdominal aortic G0389 aneurysm (AAA) screening RETURN Page 15 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program CT/CTCA CARDIAC CT and CT Coronary Angiography (CTCA) CT HEART, without contrast material, including image post processing and 0144T quantitative evaluation of coronary calcium [DO NOT use 0144T in conjunction with 0145T-0151T.] CT HEART, with contrast material(s), including noncontrast images, if performed, 0145T cardiac gating and 3D image post-processing; cardiac structure and morphology CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; CTA of coronary arteries, (including 0146T native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; CTA of coronary arteries, (including 0147T native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; cardiac structure and morphology 0148T and CTA of coronary arteries, (including native and anomalous coronary arteries, coronary bypass grafts), without quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; cardiac structure and morphology 0149T and CTA of coronary arteries, (including native and anomalous coronary arteries, coronary bypass grafts), with quantitative evaluation of coronary calcium CT HEART, with contrast material(s), including noncontrast images, if performed, 0150T cardiac gating and 3D image post-processing; cardiac structure and morphology in congenital heart disease CT HEART, with contrast material(s), including noncontrast images, if performed, cardiac gating and 3D image post-processing; function evaluation (left and right +0151T ventricular function, ejection fraction and segmental wall motion) (List separately in addition to code for primary procedure) [Use 0151T in conjunction with 0145T-0150T.] DO NOT USE WITH 0144T. S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring RETURN Page 16 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program MRI CARDIAC Magnetic Resonance Imaging (MRI) 75557 Cardiac MRI for morphology and function without contrast material; 75558 Cardiac MRI for morphology and function without contrast material; with flow/velocity 75559 Cardiac MRI for morphology and function without contrast material; with stress imaging Cardiac MRI for morphology and function without contrast material; with flow/velocity 75560 quantification and stress 75561 Cardiac MRI for morphology and function without contrast, followed by contrast; Cardiac MRI for morphology and function without contrast, followed by contrast and 75562 further sequences; with flow/velocity quantification 75563 Cardiac MRI for morphology and function without contrast, followed by contrast and further sequences; with stress imaging Cardiac MRI for morphology and function without contrast, followed by contrast and 75564 further sequences; with flow/velocity quantification and stress Only one procedure code in the series 75557-75564 should be reported per imaging session. Cardiac MRI studies may be performed at rest and/or during pharmacologic stress. o Use the appropriate stress testing code from the series: 93015-93018 in addition to 75559, 75560, 75563, and 75564. 3D Rendering (CPT 76376 and 76377) should not be used in conjunction with cardiac MRI. 3D 3D RENDERING 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other 76376 tomographic modality; not requiring image postprocessing on an independent workstation [Use 76376 in conjunction with code(s) for base imaging procedure(s).] 3D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other 76377 tomographic modality; requiring image postprocessing on an independent workstation [Use 76377 in conjunction with code(s) for base imaging procedure(s).] PET CARDIAC Positron Emission Tomography (PET) 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation Myocardial imaging, positron emission tomography (PET), perfusion; single study at 78491 rest or stress Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at 78492 rest and/or stress Cardiac PET studies (78491 and 78492) may be performed at rest and/or during pharmacologic stress. o Use the appropriate stress testing code from the series: 93015-93018 in addition to 78491 and 78492. 3D Rendering (CPT 76376 and 76377) should not be used in conjunction with cardiac PET. RETURN Page 17 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program NCM Nuclear Cardiac Imaging (NCM) MPI; (planar) single study, at rest or stress (exercise and/or pharmacologic), with or 78460 without quantification MPI; multiple studies (planar), at rest and/or stress (exercise and/or pharmacologic), and 78461 redistribution and/or rest injection, with or without quantification MPI; tomographic (SPECT) single study (including attenuation correction when 78464 performed), at rest or stress (exercise and/or pharmacologic), with or without quantification MPI; tomographic (SPECT) multiple studies (including attenuation correction when 78465 performed), at rest and/or stress (exercise and/or pharmacologic), and redistribution and/or rest injection, with or without quantification 78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitative 78468 Myocardial Imaging, infarct avid, planar; with ejection fraction by first pass technique Myocardial Imaging, infarct avid, planar; tomographic SPECT with or without 78469 quantification Cardiac Blood Pool Imaging, gated equilibrium; planar, single study at rest or stress 78472 (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing Cardiac Blood Pool Imaging, gated equilibrium; multiple studies, wall motion study plus 78473 ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification Myocardial perfusion study with wall motion, qualitative or quantification study (List +78478 separately in addition to code for primary procedure) [78478 may be used in conjunction with 78460, 78461, 78464, and 78465.] Myocardial perfusion study with ejection fraction (EF) (List separately in addition to code +78480 for primary procedure) [78480 may be used in conjunction with 78460, 78461, 78464, and 78465.] Cardiac Blood Pool Imaging planar, first pass technique; single study, at rest or with 78481 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 78483 with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification Cardiac Blood Pool Imaging, gated equilibrium, SPECT, at rest, wall motion study plus 78494 ejection fraction, with or without quantitative processing +78496 Cardiac Blood Pool Imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List in addition to code for primary procedure) [Use this code in conjunction with 78472] [78496 may be used in conjunction with 78472.] 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine CODING NOTE: Myocardial perfusion imaging (MPI) and cardiac blood pool imaging studies may be performed at rest and/or during stress. When completed during exercise and/or pharmacologic stress, providers are to use the appropriate stress testing code from the series: 93015-93018 in addition to codes: 78460-78465 and 78472-78492. RETURN Page 18 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program STRESS STRESS TESTING Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, 93015 continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report CPT 93015 is used alone to report a standard exercise stress test, (for example, a Bruce protocol treadmill stress test (TMT), without a nuclear imaging component. Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, 93016 continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, 93017 continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, 93018 continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only TTE TRANSTHORACIC ECHO (TTE) 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete 93304 Transthoracic echocardiography for congenital cardiac anomalies; follow-up study Echocardiography, transthoracic, real time with image documentation (2D), includes M- 93306 mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography Echocardiography, transthoracic, real time with image documentation (2D), includes M- mode recording, when performed, complete, without spectral or color Doppler 93307 echocardiography [DO NOT use 93307 in conjunction with 93320, 93321, and 93325.] Echocardiography, transthoracic, real time with image documentation (2D), includes M- 93308 mode recording, when performed, follow-up or limited study Doppler echocardiography, pulsed wave and/or continuous wave with spectral display +93320 (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with 93303 and 93304.] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display +93321 (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93321 may be used in conjunction with 93303, 93304, and 93308.] Doppler echocardiography color flow velocity mapping (List separately in addition to +93325 codes for echocardiographic imaging) [93325 may be used in conjunction with 93303, 93304, and 93308] RETURN Page 19 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program TEE TRANSESOPHAGEAL ECHO (TEE) Echocardiography, transesophageal, (TEE) real-time with image documentation (2D) 93312 (with or without M-mode recording); including probe placement, image acquisition, interpretation and report Echocardiography, transesophageal, (TEE) real-time with image documentation (2D) 93313 (with or without M-mode recording); placement of transesophageal probe only Echocardiography, transesophageal, (TEE) real-time with image documentation (2D) 93314 (with or without M-mode recording); image acquisition, interpretation & report only Transesophageal echocardiography (TEE) for congenital cardiac anomalies; including 93315 probe placement, image acquisition, interpretation and report Transesophageal echocardiography (TEE) for congenital cardiac anomalies; placement 93316 of transesophageal probe only Transesophageal echocardiography (TEE) for congenital cardiac anomalies; image 93317 acquisition, interpretation & report only Transesophageal echocardiography (TEE) for monitoring purposes, including probe placement, real-time 2D image acquisition and interpretation leading to ongoing 93318 assessment of cardiac pumping function and to therapeutic measures on an immediate time basis Doppler echocardiography, pulsed wave and/or continuous wave with spectral display +93320 (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with 93312, 93314, 93315, and 93317.] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display +93321 (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93321 may be used in conjunction with 93312, 93314, 93315, and 93317.] Doppler echocardiography color flow velocity mapping (List separately in addition to +93325 codes for echocardiographic imaging) [93325 may be used in conjunction with 93312, 93314, 93315, and 93317.] RETURN Page 20 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program ECHO STRESS ECHO Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording, when performed, during rest and cardiovascular stress test using 93350 treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report [Use the appropriate stress testing codes from the 93016-93018 series, in addition to CPT 93350 to report the exercise stress portion of the study.] Echocardiography, transthoracic, real-time with image documentation (2D), includes M- mode recording when performed, during rest and cardiovascular stress test using 93351 treadmill, bicycle exercise and/or pharmacologically induced stress, including performance of continuous electrocardiographic monitoring, with physician supervision [DO NOT use 93351 in conjunction with 93015-93018 or 93350.] 93352 Use of echocardiographic contrast agent during stress echocardiography [DO NOT use 93352 more than once per stress echocardiogram.] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display +93320 (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with 93350 and 93351] Doppler echocardiography, pulsed wave and/or continuous wave with spectral display +93321 (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93321 may be used in conjunction with 93350 and 93351] Doppler echocardiography color flow velocity mapping (List separately in addition to +93325 codes for echocardiographic imaging) [93325 may be used in conjunction with 93350 and 93351] RETURN Page 21 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program DOPPLER DOPPLER ECHOCARDIOGRAPHY Doppler echocardiography, pulsed wave and/or continuous wave with spectral +93320 display (List separately in addition to codes for echocardiographic imaging); complete [93320 may be used in conjunction with 93303, 93304, 93312, 93314, 93315, 93317, 93350, and 93351] Doppler echocardiography, pulsed wave and/or continuous wave with spectral +93321 display (List separately in addition to codes for echocardiographic imaging); follow-up or limited study [93320 may be used in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 93317, 93350, and 93351] Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiographic imaging) +93325 [93325 may be used in conjunction with 93303, 93304, 93308, 93312, 93314, 93315, 93317, 93350, and 93351] The procedures listed above are performed in addition to the primary procedure. o These additional procedures are designated in CPT as add-on codes with the symbol +. o Add-on codes can also be identified by specific wording in the description. For example, the codes for Doppler echocardiography include the phrase: (List separately in addition to codes for echocardiographic imaging) o Add-on codes are always performed in addition to the primary procedure and must never be reported as a stand-alone code. o All add-on codes are exempt from use of the multiple procedures modifier (-51). RETURN Page 22 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program CATH DIAGNOSTIC LEFT HEART CATHETERIZATION Catheter placement in coronary artery(s), arterial coronary conduit(s), and/or venous 93508 coronary bypass graft(s) for coronary angiography without concomitant left heart catheterization (Diagnostic coronary artery catheterization w/o left heart catheterization) Left heart catheterization, retrograde, from the brachial artery, axillary artery or 93510 femoral artery; percutaneous (Left heart catheterization by percutaneous puncture) Left heart catheterization, retrograde, from the brachial artery, axillary artery or 93511 femoral artery; by cutdown (Left heart catheterization by incision/surgical dissection to expose artery) 93514 Left heart catheterization by left ventricular puncture (Left heart catheterization by percutaneous left ventricular puncture) 93524 Combined transseptal and retrograde left heart catheterization (Left heart catheterization by transseptal route) Injection procedure during cardiac catheterization; for selective opacification of arterial 93539 conduits (eg, internal mammary), whether native or used for bypass (Coronary angiography of one or more arterial bypass grafts or arterial conduits) Injection procedure during cardiac catheterization; for selective opacification of 93540 aortocoronary venous bypass grafts, one or more coronary arteries (Coronary angiography of one or more venous bypass grafts) Injection procedure during cardiac catheterization; for selective left ventricular or left 93543 atrial angiograph (Contrast injection of left ventricle or left atrium) 93544 Injection procedure during cardiac catheterization; for aortography (Aortography of the ascending aorta and arch) Injection procedure during cardiac catheterization; for selective angiography (injection 93545 of radiopaque material may be by hand) (Coronary angiography of one or more native coronary arteries) Imaging supervision, interpretation and report for injection procedure(s) during cardiac 93555 catheterization; ventricular and/or atrial angiography (Imaging supervision for heart chambers) Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; pulmonary angiography, aortography, and/or selective coronary 93556 angiography including venous bypass grafts and arterial conduits (whether native or used in bypass) (Imaging supervision for vessels [pulmonary vessels, aorta, coronary arteries, bypass grafts, arterial conduits) RETURN Page 23 of 24

Outcomes Focused Cardiac Imaging (OFCI) Program RADIO RADIOPHARMACEUTICALS A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries (Use A9500 for Cardiolite ) A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose [Use A9502 for Myoview ] A9505 Thallium Tl-201 thallous chloride, diagnostic, per millicurie [Use A9505 for MIBG and Thallous Chloride, USP] A9526 Nitrogen N-13 ammonia, diagnostic, per study dose, up to 40 millicuries [Use A9526 with perfusion cardiac PET scans, CPT 78491 and 78492.] A9538 Technetium Tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries [Use A9538 for infarct avid MPI studies 78466-78469] A9552 Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries [Use A9552 with metabolic cardiac PET studies 78466-78469] A9555 Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries [Use A9555 with perfusion Cardiac PET scans, 78491 and 78492.] A9560 Technetium Tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries (Use this code with MUGA scans)) [Use A9560 with MUGA scans.] CONT CONTRAST AGENTS A9576 Injection, gadoteridol, (ProHance Multipack), per ml A9577 Injection, gadobenate dimeglumine (MultiHance), per ml A9578 Injection, gadobenate dimeglumine (MultiHance Multipack), per ml A9579 Injection, gadolinium-based magnetic resonance contrast, not otherwise specified per ml [Use A9579 for Omniscan ] A9700 Supply of injectable contrast material for use in echocardiography, per study Q9951 Low osmolar contrast material, 400 or greater mg/ml iodine concentration, per ml Q9953 Injection iron-based magnetic resonance contrast agent, per ml Q9955 Injection, perflexane lipid microspheres, per ml [Use for Imagent ] Q9956 Injection, octafluoropropane microspheres, per ml [Use for Optison ] Q9957 Injection, perflutren lipid microspheres, per ml [Use for Definity ] Q9965 Low osmolar contrast material, 100-199 mg/ml iodine concentration, per ml [Use Q9965 for Omnipaque 140, Omnipaque 180, Optiray 160] Q9966 Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml [Use Q9966 for Omnipaque 240, Optiray 240] Q9967 Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml [Use Q9967 for Omnipaque 300, & 350, Optiray 300, & 320, Oxilan 300, Oxilan 350] PHARMACOLOGIC STRESS AGENTS GENERIC BRAND HCPCS Dipyridamole Persantine J1245 Injection, dipyridamole, per 10 mg Adenosine Adenoscan J0152 Injection, adenosine, for diagnostic use, 30 mg Dobutamine Dobutrex J1250 Injection, dobutamine HCL, per 250 mg Regadenoson Lexiscan J2785 Injection, regadenoson. 0.1mg RETURN Page 24 of 24