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Contrast Agents and Radiopharmaceuticals

Diagnostic radiopharmaceuticals will be reimbursed according to the information within the table below. The radiopharmaceuticals administered up to 96 hours before the primary procedure will be subject to these rules.

Please note that all radiopharmaceuticals billed with a PET scan will be denied as "included in the primary procedure. Isotopes administered for therapeutic purposes will be subject to member benefits, contract exclusions and guidelines.

This information was last reviewed on January 23, 2023 and may be subject to change. Please note that no updates have been made to the content so far for 2023.

Code Code Description Allow with Code(s) Code Description Max. Units
A4641 Radiopharmaceutical, diagnostic, not otherwise classified n/a   Invoice Required
A9500 Technetium Tc-99m, Sestamibi, diagnostic, per study dose 78012-78016, 78018 Thyroid imaging 1
78070-78072 Parathyroid study 1
78075 Adrenal imaging 1
78099 Unlisted Endocrine Procedure 1
78428 Cardiac shunt detection 2
78445 Non-Cardiac Vascular Flow Imaging 1
78451-78454 Myocardial perfusion studies 2
78456-78458, 78466-78483, 78494-78496 Myocardial perfusion studies 2
78499 Unlisted cardiovascular procedure 2
78605-78606, 78800-78804, 78808 Tumor imaging 1
78830-78832 Radiopharmaceutical localization of tumor 1
78999 Unlisted diagnostic nuclear medicine 1
A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose 78012-78016, 78018 Thyroid imaging 2
78070-78072 Parathyroid study
78075 Adrenal imaging
78099 Unlisted Endocrine Procedure
78428 Cardiac shunt detection
78445 Non-Cardiac Vascular Flow Imaging
78451-78454 Myocardial perfusion studies
78456-78458, 78466-78483, 78494-78496 Myocardial perfusion studies
78499 Unlisted cardiovascular procedure
78800-78804, 78808 Tumor imaging
78830-78832 Radiopharmaceutical localization of tumor
78999 Unlisted diagnostic nuclear medicine
A9503 Technetium Tc-99m, Medronate, (MDP), diagnostic, per study dose, up to 30 mCi's 78300, 78305, 78306 Bone scan 1
78315 Bone and/or joint imaging
78350, 78351 Bone density study
78399 Unlisted MSK procedure
78803 Tumor imaging
A9505 Thallous Chloride TL-201, diagnostic, per mCi 78070-78072 Parathyroid imaging 4
78075 Adrenal imaging
78099 Unlisted Endocrine Procedure
78414 Determination of central c-v hemodynamics
78428 Cardiac shunt detection
78445 Non-Cardiac Vascular Flow Imaging
78451-78454 Myocardial perfusion studies
78456-78458, 78466-78483, 78494-78496 Myocardial perfusion studies
78499 Unlisted Cardiovascular Procedure
78800-78804, 78808 Tumor imaging
78830-78832 Radiopharmaceutical localization of tumor
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9507 Indium IN 111 Capromab Pendetide (ProstaScintâ) per study dose, up to 10 mci's 78800-78804 Tumor detection 4
78830-78832 Radiopharmaceutical localization of tumor, inflammatory process
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9510 Technetium Tc-99m Disofenin (Hepatolite ®, DISIDA), per study dose, up to 15 mCi's 78201, 78202 Liver imaging 1
78215, 78216 Liver and spleen imaging
78226, 78227 Hepatobiliary scan agent
78230-78232 Salivary gland imaging/Study
78258 Esophageal motility study
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264-78266 Gastric emptying imaging study
78267, 78268 Urea breath test
78278 Acute gastrointestinal blood loss imaging
78282 Gastrointestinal protein loss
78290 Intestine imaging
78291 Peritoneal-venous shunt patency test
78299 Unlisted gastrointestinal procedure
A9512 Technetium Tc-99m-Pertechnetate, Diagnostic, per mCi 78012-78015 Thyroid study 10
78016, 78018 Thyroid study
78070-78072 Parathyroid study
78075 Adrenal Imaging, Cortex and/or Medulla
A9512 Technetium Tc-99m-Pertechnetate, Diagnostic, per mCi 78099 Unlisted Endocrine Procedure 10
78102-78104 Bone marrow imaging;
78110, 78111 Plasma volume, radiopharmaceutical volume dilution technique
78120, 78121 Red cell volume determination
78122 Whole blood volume determination
78130 Red cell survival study
A9512 Technetium Tc-99m-Pertechnetate, Diagnostic, per mCi 78140 Labeled red cell sequestration, differential organ/tissue 10
78185 Spleen imaging only
78191 Platelet survival study
78195 Lymphatics and lymph nodes imaging
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure
78201, 78202 Liver imaging
78215, 78216 Liver and spleen imaging
78226, 78227 Hepatobiliary system imaging
78230-78232 Parotid or salivary scan
78258 Esophageal motility study
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264-78266 Gastric emptying imaging study
78267, 78268 Urea breath test
78278 Acute gastrointestinal blood loss imaging
78282 Gastrointestinal protein loss
78290 Intestine imaging
78291 Peritoneal-venous shunt patency test
78299 Unlisted gastrointestinal procedure
78481, 78483 Cardiac blood pool imaging
78600-78606, 78610 Brain study
78630, 78635, 78645, 78650 Cerebrospinal fluid flow imaging/study
78660 Dacryocystography
78699 Unlisted nervous system procedure
78700, 78701, 78707-78709, 78725 Kidney imaging morphology/study
78730 Urinary bladder residual
78740 Ureteral reflux study
78761 Testicular imaging with vascular flow
78799 Unlisted genitourinary procedure
78803 Tumor imaging
A9516 Iodine I-123 Sodium iodide capsule(s), Diagnostic per 100 Microcuries, up to 999 microcuries 78012-78014 Thyroid imaging 4
78015, 78016, 78018 Thyroid imaging
78070-78072 Parathyroid imaging
78075 Adrenal Imaging, Cortex and/or Medulla
78099 Unlisted Endocrine Procedure
A9520 Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 millicurie 78102-78104 Bone marrow imaging; 1
78110, 78111 Plasma volume, radiopharmaceutical volume dilution technique
78120, 78121 Red cell volume determination
A9520 Technetium tc-99m, tilmanocept, diagnostic, up to 0.5 millicurie 78122 Whole blood volume determination 1
78130 Red cell survival study
78140 Labeled red cell sequestration, differential organ/tissue
78185 Spleen imaging only
78191 Platelet survival study
78195 Lymphatics and lymph nodes imaging
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure
A9521 Technetium Tc-99m Exametazine (Ceretec ®), Diagnostic, per study dose, up to 25 mCi’s 78600-78606, 78610 Brain perfusion 2
78630, 78635, 78645, 78650 CSF study
78660 Radiopharmaceutical Dacryocystography
78699 Unlisted Nervous System Procedure
78803 Tumor imaging 1
A9524 Iodinated I-131-Serum Albumin, diagnostic, per 5 microcuries 78102-78104 Bone marrow imaging; 10
78110-78111, 78122 Plasma Volume
78120, 78121 Red cell volume determination
78130 Red cell survival study
78140 Labeled red cell sequestration, differential organ/tissue
78185 Spleen imaging only
78191 Platelet survival study
78195 Lymphatics and lymph nodes imaging
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure
78451, 78453, 78454 Cardiac imaging
78579-78598 Pulmonary perfusion imaging
78600-78606, 78610 Brain Imaging
78800-78804 Tumor Imaging
78472-78473, 78481, 78483 Cardiac Blood Pooling imaging
A9528 Iodine I-131 Sodium Iodide capsule(s), Diagnostic, per mCi 78012-78018, 78803 Thyroid imaging 10
78070-78072 Parathyroid planar imaging
78075 Adrenal Imaging, Cortex and/or Medulla
78099 Unlisted Endocrine Procedure
A9529 Iodine I-131 Sodium Iodide solution, Diagnostic, per mCi 78012-78018, 78803 Thyroid imaging 10
78070-78072 Parathyroid planar imaging
78075 Adrenal Imaging, Cortex and/or Medulla
78099 Unlisted Endocrine Procedure
A9531 Iodine I-131 Sodium Iodide, Diagnostic, per microcurie (up to 100 microcuries) 78012-78018, 78803 Thyroid imaging 80
78070-78072 Parathyroid planar imaging
78075 Adrenal Imaging, Cortex and/or Medulla
78099 Unlisted Endocrine Procedure
A9532 Iodinated i-125 serum albumin, diagnostic, per 5 microcuries 78102-78104 Bone marrow studies 10
78110, 78111 Plasma volume, radiopharmaceutical volume dilution technique
78120, 78121 Red cell volume determination
78122 Whole blood volume determination
78130 Red cell survival study
78140 Labeled red cell sequestration, differential organ/tissue
78185 Spleen imaging
78191 Platelet survival study
78195 Lymphatics & Lymph glands
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure
A9537 Technetium Tc-99m Mebrofenin (Choletec ®) Diagnostic, per study dose, up to 15 mCi's 78226, 78227 Hepatobiliary scan agent 1
78201, 78202 Liver imaging
78215, 78216 Liver and spleen imaging
78230-78232 Salivary gland imaging/Study
78258 Esophageal motility study
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264-78266 Gastric emptying imaging/study
78267, 78268 Urea breath test
78278 Acute gastrointestinal blood loss imaging
78282 Gastrointestinal protein loss
78290 Intestine imaging
78291 Peritoneal-venous shunt patency test
78299 Unlisted gastrointestinal procedure
A9538 Technetium Tc-99m Pyrophosphate (PYP) (Pyrolite ®) Diagnostic, per study dose, up to 25 mCi's 78300, 78306, 78315 Bone and/or joint imaging 1
78305 Bone and/or joint imaging
78350, 78351 Bone density study
78399 Unlisted musculoskeletal procedure
78466-78469 Myocardial Infarct imaging
78999 Nuclear diagnostic exam_unlisted
78414 Determination of central c-v hemodynamics
78428 Cardiac shunt detection
78445 Non-Cardiac Vascular Flow Imaging
78451, 78452, 78453, 78454 Myocardial perfusion imaging
78456-78458 Venous Thrombosis Imaging
78472, 78473, 78481, 78483, 78494, 78496 Cardiac blood pool imaging
78499 Unlisted Cardiovascular Procedure
78803 Tumor imaging
A9539 Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 25 mCi's 78291, 78645 Shunt patency agent. 500 uCi 1
78428 Cardiac Shunt detection
78445 Vascular flow study
78481, 78483 First-pass cardiac technique studies
78579, 78580, 78582, 78597, 78598 Lung ventilation
78599 Unlisted respiratory procedure
78600-78606, 78610 Brain study
78630-78650 CSF study
78660 Radiopharmaceutical Dacryocystography
78699 Unlisted Nervous System Procedure
78700, 78701, 78707-78709, 78725 Kidney imaging morphology/study
A9539 Technetium Tc-99m Pentetate, Diagnostic, per study dose, up to 25 mCi's 78730 Urinary bladder residual 1
78740 Ureteral reflux
78761 Testicular imaging with vascular flow
78799 Unlisted genitourinary procedure
78803 Tumor imaging
A9540 Technetium Tc-99m Macroaggregated Albumin (MAA), Diagnostic, per study dose, up to 10 mCi’s 78201, 78215 Liver imaging 1
78216, 78428 Cardiac Shunt Detection
78291 Peritoneal-Venous Shunt Study
78579, 78580, 78582, 78597, 78598 Lung ventilation
78599 Unlisted respiratory procedure
78800, 78801, 78803 Tumor imaging
A9541 Technetium Tc-99m Sulfur Colloid, Diagnostic, per study dose, up to20 mCi's 78102-78104 Bone marrow studies 1
78110, 78111 Plasma volume, radiopharmaceutical volume dilution technique
78120, 78121 Red cell volume determination
78122 Whole blood volume determination
78130 Red cell survival study
78140 Labeled red cell sequestration, differential organ/tissue
78185 Spleen imaging
78191 Platelet survival study
78195 Lymphatics & Lymph glands
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure
78201-78202, 78215-78216 Liver, spleen imaging
78226, 78227 Hepatobiliary system imaging
78230-78232 Salivary gland imaging/Study
78261 Gastric mucosa imaging
78258, 78262 Gastroesophageal reflux studies
78264, 78265, 78266 Gastric emptying, gastric emptying with colonic transit studies
78267, 78268 Urea breath test
78278 GI bleed studies
78282 Gastrointestinal protein loss
78290 Intestine imaging
78291 Peritoneal-pleural shunt studies
78299 Unlisted gastrointestinal procedure
78730 Urinary bladder residual study
78740 Ureteral reflux study
A9547 Indium-IN-111 Oxyquinoline, Diagnostic, per 0.5 mCi 78185 Leukocyte labeling 1
78191 Platelet labeling
78199 Blood/lymph nuclear exam_unlisted
78800-78804 Radiopharmaceutical localization of tumor
A9547 Indium-IN-111 Oxyquinoline, Diagnostic, per 0.5 mCi 78808 Injection procedure for radiopharmaceutical localization 1
78830-78832 Radiopharmaceutical localization of tumor
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9548 Indium IN-111 Pentetate (MyoScint®) Diagnostic, per 0.5 mCi 78102-78104 Bone marrow imaging; 1
78110, 78111 Plasma volume, radiopharmaceutical volume dilution technique
78120, 78121 Red cell volume determination
78122 Whole blood volume determination
78130 Red cell survival study
78140 Labeled red cell sequestration, differential organ/tissue
78185 Spleen imaging only
78191 Platelet survival study
78195 Lymphatics and lymph nodes imaging
78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure
78201, 78202 Liver imaging
78215, 78216 Liver and spleen imaging
78226, 78227 Hepatobiliary system imaging
78230-78232 Salivary gland imaging/Study
78258 Esophageal motility study
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264-78266 Gastric emptying imaging/study
78267, 78268 Urea breath test
78278 Acute gastrointestinal blood loss imaging
78282 Gastrointestinal protein loss
78290 Intestine imaging
78291 Peritoneal-venous shunt patency test
78299 Unlisted gastrointestinal procedure
78600, 78601, 78605, 78606, 78610 Brain Imaging
78630, 78635,78645 Cerebrospinal fluid flow, imaging
78650 CSF leakage and detection
78660 Radiopharmaceutical Dacryocystography
78699 Unlisted Nervous System Procedure
78800 Localization of tumor
78803 Tumor imaging
A9551 Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 10 mCi's 78700-78709 Kidney imaging 1
78725 Kidney function study
78730 Urinary bladder residual study
78740 Ureteral reflux study
78761 Testicular imaging
A9551 Technetium Tc-99m Succimer (DMSA), Diagnostic, per study dose, up to 10 mCi's 78799 Unlisted genitourinary procedure 1
78800, 78802, 78803, 78804 Tumor detection
A9554 Iodine-125 Sodium Iothalamate (Glofil-125 ®), Diagnostic, per study dose, up to 10 microcuries 78700, 78701, 78725 Renogram 1
78707-78709 Kidney imaging morphology/study
78730 Urinary bladder residual study
78740 Ureteral reflux study
78761 Testicular imaging
78799 Unlisted genitourinary procedure
A9556 Gallium Ga-67 Citrate, Diagnostic, per mCi 78808 Injection procedure for radiopharmaceutical localization 5
78830-78832 Localization of tumor
78999 Nuclear diagnostic exam_unlisted
78800-78804 Tumor imaging
A9557 Technetium Tc-99m Bicisate (Neurolite ®), Diagnostic, per study dose, up to 25 mCi's 78600-78606, 78610 Brain imaging 2
78630, 78635, 78645, 78650 Cerebrospinal Fluid Flow
78660 Radiopharmaceutical Dacryocystography
78699 Unlisted Nervous System Procedure
78803 Tumor imaging
A9558 Xenon Xe-133 Gas, Diagnostic, per 10 mCi’s 78579-78598 Pulmonary perfusion imaging 3
78599 Unlisted respiratory procedure
A9560 Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mCi’s (Ultra Tag ® or cold pyrophosphate (pyp) +99m technetium) 78201-78202 Liver scan (for Hemangioma) 1
78215, 78216, 78185 Spleen imaging
78226, 78227 Hepatobiliary system imaging
78230-78232 Salivary gland imaging/Study
78258 Esophageal motility study
78261 Gastric mucosa imaging
78262 Gastroesophageal reflux study
78264-78266 Gastric emptying imaging/study
78267, 78268 Urea breath test
78472, 78473, 78494, 78496 Cardiac blood pool imaging / Gated Equilibrium studies
78282 Gastrointestinal protein loss
78290 Intestine imaging
78291 Peritoneal-venous shunt patency test
78299 Unlisted gastrointestinal procedure
78300, 78305, 78306, 78315 Bone and/or Joint Imaging
78350, 78351 Bone density study
78399 Unlisted musculoskeletal procedure
78414 Determination of central c-v hemodynamics
78428 Cardiac shunt detection
78451-78454 Myocardial perfusion imaging
78456 Acute venous thrombosis
A9560 Technetium Tc-99m Labeled Red Blood Cell's (RBC's) Diagnostic, per study dose, up to 30 mCi’s (Ultra Tag ® or cold pyrophosphate (pyp) +99m technetium) 78466-78469 Myocardial imaging 1
78481, 78483, 78496 Cardiac blood pool imaging
78499 Unlisted Cardiovascular Procedure
78803 Tumor imaging
A9561 Technetium Tc-99m Oxidronate, Diagnostic, per study dose, up to 30 mCi's 78300-78315 Bone scan agent 1
78350, 78351 Bone density study
78399 Musculoskeletal nuclear exam_unlisted
78803 Tumor imaging
A9562 Technetium Tc-99m Mertiatide (MAG-3), diagnostic, per study dose, up to 15 mCi's 78700-78725 Renal scan agent 1
78730 Urinary bladder residual study
78740 Ureteral reflux study
78761 Testicular imaging
78799 Unlisted genitourinary procedure
78803 Tumor imaging
A9567 Technetium Tc-99m Pentetate, Diagnostic, aerosol, per study dose, up to 75 mCi’s 78579-78598 Lung ventilation 1
78599 Unlisted respiratory procedure
A9569 Technetium TC-99m Exametazime labeled autologous white blood cells, Diagnostic, per study dose 78800-78803 Tumor imaging 1
78804 Radiopharmaceutical localization of tumor
78808 Injection procedure for radiopharmaceutical localization
78830-78832 Localization of tumor
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9570 Indium-111 labeled autologous white blood cells, diagnostic, per study dose 78185 Leukocyte labeling 1
78800- 78803 Radiopharmaceutical localization of tumor
78804 Radiopharmaceutical localization of tumor
78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma)
78830-78832 Radiopharmaceutical localization of tumor
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9571 Indium in-111 labeled autologous platelets, diagnostic, per study dose 78191 Platelet labeling 1
78199 Blood/lymph nuclear exam, unlisted
78800-78804 Radiopharmaceutical localization of tumor
78808 Injection procedure for radiopharmaceutical
78830-78832 Radiopharmaceutical localization of tumor
78835 Radiopharmaceutical quantification measurement
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9572 Indium-111 Pentetreotide (OctreoScan ®), Diagnostic, per study dose, up to 6 millicuries 78075 Adrenal imaging 1
78015-78018 Thyroid imaging
78800-78804 Radiopharmaceutical localization of tumor
A9572 Indium-111 Pentetreotide (OctreoScan ®), Diagnostic, per study dose, up to 6 millicuries 78808 Injection procedure for radiopharmaceutical 1
78830-78832 Radiopharmaceutical localization of tumor
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9582 Iodine i-123 Iobenguane, diagnostic, per study dose, up to 15 millicuries AdreView ®) 78075 Adrenal imaging 1
78800-78804 Neuroblastoma imaging
78012-78016, 78018, 78070-78072 Thyroid imaging
78099 Unlisted Endocrine Procedure
78428 Cardiac shunt detection
78414 Determination of central c-v hemodynamics
78445 Non-Cardiac Vascular Flow Imaging
78456, 78457, 78458 Venous Thrombosis Imaging Venogram
78451-78454, 78466-78469 Myocardial imaging
78472-78483, 78494, 78496 Cardiac blood pool imaging
78499 Unlisted Cardiovascular Procedure
78808 Injection procedure for radiopharmaceutical localization
78830-78832 Radiopharmaceutical localization of tumor
78999 Unlisted miscellaneous, procedure, diagnostic nuclear medicine
A9584 Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries 78600-78610 Brain imaging 1
78630-78645 Cerebrospinal fluid flow, imaging
78650 Csf leakage imaging
78660 Nuclear exam of tear flow
78699 Nervous system nuclear exam
78803 Tumor imaging