LaSalle Medical Associates 2012 Matrix Revision Date: 11/26/2012

Legend: X - included in cap, no authorization required (use direct referral form for the Region of choice) A - included in cap, requires authorization (goes through RadNet; use LaSalle Prior Auth form for the Region of choice) FFS - carved out from cap, available on fee for service basis (authorization required through LaSalle and LaSalle to decide which center to send to)

Riverside County San Bernardino County INLAND EMPIRE REGION SAN BERNARDINO REGION (CAI) Corona Advanced Imaging Center (HL) San Bernardino Advanced Imaging - Highland 886 Magnolia Ave., Ste 101 Corona 92879 2131 Elks Dr., Ste 200, San Bernardino, CA 92404 (CIC) Corona Imaging Center (SBA) San Bernardino Advanced Imaging - Loma Linda 175 E. 9th St., Corona 92879 10459 Mountain View Ave., Ste E, Loma Linda, CA 92354 (GDI) Grove Diagnostic Imaging Center (RAI) Redlands Advanced Imaging 8283 Haven Ave., Ste 101 Rancho Cucamonga 91730 1901 W. Lugonia Ave., Ste 110, Redlands, CA 92374 (GDH) Grove Diagnostic - Haven VICTORVALLEY REGION 8599 Haven Ave., Suite 101 Rancho Cucamonga 91730 (VIA) Victorville Advanced - Apple Valley (HCI) HealthCare Imaging Center 18523 Corwin Rd., Ste J Apple Valley 92307 4334 Central Ave., Riverside 92506 (EAI) Elite Advanced (HCC) HealthCare Imaging Center - Citrus 17260 Bear Valley Road, Ste 109 Victorville Ca 92395 6868 Magnolia Ave., Ste 109 Riverside 92506 (VIH) Victorville Advanced - Hesperia Rd (HCMV) HealthCare Imaging Center - Moreno Valley 12677 Hesperia Rd., Ste 190 Victorville CA 92395 1141 Heacock St., Ste E Moreno Valley CA 92506 (VOM) Victorvalley Advanced - Open Scan (SJI) San Jacinto Imaging Center 12276 Hesperia Road., Ste 6 Victorville CA 92395-5838 1695 S. San Jacinto Ave Suite B, San Jacinto CA 92583 (TVA) Temecula Valley Advanced Imaging Center 25455 Medical Center Drive Suite 100, Murrieta CA 92562 (TVI) Temecula Valley Imaging Center-Murrieta 25395 Hancock Ave. Suite 110 Murrieta CA 92562 (BCT) The Breast Care Center of Temecula Valley 25455 Medical Center Drive Suite 210, Murrieta CA 92562

Registered Customer Page 1 11/29/2012 RADNET INC MASTER CPT MATRIX

EXAM CPT COMMENTS

CT Head or Brain; wo contrast 70450 A CAI,GDI,HCI,TVA,VIA,EAI,SBA, SJI CT Head or Brain; with contrast 70460 A CAI,GDI,HCI,TVA,VIA,EAI,SBA, SJI CT Head or Brain; w/wo contrast 70470 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Orbit, sella, or posterior fossa, middle or inner ear, wo contrast 70480 A CAI,GDI,HCI,TVA,VIA,SBA,SJI CT Orbit, sella, or posterior fossa, middle or inner ear, with contrast 70481 A CAI,HCI,TVA,VIA,SBA,SJI CT Orbit, sella, or posterior fossa, middle or inner ear, w/wo contrast 70482 A CAI,GDI,HCI,TVA,VIA,SBA,SJI CT maxillofacial area, w/o 70486 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT maxillofacial with contrast 70487 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT maxillofacial area, w & w/o 70488 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT soft tissue neck, wo contrast 70490 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT soft tissue neck, with contrast 70491 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT soft tissue neck, w/wo contrast 70492 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT , head with contrast 70496 A GDI,HCI,TVA,VIA CT angiography, neck with contrast 70498 A GDI,HCI,TVA,VIA CT Thorax, wo contrast 71250 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Thorax, with contrast 71260 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Thorax, w/wo contrast 71270 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT, angiography, chest 71275 A GDI,HCI,TVA,VIA(Thoracic only/no cardiac) CT Spine, Cervical, wo contrast 72125 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Cervical, with contrast 72126 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Cervical, w/wo contrast 72127 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Thoracic, wo contrast 72128 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Thoracic, with contrast 72129 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Thoracic, w/wo contrast 72130 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Lumbar, wo contrast 72131 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Lumbar, with contrast 72132 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Spine, Lumbar, w/wo contrast 72133 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT angiography, pelvis with contrast 72191 A GDI,HCI,TVA,VIA(Kidney & Renal Only) CT Pelvis, wo contrast 72192 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Pelvis, with contrast 72193 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Pelvis, w/wo contrast 72194 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Upper extremity, wo contrast 73200 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Upper extremity, with contrast 73201 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Upper extremity, w/wo contrast 73202 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT, angiography, upper extremity with contrast 73206 A GDI,HCI,TVA,VIA CT Lower Extremity, wo contrast 73700 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Lower Extremity, with contrast 73701 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Lower Extremity, w/wo contrast 73702 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT, angiography, lower extremity with contrast 73706 A GDI,HCI,TVA,VIA CT Abdomen, wo contrast 74150 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Abdomen, with contrast 74160 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI CT Abdomen, w/wo contrast 74170 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI

Registered Customer Page 2 11/29/2012 CT, angiography, abdomen with contrast 74175 A GDI,HCI,TVA,VIA CT bone density 76070 A VIA CT recon (3-D Reconstruction avail upon request) 76375 A GDI,HCI,TVA,VIA MRI, Tempromandibular joint - bilateral 70336 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI,RAI MRI orbit, face and neck 70540 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, orbit, face, neck w/contrast 70542 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, orbit, face, neck w and w/o contrast 70543 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, angiography, head, w/o contrast 70544 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,RAI MRI, angiography, head, with contrast 70545 A GDI,HCI,TVA,VIA,VIH,EAI,RAI MRI, angiography, head, with and without contrast 70546 A GDI,HCI,TVA,VIA,VIH,EAI,RAI MRI, angiography, neck w/o contrast 70547 A GDI,HCI,TVA,VIA,VIH,EAI,VOM,RAI MRI, angiography, with contrast, NECK 70548 A GDI,HCI,TVA,VIA,VIH,EAI,RAI MRI, angiography, neck with and without contrast 70549 A GDI,HCI,TVA,VIA,VIH,EAI,RAI MRI Brain, wo contrast 70551 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Brain, with contrast 70552 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Brain, w/wo contrast 70553 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Chest, without contrast 71550 A GDI,HCI,TVA,VIA,VIH,VOM,EAI,SBA,SJI,RAI MRI Chest, with contrast 71551 A GDI,HCI,TVA,VIA,VIH,VOM,EAI,SBA,SJI,RAI MRI Chest, with and without contrast 71552 A GDI,HCI,TVA,VIA,VIH,VOM,EAI,SBA,SJI,RAI MRI Angiography, chest, w/wo dye 71555 A GDI,HCI,TVA,VIA,EAI,RAI MRI Spine, Cervical, wo contrast 72141 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Cervical, with contrast 72142 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Thoracic, wo contrast 72146 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Thoracic, with contrast 72147 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Lumbar, wo contrast 72148 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Lumbar, with contrast 72149 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Cervical, w/wo contrast 72156 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Thoracic, w/wo contrast 72157 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Spine, Lumbar, w/wo contrast 72158 A CAI,GDI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI angiography, spinal canal w/wo dye 72159 A CAI,TVA,VIA,EAI,GDI,RAI MRI, pelvis, without contrast 72195 A CAI,GDI (NO ENDORECTAL COIL),HCI,TVA,VIA,VOM,EAI, SBA,SJI,RAI MRI, pelvis, w/dye 72196 A CAI,GDI (NO ENDORECTAL COIL),HCI,TVA,VIA,VOM,EAI, SBA,SJI,RAI MRI, pelvis, with and without contrast 72197 A CAI,GDI (NO ENDORECTAL COIL),HCI,TVA,VIA,VOM,EAI, SBA,SJI,RAI MRI, angiography, pelvis w/wo dye 72198 A GDI,HCI,TVA,RAI MRI, upper extremity w/o contrast 73218 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, upper extremity, with contrast 73219 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, upper extremity, with and without contrast 73220 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, joint, upper extremity without contrast 73221 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI,RAI MRI, joint, upper extremity with contrast 73222 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI,RAI MRI, joint, upper extremity with and without contrast 73223 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI,RAI MRI, angiography, upper extremity with and without contrast 73225 A GDI,HCI,TVA,VIA,EAI,RAI MRI, lower extremity without contrast 73718 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, lower extremity with contrast 73719 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, lower extremity with and without contrast 73720 A CAI,GDI,HCI,TVA,VIA,VOM,EAI EXCLUDES RUNOFF,RAI MRI Lower Extremity, Any joint wo contrast 73721 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI, lower extremity, joint, with contrast 73722 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI,RAI MRI, lower extremity, joint, with and without contrast 73723 A CAI,GDI,HCI,TVA,VIA,EAI,SBA,SJI,RAI MRI angiography, lower extremity w/wo dye 73725 A TVA,HCI,GDI,EAI,VIA,RAI MRI Abdomen, wo contrast 74181 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI Abdomen, with contrast 74182 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI

Registered Customer Page 3 11/29/2012 MRI Abdomen, with and without contrast 74183 A CAI,GDI,HCI,TVA,VIA,VOM,EAI,SBA,SJI,RAI MRI angiography, abdomen w/wo dye 74185 A HCI,TVA,VIA,EAI,GDI,RAI HCI,TVA GDI (dedicated breast coil for breast ca detection) (r/o implant rupture only- MRI, Breast Unilateral, w or wo contrast 77058 A not for dection of breast ca)VIA,RAI HCI,TVA,GDI (dedicated breast coil for breast ca detection) (r/o implant rupture only- MRI, Breast Bilateral, w or wo contrast 77059 A not for dection of breast ca),VIA,RAI MRI Computer Aided Detection (CAD) 0159T A HCI,TVA,GDI(Included with Breast MRI/CPT codes 77058, 77059),RAI Thyroid Uptake, single 78000 A GDI,HCI,TVA *Thyroid Uptake, multiple 78001 A GDI,HCI,TVA Thyroid Imaging with uptake, single 78006 A GDI,HCI,TVA Thyroid Imaging with uptake, multiple 78007 A GDI,HCI,TVA Thyroid Imaging Only 78010 A GDI,HCI,TVA Thyroid Imaging with vascular flow 78011 A GDI,HCI,TVA Thyroid Met Imaging 78015 A GDI,TVA *Thyroid Mets Imaging, whole body AKA I131 78018 A GDI,TVA+E588 Thyroid, met uptake 78020 A Exclude Parathyroid Imaging 78070 A GDI,HCI,TVA Adrenal imagine 78075 A Exclude Endocrine nuclear procedure 78099 A Exclude *Bone marrow imaging, limited AKA Sulphar Colloid (must be specified) 78102 A GDI,HCI,TVA Bone marrow imaging, multiple 78103 A GDI,HCI,TVA Bone marrow imaging, whole body 78104 A GDI,HCI,TVA Scan 78110 A GDI,HCI,TVA Spleen imaging only, without vascular flow 78185 A GDI,HCI,TVA Nuclear lymphangiography 78195 A GDI,HCI,TVA Liver imaging, Static only 78201 A GDI,HCI,TVA Liver imaging, Static with vascular flow 78202 A GDI,HCI,TVA Liver imaging SPECT w/vascular flow 78206 A GDI,TVA Liver and Spleen imaging, Static only 78215 A GDI,HCI,TVA Liver and spleen imaging, Static with vascular flow 78216 A GDI,HCI,TVA Liver Function with hepatobiliary agent 78226 A GDI,HCI,TVA *Hepatobiliary duct imaging AKA HIDA Scan 78227 A GDI, HCI (Ask for CCK as indicated) imaging 78230 A GDI,HCI Esophogeal motility studies by 78258 A TVA Gastric mucosa study 78261 A GDI,HCI GI reflux 78262 A GDI,HCI,TVA *Gastric Emptying AKA GE Scan 78264 A GDI,TVA Acute GI blood loss 78278 A TVA (Send directly to hospital for active bleed) Meckel's diverticulum 78290 A GDI,HCI,TVA Levee shunt patency 78291 A GDI,HCI,TVA *Bone and/or joint imaging, Limited area AKA Bone Scan 78300 A GDI,HCI,TVA Bone and/or joint imaging, Multiple areas 78305 A GDI,HCI,TVA Bone and/or joint imaging, Whole body 78306 A GDI,HCI,TVA Bone and/or joint imaging, Three phase 78315 A GDI,HCI,TVA Bone and/or joint imaging, SPECT 78320 A GDI,TVA Non-cardiac vascular flow imaging 78445 A GDI,HCI,TVA Aerosol lung image, single 78586 A GDI,HCI,TVA Aerosol lung image, multiple 78587 A GDI,HCI,TVA Lung V/Q, aerosol 78588 A GDI,HCI,TVA Lung quantitative differential function 78596 A GDI,TVA

Registered Customer Page 4 11/29/2012 Lung Quantitative differential Pulmonary Perfusion 78597 A GDI, TVA Lung Quantitative differential Pulmonary Perfusion 78598 A GDI, TVA Brain imaging <4 static views 78600 A GDI Brain imaging <4 static views with vascular flow 78601 A GDI Brain imaging, minimum 4 static views 78605 A GDI,HCI,TVA Brain imaging, minimum 4 static views with vascular flow 78606 A GDI,HCI,TVA *CSF fluid scan 78630 A HCI Kidney imaging, static only 78700 A GDI,HCI,TVA Kidney imaging with vascular flow only 78701 A GDI,HCI,TVA Kidney imaging, Static with function study 78707 A GDI,HCI,TVA *Kidney imag single stdy, Static w/vasc flow & function stdy AKA Renogram 78707 A GDI,HCI,TVA Kidney imaging, Single study, (w/pharmacological intervention) 78708 A GDI,HCI,TVA Kidney imaging, Multiple studies, (w/wo pharmacological intervention) 78709 A GDI,HCI,TVA Kidney imaging, SPECT 78710 A GDI, TVA Kidney imaging, Vascular flow only 78715 A GDI,HCI,TVA Kidney function study 78725 A GDI,HCI,TVA Testicular imaging 78761 A GDI,HCI,TVA Testicular imaging with vascular flow 78761 A GDI,HCI,TVA Tumor localization; limited area 78800 A HCI,TVA Tumor localization; Multiple areas 78801 A HCI,TVA Tumor localization; Whole body; single day imaging 78802 A HCI,TVA Tumor localization; SPECT 78803 A TVA Tumor localization, whole body, two or more days imaging 78804 A HCI,TVA Abscess localization; limited area 78805 A HCI,TVA Abscess localization; whole body 78806 A TVA Abscess localization; SPECT 78807 A TVA Liver imaging, SPECT 78205 A TVA Breast Biopsy; percutaneous, needle core, not using imaging guidance 19100 A GDI,HCI,TVA,EAI ( ONLY) Breast Biopsy, incisional 19101 A HCI Breast biopsy, needle, using image guidance 19102 A GDI,HCI,BCT,VIA Breast biopsy, needle, using image guidance w/vacuum assistance 19103 A GDI,HCI,BCT,VIA Breast, needle localization 19290 A VIA Each Additional placement 19291 A VIA Image guided needle placement 19295 A TVA (Breast Only) Inj. , Shoulder 23350 A GDI,HCI,TVA,VIA,EAI Inj. Arthrogram, elbow 24220 A GDI,HCI,TVA,VIA,EAI Inj arthrogram wrist 25246 A GDI,HCI,TVA,VIA,EAI Injection procedure for hip arthrography; without anesthesia 27093 A GDI,HCI,VIA Inj. Arthrogram, knee 27370 A GDI,HCI,TVA,VIA,EAI Inj. Arthrogram, Ankle 27648 A GDI,HCI,TVA,VIA,EAI Inj for 58340 A GDI,HCI,TVI AS PART OF HYSTEROSALPINGOGRAM Injection, spinal canal (exclC1-C2) for CT myelo 62284 A HCI AS PART OF CT MYELOGRAM , cervical 72240 A HCI,VIA, TVA(WITH CT ONLY) Myelogaphy, thoracic 72255 A HCI,VIA, TVA(WITH CT ONLY) Myelogaphy, lumbosacral 72265 A HCI,VIA, TVA(WITH CT ONLY) Myelography, Entire spine 72270 A HCI, TVA Shoulder arthrography 73040 A GDI,HCI,TVA,VIA Elbow arthrography 73085 A GDI,HCI,TVA,VIA Wrist Arthrography 73115 A GDI,HCI,TVA,VIA Hip Arthrography 73525 A GDI,HCI,TVA,VIA

Registered Customer Page 5 11/29/2012 Knee arthrography 73580 A GDI,HCI,TVA,VIA Ankle arthrography 73615 A GDI,HCI,TVA Hysterosalpingography, S&I 74740 A GDI,HCI,TVA up to one hour physician time 76000 A GDI Fluoroscopy, physician time over one hour 76001 A GDI Needle localization by x-ray 77022 A HCI Fluoroguidance for injection for myelogram 77002 A HCI, VIA Fluoroguide for spine injection 77003 A HCI,VIA,TVA (WITH CT Only ) (DEXA) Bone densitometry; axial skeleton; spine/hip 77080 A GDI,HCI,TVA,VIH Stereotactic breast biopsies 77031 A HCI,BCT,EAI X-ray breast specimen 76098 A HCI , single plane body section (other than with urography) 76100 A GDI,HCI,TVA,VIA 3d Rendering with interp & report of CT, MRI, US or other tomography 76376-77 A HCI,TVA,EAI,VIA CT maxillofacial; maxilla/dental 70486.52 FFS TVA CT maxillofacial; mandible/dental 70486.52 FFS TVA CT for needle biopsy 77012 FFS HCI,VIA CT for therapy guide 77014 FFS TVA CT Limited or localized follow up study, any part 76380 FFS CAI,GDI,HCI,TVA,VIA PET, brain 78608 FFS HCI,TVA,EAI PET, IMAGING LIMITED AREA 78811 FFS EAI PET, IMAGING SKULL BASE TO MID THIGH 78812 FFS EAI PET IMAGING WHOLE BODY 78813 FFS EAI ISOTOPE FDG A9552 FFS Included in PET Scan PET/CT IMAGING LIMITED AREA 78814 FFS HCI,TVA,EAI PET/CT IMAGING SKULL BASE TO MID THIGH 78815 FFS HCI,TVA,EAI PET/CT IMAGING WHOLE BODY 78816 FFS HCI,TVA,EAI Sodium Fluoride F-18 diagnostic per study dose up to 30 millicuries A9580 FFS HCI,TVA,EAI Adenosine 30mg J0152 FFS Invoice cost plus 10% Group to approve I-123 sodium iodide A9509 FFS Invoice cost plus 10% Group to approve I-123 sodium iodide capsule A9516 FFS Invoice cost plus 10% Group to approve I-131 sodium iodide capsule A9517 FFS Invoice cost plus 10% Group to approve TC-99 Ceretec A9521 FFS Invoice cost plus 10% Group to approve Indium 111 DPTA A9548 FFS Invoice cost plus 10% Group to approve Indium 111 WBC 500uCi A9547 FFS Invoice cost plus 10% Group to approve Octeotide/Octeoscan A9572 FFS Invoice cost plus 10% Group to approve Prostascint A9507 FFS Invoice cost plus 10% Group to approve CCK Sincilede Kinevac J2805 FFS Invoice cost plus 10% Group to approve Fine Needle Aspiration AKA FNA (Use with code 76942) 10022 FFS HCI, VIA (IF CLINICALLY APPROPRIATE) Cyst Aspiration, Skin/Subsequent 10160 FFS HCI,VIA Breast cyst aspiration 19000 FFS GDI,HCI,TVA,EAI Each additional cyst aspiration 19001 FFS GDI,HCI,TVA,EAI Mammary ductogram injection 19030 FFS HCI Bx, soft tissue, neck 21550 FFS VIA Thoracentesis, puncture pleural cavity 32421 FFS HCI ( IF CLINICALLY APPROPRIATE) Thoracentesis, puncture pleural cavity with tube insertion 32002 FFS HCI ( IF CLINICALLY APPROPRIATE) Bx pleura 32400 FFS Biopsy, lung or mediastinum, percutaneous needle 32405 FFS HCI (IF CLINICALLY APPROPRIATE) Inj 36005 FFS AV shunt for dialysis 36145 FFS

Registered Customer Page 6 11/29/2012 Biopsy, lymph nodes 38505 FFS HCI,VIA(IF CLINICALLY APPROPRIATE) Inj sialography 42550 FFS HCI (IF CLINICALLY APPROPRIATE) Biopsy, liver, needle, percutaneous 47000 FFS HCI,VIA(IF CLINICALLY APPROPRIATE) Liver cyst aspiration or drainage 47011 FFS HCI,VIA(IF CLINICALLY APPROPRIATE) Biopsy of , percutaneous needle 48102 FFS HCI,VIA (IF ClINICALLY APPROPRIATE) Peritoneocentesis, abdominal 49080 FFS HCI (IF ClINICALLY APPROPRIATE) Biopsy, abdominal/retroperitoneal mass 49180 FFS HCI (IF ClINICALLY APPROPRIATE) Sinogram Injection 49424 FFS HCI,VIA Renal bx 50200 FFS HCI Asp renal pelvis/cyst 50390 FFS HCI Injection procedure for visualization of ureteropyelography 50690 FFS HCI Injection procedure for 51600 FFS HCI,TVA Inj for retrograde urethrocystography 51610 FFS HCI,TVA Straight cath insertion 51701 FFS HCI Foley cath insertion 51702 FFS HCI Transcervical introduction of fallopian tube catheter 58345 FFS HCI,TVI AS PART OF HYSTEROSALPINGOGRAM Biopsy, thyroid-US/Cyst aspiration /fluid drainage 60100 FFS HCI ,VIA(IF CLINICALLY APPROPRIATE) Lumbar Puncture Routine-INJ/ASPIRATION 62270 FFS HCI AS PART OF CT MYELOGRAM Upper GI, via enteroclysis tube 74251 FFS TVA Cystography, min 3 vws, S&I 74430 FFS TVA Urethrocystography, retrograde; S&I 74450 FFS GDI,HCI Urethrocystography, Voiding, S&I 74455 FFS GDI,HCI,TVA Supervision, mammary ductogram 77053 FFS BCT Supervision, mammary ductogram, multiple 77054 FFS BCT Ultrasound, biopsy, mass, guidance, includes thoracentesis, renal cyst 76942 FFS HCI,TVA (Breast Only/use with CPT Code 19102) BREAST INCLUDED IN CAP CT guide needle biopsy 77012 FFS HCI Echography, first trimester < 14 weeks, single 76801 FFS GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, first trimester < 14 weeks, each additional 76802 FFS GDI,HCI,TVI,VIA,EAI,SBA,SJI 2D w/wo M mode Complete 93307 FFS GDI,HCI (OB ONLY) 2D w/wo M mode Limited 93308 FFS GDI,HCI (OB ONLY) Pulse and/or Cont Complete 93320 FFS HCI Pulse and/or Cont Limited 93321 FFS HCI Color Flow Doppler 93325 FFS CAI,TVI SUPPLIES AND MATERIALS 99070 IN CAP SURGICAL SUPPLY J2802 IN CAP Sincalide inject, kinevad J2805 IN CAP Depomedrol 40mg J1030 IN CAP INJECTION FUROSEMIDE, UP J1940 IN CAP Versed 10 mg J2250 IN CAP Injection fentanyl o.1mg J3010 IN CAP INJECTION THYROTROPIN ALPAA 0.9 J3240 IN CAP TC99M SESTAMIBI, DIAG PE A9500 IN CAP TC99M TETROFOSMIN 1-30 MC A9502 IN CAP TC 99 M MEDRONATE 1-25 MCI A9503 IN CAP TC099 TECHNETIUM A9504 IN CAP THALLOUS CHLORIDE TL-201 A9505 IN CAP Iodine 1-123 Sodium Iodide A9509 IN CAP TC-99 choletec A9510 IN CAP Technetium TC-99 prtechnetate A9512 IN CAP Iodine 1-131 DX cap A9528 IN CAP

Registered Customer Page 7 11/29/2012 1125 Serum albumin dx A9532 IN CAP TC 99m depreotidee, neotec A9536 IN CAP TC99m mebrofenin choletec A9537 IN CAP TC99m pyrohosphate A9538 IN CAP TC99m DTPA A9539 IN CAP TC99m MAA A9540 IN CAP TC99m Sulfur colloid A9541 IN CAP Nycomed A9546 IN CAP TC99 glucoscan A9550 IN CAP TC99 DMSA A9551 IN CAP Cr sodium chromate A9553 IN CAP 1125 iothalamate A9554 IN CAP Gallium A9556 IN CAP Neurolite A9557 IN CAP Xe133 Xenon A9558 IN CAP Technetium tc-99 red blood cells A9560 IN CAP Tc99 oxidronate, hdp A9561 IN CAP TC99 mag3 A9562 IN CAP TC99 neutro spec A9566 IN CAP Technetium tc99 dtpa aerosol A9567 IN CAP Technetium TC99 arcitumomab A9568 IN CAP Injection gadolinium base A9579 IN CAP Radiopharmaceuticl therapeutic rx noc A9699 IN CAP LOCM 300-349 mg/ml iodine Q9966 IN CAP LOCM 300-349 mg/ml iodine Q9967 IN CAP Duplex, abdominal, arterial or venous outflow 93975 X GDI ,EAI,SBA Non-invasive physio eval extracranial, complete, bilateral 93875 X EAI Duplex extracranial, complete, bilateral 93880 X GDI,HCI,TVI,EAI,SBA,SJI Duplex extracranial, unilateral or limited 93882 X GDI,HCI,TVI,EAI,SBA,SJI Non-invasive upper/lower,single level, bilat (ankle/brachial index) 93922 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Non-invasive,upper/lower, mult level bilat 93923 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Non-invasive lower artery,rest and TM stress, compl, bilater 93924 X EAI Duplex lower, complete, bilateral 93925 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex lower, unilateral or limited 93926 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex upper, complete or bilateral 93930 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex upper, unilateral or limited 93931 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Non-invasive physio venous, complete,bilateral 93965 X TVI,EAI Duplex, venous incl compression, complete bilateral 93970 X TVI(excl venous map)CAI,(incl ven map & venous sufficiency)GDI (incl venous Duplex, venous, unilateral or incomplete 93971 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex arterial and venous abdominal or pelvis ABD/PEL/ SCROTUM 93975 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex, abdominal , arterial or venous, limited 93976 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex abdominal aorta, IVC, iliac vasculature 93978 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex aorta, IVC Iliac or bypass grafts limited, unilateral 93979 X CAI,GDI,HCI,TVI,EAI,SBA,SJI Duplex, hemodialysis, arterial or venous 93990 X EAI Echo of head 76506 X GDI,HCI Echography soft tissues of head and neck (thyroid, parathyroid) 76536 X CAI,GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, chest 76604 X GDI,VIA,EAI (Non-Cardiac) Echography, breast(s) Unilateral or bilateral 76645 X GDI,HCI,TVI,EAI Echography abdominal, Complete 76700 X CAI,GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography abdominal, limited (single organ, quadrant, or follow-up) 76705 X GDI,HCI,TVI,VIA,EAI,SBA,SJI

Registered Customer Page 8 11/29/2012 Echography, retroperitoneal (renal, aorta, nodes) Complete 76770 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, etroperitoneal (renal, aorta, nodes) Limited 76775 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, Transplanted kidney; with or wo Doppler 76776 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, pregnant, B-scan > 14 weeks 76805 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, pregnant, B-scan, multiple > 14 weeks 76810 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography Uterus 76812 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography Uterus 76813 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, pregnant, B-scan, limited > 14 weeks 76815 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, pregnant, B-scan follow-up > 14 weeks 76816 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography Ob transvaginal 76817 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Fetal biophysical profile without stress 76819 X GDI,HCI ,EAI Echography, Transvaginal 76830 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Hysterosonography, with or without color flow doppler 76831 X TVI Echography, pelvic (non-obstetric) Complete 76856 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, pelvic (non-obstetric) Limited or follow-up 76857 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, Testis (scrotum) 76870 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, extremity non-vascular complete 76881 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, extremity non-vascular limited 76882 X GDI,HCI,TVI,VIA,EAI,SBA,SJI Echography, infant hips 76885 X GDI,HCI,TVI,SBA,SJI Echography, infant hips 76886 X GDI,HCI,TVI,SBA,SJI US study follow-up 76970 X CAI,GDI,HCI,TVI ,VIA,EAI,SBA,SJI Digital , screening, bilateral G0202 X CAI,GDI,GDH,HCI,TVI,BCT,VIH,EAI,SBA Digital Mammography, diagnostic, bilateral G0204 X GDI,HCI,TVI,BCT,EAI,SBA Digital Mammography, unilateral G0206 X CAI,GDI,HCI,TVI,BCT,EAI,SBA Computer Aided Detection (CAD) mammography diagnostic 77051 X HCI,BCT,EAI Computer Aided Detection (CAD) mammography screening 77052 X HCI,BCT,EAI X-ray foreign body eye 70030 X CAI,GDI,GDH,HCI,TVI,VIA,VIH,EAI, SBA,SJI Mandible X-ray, less than 4 views 70100 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Mandible X-ray, min. 4 views 70110 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Mastoids, less than 3 vws per side 70120 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Mastoids, min 3 views per side 70130 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Internal Auditory Meate, complete 70134 X CAI,GDI,GDH,HCI,TVI Facial bones, Less than 3 vw 70140 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Facial bones, min 3 vws. 70150 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Nasal bones, complete, min 3 views 70160 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Optic Framina X-ray 70190 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Orbits, complete, min 4 views 70200 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Sinuses, paranasal, less than 3 views 70210 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Sinuses, paranasal, Complete, min 3 views 70220 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Sella Turcica X-ray 70240 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Skull; less than 4 views 70250 X CAI,GDI,GDH,HCI,HCC,TVI,VIA,VIH,EAI,SBA,SJI Skull; complete; min 4 views 70260 X CAI,GDI,GDH,HCI,TVI,VIH,EAI,SBA,SJI TMJ Joint open and closed mouth, unilateral 70328 X CAI,GDI,GDH,HCI,TVI,VIH,EAI,SBA,SJI TMJ Joint open and closed mouth, bilateral 70330 X CAI,GDI,GDH,HCI,TVI,VIH,EAI,SBA,SJI Neck, soft tissue X-ray 70360 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIH,EAI,SBA,SJI Salivary gland for calculus 70380 X CAI,GDI,HCI,HCC,HCMV,TVI,SBA Chest, 1 vw 71010 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIH,EAI,SBA,SJI,HL Chest, stereo frontal 71015 X CAI,GDI,GDH,HCI,TVI,SBA,SJI,HL Chest, 2 vw, frontal & lateral 71020 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Chest, with apical lordotic 71021 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL

Registered Customer Page 9 11/29/2012 Chest with oblique(s) 71022 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Chest, with fluoroscopy 71023 X CAI,GDI,HCI,TVI,VIA,SBA,SJI Chest, complete min 4 vws 71030 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Chest, complete with fluoro 71034 X CAI,GDI,GDH,HCI,TVI,VIA,,VIH,EAI,SBA,SJI Chest, special views, decubitus 71035 X CAI,GDI,GDH,HCI,TVI,VIA,,VIH,EAI,SBA,SJI,HL Fluoroscopic localization for needle biopsy of intrathoracic lesion S&I 71036 X GDI,HCI,TVA Ribs, Unilateral; 2 vws 71100 X CAI,GDI,GDH,HCI,TVI,VIA,,VIH,EAI,SBA,SJI,HL Ribs, Unilateral; with PA chest 3 vws 71101 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Ribs; Bilateral; 3 vws 71110 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Ribs; Bilateral; with PA chest min 4 vws 71111 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Sternum, min of 2 vws 71120 X CAI,GDI,GDHHCI,TVI,VIA,,VIH,EAI,SBA,SJI,HL Sternoclavicular joint(s), min 3 vws 71130 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine Survey, entire, AP and lateral 72010 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, 1 view - Lumbar 72020 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, 1 view - Sacrum/Coccyx 72220 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, 1 view - Thoracic 72020 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, 1 view - Cervical 72020 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Cervical, 2 vws 72040 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, cervical, min 4 vws 72050 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Cervical, complete including obliques & flexion &/or extension 72052 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Thoracolumbar, standing (scoliosis study) 72069 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Thoracic, AP and lateral 72070 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Thoracic, including swimmers view of the cervicothoracic junction 72072 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Thoracic, complete including obliques, min 4 vws 72074 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Thoracolumbar, AP and lateral 72080 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Scoliosis study, including supine and erect studies 72090 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Lumboscral, AP and lateral 72100 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Lumbosacral, complete including obliques 72110 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Lumbosacral, complete including bending views 72114 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Spine, Lumbosacral, bending view only, 4 view 72120 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Pelvis, AP only 72170 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Pelvis, complete min 3 views 72190 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Sacroiliac Joints, less than 3 vws 72200 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Sacroiliac Joints, min 3 vws 72202 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Sacrum and coccyx, min 3 vws 72220 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Clavicle, Complete 73000 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Scapula, Complete 73010 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Shoulder, 1 view 73020 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Shoulder, complete, min 2 vws 73030 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Acromioclavicular joints, bilateral, w/wo weighted distraction 73050 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Humerus, Min 2 vws 73060 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Elbow: AP and lateral 73070 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Elbow: Complete min 2 views 73080 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Forearm, AP and lateral 73090 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Infant upper extremity, min 2 views 73092 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Wrist: AP and lateral 73100 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Wrist; complete min 3 vws 73110 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Hand, 2 vw 73120 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Hand, min 3 vws 73130 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Fingers, min 2 vws 73140 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL

Registered Customer Page 10 11/29/2012 Hip: Unilateral, 1 view 73500 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Hip: Unilateral, complete min 2 vws 73510 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Hips; Bilateral min 2 vws of each 73520 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Infant or child pelvis and hips, min 2 vws 73540 X CAI,GDI,GDH,HCI,HCC,HCMVTVI,VIA,,VIH,EAI,SBA,SJI,HL Sacroiliac joint arthroraphy RSI 27096 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA Femur, AP and lateral 73550 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Knee, AP and lateral 73560 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Knee, min 3 vws 73562 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Knee, complete 5 views 73564 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Knees, both standing 73565 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Tibia and Fibula, AP and lateral 73590 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Infant lower extremity, min 2 vws 73592 X CAI,GDI,GDH,HCI,HCMV,TVI,VIA,,VIH,EAI,SBA,SJI,HL Ankle, AP and lateral 73600 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIE,VIH,EAI,SBA,SJI,HL Ankle, complete, min 3 vws 73610 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIE,VIH,EAI,SBA,SJI,HL Foot, AP and lateral 73620 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIE,VIH,EAI,SBA,SJI,HL Foot, complete, min 3 vws 73630 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIE,VIH,EAI,SBA,SJI,HL Calcaneus, Min 2 vws 73650 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIE,VIH,EAI,SBA,SJI,HL Toes, Min of 2 vws 73660 X CAI,GDI,GDH,HCI,HCC,HCMV,TVI,VIA,VIE,VIH,EAI,SBA,SJI,HL Abdomen, 1 vw, AP or KUB 74000 X CAI,GDI,HCI,HCC,HCMV,TVI,VIA,VIH,EAI,SBA,SJI Abdomen, 2 vw, AP & obl or coned 74010 X CAI,GDI,HCI,HCC,HCMV,TVI,VIA,VIH,EAI,SBA,SJI Abdomen, complete decubitus and/or erect vws 74020 X CAI,GDI,HCI,TVI,VIA,VIH,SBA,SJI Abdomen, complete acute series 74022 X CAI,GDI,HCI,TVI,VIA,VIH,SBA,SJI Pharynx and/or cervical 74210 X CAI,GDI,HCI,HCMVTVI,VIA,SBA,SJI Esophagus 74220 X CAI,GDI,HCI,HCC,TVI,VIA,SBA,SJI Upper GI with or without delayed films wo KUB 74240 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Upper GI with or without delayed films with KUB 74241 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Upper GI with small bowel, includes multiple serial films 74245 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Upper GI with air contrast, high density barium, wo KUB 74246 X CAI,GDI,HCI,TVA,SBA,SJI Upper GI with Air-contrast, w or w/o glucagon, with KUB 74247 X CAI,GDI,HCI,TVA,SBA,SJI Upper GI Air-contrast, with smll bowel 74249 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Upper GI Single contrast; multiple serial films 74250 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Duodenography 74260 X CAI,HCI,TVA Colon Contrast Barium Enema with or without KUB 74270 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Colon Barium enema, w or wo KUB 74270 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Colon Barium enema, Air contrast with specific high density barium 74280 X CAI,GDI,HCI,TVA,VIA,SBA,SJI , Oral contrast 74290 X CAI,GDI,HCI,TVA,SBA,SJI Cholecystography, Oral contrast multi-day/repeat study 74291 X CAI,GDI,HCI,TVA,SBA,SJI Urography, intravenous w/wo KUB 74400 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Urography, drip infusion 74410 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Urography, Infusion drip thec and or bolus tech with nephrotomography 74415 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Urography, retrograde w/wo KUB- (VCUG) 74420 X CAI,GDI,HCI,TVA,VIA,SBA,SJI Urography, antegrade, (nephrostogram) S&I-- 74425 X GDI X-ray of penis 74445 X GDI X-ray, kidney lesion 74470 X GDI X-ray measurement of pelvis 74710 X HCI X-ray stress view 77071 X GDI,HCI Nose to for foreign body, single film, child 76010 X GDI,HCI,VIA,VIH,EAI Bone age studies 77072 X GDI,HCI,HCMV,VIA,VIH,EAI Bone length studies (orthoroentgenogram, scanogram) 77073 X CAI,GDI,HCI,HCMVTVI,VIA,EAI Osseous survey, limited 77074 X CAI,GDI,HCI,TVI,VIA,,VIH,EAI

Registered Customer Page 11 11/29/2012 Osseous survey, complete 77075 X CAI,GDI,HCI,TVI,VIA,VIH,EAI Osseous survey, infant 77076 X CAI,GDI,HCI,TVI,VIA,VIH,EAI Joint survey, single view one or more joints 77077 X CAI,GDI,HCI,TVI,VIA,VIH,EAI X-ray of fistula 76080 X GDI,VIA,TVI

Registered Customer Page 12 11/29/2012