Kepro/Hillsborough (HCHCP) Prior Authorization All CPT .

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Kepro/Hillsborough (HCHCP) Prior AuthorizationAll CPT Procedure Codes in Numerical OrderCurrent Codes:CodeDescriptionCPT 15820Blepharoplasty, lower eyelidCPT 15821Blepharoplasty, lower eyelid; with extensive herniated fat padCPT 15822Blepharoplasty, upper eyelidCPT 15823Blepharoplasty, upper eyelid; with excessive skin weighting down lidCPT 19318Reduction mammaplastyCPT 19324Mammaplasty, augmentation; without prosthetic implantCPT 19325Mammaplasty, augmentation; with prosthetic implantCPT 20550Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar"fascia")CPT 20551Injection(s); single tendon origin/insertionCPT 20552Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)CPT 20553Injection(s); single or multiple trigger point(s), 3 or more muscle(s)CPT 20610Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g.,shoulder, hip, knee joint, subacromial bursa)CPT 20931Allograft, structural, for spine surgery only (List separately in addition tocode for primary procedure)Elective InpatientUpdated July 2021Page 1

CPT 20937Autograft for spine surgery only (includes harvesting the graft); morselized(through separate skin or fascial incision) (List separately in addition toElective Inpatient code for primary procedure)CPT 20938Autograft for spine surgery only (includes harvesting the graft); structural,bicortical or tricortical (through separate skin or fascial incision) (ListElective Inpatient separately in addition to code for primary procedure)CPT 22220Elective InpatientCPT 22224Elective InpatientOsteotomy of spine, including discectomy, anterior approach, singlevertebral segment; cervicalOsteotomy of spine, including discectomy, anterior approach, singlevertebral segment; lumbarCPT 22318Open treatment and/or reduction of odontoid fracture(s) and ordislocation(s) (including os odontoideum), anterior approach, includingElective Inpatient placement of internal fixation; without graftingCPT 22319Open treatment and/or reduction of odontoid fracture(s) and ordislocation(s) (including os odontoideum), anterior approach, includingElective Inpatient placement of internal fixation; with graftingCPT 22548Elective InpatientCPT 22554Elective InpatientCPT 22558Elective InpatientCPT 22590Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlasaxis), with or without excision of odontoid processArthrodesis, anterior interbody technique, including minimal discectomy toprepare interspace (other than for decompression); cervical below C2Arthrodesis, anterior interbody technique, including minimal discectomy toprepare interspace (other than for decompression); lumbarArthrodesis, posterior technique, craniocervical (occiput-C2)Elective InpatientCPT 22595Updated July 2021Arthrodesis, posterior technique, atlas-axis (C1-C2)Page 2

Elective InpatientCPT 22600Elective InpatientCPT 22612Elective InpatientArthrodesis, posterior or posterolateral technique, single level; cervicalbelow C2 segmentArthrodesis, posterior or posterolateral technique, single level; lumbar(with lateral transverse technique, when performed)CPT 22630Arthrodesis, posterior interbody technique, including laminectomy and/ordiscectomy to prepare interspace (other than for decompression), singleElective Inpatient interspace; lumbarCPT 27130Elective InpatientCPT 27132Elective InpatientCPT 27134Elective InpatientCPT 27137Elective InpatientCPT 27138Elective InpatientCPT 27447Elective InpatientCPT 27486Arthroplasty, acetabular and proximal femoral prosthetic replacement (totalhip arthroplasty), with or without autograft or allograftConversion of previous hip surgery to total hip arthroplasty, with or withoutautograft or allograftRevision of total hip arthroplasty; both components, with or withoutautograft or allograftRevision of total hip arthroplasty; acetabular component only, with orwithout autograft or allograftRevision of total hip arthroplasty; femoral component only, with or withoutallograftArthroplasty, knee, condyle and plateau; medial AND lateral compartmentswith or without patella resurfacing (total knee arthroplasty)Revision of total knee arthroplasty, with or without allograft; 1 componentElective InpatientUpdated July 2021Page 3

CPT 27487Elective InpatientCPT 27488Elective InpatientRevision of total knee arthroplasty, with or without allograft; femoral andentire tibial componentRemoval of prosthesis, including total knee prosthesis, methylmethacrylatewith or without insertion of spacer, kneeCPT 36475Endovenous ablation therapy of incompetent vein, extremity, inclusive ofall imaging guidance and monitoring, percutaneous, radiofrequency; firstvein treatedCPT 36476Endovenous ablation therapy of incompetent vein, extremity, inclusive ofall imaging guidance and monitoring, percutaneous, radiofrequency;second and subsequent veins treated in a single extremity, each throughseparate access sitesCPT 36478Endovenous ablation therapy of incompetent vein, extremity, inclusive ofall imaging guidance and monitoring, percutaneous, laser; first vein treatedCPT 36479Endovenous ablation therapy of incompetent vein, extremity, inclusive ofall imaging guidance and monitoring, percutaneous, laser; second andsubsequent veins treated in a single extremity, each through separateaccess sitesCPT 37718Ligation, division, and stripping, short saphenous veinCPT 37722Ligation, division, and stripping, long (greater) saphenous veins fromsaphenofemoral junction to knee or belowCPT 37735Ligation and division and complete stripping of long or short saphenousveins with radical excision of ulcer and skin graft and/or interruption ofcommunicating veins of lower leg, with excision of deep fasciaCPT 37760Ligation of perforator veins, subfascial, radical (Linton type), including skingraft, when performed, open,1 legCPT 37765Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisionsCPT 37766Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisionsUpdated July 2021Page 4

CPT 37780Ligation and division of short saphenous vein at saphenopopliteal junction(separate procedure)CPT 37785Ligation, division, and/or excision of varicose vein cluster(s), 1 legCPT 43200Esophagoscopy, rigid or flexible; diagnostic, with or without collection ofspecimen(s) by brushing or washing (separate procedure)CPT 43201Esophagoscopy, rigid or flexible; with directed submucosal injection(s), anysubstanceCPT 43202Esophagoscopy, rigid or flexible; with biopsy, single or multipleCPT 43204Esophagoscopy, rigid or flexible; with injection sclerosis of esophagealvaricesCPT 43205Esophagoscopy, rigid or flexible; with band ligation of esophageal varicesCPT 43215Esophagoscopy, rigid or flexible; with removal of foreign bodyCPT 43216Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), orother lesion(s) by hot biopsy forceps or bipolar cauteryCPT 43217Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), orother lesion(s) by snare techniqueCPT 43219Esophagoscopy, rigid or flexible; with insertion of plastic tube or stentCPT 43220Esophagoscopy, rigid or flexible; with balloon dilation (less than 30 mmdiameter)CPT 43226Esophagoscopy, rigid or flexible; with insertion of guide wire followed bydilation over guide wireCPT 43227Esophagoscopy, rigid or flexible; with control of bleeding (e.g., injection,bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasmacoagulator)Updated July 2021Page 5

CPT 43228Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), orother lesion(s), not amenable to removal by hot biopsy forceps, bipolarcautery or snare techniqueCPT 43231Esophagoscopy, rigid or flexible; with endoscopic ultrasound examinationCPT 43232Esophagoscopy, rigid or flexible; with transendoscopic ultrasound-guidedintramural or transmural fine needle aspiration/biopsy(s)CPT 43234Upper gastrointestinal endoscopy, simple primary examination (e.g., withsmall diameter flexible endoscope) (separate procedure)CPT 43235Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; diagnostic, with or withoutcollection of specimen(s) by brushing or washing (separate procedure)CPT 43236Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with directed submucosalinjection(s), any substanceCPT 43237Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with endoscopic ultrasoundexamination limited to the esophagusCPT 43238Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with transendoscopicultrasound-guided intramural or transmural fine needleaspiration/biopsy(s), esophagus (includes endoscopic ultrasoundexamination limited to the esophagus)CPT 43239Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with biopsy, single ormultipleCPT 43241Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with transendoscopicintraluminal tube or catheter placementUpdated July 2021Page 6

CPT 43243Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with injection sclerosis ofesophageal and/or gastric varicesCPT 43244Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with band ligation ofesophageal and/or gastric varicesCPT 43245Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with dilation of gastricoutlet for obstruction (e.g., balloon, guide wire, bougie)CPT 43247Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with removal of foreignbodyCPT 43248Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with insertion of guide wirefollowed by dilation of esophagus over guide wireCPT 43249Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with balloon dilation ofesophagus (less than 30 mm diameter)CPT 43250Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with removal of tumor(s),polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cauteryCPT 43251Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with removal of tumor(s),polyp(s), or other lesion(s) by snare techniqueCPT 43255Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with control of bleeding,any methodCPT 43258Upper gastrointestinal endoscopy including esophagus, stomach, and eitherthe duodenum and/or jejunum as appropriate; with ablation of tumor(s),polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps,bipolar cautery or snare techniqueUpdated July 2021Page 7

CPT 43458Dilation of esophagus with balloon (30 mm diameter or larger) forachalasiaCPT 45378Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with orwithout collection of specimen(s) by brushing or washing, with or withoutcolon decompression (separate procedure)CPT 45379Colonoscopy, flexible, proximal to splenic flexure; with removal of foreignbodyCPT 45380Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single ormultipleCPT 45381Colonoscopy, flexible, proximal to splenic flexure; with directed submucosalinjection(s), any substanceCPT 45382Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding(e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe,stapler, plasma coagulator)CPT 45383Colonoscopy, flexible, proximal to splenic flexure; with ablation oftumor(s), polyp(s), or other lesion(s) not amenable to removal by hotbiopsy forceps, bipolar cautery or snare techniqueCPT 45384Colonoscopy, flexible, proximal to splenic flexure; with removal oftumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolarcauteryCPT 45385Colonoscopy, flexible, proximal to splenic flexure; with removal oftumor(s), polyp(s), or other lesion(s) by snare techniqueCPT 50590Lithotripsy, extracorporeal shock waveCPT 51726Complex cystometrogram (i.e., calibrated electronic equipment);CPT 51727Complex cystometrogram (i.e., calibrated electronic equipment); withurethral pressure profile studies (i.e., urethral closure pressure profile), anytechniqueUpdated July 2021Page 8

CPT 51728Complex cystometrogram (i.e., calibrated electronic equipment); withvoiding pressure studies (i.e., bladder voiding pressure), any techniqueCPT 51729Complex cystometrogram (i.e., calibrated electronic equipment); withvoiding pressure studies (i.e., bladder voiding pressure) and urethralpressure profile studies (i.e., urethral closure pressure profile), anytechniqueCPT 51741Complex uroflowmetry (e.g., calibrated electronic equipment)CPT 51784Electromyography studies (EMG) of anal or urethral sphincter, other thanneedle, any techniqueCPT 51797Voiding pressure studies, intra-abdominal (i.e., rectal, gastric,intraperitoneal) (List separately in addition to code for primary procedure)CPT 52000Cystourethroscopy (separate procedure)CPT 52005Cystourethroscopy, with ureteral catheterization, with or without irrigation,instillation, or ureteropyelography, exclusive of radiologic service;CPT 52204Cystourethroscopy, with biopsy(s)CPT 52214Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethralglandsCPT 52224Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with orwithout biopsyCPT 52234Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm)CPT 52240Cystourethroscopy, with fulguration (including cryosurgery or lasersurgery) and/or resection of; LARGE bladder tumor(s)CPT 52260Cystourethroscopy, with dilation of bladder for interstitial cystitis; generalor conduction (spinal) anesthesiaUpdated July 2021Page 9

CPT 52265Cystourethroscopy, with dilation of bladder for interstitial cystitis; localanesthesiaCPT 52276Cystourethroscopy with direct vision internal urethrotomyCPT 52281Cystourethroscopy, with calibration and/or dilation of urethral stricture orstenosis, with or without meatotomy, with or without injection procedurefor cystography, male or femaleCPT 52285Cystourethroscopy for treatment of the female urethral syndrome with anyor all of the following: urethral meatotomy, urethral dilation, internalurethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of thebladder neck, and fulgurationCPT 52310Cystourethroscopy, with removal of foreign body, calculus, or ureteral stentfrom urethra or bladder (separate procedure); simpleCPT 52315Cystourethroscopy, with removal of foreign body, calculus, or ureteral stentfrom urethra or bladder (separate procedure); complicatedCPT 52318Litholapaxy: crushing or fragmentation of calculus by any means in bladderand removal of fragments; complicated or large (over 2.5 cm)CPT 52320Cystourethroscopy (including ureteral catheterization); with removal ofureteral calculusCPT 52332Cystourethroscopy, with insertion of indwelling ureteral stent (e.g.,Gibbons or double-J type)CPT 53852Transurethral destruction of prostate tissue; by radiofrequencythermotherapyCPT 58150Total abdominal hysterectomy (corpus and cervix), with or without removalof tube(s), with or without removal of ovary(s);Elective InpatientCPT 58152Total abdominal hysterectomy (corpus and cervix), with or without removalof tube(s), with or without removal of ovary(s); with colpoElective Inpatient urethrocystopexy (e.g., Marshall-Marchetti-Krantz, Burch)Updated July 2021Page 10

CPT 58180Elective InpatientSupracervical abdominal hysterectomy (subtotal hysterectomy), with orwithout removal of tube(s), with or without removal of ovary(s)CPT 58200Total abdominal hysterectomy, including partial vaginectomy, with paraaortic and pelvic lymph node sampling, with or without removal of tube(s),Elective Inpatient with or without removal of ovary(s)CPT 58260Vaginal hysterectomy, for uterus 250 g or less;Elective InpatientCPT 58262Elective InpatientCPT 58263Elective InpatientVaginal hysterectomy, for uterus 250 g or less; with removal of tube(s),and/or ovary(s)Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s),and/or ovary(s), with repair of enteroceleCPT 58267Vaginal hysterectomy, for uterus 250 g or less; with colpourethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with orElective Inpatient without endoscopic controlCPT 58270Vaginal hysterectomy, for uterus 250 g or less; with repair of enteroceleElective InpatientCPT 58275Vaginal hysterectomy, with total or partial vaginectomy;Elective InpatientCPT 58280Elective InpatientCPT 58285Vaginal hysterectomy, with total or partial vaginectomy; with repair ofenteroceleVaginal hysterectomy, radical (Schauta type operation)Elective InpatientCPT 58290Vaginal hysterectomy, for uterus greater than 250 g;Elective InpatientUpdated July 2021Page 11

CPT 58291Elective InpatientCPT 58292Elective InpatientVaginal hysterectomy, for uterus greater than 250 g; with removal oftube(s) and/or ovary(s)Vaginal hysterectomy, for uterus greater than 250 g; with removal oftube(s) and/or ovary(s), with repair of enteroceleCPT 58293Vaginal hysterectomy, for uterus greater than 250 g; with colpourethrocystopexy (Marshall-Marchetti-Krantz type, Pereyra type) with orElective Inpatient without endoscopic controlCPT 58294Elective InpatientCPT 58550Vaginal hysterectomy, for uterus greater than 250 g; with repair ofenteroceleLaparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;Elective InpatientCPT 58552Elective InpatientCPT 58553Elective InpatientCPT 58554Elective InpatientLaparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less;with removal of tube(s) and/or ovary(s)Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than250 g;Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than250 g; with removal of tube(s) and/or ovary(s)CPT 62287Decompression procedure, percutaneous, of nucleus pulposus ofintervertebral disc, any method utilizing needle based technique to removeElective Inpatient disc material under fluoroscopic imaging or other form of indirectvisualization, with the use of an endoscope, with discography and/orepidural injection(s) at the treated level(s), when performed, single ormultiple levels, lumbarCPT 62310Updated July 2021Injection(s), of diagnostic or therapeutic substance(s) (includinganesthetic, antispasmodic, opioid, steroid, other solution), not includingneurolytic substances, including needle or catheter placement, includesPage 12

contrast for localization when performed, epidural or subarachnoid; cervicalor thoracicCPT 62311Injection(s), of diagnostic or therapeutic substance(s) (includinganesthetic, antispasmodic, opioid, steroid, other solution), not includingneurolytic substances, including needle or catheter placement, includescontrast for localization when performed, epidural or subarachnoid; lumbaror sacral (caudal)CPT 62350Implantation, revision or repositioning of tunneled intrathecal or epiduralcatheter, for long-term medication administration via an external pump orimplantable reservoir/infusion pump; without laminectomyCPT 62355Removal of previously implanted intrathecal or epidural catheterCPT 63001Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), 1 or 2 vertebral segments; cervicalCPT 63005Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), 1 or 2 vertebral segments; lumbar, except forspondylolisthesisCPT 63012Laminectomy with removal of abnormal facets and/or pars inter-articulariswith decompression of cauda equina and nerve roots for spondylolisthesis,Elective Inpatient lumbar (Gill type procedure)CPT 63015Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), more than 2 vertebral segments; cervicalCPT 63017Laminectomy with exploration and/or decompression of spinal cord and/orcauda equina, without facetectomy, foraminotomy or discectomy (e.g.,Elective Inpatient spinal stenosis), more than 2 vertebral segments; lumbarCPT 63020Laminotomy (hemilaminectomy), with decompression of nerve root(s),including partial facetectomy, foraminotomy and/or excision of herniatedElective Inpatient intervertebral disc; 1 interspace, cervicalUpdated July 2021Page 13

CPT 63040Laminotomy (hemilaminectomy), with decompression of nerve root(s),including partial facetectomy, foraminotomy and/or excision of herniatedElective Inpatient intervertebral disc, reexploration, single interspace; cervicalCPT 63045Laminectomy, facetectomy and foraminotomy (unilateral or bilateral withdecompression of spinal cord, cauda equina and/or nerve root[s], [e.g.,Elective Inpatient spinal or lateral recess stenosis]), single vertebral segment; cervicalCPT 63047Laminectomy, facetectomy and foraminotomy (unilateral or bilateral withdecompression of spinal cord, cauda equina and/or nerve root[s], [e.g.,Elective Inpatient spinal or lateral recess stenosis]), single vertebral segment; lumbarCPT 63056Transpedicular approach with decompression of spinal cord, equina and/ornerve root(s) (e.g., herniated intervertebral disc), single segment; lumbarElective Inpatient (including transfacet, or lateral extraforaminal approach) (e.g., far lateralherniated intervertebral disc)CPT 63075Elective InpatientDiscectomy, anterior, with decompression of spinal cord and/or nerveroot(s), including osteophytectomy; cervical, single interspaceCPT 63076Discectomy, anterior, with decompression of spinal cord and/or nerveroot(s), including osteophytectomy; cervical, each additional interspaceElective Inpatient (List separately in addition to code for primary procedure)CPT 63081Vertebral corpectomy (vertebral body resection), partial or complete,anterior approach with decompression of spinal cord and/or nerve root(s);Elective Inpatient cervical, single segmentCPT 63082Vertebral corpectomy (vertebral body resection), partial or complete,anterior approach with decompression of spinal cord and/or nerve root(s);Elective Inpatient cervical, each additional segment (List separately in addition to code forprimary procedure)CPT 64418Injection, anesthetic agent; suprascapular nerveCPT 64420Injection, anesthetic agent; intercostal nerve, singleCPT 64421Injection, anesthetic agent; intercostal nerves, multiple, regional blockUpdated July 2021Page 14

CPT 64510Injection, anesthetic agent; stellate ganglion (cervical sympathetic)CPT 64530Injection, anesthetic agent; celiac plexus, with or without radiologicmonitoringCPT 66840Removal of lens material; aspiration technique, 1 or more stagesCPT 66850Removal of lens material; phacofragmentation technique (mechanical orultrasonic) (e.g., phacoemulsification), with aspirationCPT 66852Removal of lens material; pars plana approach, with or without vitrectomyCPT 66920Removal of lens material; intracapsularCPT 66930Removal of lens material; intracapsular, for dislocated lensCPT 66940Removal of lens material; extracapsular (other than 66840, 66850, 66852)CPT 66982Extracapsular cataract removal with insertion of intraocular lens prosthesis(1-stage procedure), manual or mechanical technique (e.g., irrigation andaspiration or phacoemulsification), complex, requiring devices ortechniques not generally used in routineCPT 66983Intracapsular cataract extraction with insertion of intraocular lensprosthesis (1 stage procedure)CPT 66984Extracapsular cataract removal with insertion of intraocular lens prosthesis(1 stage procedure), manual or mechanical technique (e.g., irrigation andaspiration or phacoemulsification)CPT 66985Insertion of intraocular lens prosthesis (secondary implant), not associatedwith concurrent cataract removalCPT 66986Exchange of intraocular lensCPT 70450Computed tomography, head or brain; without contrast materialCPT 70460Computed tomography, head or brain; with contrast material(s)Updated July 2021Page 15

CPT 70470Computed tomography, head or brain; without contrast material, followedby contrast material(s) and further sectionsCPT 70480Computed tomography, orbit, sella, or posterior fossa or outer, middle, orinner ear; without contrast materialCPT 70481Computed tomography, orbit, sella, or posterior fossa or outer, middle, orinner ear; with contrast material(s)CPT 70482Computed tomography, orbit, sella, or posterior fossa or outer, middle, orinner ear; without contrast material, followed by contrast material(s) andfurther sectionsCPT 70486Computed tomography, maxillofacial area; without contrast materialCPT 70487Computed tomography, maxillofacial area; with contrast material(s)CPT 70488Computed tomography, maxillofacial area; without contrast material,followed by contrast material(s) and further sectionsCPT 70490Computed tomography, soft tissue neck; without contrast materialCPT 70491Computed tomography, soft tissue neck; with contrast material(s)CPT 70492Computed tomography, soft tissue neck; without contrast material followedby contrast material(s) and further sectionsCPT 70496Computed tomographic angiography, head, with contrast material(s),including noncontrast images, if performed, and image postprocessingCPT 70498Computed tomographic angiography, neck, with contrast material(s),including noncontrast images, if performed, and image postprocessingCPT 70540Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck;without contrast material(s)CPT 70542Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; withcontrast material(s)Updated July 2021Page 16

CPT 70543Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck;without contrast material(s), followed by contrast material(s) and furthersequencesCPT 70544Magnetic resonance angiography, head; without contrast material(s)CPT 70545Magnetic resonance angiography, head; with contrast material(s)CPT 70546Magnetic resonance angiography, head; without contrast material(s),followed by contrast material(s) and further sequencesCPT 70547Magnetic resonance angiography, neck; without contrast material(s)CPT 70548Magnetic resonance angiography, neck; with contrast material(s)CPT 70549Magnetic resonance angiography, neck; without contrast material(s),followed by contrast material(s) and further sequencesCPT 70551Magnetic resonance (e.g., proton) imaging, brain (including brain stem);without contrast materialCPT 70552Magnetic resonance (e.g., proton) imaging, brain (including brain stem);with contrast material(s)CPT 70553Magnetic resonance (e.g., proton) imaging, brain (including brain stem);without contrast material, followed by contrast material(s) and furthersequencesCPT 70554Magnetic resonance imaging, brain, functional MRI; including test selectionand administration of repetitive body part movement and/or visualstimulation, not requiring physician or psychologist administrationCPT 70555Magnetic resonance imaging, brain, functional MRI; requiring physician orpsychologist administration of entire neurofunctional testingCPT 71250Computed tomography, thorax; without contrast materialCPT 71260Computed tomography, thorax; with contrast material(s)Updated July 2021Page 17

CPT 71270Computed tomography, thorax; without contrast material, followed bycontrast material(s) and further sectionsCPT 71275Computed tomographic angiography, chest (noncoronary), with contrastmaterial(s), including noncontrast images, if performed, and imagepostprocessingCPT 71550Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation ofhilar and mediastinal lymphadenopathy); without contrast material(s)CPT 71551Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation ofhilar and mediastinal lymphadenopathy); with contrast material(s)CPT 71552Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation ofhilar and mediastinal lymphadenopathy); without contrast material(s),followed by contrast material(s) and further sequencesCPT 72125Computed tomography, cervical spine; without contrast materialCPT 72126Computed tomography, cervical spine; with contrast materialCPT 72127Computed tomography, cervical spine; without contrast material, followedby contrast material(s) and further sectionsCPT 72128Computed tomography, thoracic spine; without contrast materialCPT 72129Computed tomography, thoracic spine; with contrast materialCPT 72130Computed tomography, thoracic spine; without contrast material, followedby contrast material(s) and further sectionsCPT 72131Computed tomography, lumbar spine; without contrast materialCPT 72132Computed tomography, lumbar spine; with contrast materialCPT 72133Computed tomography, lumbar spine; without contrast material, followedby contrast material(s) and further sectionsCPT 72141Magnetic resonance (e.g., proton) imaging, spinal canal and contents,cervical; without contrast materialUpdated July 2021Page 18

CPT 72142Magnetic resonance (e.g., proton) imaging, spinal canal and contents,cervical; with contrast material(s)CPT 72146Magnetic resonance (e.g., proton) imaging, spinal canal and contents,thoracic; without contra

CPT 15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid CPT 19318. Reduction mammaplasty CPT 19324 Mammaplasty, augmentation; without prosthetic implant CPT 19325. Mammaplasty, augmentation; with prosthetic implant CPT 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar "fascia") CPT 20551

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