CPT Code Guidelines for X-Ray, CT and MRIMRI Head and Neck (soft tissue)70540 MRI Orbit, Face, Neck, Sella w/o70543 MRI Orbit, Face, Neck, Sella w/wo70551 MRI Brain w/o70553 MRI Brain w/wo70553 MRI Brain IAC w/wo70553 MRI Brain Pituitary w/wo

MRI Breast77059 MRI Bilateral Breast w/wo

MRI Spine72141 MRI Cervical Spine w/o72156 MRI Cervical Spine w/wo72146 MRI Thoracic Spine w/o72157 MRI Thoracic Spine w/wo72148 MRI Lumbar Spine w/o72158 MRI Lumbar Spine w/wo72195 MRI Sacrum & Coccyx w/o72197 MRI Sacrum & Coccyx w/wo

MRI Upper Extremity73218 MRI Upper Extremity, No Joint, w/o73220 MRI Upper Extremity, No Joint w/wo (Humerus/Forearm/Hand)73221 MRI Upper Extremity Joint w/o73223 MRI Upper Extremity Joint w/wo (Shoulder/Elbow/Wrist)

MRI Abdomen & Pelvis74181 MRI Abdomen w/o74181 MRCP w/o74183 MRI Abdomen w/wo74183 MRI Abdomen w/wo Eovist72195 MRI Pelvis w/o72197 MRI Pelvis w/wo

MRI Lower Extremity73718 MRI Lower Extremity, No Joint, w/o73720 MRI Lower Extremity, No Joint, w/wo (Femur/Tib/Fib/Foot)73721 MRI Lower Extremity Joint w/o73723 MRI Lower Extremity Joint w/wo (Hip/Knee/Ankle)

MR Angiography70544 MRA Head/COW w/o70546 MRA Head/COW w/wo70547 MRA Neck w/o70549 MRA Neck w/wo74185 MRA Abdomen w/o or w/wo

CT Head & Neck70450 CT Brain w/o Contrast70470 CT Brain w/wo Contrast70486 CT Sinus w/o70486 CT Facial Bones w/o Contrast70487 CT Facial Bones with Contrast70488 CT Facial Bones w/wo Contrast70480 CT Orbits w/o Contrast70481 CT Orbits with Contrast70482 CT Orbits w/wo Contrast70480 CT Temporal Bones w/o Contrast70481 CT Temporal Bones with Contrast70482 CT Temporal Bones w/wo Contrast70490 CT Soft Tissue Neck w/o Contrast70491 CT Soft Tissue Neck with Contrast70492 CT Soft Tissue Neck w/wo Contrast

CT Chest71250 CT Chest w/o Contrast71260 CT Chest with Contrast75571 CT Calcium Scoring71250 CT Low Dose Lung Screening

CT Extremity 73200 CT Upper Extremity w/o (Shoulder/Humerus/Elbow/ Forearm/Wrist/Hand) 73700 CT Lower Extremity w/o (Hip/Femur/Knee/Tib/Fib/ Ankle/Foot)

CT Spine 72125 Cervical Spine w/o Contrast 72128 Thoracic Spine w/o Contrast 72131 Lumbar Spine w/o Contrast

CT Abdomen & Pelvis74176 CT Abdomen & Pelvis w/o74177 CT Abdomen & Pelvis with74178 CT Abdomen & Pelvis w/wo74261 Virtual Colonoscopy Diagnostic74263 Virtual Colonoscopy Screening

CT Angiography70496 CTA Head w/wo70496/70498 CTA Carotids w/wo71275 CTA Chest/Thoracic Aorta w/wo71275 CTA Pulmonary Arteries (PE) w/wo75572 CTA Cardiac - Lt Atrium & Pulmonary Vein w/wo75574 CTA Coronary Arteries with Calcium Score w/wo75635 CTA Abdominal Aorta with Runoff w/wo74174 CTA Abdomen & Pelvis w/woDigital X-Ray Head and Neck

70110 Mandible Complete70140 Facial Bones Less than3 views70150 Facial Bones Complete70160 Nasal Bones Complete70200 Orbits Complete 4 Views Minimum70210 Sinus Less than 3 Views70220 Sinus Complete70250 Skull Less than 4 Views70260 Skull Complete70360 Soft Tissue Neck Lateral

Digital X-Ray Chest71020 Chest; 2 Views71100 Ribs; Unilateral,2 Views71101 Ribs; Bilateral, 3 Views71130 Sternoclavicular Joints

Digital X-Ray Spine72040 Cervical Spine 2-3 Views72050 Cervical Spine Complete72072 Thoracic Spine 3 Views72100 Lumbar 2-3 Views72110 Lumbar Spine Complete72114 Lumbar Complete w/Flexion & Extension

Digital X-Ray Upper Extremities73000 Clavicle Unilateral Complete73030 Shoulder Unilateral Complete73050 AC Joints 2 Views73060 Humerus 2 Views73080 Elbow Unilateral Complete73090 Forearm Unilateral 2 Views73110 Wrist Unilateral Complete73130 Hand Unilateral Complete

Digital X-Ray Abdomen74000 Abdomen/KUB Single View74020 Abdomen 2 View Supine & Erect Digital X-Ray Lower Extremities73510 Hip Unilateral 2 Views73520 Hips Bilateral w/AP Pelvis73540 Hips/Pelvis Infant73550 Femur 2 Views73562 Knee Unilateral Complete73565 Bilateral Standing Knees73590 Tibia/Fibula 2 Views73592 Lower Ext. Infant 2 views73610 Ankle Unilateral Complete73630 Foot Unilateral Complete

To schedule an appointment Call 623-847-2000.VR 408 - 08/2015

SDI Patient Assistance Programs available by calling (602) 521-6203

AT-A-GLANCEINSURANCE PLANSTax ID Number: 200382536

AETNA (ALL PRODUCTS)

ARIZONA FOUNDATION

BANNER HEALTH NETWORK

BEECH STREET

BCBS – AZ (ALL STATES)

CIGNA (ALL PRODUCTS – INCLUDES GREATWEST AND GWH)

COPPERPOINT (FORMERLY SCF ARIZONA)

CORECHOICE

COVENTRY HEALTH CARE (ALL PRODUCTS)

FIRST HEALTH

GALAXY HEALTH

HEALTH MANAGEMENT NETWORK – AMN/RAN/HMN

HEALTH NET (ALL PRODUCTS)

HUMANA (ALL PRODUCTS – EXCEPT HMOx)

INTEGRATED HEALTH PLAN

MERITUS (HMO & PPO)

MULTIPLAN

OPTUM MEDICAL NETWORK (FORMERLY LIFEPRINT)

PPO NEXT

PRIVATE HEALTHCARE SYSTEM (PHCS)

TECH HEALTH

THREE RIVERS PROVIDER NETWORK

TRICARE/UHC MILITARY & VETERANS SERVICES

UNITED HEALTHCARE (ALL PRODUCTS)

UA HEALTHCARE (ALL PRODUCTS)

USA MANAGED CARE

VA (DEPARTMENT OF VETERANS AFFAIRS - INCLUDES TRI-WEST VAPC3)

WORKERS COMPENSATION (MOST PLANS)

MEDICARESDI AND AFFILIATES ARE IN NETWORK WITH A FULL RANGE OF TRADITIONAL MEDICARE AND MEDICARE ADVANTAGE PLANS.

INCLUDING BUT NOT LIMITED TO:

AHCCCSSDI AND AFFILIATES ARE IN NETWORK WITH ALL MARICOPA COUNTY AHCCCS PLANS (PLUS RELATED MEDICARE ADVANTAGE & ALTCS PLANS).

INCLUDING BUT NOT LIMITED TO:

ARIZONA PRIORITY CARE

BANNER HEALTH NETWORK

BLUE CROSS ADVANTAGE

HEALTHCHOICE GENERATIONS

TRADITIONAL MEDICARE (FFS)/RAILROAD MEDICARE

MERCYCARE ADVANTAGE

ONECare

PHOENIX ADVANTAGE

SECURE HORIZONS/PACIFICARE

UNITED HEALTHCARE AARP Medicare Complete

AHCCCS FFS

BRIDGEWAY HEALTH SOLUTIONS

CARE 1ST

EVERCARE (ALTCS PLAN)

HEALTHCHOICE ARIZONA (EXCEPT ESSENTIALS)

INDIAN HEALTH SERVICES

MARICOPA HEALTH PLAN

MERCY CARE PLAN

PHOENIX HEALTH PLAN

UNITED HEALTHCARE COMMUNITY PLAN (FORMERLY APIPA)

• SMIL, EVDI and Valley Radiologists are affiliates of Southwest Diagnostic Imaging (SDI). All share the same Tax ID and extensive network of plans. Authorization assistance is available.• This At-A-Glance reference is intended to be a guide. For the full list or with questions call (623) 931-1128.

SCHEDULING: (623) 847-2000 • FAX: (623) 847-2001 PET/IR SCHEDULING: (623) 842-5614

NUCLEAR MEDICINE SCHEDULING: (623) 842-5910 DIGITAL RECORDS/PATIENT REPORTS: (623) 842-5620

IT SUPPORT LINE: (602) 521-6373 www.valleyradiolgists.com

Plans we are NOT contracted with: • Caremore • Health Choice Essential (marketplace plan) • Humana Phoenix HMOx (marketplace plan) • Scan/Health Care Partners • Kaiser Permanente (CA HMO plan) • Out of State Medicaid • Out of State Medicare Advantage Plans • Health Partners