Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Screening CT
0066T Colonoscopy X
Diagnostic CT
0067T Colonoscopy X
Coronary Artery Ca
0144T Score X X
0145T CT heart X X
0146T CT heart X X
0147T CT heart X X
CTA Coronary
0148T Arteries X X
CTA Coronary
0149T Arteries X X
CT heart, congenital
studies, noncoronary
0150T arteries X X
0151T CT heart X X
Computer Aided
0174T Detection, concurrent
Computer Aided
0175T Detection, remote
70010 With contrast brain X
70015 With contrast brain X
70100 Mandible X X
70110 Mandible X X
70120 Mastoids X X
70130 Mastoids X X
70134 Auditory Meatus X X
70140 Facial bones X X
70150 Facial bones X X
70160 Nasal bone X X
With contrast
70170 nasolacrimal duct X
Page 1 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
70210 Sinuses X X
70220 Sinuses X X
70240 Sella turcica X
70250 Skull X X X X
70260 Skull X X X
70332 With contrast TMJ X
MRI
Tempromandibular
70336 Joint,TMJ,Jaw Joint X
70360 Neck X X
70370 Pharynx or larynx X
70373 With contrast larynx X
70380 Salivary gland X
With contrast salivary
70390 gland X
70450 CT BRAIN, HEAD X
CT Head or Brain
70460 with Contrast X
CT Head or Brain
without and with
70470 Contrast X
CT ORBIT,EYE
SOCKET, SELLA
TURCICA,
POSTERIOR
70480 FOSSA,EAR ETC. X
CT ORBIT,EYE
SOCKET, SELLA
TURCICA,
POSTERIOR
FOSSA, EAR WITH
70481 CONTRAST X
Page 2 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
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PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
CTORBIT,EYE
SOCKET, SELLA
TURCICA,
POSTERIOR
FOSSA,EAR,W/WO
70482 CONTR. X
CT SINUS,
FACE,JAW,MANDIB
LE,MAXILLOFACIAL
70486 NO CONTRAST X
CT FACE, JAW OR
MANDIBLE,
MAXILLOFACIAL ,
70487 WITH CONTRAST X
CT FACE, JAW OR
MANDIBLE,
MAXILLOFACIAL,WI
THOUT/WITH
70488 CONTRAST X
CT NECK SOFT
TISSUES,LARNYX,T
HYROID ETC. NO
70490 CONTRAST X
CT NECK SOFT
TISSUES,LARYNX,T
HYROID,ETC.WITH
70491 CONTRAST X
CT NECK SOFT
TISSUES,
LARYNX,THYROID,
ETC.WITHOUT/WIT
70492 H CONTRAST X
70496 Ct angiography, head X
Page 3 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
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PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
70498 Ct angiography, neck X
MRI FACE , NECK,
ORBIT without
70540 contrast X
MRI FACE , NECK,
70542 ORBIT with contrast X
MRI FACE , NECK,
ORBIT without/with
70543 contrast X
Mr angiography head
70544 w/o dye X
MRA head with
70545 contrast X
MRA head without
70546 contrast X
Mr angiography neck
70547 w/o dye X
Mr angiography neck
70548 w/dye X
Mr angiograph neck
70549 w/o&w dye X
MRI BRAIN HEAD
BRAINSTEM
WITHOUT
70551 CONTRAST X
MRI HEAD, BRAIN,
BRAINSTEM WITH
70552 CONTRAST
MRI HEAD, X
BRAIN,BRAINSTEM
WITHOUT /WITH
70553 CONTRAST X
70554 MRI BRAIN X
70555 MRI BRAIN X
Page 4 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MRI brain,
intrraoperative,
70557 without contrast X
MRI brain,
intrraoperative, with
70558 contrast X
MRI brain,
intrraoperative,
70559 without/with contrast X
71010 Chest X X X X X X X X
71015 Chest, stereo X X X X X X X
71020 Chest X X X X X X X X
71021 Chest X X X X X X X
71022 Chest X X X X X X X
Chest, partial with
71023 fluoroscopy X
71030 Chest X X X X X X X
Chest, complete with
71034 fluoroscopy X
71035 Chest X X X X X X X
71040 With contrast bronchi X
71060 With contrast bronchi X
71100 Ribs X X X X
71101 Ribs X X X X
71110 Ribs X X X X
71111 Ribs X X X X
71120 Sternum X X X X
71130 Sternum X X X X
CT CHEST,
71250 THORAX X
Page 5 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
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PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
CT CHEST,
THORAX WITH
71260 CONTRAST X
CT CHEST,
THORAX WITHOUT
AND WITH
71270 CONTRAST X
Ct angiography,
71275 chest X X
MRI CHEST, without
71550 contrast X
MRI CHEST, with
71551 contrast X
MRI CHEST,
71552 without/with contrast X
MRA, MRI
ANGIOGRAPHY
CHEST[NOT
MYOCARDIUM]
WITH/WITHOUT
71555 CONTRAST X
72010 Spine, total X X X X X
72020 Spine X X X X X
72040 Spine, cervical X X X X X
72050 Spine, cervical X X X X X
72052 Spine, cervical X X X X
72069 Standing spine X X X X
72070 Spine, thoracic X X X X X
72072 Spine, thoracic X X X X X
72074 Spine, thoracic X X X X X
72080 Spine, thoracolumbar X X X X X
72090 Spine X X X X
Page 6 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
's ic r U
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C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
72100 Spine, lumbosacral X X X X X
72110 Spine, lumbosacral X X X X X
72114 Spine, lumbosacral X X X X
72120 Spine, lumbosacral X X X X X
CT CERVICAL
SPINE, NECK SPINE
72125 NO CONTRAST X
CT CERVICAL
SPINE, NECK SPINE
72126 WITH CONTRAST X
CT CERVICAL
SPINE, NECK SPINE
WITHOUT AND
72127 WITH CONTRAST X
CT THORACIC
SPINE, UPPER
BACK NO
72128 CONTRAST X
CT THORACIC
SPINE, UPPER
BACK WITH
72129 CONTRAST X
CT THORACIC
SPINE, UPPER
BACK WITHOUT
AND WITH
72130 CONTRAST X
Page 7 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
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C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
CT LUMBAR SPINE,
72131 LOW BACK X
CT LUMBAR SPINE,
LOW BACK WITH
72132 CONTRAST X
CT LUMBAR SPINE,
LOW BACK
WITHOUT AND
72133 WITH CONTRAST X
MRI CERVICAL
SPINE OR NECK
SPINE WITHOUT
72141 CONTRAST X
MRI CERVICAL
SPINE OR NECK
SPINE WITH
72142 CONTRAST
MRI THORACIC X
SPINE CHEST
SPINE UPPER
72146 BACK WITHOUT X
MRI THORACIC
SPINE OR CHEST
SPINE OR UPPER
BACK WITH
72147 CONTRAST X
MRI LUMBAR SPINE
OR LOW BACK
WITHOUT
72148 CONTRAST X
MRI LUMBAR SPINE
OR LOW BACK
72149 WITH CONTRAST X
Page 8 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
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PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MRI CERVICAL
SPINE NECK SPINE
WITHOUT/WITH
72156 CONTRAST X
MRI THORACIC
SPINE OR CHEST
SPINE
WITHOUT/WITH
72157 CONTRAST X
MRI LUMBAR SPINE
OR LOW BACK
WITHOUT/ WITH
72158 CONTRAST X
MRA, MRI
ANGIOGRAPHY
SPINAL CANAL &
CONTENTS WITH /
WITHOUT
72159 CONTRAST X
72170 Pelvis X X X X
72190 Pelvis X X X X
Ct angiograph pelv
72191 w/o&w dye X
CT PELVIS NO
72192 CONTRASTWITH
CT PELVIS X
72193 CONTRAST X
CT PELVIS
WITHOUT/WITH
72194 CONTRAST X
MRI PELVIS without
72195 contrast X
MRI PELVIS with
72196 contrast X
Page 9 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
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C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MRI PELVIS
72197 without/with contrast X
MRA , MRI PELVIS
ANGIOGRAPHY
WITH/WITHOUT
72198 CONTRAST X
72200 Sacroiliac joint X X X
72202 Sacroiliac joint X X X
72220 Sacrum and coccyx X X X X
With contrast spine,
72240 cervical X
With contrast spine,
72255 thoracic X
With contrast spine,
72265 lumbrosacral X
With contrast spine,
72270 total X
With contrast
intervertebral disk,
72285 cervical or thoracic X
With contrast
intervertebral disk,
72295 lumbar X
73000 Clavicle X X X X X
73010 Scapula X X X X X
73020 Shoulder X X X X X
73030 Shoulder X X X X X
With contrast
73040 shoulder X
73050 Shoulder X X X X X
73060 Humerus X X X X X
73070 Elbow X X X X X
73080 Elbow X X X X X
Page 10 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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Im ine lt
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PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
73085 With contrast elbow X
73090 Arm, Lower X X X X X
73092 Arm, Upper X X X X
73100 Wrist X X X X X X
73110 Wrist X X X X X
73115 With contrast wrist X
73120 Hand X X X X X X
73130 Hand X X X X
73140 Finger X X X X X
CT ARM OR UPPER
73200 EXTREMITY X
CT ARM OR UPPER
EXTREMITY WITH
73201 CONTRAST X
CT ARM OR UPPER
EXTREMITY
WITHOUT AND
73202 WITH CONTRAST
Ct angio upr extrm X
73206 w/o&w dye X
MRI UPPER
EXTREMITY ,
ENTIRE
EXTREMITY, NOT A
JOINT without
73218 contrast X
MRI UPPER
EXTREMITY ,
ENTIRE
EXTREMITY, NOT A
73219 JOINT with contrast X
Page 11 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MRI UPPER
EXTREMITY ,
ENTIRE
EXTREMITY, NOT A
JOINT without/with
73220 contrast X
MRI JOINT OF
UPPER EXTREMITY
WITHOUT
73221 CONTRAST X
MRI JOINT OF
UPPER EXTREMITY
WITHOUT
73222 CONTRAST X
MRI JOINT OF
UPPER EXTREMITY
WITHOUT/WITH
73223 CONTRAST X
MRA, MRI
ANGIOGRAPHY
UPPER EXTREMITY
WITH/WITHOUT
73225 CONTRAST X
73500 Hip X X X X X
73510 hip X X X X X
73520 Hip X X X X X
73525 With contrast hip X
Pelvis & hips, infant
73540 or child X X X X X
73542 Sacroiliac joint X
73550 Femur X X X X X
Page 12 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
73560 Knee X X X X X
73562 Knee X X X X X
73564 Knee X X X X X
73565 Knee X X X X X
73580 Knee X
73590 Tibia and fibula X X X X X
73592 Leg X X X X X
73600 Ankle X X X X X X
73610 Ankle X X X X X X
73615 With contrast ankle X
73620 Foot X X X X X X
73630 Foot X X X X X X
73650 Heel X X X X X X
73660 Toe X X X X X X
CT LEG OR LOWER
73700 EXTREMITY X
CT LEG OR LOWER
EXTREMITY WITH
73701 CONTRAST X
CT LEG OR LOWER
EXTREMITY
WITHOUT/WITH
73702 CONTRAST X
Ct angio lwr extr
73706 w/o&w dye X
MRI LEG OR
LOWER
EXTREMITY ,
OTHER THAN
JOINT, without
73718 contrast X
Page 13 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MRI LEG OR
LOWER
EXTREMITY ,
OTHER THAN
73719 JOINT, with contrast X
MRI LEG OR
LOWER
EXTREMITY ,
OTHER THAN
JOINT, without/with
73720 contrast X
MRI JOINT OF
LOWER
EXTREMITY, HIP
OR KNEE OR
ANKLE OR FOOT
73721 JOINT w/o contrast X
MRI JOINT OF
LOWER
EXTREMITY, HIP
OR KNEE OR
ANKLE OR FOOT
73722 JOINT w/ contrast X
MRI JOINT OF
LOWER
EXTREMITY, HIP
OR KNEE OR
ANKLE OR FOOT
JOINT w/ and w/o
73723 contrast X
Page 14 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MRA, MRI
ANGIOGRAPHY
LOWER
EXTREMITY
WITH/WITHOUT
73725 CONTRAST X
74000 Abdomen X X X X X
74010 Abdomen X X X X
74020 Abdomen X X X X
74022 Abdomen X X X X
CT ABDOMEN
WITHOUT
74150 CONTRAST X
CT ABDOMEN WITH
74160 CONTRAST X
CT ABDOMEN
WITHOUT AND
74170 WITH CONTRAST X
Ct angio abdom
74175 w/o&w dye X
74181 MRI ABDOMEN X
74182 Mri abdomen w/dye X
Mri abdomen w/o&w
74183 dye X
MRA, MRI
ANGIOGRAPHY
ABDOMEN
WITH/WITHOUT
74185 CONTRAST X
74190 Peritoneum X
74210 Pharynx X
74220 Esophagus X
74240 Gastrointestinal tract X
Page 15 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
74241 Gastrointestinal tract X
74245 Gastrointestinal tract X
With contrast
74246 gastrointestinal tract X
With contrast
74247 gastrointestinal tract X
With contrast
74249 gastrointestinal tract X
74250 Intestines, small X
74251 Intestines, small X
74260 Duodenum X
With contrast colon,
74270 barium enema X
With contrast colon,
74280 barium enema X
With contrast
74290 gallbladder X
With contrast
74291 gallbladder X
With contrast urinary
74400 tract X
With contrast urinary
74410 tract X
With contrast urinary
74415 tract X
With contrast urinary
74420 tract X
Page 16 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
With contrast urinary
74425 tract X X
74430 With contrast bladder X
With contrast
74440 epididymis X
With contrast
74445 corpora cavernosa X X
74450 With contrast bladder X X
74455 With contrast bladder X X
With contrast kidney,
74470 cyst X
With contrast kidney,
74475 guide catheter X X
With contrast ureter,
74480 guide catheter X
With contrast ureter,
74485 guide dilation X
74710 Pelvis, manometry X
74740 With contrast uterus X
74742 Fallopian tube X
With contrast
74775 perineum X
MRI cardiac; without
75557 contrast X
MRI cardiac; without
contrast; with
75558 flow/velocity X
Page 17 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MRI cardiac; without
75559 contrast; with stress X
MRI cardiac; without
contrast; with flow &
75560 stress X
MRI cardiac; without
contrast; followed by
contrast & further
75561 sequences X
MRI cardiac; without
contrast; followed by
contrast & further
75562 sequences; with flow
MRI cardiac; without X
contrast; followed by
contrast & further
sequences with
75563 stress
MRI cardiac; without X
contrast; followed by
contrast & further
sequences, with flow
75564 & stress abdominal
Ct angio X
75635 arteries X
Fluoroscopy, up to
one hour physician
76000 time X
Fluoroscopy,
physician time more
76001 than one hour X
With contrast joint,
76006 stress views X X
Total body, foreign
76010 body X
Page 18 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
Abscess, fistula or
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
76080 sinus tract X
76100 Body section X
76101 Body section, motion X
76102 Body section, motion X
76120 Unlisted procedure X
76125 Unlisted procedure X
76140 Consultation X
With contrast
76350 subtraction method X
CT FOLLOW-UP
OR LIMITED STUDY
76380 ANY AREA X
76390 Mr spectroscopy X
Unlisted computed
tomography
procedure (eg,
diagnostic,
76497 interventional) X
Unlisted magnetic
resonance procedure
(eg, diagnostic,
76498 interventional) X
Unlisted diagnostic
radiographic
76499 procedure X
76506 Head X
76536 Head or neck X X X
76604 Chest X
76645 Breast X
76700 Abdomen X X
76705 Abdomen X X
Page 19 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Retroperitoneal,
76770 Kidney X X
Retroperitoneal,
76775 Kidney; limited X X
Ultrasound,
76776 transplanted kidney X X
76800 Spine X
76801 Pregnant uterus X X X X X
76802 Pregnant uterus X X X X X
76805 Pregnant uterus X X X X X
76810 Pregnant uterus X X X X X
76811 Pregnant uterus X X X X X
76812 Pregnant uterus X X X X X
Ultrasound, pregnant
uterus, single or first
76813 gestation X X
Ultrasound, pregnant
uterus, each
76814 additional gestation X X
76815 Pregnant uterus X X X X X X
76816 Pregnant uterus X X X X X
76817 Pregnant uterus X X X X X X
76818 Fetus X X X X X
76819 Fetus X X X X X
76820 Fetal; umbilical artery X X
Fetal; middle
76821 cerebral artery X X
76825 Heart, fetal X X X X X X
Follow-up or repeat
76826 study X X X X X X
Page 20 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Doppler
echocardiography,
fetal cardiovascular
system, pulsed wave
and/or contiuous
76827 wave complete X X X X X X
Follow-up or repeat
76828 study X X X X X X
76830 Vagina X X X X X X
76831 Intraoperative X X X X X X
76856 Pelvis X X X X X
76857 Pelvis X X X X X X X X
76870 Scrotum X X
76872 Rectal X X X
76873 Prostate X X X
76880 Extremity X
76885 Hips, infant X
76886 Hips, infant X
76970 Follow-up X
76975 Gastrointestinal X
76999 Unlisted procedure X
Computer aided
detection screening
77051 mammography X X
Computer aided
detection diagnostic
77052 mammography X X
Mammary ductogram
or galactogram,
77053 single duct X
Page 21 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Mammary ductogram
or galactogram,
77054 multiple ducts X
Mammography,
77055 unilateral X X
Mammography,
77056 bilateral X X
Screening
mammography;
77057 bilateral X X
MRI, breast without
and/or with contrast;
77058 unilateral X
MRI, breast without
and/or with contrast;
77059 bilateral X
Manual application of
stress for joint,
including
77071 contralateral X X
77072 Bone age studies X X X
77073 Bone length studies X X
77074 Bone osseous survey X
77075 Bone osseous survey X
Bone osseous
77076 survey, infant X
Joint survey, single
view, two or more
77077 joints X X
Page 22 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Bone mineral study,
77078 axial skeleton X
Bone mineral study,
appendicular
77079 skeleton X
Bone DEXA, axial
77080 skeleton X
Bone DEXA,
appendicular
77081 skeleton X
Bone DEXA,
vertebral fracture
77082 assessment X
MRI bone marrow
77084 blood supply X
78000 Thyroid uptake X
78001 Thyroid uptake X
78003 Thyroid uptake X
Thyroid imaging with
78006 uptake X
Thyroid imaging; with
78007 uptake X
78010 Thyroid imaging X
Thyroid imaging with
78011 flow X
Thyroid imaging for
78015 metastases X
Thyroid imaging for
78016 metastases X
Thyroid imaging for
78018 metastases X
Thyroid metastases
78020 uptake X
Page 23 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Parathyroid gland
78070 imaging X
Adrenal gland
78075 imaging X
Endocrine system,
unlisted services and
78099 procedures X
Bone marrow
78102 imaging X
Bone marrow
78103 imaging X
Bone marrow
78104 imaging X
78120 Red cells X
78121 Red cells X
78122 Whole blood volumn X
78130 Red cell survival X
78135 Red cell survival X
78140 Iron, red cells X
78160 Iron, plasma X
78162 Iron absorption X
78170 Iron, utilization X
78172 Iron, chelatable X
78185 Spleen imaging X
78190 Platelet survival X
78191 Platelet survival X
78195 Lymph nodes X
Unlisted services and
78199 procedures X
78201 Liver, imaging X
78202 Liver, imaging X
78205 Liver, imaging X
78206 Liver, imaging X
78215 Liver, imaging X
Page 24 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
78216 Liver, imaging X
78220 Liver, function study X
78223 Gallbladder imaging X
Salivary gland
78230 imaging X
Salivary gland
78231 imaging X
Salivary gland
78232 function study X
78258 Esophagus, imaging X
Gastric mucosa
78261 imaging X
Stomach, reflux
78262 study X
Stomach, emptying
78264 study X
Stomach, vitamin B-
78270 12 absorption X
Stomach, vitamin B-
78271 12 absorption X
Stomach, vitamin B-
78272 12 absorption X
Gastrointestinal,
78278 blood loss study X
Gastrointestinal,
78282 protein loss study X
78290 Intestines imaging X
Gastrointestinal,
78291 shunt testing X
Unlisted services and
78299 procedures X
78300 Bone imaging X
Page 25 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
78305 Bone imaging X
78306 Bone imaging X
78315 Bone imaging X
BONE AND/OR
JOINT MULTIPLE
AREAS,
TOMOGRAHIC OR
78320 SPECT X
BONE DENSITY
DUAL PHOTON
,OSTEOPOROSIS
78351 STUDY X
Unlisted services and
78399 procedures X
78445 Blood flow imaging X
Vein, thrombosis
78455 imaging X
Vein, thrombosis
78456 imaging X
Vein, thrombosis
78457 imaging X
Vein, thrombosis
78458 imaging X
Myocardial imaging,
78459 PET X
MYOCARDIAL OR
HEART THALLIUM
PERFUSION;
78460 SINGLE STUDY X X X X
MYOCARDIAL OR
HEART MUSCLE
PERFUSION;
78461 MULTIPLE STUDIES X X X X
Page 26 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
MYOCARDIAL OR
HEART MUSCLE
SPECT; SINGLE
78464 THALLIUM* X X X X
SPECT;MYOCARDIA
78465 L/HEART X X X X
MYOCARDIAL OR
HEART MUSCLE
78466 IMAGING INFARCT X X X X
MYOCARDIAL OR
HEART MUSCLE
EJECTION
78468 FRACTION X X X X
TOMOGRAPHIC
SPECT WITH OR
WITHOUT
78469 QUANTITATION. X X X X
CARDIAC OR
HEART BLOOD
78472 POOL IMAGING X X X X
MUGA HEART
78473 SCAN X X X X
HEART WALL
78478 MOTION (ADD-ON) X X X X
HEART FUNCTION
78480 (ADD-ON)
HEART FIRST PASS X X X X
78481 SINGLE X X X X
HEART FIRST PASS
78483 MULTIPLE X X X X
Heart image (pet)
78491 single X
Heart image (pet)
78492 multiple X
Page 27 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Cardiac blood pool
imaging, gated
equilibrium, SPECT,
at rest, wall motion
study plus ejection
fraction, with or
without quantitative
78494 processing X X X X
Cardiac blood pool
imaging, gated
equilibrium, single
study, at rest, with
right ventricular
ejection fraction by
first pass technique
78496 (Add-on) X X X X
CARDIOVASCULAR
78499 NUCLEAR EXAM X X X X
Lung; imaging
78580 perfusion X
Lung, imaging
78584 perfusion X
Lung, imaging
78585 perfusion X
Lung, imaging
78586 ventilation X
Lung, imaging
78587 ventilation X
Lung, imaging
78588 ventilation X
Lung, imaging
78591 ventilation X
Lung, imaging
78593 ventilation X
Page 28 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Lung, imaging
78594 ventilation X
Unlisted services and
78599 procedures X
78600 Brain imaging X
78601 Brain imaging X
78605 Brain imaging X
78606 Brain imaging X
BRAIN SCAN OR
IMAGING SPECT
78607 OR TOMOGRAPHIC X
BRAIN PET
[POSITRON
EMISSION
78608 TOMOGRAPHY] X X
BRAIN PET
[POSITRON
EMISSION
TOMOGRAPHY]
78609 PERFUSION X X
78610 Brain, blood flow X
Brain, cerebrospinal
78630 fluid X
Brain, cerebrospinal
78635 fluid X
Brain, cerebrospinal
78645 fluid X
CEREBROSPINAL
78647 FLUID (SPECT) X
Brain, cerebrospinal
78650 fluid X
Lacrimal gland tear
78660 flow X
Page 29 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Nervous system,
unlisted services and
78699 procedures X
78700 Kidney, imaging X
78701 Kidney, imaging X
78707 Kidney, imaging X
RENAL OR KIDNEY
78710 IMAGING; SPECT X
Kidney, function
78725 study X
Bladder, residual
78730 study X
78740 Ureter reflex study X
78761 Testes, imaging X
Genitourinary
system, unlisted
services and
78799 procedures X
78800 Tumor localization X
78801 Tumor localization X
78802 Tumor localization X
TOMOGRAPHIC
78803 (SPECT) X
78804 Tumor localization X
Inflammatory
78805 process X
Inflammatory
78806 process X
TOMOGRAPHIC
78807 (SPECT) X
Tumor imaging, PET;
78811 limited area X
Page 30 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Tumor imaging,
PET;skull base to
78812 mid-thigh X
Tumor imaging, PET,
78813 whole body X
Tumor imaging, PET
78814 with CT X
Tumor imaging, PET
78815 with CT X
Tumor imaging, PET
78816 with CT X
78890 Automated data X
78891 Automated data X
Unlisted services and
78999 procedures X X
Transthoracic
echocardiography for
congenital cardiac
93303 anomalies, complete X X X X
Transthoracic
echocardiography for
congenital cardiac
anomalies, follow-up
93304 or limited study X X X X
Echocardiography,
transthoracic real
time with image
documentation 2(D)
with or without M
93307 mode recording X X X X
Page 31 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Echocardiography,
transthoracic real
time with image
documentation 2(D)
with or without M
mode recording,
follow-up or limited
93308 study X X X X
Doppler
echocardiogram,
pulsed wave and/or
continuous wave
93320 (Add-on) X X X X
Doppler
echocardiography,
pulsed wave and/or
continuous wave,
follow-up or limited
93321 study (Add-on) X X X X
Color doppler flow
velocity mapping
93325 (Add-on) X X X X
Stress echo using
treadmill, bicycle,
and/or
pharmacologically
induced stress with
intrepretation and
93350 report X X X X
Non-invasive
physiologic studies of
extracranial arteries,
complete bilateral
93875 study X X X
Page 32 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
d
un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Carotid duplex
93880 sonogram bilateral X X X
Unilateral or limited
93882 study X X X
Transcranial doppler
study of the
intraranial arteries;
93886 complete study X X X
93888 Limited study X X X
Duplex scan of lower
extremity arteries or
arterila bypass
grafts,complete
93925 bilateral study X X X
93926 Limited study X X X
Duplex scan of upper
extremity arteries or
arterial bypass grafts
complete bilateral
93930 study X X X
93931 Limited study X X X
Duplex scan of
extremity veins
complete bilateral
93970 study X X X
Unilateral or limited
93971 study X X X
Page 33 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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un
so
ra
Im ine lt
's ic r U
tr
C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
Duplex scan of
arterial inflow and
venous outflow of
abdominal, pelvic,
scrotal or
retropertoneal
93975 organs, complete X X X
93976 Limited study X X X
Duplex scan of aorta,
IVC, iliac vasculature
or bypass grafts
93978 complete study X X X
93979 Unilateral or limited
Duplex scan or X X X
arterial inflow and
venous outflow or
93980 penile vessels; X X
Follow-up or limited
93981 study X X
Duplex scan of
PET imaging access
93990 homodialysis prev X X X
G0030 PET single
Screening X
mammography;
G0202 producing direct
Diagnostic X
mammography;
G0204 producing direct
Diagnostic X
mammography;
G0206 producing direct X
Page 34 of 35 January 2008
Highmark Radiology Management Program
DIP Level Matrix
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so
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Im ine lt
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C
PF am en rap y
en ed ula
-P m sit hy
-M D g g
g
M e io o
in
M on rd iol
M om r M asc
PV ltra ilm hy
ag
U lain og y
-B ca ard
U F ap
I-W le l V
-N h d
-P so s
N
r
B ch r C
N eri un
W uc era
IO
a
-E lea
T
IP
D o
M p
EC uc
R
E
C
-N
1
2
3
4
5
6
7
8
1
6
D
0
1
2
3
4
3
4
46
47
11
45
ES
TA
T
-3
-3
-3
-3
-1
-3
-3
-3
-3
-5
-5
S-
-4
-4
-4
-4
-4
-5
-5
R
O
C
PE
T
S-
S-
S-
F-
M
M
M
M
M
M
M
M
M
M
M
C
D
C
C
N
U
U
U
U
U
U
U
PET Imaging whole
body; melanoma for
non-covered
G0219 indications X
PET Imaging, any
G0235 site NOC X
PET BREAST,
FULL/PARTIAL-
RING PET
G0252 SCANNERS ONLY, X
Magnetic source
S8035 imaging X
S8037 mrcp X
S8042 MRI low field X
Computer analysis of
full field digital
mammogram &
further physician
review for
S8075 interpretation X
Electron beam
S8092 computed tomog X X
Page 35 of 35 January 2008