Prior authorization request form Form

Questions? Please call the Alliance Pharmacy Department Monday – Friday, 7:30 am – 5 pm Phone Number: 1.510.747.4541 www.alamedaalliance.org

OPUM_RADIOLOGY AUTH UPDATE 03/12/2021
Important Update: Radiology Codes that Require Authorization

Alameda Alliance for Health (Alliance) values our dedicated provider partner community. We have an important update we would like to share with you.
Our provider partner satisfaction is a top priority. We are working to improve our Utilization Management and Claims processes to help ensure proper claim payment to our provider partners, and alignment of authorized services. To accomplish this goal, we are reviewing each benefit and we will be sending you updates, as the information is ready to share.
This communication provides an update on Radiology codes that require prior authorization (PA).
This will affect claims with date(s) of service starting Thursday, April 1, 2021, and onward. Enclosed with this notice is a code specific list for Radiology codes that shows which codes require PA. The Radiology Procedure Codes that Require Prior Authorization can be found on our website at www.alamedaalliance.org/providers/authorizations. Please refer to our website for the most up-to-date information about codes or benefits that require authorization.
In addition to the codes, our claims system will also validate that claims received match the authorization when an authorization is required. The following items will be validated: • Member name
• Provider NPI • CPT and HCPC coding
• Date(s) of service is within the authorized range • Number of units and/or visits
• Place of service matches site of care submitted on the authorization request form This update has been validated based on the current and published billable coding for 2021, and was confirmed to be covered by the California Department of Health Care Services (DHCS).
If you have questions, please call the Alliance Provider Services Department at 1.510.747.4510. Thank you for your continued partnership and for providing high-quality care to our members and the community.

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO Radiology 70010 CONTRAST X-RAY OF BRAIN The Alliance or delegate group 70015 CONTRAST X-RAY OF BRAIN The Alliance or delegate group 70450 CT HEAD/BRAIN W/O DYE The Alliance or delegate group 70460 CT HEAD/BRAIN W/DYE The Alliance or delegate group 70470 CT HEAD/BRAIN W/O & W/DYE The Alliance or delegate group 70480 CT ORBIT/EAR/FOSSA W/O DYE The Alliance or delegate group 70481 CT ORBIT/EAR/FOSSA W/DYE The Alliance or delegate group 70482 CT ORBIT/EAR/FOSSA W/O&W/DYE The Alliance or delegate group 70486 CT MAXILLOFACIAL W/O DYE The Alliance or delegate group 70487 CT MAXILLOFACIAL W/DYE The Alliance or delegate group 70488 CT MAXILLOFACIAL W/O & W/DYE The Alliance or delegate group 70490 CT SOFT TISSUE NECK W/O DYE The Alliance or delegate group 70491 CT SOFT TISSUE NECK W/DYE The Alliance or delegate group 70492 CT SFT TSUE NCK W/O & W/DYE The Alliance or delegate group 70496 CT ANGIOGRAPHY HEAD The Alliance or delegate group 70498 CT ANGIOGRAPHY NECK The Alliance or delegate group 70540 MRI ORBIT/FACE/NECK W/O DYE The Alliance or delegate group 70542 MRI ORBIT/FACE/NECK W/DYE The Alliance or delegate group 70543 MRI ORBT/FAC/NCK W/O &W/DYE The Alliance or delegate group 70544 MR ANGIOGRAPHY HEAD W/O DYE The Alliance or delegate group 70545 MR ANGIOGRAPHY HEAD W/DYE The Alliance or delegate group 70546 MR ANGIOGRAPH HEAD W/O&W/DYE The Alliance or delegate group 70547 MR ANGIOGRAPHY NECK W/O DYE The Alliance or delegate group 70548 MR ANGIOGRAPHY NECK W/DYE The Alliance or delegate group 70549 MR ANGIOGRAPH NECK W/O&W/DYE The Alliance or delegate group 70551 MRI BRAIN STEM W/O DYE The Alliance or delegate group 70552 MRI BRAIN STEM W/DYE The Alliance or delegate group ALAMEDA ALLIANCE FOR HEALTH REFERRAL AND PRIOR AUTHORIZATION (PA) PROCEDURE CODES FOR RADIOLOGY Before services are provided, please check: ▪ Member Eligibility ▪ Medical Group ▪ Benefit Coverage ▪ Contracted Provider ▪ Medi-Cal Excluded Code QUESTIONS? Please call the Alliance Provider Services Department at 1.510.747.4510 Please note: This list does not include all services. Page 1 of 8

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 70553 MRI BRAIN STEM W/O & W/DYE The Alliance or delegate group 70554 FMRI BRAIN BY TECH The Alliance or delegate group 70555 FMRI BRAIN BY PHYS/PSYCH The Alliance or delegate group 70557 MRI BRAIN W/O DYE The Alliance or delegate group 70558 MRI BRAIN W/DYE The Alliance or delegate group 70559 MRI BRAIN W/O & W/DYE The Alliance or delegate group 71250 CT THORAX DX C- The Alliance or delegate group 71260 CT THORAX DX C+ The Alliance or delegate group 71270 CT THORAX DX C-/C+ The Alliance or delegate group 71275 CT ANGIOGRAPHY CHEST The Alliance or delegate group 71550 MRI CHEST W/O DYE The Alliance or delegate group 71551 MRI CHEST W/DYE The Alliance or delegate group 71552 MRI CHEST W/O & W/DYE The Alliance or delegate group 71555 MRI ANGIO CHEST W OR W/O DYE The Alliance or delegate group 72125 CT NECK SPINE W/O DYE The Alliance or delegate group 72126 CT NECK SPINE W/DYE The Alliance or delegate group 72127 CT NECK SPINE W/O & W/DYE The Alliance or delegate group 72128 CT CHEST SPINE W/O DYE The Alliance or delegate group 72129 CT CHEST SPINE W/DYE The Alliance or delegate group 72130 CT CHEST SPINE W/O & W/DYE The Alliance or delegate group 72131 CT LUMBAR SPINE W/O DYE The Alliance or delegate group 72132 CT LUMBAR SPINE W/DYE The Alliance or delegate group 72133 CT LUMBAR SPINE W/O & W/DYE The Alliance or delegate group 72141 MRI NECK SPINE W/O DYE The Alliance or delegate group 72142 MRI NECK SPINE W/DYE The Alliance or delegate group 72146 MRI CHEST SPINE W/O DYE The Alliance or delegate group 72147 MRI CHEST SPINE W/DYE The Alliance or delegate group 72148 MRI LUMBAR SPINE W/O DYE The Alliance or delegate group 72149 MRI LUMBAR SPINE W/DYE The Alliance or delegate group 72156 MRI NECK SPINE W/O & W/DYE The Alliance or delegate group 72157 MRI CHEST SPINE W/O & W/DYE The Alliance or delegate group 72158 MRI LUMBAR SPINE W/O & W/DYE The Alliance or delegate group 72159 MR ANGIO SPINE W/O&W/DYE The Alliance or delegate group 72191 CT ANGIOGRAPH PELV W/O&W/DYE The Alliance or delegate group 72192 CT PELVIS W/O DYE The Alliance or delegate group 72193 CT PELVIS W/DYE The Alliance or delegate group Please note: This list does not include all services. Page 2 of 8

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 72194 CT PELVIS W/O & W/DYE The Alliance or delegate group 72195 MRI PELVIS W/O DYE The Alliance or delegate group 72196 MRI PELVIS W/DYE The Alliance or delegate group 72197 MRI PELVIS W/O & W/DYE The Alliance or delegate group 72198 MR ANGIO PELVIS W/O & W/DYE The Alliance or delegate group 73700 CT LOWER EXTREMITY W/O DYE The Alliance or delegate group 73701 CT LOWER EXTREMITY W/DYE The Alliance or delegate group 73702 CT LWR EXTREMITY W/O&W/DYE The Alliance or delegate group 73706 CT ANGIO LWR EXTR W/O&W/DYE The Alliance or delegate group 73718 MRI LOWER EXTREMITY W/O DYE The Alliance or delegate group 73719 MRI LOWER EXTREMITY W/DYE The Alliance or delegate group 73720 MRI LWR EXTREMITY W/O&W/DYE The Alliance or delegate group 73721 MRI JNT OF LWR EXTRE W/O DYE The Alliance or delegate group 73722 MRI JOINT OF LWR EXTR W/DYE The Alliance or delegate group 73723 MRI JOINT LWR EXTR W/O&W/DYE The Alliance or delegate group 73725 MR ANG LWR EXT W OR W/O DYE The Alliance or delegate group 74150 CT ABDOMEN W/O DYE The Alliance or delegate group 74160 CT ABDOMEN W/DYE The Alliance or delegate group 74170 CT ABDOMEN W/O & W/DYE The Alliance or delegate group 74174 CT ANGIO ABD&PELV W/O&W/DYE The Alliance or delegate group 74175 CT ANGIO ABDOM W/O & W/DYE The Alliance or delegate group 74176 CT ABD & PELVIS W/O CONTRAST The Alliance or delegate group 74177 CT ABD & PELV W/CONTRAST The Alliance or delegate group 74178 CT ABD & PELV 1/> REGNS The Alliance or delegate group 74181 MRI ABDOMEN W/O DYE The Alliance or delegate group 74182 MRI ABDOMEN W/DYE The Alliance or delegate group 74183 MRI ABDOMEN W/O & W/DYE The Alliance or delegate group 74185 MRI ANGIO ABDOM W ORW/O DYE The Alliance or delegate group 74235 REMOVE ESOPHAGUS OBSTRUCTION The Alliance or delegate group 74283 THER NMA RDCTJ INTUS/OBSTRCJ The Alliance or delegate group 74290 CONTRAST X-RAY GALLBLADDER The Alliance or delegate group 74712 MRI FETAL SNGL/1ST GESTATION The Alliance or delegate group 74713 MRI FETAL EA ADDL GESTATION The Alliance or delegate group 75561 CARDIAC MRI FOR MORPH W/DYE The Alliance or delegate group 75565 CARD MRI VELOC FLOW MAPPING The Alliance or delegate group 75571 CT HRT W/O DYE W/CA TEST The Alliance or delegate group Please note: This list does not include all services. Page 3 of 8

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 75572 CT HRT W/3D IMAGE The Alliance or delegate group 75573 CT HRT W/3D IMAGE CONGEN The Alliance or delegate group 75574 CT ANGIO HRT W/3D IMAGE The Alliance or delegate group 75600 CONTRAST EXAM THORACIC AORTA The Alliance or delegate group 75605 CONTRAST EXAM THORACIC AORTA The Alliance or delegate group 75625 CONTRAST EXAM ABDOMINL AORTA The Alliance or delegate group 75635 CT ANGIO ABDOMINAL ARTERIES The Alliance or delegate group 75901 REMOVE CVA DEVICE OBSTRUCT The Alliance or delegate group 75902 REMOVE CVA LUMEN OBSTRUCT The Alliance or delegate group 75956 XRAY ENDOVASC THOR AO REPR The Alliance or delegate group 75957 XRAY ENDOVASC THOR AO REPR The Alliance or delegate group 75958 XRAY PLACE PROX EXT THOR AO The Alliance or delegate group 75959 XRAY PLACE DIST EXT THOR AO The Alliance or delegate group 75970 VASCULAR BIOPSY The Alliance or delegate group 76380 CAT SCAN FOLLOW-UP STUDY The Alliance or delegate group 76391 MR ELASTOGRAPHY The Alliance or delegate group 76496 FLUOROSCOPIC PROCEDURE The Alliance or delegate group 76497 CT PROCEDURE The Alliance or delegate group 76498 MRI PROCEDURE The Alliance or delegate group 76499 RADIOGRAPHIC PROCEDURE The Alliance or delegate group 77001 FLUOROGUIDE FOR VEIN DEVICE The Alliance or delegate group 77002 NEEDLE LOCALIZATION BY XRAY The Alliance or delegate group 77003 FLUOROGUIDE FOR SPINE INJECT The Alliance or delegate group 77011 CT SCAN FOR LOCALIZATION The Alliance or delegate group 77012 CT SCAN FOR NEEDLE BIOPSY The Alliance or delegate group 77013 CT GUIDE FOR TISSUE ABLATION The Alliance or delegate group 77014 CT SCAN FOR THERAPY GUIDE The Alliance or delegate group 77021 MRI GUIDANCE NDL PLMT RS&I The Alliance or delegate group 77022 MRI GDN PARNCHYMA TISS ABLTJ The Alliance or delegate group 77046 MRI BREAST C- UNILATERAL The Alliance or delegate group 77047 MRI BREAST C- BILATERAL The Alliance or delegate group 77048 MRI BREAST C-+ W/CAD UNI The Alliance or delegate group 77049 MRI BREAST C-+ W/CAD BI The Alliance or delegate group 77261 RADIATION THERAPY PLANNING The Alliance or delegate group 77262 RADIATION THERAPY PLANNING The Alliance or delegate group 77263 RADIATION THERAPY PLANNING The Alliance or delegate group Please note: This list does not include all services. Page 4 of 8

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 77280 SET RADIATION THERAPY FIELD The Alliance or delegate group 77285 SET RADIATION THERAPY FIELD The Alliance or delegate group 77290 SET RADIATION THERAPY FIELD The Alliance or delegate group 77295 3-D RADIOTHERAPY PLAN The Alliance or delegate group 77299 RADIATION THERAPY PLANNING The Alliance or delegate group 77300 RADIATION THERAPY DOSE PLAN The Alliance or delegate group 77301 RADIOTHERAPY DOSE PLAN IMRT The Alliance or delegate group 77306 TELETHX ISODOSE PLAN SIMPLE The Alliance or delegate group 77307 TELETHX ISODOSE PLAN CPLX The Alliance or delegate group 77316 BRACHYTX ISODOSE PLAN SIMPLE The Alliance or delegate group 77317 BRACHYTX ISODOSE INTERMED The Alliance or delegate group 77318 BRACHYTX ISODOSE COMPLEX The Alliance or delegate group 77321 SPECIAL TELETX PORT PLAN The Alliance or delegate group 77331 SPECIAL RADIATION DOSIMETRY The Alliance or delegate group 77332 RADIATION TREATMENT AID(S) The Alliance or delegate group 77333 RADIATION TREATMENT AID(S) The Alliance or delegate group 77334 RADIATION TREATMENT AID(S) The Alliance or delegate group 77336 RADIATION PHYSICS CONSULT The Alliance or delegate group 77338 DESIGN MLC DEVICE FOR IMRT The Alliance or delegate group 77370 RADIATION PHYSICS CONSULT The Alliance or delegate group 77371 SRS MULTISOURCE The Alliance or delegate group 77372 SRS LINEAR BASED The Alliance or delegate group 77373 SBRT DELIVERY The Alliance or delegate group 77385 NTSTY MODUL RAD TX DLVR SMPL The Alliance or delegate group 77386 NTSTY MODUL RAD TX DLVR CPLX The Alliance or delegate group 77387 GUIDANCE FOR RADJ TX DLVR The Alliance or delegate group 77399 EXTERNAL RADIATION DOSIMETRY The Alliance or delegate group 77401 RADIATION TREATMENT DELIVERY The Alliance or delegate group 77402 RADIATION TREATMENT DELIVERY The Alliance or delegate group 77407 RADIATION TREATMENT DELIVERY The Alliance or delegate group 77412 RADIATION TREATMENT DELIVERY The Alliance or delegate group 77417 RADIOLOGY PORT IMAGES(S) The Alliance or delegate group 77423 NEUTRON BEAM TX COMPLEX The Alliance or delegate group 77424 IO RAD TX DELIVERY BY X-RAY The Alliance or delegate group 77425 IO RAD TX DELIVER BY ELCTRNS The Alliance or delegate group 77427 RADIATION TX MANAGEMENT X5 The Alliance or delegate group Please note: This list does not include all services. Page 5 of 8

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 77431 RADIATION THERAPY MANAGEMENT The Alliance or delegate group 77432 STEREOTACTIC RADIATION TRMT The Alliance or delegate group 77435 SBRT MANAGEMENT The Alliance or delegate group 77469 IO RADIATION TX MANAGEMENT The Alliance or delegate group 77470 SPECIAL RADIATION TREATMENT The Alliance or delegate group 77499 RADIATION THERAPY MANAGEMENT The Alliance or delegate group 77520 PROTON TRMT SIMPLE W/O COMP The Alliance or delegate group 77522 PROTON TRMT SIMPLE W/COMP The Alliance or delegate group 77523 PROTON TRMT INTERMEDIATE The Alliance or delegate group 77525 PROTON TREATMENT COMPLEX The Alliance or delegate group 77600 HYPERTHERMIA TREATMENT The Alliance or delegate group 77610 HYPERTHERMIA TREATMENT The Alliance or delegate group 77615 HYPERTHERMIA TREATMENT The Alliance or delegate group 77750 INFUSE RADIOACTIVE MATERIALS The Alliance or delegate group 77761 APPLY INTRCAV RADIAT SIMPLE The Alliance or delegate group 77762 APPLY INTRCAV RADIAT INTERM The Alliance or delegate group 77763 APPLY INTRCAV RADIAT COMPL The Alliance or delegate group 77767 HDR RDNCL SKN SURF BRACHYTX The Alliance or delegate group 77768 HDR RDNCL SKN SURF BRACHYTX The Alliance or delegate group 77770 HDR RDNCL NTRSTL/ICAV BRCHTX The Alliance or delegate group 77771 HDR RDNCL NTRSTL/ICAV BRCHTX The Alliance or delegate group 77772 HDR RDNCL NTRSTL/ICAV BRCHTX The Alliance or delegate group 77778 APPLY INTERSTIT RADIAT COMPL The Alliance or delegate group 77789 APPLY SURF LDR RADIONUCLIDE The Alliance or delegate group 77790 RADIATION HANDLING The Alliance or delegate group 77799 RADIUM/RADIOISOTOPE THERAPY The Alliance or delegate group 78075 ADRENAL CORTEX & MEDULLA IMG The Alliance or delegate group 78099 ENDOCRINE NUCLEAR PROCEDURE The Alliance or delegate group 78102 BONE MARROW IMAGING LTD The Alliance or delegate group 78103 BONE MARROW IMAGING MULT The Alliance or delegate group 78104 BONE MARROW IMAGING BODY The Alliance or delegate group 78201 LIVER IMAGING The Alliance or delegate group 78202 LIVER IMAGING WITH FLOW The Alliance or delegate group 78215 LIVER AND SPLEEN IMAGING The Alliance or delegate group 78216 LIVER & SPLEEN IMAGE/FLOW The Alliance or delegate group 78226 HEPATOBILIARY SYSTEM IMAGING The Alliance or delegate group Please note: This list does not include all services. Page 6 of 8

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 78227 HEPATOBIL SYST IMAGE W/DRUG The Alliance or delegate group 78299 GI NUCLEAR PROCEDURE The Alliance or delegate group 78300 BONE IMAGING LIMITED AREA The Alliance or delegate group 78305 BONE IMAGING MULTIPLE AREAS The Alliance or delegate group 78306 BONE IMAGING WHOLE BODY The Alliance or delegate group 78315 BONE IMAGING 3 PHASE The Alliance or delegate group 78399 MUSCULOSKELETAL NUCLEAR EXAM The Alliance or delegate group 78428 CARDIAC SHUNT IMAGING The Alliance or delegate group 78429 MYOCRD IMG PET 1 STD W/CT The Alliance or delegate group 78430 MYOCRD IMG PET RST/STRS W/CT The Alliance or delegate group 78431 MYOCRD IMG PET RST&STRS CT The Alliance or delegate group 78432 MYOCRD IMG PET 2RTRACER The Alliance or delegate group 78433 MYOCRD IMG PET 2RTRACER CT The Alliance or delegate group 78434 AQMBF PET REST & RX STRESS The Alliance or delegate group 78451 HT MUSCLE IMAGE SPECT SING The Alliance or delegate group 78452 HT MUSCLE IMAGE SPECT MULT The Alliance or delegate group 78453 HT MUSCLE IMAGE PLANAR SING The Alliance or delegate group 78454 HT MUSC IMAGE PLANAR MULT The Alliance or delegate group 78459 MYOCRD IMG PET SINGLE STUDY The Alliance or delegate group 78466 HEART INFARCT IMAGE The Alliance or delegate group 78468 HEART INFARCT IMAGE (EF) The Alliance or delegate group 78472 GATED HEART PLANAR SINGLE The Alliance or delegate group 78473 GATED HEART MULTIPLE The Alliance or delegate group 78481 HEART FIRST PASS SINGLE The Alliance or delegate group 78483 HEART FIRST PASS MULTIPLE The Alliance or delegate group 78494 HEART IMAGE SPECT The Alliance or delegate group 78496 HEART FIRST PASS ADD-ON The Alliance or delegate group 78499 CARDIOVASCULAR NUCLEAR EXAM The Alliance or delegate group 78579 LUNG VENTILATION IMAGING The Alliance or delegate group 78580 LUNG PERFUSION IMAGING The Alliance or delegate group 78582 LUNG VENTILAT&PERFUS IMAGING The Alliance or delegate group 78597 LUNG PERFUSION DIFFERENTIAL The Alliance or delegate group 78598 LUNG PERF&VENTILAT DIFERENTL The Alliance or delegate group 78599 RESPIRATORY NUCLEAR EXAM The Alliance or delegate group 78600 BRAIN IMAGE < 4 VIEWS The Alliance or delegate group 78601 BRAIN IMAGE W/FLOW < 4 VIEWS The Alliance or delegate group Please note: This list does not include all services. Page 7 of 8

SERVICE CATEGORY PROCEDURE CODE PROCEDURE CODE DESCRIPTION SUBMIT AUTHORIZATION REQUEST TO 78605 BRAIN IMAGE 4+ VIEWS The Alliance or delegate group 78606 BRAIN IMAGE W/FLOW 4 + VIEWS The Alliance or delegate group 78608 BRAIN IMAGING (PET) The Alliance or delegate group 78609 BRAIN IMAGING (PET) The Alliance or delegate group 78610 BRAIN FLOW IMAGING ONLY The Alliance or delegate group 78630 CEREBROSPINAL FLUID SCAN The Alliance or delegate group 78699 NERVOUS SYSTEM NUCLEAR EXAM The Alliance or delegate group 78799 GENITOURINARY NUCLEAR EXAM The Alliance or delegate group 78800 RP LOCLZJ TUM 1 AREA 1 D IMG The Alliance or delegate group 78801 RP LOCLZJ TUM 2+AREA 1+D IMG The Alliance or delegate group 78802 RP LOCLZJ TUM WHBDY 1 D IMG The Alliance or delegate group 78804 RP LOCLZJ TUM WHBDY 2+D IMG The Alliance or delegate group 78808 IV INJ RA DRUG DX STUDY The Alliance or delegate group 78811 PET IMAGE LTD AREA The Alliance or delegate group 78812 PET IMAGE SKULL-THIGH The Alliance or delegate group 78813 PET IMAGE FULL BODY The Alliance or delegate group 78814 PET IMAGE W/CT LMTD The Alliance or delegate group 78815 PET IMAGE W/CT SKULL-THIGH The Alliance or delegate group 78816 PET IMAGE W/CT FULL BODY The Alliance or delegate group 78830 RP LOCLZJ TUM SPECT W/CT 1 The Alliance or delegate group 78831 RP LOCLZJ TUM SPECT 2 AREAS The Alliance or delegate group 78832 RP LOCLZJ TUM SPECT W/CT 2 The Alliance or delegate group 78835 RP QUAN MEAS SINGLE AREA The Alliance or delegate group 78999 NUCLEAR DIAGNOSTIC EXAM The Alliance or delegate group 79005 NUCLEAR RX ORAL ADMIN The Alliance or delegate group 79101 NUCLEAR RX IV ADMIN The Alliance or delegate group 79200 NUCLEAR RX INTRACAV ADMIN The Alliance or delegate group 79300 NUCLR RX INTERSTIT COLLOID The Alliance or delegate group 79403 HEMATOPOIETIC NUCLEAR TX The Alliance or delegate group 79440 NUCLEAR RX INTRA-ARTICULAR The Alliance or delegate group 79445 NUCLEAR RX INTRA-ARTERIAL The Alliance or delegate group 79999 NUCLEAR MEDICINE THERAPY The Alliance or delegate group R0070 TRANS PRTBL XRAY EQP&PERS-TRIP 1 PT The Alliance or delegate group R0075 TRANS PRTBL XRAY EQP&PERS-TRIP>1 PT The Alliance or delegate group Please note: This list does not include all services. Page 8 of 8