Ambulance service, outside state per mile, transport (medicaid only)

Non-emergency transportation, per mile – vehicle provided by volunteer (individual or organization), with no vested interest

Non-emergency transportation, per mile – vehicle provided by individual (family member, self, neighbor) with vested interest

Non-emergency transportation; taxi

Non-emergency transportation and bus, intra or inter state carrier

Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems

Non-emergency transportation: wheelchair van

Non-emergency transportation and air travel (private or commercial) intra or inter state

Non-emergency transportation: per mile – case worker or social worker

Transportation ancillary: parking fees, tolls, other

Non-emergency transportation: ancillary: lodging-recipient

Non-emergency transportation: ancillary: meals-recipient

Non-emergency transportation: ancillary: lodging escort

Non-emergency transportation: ancillary: meals-escort

Ambulance service, neonatal transport, base rate, emergency transport, one way

Bls mileage (per mile)

Bls routine disposable supplies

Bls specialized service disposable supplies; defibrillation (used by als ambulances and bls ambulances in jurisdictions where defibrillation is permitted in bls ambulances)

Als mileage (per mile)

Als specialized service disposable supplies; defibrillation (to be used only in jurisdictions where defibrillation cannot be performed in bls ambulances)

Als specialized service disposable supplies; iv drug therapy

Als specialized service disposable supplies; esophageal intubation

Als routine disposable supplies

Ambulance waiting time (als or bls), one half (1/2) hour increments

Ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation

Extra ambulance attendant, ground (als or bls) or air (fixed or rotary winged); (requires medical review)

Ground mileage, per statute mile

Ambulance service, advanced life support, non-emergency transport, level 1 (als 1)

Ambulance service, advanced life support, emergency transport, level 1 (als 1 – emergency)

Ambulance service, basic life support, non-emergency transport, (bls)

Ambulance service, basic life support, emergency transport (bls-emergency)

Ambulance service, conventional air services, transport, one way (fixed wing)

Ambulance service, conventional air services, transport, one way (rotary wing)

Paramedic intercept (pi), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers

Advanced life support, level 2 (als 2)

Specialty care transport (sct)

Fixed wing air mileage, per statute mile

Rotary wing air mileage, per statute mile

Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)

Ambulance response and treatment, no transport

Unlisted ambulance service

Innovamatrix ac, per square centimeter

Mirragen advanced wound matrix, per square centimeter

Xcellistem, 1 mg

Microlyte matrix, per square centimeter

Novosorb synpath dermal matrix, per square centimeter

Restrata, per square centimeter

Theragenesis, per square centimeter

Symphony, per square centimeter

Apis, per square centimeter

Supra sdrm, per square centimeter

Suprathel, per square centimeter

Innovamatrix fs, per square centimeter

Omeza collagen matrix, per 100 mg

Phoenix wound matrix, per square centimeter

Permeaderm b, per square centimeter

Permeaderm glove, each

Permeaderm c, per square centimeter

Kerecis omega3 marigen shield, per square centimeter

Ac5 advanced wound system (ac5)

Neomatrix, per square centimeter

Skin substitute, fda cleared as a device, not otherwise specified

Syringe with needle, sterile, 1 cc or less, each

Syringe with needle, sterile 2 cc, each

Syringe with needle, sterile 3 cc, each

Syringe with needle, sterile 5 cc or greater, each

Needle-free injection device, each

Supplies for self-administered injections

Non-coring needle or stylet with or without catheter

Syringe, sterile, 20 cc or greater, each

Needle, sterile, any size, each

Sterile water, saline and/or dextrose, diluent/flush, 10 ml

Sterile water/saline, 500 ml

Sterile saline or water, metered dose dispenser, 10 ml

Refill kit for implantable infusion pump

Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately)

Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)

Infusion supplies not used with external infusion pump, per cassette or bag (list drugs separately)

Supplies for maintenance of insulin infusion catheter, per week

Supplies for external insulin infusion pump, syringe type cartridge, sterile, each

Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose sensing, per week

Infusion set for external insulin pump, non needle cannula type

Infusion set for external insulin pump, needle type

Syringe with needle for external insulin pump, sterile, 3 cc

Replacement battery, alkaline (other than j cell), for use with medically necessary home blood glucose monitor owned by patient, each

Replacement battery, alkaline, j cell, for use with medically necessary home blood glucose monitor owned by patient, each

Replacement battery, lithium, for use with medically necessary home blood glucose monitor owned by patient, each

Replacement battery, silver oxide, for use with medically necessary home blood glucose monitor owned by patient, each

Supply allowance for adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service

Supply allowance for non-adjunctive, non-implanted continuous glucose monitor (cgm), includes all supplies and accessories, 1 month supply = 1 unit of service

Alcohol or peroxide, per pint

Alcohol wipes, per box

Betadine or phisohex solution, per pint

Betadine or iodine swabs/wipes, per box

Chlorhexidine containing antiseptic, 1 ml

Urine test or reagent strips or tablets (100 tablets or strips)

Blood ketone test or reagent strip, each

Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

Platforms for home blood glucose monitor, 50 per box

Normal, low and high calibrator solution / chips

Replacement lens shield cartridge for use with laser skin piercing device, each

Spring-powered device for lancet, each

Lancets, per box of 100

Cervical cap for contraceptive use

Temporary, absorbable lacrimal duct implant, each

Permanent, long term, non-dissolvable lacrimal duct implant, each

Permanent implantable contraceptive intratubal occlusion device(s) and delivery system

Paraffin, per pound

Diaphragm for contraceptive use

Contraceptive supply, condom, male, each

Contraceptive supply, condom, female, each

Contraceptive supply, spermicide (e.g., foam, gel), each

Disposable endoscope sheath, each

Adhesive skin support attachment for use with external breast prosthesis, each

Tubing for breast pump, replacement

Adapter for breast pump, replacement

Cap for breast pump bottle, replacement

Breast shield and splash protector for use with breast pump, replacement

Polycarbonate bottle for use with breast pump, replacement

Locking ring for breast pump, replacement

Sacral nerve stimulation test lead, each

Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc.) external access

Implantable access total catheter, port/reservoir (e.g., venous, arterial, epidural, subarachnoid, peritoneal, etc.)

Disposable drug delivery system, flow rate of 50 ml or greater per hour

Disposable drug delivery system, flow rate of less than 50 ml per hour

Insertion tray without drainage bag and without catheter (accessories only)

Insertion tray without drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.)

Insertion tray without drainage bag with indwelling catheter, foley type, two-way, all silicone

Insertion tray without drainage bag with indwelling catheter, foley type, three-way, for continuous irrigation

Insertion tray with drainage bag with indwelling catheter, foley type, two-way latex with coating (teflon, silicone, silicone elastomer or hydrophilic, etc.)

Insertion tray with drainage bag with indwelling catheter, foley type, two-way, all silicone

Insertion tray with drainage bag with indwelling catheter, foley type, three-way, for continuous irrigation

Irrigation tray with bulb or piston syringe, any purpose

Therapeutic agent for urinary catheter irrigation

Irrigation syringe, bulb or piston, each

Male external catheter with integral collection chamber, any type, each

Female external urinary collection device; meatal cup, each

Female external urinary collection device; pouch, each

Perianal fecal collection pouch with adhesive, each

Extension drainage tubing, any type, any length, with connector/adaptor, for use with urinary leg bag or urostomy pouch, each

Lubricant, individual sterile packet, each

Urinary catheter anchoring device, adhesive skin attachment, each

Urinary catheter anchoring device, leg strap, each

Incontinence supply; miscellaneous

Incontinence supply, urethral insert, any type, each

Incontinence supply, rectal insert, any type, each

Indwelling catheter; foley type, two-way latex with coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

Indwelling catheter; specialty type, (e.g., coude, mushroom, wing, etc.), each

Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each

Accessories for patient inserted indwelling intraurethral drainage device with valve, replacement only, each

Indwelling catheter, foley type, two-way, all silicone, each

Indwelling catheter; foley type, three way for continuous irrigation, each

Male external catheter, with or without adhesive, disposable, each

Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, silicone elastomer, or hydrophilic, etc.), each

Intermittent urinary catheter; coude (curved) tip, with or without coating (teflon, silicone, silicone elastomeric, or hydrophilic, etc.), each

Intermittent urinary catheter, with insertion supplies

Insertion tray with drainage bag but without catheter

Irrigation tubing set for continuous bladder irrigation through a three-way indwelling foley catheter, each

External urethral clamp or compression device (not to be used for catheter clamp), each

Bedside drainage bag, day or night, with or without anti-reflux device, with or without tube, each

Urinary drainage bag, leg or abdomen, vinyl, with or without tube, with straps, each

Disposable external urethral clamp or compression device, with pad and/or pouch, each

Ostomy faceplate, each

Skin barrier; solid, 4 x 4 or equivalent; each

Ostomy clamp, any type, replacement only, each

Adhesive, liquid or equal, any type, per oz

Ostomy vent, any type, each

Ostomy belt, each

Ostomy filter, any type, each

Ostomy skin barrier, liquid (spray, brush, etc.), per oz

Ostomy skin barrier, powder, per oz

Ostomy skin barrier, solid 4 x 4 or equivalent, standard wear, with built-in convexity, each

Ostomy skin barrier, with flange (solid, flexible or accordion), with built-in convexity, any size, each

Ostomy pouch, drainable, with faceplate attached, plastic, each

Ostomy pouch, drainable, with faceplate attached, rubber, each

Ostomy pouch, drainable, for use on faceplate, plastic, each

Ostomy pouch, drainable, for use on faceplate, rubber, each

Ostomy pouch, urinary, with faceplate attached, plastic, each

Ostomy pouch, urinary, with faceplate attached, rubber, each

Ostomy pouch, urinary, for use on faceplate, plastic, each

Ostomy pouch, urinary, for use on faceplate, heavy plastic, each

Ostomy pouch, urinary, for use on faceplate, rubber, each

Ostomy faceplate equivalent, silicone ring, each

Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, without built-in convexity, each

Ostomy pouch, closed, with barrier attached, with built-in convexity (1 piece), each

Ostomy pouch, drainable, with extended wear barrier attached, (1 piece), each

Ostomy pouch, drainable, with barrier attached, with built-in convexity (1 piece), each

Ostomy pouch, drainable, with extended wear barrier attached, with built-in convexity (1 piece), each

Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each

Ostomy pouch, urinary, with standard wear barrier attached, with built-in convexity (1 piece), each

Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity (1 piece), each

Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce

Ostomy deodorant for use in ostomy pouch, solid, per tablet

Ostomy belt with peristomal hernia support

Irrigation supply; sleeve, each

Terminated December 31, 2021.

Ostomy irrigation supply; bag, each

Ostomy irrigation supply; cone/catheter, with or without brush

Ostomy irrigation set

Lubricant, per ounce

Ostomy ring, each

Ostomy skin barrier, non-pectin based, paste, per ounce

Ostomy skin barrier, pectin-based, paste, per ounce

Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built-in convexity, 4 x 4 inches or smaller, each

Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, with built-in convexity, larger than 4 x 4 inches, each

Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, 4 x 4 inches or smaller, each

Ostomy skin barrier, with flange (solid, flexible or accordion), extended wear, without built-in convexity, larger than 4 x 4 inches, each

Ostomy skin barrier, solid 4 x 4 or equivalent, extended wear, with built-in convexity, each

Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), without filter, each

Ostomy pouch, drainable, high output, for use on a barrier with flange (2 piece system), with filter, each

Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, 4 x 4 inches or smaller, each

Ostomy skin barrier, with flange (solid, flexible or accordion), without built-in convexity, larger than 4 x 4 inches, each

Ostomy pouch, closed, with barrier attached, with filter (1 piece), each

Ostomy pouch, closed, with barrier attached, with built-in convexity, with filter (1 piece), each

Ostomy pouch, closed; without barrier attached, with filter (1 piece), each

Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (2 piece), each

Ostomy pouch, closed; for use on barrier with locking flange (2 piece), each

Ostomy supply; miscellaneous

Ostomy absorbent material (sheet/pad/crystal packet) for use in ostomy pouch to thicken liquid stomal output, each

Ostomy pouch, closed; for use on barrier with locking flange, with filter (2 piece), each

Ostomy pouch, drainable, with barrier attached, with filter (1 piece), each

Ostomy pouch, drainable; for use on barrier with non-locking flange, with filter (2 piece system), each

Ostomy pouch, drainable; for use on barrier with locking flange (2 piece system), each

Ostomy pouch, drainable; for use on barrier with locking flange, with filter (2 piece system), each

Ostomy pouch, urinary, with extended wear barrier attached, with faucet-type tap with valve (1 piece), each

Ostomy pouch, urinary, with barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each

Ostomy pouch, urinary, with extended wear barrier attached, with built-in convexity, with faucet-type tap with valve (1 piece), each

Ostomy pouch, urinary; with barrier attached, with faucet-type tap with valve (1 piece), each

Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet-type tap with valve (2 piece), each

Ostomy pouch, urinary; for use on barrier with locking flange (2 piece), each

Ostomy pouch, urinary; for use on barrier with locking flange, with faucet-type tap with valve (2 piece), each

Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filter, each

Irrigation supply; sleeve, reusable, per month

Irrigation supply; sleeve, disposable, per month

Tape, non-waterproof, per 18 square inches

Tape, waterproof, per 18 square inches

Rectal catheter for use with the manual pump-operated enema system, replacement only

Adhesive remover or solvent (for tape, cement or other adhesive), per ounce

Adhesive remover, wipes, any type, each

Enema bag with tubing, reusable

Manual pump-operated enema system, includes balloon, catheter and all accessories, reusable, any type

Surgical dressing holder, non-reusable, each

Surgical dressing holder, reusable, each

Non-elastic binder for extremity

Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each

Terminated December 31, 2016.

Belt, strap, sleeve, garment, or covering, any type

Gravlee jet washer

Vabra aspirator

Tracheostoma filter, any type, any size, each

Moisture exchanger, disposable, for use with invasive mechanical ventilation

Surgical stockings above knee length, each

Surgical stockings thigh length, each

Surgical stockings below knee length, each

Surgical stockings full length, each

Incontinence garment, any type, (e.g., brief, diaper), each

Surgical trays

Non-disposable underpads, all sizes

Disposable underpads, all sizes

Electrode/transducer for use with electrical stimulation device used for cancer treatment, replacement only

Electrodes, (e.g., apnea monitor), per pair

Lead wires, (e.g., apnea monitor), per pair

Conductive gel or paste, for use with electrical device (e.g., tens, nmes), per oz

Coupling gel or paste, for use with ultrasound device, per oz

Neuromuscular electrical stimulator (nmes), disposable, replacement only

Pessary, rubber, any type

Pessary, non rubber, any type

Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each

Slings

Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustment

Splint

Topical hyperbaric oxygen chamber, disposable

Cast supplies (e.g., plaster)

Special casting material (e.g., fiberglass)

Electrical stimulator supplies, 2 lead, per month, (e.g., tens, nmes)

Cranial electrotherapy stimulation (ces) system supplies and accessories, per month

Sleeve for intermittent limb compression device, replacement only, each

Lithium ion battery, rechargeable, for non-prosthetic use, replacement

Replacement battery for external infusion pump owned by patient, lithium, 1.5 volt, each

Tubing with integrated heating element for use with positive airway pressure device

Tracheal suction catheter, closed system, each

Oxygen probe for use with oximeter device, replacement

Transtracheal oxygen catheter, each

Battery, heavy duty; replacement for patient owned ventilator

Battery cables; replacement for patient-owned ventilator

Battery charger; replacement for patient-owned ventilator

Peak expiratory flow rate meter, hand held

Cannula, nasal

Tubing (oxygen), per foot

Mouth piece

Breathing circuits

Face tent

Variable concentration mask

Tracheostomy, inner cannula

Tracheal suction catheter, any type other than closed system, each

Tracheostomy care kit for new tracheostomy

Tracheostomy cleaning brush, each

Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler

Oral and/or oropharyngeal suction catheter, each

Tracheostomy care kit for established tracheostomy

Replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient

Replacement bulb/lamp for ultraviolet light therapy system, each

Replacement bulb for therapeutic light box, tabletop model

Underarm pad, crutch, replacement, each

Replacement, handgrip, cane, crutch, or walker, each

Replacement, tip, cane, crutch, walker, each.

Replacement battery for patient-owned ear pulse generator, each

Replacement pad for infrared heating pad system, each

Replacement pad for use with medically necessary alternating pressure pad owned by patient

Radiopharmaceutical, diagnostic, not otherwise classified

Indium in-111 satumomab pendetide, diagnostic, per study dose, up to 6 millicuries

Tissue marker, implantable, any type, each

Surgical supply; miscellaneous

Implantable radiation dosimeter, each

Calibrated microcapillary tube, each

Microcapillary tube sealant

Peritoneal dialysis catheter anchoring device, belt, each

Syringe, with or without needle, each

Sphygmomanometer/blood pressure apparatus with cuff and stethoscope

Blood pressure cuff only

Automatic blood pressure monitor

Disposable cycler set used with cycler dialysis machine, each

Drainage extension line, sterile, for dialysis, each

Extension line with easy lock connectors, used with dialysis

Chemicals/antiseptics solution used to clean/sterilize dialysis equipment, per 8 oz

Activated carbon filter for hemodialysis, each

Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis, each

Bicarbonate concentrate, solution, for hemodialysis, per gallon

Bicarbonate concentrate, powder, for hemodialysis, per packet

Acetate concentrate solution, for hemodialysis, per gallon

Acid concentrate, solution, for hemodialysis, per gallon

Treated water (deionized, distilled, or reverse osmosis) for peritoneal dialysis, per gallon

y set tubing for peritoneal dialysis

Dialysate solution, any concentration of dextrose, fluid volume greater than 249 cc, but less than or equal to 999 cc, for peritoneal dialysis

Dialysate solution, any concentration of dextrose, fluid volume greater than 999 cc but less than or equal to 1999 cc, for peritoneal dialysis

Dialysate solution, any concentration of dextrose, fluid volume greater than 1999 cc but less than or equal to 2999 cc, for peritoneal dialysis

Dialysate solution, any concentration of dextrose, fluid volume greater than 2999 cc but less than or equal to 3999 cc, for peritoneal dialysis

Dialysate solution, any concentration of dextrose, fluid volume greater than 3999 cc but less than or equal to 4999 cc, for peritoneal dialysis

Dialysate solution, any concentration of dextrose, fluid volume greater than 4999 cc but less than or equal to 5999 cc, for peritoneal dialysis

Dialysate solution, any concentration of dextrose, fluid volume greater than 5999 cc, for peritoneal dialysis

Dialysate solution, non-dextrose containing, 500 ml

Fistula cannulation set for hemodialysis, each

Topical anesthetic, for dialysis, per gram

Injectable anesthetic, for dialysis, per 10 ml

Shunt accessory, for hemodialysis, any type, each

Blood tubing, arterial or venous, for hemodialysis, each

Blood tubing, arterial and venous combined, for hemodialysis, each

Dialysate solution test kit, for peritoneal dialysis, any type, each

Dialysate concentrate, powder, additive for peritoneal dialysis, per packet

Dialysate concentrate, solution, additive for peritoneal dialysis, per 10 ml

Blood collection tube, vacuum, for dialysis, per 50

Serum clotting time tube, for dialysis, per 50

Blood glucose test strips, for dialysis, per 50

Occult blood test strips, for dialysis, per 50

Ammonia test strips, for dialysis, per 50

Protamine sulfate, for hemodialysis, per 50 mg

Disposable catheter tips for peritoneal dialysis, per 10

Plumbing and/or electrical work for home hemodialysis equipment

Contracts, repair and maintenance, for hemodialysis equipment

Drain bag/bottle, for dialysis, each

Miscellaneous dialysis supplies, not otherwise specified

Venous pressure clamp, for hemodialysis, each

Gloves, non-sterile, per 100

Surgical mask, per 20

Tourniquet for dialysis, each

Gloves, sterile, per pair

Oral thermometer, reusable, any type, each

Rectal thermometer, reusable, any type, each

Ostomy pouch, closed; with barrier attached (1 piece), each

Ostomy pouch, closed; without barrier attached (1 piece), each

Ostomy pouch, closed; for use on faceplate, each

Ostomy pouch, closed; for use on barrier with flange (2 piece), each

Stoma cap

Ostomy pouch, drainable, with extended wear barrier attached, with filter, (1 piece), each

Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece), each

Ostomy pouch, drainable; with barrier attached, (1 piece), each

Ostomy pouch, drainable; without barrier attached (1 piece), each

Ostomy pouch, drainable; for use on barrier with flange (2 piece system), each

Ostomy pouch, urinary; with barrier attached (1 piece), each

Ostomy pouch, urinary; without barrier attached (1 piece), each

Ostomy pouch, urinary; for use on barrier with flange (2 piece), each

Stoma plug or seal, any type

Continent device; catheter for continent stoma

Continent device, stoma absorptive cover for continent stoma

Ostomy accessory; convex insert

Bedside drainage bottle with or without tubing, rigid or expandable, each

Urinary suspensory with leg bag, with or without tube, each

Urinary drainage bag, leg or abdomen, latex, with or without tube, with straps, each

Leg strap; latex, replacement only, per set

Leg strap; foam or fabric, replacement only, per set

Skin barrier, wipes or swabs, each

Skin barrier; solid, 6 x 6 or equivalent, each

Skin barrier; solid, 8 x 8 or equivalent, each

Adhesive or non-adhesive; disk or foam pad

Appliance cleaner, incontinence and ostomy appliances, per 16 oz.

Percutaneous catheter/tube anchoring device, adhesive skin attachment

For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe

For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient’s foot (custom molded shoe), per shoe

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with roller or rigid rocker bottom, per shoe

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with wedge(s), per shoe

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with metatarsal bar, per shoe

For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe with off-set heel(s), per shoe

For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe

For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe

For diabetics only, direct formed, compression molded to patient’s foot without external heat source, multiple-density insert(s) prefabricated, per shoe

For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees fahrenheit or higher, total contact with patient’s foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each

For diabetics only, multiple density insert, custom molded from model of patient’s foot, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each

For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, total contact with patient’s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each

Non-contact wound warming wound cover for use with the non-contact wound warming device and warming card

Collagen based wound filler, dry form, sterile, per gram of collagen

Collagen based wound filler, gel/paste, per gram of collagen

Collagen dressing, sterile, size 16 sq. in. or less, each

Collagen dressing, sterile, size more than 16 sq. in. but less than or equal to 48 sq. in., each

Collagen dressing, sterile, size more than 48 sq. in., each

Collagen dressing wound filler, sterile, per 6 inches

Gel sheet for dermal or epidermal application, (e.g., silicone, hydrogel, other), each

Wound pouch, each

Alginate or other fiber gelling dressing, wound cover, sterile, pad size 16 sq. in. or less, each dressing

Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

Alginate or other fiber gelling dressing, wound cover, sterile, pad size more than 48 sq. in., each dressing

Alginate or other fiber gelling dressing, wound filler, sterile, per 6 inches

Composite dressing, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Composite dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Composite dressing, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

Contact layer, sterile, 16 sq. in. or less, each dressing

Contact layer, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

Contact layer, sterile, more than 48 sq. in., each dressing

Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Foam dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Foam dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

Foam dressing, wound filler, sterile, per gram

Gauze, non-impregnated, non-sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Gauze, non-impregnated, non-sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Gauze, non-impregnated, non-sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Gauze, non-impregnated, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Gauze, non-impregnated, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing

Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Gauze, impregnated, water or normal saline, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Gauze, impregnated, water or normal saline, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Gauze, impregnated, water or normal saline, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size 16 sq. in. or less, each dressing

Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size greater than 16 sq. in., but less than or equal to 48 sq. in., each dressing

Gauze, impregnated, hydrogel, for direct wound contact, sterile, pad size more than 48 sq. in., each dressing

Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Hydrocolloid dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Hydrocolloid dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Hydrocolloid dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

Hydrocolloid dressing, wound filler, paste, sterile, per ounce

Hydrocolloid dressing, wound filler, dry form, sterile, per gram

Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Hydrogel dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Hydrogel dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Hydrogel dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

Hydrogel dressing, wound filler, gel, per fluid ounce

Skin sealants, protectants, moisturizers, ointments, any type, any size

Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Specialty absorptive dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each dressing

Specialty absorptive dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., with any size adhesive border, each dressing

Specialty absorptive dressing, wound cover, sterile, pad size more than 48 sq. in., with any size adhesive border, each dressing

Transparent film, sterile, 16 sq. in. or less, each dressing

Transparent film, sterile, more than 16 sq. in. but less than or equal to 48 sq. in., each dressing

Transparent film, sterile, more than 48 sq. in., each dressing

Wound cleansers, any type, any size

Wound filler, gel/paste, per fluid ounce, not otherwise specified

Wound filler, dry form, per gram, not otherwise specified

Gauze, impregnated, other than water, normal saline, or zinc paste, sterile, any width, per linear yard

Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Gauze, non-impregnated, sterile, pad size more than 16 sq. in. less than or equal to 48 sq. in., without adhesive border, each dressing

Gauze, non-impregnated, sterile, pad size more than 48 sq. in., without adhesive border, each dressing

Packing strips, non-impregnated, sterile, up to 2 inches in width, per linear yard

Eye pad, sterile, each

Eye pad, non-sterile, each

Eye patch, occlusive, each

Adhesive bandage, first-aid type, any size, each

Padding bandage, non-elastic, non-woven/non-knitted, width greater than or equal to three inches and less than five inches, per yard

Conforming bandage, non-elastic, knitted/woven, non-sterile, width less than three inches, per yard

Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to three inches and less than five inches, per yard

Conforming bandage, non-elastic, knitted/woven, non-sterile, width greater than or equal to 5 inches, per yard

Conforming bandage, non-elastic, knitted/woven, sterile, width less than three inches, per yard

Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to three inches and less than five inches, per yard

Conforming bandage, non-elastic, knitted/woven, sterile, width greater than or equal to five inches, per yard

Light compression bandage, elastic, knitted/woven, width less than three inches, per yard

Light compression bandage, elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard

Light compression bandage, elastic, knitted/woven, width greater than or equal to five inches, per yard

Moderate compression bandage, elastic, knitted/woven, load resistance of 1.25 to 1.34 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard

High compression bandage, elastic, knitted/woven, load resistance greater than or equal to 1.35 foot pounds at 50% maximum stretch, width greater than or equal to three inches and less than five inches, per yard

Self-adherent bandage, elastic, non-knitted/non-woven, width less than three inches, per yard

Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to three inches and less than five inches, per yard

Self-adherent bandage, elastic, non-knitted/non-woven, width greater than or equal to five inches, per yard

Zinc paste impregnated bandage, non-elastic, knitted/woven, width greater than or equal to three inches and less than five inches, per yard

Tubular dressing with or without elastic, any width, per linear yard

Synthetic resorbable wound dressing, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing

Synthetic resorbable wound dressing, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing

Compression burn garment, bodysuit (head to foot), custom fabricated

Compression burn garment, chin strap, custom fabricated

Compression burn garment, facial hood, custom fabricated

Compression burn garment, glove to wrist, custom fabricated

Compression burn garment, glove to elbow, custom fabricated

Compression burn garment, glove to axilla, custom fabricated

Compression burn garment, foot to knee length, custom fabricated

Compression burn garment, foot to thigh length, custom fabricated

Compression burn garment, upper trunk to waist including arm openings (vest), custom fabricated

Compression burn garment, trunk, including arms down to leg openings (leotard), custom fabricated

Compression burn garment, lower trunk including leg openings (panty), custom fabricated

Compression burn garment, not otherwise classified

Compression burn mask, face and/or neck, plastic or equal, custom fabricated

Gradient compression stocking, below knee, 18-30 mmhg, each

Gradient compression stocking, below knee, 30-40 mmhg, each

Gradient compression stocking, below knee, 40-50 mmhg, each

Gradient compression stocking, thigh length, 18-30 mmhg, each

Gradient compression stocking, thigh length, 30-40 mmhg, each

Gradient compression stocking, thigh length, 40-50 mmhg, each

Gradient compression stocking, full length/chap style, 18-30 mmhg, each

Gradient compression stocking, full length/chap style, 30-40 mmhg, each

Gradient compression stocking, full length/chap style, 40-50 mmhg, each

Gradient compression stocking, waist length, 18-30 mmhg, each

Gradient compression stocking, waist length, 30-40 mmhg, each

Gradient compression stocking, waist length, 40-50 mmhg, each

Gradient compression stocking, garter belt

Gradient compression wrap, non-elastic, below knee, 30-50 mm hg, each

Gradient compression stocking/sleeve, not otherwise specified

Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories

External urinary catheters; disposable, with wicking material, for use with suction pump, per month

External urinary catheter; non-disposable, for use with suction pump, per month

Canister, disposable, used with suction pump, each

Canister, non-disposable, used with suction pump, each

Tubing, used with suction pump, each

Administration set, with small volume nonfiltered pneumatic nebulizer, disposable

Small volume nonfiltered pneumatic nebulizer, disposable

Administration set, with small volume nonfiltered pneumatic nebulizer, non-disposable

Administration set, with small volume filtered pneumatic nebulizer

Large volume nebulizer, disposable, unfilled, used with aerosol compressor

Large volume nebulizer, disposable, prefilled, used with aerosol compressor

Reservoir bottle, non-disposable, used with large volume ultrasonic nebulizer

Corrugated tubing, disposable, used with large volume nebulizer, 100 feet

Corrugated tubing, non-disposable, used with large volume nebulizer, 10 feet

Terminated December 31, 2015.

Water collection device, used with large volume nebulizer

Filter, disposable, used with aerosol compressor or ultrasonic generator

Filter, nondisposable, used with aerosol compressor or ultrasonic generator

Aerosol mask, used with dme nebulizer

Dome and mouthpiece, used with small volume ultrasonic nebulizer

Nebulizer, durable, glass or autoclavable plastic, bottle type, not used with oxygen

Water, distilled, used with large volume nebulizer, 1000 ml

Interface for cough stimulating device, includes all components, replacement only

High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each

High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each

Combination oral/nasal mask, used with continuous positive airway pressure device, each

Oral cushion for combination oral/nasal mask, replacement only, each

Nasal pillows for combination oral/nasal mask, replacement only, pair

Full face mask used with positive airway pressure device, each

Face mask interface, replacement for full face mask, each

Cushion for use on nasal mask interface, replacement only, each

Pillow for use on nasal cannula type interface, replacement only, pair

Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap

Headgear used with positive airway pressure device

Chinstrap used with positive airway pressure device

Tubing used with positive airway pressure device

Filter, disposable, used with positive airway pressure device

Filter, non disposable, used with positive airway pressure device

One way chest drain valve

Water seal drainage container and tubing for use with implanted chest tube

Implanted pleural catheter, each

Terminated December 31, 2014.

Vacuum drainage bottle and tubing for use with implanted catheter

Terminated December 31, 2014.

Oral interface used with positive airway pressure device, each

Exhalation port with or without swivel used with accessories for positive airway devices, replacement only

Water chamber for humidifier, used with positive airway pressure device, replacement, each

Oral interface used with respiratory suction pump, each

Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each

Expiratory positive airway pressure intranasal resistance valve

Tracheostoma valve, including diaphragm, each

Replacement diaphragm/faceplate for tracheostoma valve, each

Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each

Filter for use in a tracheostoma heat and moisture exchange system, each

Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each

Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each

Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each

Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each

Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each

Tracheostomy/laryngectomy tube, non-cuffed, polyvinylchloride (pvc), silicone or equal, each

Tracheostomy/laryngectomy tube, cuffed, polyvinylchloride (pvc), silicone or equal, each

Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each

Tracheostomy shower protector, each

Tracheostoma stent/stud/button, each

Tracheostomy mask, each

Tracheostomy tube collar/holder, each

Tracheostomy/laryngectomy tube plug/stop, each

Helmet, protective, soft, prefabricated, includes all components and accessories

Helmet, protective, hard, prefabricated, includes all components and accessories

Helmet, protective, soft, custom fabricated, includes all components and accessories

Helmet, protective, hard, custom fabricated, includes all components and accessories

Soft interface for helmet, replacement only

Non-prescription drugs

Single vitamin/mineral/trace element, oral, per dose, not otherwise specified

Multiple vitamins, with or without minerals and trace elements, oral, per dose, not otherwise specified

Artificial saliva, 30 ml

Pediculosis (lice infestation) treatment, topical, for administration by patient/caretaker

Non-covered item or service

Wound suction, disposable, includes dressing, all accessories and components, any type, each

Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type

External ambulatory insulin delivery system, disposable, each, includes all supplies and accessories

Home glucose disposable monitor, includes test strips

Sensor; invasive (e.g., subcutaneous), disposable, for use with non-durable medical equipment interstitial continuous glucose monitoring system, one unit = 1 day supply

Transmitter; external, for use with non-durable medical equipment interstitial continuous glucose monitoring system

Receiver (monitor); external, for use with non-durable medical equipment interstitial continuous glucose monitoring system

Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified

Alert or alarm device, not otherwise classified

Reaching/grabbing device, any type, any length, each

Wig, any type, each

Foot pressure off loading/supportive device, any type, each

Spirometer, non-electronic, includes all accessories

Inversion/eversion correction device

Hygienic item or device, disposable or non-disposable, any type, each

Prescription digital cognitive and/or behavioral therapy, fda cleared, per course of treatment

Exercise equipment

Technetium tc-99m sestamibi, diagnostic, per study dose

Technetium tc-99m teboroxime, diagnostic, per study dose

Technetium tc-99m tetrofosmin, diagnostic, per study dose

Technetium tc-99m medronate, diagnostic, per study dose, up to 30 millicuries

Technetium tc-99m apcitide, diagnostic, per study dose, up to 20 millicuries

Thallium tl-201 thallous chloride, diagnostic, per millicurie

Indium in-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries

Iodine i-131 iobenguane sulfate, diagnostic, per 0.5 millicurie

Iodine i-123 sodium iodide, diagnostic, per millicurie

Technetium tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries

Technetium tc-99m pertechnetate, diagnostic, per millicurie

Lutetium lu 177, dotatate, therapeutic, 1 millicurie

Choline c-11, diagnostic, per study dose up to 20 millicuries

Iodine i-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries

Iodine i-131 sodium iodide capsule(s), therapeutic, per millicurie

Technetium tc-99m tilmanocept, diagnostic, up to 0.5 millicuries

Technetium tc-99m exametazime, diagnostic, per study dose, up to 25 millicuries

Iodine i-131 iodinated serum albumin, diagnostic, per 5 microcuries

Nitrogen n-13 ammonia, diagnostic, per study dose, up to 40 millicuries

Iodine i-125, sodium iodide solution, therapeutic, per millicurie

Iodine i-131 sodium iodide capsule(s), diagnostic, per millicurie

Iodine i-131 sodium iodide solution, diagnostic, per millicurie

Iodine i-131 sodium iodide solution, therapeutic, per millicurie

Iodine i-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries)

Iodine i-125 serum albumin, diagnostic, per 5 microcuries

Technetium tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries

Technetium tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries

Technetium tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries

Technetium tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries

Technetium tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries

Technetium tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries

Indium in-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries

Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries

Iodine i-131 tositumomab, diagnostic, per study dose

Terminated December 31, 2016.

Iodine i-131 tositumomab, therapeutic, per treatment dose

Terminated December 31, 2016.

Cobalt co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie

Indium in-111 oxyquinoline, diagnostic, per 0.5 millicurie

Indium in-111 pentetate, diagnostic, per 0.5 millicurie

Technetium tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicurie

Technetium tc-99m succimer, diagnostic, per study dose, up to 10 millicuries

Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries

Chromium cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries

Iodine i-125 sodium iothalamate, diagnostic, per study dose, up to 10 microcuries

Rubidium rb-82, diagnostic, per study dose, up to 60 millicuries

Gallium ga-67 citrate, diagnostic, per millicurie

Technetium tc-99m bicisate, diagnostic, per study dose, up to 25 millicuries

Xenon xe-133 gas, diagnostic, per 10 millicuries

Cobalt co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie

Technetium tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries

Technetium tc-99m oxidronate, diagnostic, per study dose, up to 30 millicuries

Technetium tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries

Sodium phosphate p-32, therapeutic, per millicurie

Chromic phosphate p-32 suspension, therapeutic, per millicurie

Technetium tc-99m fanolesomab, diagnostic, per study dose, up to 25 millicuries

Technetium tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries

Technetium tc-99m arcitumomab, diagnostic, per study dose, up to 45 millicuries

Technetium tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose

Indium in-111 labeled autologous white blood cells, diagnostic, per study dose

Indium in-111 labeled autologous platelets, diagnostic, per study dose

Indium in-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries

Injection, gadoterate meglumine, 0.1 ml

Injection, gadoteridol, (prohance multipack), per ml

Injection, gadobenate dimeglumine (multihance), per ml

Injection, gadobenate dimeglumine (multihance multipack), per ml

Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml

Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries

Injection, gadoxetate disodium, 1 ml

Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries

Injection, gadofosveset trisodium, 1 ml

Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries

Injection, gadobutrol, 0.1 ml

Florbetapir f18, diagnostic, per study dose, up to 10 millicuries

Gallium ga-68, dotatate, diagnostic, 0.1 millicurie

Fluciclovine f-18, diagnostic, 1 millicurie

Instillation, hexaminolevulinate hydrochloride, 100 mg

Iodine i-131, iobenguane, 1 millicurie

Fluoroestradiol f 18, diagnostic, 1 millicurie

Copper cu-64, dotatate, diagnostic, 1 millicurie

Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie

Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie

Piflufolastat f-18, diagnostic, 1 millicurie

Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie

Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified

Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified

Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose, not otherwise specified

Terminated December 31, 2017.

Strontium sr-89 chloride, therapeutic, per millicurie

Flortaucipir f 18 injection, diagnostic, 1 millicurie

Fluorodopa f-18, diagnostic, per millicurie

Samarium sm-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries

Radium ra-223 dichloride, therapeutic, per microcurie

Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie

Non-radioactive contrast imaging material, not otherwise classified, per study

Radiopharmaceutical, therapeutic, not otherwise classified

Supply of injectable contrast material for use in echocardiography, per study

Gallium ga-68 gozetotide, diagnostic, (locametz), 1 millicurie

Miscellaneous dme supply, accessory, and/or service component of another hcpcs code

Dme delivery, set up, and/or dispensing service component of another hcpcs code

Miscellaneous dme supply or accessory, not otherwise specified