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